bluuebunny/crossref_metadata_2025 huggingface dataset:
PD-L1 Expression on Cell Block Preparations of Pancreatic Adenocarcinoma
Authors: Costa Victoria , Kim David , Johncilla Melanie , Goyal Abha , Rao Rema
Published: September 2019

Objectives

Programmed death-ligand 1 (PD-L1) is an emerging molecular target in anticancer therapy, most notably non–small cell lung cancers. PD-L1 expression in pancreatic adenocarcinomas (PDAs) on surgical specimens is highly variable, with 10% to 60% of tumors showing expression. PD-L1 expression in PDA on endoscopic ultrasound-guided fine needle aspirations (EUS-FNAs) has been rarely studied.

Methods

Formalin-fixed, paraffin embedded (FFPE) cell blocks (CBs) from 65 EUS-FNA samples of 55 patients, with a diagnosis of PDA, with at least 20% tumor cellularity were retrieved. The cell blocks were originally fixed in CytoRich fixative. Immunohistochemical staining (IHC) for PD-L1 was performed using the M365329-1 (22C3) clone according to the manufacturer’s approved protocol and optimized for the fixation method using appropriate controls. A combined positive score (CPS) defined per CAP guidelines as the total number of positive tumor cells and inflammatory cells as a percentage of the total number of tumor cells was assessed for each case and was grouped as <1, 1-20, or >20.

Results

Twenty-five samples (38%) from 21 patients showed immunoreactivity to PD-L1, with 21 (32%) having a CPS of <1 and four (6%) having a CPS of 1-20. Eight of these 25 samples had surgical correlates, of which concordant staining was noted in five (62.5%). Of the discordant three, decreased tumor cell sampling in the core biopsy was noted in one. Overall, 20 of 21 patients (95%) with PD-L1 immunoreactivity had disease progression with 17 (81%) associated with metastatic disease and three (14%) with locally advanced disease.

Conclusion

Immunohistochemical analysis for PD-L1 is feasible on EUS-FNA CB samples when optimized and validated for the fixation method using appropriate controls. PD-L1 expression is seen in only a minority of PDAs, albeit with a very low CPS. The potential role of PD-L1 as a prognostic marker for disease progression needs further exploration.
Where in the World Is . . . My Cytology Specimen? Using Lean Six Sigma Methodology in Specimen Management
Authors: Cardenas Deb , Walls Michelle , Williams Michelle , Gehman Mary , Armentrout Alvin , Sudor Janine , Stipe Thomas , Woodbury Sara
Published: September 2019

Introduction

An automatic signal was not in place to actively identify when a cytology specimen resulted more than 28 days from collection. The project focus was to decrease the number of specimens resulted more than 28 days and improve result cycle time to enhance safe, quality care delivery.

Methods

Annually, more than 46% of the cytology specimens processed at our academic medical center originate from our Women’s Health practice site. A Lean Six Sigma Green Belt project commenced with key stakeholders from the practice site, Cytology and Clinical Laboratory Departments. The project goal was to reduce the percentage of specimen results taking longer than 28 days from the baseline of 6.7% to ≤1.7%. Voice of the customer showed 75% of patients would be satisfied with results available within 7 days. Baseline data showed 38.6% of specimens resulted within 7 days with an improvement goal of 85%.

Lean Six Sigma methodology was employed to develop standard work. The Cytology Department implemented use of work lists in the CoPathPlus system to track specimens from accession to results. Reconciliation of cytology specimens received versus ordered was performed weekly.

Conclusions

Baseline data were compared to postprocess implementation data. Hypothesis testing compared baseline to postimplementation cycle time means showing a reduction from 11.28 to 5.15 days (P < .001). Project goal of ≤1.7% for results greater than 28 days was exceeded at 0.22%. Cycle time goal of 85% for results within 7 days was exceeded at 91.6%.

Signal presence to identify results greater than 28 days was reduced with improved cycle time for results reporting. With standard work implementation, 616 annualized labor hours and an annualized labor cost reduction of more than $19,000 resulted. The standard work developed has the capability to translate across all practice locations where cytology specimens are obtained.
Solid Variant of Serous Cystadenoma of the Pancreas, Cytology Findings
Authors: Nowroozizadeh Behdokht , Vanleer Jessica , Goreal Wamda
Published: September 2019

Introduction

Serous cystadenoma of the pancreas is the most common benign neoplasm of the pancreas, tending to have a very good prognosis and treatable by surgical excision. The solid variant of serous cystadenoma of the pancreas is a very rare subtype with only a few cases reported in recent literature, mostly in elderly females.

Case History

An asymptomatic 85-year-old woman presented with a large pancreatic mass. Endoscopic ultrasound findings were consistent with an ill-defined large isoechoic mass involving almost the entire pancreas, with no significant common bile duct dilation. Fine-needle aspiration was performed.

Results

The smears showed groups of cells with uniform nuclei, ample cytoplasm, inconspicuous nucleoli, minimal cytologic atypia, and absent mitotic activity, suggesting a benign or low-grade lesion. A solid aggregate of these cells was present in the cell block, which was positive for CK7, inhibin, and PAS. Negative staining for chromogranin, synaptophysin, and B-catenin helped exclude neuroendocrine tumors and solid pseudopapillary neoplasm. Additionally, absent staining for PAX-8, ER, PR, BRST-2, GATA-3, CK20, CDX2, Melan-A, and calretinin helped exclude other metastatic clear cell lesions.

