bluuebunny/crossref_metadata_2025 huggingface dataset:
Weak Precipitin Ring from A Fecal Specimen with Markedly Elevated Alpha-1 Antitrypsin Level Measured by Radial Immunodiffusion
Authors: Xiao Yi , Leung Edward
Published: October 2021

Radial immunodiffusion (RID) is a classic methodology for antigen quantification that relies on the development of a distinct precipitin ring from precipitated antigen-antibody complex. As the precipitin ring grows, the precipitate at the inner edge of the ring constantly dissolves due to excess antigen flooding from the point of application, while new precipitate forms at the leading edge of the ring. RID plates with anti-human alpha-1-antitrypsin are prepared in our lab to measure fecal alpha-1 antitrypsin (A1AT) to aid in the diagnosis and monitoring of Protein Losing Enteropathy (PLE). The procedure has routinely produced precipitin rings with small radii and distinct edges after incubating at room temperature for 48 hours. Unexpectedly, a fecal specimen from a patient produced an extremely weak and large precipitin ring that could have been easily overlooked. Dilution studies confirmed a highly elevated A1AT level of 67 mg/g dry stool. The very weak and large precipitin ring was reproduced with a spiked specimen with similar A1AT concentration and kept expanding for several days until a distinct ring was formed eventually. Our data highlights a rare example of high-dose hook effect in RID and calls for meticulous attention and caution when reading and interpreting gel-based immunoassays with unexpected markedly elevated results to avoid additional confirmatory testing. In these cases, we recommend repeat testing with diluted specimens.
VariantDirect: An extraction-free screening approach to detect circulating SARS-CoV-2 virus strains from pooled specimens
Authors: Saadalla Abdulrahman , Stroup Brooke , Parikh Bijal
Published: October 2021

Coronavirus disease (COVID-19) caused by the SARS-CoV-2 virus has exposed clinical laboratories to unprecedented challenges. With surging case numbers, clinical laboratories were forced to acquiesce and integrate multiple testing platforms with varying workflows and analytical sensitivities in order to meet testing volumes. Now a new challenge has emerged with the evolution of viral variants, both globally and locally, raising concerns for uncontrolled spread, increased disease severity, and weakened responses to vaccinations. Preliminary data suggests that these variants may be associated with higher viral titers and prolonged infections. While primarily leveraged for epidemiologic surveillance, the clinical utility of variant detection may quickly become paramount. Furthermore, laboratories must remain vigilant and nimble enough to pivot should variant identification play a role in the patient care. To prepare for the validation of clinical assays that identify important viral variants, we designed a novel method, termed VariantDirect, to screen SARS-CoV-2 positive samples for the presence of variants, focusing initially on the increasingly prevalent UK and South African (SA) variants. The detection strategy is based on primers designed to specifically target the viral receptor-binding domain mutation, N501Y, shared by the UK and SA strains. Screening for variants will be limited to nasopharyngeal swab samples of high viral titers (Ct values <25 by RT-qPCR assay, Roche Diagnostics). Pools of 9 different samples, 50 µl each, are mixed and stored at -80°C along with aliquots of the 9 original samples. These pools will then be tested, and if positive for the N501Y variant, the pooled 9 samples will be thawed and tested separately to identify the affected specimen. Most of these specimens are also being independently sequenced via a comprehensive but more resource-intensive NGS approach. Advantages of our pooled workflow are primarily in time and cost, with the capacity of screening up to 837 specimens on a single run. In addition, our collection strategy establishes a “time capsule” to document the evolution of viral strains within our geographical region. Finally, these studies serve to optimize technical parameters for the development of clinical assays. A validated nucleic acid (NA) extraction-free RT-qPCR method will be utilized for this assay. Our internal validation data showed comparable analytical sensitivities to NA extraction-based methods. Pooled samples in transport medium are diluted in normal saline at a ratio of 1:1, and then heat-inactivated in the presence of proteinase-K and ultimately analyzed on the Applied Biosystems™ 7500 Fast Dx instrument. As new variants of interest emerge, primers and probes can be quickly redesigned and validated on clinical samples within our NGS-confirmed “time capsule”. This study will provide important information needed for current or future genomic and epidemiologic studies.
Combined utility of Glucose and HbA1C testing for screening diabetes mellitus
Authors: Samara Vishnu , Kelly Kathleen , Hilborne Lee
Published: October 2021

Screening for diabetes mellitus is accomplished by measuring fasting blood glucose or HbA1C. The American Diabetes Association (ADA) guidelines recommend HbA1C for screening patients for diabetes or pre-diabetes, the U.S. Preventative Services Task Force (USPSTF) includes HbA1C only for monitoring and either glucose or HbA1C can be used for screening. This project sought to provide clinical laboratory evidence to support HbA1C as a diabetes screening test. De-identified electronic health record (EHR) patient data from individuals visiting a large medical center and its affiliated clinics that were tested for blood glucose (either alone, basic metabolic profile or comprehensive metabolic profile) and HbA1C ordered together on the same date of service were collected. 333,360 combined glucose and HbA1C requests were received in 2020. For further analysis, we included patients only with ICD-10 routine visit code Z00.00, excluding known diabetics, patients with elevated blood glucose and HbA1C below 5.7 %because this combination may indicate a non-fasting or inadequate fasting state. From the patients with diagnosis code Z00.00 and glucose within the reference interval, 73 %had HbA1C levels greater than 5.7 %. Among them, 65 %are of pre-diabetes [HbA1C between 5.7 and 6.4%] and 35% with HbA1C over 6.5%. Medical record review of patient charts with HbA1C over 6.5 % suggested a diagnosis of diabetes and were prescribed hypoglycemic medications. Elevated glucose and HbA1C complement each other in the initial diagnosis for diabetes and pre-diabetes; where as HbA1C alone is a good indicator in screening diabetes and pre-diabetes individuals that were previously not diagnosed with diabetes. We are currently collecting 2019 data to examine the differences and adjust for the sample volume due to effect of COVID-19 pandemic on patient visits in the early 2020. We are also evaluating if other variables such as insulin levels, insulin resistance status, and their correlation with HbA1C as a screening measure.
An Examination of Non-Pathologist Physicians’ Experiences with and Perceptions of the Autopsy
Authors: Hagen E S , Mirza K M , Anderson E , Cox B
Published: October 2021

