The Significance of the “KGS Practice” in Pathology and Oncology Part 13
PART 13: TWO SAMPLE CASES: Case 1
TWO SAMPLE CASES
In these two examples, which are not actual cases, the three parts of the KGS methodology, the “KGS Grading”, “KGS Pathology Report” and “KGS Clinical Management”, are comprehensively demonstrated with the usage of the KGS parameters and KGS Index.
Case 1
Grade VIB Pancreatic Ductal Adenocarcinoma
In this example, we see an inoperable (due to anatomic location) high-range (H) profile Grade VIB Pancreatic Ductal Adenocarcinoma with duodenal obstruction. Having no metastasis, the 45 year-old male patient received palliative surgical and endoscopic treatment along with oncotherapy which included both chemotherapy and radiotherapy. Although inoperable by protocol, the tumor was partially resectable and allowed partial palliative resection and laparoscopic biopsies. The ease in the palliative surgical and endoscopic treatment, the permissiveness in diagnostic follow up, the absence of metastasis, and the relatively young age of the patient collectively provided the clinical team with encouragement to conduct an intensive oncotherapy which brought a progressively dramatic result.
Part 1: KGS GRADING
With KGS Scoring and KGS Index
KGS Scoring
The Parametric Scores in the 3rd Pathology Report:
Here, the detailed calculations of the parametric scores in the randomly chosen 3rd pathology report of the case are shown:
1. Prime Tumor Cells (PTC)
The PTC score is based on the mean prime tumor cells percentage of the10 HPF-supported LPFs from the periphery of the examined tissue. The 10 HPFs here show their prime tumor cells percentages as: 85%, 75%, 92%, 94%, 81%, 74%, 80%, 77%, 83%, 78%
85+75+92+94+81+74+80+77+83+78 819
Mean PTC = —————————————————– = ——– = 81.9
10 10
Mean PTCP 81.9
PTC Score = ———————- = ———— = 8.91
10 10
KGS Impact Factor (IF): 1
Effective PTC Score = PTC Score X IF = 8.91 X 1 = 8.91
2. Mitotic Tumor Cells (MTC)
Numbers of mitoses (MTC counts) in 10 HPFs: 3, 2, 4, 2, 5, 2, 1, 2, 3, 2
3 + 2 + 4 + 2 + 5 + 2 + 4 + 2 + 3 +2 29
MTC Score (Mean MTC Count) = ————————————————- = —- = 2.9
10 10
KGS Impact Factor: 2
Effective MTC Score = MTC Score X IF = 2.9 X 2 = 5.80
3. Circulating Tumor Cells (CTC)
CTC Counts:
The three consecutive CTC counts (Count 1, Count 2 and Count 3): 2, 4, 1
2 + 4 + 1
CTC Score = ——————- = 2.33
3
GS Impact Factor (IF): 3
Effective CTC Score = CTC Score X IF = 2.33 X 3 = 6.99
4. Necrotic Tumor Cells (NTC)
In this Grade VI tumor, the necrosis is classified as “high tumor necrosis”, and the high necrotic cells’ parametric score is calculated by the mean Necrotic Tumor Cells (NTCs) percentage, that is, the percentage of the necrosis.
NTCs percentages in 10 HPFs:
15%, 10%, 12%, 24%, 13%, 20%, 18%, 10%, 15%, 20%
15+10+12+24+13+20+18+10+15+20 157
Mean NTC = —————————————————— = ——- = 15.7
10 10
Mean NTC 15.7
NTC Score = ——————– = ——— = 1.57
10 10
KGS Impact Factor: 2
Effective KGS Score = NTC Score X IF = 1.57 X 2 = 3.14
5. Metastases (MET)
No metastases.
MET Score = 0
KGS Impact Factor (IF): 5
Effective MET Score = MET Score X IF = 0 X 5 = 0
KGS Index
The KGS Index is determined by the summation of the tumor’s five parametric data scores (PTC+MTC+CTC+NTC+MET = KGS Index).
