Elevated Serum IgG4 and Eosinophils: A Case of Indeterminate Biliary Stricture

Introduction/Objective

Diagnosis of indeterminate biliary stricture is challenging and tissue diagnosis is critical to provide adequate management. We report an unusual case of biliary stricture mimicking extrahepatic cholangiocarcinoma on ERCP.

Methods/Case Report

A 44-year-old male presented with unintentional 30 lb weight loss, scleral icterus, and dark urine for the past 3 weeks. At admission, elevated liver enzymes and bilirubin 12.3 mg/dl were noted. Imaging studies showed dilated intra- and extra-hepatic biliary ducts with abrupt transition and focal wall thickening concerning for cholangiocarcinoma. ERCP revealed frond-like mucosa and neovascularization. Additional lab investigations showed elevated CEA, presence of anti-nuclear and smooth muscle antibodies, and an elevated IgG4 (224.9 mg/dL) raising the differential diagnosis of primary sclerosing cholangitis (SC) and IgG4 sclerosing cholangitis (IgG4-SC), a manifestation of IgG4 related disease (IgG4-RD). An exploratory laparotomy with excision of bile duct stricture, cholecystectomy, and portal lymphadenectomy was performed. Histopathology showed thickened and fibrotic bile duct wall with dense inflammatory infiltrate rich in eosinophils, consistent with eosinophilic cholangitis (EC). There was no evidence of plasma cell infiltration. The gallbladder also exhibited similar changes. Symptoms suggestive of other eosinophilic gastrointestinal disorders were not present. The subsequent review showed persistent eosinophilia (absolute count 1.8 k/mm3). Stool examination was negative for ova/parasite.

Results (if a Case Study enter NA)

NA.

Conclusion

This report highlights that elevated serum IgG4 levels may be a potential overlap in the pathogenesis of EC and IgG4-RD. Eosinophilic cholangitis, a rare benign entity and a mimicker of cholangiocarcinoma, should be included in the differential diagnosis of elevated serum IgG4.

2016 Comprehensive Update of the Banff Working Group on Liver Allograft Pathology: Introduction of Antibody-Mediated Rejection

The Banff Working Group on Liver Allograft Pathology reviewed and discussed literature evidence regarding antibody-mediated liver allograft rejection at the 11th (Paris, France, June 5-10, 2011), 12th (Comandatuba, Brazil, August 19-23, 2013), and 13th (Vancouver, British Columbia, Canada, October 5-10, 2015) meetings of the Banff Conference on Allograft Pathology. Discussion continued online. The primary goal was to introduce guidelines and consensus criteria for the diagnosis of liver allograft antibody-mediated rejection and provide a comprehensive update of all Banff Schema recommendations. Included are new recommendations for complement component 4d tissue staining and interpretation, staging liver allograft fibrosis, and findings related to immunosuppression minimization. In an effort to create a single reference document, previous unchanged criteria are also included.

Immunohistochemical expression of rabphilin-3A-like (Noc2) in normal and tumor tissues of human endocrine pancreas

Involvement of rabphilin-3A-like (RPH3AL), or Noc2, the potential effector of Ras-associated binding proteins Rab3A and Rab27A in the regulation of exocytotic processes in the endocrine pancreas has been demonstrated in experimental models. Noc2 expression together with other regulatory molecules of the exocytotic machinery in human tissues, however, has not been studied. We evaluated immunohistochemical expression of the key molecules of the exocytotic machinery, Noc2, Rab3A, Rab27A, and RIM2, together with the characteristic islet cell hormones, insulin and glucagon in normal and endocrine tumor tissues of human pancreas. Normal pancreatic islets were stained for all of these proteins and showed strong cytoplasmic localization. A similar pattern of strong cytoplasmic expression of these proteins was observed in the majority of endocrine tumors. By contrast, the exocrine portions of normal appearing pancreas completely lacked Rab27A staining and showed decreased expression of the proteins, Noc2, Rab3A, and RIM2. The staining pattern of Noc2 and Rab27A was similar to the staining pattern of glucagon-producing cells within the islets. The concomitant expression of Noc2 with these molecules suggests that Noc2 may serve as an effector for Rab3A and Rab27A and that it is involved in the regulation of exocytosis of the endocrine pancreas in humans.

