Image analysis reveals differences in tumor multinucleations in Black and White patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma.

BACKGROUND: Understanding biological differences between different racial groups of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) patients, who have differences in terms of incidence, survival, and tumor morphology, can facilitate accurate prognostic biomarkers, which can help develop personalized treatment strategies. METHODS: This study evaluated whether there were morphologic differences between HPV-associated tumors from Black and White patients in terms of multinucleation index (MuNI), an image analysis-derived metric that measures density of multinucleated tumor cells within epithelial regions on hematoxylin-eosin images and previously has been prognostic in HPV-associated OPSCC patients. In this study, the authors specifically evaluated whether the same MuNI cutoff that was prognostic of overall survival (OS) and disease-free survival in their previous study, TTR , is valid for Black and White patients, separately. We also evaluated population-specific cutoffs, TB for Blacks and TW for Whites, for risk stratification. RESULTS: MuNI was statistically significantly different between Black (mean, 3.88e-4; median, 3.67e-04) and White patients (mean, 3.36e-04; median, 2.99e-04), with p = .0078. Using TTR , MuNI was prognostic of OS in the entire population with hazard ratio (HR) of 1.71 (p = .002; 95% confidence interval [CI], 1.21-2.43) and in White patients with HR of 1.72 (p = .005; 95% CI, 1.18-2.51). Population-specific cutoff, TW , yielded improved HR of 1.77 (p = .003; 95% CI, 1.21-2.58) for White patients, whereas TB did not improve risk-stratification in Black patients with HR of 0.6 (p = .3; HR, 0.6; 95% CI, 0.2-1.80). CONCLUSIONS: Histological difference between White and Black patient tumors in terms of multinucleated tumor cells suggests the need for considering population-specific prognostic biomarkers for personalized risk stratification strategies for HPV-associated OPSCC patients.

Recurrent and novel USP6 fusions in cranial fasciitis identified by targeted RNA sequencing.

Cranial fasciitis is a benign myofibroproliferative lesion of the scalp and underlying bones typically occurring in the pediatric population. Histologically, it is characterized by loose fascicles of stellate cells in a fibromyxoid background, findings similar to those described in the closely related variant nodular fasciitis. Previously characterized as a reactive process, the identification of USP6 translocations in over 90% of nodular fasciitis cases prompted their reclassification as a clonal neoplastic process. Unlike nodular fasciitis, the molecular underpinnings of cranial fasciitis are less clear. While a subset of cranial fasciitis has been associated with Wnt/ß-catenin pathway dysregulation, recent case reports suggest that this entity may also harbor USP6 fusions, a finding we sought to further investigate. We identified fifteen archival cases of cranial fasciitis, five females and ten males ranging in age from 3 months to 9 years (median 11 months), composed of formalin-fixed paraffin-embedded and fresh frozen tissues (11 and 4 cases respectively). Samples were evaluated on an RNA-based targeted sequencing panel targeting genes recurrently rearranged in neoplasia, including USP6. Five of fifteen cases (33%) were positive for USP6 rearrangements predicted to result in the fusion of the entire USP6 coding region to the promoter of the 5' partner, (three of which were novel):  two SERPINH1-USP6 (novel) and one each of COL3A1-USP6 (novel), SPARC-USP6, and MYH9-USP6. These results demonstrate the recurrent nature of USP6 rearrangements in cranial fasciitis, and highlight the success of targeted RNA sequencing in identifying known and novel fusion partners. The identification of USP6 promoter-swapping rearrangements is helpful in understanding the underlying biology of cranial fasciitis, and reinforces its biologic relationship to nodular fasciitis. Targeted RNA sequencing is a helpful tool in diagnosing this pseudosarcomatous lesion.

Does total manual rescreening of negative pap tests screened by the ThinPrep imaging system add any value?

