Cancer-testis antigen expression is shared between epithelial ovarian cancer tumors

OBJECTIVES

Cancer-testis (CT) antigens have been proposed as potential targets for cancer immunotherapy. Our objective was to evaluate the expression of a panel of CT antigens in epithelial ovarian cancer (EOC) tumor specimens, and to determine if antigen sharing occurs between tumors.

METHODS

RNA was isolated from EOC tumor specimens, EOC cell lines and benign ovarian tissue specimens. Real time-PCR analysis was performed to determine the expression level of 20 CT antigens.

RESULTS

A total of 62 EOC specimens, 8 ovarian cancer cell lines and 3 benign ovarian tissues were evaluated for CT antigen expression. The majority of the specimens were: high grade (62%), serous (68%) and advanced stage (74%). 58 (95%) of the EOC tumors analyzed expressed at least one of the CT antigens evaluated. The mean number of CT antigen expressed was 4.5 (0-17). The most frequently expressed CT antigen was MAGE A4 (65%). Antigen sharing analysis showed the following: 9 tumors shared only one antigen with 62% of the evaluated specimens, while 37 tumors shared 4 or more antigens with 82%. 5 tumors expressed over 10 CT antigens, which were shared with 90% of the tumor panel.

CONCLUSION

CT antigens are expressed in 95% of EOC tumor specimens. However, not a single antigen was universally expressed across all samples. The degree of antigen sharing between tumors increased with the total number of antigens expressed. These data suggest a multi-epitope approach for development of immunotherapy for ovarian cancer treatment.

Follicle Depletion Provides a Permissive Environment for Ovarian Carcinogenesis

We modeled the etiology of postmenopausal biology on ovarian cancer risk using germ cell-deficient white-spotting variant (Wv) mice, incorporating oncogenic mutations. Ovarian cancer incidence is highest in peri- and postmenopausal women, and epidemiological studies have established the impact of reproductive factors on ovarian cancer risk. Menopause as a result of ovarian follicle depletion is thought to contribute to higher cancer risk. As a consequence of follicle depletion, female Wv mice develop ovarian tubular adenomas, a benign epithelial tumor corresponding to surface epithelial invaginations and papillomatosis frequently found in postmenopausal human ovaries. Lineage tracing using MISR2-Cre indicated that the tubular adenomas that developed in Wv mice were largely derived from the MISR2 lineage, which marked only a fraction of ovarian surface and oviduct epithelial cells in wild-type tissues. Deletion of p27, either heterozygous or homozygous, was able to convert the benign tubular adenomas into more proliferative tumors. Restricted deletion of p53 in Wv/Wv mice by either intrabursal injection of adenoviral Cre or inclusion of the MISR2-Cre transgene also resulted in augmented tumor growth. This finding suggests that follicle depletion provides a permissive ovarian environment for oncogenic transformation of epithelial cells, presenting a mechanism for the increased ovarian cancer risk in postmenopausal women.

Metastatic prostatic adenocarcinoma diagnosed in a bronchoalveolar lavage specimen: An unusual presentation of a common tumor

Metastatic prostatic adenocarcinoma presenting as a primary lung disease is rare. We present a 52-year-old male with a 3-month history of cough, shortness of breath, and weight loss with clinical and radiological findings suggestive of a primary lung disease: Bilateral interstitial and alveolar opacities with blunting of the costophrenic angles, multiple diffuse foci of consolidations and nodules, predominantly subpleural and located in the lower lobes, and diffuse interlobular septal thickening and peribronchial thickening. The patient underwent bronchoscopy and bronchoalveolar lavage (BAL) was obtained. Cytospin smears were diagnostic for a low-grade adenocarcinoma. Clinically, the patient had elevated serum prostate-specific antigen (PSA) levels greater than 5,000 ng/mL. Because of this, immunocytochemistry for PSA was performed which was positive, confirming the diagnosis of metastatic prostatic adenocarcinoma. This unusual case of metastatic adenocarcinoma of the prostate first diagnosed by BAL highlights the significance of available clinical information and the use of immunocytochemistry for proper diagnosis.

HPV in HIV-Infected Women: Implications for Primary Prevention

Background: There is growing evidence that human immunodeficiency virus (HIV)-infected women might have a different human papillomavirus (HPV) type distribution in cervical dysplasia specimens as compared to the general population. This has implications for primary prevention.

Objective: We aimed to obtain preliminary data on the HPV genotypes prevalent in histological samples of HIV-infected women with cervical intraepithelial neoplasia (CIN) 3/CIS of the cervix in Miami, FL, USA.

Methods: Retrospective data were collected on HIV-infected women referred to the University of Miami-Jackson Memorial Hospital colposcopy clinic between years 2000 and 2008. The histology slides of CIN 3/CIS biopsies underwent pathological review and sections were cut from these archived specimens for HPV DNA extraction. HPV genotyping was then performed using the GeneSquare™ HPV genotyping assay. We report on our first set of 23 samples.

Results: Eight high-risk HPV types were detected. Types in decreasing order of frequency were 16, 35, 45, 52, 59, 31, 58, and 56. Most cases had multiple infections. HPV type 16 was the most common (45%) followed by HPV-35 and -45 with equal frequency (40%). No samples contained HPV-18.

Conclusion: Our preliminary results suggest that cervical dysplasia specimens of HIV-infected women more likely (55%) contain non-16 and -18 high-risk HPV types. We show that this held true for histologically confirmed severe dysplasia and carcinoma-in situ. Epidemiological studies guide vaccine development, therefore HPV type prevalence in CIS and invasive cervical cancer among HIV-infected women should be more rigorously explored to ensure that this highly vulnerable population receives appropriate primary prevention.

Verification of the anatomy and newly discovered histology of the G-spot complex

OBJECTIVES

To expand the anatomical investigations of the G-spot and to assess the G-spot's characteristic histological and immunohistochemical features.

DESIGN

An observational study.

SETTING

International multicentre.

POPULATION

Eight consecutive fresh human female cadavers.

METHODS

Anterior vaginal wall dissections were executed and G-spot microdissections were performed. All specimens were stained with haematoxylin and eosin (H&E). The tissues of two women were selected at random for immunohistochemical staining.

MAIN OUTCOME MEASURES

The primary outcome measure was to document the anatomy of the G-spot. The secondary outcome measures were to identify the histology of the G-spot and to determine whether histological samples stained with H&E are sufficient to identify the G-spot.

RESULTS

The anatomical existence of the G-spot was identified in all women and was in a diagonal plane. In seven (87.5%) and one (12.5%) of the women the G-spot complex was found on the left or right side, respectively. The G-spot was intimately fused with vessels, creating a complex. A large tangled vein-like vascular structure resembled an arteriovenous malformation and there were a few smaller feeding arteries. A band-like structure protruded from the tail of the G-spot. The size of the G-spot varied. Histologically, the G-spot was determined as a neurovascular complex structure. The neural component contained abundant peripheral nerve bundles and a nerve ganglion. The vascular component comprised large vein-like vessels and smaller feeding arteries. Circular and longitudinal muscles covered the G-complex.