Cumulative sum procedure in evaluation of EUS-guided FNA cytology: the learning curve and diagnostic performance beyond sensitivity and specificity

BACKGROUND

Using cumulative sum (CUSUM) chart, we address two questions: (i) Over time, how will an EUS-FNA (endoscopic ultrasound guided fine needle aspiration) service maintain an acceptable non-diagnostic rate defined as technical failures, unsatisfactory specimens and atypical and suspicious diagnoses? (ii) Over time, how will EUS-FNA maintain acceptable diagnostic errors (false-positives plus false-negative diagnosis)?

METHODS

The study included all consecutive patients who underwent EUS-FNA at our institution from July 2000 to October 2003 and were followed up until December 2004. Using a simple spread sheet, we designed CUSUM charts and used them to track trends and assess performance at a preset acceptable rate of 10% and a preset unacceptable rate of 15% for non-diagnostic rate and diagnostic errors. We assessed all cases collectively and then in groups defined by site, size and cytopathologist.

RESULTS

Of 876 patients undergoing EUS-FNA, 83 (9.5%) had non-diagnostic results: 43 (51%) of these diagnoses were 'atypical', 27(33%) were 'suspicious for malignancy', eight (10%) were 'insufficient material for diagnosis' and five (6%) were 'technical failure'. In 585 cases with adequate follow up, there were 26 (6.3%) diagnostic errors: three (0.5%) were false positive and 23 (3.1) were false negative. The overall CUSUM charts for both non-diagnostic rate and for diagnostic error rate start with a small period of learning then cross to a significantly acceptable level at case numbers 121 and 97 respectively. Our diagnostic performance was better in lymph nodes than in the pancreas and other organs and was not significantly different for lesions <or=25 mm compared with lesion >25 mm in diameter. Performance was better for pathologists with prior experience than for pathologists without experience.

CONCLUSION

In the current climate of proficiency testing, error tracking and competence evaluation, there is a great potential for the use of CUSUM charts to assess procedure failure and error tracking in quality control programs, particularly when a new procedure such as EUS-FNA is introduced in the laboratory. Additionally, the method can be used to assess trainee competency and to track the proficiency of practicing cytologists.

Phenotypic expression of Bax is a predictive marker of 5-fluorouracil treatment in colorectal cancer

3605

Background: The anti-tumor activity of 5-fluorouracil (5-FU) has been related to its ability to induce apoptosis. Therefore, we assessed the predictive value of phenotypic expression of key apoptotic molecules in colorectal adenocarcinomas (CRC) of patients treated with 5-FU-based adjuvant therapies. Methods: Archival tissues of CRCs from 56 patients who received a complete regimen of 5-FU-based chemotherapy after surgery, and 56 age, gender, ethnicity, tumor stage, tumor location, and tumor differentiation matched patients who had undergone only surgery (without any pre- or post-surgery chemo- or radiation therapy), were evaluated for immunophenotypic expression of Bax, Bcl-2 and nuclear accumulation of p53 (p53nac). Immunophenotypic expression of these markers was categorized into low and high expressors and cut-point values were determined based on their expression in benign epithelium. These tumors Ability of these markers in predicting the efficacy of 5-FU-based treatment was assessed by estimating overall survival utilizing the Kaplan-Meier and Cox proportional hazards methods. Results: There was no significant difference in overall survival rates between the two patient categories (logrank P=0.487). However, a better survival was observed for patients who received chemotherapy when their CRCs lacked Bax expression; in contrast, patients with high Bax expression CRCs had worse survival when they received chemotherapy (logrank P=0.016). Surgically treated patients with CRCs lacked Bax expression had 5.33 times higher mortality than those with high Bax expression (HR, 5.33; CI: 1.78–15.94), when controlled for tumor stage and other confounding variables. Bcl-2 or p53nac had no predictive value in either patient group. Conclusions: These preliminary findings are the first to provide good evidence to suggest that patients with CRCs lacking Bax phenotypic expression benefit from 5-FU-based adjuvant therapies but not those with high Bax expression (Supported by NIH/NCI R01-CA98932–01).

