Patients with high-risk endometrial carcinoma (HR-EC) experience substantial mortality despite multimodality therapy, molecular classification and contemporary care. We determined whether proteomic tumor programs capture lethal risk beyond established clinical and genomic classifiers and may inform translational investigations. We performed integrated clinical, genomic, and quantitative proteomic profiling of archival FFPE primary tumors from 274 patients with stage I-III HR-EC treated with curative intent and long-term follow-up. Molecular subtyping, clinical-genomic risk modeling, and proteomic analyses evaluated relationships with endometrial cancer (EC)-specific death and progression. A proteomic risk score for progression was developed and validated in 73 independent HR-EC patients. Among patients with non-POLE tumors, TCGA molecular subtype and TP53 mutation status did not significantly stratify progression or EC-specific mortality. Clinical-genomic classification and regression tree analysis identified distinct risk groups with divergent outcomes. Quantitative proteomic profiling identified reproducible tumor programs independently associated with lethal outcomes after adjustment for clinicopathologic and molecular subtypes. Semi-supervised protein clusters classified high vs. low risk of progression in either serous or grade 3 endometrioid carcinoma. A proteomic risk score stratified progression risk across training, testing, and independent cohorts and recapitulated adverse proteomic biology. Proteomic integration improved prognostic risk stratification and warrants further validation and translational investigation in HR-EC.

INTRODUCTION:Biliary brushing cytology is the standard diagnostic approach for evaluating biliary strictures, but it has low sensitivity and a high rate of atypical diagnoses. Fluorescence in situ hybridization (FISH) has become an increasingly valuable adjunct to cytology. Therefore, the aim of this retrospective quality improvement study was to evaluate the relative diagnostic performance of traditional cytology and FISH for correctly determining malignant versus benign biliary strictures from biliary brushing samples and to evaluate whether adding FISH to the diagnostic pipeline improves diagnostic accuracy over relying on cytology alone. MATERIALS AND METHODS:We conducted a retrospective study of biliary brushing and FISH results in patients evaluated for biliary strictures between April 2019 and March 2023. RESULTS:A total of 228 specimens were retrieved. For cytology results: 151 negative, 55 atypical, 6 suspicious, and 16 positive. For FISH results: 105 negative, 71 equivocal, and 52 positive. When calculating performance measures, cytology atypical and FISH equivocal were excluded; cytology suspicious was considered positive. The sensitivity and specificity of cytology were 45.8% and 100%, respectively. The sensitivity and specificity of FISH were 84.2% and 96.0%, respectively. CONCLUSIONS:Our findings indicate that FISH exhibits considerably higher diagnostic sensitivity than routine cytology in identifying malignant biliary strictures. Furthermore, combining cytology with FISH may provide a more comprehensive diagnostic approach, reducing the likelihood of false-negative results. However, positive and equivocal FISH results should be interpreted carefully and considered alongside more specific cytology findings to minimize the risk of false-positive diagnoses.

The morphologic diagnosis of colorectal carcinoma (CRC) is typically straight forward. However, there are certain subtypes of CRC that pose diagnostic challenges for daily practice due to sometimes overlapping morphologic and immunohistochemical features. These subtypes include poorly differentiated adenocarcinoma NOS, in the absence of conventional morphology (PDA-NOS), large cell neuroendocrine carcinoma (LCNEC), medullary carcinoma (MC), undifferentiated carcinoma (UC) and lymphoepithelioma-like carcinoma (LELC). This study aims to see if there is a survival difference between poorly differentiated variants of CRC, as well as other clinicopathological features that may affect prognosis. Additionally, we analyzed interobserver agreement among gastrointestinal pathologists (GP) at our institution in subclassifying poorly differentiated CRC. All consecutive patients with the diagnoses of PDA-NOS, MC, LCNEC, UC and LELC between July 2018 and July 2023 were included. Cox proportional regression test was used for multivariate analysis, while log-rank and Kaplan-Meier tests were used for univariate and survival analyses. Out of the same cohort of patients, 58 samples identified and reviewed by 3 GI-subspecialty-trained pathologists who were asked to assign the cases as PDA-NOS, LCNEC, MC, UC and LELC. Interobserver agreement was analyzed using Fleiss Kappa. Of the total 77 patients, 63 were PDA-NOS, 3 were LCNEC, 6 were MC, 4 were UC and 1 was LELC patients. Multivariate analysis using Cox proportional regression showed that tumor size (p = 0.001, HR = 1.22, 95% CI 1.08-1.38), patient age (p = 0.001, HR 1.73, 95% CI 1.24-2.40), and M stage (p = 0.02, HR 2.22, 95% CI 1.14-4.32) were significantly associated with worse OS. For the 58 cases analyzed, 3 GP agreed on 42 (72%) cases. The most common diagnosis was PDA-NOS and for 33 (57%) agreement was unanimous. There was moderate agreement (k 0.41-0.60) between all 3 GP. Our study evaluated the challenges associated with histological evaluation of colon cancers with poorly differentiated morphologies. Among the diagnoses considered in the study, MC and LCNEC had different prognostic implications compared to PDA-NOS and UC. Additionally, our GP showed moderate interobserver agreement, indicating that some level of variability in diagnosing poorly differentiated CRC subtypes may be inevitable.

