Threshold For Biopsy Research Articles

SPECTRUM OF ORAL PREMALIGNANT AND MALIGNANT LESIONS IN FANCONI ANEMIA PATIENTS: DIAGNOSTIC AND MANAGEMENT CHALLENGES

Background Fanconi anemia (FA) is characterized by congenital anomalies, progressive bone marrow failure, and increased cancer risk. FA patients have a >300-fold increased risk of developing head and neck cancers, including oral squamous cell carcinoma (OSCC). Objective To describe the spectrum of premalignant/malignant oral lesions illustrating diagnostic and management challenges in patients with FA. Methods Five patients with FA seen regularly were selected. Oral lesions and management strategies were systematically documented over time. Results All 5 patients with FA (4 male; 1 female; median age 21) developed oral lesions without evidence of human papilloma virus or typical risk factors for OSCC. All patients had received previous hematopoietic cell transplantation. Three patients developed OSCC of the lateral tongue (n = 2) and gingiva (n = 1), preceded by rapidly progressing premalignant epithelial dysplasia. All 3 had previous history of graft-vs-host disease, a known risk factor in patients with FA. Patients with OSCC developed recurrent/new dysplastic lesions within 4 years following management of OSCC. The 2 patients with no OSCC showed premalignant epithelial dysplasia and verrucous hyperkeratosis of the tongue and palatal gingiva, respectively. One patient with OSCC also developed pharyngeal wall SCC and 2 separate basal cell carcinomas of the upper lip. Our current management strategies include frequent evaluation (monthly to every 3-6 months) with low tolerance and recommendation for biopsy of suspicious lesions. Conclusions Patients with FA develop premalignant lesions and OSCC at a younger age and higher rate than non-FA patients and require screening examinations for such lesions at least every 6 months. Lower biopsy thresholds and histologic evaluation are recommended. Fanconi anemia (FA) is characterized by congenital anomalies, progressive bone marrow failure, and increased cancer risk. FA patients have a >300-fold increased risk of developing head and neck cancers, including oral squamous cell carcinoma (OSCC). To describe the spectrum of premalignant/malignant oral lesions illustrating diagnostic and management challenges in patients with FA. Five patients with FA seen regularly were selected. Oral lesions and management strategies were systematically documented over time. All 5 patients with FA (4 male; 1 female; median age 21) developed oral lesions without evidence of human papilloma virus or typical risk factors for OSCC. All patients had received previous hematopoietic cell transplantation. Three patients developed OSCC of the lateral tongue (n = 2) and gingiva (n = 1), preceded by rapidly progressing premalignant epithelial dysplasia. All 3 had previous history of graft-vs-host disease, a known risk factor in patients with FA. Patients with OSCC developed recurrent/new dysplastic lesions within 4 years following management of OSCC. The 2 patients with no OSCC showed premalignant epithelial dysplasia and verrucous hyperkeratosis of the tongue and palatal gingiva, respectively. One patient with OSCC also developed pharyngeal wall SCC and 2 separate basal cell carcinomas of the upper lip. Our current management strategies include frequent evaluation (monthly to every 3-6 months) with low tolerance and recommendation for biopsy of suspicious lesions. Patients with FA develop premalignant lesions and OSCC at a younger age and higher rate than non-FA patients and require screening examinations for such lesions at least every 6 months. Lower biopsy thresholds and histologic evaluation are recommended.

Effects of Implementing a Higher Threshold for Recommending Thyroid Biopsies on Malignancy Rates.

We implemented a new thyroid nodule classification system in which a biopsy was recommended for thyroid lesions ≥ 1 cm with at least 2 or more suspicious features. Three consecutive years of thyroid biopsies using the new classification system were reviewed for patient demographics, biopsy recommendation based on nodule size and imaging characteristics, and pathology results. The primary outcome was malignancy rates for thyroid biopsies. These results were compared to a 3-year historical data set. Review of thyroid biopsies from 2010 to 2012, prior to the implementation of current recommendations, revealed 996 thyroid biopsies with a malignancy rate of 12.8%. Subsequent to the new classification system in 2017, 483 thyroid biopsies were performed over the next 3 years with a malignancy rate of 21.9%. Implementation of the new classification system with a higher threshold for biopsy reduced our yearly biopsy volume by approximately 50% while also increasing our malignancy rate from 12.8% to 21.9%, which is more in line with published rates of malignancy. In a community setting performing less than 200 biopsies per year, the use of more stringent requirements for thyroid biopsy are necessary to achieve malignancy rates comparable to the published literature.

