bluuebunny/crossref_metadata_2025 huggingface dataset:
The value of cytology in diagnosis of body fluids with lymphoma involvement: a report of 29 cases
Authors: Ak S , Wang X , Zhang S
Published: November 2023

Introduction/Objective

Lymphoma involving body fluids (pleural, abdominal or pericardial) can be secondary or primary (such as primary effusion lymphoma). The incident rate is variable depending on the hospital setting (general or specialty hospitals), and it is generally low. Due to the large specimen volume, relatively easy collecting sample and stable cellular preservation, body fluids are good sources for diagnosis and classification of lymphoproliferative diseases.

Methods/Case Report

A retrospective case search from a tertiary academic medical center during 2015 to 2023 were performed for body fluid cytology with diagnosis of lymphoma. The results of cytology, ancillary cellblock, immunohistochemistry and flow cytometry were collected, and the synchronous or follow-up surgical biopsies/resections were cross examined.

Results (if a Case Study enter NA)

Total 29 cases of body fluids with lymphoma involvement were identified in the study period. There were 22 patients including 9 males and 13 females and age ranged from 16 to 88 years (mean

64.5 years). Only 4 patients (4/22, 18.2%) had history of lymphoma when they presented with body fluids, and the remaining 18 patients (18/22, 81.8%) presented body fluids as the initial or synchronous sign of lymphoma. 26/29 cases had cellblock or flow cytometry done and 13/29 cases had both. All 22 cases had adequate lymphoma diagnosis and classification by combined cytology and ancillary tests and included 5 high grade B cell lymphoma, 3 diffuse large B cell lymphoma, 2 Burkitt, 2 CLL/SLL, 2 small mature B cell lymphoma, NOS, 1 mantel, 1 MYC and BCL-2 double hits lymphoma, 1 primary effusion lymphoma, 1 plasma cell myeloma, 2 T lymphoblastic lymphoma, 1 anaplastic large cell lymphoma, 1 angioimmunoblastic T cell lymphoma. 11 patients had synchronous or follow-up tissue biopsies, and cytology had 100% agreement with the histology diagnosis.

Conclusion

The majority (81.8%) cases of body fluid involvement with lymphomas presented as the initial or synchronous sign of lymphomas in our study series indicating that high pathologic suspicion and adequate cytomorphological skills for lymphoproliferative disorders are necessary for making the diagnosis. Body fluid samples are excellent sources for diagnosis and classification of lymphomas using the available ancillary tools including immunohistochemistry, flow cytometry and molecular testing.
Idiopathic multicentric Castleman's disease with TAFRO syndrome: a case report
Authors: Khan A I , Khan A , Hanan A , Geetha S , Sticco K , Sheikh-Fayyaz S
Published: November 2023

Introduction/Objective

Multicentric Castleman's disease(MCD) is a nonneoplastic lymphoproliferative disorder. Individuals affected by MCD exhibit systemic symptoms accompanied by the presence of multiple enlarged lymph nodes. MCD can be associated with human herpesvirus type-8, POEMS syndrome, or idiopathic (iMCD). TAFRO syndrome, a clinical subtype of MCD is a recently recognized disorder with an unclear cause, it comes with a combination of symptoms, namely thrombocytopenia, anasarca, fever, renal dysfunction, and organomegaly. This case report aims to shed light on the diagnostic challenges due to the rarity and nonspecific nature of TAFRO syndrome.

Methods/Case Report

We report a 30-year-old female who presented with night sweats, fever, fatigue, and cough. She had significant leucocytosis, lymphopenia, thrombocytopenia, anemia requiring transfusion, and elevated creatinine, CT showed ground glass opacities in the lungs and extensive lymphadenopathy. Axillary lymph node excisional biopsy revealed paracortical hyperplasia with increased vascularity, extensive polytypic plasmacytosis, and some follicular hyperplasia. On IHC staining it was positive for CD20, CD79a, PAX 5, and negative cyclin D1 for B lymphocytes. T lymphocytes were positive for CD3, CD5, CD2, CD7, CD4>CD8, Bcl2 and CD43. Plasma cells were composed mainly of IgG cells and some IgG4(IgG4/IgG <20%). HHV8 was negative. Flow cytometry showed 89% lymphocytes with a heterogenous population of T-cells and polytypic B cells. Serology revealed markedly elevated IL- 6, IL-2, VEGF CRP, and ESR while HIV and ANA were negative. Bone marrow biopsy was suggested. A final diagnosis of idiopathic multicentric castle man disease suggestive of TAFRO syndrome was made. The patient received steroids and is currently on siltuximab.

Results (if a Case Study enter NA)

NA

Conclusion

Our case fulfills at least four of the five major diagnostic criteria of TAFRO syndrome. It serves as a valuable addition to the scarce literature on TAFRO syndrome, providing insights into its diagnostic challenges
Aldehyde Dehydrogenase Enzyme in Relation to Cord Blood stem cells Potency
Authors: Elbaz K M
Published: November 2023

Introduction/Objective

In umbilical cord blood transplantation (UCBT), the number of cluster of differentiation (CD)34+ cells and colony-forming units (CFUs) in the cord blood (CB) graft positively correlate with patient survival. Since aldehyde dehydrogenase (ALDH) activity is high in hematopoietic stem cells, the number of ALDH-bright (ALDHbr) cells was examined in comparison with the number of CD34+ cells and CFUs for the quality assessment of CB units, Aim and objectives; to correlate the aldehyde dehydrogenase (ALDH) enzyme assay with colony-forming unit–granulocyte/macrophage (CFU-GM) assay before cryopreservation of cord blood buffy coats (CBBC), in order to investigate the hypothesis that the ALDH assay might exclude apoptotic cells since it is based on enzyme activity.

