Ancillary Diagnostic Techniques Research Articles

Evaluation of the diagnostic value of transcranial electrical stimulation (TES) to assess neuronal functional integrity in horses.

To evaluate the ability of the TES technique to assess neuronal functional integrity in ataxic horses by recording TES-induced muscular evoked potentials (MEPs) in three different muscles and to structurally involve multiple ancillary diagnostic techniques, such as clinical neurological examination, plain radiography (RX) with ratio assessment, contrast myelography, and post-mortem gross and histopathological examination. Nine ataxic horses, showing combined fore and hindlimb ataxia (grades 2-4), were involved, together with 12 healthy horses. TES-induced MEPs were recorded bilaterally at the level of the trapezius (TR), the extensor carpi radialis (ECR), and tibialis cranialis (TC) muscles. Two Board-certified radiologists evaluated intra- and inter-sagittal diameter ratios on RX, reductions of dorsal contrast columns, and dural diameters (range skull-T1). Post-mortem gross pathological and segmental histopathological examination was also performed by a Board-certified pathologist. TES-MEP latencies were significantly prolonged in both ECR and TC in all ataxic horses as opposed to the healthy horses. The TR showed a mixed pattern of normal and prolonged latency times. TES-MEP amplitudes were the least discriminative between healthy and ataxic horses. Youden's cutoff latencies for ataxic horses were 24.6 ms for the ECR and 45.5 ms for the TC (sensitivity and specificity of 100%). For healthy horses, maximum latency values were 22 and 37 ms, respectively. RX revealed spinal cord compression in 8 out of 9 involved ataxic horses with positive predictive values of 0-100%. All ataxic horses showed multi-segmental Wallerian degeneration. All pathological changes recorded in the white matter of the spinal cord were widely dispersed across all cervical segments, whereas gray matter damage was more localized at the specific segmental level. TES-MEP latencies are highly sensitive to detect impairment of spinal cord motor functions for mild-to-severe ataxia (grades 2-4).

Trigeminal‐mediated headshaking: A diagnostic challenge

Trigeminal‐mediated headshaking: A diagnostic challenge

Gestational trophoblastic disease- rare, sometimes dramatic, and what we know so far.

Gestational trophoblastic disease (GTD) is a heterogeneous group of lesions that are characterized by the abnormal proliferation of the trophoblast. Morphology, behavior and clinical significance vary tremendously and range from benign, non-neoplastic lesions that cause sometimes dysfunctional uterine bleeding to aggressive, highly, malignant tumors. The recently updated 2020 World Health Organization (WHO) Classification of Female Genital Tumors divides GTD in molar pregnancies/ hydatidiform moles, gestational trophoblastic neoplasms, tumor-like lesions and abnormal (nonmolar) villous lesions. In this article we review the typical clinical presentations of GTDs, their histopathologic features, contributing immunohistochemical stains and current diagnostic criteria. We discuss novel insights in the proposed pathogenesis, newly proposed entities and advances in ancillary diagnostic techniques and their relevance to the histopathologic diagnosis of GTD. Additionally we briefly review current treatment options, prognosis and prognostic factors of GTDs.

Colorectal adenocarcinoma with enteroblastic differentiation: diagnostic challenges of a rare case encountered in clinical practice

Colorectal adenocarcinoma with enteroblastic differentiation (CAED) is a rare subtype of colonic adenocarcinoma characterized by increased α-fetoprotein (AFP) production and the expression of at least one enteroblastic marker including AFP, glypican 3 (GPC3), or Spalt like transcription factor 4 (SALL4). We report a case of a 26-year-old female who presented with low back pain and constipation which persisted despite supportive measures. Imaging revealed multiple liver lesions and enlarged retroperitoneal nodes. Tumor markers including AFP were markedly elevated. On biopsy, samples from the liver revealed infiltrating glands lined by columnar-type epithelium with mostly eosinophilic granular to focally clear cytoplasm. By immunohistochemistry, the tumor showed immunoreactivity with AFP, hepatocyte antigen, GPC3, SALL4, CDX2, SATB2, and cytokeratin 20. A colonoscopy performed subsequently revealed a mass in the sigmoid colon and biopsy of this mass revealed a similar histology as that seen in the liver. A diagnosis of CAED was made, following the results of gene expression profiling by the tumor with next-generation sequencing which identified pathogenic variants in MUTYH, TP53, and KDM6A genes and therefore supported its colonic origin. Cases such as this underscores the use of ancillary diagnostic techniques in arriving at the correct diagnosis in lesions with overlapping clinicopathologic characteristics.

