bluuebunny/crossref_metadata_2025 huggingface dataset:
Rare Presentation of Anaplastic Carcinoma as a Mural Nodule in Mucinous Cystadenoma with Concurrent Benign Brenner Tumor
Authors: Poombal F , Noor R , Pervaiz J , Khalid F , Zaman S
Published: October 2024

Introduction/Objective

Mural nodules in ovarian mucinous tumors, particularly which are anaplastic carcinomas, represent an exceedingly rare and complex diagnostic category. The literature documents only a few such tumors, predominantly sarcoma-like, with favorable prognoses. In contrast, malignant mural nodules, including anaplastic carcinoma and sarcomatous or carcinosarcomatous types, are notably rare, with fewer than ten cases reported. The co-occurrence of an anaplastic carcinoma mural nodule with a benign Brenner tumor presents distinct diagnostic and treatment complexities stemming from mixed tumor pathology and associated genetic mutations like KRAS and p53, critical in the development of these unusual nodules. This report deepens our insight into rare ovarian tumors.

Methods/Case Report

A 60-year-old woman with persistent lower abdominal pain underwent surgery for a suspected benign ovarian cyst based on initial imaging. The removed ovary contained a 10.5 x 10 x 8 cm unilocular cyst lined with benign, mucin-containing columnar epithelium. However, a 2 cm anaplastic carcinoma mural nodule was identified within the cyst, exhibiting cellular pleomorphism, nuclear atypia, and high mitotic activity.

Immunohistochemical staining confirmed the carcinoma with diffuse cytokeratin and EMA positivity. The fallopian tube was free of tumor involvement, and no capsular or lymphovascular invasion was seen. The cancer was staged as PT1a, pNx, pMx.

Results (if a Case Study enter NA)

NA

Conclusion

Anaplastic carcinoma, when present as a mural nodule within a benign-looking mucinous cystadenoma, demands an aggressive treatment strategy due to its poor prognosis and aggressive nature. Such cases require a deviation from standard benign treatment protocols to include extensive surgery, possibly, depending on disease progression, chemotherapy or radiation.
All that is squamoid is not squamous: A rare case of Squamoid Eccrine Ductal Carcinoma presenting as an intranasal mass
Authors: Sakaleshpura Mallikarjuna V , Nani C , Hagen M , Sharma D , Gilday S
Published: October 2024

Introduction/Objective

Squamoid eccrine ductal carcinoma (SEDC) is a rare adnexal tumor that poses diagnostic challenges because of the rarity, variable clinical presentation, and misdiagnosis on superficial biopsy sampling.

Methods/Case Report

We report a 52-year-old immunosuppressed male, status-post kidney and heart transplants who presented with an anterior nasal mass, the biopsy of which was interpreted as squamous cell carcinoma (SCC). Resection revealed a 2.5cm intranasal mass eroding through the hard palate. Histology showed a biphasic tumor arising from nasal vestibular skin with a superficial squamoid component (p40 positive) and a deeply invasive component demonstrating ductal differentiation (CEA positive) consistent with SEDC. SEDC has a predilection towards skin of head and neck region but SEDC presenting as an intranasal mass has not been reported. In our case, the tumor arose from nasal vestibular skin with destructive bony invasion within the nasal cavity. The patient’s long- term immunosuppression likely played a role in the etiopathogenesis and aggressive progression of this tumor.

Interestingly, he also had history of multiple sebaceous carcinomas and cutaneous T-cell lymphoma with no known genetic predisposition, further implicating immunosuppression as the key risk factor for development of his cutaneous malignances.

Results (if a Case Study enter NA)

N/A

Conclusion

This case exemplifies the potential diagnostic pitfalls in squamoid lesions of the head and neck. Given the overwhelming prevalence of conventional SCC, rarer tumors with squamous differentiation often are not considered in the differential diagnosis, especially of an intranasal mass. A superficial biopsy often is misdiagnosed as SCC due to the lack of representation of deep-seated ductal components. A high index of suspicion and adequate examination of deeper aspects of the lesion are imperative for accurate diagnosis.
Heterotopic High-Grade Salivary duct Carcinoma Likely Arising within Cervical Lymph Nodes
Authors: Asad M , Gupta G , Sieber S C
Published: October 2024

Introduction/Objective

Salivary duct carcinoma arising in heterotopic salivary gland tissue is an extremely rare occurrence, with less than five cases reported in the literature. We present a unique case of heterotopic high-grade salivary duct carcinoma likely arising within cervical lymph nodes.

Methods/Case Report

A 56-year-old male presented with enlarged cervical lymph nodes for few months. Physical examination was unremarkable. Computerized tomography (CT) scan of head and neck showed two enlarged level 1B lymph nodes, measuring 1.0 and 1.4 cm, with unremarkable salivary glands. Patient had left cervical level II lymph node biopsy that showed metastatic poorly differentiated carcinoma. Immunohistochemically, the tumor cells were positive for GATA3, cytokeratin 903, androgen receptor, p16 (variable nonspecific), and were negative for TTF-1, p40, p63, ER, PR and NKX3.1, favoring salivary gland ductal carcinoma. Positron emission tomography (PET) CT scan showed a hypermetabolic left submandibular gland and level 2A lymph nodes. Subsequently, the patient underwent left modified radical neck dissection. Sectioning of the submandibular gland revealed no discrete lesions. Multiple, firm to rubbery lymph nodes ranging from 0.4 cm to 2.3 cm, with tan-pink cut surfaces were identified. Microscopic examination showed normal submandibular salivary gland parenchyma. However, eight out of nineteen lymph nodes were positive for metastatic high-grade salivary duct carcinoma comprising tumor cells forming nests and cords with ample eosinophilic cytoplasm, pleomorphic round to oval nuclei and numerous mitotic figures. Several benign and malignant lymph nodes in levels I, II and IV showed heterotopic salivary gland tissue. Immunohistochemical stains for androgen receptor and p40 were positive and negative respectively, supported the final diagnosis of high-grade salivary duct carcinoma.

