A national survey of transrectal ultrasound-guided prostatic biopsies: time for a national guideline

The aim of this study was to elicit similarities and differences in transrectal ultrasound guided prostatic biopsy regimens in the UK and the Republic of Ireland. A telephone survey of 60 centres was conducted and information collected on the operator, the anaesthesia used, antibiotic prophylaxis and number of biopsies taken. Most prostatic biopsies were performed by urologists and most procedures involved six cores. There was a marked variation in the use of antibiotic prophylaxis, and anaesthesia was used sparingly. Our survey has shown a diversity in protocols used in transrectal ultrasound guided biopsies in the UK and Ireland. It seems sensible to standardise the technique for optimal patient satisfaction, as well as clinical efficiency. A national co-ordinated, prospective trial is needed.

The complete sequence of the rice (Oryza sativa L.) mitochondrial genome: frequent DNA sequence acquisition and loss during the evolution of flowering plants

The entire mitochondrial genome of rice (Oryza sativa L.), a monocot plant, has been sequenced. It was found to comprise 490,520 bp, with an average G+C content of 43.8%. Three rRNA genes, 17 tRNA genes and five pseudo tRNA sequences were identified. In addition, eleven ribosomal protein genes and two pseudo ribosomal protein genes were found, which are homologous to 13 of the 16 genes for ribosomal proteins in the mitochondrial genome of the liverwort (Marchantia polymorpha). A greater degree of variation in terms of presence/absence and integrity of genes was observed among the ribosomal protein genes and tRNA genes of rice, Arabidopsis and sugar beet. Transcription and post-transcriptional modification (RNA editing) in the rice mitochondrial sequence were also examined. In all, 491 Cs in the genomic DNA were converted to Ts in cDNA. The frequency of RNA editing differed markedly depending upon the ORF considered. Sequences derived from plastid and nuclear genomes make up 6.3% and 13.4% of the mitochondrial genome, respectively. The degree of conservation of plastid sequences in the mitochondrial genome ranged from 61% to 100%, suggesting that sequence migration has occurred very frequently. Three plastid DNA fragments that were incorporated into the mitochondrial genome were subsequently transferred to the nuclear genome. Nineteen fragments that were similar to transposon or retrotransposon sequences, but different from those found in the mitochondrial genomes of dicots, were identified. The results indicate frequent and independent DNA sequence flow to and from the mitochondrial genome during the evolution of flowering plants, and this may account for the range of genetic variation observed between the mitochondrial genomes of higher plants.

A novel extractionless hplc fluorescence method for the determination of glyburide in the human plasma: application to a bioequivalence study

PURPOSE

To develop a simple, sensitive and rapid HPLC fluorescence method with single step sample preparation for the determination of glyburide in the human plasma.

METHODS

Glyburide and ketoconazole (internal standard) were extracted from the 0.5 mL plasma by addition of 0.5 mL acetonitrile and 50 microL CuSO(4) solution (5% w/v in water). The separation was achieved on the Kingsorb 3 microm, C8 reverse phase column at ambient temperature with a mobile phase consisted of 45% buffer solution (0.05 M NH(4)H(2)P(4)), 40% acetonitrile and 15% methanol adjusted to pH 5.7 by diluted ammonia solution. A fluorescence detector was set at 235 nm excitation wavelength and 354 nm emission wavelengths to monitor eluted components.

RESULTS

The internal standard and glyburide eluted at about 6.7 and 9.6 min, respectively at the flow rate of 1 mL/min. The regression equation was established for every calibration curves (5 ng/mL to 400 ng/mL), which resulted in the correlation coefficient of 0.99 or greater. The absolute recovery ranged from 94.32 to 98.12% and the relative recovery ranged from 91.12 to 97.15%. The intraday coefficient of variation (CV) ranged from of 6.52 to 12.35% and interday varied from 6.21 to 16.07%. The limit of quantitation (LOQ) of glyburide was set to five ng/mL.

CONCLUSION

This simple, rapid and sensitive method is suitable for pharmacokinetic, bioavailability and biequivalence studies.

Investigating intrinsic myocardial mechanics: the role of MR tagging, velocity phase mapping, and diffusion imaging

Assessment of myocardial mechanics is an integral part of understanding and predicting heart disease. This review covers the two most common magnetic resonance (MR) methods used to measure myocardial motion: myocardial tagging and myocardial velocity mapping. Myocardial tagging has been well established in clinical research, despite its time-consuming postprocessing procedure. Myocardial velocity mapping uses the phase shifts of the spins to encode the velocity into the MR signal. This means that once the myocardial contours have been segmented, the data can be automatically processed to obtain quantitative measurements. Diffusion MR also has found applications in cardiac imaging, with preliminary results of myocardial fiber architecture being obtained recently. These three different MR techniques have provided valuable insights into the assessment of intrinsic cardiac mechanics. J. Magn. Reson. Imaging 2000;12:873-883.

