Deep convolutional neural network with fusion strategy for skin cancer recognition: model development and validation.

We aimed to develop an accurate and efficient skin cancer classification system using deep-learning technology with a relatively small dataset of clinical images. We proposed a novel skin cancer classification method, SkinFLNet, which utilizes model fusion and lifelong learning technologies. The SkinFLNet's deep convolutional neural networks were trained using a dataset of 1215 clinical images of skin tumors diagnosed at Taichung and Taipei Veterans General Hospital between 2015 and 2020. The dataset comprised five categories: benign nevus, seborrheic keratosis, basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. The SkinFLNet's performance was evaluated using 463 clinical images between January and December 2021. SkinFLNet achieved an overall classification accuracy of 85%, precision of 85%, recall of 82%, F-score of 82%, sensitivity of 82%, and specificity of 93%, outperforming other deep convolutional neural network models. We also compared SkinFLNet's performance with that of three board-certified dermatologists, and the average overall performance of SkinFLNet was comparable to, or even better than, the dermatologists. Our study presents an efficient skin cancer classification system utilizing model fusion and lifelong learning technologies that can be trained on a relatively small dataset. This system can potentially improve skin cancer screening accuracy in clinical practice.

The diagnostic utility of trichorhinophalangeal syndrome type 1 immunohistochemistry for metastatic breast carcinoma in effusion cytology specimens.

BACKGROUND: Trichorhinophalangeal syndrome type 1 (TRPS1) is a novel immunohistochemical marker with excellent performance in distinguishing breast carcinoma from other cancers in surgical specimens. The aim of this study was to evaluate the diagnostic utility of TRPS1 compared with GATA3 for metastatic breast carcinoma in effusion cytology specimens. METHODS: In total, 91 cell blocks of malignant effusion specimens, including 47 metastatic breast carcinomas (nine triple-negative breast carcinomas [TNBCs] and 38 non-TNBCs) and 44 nonmammary malignancies, were selected for TRPS1 and GATA3 immunohistochemistry. Modified H scores ≥ 200 were considered positive staining. RESULTS: The positive rate of TRPS1 was similar between TNBC and non-TNBC (77.8% vs 73.3%, p = .802), whereas the positive rate of GATA3 was lower in TNBC than in non-TNBC (66.7% vs 89.5%, p = .087). The positive rate of TRPS1 was significantly higher in breast carcinoma than in urothelial carcinoma (74.5% vs 0%, p < .001), whereas the positive rate of GATA3 showed no difference between these two (85.1% vs 85.7%, p = .956). Notably, diffuse and strong aberrant expression of TRPS1 was observed in one lung adenocarcinoma and one serous adenocarcinoma in this series. The overall sensitivity, specificity, positive predictive value, and negative predictive value of TRPS1 immunohistochemistry for breast carcinoma were 74.5%, 95.5%, 94.6%, and 77.8%, respectively. CONCLUSION: TRPS1 is a sensitive and specific marker for metastatic breast cancer in serous effusion cell-block specimens. It shows superior sensitivity and specificity compared with GATA3, especially in the TNBC setting and for excluding urothelial carcinoma.

Atypical histiocytoid cells in fine-needle aspiration cytology of metastatic papillary thyroid carcinoma: A potential diagnostic pitfall.

BACKGROUND: Fine needle aspiration (FNA) cytology of cervical lymph nodes is an effective diagnostic tool to detect metastatic papillary thyroid carcinoma (PTC) when typical cytomorphologic features of PTC are observed. However, the presence of atypical histiocytoid cells (AHCs) due to cystic degeneration sometimes poses a diagnostic challenge. The purpose of this study was to evaluate the presence and cytomorphology of AHCs in metastatic PTC. METHODS: We analyzed a total of 76 FNA cytological samples of cervical lymph nodes from 66 patients with metastatic PTC diagnosed during approximately 10-year period, from January 2010 to April 2020. Samples were either liquid based preparation (n = 53) or conventional smear (n = 23). RESULTS: AHCs were present in 38 (50%) of the 76 FNA cases and the remaining 38 cases showed classic PTC features. Among the 38 cases, eight displayed pure AHCs that constituted 10.5% of all the metastatic PTC in the lymph nodes. Pure AHCs were more commonly detected in the liquid based preparation (7/53, 13.2%) than the conventional smear (1/23, 4.3%). The remaining 30 cases had AHCs mixed with the characteristic PTC components. The presence of AHCs was found to be statistically associated with cystic background (p < .002). CONCLUSION: Metastatic PTC frequently exhibits cystic degeneration and the FNA cytology may not yield classic cytological features of PTC. Pure AHCs composed 10.5% of all cases and might be a potential pitfall for liquid based preparation in diagnosing metastatic PTC. The finding of AHCs within the cystic background should raise the concern of metastatic PTC.

