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Introduction/Objective Deaths from opioid overdose increased 12% from 2016 to 2017. This major economic burden cost roughly $78.5 billion in the US. This steep increase in drug overdose deaths can be attributed to increased synthetic opioid abuse. To better understand and reduce opioid abuse amongst patients at Henry Ford Health System, Detroit MI, we sought to collaborate with physicians to manage prescribing, interpret test results, improve patient care, and deliver more value. Primary Aim: To create a directed pain panel for ordering and interpreting pain management drugs to help providers to better manage patients and to assess compliance from test ordering history to serve patients safely and effectively. Secondary Aim: To streamline the process of prescribing pain medications and to create a patient centered approach to treat chronic non-cancer patients who actually need opioids, to minimize the risk of abuse, diversion and addiction among patients. Methods Plan Do Check Act (PDCA) cycles of process improvement were used to achieve our two aims. In the first cycle, a drug screen-ordering guide was developed to facilitate screening (qualitative) and confirmation (quantitative) ordering practices. As part of this, providers prescribing for chronic pain patients were advised to use drugs of abuse panel rather than our emergency drug screen. In the second cycle, a directed pain panel (DPP) was introduced with reflex to confirmation testing. The DPP led to discovery of unexpected fentanyl positives, which were further investigated. Results A survey was conducted to investigate provider-ordering practices, which showed that use of the new drugs of abuse panel rose from 57% to 77%. The DPP was accepted by ~60% of physicians and was frequently reordered in follow-up. Analysis of unexpected fentanyl positivity revealed 30% true positivity, thus identifying unknown patient use. A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results. Conclusion A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.

Introduction: Pyogenic granuloma (PG) or granuloma pyogenicum is essentially a capillary hemangioma on the skin or a mucosal surface which shows an exophytic growth pattern and has a lobulated appearance. The most common sites are skin (40%) and mucosal surfaces (predominantly oral cavity, 60%). We intend to report all available cases of PG of gastrointestinal (GI) tract, diagnosed at the Henry Ford hospital, a tertiary referral center. Patients and Methods: A retrospective review of pathological database was performed on all GI biopsies in the last 10 years using diagnostic codes and pathology codes searching for PG of the GI tract. Results: A total of 23 cases of pathologically diagnosed PG was diagnosed over a 10 year period. The median age of patients was 64 with almost equal gender distribution (47.8% were males, and 52.2% were females). The most common location of PG was sigmoid colon (65.2%), esophagus (17.4%) and transverse colon (13%). PG presented as a polyp in 16 patients (69.6%). The most common indication for endoscopy in these cases was screening colonoscopy (30.4% cases). Discussion: PG of GI tract is rare. To date, only about 15–20 cases have been reported in the literature and most cases have been reported from Japan and Korea. This is the largest case series of this rare pathological lesion of the GI tract. Most cases of PG were diagnosed on an endoscopy done for an unrelated reason in our series. Hence, most cases were asymptomatic, unlike previously reported cases which were mostly associated with GI bleeding.

A tissue field of somatic genetic alterations precedes the histopathological phenotypic changes of carcinoma. Genomic changes could be of potential use in the diagnosis and prognosis of pre-invasive squamous head and neck carcinoma (HNSCC) lesions and as markers for cancer risk assessment. Studies of sequential molecular alterations and genetic progression of pre-invasive HNSCC have not been clearly defined. Studies have shown recurring alterations at chromosome 9p21 (location of the CDKN2A) and TP53 mutations in the early stages of HNSCC. However, gene silencing via hypermethylation is still a relatively new idea in the development of HNSCC and little is known about the contribution of epigenetics to the development of neoplasia, its transformation, progression, and recurrence in HNSCC. This review examines the role of promoter hypermethylation of tumor suppressor genes in the progression continuum from benign papillomas to malignancy in HNSCC.

