Cautery Artifact Research Articles

Case Series of Thermal Cautery Artifact in Urine Cytology: An Uncommon Finding but a Potential Pitfall.

Therapeutic modalities used in bladder lesions/neoplasms (electrocautery, fulguration, and laser) could produce morphologic alterations leading to diagnostic challenges. While often seen on histology, they can present in urine cytology as atypia or even raise the concern for malignancy. Herein, we present clinicopathologic findings of four patients with cautery artifact in urine cytology. The authors' lists and a computerized search of urine cytology with features of thermal cautery artifact were collated. Slides and clinicopathologic variables (prior specimens, concurrent and follow-up surgical specimens, age, sex, manner of urine collection, cystoscopy, and treatment procedure during cystoscopy) were reviewed. Four cases were identified. Procedures performed during cystoscopy included laser therapy (n = 2), postbiopsy cauterization (n = 1), and fulguration (n = 1). All cases showed spindled cells with delicate bipolar cytoplasm, "cigar-shaped" nuclei, smooth to slightly irregular nuclear membranes, and arranged singly and loosely cohesive to lamellar stacks. Few atypical well-preserved, undistorted cells were identified in 2/4. The concurrent biopsies showed superficial cellular fragments with thermal artifact (n = 1) and rare atypical cells (n = 2). Follow-up biopsies in two cases had high-grade urothelial carcinoma both of which were diagnosed as atypical urothelial cells on cytology. Thermal cautery artifact in urine cytology is rare and can be seen following laser, electrocautery, and fulguration. The spindling artifact can render some degree of difficulty in assessing for the presence of urothelial atypia both in cytology and biopsy. Familiarity with these cytologic features, knowledge of the treatment procedure, attention to the cytologic findings of well-preserved cells and repeat sampling in cases with atypical urothelial cells in patients with history of malignancy is essential.

Comparison of Monopolar Versus Bipolar Repeat Transurethral Resection of Bladder Tumours.

To compare the effects of monopolar and bipolar energy sources on efficacy of both techniques and possible complications in bladder cancer patients undergoing repeat Transurethral resection of bladder tumour (re-TURBT). Descriptive study. Place and Duration of the Study: University of Health Science, Izmir Bozyaka Research and Training Hospital, Turkiye, from 2019 to 2021. Patients undergoing re-TURBT were inducted. Patients with residual tumour at initial TURBT, recurrent bladder cancer and patients with a non-urothelial pathology report in initial TURBT were excluded. The primary outcome was the complication ratio of the TURBT which were obturator reflex, bladder wall perforation, coagulum retention, fever, and TUR syndrome. The secondary outcome was the efficacy of the TURBT procedure, such as complete tumour resection, adequate sampling of deep muscle tissue, and sampling of qualified tissues without any thermal damage. One hundred and twenty-three patients were enrolled; 75 patients in re-M-TURBT group and 48 patients in re-B-TURBT group were analysed. Demographic and tumour characteristics, and complication rates according to the Clavien classification, were similar between the two groups (p = 0.302). The catheterisation time was shorter significantly in the bipolar re-TURBT group (median 4 vs. 3 days, respectively, p = 0.025). Monopolar and Bipolar energy sources are techniques that can be used safely in re-TURBT in terms of both appropriate pathology sampling (adequate muscle tissue sampling, cautery artifact) and complication (obturator reflex, hyponatraemia, haemoglobin decrease, bleeding) rates. Bladder Cancer, Monopolar, Bipolar, TURBT, Obtrator reflex, Complications.

PlasmaBlade-assisted surgical septal myectomy: technique and our experience.

