Double blind randomized controlled trial of deep brain stimulation for obsessive-compulsive disorder: Clinical trial design

Obsessive-compulsive disorder (OCD), a leading cause of disability, affects ~1–2% of the population, and can be distressing and disabling. About 1/3 of individuals demonstrate poor responsiveness to conventional treatments. A small proportion of these individuals may be deep brain stimulation (DBS) candidates. Candidacy is assessed through a multidisciplinary process including assessment of illness severity, chronicity, and functional impact. Optimization failure, despite multiple treatments, is critical during screening. Few patients nationwide are eligible for OCD DBS and thus a multi-center approach was necessary to obtain adequate sample size. The study was conducted over a six-year period and was a NIH-funded, eight-center sham-controlled trial of DBS targeting the ventral capsule/ventral striatum (VC/VS) region. There were 269 individuals who initially contacted the sites, in order to achieve 27 participants enrolled. Study enrollment required extensive review for eligibility, which was overseen by an independent advisory board. Disabling OCD had to be persistent for ≥5 years despite exhaustive medication and behavioral treatment. The final cohort was derived from a detailed consent process that included consent monitoring. Mean illness duration was 27.2 years. OCD symptom subtypes and psychiatric comorbidities varied, but all had severe disability with impaired quality of life and functioning. Participants were randomized to receive sham or active DBS for three months. Following this period, all participants received active DBS. Treatment assignment was masked to participants and raters and assessments were blinded. The final sample was consistent in demographic characteristics and clinical features when compared to other contemporary published prospective studies of OCD DBS. We report the clinical trial design, methods, and general demographics of this OCD DBS sample.

Sustained rescue of prefrontal circuit dysfunction by antidepressant-induced spine formation

The neurobiological mechanisms underlying the induction and remission of depressive episodes over time are not well understood. Through repeated longitudinal imaging of medial prefrontal microcircuits in the living brain, we found that prefrontal spinogenesis plays a critical role in sustaining specific antidepressant behavioral effects and maintaining long-term behavioral remission. Depression-related behavior was associated with targeted, branch-specific elimination of postsynaptic dendritic spines on prefrontal projection neurons. Antidepressant-dose ketamine reversed these effects by selectively rescuing eliminated spines and restoring coordinated activity in multicellular ensembles that predict motivated escape behavior. Prefrontal spinogenesis was required for the long-term maintenance of antidepressant effects on motivated escape behavior but not for their initial induction.

Refocusing the Undue Burden Test: Inconsistent Interpretations Pose a Substantial Obstacle to Constitutional Legislation

Decades after Roe, debate over abortion remains as contentious as ever. States continue to pass regulations burdening the abortion right, but lack clear guidance on how to evaluate such regulations using the undue burden test. This Article chronicles Supreme Court jurisprudence on abortion and examines how the current circuit split surrounding FDA-protocol legislation fits within the larger framework. Finally, this Article applies the proper version of the undue burden test to FDA-protocol legislation, which resolves the circuit split and provides lower courts with a clear means of analyzing abortion issues moving forward.

Telecytology: intraobserver and interobserver reproducibility in the diagnosis of cervical-vaginal smears

Telecytologic diagnosis of cervical-vaginal smears is potentially useful because it could allow more efficient use of cytopathologist resources and expertise. A pathologist in one location could, in principle, review cytotechnologists' findings using a video display hundreds or thousands of miles away. Currently, bandwidth restrictions limit practical implementation of such a system to review of fields that had been selected for review by the cytotechnologist. The purpose of our investigation was to evaluate how well this type of review correlates with a review in which the entire slide is available for examination by the pathologist. We prospectively selected 100 consecutive cervical-vaginal smears over an 11-day period in August 1999. For each smear, 4 to 12 fields containing abnormal cells from each slide were digitally imaged. Each of 3 pathologists reviewed all digitized images and all glass slides. Diagnoses based on selected digitized images were compared with those based on conventional pathologist review. The kappa statistic, a measure of chance-corrected agreement (reproducibility), was calculated in each setting. Overall, intraobserver and interobserver reproducibility of cervical-vaginal smear diagnoses is fair to excellent. The use of remote digital images for pathologist review did not introduce large (2-step) diagnostic disagreements. The disagreement between a pathologist's glass slide and digital diagnoses is less than that for different pathologists reviewing glass slides, although interobserver differences were even greater in the interpretation of digital images.

Fine needle aspiration of gastrointestinal stromal tumors

OBJECTIVE

Gastrointestinal stromal tumors (GISTs) are uncommon mesenchymal tumors of the gastrointestinal tract. Fine needle aspiration (FNA) is one option for diagnosing GISTs before surgery. This study was designed to evaluate the clinical utility of FNA in the diagnosis of GISTs.

STUDY DESIGN

FNAs from 19 GISTs originating in the stomach, small bowel and colon obtained from 1988 to 1998 were studied. Immunocytochemistry was performed on 12 cases. The GISTs were classified as benign, borderline and malignant, according to location, size, mitotic activity and clinical outcome.

RESULTS

Benign (three) and borderline (five) GISTs were all spindle cell type; malignant GISTs included five spindle cell type and six epithelioid type. Most smears contained abundant cellular material. Benign and borderline GISTs of spindle cell type tended to have cells arranged in tightly cohesive clusters, while malignant GISTs were more likely to exhibit loosely cohesive groups with many single cells, occasional nuclear pleomorphism, hyperchromasia and irregular nuclear contours. Epithelioid-type GISTs mimicked adenocarcinoma. Mitoses were seldom observed in either type. CD117 (KIT protein product) was demonstrated by immunocytochemistry in 9 cases, CD34 in 11, desmin in 3, S-100 protein in 2 and smooth muscle actin in 6 cases.

CONCLUSION

FNA can be used to diagnose GISTs as spindle cell and epithelioid types, but cytomorphology alone cannot be used to assess malignant potential. Immunocytochemical staining for CD117 is helpful in confirming the diagnosis. Care must be taken to differentiate epithelioid-type GISTs from adenocarcinoma.