Results (if a Case Study enter NA)

NA

Conclusion

Given the absence of carcinoma in the completely sampled submandibular gland, the origin of the intra- nodal tumor deposits was most likely to be heterotopic salivary gland tissue. This case emphasizes the importance of meticulous pathological sampling required for definitive diagnosis.
DICER-1 Mutation Associated Sarcoma of Thyroid in An Adult Male
Authors: MAHESHWARI T , Carithers P , Kaur N , Manucha V
Published: October 2024

Introduction/Objective

DICER-1 is an autosomal dominant tumor predisposition syndrome caused by germline DICER1 mutations. In the thyroid, it is associated with an early-onset multinodular goiter (MNG) and low-grade thyroid carcinomas. The aggressive variants thyroblastoma and poorly differentiated carcinoma are however seen in the pediatric age group. We report a case of DICER-1-associated (rhabdomyo) sarcoma without primitive components in an adult male.

Methods/Case Report

A 44-year-old healthy male with a family history of MNG, presented with a large left neck mass confirmed on imaging with largest 6.4cm, and extension into the mediastinum. FNA showed a malignant spindle cell- rich neoplasm with negative expression for Keratins, TTF-1, PAX-8, Calcitonin, INSM- 1 and SOX-10. The CEA and calcitonin were normal. The lymphoma was excluded by flow cytometry. The patient underwent a left thyroidectomy with central and left selective neck dissection. On gross examination, the left lobe of the thyroid was replaced by a tan- white, partially encapsulated solid mass. Microscopic examination revealed nests and sheets of ovoid to spindle- shaped cells with eosinophilic cytoplasm in fascicles with hypocellular areas with loose stroma. Foci of rhabdomyoblastic differentiation with straps cells, positive for desmin and myogenin were identified. Brisk mitotic activity and tumor necrosis were present. No primitive thyroid epithelium or blastemal component was identified.

Tumor cells were negative for S100, SOX10 CD34, CD31, SMA, calponin, CD99, NKX2.2, SS18-SSX which excluded malignant peripheral nerve sheath tumor, angiosarcoma, leiomyosarcoma, Ewing’s sarcoma, and synovial sarcoma. Next-generation sequencing showed a DICER1 c.4517G>A (p.W1506) and c.5437G>C (p.E1813Q) mutation, both variants reported as germ-line variants. A final diagnosis of DICER-1-associated rhabdomyosarcoma was rendered. The patient underwent rehabilitation at another facility and lost to follow-up.

Results (if a Case Study enter NA)

NA

Conclusion

The case highlights the expanding spectrum of DICER-1-associated malignant tumors and the importance of keeping it in the differential diagnosis of unusual malignant tumors of the thyroid even in adults.
Evaluation of the Hematology Analyzer Test Performance Using Six Sigma Metrics: A Cross Sectional Study
Authors: Dy P R , Damian K B , Villanueva E Q
Published: October 2024

Introduction/Objective

The six sigma metric is used to assess the performance of a measurement procedure in comparison to the medical requirement. In clinical laboratories, it can be used to assess the quality of instruments or processes. This study aims to evaluate the performance of hematology analyzers using the six sigma scale.

Methods/Case Report

This is a descriptive cross-sectional study wherein quality control data from hematology analyzers were obtained. The mean, standard deviation, coefficient of variation, bias and sigma value of the RBC, WBC, hemoglobin, hematocrit, and platelet parameters were determined and the performance of Beckman Coulter DxH 900 was assessed by plotting a normalized OPSpecs chart.

Results (if a Case Study enter NA)

The WBC and platelet parameters had sigma values of more than 6. Less stringent quality control measures could be applied these parameters which include fewer Westgard rules and fewer control runs. The RBC and hemoglobin parameters had sigma values of at least 3. The hematocrit parameter had a sigma value of less than 3. Improving this parameter could be done by performing optical channel evaluation, using multiple Westgard control rules, increasing the number of control materials and the number of runs.

Conclusion

This study has demonstrated the analytical performance of hematology analyzers on the six sigma scale, which in turn allows for the selection of the appropriate statistical quality control rule. Ultimately, statistical quality control is only one part of a laboratory’s quality management system. The sigma quality of the testing process, as well as choosing the appropriate control rules and number of controls, may provide the basis for the total quality control strategy of the laboratory. Other pre-analytic and post-analytic factors must also be considered in formulating a laboratory total quality control plan. This would allow the laboratory to provide the best possible quality of services to its clients by increasing efficiency, reducing wastage, and incorporating continuous changes to improve the system.
The Impact of Pre-biopsy Corticosteroids Use on CD20 Staining Pattern in B-cell Lymphomas
Authors: Li X , Krishnamurthy K , Choudhuri J , Wang Y
Published: October 2024

Introduction/Objective

Diffuse large B-cell lymphomas, the most common Non-Hodgkin’s lymphoma are heterogeneous in terms of varied clinical presentation. The pathological work up these lymphomas is usually initiated with a CD20/CD3 immunohistochemical panel. Due to the aggressive nature of these lymphomas, pre-diagnosis corticosteroids are necessitated in some cases. However, the corticosteroids treatment can significantly alter the antigen staining of the lymphoma delaying the pathological diagnosis and subsequent treatment. This study investigates how pre-biopsy corticosteroids administration affects CD20 staining in B-cell lymphoma cells along with CD3 and PAX5, aiming to provide insights to the practicing pathologist for prompter diagnosis in these challenging cases.

