Personalizable AI platform for universal access to research and diagnosis in digital pathology.

BACKGROUND AND MOTIVATION: Digital pathology has been evolving over the last years, proposing significant workflow advantages that have fostered its adoption in professional environments. Patient clinical and image data are readily available in remote data banks that can be consumed efficiently over standard communication technologies. The appearance of new imaging techniques and advanced artificial intelligence algorithms has significantly reduced the burden on medical professionals by speeding up the screening process. Despite these advancements, the usage of digital pathology in professional environments has been slowed down by poor interoperability between services resulting from a lack of standard interfaces and integrative solutions. This work addresses this issue by proposing a cloud-based digital pathology platform built on standard and open interfaces. METHODS: The work proposes and describes a vendor-neutral platform that provides interfaces for managing digital slides, and medical reports, and integrating digital image analysis services compatible with existing standards. The solution integrates the open-source plugin-based Dicoogle PACS for interoperability and extensibility, which grants the proposed solution great feature customization. RESULTS: The solution was developed in collaboration with iPATH research project partners, including the validation by medical pathologists. The result is a pure Web collaborative framework that supports both research and production environments. A total of 566 digital slides from different pathologies were successfully uploaded to the platform. Using the integration interfaces, a mitosis detection algorithm was successfully installed into the platform, and it was trained with 2400 annotations collected from breast carcinoma images. CONCLUSION: Interoperability is a key factor when discussing digital pathology solutions, as it facilitates their integration into existing institutions' information systems. Moreover, it improves data sharing and integration of third-party services such as image analysis services, which have become relevant in today's digital pathology workflow. The proposed solution fully embraces the DICOM standard for digital pathology, presenting an interoperable cloud-based solution that provides great feature customization thanks to its extensible architecture.

Intentional Replantation as a Starting Approach for a Multidisciplinary Treatment of a Mandibular Second Molar: A Case Report.

Intentional replantation (IR) may offer a solution for persistent periapical lesions associated with endodontically treated teeth. A 35-year-old male patient presented with pain associated with the left mandibular second molar and hypoesthesia. Upon clinical examination, increased probing pocket depth in the mid-buccal surface was detected. Cone beam computed tomography revealed a previous non-surgical root canal treatment, with root canal filling material extrusion adjacent to the inferior alveolar nerve, a fractured instrument in the mesial root, and a large periapical radiolucency involving both teeth 37 and 36. A diagnosis of symptomatic post-treatment apical periodontitis was established. After discussing treatment options with the patient, an IR of tooth 37 was performed. Extra-oral procedures were completed in 17 min. At 9 months, hypoesthesia resolution was reported, and apical healing was radiographically observed. After 2.5 years, the replanted tooth showed extensive root resorption. An extraction with alveolar ridge preservation, using leukocyte-platelet rich fibrin (L-PRF), was performed. Six months after tooth extraction and regeneration, implant placement surgery was carried out. IR presents a valid treatment modality for the management of post-treatment apical periodontitis. When orthograde retreatment or apical microsurgery prove to be unfeasible, IR is a unique procedure with the potential to promote tooth preservation in properly selected cases. Although unsuccessful after 2.5 years, the IR of tooth 37 allowed for bone regeneration, the maintenance of tooth 36 vitality, and hypoesthesia resolution.

Leiomyoma with bizarre nuclei of the scrotum: a rare entity.

Leiomyomas of the paratesticular region are a rare entity. A subtype of leiomyomas called bizarre nuclei leiomyoma is even rarer and histologically present some interesting features that are important to recognise to make the differential diagnosis with its malignant counterpart-leiomyosarcoma. We present a case of a man in his 60s, who presented with a painless mass on the right testicle. The clinical diagnosis was of an epidermoid cyst. The mass was excised and a diagnosis of leiomyoma of bizarre nuclei was made.

A Case of Acute Interstitial Nephritis After Two Doses of the BNT162b2 SARS-CoV-2 Vaccine.

