Rashmi Tondon

Aggressive variants of follicular cell derived thyroid carcinoma; the so called ‘Real Thyroid Carcinomas’

The pathological diagnoses and classification schemes for thyroid carcinoma have changed over the past 20 years and continue to do so. New entities have been described and molecular analyses have suggested better characterisation and grouping of certain tumours. Because some of the lesions have been named differently by different authors, clinicians and patients may be confused as to what a specific patients lesion represents. In this review, we discuss the thyroid tumours of follicular origin which are clinically unusual but important to recognise as their behaviour may be aggressive, they may not respond to radioiodine treatment and they may cause significant mortality. This paper describes these important but rare lesions, their pathological features, important clinicopathological correlations, molecular correlates and prognostic implications.

Quality evaluation of four hemoglobin screening methods in a blood donor setting along with their comparative cost analysis in an Indian scenario

Background: Despite the wide range of methods available for measurement of hemoglobin, no single technique has emerged as the most appropriate and ideal for a blood donation setup. Materials and Methods: A prospective study utilizing 1014 blood samples was carried out in a blood donation setting for quality evaluation of four methods of hemoglobin estimation along with cost analysis: Hematology cell analyzer (reference), HCS, CuSO4 method and HemoCue. Results: Mean value of HemoCue (mean ± SD = 14.7 ± 1.49 g/dl) was higher by 0.24 compared to reference (mean ± SD = 13.8 ± 1.52 g/dl) but not statistically significant ( P > 0.05). HemoCue proved to be the best technique (sensitivity 99.4% and specificity 84.4%) whereas HCS was most subjective with 25.2% incorrect estimations. CuSO4 proved to be good with 7.9% false results. Comparative cost analysis of each method was calculated to be 35 INR/test for HemoCue, 0.76 INR /test for HCS and 0.06-0.08 INR /test for CuSO4. Conclusion: CuSO4 method gives accurate results, if strict quality control is applied. HemoCue is too expensive to be used as a primary screening method in an economically restricted country like India.

Anti-M: Report of two cases and review of literature.

Anti-M is a fairly common naturally occurring antibody with rarely causing hemolytic transfusion reactions or hemolytic disease of the newborn. Most anti-M are not active at 37°C and can generally be ignored in transfusion practice. However, we did not find this antibody to be fairly common and detected only two cases of anti-M in the past three years. We describe these two cases; one ‘immunizing’ type and other ‘naturally occurring’ and review the literature. The immunizing type was reactive at 37°C as well as AHG phase of testing with IgG component, and showing dosage effect while the other was ‘naturally occurring’ reactive well below 37°C. Though rare, sometimes these antibodies can be of clinical significance when the antibody detected is reactive at 37°C and AHG phase. When the antibody is active at 37°C, M antigen negative cross match compatible red cell unit should be given.

Esophageal Lichen Planus: Clinical and Radiographic Findings in Eight Patients.

OBJECTIVE The purpose of this study is to present the clinical and radiographic findings of esophageal lichen planus. MATERIALS AND METHODS A search of computerized medical records identified 15 patients with pathologic findings of esophageal lichen planus on endoscopic biopsy specimens. Three other patients had presumed esophageal lichen planus, although no biopsy specimens were obtained. Twelve of these 18 patients (67%) had double-contrast esophagography performed at our institution; for eight of the 12 patients (67%), the studies revealed abnormalities in the esophagus. These eight patients constituted our study group. The barium esophagrams and medical records of these eight patients were reviewed to determine the clinical, radiographic, and endoscopic findings of esophageal lichen planus as well as the treatment and patient outcome. RESULTS All eight patients were women (median age, 66.5 years), and all eight presented with dysphagia (mean duration, 3.2 years). Four patients had previous lichen planus that involved the skin (n = 1), the oral cavity (n = 2), or both (n = 1), and one patient later had lichen planus that involved the vagina. Five patients had a small-caliber esophagus with diffuse esophageal narrowing. The remaining three patients had segmental strictures in the cervical (n = 1), upper thoracic (n = 1), and distal thoracic (n = 1) esophagus. CONCLUSION Esophageal lichen planus typically occurs in older women with longstanding dysphagia and often develops in the absence of extraesophageal disease. Barium esophagrams may reveal a small-caliber esophagus or, less commonly, segmental esophageal strictures. Greater awareness of the radiographic findings of esophageal lichen planus hopefully will lead to earlier diagnosis and better management of this condition.

