Recent eLetters

Displaying 1-10 letters out of 136 published

  1. Re:About uncertainty in IBD histological diagnosis

    Firstly, Dr Canavese and colleagues' interest in the guideline document is much appreciated. Before responding specifically, it is worth noting that there are two main diagnostic decisions to make when a patient presents with suspected chronic idiopathic inflammatory bowel disease (IBD): distinguishing IBD from other causes of inflammation; and classifying IBD as ulcerative colitis (UC) or Crohn's disease (CD). Even with full clinical details, comprehensive sampling, and assessment by a well-informed pathologist there will be a significant minority of IBD biopsies that cannot be classified confidently as UC or CD.[1, 2] There will also be a number that cannot even be categorised as IBD or non-IBD. However, I agree entirely that several other factors beyond the pathologist's control may also contribute to diagnostic uncertainty. Indeed, the proven importance of adequate clinical details and of thorough sampling are often noted in clinical guidelines.[1, 3-8] For example, limited sampling within and between sites may be one of the reasons why histopathologists are apparently less successful at diagnosing CD than diagnosing UC.[7-9] I also agree that pathologists have a responsibility to convey the level of diagnostic certainty as clearly as possible to the clinical teams. Proposed categories for the conclusion of an IBD biopsy report have been included in the BSG guideline ("PAID" scheme, Table 14).[10] The suggested terminology represents a consensus view on the best way to express probability. Accordingly, its adoption is recommended. Similarly, vague terms such as "in keeping with" are best avoided or used sparingly (Table 13).[10] Dr Canavese and colleagues' suggested solutions are helpful. I agree that the pathologist should insist on a minimum standard of clinical input. Indeed, provision of the endoscopy report to the pathologist will be recommended strongly in a forthcoming guideline for clinicians.[11] Similarly, identifiable deficiencies in the process should be noted by the pathologist interpreting the biopsies, especially if they interfere with assessment. Also, a statement in a histology report that repeat endoscopy and sampling might be informative would oblige the clinician to consider this option. However, enforcement of minimum clinical standards can be difficult. Overall, better communication between pathologists and clinicians, ideally in the setting of a regular clinicopathological meeting, is an excellent way to enhance diagnostic accuracy.[4, 10, 12] On a more general note, the scope and quality of IBD services and the reasons for suboptimal management may vary within and between countries. Attempts are being made to remedy the inconsistencies. Reassuringly, a UK services standards document for IBD includes guidance on the use of histopathology services and is cognisant both of the value of biopsy assessment and of the importance of interaction between pathologists and clinicians.[13]

    Yours sincerely,

    Professor R M Feakins

    Conflict of Interest:

    None declared

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  2. About uncertainty in IBD histological diagnosis

    Dear Prof. Feakins,

    First of all we wish to express our congratulations for your excellent reporting guidelines about the diagnosis of IBD on biopsies published in JCP, September 2013.

    About this important matter, we would like to make some comments based on our personal experience. Regarding the terminology in the histological diagnosis of IBD, it was stated (section "Probability" in the paragraph "Terminology") that "unfortunately, there are no universal agreed of terms to describe the various levels of certainty or uncertainty encountered by the histopathologists and the clinicians, unless the diagnosis is definite". In this meaning, the "level of uncertainty" of diagnosis defines the category of cases that do not satisfy the conventional criteria for a definite diagnosis of IBD or non IBD colitis, due to inadequate clinical information, as well as to inadequate number and quality of biopsies or unclear microscopic pattern (absence of IBD -specific lesions). This group of histological diagnoses with a significant level of uncertainty is relevant in IBD management for various reasons:

    1) It represents a large portion of the patients that underwent endoscopy with a clinical suspicion of IBD, given the frequent inadequacy of the prerequisites of diagnosis in clinical practice, as stated in your recent paper, published in this journal. We confirmed this trend in a recent study of our group, based on the evaluation the clinical/endoscopic information, the sampling procedures and the histological characteristics of 353 histological reports collected from 13 of the most representative gastroenterological centres in Piedmont (Italy), that evidenced a low rate of adequacy (5% adequate clinical/endoscopic information, 13% adequate sampling and no case with a correct orientation of the samples). (The first results will be presented at the Congress of the Italian Pathologists Society - SIAPEC Rome October 2013 and then published).

    2) The nomenclature of this category of cases is still heterogeneous, as well described in your paper, and often equated with a definite diagnosis in clinical practice.

    3) There is no clear indication about the management of patients with this typology of histological diagnosis. In our opinion, the effect of these anomalies is often inappropriate treatment for these patients, with the consequent modifications of the endoscopic pattern, that reduces the chance of a further diagnostic setting. Moreover, these diagnoses may be misleading in the case studies. Thus, we think it might be useful to consider this item in the management of IBD patients and to improve the quality of the histological diagnosis in the first evaluation of patients with clinical/endoscopic pattern suggestive of IBD (see also our letter to the editor [World J Gastroenterol 2013 January 21; 19(3): 426-428]) by:

    1. implementing a minimum mandatory set of clinical information and histological sampling that could fit with an appropriate diagnostic process in histology and using an univocal nomenclature for histological diagnosis that does not meet these requirements, with the goal of reducing the number of inconclusive or inappropriate diagnoses.

    2. adopting the repetition of the endoscopy (after a brief discussion with the clinical staff) for all the cases with a significant "level of uncertainty" in histological diagnosis.

    We hope that you agree with the need to obtain a more definite diagnosis for the patients, and we are strongly interested in your opinion about this topic. Thank you for your attention.

    We look forward to your kind response,


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  3. Is the Intestinal Adenoma-microcarcinoid part of a Spectrum?