Sampling, sampling errors and specimen preparation

To obtain an adequate cervical smear for making a correct cytologic diagnosis, smear taking, laboratory handling and interpretation must be optimal. Many people are involved, and only by a combined effort of all links can this target be seriously approached: the smear takers will have to be open minded about technical improvements and read the morphologic descriptions cautiously; in the laboratory, cytotechnicians and physicians will have to challenge themselves and each other. It is mandatory to discard specimens that do not meet general standards of adequacy. At present a host of new techniques are being implemented. It is not feasible for all laboratories to be engaged in testing these new methods, but we are all requested to follow the development the best we can and switch to new ways when justified. Our working conditions are very different; therefore, it is our professional responsibility and plight to respond at the right time. So far the conclusion is that the conventional Pap smear is the international standard of care for the diagnosis of cervical cancer precursers in cancer screening programs. Certainly, this may change within a very short time. Liquid-based techniques, and in particular HPV technologies, are just around the corner.

Analysis of KIT mutation and protein expression in fine needle aspirates of gastrointestinal stromal/smooth muscle tumors

OBJECTIVE

To determine if sequencing the KIT gene could facilitate more definitive FNA diagnosis.

STUDY DESIGN

Sixteen cases of gastrointestinal stromal/smooth muscle tumor (GIST) in which fine needle aspiration (FNA) was performed (mean age, 67; M/F = 12/4) were studied. DNA was extracted from cytologic preparations from all patients (15 cell blocks, 1 alcohol-fixed smear) and seven subsequent resection specimens. DNA was amplified by polymerase chain reaction, using primers designed to amplify a segment of the KIT gene exon 11 and sequenced on an ABI Prism 377 DNA sequence analyzer (Applied Biosystems, Indianapolis, Indiana, U.S.A.). Immunocytochemical staining for CD 117 (the KIT gene product) was performed on sections from 12 cell blocks and 7 surgical resections.

RESULTS

In-frame deletion of exon 11 was detected in eight cases (7 monoalleic, 1 bialleic); a point mutation was found in one case. Mutation was found only in histologically malignant (6 of 10 cases) and borderline GISTs (3 of 4 cases). No mutation was identified in benign tumors. In three cases, scant cellularity or blood precluded sequencing. CD 117 was expressed in 12 of 15 cases.

CONCLUSION

Immunocytochemical staining for CD 117 is useful in confirming a cytologic diagnosis of GIST but does not facilitate diagnosis of malignancy. FNA biopsy specimens are suitable for KIT gene sequencing; detection of a KIT mutation favors a malignant diagnosis, though absence of mutation does not preclude malignancy.

The accuracy of combined cytopathologic and flow cytometric analysis of fine-needle aspirates of lymph nodes

We studied flow cytometry in 156 fine-needle aspirations (FNAs) of lymph nodes performed between June 1993 and September 1998. Information from flow cytometry was combined with cytomorphologic evaluation, and the diagnosis determined by using combined modalities was compared with tissue biopsy results or clinical follow-up. In 74 cases, a combined cytopathologic-flow cytometric diagnosis of lymphoma was made; histologic material was available for 52 patients; in no case was a benign process found. The lymphoma grade assigned agreed with histopathologic findings in 45 of 48 cases with a specific cytologic diagnosis. Treatment was initiated on the basis of the FNA alone for 17 of 52 patients with a history of lymphoma and in 22 additional patients with no follow-up biopsy. Among 71 cases in which the diagnosis using both modalities was benign, the only false-negative was 1 case of Hodgkin disease. Of the 156 cases, 11 were considered atypical or suggestive of lymphoma; biopsies from 8 of 10 patients revealed lymphoma. A combination of flow cytometry and cytomorphology of cells obtained by FNA of lymph nodes can distinguish between benign and malignant lymphoid infiltrates and support a diagnosis of lymphoma that permits definitive therapy in most cases.

Comparison of TriPath thin-layer technology with conventional methods on nongynecologic specimens

OBJECTIVE

To evaluate the use of the TriPath PREP (previously called AutoCyte) TriPath Inc., Burlington, North Carolina, U.S.A.) in nongynecologic cytologic material by performing side-by-side comparison of conventional preparations with TriPath-prepared slides.

STUDY DESIGN

An initial study of 613 cases (set A) was conducted to compare the TriPath PREP system with conventional methods for the evaluation of nongynecologic specimens, including urine, body cavity effusions, cerebrospinal fluid, pulmonary and gastrointestinal specimens. Paired cases were evaluated for cellularity, staining quality, preservation and representation of diagnostic material. Subsequent changes in the automated technique warranted reevaluation of the TriPath method. The follow-up study of 259 cases (set B) was conducted with the same design as set A. Results of evaluated parameters were analyzed using the chi 2 test.

RESULTS

Results of the two sets were strikingly different. Prior to technical changes made by the laboratory, the TriPath method was significantly inferior. In the second set, the preferred material was most commonly the TriPath-prepared material. In particular, the majority of urine samples were prepared better by the automated, thin-layer system.

CONCLUSION

The TriPath PREP system offers a reliable preparation of urine and has potential for other nongynecologic specimens, provided that careful attention is paid to technical details and some adjustments are made to account for specimen variability.

Clinical significance of the qualification of atypical squamous cells of undetermined significance: An analysis on the basis of histologic diagnoses

OBJECTIVE

This study was undertaken to evaluate the significance of further qualification of atypical squamous cells of undetermined significance in routine Papanicolaou smears.

STUDY DESIGN

A retrospective medical records review was conducted on 316 women whose Papanicolaou smears yielded diagnoses of either atypical squamous cells of undetermined significance suggestive of the presence of an intraepithelial lesion or atypical squamous cells of undetermined significance suggestive of a reactive process.

RESULTS

The overall incidence of a squamous intraepithelial lesion (cervical intraepithelial neoplasia grades I, II, and III) was higher in the group with atypical squamous cells of undetermined significance suggestive of the presence of an intraepithelial lesion than in the group with results suggestive of a reactive process (41.1% vs 22.3%; P =.0344). Women with atypical squamous cells of undetermined significance suggestive of the presence of an intraepithelial lesion were 9.7 times more likely to have high-grade squamous intraepithelial lesion (cervical intraepithelial neoplasia III) develop than were women with atypical squamous cells of undetermined significance suggestive of a reactive process (95% confidence interval, 1.26-74.64). The incidence of high-grade squamous intraepithelial lesion was higher among women </=35 years old than among women >35 years old (17.8% vs 6.3%; P =.0378).

