Josefine Heim-Hall

Karyotype versus Microarray Testing for Genetic Abnormalities after Stillbirth

BACKGROUND Genetic abnormalities have been associated with 6 to 13% of stillbirths, but the true prevalence may be higher. Unlike karyotype analysis, microarray analysis does not require live cells, and it detects small deletions and duplications called copy-number variants. METHODS The Stillbirth Collaborative Research Network conducted a population-based study of stillbirth in five geographic catchment areas. Standardized postmortem examinations and karyotype analyses were performed. A single-nucleotide polymorphism array was used to detect copy-number variants of at least 500 kb in placental or fetal tissue. Variants that were not identified in any of three databases of apparently unaffected persons were then classified into three groups: probably benign, clinical significance unknown, or pathogenic. We compared the results of karyotype and microarray analyses of samples obtained after delivery. RESULTS In our analysis of samples from 532 stillbirths, microarray analysis yielded results more often than did karyotype analysis (87.4% vs. 70.5%, P<0.001) and provided better detection of genetic abnormalities (aneuploidy or pathogenic copy-number variants, 8.3% vs. 5.8%; P=0.007). Microarray analysis also identified more genetic abnormalities among 443 antepartum stillbirths (8.8% vs. 6.5%, P=0.02) and 67 stillbirths with congenital anomalies (29.9% vs. 19.4%, P=0.008). As compared with karyotype analysis, microarray analysis provided a relative increase in the diagnosis of genetic abnormalities of 41.9% in all stillbirths, 34.5% in antepartum stillbirths, and 53.8% in stillbirths with anomalies. CONCLUSIONS Microarray analysis is more likely than karyotype analysis to provide a genetic diagnosis, primarily because of its success with nonviable tissue, and is especially valuable in analyses of stillbirths with congenital anomalies or in cases in which karyotype results cannot be obtained. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.).

Placental findings in singleton stillbirths

OBJECTIVE: To compare placental lesions for stillbirth cases and live birth controls in a population-based study. METHODS: Pathologic examinations were performed on placentas from singleton pregnancies using a standard protocol. Data were analyzed overall and within gestational age groups at delivery. RESULTS: Placentas from 518 stillbirths and 1,200 live births were studied. Single umbilical artery was present in 7.7% of stillbirths and 1.7% of live births, velamentous cord insertion was present in 5% of stillbirths and 1.1% of live births, diffuse terminal villous immaturity was present in 10.3% of stillbirths and 2.3% of live births, inflammation (eg, acute chorioamnionitis of placental membranes) was present in 30.4% of stillbirths and 12% of live births, vascular degenerative changes in chorionic plate were present in 55.7% of stillbirths and 0.5% of live births, retroplacental hematoma was present in 23.8% of stillbirths and 4.2% of live births, intraparenchymal thrombi was present in 19.7% of stillbirths and 13.3% of live births, parenchymal infarction was present in 10.9% of stillbirths and 4.4% of live births, fibrin deposition was present in 9.2% of stillbirths and 1.5% of live births, fetal vascular thrombi was present in 23% of stillbirths and 7% of live births, avascular villi was present in 7.6% of stillbirths and 2.0% of live births, and hydrops was present in 6.4% of stillbirths and 1.0% of live births. Among stillbirths, inflammation and retroplacental hematoma were more common in placentas from early deliveries, whereas thrombotic lesions were more common in later gestation. Inflammatory lesions were especially common in early live births. CONCLUSIONS: Placental lesions were highly associated with stillbirth compared with live births. All lesions associated with stillbirth were found in live births but often with variations by gestational age at delivery. Knowledge of lesion prevalence within gestational age groups in both stillbirths and live birth controls contributes to an understanding of the association between placental abnormality and stillbirth. LEVEL OF EVIDENCE: II

