Risk factors of breast cancer and breast self-examination in early detection: systematic review of awareness among Indian women in community and health care professionals

BACKGROUND

This review aims at evaluating the awareness of risk factors for breast cancer (BC) and the knowledge of breast self-examination (BSE) among Indian women and health care professionals (HCPs).

METHODS

Literature search was conducted on multiple bibliographic databases with restrictions applied to English peer-reviewed journals.

RESULTS

We reviewed 37 published articles on this topic. The mean level of awareness for risk factors such as age at menarche (22.3%), age at menopause (27.1%) and late first pregnancy (34.6%) was low in community. The awareness was better among HCPs; however, there was still room for improvement.Knowledge of BSE varied from very poor (2%) to good (69.8%) in the community setting. The practice was similarly negligible (0%) to moderate (34.9%). Mean knowledge and practice of BSE in HCPs were 77.1 and 55.5%, respectively. A significant difference was noted in knowledge and practice of BSE between community and HCPs (P < 0.05).

CONCLUSIONS

The present review highlights the low level of awareness regarding risk factors for BC and BSE in the community as well as HCPs. Though BSE is not the ideal modality, this seems to be the best alternative for resource-limited settings.

Urine HPV-DNA detection for cervical cancer screening: prospects and prejudices

Oncogenic types of human papilloma viruses (HPVs) have been established to be the causative agents for cervical cancers and high-grade squamous intraepithelial lesions (HSILs). The clinical application of molecular tests for HPV detection for screening purposes has been of considerable interest. DNA amplification methods allow the use of self-collected samples (including urine) from material collected away from the original disease site. For screening of cervical pathology, detection of HPV-DNA in urine would be useful only if it represents cervical HPV infection and/or HPV-related cervical pathology. We conducted a review of the literature in order to ascertain: (1) if urine is an adequate sample for HPV-detection; (2) whether sensitive techniques are available for HPV-detection in urine and (3) if detection of HPV in urine truly represents cervical infection/pathology. The review process consisted of assembling facts and analysing the published literature on the following facts: anatomical considerations of the lower genital and the lower urinary tract, biological behaviour of HPV and its shedding behaviour, technical issues regarding sample collection, processing and HPV-DNA assay systems, concordance rates of HPV-DNA detection and their type specificity in the paired samples (urine and cervical scrapes) obtained in different clinico-epidemiological settings and comparative detection rates of HSILs in the paired samples.

Modified Papanicolaou staining protocol with minimum alcohol use: a cost-cutting measure for resource-limited settings

OBJECTIVE

To devise a simple, cost-effective protocol for Papanicolaou (Pap) staining of cervicovaginal smears.

METHODS

Five hundred coded paired cervical smears were collected from women as part of routine cervical cancer screening. One set of smears was stained by conventional Pap staining protocol (CP) and the other by a modified protocol (MP) in which alcohol was replaced by 1% acetic acid in all the steps except during fixation and prior to mounting; in addition, one alcohol-based counterstain, OG, was omitted. The smears were examined blindly by the pathologists and then decoded. Each pair of smears was compared and the two protocols were analysed for staining quality and diagnoses by McNemar and chi-square tests.

RESULTS

The staining quality in the MP was satisfactory. The nuclear and cytoplasmic features were comparable to the CP. Cytoplasmic transparency was maintained in the MP and the differential staining of blue/green and pink was acceptable to the pathologists and technicians. The diagnoses agreed in all cases and there was no compromise in interpreting the smears. With MP it took only 3-4 minutes to stain a batch of 50 slides. in contrast to the 20 minutes taken by CP. The MP used almost one-seventh of the amount of alcohol compared with CP, which translated into a significant cost reduction per smear.

CONCLUSIONS

The improvised Pap staining protocol with minimum alcohol use is a simple, cost-effective and technician-friendly procedure that can be easily adopted in high-volume, resource-limited laboratories for mass cervical cancer screening.

An epidemiological study to identify the risk factors with two different types of controls in high-grade cervical lesions including invasive cancer

A multidisciplinary study on pre-cancerous and early cancerous lesions of uterine cervix was carried out at our Institute from which the subjects (cases and one group of control) for the present study were selected with the objective to identify the possible risk factors related to high-grade cervical lesions including invasive cancer through an epidemiological study by selecting two different types of controls and to assess the feasibility whether the cancers of other organs could be taken as controls at the same time studying the risk factors associated with cervical cancer. One group of control was women with negative Pap smear and second group of control was the women with breast cancer but negative Pap smear. A total of 100 biopsy-proven cases of high-grade cervical intraepithelial lesions and Invasive cancer were recruited. The results of the study show that some of the risk factors associated with the cervical cancer get exaggerated when breast cancer cases were used as controls because risk factors of both cancers are opposite to each other. So it is concluded that in order to remove any bias, normal hospital controls or controls selected from multiple cancers should be taken to study the risk factors involved in cervical carcinogenesis.

Age trends in pre-cancerous and cancerous lesions of the uterine cervix in a cytology screening programme: what should be the target age group for a major thrust of screening in resource-limited settings?

OBJECTIVE

To identify the target age group where screening efforts may be concentrated in order to reduce the incidence of cervical cancer in resource-limited countries.

STUDY DESIGN

The results of cyto-screening in a hospital-based screening programme for early detection of cervical cancer were analysed retrospectively. The frequency of epithelial cell abnormalities (ECAs) was computed in different age groups.

OBSERVATIONS AND RESULTS

A total of 5.6% ECAs were detected on cyto-screening. The peak age incidence for squamous intraepithelial lesions (SILs) was in the 30-39 age group while that for malignancies was age >60 years. The mean ages for LSIL, HSIL and cancer were 34.7, 37.7 and 51.8 years respectively. Around 43% LSILs and 48% HSILs presented in the fourth decade. If both fourth and fifth decade are covered by screening we could detect almost two-thirds of SILs.

