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Matsukuma K, Gui D, Saadai P. Hirschsprung Disease for the Practicing Surgical Pathologist. Am J Clin Pathol 2023; 159:228-241. [PMID: 36565211 DOI: 10.1093/ajcp/aqac141] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/16/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Hirschsprung disease (HD) is a congenital condition defined by the absence of ganglion cells in the distal-most portion of the gastrointestinal tract. Biopsies and resections for HD can be adrenaline inducing for the general surgical pathologist because specimens are infrequent; HD is 1 of only a few neuroanatomic diseases that general surgical pathologists diagnose; numerous preanalytic factors (eg, biopsy adequacy, surgeon sampling protocol, processing artifacts) can affect histologic interpretation; and most importantly, the diagnosis has high stakes. METHODS We provide a comprehensive overview of the background, relevant clinical procedures, and pathologic assessment of HD. Grossing and frozen section protocols, an algorithmic approach to diagnosis, and histologic pearls and pitfalls are also discussed. RESULTS Evaluation and recognition of the features of HD have evolved significantly in the past 2 decades with the discovery of the value of calretinin immunohistochemistry in the late 2000s and the recent development of straightforward and reproducible histologic criteria for identification of the HD transition zone. CONCLUSIONS These advancements have substantially improved the pathologist's ability to reliably evaluate for HD. Nonetheless, as with any high-stakes surgical pathology specimen, clear communication with the clinical team is essential.
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Affiliation(s)
- Karen Matsukuma
- Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Dorina Gui
- Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Payam Saadai
- Department of Surgery, Division of Pediatric Surgery, University of California Davis School of Medicine, Sacramento, CA, USA.,Pediatric Colorectal Center, Shriners Hospitals for Children, Sacramento, CA, USA
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Pan W, Rahman AA, Stavely R, Bhave S, Guyer R, Omer M, Picard N, Goldstein AM, Hotta R. Schwann Cells in the Aganglionic Colon of Hirschsprung Disease Can Generate Neurons for Regenerative Therapy. Stem Cells Transl Med 2022; 11:1232-1244. [PMID: 36322091 PMCID: PMC9801298 DOI: 10.1093/stcltm/szac076] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 09/03/2022] [Indexed: 12/31/2022] Open
Abstract
Cell therapy offers the potential to replace the missing enteric nervous system (ENS) in patients with Hirschsprung disease (HSCR) and to restore gut function. The Schwann cell (SC) lineage has been shown to generate enteric neurons pre- and post-natally. Here, we aimed to isolate SCs from the aganglionic segment of HSCR and to determine their potential to restore motility in the aganglionic colon. Proteolipid protein 1 (PLP1) expressing SCs were isolated from the extrinsic nerve fibers present in the aganglionic segment of postnatal mice and patients with HSCR. Following 7-10 days of in vitro expansion, HSCR-derived SCs were transplanted into the aganglionic mouse colon ex vivo and in vivo. Successful engraftment and neuronal differentiation were confirmed immunohistochemically and calcium activity of transplanted cells was demonstrated by live cell imaging. Organ bath studies revealed the restoration of motor function in the recipient aganglionic smooth muscle. These results show that SCs isolated from the aganglionic segment of HSCR mouse can generate functional neurons within the aganglionic gut environment and restore the neuromuscular activity of recipient mouse colon. We conclude that HSCR-derived SCs represent a potential autologous source of neural progenitor cells for regenerative therapy in HSCR.
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Affiliation(s)
- Weikang Pan
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Department of Pediatric Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, Shaanxi, People’s Republic of China
| | - Ahmed A Rahman
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rhian Stavely
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sukhada Bhave
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard Guyer
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Meredith Omer
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Picard
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Allan M Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ryo Hotta
- Corresponding author: Ryo Hotta, MD PhD, 185 Cambridge St, CPZN 6-215, Boston, MA 02114, USA. Tel: +1 617 726 6460;
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Diagnosing Hirschsprung disease by detecting intestinal ganglion cells using label-free hyperspectral microscopy. Sci Rep 2021; 11:1398. [PMID: 33446868 PMCID: PMC7809197 DOI: 10.1038/s41598-021-80981-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 12/29/2020] [Indexed: 12/18/2022] Open
Abstract
Hirschsprung disease (HD) is a congenital disorder in the distal colon that is characterized by the absence of nerve ganglion cells in the diseased tissue. The primary treatment for HD is surgical intervention with resection of the aganglionic bowel. The accurate identification of the aganglionic segment depends on the histologic evaluation of multiple biopsies to determine the absence of ganglion cells in the tissue, which can be a time-consuming procedure. We investigate the feasibility of using a combination of label-free optical modalities, second harmonic generation (SHG); two-photon excitation autofluorescence (2PAF); and Raman spectroscopy (RS), to accurately locate and identify ganglion cells in murine intestinal tissue without the use of exogenous labels or dyes. We show that the image contrast provided by SHG and 2PAF signals allows for the visualization of the overall tissue morphology and localization of regions that may contain ganglion cells, while RS provides detailed multiplexed molecular information that can be used to accurately identify specific ganglion cells. Support vector machine, principal component analysis and linear discriminant analysis classification models were applied to the hyperspectral Raman data and showed that ganglion cells can be identified with a classification accuracy higher than 95%. Our findings suggest that a near real-time intraoperative histology method can be developed using these three optical modalities together that can aid pathologists and surgeons in rapid, accurate identification of ganglion cells to guide surgical decisions with minimal human intervention.
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Schilling F, Geppert CE, Strehl J, Hartmann A, Kuerten S, Brehmer A, Jabari S. Digital pathology imaging and computer-aided diagnostics as a novel tool for standardization of evaluation of aganglionic megacolon (Hirschsprung disease) histopathology. Cell Tissue Res 2018; 375:371-381. [PMID: 30175382 DOI: 10.1007/s00441-018-2911-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022]
Abstract
Based on a recently introduced immunohistochemical panel (Bachmann et al. 2015) for aganglionic megacolon (AM), also known as Hirschsprung disease, histopathological diagnosis, we evaluated whether the use of digital pathology and 'machine learning' could help to obtain a reliable diagnosis. Slides were obtained from 31 specimens of 27 patients immunohistochemically stained for MAP2, calretinin, S100β and GLUT1. Slides were digitized by whole slide scanning. We used a Definiens Developer Tissue Studios as software for analysis. We configured necessary parameters in combination with 'machine learning' to identify pathological aberrations. A significant difference between AM- and non-AM-affected tissues was found for calretinin (AM 0.55% vs. non-AM 1.44%) and MAP2 (AM 0.004% vs. non-AM 0.07%) staining measurements and software-based evaluations. In contrast, S100β and GLUT1 staining measurements and software-based evaluations showed no significant differences between AM- and non-AM-affected tissues. However, no difference was found in comparison of suction biopsies with resections. Applying machine learning via an ensemble voting classifier, we achieved an accuracy of 87.5% on the test set. Automated diagnosis of AM by applying digital pathology on immunohistochemical panels was successful for calretinin and MAP2, whereas S100β and GLUT1 were not effective in diagnosis. Our method suggests that software-based approaches are capable of diagnosing AM. Our future challenge will be the improvement of efficiency by reduction of the time-consuming need for large pre-labelled training data. With increasing technical improvement, especially in unsupervised training procedures, this method could be helpful in the future.
