Next-generation sequencing for pediatric CNS tumors: does it add value in a middle-income country setup?

Introduction: Advances in molecular diagnostics led to improved targeted interventions in the treatment of pediatric CNS tumors. However, the capacity to test for these is limited in LMICs, and thus their value needs exploration. Methods: We reviewed our experience with NGS testing (TruSight RNA Pan-Cancer-seq panel) for pediatric CNS tumors at KHCC/Jordan (March/2022-April/2023). Paraffin blocks' scrolls were shipped to the SickKids laboratory based on the multidisciplinary clinic (MDC) recommendations. We reviewed the patients' characteristics, the tumor types, and the NGS results' impact on treatment. Results: Of 237 patients discussed during the MDC meetings, 32 patients (14%) were included. They were 16 boys and 16 girls; the median age at time of testing was 9.5 years (range, 0.9-21.9 years). There were 21 samples sent at diagnosis and 11 upon tumor progression. The main diagnoses were low-grade-glioma (15), high-grade-glioma (10), and other histologies (7). Reasons to request NGS included searching for a targetable alteration (20) and to better characterize the tumor behavior (12). The median turnaround time from samples' shipment to receiving the results was 23.5 days (range, 15-49 days) with a median laboratory processing time of 16 days (range, 8-39 days) at a cost of US$1,000/sample. There were 19 (59%) tumors that had targetable alterations (FGFR/MAPK pathway inhibitors (14), checkpoint inhibitors (2), NTRK inhibitors (2), and one with PI3K inhibitor or IDH1 inhibitor). Two rare BRAF mutations were identified (BRAFp.G469A, BRAFp.K601E). One tumor diagnosed initially as undifferentiated round cell sarcoma harbored NAB2::STAT6 fusion and was reclassified as an aggressive metastatic solitary fibrous tumor. Another tumor initially diagnosed as grade 2 astroblastoma grade 2 was reclassified as low-grade-glioma in the absence of MN1 alteration. NGS failed to help characterize a tumor that was diagnosed histologically as small round blue cell tumor. Nine patients received targeted therapy; dabrafenib/trametinib (6), pembrolizumab (2), and entrectinib (1), mostly upon tumor progression (7). Conclusion: In this highly selective cohort, a high percentage of targetable mutations was identified facilitating targeted therapies. Outsourcing of NGS testing was feasible; however, criteria for case selection are needed. In addition, local capacity-building in conducting the test, interpretation of the results, and access to "new drugs" continue to be a challenge in LMICs.

Lymph node ratio is a more robust predictor of overall survival than N stage in stage III colorectal adenocarcinoma.

BACKGROUND: Lymph node ratio (LNR) may offer superior prognostic stratification in colorectal adenocarcinoma compared with N stage. However, candidate cutoff ratios require validation. We aimed to study the prognostic significance of LNR and its optimal cutoff ratio. METHODS: We reviewed the pathology records of all patients with stage III colorectal adenocarcinoma who were managed at the King Hussein Cancer Center between January 2014 and December 2019. We then studied the clinical characteristics of the patients, correlates of lymph node count, prognostic significance of positive lymph nodes, and value of sampling additional lymph nodes. RESULTS: Among 226 included patients, 94.2% had ≥ 12 lymph nodes sampled, while 5.8% had < 12 sampled lymph nodes. The median number of lymph nodes sampled varied according to tumor site, neoadjuvant therapy, and the grossing pathologist's level of training. According to the TNM system, 142 cases were N1 (62.8%) and 84 were N2 (37.2%). Survival distributions differed according to LNR at 10% (p = 0.022), and 16% (p < 0.001), but not the N stage (p = 0.065). Adjusted Cox-regression analyses demonstrated that both N stage and LNR at 10% and 16% predicted overall survival (p = 0.044, p = 0.010, and p = 0.001, respectively). CONCLUSIONS: LNR is a robust predictor of overall survival in patients with stage III colorectal adenocarcinoma. At a cutoff ratio of 0.10 and 0.16, LNR offers better prognostic stratification in comparison with N stage and is less susceptible to variation introduced by the number of lymph nodes sampled, which is influenced both by clinical variables and grossing technique.

Mixed sex cord-stromal tumor (gynandroblastoma) with malignant morphology involving both ovaries: a case report.