A 3‐year analysis of plateletpheresis donor deferral pattern in a tertiary health care institute: Assessing the current donor selection criteria in Indian scenario

Introduction: This study reports the frequency and nature of plateletpheresis deferrals and evaluates donors with low platelet count and hemoglobin levels so as to assess the possibility of reentry without hampering donor safety. Materials and methods: Three‐year retrospective data of plateletpheresis deferral was collected. Data from actual procedures was also reviewed to analyze the safety of performing plateletpheresis in donors with low hemoglobin and platelet values. Results: Four hundred sixteen donors were deferred for various reasons among 1,515 screened (27.5%), of which 69.7% deferrals were because of low platelet count (55.8%) and less hemoglobin levels. Among the low platelet count donor group, 20.3% had a count between 141 and 149 × 109/L and 41.8% below 120 × 109/L. Of the 14% donors deferred for low hemoglobin, 62.1% had values in the range of 11.5–12.4 g/dL with normal mean corpuscular volume and red cell distribution width in most (86.2%) of them. Expected blood loss in each procedure varied between 20 and 30 mL, whereas RBC contamination in the product varied from 0 to 1.6 mL in 538 procedures. There were 176 donations with predonation platelet count <180 × 109/L (32.7%). None of the 14 procedures performed on donors with platelet count of 150 × 109/L showed evidence of thrombocytopenia or donor reaction. Conclusion: Lowering the cut‐off value for plateletpheresis from 12.5 g/dL to 11.5 g/dL has no deleterious effect on donor safety as the blood loss is minimal. One‐fifth deferrals can be reconsidered if the criteria of plateletpheresis donor selection are relaxed for hemoglobin and platelet count. J. Clin. Apheresis, 2008.

Erythropoietic protoporphyria in an adult with sequential liver and hematopoietic stem cell transplantation: A case report

Erythropoietic protoporphyria (EPP) is a rare inherited disorder of the heme biosynthesis pathway resulting in the accumulation of protoporphyrins in the blood, erythrocytes, and other tissues. Because of a gene mutation in the FECH gene, ferrochelatase, the enzyme involved in the final step of heme synthesis, is deficient in these patients. Although the major symptom of this disorder is photosensitivity, rarely, it can cause progressive liver disease requiring liver transplantation (LT). However, LT is not curative and only bone marrow transplantation (BMT) can correct the underlying enzymatic defect. Because liver disease results from accumulation of protoporphyrin in the liver, LT without hematopoietic stem cell transplantation leaves the new liver at risk for similar EPP‐related damage. A handful of pediatric patients undergoing sequential LT and stem cell transplantation have been described in the literature; however, to date none has been described in detail in adults. We report a case of an adult male with EPP and liver failure who successfully underwent a sequential liver and hematopoietic stem cell transplantation (HSCT).

Biliary vs thyroid-like: A tale of two morphologies

Pictured here is a portacaval lymph node biopsy from a 72yearold man with an 11.9 cm liver mass and several enlarged surrounding lymph nodes. The node was involved by a tumour with two distinct morphologies—one area resembling a primary pancreaticobiliary tumour (Figure 1) and another mimicking a thyroid follicular carcinoma with microfollicles containing brightly eosinophilic, colloidlike secretions (Figure 2). Immunohistochemistry showed that the neoplastic cells stained strongly with CK7 and CK19, with patchy positive for CK20. CDX2, PAX8, TTF1, thyroglobulin and HepPar1 were negative. No other masses were identified on a body scan. Given the overall findings, a diagnosis of welldifferentiated adenocarcinoma compatible with cholangiocarcinoma with thyroidlike features was made. Cholangiocarcinoma, the second most common primary liver cancer after hepatocellular carcinoma, classically presents in the liver as a welltomoderately differentiated adenocarcinoma with varying degrees of desmoplastic stroma. Rare histological patterns are recognized, including adenosquamous, squamous, mucinous, signetring cell, clear cell, lymphoepitheliomalike, neuroendocrine and sarcomatoid.1 A thyroidlike growth pattern of cholangiocarcinoma has only been reported twice in the literature.2,3 However, this type of morphology has also been observed in tumours of other organs, such as the kidney and breast. As in the present case, the key to making this morphological diagnosis rests on establishing the absence of a primary thyroid neoplasm and demonstrating negative immunohistochemical staining for TTF1 and thyroglobulin. Once a metastatic thyroid carcinoma has been excluded, only then can a diagnosis of cholangiocarcinoma with thyroidlike features, an extremely rare morphological variant, be made.

