Interactive Pathology Tutorial in Neoplastic Hematology Disorders for Medical Hematology-Oncology Fellows.

Hematology-oncology (HO) fellows receive limited instruction in the process of establishing a diagnosis for hematologic neoplasms, and learning neoplastic hematology often occurs in limited encounters. In the current study, we developed a web-based interactive pathology tutorial in neoplastic hematologic disorders for HO fellows to work up simulated cases and establish the diagnosis. An online system ("Pathology Playground") was utilized to load case materials including microscopic images and ancillary studies. Twelve high-yield simulated cases of common leukemias and lymphoma were included. At the beginning of each case, trainees review the clinical history and slide images, and then, they are given the option to request additional pathology work-up. Based on the results, they can enter their diagnostic impression. If the diagnosis is correct, the user is shown a short educational presentation. If the diagnosis is not correct, the user gets notified by the message "Incorrect." The tutorial was integrated in the educational curriculum of our HO fellowship program, and bimonthly teaching sessions were held to review two cases each time. During the sessions, trainees request ancillary studies to complete the diagnostic work-up using the software and interpret the findings. As the case is being worked up by the trainee, the hematopathologists and HO fellowship program director discuss the findings, the appropriate work-up tools, and the implications on management. All of our six HO fellows attended the sessions, and a survey from the trainees showed high ease of use of the system and they viewed it as a very useful educational tool. A pre-test and post-test were administered for one of the sessions, and the result showed improvement in the average from 62 to 73%. Expanding the use of this online interactive tutorial and incorporating additional cases would enhance its value as a learning resource.

The prognostic significance of duodenal wall invasion in pancreatic adenocarcinoma.

OBJECTIVE: The most recent edition of the American Joint Committee on Cancer Staging Manual (AJCC, 8th edition) relies only on tumor size for staging resectable pancreatic adenocarcinoma, and the presence of duodenal wall invasion (DWI) no longer has an impact on staging. However, very few studies have evaluated its significance. In this study, we aim to evaluate the prognostic significance of DWI in pancreatic adenocarcinoma. METHODS: We reviewed 97 consecutive internal cases of resected pancreatic head ductal adenocarcinoma, and clinicopathologic parameters were recorded. All cases were staged according to the 8th edition of AJCC, and the patients were divided into two groups based on the presence or absence of DWI. RESULTS: Out of our 97 cases, 53 patients had DWI (55%). In univariate analysis, DWI was significantly associated with lymphovascular invasion and lymph node metastasis (AJCC 8th edition pN stage). In univariate analysis of overall survival, age > 60, absence of DWI, and African American race were associated with worse overall survival. In multivariate analysis, age > 60, absence of DWI, and African American race were associated with worse progression-free survival and overall survival. CONCLUSION: Although DWI is associated with lymph node metastasis, it is not associated with inferior disease-free/overall survival.

Assessment of potential predictors affecting preoperative anxiety in Indian children- A prospective observational study.

Background and Aims: Preoperative anxiety is a common problem among children undergoing surgery. The aim of the study was to assess the incidence and identify various predictors of preoperative anxiety in Indian children. Material and Methods: A prospective, observational study was conducted on 60 children of the American Society of Anesthesiologists Physical status 1/2, aged 2-6 years and scheduled for elective surgery under general anesthesia in a tertiary care teaching hospital. Preoperative parental anxiety was assessed using the State-Trait Anxiety Inventory questionnaire. The children's anxiety was assessed in the preoperative room, at the time of parental separation, and at the induction of anesthesia using modified Yale Preoperative Anxiety Scale (mYPAS) scoring by an anesthesiologist and a psychologist. Sedative premedication was employed prior to parental separation. Logistic regression analysis was carried out to identify the possible predictors of anxiety. Results: The incidence of high preoperative anxiety among the studied children was 76% in the preoperative room, 93% during parental separation, and 96% during anesthetic induction. Among the nine possible predictors identified on univariate regression, the presence of siblings was found to be a significant independent predictor on multivariate regression analysis (P = 0.04). The inter-rater agreement was excellent for the assessment of preoperative anxiety using mYPAS by the anesthesiologist and psychologist (weighted Kappa, k = 0.79). Conclusion: The incidence of preoperative anxiety in Indian children in the age group of 2-6 years is very high. The preop anxiety escalates progressively at parental separation and induction of anesthesia despite sedative premedication. The presence of siblings is a significant predictor of preoperative anxiety.