The Combined Utility of HBME-1 and Galectin-3 Immunohistochemistry and BRAF V600E Mutations in the Diagnosis of Papillary Thyroid Carcinoma.

Newer diagnostic modalities have revolutionized the pathologist’s approach to diagnosing thyroid malignancies. Molecular characterization of these malignancies has helped circumvent common morphologic diagnostic difficulties by integrating their genotypic, phenotypic, and immunohistochemical features. BRAF V600E mutation has been characterized as highly specific for thyroid carcinoma, especially papillary thyroid carcinoma (PTC); human bone marrow endothelial marker-1 (HBME-1) and galectin-3 are also such markers that are highly specific for PTC. We propose to study HBME-1 and galectin-3 expression and BRAF V600E mutation in thyroid neoplasms and do a comparative analysis to determine whether there is a correlation between BRAF V600E expression and that of HBME-1 and galectin-3. We further propose to analyze the individual and combined diagnosed utility of the above-mentioned ancillary diagnostic techniques.

A novel next generation sequencing approach to improve sarcoma diagnosis.

Sarcoma is a rare disease affecting both bone and connective tissue and with over 100 pathologic entities, differential diagnosis can be difficult. Complementing immune-histological diagnosis with current ancillary diagnostic techniques, including FISH and RT-PCR, can lead to inconclusive results in a significant number of cases. We describe here the design and validation of a novel sequencing tool to improve sarcoma diagnosis. A NGS DNA capture panel containing probes for 87 fusion genes and 7 genes with frequent copy number changes was designed and optimized. A cohort of 113 DNA samples extracted from soft-tissue and bone sarcoma FFPE material with clinical FISH and/or RT-PCR results positive for either a translocation or gene amplification was used for validation of the NGS method. Sarcoma-specific translocations or gene amplifications were confirmed in 110 out of 113 cases using FISH and/or RT-PCR as gold-standard. MDM2/CDK4 amplification and a total of 25 distinct fusion genes were identified in this cohort of patients using the NGS approach. Overall, the sensitivity of the NGS panel is 97% with a specificity of 100 and 0% failure rate. Targeted NGS appears to be a feasible and cost-effective approach to improve sarcoma subtype diagnosis with the ability to screen for a wide range of genetic aberrations in one test.

Case Report: Massive epistaxis from juvenile angiofibroma in an adolescent with severe haemophilia A

Epistaxis may be profuse in individuals with normal bleeding parameters, but in an individual with haemophilia, it may be life-threatening. It is even more dangerous when epistaxis is caused by an undetected concomitant juvenile angiofibroma, and only one such case has been reported in the English literature. We report another case, of an 18-year-old Filipino adolescent with severe haemophilia A who was referred for repeated massive epistaxis. The epistaxis had been attributed to his haemophilia and managed with nasal packing, multiple blood transfusions and Factor VIII administration. After two years of unsuccessful management, nasal endoscopy was performed for the first time, revealing an intranasal mass. Imaging showed a right intranasal vascular tumour supplied mainly by the right sphenopalatine artery. He subsequently underwent preoperative embolization and endoscopic excision of the tumour with Factor VIII transfused pre-, intra-, and post-operatively, and recombinant Factor VII added post-operatively. Final histopathology was consistent with juvenile angiofibroma. There has been no nasal obstruction or recurrence of epistaxis seven years since the surgery. Clinicians should be more meticulous in assessing epistaxis in any patient with a bleeding disorder and investigate more subtle symptoms such as nasal obstruction. Verification of the source by direct visualization and ancillary diagnostic techniques (such as imaging) when indicated should be the standard of care for all patients presenting with epistaxis, whether or not a concomitant bleeding disorder exists. A high index of suspicion for juvenile angiofibroma should be maintained in adolescent males with epistaxis and nasal obstruction.