No significant financial relationships to disclose.

Transgastric endoscopic ultrasound-guided fine-needle aspiration biopsy and flow cytometry of suspected lymphoma of the spleen

BACKGROUND AND STUDY AIMS

Masses in the spleen can be sampled by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) but the diagnosis of lymphoma using EUS-FNA and flow cytometry has not been reported. We report our experience with transgastric EUS-FNA and flow cytometry in the investigation of patients with suspected lymphoma of the spleen.

PATIENTS AND METHODS

All patients with splenic lesions that had been detected by computed tomography and who were referred for transgastric EUS-FNA over a 3-year period were enrolled in this study. The tissue obtained by EUS-FNA was evaluated by flow cytometry in all patients.

RESULTS

Six patients with splenic masses were enrolled (four men, two women; median age 58.5 years, range 41 - 82 years). The mean size of the short axis of the lesions was 37.8 mm (SD 23.76 mm) and the mean size of the long axis was 45.6 mm (SD 31.72 mm). EUS-FNA was performed successfully in all patients and the tissue obtained was evaluated by flow cytometry. Two patients were diagnosed with lymphoma; no pathology was identified in the other four patients. Lymphoma of the spleen appeared as sharply demarcated echo-poor lesions; benign lesions appeared echo-rich in comparison with the surrounding splenic tissue. The two patients who were diagnosed with lymphoma underwent chemotherapy. Of the four patients in whom no pathology was identified, one patient subsequently underwent splenectomy for evaluation of persistent abdominal pain and was diagnosed with lymphoma; the three other patients had true-negative disease on the evidence of long-term follow-up (mean 8 months; range 6 - 12 months). No complications related to the EUS-FNA procedure were encountered in any patient.

CONCLUSIONS

EUS-FNA of spleen masses is a safe technique that aids in the diagnosis of lymphoma when used in conjunction with flow cytometry.

Symptomatic lactic acidosis in hospitalized antiretroviral-treated patients with human immunodeficiency virus infection: a report of 12 cases

We retrospectively investigated the clinical and histopathologic features of hospitalized patients infected with human immunodeficiency virus who had symptomatic lactic acidosis syndrome at a university teaching hospital during 1995-2000. Twelve patients were identified, 11 during 1998-2000; of these, 5 died with rapid progression to otherwise unexplained multiple-organ failure. All had extensive prior exposure to nucleoside analog reverse-transcriptase inhibitors (NRTIs). At presentation, the most commonly identified NRTI component of antiretroviral regimens was stavudine plus didanosine. Eleven patients presented with abdominal pain, nausea, and/or emesis. Eight patients had prior acute weight loss (mean [+/-SD], 12+/-5.3 kg). Median venous plasma lactate levels were > or =2-fold greater than the upper limit of normal (2.1 mmol/L). Serum transaminase levels were near normal limits at presentation. Histopathologic studies confirmed hepatic macrovesicular and microvesicular steatosis in 6 patients. Concurrent chemical pancreatitis was identified in 6 patients. The increasing number of cases identified during the study period suggests that physicians better recognize symptomatic lactic acidosis and/or that cumulative NRTI exposure may increase the risk for this syndrome.

