Context.-The incidence of neuroendocrine tumors of the prostate increases after hormonal therapy. Neuroendocrine tumors possess a broad spectrum of morphologic features and pose challenges in the pathologic diagnosis and clinical management of patients. Objective.-To present a brief updated summary of neuroendocrine tumors of the prostate with an overview of their histopathologic and immunohistochemical profiles and differential diagnoses. Data Sources.-Literature review, personal experience in the daily practice of pathologic diagnosis, and laboratory research. Conclusions.-Our understanding of neuroendocrine tumors of the prostate classification and diagnosis continues to evolve. These advances benefit the risk stratification and management of prostate cancer.
Context.-As laboratories increasingly turn from single-analyte testing in hematologic malignancies to next-generation sequencing-based panel testing, there is a corresponding need for proficiency testing to ensure adequate performance of these next-generation sequencing assays for optimal patient care. Objective.-To report the performance of laboratories on proficiency testing from the first 4 College of American Pathologists Next-Generation Sequencing Hematologic Malignancy surveys. Design.-College of American Pathologists proficiency testing results for 36 different engineered variants and/or allele fractions as well as a sample with no pathogenic variants were analyzed for accuracy and associated assay performance characteristics. Results.-The overall sensitivity observed for all variants was 93.5% (2190 of 2341) with 99.8% specificity (22 800 of 22 840). The false-negative rate was 6.5% (151 of 2341), and the largest single cause of these errors was difficulty in identifying variants in the sequence of CEBPA that is rich in cytosines and guanines. False-positive results (0.18%; 40 of 22 840) were most likely the result of preanalytic or postanalytic errors. Interestingly, the variant allele fractions were almost uniformly lower than the engineered fraction (as measured by digital polymerase chain reaction). Extensive troubleshooting identified a multifactorial cause for the low variant allele fractions, a result of an interaction between the linearized nature of the plasmid and the Illumina TruSeq chemistry. Conclusions.-Laboratories demonstrated an overall accuracy of 99.2% (24 990 of 25 181) with 99.8% specificity and 93.5% sensitivity when examining 36 clinically relevant somatic single-nucleotide variants with a variant allele fraction of 10% or greater. The data also highlight an issue with artificial linearized plasmids as survey material for next-generation sequencing.
Context.-The updated American Society of Clinical Oncology/College of American Pathologists guideline for human epidermal growth factor receptor 2 (HER2) testing in breast cancer requires pathologists to re-evaluate HER2 status. Objective.-To define HER2 status of breast cancer using immunohistochemistry and fluorescence in situ hybridization. Design.-Diagnostic reports of invasive breast cancers made between 2014 and 2018 with HER2 immunohistochemistry and fluorescence in situ hybridization results were retrieved. HER2 status was re-defined using the updated recommendations. Results.-Of 2514 tumors, 89.7% (2254 of 2514) suggested for fluorescence in situ hybridization assay were HER2 immunohistochemistry 2(+). Approximately 8.9% (225 of 2514) and 1.4% (35 of 2514) of tumors were of immunohistochemistry 0/1(+) and 3(+), respectively. Based on the average HER2 copy number and HER2:CEP17 ratio, tumors were assigned into 5 groups, including 13.1% (330 of 2514) group 1 tumors, 2.1% (52 of 2514) group 2 tumors, 1.1% (27 of 2514) group 3 tumors, 7.0% (175 of 2514) group 4 tumors, and 76.8% (1930 of 2514) group 5 tumors. In combination with immunohistochemistry, all tumors in group 2 and group 4 changed HER2 status, from positive and equivocal into negative, respectively, while group 3 tumors remained positive. Comparative analyses of clinicopathologic features of tumors in different groups revealed that group 2 and 4 tumors displayed worse clinicopathologic features than those of group 5, while group 3 tumors shared similar clinicopathologic features to those of group 1. Conclusions.-Following the updated guideline, HER2 status is clearly designated. Significant differences regarding clinical features were observed between tumors in different groups but they share the same HER2 status, suggesting further validation of the accuracy of this diagnostic approach is warranted.