The pulsed-electron avalanche knife (PEAK) PlasmaBlade provides an atraumatic, scalpel-like cutting precision and electrocautery-like hemostasis. PlasmaBlade operates near body temperature, and its long, thin, and malleable tip can overcome the limitations of a surgical knife. In this study, we aimed to evaluate our clinical experience and histopathological outcomes of septal myectomy using PlasmaBlade. Electronic medical records were reviewed for preoperative, operative, and follow-up data of the patients who underwent septal myectomy using PEAK PlasmaBlade at our institute between January 2019 and December 2022. Histopathology of the myectomy specimens was reviewed for the depth of muscle necrosis and compared with the left atrial appendage (LAA) specimen. Twenty-nine patients underwent septal myectomy using the PEAK PlasmaBlade. No mortality was reported. The mean age was 60.6 ± 12.5 years, and 58.6% of patients were male. Peak left ventricular outflow tract (LVOT) gradients were 40.5 ± 34.9 mmHg at rest and 56.5 ± 34.9 mmHg after provocation. Concomitant procedures performed were LAA ligation in 20 (69.0%), aortic valve replacement in 5 (17.2%), and coronary artery bypass grafting in 3 (10.3%) patients. Postoperative complications were complete heart block in one (3.4%) and ventricular septal defect in two (6.9%) patients. Both the ventricular septal defects were identified intraoperatively and repaired. Histopathology of myectomy specimens demonstrated cautery artifact limited to <50 µm depth compared to >1,000 µm with conventional electrocautery. At a mean follow-up of 8.4 ± 10.3 months, the mean LVOT gradient was 4.4 ± 5.8 mmHg at rest and 9.5 ± 3.3 mmHg after provocation. All patients were alive and in New York Heart Association class I/II. No patient developed complications or required reintervention or reoperation. Adequate septal myectomy can be precisely and safely performed using the PEAK PlasmaBlade with minimal collateral damage.

Case Series of Thermal Cautery Artifact in Urine Cytology: An Uncommon Finding but a Potential Pitfall

Case Series of Thermal Cautery Artifact in Urine Cytology: An Uncommon Finding but a Potential Pitfall

An Evaluation of Monopolar and Bipolar Electrocautery in Transurethral Resection of Urinary Bladder Tumors

Background: Transurethral resection of bladder tumor (TURBT) has a role in the diagnostic evaluation and treatment of bladder cancer, which is traditionally conducted through monopolar electrocautery; however, bipolar electrocautery has gained attention these days. Cautery artifacts are known as the drawbacks of TURBT and can be seen in both monopolar and bipolar electrocautery but with varying severity. Studies comparing bipolar to monopolar TURBT have shown conflicting results. Objectives: This study was carried out to compare the occurrence of cautery artifacts and a number of important clinical outcomes between patients undergoing monopolar and bipolar electrocautery during TURBT. Methods: This prospective study included adult patients with age 18 years old or higher diagnosed with primary bladder tumors with a size ≤4 cm. The patients were randomized into monopolar and bipolar groups (34 patients per group). The occurrence of cautery artifacts, duration of surgery, the incidence of urinary bladder perforation, fall in hemoglobin, need for blood transfusion, transurethral resection syndrome, and postoperative hospital stay were compared between the two groups. Results: In our study, the incidence of cautery artifacts was significantly lower in the bipolar group than in the monopolar group (P-value &lt; 0.0001). The two groups were comparable in terms of the duration of surgery, urinary bladder perforation, fall in hemoglobin, need for blood transfusion, transurethral resection syndrome, and postoperative hospital stay. Conclusions: Bipolar TURBT is superior to monopolar TURBT regarding a reduction in the incidence of cautery artifacts.

The Impact of En-bloc Transurethral Resection of Bladder Tumour on Clinical, Pathological and Oncological Outcomes: A Cohort Study.

Background En-bloc transurethral resection of bladder tissue (ETURBT) has recently been proposed as a good alternative technique to trans-urethral resection of bladder tissue (TURBT) in terms of outcomes for bladder carcinoma. This study aims to assess the effectiveness of the technique in terms of clinical, pathological and oncological outcomes. Methodology In this prospective study, data was collected from patients who underwent ETURBT for bladder space-occupying lesions between June 2021 and June 2022. Demographic characteristics, tumour characteristics, and postoperative outcomes were recorded. Results A total of 52 patients were studied with the majority being male and a mean age of 50.87 years. Smoking was recorded in 22 (38.5%) patients and 8 (15.4%) were on antiplatelet therapy. The majority fell in the American Society of Anesthesiology (ASA) class I (59.6%). Most of the tumours were solitary (90.4%), primary (82.8%), papillary architecture (73.1%), and between 1-3 cm in size. The lateral wall was the most common position, and detrusor muscle was seen in 98.1% of the specimens. T1 stage (57.7%) and low grade (67.3%) were the common characteristics noted. 76.9% of the ETURBT was conducted using monopolar cautery. Recurrence was noted in 3 (5.8%) and bladder perforation in 1 patient (1.9%). Cautery artifact was seen in six patients (11.5%) and obturator jerk in nine patients (17.3%). Conclusion Our study suggests thatETURBT is atechnique with a good success rate for bladder tumours less than 3 cm in size. The benefitsincludehigh chances of detrusor sampling while minimising crush artefacts and cautery damage. Specimen retrieval was challenging when the bladder tumour was solid and over 2 cm.

