Surgical Pathological Confirmation Research Articles

An ultrasound based method for predicting the malignant potential of primary gastrointestinal stromal tumors preoperatively.

Gastrointestinal stromal tumors (GISTs) are difficult to identify the risk level accurately without surgical pathological confirmation. The purpose of our study was to propose a noninvasive prediction method for predicting the malignant potential of GISTs preoperatively by using contrast-enhanced ultrasound (CEUS) with gastric distention. We reviewed 47 GISTs who underwent CEUS from April 2017 to August 2023 retrospectively, all the lesions were certificated by pathology after surgery. The age of the patient, size of the lesion, shape, necrosis, calcification in the lesion, perfusion parameters including arrival time (AT), peak intensity (PI), time to peak (TTP), and area under the curve (AUC) of the lesion and surrounding normal tissue were analyzed. Logistic regression analyses were performed. Of the 47 GISTs, 26 were high-risk and 21 low-risk tumors respectively. Compared with low-risk GISTs, high-risk GIST had faster AT (7.7s vs. 11.5s, p < 0.05), higher PI (15.2dB vs. 12.5dB, p < 0.05), and larger size (4.4cm vs. 2.2cm, p < 0.001). In multivariate logistic regression, AT, PI, and size were significant features. The corresponding regression equation In (p/(1-p)=-5.9 + 4.5 size + 4.6 PI + 4.0 AT). The size, AT, and PI of the GISTs on CEUS can be used as parameters for a noninvasive risk level prediction model of GISTs. This model may help identify the different risk levels of GISTs before surgery.

Abstract PO2-23-04: Magnetic Seeds, used to Locate the Metastatic Axillary Lymph Node placed before Neoadjuvant Chemotherapy for Breast Cancer Treatment, do not interfere the pre-surgical MRI Breast response assessment

Abstract Background: Axillary management in clinically node-positive patients who converted to ycN0 after neoadjuvant chemotherapy (NAC) for breast cancer (BC) remains under research with the aim of de-escalation of axillary lymph node dissection (ALND). A magnetic seed is one of the several positive lymph nodes marking techniques used in targeted axillary dissection (TAD) for patients with cN1 breast cancer undergoing neoadjuvant systemic therapy. It has been criticized for its potential masking effect due to the artefact it produces in the MRI sequences used to assess a proper breast response. This study evaluates if the magnetic seeds placed before NAC for guided TAD have influenced in the breast MRI response assessments. Methods: From October 2021 to June 2023, patients with cT0-4 cN1 breast cancer who were candidates for primary systemic treatment were prospectively recruited. Once a breast lesion and axillary node positivity were confirmed, a based hydrogel marker and a magnetic seed, respectively, were placed prior NAC. Once systemic treatment was completed, imaging techniques were used to assess the response, with MRI being the imaging technique of choice to assess breast response and axillary ultrasound the imaging technique of choice to assess axillary response. Surgical pathological confirmation of response in the axilla was by TAD, including sentinel lymph node and magnetic clipped node resection. Results: A total of 43 patients were included and their characteristics are shown in Table 1. In 16 patients (37%) the tumour was located in the upper outer quadrant (UOQ). In this group, the susceptibility artefact produced by the magnetic seed in the MRI created a black hole obscuring the axilla with a mean diameter of 69 mm (range: 57-76 mm). In no case did the halo interfere with the correct MRI visualisation of the breast marker. By MRI, the mean distance of the artifact halo from the breast marker or residual breast lesion was 40 mm (range: 13-79 mm). Overall, complete radiological response (ycCR) was reported in 20 patients (46%), breast only in 21 (49%) and axilla only in 38 (88%) patients. In 5 patients, preoperative axillary ultrasound revealed residual axillary disease, confirmed by FNA, lead to direct ALND. In the remaining 38 patients the axillary TAD assessment was completed. In all cases, the magnetic clipped node was successfully surgically removed. Pathological complete response (pCR) was confirmed in 9 (21%), breast only in 11 (26%) and axilla only in 13 (30%) patients. MRI diagnostic performance in detecting residual breast disease after NAC was not altered by the magnetic clipped node artifact when comparing the tumour location in the UOQ to the other quadrants (AUC 0.764 vs. 0.702; p=0.698). Conclusions: Surgical axillary staging remains the most reliable method for assessing the axillary response after NAC. Target axillary dissection guided by magnetic seed placed before NAC is an effective and accurate technique. The artifact generated in the MRI does not interfere with the pre-surgical breast response assessment after neoadjuvant systemic treatment. Table 1: Patients and tumor characteristics Citation Format: Martin Espinosa-Bravo, Joaquin Rivero Deniz, Clara Morales Comas, Javier de la Torre Fernandez de Vega, Irene Vives Rosello, Enrica Esposito, Vicente Peg Camara, María De Les Neus Rus Calafell, Ignacio Miranda Gomez, Christian Siso Raber. Magnetic Seeds, used to Locate the Metastatic Axillary Lymph Node placed before Neoadjuvant Chemotherapy for Breast Cancer Treatment, do not interfere the pre-surgical MRI Breast response assessment [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-23-04.