Merlin immunohistochemistry is useful in diagnosis of tumours within the spectrum of biphasic hyalinizing psammomatous renal cell carcinoma.

AIMS: Biphasic hyalinizing psammomatous (BHP) renal cell carcinoma (RCC) is a newly described emerging entity within the spectrum of papillary RCC in the WHO 2022 classification. Molecular analyses have discovered that BHP RCC consistently harbour somatic mutations in the neurofibromin 2 (NF2) gene. The NF2 gene product, merlin, is known to primarily function as a tumour suppressor. Merlin protein loss correlates closely with the presence of NF2 mutations in benign and malignant tumours arising in different sites. In the present study we explored the role of merlin immunohistochemistry (IHC) in tumours within the spectrum of BHP RCC to determine the diagnostic utility of this marker. MATERIALS AND METHODS: We performed merlin IHC in 13 BHP RCC, 18 papillary RCC, 10 TFE3-translocation RCC, 15 TFEB-altered RCC (including 13 TFEB-rearranged and 2 TFEB-amplified), and 10 mucinous tubular and spindle cell carcinomas of unknown mutational status. RESULTS: Unequivocal loss of merlin expression in >90% of the tumour cells was observed in 12/13 BHP-RCC (92%), with the remaining tumour demonstrating weak focal cytoplasmic expression in ~10% of the tumour. In contrast, merlin was diffusely or multifocally expressed in all papillary RCC, TFE3-translocation RCC, and TFEB-altered RCC, as well as in 70% of mucinous tubular and spindle carcinomas. CONCLUSIONS: In this study, merlin IHC was ~92% sensitive and ~94% specific for BHP RCC. These data suggest that merlin IHC is a reliable surrogate marker for the presence of underlying NF2 gene inactivation, being diagnostically useful to identify BHP RCC. CONCLUSIONS: In this study, merlin IHC was ~92% sensitive and ~94% specific for BHP RCC. These data suggest that merlin IHC is a reliable surrogate marker for the presence of underlying NF2 gene inactivation, being diagnostically useful to identify BHP RCC.

Prognostic significance of venous invasion in node-negative head and neck squamous cell carcinoma.

BACKGROUND: Venous invasion (VI) is not frequently evaluated on routine histologic examination of head and neck squamous cell carcinoma (HNSCC), and the prognostic significance is largely unknown. Studies have shown that extramural venous invasion is an adverse prognostic factor in colorectal carcinoma. To our knowledge, this is the first study evaluating the prognostic significance of venous invasion in node-negative (without clinical or pathologic evidence of lymph node involvement) HNSCC, utilizing the elastic stain. METHODS: A total of 105 consecutive lymph node-negative (N0) HNSCC were evaluated for the presence of venous channel invasion by tumor utilizing the elastin stain. Clinical, demographic, and follow-up data were recorded. RESULTS: Of 37 patients with venous invasion, 19% had loco-regional recurrence, as opposed to 12% of those without. Univariate analysis revealed statistically significant decreased recurrence-free survival in the presence of venous invasion (log-rank [Mantel-Cox] test P-value .025). CONCLUSION: Identification of VI is greatly aided by elastic stain. In patients with node-negative HNSCC, presence of VI resulted in decreased recurrence-free survival on univariate analysis. The impact of VI as a prognostic marker should be further evaluated.

Lymphoma in autopsy cases.

Lymphoproliferative disorders cause significant morbidity and mortality, either related to the disease itself or therapy complications. Some cases of lymphoma may have vague clinical presentation, especially in the absence of lymphadenopathy, and a clinical work up may not be conclusive. Our study focuses on autopsy cases of lymphoma patients, emphasizing clinically unsuspected cases. Autopsy records from the last 20 years at our institution were searched, and the clinical parameters were recorded. Fifteen cases of lymphoma were identified, and 5 cases were diagnosed at the time of autopsy. Most B-cell lymphoma cases were mainly nodal disease, while T-cell lymphoma cases had widespread extra-nodal disease. Most deaths in B-cell lymphoma are due to infection/therapy induced immunosuppression, whereas T-cell lymphoma deaths are due to organ infiltration by lymphoma. Postmortem examination may reveal clinically unsuspected lymphoma, especially in rapidly deteriorating patients with vague presentation such as skin rash, bowel obstruction/bleeding or pacemaker malfunction.