Histopathology findings of chronic liver diseases in pediatric age group

Objectives: Early and accurate diagnosis of Chronic liver diseases (CLD) in children is very important as it is associated with major cause of mortality and morbidity. Though, nowadays most advanced and ancillary diagnostic techniques are available, Liver biopsy still plays a very important role in diagnosis of chronic liver diseases in children. The present study is aimed to study the role of liver biopsy in diagnosis of various chronic liver diseases in children and to evaluate the histopathologic findings of various liver and hepatobiliary diseases in children. Materials and Methods: This was a prospective study carried out in a large teaching hospital. Total 55 children in pediatric age group (1-12yrs) who presented with chronic liver disease were subjected to liver biopsy. Relevant investigations were done. The procedure was carried out under all aseptic condition after obtaining a written informed consent of the patient’s parents. The liver biopsy procedure was done through two approaches one percutaneous and second is transjugular approach. The second approach was used in patients with deranged PT/PI, to avoid the risk of internal bleeding. The biopsy piece was collected in formalin and sent to histopathology for analysis. An expert pathologist was identified for the study of these biopsy pieces. The biopsy findings were evaluated. Results: In our study the incidence of CLD was high in 6-12 yr of age group (34.34%) with a male predominance (60%). In our study the most common presenting complaint was jaundice and abdominal distension (38.18%) followed by jaundice alone (34.54%). Liver biopsy demonstrated various histopathological abnormalities like inflammation (80%) followed by ballooning of hepatocytes (74.54%). Other findings included cholestasis /necrosis/fibrosis/glycogenation/special stains positivity/cirrhosis. The incidence of cirrhosis on liver biopsy was41.81%.We diagnosed maximum cases of Wilson’s disease 12 out of which 9 patients had cirrhos

Genomic Landscape of Spitzoid Neoplasms Impacting Patient Management.

Spitzoid neoplasms are a distinct group of melanocytic proliferations characterized by epithelioid and/ or spindle shaped melanocytes. Intermediate forms that share features of both benign Spitz nevi (SN) and Spitz melanoma, i.e., malignant Spitz tumor (MST) represent a diagnostically and clinically challenging group of melanocytic lesions. A multitude of descriptive diagnostic terms exist for these ambiguous lesions with atypical Spitz tumor (AST) or Spitz tumor of uncertain malignant potential (STUMP) just naming two of them. This diagnostic gray zone creates confusion and high insecurity in clinicians and in patients. Biological behavior and clinical course of this intermediate group still remains largely unknown, often leading to difficulties with uncertainties in clinical management and prognosis. Consequently, a better stratification of Spitzoid neoplasms in benign and malignant forms is required thereby keeping the diagnostic group of AST/STUMP as small as possible. Ancillary diagnostic techniques such as immunohistochemistry, comparative genomic hybridization, fluorescence in situ hybridization, next generation sequencing, micro RNA and mRNA analysis as well as mass spectrometry imaging offer new opportunities for the distinct diagnosis, thereby allowing the best clinical management of Spitzoid neoplasms. This review gives an overview on these additional diagnostic techniques and the recent developments in the field of molecular genetic alterations in Spitzoid neoplasms. We also discuss how the recent findings might facilitate the diagnosis and stratification of atypical Spitzoid neoplasms and how these findings will impact the diagnostic work up as well as patient management. We suggest a stepwise implementation of ancillary diagnostic techniques thereby integrating immunohistochemistry and molecular pathology findings in the diagnosis of challenging ambiguous Spitzoid neoplasms. Finally, we will give an outlook on pending future research objectives in the field of Spitzoid melanocytic lesions.

Finding the herd problem in the single case

Economic realities and need for improved efficiency have required a shift in large animal veterinary practice towards more population-level consultation, with veterinarians spending less of their time treating individual animals. The population, however, is comprised of individuals who provide valuable information about the state of the herd. When presented with the individual animal who is demonstrating overt disease or poor production, the veterinarian has an opportunity to scale-up their impact by using the information obtained from the individual to benefit the herd. Veterinarians should develop a full-service mindset, which includes obtaining a definitive diagnosis through thorough history-taking, physical examination, ancillary diagnostic techniques, and premise visits. Written reports which include stepwise and attainable recommendations are used to improve communication and provide clarity regarding expectations for both the producer and the veterinarian. Follow up calls and visits demonstrate genuine concern on the part of the veterinarian for their client's success, and are an invaluable learning opportunity for the veterinarian. Professional growth for the veterinarian includes learning what works and what doesn't in a given situation. Subsequent herds under the care of a veterinarian practicing the 'no news is good news' approach fail to receive the full benefit of a veterinarian who has disciplined him or herself to follow through on every case. Veterinarians have an opportunity to become indispensable to their clients by channeling every piece of data that may be obtained from the individual to benefit the health and welfare of the herd.