Methods/Case Report

This study was carried out at Benha University Hospital on Fifty (50) samples of Human Umbilical Cord Blood which were processed for mononuclear cells (MNC) separation by density gradient centrifugation method using Ficoll-Paque media that layered on the diluted blood.

In parallel, 1 million nucleated cells were sampled and prepared for flow cytometry for analysis of ALDH activity according to the manufacturer’s

instructions.

Results (if a Case Study enter NA)

CD34+ ALDH+ (%) (Of MNC) showed significant positive correlation with ALDH++ (%) (Of CD34+) and numbers of total CFU/40000 cells. Also ALDH++ (%) (Of CD34+) showed significant positive correlation with numbers of total CFU/40000 cells.

Conclusion

The ALDH assay excludes nonviable and apoptotic cells, and therefore correlates well with CFU enumeration compared to the number of viable CD34+ cells. We propose that the ALDH assay might replace the CFU-GM method in CBU potency measurements.
Impact of Achieving Hospital Accreditation on Assuring Quality in Clinical Laboratories: Experience of an Oncology Hospital in low middle income country
Authors: Abdou B A , Ghaleb F
Published: November 2023

Introduction/Objective

Shefaa Al-Orman Oncology Hospital (SOH) is a leading cancer care facility in Upper Egypt dedicated to providing specialized treatment to cancer patients for free.

The General Authority of Healthcare Accreditation and Regulation (GAHAR, accredited from the International Society for Quality in Health Care) is the regulatory and accreditation body that ensures that healthcare facilities in Egypt comply with the highest standards of quality and safety.

Here, we aim to assess the impact of GAHAR accreditation process on:

Streamlining workflow, contributing to staff professional development and knowledge, increasing loyalty, and creating a more productive and fair work environment.

- Optimizing turnaround time (TAT).

- Compliance with the minimum retesting interval (MRI) guidelines.

- Healthcare providers' satisfaction with the laboratory services.

- Patients’ satisfaction.

Finally, we aim to emphasize the role of building an integrated lab quality management system that addresses different lab processes/procedures as a basis for la accreditation.

Methods/Case Report

laboratory personnel, healthcare providers and patients responses were measured using questionnaire method to assess the impact of accreditation on various aspects of laboratory services.

Comparative lab statistics were collected from laboratory information system.

Results (if a Case Study enter NA)

As shown by questionnaires, 95% of lab staff reported positive impact on streamlining of workflow, 100% reported in professional development and improvement in knowledge, and increased loyalty and created a fair work environment (80% in each). Healthcare providers satisfaction reached 88%, and patient satisfaction reached 93%. TAT optimization increased from 84.1% to 98.1%.

Prior to accreditation, the lab had an effective internal quality control program. GAHAR mandated enrollment in External Quality Assurance Services (EQAS) to ensure reliable results. In addition, GAHAR mandated a policy/procedure to enforce minimum retesting interval. Application of this policy led to better utilization.

Finally, pre and post-analytical processes were streamlined, leading to improved overall laboratory performance.

Conclusion

Achieving GAHAR accreditation had positive impact on laboratory workflow, staff professional development, compliance with guidelines, ensure reliable laboratory results, and overall laboratory performance. Laboratories should consider accreditation and implementing quality assurance measures to enhance the delivery of high-quality laboratory services and patient safety.
Comparative study on the effect of bacteriophage on MDR E.coli from Urinary tract infections
Authors: Abdelmonem M , Eldaly R , Abdelmageed M , Saleh Abdelfattah M , Wasim H
Published: November 2023

Introduction/Objective

Background: Urinary tract infections (UTIs) associated with urethral catheters are the most common infections during hospitalization. Hospitalization's most common infections are urethral catheter-related UTIs. Bacteriophages infect bacteria exclusively. Phage therapy, especially in Eastern Europe, was widely used before antibiotics. Due to the overuse of antibiotics and the development of resistant bacteria, this therapy approach is regaining popularity.

Methods/Case Report

Subjects and methods: 2223 UAE-based UTI patients (4–68 years old) were examined. The isolated bacteria were identified biochemically and tested for antimicrobial susceptibility using Mueller-Hinton agar disk diffusion (Kirby Bauer's). TSA (Liofilchem, Italy) kept isolates at 4 °C.for each examination. Tryptic Soy agar (TSA; Liofilchem, Italy) was used to grow one isolated colony overnight at 37 °C. This culture was transferred aseptically to 10 mL of fresh TSB medium and grown overnight at 37 °C to 0.8 optical density.

10 ml CaCl2 in 100 ml LB homogenized EMIRATE sewage water. Overnight homogenates with 9 E. coli isolates—24 hours of 37°C incubation. Samples were centrifuged at 12,000x g for five minutes—a 0.45 mm Millipore (France) filter produced phage lysate. TSA (Liofilchem, Italy) was used as a culture medium, and the centrifuged supernatant as phage suspension for the double-layer method. After 37 °C, plaques were examined. Single-plaque isolations followed. EOP was measured on double-layer agar for bacteria with a clear lysis zone (Adams, 1959). calculated EOP. Phages tested individually. EZ1 and EZ2 were negatively stained with Na-phosphotungstate for morphotype.

Results (if a Case Study enter NA)

Results: This study found presumptive E. coli colonies in 478 of 2223 (21.5%) samples by plating pre-enriched samples on MacConkey.