Conclusion

Diagnosis of solid variant serous cystadenoma of the pancreas can be challenging due to nonspecific clinical symptoms and misdiagnosis as other solid pancreatic tumors. Based on the clinical, radiologic, cytologic, and immunohistochemical features, we favor a diagnosis of solid variant of serous cystadenoma. Recognition of this lesion is important because the vast majority of solid tumors in the pancreas are malignant. The differential diagnosis includes the rare primary clear-cell “sugar” tumor of the pancreas, clear cell carcinoma, clear cell islet cell tumor, and metastatic renal cell carcinoma. Therefore, the diagnosis of solid-type serous cystadenoma of the pancreas is frequently dependent on a series of immunohistochemical and molecular studies.
Adequacy and Incidence of Primary Pancreatic Cancer on Endoscopic Ultrasound-Guided Fine-Needle Aspiration (EUS-FNA) Cytology Samples: A Retrospective Review in Veteran Population at Corporal Michael J. Crescenz Veteran Affairs Medical Center (CMCVAMC)
Authors: Dalal Sharvari , Petersen Jeffrey , Jhala Darshana
Published: September 2019

Introduction

Pancreatic cancer is the one of leading causes of cancer-related deaths, accounts for 7% of cancer related deaths, and generally is diagnosed at an advanced stage. The 5-year survival rate is about 62%. There are no current screening recommendations for pancreatic cancer, so primary diagnosis is of the utmost importance. EUS modality for FNA has revolutionized the ability for the early diagnosis and staging of cancers of the gastrointestinal tract as being safe, cost-effective, minimally invasive technology to assess the pancreas. To date, there is no study in English literature assessing the adequacy for diagnosis and ancillary studies on EUS-FNA of pancreatic mass lesions in veterans. The veteran patient population is a unique cohort with different risk factors and demographics.

Methods

As a part of quality assurance project, a search was conducted to identify all EUS of pancreatic lesions performed at our hospital from February 2, 2011, to March 3, 2019. We evaluated adequacy on the cell blocks and diagnostic accuracy of EUS-FNA among all pancreatic mass lesions.

Results

Out of the total 130 EUS-FNA pancreas cases, the diagnosis was established in 127 cases (97.6%). Three cases were insufficient and total 26 cases were diagnosed as atypia, suggesting repeat FNA for definitive diagnosis. A definitive diagnosis was made in 101 cases (77.7%). Four cases were suspicious for malignancy. Malignancy/severe dysplasia was diagnosed in total 45 cases, most being primary pancreatic adenocarcinoma (41) and four with other diagnoses.

Conclusion

EUS-FNA is highly successful for procuring adequate material on the cytology samples for pancreatic lesions. EUS-FNAs for pancreatic lesions have high sensitivity and specificity for diagnosing and directing early, appropriate clinical management in veterans. The percentage of primary pancreatic adenocarcinomas out of total tumors in this veteran population is high (91.1%).
Cytologic Features of Lymphoepithelioma-Like Carcinoma Involving the Parotid: A Case Report
Authors: Chen Fei , Modi Lopa , Zamuco Ronaldo , Yee-Chang Melissa
Published: September 2019

Fine-needle aspiration biopsies (FNABs) are a common modality used in the evaluation of salivary gland neoplasms. We present the cytologic and histologic features of a rare case of lymphoepithelioma-like carcinoma (LELC) in a 40-year-old Hispanic male with a 1.0-cm painless well-circumscribed parotid mass that had been present for 8 years. FNAB smears showed cohesive groups of intermediate-sized basaloid cells with vesicular nuclei, occasional pleomorphic nuclei and prominent nucleoli, and spindled morphology. Mature lymphocytes were seen in the background, either adjacent to the atypical epithelial cells or dispersed in the background. This lymphoid background raises considerations of salivary gland neoplasms that can have prominent lymphocytic backgrounds, such as acinic cell carcinoma and, more commonly, Warthin’s tumor or metastasis involving intraparotid lymph node. Surgical resection of the parotid showed syncytial sheets of predominantly undifferentiated cells with spindled to epithelioid morphology and occasional prominent nucleoli and focal areas of squamous differentiation. The background showed dense areas of lymphocytes with germinal center formation. Immunohistochemical (IHC) stains showed positive reactivity for p63, p40, and EBV in situ hybridization (EBV ISH) in the tumor cells and negative reactivity for p16. The findings were supportive of LELC if a metastasis from the nasopharynx was excluded. A subsequent nasopharyngeal biopsy was benign. Although histologic features of LELC are well established, we identified rare case reports describing the cytomorphology in the literature. Cytopathologists should be aware of this lesion as another salivary gland neoplasm that can show lymphocytes admixed with the tumor cells and a distinct lymphoid background. The basaloid appearance and cytologic atypia should distinguish it from acinic cell carcinoma and Warthin’s tumor. However, metastatic lesions should also be considered with a distinct lymphoid background and need to be clinically excluded before establishing the diagnosis of LELC.
Training of Super Users Contributes to Productivity in Molecular Biology Laboratories in Mozambique
Authors: Assane Mariamo , Basu Debby , Landgraft Kenneth , Pinto Isabel , Adamo Noorbebi , Macave Admiro , Nhabomba Augusto , Benzane Octavia
Published: September 2019

