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Objectives Our academic health care institution was the victim of a cyberattack that led to a complete shutdown of major patient care, operational, and communication systems, including our electronic health record (EHR), laboratory information system, pharmacy, scheduling, billing and coding, imaging software, internet, hospital shared computer drives, payroll, and digital communications. The EHR remained down for 25 days, significantly affecting our clinical pathology (CP) laboratory operations. Methods During the downtime, our CP laboratory incorporated manual interventions for patient specimen testing, recruited additional staff for reporting results, and employed multiple communication modalities to support patient care. The crisis required a swift response, employing innovative approaches to mitigate patient harm; regular, multidisciplinary engagement; and consistent, broad-reaching communications. CP leadership worked with hospital administration, staff, and our referral clients to provide the timely laboratory results needed for acute patient care. Results During this downtime, the laboratory lacked accurate information about the number of patient samples diverted to other laboratories, the number of specimens processed, and the number of test results reported. Conclusions This paper focuses on the approaches the CP division took to develop and maintain downtime operations. Laboratories should consider these strategies in preparation for a prolonged downtime.

Objectives Our institution was the victim of a cyberattack that necessitated use of manual laboratory systems for more than 25 days. These manual processes had to be created not only to enable us to process our case volume without bottlenecks but also to maintain patient safety and allow for billing. Methods Our laboratory needed to create a safe reporting process to ensure ongoing patient safety and error reduction during the downtime. Additionally, we needed to ensure the ability to bill for performed tests in some areas of the lab and maintain compliance with regulatory policies. Results Amendment rates in our system were higher than before the attack, but no patient harm was observed. Intraoperative assessments declined, but high-acuity cases continued with a discrepancy rate comparable with the normal state. Many hours and resources (human and otherwise) were necessary to reconcile the work done to bill for services, but we were able to capture revenue through careful planning. Conclusions This article records the challenges we faced and the successes we achieved in maintaining compliance and a low error rate in the face of manual processes, the steps necessary to bring the cases into the newly restored electronic health record, and how we billed for the services we rendered.

Objectives Our institution was subject to a multi-institutional, systemwide cyberattack that led to a complete shutdown of multiple major patient care, operational, and communication systems for more than 25 days. The electronic health record computer system was taken offline, as was the hospital email and authentication systems, internet access, and the laboratory information system. The impact on the hospital and patient care was substantial, and our laboratories were crippled. Methods Our laboratory endured challenges in communication because of the loss of connectivity and difficulties in laboratory management, and we recognized a need to restructure leadership to maintain operations during the crisis. As an academic institution, residents and trainees were also significantly affected by the disaster. Results We developed an incident command team (ICT), alternative methods of communication, and innovative management strategies to remain operational. Trainees were incorporated into the disaster-relief efforts, with negative impacts on resident education. Conclusions This paper focuses on the challenges in communication and lab management as well as the need for an alternative leadership structure during the crisis. We also highlight the unique experience of our trainees during this prolonged downtime, underscoring the importance of incorporating resident trainees into the daily ICT’s administrative activities as an invaluable lab management experience.

BackgroundTertiary lymphoid structures (TLS) are ectopic lymphoid organs that are localized near tumors and other sites of inflammation, and are commonly believed to support antitumor immunity. We previously published studies that show that most desmoplastic melanomas contain TLS, and that TLS in cutaneous metastatic melanomas varied widely in maturation state, in proportions of proliferating T and B cells, and in markers of B cell function, including AID and CD21. Thus, we hypothesized that there may be diversity in TLS function, or immunologic activity, among melanomas. To address this hypothesis, we evaluated TLS in primary desmoplastic melanomas (DM), and non-desmoplastic melanomas (non-DM) for markers of cell proliferation which are indicative of early immune activity.MethodsDM and non-DM tumor specimens, which included primary melanomas (PM), and cutaneous metastatic melanomas (CMM), were evaluated for TLS by multiplex Immunofluorescence histology, by staining for CD20, CD8, PNAd, Ki67, FoxP3, and DAPI. Lymphoid aggregates were identified in 20x spectrally unmixed images by visual inspection and identified as TLS if possessing organized T-cell and B-cell regions in addition to high endothelial venule-like vasculature (PNAd+). TLS were identified in 30 out of 64 screened (48%) CMM, 4/4 non-DM PM, and 8 out of 11 screened (73%) DM. Immune cells localized in TLS were enumerated using Halo software (Indica Labs). Mann-Whitney tests were used for statistical assessments.ResultsDM commonly contain a dense network of fibroblasts and associated stroma, which are not typical for other non-DM (PM and CMM). TLS in DM are located throughout the tumors, intratumorally, in sharp distinction from the peritumoral location of TLS in non-DM. Furthermore, when compared to TLS of non-DM (PM and CMM), TLS of DM contain increased densities of CD20+ B cells (PM p=0.007; CMM pConclusionsRecently published studies have identified tumor-associated fibroblasts as the likely initiating cells for TLS formation in murine melanomas. The intratumoral location of TLS in DM puts them in close proximity to the dense fibroblasts and desmoplastic stroma in these tumors, which may be responsible for their intratumoral location. The increased density of B and T cells, and higher proportion of proliferating (Ki67+) B cells, in DM than in non-DM, suggests that there may be greater immune activation, increased germinal center maturation, or less regulation in TLS of DM.Ethics ApprovalApproval was obtained for these studies under IRB protocol #’s 10598 and 19694.

