The Diagnostic Value of Routine Papanicolaou Smears for Detecting Endometrial Cancers: An Update

OBJECTIVE

The presence of degenerative endometrial debris and abnormal endometrial cells is considered to be the hint for endometrial pathology. The purpose of this study was to evaluate the efficacy of Papanicolaou (Pap) smears in detecting endometrial cancers.

STUDY DESIGN

There were 146 cases of endometrial cancer diagnosed at our institute in 2000-2002 and 271 in 2010-2012. Among them, 57 and 95 relevant reports of Pap smears 6 months prior to the histology diagnosis were retrieved for this study, respectively. In the first time period, new criteria for detecting endometrial lesions had not yet been incorporated into routine screening.

RESULTS

Twenty cases (21%) of adenocarcinoma, 12 (13%) of atypical glandular cells, 4 (4%) of endometrial debris and 59 (62%) negative reports were found among the more recent 95 relevant Pap smears. The overall efficacy of the Pap smear for detecting endometrial malignancy was 38%, higher than 10 years previously (30%).

CONCLUSION

Although the Pap smear was originally designed to screen cervical lesions, more effective detection of endometrial lesions could be achieved by adding new criteria to the routine screening.

Integrating a Web-Based Whole-Slide Imaging System and Online Questionnaires in a National Cytopathology Peer Comparison Educational Program in Taiwan

OBJECTIVE

In a peer comparison educational program, transferring glass slides between laboratories and collecting responses are time- and cost-consuming. Integrating a web-based whole-slide imaging (WSI) system and online questionnaires may serve as a promising solution.

STUDY DESIGN

Five gynecologic Papanicolaou-stained smears and 5 nongynecologic slides were selected. The 10 whole-slide images were acquired by a Leica SCN-400 system and released via an Aperio eSlide Manager. Online questionnaires generated by Google Forms with access to the 10 whole-slide images were released to all the practitioners in Taiwan by e-mail. After closing the program, an online posttest feedback survey was conducted.

RESULTS

A total of 302 participants joined the gynecologic test, and 291 joined the nongynecologic test. The correct interpretation rates were 81.8-93.7% in the former and 28.5-93.1% in the latter. In the posttest feedback survey, there were 63.2% of the participants reporting first-time WSI experience, and 97.9% of them said they would like to participate in a similar program again.

CONCLUSION

Integrating a web-based WSI system and online questionnaires is an easy method to access nationwide practitioners. Participants can make interpretations using WSI even without prior experience. The model is valuable for those who want to initiate a large-scale cytopathology peer comparison educational program.

Diagnostic challenges in cornual epithelioid trophoblastic tumor

OBJECTIVE

We present a case of primary cornual epithelioid trophoblastic tumor (ETT) because of its rarity and diagnostic and therapeutic challenge.

CASE REPORT

A 28-year-old woman, gravida 1, para 1, who missed menstruation for 3 months, had an elevated β-human chorionic gonadotropin serum level of 2764 mIU/mL, an absence of intrauterine pregnancy, and the presence of an adnexal mass detected by transvaginal ultrasound. As an ectopic pregnancy was suspected, laparoscopic surgery was performed and showed a right corneal mass. Complete excision of the tumor was done through exploratory laparotomy. Frozen pathology favored the diagnosis of squamous cell carcinoma. Since there was no apparent tumor at other sites, no additional surgery was done. The final pathology showed ETT. Primary ETT is often misdiagnosed as an ectopic pregnancy, leading to delayed treatment, and poses a diagnostic challenge in distinguishing it from squamous cell carcinoma during pathological examination.

CONCLUSION

Careful evaluation and avoidance of overtreatment are emphasized.

Ovarian immature teratoma with gliomatosis peritonei and pleural glial implant: a case report

Gliomatosis peritonei is a very rare phenomenon occurring almost exclusively in association with ovarian immature teratoma. It is characterized by numerous benign, mature glial nodules in the omentum and mesentery. The presence of glial tissue outside abdominal cavity is extremely rare in the setting of ovarian immature teratoma. We present a case of ovarian immature teratoma with both gliomatosis peritonei and pleural glial implant in a 4-year-old girl. Glial emboli were present in the pleural implant, suggesting lymphovascular dissemination might be the cause of extra-abdominal glial implantation.

