Final Histopathology Research Articles

68Ga-FAPI-04 PET/CT in Non-Small Cell Lung Cancer: Accurate Evaluation of Lymph Node Metastasis and Correlation with Fibroblast Activation Protein Expression.

Fibroblast activation protein (FAP) is a promising diagnostic and therapeutic target in various solid tumors. This study aimed to assess the diagnostic efficiency of 68Ga-labeled FAP inhibitor (FAPI)-04 PET/CT for detecting lymph node metastasis in non-small cell lung cancer (NSCLC) and to investigate the correlation between tumor 68Ga-FAPI-04 uptake and FAP expression. Methods: We retrospectively enrolled 136 participants with suspected or biopsy-confirmed NSCLC who underwent 68Ga-FAPI-04 PET/CT for initial staging. The diagnostic performance of 68Ga-FAPI-04 for the detection of NSCLC was evaluated. The final histopathology or typical imaging features were used as the reference standard. The SUVmax and SUVmean, 68Ga-FAPI-avid tumor volume (FTV), and total lesion FAP expression (TLF) were measured and calculated. FAP immunostaining of tissue specimens was performed. The correlation between 68Ga-FAPI-04 uptake and FAP expression was assessed using the Spearman correlation coefficient. Results: Ninety-one participants (median age, 65 y [interquartile range, 58-70 y]; 69 men) with NSCLC were finally analyzed. In lesion-based analysis, the diagnostic sensitivity and positive predictive value of 68Ga-FAPI-04 PET/CT for detection of the primary tumor were 96.70% (88/91) and 100% (88/88), respectively. In station-based analysis, the diagnostic sensitivity, specificity, and accuracy for the detection of lymph node metastasis were 72.00% (18/25), 93.10% (108/116), and 89.36% (126/141), respectively. Tumor 68Ga-FAPI-04 uptake (SUVmax, SUVmean, FTV, and TLF) correlated positively with FAP expression (r = 0.470, 0.477, 0.582, and 0.608, respectively; all P ≤ 0.001). The volume parameters FTV and TLF correlated strongly with FAP expression in 31 surgical specimens (r = 0.700 and 0.770, respectively; both P < 0.001). Conclusion: 68Ga-FAPI-04 PET/CT had excellent diagnostic efficiency for detecting lymph node metastasis, and 68Ga-FAPI-04 uptake showed a close association with FAP expression in participants with NSCLC.

Salivary Gland Tumors: A 20 Year Review From a Single Community Practice.

Objective: Salivary gland tumors are a heterogenous group of lesions with variable pathology and clinical outcomes. Most published data are derived from studies conducted at tertiary care centers. Our study analyzed the experience from a community setting to determine significant differences, if any, in pathological distribution and clinical outcomes compared to the existing literature. Methods: We performed a retrospective analysis of all major salivary gland tumors that presented to a large community practice over a 20 year period. Retrospective chart analysis was performed for demographics, clinical presentation, imaging, cytology, histopathology, and clinical outcome data. Results: Of 806 patients, the parotid gland was the most common site in 683 patients (84.7%), followed by submandibular in 78 (9.7%) and sublingual in 45 (5.6%). A total of 203 patients were managed conservatively with observation without definitive diagnosis or lost to follow-up. A total of 495 patients underwent surgical intervention within the community practice. Twenty-six patients underwent surgical excision at an outside hospital. Eighty-two patients were determined to have a benign diagnosis based on ultrasound-guided fine needle aspiration or excisional biopsy alone. Final histopathology was benign in 505 cases (83.7%), while 98 tumors (16.3%) received a diagnosis of primary or secondary malignancy. For the parotid gland, pleomorphic adenoma (155) and Warthin's tumor (155) were the most common benign diagnoses, while mucoepidermoid carcinoma (13), adenocarcinoma (8), and acinic cell carcinoma (8) were the most common primary malignancies. Conclusions: We found a higher rate of benign tumor pathology compared to the existing literature. While the outcome data on surgical treatment of benign tumors are comparable to the existing literature, the same conclusion cannot be drawn for malignant tumors, given relatively small numbers in our series and likely disparity in the complexity of the surgical cases in tertiary care centers.