    Your recently published paper entitled: "Composite Intestinal Adenoma -microcarcinoid Clues to Diagnosing an Under-recognized Mimic of Invasive Adenocarcinoma", by Dr. Salaria, et al., (1) immediately reminded me of a non-cited paper that I co-wrote in 1985 (2) about 3 recto-sigmoid carcinomas that presented with hepatic metastases; two patients died within a year, while one had progressive disease. A 26-year-old homosexual, likely with HIV/AIDS had a 4-cm polypoid posterior rectal mass that on subsequent excision was an ulcerated small cell undifferentiated carcinoma (SCUC). A 78-year-old-woman had a 4-cm mass 8 cm from the anal sphincter that showed a nesting, trabecular, carcinoid type SCUC associated with a gland-forming infiltrating adenocarcinoma. A 51-year- old woman had a 3-cm sessile adenomatous polyp, 20 cm from the anal sphincter that contained both infiltrating adenocarcinoma and SCUC; a liver biopsy was of a neuroendocrine carcinoma with dense core granules (DCG). The three varied histologically and ultrastructurally, as well as in the appearance of their neuroendocrine (NE) cells and size and abundance of NEG; they resembled both carcinoid and SCUC tumors. At the ultrastructural level, GI adenocarcinomas can have an unsuspected neuroendocrine component and a variable behavior. This suggests the possibility that there a spectrum, from a serendipitously discovered combined adenoma with a locally invasive/infiltrating carcinoid (1) through a highly aggressive adeno-endocrine lesion, with a metastatic neuroendocrine component. Both endodermal components are likely derived from the same crypt stem cells. Similar combinations are found by TEM in adenocarcinomas of the lung. In both cases, the behavior doesn't necessarily parallel the light and ultrastructural appearance, e.g., carcinoid versus "oat cell" (2). Thus, care must be taken when analyzing GI adenomas, not just looking for an adenocarcinomatous component, but also for a SCUC/carcinoid component; if either feature is identified, the liver and lymph nodes (patient #3) may be involved and there may be other lesion in the patient (307). 1) Salaria SN, Abu Alfa AK, Alsaigh NY, et al. Composite Intestinal Adenoma-microcarcinoid Clues to Diagnosing an Under-recognized Mimic of Invasive Adenocarcinoma. J Clin Pathol 2013 66:302-6. 2) Schwartz AM, Orenstein, JM. Small-cell undifferentiated carcinoma of the rectosigmoid colon. Arch Pathol Lab Med 1985;109:629-32.

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  4. Comment on imaging and high risk autopsies

    'High risk medicolegal autopsies: is a full post-mortem examination necessary?'

    Comment on the article by Fryer et al, J Clin Pathol 2013, 66:1-7

    The article by Fryer et al raises several critical issues - I do not agree with them on all points - and leads to an important overall conclusion for the future prosecution of autopsies in the UK.

    The piecemeal introduction of cadaveric imaging for non-homicide cases in (currently) a few centres in England is probably unstoppable, and has the backing of government (although not the central funding). As stated in their article, it is intended to avoid performing an open autopsy examination in a proportion of cases where a coroner has commanded a post-mortem examination. Interestingly whilst this article, and other publications like it, discuss replacing open autopsy with imaging, in public educational fora when presentations by pathologists and radiologists are made, the emphasis is more on imaging as an adjunct than a replacement for autopsy. What is not widely discussed anywhere is how the useful contribution of cadaveric imaging is critically dependent on clinical case-mix.

    We would all agree that having imaging data prior to commencing a standard autopsy, whether the imaging was done under hospital care prior to death or done just prior to the autopsy as with deaths in the community, is valuable. It focuses attention to relevant clinical pathologies to be examined, and provides negative information for some organs (such as the brain in ?intracranial haemorrhage). An unintended and underused consequence of pre-autopsy imaging is enabling feedback to radiologists, particularly in the in-hospital setting, of their diagnostic performance. They necessarily receive plentiful such information in cancer multi-disciplinary meetings, but do not regularly obtain information on their diagnostic hits and misses when it comes to the moribund. Like all diagnosticians they are fallible.

    High risk cases Fryer et al suggest that in cadavers of patients with suspected illicit drug intake, and known 'high-risk infection' (specifically Hazard Group category 3 infections, including HCV, HBV, HIV), an external examination plus blood sample toxicology can remove the need for autopsy in more than half the cases. The results, presented in % terms, are indeed persuasive. Toxicology alone provided the cause of death in 78% of cases, and CT scan alone in 25%. In the validation group (suspected drug abuse but no infection), the toxicology provided the cause of death in 87%.

    The arguments presented for avoiding open autopsy on high risk cases include expense, disruption to busy mortuary work, and health risk to staff. Interestingly, the authors state that some pathologists in their centre are reluctant to perform autopsies on such cases. But these general statements do not stand up to scrutiny. And crucially the data arise from only a small numbers of cases examined.

    In the 15 years covered by the study, only (my italics) 70 cases happened, ie 4.6 a year. Most were HCV+ve, 3 HIV+ve and one HBV+ve; the latter should really be excluded from the list of high risk infection in practice, since all NHS exposure-prone staff have to be successfully vaccinated against HBV and thus this poses no risk. I would contrast this very low cadaver infection rate with what happens at St Thomas' Hospital mortuary, where we see 1-2 HCV and/or HIV+ve cases a week, and have had no problems in performing them safely. Joint compilation of protocols for all eventualities by both anatomical pathology technologists (APTs) and pathologists ensures smooth, safe and efficient practice. I would suggest that the reported reluctance to perform such autopsies depends on unfamiliarity.

