Novel JAK2 Exon 14 Mutations L611S or N622Y in cis with JAK2V617F Are Associated with Distinct Clinical Phenotype of Polycythemia Vera and Concurrent Eosinophilia.

Eosinophilic phenotypes in polycythemia vera (PV) and essential thrombocythemia (ET) are rare and poorly characterized. Co-occurring JAK2 mutations in cis, specifically L611S or N622Y mutations, appear to result in a more aggressive clinical phenotype. PV/ET with eosinophilic phenotypes may require full next-generation sequencing to capture co-occurring mutations as opposed to more prevalent single-gene assays. These eosinophilic phenotypes are highly thrombotic and systemic symptoms appear responsive to early use of the janus kinase inhibitor ruxolitinib.

Programmed necroptosis is upregulated in low-grade myelodysplastic syndromes and may play a role in the pathogenesis.

Myelodysplastic syndrome (MDS) is characterized by persistent cytopenias and evidence of morphologic dysplasia in the bone marrow (BM). Excessive hematopoietic programmed cell death (PCD) and inflammation have been observed in the bone marrow of patients with MDS, and are thought to play a significant role in the pathogenesis of the disease. Necroptosis is a major pathway of PCD that incites inflammation; however, the role of necroptosis in human MDS has not been extensively investigated. To assess PCD status in newly diagnosed MDS, we performed immunofluorescence staining with computational image analysis of formalin-fixed, paraffin-embedded BM core biopsies using cleaved caspase-3 (apoptosis marker) and necroptosis markers (receptor-interacting serine/threonine-protein kinase 1 [RIPK1], phospho-mixed lineage kinase domain-like protein [pMLKL]). Patients with MDS, but not controls without MDS or patients with de novo acute myeloid leukemia, had significantly increased expression of RIPK1 and pMLKL but not cleaved caspase-3, which was most evident in morphologically low-grade MDS (<5% BM blasts) and in MDS with low International Prognostic Scoring System risk score. RIPK1 expression highly correlated with the distribution of CD71+ erythroid precursors but not with CD34+ blast cells. We found that necroptosis is upregulated in early/low-grade MDS relative to control participants, warranting further study to define the role of necroptosis in the pathogenesis of MDS and as a potential biomarker for the diagnosis of low-grade MDS.

Anaplastic Large Cell Lymphoma Manifesting as Pleural Effusion in a Patient with Long-Standing Eosinophilia.

Anaplastic large cell lymphoma (ALCL) is a lymphoma of T-cell origin, characterized by the presence of large lymphoid cells with abundant cytoplasm and pleomorphic, often horseshoe-shaped nuclei (hallmark cells), as well as strong and uniform expression of cluster of differentiation (CD)30. Two distinct clinicopathologic categories of ALCL include primary cutaneous ALCL and systemic ALCL. Systemic ALCL is further classified into anaplastic lymphoma kinase (ALK)-positive, ALK-negative, and breast implant-associated ALCL. Most ALCLs occurring in adults are ALK negative and present in lymph nodes rather than extranodal sites.Primary diagnosis of ALCL in the pleural fluid is extremely rare, with no convincing recent reports available that are based in current understanding of this entity. Herein, we describe a well-characterized case of ALK-negative ALCL with no rearrangement but amplification of DUSP22/IRF4, diagnosed by cytologic examination of the pleural effusion in a 68-year-old white man with a 3-year history of unexplained eosinophilia and pulmonary infiltrates. Also, we present a review of the literature and discuss the current understanding of ALCL based on the 2016 revision of the World Health Organization (WHO) classification of lymphoid neoplasms.

Trends in Bone Marrow Sampling and Core Biopsy Specimen Adequacy in the United States and Canada: A Multicenter Study.