Context.—Patients who undergo hematopoietic stem cell transplant are at an increased risk of developing iron overload. Objectives.—To describe the effect of hepatic iron overload on hematopoietic stem cell transplant recipients and to validate the utility of histologic scoring system of iron granules in the liver. Design.—Records of 154 post allogeneic hematopoietic stem cell transplant patients were reviewed. Forty-nine patients underwent liver biopsy. Histologic hepatic iron overload was defined as a score of 2 or greater (scale, 0–4). Results.—Twenty-eight of 49 patients (57%) evaluated by liver biopsy had hepatic iron overload; 17 had moderate to severe hepatic iron overload (score, 3 or 4). In multivariate analysis, a significant correlation was discovered between hepatic iron overload and the number of transfusions (P < .001), posttransplant serum ferritin levels (P = .004), lactate dehydrogenase levels (P = .03), and the development of blood stream infections (P = .02). There was no correlation between hepatic iron overload and abnormal liver function test results. While 37 patients (76%) died after receiving a transplant, mortality was not influenced by hepatic iron overload but was significantly higher in older patients, in patients with lower serum albumin levels, higher serum bilirubin levels, and higher clinical grade of acute graft-versus-host disease (P = .04, P = .001, P = Conclusions.—Hepatic iron overload is commonly identified in hematopoietic stem cell transplant patients and can be accurately diagnosed by liver biopsy. In addition, hepatic iron overload has been identified in patients receiving as few as 25 units of packed red blood cells, with elevated posttransplant serum ferritin levels, and with blood stream infections.

ObjectiveThere is a lack of consensus regarding the causes of the differences in the higher incidence of and the mortality from head and neck squamous cell carcinoma (HNSCC) in African Americans (AA) versus Caucasian Americans (CA). We examined a comprehensive array of risk factors influencing health and disease in an access-to-care, racially diverse, primary HNSCC cohort.Study DesignCross-sectional study.SettingPrimary care academic health care system.Subjects and MethodsThe cohort of 673 patients comprised 391 CA and 282 AA (42%). Risk variables included demographic, histopathology, and clinical/epidemiologic factors. Tumor DNA was interrogated for loss and gain of 113 genes with known involvement in HNSCC/cancer. Logistic regression for univariate analysis was followed by multivariate modeling with determination of model predictability (c-index).ResultsOf the 39 univariate differences between AA and CA, multivariate modeling (c-index = 0.81) retained 7 differences (P < .05). AA were less likely to be m...

IntroductionMicroRNAs (miRNAs) are endogenous, small, noncoding RNAs of 17 to 25 nucleotides that regulate approximately 30% of human genes. They are differentially expressed in various types of cancers compared with noncancerous tissues, suggesting that they may have crucial roles in tumorigenesis. The objective of this study was to identify laryngeal squamous cell cancer (LSCC)-specific miRNAs.Materials and methodsA retrospective cohort of 10 LSCC and five normal laryngeal squamous epithelium samples were examined using a global miRNA profiling approach (HTG, Tucson, AZ, USA, 800 human miRNAs plus 10 endogenous control miRNAs). The expression status of selected dysregulated miRNAs that were significantly different from normal were verified by real-time quantitative PCR (qPCR).ResultsTwenty-three of the 800 human miRNAs had significantly different expression levels (p < 0.05) between LSCC and normal tissues. Fifteen of the 23 have not been previously reported in HNSCC and include: miR-663b, miR-663, miR-193b, miR-1291, miR-720, miR-191, miR-1224-3p, miR-214, miR- 1285, miR-1207-5p, miR-483-5p, miR-1225-3p, miR-1228, miR-1280 and miR-638. Consistently upregulated miR-31 and miR- 193b and differentially expressed miR-663b in LSCC were verified by qPCR.ConclusionThe 15 novel miRNAs identified in this exploratory study, pending further confirmation and validation, may have clinical utility as LSCC-specific markers.How to cite this articleChen KM, Stephen JK, Havard S Shah V, Gardner G, Schweitzer VG, Worsham MJ. Novel Dysregulated MicroRNAs in Primary Laryngeal Squamous Cell Cancer. Int J Head Neck Surg 2012;3(2):76-81.