    With the implementation of universal precautions for all autopsies, the true risks of high risk autopsy practice is minimal. When such infections are common, they do not disrupt the work flows, since all bodies are essentially treated the same, and they do not engender more expense. Let us not forget that in the recent times of good safe working practice, the likelihood of acquiring such an infection at work is vastly less than the risk to life of travelling to and from the workplace.

    What are the consequences of reducing open autopsy practice by such minimal invasive techniques, and what are the opportunity costs? The focus here is on persons suspected of drug abuse with HCV or HIV.

    Refinement of causes of death I am pleased that in Table 1, autopsies were indeed done to identify the alcoholic ketoacidosis syndrome and co-morbid infections. These variants of toxic pathology cannot be addressed without tissue samples, and preferably open autopsy examination of the relevant organs. But how much other important and/or interesting pathology might be missed by not doing open examinations? Table 1 lists a good number of lesions that may not be seen with CT: heart valve vegetations, tuberculosis (a public health notifiable infection), asthma, and cirrhosis (a disease of public health concern, and not reliably identified by imaging even in the living).

    From my own observations I could add three generic scenarios: * The complicated and often critical contribution of co-morbidities, eg chronic lung and heart disease, to death from drug toxicity; it is much easier to evaluate the concepts of borderline toxicity and drug tolerance in individual cases when the whole pathology is known. * The contribution of sepsis from the IV injection habit pe se, both acutely with septic shock, and chronically through amyloidosis and renal failure. * The importance of considering the timing of a drug-related death, such as with evidence of aspiration pneumonitis, and addressing the questions of distressed relatives at inquest - for which there can be much evidence from the autopsy pathology.

    Pathology education (or lack of) This is what disturbs me most about these trends towards imaging-only post -mortem examinations. Where and how are we going to teach the next generations of pathologists in the difficult arts of dissection and, even more importantly, histological examination? The current human tissue regulations already impact badly here, and removing yet more case work (drug-related deaths are indeed interesting and have significant internal pathologies that could become unfamiliar) takes away even more opportunity. Whilst some would argue that much of this type of examination is a waste of time, I hold that it provides practice in technique and interpretation, so that when a truly difficult and nuanced case emerges, it can be addressed with experience and reason.

    Research opportunities Coronial autopsies are not intended for research but, basically, to determine whether a cause of death is natural, and an inquest may be dispensed with, or actually or potentially unnatural and so needs more investigations and inquiry. That said, because they provide >95% of adult autopsy work in the UK, they inevitably have a surveillance and potential research role. The epidemiology of diseases, including infections, changes constantly, and the autopsy provides one mode of monitoring and reporting on this.

    The prime common example (I omit transmissible spongiform encephalopathies deliberately) is HIV disease. Much of what we know of the clinico-pathological cadence of HIV disease and results of new treatments (beneficial and adverse) comes from autopsy work. And it is published as such, although the commissioning coroners are probably not aware of that.

    Coronial autopsies make a significant contribution to our understanding of cardiovascular disease in HIV-infected persons. Those not familiar with HIV may not realise the large clinical research, treatment and pharma interest into whether HIV per se and/or its anti-retroviral therapies do, or do not, activate endothelial cells and so augment arteriosclerosis, affecting the heart and brain in particular. HIV-infected suspected drug abusers thus contain within themselves at least two interesting pathological aspects (what is HIV doing and what are the drugs doing to that person), where a full autopsy can provide unique and cumulative evidence, to the ultimate benefit of public health.

    Requirement for minimal invasive post-mortem examinations As Fryer et al state, the minimal invasive system requires two robust processes in place. First rapid toxicology, and they indicate one week as satisfactory. I would argue that this is not fast enough, since bodies do decompose even whilst refrigerated and important histopathological information is lost. More practically, in London, none of the laboratories offering services performs even that fast. That should be remediable, if the paymasters (the coroners) exercised their power to force the laboratories to turn over tests within, say, 3 working days.

    Secondly, available imaging, particularly CT scanning. This is in practice impossible without proper funding; I pass over the availability of interested pathologists. At present, such non-forensic imaging is funded from now rather old government grants, or from individual initiatives such as jewish or moslem communities, or even interested radiologists with some surplus monies in their educational funds. But these are not appropriate for a nation-wide roll-out of cadaveric imaging - whether as replacement or (I would argue) as adjunct to open autopsy. These post-mortem examinations are done at the behest of coroners, and unfortunately they are not centrally but locally funded, with all that implies for variation in service provision.

    So is there a future plan? The NHS has recently issued a large post- consultation document on cadaveric imaging {ref}, written by Prof Guy Rutty in Leicester and colleagues, with input from many other relevant specialities. I do encourage all autopsy-active pathologists (and coroners) to read it.

    It provides the first realistic estimates of the actual costs of autopsies, with or without imaging costs, which alone make enlightening and disturbing reading for those involved in the economics of autopsy practice. But its main plank is the plan for future mortuary provision in England. Essentially, it is proposed that all mortuaries have attached dedicated CT scanners; that there need be only 30 such facilities in England (only 3 in London, the rest outside). And that all bodies are scanned prior to autopsy. The optimal funding for such an integrated pathology-radiology service is central government, not local source.

    Conclusion There is much controversial material in this NHS document to discuss, but I certainly endorse the significant reduction of active mortuaries, with provision of imaging facilities on-site, and the resulting concentration of expertise in such places. As well as cases I still perform myself, I review many autopsies done by others and am frequently disturbed by their suboptimal or frankly dreadful quality. It is inevitable that experience, insight and - crucially - constant audit by, and consultation with, peers does sharpen and maintain practice standards. And so with autopsies: we should be doing them as a speciality interest practice, with similarly interested colleagues, in centres that do a lot of them very well. Which brings me back to the start of this Comment: in such facilities, 'high risk infections' will pose no problems for practitioners, who will be very familiar with them and their wrinkles. So isolating that category of cases for a qualitatively different approach to post-mortem examination from all the other cases will not be necessary.

