Early Organ Metastasis in Granulomatous Mycosis Fungoides: A Systematic Review

BACKGROUND

Granulomatous mycosis fungoides (GMF) is a rare form of cutaneous T-cell lymphoma characterized by a granulomatous inflammatory infiltrate.

OBJECTIVE

The impact of granulomatous inflammation on the prognosis of the disease remains controversial as there are both favorable and unfavorable outcomes documented.

METHODS

We performed a systematic review of 116 GMF cases previously described in the literature.

RESULTS

In contrast to the classic Alibert-Bazin type of mycosis fungoides (MF), cutaneous lesions in GMF tend to involve distal extremities (lower legs, feet, hands) early in the disease course. In the literature, 30% of GMF patients developed organ metastasis, most frequently to the lung. The median time to stage progression was 25 months.

CONCLUSION

GMF is an aggressive form of mycosis fungoides. Therefore, screening for distant metastases should be considered at presentation and repeated during follow-up.

The Clinical Utility of FLT3 Mutation Testing in Acute Leukemia: A Canadian Consensus

FMS-like tyrosine kinase 3 (FLT3) mutations are detected in approximately 20-30% of patients with acute myeloid leukemia (AML), with the presence of a FLT3 internal tandem duplication (FLT3-ITD) mutation being associated with an inferior outcome. Assessment of FLT3 mutational status is now essential to define optimal upfront treatment in both newly diagnosed and relapsed AML, to support post-induction allogeneic hematopoietic stem cell transplantation (alloSCT) decision-making, and to evaluate treatment response via measurable (minimal) residual disease (MRD) evaluation. In view of its importance in AML diagnosis and management, the Canadian Leukemia Study Group/Groupe canadien d'étude sur la leucémie (CLSG/GCEL) undertook the development of a consensus statement on the clinical utility of FLT3 mutation testing, as members reported considerable inter-center variability across Canada with respect to testing availability and timing of use, methodology, and interpretation. The CLSG/GCEL panel identified key clinical and hematopathological questions, including: (1) which patients should be tested for FLT3 mutations, and when?; (2) which is the preferred method for FLT3 mutation testing?; (3) what is the clinical relevance of FLT3-ITD size, insertion site, and number of distinct FLT3-ITDs?; (4) is there a role for FLT3 analysis in MRD assessment?; (5) what is the clinical relevance of the FLT3-ITD allelic burden?; and (6) how should results of FLT3 mutation testing be reported? The panel followed an evidence-based approach, taken together with Canadian clinical and laboratory experience and expertise, to create a consensus document to facilitate a more uniform approach to AML diagnosis and treatment across Canada.

Significant Variability in the Identification and Reporting of Band Neutrophils by Participants Enrolled in the College of American Pathologists Proficiency Testing Program: Time for a Change

CONTEXT.—

Increased band neutrophils in blood smear differential counts ("bandemia") are entrenched in medicine as a flag for sepsis. However, laboratory hematology experts have long advocated for discontinuation of reporting bands separately from segmented neutrophils because of poor sensitivity and specificity, poor interobserver agreement, and availability of alternative biomarkers for sepsis.

OBJECTIVE.—

To describe band neutrophil reporting practices and reproducibility of band classification among laboratories participating in the College of American Pathologists (CAP) proficiency testing (PT) program.

DESIGN.—

A survey questionnaire was distributed to hematology PT participants. A subsequent morphologic challenge included 12 preselected cell identifications of segmented neutrophils, bands, and metamyelocytes, and a 100-cell manual differential count of a digitally scanned blood smear.

RESULTS.—

Among laboratories that reported manual differentials, most respondents reported bands (4554 of 5268; 86.4%). Only 3222 of 4412 respondents (73.0%) provided band reference ranges. Though participants classified "easy" band neutrophils well (78.0%-98.3%), categorization of cell identifications for "moderate" and "difficult" bands was poor (3.1%-39.0% of laboratories), with classification instead as segmented neutrophils. This pattern was seen regardless of laboratory demographic characteristics. Marked variability in band counts was observed on the 100-cell differential count for both CAP PT participants and CAP Hematology and Clinical Microscopy Committee (HCMC) members (coefficients of variation, 55.8% and 32.9%, respectively). Variability was significantly improved when segmented and band neutrophils were grouped together (coefficients of variation, 6.2% and 5.0%, respectively).

CONCLUSIONS.—

Most CAP PT-participating laboratories report band counts, many without reference ranges. The survey confirms significant interlaboratory variability of band enumeration when bands are separately identified from segmented neutrophils. This study reaffirms the CAP Hematology and Clinical Microscopy Committee's strong recommendation to group segmented and band neutrophils together in manual differential counts.

Overexpression of facilitative glucose transporter-3 and membrane procoagulation in maternal platelets of preeclamptic pregnancy

BACKGROUND

Preeclampsia (PE) is a hypertensive disorder during pregnancy that results in significant adverse maternal and neonatal outcomes. Platelet activation is present in PE and contributes to the thrombo-hemorrhagic states of the disorder. However, the mechanisms that initiate and/or sustain platelet activation in PE are ill-defined.

