Utility of TRPS1 in Malignant Effusion Cytology.

INTRODUCTION: Identifying metastatic breast carcinoma (mBC) in malignant effusion cytology (MEC) specimens is critical, as this will determine the patient's prognosis and therapeutic management. Overlapping cytomorphologic features of breast carcinoma (BC) with other neoplastic entities makes the use of sensitive and specific markers highly desirable. Recent studies have reported trichorhinophalangeal syndrome type 1 (TRPS1) as a sensitive and specific marker for primary BC and mBC. We aimed to investigate TRPS1 expression in MEC of mBC and its most common diagnostic mimickers. MATERIALS AND METHODS: A retrospective search from the pathology archives identified 82 MEC. TRPS1 expression in mBC was analyzed, and the results were compared to those in metastatic carcinoma of Müllerian origin (mMC) and metastatic pulmonary adenocarcinoma (mPAC). TRPS1 immunoperoxidase was performed on cytospin or cell block preparations, and p < 0.05 was considered significant. RESULTS: Nuclear expression for TRPS1 was evaluated and scored as positive (≥1% of tumor cells) or negative. Nuclear TRPS1 expression was seen in 100% (30/30) mBC, 72% (18/25) mMC, and 7% (2/27) mPAC. This resulted in sensitivity, specificity, positive predictive value, and negative predictive values of 100%, 61%, 60%, and 100%, respectively. CONCLUSION: TRPS1 is a sensitive marker for mBC and can be reliably performed on cytology specimens. TRPS1 expression was also identified in a significant proportion of mMC, creating a potential diagnostic pitfall. Therefore, caution should be exercised when evaluating MEC of mBC with TRPS1. Consequently, a combination of immunoperoxidase panels should be employed in this setting.

Application of the Milan System for Reporting Salivary Gland Cytopathology: A Single Institutional Experience of 354 Cases with Cytologic-Histologic Correlation.

BACKGROUND: Evaluation of salivary gland lesions is routinely done preoperatively by fine-needle aspiration cytology (FNAC). The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC), with diagnostic categories I-VI, has been recommended to standardize the reporting of salivary gland lesions by FNAC. We aimed to reclassify archival salivary gland FNAC samples using MSRSGC, correlate the samples with surgical resections, and calculate the risk of malignancy (ROM) for each category. METHODS: A total of 354 salivary gland FNAC samples (2013-2018) were reviewed. All FNAC results were retrospectively classified according to the MSRSGC. All cases had surgical follow-up. Histology was used to calculate the ROM, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy. RESULTS: The 354 aspirates were classified as: nondiagnostic (ND) 17.0% (60), non-neoplastic (NN) 1.4% (5), atypia of undetermined significance (AUS) 11.0% (39), benign neoplasm (BN) 49.4% (175), salivary gland neoplasms of unknown malignant potential (SUMP) 10.7% (38), suspicious for malignancy (SM) 3.4% (12), and malignant (M) 7.1% (25). The ROM was as follows: ND 22%, NN 20%, AUS 15%, BN 2%, SUMP 53%, SM 75%, and M 96%. The diagnostic accuracy for separating benign versus malignant neoplasms was 96%. Cytologic-histologic correlation yielded a false-negative rate of 2.7%, false-positive rate of 10.5%, PPV of 89%, NPV of 97%, sensitivity of 87%, and specificity of 98%. CONCLUSION: MSRSGC helps standardize cytology reports, provides useful information for appropriate clinical management, and ensures the best care of patients with salivary gland lesions.

Low-Grade Ductal Carcinoma In Situ.

OBJECTIVES: We aimed to determine the interobserver reproducibility in diagnosing low-grade ductal carcinoma in situ (DCIS). We also aimed to compare the interobserver variability using a proposed two-tiered grading system as opposed to the current three-tiered system. METHODS: Three expert breast pathologists and one junior pathologist identified low-grade DCIS from a set of 300 DCIS slides. Months later, participants were asked to grade the 300 cases using the standard three-tiered system. RESULTS: Using the two-tiered system, interobserver agreement among breast pathologists was considered moderate (κ = 0.575). The agreement was similar (κ = 0.532) with the junior pathologist included. Using the three-tiered system, pathologists' agreement was poor (κ = 0.235). CONCLUSIONS: Pathologists' reproducibility on diagnosing low-grade DCIS showed moderate agreement. Experience does not seem to influence reproducibility. Our proposed two-tiered system of low vs nonlow grade, where the intermediate grade is grouped in the nonlow category has shown improved concordance.