Mixed sex cord-stromal tumors, which consist of poorly differentiated Sertoli cells and Leydig cells and juvenile granulosa cell tumor tissue, are extremely rare. Most of these tumors are unilateral and stage I at the time of diagnosis; nonetheless, according to the available relevant English-language literature, these tumors maintain a malignant potential. We herein report a case involving a 15-year-old girl diagnosed with a mixed sex cord-stromal tumor (gynandroblastoma with juvenile granulosa cell tumor component). Left salpingo-oophorectomy was initially performed, and the diagnosis of a juvenile granulosa cell tumor was established. Right salpingo-oophorectomy was performed 1 year later, at which time the specimen showed a different growth pattern involving epithelioid cells and tubules, resembling a Sertoli-Leydig cell tumor. Immunohistochemical staining was performed and the specimen was compared with that obtained 1 year earlier. We concluded that the tumors were linked and most likely constituted a gynandroblastoma (mixed form of sex cord-stromal tumor). Although this is an extremely uncommon ovarian tumor, it should be considered when diverse tumor morphology is identified. Bilateral metachronous involvement of the ovaries is possible. The grade of the Sertoli-Leydig cell component may influence the prognosis of such a tumor.

Anaplastic lymphoma kinase rearrangements in patients with non-small cell lung cancer in Jordan.

OBJECTIVE: Anaplastic lymphoma kinase (ALK) rearrangement is an important oncogenic driver in some non-small cell lung cancers (NSCLC). Treatment with ALK tyrosine kinase inhibitors improves survival. The availability of diagnostic immunohistochemistry (IHC) has led to a paradigm shift in ALK testing. This study examined the prevalence of ALK rearrangement in Jordanian patients with NSCLC and compared the results of IHC and fluorescence in situ hybridization (FISH) for detecting ALK rearrangement. METHODS: This retrospective study on 449 patients with NSCLC treated at the King Hussein Cancer Center in Jordan tested biopsy samples for ALK rearrangement using FISH and/or IHC (D5F3) between 2018 and 2020. RESULTS: Eighteen patients (4%) had ALK-positive NSCLC. The calculated sensitivity and specificity of ALK immunostaining compared with FISH were 87.5% and 96%, respectively. ALK-positive patients were significantly younger than their ALK-negative counterparts, and women were three times more likely to carry ALK rearrangement than men. ALK rearrangement was significantly associated with smoking history, with most ALK-positive patients being non-smokers, former smokers, or light smokers. CONCLUSIONS: IHC is a reasonable alternative to FISH for ALK testing with advantages in terms of robustness, turnaround times, and cost-effectiveness.

Ultrasound-guided vacuum-assisted breast biopsy in the diagnosis of cancer recurrence at the surgical scar: a report of three cases.

Aim of the study: Ultrasound-guided vacuum-assisted biopsy is being increasingly used in the diagnosis of breast lesions. The advantages of vacuum-assisted biopsy over core needle biopsy include large sample and higher diagnostic accuracy. Indications for ultrasound-guided vacuum-assisted biopsy include suspicious calcifications visible on ultrasound, architectural distortion, and very subtle or insinuating lesions. Case description: We present three patients treated for breast cancer with breast-conserving surgery who developed suspicious findings on mammogram and MRI at or near the surgical scar. The findings were subtle, small, or atypical lesions on ultrasound. Ultrasound-guided vacuum-assisted biopsy was performed, and recurrence was diagnosed. The technique was advantageous due to real-time imaging, ability to control the path of the needle, obtaining multiple cores with a single skin puncture and single pass, supine position, no radiation, and no IV contrast. Conclusions: Ultrasound-guided vacuum-assisted biopsy should be considered in cases involving multiple suspicious findings at or near the surgical scar, with subtle or atypical sonographic correlates. Vacuum-assisted biopsy is indicated; yet ultrasound guidance is more comfortable, no radiation and no contrast.

Concomitant Langerhans cell histiocytosis of cervical lymph nodes in adult patients with papillary thyroid carcinoma: A report of two cases and review of the literature.

