Pathology's Dr. Franklin presents Hurthle Cell Neoplasms of the Thyroid
And Dr. Sanford presents Massive Transfusion

The Scope | Grand Rounds | Research In Progress

Third year VCUHS Pathology Residents, Robert Franklin, MD, and Kim Sanford, MD presented at the Pathology Grand Rounds March 26. Dr. Franklin presented Hurthle Cell Neoplasms of the Thyroid and Dr. Sanford presented Massive Transfusion.

Dr. Franklin is interested in thyroid Hurthle cell lesions because it is difficult to predict their clinical behavior before they have progressed to invasive or metastatic stages of malignancy. Researchers are anxious to identify a marker, or a panel of markers that would aid in the distinction between benign and malignant lesions at an earlier, pre-invasive stage. Typical measures of size, nuclear atypia, pleomorphism, morphonucleation, and mitosis are not predictive for Hurthle cell.

"Currently there are no specific immunohistochemical markers that allow us to distinguish between tumor types," said Dr. Franklin. Only the observed presence of a capsular or vascular invasion, or metastasis makes the distinction evident, he added. Typically, when Hurthle cells are identified in fine needle aspiration biopsies, surgery is necessary to remove the lesions and make a definitive diagnoses.

Hurthle or oxyphilic cells are large parenchymal cells with distinct borders, abundant eosinophilic cytoplasm and pleomorphic nuclei. They appear "very pink and fluffy," said Dr. Franklin, because they are full of mitochondria. Hurthle cells may be seen in a variety of inflammatory conditions including subacute Hashimoto's thyroiditis, drug-induced thyroiditis, and multi-nodular goiter. They are also found in neoplastic proliferations, adenomas and carcinomas. Hurthle cells have a high incidence of progression to malignancy and metastasis.

Dr. Franklin collaborated with Massachusetts General Hospital in one of the largest studies to date that sought to identify potential protein markers for predicting the clinical behaviors of Hurthle cells lesions. He analyzed 80 histological specimens using tissue microarray technology. Each specimen was sampled in triplicate for the array--one for Massachusetts General cases, one for VCU Medical Center cases and one for the control group. He had groups of 20 normal specimens, 20 Hurthle cell specimens from goiter, 20 Hurthle cell adenomas and 20 Hurthle cell carcinomas.

He used a grading system based on intensity of staining and percentage of staining. A positive stain was one graded 2 in intensity on a scale of 0 to 2. A positive specimen also had to have Hurthle cell staining of at least 25%. He analyzed for significant expression of the following markers: p53, a well-known tumor suppressor; ki67, associated with cell proliferation; bcl-2, an anti-apoptotic; galectin-3, which inhibits apoptosis and cell adhesion; membranous and cytoplasmic e-cadherin, a transmembrane galactoprotein that mediates epithelial cell-to-cell adhesion. In some breast cancer studies, loss of e-cadherin was associated with poor prognosis.

Dr. Franklin's analysis resulted in significant expression only for cytoplasmic e-cadherin, with p value of .0083. Seventy-three percent of the carcinoma cases graded positive for cytoplasmic e-cadherin, where only 31.6% of the adenomas graded positive. Interestingly, 47.4% of the non-neoplastic cells graded positive for cytoplasmic e-cadherin.

"We concluded that cytoplasmic e-cadherin may be useful in differentiating between benign and malignant Hurthle cell lesions," he said. Dr. Franklin's research was funded by the Lyman Resident research grant. For more information about his work, you may contact Dr. Franklin at rfranklin@vcu.edu.

"Massive transfusion is associated with numerous deleterious effects and metabolic disturbances," said Dr. Sanford. "The rate of mortality in patients who receive massive transfusion is 40%, which increases to 75% if coagulopathies develop."

The goal of Dr. Sanford's presentation was to raise awareness of the benefits and the complications involved in massive transfusions, to emphasize the value of skilled, thorough management of patients receiving them, and to highlight the roles and responsibilities of Transfusion Medicine specialists in the Department of Pathology.

There are a number of criteria for defining a transfusion as "massive." They are: 1) the replacement of a patient's total blood volume within 24 hours 2) replacement of half the total blood volume within three hours 3) the transfusion of greater than four units of packed red blood cells within four hours in the presence of persistent bleeding 4) the transfusion of a patient whose blood loss is greater than 150cc/minute.

Patients most likely to receive a massive transfusion are trauma patients, patients with upper or lower GI bleeding, patients undergoing cardiovascular surgery, those with obstetrical complications, or those who have experienced a large vessel rupture.