OBJECTIVES: To assess bone marrow (BM) sampling in academic medical centers. METHODS: Data from 6,374 BM samples obtained in 32 centers in 2001 and 2011, including core length (CL), were analyzed. RESULTS: BM included a biopsy (BMB; 93%) specimen, aspirate (BMA; 92%) specimen, or both (83%). The median (SD) CL was 12 (8.5) mm, and evaluable marrow was 9 (7.6) mm. Tissue contraction due to processing was 15%. BMB specimens were longer in adults younger than 60 years, men, and bilateral, staging, and baseline samples. Only 4% of BMB and 2% of BMB/BMA samples were deemed inadequate for diagnosis. BM for plasma cell dyscrasias, nonphysician operators, and ancillary studies usage increased, while bilateral sampling decreased over the decade. BM-related quality assurance programs are infrequent. CONCLUSIONS: CL is shorter than recommended and varies with patient age and sex, clinical circumstances, and center experience. While pathologists render diagnoses on most cases irrespective of CL, BMB yield improvement is desirable.

Fine-needle aspiration is superior to needle core biopsy as a sample acquisition method for flow cytometric analysis in suspected hematologic neoplasms.

BACKGROUND: Common minimally invasive methods for acquiring samples for flow cytometric immunophenotyping (FCI) include fine-needle aspiration (FNA) and needle core biopsy (NCB). FCI requires a sufficient quantity of viable cells for adequate evaluation. METHODS: We collected patient data from our files of all FCI cases sampled via FNA or NCB from January 1, 2003 and June 1, 2012. Total Viable Cells (TVC) was calculated by multiplying the volume, viability, and concentration and then converted to logarithmic scale as "Log TVC." Statistical analysis was performed using SPSS. RESULTS: Five hundred seventy-one FCI cases at our institution were reviewed covering the period from 2003 to 2012 and 456 total cases were analyzed. One hundred sixteen cases were sampled by NCB and 340 were sampled by FNA. Comparing FNA to NCB subgroups demonstrated FNA to be superior in mean specimen viability, TVC, and cases with a final FCI interpretation. The cellularity of the sample (in Log TVC) correlates with the likelihood of achieving a FCI interpretation. The point where at least 50% of cases have a diagnostic FCI interpretation occurs between Log TVC of 5.0-5.25. However, FNA based cases had a higher proportion of samples with an indeterminate final diagnosis. CONCLUSIONS: FNA was found to be significantly superior to NCB in obtaining material for FCI. However, NCB resulted in fewer indeterminate final diagnoses due to benefit of histologic correlation. In our opinion, NCB for histology combined with dedicated FNA material for FCI may yield the best results for a minimally invasive approach to the diagnosis of hematologic neoplasms.

Expression of c-FLIP in classic and nodular lymphocyte-predominant Hodgkin lymphoma.

Different molecular pathways are believed to be involved in the pathogenesis of classic Hodgkin lymphoma as opposed to non-Hodgkin lymphoma. Antiapoptotic mechanisms have been proposed for classic Hodgkin lymphoma, including expression of the cellular Fas-associated death domain-like interleukin-1beta-converting enzyme inhibitory protein (c-FLIP), which plays a critical role in resistance to CD95/Fas-mediated apoptosis. In this study, we compare the expression of c-FLIP in the neoplastic cells of classic Hodgkin lymphoma and nodular lymphocyte-predominant Hodgkin lymphoma cases. Sixteen cases of classic Hodgkin lymphoma and 19 cases of nodular lymphocyte-predominant Hodgkin lymphoma were reviewed. Of 16 classic Hodgkin lymphoma cases, 13 cases (81%) were c-FLIP-positive, compared with 6 of 19 (32%) nodular lymphocyte-predominant Hodgkin lymphoma cases. Strong cytoplasmic staining was seen in 7 of 13 c-FLIP-positive classic Hodgkin lymphoma cases, in contrast with only 2 of 6 c-FLIP-positive nodular lymphocyte-predominant Hodgkin lymphoma cases. The 2 cases of nodular lymphocyte-predominant Hodgkin lymphoma with strong c-FLIP expression were associated with transformation to large B-cell lymphoma. An additional 15 cases of diffuse large B-cell lymphoma were studied for c-FLIP expression. All but 1 were c-FLIP-positive. In conclusion, we detected c-FLIP in a significantly lower proportion of nodular lymphocyte-predominant Hodgkin lymphoma cases compared with classic Hodgkin lymphoma cases. Therefore, c-FLIP expression may not be the major mechanism of pathogenesis in nodular lymphocyte-predominant Hodgkin lymphoma. However, strong c-FLIP expression in nodular lymphocyte-predominant Hodgkin lymphoma was associated with transformation to large B-cell lymphoma in 2 cases. c-FLIP expression is not limited to Hodgkin lymphoma, because the majority of diffuse large B-cell lymphoma cases tested were strongly c-FLIP-positive.