Prognostic factors of primary fallopian tube cancer in a single institute in Taiwan

OBJECTIVE

To improve the understanding of primary fallopian tube carcinoma (PFTC) through an analysis of possible clinical and pathologic determinants of prognosis.

METHODS

A retrospective review of the database of a tertiary hospital in Taiwan for 1978-2007 was conducted to identify patients with a diagnosis of PFTC and to evaluate the clinicopathologic features associated with PFTC outcome.

RESULTS

Fifty-eight patients (mean age 62.5 years) had a diagnosis of PFTC. Stage III/IV disease (55%) and poorly differentiated tumors (52%) were most common. The median follow-up was 93 months (range, 11-333 months). The 5-year disease-free survival rate was 59%, and the overall survival rate was 64%. Factors important in disease-free and overall survival in univariate analysis included the presence of pelvic and/or para-aortic lymph node metastases, International Federation of Gynecology and Obstetrics stage, high preoperative carbohydrate antigen 125 serum level, completion of optimal debulking surgery, and the use of paclitaxel-based chemotherapy; however, only patients with optimal cytoreduction had a decreased hazard of recurrence (hazard ratio [HR] 0.06; 95% confidence interval [CI] 0.01-0.23) and mortality (HR 0.08; 95% CI, 0.02-0.31) in multivariate analysis.

CONCLUSION

Advanced tumor stage, in particular the presence of lymph node metastases, worsened the prognosis of patients with PFTC. However, optimal debulking surgery significantly improved the prognosis, emphasizing the importance of the treatment strategy.

Ovarian cancers arising from endometriosis: a microenvironmental biomarker study including ER, HNF1ß, p53, PTEN, BAF250a, and COX-2

BACKGROUND

The microenvironmental biomarkers of different subtypes of ovarian cancers arising from endometriosis have not been studied in Taiwan. Their expression can help in understanding the carcinogenic mechanism.

METHODS

Our study used immunohistochemistry to compare the expression of estrogen receptor (ER), hepatocyte nuclear factor-1 beta (HNF1ß), p53, phosphatase and tensin homolog (PTEN), BAF250a, and cyclooxygenase-2 (COX-2) among 79 cases of endometriosis-associated ovarian cancers, including 40 (50%) clear cell carcinomas (CCCs), 33 (41%) endometrioid (EM) adenocarcinomas, four (5%) serous carcinomas, one adenosquamous carcinoma, and one adenosarcoma.

RESULTS

Positive stainings for ER, HNF1ß, p53, and COX-2 were identified in 34 (43%), 30 (38%), 10 (13%), and 44 (56%) cases. Loss of PTEN and BAF250a were noted in 29 (37%) and 37 (47%) cases. The expression of ER was reversely correlated with that of HNF1ß (rho = -0.417, p < 0.001) and correlated with p53 (rho = 0.284, p = 0.011). ER positivity was commonly identified in EM adenocarcinomas (91%), and rarely in CCCs (8%) and serous carcinoma (0%; p < 0.001). By contrast, HNF1ß expression was frequently noted in CCCs (65%) and serous carcinomas (50%), but less in EM adenocarcinoma (6%; p < 0.001). All staining results were similar between atypical endometriosis glandular epithelium and contiguous malignant parts. Only nine cases showed 10 minor differences (10/474, 2%) in ER, HNF1ß, and BAF250a. For the staining patterns of p53, COX-2, and PTEN, there was no difference between the invasive and precursor parts.

CONCLUSION

Our results supported the suggestion that estrogen-dependent ovarian cancer arising from endometriosis is substantially more associated with EM adenocarcinoma than CCCs. The positive HNF1ß staining was a frequent finding in CCCs, but not in EM adenocarcinoma. The similar staining patterns of atypical endometriosis glandular cells with the invasive parts confirmed their precursor status.

Degenerative necrotic endometrial debris in Papanicolaou smears. The role in the prediction of endometrial pathology

A retrospective review was done to evaluate the importance of degenerative endometrial debris accompanied with benign-looking endometrial cells in Papanicolaou (Pap) smears. In total, 306 patients were divided into 2 groups according to the absence (group 1) or presence (group 2) of endometrial debris. Eighty-one (26.5%) patients received histologic follow-up. The biopsy rate for premenopausal patients in group 2 was the highest (24/48 [50%]). Multivariate analysis showed that presence of endometrial debris rather than menopausal status was more related to the biopsy procedure. Malignancy was found more often in group 2 (16/39 [41%]) than in group 1 (2/42 [5%]). A malignant result was also more closely related to endometrial debris rather than menopausal status. Thus, we suggest that benign endometrial cells in Pap smears should be reported and the presence of degenerative endometrial debris is important. Patients with degenerative endometrial debris need comprehensive evaluation, regardless of menopausal status.

