MET-FISH Evaluation Algorithm: Proposal of a Simplified Method.

MET amplifications (METamp) occur in 5% of NSCLC and represent in most case mechanisms of resistance to ALK and/or EGFR-targeted therapies. METamp detection can be performed using different techniques, although Fluorescence In-Situ Hybridization (FISH) remains the gold-standard, especially in the context of subclonality. To date current evaluation algorithms of MET amplifications are time consuming. Aim of the study was to identify a faster, equally reliable diagnostic algorithm for the detection of METamp, which is currently classified in negativity and low/intermediate/high-level amplification. N=497 NSCLC cases with available MET-FISH data had been selected. The results based on the first evaluated 20 cells had been re-calculated and compared with the definitive results based on 60 cells. For n=464 (93.4%) identical results had been obtained when counting 20 cells instead of 60 cells. Thirty-three cases (5.6%) showed a discrepancy, leading to an incorrect upgrade to a higher diagnostic category (n=25) and to an incorrect downgrade (n=8). We propose a simplified, yet equally reliable MET FISH-algorithm: after accurate screening of the whole tumor slide, twenty tumor cells have to be evaluated and results calculated: If the result is negative, or if all criteria of high-level METamp are fulfilled, the case can be signed out as such. All other cases should be considered as equivocal and additional 40 cells have to be counted. Given that, reliable results can be obtained by counting 20 cells only and an "equivocal" category for cases that need further investigation have been clearly defined.

Intraductal tubular papillary neoplasm (ITPN), a novel entity of pancreatic epithelial neoplasms and precursor of cancer: A case report and review of the literature.

BACKGROUND: Intraductal tubular papillary neoplasm (ITPN) displays a very rare subtype of epithelial neoplasms of the pancreas. ITPN is characterized by intraductal tubulopapillary growth and cellular dysplasia. In contrast to intraductal papillary neoplasm (IPMN) no overt epithelial mucin production is observed. To date, little is known about ITPN and particularly about pancreatic cancer arising in this tumor entity. CASE PRESENTATION: A 68-year-old male presented at our hospital with a distal bile duct occlusion suspicious for adenocarcinoma of the pancreatic head. Preoperative staging revealed no signs of distant metastasis. The patient was surgically explored and pylorus preserving duodenopancreatectomy was performed for a solid pancreatic head tumor. Final histopathology surprisingly revealed an ITPN with an associated invasive carcinoma pT3, pN0 (0/12), R0, G2. DISCUSSION: Patients with ITPN frequently present with jaundice suspicious for a bile duct stenosis or a malignant tumor of the pancreatic head. Although, it is possible to diagnose ITPN by endoscopic retrograde cholangiopancreaticography, many tumors are found not before histopathological examination. Differential diagnosis includes ductal adenocarcinoma of the pancreas, neuroendocrine tumors, IPMN, distal bile duct tumors, and solid pseudopapillary neoplasms. Using immunohistochemistry, other entities of pancreatic tumors can be ruled out. In case of R0 resection oncological prognosis is described to be more favorable when compared to regular ductal adenocarcinoma. CONCLUSION: ITPN displays a rare entity of pancreatic neoplasms. As shown in the present case report, there is a relevant potential of malignant transformation and therefore radical surgical resection and oncologic follow-up is warranted.

Hormone receptors analysis in idiopathic progressive subglottic stenosis.

OBJECTIVE: Idiopathic subglottic stenosis predominantly affects fertile and perimenopausal women. Estrogens and/or progesterone have been proposed as mediators of its pathogenesis by stimulating collagen deposition within the upper airway. We evaluated the presence and expression of estrogen-alpha (ER-α), estrogen-beta (ER-ß), and progesterone receptors (PR) in idiopathic stenotic patients. STUDY DESIGN: A retrospective analysis on 42 surgical specimens from idiopathic stenosis female patients (mean age, 52.4; age range, 31-79) and 28 gender- and age-matched controls. METHODS: Immunoreactivity of ER-α, ER-ß, and PR was calculated as the product of intensity (1 = weak, 2 = moderate, 3 = strong) and positive cell percentage (1-4, for < 10/10-50/50-80/ > 80%). This score was calculated on the stenotic and peristenotic tissues. Influence of menopausal status on hormonal expression and stenotic grade was tested. RESULTS: Stenosis showed ER-α overexpression versus peristenotic tissue and controls (score 6.6 ± 4.4, 0.3 ± 0.5, and 2.2 ± 1.5, respectively; P < 0.001). Overexpression was even more marked for progesterone receptors (score 8.3 ± 3.6, 0.8 ± 0.6, and 1.0 ± 0.7, respectively; P < 0.001). There was no expression of ER-ß in stenosis (score 0), whereas it was normally expressed in peristenotic tissue and controls (score 0.7 ± 0.5 and 0.5 ± 0.5; P < 0.001 vs. stenosis). Expression of ER-α was higher in postmenopausal stenotic patients (P < 0.01). This subgroup included a higher proportion of Cotton-Myer grade III stenosis than in premenopausal subjects (P < 0.001). CONCLUSION: An imbalance between ER-α, ER-ß, and PR is present in idiopathic stenosis patients. The hormonal background may be involved in inappropriate inflammation and increased stenosis susceptibility. Menopausal changes seem to play a role in both stenosis grade and receptor patterns. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:E72-E77, 2018.

