290
Correspondence
diffuse nuclear positivity (Figure 1). One parathyroid adenoma showed weak diffuse positivity, and one parathyroid carcinoma showed weak focal positivity. In discriminating parathyroid from thyroid lesions, GATA3 had a sensitivity of 100% and a specificity of 97%. GATA3 is a marker of potential utility in the assessment of urothelial, mammary and cutaneous epithelial tumours, among others. A previously unrecognized role for GATA3 immunohistochemistry is in the detection of parathyroid lesions, particularly its ability to discriminate between thyroid and parathyroid lesions. Parathyroid hormone (PTH) is a well-characterized marker that shows specificity for parathyroid over thyroid tissue; however, PTH immunoexpression has been shown to be heterogeneous across different parathyroid lesions.6 Discrimination of cystic or oncocytic parathyroid lesions can pose a diagnostic problem, and we consider GATA3 immunohistochemistry to be a valuable addition in the discrimination of these lesions. An important caveat is the relatively high rate of positivity seen in anaplastic thyroid carcinoma, although this diagnosis does not usually cause a diagnostic problem when appropriate clinical information is provided. GATA3 immunohistochemistry is reliable with commercially available specific monoclonal antibodies and easily identifiable positive internal controls in the form of T lymphocytes.1 CONFLICT OF INTERESTS
None of the authors has any conflict of interest to declare. ACKNOWLEDGEMENT
The study was funded by the Christie Histopathology Department. AUTHOR CONTRIBUTIONS
G. Betts analysed the data and wrote the paper. E. Beckett performed the research. D. Nonaka designed the study, analysed the data, and wrote the paper. Guy Betts Elizabeth Beckett Daisuke Nonaka Department of Histopathology, The Christie NHS Foundation Trust, Manchester, UK 1. Miettinen M, McCue P, Sarlomo-Rikala M et al. GATA3: a multispecific but potentially useful marker in surgical pathology: a
2.
3.
4.
5.
6.
systematic analysis of 2500 epithelial and nonepithelial tumors. Am. J. Surg. Pathol. 2013; 38; 13–22. Liu H, Shi J, Wilkerson ML et al. Immunohistochemical evaluation of GAT3 expression in tumors and normal tissues: a useful marker for breast and urothelial carcinomas. Am. J. Clin. Pathol. 2012; 138; 57–64. Van Esch H, Groenen P, Nesbit MA et al. GATA3 haplo-insufficiency causes human HDR syndrome. Nature 2000; 406; 419– 422. Grigorieva IV, Thakker RV. Transcription factors in parathyroid development: lessons from hypoparathyroid disorders. Ann. N. Y. Acad. Sci. 2011; 1237; 24–38. Nonaka D, Wang BY, Edmondson D et al. A study of GATA3 and PHOX2B expression in tumors of the autonomic nervous system. Am. J. Surg. Pathol. 2013; 37; 1236–1241. Tomita T. Immunocytochemical staining patterns for parathyroid hormone and chromogranin in parathyroid hyperplasia, adenoma and carcinoma. Endocr. Pathol. 1999; 10; 145–156.
Autopsy following complications of bariatric surgery DOI: 10.1111/his.12400 © 2014 John Wiley & Sons Ltd.
Sir: I commend the authors (Fryer et al., Histopathology, 64; 200–210) for their article on postmortem examination in the morbidly obese, with its repetition of the Davies criteria for coronary heart disease deaths, and the inclusion of sensible criteria for diagnosing obesity cardiomyopathy (OCM). Although the Oxford University Hospitals have a bariatric surgery (BS) unit, deaths following bariatric surgery are not specifically discussed; six of 202 deaths were attributable to ‘complications of surgery’, but further details are not given, and a further patient died at home of OCM some time after gastric bypass BS. Evaluating deaths after BS can be technically difficult. In 2012, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published an audit of post-BS deaths, and pathologists may find it a useful summary of what can happen.1 It depicts the different types of BS—gastric balloon insertion, gastric banding, sleeve gastrectomy, and gastric bypass; there is also, in Chapter 9, a review of the small autopsy literature, which is nearly all from the USA, and a discussion of the 29 autopsies within the audited cases. I summarize here the main findings; numerically, most deaths follow gastric bypass surgery: 1. Half of the post-BS deaths occurred in the 30 days following surgery, and the other half up to 16 years post-BS (median time, 8 weeks). 2. The causes of death were similar across the main types of BS—laparoscopic Roux-en-Y gastric Histopathology, 65, 288–291.