CONCLUSION

The anatomy of the G-spot complex was confirmed. The histology of the G-spot presents as neurovascular tissues with a nerve ganglion. H&E staining is sufficient for the identification of the G-spot complex.

High-Risk Human Papillomavirus DNA Detected in Primary Squamous Cell Carcinoma of Urinary Bladder

Context.—We reported previously that more than one-third (37%) of primary bladder squamous cell carcinomas (SCCs) demonstrate diffuse p16 immunoreactivity independent of gender. This observation made us question whether p16 overexpression in bladder carcinoma is due to human papillomavirus (HPV)–dependent mechanisms.

Objectives.—To determine whether the presence of high-risk HPV (HR-HPV) DNA could be detected in these tumor cells.

Design.—Fourteen cases of primary bladder SCC, which were positive for p16 by immunohistochemistry, were probed for the detection of HR-HPV by in situ hybridization and the signal amplification Invader assay. Samples positive for detection of HR-HPV by Invader assay were amplified by using HR-HPV type-specific primers, and amplification products were DNA sequenced.

Results.—Detection of HR-HPV by the in situ hybridization method was negative in all cases (0 of 14). However, in 3 of 14 cases (21.4%), the presence of HR-HPV DNA was detected with the Cervista HPV HR Invader assay, which was followed by identification of genotype. All positive cases were confirmed by using HR-HPV type-specific amplification followed by DNA sequencing. Identified HR-HPV genotypes included HPV 16 (2 cases) and HPV 35 (1 case).

Conclusions.—High-risk HPV DNA is detectable in a subset of primary bladder SCCs. Based on the well-documented carcinogenic potential of HR-HPV, there is a necessity for additional studies to investigate the role of HR-HPV in bladder carcinogenesis.

Cortisol and inflammatory processes in ovarian cancer patients following primary treatment: relationships with depression, fatigue, and disability

Elevations in the pro-inflammatory cytokine interleukin-6 (IL-6) and alterations in the anti-inflammatory hormone cortisol have been reported in a variety of cancers. IL-6 has prognostic significance in ovarian cancer and cortisol has been associated with fatigue, disability, and vegetative depression in ovarian cancer patients prior to surgery. Ovarian cancer patients undergoing primary treatment completed psychological self-report measures and collected salivary cortisol and plasma IL-6 prior to surgery, at 6 months, and at 1 year. Patients included in this study had completed chemotherapy and had no evidence of disease recurrence. At 6 months, patients showed significant reductions in nocturnal cortisol secretion, plasma IL-6, and a more normalized diurnal cortisol rhythm, changes that were maintained at 1 year. The reductions in IL-6 and nocturnal cortisol were associated with declines in self-reported fatigue, vegetative depression, and disability. These findings suggest that primary treatment for ovarian cancer reduces the inflammatory response. Moreover, patients who have not developed recurrent disease by 1 year appear to maintain more normalized levels of cortisol and IL-6. Improvement in fatigue and vegetative depression is associated with the normalization of IL-6 and cortisol, a pattern which may be relevant for improvements in overall quality of life for ovarian cancer patients.

p16INKa immunocytochemistry in fine-needle aspiration cytology smears of metastatic head and neck squamous cell carcinoma

OBJECTIVES

Patients with head and neck squamous cell carcinoma (HNSCC) may initially present with neck metastases diagnosed by fine-needle aspiration (FNA). In these patients, it is critical to locate the primary site so that targeted therapy can be administered. Nearly a quarter of HNSCC are associated with human papillomavirus (HPV) infection. The great majority of HPV-related primaries originate in the oropharynx. p16INKa (p16) functions as a surrogate marker of HPV infection. We sought to determine if expression of p16 by immunocytochemistry (ICC) in neck metastases could assist in localizing the primary site to the oropharynx.

STUDY DESIGN

Diagnostic FNA cytology smears of neck metastases from 90 patients with biopsy-proven primary HNSCC were reviewed. Papanicolaou-stained slides were directly subjected to ICC, using p16 antibody.

RESULTS

Twenty-seven (30%) tumors expressed p16 by ICC; 74% of these p16-positive tumors were metastases from oropharynx. There was a significantly higher proportion of p16 expression in patients with primary oropharyngeal carcinoma (47%) versus those whose primary tumor was non-oropharyngeal (15%; p = 0.0013).

CONCLUSIONS

p16 expression in FNA cytology smears of metastatic HNSCC is a useful indicator of oropharyngeal origin and can be used to help localize the primary site in cases where this is not clinically evident.

Loss of A-type lamin expression compromises nuclear envelope integrity in breast cancer

Through advances in technology, the genetic basis of cancer has been investigated at the genomic level, and many fundamental questions have begun to be addressed. Among several key unresolved questions in cancer biology, the molecular basis for the link between nuclear deformation and malignancy has not been determined. Another hallmark of human cancer is aneuploidy; however, the causes and consequences of aneuploidy are unanswered and are hotly contested topics. We found that nuclear lamina proteins lamin A/C are absent in a significant fraction (38%) of human breast cancer tissues. Even in lamin A/C–positive breast cancer, lamin A/C expression is heterogeneous or aberrant (such as non-nuclear distribution) in the population of tumor cells, as determined by immunohistology and immunofluorescence microscopy. In most breast cancer cell lines, a significant fraction of the lamin A/C– negative population was observed. To determine the consequences of the loss of lamin A/C, we suppressed their expression by shRNA in non-cancerous primary breast epithelial cells. Down-regulation of lamin A/C in breast epithelial cells led to morphological deformation, resembling that of cancer cells, as observed by immunofluorescence microscopy. The lamin A/C–suppressed breast epithelial cells developed aneuploidy as determined by both flow Cytometry and fluorescence in situ hybridization. We conclude that the loss of nuclear envelope structural proteins lamin A/C in breast cancer underlies the two hallmarks of cancer aberrations in nuclear morphology and aneuploidy.

Social influences on clinical outcomes of patients with ovarian cancer

PURPOSE

Previous research has demonstrated relationships of social support with disease-related biomarkers in patients with ovarian cancer. However, the clinical relevance of these findings to patient outcomes has not been established. This prospective study examined how social support relates to long-term survival among consecutive patients with ovarian cancer. We focused on two types of social support: social attachment, a type of emotional social support reflecting connections with others, and instrumental social support reflecting the availability of tangible assistance.

PATIENTS AND METHODS

Patients were prospectively recruited during a presurgical clinic visit and completed surveys before surgery. One hundred sixty-eight patients with histologically confirmed epithelial ovarian cancer were observed from the date of surgery until death or December 2010. Clinical information was obtained from medical records.

