Reactive Cellular Changes in Anal Cytology Smears and Its Relation to Future Dysplastic Changes in HIV+ Subjects

Introduction/Objective

The incidence of anal squamous cell carcinoma is increasing in high risk populations. There is no consensus regarding screening for anal squamous cell carcinoma. Anal pap smears are interpreted using the Bethesda System for cervical cytology. Significant challenges exist for anal cytology that do not apply to cervicovaginal cytology.

Methods/Case Report

We retrospectively reviewed the anal cytology smears performed in our institution between 2012- 2019. The smears with reactive cytology changes (RCCs) were retrieved, and corresponding follow up smears were reviewed.

Results (if a Case Study enter NA)

A total of 39 cytology smears with positive RCCs with no dysplasia diagnosis were obtained. All were HIV+. 32 cases were male and 7 females. The overall mean age was: 37.77 + 11.94 SD (range: 23-65 years). The mean age for men was 36.53 + 11.51 and 43.43 + 13.13 for women. Although this mean age was higher for women, the age difference was statistically insignificant (p=0.7, alpha=0.05). Four of the women patients had concomitant cervicovaginal cytology all of which were negative. Only 1 female had a follow up study which was negative. Of the 39 cases, 26 cases (25 men and 1 woman or a total of 66.7%) had followed up smears versus 13 (33.3%) cases with no follow up. A total of 7 out of the 26 follow ups were negative for dysplasia (26.92%). Of the 26 follow ups, a total of 18 (69.23%) were found to have progressed to either ASCUS (15 or 57.69%) or LSIL (3 or 11.53%). One ASCUS was diagnosed as possible high grade. The mean time to convert to dysplasia was 2.06 + 1.25 years (range 1-5 years). Half of the dysplastic cases developed in a 1 year period.

Conclusion

Patients who have reactive changes on anal cytology should be monitored for possible development of anal neoplasia.

Targeting Membrane HDM-2 by PNC-27 Induces Necrosis in Leukemia Cells But Not in Normal Hematopoietic Cells

BACKGROUND/AIM

Anticancer peptide PNC-27 binds to HDM-2 protein on cancer cell membranes inducing the formation of cytotoxic transmembrane pores. Herein, we investigated HDM-2 membrane expression and the effect of PNC-27 treatment on human non-stem cell acute myelogenous leukemia cell lines: U937, acute monocytic leukemia; OCI-AML3, acute myelomonocytic leukemia and HL60, acute promyelocytic leukemia.

MATERIALS AND METHODS

We measured cell surface membrane expression of HDM-2 using flow cytometry. Cell viability was assessed using MTT assay while direct cytotoxicity was measured by lactate dehydrogenase (LDH) release and induction of apoptotic markers annexin V and caspase-3.

RESULTS

HDM-2 is expressed at high levels in membranes of U937, OCI-AML3 and HL-60 cells. PNC-27 can bind to membrane HDM-2 to induce cell necrosis and LDH release within 4 h.

CONCLUSION

Targeting membrane HDM-2 can be a potential strategy to treat leukemia. PNC-27 targeting membrane HDM-2 demonstrated significant anti-leukemia activity in a variety of leukemic cell lines.

Unique Features of Prostate Cancer in African American and West Indian Patients Including Diagnosis of High Grade Cancers Using Only Elevated Serum Levels of Prostate Specific Antigen

OBJECTIVE

We have studied the occurrence and nature of prostate cancer in 330 African American patients with respect to its frequency of occurrence, the prevalence of high grade cancers (Gleason score ≥7), distribution of prostate specific antigen (PSA) levels, whether serum PSA levels correlate with Gleason scores, and whether tumor grade correlates with tumor extension and/or metastasis.

METHODS

We reviewed the medical charts of patients at the University Hospital of SUNY Downstate Medical Center for whom prostate biopsies or excisions were performed (2015-2019). We then computed the prevalence of prostate cancer and high grade tumors. To determine if there was a quantitative relationship between PSA and Gleason score, we used linear regression analysis. We further used the Fisher exact test to determine if there exists a serum PSA level beyond which the diagnosis of high-grade prostate cancer is definitive.

RESULTS

The prevalence of prostate cancer was high at 75.8%; of these cancers, 70% were found to be high grade. Ninety two percent of PSA values were ≥ 4.0ng/mL; the sensitivity was 94%; the positive predictive value was 80%. There was a poor correlation between PSA and Gleason score (R²=0.1), but almost 30 percent of PSA values were >20 ng/mL, and almost all of these corresponded to high grade tumors (Fisher exact test, p<0.00001, α=0.05). Fifteen cancers extended beyond the capsule or metastasized; all were high grade tumors.