Correspondence
bypass was used most commonly, followed by gastric banding and sleeve gastrectomy. 3. Direct surgery-related deaths and deaths from indirect causes occurred at all times post-BS. 4. After gastric bypass surgery, anastomotic leaks, abdominal sepsis and haemorrhage accounted for one third of deaths, followed by venous thromboembolism; the US experience is similar, although, in one study, cardiac arrhythmia in the absence of coronary artery disease was common.2–4 5. Other causes of death in the UK series included: bowel adhesions, malnutrition resulting from chronic short bowel, cirrhotic liver failure, H1N1 influenza, OCM, alcohol toxicity, and intraoperative anaphylaxis. 6. Two deaths followed the nominally safe procedure of gastric balloon insertion; in one case, the stomach split open during removal of the band; the other patient died of cardiac arrhythmia. Adjustable gastric banding can cause death via pressure necrosis of the stomach wall.5 Liver cirrhosis—which can be caused by obesity as such—is associated with increased mortality resulting from major surgery,6 and might be expected to contribute to death from BS. However, apart from one case in the NCEPOD series, this is not generally reported. Acute intestinal failure (short bowel syndrome after bypass) can induce acute liver microvescicular steatosis.7 To reduce mortality from postoperative venous thomboembolism, some centres offer ultrasoundguided inferior vena cava filter insertion at the time of BS.8 In the NCEPOD series, this did not prevent one patient from dying of early postoperative pulmonary thromboembolism. The long delay, in many cases, between surgery and related deaths means that the place of death may be distant from the place of operation—many patients
Histopathology, 65, 288–291.
291
are currently operated on abroad, but access the NHS with their complications.1 This means that it may be difficult for the autopsy pathologist to know precisely what procedure had been performed. Finally, Fryer et al. note that specific autopsy guidelines for morbidly obese cadavers are not available, in any country. I understand that the Royal College of Pathologists is about to revise and extend its set of such guidelines, and obesity should be included. There will also be a chapter on the pathology of obesity in the forthcoming Recent Advances in Histopathology 23, to be published in 2014. Sebastian Lucas Department of Histopathology, St Thomas’ Hospital, London, UK 1. National Confidential Enquiry into Patient Outcome and Death. Too lean a service? A review of the care of patients who underwent bariatric surgery. London: NCEPOD, 2012. http://www.ncepod. org.uk/2012bs.htm. 2. Cummings P, Le BH, Lopes BS. Postmortem findings in morbidly obese individuals dying after bariatric surgery. Hum. Pathol. 2007; 38; 593–597. 3. Goldfeder LBG, Ren CJ, Gill JR et al. Fata complications of bariatric surgery. Obes. Surg. 2006; 16; 1050–1056. 4. Melinek J, Livingstone E, Cortina G, Fischbein MC. Autopsy findings following gastric bypass surgery for morbid obesity. Arch. Pathol. Lab. Med. 2002; 126; 1091–1095. 5. Fragkouli K, Mitselou A, Vougiouklakis T. Death-related gastric necrosis after laparoscopic adjustable gastric banding in the early post-operative period. Diagn. Pathol. 2010; 5; 68. 6. Lucas SB. The autopsy pathology of sepsis-related death. InTechOpen. http://www.intechopen.com/download/get/type/ pdfs/id/27956. 7. Corcos O, Cazals-Hatem D, Durand F et al. Intestinal failure after bariatric surgery. Lancet 2013; 382; 742. 8. Kardys CM, Stoner MC, Manwaring ML et al. Safety and efficacy of intravascular ultrasound-guided inferior vena cava filter in super obese bariatric patients. Surg. Obes. Relat. Dis. 2008; 4; 50–54.
