Benchtop fine needle aspirations: An untapped source of cytologic educational material

Fine needle aspirations (FNAs) are a valuable tool for the diagnosis of a wide variety of lesions. However, obtaining proficiency in performing FNAs and finding simulated scenarios where one can practice specimen adequacy and slide smearing can all be challenging. Benchtop FNAs of fresh surgical specimens offer a novel training opportunity that addresses these needs. In this study, we describe the feasibility and practicality of benchtop FNAs of fresh surgical specimens as a training tool. We performed benchtop FNAs on multiple specimen types, although most were partial and radical nephrectomies. We documented this approach to cytology training and have provided examples of slides that were generated, along with the surgical pathology correlate. Our results suggest that benchtop FNAs of fresh surgical specimens can be a valuable training tool in the arsenal of today's cytopathologist. This technique offers several advantages over traditional training methods, including the ability to generate high-quality cytology slides, provide cyto-histo correlation, and practice almost immediate gross-microscopic correlation. However, there are also some disadvantages to this approach, including the need for immediate access to fresh surgical specimens and the potential for artifacts to be introduced. Overall, we believe that benchtop FNAs of fresh surgical specimens offer a promising new training tool that can maximize training opportunities, especially in institutions where the FNA volume is low.

Management of recurrent cervical cancer with peritoneal carcinomatosis with HIPEC

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Recurrent cervical cancer with peritoneal carcinomatosis is rare.

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Presenting two cases of recurrent cervical cancer with peritoneal carcinomatosis.

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HIPEC used in recurrent cervical cancer cases with peritoneal carcinomatosis.

Cervical cancer is the fourth most common malignancy in women in the world; however, a substantial portion of these malignancies are declining with increasingly sophisticated screening. Unfortunately, recurrent cervical cancer has a dismal prognosis and its management continues to be a growing area of research. While the foundation of treatment remains platinum-based chemotherapies, new techniques such as HIPEC have been evaluated. We present two patients with recurrent cervical adenocarcinoma with peritoneal carcinomatosis who were treated with HIPEC during de-bulking surgery with substantial disease-free survival.

One of our patients had 15 months of disease-free survival before developing biliary metastases and the other remains disease free for over 24 months.

#EBUSTwitter: Novel Use of Social Media for Conception, Coordination, and Completion of an International, Multicenter Pathology Study

CONTEXT.—

Social media sites are increasingly used for education, networking, and rapid dissemination of medical information, but their utility for facilitating research has remained largely untapped.

OBJECTIVE.—

To describe in detail our experience using a social media platform (Twitter) for the successful initiation, coordination, and completion of an international, multi-institution pathology research study.

DESIGN.—

Following a tweet describing a hitherto-unreported biopsy-related histologic finding in a mediastinal lymph node following endobronchial ultrasound-guided transbronchial needle aspiration, a tweet was posted to invite pathologists to participate in a validation study. Twitter's direct messaging feature was used to create a group to facilitate communication among participating pathologists. Contributing pathologists reviewed consecutive cases of mediastinal lymph node resection following endobronchial ultrasound-guided transbronchial needle aspiration and examined them specifically for biopsy site changes. Data spreadsheets containing deidentified data and digital photomicrographs of suspected biopsy site changes were submitted via an online file hosting service for central review by 5 pathologists from different institutions.

RESULTS.—

A total of 24 pathologists from 14 institutions in 5 countries participated in the study within 143 days of study conception, and a total of 297 cases were collected and analyzed. The time interval between study conception and acceptance of the manuscript for publication was 346 days.

CONCLUSIONS.—

To our knowledge, this is the first time that a social media platform has been used to generate a research idea based on a tweet, recruit coinvestigators publicly, communicate with collaborating pathologists, and successfully complete a pathology study.

ThyroSeq v3 for Bethesda III and IV: An institutional experience

BACKGROUND

The ThyroSeq v3 genomic classifier is a commercial molecular test that examines a wide spectrum of genomic alterations in a thyroid fine-needle aspiration (FNA) sample and reports test results as either negative or positive. The authors report their institutional experience with ThyroSeq v3.

