Final Pathology Report Research Articles

6857 Adrenal Incidentaloma In A Patient With Surgically Treated Lung Adenocarcinoma A Decade After Complete Remission

Abstract Disclosure: L. Kaur: None. R. Kaur: None. F. Haider: None. A. Iqbal: None. N. Patel: None. Adrenal incidentaloma is an adrenal mass >1 cm in size commonly discovered incidentally in up to 5-7% of patients on imaging performed for reasons other than adrenal causes. Metastasis to the adrenal glands is common due to their rich blood supply, with lung cancer being the most common primary site, followed by the stomach, esophagus and the liver. Bilateral adrenal metastasis is common, however isolated metachronous or synchronous adrenal metastasis is rare, with an incidence of 1-6%. We present a case of incidentally discovered isolated right adrenal mass ten years after curative surgical resection of right lung adenocarcinoma. A 74 year old male with history significant for adenocarcinoma of the right upper lung lobe stage 1A , negative for metastasis status post lobectomy and no adjuvant chemotherapy or radiation 10 years ago presented to the hospital for his routine follow up evaluation. His vitals were within normal limits and physical examination was unremarkable. The follow up diagnostic CT imaging was done which showed an incidental 2.1 x 1.6 x 1.2 cm right adrenal mass without any pathological lesion or lymphadenopathy. A review of CT scan done one year ago revealed no prior adrenal mass or other suspicious findings. The patient was referred to endocrinology for evaluation of the adrenal mass. He denied abdominal or right flank pain, headaches, palpitations, elevated blood pressure, sweating, muscle weakness, weight gain/loss and was healthy appearing. Lab work up including biochemical studies for hormonal over production, including aldosterone-renin ratio, adrenocorticotropic hormone, plasma catecholamines with urine metanephrines and urine cortisol were within physiological ranges. CT scan was repeated after 2 months which revealed right adrenal mass of 3.2 x 1.8 x 1.7 cm in size with heterogeneity and high pre contrast density. Given the patient's history of lung cancer, imaging characteristics and rapid interval increase in size, there was high suspicion for metastatic disease. Other differentials considered due to fast growth rate included adrenocortical carcinoma and less likely adrenal adenoma. A decision was made to proceed with right adrenalectomy for definitive resection and histological diagnosis secondary to quickly growing adrenal mass with no lymphadenopathy. The patient underwent laparoscopic adrenalectomy and the final pathological report was consistent with metastatic lung adenocarcinoma. Postoperatively the patient recovered well. At 2 week and 3 month follow up he reported no concerns. Isolated adrenal metastasis is unusual and rare but may occur in lung cancer patients years after curative resection of the primary tumor and hence long term annual follow up imaging and monitoring is recommended for prompt diagnosis and timely treatment. Presentation: 6/2/2024

Accuracy of intraoperative frozen section in surgical staging of endometrial cancer

ObjectiveThis study evaluates the role of frozen section (FS) in determining the extent of disease during surgery. Materials and methodsThis study retrospectively analyzed a cohort of patients diagnosed with endometrioid-type endometrial cancer between 2019 and 2022 who underwent surgical intervention. The frozen section (FS) results were compared with the final pathology reports, focusing on tumor grade, depth of myometrial invasion, cervical involvement, and tumor diameter. ResultsThe final analysis included 187 patients. The predictive accuracy of FS in determining PS results was 85.6 % for endometrioid histology, 95.7 % for grade 3 tumors, 90.2 % for depth of myometrial invasion, 89.7 % for cervical involvement, and 95.9 % for tumor diameter. Notably, 9.8 % of cases initially classified as grade 1 intraoperatively were upgraded with the final pathology. Similarly, 6.3 % of grade II cases were upgraded, while 60.4 % were downgraded. ConclusionOur study highlights the effectiveness of FS as a dependable tool for assessing endometrial carcinomas and guiding surgical staging decisions. By utilizing FS, the risk of unnecessary surgeries and associated morbidity in patients can be reduced.