Assessment of Her-2/neu overexpression in primary breast cancers and their metastatic lesions: an immunohistochemical study

Since the development of novel immunotherapy using Herceptin as the first agent specifically indicated for HER-2/neu overexpression in metastatic breast cancer, there has been interest in using HercepTest as a predictor of response to such therapy. There is debate whether it is justifiable to perform HercepTest on every newly diagnosed breast cancer, since only approximately 43% of the cases will have related metastatic disease, and Herceptin is indicated only for breast cancer with metastatic disease. It may be more cost-effective to limit HercepTest to the related metastatic lesions. Therefore, it is important to assess whether the pattern of HER-21neu overexpression of metastatic breast cancer is also present in the primary lesion. HercepTest was performed on formalin-fixed, paraffin-embedded tissue sections of 56 primary breast cancers and their corresponding metastatic lesions. The protocol and scoring guidelines recommended by the manufacturer were followed. Tissue sections (5 microm) of a primary and the metastatic lesion from the same case were placed parallel on a single glass slide. The pattern and intensity of HER-2/neu overexpression (32%) in the primary and metastatic lesions were found to be nearly identical. Heterogeneity was observed in only one case. The score of primary cancer was 3+, and the metastatic lesion was 2+. Both were reported as positive. Intratumor heterogeneity (1+ to 3+) was also noted in two (4%) cases. However, the same pattern was found in both the primary and related metastatic lesions. The nearly identical HercepTest results in the primary and metastatic lesions suggest the potentiality of limiting the HercepTest to breast cancer-related metastases. Currently, any superficial and most deep-seated metastatic lesions can be easily sampled by fine needle aspiration biopsy or core biopsy, providing adequate samples for HercepTest. Eliminating unnecessary use of the HercepTest may provide a cost-effective alternative approach to the management of breast cancer patients.

Assessment of prognostic factors in breast fine-needle aspirates

Because of the enhanced effects of new chemotherapeutic agents on the survival of patients with breast cancer, there has been increased interest in the use of prognostic factors. In the last several years, the literature has been saturated with new information about the prognostic/predictive value of traditional factors as well as the newly recognized biomarkers. Controversy, however, remains about the validity of each of the factors as independent prognostic indicators. The standard prognostic factors, recognized by the National Cancer Institute in 1990, include lymph node status, tumor size, nuclear grade, steroid receptor content, tumor type, and cellular proliferation rate. It is also recommended that for patients who undergo preoperative chemotherapy or radiotherapy, breast fine-needle aspirates can be used to provide prognostic information. This article is designed to discuss the traditional and also the newly recognized factors, such as DNA ploidy and proliferation rate, HER-2/neu oncogene, and tumor suppressor gene p53, in breast fine-needle aspirates and their clinical application in breast cancer management. An overview of the proposed guidelines developed by the National Cancer Institute is also presented.

Fluorescence in situ hybridization (FISH) for detection of HER-2/neu amplification in breast cancer: a multicenter portability study

Amplification and/or overexpression of HER-2/neu has been shown to be both a prognostic and predictive marker in breast cancer. Recent studies have also confirmed the efficacy of Herceptin (trastuzumab) as adjuvant therapy for patients with overexpression of HER-2/neu. Therefore, it is critical that precise and reproducible assays be used in the clinical laboratory setting for determination of the HER-2/neu status in patients with breast cancer. The objective of this study was to determine the portability (reproducibility between different institutions) of the PathVysion HER-2 fluorescence in situ hybridization (FISH) assay used for detection of amplification of the HER-2/neu gene in formalin-fixed, paraffin-embedded tissue sections of invasive ductal carcinoma of the breast. Study specimens consisted of one breast tumor with a normal HER-2/neu copy number, two tumors with a low level, and one tumor with a high level of HER-2/neu amplification. The PathVysion HER-2 assay was shown to be highly reproducible on different assay days (n = 3) and between different institutions (n = 5) in the detection of amplification of the HER-2/neu gene in routinely processed clinical specimens of breast carcinoma. In addition, this study examined the feasibility of enumerating FISH signals in 20 nuclei in contrast to 60 nuclei per specimen. Although a modest increase in variation was observed when analyzing 20 compared to 60 nuclei, the mean ratios were similar. Therefore, analysis of as few as 20 nuclei with this FISH HER-2/neu assay may be sufficient for determining the amplification level of the HER-2/neu gene.

Molecular predictive factors for local recurrence and distant metastasis of breast cancer after lumpectomy with postoperative radiation therapy

To determine the risk factors associated with the recurrence and metastasis of breast cancer after lumpectomy with postoperative radiation therapy, 112 cases were studied who had been treated during a period of 11 years at the University of Florida Health Science Center/Jacksonville. The patients were evaluated for their age, race, and clinical stage, as well as the tumor grade, stage, histological type, and node involvement. Among these cases, four (4%) recurred locally within a year of treatment; 10 (9%) cases presented with distant metastasis within three years. No obvious clinical risk factors were identified for local recurrence; however, positive-node status seemed to be associated with distant metastasis. The primary tumors of these cases were then studied using immunohistochemical staining to evaluate the potential prognostic value of tumor markers such as estrogen receptor (ER), progesterone receptor (PR), tumor suppressor gene p53, HER-2/neu oncogene, and multi-drug resistance gene (MDR). The expression of p53 was associated with all local recurrence cases as well as 50% of those who had metastasis. The expression of MDR was observed in 80% of the distant metastatic cases. This preliminary result may warrant further studies on larger number of cases to assess the predictive value of p53 and MDR in the outcome of breast cancers in patients treated with postoperative radiation therapy.

Immunoreactivity of ductal cells with putative myoepithelial markers: A potential pitfall in breast carcinoma

The identification of an intact layer of myoepithelial cells (MECs) located between epithelial cells and the basal lamina is useful in differentiating benign breast lesions and carcinoma in situ from invasive breast carcinoma. In the present study we used three antibodies considered to be putative markers of MECs (S100 protein, muscle-specific actin [HHF-35], and smooth muscle actin [SMA]) in 100 formalin-fixed, paraffin-embedded histologic sections of breast in an attempt to compare their value in demonstrating MECs in benign breast tissue and breast carcinomas. We concluded that for identifying MECs in benign breast tissue, SMA appears to be the most reliable, followed closely by HHF-35, but S100 is very unreliable for this purpose. In breast carcinoma, all three stains showed variable cross-reactivity with myofibroblasts, being greatest with SMA. A significant number of tumor cells in ductal carcinoma, both intraductal and invasive, stain with these markers and this "cross-reactivity" is extremely high with HHF-35. Thus, immunohistochemistry should be interpreted cautiously in differentiating benign, in situ, and invasive breast neoplasms. The "cross-reactivity" also suggests the possibility of myoepithelial differentiation and/or high actin content of breast tumor cells.

