Comparison of East-Asia and West-Europe cohorts explains disparities in survival outcomes and highlights predictive biomarkers of early gastric cancer aggressiveness.

Surgical resection with lymphadenectomy and perioperative chemotherapy is the universal mainstay for curative treatment of gastric cancer (GC) patients with locoregional disease. However, GC survival remains asymmetric in West- and East-world regions. We hypothesize that this asymmetry derives from differential clinical management. Therefore, we collected chemo-naïve GC patients from Portugal and South Korea to explore specific immunophenotypic profiles related to disease aggressiveness and clinicopathological factors potentially explaining associated overall survival (OS) differences. Clinicopathological and survival data were collected from chemo-naïve surgical cohorts from Portugal (West-Europe cohort [WE-C]; n = 170) and South Korea (East-Asia cohort [EA-C]; n = 367) and correlated with immunohistochemical expression profiles of E-cadherin and CD44v6 obtained from consecutive tissue microarrays sections. Survival analysis revealed a subset of 12.4% of WE-C patients, whose tumors concomitantly express E-cadherin_abnormal and CD44v6_very high, displaying extremely poor OS, even at TNM stages I and II. These WE-C stage-I and -II patients tumors were particularly aggressive compared to all others, invading deeper into the gastric wall (P = .032) and more often permeating the vasculature (P = .018) and nerves (P = .009). A similar immunophenotypic profile was found in 11.9% of EA-C patients, but unrelated to survival. Tumours, from stage-I and -II EA-C patients, that display both biomarkers, also permeated more lymphatic vessels (P = .003), promoting lymph node (LN) metastasis (P = .019), being diagnosed on average 8 years earlier and submitted to more extensive LN dissection than WE-C. Concomitant E-cadherin_abnormal/CD44v6_very-high expression predicts aggressiveness and poor survival of stage-I and -II GC submitted to conservative lymphadenectomy.

[Whipple's Disease: retrospective analysis of twelve cases and review of the literature]. / Doença de Whipple: análisis retrospectivo de doce casos e revisión de la literature.

BACKGROUND: Whipple's disease is a rare and chronic bacterial disease with multiorganic involvement. Although there is no valid estimate of its actual prevalence, only about 1,000 cases have been reported. OBJECTIVE: To describe the demographic, clinical, laboratory, endoscopic and pathologic features, type of treatment used, its duration and response. METHODS: Based on the duodenal histology, we identified twelve cases of Whipple's disease in the Hospital Centre of Vila Nova de Gaia, between 1997 and 2010. RESULTS. Nine patients (75%) were male and the mean age at diagnosis was 58 years. All patients experienced at least one gastrointestinal and general symptom. Arthralgia were reported in four patients (33%) and occurred on average six years before the onset of gastrointestinal and general symptoms. In 10 patients the initial treatment was trimethoprim-sulfamethoxazole. The initial treatment duration was one year in 8 cases (80%). Seven patients (70%) had a symptomatic resolution between the third and sixth months of antibiotic therapy, as well as an endoscopic and histological improvement. Even in these patients, there was maintenance of periodic acid-Schiff positive macrophages, although in small number and with a more diffuse distribution. Gastrointestinal symptoms predominated in cases of clinical relapse. CONCLUSIONS: The gastrointestinal and general symptoms as well as the arthralgia were the predominant manifestations. The majority of patients showed clinical and endoscopic improvement in response to treatment with trimethoprim-sulfamethoxazole. However, in these cases periodic acid-Schiff positive macrophages can remain for years. Thus, in the absence of clinical deterioration, the presence of these structures is not indicative ofactive disease.

Inking cell blocks improves scanner detection for diagnosis in pathology.

Cell blocks may be hard to be totally automatically detected by the scanner (ADS), generating incomplete whole slide images (WSIs), with areas that are not scanned, leading to possible false negative diagnosis. The aim of this study is to test if inking the cell blocks helps increasing ADS. Test 1: 15 cell blocks were sectioned, one half inked black (1HB) and the other inked green (1HG). Each of the halves was individually processed to generate a WSI stained by the H&E. 1HBs and 1HGs had similar scanning time (median 59 s vs. 65 s, p = .126) and file sizes (median 382 Mb vs. 381 Mb, p = .567). The black ink interfered less in the observation (2.2% vs. 44.4%; p < .001) than in the green one. Test 2: 15 cell blocks were sectioned, one half inked black (2HB) and the other left unstained/null (2HN). Each of the halves was individually processed to generate three WSIs-one HE, one periodic-acid Schiff (PAS), and one immunostained by cytokeratin AE1&AE3 (CKAE1AE3). HE and PAS WSIs from both 2HN and 2HB groups were all totally ADS and had similar scanning times and file sizes. Concerning immunostaining with CKAE1AE3: ADS (46.7% vs. 93.3%; p = .014), median time for scanning (57 s vs. 83 s; p < .001) and file size (178 Mb vs. 338 Mb; p < .001) were reduced significantly in the 2HN group in comparison with the 2HB. Although increasing scanning time and file size, inking the cell blocks helps increasing ADS after immunostaining, improving the safety and efficiency of the digital pathology workflow.