8106 An Uncommon Cause Of Hyperparathyroidism: A Case Report

Abstract Disclosure: A. Calderon: None. M.C. Aguilera: None. A. Kansara: None. Introduction: Parathyroid adenomas are the most common cause of primary hyperparathyroidism. Imaging techniques to locate parathyroid adenomas and hyperplasia include U/S (Sensitivity: 72%-89%), Sestamibi Tc-99 (Sensitivity of 68-95%), and 4D CT scan (Sensitivity of 80%). Combined imaging modalities increase sensitivity to 95%. We describe a case of symptomatic primary hyperparathyroidism with rapid development of hypercalcemia, and conflicting imaging findings. The final diagnosis was made after surgery and pathology review. Case presentation: A 76-year-old man with a history of hypertension, Parkinson’s disease, and prostate cancer was admitted due to a calcium level of 13 mg/dL (8.0 - 10.2 mg/dl) on routine blood tests. He had complained of progressive fatigue and constipation, attributed to Parkinson’s Disease. Five months prior his calcium was 9.7 mg/dL. Hydrochlorothiazide was discontinued due to hypotension after two months. Blood tests in the hospital showed a corrected calcium of 12.5 mg/dL, phosphorus of 1.7 (2.4 - 4.5 mg/dl), PTH of 195 (15 - 65 pg/ml), with normal vitamin D and undetectable PTHrP. A U/S of the neck showed a 0.4 x 0.5 cm cystic mass in the right-inferior pole of the thyroid. A 4D CT scan of the neck showed a non-enhancing 0.9 x 7 x 1 mm mass in the same location, and a 7 x 4.7 x 4.8 mm mildly enhancing mass in the left lower pole of the thyroid. A parathyroid nuclear scan did not identify a parathyroid adenoma. He underwent minimally invasive parathyroidectomy and was found to have a 3.2 cm enlarged and cystic right inferior parathyroid gland weighing 792 mg. Frozen section showed hypercellular parathyroid with cystic and fibrotic changes. The PTH level dropped 59% after removal of the right cystic mass. The left inferior mass identified on CT scan was identified as normal thyroid tissue. Conclusions: Parathyroid cysts are uncommon neck masses and represent less than 5% of causes of all neck masses. They can be divided into functional and non-functional. Large retrospective studies have shown that about 5% of patients manifest as classic hyperparathyroidism, whereas the most common presentation was neck mass (40%). Identification of parathyroid cysts through imaging can be challenging. In our case, the patient presented with symptomatic and rapidly progressive primary hyperparathyroidism, and imaging findings that were discordant among ultrasound, 4DCT scan and Sestamibi Tc-99 scan. The final surgical and pathology reports identified a large parathyroid cyst. This case emphasizes the variable clinical and imaging behavior of parathyroid cysts, imposing a puzzling medical challenge. Presentation: 6/3/2024

7191 When Pain Is Misdiagnosed: A Case of Parathyroid Carcinoma Masked as Fibromyalgia

Abstract Disclosure: H. Pham: None. P.V. Kumar: None. S. Taylor: None. Parathyroid carcinoma is a rare and aggressive cause of hyperparathyroidism, typically associated with <1% of primary hyperparathyroidism cases. Incidence occurs mainly in the 5th decade of life, with less than 4% of all cases presenting in patients under age 30. Here, we highlight a case involving a 28-year-old woman with fibromyalgia who presented for worsening right shoulder pain in the setting of progressive, poorly characterized pain for the past year. Her initial physical exam was unremarkable aside from a non-tender left sided neck enlargement. However, her laboratory results were significant for corrected serum calcium of 15 mg/dL, serum phosphorus of 2.3 mg/dL, parathyroid hormone (PTH) >2500 pg/mL, and alkaline phosphatase 1604 units/L. X-ray of her right shoulder demonstrated mottled bone concerning for degenerative disease. Thyroid ultrasound revealed a complex cystic lesion posterior to the left thyroid lobe measuring 5.3 x 3.9 x 2.9 cm, worrisome for giant parathyroid adenoma. CT abdomen/pelvis showed diffuse osteosclerosis and innumerable lytic lesions, consistent with osteitis fibrosa cystica, as well as bilateral nephrolithiasis, likely medullary nephrocalcinosis. Her hypercalcemia was treated with aggressive hydration with normal saline and IV pamidronate. She underwent surgical resection of her parathyroid adenoma, which was unfortunately complicated by symptomatic hypocalcemia requiring prolonged care in the ICU. Her calcium levels did improve within a few days, and she was subsequently discharged with close outpatient follow-up. Final pathology report showed predominant thickened trabecular growth pattern with focal vascular invasion consistent with parathyroid carcinoma. Our patient’s case represents a rare presentation of parathyroid carcinoma in a young patient without any additional risk factors. Although atypical, her severe symptomatic hypercalcemia, nephrolithiasis, presence of large neck mass, and diffuse skeletal disease warranted immediate concern for malignant hyperparathyroidism instead of benign adenoma. Delayed diagnosis in our patient led to prolonged bone disease and severe complications. While hungry bone syndrome typically manifests post-parathyroidectomy in patients with end-stage renal disease, our patient experienced this complication in the setting of advanced, untreated hyperparathyroidism. We should consider hypercalcemia and hyperparathyroidism in our differential diagnosis for chronic pain, especially if pain remains uncontrolled with conservative measures. The most appropriate initial test for evaluation of hypercalcemia is a PTH level to distinguish between PTH-dependent and PTH-independent etiologies. Parathyroid carcinoma, even in young patients, should be considered when PTH is >3x upper limit of normal, serum calcium is >14, or skeletal and renal involvement is present. Presentation: 6/3/2024