Objectives Our institution was affected by a multi-institution, systemwide cyberattack that led to a complete shutdown of major patient care, operational, and communication systems. The attack affected our electronic health record (EHR) system, including all department-specific modules, the laboratory information system (LIS), pharmacy, scheduling, billing and coding, imaging software, internet access, and payroll. Downtime for the EHR lasted 25 days, while other systems were nonfunctional for more than 40 days, causing disruptions to patient care and significantly affecting our laboratories. As more institutions transition to network EHR systems, laboratories are increasingly vulnerable to cyberattack. This article focuses on the approaches we developed in the anatomic pathology (AP) laboratory to continue operations, consequences of the prolonged downtime, and strategies for the future. Methods Our AP laboratory developed manual processes for surgical and cytopathology processing, redeployed staff, and used resources within the department and of nearby facilities to regain and maintain operations. Results During the downtime, our AP laboratory processed 1,362 surgical pathology and consult cases as well as 299 cytology specimens and outsourced 1,308 surgical pathology and 1,250 cytology cases. Conclusions Our laboratory successfully transitioned to downtime processes during a 25-day complete network outage. The crisis allowed for innovative approaches in managing resources.

Chondrodermatitis nodularis helicis is a benign condition that presents as a painful ear nodule and is commonly seen in older adults. Herein, we highlight a pediatric case of chondrodermatitis nodularis helicis caused by an increasingly common age-related behavior of frequent headphone use.

Late-onset focal dermal elastosis is a clinical mimic of pseudoxanthoma elasticum that lacks associations with systemic disease. Although initial reports asserted that the disorder occurs only in the elderly, a growing body of case reports document cases in patients as young as 39 years. We present a case of a 59-year-old woman with this disorder. To reflect the broad age range of patients affected by this disorder, we propose the term "focal dermal elastosis."

Desmoplastic melanomas (DM) have unique and challenging clinical presentations and histomorphology. A characteristic feature is the presence of scattered lymphoid aggregates. However, the nature of these aggregates is not defined. We hypothesized that they may be tertiary lymphoid structures (TLS), and may be associated with programmed death ligand 1 (PD-L1) expression. We searched our tissue database for 'pure' DMs and for scars as control tissues, collected clinical information, and reviewed H&E histology. We performed multispectral imaging after staining for CD8, CD20, PNAd, FoxP3, CD83, and Ki67, and assessed PD-L1 expression by immunohistochemistry. Pure DM samples were evaluable in 11 patients. All had desmoplastic stroma and lymphoid aggregates on H&E. The lymphoid aggregates of eight of the 11 (72%) DM samples and only three of the 11 scars contained features of TLS, defined as distinct clusters of B cells and CD8 T cells, CD83 dendritic cells in T-cell zones, and PNAd vasculature resembling high endothelial venules. PD-L1 was expressed by at least 1% of melanoma cells in six and by at least 5% of immune cells in 10 of the 11 DM samples. We found that most lymphoid aggregates in DM are organized, classical TLS. PD-L1 expression was detected in most cases and was highest in two cases of DM with TLS. However, low PD-L1 expression in some cases suggests that some DM cells may be unresponsive to interferon-γ. TLS support antigen presentation and T-cell responses in chronic inflammation and cancer. Their presence in DM likely reflects an adaptive immune response, which may be enhanced with immune therapies.

Optimal approaches to induce T cell infiltration of tumors are not known. Chemokines CXCL9, CXCL10, and CXCL11 support effector T cell recruitment and may be induced by IFN. This study tests the hypothesis that intratumoral administration of IFNγ will induce CXCL9-11 and will induce T cell recruitment and anti-tumor immune signatures in melanoma metastases.Nine eligible patients were immunized with a vaccine comprised of 12 class I MHC-restricted melanoma peptides and received IFNγ intratumorally. Effects on the tumor microenvironment were evaluated in sequential tumor biopsies. Adverse events (AEs) were recorded. T cell responses to vaccination were assessed in PBMC by IFNγ ELISPOT assay. Tumor biopsies were evaluated for immune cell infiltration, chemokine protein expression, and gene expression.Vaccination and intratumoral administration of IFNγ were well tolerated. Circulating T cell responses to vaccine were detected in six of nine patients. IFNγ increased production of chemokines CXCL10, CXCL11, and CCL5 in patient tumors. Neither vaccination alone, nor the addition of IFNγ promoted immune cell infiltration or induced anti-tumor immune gene signatures.The melanoma vaccine induced circulating T cell responses, but it failed to infiltrate metastases, thus highlighting the need for combination strategies to support T cell infiltration. A single intratumoral injection of IFNγ induced T cell-attracting chemokines; however, it also induced secondary immune regulation that may paradoxically limit immune infiltration and effector functions. Alternate dosing strategies or additional combinatorial treatments may be needed to promote trafficking and retention of tumor-reactive T cells in melanoma metastases.