RESULTS

In a Cox regression model, adjusting for disease stage, grade, histology, residual disease, and age, greater social attachment was associated with a lower likelihood of death (hazard ratio [HR], 0.87; 95% CI, 0.77 to 0.98; P = .018). The median survival time for patients with low social attachment categorized on a median split of 15 was 3.35 years (95% CI, 2.56 to 4.15 years). In contrast, by study completion, 59% of patients with high social attachment were still alive after 4.70 years. No significant association was found between instrumental social support and survival, even after adjustment for covariates.

CONCLUSION

Social attachment is associated with a survival advantage for patients with ovarian cancer. Clinical implications include the importance of screening for deficits in the social environment and consideration of support activities during adjuvant treatment.

Soy isoflavones in the prevention of menopausal bone loss and menopausal symptoms: a randomized, double-blind trial

BACKGROUND

Concerns regarding the risk of estrogen replacement have resulted in a significant increase in the use of soy products by menopausal women who, despite the lack of evidence of the efficacy of such products, seek alternatives to menopausal hormone therapy. Our goal was to determine the efficacy of soy isoflavone tablets in preventing bone loss and menopausal symptoms.

METHODS

The study design was a single-center, randomized, placebo-controlled, double-blind clinical trial conducted from July 1, 2004, through March 31, 2009. Women aged 45 to 60 years within 5 years of menopause and with a bone mineral density T score of -2.0 or higher in the lumbar spine or total hip were randomly assigned, in equal proportions, to receive daily soy isoflavone tablets, 200 mg, or placebo. The primary outcome was changes in bone mineral density in the lumbar spine, total hip, and femoral neck at the 2-year follow-up. Secondary outcomes included changes in menopausal symptoms, vaginal cytologic characteristics, N -telopeptide of type I bone collagen, lipids, and thyroid function.

RESULTS

After 2 years, no significant differences were found between the participants receiving soy tablets (n = 122) and those receiving placebo (n = 126) regarding changes in bone mineral density in the spine (-2.0% and -2.3%, respectively), the total hip (-1.2% and -1.4%, respectively), or the femoral neck (-2.2% and -2.1%, respectively). A significantly larger proportion of participants in the soy group experienced hot flashes and constipation compared with the control group. No significant differences were found between groups in other outcomes.

CONCLUSIONS

In this population, the daily administration of tablets containing 200 mg of soy isoflavones for 2 years did not prevent bone loss or menopausal symptoms.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00076050.

Flow immunocytochemistry of marker expression in cells from body cavity fluids

Diagnostic cytology based on the examination of cells from body cavity fluids misses approximately 50% of patients with a proven malignancy. In an earlier study, we used immunohistochemical detection of epithelial membrane antigen expression with flow cytometric detection of DNA aneuploidy to reduce the number of false negatives. In the present study, we have combined DNA flow cytometry with flow cytometric detection of marker expression to analyze cells from body cavity fluids. Seventy-nine specimens of ascites and pleural fluids were analyzed by diagnostic cytology, DNA flow cytometry, and for the expression of the following markers: Ber-EP4, progesterone (PR), MUC4, and thyroid transcription factor-1 (TTF-1). DNA index of equal to or greater than 1.2 was seen in 33/79 (41.7%) of the samples. Statistical analysis of 79 samples in which data from cytology, DNA aneuploidy, and expression of at least one of the markers was available showed that by combining data from positive marker expression with that of aneuploidy, the sensitivity was increased from 58.5 to 100%. In contrast, out of the 38 samples designated as non-malignant by diagnostic cytology, nine had aneuploid DNA content and 16 of the diploid samples had a positive marker expression. Specificity was reduced from 74.7 to 31.6% due to the presence of aneuploidy and marker expression in these samples. ALDH1(pos)/CD44(pos)/CD24(neg) expression has been reported to be associated with human breast tumor stem cells. Some of our samples had cells with this phenotype. Flow cytometry offers the advantage of rapid multiparametric analysis of DNA aneuploidy and marker expression in cells from body cavity fluids based on the analysis of a large number of cells without observer bias. By further developing the use of specific markers and aneuploidy, it may be possible to refine flow cytometric analysis for rapid detection of malignant cells in body cavity fluids.

ALDH(+)/CD44(+)/CD24(-) expression in cells from body cavity fluids

BACKGROUND

Enhanced expression of aldehyde dehydrogenase 1 (ALDH1) and phenotypic markers (CD44(+)/CD24(-)) in stem cells from breast tumors has been reported. This study was undertaken to monitor expression of these markers in cells from body cavity fluids of female patients suspected to have a malignancy.

METHODS

Cells from peritoneal and pleural fluids of 100 female patients were examined by diagnostic cytology and analyzed by laser flow cytometry for enhanced ALDH1 expression. Cells from 36 body cavity fluids with ALDH1(bright) fluorescence were then analyzed for the expression of CD44 and CD24 markers.

RESULTS

In samples positive for malignancy, ALDH1(bright) cells with both SSC(low) and SSC(high) were seen. In 15 body cavity fluids positive for malignancy, the percentage of ALDH1(bright) cells ranged from 0.26 to 6.34% of the total cells. The percentage of ALDH1(bright) cells with CD44(+)/CD24(-) expression in these samples ranged from 0.02 to 3.66%. ALDH1(bright) cells with CD44(+)/CD24(-) expression were also present in body cavity fluids of patients in whom diagnostic cytology could not detect any malignancy. However, the percentage of ALDH1(bright) and CD44(+)/CD24(-) cells amongst the 21 body cavity fluids with negative cytology was lower than that of samples with malignancy.

CONCLUSIONS

Expression of ALDH1(bright) and the CD44(+)/CD24(-) phenotype in body cavity fluids in which diagnostic cytology could not find any malignant cells suggests that this phenotype may not be restricted to the putative breast tumor stem cells. It is possible that only subsets of cells with this phenotype are the putative breast tumor stem cells.

Fine needle aspiration of salivary gland lesions with multinucleated giant cells

OBJECTIVE

To report on multinucleated giant cells (MNGCs) in salivary fine needle aspiration (FNA).

STUDY DESIGN

The cytologic reports of salivary gland region FNA during a 10-year period was searched using the keyword giant cell in the final diagnosis or microscopic description. Cases with foreign body-type giant cells secondary to previous biopsy or FNA were excluded. Histologic correlations and immunohistochemical staining for CD68, CK, EMA, S100, HMB45 and CD1a were performed on selected cases.

RESULTS

Twenty-six aspiration smears containing MNGCs were identified from 1040 salivary gland FNAs (2.5%). MNGCs were seen in some reactive or inflammatory conditions, benign neoplasms and malignant neoplasms. By type of MNGC, the salivary lesions were categorized in 3 groups: those with foreign body type, osteoclast type and tumor giant cells.

CONCLUSION

MNGCs can be seen in a wide spectrum of salivary gland lesions ranging from reactive to benign and malignant. They are of nonepithelial origin or can be of true neoplastic nature in metastatic lesions.