Artificial intelligence-assisted cancer diagnosis improves the efficiency of pathologists in prostatic biopsies.

Paige Prostate is a clinical-grade artificial intelligence tool designed to assist the pathologist in detecting, grading, and quantifying prostate cancer. In this work, a cohort of 105 prostate core needle biopsies (CNBs) was evaluated through digital pathology. Then, we compared the diagnostic performance of four pathologists diagnosing prostatic CNB unaided and, in a second phase, assisted by Paige Prostate. In phase 1, pathologists had a diagnostic accuracy for prostate cancer of 95.00%, maintaining their performance in phase 2 (93.81%), with an intraobserver concordance rate between phases of 98.81%. In phase 2, pathologists reported atypical small acinar proliferation (ASAP) less often (about 30% less). Additionally, they requested significantly fewer immunohistochemistry (IHC) studies (about 20% less) and second opinions (about 40% less). The median time required for reading and reporting each slide was about 20% lower in phase 2, in both negative and cancer cases. Lastly, the average total agreement with the software performance was observed in about 70% of the cases, being significantly higher in negative cases (about 90%) than in cancer cases (about 30%). Most of the diagnostic discordances occurred in distinguishing negative cases with ASAP from small foci of well-differentiated (less than 1.5 mm) acinar adenocarcinoma. In conclusion, the synergic usage of Paige Prostate contributes to a significant decrease in IHC studies, second opinion requests, and time for reporting while maintaining highly accurate diagnostic standards.

Demonstrating the interference of tissue processing in the evaluation of tissue biomarkers: The case of PD-L1.

The immunohistochemical (IHC) expression of PD-L1 in cancer models is used as a predictive biomarker of response to immunotherapy. We aimed to evaluate the impact of the usage of 3 different tissue processors in the IHC expression of PD-L1 antibody clones: 22C3 and SP142. Three different topographies of samples (n = 73) were selected at the macroscopy room: 39 uterine leiomyomas, 17 placentas and 17 palatine tonsils. Three fragments were collected from each sample and were inked with a specific color that represented their separate processing in a different tissue processor (A, B or C). During embedding, the 3 fragments with distinct processing were ensemble in the same cassette for sectioning of 3 slides/each: hematoxylin-eosin, 22C3 PDL1 IHC staining and SP142 PD-L1 IHC staining, that were blindly observed by 2 pathologists under digital environment. All but one set of 3 fragments were considered adequate for observation even in the presence of artifacts associated with processing issues that were recorded as high as 50.7 % for processor C. The occurrence of background non-specific staining and the presence of false positive results appear to be unrelated with the PD-L1 clone or the type of tissue processing. 22C3 PD-L1 was more frequently considered adequate for evaluation than SP142 PD-L1 that, in 29.2 % of WSIs (after tissue processor C) were considered not adequate for observation due to lack of the typical pattern of expression. Similarly, the intensity of PD-L1 staining was significantly decreased in fragments processed by C (both PD-L1 clones) in tonsil and placenta specimens, and by A (both clones) in comparison with those processed by B. This study demonstrates the need to standardize the tissue processing in pathology to cope with the growing needs of precision medicine quantifications and the production of high-quality material necessary for computational pathology usage.

p40/PD-L1 and TTF1/PD-L1 Immunohistochemical Double Staining Contributes to Intraindividual Variability Associated With PD-L1 Staining Interpretation in Lung Cancer Samples.