OBJECTIVES

We aimed to characterise this mechanism and the procoagulant potentials of platelets in PE.

METHODS

In this quantitative observational study, we analyzed platelet procoagulant membrane dynamics in patients with PE (n = 21) compared with age-matched normotensive pregnancies (n = 20), gestational hypertension (n = 10), and non-pregnant female controls (n = 19). We analyzed fluorescently labeled indicators of platelet activation, bioenergetics, and procoagulation (phosphatidylserine exposure and thrombin generation), coupled with high-resolution imaging and thrombelastography. We then validated our findings using flow cytometry, immunoassays, classical pharmacology, and convolutional neural network analysis.

RESULTS

PE platelets showed significant ultra-structural remodeling, are more extensively preactivated than in healthy pregnancies and can circulate as microaggregates. Preactivated platelets of PE externalized phosphatidylserine and thrombin formed on the platelet membranes. Platelets' expression of facilitative glucose transporter-1 increased in all pregnant groups. However, PE platelets additionally overexpress glucose transporter-3 to enhance glucose uptake and sustain activation and secretion events. Although preeclampsia platelets exposed to subendothelial collagen showed incremental activation, the absolute hemostatic response to collagen was diminished, and likely contributed to greater blood loss perioperatively.

CONCLUSIONS

We revealed 2 bioenergetic mediators in the mechanism of sustained platelet procoagulation in preeclampsia. Although glucose transporter-1 and glucose transporter-3 remain elusive antiprocoagulant targets, they may be sensitive monitors of PE onset and progression.

Monoclonal Gammopathy of Undetermined Significance in Patients With Transthyretin Amyloidosis (ATTR): Analysis Using the iStopMM Criteria

INTRODUCTION

To identify the prevalence of monoclonal gammopathy of undetermined significance (MGUS) in patients with transthyretin amyloid (ATTR). We used the iStopMM study revised reference ranges for serum free light-chain (sFLC) corrected for eGFR to identify ATTR patients with light-chain MGUS (LC-MGUS). Characteristics and frequencies of the ATTR cohort with underlying MGUS was compared to a cohort of MGUS patients without ATTR.

PATIENTS AND METHODS

A retrospective analysis of ATTR and MGUS patients evaluated at our center between January 2014 to December 2021. A total of 149, predominantly male (87.5%) ATTR patients with a median age of 82 were included. This cohort was compared to 228 MGUS patients.

RESULTS

Of the 149 ATTR patients, 27 (18.1%) had coexisting MGUS. Among ATTR patients with MGUS, 12/27 (44%) had LC-MGUS based on sFLC abnormalities assessed using the iStopMM reference ranges. Of the MGUS only cohort, 44/228 (19.3%) met criteria for LC-MGUS. Utilizing the iStopMM reference ranges, 6 ATTR patients did not meet criteria for abnormal sFLCs, uncovering a 20% false-positive rate.

CONCLUSION

We noted higher rates of MGUS, particularly LC-MGUS, among ATTR patients when compared to our MGUS only cohort. The high prevalence remained after utilizing the iStopMM sFLC corrected for eGFR reference ranges. Additionally, 6 ATTR patients with renal-dysfunction would have met MGUS criteria if not evaluated using the iStopMM revised measures. These findings emphasize careful interpretation of sFLC abnormalities and encourage providers to keep ATTR on the differential when work-up uncovers sFLC aberrations.

Amyloidosis and Carpal Tunnel Syndrome: Surgical Technique for Extended Carpal Tunnel Release with Tenosynovium and Transverse Carpal Ligament Biopsies

Carpal tunnel syndrome (CTS) is common in patients with transthyretin amyloidosis (ATTR), and many experience residual symptoms and/or develop recurrent disease following routine carpal tunnel release (CTR). An extended CTR with median nerve neurolysis is recommended for thorough nerve decompression. Tissue confirmation of amyloidosis can be performed at the time of CTR with biopsies of the transverse carpal ligament and/or tenosynovium.

METHODS

We describe a retrospective, single-center experience performing an extended CTR technique including unilateral and bilateral cases for 13 consecutive patients (18 wrists) with ATTR and symptomatic median neuropathy at the wrist.

RESULTS

The mean patient age was 83 (range 67-90) years and 11 (85%) were men. Notable intraoperative findings in all cases included thickened tenosynovium and median nerve epineurium, and adherence of the median nerve to the deep surface of transverse carpal ligament. Pathology findings were positive for amyloidosis from both the transverse carpal ligament and the tenosynovium biopsies in all patients.

CONCLUSIONS

Extended CTR with simultaneous wrist tissue biopsy can be safely performed for ATTR patients with CTS. Characteristic intraoperative findings should increase clinical suspicion for undiagnosed ATTR and prompt performance of biopsy for diagnostic confirmation. Volar wrist tenosynovial biopsy is our preferred tissue for confirmation of ATTR, for patients with and without CTS, given its safety profile and 100% pathological yield in our series.

