Digital Pathology Blog

December Case of the Month - 47 y/o male with shoulder mass

This will likely mark the last post for 2008 for a brief hiatus over the holidays. I would like to thank all my colleagues and readers for your continued support. I would also like to thank Aperio who have generously sponsored and supported this endeavor to support educational initiatives in digital pathology and pathology informatics through the blog this past year. Best wishes for a happy holiday season. Keith 

The Case of the Month for December is from a right shoulder mass in a 47 year old male. While the cytogenetic abnormalities have not been described in this entity, we had the opportunity to collect fresh tissue for cytogenetic studies from the surgical specimen at the time of frozen section. The results of those studies are shown here:  

46,XY,add(2)(q31),add(4)(q31.1)[2]/92,slx2[3]/46,sl,

der(2)t(2;4)(q14.2;p14),

der(4)t(2;4)(q14.2;p14)add(4)(q31.1)[10]/46,sdl1,

add(13)(q34)[4]/92,sdl2x2[1] 

The vast majority of the tumor showed low overall cellularity with bland appearing cells, myxoid change, distinctive "grungy" calcified matrix, and rare osteoclasts. 

The diagnosis and a reference are below the images.

Enjoy!

Diagnosis:

Phosphaturic mesenchymal tumor (mixed connective tissue variant) (PMTMCT). 

Reference:

Am J Surg Pathol. 2004 Jan;28(1):1-30.

Most osteomalacia-associated mesenchymal tumors are a single histopathologic entity: an analysis of 32 cases and a comprehensive review of the literature.

Folpe AL, Fanburg-Smith JC, Billings SD, Bisceglia M, Bertoni F, Cho JY, Econs MJ, Inwards CY, Jan de Beur SM, Mentzel T, Montgomery E, Michal M, Miettinen M, Mills SE, Reith JD, O'Connell JX, Rosenberg AE, Rubin BP, Sweet DE, Vinh TN, Wold LE, Wehrli BM, White KE, Zaino RJ, Weiss SW.

Oncogenic osteomalacia (OO) is a rare paraneoplastic syndrome of osteomalacia due to phosphate wasting. The phosphaturic mesenchymal tumor (mixed connective tissue variant) (PMTMCT) is an extremely rare, distinctive tumor that is frequently associated with OO. Despite its association with OO, many PMTMCTs go unrecognized because they are erroneously diagnosed as other mesenchymal tumors. Expression of fibroblast growth factor-23 (FGF-23), a recently described protein putatively implicated in renal tubular phosphate loss, has been shown in a small number of mesenchymal tumors with known OO. The clinicopathological features of 32 mesenchymal tumors either with known OO (29) or with features suggestive of PMTMCT (3) were studied. Immunohistochemistry for cytokeratin, S-100, actin, desmin, CD34, and FGF-23 was performed. The patients (13 male, 19 female) ranged from 9 to 80 years in age (median 53 years). A long history of OO was common. The cases had been originally diagnosed as PMTMCT (15), hemangiopericytoma (HPC) (3), osteosarcoma (3), giant cell tumor (2), and other (9). The tumors occurred in a variety of soft tissue (21) and bone sites (11) and ranged from 1.7 to 14 cm. Twenty-four cases were classic PMTMCT with low cellularity, myxoid change, bland spindled cells, distinctive "grungy" calcified matrix, fat, HPC-like vessels, microcysts, hemorrhage, osteoclasts, and an incomplete rim of membranous ossification. Four of these benign-appearing PMTMCTs contained osteoid-like matrix. Three other PMTMCTs were hypercellular and cytologically atypical and were considered malignant. The 3 cases without known OO were histologically identical to the typical PMTMCT. Four cases did not resemble PMTMCT: 2 sinonasal HPC, 1 conventional HPC, and 1 sclerosing osteosarcoma. Three cases expressed actin; all other markers were negative. Expression of FGF-23 was seen in 17 of 21 cases by immunohistochemistry and in 2 of 2 cases by RT-PCR. Follow-up (25 cases, 6-348 months) indicated the following: 21 alive with no evidence of disease and with normal serum chemistry, 4 alive with disease (1 malignant PMTMCT with lung metastases). We conclude that most cases of mesenchymal tumor-associated OO, both in the present series and in the reported literature, are due to PMTMCT. Improved recognition of their histologic spectrum, including the presence of bone or osteoid-like matrix in otherwise typical cases and the existence of malignant forms, should allow distinction from other mesenchymal tumors. Recognition of PMTMCT is critical, as complete resection cures intractable OO. Immunohistochemistry and RT-PCR for FGF-23 confirm the role of this protein in PMTMCT-associated OO. 