METHODS

Thyroid FNA specimens diagnosed as either atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) (Bethesda category III [Bethesda III] according to The Bethesda System for Reporting Thyroid Cytopathology) or follicular neoplasm/suspicious for follicular neoplasm (FN/SFN) (Bethesda IV) that had ThyroSeq v3 results available from December 2017 through October 2019 were retrieved for analysis. FNA diagnoses were correlated with ThyroSeq v3 results and follow-up histopathology.

RESULTS

In total, 415 cases (AUS/FLUS, n = 251; FN/SFN, n = 164) were retrieved: 294 (71%) were reported as ThyroSeq v3-negative, and 121 (29%) were reported as ThyroSeq v3-positive. The benign call rate (BCR) of ThyroSeq v3 for AUS/FLUS (82%; 206 of 251 cases) was significantly higher (P < .001) than that for FN/SFN (BCR, 54%; 88 of 164 cases). Histopathologic follow-up was available for 127 cases (ThyroSeq v3-positive, 96; ThyroSeq v3-negative, 31), of which 57 were benign and 70 were malignant (including noninvasive follicular thyroid neoplasm with papillary-like nuclear features). The negative predictive value of ThyroSeq v3 was significantly higher for AUS/FLUS (99.5%) than for FN/SFN (95.4%; P < .0294), given malignancy rates of 10% for AUS/FLUS and 30% for FN/SFN. Forty-five unique combinations of genetic alterations were detected in the operated ThyroSeq-positive cases, and there were only 5 false-negative cases, comprised of 4 low-risk neoplasms.

CONCLUSIONS

The high BCR of ThyroSeq v3 for AUS/FLUS prevents surgery in a majority of patients. The ThyroSeq v3 genomic classifier reveals the complexity of the genetic signature of indeterminate nodules.

Developing an interactive and illustrative laboratory management curriculum for cytopathology trainees

Laboratory management is a critically important but often overlooked portion of cytopathology training. Indeed, recent surveys of new-in-practice pathologists have consistently shown this to be an area of deficiency. Fortunately, there are a multitude of resources available to fill this need.^1-6 These resources, such as government websites and publications by professional organizations, are often freely accessible to everyone; however, the information they provide is scattered across the vast expanse of cyberspace. We offer this educational module to bridge those gaps and string together a web of resources. The curriculum content includes a pretest to assess the trainee's knowledge and a tree of clickable subject headings covering basic laboratory management topics that a graduating cytopathology fellow should be familiar with. Each subject heading is linked to a summary of the subject using tables and visual diagrams with hyperlinks to specific online resources and additional detailed information. A posttest is included to provide instant feedback. Although by no means comprehensive, we hope this will provide a stepping stone for our readers to build a sound laboratory management foundation that may guide their practice.

Thyroid cytology smear slides: An untapped resource for ThyroSeq testing

BACKGROUND

Molecular testing of thyroid nodules with indeterminate fine-needle aspiration (FNA) cytology is commonly used to guide patient management and is typically performed on freshly collected FNA samples. In this study, the authors evaluated the performance of the ThyroSeq test in cytology smear slides.

METHODS

Air-dried Diff-Quik (DQ)-stained and alcohol-fixed Papanicolaou (Pap)-stained smears were used to determine required cellularity and sensitivity of mutation detection and to compare ThyroSeq v3 Genomic Classifier (GC) results obtained in cytology smears and fresh FNA samples from the same nodules.

