Fetal Tissue Procurement for Karyotype Analysis: Clinician or Pathologist - Which is Better?

UNLABELLED: Chromosomal abnormalities are detected in up to 13% of stillbirths and over 20% of those with developmental anomalies. These estimates may be low since up to 50% of samples fail to achieve a result due to microbial overgrowth or nonviability. Tissue for cytogenetics can be procured at bedside by the clinician or by the pathologist in the laboratory. With clinical collection, tissue is placed into culture media immediately, increasing chances of growth. However, collection competes for attention with other activities, which may result in microbial overgrowth or selection of maternal rather than fetal tissue. Laboratory procurement occurs in a controlled environment using sterile technique, but delay in collection may decrease viability. Our goal was to determine which collection method yields better results. METHODS: We reviewed cases from 2007-2013 that had two samples submitted for cytogenetics, one from the clinician and one from the pathologist. Specimen source, delivery, collection, and culture setup times, harvest date, cell growth, microbial overgrowth, maternal contamination and final result were obtained from medical records and cytogenetic culture sheets. FINDINGS: There was no difference in growth rate, maternal cell contamination, or reporting time between clinician- and pathologist-procured samples despite delay in collection time for laboratory samples. Clinical samples had more microbial overgrowth. Compared to samples collected at bedside, samples collected in the laboratory had a lower rate of microbial contamination with similar growth and maternal cell contamination rates, despite prolonged time to collection. Collecting samples both at bedside and in the laboratory is unnecessary.

Urothelial Superior Vena Cava Syndrome with Limited Response to Radiation Therapy.

Radiation therapy (RT) is the standard of care for cases of superior vena cava (SVC) syndrome secondary to metastatic adenopathy. Histologies vary in radiosensitivity and response time, making alternative therapies such as chemotherapy and/or intravenous stenting preferable alternative options for certain diagnoses. Metastatic urothelial carcinoma is a particularly rare cause of SVC syndrome with only 3 cases reported in the literature. Consequently, optimal management remains challenging, particularly in cases of high tumor burden. Here we present a case of highly advanced metastatic urothelial cancer with SVC syndrome and tracheal compression. The patient started urgent RT but expired midway through her treatment course due to systemic progression of disease, requiring SVC and tracheal stenting. The authors review the literature including discussion of the few other known cases of SVC syndrome due to urothelial carcinoma and a review of this histology's response to RT. This experience suggests, that in cases of SVC syndrome with widespread advanced disease, stenting and chemotherapy with or without RT may be the most important initial treatment plan, depending on goals of care.

Tubocutaneous fistula in a premature infant.

Fistulous tracts between the uterus and skin were more common in the preantibiotic era and most often occurred after pelvic surgery. Tubocutaneous fistulas constituted a subset of this form of operative complication. With the improvement of operative techniques and use of antibiotics, the incidence of these fistulas is greatly reduced. In cases reported since 1963, the youngest patient to develop a tubocutaneous fistula was 15 years old. Reported here is an infant delivered at 25 weeks' gestation, who developed necrotizing enterocolitis requiring 2 surgical interventions. At the time of insertion of a tunneled central venous catheter, the surgeon noted a mass in the right lower quadrant, which he excised. A noninflamed tubocutaneous fistula was identified pathologically with only the distal portion of the tube present. The child's history is similar to other reports in that she had previous operations and had developed significant fibrous abdominal adhesions. Her history is unique in that she is the youngest reported case and hers is the 1st report of this complication following surgery for necrotizing enterocolitis.

What is adequate sampling of extraplacental membranes?: a randomized, prospective analysis.

CONTEXT: It is the generally accepted practice to submit 1 or 2 membrane rolls when examining placentas. OBJECTIVE: To determine whether obtaining additional sections would increase diagnostic yield and, if so, to what degree. DESIGN: A membrane roll section was prospectively procured from each quadrant of its respective singleton placenta. These placentas were submitted for routine pathologic examination, the process of which was entirely separate from this study. All study sections were randomized and assigned new numbers, thereby blinding the pathologist to the placenta of origin. We evaluated the incidence of acute chorionitis/chorioamnionitis (AC/A) and atherosis when 1, 2, 3, or 4 slides were examined. The diagnostic yield from all possible combinations of single, pairs, and triplets of sections was tabulated. When an additional slide identified more extensive acute inflammation than what was demonstrated initially, the AC/A was upstaged. RESULTS: With 1 section examined, 7 to 10 placentas had AC/A. With 2 sections, 10 to 15 placentas had AC/A; with 3 sections, 16 to 18 cases; and with 4 sections, 19 cases. Additional sections upstaged the AC/A diagnosis infrequently. A total of 4 of 53 placentas had atherosis, based on review of all 4 slides. One slide identified 1 to 3 cases of atherosis. With a second and third section, the yield increased to 2 to 4 and 3 to 4, respectively. CONCLUSIONS: Review of a single membrane roll identified, at most, 53% of cases of AC/A and 50% of cases of atherosis. Additional sections increased the yield for both diagnoses in a roughly linear manner.