Going With the Flow: An Aid in Detecting and Differentiating Bronchopulmonary Sequestrations and Hybrid Lesions

To assess the ability of prenatal ultrasound (US) in identifying systemic feeding arteries in bronchopulmonary sequestrations and hybrid lesions and report the ability of US in classifying bronchopulmonary sequestrations as intralobar or extralobar. Institutional Review Board-approved radiology and clinical database searches from 2008 to 2015 were performed for prenatal lung lesions with final diagnoses of bronchopulmonary sequestrations or hybrid lesions. All patients had detailed US examinations, and most patients had ultrafast magnetic resonance imaging (MRI). Lesion location, size, and identification of systemic feeding arteries and draining veins were assessed with US. The study consisted of 102 bronchopulmonary sequestrations and 86 hybrid lesions. The median maternal age was 30 years. The median gestational age was 22 weeks 5 days. Of bronchopulmonary sequestrations, 66 had surgical pathologic confirmation, and 100 had postnatal imaging. Bronchopulmonary sequestration locations were intrathoracic (n = 77), intra-abdominal (n = 19), and transdiaphragmatic (n = 6). Of hybrid lesions, 84 had surgical pathologic confirmation, and 83 had postnatal imaging. Hybrid lesion locations were intrathoracic (n = 84) and transdiaphragmatic (n = 2). Ultrasound correctly identified systemic feeding arteries in 86 of 102 bronchopulmonary sequestrations and 79 of 86 hybrid lesions. Of patients who underwent MRI, systemic feeding arteries were reported in 62 of 92 bronchopulmonary sequestrations and 56 of 81 hybrid lesions. Ultrasound identified more systemic feeding arteries than MRI in both bronchopulmonary sequestrations and hybrid lesions (P < .01). Magnetic resonance imaging identified systemic feeding arteries that US did not in only 2 cases. In cases in which both systemic feeding arteries and draining veins were identified, US could correctly predict intrathoracic lesions as intralobar or extralobar in 44 of 49 bronchopulmonary sequestrations and 68 of 73 hybrid lesions. Ultrasound is most accurate for systemic feeding artery detection in bronchopulmonary sequestrations and hybrid lesions and can also type the lesions as intralobar or extralobar when draining veins are evaluated.

Multidetector computed tomography vs magnetic resonance imaging for defining the upper limit of tumour thrombus in renal cell carcinoma: A study and review: Lawrentschuk N, Gani J, Riordan R, Esler S, Bolton DM, Surgery and Urology, University of Melbourne, Austin Hospital, Heidelberg, Victoria, Australia

To compare the findings of multidetector computed tomography (CT) with surgical pathology and magnetic resonance imaging (MRI), to determine the accuracy of delineating the superior extent of inferior vena cava (IVC) thrombotic involvement in renal cell cancer (RCC). A prospective database was examined of 11 patients (median age 65 years, range 45–77) being assessed for suspected IVC extension of RCC tumour thrombus with both multidetector CT and MRI. All had pathology confirming RCC, and eight of those undergoing surgery had pathological confirmation of tumour thrombus extent. All images were analysed originally, then re-analysed by two independent radiologists, an experienced urologist and a urological trainee unaware of the original reports and other imaging results, with a final determination on tumour thrombus level by consensus. The multidetector CT results were completely accurate when compared with surgical specimens and were in agreement with MRI on all but one occasion, where MRI determined the renal vein to be clear when it was involved on CT and at surgery, giving MRI an accuracy of seven of eight samples. Whilst there were few patients and further studies are needed, multidetector CT was comparable with MRI in determining tumour thrombus level. More importantly, in the eight patients with surgical pathological confirmation, multidetector CT was accurate in all. Ultimately, it may replace MRI as the ‘gold standard’ for imaging to delineate the upper limit of tumour thrombosis in RCC.