Autoimmune hepatitis (AIH)–primary biliary cirrhosis (PBC) overlap syndrome (OS) is a vaguely defined entity demonstrating features of AIH and PBC. We investigated the usefulness of IgG and IgM immunostaining for the distinction of AIH and PBC and their staining pattern in cases of possible OS. The approximate quantity of IgG+ and IgM+ periportal inflammatory cells in immunohistochemical analysis were compared in cases of AIH, PBC, and OS. AIH cases showed predominant IgG immunostaining of periportal inflammatory cells. A significant number of PBC cases also demonstrated IgG predominance rather than IgM. Six OS cases had IgG predominance, 4 had IgM predominance, and 1 was equivocal. The usefulness of IgG and IgM immunostaining is limited in PBC cases with IgM predominance for excluding AIH. IgG predominance is not specific for AIH. OS does not demonstrate either IgG or IgM predominance (P > .2) and does not help classify OS into either category.

Benign inverted papillomas have been reported as monoclonal but lacking common genetic alterations identified in squamous cell carcinoma of the head and neck. Epigenetic changes alter the heritable state of gene expression and chromatin organization without change in DNA sequence. We investigated whether epigenetic events of aberrant promoter hypermethylation in genes known to be involved in squamous head and neck cancer underlie the pathogenesis of sinonasal papillomas. Ten formalin-fixed paraffin DNA samples from three inverted papilloma cases, two exophytic (everted) papilloma cases, and two cases with inverted and exophytic components were studied. DNA was obtained from microdissected areas of normal and papilloma areas and examined using a panel of 41 gene probes, designed to interrogate 35 unique genes for aberrant methylation status (22 genes) using the methylation-specific multiplex-ligation-specific polymerase assay. Methylation-specific PCR was employed to confirm aberrant methylation detected by the methylation-specific multiplex-ligation-specific polymerase assay. All seven cases indicated at least one epigenetic event of aberrant promoter hypermethylation. The CDKN2B gene was a consistent target of aberrant methylation in six of seven cases. Methylation-specific PCR confirmed hypermethylation of CDKN2B. Recurrent biopsies from two inverted papilloma cases had common epigenetic events. Promoter hypermethylation of CDKN2B was a consistent epigenetic event. Common epigenetic alterations in recurrent biopsies underscore a monoclonal origin for these lesions. Epigenetic events contribute to the underlying pathogenesis of benign inverted and exophytic papillomas. As a consistent target of aberrant promoter hypermethylation, CDKN2B may serve as an important epigenetic biomarker for gene reactivation studies.

The nuclear immunoreactivity for thyroid transcription factor-1 (TTF-1) is a useful marker for identification of carcinomas of thyroid and lung origin. Our aim was to determine whether cytoplasmic staining in the liver is a result of cross-reaction of anti-TTF-1 antibody (clone 8G7G3/1, DAKO, Carpinteria, CA) or true positivity resulting from aberrant expression of TTF-1 or products of the alternatively sliced TTF-1 gene. Fresh tissue samples from liver, thyroid, and lung were obtained for HE-stained sections, TTF-1 immunostaining, and RNA and protein analyses. Western blot revealed an abundant band corresponding to an approximately 160-kd protein from liver but not either thyroid or lung tissue samples. By reverse transcriptase-polymerase chain reaction, messenger RNA of TTF-1 was not detectable in liver tissue. Our study demonstrates that TTF-1 immunoreactivity (clone 8G7G3/1) in the hepatocyte cytoplasm is due to an approximately 160-kd protein; this unique protein is not an alternative splicing product of TTF-1 and neither is it expressed in thyroid and lung tissues.

Human papillomavirus (HPV), particularly HPV16, is a causative agent for 25% of head and neck squamous cell cancer, including laryngeal squamous cell cancer (LSCC). HPV-positive (HPV+ve) patients, particularly those with oropharyngeal SCC, have improved prognosis. For LSCC patients, this remains to be established. The goal was to determine stage and survival outcomes in LSCC in the context of HPV infection.Historical cohort study.Primary care academic health system.In 79 patients with primary LSCC, HPV was determined using real-time quantitative polymerase chain reaction. χ(2) or Fisher exact test was used to test the association of HPV+ve with 21 risk factors including race, stage, gender, age, smoking, alcohol, treatment, and health insurance. Kaplan-Meier and log-rank tests were used to study the association of HPV and LSCC survival outcome.HPV16 was detected in 27% of LSCC patients. Caucasian American (CA) patients had higher HPV prevalence (33%) than did African American (AA) LSCC patients (16%; P = .058). HPV was significantly associated with gender (P = .016) and insurance type (P = .001). There were no differences in survival between HPV+ve and HPV-negative (HPV-ve) patients. There was no association with HPV and other risk factors including stage (early vs late).We found a high prevalence of HPV in men and a lower prevalence of HPV infection in AA compared with CA. Despite the strikingly better survival of patients with HPV+ve oropharyngeal tumors, even when adjusted for smoking, this correlation does not seem to hold true in the larynx. Larger multiethnic LSCC cohorts are needed to more clearly delineate HPV-related survival across ethnicities.