The Reversal of Immune Exclusion Mediated by Tadalafil and an Anti-tumor Vaccine Also Induces PDL1 Upregulation in Recurrent Head and Neck Squamous Cell Carcinoma: Interim Analysis of a Phase I Clinical Trial.

Myeloid Derived suppressor cells (MDSCs) play a key role in the progression and recurrence of human malignancies and in restraining the efficacy of adjuvant therapies. We have previously shown that Tadalafil lowers MDSCs and regulatory T cells (Treg) in the blood and in the tumor, primes a tumor specific immune response, and increases the number of activated intratumoral CD8+T cells in patients with primary Head and Neck Squamous Cell Carcinoma (HNSCC). However, despite these important immune modulatory actions, to date no clinically significant effects have been reported following PDE5 inhibition. Here we report for the first time interim results of our ongoing phase I clinical trial (NCT02544880) in patients with recurrent HNSCC to evaluate the safety of and immunological effects of combining Tadalafil with the antitumor vaccine composed of Mucin1 (MUC1) and polyICLC. The combined treatment of Tadalafil and MUC1/polyICLC vaccine was well-tolerated with no serious adverse events or treatment limiting toxicities. Immunologically, this trial also confirms the positive immunomodulation of Tadalafil in patients with recurrent HNSCC and suggests an adjuvant effect of the anti-tumor vaccine MUC1/polyICLC. Additionally, image cytometry analysis of scanned tumors indicates that the PDE5 inhibitor Tadalafil in conjunction with the MUC1/polyICLC vaccine effectively reduces the number of PDL1+macrophages present at the tumor edge, and increases the number of activated tumor infiltrating T cells, suggesting reversion of immune exclusion. However, this analysis shows also that CD163 negative cells within the tumor upregulate PDL1 after treatment, suggesting the instauration of additional mechanisms of immune evasion. In summary, our data confirm the safety and immunologic potential of PDE5 inhibition in HNSCC but also point to PDL1 as additional mechanism of tumor evasion. This supports the rationale for combining checkpoint and PDE5 inhibitors for the treatment of human malignancies.

Hemangioma of a Male Breast: Case Report and Review of the Literature.

BACKGROUND Male breast hemangioma is a rare benign neoplasm that is usually excised for definitive diagnosis. CASE REPORT In our case report, we present a male octogenarian with multiple comorbidities who presented with a large palpable mass in his right breast. The diagnostic imaging studies were suggestive of a benign tumor, with a BI-RADS (Breast Imaging Reporting and Data System) score of 3. Subsequent core needle biopsies were diagnostic of benign hemangioma. The patient was managed with observation due to his comorbidities. Benign vascular tumors in the male breast are exceptionally rare, and in our review of the literature we found only 14 previously published cases. Historically, fine needle aspiration has been found to be unreliable in making a definitive diagnosis and surgical excision has been the standard treatment. CONCLUSIONS Recent studies and our case report indicate that core needle biopsy may be a reliable diagnostic tool and observation is a possible option for hemangiomas in male patients who cannot undergo surgery.

Recurrent EML4-NTRK3 fusions in infantile fibrosarcoma and congenital mesoblastic nephroma suggest a revised testing strategy.

Infantile fibrosarcoma and congenital mesoblastic nephroma are tumors of infancy traditionally associated with the ETV6-NTRK3 gene fusion. However, a number of case reports have identified variant fusions in these tumors. In order to assess the frequency of variant NTRK3 fusions, and in particular whether the recently identified EML4-NTRK3 fusion is recurrent, 63 archival cases of infantile fibrosarcoma, congenital mesoblastic nephroma, mammary analog secretory carcinoma and secretory breast carcinoma (tumor types that are known to carry recurrent ETV6-NTRK3 fusions) were tested with NTRK3 break-apart FISH, EML4-NTRK3 dual fusion FISH, and targeted RNA sequencing. The EML4-NTRK3 fusion was identified in two cases of infantile fibrosarcoma (one of which was previously described), and in one case of congenital mesoblastic nephroma, demonstrating that the EML4-NTRK3 fusion is a recurrent genetic event in these related tumors. The growing spectrum of gene fusions associated with infantile fibrosarcoma and congenital mesoblastic nephroma along with the recent availability of targeted therapies directed toward inhibition of NTRK signaling argue for alternate testing strategies beyond ETV6 break-apart FISH. The use of either NTRK3 FISH or next-generation sequencing will expand the number of cases in which an oncogenic fusion is identified and facilitate optimal diagnosis and treatment for patients.

