Tajana Štoos-Veić

EUS–FNA of Brunner’s gland hamartoma: a case report

A 50-year-old woman was evaluated at an outside institution for iron deficiency anaemia. Esophagogastroduodenoscopy demonstrated a polypoid tumour in the distal duodenum. Punch biopsy was unremarkable. Multi-sliced computed tomography revealed a mass inseparable from the pancreatic head. Apart from anaemia (Hb 108 g ⁄ l), other laboratory findings were unremarkable. The patient was referred to our institution for EUS, which revealed a 40 · 63-mm mostly hypoechogenic mass with small cystic spaces, not in contact with the pancreatic head. The lesion was sited within the duodenal wall and probably originated in the fourth echolayer (Figure 1), so suspicion of gastrointestinal stromal tumour (GIST) was raised.

The Degree of Anisocytosis Predicts Survival in Patients with Primary Myelofibrosis

Background: Red cell distribution width (RDW) provides a quantitative measure of anisocytosis and it is associated with the presence of subclinical systemic inflammation and a poor outcome in a variety of diseases when elevated. Anisocytosis is a feature of primary myelofibrosis (PMF) but it’s prognostic role in PMF has not yet been evaluated. Aims: To determine whether anisocytosis bears prognostic significance in patients with PMF and its relation to disease features. Methods: 33 newly-diagnosed patients with PMF were analyzed in this study. Baseline RDW values were obtained in addition to other routine blood analyses (CRP, LDH, complete blood count and iron metabolism parameters) and JAK2 V617F mutational status. Patients were staged according to IPSS prognostic scoring system, liver and spleen size were assessed by palpation. The Mann Whitney U test, the Pearson correlation and the Χ2 test/ the Fisher test were used where appropriate. Survival analyses were performed using methods of Kaplan and Meier, the log-rank test and the Cox regression analysis. All statistical tests were two-sided and P values <0.05 were considered significant. Results: Median RDW was 19.0% (15.2% - 22.5%). RDW correlated significantly with hemoglobin (p=0.005), CRP (p=0.031), spleen size (p=0.036) and IPSS score (p=0.003). Patients with more pronounced anisocytosis had an inferior overall survival (OS) – very-high RDW (≥19.0%) vs. high RDW (15.1% - 18.9%) subgroup, HR 5.37, p=0.002. RDW remained significantly associated with OS (p=0.002) in a multivariate model including IPSS score, hemoglobin level and CRP. Summary/Conclusion: PMF pathogenesis surpasses inflammation as only cause of anisocytosis. A higher degree of anisocytosis is associated with more advanced disease features and a decreased overall survival. RDW encompasses standard prognostic score and may help in the rapid detection of patients with an unfavorable prognosis.

Liver Elastography Malignancy Prediction (LEMP) score for noninvasive characterization of Focal Liver Lesions

To analyse elastographic characteristics of focal liver lesions (FLL)s and diagnostic performance of real‐time two‐dimensional shear‐wave elastography (RT‐2D‐SWE) in order to differentiate benign and malignant FLLs.

Endoscopic ultrasound guided fine needle aspiration and useful ancillary methods

The role of endoscopic ultrasound (EUS) in evaluating pancreatic pathology has been well documented from the beginning of its clinical use. High spatial resolution and the close proximity to the evaluated organs within the mediastinum and abdominal cavity allow detection of small focal lesions and precise tissue acquisition from suspected lesions within the reach of this method. Fine needle aspiration (FNA) is considered of additional value to EUS and is performed to obtain tissue diagnosis. Tissue acquisition from suspected lesions for cytological or histological analysis allows, not only the differentiation between malignant and non-malignant lesions, but, in most cases, also the accurate distinction between the various types of malignant lesions. It is well documented that the best results are achieved only if an adequate sample is obtained for further analysis, if the material is processed in an appropriate way, and if adequate ancillary methods are performed. This is a multi-step process and could be quite a challenge in some cases. In this article, we discuss the technical aspects of tissue acquisition by EUS-guided-FNA (EUS-FNA), as well as the role of an on-site cytopathologist, various means of specimen processing, and the selection of the appropriate ancillary method for providing an accurate tissue diagnosis and maximizing the yield of this method. The main goal of this review is to alert endosonographers, not only to the different possibilities of tissue acquisition, namely EUS-FNA, but also to bring to their attention the importance of proper sample processing in the evaluation of various lesions in the gastrointestinal tract and other accessible organs. All aspects of tissue acquisition (needles, suction, use of stylet, complications, etc.) have been well discussed lately. Adequate tissue samples enable comprehensive diagnoses, which answer the main clinical questions, thus enabling targeted therapy.