Objective: MicroRNAs (miRNAs) are endogenous, small, noncoding RNAs of 17 to 25 nucleotides that regulate approximately 30% of human genes. They are differentially expressed in various types of cancers compared with noncancerous tissues, suggesting that they may have crucial roles in tumorigenesis. The objective of this study was to discover LSCC-specific miRNAs.Method: Global miRNA profiling (800 human miRNAs plus 10 endogenous control miRNAs) was performed on 8 formalin-fixed archival LSCC samples and 5 normal laryngeal squamous epithelium (HTG, Tucson, AZ, USA). Quantitative real-time PCR (qRT-PCR) approach was employed to verify expression status of selected miRNAs that were significantly different from normal controls.Results: Thirty-one of the 800 human miRNAs were significantly differentially expressed (P < .05) between LSCC vs normal tissues. Selected miRNAs (miR-31, miR-193b, miR-663b, miR-923, and miR-1826), by qRT-PCR, verified expression of consistently upregulated miR-31 and miR-193b as well ...

Diagnosis of liver allograft antibody-mediated rejection (AMR) is difficult and requires a constellation of clinical, laboratory and histologic features that support the disease and exclude other causes. Histologic features of AMR may intermix with those of biliary obstruction, preservation/reperfusion injury, and graft ischemia. Tissue examination for complement degradation product 4d (C4d) has been proved to support this diagnosis in other allografts. For this reason, we conducted a retrospective review of all ABO compatible/identical re-transplanted liver patients with primary focus on identifying AMR as a possible cause of graft failure and to investigate the utility of C4d in liver allograft specimens. We reviewed 193 liver samples obtained from 53 consecutive ABO-compatible re-transplant patients. 142 specimens were stained with C4d. Anti-donor antibody screening and identification was determined by Luminex100 flow cytometry. For the study analysis, patients were stratified into 3 groups according to time to graft failure: group A, patients with graft failure within 0-7 days (n=7), group B within 8-90 days (n=13) and C >90 days (n=33). Two patients (3.7%) met the diagnostic criteria of acute AMR. Both patients experienced rapid decline of graft function with presence of donor specific antibodies (DSA), morphologic evidence of humoral rejection and C4d deposition in liver specimens. C4d-positive staining was identified in different medical liver conditions i.e., acute cellular rejection (52%), chronic ductopenic rejection (50%), recurrent liver disease (48%), preservation injury (18%), and hepatic necrosis (54%). Univariate analysis showed no significant difference of C4d-positive staining among the 3 patients groups, or patients with DSA (P>.05). In conclusion, AMR after ABO-compatible liver transplantation is an uncommon cause of graft failure. Unlike other solid organ allografts, C4d-positive staining is not a rugged indicator of humoral rejection, thus, interpretation should be done with caution to avoid diagnostic dilemmas.

The goal was to determine recurrent or second primary status for late stomal malignancies, 16 and 17 years post-total laryngectomy in two laryngeal squamous cell carcinoma (LSCC) patients, based on DNA methylation signatures and HPV typing. Adopting a literature review based definition of late stomal recurrences as new primaries at the site of the stoma or neopharynx occurring more than 5 years after total laryngectomy, we employed a multi-gene candidate approach to examine promoter methylation in 24 tumor suppressor genes and PCR-based assays for HPV status offered additional insights into whether the late stomal tumors post total laryngectomy were related or not. The primary tumor for Patient 1 was negative for HPV but had aberrant hypermethylation of APC, MLH1, and BRCA1. The stomal biopsy 17-years later showed presence of HPV-16 without any methylated genes. In Patient 2, HPV-11 and promoter methylation of APC identified in the primary tumor was also observed in the stomal malignancy 16 years post total laryngectomy. Additional information provided by molecular typing for HPV and methylation markers underscored Patient 1’s and 2’s late stomal presentation as most likely a second primary and recurrence, respectively. DNA methylation markers are particularly advantageous because DNA methylation is an early event in tumorigenesis, and the epigenetic modification, 5-methylcytosine, is a stable marker. Molecular marks to discern genetic heterogeneity or relatedness of stomal malignancies several years post-total laryngectomy can provide clues to their status as either second primaries or likely recurrences. Our results support the hypothesis that a subset of stomal recurrences after total laryngectomy represents second primary tumors.

