Jessica Hemminger

Complete response to induction therapy in patients with Myc-positive and double-hit non-Hodgkin lymphoma is associated with prolonged progression-free survival.

Myc‐positive B‐cell non‐Hodgkin lymphoma (NHL) with or without a B‐cell chronic lymphocytic leukemia/lymphoma 2 (BCL2) rearrangement is associated with inferior progression‐free survival (PFS) and overall survival (OS). In this study, the authors reviewed the outcomes of patients with myc‐positive and double‐hit NHL at The Ohio State University.

Gray zone lymphoma with features intermediate between classical Hodgkin lymphoma and diffuse large B‐cell lymphoma: Characteristics, outcomes, and prognostication among a large multicenter cohort

Gray zone lymphoma (GZL) with features between classical Hodgkin lymphoma and diffuse large B‐cell lymphoma (DLBCL) is a recently recognized entity reported to present primarily with mediastinal disease (MGZL). We examined detailed clinical features, outcomes, and prognostic factors among 112 GZL patients recently treated across 19 North American centers. Forty‐three percent of patients presented with MGZL, whereas 57% had non‐MGZL (NMGZL). NMGZL patients were older (50 versus 37 years, P = 0.0001); more often had bone marrow involvement (19% versus 0%, P = 0.001); >1 extranodal site (27% versus 8%, P = 0.014); and advanced stage disease (81% versus 13%, P = 0.0001); but they had less bulk (8% versus 44%, P = 0.0001), compared with MGZL patients. Common frontline treatments were cyclophosphamide‐doxorubicin‐vincristine‐prednisone +/− rituximab (CHOP+/−R) 46%, doxorubicin‐bleomycin‐vinblastine‐dacarbazine +/− rituximab (ABVD+/−R) 30%, and dose‐adjusted etoposide‐doxorubicin‐cyclophosphamide‐vincristine‐prednisone‐rituximab (DA‐EPOCH‐R) 10%. Overall and complete response rates for all patients were 71% and 59%, respectively; 33% had primary refractory disease. At 31‐month median follow‐up, 2‐year progression‐free survival (PFS) and overall survival rates were 40% and 88%, respectively. Interestingly, outcomes in MGZL patients seemed similar compared with that of NMGZL patients. On multivariable analyses, performance status and stage were highly prognostic for survival for all patients. Additionally, patients treated with ABVD+/−R had markedly inferior 2‐year PFS (22% versus 52%, P = 0.03) compared with DLBCL‐directed therapy (CHOP+/−R and DA‐EPOCH‐R), which persisted on Cox regression (hazard ratio, 1.88; 95% confidence interval, 1.03–3.83; P = 0.04). Furthermore, rituximab was associated with improved PFS on multivariable analyses (hazard ratio, 0.35; 95% confidence interval, 0.18–0.69; P = 0.002). Collectively, GZL is a heterogeneous and likely more common entity and often with nonmediastinal presentation, whereas outcomes seem superior when treated with a rituximab‐based, DLBCL‐specific regimen. Am. J. Hematol. 90:778–783, 2015.

Automated detection of cells from immunohistochemically-stained tissues: application to Ki-67 nuclei staining

An automated cell nuclei detection algorithm is described to be used for the quantification of immunohistochemicallystained tissues. Detection and segmentation of positively stained cells and their separation from the background and negatively-stained cells is crucial for fast, accurate, consistent and objective analysis of pathology images. One of the major challenges is the identification, hence accurate counting of individual cells, when these cells form clusters. To identify individual cell nuclei within clusters, we propose a new cell nuclei detection method based on the well-known watershed segmentation, which can lead to under- or over-segmentation for this problem. Our algorithm handles oversegmentation by combining H-minima transformed watershed algorithm with a novel region merging technique. To handle under-segmentation problem, we develop a Laplacian-of-Gaussian (LoG) filtering based blob detection algorithm, which estimates the range of the scales from the image adaptively. An SVM classifier was trained in order to separate non-touching single cells and touching cell clusters with five features representing connected region properties such as eccentricity, area, perimeter, convex area and perimeter-to-area ratio. Classified touching cell clusters are segmented with the H-minima based watershed algorithm. The resulting over-segmented regions are improved with the merging algorithm. The remaining under-segmented cell clusters are convolved with LoG filters to detect the cells within them. Cell-by-cell nucleus detection performance is evaluated by comparing computer detections with cell locations manually marked by eight pathology residents. The sensitivity is 89% when the cells are marked as positive at least by one resident and it increases to 99% when the evaluated cells are marked by all eight residents. In comparison, the average reader sensitivity varies between 70% ± 18% and 95% ± 11%.

