Turkish Journal of Pathology - 2018; 34(2)

Techniques for Maximizing the Performance of Molecular Pathology Testing: Responsibilities of All Pathologists

Evren UZUN, S�len SARIO�LU — 2018-05-01

Molecular pathological analysis has an expanding role in patient diagnosis and management. The performance of these techniques relies on excellent laboratory procedures. However, the crucial step is obtaining the best samples for molecular analysis. Archiving and selection of these are the responsibilities of all pathologists even if they are not working at a center with molecular pathological facilities. This review focuses on the features of different types of materials for molecular pathological analysis. Many steps that might affect the results, including communication between the pathologist and the oncology team, features of different types of materials (cytological, tissue blocks, biopsy, circulating tumor cells (CTCs) and cell-free circulating nucleic acids), effects of tissue processing, methods for selecting the best material, and tissue saving and tumor enrichment methods are discussed. The procedures for referral to a center for molecular pathological analysis are also mentioned. Awareness of the importance of the cytopathological and histopathological material of the patients for future molecular pathological analysis by pathologists is of the utmost importance.

Do the Well Known Prognostic Parameters in Pancreatic Ductal Adenocarcinoma Really Reflect Survival?

Sonay KU� �ZT�RK, Esra Erden — 2018-05-01

Objective: Pancreatic ductal adenocarcinoma is an aggressive tumor with short survival. In this study we aimed to investigate the effect of well-known prognostic parameters on survival in these tumors. Material and Method: A total of 56 pancreatic ductal adenocarcinoma cases diagnosed between 2005 and 2014 were included in the study. Survival data were obtained and histopathological parameters were re-evaluated in each patient. Results: Tumor size (p=0.029), mitotic count (p=0.030), lymph node metastasis (p=0.003), metastatic lymph node ratio (p<0.001) and ampullary invasion (p=0.044) had a statistically significant relationship with survival. However, there was no relationship between survival and tumor grade, lymphovascular and perineural invasion, and peripancreatic soft tissue invasion. Conclusion: Our results showed that existent 2010 WHO pancreatic ductal adenocarcinoma grading parameters excluding mitotic count are subjective and not applicable. Considering that almost all of the tumors in our series were larger than 2 cm, we think that the 2 cm cut-off in tumor size is insufficient to make the tumor stage pT2. Peripancreatic soft tissue invasion, which is a common finding in pancreatic ductal adenocarcinoma, should also not be assessed like adjacent tissue invasion and make the tumor reach pT3 stage independent of tumor size. It is clear that the existent WHO tumor grading and pT staging parameters need to be revised and the mitotic count, which correlates with survival, should be presented in pathology reports.

BRAF V600 Mutation Profile of Metastatic Melanoma in the Thrace Region of Turkey

2018-05-01

Objective: BRAF is the most common mutation in melanoma. The most common subtype is BRAF V600E, followed by V600K. Initially, the authors aimed to investigate whether clinicopathological features of melanoma are associated with BRAF mutations. We then aimed to present the relationships between the clinicopathological features and the mutated subtype (V600E vs V600K). Material and Method: 61 patients with metastatic malignant melanoma (affecting the lymph node or other distant sites) were selected. Patient data regarding age at the time of diagnosis, sex, metastatic site (lymph node, distant metastasis or both) and primary tumour site were obtained from the hospital�s database. Tissue samples containing at least 30% tumour cells were isolated from the specimens of 61 patients (24 samples from primary tumours and 37 from metastatic foci) for BRAF analysis. Comparisons between the BRAF V600 mutation and clinicopathological and histopathological features were performed. Results: BRAF V600 mutation was detected in 34 (55.7%) patients. The subtype was BRAF V600E in 22 (64.7%) patients, BRAF V600K in 11(32.4%) patients and BRAF V600R in 1(2.9%) patient. The crucial results of the present study may be summarized as follows: i) BRAF V600 mutation was more common in older patients and tumors with BRAF V600 mutation revealed necrosis and LVI more commonly than wild-type tumors, ii) BRAF V600K mutation was more common in older patients and BRAF V600K mutated tumors exhibited ulceration more commonly than tumors with BRAF V600E mutation (close to significant). Conclusion: The BRAF V600 mutation may have interactions with prognostic clinicoptahological features of melanoma including necrosis and lymphovascular invasion. V600K mutation may be more common than expected and may have different associations with properties of the tumor such as tumor ulceration and patient age. Investigation of the mutated subtype of the BRAF gene may therefore reveal more detailed data about the management of melanoma and may also prevent missing of candidates for BRAF inhibitor therapies.