Fine-Needle Aspiration is Superior to Needle Core Biopsy as a Sample Aquisition Method for Flow Cytometric Analysis in Suspected Hematologic Neoplasms.

Background: Common minimally invasive methods for acquiring samples for flow cytometric immunophenotyping (FCI) include fine needle aspiration (FNA) and needle core biopsy (NCB). FCI requires a sufficient quantity of viable cells for adequate evaluation. Methods: We collected patient data from our files of all FCI cases sampled via FNA or NCB from 1/1/03 and 6/1/12. Total Viable Cells (TVC) was calculated by multiplying the volume, viability and concentration and then converted to logarithmic scale as "Log TVC." Statistical analysis was performed using SPSS. Results: 571 FCI cases at our institution were reviewed covering the period from 2003 to 2012 and 456 total cases were analyzed. 116 cases were sampled by NCB and 340 were sampled by FNA. Comparing FNA to NCB subgroups demonstrated FNA to be superior in mean specimen viability, TVC, and cases with a final FCI interpretation. The cellularity of the sample (in Log TVC) correlates with the likelihood of achieving a FCI interpretation. The point where at least 50% of cases have a diagnostic FCI interpretation occurs between Log TVC of 5.0 - 5.25. However, FNA based cases had a higher proportion of samples with an indeterminate final diagnosis. Conclusions: FNA was found to be significantly superior to NCB in obtaining material for FCI. However, NCB resulted in fewer indeterminate final diagnoses due to benefit of histologic correlation. In our opinion, NCB for histology combined with dedicated FNA material for FCI may yield the best results for a minimally invasive approach to the diagnosis of hematologic neoplasms. © 2014 Clinical Cytometry Society.

Predictive significance of absolute lymphocyte count and morphology in adults with a new onset peripheral blood lymphocytosis.

AIMS: Lymphocytosis is commonly encountered in the haematology laboratory. Evaluation of blood films is an important screening tool for differentiating between reactive and malignant processes. The optimal lymphocyte number to trigger morphological evaluation of the smear has not been well defined in the literature. Likewise, the significance of lymphocyte morphology has not been well studied and there are no consensus guidelines or follow-up recommendations available. We attempt to evaluate the significance of lymphocyte morphology and to define the best possible cut-off value of absolute lymphocyte count for morphology review. METHODS: 71 adult patients with newly detected lymphocytosis of 5.0×10(9)/L or more were categorised to either a reactive process or a lymphoproliferative disorder. We performed statistical analysis and morphology review to compare the difference in age, gender, lymphocyte count and morphological features between the two groups. Receiver operating characteristic analysis was performed to determine an optimal lymphocyte number to trigger morphology review. RESULTS: Lymphoproliferative disorders are associated with advanced age and higher lymphocyte count. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of lymphocyte morphology as a screening test were 0.9, 0.59, 0.60, 0.58 and 0.71, respectively. The optimal cut-off of lymphocyte number for morphology review was found to be close to 7×10(9)/L. CONCLUSIONS: We found a moderate interobserver agreement for the morphological assessment. 'Reactive' morphology was very predictive of a reactive process, but 'malignant' morphology was a poor predictor of a lymphoproliferative disorder.