Prospective validation of the Kaiser Permanente prostate cancer risk calculator in a contemporary, racially diverse, referral population

PurposeTo prospectively validate a new prostate cancer risk calculator in a racially diverse population. Materials and MethodsWe recently developed, internally validated and published the Kaiser Permanente Prostate Cancer Risk Calculator. This study is a prospective validation of the calculator in a separate, referral population over a 21-month period. All patients were tested with a uniform PSA assay and a standardized systematic, ultrasound-guided biopsy scheme. We report on 3 calculator models: Model 1 included age, race, PSA, prior biopsy status, body mass index, and family history of prostate cancer; Model 2 added digital rectal exam to Model 1 variables; Model 3 added prostate volume to Model 2 variables. We considered three outcomes: high-grade disease (Gleason score ≥7), low-grade disease (Gleason score=6), and no cancer. Predictive discrimination and calibration were calculated. How each model might alter biopsy frequency and outcomes at various thresholds of risk was assessed. We compared the performance of our calculator with two other calculators. ResultsIn 4178 patients (16.2% Asian, 11.3% African American, 13.5% Hispanic), cancer was found in 53%; 62% were Gleason score ≥7. Using a high-grade risk threshold for biopsy of ≥10%, Model 2 predictions would result in 9% of men avoiding a biopsy, while only missing 2% of high-grade cancers. At the same threshold, Model 3 predictions would result in 26% of men avoiding a biopsy, while only missing 5% of high-grade cancers. The c-statistics for Models 1, 2, and 3 to predict high-grade disease vs. low-grade or no cancer were 0.76, 0.79 and 0.85, respectively. The c-statistics for Models 1, 2, and 3 to predict any prostate cancer vs. no cancer were 0.70, 0.72 and 0.80, respectively. All models were well calibrated for all outcomes. Our Model 3 calculator had superior discrimination for high grade disease (c-statistic=0.85, 0.84-0.86) and any cancer (0.80, 0.79-0.82) compared to the PBCG calculator [(0.79, 0.78-0.80); 0.72 (0.70-0.73)] and the PCPT calculator [(0.75, 0.74-0.77); 0.69 (0.67-0.70)], respectively. In the high-grade cancer predicted risk range of 0-30%, our Model 2 was better calibrated than the PCPT and PBCG calculators. ConclusionsThis validation of our calculator showed excellent performance characteristics.

POS-357 SPECTRUM OF NON DIABETIC RENAL DISEASE IN T2DM

Diabetes mellitus is a major cause of kidney disease associated morbidity and mortality throughout the world. Diabetic nephropathy develops in one third of patients with diabetes and contributes to up to one third of all cases of end stage renal disease. Although diabetic nephropathy (DN) constitutes majority of patients of kidney disease in diabetics, non diabetic kidney (NDKD) disease is also responsible for sizeable number of cases. The aim of this study was to evaluate the renal biopsies performed on diabetic patients for suspicion of NDRD and to correlate pathological and clinical findings. Retrospective review of 180 biopsies performed in diabetics between 2014 to 2018 was done. Lesions were classified as isolated DN, isolated NDRD and NDRD superimposed on DN. Biopsy indications were presence of renal dysfunction defined as nephritic/nephrotic proteinuria or raised serum creatinine. Data examined included patient’s demographic data, clinical presentation; presence/ absence of retinopathy. Risk factors for NDKD were analyzed. Renal biopsy findings showed that 75% patients had isolated DN,22.77% had isolated NDKD, 2.22% had NDRD superimposed on top of DN. Females outnumbered males in those with NDRD. 55.55% (N =25) were females and 44.44% (n=20) were males. 53.3% (n=24) patients were in age group between 30 to 60 years, 17.77% (n=8) patients belonged to age group less than 30 years.28.8% (n=13) were greater than 60 years of age. 53.33% (n=24) had diabetes of less than 6 years duration, most common presentation in NDKD group was AKI (40%), followed by NS and RPRF with 22.2 and 17.7% respectively. Diabetic retinopathy was seen in 26.6% in isolated NDKD and NDKD with superimposed DN group. ATIN (20%) was the commonest histological diagnosis in NDKD, followed by IRGN and IgA nephropathy 20 and 17.77% respectively. Most common histopatholgical lesion in patients with diabetes with renal dysfunction is DN, but NDKD is not an uncommon diagnosis in diabetics. Duration of diabetes was less in NDKD patients ,those with NDKD belonged to a younger age group, sizable number of patients had retinopathy suggesting a low threshold for renal biopsy.