CONCLUSION

Women with a diagnosis of atypical squamous cells of undetermined significance suggestive of the presence of an intraepithelial lesion are more likely to have intraepithelial lesions develop than are those with atypical squamous cells of undetermined significance suggestive of a reactive process. Aggressive evaluation of cases of atypical squamous cells of undetermined significance suggestive of the presence of an intraepithelial lesion with colposcopy and cervical biopsies may be appropriate. Age should be considered as an independent factor in the plan of management.

Telecytologic diagnosis of breast fine needle aspiration biopsies. Intraobserver concordance

OBJECTIVE

To determine the intraobserver concordance between telecytologic and glass slide diagnosis of breast fine needle aspirates.

STUDY DESIGN

Twenty-five cases, originally received in consultation, were each examined by three cytopathologists. An average of seven compressed digital images per case were presented, together with a brief clinical history, using the http protocol and an internet browser.

RESULTS

Agreement between the telecytologic and glass slide diagnosis ranged from 80% to 96%. Nevertheless, two cases that had been unequivocally diagnosed as malignant based upon video images were considered to be benign by the same pathologist when reviewing the glass slides. Both diagnostic confidence and self-concordance were higher for one pathologist having significant previous video microscopy experience.

CONCLUSION

Although intraobserver concordance between telecytologic and glass slide diagnoses of breast fine needle aspirates is high, refinement of existing criteria for diagnosis of malignancy, taking account of the particular limitations associated with telecytologic diagnosis, may be prudent prior to widespread use of telecytology for fine needle aspiration evaluation.

Metastatic testicular Sertoli-cell tumor: cytopathologic findings on fine-needle aspiration

Malignant Sertoli-cell tumors of the testis are exceedingly rare. We present cytopathologic findings in pelvic metastasis of such a tumor in a 45-year-old man, diagnosed on fine-needle aspiration, 2 months after radical orchiectomy. Ultrasound-guided aspirate showed tissue fragments and isolated discohesive tumor cells with characteristics of testicular Sertoli cells. Immunoperoxidase (IPOX) studies and histopathologic correlation with the primary testicular tumor are also presented. Cytopathologic features complimented by IPOX studies should allow an accurate diagnosis of this rare entity, when seen at metastatic sites.

ASCUS and AGUS criteria. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial

ISSUES

The conference participants addressed the following issues: (1) reporting of equivocal diagnoses, (2) strategies to minimize the use of such diagnoses, (3) morphologic criteria, and (4) management of women with equivocal diagnoses.

CONSENSUS POSITION

Equivocal diagnoses should be minimized, to the extent possible, by emphasizing cytologist education and training, improved specimen collection and quality assurance monitoring of individual and laboratory diagnosis rates. Cases fulfilling criteria for other diagnostic entities should not be included in the equivocal category. Regardless of the term utilized, an equivocal diagnosis should be qualified in some manner to indicate that the diagnosis defines a patient at increased risk of a lesion, particularly for those cases which raise concern about a possible high grade lesion. Qualification of an equivocal diagnosis can also be accomplished by appending laboratory statistics of the likelihood of various clinical outcomes or recommendations for patient follow-up. In contrast to favoring a reactive process versus squamous intraepithelial lesion (SIL), a more rationale approach to qualification of atypical squamous cells of undetermined significance may be to separate cases equivocal for low grade SIL from those suspicious for high grade SIL. With regard to glandular lesions, the conference participants expressed unanimous support for the separation of adenocarcinoma in situ (AIS) from atypical endocervical cells of undetermined significance when sufficient criteria are present. However, the diagnosis of a precursor lesion to AIS, endocervical glandular dysplasia, was controversial. The majority of conference participants discourage the use of such terms as mild glandular dysplasia and low grade glandular dysplasia for cytologic diagnoses.

ONGOING ISSUES

Conference participants agreed that a term reflecting diagnostic uncertainty is necessary to communicate findings that are equivocal. However, participants could not agree on the wording of such a term. Opinions differed as to: (1) use of atypical, abnormal or morphologic changes to describe cell changes, (2) whether the diagnosis should indicate a squamous or glandular origin of the cells in question when this determination can be made, and (3) the value of defining morphologic criteria for such a diagnosis. The debate over terminology, as well as morphologic criteria, is ongoing, and the readership is invited to communicate opinions to Acta Cytologica. Management of women with equivocal diagnoses varies widely from locale to locale and may differ based on how the equivocal diagnosis is qualified. Findings insufficient for the diagnosis of a high grade lesion may warrant more aggressive follow-up than cases equivocal for a low grade lesion. Where sensitivity of detection of lesions is of paramount importance, follow-up will generally consist of more frequent cytology screening or colposcopy and biopsy. However, in some countries it is considered unethical to have a high percentage of false positive diagnoses, which result in overtreatment and an unnecessary burden for women participating in cervical screening. Future studies may provide a morphologic, or perhaps molecular, basis for distinguishing true precursors of neoplasia from minor lesions of no significant clinical import; this would allow a more coherent and rational approach to diagnosis and management of women with equivocal cytologic findings.

Computerized screening devices and performance assessment: development of a policy towards automation. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial

ISSUES

The extension of automation to the diagnostic assessment of clinical materials raises issues of professional responsibility, on the part of both the medical professional and designer of the device. The International Academy of Cytology (IAC) and other professional cytology societies should develop a policy towards automation in the diagnostic assessment of clinical cytologic materials.

CONSENSUS POSITION

The following summarizes the discussion of the initial position statement at the International Expert Conference on Diagnostic Cytology Towards the 21st Century, Hawaii, June 1997. 1. The professional in charge of a clinical cytopathology laboratory continues to bear the ultimate medical responsibility for diagnostic decisions made at the facility, whether automated devices are involved or not. 2. The introduction of automated procedures into clinical cytology should under no circumstances lead to a lowering of standards of performance. A prime objective of any guidelines should be to ensure that an automated procedure, in principle, does not expose any patient to new risks, nor should it increase already-existing, inherent risks. 3. Automated devices should provide capabilities for the medical professional to conduct periodic tests of the appropriate performance of the device. 4. Supervisory personnel should continue visual quality control screening of a certain percentage of slides dismissed at primary screening as within normal limits (WNL), even when automated procedures are employed in the laboratory. 5. Specifications for the design of primary screening devices for the detection of cervical cancer issued by the IAC in 1984 were reaffirmed. 6. The setting of numeric performance criteria is the proper charge of regulatory agencies, which also have the power of enforcement. 7. Human expert verification of results represents the "gold standard" at this time. Performance characteristics of computerized cytology devices should be determined by adherence to defined and well-considered protocols. Manufacturers should not claim a new standard of care; this is the responsibility of the medical community and professional groups. 8. Cytology professionals should support the development of procedures that bring about an improvement in diagnostic decision making. Advances in technology should be adopted if they can help solve problems in clinical cytology. The introduction of automated procedures into diagnostic decision making should take place strictly under the supervision and with the active participation and critical evaluation by the professional cytology community.