HIV viral suppression through antiretroviral (ARV) treatment has public health benefits in potentially reducing the risk of subsequent HIV transmissions. Mozambique has adopted the World Health Organization (WHO) “Test and Start” strategy, which assumes that all people who test positive for HIV start ARV treatment immediately. In order that treatment is guided by the respective HIV viral load (VL) test results, the MOH expanded the network of VL testing laboratories. About 26 VL testing instruments are now operational in the country. Although the increase in testing platforms increased VL tests performed, problems associated with errors, failures in user maintenance, and equipment malfunctions occur frequently. Delays in resolving equipment malfunctions contributed to lower laboratory productivity in certain periods of 2018. Therefore, the MOH, in coordination with the American Society for Clinical Pathology (ASCP) and VL testing instrument manufacturers, provided targeted training for VL laboratory Super Users (SUs). The SUs are primarily composed of laboratory technicians representing all VL laboratories. Training focused on equipment maintenance, software configuration, and troubleshooting the most common instrument-related problems and errors. Following this training, the SUs worked as in-laboratory equipment supervisors, helping laboratory staff to better perform equipment maintenance procedures. Furthermore, they worked remotely with representatives and field technicians of the instrument manufacturers to resolve small problems, such as accessory replacement and adding new users to the systems, in their own laboratories. This has led to a reduction in the overall time to equipment repair, less reliance on external field technicians, and correspondingly increased overall lab productivity and workforce capacity building for VL laboratory SU.
Utility of Flow Cytometry in the Diagnostic Evaluation of Recurrent or Persistent Nodular Lymphocyte-Predominant Hodgkin Lymphoma
Authors: Gisriel Savanah , Haberichter Kristle , Huang Sara , Huang James
Published: September 2019

Objectives

We previously reported that lymph nodes involved by nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) had unique flow cytometric features. To further validate their diagnostic utility, we have examined the flow cytometry features in cases of persistent lymphadenopathy (LAD) prior to the diagnosis of NLPHL or recurrent LAD following diagnosis and treatment for NLPHL.

Methods

We retrospectively identified nine patients (2-3 specimens per patient for a total of 20 specimens) with persistent or recurrent lymphadenopathy before or after they were diagnosed with NLPHL between the ages of 13 and 76 years. Their histopathology diagnoses were reviewed and flow cytometry data were reanalyzed.

Results

Based on our published criteria (Am J Clin Pathol 2016;145:107-115), positive flow cytometry findings (at least 12% of T cells expressing CD57 or at least 3% of T cells coexpressing CD4 and CD8) were seen in 18 specimens. Based on histopathology, 11 of them were correctly diagnosed as NLPHL, 3 of them initially underdiagnosed as atypical lymphoid proliferation, and 4 of them initially incorrectly diagnosed as negative or progressive transformation of germinal centers (PTGCs). The flow cytometry studies showed similar expression patterns of CD57, CD4, and CD8 in T cells and very similar high percentages of CD57+ T cells and CD4+CD8+ T cells between initial biopsies and subsequent biopsies in these patients. Negative flow cytometry findings were seen in two specimens pathologically confirmed as negative for NLPHL in two patients after treatment. Their initial diagnostic specimens showed positive flow cytometry findings, different from that seen in the subsequent specimens posttreatment.

Conclusion

Flow cytometry appears to be a useful adjunct in detecting early or relapsed NLPHL, especially in atypical lesions. The presence of positive flow cytometry features is very sensitive in detecting recurrent or persistent NLPHL, while absence of positive flow cytometry features helps rule out NLPHL.
EBV-Positive Primary Large B-cell Lymphoma: Highlighting the Role of XPO1 in the Diagnosis of Mediastinal Lymphomas
Authors: Maracaja Danielle Lameirinhas Vieira , Puthenpura Vidya , Pels Salley , O’Malley Dennis , Sklar Jeffrey , Finberg Karin , Xu Mina
Published: September 2019

Background

Primary mediastinal (thymic) large B-cell lymphoma (PMBL) is described to be almost always negative for EBV in the current WHO. In the context of a mediastinal lymphoma, the distinction between PMBL, classic Hodgkin lymphoma (CHL), diffuse large B-cell lymphoma, and mediastinal gray-zone lymphoma can be very difficult; hence, EBV positivity often aids in pointing away from a diagnosis of PMBL. However, since EBV positivity can occur in rare PMBLs, it should not be the deciding factor in the diagnosis; assistance from molecular studies is emerging in these difficult cases.

Case Presentation

We present a 19-year-old male patient with a 2-week history of cough, vocal changes, and occasional dysphagia who was found upon imaging to have a 6-cm mediastinal mass. The biopsy of this mass was morphologically consistent with PMBL but the tumor was EBV positive by in situ hybridization.

Methods

We performed next-generation sequencing using Oncomine Comprehensive Assay v3 (ThermoFisher Scientific) on formalin-fixed, paraffin-embedded tumor tissue with a buccal swab sample for germline control. Variant calling, filtering, and annotation were performed by the Yale Tumor Profiling Laboratory.

Results

We found somatic mutations in XPO1, SMARCB1, and MYC. Along with classic immunophenotype of PMBL including positivity for MAL, OCT2, BOB1, BCL6, CD79a, MUM1, CD20, and subset weak CD30, the diagnosis was confirmed to be PMBL.