Nephrogenic Adenoma: A Pitfall on Frozen Section of Urethral Strictures.

Urethral strictures are a common cause of urinary obstruction which can be treated with surgical resection. Frozen sections are rare and pose a diagnostic challenge to pathologists due to the presence of benign lesions such as nephrogenic adenoma. We retrospectively examined all specimens of urethral stricture resections submitted to pathology at our institution from 2012 to 2022 (n = 258). Final pathology reports were searched to identify patients with dysplasia, carcinoma, or nephrogenic adenoma. When available, frozen section reports were also examined and compared to the final report, and additional clinical history and microscopic images were collected for patients with nephrogenic adenoma. Nephrogenic adenoma was identified in 3.8% (10/258) of urethral stricture resections. Dysplasia was identified in one patient who underwent two separate resections, and squamous cell carcinoma was found in one resection. Intraoperative frozen section was requested in 3.4% of resections (9/258). In two resections, an initial diagnosis of squamous cell carcinoma was initially favoured, however when reviewed with a genitourinary pathologist the diagnosis was changed to "reactive process" with a final diagnosis of nephrogenic adenoma. Nephrogenic adenoma can be challenging on frozen section due to variable architectural patterns, inflammation, and reactive changes. While urethral strictures are relatively common, their assessment by frozen section is rare and pathologists may lack familiarity with the variable morphology of benign entities that can be seen on frozen section resulting in their misinterpretation. We highlight this potential diagnostic pitfall and demonstrate the value of a second opinion prior to definitive frozen section diagnosis of malignancy.

Sensitivity of frozen section analysis in patients with ovarian adult granulosa cell tumor, a multi-center study.

We aimed to demonstrate the sensitivity of frozen section for patients with adult granulosa cell tumor (AGCT) and analyze the clinico-pathological factors that may be associated with sensitivity. This is a multicenter study including data of 10 Gynecological Oncology Departments. Frozen-section results of patients who had ovarian AGCT at the final pathology report were retrospectively analyzed. The relation between clinico-pathological characteristics such as age, tumor size, Ca-125 level, presence of ascites, omental metastasis, menopausal status and peritoneal cytology, and the sensitivity of frozen section in patients with AGCT were evaluated. The sensitivity of frozen section diagnosis was determined by comparing the frozen section result with the final pathological diagnosis. Frozen section results of 274 patients with AGCT were obtained. The median age of the patients was 52years (range, 17-82years). Totally, 144 (52.7%, n = 273) patients were postmenopausal. The median tumour size was 90mm (range, 9-700mm). The median preoperative Ca-125 level was 23IU/mL (range, 2-995IU/mL). The sensitivity of frozen section for detecting AGCT was 76.3%. Any association between the sensitivity of frozen section and menopausal status, presence of ascites, positive cytology, omental metastasis, tumor size, Ca-125 level, age could not be shown. It is important to know the diagnosis of AGCT intraoperatively, and we demonstrated the sensitivity of frozen-section for these tumors as 76.3%.