(133) Non-Occupational SCC of the Scrotum; Case Presentation and Management

Abstract Introduction Although the incidence of scrotal malignancies is extremely low Squamous cell carcinoma (SCC) is the most common scrotal malignancy. Its overall annual incidence is approximately 1.5 per 1,000,000 persons in Western countries. It was first linked to the chronic irritation of scrotal skin by the effect of soot in occurring in chimney sweepers hence known as the first described occupational disease. Occupational scrotal SCC was also later described in association with other occupations with chronic carcinogen exposure including cotton mule spinners, paraffin and tar workers, creosote workers, shale oil workers, lathe workers, pitch workers and machine tool setters and operators. Currently most cases result from poor hygiene and chronic inflammation Objective Herein we present a very rare case of SCC of the scrotum referred to us from Dermatology department Methods This 55 years old male patient was referred from dermatology department. He had no underlying occupational hazard. He has been treated for several months of itchy inflammation of the scrotumfor 6 months. Scrotal punch biosy showed moderately differentiated SCC. Clinically there was malignant scrotal ulcer of 4x3 cm with no palpable inguinal lymph nodes. CT staging confirmed localized tumor with no LN or metastatic deposits. Complete excision with 2 cm safety margin confirmed to be negative by frozen section. Final histopathology come to be moderately differentiated SCC pT2Nx. All margins and underlying Dartos were free of tumor infiltration. Results Complete excision could be achieved with intra-operative negative frozen section. Uneventful post-operative course with complete healing of scrotal wound. Conclusions Although rare, scrotal SCC continues to be serious urogenital malignancy which should be suspected even in the absence of occupational exposure. Cooperation and awareness of Dermatologists is important for early detection and management of such rare malignancy. Complete excision with safety margin is usually sufficient for cure. Inguinal Lymphadenectomy is indicated if grossly infiltrated Disclosure No.

Protocol: revolutionizing central nervous system tumour diagnosis in low- and middle-income countries: an innovative observational study on intraoperative smear and deep learning.

The aim of this study is to assess the feasibility and implementation of a novel approach for intraoperative brain smears within the operating room, which is augmented with deep learning technology. This study is designed as an observational to evaluate the feasibility and implementation of using an innovative approach to intraoperative brain smears within the operating room, augmented with deep learning technology. The study will be conducted at Aga Khan University Hospital in Karachi, Pakistan, from May 2024 to July 2026, with an estimated sample size of 258. A neurosurgical trainee, trained by the study neuropathologist, will prepare and examine the smears under a microscope in the operating room. The findings of the trainee will be documented and compared to routine intraoperative consultations (smear and/or frozen section) and final histopathology results obtained from the pathology department. Additionally, the study will incorporate artificial intelligence tools to assist with the interpretation of smear and a telepathology interface to enable consultation from an off-site neuropathologist. The results of this study will hold significant potential to revolutionise neurosurgery practices in lowand middle-income countries by introducing a cost-effective, efficient, and high-quality intraoperative consultation method to settings that currently lack the necessary infrastructure and expertise. The implementation of this innovative approach has the potential to improve patient outcomes and increase access to intraoperative diagnosis, thereby addressing a significant unmet need in LMICs.

Clinical, Radiological, and Pathological Correlation of Mandibular Invasion in Carcinoma Bucco-alveolar Complex.

A prospective cross-sectional study was conducted to correlate clinically, radiologically, and pathologically the mandibular invasion in carcinoma bucco-alveolar complex. All biopsy-proven oral cavity cancer cases (64 patients) were assessed clinically and radiologically for involvement of the mandible. Preoperative clinicoradiological findings were compared with postoperative histopathological findings. In our study, oral cancer was 4 times more prevalent in males as compared to females and clinical evaluation was found to be highly sensitive in predicting mandibular invasion. Orthopantomogram showed sensitivity of 66.6% and specificity of 100%. CT scan showed sensitivity of 100% and specificity of 46% whereas MRI showed sensitivity of 54.5% and a specificity of 96%. MRI correlates well with final histopathology in predicting size of tumor. Prevalence of bony invasion in carcinoma oral cavity was 18%. We noted an inverse relation with tumor differentiation and mandibular invasion, and none of the verrucous carcinoma lesions showed mandibular invasion. Association of clinical T and N staging with postoperative histopathology was found to be statistically significant. Despite recent advances in molecular biology, radiological techniques, and newer modalities like visual surgical planning, exact measurement of bone invasion is still challenging. At present, CT scan and MRI along with clinical evaluation are widely used to evaluate mandibular invasion in carcinoma oral cavity, and all these are complementary to each other. The recent progress in tissue engineering technologies and stem cell biology has significantly promoted the development of regenerative reconstruction of jawbone defects.