OBJECTIVE: : Langerhans cell histiocytosis (LCH) is an uncommon entity of unknown etiology. It contains a wide range of clinical presentations. The discovery of oncogenic BRAF V600E mutation in LCH has provided additional evidence that LCH is a neoplasm. Papillary thyroid carcinoma is the most common cancer of the thyroid characterized by a high incidence of BRAF V600E mutations. LCH with concomitant PTC is rare, with few cases reported in the literature. CASES SUMMARY: We identified two cases of LCH with concomitant papillary thyroid carcinoma in adult patients. The first was a 49-year-old female with a thyroid nodule diagnosed with papillary thyroid carcinoma. Later, the patient had a left neck mass; Ultrasound-guided lymph node FNA was diagnosed with Langerhans histiocytosis. Subsequently, a chest CT scan revealed signs of Langerhans cell histiocytosis in the lung. The second case refers to a 69-year-old male who presented with a left thyroid nodule diagnosed on FNA cytology as papillary thyroid carcinoma. The patient was found to have multiple bone lytic lesions. Biopsies revealed Langerhans cell histiocytosis. Later, the patient experienced LCH involvement of the bone marrow with associated secondary myelofibrosis. CONCLUSIONS: LCH is rare in adults; the association with papillary thyroid carcinoma is reported and should be considered in the presence of Langerhans cell groups along with PTC, whether in the thyroid gland or cervical lymph nodes. Once LCH has been diagnosed, pulmonary involvement should also be investigated. This will direct treatment plans for patients with pulmonary or systemic disease involvement.

Adult Pilocytic Astrocytoma in the insula: Case report and review of the literature.

INTRODUCTION: and Importance: Adult Pilocytic Astrocytomas (APA) are infrequent low grade tumors. While supratentorial APA is considered rare, insular APA is extremely rare. CASE PRESENTATION: We present a case of pure insular APA along with surgical outcomes. Tractography and functional MRI were obtained pre-operatively. The patient underwent neuro-navigation guided microsurgical resection with sub-cortical white matter mapping, utilizing Intra-operative MRI guidance. The Sylvain fissure was opened to secure the M3 branches, and near total resection was achieved. CLINICAL DISCUSSION: APA in the insula is a very rare presentation and is considered challenging. Its proximity to the middle cerebral and lenticulostriate arteries, motor areas, and language areas makes accessing and resecting the tumor challenging. A multidisciplinary approach by an experienced team is needed to plan the management of young adult patients and reach the best outcomes. CONCLUSION: Implementing microsurgical techniques, modern imaging modalities and intraoperative mapping helps to achieve maximal safe resection without risking functions.

Diffuse midline glioma H3 K27M-mutant in adults: A report of six cases and literature review.

AIM: Diffuse midline glioma (DMG) H3 K27M-mutant is a specific entity that, as the name indicates, tends to occur in midline structures including the thalamus, brainstem, and spinal cord. DMG predominates in children, is an aggressive tumor with poor prognosis, and is considered a WHO grade IV tumor regardless of histological features. The exact frequency of these mutations in adults diagnosed with glioma in the midline is unknown. MATERIALS AND METHODS: We report a series of 6 more adult cases, and we critically review the current literature on adults with DMG H3 K27M-mutant. RESULTS: There were 5 males and 1 female. The age ranged from 26 to 52 years (median 39 years). All cases showed astrocytic differentiation, with positive staining for H3 K27M protein, and loss of H3 K27me in the tumor cells confirming the diagnosis. CONCLUSION: H3 K27M-mutant midline glioma can occur in adults, affecting midline structures. Increasing awareness of the reporting pathologists of this entity might help in a better determination of the frequency of mutant DMG in adults as well as better diagnosis and patient counseling of the outcome.

Concomitant Langerhans cell histiocytosis of cervical lymph nodes in adult patients with papillary thyroid carcinoma: A report of two cases and review of the literature

Objective : Langerhans cell histiocytosis (LCH) is an uncommon entity of unknown etiology. It contains a wide range of clinical presentations. The discovery of oncogenic BRAF V600E mutation in LCH has provided additional evidence that LCH is a neoplasm. Papillary thyroid carcinoma is the most common cancer of the thyroid characterized by a high incidence of BRAF V600E mutations. LCH with concomitant PTC is rare, with few cases reported in the literature. Cases summary We identified two cases of LCH with concomitant papillary thyroid carcinoma in adult patients. The first was a 49-year-old female with a thyroid nodule diagnosed with papillary thyroid carcinoma. Later, the patient had a left neck mass; Ultrasound-guided lymph node FNA was diagnosed with Langerhans histiocytosis. Subsequently, a chest CT scan revealed signs of Langerhans cell histiocytosis in the lung. The second case refers to a 69-year-old male who presented with a left thyroid nodule diagnosed on FNA cytology as papillary thyroid carcinoma. The patient was found to have multiple bone lytic lesions. Biopsies revealed Langerhans cell histiocytosis. Later, the patient experienced LCH involvement of the bone marrow with associated secondary myelofibrosis. Conclusions LCH is rare in adults; the association with papillary thyroid carcinoma is reported and should be considered in the presence of Langerhans cell groups along with PTC, whether in the thyroid gland or cervical lymph nodes. Once LCH has been diagnosed, pulmonary involvement should also be investigated. This will direct treatment plans for patients with pulmonary or systemic disease involvement.