High Interobserver Variability Among Pathologists Using Combined Positive Score to Evaluate PD-L1 Expression in Gastric, Gastroesophageal Junction, and Esophageal Adenocarcinoma

Reliable, reproducible methods to interpret programmed death ligand-1 (PD-L1) expression on tumor cells (TC) and immune cells (IC) are needed for pathologists to inform decisions associated with checkpoint inhibitor therapies. Our international study compared interpathologist agreement of PD-L1 expression using the combined positive score (CPS) under standardized conditions on samples from patients with gastric/gastroesophageal junction/esophageal adenocarcinoma. Tissue sections from 100 adenocarcinoma pretreatment biopsies were stained in a single laboratory using the PD-L1 immunohistochemistry 28-8 and 22C3 (Agilent) pharmDx immunohistochemical assays. PD-L1 CPS was evaluated by 12 pathologists on scanned whole slide images of these biopsies before and after a 2-hour CPS training session by Agilent. Additionally, pathologists determined PD-L1–positive TC, IC, and total viable TC on a single tissue fragment from 35 of 100 biopsy samples. Scoring agreement among pathologists was assessed using the intraclass correlation coefficient (ICC). Interobserver variability for CPS for 100 biopsies was high, with only fair agreement among pathologists both pre- (range, 0.45-0.55) and posttraining (range, 0.56-0.57) for both assays. For the 35 single biopsy samples, poor/fair agreement was also observed for the total number of viable TC (ICC, 0.09), number of PD-L1–positive IC (ICC, 0.19), number of PD-L1–positive TC (ICC, 0.54), and calculated CPS (ICC, 0.14), whereas calculated TC score (positive TC/total TC) showed excellent agreement (ICC, 0.82). Retrospective histologic review of samples with the poorest interpathologist agreement revealed the following as possible confounding factors: (1) ambiguous identification of positively staining stromal cells, (2) faint or variable intensity of staining, (3) difficulty in distinguishing membranous from cytoplasmic tumor staining, and (4) cautery and crush artifacts. These results emphasize the need for objective techniques to standardize the interpretation of PD-L1 expression when using the CPS methodology on gastric/gastroesophageal junction cancer biopsies to accurately identify patients most likely to benefit from immune checkpoint inhibitor therapy.

Artifactual Cystic Spaces in Prostatic Transurethral Resections and Related Specimens: A Potential Diagnostic Confounder.

Aims. Histopathologic benign mimickers of prostate cancer have mostly focused on glandular mimics, with non-glandular mimics mainly limited to inflammatory conditions. While there is a paucity of literature recognizing small cystic (presumably artifactual) spaces in transurethral resection specimens, in some instances they can become florid enough to mimic vascular or epithelial neoplasms. Herein, we detailed histologic, immunophenotypic, and clinicopathologic findings in a large series of specimens showing prominent diagnostically confounding cystic spaces. Methods and Results. Sixty specimens were obtained (50 transurethral resections, 7 aquablations, 3 laser enucleations), from 17 different surgeons. Seven specimens had concurrent genitourinary pathology (4 prostatic adenocarcinoma, 1 solitary fibrous tumor, 1 prostatic atypia, 1 urothelial carcinoma in situ). The extent of cystic change among overall tissue examined ranged from 1 mm-8 mm (mean 3.4 mm), with luminal content of cystic spaces characterized as empty (72%), both empty and fluid-like (17%), and both empty and mucin-like (11%; mucin histochemical stain was negative on all specimens). Notable differences in degree of tissue cautery artifact or inflammation was not found. Immunohistochemistry performed on 30 specimens showed cystic spaces negative for S100, ERG, pankeratin, and CD45. Conclusion. Although artifactual in nature, in some instances small cystic spaces encountered in prostatic transurethral resections and more novel related procedures can become florid enough to warrant recognition as a potential diagnostic confounder of vascular or epithelial neoplasms.