ONGOING ISSUES

Guidelines should be developed for the communication of technical information about the performance of automated screening devices by the IAC to governmental agencies and national societies. Also, guidelines are necessary for the official communication of IAC concerns to industry, medicolegal entities and the media. Procedures and guidelines for the evaluation of studies pertaining to the performance of automated devices, performance metrics and definitions for evaluation criteria should be established.

Medicolegal affairs. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial

ISSUES

Increasing litigation over alleged false negative cervical cytologic (CC) smears threatens the viability of this test for cervical cancer detection. The problem appears to be largely American but is beginning to appear in some other countries. In the vast majority of cases there is either a settlement or jury verdict for the plaintiff based largely on the testimony of expert witnesses. Cases are judged on an individual basis without significant consideration of the general performance of the CC smear in laboratories operating in compliance with a wide array of laboratory regulations and with documented and comprehensive quality control practices in place. It is acknowledged that there are problem laboratories and cytology practitioners. There is an emerging issue of automated preparation and screening devices and issues of informed patient consent.

CONSENSUS POSITION

Cytology professionals have done an extraordinary and commendable job of educating the public about the benefits of the CC smear. We have been less successful and conscientious about explaining and defining the limitations of the CC test. There is a need for public and professional education as to the benefits and limitations of the CC smear for cervical cancer detection. The process suggested is to work with women's groups, public health agencies, government agencies, and state and national legislatures and to coordinate professional committees working on liability issues. Contextual information could be included with the CC smear report to indicate that a negative report confers a low probability of developing cervical cancer. It is suggested that appropriate language and a menu of statements be developed. Increased efforts should be directed to physician education with respect to informed consent concerning the benefits and limitations of CC smear testing and the application of new technology to improve smear accuracy. The process should include development of appropriate statements on the use of alternative technology. The profession should develop "process guidelines" for review of CC smears in the context of possible litigation, including standardized methods for blind slide review of smears that reduce or eliminate context and outcome bias. It is suggested that review panels be anonymous, that the process be standardized and that there be limitations on liability for participating organizations. Professional cytopathology and pathology societies should formulate acceptable guidelines for expert witnesses. The standards should be applicable to both defendant and plaintiff experts. All materials to the extent practical, including consultant opinions, should be available for peer review. Professional cytopathology and pathology societies should monitor expert testimony for objectivity and scientific accuracy.

ONGOING ISSUES

For the near future, litigation will continue to focus on false negative CC smears on a case-by-case basis. Laboratories and individuals can reduce the risk of malpractice liability by directing their attention to proactive quality control and quality assurance methods. In the final analysis, consumer education about the benefits and limitations of the test is key to limiting malpractice claims. To stem the tide of continued medicolegal challenges to the integrity of cytology practice, the cytology community has now focused its efforts on developing and utilizing standards that convey to patients, attorneys and cytologists the contemporary status of and reasonable expectations for the practice of cytology. Guidelines such as those for uniform reporting terminology and clinical management of cervical abnormalities form the basis of cytology practice standards on which legal standards of practice can be based. Consensus conference reports, clinical management trials and scientifically valid studies of false negative rates that analyze the type, frequency and cause of missed cases represent sounder methods of establishing defensible

Significant reduction in the rate of false-negative cervical smears with neural network-based technology (PAPNET Testing System)

False-negative cervical Pap smears may lead to disability or death from carcinoma of the uterine cervix. New computer technology has led to the development of an interactive, neural network-based vision instrument to increase the accuracy of cervical smear screening. The instrument belongs to a new class of medical devices designed to provide computer-aided diagnosis (CADx). To test the instrument's performance, 487 archival negative smears (index smears) from 228 women with biopsy-documented high-grade precancerous lesions or invasive cervical carcinoma (index women) were retrieved from the files of 10 participating laboratories that were using federally mandated quality assurance procedures. Samples of sequential negative smears (total 9,666) were retrieved as controls. The instrument was used to identify evidence of missed cytological abnormalities, including atypical squamous or glandular cells of undetermined significance (ASCUS, AGUS), low-grade or high-grade squamous intraepithelial lesions (LSIL, HSIL) and carcinoma. Using the instrument, 98 false-negative index smears were identified in 72 of the 228 index women (31.6%, 95% confidence interval [CI]: 25% to 38%). Disregarding the debatable categories of ASCUS or AGUS, there were 44 women whose false-negative smears disclosed squamous intraepithelial lesions (SIL) or carcinoma (19.3%; 95% CI: 14.2% to 24.4%). Unexpectedly, SILs were also identified in 127 of 9,666 control negative smears (1.3%; 95% CI: 1.1% to 1.5%). Compared with historical performance data from several participating laboratories, the instrument increased the detection rate of SILs in control smears by 25% and increased the yield of quality control rescreening 5.1 times (P < 0.0001). These data provide evidence that conventional screening and quality control rescreening of cervical smears fail to identify a substantial number of abnormalities. A significant improvement in performance of screening of cervical smears could be achieved with the use of the instrument described in this report.

Ameloblastoma. Cytologic findings and literature review

OBJECTIVE

To define and elaborate the cytomorphologic features of primary and metastatic ameloblastoma (ABL) on fine needle aspiration (FNA) and to discuss the differential diagnosis with closely related entities and review the cytologic literature on the subject.

STUDY DESIGN

A retrospective study consisting of five cases of ameloblastomas, primary in the mandible (n = 3) and metastases (n = 2), diagnosed by FNA cytology with appropriate cytohistologic correlation, was done. Smears were stained with the Diff-Quik and Papanicolaou methods. Hematoxylin and eosin-stained sections of paraffin block as well as sections from the surgically resected specimens were also reviewed.

