Functional loss of tumor suppressor genes detected by loss of heterozygosity, but not driver mutations, predicts aggressive lymph node status in papillary thyroid carcinoma.

BACKGROUND: Recognizing aggressive tumor biology is essential to optimizing patient management for papillary thyroid carcinomas (PTC). Aggressive lymph node (ALN) status is one feature that influences decision-making. We evaluated genomic deletions in regions of tumor suppressor genes, detected by loss of heterozygosity (LOH) analysis, to understand causal alterations linked to thyroid cancer aggressiveness and to serve as a molecular diagnostic biomarker for ALN status. METHODS: We analyzed 105 primary PTC enriched for patients with ALN (64% with, 36% without). We also analyzed 39 positive lymph nodes (79% with, 21% without ALN). LOH was determined using a panel of 25 polymorphic microsatellite alleles targeting 10 genomic loci harboring common tumor suppressor genes. Additionally, ThyGeNEXT® and ThyraMIR® assays were performed. RESULTS: LOH was detected in 43/67 primary PTC from patients with ALN status, compared with only 5/38 primary PTC without ALN (minimal metastatic burden) (P=0.0000003). This is further supported by post hoc analyses of paired primary and metastatic samples. Paired samples from patients with ALN are more likely to harbor LOH, compared to the ALN negative group (P=0.0125). Additionally, 12/31 paired samples from patients with ALN demonstrated additional or different LOH loci in metastatic samples compared to the primary tumor samples. No association was seen between ALN and mutational, translocation, or microRNA data. CONCLUSIONS: LOH detected in primary PTC significantly predicts ALN status. Analysis of paired primary and metastatic samples from patients with / without ALN status further supports this relationship. The acquisition of LOH at additional loci is common in lymph nodes from patients with ALN status. SIMPLE SUMMARY: A subset of patients with papillary thyroid carcinoma (PTC) will develop recurrent disease. One known predictor of recurrence is the American Thyroid Association category "Aggressive Lymph Node" (ALN) disease, considering metastatic burden. Loss of heterozygosity (LOH) - chromosomal loss in regions of tumor suppressor genes - has yet to be investigated as a possible mechanism driving ALN status in PTC. The ability to predict ALN status prior to surgery can guide the extent of surgery and postoperative treatment options. We found that paired samples from patients with ALN are more likely to harbor LOH, compared to patients without ALN disease. 38% of patients with ALN demonstrated additional or different LOH loci in metastatic samples compared to the primary tumor samples. LOH complements current molecular analysis of thyroid cancer when searching for evidence of aggressive biology.

Endometrioid Squamous Proliferations of the Endometrium Express Alpha-Methylacyl-CoA Racemase (P504s).

Squamous morular metaplasia is closely associated with endometrioid proliferative lesions such as endometrial intraepithelial neoplasia, whereas endometrioid adenocarcinoma may also demonstrate squamous differentiation (morular or nonmorular). Alpha-methylacyl-CoA racemase (AMACR; P504s) is an immunohistochemistry marker expressed in many tumors, including prostate adenocarcinoma, renal cell carcinoma, and in a subset of gynecologic carcinomas, predominantly of clear cell histology. In small biopsy samples, the distinction between cervical high-grade squamous intraepithelial lesions (HSILs) involving endocervical glands from endometrioid squamous proliferations can be challenging, given their anatomic vicinity and some degree of morphologic overlap. Following the observation of AMACR positivity by immunohistochemistry within squamous morules in an index case, 35 endometrial samples containing squamous morular metaplasia (25) and nonmorular squamous metaplasia (10), and 32 cases of cervical HSIL involving endocervical glands were stained with AMACR. The endometrial cohort consisted of 2 benign anovulatory endometrium, 7 endometrial polyps, 7 endometrial intraepithelial neoplasia, 4 atypical polypoid adenomyomas, and 15 endometrioid adenocarcinomas. Positive cases were scored as diffuse (≥50%) or focal (<50%). AMACR staining was present in 96.7% of endometrial squamous lesions, including 14 (93.3%) of endometrioid carcinomas, and in all cases of endometrial intraepithelial neoplasia, endometrial polyps, atypical polypoid adenomyomas, and anovulatory endometrium with squamous morular metaplasia or nonmorular squamous metaplasia. In comparison, only 2 cases (5.8%) of cervical HSIL demonstrated positivity for AMACR. In conclusion, AMACR can reliably differentiate the cervical versus endometrial origin of squamous lesions in small biopsy specimens.

