bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing Propylene Glycol Interference at Concentrations Relevant to Serum Levels With Electronic Cigarette Use in an Enzymatic Ethylene Glycol Assay
Authors: Calvaresi Emilia , Wyness Sara , Jackson Alexandria , Genzen Jon , Johnson-Davis Kamisha
Published: September 2019

Introduction

Clinical laboratory measurement of ethylene glycol (ETG) by enzymatic methods is known to be subject to interference with high (several hundred milligrams/deciliter) concentrations of propylene glycol (PG). An estimated 10.8 million people in the United States, or almost 1 in 20 Americans, are reported to use electronic cigarettes (e-cigarettes; ie, “vaping”), in which PG is frequently used as a liquid solvent. No published reports exist investigating whether serum concentrations of PG that may be seen with e-cigarette use (generally, concentrations of 10-15 mg/dL in moderate users and up to 30 mg/dL in heavy users) can lead to either interference flags in analytical ETG measurement or falsely positive ethylene glycol concentrations being reported.

Methods

Studies were conducted to assess PG interference on enzymatic ETG measurement. Commercially acquired human AB serum (catalog # 35-060-CI; Corning Life Sciences) was spiked with various amounts of PG (catalog #158720010; Acros Organics/Thermo Fisher Scientific) to achieve both concentrations of PG expected with e-cigarette use (0-30 mg/dL) and supra-physiological concentrations (>30 mg/dL) for comparative purposes. PG-spiked sera were tested using a quantitative enzymatic ETG assay (Quantitative Ethylene Glycol kit, catalog #C504-0A; Catachem) previously validated as a laboratory-developed test on an AU5810 automated chemistry analyzer (Beckman Coulter).

Results

None of the tested PG concentrations designed to mimic physiological levels expected with e-cigarette use (0, 5, 10, 15, 20, 25, and 30 mg/dL) caused falsely positive quantitative ETG results, defined as values above the ETG limit of quantitation (LOQ) of 5 mg/dL. At these low concentrations, interference patterns neither were observed in reaction monitors, nor were instrument interference error flags triggered. As concentrations of PG approached 50 mg/dL, abnormal curve appearances were observed in the instrument reaction monitor, although this neither resulted in interference error flags nor false detection of ETG. However, as PG concentrations approached and exceeded ≥100 mg/dL, both interference flags and falsely positive ETG results were observed.

Conclusion

Results from the present experiments demonstrate that serum concentrations of PG expected with e-cigarette use did not cause interference with enzymatic ethylene glycol detection in this assay.
Automated Calculation of Turnaround Times Using Data Warehouses for Publication in Online Test Menus
Authors: Simonson Paul , Hoffman Noah , Mathias Patrick
Published: September 2019

Awareness of turnaround times (TATs) is important for time-sensitive clinical decision making and setting expectations for timing communications with patients. In fact, a significant number of clinicians consider the TAT as the most important measure of laboratory quality (PMID 24839360). TAT definitions vary considerably, ranging from rough estimates to more precisely defined statistics based on historical data, the former more typically provided in online test catalogs and the latter usually reserved for a limited number of tests for internal quality assurance and improvement. As data warehousing of laboratory information is becoming more commonplace, calculation of TATs can more easily be performed. Our goal in this project was to develop a generalized, automated approach to calculate expected TATs for publication in our online test catalog. We began by defining TAT as the amount of time between receipt of the specimen by the laboratory and the reporting of the finalized result in the laboratory information system (using specimen collection time increased median TATs by 21 minutes). The TAT of an order set/panel of tests was calculated using the time stamp of the last finalized test result of the set. For development purposes, a subset of warehouse data corresponding to all tests within a 1-month period was selected (170,363 accession numbers, 2,206,311 total test results). All accessions with “add-on requests” (tests requested by physicians using specimens collected for prior tests) were removed. The median and 90th percentile TATs were calculated using R for each test and panel, as these values are commonly used in quality assurance programs and are thought to be intuitively easy to understand in a test menu. Values were not reported if fewer than 100 test results were available for a given test. A summary table and TAT distribution graphs are provided for review by laboratory personnel before being published in the online test menu. Categorizing tests ordered “stat” versus “nonstat” generated some interesting insights, the most obvious being that, for the majority of our tests, the difference in median TATs is very small. In some cases, however, the median stat TAT was actually longer (eg, hemoglobin A1C), which might be due to blood draws at irregular hours by phlebotomists, then batching of samples with specimens collected later at regular blood draw times, suggesting that elimination of the stat option was appropriate. Distinct advantages of using data warehouses to calculate TATs include being able to provide clinicians with data-driven estimates of expected lab result TATs. Such data can also be used for internal quality assurance purposes. Areas of further development include developing a more rigorous mathematical theory of the precision associated with our median and 90th percentile TATs and tuning the frequency of data query and TAT recalculation.
Reduction in False-Positive PF4/Heparin Antibody Testing Following Implementation of a Latex Immunoturbidimetric Assay
Authors: Gangahar Chiraag , Webber Daniel , Jackups Ronald
Published: September 2019

Background

Heparin-induced thrombocytopenia (HIT) is a life-threatening complication of exposure to heparin that is caused by autoantibodies against heparin-PF4 complexes. We recently changed our in-house HIT screening platform from a manual, daily batched ELISA (Stago-Asserochrom HPIA Immunoassay) to an automated, on-demand latex immunoturbidimetric assay (LIA, HemosIL HIT-Ab) and have also implemented a reflex from a positive LIA result to the confirmatory serotonin release assay (SRA). We compared the two methods in terms of utilization, test performance, and turnaround time.