IntroductionThis study examined the contribution of promoter hypermethylation to the pathogenesis of respiratory papillomatosis (RP), including recurrences (RRP) and progression to squamous cell carcinoma (SSC).Materials and methodsA retrospective cohort of 25 laryngeal papilloma cases included 21 RRP, two of which progressed to SCC. Aberrant methylation status was determined using the multigene (22 tumor suppressor genes) methylation-specific multiplex ligationdependent probe amplification assay and confirmed using methylation specific PCR.ResultsTwenty genes had altered DNA methylation in 22 of 25 cases. Aberrant methylation ofCDKN2BandTIMP3was most frequent. Promoter hypermethylation ofBRCA2, APC, CDKN2AandCDKN2Bwas detected in 2 RRP cases with subsequent progression to SCC. Of the 25 cases, 22 were positive for HPV-6, 2 for HPV-11 and 1 for HPV-16 and 33.ConclusionConsistent aberrant methylation of multiple tumor suppressor genes contributes to the pathogenesis of laryngeal papillomas. Persistent aberrant DNA methylation events in 2 RRP cases that progressed to cancer indicate an epigenetic monoclonal progression continuum to SCC.

Primary sclerosing cholangitis (PSC) is a chronic progressive cholestatic liver disease, which usually affects young adults and is diagnosed by cholangiography. On a few occasions, the disease either starts in or exclusively involves the small intrahepatic bile ducts, referred to as small-duct PSC.A 31-year-old man presented with severe hematemesis secondary to liver cirrhosis. Over a course of 8 years, his liver decompensated and required an orthotopic liver transplantation. In this report we discuss his disease presentation, course of management, and the post-transplantation course of management, and review the morphologic diagnosis, and differential diagnosis of the disease with large-duct type and other diseases that involve small intrahepatic bile ducts.The patient's explanted liver showed changes of PSC affecting only the small- and medium-sized bile ducts in addition to three incidental nodules of hepatocellular carcinoma.Small-duct PSC has a substantially better prognosis than the large-duct type, with less chance of developing cirrhosis and an equal risk for developing hepatocellular carcinoma, but no increased risk for developing cholangiocarcinoma. Treatment seems to help relieve the symptoms but not necessarily improve survival. Liver transplantation remains the ultimate cure.

Background Graft-versus-host disease (GVHD), a common complication of hematopoietic stem cell transplant, is generally regarded to develop through cell-mediated immune response following activation of helper T cells. Since production of antibodies is also mediated by helper T cells, the role of humoral immunity in GVHD is questioned and has not yet been explored in clinical practice. We conducted a pilot study to evaluate the role of antibody production in hepatic H-GVHD and whether it can distinguish acute and chronic forms. Results C4d expression was increased in portal vessels and hepatic sinusoids of patients with histological proven evidence of GVHD 11/16 (P = 0.007). Patients classified as chronic GVHD were statistically more likely to have C4d expression in the portal vasculature and liver sinusoids (P = 0.011). Conclusion Humoral activation seems to play a role in pathophysiology of hepatic, especially chronic GVHD.