EP.07A.10 Concordance Between Lymph Node Station Examination Reported on a Checklist and the Final Pathology Report after Curative Lung Cancer Resection

EP.07A.10 Concordance Between Lymph Node Station Examination Reported on a Checklist and the Final Pathology Report after Curative Lung Cancer Resection

Digital mapping of resected cancer specimens: The visual pathology report

BackgroundThe current standard-of-care pathology report relies only on lengthy written text descriptions without a visual representation of the resected cancer specimen. This study demonstrates the feasibility of incorporating virtual, three-dimensional (3D) visual pathology reports to improve communication of final pathology reporting. Materials and methodsSurgical specimens are 3D scanned and virtually mapped alongside the pathology team to replicate grossing. The 3D specimen maps are incorporated into a hybrid visual pathology report which displays the resected specimen and sampled margins alongside gross measurements, tumor characteristics, and microscopic diagnoses. ResultsVisual pathology reports were created for 10 head and neck cancer cases. Each report concisely communicated information from the final pathology report in a single page and contained significantly fewer words (293.4 words) than standard written pathology reports (850.1 words, p < 0.01). ConclusionsWe establish the feasibility of a novel visual pathology report that includes an annotated visual model of the resected cancer specimen in place of lengthy written text of standard of care head and neck cancer pathology reports.

Intraoperative radiation therapy for early-stage breast cancer.

Intraoperative radiotherapy (IORT) offers more convenience compared to external beam radiotherapy (EBRT) following breast-conserving surgery for early-stage breast cancer. This study describes the implementation of IORT at a metropolitan academic cancer center. Demographics, tumor characteristics, margin status, adjunct EBRT, and cosmetic results were retrospectively analyzed in patients undergoing BCS with IORT. IORT consists of 20 gray delivered to the partial mastectomy cavity. From 2015 to 2020, 171 patients (65.5% African American) were included. Histologically, 104 (60.8%) patients had invasive ductal carcinoma (IDC), while 67 (39%) patients had DCIS only. Seventeen (15.9%) patients with IDC and 12 (8.6%) patients with DCIS had positive margins. There were 15 ipsilateral breast recurrences (8.8%) and three patients (20%) developed systemic disease. Twenty-five patients (14.6%) underwent adjuvant EBRT. The local recurrence-free survival at 60 months from date of IORT was 89.4% (95% CI 82.7%-93.6%). For overall survival (OS), 168 (98.2%) patients were alive at a median follow-up of 51.4 months, and three total deaths were recorded. IORT is a highly desirable and convenient alternative to EBRT for early-stage breast cancer especially for patients with poor compliance. IORT has an acceptable ipsilateral recurrence while not precluding adjunct EBRT based upon the final pathologic report.

Preoperative Computed Tomography Imaging Accurately Identifies Adrenal Gland Involvement In Patients With Renal Masses

ObjectiveTo determine the frequency of adrenal gland involvement (AGI) in patients with renal cell carcinoma (RCC) and assess the ability of preoperative computed tomography (CT) imaging to predict AGI prior to radical nephrectomy (RN). MethodsWe retrospectively identified 90 patients who underwent RN with concomitant ipsilateral adrenalectomy (CIA) between 2019 and 2021 at our institution. We reviewed the preoperative CT findings and final pathology reports to assess AGI and determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preoperative CT imaging. ResultsFive patients (5.5%) had AGI on pathological analysis. On preoperative CT, eight patients had CT findings suspicious of AGI. All five patients with pathological AGI were identified preoperatively yielding a sensitivity of 100%. Pathological analysis in all patients who did not demonstrate AGI on imaging showed no adrenal invasion, yielding a negative predictive value of 100%. High-grade tumors were significantly associated with AGI (84.4% vs. 33.6%, p = 0.02). Patients with AGI had larger tumor size when compared with those without AGI on final pathology (10 cm vs. 6.89 cm, p = 0.07). ConclusionsThe overall incidence of AGI in patients with RCC is low. Preoperative CT can accurately identify those with AGI and can thus prevent unnecessary CIA during RN.