Conclusion

This is the first EBV-positive PMBL in which molecular profiling was performed. XPO1, specifically the mutation hotspot (E571K), found in our case is involved in PMBL and CHL. This was clinically helpful in confirming the histopathologic diagnosis and also opening up a targeted therapeutic option. Selective inhibitors of nuclear export (SINEs) that block the binding of XPO1 to its cargo are in clinical development as antineoplastic agents and have shown promising activity against some hematologic malignancies.
Three Cases of Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) Involving Cerebrospinal Fluid (CSF)
Authors: Shestakova Anna , Healey Jayne , Zhao Sheila (Xiaohui) , Rezk Sherif , Nakagiri Jamie
Published: September 2019

Background

Chronic lymphocytic leukemia (CLL) is a clonal disorder of B lymphocytes, characterized by proliferation of small mature lymphocytes involving the blood, bone marrow, and lymphoid tissues. CLL can rarely involve the central nervous system (CNS), either by involving brain parenchyma or cerebrospinal fluid (CSF). We present a series of three cases with clinically significant involvement of the CNS with CLL.

Results

During the past 2 years, our medical center managed three patients with CLL who presented with symptomatic CNS involvement, as determined by flow cytometry. The immunophenotypic profile was that of a typical CLL with light chain restricted small B cells positive for CD20 (dim) and coexpressing CD5 and CD23. In addition, two patients had brain involvement by SLL that was confirmed by brain biopsy. Notably, the brain lesions had a mildly elevated Ki-67 proliferative index (10%-30%). Bone marrow was involved in two patients, showing nodular, interstitial, and diffuse patterns. Bone marrow involvement ranged from 60% to 80% and showed very low Ki-67 proliferative index. None of the patients had features suggestive of a CLL transformation. FISH was performed on either bone marrow or CSF and demonstrated that patient 1 had Del11q(ATM) and Dell13q, patient 2 had trisomy 12, and patient 3 had del17(TP53) and IGH rearrangement. All of the patients showed persistent CSF involvement, ranging from 4 to 12 weeks, requiring aggressive treatment with intrathecal chemotherapy. At the end of treatment, all of the patients were clear of CNS involvement as judged by flow cytometry of CSF.

Conclusion

We report three patients who had persistent involvement of CSF. Only one patient had del17(TP53), a cytogenetic feature that is associated with high-risk CLL. It would be interesting to study clonal evolution of CLL to understand the mechanisms that underlie involvement of the CNS.
Effect of Temperature Fluctuation and Transport Time on Complete Blood Count Parameters
Authors: Kaur Amandeep , Lee Hong-Kee , Del Giudice Denisse , Singh Irene , Eldibany Mohamed
Published: September 2019

Introduction

Reliable specimen collection and transport are fundamental to obtain high-quality test results in the hematology laboratory. Recognizing the effect of fluctuations in transport and storage conditions, time, and temperatures on the integrity of specimens and quality of results may help define the optimal transport and storage parameters. We designed an IRB-approved quality improvement study to investigate the effects of temperature fluctuation and duration of storage on blood parameters.

Methods

Ten volunteers donated blood for the study. All samples were deidentified and volunteers were blinded to the results without any review of their charts. Eight EDTA vials were collected from each volunteer and were immediately stored in heating blocks/refrigerators/freezers at selected temperatures including 0°C, 2 to 8°C, 25°C, 30°C, 35°C, 40°C, 45°C and at room temperature (21°C). Blood parameters were then measured using sysmex XN series at 0, 8, 12, 24, and 48 hours and values were analyzed.

Results

We observed that total white cell count, Hb, MCH, and platelets were stable for 12 hours at 2 to 35°C. RBCs and MPV were stable for 12 hours at 2 to 30°C, whereas blood parameters including Hct, RDW, MCV, and MCHC were stable up until 12 hours at room temperature but not at higher temperatures. All parameters were stable at 2 to 8°C even up to 48 hours.

Conclusion

It is preferable to perform CBC on blood specimens as soon as they are received. However, our data suggest that most of the blood parameters are stable for at least 12 hours at room temperature. The integrity of specimens and consequently the quality of the results deteriorate above 35°C and when stored longer than 24 hours; 2 to 8°C is the optimal temperature range for specimen transport, especially if delays in analysis are anticipated.
Malodorous Skin Lesions in a Diabetic Patient: Infectious Versus Neoplastic
Authors: Elbaz Younes Ismail , Rewerska Julia , Alagiozian-Angelova Victoria
Published: September 2019

Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma is a rare entity accounting for <1% of all cutaneous T-cell lymphomas. Almost all patients present with generalized skin lesions. This type of lymphoma has an extremely aggressive course with a median survival of 12 months. It tends to spread to other visceral sites, but lymph nodes are usually spared. We describe a case of a 59-year-old male with multiple necrotic malodours ulcers for several months. The first lesion was on his left thigh, followed by another lesion on his right chest and right eyelid. Medical history revealed newly diagnosed diabetes mellitus. The patient received antibiotics, presumptively for infectious etiology of the skin lesion, with no improvement. The right thigh lesion was excised and histomorphologic examination revealed a deep dermal proliferation of large-sized pleomorphic cells with marked pagetoid epidermotropism and skin ulceration. The adnexal skin structures were invaded by the lesion. The lesional cells were immunoreactive for CD3, CD7, CD8, and granzyme B; they were negative for CD4, CD5, CD56, and CD30. The immunophenotype confirms the entity that we have at hand in addition to the similar clinical picture that the patient presented with. This disease usually shows clonal TR gene rearrangements; nonetheless, no specific mutational aberration has been described. Our patient received chemotherapy; however, new lesions continued to erupt and he opted to proceed with palliative care. Clinical information is needed to give this diagnosis as it may look identical to a variant of lymphomatoid papulosis (type D), CD8-positive cutaneous T-cell lymphoma. We present this case due to the importance of clinical pathologic coloration to prevent misdiagnosis with mimickers as the ones pointed out earlier, and it is a provisional rare entity in the 2018 WHO classification of Tumors of Haematopoietic and Lymphoid Tissues.
Familial Platelet Disorder/Predisposition to Acute Myeloid Leukemia With Germline RUNX1 Mutation Masquerading as Idiopathic Thrombocytopenic Purpura: Case Study
Authors: Reddy Kalpana
Published: September 2019

