Maria E. Vergara-Lluri

High concordance between HercepTest immunohistochemistry and ERBB2 fluorescence in situ hybridization before and after implementation of American Society of Clinical Oncology/College of American Pathology 2007 guidelines.

Human epidermal growth factor receptor 2 (HER2, ERBB2) is an important critical predictive marker in patients with invasive breast cancer. It is thus imperative to ensure accuracy and precision in HER2 and ERBB2 testing. In 2007, the American Society of Clinical Oncology and College of American Pathologists (ASCO/CAP) proposed new guidelines for immunohistochemistry and fluorescence in-situ hybridization scoring in an effort to improve accuracy and utility of these companion diagnostic tests. The goal of the 2007 guidelines was to improve concordance rates between the diagnostic tests and decrease the number of inconclusive cases. This study examines the impact in concordance rates and number of inconclusive cases based on the recent change in guidelines in a large study cohort. HER2 immunohistochemistry and ERBB2 fluorescence in-situ hybridization were performed on all specimens from our facility from years 2003 through 2010 (n=1437). Cases from 2003–2007 (n=1016) were scored using Food and Drug Administration guidelines, with immunohistochemical 3+ cases staining >10% of tumor cells and fluorescence in-situ hybridization amplification cutoff value of 2.0. The 2007 guidelines were implemented and scored accordingly for cases from 2008–2010 (n=421), with immunohistochemical 3+ cases staining >30% of tumor cells and fluorescence in-situ hybridization amplification cutoff value of 2.2. We compared concordance rates before and after 2007 guidelines. For the 2003–2007 study population, the concordance rate between the assays was 97.6% with a corresponding kappa coefficient (k) of 0.90. For the 2008–2010 study population, concordance rate was 97.6% with a corresponding k of 0.89. There was no significant difference in number of inconclusive rates before and after 2007 guidelines. In our study, implementation of the new ASCO/CAP 2007 HER2 guidelines did not show a significant difference in concordance rates and did not decrease the number of inconclusive cases.

Autoimmune myelofibrosis: an update on morphologic features in 29 cases and review of the literature☆

Autoimmune myelofibrosis (AIMF) is a distinct clinicopathological entity associated with diffuse bone marrow fibrosis and a benign clinical course. Distinction from neoplastic etiologies of marrow fibrosis, particularly primary myelofibrosis, is imperative, but few studies have documented histopathologic features in a large series. We describe 29 patients with AIMF, defined as marrow reticulin fibrosis and lymphocytic infiltration in the context of an established autoimmune disorder (secondary AIMF) or autoantibodies without a defined disorder (primary AIMF). Excluded were cases with atypical megakaryocytes, dysplasia, basophilia, osteosclerosis, unexplained splenomegaly, or neoplasms associated with myelofibrosis (MF). All cases were stained for reticulin, CD3, and CD20, with a subset additionally stained for CD138, κ, λ, immunoglobulin G (IgG), and IgG4. Lymphoid aggregates, where present, were classified into T-cell and B-cell patterns of distribution. Most patients (93%) presented with cytopenias. Sixty-nine percent (n = 20) were considered secondary AIMF and the remainder primary AIMF (n = 9). Peripheral blood showed absent-to-rare blasts and teardrop erythrocytes and absence of eosinophilia or basophilia. Characteristic bone marrow findings included hypercellularity with erythroid and megakaryocytic hyperplasias, mild reticulin fibrosis, intrasinusoidal hematopoiesis, T-cell pattern in lymphoid aggregates, mild polytypic plasmacytosis, and absence of IgG4-positive plasma cells. Primary and secondary AIMF were pathologically indistinguishable, except for an increased incidence of granulocytic hyperplasia in primary AIMF. This series confirms and expands the utility of the original diagnostic criteria for AIMF. Recognizing the characteristic morphology of AIMF and its associated clinical and laboratory features distinguishes autoimmune from neoplastic causes of MF and guides further evaluation and management.

A novel sarcoma with dual differentiation: clinicopathologic and molecular characterization of a combined synovial sarcoma and extraskeletal myxoid chondrosarcoma.