Comparison of proliferation activity in breast carcinoma by flow cytometry analysis of S-phase and quantitative analysis of MIB-1

The S-phase which assesses tumor proliferation has been considered to be an independent prognostic factor for breast carcinoma. Quantitative analysis of MIB-1 immunoreactivity is a newly recognized method of determining cellular proliferation that offers some advantages over flow cytometry when limited tumor tissue is available. However, it has been controversial whether there is a significant correlation between MIB-1 immunostaining and S-phase in defining proliferation activity in breast cancer. In order to explore the usefulness of MIB-1 as an additional proliferation parameter and a potential prognostic factor for breast cancer, we analyzed 94 cases of invasive ductal carcinoma of the breast by both flow cytometry (for S-phase and DNA ploidy) and quantitative MIB-1 immunohistochemical analysis using formalin-fixed paraffin-embedded tissue. MIB-1 staining was quantitatively analyzed by image analysis and by visual scoring. Forty-six cases were diploid by flow, while the remaining 48 cases were aneuploid tumors. T-test results indicated that S-phase means were significantly greater (p = 0.0001) in aneuploid cases (mean = 18) compared to diploid cases (mean = 7). MIB-1 means were also greater in aneuploid patients, but these differences were only marginally significant (p = 0.05). S-phase was positively correlated with MIB-1 (r = 0.36, p = 0.003 for image analysis and r = 0.34, p = 0.001 for visual scoring). ROC curve analysis indicated that MIB-1 quantitation is a good predictor of high S-phase (i.e., > 10 percent) in aneuploid cases. A MIB-1 cutoff value of 25 percent for image analysis achieved 82 percent specificity and 80 percent sensitivity for aneuploid high S-phase, while a MIB-1 cutoff value of 40 percent for visual scoring was 73 percent specific and 85 percent sensitive. However, in diploid cases, no comparable MIB-1 cutoffs could be achieved for detecting high S-phase. In summary, our study demonstrated that aneuploid breast carcinomas proliferate more aggressively than diploid tumors. Although linear correlation between MIB-1 and S-phase was weak, MIB-1 was considered to be a good predictor of high S-phase in aneuploid breast cancer patients, possibly due to a threshold effect. Image analysis and visual scoring of MIB-1 immunoreactivity appeared to be comparable in analyzing proliferative activity in breast cancer. Thus MIB-1 assessed by visual scoring may be a less expensive alternative to image analysis.

DNA content and cell proliferation in giant congenital melanocytic naevi (GCMN). An analysis by image cytometry

GCMN may be precursors of melanoma, and it has been suggested that the presence of atypical foci could increase the risk of malignant transformation. In order to better define atypical GCMN, we analyzed DNA content and proliferative activity in 21 samples of GCMN, with (n=13) or without (n=8) cytologic atypia. Six benign acquired naevi (AN) and 6 malignant melanoma (MM) were used as controls. DNA content was determined with the CAS 200 image analyzer, and DNA histograms were classified according to the Auer classification. The proliferative indices (PI) were measured after Ki 67 immunostaining using the CAS 200 system. All AN and GCMN without atypia showed class I histograms (normal DNA content) and low PI (mean 1.9 and 2.1). Atypical GCMN showed in 10 cases an abnormal DNA content (class III or IV histograms) with low PI (mean 2.7), and in 3 cases a normal DNA content (class I histograms) with higher PI (mean 16.2). All MM displayed abnormal DNA content and high PI (mean 32.6). In conclusion, abnormal DNA content seems to correlate with cytologic atypia in GCMN. Atypical GCMN exhibit an overall pattern of DNA content and cell proliferation intermediate between non-atypical naevi and MM.

Reproducibility of LSI HER-2/neu SpectrumOrange and CEP 17 SpectrumGreen Dual Color deoxyribonucleic acid probe kit. For enumeration of gene amplification in paraffin-embedded specimens: a multicenter clinical validation study

Overexpression and/or amplification of HER-2/neu gene have been found to be prognostic and predictive in breast and other cancers. Fluorescence in situ hybridization (FISH) assay, with its sensitivity and specificity, can be a superior method of detection when its performance characteristics are demonstrated. A multicenter study was initiated to evaluate the reproducibility of the LSI HER-2/neu SpectrumOrange and CEP 17 SpectrumGreen Dual Color DNA Probe for enumeration of both the HER-2/neu gene and chromosome 17 (signals) in interphase cells. Section slides were prepared from four cell lines (H, E, R, and N) with known ratios of the HER-2/neu to CEP 17 copy numbers (approximately H = 1.10, E = 1.70, R = 4.50, N = 9.0). The study variable was the ratios of the HER-2/neu to chromosome 17 copy numbers. Reproducibility with respect to assay, site, lot, day and reader was evaluated at 3 centers. Out of 120 specimen slides, 100 percent were successfully assayed. There were no significant differences among: (1) four repeated assays of the same specimen (p = 0.99), (2) the four probe lots (p = 0.33), or (3) the four study days (p = 0.54). There was statistically significant, but not important differences among centers and between readers. The ratios of the HER-2/neu to chromosome 17 copy numbers were estimated with accuracy and precision; the mean ratios (and sd) for specimens, H, E, R, and N were 1.05 (0.06), 1.81 (0.12), 4.48 (0.28), and 8.60 (1.23), respectively. In summary, assays with the LSI HER-2/neu and CEP 17 Dual Color DNA Probe Kit, conducted at three sites by 6 different technicians, over 8 assay days, using kits from four lots, were performed with a high success rate in paraffin-embedded specimens. The signal enumeration was also accurate and precise. This study demonstrated that the results obtained by using the LSI HER-2/neu SpectrumOrange and CEP 17 SpectrumGreen Dual Color DNA Probe Kit are reliable and reproducible.