Heat shock protein 27 (HSP27/HSPB1) expression is increased in patients with primary and secondary myelofibrosis and may be affecting their survival

Marko Lucijanic , Ana Livun , Katarina Marija Tupek, Tajana Stoos-Veic, Gorana Aralica, Iva Gecek, Vlatko Pejsa and Rajko Kusec Department of Hematology, University Hospital Dubrava, Zagreb, Croatia; Clinical Institute of Laboratory Diagnosis, Division of Molecular Diagnosis and Genetics, University Hospital Dubrava, Zagreb, Croatia; Department of Clinical Cytology and Cytometry, University Hospital Dubrava, Zagreb, Croatia; School of Medicine, University of Osijek, Osijek, Croatia; Department of Pathology, University Hospital Dubrava, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia

High absolute basophil count is a powerful independent predictor of inferior overall survival in patients with primary myelofibrosis

ABSTRACT Objectives: To investigate the clinical and prognostic significance of absolute basophil count (ABC) in patients with primary myelofibrosis (PMF). Methods: We retrospectively investigated 58 patients with PMF treated in our institution in the period from 2006 to 2017. ABC was obtained in addition to other hematological and clinical parameters. Patients were separated into high and low ABC groups using the Receiver operating characteristic curve analysis. Results: ABC was higher in PMF patients than in healthy controls (P < 0.001). Patients with high ABC had higher white blood cells (P < 0.001), higher red cell distribution width (P = 0.035), higher lactate dehydrogenase (P < 0.001), more frequently had circulatory blasts (P < 0.001), constitutional symptoms (P = 0.030) and massive splenomegaly (P = 0.014). ABC was also positively correlated with absolute monocyte count (AMC) (P < 0.001) and other components of differential blood count. There was no difference in ABC regarding driver mutations or degree of bone marrow fibrosis. Univariately, high ABC was significantly associated with inferior overall survival (hazard ratio (HR) 4.79, P < 0.001). This effect remained statistically significant (HR 4.27, P = 0.009) in a multivariate Cox regression model adjusted for age, gender, Dynamic International Prognostic Scoring System (HR 2.6, P = 0.001) and AMC (HR 8.45, P = 0.002). Discussion: High ABC reflects higher disease activity and stronger proliferative potential of disease. ABC and AMC independently predict survival and therefore seem to reflect different underlying pathophysiologic processes. Hence, both have a potential for improvement of current prognostic scores. Conclusion: Basophils represent a part of malignant clone in PMF and are associated with unfavorable disease features and poor prognosis which is independent of currently established prognostic scoring system and monocytosis.

EUS‐FNA of the Merkel cell carcinoma metastasis to the pancreas: Cytomorphology and immunocytochemistry on direct cytological smears

To report two cases of Merkel cell carcinoma (MCC) metastatic to the pancreas diagnosed with endoscopic ultrasound‐guided‐fine needle aspiration (EUS‐FNA) and to add the case of concomitant chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL) and MCC to the literature. The aim is to alert the cytopathologists once more to the problems of differential diagnosis of pancreatic metastasis of MCC and to describe the possibilities of ancillary methods performed on direct cytological smears.