Reader response: The neurologic exam: Is it extinct?

Is the neurologic examination becoming extinct?1 Possibly. There are not many formal teaching conferences dedicated exclusively to this topic in neurology residency training programs. Books describe examinations that would take hours to perform. To be useful, an examination has to be brief but sensitive to neurologic disease. Its interpretation has to be based in an adequate knowledge of neuroanatomy,2 which makes our specialty somewhat daunting but also enjoyable. Having recently edited 2 neuroimaging volumes,3 I cannot be accused of lack of interest in ancillary diagnostic techniques. However, even more than when I began to practice clinical neurology 44 years ago, before the CT and MRI era, I find the history and the physical examination essential to orient my ordering of ancillary procedures and to interpret their results.

Identification of infectious organisms in cytopathology: A review of ancillary diagnostic techniques.

Cytology samples obtained from exfoliative sources and fine-needle aspiration (FNA) procedures can all be used to detect microorganisms and/or the associated cytopathologic effects (CPE) caused by an infection. There are many advantages to utilizing cytology samples as an adjunct to routine microbiology laboratory methods. For example, cytology samples can be obtained by non-invasive and minimally invasive techniques, and interpretation is affordable, accurate, and fast. Furthermore, routine cytology stains, including the Papanicolaou (Pap) and the Diff-Quik (DQ) stains, can adequately identify a number of microorganisms. Finally, material obtained by these procedures can also be used for cytologic ancillary testing, microbiology culture, and molecular studies. Currently, there are a variety of ancillary diagnostic techniques that are routinely utilized in the cytopathology laboratory. Additionally, the increasing utilization of molecular-based, diagnostic techniques on fluid specimens, as well as FFPE material, is expanding the role of cytopathology for infectious disease diagnostics. In this review, we provide an overview of the most practical ancillary techniques commonly used to identify microorganisms on cytology specimens.

Primary Intraprostatic Synovial Sarcoma.

Primary intraprostatic synovial sarcoma is a rare presentation of an otherwise well-studied disease, and it is one of the few primary sarcomas to occur in the prostate. Ancillary diagnostic techniques including immunohistochemistry and molecular genetics are useful to establish a definitive diagnosis. Despite its unorthodox location, it shares histologic and molecular genetic characteristics with tumors found elsewhere in the body. Most notably, the chromosomal translocation t(X;18)(p11;q11) encodes a chimeric transcription-activating protein, SS18-SSX, which has been identified as the primary driver mutation. The SS18-SSX fusion gene provides a consistent and dependable means of establishing a definitive diagnosis via reverse transcription-polymerase chain reaction or fluorescence in situ hybridization. Recent studies have continued to provide insight into the oncogenesis of this disease. The goal of this review is to elaborate on the clinicopathologic characteristics and underline those techniques that best facilitate the diagnosis of primary intraprostatic synovial sarcoma.

Vortex-dislodged cells from bone marrow trephine biopsy yield satisfactory results for flow cytometric immunophenotyping.

A good bone marrow (BM) sample is essential in evaluating many hematologic disorders. An unsuccessful BM aspiration (BMA) procedure precludes a successful flow cytometric immunophenotyping (FCI) in most hematologic malignancies. Apart from FCI, most ancillary diagnostic techniques in hematology are less informative. We describe the feasibility of FCI in vortex-dislodged cell preparation obtained from unfixed trephine biopsy (TB) specimens. In pancytopenic patients and dry tap cases, routine diagnostic BMA and TB samples were complemented by additional trephine biopsies. These supplementary cores were immediately transferred into sterile tubes filled with phosphate-buffered saline, vortexed, and centrifuged. The cell pellet obtained was used for flow cytometric immunophenotyping. Of 7955 BMAs performed in 42 months, 34 dry tap cases were eligible for the study. Vortexing rendered a cell pellet in 94% of the cases (32 of 34), and FCI rendered a rapid diagnosis in 100% of the cases (32 of 32) where cell pellets were available. We describe an efficient procedure which could be effectively utilized in resource-limited centers and reduce the frequency of repeat BMA procedures.

