D. Gibbons

Prognostic significance of tumor budding in rectal cancer biopsies before neoadjuvant therapy

Tumor budding is an increasingly important prognostic feature for pathologists to recognize. The aim of this study was to correlate intra-tumoral budding in pre-treatment rectal cancer biopsies with pathological response to neoadjuvant chemoradiotherapy and with long-term outcome. Data from a prospectively maintained database were acquired from patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy. Pre-treatment rectal biopsies were retrospectively reviewed for evidence of intra-tumoral budding. Multivariate logistic regression was used to identify factors contributing to cancer-specific death, expressed as hazard ratios with 95% confidence intervals. Of the 185 patients with locally advanced rectal cancer, 89 patients met the eligibility criteria, of whom 18 (20%) exhibited budding in a pre-treatment tumor biopsy. Intra-tumoral budding predicted a poor pathological response to neoadjuvant chemoradiotherapy (higher ypT stage, P=0.032; lymph node involvement, P=0.018; lymphovascular invasion, P=0.004; and residual poorly differentiated tumors, P=0.005). No patient with intra-tumoral budding exhibited a tumor regression grade 1 or complete pathological response, providing a 100% specificity and positive predictive value for non-response to neoadjuvant chemoradiotherapy. Intra-tumoral budding was associated with a lower disease-free 5-year survival rate (33 vs 78%, P<0.001), cancer-specific 5-year survival rate (61 vs 87%, P=0.021) and predicted cancer-specific death (hazard ratio 3.51, 95% confidence interval 1.03–11.93, P=0.040). Intra-tumoral budding at diagnosis of rectal cancer identifies those who will poorly respond to neoadjuvant chemoradiotherapy and those with a poor prognosis.

Liquid‐based cytology improves productivity in cervical cytology screening

Objectives:  The ThinPrep® test was introduced into our institution on a phased basis over 3 years between January 2002 and December 2004. This study set out to assess its effect on productivity (as measured by output of cases per medical scientist per day) during the changeover period. Numbers of high and low‐grade lesions and of unsatisfactory slides were also monitored.

Reproducibility of the Rapid Bud Count Method for Assessment of Tumor Budding in Stage II Colorectal Cancer