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Affiliation(s)
- Florian Schilling
- Institute of Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 9, 91054, Erlangen, Germany.,Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 9, 91054, Erlangen, Germany
| | - Carol E Geppert
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 9, 91054, Erlangen, Germany
| | - Johanna Strehl
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 9, 91054, Erlangen, Germany
| | - Arndt Hartmann
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 9, 91054, Erlangen, Germany
| | - Stefanie Kuerten
- Institute of Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 9, 91054, Erlangen, Germany
| | - Axel Brehmer
- Institute of Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 9, 91054, Erlangen, Germany
| | - Samir Jabari
- Institute of Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 9, 91054, Erlangen, Germany. .,Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 9, 91054, Erlangen, Germany.
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Kapur RP, Raess PW, Hwang S, Winter C. Choline Transporter Immunohistochemistry: An Effective Substitute for Acetylcholinesterase Histochemistry to Diagnose Hirschsprung Disease With Formalin-fixed Paraffin-embedded Rectal Biopsies. Pediatr Dev Pathol 2017. [PMID: 28649946 DOI: 10.1177/1093526617697060] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acetylcholinesterase enzymatic histochemistry (AChE EHC), which highlights abnormal cholinergic nerves in the mucosa of aganglionic bowel, has been used for decades to evaluate rectal biopsies for Hirschsprung disease (HSCR). While useful diagnostically, AChE EHC is not compatible with conventional formalin-fixed and paraffin-embedded (FFPE) tissues and is not widely available. The choline transporter (ChT) is a putative alternative marker of cholinergic nerves. ChT immunohistochemistry (IHC) was investigated using FFPE biopsies and resections from patients with confirmed HSCR, as well as appropriate non-HSCR controls. ChT immunostaining was effective at identifying cases with HSCR and qualitatively similar to AChE EHC on frozen section. Among 3 pathologists, the diagnostic positive and negative predictive values based on ChT IHC ranged from 0.84-0.94 and 0.85-0.89, respectively, with good inter-observer agreement (Cohen kappa = 0.70-0.90). ChT IHC was useful in unusual scenarios in which calretinin (CR) IHC failed to correctly identify patients with HSCR. In 10 cases of short-segment HSCR, abnormal ChT+ mucosal innervation was present through the entire aganglionic segment and into portions of the TZ with submucosal nerve hypertrophy. In contrast, mucosal CR IHC was retained in the TZ and adjacent aganglionic bowel, which could lead to misinterpretation of a biopsy as ganglionic bowel. Indeed, 6 such patients were identified with paradoxical CR-positive mucosal innervation in their diagnostic biopsies. ChT IHC was interpreted as unequivocal HSCR in these cases, and HSCR was confirmed on resection. In summary, ChT IHC in FFPE tissue demonstrates high positive and negative predictive values for HSCR, is superior to CR IHC in a subset of cases, and can be incorporated into routine practice without the need for specialized techniques.
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Affiliation(s)
- Raj P Kapur
- 1 Department of Pathology, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Philipp W Raess
- 2 Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Samuel Hwang
- 2 Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Conrad Winter
- 1 Department of Pathology, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
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Terra SA, de Arruda Lourenção PL, G Silva M, A Miot H, Rodrigues MAM. A critical appraisal of the morphological criteria for diagnosing intestinal neuronal dysplasia type B. Mod Pathol 2017; 30:978-985. [PMID: 28304401 DOI: 10.1038/modpathol.2017.4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 01/23/2023]
Abstract
Intestinal neuronal dysplasia type B is a controversial entity expressed by complex changes in the enteric nervous system. Diagnosis depends on rectal biopsy histopathology and diagnostic criteria, both qualitative and quantitative, have changed over time, hindering the diagnostic practice. We analyzed the morphological criteria for the histological diagnosis of intestinal neuronal dysplasia type B in a series of patients with intestinal neuronal dysplasia type B according to the 1990 Frankfurt Consensus criteria and verified the applicability of the numerical criteria proposed by Meier-Ruge et al in 2004 and 2006. Qualitative criteria adopted for the histological diagnosis of intestinal neuronal dysplasia type B included hyperplasia of the submucous plexus with hyperganglionosis and hypertrophy of the nerve trunks. Quantitative criteria considered more than 20% giant ganglia in the submucosa, with more than eight neurons each on 25 ganglia, and children aged over 1 year. Distal colon surgical specimens from 29 patients, aged 0-16 years, diagnosed with intestinal neuronal dysplasia type B were retrospectively analyzed using sections processed for conventional histology (H&E) and calretinin immunohistochemistry. Hyperplasia of the submucosal nerve plexi with hyperganglionosis and hypertrophy of the nerve trunks was observed in all cases. Ganglia with small, immature neurons were detected in the majority of cases. Quantitative analysis confirmed hyperganglionosis (mean number=10.7 neurons per ganglion) and hypertrophy of the nerve trunks (median=44.6 μm thickness). Neurons showed immunostaining for calretinin, but neuron counts in calretinin-stained sections were lower compared with H&E (P<0.01). No significant differences were verified between children aged under and over 1 year regarding hyperganglionosis (P=0.79), neuron counts (P=0.36), and immature ganglia (P=0.66). Only one patient met the numerical criteria proposed by Meier-Ruge et al in 2004 and 2006. In conclusion, the numerical criteria showed limited applicability when transposed to conventional histopathology. Children aged over 1 year presented very similar histological features of neuronal immaturity to younger children, questioning the need for an age criterion when diagnosing intestinal neuronal dysplasia type B.
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Affiliation(s)
- Simone A Terra
- Department of Pathology, Botucatu School of Medicine, São Paulo State University (Unesp), Botucatu, Brazil
| | - Pedro L de Arruda Lourenção
- Department of Surgery, Division of Pediatric Surgery, Botucatu School of Medicine, São Paulo State University (Unesp), Botucatu, Brazil
| | - Márcia G Silva
- Department of Pathology, Botucatu School of Medicine, São Paulo State University (Unesp), Botucatu, Brazil
| | - Hélio A Miot
- Department of Pathology, Botucatu School of Medicine, São Paulo State University (Unesp), Botucatu, Brazil
| | - Maria A M Rodrigues
- Department of Pathology, Botucatu School of Medicine, São Paulo State University (Unesp), Botucatu, Brazil
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Subramanian H, Badhe BA, Toi PC, Sambandan K. Morphometric profile of large intestinal neuronal plexuses in normal perinatal autopsies and Hirschsprung disease. Neurogastroenterol Motil 2017; 29. [PMID: 27620161 DOI: 10.1111/nmo.12939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 08/08/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To derive objective values for the diagnosis of Hirschsprung disease (HSCR) from a comparison of the morphometric profile of large intestinal neuronal plexuses in normal perinatal autopsies and surgical specimens of HSCR. METHODS A cross-sectional comparative study with 40 subjects each in (i) non-HSCR perinatal group encompassing neonates and stillborn babies beyond 30 weeks of gestation on whom autopsies were conducted and (ii) HSCR group comprising all patients clinicoradiologically diagnosed as HSCR. The morphometric assessment was done on hematoxylin-and-eosin-stained sections. KEY RESULTS The morphometric profile in terms of average number of ganglia/linear mm of colon, interganglion distance, number of ganglion cells/ganglion, average ganglion cell length, ganglion cell nuclear area, ganglion cell nuclear diameter, nerve trunk thickness, and density has been outlined. On comparison with the neuroanatomically normal zone of HSCR, the cut-offs to identify hypertrophic nerve trunks (nerve trunk thickness of >37.85 μm) and reduced number of ganglia (number of ganglia/linear mm of colon <2.05 and interganglion distance of >229 μm) were derived. CONCLUSIONS & INFERENCES The determined objective values, after testing on diagnostic rectal biopsies, may serve to formulate a diagnostic algorithm along with immunostaining for diagnosis of HSCR in colorectal specimens.