Application of Immunohistochemistry to Soft Tissue Neoplasms

CONTEXT Soft tissue tumors are composed of numerous and complex diagnostic entities. Because of this complexity and the recognition of an intermediate malignancy category including some tumors with a deceptively bland histologic appearance, soft tissue tumors may represent a major diagnostic challenge to the general practicing pathologist. OBJECTIVE To correctly diagnose soft tissue tumors with the ancillary use of immunohistochemistry. DATA SOURCES Review of the current literature with emphasis on those tumors for which immunohistochemistry has proven to be particularly useful. CONCLUSIONS Immunohistochemistry plays an important role in the diagnosis of soft tissue tumors. One of its major utilities is to correctly identify a tumor as being of mesenchymal or nonmesenchymal origin. Once mesenchymal origin has been established, histologic subtyping according to specific cell lineage may be achieved with the use of lineage-specific markers. Tumors of uncertain cell lineage and tumors with primitive small round cell morphology are often characterized by a unique immunohistochemical phenotype. In this group of tumors, immunohistochemistry is most widely applied and is of greatest value. Despite the rapid development of molecular genetic techniques, immunohistochemistry still remains the most important diagnostic tool in the diagnosis of soft tissue tumors aside from recognition of morphologic features and clinical correlation.

Levels of Endothelial Nitric Oxide Synthase and Calcitonin Gene-related Peptide in the Charcot Foot: A Pilot Study

UNLABELLED The pathogenesis of Charcot neuroarthropathy is unclear. To investigate the possibility that decreased levels of calcitonin gene-related peptide and endothelial nitric oxide synthase are involved in the process, we studied bone samples from healthy subjects (n = 4), subjects with diabetic neuropathy (n = 4), and subjects with Charcot neuroarthropathy (n = 4). A statistically significant difference was found in endothelial nitric oxide synthase expression between bone specimens in patients with diabetic neuropathy, Charcot neuroarthropathy, and normal bone (P = .008). A trend toward calcitonin gene-related peptide intensification was observed in normal bone as compared to diabetic neuropathy and Charcot neuroarthropathy bone specimens, but it did not reached statistical significance (P = .23). This pilot study suggests that abnormal calcitonin gene-related peptide and endothelial nitric oxide synthase activity may play a role in the development of Charcot neuroarthropathy. LEVEL OF CLINICAL EVIDENCE 4.

The Stillbirth Collaborative Research Network (SCRN) placental and umbilical cord examination protocol.

The Stillbirth Collaborative Research Network (SCRN) was organized to study the scope and causes of stillbirth (SB) in the United States. The objective of this report is to describe the approach used for the placental examination performed as part of the study. The SCRN consists of a multidisciplinary team of investigators from five clinical sites, the National Institute of Child Health and Human Development, and the Data Coordination and Analysis Center. The study is a population-based cohort and nested case-control study, with prospective enrollment of women with SB and live births (LB) at the time of delivery. Detailed and standardized postmortem examination was performed on SB and placental examination in both groups. A total of 663 women with SB and 1932 women with LB were enrolled into the case-control study. In the SB group, there were 707 fetuses. Of these cases, 654 (98.6%) had placental examination. Of these LB controls, 1804 (93.4%) had placental examination. This is the largest prospective study to include population-based SB and LB, using standardized postmortem and placental examination, medical record review, maternal interview, collection of samples, and a multidisciplinary team of investigators collaborating in the analyses. Thus it has the potential to provide high-level evidence regarding the contribution of placental abnormalities to stillbirth.

The Stillbirth Collaborative Research Network Neuropathologic Examination Protocol

We describe the neuropathologic procedure utilized in the Stillbirth Collaborative Research Network (SCRN), focusing on the examination of central nervous system (CNS) in stillbirth (SB). The SCRN was organized to perform a case-control study to determine the scope and causes of SB. Pathologists at all the participating centers agreed on and used the same standardized neuropathologic techniques. Standardized sections were taken and detailed data were collected. Fresh brain tissue was saved for investigative purposes. A total of 663 women with SB were enrolled into the case-control study: 620 delivered a single stillborn, 42 delivered twins, and 1 delivered triplets. Of the 560 (84.5%) who consented to postmortem examination, 465 (70.1%) also gave consent to the examination of the CNS. In the 440 stillborn infants in whom CNS examination was possible, 248 (56.4%) of the brains were intact, 72 were fragmented (16.4%), and 120 (27.3%) were liquefied. In summary, this is the largest prospective study dedicated to investigate the causes of SB and collect essential information and biological samples in the United States. A protocol for neuropathologic examination was instituted, and a brain tissue repository was created to provide samples and related data for future investigations.