Innovation at University of Michigan and Around the State

"The University of Michigan established the Medical Innovation Center to encourage new ideas in the state. The Center was formed to help clinicians overcome a number of barriers, help others navigate the complexities of commercialization, improve public health, develop an effective education curriculum, and provide introductions to collaborators, funding sources, and industry partners.

Once the Innovation Center has sufficient funds, a Global Innovation Alliance Program will be established. This program will provide international fellows the opportunity to be trained at UM and the university will support innovative programs to develop low-cost biomedical technologies. These technologies will be used to help emerging countries and for individuals suffering from rare or orphan diseases.

Recently, the University of Michigan’s C.S. Mott Children’s Hospital received a $100,000 Grand Challenges Explorations Grant from the Bill & Melinda Gates Foundation. Matthew M. Davis, M.D., Associate Professor of General Pediatrics and Internal Medicine at the UM Medical School will lead the project.

This project is one of 104 grants announced by the Gates Foundation for the first funding round of Grand Challenges Explorations, a five year $100 million initiative to help scientists around the world explore bold new solutions for health challenges in developing countries.

Davis will work with other UM experts in vaccines and economics on the project. The idea is to link biotech companies and researchers in the industrialized world with vaccine manufacturers in developing countries to enable the transfer of new vaccine technologies from one phase and place of vaccine development to another. Priority will be given to vaccines against HIV/AIDS, tuberculosis, malaria, diarrheal diseases, and pneumonia.

In another advance, the University of Michigan Health System implemented the UM-CareLink computerized provider order entry system in the University Hospital and the Cardiovascular Center. Even before the system was completed, there had been a 29 percent reduction in medication errors and a 40 percent cut in time between ordering and administrating urgent medications.

In addition, UMHS received a grant from the William and Flora Hewlett Foundation to provide comprehensive pre-clinical health curricula worldwide via the Internet. The University of Michigan, the Open Society Institute, and the Foundation for Advancement of International Medical Education and Research are providing financial support.

The UM Medical School is leading the project and working with the UMHS schools and partner institutions in Africa at the University of Cape Town and the University of Ghana. A key part of this effort will be to convert existing educational materials into Open Educational Resources available online. The Medical School and the Schools of Public Health and Dentistry will provide materials for the pilot.

In the state and federal government sector, Michigan’s Department of Community Health’s (MDCH) Office of Public Health Preparedness is overseeing projects through CDC’s funding of $24 million made available for pandemic influenza preparedness. The state of Michigan received more than $2 million for projects.

MDCH will provide the oversight to three projects. The first project involves expanding the Michigan Care Improvement Registry (MCIR). The MCIR All Hazards Enhancement Project developed through MDCH’s Bureau of Epidemiology will expand the registry to achieve timely reporting, data aggregation, and data exchange in the event of an influenza pandemic.

The second project is using a new electronic PHIN compliant electronic mortality reporting system developed through MDCH’s Bureau of Local Health and Administrative Services to exchange mortality data with federal partners and then integrate this data into existing disease reporting systems.

The final MDCH project developed through Spectrum Health of Grand Rapids is working on a set of planning and operations guidelines to identify and provide essential healthcare if it becomes necessary to care for large numbers of hospitalized and home bound patients during a pandemic.

The Michigan Institute for Clinical and Health Research part of the NIH Roadmap Clinical and Translational Science Award created the Pilot and Collaborative Grant Program with $5 million in funds. The program looks for proposals promoting the development of novel solutions to improve patient and community health outcomes. In addition to clinical and translational research, proposals are accepted on health services studies, outcomes or policies that test new interventions, and proposals relevant to developing new methods or best practices.

The types of grants available in this program include seed grants, pilot grants, collaborative grants, clinical trial planning grants community-university research partnerships, health disparities research, and research on ethics projects."

Telemedicine Saves Time and Money

Little cost benefit ratio exists for telepathology as much as it does for other telemedicine specialities.  What data does exist suggests a very high return with using telepathology whether it is for primary diagnosis or secondary consultation. Several models include decreased time spent traveling to remote sites, expanding reach of subspecialty services and risk management with the use of real-time teleconsultation.  I presume with increased adoption of the digital pathology these types of studies will continue to show the financial benefits of digital pathology for teleconsultation. 

Here is a synopsis of a study from the ER literature and what the investigators found. 

"Research shows up to 70% of children's emergency room visits are actually for non-emergency problems. That's a lot of time and money wasted for both parents and hospital staff. A visit to the ER can cost seven times more than a trip to a doctor's office for the same problem. Now, there's a new way to see the doctor, that makes life easier.