Right hepatectomy in absence of the left portal vein using the porto-rex shunt procedure

Abstract Objectives Exact knowledge of the portal vein (PV) anatomy is essential for any hepatobiliary procedure. Absence of the portal bifurcation with the complete blood flow to the left lobe coming from the right portal vein (RPV) is an extremely rare anatomical variation. Case presentation In this situation, a solitary metachronous colorectal liver metastasis with suspected infiltration of the RPV and the right bile duct was detected in a 51-year-old male patient. Neither percutaneous ablation nor stereotactic radiotherapy were considered indicated due to the close proximity to the central structures. Hence, a surgical two-step procedure was scheduled. First, a porto-rex shunt with an 8 mm PTFE graft to maintain the portal blood flow to the left lobe was performed. In addition, the RPV was ligated during the same procedure. After recovery, the procedure was completed with a right hepatectomy. The final pathological report confirmed invasion of the right bile duct and the RPV and resection margins were tumor-free. Conclusion This case shows that careful preoperative assessment of vascular anatomy is critical. The use of the porto-rex shunt allowed a potentially curative resection in an otherwise irresectable situation.

Pattern of Clinical Presentation, Staging and Surgical Treatment of Lung cancer in 250 Consecutive Patients.

Introduction: GLOBOCAN 2022 showed lung cancer to be leading cancer in Nepal accounting for about 11% (2431) of all new cancer cases and about 15% (2207) of all cancer deaths. We reviewed the pattern, clinical presentation, stage and multimodality treatment of lung cancer results in Nepal. Methods: Two hundred fifty consecutive patients with clinical stages of I-IIIA, who were considered for lung resectional surgery were studied. Bronchoscopy and Computed Tomography were used for diagnosis and staging. Results: Surgery alone was done in 36% cases, rest of the patients (64%) underwent multimodality approach. Lobectomy, bilobectomy, pneumonectomy, sub lobar resection and sleeve resection were done in 85.6%, 4%, 6.4%, 2% and 2% respectively. Final histology revealed squamous cell carcinoma, adeno carcinoma, and others in 72.4%, 18.4%, 9.2% respectively. Final pathological report showed stage I, II, and III in 14.8%, 30% and 55.2% cases. Thirty-day mortality was observed in 1.6% of cases. Air leak was most common post operative complication (8.4%). Conclusion: Squamous cell carcinoma still remains the commonest pathological variant of lung cancer in Nepal. Lobectomy remains the most commonly performed surgical procedure

The Role of Endobronchial Ultrasound for Mediastinal Staging in Mesothelioma

BackgroundInvasive mediastinal staging is a crucial component of the preoperative evaluation for potential surgical candidates with pleural mesothelioma (PM). Endobronchial ultrasound (EBUS) is less invasive than mediastinoscopy for staging; however, its accuracy in patients with PM remains undefined. We present our institutional experience with EBUS staging in patients with PM. MethodsPatients with PM who underwent EBUS for mediastinal staging between January 2017 and February 2021 (Brigham and Women's Hospital, Boston, MA) followed by surgical resection were retrospectively reviewed. EBUS cytology was compared with final pathology reports for the corresponding lymph node removed at the time of pleurectomy to assess EBUS accuracy. ResultsDuring the study period, 91 patients with PM met inclusion criteria. EBUS diagnostic yield was highest at nodal station 7 (84%) and lowest at station 4L (40%). There were 74 patients taken for surgical resection, and 41 patients had matching lymph nodes for analysis. In our series, EBUS had a sensitivity of 81%, a specificity of 93%, a positive predictive value of 90%, and a negative predictive value of 84%. ConclusionsEBUS is a reasonable alternative to mediastinoscopy for mediastinal staging in patients with mesothelioma.

Timeliness and Completeness of Endometrial Cancer Pathology Reports Before and After the FIGO 2023 Endometrial Cancer Staging Guidelines Update