Optimizing biopsy procedures during colposcopy and detection of high-grade cervical lesions

Objective: To investigate the value of biopsies on diagnosing cervical intraepithelial neoplasia of grade 2 or worse (CIN Ⅱ+), and optimize biopsy procedures of risk-based colposcopy practice. Methods: A prospective study was performed on 346 women referred to colposcopy following abnormal cervical cancer screening results at the First Affiliated Hospital of Nanjing Medical University, from April 2017 to December 2019. Up to 4 cervical biopsies were taken during colposcopy and each biopsy specimen was evaluated separately in histology. CIN Ⅱ+ identified by any biopsy was the reference standard of disease used to evaluate the diagnostic value of targeted biopsy and random biopsy, and to quantify the improved detection of CIN Ⅱ+ by taking multiple biopsies. Cervical cytology, HPV genotyping, and colposcopic impression were used to establish different risk strata to select various multiple biopsies procedures during colposcopy to improve accuracy and efficiency of CIN Ⅱ+ detection. Results: In total 346 women, 190 (54.9%, 190/346) cases of them were diagnosed as CIN Ⅱ+. (1) In total 346 women, 96.8% (184/190) CIN Ⅱ+ were detected by targeted biopsies, 27.9% (53/190) CIN Ⅱ+ were detected in biopsies targeted grade 1 abnormal colposcopic findings (G1) on the cervix, and 68.9% (131/190) CIN Ⅱ+ were detected in biopsies targetrd grade 2 abnormal colposcopic findings (G2) on the cervix. Colposcopy had a sensitivity of 68.9% when the biopsy threshold was G2, sensitivity increased to 96.8% when the biopsy threshold was defined to be G1. Among women with G1, adding 2 targeted biopsies to the first biopsy were sufficient to detect all CIN Ⅱ+, among women with G2, adding 1 targeted biopsy was sufficient. (2) Among 270 women, random biopsies targeted normal colposcopic findings on the cervix were performed in addition to targeted biopsies and in total 3.2% (6/190) additional CIN Ⅱ+ were detected. As the number of cervical quadrants involved by abnormal colposcopic images increased, random biopsy detected fewer CIN Ⅱ+ that would have otherwise been missed by targeted biopsies (P=0.010). (3) Women with atypical squamous cells,cannot exclude high grade squamous intraepithelial lesion (ASC-H), high grade squamous intraepithelial lesion (HSIL) or atypical glandular cell (AGC) referral cytology, HPV 16-positive, G2 were more likely to have CIN Ⅱ+(P<0.01); for those meeting only one category, the yield of CIN Ⅱ+ increased from 34.0% for one biopsy to 51.0% for two biopsies, the absolute increase in CIN Ⅱ+ yield increased from the first to the second biopsy was 17.0%, two biopsies were sufficient to detect all CIN Ⅱ+; for those meeting at least two categories, the yield of CIN Ⅱ+ increased from 90.7% for one biopsy to 92.6% for two biopsies, the absolute increase in CIN Ⅱ+ yield increased from the first to the second biopsy was 1.9%, two biopsies were sufficient to detect all CIN Ⅱ+; for those not meeting any category, the yield of CIN Ⅱ+ increased from 8.8% for one biopsy to 17.6% for two biopsies, to 23.5% for three biopsies, the absolute increase in CIN Ⅱ+ yield increased from the first to the second biopsy, from the second to the third biopsy was 8.8%, 5.9%, three biopsies were sufficient to detect all CIN Ⅱ+. Conclusions: Performing multiple targeted biopsies could improve efficiency of CIN Ⅱ+ detection. Adding random biopsies to multiple targeted biopsies showed very limited additional benefit for detection of CIN Ⅱ+. The biopsy procedures undertaken during the colposcopy visit could be modified based on various colposcopic impressions and reasons for referral.

Heart Transplantation Single Center Experience of 63 Heart Transplantation Procedures Performed during the COVID 19 Pandemic