Case report: Immune profiling links neutrophil and plasmablast dysregulation to microvascular damage in post-COVID-19 Multisystem Inflammatory Syndrome in Adults (MIS-A)

Despite surviving a SARS-CoV-2 infection, some individuals experience an intense post-infectious Multisystem Inflammatory Syndrome (MIS) of uncertain etiology. Children with this syndrome (MIS-C) can experience a Kawasaki-like disease, but mechanisms in adults (MIS-A) are not clearly defined. Here we utilize a deep phenotyping approach to examine immunologic responses in an individual with MIS-A. Results are contextualized to healthy, convalescent, and acute COVID-19 patients. The findings reveal systemic inflammatory changes involving novel neutrophil and B-cell subsets, autoantibodies, complement, and hypercoagulability that are linked to systemic vascular dysfunction. This deep patient profiling generates new mechanistic insight into this rare clinical entity and provides potential insight into other post-infectious syndromes.

Amyloidosis and COVID-19: experience from an amyloid program in Canada

Severe acute respiratory syndrome coronavirus (SARS-CoV2) and associated COVID-19 infection continue to impact patients globally. Patients with underlying health conditions are at heightened risk of adverse outcomes from COVID-19; however, research involving patients with rare health conditions remains scarce. The amyloidoses are a rare grouping of protein deposition diseases. Light-chain and transthyretin amyloidosis are the most common disease forms, often present with systemic involvement of vital organs including the heart, nerves, kidneys, and GI tracts of affected individuals. The Amyloidosis Program of Calgary examined 152 ATTR patients and 103 AL patients analyzing rates of vaccination, COVID-19 testing, infection outcomes, influence referrals, and excess deaths. Results showed 15 total PCR-confirmed COVID-19 infections in the tested population of amyloid patients, with a higher frequency of infections among patient with AL compared to the ATTR cohort (26.2% vs 5.1%). Four patients (26.6%) required hospital admission for COVID-19 infection, 2 ATTR, and 2 AL patients. Of the confirmed cases, 1 (0.07%) unvaccinated ATTR patient died of a COVID-19 infection. An excess of deaths was found in both the ATTR and AL cohorts when comparing pre-pandemic years 2018 and 2019 to the pandemic years of 2020 and 2021. The finding suggests that amyloidosis patients are likely at a high risk for severe COVID-19 infection and mortality, especially those of advanced age, those on an active treatment with chemotherapy, and those with concomitant B-cell or plasma cell disorder. The impact of virtual healthcare visits and pandemic measures on the excess of deaths observed requires further research.

Amyloidosis Tissue Confirmation for Tafamidis Eligibility Using Transverse Carpal Ligament and Tenosynovium Biopsy

In most Canadian provinces, eligibility criteria for public reimbursement coverage for tafamidis for treatment of transthyretin amyloidosis cardiomyopathy (ATTR-CM) include tissue biopsy confirmation of amyloidosis. Carpal tunnel syndrome requiring surgical release is common in ATTR-CM. We report our experience performing simultaneous transverse carpal ligament and tenosynovium biopsy during CTR, with all patients positive for amyloidosis, facilitating initiation of tafamidis.

Risk-Assessment of Hospitalized Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infected Patients Using Laboratory Data and Immune Cell Morphological Assessment

CONTEXT

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious agent, with the propensity to cause severe illness. While vaccine uptake has been increasing in recent months, many regions remain at risk of significant coronavirus disease 19 (COVID-19) related healthcare burden. Health systems will continue to benefit from the availability of a variety of clinical and laboratory model when other triaging models are equivocal.

OBJECTIVE

To validate previously reported clinical laboratory abnormalities seen in COVID-19 patients and identify what laboratory parameters might be outcome-predictive.

DESIGN

We undertook an observational study of hospital-admitted COVID-19 patients (n=113), looking at a broad selection of clinical, laboratory, peripheral blood smear, and outcome data over discrete discovery and validation periods from March 2020 to November 2020.

RESULTS

We confirmed the findings of previous studies noting derangement of a variety of laboratory parameters in COVID-19 patients, including peripheral blood morphological changes. We also devised a simple-to-use decision tree by which patients could be risk stratified on the basis of Red Blood Cell count, creatinine, urea, and atypical plasmacytoid lymphocyte ("covidocyte") count. This outcome classifier performed comparably to the World Health Organization clinical classifier and the neutrophil-lymphocyte ratio.

CONCLUSIONS

Our data add to the increasing number of studies cataloguing laboratory changes in COVID-19, and support the clinical utility of incorporating blood morphological assessment in the workup of hospitalized COVID-19 patients.

Out-of-pocket expenditures in France to manage psoriasis in adult patients: results from an observational, cross-sectional, non-comparative, multicentre study

BACKGROUND

In 2018 in France, overall mean health-related out-of-pocket (OOP) expenditures were 214.00€/year/patient.

AIM

To evaluate OOP expenditures for psoriasis patients in France.

METHODOLOGY

Observational, cross-sectional, non-comparative, multicentre study in 3000 patients with clinically confirmed psoriasis who responded to a specific digital questionnaire collecting demographic and socio-economic characteristics, assessing the 3 domains (severity, psychosocial impact and past history and interventions) of the patient's Simplified Psoriasis Index (sa-SPI) and expenditures to manage psoriasis, including OOP. Multivariate linear regression was conducted to search for factors associated with higher OOP.