KGS Index = PTC + MTC + CTC + NTC + MET
KGS Index = 8.91 + 5.80 + 6.99 + 3.14 + 0 = 24.84
Part 2: KGS PATHOLOGY REPORT
With KGS Diagnostic Profile and KGS Cellular Profile
KGS Diagnostic Profile in the 3rd Pathology Report:
Biopsy: Pancreatic Tumor
Date of Collection: 13.06.2013
Date of Report: 21.06.2013
Clinical Diagnosis: Pancreatic Ductal Adenocarcinoma
Microscopic Description: With a sizeably, but not extensively, infiltrative growth pattern, the moderately differentiated Grade VIB cells within dominating poorly-differentiated neoplastic glandular mucoepidermoid and pleomorphic structures; slight Grade VIIA tendency with a few sporadically seen clusters of Grade VIIA cells which quantitatively are not enough to qualify the tissue as Grade VIIA; in 10 HPFs, 29 Grade VIBm (mitotic) cells (29/10PHF) and Grade VIBn (necrotic) cells which occupy around 15% of the tumor tissue; sporadic small Grade VC and Grade VIA areas.
KGS Grade: VIB / VIIA
Overall KGS Grade: VIB
KGS Index: 24.84
KGS Prognostic Range: H (High Range)
Pathologic Diagnosis: “Grade VIB Pancreatic Ductal Adenocarcinoma”
KGS Diagnostic Profile in the Final Pathology Report:
Biopsy: Post-therapy Pancreatic Tumor
Date of Collection: 07.08.2014
Date of Report: 15.08.2014
Clinical Diagnosis: Regressed Pancreatic Ductal Adenocarcinoma
Microscopic Description: The Grade VIB tumor’s substantial regression to Grade VIR0 with a zero PTR (Post-Therapy Regression) score (KGS 0) ending up in Grade I with a normal-range profile (N); dominating necrosis and fibrosis; no visible/viable tumor cells; rare dying Grade VIB cells among overwhelming groups of Grade VIRn (necrotic) cells; no Grade VIBm (mitotic) cells in 10 HPFs (0/10PHF); 7 Grade VIBo (apoptotic) cells in 10 HPFs (7/10PHF).
Original KGS Grade: VIB
Overall KGS Grade: VIR (VIR0)
KGS Index: 0.20
First KGS Index: 24.84 [Report Date: 21.06.2013]
PTR (Post-Therapy Regression) Score: 0 (KGS 0)
KGS Prognostic Range: N
Pathologic Diagnosis: “Regressed Grade VIB Pancreatic Ductal Adenocarcinoma”
KGS Cellular Profile
Since the narrow range of the tumor’s cellular KGS grades remains only between Grade VIB and Grade VIIA, a detailed KGS Cellular Profile is not crucially necessary in this case.
Although a highly important diagnostic and prognostic guiding tool, the KGS Cellular Profile is not routinely-used in the KGS; its contribution to the KGS grading is significant and gets included in the KGS Patholgy Report only in tumors of wide-ranged cellular grades (Figures 1-3).
Part 3: KGS CLINICAL MANAGEMENT: KGS Prognostic Profile and KGS Prognostic Chart (KGS Chart)
KGS Prognostic Profile
The periodic KGS Index values make up the KGS Prognostic Profile.
DATE……….KGS INDEX……….KGS Prognostic Range……….KGS GRADE
16.02.13……………38.72 …………………………….E…………………………………VIB……..
15.04.13……………30.25 …………………………….E…………………………………VIB……..
21.06.13……………24.84 ……………………………H ………………………………..VIB……..
14.08.13……………21.15 …………………………….H…………………………………VIB……..
25.10.13……………18.39 ……………………………M………………………………..VIR4……
19.12.13……………10.85 ……………………………M………………………………..VIR3…….
18.02.14…………….4.50 ……………………………L………………………………….VIR2…….
21.04.14…………….1.55 …………………………….L………………………………….VIR1…….
11.06.14…………….0.50 ……………………………N…………………………………VIR0…….
15.08.14…………….0.20 ……………………………N……………………………………I…………
Table 5: KGS Prognostic Profile. In this “KGS Prognostic Profile” table, the parametric KGS Profile of the above case through its prognosis is shown in the standard format seen in its pathology reports and clinical files. In this regressing Grade VIIB Pancreatic Ductal Adenocarcinoma, we see a dramatically changing KGS Index over a period of 18-month oncotherapy at the end of which we see a replacing normal (Grade I) pancreatic tissue.