Use of a panel of markers in the differential diagnosis of adenocarcinoma and reactive mesothelial cells in fluid cytology

To evaluate the use of a panel of markers to differentiate adenocarcinoma and the reactive/inflammatory process in fluid cytology, we stained 29 formalin-fixed, paraffin-embedded cell blocks of effusion fluid from patients with metastatic adenocarcinoma and 24 cell blocks from patients with benign effusion with mucicarmine and antibodies to carcinoembryonic antigen (CEA), B72.3, and calretinin. Positive staining with CEA, B72.3, and mucicarmine was seen in 22 (76%), 20 (69%), and 18 (62%) adenocarcinoma cases, respectively. All except 1 adenocarcinoma was negative for calretinin. No benign cases were positive for B72.3 and mucicarmine. In 1 benign case, scattered epithelial cells demonstrated weak positivity for CEA. The majority of combinations were 100% specific for adenocarcinoma. The highest sensitivity (86%) for adenocarcinomas was achieved with the staining combination of negative for calretinin and positive for any adenocarcinoma marker (CEA, B72.3, or mucicarmine). The use of a panel of markers that recognize adenocarcinoma and mesothelial cells is useful in the differential diagnosis between metastatic adenocarcinoma and the reactive/inflammatory process. The profile of positive staining with at least one of the adenocarcinoma markers and negative calretinin staining is highly specific and sensitive for identifying adenocarcinoma in fluid cytology.

Role of DNA ploidy analysis in endometrial adenocarcinoma

Endometrial adenocarcinoma is the leading cause of malignancy of the female genital tract. Prognosis of this tumor, which has implications on patient management, is determined by evaluation of the stage of disease, architectural grade, nuclear grade, myometrial invasion, and peritoneal cytology. These parameters have inherent subjectivity and, therefore, the search for an objective reliable parameter to determine prognosis is required. DNA ploidy is under investigation as an objective and reproducible prognostic parameter. This study will evaluate the role of DNA ploidy and its relationship to the traditional parameters as predictors of prognosis in patients with endometrial carcinoma. Fifty-eight patients were evaluated by two observers for architectural grade according to the International Federation of Gynecology and Obstetrics classification, nuclear grade, and depth of myometrial invasion. DNA ploidy was evaluated using flow cytometer (FACscan, Becton Dickinson, San Jose, CA). Histologic parameters were than compared with DNA ploidy. Survival data were obtained from the tumor registry. Results of patient survival were compared with histologic parameters and DNA ploidy. Higher nuclear grade and aneuploidy correlated with poor survival rate (P <.05). Higher nuclear grade correlated with aneuploidy. The survival of patients with architectural grade 2 (moderately differentiated) endometrial adenocarcinoma is poorer if the tumor is aneuploid as compared with diploid as determined by flow cytometry. In conclusion, aneuploidy and nuclear grade correlates with poor patient survival. The poorer survival rates with aneuploid architectural grade 2 endometrial adenocarcinoma may have an impact on clinical management.

Molecular characterization of colorectal neoplasia in translational research

OBJECTIVE

To present recent advances in the use of molecular markers in diagnosis, in prognosis, in early detection, in novel therapies, and in understanding the molecular pathogenesis of colorectal neoplasia.

DATA AND LITERATURE SOURCES

A review of studies of molecular markers in colorectal neoplasia, published in English and available on MEDLINE and BioMednet, indicates that molecular markers are being increasingly studied to predict clinical outcomes in patients with colorectal adenocarcinoma (CRC). We have used this resource, together with our published and unpublished observations at the University of Alabama at Birmingham, to provide an overview of translational research related to molecular markers in colorectal neoplasia.

CONCLUSIONS

Currently, the prognosis of patients with CRC is predicted primarily on the basis of clinicopathologic staging; however, pathologists and oncology surgeons have recently begun to investigate the use of molecular markers to diagnose and/or understand the progression of CRC. In recent years, much has been learned about the molecular events responsible for the development of CRC. Also, several studies have reported the implication of some molecular markers in metastasis and tumor aggression and their usefulness in predicting clinical outcome. In this article, we discuss the use of specific molecular markers, including tumor-associated glycoprotein 72 (TAG-72), carcinoembryonic antigen (CEA), and oncofetal tumor antigens (Lewis X and Y) in diagnosis and as targets for novel therapies, as well as the phenotypic expression of bcl-2, mucin antigens (MUC1 and MUC2), and nuclear accumulation of p53 in predicting the clinical outcome of patients with CRC. We also review the ways in which molecular markers may aid the early detection of colorectal neoplasia and promote our understanding of the earliest changes in colorectal neoplasia.