Neoadjuvant chemotherapy enhances tumor-specific T cell immunity in patients with HPV-associated oropharyngeal cancer.

BACKGROUND: Treatment of patients with newly diagnosed HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) with neoadjuvant chemotherapy (NAC) results in a high rate of 5-year recurrence free survival with few patients requiring adjuvant treatment. We hypothesized that NAC enhances primary tumor HPV-specific T cell responses. METHODS: HPV-specific responses in tumor infiltrating lymphocytes (TILs) before and after NAC were determined using autologous co-culture assays. RESULTS: Greater HPV16-specific TIL responses, sometimes polyclonal, were observed after NAC compared to before in 8 of 10 patients (80%) with PCR-verified HPV16-positive tumors. A significant association was observed between net-negative change in HPV-specific TIL response and disease relapse (p = 0.04, Mann-Whitney test), whereas pathologic complete response at time of surgery did not correlate with recurrence. CONCLUSIONS: NAC induces HPV-specific tumor T cell responses in patients with newly diagnosed HPV-associated OPSCC; whereas lack of an increase following NAC may associate with risk of relapse.

Minor Salivary Gland Carcinosarcoma of the Floor of the Mouth.

Carcinosarcoma is an uncommon tumor consisting of malignant epithelial and mesenchymal elements. Salivary gland carcinosarcoma is aggressive in nature, and given its biphasic histologic appearance, it has the potential to be mistaken for a less concerning entity. Intraoral minor salivary gland carcinosarcoma is exceedingly rare with the palate being the site most frequently involved. Only two cases of carcinosarcoma arising from the floor of the mouth (FOM) have been reported. We present a case of a non-healing FOM ulcer that was identified as a minor salivary gland carcinosarcoma on surgical pathology along with the steps and importance of accurate diagnosis.

WPOI-5: Accurately Identified at Intraoperative Consultation and Predictive of Occult Cervical Metastases.

BACKGROUND: Frozen section analysis of oral cancer specimens is ideal for assessing margin distances and depth of invasion (DOI); the latter impacts intraoperative decisions regarding elective neck dissection (END). Here, we show that intraoperative determination of worst pattern of invasion (WPOI), specifically WPOI-5, has a high level of accuracy. This relates to our demonstration herein that WPOI-5 predicts occult cervical metastases (OCM) for pT1 oral squamous carcinoma (OSC). METHODS: The presence of OCM was correlated with WPOI in 228 patients with primary T1/T2/cN0 OSC undergoing resection and END. Concordance between intraoperative and final pathology WPOI determination was assessed on 51 cases of OSC. RESULTS: WPOI-5 predicts OCM in pT1 patients, compared with WPOI-4/WPOI-3 (p < 0.0001). Most pT1 WPOI-5 tumors had DOI of 4-5 mm (24/59 or 40.7%). Only two pT1 WPOI-5 tumors had DOI < 4 mm (3.0 and 3.5 mm). If END were performed in this pT1 cohort for all WPOI-5 OSC patients regardless of DOI, OR all OSC patients with DOI ≥ 4 mm regardless of WPOI, then no OCM would be missed (p = 0.017, 100% sensitivity, 29% specificity, 77% positive predictive value, 23% negative predictive value). With respect to intraoperative WPOI-5 determination, the accuracy, sensitivity, and specificity was 92.16, 73.33, and 100.0%, respectively. CONCLUSIONS: DOI ≥ 4 mm is the dominant predictor of OCM. For the rare WPOI-5 OSC with DOI < 4 mm, it is reasonable to suggest that surgeons perform END. WPOI-5 may be accurately determined intraoperatively. As microscopic instruction is needed to accurately assess WPOI-5, a teaching link is included in this manuscript.

Histology segmentation using active learning on regions of interest in oral cavity squamous cell carcinoma.

