Post-surgical Histopathology Research Articles

Differentiating the histologic grades of gliomas preoperatively using amide proton transfer‐weighted (APTW) and intravoxel incoherent motion MRI

The purpose of this work was to investigate the diagnostic performance of amide proton transfer-weighted (APTW) and intravoxel incoherent motion (IVIM) magnetic resonance imaging (MRI) in the preoperative grading of gliomas. Fifty-one patients with suspected gliomas were recruited and underwent a preoperative MRI examination that included APTW and IVIM sequences. All cases were confirmed by postsurgical histopathology. APTW signal intensity, true diffusion coefficient (D), perfusion fraction (f) and pseudo-diffusion coefficient (D*) were applied to assess the solid tumor component and contralateral normal-appearing white matter. The relative APTW signal intensity (rAPTW) was also used. Independent-sample and paired-sample t-tests were used to compare differences in MRI parameters between low-grade glioma (LGG) and high-grade glioma (HGG) groups. The diagnostic performance was assessed with the receiver operating characteristic curve. Twenty-six patients were pathologically diagnosed with LGG and 25 were diagnosed with HGG. APTW, rAPTW and f values were significantly higher (all p<0.001), whereas D values were significantly lower (p<0.001) in the HGG group than in the LGG group. There was no significant difference between D* values for the two groups. rAPTW had an area under the curve (AUC) of 0.957, with a sensitivity of 100% and a specificity of 84.6%, followed by APTW, f, D and D*. The combined use of APTW and IVIM showed the best diagnostic performance, with an AUC of 0.986. In conclusion, APTW and IVIM, as two promising supplementary sequences for routine MRI, could be valuable in differentiating LGGs from HGGs.

Arterial spin labelling MRI for detecting pseudocapsule defects and predicting renal capsule invasion in renal cell carcinoma

To evaluate prospectively the performance of combining morphological and arterial spin labelling (ASL) magnetic resonance imaging (MRI) for detecting pseudocapsule defects inrenal cell carcinoma (RCC), and to predict renal capsule invasion confirmed histopathologically. Twenty consecutive patients with suspicious renal tumours underwent MRI. Renal ASL imaging was performed and renal blood flow was measured quantitatively. The diagnostic performance of T2-weighted images alone, and a combination of T2-weighted and ASL images for predicting renal capsule invasion were assessed. Twenty renal lesions were evaluated in 20 patients. All lesions were clear cell RCCs (ccRCCs) confirmed at post-surgical histopathology. Fifteen ccRCCs showed pseudocapsule defects on T2-weighted images, of which 12 cases showed existing blood flow in defect areas on perfusion images. To predict renal capsule invasion, the sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 71.4%, 86.7%, 100%, respectively, for T2-weighted images alone, and 92.3%, 100%, 100%, 87.5%, respectively, for the combination of T2-weighted and ASL images. ASL images can reflect the perfusion of pseudocapsule defects and as such, the combination of T2-weighted and ASL images produces promising diagnostic accuracy for predicting renal capsule invasion.

VEGF-C Is a Thyroid Marker of Malignancy Superior to VEGF-A in the Differential Diagnostics of Thyroid Lesions.