    Whether the NHS plan is rolled out as proposed, or through other exigencies the number of active mortuaries declines, the end result of fewer, but properly specialised facilities is appropriate. Pre-examination imaging will find it right place and 'high risk' cases will be optimally prosected.

    Prof Sebastian Lucas Dept of Histopathology St Thomas' Hospital London SE1, UK 28th Jan 2013

    Reference "Can Cross-Sectional Imaging as an Adjunct and/or Alternative to the Invasive Autopsy be Implemented within the NHS?" Report from the NHS Implementation Sub-Group of the Department of Health Post Mortem, Forensic and Disaster Imaging Group (PMFDI). October 2012. The document can be downloaded from the East Midlands Forensic Pathology Unit. The full website address is: Sectional%20Imaging%20as%20an%20Adjunct%20and- or%20Alternative%20to%20the%20Invasive%20Autopsy%20be%20Implemented%20within%20the%20NHS%20 -%20FINAL.pdf

    Conflict of Interest:

    None declared

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  5. IgG4-related disease in synovial tissues

    Dear Editor, We read with interest the comprehensive review on IgG4-related disease (IgG4-RD) by Drs Culver and Bateman [1], and wish to add on IgG4-RD in synovial tissue. A previous report suggested that up to 10% of patients with IgG4-RD have arthritis [2]. Two reports of arthropathy by Umekita K et al and Shinoda K et al showed evidence of infiltration of IgG4-positive plasma cells in the synovium [3, 4]. It is therefore interesting to speculate if specific biomarkers of tissue IgG4-RD exist either in the plasma or clinically relevant tissue filtrate (i.e., CSF, synovial fluid etc) that is similar to the authors' concept of examining clinically non- involved tissues for IgG4-RD.

    Synovial fibroblasts or fibroblast-like synoviocytes in rheumatoid arthritis use B-cell activating factor (BAFF) and TLR3 to promote immunoglobulin class switch [5], that is evidence of perpetuation of autoimmunity in non-lymphoid tissue and possibly similar to what happens in IgG4-RD. Ugo Fiocco and colleagues from Italy have tried to identify candidate synovial biomakers in psoriatic arthritis, and showed that synovial fluid interleukin-6 (SF- IL-6) and SF-IL-1b levels along with synovial tissue (ST)-CD45+ and ST-CD31+ levels were altered significantly as well as disease activity after anti-TNF therapy [6]. A new report now suggests that basophil-TLR and basophil/B cell-BAFF interaction may lead to the development of IgG4-RD [7]. It is certainly not the end of the road for this intriguing disease.

    Conflict of interests: None declared

    Authors: Sujoy Khan, Consultant Allergy & Immunology, Apollo Gleneagles Hospital, Kolkata, India; Ratnadeep Ganguly, Consultant Histopathologist, Apollo Gleneagles Hospital, Kolkata, India

    References: 1. Culver EL, Bateman AC. IgG4-related disease: can non-classical histopathological features or the examination of clinically uninvolved tissues be helpful in the diagnosis? J Clin Pathol. 2012;65:963-9.

    2. Masaki Y, Dong L, Kurose N et al. Proposal for a new clinical entity, IgG4-positive multiorgan lymphoproliferative syndrome: analysis of 64 cases of IgG4-related disorders. Ann Rheum Dis 2009; 68; 1310-5.

    3. Umekita K, Kaneko Y, Yorita K et al. Arthropathy with infiltrate IgG4-positive plasma cells in synovium. Rheumatology (Oxford). 2012;51:580 -2. 4. Shinoda K, Matsui S, Taki H et al. Deforming arthropathy in a patient with IgG4-related systemic disease: Comment on the article by Stone et al. Arthritis Care Res 2011; 63: 172.

    5. Alsaleh G, Fran?ois A, Knapp AM et al. Synovial fibroblasts promote immunoglobulin class switching by a mechanism involving BAFF. Eur J Immunol. 2011;41:2113-22.

    6. Fiocco U, Oliviero F, Sfriso P et al. Synovial biomarkers in psoriatic arthritis. J Rheumatol Suppl. 2012;89:61-4.

    7. Watanabe T, Yamashita K, Sakurai T et al. Toll-like receptor activation in basophils contributes to the development of IgG4-related disease. J Gastroenterol. 2012 Jun 29. [Epub ahead of print]

    Conflict of Interest:

    None declared

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  6. Mucosal large cell neuroendocrine carcinoma of the head and neck regions:inconsistent data

    Dear Editor,

    I read with interest the recent original article entitled 'Mucosal large cell neuroendocrine carcinoma of the head and neck regions in Japanese patients: a distinct clinicopathological entity' by Kusafuka et al.[1] The patient (Case 2) in this article had been previously reported.[2] I note some discrepancies between these two papers. In this original article, the patient (Case 2) was a 65-year-old man. The mitotic rate of this tumor was not specified, but >15 per 10 high power fields. Immunohistochemically, the tumor cells were focally positive for chromogranin-A, but negative for synaptophysin. The Ki-67 labeling index was 90.8%[1]. In the case report[2], this patient was a 79-year-old man. The mitotic rate was 13 per 10 high-power fields. The tumor cells were focally positive for synaptophysin (shown in Figure 3c), but negative for chromogranin-A. The Ki-67 labeling index was 82%.