Context.-The coronavirus disease 2019 (COVID-19) is a highly contagious respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Coagulation dysfunction is a hallmark in patients with COVID-19. Fulminant thrombotic complications emerge as critical issues in patients with severe COVID-19. Objective.-To present a review of the literature and discuss the mechanisms of COVID-19 underlying coagulation activation and the implications for anticoagulant and thrombolytic treatment in the management of COVID-19. Data Sources.-We performed a systemic review of scientific papers on the topic of COVID-19, available online via the PubMed NCBI, medRxiv, and Preprints as of May 15, 2020. We also shared our experience on the management of thrombotic events in patients with COVID-19. Conclusions.-COVID-19-associated coagulopathy ranges from mild laboratory alterations to disseminated intravascular coagulation (DIC) with a predominant phenotype of thrombotic/multiple organ failure. Characteristically, high D-dimer levels on admission and/or continuously increasing concentrations of D-dimer are associated with disease progression and poor overall survival. SARS-CoV-2 infection triggers the immunehemostatic response. Drastic inflammatory responses including, but not limited to, cytokine storm, vasculopathy, and NETosis may contribute to an overwhelming activation of coagulation. Hypercoagulability and systemic thrombotic complications necessitate anticoagulant and thrombolytic interventions, which provide opportunities to prevent or reduce "excessive" thrombin generation while preserving "adaptive" hemostasis and bring additional benefit via their anti-inflammatory effect in the setting of COVID-19.
Context.-The pandemic of a novel coronavirus, termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has created an unprecedented global health burden. Objective.-To investigate the effect of the SARS-CoV-2 infection on maternal, fetal, and neonatal morbidity and other poor obstetrical outcomes. Design.-All suspected cases of pregnant women with coronavirus disease 2019 (COVID-19) admitted into one center in Wuhan from January 20 to March 19, 2020, were included. Detailed clinical data of those pregnancies with COVID-19 were retrospectively collected and analyzed. Results.-Twenty-seven pregnant women (4 early pregnancies included) with laboratory or clinically confirmed SARS-CoV-2 infection and 24 neonates born to the 23 women in late pregnancy were analyzed. On admission, 46.2% (13 of 27) of the patients had symptoms, including fever (11 of 27), cough (9 of 27), and vomiting (1 of 27). Decreased total lymphocytes count was observed in 81.5% (22 of 27) of patients. Twenty-six patients showed typical viral pneumonia by chest computed tomography scan, whereas 1 patient confirmed with COVID-19 infection showed no abnormality on chest computed tomography. One mother developed severe pneumonia 3 days after her delivery. No maternal or perinatal death occurred. Moreover, 1 early preterm newborn born to a mother with the complication of premature rupture of fetal membranes, highly suspected to have SARS-CoV-2 infection, was SARS-CoV-2 negative after repeated real-time reverse transcriptase polymerase chain reaction testing. Statistical differences were observed between the groups of women in early and late pregnancy with COVID-19 in the occurrence of lymphopenia and thrombocytopenia. Conclusions.-No major complications were reported among the studied cohort, though 1 serious case and 1 perinatal infection were observed. Much effort should be made to reduce the pathogenic effect of COVID-19 infection in pregnancies.
Context.-High levels of autofluorescence in bone marrow tissue constitute a major obstacle to immunofluorescence analysis of bone marrow biopsies. Objective.-To present a simple, efficient method to eliminate autofluorescence in bone marrow biopsies. Design.-Autofluorescence of paraffin bone marrow tissues was examined in different hematologic disorders with confocal laser scanning microscopy. Strong autofluorescence was observed in primary myelofibrosis and acute leukemia with reticulin myelofibrosis in 488-nm and 561-nm channels. To eliminate autofluorescence, AutoFluo Quencher was used on bone marrow sections with different incubation times. The effects of AutoFluo Quencher on immunofluorescence analysis of bone marrow biopsies was tested using antibodies tagged with different fluorophores. Results.-AutoFluo Quencher thoroughly eliminated the strong autofluorescence of bone marrow but did not decrease the intensity of fluorophores, leaving the specific signals of target proteins clearly visible. Conclusions.-This study presents a simple, efficient method to eliminate autofluorescence in bone marrow paraffin tissue, and it opens the way to better results in the immunofluorescence analysis of bone marrow biopsies.