We report on an unusual case of a 43-year-old woman who developed a malignant soft tissue tumor of the arm with overlapping morphology between synovial sarcoma (SS) and extraskeletal myxoid chondrosarcoma (EMC). The tumor recurred 7 years after the initial diagnosis and continued to demonstrate both SS and EMC histology. Immunophenotypically, the primary and recurrent tumors were both positive, focally, for cytokeratin, S-100, bcl-2, and epithelial membrane antigen. At the time of recurrence, the primary and recurrent tumors were further characterized for genetic and molecular abnormalities. Intriguingly, fluorescence in situ hybridization of the primary tumor revealed rearrangements of both the SS18 and EWSR1 genes. Furthermore, reverse transcriptase-polymerase chain reaction studies of both the primary tumor and the recurrence confirmed the presence of both SS18-SSX2 and EWSR1-NR4A3 (exon 3) gene fusions, characteristic of SS and EMC, respectively. This is the first reported case of a remarkable soft tissue sarcoma that exhibits overlapping morphologic features between SS and EMC and that also harbors a combination of SS18-SSX2 and EWS-NR4A3 gene fusions. This case supports the fact that specific, reproducible gene fusions frequently direct, cooperatively or competitively, basic histogenetic processes to produce tumor phenotypes.

Comparative Evaluation of ProEx C and ImmunoCyt/uCyt Assays in Atypical Urine Cytology

CONTEXT Detection of urothelial carcinoma by urine cytology can be challenging. Recently, ProEx C has been studied as a marker to improve detection of urothelial carcinoma. ProEx C is an assay targeting expression of topoisomerase II-α and the minichromosome maintenance protein-2 and is used to assist in diagnoses of gynecologic specimens. OBJECTIVE To evaluate the utility of ProEx C and uCyt in atypical urine cytology. DESIGN Sixty-eight specimens with a diagnosis of atypical urine cytology, concurrent uCyt testing, and surgical biopsy follow-up were included. Slides were restained with ProEx C. ProEx C was recorded as positive when nuclear staining was seen in at least one morphologically atypical urothelial cell. The uCyt was scored as positive if at least one morphologically atypical urothelial cell showed positive fluorescence staining. Thirteen cases (19%) had benign histologic diagnoses, 18 (26%) had low-grade papillary urothelial carcinoma, and 37 (54%) had high-grade urothelial carcinoma. RESULTS The overall sensitivity was 85% for ProEx C, 85% for uCyt, and 93% for the combination of the 2 assays. The overall specificity was 69% for ProEx C, 31% for uCyt, and 23% for the combination of the 2 tests. In predicting high-grade urothelial carcinoma, sensitivity was 92% for ProEx C, 86% for uCyt, and 92% for both tests. In predicting low-grade papillary urothelial carcinoma, sensitivity was best with the combination of the 2 tests at 94%. CONCLUSION ProEx C has superior specificity to uCyt. The combination of the 2 tests yielded high sensitivity not only for high-grade urothelial carcinoma but also for low-grade papillary urothelial carcinoma.

Utility of ProEx C in the histologic evaluation of the neoplastic and nonneoplastic urothelial lesions

ProEx C is an antibody cocktail targeting the expression of topoisomerase IIα and minichromosome maintenance protein 2. ProEx C staining is being used mainly to assist in diagnoses of dysplasia in gynecological specimens. This study was designed to determine the utility of ProEx C in assessing the urothelial lesions. Sixty-four patient specimens were divided into 5 groups: group I, 22 benign; group II, 13 low-grade noninvasive papillary urothelial carcinoma; group III, 10 high-grade urothelial carcinoma in situ (flat lesion); and group IV, 19 high-grade noninvasive papillary and invasive urothelial carcinomas. ProEx C reactions were scored in basal, parabasal, intermediate, and superficial cell layers. A sample was recorded as positive when nuclear staining was seen in the cells of the intermediate and/or superficial layers. Of 22 cases in group I, 21 were negative for ProEx C with a specificity of 95%. Of 13 cases in group II, 11 had positive results with sensitivity of 85%. All cases in groups III and IV had positive staining pattern with ProEx C with a sensitivity of 100%. In this study, ProEx C stain had an overall 95% sensitivity and specificity with positive and negative predictive values of 98% and 91%, respectively, for detection of urothelial carcinoma. We conclude that ProEx C is effective in differentiating carcinoma in situ and benign urothelial lesions. It also resolves issues in low- versus high-grade papillary urothelial carcinomas. To our knowledge, this is the first publication on the diagnostic application of ProEx C in histopathology of the urothelial lesions.