RESULTS

The smears were hypercellular and occasionally showed tissue fragments of basaloid cells with peripheral palisading. A distinct, two-cell population was seen, consisting of small, hyperchromatic, basaloid-type cells and scattered larger cells with more open chromatin. Occasional fragments of mesenchymal cells with more elongated nuclei and ample, clear cytoplasm were also noted. Malignant cases that metastasized showed prominent cytologic pleomorphism, cellular crowding with molding and a high mitotic/karyorrhectic index.

CONCLUSION

In the right clinical setting and with proper radiologic evidence, the cytologic features of primary and metastatic ameloblastoma are unique. Diagnostic problems may arise when these lesions are pleomorphic and frankly malignant, especially at metastatic sites, such as the lung. FNA, therefore, is a valuable diagnostic tool in the initial diagnosis and follow-up of patients with a history of ameloblastoma.

Computerized scanning devices for Pap smear screening: current status and critical review

Automation of the Pap smear has taken almost half of a century. Two systems have recently received FDA approval for routine use as quality control (rescreening) devices. Technical triumphs are overshadowed by current conflicts among cytopathology professionals, clinicians, patients, and device manufacturers. The historic perspective of this potentially volatile situation provides the backdrop for possible solutions based on the scientific validity of this evolving technology.

Differential diagnosis of Hürthle cell neoplasms on fine needle aspirates. Can we do any better with morphometry?

OBJECTIVE

To determine the value of computerized interactive morphometry in the preoperative prediction of malignancy in fine needle aspirates of Hürthle cell neoplasms.

STUDY DESIGN

Alcohol-fixed, Papanicolaou-stained fine needle aspiration smears of histologically proven Hürthle cell adenomas (HCA) (n = 10) and Hürthle cell carcinomas (HCC) (n = 9) were studied by interactive computerized morphometry. The measured features included the areas, perimeters and shape factors of individual cells, nuclei and nucleoli; the nucleocytoplasmic and nucleolonuclear ratios; and the eccentricities of nuclei and nucleoli.

RESULTS

Only nucleolar features showed statistically significant differences between HCA and HCC. These features were the nucleolar area and its standard deviation, the nucleolar form factor and circularity, and the nucleolonuclear ratio. The most effective, albeit imperfect, discrimination was achieved by the nucleolar form factor.

CONCLUSION

Nucleolar features, such as size, variation in size and roundness, may be more effective than cellular or nuclear features in differentiating between HCA and HCC in fine needle aspiration smears.

Polymerase chain reaction-based K-ras mutation detection of pancreatic adenocarcinoma in routine cytology smears

The cytologic diagnosis of pancreatic carcinoma is notoriously difficult, particularly in distinguishing benign atypia from well-differentiated adenocarcinoma. Mutation of codon 12 in the K-ras oncogene is frequently found with pancreatic cancers. Detection by polymerase chain reaction (PCR) followed by restriction endonuclease digestion can provide a powerful tool to improve and confirm diagnosis. The authors examined the utility of PCR-based detection in the diagnosis of pancreatic carcinoma using routinely obtained cytology smears that could be collected at most hospitals. Pancreatic cytology smears were collected retrospectively from 60 patients. DNA was extracted from the slides and amplified by PCR using mismatched primers that generated a Bst-N1 recognition site with the wild type codon 12 but not with the mutant allele. Results were compared with clinical follow-up. K-ras codon 12 mutations were observed in 44 of 46 (95.7%) cases of pancreatic cancer, but not in 12 benign cases nor in 2 cases of islet cell tumor. The amplification and digestion steps proved robust and sensitive, capable of detecting mutant K-ras alleles from cytology smears that contained only small foci of suspicious cells. Our results indicate that K-ras mutation analysis can be done reliably within 1 to 2 days from routine cytology slides without special handling, increasing the sensitivity of diagnosis in ambiguous cases while maintaining cost-effective and relatively noninvasive sampling strategy.

Computer-assisted rescreening of clinically important false negative cervical smears using the PAPNET Testing System

OBJECTIVE

To investigate the efficacy of the PAPNET Testing System and its ability to detect significant areas on clinically important false negative gynecologic smears.

STUDY DESIGN

Sixty-two gynecologic smears that had been obtained from women studied in a previous case-control investigation, completed in 1987, and had originally been interpreted as negative were rescreened by two independent, blind cytotechnologist-cytopathologist teams. Twenty-nine of these "negative" smears were from 19 women who had been subsequently diagnosed with invasive squamous cell carcinoma and had self-reported a history of only negative gynecologic smears. Thirty-three smears were from 33 control women who did not develop cervical cancer. One team, at the University of Southern California (USC), manually rescreened the smears as part of the original study. The other team, at the University of California at Los Angeles (UCLA), recently used the PAPNET Testing System to rescreen the same smears. This computer-assisted system utilizes neural network technology to recognize and select potentially abnormal cell scenes on a conventionally prepared gynecologic smear. The PAPNET-selected scenes are displayed for review by trained cytologists, who ultimately diagnose the smear.

RESULTS

Manual reevaluation of the smears by the USC team in 1987 resulted in the reclassification of 9 of the 29 case smears (31%) and 2 of 33 control smears (6%) as class II to V (atypical squamous cells of undetermined significance to invasive carcinoma). Using the PAPNET System to scan and review the same smears, the cytotechnologist at UCLA referred 24 case smears to the cytopathologist, who ultimately reclassified 12 of the 29 case smears (41%) and 5 of the 33 control smears (15%) as abnormal.

CONCLUSION

This study supports the use of the PAPNET System as an effective, routine rescreener for the detection of clinically significant false negative gynecologic smears.

Bronchoalveolar lavage in a girl with Gaucher's disease. A case report

A case of Gaucher's disease with pulmonary involvement occurred. Numerous Gaucher cells were seen in bronchoalveolar lavage (BAL) fluid on two occasions in a girl with Gaucher's disease and respiratory symptoms. The Gaucher cells resembled macrophages with eccentric, small, oval nuclei but were distinguished by their abundant cytoplasm with the characteristic "rumpled tissue paper" appearance. The Gaucher cells were in a cellular background composed mainly of macrophages. These cells stained strongly positive with periodic acid-Schiff stain. Electron microscopy revealed numerous intracytoplasmic, elongated, membrane-bound lysosomes containing the characteristic twisted tubular structures. Severe pulmonary involvement is seen infrequently in all types of Gaucher's disease, and it is especially rare in the adult and juvenile forms (types I and III). To our knowledge, Gaucher cells have never been found before in BAL fluid. This case shows that BAL can be a useful adjunct in diagnosing and following the progression of pulmonary involvement in patients with Gaucher's disease.