Introduction: Uterine cancer is the most common gynecologic malignancy among women in the United States with an estimated 66,200 new cases and 13,030 deaths in 2023.1 These cancers are divided into endometrial adenocarcinomas (EAC) and uterine sarcomas. In 2013, the Cancer Genome Atlas (TCGA) proposed four new molecular classifications based on genome and exome sequencing of EACs including POLE-mutant, mismatch repair deficiency (MMRd), p53 abnormal, and no specific molecular profile (NSMP).4 In June of 2023, the International Federation of Gynecology and Obstetrics (FIGO) published an updated staging system for uterine cancer to incorporate these molecular indices along with the traditional anatomical distribution of disease and histology used in older FIGO staging guidelines.5 The primary objective of this project was to analyze the timeliness and completeness of pathology reports and IHC staining of patients who underwent hysterectomies for uterine cancer at Detroit Medical Center from October 2022 – December 2023. Methods: Patients were identified from the list of patients presented at the Karmanos Cancer Insitute’s (KCI) Gynecologic Oncology Tumor Board. Given the June publication timing of the FIGO 2023 staging guidelines, this served as the intervention for the study. The pre-intervention group consists of surgical cases from October 2022 through June 2023, and the post-intervention group consists of cases from July 2023-December 2023. Differences in time from surgery to pathology report, surgery to IHC result, pathology report to IHC result as well as completeness of IHC results were compared pre- and post-intervention. Because neither group was normally distributed, a MannWhitney-U test was used to calculate P-value. IHC result completeness pre- and post-intervention was calculated using a Fisher exact test. Results: A total of 106 cases were included, of which 67 were preintervention (63%) and 39 were postintervention. The median number of days from surgery to final pathology report was statistically significant (p=0.003) between the groups. The median number of days from pathology report to IHC result was not a statistically significant difference (p=0.19). The median number of days from surgery to completed IHC also not statistically significant. In terms of IHC staining, there was a statistically significant difference in the number of specimens pre- and post-intervention for p53 (p=0.004) and HER2 (p=0.04). There was no change in the MMR and MSI testing between the two groups. Conclusions: Following the implementation of the FIGO 2023 staging guidelines in June of 2023, there was a significant decrease in the time from surgery to finalized pathology report and a significant change in the completeness of staining for p53 and HER2 on hysterectomy specimens. By finalizing the results of both pathology and IHC for endometrial cancer specimens in a timelier manner, patients can be informed of their diagnosis sooner. Additionally, with a complete pathologic and molecular diagnosis, our gynecologic oncologists can also more efficiently and effectively communicate within a multidisciplinary team of providers including radiation oncology and genetic counseling colleagues to formulate a treatment plan.

Prognostic impact of intraoperative rupture in early-stage epithelial ovarian cancer: an ancillary study of GORILLA-3002

ObjectiveTo evaluate whether intraoperative rupture affects oncological outcomes in patients with early-stage epithelial ovarian cancer (EOC). MethodsA multicenter retrospective study was conducted on patients with early-stage EOC based on surgical and final pathological reports between 2007 and 2021. Oncologic outcomes were compared between the unruptured group (International Federation of Gynaecology and Obstetrics [FIGO] stage IA/IB) and ruptured group (FIGO stage IC1). The primary endpoint was progression-free survival (PFS). Propensity score matching (PSM) was performed to adjust for the imbalance in prognostic factors between the groups. ResultsOverall, 197 (58.3 %) patients comprised the unruptured group (FIGO stage IA/IB), and 141 (41.7 %) were in the intraoperatively ruptured group (FIGO stage IC1). No significant difference in the 5-year PFS was observed between the two groups before PSM (92.65 % vs. 92.80 %, P = 0.93). After PSM, the 5-year PFS showed a noticeable decrease in the ruptured group compared to the unruptured group, although this difference showed borderline statistical significance (96.90 % vs. 89.82 %, P = 0.061). This trend was particularly discernible in cases with aggressive tumor characteristics; intraoperative rupture remained an independent prognostic factor for shorter PFS in patients with high-grade histology (adjusted hazard ratio = 14.4, 95 % confidence interval = 2.8–74.1). ConclusionsAlthough not statistically significant, intraoperative rupture may negatively affect PFS in these patients after PSM. Therefore, rupture during surgery should be avoided as it can cause upstaging and unnecessary chemotherapy.

Can Incidental Cancer be Predicted Before Cholecystectomies for Benign Diseases?