A Comprehensive Review of Oxidative Stress as the Underlying Mechanism in Atherosclerosis and the Inefficiency of Antioxidants to Revert this Process.

BACKGROUND: Cardiovascular diseases account for the highest mortality rate in the United States. The major underlying mechanism driving the onset and maintenance of cardiovascular diseases is atherosclerosis. Atherosclerosis is a chronic disease affecting large and medium-size arteries; it proceeds through four main stages along different decades of life, beginning at birth. Atherosclerosis is a consequence of oxidative stress, where homeostasis between endogenous antioxidants and reactive oxygen species is disrupted. Failure of intrinsic antioxidants and prophylactic antioxidant supplements to prevent atherosclerosis formation is an ongoing area of research in the race to avert, manage and cure atherosclerosis. METHODS: The purpose of this work was to elucidate the actions of reactive oxygen species and oxidative stress on the formation of atherosclerosis as well as the different stages of atherosclerosis and the different mechanisms to prevent it. Through an extensive review of scientific literature, this paper correlates cell damage caused by oxidative stress to atheromatous plaque formation, as well as an in-depth analysis of high-density lipoproteins and enzymatic and non-enzymatic antioxidant role on atherosclerosis prevention. The antioxidant mechanism is overwhelmed by atherosclerotic processes and fails to be the ideal treatment of atherosclerosis. There is no scientific data that correlates prophylactic and non-prophylactic antioxidant treatment to a decrease in mortality or comorbidities pertaining to atherosclerosis. This is thought to be due to lack of consensus of optimal therapeutic doses, lack of reliable markers indicating which patient is to benefit from therapy and the chemical complexity of antioxidants in vivo. Current treatments for atherosclerosis include HMG-CoA reductase inhibitors which directly target low-density lipoproteins to tackle atherosclerotic plaque formation. CONCLUSION: HMG-CoA reductase inhibitors are not enough for the treatment of atherosclerosis given the complexity of the disease which has immune, musculoskeletal, genetic and hematologic aspects besides the involvement of lipids and lipoproteins. Therefore, other pharmacologic targets such as the PCSK9 enzyme and NFK- ß should be researched in depth as possible treatments for atherosclerosis.

HPV-related Multiphenotypic Sinonasal Carcinoma: An Expanded Series of 49 Cases of the Tumor Formerly Known as HPV-related Carcinoma With Adenoid Cystic Carcinoma-like Features.

Human papillomavirus (HPV)-related multiphenotypic sinonasal carcinoma (HMSC), originally known as HPV-related carcinoma with adenoid cystic carcinoma-like features, is a peculiar neoplasm that is restricted to the sinonasal tract, exhibits features of both a surface-derived and salivary gland carcinoma (particularly adenoid cystic carcinoma), and is associated with high-risk HPV. Given the limited number of published cases, the full clinicopathologic spectrum of this neoplasm is unclear. Here, we present an updated experience of 49 cases. All cases of HMSC were obtained from the authors' files. Immunohistochemistry for p16, c-kit, and myoepithelial cell markers (S100, actin, calponin, p63, and/or p40) was performed along with RNA in situ hybridization for HPV (type 33-specific as well as a high-risk cocktail). Fluorescence in situ hybridization studies for fusions of MYB, NFIB, and MYBL1 was performed on a subset of cases. Clinical follow-up was obtained from medical records. A total of 49 cases of HMSC were collected. Twenty-eight (57%) were from women and 18 (43%) from men, ranging in age from 28 to 90 years (mean, 54 y). Of 40 cases with detailed staging information, 43% of HMSCs presented with a high T-stage (T3 or T4). Histologically, most grew predominantly as solid nests of basaloid cells exhibiting high mitotic rates and frequent necrosis, with histologic and immunohistochemical evidence of myoepithelial differentiation. Most cases also demonstrated foci of cribriform and/or tubular growth, along with an inconspicuous population of ducts. Thirty-four (69%) cases demonstrated an unusual pattern of surface involvement where markedly atypical squamous cells colonized tracts of the sinonasal mucosa. Less consistent histologic features included squamous differentiation within the invasive tumor (n=6), sarcomatoid transformation (n=5) including overt chondroid differentiation (n=3), and prominent epithelial-myoepithelial carcinoma-like growth (n=3). All cases were positive for p16 by immunostaining and HPV by RNA in situ hybridization. Thirty-three (67%) were positive for HPV 33. No cases tested for MYB, MYBL1, or NFIB gene fusions were positive. In the 38 cases with follow-up data, (mean follow-up, 42 mo) 14 recurred locally and 2 metastasized (lung, finger). There were no regional lymph node metastases, and no tumor-related deaths. HMSC is a distinct sinonasal neoplasm characterized by myoepithelial differentiation, frequent surface epithelial involvement, and the presence of high-risk HPV (especially type 33). Although it classically exhibits a cribriforming pattern that closely resembles adenoid cystic carcinoma, our expanded series highlights a histologic spectrum that is much broader than previously recognized, warranting a change in terminology. HMSC usually presents as a large and destructive sinonasal mass with high-grade histologic features, but it paradoxically behaves in a relatively indolent manner, underscoring the importance of distinguishing HMSC from true adenoid cystic carcinoma, squamous cell carcinoma, and other histologic mimickers.