Managing these patients requires a thorough understanding of the risks. Dr. Sanford illustrated her point with a description of a typical case, a 22-year-old, Rh negative female involved in a high speed auto accident. The patient was brought to the operating room with massive abdominal blunt trauma, intra-abdominal hemorrhage, and hepatic capsular rupture. During exploratory laporotomy a right hepatic lumpectomy was performed. She was returned to intensive care to correct coagulopathy and hypothermia. The next morning she was taken back to surgery to remove revitalized hepatic tissue. Surgeons used argon beam coagulation to control bleeding and placed her on veno-venus bypass for hypothermia.

During the two surgical procedures, the patient received 37 units of packed red blood cells (RBCs) to correct blood loss. Twenty of those units were Rh positive. She also received seven units of autologous RBCs (her own blood products) which were collected and reinfused using a cell saber. Additionally, she received nine liters of colloid solution to correct hypovolaemia, 20 units of cryoprecipitate to maintain hemostasis, two doses of platelets to maintain blood coagulation, and one dose of recombinant activated factor VII to stop the bleeding.

The primary goals, she said, in managing patients who've received a massive transfusion are to maintain intervascular blood volume and to preserve the patients tissue and organs from damage. There are three stages of the management process: fluid resuscitation, tissue oxygenation and hemostatic restoration. Typically, asanguineous fluids and RBCs are administered to resuscitate fluids. Women of child bearing years with unknown ABO and Rh types, as well as patients with anti-D anitbody, are given O negative RBCs.

Three components are used to restore hemostasis: platelets, fresh frozen plasma (FFP) and cryoprecipitate. It's important to be aware, said Dr. Sanford, that a normal platelet count may be an inappropriately low value if a patient continues bleeding or requires transfusion. FFP is a component which contains all the coagulation factors including the labile factors and fibrinogen. It is indicated for actively bleeding patients in which there is a loss or dilution of multiple coagulation factors causing an increase in the PT or PTT greater than 1.5 times the upper limit of normal. Cryoprecipitate is an FFP-derived component. It is made by thawing FFP at 1-6 degrees Celsius. During this process the cold insoluble portion of plasma precipitates, creating a component that has 10 times the normal concentrations of fibrinogen, vonWillebrand factor, factor VIII, and factor XIII, which play a role in the coagulation cascade.

Other complications of massive transfusion are:

• hypocalcaemia and citrate toxicity caused by decreased citrate metabolism

• transient hyperkalaemia, particularly in neonates and patients with end-stage renal disease

• hypocalcaemia caused by hypovolemic activation of the renin-angiotension aldosterone pathway

• decreased oxygenation to the peripheral tissues due to decreased 2, 3-dpg levels in packed RBCs transfused close to their expiration date

• persistent acidosis caused by continued hemorrhaging, hypovolemia or ischemia

• hypothermia caused by infusion of RBCs stored at four degrees Celsius

• pulmonary edema

• air emboli

• microaggregates hindering blood delivery, caused by the formation of fibrin, white blood cells and platelets in packed RBCs undergoing prolonged storage

• transfusion related acute lung injury (TRALI), a  noncardiogenic pulmonary edema occurring within six hours of transfusion.

Because of the risks involved, said Dr. Sanford, alternatives to massive transfusion may be indicated. Some of these are alternatives in surgical techniques like electrocautery, and the staging of complex surgery. Another is acute normovolemic hemodilution, a technique for removing whole blood from a patient, while maintaining the circulating blood volume using acellular fluid. Protein components can be used, like recombinant activated Factor VII, used to stop the bleeding, and erythropoietin, used to stimulate the production of red blood cells. Another is to supplement with iron intravascularly.

An exciting alternative generating a great deal of academic and commercial study is the development of red blood cell substitutes. There are many biocompatibility challenges to overcome.  Also, these substitutes significantly interfere with normal lab values making it difficult to accurately monitor patients. Yet, the benefits are so promising, they may someday offer a viable treatment alternative.

For more information about her work, please feel free to contact Dr. Sanford at ksanford@vcu.edu.

Pathology Grand Rounds are held in the Sanger Hall Conference Room 4-026 every Friday, September-June, 12noon-1pm. A schedule is posted on the Pathology Web: http://www.pathology.vcu.edu/news/rounds.html

Nancy Dryden is the Pathology Grand Rounds Coordinator; for information regarding
Pathology Grand Rounds please feel free to contact her at (804) 828-0183 or nsdryden@vcu.edu