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A 2240 gram boy was born at 33.2 weeks gestation with nonblanching, deeply erythematous plaques and papules on the back, flanks, and scalp (Figure 1). His mother was GBS positive and on antibiotic suppression for prior cutaneous MRSA and urinary tract infections. Intrapartum intravenous Penicillin G was administered, and the amniotic sac was artificially ruptured 4 hours prior to delivery to facilitate labor. The delivery was uncomplicated without concern for chorioamnionitis, but the patient initially required CPAP for respiratory distress with 1-minute and 5-minute Apgar scores of 7 and 8, respectively. A skin punch biopsy is shown (Figure 2).
Image-guided percutaneous biopsy of abdominal masses is a safe, minimally invasive procedure with a high diagnostic yield for a variety of pathologic processes. This article describes the basic technique of percutaneous biopsy, including the different modalities available for imaging guidance. Patient selection and preparation for safe performance of the procedure is emphasized, and the periprocedural management of coagulation status as well as basic indications and contraindications of the procedure are briefly discussed. In particular, the role of biopsy in the diagnosis of liver and renal masses is highlighted.
Copyright © 2015 Elsevier Inc. All rights reserved.
Despite advances in perfusion imaging, burn wound imaging technology continues to lag behind that of other fields. Quantification of blood flow is able to predict time for healing, but clear assessment of burn depth is still questionable. Active dynamic thermography (ADT) is a noncontact imaging modality capable of distinguishing tissue of different thermal conductivities. Utilizing the abnormal heat transfer properties of the burn zones, we examined whether ADT was useful in the determination of burn depth in a model of early burn wound evaluation. Duroc pigs (castrated male; n = 3) were anesthetized, and two burns were created with an aluminum billet at 3 and 12 seconds. These contact times resulted in superficial partial and deep partial thickness burn wounds, respectively. ADT and laser Doppler imaging (LDI) imaging were performed every 30 minutes postburn for a total of five imaging sessions ending 150 minutes postburn. For ADT, imaging excitation was performed for 42-120 seconds with dual quartz-infrared lamps, and subsequent infrared image capture was performed for 300 seconds. MATLAB-assisted image analysis was performed to determine burn zone region of interest thermal relaxation and characteristic patterns. LDI was performed with a moorLDI system, and biopsies were captured for histology following the 150-minute imaging session. Both ADT and LDI imaging modalities are able to detect different physical properties at 30, 60, 90 120, and 150 minutes postburn with statistical significance (P < 0.05). Resultant ADT cooling curves characterize greater differences with greater stimulation and a potentially more identifiable differential cooling characteristic. Histological analysis confirmed burn depth. This preliminary work confirms that ADT can measure burn depth and is deserving of further research either as a stand-alone imaging technology or in combination with a device to assess perfusion.
OBJECTIVES - Immunohistochemical markers have been shown to assist in the stratification of breast papillary lesions. We evaluated the ability of different cytokeratin (CK) and p63 expression profiles on needle biopsy specimens to predict excision diagnoses.
METHODS - A CK5/p63/CK8/18 antibody cocktail was applied to 58 needle biopsy specimens (32 papillomas, 7 atypical papillomas, 19 papillary carcinomas on excision).
RESULTS - p63 expression was greater in papillomas than in atypical papillomas (P = .044) and papillary carcinomas (P< .0001). Papillary carcinomas and atypical papillomas showed greater CK8/18 expression (and conversely less CK5 expression) than did papillomas (P < .0001). Negative or focal p63 expression was 96% sensitive for diagnosing any atypical lesion (atypical papilloma or papillary carcinoma) on excision, whereas CK8/18 predominant expression (≥80% cells) was 100% sensitive. In contrast, the sensitivity of the original diagnosis was only 81%. The greatest accuracy for the diagnosis of atypical papillary lesions (95%) was achieved when both p63 and cytokeratins were used in combination in an algorithmic fashion. This method also correctly identified all cases that had papillary carcinoma (100% sensitivity) on excision.