Can GATA3 Immunocytochemistry be Utilized as a Reliable Diagnostic Marker for Metastatic Breast Carcinoma in Cytological Materials?A Comparative Study with Mammaglobin and GCDFP-15 Expression

Nesreen H. HAFEZ , HebatAllah M. SHAABAN — 2018-05-01

Objective: Cytomorphologic differentiation of metastatic breast carcinoma from non breast metastases in cytological materials can be difficult. Current breast immunocytochemical markers have low sensitivities. Transcription factor GATA 3 is a promising marker for detecting breast differentiation in cytological materials. The aim of the study was to assess the diagnostic value of GATA 3 as a breast differentiation marker in metastatic cytological materials and to compare it with expression of mammaglobin and gross cystic disease fluid protein-15 (GCDFP-15). Material and Method: We retrospectively retrieved 133 cases of metastatic breast carcinoma from the archive the of Cytology Unit between December 2013 and June 2015. They included 77 fine needle aspiration and 56 serous effusion samples. Forty-five cytological materials from non mammary metastatic tumors were used as a control. Immunostaining was performed on cell blocks for the presence of GATA 3, mammaglobin and GCDFP-15. Results: GATA 3 nuclear staining was detected in 82.7% of metastatic breast carcinomas, and 11.1% of metastatic non mammary adenocarcinomas (p < 0.001). GATA 3 sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 82.7%, 88.9%, 95.7%, 63.5% and 84.3%, respectively. Mammaglobin and GCDFP-15 staining of metastatic breast carcinoma cases was positive in 70.7% and 47.1%, respectively. GATA 3 staining was significantly higher compared with mammaglobin and GCDFP-15 (p< 0.001). Conclusion: GATA 3 is more sensitive marker than mammaglobin and GCDFP-15 for diagnosing metastatic breast carcinoma in cytological cell block materials. Adding mammaglobin to GATA 3 resulted in improvement in its sensitivity. GATA 3 was occasionally positive in some metastatic non mammary carcinoma that may cause misdiagnosis.

EZH2, Endothelin-1, and CD34 as Biomarkers of Aggressive Cervical Squamous Cell Carcinoma: An Immunohistochemical Study

Anan FATHY, Aziza E. ABDELRAHMAN — 2018-05-01

Objective: Cervical cancer has an increasing incidence in developing countries with a predominance of squamous cell carcinoma. In this work, we aimed to analyze the role of EZH2, Endothelin-1, and CD34 as indicators of the aggressiveness in cervical squamous cell carcinoma. Material and Method: Immunohistochemical expression of EZH2, Endothelin-1, and CD34 was studied in 54 paraffin-embedded tissue specimens of cervical squamous cell carcinoma. Their correlation to the clinicopathologic features and the potential angiogenic role were analyzed. Results: High EZH2 expression was noted in 78% of cervical squamous cell carcinoma with a significant relation with tumor grade, FIGO stage and lymph node metastasis (p=<0.001, p=0.007, p=0.03 respectively). Endothelin-1 overexpression was detected in 63% of the studied cases with a significant association with tumor size, FIGO stage and lymph node metastasis (p=0.009, p=0.002, p=0.02 respectively). High CD34 expression (MVD) was noted in 56% of the cases and associated with the tumor size, FIGO stage and lymph node metastasis (p<0.001, p<0.001, p=0.04 respectively). The three markers were significantly associated (p<0.05). Conclusion: EZH2, ET-1, and CD34 may act as biomarkers of aggressive cervical squamous cell carcinoma. They may contribute to the signaling pathway of angiogenesis. Therefore, they could potentially be used in targeted therapy.

Evaluation of Midkine Expression in Dentigerous Cysts, Odontogenic Keratocysts and Different Types of Ameloblastoma

2018-05-01

Objective: Midkine is a heparin-binding growth factor whose expression is increased in most tumors, namely ameloblastomas. This study aimed to compare Midkine expression in different odontogenic lesions. Material and Method: This analytical cross-sectional study was performed on 52 definitely diagnosed odontogenic lesions including 15 dentigerous cysts, 13 odontogenic keratocysts, and 17 unicystic and 5 multicystic ameloblastomas archived from 1997 to 2015. Midkine expression was examined in tissue samples through immunohistochemistry. The nonparametric Kruskal-Wallis and Mann-Whitney tests were run as appropriate (P < 0.05). Results: The frequency of Midkine expression was < 20% in 7.7%, 20-50% in 25%, and > 50 % in 67.3% of the samples, indicating significant differences among the groups (P = 0.002). Moreover, the expression intensity was strong in 63.5%, moderate in 23.1%, and weak in 13.5% of odontogenic lesion samples (P = 0.071). The total staining score was weak in 3.8%, moderate in 48.1%, and strong in 48.1% of the cells, displaying significant differences between the study groups in this regard (P = 0.043). Conclusion: Midkine can be considered as both a differentiating factor and a molecular-targeted therapy in odontogenic lesions. Yet, further studies are required to approve the role of this cytokine in different biological and pathological stages of the tumors.