CONCLUSIONS

A distinct latent period of more than a decade between the onset of SIL and development of frank cancer provides us with ample opportunity to prevent cervical cancer through screening. Our data validate the WHO recommendation of once in a lifetime screening of women in their fourth decade, for low-resource settings. If resources permit, screening can be extended to include women in the fifth decade. This approach would enable us to pick up maximum SILs within the available resources and prevent their progression to cancer.

Cell block as an adjunct to conventional Papanicolaou smear for diagnosis of cervical cancer in resource-limited settings

OBJECTIVE

To assess the utility of indigenously prepared cell blocks (CBs) as an adjunct to a conventional smear test in providing a reliable diagnosis of clinically suspicious cervical cancer in resource-limited settings.

METHODS

Eighty-six clinically suspicious cervical cancer cases underwent a conventional smear test, CB preparation from residual cellular samples and biopsies at the same sitting. Correlations were performed between these modalities in order to derive the sensitivity and specificity of the CB technique to diagnose cervical cancer.

OBSERVATION & RESULTS

Out of 86 clinically suspicious cervical cancers, 72 (83.7%), 70 (81.4%) and 67 (77.9%) cases were diagnosed as malignant on tissue biopsies, CBs and smears respectively. CB-biopsy agreement in the diagnosis of malignancy was feasible in 87.5% of the cases while CB-Pap smear agreement was feasible in 92.5% of the cases. Sensitivity and specificity of CB preparation to diagnose malignancy was 92.5% and 100%, respectively, when the smear was taken as the reference test (excluding the unsatisfactory smears). When biopsy was taken as the gold standard, the sensitivity and specificity of CBs were 87.5% and 100% respectively (excluding the unsatisfactory biopsies). In 8/19 cases where the smear diagnoses were either unsatisfactory or atypical squamous cells/atypical glandular cells, CBs picked up malignant lesions.

CONCLUSION

CBs prepared from the residual cellular sample of conventional cervical scrapes augment the sensitivity of the smear test. When used as an adjunct to the smear, CBs aid in providing a reliable diagnosis of cervical cancer in the majority of the clinically suspected cases and thus the biopsy load can be reduced significantly in resource-poor settings.

Test characteristics of various screening modalities for cervical cancer: a feasibility study to develop an alternative strategy for resource-limited settings

OBJECTIVE

To determine test characteristics - sensitivity, specificity, positive and negative predictive values - of different screening modalities to detect cervical precancerous and cancerous lesions in order to devise an effective alternative strategy for cervical cancer screening in resource-poor settings.

METHODS

A total of 472 women presenting with nonspecific gynecologic symptoms were screened by cytology, visual inspection with acetic acid application (VIA), VIA with magnification (VIAM) and human papillomavirus (HPV)-DNA testing. Colposcopic examination was performed in all and on-site biopsy was taken if any grade I and above lesion was detected on colposcopy (230). On histopathological examination, 105 showed cervical intraepithelial neoplasia II and above lesions. Sensitivity, specificity and predictive values for each test were calculated taking colposcopy and or directed biopsy as the gold standard. Comparisons were made with cytology in order to assess the feasibility of alternative strategies in resource-poor settings.

RESULTS

VIA was less sensitive (86.7% versus 91.4%) but more specific (90.7% versus 86.6%) than cytology at low grade squamous intraepithelial lesion (LSIL) threshold but the difference was not statistically significant (P > 0.01). HPV testing improved the sensitivity over cytology (97.1% versus 91.4%) but there was a nonsignificant loss of specificity (84.2% versus 86.6%). Results of VIAM were more or less similar to VIA.

CONCLUSION

VIA can be used as a mass screening tool for cervical cancer in resource-poor settings.

Community based study on sero-prevalence of syphilis in New Delhi (India)

Syphilis continues to be a major health problem in India. Data regarding sero-prevalence of syphilis is largely hospital based. Majority of community based studies have been conducted on select groups. Therefore, these studies do not reflect the true prevalence of syphilis in general population. The objective of the study was to determine the sero-prevalence of syphilis in the urban and rural communities of New Delhi, using both VDRL and TPHA for screening and FTA-ABS for confirmation and discrepant analysis. Serum specimens from 178 males and 227 females aged between 15-49 years were tested. VDRL test was put up using VDRL antigen from serologist, Kolkata. TPHA and FTA-ABS were performed using commercially available kits. 6.91% (28/405) subjects were found to be seropositive for syphilis (males 10.11%, females 4.40%). Syphilis seropositivity was found to be significantly associated with low income (p=0.02) and presence of symptoms suggestive of STIs (p=0.00) among males. Positive syphilis serology was significantly associated with trichomoniasis in females (p=0.00). Community based studies utilizing one non-treponemal test plus one treponemal test for screening purpose and an additional specific test for confirmation should be used for designing a control programme.

Why is high grade squamous intraepithelial neoplasia under-diagnosed on cytology in a quarter of cases? Analysis of smear characteristics in discrepant cases

BACKGROUND

The accuracy of cervical cytology has been questioned due to high false negative rate. In order to improve the sensitivity of cytology it is prudent to analyze the factors which hamper with the diagnosis of high grade lesions.

AIMS

To study the cyto-histologic agreement in High grade squamous intraepithelial lesions (HSIL) of uterine cervix and to analyze the smear characteristics in discrepant cases.

