2015 Vol. 6, No. 3

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Original Contributions
Abstract:
  Objective  To explore the difference in clinicopathological characteristics between invasive micropapillary carcinoma (IMPC) and invasive carcinoma of no special type (NST), and analyze its association with axillary lymph node metastasis.  Methods  The clinicopathological data of 92 IMPC cases treated within the period from August 2010 to August 2013 in Peking Union Medical College Hospital were retrospectively analyzed. From patients in the same period, 368 NST cases were randomly selected as control group. The difference in clinicopathological characteristics between IMPC and NST were compared, and the factors associated with axillary lymph node metastasis were analyzed.  Results  There were significant differences in tumor size[(2.9±1.9)cm vs. (2.1±1.4)cm, P=0.001], lymph-vascular invasion rate(85.9% vs. 6.0%, P < 0.001), axillary lymph node metastatic rate (71.7% vs. 47.3%, P < 0.001), number of involved lymph node(8.2±9.9 vs. 2.9±5.7, P < 0.001), progestogen receptor expression (P=0.047), human epidermal growth factor receptor-2 (HER-2) expression (P=0.009), Ki-67 index (P < 0.001), TNM staging (P < 0.001), and molecular subtype (P < 0.001) between IMPC and NST. The axillary lymph node metastatic rates of tumor containing ≤ 24%, 25%-49%, 50%-75% and ≥ 76% IMPC component were 73.9%, 56.3%, 72.2% and 77.1%, respectively. The axillary lymph node metastatic rate was not correlated with the percentage of IMPC component (P=0.347), but correlated with T-staging(P=0.001), HER-2 expression (P=0.029), molecular subtype (P=0.003), P53 expression(P=0.003), and Ki-67 index (P=0.045). The axillary lymph node metastasis of NST was found correlated with T-staging(P < 0.001), histological grade (P=0.001), lymph-vascular invasion (P < 0.001), estrogen receptor α expression (P=0.007), progestogen receptor expression (P=0.031), HER-2 expression (P=0.008), and molecular subtype (P < 0.001).  Conclusions  IMPC is a distinct variant of invasive breast carcinoma with a high propensity for lymph-vascular invasion and axillary lymph node involvement. IMPC and NST have different clinicopathological characteristics. The percentage of IMPC component does not correlate with axillary lymph node metastasis. Compared with NST, there are less clinicopathological determinants for axillary lymph node metastasis in IMPC.
Abstract:
  Objective  To analyze the causes of missed diagnosis and misdiagnosis of abdominal organ lesions through reviewing preoperative transabdominal ultrasound reports.  Methods  Data of the patients who received abdominal operation for abdominal organ lesions (including liver, gallbladder, biliary tract, pancreas, spleen, kidney, adrenal gland, and appendix) in Peking Union Medical College Hospital within the period from March 1 to August 31 in 2013 were exported from pathological workstation. The preoperative ultrasound reports of these patients were reviewed. The missed diagnosis and misdiagnosis cases were recorded, and causes of the mistakes were analyzed.  Results  Altogether 58 cases of missed diagnosis or misdiagnosis were identified from 1081 ultrasound reports (5.37%, 58/1081), including 6 liver lesions (5.77%, 6/104, all misdiagnosed), 6 gall-bladder and biliary tract lesions (1.30%, 6/462, 5 missed and 1 misdiagnosed), 14 pancreatic lesions (19.72%, 14/71, all missed), 20 kidney and adrenal lesions (6.47%, 20/309, 11 missed and 9 misdiagnosed), and 12 appendical lesions (16.00%, 12/75, 11 missed and 1 misdiagnosed). The average maximum diameter of the missed nodular lesions was significantly smaller than that of the misdiagnosed lesions (P=0.001).  Conclusions  Missed diagnosis and misdiagnosis of ultrasound are attributable to various causes, including the nature, location, and size of abdominal organ lesions and the limitation of transabdominal ultrasound technology. The clinical ultrasound examination should be carried out very carefully and thoroughly. Ultrasound radiologists should have a thorough understanding of characteristics of different organ lesions and the limitation of ultrasound technique, in order to avoid missed diagnosis and misdiagnosis in clinical practice.
