Developing indicators for quality assurance in cytopathology. Catalan Society of Cytopathology

BACKGROUND

Quality control in cytology must be established through reliable and easily measurable indicators.

METHODS

From the Catalan Society of Cytopathology a group of experts has been established to write a document with 13 indicators that cover the entire cytological process, based on its Cytopathology Quality Guide. It has been elaborated through guides and documents with scientific evidence and DELPHI methodology in order to reach a structured consensus on the opinions of a group of experts.

RESULTS

Thirteen indicators, covering all the cytologic process are expressed in worksheets specifying all their characteristics.

CONCLUSION

This document allows the control of all stages of the cytological process.

Long-term protection of HPV test in women at risk of cervical cancer

Objective

To evaluate the 9-year incidence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and cumulative adherence to perform a next test in a cohort of women aged 40+ years with no cervical screening cytology within a window of 5 years (underscreened women), after baseline cervical cytology and HPV tests.

Methods

In Catalonia, Spain, co-testing with cytology and HPV test has been recommended in the Public Health system since 2006 for underscreened women. In 2007, 1,594 women with underscreened criteria were identified and followed through medical records form Pathological Department. 9-year cumulative incidence of histologically confirmed CIN2+ and cumulative adherence to perform a next test were estimated using Kaplan-Meier statistics.

Results

Follow-up was available for 1,009 women (63.3%) resulting in 23 women with. CIN2+ (2.3%). Of them, 4 women (17%) had both tests negative at baseline (3CIN2 and 1CIN3) with cumulative incidence of CIN2+ of 0.4% (95% CI: 0.1–1.4) at 5-years and 1.3% (95% CI: 0.4–3.7) at 9-years. During the first year, the prevalence among women with both tests positive was 27.0% (95% CI: 13.0–50.6) for CIN2+. Lost to follow-up was higher among women with both tests negative compared to those with both positive tests (38.7% vs 4.2%, p-value <0.001). 40.5% of the women HPV-/cyto- had a re-screening test during the 4 years following the baseline, increasing until 53.5% during the 6 years of follow-up.

Conclusions

HPV detection shows a high longitudinal predictive value at 9-year to identify women at risk to develop CIN2+. The data validate a safe extension of the 3-year screening intervals (current screening interval) to 5-year intervals in underscreened women that had negative HPV result at baseline. It is necessary to establish mechanisms to ensure screening participation and adequate follow-up for these women.

Stem cell-like transcriptional reprogramming mediates metastatic resistance to mTOR inhibition

Inhibitors of the mechanistic target of rapamycin (mTOR) are currently used to treat advanced metastatic breast cancer. However, whether an aggressive phenotype is sustained through adaptation or resistance to mTOR inhibition remains unknown. Here, complementary studies in human tumors, cancer models and cell lines reveal transcriptional reprogramming that supports metastasis in response to mTOR inhibition. This cancer feature is driven by EVI1 and SOX9. EVI1 functionally cooperates with and positively regulates SOX9, and promotes the transcriptional upregulation of key mTOR pathway components (REHB and RAPTOR) and of lung metastasis mediators (FSCN1 and SPARC). The expression of EVI1 and SOX9 is associated with stem cell-like and metastasis signatures, and their depletion impairs the metastatic potential of breast cancer cells. These results establish the mechanistic link between resistance to mTOR inhibition and cancer metastatic potential, thus enhancing our understanding of mTOR targeting failure.

Aberrant gene methylation and bronchial dysplasia in high risk lung cancer patients

INTRODUCTION

The risk for lung cancer is incremented in high degree dysplasia (HGD) and in subjects with hypermethylation of multiple genes. We sought to establish the association between them, as well as to analyze the DNA aberrant methylation in sputum and in bronchial washings (BW).

METHODS

Cross sectional study of high risk patients for lung cancer in whom induced sputum and autofluorescence bronchoscopy were performed. The molecular analysis was determined on DAPK1, RASSF1A and p16 genes using Methylation-specific PCR.

RESULTS

A total of 128 patients were enrolled in the study. Dysplasia lesions were found in 79 patients (61.7%) and high grade dysplasia in 20 (15.6%). Ninety eight patients out of 128 underwent molecular analysis. Methylation was observed in bronchial secretions (sputum or BW) in 60 patients (61.2%), 51 of them (52%) for DAPK1, in 20 (20.4%) for p16 and in three (3.1%) for RASSF1A. Methylated genes only found in sputum accounted for 38.3% and only in BW in 41.7%, and in both 20.0%. In the 11.2% of the patients studied, HGD and a hypermethylated gene were present, while for the 55.1% of the sample only one of both was detected and for the rest of the subjects (33.6%), none of the risk factors were observed.