We compared the performance of utilizing the ThinPrep® Imaging System (TIS) according to the manufacturer's directions to screening with the TIS plus total manual rescreening in Pap tests that were initially diagnosed as NIL to determine whether manual rescreening decreases the false-negative rate for epithelial lesions. Three thousand three hundred forty cases were diagnosed as NIL on the 22 fields of view selected by the TIS and subsequently manually rescreened by the same cytotechnologist. Six hundred seventy-four cases were sent to a cytopathologist for final diagnosis based on review criteria. Biopsy follow-up and Human Papilloma Virus (HPV) test results were noted if available for cases with a diagnosis of ASCUS or above. Three thousand one hundred fifty-nine (94.6%) were confirmed NIL and 181 cases were diagnosed as abnormal on manual rescreen. There were 147 ASCUS, 6 ASCH, 9 AGC, 19 LSIL, and 0 HSIL cases. The overall false-negative rate of screening for atypia/SIL with the TIS was 5.4%. Of the 147 cases with HPV results, 43 (29%) were positive. Only 1 cervical intraepithelial neoplasia 2 was found on biopsy follow-up, in a case of ASCUS with a positive HPV. Based on our data, the TIS for screening of Pap tests is reliable in NIL cases as compared to total manual rescreening. The majority of the false-negative cases were diagnosed as ASCUS on subsequent review, with 0 HSIL cases. Our results confirm that the TIS is highly accurate in excluding HSIL, negating the need for total manual rescreening of NIL Pap tests.

Glandular cells in vaginal cytology Papanicolaou tests in patients with hysterectomy for endometrial adenocarcinoma.

The vaginal apex is the most common site of recurrence in patients with endometrial cancer. Although studies demonstrate that <1% of asymptomatic vaginal recurrences are detected by routine vaginal cytology alone, many practitioners still include it as part of the routine surveillance in these patients after hysterectomy. To further evaluate the effectiveness of vaginal cytology as a surveillance tool, we assessed the subsequent findings in patients reported to have benign and atypical glandular cells on vaginal cytology after hysterectomy performed for endometrial cancer.

Transmastoid extradural-intracranial approach for repair of transtemporal meningoencephalocele: a review of 31 consecutive cases.

OBJECTIVE: To review the clinical presentation, surgical techniques, and outcomes of the transmastoid extradural-intracranial (TMEDIC) approach for the treatment of transtemporal meningoencephalocele. HYPOTHESIS: The TMEDIC is a safe and effective approach to repair meningoencephalocele originating from the middle or posterior cranial fossa. STUDY DESIGN: Retrospective chart review. SETTING: Academic neurotologic tertiary referral center. PATIENTS: Thirty-one consecutive patients diagnosed with transpetrous meningo(encephalo)cele, with or without cerebrospinal fluid leak, between January of 2003 and October of 2010. INTERVENTION: TMEDIC approach for repairing herniated neural tissue through the tegmen or posterior fossa plate using the combination of autologous cartilage, fascia, and tissue sealant. MAIN OUTCOME MEASURES: Anatomic location, size, and number of defects, presence of herniated brain tissue, pre- and postoperative hearing thresholds, and failure rate. RESULTS: Mean age was 62 ± 26 years. The etiology was spontaneous in 25/31 (80%), congenital in 3/31 (10%), chronic otitis media in 2/31 (6%), and posttraumatic in 1/31 (4%). Posttympanostomy tube clear otorrhea was the presenting sign in 21/31 (68%) of patients. The mean duration of symptoms was 26 months (range: 1-240). The defect involved the middle fossa (MF) floor in 25/31 (90%). Both the tegmen tympani and mastoideum were involved in 12/31 (39%) of patients and multiple dehiscences were seen in 7/31 (22%). In 17/31 (55%) of cases the size exceeded 1 cm. No recurrences were seen. CONCLUSION: The TMEDIC is a safe and effective method to repair transtemporal meningoencephalocele obviating the need for a middle fossa craniotomy in certain cases.

A phase II trial of fosbretabulin in advanced anaplastic thyroid carcinoma and correlation of baseline serum-soluble intracellular adhesion molecule-1 with outcome.

BACKGROUND: Fosbretabulin is a novel vascular-disrupting agent that has antitumor activity against anaplastic thyroid cancer (ATC) cell lines, xenografts, and demonstrable efficacy in a phase I trial. This phase II study determined the efficacy and safety of fosbretabulin in patients with advanced ATC and whether fosbretabulin altered the natural history of ATC by virtue of doubling the median survival. A secondary aim evaluated the prognostic value of serum soluble intracellular adhesion molecule-1 (sICAM). METHODS: Twenty-six patients received fosbretabulin 45 mg/m(2) as a 10-minute intravenous infusion on days 1, 8, and 15 of a 28-day cycle. sICAM levels were obtained at baseline, over the first two cycles, and end of therapy. Treatment was continued until disease progression. RESULTS: Fosbretabulin was well tolerated; grade 3 toxicity was observed in nine patients (35%), and grade 4 toxicity in one (4%). QTc prolongation delayed treatment in four causing one to stop treatment. Median survival was 4.7 months with 34% and 23% alive at 6 and 12 months, respectively. Median duration of stable disease in seven patients was 12.3 months (range, 4.4-37.9 months). Baseline serum sICAM levels were measured in 24 patients with a median 253.5 ng/mL. There was a significant difference in event-free survival among tertiles of baseline sICAM levels (p < 0.009). CONCLUSIONS: There were no objective responses seen with single-agent fosbretabulin as administered in this trial, and we did not observe a doubling of survival as our primary endpoint. This is among the largest prospective trials ever conducted for ATC. Fosbretabulin has an acceptable safety profile in patients with advanced ATC, and one-third survived more than 6 months. Despite a small sample size, low baseline sICAM levels were predictive of event-free survival. Further prospective validation of sICAM as a therapeutic biomarker and exploring combination regimens with fosbretabulin are warranted.

