Diagnostic proficiency test using digital cytopathology and comparative assessment of whole slide images of cytologic samples for quality assurance program in Korea

Background@#The Korean Society for Cytopathology introduced a digital proficiency test (PT) in 2021. However, many doubtful opinions remain on whether digitally scanned images can satisfactorily present subtle differences in the nuclear features and chromatin patterns of cytological samples. @*Methods@#We prepared 30 whole-slide images (WSIs) from the conventional PT archive by a selection process for digital PT. Digital and conventional PT were performed in parallel for volunteer institutes, and the results were compared using feedback. To assess the quality of cytological assessment WSIs, 12 slides were collected and scanned using five different scanners, with four cytopathologists evaluating image quality through a questionnaire. @*Results@#Among the 215 institutes, 108 and 107 participated in glass and digital PT, respectively. No significant difference was noted in category C (major discordance), although the number of discordant cases was slightly higher in the digital PT group. Leica, 3DHistech Pannoramic 250 Flash, and Hamamatsu NanoZoomer 360 systems showed comparable results in terms of image quality, feature presentation, and error rates for most cytological samples. Overall satisfaction was observed with the general convenience and image quality of digital PT. @*Conclusions@#As three-dimensional clusters are common and nuclear/chromatin features are critical for cytological interpretation, careful selection of scanners and optimal conditions are mandatory for the successful establishment of digital quality assurance programs in cytology.

A Case of Epithelial-Myoepithelial Carcinoma of Parotid Gland and Analysis of 33 Cases Reported in Korea / 대한두경부종양학회지

Epithelial-myoepithelial carcinoma is rare, low-grade malignant neoplasm that compromises approximately 1% of all salivary gland neoplasms. We reported a 68-year-old woman with epithelial-myoepithelial carcinoma in the parotid gland. We analyzed demographic and clinicopathological characteristics of salivary gland epithelial-myoepithelial carcinoma which has been reported in 33 cases in Korea from 1992 to 2017, and compared this result to overseas retrospective cohort studies. There was no significance in terms of mean age at diagnosis, the predominance of females, low frequency in regional lymph nodes, and distant metastasis between the two groups. However, T classification and AJCC stage at diagnosis in domestic cases are more advanced than those of overseas cases. Although the recurrence rate in domestic cases has been reported lower than that of overseas, further study may be needed considering that the follow-up period after treatment is short in domestic cases.

Continuous quality improvement program and its results of Korean Society for Cytopathology

Since 1995, the Korean Society for Cytopathology has overseen the Continuous Quality Improvement program for cytopathology laboratories. The Committee of Quality Improvement has carried out an annual survey of cytology data for each laboratory and set standards for proficiency tests. Methods: Evaluations were conducted four times per year from 2008 to 2018 and comprised statistics regarding cytology diagnoses of previous years, proficiency tests using cytology slides provided by the committee, assessment of adequacy of gynecology (GYN) cytology slides, and submission of cytology slides for proficiency tests. Results: A total of 206 institutes participated in 2017, and the results were as follows. The number of cytology tests increased from year to year. The ratio of liquid-based cytology in GYN gradually decreased, as most of the GYN cytology had been performed at commercial laboratories. The distribution of GYN diagnoses demonstrated nearly 3.0% as atypical squamous cells. The rate for squamous cell carcinoma was less than 0.02%. The atypical squamous cell/squamous intraepithelial lesion ratio was about 3:1 and showed an upward trend. The major discordant rate of cytology-histology in GYN cytology was less than 1%. The proficiency test maintained a major discordant rate less than 2%. The rate of inappropriate specimens for GYN cytology slides gradually decreased. Conclusions: The Continuous Quality Improvement program should be included in quality assurance programs. Moreover, these data can contribute to development of national cancer examination guidelines and facilitate cancer prevention and treatment.