Expression of HER-2/neu oncogene in normal, hyperplastic, and malignant endometrium

HER-2/neu oncogene is believed to be involved in tumorigenesis of several human malignancies. To assess the pattern of expression of this oncogene in normal, hyperplastic, and neoplastic endometrium, immunocytochemistry was applied to paraffin-embedded tissue sections obtained from 146 patients with endometrial adenocarcinoma. A spectrum of hyperplastic changes ranging from simple hyperplasia to atypical hyperplasia was seen in 15 percent (22/146) of cases. Expression for HER-2/neu oncogene was demonstrated as cell membrane staining. Normal, hyperplastic and neoplastic epithelial cells showed a heterogeneous expression for HER-2/neu oncogene. The intensity of the immunostaining and the number of cells stained for HER-2/neu oncogene had no significant association with surgical stage or histologic grade, although the proportion of patients demonstrating overexpression increased significantly as the histologic grade of their tumor increased (p = 0.030). Furthermore, in a multivariate analysis, a statistically significant correlation was found between the level of expression of HER-2/neu oncogene and overall survival (p = 0.025). This study demonstrated that HER-2/neu oncogene expression is variably present in normal and hyperplastic endometrium. Association between HER-2/neu oncogene expression, higher grade lesions and poor survival in patients with endometrial cancer may also justify assessment of HER-2/neu oncogene as a reliable prognostic indicator.

Nuclear grooves in fine-needle aspiration biopsies of breast lesions: do they have any significance?

Nuclear grooving is a recognized morphologic feature frequently seen in papillary carcinoma of the thyroid. This feature is also occasionally seen in other nonneoplastic and neoplastic conditions. Nuclear grooves have been described in tubular carcinoma of the breast. However, the significance of nuclear grooves in benign and malignant conditions of the breast has been rarely studied. In a retrospective study, we searched for the presence of nuclear grooves in Papanicolaou-stained and Diff-Quik-stained fine-needle aspiration biopsies (FNAB) of 50 cases of primary breast carcinomas, 25 cases of proliferative breast disease, and 25 cases of fibroadenoma. In addition, 10 cases of metastatic breast carcinoma diagnosed by FNAB were reviewed. Nuclear grooves were identified in 39 of 50 (78%) of the histologically confirmed primary breast carcinomas and in 9 of 10 (90%) of the cases of metastatic breast carcinomas in the Papanicolaou-stained smears. Nineteen of 50 (38%) of the cases of proliferative breast disease/fibroadenoma showed nuclear grooves in the Papanicolaou-stained smears. The difference between the percentage of cases showing nuclear grooves seen in the Papanicolaou-stained primary breast carcinomas and metastatic breast carcinomas compared with the benign breast lesions was statistically significant (P < 0.001 in the primary breast carcinoma cases and P < 0.01 in the metastatic breast cancer cases). Nuclear grooves were identified less often in the Diff-Quik-stained smears, and their presence in malignant lesions versus cases diagnosed as benign breast disease was not statistically significant. This study suggests that although the presence of nuclear grooves is more frequently seen in malignant breast lesions, their presence cannot totally exclude the possibility of benign breast disease. The presence of nuclear grooves, however, may serve as a diagnostic clue in metastatic tumors of unknown primary.

Interobserver variability in the classification of proliferative breast lesions by fine-needle aspiration: results of the Papanicolaou Society of Cytopathology Study

This study evaluates the applicability of the published cytologic criteria in the categorization of proliferative breast lesions by assessing the diagnostic accuracy and interobserver reproducibility of a panel of experts. Twelve breast fine-needle aspiration (FNA) specimens of biopsy-proven nonproliferative breast lesion (NPL) (1 case), proliferative lesions without atypia (PL) (7 cases), proliferative lesion with atypia (PLA) (1 case), and low-nuclear grade ductal carcinoma in situ (DCIS) (3 cases) were selected. Six FNAs were Papanicolaou (PAP) and 6 were Diff-Quik-stained (DQ). Six expert cytopathologists classified the smears using a summary of published criteria as a guideline. All 6 participants rendered the same cytologic diagnosis in 2/12 (16%) cases. The agreement among the 6 raters was low (Kappa = 0.35). Cytohistologic correlation was achieved in 26/72 (36%) FNA diagnoses. The correlation of the PAP-stained cases was better than the DQ: 17/36 (47%) PAP and 9/36 (25%) DQ correlated. Improving the correlation was achieved by amalgamation of NPL and PL into "low risk" and PLA and DCIS into "high risk" categories: 47/72 (65%) FNA diagnoses then correlated with histology [29/36 (81%) PAP and 18/36 (50%) DQ]. We conclude that the cytologic criteria of proliferative breast lesions need to be further defined and assessed. Consideration should be given to minimizing the number of diagnostic categories and adopting a terminology that has a direct effect on patient management.