PurposeThe COVID19 (C19) pandemic has resulted in a significant reduction in cardiac surgical procedures worldwide and in particular heart (OHT) transplantations. This was primarly due to increased risk of C19 infection and severity in immunocompromised patients (pts). Donor aviability decreased steeply, as intensive care units are struggling with C19 patients. Yet, number of patients requiring OHT increased rapidly, comprising of individuals with dreadful complications of untreated acute coronary syndromes.MethodsBetween March and October 2020 63 pts underwent OHT. The age range was 21-65 yrs and a median of 52 yr. All patients were evaluated by a multidisciplinary heart failure team (MDT), and placed on the HT waiting list once eligible. Once a donor has been identified, clinical history and examination obtained, a chest CT was taken and real time RTPCR test is ordered. Every recipient was subject to clinical screening, chest XRay, real RTPCR (24 hrs within HT)upon admission. All pts were looked after by experienced staff who tested negative for SARS-CoV-2, wearing PPE, working in isolation, single room care and visitors were not admitted.ResultsNo recipient or donor tested positive for SARS-CoV-2 at any stage in their care. 5 (8%) pts died, >30 days after the procedure, of multiorgan failure; all 5 pts were in INTERMACS II at the time of OHT. All patients were managed with our standard immunosuppression therapy consisting of mycofenolante mofetil and steroids in addition to calcineurin inhibitor (tacrolimus). According to recent results 25 patients (40%) had allograft rejection of ISHLT grade 3a detected by routine endomyocardial biopsies within first 3 months. The highdose steroids therapy was involved and positive response (ISHLT grade 0) was observed. 56 pts had a hospital stay of 30 d or less, 7 pts more than 30 d. Follow up visits were conducted using telemedicine unless it was absolutely necessary to see the pt in hospital. Also, we raised the threshold for endomyocardial biopsies by relying on clinical judgement and stable allograft function.ConclusionBy creating a robust system of care based on team work, early testing and retesting of patients and staff for SARSCoV2, the use of proper PPE's, adequate isolation and subsequent minimization of contact with pts, we were able to demonstrate that HT in the era of COVID19 pandemic can be performed safely.

A Rare Case of Porocarcinoma and Trichoblastoma Arising in a Nevus Sebaceus of Jadassohn

Nevus sebaceus of Jadassohn, or “organoid nevus,” is a common, benign hamartoma of the skin consisting of epithelial and adnexal components. Its natural history and association with neoplastic growths is well documented. The majority of concomitant neoplasms are benign—trichoblastoma and syringocystadenoma papilliferum are most frequently discovered—but malignant tumors have been described. We present the case of a 58-year-old male with a congenital nevus sebaceus of Jadassohn on his left parietal scalp that had been enlarging, changing color, and bleeding over the prior year. Clinical exam and histology disclosed the presence of a trichoblastoma and porocarcinoma arising within the nevus sebaceus. Porocarcinoma is a rare, intermediately aggressive, malignant eccrine gland tumor that is frequently metastasized at presentation. Otolaryngology performed wide local resection with sentinel lymph node biopsy. This case highlights the diversity of tumors associated with nevus sebaceus of Jadassohn, potential for malignant expansion, and necessity for close monitoring and maintaining a low threshold for biopsy in evolving lesions.

Needle biopsy compared with surgical biopsy: pitfalls of small biopsy in histologial diagnosis of IgG4-related disease

ObjectiveThe growing utilization of needle biopsy has challenged the current pathology consensus of IgG4-related disease (IgG4-RD). The aims of this study were to identify the histological characteristics of needle biopsy and surgical specimens and evaluate the ability of needle biopsy in histological diagnosis of IgG4-RD.MethodsBiopsies from patients who were referred to as IgG4-RD by the 2019 ACR/EULAR IgG4-RD classification criteria in Peking University People’s Hospital from 2012 to 2019 were re-evaluated. Typical histological features and diagnostic categories were compared between needle biopsy and surgical biopsy.ResultsIn total, 69 patients met the 2019 ACR/EULAR classification criteria and 72 biopsies of them were re-evaluated. All cases showed lymphoplasmacytic infiltrate, while storiform fibrosis and obliterative phlebitis were only present in 35 (48.6%) and 23 (31.9%) specimens, respectively. Storiform fibrosis was more likely to be seen in retroperitoneum lesion (P = 0.033). Surgical biopsy showed significantly higher IgG4+ plasma cells/high-power field (IgG4/HPF) count (P < 0.01) and higher proportion of IgG4/HPF > 10 (P < 0.01). No significant difference was observed with regard to the ratio of IgG4+ plasma cells/IgG+ plasma cells (IgG4/IgG) (P = 0.399), storiform fibrosis (P = 0.739), and obliterative phletibis (P = 0.153). According to the 2011 comprehensive diagnostic criteria, patients who performed a needle biopsy were less likely to be probable IgG4-RD (P = 0.045). Based on the 2011 pathology consensus, needle biopsy was less likely to be diagnosed as IgG4-RD (P < 0.01), especially to be highly suggestive IgG4-RD (P < 0.01). Only 1/18 (5.6%) needle salivary specimens fulfilled the cutoff of IgG4/HPF > 100, which was significantly less than 15/23 (65.2%) of surgical ones (P < 0.01).ConclusionsNeedle biopsy shows an inferiority in detecting IgG4/HPF count but not in IgG4/IgG ratio, storiform fibrosis, and obliterative phlebitis. Compared with surgical samples, needle biopsy is less likely to obtain a histological diagnosis of IgG4-RD. A different IgG4/HPF threshold for needle biopsy of the salivary glands may be considered.

