Evita Henderson-Jackson

Diagnostic digital cytopathology: Are we ready yet?

Background: The cytology literature relating to diagnostic accuracy using whole slide imaging is scarce. We studied the diagnostic concordance between glass and digital slides among diagnosticians with different profiles to assess the readiness of adopting digital cytology in routine practice. Materials and Methods: This cohort consisted of 22 de-identified previously screened and diagnosed cases, including non-gynecological and gynecological slides using standard preparations. Glass slides were digitalized using Aperio ScanScope XT (×20 and ×40). Cytopathologists with (3) and without (3) digital experience, cytotechnologists (4) and senior pathology residents (2) diagnosed the digital slides independently first and recorded the results. Glass slides were read and recorded separately 1-3 days later. Accuracy of diagnosis, time to diagnosis and diagnostician′s profile were analyzed. Results: Among 22 case pairs and four study groups, correct diagnosis (93% vs. 86%) was established using glass versus digital slides. Both methods more (>95%) accurately diagnosed positive cases than negatives. Cytopathologists with no digital experience were the most accurate in digital diagnosis, even the senior members. Cytotechnologists had the fastest diagnosis time (3 min/digital vs. 1.7 min/glass), but not the best accuracy. Digital time was 1.5 min longer than glass-slide time/per case for cytopathologists and cytotechnologists. Senior pathology residents were slower and less accurate with both methods. Cytopathologists with digital experience ranked 2 nd fastest in time, yet last in accuracy for digital slides. Conclusions: There was good overall diagnostic agreement between the digital whole-slide images and glass slides. Although glass slide diagnosis was more accurate and faster, the results of technologists and pathologists with no digital cytology experience suggest that solid diagnostic ability is a strong indicator for readiness of digital adoption.

Novel Molecular Markers of Malignancy in Histologically Normal and Benign Breast

To detect the molecular changes of malignancy in histologically normal breast (HNB) tissues, we recently developed a novel 117-gene-malignancy-signature. Here we report validation of our leading malignancy-risk-genes, topoisomerase-2-alpha (TOP2A), minichromosome-maintenance-protein-2 (MCM2) and “budding-uninhibited-by-benzimidazoles-1-homolog-beta” (BUB1B) at the protein level. Using our 117-gene malignancy-signature, we classified 18 fresh-frozen HNB tissues from 18 adult female breast cancer patients into HNB-tissues with low-grade (HNB-LGMA; N = 9) and high-grade molecular abnormality (HNB-HGMA; N = 9). Archival sections of additional HNB tissues from these patients, and invasive ductal carcinoma (IDC) tissues from six other patients were immunostained for these biomarkers. TOP2A/MCM2 expression was assessed as staining index (%) and BUB1B expression as H-scores (0–300). Increasing TOP2A, MCM2, and BUB1B protein expression from HNB-LGMA to HNB-HGMA tissues to IDCs validated our microarray-based molecular classification of HNB tissues by immunohistochemistry. We also demonstrated an increasing expression of TOP2A protein on an independent test set of HNB/benign/reductionmammoplasties, atypical-ductal-hyperplasia with and without synchronous breast cancer, DCIS and IDC tissues using a custom tissue microarray (TMA). In conclusion, TOP2A, MCM2, and BUB1B proteins are potential molecular biomarkers of malignancy in histologically normal and benign breast tissues. Larger-scale clinical validation studies are needed to further evaluate the clinical utility of these molecular biomarkers.

IκB Kinase ɛ Expression in Pancreatic Ductal Adenocarcinoma

IκB kinase (IKKε) is a serine/threonine protein kinase that belongs to the IKK kinase family. Recent studies have shown that IKKε functions as a breast and ovarian cancer oncogene. We demonstrated frequent overexpression of IKKε in pancreatic ductal adenocarcinoma (PDA). We immunohistochemically evaluated 78 PDAs using the avidin-biotin-peroxidase method and the anti-IKKε rabbit polyclonal antibody. Elevated IKKε reactivity (immunohistochemical score, 4-9) was observed in 64% of PDAs (50/78), but in 0.0% of nonneoplastic pancreatic ductal epithelium (0/113; P < .001). Kaplan-Meier analysis of overall survival revealed that patients with high IKKε-immunohistochemical scores (4-9) had significantly shorter survival than did patients with low IKKε immunohistochemical scores (0-3; P = .023; log-rank test) independent of tumor stage or grade. These data indicate that deregulation of IKKε is a common event in PDA and might have an important role in the pathogenesis of this deadly disease. In addition, IKKε could serve as a prognostic marker and potential therapeutic target for PDA intervention.

