RESUMO
UNLABELLED: The occurrence of contrast induced nephropathy (CIN) is associated with increased mortality after percutaneous revascularization procedures. However, the exact correlation between various levels of creatinine elevation relative to the baseline and subsequent mortality in patients with chronic renal insufficiency (CRI) is not well established. In addition, the relationship between elevated postprocedural creatinine and ensuing mortality in patients with normal baseline renal function needs to be investigated. METHODS: All percutaneous coronary intervention (PCI) patients (n = 12,997) were analyzed for any rise in serum creatinine (SCr): CRI group (BSC > or = 1.5 mg/dl) (n = 1,853) and normal baseline renal function (NBR BSC < 1.5 mg/dl) group (n = 11,144). Patients in each group were analyzed for any elevation in SCr postprocedure and subdivided based on the SCr ratio [peak SCr/Baseline creatinine (BSC)] of <1.25, 1.25-1.5, and >1.5. The overall incidence of CIN (defined as an increment of 25% over baseline creatinine) was 5.9%: 11.3% in the CRI group versus 5.1% in normal BSC group (P < 0.01). Recursive partitioning and Cox hazard modeling were used to assess significant variables associated with mortality within 1 year. Only serum creatinine ratio (SCrR) > 1.5 correlated with increased mortality in both CRI group as well as normal BSC group. CONCLUSIONS: SCrR > 1.5 predicts mortality at 1 year after PCI. The association between SCrR > 1.5 and increased mortality at follow-up is observed in patients with CRI as well as normal baseline renal function. SCrR may thus serve as a useful clinical tool for risk stratification and prognostication of patients after PCI.
Assuntos
Angioplastia Coronária com Balão/mortalidade , Meios de Contraste/efeitos adversos , Angiografia Coronária/efeitos adversos , Creatinina/sangue , Cardiopatias/terapia , Testes de Função Renal , Rim/fisiopatologia , Radiografia Intervencionista/efeitos adversos , Insuficiência Renal Crônica/complicações , Idoso , Biomarcadores/sangue , Bases de Dados como Assunto , Feminino , Cardiopatias/sangue , Cardiopatias/complicações , Cardiopatias/diagnóstico por imagem , Cardiopatias/mortalidade , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Regulação para CimaRESUMO
OBJECTIVES: The objective of this study is to analyze the clinical outcomes and treatment strategies of coronary wire perforations (WPs) in the era of heparin use compared to the era of bivalirudin use. BACKGROUND: Percutaneous coronary intervention (PCI) advances have led to progressive decrease in complications. Therefore, complex coronary lesions such as chronic total occlusions and calcified lesions are being attempted with stiff/hydrophilic wires with resultant higher incidence of coronary WP. METHODS: A single-center retrospective data analysis of coronary perforation (CP) for the last 4 years with review of coronary angiograms was done and WPs were identified. A simple classification scheme based on angiographic appearance of CP was made: Type I ("myocardial stain," with no frank dye extravasation) and type II ("myocardial fan," with dye extravasation to pericardial cavity or cardiac chambers). RESULTS: Overall incidence of CP was 0.49% (82/16,859). Of these 50 (61%) were caused by WP; 30 occurred with heparin use (Group A) and 20 with bivalirudin use (Group B). WPs always occurred in type B2/C lesions (100%) and commonly with use of hydrophilic guidewires (70%). Major adverse cardiac events and cardiac tamponade were frequent in group A (50%) and none in group B (0%); P < 0.01. All WP in group B responded to stopping anticoagulation and prolonged balloon inflation, while group A type II perforations frequently required additional interventions (pericardiocentesis, coil embolization). CONCLUSIONS: Cardiac tamponade and major adverse cardiac events from WPs were less frequent with bivalirudin use compared to heparin use. This beneficial effect of bivalirudin may be explained on the basis of its short half-life and reversible thrombin inhibition property. Therefore, bivalirudin may offer a safer alternative for anticoagulation in complex PCI.
Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Anticoagulantes/efeitos adversos , Tamponamento Cardíaco/terapia , Doença da Artéria Coronariana/terapia , Vasos Coronários/lesões , Heparina/efeitos adversos , Hirudinas/efeitos adversos , Fragmentos de Peptídeos/efeitos adversos , Ferimentos Penetrantes/terapia , Idoso , Angioplastia Coronária com Balão/instrumentação , Angioplastia Coronária com Balão/mortalidade , Oclusão com Balão , Tamponamento Cardíaco/diagnóstico por imagem , Tamponamento Cardíaco/etiologia , Tamponamento Cardíaco/mortalidade , Cineangiografia , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Feminino , Antagonistas de Heparina/uso terapêutico , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Pericardiocentese , Proteínas Recombinantes/efeitos adversos , Sistema de Registros , Estudos Retrospectivos , Resultado do Tratamento , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/etiologia , Ferimentos Penetrantes/mortalidadeRESUMO
BACKGROUND: Urine cytology is the most frequently utilized test to detect urothelial cancer. Secondary bladder neoplasms need to be recognized as this impacts patient management. We report our experience on nonurothelial malignancies (NUM) detected in urine cytology over a 10-year period. METHODS: A 10-year retrospective search for patients with biopsy-proven NUM to the urothelial tract yielded 25 urine samples from 14 patients. Two cytopathologists blinded to the original cytology diagnosis reviewed the cytology and histology slides. The incidence, cytomorphologic features, diagnostic accuracy, factors influencing the diagnostic accuracy, and clinical impact of the cytology result were studied. RESULTS: The incidence of NUM was <1%. The male:female ratio was 1.3. An abnormality was detected in 60% of the cases; however, in only 4% of the cases, a primary site was identified accurately. Of the false negatives, 96% was deemed as sampling errors and 4% was interpretational. Patient management was not impacted in any of the false-negative cases due to concurrent or past tissue diagnosis. CONCLUSION: Colon cancer was the most frequent secondary tumor. Sampling error attributed to the false-negative results. Necrosis and dirty background was often associated with metastatic lesions from colon. Obtaining history of a primary tumor elsewhere was a key factor in diagnosis of a metastatic lesion. Hematopoietic malignancies remain to be a diagnostic challenge. Cytospin preparations were superior for evaluating nuclear detail and background material as opposed to monolayer (Thinprep) technology. Diagnostic accuracy was improved by obtaining immunohistochemistry. Diagn. Cytopathol. 2016. © 2016 Wiley Periodicals, Inc. Diagn. Cytopathol. 2017;45:22-28. © 2016 Wiley Periodicals, Inc.
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Biomarcadores Tumorais/urina , Neoplasias Colorretais/patologia , Erros de Diagnóstico/estatística & dados numéricos , Linfoma/patologia , Melanoma/patologia , Neoplasias da Próstata/patologia , Urina/citologia , Neoplasias Colorretais/urina , Feminino , Humanos , Linfoma/urina , Masculino , Melanoma/urina , Sistemas Multi-Institucionais/estatística & dados numéricos , Neoplasias da Próstata/urinaRESUMO
BACKGROUND: The authors' fine-needle aspiration (FNA) clinic opened in 2010, allowing cytopathologists to increase their proficiency and experience in FNA performance. Here, they report their 5-year experience. METHODS: The FNA clinic log book and the institution's database were retrospectively reviewed to record patients' demographics, the number of FNAs performed per year by each cytopathologist, the number of passes, rapid on-site evaluation (ROSE) and diagnosis, adequacy-diagnosis concordance, and follow-up histology when available. The numbers and types of cases per year and variations among cytopathologists were compared. RESULTS: In total, 474 cases were identified within a 5-year time-frame. The discrepancy rate between the on-site and final diagnoses decreased progressively, from 4.4% to 2.4%. The nondiagnostic rate decreased from 2011 to 2015, with the exception of 2014, when an increase was noted, possibly because of a lower number of cases. Cytopathologists' performance was assessed over a 3-year period. The number of passes for each FNA decreased over time. The cytology-histology concordance was 100% over time for all cytopathologists. There was a diagnostic discrepancy between the ROSE and final diagnoses for 3 of 104 cases in 2013 and for 3 of 124 cases in 2015. The total number of passes was not consistently recorded until 2014, when a final report template was instituted. The technique improved over time because of accumulated experience, constant practice with phantoms, and attending the College of American Pathologists' training in ultrasound-guided FNA. CONCLUSIONS: FNAs performed by cytopathologists have a high-rate of ROSE/adequacy and a low diagnostic discrepancy rate. Cytopathologists as interventionalists provide optimal care and excellent patient satisfaction. Cancer Cytopathol 2017;125:161-168. © 2016 American Cancer Society.