Evaluation of p53 and Ki67 Expression Profiles in Basal Cell Carcinomas in a Usual and an Unusual Location

2018-05-01

Objective: Owing to their importance in cell proliferation in cutaneous malignancies, we aimed to immunohistochemically compare the expression profiles of p53 and Ki67 in basal cell carcinoma (BCC) cases in both a usual and an unusual locations in this study. Material and Method: In this study we included 12 in an unusual location of BCC cases and 21 BCC cases in a usual location. Immunohistochemical expression of p53 and Ki67 antibodies were studied in 33 paraffin-embedded tissue specimens of basal cell carcinoma. We compared the p53 and Ki67 staining scores with clinicopathologic features. Results: The tumor size was found to be greater in BCC cases in an unusual location than those in a usual location. The relationship between age and tumor size was also evaluated in both groups and it was found that tumor size increased with age. A comparative study between the two groups showed no difference p53 and Ki67 expression percentages. There was a linear correlation between the Ki67 and p53 marker staining rates (ρ=0.420; p=0.015). In the samples taken from cases in a usual region, there was a linear and moderate relationship between the markers (ρ=0.513; p=0.017). Median tumor diameter results were similar to the marker staining score (p>0.05). Conclusion: This is the first study comparing the expression profiles of p53 and Ki67 of BCC cases in an unusual and a usual location. No significant difference was found concerning Ki67 and p53 expression levels between the two groups.

Acute Myeloid Leukaemia with Gene Mutation: A Correlation with Haematological and Immunophenotypic Characteristics and Our Experience in a Tertiary Care Cancer Center in South India

2018-05-01

Objective: Molecular genetic analysis of FLT3, NPM1, and CEBPA is already the standard of care in patients with acute myeloid leukaemia (AML) and represents the most frequent genetic alterations and important diagnostic and prognostic indicators. This study was undertaken to determine the frequency of FLT3 and NPM1 gene mutations in our institution and to characterize the association between gene mutations and haematological parameters as well as immunophenotypic features. Material and Method: Morphological, haematological and immunophenotypic characteristics of NPM1 and FLT3 mutations in 126 patients of de novo AML including adults and children were studied. Apart from the French American British (FAB) method for classification, blasts were assessed for cuplike morphology as per strict definition for cuplike nuclei, ≥10% blasts with nuclear invaginations ≥25% of the nuclear area. Results: FLT3 mutation in 31/126 (25%) and NPM1 mutation was found in 17/126 (13.4%) of the AML patients. 6 (5%) samples were positive for both NPM1 and FLT3/ITD mutations. Associations between the FLT3 and NPM1 gene mutations with haematological and immunophenotypic characteristics are reported. Conclusion: The results suggest that presence of distinct morphology and haematological and immunophenotypic characteristics together may serve as important indicators and surrogate for NPM1 and FLT3/ITD mutations. Further, comprehensive studies on the biological effects of NPM1 and FLT3/ITD mutations and their interactions with other genetic alterations are needed to gain insight into the molecular mechanism of these mutations involved in the pathogenesis of AML.

Histopathological Diagnostic Dilemma in Retrorectal Developmental Cysts: Report of a Case and Review of the Literature

Meltem AZAT�AM, Eren ALTUN, Veli AVC� — 2018-05-01

Retrorectal developmental cysts are lesions that are classified according to their histopathological characteristics and origins. The major types are epidermoid cyst, dermoid cyst, rectal duplication cyst, rectal cystic hamartoma and teratoma. These cysts grow slowly and the majority of cases are asymptomatic. Total excision is required and histopathological examination should be carefully performed for retrorectal localized developmental cysts, since the cystic lesions may show malignant transformation. Here, a 3-year-old male patient with retrorectal mass, which was histopathologically compatible with tailgut cyst, is presented and the differential diagnosis of retrorectal developmental cysts is discussed.