Methods/Case Report

14 biopsy cases of B-cell lymphoma pretreated with corticosteroids were included in this study. Clinicopathological parameters including corticosteroids usage are collected. H&E and immunohistochemistry slides were reviewed to analyze CD20, CD3 and PAX5 staining patterns.

Results (if a Case Study enter NA)

Of 14 cases, 10 cases showed cytoplasmic and granular staining with CD20, with extracellular spilling instead of the typical membranous pattern. This change was more frequent with intravenous dexamethasone (7/9) compared to oral prednisone (3/5), high dose (80%) compared to moderate and low dose (67%), short-term corticosteroids usage (86%) compared to intermediate-term and long-term (57%) usage and shorter dosing interval (100% in Q6H). The impact of prebiopsy corticosteroids was seen more on lymph node (5/7) compared to bone marrow (3/5). This cytoplasmic granularity was also observed in CD3 in the background non-neoplastic T lymphocytes in 25% of the cases. Though nuclear stains such as PAX5, Ki67, MUM1 and BCL6 also showed granularity in a significant number of cases, it was limited to the nucleus.

Conclusion

Pre-biopsy corticosteroids leads to alteration in CD20 staining pattern of the lymphoma cells leading to cytoplasmic granularity with extracellular spillage, which causes diagnostic challenge. This effect varies according to the type, route, dose, and duration of corticosteroids usage.
A discussion of pediatric therapy-related acute myeloid leukemia with a rare t(8;16) translocation
Authors: Brown H , Leffew M , Stalling M
Published: October 2024

Introduction/Objective

Secondary acute myeloid leukemia is a type of blood cancer that arises after a previous myeloid neoplasm or after exposure to chemotherapy. Certain genetic mutations and chromosomal abnormalities can occur as a result of said cytotoxic drug-related effects. Here, we discuss a case of secondary acute myeloid leukemia with a rare translocation following hemophagocytic lymphohistiocytosis Etoposide treatment in a 13-year-old female. After less than a year into her initial treatment, the patient presented to the emergency department with severe bone pain. A full hematologic workup was performed, including bone marrow biopsy, flow cytometry analysis, and subsequent genetic studies. A diagnosis of therapy-related acute myeloid leukemia was made. Genetic studies revealed a rare t(8;16) translocation which presents with a unique morphology and prognosis that will be discussed here.

Methods/Case Report

A 13-year-old female presented to the emergency department for evaluation of fever, myalgia, and swelling in her clavicle. The patient’s history was notable for hemophagocytic lymphohistiocytosis with subsequent Etoposide chemotherapy treatment which she received less than a year prior to her visit. CBC was notable for low white blood cell count, low hemoglobin, increased neutrophilic bands, and decreased lymphocytes.

Given her past medical history and worsening pain without a clear reason, hematology was consulted.

Results (if a Case Study enter NA)

A blast count of 61.8% was reported via flow cytometry with the cells seen in the dim CD45+, moderate to bright side-scatter region, co-expressing CD4, CD14 (dim, heterogeneous), CD15, CD16 (dim), CD64, HLA-DR, and MPO. The bone marrow biopsy was described as hypercellular with the predominant cell type as blasts at 66.4%. Numerous hemophagocytic blasts were noted as well. Acute leukemia next generation sequencing panel revealed a t(8;16)(p11;p13.3) KATA6A::CREBBP fusion without other abnormalities in the evaluated genes. This workup as a whole rendered the diagnosis of acute myeloid leukemia with KAT6A::CREBBP.

Conclusion

Diagnosing acute myeloid leukemia with KATA6A::CREBBP is important for prognostic factors. Knowing the patient’s history regarding her prior chemotherapy with Etoposide is also imperative for distinguishing a de novo presentation of this rare subtype, versus a therapy-related myeloid neoplasm. The patient was started on chemotherapy for her acute myeloid leukemia shortly thereafter the diagnosis.
A Rare Case of Acute Promyelocytic Leukemia with Concomitant PML-RARA Fusion and TP53 Loss/ider(17)(q10)t(15;17) Showing Complete Clinical and Molecular response: A Case Report
Authors: Elkady M , Al-Quran S , Al-Kawaaz M , Kalantri S , Yasin H
Published: October 2024

Introduction/Objective

To report a case with rare cytogenetic abnormality: a patient with newly diagnosed acute promyelocytic leukemia (APL) with cytogenetic findings of t(15;17)(q24;q21), trisomy 8 and ider(17)(q10)t(15;17)-TP53 loss. The presence of isochromosome 17q may indicate the possibility of an unfavorable outcome. However, the case showed complete clinical and molecular response.

Methods/Case Report

A case of a 53-year-old female with history of ITP post-splenectomy presented with persistent hematuria, easy bruising, and worsening fatigue. She had mild microcytic anemia, moderate thrombocytopenia, 3% promyelocytes, and 14% blasts on differential CBC count. With increased PT, PTT, LDH, Uric acid and decreased fibrinogen level, APL was clinically suspected. The patient was initiated on all-trans retinoic acid (ATRA), allopurinol, and IV fluids. Bone marrow (BM) biopsy confirmed the diagnosis with unusual cytogenetic findings. The patient underwent induction and consolidation therapies (4 weeks each) with ATRA plus Arsenic Trioxide (ATO) and followed- up with a series of marrow biopsies, cytogenetic and molecular studies.

