The Dna Content and Nuclear Size in Normal, Dysplastic and Carcinomatous Laryngeal Epithelium: A Spectrophotometric Study

Discriminant analysis between malignant mesothelioma and reactive mesothelium using nuclear three-dimensional analysis is useful for morphologically suspicious cases

OBJECTIVE

Morphological discrimination between malignant mesothelioma (MM) and reactive mesothelium (RM) is often difficult. Stereological analysis of nuclear luminance using centrifuged smear samples from coelomic fluid and discriminant analysis based on Mahalanobis distance may help to more accurately discriminate between MM and RM. In the present study, discriminant analysis was conducted on cytological specimens using the auto-smear method in a blinded manner with regard to histological results.

STUDY DESIGN

Coelomic fluid samples of 28 cases, cytologically diagnosed using the auto-smear method, were analyzed to determine pixel counts, the number of focus layers, 3-dimensional variation in the coefficient of variation of nuclear luminance between the focus layers as well as roundness in about 30-50 atypical cell nuclei per case. These measurements were employed to determine malignancy based on Mahalanobis distance.

RESULTS

Discrimination rates were as high as 91.7% for MM and 82.7% for RM. The discrimination rates of MM with histology were >80% in 8 of 10 suspicious cases with the initial cytology.

CONCLUSION

Our method allowed accurate discrimination between MM and RM and provides a useful alternative for the diagnosis of suspicious cases where morphological diagnosis of malignancy is difficult.

Diagnostic cellular abnormalities in neoplastic and non-neoplastic lesions of the epidermis: a morphological and statistical study

BACKGROUND

Distinguishing cellular abnormalities in reactive and malignant lesions is challenging. We compared the incidence and severity of cytological abnormalities in malignant/premalignant and benign epidermal lesions.

METHODS

One hundred fifty-two biopsies representing 69 malignant/premalignant squamous lesions and 83 benign conditions were studied. Cytological features, including nuclear hyperchromasia, nuclear overlap (crowding), irregular nuclei, high nuclear/cytoplasmic (N/C) ratio, conspicuous nucleoli, delicate inconspicuous nucleoli, clumped chromatin, pleomorphic parakeratosis, normal and abnormal mitotic figures and necrotic keratinocytes, were evaluated and graded. Statistical analysis was performed.

RESULTS

Irregular nuclei, increased N/C ratio, conspicuous single prominent nucleoli, nuclear overlap (crowding), pleomorphic parakeratosis, nuclear hyperchromasia, necrotic keratinocytes, normal and abnormal mitotic figures and coarse chromatin were seen more frequently in malignant neoplasms (p < 0.05). Abnormal mitotic figures, although uncommon (20.3%), were only noted in the malignant/premalignant group. Certain cytological features were common among both malignant and benign lesions, suggesting that they are of little value.

CONCLUSION

In the setting of an atypical cutaneous squamous proliferation, nuclear irregularity, increased N/C ratio, conspicuous nucleoli, crowding and hyperchromasia are the most useful indicators of malignancy. In contrast, mitotic figures, necrotic cells and coarse chromatin are less useful. The presence of abnormal mitotic figures is very helpful when present; however, their overall rarity limits their utility.

Grading of precancerous laryngeal lesions by multiparameter image analysis at separate epithelial layers

In order to detect early precancerous changes which do not involve the whole thickness of the epithelium, we used a novel image analysing program based on an IBAS system (Kontron, Germany) to determine nuclear DNA content (NC) as well as average nuclear area (NA) and variation of nuclear area (VA), in the entire epithelium and in three sublayers, parabasal, intermediate, and superficial. DNA aneuploidy was found in only half of the cases classified as 'high-grade' (HG) lesions, comprising carcinoma in situ (CIS) and severe epithelial dysplasias (EDIII), and was chiefly demonstrable in the parabasal third of the epithelium. The other lesions were DNA euploid. HG lesions showed highly significant increases of NA and VA at the lower levels of the epithelium when compared with 'low-grade' (LG) lesions comprising moderate and mild epithelial dysplasias (EDII and EDI). Our data show that the combination of multiparameter image analysis with conventional morphology assists in the objective grading of precancerous lesions and permits the reliable detection of high-grade lesions.

