bluuebunny/crossref_metadata_2025 huggingface dataset:
Leiomyosarcoma of Urinary Bladder, A Review of Two Cases
Authors: Fakhri N , Bhalla R
Published: October 2020

Introduction/Objective

Leiomyosarcomas of the urinary bladder are rare smooth muscle tumor, and constitute 1% of all bladder malignancies. Although rare, leiomyosarcoma is a clinically significant disease, presenting as a high-grade advanced malignancy with associated substantial morbidity and mortality, if not treated early. The diagnosis can be delayed because of the asymptomatic presentation until the tumor reaches an advanced stage.

Methods

We present two cases of leiomyosarcoma of the urinary bladder. First case: a 63 years old female with a history of cervical carcinoma treated with radiation, 25 years ago, followed by uncomplicated clinical course, until recent development of vesicovaginal fistula. During her work up with cystoscopy, a large bladder mass was identified. Second case: a 71 years old female with a history of treated breast cancer, who presented with recurrent history of cystitis and hematuria. Cystoscopy revealed a nodular mass in the right posterior bladder wall.

Results

Microscopically, both lesions were highly cellular with infiltrative, interlacing fascicles of spindle cells and associated mitosis, cellular atypia and necrosis. Immunohistochemistry revealed positive expression of muscle- specific actin, desmin, and caldesmon; with negative expression of ALK-1, EMA, Cytokeratins and GATA3, in both the cases. Other spindle cell lesions including, leiomyoma, inflammatory myofibroblastic tumor and sarcomatoid carcinoma were included in the differential diagnosis, and ruled out by morphology and immunohistochemistry.

Conclusion

Our cases highlight the importance of awareness of the occurrence of leiomyosarcomas, a rare manifestation in bladder. Although rare, but they present with a poor outcome. The differential diagnosis of spindle cell lesions is extensive, including close benign and malignant mimics, the treatment of all being very different. Immediate radical cystectomy has been associated with longer survival rates for leiomyosarcoma. Leiomyosarcoma, being aggressive, with associated high recurrence rate and metastatic potential, an early correct diagnosis would aid in the institution of proper management.
Malignant Extrarenal Rhabdoid Tumor in a 5-Month-Old Male With Mediastinal and Heart/Great Vessel Involvement
Authors: Khokhar H , Craver R , Stark M
Published: October 2020

Introduction/Objective

Extrarenal rhabdoid tumor is a high-grade soft-tissue predominately pediatric malignancy with a frequency of 0.15 per million children less than 15 years. It is associated with del(22) (q11.2) with SMARCB1 loss, recognized by loss of INI-1 staining. It has distinct perinuclear hyaline inclusions; however, this feature can be present in other tumors. We describe a malignant extrarenal rhabdoid tumor involving the heart and great vessels to highlight the multiple modalities required for the diagnosis of this tumor in this unusual location.

Methods

We utilized routine histology, immunohistochemistry, and electron microscopy.

Results

This 5 -month -old male presented with respiratory distress due to a mass that invaded the heart, surrounding the great vessels. The tumor was composed of sheets of polygonal large cells with light pink to clear cytoplasm, eccentric nuclei with mild anisonucleosis, peripherally marginating chromatin, prominent nucleoli, with 2 mitoses per 10 high power field. Hyaline perinuclear inclusions were inapparent. There were frequent clusters of lymphocytes and eosinophils, with 10 percent necrosis and moderately increased vascularity. The tumor was positive for vimentin, SMA, EMA, MSA, S-100, keratin, and WT1, and negative for INI-1, CD34, ALK, AFP, PLAP, CD30, myogenin, NeuN1, synaptophysin, chromogranin, and NSE. Electron microscopy demonstrated occasional cells with perinuclear collections of intermediate filaments, some with whorls. The strong positivity for vimentin, keratin, SMA, MSA, S-100, negative staining for INA-1 and CD34, and visualization of perinuclear intermediate filament whorls by electron microscopy helped make the diagnosis of extrarenal rhabdoid tumor.

Conclusion

Malignant extrarenal rhabdomyosarcomas may occur in the middle mediastinum, invade the heart, occur in the first 6 months of life, and not have the typical rhabdoid cells. Diagnoses depend on multiple modalities
Abdominal Inflammatory Myofibroblastic Tumor: Minimal Inflammatory Infiltrate and Diffuse Immunoreactivity for Caldesmon are Potential Diagnostic Pitfalls
Authors: Alawad M , Dehghani A , Levitan D , Cruickshank K
Published: October 2020

Introduction/Objective

Inflammatory myofibroblastic tumor (IMT) is an uncommon spindle cell lesion that can involve various organs and occurs in multiple body sites. While older terminology (i.e. inflammatory pseudotumor) suggested otherwise, recent molecular studies point toward a neoplastic pathogenesis for IMTs. Herein, we report a case of an abdominal IMT and discuss the morphologic and immunohistochemical pitfalls pertaining to this entity.