E. coli B2 and B4 were sensitive to Ciprofloxacin, but most strains were resistant to antibiotics. E. coli B3 was Metronidazole-sensitive. Individual E. coli strains were susceptible to phage infection. Podoviruses were the two phages. 3 log decreased due to E. coli growth.

Conclusion

This study shows that a single dose of phage can reduce pathogenic MDR E.coli. Phages' high bacterial inactivation efficiency, safety, and prolonged survival, even in urine samples, allow depth studies, especially in vivo studies, to control urinary tract infection and overcome E.coli resistance.
Sustained Culture of Safety After Select Agent Exposure
Authors: Larsen J , Lau J , Karsten J , Grys T , Graf E , Wrobel R , Francis D
Published: November 2023

Introduction/Objective

In January of 2021 our laboratory experienced the occupational exposure of 3 technologists to the select agent Burkholderia pseudomallei due to improper recognition and manipulation outside a biosafety cabinet. Subsequently, an interactive computer module was created to train technologists on timely recognition, followed by a “fake” patient test to evaluate comprehension. In that initial period, 100% compliance and successful recognition was demonstrated. To evaluate sustained compliance and recognition, another wave of evaluation was performed Jan- Dec 2022.

Methods/Case Report

During the study period several new staff members were hired and demonstrated compliance with completing the computer module. Clinical isolates suspicious for a select agent were reported to the Medical Director on rounds daily and reviewed for potential exposure, which was defined as manipulation of the suspicious isolate outside of the biosafety cabinet. Additional challenge “fake” patients were circulated.

Results (if a Case Study enter NA)

During the study period, 16 isolates were deemed suspicious for select agents based on macroscopic and microscopic morphology and biochemical reactions. Of these, 0 resulted in laboratory exposures. Of the challenge isolates, 1 resulted in a near-miss potential for exposure due to the lack of recognition of macroscopic characteristics.

Conclusion

The use of an interactive computer module focused around timely recognition and safe handling of potential select agents resulted in sustained laboratory safety and avoidance of potential occupational exposures.
Key Considerations when Evaluating Whether to Establish a PD-L1 Laboratory Developed Test (LDT)
Authors: Hung Y , Liu X , Nam M , Rosa M , Saeed L , Schulte J J , Zhang H , Zhang W , Chivukula M , Beumer K , Kelly M , Kim J , Lazure P , Murray S
Published: November 2023

Introduction/Objective

Programmed death ligand-1 (PD-L1) immunohistochemistry (IHC) testing is often used to identify patients with cancer who may be eligible for immune checkpoint inhibitor therapy. The complexity around using different assays and platforms has caused confusion and reluctance to perform in-house PD-L1 testing. Some labs have established a laboratory developed test (LDT) that may be used across multiple types of tumors. To evaluate the role of PD-L1 LDTs, ASCP formed an ad-hoc working group to identify key considerations.

Methods/Case Report

In early 2023, 40 pathologists and laboratory professionals joined the ASCP PD-L1 Learning Collaborative to explore ways to improve PD-L1 testing processes. An ad-hoc working group focused on LDTs and reviewed the literature, spoke with labs using LDTs, and developed guidance questions.

Results (if a Case Study enter NA)

The working group identified these key topics and questions:

Testing volume and types of cancers: How many tests are performed each month to justify an in-house PD-L1 test? Which types of cancers are tested? Do we have (or do we plan to develop) reflex PD-L1 testing protocols for certain types of tumors?

Buy-in from oncologists: Do our medical oncologists feel that a PD-L1 LDT provides the results they need to make treatment decisions across different types of cancers?

Assay selection and testing platforms: Which IHC platform (eg, Ventana, Dako, Leica, etc.) do we currently use and which assay (eg, 22C3, 28-8, SP263, E1L3N, etc.) should we use? How well do these assays stain tumor cells vs. immune cells?

IHC testing processes: What is our volume of IHC testing and how would adding PD-L1 impact our workflow for all IHC tests? How often do we encounter technical issues? How much staff time will it take to add PD-L1? What are the maintenance costs?

Interpretation and scoring: Which pathologists are trained to interpret PD-L1 tests? Are they trained to interpret tumor cells, immune cells, or both? Do we train residents? Which scoring systems will we use and how will we report results?

Validation: How many cases are needed for validation? Should validation samples include tumor cell and immune cell staining?

Reimbursement: How will the lab be reimbursed for performing PD-L1 testing and interpretation?

Conclusion

Before establishing a PD-L1 LDT, the medical laboratory must review these questions against the backdrop of an evolving PD-L1 testing landscape. An LDT may be an appropriate approach for labs that aim to simplify PD-L1 testing based on the IHC platform(s) they are using.
Veteran Healthcare System: A Unique Healthcare Setting Providing Equitable Access to all Patients with Metastatic Lung Cancer in the Era of Precision Diagnostics
Authors: Dalal S , Petersen J M , Jhala D , Allbee A
Published: November 2023

Introduction/Objective

The National Comprehensive Cancer Network (NCCN) Non-Small Cell Lung Cancer (NSCLC) Guidelines Panel strongly advises broad molecular tumor profiling to identify mutations that help guide precision- based patient tailored therapy and subsequent patient counseling. Liquid biopsy with next generation sequencing represents a powerful tool to obtain this information through phlebotomy but is costly and only recently available.

Although ethnic minorities may not have the same access to health care resources, studies of ethnic access to liquid biopsies in the setting of Veteran patients at a Veteran Affairs Medical Center (VAMC) with metastatic lung cancer have not been well studied.