CONCLUSIONS

These patients presented with a high frequency of high-grade prostate cancer and elevated PSA values, such that PSA> 20ng/mL are virtually diagnostic of high-grade prostate cancer. Since the average age, 65, of screening for biopsy in this population is the same as for other demographic groups, screening should be performed at younger ages in this population.

EPB41L5 is Associated With the Metastatic Potential of Low-grade Pancreatic Neuroendocrine Tumors

BACKGROUND/AIM

Low-grade pancreatic neuroendocrine tumors (LG-PNETs) behave unpredictably. The aim of the study was to identify biomarkers that predict PNET metastasis to improve treatment selection.

PATIENTS AND METHODS

Five patients with primary non-metastatic LG-PNETs, six with primary LG-PNETs with synchronous or metachronous metastases (M-PNETs), and six metastatic to liver LG-PNETs (ML-PNETs) from the group of six M-PNET patients were selected. RNA data were normalized using iterative rank-order normalization. Student's t-test identified differentially-expressed genes in LG-PNETs versus M-PNETs. A 2-fold difference in expression was considered to be significant. Results were validated with an independent dataset of LG-PNETs and metastatic LG-PNETs.

RESULTS

Overall, 195 genes had a >2-fold change (in either direction). A total of 29 genes were differentially overexpressed in M-PNETs. Erythrocyte membrane protein band 4.1-like 5 (EPB41L5) had a 2.07-fold change increase in M-PNETs and the smallest p-value. EPB41L5 was not statistically different between M-PNETs and ML-PNETs. EPB41L5 differential expression between primary and metastatic LG-PNETs was confirmed by immunohistochemistry.

CONCLUSION

These results support further investigation into whether EPB41L5 is a biomarker of PNETs with high risk for metastases.

Pathology Report: Presacral Noncommunicating Enteric Duplication Cyst

BACKGROUND

Gastrointestinal (GI) tract duplication cysts or enteric duplication cysts are rare congenital malformations sometimes found on the mesenteric aspect of segments of the alimentary tract. Enteric duplication cysts are lined by normal GI epithelium and may be classified as foregut, mid-gut, and hindgut cysts. Except in very rare cases of retroperitoneal enteric duplication cysts, these cysts communicate with the GI tract and share a common blood supply. Concurrent congenital malformations are not uncommon and malignant transformation within enteric duplication cysts has also been reported.

METHODS

We describe a case of a noncommunicating enteric duplication cyst in a 52-year-old woman.

RESULTS

The patient presented with a presacral cystic mass requiring frequent drainage procedures that was primarily believed to be of neural origin. Upon resection, the lesion contained heterotopic tissue, including ciliated bronchial epithelium, squamous and transitional epithelia, and pancreatic and gastric tissue. Focal, low-grade intestinal adenoma was present, but malignancy was not detected in this case.

CONCLUSION

To our knowledge, this is the sixth reported case of a noncommunicating enteric duplication cyst in the English medical literature.

Cytology as a screening tool for anal squamous intraepithelial lesion for HIV positive men: 10-year experience in an inner city hospital

INTRODUCTION

Human papillomavirus (HPV) and anal carcinoma are prevalent in high-risk patients including human immunodeficiency virus (HIV)-positive patients. There are currently no clear guidelines for screening, however. We assessed anal cytology specimens and HPV testing at an inner-city hospital by correlating anal cytology with anal biopsy (bx), and evaluated if results differed with traditional proctoscopy (TP) or high-resolution anoscopy (HRA).

MATERIALS AND METHODS

209 anal cytology and subsequent biopsies taken during the period 2003-2014 from 152 male patients were reviewed. Demographic data for age, sex, HIV, HPV, cytology, histology, and the method of biopsy were analyzed.

RESULTS

All specimens were followed by a biopsy within a period of 6 months. Ninety-seven percent of patients were HIV-positive and 43% had AIDS. Lesions most diagnosed on cytology were low-grade squamous intraepithelial lesion (LSIL) (52%) and atypical squamous cells of undetermined significance (ASC-US) (21.5%). Lesions most diagnosed on bx were anal intraepithelial neoplasia (AIN) grade 2-3 (52%) and AIN grade 1 (37%). Almost all ASC-US cases tested for HPV were positive (97%). There was cytology histology correlation in 48% of LSIL and 83% of high-grade squamous intraepithelial lesions. Anal cytology had 97% sensitivity in detecting AIN and carcinoma and a positive predictive value of 96%. There was no difference in rate of detection of AIN 1and AIN 2-3 on bx using TP versus HRA.