Identifying prostate cancer in men with non-suspicious multi-parametric magnetic resonance imaging of the prostate.

To formulate clinical pathways for identifying clinically significant prostate cancer (csPC) and avoiding insignificant prostate cancer (isPC) in those without suspicious regions of interest on multi-parametric magnetic resonance imaging (mpMRI) of the prostate. A retrospective review identified patients with negative mpMRI who underwent subsequent transperineal prostate biopsy across two centres. Patient characteristics and association with biopsy results were evaluated using univariate and multivariate regression analyses. A total of 144 patients were identified as having negative mpMRI and undergoing subsequent transperineal prostate biopsy; 18% (25/144) of the cohort were found to have csPC. Logistic regression analysis failed to identify statistically significant predictive factors. In this cohort, if all patients with prostate-specific antigen > 3.0 were biopsied the least amount of csPC is missed, at 20% (5/25) however all isPC would be diagnosed. The least amount of isPC is diagnosed with a biopsy threshold of >15% from the European Randomized Study of Screening for Prostate Cancer calculator with 20% (5/25) of isPC diagnoses made however only 10.5% (2/19) csPC would be diagnosed. A biopsy threshold of >5% risk reduces the number of csPC missed to 37% (7/19) however increases isPC diagnoses to 54% (13/24) of the population. False-negative rates of prostate MRI for csPC are significant within our cohort at 18%. The decision to biopsy should be made in conjunction with a risk profile acceptable by the patient and clinician. The current study demonstrates that there is a need to balance the risk of missing csPC and harm of diagnosing isPC.

A case report of granulomatosis with polyangiitis (GPA) – A rare presentation of strawberry gingiva to dentists and oral and maxillofacial surgeons

We present a case of isolated strawberry gingivitis without systemic involvement in an otherwise healthy young male.Early recognition and biopsy allowed for successful management of the lesion and initiation of systemic therapy for the Granulomatosis with polyangiitis (GPA), with no recognised end-organ damage.The key learning points include having a low threshold for biopsy and early referral to an oral and maxillofacial surgeon with a view to prompt assessment and commencement of treatment with planned long term follow up.

Development and validation of an artificial intelligence system for grading colposcopic impressions and guiding biopsies

BackgroundColposcopy diagnosis and directed biopsy are the key components in cervical cancer screening programs. However, their performance is limited by the requirement for experienced colposcopists. This study aimed to develop and validate a Colposcopic Artificial Intelligence Auxiliary Diagnostic System (CAIADS) for grading colposcopic impressions and guiding biopsies.MethodsAnonymized digital records of 19,435 patients were obtained from six hospitals across China. These records included colposcopic images, clinical information, and pathological results (gold standard). The data were randomly assigned (7:1:2) to a training and a tuning set for developing CAIADS and to a validation set for evaluating performance.ResultsThe agreement between CAIADS-graded colposcopic impressions and pathology findings was higher than that of colposcopies interpreted by colposcopists (82.2% versus 65.9%, kappa 0.750 versus 0.516, p < 0.001). For detecting pathological high-grade squamous intraepithelial lesion or worse (HSIL+), CAIADS showed higher sensitivity than the use of colposcopies interpreted by colposcopists at either biopsy threshold (low-grade or worse 90.5%, 95% CI 88.9–91.4% versus 83.5%, 81.5–85.3%; high-grade or worse 71.9%, 69.5–74.2% versus 60.4%, 57.9–62.9%; all p < 0.001), whereas the specificities were similar (low-grade or worse 51.8%, 49.8–53.8% versus 52.0%, 50.0–54.1%; high-grade or worse 93.9%, 92.9–94.9% versus 94.9%, 93.9–95.7%; all p > 0.05). The CAIADS also demonstrated a superior ability in predicting biopsy sites, with a median mean-intersection-over-union (mIoU) of 0.758.ConclusionsThe CAIADS has potential in assisting beginners and for improving the diagnostic quality of colposcopy and biopsy in the detection of cervical precancer/cancer.