Recurrent cutaneous necrotising eosinophilic vasculitis.

Recurrent cutaneous necrotising eosinophilic vasculitis (RCNEV) is a rare disease that was first described in 1994. We report a case of RCNEV treated with corticosteroid, and 18 cases that we identified in the literature. Our review of the literature shows that RCNEV was frequently identified in middle-aged females from Asia and usually presents as erythematous to purpuric papuloplaques, angio-oedema on the extremities, as well as peripheral eosinophilia. Histopathologically, RCNEV is characterised by exclusively eosinophilic infiltration around the vascular plexus, the absence of leukocytoclasis and fibrinoid degeneration of vascular walls. Although, RCNEV responds to corticosteroid treatment, relapses have occurred during dose tapering. We also discuss the mechanisms of vascular destruction, the differential diagnosis and steroid-sparing therapies for RCNEV.

Utility of cell block as an adjunct to liquid-based cytology for diagnosing papillary thyroid carcinoma.

BACKGROUND: Although liquid-based cytology (LBC) has gained popularity among clinical laboratories, it is unclear whether it is equivalent to conventional smears for making a definite diagnosis of papillary thyroid carcinoma (PTC). The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) suggests a definite diagnosis of PTC is preferred when there are at least one of three features (papillary architecture, psammomatous calcifications, and frequent pseudonuclear inclusions) plus other typical cytomorphological findings. This study evaluated whether an additional cell block (CB), prepared from the residual LBC material, could help improve the diagnosis of PTC. MATERIALS AND METHODS: A total of 62 cases with both ThinPrep LBC and CB preparations and histopathological follow-up of PTC were retrieved between November 2016 and March 2019. The ThinPrep LBC and CB slides were reviewed separately to identify any papillary architecture, psammomatous calcifications, or pseudonuclear inclusions for diagnosing PTC. RESULTS: Among the 51 cases with cytological diagnosis of PTC in the LBC+CB slides, the CB provided additional diagnostic information in 15 cases, which were initially diagnosed as suspicious for PTC based on the LBC slides alone. This information included papillary architecture (n=11), psammomatous calcification (n=1) and pseudonuclear inclusions (n=5). The number of specimens in the 51 cases containing at least one of the three features increased from 42 (LBC) to 51 (LBC+CB). The accuracy for diagnosing PTC increased from 58.1% for LBC alone to 82.3% for the LBC+CB examination. CONCLUSION: An adjunctive CB preparation may improve the LBC technique for diagnosing PTC.

Application of the Milan System for Reporting Salivary Gland Cytopathology: A retrospective study in a tertiary institute.

BACKGROUND: Fine needle aspiration (FNA) cytology has been widely used in the preoperative evaluation of salivary gland lesions. The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) is a tiered risk-stratification scheme designed to standardize reporting and facilitate decision making. We aimed to clarify the validity and diagnostic utility of the MSRSGC-based classification of salivary gland lesions. METHODS: A total of 1020 salivary gland FNA specimens were retrieved between 2008 and 2017, with histologic follow-up data available for 349 specimens. Within the present retrospective study, each specimen with follow-up data was reclassified according to the MSRSGC diagnostic categories: nondiagnostic, nonneoplastic, atypia of undetermined significance (AUS), benign neoplasm, salivary gland neoplasm of uncertain malignant potential (SUMP), suspicious for malignancy (SM), and malignant. The risk of malignancy (ROM) was calculated based on the histologic follow-up data. RESULTS: The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the MSRSGC-based classification of the malignant potential of salivary gland lesions were 80.1%, 70.4%, 99.2%, 90.5%, and 96.7%, respectively. The ROM calculated for specimens assigned to the nondiagnostic, nonneoplastic, AUS, benign neoplasm, SUMP, SM, and malignant categories were 8.6%, 15.4%, 36.8%, 2.6%, 32.3%, 71.4%, and 100%, respectively. CONCLUSION: The present results confirm the validity and diagnostic utility of MSRSGC, supporting its use in clinical practice to help devise adequate management strategies for salivary gland lesions.