CONCLUSION

Screening in high-risk patients detected almost all high- and low-grade squamous intraepithelial lesions, however, anal cytology alone could not predict the degree of dysplasia. It may be prudent to perform anal bx in all atypical anal cytology. Clear guidelines are needed for screening of a high risk population.

Atypical Findings on Cervicovaginal Smears Correlate with Cervical Involvement by Malignant Mixed Müllerian Tumors of the Uterus

OBJECTIVE

A malignant mixed müllerian tumor (MMMT) is a high-grade neoplasm commonly arising from the uterus. Patients present with bleeding and a mass protruding from the cervix. This study was designed to correlate Papanicolaou (Pap) smear findings with histological findings in women diagnosed with MMMT.

STUDY DESIGN

Women diagnosed with MMMT were identified. Preoperative Pap tests were correlated with histological findings. Statistical analysis was performed to assess associations between abnormal Pap tests and histological findings.

RESULTS

Forty patients with MMMT were included in the study. Age ranged from 37-85 years and tumor size ranged from 1.2 to 21 cm. In presurgical Pap tests (4 conventional and 36 liquid based), 11 smears (27.5%) were diagnosed as negative, 5 (12.5%) as atypical squamous cells of undetermined significance, 6 (15%) as atypical glandular cells, 16 (40%) as malignant and 2 (5%) as high-grade squamous intraepithelial lesion. Malignant cells detected on Pap smears showed a strong correlation with endocervical involvement by MMMT (p = 0.002). Larger tumors were more likely to involve the cervix (p = 0.0115).

CONCLUSIONS

The Pap test can predict cervical involvement by MMMT. On Pap smears, MMMT cells showed no correlation with other adverse histological features (lymphovascular invasion, myoinvasion or adnexal involvement).

Pilot study of vitamin D supplementation in adults with cystic fibrosis pulmonary exacerbation: A randomized, controlled trial

<u>Background:</u> Vitamin D insufficiency is common in cystic fibrosis (CF) and vitamin D repletion may have an important role in improving clinical outcomes in CF. This randomized, placebo-controlled, pilot study examined the feasibility and impact of a single, large dose of cholecalciferol on vitamin D status and clinical outcomes in subjects with CF.

<u>Methods:</u> Thirty adults with were randomized in a double-blinded, pilot study to receive 250,000 IU cholecalciferol or placebo within 48 h of hospital admission for a pulmonary exacerbation. Concentrations of 25-hydroxyvitamin D (25(OH)D), clinical outcomes and potential adverse events were assessed up to one year after randomization. Mixed effects linear regression models were used to evaluate the difference in mean serum concentrations and log-rank analyses were used to evaluate survival.

<u>Results:</u> Data from all subjects was analyzed. Serum 25(OH)D concentrations increased from a mean of 30.6 ± 3.2 ng/mL to 58.1 ± 3.5 ng/mL (p < 0.001) at one week and 36.7 ± 2.6 ng/mL by 12 weeks (p = 0.06) in the vitamin D group; in contrast, serum 25(OH)D concentrations remained unchanged in the placebo group. Unadjusted, one-year survival and hospital-free days were increased in the vitamin D group (p = 0.029, p = 0.036; respectively). There was also a trend toward increased IV antibiotic therapy-free days in the vitamin D group (p = 0.073). There were no signs of hypervitaminosis D or adverse events. Serum PTH and calcium concentrations were similar across both groups.

<u>Conclusions:</u> In this pilot study, a single, oral bolus of cholecalciferol increased serum 25(OH)D concentrations and was associated with a trend toward improved clinical outcomes in CF subjects hospitalized for a pulmonary exacerbation. Further investigation is needed into the clinical impact of improved vitamin D status in patients with CF.

Risk factors for vitamin D deficiency and relationship with cardiac biomarkers, inflammation and immune restoration in HIV-infected youth

BACKGROUND

Vitamin D deficiency is common in HIV-infected individuals. In adults, traditional and HIV-related factors play a role in vitamin D status, and deficiency appears to impair immune restoration and exacerbate HIV complications, like cardiovascular disease (CVD). This study sought to determine factors contributing to vitamin D status in HIV-infected youth and investigate the relationship with CVD risk, inflammation and immune restoration.

