Assessment of Isocitrate Dehydrogenase 1 Mutation by Immunohistochemistry in Egyptian Patients with High-grade Gliomas

BACKGROUND: At present, the classification of central nervous system tumors relies on molecular factors in addition to histologic features to identify many tumor types. This should subsequently results in more accurate diagnosis as well as addressing specific markers of potential prognostic and predictive value. AIM: This study was conducted to emphasize the importance of including isocitrate dehydrogenase 1 (IDH1) evaluation as a crucial part of the diagnosis and categorization of high-grade glioma cases. This also may help to individualize the treatment of high-grade glioma patients. MATERIALS AND METHODS: The current study included 60 cases of high-grade gliomas, studied histologically and immunohistochemically for the detection of IDH1 mutation. The results were correlated with different clinicopathologic variables and course of the disease. RESULTS: IDH1 immunohistochemical expression was positive in 46.67% of the studied high-grade glioma cases. A statistically significant relationship was detected between IDH1 expression and tumor histologic grade as 100% of Grade III anaplastic oligodendroglioma cases and 80% of the Grade III anaplastic astrocytoma cases were IDH1 positive while only 40.4% of Grade IV glioblastoma cases were IDH1 positive (p = 0.03). In addition, patients who were IDH1 mutant were in a better category of response to radiotherapy (p = 0.019) and also to chemotherapy (p < 0.001). Moreover, patients who expressed IDH1 had prolonged overall survival (OS) and progression-free survival than those who showed negative IDH1expression (p < 0.001). On the other hand, no statistically significant relationship was detected between IDH1 expression and patients age, sex, tumor site, tumor size, motor symptoms, sensory symptoms, and increased intracranial tension (p > 0.05). CONCLUSIONS: It is suggested that IDH1 is a good prognostic marker for gliomas and is a good predictive marker for response to treatment. IDH1 is a promising target for therapy in high-grade gliomas through the emerging IDH1 inhibitors. Immunohistochemical testing for IDH1 is a practical and cost-effective method that should be applied in all glioma cases. Further study on a larger sample size is recommended to validate the current results. Moreover, applying molecular analysis to detect IDH1 mutation is recommended to be able to precisely detect the IDH1 wild-type tumor

Expression of “Connexin 43” in Colorectal Carcinomas: Histopathological and Immunohistochemical Study

BACKGROUND: Colorectal cancer is one of the most common cancers worldwide and leading cause of cancer related deaths. Connexins are integral membrane proteins that form channels between adjacent cells. Gap junction intercellular communication plays essential roles in tissue homoeostasis and regulation of cell growth and differentiation. Connexins can act as either tumor suppressors or tumor promoters. The human connexin protein family contains 21 members, of which the most widely studied is connexin 43 (Cx 43). OBJECTIVES: Investigation of immunohistochemical expression of Cx 43 in cases of colorectal adenoma and carcinoma and correlation of this expression with the clinico-pathological aspects of the tumors. MATERIALS AND METHODS: Seventy formalin fixed paraffin embedded BC tissue sections were randomly collected. All the available data were collected from the patients’ reports. The paraffin blocks were sectioned and stained with hematoxylin and eosin stains for histologic evaluation. Additional sections were immunostained with Cx 43. RESULTS: Cx 43 expression was negative in all studied cases. CONCLUSION: Cx 43 is a tumor suppressor that is lost early in colorectal carcinogenesis and can be considered as potential target for cancer chemoprevention and chemotherapy aiming at restoration of normal connexin expression and functional gap junctions.

Ki 67 assessment in breast cancer in an Egyptian population: a comparative study between manual assessment on optical microscopy and digital quantitative assessment

Background

Breast cancer is by far the most frequent cancer among women. The proliferative index, Ki-67, is more and more taken into consideration for treatment decisions. However, the reliability of the established Ki-67 scoring is limited. Digital pathology is currently suggested to be a potential solution to Ki 67 assessment problems.

Methods

This is a retrospective and prospective study including 100 patients diagnosed with invasive breast cancer. Three senior pathologists have been asked to estimate the Ki-67 proliferative index for each of the 100 cases by examining the whole glass slides on optical microscope and providing a continuous score then a categorical score (‘high’ and ‘low’ Ki 67 index) using once 14%, once 20% as threshold indicative of high Ki67 status. Finally, a digital quantitative assessment of Ki67 was performed.