Methods

Data were collected retrospectively from a 7-month period before (June-December 2017) and after (June-December 2018) implementation of the HemosIL LIA in the clinical laboratory at a large academic institution. This study includes consecutive test results from adults (median age: 64 years, range: 19-98 years) seen at our 1,300-bed main hospital. Test utilization, turnaround time (sample receipt to verification), and test performance characteristics were compared between the two methods. Repeat testing was excluded from the analysis. Samples with a positive result on the HemosIL LIA were reflexed to a serotonin release assay (SRA), performed at a large reference laboratory, whereas samples tested with the earlier ELISA assay were referred for SRA testing based upon clinical judgment. When performed, SRA was considered the gold standard for diagnosis of HIT.

Results

During the 7 months before and after switching methods, there were 109 of 594 (18.4%) positive ELISA results and 45 of 523 (8.6%) positive LIA results. Only 90 of 109 (82%) of the positive results from the ELISA HIT Ab test were sent out by clinicians for SRA testing, whereas 45 of 45 (100%) of the positive results from LIA testing were reflexed to SRA per protocol. Although fewer LIA tests were sent out for SRA testing, there were an equal number of SRA-confirmed cases of HIT with the ELISA (PPV: 16/90 [17.8%]) and LIA methods (PPV: 16/45 [35.6%]), resulting in a high positive predictive value (PPV) with the newly implemented method. Not only was the PPV higher with the LIA test, but it had a significantly shorter mean turnaround time of 96 minutes compared to the ELISA TAT of 1,234 minutes (P < .0001).

Conclusions

With the new testing protocol, patients received results faster (average 96-minute TAT) and had fewer false-positive results (74/594 pre vs 29/523 post), with no apparent reduction in detection of true-positive cases of HIT (16/594 pre vs 16/523 post).
PT and aPTT Are Not Predictors of Thromboembolic Events
Authors: Shervinrad Mohammadreza , Tormey Christopher , Siddon Alexa
Published: September 2019

Background

VTEs remain a common occurrence in both ambulatory and hospitalized patients, with over 900,000 VTEs in the United States annually, of which almost 300,000 are fatal. Besides the factors of Virchow’s triad (trauma, stasis, and endothelial activation), it has been recognized that intrinsic abnormalities of the clotting cascade may lead to a predisposition to clot. Recently, it has been noted that elevated levels of normal procoagulant factors can predispose to hypercoagulability and have been associated with an increase in VTEs; also, a shortened time in the aPTT test has been associated with an increase in “idiopathic” VTEs.

One of the foremost goals of thrombosis research is to develop simple and inexpensive test systems to estimate the likelihood for a future VTE. A strong association between an increased risk for VTE and a short activated partial thromboplastin time (APTT) was found in several studies.

The aim of our study is to evaluate relationship between shortened PT and aPTT with thrombotic events in broad random population; we conducted a retrospective analysis of aPTT and PT at our institution. Using a computer system, results from our facility’s central laboratory were reviewed for PT and aPTT blood samples that were collected from our hospital and surrounding afﬁliated clinics over a 5-year period. Our population was composed of retired service members and their dependents (ie, spouse and children). The samples included both outpatients and hospitalized patients. A short aPTT and PT was deﬁned as aPTT and PT less than the lower limit of normal in our laboratory.

Results

We reviewed results from 239 activated partial thromboplastin times and prothrombin time during the study period. Nine percent of our patients were female and 91% were male. The means of age, aPTT, PT, and INR of patients were 58.87, 30.79, 10.01, and 0.89, respectively. We did not find any history of thromboembolic events in our patient population with shortened PT and aPTT.

Discussion

Shortened aPTT and PT are more and more being known as a potential risk factors for developing VTEs. Many studies showed shortened aPTT and PT are associated with thromboembolic events. To the best of our knowledge, this is the first study that has shown there is no relationship between shortened aPTT and PT and thromboembolic events.

To evaluate whether a shortened aPTT and PT represent an increased risk of VTEs, we would need to include patient clinical factors. Additionally, evaluating for increased levels of factors II, VIII, IX, XI, and ﬁbrinogen and factor VII would also be worthful since increased levels of any of these can shorten the aPTT and PT. Following a patient population prospectively would enable us to characterize the natural history of patients with shortened aPTT and PT.
Endocervical Adenocarcinoma With Skip Lesion in a Fundal Endometrial Polyp Mimicking Endometrioid Adenocarcinoma Arising From Endometrial Polyp
Authors: Aakash Nfn , Murzabdillaeva Albina , Lin Mei , Zhang Songlin
Published: September 2019