    There are also some discrepancies between this original article and their recent review article[3]. In the review[3], they mentioned that four of their eight mucosal large cell neuroendocrine carcinomas arose in the larynx (supraglottis). The follow up periods were 12-96 months, and only one patient died of disease. The authors concluded that the Japanese cases of mucosal large cell neuroendocrine carcinoma had a better prognosis than that reported in the literature. Three cases were immunopositive for thyroid transcription factor-1. But in this original article[1], four tumors occurred at the larynx, with three at the supraglottis and one at the infraglottis. Three patients died of disease, and one patient died of another disease (shown in Table 2), which led to the conclusion that their Japanese series of large cell neuroendocrine carcinoma also indicated a relatively poor prognosis as that reported in the literature. The follow up periods were 15-90 months (shown in Table 2). Only two cases were immunopositive for thyroid transcription factor-1.

    Discrepancies were also present in this original article[1]. In the section of Results, the age of the eight patients ranged from 52 to 75 years (mean 64.6 years). In the section of Discussion, they stated all the cases in the present series were aged >65 years and the follow up periods of the patients that have been disease-free were 24-108 months. But in Table 2, the age ranged from 52 to 74 years and four patients were alive without disease (31 months, 18 months, 24 months and 90 months after surgery, respectively).

    In conclusion, there are many inconsistent data in these articles concerning mucosal large cell neuroendocrine carcinoma by Kusafuka et al.[1-3] They should verify the original data and make a correction.

    Sincerely, Shaodong Yang. Department of Oral Histopathology, Hainan Medical College, 3 Xueyuan Road, Longhua District, Haikou, China.

    REFERENCES 1. Kusafuka K, Abe M, Iida Y, et al. Mucosal large cell neuroendocrine carcinoma of the head and neck regions in Japanese patients: a distinct clinicopathological entity. J Clin Pathol 2012;65:704-9. 2. Kusafuka K, Asano R, Kamijo T, et al. Large cell neuroendocrine carcinoma of the tongue base: case report of an unusual location with immunohistochemical analysis. Int J Oral Maxillofac Surg 2009;38:296-9. 3. Kusafuka K, Ferlito A, Lewis JS Jr, et al. Large cell neuroendocrine carcinoma of the head and neck. Oral Oncol 2012;48:211-5.

    Conflict of Interest:

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  7. EGFR expression in vulvar carcinomas: correlation with gene status

    Re: EGFR gene copy number increase in vulvar carcinomas is linked with poor clinical outcome. Woelber et al. J Clin Pathol. 2012 Feb;65(2):133-9.

    Dear editor,

    A very novel issue was assessed by Woelber et al.[1] in their recently published study. This subject has major importance since the medical interest for vulvar carcinoma has increased in the last decade as the recognition of the increasing incidence of the disease, especially among young women. However, the fact that this carcinoma is an uncommon neoplastic disease makes its relative rarity an obstacle in designing studies to evaluate the effectiveness of the prognostic factors of molecular markers for this type of tumor. Thus, all experience on this type of tumor regarding the molecular aspects, becomes of paramount importance and we would like to share our experience in this field. Woelber et al.[1] studied a series of 183 formalin-fixed paraffin-embedded (FFPE) vulvar squamous cell carcinomas (VSCC) arranged in two TMAs, in which FISH analysis for EGFR, HER-2, CCND1 and MYC, IHQ for EGFR, HER-2 and CCND1, besides HPV detection by conventional PCR were performed. All data were associated to clinicopathological features. As the main results, EGFR copy number increase was found in 39.3% of the tumors and amplification of the EGFR gene in 9%. By IHQ, 53.3% of the samples showed 3+ staining for EGFR, being EGFR protein expression significantly correlated to EGFR copy number increase (p<0.05). Copy number gain of the EGFR locus was associated with high-invasion depth (p=0.045), non- basaloid phenotype (p=0.03), high-tumour stage (p<0.001), human papillomavirus negativity (p=0.04) and the number of lymph node metastases (p=0.02). Therefore, the authors showed that EGFR copy number gains were significantly related to unfavorable patient outcome and suggest the potential role of EGFR as a suitable therapeutic target in a subgroup of vulvar carcinomas. In a very similar fashion, our group studied 139 invasive VSCC arranged in two TMAs in which IHQ and FISH were performed for EGFR. In our approach, IHQ was held on automated Benchmark? Platform (Ventana Medical Systems) using the Zymed 31G7 mouse monoclonal antibody diluted 1:20, being this dilution previously standardized on whole slides of vulvar carcinomas. The absolute intensity of EGFR immunostaining was performed on a fourpoint scale as suggested by several authors [2,3,4] in vulvar carcinomas: (0=negative, 1=weakly positive, 2=positive, 3=strongly positive). In the same way of the study of Woelber and colleagues[1], we used FISH probes ZytoLight SPEC EGFR/CEN 7 Dual Color Probe (ZytoVision?) and the analysis were also performed as Woelber et al[1]. In order to analyze the relationship between the results obtained from IHC and FISH, associations between these data and histopathological features from the classification of the tumors (such as histological type, vascular and perineural invasion among others) and clinical data (such as recurrence, death by cancer and lymph node involvement), obtained from the clinical records of all the 139 patients were performed using the Chi-square test (X2) adopting p<0,05 as significant level. Regarding the amplification of EGFR gene, our results showed a lower rate of amplification (5 out of 78 cases - 6.4%) than those data raised by Woelber et al.[1] - 9%; and Growdon et al. (2008)[4] - 11,7%. Similarly, our IHQ analysis demonstrated only 3.9% of overexpression (3+) among our cases, which is contradictory to previous findings that reported an overexpression of 41-68% for this receptor [1,2,3]. Regarding the correlation between protein expression and amplification, among our cases, all tumors exhibiting amplification demonstrated an intense 3+ immunostaining by IHC, demonstrating a 100%correlation between FISH and IHC. These results corroborate the findings of Growdon et al. (2008) [4] to the observation that all tumors with intense 3+ expression of this receptor exhibited EGFR amplification and contradicts Woelber et al. [1] findings, regarding the occurrence of 20 vulvar carcinomas with EGFR copy number increase (including tumors with high polysomy or amplification) exhibiting low or intermediate levels of EGFR expression (scores 0, 1+ or 2+). Moreover, contrary to Woelber et al[1] study , our results showed no correlation between EGFR expression and the clinical and pathological features evaluated. The only association observed was statistically marginal and was related to FIGO staging, in which the most part of tumors stained negative for EGFR on the membrane (scores 0 and 1+) were classified as FIGO I or II, while the tumors EGFR positive (scores 2+ and 3+) were FIGO III or IV (p=0.08) which, as mentioned by Woelber et al.(2012)[1], may underline the influence of EGFR on tumor progression. Regarding the lack of association between EGFR expression and the clinical and pathological features evaluated, we attribute this result to the great heterogeneity of the intensity of immunostaining for EGFR observed in our cases, also described by Brustmann (2007) [2]. This heterogeneity leads us to believe that TMAs may not be useful for analyzing EGFR amplification in vulvar carcinomas. Anyway, it seems unanimous in the literature and among our results the fact that EGFR is, on greater or lesser extent, amplified in vulvar carcinomas and its overexpression could benefit a small group of patients with the therapy against this tyrosine kinase receptor and that more studies, regarding clinical trials, are required to elucidate this field.

