This report concerns a 71-year-old female with long standing untreated toxic multinodular goiter (TMG) coexisting with anaplastic thyroid carcinoma who presented with progressive shortness of breath and easy fatigability. Thyroid function tests showed suppressed TSH and elevated FT4 and FT3. Anti-thyroid hormone drugs were started. Thyrotropin receptor antibody was negative. A thyroid scan revealed both hot and cold nodules and fine needle aspiration biopsy (FNAB) of the thyroid gland showed colloid nodule. Chest CT scan imaging revealed an enlarged thyroid gland with the right lobe compressing the trachea. Patient underwent total thyroidectomy, final histopathology showed Anaplastic thyroid carcinoma. Our case is interesting from a pathophysiologic perspective,since it suggests that TMG can potentially transform into an aggressive form of thyroid carcinoma. High index of suspicion in patients with TMG with other risk factors for malignancy requires careful evaluation to detect cancer.

Introduction. To determine the reliability of intraoperative frozen section (FS) assessment of sentinel lymph nodes (SLN) in breast cancer patients and describe the factors affecting its evaluation.

Objectives. Known for their poor outcomes, triple negative breast cancers (TNBCs) have been investigated for immune checkpoint inhibitors that target Programmed death ligand 1 (PD-L1). In the recent decade, tumor-infiltrating lymphocytes (TILs) have also become potential biomarkers. The aim of the study is to determine the reproducibility of PD-L1 scoring system for TNBC (SP142 clone) and TILs interpretation in the local setting through intra-and interobserver agreement.Methodology. Forty-three primary resection specimens TNBC were evaluated on two occasions with PD-L1 (Roche VENTANA SP142 assay) and TILs by two breast pathologists and one general pathologist on physical glass slides. PD-L1 expression was determined by at least 1% positivity among immune cells within the tumoral area and contiguous peritumoral stroma while TILs was assessed based on International Immuno-Oncology Biomarker Working Group on Breast Cancer. Kappa statistic for PD-L1 and TILs categories while intraclass correlation coefficient (ICC) were assessed, with cutoffs of 0.80 and 0.70, respectively.Results. The overall interrater kappa statistic for PD-L1 on the first and second rounds were weak at 0.506 (95% CI: 0.334-0.679) and minimal at 0.314 (95% CI: 0.142-0.487), respectively. Intraobserver kappa statistic for PD-L1 were varied across the three readers while interobserver kappa values for PD-L1 showed none (0.181) to moderate (0.789) agreement. The TILs intraobserver reliability showed poor to good agreement, with the highest ICC of 0.889 (95% CI: 0.805-0.938). Conclusion.This study demonstrated variable intra and interobserver agreement for both TILs and PD-L1 expression. Although it is desirable to have strong to almost perfect agreement, the kappa and ICC values suggest additional room for improvement. In light of the repercussions in management of patients who will undergo immune checkpoint inhibitor therapy, regular training sessions, concurrences of equivocal results, and possible use of digital pathology as a medium in interpreting TILs and PD-L1 stains to achieve consistent results.

Background.A fine needle aspiration biopsy has been established as a safe, minimally invasive procedure in evaluation of salivary gland lesions. The complex overlapping cytomorphology of these lesions are challenging for pathologists, hence the introduction of an evidence-based system, the Milan System of Reporting Salivary Gland Cytopathology, to improve overall patient care. The study was taken up to reclassify salivary gland lesions from previous FNA biopsies in order to determine sensitivity, specificity, positive and negative predictive values of FNA, and evaluate the risk of malignancy of the various categories of the Milan system.Methodology. This was a 6-year retrospective descriptive study in a tertiary medical center. All salivary gland FNA cases were reviewed by two pathologists, and re-classified into the six categories of the Milan System. The number of false positive, false negative, true positive and true negative cases were obtained by comparing with the final histopathology diagnosis, and the risk of malignancy per category were calculated.Results. A total of 76 cases were reviewed and the overall average of the two readers diagnostic accuracy were 85.02% (95% CI: 84.50-85.60%), sensitivity and specificity were 80.77% (95% CI: 79.90-81.60%) and 86.19% (95% CI: 85.70-86.70%), respectively; positive and negative predictive values were 62.16% (95% CI: 60.70-63.60%) and 94.17% (95% CI: 94.00-94.40%), respectively. Conclusion.The Milan System category with the highest risk of malignancy was Malignant (Category VI -100%). FNAB is still a reliable tool for clinicians, and use of the Milan System of Reporting Salivary Gland Cytopathology is beneficial in increasing efficacy of communication among clinicians to improve patient care.