CONCLUSIONS - Although a single stain or combination cannot independently stratify papillary lesions, a CK5/p63/CK8/18 antibody cocktail is a useful adjunct to morphology for evaluating breast papillary lesions in needle biopsy specimens.
Prostatic adenocarcinoma with aberrant diffuse expression of p63 (p63-PCa) is a recently described variant of prostatic adenocarcinoma. The aim of this study was to investigate the clinical and pathologic features of p63-PCa at radical prostatectomy (RP). We reviewed 21 cases of p63-PCa diagnosed on needle biopsy at subsequent RP. Immunohistochemical analysis for PIN4 and Ki-67 was performed in all RP cases. p63-PCa showed a distinctive morphology consisting of atrophic, poorly formed glands, with multilayered and often spindled nuclei. Gleason grading was 3+3=6 in 28.5%, 3+5=8 in 38%, 3+4=7 in 14.3%, and 4+3=7, 5+3=8, and 5+4=9 in 9.5%. Usual-type acinar carcinoma coexisted in 85.7% with only p63-PCa present in the remaining cases. The usual-type carcinoma was Gleason grade 3+2=5 in 4.7%, 3+3=6 in 57%, 3+4=7 in 19%, and 4+3=7 in 4.3%. Overall, p63-PCa represented 65% of the total cancer volume (median 80%). The tumor was organ-confined in 16 cases (76.2%). In the remaining 5 cases, 2 had p63-PCa extending to the margin in areas of intraprostatic incisions, 2 had usual-type acinar adenocarcinoma extending to the margin and extraprostatic tissue, respectively, and 1 had p63-PCa with an unusual cribriform morphology involving the bladder neck. Ki-67 was low, <5% in all cases of p63-PCa, with similar expression in the coexisting acinar-type carcinoma. In summary, it is recommended that these tumors not be assigned a Gleason score and their favorable findings at RP be noted.
BACKGROUND - Sinonasal undifferentiated carcinoma (SNUC) remains a poorly characterized malignancy at both the clinical and molecular level, and, consequently, the optimal treatment strategy remains undefined.
METHODS - We used a mass spectroscopy-based approach (Sequenom) to evaluate 95 hallmark single nucleotide variations (SNVs) within 12 oncogenes or tumor suppressor genes (AKT, BRAF, CDK4, Beta-catenin, epidermal growth factor receptor [EGFR], FBXW7, JAK2, c-KIT, KRAS, PDGFR, PI3K, and vascular endothelial growth factor [VEGF]) in 13 histologically confirmed SNUC cases.
RESULTS - None of the samples demonstrated activating mutations in any of the 95 SNVs.
CONCLUSION - Select clinically relevant activating genomic mutations were not identified in the 13 patient samples. However, polymorphisms were noted within the promoter region of VEGF. These may merit future studies as predictive biomarkers for treatment response or overall survival. Additionally, future studies focusing on larger tumor sets and utilizing whole genome or exome sequencing may help define genetic aberrations in SNUC that can be clinically targeted with available or emerging biological agents.
Copyright © 2013 Wiley Periodicals, Inc.