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Affiliation(s)
- H Subramanian
- Department of Pathology (Histopathology section), Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - B A Badhe
- Department of Pathology (Histopathology section), Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - P C Toi
- Department of Pathology (Histopathology section), Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - K Sambandan
- Department of Paediatric Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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Effectiveness of calretinin and role of age in the diagnosis of Hirschsprung disease. Pediatr Surg Int 2016; 32:723-7. [PMID: 27369965 DOI: 10.1007/s00383-016-3912-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Gold standard in Hirschsprung disease (HD) diagnosis is rectal suction biopsy (RSB) with hematoxylin and eosin and acetylcholinesterase (ACE) stainings. Sensitivity is 83-93 % and specificity is between 95 and 99 %. The rate of non-conclusive results (NC) due to inadequate samples or variability in the interpretation is about 11-37.8 %. Interpretation is still difficult in neonates. Calretinin (C) is a calcium-binding protein, expressed in the nervous system. It has been introduced as a marker to improve the diagnosis accuracy in HD. We compare sensitivity, specificity between ACE and ACE + C and investigate whether the introduction of C could reduce the rate of inconclusive results. We also tried to define the most adequate age to obtain accurate results from RSB. METHODS Data from patients undergoing rectal suction biopsies from 2005 to 2014 was analyzed. Until 2010 we used ACE; since 2011 we used ACE + C. The ROC curve analysis of the NC results regarding the age, showed an optimal cut-off point at 1.5 months (m). It divides the sample into two groups which we compared. RESULTS We analyzed 91 patients. Results of the RSB: 40 HD (44 %), 34 no Hirschsprung (37.4 %) and 17 NC (18.7 %). Sensitivity = 97.5 %, specificity = 97.1 %, not including the NC (1 false positive, 1 false negative). Results depending on the staining: ACE (n = 58) (%) ACE + C (n = 33) (%) p Sensitivity 96 100 1 Specificity 94.7 100 1 NC 24.1 9.1 0.077 Results depending on the age: <1.5 m (n = 27) (%) >1.5 m (n = 64) (%) p Sensitivity 92.3 100 0.325 Specificity 100 96.8 1 NC 40.7 9.4 0.001 CONCLUSION: Calretinin decreases the rate of inconclusive results, but not significantly. The percentage of inconclusive results decreases in patients olders than 1.5 m. Further studies are necessary to determine if this technique is useful to improve RSB results in infants younger than 1.5 months.
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Abou Gabal HH, Osman WM, Abd El Atti RM. Effectiveness of calretinin immunohistochemistry with digital morphometry in mapping of different segments of Hirschsprung disease. EGYPTIAN JOURNAL OF PATHOLOGY 2016; 36:9-18. [DOI: 10.1097/01.xej.0000482435.40584.bd] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Naguib MM, Robinson H, Shoffeitt C, Howe H, Metry D, Shehata BM. Modified Rapid AChE Method (MRAM) for Hirschsprung Disease Diagnosis: A Journey from Meier-Ruge Until Now. Fetal Pediatr Pathol 2016; 35:399-409. [PMID: 27551930 DOI: 10.1080/15513815.2016.1214200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Hirschsprung disease (HSCR) can be diagnosed using a variety of histological and immunohistochemical methods and stains. Because of the nature of the condition and the need for a rapid diagnostic confirmation, those methods with high accuracy and fast turnaround times are preferred. The authors of this paper have used rapid acetylcholinesterase (AChE) immunohistochemistry in conjunction with standard H&E in order to optimize diagnostic accuracy, and present a modified rapid AChE method (MRAM) that has been successfully utilized for over 20 years. The authors also present a list of over 30 different methods and stains that have been proposed for Hirschsprung disease diagnosis.
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Affiliation(s)
- Mina M Naguib
- a Department of Pathology , Emory University School of Medicine , Atlanta , Georgia , USA
| | - Haynes Robinson
- b Department of Pathology , Todelo Children's Hospital , Toledo , Ohio , USA
| | - Carla Shoffeitt
- a Department of Pathology , Emory University School of Medicine , Atlanta , Georgia , USA
| | - Helena Howe
- b Department of Pathology , Todelo Children's Hospital , Toledo , Ohio , USA
| | - Diana Metry
- a Department of Pathology , Emory University School of Medicine , Atlanta , Georgia , USA
| | - Bahig M Shehata
- a Department of Pathology , Emory University School of Medicine , Atlanta , Georgia , USA
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Waseem SH, Idrees MT, Croffie JM. Neuroenteric Staining as a Tool in the Evaluation of Pediatric Motility Disorders. Curr Gastroenterol Rep 2015; 17:30. [PMID: 26143629 DOI: 10.1007/s11894-015-0456-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The diagnosis of enteric neuromuscular disorders has come a long way since the first description of an enteric neuropathic disorder by the Danish physician Harald Hirschsprung in 1886. Advances in specialized enteric histopathological staining techniques have made it possible to identify subtle neuropathies and myopathies that cause intestinal motility disorders, from the common and now better understood and relatively easily diagnosed Hirschsprung's disease to the less common and more severe and not well-characterized chronic idiopathic intestinal pseudoobstruction, which continues to present a diagnostic challenge to the gastroenterologist and histopathologist alike. This article will discuss the common gastrointestinal motility disorders and some of the specialized histological stains, such as the relatively common enzyme stain, acetylcholinesterase, used to diagnose Hirschsprung's disease; advanced tinctorial stains, such as Masson trichrome, which may aid in diagnosis of enteric myopathies causing pseudoobstruction; and immunohistochemical stains such as C-Kit or PG 9.5, which may aid in the diagnosis of enteric neuropathies causing pseudoobstruction.