Diagnostic pitfalls of infarcted Warthin tumor in frozen section evaluation.

Warthin tumor (WT) is the second most common benign salivary gland neoplasm and has characteristic cytologic and histologic findings. Fine-needle aspiration is a common and useful preoperative diagnostic technique, which sometimes leads to ischemic injury resulting in the infarction of these lesions. Infarcted WT may demonstrate variable gross and histologic alterations that may render the diagnosis challenging, particularly during intraoperative frozen section evaluation. In this study, we collected 11 resection specimens from 9 patients with infarcted WT. Seven patients were men and 2 were women, ranging from 49 to 85 years (mean, 69). All the patients had fine-needle aspiration before the resection. Macroscopically, the tumors were tan-white and contained soft, yellow, exudative material. The histologic findings were variable and included necrosis, ghosts of papillae, squamous metaplasia, cholesterol clefts, foamy macrophages, multinucleated giant cell reaction, necrotizing granulomas, and fibrosis. Each case predominantly demonstrated 1 or 2 of these histomorphologic features. In the permanent sections, additional sampling revealed foci of residual viable WT in 8 cases. Three cases were completely infarcted; however, they all had ghost-like papillae in which the architecture of WT was evident. Infarcted WT may present a diagnostic challenge during intraoperative frozen section evaluation. Associated morphologic alterations may preclude a definitive diagnosis of WT and may mimic malignancy. Awareness of the gross and microscopic features associated with infarcted WT is important, particularly for accurate frozen section evaluation of these salivary gland tumors.

Paget's disease of the nipple.

Paget's disease of the breast is a disorder of the nipple-areola complex that, while rare, is often associated with an underlying carcinoma. It is characterized by eczematoid changes of the nipple. Two theories have been proposed to explain the pathogenesis of Paget's disease. The Epidermotropic, which is the most accepted theory, suggests that Paget's cells originate from ductal cancer cells that had migrated from the underlying breast parenchyma. It is supported by the predominance of breast cancer markers found in Paget's disease. This article provides an overview of Paget's disease of the breast with special attention to immunohistochemistry and raises the question of new therapeutic approaches.

FOXP3 subcellular localization predicts recurrence in oral squamous cell carcinoma.

Forkhead box protein P3 (FOXP3) expression in tumor infiltrating CD4(+)T cells is generally associated with an intrinsic capacity to suppress tumor immunity. Based on this notion, different studies have evaluated the prognostic value of this maker in cancer but contradictory results have been found. Indeed, even within the same cancer population, the presence of CD4(+)FOXP3(+)T cells has been associated,with either a poor or a good prognosis, or no correlation has beenfound. Here, we demonstrate,in patients with oral squamous cell carcinoma (OSCC), that what really represents a prognostic parameter is not the overall expression of FOXP3 but its intracellular localization.While overallFOXP3 expression in tumor infiltrating CD4(+)T cells does not correlate with tumor recurrence, its intracellular localization within the CD4 cells does: nuclear FOXP3 (nFOXP3) is associated with tumor recurrence within 3 years, while cytoplasmicFOXP3 (cFOXP3) is associated with a lower likelihood of recurrence. Thus, we propose elevated levels of the cFOXP3/nFOXP3 ratio within tumor infiltrating CD4(+) T cells as a predictor of OSCC recurrence.

GREB1 functions as a growth promoter and is modulated by IL6/STAT3 in breast cancer.