Intramedullary fracture reduction of long bone under visual control: experimental results of an endoscopic technique.

In controlling the closed reduction of a shaft fracture of long bone during an operation, intraoperative radiography is essential. The amount of imaging needed depends on the patient, the fracture, and the surgeon. This article documents our first experimental results of closed fracture reduction performed under direct visual control with the endoscopic technique of intramedullary bone endoscopy (IBE), which eliminates the need for fluoroscopy. On 3 human tibial cadaveric bones, an artificial shaft fracture was set. The lower leg was fixed on a brace, and the endoscope was inserted at the standard entry point for intramedullary nailing. The endoscope was gently pushed distally to prepare the medullary canal under visual control with the use of endoscopic instruments. At the level of fracture, surgeons achieved a closed reduction by "looking around" for the distal part of the fracture by using the stiff endoscope similarly to a "joystick." Thus, the proximal fragment was automatically guided into the correct position, and the fracture was reduced. The endoscopic tool was pushed down the medullary canal into the distal fragment in the way that a guidewire would be placed. Through this technique, it has been possible in all patients to reduce fractures under visual control. Fluoroscopy can be eliminated in these cases.

HOPE--a new fixing technique enables preservation and extraction of high molecular weight DNA and RNA of > 20 kb from paraffin-embedded tissues. Hepes-Glutamic acid buffer mediated Organic solvent Protection Effect.

The growing number of molecular pathologic tools that are currently available require material with good long term preservation of morphology, nucleic acids, and antigenic structures. However, pathologic investigations of tissues done at a molecular level are often hampered by the fixatives in use. We thus endeavored to design a new fixing system, including subsequent paraffin-embedding and sectioning, that makes complete pathologic analyses possible, with special consideration of immunohistochemistry (IHC), in situ hybridization (ISH), and molecular pathology. The optimized HOPE (Hepes-Glutamic acid buffer mediated Organic solvent Protection Effect) fixing technique allows us to preserve and extract high molecular weight DNA and RNA of > 20 kbp suitable for downstream applications, such as PCR and RT-PCR from HOPE-fixed, paraffin-embedded tissues that are up to 5 years old. This technique will most probably lead to new impacts on molecular pathology.

Intramedullary pressure during endoscopy of the long bone: experimental results of a new endoscopic technique.

This study shows the local changes in intramedullary pressure during a new endoscopic technique for the medullary canal of the long bone. The procedure of intramedullary bone endoscopy (IBE) was performed on 4 tibial amputations. By slowly pushing the endoscope distally under visual control and endoscopic preparation of the medullary canal, a "neocavum" for endoscopy was created. During the procedure, the intramedullary pressure was continuously measured: Highest peak pressure was 125 mm Hg. We therefore conclude that the procedure of IBE is a safe intervention within the medullary canal of the long bone. Local or systemic side effects, common to intramedullary reaming in fracture treatment (fat-embolism, local bone necrosis, reduction in cortical blood flow) should not be expected.

Mobile IT solutions for home health care.

PURPOSE: Harnessing the advantage of mobile information technology (IT) solutions at the point of care and contributing to patients' safety by involving them. DESIGN/METHODOLOGY/APPROACH: International collaboration between specialists in health communication processes and information management and systems. METHODS USED: Case studies, design science. FINDINGS: User-friendly portable IT applications going beyond documentation of patient records and administration require an understanding of complex communication processes between patients and the different caregivers. Home care increasingly faces structural deficits to be mitigated by integration of IT solutions. Platforms chosen in combination with services should be well established. How to implement this must be scrutinized by comprehensive research as initiated here. Preliminary results indicate potentials for novel mobile applications. PRACTICAL IMPLICATIONS: Contribution to increasing patients' safety by developing mobile solutions to support health care. Those may also contribute to cost savings in health care. SOCIAL IMPLICATIONS: Health care experiences an increasing significance for Western industrialized countries because of demographic developments. Care generally shifts from inpatient to outpatient settings; the global shortage of qualified nurses becomes even more prevailing. More support, among others by IT and enhanced interprofessional communication, is demanded for an improved quality and efficiency of care processes. ORIGINALITY/VALUE: Mutual approach benefits from the partner's understanding of complex interactions among clinicians, health services, and patients: the ability to design, monitor, and evaluate research strategies integrating care (information) needs is invaluable when applying creative technology solutions within health care domain.