Tumor size is a significant prognostic indicator for invasive mammary carcinoma. By current standards, this is routinely reported during pathologic evaluation of the definitive excision, but no recommendations exist for reporting tumor size in needle biopsy material. The purpose of this study is to evaluate the relationship between tumor size on breast needle biopsy specimens and that on subsequent definitive excision specimens and to evaluate the impact of the former, if any, in determining the final pathologic tumor stage. This was achieved by an evaluation of 222 consecutive cases of invasive mammary carcinoma for which both the diagnostic biopsy and definitive excision were available for review. Of 200 cases without a history of neoadjuvant therapy, there were 161 (80.5%) cases in which the tumor size on biopsy was smaller, 15 (7.5%) cases in which the sizes were equal, and 24 (12%) in which the size on biopsy was greater, including 6 (3%) cases with no residual tumor on excision. The average size change (excision size minus biopsy size) increased with increasing tumor stage, with these being significantly lower in pT1a compared with pT1b tumors (-0.14 vs. 0.17 mm; P=0.0002), pT1a/b compared with pT1c tumors (0.12 vs. 0.53 mm; P<0.0001), and pT1 compared with pT2/3 tumors (0.32 vs. 2.2 mm; P<0.001). Of the 24 cases in which tumor size on biopsy was greater than that on excision, there were 15 (7.5% of cohort) in which the tumor size on biopsy was the sole determinant of a higher final pathologic T stage. A larger tumor size on biopsy compared with that on excision was significantly associated with a lower final pathologic T stage (P<0.001) but not with patient age, histologic type, histologic grade, mitotic score, or the presence/absence of ductal carcinoma in situ. Evaluation of the remaining 22 cases also showed that there was a clear association between a history of neoadjuvant therapy and the finding of a larger size on biopsy compared with that on excision (P<0.0001). These findings indicate that tumor size on breast needle biopsy is not infrequently larger than that on excision and can also dictate the final pathologic T stage. Accordingly, it is recommended that the greatest extent of invasive carcinoma is reported in all needle biopsy specimens.
PURPOSE - An optimal prostate biopsy in clinical practice is based on a balance among adequate detection of clinically significant prostate cancers (sensitivity), assuredness regarding the accuracy of negative sampling (negative predictive value), limited detection of clinically insignificant cancers and good concordance with whole gland surgical pathology results to allow accurate risk stratification and disease localization for treatment selection. Inherent within this optimization is variation of the core number, location, labeling and processing for pathological evaluation. To date, there is no consensus in this regard. The purpose of this review is to 1) define the optimal number and location of biopsy cores during primary prostate biopsy among men with suspected prostate cancer, 2) define the optimal method of labeling prostate biopsy cores for pathological processing which will provide relevant and necessary clinical information for all potential clinical scenarios, and 3) determine the maximal number of prostate biopsy cores allowable within a specimen jar which would not preclude accurate histological evaluation of the tissue.
MATERIALS AND METHODS - A bibliographic search using PubMed® covering the period up to July 2012 yielded approximately 550 articles. Articles were reviewed and categorized based on which of the 3 objectives of this review was addressed. Data were extracted, analyzed and summarized. Recommendations are provided based on this literature review and our clinical experience.
RESULTS - The use of 10 to 12-core extended sampling protocols increases cancer detection rates compared to traditional sextant sampling methods and reduces the likelihood of repeat biopsy by increasing negative predictive value, ultimately allowing more accurate risk stratification without increasing the likelihood of detecting insignificant cancers. As the number of cores increases above 12, the increase in diagnostic yield becomes marginal. Only limited evidence supports the use of initial biopsy schemes involving more than 12 cores or saturation. Apical and laterally directed sampling of the peripheral zone increases cancer detection rate, reduces the need for repeat biopsies and predicts pathological features on prostatectomy while transition zone biopsies do not. There are little data to suggest that knowing the exact site of an individual positive biopsy core provides meaningful clinical information. However, determining laterality of cancer on biopsy may be helpful for predicting sites of extracapsular extension and therapeutic planning. Placement of multiple biopsy cores in a single container (greater than 2) appears to compromise pathological evaluation, which can reduce cancer detection rate and increase the likelihood of equivocal diagnoses.
CONCLUSIONS - A 12-core systematic biopsy that incorporates apical and far-lateral cores in the template distribution allows maximal cancer detection, avoids repeat biopsy, and provides information adequate for identifying men who need therapy and planning that therapy while minimizing the detection of occult, indolent prostate cancers. This literature review does not provide compelling evidence that individual site specific labeling of cores benefits clinical decision making regarding the management of prostate cancer. Based on the available literature, we recommend packaging no more than 2 cores in each jar to avoid reduction of the cancer detection rate through inadequate tissue sampling.
Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.