To the Editor: Tumor budding, which is manifested by the migration of small discrete groups of tumor cells into desmoplastic stroma at the invasive tumor front, has been shown to be a negative prognostic factor in patients with stage II colorectal carcinoma (CRC). It is postulated to be a manifestation of the epithelialmesenchymal transition, with epithelial cells migrating as fibroblast-like cells. A recent study in our department has compared a new rapid bud count method (RBCM) for counting tumour buds with the conventional bud count method (CBCM). This has shown the RBCM to be equivalent to the CBCM, and has shown pT3N0 tumors to be divisible into ‘‘high budding’’ and ‘‘low budding’’ groups with significant differences in cancer-specific survival. We aimed in this study to assess the reproducibility of the RBCM between a group of practicing surgical pathologists of varied levels of experience in a busy academic surgical pathology department. The 40 stage II CRC cases used in the reproducibility component of an earlier reported study formed the basis for this study. Each case comprised between 3 and 9 H&E-stained slides, representing slides from all of the tumor blocks. A tumor bud was defined as a group of less than 5 detached tumor cells, usually at the invasive front (Fig. 1). Each case had been examined by LW and KS and classified, by consensus, as either high or low budding by the ‘‘gold standard’’ CBCM. By this method, each slide was initially scanned at 40 magnification to identify 5 areas with the highest concentration of tumor buds. These areas were then reexamined at 200 magnification. Tumor buds were formally counted in each of the five 200 fields, yielding 5 bud scores per slide. The process was repeated for each slide in the case, resulting in a total of between 15 and 45 bud scores per case. All of the bud scores from a case were collected and a median value calculated. Cases with a median bud score of Z1 were classified as high budding, whereas those with a median bud score of <1 were classified as low budding. The original study found that this definition achieved the best cut-off for stratifying survival data between the 2 groups. In essence, it meant that once a case showed tumor buds in more than half of the examined 200 microscopic fields, it was classified as high budding. In addition to the consensus CBCM, both LW and KS had individually applied the RBCM to the 40 cases. This method was identical to the CBCM except that when the 5 selected areas per slide were reexamined at 200 , the absolute number of tumor buds was not counted. Instead, the presence of any tumor bud in a given 200 microscopic field was recorded as positive (denoted by bud score ‘‘1’’) and similarly when no tumor bud was observed, it was recorded as negative (denoted by bud score ‘‘0’’). A median bud score of <1 defined a case as low budding by this method, with highbudding cases having a median bud value of 1. Each of the 4 study participants (BH, AM, NC, DG) underwent brief training in assessing tumor budding by the RBCM comprising review of a PowerPoint presentation, review of the original paper and review of a set of sample cases with one of the authors (KS). Results were recorded on a standardized form, and agreement was measured using percentages and free-marginal k statistics for multiple raters of dichotomous data. There was substantial agreement between the 4 pathologists (k=0.617) on the presence of low or high budding (Table 1). There was complete agreement (4:0) in 62.5% of cases (25/40), and complete disagreement (2:2) in one case (2.5%). In the remaining 14 cases (35%) there was 3-way agreement. In 10 of these cases the disagreeing pathologist underestimated budding relative to the other participants, and in 4 cases there was overestimation. The mean deviation in the number of bud-positive 200 microscopic fields scored by the disagreeing pathologist was low and was similar in cases of underestimation (4.1 or 28%) and overestimation (4.125 or 33%). In 3 of the cases of underestimation, the degree of deviation in the number of positive fields was marginal (less than 1, or 4%), FIGURE 1. Tumor buds in a desmoplastic stroma. LETTERS TO THE EDITOR

Pilomatrix carcinoma presenting as an extra axial mass: clinicopathological features

Pilomatrix carcinoma is the rare malignant counterpart of pilomatrixoma, a skin adnexal tumour originating from hair matrix cells. Pilomatrix carcinoma can arise as a solitary lesion de novo, or through transformation of a pilomatrixoma. Pilomatrixoma was first described erroneously as being of sebaceous gland origin but was later discovered to be derived from hair matrix cells. They are rare, slow growing tumours of the skin found in the lower dermis and subcutaneous fat and are predominantly found in the neck and the scalp. While known to be locally aggressive, no malignant form was thought to exist until it was described relatively recently. Since then, approximately ninety cases of pilomatrix carcinoma have been reported.We report the case of a 41 year old mentally retarded male who had a longstanding lesion in the left neck for approximately fifteen years previously diagnosed as a pilomatrixoma. He presented with severe headache, falls and visual disturbance and a biopsy showed pilomatrix carcinoma of the occipital region which, on computed tomography ( CT ) invaded the occipital bone, the cerebellum and the left temporal lobe. At his initial presentation he had a craniotomy and subtotal excision of the lesion but received no adjuvant therapy. After an early intracranial recurrence he had further debulking and adjuvant external beam radiotherapy. He has had no further intracranial recurrence after three and a half years of follow-up. Here we present the pathological features of this uncommon tumour.

Recurrent malignant pilomatrixoma invading the cranial cavity: Improved local control with adjuvant radiation.

We report the case of a 41‐year‐old mentally retarded male with recurrent pilomatrix carcinoma of the occipital region which invaded the occipital bone, left cerebellum and left temporal lobe. At his initial presentation the patient had a craniotomy and subtotal excision of the lesion with positive margins. He received no adjuvant therapy. After an early intracranial recurrence he had subtotal debulking and was referred for external beam radiotherapy. At 27 months follow‐up after adjuvant external beam radiotherapy the intracranial component has not progressed and the patient remains clinically well.

Anal intraepithelial neoplasia: a single centre 19 year review

There is debate about whether the traditional three‐tiered grading of anal intraepithelial neoplasia (AIN) should be replaced by a more reproducible two‐tiered system. In this study, we review our experience with AIN to determine the most suitable classification system.