Classification of follicular lymphoma: the effect of computer aid on pathologists grading

BackgroundFollicular lymphoma (FL) is one of the most common lymphoid malignancies in the western world. FL cases are stratified into three histological grades based on the average centroblast count per high power field (HPF). The centroblast count is performed manually by the pathologist using an optical microscope and hematoxylin and eosin (H&E) stained tissue section. Although this is the current clinical practice, it suffers from high inter- and intra-observer variability and is vulnerable to sampling bias.MethodsIn this paper, we present a system, called Follicular Lymphoma Grading System (FLAGS), to assist the pathologist in grading FL cases. We also assess the effect of FLAGS on accuracy of expert and inexperienced readers. FLAGS automatically identifies possible HPFs for examination by analyzing H&E and CD20 stains, before classifying them into low or high risk categories. The pathologist is first asked to review the slides according to the current routine clinical practice, before being presented with FLAGS classification via color-coded map. The accuracy of the readers with and without FLAGS assistance is measured.ResultsFLAGS was used by four experts (board-certified hematopathologists) and seven pathology residents on 20 FL slides. Access to FLAGS improved overall reader accuracy with the biggest improvement seen among residents. An average AUC value of 0.75 was observed which generally indicates “acceptable” diagnostic performance.ConclusionsThe results of this study show that FLAGS can be useful in increasing the pathologists’ accuracy in grading the tissue. To the best of our knowledge, this study measure, for the first time, the effect of computerized image analysis on pathologists’ grading of follicular lymphoma. When fully developed, such systems have the potential to reduce sampling bias by examining an increased proportion of HPFs within follicle regions, as well as to reduce inter- and intra-reader variability.

Entropy based quantification of Ki-67 positive cell images and its evaluation by a reader study

Presence of Ki-67, a nuclear protein, is typically used to measure cell proliferation. The quantification of the Ki-67 proliferation index is performed visually by the pathologist; however, this is subject to inter- and intra-reader variability. Automated techniques utilizing digital image analysis by computers have emerged. The large variations in specimen preparation, staining, and imaging as well as true biological heterogeneity of tumor tissue often results in variable intensities in Ki-67 stained images. These variations affect the performance of currently developed methods. To optimize the segmentation of Ki-67 stained cells, one should define a data dependent transformation that will account for these color variations instead of defining a fixed linear transformation to separate different hues. To address these issues in images of tissue stained with Ki-67, we propose a methodology that exploits the intrinsic properties of CIE L∗a∗b∗ color space to translate this complex problem into an automatic entropy based thresholding problem. The developed method was evaluated through two reader studies with pathology residents and expert hematopathologists. Agreement between the proposed method and the expert pathologists was good (CCC = 0.80).

IgG Subclass Staining in Routine Renal Biopsy Material.

Immunofluorescence staining plays a vital role in nephropathology, but the panel of antibodies used has not changed for decades. Further classification of immunoglobulin (Ig)G-containing immune-type deposits with IgG subclass staining (IgG1, IgG2, IgG3, and IgG4) has been shown to be of diagnostic utility in glomerular diseases, but their value in the evaluation of renal biopsies has not been addressed systematically in large renal biopsy material. Between January 2007 and June 2014, using direct immunofluorescence, we stained every renal biopsy for the IgG subclasses if there was moderate to prominent glomerular IgG staining and/or IgG-predominant or IgG-codominant glomerular staining. The total number of biopsies stained was 1084, which included 367 cases of membranous glomerulonephritis, 307 cases of lupus nephritis, 74 cases of fibrillary glomerulonephritis, 53 cases of proliferative glomerulonephritis with monoclonal IgG deposits, and 25 cases of antiglomerular basement membrane disease, among others. We found that monoclonality of IgG deposits cannot always be reliably determined on the basis of kappa and lambda light chain staining alone, particularly if concomitant (frequently nonspecific) IgM staining is present. In IgG heavy and heavy and light chain deposition disease (3 cases), subclass staining is very helpful, and in proliferative glomerulonephritis with monoclonal IgG deposits subclass staining is necessary. IgG subclass staining is useful in differentiating primary from secondary membranous glomerulonephritis. In proliferative glomerulonephritis with polyclonal IgG deposition, IgG1 dominance/codominance with concomitant IgG3 and IgG2 but weak or absent IgG4 staining favors an underlying autoimmune disease. IgG subclass staining is a very useful diagnostic method in a selected cohort of renal biopsies, particularly in biopsies with glomerulonephritis with monoclonal IgG deposits.

Unique pattern of renal κ light chain amyloid deposition with histiocytic transdifferentiation of tubular epithelial cells.