Assuntos
Biópsia por Agulha Fina/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia por Agulha Fina/normas , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , UltrassomRESUMO
Discovery of driver mutations in pulmonary adenocarcinoma has revolutionized the field of thoracic oncology with major impact on therapy and diagnosis. Testing for EGFR, ALK, and KRAS mutations has become part of everyday practice. We report a case with multiple synchronous primary pulmonary adenocarcinomas in a 72-year-old female with previous history of smoking. The patient presented with cough and bilateral lung ground glass opacities. A positron emission tomography/computed tomography scan showed no activity in mediastinal lymph nodes. She underwent a left upper lobe biopsy and a right upper lobe wedge resection. Pathology revealed 4 morphologically distinct adenocarcinoma foci, suggestive of synchronous primary lung tumors. Molecular testing demonstrated no mutation in the left tumor. Three different driver mutations were present in the right lung tumors: KRAS codon 12 G12D and G12V and EGFR exon 21 L858R mutation, confirming the initial histologic impression. Subsequently, left upper lobe lobectomy showed 3 additional foci of adenocarcinoma with different morphologies, suggestive of synchronous primaries as well. No additional molecular testing was performed. Synchronous pulmonary adenocarcinomas are not uncommon; however, 4 or more synchronous tumors are rare. Distinguishing multiple primary tumors from intrapulmonary metastases is a common problem in thoracic oncology with major implications for staging, prognosis, and treatment. Lung adenocarcinoma subclassification based on predominant and coexisting histologic patterns can greatly facilitate differentiation between intrapulmonary metastases and multiple synchronous tumors. Use of molecular profiling is recommended since it further increases confidence in the diagnostic workup of multiple pulmonary adenocarcinomas and helps guiding therapy.
Assuntos
Adenocarcinoma/diagnóstico , Neoplasias Pulmonares/diagnóstico , Neoplasias Primárias Múltiplas/diagnóstico , Adenocarcinoma/metabolismo , Adenocarcinoma/patologia , Idoso , Feminino , Humanos , Pulmão/metabolismo , Pulmão/patologia , Neoplasias Pulmonares/metabolismo , Neoplasias Pulmonares/patologia , Mutação , Neoplasias Primárias Múltiplas/metabolismo , Neoplasias Primárias Múltiplas/patologia , Patologia Molecular , Prognóstico , FumarRESUMO
Adenoid cystic carcinoma (ACC) is a rare malignant tumor of the salivary glands, with higher frequency in the submandibular gland, a prolonged clinical course, and poor long-term survival. It tends to metastasize to lungs, bone, liver, brain, and rarely to skin. Comprehensive skin examination and appropriate follow-up is recommended, since cutaneous metastasis represents disease progression, requiring management and prognosis adjustment.
RESUMO
BACKGROUND: The Bethesda system (TBS) for the reporting of thyroid cytopathology established the category of atypia of undetermined significance (AUS) with a 7% target rate and a 5% to 15% implied malignancy risk. Recent literature has reported a broad range of AUS rates, subsequent malignancy rates, and discrepant results from repeat fine-needle aspiration (FNA) versus surgical follow-up. Therefore, this study examined AUS data from the Hofstra North Shore-LIJ School of Medicine to determine the best clinical follow-up. METHODS: Thyroid aspirates interpreted as AUS in 2012-2014 at the Hofstra North Shore-LIJ School of Medicine were collected. Repeat FNA and surgical follow-up data were tabulated to establish AUS, secondary AUS (diagnosed upon repeat FNA follow-up of a primary FNA AUS diagnosis), atypia of undetermined significance/malignancy (AUS:M) ratios (according to the TBS categories), and malignancy rates for AUS. RESULTS: The AUS rate was 8.5% (976/11,481), and there was follow-up data for 545 cases. The AUS:M ratio was 2.0. Repeat FNA was performed for 281 cases; 57 proceeded to surgical intervention. Repeat FNA reclassified 71.17% of the cases. The malignancy rates for AUS cases proceeding directly to surgery and for those receiving a surgical intervention after a repeat AUS diagnosis were 33.33% and 43.75%, respectively. CONCLUSIONS: Repeat FNA resulted in definitive diagnostic reclassification for 67.61% of primary AUS cases and reduced the number of patients triaged to surgery, with 56.58% of the cases recategorized as benign. Cases undergoing surgery after repeat AUS had a higher malignancy rate than those going straight to surgery, and this emphasizes the value of repeat FNA in selecting surgical candidates. In addition, this study highlights the utility of AUS rate monitoring as a quality measure that has contributed to the ability of the Hofstra North Shore-LIJ School of Medicine to adhere closely to TBS recommendations.
