Selective deployment of dynamic telecytology for rapid evaluation of cytology smears: assessment of workflow processes and role of cytopathology fellows as on-site operators.

INTRODUCTION: The deployment of telecytology (TC) requires a substantial investment of financial and human resources. To offset the high demand for rapid on-site evaluation, we performed a limited deployment of dynamic TC and have detailed the workflow processes and the role of trainees. MATERIALS AND METHODS: TC systems were installed in radiology suites with a high volume of cases. Validation was performed using retrospective and prospective cases. Cytotechnologists and cytopathology fellows were the operators of the instrument. TC malignant and benign diagnoses were correlated with the final sign-out diagnoses. RESULTS: Of the 120 cases, 50 (41.6%) were fine needle aspirations and 70 (58.3%) were touch imprint smears of core biopsy specimens. The cytotechnologists were the operators for 34 cases (28.3%) and cytology fellows for 86 cases (71.6%). Adequacy concordance with the final diagnosis was 100% and 98.5% in the retrospective and prospective cases, respectively. In the prospective cases, concordance of TC with the final diagnosis of malignancy was 42 of 45 (93.3%), with 2 of 45 (4.4%) discordant and a downgrade rate of 2.7%. For the benign diagnoses, the concordance was 90%. For the malignant diagnoses, the sensitivity of TC was 97.67% (95% confidence interval [CI], 87.71 to 99.94%; specificity, 81.82%; 95% CI, 48.22% to 97.72%). The positive predictive value was 95.45% (95% CI, 85.69% to 98.66%), the negative predictive value was 90.00% (95% CI, 55.98% to 98.45%), and the accuracy was 94.44% (95% CI, 84.61% to 98.84%). CONCLUSIONS: TC can be deployed in a limited fashion as an option for cytopathologists to offset the high demand for rapid on-site evaluations. Trainee participation in TC service is important for building confidence and honing their cytology skills.

Secondary Angiosarcoma With C-MYC Amplification Following Prophylactic Bilateral Mastectomy and Autologous Breast Reconstruction: Report of a Case and Review of the Literature.

In this article, we report a very rare case of secondary angiosarcoma in a young woman with no prior history of breast cancer who had bilateral prophylactic mastectomies with autologous reconstruction due to a strong family history of breast cancer and BRCA1 gene variant of uncertain significance. The surgery was complicated by recurrent fat necrosis requiring several excisions and additional reconstruction followed by the development of localized lymphedema and subsequent angiosarcoma in the reconstructed breast 10 years later. The angiosarcoma was high grade with prominent epithelioid features associated with abundant tumor-infiltrating lymphocytes. Amplification of C-MYC locus 8q21.24 was demonstrated by fluorescence in situ hybridization study. We postulate that chronic trauma from several surgeries including tissue hypoxia and impaired lymphatic drainage may have provided a milieu for angiogenesis and mutagenic transformation. Amplification of C-MYC locus 8q21.24 was most likely a strong oncogenic driver of angiosarcoma. To the best of our knowledge, this is the first report of its kind in the literature.

Role of cytotechnologists in rapid onsite adequacy assessment of cytology materials for diagnostic workup and specimen allocation for ancillary testing using a standardized protocol.

INTRODUCTION: Data on the performance of cytotechnologists in assessing specimen adequacy of needle core biopsies (NCB) is scant and their role in specimen triaging for ancillary studies have not been well established. MATERIALS AND METHODS: We retrospectively analyzed rapid onsite evaluation (ROSE) performed exclusively by cytotechnologists on 248 NCB and fine-needle aspiration (FNA) specimens. Overall adequacy and accuracy rates were determined by comparing to final diagnosis. We also reviewed the process of specimen allocation for ancillary testing to determine whether specimens were appropriately triaged at the time of ROSE. RESULTS: Of the 248 cases, 222 (89.5%) were touch imprint and 26 (10.5%) were FNA smears. The overall adequacy rate was 73.4% (182 of 248). Concordance for "adequate" interpretation by ROSE with unequivocal malignant or benign diagnoses on final interpretation was 95.6%. The sensitivity, specificity, and accuracy of ROSE for a final "positive for malignancy" were 89.2% (95% CI 83.04% to 93.69%), 43.24% (95% CI 31.77% to 55.28%), and 73.87% (95% CI 67.57% to 55.28%), respectively. Cases with "positive for malignancy" on final diagnosis were "adequate" by ROSE in 89.1% (132 of 148) and "inadequate" in 10.8% (16 of 148), P < 0.0001. Ancillary tests were performed in 168 of 248 (67.7%); the majority were immunohistochemical stains for determining tumor subtype. Predictive biomarkers were performed successfully in 100% of metastatic breast cancers. CONCLUSIONS: Cytotechnologists performed at a high level of competency in providing ROSE and allocating specimens for ancillary testing, which were performed successfully in the majority of cases. Implementation of a standardized protocol for tissue management/prioritization is of paramount importance to maximize tissue preservation and minimize wastage.