BACKGROUND: Growth Regulation by Estrogen in Breast cancer (GREB1) was an estrogen receptor (ER) target gene, and GREB1 expression inversely correlated with HER2 status, possibly as a surrogate marker for ER status and a predictor for tamoxifen resistance in breast cancer patients. In the present study, we examine the function and regulation of GREB1 in breast cancer, with the goal to develop GREB1 as a biomarker in breast cancer with de novo and acquired tamoxifen resistance. METHODS: We overexpressed GREB1 using adenovirus containing the full length GREB1 cDNA (Ad-GREB1) in breast cancer cell lines. The soft agar assay was used as a measure of anchorage independent growth. The effects of GREB1 on cell proliferation in MCF-7 cells transduced with Ad-GREB1 were also measured by the me olic activity using AlamarBlue assay. We tested whether there was interaction between STAT3 and ER, which could repress GREB1 expression by immunoprecipitation assay. The effects of IL-6/JAK/STAT3 cascade activation on estrogen-induced GREB1 promoter activity were determined by luciferase assay and those on gene expression were measured by real time reverse transcription polymerase chain reaction (qRT-PCR). RESULTS: We found that the ability of breast cancer cells to grow in soft agar is enhanced following GREB1 transfection. In MCF-7 cells transduced with Ad-GREB1 or transfected with siRNA GREB1, the metabolic activity was increased or completely abolished, suggesting that GREB1 may function as a growth promoter in breast cancer. E2 treatment increased GREB1 promoter luciferase activity. IL-6 inhibited E2-induced GREB1 transcription activity and GREB1 mRNA expression. Constitutively expressing active STAT3 construct (STAT3-C) dramatically decreased GREB1 transcription. CONCLUSIONS: These data indicate that overexpression of GREB1 promotes cell proliferation and increases the clonogenic ability in breast cancer cells. Moreover, Il6/STAT3 modulates estrogen-induced GREB1 transcriptional activity in breast cancer cells.

Evaluation of immunohistochemical fine sectioning for sentinel lymph node biopsy in oral squamous cell carcinoma.

OBJECTIVE: To determine the level of sentinel lymph node sectioning necessary to accurately detect nodal micrometastasis. STUDY DESIGN: Cross-sectional. SETTING: Tertiary care university medical center. SUBJECTS AND METHODS: Fine sections of oral squamous cell carcinoma sentinel lymph nodes previously sectioned at 2-mm intervals in a prospective clinical trial were reexamined. The results yielded from prior hematoxylin and eosin and immunohistochemical staining were compared with results following exhaustive serial sectioning at 150-µm intervals using identical staining methods. These experimental findings were compared with pathologic results of immediate completion selective neck dissection, previously recorded prospectively. RESULTS: Reexamination of 35 sentinel nodes at 150-µm intervals has not revealed any missed micrometastatic disease at 2-mm intervals used initially. Both comparisons of 150-µm sectioning analysis to the original 2-mm section samples and to the neck dissection pathology reports demonstrate a 100% negative predictive value. CONCLUSION: These data suggest that sentinel lymph node sectioning at 2-mm intervals for oral carcinoma using hematoxylin and eosin staining and then immunohistochemical analysis maximizes efficiency, accuracy, and expenditure for the detection of micrometastasis.

Fine-needle aspiration (FNA) and pleural fluid cytology diagnosis of benign metastasizing pleomorphic adenoma of the parotid gland in the lung: a case report and review of literature.

Lesions that contain abundant benign myoepithelial cells, including pleomorphic adenomas of salivary gland origin, may present a diagnostic challenge in fine-needle aspiration (FNA) specimens. Benign metastasizing pleomorphic adenoma is a rare neoplasm, in which the benign appearing pleomorphic adenoma, without any histological evidence of malignancy, metastasizes to distant sites including lung. In the absence of clinical history of a pre-existing myoepithelial neoplasm, the presence of myoepithelial cells in the lung or any other organs besides salivary glands may create diagnostic difficulty. Here we present the cytologic findings of such a metastatic tumor found in the lung FNA and pleural fluid specimens from a 64-year-old woman, with a history of local recurrent salivary gland pleomorphic adenomas, who presented with multiple bilateral pulmonary nodules and pleural effusion. The diagnosis of benign metastasizing pleomorphic adenoma was made based on clinical information and cytomorphology, and confirmed by immunocytochemistry.

Metastatic renal cell carcinoma to the ovary: a case report and discussion of differential diagnoses.

The clinical presentation of renal cell carcinoma in the ovary is rare and may closely resemble that of other ovarian clear cell tumors. Metastatic renal cell carcinoma was diagnosed in a patient who presented with a right adnexal mass and no other significant past medical history. The gross appearance of the tumor suggested a primary ovarian neoplasm. However, microscopic and immunohistochemical analysis revealed involvement of both ovaries by a clear cell tumor with features of renal cell carcinoma. A renal mass was subsequently discovered. We discuss the clinical, histologic, and immunohistochemical features of this tumor and the features of other clear cell neoplasms in the differential diagnosis.