Automation in cytology: a survey conducted by the New Technology Task Force, Papanicolaou Society of Cytopathology

Despite the overwhelming interest in the development of several computer based technologies in the last several years, the role of automation in cytology has remained controversial. The potential of these technologies in the reduction of false negative results in pap smears is well recognized. However, there is still remarkable confusion as how to incorporate automation in the routine practice of cytology. This prompted the New Technology Task Force of the George Papanicolaou Society of Cytopathology to design a survey to seek the opinion of those engaged in cervicovaginal cytology screening regarding the value of automation in cytology. In 1996, a ten question survey was sent to 1800 cytopathology laboratories throughout the nation. The response rate was 23% (416/1800). The responders represented laboratories varying from those with less than 5,000 pap smears to those with over 100,000 cases per year. The majority of the responders did not believe that automation is essential for cervicovaginal cytology. This was evidenced by the fact that only 12% of the laboratories were engaged in automated cytology and predominantly used it for quality control measures. The inability of small laboratories to absorb the extra expense involved in the integration of automated cytology in their practice, particularly in the current era of managed care was a major concern. There was also concern about the potential for compromise of patient care by the drive for corporate profits and the dissemination of wrong information to the public and physicians. Suggestions most frequently proposed included appropriate patient and physician education about the merits and pitfalls of the pap smear, and also endorsing an affordable universal fee for pap smears. Rescreening for all pap smears, reassessing the benefits of automation in cytology and development of the standards were other proposals. Partnership with larger cytology laboratories, creation of "cytology consortiums" with shared resources to provide regionalized automated rescreening services were also strongly suggested. This survey clearly indicates the need for further evaluation of automation in cytopathology and a focused attention to various issues surrounding cervicovaginal cytology screening.

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

ISSUES

Cervical squamous cell carcinomas, adenocarcinomas and their precursors are caused by the human papillomavirus (HPV). Although HPV appears to be essential to the transformation of these epithelial cells, it is not sufficient, and a variety of cofactors and molecular events must take place between when an HPV infection occurs and a cervical cancer or its precursor develops. This review examines the data supporting these contentions, briefly outlines the molecular events that occur, considers the epidemiology and natural history of the disease, and details the implications of using HPV detection and typing in both clinical management and population-based screening programs.

CONSENSUS POSITION

1. Based on the available molecular, clinical and epidemiologic data, a subset of HPVs are unequivocally the etiologic agents for cervical cancers and their precursors. 2. Different mucosotropic HPVs have varying neoplastic potential. However, the great majority of cervical HPVs have oncogenic potential. Since oncogenic HPV-induced epithelial transformation to a high grade lesion or cancer is rare relative to the rate of infection, the term high risk is discouraged. 3. HPV's interaction with host cells has two principal biologic consequences: a) All anogenital HPVs induce low grade squamous lesions, which are the morphologic correlate of a productive infection. b) Rarely, HPVs induce a proliferative epithelial phenotype that pathologists recognize as a high grade lesion and that is the proximate cytohistologic precursor of invasive cervical carcinoma. 4. HPV biology and issues of practical clinical management should be reflected in the classification systems used for cytologic and histologic diagnosis.

ONGOING ISSUES

The molecular identification of HPVs (HPV testing) potentially may be very useful for primary screening or secondary triage of patients with certain lesions. However, the technology available to the practicing clinician is still evolving. Optimization of type spectrum, sensitivity, specificity and ease of use is under development. Data regarding these factors as well as a clear cost benefit analysis are sparse or pending in several large trials. Until such data are available, caution in clinical implementation of HPV testing is warranted.

The prognostic value of HER-2/neu oncogene in cervical cancer

BACKGROUND

Expression of the HER-2/neu oncogene has been suggested to confer added virulence or aggressive behavior in gynecologic malignancies. The aim of this study is to determine the frequency of HER-2/neu expression in invasive cervical cancer and its impact on survival in women with cervical cancer.

DESIGN

Archival tissue from 150 patients with cervical carcinoma was evaluated immunohistochemically for HER-2/neu oncoprotein expression. Survival information was retrieved retrospectively from patients' medical records.

RESULTS

The HER-2/neu expression was observed in 34 out of 150 tumors (22%). The HER-2/neu positive tumors exhibited considerable heterogeneity in the distribution of immunoreactive tumor cells. Tumor grade and histology did not influence the pattern or intensity of HER-2/neu expression. There was no statistically significant difference in survival of patients with HER-2/neu positive and those with HER-2/neu negative tumors (P = 0.50). Tumor stage at diagnosis was the only covariate with prognostic significance in patient survival (P < 0.001).

CONCLUSION

Expression of HER-2/neu oncogene is a rare event in cervical cancer. Immunohistochemical detection of HER-2/neu expression is neither a predictor of survival of patients with cervical cancer nor does it identify subgroups of patients at higher risk for recurrence of disease.

Why women still die from cervical cancer

Cervicovaginal cytology, known as Pap smear, is the most effective screening test in medical oncology. Introduced by Dr. George Papanicolaou in 1940, the Pap smear is now being recognized as a major contributor to the remarkable decrease in cervical cancer morbidity and mortality among women throughout the world. However, there are still significant numbers of women who lose their lives to cervical cancer every day. To overcome this major problem, first, we must search for the reasons for these lost lives and then take appropriate measures to resolve the existing issues. There is now substantial evidence that emphasizes the importance of an effective screening program. This program must integrate education and accessibility to health care for all women regardless of age, race, ethnic background and socioeconomic status. The public, the media, the government and health care providers must also become acutely aware of the inherent difficulties involved in providing a high-quality Pap smear. Compounded by medicolegal pressures and reimbursement issues, the Pap smear has become one of the more difficult tests to perform. Current reimbursement mechanisms are not appropriate for the cost of providing the service and cannot guarantee the resources necessary for a high-quality Pap smear. Congress should consider mandating direct billing to the patient for the service, so that cervicovaginal cytology could be reimbursed on a level commensurate with the requirements of providing quality service. A concerted effort should also be made to enhance the level of public knowledge about the issues surrounding Pap smear. This could be achieved by fostering the idea of designating a "Cervical Cancer Awareness Month," and by encouraging the spirit of community networking.