Focal Thickening at the Fundus of the Gallbladder: Computed Tomography Differentiation of Fundal Type Adenomyomatosis and Localized Chronic Cholecystitis

BACKGROUND/AIMS: The objective of our study was to identify useful computed tomography (CT) findings for differentiating fundal type adenomyomatosis from localized chronic cholecystitis involving the fundus of the gallbladder. METHODS: We retrospectively identified cases of 41 patients with pathologically proven adenomyomatosis (n=21) or chronic cholecystitis (n=20) who had fundal thickening of the gallbladder on preoperative abdominal CT. Analysis of the CT findings included evaluation of the thickness, contour, border, intralesional cystic area, adjacent gallbladder wall thickening, presence of inner layer enhancement, enhancement grade, enhancement pattern, and presence of stones. Statistical analyses were performed using the Mann-Whitney U test and Fisher exact test. RESULTS: Oval contour, inner layer enhancement and intralesional cystic area were more frequently noted in adenomyomatosis than in chronic cholecystitis (p<0.05 for each finding). Flat contour and adjacent gallbladder wall thickening were more frequently observed in chronic cholecystitis than in adenomyomatosis. No differences between adenomyomatosis and chronic cholecystitis in terms of the thickness, enhancement grade, enhancement pattern and presence of stones were apparent. CONCLUSIONS: CT may help to differentiate fundal type adenomyomatosis from localized chronic cholecystitis involving the fundus of the gallbladder.

Pulmonary Cryptococcosis That Mimicked Rheumatoid Nodule in Rheumatoid Arthritis Lesion / 결핵및호흡기질환

Recently, the incidence of pulmonary cryptococcosis is gradually increasing in rheumatoid arthritis (RA) patients. Pulmonary rheumatoid nodules (PRN) are rare manifestations of RA. Eighteen months ago, a 65-year old woman was admitted to hospital due to multiple nodules (2.5x2.1x2 cm) with cavitations in the right lower lobe. She was diagnosed with RA three year ago. She had been taking methotrexate, leflunomide, and triamcinolone. A video-assisted thoracoscopic surgery biopsy was performed and PRN was diagnosed. However, a newly growing huge opacity with cavitation was detected in the same site. Pulmonary cryptococcal infection was diagnosed through a transthoracic computed tomograpy guided needle biopsy. Cryptococcus antigen was detected in serum but not in cerebrospinal fluid. The patient was treated with oral fluconazole which resulted clinical improvement and regression of the nodule on a series of radiography. Herein, we report the case of pulmonary cryptococcosis occurring in the same location as that of the PRN.

A Case of Sjogren's Syndrome Associated with Neuromyelitis Optica

Neuromyelitis optica (NMO) is an idiopathic inflammatory demyelinating disease, characterized by optic neuritis and myelitis. NMO is a very uncommon and serious neurologic manifestation of Sjogren's syndrome. We report on a 32-year-old female with NMO as central nerve system involvement of Sjogren's syndrome. She had a transverse myelitis ten years ago and did not have symptoms for a long period of time. She visited the emergency center because of worsening weakness of both limbs. She had an appendectomy three days ago before hospitalization. Cervical spinal magnetic resonance imaging showed increased signal intensity in T2-weighted images from the cervical (C2) to the upper thoracic (T4) spinal cord. As serum NMO-IgG was positive, we diagnosed neuromyelitis optica and treated with high dose steroid, but failed. Therefore, we treated with plasmapheresis and the patient was discharged without any neurological deficits.

A Case of Warfarin-Induced Bleeding in a Patient with CYP2C9 and VKORC1 Gene Polymorphism, Detected by a Point-of-Care Gene Test Device / 대한내과학회지

A 69-year-old female Korean patient was initially prescribed warfarin for the prevention of systemic thromboembolism due to atrial fibrillation. One month later, multiple bruises and subcutaneous hematomas were evident, and laboratory testing revealed a prolonged prothrombin time (PT) of > 106s. After admission, the PT was corrected via fresh frozen plasma transfusion and intravenous vitamin K infusion. We sought to determine the cause of the PT prolongation, suspecting that genetic cause may have had an effect on the variation in the warfarin dose requirement. A point-of-care gene test device (Verigene(R) system; Nanosphere, Northbrook, IL) revealed CYP2C9*1/*3 heterozygosity and a VKORC1 A/A single nucleotide polymorphism. Although it is well established that CYP2C9 or VKORC1 gene polymorphisms can influence warfarin dose requirements, they can be easily neglected, with detrimental outcomes. Through our experience with CYP2C9 and VKORC1 polymorphism causing bleeding complications during warfarin treatment, we aim to emphasize the importance of pharmacogenetic testing to avoid this potential oversight.