Frequency of Mismatch Repair Protein (MMRP) Deficiency among Young Jordanians Diagnosed with Colorectal Carcinoma (CRC).

PURPOSE: Microsatellite instability (MSI) caused by mismatch repair protein (MMRP) deficiency is detected in 15% of sporadic colorectal cancers (CRCs). Our aim is to investigate the frequency of MMRP deficiency in young CRC patients, using immunohistochemical analysis. METHODS: This study targeted cases of CRC at King Hussein Cancer Center from 2004 until 2012 in patients 45 years of age or younger at the time of diagnosis. Clinicopathological data was obtained from 155 patients' records. Immunohistochemistry for MLH1, MSH2, PMS2, and MSH6 proteins was performed on paraffin-embedded tissue containing carcinoma. RESULTS: The median age of patient at diagnosis was 38 years. A total of 29 (19%) cases showed deficient MMRP(dMMRP)expression. Loss of expression of PMS2 was seen in 17 cases, 12 cases of which showed loss of MLH1 expression. Loss of expression of MSH6 was seen in 10 cases, 9 of which showed loss of MSH2 expression. One case (3.4%) showed loss of all four MMR proteins, and another case (3.4%) showed loss of PMS2/MLH1 and MSH6. There was a significant association between abnormal MMR protein expression and tumor location proximal to splenic flexure (p value 0.000), pathologic features suggestive of microsatellite instability (p value 0.000), P53 negativity (p value 0.000), and stage (p value 0.02). Patients with dMMRP CRC appeared to have a significantly better overall survival compared to patients with proficient MMRP(pMMRP)(p value 0.02). Loss of MSH2/MSH6 was significantly associated with positive family history of cancer (p value = 0.020). CONCLUSIONS: The prevalence of dMMRP tumors in this age group appears to be similar to international literature. dMMRP tumors tends to be associated with earlier stages and better outcomes compared to pMMRP cases. dMMRP can serve as a biomarker for better prognosis. These results are of value in directing the clinical management of young patients with CRC.

Prevalence of Abnormal Pap Smears: A Descriptive Study from a Cancer Center in a Low-Prevalence Community

Background and aims: Cervical cancer is the fourth most common cancer in women worldwide and the 13th in Jordan. The cervical smear (Pap smear) is a simple approach to detect pre-cancerous cervical lesions. The aim of this study was to evaluate the prevalence of abnormal cervical smears in women seen at the Early Detection/Community Outreach clinic of King Hussein Cancer Center (KHCC). Materials and Methods: In this retrospective study, reports of routine cervical Pap smears performed in the pathology department at KHCC from January 2007 to December 2016, were reviewed. During this period, a total of 5,529 routine smears were assessed for epithelial abnormalities and histopathological grading. Results: A total of 210 (3.8%) abnormal Pap smears were found, with atypical squamous cell of undetermined significance (ASC-US) reported in 110 (52.4%) cases, atypical glandular cells of undermined significance (AGUS) in 58 (27.6%), low grade squamous intra-epithelial lesion (LSIL) in 27 (12.9%) and high grade intra-epithelial lesion (HSIL) in 13 (6.2%). Only single cases of ASC-H and squamous cell carcinoma were reported. The available biopsies showed benign findings in 70.1% of cases, low grade squamous intraepithelial lesions in 11.5% and high grade squamous intraepithelial lesions in 18.4%. Conclusions: The low epithelial cell abnormality (EPCA) prevalence illustrated in this study argues against introduction of population-based HPV testing and vaccination. It calls for a more cost-effective measures in a country with limited resources, where a more widely available Pap-smear testing might suffice.