Methods

A 75-year-old woman presented with complaints of generalized abdominal pain and distention. An abdominal CT scan showed multiple peritoneal masses, the largest of which measured 23 cm. Biopsy revealed compact fascicles of bland spindle cells exhibiting diffuse actin and caldesmon immunoreactivity, consistent with a spindle cell tumor with smooth muscle differentiation. Mitotic activity was low-to-unapparent. Surgical excision was performed. The cut surface of the tumor was tan-white with hemorrhagic foci. Histopathologic examination of the tumor showed elongated spindle cells set in a loose myxoid stroma rich in blood vessels and a mixed inflammatory infiltrate. Deeper sections of the tumor were more cellular, showing a similar morphology to that seen in the original biopsy, which was virtually devoid of inflammatory cells. Immunohistochemistry showed diffuse staining for desmin, caldesmon, smooth muscle actin, and ALK. FISH analysis showed ALK gene rearrangement in 52% of tumor cells, confirming the diagnosis of IMT.

Results

Studies in the literature show that IMTs express smooth muscle markers such as SMA (90%) and desmin (50%). However, immunoreactivity for caldesmon is rarely reported. ALK immunoreactivity is seen in about 35–60% of cases, and when gene rearrangement involving ALK is detected the diagnosis can be confirmed.

Conclusion

Historically, several terms have been used to describe IMTs, including inflammatory pseudotumor and inflammatory pseudosarcomatous fibromyxoid tumor. While the nomenclature consistently implies an inflammatory infiltrate, this tumor could have various morphological patterns with some areas showing very little to absent inflammation, as demonstrated in our case. Hence, making an accurate diagnosis could be challenging on a limited biopsy. Therefore, ALK testing should be included as part of the diagnostic workup of spindle cell neoplasms with smooth muscle differentiation.
Benign Rete Testis Mimicking as a Small Cell Carcinoma in a Hydrocele Specimen – A Rare Finding in a Veteran Patient and a Diagnostic Pitfall
Authors: Dalal S , Petersen J M , Jhala D
Published: October 2020

Introduction/Objective

Hydrocele specimens are one of the most common and routine urological specimens sent to pathology with mostly a benign outcome. Microscopic examination usually reveals loose connective tissue, mesothelial lining and possibly chronic inflammation, squamous metaplasia in long standing cases.

Methods

We present here a case of a veteran with rare finding of small, blue clusters of hyperchromatic cells in a hydrocele specimen mimicking small cell carcinoma.

Results

An elderly African American patient presented to the urology with a symptomatic hydrocele for elective removal. His review of systems preoperatively and intraoperative finding was otherwise unremarkable. Gross examination of the specimen showed a fibro-membranous tissue without any nodules or lesions. Microscopic examination showed fibromuscular tissue with scattered, detached clusters of small, blue, hyperchromatic cells with high nucleo-cytoplasmic ratio, nuclear molding without prominent nucleoli. Morphologically these features were suspicious for malignancy such as small cell carcinoma. However, no apparent mitotic figures or necrosis was noted. On immunohistochemical stains, these cells showed expression of CD 56, however proliferation rate on Ki67 was very low (0–1%).

Conclusion

Non-neoplastic proliferations are rare in testis and para-testicular structures. Rete testis is an anastomosing network of delicate channels located in the testicular hilum lined by flattened cuboidal to columnar epithelium with numerous microvilli. In a long-standing hydrocele specimen, the cells of rete testis may get sloughed off and form aggregates of small, blue hyperchromatic cells, morphologically mimicking as small cell carcinoma.

However, on close examination, these cells in cluster were “streaming”, no necrosis, atypical mitotic figures or apoptotic cells were noted. Also, it has been well known that normal rete testis cells are positive for CD 56. Thus, low ki67 proliferation rate, CD 56 positivity and absence of necrosis or mitotic figures were consistent with sloughed rete testis cells. This is a very rare finding in a routine hydrocelectomy specimens, not only highlighting the importance of thoroughly grossing the specimens; at the same time, knowledge of this benign mimicker is important to avoid erroneous diagnosis and management.
Histopathological Spectrum in Pancreaticoduodenectomy Specimens: Fifteen Year Study from a Tertiary Care Centre in North India
Authors: Siddiqui S H , Kumari N , Krishnani N
Published: October 2020

Introduction/Objective

The periampullary region is histologically complex owing to the confluence of three different kinds of epithelia (duodenal, pancreatic, biliary) harbouring four types of cancers. Although anatomical proximity warrants a common surgical approach, overall survival depends largely on the type of surgical indication. Malignant epithelial tumors are the predominant indications, accompanied by a myriad of benign tumors and tumor-like lesions. We reviewed our archival pancreaticoduodenectomies to analyze the spectrum of these lesions.

Methods

All pancreaticoduodenectomy specimens received in Department of Pathology, from 2005–2019 (15 years) were analyzed for histological spectrum.

Results

A total of 786 pancreaticoduodenectomies were received with an overall M:F= 2.3:1 and age range 17–91 years. Of these, 94.4% were neoplastic (742 cases) and 5.6% were non-neoplastic. Benign neoplastic lesions (19 cases, 2.4%) included adenomyoma (7 cases, 0.9%), solid-cystic pseudopapillary tumor of pancreas (5 cases, 0.6%), intraductal papillary mucinous neoplasm (2 cases, 0.3%) and one case each of serous cystadenoma, mucinous cystic neoplasm, dermoid cyst, gangliocytic paraganglioma and Peutz-Jeghers polyp. Ampullary adenocarcinoma was the predominant malignant epithelial lesion (609 cases, 77.5%) followed by distal CBD cancer (43 cases, 5.5%), pancreatic head cancer (20 cases, 2.5%), neuroendocrine tumors (22 cases, 2.8%), carcinoma gallbladder (5 cases, 0.6%) and one case of ampullary adenosquamous carcinoma (0.1%). Non-epithelial tumors included 9 cases of GIST (1.1%), 3 of carcinosarcoma and one case each of leiomyosarcoma and lymphoma. Non-neoplastic lesions (3.2%) included 22 cases of chronic pancreatitis and one case each of xanthogranulomatous pancreatitis, lymphoplasmacytic slcerosing pancreatitis and xanthogranulomatous cholecystitis. Ectopic pancreas was rare (2 cases, 0.3%) and 16 cases (2%) were negative for any specific pathology.