RESULTS

In total, 2681 patients completed the questionnaire and, of those, 2562 provided clinically validated data. Overall, 60% were women; the mean age was 49.4 ± 14.8 years. 30% of the patients declared that they suffered from psoriatic arthritis. The final mean sa-SPI core was 10.86 ± 9.70. Of these 2562 patients, 243 (9.5%) had severe, 442 (17.3%) moderate and 1877 (73.3%) mild psoriasis. In addition, 932 (36.4%) patients reported facial involvement, 724 (28.25%) genital impairment and 1124 (43.8%) lesions on the limbs. Mean OOP expenditures to manage psoriasis per patient were 531.00€, 439.74€ ± 939.85€ for patients with mild, 791.06€ ± 1367.67€ with moderate and 1077.64€ ± 1680.14€ for patients with severe psoriasis. For patients with psoriasis in the genital area, the median amount of expenditures (251.17€; CI95% [138.35;363.99]) was significantly higher than that for the face (183.85€; CI95% [78.76;288.94]) or limbs (199.96€; CI95% [93.77;306.15); (P < 0.001). More than 90% of the patients had OOP expenditures for over-the-counter products (97.5%) and alternative care (92.0%), especially for emollients and/or hydrating products.

CONCLUSION

In France, in 2019, OOP expenditures to manage psoriasis were on average more than twice as high as the overall mean health-related OOP expenditures estimated by the French Health Agency in 2018. These results should lead health authorities to review certain standards of healthcare reimbursement.

THU0524 FACTORS EXPLAINING PATIENT PERSPECTIVE IN PSORIASIS AND PSORIATIC ARTHRITIS (PSA): THE ROLE OF INFLAMMATION AND STRUCTURAL DAMAGE DETECTED BY ULTRASOUND (THE ECHOPRO STUDY)

Background:

Patient reported outcomes (PROs) reflect patients’ opinion on disease activity, impact of disease, quality of life (QoL) and are essential in the assessment of PsA patients. PROs may be influenced by several factors other than disease activity and severity. Ultrasound (US) is an objective tool to evaluate joint inflammation and structural damage in PsA.

Objectives:

This cross-sectional study aimed at evaluating the role of US-detected inflammation (synovitis, tenosynovitis, enthesitis) and structural damage (erosions, enthesophytes, osteophytes, cortical irregularities), to explain PROs in PsA and to compare that to psoriasis (PsO) patients with and without musculoskeletal (MSK) symptoms.

Methods:

PsA (CASPAR criteria) [1], PsO with MSK symptoms without fulfilling CASPAR criteria (symptoPsO) and PsO with no MSK symptoms (asymptoPsO) were included. Socio-demographic characteristics, comorbidities, disease duration and treatment were collected. All patients underwent to: a) dermatological and rheumatologic assessment: PsO severity, swollen joint count (SJC), tender JC (TJC), number of dactylitis and enthesitis; b) US evaluation of joints, tendons and entheses according to OMERACT definitions[2], (figure 1); c) PROs assessement: fatigue, disability (HAQ) and QoL (SF36). Variables were compared across groups (chi square or one-way ANOVA test). Correlations were evaluated using Spearman’s test.

Results:

208 patients (76 PsA, 64 symptoPsO and 68 asymptoPsO) with similar socio-demographic characteristics and PsO duration were included (table 1). Except for enthesophytes, all US changes were significantly higher in PsA, followed by symptoPsO patients.

Table 1.

Characteristics of the patients:

PsAN= 76SymptoPsON=64AsymptoPsON=68pFemales, N (%)33 (43.4)39 (55.7)23 (37.1)NSAge55.58 ± 12.7152.16 ± 15.6150.03 ± 14.66NSPsoriasis duration18.76 ± 13.3719.47 ± 15.9815.03 ± 12.29NSPASI0 (0; 36)3 (0; 16)5.5 (0; 22.1)<0.00168 TJC4 (0; 30)2 (0; 23)0<0.00166 SJC0 (0; 23)0 (0; 3)0<0.001Number of enthesitis3 (0; 13)2 (0; 13)0<0.001Number of dactylitis0 (0; 5)00NSFibromyalgia, N (%)6 (7.9)4 (5.7)0NSN of joints with US synovitis1 (0; 32)0 (0; 7)0 (0; 6)0.001N of US enthesitis0 (0; 11)0 (0; 2)0 (0; 2)<0.001N of US tenosynovitis0 (0; 7)0 (0; 1)0 (0; 1)0.005N of joints with US osthephytes/cortical irregularities2 (0; 22)1 (0; 25)1 (0; 21)0.027N of joints with US erosions0 (0; 4)0 (0; 2)0 (0; 2)0.016N of US entheses with enthesopthytes/calcifications3 (0; 9)2 (0; 10)1 (0; 8)NSN of US enthesis with erosions0 (0; 5)0 (0; 1)0 (0; 2)0.001Fatigue (0-10)4.91 ± 3.083.46 ± 3.402.57 ± 2.86<0.001HAQ (0-3)1 (0; 2)0 (0; 2)0 (0; 1)<0.001SF36 PF61.31 ± 30.0877.46 ± 25.0289.35 ± 19.25<0.001