Screening for Lynch Syndrome by Immunohistochemistry of Mismatch Repair Proteins: Significance of Indeterminate Result and Correlation With Mutational Studies.

CONTEXT.­: Immunohistochemical expression of mismatch repair (MMR) protein is a well-accepted method for routine screening for Lynch syndrome with relatively high sensitivity and specificity. Occasionally, however, immunohistochemistry (IHC) can yield an equivocal result with poor reproducibility and the potential for misdiagnosis. OBJECTIVE.­: To determine the frequency and significance of indeterminate MMR IHC expression in patients routinely screened for Lynch syndrome and correlation with germline mutation studies. DESIGN.­: Semiquantitative scoring of MMR IHC was performed by image analysis in 479 cases, of which 380 were colorectal and 99 endometrial cancer. Scores of 10% or more, less than 10%, and 0% were used as cutoffs for retained, indeterminate, and loss of expression, respectively. Negative and indeterminate IHC results were confirmed by mutational studies. RESULTS.­: Four hundred eighteen of 479 cases (87.2%) were reported as retained expression, 45 (9.3%) as loss of expression, and 16 (3.3%) as indeterminate expression. Fifteen of 45 (33.3%) and 8 of 16 (50%) with loss and indeterminate expression, respectively, were found to have Lynch syndrome by germline studies. The overall frequency of Lynch syndrome in our patient population was 4.8% (23 of 479), and 34.7% of these (8 of 23) were associated with indeterminate IHC expression. In the indeterminate group, MLH1 germline mutation was the most frequent (6 of 13; 46.2%), followed by MSH6 (4 of 13; 30.7%). CONCLUSIONS.­: Our findings provide further evidence that indeterminate IHC should be further investigated for possible MMR germline mutation. Guidelines for interpretation of MMR IHC and the establishment of more objective criteria for defining indeterminate results are important to improve the sensitivity and specificity of the IHC assay.

Comparison of residual cancer burden, American Joint Committee on Cancer staging and pathologic complete response in breast cancer after neoadjuvant chemotherapy: results from the I-SPY 1 TRIAL (CALGB 150007/150012; ACRIN 6657).

PURPOSE: Several pathologic staging systems characterize residual tumor in patients undergoing neoadjuvant chemotherapy for breast cancer. Pathologic complete response (pCR) is now accepted by the Food and Drug Administration as an endpoint for granting accelerated drug approval. Two other systems of post-neoadjuvant pathologic tumor staging-residual cancer burden (RCB) and the American Joint Committee on Cancer post-neoadjuvant therapy staging system (yAJCC)-have been developed to characterize residual tumors when patients do not achieve pCR. The optimal system and the ways in which these systems complement each other have not been fully determined. METHODS: Using data from the I-SPY 1 TRIAL, we compared pCR, RCB, and yAJCC as predictors of early recurrence-free survival (RFS) to identify ways to improve post-neoadjuvant pathologic evaluation. RESULTS: Among 162 patients assessed, pCR identified patients at lowest risk of recurrence, while RCB and yAJCC identified patients at highest risk. Hormone-receptor (HR) and HER2 subtypes further improved risk prediction. Recursive partitioning indicated that triple-negative or HER2+ patients with yAJCC III or RCB 3 have the highest recurrence risk, with an RFS of 27%. Our analysis also highlighted discrepancies between RCB and yAJCC stratification: 31% of patients had discrepant RCB and yAJCC scores. We identified differential treatment of lymph node involvement and tumor cellularity as drivers of these discrepancies. CONCLUSIONS: These data indicate that there is benefit to reporting both RCB and yAJCC for patients in order to identify those at highest risk of relapse.