Exploring salivary duct carcinoma: clinicopathologic features, morphologic spectrum and genetic changes

Background Salivary duct carcinoma (SDCa) has been slow in gaining recognition. Awareness, high index of suspicion and clinicopathological correlation are essential for accurate diagnosis. Genetic changes like HER2 amplification and BRAF mutation are being explored in SDCa. Methods Salivary gland malignancies at Royal Prince Alfred Hospital and Sydney Head and Neck Cancer Institute (1989–2014) were reviewed to identify SDCa. Results 22 cases of SDCa were identified predominantly in men, age range 41–88 years, predominantly involved the parotid with size range 15–90 mm. Facial nerve deficit and cervical lymph node metastases were present in 21% and 71% of patients respectively, requiring salivary gland resection with neck dissection. Histologically, the tumours resembled high-grade invasive and in-situ ductal carcinoma of breast. Micropapillary, rhabdoid and mucinous variants were seen. HER2 was positive in 48% and BRAF (V600E) mutation present in 27%. Most patients received adjuvant radio- and chemotherapy. Ten patients died of disease within 6–33 months (median 13 months). Five patients developed local recurrence. Ten patients developed lung, bone, liver, axilla, mediastinal and brain metastases. Conclusion SDCa are aggressive malignancies with a large histopathologic spectrum including micropapillary and sacomatoid variants. HER2 amplification, BRAF mutation detectable by ancillary diagnostic techniques may provide therapeutic options requiring accurate diagnosis.

Application of the tissue transfer technique in veterinary cytopathology.

Limited availability of diagnostic cytopathologic material may preclude additional diagnostic techniques. Tissue transfer allows for preparation of additional slides from a single original slide. Information pertaining to the application of the tissue transfer technique in veterinary cytopathology is lacking. The objectives were to evaluate the application of the tissue transfer technique on Quick Dip-stained veterinary cytologic smears and to assess if a selection of histochemical and immunocytochemical stains, and PCR analyses could be performed on transferred material. Archived Quick Dip-stained canine lymph node aspirate smears from previously diagnosed lymphoma cases were utilized to validate and optimize the tissue transfer technique. In this technique, diagnostic material is lifted from the original stained slide, is divided and transferred to multiple new slides. Histochemical stains such as Gram, periodic acid Schiff, Congo red, and Ziehl-Neelson, immunohistochemistry for CD3 and PAX5, and PCR for cryptococcal and mycobacterial organisms were selectively performed on transferred material. The tissue transfer technique was simple, and transferred Quick Dip-stained material retained cellular morphology. Histochemical and immunohistochemical stains, and PCR analysis yielded reliable results when performed on the additional smears produced by this technique. The tissue transfer technique was simple and easy to perform on previously Quick Dip-stained cytology smears. Cellular detail was preserved and multiple additional ancillary diagnostic techniques were facilitated, such as histochemical and immunohistochemical stains, and PCR analysis.

Ancillary Diagnostic Techniques in the Evaluation of Adult Epithelial Renal Neoplasms

The role played currently by the different ancillary diagnostic techniques in the diagnosis of adult epithelial renal tumors continues to be debated. It has also become clear that in some instances light microscopic appearance alone cannot be used to classify these neoplasms into specific categories with the degree of precision required for therapeutic purposes. Renal cell carcinoma (RCC) subtypes may share common histologic characteristics but exhibit different biological behavior and response to therapy which clearly indicates the crucial role that advanced pathologic speciation plays in the current assessment of these neoplasms. Although immunohistochemistry is widely used for the purpose of categorizing renal tumors because of its widespread availability, the immunoprofiles of the various types of renal neoplasms overlap significantly, making definitive diagnostic determinations difficult and challenging at times. This manuscript will address how ancillary diagnostic techniques can be incorporated into the routine evaluation of neoplastic renal masses to improve classification. Both cytology and surgical specimens will be addressed, as fine needle aspiration (FNA) is being used with preference in many cases in the diagnosis of renal masses. Surgical and cytopathologists must intelligently select the ancillary diagnostic technique/s that will provide the information needed to solve the differential diagnosis under consideration in a given case. However, in some cases >1 of these techniques should be used to make an accurate diagnosis with the aim of arriving at an unequivocal diagnosis. The identification of specific signaling pathways that are defective in certain types of renal neoplasms has made possible the design of target-specific therapies that are directed towards the aberrant pathways associated with the defective proteins found in these tumors. This makes the exact classification of these neoplasms and the detection of these aberrant proteins targeted for treatment an absolute requirement for the application of these molecular-based therapeutic interventions. The role that the pathologic assessment plays in the classification of renal tumors becomes more important than ever to take advantage of this and similar new molecular-oriented therapies.