Background: Rapid on-site evaluation (ROSE) by remote cytopathologists using telecytology has expanded with the increase in small biopsies.In sites requiring ROSE without cytopathology staff present on-site, robotic microscopy and rapid slide scanners can be advantageous.We compared telecytology ROSE using a mini-slide scanner with various scanning modalities and compared performance with review of glass slides. Design:The Grundium Ocus®20 portable digital microscope/slide scanner was used in a remote site in our rural healthcare system lacking on-site cytopathology staff.Telecytology ROSE was compared to glass slide reads with a 2-week washout, to examine concordance.The time for scanning the whole slide material was compared to targeted scanning of small areas of interest.[Figure 1] In addition, the ease of use for the remote pathologist was documented semiquantitatively (scale of 1 (easy)-5 (hard)).At least 2 pathologists evaluated each slide.Results: A total of 66 reviews were completed on 30 cases by 6 pathologists.The cases included 22 (73%) fine needle aspirations (FNA) and 8 (27%) core needle biopsy (CNB) touch preparations (TPs), from a variety of locations (4(13%) lung, 4(13%) liver, 7(23%) thyroid, 7(23%) lymph node, 2(7%) bone/soft tissue, 6(20%) other).There were 19 (63.5%) neoplastic, 7 (23.5%)benign, 3 (10%) non-diagnostic, and 1 (3%) atypical.There was 1 (1.5%) major and 8 (12%) minor disagreements between telecytology and glass diagnoses.The average time to evaluate glass slides was faster (average 1.9 minutes) than targeted scan reviews (3.2 min) and whole material review (6.5 min).The average rating for ease of use was 1.6, with nondiagnostic cases being more difficult (2.8).[Table 1] CASE INFORMATION TELECYTOLOGY GLASS Case FNA site Type of Preparation Number of Pathologist Reviews Diagnosis Avg Time to Diagnose-Whole area (min)study, we retrospectively reviewed the FNA cytomorphology of the cases with CNVs and correlated them with histopathologic follow-up. Design:The pathology database was searched for thyroid FNA cases with a diagnosis of follicular lesion of undetermined significance (FLUS) and follicular neoplasm (FN)/Hurthle cell neoplasm (HCN) with molecular testing performed by ThyroSeq v3 GC between October 2017 and January 2021.Patients' demographics, cytology, ThyroSeq testing and histopathologic follow-up were retrospectively reviewed.Fischer exact test was used to analyze the relationship between variables.Results: A total of 324 thyroid FNA cases including 228 FLUS, 46 HCN and 50 FN cases were included in the study.FLUS cases were further classified as Hurthle cell type (FLUS-HCT, 20 cases) and non-Hurthle cell type (FLUS-NHCT, 208 cases).HCN or FLUS-HCT cases showed a much higher prevalence of CNVs or CNVs with other molecular alterations (23/66=35%), compared to those classified as FN or FLUS-NHCT 14/258=5%) (p<0.001).A total of 105 patients (32%) had surgical follow-up.Cases with CNVs (with or without other molecular alterations) were more likely to be neoplastic (18/26; 69%), mostly with follicular pattern neoplasm (14/18, 78%) compared to cases without any molecular alteration (8/24=33% neoplastic) (p<0.05).In HCN/FLUS-HCT cases with CNVs (n=14), Hurthle cell morphology was seen in 13 (93%) cases on surgical follow up, in contrast to those without CNVs (n=17) where only 6 cases (35%) showed Hurthle cell morphology (p<0.05).Furthermore, cases with CNVs were more likely to be neoplastic (9/14, 64%) on surgical follow-up compared to the cases without CNVs (3/17, 18%) (p<0.05).Conclusions: Our study demonstrated that CNVs identified in thyroid FNAs are associated with Hurthle cell morphology.The presence of CNVs with a cytological diagnosis of HCN/FLUS-HCT is suggestive of a neoplasm with Hurthle cell features, which may help triage patients who would benefit from surgical management.

