Eric Huang

Large-Scale Screening and Molecular Characterization of EML4-ALK Fusion Variants in Archival Non–Small-Cell Lung Cancer Tumor Specimens Using Quantitative Reverse Transcription Polymerase Chain Reaction Assays

Introduction: The objective of this study was to identify and characterize echinoderm microtubule-associated protein-like 4 anaplastic lymphoma kinase fusion (EML4-ALK+) cancers by variant-specific, quantitative reverse transcription polymerase chain reaction (RT-PCR) assays in a large cohort of North American non–small-cell lung cancer (NSCLC) patients. Methods: We developed a panel of single and multiplex RT-PCR assays suitable for rapid and accurate detection of the eight most common EML4-ALK+ variants and ALK gene expression in archival formalin-fixed, paraffin-embedded NSCLC specimens. EGFR and KRAS genotyping and thymidylate synthase RNA level by RT-PCR assays were available in a subset of patients. Results: Between December 2009 and September 2012, 7344 NSCLC specimens were tested. An EML4-ALK+ transcript was detected in 200 cases (2.7%), including 109 V1 (54.5%), 20 V2 (10.0%), 68 V3 (34.0%), and three V5a (1.5%) variants. Median age was 54.5 years (range, 23–89), and 104 patients (52.0%) were women. The great majority (n=188, 94.0%) of EML4-ALK+ NSCLC tumors had adenocarcinoma histology. ALK expression level varied significantly among different EML4-ALK+ variants and individual tumors. Only one case each of concurrent EGFR or KRAS mutation was detected. The median thymidylate synthase RNA level from 85 EML4-ALK+ cancers was significantly lower compared with that of EML4-ALK-negative lung adenocarcinomas (2.02 versus 3.29, respectively, p<0.001). Conclusions: This panel of variant-specific, quantitative RT-PCR assays detects common EML4-ALK+ variants as well as ALK gene expression level in archival formalin-fixed paraffin-embedded NSCLC specimens. These RT-PCR assays may be useful as an adjunct to the standard fluorescence in situ hybridization assay to better understand biologic variability and response patterns to anaplastic lymphoma kinase inhibitors.

Critical diagnoses in surgical pathology: a retrospective single-institution study to monitor guidelines for communication of urgent results.

Recent attention has shifted toward defining critical values in surgical pathology, as used in clinical pathology for urgent laboratory results, which require immediate physician notification. The Association of Directors of Anatomic and Surgical Pathology recently proposed a schema for critical values in surgical pathology, better defined as critical diagnoses (CDs). To this end, our department established guidelines defining the timely communication and documentation of urgent findings. To monitor policy effectiveness and to refine a customized list of CDs, we analyzed reports over two identical 6-month periods in 2006 and 2007 for the proper documentation and communication of urgent results. Of all the general surgical pathology cases examined, slightly more than 3% were communicated urgently to the requesting physicians. Approximately 20% of those cases fell into one of the recently proposed CD categories, whereas the remaining cases had conditions that were not specified by the Association of Directors of Anatomic and Surgical Pathology, but nonetheless justified immediate notification based on local practice, such as graft-versus-host disease, acute tubulo-interstitial nephritis, and unsuspected amyloidosis. Consecutive cases from a 4-day period reviewed in 2006 showed that 23.5% notified cases were not properly documented in the final report. However, the compliance rate improved to 100% for a similar period in 2007. Our study demonstrates the need for any CD list to be customized at a given institution to address all the potential diagnoses necessary for patient care and management. It further shows that continuous monitoring and education with regard to CDs and timely communication and documentation of unexpected surgical pathology findings are important measures for optimizing patient safety.

Clinical outcome in diagnostically ambiguous foci of ‘gland crowding’ in the endometrium

Premalignant endometrial lesions (endometrial intraepithelial neoplasia (EIN)) are clonal neoplasms that arise focally and can be diagnosed using specific criteria: (1) area of glands exceeds that of stroma (glands/stroma >1), (2) nuclear and/or cytoplasmic features of epithelial cells differ between architecturally abnormal glands and normal background glands, and (3) maximum linear dimension exceeds 1u2009mm. However, localized groups of crowded endometrial glands may be encountered that do not fulfill all of the criteria for EIN, are interpreted as ambiguous, and are reported as ‘focal gland crowding’. We conducted a retrospective study of gland crowding using a free-text index search for this term in our pathology files. The age of the patients, number of subsequent specimens, the duration, and the outcome of the follow-ups were recorded. Of the 71u2009579 consecutive gynecological pathology reports, 206 (0.3%) ‘gland crowding’ cases were identified, in which 69% (143/206) had follow-up sampling. Of these, 33 (23%) had an outcome diagnosis of EIN (27 cases; 19%) or carcinoma (6 cases; 4%). Included were 18 cases (55%) diagnosed within the first year and presumed concurrent, and an additional 15 (45%) discovered after 1 year and interpreted as a later phase of disease or new events. The term ‘crowded glands’ is a highly significant finding that carries a substantial risk of an outcome of EIN and occasionally malignancy. It underscores the importance of follow-up when some but not all of the criteria for EIN are encountered in the appropriate clinical setting.

Evaluation of the Cyclic Endometrium and Benign Endometrial Disorders

Abstract Endometrial sampling is a major component of gynecologic care as practitioners endeavor to identify the causes of abnormal uterine bleeding (AUB), potential explanations for infertility, and abnormalities that might place the patient at greater risk for malignancy. The plethora of patterns that might be encountered during reproductive life and postmenopause can be confusing, and an informed pathologist is critical to optimal care. Fundamental to this task is a thorough understanding of and a systematic approach to non-neoplastic endometrial disorders. This chapter brings together detailed descriptions of the entities encountered when evaluating uterine bleeding and an authoritative clinical perspective. The goal is to provide the reader a road map of benign endometrial disorders from both a pathologic and clinical perspective, and provide the foundation needed to address both benign and neoplastic endometrium.