Phosphohistone-H3 and Ki67: Useful Markers in Differentiating Dermatofibroma From Dermatofibrosarcoma Protuberans and Atypical Fibrohistiocytic Lesions.

Dermatofibromas (DF) are common, benign, skin tumors, usually easily differentiated from dermatofibrosarcoma protuberans (DFSP) by the presence of a relative low cellularity, lesser degree of infiltration of subcutaneous tissue, and immunohistochemical pattern (eg, FXIIIa in DF and CD34 in DFSP). Atypical fibrohistiocytic lesions (AFL) have features intermediate to DF and DFSP (trunk location, storiform pattern, infiltration of the subcutaneous tissue, and focal expression of both CD34 and Factor XIIIa). It is unclear if mitotic counts/degree of proliferation is helpful to distinguish DF from DFSP. To study the mitotic rate and proliferation index in DF, AFL/DFSP, anti-ki67, and anti-PHH3 were performed on 10 cases of DF (including 4 cellular DF), 10 standard DFSP, and 2 AFL. The proliferation index and mitotic figures were counted per square millimeter in a "hotspot" (in a fashion similar to mitotic counts in melanoma). All cases of DF showed much higher Ki67 proliferation index (P = 0.0001) along with increased mitotic figures both on H&E and with anti-PHH3 (P = 0.0001) when compared to AFL/DFSP. Our data indicate that DF has a higher proliferation index and mitotic counts when compared to superficial/peripheral portion of AFL and DFSP. This finding may be helpful in the differential diagnosis among these fibrohistiocytic lesions.

Myxofibrosarcoma in Head and Neck: Case Report of Unusually Aggressive Presentation.

Myxofibrosarcoma (MFS) is a malignant fibroblastic tumor that primarily affects the lower and upper extremities. It is usually described as a slow-growing tumor with high recurrence rates but low metastatic potential. The reported incidence of head and neck MFS is 2 to 4% and rarely presents with distant metastases. This report describes a case of maxillary MFS in a 72-year-old woman whose disease progression followed an atypical course with an extremely rapid rate of growth and early pulmonary and central nervous system lesions. The pulmonary symptoms at initial presentation made a final diagnosis a challenge. Various diagnostic modalities and multidisciplinary collaboration were required. The disease course and management are outlined. To the authors' knowledge, this is the first case of MFS originating in the maxillary alveolus with multiple metastases, including the brain and lungs, in the early course of the disease.

Effect of aqueous ethanol on the triple helical structure of collagen.

Collagen, the most abundant protein in mammals, is widely used for making biomaterials. Recently, organic solvents have been used to fabricate collagen-based biomaterials for biological applications. It is therefore necessary to understand the behavior of collagen in the presence of organic solvents at low (≤50%, v/v) and high (≥90%, v/v) concentrations. This study was conducted to examine how collagen reacts when exposed to low and high concentrations of ethanol, one of the solvents used to make collagen-based biomaterials. Solubility testing indicated that collagen remains in solution at low concentrations (≤50%, v/v) of ethanol but precipitates (gel-like) thereafter, irrespective of the method of addition of ethanol (single shot or gradual addition); this behavior is different from that observed recently with acetonitrile. Collagen retains its triple helix in the presence of ethanol but becomes thermodynamically unstable, with substantially reduced melting temperature, with increasing concentration of ethanol. It was also found that the CD ellipticity at 222 nm, characteristic of the triple-helical structure, does not correlate with the thermal stability of collagen. Time-dependent experiments reveal that the collagen triple helix is kinetically stable in the presence of 0-40% (v/v) ethanol at low temperature (5 °C) but highly unstable in the presence of ethanol at elevated temperature (~34 °C). These results indicate that when ethanol is used to process collagen-based biomaterials, such factors as temperature and duration should be done taking into account, to prevent extensive damage to the triple-helical structure of collagen.

Encapsulated Papillary Oncocytic Neoplasm: A Newly Recognized Hurthle Cell Neoplasm With Unique Morphology.