Toe Absence Related to Verrucous Carcinoma

Abstract Introduction: Verrucous carcinoma is a rare variant of squamous cell carcinoma. It generally grows exogenously and bone erosion is rare. Here we present a case of verrucous carcinoma on the foot with toe absence. Case presentation: A 64-year-old man presented with a 6-year history of a slowly growing exogenous hyperkeratotic verrucous lesion on the right fifth toe, which had been absent for 1 year. Before the lesion appeared, he had undergone nail extraction on this toe. The culture of fungi and mycobacteria were negative. Three-dimensional computed tomography showed that the fifth toe of the right foot was absent. Histopathological examination showed that the lesion was exogenous and verrucous and exhibited moderate keratinocyte hyperplasia. Combined with clinical manifestation and histopathological examination, verrucous carcinoma is suggested. The lesion was surgically excised, and the patient was followed up for more than 6 months without recurrence. Discussion: Verrucous carcinoma is an exophytic tumor with verrucous growth at the beginning, which can invade deep tissues and even cause limb mutilation. When encountering a patient with a wart-like plaque on the foot that responds poorly to conventional treatments, clinicians should maintain a high degree of clinical vigilance and a low threshold for biopsy. Conclusion: We observed a rare outcome of toe absence associated with verrucous carcinoma. Therefore, early diagnosis of verrucous carcinoma is very important. Surgical excision is an effective treatment at present. Extensive resection is usually required to avoid recurrence.

Investigating the threshold for early renal allograft biopsy: A South African single-centre perspective.

The most common clinical indication for renal biopsy in the early post-transplant period is early graft dysfunction (EGD), which may present either as delayed graft function (DGF) or acute graft dysfunction. Even though it is a valuable diagnostic tool, renal allograft biopsy is not without risk of major complications. Recent studies have suggested that, with modern immunosuppressive induction regimens and more accurate ways to determine high immunological risk transplants, early acute rejection (AR) is uncommon and routine biopsy for EGD does not result in a change in management. To describe the histological findings and complications of renal allograft biopsies for EGD in our setting, and to determine whether our current threshold for biopsy is appropriate. This study was a retrospective audit that included all patients who underwent renal allograft biopsy within the first 30 days of transplantation at Groote Schuur Hospital, Cape Town, South Africa, from 1 June 2010 to 30 June 2018. The indication for biopsy was any patient who showed significant EGD, characterised by acute graft dysfunction or DGF with dialysis dependence. During the study period, 330 patients underwent renal transplantation, of whom 105 (32%) had an early biopsy and were included in the study. The median age of recipients was 39 (range 17 - 62) years, with 65% males and 35% females. The majority of donors were deceased donations after brain death (70%), with an overall median cold ischaemic time of 9 hours (interquartile range (IQR) 4 - 16). The average number of human leukocyte antigen mismatches was 5 (IQR 4 - 7). A donor-specific antibody was recorded for 18% of recipients and a panel-reactive antibody score of &gt;30% was recorded for 21%. The median duration after transplant for biopsy was 8 (IQR 6 - 10) days. During the first month of EGD, AR was diagnosed in 42% of patients who underwent biopsies. In 21% of these patients, there was acute cellular rejection, in 16% antibody-mediated rejection, and in 5% both of these. Acute tubular necrosis was the primary finding in 32%, with acute interstitial nephritis in 8%, and acute calcineurin toxicity in 4% of cases. A significant biopsy-related complication was recorded in 3 patients: 1 small-bowel perforation repaired via laparotomy, and 2 vascular injuries successfully embolised by interventional radiology. Considering the relative safety and high rate of detection of AR, a liberal approach to renal biopsy for EGD remains justifiable in our setting.

A discussion on controversies and ethical dilemmas in prostate cancer screening

Prostate cancer (PCa) is one of the the most common cancers in men. A blood test called prostate-specific antigen (PSA) has a potential to pick up this cancer very early...

Langerhans cell sarcoma of the vulva: Case report and review of the literature

Langerhans cell sarcoma (LCS) is a rare, malignant neoplastic disorder of Langerhans cells thought to arise from antecedent Langerhans cell histiocytosis (LCH) or de novo. There are less than 70 cases of LCS reported in the medical literature, with this case being the first report of primary vulvar LCS. We present the case of a 73-year-old female with a painful 2 cm ulcerated lesion of the right labia majora. The patient was treated with oral antibiotics without resolution. On referral to gynecologic oncology an office biopsy showed LCS. Surgical excision was performed with clear margins and diagnostic confirmation of LCS by histopathological features and immunohistochemical evaluation. The patient received adjuvant radiation therapy (45.6 Gy). After 33 months of surveillance, the patient remains with no evidence of disease. Due to the rarity of this disease, there is a lack of standardized recommendations for adjuvant therapy, including radiotherapy and chemotherapy regimens for both localized and systemic LCS. This case report supports the management of localized disease by surgical excision followed by radiotherapy as effective for preventing recurrence and metastatic progression. Early recognition and treatment are critical for cure, and can be accomplished by prompt referral to a specialist as well as low threshold for biopsy. Further investigation is needed for establishing a standardized management guideline for LCS.