A 25-year-old female underwent emergent laparoscopic salpingectomy when she presented with an ectopic pregnancy (G1P0). A bone marrow biopsy performed for moderate persistent thrombocytopenia (60-105 K/μL) showed normocellularity, maturing trilineage hematopoiesis, and mildly increased morphologically normal megakaryocytes reported as consistent with idiopathic thrombocytopenic purpura (ITP). However, on further inquiry, the patient stated that her sister, father, paternal aunt, and paternal grandfather have/had low platelets. Her father had been diagnosed with myelodysplasia (MDS). Her paternal grandmother had died of acute myeloid leukemia (AML). Thus, although her marrow morphology revealed no evidence of overt dysplasia and despite her normal karyotypic study, a sample was sent for RUNX1 sequence analysis. A splice site mutation (c.967 + 2_967 + 5delTAAG) in RUNX1 was detected and initially interpreted as a somatic mutation. However, given the strong family history of thrombocytopenia and MDS/AML, a sample from her father was also sent for RUNX1 sequence analysis, and the identical intronic sequence variant in the RUNX1 gene was detected in him. This confirmed the RUNX1 mutation to be germline. In the context of autosomal dominant thrombocytopenia in the patient’s family, the finding of this variant in the affected patient and her similarly affected father was consistent with a pathogenic role. Since this patient was of reproductive age actively trying to have children, these molecular genetic findings had important implications. She elected to undergo in vitro fertilization in order to choose embryos without the RUNX1 mutation for implantation. Considering that her father and paternal grandmother developed MDS/AML, and because familial platelet disorder with predisposition to AML appears to show “anticipation,” she would require close future monitoring for blastic transformation. This case illustrates the significance of careful history taking and high suspicion index that can lead to simplified targeted cost-effective molecular testing resulting in the correct diagnosis without necessarily employing large gene panels.
Hemoglobin Phenotypes in Nigeria: Data From a National Reference Laboratory
Authors: Adewoyin Ademola , Busari Olusogo , Aworanti Oladapo
Published: September 2019

On a global scale, 5% to 7% of the population carries an abnormal hemoglobin. With a sickle hemoglobin (HbS) carrier prevalence of 25% to 40%, Nigeria bears the greatest burden of sickle cell disorder worldwide. Until recent times, detection of other clinically significant hemoglobin variants associated with HbS has been unavailable, resulting in missed/wrong diagnosis, weak national data, and suboptimal control of hemoglobin disorders. This study aimed to review hemoglobin assays over a 2-year period at a national reference laboratory in Nigeria, in order to describe the prevalent hemoglobin phenotypes for health planning. The study was a retrospective, laboratory data-based survey. Sociodemographics and hemoglobin assay results of 6,851 specimens between January 2016 and December 2017 were analyzed. Study protocol was approved by the Institutional Review Board. Participants aged less than 1 year and who had recent transfusions and a history of hydroxyurea therapy were excluded. At the hemoglobin laboratory, specimens were analyzed using cation exchange high-performance liquid chromatography (CE-HPLC) (Bio Rad D10, California). When indicated, further analysis of suspected abnormal hemoglobins was confirmed using a second method, capillary electrophoresis (SEBIA Capiflex II, France). The distribution of the identified hemoglobin phenotypes was determined as a proportion of the total number of participants. The mean (SD) age of the participants was 31.8 (14.9) years. The most frequent hemoglobin phenotypes were AA (59.4%), AS (23.3%), and SS (13.3%). Hemoglobin phenotypes AC (2.1%), SC (0.9%), AGPhiladelphia (0.2%), and CC (0.2%) were less frequent. Least occurring phenotypes were ADIbadan, AE, AGPhiladelphia, AOArab, DD, and hereditary persistence of fetal hemoglobin (HPFH). In the Nigerian context, accurate diagnosis of hemoglobin variants using quantitative, high-resolution hemoglobin assays, compared to zone (cellulose acetate) electrophoresis at alkaline pH will provide data for health planning, better access to genetic counseling, informed reproductive health choices, and secondary prevention of hemoglobinopathies.
Determining if Residual Eosin From Dehydration and Clearing Solutions Has an Effect on Immunohistochemistry
Authors: Gardner Christine
Published: September 2019

Objectives

Immunohistochemistry is a diagnostic stain that gives more specificity in testing for a disease and/or condition of patient tissue. Moore Regional Hospital is on the cusp of the LEAN Principle and currently in the early stages. The histology laboratory encountered a “waiting waste” problem due to two areas of histology sharing a common instrument. It is proposed to create a protocol on the Tissue-Tek Prisma stainer specifically for running down immunohistochemistry slides using the same alcohols and xylenes within the current H&E staining protocol. Research is scarce on whether residual eosin, from the dehydrating and coverslip phase, has an effect on immunohistochemistry morphology.