BACKGROUND: The development of vaccines to prevent COVID-19 breakouts came with highly positive results but some unexpected side effects. Rare side effects have been seen with the BNT162b2 SARS-CoV 2 vaccine. CASE PRESENTATION: We present the case of a 45-year-old female patient who developed an acute kidney injury needing urgent hemodialysis one week after the second administration of the BNT162b2 SARS-CoV 2 vaccine. She developed a macular rash on her lower limbs and palms as well. A kidney biopsy was performed 10 days after vaccine inoculation, diagnosing acute interstitial nephritis and acute tubular necrosis with cellular casts. The patient was treated with three corticosteroid pulses followed by daily prednisolone. We witnessed clinical improvement 4 days after the initial corticosteroid treatment with progressive recovery of kidney function and hemodialysis withdrawal. After 2 weeks, the patient had recovered her kidney function. Immunophenotyping was performed, diagnosing a hypersensitivity to the vaccine and the polyethylene glycol excipient. CONCLUSION: Patients may develop acute reactions to vaccines. In this case, symptoms seem to correlate significantly with its inoculation and, although this case had a favourable outcome, these side effects must be made aware for clinicians and patients.

Impact of Positive Surgical Margins After Partial Nephrectomy.

BACKGROUND: The impact of positive surgical margins (PSMs) after partial nephrectomy (PN) is controversial. OBJECTIVE: To evaluate the risk factors for a PSM and its impact on overall survival. DESIGN SETTING AND PARTICIPANTS: This is a retrospective study of 388 patients were submitted to PN between November 2005 and December 2016 in a single centre. Two groups were created: PSM and negative surgical margin (NSM) after PN. A p value of <0.05 was considered significant. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Relationships with outcome were assessed using univariable and multivariable tests and log-rank analysis. RESULTS AND LIMITATIONS: The PSM rate was 3.8% (N = 16). The mean age at the time of surgery (PSM group: 64.1 ± 11.3 vs NSM group: 61.8 ± 12.8 yr, p = 0.5) and the mean radiological tumour size (4.0 ± 1.5 vs 3.4 ± 1.8 cm, p = 0.2) were similar. Lesion location (p = 0.3), surgical approach (p = 0.4), warm ischaemia time (p = 0.9), and surgery time (p = 0.06) had no association with PSM. However, higher surgeon experience was associated with a lower PSM incidence (2.6% if ≥30 PNs vs 9.6% if <30 PNs; p = 0.02). Higher operative blood loss (p = 0.02), higher-risk tumours (p = 0.03), and larger pathological size (p = 0.05) were associated with an increase in PSM. In the PSM group, recurrence rate (18.7% vs 4.2%, p = 0.007) and secondary total nephrectomy rate (25% vs 4.4%, p < 0.001) were higher. However, overall survival was similar. Multivariate analysis revealed that high-risk tumour (p = 0.05) and low experience (p = 0.03) could predict a PSM. Limitations include retrospective design and reduced follow-up time. CONCLUSIONS: PSMs were mainly associated with high-risk pathological tumour (p = 0.05) and low-volume surgeon experience. Recurrence rate and need for total nephrectomy were higher in that group, but no impact on survival was noticed. PATIENT SUMMARY: The impact of positive surgical margins (PSMs) after partial nephrectomy is a matter of debate. In this study, we found that PSMs were mainly associated with aggressive disease and low surgeon experience.

Granulomatous interstitial nephritis: a rare diagnosis with an overlooked culprit.

Granulomatous interstitial nephritis (GIN) is a rare entity identified in <1% of native kidney biopsies. The most frequent aetiology is drug-related, followed by systemic granulomatous conditions. Among drugs implicated in GIN, antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequent. We report the case of a 45-year-old white man referred to a nephrology consult due to chronic kidney disease. He had a history of arterial hypertension with 10 years of evolution, hyperuricaemia, medicated with allopurinol and NSAID abuse for at least 20 years. Urine sediment was blunt, without proteinuria. Renal ultrasound was normal. A kidney biopsy revealed well-defined epithelioid granulomas with glomerular wrinkling and collapse. Infectious and systemic conditions were excluded, favouring the hypothesis of drug-induced GIN, probably related to NSAIDs. Kidney biopsy remains the gold standard for the diagnosis of GIN. Facing a patient with renal failure without significant proteinuria or active sediment, one should look for causes of tubulointerstitial injury.

Parvoviral infection with systemic impact and renal consequences.