Giant intrathyroid parathyroid adenoma: a preoperative and intraoperative diagnostic challenge.

We describe the case of an unusually large (giant) cystic intrathyroid parathyroid adenoma in a 73-year-old woman who had a 1-year history of hypercalcemia and a 5-year history of an asymptomatic enlargement of the left lobe of the thyroid. This unique case highlights the potential difficulties that can arise in the evaluation of thyroid nodules in patients with hyperparathyroidism. These difficulties were accentuated in this case by the large size of the mass, its intrathyroid location, and cytologic features that were compatible with a lesion of thyroid origin. In some cases, including this one, even a thorough preoperative evaluation that includes fine-needle aspiration biopsy and radiographic and nuclear medicine studies may not allow for a definitive preoperative diagnosis. The histologic overlap between thyroid and parathyroid lesions can also be problematic at the time of intraoperative frozen-section evaluation. Intraoperative parathyroid hormone monitoring may be helpful in these difficult cases.

Molecular classification of thyroid nodules by cytology.

OBJECTIVES: Fine needle aspiration (FNA) biopsy of thyroid nodules provides cytologic specimens whose interpretation can direct patients toward either thyroidectomy or observation. Approximately 20% of FNA specimens yield an indeterminate result. Recent studies have characterized differences in gene expression between benign and malignant conditions, most often using whole tissue. Our goal was to determine the feasibility of quantitative polymerase chain reaction (qPCR)-based gene expression analysis in cytologic samples. For five genes shown to be over-expressed in thyroid carcinomas (fibronectin, galectin-3, Met/HGFR, MUC1, and GA733-precursor), we compared expression among pathologic states. STUDY DESIGN: Prospective laboratory analysis of 20 thyroidectomy specimens. METHODS: Routine microscopy was performed. Cytologic samples were obtained from the dominant nodules, and RNA was extracted. Preliminary analysis using fluorometry and reverse-transcriptase (RT)-PCR was performed. Expression levels of the test genes in nodules and from control samples were measured by real-time qPCR. Fold changes in gene expression were compared. RESULTS: Only one specimen did not yield sufficient intact RNA for gene expression analysis. RT-PCR revealed satisfactory RNA recovery in all other specimens. qPCR showed significant over-expression of fibronectin in the papillary carcinomas compared with the goiters (P = .0013), follicular adenomas (P = .0014), and follicular carcinomas (P = .0001). Differences in both fibronectin and MUC1 expression between the follicular carcinomas and the follicular adenomas were also significant (P = .025 and .045, respectively). CONCLUSIONS: Cytologic specimens were a satisfactory source of tissue for qPCR-based gene expression analysis. Both fibronectin and MUC1 were differentially expressed in follicular adenomas and follicular carcinomas, and fibronectin expression differed in papillary carcinomas compared with the other lesions. These results may form the basis of a clinical predictor for lesions with indeterminate or suspicious cytology.

Inflammatory pseudotumor of the middle ear masquerading as Bell's palsy.

We describe the case of a 28-year-old woman who presented with an acute dense left facial paralysis. Magnetic resonance imaging demonstrated enhancement of the labyrinthine portion of the facial nerve, and Bell's palsy was the presumed initial diagnosis. After 2 months without recovery despite receiving steroid and antiviral therapy, the patient underwent further workup. Computed tomographic scan demonstrated a mass lesion adjacent to the tympanic portion of the facial nerve, and electromyography showed active denervation and prominent fibrillation potentials. Surgical excision of the tumor was performed with decompression and sparing of the facial nerve. Histologically, the tumor proved to be an inflammatory pseudotumor (IPT). At the 3-year follow-up, the patient had an improvement in her facial nerve function, progressing to a House-Brackman grade III. An IPT can masquerade as Bell's palsy with sudden complete facial paralysis. Failure to obtain even slight recovery in Bell's palsy should prompt further workup, including appropriate imaging, to assess for a mass lesion. Confusion of an IPT with a nerve-based tumor on frozen section and imaging could lead to inappropriate resection and cable grafting of the facial nerve. Therefore, the relationship between an IPT and facial nerve paralysis is vital and must be recognized for treatment and to maximize postoperative facial nerve function.