Is the nodule location a predictive risk factor for cancer in AUS/FLUS thyroid nodules? A retrospective cohort study

Atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is a heterogeneous category of thyroid nodules with uncertain cytology and controversial management. This study aimed to assess the association between nodule location and malignancy risk and whether the location can be used as a predictive risk factor for cancer in AUS/FLUS nodules. A cohort of 102 patients (79 [77.5%] women, 23 [22.5%] men) was retrospectively analyzed. Only patients with a final histopathology of benign or well-differentiated thyroid cancer and an available nodule location were included. Sociodemographic, histopathological, and sonographic data were statistically evaluated and correlated. Based on pathology findings, 54 (52.9%) and 48 (47.1%) nodules were benign and malignant, respectively. Most nodules were right-sided (54.9%). Considering the nodule location, 41.2% of nodules occupied the whole lobe, 20.6% only the lower pole, 15.7% only the upper pole, and 2.9% the isthmus. Cases with nodules occupying only the upper, middle, or lower pole showed significant associations with cancer risk (odds ratio, [95% confidence interval]: 2.6, [1.1-5.7]; 2.0, [1.0-4.7]; and 1.9, [1.0-3.9], respectively). Male sex and the presence of a peripheral halo were significantly associated with malignancy risk (3.3, [1.2-9.1], P=0.014; and 2.7, [1.0-9.5], P=0.049, respectively). Isthmic nodules had the highest malignancy level (66.7%). Nodule location is a promising predictor of malignancy in AUS/FLUS nodules. Furthermore, isthmic nodules had the highest malignancy level, emphasizing the significance of careful evaluation of these nodules. Further large prospective studies are required to confirm these findings.

High Malignancy Risk and Its Predictors in South Indian Patients With Bethesda II Thyroid Nodules.

Global data reports a low malignancy risk, whereas regional data report a variable risk of malignancy in Bethesda II thyroid nodules. The limited availability of surgical histopathology might have underestimated the risk of malignancy. Here, we report the prevalence of malignancy and its predictors in Bethesda II thyroid nodules for which the surgical histopathological diagnosis was available. This retrospective study was done at a tertiary healthcare center in South India between January 2008 and September 2015. Case records of adults with thyroid nodules who underwent surgery were collected. Patients with inadequate data were excluded from the study. The data was analyzed using SPSS version 21.0 and a p-value of < 0.05 was considered statistically significant. A total of 563 patients were included in the study with a mean age of 36±12 years. Serum thyrotropin (TSH) was low in 87 (15.4%) patients whereas 362 (64.2%) patients had multinodular goiter (MNG). Sonographic evidence of suspicious cervical lymph node and microcalcification was seen in four (0.7%) and 48 (8.5%) patients, respectively. A total of 48 (8.5%) patients had thyroid carcinoma in the final histopathology. Of these, 42 (87.5%) had papillary thyroid carcinoma, five (10.4%) had follicular thyroid carcinoma and one (4.1%) had anaplastic carcinoma. Age, gender, and maximum nodule size were not associated with malignancy. Thyrotoxicosis was negatively associated with malignancy whereas multi-nodularity, thyroid calcification, or suspicious cervical lymph node on ultrasound and total thyroidectomy were positively associated with malignancy on univariate analysis. On binary logistic regression, only the former four, but not total thyroidectomy, were independent predictors of malignancy. We report a high (8.5%) prevalence of malignancy among South Indian patients with Bethesda II thyroid nodules. Thyroid microcalcification, presence of suspicious cervical lymph node on ultrasound, and multinodularity were associated with high and suppressed TSH with low risk of malignancy. Further prospective studies are warranted to confirm the study observations.

A preoperative magnetic resonance imaging can aid in staging and treatment choice for upper tract urothelial carcinoma.