Multidetector computed tomography vs magnetic resonance imaging for defining the upper limit of tumour thrombus in renal cell carcinoma: a study and review

To compare the findings of multidetector computed tomography (CT) with surgical pathology and magnetic resonance imaging (MRI), to determine the accuracy of delineating the superior extent of inferior vena cava (IVC) thrombotic involvement in renal cell cancer (RCC). A prospective database was examined of 11 patients (median age 65 years, range 45-77) being assessed for suspected IVC extension of RCC tumour thrombus with both multidetector CT and MRI. All had pathology confirming RCC, and eight of those undergoing surgery had pathological confirmation of tumour thrombus extent. All images were analysed originally, then re-analysed by two independent radiologists, an experienced urologist and a urological trainee unaware of the original reports and other imaging results, with a final determination on tumour thrombus level by consensus. The multidetector CT results were completely accurate when compared with surgical specimens and were in agreement with MRI on all but one occasion, where MRI determined the renal vein to be clear when it was involved on CT and at surgery, giving MRI an accuracy of seven of eight samples. Whilst there were few patients and further studies are needed, multidetector CT was comparable with MRI in determining tumour thrombus level. More importantly, in the eight patients with surgical pathological confirmation, multidetector CT was accurate in all. Ultimately, it may replace MRI as the 'gold standard' for imaging to delineate the upper limit of tumour thrombosis in RCC.

The Isolated Pancreatic Duct (PD) Stricture with Negative Brush Cytology: EUS for the Detection of Underlying Malignancy

Background: Pancreatic cancer and chronic pancreatitis cause the vast majority of isolated PD strictures. The diagnostic workup requires the differentiation of benign from malignant strictures. This vital distinction leads to the consideration of surgical pancreatic resection for malignant disease while benign strictures can often be managed by endoscopy. Unfortunately, brush cytology (BC) of malignant strictures yields positive findings in less than one half of patients. In the absence of positive brush cytology, one must consider alternative methods to judge the likelihood of malignancy. Objective: Determine the diagnostic performance of EUS in the detection of pancreatic cancer in the setting of an isolated PD stricture with negative BC. Methods: From January 2000 to November 2004, 2692 patients underwent ERCP among whom 131 had BC negative PD strictures. Fifty one patients had isolated PD strictures while the remaining 80 cases had concomitant biliary strictures. All patients who had an isolated PD stricture and had undergone EUS examination were included in the study (28 patients, 14 females, median of age: 55, age range: 26-79). A compound criteria was used for the final diagnosis. 24 patients had benign strictures based on (a) surgical-pathologic confirmation (8 patients) or (b) results of clinical follow-up of at least 12 months demonstrating a lack of clinical or radiologic disease progression (16 patients). In 4 patients with malignant stricture, this determination was based on (a) malignant cytologic results at endoscopic US–guided FNAB, with a subsequent clinical course consistent with malignant disease (1 patient) or (b) surgical-pathologic confirmation (laparotomy) (3 patients). The results of initial EUS studies were compared to the final diagnosis. The presence of a mass was considered indicative of malignancy on EUS exam. Results: Twenty four patients had benign strictures while 4 patients had malignant strictures (prevalence of 15%). All patients with malignant strictures were accurately identified on EUS exam. There were no false negative findings. Of the 24 patients with benign strictures 22 were accurately identified on EUS exam. Two cases were falsely positive (mass visualized). The sensitivity, specificity, PPV, and NPV of EUS in our set of patients were 100%, 92%, 67%, and 100% respectively. Conclusion: In the setting of an isolated PD stricture, the absence of a mass lesion on EUS effectively excludes underlying malign. Background: Pancreatic cancer and chronic pancreatitis cause the vast majority of isolated PD strictures. The diagnostic workup requires the differentiation of benign from malignant strictures. This vital distinction leads to the consideration of surgical pancreatic resection for malignant disease while benign strictures can often be managed by endoscopy. Unfortunately, brush cytology (BC) of malignant strictures yields positive findings in less than one half of patients. In the absence of positive brush cytology, one must consider alternative methods to judge the likelihood of malignancy. Objective: Determine the diagnostic performance of EUS in the detection of pancreatic cancer in the setting of an isolated PD stricture with negative BC. Methods: From January 2000 to November 2004, 2692 patients underwent ERCP among whom 131 had BC negative PD strictures. Fifty one patients had isolated PD strictures while the remaining 80 cases had concomitant biliary strictures. All patients who had an isolated PD stricture and had undergone EUS examination were included in the study (28 patients, 14 females, median of age: 55, age range: 26-79). A compound criteria was used for the final diagnosis. 24 patients had benign strictures based on (a) surgical-pathologic confirmation (8 patients) or (b) results of clinical follow-up of at least 12 months demonstrating a lack of clinical or radiologic disease progression (16 patients). In 4 patients with malignant stricture, this determination was based on (a) malignant cytologic results at endoscopic US–guided FNAB, with a subsequent clinical course consistent with malignant disease (1 patient) or (b) surgical-pathologic confirmation (laparotomy) (3 patients). The results of initial EUS studies were compared to the final diagnosis. The presence of a mass was considered indicative of malignancy on EUS exam. Results: Twenty four patients had benign strictures while 4 patients had malignant strictures (prevalence of 15%). All patients with malignant strictures were accurately identified on EUS exam. There were no false negative findings. Of the 24 patients with benign strictures 22 were accurately identified on EUS exam. Two cases were falsely positive (mass visualized). The sensitivity, specificity, PPV, and NPV of EUS in our set of patients were 100%, 92%, 67%, and 100% respectively. Conclusion: In the setting of an isolated PD stricture, the absence of a mass lesion on EUS effectively excludes underlying malign.