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Affiliation(s)
- Shamaila H Waseem
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, 705 Riley Hospital Drive #4210, Indianapolis, IN, 46202, USA,
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Fujiya K, Chong JM, Ando M, Akita H, Fukuda A, Nagahama T, Arai K. Sigmoid volvulus is associated with a decrease in enteric plexuses and ganglion cells: a case-control study. Int J Colorectal Dis 2015; 30:673-8. [PMID: 25690706 DOI: 10.1007/s00384-015-2159-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Although sigmoid volvulus (SV) causes acute obstruction, its pathogenesis and mechanism of torsion are unknown, and few reports have described its pathological findings. Here, we evaluated the clinicopathological characteristics of volvulus and factors contributing to volvulus of the sigmoid colon. METHODS We compared 14 patients with SV (10 men and 4 women; median age, 78.5 years) with 14 age- and sex-matched control patients for differences in clinical characteristics, focusing on dysmotility (enteric visceral myopathy, neuropathy, and mesenchymopathy). RESULTS Of the 14 SV patients, 7 had recurrent volvulus, 11 had an associated condition, and 5 required emergency surgery. Atrophy and fibrosis of the inner muscle were more prevalent in the SV than control patients (p = 0.041). Median extent (per centimeter of muscularis propria) of the myenteric plexus (12.5 versus 17.5, p < 0.001) and submucous plexus (15.0 versus 25.5, p < 0.001) was lower in the SV patients, as were the median numbers of myenteric (9.7 versus 30.4, p < 0.001) and submucous ganglion cells (10.0 versus 23.2, p < 0.001). Inflammatory neuropathy was more prevalent in the SV than control patients (p = 0.046); whereas, the prevalence of mesenchymopathy did not differ (p = 0.481). CONCLUSIONS A decrease in the extent of enteric plexus and ganglion cells precedes the clinical manifestation of SV. Although further elucidation is needed, this decrease may play an important role in the diagnosis of SV and in identifying the mechanism leading to torsion in SV.
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Affiliation(s)
- Keiichi Fujiya
- Department of Surgery, Tokyo Metropolitan Health and Medical Corporation Toshima Hospital, Tokyo, Japan
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Value of calretinin immunostaining in diagnostic pathology: a review and update. Appl Immunohistochem Mol Morphol 2015; 22:401-15. [PMID: 24185118 DOI: 10.1097/pai.0b013e31829b6fbd] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Calretinin is a member of the EF-hand family of calcium-binding proteins. Because its expression is highly restricted to mesotheliomas, calretinin is, at present, the most commonly used positive mesothelioma marker that is most often recommended to be included in the various immunohistochemical panels used to assist in the differential diagnosis of these tumors. Calretinin expression has also been reported to be commonly expressed in a wide variety of other neoplasms, including sex cord-stromal tumors, adrenal cortical neoplasms, olfactory neuroblastomas, Schwann cell tumors, cardiac myxomas, and ameloblastomas. This article reviews the information that is currently available on calretinin expression in tumors and on its application as an immunohistochemical marker in diagnostic pathology.
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Bachmann L, Besendörfer M, Carbon R, Lux P, Agaimy A, Hartmann A, Rau TT. Immunohistochemical panel for the diagnosis of Hirschsprung's disease using antibodies to MAP2, calretinin, GLUT1 and S100. Histopathology 2015; 66:824-35. [PMID: 25123159 DOI: 10.1111/his.12527] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 08/09/2014] [Indexed: 11/28/2022]
Abstract
AIMS The diagnosis of Hirschsprung's disease is currently based on the identification of aganglionosis and the presence of an increase in acetylcholinesterase-positive hypertrophic nerve fibres in the large bowel submucosa. However, acetylcholinesterase staining is laborious and requires a skilled technician. The aim of this study was to identify a method for diagnosing Hirschsprung's disease reliably using an immunohistochemical panel of recently proposed markers. METHODS AND RESULTS Sixty-nine specimens from 37 patients were evaluated. MAP2 and calretinin antibodies were shown to stain ganglia reliably in the submucosal and myenteric plexuses of normal tissue. By contrast, reduced staining of ganglia was observed in patients with Hirschsprung's disease. Staining for GLUT1 and S100 was used to evaluate the number and thickness of nerve fibres. Gain of GLUT1 and S100 expression was in contrast to the loss of calretinin and MAP2. Hypertrophic submucosal nerve fibres in Hirschsprung's disease develop a perineurium with a ring-like GLUT1 staining pattern similar in size and intensity to that observed in deeper subserosal tissue. CONCLUSIONS The diagnosis of Hirschsprung's disease using immunohistochemical panels could be as accurate as with conventional frozen section techniques. In particular, the use of a combination of markers for ganglia and hypertrophic nerve fibres highlighting a prominent perineurium in Hirschsprung's disease could be an alternative method.
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Affiliation(s)
- Leonhard Bachmann
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany; Comprehensive Cancer Centre Erlangen - Metropolitan Region Nuremberg, Erlangen, Germany
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15
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Calretinin immunohistochemistry for the diagnosis of Hirschprung disease in rectal biopsies. Pathol Res Pract 2015; 211:50-4. [DOI: 10.1016/j.prp.2014.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 08/15/2014] [Accepted: 08/22/2014] [Indexed: 11/21/2022]
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16
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Badizadegan K, Thomas AR, Nagy N, Ndishabandi D, Miller SA, Alessandrini A, Belkind-Gerson J, Goldstein AM. Presence of intramucosal neuroglial cells in normal and aganglionic human colon. Am J Physiol Gastrointest Liver Physiol 2014; 307:G1002-12. [PMID: 25214400 PMCID: PMC7864228 DOI: 10.1152/ajpgi.00164.2014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The enteric nervous system (ENS) is composed of neural crest-derived neurons (also known as ganglion cells) the cell bodies of which are located in the submucosal and myenteric plexuses of the intestinal wall. Intramucosal ganglion cells are known to exist but are rare and often considered ectopic. Also derived from the neural crest are enteric glial cells that populate the ganglia and the associated nerves, as well as the lamina propria of the intestinal mucosa. In Hirschsprung disease (HSCR), ganglion cells are absent from the distal gut because of a failure of neural crest-derived progenitor cells to complete their rostrocaudal migration during embryogenesis. The fate of intramucosal glial cells in human HSCR is essentially unknown. We demonstrate a network of intramucosal cells that exhibit dendritic morphology typical of neurons and glial cells. These dendritic cells are present throughout the human gut and express Tuj1, S100, glial fibrillary acidic protein, CD56, synaptophysin, and calretinin, consistent with mixed or overlapping neuroglial differentiation. The cells are present in aganglionic colon from patients with HSCR, but with an altered immunophenotype. Coexpression of Tuj1 and HNK1 in this cell population supports a neural crest origin. These findings extend and challenge the current understanding of ENS microanatomy and suggest the existence of an intramucosal population of neural crest-derived cells, present in HSCR, with overlapping immunophenotype of neurons and glia. Intramucosal neuroglial cells have not been previously recognized, and their presence in HSCR poses new questions about ENS development and the pathobiology of HSCR that merit further investigation.