SETTINGS AND DESIGN

Cervical smears of 100 histology proven cases of Cervical intraepithelial neoplasia III (CIN III) were retrieved and reviewed to study cyto-histologic agreement in the diagnosis of high grade lesions. The discrepant smears, undercalled on cytology, were further analyzed to determine the reasons for misinterpretations. Statistical analysis was performed to find out any significant factors for discrepancies.

RESULTS

Cytology was able to correctly identify 74 HSILs while in 26 cases a diagnosis of Low grade squamous intraepithelial lesions (LSIL) or below was given. On review, 16 of these non correlating cases could be reclassified as HSIL on cytology while in 10 the diagnosis of LSIL or less persisted. 12/16 (75%) discrepant cases, reclassified as HSIL represented interpretive errors. Sampling errors (7/10) and air drying (5/10) were more frequent in under diagnosed cases. The statistical analysis did not yield any significant differences in the two review groups.

CONCLUSION

26% of HSIL cases were underdiagnosed on cervical smears. The major confounding factors responsible for under interpretation on cytology included air drying artifacts and metaplastic maturation of abnormal cells.

Primary malignant melanoma of uterine cervix: a rare entity diagnosed on fine needle aspiration cytology--report of a case

Primary malignant melanoma of uterine cervix is a rare neoplasm. Its diagnosis on cervical fine needle aspiration cytology, a first of its kind in the literature, has been reported. Although cervix is a rare site for melanoma, cytopathologists should be familiar with it and be able to diagnose this entity on cervical cytology when pigment containing tumour cells are present. In a patient with visible growth on cervix, fine needle aspiration cytology may prove to be a useful diagnostic tool, especially when cervical smear/scrape cytology is non-diagnostic.

Atypical squamous cells of undetermined significance: is it worthwhile to qualify them further?

BACKGROUND

In Bethesda System of reporting cervico-vaginal smears, the equivocal epithelial cell abnormalities have been categorised as "atypical squamous and glandular cells of undetermined significance" (ASCUS and AGUS). These abnormalities may harbour minor lesions attributed to mere inflammatory changes to potentially serious high grade lesions. It is recommended to further qualify these lesions according to whether they favor a reactive or a neoplastic outcome.

AIMS

We undertook the present study to assess the significance of ASCUS qualifiers.

MATERIAL AND METHODS

A total of 12071 women were screened for early detection of cancer cervix. The women with ASCUS diagnosis were further qualified as ASCUS favor reactive and ASCUS favor SIL (Squamous intraepithelial lesion) according the Bethesda 1991 system of reporting. ASCUS-reactive cases were followed up by a repeat smear examination and persistent ASCUS cases were taken up for colposcopy and biopsy if indicated. All ASCUS-SIL cases were taken up for immediate colposcopy.

RESULTS

The pick up rate of high grade lesions was not significantly different (P=0.47; Chi square test) on the follow up of ASCUS-reactive (2/222) and ASCUS-SIL (2/130) groups. The low grade lesions were picked up in 10/222 ASCUS-reactive and 58/130 in ASCUS-SIL, which was statistically significant (P < 0.001).

CONCLUSIONS

The results of our study indicate that it is not worthwhile to qualify these lesions as majority of ASCUS-SIL also revealed only low grade epithelial which have a benign biological behaviour.

Early detection of cervical cancer through acetic acid application--an aided visual inspection

OBJECTIVE

To assess the sensitivity and specificity of visual inspection of cervix for detection of precancerous and early cancerous lesions of cervix.

METHODS

In a Maternal and Child Health Care setting of New Delhi women underwent a detailed pelvic examination, visual inspection of cervix after 5% acetic acid application, cytology (pap smear), detailed colposcopic examination and colposcopic directed biopsy when indicated.

RESULTS

Findings of aided visual inspection using 5% acetic acid and of cytology were evaluated among symptomatic 402 women against colposcopic findings and/or histologic reports. Seventy-three mild dysplasias, 50 moderate dysplasias, 45 severe dysplasias/Carcinoma in-situ and 40 early invasive cancerous cases were diagnosed histologically. The sensitivity of cytology (75.3%) was higher compared to that of acetic acid application (52.0%) for mild dysplasias. On the other hand, the sensitivity for detecting moderate dysplasias was 78% for cytology and 81.6% for acetic acid; for severe dysplasias/carcinoma in-situ it was 73.3% for cytology and 86.7% for acetic acid. For invasive cancers sensitivity for acetic acid application and cytology (95% for both modalities) was comparable. The specificity of cytology (99%) was higher compared to that of acetic acid application (94.3%). The false positive rate for cytology was 1.0% as against 5.7% for acetic acid application. The results of acetic acid application also showed a remarkable improvement in the sensitivity of unaided visual inspection for early cancerous lesion which was about 60% for early cancerous lesion and only 12% for mild dysplastic and 20% for moderate and severe dysplastic lesions in our earlier experience. It also reduced the false positive rates from 12% by unaided visual inspection to 5.7% by acetic acid application. Furthermore, cost of detection of one true lesion through acetic acid application (Rs.1689.00) was much lower as compared to the cost involved in cytology detected true lesions (Rs.2227.00). Visual inspection without acetic acid incurred Rs.6608.60 for detection of true lesion.

CONCLUSION

Screening for cervical precancerous and cancerous lesions using visual inspection aided by acetic acid may be a suitable low-cost and a feasible alternative modality for control of cervical cancer in a resource poor setting.

Microfilariae in association with neoplastic lesions: report of five cases

Microfilariae and adult filarial worms have occasionally been detected in association with neoplastic lesions in cytological smears. The presence of microfilariae along with neoplasms is generally regarded as a chance association, yet some authors suggest that such parasitic infestations may be a causative factor for tumourigenesis. There are only a few reported cases in cytology literature documenting this association. We report the presence of microfilariae in routine cytology smears from one benign and four malignant tumours. Microfilariae could not be identified on histopathology available in four of these cases.

