Recommendations for pathologic practice using digital pathology: consensus report of the Korean Society of Pathologists.

Digital pathology (DP) using whole slide imaging (WSI) is becoming a fundamental issue in pathology with recent advances and the rapid development of associated technologies. However, the available evidence on its diagnostic uses and practical advice for pathologists on implementing DP remains insufficient, particularly in light of the exponential growth of this industry. To inform DP implementation in Korea, we developed relevant and timely recommendations. We first performed a literature review of DP guidelines, recommendations, and position papers from major countries, as well as a review of relevant studies validating WSI. Based on that information, we prepared a draft. After several revisions, we released this draft to the public and the members of the Korean Society of Pathologists through our homepage and held an open forum for interested parties. Through that process, this final manuscript has been prepared. This recommendation contains an overview describing the background, objectives, scope of application, and basic terminology; guidelines and considerations for the hardware and software used in DP systems and the validation required for DP implementation; conclusions; and references and appendices, including literature on DP from major countries and WSI validation studies.

WSB1 overcomes oncogene-induced senescence by targeting ATM for degradation.

Oncogene-induced senescence (OIS) or apoptosis through the DNA-damage response is an important barrier of tumorigenesis. Overcoming this barrier leads to abnormal cell proliferation, genomic instability, and cellular transformation, and finally allows cancers to develop. However, it remains unclear how the OIS barrier is overcome. Here, we show that the E3 ubiquitin ligase WD repeat and SOCS box-containing protein 1 (WSB1) plays a role in overcoming OIS. WSB1 expression in primary cells helps the bypass of OIS, leading to abnormal proliferation and cellular transformation. Mechanistically, WSB1 promotes ATM ubiquitination, resulting in ATM degradation and the escape from OIS. Furthermore, we identify CDKs as the upstream kinase of WSB1. CDK-mediated phosphorylation activates WSB1 by promoting its monomerization. In human cancer tissue and in vitro models, WSB1-induced ATM degradation is an early event during tumorigenic progression. We suggest that WSB1 is one of the key players of early oncogenic events through ATM degradation and destruction of the tumorigenesis barrier. Our work establishes an important mechanism of cancer development and progression in premalignant lesions.

WSB1 promotes tumor metastasis by inducing pVHL degradation.

The von Hippel-Lindau tumor suppressor pVHL is an E3 ligase that targets hypoxia-inducible factors (HIFs). Mutation of VHL results in HIF up-regulation and contributes to processes related to tumor progression such as invasion, metastasis, and angiogenesis. However, very little is known with regard to post-transcriptional regulation of pVHL. Here we show that WD repeat and SOCS box-containing protein 1 (WSB1) is a negative regulator of pVHL through WSB1's E3 ligase activity. Mechanistically, WSB1 promotes pVHL ubiquitination and proteasomal degradation, thereby stabilizing HIF under both normoxic and hypoxic conditions. As a consequence, WSB1 up-regulates the expression of HIF-1α's target genes and promotes cancer invasion and metastasis through its effect on pVHL. Consistent with this, WSB1 protein level negatively correlates with pVHL level and metastasis-free survival in clinical samples. This work reveals a new mechanism of pVHL's regulation by which cancer acquires invasiveness and metastatic tendency.

Parkin Regulates Mitosis and Genomic Stability through Cdc20/Cdh1.

Mutations in the E3 ubiquitin ligase Parkin have been linked to familial Parkinson's disease. Parkin has also been implicated in mitosis through mechanisms that are unclear. Here we show that Parkin interacts with anaphase promoting complex/cyclosome (APC/C) coactivators Cdc20 and Cdh1 to mediate the degradation of several key mitotic regulators independent of APC/C. We demonstrate that ordered progression through mitosis is orchestrated by two distinct E3 ligases through the shared use of Cdc20 and Cdh1. Furthermore, Parkin is phosphorylated and activated by polo-like kinase 1 (Plk1) during mitosis. Parkin deficiency results in overexpression of its substrates, mitotic defects, genomic instability, and tumorigenesis. These results suggest that the Parkin-Cdc20/Cdh1 complex is an important regulator of mitosis.

Multiple osteochondritis dissecans of knee joint in a patient with Wilson disease, focusing on magnetic resonance findings.