The aim was to investigate the predictive abilities of a preoperative diffusion-weighted MRI (dwMRI) among patients with surgically treated upper tract urothelial carcinoma (UTUC). Written consent was obtained from all participants in this prospective and ethically approved study. Thirty-five UTUC patients treated with radical surgery were examined with a preoperative dwMRI and prospectively included during 2017-2022. Two radiologists examined the CT scans and dwMRIs for radiological stage, and the apparent diffusion coefficient (ADC) in the tumours at the dwMRI was registered. The radiologists were blinded for patient history, final histopathology and the readings of the other radiologist. The radiological variables were analysed regarding their abilities to predict muscle-invasive disease (MID, T2-T4) and tumour grade at final pathology after radical surgery. The predictive abilities were assessed using chi-square tests, Student's t-test and calculating the area under the curve in a receiver operating characteristic (ROC) curve. Correlation between the two radiologists was quantified calculating the intra-class correlation coefficient. P-values <0.05 were considered statistically significant. Mean age was 72 years, 20 had high-grade tumour, and 13 patients had MID. The ADC values at the dwMRI were significantly lower among patients with MID compared to patients with non-muscle-invasive disease (930 vs 1189, p = <0.001). The area under the ROC curve (AUC) in an ROC curve to predict MID was 0.88 (CI 0.77-0.99, p = <0.001). The ADC values were significantly lower among patients with high-grade tumours compared to low-grade tumours (1005 vs 1210, p = 0.002). The correlation of the ADC measurements between the two radiologists was of 0.93 (CI 0.85-0.96, p < 0.001). Tumour ADC at the MRI emerges as a potential biomarker for aggressive disease. The results are promising but should be validated in a larger, multicentre study.

Feasibility of new-generation endocytoscopy for the real-time diagnosis of ampullary lesions: A pilot study (with video).

An early and accurate diagnosis of ampullary neoplasia is crucial; however, sampling bias is still a major concern. New-generation endocytoscopy enables real-time visualization of cellular structures and enables an accurate pathological prediction; however, its feasibility for small ampullary lesions has never been investigated. We developed a novel endocytoscopic (EC) classification system for ampullary lesions after an expert review and agreement from five experienced endoscopists and one pathologist. We then consecutively enrolled a total of 43 patients with an enlarged ampulla (<3cm), all of whom received an endocytoscopic examination. The feasibility of endocytoscopy was evaluated, and the performance of the EC classification system was then correlated with the final histopathology. In five cases (11.6%), the endocytoscope could not approach the ampulla, and these cases were defined as technical failure. Among the remaining 38 patients, 8 had histopathology-confirmed adenocarcinoma, 15 had adenoma, and 15 had non-neoplastic lesions. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the EC classification system to diagnose ampullary neoplasias were 95.7%, 86.7%, 91.7%, 92.9%, and 92.1%, respectively. Moreover, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the EC classification to diagnose ampullary cancer were 62.5%, 100%, 100%, 90.9%, and 92.1%, respectively. One case with intra-ampullary papillary-tubular carcinoma was classified as having a non-neoplastic lesion by endocytoscopy. Endocytoscopy and the novel EC classification system demonstrated good feasibility to discriminate ampullary neoplasias from non-neoplastic lesions and may be useful for optical biopsies of clinically suspicious ampullary lesions.

The Role of Level III Dissection in Locally Advanced Breast Cancer following Neoadjuvant Chemotherapy-A Prospective Study.

Nisha Prasannan Breast cancer is the most common female cancer in India, with a significant number presenting as locally advanced breast cancer (LABC). Level III clearance is routinely performed in our institute in LABC following neoadjuvant chemotherapy (NACT). In our previous retrospective study, level III positivity rate was 15.5%. We aim to prospectively assess level III positivity rate in LABC patients post-NACT. This is a prospective study of female patients with LABC (defined as cT3N1-3M0 or cT4N0-3M0 or cT any N2,3M0) who received NACT and underwent surgery including level III dissection from November 2019 to October 2021. Data collected included age, menopausal status, TNM stage at presentation, grade, hormone receptor and HER2 status, treatment response, ycT and ycN stage, and final histopathology. Univariate and multivariate analysis was undertaken. p -Value less than or equal to 0.05 was considered significant. Study recruited 598 patients. Level III node positivity rate was 8.4%. The clinical complete response rate (cCR) was 36% (215/598). On univariate analysis, significant association was present between level III node and cCR ( p < 0.01), ycT0 stage ( p = 0.001), ycN0 stage ( p = 0.028), level II node positivity ( p = 0.001), ypT stage ( p = 0.001), and ypN stage ( p = 0.001). On multivariate analysis, significant association was present between level III node and ycT stage ( p < 0.001), ypT stage ( p = 0.001), and ypN stage ( p = 0.001). Level III positivity rate in LABC post-NACT is high. In patients with advanced ycT stage, it would be advisable to offer complete axillary dissection including level III. Level III dissection may be avoided in patients with ycT0 or ycN0 or with cCR.