Introduction/Objective

The autopsy is an undervalued and underutilized resource in medicine. Many people believe autopsies are used solely in forensics while in fact much of what we know about human disease comes from examining the human body at autopsy. The decrease in requests for autopsy over the past several decades possibly results from medical professionals’ lack of exposure to and understanding of autopsy. We conducted a survey to explore non-pathologist physicians’ exposure to and understanding of the autopsy and discover challenges and barriers faced by non-pathologists when requesting an autopsy. Better understanding of non-pathologist physicians’ views and experiences can guide further inquiry or intervention to remove barriers to autopsy requests.

Methods/Case Report

We disseminated a Google Forms survey via Twitter, tweeting weekly between 10/26/20- 2/26/2021 to obtain a convenience sample. Mean differences in continuous variables were assessed using an independent samples T-test. Chi-squared analyses were employed to report proportional differences in categorical variables. Where appropriate, comparisons of Likert scores (percentages) were performed using ordinal regression methods and reported as odds ratios. Analyses were performed on SPSS statistical software (v.27). P-value was considered significant if <0.05.

Results (if a Case Study enter NA)

162 physicians responded to the survey. 29 responses were excluded (work outside US, practice pathology, or in residency), resulting in 133 surveys for analysis. Preliminary analysis suggests that Likert scores were generally favorable (>3) for questions that asked whether the autopsy was of benefit to the clinical team, public health, and family closure. Also, Likert scores revealed that physicians experience barriers surrounding the autopsy in terms of understanding and comfort with tasks related to the autopsy.

Conclusion

Our study reveals that physicians are often unsure about the cause of their patients’ death, highlighting the continued importance of the autopsy in patient care. Barriers to autopsy use may include limited understanding of the procedure, how it is financed, and how to request an autopsy. Physicians also express discomfort with discussing autopsy with families. Education and specific training on conversations about the autopsy may increase use.
Relationship between Usher Syndrome and Ciliary Dysfunction in a pregnant woman with Multidrug-resistant Pneumonia: A Case Report and Literature Review
Authors: Omo-Ogboi A C , Savariya B , Rivera Rivera X , Zhao B
Published: October 2021

Introduction/Objective

Usher syndrome is a rare genetic disorder that consists of auditory and visual disturbances, affecting approximately 4-17 per 100,000 people. In the airways, cilia function in concert with airway mucus for mucociliary clearance, cleansing the airways of inhaled particles and pathogens. Ciliary dysfunction could lead to recurrent pulmonary infections, including from organisms resistant to more than one antibiotic. Few cases have been reported in the literature suggesting a relationship between usher syndrome and ciliary dysfunction. Hence, we would like to report an autopsy case of multidrug-resistant bacterial pneumonia in a pregnant patient with usher syndrome, discussing the possible relationship between usher syndrome, ciliary dysfunction, and multidrug-resistant pneumonia in pregnancy.

Methods/Case Report

We present a 31-year-old pregnant woman with a history of usher syndrome, hypothyroidism, and hydrocephalus presenting with shortness of breath, cough, and acute respiratory distress syndrome. She further developed refractory hypoxemia and hypercapnia complicated by multidrug-resistant bacteria infection, then intubated. Despite further management of the refractory respiratory failure, she showed no improvement. She was eventually placed on comfort care and died 49 days after she was admitted.

Results (if a Case Study enter NA)

At autopsy, the pleural surface has exudates and fibrotic adhesion. Both lungs are congested and have consolidations with variable severity on all lobes of both lungs. Microscopically, the most striking finding is the mucin accumulation in large and small airways, even in dilated alveolar spaces. There is evidence of chronic lung injury with significant interstitial fibrosis, diffuse peri-bronchial epithelial metaplasia, also with mucin accumulation. The respiratory epithelium has cilia present.

Conclusion

Although cilia were present microscopically, their function was not ascertained. The increase in progesterone during pregnancy inhibits cilia beat frequency. Therefore, the hormonal state of pregnancy and the proposed ciliary dysfunction in usher syndrome may worsen the severity of pulmonary infections seen in this patient and eventually caused her death.
Low-grade fibromyxoid sarcoma with heterotopic bone formation: case report and review of the literature
Authors: Serinelli S , Gitto L , de la Roza G , Zaccarini D J , Mookerjee G G , Damron T
Published: October 2021

Introduction/Objective

Low-grade fibromyxoid sarcoma (LGFMS) is an uncommon soft tissue malignancy with deceptively bland histologic appearance, and a tendency for late recurrence and metastasis. Cases with significant heterotopic ossification are rare. This presentation aims to characterize the features of LGFMSs showing heterotopic ossification reported in the literature, and further review the morphologic spectrum of this malignant neoplasm.

