Rheumatologic Perspective on Persistent Right-Hand Tenosynovitis Secondary to Mycobacterium marinum Infection.

Background: Rheumatologic conditions share many symptoms with infectious processes. The immunosuppressive therapies used in rheumatology unfavorably impact any underlying infection. Nontuberculous mycobacteria (NTM) are difficult to grow in culture media and may affect the musculoskeletal system, developing manifestations that may imitate rheumatic inflammatory arthritis. For this reason, surgical debridement and biopsy culture are essential in cases where suspicion remains high. Case Presentation: We present the case of a patient with progressively worsening right-hand tenosynovitis who was evaluated for rheumatic conditions given initial negative synovial tissue biopsy cultures. He was finally diagnosed with Mycobacterium marinum infectious tenosynovitis after repeated surgical debridement. Conclusions: Our case reinforces the vital role of history gathering in establishing diagnoses and underscores the value of clinical suspicion in patients unresponsive to standard treatment for inflammatory arthritis. Tissue biopsy with culture for acid-fast bacilli is crucial for accurate diagnosis in NTM infection, which may imitate rheumatic inflammatory arthritis. Physicians should be keenly aware of this fastidious, indolent organism in the setting of persistent localized tenosynovitis.

"Ask The Pathologist": An Internet Forum Facilitating Communication Between Cancer Registrars and Pathologists.

CONTEXT.­: Cancer registrars should work closely with pathologists to ensure compliance with reporting standards. Many registrars, however, have little contact with pathologists, resulting in a lack of "real-time" interaction that is essential for their professional activities and development. OBJECTIVE.­: To facilitate registrars' case management, as cancer biology becomes more complex, we developed the ATP (Ask the Pathologist) forum as a place to ask pathology-related questions about neoplasms, such as terminology, biology, histologic classification, extent of disease, molecular markers, and prognostic factors. DESIGN.­: Questions posted are reviewed by the ATP multidisciplinary oversight committee, which consists of 3 pathologists, 4 cancer registrars, 1 internal medicine physician, the pathology resident member of the College of American Pathologists Cancer Committee, and 2 medical technologists. The oversight committee may answer the question. Alternatively, the committee may forward the question to a content expert pathologist, determine that the question is better suited for another reference Web site, or both. RESULTS.­: Since September 2013, when the ATP forum became available, users have posted 284 questions, of which 48 (17%) related to gastrointestinal tumors, 43 (15%) to breast tumors, and 37 (13%) to general pathology. The average turnaround time, from question posted to response, is 11.1 days. CONCLUSIONS.­: The ATP forum has had a positive impact in the daily activities of cancer registrars. Of 440 registrars surveyed, more than 90% considered that questions were answered satisfactorily, and one-third reported that ATP answers affected how they managed a given case.

Vessel morphometric parameters-correlation with histologic grade and VEGF expression in oligodendroglioma.

The contributions of histologic features including microvascular proliferation to the determination of malignancy in oligodendrogliomas remain uncertain. We have retrospectively performed morphometric assessments in 20 tumors histologically classified as well-differentiated (WHO Grade II, n=8) or anaplastic (WHO Grade III, n=12) oligodendrogliomas (WDO or AO). Quantitative studies utilized image analysis of double immunolabeled vasculature with anti CD34 with VIP chromogen (purple) and proliferating nuclei with anti MIB-1, using DAB (brown). Mean values are reported from five fields for each of twenty cases. The total number of MIB-1 positive tumor nuclei was 10 fold higher in AO vs WDO. The area occupied by vessels was also markedly increased in AO vs WDO, as was the microvessel density. Proliferating endothelial cells i.e. those with MIB-1 positive nuclei in CD34 positive cells were significantly increased (4.6 vs 0.26 positive nuclei per unit tumor area, P≤0.001) in AO. While in most areas these changes were evident as typical microvascular proliferation, other areas showed thin walled vessels with increased MIB-1 positivity. VEGF was only assessed morphologically and showed positive staining of vasculature only, in WDO, while AO also showed immunoreactivity of vessels and multiple areas of tumor cells. These findings support a contributory role for vascular proliferation in assessing histologic grade. These findings also suggest that VEGF expression which is confined to blood vessels in lower grade tumors but eventually is expressed by tumor cells in higher grade oligodendrogliomas may be an important factor as the tumor progresses.