Impact of body mass index and viral load on liver histology in hepatitis B e antigen-negative chronic hepatitis B

BACKGROUND & AIMS

The impact of overweight and obesity on chronic hepatitis B (CHB) is unclear. This study was to examine the relationship among body mass index, viral load and liver histology in HBeAg-negative CHB.

METHODS

The study retrospectively investigated 136 HBeAg-negative chronic hepatitis B patients who had undergone liver biopsies in Taiwan. Factors associated with significant liver histology were analyzed. Definitions of overweight and obesity for the Asian population were body mass index≥23 kg/m(2) and ≥25 kg/m(2), respectively.

RESULTS

The prevalence of overweight, obesity, and type 2 diabetes mellitus in the 136 patients were 22.8%, 52.2%, and 12.5%, respectively. Multivariate analysis identified obesity, AST>40 U/L, HBV DNA>20,000IU/mL and platelet count<150 × 10(9)/L as independent factors associated with significant liver fibrosis. Similarly, overweight/obesity, ALT>80 U/L, HBV DNA>1,000,000IU/mL, and platelet count<150 × 10(9)/L were independent predictors of significant hepatic necro-inflammation. By stratification, high BMI and high viral load patients had more advanced stage and grade of liver histology.

CONCLUSIONS

Body mass index and HBV viral loads may have synergistic effect on disease progression in HBeAg-negative CHB. Both controlling body weight and anti-viral therapy are important in the management of CHB.

Synchronous breast invasive ductal carcinoma and endometrial endometrioid adenocarcinoma: case report

Diagnosis of synchronous primary cancers in one patient is a relatively rare event. The well-known synchronous primary cancers of women are combined ovarian and endometrial cancers, especially when both are the endometrioid cell type. Although breast cancer and endometrial cancer are two common female malignancies, they often occur during the postmenopausal period. Therefore, the possibility of concomitant breast cancer and endometrial cancer in a younger woman (premenopausal) is often neglected. The reported case is an example of this situation. A 37-year-old woman was diagnosed with synchronous breast invasive ductal carcinoma and endometrial endometrioid adenocarcinoma. Since this condition is rarely reported, the correlated risk factors are worthy of our attention and the strategy for prevention is highlighted.

Uterine adenosarcoma detected by conventional papanicolaou smear: A case report with emphasis on integrating the immunocytochemical staining

Adenosarcoma is a rare uterine malignant tumor composed of benign to atypical epithelial element and a usually low-grade sarcomatous component. Although it is well known histologically, its cytological features are rarely described in the literature. We report a case of uterine adenosarcoma being the first one that was accurately diagnosed before operation by the conventional Papanicolaou (Pap) smear with emphasis on the contribution of the integrated immunocytochemical staining. A 46-year-old woman with abnormal vaginal bleeding and a protruding mass from her cervical os. Her Pap smear revealed: (a) presence of endometrial necrotic debris in the background, which indicated the presence of an endometrial lesion, (b) presence of both abnormal endometrial glandular cells (compact and tight clusters with slight hyperchromasia, increased nucleus/cytoplasm (N/C) ratio, apparent nucleoli and moderate vimentin stain) and abnormal stromal cells (loose aggregates of spindle to polygonal cells with hyperchromasia, increased N/C ratio and very strong vimentin staining). The characteristic degenerative necrotic debris indicating endometrial lesion plus the application of immunocytochemistry, which can increase the detection rate of endometrial lesion by the Pap smears. Awareness of the cytological findings of adenosarcoma can aid to make a correct preoperative diagnosis of this rare disease.

Correlation between clinical indication for treatment and liver histology in HBeAg-negative chronic hepatitis B: a novel role of alpha-fetoprotein

BACKGROUND

It is unclear whether clinical indication for antiviral treatment is in agreement with histological indication in HBeAg-negative chronic hepatitis B (CHB). This study aimed to clarify this relationship and identify factors associated with liver histology.

