Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021, interpretation and expectation / 中华危重病急救医学

The Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021 (2021 guideline) was recently released. The guidelines summarized the evidences from literatures through to July 2019, and composed by 6 parts as "screening and early treatment", "infection", "hemodynamic management", "ventilation", "additional therapies" and "long-term outcomes and goals of care" with a total of 93 items and 99 recommendations. Compared with the 2016 guideline (96 recommendations), although the total number of recommendations in the 2021 guideline is similar, the number of "strong recommendations (recommend)" in 2021 guideline has dropped significantly, while as the number of "weak recommendations (suggest)" has increased significantly, and the level of the quality of evidence on which the recommendations are based has been significantly lowered. Furthermore, 2021 guideline has also markedly deleted or simplified the recommendations regarding infection prevention, acute respiratory distress syndrome (ARDS) treatment, nutritional support and so on. While, the most obvious improvement appears in the segment of "long-term outcomes and goals of care", in which the patients and their families could get help in term of determining their physical rehabilitation and discharge follow-up plans and formulating exact goals of care. 2021 guideline did not adopt new and emerging therapies or treatments, such as metagenomic next-generation sequencing (mNGS), diaphragm protective ventilation, timing of initiating renal replacement therapy for acute kidney injury, early mobility, endotoxin adsorption, tranexamic acid, E-medicine and telemedicine, big data & artificial intelligence and other new therapies. Collectively, it may suggest the 2021 guideline tend to be conservative and simplified rather than fairly optimized and logicalized, which may arouse controversy in the future and affect clinician compliance.

Clinical value of endoscopic precise muscular dissection for early gastric cancer with submucosal severe fibrosis (with video) / 中华消化内镜杂志

A total of three early gastric cancers (EGC)patients with submucosal severe fibrosis were successfully treated by endoscopic precise muscular dissection (EPMD) from May 2018 to August 2020.All the three lesions were en bloc resection and specimens were not damaged. The maximum diameter of specimens and fibrosis areas were 2.0-5.7 cm and 0.5-0.8 cm, respectively. The operation time was from 30 to 70 mins. Intraoperative perforation occurred in one case, post-operation fever cccured in one case, and no delayed perforation or bleeding occured. Two cases were cured resection and one case was non-cured resection without additional treatment. No recurrence or metastasis was observed during follow-up period.According to primary results, EPMD can be used for EGC with submucosal severe fibrosis, but the safety and effectiveness need clinical validation with more samples.

Dedifferentiated liposarcoma with inflammatory myofibroblastic tumor-like features: a clinicopathological analysis of five cases / 中华病理学杂志

Objective@#To investigate the clinicopathological features, diagnosis and differential diagnosis of dedifferentiated liposarcoma (DDLPS) with inflammatory myofibroblastic tumor (IMT)-like features.@*Methods@#Five cases of DDLPS with IMT-like features were collected from the First Affiliated Hospital of Nanjing Medical University, the Affiliated Hospital of Nanjing University of Traditional Chinese Medicine and the First People′s Hospital of Qinzhou between 2013 and 2018. EnVision method and fluorescence in situ hybridization (FISH) were used to detect the immunophenotype of the tumor cells and the profile of MDM2 gene amplification respectively.@*Results@#All five cases were male and the median age was 61 (range 53 to 65) years. The clinical symptoms were mainly related to the space-occupying lesions. The tumors were located in duodenal mesentery (two cases), intestinal wall (one case), retroperitoneum (one case), and spermatic cord (one case). Grossly, the tumors were not well encapsulated, ranging from 3 to 13 cm (median 6.7 cm) in diameter, with tan to gray and firm cut surface. Histologically, the dedifferentiated component closely resembled inflammatory myofibroblastic tumor (IMT), with spindle/polygonal/stellate-shaped cells arranged in storiform, sheet-like, or random pattern, with varying degrees of chronic inflammation and fibrosis. All three major patterns seen in IMT (myxoid, cellular and hypocellular fibrous) were observed, the hypocellular fibrous pattern was the most common. Well-differentiated liposarcomatous component was found in the peripheral areas of all the tumors. One case had high grade dedifferentiated component. Four cases were strongly positive for MDM2 and p16. Two cases were positive for SMA, and one case was focally positive for desmin and one for CD34. None of the cases stained for ALK-1. FISH demonstrated MDM2 gene amplification in all five cases. Clinical follow-ups were available in all five cases and the interval ranged from 3 to 66 months (median 23 months). Two patients developed recurrences and one patient had metastasis. The remaining two patients were alive with no evidence of tumor recurrence at 3 and 14 months after surgery respectively.@*Conclusions@#DDLPS with IMT-like features is a more aggressive neoplasm than its histological mimic (IMT), and should not be misdiagnosed as other intermediate or low-grade malignant tumors, such as IMT, sclerosing liposarcoma, inflammatory liposarcoma, aggressive fibromatosis, solitary fibrous tumors, low-grade myofibroblastic sarcoma, and low-grade fibrosarcoma.