Erythrocyte folate levels, oral contraceptive use and abnormal cervical cytology

The initial hypothesis of this study was that folate depletion is a risk factor for human papillomavirus infection and cervical epithelial cell abnormalities, including dysplasia. The prevalences of low erythrocyte folate levels (defined as < 140 ng/mL erythrocytes and determined by the growth of Lactobacillus) were measured in 250 University of California at Los Angeles students. Among oral contraceptive users, low erythrocyte folate was a risk factor for an abnormal cytologic smear in both benign atypia and squamous intraepithelial lesions. Odds ratios were statistically significant for biopsied women who did not have condyloma and for those who did not have squamous intraepithelial lesions but not for those with histologically confirmed intraepithelial lesions. Low erythrocyte folate was a risk factor for a positive Virapap result in oral contraceptive users. If the folate effects are causal, the findings suggest that erythrocyte folate levels should be higher in oral contraceptive users than in nonusers to protect against an abnormal cytologic smear.

HPV DNA and the risk of squamous intraepithelial lesions of the uterine cervix in young women

A population-based case-control study of college students was undertaken to estimate the effect of a positive clinical test for human papillomavirus (HPV) DNA (the Virapap test) on the rate of squamous intraepithelial lesions (SIL) of the uterine cervix. When age, multiple lifetime sexual partners, and oral contraceptive use were controlled by logistic regression, the adjusted odds ratio (OR) for a positive Virapap test was 7.3 (3.3, 17) for a cytologic diagnosis of SILs and 3.4 (1.4, 8.5) for a cytologic diagnosis of squamous intraepithelial lesions of undetermined significance (equivocal atypia). When case status was defined as patients whose Pap smears were confirmed histologically as high-grade SIL, the adjusted OR was 10.3 (3.3, 32), reflecting the high proportion of individuals with SILs who were harboring high-grade squamous intraepithelial lesions. These results confirm the many previous findings of a strong association between HPV DNA, and demonstrate that strength of the association persists when important confounding variables are controlled. This suggests a causal role for HPV in cervical neogenesis. Believing that HPV infection is a major causal agent for cervical cancer precursors suggests that in this time of rapidly increasing HPV prevalence, especially among young persons, the incidence of cervical neoplasia will rise. This underscores the importance of increasing the availability, usage, and perhaps the frequency of Pap smear screening.

A 35-year experience with the post-sophomore fellowship in pathology: analysis of its effectiveness as a recruitment resource

Recent reports have indicated a shortage of pathologists coming out of training programs over the next few years. This is due, in part, to a decrease in the number of medical students entering pathology and an overall decline in the popularity of the field as a specialty choice. Medical students electing to spend a year in a post-sophomore fellowship in pathology would be expected to enter the field at a higher than average rate. In this study, the specialty choices of 140 former student fellows were analyzed. The students included in the study were enrolled in a year-long University of California, Los Angeles post-sophomore fellowship in pathology between 1953 and 1988. Twenty-seven of the 140 students (19.3%) ultimately chose pathology as a career. This represents a 9- to 10-fold increase over the average percentage of medical students entering pathology through the match (less than 2%) for any given year. Of all students from the University of California, Los Angeles who entered pathology, 75% did not elect to spend a year in fellowship. Eighty percent of the former fellows chose some other field, medicine and surgery being the most popular choices.

Role of percutaneous fine-needle aspiration biopsy in suspected intrathoracic malignancy

Percutaneous fine-needle aspiration (PFNA) biopsy is an accepted technique for the diagnosis of suspected intrathoracic malignancy, but the appropriate indications for its use have not been clearly defined. To help establish guidelines, we performed a retrospective analysis of 188 patients who underwent PFNA biopsy for suspected intrathoracic malignancy. Biopsy led to a diagnosis in 72% (135/188) of the patients, but in 27% (50/188) samples were inadequate for cytological diagnosis, and in 2% (3/188) samples were adequate but failed to yield a diagnosis. Fifty-three patients underwent surgical intervention, thus allowing histological confirmation of the cytological diagnosis. In patients with a diagnosis from PFNA biopsy, operation confirmed malignancy in 97% (37/38) and a specific cell type in 79% (30/38). In patients without a diagnosis after biopsy, a malignancy was found in 73% (11/15) at the time of operation. This suggests a high rate of accuracy when PFNA biopsy provides a diagnosis. However, it also illustrates that a substantial percentage of PFNA biopsy attempts fail to yield a diagnosis in patients ultimately found to have malignancies. This implies that PFNA biopsy might best be reserved for patients who are not surgical candidates.

Sources of diagnostic error in fine needle aspiration of the thyroid

Smears obtained from 795 patients with suspicious thyroid nodules by fine needle aspiration (FNA) of the thyroid gland were seen over a 5-year period at the UCLA Center for the Health Sciences. From 72 patients who underwent subsequent surgical excision of their nodules, inadequate or discrepant FNA diagnoses were noticed in 20 cases (27.8%). These errors could be attributed to inadequate material for diagnosis (n = 6), sampling errors (n = 2), and cytodiagnostic errors (n = 12). If the diagnosis of follicular neoplasm was treated as indeterminate for malignancy, the overall efficiency of FNA was 88.9%. All false-negative diagnoses were related to procedure (i.e., inadequate smears or missed sampling of the lesion). The frequency of inadequate smears, in turn, was strongly related to the type of physician performing the aspiration. The frequency was highest among community-based clinicians (32.4%) and lowest among hospital-based cytopathologists (6.4%). With adequate sampling, the finding of 100% sensitivity in the diagnosis of malignant neoplasms by FNA cytology reaffirms its role as the procedure of choice in the initial screening of thyroid nodules.