Cutaneous adnexal adenocarcinoma with exquisite sensitivity to trastuzumab.

BACKGROUND: Cutaneous adnexal adenocarcinoma is a rare cancer that is occasionally human epidermal growth factor receptor-2 (HER-2)-positive, and demonstrates variable response to HER-2 inhibitors. METHODS: We report a case of adnexal adenocarcinoma of the scalp in a 56-year-old man. He underwent wide local excision with cervical node dissection followed by radiation, but had extensive local recurrence. RESULTS: Pathology demonstrated a poorly differentiated adnexal adenocarcinoma with HER-2 overexpression by immunohistochemistry (IHC) and high HER-2 gene amplification by fluorescence in situ hybridization. The patient was treated with trastuzumab-based therapy with dramatic response and clinical resolution of the tumor. Upon pausing trastuzumab, he developed local relapse, but had an excellent response to restarting trastuzumab monotherapy. He lacks visible disease 43 months after the initial diagnosis. CONCLUSION: We believe the exquisite sensitivity of the primary carcinoma and subsequent recurrence to trastuzumab therapy was due to strong HER-2 expression both at the protein and gene level. © 2017 Wiley Periodicals, Inc. Head Neck 39: E69-E71, 2017.

Molecular heterogeneity in adjacent cells in triple-negative breast cancer.

PURPOSE: This study interrogates the molecular status of individual cells in patients with triple-negative breast cancers and explores the molecular identification and characterization of these tumors to consider the exploitation of a potential-targeted therapeutic approach. PATIENTS AND METHODS: Hyperspectral immunologic cell by cell analysis was applied to touch imprint smears obtained from fresh tumors of breast cancer patients. RESULTS: Cell by cell analysis confirms significant intratumoral molecular heterogeneity in cancer markers with differences from polymerase chain reaction marker reporting. The individual cell heterogeneity was recognized in adjacent cells examined with panels of ten molecular markers in each single cell and included some markers that are considered to express "stem-cell" character. In addition, heterogeneity did not relate either to the size or stage of the primary tumor or to the site from within the cancer. CONCLUSION: There is a very significant molecular heterogeneity when "adjacent cells" are examined in triple-negative breast cancer, thereby making a successful targeted approach unlikely. In addition, it is not reasonable to consider that these changes will provide an answer to tumor dormancy.

Evaluation of HER2/neu Status by Immunohistochemistry Using Computer-Based Image Analysis and Correlation With Gene Amplification by Fluorescence In Situ Hybridization Assay: A 10-Year Experience and Impact of Test Standardization on Concordance Rate.

CONTEXT: The American Society of Clinical Oncology/College of American Pathologists proposed several recommendations for human epidermal growth factor receptor 2 (HER2) test standardization. One suggestion was that image analysis (IA) could be useful for scoring of HER2/neu immunohistochemistry. The utilization of IA in a real-world practice in a large cohort of cases has not been previously reported. OBJECTIVES: To compare HER2/neu quantification by IA with gene amplification by fluorescence in situ hybridization (FISH); to determine sensitivity, specificity, and concordance rates with the FISH assay; and to determine association between HER2 status with estrogen receptor (ER), progesterone receptor (PR), and Ki-67 expression. DESIGN: We evaluated HER2 results performed by immunohistochemistry and FISH in conjunction with ER, PR, and Ki-67 in 3093 invasive breast cancer cases from 2002 to 2011. RESULTS: The overall concordance between immunohistochemistry and FISH was 87.3% (1768 of 2026). When analyzed by year, there was an improvement in the positive concordance rate from 49.4% (44 of 89) to 95.0% (57 of 60) (P < .001). The negative concordance rate was at least 95% with a median false-negative rate of 1.5%. In the FISH+ group, amplification ratio showed significant correlation with IA scores (P < .001). Positive versus negative HER2 status was associated with lower ER and PR levels (P < .001) and higher Ki-67 expression (P < .001). CONCLUSION: Scoring of HER2/neu by IA was associated with high false-positive rates before 2008. Improvement in concordance rate after 2008 may be due to proper tissue handling, improved HER2/neu scoring by IA, and assay standardization.