Inflammatory breast cancer as a model disease to study tumor angiogenesis: results of a phase IB trial of combination SU5416 and doxorubicin.

PURPOSE: We used inflammatory breast cancer (IBC) as a model disease to investigate biological changes associated with an antiangiogenesis agent, SU5416, combined with doxorubicin. EXPERIMENTAL DESIGN: Patients with stage IIIB or IV IBC were treated neoadjuvantly with the combination of SU5416 and doxorubicin for induction therapy. The dose of SU5416 (administered on days 1 and 4, every 3 weeks) and doxorubicin (administered on day 1 every 3 weeks) were escalated in cohorts of three patients starting at 110 and 60 mg/m2, respectively, for a total of five cycles leading up to mastectomy. Patients underwent serial assessment (pharmacokinetic sampling, biopsy of breast, tumor blood flow dynamic contrast-enhanced magnetic resonance imaging, plasma angiogenesis, and endothelial cell damage markers) prior to treatment, at the end of cycles no. 2 and no. 5, and after mastectomy. RESULTS: Eighteen patients were enrolled; neutropenia was dose-limiting, and overall median survival was not reached (50 months of study follow-up). Four patients (22%) experienced congestive heart failure, which resolved and were likely attributable to a smaller volume of distribution and higher Cmax of doxorubicin in combination with SU5416. We did observe a significant decline in tumor blood flow using Kep calculated by Brix (pretreatment versus post-cycle no. 5; P = 0.033), trend for a decline in tumor microvessel density after treatment, and low baseline levels of soluble intracellular adhesion molecule were associated with improved event-free survival. CONCLUSIONS: This study showed evidence of an unfavorable cardiac interaction between SU5416 and doxorubicin, which prohibits further investigation of this combination. However, this study supports the importance of using IBC as a model for investigating angiogenesis inhibitors.

Tissue-engineered calcium alginate patches in the repair of chronic chinchilla tympanic membrane perforations.

OBJECTIVE: Chronic tympanic membrane perforations are a common problem in the United States. A high number of these cases results from placement of pressure equalization tubes. These perforations may initially be treated with paper patch techniques and although safe and well tolerated, the procedure demonstrates poor efficacy. The ideal treatment for small perforations should be rapid, minimally invasive, and efficacious. Calcium alginate-based tissue engineered tympanic membrane patches represent an attractive option, but in vivo data are required. METHODS: A controlled prospective study of tympanic membrane perforation repair using a well-known chinchilla model of chronic tympanic membrane perforation was performed. Calcium alginate-based tympanic membrane patches were created using computer-aided design techniques. A previously described chinchilla model of chronic tympanic membrane perforations was used to create stable perforations ranging from 2 to 5 mm. Ears with chronic perforations were divided into three groups: control (no patch), paper patch, and calcium alginate plugs. At 10 weeks postimplantation, all animals were killed and inspected both grossly and histologically for healing. RESULTS: In the chinchilla model, the alginate grafts demonstrated significantly improved healing rates over both the untreated control group (spontaneous repair) and the paper patch group; nine of 13 healed in the alginate group versus two of nine healed in the paper patch group (P < .05) versus one of 11 healed in the control group (P < .05). CONCLUSION: Calcium alginate tympanic membrane perforation patches offer a significant advantage in the repair of chronic perforations over traditional techniques in the chinchilla perforation model and may offer attractive opportunities in the clinical setting.

Novel Phase I dose de-escalation design trial to determine the biological modulatory dose of the antiangiogenic agent SU5416.