Methods/Case Report

We report the case of a 42-year-old male presenting with a 20-year history of a painless tumor in his left upper thigh. Computed tomography images showed coarse punctate peripheral calcifications, and the mass was resected. The tumor cells were immunohistochemically positive for MUC4, and positive for FUS (16p11.2) gene rearrangement by fluorescence in situ hybridization. Lamellar and woven bone with admixed adipose tissue was seen. Immunohistochemistry also showed focal weak to moderate staining for TLE-1. An English literature search using the terms “Evans tumor”, “low-grade fibromyxoid sarcoma”, “ossification”, “osseous metaplasia”, “bone metaplasia” and “bone formation” was performed. Nine cases were identified. The majority of subjects were males, with a mean age of 38 years (range of 12-61 years). The duration of symptoms before diagnosis ranged from a few months to 10 years. The tumor size ranged from 2.5 and to more than 12 cm. In a minority of subjects, calcifications were identified on imaging studies. Histologically, bone metaplasia was mainly seen at the periphery of the tumor. The majority of cases had a chromosomal translocation (FUS-CREB3L2 in 5 cases and EWSR1-CREB3L1 in one).

Results (if a Case Study enter NA)

NA

Conclusion

LGFMS is a tumor that can occur in a wide range of anatomical sites, and should be included in the differential diagnosis of any spindle cell neoplasm with hypocellular areas and bland cytology. Pathologists and clinicians should be aware of the rare possibility of heterotopic ossification in this tumor type, which can be radiologically detected as calcification and then confirmed histopathologically.
Is Oncotype DX Testing Necessary For Patients With Node Negative, Low-Grade Invasive Ductal Breast Carcinoma?
Authors: Ali M , Mandich D , Assaad M , Cartun R W
Published: October 2021

Introduction/Objective

Oncotype DX (Genomic Health/Exact Sciences, Redwood City, CA) is a 21-gene expression test that is used to predict the risk of recurrence following hormonal therapy and adjuvant chemotherapy (CT) benefit for patients with early-stage, ER-positive and HER2-negative invasive breast carcinoma (IBC). Testing is performed on formalin-fixed, paraffin-embedded tumor tissue from patients that are either lymph node (LN) negative, have micro- metastases, or 1-3 positive LNs. For years pathologists have studied traditional prognostic features of IBC (tumor grade, size, and LN status), as well as biomarker testing results (ER, PR, HER2, and Ki-67), in an effort to identify surrogate equations that could help identify patients that would benefit from CT. The “TAILORx” clinical trial, performed to study CT benefit in patients with midrange recurrence scores (11-25), has shown that the majority of these patients do not derive benefit from CT. Post-TAILORx, we have observed that only a small subset of our node- negative patients who were tested showed a benefit for CT. Following the examination of Oncotype DX results from testing performed on our patients, we hypothesized that overall tumor grade (Nottingham) might predict which patients with invasive ductal breast carcinoma (IDBC) do not require Oncotype DX testing; therefore, eliminating the need for Oncotype DX testing.

Methods/Case Report

We reviewed the surgical pathology reports and Oncotype DX reports for 251 patients with node-negative disease who underwent surgery at our institution from September 2019 through June 2021. All excisional tumors sent for Oncotype DX testing were ER-positive (Allred score ≥6/8) and HER2-negative by IHC and/or FISH.

Results (if a Case Study enter NA)

Oncotype DX recurrence scores ranged from 0-65. A benefit for CT was seen in 10.4% (26/251) of the patients with node-negative IDBC. A benefit for CT was seen in 6.1% (7/114) of patients with an overall tumor grade of II and 44.2% (19/43) of patients with an overall grade of III. No patients (0/94) with IDBC and an overall tumor grade of I showed a benefit for CT.

Conclusion

In the post-TAILORx era, patients with ER-positive (Allred ≥6/8), HER2-negative IDBC, who are node- negative and show an overall tumor grade of I, apparently do not require Oncotype DX testing. Additional studies from other institutions are needed to confirm our observation.
HER2 testing in metastatic breast cancer – is reflex in situ hybridization necessary in cases that are equivocal by immunohistochemistry?
Authors: Liwski C R , Castonguay M , Barnes P , Bethune G , Rayson D
Published: October 2021

Introduction/Objective

Current guidelines recommend HER2 testing on all primary invasive breast cancers and at least one metastatic lesion. Typical HER2 testing involves immunohistochemistry (IHC), with reflex in situ hybridization (ISH) in the event of equivocal (2+) IHC. ISH testing is time consuming and resource intensive, and there may be situations where it is unnecessary. The incidence of discordance between HER2 negative primary tumors and HER2 IHC2+ metastases that are ISH positive is unknown. We hypothesize that the majority of such cases are non- amplified.

Methods/Case Report

A retrospective review of IHC2+ metastatic lesions further assessed with ISH at our center from 2013-2021 was undertaken. A total of 105 cases were identified after exclusion of cases missing HER2 results, with primaries of unconfirmed origin, and cases of synchronous primary and metastatic disease. IHC and ISH results were recorded, with a detailed slide review of discordant cases.