KIF14 promotes AKT phosphorylation and contributes to chemoresistance in triple-negative breast cancer.

Despite evidence that kinesin family member 14 (KIF14) can serve as a prognostic biomarker in various solid tumors, how it contributes to tumorigenesis remains unclear. We observed that experimental decrease in KIF14 expression increases docetaxel chemosensitivity in estrogen receptor-negative/progesterone receptor-negative/human epidermal growth factor receptor 2-negative, "triple-negative" breast cancers (TNBC). To investigate the oncogenic role of KIF14, we used noncancerous human mammary epithelial cells and ectopically expressed KIF14 and found increased proliferative capacity, increased anchorage-independent grown in vitro, and increased resistance to docetaxel but not to doxorubicin, carboplatin, or gemcitabine. Seventeen benign breast biopsies of BRCA1 or BRCA2 mutation carriers showed increased KIF14 mRNA expression by fluorescence in situ hybridization compared to controls with no known mutations in BRCA1 or BRCA2, suggesting increased KIF14 expression as a biomarker of high-risk breast tissue. Evaluation of 34 cases of locally advanced TNBC showed that KIF14 expression significantly correlates with chemotherapy-resistant breast cancer. KIF14 knockdown also correlates with decreased AKT phosphorylation and activity. Live-cell imaging confirmed an insulin-induced temporal colocalization of KIF14 and AKT at the plasma membrane, suggesting a potential role of KIF14 in promoting activation of AKT. An experimental small-molecule inhibitor of KIF14 was then used to evaluate the potential anticancer benefits of downregulating KIF14 activity. Inhibition of KIF14 shows a chemosensitizing effect and correlates with decreasing activation of AKT. Together, these findings show an early and critical role for KIF14 in the tumorigenic potential of TNBC, and therapeutic targeting of KIF14 is feasible and effective for TNBC.

Neuregulin 1-HER axis as a key mediator of hyperglycemic memory effects in breast cancer.

Poor outcomes in diabetic patients are observed across a range of human tumors, suggesting that cancer cells develop unique characteristics under diabetic conditions. Cancer cells exposed to hyperglycemic insults acquire permanent aggressive traits of tumor growth, even after a return to euglycemic conditions. Comparative genome-wide mapping of hyperglycemia-specific open chromatin regions and concomitant mRNA expression profiling revealed that the neuregulin-1 gene, encoding an established endogenous ligand for the HER3 receptor, is activated through a putative distal enhancer. Our findings highlight the targeted inhibition of NRG1-HER3 pathways as a potential target for the treatment breast cancer patients with associated diabetes.

Hormone receptor status rather than HER2 status is significantly associated with increased Ki-67 and p53 expression in triple-negative breast carcinomas, and high expression of Ki-67 but not p53 is significantly associated with axillary nodal metastasis in triple-negative and high-grade non-triple-negative breast carcinomas.

Triple-negative (TN) breast carcinoma is associated with a higher recurrence rate and shorter survival and lacks the benefit of specific therapy. TN tumors usually express high levels of Ki-67 and p53 that are considered prognostic markers for breast cancer. We compared Ki-67 and p53 expression between TN and high-grade non-TN invasive carcinomas in a total of 214 cases and investigated an association between their expression and axillary nodal metastasis in these tumors. Our findings demonstrate that TN tumors are associated with significantly higher expression of Ki-67 and p53 compared with non-TN tumors, which may contribute to the poorer prognosis in TN tumors. Hormone receptor negativity rather than HER2 negativity is associated with the significantly increased Ki-67 and p53 expression in TN tumors. Furthermore, a high expression level of Ki-67 but not p53 is more likely to be associated with axillary nodal metastasis in these cases.