Results (if a Case Study enter NA)

The patient demonstrated complete clinical, histological, and molecular response. She tolerated the treatment without major side effects, showing improvement in CBC counts, coagulation profile and tumor lysis labs. Initial BM exam revealed hypercellularity with infiltrating sheets of atypical hypergranular promyelocytes (~80%) and minimal residual left trilineage hematopoiesis. Flow cytometry revealed a CD34 negative, CD117 variable abnormal promyelocyte population (~67% of total events). FISH was positive for PML/RARA translocation (15; 17) and TP53 loss. Karyotype showed 46,XX,der(15)t(15;17)(q24;q21),ider(17)(q10)t(15;17)[12]/47,idem,+8[9]. By the end of treatment, BM biopsy was normocellular with trilineage hematopoiesis and no definitive evidence of acute leukemia or increase in blasts. The Karyotype was normal. Quantitative PCR for PML-RARA was negative, indicating complete molecular remission.

Conclusion

In this unique case of APL with unusual cytogenetic abnormalities the literature demonstrates controversial data. The patient achieved complete clinical and molecular remission following standard treatment. This may indicate the limited prognostic significance of these additional cytogenetic abnormalities in this case.
Utility of MEF2B Immunohistochemistry in Distinguishing Follicular Lymphoma and Marginal Zone Lymphoma in Diagnostically Challenging Cases
Authors: Oyedeji O , King R , Dalland J C
Published: October 2024

Introduction/Objective

Distinguishing follicular lymphoma (FL) from marginal zone lymphoma (MZL) can be challenging, as the morphology and immunophenotype can overlap particularly in CD10-negative cases or those with marginal zone differentiation (MZD). MEF2B (Myocyte enhancer binding factor B) is a transcription factor that controls BCL6 expression in germinal center (GC) B-cells. Previous studies report MEF2B to have a high sensitivity and specificity for FL compared to other GC markers. We investigated the expression of MEF2B in low grade B cell lymphomas (LGBCL) to evaluate its utility in classifying diagnostically challenging cases and FL with MZD.

Methods/Case Report

Our archives were searched from 2005-2023 to identify excisional biopsies of LGBCL with MZD, including (FL), splenic MZL (SMZL), MZL of mucosa-associated lymphoid tissue (MALT), nodal MZL (NMZL) and difficult-to-classify (DTC) cases with a differential diagnosis of MZL and FL. MEF2B immunohistochemistry was performed retrospectively (Atlas Antibodies). Two hematopathologists assigned a pre-and post-MEF2B diagnosis to DTC cases.

Results (if a Case Study enter NA)

57 cases were included: 21 FL (12 with MZD), 11 SMZL, 13 MALT, 4 NMZL, and 8 DTC cases. 19/21 FL cases (90%) were positive for MEF2B, including 11/12 (92%) cases with MZD. However, MEF2B expression was restricted to the follicles and negative in MZD areas in 7/11 cases (64%), while 4 cases showed partial weak expression in the areas of MZD. 0/11 SMZL (0%), 0/13 MALT (0%), and 0/4 (0%) NMZL were positive for MEF2B. 6/8 DTC cases (75%) were positive for MEF2B. Within DTC cases, retrospective inclusion of MEF2B results helped to render a more definitive diagnosis in 5 cases (2 negative/3 positive).

Conclusion

MEF2B immunohistochemistry can aid in distinguishing FL from MZL in challenging cases. However, it is often negative in areas of FL with MZD so care must be taken on interpretation in small biopsies.
ALK-positive Anaplastic Large Cell Lymphoma Involving the Spinal Cord
Authors: Hwaung P , Tian D
Published: October 2024

Introduction/Objective

ALK-positive anaplastic large cell lymphoma (ALCL) is a mature T-cell lymphoma that accounts for approximately 3% of non-Hodgkin lymphoma cases in the adult population. Lymph node involvement is most commonly seen, followed by extra-nodal involvement of the skin, soft tissue, and bone. Central nervous system involvement is rare at the time of diagnosis. This case study features a patient with systemic ALK-positive ALCL involving multiple nodal and extra-nodal sites, most notably the spinal cord.

Methods/Case Report

A 22-year-old female presented to the hospital with worsening back pain accompanied by neurological symptoms. MRI scans of her spine revealed extensive patchy abnormal marrow signal with enhancement of the thoracolumbar vertebrae (T1-L2) and adjacent extension into the spinal canal (T3-T7, T10-L1, L3-S1) and paraspinal soft tissues. A laminectomy of the T5-T7 and T11-T12 levels was performed for surgical decompression, and epidural and paraspinal resection specimens were submitted. These specimens, along with an excisional axillary lymph node biopsy, demonstrated ALK-positive ALCL after comprehensive immunohistochemical studies. In-situ hybridization for EBV was negative. CHOP therapy was initiated, but treatment was complicated by Candidemia and disseminated intravascular coagulation. The patient rapidly declined and passed away less than a month after hospital admission.