Parvovirus infection is usually asymptomatic especially in immunocompetent adults. When symptomatic it can range from mild to life threatening depending on the patient's age and comorbidities. We report a case of a 40-year-old male patient with parvovirus infection who presented a purpuric rash in distal extremities, acute kidney injury, type II mixed cryoglobulinaemia and hypocomplementaemia. His renal biopsy showed a mesangioproliferative glomerulonephritis with positive immunoreactivity to C3, IgM and C1q. Parvovirus B19 was detected in the biopsy tissue by PCR. He was treated with prednisolone with total remission after 1 month. We discuss the diagnosis of kidney lesion due to parvovirus in an immunocompetent person, which is a very rare condition and its association with the cryoglobulinaemia diagnosis.

Mixed extragonadal germ cell tumour of the prostate.

Extragonadal germ cell tumours (EGGCTs) originated in prostate are extremely rare, with <20 cases described in the literature. We report a case of a patient with a primary prostatic mixed EGGCT. A 47-year-old man presenting severe low urinary tract symptoms and signs of prostatic enlargement, with no malignancy suspicion, underwent transurethral resection of the prostate. The histopathological evaluation suggested the diagnosis of a retroperitoneal sarcoma. The patient underwent neoadjuvant chemotherapy and then was submitted to radical cystoprostatectomy. Histology revealed a mixed EGGCT of the prostate with yolk sac tumour and seminoma components. No testicular abnormalities were identified on the postoperative scrotal ultrasound. The patient went through four cycles of chemotherapy with bleomycin, etoposide and cisplatin. After 12 months of follow-up, the patient is alive and free of recurrence.

Heterogeneity in Lung Cancer.

Lung cancer diagnosis is a challenge since it is also one of the most frequently diagnosed cancers. Diagnostic challenges are deeply related to the development of personalized therapy and molecular and precise histological characterizations of lung cancer. When addressing these features, it is very important to acknowledge the issue of tumour heterogeneity, as it imposes several questions. First of all, lung cancer is a very heterogeneous disease, at a cellular and histological level. Cellular and histological heterogeneity are addressed with emphasis on the diagnosis, pre-neoplastic lesions, and cell origin, trying to contribute to a better knowledge of carcinogenesis. Molecular intra-tumour and inter-tumour heterogeneity are also addressed as temporal heterogeneity. Lung cancer heterogeneity has implications in pathogenesis understanding, diagnosis, selection of tissue for molecular diagnosis, as well as therapeutic decision. The understanding of tumour heterogeneity is crucial and we must be aware of the implications and future developments regarding this field.

Birt-Hogg-Dubé syndrome: awareness is important!

Birt-Hogg-Dubé (BHD) is a rare syndrome of inherited renal cell carcinomas, characterised by cutaneous lesions and pulmonary cysts and pneumothorax in a vast majority of the patients. Awareness of this syndrome is important in order to refer patients for genetic counselling and personalised follow-up as soon as possible. We describe a case of a 30-year-old female referred to our institution due to incidental discovery of solid bilateral renal masses. Renal biopsies were consistent with chromophobe tumour, and bilateral nephrectomy was performed. Gross examination revealed deformed kidneys with 28 brown and solid lesions, size variable between 0.1 and 6 cm, histologically corresponding to renal cell carcinomas, chromophobe type. Genetic test was required that showed a c.573delGAinsT frameshift mutation in heterozigosity at the folliculin gene, consistent with BHD diagnosis.

Bronchial schwannoma: a singular lesion as a cause of obstructive pneumonia.

Bronchial schwannomas are very rare pulmonary lesions, but its awareness is important to reach correct diagnosis and decide proper intervention. Clinical and radiological characteristics are mainly unspecific and pathological examination usually provides the definite diagnosis. In small lesions, endoscopic approach may be sufficient, but in large lesions associated with organising pneumonia surgical intervention may be required. Prognosis is typically favourable. We describe a case of a woman, aged 66 years, with productive cough and sporadic haemoptysis, dyspnoea, anorexia, excessive sweating and weight loss with 2 months evolution. CT scan showed a soft tissue dense lesion on the left hilum with 3.75 cm with 18-Fludeoxyglucose uptake. Left upper lobectomy was performed. Gross examination revealed a polypoid mass without necrosis, histologically showing cellular dense (Antoni A) and less dense (Antoni B) areas with Verocay bodies, slightly pleomorphic spindle cells, without mitotic activity and positive for S100 protein on immunohistochemistry.