Results (if a Case Study enter NA)

91/105 metastases had HER2 negative primaries (87%). A metastasis was significantly more likely to be HER2 negative when the primary was HER2 negative (93%) versus positive (43%) (p < 0.0001). 54/91 primaries were IHC2+/ISH negative, and 50/54 (93%) corresponding metastases had identical results. Of the 37 HER2 negative primaries that were IHC0/1+, 35 (95%) corresponding metastatic tumors were ISH negative. Six metastatic lesions in cases with HER2 negative primaries were discordant and slides were reviewed. Characteristics of metastatic tumors suggesting ISH testing was warranted to assess for discordance included IHC heterogeneity, morphological discordance, and increased staining of moderate intensity. These factors were present in all six discordant metastases.

Conclusion

Our results suggest that selective rather than reflex ISH testing on HER2 IHC2+ breast cancer metastases in the context of HER2 negative primary disease may be appropriate when there is careful review of the IHC. Validation of our findings await further studies with larger sample sizes.
Effect of 1 vs. 2 decimal place reporting of creatinine (mg/dL) for calculation of estimated glomerular filtration rate (eGFR)
Authors: Reganis M N , Stickle D
Published: October 2021

Introduction/Objective

Our multi-hospital system recently adopted uniform use of 2 decimal places for reporting of creatinine (mg/dL), in accordance with NIH guidelines. Surprisingly, this change in patient reports fostered complaints from clinicians. Use of 2 decimal places is both analytically appropriate and reduces imprecision in calculations of estimated glomerular filtration rate (eGFR). Primary literature is devoid, however, of a delineation of the scale of the effect of using 1 vs. 2 decimal places to calculate eGFR. We examined this effect for both the Modified Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) eGFR equations.

Methods/Case Report

Creatinine is an input to a single multiplicative creatinine factor in eGFR calculations for MDRD and CKD-EPI equations. We calculated the creatinine factor for these equations for creatinine=0.6-10 mg/dL, and evaluated the % difference in this factor when using increments of 0.1 mg/dL (1 decimal place) compared to increments of 0.1±0.05 mg/dL (viz., the 2 decimal place boundaries of a rounded 1 decimal place report). The observed % differences reflect those that would be observed in associated eGFR results.

Results (if a Case Study enter NA)

Input of 1 vs. 2 decimal places for creatinine in eGFR calculations, using either MDRD or CKD-EPI, produces differences in eGFR of greater than ±5% only for creatinine <1.2 mg/dL, and greater than ±10% only for creatinine <0.6 mg/dL (MDRD only). These ranges for creatinine are within or near-to reference ranges for both males (0.7-1.4 mg/dL) and females (0.6-1.0 mg/dL), and encompass approximately 70% of all patient reports for our patient population. For comparison, eGFR has a 95% confidence interval of approximately ±30% across all eGFR’s.

Conclusion

The ±5% reduction in precision in eGFR for such a large fraction of results by use of only 1 decimal place for creatinine was deemed unwarranted. Clinician complaints were handled by one-to-one discussions.
Immunoglobulin D Multiple Myeloma with a “Hidden” Lambda Light Chain
Authors: Lee J K , Flowers A , Williams J , Li S , Yi X , Huang R
Published: October 2021

Introduction/Objective

In rare cases, the conventional immunofixation gel electrophoresis technique fails to detect the light chain of an M-protein. We report a case of immunoglobulin (Ig) D multiple myeloma with a hidden lambda (λ) light chain.

Methods/Case Report

Capillary electrophoresis (CE) (Sebia CAPILLARYS 2) was used to detect and quantify M- proteins in serum specimens. Immunosubtraction (IS) on the CAPILLARYS 2 systems was used to identify the classes of M-proteins. Conventional gel immunofixation electrophoresis (IFE) was performed, using monospecific antisera for IgD, IgE, kappa (κ) or λ in the Sebia HYDRASYS system, and IgG, IgA, IgM, κ or λ in the Helena SPIFE3000 system. Beta-mercaptoethanol (BME) with Fluidil were used as reduction agents.

Results (if a Case Study enter NA)

Results of serum CE showed two abnormal peaks in beta 2 and gamma regions, suspected to be positive for M-proteins. IS results showed subtraction for λ light chain only in both peaks, suggesting two monoclonal λ light chains. In contrary, no monoclonal λ light chain was detected in gamma region by IFE (Sebia). Epitope masking in the folded monoclonal protein was suspected to cause the “hidden λ light chain” and was further investigated by two laboratory approaches. IFE performed on the Helena SPIFE3000 system found two λ bands in beta 2 and gamma regions, which was consistent with the results from IS. The treatment of BME with Fluidil helped unmasking the hidden epitope and revealed the λ band in gamma region on IFE (Sebia).

Conclusion

The medical laboratories should be aware of the described scenario. The failure to detect light chains of certain intact M-proteins is most likely due to the structurally inaccessibility of light chains. It is recommended that treatment with reduction agents or use of an alternative methodology or IS might be helpful for investigating suspected heavy chain only cases, due to the limitation of conventional methodology.
Longitudinal Study of SARS-CoV-2 Antibody Characteristics Using Label-Free Immunoassays
Authors: Luo Y R , Yun C , Wu A H , Lynch K L , Chakraborty I
Published: October 2021

Introduction/Objective

Since the start of the COVID-19 pandemic, much research has focused on the kinetics and magnitude of humoral immune response. With the advantages of monitoring real-time immunoreactions, label-free immunoassay (LFIA) is becoming a powerful tool in serology studies. We have developed LFIAs to measure SARS- CoV-2 antibody avidity and neutralization activity in a cohort of COVID-19 patients and determine if they correlate with antibody concentration. Serial serum samples collected from mild to severe COVID-19 patients were measured out to 8 months post-symptom onset to determine the durability of the neutralizing antibody response.