At autopsy, enlargement of lymph nodes, the left ovary (17.8 g), and spleen (383.6 g) were noted on gross examination. A solid, white-tan lesion (2.1 x 0.9 x 0.8 cm) was found in the left ovary. Necrosis and infiltrates of large, pleomorphic lymphoid cells with irregular nuclear contours and prominent nucleoli were seen on microscopic examination of the spinal cord and leptomeninges, vertebral bone marrow, mediastinal lymph nodes, spleen, and left ovary. Consistent with previously submitted surgical specimens, the viable neoplastic cells stained strongly positive for ALK-1, CD4, and CD30.

Results (if a Case Study enter NA)

NA

Conclusion

This case study highlights an atypical presentation of ALCL with a fatal outcome. Given the availability of effective treatment options, prompt diagnosis is crucial to improving survival outcomes. Additional research is necessary to elucidate the clinical and pathological features of ALCL. The differential for back pain is broad, but including this entity for patients with similarly insidious clinical presentations can prevent a delay in diagnosis that allows for rapid progression of disease.
Case Series: Unveiling mass-forming neoplastic extramedullary hematopoiesis in chronic myeloid leukemia
Authors: Iashvili L , Christie-Nguyen P , Ibrahim N , Rivera D , mai B , Armstrong J A
Published: October 2024

Introduction/Objective

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm characterized by BCR::ABL1 fusion and predominantly granulocytic proliferation. Three main phases of disease have previously been recognized: chronic, accelerated and blast phase, though accelerated phase has become controversial. During the chronic phase, leukemic cells exist predominantly in the peripheral blood and bone marrow; however, during blast phase, blasts can proliferate in the blood, bone marrow, or extramedullary tissues.

Methods/Case Report

We present two instances of cutaneous extramedullary hematopoiesis associated with CML at our institution.

Results (if a Case Study enter NA)

Case 1: A 34-year-old man previously diagnosed with CML presented with painful pustules on his right thigh. Biopsy revealed an infiltration of primarily left-shifted granulocytes, along with scattered megakaryocytes, and rare erythroid precursors. Immunohistochemical studies were consistent with maturing extramedullary hematopoiesis, devoid of sheets or clusters of blasts. Peripheral blood analysis revealed marked neutrophilic leukocytosis with basophilia and eosinophilia. Bone marrow examination depicted left-shifted granulocytic hyperplasia, megakaryocytic hyperplasia, and fewer than 5% blasts.

Case 2: A 40-year-old man presented with fatigue, night sweats, weight loss, hepatosplenomegaly and palpable nodules on his left arm and thighs. The biopsy of the thigh nodule uncovered leukemic cells at different developmental stages, along with eosinophils, erythroid precursors, and megakaryocytes. Immunohistochemical staining confirmed their presence, with only a few blasts observed. Blood and bone marrow tests showed leukocytosis with blasts less than 5%, indicating CML in the chronic phase. Molecular analysis confirmed BCR-ABL1 fusion.

Conclusion

Mass-forming neoplastic extramedullary hematopoiesis in the skin during chronic phase of CML is a feature that is not well-documented in the literature. This entity shows immature granulocytic precursors, but does not exhibit an increase in blasts and therefore should not be called leukemia cutis or myeloid sarcoma. It is important to raise awareness of this entity to prevent misinterpretation as myeloid sarcoma and subsequent unnecessarily aggressive therapy.
An Unusual Case of Lymphoplasmacytic Variant of Multiple Myeloma
Authors: Raafey M , Youngberg G , Wheeler Y
Published: October 2024

Introduction/Objective

Multiple myeloma is characterized by unregulated growth of monoclonal plasma cells with overt production of nonfunctional intact immunoglobulins or immunoglobulin chains. Immunohistochemically, the plasma cells are positive for CD138 and CD38, and are rarely positive for CD20 or cyclin D1. CD20 positivity and plasmacytoid morphology in our case pointed towards a lymphoplasmacytic variant of multiple myeloma. The translocation t(11;14) has been detected in this variant, which can explain the positive cyclin D1 immunostaining. The differential diagnosis of this myeloma variant includes lymphoplasmacytic lymphoma.

Methods/Case Report

We present a case of a 75-year-old female with no significant past medical history who suffered a fall and hesitated to get evaluated until her pain persisted. Initial ER evaluation revealed she had a compression fracture of the T10 and T11 vertebrae with no other abnormality identified. Subsequently, she underwent kyphoplasty, and bone biopsies were performed. The biopsies showed prominent monotonous lymphocytes and some plasmacytoid cell proliferation. Immunostains showed the tumor cells were positive for CD20, Pax-5, Bcl-2, cyclin D1, CD138, and kappa light chain, weakly positive for CD23; and negative for CD5, CD3, CD10, Sox11, and lambda light chain. Based on the morphology and immunoprofile, current findings were considered suggestive of a low-grade B cell lymphoplasmacytic proliferation with cyclin D1 expression. The differential diagnosis includes a lymphoplasmacytic lymphoma or lymphoplasmacytic variant of multiple myeloma. This case was forwarded to a higher-level care facility for consultation and the diagnosis of plasmacytoma, kappa light chain restricted, was rendered.

