Lifting agent granuloma presenting as a colonic mass mimicking cancer: a report of three cases.

Background: The Food and Drug Administration (FDA)-approved submucosal injection of lifting agents such as ORISE® has become a widespread, routine and standard practice in endoscopic mucosal resection and endoscopic submucosal dissection of gastrointestinal lesions. Lifting agent granulomas result from transformation of injected material into a mass-forming amorphous hyaline-like material eliciting a strong foreign body giant cell reaction. This report of three cases shows how lifting agent granulomas can act as potential clinical and gross mimickers of invasive adenocarcinoma. Cases Description: Three cases were identified in a six-month span based on the histological presence of a lifting agent granuloma in a colonic/colorectal resection specimen with associated clinical, imaging and gross concern for invasive malignancy. Each case resulted in an escalation of clinical and surgical management due to the suspicion of an unresectable neoplastic process that was at least partially involved by an exuberant granulomatous reaction due to the utilization of a lifting agent. Colonic transmural involvement and sub-serosal vascular infiltration by the granulomas are described. Conclusions: Lifting agent granulomas have become a routine endoscopic technique to help achieve full resection of flat/sessile colorectal polyps and early-stage cancers. This report confirms that these granulomas exhibit colonic transmural involvement. Sub-serosal blood vessel involvement is reported for the first time. It is important to recognize the unique characteristics of these new synthetic lifting agents. Their propensity to develop a mass-forming granulomatous reaction has the potential to mimic invasive adenocarcinoma clinically, radiologically and pathologically. This can significantly impact patient care and management both clinically and surgically.

Anatomy of a Cyberattack: Part 4: Quality Assurance and Error Reduction, Billing and Compliance, Transition to Uptime.

OBJECTIVES: Our institution was the victim of a cyberattack that necessitated use of manual laboratory systems for more than 25 days. These manual processes had to be created not only to enable us to process our case volume without bottlenecks but also to maintain patient safety and allow for billing. METHODS: Our laboratory needed to create a safe reporting process to ensure ongoing patient safety and error reduction during the downtime. Additionally, we needed to ensure the ability to bill for performed tests in some areas of the lab and maintain compliance with regulatory policies. RESULTS: Amendment rates in our system were higher than before the attack, but no patient harm was observed. Intraoperative assessments declined, but high-acuity cases continued with a discrepancy rate comparable with the normal state. Many hours and resources (human and otherwise) were necessary to reconcile the work done to bill for services, but we were able to capture revenue through careful planning. CONCLUSIONS: This article records the challenges we faced and the successes we achieved in maintaining compliance and a low error rate in the face of manual processes, the steps necessary to bring the cases into the newly restored electronic health record, and how we billed for the services we rendered.

Gynecologic melanomas: A clinicopathologic and molecular analysis.

OBJECTIVE: Melanoma originating from gynecologic sites (MOGS), including the vulva, vagina, and cervix, is a rare and aggressive form of melanoma with poor long-term clinical outcome. The clinicopathologic features of vulvar and non-vulvar tumors remain relatively understudied, and in contrast to cutaneous melanomas at non-sun-exposed sites, MOGS typically do not harbor BRAF mutations. Thus, we sought to analyze the clinicopathologic and molecular features of MOGS. METHODS: A large retrospective cohort of patients with MOGS (n=59) at a single large academic institution over a 28-year period was identified. Associations among clinicopathologic characteristics were assessed via standard statistical approaches, and clinical outcome was examined using Cox regression analysis. Sanger sequencing was utilized to identify mutations in hotspot regions of BRAF, KIT, NRAS, and CTNNB1. RESULTS: Tumors involving the vagina and/or cervix (non-vulvar) are significantly associated with high-risk clinicopathologic features, including increased tumor thickness, ulceration, positive resection margins, lymph node metastasis, and poor long-term clinical outcome (with increased risk of death due to disease). The aggressive clinical behavior of non-vulvar tumors is independent of advanced clinical stage and lymph node metastasis in multivariate analysis. Targeted molecular analysis confirms an overall low rate of oncogenic mutations in our MOGS cohort, although KIT mutations (particularly in exon 11) are relatively enriched. CONCLUSIONS: Overall, our results show that non-vulvar MOGS are aggressive tumors with poor long-term clinical outcome and indicate that few targeted therapeutic options are currently available to patients with MOGS.

The effectiveness of acetic acid wash protocol and the interpretation patterns of blood contaminated cervical cytology ThinPrep(®) specimens.