S2021 Dilemma of a Rectal Mass

Introduction: Mucosal prolapsing polyps of the colon are uncommon findings during colonoscopy that are often misdiagnosed as malignant lesions that many times lead to unnecessary endoscopic and surgical resection. At times rectal prolapse/ mucosal prolapse syndrome can present as rectal submucosal mass similar to one another. Herein we present a case of a 63-year-old male with rectal prolapse that mimicked Submucosal rectal mass. Case Description/Methods: A 63-year-old male with prior medical history of hypertension, hyperlipidemia, obesity, treated Heliobacter pylori, hemorrhoids presented to the gastroenterology clinic due to 3-month history of dizziness, abdominal pain and bright red blood per rectum. Initial vitals were stable except for tachycardia. Physical examination was unremarkable except for external rectal hemorrhoids that were appreciated. Labs were also unremarkable on admission except for Normocytic anemia. Patient was planned and taken for colonoscopy which had poor bowel preparation, revealed large rectal mass, 2 small polyps in ascending and transverse colon which were resected. Patient was planned for flexible sigmoidoscopy and lower endoscopic ultrasound evaluation of rectal mass which revealed a hypoechoic, submucosal lesion measuring 14mm by 7mm. Patient underwent endoscopic submucosal resection of the rectal mass and removal of lesion. Post op he had rectal pain along with hypotension, which led patient to be admitted for overnight observation. On follow up patient complained of recurrent dizziness and BRBPR, sigmoidoscopy was planned and revealed superficial mucosal ulceration which was treated with bipolar cautery. Pathology of the rectal mass revealed largely denuded benign appearing congested polyp with granulation tissue and cautery artifacts. Patient’s symptoms improved on subsequent follow ups (Figure). Discussion: Mucosal prolapse presents as a common underlying mechanism rectal prolapse, inflammatory polyps, solitary rectal ulcer syndrome that were previously proposed to be grouped under the umbrella term “mucosal prolapse syndrome”. Mucosal prolapse can manifest as ulcerated, flat erythematous, or polypoid lesions. At times they can even mimic adenocarcinomas, adenomas both endoscopically and histologically. Most of the time rectal prolapses polyps have been seen in patients with mucosal prolapse syndrome. Thus, it is vital to differentiate and diagnose rectal prolapse versus true rectal mass in order to exclude malignancies. This will help guide management and surveillance strategy.Figure 1.: Nodules from Colonoscopy.

Comparison of Two Different Bipolar Energy Resources in Transurethral Resection of Bladder Tumors

Purpose: To determine whether the use of different bipolar resources is associated with different results on tissue and perioperative parameters in patients undergoing bipolar transurethral bladder tumor resection (bTURBT). Methods: In this single-center prospective study, patients diagnosed with bladder tumor randomized to undergo TURBT either with a Gyrus PlasmaKinetic system (n = 62) or Olympus TUR in saline (TURis) system (n = 51). Primary endpoint was to evaluate the alteration of patients’ perioperative parameters, while secondary aim was to assess the thermal effect of these 2 different bipolar devices on the resected tissue samples by a grading system determined by tissue characteristics. Results: One hundred thirteen patients were randomized in the study, and 43 were excluded from the analysis due to the exclusion criteria. There were no significant differences between the groups in terms of mean age, tumor site, number of tumors, operative time, alteration in hemoglobin or hematocrit, blood transfusion rate, catheterization time, and postoperative stay. On the other hand, the ratio of obturator jerk was significantly higher in the Olympus TURis group (p = 0.028). The histopathological analyses of both groups determined muscularis propria and cautery artifact presence without a statistically significant difference (χ²: 0.476, p = 0.788). Conclusion: Although the perioperative complications of bTURBT are low in nature, bladder perforation resulted from obturator jerk still poses a risk for extravesical tumor implantation. Urologists should be aware of this risk especially when they are using a TURis system.

Safety and Efficacy of Bipolar vs Monopolar Transurethral Resection of Bladder Tumor- A Randomized Controlled Trial

Monopolar Transurethral resection of bladder tumor (TURBT) has been a gold standard for bladder tumor. Initial studies of bipolar TURBT were promising, however, no high level evidence exists and its exact role remains undefined. We compared the safety and efficacy of bipolar and monopolar TURBT. Primary objective was to compare the incidence of obturator jerk. The secondary objectives included the comparison of decrease in hemoglobin, recoagulation and transfusion requirements, bladder perforation, decrease in sodium, resection syndrome and resection time, hospital stay, detrusor muscle identification and severe cautery artifact in resected specimen in two groups. A randomized control trial was conducted for one year. All patients undergoing TURBT for suspected bladder tumors were eligible. Patient’s refusal to participate, unfitness for spinal anesthesia and lack of tumor in lateral wall were excluded. Of the 118 TURBT done during study period, 48 were excluded and 70 patients, 36 in monopolar and 34 in bipolar arms, were analyzed. The incidence of obturator jerk was less in bipolar arm but not significantly different (26.4% vs. 47.2%, p=0.073). There was no significance difference in most of the secondary outcomes except lesser hemoglobin drop (0.49gm/dl vs. 0.98gm/dl, p=0.016) and lesser resection time in bipolar arm (33.0 mins vs. 46.8mins, p=0.008). Bipolar was not different to monopolar TURBT with respect obturator jerk and most of the secondary outcomes. However, with bipolar TURBT, there was significantly less resection time and although hemoglobin drop was less as well, it was not clinically significant.