Cytomorphology of filariasis revisited. Expansion of the morphologic spectrum and coexistence with other lesions

OBJECTIVE

To review the cytomorphologic spectrum of the filarial worm and associated tissue response in 33 cases.

STUDY DESIGN

Retrospective analysis was carried out in clinically unsuspected cases of filariasis diagnosed on cytology over a period of 10 years. Twenty-nine aspirate smears from 28 patients were air dried and stained with May-Grünwald-Giemsa stain. Four routine cervical smears and one centrifuged smear of urine were stained with Papanicolaou stain.

RESULTS

Microfilariae alone and along with adult gravid females were present in 25 and 4 cases, respectively. In one case both adult male and female worms with microfilariae and eggs were seen. The diagnosis was based on the presence of eggs alone in one case and fragments of female worms in two. Four of these cases were neoplastic lesions, and microfilariae were found incidentally. In one case of splenomegaly microfilariae were seen along with Leishman-Donovan bodies.

CONCLUSION

Filariasis can be diagnosed on cytology by demonstrating microfilariae, a male or female worm, or eggs alone. It can be seen in association with neoplastic lesions and rarely with other parasitic infections.

Nuclear grooves in intermediate cells in cervical smears

One thousand cervical smears from women who took part in a hospital-based screening programme for early detection of cervical cancer were studied for the presence of nuclear grooves. Grooved nuclei were frequently detected in intermediate cells in all phases of the menstrual cycle, although their frequency of occurrence was slightly lower in the luteal and premenstrual phases. The mean number of nuclear grooves varied from 3.6 to 4.2 in different phases of the menstrual cycle. The differences, however, were not statistically significant. The presence of nuclear grooves in cervical cells appears to be a nonspecific finding at present.

Low-cost technology for screening uterine cervical cancer

We report on an illuminated, low-cost (Rs 1500 (US$ 36)) magnifying device (Magnivisualizer) for detecting precancerous lesions of the uterine cervix. A total of 403 women attending a maternal and child health care clinic who had abnormal vaginal discharge and related symptoms were referred for detailed pelvic examination and visual inspection by means of the device after the application of 5% (v/v) acetic acid. Pap smears were obtained at the same time. The results were compared with those obtained using colposcopy and/or histology. The Magnivisualizer improved the detection rate of early cancerous lesions from 60%, for unaided visual inspection, to 95%. It also permitted detection of 58% of cases of low-grade dysplasia and 83% of cases of high-grade dysplasia; none of these cases were detectable by unaided visual inspection. For low-grade dysplasia the sensitivity of detection by means of the Magnivisualizer was 57.5%, in contrast with 75.3% for cytological examination. However, the two methodologies had similar sensitivities for higher grades of lesions. The specificity of screening with the Magnivisualizer was 94.3%, while that of cytology was 99%. The cost per screening was approximately US$ 0.55 for the Magnivisualizer and US$ 1.10 for cytology.

Solitary nodular goiter. Review of cytomorphologic features in 441 cases

OBJECTIVE

To study the cytomorphologic features of solitary nodular goiters (SNG).

STUDY DESIGN

May-Grünwald-Giemsa-stained smears in 441 SNG diagnosed by ultrasonography and fine needle aspiration (FNA) and found to have optimum cellular material at review were subjected to detailed cytologic assessment. The age of the patients ranged from 11 to 75 years, with a median of 35. Male: female ratio was 69:372. The parameters for cytologic assessment included cellularity, colloid content, acinar formation, papillary formation, intranuclear cytoplasmic inclusions, nuclear grooves, marginal vacuoles, Hürthle cells and various inflammatory cells. Histopathology reports on thyroidectomy specimens were available in 27 cases from two Delhi hospitals.

RESULTS

Hyperplastic nodules (68 cases) differed significantly from colloid goiters (269 cases) by having more cases with excessive cellularity, acinar formation and marginal vacuoles (P < .001). There was also a significant difference with respect to papillary formation and moderate-to-excessive colloid content (P < .001). As compared to hyperplastic nodules, neoplasms (60 cases) had a significantly higher number of cases with papillary formation, intranuclear inclusions and nuclear grooves but lower number of cases with marginal vacuoles (P < .01-.001). Among neoplasms, usual papillary carcinoma (19 cases) differed from follicular neoplasms (20 cases) with respect to acinar formation, papillary formation and nuclear grooves (P < .001). A significant difference was also observed with respect to colloid content and nuclear inclusions. Follicular variant of papillary carcinomas (FVPC) (10 cases) emerged as a distinct cytologic entity following review and differed from usual papillary carcinomas in having a higher number of cases with acinar formation, tubular formation and marginal vacuoles (P < .01-.001) and lower number of cases with nuclear grooves (P = .05). FVPC also differed from follicular neoplasms with respect to papillary formation, tubular formation, intranuclear inclusions and nuclear grooves (P < .01-.001). Overall cytohistologic agreement was achieved in 24 of 27 (88.9%) cases.

CONCLUSION

Detailed cytologic assessment of FNA smears-in SNG was helpful in highlighting parameters that differentiate between various types of goiters.

Columnar and metaplastic cells in vault smears: cytologic and colposcopic study

Vault smears (n = 250) were examined as routine follow up of hysterectomized individuals. Although the majority of these smears were normal, 14 of them revealed the presence of columnar cells or metaplastic cells. None of these patients had any known cause which could account for the presence of these cells in a post-hysterectomy smear. The possible explanations could be (i) the common mullerian origin of the upper vaginal mucosal cells, (ii) exfoliated reparative squamous parabasal and basal cells mimicking columnar cells, (iii) goblet cell metaplasia in atrophic vaginal epithelium.

