Editors: Rouzan Karabakhtsian, MD, PhD, professor of pathology and director of the Women’s Health Pathology Fellowship, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY; Nicole Panarelli, MD, associate professor of pathology, Albert Einstein College of Medicine, Montefiore Medical Center; Shaomin Hu, MD, PhD, gastrointestinal/liver pathology fellow, University of Chicago; and S. Emily Bachert, MD, pathology resident, Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington.
Clinical significance of Crohn disease activity at resection margins
March 2020—Conflicting data about the clinical significance of microscopic Crohn disease activity at resection margins have led to varying practice patterns for routine reporting by pathologists. The authors performed a multicenter retrospective cohort study of 101 consecutive Crohn disease bowel resections during a 10-year period to characterize the association between active disease at resection margins and postoperative Crohn disease recurrence and time to recurrence. Margin slides were reviewed, and Crohn disease activity at the margins was graded as none, mild, moderate, or severe. The authors used logistic regression and Cox regression analyses, respectively, to evaluate the association between microscopic Crohn disease activity at the margins and postoperative recurrence and time to recurrence. They found that Crohn disease activity at resection margins was reported in 43 percent of pathology reports. Resection margins had Crohn disease involvement in 39.6 percent of 96 cases for which the authors were able to determine margin disease activity following slide review. Twenty of the cases were classified as mild, six as moderate, and 12 as severe activity. Although patients with mild (odds ratio, 1.14; 95 percent confidence interval [CI], 0.40–3.20) and moderate to severe (odds ratio, 1.97; 95 percent CI, 0.62–6.35) activity were at increased risk of disease recurrence, the differences were not statistically significant. Patients with mild (hazard ratio, 0.97; 95 percent CI, 0.50–1.91) and moderate to severe (hazard ratio, 1.29; 95 percent CI, 0.65–2.55) disease activity at margins did not have significantly different time to recurrence compared to those without disease activity. This study suggests that Crohn disease activity at resection margins is not significantly associated with postoperative Crohn disease recurrence.
Setoodeh S, Liu L, Boukhar SA, et al. The clinical significance of Crohn disease activity at resection margins. Arch Pathol Lab Med. 2019;143(4):505–509.
Correspondence: Dr. P. Gopal at purva.gopal@utsouthwestern.edu
Teratoid Wilms tumor: extreme end of heterologous element differentiation
Wilms tumor may show a diverse range of heterologous elements. Cases with predominant/prominent heterologous elements (HEs) have been reported as “teratoid” Wilms tumor (WT), albeit on the basis of poorly defined criteria. It has been suggested that teratoid WTs are rare and associated with poor response to chemotherapy but with good outcome. However, these claims have not been tested previously in a large cohort of cases. The authors performed a systematic study to determine the incidence, diversity, and clinicopathologic association of HEs in 691 WTs. All of the WTs were treated according to the same protocol, which included preoperative chemotherapy and central pathology review. The authors found that four percent (28 of 691) of WTs showed three or more HEs (teratoid WT in this study), which was comparable to the numbers of completely necrotic, epithelial, focal anaplastic, and blastemal WTs. Teratoid WTs were strongly associated with younger age at presentation (21 versus 39 months; P = .0001), bilateral disease (28.6 versus 7.2 percent; P = .001), stromal-type WT (57.1 versus 11 percent; P < .00001), and intralobar nephrogenic rests (35.7 versus 11.9 percent; P = .0001), when compared with non-teratoid WT. The authors also found that stromal-type WT, regardless of HE differentiation, was associated with younger age, bilateral disease, and intralobar nephrogenic rests. Furthermore, more than 80 percent of cases that had three or more HEs, two HEs, and one HE showed 50 percent or more stroma in their viable components. The authors concluded that a tendency toward stromal differentiation is a strong and unifying factor in HE formation. Teratoid WT represents the more extreme end of HE differentiation, rather than a separate entity, so the term should not be used in the final diagnosis. The prognosis of WTs depends only on their overall histologic type and stage and is not influenced by the presence of teratoid features.
D’Hooghe E, Mifsud W, Vujanić GM. “Teratoid” Wilms tumor: the extreme end of heterologous element differentiation, not a separate entity. Am J Surg Pathol. 2019;43(11):1583–1590.