Premalignant lesions of the upper aerodigestive tract: biomarkers of genetic alterations, proliferation, and differentiation

The normal distribution of cell division in squamous mucosa is in the basal or adjacent suprabasal cell layers. Migration of cells toward the epithelial surface results in cell differentiation, most often expressed by high molecular weight keratin intermediate filaments and components of the cornified envelope, including "involucrin." These latter expressions of terminal differentiation are common in keratinizing dysplasia and invasive squamous cell carcinomas. However, they are less common in the non-keratinizing dysplasias, which fail to express evidence of epithelial maturation. Cell proliferation occurs in or near the basal layer in normal or reactive/reversible hyperplasias. In dysplasia (both keratinizing and non-keratinizing), cell proliferation is observed at all levels of the epithelium. Concomitant with these abnormalities in proliferation and differentiation are nuclear changes characterized by large hyperchromatic nuclei. The enlarged nuclei reflect increased DNA content, as documented by flow cytometry and image analysis techniques. DNA aneuploidy represents a spectrum of genomic alterations reflecting steps toward the progression to invasive carcinoma, which for the most part, have not yet been identified.

Comparison of quantitative DNA measurements and cytomorphology in squamous cell carcinomas of the upper aerodigestive tract with and without lymph node metastases

Cytologic smears of squamous cell carcinomas (UICC T2 through T4) from the mucosa of the upper aerodigestive tract without cervical lymph node metastases (n = 10) and with metastases (n = 20) were examined. Subsequently, the cytologic smears of the metastases (n = 20) obtained by fine-needle aspiration or following neck dissection were evaluated morphologically. Each specimen was then stained with Papanicolaou and Feulgen techniques, and quantitative DNA measurements were performed with an image analysis system. Morphologically, the primary tumors with metastases revealed an increased mean nuclear perimeter and mean nuclear area compared with tumors unassociated with metastases. On quantitative DNA measurements, the tumors with metastases had an increased DNA content, a higher 2c deviation index, and a higher DNA malignancy grade and increased number of aneuploid cells. The specimens obtained from the metastatic nodes yielded the highest values for mean DNA content, 2c deviation index, aneuploidy, and malignancy grade. The stem lines of metastasis were always nondiploid. These data indicate a positive correlation between aneuploid tumor cell clones in primary cancer and the manifestation of lymph node metastases.

Laryngeal intraepithelial neoplasia (LIN). An analytical morphometric approach

Laryngeal Intraepithelial Neoplasia (LIN) is graded in 3 levels (LIN Grade I-II-III), corresponding to the classic aspects of mild, moderate and severe dysplasia-in situ carcinoma, on the basis of the number and position of mitoses and of the undifferentiated or atypical cells limited to the basal or extended to the intermediate or the superficial layers of epithelium. In order to reduce the subjective imprecision of these parameters we have applied not only traditional dimensional evaluators but also procedures of analytical morphometry to the nuclear shape. By using the software system S.A.M. (Shape Analytical Morphometry) we have examined fifty nuclei of the basal layer in LIN grade I, II and III, fifty nuclei in normal laryngeal mucosa and fifty nuclei in invasive carcinoma of the larynx (twenty-five cases in all). Normal and dysplastic nuclei did not show any dimensional differences, while the carcinomatous nuclei were significantly larger. An asymmetric distortion of the nuclear contour was noted in the moderate and severe dysplasia, but not in carcinomatous cells. Also the Fourier parameters, increased in severe dysplasia, decreased dramatically in carcinomatous cells which showed nuclei with minor contour irregularities than the normal cells. These findings outline the discriminative power of the analytical morphometry and suggest a possible correlation between nuclear shape and cell biology.

Stereological estimation of nuclear volume and other quantitative histopathological parameters in the prognostic evaluation of supraglottic laryngeal squamous cell carcinoma

The aim of this study was to investigate various approaches to the grading of malignancy in pre-treatment biopsies from patients with supraglottic laryngeal squamous cell carcinoma. The prospects of objective malignancy grading based on stereological estimation of the volume-weighted mean nuclear volume, nuclear Vv, and nuclear volume fraction, Vv(nuc/tis), along with morphometrical 2-dimensional estimation of nuclear density index, NI, and mitotic activity index, MI, were investigated and compared with the current morphological, multifactorial grading system. The reproducibility among two observers of the latter was poor in the material which consisted of 35 biopsy specimens. Unbiased estimates of nuclear Vv were on the average 385 microns3 (CV = 0.44), with more than 90% of the associated variance attributable to differences in nuclear Vv among individual lesions. Nuclear Vv was positively correlated with MI, negatively with NI, whereas no correlation with Vv(nuc/tis) was found. No relationship between nuclear Vv and the morphologically interpreted degree of nuclear dedifferentiation was demonstrated. Nuclear Vv showed no differences between lesions in different clinical T-stage of disease. None of the investigated categorical and quantitative parameters (cutoff points = means) reached the level of significance with respect to prognostic value. However, nuclear Vv showed the best information concerning survival (2p = 0.08), and this estimator offers optimal features for objective malignancy grading. Further analyses of larger series of patients are needed to establish the prognostic value of nuclear Vv for objective malignancy grading of supraglottic laryngeal squamous cell carcinoma.