Monoclonal gammopathies can cause renal tubular epithelial damage through multiple mechanisms, the most common manifestation being myeloma cast nephropathy. Amyloid light chain amyloidosis rarely affects the renal tubular epithelium directly and usually causes glomerular injury. Amyloid deposition can also be seen within vessel walls and in the renal tubulointerstitium. Herein, we describe a unique pattern of κ light chain amyloid deposition involving the proximal tubule epithelium in a patient with multiple myeloma, characterized by intracellular amyloid globule formation with concomitant phenotypic changes suggestive of histiocytic differentiation of tubular epithelial cells. Amyloid pathogenesis is thought to be closely associated with the reticuloendothelial system, more specifically macrophages, and histiocytic differentiation of mesangial cells seems to be an integral step in glomerulopathic amyloid production. Our report proposes a similar mechanism of amyloidogenesis in the renal tubular epithelium.

Combination therapy with capecitabine and temozolomide in patients with low and high grade neuroendocrine tumors, with an exploratory analysis of O 6 -methylguanine DNA methyltransferase as a biomarker for response

Recent advances in the treatment of neuroendocrine tumors (NET), including the combination regimen of capecitabine and temozolomide (CAPTEM), have mostly focused on grade 1 and 2 pancreatic neuroendocrine tumors (pNET). We undertook a retrospective review of 38 patients with advanced NET treated with CAPTEM, including patients with non-pancreatic tumors as well as grade 2 and 3 tumors. O6-methylguanine DNA methyltransferase (MGMT) expression was assessed as a predictive biomarker. We found that CAPTEM demonstrated activity in patients with all grades and in pNET and non-pNET. Median progression free survival (mPFS) was 13.0 months (95% CI: 5.6-17.0) and median overall survival (mOS) 29.3 months (95% CI 17.7 - 45.3). Among evaluable patients, there were 11 (38%) partial responses, 15 (52%) stable disease, and 3 (10%) progressive disease for a disease control rate of 90%. A higher rate of partial responses occurred in patients whose tumors had low levels of MGMT expression (63%) compared to intermediate-high (17%) (p=0.19). Our results show that CAPTEM therapy is active in patients with NET including in previously treated patients and in those with poorly-differentiated histology. We observed a trend towards increased response rate, median PFS, and median OS in patients whose tumors had low MGMT protein expression.

BRAF V600E expression in histiocytic sarcoma associated with splenic marginal zone lymphoma: a case report

BackgroundHistiocytic sarcoma is a rare histiocytic neoplasm of unknown etiology that constitutes less than 1% of hematologic malignancies. A few cases of histiocytic sarcoma harboring the BRAFV600E mutation have been reported, but this finding has not been confirmed in all studies.Case presentationWe report the case of a 63-year-old white woman with a history of splenic marginal zone lymphoma who presented with 2 weeks of right-sided neck swelling. Positron emission tomography revealed an intensely hypermetabolic and destructive soft tissue mass in her right skull base. A bone marrow biopsy was performed, which revealed an infiltrate of malignant cells characterized as large pleomorphic cells with frequent folded/irregular nuclei, variably prominent nucleoli, fine chromatin, and abundant amounts of eosinophilic cytoplasm. The malignant cells were positive for CD163, CD68 (granular), lysozyme (granular), CD4, and CD45 (partial). Based on the biopsy findings, she was diagnosed as having histiocytic sarcoma. The malignant cells tested positive for the BRAFV600E protein using immunohistochemistry. Before treatment of her histiocytic sarcoma could be initiated, she developed disseminated intravascular coagulation and acute hypoxemic respiratory failure secondary to non-cardiogenic pulmonary edema. She decided to pursue comfort care and died in our hospital 2 weeks following admission.ConclusionsOur case illustrates the aggressive nature of histiocytic sarcoma, and provides rare evidence that histiocytic sarcoma associated with indolent lymphomas may harbor the BRAFV600E mutation. Further research is needed to clarify the role of targeted therapies such as vemurafenib in the treatment of patients with this disorder.

Staphylococcus Infection-Associated Glomerulonephritis

Staphylococcus infection-associated glomerulonephritis (SAGN) is a well-recognized disease entity, and over the last decade has been seen with increasing frequency in western countries. The associated Staphylococcal infections tend to be quite aggressive and invasive and the affected population is primarily elderly patients with one or more preexisting comorbidities, which can make this a difficult disease to treat. Furthermore, the diagnosis can be challenging due to subtle clinical presentation of the underlying infection, varied histopathological features, and occasional positive ANCA serology. Importantly, the glomerulonephritis either coincides with the onset of infection or occurs during the course of the infection, which is in contrast to post-streptococcal glomerulonephritis which typically occurs after a distinct latent period following complete resolution of the infection. This chapter succinctly describes the wide spectrum of histologic features, immunofluorescence staining patterns and ultrastructural features in SAGN along with diagnostic pitfalls. The last section gives a brief overview of the microbiologic and immunologic aspects of Staphylococcus.