Biological behavior and etiology of inflammatory cervical smears

Two hundred and fifty-seven consecutive women attending a major maternal and child health (MCH) center were studied clinically, colposcopically, cytologically, and microbiologically for different gynecologic infections. Out of 257 cases, 207 (80.5%) had inflammatory cervical smears, of which 183 (88.4%) were infected with one or more genital tract infections. Bacterial vaginosis (risk, 22.6-fold), chlamydia (risk, 21.6-fold), and human papillomavirus (HPV) (risk, 13.5-fold) were independently associated with inflammatory smears. In addition, significantly higher proportions of women with inflammatory smears had cervical ectopies (28.5% vs. 10.2%) and bleeding ectopies (30.9% vs. 4.1%) as compared to noninflammatory smears. Women infected with bacterial/parasitic genital infections were given specific treatment. These women were followed up at regular intervals to assess the efficacy of antimicrobial therapy. During follow-up examination, only 26 women (12.6%) showed negative smears. Sixteen women developed squamous intraepithelial lesions (SIL) during follow-up, and 163 women had persistent inflammatory smears. Multivariate analysis revealed that persistent inflammatory smears were associated with herpes simplex virus (HSV) infection, as revealed through detection of IgA antibodies to HSV (risk, 11.5-fold). Progression of SIL was associated with HPV infection (risk, 17.6 fold). Thus, inflammatory smears are associated with different types of infection, most of which do not respond to antimicrobial therapy.

Sialadenosis of parotid gland: a cytomorphologic and morphometric study of four cases

BACKGROUND

Sialadenosis is recurrent, noninflammatory, nonneoplastic enlargement of salivary glands usually associated with an underlying systemic disorder.

CASES

Fine needle aspiration was performed on four patients with bilateral, painless parotid swellings. The cytologic picture was distinctive and identical in all the cases. Smears revealed clusters of swollen acini and numerous naked nuclei of acinar origin in the background. There was absence of inflammatory cells. Diagnosis of sialadenosis was made in each case. Morphometric measurements were performed using an ocular micrometer. Results indicated a significant increase in mean acinar diameter in a sialadenotic gland as compared to a normal gland (76.03 microns vs. 53.79 microns).

CONCLUSION

Cytomorphologic features of sialadenosis are distinctive enough to enable its diagnosis on fine needle aspiration. It is important to be aware of this entity as most cases do not require surgical intervention.

Ultrasound-guided fine-needle aspiration cytology diagnosis of gallbladder lesions: a study of 82 cases

Carcinoma of the gallbladder (GB) is among the five most common forms of cancers and tops the list of gastrointestinal malignancies in females of the Delhi region. Lack of specific signs and symptoms prevents early detection of GB carcinoma. However, in recent years ultrasonographically (US)-guided fine-needle aspiration (FNA) cytology has been found to be a reliable procedure for its diagnosis. The present study was carried out during a period of 5 yr (1986-1990) in 64 female and 18 male patients to find out the diagnostic utility of US-guided FNA cytology in gallbladder lesions. Ultrasonography in these 82 cases revealed a mass in the gallbladder/GB area in 74 (90.2%), a mass in the GB/pancreas in 1 (1.2%), gallstones in 32 (39.0%), and miscellaneous gallbladder lesions in 4 (4.9%). The other findings included space-occupying lesions in liver in 18 (22.0%), portal lymphadenopathy in 12 (14.6%), and infiltration in other organs in 7 (8.5%). The initial cytodiagnosis was malignancy in 48 cases, inflammatory in 12, and inadequate in 22. Following review of the smears by one of the investigators (D.K.D.), the number of malignant cases remained 48 (58.5%). There were 10 (12.2%) inflammatory and 24 (29.3%) inadequate cases. Adenocarcinoma was the most common malignancy (83.3%), followed by squamous-cell and adenosquamous carcinoma (12.5%) and small round cell tumors (4.2%). The 10 inflammatory lesions showed slight (+) to excessive (+3) neutrophilic infiltration and included one case each of xanthogranulomatous cholecystitis and a necrotizing granulomatous lesion likely to be of tuberculous etiology.

Role of guided fine needle aspiration cytology in diagnosis and classification of liver malignancies

Ultrasound or CT-guided fine needle aspiration was performed on 212 patients with space occupying lesions of the liver during a period of 5 years (1986-1990) to study the utility of fine needle aspiration (FNAC) in the diagnosis of hepatic malignancies. The initial FNAC diagnosis was malignancy in 91 cases. However, following review of the smears by one of the investigators (DKD) 93 (43.9%) cases were found to be malignant. Age of the patients with malignancy ranged from 20 days to 85 years. Male to female ratio was 57:36. The clinical diagnosis was malignancy in 58% which improved to 72% following imaging whereas nonspecific diagnosis was reduced from 34% to 20%. The primary malignancies consisted of 21 cases of hepatocellular carcinoma (HCC) and 7 hepatoblastomas. There were 61 metastatic lesions which included 43 adenocarcinomas, 6 small cell anaplastic carcinomas, 3 leiomyosarcomas, 2 cases each of malignant melanoma, paraganglioma and germ cell tumour, and one case each of squamous cell carcinoma, neuroendocrine tumour and undifferentiated carcinoma/soft tissue sarcoma. In two cases decision between HCC and secondaries was not possible. There were also two cases of non-Hodgkin's lymphoma. Thirty six percent of primary malignancies and 58% of secondaries were correctly diagnosed or suggested as one of the possibilities by combined clinical examination and imaging prior to FNAC. Thus, US/ CT guided FNAC played an important role in diagnosis and classification of malignancies of liver.