BACKGROUND: ThinPrep(®) (TP) cervical cytology, as a liquid-based method, has many benefits but also a relatively high unsatisfactory rate due to debris/lubricant contamination and the presence of blood. These contaminants clog the TP filter and prevent the deposition of adequate diagnostic cells on the slide. An acetic acid wash (AAW) protocol is often used to lyse red blood cells, before preparing the TP slides. DESIGN: From 23,291 TP cervical cytology specimens over a 4-month period, 2739 underwent AAW protocol due to initial unsatisfactory smear (UNS) with scant cellularity due to blood or being grossly bloody. Randomly selected 2739 cervical cytology specimens which did not undergo AAW from the same time period formed the control (non-AAW) group. Cytopathologic interpretations of AAW and non-AAW groups were compared using the Chi-square test. RESULTS: About 94.2% of the 2739 cases which underwent AAW were subsequently satisfactory for evaluation with interpretations of atypical squamous cells of undetermined significance (ASCUS) 4.9% (135), low-grade squamous intraepithelial lesions (LSIL) 3.7% (102), and high-grade squamous intraepithelial lesions (HSIL) 1% (28). From the 2739 control cases, 96.3% were satisfactory with ASCUS 5.5% (151), LSIL 5.1% (139), and HSIL 0.7% (19). The prevalence of ASCUS interpretations was similar (P = 0.33). Although there were 32% more HSIL interpretations in the AAW group (28 in AAW vs. 19 in non-AAW), the difference was statistically insignificant (P = 0.18). AAW category; however, had significantly fewer LSIL interpretations (P = 0.02). The percentage of UNS cases remained higher in the AAW group with statistical significance (P < 0.01). CONCLUSIONS: While AAW had a significantly higher percent of UNS interpretations, the protocol was effective in rescuing 94.2% of specimens which otherwise may have been reported unsatisfactory. This improved patient care by avoiding a repeat test. The prevalence of ASCUS and HSIL interpretations between AAW and non-AAW groups were comparable. Though not statistically significant, HSIL interpretations were relatively higher in the AAW group. LSIL interpretations showed lower prevalence in AAW group.

Core Needle Biopsy Wash Optimization: Enabling Specimen Integrity for both Cytological and Histological Evaluation.

BACKGROUND: The recovery of cells after washing core needle biopsies represents an under-utilized approach to extend the diagnostic capacity of these diminutive specimens. Recovery of these cells can be dedicated for molecular studies so that the biopsy itself can be used apropos for its intended purpose, diagnosis. Non-enzymatic and enzymatic reagents have the potential to increase the number of cells dissociating from the tissue core, but can also negatively impact the quality of the tissue itself. MATERIALS AND METHODS: Three different means (phosphate-buffered saline, a non-enzymatic and an enzymatic solution) were used to wash core needle biopsies. The washed cells were recovered by traditional preparatory methods and evaluated for cellularity and cytomorphology. The post-washed cores were processed by formalin fixation, paraffin embedding and evaluated for integrity and morphological quality. RESULTS: The enzymatic solution damaged both the cytological and tissue specimens, while the saline and non-enzymatic process allowed for the comparable recovery of cells and tissue for evaluation. CONCLUSION: Adequate numbers of cells are dissociated from the tissue core when needle biopsies are washed. The recovery and preservation of cells and tissue for morphological interpretation was optimal when solutions devoid of enzymes were used for washing.

Authors attain comparable or slightly higher rates of citation publishing in an open access journal (CytoJournal) compared to traditional cytopathology journals - A five year (2007-2011) experience.

BACKGROUND: The era of Open Access (OA) publication, a platform which serves to better disseminate scientific knowledge, is upon us, as more OA journals are in existence than ever before. The idea that peer-reviewed OA publication leads to higher rates of citation has been put forth and shown to be true in several publications. This is a significant benefit to authors and is in addition to another relatively less obvious but highly critical component of the OA charter, i.e. retention of the copyright by the authors in the public domain. In this study, we analyzed the citation rates of OA and traditional non-OA publications specifically for authors in the field of cytopathology. DESIGN: We compared the citation patterns for authors who had published in both OA and traditional non-OA peer-reviewed, scientific, cytopathology journals. Citations in an OA publication (CytoJournal) were analyzed comparatively with traditional non-OA cytopathology journals (Acta Cytologica, Cancer Cytopathology, Cytopathology, and Diagnostic Cytopathology) using the data from web of science citation analysis site (based on which the impact factors (IF) are calculated). After comparing citations per publication, as well as a time adjusted citation quotient (which takes into account the time since publication), we also analyzed the statistics after excluding the data for meeting abstracts. RESULTS: Total 28 authors published 314 publications as articles and meeting abstracts (25 authors after excluding the abstracts). The rate of citation and time adjusted citation quotient were higher for OA in the group where abstracts were included (P < 0.05 for both). The rates were also slightly higher for OA than non-OA when the meeting abstracts were excluded, but the difference was statistically insignificant (P = 0.57 and P = 0.45). CONCLUSION: We observed that for the same author, the publications in the OA journal attained a higher rate of citation than the publications in the traditional non-OA journals in the field of cytopathology over a 5 year period (2007-2011). However, this increase was statistically insignificant if the meeting abstracts were excluded from the analysis. Overall, the rates of citation for OA and non-OA were slightly higher to comparable.