Methods/Case Report

A retrospective review was performed of all patients with a submitted liquid biopsy specimen at a VAMC and a history of metastatic lung cancer from November 26th, 2019, to March 3rd, 2023. Demographic data

was collected for each patient specimen and compared with the ethnic proportions noted in the census of the city where the VAMC is located.

Results (if a Case Study enter NA)

There were a total of 35 patient specimens, with the first liquid biopsy collection occurring on November 26th, 2019. The mean age of the patients was 70. The ethnic composition of the population was as follows: 16 were African American (45.7%), 16 were Caucasian American (45.7%), 2 mixed ethnicity (5.7%), and 1 declined to answer or were of unknown ethnicity (2.9%). The census of the surrounding metropolitan area demonstrated a general population ethnic composition of 43.6% African American and 44.4% Caucasian American.

Conclusion

The proportion of Veteran patients of each ethnicity with metastatic lung cancer that received liquid biopsy testing was similar to the ethnic distribution of the general population of the surrounding metropolitan area. This demonstrates that there was equitable access to this testing modality at the VAMC with potential to deliver best cancer care to the veterans by detection, prognosis, and monitoring treatment outcomes.
Primary Carcinosarcoma of the Pancreas with Focal Cartilaginous Differentiation
Authors: Mirzaei Baboli K , Salehiazar S , Mousavi S , Rector A R
Published: November 2023

Introduction/Objective

Carcinosarcoma is a neoplasm reported in multiple sites with a biphasic pattern sharing both sarcomatous and epithelial morphology. Each component should constitute 30% of the neoplasm to qualify as carcinosarcoma, according to the World Health Organization (WHO) classification. This subtype of malignancy is most frequently found in the uterus but carcinosarcoma of the pancreas is extremely rare. It is a very aggressive tumor with a low survival rate.

Methods/Case Report

A 76-year-old Caucasian man with a history of hypertension was admitted to the emergency department with new-onset atrial fibrillation and ischemic stroke 5 months ago. Initial workup showed "moth-eaten" lesions in the skull base and clivus bone, suggesting malignancy. The further evaluation led to chest/abdomen and pelvis CT scans, revealing a subtle attenuation in the pancreatic tail. MRI of the abdomen showed a pancreatic tail mass concerning pancreatic cancer. CA19-9 and CEA were elevated (133 U/ mL, and 10 ng/ mL, respectively).

Endoscopic ultrasound was performed and showed a 2 cm mass in the tail of the pancreas and fine needle aspiration (FNA) confirmed malignancy with a diagnosis of adenocarcinoma. The patient received neoadjuvant chemotherapy with gemcitabine and paclitaxel and underwent distal pancreatectomy, splenectomy, and left adrenalectomy.

Histopathologic examination revealed a biphasic neoplasm with moderately differentiated adenocarcinoma and abruptly transitioning spindle cell malignancy with focal cartilaginous differentiation. Due to the presence of focal cartilaginous differentiation, no immunohistochemistry (IHC) was required and a final diagnosis of carcinosarcoma of the pancreas with multiple lymph node involvement (ypT2, pN2) was made.

Results (if a Case Study enter NA)

NA

Conclusion

Carcinosarcoma is a neoplasm of mixed epithelial and mesenchymal-like tumor cells on pathologic examination. IHC is often very helpful for correct diagnosis, especially Cytokeratin and CEA. In this case, due to the presence of high-grade spindle cell sarcoma and cartilaginous differentiation, no IHC is required. Surgical resection is the definitive treatment for operable patients and is recommended when possible. In this case, only the adenocarcinoma component was identified preoperatively on FNA, and standard pancreatic adenocarcinoma neoadjuvant chemotherapy was also utilized in treatment.
Sepsis Inpatient Diagnostic Testing at Mid-Size Academic and Non-academic Health Systems
Authors: Zhou Y , Windham A K , Staker C , Whitted M , Brimhall B , Podichetty A , Clark K
Published: November 2023

Introduction/Objective

Comparison of clinical laboratory test and radiology imaging utilization for sepsis inpatients across multiple academic and non-academic health systems would be useful for healthcare resource utilization benchmarking.

Methods/Case Report

We compared laboratory and imaging utilization for adult patients hospitalized for sepsis procedures at mid-size (250-450 hospital beds), academic (N=12; 31,353 hospitalizations) and non-academic (N=18; 54,192 hospitalizations), hospitals using the Vizient Clinical Data Base™ over 3 years (2019-2021). We used Medicare Severity Diagnosis Related Groups (MSDRG), used by the US Centers for Medicare and Medicaid Services (CMS), to identify hospitalizations for sepsis (MSDRG triplet 870/871/872). We stratified patients by severity comorbid conditions and complications into high, moderate, and low severity groups. We compared the mean number of clinical laboratory (CPT codes 80000-89999) and imaging studies (CPT codes 70000-79999) per hospitalization and per hospital day. We also measured aggregate clinical Resource Intensity Weight (RIW) per hospitalization to quantify diagnostic resource consumption for each encounter. The RIW is based on the US Centers for Medicare and Medicaid Services (CMS) Ambulatory Payment Classification (APC) weights.