Cytohistological correlation as a measure of quality assurance of a cytology laboratory

In a hospital-based cytology screening programme for the early detection of preinvasive lesions of the uterine cervix, 166 women with abnormal smears (human papillomavirus (HPV) changes, cervical intraepithelial neoplasia (CIN) and invasive carcinoma) were referred to the central colposcopy clinic between January 1989 and December 1991. The colposcopist (V.S.) was able to take a direct biopsy in 156 cases. In the remaining 10-cases, biopsy could not be taken because of unsatisfactory colposcopy. A cytohistological correlation was obtained in 121/156 (77.5%) cases, and the remaining 35 cases showed a disparity in diagnosis. These were reviewed by one of us (P.S.) and the reasons for underdiagnosis/false negatives and overdiagnosis/false-positive results were analysed. It was found that sampling error was the cause of false negativity and underdiagnosis in most cases while interpretative errors resulted in the overdiagnosis and false-positive smears. The reasons for interpretative errors were studied in detail.

Colposcopy as a tool for detection of human papillomavirus infection of uterine cervix in the setting of high prevalence of gynaecologic infections

A cross sectional study involving 257 women from the Maternal and Child Health Centre (MCH) in Delhi was initiated for screening clinically, cytologically, colposcopically, and microbiologically for several gynaecologic infections. Eighty percent of the women had one or more gynaecologic infections and 31.1% had three or more infections. Cytology revealed changes suggestive of condyloma in 3 (1.2%) women only, while colposcopic examination suggested HPV changes in 117 (45.5%) women. A very high proportion of colposcopically detected lesions (78.6%) had evidence of HPV related changes in histology. The specificity of these lesions were further confirmed by Pan HPV DNA in-situ hybridisation, when 84% of the colposcopy is a valuable tool for detecting subclinical HPV lesions in a setting with high prevalence of gynaecologic infections.

Absence of human papillomavirus DNA in breast cancer as revealed by polymerase chain reaction

Oncogenic human papillomavirus (HPV) types 16 and 18 commonly associated with cervical cancer are found in many epithelial malignancies at extra-genital sites including breast. The transforming gene products of HPV have also been shown to immortalize breast epithelial cells in vitro. But the findings of HPV DNA in breast carcinoma are found to be contradictory. In the present study fine needle aspirate cell (FNAC) samples from 26 breast cancer patients and four breast tumour biopsies were analysed for the presence of HPV 16 and 18 DNA sequences by both polymerase chain reaction (PCR) and Southern blot hybridization. Of 26 fine needle aspirate cell samples and four breast cancer biopsies, not a single sample was found to be positive by either PCR or Southern blot hybridization. The observation of complete absence of HPV DNA sequences in breast cancer refute the possibility of any role for oncogenic genital HPV types 16 and 18 in the pathogenesis of breast cancer.

Genetic alterations at 5p15: a potential marker for progression of precancerous lesions of the uterine cervix

BACKGROUND

Development of uterine cervical cancer is preceded by preneoplastic proliferative changes in the cervical epithelium called "intra-epithelial neoplasia" or "dysplasia." The genetic basis of the origin and progression of such preneoplastic lesions is not known. By analysis of carcinomas for loss of constitutional heterozygosity (LOH), we have previously shown a high frequency of allelic loss in the short arm of chromosome 5 (5p), suggesting loss of a candidate tumor suppressor gene located in 5p and associated with the development of this tumor.

PURPOSE

To further understand the role of genetic alterations that affect 5p in cervical carcinogenesis, we evaluated the status of microsatellite polymorphisms at five loci mapped to 5p14-ter in precancerous and cancerous lesions.

METHODS

Biopsy specimens from two groups of patients were analyzed for genetic alterations affecting 5p. One group comprised 14 cases of precancerous lesions (i.e., dysplasias) and five cases of carcinoma in situ (CIS); the second group comprised 46 previously untreated patients with invasive carcinoma. Tumor and normal DNAs were analyzed by polymerase chain reaction for genetic losses and instability at five polymorphic microsatellite loci (D5S392, D5S406, D5S208, D5S117, and D5S432) mapped to 5p.

RESULTS

LOH was observed in 25 (55.6%) of 45 informative invasive carcinomas, one (20%) of five cases of CIS, and three (21%) of 14 precancerous lesions. Among the loci tested, D5S406 (5p15.1-15.2) exhibited LOH in 12 (48%) of 25 invasive carcinomas, one (33%) of three cases of CIS, and three (60%) of five precancerous lesions, suggesting this to be the site in 5p of the novel candidate tumor suppressor gene. In addition, replication error-type alterations were noted in the 5p14-ter region in six (13%) of 46 invasive carcinomas, two (40%) of five cases of CIS, and three (21%) of 14 precancerous lesions. Instability affected D5S406 in eight (66.7%) of 12 instances that showed microsatellite instability.

CONCLUSION

These observations suggest that allelic loss and microsatellite instability in the region of D5S406 may play a role early in the development of cervical carcinoma and identify the site of a candidate tumor suppressor gene. These genetic markers (allelic loss and microsatellite instability) may also define CIS and precancerous lesions at high risk for progression to invasive cancer.

IMPLICATIONS

The future molecular cloning of the candidate tumor suppressor gene at 5p15.1-15.2 may provide new insights into the genetic mechanisms of cervical carcinogenesis. Analysis and clinical follow-up of a large cohort of prospectively ascertained cases of precancerous lesions would help to validate the usefulness of these markers.