The clinical decision-making value of prostate specific antigen and its derived indicators in prostate imaging reporting and data system version 2 3 lesions

Objective: To explore the decision-making value of clinical data in prostate imaging reporting and data system version 2 (PI-RADS V2) 3 lesions, and to compare the diagnostic value of related data for prostate cancer (PCa) and clinically PCa(csPCa). Methods: From March 2016 to October 2018,a subset of 121 men with 121 PI-RADS 3 index lesions were retrospectively analyzed. There were 31 PCa lesions and 14 csPCa lesions, aged from 46 to 91 years with a mean age of (71±9) years. The clinical data of the age, prostate specific antigen (PSA), free PSA (fPSA), f/tPSA, PSA density (PSAD) and prostate volume (PV) were compared between PCa group and non-PCa group, csPCa group and non-csPCa group using univariate analysis, respectively.The receiver operating characteristic (ROC) curve was used to evaluate the efficiency of statistically data in detecting PCa and csPCa in men with PI-RADS 3 index lesions. Results: The differences of PSA, f/tPSA and PSAD were all statistically significant (Z=-2.004, -2.527, -2.623, all P<0.05) between PCa group and non-PCa group, and they were all also statistically significant(Z=-2.415, -2.158, -2.870, all P<0.05) between csPCa group and non-csPCa group. Both PSAD had the best diagnostic efficiency, the ROC curve of detecting PCa and csPCa was 0.658 and 0.736, respectively. If used PSAD>0.20 μg·L(-1)·ml(-1) as the biopsy threshold, the sensitivity, specificity, positive predictive value and negative predictive value of csPCa were 78.6%, 58.9%, 20.0%, 95.4%, and 54.5% (66/121) of the enrolled men can avoid biopsy, resulting only 3 cases of csPCa missed. Conclusion: PSA, f/tPSA, PSAD, especially PSAD can improve the detection efficiency of PCa,especially csPCa in PI-RADS 3 lesions, assisting clinical decision-making.

MP75-05 EFFECT OF SEXUAL BEHAVIOR ON PROSTATE-SPECIFIC ANTIGEN LEVELS IN MIDDLE-AGED MEN SCREENED FOR PROSTATE CANCER

INTRODUCTION AND OBJECTIVE: Factors such as prostatitis or benign prostate hyperplasia are known to increase PSA levels. Previous studies have found higher PSA levels after ejaculation, however, knowledge about whether various aspects of sexual behavior lead also to higher PSA levels is lacking. Therefore, the aim of this study was to investigate the effect of sexual behavior on prostate-specific antigen (PSA) levels in middle-aged men screened for prostate cancer. METHODS: PSA levels of 13,607 45-year-old men were analyzed from the ongoing PROBASE trial between 04/2014 and 04//2018. Multiple linear regression was performed on log-transformed PSA levels to determine the effect of various aspects of sexual behavior on PSA levels. RESULTS: Age at first sexual intercourse, number of lifetime sexual partners, self-perceived intravaginal ejaculatory latency time (IELT), anal intercourse, and sexual identity were not associated with alterations in PSA levels. Partnered sexual activity (2-3 times/week: 10% and ≥4 times/week: 13%) and solo-masturbation (2-3 times/week: 5% and ≥4 times/week: 12%) were associated with higher PSA levels, respectively. Due to the additive effect in the multiple model for log-PSA levels, effects could be multiplied. The combination of being sexually active ≥4 times/week and masturbating ≥4 times/week simultaneously was associated with a higher PSA level of 27%. CONCLUSIONS: Higher frequency of masturbation and sexual activity are associated with higher PSA levels in middle-aged men and, consequently, these men are at increased risk of unnecessary biopsies. Therefore, when their first PSA test passes slightly the biopsy threshold, they should abstain from ejaculation for 48 hours prior to the confirmation PSA test. In contrast, factors such as anal intercourse, sexual identity or number of lifetime sexual partners are not associated with alterations in PSA levels and should be ignored when interpreting a PSA level. These patients should rather be reassured to undergo a prostate biopsy in case of an elevated PSA level. Source of Funding: German Cancer Aid

Clinicopathologic Diagnostic Criteria for Vulvar Lichen Planus.