A 17-year-old man was admitted with a complaint of knee pain. He was diagnosed with Wilson disease by ophthalmologic and laboratory studies during hospitalization. Initial plain radiography of both knees showed multiple osteochondritis dissecans (OCD) on the medial and lateral femoral condyles of both knees. Subsequent magnetic resonance imaging showed multiple OCDs, which were symmetric on both knees. Subchondral cysts on the medial condyle and trochlear dysplasia were additionally evident on both femurs. We report this case with a focus on the imaging findings.

Diagnostic accuracy of narrow band imaging for predicting colon polyp histology can be affected by polyp characteristics.

BACKGROUND/AIMS: Narrow band imaging (NBI) is an optical endoscopic technique for predicting polyp histology during colonoscopy. However, it has not been elucidated the impact of polyp characteristics on the diagnostic capabilities of NBI. We aimed to evaluate which polyp characteristics can influence the diagnostic accuracy of NBI for discriminating neoplastic from non-neoplastic colorectal polyps. METHODOLOGY: A total of 232 colorectal polyps from 134 patients undergoing screening or surveillance colonoscopy were retrospectively analyzed. White light imaging (WLI) and NBI images of polyps were assessed by two experienced endoscopists and two trainees and then compared with histopathology. RESULTS: When classified according to polyp morphology, NBI as well as WLI had a significantly lower sensitivity and diagnostic accuracy for non-polypoid lesions than for polypoid lesions in both experienced and trainee groups. In contrast, the specificity of NBI and WLI for non-polypoid lesions was higher than that for polpyoid lesions. As for polyp size, the diagnostic accuracy of NBI for polyps ≤5mm was significantly lower than for polyps of 6 to 9mm or ≤10mm in the experienced group. CONCLUSIONS: NBI had a significantly lower diagnostic accuracy for predicting polyp histology in non-polypoid or diminutive colorectal lesions.

Microsurgical training with fresh chicken legs.

PURPOSE: With the increasing use of microsurgical techniques in clinical work, regular laboratory training in these techniques has become essential. Several specialized materials have been used for this purpose. We investigated whether effective training could be provided with greater convenience and less expense using fresh chicken thighs. Also, we present the histologic characteristics of chicken femoral neurovascular structures. METHODS: The femoral neurovascular bundles of fresh chicken thighs were dissected. Microanastomosis of vessels and nerves were performed with the aid of a microscope. Tissue from the midthigh of 8 chickens was examined histologically. RESULTS: It was found to reduce the time taken to perform anastomoses using the chicken thigh model with statistically significance. The mean diameters (± standard deviations) of the arteries, veins, and nerves were 2.04 ± 0.17 mm, 1.45 ± 0.06 mm, and 1.24 ± 0.08 mm, respectively. The observed tunica adventitia to media ratio was 1:1 and multiple nerve fascicles were wrapped in a single epineurium. Microsurgery training with this material provides several advantages: ready availability, minimal expense, no scheduling or location limitations, neurorrhaphy training, no need for special facilities for animal care or anesthesia, and no need for the trimming of adventitia. CONCLUSION: The femoral neurovascular bundles of chicken are an appropriate and effective model for teaching and practicing microsurgery.

Human cutaneous protothecosis: report of a case and literature review.

The Prototheca species is achlorophyllic algae and rarely causes human infection. Human protothecosis presents clinically as a cutaneous infection, olecranon bursitis, and disseminated systemic disease. We report a case of human cutaneous protothecosis involving the left wrist. A 68-year-old man presented with an ill-defined erythematous lesion with crust at the dorsal aspect of his left wrist. A punch biopsy was performed to reveal the histologic features of granulomatous inflammation with necrosis at the upper dermis, containing Prototheca organisms, of which, the characteristic features were highlighted by special staining. Through a molecular study, the Prototheca zopfii species was identified.

Expression of endothelial nitric oxide synthase in the uterus of patients with leiomyoma or adenomyosis.