A comparative study between the diagnostic performance of contrast-enhanced digital mammography and dynamic contrast-enhanced MRI in invasive lobular carcinoma of the breast

BackgroundInvasive lobular carcinoma is the second most prevalent histological subtype of breast cancer after invasive duct carcinoma, with a reported increased incidence in the last two decades. It often presents with challenging imaging characteristics that lower the sensitivity of mammography in their detection and delineation of their extent. Moreover, an increased risk of having synchronous lesions in the same or opposite breast was reported in cases with invasive lobular carcinoma. This obviates the need for other imaging modalities, specifically contrast-enhanced imaging modalities, to improve early detection as well as allow precise determination of the extent of the disease. Our aim in this study was to compare the diagnostic performance of contrast-enhanced digital mammography and dynamic contrast-enhanced magnetic resonance imaging (MRI) in the local staging of invasive lobular carcinoma regarding the size, extensions, multiplicity and bilaterality.MethodsThis study included 46 female patients with pathologically proven invasive lobular carcinoma. They underwent full-field digital mammography with a complementary ultrasound examination, contrast-enhanced digital mammography, and dynamic contrast-enhanced MRI. The findings encountered by the three imaging modalities were evaluated independently, and the results were compared with final histopathology.ResultsIn the current study, dynamic contrast-enhanced MRI study was the most sensitive modality in the detection of the index lesion, synchronous ipsilateral and contralateral lesions and achieved a sensitivity of 100% in each analysis as compared to contrast-enhanced digital mammography, which achieved a sensitivity of 97.8%, 85.7% and 80%, respectively. Regarding the assessment of the lesion extent to the surroundings, there was a tendency to overestimation by MRI examination.ConclusionsAlthough dynamic contrast-enhanced MRI is the most sensitive imaging modality for detecting the index lesion, multiplicity and bilaterality, contrast-enhanced digital mammography achieved comparable overall accuracy. Regarding the locoregional staging of invasive lobular carcinoma, there was a tendency for relative overestimation by MRI examination.

Correlation between pre-radical prostatectomy standardized SUVmax ratios detected on 68Ga-PSMA-I&T PET/CT and final histopathology outcomes: an in-depth analysis

ObjectiveTo evaluate the predictive potential of the maximum standardized uptake value(SUVmax) value of intraprostatic tumors derived from preoperative 68Ga-PSMA-I&T PET/CT (SUVT), and its ratios to SUVmax in the liver (SUVTLR) and parotid gland (SUVTPR) with respect to histopathological findings. Materials and methodsData from patients who underwent radical prostatectomy (RP) for prostate cancer (PC) at our clinic between 2017 and 2020 were assessed. Patients with a secondary malignancy, a history of transurethral prostate resection, prior treatment for PC, or who received salvage RP were excluded. Whole-body images obtained using the same device, as per the guidelines, were reviewed by two nuclear medicine specialists with more than a decade of experience to reach a consensus for each lesion. The relationships between age, PSA, Prostate Volume, clinical T stage, biopsy International Society of Urological Pathology grade (ISUP), D’amico risk group, intraprostatic tumor volume (HPTV) identified in the final histopathological specimen review, HP-ISUP grade, seminal vesicle invasion (SVI), extracapsular invasion (ECI), positive surgical margine (PSM), SUVT, SUVTLR, and SUVTPR were analyzed. ResultsThe mean age of the 64 included patients was 64.1 ± 5.3. A statistically significant correlation was found between SUVT, SUVTLR, SUVTPR values, and histopathologic stage parameters, such as biopsy ISUP, D'amico Risk Classification, HP-ISUP, HPTV (p < 0.05). PSMATV, SUVT, and SUVTLR were statistically significant predictors of extracapsular invasion, while PSA, PSMATV, and SUVTLR were significant predictors of SVI (p < 0.05). ConclusionThe standardized SUVT, SUVTLR, and SUVTPR values could be employed as noninvasive markers to assist in predicting postoperative histopathological findings, particularly ECI, SVI, and PSM.

Extraskeletal osteosarcoma misdiagnosed as metastatic breast cancer: A case report

IntroductionExtraskeletal osteosarcomas are rare tumors with poor overall survival and a high propensity for recurrence. It frequently arises in the lower extremities and has been reported to metastasize commonly in the lungs. Controversy exists as to whether it should be treated as a soft tissue sarcoma or an osteosarcoma. Various adjuvant treatment approaches have also been studied with conflicting results. Case reportWe present a 73-year-old female with a painless, gradually enlarging right upper arm mass for 2 months. She previously underwent a left mastectomy 5 years ago for a stage II breast cancer. Preoperative imaging showed a resectable, heterogenous right upper arm mass. She subsequently underwent radical excision with frozen section revealing spindle cell neoplasm. Final histopathology was consistent with extraskeletal osteosarcoma. The patient remains disease-free as of most recent follow-up. DiscussionThere are several proposed mechanisms for extraskeletal osteosarcomas. Based on the history and location of the tumor, we initially thought that this was metastatic breast cancer. Preoperative imaging determines resectability and surgical approach. Radical surgery is frequently performed which largely depends on the site of the tumor. Complete primary resection with adequate margins remains to be the treatment of choice to prevent recurrence or metastasis. The role of adjuvant radiotherapy or chemotherapy is still to be established. ConclusionThis case highlights the various treatment options and the need for further research on its clinical behavior and potential targeted therapies.