Prognostic implications of low transferrin saturation in patients with primary myelofibrosis

OBJECTIVES Transferrin saturation (TSAT) 20% or less is considered to represent functional iron deficiency in the context of malignant disease, phenomenon mediated through inflammatory changes of iron homeostasis. We aimed to investigate clinical and prognostic significance of low TSAT in patients with primary (PMF) and secondary myelofibrosis (SMF), malignant diseases characterized by strong inflammatory milieu. METHODS We retrospectively analyzed 87 patients with myelofibrosis and compared TSAT with disease specific parameters. RESULTS One-third of patients had TSAT ≤20%. Lower TSAT was significantly associated with Janus-kinase-2 (JAK2) mutation (P = 0.007), transfusion independency (P = 0.003), higher platelets (P = 0.004), lower mean-corpuscular-volume (P < 0.001), lower ferritin (P < 0.001), higher absolute-neutrophil-count (P = 0.027), lower absolute-lymphocyte-count (P = 0.041) and lower albumin (P = 0.018). PMF patients presenting with low TSAT (≤20%) experienced significantly shorter overall-survival (OS) (HR = 2.43; P = 0.017), whereas TSAT did not affect OS of SMF patients (HR = 1.48; P = 0.623). Low TSAT remained significantly associated with inferior OS in PMF in a series of multivariate Cox regression models comparing its properties to anemia, transfusion dependency, ferritin and Dynamic-International-Prognostic-System (DIPSS). CONCLUSIONS Low TSAT has detrimental effect on survival of PMF patients. This effect is independent of anemia and of ferritin levels that seem to be better at representing iron overload in PMF patients.

Higher Sclerostin/SOST expression is associated with lower percentage of circulatory blasts and better prognosis in patients with myelofibrosis

Dear Editor, Sclerostin (a product of SOST gene) acts as a main negative regulator of bone metabolism, exerting its properties through inhibition of canonical-WNT signaling-pathway (cWNT) in osteoblasts [1]. It is produced by osteocytes and bone marrow (BM) cells. cWNT activation is implicated in pathogenesis of Philadelphia chromosome-negative myeloproliferative neoplasms (PhMPNs) [2, 3], diseases characterized by remodeling of BM stroma and development of BM fibrosis/ osteosclerosis during course of the disease. We aimed to investigate Sclerostin/SOSTexpression in BM tissues of patients with primary (PMF) and secondary post PhMPN myelofibrosis (SMF) and to assess its clinical correlations. We retrospectively investigated Sclerostin/SOST expression in BM of 66 diseased patients (51 PMF, 15 post-PV/ post-ET-SMF, diagnoses were established according to the WHO [4] and the IWG-MRT [5] criteria) and 18 ageand sex-matched controls (limited-stage aggressive non-Hodgkin lymphoma patients without BM involvement) using immunohistochemistry (IHC; Sclerostin 21933-1-AP rabbit polyclonal Proteintech primary antibody) and real-time polymerase chain reaction (RT-PCR; SOST Hs00228830_m1 Thermo Fischer Scientific TaqMan assay; evaluated from BM aspirates). Sclerostin expression was expressed as a percentage of positive cells. SOST mRNA expression was normalized to Abl and expressed as a ΔCT value. Correlations with clinical parameters were made. Optimal cut-off values for survival were determined using the ROC curve analysis. The MannWhitney U test, the Spearman rank correlation, the CoxMantel log rank test [6], and the Cox regression analysis were used. Analyses were done using MedCalc Statistical Software ver.18 (MedCalc Software bvba, Ostend, Belgium). P values < 0.05 were considered statistically significant. All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. All patients provided written informed consent. The median age of patients was 67 years; 59% were males, 67% had grades II-III BM fibrosis, and 70, 11, and 2% were JAK2, CALR, and MPL mutated, respectively. Median followup of our cohort was 74 months with median overall survival of 69 months. Sclerostin/SOST expression did not significantly differ between PMF and SMF, nor between patients and controls. However, non-significantly higher expression was observed in myelofibrosis patients (both PMF and SMF) than that in controls; result was near statistical significance for SOST (P = 0.056). In diseased patients, higher Sclerostin expression measured by IHC was significantly correlated with lower percentage of circulatory blasts (rho − 0.28, P = 0.042) and transfusion dependency (P = 0.049). Higher SOST expression measured by RT-PCR was similarly significantly correlated with lower percentage of circulatory blasts (rho − 0.44, P = 0.042), but also higher platelets (rho 0.4, P = 0.031) and smaller spleen size (rho − 0.6, P = 0.001). We found no significant association of Sclerostin/SOST expression with JAK2, CALR, and MPL mutation status or degree of bonemarrow fibrosis. Patients with higher Sclerostin expression (HR = 0.35, P = 0.006) and higher SOST expression (HR = 0.44, P = 0.044) had superior overall survival than patients presenting with lower Sclerostin/SOST expression as shown in a Fig. 1. This association remained significant for SOST (HR = 0.21, P = 0.025) after adjusting for age, gender, and circulatory blasts (HR = 1.06, P = 0.002). * Marko Lucijanic markolucijanic@yahoo.com