Results (if a Case Study enter NA)

Mean laboratory tests were significantly greater (p<.01) at academic hospitals per encounter (152.2 vs. 95.4 tests, 59.5% higher) and per hospital day (14.5 vs. 9.9 tests, 46.5% higher). Laboratory RIW was also higher per hospitalization (21.0 vs. 13.5 RIW, 55.6% higher) and per hospital day (2.0 vs. 1.4 RIW, 42.9% higher) at academic hospitals. Mean imaging studies at academic hospitals were higher per case (7.8 vs. 7.2 studies, 8.3% higher) but not different per day (0.80 for both hospital groups). Imaging RIW was not significantly different between academic and non-academic hospitals either by encounter (11.1 vs. 9.9, 12.1% higher) or per day (1.2 for both hospital groups). Imaging comparisons lacked statistical significance. Analysis of utilization after stratification for severity levels revealed a similar pattern with greater differences in the high severity group.

Conclusion

Mean laboratory tests and laboratory RIW per hospitalization are greater at academic hospitals. These differences persist after adjustment for hospital length of stay and severity level. Differences in imaging studies and imaging RIW were not significant.
Atypical Teratoid Rhabdoid Tumor: 28-years institutional experience
Authors: Shaheen M , Vortmeyer A O
Published: November 2023

Introduction/Objective

Atypical teratoid/rhabdoid tumor (ATRT) is a malignant central nervous system tumor affecting young children, characterized by biallelic mutations of SMARCB1 (hSNF5/INI1), consisting of a varying mixture of rhabdoid cells, small round blue cell (SRBC) and epithelial/mesenchymal components. Combination of surgical resection, chemoradiotherapy and autologous stem cell transplantation (SCT) has led to significant improvement in survival.

Methods/Case Report

Cases of ATRT in the past 28 years have been re-examined, including H&E stains, immunohistochemistry, available molecular studies and clinical charts.

Results (if a Case Study enter NA)

A total of 23 cases of ATRT were recruited to include 20 pediatric (age 3-36 months, median 13.5 months) and 3 adult cases (27, 38 and 46 years). 73.9% were male. Two pediatric cases presented in patients with Pierre-Robin sequence and Phelan-McDermid syndrome and one adult had history of Choriocarcinoma. 72.7% of cases initially presented in the posterior fossa, with 3 cases presenting in temporal lobe, 1 in frontal lobe, 1 in 3rd ventricle and 1 in pituitary gland. Mean size at presentation was 4.7 cm (range 2-10 cm).

Median survival was 12.5 weeks with 8 patients surviving 5-13 years. 10/22 cases developed recurrences and/or spinal drop metastasis. Median time to first recurrence/ drop metastasis was 3.5 months (range 0-66 months). Cases showed varying proportions of rhabdoid, SRBC, epithelioid and mesenchymal components. By immunohistochemistry, INI1 was lost in 19/19 cases. Keratins, GFAP and Synaptophysin were positive in 13/17, 14/20 and 17/21 cases, respectively. Interestingly, GAB-1 and YAP1 were positive in 5/6 and 4/4 cases, respectively. Five cases had SMARCB1 mutation on NGS, one had NF2 truncation and another showed variation of unknown significance involving mainly NOTCH1 gene. 21/22 patients underwent surgical resection, of which 17 additionally received a combination of chemoradiotherapy and SCT and 1/22 underwent palliation.

Conclusion

Our data highlights the spectrum of presentation and survival of cases of ATRT and the importance of INI1 immunohistochemistry in the diagnosis, especially for the occasional cases co-expressing GAB1 and YAP, a potential diagnostic pitfall with medulloblastoma.
Case of Metastatic Atypical Meningioma to Lung: Utility of Cytological Preparations for Intraoperative Diagnosis
Authors: Guo Y , Valk J E , Fecher R , O'Toole K , Saqi A , Sonett J
Published: November 2023

Introduction/Objective

Meningiomas are the most common primary intracranial and intraspinal tumors. They are typically benign with an indolent behavior but can metastasize extracranially to the skin, bone, lymph node and liver. Lung metastasis is exceptionally rare, and the diagnosis can be challenging, especially during intraoperative diagnosis without ancillary studies. We describe a metastatic atypical meningioma to the lung for which intraoperative cytology facilitated the diagnosis and guided management.

Methods/Case Report

A 53-year-old woman with a history of left frontal atypical meningioma and multiple surgical resections for recurrences at outside hospitals, presented with an incidental left lung nodule. A lung wedge resection was performed and submitted for intraoperative diagnosis. Gross examination revealed a well-circumscribed, tan- white, and rubbery subpleural nodule. Cytological preparations— Diff-Quik and H&E stains—and frozen section were prepared.

Cytologically, the nodule displayed cohesive distinctive papillary whorls of uniform eosinophilic cells with indistinct cell membranes, round to oval nuclei with central nucleoli and intranuclear pseudoinclusions. The frozen section exhibited similar cytological features, few identifiable whorls and predominantly solid sheets of tumor cells typical of non-small cell carcinoma. Based primarily on the cytological findings, the intraoperative diagnosis was a neoplasm with papillary growth pattern, and a metastasis was favored based on the whorled pattern and clinical history; no further resection was performed.

Permanent sections displayed mitoses and no necrosis. Immunohistochemical analysis revealed positivity for somatostatin receptor 2a, progesterone receptor, and EMA (focal); no staining was seen with pancytokeratin, TTF-1, or p40. A diagnosis of atypical meningioma, WHO grade 2, was rendered. Subsequently, an atypical cranial and temporalis muscle meningioma at the site of the prior craniotomy bone flap was resected and had an identical molecular profile (1p36 deletion) to that in the lung, further supporting metastasis to the lung.