CONCLUSIONS

Our data determines DNA aberrant methylation panel in bronchial secretions is present in a 61.2% and HGD is found in 15.6%. Although both parameters have previously been identified as risk factors for lung cancer, the current study does not find a significative association between them. The study also highlights the importance of BW as a complementary sample to induced sputum when analyzing gene aberrant methylation.

Assessing associations between the AURKA-HMMR-TPX2-TUBG1 functional module and breast cancer risk in BRCA1/2 mutation carriers

While interplay between BRCA1 and AURKA-RHAMM-TPX2-TUBG1 regulates mammary epithelial polarization, common genetic variation in HMMR (gene product RHAMM) may be associated with risk of breast cancer in BRCA1 mutation carriers. Following on these observations, we further assessed the link between the AURKA-HMMR-TPX2-TUBG1 functional module and risk of breast cancer in BRCA1 or BRCA2 mutation carriers. Forty-one single nucleotide polymorphisms (SNPs) were genotyped in 15,252 BRCA1 and 8,211 BRCA2 mutation carriers and subsequently analyzed using a retrospective likelihood approach. The association of HMMR rs299290 with breast cancer risk in BRCA1 mutation carriers was confirmed: per-allele hazard ratio (HR) = 1.10, 95% confidence interval (CI) 1.04-1.15, p = 1.9 x 10(-4) (false discovery rate (FDR)-adjusted p = 0.043). Variation in CSTF1, located next to AURKA, was also found to be associated with breast cancer risk in BRCA2 mutation carriers: rs2426618 per-allele HR = 1.10, 95% CI 1.03-1.16, p = 0.005 (FDR-adjusted p = 0.045). Assessment of pairwise interactions provided suggestions (FDR-adjusted pinteraction values > 0.05) for deviations from the multiplicative model for rs299290 and CSTF1 rs6064391, and rs299290 and TUBG1 rs11649877 in both BRCA1 and BRCA2 mutation carriers. Following these suggestions, the expression of HMMR and AURKA or TUBG1 in sporadic breast tumors was found to potentially interact, influencing patients' survival. Together, the results of this study support the hypothesis of a causative link between altered function of AURKA-HMMR-TPX2-TUBG1 and breast carcinogenesis in BRCA1/2 mutation carriers.

Metaplastic carcinoma of the breast with chondroid differentiation (matrix-producing carcinoma): study of the diagnostic cost-effectiveness of fine-needle aspiration biopsy and needle core biopsy

Metaplastic carcinoma with chondroid differentiation (MMPC) is a subtype of breast metaplastic carcinoma with mesenchymal differentiation. Although fine-needle aspiration (FNAB) and core-needle biopsy (CNB) are commonly used for the diagnosis of breast cancer, not enough studies proving the diagnostic cost-effectiveness of these techniques for the identification of MMPC have been published so far. The aim of this study was to investigate the concordance between the presurgical diagnosis using FNAB/CNB and the definitive diagnosis in the surgical specimen in pure MMPC. A case of MMPC is also reported.

STUDY DESIGN

All cases of MMPC diagnosed in our institution from 1995 to 2011 were reviewed. The presence of chondroid differentiation in cytological studies or biopsies and the proportion of chondroid matrix in the surgical specimen were evaluated.

RESULTS

A total of 13 cases of pure MMPC were collected. The diagnosis was suspected in 25% of FNABs and was rendered in 40% of CNBs.

CONCLUSIONS

The chondroid component in MMPC is hard to identify by FNAB and CNB. The random distribution and proportion of the chondroid differentiation in the tumour and the expertise in performing the technique and in identifying the chondroid component may play an important role in the diagnosis of MMPC using these techniques.

A quick diagnosis unit as an alternative to conventional hospitalization in a tertiary public hospital: a descriptive study

INTRODUCTION

 Reports indicate that a significant number of patients admitted to internal medicine units could be studied on an outpatient basis.

OBJECTIVES

 This article assesses a quick diagnosis unit (QDU) as an alternative to acute hospitalization for the diagnostic study of patients with potentially serious diseases and suspected malignancy. 

PATIENTS AND METHODS

 Between March 2008 and June 2012, 1226 patients were attended by the QDU. Patients were referred from the emergency department, primary health care centers, and outpatient clinics according to well‑defined criteria. Clinical information was prospectively registered in a database. 