Neurovascular Structure-Adjacent Frozen-Section Examination (NeuroSAFE) Technique of Nerve-Sparing Robot-Assisted Radical Prostatectomy (RARP) in Indian Scenario: Technique, Feasibility, and Early Outcomes.

Potency and urinary continence are adversely affected post-prostatectomy. The primary objective is oncological safety by ensuring negative surgical margins (NSM) and best functional recovery through nerve preservation in appropriate patients. NeuroSAFE technique of intra-operative frozen-section (IFS) analysis was devised for comprehensive assessment of surgical margins adjacent to the neurovascular tissue surface of the prostate. We analyzed our initial experience with this technique. Five NS-RARPs were performed utilizing the NeuroSAFE technique between October 2021 and February 2022. Patient demographics, disease stage, operative console time, post-operative complications, final histopathology, biochemical recurrence (BCR), erectile function, and urinary continence were recorded. The mean age of patients was 59.2 ± 1.3years. All had clinically organ-confined disease with ISUP grade ≤ 3. The mean operative time of NS-RARP with NeuroSAFE was 240 ± 21min and average NeuroSAFE time was 45 ± 3.8min. All patients had NSM on IFS. No patient had Clavien-Dindo grade > 1 complications. Margins were negative on final histopathology. No patient had BCR at 6 and 12weeks. Three patients were able to have sexual intercourse and only one patient required single precaution pad at 12weeks. NeuroSAFE is feasible and can ensure intra-operative oncological safety of the NS procedure. Moreover, it gives the opportunity to convert positive surgical margin to prognostically favorable NSM by secondary resection. Our initial experience which is the first in India is encouraging with favorable functional outcomes. Large prospective studies and longer follow-up are required specially to evaluate the oncological benefit.

Correlation of intra operative specimen imaging with final histopathology in breast conserving surgery for breast cancer.

To determine the effectiveness of specimen mammography in breast conserving surgery cases with respect to reduction in margin positivity rate, and to see whether the rate of secondary surgeries is decreased by intra-operative excision based on specimen mammography evaluation. The retrospective study was conducted at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data from January 2018 to December 2019 related to all female breast cancer patients who underwent mastectomy or breast conserving surgery with the involvement of specimen mammography. Sensitivity, specificity, positive predictive value and negative predictive value of specimen mammography were calculated. Data was analysed using SPSS 20. Of the 226 patients initially assessed, 65(28.7%) were excluded, and the final sample comprised 161(71.2%) women with mean age 46.71±10.47 years. The sensitivity, specificity, positive predictive value and negative predictive value of specimen mammography for the sample were 65.8%, 80.8%, 54% and 87.3%, respectively. Performing specimen mammography for intra-operative margin assessment in 12 patients was likely to spare one patient from re-excision. Intra-operative specimen mammography was found to be a reliable tool for assessing margin status.

Plasmoacanthoma of Lip-A Rare Case with Review of Literature.

Plasmoacanthoma is an extremely rare benign verrucous lesion, with few cases reported in the literature, and it often goes misdiagnosed. An attempt was made to discuss the features and compare them to reduce the diagnostic dilemma in cases of plasmoacanthoma, which mimics squamous cell carcinoma, both for the clinician and pathologist. Written informed consent was obtained from the patient for the case report. Institutional ethical clearance was obtained. A review of the literature was conducted after a PubMed search with the keyword "Plasmoacanthoma" on September 20, 2023. Nine articles were obtained, out of which two were not available. One was excluded since it was on plasma cell cheilitis. Five articles, all of which were in the English language, with a diagnosis of plasmoacanthoma were retrieved for the study. A 70-year-old female presented with an ulcer-exophytic lesion involving the lower lip, mimicking a typical squamous cell carcinoma, for which an edge biopsy of the lesion was taken to confirm. Histopathology revealed it to be plasma cell mucositis. The patient was put on the medical line of management with corticosteroids as per guidelines, with no response. A wedge excision was later done as the patient was not responding to medical therapy, and the final histopathology came out to be "plasmoacanthoma". Due to their close resemblance to malignant lesions and histologically mimicking plasma cell mucositis, such lesions often get misdiagnosed, leading to inadequate management. Various sources of literature related to plasmoacanthoma were compared, and the features and histological findings were tabulated so that if any cases were similar to the present case reports, then we could have other differential diagnoses and work accordingly. Plasmoacanthoma may be present in any age group, and the clinical features may be similar to those of squamous cell carcinoma. PCM and plasmoacanthoma are clinically and histologically mimicking conditions that should be confirmed by excisional biopsy on histopathological examination rather than incisional biopsy to avoid pathological adversity, as seen in our case. IHC with kappa and lambda light chains will help identify clonal plasma cells seen in plasmoacanthoma.