Results

A high inter-observer agreement was found when using optical microscopy for Ki 67 assessment, with correlation coefficient (CC) estimated at 0.878 (p value < 0.01). The overall agreement between manual and automated evaluation of Ki 67 was only substantial (CC estimated at 0.745 (p value < 0.01)). When using categorical scores, the inter-observers concordance was substantial using both cutoff points with kappa value estimated at 0.796 ([0.696–0.925] while using 14% as a cut off point and at 0.766 ([0.672–0.938] while using 20% as a cutoff point (p value < 0). The inter-observers agreement was better while using 14% as cutoff point. Agreement between manual and automated assessment of Ki 67 indices using both cutoff points was only substantial (Kappa estimated at 0.623, p value < 0.01). In comparison to automated assessment of Ki 67 index, while using 14% as a cutoff point, the overall tendency of all observers was to overestimate the Ki 67 values but to underestimate the proliferation index while using 20% as a cutoff point.

Conclusion

Automated assessment of Ki 67 value would appear to be comparable to visual Ki 67 assessment on optical microscopy. Such study would help define the role of digital pathology as a potential easy-to use tool for a robust and standardized fully automated Ki 67 scoring.

Chronic Mastitis in Egypt and Morocco: Differentiating between Idiopathic Granulomatous Mastitis and IgG4-Related Disease

Idiopathic granulomatous mastitis (IGM) is a benign, frequently severe chronic inflammatory lesion of the breast. Its etiology remains unknown and reported cases vary in their presentation and histologic findings with an optimal treatment algorithm yet to be described owing mainly to the disease's heterogeneity. IgG4‐related disease (IgG4‐RD) is a newly recognized systemic fibroinflammatory condition characterized by a dense lymphoplasmacytic infiltrate with many IgG4‐positive plasma cells, storiform fibrosis, and obliterative phlebitis. Immunosuppressive therapy is considered to be an effective first‐line therapy for IgG4‐RD. We sought to clarify and classify chronic mastitis according to the histologic findings of IgG4‐RD mastitis with respect to IGM and to develop a robust diagnostic framework to help select patients for optimal treatment strategies. Using the largest collection to date (43 cases from Egypt and Morocco), we show that despite sharing many features, IGM and IgG4‐RD mastitis are separate diseases. To diagnostically separate the diseases, we created a classification schema—termed the Michigan Classification—based upon our large series of cases, the consensus statement on IgG4‐RD, and the histologic description of IGM in the literature. Using our classification, we discerned 17 cases of IgG4‐RD and 8 cases of IGM among the 43 chronic mastitis cases, with 18 indeterminate cases. Thus, our Michigan Classification can form the basis of rational stratification of chronic mastitis patients between these two clinically and histopathologically heterogeneous diseases.

Comparative study between quantitative digital image analysis and fluorescence in situ hybridization of breast cancer equivocal human epidermal growth factor receptors 2 score 2(+) cases

Background:

Optimization of workflow for breast cancer samples with equivocal human epidermal growth factor receptors 2 (HER2)/neu score 2⁺ results in routine practice, remains to be a central focus of the on-going efforts to assess HER2 status. According to the College of American Pathologists/American Society of Clinical Oncology guidelines equivocal HER2/neu score 2⁺ cases are subject for further testing, usually by fluorescence in situ hybridization (FISH) investigations. It still remains on open question, whether quantitative digital image analysis of HER2 immunohistochemistry (IHC) stained slides can assist in further refining the HER2 score 2⁺.

Aim of this Work:

To assess utility of quantitative digital analysis of IHC stained slides and compare its performance to FISH in cases of breast cancer with equivocal HER2 score 2⁺.

Materials and Methods:

Fifteen specimens (previously diagnosed as breast cancer and was evaluated as HER 2^- score 2⁺) represented the study population. Contemporary new cuts were prepared for re-evaluation of HER2 immunohistochemical studies and FISH examination. All the cases were digitally scanned by iScan (Produced by BioImagene [Now Roche-Ventana]). The IHC signals of HER2 were measured using an automated image analyzing system (MECES, www.Diagnomx.eu/meces). Finally, a comparative study was done between the results of the FISH and the quantitative analysis of the virtual slides.

Results:

Three out of the 15 cases with equivocal HER2 score 2⁺, turned out to be positive (3⁺) by quantitative digital analysis, and 12 were found to be negative in FISH too. Two of these three positive cases proved to be positive with FISH, and only one was negative.

Conclusions:

Quantitative digital analysis is highly sensitive and relatively specific when compared to FISH in detecting HER2/neu overexpression. Therefore, it represents a potential reliable substitute for FISH in breast cancer cases, which desire further refinement of equivocal IHC results.