A Comparative Analysis of Biomarker Expression and Molecular Subtypes of Pure Ductal Carcinoma In Situ and Invasive Breast Carcinoma by Image Analysis: Relationship of the Subtypes with Histologic Grade, Ki67, p53 Overexpression, and DNA Ploidy.

There is a paucity of data regarding molecular subtypes of pure ductal carcinoma in situ (pDCIS). We evaluated the expression of ER, PR, HER2, Ki67, and p53 and DNA ploidy in 118 pDCIS and 100 invasive breast carcinomas (IBCAs) by routine IHC and classified them according to molecular subtypes. Quantification of biomarkers and DNA ploidy was performed by image analysis. Expression of ER, PR, and high ki67 was more frequent in pDCIS compared to IBCA. High-grade tumors had lower ER and PR expression, high Ki67, overexpression of HER2 and p53, and DNA aneuploidy. Luminal A and HER2 subtypes were more common in pDCIS, and triple negative was more prevalent in IBCA. In both groups, HER2 and triple negative subtypes were characterized by high ki67, overexpression of p53, and DNA aneuploidy compared to luminal subtypes. Molecular subtypes of IBCA are distinct from those of pDCIS. Invasion is characterized by change in phenotype in some tumors.

Intratumoral expression level of epidermal growth factor receptor and cytokeratin 5/6 is significantly associated with nodal and distant metastases in patients with basal-like triple-negative breast carcinoma.

Triple-negative (TN) breast carcinoma, characterized by estrogen receptor, progesterone receptor, and HER2 negativity, is a group of aggressive tumors that can be further classified into 2 subtypes: basal-like, defined as CK5/6 and/or epidermal growth factor receptor (EGFR) positive by immunohistochemistry; and non-basal-like. Clinical characteristics and tumor profiles were analyzed in 105 cases of TN tumors. Among these cases, 35 had distant metastasis, 34 had axillary nodal metastasis only, and 36 were nodal negative. Our results indicate basal-like TN breast tumors with nodal and distant metastases are significantly associated with a higher intratumoral expression of EGFR and CK5/6 compared to those in the nodal negative group. High level of intratumoral EGFR and CK5/6 expression may play a role in development of nodal or distant metastases in patients with basal-like TN tumors and may be predictive of metastatic disease. Furthermore, EGFR targeted therapy may be potentially useful in the treatment of basal-like TN breast cancer.

Recurrent phyllodes tumor of the vulva: a case report with review of diagnostic criteria and differential diagnosis.

Phyllodes tumor of the vulva is extremely rare with only 6 cases reported in the literature. We report a case of recurrent phyllodes tumor of the vulva in a 39-year-old woman. The tumor showed biphasic morphology with a typical leaf-like pattern and a cellular stroma with rare mitosis. Expression of estrogen receptors, progesterone receptors mammoglobin, and BRST-2 was shown in the epithelial component. Review of literature with emphasis on diagnostic features and differential diagnosis are discussed.

Dedifferentiated epithelial-myoepithelial carcinoma of the parotid gland with aberrant expression of prostate specific antigen: a case report.

This report describes a rare case of dedifferentiated epithelial-myoepithelial carcinoma (EMCa) of the parotid gland. The tumor had 2 distinct components; a well-differentiated EMCa comprising of ductal and myoepithelial cells with low nuclear grade and low proliferation index. The second component showed a completely different morphology comprising of sheets and clusters of poorly differentiated cells with high nuclear grade and proliferative activity. The dedifferentiation was associated with an accelerated clinical course. Dedifferentiated EMCa is extremely rare with only 8 cases reported in the English literature. An unusual feature, hitherto not described in this tumor is the aberrant expression of prostate-specific antigen in the dedifferentiated component. In male patients, this may cause diagnostic confusion with metastatic prostate carcinoma.

Interdigitating dendritic cell sarcoma of the parotid gland: case report and literature review.