EUS-guided fine needle aspiration with and without trucut biopsy of pancreatic masses

CONTEXT

Endoscopic ultrasound-guided trucut biopsy (EUS TCB) has a lower yield than fine needle aspiration (FNA) in pancreatic masses but the additional use of TCB to FNA may improve the diagnostic accuracy over FNA alone.

OBJECTIVE

To compare the yield of EUS FNA alone or combined with EUS TCB for diagnosis of pancreatic masses.

DESIGN

Single center retrospective case control study conducted at academic tertiary center. Study conducted between March 2004 and April 2007.

PARTICIPANTS

A total of 126 consecutive patients referred for EUS guided biopsy of pancreatic mass; three patients excluded from analysis, final cohort comprised 123 patients (108 malignant and 15 benign). EUS FNA was performed in 72 patients and EUS FNA+TCB was performed in 51 patients.

MAIN OUTCOME MEASURES

The diagnostic performance of EUS FNA versus EUS FNA+TCB was compared.

RESULTS

The sensitivity, specificity and frequency of cases correctly identified for malignancy of FNA alone were 87.1% (54/62), 100% (10/10) and 88.8% (64/72), while for the combination of FNA+TCB they were: 95.7% (44/46), 100% (5/5) and 96.0% (49/51), respectively (P=0.184, 1.000, and 0.193 FNA versus FNA+TCB). No major complication occurred in either group.

CONCLUSION

FNA+TCB can be safely performed in selected lesions but sensitivity is not statistically improved over FNA alone (95.7% versus 87.1%).

Cytologic differentiation of struma ovarii from other ovarian neoplasms

OBJECTIVE

To present the cytologic findings of struma ovarii and value of cytology and immunocytochemistry (ICC) using thyroglobulin (TGB) and thyroid transcription factor-1 (TTF-1) in evaluation of this unusual ovarian neoplasm, together with the diagnostic pitfalls.

STUDY DESIGN

Intraoperative cytologic findings of 7 patients with struma ovarii are reviewed. Cytologic material of both cystic and solid components was collected intraoperatively. ICC staining was done, and cell block preparation performed on selected cases.

RESULTS

The cases were divided in to 3 groups: group 1--diagnosis of struma ovarii was made by cytology and confirmed by ICC (1 case); group 2--diagnosis was suggestive on cytology or cell block and confirmed by ICC staining (4 cases); group 3--on cytologic diagnosis indistinguishable from other cystic ovarian neoplasms (2 cases). Cytologic findings were typically colloid with mosaic pattern, follicles, follicular cells only, sheets of follicular cells, both colloid and follicular cells, proteinaceous background or degenerated epithelial cells indistinguishable from other cystic ovarian neoplasms.

CONCLUSION

Cytologic findings of struma ovarii are distinct enough to be suggested intraoperatively, and ICC for TGB or TTF-1 is a valuable tool for preoperative fine needle aspiration biopsy and intraoperative diagnosis of this benign ovarian neoplasm.

Neoadjuvant, surgery and adjuvant chemotherapy without radiation for esophageal cancer

BACKGROUND

A phase II trial to evaluate neoadjuvant (NAD), surgery and adjuvant (AD) combination chemotherapy without radiation therapy (RT) for patients with esophageal adenocarcinoma staged with endoscopic ultrasound and CT as T3N1 was carried out.

METHODS

Thirty-three eligible patients were enrolled. NAD therapy was administered in two 49-day cycles and included cisplatin, floxuridine, paclitaxel and leucovorin. Esophageal resection was performed followed by AD therapy.

RESULTS

Thirty-three patients initiated NAD therapy; 10 experienced grade 3 and 4 toxicities, which included leucopenia, fatigue, nausea, diarrhea and stomatitis. Additionally, 16 patients experienced grade 1 and 2 hematologic and non-hematologic toxicities. Fifteen patients were down-staged, of whom five were T2, seven were T1, and three had nodal disease with no evidence of residual cancer in the esophageal bed. Fifteen patients remained T3, and two showed progressive disease. Thirty-two patients proceeded to surgery and 30 were resected. Although all resected patients were eligible for AD therapy, 15 did not receive it either because of patient refusal or surgeon recommendation. Fifteen patients received AD therapy: nine who had remained T3 and six who had down-staged. Three patients experienced grade 3 and 4 toxicities similar to those in NAD therapy. Six patients had grade 1 and 2 toxicities. Kaplan-Meier estimates of overall survival at 1, 3 and 5 years were 73% (95% CI: 58-88%), 52% (95% CI: 34-69%) and 29% (95% CI: 13-45%), respectively. Median survival was 42 months.

CONCLUSION

Deletion of RT may safely allow for more aggressive chemotherapy and increase chances of survival. The results need to be confirmed in a randomized phase II or larger phase III trial.

P63 in cytologic material is helpful for detection of squamous differentiation in non-small cell carcinomas of lung and treatment selection

18052

Background: Bevacizumab in combination with carboplatin and paclitaxel improves overall response and survival in patients with advanced or recurrent non-small cell lung carcinoma. However, this drug is not recommended in patients with carcinomas with squamous differentiation. Therefore, identification of squamous cell component is desirable. In many instances, cytology is the diagnostic tool of choice; however, routine cytomorphology is limited in classification of non small-cell carcinomas into squamous and non-squamous subtypes. The aim of this study is to identify the value of immunocytochemistry for p63 in this distinction. Methods: Review of cytology records identified 51 consecutive pulmonary specimens with the diagnosis of non-small cell carcinoma (9 squamous cell carcinomas and 42 carcinomas without squamous differentiation). Histologically, they proved to be 26 squamous cell carcinomas and 25 non-small cell carcinomas without squamous differentiation. P63 immunocytochemical stain was performed on archival alcohol-fixed Papanicolaou stained cytology slides, using standard immunocytochemical methods. Results: Twenty-three (88 %) of the 26 histologically proven squamous cell carcinomas were positive for p63 on cytologic smears. Using p63, we detected 14 carcinomas with squamous differentiation not identified by cytomorphology. Smears from all carcinomas with squamous differentiation were positive for p63. Sensitivity of cytology for the detection of squamous differentiation increased from 35% to 88% using p63 immunocytochemistry (p=0.001, McNemar’s test). Four carcinomas with squamous differentiation were detected only in cytologic and not in corresponding histologic samples. Conclusions: 1- p63 is a useful marker for the detection of squamous differentiation in cytologic pulmonary samples; 2- p63 immunocytochemistry significantly increases the sensitivity for the identification of squamous cell carcinomas of lung from 35% to 88% (p=0.001); 3- p63 immunocytochemistry should be used in all pulmonary cytologic samples with a diagnosis of non-small cell carcinoma to improve therapeutic selection of patients; 4- Cytologic sampling may provide better representation of tumor subtypes.

No significant financial relationships to disclose.