IntroductionThyroid nodular goiter is one of the most common medical conditions affecting even over a half of adult population. The risk of malignancy is rather small but noticeable–estimated by numerous studies to be about 3–10%. The definite differentiation between benign and malignant ones is a vital issue in endocrine practice. The aim of the current study was to assess the expression of vascular endothelial growth factor A (VEGF-A) and VEGF-C on the mRNA level in FNAB washouts in case of benign and malignant thyroid nodules and to evaluate the diagnostic value of these markers of malignancy.Materials and MethodsPatients undergoing fine-needle aspiration biopsy (FNAB) in our department between January 2013 and May 2014 were included. In case of all patients who gave the written consent, after ultrasonography (US) and fine-needle aspiration biopsy (FNAB) performed as routine medical procedure the needle was flushed with RNA Later solution, the washouts were frozen in -80 Celsius degrees. Expression of VEGF-A and VEGF-C and GADPH (reference gene) was assessed in washouts on the mRNA level using the real-time PCR technique. Probes of patients who underwent subsequent thyroidectomy and were diagnosed with differentiated thyroid cancer (DTC; proved by post-surgical histopathology) were analyzed. Similar number of patients with benign cytology were randomly selected to be a control group.ResultsThirty one DTCs and 28 benign thyroid lesions were analyzed. Expression of VEGF-A was insignificantly higher in patients with DTCs (p = 0.13). Expression of VEGF-C was significantly higher in patients with DTC. The relative expression of VEGF-C (in comparison with GAPDH) was 0.0049 for DTCs and 0.00070 for benign lesions, medians – 0.0036 and 0.000024 respectively (p<0.0001).ConclusionsMeasurement of expression VEGF-C on the mRNA level in washouts from FNAB is more useful than more commonly investigated VEGF-A. Measurement of VEGF-C in FNAB washouts do not allow for fully reliable differentiation of benign and malignant thyroid nodules and should be interpreted carefully. Further studies on larger groups are indicated. However, measurement of VEGF-C on mRNA level can bring important information without exposing patient for additional risk and invasive procedures.

Diffusion-weighted and hepatobiliary phase gadoxetic acid-enhanced quantitative MR imaging for identification of complete pathologic response in colorectal liver metastases after preoperative chemotherapy.

To evaluate the diagnostic performance of diffusion-weighted imaging (DWI) and gadoxetic acid-enhanced magnetic resonance imaging (MRI) to differentiate colorectal liver metastasis (CRLM) with complete pathologic response from those with incomplete response in patients treated with preoperative chemotherapy. Gadoxetic acid-enhanced liver MRI and DWI were performed after completion of preoperative chemotherapy in patients with CRLM scheduled for liver resection. Metastases were classified as those with complete pathologic response (CR-CRLM) or incomplete response (IR-CRLM) according to postsurgical histopathology. Quantitative analysis was performed on non-contrast-enhanced images and hepatobiliary phase images following gadoxetic acid administration. Apparent diffusion coefficient values (ADC), normalized relative enhancement (NRE), and relative signal intensity difference (RSID) along with their diagnostic measures for detection of CR-CRLM were calculated for all lesions. In 23 patients, 10 CR-CRLM and 35 IR-CRLM (mean diameter, 21.2 mm) were evaluated. In CR-CRLM, ADC was significantly higher after exclusion of the outliers (p = 0.030); and RSID was significantly lower (p = 0.008). Combined indices range of ADC = 1.25-1.9 × 10(-3) mm(2)/s, NRE = 0-35% and RSID <120 had 60% sensitivity and 100% specificity for detection of CR-CRLM. DWI and gadoxetic acid-enhanced MRI appear promising for the detection of CRLM with complete response to preoperative chemotherapy. This could have significant implications for liver resection planning after preoperative chemotherapy.

The usefulness of standardized uptake value in differentiation between benign and malignant thyroid lesions detected incidentally in 18F-FDG PET/CT examination.

