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Stay tuned for the latest news in Medicine and Pathology.

Silver Cross Hospital participates in clinical plasma trial to treat COVID-19

First patient to receive the treatment discharged
By Rex Robinson | 5/11/2020, 1:51 p.m. | Updated on 5/11/2020, 1:51 p.m.


Silver Cross Hospital in New Lenox recently became the area’s first hospital to offer an investigational treatment for patients with COVID-19 called Convalescent Plasma Therapy.

The first coronavirus patient from Silver Cross involved in the trial received the treatment in late April. The patient was later discharged from the hospital to an acute rehabilitation facility for strengthening, a hospital spokesperson said.

The treatment uses antibodies from plasma donated by individuals who have recovered or in the process of recovering from COVID-19. The plasma is then transfused into patients currently fighting the virus. The nationwide study is led by researchers at the prestigious Mayo Clinic in Rochester, Minn.; Silver Cross is one of 2,000 participating hospitals across the U.S.

Silver Cross First to Offer Experimental Treatment

“Silver Cross was the first in the area to participate in this trial with the first patient receiving the treatment on April 28”, said Dr. Samer Dola, pathologist at Silver Cross. As the principal investigator, Dola oversees the team of doctors, coordinators and the blood bank involved in the study at Silver Cross.

The team’s clinical coordinator is Mary Shanahan, Administrative Director of Nursing Operations, Nursing Practice and Nursing Quality/Safety at Silver Cross. Shanahan is responsible for documenting patient response to the treatment and sharing it with researchers at Mayo Clinic. “We are still very early in this trial, but we are hopeful that we are on the right path,” she said.

Patients Eligible for the Experimental Therapy

“With all experimental therapies, the patients who are eligible to receive this treatment are the ones who have tried everything already without success and are facing severe or life-threatening manifestations of COVID-19,” Dola said. “The treating physician is the one who makes the recommendation to register the patient in the trial as long as consent is given by the patient or their family.” The strict criteria does not allow for asymptomatic or mildly symptomatic patients to participate, as their immune system is providing the necessary antibodies to fight on their own. 

Proving Therapy is a Success

“Thousands of patients across the U.S. are needed to determine if the treatment works,” Dola explained. “It’s a numbers game, and the numbers need to show that the experimental treatment is not harming anyone, but most importantly that it is effective. The data that we and all the participating hospitals across the nation are providing is what will show that hopefully positive result.”

Forging Ahead in the Fight against COVID-19

“I am so proud to be a part of this progressive research therapy team, as the results not only benefit the patients we fight for in our hospital, but we are part of something bigger, a national effort in the fight against COVID-19,” he added. For more information about Silver Cross Hospital, visit www.silvercross.org

To learn more about the Convalescent Plasma Therapy, visit uscovidplasma.org/ 

This story appears in The Times Weekly.com at the following link:  http://m.thetimesweekly.com/news/2020/may/11/silver-cross-hospital-participates-clinical-plasma/ 

THYROID

Fine needle aspiration: Atypical follicular lesion of undetermined significance (AFLUS) and molecular testing

Fine needle aspiration (FNA) of the thyroid has become the standard of care in the management of thyroid lesions. In the majority of cases, the results of a fine needle aspiration guide the physician and the patient towards the selection of the appropriate method of treatment, whether it be a watchful observation or surgical excision of a thyroid lesion. Fine needle aspiration, in conjunction with radiological and clinical findings, carries a high level of sensitivity and specificity in the detection of thyroid cancer. However, a small number of lesions defy categorization and fall into a group designated as "atypical follicular lesion of undetermined significance" (AFLUS), according to the latest revision of the Bethesda System of Classification for Thyroid Cytopathology (ref), The majority of these lesions end up being benign, but a small number do turn out ultimately to be malignant. This testifies to the fact that limitations exist with this particular method of testing. In fact, not many cases in real-life fit neatly into the textbook definition of a particular pathological condition. The current recommendation for the AFLUS category of lesions per (ref), is to repeat the FNA within 3-6 months, which usually resolves the uncertainty in the majority of cases, with most of the repeat FNAs resulting in a benign diagnosis. However, some cases persist with atypical findings, and even with findings of a higher level of suspicion, or malignancy, that would require surgical consultation and potential intervention. Needless to say, the watch and wait approach is not an ideal situation for a patient in which an FNA of the thyroid yields atypical findings. One would like to avoid unnecessary surgery if possible, but at the same time, one would not want to delay surgery that would be necessary if, in fact, the lesion is neoplastic. Enter molecular testing. Recent advances in molecular testing take us now to consider the use of these methods to aid in the diagnosis and treatment of cancer. Numerous molecular markers have been associated with several types of cancer that are now available. These markers could be particularly helpful in the diagnosis of cases where the usual standards of testing are limited, and the results that are obtained are inconclusive, AFLUS being a good example. AFLUS has been studied in particular with a combination of molecular markers that have been used to try to achieve the highest levels of specificity and sensitivity in the detection of thyroid cancer and proven successful (ref). The test is now currently available and is FDA approved for this particular circumstance, offering an alternative to an uncertain diagnosis, potentially avoiding unnecessary surgery, and potentially reducing a delay in treatment and improving the chances for a better patient outcome when surgery is necessary.