METHODS

HIV-infected subjects (1-25 years old) were enrolled prospectively along with healthy controls that were group-matched by age, sex and race. HIV data were collected for the HIV-infected group, while traditional risk factors, including vitamin D intake, sun exposure, skin pigmentation, physical activity level and body mass index (BMI) were collected for both groups. Fasting lipids, plasma 25-hydroxyvitamin D (25[OH]D), and inflammation markers were measured.

RESULTS

In total, 200 HIV-infected subjects and 50 controls were enrolled. HIV group had 53% male, 95% Black and a mean age of 17.2 ±4.6 years. There was no difference in 25(OH)D between groups; 77% of HIV+ and 74% of controls had 25(OH)D<20 ng/ml. Only Fitzpatrick skin type was independently associated with 25(OH)D. No HIV variables were associated with 25(OH)D, even when HIV sub-populations were examined. Inflammation, CVD risk factors and immune restoration were not independently associated with 25(OH)D.

CONCLUSIONS

Vitamin D deficiency is common among HIV-infected youth. However, HIV factors, CVD risk, inflammation and immune restoration do not appear to have the same relationship with vitamin D as has been shown in adults. Supplementation trials are needed to determine if increasing 25(OH)D concentrations could better elucidate these relationships.

Effects of sunlight and diet on vitamin D status of pulmonary tuberculosis patients in Tbilisi, Georgia

OBJECTIVE

Vitamin D deficiency is common in tuberculosis (TB) and this may modulate immune responses. This study investigated vitamin D status in patients with TB and examined the sources of vitamin D in Tbilisi, Georgia.

METHODS

We measured plasma 25-hydroxyvitamin D (25[OH]D) and dietary vitamin D intake in patients with pulmonary TB (n = 85) in Tbilisi, Georgia. To determine the impact of season on vitamin D status, we tested the in vitro conversion of 7-dehydrocholesterol (7-DHC) to previtamin D(3) after sunlight exposure.

RESULTS

In subjects with TB, mean plasma 25(OH)D concentrations were 14.4 ± 7.0 ng/mL, and vitamin D insufficiency (25[OH]D <30 ng/mL) occurred in 97% of subjects. The dietary sources of vitamin D were mainly fish, eggs, and butter. The daily intake was well below recommended daily intakes in subjects with TB (172 ± 196 IU). The conversion of 7-DHC to previtamin D(3) was undetectable from October to March and highest in June and July from 11:00 to 14:00 h.

CONCLUSION

An insufficient vitamin D dietary intake and a limited production of vitamin D from sunlight for most of the year may explain the high prevalence of vitamin D insufficiency in patients with TB in Tbilisi.

Vitamin D supplementation and endothelial function in vitamin D deficient HIV-infected patients: a randomized placebo-controlled trial

BACKGROUND

Studies suggest that vitamin D deficiency is a risk factor for cardiovascular disease and diabetes. Vitamin D deficiency is prevalent in HIV patients but the effect of vitamin D supplementation on cardiovascular risk in this population is unknown.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial among 45 HIV-infected adults in Cleveland (OH, USA) on stable antiretroviral therapy with durable virological suppression and a baseline serum 25-hydroxyvitamin D level of ≤20 ng/ml. Participants were randomized 2:1 to vitamin D3 4,000 IU daily or placebo for 12 weeks. The primary outcome was a change in flow-mediated brachial artery dilation (FMD).

RESULTS

Baseline demographics were similar except for age (vitamin D versus placebo, mean ±sd 47 ±8 versus 40 ±10 years; P=0.009). Both groups had reduced FMD at baseline (median values 2.9% [IQR 1.6-4.8] for vitamin D versus 2.5% [IQR 1.7-6.4] for placebo; P=0.819). Despite an increase in the concentration of serum 25-hydroxyvitamin D from baseline to 12 weeks (5.0 ng/ml [IQR -0.9-7.4] versus -1.9 ng/ml [IQR -4.0-0.1] for vitamin D versus placebo, respectively; P=0.003), there was no difference in FMD change (0.55% [IQR -1.05-2.13] versus 0.29% [IQR -1.61-1.77]; P=0.748). Vitamin D supplementation was associated with a decrease in total and non-high-density lipoprotein cholesterol, and an increase in indices of insulin resistance.

CONCLUSIONS

Among HIV-infected individuals with vitamin D deficiency, supplementation with 4,000 IU vitamin D3 daily for 12 weeks modestly improved vitamin D status and cholesterol but worsened insulin resistance without change in endothelial function. The mechanisms of resistance to standard doses of vitamin D and the complex role of vitamin D in glucose metabolism in this population require further investigation.