Significance of inflammatory cervical smears

Two hundred and fifty-seven women attending a Maternal and Child Health Centre (MCH) were examined for different colposcopic and histological patterns associated with cervical inflammation as detected by cytology and for their association with different gynaecological infections. The cytodiagnosis revealed inflammation in 207 women (80.5%) and non-inflammation in 49 (19.5%); one smear was inadequate for evaluation. Fifty-six per cent of the women with inflammation and 20% with non-inflammation had an atypical transformation zone (ATZ), the risk of ATZ being 4.9-fold higher in those with inflammation. Biopsies from 128 women with abnormal colposcopy revealed morphological changes suggestive of human papillomavirus (HPV) in 89 (69.5%) and dysplasia of varying grades in 8 (6.3%). Seventy per cent of histologically diagnosed HPV lesions stained immunohistochemically, whereas 84% reacted with a biotinylated Pan-HPV probe by DNA in situ hybridization (DISH). In addition to HPV, chlamydia (OR 15.6, 95% CI 2.2, 311.6), T. vaginalis (OR 18.4), bacterial vaginosis (OR 24.7, 95% CI 3.5, 492) and herpes simplex virus (OR 4.9, 95% CI 1.4, 20.9) were significantly associated with inflammatory smears. Of 11 dysplasias detected by colposcopy and confirmed by biopsy, 8 (72.7%) had inflammatory cytology in the initial Pap smears. Thus a large proportion of women with inflammatory smears had multiple gynaecological infections and may be at increased risk of developing preneoplastic or neoplastic changes. Furthermore, they risk transmitting the infections to their partners.

Transthoracic (percutaneous) fine needle aspiration cytology diagnosis of pulmonary tuberculosis

OBJECTIVE

The present study was carried out to assess the utility of transthoracic (percutaneous) fine needle aspiration (FNA) cytology in the diagnosis of pulmonary tuberculosis.

DESIGN

During a period of 6 years (1985-90), 202 ultrasound and computerized tomography (CT)-guided transthoracic FNA of pulmonary lesions were performed. Review of smears available in 190 cases revealed 38 (20%) cases of pulmonary tuberculosis. Age of the patients ranged from 11 months-75 years with a median of 40 years. The common clinical diagnoses were malignancy (14 cases), tuberculosis (8 cases) and pneumonitis (7 cases). The sites of FNA were lungs in 36 cases and pleural based lesions in 2 cases.

RESULTS

Epithelioid granuloma without necrosis (type 1 reaction) were observed in 4 (10.5%) cases. Epithelioid granuloma with necrosis (type 2 reaction) and necrosis without epithelioid granuloma (type 3 reaction) were seen in 17 (44.7%) cases each. The overall rate of AFB positivity was 45.8%. The rate of acid-fast bacilli (AFB) positivity in type 1, 2 and 3 reactions were 0%, 38.5% and 60.0% respectively.

CONCLUSION

This study shows that transthoracic (percutaneous) FNA is a useful means for diagnosis of pulmonary tuberculosis, especially when the clinical and/or radiological features are non-specific or point towards malignancy rather than tuberculosis.

Association between reproductive tract infections and cervical inflammatory epithelial changes

OBJECTIVE

To determine the association, if any, between different reproductive tract infections and cervical inflammatory epithelial changes.

STUDY DESIGN

Clinical, colposcopic, cytologic, and microbiologic screening for reproductive tract infections was conducted. Subjects were screened for Chlamydia trachomatis, Neisseria. gonorrhoeae, Trichomonas vaginalis, bacterial vaginosis, yeast vaginitis, human papillomavirus, and serology for herpes simplex viruses, syphilis, and human immunodeficiency virus-1 and -2. The subjects were 257 women who visited a maternal and child health center between January 1992 and December 1993.

RESULTS

Cervical cytology revealed inflammatory epithelial changes in 207 women (80.5%), the highest proportion in the published series. Inflammatory epithelial changes were significantly associated with the number of reproductive tract infections. Risk increased up to 72.6 fold when women were infected with two or more agents. The positive predictive value of inflammatory epithelial changes for any infection was 88.4%, whereas the negative predictive value for any infection was 63.4%. In univariate analysis, the cervical inflammatory epithelial changes were significantly associated with infections such as chlamydia (28.0%), human papillomavirus (56.5%), Trichomonas vaginalis (18.3%), bacterial vaginosis (38.2%), and herpes simplex virus as evidenced by the presence of immunoglobulin M antibodies (28%). Multivariate analysis, however, revealed an independent association of inflammatory epithelial changes with chlamydia (odds ratio, 21.3; 95% confidence interval, 2.6, 181.3), human papillomavirus (odds ratio, 13.5; 95% confidence interval, 4.5, 39.6), and bacterial vaginosis (odds ratio, 22.6; 95% confidence interval, 2.9, 181) only.

CONCLUSION

Cervical inflammatory epithelial changes are significantly associated with reproductive tract infection. Cervical inflammatory epithelial changes predict correctly to an extent of 81% infections with chlamydia, bacterial vaginosis, and human papillomavirus infection. A negative smear, on the other hand, rules out these infections to an extent of 83%.

Epidemiologic analysis of Trichomonas vaginalis infection in inflammatory smears

Infections of the lower reproductive tract are common in Indian women of reproductive age. Hospital-based cytologic screening was undertaken on 63,265 women. The smears were examined for the presence of specific infections, such as Candida, herpes simplex virus, human papillomavirus, Trichomonas vaginalis (TV) and Chlamydia. This paper highlights the prevalence of TV infection in inflammatory cervical smears. Among the various infections detected, the rate of TV infection was the highest (5.1%). On further analysis the rate of TV infection showed an increasing trend up to the age of 49 years; an inverse association was observed with the educational status of the women. The prevalence was high in women with clinical signs (vaginitis, 6.9%) and low in those with a prolapsed uterus (1.2%) as compared to a normal cervix. These observations reveal the need for providing proper counseling and education on sexual behavior and genital hygiene besides treatment to control and prevent these infections.