Pasteurella multocida, a gram-negative bacillus, is present in the oropharyngeal secretions of livestock, wild animals, and domesticated pets and can cause infection in humans. The most common route of entry has been shown to be via an animal bite, but a significant portion of cases of human infection lack evidence of such a wound. Review of the literature reveals that patients with a history of an animal bite tend to have a less aggressive clinical course than patients without an animal source of infection. We present a case, however, of Pasteurella multocida bacteremia which resulted in the death of an immunocompromised 80-year old woman in which the route of infection was found at autopsy to be a cat bite. This case highlights the importance of educating patients, particularly those with underlying immunocompromised conditions, of the possible lethal complications that can result from animal inflicted wounds and the importance of seeking medical assistance should a bite occur.

The ingestion of large amounts of boric acid, a component of household insecticides, is a rare occurrence, characterized by a diffuse desquamative skin eruption, neutropenia, thrombocytopenia, delirium, acute renal failure and prolonged ileus. A 56-year-old male with a history of multiple previous suicide attempts was witnessed ingesting household roach killer and 4 days later presented to the hospital with lethargy, stiffness and a diffuse erythematous and desquamative eruption with bullous formation. He subsequently developed erythema of both palms as well as alopecia totalis. Histopathology from a right arm shave biopsy revealed a mostly intact epidermis with subtle vacuolar alteration of the basal layer, scattered intraepidermal apoptotic keratinocytes, parakeratosis with alternating layers of orthokeratosis and considerable superficial exfoliation; accompanying dermal changes included vasodilatation and mild perivascular inflammation. This report describes the cutaneous and systemic complications in a rare case of boric acid ingestion. There is little published material on the symptoms and histopathology following boric acid ingestion, but knowledge of this entity is important, both to differentiate it from other causes of desquamative skin rashes and to allow the initiation of appropriate clinical care. Language: en

Background We report a case of sarcoidosis in a patient with metastatic melanoma managed with combination ipilimumab/nivolumab. Sarcoid development has been linked with single agent immunotherapy but, to our knowledge, it has not been reported with combination ipilimumab/nivolumab treatment. This case raises unique management challenges for both the melanoma and the immunotherapy-related toxicity. Case presentation A 46 year old Caucasian female with M1c-metastatic melanoma was managed with ipilimumab/nivolumab combination. Patient experienced response in baseline lesions but developed new clinical and radiographic findings. Biopsy of new lesions at two different sites both demonstrated tumefactive sarcoidosis. Staining of the biopsy tissue for PD-L1 expression demonstrated strong PD-L1 staining of the histiocytes and lymphocytes within the granulomas. Monotherapy nivolumab was continued without progression of sarcoid findings or clinical deterioration. Conclusions Tissue biopsy for evaluation of new lesions on immunotherapy is an important step to help guide decision making, as non-melanoma lesions can mimic disease progression.

Intranodal spindle cell lesions on biopsy are problematic for a surgical pathologist, often requiring an extensive immunohistochemical evaluation with variable and frequently unsatisfactory results. In the absence of a history of malignancy, the differential diagnosis of a spindle cell tumor must include both a primary nodal proliferation and a metastatic process. Particularly challenging are those lesions that share morphologic and immunohistochemical features; spindle cell melanomas (SCM) and interdigitating dendritic cell sarcomas (IDCS) belong to this category. At present, electron microscopy is the only method proposed to distinguish between the 2 entities; however, this method is often unavailable and impractical. In this study, we assessed the comparative immunophenotypes of 18 cases of SCM and 8 cases of IDCS, with particular emphasis on the expression of MUM-1, β-catenin, SOX-10, MiTF, and p75. Our results showed nearly equivalent staining patterns and profiles; 12% and 17% of IDCS and SCM were labeled for MUM-1, 75% and 83% stained for β-catenin, 0% and 24% expressed MiTF, and 100% and 94% labeled for p75, respectively. All cases of IDCS and SCM displayed strong nuclear reactivity for SOX-10. On the basis of our study and pertinent literature, the morphologic and immmunophenotypic features of SCM and IDCS appear to be virtually indistinguishable from one another, raising the question as to whether these 2 entities represent a pathobiologically similar or even identical process.