    References: [1] Woelber L, Hess S, Bohlken H et al. EGFR gene copy number increase in vulvar carcinomas is linked with poor clinical outcome. J Clin Pathol. 2012 Feb;65(2):133-9.

    [2] Brustmann, H. Epidermal growth factor receptor is involved in the development of an invasive phenotype in vulvar squamous lesions, but is not related to MIB-1 immunoreactivity. Int J Gynecol Pathol. 2007;26(4):481-89.

    [3] Oonk MH, de Bock GH, van der Veen DJ, Ten Hoor KA, de Hullu JA, Hollema H et al. EGFR expression is associated with groin node metastases in vulvar cancer, but does not improve their prediction. Gynecol Oncol 2007.104(1):109-13.

    [4] Growdon WB, Boisvert SL, Akhavanfard S, Oliva E, Dias-Santagata DC, Kojiro S et al. Decreased survival in EGFR gene amplified vulvar carcinoma. Gynecol Oncol 2008.111(2):289-97.

    Conflict of Interest:

    None declared

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  8. Enhanced Biomedical Scientist roles - experiences from Southampton

    Dear Editor,

    We read this article with great interest and would like to share our own similar experiences in support of this growing evidence base. Our department has the added complexity of being one of the UK ST1 training schools, with between ten and fifteen ST1 - ST5 trainees per year. We have trained and developed a senior Biomedical Scientist (BMS) in all specimen dissections who has gained the RCPath Diploma of Expert Practice in Histological Dissection and been appointed as an Advanced Practitioner (AP). This post covers all surgical specialties, and the AP currently dissects the majority of specimens, both simple and complex, as and when appropriate knowledge and experience has been gained. In terms of colorectal specimens, all types are dissected by the AP, including Extralevator Abdomino-Perineal Excision (ELAPE) specimens where the levator ani and/or coccyx are also resected.


    In terms of macroscopic assessment we follow a similar defined protocol to that of Sanders et al, with triage of each colorectal cancer specimen before dissection. Included in this discussion is most appropriate block selection. This process occurs for both the AP and the trainees, with the AP following the same pathway as that of the trainees. The AP and trainee take similar numbers of blocks, as appropriate to the case, in keeping with the departmental protocol (at least four blocks required). A macroscopic proforma is used to record data items during dissection. This is used by all staff, regardless of grade, and is seen as a method of ensuring that the minimum data items are recorded. Evidence has shown there to be more chance of identifying extramural vascular invasion (EVI) where additional tumour blocks are sampled [1]. In the study by Sanders et al it would be interesting to know how often EVI was identified where additional tumour blocks were taken by the BMS, as this may not be an appropriate criticism of practice.


    We recently performed an audit to assess lymph node harvesting. This showed the average lymph node harvest of the AP was twenty-five percent higher that that of her histopathologist colleagues (consultant and trainee) (20 vs 15). All staff groups achieve the RCPath requirement of a harvest of twelve lymph nodes per case [2]. These findings were statistically significant (p=<0.001) and were presented at a national meeting [3]. The AP was less likely to perform resampling for additional lymph nodes (8.1% vs 16.6%). This was attributed to the level of training and experience of the AP in comparison to some trainee pathologists. In Sanders et al study the mean numbers of lymph nodes harvested by medical staff are similar to our own, but those harvested by the BMS are lower. This may be related to the experience of the BMS, as a similar decrease is seen with the least experienced trainees in our laboratory. Time spent on dissection may be a factor as our AP takes on average forty-five to sixty minutes per case.


    As part of the Histopathology team our AP routinely reviews the slides generated from her colorectal cancer dissections. Reports are generated using a microscopic minimum dataset proforma and a paper copy of this is initially completed by the AP for joint review with the consultant before generation of the final report and authorisation by the consultant. This pathway is identical to that of the trainees within our department.

    Development of scientific staff

    Our AP has a specific interest in gastrointestinal pathology and is currently leading a research study around colorectal cancer diagnostics as part of a Professional Doctorate in Biomedical Science. This follows the Modernising Scientific Careers (MSC) programme which aims to provide the most appropriate developmental opportunities to high achieving scientists in their field [4]. Achieving the RCPath Specialist Diploma in lower gastrointestinal histopathology is also a current aim for our AP. To improve the knowledge base surrounding colorectal cancer management, she also regularly attends the local colorectal cancer multidisciplinary team meeting with one of the specialist consultants. This has the additional benefits in that it publicises the role of the AP within the team, and also provides an essential feedback mechanism on her performance. We feel that the performance of the AP is similar to that of an experienced registrar, and that she should be treated in the same way.