Multifactor analysis of intermediate cells from the uterine cervix. The importance of slide effects on variance components

The ability to retrospectively examine cytologic material with digital image analysis is often desirable, particularly when long-term follow-up information is available for correlation with cell parameters. In an effort to characterize the magnitude of slide-age and staining-batch effects on cell parameters from digital image analysis, the cell features in 32 Papanicolaoustained cervical smears that varied in age from 10 to 16 years were analyzed. The slides were selected from eight patients sampled on four different occasions approximately one year apart. The findings indicate that the variance of cell features from an intermediate cell population within a slide is somewhat greater than is the variance among slides from the same woman or the variance among women. Aging effects were not detectable. The significant differences observed among replications of slides from the same woman as well as between women with no evidence of cervical disease should caution other researchers to account for this potential source of random error in their statistical models.

Canonical analysis of cells in normal and abnormal cervical smears

Over 4,000 cells from 105 normal and 96 abnormal uterine cervical scrapes were prepared according to the UCLA monolayer procedure, stained by a routine Papanicolaou method and visually classified by two cytopathologists and a technologist into seven classes: parabasal, metaplastic, mild dysplasia, moderate dysplasia, severe dysplasia, carcinoma in situ and invasive carcinoma. Canonical analysis was used to correlate effects-coded class membership variables with 23 cell features derived from digital image analysis. In general, nuclear texture measures derived from linear combinations of run-length correlations along with features derived from a Markov transitional probability matrix provided the best predictors of cell class. After cells were divided into benign (moderate dysplasia or less) and malignant (severe dysplasia or worse) groups, discriminant analysis correctly classified 84% of the benign cells and 91% of the malignant cells.

Microcomputer-based image processing workstations for cytology

Image processing workstations coupled to automated microscopes will play an increasingly important role in computer-aided cytological and histopathological diagnosis. Off-the-shelf hardware and software tools are becoming more powerful and are available at a fraction of the cost of their predecessors. This paper describes the results of our efforts at configuring a microcomputer-based workstation suitable for automated microscopy and computer-aided diagnosis. Important concepts and trends in microcomputer workstations are additionally discussed.

Prognosis of moderate dysplasia. Predictive value of selected markers in routinely prepared cervical smears

Digital image analysis was used to extract features from 1,123 abnormal cells in 23 routinely prepared, Papanicolaou-stained cervical smears. All slides examined had a cytologic diagnosis of moderate dysplasia. Seven slides came from patients who eventually progressed to either a severe dysplasia or carcinoma in situ; the other 16 slides came from patients whose dysplasias regressed without evidence of more serious disease. Linear discriminant analysis correctly classified approximately 73% of the cells from the regression group and 66% of the cells from the progression group. Cell features contributing to the majority of variance in the model were the mean optical density of the nucleus, an autocorrelation measure, the mean optical density of the cytoplasm and the nuclear-cytoplasmic ratio. At the patient level, 13 (81.2%) of the 16 slides from the regression group and 6 (85.7%) of the 7 slides from the progression group were correctly classified. These figures yield a sensitivity of 66.7%, a specificity of 92.9%, a predictive value of a progression prognosis of 85.9% and a predictive value of a regression prognosis of 81.2%. The overall efficiency of the model was 82.6%. These preliminary results should encourage further studies for the identification of markers to indicate which patients are at high risk for progression of their cervical dysplasias.

Prediction of cervical neoplasia diagnosis groups. Discriminant analysis on digitized cell images

The purpose of this study was to develop discriminant analysis models for predicting cervical dysplasia/neoplasia case diagnoses using cytometric features derived from the digital image analysis of cell monolayers. The data base consisted of 925 cells from 27 cases diagnosed either as moderate dysplasia (n = 10), severe dysplasia (n = 5), carcinoma in situ (n = 8) or invasive carcinoma (n = 4) on both tissue biopsy and monolayer preparations. Cell features examined were cell diameter, nuclear diameter, nuclear mean optical density (OD), nuclear integrated OD (IOD), nuclear OD standard deviation, normalized IOD, nuclear texture and nuclear-cytoplasmic ratio. Features derived from cells visually classified as moderate dysplasia correctly predicted the case diagnosis of moderate dysplasia versus more severe disease for 85% of the cells. Prediction models using summary measures (mean and variance) derived from all visually classified abnormal cells within each case correctly separated all cases into their respective diagnostic categories. These findings suggest that dysplastic cells in a cytologic sample have features that collectively reflect the tissue diagnosis, regardless of the visual differences among the cells. Such information has potential use for diagnosis and possibly for prognosis.

Detection of chlamydial cervicitis with Papanicolaou-stained smears and cultures in a university student population

Over a 34-month period, 12,647 Papanicolaou smears were obtained from a student health service outpatient gynecologic population at moderate risk of chlamydial infection. We found 287 (2.3%) to have cytologic features suggestive of chlamydial cervicitis. Chlamydia trachomatis was definitely isolated by endocervical culture in only 4.5% of these 287 subjects. Cytologic features suggestive of chlamydial cervicitis were found to be unreliable in diagnosing chlamydial infection.

Cytology in the diagnosis of benign lung diseases

While cytologic techniques have traditionally been concerned with cancer diagnosis, reactive and infectious pulmonary diseases can often be easily and accurately diagnosed, obviating the need for thoracotomy. High diagnostic yields necessitate a team approach. With close cooperation among the bronchoscopist, radiologist, and pathologist, patient care can be greatly enhanced.

Techniques in the preparation of a monolayer of gynecologic cells for automated cytology. An overview

The computer-assisted microscope demands rigid specifications for specimen preparation. This paper addresses the variety of techniques developed by researchers attempting to automatically screen uterine cervical specimens. These same techniques could also be utilized for specimens from other body sites. In contrast to the easily prepared routine Papanicolaou smear, these techniques can be broken down into various steps as follows: transport media, cellular disaggregation, cell number estimation, cell separation and specimen enrichment, cellular adhesion to glass slide and cell transfer onto the slide. Variations on the theme are contrasted among specimen preparation methods utilized by prominent research groups. The plea for a simpler preparation method or, hopefully, utilization of the routine Papanicolaou smear for computer-assisted microscopy is made.

Preparation and cytologic evaluation of intraocular fluids

The cytologic analysis of intraocular fluids obtained during vitreous surgery and anterior chamber aspiration can confirm the diagnosis of many intraocular conditions, including phacolytic glaucoma, fungal infection, proliferative diabetic retinopathy, intraocular neoplasm, ghost-cell glaucoma and certain inflammatory conditions. This paper describes our technique for processing intraocular fluids for cytologic examination and presents our findings in over 300 intraocular fluid specimens.