Conclusion

This is the largest data on histological spectrum of pancreaticoduodenectomies from India. The malignant lesions form the major bulk (94%), however benign lesions also account for a substantial percentage of surgical indications. Among malignant lesions, ampullary cancers outreach far above pancreatic cancers in the Indian subcontinent.
A PAX-8-positive Female Urethra Adenocarcinoma: A Case Report with Diagnostic Challenges in Intestinal- Type Adenocarcinoma
Authors: Torrez M , Allen R , Zhou J
Published: October 2020

Introduction/Objective

Female urethra adenocarcinoma (FUA) in women is extremely rare, representing 0.02% of all women’s cancers and <1% of cancers in the female genitourinary tract. Intestinal-type primary adenocarcinoma of the urethra is even rarer, with only one documented case to our knowledge. Furthermore, PAX-8 immunoexpression in this entity has not been reported. Here we report an intestinal-type primary urethral adenocarcinoma that developed from inflammation-related metaplasia in urethral diverticulum with positive PAX-8 staining.

Methods

Clinical chart review and microscopic examination on the lung, urethral, and vaginal wall biopsies and immunohistochemistry were performed.

Results

A 64-year-old female with a 32-pack-year history of tobacco use was found to have multiple pulmonary nodules on imaging. The tumor cells were positive for CK7, CK20, SAT-B2, and PAX-8 and negative for TTF- 1/Napsin and ER. Positive PAX-8 immunoexpression raised the possibility of a gynecologic/Mullerian primary.

Subsequent colonoscopy and imaging showed no evidence of colorectal or uterine tumors. The patient began having hematuria with intermittent urinary retention, and cystoscopy showed a 4 x 3 cm mass involving bladder neck circumferentially and invading into the vaginal wall. Urethral and vaginal tumor biopsies were performed. Morphologic examination of the urethral biopsy demonstrated intestinal metaplasia of squamous mucosa with transition from a mature to dysplastic phenotype where the adenocarcinoma originated from. The vaginal wall biopsy showed the same morphology. The urethral and vaginal wall biopsies showed a similar immunophenotype as the pulmonary nodule biopsy.

Conclusion

FUA is a rare, aggressive tumor that occurs in Skene’s glands. In our current case, however, it appeared to arise from inflammation-related metaplasia in urethral diverticulum. Another important finding of the case is the positive PAX-8 expression. Therefore in PAX-8 positive tumors, primary adenocarcinoma of lower urinary tract should be in the differential, along with gynecologic/Mullerian tumors.
Amyloid Deposition Within a Large Pelvic Chronic Expanding Hematoma
Authors: Montoya-Cerrillo D M , Diaz-Perez J A , Rosenberg A E
Published: October 2020

Introduction/Objective

Chronic expanding hematoma (CEH) is a relatively rare complication of trauma that is usually mistaken for a soft tissue neoplasm. The identification of amyloid protein is of paramount clinical importance to exclude serious conditions causing systemic amyloidosis.

Methods

The case was retrieved from the pathology files at the University of Miami Hospital (UMH). Morphology and special stains were reviewed. The study was approved by the Institutional Review Board at UMH.

Results

A 44-year-old man with past history of a stab wound in the left buttock in the 1990s, was admitted with worsening abdominal pain, constipation, urinary obstruction and acute kidney injury. CT-scan showed a large mass involving the left gluteal area and pelvic cavity involving urinary bladder causing outlet obstruction and bilateral hydroureteronephrosis. Multiple radiology-guided biopsies were taken all identifying only fibrin, blood cells, and necrotic inflammatory cells. Excision of the gluteal mass and drainage of the pelvic component was performed confirming the diagnosis of CEH. Amyloid deposition with congo red stain birefringence under polarized light was identified. The patient’s symptoms and renal function improved and have been under follow-up for 1 month.

Conclusion

We have identified amyloid protein deposition whiting a CEH. This is an unusual finding with no previous description found in our search. The identification of amyloid whiting tumor-like lesions is relevant to exclude causes of systemic amyloidosis.
Eosinophilic Myocarditis as a Cause of Death: A Case Diagnosed at Autopsy
Authors: Khokhar H , Beversdorf W , Fox S
Published: October 2020

Introduction/Objective

Eosinophilic (Loffler) myocarditis is a rare disease defined by the influx of eosinophils into the endocardium and myocardium. Etiologies are numerous and include drug or hypersensitivity reactions, hypereosinophilic syndrome, hematologic malignancies, and parasitic infections. It is a diagnostically challenging entity. Presenting symptoms recorded in the literature are indefinite and nonspecific; heart failure, demonstrable arrhythmia, and elevated cardiac biomarkers. This is especially the case among younger, otherwise healthy patients without classical risk factors for atherosclerotic coronary artery disease.