Context.-Reports for atypical squamous cells of undetermined significance (ASC-US) and histologic findings are rare in China. Objective.-To analyze the correlation findings of ASCUS cytology with high-risk human papillomavirus (hrHPV) test and histopathologic follow-ups. Design.-ASC-US cases with hrHPV test and histologic follow-ups between 2011 and 2015 were analyzed at a College of American Pathologists-certified laboratory. Results.-A total of 2 206 588 Papanicolaou (Pap) tests were performed, including 1 513 265 liquid-based cytology preparations (68.58%), and 693 323 conventional Pap tests (31.42%). The overall ASC-US reporting rate was 3.77% (83 199 of 2 206 588), with the highest in women aged 40 to 49 years. Of 18 574 women with ASC-US Pap and HPV testing, the hrHPV positivity rate was 34.98% (6498 of 18 574) with the highest in women younger than 30 years. A total of 6012 women with ASC-US Pap test findings had histologic follow-ups within 6 months; the overall cervical intraepithelial neoplasia 2 and above (CIN2+) detection rate was 7.87% (473 of 6012). One thousand nine hundred nine women with ASC-US Pap and HPV testing had histologic results. CIN2+ lesion was found in 13.98% (124 of 887) of women with ASC-US Pap/HPV-positive test results, significantly higher than 2.84% (29 of 1022) for women with ASC-US Pap/HPV-negative test results. Cervical squamous cell carcinoma was found in 3.95% (35 of 887) of women with ASC-US/HPV-positive test results. Conclusions.-This is one of the largest studies to investigate HPV and histologic follow-up findings in women with ASC-US in China. The ASC-US reporting rate, HPV positivity rate, and CIN2+ detection rate were all within the currently recognized benchmark ranges. These findings may contribute to establishing a baseline for better understanding of the status of cervical screening in China.
Context.-A vast majority of neoplasms arising from lung or pleura are initially diagnosed based on the histologic evaluation of small transbronchial, endobronchial, or needle core biopsies. Although most diagnoses can be determined by morphology alone, immunohistochemistry can be a valuable diagnostic tool in the workup of problematic cases. Objective.-To provide a practical approach in the interpretation and immunohistochemical selection of lung/pleura-based neoplasms obtained from small biopsy samples. Data Sources.-A literature review of previously published articles and the personal experience of the authors were used in this review article. Conclusion.-Immunohistochemistry is a useful diagnostic tool in the workup of small biopsies from the lung and pleura sampled by small biopsy techniques.
Context.-Pathologic diagnosis of tumors in the genitourinary system can be challenging based on morphology alone, particularly when diagnostic material is limited, such as in core biopsies. Immunohistochemical stain can be a useful tool to aid in the diagnosis. Objective.-To provide an update on practical applications and interpretation of immunohistochemical stains in the diagnosis of tumors in prostate, kidney, bladder, and testis. We particularly focus on difficult differential diagnoses, providing our insights in frequently encoun-tered challenging situations. Commonly used immunohistochemical panels are discussed. Data Sources.-Review of literature and our own experience. Conclusion.-Immunohistochemical stain is a valuable tool in the diagnosis of genitourinary tumors when appropriately used.
Context.-The Bethesda System for Reporting Thyroid Cytopathology recommends against the use of intraoperative frozen section (FS) during lobectomy of a thyroid nodule with a fine-needle aspiration (FNA) diagnosis of malignant. Bethesda recommendations for FS in the FNA category of suspicious for malignancy (SFM) is less well-defined. In some institutions in China, FS examination is performed during lobectomy even for FNA-proven malignant cases. Objective.-To compare the efficacy of FNA versus FS in the evaluation of malignant thyroid lesions. Design.-A 3-year retrospective analysis from a single institution was performed on cases with an FNA diagnosis of SFM or malignant with subsequent FS examination during thyroidectomy. The results of FNA and FS findings were compared to the final thyroidectomy pathology. Results.-A total of 5832 thyroidectomy procedures were performed: 1265 cases had FNA and FS results available. Fine-needle aspiration gave a diagnosis of SFM to 306 cases and a diagnosis of malignant to 821 cases. Of the SFM cases, 10.5% (32 of 306) had benign/indeterminate, 4.6% (14 of 306) suspicious, and 84.9% (260 of 306) malignant FS results. Final pathology showed 56.3% (18 of 32), 64.3% (9 of 14), and 100% (260 of 260) malignancy rates, respectively. For the malignant FNA group, 10.0% (82 of 821) had benign/indeterminate, 4.4% (36 of 821) suspicious, and 85.6% (703 of 821) malignant FS results. The final pathology showed 96.4% (79 of 82), 97.2% (35 of 36), and 99.9% (702 of 703) malignancy rates, respectively. Conclusions.-Frozen section should not be performed for the malignant FNA category because FS evaluation may result in 10% falsely negative findings. Performing FS for SFM may be better justified; however, more than half of FS cases read as benign in this category had malignant final pathology. Therefore, caution should be taken for FS results even in the SFM group.