Methods/Case Report

Based on thin-film interferometry technology, we established a label-free IgG avidity assay and a label-free surrogate virus neutralization test (LF-sVNT). For measurement, sensing probes pre-coated with receptor-binding domain (RBD) of SARS-CoV-2 spike protein are applied to serum samples containing SARS-CoV-2 antibodies. The label-free IgG avidity assay measures the binding strength between RBD and IgG under urea dissociation. The LF-sVNT analyzes the binding ability of RBD to ACE2 after neutralizing RBD with antibodies.

Results (if a Case Study enter NA)

IgG avidity indices and neutralizing antibody titers (IC50) were determined from serum samples (n=246) from COVID-19 patients (n=113). IgG concentrations were measured using a fluorescent immunoassay. The neutralizing antibody titers showed a weak correlation with IgG concentrations and no correlation with IgG avidity indices. Over the time course up to 8 months post-symptom onset, IgG concentrations and neutralizing antibody titers presented similar trends: an initial rise, plateau and then in some cases a gradual decline after 40 days. The IgG avidity indices, in the same cases, plateaued after the initial rise.

Conclusion

The results demonstrated that LFIA could be used an excellent solution in the determination of SARS- CoV-2 antibody characteristics. The study found that IgG concentration and neutralizing antibody titer declined over time, while IgG avidity index remained constant after reaching a plateau. The decline of antibody neutralization activity can be attributed to the reduction in antibody quantity rather than the deterioration of antibody quality, as measured by antibody avidity.
Excellence in Laboratory Practice with the Validation of Opiate Confirmation using Liquid Chromatography/Mass Spectrometry
Authors: Dalal S , Jhala D
Published: October 2021

Introduction/Objective

Veterans are more susceptible to opioid addiction as they are more likely to suffer from chronic pain which leads to increased need of confirmed identification of opiates in toxicology laboratories. Gas chromatography-mass spectrometry (GC-MS) had been a long-accepted method for the quantitative analysis of opiates in urine, but requires tedious, time-consuming, and complex sample preparation steps. On the other hand, liquid chromatography-mass spectrometry (LC/MS) has comparatively simpler sample preparation steps, can handle three times the number of specimens, much faster turnaround times and produces equally valid results. However, the validation experience of this simpler detection method has not been well published, particularly in a Veterans Healthcare Clinical Laboratory setting.

Methods/Case Report

The quality assurance goal of the validation is to demonstrate that the Agilent 6410 Triple Quadrupole LC/MS (Wilmington DE) is able to identify the same opiate drug analytes performed by the GC-MS. Method to method correlation, within run precision, day to day precision, carryover study, matrix (ion) suppression study, and a limit of detection study were performed as part of this validation.

Results (if a Case Study enter NA)

For the total of 156 specimens run for the method comparison, there was 94.9% agreement, or 148/156 samples were concordant. The 8 discrepancies had drugs that were present below the cutoff limit of the LC/MS. Within run precision with 20 replicates of negative, positive, and at the cutoff were run with all results as expected. The day to day precision of a positive and negative sample run over 10 days also yielded results as expected. The carryover study demonstrated minimal carryover. The matrix (ion) suppression study showed ion suppression at 16.8%, which is below the amount needed to affect analyte concentrations. The LC/MS was highly sensitive with a limit of detection of >97% at 25 ng/mL. Thus, the result of comparison showed good concordance.

Conclusion

LC/MS is a simpler, more efficient method of opiate testing that is comparable to GC-MS for the detection of opiate drugs of abuse in urine. This is an example of excellence in laboratory practice by extending the best quality laboratory care with proper validation of instrument methods conducive to laboratory workflow.
A Unique Case of der(16)t(1;16) Identified in B-Lymphoblastic Leukemia
Authors: Fenu E M , Lyalin D , Insuasti-Belrtran G , Beaty M , Pettenati M , Maracaja D
Published: October 2021

Introduction/Objective

A derivative chromosome 16 is rare in hematologic malignancies. There are only two previously reported cases to date, both associated with acute myeloid leukemia (AML). In these cases, the t(1;16) presented as a der(16)t(1;16) resulting in trisomy 1q. This was the sole anomaly in each case. Cytogenetic abnormalities in B-ALL are common and important for understanding of the pathogenesis, classification and prognosis of the disease. Herein we describe a case of der(16)t(1;16)(q12;q24) identified for the first time in a patient with B-cell acute lymphoblastic leukemia (B-ALL), with correlation with morphologic and immunophenotypic findings.

Methods/Case Report

The patient is a 65 year-old male who initially presented with one week of fatigue. A complete blood count showed leukocytosis (white blood cell count of 24.6 x 103/uL), anemia (hemoglobin of 7.9 g/dL), marked thrombocytopenia (platelets of 5 x 103/uL). A differential showed 64% blasts and peripheral blood flow cytometry confirmed B-lymphoblastic differentiation, with two distinct immunophenotypic populations. The patient’s bone marrow biopsy was hypercellular (>95% cellularity) with panhypoplasia and a marked increase in blasts (88% by aspirate manual differential). Cytogenetic analysis of the bone marrow also demonstrated the presence of two clonal cell lines. The first cell line was chromosomally normal, while the second had a t(9;22) translocation and a derived chromosomes 16 from a t(1;16). FISH analysis confirmed 59% of cells demonstrated a BCR/ABL1 fusion event.