RESULTS

ThyroSeq testing of 31 cytology smears revealed that 25 smears (81%) were adequate for ThyroSeq analysis, including 14 Pap-stained smears (100%) and 11 DQ-stained smears (65%), whereas 6 DQ-stained smears (35%) failed RNA sequencing. The overall accuracy for detecting molecular alterations was 98%, with 100% concordance for mutations and gene expression alterations, 96% concordance for fusions, and 94% concordance for copy number alterations. Cytology smears were adequate for ThyroSeq analysis when at least 200 to 300 cells were present in 1 to 3 slides. ThyroSeq detected all studied mutations down to 5% allele frequency and BRAF mutations down to 1% allele frequency. Testing of smears yielded a positive ThyroSeq GC result in all nodules originally classified as positive.

CONCLUSIONS

Thyroid FNA cytology smear slides with adequate cellularity can be successfully used for ThyroSeq GC testing in approximately 80% of cases, with an even higher success rate in Pap-stained smears. Compared with FNA samples collected into preservative solution, 94% to 100% of different genetic alterations could be accurately detected in smears, validating cytology smears as an alternative for ThyroSeq testing in patients with indeterminate thyroid cytology.

Practice Paradigms Before and After Introduction of the Diagnosis-Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features (NIFTP): an Institutional Experience

The recently adopted terminology of "Noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP) reflects the indolent behavior of these tumors. In contrast to conventional papillary thyroid carcinomas, NIFTP can be managed conservatively. The purpose of this study was to investigate changes in surgical and pathologic practice patterns at our institution since the introduction of the NIFTP diagnosis in 2016. A retrospective analysis of all thyroid specimens received in our laboratory between January 2015 and April 2017 was performed. The final cohort consisted of 1508 thyroidectomy specimens from 1508 patients (1153 (76.5%) women and 355 (23.5%) men), of which 1011 (67%) were total thyroidectomies and 497 (33%) were partial thyroidectomies. There were 558 (69.2%) total thyroidectomies and 248 (30.8%) partial thyroidectomies performed prior to introduction of the NIFTP diagnosis and 453 (64.5%) and 249 (35.5%) total and partial thyroidectomies, respectively, after the change in nomenclature. Within a year following the initial use of this diagnosis, 67 NIFTP cases were identified (9.5% of all thyroidectomies), whereas compared with the year preceding it, malignant diagnoses decreased from 54.5 (439) to 44.6% (313), and the benign category remained unchanged from 44.5 (367) to 45.9% (322). For the entirely submitted 67 NIFTP cases, the mean number of blocks submitted was 14.7 (0.98 blocks/g); for malignant lesions 17.7 (0.92 blocks/g); and for benign lesions 16.6 (0.75 blocks/g). The results of our study suggest that NIFTP are encountered in almost 10% of thyroidectomies at our institution with expected shifts in cytology and surgical pathology diagnoses as a result of the change in nomenclature. During this time period, significant shifts towards less aggressive surgical management were not observed. All 67 NIFTP nodules were submitted entirely with no significant difference in the number of cassettes submitted for NIFTP nodules as compared with follicular variant papillary thyroid carcinoma (PTC), classic variant PTC, or follicular adenoma.

MON-498 Thyroseq V3 GC for Bethesda III and IV: An Institutional Experience

Background:

Molecular testing of thyroid nodules classified as indeterminate on fine-needle aspiration (FNA) is used for patient management. ThyroSeq® v3 genomic classifier is a commercially available test that examines a wide spectrum of genomic alterations in a thyroid FNA sample based on algorithmic analysis and reports test results as either negative (including currently negative) or positive. This study reviews our institutional experience with Thyroseq® V3 to distinguish between benign disease versus cancer in thyroid nodules diagnosed as Bethesda III or IV on cytology.

Methods:

Thyroid nodules with Bethesda III or IV cytology diagnoses and available Thyroseq® V3 results from 12/17 to 8/19 were retrieved from the pathology database. Cytopathology diagnoses were correlated with molecular testing and histopathology.