Across all 3 groups, all PROs correlated mainly with demographic variables, comorbidities, TJC, clinical enthesitis, skin severity, depression and fibromyalgia points (r=0.24-0.72). SymptoPsO and PsA reported similar scores of fatigue and impact on most QoL domains, significantly higher than asymptoPsO. HAQ correlated with total number of joints with US irregularities/osteophytes in PsA (r= 0.23; p=0.05), and SF36 physical function with both US inflammatory and damage variables in all three groups (r=0.24-0.34).

Conclusion:

Quality of life, disability and fatigue were more impaired in PsA and symptoPsO patients than asymptoPsO. In all groups, PROs seem to be mostly associated with socio-demographic characteristics and comorbidities rather than objective measures such as US changes or clinical variables.

References:

[1]Taylor, Arthritis Rheum 2006

[2]Bruyn,J Rheumatol 2019

Acknowledgments:

This work was supported by PARTNER fellowship.

Disclosure of Interests:

None declared

SAT0499 PREVALENCE OF ULTRASOUND FINDINGS SUGGESTIVE OF INFLAMMATORY ARTHRITIS IN CHILDREN WITH SKIN PSORIASIS (ChildEchoPso)

Background:

The prevalence of psoriasis (PsO) in children is estimated between 0.5-1% (1), and can be associated with muskuloskeletal involvement, although the prevalence and typology of such involvement is unknown. (2)

Over the last years ultrasound associated with Doppler (PDUS) has become an important tool for evaluating joint involvement in children with Juvenile Inflammatory arthritis (JIA). Several studies have shown the high sensitivity of this technique for detecting joint involvement, as well as high acceptability, due to the lack of radiation or of sedation (3).

Objectives:

To evaluate the prevalence of joints and entheses involvement in children affected by PsO.

Methods:

Observational cross-sectional study aiming at evaluating 150 consecutive children (≤16 years) affected by skin PsO and addressed by a dermatologist. For each child a standardized clinical and ultrasound evaluation of joint and entheses is performed at the following bilateral sites: a) Entheses: quadriceps tendon, proximal and distal patellar ligament, Achilles tendon, plantar fascia and extensor elbow tendon), b) joints: metacarpophalangeal, proximal and distal interphalangeal, wrist, elbow, knee, ankle, and metatarsophalangeal. PDUS evaluation is performed by an independent examiner, blinded to the clinical assessment of each subject.

Results:

41 patients were included until now, where 9 patients presented some kind of symptom (painful joint or enthesis), 24 patients have family history of psoriasis and none of them had family history of psoriatic arthritis. Demographic and clinical characteristics are shown in table 1, whilst PDUS findings in Table 2.

Table 1.

Demographic and clinical characteristics:

Total (n=41)Asymptomatic (n=32)Symptomatic (n=9)pMales22 (53.7%)18 (56.3%)4 (44.4%)NSAge9.4 ± 3.98.91 ± 3.511.3 ± 4.6NSPso duration (years)3.5 ± 3.42.9 ± 2.95.6 ± 4.5<0.05PASI5 ± 4.34.8 ± 4.55.7 ± 3.56NSBSA4.3 ± 3.94.47 ± 4.34.1 ± 2.26NSNail involvement25 (61%)19 (59.4%)6 (66.7%)NSPlaques psoriasis20 (48.8%)14 (43.8%)6 (66.7%)NSTJC ≥1, n/tot (%)9 (22%)0 (0)9 (100%)<0.001SJC ≥1, n/tot (%)2 (4.9%)0 (0)2 (22.2%)<0.05Entheseal pain, n/tot (%)6 (14.6%)0 (0)6 (66.7%)<0.001Dactylitis000NA

PASI: Psoriasis area severity index. BSA: Body surface area. TJC: Tender Joint Count. SJC: Swollen Joint Count.

Table 2

PDUS Findings:

PatientsTotal (n=41)Asymptomatic (n=32)Symptomatic (n=9)p≥1 ultrasound abnormality, n/tot (%)19 (46.3%)13 (40.6%)6 (66.7%)NS≥1 joint effusion, n/tot (%)11 (26.8%)9 (28.1%)2 (22.2%)NS≥1 synovitis, n/tot (%)3 (7.3%)1 (3.1%)2 (22.2%)NS≥1enthesitis, n/tot (%)7 (17.1%)3 (9.4%)4 (44.4%)<0.05≥1 tenosynovitis, n/tot (%)0 (0)0 (0)0 (0)NA≥1 nail with modified structure, n/tot (%)22 (53.7%)19 (59.4%)3 (33.3%)NS

Conclusion:

This study shows that the presence of ultrasound abnormalities was higher in the symptomatic group and considering the fact that the most frequent inflammatory ultrasound finding was enthesitis, we might consider the enthesis as a possible landmark for developing juvenile psoriatic arthritis.