Human papillomavirus–related adenocarcinomas account for approximately 20% of all cervical cancers. Most of them arise in the transformation zone but may be found exclusively in endocervical canal. Contiguous spread into the lower uterine segment is known to occur, but finding a “skip” lesion in a fundal endometrial polyp poses an interesting pathologic conundrum. We present a case of a 57-year-old woman with a history of postcoital bleeding and abnormal cervical smear. Cervical exam showed a 2-cm exophytic mass on anterior cervix. Biopsy revealed invasive endocervical adenocarcinoma. Patient underwent radical hysterectomy. Gross examination revealed large cervical mass without involvement of low uterine segment and a benign-appearing small uterine fundal polyp. Microscopic examination confirmed the deeply invasive endocervical adenocarcinoma, and the benign-appearing endometrial polyp had similar atypical glands on the polyp surface and admixed with benign endometrial glands. Both cervical tumor and the carcinoma involving endometrial polyp demonstrated identical immunohistochemistry showing diffuse positive p16 and CEA(m) and negative for ER and vimentin. The authors report a rare case of endocervical adenocarcinoma with skip lesion in the endometrial fundal polyp, and rare cases with skip lesion in the fallopian tubes from endocervical adenocarcinoma have been reported in the literature. High clinical suspicion and ancillary immunohistochemistry are necessary to differentiate the lesion from endometrioid or papillary carcinoma arising from endometrial polyp.
Multiorgan Sarcoidosis-Like Reaction Mimicking Metastatic Disease in Microsatellite Instability-High Melanoma Patient Treated With Checkpoint Inhibitor Nivolumab
Authors: Jagannathan Geetha , Bernabeu Belen Quereda , Tuluc Madalina
Published: September 2019

Introduction

Melanomas and tumors with high microsatellite instability (MSI-H) carry heavy tumor mutation burden. The resulting neo-antigens elicit a host immune response in an attempt to contain the tumor. Immune checkpoint pathways (PD-1/PD-L1 and CTLA-4) downregulate T-cell activation, limiting damage to healthy tissue during physiologic immune response. Tumors take advantage of these pathways as a mechanism of immune escape. Checkpoint inhibitors (CPIs) such as Nivolumab (PD-1 inhibitor) and others inhibit these pathways, allowing immune-mediated destruction of tumor cells. Unsurprisingly, these drugs are associated with a spectrum of immune-related adverse effects (irAEs). We report a case of a patient with MSI-H metastatic melanoma who developed an unusual irAE during nivolumab immunotherapy.

Case Report

A 35-year-old man with a history of ocular melanoma presented with omental metastasis. The metastatic focus was MSI-H by NGS with deficient MSH1/PMS2 by immunohistochemistry. Nivolumab therapy was initiated. Initial follow-up imaging showed complete response. At 7 months, clinical exam and PET imaging showed new skin nodules, hypermetabolic mediastinal lymphadenopathy, and a hypermetabolic vertebral (L3) lesion concerning for disease progression. Biopsies from all three sites revealed sarcoidosis-like granulomatous inflammation. Special stains for fungus and mycobacteria and microbial cultures were negative. The patient was asymptomatic and did not require antisarcoid treatment. He remains in remission for melanoma.

Conclusion

Sarcoidosis-like reaction is a rare irAE of CPIs that can clinically/radiologically mimic metastatic disease. Bone involvement as seen in our patient is extremely rare. Importantly, biopsy/histopathological examination is required to rule out disease progression. Infectious causes for granulomas should be excluded as these patients are immunocompromised. Evidence suggests that irAE with CPIs may be associated with better outcomes. MSI-H status is infrequent in melanomas but is hypothesized to be a predictive biomarker for CPI response. Our patient is predicted to do well.
Adequacy of Tissue Sampling in Breast Specimen
Authors: Khawar Sidrah , Hamza Ameer , Alrajjal Ahmed , Salehi Sajad , Qu Hong
Published: September 2019

Objectives

Due to inadequate sampling concerns, pathologists frequently request additional tissue sections (ie, more tissue sections in addition to initial representative sections) in breast specimens. This study explores the effectiveness of the additional tissue sections in the breast specimens.

Methods

Breast specimens received in our institution on which additional tissue sections were requested were included in the study. Pathology reports and glass slides for these specimens were reviewed. Additional tissue sections were considered effective if they changed the final diagnosis altogether, changed a benign entity to borderline or malignant category, changed pathologic tumor stage, changed margin status, changed tumor focality, or if lymphovascular invasion was identified.

Results

A total of 325 specimens were identified. Of these, 98 (30.1%) were benign while 224 (68.9%) were malignant. Among malignant cases, 53 (23.7%) had neoadjuvant therapy. Overall mean initial representative sections submitted were 15.1 ± 8.7 while additional tissue sections were 10.7 ± 8.0. There was no difference in additional sections submitted for benign versus malignant cases (9.8 ± 7.7 vs 11.2 ± 8.0; P = .96). Also there was no difference in additional sections submitted for cases with neoadjuvant therapy versus those without any therapy (10.4 ± 6.9 vs 11.6 ± 8.4; P = .36). Twenty-five (7.7%) specimens benefited from submission of additional tissue sections. All 25 cases were malignant; 7 had neoadjuvant therapy while 18 did not. No tumor was identified in initial representative sections in 6 cases, pathologic tumor stage was changed in 12 cases, margin status changed in 2 cases, tumor focality changed in 4 cases, and an extra positive lymph node was identified in 1 case.