Materials

Three trial runs were conducted using a cytokeratin immunohistochemistry control. Each trial had dependent variables of staining times, staining parameters, and the changes of alcohol and xylenes. Cytokeratin is a feasible slide to use considering time stipulations and due to its prominent positivity. The instruments used in this validation were the BenchMark Ultra and the Tissue-Tek automatic stainer. The reagents used in this validation were the DAB chromagen, Hematoxylin (Ventana), Bluing (Ventana), Xylene (Cardinal), and Alcohol (Cardinal).

Results

Interpretations concluded that residual eosin does not have any direct artifact or undesirable outcomes. However, minor findings were noted on how the depar solutions did affect the visual quality of the cytokeratin.

Conclusions

Pros and cons were discussed in terms of moving forward with this process and improving the overall quality of the histology laboratory. It was decided that the lab move forward with the process or automatically running immunoslides down in automatic stainer. The overall quality of the slides improved due to the decrease in human variability and there is time added for the IHC tech to complete other tasks.
Epidermoid Cyst in the Intrapancreatic Accessory Spleen: A Case Report and Review of the Literature
Authors: Nakanishi Yukihiro , Behl Preeti , Kadi Abida , Crawford Byron
Published: September 2019

Epidermoid cyst in the intrapancreatic accessory spleen (ECIAS) is an exceedingly rare nonneoplastic entity. It generally does not require therapeutic intervention, but it is often misdiagnosed preoperatively as a cystic tumor, such as a mucinous cystic neoplasm or a cystic degeneration in a solid pancreatic neuroendocrine tumor or solid pseudopapillary neoplasm. We herein report a rare case of ECIAS in a 33-year-old African American man with a history of end-stage renal disease secondary to IgA nephropathy, congestive heart failure, and sickle cell trait who was referred to our facility for a renal transplant workup. A contrast-enhanced abdominal computed tomography during the workup revealed a bilobed low attenuating mass (3.4 × 3.4 × 2.5 cm) in the tail of the pancreas. Because malignancy could not be excluded, the patient underwent a distal pancreatectomy and splenectomy. Gross examination of the surgical specimen revealed a smooth-walled, multiloculated cyst (3.7 × 2.7 × 2.0 cm), containing serous fluid within the pancreatic parenchyma. Microscopically, the cyst was lined by nonkeratinizing stratified squamous epithelium without skin appendages, surrounded by benign splenic tissue in the pancreatic parenchyma. No dysplasia or malignancy was seen. Immunohistochemically, the lining epithelium was positive for p63, CK5/6, and CEA and negative for CA19-9, which supports the above diagnosis. The postoperative course was uneventful. In conclusion, ECIAS is a rare benign entity that can mimic malignant conditions and should be considered in the differential diagnosis of cystic lesions in the tail of pancreas.
Frozen Sections of Sentinel Lymph Nodes From Breast Cancer Patients Who Undergo Neoadjuvant Therapy Are Accurately Diagnosed Using Telepathology
Authors: McMurtry Valarie , Factor Rachel
Published: September 2019

Objectives

Telepathology enables histologic diagnosis to be made from a scanned slide visualized on a computer. Frozen sections (FSs) can be performed at remote locations and read by a pathologist at a central site. At our institution, qualifying breast cancer patients are enrolled in clinical trials that require FS on sentinel lymph nodes (SLNs) after neoadjuvant therapy (NAT), including chemotherapy or endocrine therapy. In this setting, histology is complicated by treatment effect and biopsy site changes. Others have reported good accuracy of FSs on SLNs after NAT. We investigated whether pathologists are accurate in diagnosing SLN FSs for such cases while using telepathology. To our knowledge, this has not been reported previously.

Methods

SLNs were entirely submitted and serially sectioned (2-mm thickness). At least two levels were cut. All FSs were submitted for formalin-fixed, paraffin-embedded permanent sections. A pathology assistant at the remote location prepared the FSs and scanned slides using the VisionTek M6 digital microscope ecosystem (East Dundee, IL). Cases were interpreted by board-certified pathologists who completed training on the VisionTek system. For this study, diagnoses from FSs and permanents were compared.

Results

Forty-five SLNs from 19 breast neoadjuvant cases were read by VisionTek from March 2017 to January 2019. Forty-three cases (96%) called negative by FSs were confirmed negative (on permanents). One hundred percent called positive by FSs were positive. Four SLN called atypical on FSs were positive. Three of these were neoadjuvant endocrine cases for invasive lobular carcinoma. Two cases called atypical were negative. One of these, called atypical/suspicious, resulted in axillary dissection. This case was reviewed by three pathologists at the time of surgery. It had abundant treatment effect, mimicking carcinoma.

Conclusion

While pitfalls exist, overall, the diagnostic accuracy of frozen section analysis by telepathology of SLNs from breast cases after neoadjuvant therapy is high.
Quality Management: Institution of Incident Reporting in the Clinical Laboratory
Authors: Reeves Melissa , Ullah Ehsan , Hufnagel Robert , Tumminia Santa
Published: September 2019

Introduction

Risk assessment is a critical part of quality management for a clinical laboratory. As a part of risk management, it is important to track any deviances from standard operating procedures (SOPs) and document equipment or assay failures consistently.