Infiltration of cancers by T cells is associated with improved patient survival and response to immune therapies; however, optimal approaches to induce T cell infiltration of tumors are not known. This study was designed to assess whether topical treatment of melanoma metastases with the TLR7 agonist imiquimod plus administration of a multipeptide cancer vaccine will improve immune cell infiltration of melanoma metastases.Eligible patients were immunized with a vaccine comprised of 12 melanoma peptides and a tetanus toxoid-derived helper peptide, and imiquimod was applied topically to metastatic tumors daily. Adverse events were recorded, and effects on the tumor microenvironment were evaluated from sequential tumor biopsies. T cell responses were assessed by IFNγ ELIspot assay and T cell tetramer staining. Patient tumors were evaluated for immune cell infiltration, cytokine and chemokine production, and gene expression.Four eligible patients were enrolled, and administration of imiquimod and vaccination were well tolerated. Circulating T cell responses to the vaccine was detected by ex vivo ELIspot assay in 3 of 4 patients. Treatment of metastases with imiquimod induced immune cell infiltration and favorable gene signatures in the patients with circulating T cell responses. This study supports further study of topical imiquimod combined with vaccines or other immune therapies for the treatment of melanoma.

Background Mycosis fungoides (MF) is the most common primary cutaneous T-cell lymphoma (CTCL), followed by CD30+ lymphoproliferative disorders, including lymphomatoid papulosis (LyP) and primary cutaneous anaplastic large cell lymphoma (pcALCL). The objective was to report on a series of patients with different types of CTCL at different times in their clinical course, with a focus on clonality studies. Methods Four patients with multiple diagnoses of CTCLs were identified. The clinical information, treatment interventions, and histopathology were reviewed. T-cell receptor (TCR) gene rearrangement studies were performed on all available specimens. Results The four patients carried diagnoses of: (1) pcALCL and MF; (2) pcALCL, LyP, and pcALCL; (3) LyP, MF, and pcALCL; (4) LyP, pcALCL, and MF; each with characteristic presentation and histopathologic findings. The results of the TCR polymerase chain reaction showed that all tumors expressed and retained a TCR clone(s) as follows: (1) biallelic clone; (2) single clone; (3) biallelic clone with additional clone; and (4) single clone, respectively. Conclusion We report a series of four cases of individual patients with coexisting diagnoses of some combination of MF, LyP, and pcALCL, whose lesions presented in nontraditional sequence and demonstrated a retained clone by gene rearrangement analysis.

The ingestion of large amounts of boric acid, a component of household insecticides, is a rare occurrence, characterized by a diffuse desquamative skin eruption, neutropenia, thrombocytopenia, delirium, acute renal failure and prolonged ileus. A 56-year-old male with a history of multiple previous suicide attempts was witnessed ingesting household roach killer and 4 days later presented to the hospital with lethargy, stiffness and a diffuse erythematous and desquamative eruption with bullous formation. He subsequently developed erythema of both palms as well as alopecia totalis. Histopathology from a right arm shave biopsy revealed a mostly intact epidermis with subtle vacuolar alteration of the basal layer, scattered intraepidermal apoptotic keratinocytes, parakeratosis with alternating layers of orthokeratosis and considerable superficial exfoliation; accompanying dermal changes included vasodilatation and mild perivascular inflammation. This report describes the cutaneous and systemic complications in a rare case of boric acid ingestion. There is little published material on the symptoms and histopathology following boric acid ingestion, but knowledge of this entity is important, both to differentiate it from other causes of desquamative skin rashes and to allow the initiation of appropriate clinical care.

This article presents the results of a retrospective analysis of anesthesia care and perioperative outcomes in children up to 2 years of age who underwent strabismus surgery during a five-year period at the University of Minnesota Amplatz Children's Hospital. We reviewed the charts of 74 children to determine perioperative outcomes--namely discomfort, emergence agitation/delirium, and postoperative nausea and vomiting (PONV).We found that although PONV was not an issue in this age group, as it was with older children, discomfort and emergence agitation/delirium do need to be considered during their care.

e18509 Background: Trop-2, a component of tight junctions, is highly expressed in many epithelial cancers, and its intracellular expression has been associated with prolonged survival in breast ade...

A major obstacle to cancer rejection is the failure of T cells to infiltrate and function within the tumor microenvironment (TME). Direct modulation of the TME to promote T cell homing and activation may enhance tumor control. Two pilot clinical trials were conducted to test the hypotheses that either intratumoral interferon-gamma (IFN-γ, Trial A, NCT00977145), or application of a TLR7 agonist, imiquimod (Trial B, NCT01264731) would induce favorable immune signatures and infiltration of CD8+ T cells into the TME.