Correlations of mutations of IDH1,IDH2,p53 gene and Ki-67 protein expression in gliomas with the clini cal features of pathological grading / 实用医学杂志

Objective To investigate the mutations of IDH1,IDH2,p53 gene,and Ki-67 protein expression in different grade of gliomas and identify the association with its clinical relevance. Methods The mutations of IDH1,IDH2 and p53 gene were detected by direct DNA sequencing,and protein expression of Ki-67 was analyzed by immunohistochemistry. The correlations between gender,age,tumor site,differentiation degree and pathological type of patients were analyzed. Results R132H mutation of IDH1 gene was detected in 32.6% samples (14/46 cases),of which the proportion of WHO classification grade Ⅱ was 40.0%,and grade Ⅲ was 58.3%. IDH1 mutations were shown correlated with age,pathology level Ⅱ-Ⅲ,and Ki-67 low expression. p53 mutations were detected in 4 glioblastomas,with mutations located at exon 7,8. IDH1 gene mutation was negatively correlated with Ki-67 expression. Conclusions The proportion of IDH1 gene mutation in different pathological types of gliomas is different,which is the highest in gradeⅡ~Ⅲ. It is suggested that the subtypes should be listed independently by routine tests. Mutations in p53 gene are more common in primary glioblastomas and may be associated with adverse outcomes. The combined detection of DH1,p53 and Ki-67 is conducive to the diagnosis and prognosis of glioma.

Transperineal targeted prostate biopsy with real-time fusion imaging of multiparametric magnetic resonance imaging and transrectal ultrasound / 中华超声影像学杂志

Objective To evaluate the value of transperineal targeted biopsy with real-time fusion images of transrectal ultrasound (TRUS)and multiparametric magnetic resonance imaging (mpMRI)for the diagnosis of prostate cancer (PCa).Methods Clinical and imaging data of 62 consecutive patients suspected of PCa at the mpMRI scan and PSA>4.0 μg/L were retrospectively analyzed.Targeted biopsies (TB)were carried out for each cancer-suspicious lesion,and followed a systematic 12-core biopsy (SB) protocol.Pathological findings of TB and SB were analyzed.Results The age of the patients was (68.38± 6.57)years (range 5 1 -79 years).The preoperative PSA value was (10.21 ±5.57)μg/L (range 4.5 -30.1μg/L).Preoperative prostate volume was (34.05±9.86)ml (range 19-64 ml).The PCa patients detected by SB and/or TB were 34 (54.8%).Cancer-detected rates of SB and TB cores were 7.53% and 26.2%, respectively (P <0.001).The positive core length of SB and TB cores were (3.71 ±2.77)mm (range 1 -14 mm)and (5.00±3.04)mm (range 2-1 7 mm),respectively (P =0.016).The positive core percent of SB and TB cores were (28.77 ± 20.13 )% (range 7 - 100%)and (35.76 ± 1 8.73 )% (range 1 1 % - 100%), respectively (P =0.048).Moreover,clinically cores detected by the SB and TB for final diagnosis of PCa were 19 cores (2.6%)and 48 cores (1 8.5%),respectively (P < 0.001 ).Conclusions Transperineal TB using real-time TRUS and mpMRI fusion imaging can improve sampling quality and elevate clinically detection rate of PCa when application combined with SB.

