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Articles by our Physicians
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Publication: Interdigitating dendritic cell sarcoma: A report of four cases. Am J Clin Pathol 2001;115:589-597 Gaertner EM, Tsokas M, Derringer GA, Neuhasuer TS, Arcerio CA, Andriko JW.
To better define the clinical and pathologic features of interdigitating dendritic cell sarcoma (IDCS), we report 4 cases, including the first reported in the tonsil. There were 2 male and 2 female patients (mean age, 70 years). Sites of tumor included 1 case each in the right cervical lymph node, left axillary lymph node, right tonsil, and right inguinal lymph node. Histologically, all showed diffuse effacement of the lymphoid tissue by pleomorphic round to spindled cells with convoluted nuclei and abundant eosinophilic cytoplasm. All were immunoreactive for S-100, CD68, lysozyme, and vimentin. CD45 was positive in 3 cases and CD1a in 1 case. Fascin was positive in 3 cases. Other immunostains, including CD3, CD20, CD21, CD30, actin, cytokeratin, and HMB-45, were negative. Ultrastructurally, the tumor cells were elongated and showed indented nuclei, variable numbers of lysosomes, and interdigitating cytoplasmic processes. Follow-up was available for all cases. One patient died of widespread disease 2 months after diagnosis. One was alive with metastatic lung disease at 12 months. Two patients were disease free at 5 and 9 months.
Publication: Preoperative diagnosis of intraductal papillary mucinous tumors of the pancreas by endoscopic pancreatic biopsy. Gastrointest Endosc 2001 Apr;53(4):510-513 Hurwitz LK, Daniels A, Barkin JS, Petruff C, Gaertner E, Moses F.
Intraductal papillary mucinous tumors (IPMTs) make up approximately 11% of cystic tumors of the pancreas. This entity, first described by Ohhashi et al. in 1982, manifests as a cystic dilation of the main pancreatic duct or secondary branches with copious mucus secretion filling the ductal lumen. Since the initial report, more than 300 cases of IPMTs have been reported, predominantly from Japan. Yamaguchi et al. suggest that IPMTs be classified into 3 categories based on histology: benign (hyperplasia or adenoma with mild to moderate atypia), borderline (adenoma with severe atypia), and malignant. However, the tumor category can only be determined after surgical resection. Multiple factors have been reported to be associated with an increased risk of malignancy including diabetes, involvement of the main pancreatic duct, large tumor size, marked dilation of the main pancreatic duct, and the presence of large mural nodules. Rarely, endoscopic brush cytology and biopsies of the pancreatic duct have been reported to establish the preoperative diagnosis and determine the presence of malignancy.  This report describes the preoperative diagnosis of IPMT in 3 patients who underwent ERCP and transpapillary pancreatic duct biopsy and reviews published information regarding preoperative tissue diagnosis.
Publication: Fine-needle aspiration of renal angiosarcoma. Arch Pathol Lab Med. 2002 Apr;126(4):478-480 Johnson VV, Gaertner EM, Crothers BA.
Angiosarcoma of the kidney is an unusual neoplasm, and primary renal angiosarcoma is exceedingly rare, with fewer than 11 well-documented cases reported to date. To our knowledge, no publication to date has correlated the fine-needle aspiration cytologic findings in renal angiosarcoma with the gross, histologic, and immunohistochemical findings. A 50-year-old man presented with a left kidney mass and multiple liver and pulmonary nodules. Computed tomography-guided fine-needle aspiration biopsies of the renal mass and a hepatic nodule were performed and demonstrated malignant spindle cells consistent with angiosarcoma. The diagnosis was confirmed at autopsy through histologic examination and associated ancillary studies. This case presents the fine-needle aspiration cytologic findings in renal angiosarcoma and correlates these findings with the gross pathologic, histologic, and immunohistochemical findings.
Publication: Papular spongiotic dermatitis of smallpox vaccination: Report of two cases with review of the literature. Arch Pathol Lab Med. 2004 Oct;128(10):173-175 Gaertner EM, Groo S, Kim J.
We report 2 cases of nonspecific postvaccinial dermatitis following smallpox vaccination. The patients presented with diffuse, pruritic, erythematous macules and papules 11 days (case 1) and 7 days (case 2) following routine smallpox vaccination. Biopsies of the lesions demonstrated spongiotic dermatitis without evidence of viral cytopathic changes. One case showed a pityriasis rosea-like histologic pattern. The exanthema resolved without sequelae with symptomatic treatment (case 1). Review of historical literature demonstrated the association of a variety of nonspecific cutaneous complications with vaccinia inoculation, including erythema multiforme, urticaria, and pityriasis rosea. The association of these various dermatitides with smallpox immunization is not well known and is likely underreported.