Ethnicity and age disparities in Ewing sarcoma outcome

This institutional retrospective review studied Ewing sarcomas from 1987–2011. Among 135 patients, 127 (19 Hispanic and 108 white/non-Hispanic) were analyzed (excluding small sample sized groups) finding 15% Hispanic, 85% non-Hispanic, 27% <18 years, 21% >40 years and 1–272 months follow-up (median 41). Age was significantly associated with overall survival (OS) (p = 0.01), whereby <18 years had a higher probability of 5-year survival (OS 61%) than >40 years (OS 37.6%). Ethnicity was marginally statistically significant (OS, p = 0.065); whereby median survival was clinically significant (white non-Hispanic 63 months and Hispanic 23 months). Hispanic ethnicity and older age are independent poor prognostic factors.

RUNX1T1: a novel predictor of liver metastasis in primary pancreatic endocrine neoplasms.

Objectives: Using gene expression profiling on frozen primary pancreatic endocrine tumors (PETs), we discovered RUNX1T1 as a leading candidate progression gene. This study was designed (1) to validate the differential expression of RUNX1T1 protein on independent test sets of metastatic and nonmetastatic PETs and (2) to determine if RUNX1T1 underexpression in primary tumors was predictive of liver metastases. Methods: Immunohistochemical expression of RUNX1T1 protein was quantified using Allred scores on archival metastatic (n = 13) and nonmetastatic (n = 24) primary adult PET tissues using custom-designed tissue microarrays. Wilcoxon rank sum/Fisher exact tests and receiver operating characteristic curves were used in the data analysis. Results: Median RUNX1T1 scores were 2 (2-7) and 6 (3-8) in metastatic versus nonmetastatic primaries (P < 0.0001). Eleven of 13 metastatic and 1 of 24 nonmetastatic primaries exhibited RUNX1T1-scores of 4 or less (P < 0.0001). Low RUNX1T1 expression was highly associated with hepatic metastases (P < 0.0001), whereas conventional histological criteria (Ki-67 index, mitotic rate, necrosis) were weakly associated with metastases (P = 0.08-0.15). Considering RUNX1T1 expression (Allred) score of 4 or less to be predictive, the sensitivity to predict hepatic metastases was 85%, with a specificity of 96%. Conclusions: RUNX1T1 protein is underexpressed in well-differentiated metastatic primary PETs relative to nonmetastatic primaries and emerges as a promising novel biomarker for prediction of liver metastases.

Molecular Pathology of Soft-Tissue Neoplasms and Its Role in Clinical Practice.

BACKGROUND Soft-tissue neoplasms embody a histologically diverse group of mesenchymal tumors. Oftentimes the histopathological diagnosis of soft-tissue tumors is challenging due to overlapping pathological features. METHODS We reviewed the current and most importantly known recurrent or tumor-specific genetic abnormalities involving soft-tissue tumors, focusing on how they are useful in working up differential diagnoses and the relevance of potentially targeted therapies. RESULTS Molecular diagnostic tools have shown great advantage as an aid in the differentiation between different soft-tissue tumor entities, providing a potential avenue in the identification of novel therapeutic targets. Gastrointestinal stromal tumor is a well-known example of a soft-tissue tumor with a successful, molecularly driven treatment with response rates of more than 80% in stable disease and partial remission. Classifying soft-tissue neoplasms by their molecular genetic pathology has been considered as molecular testing becomes more integrated into various diagnostic and prognostic algorithms. CONCLUSIONS Molecular pathology provides a unique opportunity for pathologists to play a crucial role in the multidisciplinary care of patients with sarcoma. These opportunities include but are not limited to the appropriate triage of tissue for molecular testing and the integration of molecular testing results, with histological and immunohistochemical findings providing actionable information for the diagnosis, prognosis, and choice of therapeutic modality.