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Affiliation(s)
- Kamran Badizadegan
- 1Department of Pathology and Laboratory Medicine, Nemours Children's Hospital, Orlando, Florida;
| | - Alyssa R. Thomas
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Nandor Nagy
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; ,3Department of Human Morphology and Developmental Biology, Faculty of Medicine, Semmelweis University, Budapest, Hungary; and
| | - Dorothy Ndishabandi
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Sarah A. Miller
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Alessandro Alessandrini
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Jaime Belkind-Gerson
- 4Division of Pediatric Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Allan M. Goldstein
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
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17
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Kapur RP. Calretinin-immunoreactive mucosal innervation in very short-segment Hirschsprung disease: a potentially misleading observation. Pediatr Dev Pathol 2014; 17:28-35. [PMID: 24168728 DOI: 10.2350/13-10-1387-oa.1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Absent calretinin-immunoreactive (CRir) mucosal innervation in aganglionic rectal biopsies is considered a useful diagnostic finding for Hirschsprung disease. Analysis of a series of rectosigmoid resections from patients with short-segment (>2-cm aganglionic, n = 9) and very short-segment (≤2-cm aganglionic, n = 9) Hirschsprung disease demonstrates that CRir mucosal nerves extend into the proximal 1-2 cm of aganglionic bowel, where their presence in distal rectal biopsies could complicate diagnosis of very short-segment disease. Indeed, retrospective analysis of preoperative, aganglionic, distal rectal biopsies from 4 of 9 patients with very short-segment Hirschsprung disease revealed CRir mucosal innervation. Accurate diagnosis was possible based on generous histopathological submucosal sampling to exclude ganglion cells and the presence of abundant large-caliber submucosal nerves (more than 4 nerves >30 µm thick/×200 field or more than 2 nerves >40 µm thick/×200 field). Absent CRir mucosal innervation supports the diagnosis of Hirschsprung disease, but the presence of CRir mucosal nerves does not exclude aganglionosis, especially in distal rectal biopsies from patients with very short-segment Hirschsprung disease.
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Affiliation(s)
- Raj P Kapur
- Department of Laboratories, 0C.8.720, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
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18
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Chua AC, Chua GD, Kelly DR. Preservation of acetylcholinesterase enzyme activity in non-frozen rectal biopsy specimens for Hirschsprung disease. J Histotechnol 2013. [DOI: 10.1179/2046023612y.0000000005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Yang WI, Oh JT. Calretinin and microtubule-associated protein-2 (MAP-2) immunohistochemistry in the diagnosis of Hirschsprung's disease. J Pediatr Surg 2013; 48:2112-7. [PMID: 24094966 DOI: 10.1016/j.jpedsurg.2013.02.067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 02/19/2013] [Accepted: 02/20/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND/PURPOSE Identifying ganglion cells by rectal suction biopsy is a basic diagnostic tool for the diagnosis of Hirschsprung's disease (HD). However, the difficult interpretation of conventionally processed slides often necessitates ancillary staining methods. The aim of this study was to evaluate the usefulness of calretinin and microtubule-associated protein-2 (MAP-2) immunohistochemistry in the diagnosis of HD. METHODS We analyzed 52 rectal suction biopsy specimens (37 from 15 HD patients and 15 from 7 non-HD patients) for ganglion cells with calretinin and MAP-2 immunohistochemistry. We also analyzed full-thickness, frozen biopsy samples obtained from 15 HD patients who underwent surgery utilizing calretinin and MAP-2 immunohistochemistry. RESULTS Both calretinin and MAP-2 positively stained ganglion cells in the submucosal plexus of the ganglionic bowel but not aganglionic bowel. Calretinin usually stained ganglion cell cytoplasm and nuclei more intensely than MAP-2, which only stained cytoplasm. No nerve fiber staining in the submucosal layer was observed for either antibody. In 21.1% (11/52) of samples, calretinin and MAP-2 staining found ganglion cells which were reported not to have ganglion cells in the original surgical pathology reports. Immunohistochemical staining for calretinin using paraffin-embedded tissue sections after cryostat sections clearly demonstrated decreased staining intensity compared to MAP-2. CONCLUSION Calretinin and MAP-2 are useful diagnostic markers for diagnosing HD in rectal suction biopsies. These complementary methods could ameliorate the diagnostic difficulties associated with HD.
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Affiliation(s)
- Woo Ick Yang
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
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20
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Gonzalo DH, Plesec T. Hirschsprung Disease and Use of Calretinin in Inadequate Rectal Suction Biopsies. Arch Pathol Lab Med 2013; 137:1099-102. [DOI: 10.5858/arpa.2012-0220-oa] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Up to 17% of all rectal suction biopsies performed in the evaluation of Hirschsprung disease are considered inadequate. In most instances, inadequate biopsies contain too little submucosa or are taken within the anal transition zone.
Objectives.—To examine the utility of calretinin stain in the workup of inadequate biopsies for patients with clinical suspicion of Hirschsprung disease.
Design.—A retrospective analysis was conducted of all rectal suction biopsies performed in the evaluation of Hirschsprung disease during the previous 12 years that were considered “inadequate.” Seventeen cases were identified, and Hirschsprung disease status was determined by clinical or surgical follow-up. Immunohistochemistry for calretinin was performed for all cases containing columnar mucosa, which were evaluated without knowledge of clinical course.
Results.—All 12 patients without Hirschsprung disease had calretinin-positive nerve fibers in the lamina propria or muscularis mucosae, and all 5 patients with Hirschsprung disease had no calretinin staining of nerves.
Conclusions.—In this retrospective series, calretinin immunohistochemistry correctly predicted outcome in all instances. Although the gold standard for the diagnosis of Hirschsprung disease in rectal suction biopsies remains the evaluation of ganglion cells in a hematoxylin-eosin staining with sufficient submucosa, calretinin immunohistochemistry is quite helpful in triaging further workup based on clinical suspicion.
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Affiliation(s)
| | - Thomas Plesec
- From the Department of Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio
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21
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Butler Tjaden NE, Trainor PA. The developmental etiology and pathogenesis of Hirschsprung disease. Transl Res 2013; 162:1-15. [PMID: 23528997 PMCID: PMC3691347 DOI: 10.1016/j.trsl.2013.03.001] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 02/25/2013] [Accepted: 03/01/2013] [Indexed: 02/08/2023]
Abstract
The enteric nervous system is the part of the autonomic nervous system that directly controls the gastrointestinal tract. Derived from a multipotent, migratory cell population called the neural crest, a complete enteric nervous system is necessary for proper gut function. Disorders that arise as a consequence of defective neural crest cell development are termed neurocristopathies. One such disorder is Hirschsprung disease (HSCR), also known as congenital megacolon or intestinal aganglionosis. HSCR occurs in 1/5000 live births and typically presents with the inability to pass meconium, along with abdominal distension and discomfort that usually requires surgical resection of the aganglionic bowel. This disorder is characterized by a congenital absence of neurons in a portion of the intestinal tract, usually the distal colon, because of a disruption of normal neural crest cell migration, proliferation, differentiation, survival, and/or apoptosis. The inheritance of HSCR disease is complex, often non-Mendelian, and characterized by variable penetrance. Extensive research has identified a number of key genes that regulate neural crest cell development in the pathogenesis of HSCR including RET, GDNF, GFRα1, NRTN, EDNRB, ET3, ZFHX1B, PHOX2b, SOX10, and SHH. However, mutations in these genes account for only ∼50% of the known cases of HSCR. Thus, other genetic mutations and combinations of genetic mutations and modifiers likely contribute to the etiology and pathogenesis of HSCR. The aims of this review are to summarize the HSCR phenotype, diagnosis, and treatment options; to discuss the major genetic causes and the mechanisms by which they disrupt normal enteric neural crest cell development; and to explore new pathways that may contribute to HSCR pathogenesis.