Conclusion

Additional tissue sections contributed to final diagnosis in 7.7% cases. Surgical pathology breast specimens require specialized handling and thorough sampling for accurate diagnosis and staging.
Maxillary Ameloblastoma With Pulmonary Metastasis: Management Challenges in Resource-Limited Setting—A Case Report
Authors: Mlaga Salvatory , Brown Tupokigwe , Malango Atuganile , Sohal Karpal , Vuhahula Edda
Published: September 2019

Introduction: Ameloblastoma is a benign odontogenic tumor that may exhibit aggressive biological behavior with local recurrence. It more commonly occurs in the mandible than the maxilla. Rarely, ameloblastoma may metastasize to local regional lymph nodes and/or distant organs, notably lungs, brain, and skin, hence the term metastasizing (malignant) ameloblastoma (MA), in keeping with the WHO definition of MA in its recent classification of odontogenic tumors (2017). Here, we report a rare case of maxillary ameloblastoma that metastasized to the lungs in a 22-year-old African male. Radiological evaluation revealed a massive maxillary tumor that had a local extension to the brain. Chest x-ray and CT scan pointed out metastatic mass to the lungs. Histology of the tumor mass revealed it to be follicular ameloblastoma with aggressive behavior shown by abnormal mitoses and further characterization by immunohistochemical reactivity to Ki-67. CT-guided fine-needle aspiration cytology of the lung mass showed microscopic features of ameloblastoma bearing resemblance to the primary jaw tumor. Socioeconomic constraints on the patient’s side and limited medical resources necessitated planning that served the purpose of proper diagnosis and treatment options. In this paper, we discuss the clinical behavior, differential diagnosis, and challenges faced by clinicians in managing metastatic ameloblastoma in a resource-limited setting. Conclusively, reporting this rare case and first of its kind in our locality raises awareness, hence reducing misdiagnosis of primary tumor in sites other than the jaw, while also sharing our experience of managing metastasizing ameloblastoma in a resource-limited setting to the larger medical community.
Uterine Tumors Resembling Sex Cord Stromal Tumors: A Distinctive Entity to Consider in Evaluating the Adenosarcoma
Authors: Sameeta Fnu , Haque Monira , Haleema Sadia , Roveda Kelly , Mneimneh Wadad
Published: September 2019

Objectives

Uterine tumors resembling ovarian sex cord tumors (UTROSCTs) are rare neoplasms. Approximately 60 cases of UTROSCT are reported in the literature.

Methods

A 53-year-old female was referred to our institution for definitive surgery following an endometrial biopsy diagnosed as adenosarcoma of the uterus. Her history and physical examination were unremarkable. CT scan showed no evidence of metastatic disease. She underwent a staging hysterectomy with bilateral salpingo-oophorectomy. Grossly, a polypoid mass was seen in the uterine cavity with extension into the myometrium.

Results

Histologic examination of the mass revealed anastomosing cords and nests of epithelioid cells with bland ovoid nuclei, inconspicuous nucleoli, and scant eosinophilic cytoplasm, embedded within a fibromuscular stroma, resembling sex cord stromal tumors of the ovary. Cellular atypia, necrosis, or mitotic activity were not noted. Immunohistochemically, the neoplastic cells expressed cytokeratin AE1/AE3, WT1, CD99, calretinin, inhibin, melan A, and estrogen receptor. These features were consistent with the diagnosis of UTROSCT.

Conclusion

UTROSCT accounts for less than 0.5% of all uterine malignancies. These tumors arise in perimenopausal females and historically follow a benign course. Although their histomorphologic and polyphenotypic immunoprofile such as sex cord, epithelial, and myoid seems to be unique among uterine mesenchymal neoplasms and can be diagnostically useful, their diagnosis can be confused with more common tumors such as low-grade stromal sarcomas, carcinosarcoma, and adenosarcoma, especially in superficial endometrial biopsies. As in our case, the initial endometrial biopsy, being superficial, revealed endometrial polyp with rare component of sex cord stromal elements, misleading to the diagnosis of adenosarcoma. However, microscopic examination of the hysterectomy specimen revealed the bulk of the sex cord tumor elements within the myometrium, which was not accessible to biopsy. This case, apart from being rare, also highlights the importance of considering this tumor in the differential diagnosis in superficial endometrial biopsies.
Ameloblastic Fibroma: A Rare Entity of the Mandible
Authors: Sakshi Sakshi , Kuklani Riya
Published: September 2019

Ameloblastic fibroma (AF) is an uncommon benign odontogenic true mixed tumor comprising neoplastic epithelial and mesenchymal tissues. It constitutes only approximately 2% of odontogenic tumors and is defined by the World Health Organization (WHO) as “neoplasm composed of proliferating odontogenic epithelium embedded in cellular ectomesenchymal tissue that resembles the dental papilla and epithelial strands and varying degrees of inductive changes and dental hard tissue formation.” The tumor is most common in the first and second decades of life with a slight male predilection. The most common site is the posterior mandible and 75% of the cases are associated with an unerupted tooth. Radiologically, it may present as a unilocular or multilocular lesion. The treatment of choice could range from aggressive curettage for a small unilocular lesion to wide local excision for a large multilocular lesion. The prognosis is usually good, with a recurrence rate of approximately 20%.

Here we present a case of a 13-year-old male with a multilocular expansile cystic lesion associated with nonvital tooth 20 and tooth 21 since 2016. An incisional biopsy was performed and the microscopic examination revealed small masses of cellular fibrous and myxoid connective tissue containing long narrow cords of odontogenic epithelium. The odontogenic islands were basophilic with peripheral nuclear palisading of the basal cell layer, consistent with an ameloblastic fibroma. Complete curettage was performed and the patient is being followed up with no recurrence since 2 months.