AIM: To confirm the difference in the expression of endothelial nitric oxide synthase in the normal endometrium and myometrium of women who have leiomyoma or adenomyosis compared with controls, and its correlation with the pathogenesis of menorrhagia or dysmenorrhea in patients with uterine leiomyoma. METHODS: Fifty-one hysterectomized patients were divided into three groups: (i) patients with leiomyoma (n=24); (ii) those with adenomyosis (n = 19); and (iii) the control group (n=8). The expression of endothelial nitric oxide synthase was confirmed on immunohistochemistry and analyzed using an evaluation nomogram. RESULTS: The expression of endothelial nitric oxide synthase was significantly higher in the leiomyoma group and the adenomyosis group as compared with the control group. In the subgroup analysis of leiomyoma depending on symptoms (menorrhagia or dysmenorrhea or both), the expression of endothelial nitric oxide synthase was significantly higher in the symptomatic subgroup than the asymptomatic subgroup (endometrium P=0.0029, myometrium P=0.0276). CONCLUSIONS: Based on the findings that the expression of endothelial nitric oxide synthase was significantly higher in the uterus with leiomyoma or adenomyosis, it can therefore be inferred that nitric oxide might have a pathological effect on the uterus with the above diseases. In particular, it is also presumed that endothelial nitric oxide synthase is closely associated with menorrhagia and dysmenorrhea.

Ascorbic acid alleviates toxicity of paclitaxel without interfering with the anticancer efficacy in mice.

Paclitaxel is used extensively as a chemotherapeutic agent against a broad range of tumors but often leads to the early termination of treatment due to severe toxic side effects. In this study, we hypothesized that ascorbic acid could reduce the toxic side effects without interfering with the anticancer effect of paclitaxel. To demonstrate this, we examined the effect of the combinational treatment of ascorbic acid and paclitaxel using H1299 (a non-small cell lung cancer cell line) and BALB/c mice implanted with or without sarcoma 180 cancer cells. In H1299 cells, the anticancer effects of the combinational treatment with paclitaxel and ascorbic acid were up to 1.7-foldhigher than those of single-agent paclitaxel treatment. In addition, it was shown that the viability of the HEL299 normal cells was up to 1.6-fold higher with the combinational treatment than with paclitaxel treatment alone. In vivo mouse experiments also showed that mice co-treated with paclitaxel and ascorbic acid did not exhibit the typical side effects induced by paclitaxel, such as a reduction in the numbers of white blood cells and red blood cells and the level of hemoglobin (P < .05). The analysis of cancer-related gene expression by quantitative real-time polymerase chain reaction and immunohistochemistry revealed that the combinational treatment suppressed cancer cell multiplication. Taken together, these results suggest that combinational chemotherapy with ascorbic acid and paclitaxel not only does not block the anticancer effects of paclitaxel but also alleviates the cytotoxicity of paclitaxel in vivo and in vitro.

Multiple large cysts arising from nevus comedonicus.

Nevus comedonicus is a type of hamartoma that arises from a developmental anomaly of the mesodermal part of the pilosebaceous gland. In most cases of nevus comedonicus, an acne-like skin condition develops. Repeated inflammation can cause a morphological change to the cyst, papule, to abscess. We experienced a case of congenital nevus comedonicus, which led to the formation of large multiple cysts. A 50-year-old man was referred with a 12.5×10 cm lobulated mass on the posterior neck and upper back. The patient had a widespread presence of nevus comedonicus in the region ranging from the right superior chest to the posterior neck. The patient had a 30-year history of six prior excisions. A magnetic resonance imaging review led to a diagnosis of nevus comedonicus. Surgical treatment consisted of excision of the mass and wide excision for the patch type of nevus comedonicus around the neck. On histopathology, multiple masses were diagnosed as typical cysts containing keratinized tissue. The diffuse comedone lesions were diagnosed as nevus comedonicus. This case shows that large, multiple cysts can occur as a long-term complication of nevus comedonicus, and also highlights the importance of radical resection to prevent its further invagination.

Condensed chromatin staining of CKAP2 as surrogate marker for mitotic figures.

PURPOSE: Proliferation activity has long been known to be one of the strongest prognostic factors in many different cancers. Nevertheless, microscopic evaluation of mitotic figures remains time-consuming and, furthermore, is relatively subjective. As the expression of cytoskeleton-associated protein 2 (CKAP2) is closely related to the mitotic phase, CKAP2 was evaluated as a surrogate mitotic figure (MF) marker. METHODS: A monoclonal antibody specific to human CKAP2 was produced, and immunohistochemistry was performed on normal tissue array sections and 30 breast cancer tissues. RESULTS: The expression of CKAP2 in the normal human tissues was limited to well-known cell proliferation zones. Strong, readily visible, condensed chromatin staining of CKAP2 was observed specifically in mitotic cells, and the number of these cells was tightly correlated with the MF count in breast cancer tissues (P < 0.001, ρ = 0.743), suggesting its usefulness as a surrogate marker for MF counting. CONCLUSION: Immunohistochemical staining with CKAP2 monoclonal antibody can be considered to be a new, effective approach to the assessment of proliferation activity in cancer tissues.

