Acute Hemorrhage Related Colonic Injury Misdiagnosed as Signet-Ring Cell Carcinoma

Introduction/Objective

Hypovolemic shock/hypoperfusion-related gastrointestinal injury is an unusual event in the practice of oncological pathology. The histologic findings can be ambiguous, potentially masquerading other entities, especially epithelial neoplasms. One needs to pay close attention to the subtle microscopic features and the associated sudden clinical event(s). Concordant hypovolemic history will help decision-making but can be overlooked or unaware of.

Methods/Case Report

A 72-year-old gentleman with prostate hypertrophy, rheumatoid arthritis, and hypertension presented to the emergency room with palpitation, dizziness, and dyspnea. He was diagnosed with atrial fibrillation and started on anticoagulation. Unexpectedly, the patient returned 3 days later with sudden gastrointestinal hemorrhage and severe anemia (hemoglobin 2.7). Emergency colonoscopy identified mucosal hemorrhage, erosion, and a friable, mass-like area in the sigmoid colon; the corresponding biopsy was called signet-ring cell carcinoma. Subsequently, the patient was referred to our institution for consultation.

Results (if a Case Study enter NA)

The provided biopsy showed multiple clusters of signet-ring-like cells with extravasated mucin, detached or distributed within edematous colonic fragments, resembling signet-ring cell carcinoma. However, no overt cytologic or architecture atypia or mitosis was appreciated; instead, microscopic hemorrhage, capillary thrombi, withering and distorted crypts, and mucosal necrotic sloughing were present, worse on the luminal surface. Furthermore, no background dysplasia or adenoma was identified. These findings uncovered an originally misdiagnosed acute colitis due to hypoperfusion. Subsequent imaging studies detected no gastrointestinal mass/lesion. 22-months later, the patient’s clinical follow-up was unremarkable.

Conclusion

Severe hemorrhage/hypoperfusion-induced colitis may pose a dilemma clinically and histopathologically when the contributing event is underrecognized. Detailed history and laboratory review and astute microscopic inspection are warranted.

Unusual liver Involvement by Small Cell Carcinoma Arising in an Ovarian Malignant Mixed Mullerian Tumor

Introduction/Objective

Malignant mixed Mullerian tumor (MMMT) is a rare and aggressive tumor with patient survival of fewer than three years. MMMT harbors multilineage differentiation associated with malignant epithelial and stromal components. Awareness and familiarity with these characteristics are essential for patient stratification and clinical management.

Methods/Case Report

A 64-year-old female presented with refractory lower abdominal pain and bloating. Imaging studies revealed a 14-cm pelvic mass. The patient underwent urgent hysterectomy with salpingo-oophorectomy. She was diagnosed with ovarian MMMT(A) and received chemotherapy. The patient returned 2 months later with new- onset abdominal pain. CT detected numerous liver lesions; a biopsy was performed.

Results (if a Case Study enter NA)

The liver biopsy revealed metastatic small cell carcinoma (SCC[B], positive for synaptophysin and CD56; Ki67 >90%.). However, no concurrent lesions were identified on imaging. Further testing was attempted to locate the source of the SCC. Re-review of the MMMT with additional tissue sectioning identified sheets of high-grade pleomorphic malignant cells with a high N:C ratio, arranged in rosettes and without mucin. Additional immunohistochemistry labeled this MMMT diffusely with synaptophysin(C), chromogranin, and CD56. Furthermore, microscopic foci of MMMT showed higher grade histomorphology similar to the liver SCC which stained for PAX5(D). These findings illustrate a rare MMMT with a neuroendocrine carcinoma/SCC component which gave rise to liver metastasis.

Conclusion

This unusual liver SCC in a patient with prior MMMT exemplifies the multipotent malignant potential of MMMT and demonstrates the importance of having a spectrum of differentials and carrying out meticulous histomorphologic and ancillary analyses, especially when there is unusual histomorphology and discordance in clinical course.

Using Deep Learning for Whole Slide Image Prostate Cancer Diagnosis and Grading in South Florida Veteran Population

Introduction/Objective

Prostate cancer is the most common non-cutaneous malignancy in veterans, with approximately 11,000 new prostate cancer cases diagnosed in the Veteran’s Affairs system each year. Prostate cancer diagnosis and grading can be challenging even for experienced pathologists. Although large VA medical centers have pathologists that specialize in urologic pathology, the vast majority have not. We hypothesized that the AI-augmented diagnosis and grading may provide the solution for such situations.

Methods/Case Report

Dataset consisted of 10,000 prostate biopsy whole slide images (WSI) from the Kaggle PANDA challenge, and 6,000 WSI from the James A. Haley Veterans’ Hospital. Two Classification models were trained on the combined Kaggle and VA datasets using whole slide labels, and not annotated slides that resemble semi-supervised training.

Two-Class Classification to predict Benign: ISUP [0] / Cancerous: ISUP [1,2,3,4,5] Three-Class Classification to predict Benign: ISUP [0] / Low-grade: ISUP [1,2] / High-grade: ISUP [3,4,5] WSI split into “tiles” were used for training the models to reduce whitespace around samples, manage large images, and normalize dimensions/orientations.