Neutrophil-rich anaplastic large cell lymphoma of T-cell lineage. A report of two cases arising in HIV-positive patients

Neutrophil-rich anaplastic large cell lymphoma (ALCL) is an uncommon morphologic variant of ALCL. We report 2 cases of neutrophil-rich T-cell ALCL that presented as scalp masses in HIV-positive men. Histologically, the neoplastic cells extensively infiltrated the dermis and subcutaneous tissue. The neoplastic cells strongly expressed CD30 and were of T-cell lineage, positive for CD3 and CD45RO, and negative for CD20. The neoplastic cells were negative for anaplastic lymphoma kinase-1. Numerous admixed neutrophils also were present, representing up to 70% of all cells in some microscopic fields. Neither patient had peripheral blood leukocytosis. One patient had relative neutrophilia, 79% (0.79; reference range, 50%-70% [0.50-0.70]). The absolute CD4 counts were 160 cells/microL (160 x 10(6)/L) and 150 cells/microL (150 x 10(6)/L), respectively (reference range, 431-1,623/microL [431-1,623 x 10(6)/L]). Both patients were treated with multiagent chemotherapy but died of Pneumocystis carinii pneumonia within 6 months of diagnosis. In our review of the literature, we identified 5 similar T-cell cases, including 1 in an HIV-positive patient. Neutrophil-rich T-cell ALCL is a rare morphologic variant of ALCL that should be considered in the histologic evaluation of neutrophil-rich biopsy specimens.

Quality assurance and risk reduction guidelines

Cervical cancer continues to be a major cause of death in women worldwide. The major problem facing most women is the unavailability of screening Pap tests in poor and underdeveloped countries. While rates of cancer deaths have decreased 60-80% in developed countries since the Pap test became available, the accuracy of Paps was challenged recently. In order to instill public confidence and promote optimal patient care, measures to improve the quality of the entire screening process should be undertaken. Continuous quality improvement processes are more appropriate than traditional quality assurance monitors. Although no standards can be defined that are applicable to all laboratory settings and nations, this document provides current views on universal quality procedures and risk reduction. Procedure/policy manuals, workload assessment, hierarchic/peer review, discrepancy analysis, rescreening studies and cytohistologic correlation are examples of universally applicable quality tools. The variability in practices in different parts of the world is also discussed.

The effects of short-term lansoprazole therapy on Helicobacter pylori infection and antral gastritis in duodenal ulcer patients

BACKGROUND/AIMS

Lansoprazole is a new potent proton pump inhibitor that exhibits activity against Helicobacter pylori in vitro. This study endeavored to determine the effects of 4 wk of lansoprazole therapy upon H. pylori infection and antral gastritis in duodenal ulcer patients and to determine the relationship of the gastritis with Helicobacter infection and with ulcer activity.

METHODS

Satisfactory antral biopsies were obtained from 119 duodenal ulcer patients before and after 4 wk of therapy with lansoprazole, ranitidine, or placebo. Sections were scored blindly for degree of active and chronic inflammation and extent of H. pylori infection.

RESULTS

Four weeks of lansoprazole (30 mg daily) or ranitidine (300 mg daily) therapy produced a significant decrease in H. pylori infection. The reduction of H. pylori infection, but not ulcer healing per se, correlated with the decrease in active and chronic antral inflammation. Reduction of H. pylori infection, however, did not improve the good ulcer-healing rates already achieved at 4 wk by potent acid inhibition.

CONCLUSIONS

Lansoprazole exhibits activity against H. pylori in vivo. Short-term improvement in antral gastritis is affected by reduction of H. pylori infection but not by ulcer healing.