Methods

Herein we present several cases of sudden cardiac death in young adults, including a case of unknown eosinophilic myocarditis, which highlights the potential trials in the diagnosis of this disease.

Results

Autopsies were performed on several adults (age range, 30-40 years) thought to have died of cardiac causes. This included a 30-year-old African American female with no significant known medical history who presented with a chief complaint of palpitations. The initial clinical impression at an outside institution was of cardiac amyloidosis. But the Technetium99 scan was inconclusive. Despite clinical management, she developed ventricular arrhythmias and could not be resuscitated. There was a vague history of taking nutritional supplements from a local grocery store. Gross findings at autopsy included circumferential subepicardial erythema, thymic enlargement (60g), and congested lungs. The heart was thoroughly sampled. Microscopic examination revealed diffuse infiltration of eosinophils, mast cells, lymphocytes and macrophages with mild myocyte necrosis and interstitial edema in all sections. There were no giant cells, no interstitial deposition of amorphous acellular material and no focus of infarcted myocardium. Thymic sections were histologically normal. Acetylcholine receptor antibody panel was negative.

Conclusion

We conclude that eosinophilic myocarditis though rare (0.5% unsuspected and 0.1% suspected cases), is a distinctive cause of death with a specific microscopic presentation. Our case also included thymic enlargement at autopsy – a finding not previously noted.
The Crushing Effects Of Opiate Abuse: Two Cases Illustrating The Morphologic Features Of Acute And Chronic Intravenous Administration Of Crushed Oral Opiates
Authors: Clarke-Brodber A , Lee J , Victor T , Kaur A
Published: October 2020

Introduction/Objective

Drug overdose related deaths in the US have shown a four-fold increase over the past two decades, increasing from 6.1 to 21.7 per 100,000, the increasing majority of which involve synthetic opioid use. With this continuing increase, it is important for pathologists to become aware of unusual gross and microscopic changes related to unconventional modes of drug abuse. A less recognized unconventional method for opiate abusers to ingest these substances exemplified by our two cases is by crushing oral tablets and inhaling or injecting the drug intravenously, subcutaneously or intramuscularly.

Methods

The two cases being presented show morphological features of acute and chronic opiate abuse by autopsy study. Case 1 was a 38-year old female, who underwent spinal fusion surgery 1 month prior, and was found unresponsive at home. Case 2 was a 37-year-old female with a history of Antiphospholipid Antibody Syndrome (APA) and upper limb DVTs who was found unresponsive one day after elective utero-vaginal prolapse surgery.

Results

At autopsy, Case 1 showed extensive embolization of polarizable foreign body material (possible “pill filler”) and fibrin in small and medium sized vessels without inflammatory reaction in the lungs bilaterally. The foreign material was also present in the small vessels of the heart associated with multifocal acute inflammation, hemorrhage, foreign body giant cell reaction and multiple myocardial infarcts (elevated troponin levels clinically). Blood and vitreous fluid were positive for oxycodone. At autopsy, Case 2 showed an extensive angiocentric miliary pattern of granulomatous reaction to polarizable foreign material, consistent with pill filler in the lungs bilaterally. This foreign material was also present within the lumens and walls of pulmonary vessels and in the skin of the legs. Chronic changes of hypertrophic cardiomyopathy, hepatic cirrhosis and congestive splenomegaly were evident. The blood oxycodone levels were ten times the normal limit.

Conclusion

These cases illustrate the importance of recognizing the clinical and morphological features of unorthodox acute and chronic opiate abuse. Lack of familiarity with their differing features can lead to a delay in diagnosis and institution of appropriate timely management and treatment.
Lymphamatosis Cerebri With Rare Marginal Zone Lymphoma Phenotype: An Autopsy Case Report In A Patient With History Of Peripheral Diffuse Large B Cell Lymphoma And Chronic Lymphocytic Leukemia
Authors: Kaur A , Clarke-Brodber A , Eldibany M , Alikhan M , Lee J
Published: October 2020

Introduction/Objective

Lymphomatosis cerebri (LC) is a term used to describe primary central nervous system lymphomas which may present as diffuse, non-enhancing, infiltrative lesions. Although most of these are diffuse large B-cell lymphomas, there are other cases in the literature of low-grade B-cell lymphoma, Burkitt lymphoma and T-cell lymphoma.

Methods

We present a 76-year-old male with a past medical history of chronic lymphocytic leukemia (2014), diffuse large B cell lymphoma of right jaw (2019) s/p chemotherapy, prostate cancer s/p prostatectomy and radiation. The patient presented 3 weeks prior to admission due to generalized weakness with rapidly declining mental status, anorexia and deconditioning. MRI brain revealed scattered T2/FLAIR signal abnormalities in the cerebrum and cerebellum. An assessment of encephalitis was rendered. The patient continued to worsen and passed away.

Results

On autopsy of the brain, there was extensive involvement of the basal ganglia, cerebellum and all cerebral lobes by a lymphoid process. It had a predominant perivascular, parenchymal and leptomeningeal distribution.

Microscopically, there was a diffuse proliferation of small to intermediate sized lymphocytes with mature chromatin. These lymphocytes were neoplastic B cells which stained for CD20, CD43 and negative for CD5, CD3 and CD23. It also showed low Ki67 index. This immunophenotype is most consistent with a marginal zone lymphoma.