The important developments achieved in recent years with a consequent paradigm shift in the treatment of non-small cell lung cancer (NSCLC), including the latest immune checkpoint inhibitors, have led to an increasing need to optimize the scarce material usually available in the diagnosis of these tumors. In this sense, this study intends to evaluate the performance of double immunohistochemistry (IHC) in comparison to simple IHC for programmed death-ligand 1 (PD-L1) evaluation with 22C3 clone for selection to therapy with pembrolizumab. For that, 38 histologic samples of NSCLC small biopsies sent to our laboratory were selected. Double IHC were performed with the doublets TTF1/PD-L1 and p40/PD-L1, after all the usual diagnostic routine and molecular study was performed. The slides were interpreted by 2 independent pathologists and the results obtained were compared with each other and with the results obtained at diagnosis. A perfect agreement was observed when comparing the immunoexpression of TTF1 and p40 in double IHC in relation to single IHC. Although the agreement was substantial in the analysis of the positive/negative PD-L1 IHC (81.6% to 92.1%; κ=0.610 to 0.829) and in the analysis of the 50% cut-off (86.8% to 89.5%; κ=0.704 to 0.759), it fell short of the expected and desirable agreement for a biomarker such as PD-L1, since this result will have a major role in the institution of a treatment. In conclusion, this small series does not allow us to recommend this methodology for the evaluation of the PD-L1 biomarker in double staining IHC with the 22C3 clone for therapy selection.

Digital Versus Optical Diagnosis of Follicular Patterned Thyroid Lesions.

OBJECTIVES: To study the concordance between pathologists in the diagnosis of follicular patterned thyroid lesions using both digital and conventional optical settings. MATERIAL AND METHODS: Five pathologists reviewed 50 hematoxylin and eosin-stained slides of follicular patterned thyroid lesions using both digital (the D-Sight 2.0 scanner and navigator viewer) and conventional optical instruments with washout interval time. RESULTS: The mean concordance rate with the ground truth (GT) was similar between conventional optical and digital observation (83.2 and 85.2%, respectively). The most frequent reason for diagnostic discordance with GT on both systems was the evaluation of nuclear features (69.1% for conventional optical observation and 59.4% for digital observation). The intraobserver diagnostic concordance mean was 86.8%. Time for digital observation (mean time per case = 2.9 ± 0.8 min) was higher than that for conventional optical observation (mean time per case = 2.0 ± 0.7 min). Interobserver correlation of measurements was higher in the digital observation than the conventional optical observation. CONCLUSION: Conventional optical and digital observation settings showed a comparable accuracy for the diagnosis of follicular patterned thyroid nodules, as well as substantial intraobserver agreement and a significant improvement in the reproducibility of the measurements that support the use of digital diagnosis in thyroid pathology. The origins underlying the variability of the diagnosis were the same in both conventional optical microscopy and digital pathology systems.

Digital Pathology Workflow Implementation at IPATIMUP.

The advantages of the digital methodology are well known. In this paper, we provide a detailed description of the process for the digital transformation of the pathology laboratory at IPATIMUP, the major modifications that operate throughout the processing pipeline, and the advantages of its implementation. The model of digital workflow implementation at IPATIMUP demonstrates that careful planning and adoption of simple measures related to time, space, and sample management can be adopted by any pathology laboratory to achieve higher quality and easy digital transformation.

Artificial Intelligence Improves the Accuracy in Histologic Classification of Breast Lesions.

OBJECTIVES: This study evaluated the usefulness of artificial intelligence (AI) algorithms as tools in improving the accuracy of histologic classification of breast tissue. METHODS: Overall, 100 microscopic photographs (test A) and 152 regions of interest in whole-slide images (test B) of breast tissue were classified into 4 classes: normal, benign, carcinoma in situ (CIS), and invasive carcinoma. The accuracy of 4 pathologists and 3 pathology residents were evaluated without and with the assistance of algorithms. RESULTS: In test A, algorithm A had accuracy of 0.87, with the lowest accuracy in the benign class (0.72). The observers had average accuracy of 0.80, and most clinically relevant discordances occurred in distinguishing benign from CIS (7.1% of classifications). With the assistance of algorithm A, the observers significantly increased their average accuracy to 0.88. In test B, algorithm B had accuracy of 0.49, with the lowest accuracy in the CIS class (0.06). The observers had average accuracy of 0.86, and most clinically relevant discordances occurred in distinguishing benign from CIS (6.3% of classifications). With the assistance of algorithm B, the observers maintained their average accuracy. CONCLUSIONS: AI tools can increase the classification accuracy of pathologists in the setting of breast lesions.

CD44v6 High Membranous Expression Is a Predictive Marker of Therapy Response in Gastric Cancer Patients.