Histological and immunohistochemical features of the spleen in persistent polyclonal B-cell lymphocytosis closely mimic splenic B-cell lymphoma.

Persistent polyclonal B-cell lymphocytosis (PPBL) is rare and intriguing hematological disorder predominantly reported in young to middle- aged smoking women. It is characterized by persistent moderate polyclonal B-cell lymphocytosis with circulating hallmark binucleated lymphocytes and elevated polyclonal serum IgM. Most patients have benign clinical course on long-term follow-up. Some pathologic features of PPBL may resemble malignant lymphoma, including morphology as well as frequent cytogenetic and molecular abnormalities. Significant symptomatic splenomegaly requiring splenectomy is very unusual for this disorder; therefore there is a lack of descriptions of the morphologic features of the spleen in the literature. We present here one of the first detailed descriptions of the morphologic and immunohistochemical features of the spleen from a young female with PPBL who developed massive splenomegaly during 6-year follow up. Splenectomy was performed for symptomatic relief and suspicion of malignant process. The morphological and immunohistochemical features of the spleen closely mimicked involvement by B-cell lymphoma, however there was no monotypic surface light chain restriction seen by flow cytometry and no clonal rearrangement of IgH gene was detected by molecular analysis. Evaluating a splenectomy sample in cases like this may present a diagnostic challenge to pathologists. Therefore, correlation with B cell clonality studies (by flow cytometry and molecular analysis), clinical findings and peripheral blood morphology searching for characteristic binucleated lymphocytes is essential to avoid misdiagnosing this benign process as B-cell lymphoma. We also present here a literature review on pathogenesis of PPBL. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/5329558967545656.

Mediastinal neoplasms in patients with Graves disease: a possible link between sustained hyperthyroidism and thymic neoplasia?

BACKGROUND: Anterior mediastinal masses are a rare but well documented finding in Graves disease. The vast majority of these lesions represents benign thymic hypertrophy and regress after treatment of the hyperthyroidism. A small percentage of these cases however represent neoplastic/malignant diseases which require further treatment. CASES: 12 year old boy with one year history of refractory Graves disease was found to have an anterior mediastinal mass and underwent curative thyroidectomy for sustained hyperthyroidism. Cervical lymphadenopathy was detected during the procedure and biopsy was obtained. A 23 year old woman who presented with a one month history of hyperthyroid symptoms, was diagnosed with Graves disease and also was found to have an anterior mediastinal mass on imaging. Biopsy of the anterior mediastinal mass was obtained and subsequently the patient underwent robotic thymectomy. Histologic examination and immunophenotyping of the cervical lymph node in a 12 year old boy revealed neoplastic proliferation of T lymphoblasts diagnostic of T lymphoblastic leukemia/lymphoma. Examination of the anterior mediastinal mass biopsy in the 23 year old woman revealed type B1 thymoma which was confirmed after examination of the subsequent robotic thymectomy specimen. CONCLUSION: This is the first reported case of T cell lymphoblastic lymphoma and the third reported case of thymoma associated with sustained hyperthyroidism due to Graves disease. These cases indicate that an anterior mediastinal mass in a patient with active Graves disease may be due to a neoplastic cause, which may require definitive treatment. Caution should be exercised when dismissing a mediastinal mass as benign thymic hyperplasia in patients with active Graves disease.

A novel breast/ovarian cancer peptide vaccine platform that promotes specific type-1 but not Treg/Tr1-type responses.

