Blasting the myth of predictive INR changes related to plasma transfusion: an academic institution's experience

INTRODUCTION

Plasma transfusion is a common therapeutic strategy used to lower international normalized ratio (INR) values in the non-emergent setting. However, due to lack of evidence of its efficacy, standardized guidelines for this practice have not been well established.

METHODS

This retrospective observational cohort study analyzed 276 inpatient encounters that involved plasma transfusions focusing on change in INR values from pre- to post-transfusion, with respect to the following predictor variables: vitamin K co-administration, number of plasma units transfused, order indication and body mass index (BMI).

RESULTS

The overall average change in the INR was 1.35. Patients who received vitamin K showed an average change of 2.51, while patients that did not receive vitamin K demonstrated an average change of 0.70. Increased numbers of plasma units transfused showed benefit up to three-unit orders. Greater decreases in the INR were observed for patients requiring plasma for anticoagulation reversal or active bleeding. There was no significant difference in the change in INR based on the BMI. By multivariate and regression analyses, the stepwise addition of each successive predictor variable demonstrated an increase in the shared variance in the outcome of the post-transfusion INR: the pre-transfusion INR and vitamin K co-administration alone was not significant (p = 0.45); the additional number of plasma units transfused was significant (R² = 0.13, p < 0.001), and; the subsequent additional plasma order indications (R² = 0.19, p < 0.001) and BMI (R² = 0.18, p < 0.001) were increasingly significant.

CONCLUSION

Taking into consideration the combination of multiple predictive factors may aid in a more efficient use of plasma products.

Abstract 5627: Functional tertiary lymphoid structure (TLS) and outcome in HER2-positive (HER2+) breast cancer in NCCTG N9831 (Alliance)

Background: Previous studies showed conflicting results regarding association between stromal tumor infiltrating lymphocytes (sTIL) and outcome in HER2+ breast cancer. While sTIL were not associated with outcome in patients (pts) treated with trastuzumab in N9831, immune functions genes are linked to outcome in these pts. TLS is an organized form of ectopic lymphoid aggregates (LA) with secondary lymphoid organ structure. Several studies showed that TLS associates with improved outcome in multiple cancers. However, distinguishing TLS and simple LA is challenging, particularly when germinal center is absent. In this study, we evaluated integrated pathological quantification and genomic data to assess functional TLS.

Methods: Pathological evaluation of LA in H&E slides from pts treated in Arm A (chemotherapy alone) and Arm C (chemotherapy with concurrent trastuzumab) in N9831 was performed. NanoString was used to quantify mRNA. Wilcoxon rank sum test, Chi squared test, Kaplan-Meier method and Cox regression model were used to evaluate association between LA and baseline characteristics as well as outcomes.

Results: LA was quantified in 1011 pts (526 Arm A, 485 Arm C). Greater number of LA was significantly associated with higher tumor grade, ER/PR negativity and increasing sTIL, but not age, tumor size or lymph node status. Increasing numbers of LA were associated with improved RFS in both arms combined (p 0.028). However, using multivariable Cox regression analysis in each treatment arm, LA (≥ 1 vs 0) was associated with improved RFS only in Arm A (HR 0.6, 95%CI 0.43-0.84, p 0.003) but not Arm C (HR 0.72, 95%CI 0.47-1.1, p 0.134). Further evaluation of expression of TLS-related immune genes including IFNG, ICOSLG, CXCL13, CXCR3, BCL6, IL21R, ICOS, PDCD1, CXCR5, CXCL9, TBX21, CD38, CXCL10, CLXCL11, IL21, CD200 was carried out among 252 pts in Arm C with LA ≥ 1. Among these 16 TLS-related immune genes, as a continuous variable, higher expression of BCL6 (HR 0.61, 95%CI 0.41-0.92, p 0.019) and IL21R (HR 0.78, 95%CI 0.62-0.98, p 0.03) were associated with improved RFS in Arm C pts with LA ≥ 1. However, these genes were not significantly associated with outcome in Arm C pts without LA with BCL6 HR1.07 (95%CI 0.67-1.71, p 0.776) and IL21R HR 0.96 (95%CI 0.71-1.29, p 0.775).