Diagnosis of oncocytic neoplasm of the thyroid gland can be challenging especially on fine needle aspiration biopsy (FNAB), given the wide differential diagnoses. In this report, we present the case of a 66-year-old male with an incidental thyroid nodule identified on imaging. In this case, identification of the distinctive cytologic features leads to the diagnosis of papillary oncocytic neoplasm on FNAB and helped to decide the appropriate surgical management. To date, the cytomorphologic features of this lesion are not well studied and established, with only a single case report in the literature. Herein, we describe the characteristic cytomorphologic and immunophenotypic features of this neoplasm. The recognition of the unique cytomorphologic features and awareness of the non-classic expression of the thyroid lineage markers will help in accurate diagnosis and management of this entity.

HPV Associated Squamous Cell Carcinoma in the Rectal Tonsil.

Mucosa-associated lymphoid tissue has been reported throughout the gastrointestinal tract including rectum. Rarely, a nodular proliferation of predominantly submucosal lymphoid tissue in the rectum has been documented as rectal tonsil. Here we report a patient with HPV-associated squamous cell carcinoma of the rectal tonsil, presenting as a polyp. Previously, rare reports of HPV-associated lymphoepithelial carcinoma have been reported in the literature. We are presenting an extremely rare occurrence and emphasizing the importance of appropriate nomenclature based on the pathogenesis of the neoplasm.

Pathology Playground: An Interactive Web-Based System for Pathology Unknowns With Immunohistochemistry and Molecular Studies.

CONTEXT.­: Anatomic pathology slide unknown conferences are usually limited to a microscopic slide, slide images, or a virtual slide that is previewed prior to a conference. The answer is provided at a conference along with the ancillary studies, such as immunohistochemical or molecular studies, that enabled the diagnosis. In this rigid system the learner never gains experience with an appropriate workup for cases that will enable the definitive diagnosis. OBJECTIVE.­: To develop an interactive system in which the user can work through a difficult case, ordering stains and other special studies, ideally leading to more involvement and retention. DESIGN.­: An online system was developed using HTML, PHP Hypertext Preprocessor, and JavaScript for ordering and result display. When the user selects a study, an image or text result is displayed. Studies include immunohistochemistry, cytogenetics, flow cytometry, molecular, and radiology. The user then selects the diagnosis and, if correct, is shown some additional didactics. RESULTS.­: Unknown conferences were held at 3 institutions using this novel teaching method that allowed residents to work up unknown cases. Conferences are available online (http://www.drdoubleb.com/unknowns/) and include general, soft tissue, and hematopathology cases. Evaluations were obtained that showed that residents enjoyed the system, considered it better than standard unknown sessions and lectures, and wanted more sessions. CONCLUSIONS.­: This system was very highly received by the residents in all programs, who enjoyed getting immediate results and being able to work through interesting cases. More widespread use of this system could make for an effective learning tool.

Investigation on Centrifugally Spun Fibrous PCL/3-Methyl Mannoside Mats for Wound Healing Application.

Fibrous structures, in general, have splendid advantages in different forms of micro- and nanomembranes in various fields, including tissue engineering, filtration, clothing, energy storage, etc. In the present work, we develop a fibrous mat by blending the bioactive extract of Cassia auriculata (CA) with polycaprolactone (PCL) using the centrifugal spinning (c-spinning) technique for tissue-engineered implantable material and wound dressing applications. The fibrous mats were developed at a centrifugal speed of 3500 rpm. The PCL concentration for centrifugal spinning with CA extract was optimized at 15% w/v of PCL to achieve better fiber formation. Increasing the extract concentration by more than 2% resulted in crimping of fibers with irregular morphology. The development of fibrous mats using a dual solvent combination resulted in fine pores on the fiber structure. Scanning electron microscope (SEM) images showed that the surface morphology of the fibers in the produced fiber mats (PCL and PCL-CA) was highly porous. Gas chromatography-mass spectrometry (GC-MS) analysis revealed that the CA extract contained 3-methyl mannoside as the predominant component. The in vitro cell line studies using NIH3T3 fibroblasts demonstrated that the CA-PCL nanofiber mat was highly biocompatible, supporting cell proliferation. Hence, we conclude that the c-spun, CA-incorporating nanofiber mat can be employed as a tissue-engineered construct for wound healing applications.

