Single Center Experience with Isolated Spinal Cord Neurosarcoidosis

INTRODUCTION

Isolated spinal cord neurosarcoidosis is extremely rare. The potential implications of long-term immunosuppressant therapy make correct diagnosis imperative. However, there are challenges inherent in isolated spinal cord involvement that require a multidisciplinary approach. Here we present the largest series of definite and possible isolated spinal neurosarcoidosis and discuss our institutional experience in managing this rare but morbid condition.

METHODS

A retrospective review was performed to identify all neurosarcoidosis cases starting from 2002 to 2020 at our institution. Patients were screened for cases of isolated spinal neurosarcoidosis. A descriptive analysis was performed for each case.

RESULTS

A total of 64 cases of neurosarcoidosis were identified. The spine was involved in 26 (40.6%) patients. Only 4 (6.3%) cases had isolated spinal cord involvement. A full medical and imaging workup was performed in determining isolated spinal cord involvement. Three patients subsequently underwent surgical biopsy, and 1 did not undergo biopsy because of patient preference. One of the patients who underwent biopsy had an initial nondiagnostic biopsy and had a repeat biopsy. Corticosteroids were employed in all cases with additional immunosuppressive agents for maintenance therapy and refractory cases. All showed radiographic improvement and were clinically stable to improved.

CONCLUSION

Isolated spinal cord involvement of neurosarcoidosis is rare and can present challenges in diagnosis. A biopsy can be performed when necessary. However, a biopsy of the spinal cord carries inherent risks and may not always be possible or result in a nondiagnostic sample. In the setting of high clinical suspicion, maximal medical therapy is still employed.

Teaching Pathology in an Integrated Preclinical Medical School Curriculum and Adaptations to COVID-19 Restrictions

The coronavirus disease 2019 (COVID-19) pandemic has had a major impact on education at all age levels, including professional schools and health professions programs. We describe the experience of adapting preclinical medical school courses within an integrated curriculum to virtual instruction. A major feature of two of the courses were pathology small groups adapted from pathology courses in the previous medical school curriculum. These small groups were designed to use facilitated groups of 8 to 10 students. With a sudden change to virtual learning, these small groups were shifted to large group virtual sessions. In general, the conversion went well, with ongoing optimization of the format of the large group sessions mainly occurring over the first several sessions. End-of-course student evaluations were generally positive, but with a preference toward returning to live sessions in the future. Scores on 5 multiple choice examinations in the spring 2020 course were essentially identical in mean, standard deviation, and distribution to examinations in the previous 2 years of the course that had similar layout and topic organization. We discuss the challenges and successes of the switch to virtual instruction and of teaching pathology content within an integrated medical school curriculum.

Visual and Hormone Outcomes in Pituitary Apoplexy: Results of a Single Surgeon, Single Institution 15-Year Retrospective Review and Pooled Data Analysis

Introduction Pituitary apoplexy commonly presents with visual and hormonal deficits. While traditionally regarded as an emergency, there have been increasing trends toward conservative management. Our institutional practice consists of early surgery; therefore, we reviewed our series evaluating vision outcomes, hormone function, and complications compared with the present literature.

Methods We retrospectively reviewed our institution's medical records to identify pituitary apoplexy patients who were treated via the endoscopic endonasal approach by a single neurosurgeon (senior author). We recorded basic demographics, radiographic and operative features, and preoperative and postoperative vision and hormone status. Univariate and multivariate statistical analyses were performed. Pooled data analysis of visual outcomes in the current literature using Bayesian inference was performed.

Results We identified 44 patients with histologically confirmed pituitary apoplexy treated by endoscopic transsphenoidal decompression; 77% were treated within 24 hours of presentation. Total 45% had cranial nerve (CN) palsy, 36% anopsia, and 20% had visual acuity deficits. Postoperatively, 100% of CN palsies improved, 81% of anopsias improved, and 66.7% of visual acuity deficits improved. Long-lasting panhypopituitarism (25%) and hypothyrodism (22%) were common. Cavernous sinus involvement predicted residual tumor (p = 0.006). Pooled Bayesian inference showed 30% improvement in vision outcomes with surgical management compared with medical management with a number needed to treat of 3.3.