Detection of occult sentinel lymph node micrometastases by immunohistochemistry in breast cancer. An NSABP protocol B-32 quality assurance study.

BACKGROUND: Occult metastases, by definition, are not detected on initial examination. They may be present on slides but missed during screening or may be present in paraffin embedded tissue blocks and undetected without additional levels. Anticytokeratin immunohistochemistry (CK IHC) enhances detection of occult metastases, particularly micrometastases (> 0.2 mm but not larger than 2.0 mm) or isolated tumor cell clusters (< or = 0.2 mm). This study defines the rate at which pathologists miss metastases on CK IHC of sentinel lymph nodes (SLN). METHODS: CK IHC sections 0.5 and 1.0 mm from the original surface of SLN tissue blocks were screened by pathologists using standard bright field light microscopes (LM) and by supervised computer assisted cell detection (CACD). All blocks were from breast cancer patients, initially classified 'node negative' on review of routinely stained sections from the surface of each block. Cases missed by LM screening but detected by CACD defined false negative screens. RESULTS: Of 236 cases screened, LM detected 34 (14.4%; 95% CI: 9.6-20.2) cases and, in the 202 cases negative by LM, CACD detected an additional 30 (14.9%; 95% CI: 9.6-21.2%) cases with occult metastases. Occult metastases missed by LM screening ranged from 0.01 to 0.1 mm in greatest dimension. The probability of missing an occult metastasis < or = 0.02 mm; < or = 0.05 mm, and < or = 0.10 mm was 75%, 69.2%, and 61.2%, respectively. No occult metastases larger than 0.10 mm were missed by LM screening. CONCLUSIONS: Pathologists screening the CK IHC stained slides may frequently miss detecting metastases < 0.10 mm.

Significance of perivillous fibrin/oid deposition in uterine evacuation specimens.

A small proportion of miscarriage specimens obtained by uterine evacuation exhibit increased perivillous fibrin/oid deposition (PVFD). To understand the significance of this finding, the authors reviewed cases from 5/20/02 to 11/10/04 in which surgical pathologists recognized this finding and documented it in their reports. Of 55 cases initially collected, 29 contained at least 30 villi on the slide with at least 50% of villi showing adherent fibrin/oid, and showed no molar change or extensive coagulative necrosis. Review of these 29 cases identified 2 patterns of fibrin/oid deposition: nodular (8 cases) and diffuse (21 cases). A maternal and gestational age-matched control group was collected (21 cases). The diffuse pattern of PVFD encased villi and had tinctorial characteristics of fibrin. Its pattern is similar to that seen in maternal floor infarction and massive perivillous fibrin deposition. The nodular pattern is an exaggerated form of the nodular deposition of matrix-type fibrinoid seen in normal placentas. Comparison of the 3 groups identified a longer duration of vaginal bleeding before uterine evacuation in the diffuse pattern (P=0.001). One patient had a history of 8 miscarriages, 2 of which were represented in this study. All other obstetrical factors studied showed no significant difference between the 3 groups. Thus, diffuse PVFD in miscarriage specimens is associated with prolonged vaginal bleeding and not with maternal thrombophilia or autoimmune disease. Rarely, a patient showing this pattern may have a history of repeated miscarriages.

Cutting injuries in an academic pathology department.

CONTEXT: Cutting injuries pose an infrequent but serious threat to anatomic pathology personnel. Although cut-resistant gloves may reduce this danger, it is imperative to recognize specific behaviors that increase the chance of an injury. OBJECTIVE: To examine the incidence of cutting injuries in an academic pathology department and the mechanisms by which such injuries occurred. DESIGN: Hospital Report of Event forms completed for laboratory incidents of cutting injury from March 1998 to September 2003 were evaluated. Further information regarding the incidents was obtained, when possible, by interviews with those personnel involved. SETTING: A university-based pathology laboratory was the setting for this study. On average, 505 autopsies and 29,000 surgical specimens were processed each year during the 5.5-year time period. PARTICIPANTS: Pathology attending physicians, residents, dieners, and pathologists' assistants who performed autopsies and surgical specimen examinations. RESULTS: Eight scalpel injuries occurred during the study period. No needle-stick injuries were reported. Searching for lymph nodes and cutting firm tissue each accounted for 3 of the injuries. Only 2 of the 8 individuals were in compliance with the departmental policy regarding protective glove wear. Hospital Report of Event forms alone failed to elicit sufficient detail regarding the mechanism of injury. CONCLUSIONS: A laboratory-based form may be necessary to supplement the hospital form, so as to obtain full details of each injury. This information may then be disseminated to all who handle blades, with the goal of preventing future cutting injuries.

The protein C system in placental massive perivillous fibrin deposition.