Context.-Bilirubin has strong anti-inflammatory and antioxidative stress action. Progression of inflammation involving arteries is a crucial activator in pathogenesis of Takayasu arteritis (TA). Objective.-To investigate the relationship between serum bilirubin and TA. Design.-Our study involved 115 consecutive TA patients. Patients with active-phase disease were followed and received prednisone therapy. Results.-Lower concentrations of serum bilirubin were detected in TA patients compared with healthy subjects (0.6 +/- 0.31 versus 0.7 +/- 0.22 mg/dL, P = .02). Serum bilirubin concentrations in active TA patients were lower than those in inactive patients (0.5 +/- 0.20 versus 0.8 +/- 0.32 mg/dL, P >.001). In all patients with TA, serum bilirubin correlated positively with total protein (r = 0.193, P =.04) and negatively with C-reactive protein and erythrocyte sedimentation rate (r = -0.213, P = .03, and r = -0.532, P < .001, respectively). Multiple logistic regression analysis showed that each decrease of 1 mg/dL in serum bilirubin was associated with a 1.10 times increase in the odds for TA compared with the controls (odds ratio = 0.913, 95% CI, 0.856-0.974; P = .006). Serum bilirubin was correlated with erythrocyte sedimentation rate (beta = -0.170, P > .001) in multiple linear regression analysis. The area under the curve for serum bilirubin in predicting active TA patients was 0.802. Serum bilirubin levels were found to be significantly increased after prednisone treatment (0.5 +/- 0.20 versus 0.7 +/- 0.15 mg/dL, P = .002). Conclusions.-Lower serum bilirubin levels are associated with TA, and serum bilirubin may be influenced by prednisone therapy in active TA patients. Serum bilirubin levels in TA patients correlate negatively with erythrocyte sedimentation rate.
Context.-The mutation analysis of epidermal growth factor receptor (EGFR) has become a common test to guide therapeutic decision making for lung cancer. Molecular testing with circulating tumor DNA in plasma allows diagnosis of mutations when tumor tissue is not available as well as monitoring treatment response with repeat biopsies. Objectives.-To develop a timely and cost-effective assay that can accurately detect EGFR mutations in circulating tumor DNA and to evaluate the analytic and clinical performance of the assay. Design.-Analytic assessment was conducted with a set of reference materials carrying classic EGFR mutations. A recently developed Poisson distribution-based approach was employed to understand the assay sensitivity. Clinical evaluation was performed with 224 pairs of plasma and matched tissues from patients with stage I to IV disease. EGFR mutation rates of 390 consecutive plasma samples processed in the central service laboratory were compared with previously reported prevalence in an Asian population. Results.-Our results suggested that limit of detection for the EGFR quantitative polymerase chain reaction assay was 10 mutation copies, and the lowest detectable copy numbers could be extended to a single-digit level. The clinical sensitivity was 53.3% for all stages combined and 81.4% for late stages, with a high specificity of 100%. Clinical observations showed an overall positive finding rate of 32.5% and 41.4% for stage IV disease, which is consistent with previously reported EGFR mutation prevalence in an Asian population. Conclusions.-Our results supported the clinical utility of the ultrasensitive, quantitative polymerase chain reaction assay for EGFR mutation analysis with circulating tumor DNA.
Context.-Reliable quantification of alpha -fetoprotein (AFP) is critical for clinical diagnosis. Accuracy in AFP analysis relies on traceability to reference materials with confirmed commutability. Objective.-To assess the commutability of the reference materials for AFP. We screened for appropriate reference materials for the calibration of clinical AFP analysis and for application in an external quality assessment scheme. The feasibility of using water to dilute a reference material from the World Health Organization was also evaluated. Design.-Patient serum samples with various levels of AFP were randomly interspersed among AFP reference materials from the World Health Organization, the Beijing Center for Clinical Laboratories, and Beijing Controls and Standards Biotechnology and quality controls from BioRad. The samples were analyzed on 5 different platforms to assess the comparability of the results and commutability of the reference materials. Results.-Significant variations in AFP measurement were observed among the 5 instrument platforms. The Beijing Center for Clinical Laboratories and Beijing Controls and Standards Biotechnology reference materials were commutable across all the instrument platforms. The World Health Organization AFP 72/225 reference material diluted with distilled water was also commutable at high concentrations. The Bio-Rad quality control materials for AFP were commutable among 4 out of 5 instrument platforms. Conclusions.-Our results suggested that the Beijing Center for Clinical Laboratories and Beijing Controls and Standards Biotechnology materials were commutable across all 5 instrument platforms, whereas the Bio-Rad quality controls were limited by the concentration of AFP and the instrument platforms used. Caution needs to be taken in using water to dilute the World Health Organization 72/225 reference material because its commutability is limited to high concentrations.