Methods

Our laboratory instituted an incident reporting system for reporting any deviances from protocol or equipment failures to track recurrent issues and determine if changes to protocols were necessitated. A guidance for completing the form was used so that the forms were completed in a standardized manner. Each incident is given a unique ID for tracking and identifies who discovered the incident and a secondary person that the incident was reported to at the time of occurrence. The incident is classified as Process, Instrument, Personnel, or Other and could be grouped into more than one category. The Other category includes incidents such as those involving reagent or equipment malfunctions. Incident reports are reviewed and discussed during the weekly lab meeting to determine the most appropriate category(s) for classification. Further, a fixed decision-making algorithm was applied to intervene specifically if the incident (a) was recurring, (b) required an SOP investigation or additional personnel training, and (c) needed to be reported to the institutional review board (IRB). Incidents are tracked until corrective action has been completed and reviewed periodically by the laboratory director. We reviewed the data after our first year of incident reporting to evaluate trends in incident categories.

Results and Conclusion

Forty-nine incidents were reported December 2017-2018. The highest classification categories included Other and a dual category, Process and Personnel, with 10 reports in each (40.8% overall). Twelve incidents were considered Recurring, 16 prompted SOP updates, and 1 was reported to the IRB. Through incident reporting, we were able to identify and resolve key risk areas in our procedures, which improved our operations and overall quality.
Sensitivity of Automated Urine Chemstrip Analysis for Detecting Microscopic Abnormalities
Authors: Robertson-Patera Jessica , Nakashima Megan
Published: September 2019

Objectives

Urinalysis (UA) is used to screen for multiple medical abnormalities. Microscopic analysis of urine requires trained morphologists and can be time-consuming; therefore, a reflex strategy where microscopic analysis is only performed when the chemstrip is positive is an attractive strategy. We previously described the retrospective performance of the iChem VELOCITY (Beckman Coulter, CA, USA) and CLINITEK Novus strip cassettes (Siemens, Munich, DE) for detecting microscopic abnormalities. The iRICELL is iQ microscopic and is now paired with the AX-4030 (Arkray, JP). During our validation of the new workcell, we tested the sensitivity and specificity of the chemstrip results for microscopic abnormalities.

Methods

A total of 60 samples were analyzed on both the VELOCITY and AX-4030. Microscopic evaluation was performed by centrifuging the urine and examining by light microscope. Sensitivity and specificity for each chemstrip result were calculated and compared.

Results

Looking at sensitivity of any chemistry abnormality for any microscopic abnormality, the AX-4030 was 90.2% sensitive compared to 80.5% on the VELOCITY. The AX-4030 leukocyte esterase result was slightly less sensitive but more specific than the VELOCITY for presence of leukocytes (94.7% sensitivity and 95.1% specificity compared to 100% sensitivity and 87.8% specificity). The AX-4030 blood results were slightly more sensitive for detection of RBC (77.8% vs 72.2%) and more specific (100% vs 92.9%), perhaps related to the known interference of ascorbic acid with the VELOCITY strips.

Conclusion

Overall, the AX-4030 chemstrip results were more sensitive for microscopic abnormalities than the VELOCITY, although 10% of cases would still be missed. For a general population, a reflex methodology may be adequate. However, in patients with a higher likelihood of microscopic abnormalities, performing routine microscopic analysis may still be prudent.
Discovery of Enteric Pathogens in the Alaskan Subsistence Diet
Authors: Leu-Burke Grace , Beacham Robert , Bennetts Courtney
Published: September 2019

Objectives

Transmission of enteric pathogens from food ingestion is an ongoing public health concern, with commensal bacteria in ruminant animal species causing human disease. Enteric pathogens Salmonella, Shigella, and Shiga toxin producing Escherichia coli (STEC) have been isolated from domesticated animals. However, the Alaskan subsistence diet relies on wild game, such as reindeer, caribou, and moose for their food supply. Research concerning enteric pathogens in wildlife has not established. Therefore, we conducted a pilot survey on moose and reindeer to determine potential enteric pathogen transfer risk.

Methods

Between July 2018 and January 2019, we collected 72 fecal samples from reindeer and moose migrating in Fairbanks, Anchorage, and the Matanuska Valley. Samples were cultured for enteric pathogens, including E coli 0157, using standard clinical microbial process. Phenotypic Shiga toxin production was verified by enzyme immunoassay.

Results

Reindeer were statistically significant for enteric pathogens when compared to moose (P < .05) Eighty percent of the reindeer population were colonized for either Shigella, Yersinia, or Shiga toxin-producing E coli, with 20% positive for multiple pathogens. Non-0157 Shiga toxin production was observed in 30% of reindeer samples, generated by a sorbitol fermenting E coli. In contrast, moose population showed a near absence of enteric pathogens with only 5% positive for Shigella. Salmonella was not identified in either animal.

Conclusion

Reindeer, moose, and caribou meat are prominent in the Alaskan subsistence diet. Although moose had limited enteric pathogen colonization, reindeer were significant for transmission risk, including non-0157 Shiga toxin producing E coli, which has been linked to hemolytic uremic syndrome. Isolation of a non-0157 STEC in wildlife indicates environmental colonization. Because reindeer and caribou are closely linked in diet and migration, Alaska clinical laboratories should screen for enteric pathogens, including non-0157 Shiga toxins.
Reducing Culture Reporting Errors in the Microbiology Laboratory
Authors: Hogan Kathryn , Umar Beena , Alhamar Mohamed , Callahan Kathleen , Samuel Linoj
Published: September 2019

Objectives

There are few papers that characterize types of errors in microbiology laboratories and scant research demonstrating the effects of interventions on microbiology lab errors. This study aims to categorize types of culture reporting errors found in microbiology labs and to document the error rates before and after interventions designed to reduce errors and improve overall laboratory quality.