PATIENTS AND METHODS

We investigated 152 consecutive, treatment-naïve, HBeAg-negative CHB patients who had undergone liver biopsies at a tertiary medical centre in Taiwan. Clinical indications for treatment included a serum alanine aminotransferase level more than twice the upper limit of normal and an hepatitis B virus DNA level > 2000 IU/ml. Factors associated with the histological indication (Ishak's grade > or = 7 and/or stage > or = 2) were analysed.

RESULTS

The association between the clinical and the histological indications was significant (P=0.011). However, the agreement was poor (kappa value=0.197). In patients satisfying the clinical indication, age > 52 years [odds ratio (OR)=2.669, P=0.042], serum alpha-fetoprotein (AFP) level > 7 ng/ml (OR=7.070, P<0.001) and platelet count < 130 x 10(9)/L (OR=11.720, P=0.025) were identified to be independent factors associated with histological indication. In patients who did not satisfy the clinical indication, multivariate analysis revealed that only an AFP level > 7 ng/ml (OR=10.345, P=0.021) was independently associated with histological indication. Combining the clinical indication and/or AFP level > 7 ng/ml to predict liver histology, the sensitivity and the negative predictive value could improve from 86 to 94.4% and 66.7 to 81% respectively.

CONCLUSION

AFP level is associated with liver histology in HBeAg-negative CHB. Serum AFP level can serve as a surrogate indicator to identify patients who need antiviral treatment.

Multinational comparison of diagnostic clues for uterine cervical lesions among cytotechnologists in Asian countries

Vaccination has been underway in several countries for sexually inactive young girls or women against HPV 16 and 18 to prevent them from infection of these HPV types and concurrent cancer development. However, uterine cervical cancers may remain uncontrolled among some Asian countries, where other types of HPV infection are more frequent. A sensitive cancer screening system would remain important for detection of the earlier stage cervical cancers in Asian countries. In this study, 130 cytotechnologists (CTs) in Asian countries (Taiwan 80, Japan 18, Korea 15, Thailand 11, Singapore 3, Bhutan 2, and Mongolia 1) participated in the vote. Selected 10 cervical Pap smears that would be adequate to identify the diagnostic clues especially for atypical squamous cells (ASC) with two or three representative pictures for each case were displayed on the website. The percentages of consistent diagnosis voted by certified CTs with ≥5 years of experience were compared among 10 cervical cases or among Asian countries enrolled. As results, low consistency for ASC cases and high consistency for squamous intraepithelial lesion (SIL) were observed. Examining specimens for the diagnostic clues of ASC in TBS is crucial to maintain the high sensitivity and positive predictive value of SIL in Asian countries.

The relationship between human papillomavirus and Epstein-Barr virus infections in relation to age of patients with cervical adenocarcinoma

OBJECTIVE

To examine the relationship between human papillomavirus (HPV) and Epstein-Barr virus (EBV) infections in relation to age of patients with cervical adenocarcinoma.

MATERIALS AND METHODS

Thirty samples of human cervical adenocarcinoma tissue were collected from the surgical pathology archive at Taipei Veterans General Hospital from 1996 to 2008. All samples were examined for EBV, HPV-16 and HPV-18 E6 DNA by conventional and real-time quantitative polymerase chain reaction assays.

RESULTS

HPV-16 DNA was detected in 10 cases (33.3%), HPV-18 DNA in 12 cases (40%), and EBV DNA in three cases (10%); there were negative findings in seven cases (23.3%). EBV combined with HPV-16 or HPV-18 was also detected in one case each. No link could be demonstrated between HPV and EBV in endocervical lesions. When 20 patients 45 years old were compared with 10 patients > 45 years old, HPV-18 E6 DNA was detected in 45% vs. 30% (9/20 vs. 3/10), HPV-16 E6 DNA in 40% vs. 20% (8/20 vs. 2/10), EBV DNA in 10% vs. 10% (2/20 vs. 1/10), and no virus DNA was detected in 10% vs. 50% (2/20 vs. 5/10). HPV and EBV were significantly more common in younger women (p < 0.001).