Partial response of a rare malignant metastatic diffuse tenosynovial giant cell tumor with benign histologic features, treated with SCH 717–454, an insulin growth factor receptor inhibitor, in combination with everolimus, an MTOR inhibitor

Tenosynovial giant cell tumor (TGCT) is a neoplastic proliferation arising in tendon sheath, bursa, and/or synovium. Decades ago, it was thought to be an inflammatory process, owing to the presence of large numbers of macrophages within the tumor. However, TGCT is now considered a neoplastic process composed of compact foci of polyhedral cells with varying numbers of multinucleated giant, lipid, and hemosiderin-laden cells. These tumors can be subdivided based on the degree of synovial involvement into localized (circumscribed) or diffuse forms. Localized TGCT tends to occur in the finger and is nodular. Though it may recur, it is generally amenable to local resection. On the other hand, diffuse type TGCT more frequently affects larger joints, especially the knee and wrist. This diffuse type can be intra-articular (also called pigmented villonodular tenosynovitis) or extra-articular, and is notoriously difficult to control with local resection, tending to recur frequently. In the WHO classification of soft tissue tumors, both localized and diffuse forms of TGCT are included in the benign category. While diffuse TGCT has a much higher recurrence rate than the localized counterpart, malignant behavior is exceedingly rare. Reports of so-called malignant TGCT primarily describe tumors with atypical or frankly malignant histological features such as sarcomatous change [1–3]. Metastatic sites in these cases included lymph nodes, subcutaneous tissue, and lungs. Development of metastasis in histologically benign TCGT is even more exceptional, with less than a handful of documented cases in the literature [3]. Even when pathological findings are consistent with a benign lesion, treatment with surgical resection can be inadequate. Reports of recurrence rates have ranged from 8 to 60 % varying by report [4]. One predictor of recurrence is incomplete synovial resection. However, even with complete synovectomy, tumor often recurs. Furthermore, surgical resection S. Sikaria :M. Mita Experimental Therapeutics Program, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, SCCT Mezzanine MS 35, 8700 Beverly Blvd, Los Angeles, CA 90048, USA

Characterization of localized osteosarcoma of the extremity in children, adolescents, and young adults from a single institution in south texas

Background: Osteosarcoma is the most common bone malignancy in children, adolescents, and young adults. Most study cohorts have 10% to 15% Hispanic patients that encompass many different Hispanic backgrounds. This study characterizes the effect of mainly Mexican American ethnicity on the outcome of children, adolescents, and young adults with osteosarcoma. Methods: A retrospective analysis of demographics, tumor characteristics, response to treatment, and survival outcome of all localized osteosarcoma of the extremity patients below 30 years of age was performed. A Kaplan-Meier estimates with log-rank tests and Cox proportional hazard regression models were used. Results: Fifty patients (median age, 15; range, 2 to 28 y) with localized high-grade osteosarcoma of the extremity were diagnosed between January 2000 and December 2010. The cohort was 70% Mexican Americans. With a median follow-up of 39 months (range, 5 to 142 mo), patients had a 5-year overall survival and event-free survival of 65% and 48%, respectively. We observed a significantly decreased 5-year event-free survival in patients diagnosed before age 12 relative to patients diagnosed between ages 12 and 29 (11% vs. 57%, P<0.001). We also found that tumor necrosis was not predictive of outcome in our patients. Conclusions: The preadolescent patients of predominately Mexican American ethnicity had an increased rate of relapse when compared with previous studies. Tumor necrosis is not directly predictive of outcome in this population.

Fetal hydrops: A systematic approach for the pathologist

Hydrops fetalis is identified clinically by antenatal ultrasound or upon delivery. It comes to the surgical pathologists attention through receipt of an abnormal placenta or through request for perinatal autopsy. Abnormal fluid accumulation within multiple fetal body sites defines hydrops fetalis. Unfortunately, this clinical finding is common to a large variety and number of etiologies, and in approximately 14% to 32% of cases of fetal loss, no specific cause is identified. Etiologies may overlap among different categories but are addressed here as immune hemolysis, structural abnormalities, chromosomal/syndromes, nonimmune anemias, infection, and neoplasia. Here, we review both the pathophysiology of immune and nonimmune hydrops fetalis and suggest a systematic approach to fetal and placental autopsy to mitigate the difficulty of a comprehensive workup and identify a cause of fetal instability or loss.