Results (if a Case Study enter NA)

NA

Conclusion

This case illustrates a rare presentation of metastatic atypical meningioma and highlights the distinctive intraoperative utility of cytology preparations—architectural and cytological details—for diagnosis and appropriate management. Cytology preparations can be a valuable tool and complement frozen sections, in which certain morphological features may be less obvious or confounded by freezing artifact.
Primary Chest Wall Ewing Sarcoma with Indolent Behavior in an Elderly Male
Authors: Sagan O , Schmidt A L , McMullen P
Published: November 2023

Introduction/Objective

Ewing sarcoma (ES) is the second most common primary malignant bone tumor, primarily affecting children and young adults within the first two decades of life. Over 80% of cases are positive for CD99 and exhibit a characteristic t(11;22) translocation resulting in an EWSR1::FLI1 fusion. Extraosseous ES is extremely rare and most reported cases occur in patients less than 50 years old. We report an unusual case of extraosseous ES arising from the chest wall in an elderly male that showed slow interval progression on imaging studies.

Methods/Case Report

An 83-year-old male with a past medical history of COPD and tobacco use presented to the emergency department for a mechanical ground level fall and a worsening cough over the prior week. Of note, he was found to have a 6.1 cm pleural based mass seven years prior. The patient was ultimately discharged home with recommended oncologic follow-up for this long-standing chest wall mass due to an increase in size on imaging. A PET scan showed a hypermetabolic subpleural mass in the right lower chest wall measuring 7.6 cm with invasion through the adjacent ribs and intercostal spaces into the adjacent soft tissue. A core biopsy was performed, which demonstrated a small round blue cell tumor diffusely positive for CD99 and Bcl-2, lacking significant mitotic activity and necrosis. Given the unusual clinical features, a next generation sequencing (NGS) panel for sarcoma fusions was performed and identified an EWSR1::FLI1 fusion, supporting the diagnosis of ES/primitive neuroectodermal tumor (PNET).

Results (if a Case Study enter NA)

NA

Conclusion

ES is relatively common as a primary bone tumor in children and young adults, but is rare in the chest wall and pleura and is extremely rare in the elderly. The clinical course for ES is typically aggressive. Diagnosis of ES can be challenging as CD99 positivity is nonspecific. The characteristic t(11;22) EWSR1::FLI1 fusion can be identified through FISH or NGS. At 83 years old, this is, to our knowledge, the oldest patient reported in the literature with this diagnosis. The slow interval growth of this mass over a period of seven years is also unusual. These combined clinicopathologic features are exceedingly unique and expand upon the reported spectrum and behavior of the Ewing’s family of sarcomas. The use of broad NGS panels among pathologists may result in increased identification of ES in unusual clinical settings in the future, while also providing more confident pathologic classification in challenging situations.
A diagnostically challenging case of Lymphoplasmacytic lymphoma involving the kidney clinically mimicking benign hypertension associated chronic kidney disease
Authors: George R S , Huang X , Lightle A
Published: November 2023

Introduction/Objective

Lymphomas involving the kidneys are under-recognized and often do not present clinically with signs and symptoms raising suspicion for a hematological malignancy. Worsening renal function may necessitate renal biopsy, but often the clinical picture may not warrant a biopsy. We herein present a case of lymphoplasmacytic lymphoma involving the kidney clinically mimicking benign renal vascular disease associated chronic kidney disease.

Methods/Case Report

Elderly male with past medical history of stage 3 chronic kidney disease presumed to be due to benign hypertension and undergoing treatment for the same presented to his nephrologist for routine follow up. His renal parameters were stable, but his high blood pressure seemed to be difficult to control despite maximum medical intervention. Upon the patient’s request to know exact etiology of his kidney problem, a renal biopsy was performed. Histomorphological evaluation revealed multifocal areas of renal parenchymal infiltration by atypical lymphocytic aggregates with background renal parenchyma showing moderate arteriosclerosis, mild interstitial fibrosis, tubular atrophy and no significant glomerulopathy. Further workup of the lymphoid aggregates led to the finding of a low grade CD5 negative, CD10 negative B-cell lymphoma with plasmacytic differentiation. Molecular testing for final characterization revealed a MYD88 mutation, which along with the immunomorphological findings confirmed the diagnosis of lymphoplasmacytic lymphoma (LPL). The patient was referred to hematology-oncology and was recommended to start chemotherapy due to renal involvement.

Results (if a Case Study enter NA)

n/a

Conclusion

In medical renal biopsies, lymphocytic infiltrates in areas of interstitial fibrosis are very common, and an atypical lymphocytic infiltrate can be easily overlooked. Pathologists evaluating these biopsies should have a high degree of suspicion for a hematological malignancy if they encounter atypical lymphocytic infiltrates in the renal parenchyma. Accurate diagnosis is essential, as renal lymphoma whether primary or metastatic, requires initiation of timely systemic chemotherapy.
Blood Type Verification Rejection Rate Reduction
Authors: Abdelmonem M , Cai W , Kilambi S , Yoshizuka S , Nguyen A , Quach T , Howard E , Chang S , Vukic K , Shan H , Yunce M
Published: November 2023

Introduction/Objective

Specimen collection is an initial pre-analytical process that ensures accurate, reliable, and timely patient results. In accordance with AABB and CAP Standards, Transfusion Service rejects specimens if they do not meet predefined technical requirements for each specific analyte. First-time patients admitted to Stanford Health Care (SHC), requiring blood transfusions, must have a current blood type on file. The blood type must be confirmed with a second, independent blood specimen called the Blood Type Verification (BTVI). Collection of the BTVI ensures that the patient’s blood type is confirmed. This is required in order to help prevent transfusion of ABO-incompatible blood products, which could result in a potentially severe transfusion reaction. SHC policy requires the Type and Screen (TNS) and BTVI to be drawn at least one minute apart. If collected at the same time, the BTVI specimen is rejected a and a redraw is requested. This process could potentially delay patient care and cause patient discomfort.