Results (if a Case Study enter NA)

NA

Conclusion

Misdiagnosis of lymphoma can be made in lesions showing classic plasma cells, numerous lymphoplasmacytic cells, and cyclin-D1 positivity on immunohistochemistry if additional testing is not performed. We recommended further testing, including but not limited to bone marrow biopsy, molecular testing, FISH, and genetic testing for a definitive diagnosis.
Mixed Gangliocytoma-Pituitary Adenoma: Incidental Discovery During Eye Injury Evaluation: A Case Study
Authors: Blackburn S , Ibrahim N , Aljumaili Z , Brown C , Ak S , Bhattacharjee M
Published: October 2024

Introduction/Objective

Mixed gangliocytoma-adenoma is exceedingly rare, representing less than 0.5% of sellar tumors. We present a unique case of mixed gangliocytoma-pituitary adenoma incidentally diagnosed during the evaluation of traumatic eye injury. We aim to clarify the diagnostic process using real clinical data, stressing how such cases might be missed without careful histopathological examination

Methods/Case Report

A 32-year-old male presented for elective transsphenoidal resection (TSR) due to a suspected growth hormone (GH) secreting pituitary tumor. Surprisingly, the adenoma was discovered incidentally during an eye injury evaluation. Referred from an ophthalmology clinic, initial concerns were a possible blood clot or foreign body in the left eye, following a forceful encounter with a tree branch

Results (if a Case Study enter NA)

Imaging incidentally identified a 2 cm pituitary mass. Further evaluation showed elevated levels of insulin-like growth factor 1 (IGF1) at 1162 ng/ml and GH at 10.2 ng/ml. Remarkably, the patient had not observed signs of acromegaly, until photographic comparison between past and present appearances was made. TSR of the pituitary mass was done. Microscopic examination revealed monomorphic cells with round nuclei with the typical speckled chromatin pattern of neuroendocrine cells with cytoplasm ranging from chromophobic to eosinophilic, consistent with pituitary adenoma. An additional unexpected finding was the presence of large gangliocytic cells (large neurons), dispersed throughout the tumor as single or clustered cells. In some regions, distinct patches of fine neuropil stroma were associated with the clustered ganglion cells. IHC staining with synaptophysin and neurofilament highlighted the gangliocytic component. CAM 5.2 IHC stain showed perinuclear dot-like expression in the adenoma cells, GH IHC showed patchy expression, and prolactin IHC was expressed in scattered cells. Ki67 index was ~ 2%. There was no evidence of necrosis nor mitosis. The coexistence of sellar gangliocytoma with pituitary adenoma, as observed in this case, represents a rare entity known as mixed gangliocytoma-pituitary adenoma

Conclusion

The adenomatous component of mixed gangliocytoma-pituitary adenoma often secrete GH, leading to its classification as pituitary somatotroph adenoma. This poses a diagnostic challenge due to the lack of specific symptoms or unique brain imaging features, necessitating thorough histological evaluation for precise diagnosis and to ensure the gangliocytoma component is not overlooked
Multifaceted Interventions to Enable Elimination of Clinician-ordered Blood Smear Reviews: A Rural Academic Medical Center Experience
Authors: Ghafari G , Dhesi M S , Grant M
Published: October 2024

Introduction/Objective

Blood smears (BS) evaluate a variety of clinical disorders. At Geisinger, clinician ordered pathologist review of blood smears (CBS) have increased despite usage of highly sophisticated hematology analyzers and automatic blood smear (ABS) review criteria. We hypothesized that CBS impact pathologists’ and technologists’ workloads and increase costs and turn-around times, with rare improvement in value-based patient care. This study aimed to analyze CBS ordering practices and improve the utilization of BS review.

Methods/Case Report

In October 2020, a prospective CBS utilization study was completed by 8 clinical pathologists for 172 CBS. Subsequently, a clinical question was required for CBS orders from January 1, 2022, to January 1, 2023, to investigate clinician ordering practices based on campus, department, and indications. Findings were used to support new interventions including: clinician education; cancellation of repeat BS ordered within 24 hours, creation of alternative tests (schistocyte technologist smear review, clinician order for independent slide review), standardization of morphology reporting, ABS audits, and elimination of orderable CBS replaced by an electronic BS review request, that is reviewed by a clinical pathologist prior to determine if a BS is indicated.

Results (if a Case Study enter NA)

Part of the Conclusions section for Lab Practice abstract.

Conclusion

Prospective utilization audit of 172 CBS orders showed 17% changed clinical management. Audit of 3,693 CBS orders demonstrated common reasons for review included tick-borne illness, hemolysis, erythrocytosis, thrombocytosis, and iron deficiency anemia. Systematic implementation of multiple interventions enabled the elimination of CBS, with no known adverse effect on patient management to date. The streamlined BS review guidelines allowed for better-allocation of resources, appropriate patient turn-around times, empowerment of laboratory technologists and reduced hospital costs. We propose maximizing the incorporation of technologist skills to improve the utilization and efficiency of BS reviews and establishing standardized, evidence-based, and institutional- specific guidelines to determine BS reviews.
Laboratory Science Workforce Pipeline Strategies
Authors: Pregnall K , Mantooth M
Published: October 2024

Introduction/Objective

The U.S. Bureau of Labor Statistics projects 24,000 openings for clinical laboratory jobs each year until 2031 (BLS, 2022). The American Society for Clinical Pathology (ASCP, 2023) reported a 14.8% vacancy rate for medical laboratory scientists in the South-Central Atlantic region; this region includes South Carolina. There are not enough MLT or MLS certified laboratorians to keep up with current or future demands. On average, 3779 new certifications were awarded annually between 2019-2023. Pathology and Laboratory Medicine at the Medical University of South Carolina is taking short- and long-term approaches to address workforce challenges.

Methods/Case Report

Since 2018, Pathology and Lab Medicine has increased the number of clinical affiliates from 2 to 9 and have trained a total of 39 MLS students and 37 MLT students. In 2023, through collaboration with the MLT program at the local technical college, we began providing didactic education for 15 current lab team members with bachelor’s degrees but no clinical laboratory background.