In digital pathology, deep learning has been shown to have a wide range of applications, from cancer grading to segmenting structures like glomeruli. One of the main hurdles for digital pathology to be truly effective is the size of the dataset needed for generalization to address the spectrum of possible morphologies. Small datasets limit classifiers' ability to generalize. Yet, when we move to larger datasets of whole slide images (WSIs) of tissue, these datasets may cause network bottlenecks as each WSI at its original magnification can be upwards of 100 000 by 100 000 pixels, and over a gigabyte in file size. Compounding this problem, high quality pathologist annotations are difficult to obtain, as the volume of necessary annotations to create a classifier that can generalize would be extremely costly in terms of pathologist-hours. In this work, we use Active Learning (AL), a process for iterative interactive training, to create a modified U-net classifier on the region of interest (ROI) scale. We then compare this to Random Learning (RL), where images for addition to the dataset for retraining are randomly selected. Our hypothesis is that AL shows benefits for generating segmentation results versus randomly selecting images to annotate. We show that after 3 iterations, that AL, with an average Dice coefficient of 0.461, outperforms RL, with an average Dice Coefficient of 0.375, by 0.086.

Tall cell variant papillary thyroid carcinoma impacts disease-free survival at the 10 % cut-point on multivariate analysis.

INTRODUCTION: The diagnosis of tall cell variant papillary thyroid carcinoma (TCV-PTC) corresponds to the feature of "aggressive histology" within the framework of the American Thyroid Association (ATA) Risk of Recurrence (ROR) guidelines. Using the current World Health Organization (WHO) definition for TCV-PTC (tall cells with height at least twice the width, distribution ≥ 30 %), we examined the impact of this diagnosis on disease-free survival (DFS). METHODS: The study cohort consisted of 347 patients treated for primary papillary thyroid carcinoma (PTC). Current ATA guidelines were followed for the extent of surgery and the administration of adjuvant radioiodine therapy. Clinical surveillance included ultrasound examination and biochemical parameters according to ATA standards. The outcome was measured as time from surgery to first disease recurrence (DR) versus time from surgery until the last documented disease-free encounter (no evidence of disease, NED). Disease-free patients with fewer than 6 months of follow-up were excluded from this cohort. Structural recurrences are documented by histology or cytology whereas biochemical recurrences are documented by rising serum thyroglobulin in the absence of structural disease. All slides on all patients were examined by two pathologists with the substantial interobserver agreement (Kappa = 73 %). The primary tumors are categorically classified either as (1) TCV-PTC (definition above), (2) Papillary thyroid carcinoma with tall cell features (PTC-TCF) (≥ 10 % < 30 % tall cells), or (3) Control (< 10 % tall cells). Tumor size is categorized as either (1) ≤ 10 mm, (2) 11-29 mm, or (3) ≥ 30 mm. Degree of ETE is categorized as either intrathyroidal, microscopic ETE, histologic spread to strap muscles, or pT4 disease. RESULTS: 185 patients are classified as TCV-PTC (≥ 30 % tall cells), 62 as PTC-TCF (≥ 10 % < 30 % tall cells), and 100 as control group (< 10 % tall cells). TCV-PTC is associated with ≥ 30 mm size (p = .0246) and invasion of strap muscles and/or pT4 (p = .0325). There was no relationship between TCV-PTC and aggressive lymph node (ALN) status defined by ATA. Overall follow-up ranged from two months (one patient death) to 203 months (mean 40.8, median 33.0). DR occurred in 61 patients (mean 31.4 months, range 0 -184, 59 structural recurrences, 2 biochemical recurrences). Three models for TCV-PTC were examined: Model 1 - Tall cells ≥ 10% versus control, Model 2 - TCV-PTC versus TCF-PTC versus control, and Model 3 - TCV-PTC versus control. Kaplan Meier curves demonstrated decreased DFS with ALN status (p = .0001), ETE (p = .0295), and TCV-PTC (Model 1, p = .041). On multivariate analysis, TCV-PTC (Model 1) remained significantly predictive when adjusted for ALN (p = .0059). ETE dropped out of the model. CONCLUSION: TCV-PTC is significantly associated with larger tumors and a greater degree of ETE. The diagnosis of TCV-PTC significantly impacts DFS at the 10 % cut-point on multivariate analysis.

Incongruent radiographic indication of calvarial metastatic diploic space invasion with absent histologic findings in a patient with basal cell carcinoma of the scalp.

BACKGROUND: Radiographic imaging is often used to determine basal cell carcinoma (BCC) extension and invasion and to define a surgical plan. However, imaging modalities may overestimate tumor invasion and lead to unnecessarily aggressive treatment. METHODS: A 77-year-old woman was seen with a growing BCC of the scalp with MRI imaging indicative of calvarial diploic space invasion. The patient underwent Mohs surgery followed by a parietal craniectomy. RESULTS: Contrary to the MRI findings, histological evaluation of the cortical parietal calvarium and the diploic space did not demonstrate BCC. CONCLUSIONS: Surgeons should be wary of diploic space changes in the absence of cortical erosion demonstrated in MRI as it may not explicitly indicate tumor invasion. Biopsy of the diploe is necessary in such cases to determine the surgical course and to avoid morbidity associated with calvarium removal.