Mesothelial cells in transbronchial biopsies: a rare complication with a potential for a diagnostic pitfall

The presence of pleural tissue in transbronchial biopsies (TBs) is an incidental finding that has been rarely reported in the literature. It has the potential for causing wrong histologic diagnoses. Clinically, the significance of unintended pleural sampling by bronchoscopy is unknown. TBs containing mesothelial cells from 6 adult patients were studied using immunohistochemical stains. Clinical information was obtained with emphasis on the immediate postbronchoscopy period. The TBs were performed by 6 different bronchoscopists at 4 institutions because of pulmonary infiltrates in 5 patients and a mass lesion in 1 patient. All samples contained lung parenchyma and bronchial wall. They showed clusters of medium to large size polygonal cells with pink to amphophilic dense cytoplasm, round to oval nuclei, and prominent nucleoli. Some of the cells lined stroma and others were detached forming ribbons. They were initially disregarded, interpreted as carcinoma, judged as mesothelial cells, or interpreted as drug-induced reactive epithelial cells. They were positive for cytokeratin and showed nuclear staining for calretinin. They were negative for TTF-1, S100, CEA, and CD68. However, in 1 case, CD-68 positive histiocytes were admixed with enlarged reactive mesothelial cells corresponding to the so-called nodular histiocytic mesothelial hyperplasia. Chest x-ray films performed the same day after bronchoscopy showed no pneumothorax. Incidental sampling of the pleura may occur during the performance of TB and mesothelial cells may mimic carcinoma, pneumocytes, or macrophages. It is important to be aware of the presence of mesothelial cells in clinically uncomplicated TB to avoid an erroneous diagnosis of malignancy.

Kaposi's sarcoma of the thyroid gland in an HIV-negative woman: a case report

BACKGROUND

Kaposi's sarcoma (KS) is a neoplastic disease that affects primarily the skin, but visceral involvement is not uncommon. Most of the cases are seen in AIDS patients and transplant recipients; however, rare HIV-negative cases have also been reported. Involvement of the thyroid is exceedingly rare, with only a fw cases reported, all of them associated with AIDS.

CASE

A 45-year-old, black, Haitian woman presented with a slowly enlarging left side of the thyroid. Computed tomography showed multiple thyroid nodules, and there was no uptake of iodine on the nuclear scan. Fine needle aspiration of the lesion was performed. The smears were composed of spindle and plasmacytoid cells, which raised the possibility of medullary carcinoma. The patient underwent left hemithyroidectomy. Histologic examination showed KS in the thyroid.

CONCLUSION

We present the first case of KS of the thyroid in a HIV-negative patient. Familiarity with the cytologic features can be useful in making the diagnosis.

Use of p63 for distinction of glandular versus squamous lesions in cervicovaginal specimens

BACKGROUND

Differentiating primary glandular from high-grade squamous intraepithelial lesions (HSIL) that involve endocervical glands is not an uncommon diagnostic problem in liquid-based gynecological cytology. Squamous and atypical glandular cell lesions may show similar cytomorphologic features. The aim of this study was to evaluate the use of p63 as a marker of basal and/or squamous cell derivation in this differential diagnosis.

METHODS

Of 59,257 liquid-based cervicovaginal specimens collected over a 3-year period, 149 were diagnosed as atypical glandular cells of uncertain significance (AGUS) or adenocarcinoma and had histological follow-up. Ten cases (8AGUS and 2 adenocarcinomas) were proven to be high-grade dysplasia on cervical biopsies and the remaining cases represented glandular pathology. Slides from discrepant cases were stained with p63 antibody. In addition, the authors stained 25 control cases (10 adenocarcinomas, 10 HSIL, and 5 negative cervicovaginal specimens).

RESULTS

In all 10 discrepant cases, the abnormal groups originally interpreted as glandular in origin showed a homogeneous strong nuclear staining for p63 that indicated their squamous origin. Nuclei of isolated HSIL cells and basal cells from atrophic smears were also positive for p63. Benign and malignant glandular cells were uniformly negative. Isolated metaplastic, intermediate, and superficial squamous cells were likewise negative for this antibody.

CONCLUSIONS

p63 is a useful immunocytochemical marker for differentiating primary glandular pathology from HSIL in cervicovaginal specimens. It also detects isolated HSIL cells ("litigation cells"). This antibody is not expressed in AGUS, adenocarcinoma, or normal glandular cells. p63 stains basal cells and may be a diagnostic pitfall in atrophic cervicovaginal specimens.

Detection of tumor cells in body cavity fluids by flow cytometric and immunocytochemical analysis

Measurement of electronic volume versus DNA content of nuclei can be used to discriminate between normal and malignant cells. Epithelial membrane antigen immunocytochemistry (EMA-ICC), a helpful ancillary test in body cavity fluids, is not universally accurate for detecting malignancy in effusions. The current study was undertaken to determine if multiparametric flow cytometry (based on simultaneous analysis of light scatter, nuclear volume, DNA, and nuclear protein content) in combination with (EMA-ICC) could be used for the detection of malignant cells in peritoneal and pleural fluids. We studied 130 body cavity fluids (68 peritoneal and 62 pleural fluids) by conventional cytology and multiparametric laser flow cytometry. EMA-ICC was performed using EMA antibodies and L-SAB detection system (DakoCytomation, Carpinteria, CA). EMA-ICC had significantly higher sensitivity than conventional cytology (79% versus 59%, P = 0.016) and ploidy (79% versus 38%, P = 0.001). Cytology had significantly higher specificity than ploidy (97% versus 82%, P = 0.012). The differences in specificity between EMA-ICC and ploidy (87% versus 82%, P= 0.607) or EMA-ICC and cytology (87% versus 97%, P = 0.109) were not statistically significant. However, assuming serial testing, sensitivity increased significantly for the combinations of cytology and EMA-ICC (79.4%, P = 0.016) and cytology and ploidy (73.5%, P = 0.004) as compared to cytology alone (58.8%). Also, the combination of cytology and ploidy had a higher sensitivity than ploidy alone (73% versus 38%, P < 0.0001). However, the sensitivity associated with the three tests used in serial (85.3%) was not significantly different from the sensitivities corresponding to the combination of cytology and EMA-ICC (79%) or cytology and ploidy (73%). Multiparametric flow cytometry utilizing high resolution DNA, nuclear volume, protein measurement, and ICC, in combination with cytomorphology, may be a valuable tool for rapid identification of malignant cells in body cavity fluids.