IntroductionIn the last decade, (18)F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET and PET/CT) has become one of the major diagnostic tools used in oncology. A significant number of patients who undergo this procedure, due to non-thyroidal reasons, present incidental uptake of (18F-FDG) in the thyroid. The aim of the study was to compare the SUVmax (standardized uptake value) of thyroid focal lesions, which were incidentally found on PET/CT, in relation to the results of thyroid fine-needle aspiration biopsy (FNAB) and/or histopathological evaluation.Materials and MethodsPatients referred for PET/CT examination, due to non-thyroidal illness, presented focal 18F-FDG uptake in the thyroid and were advised to undergo ultrasonography (US), hormonal evaluation, FNAB and/or total thyroidectomy at our institution.Results6614 PET/CT examinations performed in 5520 patients were analyzed. Of the 122 patients with focal thyroid 18F-FDG activity, 82 patients (67.2%) underwent further thyroid evaluation using FNAB. Benign lesions were diagnosed in 46 patients, malignant - in 19 patients (confirmed by post-surgical histopathology), while 17 patients had inconclusive results of cytological assessment. Mean SUVmax of benign lesions was 3.2±2.8 (median = 2.4), while the mean SUVmax value for malignant lesions was 7.1±8.2 (median = 3.5). The risk of malignancy was 16.7% for lesions with a SUVmax under 3, 43.8% for lesions with a SUVmax between 3 and 6, and 54.6% for lesions with a SUVmax over 6. In the group of malignant lesions, a positive correlation between the lesion’s diameter and SUVmax was observed (p = 0.03, r = 0.57).ConclusionsSubjects with incidental focal uptake of 18F-FDG in thyroid are at a high risk of thyroid malignancy. A high value of SUVmax further increases the risk of malignancy, indicating the necessity for further cytological or histological evaluation. However, as SUVmax correlated with the diameter of malignant lesions, small lesions with focal uptake of 18F-FDG should be interpreted cautiously.

Evaluation of FLT-PET/CT usefulness in diagnosis and qualification for surgical treatment of gastric cancer

Aim of the studyEvaluation of FLT/PET/ CT usefulness in diagnosis and qualification for surgical treatment of gastric cancer.Material and methodsThe FLT/PET/CT test was carried out in a group of 50 gastric cancer patients. Based on the test result, a decision followed about the therapeutic procedure to be applied. A comparison was made with regards to the consistency of the cancer growth advancement degree evaluation in the initial preoperative FLT/PET/CT test against the evaluation of postoperative degree of cancer advancement in histopathology.ResultsIn the group of 50 diagnosed patients a surgical treatment was used for 37 patients. 21 resections were performed out of which 19 operations were radical In the group of 16 non-resective operations 2 post-laparotomic patients were selected for inductive treatment. In the group of 13 patients who did not undergo any surgery, 10 were directed to palliative care and 3 for inductive treatment. In the group of 50 patients, the applied FLT-PET/CT test confirmed presence of primary tumor in 49 patients. The presence of increased uptake of FLT in the local lymph nodes during the preoperative FLT-PET/CT test was confirmed in 22 cases. In 14 patients with FLT-PET/Ct N(+) with the M(–) feature resection surgery was performed. The increased uptake of FLT in localizing metastases (nodal and non-nodal) FLT-PET/CT (M+) was detected in 22 patients. The presence of nodal metastases in the postoperative histopathology examination (hpN+) was detected in 14 cases. In these cases preoperative FLT-PET/CT test proved the N(+) feature in 11 patients. The result FLT-PET/CT N(–) was truly negative in 2 patients, and false negative in 1 patient. In the group of 7 operated hpN(–) patients, in 3 patients a preoperative result FLT-PET/ CT N(+) (false positive result) was obtained. The consistency (positive) of nodal metastases identification in FLT-PET/CT as compared to post-surgical histopathology examination scored 11/15, which equals 73.3%. In the group of patients in whom resection surgery was performed, 4 false negative results were obtained [hp(N+), FLT-PET/CT (N–)] and 3 false positive results [hp(N–), FLT-PET/CT N(+)].ConclusionsThe initial test results indicate that FLT-PET/CT is an effective method in evaluating the primary tumor and the regional lymph nodes and is useful and beneficial in the diagnosis and further treatment evaluation of gastric cancer. FLT-PET/CT examination facilitates making proper therapeutic decisions – it allows the number of unnecessary laparotomies to be lowered.