Fat embolism with the use of intraosseous infusion during cardiopulmonary resuscitation

The objective of this prospective study was to assess the incidence and magnitude of fat emboli after cardiopulmonary resuscitation and intraosseous infusions. An animal laboratory at a university center was used to study 33 mixed-breed piglets. The piglets underwent hypoxic cardiac arrest followed by chest compressions and mechanical ventilation for a minimum of 30 minutes. The animals were divided in groups: group 1 (n = 5), which had no intraosseous cannulas, group 2 (n = 6), which had intraosseous cannulas with infusion, groups 3 (n = 6), 4 (n = 6), and 5 (n = 8), which had intraosseous cannulas with infusion of epinephrine, normal saline, and sodium bicarbonate respectively, and group 6 (n = 2), which was a sham group with no intraosseous cannulas and no cardiopulmonary resuscitation. At cessation of cardiopulmonary resuscitation, representative lung samples were collected from upper and lower lobes of each lung and observed for fat globules and bone marrow elements. Fat globules were seen in the peribronchial blood vessels and intravascular areas throughout all lung fields of groups 1 through 5. There was no difference in appearance or distribution of fat globules among the 5 treatment groups. Analysis of variance showed no statistical significance (P < 0.05) within or among groups 1 through 5. The use of the intraosseous cannula for infusion of emergency drugs and fluids did not increase the magnitude of fat embolization over cardiopulmonary resuscitation alone in this animal model. The benefits of using this procedure in critically ill children as a means of rapid vascular access for resuscitation is well established. However, the risk of fat embolism in this population needs further study.

Estrogen receptor immunocytochemistry in endometrial carcinoma: a prognostic marker for survival

Only a few parameters such as tumor grade and stage are of value in prognosticating disease course in endometrial carcinoma. Biochemical steroid hormone receptor assays could also be useful but are difficult to perform and interpret. Immunocytochemical assay (ICA) might be the method of choice for detecting endometrial receptors.

METHODS

Frozen tissue from 78 cases of endometrial adenocarcinoma was examined for the presence of estrogen (ER) and progesterone receptors (PgR) with specific monoclonal anti-receptor antibodies and the peroxidase-antiperoxidase method. In over 60 cases, frozen tissue was also assayed for ER and PgR by biochemical means.

RESULTS

Fifty-five (71%) of the endometrial carcinomas were ERICA-positive and 55 (71%) PgRICA-positive. Although both ERICA and PgRICA correlated significantly with biochemical ER and PgR only ERICA was predictive of survival. A woman with a negative ERICA was 4 times more likely to die of her disease than if she were ERICA-positive (P = 0.009; mean follow-up, 37.5 months). Three cases ERICA-positive and PgRICA-negative survived while 3 others ERICA-negative and PgRICA-positive died.

CONCLUSION

ERICA, a technique easy to perform and interpret at the community hospital level, appears to provide prognostic information independent of tumor stage and grade. Such information might be of value in planning postoperative therapies for women with endometrial cancer.

Breast health. Challenges and promises

There has been significant improvement in breast health care in the United States over the past few decades primarily due to advances in health research by diverse teams of basic scientists, physicians, pharmacists, industries, nurses, and social workers. This research has involved inquiries about fundamental biological alterations in breast cancer, differences in diagnostic modalities, and treatment options and various outcome studies. Increase in public awareness of breast cancer, an interest in women's health issues, advances in radiologic imaging, development of new chemotherapeutic agents and the availability of molecular genetic testings have brought remarkable opportunities to a new insight in breast cancer. These efforts have resulted in earlier detection and prolonged disease-free intervals, however, the overall survival time has remained the same. This is mainly attributable to the wide range of individual therapy for breast cancer, which responds to a range of disease curable by surgery alone to one refractory to treatment and marked by rapid metastatic progression. Challenges remain in fostering adequate funding for biomedical, as well as behavioral and social research. Attempts should also be made to promote clinical and population-based studies and to emphasize the value of effective delivery of health-care services to all women with benign, high risk, premalignant and malignant breast disease.

Altered expression of alpha-smooth muscle isoactin in Hirschsprung's disease

OBJECTIVE

To analyze the expression of smooth muscle actin (SMA) contractile proteins in the intestinal muscle of patients with Hirschsprung's disease.

DESIGN

A total of 56 colonic whole-wall specimens were tested with immunohistochemistry and monoclonal antibodies directed against, respectively, alpha and pan (alpha and gamma) SMA.

PATIENTS

The study included both aganglionic and dilated normoganglionic colonic samples from 29 children who had undergone definitive surgery for Hirschsprung's disease. Morphologically normal (n = 6) and dilated colons (n = 5) from 11 patients suffering from conditions unrelated to Hirschsprung's disease served as controls.

RESULTS

The alphaSMA immunostaining showed a pattern identical to normal controls in all the aganglionic areas and in 70% of the normoganglionic segments. In contrast, a lack of alphaSMA expression confined to the circular muscle cells was observed in 30% of the normoganglionic specimens and in the five dilated control specimens. The same areas showed a faintly reduced immunoreactivity with the antibody to pan SMA, consistent with the absence of alpha-isoactin, but implying the presence of gamma-isoactin. In the Hirschsprung's disease cases, the absence of alphaSMA expression at the time of surgery was associated with the occurrence of long-term postoperative motility problems (p<.01).

CONCLUSION

These data suggest that alphaSMA expression defect in Hirschsprung's disease may be acquired and related to chronic colonic obstruction and subsequent dilatation. The observed changes correlate with disturbances of peristalsis and could be used to assess the risk of intestinal dysmotility frequently reported after surgical removal of the aganglionic bowel.