Autoimmune Myelofibrosis: Clinical Features, Course, and Outcome

Background: Autoimmune myelofibrosis (AIMF) is an underrecognized cause of nonmalignant bone marrow fibrosis which occurs in the presence or absence of a defined systemic autoimmune disease. Patients with AIMF present with cytopenias and autoantibodies, and have a distinctive nonclonal myelofibrosis on bone marrow examination. AIMF is distinguished from primary myelofibrosis by the absence of splenomegaly, eosinophilia, or basophilia, and the absence of abnormal myeloid, erythroid, or megakaryocytic morphology. Objectives: The objective of the study was to describe the clinical presentation and outcomes of patients with AIMF. Methods: We conducted a single-institution, retrospective chart review of patients diagnosed with AIMF to investigate clinical presentations, therapies, and outcomes. Results: Twelve patients with AIMF were identified with a mean follow-up of 5.8 years. All patients had detectable autoantibodies and the majority had concomitant autoimmune disorders. Four patients experienced a complete response of cytopenias and 3 patients experienced a partial response (PR) of cytopenias with immunosuppressive therapy. One patient achieved a PR following splenectomy. No patients were diagnosed with myeloproliferative neoplasms during the follow-up period. Conclusions: AIMF contributes to cytopenias in the subset of patients with various autoimmune disorders. The majority of patients with AIMF experience an improvement in cytopenias with immunosuppressive therapy.

Comprehensive adipocytic and neurogenic tissue microarray analysis of NY-ESO-1 expression - a promising immunotherapy target in malignant peripheral nerve sheath tumor and liposarcoma.

Background Immunotherapy targeting cancer-testis antigen NY-ESO-1 shows promise for tumors with poor response to chemoradiation. Malignant peripheral nerve sheath tumors (MPNSTs) and liposarcomas (LPS) are chemoresistant and have few effective treatment options. Materials Methods Using a comprehensive tissue microarray (TMA) of both benign and malignant tumors in primary, recurrent, and metastatic samples, we examined NY-ESO-1 expression in peripheral nerve sheath tumor (PNST) and adipocytic tumors. The PNST TMA included 42 MPNSTs (spontaneous n = 26, NF1-associated n = 16), 35 neurofibromas (spontaneous n = 22, NF-1 associated n = 13), 11 schwannomas, and 18 normal nerves. The LPS TMA included 48 well-differentiated/dedifferentiated (WD/DD) LPS, 13 myxoid/round cell LPS, 3 pleomorphic LPS, 8 lipomas, 1 myelolipoma, and 3 normal adipocytic tissue samples. Stained in triplicate, NY-ESO-1 intensity and density were scored. Results NY-ESO-1 expression was exclusive to malignant tumors. 100% of myxoid/round cell LPS demonstrated NY-ESO-1 expression, while only 6% of WD/DD LPS showed protein expression, one of which was WD LPS. Of MPNST, 4/26 (15%) spontaneous and 2/16 (12%) NF1-associated MPNSTs demonstrated NY-ESO-1 expression. Strong NY-ESO-1 expression was observed in myxoid/round cell and dedifferentiated LPS, and MPNST in primary, neoadjuvant, and metastatic settings. Conclusions We found higher prevalence of NY-ESO-1 expression in MPNSTs than previously reported, highlighting a subset of MPNST patients who may benefit from immunotherapy. This study expands our understanding of NY-ESO-1 in WD/DD LPS and is the first demonstration of staining in a WD LPS and metastatic/recurrent myxoid/round cell LPS. These results suggest immunotherapy targeting NY-ESO-1 may benefit patients with aggressive tumors resistant to conventional therapy.

Recurrence rates in breast cancer patients who had sentinel lymph node biopsy alone versus completion axillary lymph node dissection: a 7-year clinical follow-up study.