We reviewed the literature with regard to clinical, histopathological, and radiological findings and reached the conclusion that malignant transformation of ameloblastic fibroma into ameloblastic fibrosarcoma is uncommon but well documented. AF needs to be distinguished from ameloblastoma and ameloblastic fibrosarcoma, since these two tumors can be locally invasive and have greater potential for recurrence than ameloblastic fibroma.
Rare Case of Metastatic Ovarian Clear Cell Carcinoma With an In Vitro Fertilization Pregnancy
Authors: Inamdar Arati , Loo Abraham
Published: September 2019

The risk of ovarian malignancy is rare in pregnancy with a reported incidence of approximately 1 in 50,000. Ovarian clear cell carcinoma (OCCC) accounts for 5% to 10% of all ovarian carcinomas with mean age of 50 to 55 years and is often associated with endometriosis. We present a case of 38-year-old G2P1 Asian female with an in vitro fertilization pregnancy and history of endometriosis who presented with the right adnexal mass. The transvaginal ultrasound performed during the early pregnancy was suggestive of endometrioma or desmoid tumor. At 32 weeks, the patient presented to the emergency department with preeclampsia and severe headache. An emergency cesarean section was performed due to worsening of the patient’s condition. An ovarian mass arising from the right ovary and with a friable and hemorrhagic internal surface was excised, which weighed 63 g and measured 14.0 × 10.5 × 3.0 cm. Its external surface was smooth, hemorrhagic, but without any excrescences. The serial sectioning revealed multiple cystic lesions filled with necrotic material overall occupying 80% of the mass. Microscopically, the viable ovarian tissue demonstrated tubulocystic/papillary architecture lined by hyperchromatic hobnail cells along with focal areas of solid sheets of tumor cells displaying clear cytoplasm. Immunohistochemical stains for Wilm’s tumor 1 and p53 were negative while positive for PAX8. These findings were indicative of OCCC without overexpression of wild-type p53. The PET scan performed few weeks after delivery showed widespread metastasis. We present a unique case of metastatic OCCC removed at the time of cesarean section in the late-preterm period. Our case not only emphasizes the need for definitive treatment option for endometriosis but also a close imaging surveillance of all masses diagnosed during pregnancy in women with risk factors such as endometriosis and Asian ethnicity. Furthermore, our study advocates the need for possible guidelines for management of such rare cases.
Ovarian Endometrioid Borderline Tumor With Massive Squamous Differentiation: A Case Report
Authors: Khedr Maha , Chen Adam , Liu Weiguo
Published: September 2019

Introduction

Ovarian endometrioid borderline tumor is uncommon and constitutes only 0.2% of all epithelial ovarian tumors. Many patients have associated endometriosis, and coexisting endometrial hyperplasia and/or carcinoma is commonly present.

Methods

Here we report an ovarian endometrioid borderline tumor with massive squamous differentiation. The peculiar histologic features made the diagnosis of this uncommon entity even more challenging. The patient was a 43-year-old female with a history of chronic pelvic pain. A pelvic ultrasound showed a 7.9-cm complex solid and cystic right ovarian mass and a hypoechoic left ovarian mass. Patient underwent a hysterectomy with bilateral salpingo-oophorectomy. Grossly, the right ovary showed a 2.5-cm solid and cystic lesion with focal papillary inner surface. Microscopic examination showed uterine adenomyosis with serosal endometriosis. The left ovary showed endometriosis with atypical hyperplasia. Initial representative sections from the right ovary demonstrated extensive squamous cell proliferation with papillary architecture. The squamous cells had pink or clear cytoplasm, intracellular bridging, irregular nuclei, and prominent nucleoli. Immunostains confirmed the squamous differentiation. Based on the histologic features and immunophenotype, a well-differentiated squamous cell carcinoma was considered one of the differential diagnoses. However, further examination of additional sections from entirely submitted lesion showed some areas with classic morphologic features of endometriosis with atypical hyperplasia. With the consideration of clinical-pathological correlations, a diagnosis of endometrioid papillary cystic borderline tumor with massive squamous differentiation was rendered and close follow-up was recommended. The patient was doing well at 4-month postoperative follow-up.

Conclusion

We present this case to emphasize (1) extensive squamous metaplasia arising in endometriosis can make the rendering of a definitive diagnosis challenging. (2) Primary squamous cell carcinoma of ovary is very rare. (3) Careful sampling is very important for achieving a precise pathologic diagnosis.
Low-Grade Fibromyxoid Sarcoma: A Rare Case in an Unusual Location
Authors: Perez Diandra , El-Zammar Ola , Naous Rana
Published: September 2019

Introduction

Low-grade fibromyxoid sarcoma, also known as Evans tumor, is a low-grade sarcoma that most commonly arises in the deep soft tissue of the proximal extremities or trunk in young adults. It is very rare in the viscera as a primary site with only a few cases reported in the literature. Here we present a case of Evans tumor occurring in an unusual and rarely reported location: the mediastinum.

Method

A 32-year-old male presented with history of persistent cough, and subsequent imaging revealed a left diaphragmatic tumor measuring around 11 cm with associated chest wall implants. Grossly, the tumor was well circumscribed, arising from the parietal pleura with attachment to both lung and diaphragm and focally involving visceral pleura with no extension into the underlying lung parenchyma. Histologically, the tumor was composed of uniform and bland-appearing spindle cells interspersed among large areas of hyalinized rosettes, so-called giant rosettes. By immunohistochemistry, the tumor was positive for EMA, bcl-2, TLE-1, and MUC-4 and negative for STAT-6, ruling out solitary fibrous tumor. FISH for SYT gene rearrangement was performed and was negative, ruling out synovial sarcoma. Given the overall morphology and the phenotype, the final diagnosis was low-grade fibromyxoid sarcoma with giant collagen rosettes (also known as hyalinizing spindle cell tumor with giant rosettes).