Biallelic inactivation of the SDHC gene in renal carcinoma associated with paraganglioma syndrome type 3.

The etiology and pathogenesis of renal cell carcinoma (RCC) are only partially understood. Key findings in hereditary RCC, which may be site specific or a component of a syndrome, have contributed to our current understanding. Important heritable syndromes of RCC are those associated with pheochromocytoma, especially von Hippel-Lindau disease (VHL) associated with germline VHL mutations, and pheochromocytoma and paraganglioma syndrome (PGL) associated with mutations in one of the four genes (SDHA-D) encoding succinate dehydrogenase. A subset of individuals with SDHB and SDHD germline DNA mutations and variants develop RCC. RCC has never been described as a component of SDHC-associated PGL3. The European-American Pheochromocytoma and Paraganglioma Registry comprises 35 registrants with germline SDHC mutations. A new registrant had carotid body tumor (CBT) and his mother had CBT and bilateral RCC. Blood DNA, paragangliomas, and RCCs were analyzed for mutations and loss-of-heterozygosity (LOH) in/flanking SDHC and VHL. The proband with unilateral CBT had a germline SDHC c.3G>A (p.M1I) mutation. His mutation-positive mother had CBT at age 42, clear cell RCC (ccRCC) at age 68, and papillary RCC (pRCC) at age 69. Both paraganglial tumors showed somatic LOH of the SDHC locus. Both ccRCC and pRCC did not have a somatic SDHC mutation but showed LOH for intragenic and flanking markers of the SDHC locus. LOH was also present for the VHL locus. Our findings suggest that RCC is a component of PGL3. Biallelic inactivation of the SDHC gene may represent a new pathway of pathogenesis of syndromic and nonsyndromic RCC, perhaps of both clear cell and papillary histologies.

An unusual cause of dysphagia: esophageal tuberculosis.

A 25-year old Indian exchange-student presented to our department with a three week history of dysphagia. Diagnostic evaluation by upper gastrointestinal endoscopy, endosonography and chest-CT revealed a tumor-suspect ulcerative lesion at the middle esophagus, and a mediastinal lymph node enlargement. Initial histopathological evaluation of multiple esophageal tissue biopsies showed an unspecific esophagitis without signs for malignancy. A positive T-spot (R) TB assay result, together with the bronchoscopic detection of a small exophytic lesion at the right main bronchus depicting caseating epitheloid cell granulomas, provided evidence for a tuberculous etiology of the esophageal tumor. Multiple further deep submucosal biopsies were needed to finally detect epitheloid cell granulomas in the esophageal lesion. Microbacteriological or molecular tests were negative for M. tuberculosis. Tuberculostatic treatment resulted in a good response with complete remission of the esophageal lesion and the mediastinal lymph node enlargement. Esophageal tuberculosis is rare in developed countries, and its possible presence deserves consideration particularly in patients at risk.

Prognostic relevance of altered pRb and p53 protein expression in surgically treated non-small cell lung cancer patients.

OBJECTIVE: The prognostic value of pRb and p53 altered expression in non-small cell lung cancer (NSCLC) remains debatable. We assessed the occurrence of altered pRb and p53 protein expression, and the prognostic value of these assays considered as separate and combined variables in operable NSCLC. The study group included 195 NSCLC consecutive patients from one institution who underwent curative pulmonary resection between 1994 and 1999. METHODS: Expression of pRb and p53 was assessed immunohistochemically with the use of monoclonal antibodies (LM95.1 and Pab 1801, Oncogene Science, respectively). RESULTS: A lack of pRb and abnormal p53 protein expression were found in 57 (29%) and 92 samples (47%), respectively, whereas both abnormalities (pRb-/p53+) occurred in 24 samples (12%). There was no relationship between altered pRb/p53 expression and major clinico-pathological characteristics, neither was there a significant difference in disease-free and overall survival between particular groups of patients with tumors carrying four possible pRb/p53 phenotypes. In uni- and multivariate analysis, the only variable associated with shortened disease-free and overall survival was stage of disease (p < 0.001) and degree of tumor differentiation (p = 0.005). CONCLUSION: These results suggest that altered pRb and p53 expression does not provide prognostic information in operable NSCLC patients.