Lymphatic obstruction: a novel etiologic factor in the formation of antrochoanal polyps

OBJECTIVES

Antrochoanal polyps (ACPs) originate from the inner wall of the maxillary sinus and either pass through the natural sinus ostia or cause pressure-induced destruction of the medial sinus wall. Eventually, they extend into the choanae and nasopharynx. Most authors who have studied the microstructure of ACPs, including the component stromal cells and surface epithelium, have not examined the transitional area between the sinus mucosa and the pedicle of the polyp. No explanation has been given for the absence of a cystic intrasinus portion of the polyp, in many cases refuting the therapy (most accepted) that polyps are caused by a mucous gland with a blocked acinus. We noted during endoscopic removal of the ACPs that the antral part of the polyp was cystic in only 5% of patients, and polypoid in 95%. The cystic intrasinus portion of the polyp is a cornerstone of the pathophysiology of ACPs, whether caused by inflammation, cicatrization, or allergy. This finding prompted us to examine the transitional area between the sinus mucosa and the pedicle of the polyp to verify the possibility that lymphatic obstruction--whether primary (areas of higher tissue pressure) or secondary (cicatrization or inflammation)-could be an etiologic factor in the formation of ACPs.

METHODS

The study material consisted of 25 ACPs and 25 chronic maxillary sinusitis mucosal biopsy specimens (control group). The detection of lymphatic vessels was based on the identification of lymph vessel endothelial hyaluronic acid receptor I (LYVE-I) in the endothelial cells of the lymphatic capillaries. This was the first lymph-specific hyaluronic acid receptor to be characterized, and is a uniquely powerful marker for lymph vessels, differentiating them from (blood) capillaries.

RESULTS

The density of the lymphatic vessels was marked in 22 of the 25 ACP specimens, ie, 88% of the ACP cases, compared with 16% of the control group.

CONCLUSIONS

This study resulted in two main findings. The first was the absence of intramaxillary cysts in the ACPs in 23 cases (92%). The second was the markedly high density of lymphatic vessels in the transitional area between the sinus mucosa and the pedicle of the ACPs, in comparison with the density in the control group. These two findings refute the "blocked acinus theory" and indicate that lymphatic obstruction, whether primary or secondary to chronic sinus infection, might play a leading role in the formation and further growth of ACPs.

Virtual microscopy beyond the pyramids, applications of WSI in Cairo University for E-education & telepathology

BACKGROUND

Telepathology, the practice of pathology at a long distance, has advanced continuously since 1986. The progress of telepathology passed through four stages: Static, Dynamic, Hybrid & Whole Slide Imaging.

MATERIALS AND METHODS

A pilot project between the Italian Hospital in Cairo & the Civico Hospital in Palermo was completed successfully, applying the static & dynamic techniques of telepathology. This project began in 2003 and continued till now. In 2004, centers in Venice, London and Pittsburgh participated actively in our project.

RESULTS

Over eight years we consulted on many problematic pathological cases with specialized pathological centers in Italy, U.K. & U.S.A. In addition to the highly specialized scientific value, we saved a lot of time and money.

CONCLUSION

We concluded from our experience that telepathology is a very useful and applicable tool for additional consulting on difficult pathological cases especially for emerging countries. In view of this success we have already established our Digital Telepathology Unit in Cairo University, using the WSI technique in teaching which was greatly successful and encouraged us to build a huge digital pathology library which will expand our telepathology & E-learning programs to cover staff and students in Egypt and Eastern Mediterranean.

Prevalence of extramucosal fungal elements in sinonasal polyposis: a mycological and pathologic study in an Egyptian population

OBJECTIVE AND HYPOTHESIS

The objective of the study was to define the true incidence of fungal elements in the nasal and sinus mucous in cases of chronic rhinosinusitis (CRS) with bilateral polyposis compared with normal controls-in an Egyptian African population-via mycological and histologic techniques.

STUDY DESIGN

This study was conducted prospectively on 100 patients with the clinical diagnosis of CRS with bilateral nasal polyposis. Fifty volunteers with no history of nasal or paranasal sinus disease served as a control group.

RESULTS AND CONCLUSION

The postulated criteria for the diagnosis of allergic fungal sinusitis were present in 92% of CRS with polyposis, suggesting that fungi are involved in the disease process of most CRS patients.