RESULTS

 There were 634 men (51.7%), with a mean age of 60.5 ±17.5 years. The mean time to the first visit was 3.5 ±5.3 days. Most patients (65.7%) required only 2 visits. The mean interval to diagnosis was 12.2 ±14.7 days. A total of 324 patients (26.4%) had cancer. The diagnosis was  solid tumor in 81.5% of the cases, lymphoma in 19.8%, and various hematologic malignancies in 4.3%. The second most common diagnosis was anemia not associated with cancer (8.6% of the cases). Admission to the QDU allowed to avoid conventional hospitalization for diagnostic studies in 71.5% of the patients, representing a mean freeing‑up rate of 7 internal medicine beds per day. In a satisfaction survey, 97% of the patients were completely or very satisfied and 96% preferred the QDU to conventional hospitalization. 

CONCLUSIONS

 A QDU may be a feasible alternative to conventional hospitalization for the diagnosis of otherwise healthy patients with suspected severe disease. Appropriately managed and supported, QDUs can lighten the burden of emergency departments and reduce the need for hospitals beds.

Prediction of cervical intraepithelial neoplasia grade 2+ (CIN2+) using HPV DNA testing after a diagnosis of atypical squamous cell of undetermined significance (ASC-US) in Catalonia, Spain

Background

A protocol for cervical cancer screening among sexually active women 25 to 65 years of age was introduced in 2006 in Catalonia, Spain to increase coverage and to recommend a 3-year-interval between screening cytology. In addition, Human Papillomavirus (HPV) was offered as a triage test for women with a diagnosis of atypical squamous cells of undetermined significance (ASC-US). HPV testing was recommended within 3 months of ASC-US diagnosis. According to protocol, HPV negative women were referred to regular screening including a cytological exam every 3 years while HPV positive women were referred to colposcopy and closer follow-up. We evaluated the implementation of the protocol and the prediction of HPV testing as a triage tool for cervical intraepithelial lesions grade two or worse (CIN2+) in women with a cytological diagnosis of ASC-US.

Methods

During 2007-08 a total of 611 women from five reference laboratories in Catalonia with a novel diagnosis of ASC-US were referred for high risk HPV (hrHPV) triage using high risk Hybrid Capture version 2. Using routine record linkage data, women were followed for 3 years to evaluate hrHPV testing efficacy for predicting CIN2+ cases. Logistic regression analysis was used to estimate the odds ratio for CIN2 +.

Results

Among the 611 women diagnosed with ASC-US, 493 (80.7%) had at least one follow-up visit during the study period. hrHPV was detected in 48.3% of the women at study entry (mean age 35.2 years). hrHPV positivity decreased with increasing age from 72.6% among women younger than 25 years to 31.6% in women older than 54 years (p < 0.01).

At the end of the 3 years follow-up period, 37 women with a diagnosis of CIN2+ (18 CIN2, 16 CIN3, 2 cancers, and 1 with high squamous intraepithelial lesions -HSIL) were identified and all but one had a hrHPV positive test at study entry. Sensitivity to detect CIN2+ of hrHPV was 97.2% (95%confidence interval (CI) = 85.5-99.9) and specificity was 68.3% (95%CI = 63.1-73.2). The odds ratio for CIN2+ was 45.3 (95% CI: 6.2-333.0), when among ASC-US hrHPV positive women were compared to ASC-US hrHPV negative women.

Conclusions

Triage of ASC-US with hrHPV testing showed a high sensitivity for the detection of CIN2+ and a high negative predictive value after 3 years of follow-up. The results of this study are in line with the current guidelines for triage of women with ASC-US in the target age range of 25-65. Non adherence to guidelines will lead to unnecessary medical interventions. Further investigation is needed to improve specificity of ASC-US triage.

Interplay between BRCA1 and RHAMM regulates epithelial apicobasal polarization and may influence risk of breast cancer

Differentiated mammary epithelium shows apicobasal polarity, and loss of tissue organization is an early hallmark of breast carcinogenesis. In BRCA1 mutation carriers, accumulation of stem and progenitor cells in normal breast tissue and increased risk of developing tumors of basal-like type suggest that BRCA1 regulates stem/progenitor cell proliferation and differentiation. However, the function of BRCA1 in this process and its link to carcinogenesis remain unknown. Here we depict a molecular mechanism involving BRCA1 and RHAMM that regulates apicobasal polarity and, when perturbed, may increase risk of breast cancer. Starting from complementary genetic analyses across families and populations, we identified common genetic variation at the low-penetrance susceptibility HMMR locus (encoding for RHAMM) that modifies breast cancer risk among BRCA1, but probably not BRCA2, mutation carriers: n = 7,584, weighted hazard ratio ((w)HR) = 1.09 (95% CI 1.02-1.16), p(trend) = 0.017; and n = 3,965, (w)HR = 1.04 (95% CI 0.94-1.16), p(trend) = 0.43; respectively. Subsequently, studies of MCF10A apicobasal polarization revealed a central role for BRCA1 and RHAMM, together with AURKA and TPX2, in essential reorganization of microtubules. Mechanistically, reorganization is facilitated by BRCA1 and impaired by AURKA, which is regulated by negative feedback involving RHAMM and TPX2. Taken together, our data provide fundamental insight into apicobasal polarization through BRCA1 function, which may explain the expanded cell subsets and characteristic tumor type accompanying BRCA1 mutation, while also linking this process to sporadic breast cancer through perturbation of HMMR/RHAMM.