Cold en bloc excision (CEBE) of bladder tumours using Zedd excision scissors: a prospective, pilot, safety and feasibility study.

Background:Transurethral resection of bladder tumour (TURBT) is the traditional technique of choice for endoscopically suspected bladder tumours. Cold En Bloc Excision (CEBE) using novel Zedd scissors is proposed for endoscopic treatment of patients with non-muscle invasive bladder cancer (NMIBC). The aim of this study was to evaluate feasibility and safety of CEBE of bladder tumours using Zedd scissors.Methods:A pilot prospective study of patients who underwent a CEBE of suspicious bladder tumours using Zedd scissors was conducted. A total of 23 patients underwent CEBE for suspected bladder tumours using Zedd scissors. New and recurrent tumours <3 cm were included in the study. The outcome measures were the presence of detrusor muscle (DM) and obturator nerve reflex (ONR), bladder perforation rates, specimen cautery artefacts, recurrence rates and complication rates. The mean age was 64 years ± 10.41 (range: 49–83 years). The median follow up was 4 months (range 1–9 months). The mean tumour size was 1.8 cm ± 0.40 (range: 0.8–2.6 cm). Tumours were located in the lateral wall (n = 11), dome (n = 2), posterior wall (n = 6), trigone (n = 2), anterior wall (n = 4) and the junction of lateral and posterior wall (n = 4).Results:There was no ONR or bladder perforation and none of the patients had any complications. DM was present in 21 patients (91%). There was no tumour identified at the circumferential margins. There was no cautery artefact reported in any case. No patients had a recurrence at first follow up cystoscopy and two patients had out of field recurrence at subsequent cystoscopies.Conclusion:CEBE with Zedd scissors is a promising en bloc excision technique for bladder tumour. It is a safe and feasible for excision of tumours less than 3 cm. The early oncological outcomes are comparable with existing en bloc resection techniques (ERBT) for NMIBC.

915 A Comparison of Endoscopic Submucosal Resection (EMR) vs. Endoscopic Submucosal Dissection (ESD) on Histologic Margins and Pathologic Evaluation for Endoscopically Managed Early Esophageal Adenocarcinoma

INTRODUCTION: Accurate histologic determination is important to determine the completeness of endoscopic resection for esophageal adenocarcinoma (EAC) and gauge risk of recurrence. EMR and ESD are both endoscopic resection techniques used for the treatment of early EAC. ESD advocates believe ESD specimens allow for more precise histopathologic analysis than EMR, but this has never been proven. We aim to determine the effect of EMR vs ESD techniques on histologic analysis in endoscopically treated early EAC. METHODS: This is a retrospective, single center study of EMR and ESD resection specimens with pathologic confirmation of HGD or T1 EAC between 1/15-12/18. Lesions with suspected invasion into the muscularis mucosa or beyond (T2 carcinoma or higher) were excluded. Endoscopic and histologic characteristics were collected. Pathology slides were re-analyzed by a blinded GI pathologist for typical pathologic features. RESULTS: 52 patients with early EAC were analyzed (23 ESD;29 EMR) [Table 1]. ESD-resected tumors were larger compared to those resected by EMR (20 mm [20.0, 28.0] vs 11 mm [9.0, 13.0], P &lt; 0.001) [Table 2]. As per Table 3, EMR specimens were more likely to have positive lateral margins compared to ESD (38% vs 13%, P &lt; 0.005) and have lower confidence in determining lateral margins. Reasons for lower confidence in the EMR group included cautery artifact (37.9%) and difficulty in orientation (20.7%). When accounting for differences in specimen thickness, EMR had a higher percentage of cauterized tissue per total tissue thickness (11.8% vs 3.9%, P &lt; 0.001). EMR specimens had cautery effect abutting the lesion while ESD did not (0 μm vs 2259 μm distance of lesion from nearest cautery, P = 0.001). Cautery effect was more likely to interfere with margin evaluation in EMR (38% vs 13%, P = 0.04). ESD specimens were well-oriented compared to EMR (P = 0.011). EMR and ESD had no difference in positive vertical margins (7% vs 9%, P = 0.33), lymphovascular invasion (P = 0.11), or submucosal invasion (P = 0.62). CONCLUSION: Cautery effect and the inability to orient the specimens appropriately play a role in limiting the evaluation of EMR specimens. EMR and ESD had similar rates of positive vertical margins but rates of positive lateral margins were significantly higher in EMR, despite a smaller lesion size resected with EMR. We postulate that this is a limitation of EMR technique and there is a certain lateral size that is unsuitable for EMR as it may not be able to resect enough of a “normal” margin to the tumor compared to ESD.