Publication: Malignant extragastrointestinal stromal tumor presenting as a vaginal mass: report of an unusual case with literature review. Int J Gynecol Cancer. 2005 15:1 Weppler EH, Gaertner EM.
The clinical and pathologic features of a malignant extragastrointestinal stromal tumor presenting as a vaginal mass are discussed. A 66-year-old female presented with copious vaginal bleeding and spontaneous passage of tumoral tissue per vagina. Histologic assessment showed a mitotically active spindle cell neoplasm. Immunohistochemical analysis demonstrated the neoplasm to be positive for CD117 (transmembrane tyrosine kinase) and CD34, consistent with a malignant extragastrointestinal stromal tumor. Subsequent clinical examination revealed an 8-cm posterior vaginal wall mass, with probable origin from the rectovaginal septum. This case is unique based on the primacy of presenting gynecologic complaints, and the unusual anatomic location of the lesion. A literature review of the pathologic features of extragastrointestinal stromal tumors and factors predictive of biologic behavior are discussed. Correct tumor diagnosis is emphasized given the effective treatment possible with imatinib for patients with unresectable tumors.
Publication: Pathologic quiz case: persistent hemopericardial effusion in a 54-year-old man. Primary cardiac angiosarcoma. Arch Pathol Lab Med. 2005 Jan;129(1):117-8 Tremaine L, Gaertner EM.
Abstract not available.
Publication: Use of methylene blue for detection of specialized intestinal metaplasia in GERD patients presenting for screening upper endoscopy. Dig Dis Sci. 2005 Feb;50(2):389-93 Duncan MB, Horwhat JD, Maydonovitch CL, Ramos F, Colina R, Gaertner E, Yang H, Wong RK.
The ability of randomly obtained biopsy specimens to identify intestinal metaplasia in the distal esophagus is low. Use of vital staining has been suggested, as stains are taken up by areas histologically identified as specialized intestinal metaplasia (SIM). This study evaluated the role of methylene blue (MB) staining for identification of SIM in GERD patients undergoing a screening endoscopy. Chromoendoscopy of the distal esophagus using 1% MB was performed on 52 GERD patients presenting for their first endoscopy. Biopsies were obtained from areas that were stained darkly, stained lightly, unstained, or macroscopically abnormal. In patients with no MB staining, four-quadrant biopsy of the distal esophagus was performed. Twenty-seven patients (52%) showed staining with MB, while 25 patients did not. Two hundred sixty-six biopsies were obtained. SIM was detected in 11 (21%) subjects (SIM+) but not in the remaining 41 (SIM-). One hundred sixty-five biopsies were unstained (25 SIM+, 140 SIM-) and 101 were stained (12 SIM+, 89 SIM-). The per-biopsy sensitivity and specificity of MB for detection of SIM were 32.4 and 85%, while the per-patient sensitivity and specificity were 63.3 and 51.2%. MB staining for detection of SIM in GERD patients without a macroscopic appearance suggestive of a columnar-lined esophagus is a poor screening tool for SIM.
Publication: Interobserver and intraobserver variability of a two-tier system for grading ovarian serous carcinoma. Am J Surg Pathol 2007 Aug;31(8):1168-1174 Malpica A, Deavers MT, Tornos C, Kurman RJ, Soslow R, Seidman J, Munsell MF, Gaertner E, Frishberg D, Silva EG.
Although grading has been demonstrated to be an important prognostic factor in ovarian serous carcinoma, there is no system universally used to perform this task. A few years ago, we proposed a two-tier system for grading ovarian serous carcinoma that is based primarily on the assessment of nuclear atypia (uniformity vs. pleomorphism) in the worst area of the tumor. Tumor grade in this two-tier system is correlated with survival. After being used by numerous pathologists and trainees at The University of Texas M.D. Anderson Cancer Center (MDACC) for 15 years, we have observed that this system is user-friendly and reproducible. We undertook this study to evaluate the interobserver and intraobserver variability among a group of 7 gynecologic pathologists and 2 general surgical pathologists using this grading system. A total of 80 cases of ovarian serous carcinoma, 40 low-grade and 40 high-grade, were circulated twice among these pathologists. Slides with examples of low-grade and high-grade serous carcinoma were sent with the unknowns. Statistical analysis demonstrated an overall kappa statistic among the different observers of 0.909. The intergrader kappa's ranged from 0.717 to 1.000 in the first round of the review and from 0.701 to 1.000 in the second round. Eight of the participants had an intragrader kappa ranging from 0.775 to 1.000 (excellent agreement), whereas a single participant had an intragrader kappa of 0.725 (good agreement). This study demonstrates that the two-tier grading system (the MDACC grading system) for ovarian serous carcinoma on the basis of the assessment of nuclear atypia is easy to learn and is highly reproducible. These findings would support its universal use, which would be beneficial for the standardization of clinical trials and protocols, thus facilitating the understanding of this disease and investigation into the treatment of patients affected by these tumors.