Neoadjuvant and adjuvant chemotherapy without radiation for esophageal cancer

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Background: A Phase II trial to evaluate neoadjuvant (NAD) and adjuvant (AD) combination chemotherapy (CT) without radiation therapy (RT), for Stage III esophageal adenocarcinoma. Methods: Stage III disease by CAT scan or EUS and ECOG performance status 0–1. The CT cycles included Cisplatin, Taxol, FUDR and Leucovorin. The chemotherapy was given for 16 weeks prior to surgery, followed by adjuvant chemotherapy for patients whose pathology at the time of surgery demonstrated microscopic disease. Survival was estimated via Kaplan Meier. Results: 33 patients were enrolled: 28 completed NAD, 15 received AD. Of 33 pts given NAD, 16 had grade I/II toxicity and 14 had grade III/IV. In addition, 6 of 15 pts receiving AD had grade I/II toxicity and 3 had grade III/IV during that phase of treatment. Thirty-two (32) patients went to surgery, 30 patients were resected: 24 transhiatial and 6 transthoracic. Of the 28 patients who completed NAD, 19 (68%) demonstrated improvement in dysphagia; 11 (41%) gained weight, and 7 (26%) had no weight change. Pathologic response to NAD: 30 patients had partial response and 2 patients had progressive disease, one died prior to surgery, post carotid endarterectomy. Ten (10) patients showed no gross disease. Twenty-three (23) patients have expired, 17 disease related with distant metastasis, 1 with local recurrence and distant metastasis, 3 non-disease related and 2 unresectable cases. Kaplan-Meier estimates of overall survival at 1, 3, and 5 years were 73% (95% CI: 58 to 88%), 52% (95%CI: 34 to 69%), and 29% (95% CI: 13 to 45%), respectively. Median survival was 42 months (95% CI: 14 to 52 months). Ten (10) patients are alive after a median follow up of 73 months (range 45 to 89). Seven (70%) of the surviving patients received both NAD (2 cycles) and AD (1 to 2 cycles) and all had no evidence of disease as of last clinical and radiological evaluation. Conclusions: This regimen of combination CT for locally advanced esophageal adenocarcinoma is safe and comparable with those regimens that contain RT. There has been 1 local recurrence; 17 patients have recurred distantly. Omission of RT may allow for a more aggressive CT and reduction in the local complications post-surgery. This study needs to be confirmed in a larger phase II or in randomized phase III trial.

No significant financial relationships to disclose.

Hand-assisted laparoscopic removal of retroperitoneal liposarcoma

Liposarcoma is known to be the most common soft-tissue sarcoma, and the treatment of retroperitoneal disease is surgical excision. We present a case of complete surgical removal with concomitant nephrectomy using a hand-assisted laparoscopic approach and provide a review of the published studies.

Neonatal gastrointestinal stromal tumor. Report of a case and review of literature

Gastrointestinal stromal tumor (GIST) is very rare in infancy. Most of the reported cases in the literature are in adults; some are in children but there are a few reported cases in the literature. The present case is a 6-day-old female neonate presenting with lethargy, poor feeding, constipation, abdominal distention, and rectal bleeding. She was operated on with the impression of intestinal obstruction, and right hemicolectomy was performed on her. Surgical specimen showed a well-defined and round 3-cm mass in the cecal area. Diagnosis was made by histologic and immunohistochemical studies which showed a GIST. The tumor showed positive vimentin and c-kit but negative for all other markers (desmin, actin, S100, NSE, and CD-34). So the case was an undifferentiated GIST. After 1 year of follow-up the patient was completely normal.

Immunohistochemistry of estrogen and progesterone receptors reconsidered: experience with 5,993 breast cancers

Paraffin sections or fine-needle aspiration smears from 5,993 cases of invasive mammary carcinomas were assessed immunohistochemically for estrogen receptor (ER; 1D5) and progesterone receptor (PR; 636) expression. Staining pattern and intensity were correlated with histologic subtypes and nuclear grades of tumors. Positive nuclear staining for ER and PR was observed in 75% and 55% of invasive carcinomas, respectively. In 92% of ER+ cases, diffuse and uniform staining of most tumor cells was observed. In the remaining 8%, a focal ER reaction was seen, usually because of inadequate fixation. In 21% of PR+ tumors, the reaction was heterogeneous or focal but unrelated to fixation. There were no ER-, PR+ tumors. All pure tubular, colloid, and infiltrating lobular carcinomas were ER+. All medullary, apocrine, and metaplastic and most high-nuclear-grade carcinomas were ER-. With monoclonal antibody 1D5 and antigen retrieval, immunohistochemical reaction for ER in breast cancer usually is an all-or-none phenomenon; therefore, quantitation of results is unnecessary. Despite antigen retrieval, inadequate fixation can cause false-negative results; evaluation of internal positive control samples is imperative. ER positivity and negativity are predictable in certain histologic types and nuclear grades of breast cancer. The reaction for PR can be heterogeneous or focal.

'Atypical' and 'suspicious' diagnoses in breast aspiration cytology

BACKGROUND

In 1996, the National Cancer Institute (NCI) recommended five categories for the diagnosis of breast aspiration cytology: benign, atypical, suspicious, malignant, and unsatisfactory. The authors evaluated the usefulness of separating inconclusive diagnoses into the aforementioned atypical and suspicious categories. The current study examined the correlation between cytologic and histologic findings made in breast aspiration cytology specimens that were categorized in accordance with these NCI guidelines.

METHODS

From 1992 to 2000, 7727 breast aspirations were performed at the University of Miami/Jackson Memorial Medical Center (Miami, FL). Aspirates were classified using criteria similar to the NCI recommendations. Four hundred eighty-nine aspirates (6%) were classified as being cytologically 'atypical' or 'suspicious'. Of those, 225 'atypical' aspirates and 162 'suspicious' aspirates had available histologic follow-up data and were included in the study.

RESULTS

Among the 'atypical' aspirates, 118 (52%) yielded malignant findings on histologic evaluation. Infiltrating ductal carcinoma (n = 87; 74%) was the most common malignant diagnosis, followed by infiltrating lobular carcinoma (n = 12; 10%). Among 'suspicious' aspirates, 135 (83%) yielded malignant findings on histologic analysis. The most common benign diagnosis in both 'atypical' and 'suspicious' aspirates was proliferative fibrocystic changes with or without atypia, followed by fibroadenoma.

CONCLUSIONS

Most aspirates that yielded suspicious findings on cytologic examination proved to be malignant, as did > 50% of aspirates that yielded atypical findings. Infiltrating lobular carcinoma commonly was underdiagnosed as being atypical on cytologic examination. Benign lesions with atypical or suspicious cytologic diagnoses included certain cases of atypical ductal hyperplasia. The authors concluded that the distinction between the atypical and suspicious categories, as recommended by the NCI, is not warranted. Therefore, they suggest the use of a single term, such as 'equivocal', to describe inconclusive diagnoses on breast fine-needle aspiration cytology.

Androgen and vitamin D receptor expression in archival human breast tumors

BACKGROUND

The present study was undertaken for quantitation of androgen (AR) and vitamin D (VDR) receptor expression in human male and female breast tumors by flow cytometry.

METHODS

Nuclei isolated from sections of paraffin-embedded tumors by pepsin digestion were treated for antigen unmasking and incubated with antibodies to AR and VDR. Flow cytometric analysis was used to determine the percentage of receptor-positive nuclei with fluorescence greater than 95% of the isotype nuclei. Mean log fluorescence channel values were used for comparing antigen density of the isotype and the antibody-treated nuclei.