    The benefits to us are multiple. Consultant histopathologists benefit from more time to perform other important duties and the ability to delegate dissection training where appropriate. We would argue that in many cases reporting is quicker with the AP than with a trainee, as specimens are less likely to require resampling. Trainee histopathologists benefit from the additional dissection training, supervision and an additional source of advice. Due to the protocol driven nature of the AP's practice, she is able to provide the trainees with examples of agreed best practice within the department. APs benefit from career development which was previously unavailable, with the potential of eventual consultant healthcare scientist status when at doctoral level and with appropriate experience [4]. Patients benefit from the knowledge that dissection practice is standardised and that they are receiving the correct treatment based on appropriate staging.

    In conclusion, we feel that there is an important clinical role for scientists within the histopathology team. Rather than simply working on the laboratory based aspects of the service, high achievers within this staff group should be utilised more appropriately. This may be in specimen dissection and microscopy, but could equally be within immunohistochemistry or molecular pathology. We agree that the evidence base needs to be improved in order to support further development within this area.

    Conflict of Interest:

    None declared

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    In defining underlying causes of pulmonary granulomatous inflammation in their study population(s), Mukhopadhyay et al[1] correctly list immunodeficiency disorders as one possible association. They define a causal link between pathologist-observed granulomata and immune deficit where the latter has been already been identified clinically in individual patients. However, granulomatous disease can be a presenting feature of underlying, unsuspected immune deficiency, particularly in the context of some primary antibody deficiency disorders. The relationship of granulomatous inflammation in a biopsy and immunodeficiency needs to be considered beyond the simple circumstance of a patient with a previously defined immune deficit, in particular in the context of a) granulomatous disease with an alternative diagnostic label (e.g. sarcoidosis) and b) granulomatous disease of unknown aetiology. Awareness of the association of granulomata and immune deficiency is important, whether in the context of a geographically high incidence of sarcoidosis as a cause of pulmonary granulomata or of a high rate of no underlying aetiological factor being identified. Although relatively rare, primary immunodeficiency is an important issue for clinicians caring for patients with granulomatous disease to consider, identify, classify, risk assess and optimally manage.

    Anecdotal local experience in the North of Scotland demonstrates that occasional 'sarcoid' patients (not included in the population studied by Mukhopadhyay et al) with pulmonary or extrapulmonary granulomatous inflammation are ultimately shown to have a primary immunodeficiency disorder (most frequently one of the common variable immune deficiency group of diseases, CVID[2]) but only after significant diagnostic delay. Such delay in these circumstances is relatively commonplace and is frequently associated with either overt or insidious secondary disease complications (usually pulmonary) which may be prevented or retarded by early immunoglobulin replacement and/or immunomodulatory treatment. Subtle histological differences have been described in the granulomata of sarcoid and CVID[3]. Granulomatous disease (particularly with splenic involvement), recurrent infections, cytopaenias and hypogammaglobulinaemia (rather than the hypergammaglobulinaemia of sarcoid) are, collectively, indicators of significant immune dysregulation and should prompt consideration of CVID as a potentially unifying diagnosis. Clinicians should consider routine measurement of serum immunoglobulins in granulomatous disease of unknown aetiology and as part of the diagnostic work-up in sarcoidosis. Similar recommendations, for similar reasons, have recently been made in the context of non-cystic fibrosis bronchiectasis[4]. Albeit relatively rarely, proactive detection of underlying immune deficiency as a cause of granulomatous inflammation will aid earlier diagnosis in conditions like CVID, allow more definitive and accurate aetiological classification of some cases at the clinician:pathologist interface and, not incidentally, will enhance opportunities for improvements in morbidity, mortality and quality of life for this group of complex patients.


    1. Mukhopadhyay S, Farver CF, Vaszar LT, et al. Causes of pulmonary granulomas: a retrospective study of 500 cases from seven countries. J Clin Pathol 2012; 65: 51-7

    2. Morimoto Y, Routes JM. Granulomatous disease in common variable immunodeficiency. Curr Allergy Asthma Rep 2005; 5: 370-5

    3. Bates CA, Ellison MC, Lynch DA et al. Granulomatous-lymphocytic lung disease shortens survival in common variable immunodeficiency. J Allergy Clin Immunol 2004; 114: 415-21

    4. Pasteur MC, Bilton D, Hill AT. British Thoracic Society guideline for non-CF bronchiectasis. Thorax 2010; 65: i1-58

    Conflict of Interest:

    None declared

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  10. Expression of NCAM may be associated with the immune response against well differentiated thyroid carcinoma.

    Dear Editor,

    A very important issue was assessed by Yang et al in their outstanding study recently published by this journal1. As pointed out by the authors, distant metastasis is the most preoccupant complication of differentiated thyroid carcinoma (DTC) and a very anguishing therapeutic challenge for the attending physician. A series of studies have been trying to establish a molecular pattern able to predict more aggressive follicular cell behavior. One of the most promissory markers integrating this molecular pattern is the expression of neural cell adhesion molecules (NCAM).