Objective: Gallbladder cancer is a rare disease with a high mortality rate. The gold standard of treatment is based on early diagnosis and eradication of the disease with effective surgery. Almost 70% of cases are detected incidentally in the final pathology report of routine cholecystectomies. Our study aims to predict incidental gallbladder cancer in patients scheduled for surgery for benign reasons. Methods: Biological characteristics, medical history, family history of hepatobiliary disease, radiological imaging, and laboratory parameters were analyzed in 2852 patients operated on for benign reasons in the general surgery department over 63 months. Patients with incidental gallbladder cancer were compared with patients with cholecystitis. The effects of independent variables in predicting cancer between the two groups were analyzed. Results: Of 2852 patients who underwent cholecystectomy, 13 (0.45%) had incidental gallbladder cancer. The cancer incidence rate was 0.28% (2/700) in men and 0.51% (11/2139) in women. This difference was not statistically significant (p: 0.34). Among the biological characteristics, history of acute cholecystitis (p: 0.001), and laboratory findings, neutrophil-to-lymphocyte ratio (NLR) (p: 0.001) were the most striking variables. When variables with proven statistical value were tested by logistic regression analysis, NLR (p: 0.001), biliary polyps (p: 0.001), and gallstones (p: 0.038) were ranked as the most valuable cancer predictors, respectively. Conclusions: In older patients with a history of acute cholecystitis, especially if there are large stones, polyps, and wall thickening on imaging, the possibility of cancer should be considered considering the NLR value, and surgery should be performed under optimal conditions by informing the patient and relatives.

Colombian consensus for the molecular diagnosis of endometrial cancer

Objective: The Cancer Genome Atlas research program (TCGA) developed the molecular classification for endometrial cancer with prognostic and therapeutic utility, which was replaced by the ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer) classification by consensus and international guidelines due to its high cost. This article aims to present national recommendations from an expert consensus that allows unification and implementation of the molecular classification for women with endometrial cancer nationwide, with a rational use of resources and technology. Methods: Consensus of 36 experts in clinical oncology, oncological gynecology, pathology, and genetics, with clinical practice in the national territory. The leader group performed a literature review and structuring of questions rated 1 to 9 points. A modified nominal group technique was used. There was a face-to-face meeting with master presentations, deliberative dialogue, and Google Forms (Google LLC, Mountain View, CA, USA) questionnaire voting with analysis and discussion of responses. The non-consensual responses led to a second round of voting. The final manuscript was finally prepared and revised. Results: Seven recommendations were formulated integrating the panelist responses based on evidence, but adjusted to the Colombian context and reality. Recommendation 1. The molecular classification is recommended in all the endometrial cancers using the immunohistochemistry markers as subrogated results from the molecular profile initially proposed in the TCGA classification. Recommendation 2. The sequential test strategy is recommended, starting with the immunohistochemistry markers (p53, MLH1, MSH 2, MSH6, PMS2) simultaneously in all the patients, defining to request POLE (DNA polymerase epsilon) (if available) according to the risk classification based on the surgical piece. Recommendation 3. It is recommended, that the gynecologist oncologist should be the one to request the POLE (if available) according to the final pathology report. This test must be requested for all endometrial cancers stage I-II, except in low risk (stage IA low grade endometrioid histology without linfovascular invasion normal p53) and, stages III-IV without residual disease, without affecting the request of subrogated immunohistochemistry molecular markers upon histology. The consensus proposes that the POLE is requested after the immunohistochemistry and according to the categories in the risk classification established by the 2020 ESGO/ESTRO/ESP guidelines. Recommendation 4. It is recommended to perform immunohistochemistry for hormonal receptors for all women with endometrial cancer and the HER2 in patients with p53abn, simultaneously with the others immunohistochemistry markers. Recommendation 5. It is recommended to perform the immunohistochemistry markers (p53, MLH1, MSH2, MSH6 y PMS2) in an initial endometrial biopsy or curettage when the specimen is adequate and available. In case the initial immunohistochemistry is inconclusive, or there are histological discrepancies between the initial and definitive pathology, it is recommended to repeat the molecular profile in the surgical pathology. The immunohistochemistry markers must be reported in the pathology report according to the CAP (College of American Pathologists) recommendations, independently of the type of sample. Recommendation 6. It is recommended to perform MLH1 promoter methylation testing in patients who exhibit loss of expression of MLH1 in immunohistochemistry whether it is accompanied or not with loss of expression of PMS2. All the patients with deficient MMR (mismatch repair), should be sent for genetic counseling to rule out Lynch syndrome. Recommendation 7. It is recommended to consider the molecular classification in addition to the classical histopathological criteria when making adjuvant judgments, as incorporated by the classification of prognostic groups of the 2020 ESGO/ESTRO/ESP guidelines. Conclusions: It is necessary to implement the molecular classification of endometrial cancer in clinical practice in accordance to the Colombian context, due to its prognostic and probably predictive value. This will enable the characterization of the Colombian population in order to offer individualized guided treatments. This is an academic and nonregulatory document.