RESULTS

Six of 23 female breast tumors had aneuploid DNA content. Nineteen of 20 estrogen receptor-positive female tumors by immunohistochemical analysis (IHC) were also AR positive by flow analysis. Aneuploid subpopulations had higher percentages of AR-positive nuclei than did diploid populations. Eight of 33 male breast tumors had aneuploid DNA content. Twenty-three of 33 male breast tumors were AR positive by flow analysis compared with six that were AR positive by IHC. Six AR-positive (IHC) male tumors were also AR positive by flow analysis. VDR expression was higher in diploid female tumors than in aneuploid tumors.

CONCLUSIONS

Lack of a strong correlation between IHC and flow analysis may be due to differences in criteria used for identification of receptor-positive and -negative tumors by the two methods.

Papillary squamous cell carcinoma of the uterine cervix: an immunophenotypic appraisal of 12 cases

OBJECTIVE

The objective was to evaluate the role of human papillomavirus (HPV) in the pathogenesis of papillary squamous cell carcinoma (PSCC) of the cervix and to determine cell proliferative activity and p53 abnormalities in these rare variants of cervical cancer.

METHODS

Twelve examples of PSCC of the cervix were diagnosed between 1990 and 1999. Formalin-fixed paraffin sections of each tumor were stained by immunoperoxidase method using antibodies to p53 gene product (CM-10) and Ki-67 (MIB-1). In situ hybridization for HPV DNA (ENZO) was used to detect specific sequences of DNA shared by most types of genital HPV, followed by confirmatory PCR analysis. The nuclear staining for Ki-67 was graded as minimal (<10% of cells), moderate (between 10 and 50% of cells), and high (>50% of cells).

RESULTS

Fifty-percent of the tumors showed presence of HPV DNA. Three tumors (25%) showed nuclear accumulation of p53. Moderate and high proliferative activity was observed in four and eight of tumors, respectively. Eight patients presented with stage IB1 tumor (67%), 3 with stage IA1 tumor (25%), and 1 with stage IIIA tumor (8%). Eleven patients (92%) were alive as of last contact with a mean follow-up of 34.2 months (range: 5 days to 84 months).

CONCLUSION

In this series of patient, PSCC of the uterine cervix had a low rate of HPV DNA in their genome and a low rate of p53 gene abnormality. These genotypic differences may explain the differences between the clinical behavior of PSCC and the common types of squamous cell carcinomas of the cervix.

Thyroid transcription factor 1: a marker for lung adenoarinoma in body cavity fluids

BACKGROUND

Adenocarcinomas are the most common epithelial malignancies in body cavity fluids. Subclassification of adenocarcinomas according to primary site can be a challenging task. Thyroid transcription factor 1 (TTF-1) is a nuclear transcription factor that is expressed in normal lung, in thyroid, and in their neoplasms. Because thyroid carcinomas rarely metastasize to the serosal surfaces, the authors used TTF-1 as a marker to distinguish adenocarcinomas of the lung from carcinomas of other organs.

METHODS

The authors studied 113 body cavity fluids (92 pleural fluid samples and 21 ascitic samples) from 113 patients with a diagnosis of adenocarcinoma on the basis of routine cytology. The primary sites of origin were confirmed clinically or histologically for all patients. There were 39 adenocarcinomas of the lung, 24 adenocarcinomas of the breast, 34 adenocarcinomas of the genitourinary tract, and 16 adenocarcinomas of the gastrointestinal tract. Archival Papanicolaou-stained, cytocentrifuged slides were used without destaining for immunocytochemistry with the monoclonal TTF-1 antibody using a commercial available method.

RESULTS

TTF-1 was expressed in 21 of 39 lung adenocarcinomas (54%). Intense nuclear staining was present in tumor cells that occurred in groups or in isolated form. In contrast, none of the other types of adenocarcinomas expressed TTF-1.

CONCLUSIONS

TTF-1 is a highly specific marker for adenocarcinomas of the lung in body cavity fluids. Immunocytochemistry using this antibody can be performed easily on archival Papanicolaou-stained, cytocentrifuged slides of fluid specimens.

Normal endometrial cells in Papanicolaou smears: prevalence in women with and without endometrial disease

OBJECTIVE

To determine whether the prevalence of normal endometrial cells in Papanicolaou smears of women with and those without endometrial carcinoma or hyperplasia differs significantly.

METHODS

Papanicolaou smears of women with biopsy-proved endometrial hyperplasia or carcinoma diagnosed between 1990 and 1998 were reviewed for the presence of normal endometrial cells. Chi-square and a power analysis were used to compare these smears with results of smears from women older than 35 years of age with tissue diagnoses other than hyperplasia or carcinoma. All Papanicolaou smears obtained within the 5 years before endometrial sampling were reviewed. Each patient had at least one smear done within the previous 12 months. Clinical information was available for all patients.

RESULTS

Of the 201 women in whom endometrial hyperplasia (n = 103) or carcinoma (n = 98) was diagnosed, 4 (2%) had normal endometrial cells in otherwise negative Papanicolaou smears. Of the 289 women in the comparison group, 15 (5%) had normal endometrial cells in their Papanicolaou smears. The prevalence of normal endometrial cells did not differ significantly between the two groups (P =.071). The study had 80% power to detect a 5% or greater difference between groups.

CONCLUSION

The prevalence of normal endometrial cells in Papanicolaou smears of women with endometrial carcinoma or hyperplasia does not significantly differ from that in women without these conditions. Reporting normal endometrial cells in Papanicolaou smears according to the recommendations of the Bethesda System may lead to unnecessary procedures and patient anxiety.

Small cell carcinoma versus other lung malignancies: diagnosis by fine-needle aspiration cytology

BACKGROUND

When a diagnosis of small cell carcinoma is reached in a patient with a lung mass, a surgical treatment approach is no longer considered and chemotherapy becomes the treatment of choice. The aim of this study is to compare the diagnostic accuracy of fine-needle aspiration cytology in the diagnosis of small cell carcinoma with the diagnoses of other lung malignancies. The capacity of this technique to distinguish between these two categories is assessed.

METHODS

Two hundred fifty-nine consecutive transthoracic fine needle aspirations of lung tissue from 235 patients with histologic diagnosis of malignancy were reviewed. The aspirates were performed over a 10-year period at the University of Miami/Jackson Memorial Medical Center, Miami, Florida. Two hundred and forty-two fine-needle aspirations from 221 patients yielded satisfactory smears and were included in the study. Fourteen patients were excluded. The cytologic diagnoses were classified into 5 categories: 1) small cell carcinoma (18 smears, 7%); 2) other lung malignancies (158 smears, 65%); 3) suspicious for malignancy (19 smears, 8%); 4) inflammatory process (7 smears, 3%); and 5) negative for malignancy (40 smears, 17%).