34BetaE12 and Alfa-Methylacyl Coenzyme A Racemase (AMACR) Antibodies Better Than p63 Antibody Distinguish Normal and Neoplastic Glands in Prostatic Tissue With Thermal Artifacts.

The occurrence of inked margins with crush artifact derived from the electrocauterization in radical prostatectomy and/or the presence of crushed areas with distorted glands in prostatic samples after transurethral resection of prostate (TURP) can induce a significant interobserver variability during histopathologic evaluation of specimens. The specific immunostaining for basal cell markers 34BetaE12 and p63 and for alfa-methylacyl coenzyme A racemase (AMACR) in neoplastic cells is commonly used as an ancillary tool to establish benign and malignant glands. In this study we carried out the immunohistochemical reactions for p63, 34BetaE12, and AMACR on 3 different and successive paraffin sections to discriminate malignant and benign prostatic glands, distorted and crushed by the thermal artifacts in 60 radical prostatectomies and 50 TURP samples. All prostatic acinar adenocarcinoma showed the loss of basal cell markers and expression of AMACR, whereas p63 failed to stain the basal cell layer in benign crushed prostatic glands. The same cauterized glands were steadily positive for 34BetaE12. The high percentage of p63 false negative cases in benign distorted and crushed glands could be explained by the thermal artifacts which might cause lack of p63 antigenicity. In contrast, the antigenicity of 34BetaE12 and AMACR seem not to be affected by cautery artifacts. Thus, in cauterized suspicious prostatic glands an immunohistochemistry panel including, p63, 34BetaE12, and AMACR or only 34BetaE12 is recommended. In addition, after the first evaluation with only p63, we suggest that a separate and confirmatory staining for 34BetaE12 is strongly recommended.

Successful outcomes of a new combined solution of hyaluronic acid, chondroitin sulfate and poloxamer 407 for submucosal injection: animal survival study.

Background and study aims Endoscopic resection requires use of submucosal injection. This study was conducted to assess efficacy and impact on early healing of hyaluronic acid combined with chondroitin sulfate and poloxamer 407 (Ziverel) when used as a solution for submucosal injection. Materials and methods Prospective and comparative study of gastric endoscopic mucosal resection (EMR) with three groups of two Yorkshire pigs. Six submucosal cushions were created in each animal by injecting 2 mL of Ziverel (Group 1) or succinylated gelatin (SG) (Group 2), enabling 12 EMR in each group. Submucosal cushions were created with Ziverel in Group 3, without resection. Electrosurgery unit settings were the same in all cases. EMR defects and injection sites were marked with clips. The animals were sacrificed 7 days later. EMR specimen size and duration of procedure were recorded. EMR specimens and EMR scars and injection sites were evaluated by a blinded pathologist. Results We successfully performed 24 EMR (15 en-bloc and 9 piecemeal, without differences between groups 1 and 2). Mean EMR specimen dimensions were significantly larger in Group 1 (median 19 mm, range 6 – 40 vs 16.6 mm, range 5‑25; P = 0.019), without changing the electrocautery unit settings. Blinded histopathologist assessment of EMR specimens showed less fibrosis in the submucosa and a trend to fewer cautery artifacts with Ziverel and did not identify any significant differences in early healing of resection sites. Conclusion The combination of Ziverel enables EMR and does not negatively affect early healing.