Results (if a Case Study enter NA)

NA

Conclusion

The patient’s der(16)t(1;16)(q12;q24) represents a novel genetic abnormality that has not previously been reported in B-ALL. Although it has been described in other acute leukemias, little is known about this abnormality in B-ALL and its implications in pathogenesis and prognosis. Additional molecular testing, including chromosomal microarray analysis, mate-pair, or long-range DNA sequencing or RNA sequencing, could potentially identify the fusion partners and shed light on pathophysiological mechanisms implicated in the leukemic process.
Merkel Cell Carcinoma Presenting as a Malignant Pleural Effusion Post-COVID-19 Hospitalization: a Case Report and Literature Review
Authors: Toprak M , Lanceta J , Rosca O C
Published: October 2021

Introduction/Objective

Merkel cell carcinoma (MCC) is a rare, highly aggressive neuroendocrine carcinoma of the skin, associated with immunosuppression, UV light exposure, and the Merkel cell polyomavirus (MCPyV). Metastatic MCC diagnosed in body fluid cytology is extremely rare. Here, we report on a case of a 65-year-old male presenting with a right pleural effusion and a remote history of MCC, unknown to us during the cytologic evaluation of the effusion. To the best of our knowledge, this is the sixth case of metastatic MCC diagnosed in body fluid cytology reported in English literature, and the first one reported in a patient previously admitted for COVID-19 pneumonia.

Methods/Case Report

A 65-year-old male presented with dyspnea and acute hypoxic respiratory failure. Past medical history was significant for squamous cell carcinoma of the right forearm excised four months prior and ulcerative colitis. The patient had two recent hospitalizations for COVID-19 pneumonia. Chest x-ray on admission demonstrated an enlarged, loculated right pleural effusion. Emergent thoracentesis was performed and 1500 cc of bloody pleural fluid was sent for cytology. The patient’s respiratory status improved. A ThinPrep and a cell block were prepared. Both displayed clusters of small round blue cells with hyperchromatic nuclei, scant cytoplasm, and fine chromatin in a background of rare mesothelial cells, macrophages, and numerous lymphocytes. Immunohistochemical (IHC) studies showed CK20, AE1/AE3, and CAM 5.2 in a perinuclear dot-like staining pattern. CD56, chromogranin, and synaptophysin were also positive. Ki-67 proliferative index was about 40%. TTF-1 was negative, while CD45 highlighted background lymphocytes. The primary care physician was contacted and the patient’s past medical history was significant for MCC. Subsequent MCPyV and SATB2 demonstrated nuclear positivity in the tumor cells. Diagnosis of MCC was done.

Results (if a Case Study enter NA)

NA

Conclusion

MCC is a highly aggressive malignancy rarely reported in body fluids. MCC should be included in the differential diagnosis of malignant pleural effusions, especially in cases of the small blue round cells. Using IHC, like CK20 and neuroendocrine markers including the newer SATB2, can lead to an accurate diagnosis. Additional reporting of such cases may increase awareness, especially where prior history is not readily available, such as in this present instance.
Accuracy of the Milan System for Detecting Neoplastic vs Non-Neoplastic Salivary Gland Lesions: A Retrospective Review
Authors: Fakhri N , Khokhar H , Khreefa Z , Shahmirzadi M , Bhalla R
Published: October 2021

Introduction/Objective

Overlapping morphology and heterogeneity of salivary gland tumors (SGT) poses a diagnostic challenge. FNA is commonly used diagnostic tool for evaluation of superficial and deep lesions of any site, but above limitations restrict its maximum utility. To standardize reporting and to address above limitations, Milan system (MS) of reporting salivary gland cytology, has been developed and implemented by labs. We conducted a retrospective study, applying MS to salivary gland lesions (SGL) to evaluate its accuracy and usefulness in discriminating between neoplastic and non-neoplastic conditions, and thus directing patient management (PM)

Methods/Case Report

10 yr retrospective review was performed to include patients with FNA for SGL, cytology diagnosis categorized using MS, cytology-histology (CH) correlation performed, and patients’ charts reviewed for follow up. Attention given to diagnostic discrepancies between MS categories and the histologic diagnosis

Results (if a Case Study enter NA)

152 patients (20-88yrs) were retrieved, peak incidence 40-49 yrs; M:F ratio 1.2:1. Distribution of the cases in the MS categories: Non-diagnostic (ND) 24, Non-neoplastic (NN) 33, Atypia of Undetermined Significance (AUS) 4, Neoplasm (N) 71, Suspicious for malignancy (SUN) 7, and Malignant (M) 10. 60 cases identified with follow-up histology, of which 51 cases were correlated, distributed as 4 ND, 4 NN, 0 AUS, 37 N, 3 SUN, and 3 M. The uncorrelated 9 cases were distributed as 4 ND due to scant sampling; 2 NN, histologically Warthin’s tumor and sialolipoma; 2 AUS, histologically basal cell neoplasm and infarcted Warthin’s tumor; 1 malignant, histologically cystic mucoepidermoid carcinoma; 0 cases for neoplastic and suspicious for malignancy categories