Results (if a Case Study enter NA)

Models trained purely as binary and 3-class classifiers performed very well. Two-Class Model:

Accuracy = 0.937

Precision = 0.965

F1 = 0.94

AUC = 0.979

Three-Class Model:

Accuracy 0.89

o Benign:

Precision=0.897

f1=0.928

o Low-grade:

Precision=0.866

f1=0.841

o High-grade:

Precision=0.91

f1=0.878

We plan to develop multi-stage prediction models using these 2-Class and 3-Class classifiers as the first stage and a cancer grade predictor in the second stage.

Conclusion

We successfully showed that AI can augment pathologist’s diagnosis and grading of prostate cancer.

Repeatability and reproducibility of multiparametric magnetic resonance imaging of the liver

As the burden of liver disease reaches epidemic levels, there is a high unmet medical need to develop robust, accurate and reproducible non-invasive methods to quantify liver tissue characteristics for use in clinical development and ultimately in clinical practice. This prospective cross-sectional study systematically examines the repeatability and reproducibility of iron-corrected T1 (cT1), T2*, and hepatic proton density fat fraction (PDFF) quantification with multiparametric MRI across different field strengths, scanner manufacturers and models. 61 adult participants with mixed liver disease aetiology and those without any history of liver disease underwent multiparametric MRI on combinations of 5 scanner models from two manufacturers (Siemens and Philips) at different field strengths (1.5T and 3T). We report high repeatability and reproducibility across different field strengths, manufacturers, and scanner models in standardized cT1 (repeatability CoV: 1.7%, bias -7.5ms, 95% LoA of -53.6 ms to 38.5 ms; reproducibility CoV 3.3%, bias 6.5 ms, 95% LoA of -76.3 to 89.2 ms) and T2* (repeatability CoV: 5.5%, bias -0.18 ms, 95% LoA -5.41 to 5.05 ms; reproducibility CoV 6.6%, bias -1.7 ms, 95% LoA -6.61 to 3.15 ms) in human measurements. PDFF repeatability (0.8%) and reproducibility (0.75%) coefficients showed high precision of this metric. Similar precision was observed in phantom measurements. Inspection of the ICC model indicated that most of the variance in cT1 could be accounted for by study participants (ICC = 0.91), with minimal contribution from technical differences. We demonstrate that multiparametric MRI is a non-invasive, repeatable and reproducible method for quantifying liver tissue characteristics across manufacturers (Philips and Siemens) and field strengths (1.5T and 3T).

Vitamin D intake in Australian adults and the modeled effects of milk and breakfast cereal fortification

OBJECTIVE

Vitamin D intake from foods or supplements is a safe and attractive means to improve vitamin D status of populations. The aim of this study was to help identify population subgroups that would benefit most from efforts to increase intake. To do so, we investigated which personal characteristics are associated with vitamin D intake in an Australian population and modeled possible effects of expanded food fortification practices.

METHODS

We investigated vitamin D intake in a population-based random sample of 785 adults, using a validated food frequency questionnaire, and assessed associations with personal and behavioral characteristics. We identified vitamin D food sources and modeled the hypothetical effects of blanket fortification of milk and breakfast cereals.

RESULTS

Average total vitamin D intake was 4.4 (±4.0) μg/g and below adequate intake for most participants in all age and sex subgroups. Higher intake was associated with being female, having a serious medical condition, energy intake below the median, and vitamin D supplement use (all P < 0.05). The "meat, fish, and eggs" food group contributed most to total vitamin D intake (51%), followed by dairy products and related foods (43%). If all milk and breakfast cereals were to be fortified with vitamin D, the average intake of vitamin D from foods would increase from 3.6 (±2.4) μg/d to 6.3 (±3.2) μg/d, with similar increases in all age and sex subgroups.

CONCLUSIONS

Vitamin D intake in Australia is generally below recommended levels, and few personal characteristics help to identify subgroups with low intake. Blanket vitamin D fortification of milk and breakfast cereals would substantially increase average vitamin D intake in Australian adults of all ages.

Sun protection and vitamin D status in an Australian subtropical community

OBJECTIVE

Claims have been made that sun protection may negatively affect vitamin D status, but very few data are available about whether this applies to people in uncontrolled settings.

METHOD

In 1996 we measured 25(OH)-vitamin D concentrations in 1113 adults in Nambour, a subtropical community, who reported their concurrent sun protection behaviours in a skin cancer prevention trial. Estimates were adjusted for time outdoors, vitamin D intake and other factors known to affect vitamin D status.

RESULTS

Persons who tended to stay in the shade had lower vitamin D levels than those who never stayed in the shade (62.5 vs. 68.8 nmol/L respectively, p=0.01), and this association remained in persons who spent less than 50% (p=0.02) but not in those who spent more than 50% of their time outdoors. Wearing a hat, long sleeves, sunglasses and use of sunscreen or umbrella were not associated with vitamin D status after adjustments, including after stratification by time outdoors.

CONCLUSION

Sun protection behaviour to reduce the risk of skin cancer can be maintained without affecting vitamin D serum status, although consistently seeking shade when spending less than 50% of daytime outdoors is associated with lower vitamin D levels.