Percutaneous and intraoperative aspiration biopsy cytology of pancreatic neuroendocrine tumors: cytomorphologic study with an immunocytochemical contribution

OBJECTIVE

To evaluate the efficacy and accuracy of fine needle aspiration biopsy (FNAB) in the diagnosis and recognition of pancreatic neuroendocrine tumors (NETs).

STUDY DESIGN

The study group consisted of six cases of pancreatic tumors correctly diagnosed or strongly suggested to be NET based on fine needle aspiration biopsy (FNAB) cytology and was retrospectively reviewed. Also reviewed and examined were the immunocytochemical (ICC) stains applied to five of the aspirates and electron microscopic (EM) study done on one case.

RESULTS

Five cases were collected by computed tomography (CT)-guided aspiration, and one case was obtained intraoperatively by the surgeon. All six cases showed characteristic cytomorphologic features sufficient for their recognition and separation from pancreatic adenocarcinoma and other lesions. The ICC staining results and EM study were very helpful in confirming the cases' neuroendocrine cell origin. Histologic confirmation was available for four cases.

CONCLUSION

Intraoperative and CT-guided FNAB of the pancreas is a valuable method in the recognition of NET of the pancreas, particularly when coupled with ICC studies and appropriate clinical and radiologic settings.

Cytopathology and the pathology resident. A survey of residency program directors

OBJECTIVE

To collect information on the status of cytopathology training in the United States.

DESIGN

Questionnaire survey mailed in June 1994.

SETTING

Pathology residency training programs in the United States.

PARTICIPANTS

Pathology residency directors.

MAIN OUTCOME MEASURES

Training length, numbers of cytology specimens, teaching methods and topics, and graduated responsibility.

RESULTS

Of the 196 surveys mailed, 101 (52%) programs responded. The average length of required training was 3 months. The perceived optimal training time averaged 4.5 months, however, with 80% of programs requiring less than their stated optimum. The median numbers of gynecologic, nongynecologic, and fine-needle aspiration biopsy specimens examined per resident were 1100, 500, and 200, respectively. Cytopreparatory techniques, laboratory management, computer systems, and immunocytochemistry were included in over 75% of cytopathology training programs. Teaching at the microscope was rated as the most important teaching method by 90% of respondents. The majority of senior residents performed fine-needle aspiration biopsy procedures and screened and signed out cases with direct faculty supervision, but fewer than 20% of programs allowed senior residents to independently sign out specimens.

CONCLUSIONS

Recommendations based on this review include a minimum training time of 3 months, improved training in both fine-needle aspiration biopsy techniques and gynecologic cytology, continuous exposure to cytopathologic techniques, and increased graded responsibility for senior residents.

Prognostic factors in breast cancer: use of cytologic preparations

There is increasing evidence that certain morphological features and biological markers found in breast tumors may provide prognostic information by predicting the risk of recurrence and metastasis in early breast cancer. This information may also be important in choosing therapeutic options in patients with advanced disease. Prognostic testing is commonly performed on surgically excised lesions. However, there are clinical conditions in which a surgical specimen may not be suitable or available for such analysis. In these circumstances, fine-needle aspiration biopsy and imprint preparation provide an attractive sample for prognostic testings. This review summarizes the current approach to the use of cytologic preparation for assessment of established and newly recognized prognostic factors.

Value of ancillary studies in fine-needle aspiration biopsy

With growing interest in the application of fine-needle aspiration biopsy (FNAB) in primary diagnosis of benign and malignant lesions, there has been a significant increase in the use of ancillary studies in the aspirated material. To assess the value of such studies, we reviewed 254 morphologically difficult aspiration biopsy cases obtained from different sites that underwent ancillary studies which included microbiology (MC), special stains (SS), immunocytochemistry (ICC), electron microscopy (EM) and flow cytometry (FC). Correlation with available histologic material and/or pertinent clinical information was used as a "gold" standard. In some cases, more than one ancillary study was performed on a single aspirate. According to the impact of the ancillary studies on the final diagnosis, these studies were divided into three categories: confirmatory/diagnostic (22%), helpful (41%), and non-helpful (37%). Overall, more studies had positive contributory effect to the diagnosis (63%) than those with non-helpful results (37%). Among these adjunct testings, ICC were the most commonly used tests (135/296, 46%), while the EM studies had more positive impact in establishing the diagnosis. These findings emphasize the usefulness of ancillary testings in FNAB and justify the more selective use of these studies in the aspirated material.

Prediction of recurrence for advanced breast cancer. Traditional and contemporary pathologic and molecular markers

Approximately 50% of patient with breast cancer ultimately develop metastases, among which only 10% to 15% of patients live 5 years or more. Patients with locally advanced (stage III) breast cancer have a 5-year survival rate of approximately 20% to 30%. Thus, despite high remission rates obtained with current therapies, the poor long-term results associated with the apparent plateau of response achievable with systemic therapies emphasize the necessity of identifying accurate prognostic factors for this group of patients. This will allow an informed discussion with the individual patient. In addition, prognostic information could be used to guide the therapy and also to identify those subgroups of patients who may benefit with less-aggressive therapies. Furthermore, in the context of randomized studies, prognostic factors can be used to stratify patients. Prognostic factors have been extensively studied in early-stage breast cancer. In comparison, only a few studies exist on biologic prognostic factors in advanced breast cancer. Based on the limited information available, it appears that the biologic factors prognostic for locally advanced breast cancer are similar to those reported for early-stage breast cancer. Apparently, certain factors have a prognostic value irrespective of the stage of the disease at the time of presentation. This would then suggest that certain factors maintain their significance as the breast cancer progresses from an overtly local to a systemic disease. It is already well recognized that histologic grade is a significant prognostic factor for early-stage as well as metastatic breast disease. Hormone receptors have been reported to be of prognostic value at all stages of disease. Proliferation rate assessed by a variety of techniques as well as determination of the Nottingham Primary Prognostic Index provides important information about the rate of the growth of the tumor. Thymidine labeling index and S-phase fraction also provide information in regard to response to chemotherapy. DNA ploidy has been reported to be of significance in prediction of response to adjuvant chemotherapy and to a lesser extent to hormone therapy. The value of DNA ploidy in relation to survival in advanced breast cancer, however, remains controversial. Other prognostic factors such as oncogenes, tumor suppressor genes, and growth factors have also shown some predictive value in advanced breast cancer. Similar to what has also been suggested in early breast cancer, much research still needs to be done to clarify the role of currently available prognostic factors and to identify new, more powerful discriminants.(ABSTRACT TRUNCATED AT 400 WORDS)