Pityriasis Lichenoid-like Mycosis Fungoides in a 9-year-old Boy: A Case Report.

Dear Editors, Pityriasis lichenoides (PL)-like mycosis fungoides (MF) is a rare variant of MF, presenting clinical findings of PL but histological features of MF. It was first reported by Ko et al. (1) and only a few cases have been reported since (2-5). Herein we report the case of a boy with PL-like MF and review the related literature. A 9-year-old boy presented with a 1-year history of multiple pruritic crusted erythematous papules and scaly pink maculopatches on the face, trunk, and extremities (Figure 1, a and b). Histologic examination of a papule revealed lymphocytic epidermotropism and lymphocytes tagging the dermoepidermal junction. The nuclei of the lymphocytes were hyperchromatic and irregular (Figure 1, c and d). Immunohistochemically, the infiltrating lymphocytes revealed positivity for CD2, CD3, CD5, CD7, and CD8, but were negative for CD4, CD20, CD30, CD68, and CD163 (Figure 1, e-g). T-cell receptor gene rearrangement analysis (TCR-GRA) demonstrated the rearrangement of the gamma chain (Figure 1, h). PL-like MF was diagnosed. The patient was started on narrowband ultraviolet B (NBUVB) phototherapy. The skin lesions markedly improved after 6 months of treatment. There was no recurrence during the 2 years of follow-up. There has long been a controversy regarding whether PL is just an inflammatory dermatosis or a genuine T-cell lymphoproliferative disease. Wang et al. (2) proposed three categories for the relationship between PL and MF: (A) PL with a dominant T-cell clone, (B) PL subsequently progressing into MF, and (C) PL-like MF. In the first category, PL is a monoclonal T-cell-mediated inflammatory disorder, in which T-cell clones were found in about 50% of patients (6,7). The second category involves progression from long-term PL to MF (8,9). The average time-to-progression is about 8 years. It has been speculated that the PL-related immunologic microenvironment is favorable for developing a tumoral clone. Our patient presented with PL-like lesions clinically, while biopsy findings, results of immunohistochemistry, and TCR-GRA all suggested that this case was MF. Due to the short duration (only one year) of his lesions, we established the diagnosis of PL-like MF de novo, rather than evolution from PL to MF. The features of previously reported cases of PL-like MF and those of our patient are summarized in Table 1 (1-5). Men were predominant (18:7) among the total of 25 patients. Most patients were children or young adults (mean age of 23.4 years).The interval between presence of lesions and diagnosis varied from 1 month to 10 years. The cutaneous eruptions were all PL in appearance and almost all involved both the trunk and extremities. Pruritus was reported by approximately half of the patients. Histologically, the scaly papules were usually indistinguishable from classical MF, showing epidermotropism, haloed lymphocytes, lymphocytes aligning along the dermoepidermal junction, and Pautrier's microabscesses. Immunohistochemically, all tested cases demonstrated positivity for CD3 but were negative for CD20 and CD30. Cases with predominantly CD8-positive cells were twice as prevalent as cases with predominantly CD4-positive cells. TCR-GRA was performed in 20 cases, 15 of which revealed monoclonality. Most patients received psoralen combined with ultraviolet A or NBUVB phototherapy, and demonstrated either a complete or partial response. Recurrence was reported in only 2 cases (5). In summary, PL-like MF is a rare variant of MF. It has some features distinct from classic MF, such as a higher incidence in young men and predominantly CD8-positive T-cells infiltration. Phototherapy can be used as the first line of treatment. A good response and a favorable prognosis can be expected.

Mycosis fungoides in Taiwan shows a relatively high frequency of large cell transformation and CD56 expression.