A current shortcoming in cancer prognostication and treatment is a lack of methods that adequately address the complexity and diversity of the disease. Prognostic marker systems based on single parameters have generally proven inadequate. Thus, multiparametric methods, which rely on many pieces of information, are ideally suited to the grouping of tumor subtypes and the identification of specific patterns of disease progression.This study investigated, on an exploratory basis, whether genome wide alterations of loss and gain, using a panel of 122 gene probes (112 unique genes), discriminated between early stage (stage 1 and 2) and late stage (stage 3 and 4) laryngeal squamous cell carcinomas (LSCC). The LSCC cohort comprised 29 patients, 12 early and 17 late staged. Formalin-fixed LSCC DNA was interrogated by a genome wide candidate gene panel (122 genes) using the multiplex ligation-dependent probe amplification assay.Statistical analysis employed the nonparametric Wilcoxon 2-sample test. Significant differences between tumor stages of early versus late were seen for the following genes: ERBB4, CASP2, RECQL4, and BCL7A. Loss of ERBB4 (P=0.045) and BCL7A (P=0.019) significantly discriminated between early and late stage LSCC. Gain of RECQL4 copy number (P=0.043) was associated with late LSCC. Gain of CASP2 (P=0.043) marked early LSCC, whereas loss was associated with late LSCC.High-throughput genome wide approaches have the potential to yield discrete gene repertoires of early and late stage LSCC differentiation.

Advanced breast cancers frequently metastasize to bone, resulting in osteolytic lesions, yet the underlying mechanisms are poorly understood. Here we report that nuclear factor-kappaB (NF-kappaB) plays a crucial role in the osteolytic bone metastasis of breast cancer by stimulating osteoclastogenesis. Using an in vivo bone metastasis model, we found that constitutive NF-kappaB activity in breast cancer cells is crucial for the bone resorption characteristic of osteolytic bone metastasis. We identified the gene encoding granulocyte macrophage-colony stimulating factor (GM-CSF) as a key target of NF-kappaB and found that it mediates osteolytic bone metastasis of breast cancer by stimulating osteoclast development. Moreover, we observed that the expression of GM-CSF correlated with NF-kappaB activation in bone-metastatic tumor tissues from individuals with breast cancer. These results uncover a new and specific role of NF-kappaB in osteolytic bone metastasis through GM-CSF induction, suggesting that NF-kappaB is a potential target for the treatment of breast cancer and the prevention of skeletal metastasis.

Thrombotic microangiopathy (TMA) in renal transplant recipients is commonly associated with calcineurin inhibitors (CNIs), though several factors such as vascular rejection, viral infections and other drugs may play a contributory role. We report a series of 29 patients with TMA, all of whom were on CNIs. Though plasma exchange (PEx) is widely used to treat TMA, therapeutic guidelines are not well defined. All our patients were treated with PEx and discontinuation of CNIs. Thrombotic microangiopathy was diagnosed at a median of 7 days post-transplant. The mean decrease in Hgb and platelets during TMA was 66% and 64%, respectively, and peak serum creatinine during TMA was 7.4 +/- 2.9 mg%. Mean duration of PEx therapy was 8.5 (range 5-23) days. Recovery of platelet count to 150K/mcL and Hgb to 8-10 g/dL were used as endpoints for PEx. Twenty-three/29 (80%) patients recovered graft function after PEx. Twenty/23 (87%) patients who recovered were placed back on CNl. Nineteen/20 (95%) patients tolerated reinstitution of CNl without recurrence of TMA. In post-transplant TMA, PEx was associated with a graft salvage rate of 80%, reversal of hematological changes can be used as the endpoint for PEx therapy and CNl can be reintroduced without risk of recurrence in the majority of patients.

To the Editor I read with great interest the study by Lee et al1 evaluating IgG and IgM immunohistochemical staining of inflammatory cells in liver biopsy specimens of patients with autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), and overlap syndromes. The authors report an IgG-predominant infiltrate in all cases of AIH. However, a large proportion (12/26) of PBC cases also showed a predominantly IgG+ infiltrate, which would potentially decrease the usefulness of IgM and IgG immunohistochemical staining in this setting. In contrast with these results, Daniels et al2 reported IgG-predominant infiltrates in all cases of AIH (n = 38) and IgM-predominant infiltrates in the vast majority (16/18 [89%]) of PBC cases. Similarly, our group recently published a study3 evaluating IgM and IgG immunohistochemical staining in various forms of liver disease, including AIH, PBC, primary sclerosing cholangitis …

