Quality Assurance

ANNUAL MEETING ABSTRACTS 501A 2015 Increased IgG4 Density and IgG4:IgG Ratios in Interstitial Design: We routinely receive requests for either a Quad screen or a cfDNA Lung Disease Are Associated with Rheumatologic Diseases and Usual Screening Test. Our department recently noticed an increase in cfDNA test requests. Interstitial Pneumonia Retrospectively, we reviewed requests for the Quad Screen or Cell-Free DNA Screening Yang Zhang, Allen P Burke, Nevins W Todd. University of Maryland Medical Center, Test over the last 9 months. Baltimore, MD. Results: There were 57 requests identified. Forty-three were for cfDNA testing with Background: IgG4-related lung disease has expanded to include an interstitial alpha-fetoprotein (AFP), and 14 were for Quad screen with cfDNA testing. Thirteen inflammatory pattern similar to non-specific interstitial pneumonia (NSIP) and even of 14 Quad screen test results were negative and correlated with cfDNA findings. One usual interstitial pneumonia (UIP). It is unknown how often NSIP or UIP have IgG4 patient had a positive Quad Screen suspicious for trisomy 18 but a negative cfDNA plasma cell infiltrates, or what defines an abnormal number of IgG4+ cells in interstitial result. Fifty-five patients had negative cfDNA results. Two patients had positive cfDNA lung disease (ILD). test for Trisomy 21. Results of cfDNA tests accurately predicted clinical outcome. Design: We selected 14 cases of cellular NSIP, and 6 cases of UIP based on the presence Conclusions: Our study suggests that the cfDNA test has higher sensitivity and lower of numerous plasma cells on routine staining. No patient had a history of IgG4 disease. false positive rate than a Quad Screen. The utilization of cfDNA test may decrease the Immunohistochemical staining identified IgG positive and IgG4 positive plasma cells. use of more invasive testing such as amniocentesis. Ordering cfDNA test combined In areas of maximal numbers, IgG4 density and IgG4:IgG ratios were quantitated per with AFP appears to have a greater accuracy, is a more cost effective approach for the high-power field (hpf) and averaged over 4 hot spots. There were 9 explants and 11 evaluation of fetal trisomies, and is available in the first trimester. wedge biopsies. Results: There were 9 women and 11 men; five patients had a history of autoimmune 2018 Discordances in Evaluation of Melanocytic Lesions and Its disease. No case had fibroinflammatory lesions suggestive of IgG4-related masses. Impact on Management: A Study of 1518 Cases Mean IgG4 density was 3.9 ± 4.8 in cases of NSIP (highest 14) vs. 8.2 ± 7.6 in cases Rami Al-Rohil, George Jour, Priyadharsini Nagarajan, Phyu P Aung, Michael T Tetzlaff, of UIP (highest 22) (p=0.15). Mean IgG4 ratio was 6.8% (range 0-31) in cases of Jonathan L Curry, Carlos A Torres-Cabala, Doina Ivan, Victor G Prieto. Vanderbilt NSIP vs. 19.3% (range 5-32) in cases of UIP (p= 0.016). The highest IgG4 ratio in the University, Nashville, TN; MD Anderson Cancer Center at Cooper, Camden, NJ; MD NSIP group (31%) was in a woman with an elevated serum IgG4 level. There was a Anderson Cancer Center, Houston, TX. significant increase in mean IgG4+ plasma cells between patients with rheumatologic Background: Accurate diagnosis of melanocytic lesions carries a significant clinical disease and those without (p=0.04). By multivariate analysis, a history of autoimmune implication as appropriate management does not only depend on the correct diagnosis disease (p=.006) and UIP histologic pattern (p=0.01) were associated with increased but varies according to the pathologic stage. The objective of this study is to evaluate IgG4 ratio, as well as between autoimmune disease and IgG4 density (p=0.01). the degree of discordance between primary histopathologic diagnosis and secondary Conclusions: IgG4+ cells are associated with autoimmune ILD, and are more numerous review of melanocytic lesions, parameters of melanoma, and the subsequent impact in UIP vs. NSIP. Although there is a wide range, an upper normal limit of interstitial on clinical management and follow-up. plasma cells would be approximately 20/hpf, with an IgG4:IgG ratio of over 25%. Design: In a retrospective review of 1518 referral cases to MD Anderson Cancer Center (MDACC) of melanocytic lesions from 1/2010 to 1/2011, initial diagnoses from the referring institution were compared to the MDACC second opinion reports. If any Quality Assurance discordance was noted at time of review, a consensus diagnosis by at least 4 different dermatopathologists was rendered prior to approving the discordance. The discordances 2016 Detecting Incidental Gallbladder Adenocarcinoma: When to were classified as (i) major discordance if they resulted in change in diagnosis and stage Submit the Entire Gallbladder of melanoma and thus, the clinical management and (ii) minor discordance if there was Ashwin Akki, Qiang Liu, Sun M Chung, Kathryn E Tanaka, Nicole C Panarelli. no impact on clinical management. Montefiore Medical Center, Bronx, NY. Results: The concordance rate was 100% among metastatic melanoma, (n=214 