Methods

To improve documentation of error incidence, a self-reporting system was changed to an automatic reporting system. Errors were categorized into five

types

Gram stain (misinterpretations), identification (incorrect analysis), set up labeling (incorrect patient labels), procedures (not followed), and miscellaneous. Error rates were tracked according to technologist, and technologists were given real-time feedback by a manager. Error rates were also monitored in the daily quality meeting and frequently detected errors were discussed at staff meetings. Technologists attended a year-end review with a manager to improve their performance. To maintain these changes, policies were developed to monitor technologist error rate and to define corrective measures. If a certain number of errors per month was reached, technologists were required to undergo retraining by a manager. If a technologist failed to correct any error according to protocol, they were also potentially subject to corrective measures.

Results

In 2013, we recorded 0.5 errors per 1,000 tests. By 2018, we recorded only 0.1 errors per 1,000 tests, an 80% decrease. The yearly culture volume from 2013 to 2018 increased by 32%, while the yearly error rate went from 0.05% per year to 0.01% per year, a statistically significant decrease (P = .0007).

Conclusion

This study supports the effectiveness of the changes implemented to decrease errors in culture reporting. By tracking errors in real time and using a standardized process that involved timely follow-up, technologists were educated on error prevention. This practice increased safety awareness in our micro lab.
Clinical Validation of the Lymph3Cx Assay to Distinguish Primary Mediastinal Large B-Cell Lymphoma From Diffuse Large B-Cell Lymphoma
Authors: Ramsower Colleen , Yip Tameson , Glinsmann-Gibson Betty , Robetorye Ryan , Rimsza Lisa
Published: September 2019

Introduction

Primary mediastinal large B-cell lymphoma (PMLBCL) is recognized as a distinct lymphoid neoplasm. However, differentiation from diffuse large B-cell lymphoma (DLBCL) can be difficult due to the need for close clinicopathologic correlation and variability in morphology and immunophenotype. In addition, a recent study identified lymphomas that share molecular and morphological features with PMBCL, yet do not involve the mediastinum. Correct classification of PMBCL may impact therapeutic decision making, increasing the demand for more accurate diagnostic methods. Recent research identified a new gene expression signature that robustly differentiated PMLBCL from DLBCL in both training and independent validation cohorts using RNA isolated from routinely available formalin-fixed, paraffin-embedded (FFPE) tissues.

Methods

This assay, known as the “Lymph3Cx,” utilizes the nCounter platform (NanoString Technologies, Seattle, WA) and consists of probes for 58 target genes (including both discriminatory and housekeeping genes) that can distinguish PMLBCL cases from DLBCL as well as the “cell-of-origin” subtypes of DLBCL. In the current study reported here, the Molecular Diagnostics–Arizona Laboratory (MDAZL) performed a full validation of the Lymph3Cx assay for use in our clinical diagnostic laboratory.

Results

Assay performance

included

accuracy (92.9%), precision (100%), analytical sensitivity (100 ng RNA limit of detection), analytical specificity (measures are in place to prevent interfering substances), reproducibility between technologists and technical replicates (100%), specimen stability (18 months for unstained tissue sections), and RNA Isolation Kit Utility (two kits with equal performance) in order to become the first CLIA-certified, CAP-accredited clinical diagnostics laboratory to offer a molecular assay for distinction of PMLBCL from DLBCL.

Conclusion

The Lymph3Cx assay will be prospectively used for evaluation of Mayo Clinic patients and for use as an integrated biomarker in clinical trials.
Laboratory-Diagnosed Gonorrhea and Chlamydia Infection Rate in the Veteran Population: The Corporal Michael J. Crescenz Veteran Affairs Medical Center (CMCVAMC) Experience
Authors: Petersen Jeffrey , Patel Sahil , Dalal Sharvari , Jhala Darshana
Published: September 2019

Introduction

Sexually transmitted infections (STIs) due to gonorrhea and/or chlamydia remain a major public health problem. Previously, it has been documented in the literature that active duty/deployed military personnel may have a higher incidence of STI infections compared with the general population; however, similar studies for the veteran population (after discharge from military service) appear sparse. For facilities that diagnose gonorrhea and chlamydia by a real-time polymerase chain reaction (PCR) assay, an understanding of the expected rate of gonorrhea and chlamydia is helpful for monitoring the assay, both for epidemiological purposes and as a check on assay to detect abnormal trends; therefore, we present the unique experience of the CMCVAMC.

Method

Quality assurance/improvement quarterly data from October 1, 2013, to December 31, 2018, were reviewed to obtain both the test volume of PCR for gonorrhea and chlamydia as well as the number of positive test results at the CMCVAMC. Testing had been performed using the Abbott m2000 RealTime System (Abbott Park, Illinois).

Results

A total of 12,856 PCR tests for gonorrhea and chlamydia had been performed on the veteran population; of these, 257 were positive for gonorrhea and 410 were positive for chlamydia. Quarterly percentage rates on a quarterly basis ranged from 1.67% to 5.30% (chlamydia) and 1.01% to 3.25% (gonorrhea) with average rates of 3.29% and 2.01% for chlamydia and gonorrhea, respectively, and expected rates <6% at the CMCVAMC.

Conclusions

The establishment of the average expected rate of positive laboratory-diagnosed chlamydia and gonorrhea at the CMCVAMC makes a significant contribution to the epidemiological data concerning veterans and provides a valuable benchmark for similar facilities performing quality assurance of their PCR assay for these STIs.