Abstract:
  Objective  To investigate the distribution and antimicrobial resistance of clinical isolates from surgery wards in Peking Union Medical College Hospital (PUMCH).  Methods  A total of 3084 non-duplicate clinical isolates were collected from PUMCH surgery wards during the period from January 1, 2012 to December 31, 2013. Disc diffusion test (Kirby-Bauer method) and automated systems were employed to detect the antimicrobial resistance of these isolates. The data were analyzed by WHONET 5.6 software according to Clinical and Laboratory Standards Institute 2013 breakpoints.  Results  Of the 3084 clinical isolates, the 10 most common bacteria isolated were:A.baumannii(14.1%), E.coli (12.4%), P.aeruginosa(12.4%), K.pneumonia(11.8%), S.aureus(8.9%), E.faecalis(5.4%), coagulase-negative staphylococcus(5.3%), E.cloacae(3.7%), S.maltophilia(3.6%) and E.faecium(3.2%), in which gram-negative bacteria accounted for 71.6% (2208 isolates) and gram-positive accounted for 28.4% (876 isolates). In S.aureus and coagulase-negative staphylococcus, methicillin-resistant strains (MRSA and MRCNS) accounted for 42.7% (117/274) and 77.3% (119/154), respectively. The resistance rates of methicillin-resistance strains to β-lactams and other antimicrobial agents were much higher than those of methicillin-susceptive strains including methicillin-susceptible Staphylococcus aureus(MSSA) and methicillin-susceptible coagulase-negative Staphylococcus(MSCNS). In addition, 80.3% of MRSA strains were still susceptible to trimethoprim-sulfamethoxazole, while 95.0% of MRCNS strains were susceptible to rifampin. No staphylococcal strains were found resistant to vancomycin, teicoplanin, or linezolid. The drug resistance rates of E.faecalis strains to most antimicrobials tested were much lower than those of E.faecium, except for the resistance rate to chloramphenicol, which was only 4.3% in E.faecium. One strain of E.faecalis and 5 strains of E.faecium were found resistant to vancomycin. No linezolid-resistant strains were found in enterococcal isolates. Extended spectrum β-lactamases (ESBLs)-producing strains accounted for 56.7% (217/383), 23.8% (97/408), and 22.8% (13/57) in E.coli, Klebsiella species(K.pneumoniae and K.oxytoca), and P.mirabilis, respectively. The drug resistance rates of ESBLs-producing strains were higher than the corresponding non-ESBLs-producing strains. Enterobacteriaceae strains were still highly susceptible to carbapenems, the overall resistance rates being 1.6%-3.3%. A few pan-resistant strains of K. pneumoniae(0.8%, 3/363)were identified. The resistance rates of P.aeruginosa to imipenem and meropenem were 19.5% and 15.0%, respectively, while the resistance rate to amikacin was the lowest (8.6%). The resistance rates of A.baumannii to imipenem and meropenem were 74.1% and 74.0%, respectively, compared with the lowest resistance rates to cefoperazone-sulbactam (51.5%) and minocycline (28.9%). The prevalence of pan-resistant strains in A.baumannii and P.aeruginosa were 44.3% (193/436) and 0.8% (3/381), respectively.  Conclusion  Regular surveillance of bacterial resistance could provide practical guidance of rational selection of antimicrobial agents for clinicians.
Abstract:
  Objective  To investigate the co-mutation of PIK3CA gene and other oncogenes in non-small cell lung cancer(NSCLC) patients in China.  Methods  Data were obtained from the patients with pathologically confirmed NSCLC and receiving gene mutation testing in 25 hospitals in China between September 2009 and April 2012. Nine genetic loci were tested and analyzed, including PIK3CA E9, PIK3CA E20, KRAS E2, KRAS E3, BRAF, and EGFR(E18, E19, E20, E21).  Results  A total of 5125 patients were included in this study, of which 161(3.14%) had multiple mutations, including 77 with mutations in PIK3CA, 50 in E9 and the other 27 in E20.The other oncogene mutations coexisting with PIK3CA mutations included KRAS E2 (11 cases), KRAS E3 (1 case), BRAF (2 cases), EGFR E18 (4 cases), EGFR E20 (5 cases), EGFR E21(28 cases), and EGFR E19 deletions (37 cases).Among mutations in PIK3CA, E9 was more likely than E20 to have coexisting mutations, also more likely to coexist with EGFR E21 L858R than EGFR E20; whereasamong mutations in PIK3CA E20, H1047R was more common than H1047L.Mutations in KRAS coexisting with PIK3CA appeared mostly in E2 G12 locus. Mutations in BRAF V600E were also inclined to coexist with PIK3CA.  Conclusions  PIK3CA might tend to appear concurrently with other oncogene mutations in Chinese NSCLC patients, while mutations in PIK3CA E9 and E20 are mutually exclusive. Further research is need to reveal the significance of coexistence of PIK3CA and other oncogene mutations in NSCLC and its impact on patient outcome.