Complete portal robotic sleeve resection of the bronchus intermedius

Parenchymal sparing sleeve resection of the bronchus intermedius has been performed for isolated strictures of the bronchus intermedius. We report a complete portal robotic sleeve resection of the bronchus intermedius in a patient with a benign tumor. A 68-year-old woman found to have an endobronchial lesion and underwent endoscopic resection. Cautery artifact obscured the diagnosis but the pathology was suspicious for carcinoma. The clinical picture was more suggestive of a benign lesion. We performed a robotic sleeve resection of the bronchus intermedius for definitive diagnosis and management of this lesion. The airway was divided just below the upper lobe takeoff and just above the middle and superior segmental bronchi. The diagnosis was confirmed as benign adenoma. The airway was reconstructed in an end-to-end fashion with a running suture. The patient was discharged on postoperative day 5. There were no anastomotic or other complications. We have previously reported this technique with an open approach for benign strictures of the bronchus intermedius. A minimally invasive approach is feasible and useful in the management of benign pathology of the bronchus intermedius.

MP58-06 AUTOMATED STAGING OF T1 BLADDER CANCER USING DIGITAL PATHOLOGIC H&E IMAGES: A DEEP LEARNING APPROACH

You have accessJournal of UrologyBladder Cancer: Basic Research & Pathophysiology II1 Apr 2018MP58-06 AUTOMATED STAGING OF T1 BLADDER CANCER USING DIGITAL PATHOLOGIC H&E IMAGES: A DEEP LEARNING APPROACH Muhammad Khalid Khan Niazi, Thomas Tavolara, Vidya Arole, Anil Parwani, Cheryl Lee, and Metin Gurcan Muhammad Khalid Khan NiaziMuhammad Khalid Khan Niazi More articles by this author , Thomas TavolaraThomas Tavolara More articles by this author , Vidya AroleVidya Arole More articles by this author , Anil ParwaniAnil Parwani More articles by this author , Cheryl LeeCheryl Lee More articles by this author , and Metin GurcanMetin Gurcan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1838AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The American Joint Committee on Cancer defines T1 bladder cancer as the invasion of tumor cells into the lamina propria (LP), yet pathologists often struggle to confirm LP and/or muscularis mucosae invasion using H&E stains from bladder biopsies. Accurate reporting of the depth of LP invasion is important because of the worsened clinical outcomes observed in patients with deep invasion. We present an automated image analysis method that can recognize urothelium (U), LP, and muscularis propria (MP) from digital images of H&E-stained slides of bladder tissue. Its future clinical applications include automated risk stratification of T1 bladder cancer patients based on depth of LP invasion. METHODS Our method uses transfer learning in conjunction with convolutional neural networks (CNN) to identify different bladder layers from H&E images of bladder biopsies. Transfer learning enables CNN to equip computers with an ability to recognize and apply relevant knowledge from previous learning experiences when they encounter new tasks. Our proposed method is trained, cross-validated, and tested on 50,000 non-overlapping regions of size 64x64 pixels captured at 10x magnification. These regions are labeled for U, LP, MP, red blood cells (RBCs), inflammation (I), and cautery artifacts (C) by a GU pathologist. Each test image is processed by the CNN, producing six confidence heatmaps for each label. The MP and U maps are converted to binary masks, which represent the position of their respective bladder feature with ones and everything else with zeros. Depth of LP invasion is measured by determining the shortest distance from a given tumor nuclei in LP to the closest pixel with value 1 of the U binary mask. RESULTS The proposed method has 93.0% agreement with the pathologist in identification of bladder layers when tested on images of bladder cancer biopsies acquired from 86 patients. Additionally, given a set of tumor nuclei within LP, it precisely and accurately determines the depth of LP invasion, opening up the potential to sub stage T1 bladder cancer. When trained on samples from only three classes (U, LP, and MP), the method confuses I for U, RBCs for MP, and C for U, LP, and MP 90.0% of the times. This effect disappears in a six class method, thus a six class method is desirable. CONCLUSIONS Through accurate, automated segmentation of bladder layers from images of H&E biopsies and a given set of tumor nuclei, the depth of LP invasion can be quantified, allowing pathologists to make more informed, expedited, and accurate diagnoses of T1 bladder cancer. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e775 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Muhammad Khalid Khan Niazi More articles by this author Thomas Tavolara More articles by this author Vidya Arole More articles by this author Anil Parwani More articles by this author Cheryl Lee More articles by this author Metin Gurcan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pathology outcomes in patients with transurethral bladder tumour resection in a Turkish population: A retrospective analysis.