PURPOSE: To determine the biological modulatory dose of SU5416, we employed a novel trial design, where "dose de-escalation" was based on demonstrable biological changes observed at the maximum tolerated dose. If such an effect was shown, dose de-escalation to a predefined dose level would occur to determine if the lower dose exhibited the same amount of pharmacodynamic effect as the higher dose. EXPERIMENTAL DESIGN: Ten patients with advanced solid tumors were enrolled at each dose level. One of the following pharmacodynamic effects was considered significant: (a) a 35% decrease in microvessel density in sequential tumor biopsies and (b) a 35% decrease in blood flow within tumor as assessed by dynamic contrast-enhanced magnetic resonance imaging. In addition, soluble E-selectin, soluble intercellular adhesion molecule, soluble vascular cell adhesion molecule, and plasma vascular endothelial growth factor were measured sequentially. RESULTS: Nineteen patients were enrolled. Sequential tumor biopsies in all evaluable patients showed an increase in microvessel density. Only one patient met the intended pharmacodynamic end point of >35% reduction in blood flow. There was a significant increase in both soluble E-selectin and soluble intercellular adhesion molecule levels pretreatment versus levels at the time of removal of patients from study (P = 0.04 and P = 0.0007, respectively). Levels of serum fibrinogen rose with therapy. There was a trend toward increase in plasma vascular endothelial growth factor levels. CONCLUSION: SU5416 does not result in decreased blood flow in tumors or a decrease in microvessel density. This corresponds to the lack of clinical activity seen with this agent. Our clinical trial design termed dose de-escalation is a novel approach to determine the in vivo biological effects of targeted therapies in cancer patients.

Xanthogranulomatous sialadenitis: a case report and literature review.

Xanthogranulomatous tissue reaction is an uncommon but well-documented process that occurs at many sites in the body. It is most often recognized in the kidney and gallbladder, where its etiology is believed to involve an outflow obstruction. We report the case of a man with a parotid mass that exhibited features consistent with an inflammatory process on fine-needle aspiration biopsy. The mass persisted despite medical management, and the patient subsequently underwent a superficial parotidectomy. Histologic examination of the resected specimen identified a xanthogranulomatous tissue reaction adjacent to a Warthin's tumor. We compare the features of this case with those of the 2 previously reported cases of xanthogranulomatous sialadenitis, and we discuss its possible etiologies.

Mesodermal adenosarcoma of the testis.

Biphasic neoplasms with a benign to atypical epithelial component and a usually low-grade malignant stromal component have been reported in various sites, probably being best known for their occurrence in the uterine corpus (mullerian adenosarcoma). We report a tumor of this type that occurred in the testis of a 76-year-old man and, to our knowledge, is the first mesodermal adenosarcoma reported at this site. The patient had scrotal swelling for many years with a pronounced increase in the swelling over the past 2 years. A large complex solid-cystic testicular tumor was evident on ultrasound, and examination of a radical orchiectomy specimen showed a 6.5-cm mass. On microscopic examination, the neoplasm had a phyllodes-like appearance with bland cuboidal to flattened epithelium covering polypoid fronds, and lining glands and cysts. The stroma varied from cellular, particularly where it condensed around the glands and cysts, to hypocellular and hyalinized. It was immunoreactive for muscle specific actin, CD10, and to a lesser degree, desmin. This case expands the known sites where mesodermal adenosarcoma may occur. The histogenesis is speculative, but possible options are discussed.

Histopathologic correlation of atypical parakeratosis diagnosed on cervicovaginal cytology.

OBJECTIVE: To retrospectively examine the histopathologic findings in women with the isolated finding of atypical parakeratosis (PK) on a Pap test. STUDY DESIGN: The cytology files (1999-2001) were searched for cervicovaginal Pap tests interpreted as atypical PK. Cases were included for study only if there was a subsequent cervicovaginal tissue sample within 1 year of the cytologic interpretation and there was no diagnosis of squamous intraepithelial lesion (SIL) within the previous five years. RESULTS: Of 355 patients with atypical PK, 109 (aged 14-69 years, mean 31.5) met the inclusion criteria of the study. The interval between the cytologic interpretation and cervicovaginal tissue examination ranged from 0.5 to 12 months (mean, 2.5). Sixty-one patients underwent both endocervical curettage (ECC) and cervical biopsy (CBx), 20 patients underwent ECC only, 19 patients underwent CBx only, and the remainder underwent other procedures. Histopathologic findings on the tissue samples included: no significant pathologic change but no squamous epithelium present for evaluation (n = 10, 9.2%), benign changes other than hyperkeratosis and/or PK (n = 50, 45.9%), hyperkeratosis and/or PK (n = 8, 7.3%), low grade SIL (n = 33, 30.3%), high grade SIL (n = 6, 5.5%) and invasive squamous cell carcinoma (n = 2, 1.8%). CONCLUSION: The isolated finding of atypical PK on a Pap test correlated with the presence of an underlying SIL or invasive carcinoma in approximately 40% of patients. Of these, 80% had low grade SIL. The cytologic finding of atypical PK warrants further investigation in order to exclude SILs and/or carcinoma. We suggest that atypical PK be routinely included in the category of atypical squamous cells of undetermined significance.