Abstract:
  Objective  To explore the clinicopathological features of adrenocortical oncocytic carcinoma and protein expression, gene mutation, and gene copy number alteration of epidermal growth factor receptor (EGFR) in this carcinoma.  Methods  We reviewed the clinical and histomorphological features of 9 adrenocortical oncocytic carcinoma cases who received surgical resection in the period of January 2000 to December 2009 in Peking Union Medical College Hospital, and 9 adenoma cases were included as control. EGFR protein expression, EGFR gene mutation and EGFR gene copy number alteration in both groups were detected by immunohistochemistry, Scorpion Amplification Refractory Mutation System (ARMS), and fluorescence in situ hybridization (FISH), respectively.  Results  The 9 cases of adrenocortical oncocytic carcinomas included 2 cases of Cushing's syndrome and 7 cases of nonfunctional cortical carcinoma. All cases were followed up for 6 to 56 months, and 2 patients with adrenocortical oncocytic carcinomas lost to follow-up, and 6 died. In the adrenocortical oncocytic carcinoma patients, EGFR overexpression was found in 77.8% (7/9), and EGFR FISH was positive in 55.6% (5/9). In contrast, only 22.2% (2/9) of the adrenocortical adenoma patients showed EGFR weak expression and none had positive FISH result. No EGFR gene amplification or mutation was found in the 2 groups of patients.  Conclusions  Adrenocortical oncocytic carcinoma is rare. EGFR overexpression and chromosome 7 polysomy are frequent abnormality in the adrenocortical oncocytic carcinomas, which may be used in the differential diagnosis. Also, an investigation of the gene status of EGFR should facilitate the identification of a target therapeutic regimen for carcinoma patients.
Abstract:
  Objective  To investigate the clinicopathological and immunohistochemical features of adenoid cystic carcinoma (ACC) of the uterine cervix.  Methods  Four cases who were diagnozed with ACC of the uterine cervix in the period from January 2003 to December 2013 were collected from the pathological databank and consultation database of Peking Union Medical Hospital. Immunohistochemical examination was conducted on the formalin-fixed, paraffin-embedded tissue specimens from the 4 patients. Clinical information, pathological features, treatment, and outcomes of these patients were summarized.  Results  The average age of the 4 ACC patients was 61.5 years. The patients were mostly post-menopausal (3/4) and their chief complaint was vaginal bleeding (3/4). The tumors were primarily protruding masses (3/4). Histologically, 3 of the 4 cases were ACC combined with invasive squamous cell carcinoma, the other 1 was ACC alone. The growth pattern of ACC in all of the 4 cases was cribriform composed of luminal adenoepithelial and abluminal myoepithelial cells. Immunohistochemical findings supported the identification of 2 components in ACC:positive expression of CK7 in luminal adenoepithelial cells, and positive expressions of P63 and SMA in abluminal myoepithelial cells. C-MYB, a ACC-specific marker, was found with strong positive expression in all the 4 cases. Three of the 4 patients had total hysterectomy, the other 1 had conization. All were in stage I in terms of clinical staging. Postoperative radiotherapy was administered in all the 4 cases, combined with chemotherapy in 2. The mean follow-up period was 21.25 months, finding all the 4 patients in disease-free survival.  Conclusions  ACC of the uterine cervix is a rare special type of adenocarcinoma, usually coexisting with other types of cervical tumors. The immunohistochemical findings in ACC of the uterine cervix are similar with ACC in other organs, but associated with poorer prognosis. Radiotherapy and chemotherapy after sugery is recommended. Early detection and treatment could improve survival.
Abstract:
  Objective  To investigate the characteristics of laparoscopic surgery for ovarian cysts in second trimester.  Methods  Between April 2002 and December 2013, 30 patients were treated with laparoscopic surgery for clinically suspected ovarian cyst in second trimester at Department of Obstetrics and Gynecology, Peking Union Medical College Hospital. Clinical data of these patients were reviewed for identification of clinical characteristics, and assessment of feasibility and indications of the surgery.  Results  Of the 30 patients, the mean age was (28.5±3.1) years, gestational age was (14.7±2.5) weeks, mean operation time was (50±20)minutes, and mean length of hospital stay was (4.5±0.8)days. Between the patients with gestational age ≥ 16 weeks (11/30, 36.7%) and those with gestational age < 16 week (19/30, 63.3%), no difference was noted in operation time (P>0.05). In the 30 patients, only 5 (16.7%) patients had known about the ovarian masses before pregnancy. The mean diameter of the masses was (9.0±5.4) cm. In the 12 patients (40%) who had masses with diameter ≥ 9 cm, the operation time was significantly longer than that in the 18 patients (60%) who had masses < 9 cm (P < 0.05). Five patients (16.7%) received emergency surgery, including 2 cases (6.7%) receiving simple salpingo-oophorectomy for ovarian necrosis due to adnexal torsion. In the other 28 patients(93.3%), the ovary cysts were removed. Postoperative pathological examination showed teratoma in 18 cases (60%), serous cyst in 6 cases (20%), corpus luteum cyst in 3 cases (10%), mucinous cystadenoma in 2 cases (6.7%), and foam fibroma in 1 case (3.3%). One patient (3.3%) experienced postoperative contractions, which were cured by magnesium sulfate and progestin. No severe complications occurred. Twenty-six(86.7%) patients delivered healthy full-term infants, and the other 4 (13.3%) cases lost to follow-up.  Conclusions  Laparoscopic surgery is a safe and feasible procedure for the treatment of ovarian cysts in second trimester of pregnancy. For adnexal masses persistent or suspicious for torsion, surgical management is warranted. Close maternal and fetal monitoring is essential during and after the operation.