Hyperfunctional Parathyroid Carcinoma With Mediastinal Extension

Parathyroid carcinoma (PC) is an extremely rare malignancy, of which 0.005% are of all tumours and between 0.5% and 5% of all parathyroid neoplasms. Preoperative diagnosis is often difficult and is almost always obtained only after post-surgical histopathology. The prognosis is related to the local extent of disease and to complete surgical resection of the tumour.We report an uncommon case of hyperfunctional PC with mediastinal extension, emphasising the diagnostic difficulties, histopathological features and treatment strategies. The most recent data in the literature are analysed as well.

Prediction of lack of response to neoadjuvant chemotherapy in rare breast tumour histology with Tc-99m sestamibi scintimammography

The authors report a case of a 47-year-old female with a malignant lump in the right breast and ipsilateral axillary nodal involvement. She was pathologically misinterpreted as a case of ductal cell carcinoma with papillary component on fine needle aspiration cytology (FNAC) pre-operatively. On lines of the FNAC report, the patient underwent scintimammography (SMM) for prediction of treatment response based on washout pattern. The SMM revealed rapid washout of radiotracer predictive of poor responder. Despite unfavourable result seen with SMM, the patient received 4 cycles of neo-adjuvant chemotherapy (NACT). However, there was no clinical response after chemotherapy. The post-surgical histopathology revealed the actual histology to be pleomorphic liposarcoma. This case highlights that SMM has the ability to predict non-responsiveness of unusual tumour histology to standard NACT.

Carcinoma hiperfuncionante paratiroideo con extensión mediastínica

Parathyroid carcinoma (PC) is an extremely rare malignancy, 0.005% of all tumours and between 0.5% and 5% of all parathyroid neoplasms. Preoperative diagnosis is often difficult and is almost always obtained only after post-surgical histopathology. The prognosis is related to the local extent of disease and to complete surgical resection of the tumour. We report an uncommon case of hyperfunctional PC with mediastinal extension, emphasising the diagnostic difficulties, histopathological features and treatment strategies. The most recent data in the literature is analysed as well.

An attempt to define the type of biopsy in a sinonasal lesion showing bony erosion

To present a case of sino-nasal destructive mass initially diagnosed as an inflammatory lesion following punch biopsy from the lesion however the post surgical histopathology was diagnostic of Grade 2 angiocentric immunoproliferative lesion (AIL). The reasons for the initial misdiagnosis are analyzed. A 76-year-old male patient presenting with progressive bilateral nasal obstruction for 1 year. Repeated punch biopsies from the mass were suggestive of an inflammatory lesion. The patient underwent surgical exenteration of the mass and the final histopathology report suggested AIL Grade 2. The patient was thereafter treated with chemotherapy and radiotherapy. Initial superficial punch biopsies lead to incorrect diagnosis leading to an unnecessary surgical exenteration. The explanations for the initial misdiagnosis are given below and appropriate diagnostic protocols, mode and depth of biopsy are suggested based on the case study.

Analysis of malignant and borderline ovarian tumors, comparing pre- and post-laparoscopic diagnoses

Purpose: To evaluate the incidence, character, and prognosis of ovarian tumors diagnosed as benign before laparoscopic surgery but identified as malignant or of borderline malignancy by postoperative histopathology.Subjects: Of 1,066 laparoscopic ovarian tumor resections at Tohoku Kosai Hospital from April 2001 to May 2010, a total of 22 patients were postoperatively confirmed as having overt or borderline malignancies. Methods: For this patient subset, the following factors were analyzed: postsurgical histopathology, patient age, tumor size, solid tumor component, CA125 and CA19-9 markers, laparoscopic technique, tumor capsule status, adjunctive therapy, and prognosis.Results: The rate of preoperative diagnostic error was 2.2% (22/1,066). Of the 22 misinterpreted tumors, five were clearly malignant, and 17 were of borderline malignant potential. Although no specific tendencies were evident, based on analysis of preoperative features, malignant lesions were more likely in older patients or in those with large sized cysts. For two of the five patients with malignancies, definitive cancer surgery was performed, followed by chemotherapy, while the other three received chemotherapy alone. Three of the 17 patients with borderline malignancy also opted for surgery. Endometrial carcinoma was found in one patient with malignancy, and recurrent mucinous cysts occurred in two patients with borderline tumors, but the long-term prognosis for these patients in close follow-up was fairly good.Conclusion: Preoperative misdiagnosis of ovarian malignancies may be unavoidable, despite thorough assessment. However, even with laparoscopic resection, the prognosis of such tumors is not poor, given adequate adjunctive therapy and/or careful clinical follow-up.