Results:

416 cases (Bethesda III n=252, Bethesda IV n=164) were retrieved: 295 (71%) were reported as Thyroseq® V3 negative and 121 (29%) as positive. The 82.1% (207/252) benign call rate (BCR) of Thyroseq® v3 for Bethesda III was significantly higher (p<0.001) than that for Bethesda IV, BCR 54% (88 /164). Histopathologic follow-up was available for 128 cases (96 ThyroSeq® v3 positive, 32 ThyroSeq® v3 negative): 57 benign and 71 malignant (including NIFTP). For Bethesda III and IV diagnoses respectively, the test demonstrated 91.7 % (95% Cl 73%-99%) and 91.5% (95% Cl 80%-98%) sensitivity, 94% (95% Cl 90%-97%) and 82.4% (95% Cl 74%-89%) specificity, 99% (95% Cl 96%-99%) and 95% (95% Cl 89%-98%) negative predictive value and 63% (95% Cl 50%-74%) and 70.5% (95% Cl 61%-79%) positive predictive value, given malignancy rates 10% Bethesda III; 32% Bethesda IV. 45 unique combinations of genetic alterations were detected in the 96 operated ThyroSeq® v3 positive cases—34 combinations (76%) were present in <2 cases and only 3 combinations occurred 7 or more cases. Forty-six (48%) nodules had RAS mutations, either combined with other mutations 31% (23/30, 77% malignant) or alone, 17% (10/16, 63% malignant), followed by

THADA/IGF2BP3 gene fusion changes,11.5% (10 /11 malignant). Three cases with BRAF mutations (1 V600E, 1 K601E, 1 K601N) were malignant. Copy numbers alterations alone were present in 10 (5/ 10 malignant) and the gene expression profile alone was positive in 5 cases (all malignant). Mutations that were associated with benign pathology were PTEN, DICER1, E1F1AX and TP53. There were 6 false negative cases, 5 low risk cancers by American Thyroid Association criteria and 1 NIFTP.

Conclusion:

The high BCR of Thyroseq® v3 for Bethesda III category avoids surgery for majority of patients. A more comprehensive mutational and fusion panel reveals the complexity of the genetic signature of indeterminate nodules. Future larger and likely multicenter studies will be required to define the associated cancer risk and potential prognosis associated with adjunct molecular testing.

Atypical Glandular Cells: Interobserver Variability according to Clinical Management

OBJECTIVE

The 2014 Bethesda System diagnostic criteria for atypical glandular cells (AGC) aids in classification of atypical cells in cervical cytology. There is limited literature regarding reproducibility and interobserver variability in the application of the 2014 AGC criteria. Our aim is to assess the interobserver variability of AGC with a focus on how diagnostic categories link with guideline-driven management.

STUDY DESIGN

Three observers re-reviewed 51 previously diagnosed AGC Papanicolaou tests. The diagnoses were categorized as follows: (1) according to guideline-specified management, and (2) as glandular vs. squamous lesions. The κ statistic was used to evaluate interobserver agreement.

RESULTS

The interobserver variability per guideline management by weighted 2-observer κ ranged from 0.009 to 0.530, with half of the interobserver pairings meeting the threshold for at least fair-moderate agreement. For categorization as glandular, squamous, or both, unweighted κ yielded at best fair interobserver agreement (κ = 0.250) in 1 pairing, with low κ scores in the remainder of reviewer pairs (range 0.015-0.152).

CONCLUSIONS

There is significant interobserver variability in the diagnosis of AGC. The AGC cases when divided by clinical management had fair-moderate interobserver agreement, suggesting that diagnostic variability likely has a real effect on patient care. This diagnostic uncertainty should be understood by cytologists and clinicians.