Fourth branchial arch defect: a case study

Horses that present with abnormal upper respiratory noise at exercise can have a myriad of different laryngeal and pharyngeal structures collapsing into the airway, and exercising endoscopy provides the only way of providing a definitive diagnosis (or diagnoses in the case of composite collapse). However, a thorough clinical examination, endoscopic examination at rest and other ancillary diagnostic techniques can be very useful in some cases. This case study describes the clinical and endoscopic findings of a horse with suspected fourth branchial arch defect (4-BAD), a syndrome in which laryngeal palpation, radiography and ultrasound can all be very useful in addition to resting and exercising endoscopy when making a diagnosis.

Undifferentiated pleomorphic sarcoma with osteoclast-like giant cells of the female breast

The authors describe a case of undifferentiated pleomorphic sarcoma of the breast occurring in a 50-year-old woman who presented with a palpable mass in her right breast. She first noticed the mass one month previously. Core needle biopsy showed connective tissue including epithelioid and spindle cells. The patient underwent total mastectomy without axillary lymph node dissection. Based on examination of the excised tumor, the initial pathologic diagnosis was atypical spindle-shaped and ovoid cells with uncertain malignant potential. Histological findings with immunomarkers led to the final diagnosis of undifferentiated pleomorphic sarcoma.This case highlights a rare and interesting variant of primary breast sarcoma and the important role of immunohistochemistry in defining histological type and differential diagnosis. Hence, undifferentiated pleomorphic sarcoma has been a diagnosis of exclusion performed through sampling and critical use of ancillary diagnostic techniques.

Equine paranasal sinus disease: A long‐term study of 200 cases (1997–2009): Ancillary diagnostic findings and involvement of the various sinus compartments

There is a lack of objective information on the value of ancillary diagnostic techniques used to investigate equine sinus disease, and also on which sinus compartments are commonly affected in this disorder. To record the ancillary diagnostic findings used to investigate equine sinus disease and to document which compartments are affected. The clinical case records of 200 consecutive cases of sinus disease, including subacute (<2 months' duration) primary (n = 52); chronic (>2 months' duration) primary (n = 37); dental (n = 40); traumatic (n = 13); sinus cyst (n = 26); sinus neoplasia (n = 10); dental related oromaxillary fistula (n = 8); mycotic sinusitis (n = 7) and intra-sinus progressive ethmoid haematoma (n = 7) were retrospectively examined. Nasal endoscopy showed exudate draining from the sino-nasal ostia in 88% of cases and a sino-nasal fistula was present in 15% of cases. Sinoscopy was performed in 79% of cases and was of great diagnostic value. More recently, 22% of cases had fenestration of the ventral conchal bulla performed to allow sinoscopy of the rostral sinus compartments. Radiography was performed in 97% of cases and showed intra-sinus fluid lines to be common (69% prevalence) in subacute primary sinusitis. Radiographic dental apical changes were not specific to dental sinusitis, e.g. 29% of chronic primary sinusitis cases had radiographic dental changes. Scintigraphy was performed in 20% of cases and was helpful in identifying dental apical changes when radiography was inconclusive. Overall, the caudal maxillary (78% involvement) and rostral maxillary (61%) sinuses were most commonly affected, with the ventral conchal sinus (VCS) (54% involvement) and conchofrontal sinuses (48%) less so. The VCS showed the greatest tendency to contain inspissated pus (present in 46% of all affected VCS). Nasal endoscopy, sinoscopy and skull radiography are of great value in diagnosing the presence and causes of equine sinus disease.