Conclusion

Milan System is a useful cytologic tool for diagnosing and segregating patients with salivary gland pathologies, however, our study shows MS to be more reliable diagnostic tool with higher accuracy (combined 98%) in N, SUN & M categories as compared to ND, NN & AUS categories (combined 50%)
Diffuse Idiopathic Neuroendocrine Cell Hyperplasia (DIPNECH) on Electromagnetic Navigation Bronchoscopy (EMN) Guided Fine Needle Aspiration (FNA): A Case Report
Authors: Alfattal R , Palacio D M , Shah S , Nawgiri R , Muthukumarana P V
Published: October 2021

Introduction/Objective

DIPNECH is a clinicopathological diagnosis characterized by abnormal proliferation of single or clusters of neuroendocrine cells in the bronchial mucosa. The World health organization includes DIPNECH as a preinvasive lesion to carcinoid tumors of the lung. Diagnosis is often delayed or missed due to insidious presentation and rarity of the disease. High degree of suspicion in the appropriate clinical and radiological context is important for early diagnosis. We describe a unique case of DIPNECH diagnosed by EMN guided aspiration cytology in the setting of multiple incidental lung nodules and confirmed on surgical resection.

Methods/Case Report

A 69-year-old female with history of insidious cough was referred to pulmonology clinic for multiple incidental bilateral lung nodules detected by CT scan, largest involving the right middle lobe. Although the main diagnostic consideration was pulmonary metastasis, several radiological features, including diffuse mosaic attenuation pattern, prompted the possibility of a diffuse neuroendocrine process. Electromagnetic navigation bronchoscopy (ENB) guided fine needle aspiration cytology was performed. Air-dried and Papanicolaou stained smears were scant but showed dispersed and clusters of small cells with fine chromatin with minimal cytoplasm. No necrosis or mitosis were seen. A cell block was prepared that showed rare clusters of tumor cells positive for immunostains synaptophysin, chromogranin, CD56, with a Ki-67 of 1%. In the appropriate clinical and radiological context findings were consistent with a well differentiated neuroendocrine process such as DIPNECH. Right middle lobe resection confirmed extensive DIPNECH with multiple typical carcinoid tumors and tumorlets.

Results (if a Case Study enter NA)

NA

Conclusion

It is essential to be familiar with the clinical and radiological findings of DIPNECH and include it in the differential diagnosis of its mimickers. Although the diagnosis is challenging on limited specimens, this report indicates that EMN guided aspiration cytology can be used as a valuable early tool for accurate diagnosis and timely management of DIPNECH.
Reactive Cellular Changes in Anal Cytology Smears and Its Relation to Future Dysplastic Changes in HIV+ Subjects
Authors: Seydafkan S , Loukeris K , Pincus M R
Published: October 2021

Introduction/Objective

The incidence of anal squamous cell carcinoma is increasing in high risk populations. There is no consensus regarding screening for anal squamous cell carcinoma. Anal pap smears are interpreted using the Bethesda System for cervical cytology. Significant challenges exist for anal cytology that do not apply to cervicovaginal cytology.

Methods/Case Report

We retrospectively reviewed the anal cytology smears performed in our institution between 2012- 2019. The smears with reactive cytology changes (RCCs) were retrieved, and corresponding follow up smears were reviewed.

Results (if a Case Study enter NA)

A total of 39 cytology smears with positive RCCs with no dysplasia diagnosis were obtained. All were HIV+. 32 cases were male and 7 females. The overall mean age was: 37.77 + 11.94 SD (range: 23-65 years). The mean age for men was 36.53 + 11.51 and 43.43 + 13.13 for women. Although this mean age was higher for women, the age difference was statistically insignificant (p=0.7, alpha=0.05). Four of the women patients had concomitant cervicovaginal cytology all of which were negative. Only 1 female had a follow up study which was negative. Of the 39 cases, 26 cases (25 men and 1 woman or a total of 66.7%) had followed up smears versus 13 (33.3%) cases with no follow up. A total of 7 out of the 26 follow ups were negative for dysplasia (26.92%). Of the 26 follow ups, a total of 18 (69.23%) were found to have progressed to either ASCUS (15 or 57.69%) or LSIL (3 or 11.53%). One ASCUS was diagnosed as possible high grade. The mean time to convert to dysplasia was 2.06 + 1.25 years (range 1-5 years). Half of the dysplastic cases developed in a 1 year period.

Conclusion

Patients who have reactive changes on anal cytology should be monitored for possible development of anal neoplasia.
Meningothelial Hamartoma of the Scalp: Clinicopathologic Review of an Unusual Tumor Mimicking a Vascular Neoplasm with Review of Literature
Authors: Li L , Suster D
Published: October 2021

Introduction/Objective

Benign meningothelial hamartoma of the scalp is a rare entity with only scattered case reports existing in the literature. The hamartomatous process is believed to occur secondary to ectopic displacement during embryogenesis with the migration of meningothelial cell precursors to the incorrect location or secondary to an obliterated meningocele. This tumor may be easily missed and may be misdiagnosed as lipoma or sometimes as cutaneous angiosarcoma due to the several histologic features that mimic the histology of a vascular neoplasm.

Methods/Case Report

We report an unusual benign skin lesion occurring in a 19-year-old man with no significant past medical history. The lesion had been present since he was an infant and had been slowly enlarging over the past 15 years. The lesion caused pain and discomfort and the patient underwent an excisional biopsy of the lesion. Histologic examination showed a subcutaneous lesion with ill-defined borders and peripheral areas of infiltration between adnexal structures. Immunohistochemistry performed on the tumor cells showed that they were positive for EMA, progesterone receptor, D2-40, and vimentin. A next-generation sequencing study using a hybrid capture-based panel examining 50 commonly mutated genes in human neoplasia was performed and showed no molecular alterations supporting the benign or non-neoplastic nature of the lesion. Along with this case, we review 20 cases of meningothelial hamartomas from 13 papers and summarize them in the table.