KGS Prognostic Profile Table
Parameter Parametric KGS Score
________________________________________________________________ VIB VIB VIB VIR5 VIR4 VIR3 VIR2 VIR1 VIR0 I
__________________________________________________________
PTC 12.52 10.88 8.91 7.45 6.84 4.75 2.85 1.90 1.70 0 __________________________________________________________
MTC 8.91 6.95 5.80 5.22 4.75 3.90 3.65 2.70 2.40 0.70
__________________________________________________________ CTC 9.75 7.90 6.99 6.40 5.80 3.70 0 0 0 0
__________________________________________________________ NTC HN 7.54 4.79 3.14 2.08 1 0 0 0 0 0 LN 0 0 0 0 0 -1.50 -2.00 -3.05 -3.60 -0.50
__________________________________________________________
MET 0 0 0 0 0 0 0 0 0 0
__________________________________________________________ KI 38.72 30.52 24.84 21.15 18.39 10.85 4.50 1.55 0.50 0.20
Range E E H H M M L L N N
Date 16.02.13 I I I I I I I I 15.08.14
_______________________________________________________________
Table 6: KGS Prognostic Profile Table. This standard table of the detailed “KGSPrognostic Profile“ shows the parametric KGS Data of the sample case, the Grade VIB Pancreatic Ductal Adenocarcinoma, with a dramatically changing KGS Index over a period of 18-month oncotherapy. This profile table provides a straight and clear view of the prognosis and a practical advantage in the follow-up. KGS parameters: PTC: Prime Tumor Cell, MTC: Mitotic Tumor Cell, CTC: Circulating Tumor Cell, NTC: Necrotic Tumor Cell, MET: Metastasis. KGS tumor grades> VIB: Neoplastic grade; VIR5, VIR4, VIR, VIR2, VIR1 and VIR0: Regressive neoplastic grade; I: Normal grade. HN: High necrosis, LN: Low necrosis, KI: KGS Index.
KGS Prognostic Chart (KGS Chart)
Presenting this tumor’s KGS Prognostic Profile, the KGS Prognostic Chart (KGS Chart) below is the statistical distribution display of the clinical prognosis of the case (Figure 5) with the tumor’s changing ranges and grades within the progression of theKGS Index through the prognostic period.
…….VIB……VIB……VIB……VIR5…..VIR4…..VIR3…..VIR2…VIR1….VIR0…..I….
U…………………………………………………………………………………………………………..
…..38.72…………………………………………………………………………………………………
E……………30.25……………………………………………………………………………………..
………………………..24.84……………………………………………………………………………
H………………………………….21.15………………………………………………………………..
……………………………………………….18.39……………………………………………………..
M………………………………………………………..10.85…………………………………………
………………………………………………………………………4.50………………………………..
L………………………………………………………………………………1.55………………………
……………………………………………………………………………………………0.50…………..
N……………………………………………………………………………………………………0.20..
_________________________________________________
16.02.13……..ı………ı………..ı………….ı………… ı……….ı………. ı………..ı….15.08.14
______________________________________________________
Figure 5: The “KGS Prognostic Chart” (KGS Chart) of the patient in Case 1: Displaying the “Prognostic KGS Ranges” together with a gradually decreasing “KGS Index” by dates, this standard KGS Chart shows the prognostic profile of an inoperable non-metastatic “Grade VIB Pancreatic Ductal Carcinoma” during a successful chemotherapy and radiotherapy period through which the Grade VIB tumor dramatically regresses being eventually replaced by a normal (Grade I) tissue.
Prognostic KGS Ranges> N=Normal, L=Low, M=Medium, H=High, E=Extreme, U=Ultimate. KGS Grades> VIB: Neoplastic grade; VIR5, VIR4, VIR, VIR2, VIR1 and VIR0: Regressive neoplastic grade; I: Normal grade. (The dates of the KGS pathology reports are shown below the base line)
Copyright © 2010-2015 M. M. Karindas, MD