A cyclodextrin-based macrocyclic oligosaccharide cavitand with a dual functionality limits the collagen fibrillogenesis: A possible carbohydrate-based therapeutic molecule for fibrotic diseases.

ß-Cyclodextrin (ß-CD), a macrocyclic oligosaccharide cavitand, is a well-known candidate for drug delivery and formulation. In this study, we extended the application of ß-CD using a ß-cyclodextrin sulfate (ß-CDS) as a possible therapeutic for fibrotic diseases caused by excess deposition of collagen fibrils. We have strategically chosen ß-CDS, which mimics the natural existence of dermatan sulfate in the extracellular matrix, for limiting collagen fibrillation. The hydrophobic nature of the inner core ß-CDS is expected to form an inclusion complex with hydrophobic side chain amino acids with the simultaneous action of forming an ionic bond through a negative charge on sulfate group with positively charged amino acids side chain in collagen. Various results suggested that such dual action not only limited the collagen fibrillation but also reduced the fibril size formed in the presence of ß-CDS. The contemporary results thus indicate that ß-CDS can be explored as a therapeutic molecule in fibrotic diseases.

Quantitative assessment shows loss of antigenic epitopes as a function of pre-analytic variables.

Pre-analytic variables, specifically cold ischemic time, have been implicated as key variables in the measurement of proteins by immunohistochemistry. To determine the significance and magnitude of antigenic loss due to pre-analytic variables, we have compared protein antigenicity in core needle biopsies, with essentially no cold ischemic time, with that in routinely processed tumor resection specimens. Two cohorts of matched core needle biopsies and tumor resections were collected with 20 matched pairs and 14 matched pairs, respectively. Both series were analyzed by quantitative immunofluorescence using the AQUA® method. Epitopes phospho-ERK, total ERK, phospho-AKT, total AKT, phospho-S6K1, total S6K1, estrogen receptor (ER), Ki67, cytokeratin and GAPDH were assessed. Detection levels for all phospho-epitopes were significantly decreased in tumor resections compared with biopsies while no significant change was seen in the corresponding total proteins. Of the other four proteins examined, ER and cytokeratin showed significant loss of antigenicity. This data suggest that measurement of phospho-protein antigenicity in formalin-fixed tissue by immunological methods is dramatically affected by pre-analytic variables. This study suggests that core needle biopsies are more accurate for assessment of tissue biomarkers.

Regulation of interleukin-6 expression in human decidual cells and its potential role in chorioamnionitis.

Chorioamnionitis frequently precedes both genital tract and placental inflammation and is both a primary cause of maternal morbidity and a major antecedent of preterm premature rupture of the membranes (PPROM) as well as preterm delivery (PTD). In most cases of chorioamnionitis, neutrophils dominate the decidua. In a subset of these cases, a predominance of monocytes is uniquely associated with both neonatal intraventricular hemorrhage and death. The multifunctional cytokine, interleukin-6, promotes local monocyte dominance via several mechanisms. In this study, immunostaining of placental sections revealed significantly higher interleukin-6 HSCOREs in decidual cells (DCs) but not in interstitial trophoblasts, in chorioamnionitis versus gestational age-matched control placentas (P < 0.05). In confluent leukocyte-free term DCs, secreted interleukin-6 levels in incubations with estradiol-17ß were increased 2500-fold by IL-1ß (P < 0.05). This up-regulation was inhibited by more than 50% in parallel incubations that included medroxyprogesterone acetate (n = 12, P < 0.05). Western blotting data confirmed these enzyme-linked immunosorbent assay results; quantitative RT-PCR findings demonstrated corresponding changes in interleukin-6 mRNA levels. Specific inhibitors of signaling for both nuclear factor-κB activation and p38-mitogen-activated protein kinase, but not for protein kinase C, significantly decreased IL-1ß-enhanced interleukin-6 expression levels in cultured DCs. In conclusion, in situ and in vitro results indicate that significantly enhanced interleukin-6 expression levels in DCs during chorioamnionitis could be pivotal in skewing decidual monocyte differentiation to macrophages.

Ferulic acid loaded microspheres reinforced in 3D hybrid scaffold for antimicrobial wound dressing.