Interdigitating dendritic cell sarcoma (IDCS) is an exceedingly rare neoplasm arising from the antigen-presenting cells of the immune system. We report a case of IDCS occurring in a 69-year-old man who presented to an outside institution with a painless mass in his right parotid gland for several months. He presented to our institution after undergoing a superficial parotidectomy. A diagnosis of undifferentiated neoplasm, favoring poorly differentiated carcinoma, was made at that time. He underwent a total parotidectomy and neck dissection at our institution. Microscopically, the tumor was composed of atypical spindle cells involving the parotid gland and an ipsilateral level III lymph node. Immunophenotypic analysis demonstrated positive staining for S100, fascin, vimentin, and HLA-II. Follicular dendritic cell, lymphoid, epithelial, myoepithelial, and melanoma markers were negative. Taken together, the above features were consistent with IDCS. An IDCS of the parotid gland is extremely rare, with only 2 cases reported in the literature. The unusual location and morphological similarity to follicular dendritic sarcoma and other types of soft tissue sarcomas can be a diagnostic challenge. Awareness of this tumor and the use of appropriate markers are crucial in making the diagnosis. The patient did well postoperatively, and he underwent a complete course of postoperative irradiation to the right parotid and neck.

Primary mucinous adenocarcinoma of the thymus: a case report and review of the literature.

Primary thymic mucinous adenocarcinoma is extremely rare; to our knowledge, only 2 cases have been reported to date. We describe a third case of primary mucinous adenocarcinoma of the thymus in a 41-year-old man who presented with an anterior mediastinal mass with subsequent metastasis to the lung. The initial diagnosis was of metastatic mucinous adenocarcinoma, but extensive clinical workup of the patient failed to reveal a primary tumor elsewhere in the body. The specific identification of mucinous adenocarcinoma as a primary thymic neoplasm can be difficult or impossible. Morphologic and immunophenotypic similarities to mucinous adenocarcinomas of the gastrointestinal tract can pose diagnostic challenges for surgical pathologists, especially in small biopsy specimens.

Fine needle aspiration cytology of collecting duct carcinoma of the kidney: report of a case with distinctive features and differential diagnosis.

BACKGROUND: The relative rarity of collecting duct carcinoma (CDC) of the kidney in conjunction with a lack of distinctive cytologic features is a diagnostic challenge for any cytopathologist when dealing with such a tumor on fine needle aspiration cytology. In previous cytologic reports, CDC is not well characterized, and the features overlapped with those of high grade renal cell carcinoma (RCC). Because of the differences in behavior and treatment from conventional RCC, it is important to attempt to diagnose this tumor correctly. CASE: The cytologic findings of CDC in a 56-year-old woman were distinctive and not emphasized previously. Ductal/tubular differentiation, prominent desmoplastic stromal component, neutrophilic infiltration and the presence of numerous tubules ranging from benign to dysplastic and frankly malignant were notable features of this tumor. The expression of high-molecular-weight cytokeratin and Ulex europaeus agglutinin helped to confirm the diagnosis. CONCLUSION: The present case highlights several characteristic cytologic features that were useful in suggesting the diagnosis of CDC on fine needle aspiration cytology. Immunohistochemical stains, such as high-molecular-weight cytokeratin and lectin, helped to confirm the diagnosis.

Fine-needle aspiration cytology and differential diagnoses of fibrolamellar hepatocellular carcinoma metastatic to the mediastinum: case report.

We report a case of fibrolamellar hepatocellular carcinoma (FL-HCC) that metastasized to the posterior mediastinum. The diagnosis was made on fine-needle aspiration biopsy (FNAB). The cytologic features were characterized by the presence of large, dishesive, polygonal cells with granular cytoplasm and well-defined cell outlines resembling oncocytes. Groups of neoplastic hepatocytes containing bile pigment were also noted. The diagnosis of FL-HCC in a metastatic site can pose diagnostic challenges on FNAB. The cytologic features overlap with a variety of tumors that have oncocytic features and also with melanoma and paraganglioma. Recognition of specific cytologic features of FL-HCC can facilitate accurate diagnosis in a metastatic site. The cytologic findings and differential diagnoses of FL-HCC that metastasized to the posterior mediastinum are discussed.