Basal cell nevus syndrome showing several histologic types of Basal cell carcinoma.

Basal cell nevus syndrome (BCNS), or Gorlin Syndrome, is an autosomal dominant disorder, characterized by multiple developmental abnormalities and associated with germline mutations in the PTCH gene. Patients show multiple and early onset basal cell carcinomas (BCCs) in skin, odontogeniccysts in the jaw, pits on palms and soles, medulloblastoma, hypertelorism, and calcification of the falx cerebri. Clinical features of BCCs in these patients are indistinguishable from ordinary BCCs. However, some patients show variable histologic findings in subtypes of BCCs, and only one case associated with several histologic types of BCCs in the syndrome has been reported in Korea. We present a case of BCNS characterized by multiple BCCs, odontogenic keratocysts, multiple palmar pits, and calcified falx cerebri. Histopathologic findings of BCCs showed several patterns, which were nodular, superficial, and pigmented types.

Comparative analysis of thymidylate synthase at the protein, mRNA, and DNA levels as prognostic markers in colorectal adenocarcinoma.

BACKGROUND AND OBJECTIVES: To determine the best routinely available molecular methodology for assessing thymidylate synthase (TS) as a prognostic marker in colorectal adenocarcinoma, TS was examined at the protein, mRNA, and DNA levels. Direct comparison of these routinely available assays has not been systematically studied across a large colon cancer patient cohort with long-term follow-up. METHODS: We studied 150 surgically resected colorectal adenocarcinoma patients who received postoperative 5-Fluorouracil (5-FU) chemotherapy. TS immuunohistochemistry and real-time quantitative RT-PCR and PCR genotyping on patient-matched tumor and normal tissues were performed. RESULTS: Surprisingly, mRNA values in normal tissue varied from 0.11 to 62.0 and significantly correlated with mRNA values of matched tumor tissues. Although higher tumor/normal ratios of mRNA expression trended toward poorer patient survival, neither this nor TS immunohistochemistry results were statistically significant predictors. TS tumor genotype was generally concordant with matched normal tissues. Further, the 2R/3R genotype of 5'-TSER was significantly correlated with poorer patient survival (P = 0.0249) and was also an independent prognostic marker on multivariate analysis. CONCLUSION: TS genotyping on paraffin-embedded fixed tissues proved to be the most useful method for prediction of outcome of 5-FU treatment in patients with colorectal adenocarcinoma.

High dose concentration administration of ascorbic acid inhibits tumor growth in BALB/C mice implanted with sarcoma 180 cancer cells via the restriction of angiogenesis.

To test the carcinostatic effects of ascorbic acid, we challenged the mice of seven experimental groups with 1.7 x 10(-4) mol high dose concentration ascorbic acid after intraperitoneal administrating them with sarcoma S-180 cells. The survival rate was increased by 20% in the group that received high dose concentration ascorbic acid, compared to the control. The highest survival rate was observed in the group in which 1.7 x 10(-4) mol ascorbic acid had been continuously injected before and after the induction of cancer cells, rather than just after the induction of cancer cells. The expression of three angiogenesis-related genes was inhibited by 0.3 times in bFGF, 7 times in VEGF and 4 times in MMP2 of the groups with higher survival rates. Biopsy Results, gene expression studies, and wound healing analysis in vivo and in vitro suggested that the carcinostatic effect induced by high dose concentration ascorbic acid occurred through inhibition of angiogenesis.

Proteomic analysis reveals upregulation of RKIP in S-180 implanted BALB/C mouse after treatment with ascorbic acid.