Assuntos
Adenocarcinoma Folicular/patologia , Glândula Tireoide/patologia , Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgia , Adenocarcinoma Folicular/diagnóstico , Biópsia por Agulha Fina/métodos , Biópsia por Agulha Fina/estatística & dados numéricos , Estudos de Coortes , Diagnóstico Diferencial , Gerenciamento Clínico , Feminino , Humanos , Imuno-Histoquímica , Masculino , Controle de Qualidade , Pesquisadores , Estudos Retrospectivos , Terminologia como Assunto , Neoplasias da Glândula Tireoide/diagnóstico , Tireoidectomia/métodosRESUMO
BACKGROUND: Subtyping of lung carcinoma with immunohistochemistry is essential for diagnosis, whereas molecular testing (MT) is required for therapy guidance. In the current study, the authors report on MT performed on fine-needle aspiration specimens at the study institution over a 2-year period preceding the April 2013 College of American Pathologists (CAP)/International Association for the Study of Lung Cancer (IASLC)/Association for Molecular Pathology (AMP) Molecular Testing Guideline (MTG) publication. METHODS: The database of the study institution was retrospectively queried for cases of lung and thoracic/lower cervical lymph node fine-needle aspiration specimens for 2011 through 2012. RESULTS: Of 246 selected cases, 26 featured a limited amount of material in cell blocks. MT increased significantly between 2011 and 2012 and was requested in 39.4% of cases (97 of 246 cases): 86 of those cases had at least 1 MT result and 11 had insufficient material for any MT. Anaplastic lymphoma kinase (ALK) testing was performed in 9 cases in which DNA was insufficient for epidermal growth factor receptor (EGFR) testing. In addition, 13 cases of adenocarcinoma/non-small cell lung carcinoma had at least 1 MT canceled because of insufficient DNA, but at the same time had an average of 3.46 immunohistochemical stains performed. CONCLUSIONS: Of all the cytology specimens, 10.6% featured limited material; however, no universally accepted testing sequence priority was available at the time the study was performed. As per the MTG, MT should take precedence over immunohistochemistry in cases of adenocarcinoma/non-small cell lung carcinoma. Approximately 5.3% of the specimens in the current study had insufficient material for MT while having multiple stains performed instead. The MTG also recommend performing EGFR before ALK testing; the authors found 9 cases with insufficient material for EGFR testing that had ALK testing performed. The results of the current study underscore the need for a testing prioritization algorithm in view of the MTG publication to serve as reference for both clinicians and pathologists.
Assuntos
Adenocarcinoma/genética , Carcinoma Pulmonar de Células não Pequenas/genética , Citodiagnóstico , Neoplasias Pulmonares/genética , Técnicas de Diagnóstico Molecular/normas , Guias de Prática Clínica como Assunto/normas , Adenocarcinoma/patologia , Quinase do Linfoma Anaplásico , Biópsia por Agulha Fina , Carcinoma Pulmonar de Células não Pequenas/patologia , Receptores ErbB/genética , Seguimentos , Rearranjo Gênico , Humanos , Neoplasias Pulmonares/patologia , Mutação/genética , Estadiamento de Neoplasias , Prognóstico , Proteínas Proto-Oncogênicas/genética , Proteínas Proto-Oncogênicas p21(ras) , Editoração , Receptores Proteína Tirosina Quinases/genética , Estudos Retrospectivos , Sociedades Médicas , Proteínas ras/genéticaRESUMO
High-density lipoprotein (HDL) cholesterol level is a strong predictor of morbidity and mortality in the general population. Conflicting data exist on the protective effects of high HDL cholesterol in patients with optimal low-density lipoprotein (LDL) cholesterol levels. To determine the association of high HDL cholesterol with mortality in patients with LDL cholesterol levels <70 mg/dl who undergo percutaneous coronary intervention, 3,616 consecutive patients with LDL cholesterol levels <70 mg/dl who underwent percutaneous coronary intervention from July 1, 1999, to June 1, 2007, were retrospectively analyzed and followed through July 1, 2007. All-cause mortality was identified using the National Death Index. The mortality rates was 34.7, 25.2, 23.7, and 18.8 per 1,000 person-years in patients with HDL cholesterol levels of <40, 40 to 49, 50 to 59, and > or =60 mg/dl, respectively (p for trend <0.001). After multivariate adjustment for demographic characteristics, cigarette smoking, biochemical variables, and co-morbid conditions, the hazard ratios for mortality in patients with HDL cholesterol levels of 40 to 49, 50 to 59, and > or =60 mg/dl, compared with their counterparts with HDL cholesterol levels <40 mg/dl, were 0.68 (95% confidence interval [CI] 0.50 to 0.93), 0.55 (95% CI 0.35 to 0.85), and 0.45 (95% CI 0.27 to 0.74), respectively. For each 1-SD increase in HDL cholesterol level (14 mg/dl), the multivariate-adjusted hazard ratio for all-cause mortality was 0.68 (95% CI 0.58 to 0.79). In conclusion, in patients with LDL cholesterol levels <70 mg/dl who underwent percutaneous coronary intervention, a strong inverse association was present between HDL cholesterol level and all-cause mortality.