Publication: A randomized comparison of methylene blue-directed biopsy vs conventional four-quadrant biopsy for the detection of intestinal metaplasia in patients with long-segment Barrett’s Esophagu Horwhat JD, Maydonovitch CL, Ramos F, Colina R, Gaertner E, Lee H, Wong RK.
Objectives: Methylene blue (MB) selectively stains specialized intestinal metaplasia (SIM) and may assist in surveying a columnar-lined esophagus for Barrett's esophagus associated dysplasia.
Methods: This is a prospective, randomized crossover study comparing 4-quadrant random biopsies (4QB) versus MB-directed biopsies for the detection of SIM and dysplasia in 48 patients with long segment Barrett's esophagus (LSBE). Patients randomly underwent two endoscopies over a 4-wk time period with either 4QB or MB-directed biopsies as their first or second exam. Our aim was to correlate stain intensity with histology.
Results: The sensitivity of MB for SIM and dysplasia was 75.2% and 83.1%, respectively. The yield of 4QB for identifying nondysplasia SIM was 57.6% (523/917) and for dysplasia was 12% (111/917). Dark staining was significantly associated with histologic grade (P < 0.007). The final diagnosis was correct in 43 (90%) patients using MB and in 45 (94%) using 4QB. The 4QB technique missed dysplasia in 3 of 21 patients while MB biopsies missed dysplasia in 5 of 21 patients. The discordance between the two techniques was not significant (P= 0.727, McNemar's test). The mean number of biopsies taken during 4QB was 18.92 +/- 6.36 and with MB was 9.23 +/- 2.89 (P < 0.001).
Conclusion: MB requires significantly fewer biopsies than 4QB to evaluate for SIM and dysplasia. Dark staining correlates more with HGD than LGD in our experience. While MB is not more accurate than 4QB, MB may help to define areas to target for biopsy during surveillance endoscopy in patients with LSBE.
Publication: Onychomatricoma: Report of an unusual case with review of the literature. J Cutan Pathol 2009 Oct;36 Suppl 1:66-9. Epub 2009 Mar 16. Gaertner E, Gordon M, Reed T.
Onychomatricoma is rare subungual tumor of nail matrix origin. We report a 40-year-old white man with an onychomatricoma of the left index finger that highlights the characteristic clinical and pathological features and expands the known case material. We also review the published medical literature on the subject.
Publication: Focus Issue on Squamous Cell Carcinoma: Practical Concerns Regarding the 7th Edition AJCC Staging Guidelines. Department of Dermatology, University of Texas Southwestern Medical Center Buethe D, Warner C, Miedler J, Cockerell CJ
The 7th edition of the AJCC Cancer Staging Manual represents a dramatic shift in the way that cutaneous squamous cell carcinoma (cSCC) is staged, in that it is first attempt to incorporate evidence-based medicine into the staging guidelines for cSCC. In our opinion, the changes made to the seventh edition represent a significant improvement over previous editions and will ultimately lead to improved patient stratification, more accurate prognostic data, and a better framework to guide clinical decision making. However, there are a number of issues within the latest guidelines that require clarification or are impractical for clinical practice. The purpose of this paper is to highlight the key changes to the 6th edition staging manual as they pertain to cSCC, to point out impractical component of the 7th edition and/or aspects that require further clarification, and to make recommendations that address any current shortcomings to improve subsequent editions. Specific focus will be given to the inclusion of separate guidelines for cSCC and Merkel cell carcinoma (MCC), the incorporation of high-risk factors as modifiers of T stage, the addition of new guidelines for advanced T stage, and the changes in stratification of lymph node status. This paper is modified from a more comprehensive treatment of the staging of nonmelanoma skin cancer by Warner and Cockerell entitled "The new 7th edition American joint committee on cancer staging of cutaneous nonmelanoma skin cancer: a critical review," in the American Journal of Clinical Dermatology (paper accepted, pending publication).
PMID: 21151529 [PubMed - in process]PMCID: PMC2990020