Employing youth apprentices is a long-term strategy being initiated in the 24-25 academic year. Juniors and seniors in high school are eligible for a two-year paid apprenticeship. Training includes medical lab assistant and phlebotomy certification. Through recruitment activities, we can increase awareness of the role of laboratory professionals in medicine. Long-term, the apprenticeship training provides an academic pathway to MLT and MLS certification.

Results (if a Case Study enter NA)

N/A

Conclusion

The short-term strategies have met with varying success and course corrections have been made. Successes and barriers will be discussed. Strategies for recruiting and selecting youth apprentices will be outlined. Training plans for youth apprentices will be presented.
Precision Pathology: Unveiling the role of Interval Sectioning Protocol for Optimal Diagnosis in Pancreatic, Ampullary, and Bile Duct Biopsies
Authors: Talbott P , Shilpa J
Published: October 2024

Introduction/Objective

Endoscopic techniques offer advanced diagnostics but encounter challenges in obtaining limited pancreaticobiliary biopsies, including ampullary (AMP), EUS-guided pancreatic (PAN), and spy bite biliary (BD) biopsies. Interval sectioning optimizes immunohistochemical stain utility and tissue conservation. This study evaluates interval sectioning protocols’ impact on diagnostic precision and tissue preservation at our institution.

Methods/Case Report

This analysis examines cases over four months before and after a protocol change, focusing on AMP, BD, and PAN biopsies. Previously, AMP and BD biopsies used three H&E-stained slides, while PAN required two H&E-stained and five unstained slides (USS). The new protocol adopts seven slides with H&E staining on levels 1, 4, and 7, emphasizing consistency. Parameters assessed include diagnosis, turnaround time (TAT), and USS utilization. A 30% USS utilization cutoff justifies upfront interval sectioning.

Results (if a Case Study enter NA)

A total of 77 cases from the old protocol and 142 from the new protocol were reviewed. No significant difference in TAT between old and new protocols was found (p=0.340). However, PAN TAT notably improved (4848 min vs. 2932 min). Usage rates varied by site: 22.2% (AMP), 33.3% (BD), and 34.4% (PAN).

Conclusion

USS usage was lowest for AMP cases (22.2%), below the 30% threshold for upfront interval sectioning justification. Eliminating interval sectioning for AMP would save 116 USS in the new protocol. BD and PAN cases warrant upfront interval sectioning, with USS usage rates of 31.5% and 33.7%, respectively. While PAN cases show no cost difference, the new protocol improves specimen visualization, correlates immunohistochemical stains better, and significantly enhances turnaround time.
Red Blood Cell (RBC) Antigen Confirmation Workflow – A Positive Impact at an Academic Medical Center
Authors: Abdelmonem M , Yoshizuka S , Quach T , Nguyen A , Vukic K , Chang S , Kilambi S , Virk M S , Pham T , Yunce M
Published: October 2024

Introduction/Objective

Introduction: Blood group antigens, present on the surface of red blood cells (RBCs), play a crucial role in transfusion medicine. These antigens are recognized serologically and form the basis of RBC phenotyping. Understanding the significance of antigen-negative RBCs is essential for mitigating the risk of hemolytic transfusion reactions and hemolytic disease of the fetus and newborn (HDFN). This study aims to assess the impact of implementing a new RBC antigen confirmation workflow on transfusion service efficiency and patient outcomes.

Methods/Case Report

Method: The study involved collaboration between our Transfusion Services Department (TS), the Blood Center supplier, and the Apheresis department. A comprehensive review of historical practices and FDA recommendations regarding RBC antigen labeling was conducted. Changes were implemented to streamline antigen confirmation testing and labeling processes. The impact on TS workload, turnaround time, and patient care metrics was evaluated.

Results (if a Case Study enter NA)

Results: Implementation of the new RBC antigen confirmation workflow led to a significant reduction in antigen confirmation tests performed by TS, with a 607% decrease observed from 2020 to 2023. Concurrently, the workload for reference lab workups increased by 337% over the same period. This shift in workload distribution allowed TS staff to focus more on patient reference workup cases and case review. The improved workflow efficiency resulted in enhanced turnaround times for providing patients with antigen-negative RBCs, ultimately improving the patient experience.

Conclusion

Conclusion: The adoption of the new RBC antigen confirmation workflow has resulted in compliance with FDA labeling requirements, efficient utilization of TS staff resources, and decreased turnaround times for blood delivery. These improvements have positively impacted patient care by ensuring timely access to compatible blood products. Future steps include developing reports to track turnaround time for patients with special blood product needs and continuing collaboration with the blood supplier and the Apheresis department to optimize inventory management and transfusion processes.
“You Should Get That Checked Out”: An Exploratory Analysis of Health-Related Discussions on Reddit
Authors: Chan G , Fung M , Warrington J , Nowak S
Published: October 2024

Introduction/Objective

Social media has become a widely-used way for people to share opinions about healthcare and medical topics. Social media data can be leveraged to understand patient concerns and provide insight into why patients may turn to an internet forum, rather than the healthcare system, for health advice. Data collected on users’ questions and discussions can be used to better manage healthcare resources, including laboratory tests. We aimed to investigate Reddit posts discussing medical conditions and characterize their implications.

Methods/Case Report

We collected one year of Reddit posts containing the phrases “get tested” and “get checked.” An initial selection of posts was manually read by the authors to categorize the issues discussed in the posts into conditions. An automated script was then developed to assign additional posts to conditions, based on keywords.