Mycosis fungoides (MF) is an indolent cutaneous T-cell lymphoma and may transform into large cell lymphoma in the disease course. The incidence of MF in Taiwan is lower as compared to that in the West. In this study we aimed to characterise the clinicopathological, immunohistochemical, and genetic features of transformed MF (t-MF) in Taiwan. We retrospectively collected MF cases from April 2004 to April 2015 from four medical centres in Taiwan, reviewed the clinical history and histopathology, and performed immunohistochemistry, in situ hybridisation for EBV (EBER), and fluorescence in situ hybridisation (FISH) for DUSP22/MUM1 gene translocation. Fifty-one specimens from 32 patients with MF were identified with a male to female ratio of 1.5:1 and a median age of 50.5 (range 16-82). Tumours from 11 patients (34%) underwent large cell transformation, with the median age at 61 (range 26-82). The tumour cells of t-MF expressed CD30 and MUM1 in 82% and 100% cases, respectively. CD56 was expressed in two (10%) of 21 MF cases and two (18%) of 11 t-MF cases, respectively; and all four CD56-positive cases were of a helper T-cell phenotype. All CD56 expressing MF and t-MF tumours tested for EBER were negative. FISH study showed rearranged DUSP22/IRF4 in one (9%) of 11 t-MF cases, but not in any of the 19 non-transformed MF specimens. Four patients with t-MF died of disease and six were alive with disease in a median follow-up time of 25 months (mean 44.7 months). Large cell transformation and aberrant CD56 expression were more frequent in patients with MF in Taiwan compared to those in the West. Larger case series and/or national studies are needed to clarify the significance and impact of large cell transformation on the prognosis of patients with MF.

Percutaneous biopsy of the renal mass: FNA or core needle biopsy?

BACKGROUND: In recent years, there have been increasing indications for percutaneous renal biopsy. Fine-needle aspiration (FNA), with or without core needle biopsy (CB), has been used increasingly in the management of renal tumors at the study institution. METHODS: A computerized search of laboratory records was conducted to retrieve FNA cases of renal masses as well as the correlating CB and/or nephrectomy specimens. The cases spanned a period of 10 years (2006-2015). The diagnoses were classified into 5 categories: malignant, suspicious for malignancy, neoplastic, atypical, and negative/nondiagnostic. Based on the results of the nephrectomy specimens, the diagnostic rate, sensitivity, and diagnostic accuracy were calculated among 3 groups of specimens: FNA only, CB only, and combined FNA and CB. RESULTS: A total of 247 cases of FNA with 123 correlating CB and 101 follow-up nephrectomy specimens were identified. The diagnostic rate, sensitivity, and diagnostic accuracy were 72%, 78%, and 96%, respectively, for FNA; 87%, 92%, and 94%, respectively, for CB; and 92%, 92%, and 94%, respectively, for the combined FNA and CB group. Renal cell carcinoma and its variants were the most common histologic diagnoses (112 of 174 cases; 64%). Significant diagnostic discrepancy was noted in one case: a malignant melanoma that was misdiagnosed as renal cell carcinoma in both the preoperative FNA specimen and in the CB specimen. CONCLUSIONS: In the current study, both FNA and CB demonstrated excellent diagnostic accuracy (96% and 94%, respectively). The combination of FNA and CB was found to significantly improve the diagnostic rate when compared with either FNA alone (92% vs 72%; P<.05) or CB alone (92% vs 87%). Cancer Cytopathol 2017;125:407-15. © 2017 American Cancer Society.

High apoptotic index in urine cytology is associated with high-grade urothelial carcinoma.

BACKGROUND: The significance of apoptosis and its association with high-grade urothelial carcinoma (HGUC) in urine cytology has yet to be determined. METHODS: A computerized search of the study laboratory information system was performed over a 3-year period for all urine cytology specimens processed using the SurePath liquid-based preparation technique. Only those cases with correlating surgical pathology obtained within 6 months after the urine cytologic samples were included in the current study. Cases from ileal conduit samples were excluded. A semiquantitative numerical scoring system (apoptotic index) was used to assess the amount of pyknosis or karyorrhexis, with 0 indicating none, 1 indicating < 10 per 10 high-power fields, 2 indicating 10 to 30 per 10 high-power fields, and 3 indicating > 30 per 10 high-power fields. Statistical analysis using the Pearson chi-square test was performed. RESULTS: A total of 228 cases including 105 benign cases, 79 cases of HGUC, and 44 cases of low-grade urothelial carcinoma (LGUC) diagnosed on follow-up surgical pathology were selected. A score of 0 was observed in 70 benign, 11 HGUC, and 8 LGUC cases; a score of 1 was observed in 31 benign, 21 HGUC, and 23 LGUC cases; a score of 2 was observed in 3 benign, 27 HGUC, and 9 LGUC cases; and a score of 3 was observed in 1 benign, 20 HGUC, and 4 LGUC cases. CONCLUSIONS: Excluding ileal conduit urine specimens, the finding of a high apoptotic index (score ≥ 2) with the presence of pyknosis or karyorrhexis in ≥10 per 10 high-power fields in the urine cytology appears to be significantly associated with HGUC (P<.05). Cancer Cytopathol 2016;124:546-51. © 2016 American Cancer Society.