Low Referral Rate for Genetic Testing in Racially and Ethnically Diverse Patients Despite Universal Colorectal Cancer Screening

BACKGROUND & AIMS: Guidelines recommend that all colorectal tumors be assessed for mismatch repair deficiency, which could increase identification of patients with Lynch syndrome. This is of particular importance for minority populations, in whom hereditary syndromes are under diagnosed. We compared rates and outcomes of testing all tumor samples (universal testing) collected from a racially and ethnically diverse population for features of Lynch syndrome. METHODS: We performed a retrospective analysis of colorectal tumors tested from 2012 through 2016 at 4 academic centers. Tumor samples were collected from 767 patients with colorectal cancer (52% non‐Hispanic white [NHW], 26% African American, and 17% Hispanic patients). We assessed rates of tumor testing, recommendations for genetic evaluation, rates of attending a genetic evaluation, and performance of germline testing overall and by race/ethnicity. We performed univariate and multivariate regression analyses. RESULTS: Overall, 92% of colorectal tumors were analyzed for mismatch repair deficiency without significant differences among races/ethnicities. However, minority patients were significantly less likely to be referred for genetic evaluation (21.2% for NHW patients vs 16.9% for African American patients and 10.9% for Hispanic patients; P = .02). Rates of genetic testing were also lower among minority patients (10.7% for NHW patients vs 6.0% for AA patients and 3.1% for Hispanic patients; P < .01). On multivariate analysis, African American race, older age, and medical center were independently associated with lack of referral for genetic evaluation and genetic testing. CONCLUSION: In a retrospective analysis, we found that despite similar rates of colorectal tumor analysis, minority patients are less likely to be recommended for genetic evaluation or to undergo germline testing for Lynch syndrome. Improvements in institutional practices in follow up after tumor testing could reduce barriers to diagnosis of Lynch diagnosis in minorities.

Velvety-Red Esophageal Mucosa and Dysphagia: Coincidental or Causal?

DIS 5.4.0 DTD YGAST60520 proof 29 August 2016 6:14 pm ce Gastr 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 Question: A 64year-old physician was referred for outpatient esophagogastroduodenoscopy after 5 years of intermittent solid food dysphagia, several episodes of esophageal food impaction over the last year, and a recent barium study demonstrating a ring-like esophageal stenosis (Figure A). His medical history included hypertension, eczema, and allergic rhinitis. Prior medications were significant for potassium chloride and alendronate sodium tablets. His weight, appetite, and bowel habits were stable, and physical examination was 102 103 104 105 106 107 108 109 unremarkable. A complete blood count with differential and a comprehensive metabolic panel were both normal. At endoscopy, there was a large, circumferential segment of velvety-red mucosa in the proximal esophagus spanning 19 to 24 cm from the incisors (Figure B, C). Immediately below this region, at 25 cm from the incisors, there was a short, ring-like stricture followed by normal appearing mucosa in the midand distal esophagus. The stricture was dilated with a throughthe-scope balloon from 12 to 15 mm, and cold forceps biopsies were obtained (Figure D). Based on the patient’s clinical presentation, imaging, and endoscopic findings, what is the likely diagnosis? Look on page 000 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 110 111 112 113 114 115 Conflicts of interest The authors disclose no conflicts.

Tu1298 Neoplasia in Patients With Atrophic Metaplastic Autoimmune Gastritis (AMAG): Screening and Surveillance Endoscopy Should Become Standard of Care

Background: AMAG is an autoimmune condition in which antibodies attack oxyntic mucosa leading to intestinal metaplasia (IM), hypergastrinemia, and type 1 well-differentiated neuroendocrine tumors (WDNET). While IM is a wellestablished risk factor for adenocarcinoma in the esophagus, the risk of neoplastic progression in AMAG is thought to be low (2-3x general population). In contrast to Barrett esophagus (BE), current guidelines do not call for surveillance upper endoscopy in this population. We report the clinical/pathologic characteristics of AMAG patients who underwent evaluation at our center over a five year period to determine frequency/timing of neoplasias.