Cytologic detection of strongyloides stercoralis in a routine cervicovaginal smear. A case report

A 28-year-old, lactating woman came for a routine checkup. Her cytologic smear revealed a single larva of Strongyloides stercoralis. On reviewing the literature on parasites encountered in cytologic smears, S stercoralis was found to be extremely rare. Our case is probably the second in the world and the first reported from India. A review of the literature on various parasites encountered in the cytologic smear is presented.

ERBB2 (HER2/neu) oncogene is frequently amplified in squamous cell carcinoma of the uterine cervix

We evaluated a panel of 22 protooncogenes for amplification in 50 primary, untreated squamous cell carcinomas of the uterine cervix. The tumors studied belonged to clinical stages II and III; histologically, the majority of them were moderately to well differentiated. Amplification represented by 5 or more copies was observed for the genes MYCL1, SEA, CCND1, BCL1, and GLI in one case each (2%); HRAS in 2 cases (4%); and ERBB2 in 7 cases (14%). Amplification of ERBB2 ranged from 5 to 68 copies. In addition, 2 tumors with ERBB2 amplification showed additional restriction fragments suggesting possible mutation or rearrangement of the gene. The high incidence of ERBB2 amplification in cervical cancer suggests that this gene may play an important role in tumorigenesis.

Fine-needle aspiration diagnosis of intra-thoracic and intra-abdominal lesions: review of experience in the pediatric age group

Review of fine-needle aspiration (FNA) smears from 121 pediatric patients with intra-thoracic and intra-abdominal lesions revealed 42 (34.7%) cases of neoplasms, 35 (28.9%) cases of tuberculosis, 12 (9.9%) cases of non-tuberculous inflammations, 4 (3.3%) cases of benign cystic lesions, and 28 (23.1%) inadequate/inconclusive cases. The age of the patients ranged from 20 days to 18 yr. Ultrasound and/or CT study done in 105 cases localized the lesions in following common sites: lungs (19 cases), mediastinum (22 cases), liver (14 cases), intestines (11 cases), and lymph nodes (17 cases). The neoplastic lesions consisted of 39 malignant, one suspicious, and two benign neoplasms. Among the neoplasms, the small round cell tumors were the most frequent (27 cases), followed by germ cell tumors (eight cases) and miscellaneous neoplasms (seven cases). The common small round cell tumors were non-Hodgkins lymphoma (eight cases), hepatoblastoma (seven cases), neuroblastoma (five cases), and nephroblastoma (three cases). A combined clinical, imaging, and FNA cytology approach was found to be useful in arriving at a tissue diagnosis.

Intranuclear inclusions in pleomorphic adenoma of salivary gland: a case report

On reviewing extensive literature on intranuclear cytoplasmic inclusions, one finds that the entity is almost synonymous with papillary carcinoma of the thyroid. But over the years, normal tissue aspirates as well as aspirates from many benign and malignant tumors have revealed the presence of these vacuoles. As more and more aspirations of cervical region are being done, it is becoming evident that intranuclear vacuoles are of decreasing specificity for papillary carcinoma of thyroid. This case is probably the first case report of intranuclear vacuoles from a pleomorphic adenoma of salivary gland and is being reported here for this unusual finding.

Inflammatory lesions of the breast: diagnosis by fine needle aspiration

Amongst 1061 breast lesions diagnosed by fine needle aspiration (FNA) over a period of 6 years (1985-1990), 128 were reported to be showing changes consistent with an inflammatory lesion. On review, the cytodiagnosis was found to be inaccurate in 31 cases. The cytological features of the 97 cases that were correctly reported are described in this report. The cytological diagnoses issued in these 97 cases were acute mastitis or breast abscess (57 cases) and tuberculous mastitis (30 cases). Non-specific chronic mastitis and miscellaneous conditions accounted for four and six cases respectively. Acid fast bacilli (AFB) were demonstrated in 28.0% of tuberculous mastitis cases and 10.0% of those diagnosed as acute mastitis or breast abscess. FNA cytology was found to be useful for the diagnosis of inflammatory lesions of breast and their classification, as only five out of 57 cases of acute mastitis/breast abscess and one out of 30 tuberculous mastitis cases were suspected on clinical grounds.

Superficial and deep-seated tuberculous lesions: fine-needle aspiration cytology diagnosis of 574 cases

Over a period of 2 yr (1987-1988), FNA smears in 574 cases were found to have cytologic features suggestive of or consistent with tuberculous lesions. The age of the patients ranged from 6 mo to 75 ye, with a median of 24 yr. The male to female ratio was 273:301. Sites of FNA were superficial lymph nodes (SLN) in 440 (76.7 percent) cases, superficial extranodal sites (SENS) in 50 (8.7 percent), both SLN and SENS in 7 (1.2%), the thoracic cavity in 16 (2.8%), and the abdominal cavity in 61 (10.6%). Cytologic features were described under 3 major cytologic patterns, i.e., type I: epithelioid granuloma without necrosis, type II: epithelioid granuloma with necrosis, type III: necrosis without epithelioid granuloma. Type I, II, and III reactions were observed in 181 (31.5%), 183 (31.9%), and 210 (36.6%) cases, respectively. The overall AFB positivity was 30.8%. The AFB positivities for type I, II, and III cytologic reactions were 5.4%, 32.0%, and 48.5%, respectively. The AFB positivity was low (less than 30.0%) in swellings of the body surface (23.8%) and abdominal organs (18.9%). High positivity (greater than 60.0%) was observed in lesions of the thorax (63.6%) and thyroid (62.5%).