Preoperative Factors for Lymphovascular Invasion in Prostate Cancer: A Systematic Review and Meta-Analysis.

Lymphovascular invasion (LVI) is one of the most important prognostic factors in prostate cancer (PCa) and is correlated with worse survival rates, biochemical recurrence (BCR), and lymph node metastasis (LNM). The ability to predict LVI preoperatively in PCa may be useful for proposing variations in the diagnosis and management strategies. We performed a systematic review and meta-analysis to identify preoperative clinicopathological factors that correlate with LVI in final histopathological specimens in PCa patients. Systematic literature searches of PubMed, Embase, and Web of Science were performed up to 31 January 2023. A total of thirty-nine studies including 389,918 patients were included, most of which were retrospective and single-center. PSA level, clinical T stage, and biopsy Gleason score were significantly correlated with LVI in PCa specimens. Meta-analyses revealed that these factors were the strongest predictors of LVI in PCa patients. Prostate volume, BMI, and age were not significant predictors of LVI. A multitude of preoperative factors correlate with LVI in final histopathology. Meta-analyses confirmed correlation of LVI in final histopathology with higher preoperative PSA, clinical T stage, and biopsy Gleason score. This study implies advancements in risk stratification and enhanced clinical decision-making, and it underscores the importance of future research dedicated to validation and exploration of contemporary risk factors in PCa.

Role of Intraoperative Frozen Section Assessment of Proximal Bile Duct Margins and the Impact of Additional Re-Resection in Perihilar Cholangiocarcinomas.

Intraoperative frozen section (FS) analysis to assess the bile duct margin status is commonly used to assess the completeness of resection during surgery for perihilar cholangiocarcinoma (pCCA) resection. However, the impact of additional re-section on the long-term outcome after obtaining an initial positive margin remains unclear. Patients diagnosed as pCCA on preoperative imaging and subjected to curative intent surgery from May 2013 to June 2021 with a minimum follow-up of 2years were included. Intraoperative FS analysis of the proximal bile duct margin was performed in all patients. A positive margin was defined by the presence of invasive cancer. Out of the 62 patients with a preoperative diagnosis of pCCA on imaging, 35 patients were included for final analyses after excluding patients with inoperable disease (on staging laparoscopy or local exploration) and other/benign pathology on the final histopathology report. Out of the 35 patients, patients with postoperative 90-day mortality were excluded from the final survival analysis. FS analysis revealed an initial positive margin in 10 (28.5%) patients. Among 10 patients who underwent re-resection to achieve negative proximal margins, only 5 patients achieved a negative margin (secondary R0). An initial positive margin was associated with poor long-term outcomes. Median disease-free survival (DFS) and overall survival (OS) were 16 and 19.6months for patients with an initial positive margin, but 36 and 58.2months for patients with an initial negative margin, respectively (p = 0.012). The median DFS and OS were significantly lower for those with secondary R0 as compared to primary R0 (16 vs. 36months for DFS, p = 0.117 and 19.6 vs. 58.2months for OS, p = 0.027, respectively). An intraoperative FS positive proximal hepatic duct margin dictates poor long-term outcomes for patients with resectable pCCA. Additional resection has a questionable benefit on survival, when a secondary negative margin is achieved.