Here we report the preparation of biomimetic fibrin/chitosan/keratin hybrid scaffolds with a synergistic combination of ferulic acid loaded silica microspheres for antimicrobial wound dressing applications. The infrared and X-ray powder diffraction studies confirm the homogenous nature of the prepared hybrid scaffolds without any major interactions between the constituents. The developed hybrid scaffolds show good thermal, porosity, compression and water uptake properties. Scanning electron microscopic analysis shows that the as-synthesized ferulic acid loaded silica microspheres exhibit an average size of 35 ± 10 µm and also exposes the smooth surface with interconnected porosity in the prepared hybrid scaffolds. The incorporated ferulic acid loaded silica microspheres hybrid scaffolds show effective antimicrobial activity against the common wound pathogens. In vitro NIH3T3 fibroblast cell culture and drug release studies reveal that the prepared hybrid scaffolds have enhanced cell proliferation and adhesion with a prolonged drug release for about 72 h. In vitro wound healing and actin cytoskeleton analysis reveal that the incorporated ferulic acid loaded silica microspheres in fibrin/chitosan/keratin hybrid scaffolds facilitates cell growth and migration to damaged area through cell-cell interactions. These results suggest that the prepared hybrid scaffolds with ferulic acid loaded silica microspheres have great potential for soft tissue engineering applications particularly for the treatment of chronic and infected wounds.

Biphasic Hyalinizing Psammomatous Renal Cell Carcinoma: Another Provisional Entity Emerging From the Papillary Renal Cell Carcinoma Pandora's Box.

Papillary renal cell carcinoma (especially type 2) is a Pandora's box with many newly described renal cell carcinomas emerging from it as a result of enhanced molecular techniques. Biphasic hyalinizing psammomatous renal cell carcinoma (BHPRCC) is the latest addition, which was first described a few months ago. Here, we report a case of BHPRCC to supplement the very limited literature available about this entity, and to highlight the characteristic morphology as well as the recurring molecular alterations in the neurofibromatosis 2 gene.

Pitfalls in Morphologic Diagnosis of Pathogens: Lessons Learned From the Pseudo-Cystoisospora Epidemic.

Multiple groups have recently reported involvement of the gallbladder mucosa of immunocompetent patients by cystoisospora organisms. However, this has recently been disproved with the support of molecular and ultrastructural studies. Here we present a summary of these events, recounting how this pseudo-Cystoisospora epidemic began and ended. This review also highlights the important role played by ancillary techniques in supplementing the morphologic diagnosis of pathogens.

High expression of BCL-2 predicts favorable outcome in non-small cell lung cancer patients with non squamous histology.

BACKGROUND: Bcl-2 promotes cell survival by inhibiting adapters needed for the activation and cleavage of caspases thus blocking the proteolytic cascade that ultimately dismantles the cell. Bcl-2 has been investigated as a prognostic factor in non small cell lung cancer (NSCLC) patients with conflicting results. METHODS: Here, we quantitatively assessed Bcl-2 expression in two large and independent cohorts to investigate the impact of Bcl-2 on survival. AQUA(R), a fluorescent-based method for analysis of in situ protein expression, was used to measure Bcl-2 protein levels and classify tumors by Bcl-2 expression in a cohort of 180 NSCLC patients. An independent cohort of 354 NSCLC patients was used to validate Bcl-2 classification and evaluate outcome. RESULTS: Fifty % and 52% of the cases were classified as high expressers in training and validation cohorts respectively. Squamous cell carcinomas were more likely to be high expressers compared to adenocarcinomas (63% vs. 45%, p = 0.002); Bcl-2 was not associated with other clinical or pathological characteristics. Survival analysis showed that patients with high BCL-2 expression had a longer median survival compared to low expressers (22 vs. 17.5 months, log rank p = 0.014) especially in the subset of non-squamous tumors (25 vs. 13.8 months, log rank p = 0.04). Multivariate analysis revealed an independent lower risk for all patients with Bcl-2 expressing tumors (HR = 0.53, 95% CI 0.37-0.75, p = 0.0003) and for patients with non-squamous tumors (HR = 0.5, 95% CI 0.31-0.81, p = 0.005). CONCLUSIONS: Bcl-2 expression defines a subgroup of patients with a favorable outcome and may be useful for prognostic stratification of NSCLC patients.