Conclusion

Mediastinal low-grade fibromyxoid sarcoma is a rare entity that should be considered in the differential diagnosis of visceral soft tissue tumors. Pathologic examination and a thorough immunohistochemical and molecular workup play a vital role in establishing this rare and challenging diagnosis.
Clinicopathologic Characterization of Early Onset Endoscopically Unresectable Adenomas (EOEUAs)
Authors: Saade Rayan , Fu Zhiyan , Lee Hwajeong
Published: September 2019

Objectives

Early onset colorectal carcinoma (CRC), defined as CRC detected in patients ≤50 years old, are frequently located in the distal colorectum and are associated with risk factors that are common to adenoma. We examined the risk factors, pathologic features, and clinical implications associated with EOEUA.

Methods

A retrospective cohort of 154 patients with EOEUA was retrieved. Clinical data were obtained from electronic medical records. A minimum of 12 months follow-up was considered valid follow-up data. Archived pathology slides were evaluated for the presence of high-grade dysplasia (HGD) and Paneth cells (PCs) in adenomatous crypts. Additional pathologic data were retrieved from pathology reports. The patients were stratified into age >50 vs ≤50 years. Fisher’s exact test and Student t test were performed when indicated (P < .05 was considered statistically significant).

Results

In the ≤50-year group, EOEUAs were common in the rectosigmoid colon compared to >50-year group (41.2% vs 16.8%; P = .025). The association with diabetes, obesity, and alcohol consumption was similar in the two groups, whereas the incidences of hypertension, hyperlipidemia, and smoking were significantly lower in the ≤50-year group. No significant differences in gender distribution, adenoma size, HGD, PC presence, and future adenoma burden were observed between the two groups.

Conclusion

The association with established risk factors of adenoma to include diabetes, obesity, and alcohol consumption in EOEUA is comparable to that of older patients. In contrast, hypertension, hyperlipidemia, and smoking do not appear to be associated with an increased risk of endoscopically unresectable adenoma in this age group. Similar to early onset CRC, EOEUAs are common in the rectosigmoid, supporting the premise that flexible sigmoidoscopy may be a viable screening alternative in this age group, especially for patients with diabetes, obesity, or alcohol history.
Two Cases of Plexiform Angiomyxoid Myofibroblastic Tumor (PAMT) of Gastrointestinal (GI) Tract: One With 8-Year Follow-up, One in Distal Jejunum
Authors: Arslan Mustafa Erdem , Jennings Timothy , Li Hua , Lee Edward , Nigam Ankesh , Lee Hwajeong
Published: September 2019

Objectives

PAMT is an exceedingly rare mesenchymal tumor of the gastric antrum that was first described in 2007. Although likely benign, long-term follow-up is limited due to its recent description and rarity. In small bowel, only four cases of PAMT have been reported, two in duodenum and two in proximal jejunum.

Methods

(A) A 16-year-old female presented with GI bleeding and gastric outlet obstruction. Imaging studies suggested a gastrointestinal stromal tumor (GIST) arising in duodenum. An open biopsy revealed a bland spindle cell neoplasm. Resection of the tumor was performed. (B) A 68-year-old male presented with an incidental mesenteric mass on imaging during hematuria workup. He underwent surgical resection of the mass to exclude a GIST.

Results

Case A was a 15.0-cm mass arising in gastric antrum, and case B was an 8.0-cm mass arising in antimesenteric side of distal jejunum. Both tumors showed multinodular plexiform growth pattern and foci of cystic changes, with a proliferation of bland spindle cells in a prominent myxoid matrix. Numerous vascular structures were noted without tumor necrosis, nuclear atypia, or mitotic activity. The lesional cells were positive for actin and negative for desmin. The lesional cells were negative for other markers including cytokeratin, CD34, CD117, DOG-1, S-100, and PDGFRA (case B). Both masses were based in the subserosa with focal extension to the muscularis propria in case A. Patient A was followed up for 8 years with no evidence of disease. Patient B was lost to follow-up.

Conclusion

While clinical presentation and imaging finding of PAMT overlap with GIST, PAMT appears to be more indolent. PAMT of distal jejunum has not been previously reported. Small bowel PAMT is much less common than gastric PAMT but can involve variable segments. PAMT may be underdiagnosed.
Refractory Duodenal Ulcer and Upper Gastrointestinal Bleeding Following Yttrium-90 Transarterial Radioembolization
Authors: Dong Yimin , Sun Belinda , Bhattacharyya Achyut
Published: September 2019

Transarterial radioembolization (TARE) with Yttrium-90 (Y90) is widely used for management of primary or secondary liver malignancies that are not amenable to surgery. Nevertheless, complications of Y90 treatment, including rare events of gastric and duodenal ulceration and cirrhosis, may be critical. Here we report a case of a 79-year-old man who received Y90 TARE for metastatic neuroendocrine tumor to liver from bronchial primary and developed multiple iatrogenic GI complications. Following TARE, a gastroduodenal artery (GDA) coil was instituted to prevent migration of Y90 beads. One year following TARE, the patient presented with cirrhosis of unknown etiology, thrombocytopenia, and multiple episodes of upper gastrointestinal bleeding (UGB). Endoscopy demonstrated GDA coil eroding into duodenum through mucosal ulcer base. Three years following TARE, an emergent esophagogastroduodenoscopy was performed due to upper GI bleeding. The histopathologic examination of stomach and duodenum revealed mucosal hemorrhage, submucosal and serosal fibrosis, and chronic inflammation associated with Y90 intravascular beads. A cholecystectomy was performed for fibrotic gallbladder that showed chronic cholecystitis with cholelithiasis and intravascular Y90 beads. GDA coil was removed, which showed attached food material, bacterial colonies, and Candida spp. A subsequent liver biopsy showed previously treated area with Y90 beads, inflammation, and fibrosis in adjacent parenchyma.