Methods/Case Report

It was identified that a key component to decrease specimen rejections would be to leverage technology to drive adherence to policy, rather than rely on human-driven, manual processes. In collaboration with Nursing and IT, a technological mechanism was developed to disallow the printing of the BTVI label until the TNS is documented as collected within the electronic health record (EHR). The BTVI would be accessible one minute after the TNS is collected to ensure that a second, independent patient verification is completed. The IT solution ensures that the documentation time follows policy and standards, which, enhances patient safety by reminding staff to complete a second patient verification as needed

Results (if a Case Study enter NA)

We implemented the IT solution for BTVI in October 2022. The BTVI rejection rate for samples accounted for 52% of overall rejected specimens in the department. In October, November, and December, the BTVI sample rejection rate accounted for 47%, 10%, and 0% of overall rejected samples in the department, respectively. We continue to monitor BTVI rejection rates closely to ensure that the IT solution is working as expected and that standard workflow is followed per SHC policy

Conclusion

This IT enhancement has improved patient safety by ensuring that accurate blood type is determined to provide cross- matched blood products to patients in a timely manner. Additionally,, it has improved patient care by reducing the number of redraws and preventing transfusion delays.
Prevalence and Distribution of ABO and Rh (D) Factor among Blood Donors in the United Arab of Emirates
Authors: Abdelmonem M , Altayyari K , Wasim H , Saleh Abdelfattah M
Published: November 2023

Introduction/Objective

Karl Landsteiner discovered the ABO blood group system in 1900, which was the first human blood group system. The Rh blood group system was found forty years later. The antigens on the surface of red blood cells are used to classify people into ABO blood groups. In the ABO system, there are four types: A, B, AB, and O; in the rhesus system, there are two types: Rh-positive and Rh-negative. Blood group identification is critical for efficiently managing blood banks and blood transfusion services to avoid serious transfusion reactions.

Methods/Case Report

The study was performed on a total of 5996 healthy blood donors in the United Arab of Emirates (UAE). ABO and Rh (D) groupings were performed on all donors' samples by the gel electrophoresis technique. Data on the frequency of ABO and Rh(D) blood groups were reported in numbers and percentages.

Results (if a Case Study enter NA)

The study revealed that type O is the most prevalent blood group in the United Arab Emirates (43.83%), followed by A at 26.68% and B at 23.90%, with AB having the lowest prevalence at 5.58%; O

> A > B > AB. Our study found that 92.57% of the donor population was Rh-positive, whereas 7.43% was Rh- negative. The IA, IB, and IO allele frequencies were determined using the Hardy-Weinberg rule of equilibrium. The gene frequencies are calculated to be 0.1942 for IA (p), 0.1438 for IB (q), and 0.6620 for IO (r). O (r) has the most

value in UAE, followed by A (p) and B (q); O > A > B. OO constituted 43.83% of the homozygous types, AA 3.77%, and BB 2.06%. The heterozygous types were 25.71% for AO, 19.03% for BO, and 5.58% for AB.

Conclusion

The study gives reliable ABO gene frequency statistics and information on the distribution of ABO blood group Rh groups of various alleles in the United Arab Emirates. This knowledge aids in the efficient management of the blood bank's inventory. It will aid transfusion services in anticipating future health issues and improving blood transfusion practice.

The study is the first to give reliable ABO gene frequency statistics and information on the distribution of ABO blood group Rh groups of various alleles in the United Arab Emirates. This knowledge aids in the efficient management of the blood bank's inventory. It will aid transfusion services in anticipating future health issues and improving blood transfusion practice.
Ectoparasitosis induced severe anemia: a rare cause of severe iron deficiency anemia
Authors: Kokabee M , Murrell D , Otero Espinal D , Levine R
Published: November 2023

Introduction/Objective

Ectoparasites generally infest human’s head and body. It is primarily asymptomatic, however, it can cause iron deficiency anemia on rare occasions, even in developed countries. Bird mites can feed on the blood of people who live near infested pigeons or other infested animals.

Methods/Case Report

We present a 53 years old homeless male who lives in the New York City’s streets. He was brought to the emergency department by EMS due to ataxia and not being able to stand. Upon arrival, he was covered with countless small ectoparasites later identified as bird mites according to an exterminator.

Decontamination and stabilization of patient was begun. No active bleeding or sign of trauma was identified. Complete blood count (CBC) was performed and hemoglobin (Hb) of 2.2 g/dL with Hematocrit of 9.2 % was confirmed after repeat on a second sample. Mean corpuscular volume (MCV), red blood cell (RBC) count, reticulocyte percent and red cell distribution width (RDW) was 73.3 fl, 1.26 M/uL, 3.3 % and 19.9 % respectively. Iron study was not performed initially. White blood cell and Platelets count were normal. Hemoglobin electrophoresis was negative for hemoglobinopathies. After initial transfusion of 2 packs of RBC, the Hb was 3.4 g/dL. He started to have seizures and was intubated. He was transferred to ICU. Ferritin level was checked after transfusion and was still markedly decreased (10.9 ng/mL). He received 6 packs of RBC in total (within 10 hours) and Hb reached 8.7 g/dL, and 48 hours after intubation he was extubated. The patient discharged himself against medical advice the next day.