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de Arruda Lourenção PLT, Takegawa BK, Ortolan EVP, Terra SA, Rodrigues MAM. A useful panel for the diagnosis of Hirschsprung disease in rectal biopsies: calretinin immunostaining and acetylcholinesterase histochesmistry. Ann Diagn Pathol 2013; 17:352-6. [PMID: 23683882 DOI: 10.1016/j.anndiagpath.2013.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 04/07/2013] [Indexed: 11/17/2022]
Abstract
The pathological evaluation of rectal biopsies for the diagnosis of Hirschsprung disease has been a challenging issue. We analyzed prospectively the usefulness of calretinin immunostaining and acetylcholinesterase (AChE) histochesmistry in rectal biopsies for the diagnosis of Hirschsprung disease. Frozen tissue samples from 43 patients were used for AChE histochemistry and paraffin-embedded sections for calretinin immunohistochemistry and conventional histology (hematoxylin and eosin [H&E]). Activity for AChE, was demonstrated in 13 of 43 cases, and the absence of immunoreactivity for calretinin was observed in 14 of 43 cases. Conventional histology (H&E) did not reveal ganglion cells in 24 of 43 cases. The results on calretinin were in good agreement with AChE according to the κ index (0.946; P<.001) and presented significantly higher specificity (96.7×63.3; P<.002) and accuracy (97.6×74.4; P<.003) when compared with conventional histology (H&E). The final diagnosis of Hirschsprung disease was confirmed in 13 of 43 patients who were submitted to surgical treatment. The results of the present study indicate that calretinin can be a good tool in ruling out the diagnosis of Hirschsprung disease, by showing positive staining in ganglion cells and intrinsic nerve fibers, whereas AChE is useful in confirming the diagnosis of Hirschsprung disease, by revealing activity of this enzyme in hypertrophied nerve fibers. The association between calretinin and AChE can be a useful panel for the histopathologic evaluation of rectal biopsies for the diagnosis of Hirschsprung disease.
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23
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Coron E, Auksorius E, Pieretti A, Mahé MM, Liu L, Steiger C, Bromberg Y, Bouma B, Tearney G, Neunlist M, Goldstein AM. Full-field optical coherence microscopy is a novel technique for imaging enteric ganglia in the gastrointestinal tract. Neurogastroenterol Motil 2012; 24:e611-21. [PMID: 23106847 PMCID: PMC3866795 DOI: 10.1111/nmo.12035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Noninvasive methods are needed to improve the diagnosis of enteric neuropathies. Full-field optical coherence microscopy (FFOCM) is a novel optical microscopy modality that can acquire 1 μm resolution images of tissue. The objective of this research was to demonstrate FFOCM imaging for the characterization of the enteric nervous system (ENS). METHODS Normal mice and EdnrB(-/-) mice, a model of Hirschsprung's disease (HD), were imaged in three-dimensions ex vivo using FFOCM through the entire thickness and length of the gut. Quantitative analysis of myenteric ganglia was performed on FFOCM images obtained from whole-mount tissues and compared with immunohistochemistry imaged by confocal microscopy. KEY RESULTS Full-field optical coherence microscopy enabled visualization of the full thickness gut wall from serosa to mucosa. Images of the myenteric plexus were successfully acquired from the stomach, duodenum, colon, and rectum. Quantification of ganglionic neuronal counts on FFOCM images revealed strong interobserver agreement and identical values to those obtained by immunofluorescence microscopy. In EdnrB(-/-) mice, FFOCM analysis revealed a significant decrease in ganglia density along the colorectum and a significantly lower density of ganglia in all colorectal segments compared with normal mice. CONCLUSIONS & INFERENCES Full-field optical coherence microscopy enables optical microscopic imaging of the ENS within the bowel wall along the entire intestine. FFOCM is able to differentiate ganglionic from aganglionic colon in a mouse model of HD, and can provide quantitative assessment of ganglionic density. With further refinements that enable bowel wall imaging in vivo, this technology has the potential to revolutionize the characterization of the ENS and the diagnosis of enteric neuropathies.
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Affiliation(s)
- E Coron
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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24
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Montedonico S, Cáceres P, Muñoz N, Yáñez H, Ramírez R, Fadda B. Histochemical staining for intestinal dysganglionosis: over 30 years experience with more than 1,500 biopsies. Pediatr Surg Int 2011; 27:479-86. [PMID: 21327554 DOI: 10.1007/s00383-010-2849-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Intestinal dysganglionosis are a group of anomalies of the enteric nervous system that constitute infrequent but severe forms of constipation. Histochemical stainings are the gold standard diagnostic procedure for intestinal dysganglionosis. This study describes our experience with histochemistry in a large series of patients. METHODS Between 1977 and 2010, 1,589 biopsies from children with persistent chronic constipation were studied. The specimens were snap frozen, sectioned and stained with acetylcholinesterase (AChE), acetylcholinesterase counterstained with hematoxilin and succinic dehydrogenase (SDH) histochemical stainings. RESULTS Among the 1,589 biopsies, 946 (59.5%) were rectal biopsies, 242 (15.2%) were internal sphincter biopsies, 346 (21.8%) were intestinal mapping studies and 42 (2.7%) of them were colon specimens from surgical resections. From the rectal biopsy group, 544 (57.5%) patients were reported as normal. Hirschsprung disease was found in 163 (17.2%) patients with a median age at diagnosis of 8 months and a male to female ratio of 3:1. Intestinal neuronal dysplasia was found in 162 (17.2%) patients, hypoganglionosis in 3 (0.3%) of them and ganglioneuromatosis in 1 (0.1%). In 73 (7.7%) patients, the biopsy was not conclusive for different reasons. 34 out of the 42 resected colon specimens were Hirschsprung disease. Intestinal neuronal dysplasia was found in the proximal segment of the aganglionic bowel in 15 out of 34 (44%) patients. All the aganglionic resected colon specimens had a previous aganglionic rectal biopsy. There were no false positive results in this group. CONCLUSIONS Histochemical stainings continue to be the gold standard in the diagnosis of intestinal dysganglionosis. The combination of two histochemical staining techniques provides a high level of accuracy in the diagnosis of intestinal dysganglionosis.