BBilateral Intranasal Supernumerary Teeth

The presence of an ectopic supernumerary tooth in the nose is an uncommon phenomenon. A supernumerary tooth may be asymptomatic but must be given special attention as it has the potential to cause significant morbidity. Bilateral intranasal supernumerary teeth are an extremely rare disease entity. We report the clinical and radiologic findings of bilateral ectopic supernumerary teeth erupted from the nasal floor.

Delayed-Onset Complete Atrioventricular Block in a Patient with Murine Typhus Myocarditis / 대한내과학회지

Murine typhus is a flea-borne infectious disease caused by Rickettsia typhi, of which myocarditis is a rare complication in the acute disseminating phase. A 62-year-old female presented with a fever and was diagnosed with murine typhus. She was treated with doxycycline and discharged after complete resolution of the fever. However, recurrent presyncope and exertional dyspnea developed 6-8 weeks later. Complete atrioventricular (AV) block with a wide QRS escape rhythm and a left bundle branch block configuration was documented. Subacute myocarditis was diagnosed based on persistent cardiac troponin-I elevation and typical cardiac magnetic resonance imaging findings. A permanent pacemaker was implanted for symptomatic complete AV block. Few reports of myocarditis in murine typhus have been published. We report a case of murine typhus myocarditis complicated by complete AV block in the late convalescence phase.

A Giant Unruptured Right Coronary Sinus of Valsalva Aneurysm

There have been few case reports on giant sinus of Valsalva aneurysm (SVA). We report a case of a giant unruptured right coronary SVA that was confused with a pericardial cyst by transthoracic echocardiography.

A Giant Unruptured Right Coronary Sinus of Valsalva Aneurysm

There have been few case reports on giant sinus of Valsalva aneurysm (SVA). We report a case of a giant unruptured right coronary SVA that was confused with a pericardial cyst by transthoracic echocardiography.

Cardiogenic Shock From Global Myocardial Ischemia Induced by Simultaneous Multivessel Coronary Spasm

Coronary artery spasm is an uncommon, but well recognized, etiology for acute myocardial infarction. However, cardiogenic shock with myocardial infarction resulting from simultaneous multiple coronary artery spasm has been rarely reported, and not in Korea. Recently, we experienced such a case in a 50-year-old Korean man without previous diagnosis of variant angina. The patient, hospitalized for blood sugar control, developed severe chest pain accompanying ST-segment elevation in multiple leads. The patient immediately received cardiac catheterization because of cardiogenic shock. Coronary angiogram revealed the severe and simultaneous spasm of three major epicardial arteries, which was promptly relieved by an intracoronary administration of isosorbide dinitrate. This case highlights the need to rule out the potential mechanism of coronary spasm even in the most severe episodes of acute coronary syndrome.

A Case of Actinomycosis of the Maxillary Sinus Accompanied with Fungal Ball

Actinomycosis of the paranasal sinuses is rare and usually arises from the oral cavity after a dental procedure or trauma. Actinomycosis of the maxillary sinus is very rare and found only in isolated case reports. We report the case of a 62-year-old patient with actinomycosis accompanied by a fungal ball in the maxillary sinus.

Anesthesia of a dental patient with Angelman syndrome: A case report / 대한마취과학회지

Angelman syndrome is characterized by a partial deficit of paired autosomal chromosome 15, which contains a subunit of the GABA (Gamma-Amino Butyric Acid) receptor. Many drugs that act on the CNS (Central Nerve System) during anesthesia are believed to exert their effects via the GABA receptors. We describe the anesthesia of a 7 year-old female patient with Angelman syndrome who underwent surgery for dental caries. The basic factors that needed to be considered when administering anesthesia to this patient were epilepsy, significant dominance of the vagal tone, craniofacial abnormalities and peripheral muscular atrophy. Inhalational anesthetics (sevoflurane) were employed for this patient. The patient had an uneventful peri-operative period and was discharged home on the same day of the operation.

Anesthesia of a dental patient with Angelman syndrome: A case report / 대한마취과학회지

Angelman syndrome is characterized by a partial deficit of paired autosomal chromosome 15, which contains a subunit of the GABA (Gamma-Amino Butyric Acid) receptor. Many drugs that act on the CNS (Central Nerve System) during anesthesia are believed to exert their effects via the GABA receptors. We describe the anesthesia of a 7 year-old female patient with Angelman syndrome who underwent surgery for dental caries. The basic factors that needed to be considered when administering anesthesia to this patient were epilepsy, significant dominance of the vagal tone, craniofacial abnormalities and peripheral muscular atrophy. Inhalational anesthetics (sevoflurane) were employed for this patient. The patient had an uneventful peri-operative period and was discharged home on the same day of the operation.