Analysis on pathology features and prognosis of appendiceal mucinous neoplasm / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the pathological features and prognosis of appendiceal mucinous neoplasms (AMN) based on WHO classification 2010.</p><p><b>METHODS</b>Seventy consecutive cases of AMN were classified into 5 groups according to WHO classification of digestive system tumors in 2010 including mucinous adenomas/cystadenoma (MA), low grade appendiceal mucinous neoplasms (LAMN), low grade pseudomyxoma peritoneum originated from appendix (PMP-L), invasive mucinous adenocarcinomas (MAC) and high grade pseudomyxoma peritoneum originated from appendix (PMP-H). Clinicopathological features, classification, treatment and prognosis of AMN were investigated retrospectively.</p><p><b>RESULTS</b>There were 11 cases of MA with neoplastic epithelium and mucin being defined in lumen and mucosa but without invasive lesions, and no relapse or death was found. In 41 LAMN cases, mucin was found in submucosa, muscularis proparis, or serosa of appendix, no or only scant mucinous epithelium with low grade dysplasia presented in mucinous pools in most cases (39/41). Among 41 LAMN cases, 3 developed relapse or PMP-L, and no death was observed. In 7 PMP-L cases, low grade dysplastic mucinous epithelium in mucinous pools could be found easily in 3 cases and was very scanty in 4 cases, with 1 relapse and 1 death. Eleven invasive carcinomas were found, including 7 MAC cases and 4 PMP-H cases, with local high grade dysplastic epithelium at least. In these invasive lesions, 4 cases recurred and 3 case died (including 2 recurred cases above). MA and LAMN were both non-invasive neoplasms histologically, however, PMP-L, MAC and PMP-H were regarded as adenocarcinomas according to their biological behavior.</p><p><b>CONCLUSION</b>AMN displays a relatively homogeneous group of neoplasms that pursues a predictable clinical course based on their nature, so it is necessary to diagnose and administrative accurately with consistently standards for these neoplastic entities.</p>

HER2 protein testing in gastric cancer: a retrospective analysis of 1 471 cases during two different periods in a single medical center / 中华病理学杂志

<p><b>OBJECTIVE</b>To study the potential factors in influencing the performance of immunohistochemical testing for HER2 protein in gastric cancers.</p><p><b>METHODS</b>The HER2 protein expression status of 1 471 surgically resected archival gastric cancer cases in Drum Tower Hospital collected during two different periods was retrospectively analyzed. The materials included 957 cases tested during the period from 2007 to 2009 (group 1) and 514 cases from 2012 to 2013 (group 2). The test procedures and results observed during these two periods were compared.</p><p><b>RESULTS</b>The percentages of score 3 HER2 protein expression (14.4%, 74/514 versus 9.5%, 91/957) and score 2 or score 3 HER2 protein expression (27.2%, 140/514 versus 21.7%, 208/957) were both higher in group 2 than in group 1 (P < 0.05). In group 1, the cancer tissue was fixed in 10% formalin, stained manually with HER2 antibody A0485 (Dako) and assessed by different pathologists.In group 2, the tissue was fixed in 10% neutral buffered formalin (pH 7.2), stained using automated immunostaining system (Roche Benchmark XT) with HER2 antibody 4B5 (Ventana) and assessed by a specialized team of pathologists.</p><p><b>CONCLUSION</b>The results of HER2 immunostaining in gastric cancer are influenced by a number of factors including type of fixative, clone number of primary antibody, staining methods and experience of pathologists.</p>

Expression and its significance of Her-2/neu protein and androgen receptor in human prostate cancer / 中华老年医学杂志