Natural killer cell-based adoptive immunotherapy eradicates and drives differentiation of chemoresistant bladder cancer stem-like cells.

BACKGROUND: High-grade non-muscle invasive bladder cancer (NMIBC) has a high risk of recurrence and progression to muscle-invasive forms, which seems to be largely related to the presence of tumorigenic stem-like cell populations that are refractory to conventional therapies. Here, we evaluated the therapeutic potential of Natural Killer (NK) cell-based adoptive immunotherapy against chemoresistant bladder cancer stem-like cells (CSCs) in a pre-clinical relevant model, using NK cells from healthy donors and NMIBC patients. METHODS: Cytokine-activated NK cells from healthy donors and from high-grade NMIBC patients were phenotypically characterized and assayed in vitro against stem-like and bulk differentiated bladder cancer cells. Stem-like cells were isolated from two bladder cancer cell lines using the sphere-forming assay. The in vivo therapeutic efficacy was evaluated in mice bearing a CSC-induced orthotopic bladder cancer. Animals were treated by intravesical instillation of interleukin-activated NK cells. Tumor response was evaluated longitudinally by non-invasive bioluminescence imaging. RESULTS: NK cells from healthy donors upon activation with IL-2 and IL-15 kills indiscriminately both stem-like and differentiated tumor cells via stress ligand recognition. In addition to cell killing, NK cells shifted CSCs towards a more differentiated phenotype, rendering them more susceptible to cisplatin, highlighting the benefits of a possible combined therapy. On the contrary, NK cells from NMIBC patients displayed a low density on NK cytotoxicity receptors, adhesion molecules and a more immature phenotype, losing their ability to kill and drive differentiation of CSCs. The local administration, via the transurethral route, of activated NK cells from healthy donors provides an efficient tumor infiltration and a subsequent robust tumoricidal activity against bladder cancer with high selective cytolytic activity against CSCs, leading to a dramatic reduction in tumor burden from 80 % to complete remission. CONCLUSION: Although pre-clinical, our results strongly suggest that an immunotherapeutic strategy using allogeneic activated NK cells from healthy donors is effective and should be exploited as a complementary therapeutic strategy in high-risk NMIBC patients to prevent tumor recurrence and progression.

Invasive bladder urothelial carcinoma, plasmacytoid variant: case report / Carcinoma urotelial invasor de bexiga, variante plasmocitoide: relato de caso

ABSTRACT Invasive bladder urothelial carcinoma, plasmacytoid variant is a rare entity with scarce cases reported in the literature. We report a case of a 79 years old male, subjected to transurethral resection of bladder tumor, which histological examination revealed a pT1 high-grade urothelial carcinoma. Subsequently, he underwent radical cystoprostatectomy, which showed urothelial carcinoma with lack of cohesion, plasmacytoid variant, positive for citokeratin 7 (CK7), citokeratin 20 (CK20) and trans-acting T-cell-specific transcription factor (GATA-3), and negative for E-cadherin and CD138. It is important to recognize the plasmacytoid variant of the invasive urothelial carcinoma, since it avoids a potential misdiagnosis of metastatic cancer.

RESUMO Carcinoma urotelial invasor da bexiga, variante plasmocitoide, é uma entidade rara, com poucos casos descritos na literatura. Relatamos o caso de um homem, 79 anos, submetido à resseção transvesical de tumor da bexiga, cuja histologia revelou carcinoma urotelial de alto grau pT1. Posteriormente, foi submetido à cistoprostatectomia radical, que mostrou carcinoma urotelial invasor, descoeso, de tipo plasmacitoide, positivo para citoqueratina 7 (CK7), citoqueratina 20 (CK20) e fator de transcrição de ação"trans" específico de células T (GATA-3) e negativo para E-caderina e CD138. É importante reconhecer a variante plasmocitoide do carcinoma urotelial invasor, uma vez que se evita potencial diagnóstico errado de doença metastática.

Genome-culture coevolution promotes rapid divergence of killer whale ecotypes.