A Case of Sialectasis of Stensen's Duct / 대한이비인후과학회지

Sialectasis of Stensen's duct is a rare disease that is characterized by abnormal dilatation of the duct. The underlying pathology in this condition is obscure, but ductal dilation most commonly occurs as a consequence of ductal stenosis or narrowing. In this report, a rare case of sialectasis of Stensen's duct confirmed by radiologic study is presented with a review of the literature.

A Case of Laryngeal Amyloidosis / 대한이비인후과학회지

Amyloidosis is not a single entity but rather a group of diseases characterized by the presence of extracelluar deposition of insoluble, fibrillar, proteinaceous material with a well-defined, beta-pleated sheet ultrastructure, mainly in tissues derived from the mesoderm. Approximately 9% to 15% of amyloid tumors are localized. The larynx is the most usually involved site in the head and neck. It is estimated that less than 1% of the benign tumors is found in the larynx. We report a case of laryngeal amyloidosis with a review of its clinical patterns, diagnostic tools, pathologic findings and treatments.

Occluded Espocan(R) needle and accidental dural puncture during combined spinal-epidural anesthesia: A case report / 대한마취과학회지

Here, we report a case of an occluded modified Tuohy needle (Espocan(R), B. Brown, Germany) due to the patient's own tissue. A 70-year-old female with left knee osteoarthritis was admitted for a total knee replacement arthroplasty under combined spinal-epidural anesthesia. Insertion of the Tuohy needle proceeded from the skin to 6 cm and then 6.5 cm, but there was no loss of resistance. We removed the needle from the patient and discovered a fibrous, white tissue inside the needle. We tried again and did the spinal-epidural anesthesia in another interspinous space. This time, we could feel the loss of resistance at 4 cm, but permanent leakage of clear fluid was seen in the epidural catheter so we removed the catheter. We observed the patient closely in the recovery room and ward, and no further complications were found. We present this case to remind the operator the importance of checking the epidural needle that possible may be occluded by a foreign body.

The Relationship between the Methylenetetrahydrofolate Reductase Genotypes and the Methylation Status of the CpG Island Loci, LINE-1 and Alu in Prostate Adenocarcinoma

BACKGROUND: Genetic polymorphism of methylenetetrahydrofolate reductase (MTHFR), in association with the influence of MTHFR upon DNA methylation, may cause differences of the methylation profile of cancer. Thus, we investigated the relationship between the methylation status of prostate adenocarcinoma and the genetic polymorphism of MTHFR. METHODS: We examined 179 cases of prostate adenocarcinoma for determining the genotypes of MTHFR 677 and 1298, the methylation status of 16 CpG island loci and the methylation levels of the LINE-1 and Alu repeats with using polymerase chain reaction/restriction fragment length polymorphism, methylation-specific polymerase chain reaction and combined bisulphite restriction analysis, respectively. RESULTS: There was a higher proportion of the CT genotype of MTHFR 677 in the prostate adenocarcinoma than that in the normal control. The TT genotype of MTHFR 677 showed the highest frequency of methylation in six out of nine major CpG island loci, and these were which were frequently hypermethylated in prostate adenocarcinoma. The CT type showed the lowest methylation levels of LINE-1 and Alu among the MTHFR 677 genotypes. Interestingly, the CC type of MTHFR 1298 demonstrated favorable prognostic factors. CONCLUSIONS: Our study is the first to examine the methylation profile of prostate adenocarcinoma according to the MTHFR genotypes. The differences of the cancer risk, the genomic hypomethylation and the prognosis between the MTHFR genotypes in prostate adenocarcinoma should be further explored.

Cardiac arrest after position change in a morbidly obese patient: A case report / 대한마취과학회지

Morbid obesity presents many clinical problems. Especially, morbid obesity has a significant effect on airway management and pulmonary function. We experienced a cardiac arrest of a morbidly obese (Body Mass Index of about 62 kg/m2). 21-year-old male patient that necessitated cardiopulmonary resuscitation (CPR). The patient was scheduled for an emergency cystoscopy under local anesthesia. After change to supine position in the operation room, dyspnea, tachypnea, agitation, and, subsequently, cardiac arrest developed.