Objective To observe the expression of Her-2/neu protein and androgen receptor (AR) in human prostate cancer and to evaluate their significances in the progression of prostate cancer. Methods The Her-2/neu protein and AR immunohistochemical stain were carried out in human prostate tissue microarray that consisted of prostate cancer (107 cases) and benign prostate tissue (42 cases). The prostate cancer cases were divided into 4 groups: group one (Gleason score 6),group two (Gleasonscore 7), group three (Gleasonscore 8) and group four (Gleasonscore 9) according to the Gleason score. The immunostains immunohistochemical stain were interpreted in two aspects of the staining intensity and the percentage of positive cells. The significance and relationships between the expression of Her-2/neu protein and AR in prostate cancer and benign prostate tissue (BPT) and the grouping of different Gleason scores of prostate cancer were then evaluated. Results The positive expression rate of Her-2/neu protein was significantly higher in prostate cancer tissue than in BPT [43.9%(47/107) vs. 14.3%(6/42), x2=11.562, P=0.009], and the positive expression intensity of Her-2/neu immunoreactivity was also higher (x2= 11.764, P=0.008). There were significant differences in positive expression intensity of Her-2/neu immunoreactivity among the different Gleason scores groups (x2 = 20. 512, P = 0. 015), and the expression intensity was significantly positively correlated with Gleason scores ( r= 0. 269, P = 0. 005). There was significant difference in AR immunoreactivity between in prostate cancer (67 %, 72/107) and in BPT (50 %, 21/42, x2 =3. 843, P=0. 050). Among prostate cancer cases, the positive expression intensity of AR was not significantly different among groups 1 through 4 (x2 = 4. 318, P = 0. 229), and was not significantly correlated with Gleason scores ( r = - 0. 065, P = 0. 505 ). Moreover, the positive expression intensity of Her-2/neu protein was not significantly correlated with that of AR (r = -0. 115, P=0. 237). Conclusions Overexpression of Her-2/neu protein in human prostate cancer tissue suggests that Her-2/neu may have some role in prostate tumorigenesis. Her-2/neu protein expression is positively correlated with Gleason score in prostate cancer, which suggests that Her-2/neu may be a potential prognostic predictor of prostate cancer.

Expression of potential molecular markers in prostate cancer: correlation with progression in patients after endocrine therapy / 中华泌尿外科杂志

Objective To evaluate the expression of molecular markers in prostate cancer and to clarify the significance of these markers as prognostic indicators for androgen deprivation therapy. Methods A series of 116 prostate cancer patients under androgen deprivation therapy as a single treatment was reviewed. Expression levels of 7 proteins, including androgen receptor(AR),E-cadherin, Chromogranin A(CgA) , Ki-67, Survivin, EZH2 and hepsin, were measured by immunohistochemical staining. Results Of the 7 molecules. Ki67,EZH2 and Survivin expression were significantly associated with several conventional prognostic factors. Univariate analysis identified clinical stage, Glea-son scores,pretreatment serum PSA level, Ki-67 and Survivin expression as significant predictors for prostate-specific antigen (PSA) progression after endocrine therapy. Of these significant factors, Survivin expression, clinical stage and Gleason scores appeared to be independently related to PSA progression after endocrine therapy by multivariate analysis. Furthermore, there were significant differences in PSA progression-free survival according to positive numbers of these three independent risk factors. Conclusion Survivin could be a useful independent prognostic factor in prostate cancer with endocrine therapy, besides clinical stage and Gleason score.

Subcutaneous panniculitis-like T-cell lymphoma / 临床与实验病理学杂志

Purpose　To inquire into the clinical and pathological features of subcutaneous panniculitis-like T-cell lymphoma. Methods　The histopathology and immunophenotypes of subcutaneous panniculitis-like T-cell lymphoma in 8 cases were observed. Results　Clinically one or more subcutaneous nodules were first found, then the lesion infiltrated up to the epiderm or down to the fascia. Half of the cases were stable for long time without systematic symptoms. The others got high fever with bone marrow, lymphonode involvement, had tumescent liver, and spleen, and decreasing of the counts of thrombocytes or whole blood cells. A few were accompanied with lethal hematophage syndrome. Some rapidly advanced and died less than 3 years. Pathologically, atypical large, midium-size and small lymphocytes with variable ratio rounded the lipocytes like rosettes and were confluent to small patchs or foci or formed a reticular pattern. There were many karyokineses and karyorrhexis made of distinct karyorrhexis bodies. The histocytes reactively proliferated accompanied with phagoerythrocytic phenomena, and polynuclear giant cells and granulomatoid reaction were found. The tumor cells infiltrated in the lipolubules. They expressed T-cell immunophenotype. Conclusions　This tumor is a special type of skin lymphoma involving subcutaneous fat tissue and special clinicophathological features.