Analysing population genomic data from killer whale ecotypes, which we estimate have globally radiated within less than 250,000 years, we show that genetic structuring including the segregation of potentially functional alleles is associated with socially inherited ecological niche. Reconstruction of ancestral demographic history revealed bottlenecks during founder events, likely promoting ecological divergence and genetic drift resulting in a wide range of genome-wide differentiation between pairs of allopatric and sympatric ecotypes. Functional enrichment analyses provided evidence for regional genomic divergence associated with habitat, dietary preferences and post-zygotic reproductive isolation. Our findings are consistent with expansion of small founder groups into novel niches by an initial plastic behavioural response, perpetuated by social learning imposing an altered natural selection regime. The study constitutes an important step towards an understanding of the complex interaction between demographic history, culture, ecological adaptation and evolution at the genomic level.

Amplification of FGFR1 gene and expression of FGFR1 protein is found in different histological types of lung carcinoma.

Although lung cancer continues to be the leading cause of cancer-related death, accurate diagnosis followed by personalized treatment is expected to raise the 5-year survival rate. Targeted therapies are now in routine clinical use, in particular for lung adenocarcinoma (ADC). Fibroblast growth factor receptor 1 (FGFR1) has recently emerged as a molecular target, especially in squamous cell/epidermoid carcinoma (SQC) of the lung. This paper evaluates FGFR1 expression and gene copy number in adenocarcinomas, squamous cell carcinomas, pleomorphic carcinomas (PLEOMC) and adenosquamous carcinomas (ADSQC) of the lung and also explores the epithelial-mesenchymal transition (EMT) pathway. We studied 76 lung carcinomas: 34 ADC, 24 SQC, 10 PLEOMC and 8 ADSQC. FGFR1 expression was evaluated by immunohistochemistry and gene amplification by fluorescence in situ hybridization (FISH). Higher FGFR1 protein expression was observed in all tumour types compared to non-tumour tissue. FGFR1 expression was higher in ADC and PLEOMC than in SQC. We found a tendency to higher expression in ADC than in SQC and significantly higher expression in PLEOMC than in other histological subtypes. FISH-based amplification of FGFR1 was identified in 15 (20 %) lung carcinomas: 5 (15 %) ADC, 5 (21 %) SQC, 3 (30 %) PLEOMC and 2 (25 %) ADSQC. Amplification was more frequent in SQC without significant differences. FGFR1 protein is expressed in the majority of lung carcinomas, though it is higher in ADC and PLEOMC (the latter may reflect the importance of FGFR1 control of the EMT pathway). FGFR1 amplification was identified in all types of lung carcinoma. Although FGFR1 is most frequently amplified in SQC, other histological types merit assessment of FGFR1 amplification, in order to select patients that might benefit from targeted therapy.

Cast nephropathy: an extremely rare renal presentation of Waldenström's macroglobulinaemia.

Renal involvement in Waldenström's macroglobulinaemia (WM) is very unusual when compared to multiple myeloma. We report a case of a patient who developed anuric acute kidney injury secondary to cast nephropathy, dependent on high-flux haemodialysis. Complementary study revealed the presence of blood IgM monoclonal gammopathy and a massive bone marrow lymphoplasmacytic infiltration. There were no osteolytic lesions and no clinical signs/symptoms of hyperviscosity syndrome. The diagnosis of WM was established and a dexamethasone plus cyclophosphamide regime was started, in addition to plasmapheresis. The patient partially recovered renal function allowing haemodialysis and plasmapheresis withdrawal. He remained asymptomatic with a good response to chemotherapy and 12 months after his renal function remained stable. This is a rare clinical case in which WM presented as an IgM cast nephropathy, which in turn is an extremely rare renal presentation of this equally rare haematological disorder.

Functional and molecular characterization of cancer stem-like cells in bladder cancer: a potential signature for muscle-invasive tumors.

Striking evidence associates cancer stem cells (CSCs) to the high recurrence rates and poor survival of patients with muscle-invasive bladder cancer (BC). However, the prognostic implication of those cells in risk stratification is not firmly established, mainly due to the functional and phenotypic heterogeneity of CSCs populations, as well as, to the conflicting data regarding their identification based on a single specific marker. This emphasizes the need to exploit putative CSC-related molecular markers with potential prognostic significance in BC patients.This study aimed to isolate and characterize bladder CSCs making use of different functional and molecular approaches. The data obtained provide strong evidence that muscle-invasive BC is enriched with a heterogeneous stem-like population characterized by enhanced chemoresistance and tumor initiating properties, able to recapitulate the heterogeneity of the original tumor. Additionally, a logistic regression analysis identified a 2-gene stem-like signature (SOX2 and ALDH2) that allows a 93% accurate discrimination between non-muscle-invasive and invasive tumors.Our findings suggest that a stemness-related gene signature, combined with a cluster of markers to more narrowly refine the CSC phenotype, could better identify BC patients that would benefit from a more aggressive therapeutic intervention targeting CSCs population.