Conclusion

It is quite rare that our patient’s infiltrative process was a small mature B-cell lymphoma most compatible with marginal zone B-cell lymphoma. Our case illustrates the importance of recognizing this entity, particularly in context with different morphology since our patient had three different types of lymphoma. The dilemma in diagnosing such lesions can lead to delay in diagnosis and institution of appropriate management. Thus, knowledge about its imaging and morphological features is very critical for correct categorization and to avoid potential misdiagnosis.
Tackling The Challenge Of Opioid Use And Abuse And Treatment Of Chronic Pain Management
Authors: Arora K , Umar B , Hogan K , Winston-McPherson G N , Copeland J R , Varney R , Shah V , Totten A
Published: October 2020

Introduction/Objective

Deaths from opioid overdose increased 12% from 2016 to 2017. This major economic burden cost roughly $78.5 billion in the US. This steep increase in drug overdose deaths can be attributed to increased synthetic opioid abuse. To better understand and reduce opioid abuse amongst patients at Henry Ford Health System, Detroit MI, we sought to collaborate with physicians to manage prescribing, interpret test results, improve patient care, and deliver more value.

Primary Aim: To create a directed pain panel for ordering and interpreting pain management drugs to help providers to better manage patients and to assess compliance from test ordering history to serve patients safely and effectively.

Secondary Aim: To streamline the process of prescribing pain medications and to create a patient centered approach to treat chronic non-cancer patients who actually need opioids, to minimize the risk of abuse, diversion and addiction among patients.

Methods

Plan Do Check Act (PDCA) cycles of process improvement were used to achieve our two aims. In the first cycle, a drug screen-ordering guide was developed to facilitate screening (qualitative) and confirmation (quantitative) ordering practices. As part of this, providers prescribing for chronic pain patients were advised to use drugs of abuse panel rather than our emergency drug screen. In the second cycle, a directed pain panel (DPP) was introduced with reflex to confirmation testing. The DPP led to discovery of unexpected fentanyl positives, which were further investigated.

Results

A survey was conducted to investigate provider-ordering practices, which showed that use of the new drugs of abuse panel rose from 57% to 77%. The DPP was accepted by ~60% of physicians and was frequently reordered in follow-up. Analysis of unexpected fentanyl positivity revealed 30% true positivity, thus identifying unknown patient use. A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.

Conclusion

A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.
Cutaneous Plasmacytosis: A Pitfall For B and Plasma Cell Neoplasms
Authors: Giraldo C N , Myers D , Holmes A , Dodd J , Wendi W
Published: October 2020

Introduction/Objective

Cutaneous plasmacytosis (CP) is an uncommon condition typically affecting Asian males in the 3rd to 5th decades. It is thought to be a reactive process that classically presents with asymptomatic, red-brown, plaques and nodules on the face and neck. It has been associated with polyclonal hypergammaglobulinemia and systemic involvement. Histologically it is characterized by dense superficial and deep dermal infiltrates of mature plasma cells with polyclonal differentiation on in-situ hybridization (ISH). The differential diagnosis includes neoplastic plasma cell processes, characteristically with monoclonal plasma cell infiltrate, and mature B cell neoplasms with polyclonal plasma cell differentiation.

Methods

We report a case of a 69 year old Caucasian male who presented with asymptomatic, enlarging red-brown nodules on bilateral nasal ala. Histologic examination revealed dense, superficial plasma cell infiltrate, concerning for a plasma cell neoplasm. CD138 and Kappa/Lambda ISH demonstrated plasma cell polyclonality. Further workup ruled out infectious or systemic involvement and a plasma cell dyscrasia was ruled out by Hematology/Oncology.

Results

These findings supported the diagnosis of CP. Treatment with intralesional steroids showed initial improvement with regrowth of the nodules. To date, treatment with topical steroids and CO2 laser ablation are being considered.

Conclusion

CP is reported as type of pseudolymphoma, which is described as a reactive lymphoproliferation that histopathologically and/or clinically imitates cutaneous lymphoma. The pathogenesis is unknown, however, there are studies suggesting an association with increased interleukin-6, which is involved in the differentiation of B cells to mature plasma cells. The majority of patients with CP have a favorable prognosis. There has been variable success with both topical and intralesional treatment to include, cyclophosphamide, topical tacrolimus, prednisone, intralesional steroid therapy, topical psoralens combined with ultraviolet A exposure, and other chemotherapies. Familiarity with this rare entity is imperative to prevent misdiagnosis and overtreatment.
Excellence Available Everywhere: The Virtual Pathology Grand Rounds Experience
Authors: Wobker S E , Mirza K M , Jiang X , Gonzalez R
Published: October 2020

Introduction/Objective

Grand Rounds seminars are a cornerstone of scholarship in all academic departments. They provide education, stimulate discussion, and build faculty reputation. The COVID-19 pandemic led to cancellations in teaching conferences and lost opportunities for all of the above starting in March 2020. The social medial hashtag #VirtualPathGR and @VirtualPathGR Twitter (San Francisco, CA) accounts (VPGR) were created to address a need for continued engagement in academic pathology, during and after periods of physical distancing.