Hypertetraploid cells in vocal cord epithelia

DNA measurements yield information about the nature of cells and may provide diagnostic and prognostic information. Static cytofluorometry was performed on smears removed at microlaryngoscopy from 107 vocal cord lesions (96 patients). All stem cell lines were diploid except 3; 2 carcinomas and 1 severe dysplasia were polyploid. The mean proliferative activity (percentage of nuclei greater than diploid peak) was 2.1% for the group of epithelia with hyperplasia and mild dysplasia, 3.1% for those with moderate dysplasia, 4.0% for severe dysplasia, and 6.8% for carcinomas. Hypertetraploid cell nuclei (HT cells) were not found in epithelia with hyperplasia and mild dysplasia. Seven out of 15 patients with epithelia showing moderate dysplasia had HT cells; 5 of these patients developed a carcinoma. One of 8 without HT cells developed a severe dysplasia. Nine patients with severe dysplasia had HT cells; 4 had recurrences and 4 developed carcinoma within 4 years. In 14 patients without HT cells, 3 had recurrences and 1 developed a carcinoma 6 years later. HT cells were found in 15 patients with T1 & T2 carcinomas; residual carcinoma was present in 2 after radiotherapy and 4 had recurrences within 11 months. Fourteen patients with T1 & T2 carcinoma did not have any HT cells; one had residual carcinoma after radiotherapy and 3 had recurrences between 18 months and 4 years. DNA measurements and, especially, the demonstration of epithelia with HT cells prove to be of prognostic importance.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical relevance of classification of squamous cell hyperplasia of the larynx by morphometry

By means of morphometry, differentiation between the classes of laryngeal squamous cell hyperplasia can easily be performed, mutually (Kleinsasser's classification) and in comparison with normal epithelium. It is rather difficult, however, to distinguish between class II (hyperplasia and atypia) and class III (carcinoma in situ). In the group of class II lesions, two groups of patients could be differentiated: a prognostically favourable and an unfavourable group. When using a linear discriminant analysis, the two groups mentioned could be distinguished morphometrically. In histopathological examination, lesions classified as hyperplasia and atypia (class II), must also be examined with morphometry, because in this way the group at risk can be traced.

Comparison between the nuclear diameters of primary and metastatic breast cancer cells obtained by cytologic aspiration

In order to determine if there are morphologically identifiable characteristics between malignant cells obtained from a primary cancer and its metastasis the nuclear diameter was used as an indicator of the degree of malignancy, since there is good correlation between nuclear size, DNA content, and chromosome numbers. The nuclear diameter of primary and metastatic mammary carcinoma cells, obtained by cytologic aspirates, was measured by ocular micrometry. The purpose was to investigate whether a cell population at the primary site developed, at the metastatic sites, a population with the same nuclear size or one having larger and more anaplastic nuclei. One hundred eighty-five patients with infiltrating ductal carcinoma of the common variety were examined. The primary cancer and axillary nodal metastasis were examined in 97 patients before treatment. Thirty had cytologic examination of the breast cancer, as well as of the metastasis, which developed 1 to 14 years after treatment. Eleven were examined before radical breast irradiation and again at the time of relapse in the breast. Forty-seven had bilateral synchronous mammary carcinoma and both primary cancers were studied. The data presented indicate that there is extreme similarity between the nuclear diameters of the primary tumor and its metastasis. This similarity persists for several years regardless of both the location of the recurrence or radical irradiation. These results support the view that the majority of tumors are monoclonal in origin. The clone that invades the metastatic site appears to be the same as the one that initiated the primary cancer. In contrast, the nuclear diameters of cell populations obtained from synchronous bilateral breast cancer were dissimilar, indicating that they arose from separate clones of malignant cells.

Quantitative morphometry of squamous cell hyperplasia of the larynx

The histopathological diagnosis of squamous cell hyperplasia of the larynx is very subjective. Since morphometry is highly reproducible, this method was applied to routine processed slides of 45 such lesions to assess objectively the epithelial characteristics. In each case measurements of nuclei of 50 cells in the basal, intermediate, and superficial cell layers were carried out. The data were analysed statistically. The findings suggest that quantitative morphometry may be helpful for the histopathological classification of squamous cell hyperplasia of the laryngeal mucosa.

Measurement of nuclear DNA in the management of cervical intraepithelial neoplasia

Cytophotometry was used to study the DNA content in 166 smears. The results were compared with the histological findings at cone biopsy which showed 117 carcinomas in situ, 30 microinvasive cancers, and 19 invasive carcinomas. There were statistically significant differences in DNA content and distribution between the intraepithelial neoplasia and microinvasive or invasive carcinoma. We also found cytophotometric differences between exocervical and endocervical in situ carcinoma and invasive cancers. The DNA content of cells did not vary significantly with age. Exocervical carcinoma in situ to have aneuploid histograms while endocervical in situ carcinoma had a euploid distribution of DNA, cytophotometry can help in planning the limits or extent of a cone biopsy.