The aim of the study was to describe the clinical and histopathologic features required for a clinicopathologic diagnosis of vulvar lichen planus (LP), which is divided into 3 types: erosive, classic, and hypertrophic. The International Society of the Study of Vulvovaginal Diseases tasked the Difficult Pathologic Diagnoses committee with development of a consensus document for the clinicopathologic diagnosis of vulvar LP, lichen sclerosus, and differentiated vulvar intraepithelial neoplasia. The LP subgroup reviewed the literature and formulated diagnostic criteria, then approved by the International Society of the Study of Vulvovaginal Diseases membership. The clinicopathologic diagnosis of erosive LP incorporates 5 criteria: (a) a well-demarcated, glazed red macule or patch at labia minora, vestibule, and/or vagina, (b) disease affects hairless skin, mucocutaneous junction, and/or nonkeratinized squamous epithelium, (c) evidence of basal layer damage, categorized as degenerative or regenerative, (d) a closely applied band-like lymphocytic infiltrate, and (e) absent subepithelial sclerosis. The clinicopathologic diagnoses of classic and hypertrophic LP each require a characteristic clinical appearance accompanied by hyperkeratosis, hypergranulosis, acanthosis, basal layer degeneration, a closely applied lymphocytic infiltrate, and absent dermal sclerosis, with hypertrophic LP showing marked epithelial abnormality compared with classic LP. Clinicopathological correlation yields the most reliable diagnosis of vulvar LP. Disease appearance overlaps with other physiologic, dermatologic, infectious, and neoplastic entities; a low threshold for biopsy at all morphologically distinct areas is recommended. Use of the histopathologic criteria described in this document may reduce the nondiagnostic biopsy rate for clinically diagnosed LP.

Performance of PI-RADS v2 assessment categories assigned prior to MR-US fusion biopsy in a new fusion biopsy program

ObjectiveTo validate the performance of PI-RADS v2 for detection of clinically significant prostate cancer (csPca, Gleason ≥7) within the context of a new fusion biopsy program. Material and methodsPatients with a PI-RADS v2 assessment category assigned on pre-biopsy mpMRI between March 2015 and November 2017 were identified. Diagnostic performance of PI-RADS v2 was calculated using fusion biopsy results as reference standard using receiver operating characteristic curve analysis. Patient and lesion characteristics were analyzed with one-way ANOVA and Wilcoxon rank sum test. ResultsOf 83 patients with 175 lesions, 115/175 (65.7%) were benign, 21/175 (12%) were Gleason 6, and 39/175 (22.3%) were Gleason ≥7. csPCa rates were 0% (0/5) for PI-RADS 1, 7.4% (2/27) for PI-RADS 2, 5.8% (3/52) for PI-RADS 3, 31.2% (24/77) for PI-RADS 4, and 71.4% (10/14) for PI-RADS 5 (p < 0.0001). For prediction of csPCa, patient-level AUC was 0.68 and lesion-level AUC was 0.77. Biopsy threshold of PI-RADS ≥3 was 92.6% sensitive and 22.1% specific. A threshold of PI-RADS ≥4 was 87.2% sensitive and 58.1% specific. Rate of csPca detection on concurrent standard 12 core biopsy only was 6.7%. ConclusionPI-RADS v2 assessment categories assigned prior to biopsy predict pathologic outcome reasonably well in a new prostate fusion biopsy program. Biopsy threshold of PI-RADS ≥3 is highly sensitive. A threshold of ≥4 increases specificity but misses some csPCa.

Pediatric thyroid ultrasound: a radiologist's checklist.

Ultrasonography (US) is the imaging method of choice for evaluating the pediatric thyroid gland, complemented by scintigraphy and thyroid function tests, especially when evaluating children with suspected congenital hypothyroidism, goiter, infectious or autoimmune diseases, or neoplasm. Diagnostic considerations in newborns with congenital hypothyroidism mainly include dysgenesis, dyshormonogenesis, transient hypothyroidism and central (hypophyseal) hypothyroidism. The midline of the neck should be scrutinized for thyroid tissue from the floor of the mouth to the thoracic inlet. Cystic and echogenic ultimobranchial remnants should not be misinterpreted as orthotopic thyroid tissue. Diffuse thyroid diseases affect older children; these comprise Hashimoto and Graves diseases and infectious thyroiditis and exhibit features similar to those in adults. It is important to note that the diffuse sclerosing variant of papillary thyroid cancer can complicate thyroiditis and should not be confused with Hashimoto disease. In children with solid nodules the threshold for fine-needle aspiration biopsy or surgery should be lower compared to adults because of a higher likelihood of malignancy compared with adults. Biopsy should be considered in nodules with suspicious ultrasonographic features, even when smaller than 1cm. Adult classification systems of thyroid nodules, although useful, are not sufficient to safely discriminate the nodules' likelihood of malignancy in children. We describe key sonographic findings and suggest a standard checklist that might be considered while performing and interpreting thyroid US in neonates and children.