COAGULATION

Thromboembolism: More common than we think!

The incidence of thromboembolism in the general population is not known, but it is estimated that the cumulative probability for confirmed thromboembolism ranges from 0.5% before age 50, to almost 11% by the age of 80. However, many events are not clinically recognized, which has led some authors to believe that the true cumulative incidence is about 28%.
Risk factors for a thromboembolic event are many: prolonged immobility, due to a leg fracture, a long car or airplane trip, or paralysis; varicose veins; obesity, with decreased physical activity; cardiac diseases, like congestive heart failure, or atrial fibrillation; increased estrogen, due to oral contraception, estrogen replacement, Tamoxifen, or pregnancy; autoimmune diseases, like Systemic Lupus Erythematosus; and cancer, typically colonic, ovarian, or multiple myeloma. Still, many cases appear without a clear etiologic factor. These cases are most likely associated with congenital abnormalities of coagulation factors, specifically Factor II and Factor V Leiden.
Testing for the presence of mutation of these factors is now available.
The Factor V Leiden gene mutation is the most common genetic risk factor for thrombosis and accounts for 90% of cases with activated protein C (APC) resistance. This mutation is involved in 20-40% of venous thrombosis cases and is present in 5% of the general population. Inherited thrombosis due to APC resistance is considered an autosomal dominant disease. Heterozygous carriers of the Factor 5 Leiden polymorphism have an increased risk of thrombosis of 5 to 10 times the general population. Homozygotes have a 50 to 100 fold increased risk of thrombosis. The presence of this mutation in pregnant women is also associated with a higher risk of adverse pregnancy outcomes. The estimated penetrance for homozygotes is close to 80%, with a reduced penetrance for heterozygotes (approximately 12 to 20%).
Some indications for Factor V Leiden gene mutation are venous thrombosis, pulmonary embolism, transient ischemic attack or premature stroke, peripheral vascular disease, particularly lower extremity occlusive disease, cerebral vein thrombosis, multiple spontaneous abortions, history of a thrombotic event, family history of venous thrombosis, relative known to have factor V Leiden, presence of another known genetic hypercoagulability in an individual with a history of thrombosis, and prior to major surgery, pregnancy, oral contraceptive use, or estrogen therapy if there is a personal or family history of thrombosis.
The Factor II (20210A) gene mutation is also a common risk factor for thrombosis and is associated with elevated factor II (Prothrombin) levels in the peripheral blood. It is present in 1-3% of the general population, and after the factor V Leiden mutation, it is the most common genetic risk factor for venous thrombosis. Higher concentrations of prothrombin lead to increased rates of thrombin generation, resulting in excessive growth of fibrin clots. It is an autosomal dominant disorder, with heterozygotes being at a 3 to 11 fold increased risk of thrombosis. Although homozygosity is rare, the inheritance of two G20210A alleles would increase the risk of developing thrombosis further. If a patient is doubly heterozygous for both the Factor II (G20210A) Mutation and the Factor V Leiden (G1691A) Mutation, the combined heterozygosity leads to an earlier onset of thrombosis and tends to be more severe than single-gene heterozygosity.
Some indications for Factor II gene mutation testing are venous thrombosis, pulmonary embolism, premature myocardial infarction in women, premature ischemic stroke in the absence of hypertension, diabetes or hypercholesterolemia, cerebral vein thrombosis, history of a thrombotic event, family history of thrombosis, relative known to have the prothrombin (factor II) mutation, presence of another known genetic hypercoagulability in an individual with a history of thrombosis, and prior to major surgery, pregnancy, oral contraceptive use or estrogen therapy if there is a personal or family history of thrombosis.
Testing for Factor II and Factor V-Leiden gene mutation is available at Ingalls Hospital Molecular Diagnostic Laboratory. These mutations are detected by the Invader Assay (Third Wave Technologies) using Fluorescence Resonance Energy Transfer (FRET) Detection.
Mutations are other than the Factor II or V Leiden Gene Mutation that may cause elevated prothrombin and/or increased risk of venous thrombosis are not ruled out by this assay.
Due to the unique nature of genetic susceptibility testing, patients should receive pre-test and post-test counseling.
These tests are reported as: negative, heterozygous, or homozygous.
For any questions, please call the Department of Pathology and Laboratory Services at Ingalls Hospital (708) 915-5763.