Application of immunostaining for muscle specific actin in detection of myoepithelial cells in breast fine-needle aspirates

Myoepithelial cells play an important role in the interpretation of breast fine-needle aspiration biopsy, since these cells are believed to be a component of a benign process in breast lesions. Myoepithelial cells are usually easy to recognize, however, other cells can morphologically simulate myoepithelial cells and make the distinction difficult. To assess the feasibility of immunostaining as an adjunct to identify myoepithelial cells, we have used immunocytochemistry using monoclonal antibody against muscle specific actin (MSA) in our breast fine-needle aspirates. Herein, we report our experience in immunocytochemical detection of myoepithelial cells using labeled Streptavidin Biotin Detection System on destained Papanicolaou stained smears and cell block preparations obtained from breast aspirates.

Preoperative factors of prognostic significance in gastric cancer

This study was undertaken to investigate the ability of local anatomical and primary histological features of gastric cancers, as well as DNA analysis, to predict prognosis. Using multivariate analysis, results indicate that location of a tumor in the gastric cardia, poor differentiation, involvement of adjacent organs, and aneuploidy are all independent predictors of survival. All of the factors studied can be determined by endoscopic procedures preoperatively on patients with gastric cancers and could be helpful in selecting some patients for perioperative adjunctive therapies.

Unsuspected metastatic renal cell carcinoma diagnosed by fine needle aspiration biopsy. A report of four cases with immunocytochemical contributions

Fine needle aspiration biopsy (FNAB) is currently considered a valid procedure in the diagnosis of various primary and metastatic neoplasms. It is also known that computed tomography (CT)-guided percutaneous FNAB of the kidney is very useful in diagnosing primary renal cell carcinoma (RCC) and has a high accuracy rate. Nonetheless, its usage in the detection of unsuspected metastatic RCC has been described rarely. Below we report four unusual cases of metastatic RCC discovered by FNAB. The patients presented with subcutaneous, pulmonary, adrenal and flank masses with no previous history of RCC. Immunocytochemical (ICC) stains, including cytokeratin, epithelial membrane antigen, vimentin and fat stain, were obtained on two cases and were very helpful in establishing the diagnosis. We suggest that cytopathologists consider metastatic RCC a possibility when evaluating patients with tumors of unknown origin and that FNAB can be useful in diagnosing unsuspected metastatic RCC, especially when assisted by ICC and fat stain.

Prognostic and diagnostic implications of estrogen and progesterone receptor assays in cytology

Scientific evidence suggests that cancer is a consequence of genetic changes that result in uncontrolled cellular growth, tissue invasion, and metastasis. This concept has led to a great deal of excitement in the medical community in the hope that precise identification of genes involved in human cancer could potentially facilitate our understanding of human malignancies. It may also be possible to apply this information directly to different clinical settings. Many technologies are now available which offer opportunities for pathologists to not only expand their diagnostic abilities, but also to assess the prognosis of a given tumor in a specific patient. These include immunocytochemistry, flow cytometry, cell image analysis, and molecular genetic studies. In this review, the role of immunocytochemical hormone receptor assay as an aid in tumor prognosis and in prediction of tumor response to endocrine therapy will be discussed. Emphasis will be placed on the use of hormone receptor assay as an adjunct in diagnostic pathology and in assessment of metastatic tumors of unknown origin. The potential value of assessment of hormone receptors in different cytologic preparations will also be discussed.

Ductal carcinoma in situ of the breast

DCIS is an early localized stage of mammary malignancy that has an especially favorable prognosis with appropriate management. It seems to be a direct precursor to invasive carcinoma of the breast and has the same therapeutic options. There are still many outstanding issues to be resolved before the intriguing potential of this disease can be fully realized. Any physician involved in the management of diseases of the breast must be committed to a thorough understanding of all aspects of the biologic factors of this entity, so as to be able to rationally provide appropriate advice and treatment. Ongoing investigations should advance the knowledge and experience with this disease in future years.

Differential oncogenic expression in thyroid follicular and Hürthle cell carcinomas

Although Hürthle cell tumors are considered to be variants of follicular neoplasms, they have distinct cytologic and behavioral characteristics. To elucidate the basis for these differences, the expression of 5 oncogenes and growth factors (Pan-ras, N-myc, transforming growth factor-alpha [TGF-alpha], transforming growth factor-beta [TGF-beta], and insulin-like growth factor 1 [IGF-1]) was compared between 12 follicular carcinomas and 8 Hürthle cell carcinomas by immunocytochemistry. The percentage of follicular carcinomas and Hürthle cell carcinomas that stained positively for the different oncogenes was as follows and respectively: Pan-ras 8% versus 63%; TGF-alpha 17% versus 63%; TGF-beta 25% versus 88%; IGF-1 17% versus 88%; and N-myc 17% versus 100%. All these differences were highly significant by the chi 2 test. This difference in the expression of oncogenes between Hürthle cell carcinomas and follicular carcinomas suggests that these two tumors could, in fact, represent separate entities.