Results (if a Case Study enter NA)

N/A

Conclusion

To our knowledge, this is the first reported case of one of these lesions with associated molecular genetic testing. The molecular study carried out, in this case, did not disclose any genetic variants commonly associated with human neoplasia supporting the notion that this lesion does not represent the neoplastic process but rather a hamartomatous process. Meningothelial hamartoma is an exceedingly rare, benign lesion that may be confused with a low-grade vascular neoplasm due to its rare nature and unusual histologic features.
Solid Cell Nests Hyperplasia (Ultimobranchial Body Remnants) of the Thyroid: A Pitfall
Authors: Bharadwaj H , Khan A
Published: October 2021

Introduction/Objective

Solid cell nests (SCN) are small epithelial cell nests interspersed within thyroid parenchyma, resembling squamous/transitional epithelium. SCNs, which are ultimobranchial remnants, are popularly considered pluripotent stem-cells responsible for developing follicular and C-cells. While SCNs are not an uncommon incidental findings in thyroid, solid cell nest hyperplasia is rare. SCNs are often mistaken for benign entities such as C-cell hyperplasia (CCH) or malignant lesions such as papillary thyroid carcinoma (PTC), metastatic squamous cell carcinoma, or medullary thyroid microcarcinoma (MTC).

Methods/Case Report

To reiterate this diagnostic dilemma, we present a case of a 57-year-old male with a six-year history of Hashimoto thyroiditis and multiple bilateral thyroid nodules. Ultrasonography revealed two nodules, one in each lobe, measuring 2.0x1.9x1.8cm(right) and 1.6x1.5x1.5cm(left). Both were solid, hypoechoic nodules with smooth margins and no echogenic foci. Fine-needle aspiration of right nodule was suspicious for follicular neoplasm, Hürthle- cell type, and the left nodule was atypia of unknown significance. Right-hemithyroidectomy specimen revealed follicular adenoma and oncocytic adenomatous nodules in a background of florid lymphocytic thyroiditis (Hashimoto). In two blocks, small solid nests of cells were identified, largest focus measuring 0.5 cm. The cells were polygonal to epithelioid with moderate amphophilic cytoplasm. Nuclei were centrally located, irregular to oval with occasional grooves. While nests had a squamoid appearance, they did not have intercellular bridges. Although nuclear grooves and evenly dispersed chromatin and chromocenters were noted, they lacked optical clearing or intra-nuclear inclusions characteristic for PTC. Thus, excluding these two possibilities, primary diagnostic considerations were SCN versus CCH. Immunohistochemical analysis showed cells positive for P63 and CK5/6 and negative for PAX-8, TTF-1, thyroglobulin, CEA, and calcitonin.

Results (if a Case Study enter NA)

NA

Conclusion

If wrongly diagnosed as CCH, patients may be placed in a high-risk category for possible development of MTC. It is, thus, necessary to be aware of SCN, which can occasionally become hyperplastic, to prevent misdiagnosis.
The Variations of Insulin-like Growth Factor 1 Measured between Siemens Immulite, DiaSorin Liaison and IDS iSYS
Authors: Lee J K , Li S
Published: October 2021

Introduction/Objective

Insulin-like Growth Factor 1 (IGF-1) is a biomarker for the evaluation of growth hormone activity in the hypothalamic-pituitary axis. The current most common methodology for IGF-1 measurement is automated immunometric assays. In this study, we compared the IGF-1 on Siemens Immulite 2000, DiaSorin Liaison XL and IDS iSYS.

Methods/Case Report

Residual 30-110 serum specimens were randomly selected from routine hospital orders. IGF- 1 was measured on these three platforms and compared with Passing-Bablok regression. Bias was evaluated using the Bland-Altman method.

Results (if a Case Study enter NA)

Weighted Deming regression analysis showed approximately 80% and 56% positive bias on IDS iSYS and DiaSorin Liaison, compared with Siemens Immulite (iSYS=1.81*Immulite-117.65, r=0.91; Liaison=1.56*Immulite-4.58, r=0.98). There was approximately 8% positive bias on Liaison, compared with iSYS (Liaison=1.08*iSYS+0.56, r=0.99). The Passing-Bablok regression analysis revealed approximately 67% and 54% positive bias (iSYS=1.67*Immulite-75, r=0.91; Liaison=1.54*Immulite-3.44, r=0.91). Approximately 8% positive bias on Liaison was observed, compared with iSYS (Liaison=1.08*iSYS+5.65, r=0.99). The Bland-Altman plot showed the agreement between iSYS and Immulite IGF-1 was on average 129.6±123.3 ng/mL, 98.6±148.8 ng/mL between Liaison and Immulite and 37.0±46.5 ng/mL between Liaison and iSYS.

Conclusion

Immunoassays rely on the specificity of antibodies. There are wide variations between different immunoassay platforms for IGF-1 measurement. The standardization of IGF-1 assay is lack. It would be a challenge for clinicians to monitor IGF-1 or treat the patients with pituitary disorders, when switching to another platform. The potential impact of the variations in IGF-1 measurement between different immunoassay platforms should be aware.