Conclusion Early surgery for pituitary apoplexy was associated with excellent visual outcomes and the need for long-term hormone replacement is common. Cavernous sinus involvement is an independent predictor of residual tumor. Pooled statistical analysis favors aggressive surgical management of apoplexy for improved visual outcomes.

Brain metastases from adenocarcinoma of the lung with truly cystic magnetic resonance imaging appearance

Metastatic disease represents over half of all malignancies in brain parenchyma, and carcinoma when metastatic will often spread to the brain, with lung and breast tumors being the most common culprits. The suggestive features of metastatic disease on magnetic resonance imaging include peritumoral, vasogenic edema and avid postcontrast enhancement. We present the case of a 50-year-old male with an established diagnosis of metastatic adenocarcinoma of the lung treated with erlotinib who developed multiple cystic brain lesions on surveillance MRI. These cysts demonstrated T2 prolongation, suppressed completely on FLAIR, lacked surrounding edema, and featured a complete lack of enhancement. Due to the ambiguous imaging findings, brain biopsy was performed to establish the diagnosis. The pathology revealed a single layer of malignant cells lining brain parenchyma and focal areas of glandular growth. The intracranial lesions responded well to total brain radiation. This case is unique for the imaging findings most characteristic of simple cysts in biopsy-proven metastatic disease and may relate to the effects of erlotinib on metastatic brain tumors.

Using Focused Laboratory Management and Quality Improvement Projects to Enhance Resident Training and Foster Scholarship

Training in patient safety, quality, and management is widely recognized as an important element of graduate medical education. These concepts have been intertwined in pathology graduate medical education for many years, although training programs face challenges in creating explicit learning opportunities in these fields. Tangibly involving pathology residents in management and quality improvement projects has the potential to teach and reinforce key concepts and further fulfill Accreditation Council for Graduate Medical Education goals for pursuing projects related to patient safety and quality improvement. In this report, we present our experience at a pathology residency program (University of Iowa) in engaging pathology residents in projects related to practical issues of laboratory management, process improvement, and informatics. In this program, at least 1 management/quality improvement project, typically performed during a clinical chemistry/management rotation, was required and ideally resulted in a journal publication. The residency program also initiated a monthly management/informatics series for pathology externs, residents, and fellows that covers a wide range of topics. Since 2010, all pathology residents at the University of Iowa have completed at least 1 management/quality improvement project. Many of the projects involved aspects of laboratory test utilization, with some projects focused on other areas such as human resources, informatics, or process improvement. Since 2012, 31 peer-reviewed journal articles involving effort from 26 residents have been published. Multiple projects resulted in changes in ongoing practice, particularly within the hospital electronic health record. Focused management/quality improvement projects involving pathology residents can result in both meaningful quality improvement and scholarly output.

Pathology Milestones: Assessing Clinical Competency by Committee

All Accreditation Council for Graduate Medical Education accredited pathology residency training programs are now required to evaluate residents using the new Pathology Milestones assessment tool. Similar to implementation of the 6 Accreditation Council for Graduate Medical Education competencies a decade ago, there have been challenges in implementation of the new milestones for many residency programs. The pathology department at the University of Iowa has implemented a process that divides the labor of the task in rating residents while also maintaining consistency in the process. The process is described in detail, and some initial trends in milestone evaluation are described and discussed. Our experience indicates that thoughtful implementation of the Pathology Milestones can provide programs with valuable information that can inform curricular changes.

Identification of a novel, recurrent SLC44A1-PRKCA fusion in papillary glioneuronal tumor