A case report of MiNEN: concomitant primary small-cell neuroendocrine carcinoma and high-grade papillary urothelial carcinoma of the urinary badder. Composite or Collision Tumor?

Bladder cancer is the tenth most diagnosed cancer worldwide, and urothelial carcinoma is the most common histologic type. On the contrary, small primary cell neuroendocrine carcinoma of the bladder is sporadic and accounts for less than 1% of all bladder tumors. These malignancies can be observed in mixed neuroendocrine/non-neuroendocrine neoplasms (MiNENs), which have been studied more in the gastrointestinal tract and lungs but scarcely in this organ due to their low incidence. There are concerns about the pathogenic connection between these two tumors, and the limited evidence accounts for the lack of consensus regarding prognosis and treatment for these patients; therefore, they may need a multimodal approach. Here, we describe the case of a 63-year-old woman who presented with gross hematuria, weight loss, and hypogastric discomfort for the past five months. An intravesical mass was found, and transurethral resection was performed. The Histopathology revealed a high-grade papillary urothelial carcinoma with an invasive component through muscularis propria of the bladder, so she was taken to radical cystectomy with extended pelvic lymphadenectomy. The final pathology report revealed an accompanying primary small cell neuroendocrine carcinoma intermingled with the urothelial one. She received postoperative adjuvant chemotherapy and finally died six months after surgery.

Outcomes of Patients Undergoing Segmentectomy for Occult Node-Positive Clinical Stage IA Lung Cancer

BackgroundResults of recent clinical trials suggest that segmentectomy may be an acceptable alternative to lobectomy for selected patients with early-stage non-small cell lung cancer (NSCLC). Increased use of segmentectomy may result in a concomitant increase in occult node-positive (N+) disease on surgical pathology examination. The optimal management for such patients remains unknown. MethodsClinicopathologic data were abstracted from a prospective institutional database to identify patients with pathologic N+ disease after segmentectomy for cT1 N0 M0 NSCLC. Propensity score matching identified a comparable lobectomy cohort for assessment of cumulative incidence of recurrence and overall survival (OS). ResultsOf 759 included patients, 27 (4%) had nodal upstaging on the final pathology report. Of these 27 patients, 4 (15%) had skip metastasis to N2 stations, and 20 (74%) received adjuvant therapy; no completion lobectomies were performed. Ten patients (37%) had disease recurrence: 3 isolated locoregional (11%) and 7 distant (26%). The median time to recurrence among patients with recurrence was 1.8 years; OS after recurrence was 3.4 years. After 5:1 matching with 109 patients who underwent lobectomy, all variables were balanced between the groups, except pathologic N2 stage and open surgical approach. The 5-year cumulative incidence of recurrence was not significantly different between segmentectomy and lobectomy (42% vs 52%, respectively; Gray’s P = .1). The 5-year OS (63% and 50%) and rate of locoregional recurrence (12% vs 13%) were not statistically different between the groups. ConclusionsPatients with occult N+ disease after segmentectomy for cT1 N0 M0 NSCLC had limited isolated locoregional recurrences and outcomes similar to those in patients who underwent lobectomy. Lobectomy may not provide an advantage in these patients.

Frozen Section of Placental Membranes and Umbilical Cord: A Valid Diagnostic Tool for Early-Onset Neonatal Sepsis Management.

Early-onset neonatal sepsis (EONS), a serious infection in newborns within 3 days, is challenging to diagnose. The current methods often lack accuracy, leading to unnecessary antibiotics or delayed treatment. This study investigates the role of the frozen section examination of placental membranes and umbilical cord (FSMU) to improve EONS diagnosis in the daily lab practice. This retrospective study reviewed data from 59 neonates with EONS risk factors who underwent FSMU according to our institutional protocol. Concordance between the FSMU and the Final Pathological Report (FPR) was assessed. The FSMU demonstrated a high concordance (Kappa = 0.88) for funisitis diagnosis, with excellent accuracy (98.3%). A moderate concordance was observed for chorioamnionitis stage and grade. The FSMU shows promise as a rapid and accurate tool for diagnosing EONS, particularly for funisitis. This study suggests that the FSMU could be a valuable tool for EONS diagnosis, enabling a more judicious antibiotic use and potentially improving outcomes for newborns.