Methods

#VirtualPathGR was first used on March 21, 2020 to assess interest in a VPGR format. Six pathologists organized a social-media based platform, utilizing video conferencing. Zoom (San Jose, CA) was selected because it is free and easy to use. A committee developed criteria for inviting hosts and speakers, developed a logo and template for announcements and promoted VPGR. Potential speakers were selected initially via self-nomination and subsequently by selections from the VPGR board. Free pre-registration was required to minimize risk of disruption by malicious actors. Academic institutions served as “hosts” similar to traditional GR, and the speaker was introduced by one of the VPGR board members. Evaluations were sent to participants via the chat function in Zoom. Lectures were recorded and archived via YouTube (San Bruno, CA).

Results

As of May 1, #VirtualPathGR has 2.6 million impressions and the Twitter account has 808 followers. From April 2 to May 1, five VPGR were held with 1,720 registrations (average 344 per event) and 829 Zoom attendees overall (average 165 per event). 4 separate academic host institutions were involved and speakers included Assistant to Full Professors. Participants from 16 different countries attended the live sessions. The archived talks have been viewed 954 times via YouTube. VPGR received support from the American Society for Clinical Pathology (Chicago, IL), leading to a partnership to provide CME credit.

Conclusion

VPGR serves as strong proof of concept of the ability and demand for high quality academic pathology talks to be given remotely. VPGR promotes academic engagement and provides career-building opportunities by partnering with host universities. While remote learning comes with challenges, VPGR shows that the pathology community can harness the power of remote technologies to enhance learning across the world, now and in the future.
An Unusual Case Of Disseminated Histiocytic Sarcoma Preceded By Myeloid Sarcoma With Concomitant Acute Myeloid Leukemia
Authors: Reddy A C , Reddy K S
Published: October 2020

Introduction/Objective

Histiocytic sarcoma (HS) is rare (<1% of hematolymphoid neoplasms), and can present extranodally as disseminated disease. Immunophenotypically, the cells express CD163, CD68, lysozyme and CD45. HS often occurs as a secondary event following B-cell lymphomas, acute lymphoblastic leukemia or acute myeloid leukemia (AML) typically with monocytic differentiation retaining the same molecular/cytogenetic abnormalities as the primary tumor.

Results

Our patient, a 47 year old male was diagnosed with myeloid sarcoma (MS) following FNA of a new neck mass. A bone marrow biopsy revealed AML without monocytic differentiation. Flow cytometric findings of both marrow and neck mass were similar (positive for CD34, CD117, CD33, CD11b, CD13, CD15, CD64, CD7; negative for CD4, CD14, CD56). Karyotypic and FLT3 ITD mutation analysis were normal. CNS involvement was diagnosed 2 months later, while a marrow biopsy (status post therapy) confirmed resolution of AML. A hypermetabolic left perinephric mass noted by PET CT, when biopsied, showed large epithelioid polygonal cells with amphophilic cytoplasm and atypical vesicular nuclei (positive for CD68, PU.1; negative for LCA, CD163, CD34, CD4, pankeratin). A diagnosis of atypical epithelioid neoplasm suggestive of HS was rendered, although negativity for LCA and CD163 was unusual. No treatment was given for HS. A month later, the patient presented with a cheek mass diagnosed again as being suggestive of HS. His AML also relapsed. Next-generation sequencing (37 genes including BRAF) from both marrow and tissue samples detected the presence of a nonsense mutation in exon 7 of WT1 (p.Ser169).

Conclusion

Our case appears to be the first reported one of disseminated HS preceded by MS and concomitant AML, lacking monocytic differentiation. The findings overall support the hypothesis of origin as being from a common progenitor cell differentiating along both myeloid and histiocytic/other cell lineages at different time points.
Acute Myeloid Leukaemia with Vitreous Haemorrhage: Management Challenge in a Third World Country
Authors: Olatinwo A T , Ogbenna A A , Bolarinwa A
Published: October 2020

Casestudy

Leukaemic ophthalmopathy is commoner in acute myeloid leukaemias. Ophthalmic involvement in leukaemias is classified into: Primary or Secondary.

Methods

A 35-year-old man with history of working in an oil and gas company for 3years who presented 9months ago on account of one month history of recurrent fever, occasional bone pain and generalised body weakness.Had associated history of passage of dark coloured urine, mouth ulcers, mouth bleeds and dizziness. CBC at presentation showed WBC of 102,300/mcl with 79% blasts, hemoglobin of 5.4g/dL, platelet count of 12,000/mcl. Symptoms were consistent with leukostasis, and he had leukoreduction with exchange blood transfusion and hydroxyurea. Bone marrow aspirate confirmed the diagnosis of AML FAB M2. Bone marrow biopsy showed hypercellular marrow with increased myeloid series, other series depressed.

Three days after admission, he complained of painless blurred vision bilaterally and feeling of objects appearing reddish, a review by ophthalmologist with an assessment of bilateral retinal haemorrhage secondary to AML. B – Scan done showed whitish elevated hyperechoic mass (parapapillary) with moderate dot echoes in the vitreous bilaterally. They planned for dilated fundoscopy and advised haematologist to commence chemotherapy as planned.