Cytophotometric determinations of DNA, histone, arginine, lysine, and their concentrations in eu- and heterochromatin of the cell nucleus of dysplasias, carcinoma in situ, and carcinoma of the human cervix uteri

In the cell nuclei of dysplasias, carcinoma in situ, and carcinoma the amount of DNA, histone, arginine, lysine, and their condensed areas were determined by cytophotometry. Moreover their concentrations in the euchromatic and heterochromatic areas of the nuclei were measured. Statistical analysis showed that the quantitative relations between parameters did not change during carcinogenesis. The significantly increased amount of lysine underlines the role of the lysine-rich histones in producing denser coiling of the chromatin fibril in heterochromatin.

Hyperplasia, keratosis, dysplasia and carcinoma in situ of the vocal cords--a follow-up study

Comparison of reported series of laryngeal lesions is complicated by the inconsistency in the terminology. The classification of these lesions should logically be based on the degrees of dysplasia, as this has a bearing on the prognosis. The material for this study consisted of 193 patients with hyperplasia and/or keratosis, with or without mild dysplasia (Group I), moderate dysplasia (Group II), and severe dysplasia and carcinoma in situ (Group III). They were treated over a 14-year period (1966-1979) at Linköping University Hospital. Of the 98 patients in Group I available for follow-up, 23 had repeat excisions. Moderate dysplasia developed in 3 patients, severe dysplasia in 2, and invasive carcinoma in another 2 within 3 and 3.5 years; they both underwent laryngectomy. Among the 24 patients in Group II available for follow-up, severe dysplasia developed in 3 and invasive carcinoma in 3 up to 13 years after the initial diagnosis, all but one (with severe dysplasia) received a full course of radiotherapy, on one case total laryngectomy was subsequently performed for recurrent carcinoma. Of the 39 patients with severe dysplasia and carcinoma in situ 16 were given primary radiotherapy; 4 of these developed invasive carcinoma; 3 of them underwent total laryngectomy and one partial laryngectomy. Excision or stripping of the vocal cords was the primary treatment in 23 cases; 5 of these developed invasive carcinoma; 2 of them underwent total laryngectomy. Diffuse lesions and well differentiated forms of severe dysplasia caused most problems and had the highest incidence of invasive carcinoma irrespective of the form of treatment. Patients with hyperplasia, keratosis, dysplasia and carcinoma in situ should be carefully followed up, as invasive carcinoma may develop many years after the initial diagnosis.

Photometric evaluation of laryngeal epithelium exhibiting hyperplasia, keratosis and moderate dysplasia

Photometric examination of vocal cord epithelia disclosed no difference in the nuclear DNA content or nuclear area of normal and keratotic laryngeal epithelia. For 2 out of 3 epithelia displaying hyperplasia the values were slightly elevated. There seem to be no morphologic or photometric grounds for considering either hyperplasia or keratosis to be premalignant. Eight patients with moderate dysplasia were selected; 3 with and 5 without subsequent development of severe dysplasia or carcinoma in situ. In all 8 cases the DNA values were not increased, but in 6 there was an increased variation about the mean. There were no morphologic or photometric differences between the epithelia subsequently developing severe dysplasia or carcinoma in situ and those that did not. The 3 patients developing severe dysplasia or carcinoma in situ were then followed for 112, 27 and 106 months and showed no evidence of invasive carcinoma. The other 5 patients with moderate dysplasia were followed for 48 to 123 months without any sign of recurrent disease. There are no photometric grounds for considering moderate dysplasia as a precancerous lesion. Long-term investigation is required to ascertain the risk that carcinoma in situ or invasive carcinoma will develop in patients with laryngeal hyperplasia, keratosis and moderate dysplasia.

Chondrosarcoma of the larynx

A chondrosarcoma arising in the posterior cricoid plate is presented. The tumour gave rise to increasing inspiratory stridor: laryngectomy was performed. The tumour consisted of loose cartilaginous tissue with great predominance of highly differentiated cartilage cells and only small areas with nuclear polymorphism. This complicated the differential diagnosis between chondroma and highly differentiated chondrosarcoma. From the fact that the patient died from massive pulmonary metastases 3 1/2 years later, it is evident that the degree of malignancy of cartilaginous tumours should be determined even on small polymorphic foci. The DNA histogram for the foci of the laryngeal tumour with atypia differed distinctly from those for benign chondroma and normal cartilage, but resembled those of the pulmonary and splenic metastases and of a nasal chondrosarcoma. Photometric examination may provide an aid in the difficult differential diagnosis between chondroma and highly differentiated chondrosarcoma.