This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page e107. Learning Objective-Upon completion of this activity, successful learners will be able to diagnose microscopic colitis in a resource efficient manner; recognize the limitations of regional sampling of the colon for microscopic colitis; understand the distribution of microscopic colitis in the colon; understand regional variations in collagenous and lymphocytic colitis. BACKGROUND & AIMS: Lymphocytic and collagenous colitis are types of microscopic colitis (MC) that commonly cause chronic watery diarrhea, but there are no macroscopic features of MC that can be detected during colonoscopy. Endoscopists therefore often collect multiple random colonic biopsies, potentially oversampling, increasing times of colonoscopy and slide review. We sought to identify sites from which biopsies could be taken and analyzed to identify patients with MC with a high level of sensitivity and determine the appropriate number of biopsies to take at these sites. METHODS: We performed a retrospective study using biopsies from 101 consecutive patients with MC (52 cases of collagenous colitis, 42 cases of lymphocytic colitis, 7 combined cases), without comorbidities, from 2017 through 2018. Slides were reviewed, and the proportion of biopsies that were diagnostic of MC were calculated at each biopsy site. RESULTS: The proportions of biopsy fragments from each site of the colon found to be positive for MC were as follows: cecum, 90.0%; ascending colon, 96.9%; hepatic flexure, 77.8%; transverse colon, 95.7%; splenic flexure, 75.0%; descending colon, 85.0%; sigmoid colon, 90.9%; and rectum, 82.2%. For biopsies labeled random, 95.7% were positive for MC. When findings from ascending and descending colon biopsies were combined, 100% of MC cases were detected. CONCLUSIONS: MC can be detected with certainty by analyzing biopsies from the ascending and descending colon. Fewer biopsies than were collected from our cases are sufficient for diagnosis. We propose a Western protocol (taking 2 biopsies from each of the ascending and descending colon) in evaluation of patients for MC.

BackgroundChronic hepatitis B (CHB) is a dynamic disease that may be affected by immune changes in pregnancy. Guidelines suggest consideration of nucleos/tide analogs (NA), i.e., tenofovir, (TDF) in highly viremic mothers to reduce vertical transmission risk. HBV variability affects CHB outcome, but little is known about HBV genetic changes in pregnancy due to immune or NA selection.ObjectivesTo evaluate HBV diversity in NA treated or untreated pregnant vs. post-partum CHB carriers.Study DesignIn plasma collected from 21 mothers (7 matching pre/post-partum), HBV serological tests, genotype and viral load were assayed. The HBV pre-surface (S) /S overlapping polymerase (P) (N = 20), pre-core (C) /C (N = 11) and/or full genome PCR amplicons (N = 3) underwent clonal sequence analysis.ResultsThe median age was 31 y, 71% Asian, 68% genotype B or C, 33% HBV eAg+, 5 received TDF (median HBV DNA 8.5 log IU/ml). In untreated mothers, median antepartum vs. post-partum ALT was 21 vs. 24 U/L and HBV DNA was 2.7 vs. 2.4 log(10) IU/ml. ALT and/or HBV DNA flares occurred during pregnant and/or post-partum period in 47% (10/21). Clonal sequencing antepartum showed the presence of minor “a determinant” and/or vaccine escape mutants (VEM) but drug resistant variants were infrequent. Analysis of pregnant vs. post-partum samples showed different HBV variants and viral diversity.ConclusionsDifferences in immune and/or by NA selective pressures during pregnancy may affect HBV evolution during pregnancy. The presence of minor VEM warrant infant follow-up.

Republic of (South)Purpose/Objective(s): To investigate the clinical significance of 18F-Flurodeoxyglucose-positron emission tomography (FDG-PET) parameters and carbohydrate antigen 19-9 (CA 19-9) levels in stratifying prognostic groups in patients with locally advanced pancreatic cancer after concurrent chemoradiotherapy (CRT) Materials/Methods: From our institutional database, we selected 257 patients with locally advanced pancreatic cancer who underwent both pretreatment 18F-FDG PET and CA 19-9 test, and received concurrent CRT between January 2004 and December 2011. The maximum standardized uptake value (SUVmax) was calculated at regions of primary tumors from pre-CRT and post-CRT FDG-PETs. SUV parameters (preand post-CRT SUVmax), SUV decline rate (%), CA 19-9 levels (pre-and post-CRT CA 19-9), and CA 19-9 decline rate (%) were analyzed for comparing radiologic response and survival outcomes (progression-free survival (PFS), overall survival (OS)). Results: Median OS and PFS were 14.6 months and 8.8 months from the date of first diagnosis, respectively, at a median follow-up time of 14.2 months (range, 2.3-133.8 months). Radiologic responses after CRT (complete or partial response) were firstly obtained in 17% of the patients (nZ43). Of the 164 patients with recurrences after CRT, distant metastasis (DM) was the most common (nZ141, 86%), followed by local recurrence (LR) (nZ12, 7%), and LR+DM (nZ11, 7%). Additional surgical resection, maintenance chemotherapy, post-CRT CA 19-9 <66, and CA 19-9 decline ratio 91.2% were independent predictors of favorable PFS (pZ<0.001, <0.001, 0.001, and 0.003), and pre-CRT CA 19-9 <760, CA 19-9 decline ratio 91.2% were independent predictors of favorable OS (pZ0.017, <0.001) in multivariate analysis. For the PET parameters, SUV decline 63% was the most significant prognostic factor (pZ0.029 for PFS, 0.017 for OS). Patients with SUV decline 63% were included in the responder group more than in the non-responder group (12% vs. 2%, pZ0.057). We also divided patients into 4 risk groups according to the number of positive favorable factors (SUV decline ratio 63%, pre-CRT CA 19-9 <760 (for OS groups) or post-CRT CA 19-9 <66 (for PFS groups), and CA 19-9 decline ratio 91.2%) (0: high-risk, 1: intermediate high-risk, 2: intermediate low-risk, 3: low risk). The low-risk group showed significantly favorable PFS than other groups (median 59.4 months, pZ0.001, 0.014, and 0.005, respectively). The low-risk group also showed the most favorable OS than others (median 85.4 months, pZ0.020, 0.043, and 0.109, respectively). Conclusion: In patients with locally advanced pancreatic cancer, the use of a combination of double biomarkers, SUVmax and CA 19-9, appears useful in predicting survival outcomes after CRT. In other words, three prognostic factors such as SUV decline ratio, pre or post-CRT CA 19-9, and CA 19-9 decline ratio seem to have substantial advantages over singleparameter by facilitating better treatment selection for locally advanced pancreatic tumors.Purpose/Objective(s): While HA...

This study aimed to characterise priority or ‘rush’ surgical pathology requests and identify potentially targetable factors. We performed a retrospective descriptive analysis of rush requests at our institution from 2016 to 2019 and conducted a survey asking pathologists about their perspectives on rush cases. There were 3677 rush cases, with case characteristics generally stable over the study period. Two categories of requests were identified based on hospital status; outpatient requests more frequently provided a specific date for diagnosis, while inpatient rush requests generally required a diagnosis as soon as possible. Most pathologists found rush cases to be somewhat more stressful compared with routine cases (65.2%) and found it very or extremely useful to know when a result is needed (86.9%). The use of hospitalisation status, and identifying if results are required by a certain date, may help in more effective triaging of rush surgical pathology cases.