Dr. Kenneth McConnochie, General Pediatrician at the University of Rochester Medical Center claims telemedicine significantly reduces visits to the emergency room. He found close to a 24% reduction in emergency department use through telemedicine.

Telemedicine assistants gather information, take pictures and even record lung sounds of sick kids at selected day care centers and schools. It's all sent online to a doctor in your city. A telemedicine visit is done pretty quickly, usually within five minutes.

Researchers said after the program started, absence from day care centers due to illness dropped more than 60%. 96% of visits that come to doctors by telemedicine from day care and schools can be diagnosed and treated exclusively through the system. The other 4 percent require additional testing, hands-on examination or emergency services."

What are you really eating in fast food hamburgers?

Dr. Richard Prayson from the Cleveland Clinic along with a family member and a colleague from anatomic pathology recently asked and answered this question.  Their results are in a recent publication in the Annals of Diagnostic Pathology.

It turns out in their study of eight different brands of hamburgers looked at are actually comprised of little meat (12% on average), more than 1/2 their weight is water and unexpected tissue types found in some hamburgers were as diverse as bone, cartilage & plant material.  On a positive note, no brain tissue was identified in their study although parasites were found in 2 burgers.

If you already read Fast Food Nation by Eric Schlosser, some of this may look familiar to you, if not, check out their publication.

Download Prayson_AnnDiagPath_Dec2008

"Americans consume about 5 billion hamburgers a year. It is presumed that most
hamburgers arecomposed primarily of meat. The purpose of this study is to assess
the content of 8 fast food hamburger brands using histologic methods. Eight
different brands of hamburgers were evaluated for water content by weight and
microscopically for recognizable tissue types. Glial fibrillary acidic protein (GFAP)
staining was used to evaluate for brain tissue. Water content by weight ranged from
37.7% to 62.4% (mean, 49%). Meat content in the hamburgers ranged from 2.1% to
14.8% (median, 12.1%). The cost per gram of hamburger ranged from $0.02 to $0.16
(median, $0.03) and did not correlate with meat content. Electron microscopy showed
relatively preserved skeletal muscle. A variety of tissue types besides skeletal muscle
were observed including connective tissue (n = 8), blood vessels (n = 8), peripheral
nerve (n = 8), adipose tissue (n = 7), plant material (n = 4), cartilage (n = 3),
and bone (n = 2). In 2 hamburgers, intracellular parasites (Sarcocystis) were
identified. The GFAP immunostaining was not observed in any of the hamburgers.

Lipid content on oil-red-O staining was graded as 1+ (moderate) in 6 burgers and
2+ (marked) in 2 burgers. Fast food hamburgers are comprised of little meat
(median, 12.1%). Approximately half of their weight is made up of water. Unexpected
tissue types found in some hamburgers included bone, cartilage, and plant material;
no brain tissue was present. Sarcocystis parasites were discovered in 2 hamburgers."

Telemedicine Improves Outcomes

Another success for telemedicine from Federal Telemedicine News

Stroke patients have a better chance of surviving and living independently when they receive specialized stroke care in community hospitals using telecommunications to communicate with major stroke centers. This has been reported in a study appearing in “Stroke: Journal of the American Heart Association”.

Most community hospitals don’t have dedicated stroke units because of a shortage of experienced physicians and lack of access to stroke related clinical expertise at major medical centers. Rural areas in particular often have inadequate resources to provide specialized stroke care.

In Germany, the Telemedical Project for Integrative Stroke Care (TEMPiS) funded by the German Federal Ministry of Research, examined the feasibility and potential value for extending specialized stroke care to a large area of the Bavarian region of Southeastern Germany. TEMPiS, is a collaborative effort between two academic stroke centers and community hospitals in Bavaria.

The TEMPiS program is to:

• Establish stroke units at community hospitals along with multidisciplinary stroke teams to provide care
• Install and monitor equipment and facilities
• Train and educate the stroke team plus have specialist physicians, nurse, and therapists provide continuous bedside teaching
• Implement standard treatment protocols
• Provide for 24 hour telemedicine consultations by academic stroke centers

The outcomes for the stroke patients treated at five TEMPiS hospitals with patient outcomes at five non TEMPiS hospitals in the same geographic region were compared. The study included 3,060 stroke patients with 1,938 treated at TEMPiS hospitals and 1,122 treated at other hospitals.

The patients treated at the TEMPiS hospitals had a 35 percent lower probability of death and dependency at 12 months and almost a 20 percent reduced probability for a poor outcome at 30 months as compared with non TEMPiS patients.