Masson's Tumor Masquerading as a Papillary Adenocarcinoma on Fine Needle Aspiration Cytology: A Case Report

Anita NANGIA, Shivali SEHGAL, Kiran AGARWAL — 2018-05-01

Intravascular papillary endothelial hyperplasia, previously known as Masson's tumor, is a relatively uncommon reactive endothelial proliferation that occurs most commonly in the vessels of the head, neck, and extremities. We report a case of intravascular papillary endothelial hyperplasia in the neck in a 40-year-old female that was misdiagnosed as papillary adenocarcinoma on fine needle aspiration. The cytologic picture of intravascular papillary endothelial hyperplasia is diverse, making a pinpoint diagnosis of this entity difficult on fine needle aspiration.

Early Stage Prurigo Pigmentosa : A Case Report

Emel ONAYG�L, Abdullah SONGUR, Zekayi KUTLUBAY, Cuyan DEM�RKESEN — 2018-05-01

Prurigo pigmentosa is a rare inflammatory dermatosis that primarily affects adolescents and young adults. Even though it is most commonly seen in Japanese women, other countries have reported cases with increasing frequency. It is characterized by erythematous papules and macules on the trunk, neck and chest that resolve leaving a reticulate hyperpigmentation. Some endogenous factors related with ketosis like fasting, diet, diabetes, pregnancy and exogenous agents like chrome, nickel, para-amino compounds have been accused of playing a role in etiology. Here we would like to present a case of a 16-year-old female patient who was referred to our clinic with pruritic lesions on the trunk and neck, consistent with the initial phase of prurigo pigmentosa, after a period of strict diet. Prurigo pigmentosa is a disease with distinctive histologic and clinical features. Due to its rare occurrence, an accurate diagnosis may be particularly challenging. Clinicopathological correlation is therefore crucial in the diagnosis of the disease in its early phase.

Solitary Fibrous Tumor of the Vagina with Potentially Malignant Features: A Case Report and Review of the Literature

Asuman Nihan HABERAL REYHAN — 2018-05-01

Extrapleural solitary fibrous tumors are being increasingly reported. The retroperitoneum, deep soft tissues of the proximal extremities, abdominal cavity, trunk, head and neck are among the most common extraserosal locations reported. A recurrent solitary fibrous tumor involving the vagina of a 25-year-old woman is reported. Microscopically, the tumor was hypercellular and composed of mitotically active spindle cells. Immunohistochemically, the tumor cells were positive for vimentin, CD34, and bcl-2. Four cases of solitary fibrous tumors involving the vagina have been reported previously. To the best of our knowledge, this is the first case with clinical and histological features suggestive of a malignant behavior.

Non-Hodgkin Lymphoma and Pleural Mesothelioma in a Person Exposed to Asbestos

Claudio BIANCHI, Tommaso BIANCHI — 2018-05-01

Non-Hodgkin lymphoma and pleural mesothelioma may co-exist in the same patient. A large cell non-Hodgkin lymphoma of the inguinal lymph nodes was diagnosed in a 73-year-old woman. The patient was treated by chemotherapy. She did not receive radiotherapy. The patient had been exposed to asbestos having worked in a cotton mill and in a distillery. Four years after the diagnosis of lymphoma, she presented with a left pleural effusion. Large biopsies of the pleura showed a malignant mesothelioma, biphasic type, and pleural plaques. Epidemiological studies about the asbestos-lymphoma relationship gave conflicting results. The lymphoma-mesothelioma association is not exceptional, and suggests that asbestos plays a role in the etiology of both malignancies.

Prominent Signet Ring Cell Morphology in a Pulmonary Squamous Cell Carcinoma

Nuri Y��T, Ertu�rul �EL�K, �brahim YAVAN — 2018-05-01

In daily practice, signet ring cell morphology immediately brings to the mind the possibility of an adenocarcinoma at first glance. The signet ring cell appearance has been described and is well-known in a wide variety of some other neoplasms as well. Surprisingly however, neoplastic cells having the same morphology can unexpectedly be encountered in not previously well-documented tumors. Here, we present an 85-year-old man diagnosed with primary pulmonary squamous cell carcinoma and a large signet ring cell population. Examination of the lobectomy specimen and further radiological workup was consistent with stage I disease. Signet ring cell variant of squamous cell carcinoma is a very infrequent tumor and has been reported in only eight cases from skin, cervical and oral cavity biopsies as well as in one case of pulmonary acantholytic variant of squamous cell carcinoma with focal signet ring cells. To be aware of this entity is crucial for pathologists to reach the correct diagnosis, particularly in cytological samples, because of its potentially modifying effect on treatment options and patient management compared to adenocarcinomas. Our patient remained in clinical remission during the 9-month follow-up.