Ten patients with high-grade transformation of acinic cell carcinomas: Expression profiling of ß-catenin and cyclin D1 is useful.

Conventional acinic cell carcinoma (CACC) represents a prototypical low-grade salivary malignancy. Rarely, acinic cell carcinoma (ACC) can demonstrate aggressive features (zones of necrosis, apoptosis, varying nuclear atypia) warranting classification as "ACC with high-grade transformation" (HGT-ACC) or "dedifferentiated" ACC. This study reports ten new cases of HGT-ACC. There is potential for subtlety in recognizing high-grade transformation and distinguishing discrete nodules of necrosis from cytology aspiration changes. We compared immunohistochemical (IHC) profiles, specifically ß-catenin (bCAT) and cyclin D1 expression, which have been touted as potentially helpful in this context. We quantified morphology (primary axis nucleus, nuclear area and perimeter) in HGT-ACC and CACC. Clinical outcome is known for eight HGT-ACC patients; three patients developed locoregional or distant metastases, five remained disease-free. Nine of ten HGT-ACC expressed strong, diffuse, membranous bCAT. CACC demonstrated lower intensity of membranous bCAT expression. Strong, diffuse nuclear cyclin D1 was seen in five of ten HGT-ACC whereas no CACC demonstrated cyclin D1 with distribution greater than 50 %. The quantified nuclear morphologic features of CACC and HGT-ACC demonstrated overlapping means values. Maximum values for nuclear primary axis, area, and perimeter were greater for HGT-ACC versus CACC, corresponding to a subpopulation of larger tumor cells in HGT-ACC. The poor outcome associated with HGT-ACC justifies its recognition, which should alter surgical approach with respect to elective neck dissection or possible facial nerve sacrifice. With respect to ancillary IHC studies, strong, diffuse membranous bCAT expression, with or without strong nuclear cyclin D1 ≥ 50 % distribution or Ki67 index ≥ 25 % supports this diagnosis.

Pigs in a blanket: an unusual presentation of malignant ascites in prostatic adenocarcinoma.

Malignant ascites in prostatic acinar adenocarcinoma is very rare. We present an 84-year-old man with a rare malignant ascites due to prostatic adenocarcinoma demonstrating hepatoid differentiation by immunohistochemistry. The patient was diagnosed with the malignant ascites due to metastatic prostatic adenocarcinoma. We identified the unique cytological feature of envelopment of tumour cell clusters by benign mesothelial monolayers.

The hippocampus and TNF: Common links between chronic pain and depression.

Major depression and chronic pain are significant health problems that seriously impact the quality of life of affected individuals. These diseases that individually are difficult to treat often co-exist, thereby compounding the patient's disability and impairment as well as the challenge of successful treatment. The development of efficacious treatments for these comorbid disorders requires a more comprehensive understanding of their linked associations through common neuromodulators, such as tumor necrosis factor-α (TNFα), and various neurotransmitters, as well as common neuroanatomical pathways and structures, including the hippocampal brain region. This review discusses the interaction between depression and chronic pain, emphasizing the fundamental role of the hippocampus in the development and maintenance of both disorders. The focus of this review addresses the hypothesis that hippocampal expressed TNFα serves as a therapeutic target for management of chronic pain and major depressive disorder (MDD).

Prognostic value of tumor-infiltrating mast cells in outcome of patients with esophagus squamous cell carcinoma.

BACKGROUND: Squamous cell carcinoma (SCC) of the esophagus is one of the most common malignancies of the gastrointestinal tract and carries poor prognosis. The role of mast cell density (MCD) in the prognosis of most human tumors is partly known, and there is a growing body of studies addressing it. However, the prognostic value of MCD has not been investigated in esophageal SCC, and thus, it was the subject during this study. METHODS: In this study, 78 patients with esophageal SCC in pT = 3 were selected, their MCD was evaluated with toluidine blue staining, and the relationship with survival rate was analyzed. Patients were compared in identical groups of lymph node involvement and post-surgery complementary therapy. RESULTS: Survival rate was significantly decreased in patients with high MCD based on Kaplan-Meier analysis (P < 0.001). This relationship was also found in groups with similar lymph node involvement and post-surgery therapies. CONCLUSIONS: The results of the current study showed that high MCD in the invasive edge of tumor is related to tumor progression and decreased survival rate following surgery.