Due to rich vascularity, TARE is considered an ideal treatment choice for neuroendocrine tumor. GI ulceration is the most common complication, which occurs in less than 4% patients, and usually can be managed with proton pump inhibitor. A surgery should be performed upon failure of medical treatment. Radiation-associated fibrosis has been reported mainly in hepatocellular carcinoma patients, who often have cirrhosis before the procedure. To conclude, this is the first case report of Y90 TARE complications in multiple GI organs in a metastatic NET patient.
Utility of Additional Tissue Sections in Genitourinary Specimen
Authors: Hamza Ameer , Alrajjal Ahmed , Salehi Sajad , Qu Hong
Published: September 2019

Objectives

Adequate sampling of surgical pathology specimens is vital to arriving at the correct pathologic diagnosis. To minimize sampling error and to establish an accurate pathologic diagnosis, pathologists use recuts and/or additional tissue sections (ie, more tissue sections in addition to initial representative sections). This study explores the utility of additional tissue sections in genitourinary specimen.

Methods

Following institutional review board approval, we did a retrospective analysis of genitourinary pathology specimens received in our institution from 2012 to 2016 on which additional tissue sections were requested. A total of 59 specimens were identified.

Results

Among total of 59 specimens, 23 (39%) were nephrectomy, 14 (23.7%) were orchiectomy, 13 (22%) were cystectomy/cystoprostatectomy, and 9 (15.3%) were adrenalectomy. Mean initial representative sections were 12.4 ± 4.1 in nephrectomy, 29.7 ± 13.7 in cystectomy/cystoprostatectomy, 9.1 ± 5.0 in orchiectomy, and 7.2 ± 3.4 in adrenalectomy specimens. Mean additional tissue sections were 9.0 ± 8.1 in nephrectomy, 19.5 ± 15.1 in cystectomy/cystoprostatectomy, 10.4 ± 7.3 in orchiectomy, and 10.6 ± 8.7 in adrenalectomy specimens. Significantly higher number of initial representative sections (P < .0001) and additional tissue sections (P = .02) were submitted in cystectomy/cystoprostatectomy specimens as compared to other specimens. Additional tissue sections proved useful in two nephrectomy specimens whereby renal vein invasion was identified; however, staging remained unchanged, and in one cystprostatectomy specimen whereby no residual was initially identified while on additional sampling, a focus of tumor was identified, changing the pathologic stage from ypT0 to ypT1.

Conclusion

Renal vein is frequently undersampled in nephrectomy specimens. Cystectomy and cystoprostatectomy specimens are complex and require thorough sampling. If initial representative sections are deemed inadequate, additional tissue sections should be submitted to arrive at an accurate diagnosis.
Lupus Enteritis, a Severe and Potentially Fatal Complication of Systemic Lupus Erythematosus
Authors: Meawad Hany , Kobalka Andrew , Alastal Yaseen , Koltz Brooke
Published: September 2019

Objectives

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease that can show wide manifestations in many organs. The gastrointestinal tract (GI) is commonly affected in SLE; symptoms are often related to the side effect of medications or to infections. One rare GI complication of SLE is lupus enteritis, a complex of manifestations including intestinal vasculitis and enteric ischemia, which presents with vague symptoms of severe abdominal pain, nausea, vomiting, and diarrhea.

Methods

We present the case of a 25-year-old female who was admitted to the hospital with complaints of abdominal pain, vomiting, diarrhea, and a history of SLE. Complicating the patient’s clinical picture and diagnosis was gastrointestinal bleeding requiring multiple blood product transfusions secondary to bleeding Meckel’s diverticulum, lupus flare, and positive stool culture for campylobacter antigen. Repeated upper and lower GI endoscopies with biopsy failed to identify the exact cause of bleeding and GI symptoms; the patient underwent exploratory laparotomy with right hemicolectomy to control bleeding. Microscopic examination revealed marked small vessel acute vasculitis consistent with lupus enteritis, ischemic enteritis, and Meckel’s diverticulum with gastric heterotopia.

Results

Our patient was subsequently aggressively treated; however, she developed further associated complications and died.

Conclusion

The pathologic diagnosis of lupus enteritis is challenging due to the nonspecific clinical symptoms and paucity of pathologic findings on most biopsy specimens. Lupus enteritis must be considered in the differential diagnosis of severe abdominal pain in lupus patients to aid in early diagnosis and treatment as this condition could be severe and potentially fatal.
Contemporary International Society for Urological Pathology Grade Group System 2014: A 2-Year Retrospective Review of Prostate Cancers Diagnosed in Lagos University Teaching Hospital
Authors: Odukoya Lateef , Adebayo Luqman , Anunobi Charles
Published: September 2019

Introduction

Prostate cancer is the second most frequent cancer worldwide. It is the commonest cancer among men in Nigeria. Gleason grading and scoring system constitute the most useful prognostic indicator in prostate cancer diagnosis and management. Over the years, it has gone through important modifications. The most recent of these changes was in 2014 by the International Society for Urological Pathology (ISUP). The WHO adopted the new grading system in 2016. It was not adopted as part of routine reporting of prostate cancer biopsies in Lagos University Teaching Hospital (LUTH) until 2017. The aim of this study is to categorize prostate cancers diagnosed in LUTH based on the grade group system and determine the pattern of prognostic distribution of prostate cancer cases since its adoption.