Cytologic features of villous adenoma of the ampullary region.

Villous adenoma of the ampulla of Vater is a rare but distinct pathologic entity. We studied seven brush cytology specimens from four patients with this unusual lesion all of whom had surgical pathologic confirmation and clinical follow-up. The distinguishing cytologic appearance includes the presence of slender, elongate columnar cells arranged singly or in small sheets and clusters. Long, thin, basally oriented nuclei occupy about one third of the cell and have fine, granular chromatin with one or more nucleoli. Although brushings of villous adenoma of the ampullary region may reveal a relatively benign but distinctive morphologic pattern, the aggressive nature of these lesions has been well documented, including those in our patients.

Syphilis of the Esophagus

SYPHILIS of the esophagus, like gastric syphilis or syphilis of other portions of the alimentary tract, presents many problems, the chief of which is probably diagnosis. Unfortunately there is little available information on this subject in the literature. While syphilis of the esophagus has been recognized for the past two centuries, there have been only occasional reports on the subject. One author states that there have been less than 100 cases reported, and of these, many are not proven or authentic. When we consider the problem from the diagnostic point of view, realizing how often it is almost impossible to prove this diagnosis, even when all signs point to this condition, it is not difficult to understand why there is such a paucity of authentic literature. Lack of confirmation of diagnosis may be attributable in large part to the following factors: (1) No indications for operation and surgical-pathologic confirmation. (2) Amenability to treatment. (3) Similarity to other lesions and co-existence with them. (4) Difficulty in securing biopsy material. (5) Non-recognition of lesions by esophagoscopist or failure to make the esophagoscopic examination. (6) Infrequent postmortem confirmation—the esophagus is seldom examined. We are again confronted by the problem of very few available statistics as to the incidence of syphilis of the esophagus. There is no doubt, however, that it is an unusual disease. We know that syphilis attacks the gastro-intestinal tract less frequently than other portions of the body, with the exception of the mouth and pharynx, and is less commonly found in the esophagus than in other portions of the alimentary tract. Lawrence states that syphilis of the esophagus is diagnosed as such in only one or two of every thousand cases in which lesions are present. Lukens and Ono found in the literature only 12 cases of tracheo-esophageal fistula attributable to syphilis. Another author found four syphilitic lesions of the esophagus in 350 consecutive cases of dysphagia, while still another writer claims that thousands of esophageal examinations may be made without finding a single case of syphilitic involvement. Myerson claims that from 95 to 98 per cent of all esophageal lesions in adults are carcinomas. Even though we admit that syphilis of the esophagus is occasionally unrecognized, it must still be considered a lesion, the diagnosis of which is seldom established. The disease exhibits the same pathologic changes as those which occur in syphilis of other portions of the gastro-intestinal tract. Rarely is it in the congenital form, but it does occur. There is an esophagitis in the secondary stage often associated with mucous plaques and ulceration. We find the gumma and the contractural sclerosis in the tertiary stage. Esophagitis occurs more often in the middle half, while gummas are usually in the upper or lower thirds. There may be induration and spasm. A gumma may ulcerate and rupture.