He then had standard induction with cytarabine and daunorubicin.Post chemotherapy showed pancytopenia secondary to chemotherapy. Further review by Ophthalmologist showed bilateral vitreous haemorrhage secondary to bilateral choroidal mass and then planned for vitrectomy and also had bilateral intravitreal bevacizumab

Day 14 bone marrow exam showed hypocellularity with absence of blasts indicating remission. He subsequently underwent cycle 1 of consolidation with high-dose cytarabine with the goal to proceed with allogeneic hematopoietic stem cell transplant (HSCT). Post consolidation, patient has had surgeries of both eyes and subsequently regained full vision in both eyes. Though patient is yet to re-present for post consolidation chemotherapy despite adequate counsel due to financial constraints and yet to have allogeneic hematopoietic stem cell transplant (HSCT) and last showed up for follow up four months ago.

Results

Patient regained full vision in both eyes

Conclusion

This case illustrates that vitreous haemorrhage in Patients with AML can be effectively managed in a resource limited setting.
Pediatric-Type Follicular Lymphoma With A Prolonged Clinical Course And Unusual Mutational Profile
Authors: Muldoon J , Phelan A , Kitagawa Y , Czader M
Published: October 2020

Casestudy: Pediatric-type follicular lymphoma is crucial to differentiate from other subtypes of follicular lymphomas since it carries an excellent prognosis and generally does not require radio- or chemotherapy. We present a 22-year-old male with an 8-year history of a left submandibular mass. Interval imaging studies showed no change in the mass size over time and no other sites of involvement. The patient underwent excision of the mass. Histologic sections showed effacement of nodal architecture with expansile follicles composed of medium sized to large lymphoid cells with blastoid features. Follicles showed abundant tingible body macrophages. Polarization was not seen. Neoplastic follicles were positive for CD20, PAX5, BCL6, CD10, and FOXP1, and negative for BCL2. PD1 positive cells were localized peripherally in the follicles. Clonality was confirmed by flow cytometry (kappa restricted CD10 positive B-cells in a polyclonal background) and by IGH PCR analysis (clonal peaks in FR1 and FR2).

Molecular genetic testing showed the following mutations: TNFRSF14 W12* (VAF 14.8%), MAP2K1 F53V (5.7%), EZH2 Y646N (6.9%), ARID1A R1461* (7.1%). BCL2 rearrangement was not detected. MAP2K1 and TNFRSF1 are frequently reported in pediatric-type follicular lymphoma, however in the majority of cases they do not occur together. EZH2 mutation does not typically occur in pediatric-type follicular lymphoma, and is more common in classic adult- onset follicular lymphomas. Despite typical morphologic and clinical features, this patient showed a more complex genetic profile and EZH2 mutation, unusual findings in pediatric-type follicular lymphoma. It is conceivable that a higher genetic complexity has been acquired over time and is related to the long duration of the disease.
Evaluation of Renal Biopsy for Transplant: The Significance of Whole Slide Imaging (WSI) in Telepathology
Authors: Sonawane S , Borys E , Borys D , Picken M
Published: October 2020

Introduction/Objective

Percutaneous Renal biopsy remains a gold standard technique to provide diagnostic and prognostic information post kidney transplantation. Recently Whole slide imaging (WSI) telepathology systems have been widely used for clinical, education and research purposes. Our aim was to examine reliability and accuracy of WSI telepathology service in the pathology diagnosis of biopsy specimens from transplanted kidney.

Methods

At our institution we have two renal pathologists. They utilize WSI telepathology service with Aperio scanner for rapid initial assessment of the transplant renal biopsy specimens. We retrospectively reviewed reports of all transplant renal biopsies which were examined remotely utilizing WSI telepathology service and compared the results for initial versus final diagnoses.

Results

In period from Jan 2019 to April 2020 total 160 renal transplant biopsies were evaluated remotely utilizing the WSI scanner. The diagnosis was divided in 4 subcategories as reperfusion injury, rejection (Antibody mediated or T cell mediated), mixed inflammation-favor infection and Polyoma virus infection. There were 48 cases of reperfusion injury; 5 cases of polyoma virus infection, 37 cases of rejection and 28 cases with mixed inflammation and 42 cases with no significant histopathologic findings. There was no discrepancy between the preliminary and final diagnosis for all 160 cases. The ancillary studies including special stains and electron microscopy added to the final diagnosis or confirmed the preliminary diagnosis.

Conclusion

WSI telepathology is a reliable and simple method to rapidly review transplant kidney biopsies. The ability to transmit images from hospitals to pathologists with WSI scanner has the potential for not only an accurate assessment of the rejection but also for additional histopathological findings. Digital pathology enhances the clinical usefulness of immediate assessments of transplant biopsy samples and also provides a platform to share the scanned images with clinicians which also can be utilized for education of trainees.
Anaerobes Direct from Blood Culture Bottles Can Be Identified by Early Matrix-Assisted Laser Desorption Ionization/ Time-of-Flight Mass Spectrometry (MALDI-TOF MS) at 24 Hours or Less
Authors: Berg H E , Shannon S , Schuetz A N
Published: October 2020

Introduction/Objective

Matrix-assisted laser desorption ionization/ time-of-flight mass spectrometry (MALDI-TOF MS) direct from positive blood culture bottles has facilitated drastic drops in turn-around times for microorganism identification but has been poorly studied for anaerobes. We investigated the ability of MALDI-TOF to provide early anaerobe identification at 4 hours and 18-24 hours of growth on agar from anaerobic blood culture bottles.