Loss of response to azacitidine is associated with deletion 12p13 in a patient with myelodysplastic syndrome with unique translocation t(13;17)(q12;q25) after prior breast cancer and acute promyelocytic leukemia

Dear Editor, With increasingly successful treatment of malignancies, therapy-related leukemia (TRL) and myelodysplastic syndrome (MDS) are increasingly observed, especially in association with prior radiotherapy and the use of alkylating agents or topoisomerase-II inhibitors [1, 2]. They are characterized by lesions of chromosomes 5 and 7 and poor survival (median 7–10 months) [3, 4]. Azacitidine may be a reasonable treatment choice [5] although safety concerns in patients with complex cytogenetics [6] or previous acute promyelocytic leukemia (APL) exist [7]. Here, we present a case of two consecutive, individually rare TRLs following initial solid tumor and subsequent treatments with the development of unique translocation (13;17)(q12;q25). Azacitidine was successfully used achieving 1-year-long remission when patient relapsed, revealing a distinctive karyotype (Fig. 1). A female patient aged 61 was diagnosed with breast cancer in 2006. She had mastectomy, received four cycles of doxorubicin/cyclophosphamide, four cycles of paclitaxel, and radiotherapy accomplishing remission. In 2009, APL was diagnosed, PML/RARα positive (47, XX,+8,t(15;17)(q24;q21)[10]). Antracycline/ATRA-based induction and three consolidation therapies were followed by 2year ATRA/6-MP/methotrexate maintenance. Remission was soon achieved, and patient remained without detectable PML/ RARα transcript thereafter. In 2013, the patient developed anemia requiring transfusion support. MDS (18 % blasts) with complex cytogenetics (45,XX,del(5)(q22q33),-7,t(13;17)(q12;q25), del(12)(p13),add(20)(q11)[cp15]) was diagnosed. Azacitidine was instituted as salvage therapy, and the patient became transfusion independent, achieving hematological remission. After 11 cycles, azacitidine had to be stopped due to the development of anemia and thrombocytopenia. Repeated revisions showed increased number of blasts (15 % progressing to 72 %) and alt e r ed cy togene t i c s (45 ,XX,de l (5 ) (q22q33 ) , 7 , t(13;17)(q12;q25),del(12)(p13)[20]). Fluorescence in situ hybridization (FISH) was performed on the actual sample and retrospectively (at the time of MDS diagnosis) revealing 12p13 deletion was initially present in a subclone comprising 35 % of cells and now prevailing in 90 % of cells. 17p13 deletion was absent in both samples. The patient receives supportive treatment and remains alive more than 18 months since diagnosis. * Ozren Jaksic ojaksic@kbd.hr