Methods

This is a descriptive study; data were retrieved from the histopathologic records of the Department of Anatomic Pathology. Prostate cancers cases diagnosed between 2017 and 2018 were stratified using the WHO-adopted 2014 ISUP grading system.

Results

During the 2 years, 93 cases of prostate cancers were diagnosed by core needle biopsies. Overall, mean age of cases was 69.85 years (SD 8.49, median = 70 years). Nearly 39% of the 93 cases were ISUP grade group 5 and about 24% were ISUP grade group 4. Together ISUP grade groups 3, 4, and 5 constituted 76.35% of all cases of prostate cancers. There was no statistically significant association between ISUP grade group and age (P = .266). Perineural invasion was present in 35.82% of cases. Sixty-seven percent of these were ISUP grade group 5.

Conclusion

The data from this study suggest that high-grade cancers, particularly those of the ISUP grade group 5, are the most frequently diagnosed prostate cancers in our institution. Further studies are required to document biochemical recurrence-free progression and survival among our patients.
Intraconal Metastasis Leading to the Diagnosis of Hepatocellular Carcinoma
Authors: Madabhavi Irappa , Mallikarjuna Vinay Sakaleshpura , Sandeep K S , Sarkar Malay , Shah Mansi , Modi Mitul
Published: September 2019

Hepatocellular carcinoma (HCC) is the most common malignant cancer of the liver, with intrahepatic and extrahepatic metastasis accounting for 50% to 75% of HCC cases. Lung and regional lymph nodes are the most common sites of metastasis; however, bone, skin, and adrenal glands are rare sites. Orbital metastasis and intracranial invasion are extremely rare and believed to occur in 2% to 3% of patients with systemic cancer. Here, we present a case report of a 72-year-old man evaluated for progressive painful proptosis of the left eye with weight loss, loss of appetite, and generalized weakness of 3 months duration. Physical examination showed a 5.5 × 3.5-cm, firm, mildly tender mass in the upper and lateral part of the left eye with proptosis and hepatomegaly with no ascites. Laboratory investigations were within normal limits except for positive hepatitis B surface antigen and HBV-DNA. CT scan of the head and neck revealed a 5.7 × 4.7-cm heterogeneously enhancing irregular extraconal mass seen in superolateral aspect of the left orbit. Abdominal CT scan showed hepatomegaly with multiple heterogeneous enhancing lesions in the liver. Fine-needle aspiration from the orbital and liver lesions showed individually scattered clusters and sheets of round to polyhedral cells with enlarged, hyperchromatic nuclei, prominent nucleoli, and abundant eosinophilic cytoplasm. Immunohistochemistry showed tumor cells strongly positive for hepatocyte paraffin 1 (HepPar 1) and CD10 but negative for TTF-1, CEA, ALK-1, LCA, vimentin, S-100, and chromogranin, consistent with the diagnosis of HCC. Patient was started on chemotherapy and showed significant improvement with decrease in the size of the liver and orbital mass. Based on the present case and review of literature published since 2009, the current study recommends that metastasis must be considered when diagnosing retrobulbar head lesions in patients with HCC, regardless of contradictory imaging findings and other clinical indicators.
Submucosal Lifting Agent ORISE Gel Remnants Histopathologically Mimic Mucin and Malignancy: A Case Series
Authors: Cypher Luke , Sun Shaoli , Forster Erin , Hoffman Brenda , Lewin David
Published: September 2019

Introduction

There were an estimated 18.1 million new cancer cases in 2018, with colon cancer being the third most common worldwide. Colon cancer development is an accumulation of mutations resulting in normal epithelial cells transforming into adenomas and then adenocarcinomas. In certain scenarios, endoscopic interventions have gained considerable momentum over invasive surgery as an alternative to manage early gastrointestinal lesions. New techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection allow for removal of large, flat sessile polyps. Successful EMR is dependent on expanding the submucosal space to create adequate lift of the polyp to facilitate tissue capture and to avoid perforation and excess bleeding. ORISE gel (Boston Scientific) is a submucosal lifting agent currently in use in the United States.

Methods

We present three cases of gastrointestinal specimens obtained using ORISE gel. Histological analysis with hematoxylin and eosin revealed submucosal amorphous deposits that appeared to be mucin. Due to the concern for malignancy, additional stains were performed, including periodic acid–Schiff with diastase digestion (DPAS) to identify mucin. DPAS staining for mucin was negative, indicating the mucinous-appearing amorphous material seen on hematoxylin and eosin staining was not mucin but a likely remnant ORISE gel used during EMR. Additional immunohistochemical stains for epithelial cells (cytokeratin AE1/AE3) were also performed to exclude the presence of infiltrating tumor cells.

Conclusion

These three cautionary cases reveal the importance of good communication between endoscopists and pathology. In an effort to avoid overdiagnosis and/or the usage of unnecessary additional stains, pathologists should be alerted of ORISE gel usage.