College of American Pathologists Cancer Protocols: Optimizing Format for Accuracy and Efficiency.

CONTEXT: -The data in College of American Pathologists cancer protocols have to be presented effectively to health care providers. There is no consensus on the format of those protocols, resulting in various designs among pathologists. Cancer protocols are independently created by site-specific experts, so there is inconsistent wording and repetition of data. This lack of standardization can be confusing and may lead to interpretation errors. OBJECTIVE: -To define a synopsis format that is effective in delivering essential pathologic information and to evaluate the aesthetic appeal and the impact of varying format styles on the speed and accuracy of data extraction. DESIGN: -We queried individuals from several health care backgrounds using varying formats of the fallopian tube protocol of the College of American Pathologists without content modification to investigate their aesthetic appeal, accuracy, efficiency, and readability/complexity. Descriptive statistics, an item difficulty index, and 3 tests of readability were used. RESULTS: -Columned formats were aesthetically more appealing than justified formats (P < .001) and were associated with greater accuracy and efficiency. Incorrect assumptions were made about items not included in the protocol. Uniform wording and short sentences were associated with better performance by participants. CONCLUSIONS: -Based on these data, we propose standardized protocol formats for cancer resections of the fallopian tube and the more-familiar colon, employing headers, short phrases, and uniform terminology. This template can be easily and minimally modified for other sites, standardizing format and verbiage and increasing user accuracy and efficiency. Principles of human factors engineering should be considered in the display of patient data.

Utility of tissue-specific transcription factors thyroid transcription factor 1 and Cdx2 in determining the primary site of metastatic adenocarcinomas to the brain.

CONTEXT: Brain metastases of adenocarcinoma of unknown primary pose a diagnostic dilemma to the surgical pathologist. Although the most common source in these cases is the lung, determining a primary source is difficult on routinely stained slides. Immunohistochemical stain panels including differential cytokeratins, hormone receptors, and breast-specific proteins are commonly used in these cases. Recently, attention has turned to tissue-specific transcription factors, such as thyroid transcription factor 1 (TTF-1) and Cdx2, in the appraisal of metastatic adenocarcinomas. OBJECTIVE: To characterize the previously unpublished immunohistochemical expression of the relatively new tissue-specific transcription factor Cdx2 in metastatic adenocarcinomas to the brain. DESIGN: We reviewed the surgical pathology files of the H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla, and retrieved 38 consecutive cases of metastatic adenocarcinoma (22 pulmonary, 10 breast, 6 gastrointestinal [2 esophagus/gastroesophageal junction, 4 colorectal]) to the brain with confirmation of the primary site by chart review and histologic evaluation. Sections were immunohistochemically stained with antibodies to TTF-1, Cdx2, and cytokeratins 7 and 20 by standard methods. RESULTS: Specificities and positive predictive values for Cdx2 and TTF-1 equaled 100% for metastatic gastrointestinal and pulmonary adenocarcinomas, respectively. The negative predictive value of Cdx2 was also very high at 97%. CONCLUSIONS: Cdx2 is a specific and valuable tool for the surgical pathologist when faced with the common problem of metastatic adenocarcinoma of unknown primary. In conjunction with TTF-1, cytokeratin 7, and cytokeratin 20, Cdx2 can accurately differentiate the most common sources of metastatic adenocarcinoma to the brain.

Rhinocerebral mucormycosis with perineural spread.

We describe the histopathologic findings of perineural invasion in orbital mucormycosis in a man with diabetes in ketoacidosis. Linear enhancement on MRI beginning at the orbital apex was correlated with fungal tracking of the trigeminal and lacrimal nerves. Mucormycosis can spread considerable distances from its primary focus of infection along peripheral nerves, a phenomenon that can be identified clinically with contrast-enhanced MRI.