Prevalence and distribution of 15 high-risk human papillomavirus types in squamous cell carcinoma of the scrotum

Which subtype(s) of high-risk human papillomavirus (hrHPV) are involved in squamous cell carcinoma (SCC) of the scrotum is unknown. Twenty-seven cases of SCC of the scrotum were retrieved, and all 15 subtypes of hrHPV and their viral loads were assessed using multiplex real-time polymerase chain reaction. The results were correlated with the histopathologic features, p16 expression, and in situ hybridization for hrHPV. hrHPV was identified in 18 (67%) of 27 of the cases, including HPV16 (n=8), HPV35 (n=7), HPV31 (n=5), HPV59 (n=5), HPV33 (n=3), HPV18 (n=2), HPV51 (n=2), HPV39 (n=1), HPV56 (n=1), and HPV82 (n=1). Of the 18 cases, 10 (56%) were infected by multiple hrHPV subtypes. In situ carcinomas had higher viral loads than invasive (50M versus 2M in average). The average age of HPV-positive and -negative cases was similar, 55 and 51, respectively. Of 11 cases of invasive carcinoma, 5 (45%) were positive for hrHPV versus 13 of 16 (81%) of in situ carcinomas. The highest proportion of hrHPV-positive cases was seen in basaloid type (7/7; 100%) and warty type (4/4; 100%), followed by usual type (7/16; 44%). Of 18 of the HPV-positive cases, 9 (50%) were also positive for p16 by immunohistochemistry and 6 of 18 (33%) were positive by in situ hybridization. Similar to SCC of the vulva and penis, the most frequently HPV-positive tumors are basaloid and warty types. However, a proportion of SCC usual type are also positive for hrHPV. Our results show that 8 (44%) of 18 of cases are associated with hrHPV subtypes other than 16 and 18. Additionally, 7 (70%) of 10 of hrHPV16/18-positive cases are coinfected with other subtypes.

Effect of maternal obesity on lactation: systematic review

OBJECTIVE

The short duration or lack of breastfeeding has been associated with maternal obesity. The purpose of this study was to systematically review prospective studies that assessed the effect of maternal obesity on lactation.

METHODS

A search of studies was conducted in Pubmed, these included prospective studies on maternal obesity and initiation, intention and duration of breastfeeding: 653 articles were found, only seven were prospective studies. After adding other studies found by hand, a total of nine studies were analyzed.

RESULTS

Three out of four papers observed a higher risk for delay lactogenesis among obese mothers, odds ratio ranging from 1.02 to 1.10. The study assessing the initiation of lactation showed that non-obese mothers initiated lactation sooner, OR: 0.39 (95% CI: 0.25-0.62). The overall risk for cessation of breastfeeding showed that obese mothers had higher risks of early cessation, HR: 1.50 (CI 95% 1.11-2.04). In one study it was observed that obese mothers were not more likely to never breastfeed, OR = 1.56 (95% CI: 0.97-1.50).

CONCLUSIONS

This review shows that in prospective studies, obese mothers are more likely to have delayed lactogenesis and reduced lactation. Therefore, weight control and breastfeeding promotion should be reinforced before and during pregnancy. In overweight and obese mothers, breastfeeding should be closely monitored after birth.

Long-term efficacy of high-protein diets: a systematic review

The rationale for the use of high-protein diets is that they offer a higher level of satiety for a longer period of time when compared with carbohydrates or fats; this diminishes calorie consumption in the long-run. The purpose of this review was to assess the efficacy of long-term randomized clinical trials. We used Pubmed, EBSCO and SCIELO to conduct our searches. Inclusion criteria were: randomized clinical trials conducted in adults, with an intervention/follow-up of at least 24 weeks, stating the specific amount of energy protein (in percentages) in the diet; with a control group with either a conventional energy restricted diet or a high-fat/high-carbohydrate diet, also the studies should provide at least body weight or body mass index (BMI) at the beginning and at the end of the intervention. A total of 481 studies were found. Eight studies met the inclusion criteria. Weight loss difference in those with the highest weight loss with the high-protein diet ranged from 3.7 kg in a six month trial to 1.2 kg in a 17 month trial. The average weight loss of the eight studies in the high-protein diet was 6.3 kg and in the standard diet was 5.0 kg. Although half of the studies showed a higher weight loss with a high-protein diet, three out of four studies with the longest intervention show no statistical difference in weight loss. In this systematic review it was observed that the long-term effect of high-protein diets is neither consistent nor conclusive.