Mixed neuronal-glial tumors are rare and challenging to subclassify. One recently recognized variant, papillary glioneuronal tumor (PGNT), is characterized by prominent pseudopapillary structures and glioneuronal elements. We identified a novel translocation, t(9;17)(q31;q24), as the sole karyotypic anomaly in two PGNTs. A fluorescence in situ hybridization (FISH)-based positional cloning strategy revealed SLC44A1, a member of the choline transporter-like protein family, and PRKCA, a protein kinase C family member of serine/threonine-specific protein kinases, as the 9q31 and 17q24 breakpoint candidate genes, respectively. Reverse transcription-polymerase chain reaction (RT-PCR) analysis using a forward primer from SLC44A1 exon 5 and a reverse primer from PRKCA exon 10 confirmed the presence of a SLC44A1-PRKCA fusion product in both tumors. Sequencing of each chimeric transcript uncovered an identical fusion cDNA junction occurring between SLC44A1 exon 15 and PRKCA exon 9. A dual-color breakpoint-spanning probe set custom-designed for interphase cell recognition of the translocation event identified the fusion in a third PGNT. These results suggest that the t(9;17)(q31;q24) with the resultant novel fusion oncogene SLC44A1-PRKCA is the defining molecular feature of PGNT that may be responsible for its pathogenesis. The FISH and RT-PCR assays developed in this study can serve as valuable diagnostic adjuncts for this rare disease entity.

Competency assessment of residents in surgical pathology using virtual microscopy

Our goal was to develop an efficient and reliable performance-based virtual slide competency examination in general surgical pathology that objectively measures pathology resident's morphologic diagnostic skill. A Perl scripted MySQL database was used to develop the test editor and test interface. Virtual slides were created with the Aperio ScanScope. The examination consisted of 20 questions using 20 virtual slides. Slides were chosen to represent general surgical pathology specimens from a variety of organ systems. The examination was administered in a secure environment and was completed in 1 to 1 1/2 hours. Examination reliability, as an indicator of the test's ability to discriminate between trainee ability levels, was excellent (r = 0.84). The linear correlation coefficient of virtual slide competency examination score versus months of surgical pathology training was 0.83 (P = .0001). The learning curve was much steeper early in training. Correlation of virtual slide competency examination performance with resident's performance on the 64 item Resident In-Service Examination surgical pathology subsection was 0.70. Correlation of virtual slide competency examination performance with global end of rotation ratings was 0.28. This pilot implementation demonstrates that it is possible to create a short, reliable performance-based assessment tool for measuring morphologic diagnostic skill using a virtual slide competency examination. Furthermore, the examination as implemented in our program will be a valid measure of an individual resident's progress in morphologic competency. Virtual slide technology and computer accessibility have advanced to the point that the virtual slide competency examination model implemented in our program could have applicability across multiple residency programs.

Accreditation Council for Graduate Medical Education (ACGME) Competencies in Neuropathology Training

The Accreditation Council for Graduate Medical Education (ACGME) has defined 6 core competencies for all physicians: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism; and systems-based practice. However, the specific wording of the descriptions often assumes that the physician is a clinician rather than a pathologist. Therefore, the American Association of Neuropathologists, Inc. asked its Professional Affairs Committee to examine the core competencies and determine how they relate to training in neuropathology. The Committee's report is presented here in 6 sections, corresponding to the 6 competencies. In each section, the ACGME definition of that particular competency is either quoted directly or, more often, modified slightly to clarify how the competency applies to neuropathology. Each of the defined competencies is then followed by possible assessment tools, selected from those recommended in the ACGME's "toolbox." Specific suggestions are given for designing tools that apply to neuropathology. Many of the suggested activities and documentation methods can be combined into efficient, carefully formulated training/evaluation exercises. Different tools may be more applicable in some training programs.

Recurrent chromosomal imbalances and structurally abnormal breakpoints within complex karyotypes of malignant peripheral nerve sheath tumour and malignant triton tumour: a cytogenetic and molecular cytogenetic study

BACKGROUND

Cytogenetic studies of malignant peripheral nerve sheath tumours (MPNSTs) and malignant triton tumours (MTTs) are rare.

AIMS

To undertake cytogenetic analysis of these tumours.

METHODS

Conventional cytogenetic analysis of 21 MPNSTs and MTTs from 17 patients (nine with peripheral neurofibromatosis (NF1)) was carried out using standard culture and harvesting procedures. For a more precise identification of composite structural rearrangements and marker chromosomes, spectral karyotypic analysis (SKY) was applied to a subset of cases. In addition, EGFR gene copy number was assessed by fluorescence in situ hybridisation (FISH) analysis in a subset of cases.