Massive perivillous fibrin deposition (MPFD) is associated with intrauterine growth retardation and first-trimester and second-trimester spontaneous abortion. Histologically, villi near the maternal interface are completely surrounded by fibrinoid material. This work compared the expression of thrombomodulin (TM) and endothelial protein C receptor (EPCR) in early miscarriage specimens with and without MPFD. Ten specimens with a gestational age of 7-12 weeks (mean 10 weeks) and 10 age-matched miscarriage specimens lacking MPFD were sampled. Formalin-fixed paraffin-embedded sections were stained with monoclonal antibodies against TM and EPCR using an immunoperoxidase method. The slides were independently reviewed by two pathologists using a semiquantitative grading system. Among unaffected villi, there was no difference in staining for TM or EPCR in cases of massive perivillous fibrin deposition compared with the control group. In the MPFD cases, loss of membrane positivity was noted for both TM and EPCR at the junction between normal villous epithelium and villous epithelium with deposition of fibrin. This could imply an underlying defect of trophoblastic protein C activation. Alternatively, it may represent a degenerative change secondary to impedence of oxygen and nutrient supply to the trophoblastic epithelium.

Maternal vascular underperfusion: nosology and reproducibility of placental reaction patterns.

Placental examination can be a useful tool for specifying the etiology, prognosis, and recurrence risk of pregnancy disorders. The purpose of this study was to test the reliability of a predetermined set of placental reaction patterns seen with maternal vascular underperfusion in the hope that this might provide a useful diagnostic framework for practicing pathologists. Study cases (14 with clinical and pathologic evidence of maternal underperfusion plus 6 controls) were evaluated for the presence or absence of 11 lesions by eight perinatal pathologists. After analysis of initial results, diagnostic criteria were refined and a second, overlapping set of cases was reviewed. The collective sensitivity, specificity, and efficiency of individual assessments for the 11 lesions relative to the group consensus ranged from 74-93% (22/33 > 90%). Reproducibility was measured by unweighted kappa-values and interpreted as follows: < 0.2 poor, 0.2-0.6 fair/moderate, > 0.6 substantial. Kappa values for lesions affecting villi and the intervillous space were increased syncytial knots (any -0.42, severe -0.50), villous agglutination (0.42), increased intervillous fibrin (0.25), and distal villous hypoplasia (0.57). Individual estimates of percent involvement for syncytial knots, intervillous fibrin, and distal villous hypoplasia were correlated with placental and fetal weight for gestational age. Extent of increased intervillous fibrin showed the strongest correlation with both placental weight ( R = -0.64) and fetal weight ( R = -0.45). Kappa values for lesions affecting maternal vessels and the implantation site were acute atherosis (0.50), mural hypertrophy of membrane arterioles (0.43), muscularized basal plate arteries (0.48), increased placental site giant cells (0.54), and immature intermediate trophoblast (0.36). Correlation of maternal vessel and implantation site lesions with the clinical diagnosis of preeclampsia showed that excessive placental site giant cells and immature intermediate trophoblast were more sensitive and efficient predictors, whereas atherosis and muscularized basal plate arteries were more specific. Kappa value for a thin umbilical cord, a possible indicator of fetal volume depletion, was 0.61. Reproducibility for a global impression of maternal vascular underperfusion, taking into account all of the above lesions, was moderate (kappa 0.54) and improved after inclusion of additional pathologic and clinical data (kappa 0.68). Adoption of this clearly defined, clinically relevant, and pathologically reproducible terminology could enhance clinicopathologic correlation and provide a more objective framework for future clinical research.

Prenatal role of the ductus arteriosus in absent pulmonary valve syndrome.

Absent pulmonary valve with ventricular septal defect is associated with ductal agenesis and markedly dilated main and branch pulmonary arteries. The less common variant with intact ventricular septum generally exhibits a patent ductus and smaller branch pulmonary arteries, and may be associated with tricuspid atresia. We identified 7 patients with the prenatal diagnosis of absent pulmonary valve, 5 with ventricular septal defect (Group 1) and 2 with an intact ventricular septum (Group 2). Imaging, color Doppler, and pulsed-Doppler recordings were analyzed. The branch and main pulmonary arteries were measured and expressed as a ratio with the descending aorta. Pulmonary regurgitation time (PRT) and diastolic acceleration time (DAT) were derived, and DAT/PRT was calculated to characterize diastolic pulmonary flow. Group 1 patients all had a large ventricular septal defect, normal biventricular size and function, and dilated main and branch pulmonary arteries. Group 2 patients had dilated main but smaller branch pulmonary arteries, moderate right ventricular dilation with severe dysfunction, and limited or absent tricuspid inflow. Group 1 demonstrated shorter acceleration time and earlier peak velocity, resulting in a smaller DAT/RT ratio. We speculate that free communication between the fetal aorta and the ventricles may limit atrial inflow and elevate diastolic pressure, affecting cardiac output, ventricular function, and atrioventricular valve development. With an intact ventricular septum, these physiologic and anatomic repercussions are limited to the right ventricle, but with a ventricular septal defect, both ventricles would experience similar consequences and cardiac performance could be critically impaired.