Results (if a Case Study enter NA)

NA

Conclusion

With increasing homelessness, physicians should be aware that ectoparasitosis: 1) is a rare cause of iron deficiency anemia, and 2) because of the gradual onset of the anemia, rapid correction with a massive transfusion is neither warranted nor advised.
Difficulties in identifying antibodies of high frequency antigens: A case report of anti-Holley antibody
Authors: Muldoon J , Gabbard A P , LePage N L , Bielen K
Published: November 2023

Introduction/Objective

The Dombrock blood group system consists of the Dombrock (Do), Gregory (Gya), Holley (Hy), and Joseph (Joa) antigens, of which, the Gya, Hy, and Joa represent high prevalence antigens. Anti-Hy antibodies have been implicated in hemolytic transfusion reactions and hemolytic disease of the fetus and newborn.

Methods/Case Report

We report a 22-year-old black female who presented with extensive burns following trauma. At admission the patient typed O, D-positive with a negative indirect antibody test (IAT). After receiving multiple units of red cells, plasma, and platelet products (>100 units total) the patient’s IAT, direct antiglobulin test (DAT) polyclonal, DAT IgG, and DAT C3 became seropositive (day 15 of ongoing transfusions). Elution was negative at all tested phases. An antibody rule-out panel was performed with pan-reactivity at polyethylene glycol (PEG)- anti-human globulin (AHG) (2+), Low ionic strength saline (LISS)-AHG (weak +), Ficin-AHG (2+), and negative with dithiothreitol (DTT)-PEG-AHG. Common DTT sensitive antigens were ruled out. Antigen typing displayed mixed field reactions secondary to transfusions. Hy-Jo(a-) confirmed cells were non-reactive at immediate spin and PEG-AHG. The patient was Dob positive, ruling out a null phenotype. Molecular testing could not be confirmed with serologic testing due to the extensive number of transfusions. Subsequent crossmatching demonstrated 1+ reactivity. The patient clinically tolerated the incompatible units. Her IAT resolved on day 29 of ongoing transfusions and remained negative throughout subsequent testing and transfusion.

Results (if a Case Study enter NA)

NA

Conclusion

Identification of antibodies to high frequency antigens is challenging due to the limitation of antigen negative sera in the setting of pan-reactive cells. Furthermore, blood contaminated with donor product limits the ability to perform serologic testing in the setting of mixed field reactivity. This case highlights the difficulty in identifying antibodies to high frequency antigens as well as the limitations in patient testing after extensive transfusion.
Quality Analysis of Lupus Anticoagulant Testing: Indeterminate and Interference
Authors: Bell Timothy , Gil Morayma Reyes , Duckworth Lauren (Ashley) , Mannion Peter , Alnaqshabandi Sarah , Bhattarai Narendra
Published: November 2023

Lupus anticoagulant (LA) testing is a commonly performed test within hemostasis laboratories. Criteria for diagnosing a LA based on the International Society on Thrombosis and Hemostasis are: prolonged phospholipid-dependent (PD) clotting test, evidence of an inhibitor, evidence the inhibitor is PD, and exclusion of specific inhibitors. At our academic institution, we analyzed Lupus anticoagulant results to establish common sources of drug interference (DI), identify causes of indeterminate results, and evaluate if repeat testing was performed on patients with an initial indeterminate test. At this institution, Lupus anticoagulant evaluation includes activated partial thromboplastin time (aPTT), Anti-Xa activity, Thrombin Time (TT), diluted Russell Viper Venom Time, hexagonal phase phospholipid assay, and Platelet Neutralization Procedure. Samples with Anti-Xa activity >0.1 IU/mL and/or elevated TT are treated with hepzyme; if the Anti-Xa activity or TT does not correct, testing is not completed. Samples with elevated aPTT undergo an immediate and incubated mixing study (MS). Samples are considered positive (POS) for LA if there is a positive screening test (+ST), +MS, and evidence of PD in at least one assay. Tests are resulted as indeterminate (IND) with a +ST and either +MS or +PD. LA results are reported as unlikely (UNL) if only a single phospholipid panel is positive without +ST or +MS, and negative (NEG) if the ST, MS, and PD assays are all negative. Patients with indeterminate LA testing are recommended to have repeat LA testing after 12 weeks. A total of 3025 cases were identified over the 18-month period (July 2020 – December 2021). The majority of cases were interpreted as NEG (2310; 76%) followed by 8% POS (229), 6% IND (174), and 1% UNL (34). While the majority of IND met the ST (99%) and PD (71%) criteria, only 32% were +MS, indicating failure of an inhibitor detection in the mixing study is the major factor preventing an IND from becoming positive. Within the IND group, only 25% (43) underwent the recommended repeat LA testing. The results of repeated 43 IND tests are as follows: 16 NEG, 4 POS, 19 IND, 3UNL, 1 DI. While a significant proportion of IND repeated testing became negative, a majority remained IND, arguing for more comprehensive LA testing. This quality study demonstrates the majority of patients at this institution who receive an interpretation of IND LA do not undergo the recommended repeat testing, underscoring the importance of follow-up and education to standardize care. Prospective studies maybe needed to elucidate the clinical significance of IND LAs. Additionally, 278 (9%) cases were canceled due to drug interference, the majority (192; 69%) due to direct oral anticoagulants (DOAC). Testing for LA in patients actively receiving DOACs should be discouraged. Alternatively, methods to remove DOAC interference should be standardized.