References:

[1]Michalek et al. J Eur Acad Dermatol Venereol, 2017

[2]Petty et al. J Rheumatol, 2004

[3]Buchmann et al. Radiol Clin N Am, 2004

Acknowledgments:

This research was conducted while Luis Coronel was a PARTNER Fellow

Disclosure of Interests:

None declared

Age-specific characteristics of neutrophilic dermatoses and neutrophilic diseases in children

BACKGROUND

Our suggested 'modern' concepts of 'neutrophilic dermatoses' (ND) and 'neutrophilic disease' were based on observations in adult patients and have not been studied in paediatric patients. Only a minority of ND occurs in children, and little is known about age-specific characteristics.

OBJECTIVES

To describe age-specific characteristics of ND in children and to study whether our suggested 'modern' classification of ND may be applied to children.

METHODS

We conducted a retrospective multicentre study in a French cohort of 27 paediatric patients diagnosed with pyoderma gangrenosum (PG) or Sweet's syndrome (SS).

RESULTS

Demographics and distribution of typical/atypical forms were similar in patients diagnosed with PG and SS. Atypical ND were more frequent in infants (90%), when compared to young children (60%) and adolescents (33%). Neutrophilic disease was observed in 17/27 patients and was most frequent in infants. Neutrophilic disease of the upper respiratory tract, as well as cardiac neutrophilic disease, was only observed in infants, whereas other locations were similarly found in infants, young children and adolescents. In infants and young children, ND were associated with a large spectrum of general diseases, whereas in adolescents associations were limited to inflammatory bowel disease and Behçet's disease.

CONCLUSIONS

Our study describes the concept of ND in paediatric patients and shows that they have some characteristics different from ND occurring in adults. ND occurring in infants can be associated with a large spectrum of general diseases. Occurrence of neutrophilic disease is frequent in children. Thus, ND occurring in young paediatric patients should incite clinicians to schedule complementary explorations in order to search for involvement of other organs and to rule out monogenetic autoinflammatory syndromes.

JAK2-tree: a simple CBC-based decision rule to guide appropriate JAK2 V617F mutation testing

Aims

The JAK2 V617F mutation is highly recurrent in many of the myeloproliferative neoplasms, a molecular variant that can be easily detected using sensitive and minimally invasive techniques. Given the ease of JAK2 V617F testing, this test may be improperly requested for the purposes of patient ‘screening’ and to optimise laboratory resource utilisation, it behooves clinicians and laboratorians to perform JAK2 V617F testing only when most appropriate.

Methods

To assist with the screening of patients being considered for JAK2 V617F testing, we developed a clinical decision rule, “JAK2-tree”, which can be easily applied to basic CBC parameters (haemoglobin, platelet and white blood cell counts).

Results

We tested JAK2-tree on two independent datasets, one an unselected population-based sample (the Copenhagen General Population Study) and the other an historical clinical laboratory referral set, with sensitivities for JAK2 V617F detection of 91% and 94%, respectively. As applied to the historical laboratory referral dataset, moreover, the JAK2-tree algorithm would have reduced JAK2 V617F testing volume over the period of evaluation by 15%.

Conclusions

Our work supports a simple decision-tree-based screening approach to optimize the selection of patients most appropriate for JAK2 V617F testing.

T cell clonality assessment: past, present and future

T cell clonality testing has important clinical and research value, providing a specific and reproducible assessment of clonal diversity in T cell proliferations. Here we review the conceptual foundations of T cell clonality assays, including T cell ontogeny and T cell receptor structure and function; we also provide an introduction to T cell receptor genomics and the concept of the T cell clonotype. This is followed by a review of historical and current methods by which T cell clonality may be assayed, including current assay limitations. Some of these assay limitations have been overcome by employing next-generation sequencing (NGS)-based technologies that are becoming a mainstay of modern molecular pathology. In this vein, we provide an introduction to NGS technologies, including a review of the preanalytical, analytical and postanalytical technologies relevant to T cell clonality NGS assays.

Acute HIV infection presenting as hemophagocytic lymphohistiocytosis: case report and review of the literature

Background

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon systemic inflammatory condition that can result from infections, autoimmune diseases and malignancies. It is a rarely reported life threatening complication of an acute HIV infection, with only ten documented case reports per our literature search. We present a case of HLH secondary to acute HIV infection with a negative HIV antibody-based assay and high plasma viral load.

Case presentation

A 45 year old male with a past medical history of well controlled hypertension presented with fever, dizziness and non-bloody diarrhea. Initial lab work revealed a new thrombocytopenia, marked renal failure and an elevated creatine kinase, ferritin, lactate dehydrogenase and D-dimer. A bone marrow biopsy revealed HLH. As part of the work up for thrombocytopenia, a rapid HIV antibody based assay was done and was negative. The sample was later routinely tested with a fourth generation antigen/antibody assay as per local protocol and was strongly positive. The plasma RNA viral load was >10,000,000 copies /mL confirming the diagnosis of an acute HIV infection. The patient was urgently started on antiretroviral therapy and recovered.