RESULTS

Cytogenetic analysis revealed predominantly complex karyotypes. SKY analysis was useful in further defining many structural anomalies. Structural aberrations most frequently involved chromosomal bands or regions 1p31-36, 4q28-35, 7p22, 11q22-23, 19q13, 20q13, and 22q11-13. Overall, loss of chromosomal material was much more common than gain. Loss of chromosomes or chromosomal regions 1p36 (48%), 3p21-pter (52%), 9p23-pter (57%), 10 (48%), 11q23-qter (48%), 16/16q24 (62%), 17(43%), and 22/22q (48%), and gains of 7/7q (29%) and 8/8q (29%) were most prominent. These gains and losses were distributed equally between MPNST and MTT, demonstrating that these entities are similar with respect to recurrent genomic imbalances. Similarly, none of the recurrent chromosomal breakpoints or imbalances was restricted to either NF1 associated or sporadic MPNSTs. FISH analysis was negative for amplification.

CONCLUSIONS

These cytogenetic and molecular cytogenetic findings expand the knowledge of chromosomal alterations in MPNST and MTT, and point to possible recurring regions of interest.

Chromosome 22q dosage in composite extrarenal rhabdoid tumors: clonal evolution or a phenotypic mimic?

Composite extrarenal rhabdoid tumors (CERTs) represent a diverse group of neoplasms with rhabdoid shape in combination with one of several distinctive tumor types. Like the classic renal and extrarenal malignant rhabdoid tumor (MRT), as well as the atypical teratoid/rhabdoid tumor (AT/RT) of the central nervous system, CERTs typically show aggressive clinical behavior. Deletions and mutations of the INII gene on 22q11.2 have been identified in most classic MRTs and AT/RTs; however, it is not known whether the rhabdoid components in CERTs have similar genetic abnormalities. Using fluorescence in situ hybridization (FISH) on archival, paraffin-embedded tissue with a commercially available probe in close proximity to the INII locus (bcr), as well as other chromosome 22 probes, we studied 4 cases of MRT, 13 of AT/RT, and 16 of CERT (3 melanoma, 4 meningioma, 7 carcinoma, 1 rhabdomyosarcoma, and 1 neuroblastoma). Deletion of the 22q11.2 locus was demonstrated in 10 (77%) of 13 AT/RTs and 3 (75%) of 4 MRT, including 1 congenital MRT. Of the 16 CERTs, only 2 (a rhabdoid meningioma and a carcinoma with rhabdoid features; 13%) harbored a deletion at this locus. This difference was statistically significant (P <.001). We conclude that deletion of 22q11.2, typical of most classic MRTs and AT/RTs, is infrequently seen in CERTs. This suggests that the rhabdoid component of CERTs does not evolve by way of the genetic alteration characteristic of MRTs or AT/RTs, but represents instead a distinct phenotype shared by a number of tumors as they undergo anaplastic progression.

Mycoplasma pneumoniae infection, meningoencephalitis, and hemophagocytosis

Central nervous system manifestations are a common extrapulmonary complication of Mycoplasma pneumoniae infection, of which encephalitis is a well-recognized abnormality in children. In this report the first description of M. pneumoniae infection simultaneously complicated by meningoencephalitis and hemophagocytosis is presented.

A role for fluorescence in situ hybridization detection of chromosome 22q dosage in distinguishing atypical teratoid/rhabdoid tumors from medulloblastoma/central primitive neuroectodermal tumors

It has been postulated that infants with medulloblastomas/central primitive neuroectodermal tumors (MB/PNET) may fare worse than older patients because some of them harbor unrecognized atypical teratoid/rhabdoid tumors (AT/RT), rare intracranial neoplasms that are typically unresponsive to therapy and rapidly fatal. Although small primitive cells are common to both entities, chromosome 22q11.2 deletions are common only in AT/RTs. Using fluorescence in situ hybridization (FISH) on archival, paraffin-embedded biopsy tissue with commercially available probes to 22q11.2, the region associated with RTs, we studied 8 cases of AT/RT, 12 cases of MB/PNET, and 4 cases of primitive central nervous system (CNS) neoplasms, which were difficult to classify. 22q Deletions were identified in 6 of 8 (75%) conventional AT/RTs and 0 of 12 (0%) children with classic MB/PNET. Of the 4 originally "difficult to classify" cases, 3 had deletions of 22q. In light of the FISH results, review of the morphology and immunophenotype resulted in 3 tumors being reclassified as AT/RTs and 1 as a large cell MB. These 4 cases highlight the potential diagnostic use of FISH for selected cases of primitive CNS malignancies in children and substantiate the notion that misdiagnosed AT/RTs may, in part account for the worse prognosis associated with "MB/PNET" in children younger than 2 years of age.