Virtual telepathology in Egypt, applications of WSI in Cairo University

Telepathology, the practice of pathology at a long distance, has advanced continuously since 1986. Today, fourth-generation telepathology systems, so-called virtual slide telepathology systems, are being used for education applications. Both conventional and innovative surgical pathology diagnostic services are being designed and implemented as well. We have a successful experience in Egypt in applying the static & dynamic techniques in a pilot project between the Italian Hospital in Cairo (NPO) and the Civico Hospital in Palermo This project began in 2003 and continued till now. In 2004, centers in Venice, London and Pittsburgh participated actively in our project. During the past seven years we consulted on many problematic pathological cases with these different specialized pathological centers in Italy, UK & USA. In addition to the highly specialized scientific value of consulting on the cases and exchanging knowledge, we saved a lot of time and money and succeeded in providing our patients with a better medical service. In view of this success we have already established a new Digital Telepathology unit (DTU) in the pathology department, Cairo University, using the latest technique of telepathology which is Whole Slide Imaging (WSI) since one year. This unit is considered the first Digital pathology unit in all the universities of the whole Middle East. During the passed year we created a digital pathology library for the under graduate students using the WSI technique and changed the teaching method of the histopathology slides to be completely digital. We are building another digital pathology library (for post graduate candidates) which will be available to all pathology candidates in Egyptian universities & universities in the surrounding Arabic countries. We are also creating a digital pathology network between pathology centers in the Middle East for exchanging knowledge & telepathology.

Quantitative analysis of uvular muscles in cases of simple snoring and obstructive sleep apnea: an image analysis study

Studies on the histopathological changes of the palatine muscles in cases of obstructive sleep apnea (OSA) and simple snoring are controversial, while some authors confirm the presence of muscle hypertrophy and increase in total muscle bulk (obstructive theory), others deny this confirming the presence of muscle atrophy and decrease in the muscle bulk (neurogenic theory), but all these studies depended on subjective observer dependent methods to calculate the muscle bulk. We are carrying a unique study to calculate the muscle bulk in uvular specimens in ten cases of OSA comparing it to ten cases with simple snoring and controls using digital computer dependent software (image analysis). Cases of OSA are associated with definite increase in the total muscle bulk of the palatine muscles when compared to cases of simple snoring and controls. Uvular muscular hypertrophy and the obstructive theory seem to explain the pathophysiology of OSA.

A comparative study between ciliary count and the degree of opacity of paranasal sinus CT scans in chronic sinusitis pre and post FESS

OBJECTIVE

To investigate the relationship between the extent of sinus disease in chronic sinusitis as detected radiologically by computed tomography (CT) scan and the population of cilia (ciliary area) both before and after functional endoscopic sinus surgery (FESS). In a simple way this is a trial to statistically prove that the CT scan could be a valid indicator and a mirror of the histological status of the sinus mucosa.

DESIGN

Twenty adult patients were enrolled in this study. Radiological extension of the sinus disease was quantitated using the classification proposed by Kennedy in 1992 and the ciliary population was studied using scanning electron microscopy and image analysis softwares.

RESULTS AND CONCLUSION

The more advanced the sinusitis, as evidenced by CT scans, the more the expected reduction in the ciliary area (CA) and in the ciliary count. But after FESS the degree of ciliary regeneration does not depend statistically on the radiological condition of the sinuses and the degree of opacity prior to intervention, i.e. a statistically valid inverse relationship exists between the radiological stage of sinusitis and the ciliary population pre-operatively but the same relation does not extend to the ciliary population post-operatively.

Short-course norfloxacin and trimethoprim-sulfamethoxazole treatment of shigellosis and salmonellosis in Egypt

In a double-blind clinical study, 109 adult Egyptian patients infected with Shigella spp. and 45 infected with Salmonella spp. were randomly assigned to three treatment groups: 1) norfloxacin in a single 800-mg dose, 2) norfloxacin, 400 mg twice a day for three days, and 3) trimethoprim (160 mg)-sulfamethoxazole (800 mg) (TMP-SMX), twice a day for three days. Among Shigella-infected patients, diarrheal symptoms had resolved in 86-97% and bacteriologic failure (repeat positive stool culture) occurred in only two patients five days after the start of the three treatment regimens. Among Salmonella-infected patients, diarrheal symptoms had resolved in 76-82% of patients and bacteriologic failure was common (18-36%) five days after the start of therapy. These data indicate that short-course therapy with either norfloxacin or TMP-SMX can be effectively used to treat shigellosis in adults in developing countries. However, for uncomplicated Salmonella spp. infection, short-course therapy with norfloxacin and TMP-SMX may not lead to a rapid resolution of symptoms or consistently eliminate this enteropathogen.