Conclusion

This case illustrates a diagnostic approach to HLH which is an uncommon but life threatening multisystem disease, requiring the involvement of a multidisciplinary team of experts. Following any diagnosis of HLH, rapid identification and treatment of the underlying condition is critical. A negative rapid HIV antibody test can be misleading in the context of early HIV infection and the additional use of fourth generation antigen/antibody test or plasma RNA viral load may be required within the right clinical context for diagnosis.

Abstract 846: Improving T-cell receptor clonotyping of T-cell lymphomas using hybrid-Capture and next-generation sequencing

Background

T-cell clonality assays (TCAs) support a variety of clinical and research interests including T-cell malignancy clone identification, minimal-residual disease (MRD) testing and T-cell receptor (TCR) repertoire characterization for the purposes of immunotherapy. Unfortunately, many TCAs are unable to interrogate alpha, beta, gamma, and delta TCR loci simultaneously. Aiming to overcome these limitations, we designed a T-cell clonality assay (the “NTRA”), capable of identifying T-cell gene rearrangements from all four TCR loci, using hybrid-capture followed by deep next-generation sequencing (NGS). A novel informatics package exploiting the Burrows Wheeler Alignment algorithm and finding of CDR3 seed sequences was also deployed. We then validated the assay using orthogonal methods and in a series of clinical T-cell malignancy specimens.

Methods

We used DNA probes for hybrid-capture of all V and J segments in the TCR loci, followed by NGS on the Illumina NextSeq 500 platform. Analytical validation used a series of 10 specimens, including 6 flow-cytometry characterized T-cell specimens of variable degrees of immunophenotypic uniformity and 4 cell-lines with known TCR rearrangements. PCR/gel electrophoresis and Sanger sequencing were used for orthogonal validation, using primer sets designed to test each specimen for all 90th-centile V-J configurations. Subsequently, 61 clinical T-cell lymphoma specimens were tested, each previously assessed for T-cell clonality using the clinical gold standard (i.e. PCR/ electrophoresis using the BIOMED-2 consensus primers for the TCR-beta (TRB) and TCR-gamma (TRG) loci).

Results

PCR confirmed the NTRA-identified V-J configurations with an area-under-the-curve (AUC) by receiver-operator characteristic (ROC) analysis of 0.91. Relative to single-strand Sanger sequencing, the NTRA CDR3 sequence results showed a ROC AUC of 0.83. In a DNA dilution series employing the results of a “clonal” specimen (a Jurkat cell line) spiked into a “polyclonal” specimen (a mononuclear peripheral blood specimen), we could identify “clonal” specimen-specific V-J combinations and error-corrected CDR3 sequences down to less than 10⁁-5. In the final clinical validation, the NTRA performed with a ROC AUC of 0.82 relative to the current TRB & TRG BIOMED-2 clinical assay.

Conclusions

Our novel assay can overcome the current TCR locus data-yield limitations resulting from primer-based TCAs in a single-tube. The NTRA shows comparable sensitivity and specificity relative to current standard assays and excellent performance relative to current MRD techniques when applied to clinical T-cell lymphoma specimens.

Citation Format: Etienne Mahe, David Mulder, Mark Dowar, Mahadeo Sukhai, Linh Nguyen, Pamela Ohashi, Jan Delabie, Tracy L. Stockley, Trevor Pugh, Suzanne Kamel-Reid. Improving T-cell receptor clonotyping of T-cell lymphomas using hybrid-Capture and next-generation sequencing. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 846.

CD10-positive mantle cell lymphoma: biologically distinct entity or an aberrant immunophenotype? Insight, through gene expression profile in a unique case series

Background

Mantle cell lymphoma (MCL) is an aggressive disease with genetic heterogeneity and discrete clinical subtypes. MCL is rarely CD10 positive. These cases raise the question whether a subset of MCL may be germinal centre (GC) derived, and have distinct clinicopathological characteristics.

Aims and methods

A series of nine CD10-positive MCL cases is described herein. The clinicopathological and immunophenotypic features, immunoglobulin somatic hypermutation (SHM) status and gene expression profile (GEP) data are detailed. These features were compared with two independent sets (n=20, each) of CD10-negative MCL cases (controls), which were randomly selected from our institutional registry.

Results

GEP showed distinct expression of a GC signature in CD10-positive MCL cases with minimal impact on downstream signalling pathways. There were no significant differences in the clinicopathological features or clinical outcome between our CD10-positive and CD10-negative MCL cases. The frequency of SHM was comparable with established data.

Conclusions

This study provides convincing evidence that CD10 expression is related to a distinct GC signature in MCL cases, but without clinical or biological implications.