Thyroid cancer, clinical and hystopathological study on patients under 25 years in Tabriz, Iran (2000-2012).

Thyroid cancer comprises a broad spectrum of diseases with variable prognoses. The aim of this study was to assess thyroid cancer in young population using the surveillance, epidemiology and end results database and whether radioactive fallout from the Chernobyl accident in 1986 influenced thyroid cancer incidence among children and adolescents in Tabriz, Iran. Patients aged 5-25 in Tabriz from April 2000 to April 2012 were studied. Using the surveillance and end results database, the study examined the overall incidence of thyroid cancer with variations based on tumor pathology, size and stage, as well as the current surgical therapy of thyroid carcinoma. This study demonstrated a positive correlation between thyroid carcinoma tumor size and stage of disease. Mortality rates were higher among men than women. Recurrence rates are also higher in men. Compared with women, men have greater likelihood ofloco regional lymph node involvement and more than twice the rate of distant metastases. Operative treatment for thyroid cancer also has shifted with Radical dissection+Total thyroidectomy replacing partial thyroidectomy as the most common surgical procedure. Our data indicate that the increasing incidence of thyroid cancer cannot be accounted for fully by an increased detection of small neoplasms. This study show the increasing in thyroid cancer incidence related to exposure to radiation from the Chernobyl accident.

Diagnostic value of serum P35 in comparison with tissue P35 in gastric adenocarcinoma and their relationship with microscopic prognostic factors.

Early diagnosis of Gastric adenocarcinoma could increase survival of the patients and also remarkably reduce treatment costs. This study aimed at evaluating the diagnostic value of serum P35 in comparison with tissue P35 in gastric adenocarcinoma and their relationship with microscopic prognostic factors. In this descriptive analytical study, 35 patients (74.3% male and 25.7% female with mean age of 63.00 +/- 12.75 years with gastric adenocarcinoma were evaluated. Blood samples were taken from all patients before gastrectomy to evaluate serum P35 with ELISA method and after surgery tissue samples were gathered to evaluate tissue P35 with immunohistochemical method. The relation between tissue and serum P35 with severity of the disease and microscopic findings was assessed. Tissue P35 was negative in 57.1%, positive in 22.9% and very positive in 20%. Mean serum P35 was 1.34 +/- 0.43 mg dL(-1). There was no relation between serum P35 and adenocarcinoma type, tumor grade, vascular and neurological invasion and number of lymph node involved. Serum P35 levels significantly increased by increase in tissue P35 positivity (p = 0.004). There was significant correlation between tissue P35 and adenocarcinoma type (p = 0.006), neurological involvement (p = 0.04) and number of involved lymph nodes (p = 0.001). Although serum P35 level was higher in cases with more lymph node involvement and vascular and neural invasion, the marker was not capable to predict the involvement degree of stomach cancer. In comparison with serum P35, tissue P35 plays more significant role in these cases.

A clinical epidemiologic study of thyroid carcinoma in patients under 25 years old in Tabriz, Iran (1995-2010).

OBJECTIVE: To evaluate the epidemiology and prognostic factors of thyroid cancer among children and adolescents in Tabriz, Iran. METHODS: The retrospective descriptive-analytical study, assessing the tumour and characteristics of 356 patients with thyroid carcinoma aged 5-25, was conducted at the Department of Surgery, Imam Khomeini Hospital, Tabriz University of Medical Sciences from April 1995 to April 2010. All malignant neoplasms of the thyroid gland registered during the study period were studied, and their demographic and medical data was evaluated and, compared to identify the epidemiology and prognosis factors related to survival. SPSS 16 was used for statistical analysis. RESULTS: Of the total, there were 100 (28%) male and 256 (72%) female subjects, with their mean age being 12.6+/-8.4 years. In terms of the disease, there was no statistically significant difference between the two genders (p=0.65). The five-year survival rate was 345 (97%) in patients aged 5-25 years. Gender was not a statistically significant marker (p=0.82). CONCLUSION: The study indicated an increase in cases of thyroid cancer incidence. It also underlined the need for standardisation of diagnostic, classification and registration criteria which shall be a fundamental requirement for future studies of thyroid carcinoma in young people.