RESULTS

The histologic diagnoses were divided into two groups: small cell carcinomas (29 smears, 12%), and other lung malignancies (213 smears, 88%). The efficiency of fine-needle aspiration cytology in the diagnosis of these two groups was 96% versus 88%, respectively, with an equal specificity of 100%, and a sensitivity of 67% versus 81%. Once the diagnosis of malignancy was established, fine-needle aspiration cytology was found to be highly accurate in distinguishing small cell carcinoma from other neoplasms.

CONCLUSION

We conclude that fine-needle aspiration cytology of the lung is an accurate diagnostic tool for the diagnosis of lung malignancies and is an excellent technique for distinguishing small cell carcinoma from other malignant neoplasms. It can be used with confidence to select treatment modalities and to avoid unnecessary surgeries in patients with lung malignancies.

Fine-needle aspiration cytology of bone: accuracy and pitfalls of cytodiagnosis

BACKGROUND

Fine-needle aspiration cytology has proved to be an accurate, cost-effective, and safe technique for diagnosing inflammatory and neoplastic lesions at different body sites. Its applicability in bone pathology, however, has been controversial due to a high percentage of inadequate samples and nonspecific results in the diagnosis of primary bone lesions. In this study, the diagnostic accuracy of the technique and its capacity for diagnosing primary bone lesions were assessed. In addition, the authors analyzed the diagnostic limitations with focus on specimen adequacy.

METHODS

The authors reviewed 314 consecutive fine-needle aspirations of bone from 308 patients. Direct or cytospin smears from aspirated material were fixed in 95% alcohol and stained by a modified Papanicolaou technique. Ninety-seven smears (31%) initially were considered unsatisfactory and excluded from the study. A diagnosis was rendered in 217 cases (69%), which were classified into 4 categories: primary bone lesions (benign and malignant) (42%), metastatic bone tumors (37%), suspicious for malignancy (5%), and negative (16%).

RESULTS

The overall accuracy was 95%. Seventy-eight percent of primary bone lesions were correctly diagnosed by cytology. All cases diagnosed as metastatic by cytology were correct. The authors encountered difficulties diagnosing fibro-osseous lesions. Thirteen percent of cases were erroneously diagnosed as "negative" or "inflammatory conditions." On review, the absence of adequate cytologic material was noted in all of them. This sampling error could have been avoided by the presence of an on-site cytopathologist.

CONCLUSIONS

Fine-needle aspiration of bone is a simple, reliable, and accurate diagnostic technique that can facilitate patient management and preoperative decision-making and/or avoid unnecessary invasive procedures for patients with primary or metastatic bone lesions. However, the radiologist, cytopathologist, and orthopedic surgeon should work together for optimal results. Moreover, a definitive pathologic diagnosis should not be issued if diagnostic material is not adequate and/or clinicoradiologic information is incompatible.

Reporting normal endometrial cells in Pap smears: an outcome appraisal

OBJECTIVE

The purpose of this study was to determine the clinical relevance of reporting the presence of normal endometrial cells in the Pap smears of women over the age of 35 years and the significance of this practice as it relates to patient management.

METHODS

From January 1992 to December 1995, normal endometrial cells were reported in 206 consecutive Pap smears of women over the age of 35 years. Clinical follow-up was available for all patients, including the results of diagnostic procedures whenever performed.

RESULTS

Of the 206 women with normal endometrial cells in their Pap smears, 162 presented with the chief complaint of abnormal vaginal bleeding. They were all evaluated by direct endometrial sampling, resulting in detection of 10 endometrial hyperplasias and 7 endometrial carcinomas. The remaining 44 women who were clinically asymptomatic were followed up with only routine annual gynecologic examinations for a minimum of 3 years. All had negative clinical courses.

CONCLUSION

Reporting the presence of normal endometrial cells in Pap smears has little, if any, impact on subsequent patient management. Women who present with abnormal uterine bleeding are worked up for endometrial disease regardless of their Pap smear findings. In clinically asymptomatic patients, practitioners may, and in our experience often do, choose to disregard normal endometrial cells in Pap smear reports. The negative follow-up for the asymptomatic women in our study supports this practice. Therefore, reporting the presence of normal endometrial cells in Pap smears is of no clinical relevance and may, in fact, create a management dilemma for clinicians.

Significance of intraperitoneal cytology in patients undergoing radical hysterectomy

The incidence and prognostic significance of positive intraperitoneal cytology taken during a radical hysterectomy was reviewed. A prospective study looking at intraperitoneal cytology was conducted by using 400 consecutive radical hysterectomies from January 1988 through June 1996. All selected patients had peritoneal washings performed prior to a radical hysterectomy with pelvic and para-aortic lymphadenectomy. A single pathologist reviewed all cytological and histologic specimens. A total of 400 patients were included in the study. Only 7 of 400 (1.8%) had positive intraperitoneal cytology. Four had squamous cell cancer and 3 had adenocarcinoma. Five had stage IB cervical cancer and the remainder were stage IIA. Three had positive nodes. Six of 7 had tumor size greater than 3 cm. Three of 7 had > 50% invasion and 2 of 7 had lymphovascular space invasion. No other risk factors were present in these specimens. Six of 7 recurred within 18 months of surgery. Recurrences were local or retroperitoneal; none were upper abdomen or intraperitoneal. The incidence of positive peritoneal cytology during radical hysterectomy is 1.8%. The cost of these cytology specimens did not offer an advantage to the current surgical-pathological factors used to determine prognosis and adjuvant therapy.

Cytologic characteristics of meningeal carcinomatosis: increased diagnostic accuracy using carcinoembryonic antigen and epithelial membrane antigen immunocytochemistry

BACKGROUND AND OBJECTIVES

Traditionally, the diagnosis of meningeal carcinomatosis has been based on clinical suspicion and confirmed by cytologic study of cerebrospinal fluid. However, routine cytologic study may fail to detect malignant cells in a relatively large number of cases. We used immunocytochemistry in an attempt to increase the sensitivity of cytologic detection of malignant neoplasms in cerebrospinal fluid.

MATERIALS AND METHODS

Thirty-eight consecutive cerebrospinal fluid specimens from patients with clinically suspected meningeal carcinomatosis were selected for this study. Immunocytochemistry for carcinoembryonic antigen and epithelial membrane antigen were used on the archival Papanicolaou-stained cerebrospinal fluid preparations.

RESULTS

Of the 23 specimens from patients with proven meningeal carcinomatosis, 13 were correctly diagnosed using cytomorphologic criteria alone. The diagnosis of malignant neoplasm in 8 cytologically suspicious and 1 cytologically negative specimen was confirmed using immunocytochemistry. All cases that were negative on follow-up were also negative cytologically and immunocytochemically.

CONCLUSIONS

We conclude that in using common antibodies, such as carcinoembryonic antigen and epithelial membrane antigen, the sensitivity of the cytologic diagnosis of meningeal carcinomatosis increases, and that previously Papanicolaou-stained preparations are suitable for immunocytochemical studies.