What are the preoperative factors that can determine the presence of metastases in other axillary nodes in breast cancer when the sentinel node is positive?

AIM

To determine whether preoperative factors, such as size of metastases in the sentinel lymph node (SLN), number of positive SLNs (1, >1), tumoral grade, lymphovascular invasion (LVI) and tumoral size can predict the presence of metastases in non-SLNs, when the SLN is positive.

METHODS

The study population was 1 146 breast cancer patients. Lymphadenectomy was performed in 150. Three groups of patients were established depending on the size of the metastases in SLNs: group A: <2 mm; group B: 2 < or =GC < or =5 mm; group C: > 5 mm. Either the chi(2) test or Fisher's test was performed to compare categorical variables, and a multivariate conditional logistic regression model for data sets was performed to identify the deterministic factors of metastases presence.

RESULTS

Ten percent of group A, 28% of group B and 52% of group C presented non-SLN metastases. Patients with >1 positive-SLN presented significantly more non-SLN metastases than those with only one positive-SLN; 56% of patients with LVI presented non-SLN metastases versus 26% of those without LVI. The tumoral grade and size did not seem to have any influence on the number of patients with non-SLN metastases. The number of positive-SLNs and size of metastases were statistically associated with the presence of metastases.

CONCLUSIONS

In this study population, the probability of finding non-SLN metastases was statistically related to the size of the SLN metastases and the number of positive-SLNs.

Linfogammagrafía y biopsia del ganglio centinela en el carcinoma no palpable de mama

OBJECTIVE

The aim of the study was to evaluate the efficacy of lymphatic mapping and sentinel node biopsy in non-palpable breast cancer (NPBC) patients in comparison with palpable breast cancer (PBC) patients.

MATERIAL AND METHODS

199 breast cancer patients were studied. Patients were classified into two groups: NPBC and PBC. Following sentinel node biopsy all patients underwent axillary lymphadenectomy. Surgery was performed at 4-24 h after peritumoral injection of 111MBq 99mTc-nanocolloid. Histological sentinel node analysis was performed by cytological imprinting and delayed study. The following parameters were analyzed in both groups: scintigraphic and surgical detection rates, true positives (TP), true negatives (TN), sensitivity (S), predictive negative value (PNV), false negative rate (FNR) and global precision (GP) of the technique.

RESULTS

No significant differences were observed (p > 0.05) in either the lymphoscintigraphy or surgical sentinel node detection, or drainage to internal mammary chain (p = 0.211) in both groups. Metastatic axillary prevalence was lower in NPBC group (p = 0.019). Similar S, NPV and GP values (>90 %) and FNR (< or = 6 %) were found in both groups.

CONCLUSIONS

The reliability of the technique is similar in both groups. Drainage is predominantly axilar. Drainage to internal mammary chain was more frequently seen in medial tumours and in NPBC. Metastatic axillary prevalence was lower in the NPBC group.

Cervical human papillomavirus infection in the female population in Barcelona, Spain

BACKGROUND AND OBJECTIVE

Human papillomavirus (HPV) is a major cause of invasive cervical cancer. Identification of HPV determinants might allow for targeting of high-risk groups for cervical cancer.

GOAL

The goal was to estimate the HPV prevalence and its determinants among women from the general population of Barcelona.

STUDY DESIGN

We studied a random sample of female residents in metropolitan Barcelona, Spain (n = 973). Information was obtained through personal interviews and laboratory testing of cervical exfoliated cells. HPV was detected using a GP5+/6+ polymerase chain reaction assay.