    Yang et al studied a series of 365 surgical cases of thyroid disease - 214 DTC and 151 benign lesions. Immunohistochemistry showed that most benign lesions presented NCAM expression, whereas a significant proportion of DTC lost completely or showed a reduced NCAM expression, which confirms previous results suggesting that NCAM could be a diagnostic marker of DTC 2. We also studied NCAM expression in a series of 527 surgical cases of thyroid tissues - 395 DTC (343 papillary thyroid carcinomas and 52 follicular carcinomas) and 132 nonmalignant thyroid tissues (18 normal thyroids, 58 goiters and 56 adenomas). One hundred fifty-three of our patients presented metastasis at diagnostic and 58 developed distant metastasis during a follow-up of 12-298 months (43.50?33.29 months), Mo=21 months. NCAM expression was evaluated by immunohistochemistry and the same technique used by Yang et al, but with anti-NCAM monoclonal 123C3 clone antibody (DAKO- Carpenteria, CA, USA). We also considered NCAM positive those cases with NCAM expression in more than 30% of tumor cells. Fisher's exact test showed total loss or reduction of NCAM expression in 74.65% of DTC cases, while a significant portion (52.73%) of benign lesions were positive for NCAM (p< 0.0001). However, NCAM expression was not able to predict malignancy due to low sensibility (25.35%) and low specificity (47.27%), suggesting that NCAM alone is not a useful diagnostic marker.

    In addition, Yang et al found that persistent NCAM expression in DTC is associated with a higher rate of metastasis. In our cohort, NCAM expression was not correlated with the presence of metastasis at diagnosis (p=0.4506), neither to tumor size (p=0.3814) nor to extrathyroid invasion (p=0.9855), multifocality (p=0.2747) or pTNM stage (p=0.6928). A log-rank test failed to show NCAM expression as a prognostic marker of relapse-free survival (p=0.8846). Nevertheless, NCAM positivity was more frequent in encapsulated tumors (37.78%) than in nonencapsulated tumors (20.62%; p=0.0399), suggesting that the peritumoral fibrotic reaction is associated with NCAM expression. In fact, 51.11% of our NCAM positive cases presented concurrent chronic lymphocytic thyroiditis (CLT), while only 25.89% of NCAM negative cases presented concurrent CLT (p=0.0045). We also evaluated the presence of tumor infiltrating lymphocytes (TIL) in DTC specimens by a routine HE staining. We found that NCAM expression was associated with the presence of TIL (p=0.0427). In order to distinguish TIL subsets, we performed immunohistochemical analysis using classical immune cell markers. We observed that NCAM expression was associated with the presence of CD4+ lymphocytes (p=0.0477), CD8+ lymphocytes (p=0.0015), CD20+ lymphocytes (p=0.0284) and FoxP3+ lymphocytes (p=0.0024). Interestingly, most NCAM negative cases (80.10%) were also negative for sodium/iodine symporter (NIS) protein immunohistochemical expression, whereas 71.43% of NCAM positive cases were positive for NIS as well (p< 0.0001), suggesting that NCAM could boost immunogenicity in DTC. These results suggest that NCAM expression is engaged in the antitumor immune response. However, the outcome of patients is not modified by NCAM expression, perhaps because an appropriate management of DTC patient is the most important and modifiable prognostic factor, impeding the natural course of malignancy.

    The differences between Yang results and our data could be related to different population backgrounds, which are thought to affect antitumor immunity in DTC 3. Since the tumorigenic process is a complex biological system in which multiple molecular interactions may occur, minimum genetic differences in populations might affect dramatically the obtained results. An antitumor effect of NCAM may be expected in cases presenting genetic background that facilitates antitumor immune defense 3-4. We also cannot exclude that the different antibody used may lead to different results. In addition, it is worthy noting that NCAM may be engaged in pleiotropic functions in tumor progression, making the interpretation of NCAM expression a difficult task. More studies are warranted to understand the functional biologic role of NCAM expression in DTC tumors. Unfortunately, our data do not support the conclusion of Yang et al that NCAM expression in well differentiated thyroid carcinoma is an indicator for a higher risk of distant metastasis.


    Lucas Leite Cunha1, Elaine Cristina Morari2, Suely Nonogaki3, Fernando Augusto Soares4, Jose Vassallo5, and Laura Sterian Ward1.

    1Laboratory of Cancer Molecular Genetics, Faculty of Medical Sciences - University of Campinas (Unicamp). 126 Tessalia Vieira de Camargo Street, Campinas, SP, Brazil.

    2Department of biological sciences and health- State University of Roraima. 231, Sete de Setembro Street, Boa Vista, Roraima, Brazil.

    3. Adolfo Lutz Institute. 355, Doutor Arnaldo Avenue, S?o Paulo, Brazil.

    4Department of Pathology, A. C. Camargo Cancer Hospital. 211 Antonio Prudente Street, S?o Paulo, SP, Brazil.

    5Laboratory of Investigative and Molecular Pathology (Ciped), Faculty of Medical Sciences - University of Campinas (Unicamp). 126, Tessalia Vieira de Camargo Street, Campinas, SP, Brazil.


    1. Yang AH, Chen JY, Lee CH. Expression of NCAM and OCIAD1 in well- differentiated thyroid carcinoma: correlation with the risk of distant metastasis. J Clin Pathol 2011;

    2. El Demellawy D, Nasr AL, Babay S, Alowami S. Diagnostic utility of CD56 immunohistochemistry in papillary carcinoma of the thyroid. Pathol Res Pract 2009;205:303-9.

    3. Cunha LL, Tincani AJ, Assumpcao LV, Soares FA, Vassallo J, Ward LS. Interleukin-10 but not interleukin-18 may be associated with the immune response against well-differentiated thyroid cancer. Clinics (Sao Paulo) 2011;66:1203-8.

    4. Scarpino S, Di Napoli A, Melotti F, Talerico C, Cancrini A, Ruco L. Papillary carcinoma of the thyroid: low expression of NCAM (CD56) is associated with downregulation of VEGF-D production by tumour cells. J Pathol 2007;212:411-9.

    Conflict of Interest:

    None declared

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