To the Editor: Lymph node status is known to be the most important prognostic factor in breast cancer. Sentinel lymph node (SLN) biopsy has been standard of care for clinically node negative (cN0) patients. In the past few years, a paradigm shift has occurred with the publication of American College of Surgeons Oncology Group (ACOSOG) Z0011 trial (1), which advocated for conservative management in even SLN positive patients. The Z0011 trial suggested completion axillary lymph node dissection (cALND) was not necessary in T1 and T2 breast carcinoma patients, since survival and recurrence rates did not appear to differ between those who had cALND versus those who had SLN biopsy alone (SLNB), up to two positive SLN, and adjuvant radiation therapy. We explored the validity and applicability of ACOSOG Z0011 trial to our own patient population. Our retrospective study identified a total of 302 patients with invasive breast cancer at our institution (2003– 2007), after obtaining institutional research board approval. Patients with invasive breast cancer without neo-adjuvant chemotherapy, those with complete pathology information, and clinical follow-up at a minimum of 24 months were included. Patients were excluded if they had cALND without SLNB or clinically multiple positive and/or matted axillary lymph nodes. Median clinical follow-up was 6.8 years (range 28– 115 months). From SLN negative group, mean age was 57.9 years (range 31–86); 71% postmenopausal and 28% premenopausal patients. Median tumor size was 1.5 cm. Pathologic tumor stages were 70% pT1, 29% pT2, and 1% pT3 cases. From SLN positive group, mean age was 54.7 years (range 27–80); 58% postmenopausal and 41% premenopausal patients. Median tumor size was 2.3 cm. Pathologic tumor stages were 39% pT1, 50% pT2, 10% pT3, and 1% pT4 cases. SLN negative and positive patients comprised 69% and 31% of the cohort, respectively (See Fig. 1). Patients with SLN negative, ITC, micrometastasis, and macrometastasis undergoing cALND had nodal involvement as follows: 8% (2 of 24), 14% (one of seven ITC), 38% (five of 13 micrometastasis), 60% (30 of 50 macrometastasis), respectively. The risk of having positive non-SLNs in cALND was approximately 12 times higher in a patient with positive SLN than in a patient with negative SLN (Odds Ratio = 11.667; 95% CI 3.211 to 42.391, p < 0.0001). Local-regional recurrence and distant metastasis (LR/DM) were investigated. In SLN negative cases, LR/DM rates in cALND versus SLNB were 12.9% versus 6.7%, respectively (p = 0.266). In SLN positive cases, LR/DM in cALND versus SLNB were 14.2% versus 3.3%, respectively (p = 0.159). Within SLN negative cases only, LR/DM in cALND versus SLNB were 16.7% versus 6% (p = 0.082). Within SLN ITC group, LR/DM in cALND versus SLNB were 0% versus 16.7% (p = 0.508). Within SLN micrometastatic group who underwent cALND or SLNB, no patient experienced LR/DM. Lastly, in the SLN macrometastatic group with cALND versus SLNB, LR/DM were18% versus 4.5%, respectively (p = 0.161). None of the differences in LR/DM between cALND or SLNB were statistically significant. LR/DM and mortality rates between SLN negative and SLN positive patients were not significantly different, 8% versus 11%, respectively (p = 0.381). As SLNB has been shown to be noninferior to cALND in SLN negative patients (1,2), the role of Address correspondence and reprint requests to: Sophia K. Apple, MD, 10833 Le Conte Ave CHS 1P-244, Los Angeles, CA 90098-1732, USA, e-mail: sapple@mednet.ucla.edu

Fine-needle aspiration of bilateral small round blue cell tumors in neck in a 65-year-old man: Significance of a wider differential

Q1. What is your interpretation? a. Small cell carcinoma b. Diffuse large B‐cell lymphoma c. Human papillomavirus‐associated squamous cell carcinoma d. Olfactory neuroblastoma. This article may be cited as: Chang S, Hirschowitz S, Lu DY, Montoya RC, Vergara-Lluri M, Moatamed NA. Fine-needle aspiration of bilateral small round blue cell tumors in neck in a 65-year-old man: Significance of a wider differential. CytoJournal 2018;15:7. CytoJournal Co‐editors‐in‐chief: Lester J. Layfield, MD, (University of Missouri, Columbia, MO, USA) Vinod B. Shidham, MD, FIAC, FRCPath (WSU School of Medicine, Detroit, USA) Executive editor: Vinod B. Shidham, MD, FIAC, FRCPath Wayne State University School of Medicine, Detroit, MI, USA For entire Editorial Board visit : http://www.cytojournal.com/cptext/eb.pdf PDFs FREE for Members (visit http://www.cytojournal.com/CFMember.asp) OPEN ACCESS HTML format

Fine-needle aspiration of a right neck mass in a 10-year-old boy: Diagnostic clues and workup for tumors with small round blue cells

10.4103/cytojournal. cytojournal_31_16 Enlarging right neck mass in 10-year-old boy since 1 month with 5-pound weight loss, new onset cough, and change in voice. Examination of the oral cavity showed 8 cm × 8 cm oropharyngeal mass involving the entire right tonsillar region crossing the midline with deviation of the uvula. Computed tomography studies showed involvement of the parapharyngeal space from skull base to the omohyoid area with encasing of carotid artery. Fine-needle aspiration (FNA) [Figure 1] revealed highly cellular smears composed of small round blue cells with oval nuclei showing mild to marked anisonucleosis, lobulated to irregular nuclear contours, and intense hyperchromasia with occasional bare tumor nuclei and mitotic figures. Occasional loosely cohesive clusters and possible rosette formation were seen. Tumor karyotype was highly abnormal, complex, hyperdiploid with several structural and numerical aberrations, including gains of chromosomes 5, 8, 12 and 13. Fluorescence in situ hybridization (FISH) showed extra copy of the 13q14/ FOXO1-specific signal in 85.7% of interphase nuclei (gain of chromosome 13q) without 13q14 (FOXO1) rearrangement. Published: 27 December 2017 Received: 22 August 2016 CytoJournal 2017, 14:30 Accepted: 11 June 2017 This article is available from: http://www.cytojournal.com/content/14/1/30