Adenocarcinomas of the esophagus: Response to chemoradiotherapy is associated with decrease of metabolic tumor volume as measured on PET–CT: Comparison to histopathologic and clinical response evaluation

Purpose We determined whether evaluation of treatment response is feasible by measuring metabolic tumor volume parameters on 18F-FDG (Fluorodeoxyglucose) PET–CT (Positron emission tomography–Computed tomography). We compared the response evaluation based on metabolic tumor volume parameters to a histopathologic and clinical response evaluation (clinical response criteria: RECIST criteria = Response evaluation criteria in solid tumors, and WHO criteria = World health organization). Patients and methods A total of 51 study subjects with adenocarcinomas (Type I due to Siewert classification) of the esophagus underwent PET–CT scans before and after neoadjuvant chemoradiotherapy. Tumor volume, maximum and mean standardized uptake values (SUV) were assessed before and after chemoradiotherapy. Furthermore, the total lesion glycolysis (TLG) was calculated by multiplying the tumor volume by the mean SUV of the volume. Clinical response evaluation was performed with endoscopic ultrasound and CT using RECIST and WHO criteria. The reference standard for treatment response was the postsurgical histopathology. Results The decrease of tumor volume between the pre- and post-treatment PET–CT scans was a better predictor of histopathologic response and survival than the decrease of the SUV and of the clinical response evaluation based on RECIST and WHO criteria. The highest accuracy, however, was achieved when using the TLG for the identification of treatment responders. A decrease of the TLG by >78% between pre- and post-therapy scans predicted histopathologic response with a sensitivity and specificity of 91% and 93%, respectively. Conclusions Tumor volume and TLG can be used to assess treatment response and survival in patients with esophageal adenocarcinoma.

Stereotactic core needle biopsy in non-palpable breast lesions. What number is needed?

To investigate whether three stereotactic core needle biopsies (S-CNB) in non-palpable breast lesion are enough for accurate preoperative diagnosis. Between September 1994 and December 2000, 523 patients with mammographically detected breast lesions and who proceeded to surgery were preoperatively stereotactically biopsied with an automated 14-gauge biopsy device. Three samples were taken from each lesion irrespective of whether the lesion presented as "microcalcifications only", "microcalcifications and a mass", or a "mass, architectural distorsion, or stellate lesion without microcalcifications". The histopathology was divided into three subgroups: diagnostic, atypia (ranging from atypical cells to probably cancer), and non-diagnostic material. Post-surgical histopathology diagnosed 454 (87%) malignant tumors and 69 (13%) benign lesions. Three S-CNB correctly diagnosed the malignant tumors in 84% in the subgroup "microcalcifications only". In the category "microcalcifications and a mass", the diagnostic accuracy was 97% and in the subgroup "mass, architectural distorsion, or stellate lesion without microcalcifications" 3 S-CNB resulted in 93% correct diagnostic material. In 19 of the 454 patients (4%) 1, 2 or all 3 preoperative S-CNB showed atypia. In 20 patients (4%), all 3 S-CNB were non-diagnostic. Thirteen of these 20 patients had "microcalcifications only" and 7 had a mass without microcalcifications. Three S-CNB were enough for correct diagnosis in "masses, architectural distorsions, or stellate lesions without microcalcifications" and in "microcalcifications and a mass", but were not sufficient in "microcalcifications only".