Breast lesions diagnosed by fine needle aspiration

Fine needle aspiration (FNA) of the breast offers patient and clinican a rapid, non-morbid, inexpensive, and highly accurate means of diagnosing both benign and malignant breast lesions. Breast FNA can replace frozen section diagnosis, and in fact has the advantage of providing a known diagnosis before the time that operations are performed. This situation enables the patient and surgeon to discuss and plan therapeutic alternatives in a rational atmosphere. As with any other technique, experience of the aspirator and diagnostician minimizes false positive and false negative rates.

Monoclonal antibodies against transitional cell carcinoma for detection of malignant urothelial cells in bladder washing

The diagnosis of transitional cell carcinoma by cytological examination of exfoliated urinary cells is important in the early detection and followup of patients with this disease. Proper interpretation requires a skilled pathologist. Accuracy also is influenced by collection methods and nonmalignant pathological conditions of the bladder. An immunocytochemical technique using monoclonal antibodies G4 and E7 successfully identified tumor-associated antigens on the surface of transitional carcinoma cells obtained by bladder washings. The method, which uses immunoperoxidase staining, was compared to conventional Papanicolaou staining of bladder washings from 75 patients with and without transitional cell carcinoma. Patients were divided into 4 groups: group 1 (nontumor control)--15 patients with no pathological condition of the bladder or nonmalignant urological diseases, group 2 (nontransitional cell carcinoma)--19 patients with other urological malignancies, group 3-18 patients with active transitional cell carcinoma and group 4-23 patients with a history of transitional cell carcinoma but no evidence of tumor at the time of the washing. The incidence of positive staining in these groups was 0, 5, 78 and 0 per cent, respectively. The diagnostic value of immunoperoxidase staining was similar to that of Papanicolaou staining in the control group and in patients with high grade transitional cell carcinoma, and provided specific morphological criteria not possible by conventional cytology studies. Interpretation of immunoperoxidase staining was difficult in washings with a large number of inflammatory cells if endogenous peroxidase activity was not blocked properly. The application of the immunoperoxidase staining method for diagnosis of low grade tumor is under further investigation.

Cytomorphometric differences among individual "moderate dysplasia" cells derived from cervical intraepithelial neoplasia

Individual abnormal cervical epithelial cells can be categorized either by the lesion from which they are derived or by their unique cytologic characteristics. In building a data base for image analysis of cervical epithelial cells, categories of cells were defined according to distinct cytomorphologic characteristics, without knowledge of the lesion of origin. The three individual scorers, two cytopathologists and one senior cytotechnologist, most frequently agreed upon the cells classified as "moderate dysplasia." The measurements of digitized cells in this category had the smallest confidence intervals of any of the abnormal cell categories. For these two reasons, as well as the ubiquitous nature of "moderate dysplasia" cells in smears obtained from all patients with cervical epithelial neoplasia, cells in this category were studied in greater detail. Significant differences were noted in cell measurements among cells in this class when the cells came from patients with different grades of cervical neoplasia. The findings indicate that visually similar "moderate dysplasia" cells can be separated by digitized measurements into clusters dependent upon the parent lesion. The biologic implications are not yet clear, but such findings suggest that each disease is perhaps a committed lesion from inception. Therefore, predictability of ultimate outcome could be based on image analysis of cells derived from early cervical lesions, which would allow therapy to be performed on a more logical basis.

Fine needle aspiration of pulmonary lesions via fiberoptic bronchoscopy

Mediastinal and hilar masses not associated with an endoscopically visible lesion and processes involving only the bronchial submucosa are often difficult to diagnose despite the ability to obtain cytologic and histologic samples via the flexible fiberoptic bronchoscope; necrotic endobronchial lesions are often suspected to be tumorous but may not be biopsied for fear of creating further and uncontrollable bleeding. Diagnostic material from such lesions can be obtained by aspiration with a thin needle localized via the bronchoscope at the site of the lesion and then inserted through the bronchial wall into the mediastinum, hilum or bronchial submucosal area. Not only can the question of neoplasia be answered by this technique, but staging in an inexpensive and non-morbid way can be accomplished. Indications for transbronchial fine needle aspiration, the excellence of cytologic samples thus obtained and the problems encountered using existing disposable equipment are discussed. Four cases are reported briefly as examples of the use of the technique.

The effect of filtration on the loss of abnormal cervical cells in specimen preparation for automated cytology

The UCLA monolayer procedure is used to produce a preparation of cervical epithelial cells for automated cytology. We investigated the nylon mesh filtration step of the procedure to determine if it altered the proportion of abnormal epithelial cells in the specimen. The proportion of such cells was found to be significantly lower (P less than 0.05) in the final specimen retained by a 10 micron nylon mesh filter than in the filtrate, which has been routinely discarded in our studies. The filtrate specimen is contaminated by large numbers of polymorphonuclear leukocytes, however, making it unusable for automated cytology at present. The implications of our findings for the cost effectiveness of classifier performance are considered, and the implications of the results for further improvements in specimen preparation are discussed.

Cytologic diagnosis of olfactory neuroblastoma. Report of a case with multiple diagnostic parameters

We present the first case report of an olfactory neuroblastoma (esthesioneuroblastoma) diagnosed by cytologic examination. The patient was a 40-year-old male who had a 13-year history of "adenocarcinoma" of the nasal cavity until the correct diagnosis of olfactory neuroblastoma was made cytologically from pleural fluid shortly before his death. The cells had the typical features of rosette formation, scanty elongated cytoplasm, clustering of cells and nuclear compression resulting in an "onion-skin" appearance. Surgical specimens, several biopsies and fine needle aspiration of a metastatic deposit in a lymph node all showed, retrospectively, features of esthesioneuroblastoma. Electron microscopy showed membrane-bound dense-core secretory granules. Autopsy findings revealed multiple metastases but no tumor at the original site; that tumor had been treated with high-dose radiation therapy as well as systemic chemotherapy. Olfactory neuroblastoma is a rare tumor, but it is important to recognize because it has a better prognosis than the more commonly encountered malignancies of the nose.