Initial results showed that specialized stroke care improved with the use of telemedicine. Factors such as making high quality stroke care available, providing for rapid brain imaging, providing patients with clot dissolving drugs on a frequent basis, having the ability to assess stroke related swallowing disorders, initiating early stroke rehabilitation, and using telemedicine was shown to contribute to this improvement in stroke care.

Recent paper on automated whole slide imaging

Authors: Amin, Waqas; Srintrapun, S Joseph; Parwani, Anil V

Source: Expert Opinion on Medical Diagnostics, Volume 2, Number 10, October 2008 , pp. 1173-1181. Publisher: Informa Healthcare

Abstract:

Background: Automated high-speed, high-resolution whole slide image (WSI) technology is being rapidly adopted in pathology owing to increased speed of computing, rapid networking, and high image quality and potential to reduce the overall turnaround time required for slide assessment.

 

Method/objectives: This review presents the structure, functioning and performance of some of the WSI systems available in the market and highlights a few validation studies that have been performed to assess the overall utility of WSI systems.

 

Conclusion: The automated WSI is a robotic microscope that digitizes the entire slide field by field and uses software to merge or stitch individual fields into a composite image. Commercially available systems provide many improved functions that are useful for editing the digital images and improving the image quality.

Keywords: automated whole slide imaging; digital pathology

Document Type: Research article

DOI: 10.1517/17530059.2.10.1173

Patience Lost - Lines from a Hospital Trench

Dr. Lucien E. Nochomovitz, Vice-Chairman of the Department of Pathology from North Shore-Long Island Jewish Health Care System (Manhasset campus) has an interesting monolgoue about his experiences in academic surgical pathology at www.yourbiopsyandmore.com. 

He offers "a short trip through a somewhat arcane yet crucial piece of medical landscape onto which the tide of baby boomers is already stumbling.

He speaks his mind and discusses a number of interesting issues concerning academia, pathology & medicine. 

Medical and non-medical professionals will enjoy his insight.

Here are some excerpts from the introduction:

"I have tried to describe an obscure corner of the medical world, one that intrudes unexpectedly and rudely into the lives of millions of Americans.

I write from a position well below the radar of the average columnist, and beyond the discernment of even the average clinician.

The general application in Medicine of an efficiency model, however, feeds impatience with things that take long to accomplish, and discourages the idea that it may be wise and mature to wait."

Early Registration Discount for Pathology Visions 2009

Pathology Visions brings together members of the healthcare and scientific community to discuss real-world, practical applications and learn about the latest advances in digital pathology for research, clinical, education, IT, and veterinary pathology applications.

Next year's meeting will take place September 13-15, 2009 at the Marriott Hotel and Marina in San Diego, CA.

Registration is now open and attendees who register before January 31 are being offered the 2008 rate of $399.

This year's meeting will feature poster sessions new this year as well.  Click here to submit a poster or abstract for consideration.

 

I would encourage anyone interested in digital pathology to consider attending this meeting. 

 

I thought this year's meeting had an excellent program with several networking opportunities as well as multiple vendors in this space to meet with. 

 

More information is available on the meeting website at www.pathologyvisions.com or e-mail

info@pathologyvisions.com.

"Dogmatic and unyielding at scanning magnification" & "reasonable and accommodating at high power"

Over the weekend I passed along the death of Dr. Ackerman. There is a more compete obituary today.

This line from the obit sums up Dr. Ackerman:

"Asked to describe himself in an interview with a medical journal, Dr. Ackerman used the terminology of the microscope. He said he was “dogmatic and unyielding at scanning magnification” but “reasonable and accommodating at high power” and “humane and empathic up close.”"

epathologies.com

 

This is an interesting website run by Dr. Gerard Abadjian, Associate Professor of Pathology at St. Joseph University in Beirut, Lebanon.  Several parts of the site are bilingual or limited only to French.

One of the links provides an MP3 file about the site with an orientation to the major parts of the site.

The site is "dedicated to the communication of surgical pathology cases" from cases collected at St. Joseph University. 

One of the most interesting aspects of the site are cases presented in pseudo-virtual slide format whereby you can see selected fields at higher power.  Here is one example.

One the same page you can also view gross photomicrographs with corresponding histology images selected from the gross image as seen here.

I would encourage you to listen to the introduction first to help you navigate around the site and check out "Tests - Quiz Page", "Les Observations", and "New Cases" which has been recently updated. 

In general, the gross and histology images are of good to excellent quality and there are several interesting cases from several surgical pathology subspecialties to view.

The site also has some instructional videos on histology, presentations in PDF format from staff, trainees and those presented at meetings as well as links to other pathology sites.