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Affiliation(s)
- Sandra Montedonico
- Department of Biomedical Sciences, School of Medicine, Universidad de Vaparaíso, Edificio Bruno Ghünter, Hontaneda 2664, Valparaíso, Chile.
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25
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Granström AL, Orrego A, Svensson PJ, Almström M, Skikuniene J, Wester T. Nerve growth factor receptor immunohistochemistry has a limited additional value to diagnose Hirschsprung's disease. Pediatr Surg Int 2011; 27:431-5. [PMID: 20848287 DOI: 10.1007/s00383-010-2728-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE The diagnosis of Hirschsprung's disease (HSCR) is based on the histopathological evaluation of rectal suction biopsies (RSB), using haematoxylin and eosin (H&E) stains and acetylcholinesterase (AChE) histochemistry. The use of different immunohistochemical markers, such as nerve growth factor receptor (NGFR), has been suggested to facilitate the diagnosis of HSCR. The aim of this study was to evaluate the addition of NGFR immunohistochemistry to diagnose HSCR. METHODS RSB from 23 HSCR patients and 16 patients investigated for, but not diagnosed with, HSCR were retrospectively reviewed. The histopathology report supported or did not support the diagnosis of HSCR. RESULTS In patients with HSCR, the primary biopsies confirmed the diagnosis in 21 of 23 cases with H&E staining, in 16 of 23 cases with AChE histochemistry, and in 8 of 23 cases with NGFR immunohistochemistry. Due to inadequate biopsies or equivocal interpretation, the biopsies were repeated in seven of the patients with HSCR and two patients underwent biopsies a third time. In the 16 patients investigated for but not diagnosed with HSCR, the three tests were normal in all cases. CONCLUSION We conclude that NGFR immunohistochemistry has limited additional value to diagnose HSCR.
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Affiliation(s)
- Anna Löf Granström
- Division of Pediatric Surgery, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.
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26
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Abstract
Varied intestinal neuromuscular pathologies are responsible for Hirschsprung disease and other forms of chronic pseudo-obstruction that are encountered in pediatrics. Pathologically distinct subtypes discussed in this review include aganglionosis, hypoganglionosis, neuronal intranuclear inclusion disease, ganglionitis, degenerative neuropathy, diffuse ganglioneuromatosis, neuronal dysplasia, malformations of the muscularis propria, degenerative leiomyopathy, leiomyositis, and mitochondriopathies. Emphasis is given to the histopathologic features that distinguish these conditions and their differential diagnoses.
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Affiliation(s)
- Raj P Kapur
- Department of Laboratories, Seattle Children's Hospital University of Washington, A6901, 4800 Sand Point Way North East, Seattle, WA 98105, USA.
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27
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Yanlei Huang, Anupama B, Shan Zheng, Xianmin Xiao, Lian Chen. The Expression of Enteric Nerve Markers and Nerve Innervation in Total Colonic Aganglionosis. Int J Surg Pathol 2010; 19:303-8. [PMID: 20643668 DOI: 10.1177/1066896910361738] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective. To study differences in the expression of various nerve markers between total colonic aganglionosis (TCA) and common-segment-type Hirschsprung’s disease (HD) using immunohistochemistry. Methods. All-layer colon and ileum specimens were extracted from 18 patients diagnosed with TCA and treated at the Children’s Hospital of Fudan University between January 1996 and December 2005. The reference group consisted of 10 cases each of common-segment-type HD and anorectal malformations (ARMs). Immunohistochemical comparison was conducted on the expression levels of the enteric nerve markers protein gene product 9.5 (PGP9.5), S-100 protein, neuron-specific enolase (NSE), and peripherin. Results. There were no statistically significant differences in expression of PGP9.5, S-100 protein, NSE, and peripherin in ganglionic intestinal sections from the TCA group, HD group, or ARM group ( P > .05). A few mature and immature ganglion cells were observed in the transitional sections from the TCA group, and expression levels of the nerve markers were lower than in the HD group ( P < .01). Ganglion cells were found in the far-end intestinal section in none of the 18 cases of TCA, where thick nerve trunks were fewer and nerve marker expression levels were lower than in the HD group ( P < .01), most evidently in the cases of PGP9.5. Conclusions . The study revealed evident differences in the positive expression of nerve markers in the enteric sections when TCA and common-segment HD were compared, indicating differences in enteric nerve innervation in these conditions.
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Affiliation(s)
- Yanlei Huang
- Children's Hospital of Fudan University, Shanghai 201102, China
| | - Basnet Anupama
- Children's Hospital of Fudan University, Shanghai 201102, China
| | - Shan Zheng
- Children's Hospital of Fudan University, Shanghai 201102, China
| | - Xianmin Xiao
- Children's Hospital of Fudan University, Shanghai 201102, China
| | - Lian Chen
- Children's Hospital of Fudan University, Shanghai 201102, China
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28
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Abstract
Diagnosis and management of Hirschsprung's disease (HSCR) requires understanding of the malformation's anatomic features and multigenic nature. Rectal biopsies, intraoperative frozen sections, and resection specimens provide invaluable information. Extraction of these data requires thoughtful biopsy technique, adequate histologic sections, histochemistry, and collaboration of surgeon and pathologist. Critical consideration of transition zone anatomy and published studies of "transition zone pull through" indicate that more research is needed to determine how much ganglionic bowel should be resected from HSCR patients. Many HSCR-susceptibility genes have been identified, but mutational analysis has limited practical value unless family history or clinical findings suggest syndromic HSCR.
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Affiliation(s)
- Raj P Kapur
- Department of Laboratories, Seattle Children's Hospital, University of Washington, Seattle, Washington 98115, USA.
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Calretinin immunohistochemistry: a simple and efficient tool to diagnose Hirschsprung disease. Mod Pathol 2009; 22:1379-84. [PMID: 19648883 DOI: 10.1038/modpathol.2009.110] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Diagnosis of Hirschsprung disease (HD) is quite entirely based on the histopathological analysis of suction rectal biopsies. This hematoxylin and eosin approach has some limitations, despite the help of acetylcholinesterase staining. The aim of this study was to assess the diagnostic value of calretinin immunochemistry as a simple and reliable method in the diagnosis of HD. A total of 131 initial rectal biopsies carried out for suspicion of HD in children were retrieved, and calretinin immunohistochemistry was carried out on paraffin-embedded biopsies. Diagnosis of HD was made when no staining was observed. The results were statistically analyzed in comparison with our standard method (histology and acetylcholinesterase staining). 130 biopsies were accurately diagnosed on the basis of the positivity or negativity of calretinin staining. The senior pathologists diagnosed all cases of HD with no false positives. Furthermore, 12 additional cases initially considered as doubtful for HD using the standard method, were accurately diagnosed using calretinin immunohistochemistry. The false negative was a case of HD with a calretinin-positive biopsy. We also demonstrate the ease of calretinin interpretation compared with acetylcholinesterase for the junior pathologist. Calretinin immunohistochemistry overcomes most of the difficulties encountered using the combination of histology and acetylcholinesterase staining, and detects almost all cases of HD with confidence, with no false positives. Thus, we demonstrate that calretinin is superior to acetylcholinesterase to complete histology and could advantageously substitute for acetylcholinesterase.