In light of lack of efficacy associated with current cancer vaccines, we aimed to develop a novel vaccine platform called DepoVax as a therapeutic vaccine for breast/ovarian cancer. This study was designed to examine the efficacy of this novel platform over conventional emulsion vaccine using human class I MHC transgenic mice. We have developed a water-free depot vaccine formulation (DPX-0907) with high immune activating potential. Naturally processed peptides bound to HLA-A2 molecules isolated from independent breast and ovarian tumor cell lines, but not normal cells, were isolated and used as antigens in DPX-0907 along with a proprietary adjuvant and a T helper peptide epitope. Efficacy of vaccine was tested in immunized HLA-A*0201/H2Dd transgenic mice by measuring the frequency of IFN-gamma secreting cells in the draining lymph nodes, and regulatory T-cell frequencies in the spleen. Compared with a water-in-oil emulsion vaccine, DPX-0907 enhanced IFN-gamma+CD8+ T cells in vaccine site-draining lymph nodes, as seen by immunofluorescence staining and increased the frequency of IFN-gamma+ lymph node cells as seen by enzyme-linked immunosorbent spot assay. Notably, while conventional vaccine formulations elicited elevated levels of splenic Foxp3+CD4+ and IL10-secreting T cells, this was not the case for DPX-0907-based vaccines, with treated animals exhibiting normal levels of regulatory T cells. These data support the unique capabilities of a vaccine formulation containing novel tumor peptides and DPX-0907 to elicit type-1 dominated, specific immunity that may represent a potent clinical therapeutic modality for patients with breast or ovarian carcinoma.

Activated protein C improves ischemic flap survival and modulates proangiogenic and antiinflammatory gene expression.

BACKGROUND: Flap necrosis remains a major complication in reconstructive surgery. The authors evaluated whether systemic activated protein C, a natural serum anticoagulant with anti-inflammatory, proangiogenic, and cytoprotective properties, can improve ischemic skin flap survival. METHODS: Cranially based dorsal cutaneous flaps were elevated on 44 rats. Animals received intravenous injections of activated protein C (25 microg/kg) or saline. Rats were divided into three groups depending on the timing of the first injection: postoperative (45 minutes postoperatively, n = 12), late preoperative (45 minutes preoperatively, n = 5), and early preoperative (3 hours preoperatively, n = 5). In all groups, second and third injections were performed at 3 and 24 hours postoperatively. Flap survival was measured on day 7. Histological and real-time polymerase chain reaction specimens were collected on days 2 and 7 and at 3 and 24 hours, respectively. RESULTS: Postoperative activated protein C improved flap survival (68.9 +/- 4.3 percent) compared with control treatment (39.3 +/- 1.5 percent; p < 0.001). Late preoperative treatment produced diffuse flap hemorrhage. Early preoperative activated protein C injection produced near-complete flap survival (96.1 +/- 1.1 percent for activated protein C versus 50.1 +/- 3.3 percent for control; p < 0.001). Significantly fewer inflammatory cells, improved muscle viability, and increased blood vessel density were observed in activated protein C-treated versus control rats. Activated protein C treatment significantly reduced mRNA levels of intercellular adhesion molecule-1 and tumor necrosis factor-alpha, while increasing levels of Egr-1, vascular endothelial growth factor receptor 2, and Bcl-2. CONCLUSIONS: Systemic activated protein C modulates genes involved in angiogenesis, inflammation and apoptosis and improves ischemic flap survival.

Erdheim-Chester disease of the breast: a case report and review of the literature.

Erdheim-Chester disease (ECD) is a rare xanthomatous non-Langerhans cell histiocytosis which involves the marrow space of the long bones. Extraosseous sites most commonly affected include the eyes, lungs, pituitary glands, and kidneys. We report the case of a 49-year-old woman who presented with palpable breast nodules, followed by progressive soft tissue and subcutaneous disease, and involvement of the long bones, dysarthria, and dysphagia. The histopathologic features and skeletal radiography findings are consistent with ECD. This case represents an unusual presentation, which led to delayed diagnosis, as ECD of the breast has been rarely reported. ECD should be considered in the differential diagnosis of histiocytoid breast lesions, including fat necrosis and histiocytoid invasive mammary carcinoma.