HER2 (ERBB2) gene status serves as a strong predictive marker of response to HER2-targeted agents in invasive breast cancers, albeit with heterogeneous response. Our aim was to determine the distribution and prognosis of HER2 groups by fluorescent in situ hybridization (FISH) using the updated 2018 American Society of Clinical Oncology–College of American Pathologist (ASCO–CAP) guidelines. We identified 226 cases of equivocal or positive HER2 FISH invasive breast cancer (interpreted by ASCO–CAP guidelines at the time of reporting) who received HER2-targeted agents from 2006 to 2017. We subcategorized Group 1 further into three subgroups: low amplified (HER2/CEP17 ratio ≥ 2.0–2.99, mean HER2/cell 4.0–5.9), amplified (HER2/CEP17 ratio ≥ 2.0–2.99, mean HER2/cell ≥ 6), and excessive amplification (HER2/CEP17 ratio ≥ 3.0, mean HER2/cell ≥ 4.0). Outcomes studied were recurrence, metastasis, second breast primary, disease-specific survival (DSS), and overall survival (OS). Univariate analysis showed that the five categories of HER2 FISH were significantly associated with OS (p < 0.01), specifically higher HER2 amplification was associated with fewer deaths. HER2 FISH status also statistically significantly relates to DFS (p < 0.01) and metastasis (p = 0.01) but not with recurrence or second breast primary in our study. Tumor type and HER2 ISH Groups are independent predictors for both OS and DFS in our cohort. The proposed Group 1 subcategories were significantly associated with OS (p < 0.01) and DFS (p < 0.01), excessive HER2 amplification was associated with longer median survival. The Cox regression models showed better survival outcomes for the excessive amplification subgroup than the low amplified subgroup, with OS (hazard ratio = 0.63, 95% CI 0.42–0.93) and DFS (HR = 0.55, 95% CI 0.37–0.83). We demonstrated that in HER2 FISH Group 1 patients, high HER2 amplification was significantly associated with longer OS and DFS; these patients seem to benefit more from HER2-targeted regimens. We recommend reporting these Group 1 subcategories when assessing HER2 FISH.

Objective: We assessed the prognostic value of histomorphologic features of lymph node (LN) metastases in patients with prostate cancer treated with radical prostatectomy Materials and Methods: We evaluated the effect of the features of LN metastasis on the risk of biochemical recurrence (BCR) in 280 LN-positive patients who underwent radical prostatectomy between 2006 to 2018. LN specific parameters recorded included number of metastatic LNs, size of the largest metastatic focus, Gleason Grade (GG) of the metastatic focus, and extranodal extension (ENE). Results: A solitary positive LN was found in 166/280 (59%), 95/280 (34%) patients had 2-4 positive LNs, and 19/280 (7%) had 5 or more positive LNs. The size of the largest metastatic focus > 2 mm (macrometastasis) in 154/261 (59%). GG of the metastatic focus was as follows: GG 1-2: 29/224 (13%); GG 3: 27/224 (12%); and GG 4-5: 168/224 (75%). ENE was identified in 99/244 (41%). We found the number of LNs positive (2-4 vs. 1 Hazard ratio (HR) = 1.60; 95% CI: 1.02 to 2.5; P = 0.04) and GG of the metastatic focus (GG 4&5 vs. 1-3 HR = 1.90; 95% CI: 1.14-3.2; P= 0.014) to be independent predictors of the risk of BCR after surgery on multivariate analysis. Conclusions: Our study showed the number of LNs positive and GG of the LN metastatic focus to be significant independent predictors of BCR after radical prostatectomy. We recommend reporting histomorphologic parameters of LN metastasis as they may help in defining BCR risk categorization. (C) 2021 Elsevier Inc. All rights reserved.

Objectives: The aim of this study was to evaluate the prognostic value of peritoneal cytology status among other clinicopathological parameters in uterine serous carcinoma (USC). Methods: A retrospective study of 148 patients diagnosed with uterine serous carcinoma from 1997 to 2016 at two academic medical centers in the Detroit metropolitan area was done. A central gynecologic pathologist reviewed all available slides and confirmed the histologic diagnosis of each case of USC. We assessed the prognostic impact of various clinicopathological parameters on overall survival (OS) and endometrial cancerspecific survival (ECSS). Those parameters included race, body mass index (BMI), stage at diagnosis, tumor size, lymphovascular invasion (LVSI), peritoneal cytology status, receipt of adjuvant treatment, and comorbidity count using the Charlson Comorbidity Index (CCI). We used Cox proportional hazards models and 95% confidence intervals for statistical analysis. Results: Positive peritoneal cytology had a statistically significant effect on OS (HR: 2.09, 95% CI: [1.19, 3.68]) and on ECSS (HR: 2.02, 95% CI: [1.06 - 3.82]). LVSI had a statistically significant effect on both OS (HR: 2.27, 95% CI: [1.14, 4.53]) and ECSS (HR: 3.45, 95% CI: [1.49, 7.99]). Black or African American (AA) race was also found to have a significant effect on both OS (HR: 1.92, 95% CI: [1.07, 3.47]) and ECSS (HR: 2.01, 95% CI: [1.02, 3.98]). Other factors including BMI and tumor size > 1 cm did not show a statistically significant impact on OS or ECSS. Conclusions: Peritoneal washings with positive cytology and LVSI are important prognostic tools that may have a significant impact on overall survival in USC and can be used as independent negative prognosticators to help guide adjuvant treatment.