CONCLUSION

HPV-18 plays a major role in adenocarcinomas at any age. A high prevalence of HPV DNA is significantly associated with cervical adenocarcinoma, especially in younger women. The results do not support a role for EBV in cervical adenocarcinogenesis or any relationship between EBV and HPV infection in adenocarcinoma.

Prognostic nomogram for overall survival in stage IIB-IVA cervical cancer patients treated with concurrent chemoradiotherapy

OBJECTIVE

On the basis of outcome data from concurrent chemoradiotherapy (CCRT) for locally advanced cervical squamous cell carcinoma, the authors developed a nomogram for predicting survival outcome.

STUDY DESIGN

Two hundred fifty-one eligible patients with International Federation of Gynecology and Obstetrics stage IIB-IVA squamous cell carcinoma of the uterine cervix who underwent CCRT were included for the construction of the nomogram. Predictor variables included age, serum squamous cell carcinoma antigen, tumor size, parametrium invasion, hydronephrosis, bladder/rectum invasion, and lymph node metastases. Internal validation of the nomogram was performed.

RESULTS

A nomogram for predicting the 5 year overall survival for these patients was constructed on the basis of a Cox regression model from 7 parameters. The concordance index was 0.69.

CONCLUSION

This nomogram is a predictive tool, upon external validation, that can be used to counsel patients in predicting outcomes. The discriminatory ability of the nomogram indicates that this population should not be considered homogeneous with respect to risk of death.

Thalidomide decreases intrahepatic resistance in cirrhotic rats

Increased intrahepatic resistance (IHR) within cirrhotic liver is caused by increased endotoxemia, cytokines tumor necrosis factor-alpha (TNF-alpha), vasoconstrictor thromboxane A(2) (TXA(2)), and disrupted microvasculatures. We evaluated the effects of thalidomide-related inhibition of TNF-alpha upon the hepatic microcirculation of cirrhosis in rats. Portal venous pressure (PVP), hepatic TNF-alpha, expression of thromboxane synthase (TXS), and leukocyte common antigen (LCA) were measured in bile-duct-ligated (BDL) rats receiving 1 month of thalidomide (BDL-thalido rats). Portal perfusion pressure (PPP), IHR, and hepatic TXA(2) production were measured in the isolated liver perfusion system. Intravital microscopy was used to examine hepatic microvascular disruptions. In BDL-thalido rats, PVP, PPP, IHR, hepatic TXA(2) and TNF-alpha, hydroxyproline content, expression of TXS and LCA, and LPS-induced leukocyte recruitment were significantly decreased. Conversely, hepatic microvascular density and perfused sinusoids were significantly increased. Thalidomide decreased PVP and IHR by reducing hepatic TXA(2) and improving hepatic microvascular disruptions in rats with biliary cirrhosis.

Expression of Aurora kinase A and B in normal and malignant cervical tissue: high Aurora A kinase expression in squamous cervical cancer

OBJECTIVE

Aurora kinases such as Aurora A and B are key regulators of mitosis and tumorigenesis and have been reported to be overexpressed in various malignancies. However, the expression of Aurora kinases in normal and neoplastic cervical tissues remains undetermined.

STUDY DESIGN

Immunohistochemical expression of Aurora A and B kinase was examined in 20 normal cervix, 35 cervical intraepithelial neoplasm 3 (CIN 3) and 95 cervical cancers, including squamous cell carcinoma (SCC) (n=76) and adenocarcinoma (AC) (n=19). Expression of Aurora A and B kinase was confirmed by Western blot. The correlation between Aurora A and B kinases expression and the clinico-pathological parameters was analyzed by statistical analysis.

RESULTS

The Aurora A and B expression was significantly increased in carcinoma and CIN 3, compared with normal cervix. However, expression of Aurora A and B showed no significant correlation between CIN 3 and cervical cancer. The nuclear expression of Aurora A showed a significantly positive correlation with the expression of Aurora B (P=0.018). The percentage of Aurora A overexpression between SCCs and ACs showed a significant difference (50% vs. 21.1%, P=0.023). However, there was no correlation of Aurora A and B expression with patient survival.

CONCLUSION

According to our study, Aurora A and B overexpression is a relatively early phenomenon in the genesis of malignant epithelial neoplasm tumorigenesis. Based on the results of this study, it would be interesting to know whether Aurora kinases play a role in pathogenesis of cervical dysplasia and SCC patients.