Neuroendocrine Neoplasms of the Appendix

Primary neoplasms of the appendix showing neuroendocrine differentiation include neuroendocrine tumors (NETs), neuroendocrine carcinomas (NECs), and mixed adenoneuroendocrine carcinomas (MANECs), including goblet cell carcinoids. NETs comprise 50–77 % of all appendiceal neoplasms and 19 % of all gastrointestinal (GI) NETs. Primary NECs of the appendix are extremely rare and exhibit immunohistopathologic profile similar to NECs at other sites within the GI tract. MANECs arise from a pre-existing goblet cell carcinoid (GCC) and consist of a mixture of exocrine (signet ring type or poorly differentiated) and endocrine carcinoma components, with one component exceeding 30 %. Appendiceal NETs are more frequent in females, and most are diagnosed incidentally in the distal third (75 %) of the appendix. Mean age at presentation is 32–43 years; tubular NETs occur at younger age compared to goblet cell carcinoids. Most appendiceal neoplasms are clinically silent or may simulate acute appendicitis with intermittent abdominal pain or pain localized in the right lower abdomen. Carcinoid syndrome is rare and suggests extensive metastatic disease. Most appendiceal NETs are enterochromaffin cell (EC cell) serotonin-producing neoplasms. Less frequent subtypes include L cell NETs and tubular carcinoids. The latter can be misdiagnosed as metastatic adenocarcinoma as it lacks direct contact with the appendiceal mucosa. GCCs are relatively rare, while primary NECs, or MANECs, are extremely rare, but can pose diagnostic challenges for practicing pathologists and need careful sampling, review, and workup. The vast majority of patients with NETs of the appendix have favorable prognosis, with 88–94 % 5-year survival for localized disease and 25–31 % with distant metastatic disease. Prognosis of GCC is intermediate between carcinoids and appendiceal adenocarcinomas with an overall 5-year survival of 76 %. Since patients with appendiceal NETs are at increased risk for other GI malignancies, follow-up with colonoscopic screening is warranted.

Neuroendocrine Neoplasms of the Stomach

Based on rising incidence in recent decades, gastric neuroendocrine tumors (G-NETs) or gastric carcinoids (GCs) are being increasingly identified at endoscopy, both as polypoid and nonpolypoid gastric lesions. There are four types of G-NETs with important epidemiological, pathophysiological, histopathologic, and endoscopic differences that affect their diagnosis, prognosis, and patient management. The underlying pathogenetic mechanism, hypergastrinemia, results from achlorhydria in patients with chronic atrophic gastritis (type I G-NETs) and from gastrinoma in patients with MEN1 (multiple endocrine neoplasia type I) syndrome (type II G-NETs). Both ECL-cell dysplasia and severe hyperplasia increase risk for G-NET development in type A chronic atrophic gastritis with hypergastrinemia/G-cell hyperplasia. Type III G-NETs occur sporadically, independent of gastrin levels. The histologic typing, grading, and Ki67 index are important for prognostication and patient management. Type I G-NETs 1 cm should be resected due to small risk of lymph node metastases. Both type I G-NETs >1 cm and type II G-NETs should be evaluated for invasion beyond the submucosa prior to endoscopic resection. Type III G-NETs should be managed similar to gastric adenocarcinoma. The treatment of advanced G-NETs needs to be multimodal and best accomplished in subspecialty referral centers with advanced clinical, pathologic, and imaging expertise. In order to succeed with more personalized patient management strategies, analytical and clinical validation of relevant biomarkers will be critical in the near future.

Cytoplasmic Clusterin expression correlates with pancreatic neuroendocrine tumor size and pathological stage.

Objectives Cytoplasmic clusterin (Clusterin), a ubiquitous multifunctional secretory sulfated glycoprotein, plays a role in apoptosis and is reportedly overexpressed in a variety of tumors. The role of Clusterin in pancreatic neuroendocrine tumors (PNETs) has not been investigated. In this study, Clusterin expression was evaluated in a subset of PNETs, and the results were correlated with the clinical-pathological features of the tumors. Methods Fifty-nine surgical cases were used to evaluate the immunohistochemical expression of Clusterin in PNETs. Using the avidin-biotin complex method, tissue sections from each case were stained with a rabbit anticlusterin antibody (Abcam, Cambridge, Mass). The immunohistochemical reactions were qualitatively and semiquantitatively evaluated by 2 pathologists. Results Strong Clusterin reactivity was identified in 36 (61%) of 59 PNETs. In 23 (39%) of 59 cases, the Clusterin score was 3 or less. Clusterin expression scores significantly associated with tumor size (P = 0.03) and with tumor stage (P = 0.02). The immunohistochemical score index did not correlate with tumor grade (P = 0.15). Conclusions We report the expression of Clusterin in PNETs. The correlation of Clusterin with tumor size and stage suggests involvement of this molecule in pancreatic neuroendocrine tumor progression. Clusterin may represent a new target of therapy for PNETs.

Bone and Soft Tissue Pathology : Diagnostic and Prognostic Implications

Soft tissue and bone tumors are a heterogeneous group of tumors most often classified according to the type of tissue they most closely histologically resemble. Although sarcomas are rare, greater than 100 histologic subtypes of benign and malignant soft tissue and bone tumors are currently recognized. In this article, the authors review the current pathologic definitions, the classification and grading systems, supportive ancillary techniques, and the prognostic implications for some of the more common soft tissue and bone tumors.