Conclusion: Similar to sTIL, greater number of LA was associated with improved outcome in HER2+ pts treated with chemotherapy alone but not chemotherapy in combination with trastuzumab. Using histogenomic integration with the combination of pathological LA and TLS-related immune genes, we identified that pts with functional TLS with LA ≥ 1 and higher expression of BCL6 or IL21R had significantly improved outcome when treated with trastuzumab. Future studies are needed to further confirm these findings.

Support: U10 CA180821, U24 CA196171, https://acknowledgments.alliancefound.org; Genentech;

Clinicaltrials.gov Id: NCT00005970

Citation Format: Saranya Chumsri, Tracy R. Shachner, Zhuo Li, Nadine Norton, Alvaro Moreno-Aspitia, Gerardo Colon-Otero, Edith A. Perez, E. A. Thompson, Aziza Nassar, Keith L. Knutson. Functional tertiary lymphoid structure (TLS) and outcome in HER2-positive (HER2+) breast cancer in NCCTG N9831 (Alliance) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5627.

Improving ROSE: Discrepant touch preparation and histology findings in cytology of renal masses: A 10-year retrospective review

BACKGROUND

The number of "renal incidentalomas" is on the rise due to increasing use of radiologic studies. Image-guided core needle biopsies (CNB) with touch preparations are performed to guide specimen collection and triage of sample for additional studies. Results allow the clinical team to make appropriate treatment decisions.

DESIGN

Our electronic database was searched for a 10-year period to identify 180 image-guided biopsies of renal masses with rapid on-site evaluations (ROSE) and corresponding biopsy/resection specimens. Touch preparations were classified as non-diagnostic, negative/benign, adequate/positive for malignancy/oncocytic predominance, or atypical. These results were compared to the final diagnosis on the biopsy or resection specimen (if available). Diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values were determined. Non-diagnostic cases and cases in which ROSE and final diagnosis were discordant were reviewed by cytopathologists blinded to the original interpretation to reconcile discrepancies and highlight interpretation pitfalls.

RESULTS

A ROSE diagnosis was rendered in 133 of 180 cases; 47 cases were non-diagnostic. Of the 133 diagnostic cases, the ROSE diagnosis was concordant with the core biopsy final diagnosis in 125 cases, yielding a diagnostic accuracy of 94%. The overall sensitivity was calculated to be 80.1%; specificity 72.4%; positive predictive value 94%; and negative predictive value 41.2%.

CONCLUSIONS

Touch preparation slides are vital but imperfect tools in evaluating renal masses. In our study, distinction between malignant and benign samples was accomplished in most cases (94% accuracy), but there are limitations. Awareness of interpretation pitfalls allows informed decisions to be made regarding specimen collection and patient management.

Metastatic melanoma of the uterine cervix diagnosed on cervical Pap smear: Case report and literature review

Metastatic cancer involving the uterine cervix is exceedingly rare, and accounts for less than 1% of cancer deaths. The cervix is an uncommon location for metastatic lesions due to its limited blood supply and fibrous stroma and metastatic melanoma of the cervix is particularly infrequent. To the best of our knowledge and literature review, there have only been nine reported cases in the literature of metastatic melanoma involving the uterine cervix that were diagnosed via cervicovaginal Pap smears, including the case being reported in this paper. Diagnosing metastatic melanoma on cervicovaginal cytology specimens is challenging, not only because of its rarity, but also because of the inherent ability of melanoma to take on many different cytomorphologic appearances. In such cases, the differential diagnosis may include a high-grade squamous intraepithelial lesion, atypical glandular cells, adenocarcinoma and other poorly differentiated malignancies. We report a case of malignant melanoma to the cervix diagnosed by a routine cervical Pap smear in a young woman who was diagnosed with cutaneous melanoma 3 years prior. Because of the diagnosis rendered on her cervical Pap smear, she was subsequently found to have widespread metastatic disease. Although the cervical Pap smear is primarily intended to screen for squamous intraepithelial lesions, a high index of suspicion must be maintained for other less common entities, particularly when there is no evidence of a squamous intraepithelial lesion.