Correspondence
diffuse nuclear positivity (Figure 1). One parathyroid adenoma showed weak diffuse positivity, and one parathyroid carcinoma showed weak focal positivity. In discriminating parathyroid from thyroid lesions, GATA3 had a sensitivity of 100% and a specificity of 97%. GATA3 is a marker of potential utility in the assessment of urothelial, mammary and cutaneous epithelial tumours, among others. A previously unrecognized role for GATA3 immunohistochemistry is in the detection of parathyroid lesions, particularly its ability to discriminate between thyroid and parathyroid lesions. Parathyroid hormone (PTH) is a well-characterized marker that shows specificity for parathyroid over thyroid tissue; however, PTH immunoexpression has been shown to be heterogeneous across different parathyroid lesions.6 Discrimination of cystic or oncocytic parathyroid lesions can pose a diagnostic problem, and we consider GATA3 immunohistochemistry to be a valuable addition in the discrimination of these lesions. An important caveat is the relatively high rate of positivity seen in anaplastic thyroid carcinoma, although this diagnosis does not usually cause a diagnostic problem when appropriate clinical information is provided. GATA3 immunohistochemistry is reliable with commercially available specific monoclonal antibodies and easily identifiable positive internal controls in the form of T lymphocytes.1 CONFLICT OF INTERESTS
None of the authors has any conflict of interest to declare. ACKNOWLEDGEMENT
The study was funded by the Christie Histopathology Department. AUTHOR CONTRIBUTIONS
G. Betts analysed the data and wrote the paper. E. Beckett performed the research. D. Nonaka designed the study, analysed the data, and wrote the paper. Guy Betts Elizabeth Beckett Daisuke Nonaka Department of Histopathology, The Christie NHS Foundation Trust, Manchester, UK 1. Miettinen M, McCue P, Sarlomo-Rikala M et al. GATA3: a multispecific but potentially useful marker in surgical pathology: a
2.
3.
4.
5.
6.
systematic analysis of 2500 epithelial and nonepithelial tumors. Am. J. Surg. Pathol. 2013; 38; 13–22. Liu H, Shi J, Wilkerson ML et al. Immunohistochemical evaluation of GAT3 expression in tumors and normal tissues: a useful marker for breast and urothelial carcinomas. Am. J. Clin. Pathol. 2012; 138; 57–64. Van Esch H, Groenen P, Nesbit MA et al. GATA3 haplo-insufficiency causes human HDR syndrome. Nature 2000; 406; 419– 422. Grigorieva IV, Thakker RV. Transcription factors in parathyroid development: lessons from hypoparathyroid disorders. Ann. N. Y. Acad. Sci. 2011; 1237; 24–38. Nonaka D, Wang BY, Edmondson D et al. A study of GATA3 and PHOX2B expression in tumors of the autonomic nervous system. Am. J. Surg. Pathol. 2013; 37; 1236–1241. Tomita T. Immunocytochemical staining patterns for parathyroid hormone and chromogranin in parathyroid hyperplasia, adenoma and carcinoma. Endocr. Pathol. 1999; 10; 145–156.
Autopsy following complications of bariatric surgery DOI: 10.1111/his.12400 © 2014 John Wiley & Sons Ltd.
Sir: I commend the authors (Fryer et al., Histopathology, 64; 200–210) for their article on postmortem examination in the morbidly obese, with its repetition of the Davies criteria for coronary heart disease deaths, and the inclusion of sensible criteria for diagnosing obesity cardiomyopathy (OCM). Although the Oxford University Hospitals have a bariatric surgery (BS) unit, deaths following bariatric surgery are not specifically discussed; six of 202 deaths were attributable to ‘complications of surgery’, but further details are not given, and a further patient died at home of OCM some time after gastric bypass BS. Evaluating deaths after BS can be technically difficult. In 2012, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published an audit of post-BS deaths, and pathologists may find it a useful summary of what can happen.1 It depicts the different types of BS—gastric balloon insertion, gastric banding, sleeve gastrectomy, and gastric bypass; there is also, in Chapter 9, a review of the small autopsy literature, which is nearly all from the USA, and a discussion of the 29 autopsies within the audited cases. I summarize here the main findings; numerically, most deaths follow gastric bypass surgery: 1. Half of the post-BS deaths occurred in the 30 days following surgery, and the other half up to 16 years post-BS (median time, 8 weeks). 2. The causes of death were similar across the main types of BS—laparoscopic Roux-en-Y gastric Histopathology, 65, 288–291.