Condition assignment was performed on the entire one-year Reddit dataset. Related conditions were grouped into broader medical topics. Analysis of the condition assignments was then performed to assess condition and medical topic frequencies in medical condition-focused subreddits and general (non-medical-focused) subreddits.

Results (if a Case Study enter NA)

Among all conditions, STIs, eye disorders, anxiety, and pregnancy had the highest post frequency. Of the broader medical topics, the most frequent were psychiatry and mental health; genitourinary and reproductive health; infectious disease; and endocrinology, nutrition, and metabolism. Overall, conditions that appeared most frequently as a top-five condition in general subreddits included addiction and drug use, ADHD, abuse, and STIs. These conditions may be associated with fear of stigmatization.

Conclusion

Overall, we find that health discussions center on certain topics on Reddit. These topics may represent areas where people feel more comfortable discussing their health online, and where the healthcare system could focus additional outreach and resources. They may also shed light on how laboratory tests can be best managed.
Collaboration between a veterinary laboratory and a clinical cytogenetics laboratory
Authors: Van Rheeden R V , Nagy J , Robinson J , States K , Kuster C
Published: October 2024

Introduction/Objective

One major issue facing pig breeders is the presence of karyotypic abnormalities which reduce fertility. Karyotypic abnormalities may also persist in breeding population increasing the magnitude of lost animal production over time. Assessment of porcine chromosomes is a valuable service to be offered to the livestock industry.

Methods/Case Report

Chromosome testing of young boars prior to breeding is mandatory in France and much of Western Europe. Such testing is not common in the USA even though chromosome abnormalities are known to exist in swine breeding populations. Due to the lack of this service in the US, we established a collaboration between a clinical cytogenetics laboratory and a veterinary laboratory to validate and offer karyotype testing for breeder boards. To established this service Kuster Research and Consulting, Inc (KRC), a veterinary consulting service in Atkinson Illinois, reached out to the Shivanand R. Patil Cytogenetics and Molecular Laboratory at University of Iowa Healthcare for assistance in setting up chromosome testing for breeder boars based on the laboratory’s experience in culturing mammalian cells for chromosome analysis. Technologists from KRC traveled to the clinical cytogenetics lab for training. After a dedicated period of work and collaboration, a reproducible culture and harvest protocol was developed to obtain G-band metaphase spreads. Additional assistance for analysis was provided by Dr. Alain Pinton at the National Veterinary College (ENVT) in Toulouse, France. Dr. Pinton’s cytogenetic laboratory provided training in porcine chromosome analysis as well as providing protocols used in that laboratory. Kuster Research and Consulting also worked with SmartType to adapt proprietary karyotype software to assist in analysis of porcine chromosomes.

The collaboration established the first of its kind cytogenetic testing in a private USA veterinary laboratory,

Results (if a Case Study enter NA)

Active collaboration between clinical and veterinary service laboratories resulted in the successful development of testing protocols. In addition, the clinical lab gained experience in analysis of porcine chromosomes which has created opportunities for research using a porcine model.

Conclusion

Opportunities to share expertise should be sought and and encouraged to provide needed laboratory services in a non traditional setting.
Calcifying Nested Stromal-Epithelial Tumor of the Liver: A Rare Find
Authors: Talreja S , Laury R , Kumar S , Zahid H
Published: October 2024

Introduction/Objective

Calcifying Nested Stromal-Epithelial Tumor (CNSET) is a rare tumor of the liver with less than 40 cases described in the literature. It is a low-grade tumor characterized by a distinctive nested architecture surrounded by a cellular myofibroblastic stroma and psammomatous calcifications. CTNNB1 gene deletions have been identified in several cases. CNSET typically arises in the right lobe and there is a female predominance with a predilection for children, adolescents, and young adults.

Methods/Case Report

We report an interesting case of CNSET in a 13-year-old male with no pertinent medical history who presented with a one-month history of fatigue, paleness, and liver mass on physical examination. MRI abdomen showed a 9.8 cm heterogenous mass with a central scar involving the right lobe of the liver, radiologically favored to be fibrolamellar hepatocellular carcinoma. AFP levels were normal. The patient underwent a partial hepatectomy.

On gross examination, the specimen showed a yellow, circumscribed, firm mass. H&E slides showed scattered round to oval nests of bland spindle and epithelioid cells arranged in short fascicles at the periphery of nests. Collagenous stroma surrounding the nests showed spindle cells with tapered nuclei and pinpoint nucleolus. Areas with calcification and osseous metaplasia were also present. Immunohistochemistry performed showed the tumor cells to be positive for pan-cytokeratin (weak), WT-1, and vimentin, and negative for Hepar-1, arginase-1, synaptophysin, chromogranin, S100, NUT-1, myogenin, and desmin. Beta-catenin showed nuclear and cytoplasmic staining pattern. INI-1 was retained within the tumor cells and Ki-67 showed a proliferative index of approximately 10-20%. On MSK-Impact (next- generation sequencing), a mutation in CTNNB1 was detected. Archer FusionPlex was negative for gene fusions within the tumor.

Results (if a Case Study enter NA)

NA

Conclusion

It is crucial to become familiar with this rare entity and to avoid mistaking it for hepatoblastoma. CNSET exhibits a biphasic morphology characterized by a nested architecture featuring bland and uniform epithelioid and spindle cells, surrounded by a cellular myofibroblastic stroma. Confirming the diagnosis can be aided by nuclear β- catenin and the expression of WT1.