Bronchial-pulmonary adenocarcinoma subtyping relates with different molecular pathways.

Lung cancer is one of the most common cancers in the world with a high mortality rate. We analyzed 45 surgical samples of the adenocarcinoma, 13 with lymph node metastasis. APC, BCL2, chromogranin A, CK 5/6/18 (LP34), CK20, CK7, cyclin D1, EGFR, ERCC1, HER2, Ki67, LRP, MRP, P53, RB and TTF1 expressions were evaluated by immunohistochemistry (IHC). Higher Ki67, APC, ERCC1 expressions and lower TTF1 expression were identified in advanced stages (IIA and IIIA) of adenocarcinomas, which reflect a more aggressive, less differentiated, possibly a non-TRU adenocarcinoma. Acinar, micropapillary and BA/lepidic adenocarcinoma patterns were the most similar patterns and papillary was the most different pattern followed by solid pattern, according to expression of these markers. Different adenocarcinoma patterns are engaged with different molecular pathways for carcinogenesis, based on the differences of expression. Acinar, BA/lepidic and micropapillary showed higher TTF1 expression (type TRU), and papillary and solid patterns revealed less TTF1 expression, exhibiting a non-TRU/bronchial phenotype. Solid pattern revealed lower HER2 and higher EGFR and ERCC1 (this compared to papillary) expression; papillary higher HER2 and lower ERCC1 expressions; micropapillary higher RB expression; and acinar lower ERCC1 and higher EGFR expressions. Ciclin D1 seems to have more importance in acinar and BA/lepidic patterns than in micropapillary. ERCC1 protein expression in micropapillary, solid and BA/lepidic patterns may indicate DNA repair activation. Inhibition of apoptosis could be explained by BCL2 overexpression, present in all adenocarcinoma patterns. MRP-1 and LRP were overexpressed in all patterns, which may have implications for drug resistance. Further studies are needed to interpret these data regarding to therapy response in advanced staged bronchial-pulmonary carcinomas.

Lung adenocarcinoma: Sustained subtyping with immunohistochemistry and EGFR, HER2 and KRAS mutational status.

Pulmonary adenocarcinomas are still in the process of achieving morphological, immunohistochemical and genetic standardization. The ATS/ERS/IASLC proposed classification for lung adenocarcinomas supports the value of the identification of histological patterns, specifically in biopsies. Thirty pulmonary adenocarcinomas were subjected to immunohistochemical study (CK7, CK5, 6, 18, CK20, TTF1, CD56, HER2, EGFR and Ki-67), FISH and PCR followed by sequencing and fragment analysis for EGFR, HER2 and KRAS. Solid pattern showed lower TTF1 and higher Ki-67 expression. TTF1 expression was higher in non-mucinous lepidic and micropapillary patterns when compared to acinar and solid and acinar, solid and mucinous respectively. Higher Ki67 expression was present in lepidic and solid patterns compared to mucinous. EGFR membranous staining had increasing expression from non-mucinous lepidic/BA pattern to solid pattern and micropapillary until acinar pattern. EGFR mutations, mainly in exon 19, were more frequent in females, together with non-smoking status, while KRAS exon 2 mutations were statistically more frequent in males, especially in solid pattern. FISH EGFR copy was correlated gross, with mutations. HER2 copy number was raised in female tumours without mutations, in all cases. Although EGFR and KRAS mutations are generally considered mutually exclusive, in rare cases they can coexist as it happened in one of this series, and was represented in acinar pattern with rates of 42.9% and 17.9%, respectively. EGFR mutations were more frequent in lepidic/BA and acinar patterns. Some cases showed different EGFR mutations. The differences identified between the adenocarcinoma patterns reinforce the need to carefully identify the patterns present, with implications in diagnosis and in pathogenic understanding. EGFR and KRAS mutational status can be determined in biopsies representing bronchial pulmonary carcinomas because when a mutation is present it is generally present in all the histological patterns.