Correspondence
bypass was used most commonly, followed by gastric banding and sleeve gastrectomy. 3. Direct surgery-related deaths and deaths from indirect causes occurred at all times post-BS. 4. After gastric bypass surgery, anastomotic leaks, abdominal sepsis and haemorrhage accounted for one third of deaths, followed by venous thromboembolism; the US experience is similar, although, in one study, cardiac arrhythmia in the absence of coronary artery disease was common.2–4 5. Other causes of death in the UK series included: bowel adhesions, malnutrition resulting from chronic short bowel, cirrhotic liver failure, H1N1 influenza, OCM, alcohol toxicity, and intraoperative anaphylaxis. 6. Two deaths followed the nominally safe procedure of gastric balloon insertion; in one case, the stomach split open during removal of the band; the other patient died of cardiac arrhythmia. Adjustable gastric banding can cause death via pressure necrosis of the stomach wall.5 Liver cirrhosis—which can be caused by obesity as such—is associated with increased mortality resulting from major surgery,6 and might be expected to contribute to death from BS. However, apart from one case in the NCEPOD series, this is not generally reported. Acute intestinal failure (short bowel syndrome after bypass) can induce acute liver microvescicular steatosis.7 To reduce mortality from postoperative venous thomboembolism, some centres offer ultrasoundguided inferior vena cava filter insertion at the time of BS.8 In the NCEPOD series, this did not prevent one patient from dying of early postoperative pulmonary thromboembolism. The long delay, in many cases, between surgery and related deaths means that the place of death may be distant from the place of operation—many patients
Histopathology, 65, 288–291.
291
are currently operated on abroad, but access the NHS with their complications.1 This means that it may be difficult for the autopsy pathologist to know precisely what procedure had been performed. Finally, Fryer et al. note that specific autopsy guidelines for morbidly obese cadavers are not available, in any country. I understand that the Royal College of Pathologists is about to revise and extend its set of such guidelines, and obesity should be included. There will also be a chapter on the pathology of obesity in the forthcoming Recent Advances in Histopathology 23, to be published in 2014. Sebastian Lucas Department of Histopathology, St Thomas’ Hospital, London, UK 1. National Confidential Enquiry into Patient Outcome and Death. Too lean a service? A review of the care of patients who underwent bariatric surgery. London: NCEPOD, 2012. http://www.ncepod. org.uk/2012bs.htm. 2. Cummings P, Le BH, Lopes BS. Postmortem findings in morbidly obese individuals dying after bariatric surgery. Hum. Pathol. 2007; 38; 593–597. 3. Goldfeder LBG, Ren CJ, Gill JR et al. Fata complications of bariatric surgery. Obes. Surg. 2006; 16; 1050–1056. 4. Melinek J, Livingstone E, Cortina G, Fischbein MC. Autopsy findings following gastric bypass surgery for morbid obesity. Arch. Pathol. Lab. Med. 2002; 126; 1091–1095. 5. Fragkouli K, Mitselou A, Vougiouklakis T. Death-related gastric necrosis after laparoscopic adjustable gastric banding in the early post-operative period. Diagn. Pathol. 2010; 5; 68. 6. Lucas SB. The autopsy pathology of sepsis-related death. InTechOpen. http://www.intechopen.com/download/get/type/ pdfs/id/27956. 7. Corcos O, Cazals-Hatem D, Durand F et al. Intestinal failure after bariatric surgery. Lancet 2013; 382; 742. 8. Kardys CM, Stoner MC, Manwaring ML et al. Safety and efficacy of intravascular ultrasound-guided inferior vena cava filter in super obese bariatric patients. Surg. Obes. Relat. Dis. 2008; 4; 50–54.