MOLECULAR TESTING

Ancillary Testing in Urinary Cytopathology: The UroVysion™ Test

Bladder neoplasms comprise 2 to 6 percent of all tumors. Men are affected more often than women (2.7 to 1) and Caucasians more often than people of other racial backgrounds. According to statistics from the Surveillance, Epidemiology, and End Results (SEER) databank, the incidence has been rising steadily over the last three decades, and more than 70,000 new cases/year are expected. The estimated death rate has also been rising, currently estimated to reach >14,000/year. Urinary cytopathology is useful for the detection and monitoring of patients with urothelial carcinoma. This approach is best applied to high-grade neoplasms, where nearly all of the features usually ascribed to cancerous cells can be appreciated inadequate samples.

Urinary cytopathology is less useful for the detection and monitoring of very low-grade neoplasms, primarily because most of these tumors are composed of cells lacking features of malignancy but also because not all of the cells have all of the features usually ascribed to low-grade neoplasms even when these cells are present in the sample. Using urinary cytopathology, nearly all aggressive urothelial neoplasms can be detected inadequately sampled bladders, whether these neoplasms occur as primary or recurrent tumors. The inability to detect low-grade neoplasms is not a major limitation to the use of urinary cytopathology since low-grade lesions are rarely aggressive and can be readily detected cystoscopically. Considering the limitations of the methodology, urinary specimens are best classified in four basic categories: (1) negative, to include reactive cellular changes; (2) dysplastic cells, rule out low-grade neoplasm; (3) cells suspicious for a high-grade neoplasm; (4) malignant tumor cells consistent with a high-grade neoplasm. Its limitations notwithstanding, urinary cytopathology is an important technique and should be integrated into every detection and monitoring program for neoplasms of the urinary bladder.

Ancillary testing: Urothelial tissues and cells can be examined for their total DNA (ploidy), quantitative morphometric features, structural antigenic composition, genetic and chromosomal constitution, gene protein products, and presence and rate of DNA synthesis. Information is often obtained using immunohistochemistry and the light microscope. Other methods include enzyme-linked immunoabsorbent assay, fluorescence in situ hybridization and in situ hybridization, silver impregnation, instrumentation using computerized programs for capturing and reconstructing light scatter from dyes exposed to laser beams, laser capture microdissection, DNA (RNA) microarray analysis, and polymerase chain reactions.

Chromosomes and genes (UroVysion Testing). To date, no ancillary method of detection can distinguish between the low-grade, nonaggressive neoplasms that do not require early detection and treatment and the life-threatening high-grade aggressive urothelial neoplasms that do. Most chromosomal and genetic aberrations are confined to high-grade carcinomas, raising the possibility of epiphenomena. Further, the ability to recognize a single genetically abnormal cell raises questions concerning the point at which early detection has meaningful implications for patient care. These caveats notwithstanding, a great deal of current interest has settled on the Vysis test (UroVysion) using FISH technology. This test is FDA approved. Vysis FISH is basically a cytogenetics test that searches for abnormalities in chromosomes 3,7,9, and 17. These particular chromosomes were chosen after screening with DNA array technology revealed high correlations with urothelial neoplasms, not because the chromosomes were necessarily suspected of being involved in the histogenesis of urothelial tumors. The high rates of specificity and sensitivity documented in most publications are associated with rather low positive predictive values and may require the retesting of as many as 22% of specimens. In other words, a positive Vysis FISH result may NOT indicate the presence of a urothelial neoplasm in about 50% of patients being followed for this disease. Higher positive predictive values are achieved only by including specimens with cytologic abnormalities detected under the light microscope. When Vysis FISH is used to screen patients with hematuria, the positive predictive values are dismal (< 10% to about 25%). Once usable preparations are obtained, the observer must carefully record at least 25 nuclei (under oil) to register a positive result, and it is necessary to examine all urothelial nuclei in the specimen to assure a negative result. In most instances, Vysis FISH apparently does not detect cells that are invisible to cytopathologists, but this method does accept a lower threshold for positive and simplifies the analysis. Nevertheless, Vysis FISH might well be beneficial to certain patients, for example, those with suspicious or dysplastic cells in their voided urines and those at very high risk for recurrent high-grade urothelial carcinoma. The test should not be used as the only method of detection, and a urinary cytopathology analysis should be performed on the same specimen if at all feasible.

For any questions, please call the Department of Pathology and Laboratory Services at Ingalls Hospital (708) 915-5763.

* Taken and modified from the Narrative Syllabus “PRACTICAL APPROACHES TO BLADDER CANCER IN THE INFORMATION AGE”; by William M. Murphy, M. D.; Consultant, Urologic Pathology; Professor of Pathology, Emeritus; University of Florida, Gainesville. FL (Presented at the ASCP meeting, May 2010, Toronto).


 A Doctor Looking Through Microscope

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