Abstract:
  Objective  To investigate the clinical characteristics of hysteroscopic patients and to discuss some inconclusive questions in hysteroscopy.  Methods  A total of 315 patients who underwent hysteroscopy in Peking Union Medical College Hospital from July to December, 2014 were included in this retrospective study. Clinical and pathological features of these patients were summarized. Clinically relevant inconclusive questions including PALM-COEIN classification, ultrasonic diagnosis of endometrial polyp, case characteristics of adenomyomatous polyp, intrauterine space-occupying lesion induced by adjuvant endocrine therapy for breast cancer, and uterine scar diverticulum were analyzed based on the data of these patients.  Results  Among the 315 patients, 172 cases presented with abnormal uterine bleeding (AUB), and the other 143 were asymptomatic. Malignant lesions were more common in AUB patients compared with asymptomatic patients (15.7% vs. 2.1%, P=0.000). In the AUB patients, 128 were of reproductive age, in whom the most common condition was endometrial polyps (58 cases, 45.3%) according to PALM-COEIN classification system. All together 160 cases of endometrial polyps were identified. The positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of transvaginal ultrasound in diagnosing endometrial polyps were 80%, 75%, 71%, 81%, and 76%, respectively. Seventeen patients had adenomyomatous polyp, including 3 with atypical pathological features; 10 patients had history of surgically treated breast cancer, 9 of whom received adjuvant endocrine therapy, and all had benign results of endometrial pathological examination; 5 patients had scar diverticulum after cesarean section, all with specific hysteroscopic demonstrations.  Conclusions  As a minimally invasive technique, hysteroscopy plays an important role in diagnosis and treatment of AUB and intrauterine space-occupying lesion. For most benign lesions, such as endometrial polyps, endometrial hyperplasia following postoperative endocrine therapy of breast cancer, and cesarean scare diverticulum, hysteroscopy allows therapeutic operation while confirming diagnosis. Investigation into hot topics in diagnosis and treatment with hysteroscopy could help to optimize clinical strategies.
Abstract:
  Objective  To investigate the clinical characteristics and significance of diagnosis and treatment associated with persistent real low-level elevation of human chorionic gonadotropin (hCG).  Methods  Six patients diagnosed with persistent real low-level hCG elevation at Peking Union Medical College Hospital in the period from August 2011 to March 2015 were collected. Clinical records of the 6 patients were reviewed to retrospectively analyze clinical features, diagnosis and treatment approaches, and follow-up results.  Results  Among the 6 patients, 3 were secondary to uterine curettage for hydatidiform moles, and the other 3 had received chemotherapy for invasive moles, in whom the median chemotherapy cycle number was 8 and all experienced failure of at least one chemotherapy regimen. The median follow-up time was 24 months. The median period between the termination of treatment and the initial low-level hCG elevation was 5.5 months. The median duration of low-level hCG elevation was 16.5 months. Four patients had no evidence of progression, 1 patient progressed to choriocarcinoma, and 1 presented with the hCG level decreasing to the normal range after spontaneous delivery.  Conclusion  Persistent real low-level hCG elevation may persist for a long time and not respond to chemotherapy. Long-term close monitoring is necessary, but treatment is not recommended.
2015, 6(3): 161-165. doi: 10.3969/j.issn.1674-9081.2015.03.001
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2015, 6(3): 165-165.
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2015, 6(3): 216-220. doi: 10.3969/j.issn.1674-9081.2015.03.011
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2015, 6(3): 221-223. doi: 10.3969/j.issn.1674-9081.2015.03.012
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2015, 6(3): 224-229. doi: 10.3969/j.issn.1674-9081.2015.03.013
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2015, 6(3): 230-233. doi: 10.3969/j.issn.1674-9081.2015.03.014
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2015, 6(3): 234-236. doi: 10.3969/j.issn.1674-9081.2015.03.015
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2015, 6(3): 237-239. doi: 10.3969/j.issn.1674-9081.2015.03.016
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