RESULTS

The average age of participants was 43 years (standard deviation = 16.1 y) and the percentage of lifetime monogamy was 79%. The age-adjusted HPV prevalence was 3.0%. Independent HPV determinants were being born overseas (odds ratio [OR], 8.1; 95% confidence interval [CI], 1.9-33.5), being divorced (OR, 6.7; 95% CI, 1.9-24.3), reporting more than one sexual partner (OR, 2.6; 95% CI, 1.0-6.5), and smoking marijuana and related products (OR, 5.2; 95% CI, 1.2-21.7). Use of condoms with regular partner was protective (OR, 0.14; 95% CI, 0.02-1.0).

CONCLUSION

The study confirms a low overall HPV prevalence in a largely monogamous population. The protection observed with condom use needs further evaluation.

Meningeal carcinomatosis as the first manifestation of a transitional cell carcinoma of the bladder

Meningeal carcinomatosis (MC) as first manifestation of a transitional cell carcinoma (TCC) of the bladder is rare. We report a 66-year-old man, smoker, who presented with two episodes of secondarily generalized partial motor seizures. The routine blood test, brain computed tomography (CT) scan, brain magnetic resonance imaging and electroencephalogram were normal. Cerebral spinal fluid (CSF) revealed a significant pleocytosis and a morphology compatible with non-differentiated non-small cell carcinoma. Broncofiberscopy, gastrofiberscopy, thoracicoabdominopelvic CT-scan and bone scintigraphy were normal but the urine cytology revealed malignant cells similar to those found in the CSF. TCC was diagnosed by cystoscopy and later necropsy confirmed the MC of this tumor. In this report we review the literature and analyze patient survival.

Frequent expression of the multi-drug resistance-associated protein BCRP/MXR/ABCP/ABCG2 in human tumours detected by the BXP-21 monoclonal antibody in paraffin-embedded material

Breast cancer resistance protein (BCRP/MXR/ABCP/ABCG2; hereafter ABCG2) is a member of the ATP-binding-cassette family of transporters that causes multi-drug resistance to various anticancer drugs. The expression of ABCG2 in human tumours and its potential involvement in clinical drug resistance are unknown. Recently, two monoclonal antibodies against human ABCG2 were produced, BXP-34 and BXP-21. This study describes an immunohistochemical method using BXP-21 to study ABCG2 expression in formalin-fixed, paraffin-embedded tissues. No staining was seen using BXP-34 with the same protocols. The expression of ABCG2 was then investigated in a panel of 150 untreated human solid tumours comprising 21 tumour types. Overall, ABCG2 expression was frequent. Specificity of immunohistochemistry was confirmed by the detection of a 72 kD band in western blotting. ABCG2 expression was seen in all tumour types, but it seemed more frequent in adenocarcinomas of the digestive tract, endometrium, and lung, and melanoma. Positive tumours showed membranous and cytoplasmic staining. In certain adenocarcinomas, prominent membranous staining was seen. Endothelial cells frequently displayed moderate to strong staining. ABCG2 is widely present in untreated human solid tumours and may represent a clinically relevant mechanism of drug resistance. Future studies in specific tumour types are needed to ascertain its clinical relevance. BXP-21 and the immunohistochemical protocol described here will be of value in these investigations.

Churg-Strauss syndrome involving the breast: a rare cause of eosinophilic mastitis

Churg-Strauss syndrome is a rare immunoallergic disorder that usually affects lungs, skin and nervous system. The clinical and radiological findings of Churg-Strauss disease involving the breast are reported and attention is drawn to the fact that, although uncommonly, the breast can be involved by immunological diseases.

Intraoperative fine needle aspiration cytology of pancreatic lesions. A study of 90 cases

Undiagnosed masses in the pancreas represent a problem at laparotomy. Intraoperative biopsy of pancreatic lesions frequently fails to detect carcinoma and may cause severe complications. The aim of the present study was to determine the diagnostic accuracy of intraoperative fine needle aspiration cytology (FNAC) of pancreatic lesions. Ninety patients were studied from January 1988 to June 1992. The cytologic diagnoses were correlated with histology, autopsy results or clinical follow-up. Aspirates were reported as benign, suspicious, malignant or unsatisfactory. Final diagnosis of malignant pancreatic disease (MPD) was established in 60 patients and of benign pancreatic disease in 30. Among the 60 cases with MPD, the cytologic diagnosis was concordant in 42 and interpreted as suspicious in 4. Seven patients with benign cytology and 7 with unsatisfactory cytology later proved to have malignant disease. A total of 30 patients had benign disease; 26 of them had benign cytology. The remaining four had "unsatisfactory" cytologic reports. No false positives were reported. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy for intraoperative FNAC results were 80%, 100%, 100%, 70% and 91%, respectively. No complications followed the procedure. Intraoperative FNA of the pancreas is a safe and highly accurate diagnostic method for pancreatic lesions at laparotomy.