Molecular Genetics Augment Cytopathologic Evaluation and Surgical Planning of Pediatric Thyroid Nodules

PurposeMolecular genetic testing in conjunction with cytopathology may improve prediction of malignancy in thyroid nodules, particularly those with indeterminate cytology (Bethesda III/IV). Though now commonplace in adults, pediatric data are limited. This study examines molecular genetics of pediatric nodules with correlation to cytologic and histologic classification at time of surgery and the distribution of mutations. MethodsRetrospective chart review of 164 patients <22 years who underwent surgical resection of a thyroid nodule between 2002 and 2020 with molecular testing on fine-needle aspiration biopsy (FNA) or final histopathology. Results85 (52 %) of 164 patients undergoing thyroid resection had available molecular genetic testing. BRAF V600E testing was performed on the FNA samples of 73 (86 %) patients and on 15 (18 %) surgical specimens; 31 (37 %) were positive. Of the remaining 54 patients, 21 had additional mutation/fusion testing. In 17 (81 %) cases, an alternate mutation/fusion was identified including 8 gene fusions, 3 DICER1 mutations, 4 NRAS mutations, one BRAF variant, and one unknown variant. BRAF, DICER1 mutations, and gene fusions predicted malignancy. Greater than 95 % of BRAF mutations were in Bethesda V/VI lesions and associated with classic variant PTC whereas fusions and DICER1 mutations clustered in Bethesda IV nodules. Bethesda III nodules harbored BRAF and NRAS mutations. In Bethesda IV nodules, a gene fusion or DICER mutation altered the surgical decision-making (upfront thyroidectomy rather than lobectomy) in 70 % of nodules submitted for genetic testing. ConclusionExpanded molecular genetic testing on FNA of pediatric thyroid nodules, particularly Bethesda III/IV, may improve prediction of malignancy and augment surgical decision-making. Level of EvidenceIII.

Utility of 99mTc-Sestamibi Single-Photon Emission Computed Tomography (SPECT)/CT Single Imaging Strategy in the Preoperative Localization of Parathyroid Adenoma.

Background Primary hyperparathyroidism is an endocrinopathy associated with dysregulated calcium homeostasis. The most common etiology is a parathyroid adenoma most definitely managed via a parathyroidectomy. The two main surgical approaches include a minimally invasive parathyroidectomy (MIP) and open four-gland exploration (4-GE). MIP is the preferred operative strategy since it is associated with less postoperative complications. Accurate preoperative imaging is essential in informing the optimal approach to surgery. MIP is only considered if adenoma is able to be localized precisely. The most commonly used imaging modality includes ultrasound and sestamibi single-photon emission computed tomography (SPECT)/CT, either as a singleor combination strategy. Other options include MRI, PET, and 4D CT. There is no universally accepted preoperative imaging strategy. The literature is discordant and recommendations proposed by existing guidelines are incongruous. Objectives This study aimed to evaluate currently utilized preoperative parathyroid imaging modalities at our institution and correlate them with surgical and histological findings to determine the most efficient imaging strategy to detect adenomas for our patient cohort. This will ultimately guide the best surgical approach for patients receiving parathyroidectomies. Methods This is a retrospective observational study of all patients undergoing first-time surgery for biochemically proven primary hyperparathyroidism at our institution over the past five years. Multiple data points were collected including modality of preoperative disease localization, operation type, final histopathology, biochemical investigations, and cure rate. Patients were categorized into one of three groups based on the method of disease localization. Results A total of 244 patients had parathyroidectomies performed at our institution in the past five years from January 2018 to December 2022. Ninety-six percent (n=235) of all patients received dual imaging preoperatively with SPECT/CT and ultrasound performed on the same day and therefore included in this study. A total of 64.3% (n=151) underwent MIP. Eighty percent (n=188) of all histopathology revealed adenomas and 26.8% (n=63) of patients had adenoma localized on SPECT/CT only (sensitivity: 58.1%, specificity: 71%, and positive predictive value {PPV}: 85.7%). A total of 9.8% (n=23) had adenoma localized on ultrasound only (sensitivity: 15.6%, specificity: 73.3%, and PPV: 65.2%). A total of 45.1% (n=106) were dual localized on both SPECT/CT and ultrasound (sensitivity: 75.6%, specificity: 46.6%, and PPV: 84.9%). The cure rate was 91.5% in the dual-localized group, 86% in the dual-unlocalized group, and 96.5% when localized with SPECT/CT alone. Conclusion A dual-imaging modality with SPECT/CT and ultrasound should remain the first-line imaging strategy. This approach has higher sensitivity rates and poses no inherent patient or surgical-related risks. Patients with disease unlocalized on SPECT/CT alone had a positive predictive value, specificity, and likelihood ratio for adenoma detection comparable to dual-localized patients. Therefore, SPECT/CT alone is sufficient for directing MIP in the presence of a negative ultrasound.