Additionally, we reviewed medical records of such patients to ascertain impact of early identification on antimicrobial treatment.

Methods

Over 9 months, we ran MALDI-TOF on early growth from blood cultures positive for growth in BACTEC™ Lytic/ 10 Anaerobic/F bottles. Broth from each bottle was subbed to sheep blood agar (4 hours, 5% CO2) and 2 CDC (BD-BBL™) anaerobic blood agar plates (examined 18-24 hours and 48 hours). Bruker Biotyper® RUO v7854 and Mayo Clinic Custom MALDI-TOF MS libraries were used for identification.

Results

144/184 (78%) bottles resulted in growth of aerobic bacteria. Of the remaining bottles with growth of anaerobes, 38 were assessed by early MALDI-TOF. Early MALDI-TOF at 4 hours identified 3 Clostridium perfringens (8%) and an additional 26/38 (68%) isolates at 18-24 hours (both Gram-positive and –negative). Routine 48 hour identification was required for 9 (24%) isolates. In 7 cases, early MALDI-TOF resulted in a change to more appropriate antimicrobial therapy, most often for Bacteroides.

Conclusion

29/38 (76%) of anaerobes from blood culture bottles were identified by early MALDI-TOF and reported to the clinician at least 24 hours before routine review of anaerobic sub plates for growth. All C. perfringens and Bacteroides were identified by 4 and 24 hours, respectively. Although early MALDI-TOF resulted in antimicrobial therapy adjustments in a minority of cases, it may allow for more targeted and earlier antimicrobial therapy. Early MALDI-TOF from anaerobic blood culture bottles should be considered for improved patient care and antimicrobial stewardship.
Epidemiology Of Helicobacter Pylori In Delta Egypt
Authors: Abdelmonem M , Elshamsy M , Wasim H , Shedid M , Boraik A
Published: October 2020

Introduction/Objective

Introduction: Helicobacter pylori (H. pylori) infection is one the most prevalent bacterial infection in the world, affecting more than 50% of the world’s population. H. pylori are gram negative bacteria usually found in the stomach, penetrate the lining of the stomach, small intestine, or esophagus. After many years, they can cause sores, called ulcers, in the lining of your stomach or the upper part of your small intestine. For some people, an infection can lead to Gastric cancer which is the second most common cancer worldwide

Objectives: The aim of this study is to predict the prevalence of Helicobacter pylori infection in gastrointestinal tract patients in Egypt.

Methods

Subjects and methods: A total of 1120 patients were enrolled in this study from The Delta region in Egypt. Enzyme-linked immunosorbent assay (ELISA) kits were used to detect H. pylori stool Antigen. Among the 1120 patient; 301 patients (26.9%) were males, 510 patients (45.6%) were females and 309 patients (27.5%) were children with age range from 1 years to 76 years. The mean of the age was 8,35,34 for children, males and females respectively.

Results

The overall prevalence of H. pylori infection was 52%. Among the 1120 patients, 576 patients (48%) were negative while 624 patients (52%) of the patients were Positive. It was observed that 169 patients (51.6%) of males were positive,275 patients (52.9%) of females were positive and 135 patients (41%) of children were positive. Furthermore, 133 patients (48.4%) of males were negative, 227 patients (47.2%) of females were negative and 181 patients 59% of children are negative.

Conclusion

This study revealed that the incidence and prevalence rates of H. Pylori in Egypt are relatively high. The high H. pylori prevalence is related to poor standard of living, low socio-economic conditions, poor sanitation and fecal contamination of food or water. It is crucial to launch educational awareness program for H. pylori in Egypt.
Leading Laboratory Testing through a Viral Pandemic
Authors: Bradley J A , Thrasher-Stallard L
Published: October 2020

Introduction/Objective

In March, thrown into the 2019 Novel Coronavirus pandemic the first test result was returned on the first suspected of this virus. Since, we implemented numerous plans of action, control measures, test procedures and managed the flow of accurate information to the entire facility.

Methods

Control and leadership engagement were key to our success. Control of collection process, creating collection “kits”, methods of shipment, results reporting and regulated distribution. Key players maintained order and track all samples on a spreadsheet. The spreadsheet utilized was the most vital tool in weeks to come. Daily updates for both supplies and samples. Simultaneously, researching test capabilities with current analyzers. Daily huddles and group meetings to coordinate all efforts which included manning.

Results

Supply counts three times a day at the start and collection “kits” weekly. This measured the capabilities initially. Counting errors lead to numerous redundancies. This was a burden and abandoned. Reference laboratory instructions were verified for all transport media allowed and was as a starting point. Daily usage was subtracted. Patient management was populated with sample specificities, patient demographics and testing locations. Every result called to provider, public health, infectious disease, and a sanitized report to hospital management. This data became “the” source and used as a check against other methods. Later only positives were notified. In April, microbiology implemented Cepheid GeneXpert (Sunnyvale, Ca.). Protocols established changed rapidly. Confusion drove subpar test utilization this created processing errors. Multiple shifts were trained previously and no lag was noted. A back-up, BioFire Torch (Salt Lake City, Utah), was validated.

Conclusion

After eight weeks, over 900 tests, 800 patients and two systems brought online. Overall, a dedicated white board specific to COVID news was established. The “normalcy” phase has hit. Some early protocols have been established as working methods and new members were brought into the fold.