Vacuolar neuritic dystrophy in aged mouse superior cervical sympathetic ganglia is strain-specific

We have developed a model of autonomic nervous system aging using the mouse superior cervical sympathetic ganglion (SCG) which is characterized by the reproducible development of distinctive, markedly-enlarged neuritic swellings (vacuolar neuritic dystrophy, VND). These structures contained an admixture of lucent vacuoles and subcellular organelles, and involved both presynaptic and postsynaptic ganglionic elements. Quantitation of the frequency of VND was accomplished at the light microscopic level and validated by ultrastructural examination. VND lesions were 30-100-fold more frequent in the aged mouse paravertebral SCG than in the prevertebral celiac/superior mesenteric (C/SMG) sympathetic ganglia. Although VND was identified in all ages of mice examined, the number of lesions increased significantly with age. The frequency of VND was a function of the strain of mouse examined with a 40-fold difference in VND frequency between C57BL6 mice, the least involved strain, and the DBA/2J strain, which was most affected and began to develop significant numbers of lesions at an early age. As in our human studies of aging in the sympathetic nervous system, there was a prominent gender effect with males developing twofold greater numbers of VND lesions than females. Mice maintained on a significant calorie restricted diet for 30 months developed 70% fewer lesions than ad libitum-fed, age and sex matched controls. The aging mouse SCG, therefore, represents a robust animal model with reproducible, quantifiable and unambiguous neuropathology. Insights into pathogenetic mechanisms gained in the subsequent analysis of this relatively simple peripheral sympathetic nervous system model may contribute to the understanding of some of the most complex and significant problems involving higher brain function.

Pulmonary pathology of patients treated with partial liquid ventilation

Initial trials of partial liquid ventilation (PLV), which is gas ventilation of perfluorocarbon-filled lungs, are underway in patients with severe respiratory failure. We report the first study of the effects of the perfluorocarbon, perflubron, on the lung. Necropsies were conducted in nine patients (seven adults and two neonates; mean adult age, 31 +/- 5 yr) managed with PLV (average number of doses, 4 +/- 1). All of the patients required extracorporeal life support. The patients had pneumonia with the acute respiratory distress syndrome (six patients), trauma/capillary leak syndrome (one patient), congenital diaphragmatic hernia (one patient), and primary pulmonary hypertension (one patient). Nine adult patients (mean age, 37 +/- 5 yr) with acute respiratory distress syndrome requiring extracorporeal life support served as a control. Pathologic findings were evaluated in both groups. Lung weights in the adult patients of both groups were elevated (mean weight of PLV-treated right lung, 1401 +/- 186 g; mean weight of PLV-treated left lung, 1131 +/- 177 g; mean weight of control right lung, 1018 +/- 91 g; mean weight of control left lung, 988 +/- 80 g). There was no significant difference between the two groups (right lung, P = .066; left lung, P = .436). Frequent gross findings included focal consolidation, patchy hemorrhage, and glassy cut surfaces. The histologic findings were similar in both groups. Diffuse alveolar damage (either proliferative phase or mixed proliferative and exudative phases) was seen in all nine of the study patients. Eight of the nine control patients had diffuse alveolar damage (five had proliferative phase only, one had mixed proliferative and exudative phases, and two had exudative phase only). One other patient had extensive parenchymal necrosis. Other frequent findings were intra-alveolar hemorrhage, numerous intra-alveolar macrophages, and organization of exudate. PLV with perflubron in patients with adult and neonatal respiratory distress syndromes is not associated with unique pathologic findings in the human lung.