Effects of Radiation on Levels of DNA Damage in Normal Non-adjacent Mucosa from Colorectal Cancer Cases

PurposeDefects in DNA repair pathways have been linked with colorectal cancer (CRC). Adjuvant radiotherapy has become commonplace in the treatment of rectal cancer however it is associated with a higher rate of second cancer formation. It is known that radiation results in DNA damage directly or indirectly by radiation-induced bystander effect (RIBE) by causing double-strand breaks (DSBs). The majority of work in RIBE has been performed in cell lines and limited studies have been in or ex vivo.MethodsThe first study aim was to examine by immunohistochemistry, levels of DSB (expression of the protein MRE11) in normal colonic tissue outside the irradiated field post neo-adjuvant radiotherapy (group 1). These levels were compared to (a) irradiated tumour tissue post neo-adjuvant radiation within the same group, (b) a CRC patient group (group 2) who had not undergone neo-adjuvant radiotherapy and (c) a non-cancer patient group (group 3). The second aim was to determine if MRE11 expression levels were related to survival or radio-sensitivity post neo-adjuvant radiotherapy.ResultsThere was a highly significant increase in MRE 11 expression in group 1 versus groups 2 and 3 (p < 0.001). There was no association between MRE11 levels and survival or radio-sensitivity.ConclusionOur findings show radiotherapy causes DSBs at significantly higher levels in normal colonic mucosa of patients post neo-adjuvant treatment which may represent RIBE. If this damage remains unrepaired, increased levels of genomic instability may contribute to the higher occurrence of second cancers in patients treated post neo-adjuvant radiotherapy.

Post irradiation olfactory neuroblastoma (esthesioneuroblastoma): A case report and up to date review

ultrasonography, which revealed only an intrahepaticlesion. However, a subsequent PET/CT scan of thewhole body revealed another two incidental foci,which was confirmed by the postoperative pathologicresults (i.e., lesions with a high glucose uptake werepathologically malignant: GIST and ICC). In sum-mary, the whole-body PET/CT scan played animportant role in guiding further investigation andenhancing an accurate and early diagnosis for thispatient.Pulmonary hamartomas are benign neoplasmsthat usually present in asymptomatic adult men.Because they often present as a single peripheralnodular lesions radiographically [5], pulmonaryhamartomas can be misinterpreted clinically asmetastatic lesions, although PET/CT will show noincreased FDG uptake. Wedge resection is adequatefor these tumors which have little or no risk ofmalignant transformation or recurrence.In summary, we have described the first case of aGIST with a simultaneously diagnosed ICC andpulmonary hamartoma. The whole body PET/CTscan can make possible accurate and early detectionof these neoplasms, and appropriate treatmentstrategy (removal of all these tumors and adjuvantimatinib therapy for the GIST) may contribute to afavorable outcome.AcknowledgementsThe authors thank George Y. Wu, M.D., Ph.D., forhis critical review of the manuscript.References

The number of dyskaryotic cells on an initial ThinPrep® cervical sample showing mild dyskaryosis has predictive value

Objectives:  Recent National Health Service Cervical Screening Programme (NHSCSP) guidelines suggest referral for colposcopy following an initial result of mild dyskaryosis. The aim of this study was to investigate if the number of dyskaryotic cells counted on an initial ThinPrep® cervical sample showing mild dyskaryosis has predictive value.

Decrease in numbers of glandular cell groups in post-LLETZ liquid-based cytology preparations.

Objective:  Large loop excision of the transformation zone (LLETZ) has become standard of care in the management of cervical squamous neoplasia and with cone biopsy glandular intraepithelial neoplasia. Controversy remains about the long‐term effects of this traumatic procedure. The aim of this study was to count and compare the number of endocervical glandular cell groups in pre‐ and post‐LLETZ cervical preparations using liquid‐based cytology to establish a cyto‐morphological correlate of destruction of the transformation zone.