Tumor cells have an invasive and metastatic phenotype that is the main cause of death for cancer patients. Tumor establishment and penetration consists of a series of complex processes involving multiple changes in gene expression. In this study, intraperitoneal administration of a high concentration of ascorbic acid inhibited tumor establishment and increased survival of BALB/C mice implanted with S-180 sarcoma cancer cells. To identify proteins involved in the ascorbic acid-mediated inhibition of tumor progression, changes in the liver proteome associated with ascorbic acid treatment of BALB/C mice implanted with S-180 were investigated using two-dimensional gel electrophoresis and mass spectrometry. Eleven protein spots were identified whose expression was different between control and ascorbic acid treatment groups. In particular, Raf kinase inhibitory protein (RKIP) and annexin A5 expression were quantitatively up-regulated. The increase in RKIP protein level was detected in the tumor tissue and accompanied by an increase in mRNA level. Our results suggest a possibility that these proteins are related to the ascorbic acid-mediated suppression of tumor formation.

First report of ovarian dysgerminoma in Cowden syndrome with germline PTEN mutation and PTEN-related 10q loss of tumor heterozygosity.

We present the first report of ovarian dysgerminoma in Cowden syndrome, presenting in a 7-year-old girl. In her second decade, a hamartomatous soft tissue extremity mass and diffuse gastrointestinal hamartomatous polyposis with pathologic features suggestive of either juvenile, Peutz-Jeghers, or Cowden polyps were identified, along with diffuse esophageal glycogenic acanthosis and skin manifestations. During regular thyroid cancer surveillance under the provisional diagnosis of Cowden syndrome, papillary thyroid carcinoma and benign follicular nodules were diagnosed at age 23. PTEN mutational analysis revealed a novel germline nonsense point mutation of Q219X. Loss of PTEN heterozygosity was also present in the ovarian dysgerminoma. Parental mutation testing and phenotype screening were negative. The correct classification of Cowden syndrome is difficult because of its protean manifestations and overlapping phenotypes with other genetic and noninherited pathologies, particularly regarding various gastrointestinal polyposis syndromes. Despite the challenges, correct classification is critical to patient care because of the associated cancer predispositions and necessary surveillance programs. This is the first report of Cowden syndrome presenting with ovarian dysgerminoma, which implicates PTEN in the molecular pathogenesis of dysgerminoma and adds it to the phenotypic manifestations of Cowden syndrome.

RHEB expression in fibroadenomas of the breast.

Although fibroadenoma is one of the most common types of benign breast tumor, genes specific to the tumor have not been identified. Microarrays were used to identify differentially expressed genes between fibroadenoma and infiltrating ductal carcinoma. The comparative expression of one of the identified genes, RAS homolog enriched in the brain (RHEB), was further explored using reverse transcriptase-polymerase chain reaction (RT-PCR). Microarray analysis was performed on tissue samples from five patients with fibroadenoma. In the fibroadenoma samples, the genes HDAC1, ROS1, TNFRSF10A, WASP2, TYRP1, WEE1, and RHEB were expressed at levels more than twofold higher than in the normal tissues. RT-PCR for RHEB indicated increased expression of RHEB in fibroadenoma compared to breast cancer. When studied with real-time PCR, the average RHEB/beta-actin ratio in fibroadenoma samples was 1.99, 2.46-fold greater than the average RHEB/beta-actin ratio in breast carcinoma of 0.81 (P < 0.01). Immunohistochemistry and PCR followed by microdissection shows increased expression of RHEB in epithelial cells compared to the stromal cells of fibroadenoma. Therefore, RHEB could be used cytopathologically to distinguish fibroadenoma from malignant breast carcinomas as a secondary diagnostic tool.

Association between the implementation of a laboratory information system and the revenue of a general hospital.

CONTEXT: A laboratory information system (LIS) is a useful tool for the management of laboratory processes and data, as well as for improving quality. OBJECTIVE: To examine the association between the implementation of a LIS with the outpatient and inpatient revenues of a general hospital. DESIGN: This study analyzed the outpatient and inpatient revenue data of all 212 general hospitals in South Korea; data were obtained from the Korean National Health Insurance Corporation during the period from 1996 through 1999. The mixed model was used for the repeated measure data. The following listed variables were used in the analysis: LIS implementation status, the population size, the state of competition, average local income, the hospital location, the hospital size, whether or not the hospital was a teaching hospital, whether the hospital was private or public, and the effect of the implementation time. RESULTS: The revenues from both the outpatient and inpatient departments were significantly higher 1 year after implementing a LIS, even after controlling for confounding variables. CONCLUSIONS: Although the causality needs to be clarified, the implementation of a LIS was found to be significantly associated with higher outpatient and inpatient revenues.