Background: Gallbladder adenocarcinomas are rare and a substantial proportion is cases, 14%). Discordance in primary melanocytic lesions occurred in 10.7% of cases detected incidentally in routine cholecystectomy specimens. It is currently unclear (140/1304). Minor and major discordances were found in 38% (n= 53) and 62% (n=87) which findings in initial sections are associated with incidental adenocarcinoma, and of the primary melanocytic lesions, respectively. Major discordance categories included sampling practices are highly variable when intestinal metaplasia (IM), low-grade inaccurate mitotic count 40/87 (46%), followed by change in diagnosis 39/87 (44.9%), dysplasia (LGD), or high–grade dysplasia (HGD) are found upon routine review. The change in Breslow thickness 6/87 (6.9%), change in Breslow thickness and mitotic purpose of this study was to correlate findings in initial sections of cholecystectomy count 1/87 (1.1%), and change in Breslow thickness, mitotic count and ulceration specimens with final diagnoses, in order to determine whether detection of any of these 1/87 (1.1%). Follow-up ranged between 6 to 131 months (mean 52 months). Among features warrants more extensive sampling. cases with major discordance, 80% (n=69) showed no evidence of residual/recurrent Design: We retrospectively reviewed all cholecystectomy specimens over a 26-month disease, 7% (n=6) died of disease, 2% (n=2) died of other causes, 2% (n=2) are alive period in order to identify those that had additional sections submitted following review with disease, and 9% (n=8) were lost to follow-up. of the original slides. Four pathologists with an interest in gastrointestinal pathology, Conclusions: Our results show that critical review of melanocytic lesions may lead to who were blinded to the original diagnoses and findings on the additional sections, significant changes in the diagnosis of melanoma, tumor classification as well as staging, reviewed the initial slides (mean: 2, range 1-7) to assess for the presence or absence of thus resulting in critical changes in clinical management and impacting patient survival. IM, LGD (including BilIN 1 and 2), HGD (BilIN 3), or adenocarcinoma. Diagnostic discrepancies were resolved by consensus. 2019 Checklist Implementation for Intraoperative Consultations: Results: Additional sections were submitted in 51 of 4059 (1%) cases. These contained Improved Quality and Safety IM (n=44, 86%), LGD (n=18, 35%), and HGD (n=5, 10%). A mean of 10 additional Kevin Anderson, Jia Xu, Yigu Chen, Jeffrey D Goldsmith, Yael K Heher. Beth Israel cassettes were submitted (range: 2-26). All cases with dysplasia were submitted Deaconess Medical Center, Boston, MA; Boston Children’s Hospital, Boston, MA. entirely. Interobserver agreement was fair (κ=0.4) for LGD and high (κ=0.8) for HGD. Background: Intraoperative consultation (IOC) is a fundamental part of surgical The diagnosis of IM was agreed upon by all pathologists in all cases. Five incidental pathology, providing surgeons with real-time information central to patient care. Correct adenocarcinomas were detected, including 2 (40%) that were not present in initial IOC slide labeling, typically manually performed in a time pressured setting, is critical to sections. These two cases displayed HGD in the original slides, which was independently avoid patient harm. A recent serious adverse event due to IOC labeling mixup prompted diagnosed by all four pathologists. The remaining 3 adenocarcinomas were associated workflow redesign. A checklist was implemented aimed at standardizing slide labeling with HGD in the background mucosa. Incidental cancers were not detected in cases and monitoring other data points central to quality management. Checklist effects on with only IM or LGD on initial sections; LGD was detected in 8 cases with IM on initial slide labeling defect rates and frozen section TAT were studied. sections, and 2 cases with LGD displayed HGD upon further sampling. Design: Data were collected for all IOC cases over a 9 month period. Slide labeling Conclusions: The presence of HGD should prompt complete submission of defect rates and IOC TAT were recorded and compared for the pre and post cholecystectomy specimens, as they may harbor adenocarcinoma and require further implementation periods. A slide labeling defect was defined as a lack of any 3 elements treatment. Pathologists should consider seeking a second opinion when LGD is present on a slide label per hospital policy: patient name, medical record number (MRN), and and submitting additional sections that target abnormal areas; examination of the entire specimen designation by surgeon. specimen is needed if these yield HGD. Cases that show IM are adequately examined Results: 839 IOC cases were analyzed. Pre-intervention slide labeling showed that with routine sampling in the absence of gross abnormalities. the patient’s name, MRN and specimen designation were absent in 23%, 39% and 84% of cases, respectively, with 85% of cases containing at least one defect (n=565).

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