Transurethral bladder tumour resection (TURBT) is the common surgical method used in the diagnosis, staging and treatment of patients with bladder tumour. Most of the rare tumours other than the urothelial carcinomas of the bladder are in advanced stage on diagnosis and necessitate aggressive treatment. In our study, we aimed to the histologic types of bladder cancer and to determine the regional incidence of rare bladder cancer types in our region. We retrospectively evaluated 815 patients who underwent TURBT surgery between January 2010 and March 2016 in our clinic with a diagnosis of bladder cancer and at least 1 year follow-up. Patients with tumour histopathological examination including histological tumour type, grade and were reported. Thirty-nine patients with an unclear pathology report (neighboring organ invasion, cautery artifact, etc) and 17 patients whose data could not be accessed were excluded from the study. The patients who had received chemotherapy or radiotherapy due to any type of malignancy (23) were also excluded from the study. The outcomes of 736 patients operated in our clinics due to bladder tumour were evaluated. The mean age was 65.2 ± 8.4; 135 were female and 601 were male. Among them 711 patients with urothelial carcinoma were reported (94.2%). According to TNM classification, stage Ta was observed in 270 patients (37.9%), stage T1 in 297 (41.7%), and stage T2 in 144 (20.3%). Non-urothelial cancers were reported in 25 cases (3.3%). The incidence of bladder carcinoma varies between regions. The results of our study are similar to those of the western countries. Increased smoking and exposure to environmental carcinogenetic agents may lead to altered incidences and histological types of bladder tumours. Revision of regional tumour records may be useful to develop and evaluate future treatment strategies.

Retrospective Analysis of Atypical Glands Suspicious for Carcinoma in Transurethral Resection of Prostate.

Prostate biopsies with foci of atypical glands suspicious, but not diagnostic of carcinoma (ATYP) are associated with an increased risk of cancer diagnosis in subsequent biopsies. The significance of similar findings in transurethral resections of the prostate (TURP) is unknown. A total of 1338 specimens without a diagnosis of cancer were retrieved from our surgical pathology files from 1994 through 2014. Of these, 18 cases (1.3%) were identified with the diagnosis of ATYP. Immunohistochemistry (IHC) for p63, high molecular weight cytokeratin, and racemase (PIN4) was performed in all cases. The cases were grouped based on the main benign mimicker of cancer that could not be excluded from the differential diagnosis and prevented a definitive diagnosis. Adenosis accounted for 50% of the cases (9/18), 33.3% of the cases (6/18) were cautery artifact, 11% of the cases (2/18) were basal-cell hyperplasia with nucleoli and 5.6%, a single case, cribriform clear cell hyperplasia could not be excluded. Eight patients had follow-up biopsies and 2 were diagnosed with prostatic adenocarcinoma Gleason grade 3+3=6; both were alive 3 years after initial diagnosis. Although the most frequent benign mimickers that prevent a definitive diagnosis of cancer in needle biopsies are the small size of the atypical foci, PIN and partial atrophy, in TURPs, they are adenosis and cautery artifact. The rate of cancer diagnosed in follow-up is similar or lower than in patients with prior benign prostate needle biopsies and significantly lower than in patients with a prior diagnosis of ATYP in biopsies of the peripheral zone.

Hot avulsion may be effective as salvage treatment for focal Barrett’s esophagus remaining after endoscopic therapy for dysplasia or early cancer: a preliminary study

Both endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are used to treat Barrett's esophagus (BE) complicated by dysplasia and intramucosal cancer. However, focal areas of BE can remain after otherwise successful application of these techniques. We report the results of hot avulsion using a hot biopsy forceps to resect these residual focal areas. This was a retrospective study from a prospective database in a tertiary reference center from August 2013 to May 2015. All included patients had undergone hot avulsion for eradication of residual focal areas of BE that were ≤ 1 cm and not suspicious for dysplasia, following at least one previous endoscopic treatment for dysplasia or intramucosal cancer. 35 patients harboring 124 residual areas of 1 - 7 mm were treated with hot avulsion. After a mean follow-up of 17.4 months, all patients achieved complete eradication of residual focal BE. One of the patients required a second hot avulsion treatment. Hot avulsion provided samples in all cases but limited the assessment of dysplasia (cautery artifact) in 20.2 % of them. The only complication was bleeding in two patients, which was easily stopped by soft coagulation. Hot avulsion appears to be effective and safe in removing focal BE ≤ 1 cm at its greatest length remaining after endoscopic treatment for dysplasia or early cancer. Further studies are required before this technique can be considered the standard of care.