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30
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Gastrointestinal neuromuscular pathology: guidelines for histological techniques and reporting on behalf of the Gastro 2009 International Working Group. Acta Neuropathol 2009; 118:271-301. [PMID: 19360428 DOI: 10.1007/s00401-009-0527-y] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 03/19/2009] [Accepted: 03/22/2009] [Indexed: 01/30/2023]
Abstract
The term gastrointestinal neuromuscular disease describes a clinically heterogeneous group of disorders of children and adults in which symptoms are presumed or proven to arise as a result of neuromuscular, including interstitial cell of Cajal, dysfunction. Such disorders commonly have impaired motor activity, i.e. slowed or obstructed transit with radiological evidence of transient or persistent visceral dilatation. Whilst sensorimotor abnormalities have been demonstrated by a variety of methods in these conditions, standards for histopathological reporting remain relatively neglected. Significant differences in methodologies and expertise continue to confound the reliable delineation of normality and specificity of particular pathological changes for disease. Such issues require urgent clarification to standardize acquisition and handling of tissue specimens, interpretation of findings and make informed decisions on risk-benefit of full-thickness tissue biopsy of bowel or other diagnostic procedures. Such information will also allow increased certainty of diagnosis, facilitating factual discussion between patients and caregivers, as well as giving prognostic and therapeutic information. The following report, produced by an international working group, using established consensus methodology, presents proposed guidelines on histological techniques and reporting for adult and paediatric gastrointestinal neuromuscular pathology. The report addresses the main areas of histopathological practice as confronted by the pathologist, including suction rectal biopsy and full-thickness tissue obtained with diagnostic or therapeutic intent. For each, indications, safe acquisition of tissue, histological techniques, reporting and referral recommendations are presented.
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Utility of Microtubule Associated Protein-2 (MAP-2) Immunohistochemistry for Identification of Ganglion Cells in Paraffin-Embedded Rectal Suction Biopsies. Am J Surg Pathol 2009; 33:1025-30. [DOI: 10.1097/pas.0b013e31819b23f2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Scudiere JR, Maitra A, Montgomery EA. Selected topics in the evaluation of pediatric gastrointestinal mucosal biopsies. Adv Anat Pathol 2009; 16:154-60. [PMID: 19395878 DOI: 10.1097/pap.0b013e3181a12dec] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The practice of pediatric gastrointestinal pathology provides specific challenges to the pathologist. Often the clinical information accompanying a biopsy specimen will read simply, "failure to thrive." Other situations, such as the evaluation of a neonate's rectal suction biopsy for Hirschsprung disease, are notorious for providing diagnostic challenges in high-pressure situations. In this review, we will discuss several commonly encountered situations in pediatric pathology: the evaluation of pediatric esophageal eosinophilia, a child who has swallowed a non food item, caustic substance, or hot liquid, the evaluation of a pediatric colorectal biopsy with focal active colitis, and the evaluation of rectal suction biopsies for Hirschsprung disease. With each topic, we will discuss a general approach to the case, diagnostic tips, and how to avoid commonly encountered pitfalls. Finally, we highlight key references pertinent to these issues that can he used to help convey pathologic findings to pediatric gastroenterologists.
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Kapur RP, Reed RC, Finn LS, Patterson K, Johanson J, Rutledge JC. Calretinin immunohistochemistry versus acetylcholinesterase histochemistry in the evaluation of suction rectal biopsies for Hirschsprung Disease. Pediatr Dev Pathol 2009; 12:6-15. [PMID: 18442301 DOI: 10.2350/08-02-0424.1] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Accepted: 04/17/2008] [Indexed: 11/20/2022]
Abstract
Diagnosis of Hirschsprung disease (HSCR) relies on histologic and/or histochemical staining of sections from suction rectal biopsies. Acetylcholinesterase histochemistry (AChE) facilitates diagnosis but is not universally employed, in part because it requires special tissue handling. Calretinin immunohistochemistry (IHC) may be a useful alternative, because loss of calretinin immunoreactive nerves reportedly correlates spatially with aganglionosis. We investigated the patterns of calretinin IHC in suction rectal biopsies from HSCR and non-HSCR patients and compared the diagnostic value of calretinin IHC with a widely used rapid AChE method. In suction rectal biopsies that contain ganglion cells, small nerves in the lamina propria, muscularis mucosae, and superficial submucosa contain granular aggregates of calretinin immunoreactivity. Immunolabeling of these nerves is completely absent in the aganglionic biopsies of HSCR patients. Multiple observers independently reviewed calretinin IHC and AChE sections of suction rectal biopsies from 14 HSCR patients and 17 non-HSCR controls. Five observers, blinded to the correct diagnosis, scored each patient's calretinin IHC and AChE slides as HSCR, not HSCR, or equivocal. The frequencies of major and minor discrepant diagnoses were compared. Calretinin IHC yielded no misdiagnoses or major discrepancies between observers. In contrast, 2 misdiagnoses and significantly more interobserver disagreement resulted from the AChE-stained sections. Calretinin IHC appears to be a reasonable, and potentially superior, alternative to AChE as an adjunctive diagnostic method for evaluating suction rectal biopsies for HSCR.
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Affiliation(s)
- Raj P Kapur
- Department of Laboratories, Chidren's Hospital and Regional Medical Center, Seattle, WA, USA.
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Staines WA, Bettolli M, De Carli C, Swinton E, Sweeney B, Krantis A, Rubin SZ. Fast evaluation of intraoperative biopsies for ganglia in Hirschsprung's disease. J Pediatr Surg 2007; 42:2067-70. [PMID: 18082709 DOI: 10.1016/j.jpedsurg.2007.08.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Accepted: 08/08/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE The most important diagnostic features of Hirschsprung's disease (HD) are the combination of aganglionosis and hypertrophic nerve bundles. Acetylcholinesterase staining is widely used for diagnosis of HD as it identifies hypertrophic nerves in both diagnostic and intraoperative biopsies. The main drawback of this method is in the identification of ganglia. It has been suggested that the combination of this method together with another histochemical marker would be a superior diagnostic tool. Hematoxylin and eosin is still the diagnostic measure of choice for identifying ganglia in many centers, although it presents a persistent diagnostic challenge for pathologists trying to rapidly and accurately interpret the frozen biopsies that guide intraoperative decision making. METHODS Therefore, we sought to develop a fast, intraoperative immunohistochemical protocol for visualization of ganglia and nerves in HD specimens that can be used in conjunction with these other tools. RESULTS With the use of acetone fixation and immunofluorescence staining with antibodies to neurofilament 68 and tubulin, ganglia in sections of full thickness and suction biopsies could be visualized in only 10 minutes. This protocol facilitated the identification of ganglia in hematoxylin and eosin-stained adjacent sections and also identified hypertrophic nerve trunks. CONCLUSION This method should significantly enable the identification of ganglia in suction and full thickness biopsies.
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Affiliation(s)
- W A Staines
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada.
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