Abstract 4313 Introduction Iron overload has increasingly been recognized as a cause of morbidity and mortality among allogenic hematopoietic stem cell transplant (HSCT) recipients. Estimation of liver iron is considered the gold standard method that reflects the overall body iron burden. Aim We attempted to correlate the severity of liver iron overload to various clinical parameters in allogenic HSCT recipients. Methods We studied 49 adult allogenic HSCT recipients who had a minimum of one liver biopsy performed after transplant. All patients had been diagnosed, transplanted and followed up in our institution since 1998. Biopsies were performed due to abnormal liver function tests under the initial clinical suspicion of GVHD with a mean of 185 days (range: 23-844 days) post-transplant. Sections from each biopsy were stained with hematoxylin and eosin, Masson trichome and Perl's iron stains. We used the histological semiquantitative grading of liver iron (grade 0-4), evidence of GVHD (score 0-3) and fibrosis (stage 0-4). Iron overload was defined as a score of 2 and above (correlating with hepatic iron concentration >1.4 mg/g dry weight). Various clinical parameters were also assessed including age, sex, underlying malignancy, number of transfusions, source and type of stem cell transplant, liver function tests, clinical grading of GVHD, significant bacteremia, other infections, survival and cause of death. Results In this cohort, 28 of 49 patients had iron overload. The overall prevalence of iron overload was 57% (95% confidence interval, 42%-71%). Iron overload in 7 of the 49 patients (14%) was the only histological explanation of liver dysfunction. The degree of iron overload was directly correlated to the number of transfusions (r=0.69, p Conclusion Iron overload is a common adverse effect of allogenic HSCT (57% prevalence). Iron overload occurred in some of our patients after as few as 10 red blood cell units. In this cohort, iron overload statistically correlated to the number of transfusions, development of significant bacteremia and clinical acute GVHD. We did not find a statistically significant association with mortality, likely due to our small sample size and complex clinical picture. Iron overload was the only histological explanation of abnormal liver functions in 14% of our patients. More studies are needed to determine the impact of iron overload in long-term morbidity and mortality in allogenic transplant patients. Disclosures: No relevant conflicts of interest to declare.

Objective To investigate the contribution of promoter methylation-mediated epigenetic events in recurrent respiratory papillomatosis tumorigenesis. Design Archival tissue DNA, extracted from microdissected papilloma lesions, was interrogated for methylation status by means of the novel, multigene methylation-specific multiplex ligation-dependent probe amplification assay. Subjects Fifteen subjects with recurrent respiratory papillomatosis, 3 females and 12 males, all with adult onset of illness (age range, 23-73 years) except for 1 female patient with juvenile onset (1 year old). Results Promoter hypermethylation was recorded in 14 of 15 cases, and 19 of 22 unique methylation-prone cancer genes in the multigene panel had altered DNA methylation in at least 1 laryngeal papilloma biopsy specimen. Identical abnormally methylated genes were found in 5 of 15 recurrent cases, of which the CDKN2B gene was hypermethylated in all 5 cases. Dissimilar epigenetic events were noted in the remaining cases. Conclusions A clonal origin was derived for 5 of 15 recurrent respiratory papillomatosis biopsy specimens based on identical epigenetic events. The high frequency of epigenetic events, characterized by consistent promoter hypermethylation of multiple tumor suppressor genes, points to the use of gene silencing mechanisms in the pathogenesis of recurrent respiratory papillomatosis.

This study examined molecular (DNA hypermethylation), clinical, histopathological, demographical, smoking, and alcohol variables to assess diagnosis (early versus late stage) and prognosis (survival) outcomes in a retrospective primary laryngeal squamous cell carcinoma (LSCC) cohort. The study cohort of 79 primary LSCC was drawn from a multi-ethnic (37% African American), primary care patient population, diagnosed by surgical biopsies in the Henry Ford Health System from 1991 to 2004 and followed from 5 to 18 years (through 2009). Of the 41 variables, univariate risk factors of p p ESR1; p = 0.01), race as African American (p = 0.04), and tumor necrosis (extensive; p = 0.02) were independent predictors of late stage LSCC. Independent predictors of poor survival included presence of vascular invasion (p = 0.0009), late stage disease (p = 0.03), and methylation of the hypermethylated in cancer 1 (HIC1) gene (p = 0.0002). Aberrant methylation of ESR1 and HIC1 signified independent markers of poorer outcome. In this multi-ethnic, primary LSCC cohort, race remained a predictor of late stage disease supporting disparate diagnosis outcomes for African American patients with LSCC.