In gastric cancer (GC), biomarkers that define prognosis and predict treatment response remain scarce. We hypothesized that the extent of CD44v6 membranous tumor expression could predict prognosis and therapy response in GC patients. Two GC surgical cohorts, from Portugal and South Korea (n = 964), were characterized for the extension of CD44v6 membranous immuno-expression, clinicopathological features, patient survival, and therapy response. The value of CD44v6 expression in predicting response to treatment and its impact on prognosis was determined. High CD44v6 expression was associated with invasive features (perineural invasion and depth of invasion) in both cohorts and with worse survival in the Portuguese GC cohort (HR 1.461; 95% confidence interval 1.002-2.131). Patients with high CD44v6 tumor expression benefited from conventional chemotherapy in addition to surgery (p < 0.05), particularly those with heterogeneous CD44v6-positive and -negative populations (CD44v6_3+) (p < 0.007 and p < 0.009). Our study is the first to identify CD44v6 high membranous expression as a potential predictive marker of response to conventional treatment, but it does not clarify CD44v6 prognostic value in GC. Importantly, our data support selection of GC patients with high CD44v6-expressing tumors for conventional chemotherapy in addition to surgery. These findings will allow better stratification of GC patients for treatment, potentially improving their overall survival.

Pleomorphic Adenoma of the Eyelid with Apocrine Gland Origin; an Atypical Location.

PURPOSE: To describe the clinical presentation and treatment of a patient with a cutaneous pleomorphic adenoma of the eyelid. CASE REPORT: A 73-year-old male patient presented with a nodular mass on the lateral third of his right upper eyelid, which had slowly enlarged over 10 years. Radiologic features were of an extra-conical mass, with no invasion of adjacent structures. An excisional biopsy of the lesion was performed. The histopathological examination revealed a biphasic tumor, composed of tubules with a double layer of epithelial cells arranged in a chondromyxoid stroma. The inner epithelial cells were positive for pancytokeratins AE1/AE3 and carcinoembryonic antigen. The outer epithelial cells and stromal component expressed vimentin and S100 protein. These pathologic findings were consistent with a palpebral pleomorphic adenoma, with an apocrine gland origin. CONCLUSION: Pleomorphic adenomas of the skin are rare tumors, and even less frequent as tumors of the ocular adnexa. These lesions should be considered in the differential diagnosis of palpebral nodular masses, and complete excision should be attempted due to the possibility of malignant transformation.

Impact of splenic artery ligation after major hepatectomy on liver function, regeneration and viability.

It was reported that prevention of acute portal overpressure in small-for-size livers by inflow modulation results in a better postoperative outcome. The aim is to investigate the impact of portal blood flow reduction by splenic artery ligation after major hepatectomy in a murine model. Forty-eight rats were subjected to an 85% hepatectomy or 85% hepatectomy and splenic artery ligation. Both groups were evaluated at 24, 48, 72 and 120 post-operative hours: liver function, regeneration and viability. All methods and experiments were carried out in accordance with Coimbra University guidelines. Splenic artery ligation produces viability increase after 24 h, induces a relative decrease in oxidative stress during the first 48 hours, allows antioxidant capacity increment after 24 h, which is reflected in a decrease of half-time normalized liver curve at 48 h and at 72 h and in an increase of mitotic index between 48 h and 72 h. Splenic artery ligation combined with 85% hepatectomy in a murine model, allows portal inflow modulation, promoting an increase in hepatocellular viability and regeneration, without impairing the function, probably by inducing a less marked elevation of oxidative stress at first 48 hours.

Isolated tuberculous lymphadenitis with tracheal involvement in an elderly patient.

Mediastinal tuberculosis without lung involvement is an uncommon finding in an immunocompetent adult. We report the case of an 80-year-old male smoker who presented with dyspnea and stridor. He was found to have a mass in the middle mediastinum which also involved the anterior wall and 50% lumen if of the lower trachea. Histology and mycobacterial cultures of the lesion led to the diagnosis of mediastinal tuberculosis. Antituberculous treatment led to complete resolution of airway symptoms and reduction in the size of the mediastinal mass.

Primary cutaneous CD30-positive anaplastic large-cell lymphoma of the external auditory canal.

Primary cutaneous T-cell lymphoma is rare. Cutaneous lymphoma is defined as primary when there is an absence of nodal or systemic disease during the first 6 months following diagnosis. We report what we believe to be the first documented case of a primary cutaneous CD30-positive anaplastic large-cell lymphoma of the external auditory canal. The patient was an elderly woman who presented with progressively worsening right otalgia and hypoacusis. Otoscopy revealed an erythematic, ulcerative, nonbleeding, localized lesion in the anterosuperior area of the external auditory canal. The patient underwent an excisional biopsy, and after the diagnosis was established, she underwent 22 sessions of radiotherapy. During follow-up, she exhibited no evidence of recurrence.