PARP1 expression in mantle cell lymphoma: the utility of PARP1 immunohistochemistry and its relationship with markers of DNA damage

Mantle cell lymphoma (MCL) is an aggressive disease with poor overall survival, attributable in part to frequent defects of the DNA repair genes. In such malignancies, additional inhibition of the ubiquitous DNA damage repair protein, poly-ADP ribose polymerase-1 (PARP1) has shown enhanced cytotoxicity (so-called synthetic lethality). We studied PARP1 expression in a series of clinical cases of MCL, with the secondary aim to ascertain the relationship between PARP1 expression and DNA repair gene expression (namely ATM and p53) by immunohistochemical methods. We also examined the relationship between PARP1 expression and the well-established prognostic biomarker Ki-67, in addition to correlating PARP1 expression with the overall survival. From amongst our series of 79 unselected cases of MCL, we detected PARP1 expression in all but two cases with variable intensity. We also noted correlations between PARP1 expression and ATM and p53 expression. As described in previous studies, we identified a significant survival difference on the basis of Ki-67 and p53 expression. When digital H-score analysis of PARP1 expression was performed, there was a distinct survival advantage noted in patients with lower levels of expression. When our biomarker data were assessed by Cox regression, furthermore, the dominant effects of p53 and PARP1 expression were highlighted. Our data support the need for further research into the potential utility of PARP1 as a biomarker in MCL and for the potential direction of future PARP1 inhibitor-targeted therapy studies.

Frozen section of placental membranes and umbilical cord: an aid to early postpartum diagnosis of intra-amniotic infection

OBJECTIVES

We devised a rapid frozen section (FS) assessment technique of placental tissues and performed the first rigorous assessment of FS relative to conventional workup.

METHODS

We evaluated 49 placentas with clinical/gross suspicion of intra-amniotic infection by FS. Relative to formalin-fixed and paraffin-embedded tissues, we compared the grading, staging, and interobserver variability.

RESULTS

FS assessment demonstrated a sensitivity of 0.91 (95% CI, 0.77-0.97) and a specificity of 0.60 (95% CI, 0.36-0.80) for the presence of chorioamnionitis and a sensitivity of 0.89 (95% CI, 0.75-0.96) and a specificity of 0.69 (95% CI, 0.42-0.87) for the presence of funisitis. The χ2 goodness of fit for grade and stage in both placental membrane and umbilical cord sections was significant (P<.001). There was no significant difference in interobserver variability in comparison with permanent section results (P=0.06).

CONCLUSIONS

We conclude that FS is a reasonably sensitive screening technique, correlating well with conventional assessment, without significantly different interobserver variability.

Invasive micropapillary breast carcinoma: a retrospective study of classification by pathological parameters

Micropapillary breast carcinoma has been recognized as a morphologically and biologically distinct form of breast carcinoma. Although data suggest that patient outcomes in cases of micropapillary breast carcinoma do not differ significantly from other breast carcinomas, the impact that a micropapillary component might have on the pathological work-up of a case of breast carcinoma remains an important point of discussion (especially as pertaining to the risk of lymphovascular disease). In this study, we perform an extensive retrospective study of the pathological parameters of seven years of breast surgical pathology cases to explore the relationship that micropapillary morphology might have with other important pathological parameters of a breast cancer case work-up (e.g. tumour size, lymphovascular invasion, lymph node status). We also analyze our data set to see if a micropapillary component would influence hierarchical classification by pathological parameters. Micropapillary features correlated with a higher frequency of ER positivity and lymphovascular invasion; there was no statistical difference between those cases with and without a micropapillary component from the perspective of other clinicopathological parameters, however. The presence of micropapillary features did influence classification, however, and produced a distinct cluster amidst comparison of other pathological variables.

Intraoperative pathology consultation: error, cause and impact

BACKGROUND

Correlation of intraoperative frozen section diagnosis with final diagnosis can be an important component of an institution's quality assurance process.

METHODS

We performed a quality assurance review of 1207 frozen section diagnoses from 812 surgical cases performed in the Hamilton Regional Laboratory Medicine Programme during a 6-month period in 2007. We reviewed the frozen section and permanent slides from all potentially discordant cases using a multiheaded microscope to arrive at a consensus pertaining to the type and reason for error. We reviewed the clinical record to determine whether there had been a potential adverse impact on immediate clinical management.

RESULTS

Frozen sections were most commonly requested for head and neck, nervous system and female genital tract specimens. Twenty-eight frozen sections (3%) were deferred. We identified 24 discordant diagnoses involving 3% of cases and 2% of specimens. The organ systems showing the greatest frequency of discordance relative to the total number from that system were the nervous system, head and neck, and the lungs. Of the errors identified, most occurred owing to diagnostic misinterpretation, followed by problems related to tissue sampling. There was a potential adverse impact on immediate clinical management in 14 cases.

CONCLUSION

Our results add to the Canadian data on the correlation between frozen sections and permanent sections; we note comparability to the concordance rates reported in the literature.

Giant cell temporal arteritis associated with overlying basal cell carcinoma: co-incidence or connection?

Giant cell arteritis is a granulomatous vasculitis of large and medium sized arteries manifesting as temporal arteritis and/or polymyalgia rheumatica. The histological assessment of temporal artery biopsies is frequently encountered in anatomical pathology and has important diagnostic consequences in patients clinically suspected of having giant cell arteritis. We present an intriguing case of giant cell arteritis associated with a Basal cell carcinoma and discuss the ongoing controversy pertaining to the association of giant cell arteritis/polymyalgia rheumatica with malignancy.