Correspondence: Dr. G. M. Vujanić at gvujanic@sidra.org
Secretory carcinoma of the breast: a clinicopathologic profile emphasizing distant metastatic potential
Secretory carcinoma of the breast is a rare histological type of breast carcinoma, and its clinical course is typically indolent. The authors conducted a study to elucidate the clinical, pathological, and molecular findings of secretory carcinoma of the breast (SCB) cases and identify characteristics associated with an aggressive clinical course. They identified from the pathology files (1992–2017) at Memorial Sloan Kettering Cancer Center 14 patients with SCB—12 women and two men (median age, 56 years; range, 8–81 years)—and reviewed clinical data, histological diagnosis, molecular findings, and follow-up. Eight patients had presented with palpable masses and four with radiographic abnormalities. All cases were unilateral. Surgical procedures included excisional biopsies and ipsilateral mastectomies. In 10 cases, estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) results had been obtained, and six SCBs were positive for ER and three for PR. All cases lacked HER2 overexpression. Sentinel lymph node biopsy had been performed in 10 cases, and two patients had axillary lymph node metastasis. Follow-up ranged from 21 to 212 months (median, 70 months). Two patients developed distant metastasis of SCB. Molecular analysis of these aggressive tumors revealed amplification of the 16p13.3 locus, a TERT promotor mutation, and loss of the 9p21.3 locus. The authors also reviewed literature for SCB cases with distant metastases. They concluded that although SCBs are generally associated with a favorable prognosis, this study and literature review demonstrate that a subset of SCBs may develop distant metastases. Additional studies are warranted to identify markers predictive of more aggressive clinical behavior in this rare breast cancer subtype.
Hoda RS, Brogi E, Pareja F, et al. Secretory carcinoma of the breast: clinicopathologic profile of 14 cases emphasising distant metastatic potential. Histopathology. 2019;75(2):213–224.
Correspondence: Dr. H. Y. Wen at weny@mskcc.org
Diagnostic yield of SharkCore EUS-guided fine-needle biopsy
Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the standard diagnostic procedure for many intrathoracic and intra-abdominal lesions. Next-generation fine-needle biopsies (FNBs) can increase diagnostic yield by procuring tissue suitable for histological processing. The authors evaluated the diagnostic yield and operating characteristics of the SharkCore FNB (SC-FNB; Medtronic Corp.) in a tertiary referral facility. They performed a single-center retrospective review of SC-FNB–acquired tissue between January 2014 and March 2018. They obtained patient demographic data, endoscopic features, and pathology data from the electronic medical record. The authors assessed diagnostic yield by the ability to obtain a definitive diagnosis, defined as malignant or benign interpretations. Operating characteristics were also calculated. The authors sampled 179 lesions in 157 patients (mean age, 63 years; 57 percent male) using the SC-FNB. Of these, 31 lesions were concomitantly sampled with a conventional FNA needle. Most lesions (49 percent) were pancreatic. Diagnostic yield was 86 percent, which was independent of lesion location, lesion size, and needle gauge. Diagnostic accuracy was highest when histology and cytology specimens were analyzed concurrently (96.5 percent). In patients with a history of chronic pancreatitis, the accuracy, sensitivity, and negative predictive values were reduced (71.4, 20, and 69.2 percent, respectively). Rapid on-site evaluation occurred in 64.8 percent of cases and was more likely to be diagnostic at the time of rapid evaluation if SharkCore-acquired tissue was used in lieu of FNA-acquired tissue (P = .03). However, final diagnostic yield did not differ between needles (P = .13). The authors concluded that SC-FNB shows high diagnostic yield and accuracy and provides diagnostic tissue for rapid on-site evaluation. SC-FNB is an effective alternative to conventional FNA.
Fitzpatrick MJ, Hernandez-Barco YG, Krishnan K, et al. Diagnostic yield of the SharkCore EUS-guided fine-needle biopsy. J Am Soc Cytopathol. 2019;8(4):212–219.
Correspondence: Dr. Megan J. Fitzpatrick at mjfitzpatrick@partners.org