"ASCUS, rule out HSIL": cytologic features, histologic correlates, and human papillomavirus detection

Risk factors, cytologic and histopathologic features, and human papillomavirus (HPV) detection associated with 75 cervical smears classified as atypical squamous cells of undetermined significance, rule out high-grade squamous intraepithelial lesion (ASCUS, rule out HSIL) were reviewed. Cases were identified in a pathology panel review of material collected from 1953 women participating in a 5-year prospective study of HPV infection and squamous intraepithelial lesions at Kaiser Permanente, Portland, Oregon, sponsored by the National Cancer Institute. Initial abnormal smears diagnosed as ASCUS, rule out HSIL by one panelist or diagnosed as ASCUS by one pathologist and as HSIL by another were included. The 75 ASCUS, rule out HSIL smears identified were examined again by two pathologists after the study. These cases were compared with cases of ASCUS, not otherwise specified (ASCUS, NOS) and HSIL identified in the same group of 1953 women. Findings in ASCUS, rule out HSIL included tissue fragments (21%); atypical immature metaplasia (17%); atypical mature metaplasia (15%); small atypical cells (9%); and atypical repair (4%). A final patient classification of HSIL, reflecting all available data, was assigned to 11 (24%) of 46 women with ASCUS, rule out HSIL and to 1(1%) of 80 women with ASCUS, NOS in the original review (P < .001). Detection of oncogenic HPV types at diagnosis in ASCUS, rule out HSIL; ASCUS, NOS; and HSIL was similar, but data were unavailable for many subjects. Among women not tested at diagnosis, enrollment testing (1 to 4 years earlier) revealed that HPV detection in women with ASCUS, rule out HSIL was intermediate in frequency between ASCUS, NOS and HSIL. These data suggest that ASCUS, rule out HSIL is a distinct diagnosis from ASCUS, NOS because it is more often associated with an underlying HSIL. Consequently, women with ASCUS, rule out HSIL should be referred for colposcopic examination.

Soluble interleukin 2 receptor levels and cervical neoplasia: results from a population-based case-control study in Costa Rica

Progression from infection with human papillomavirus (HPV) to cervical cancer in some women is thought to involve a permissive host environment, one in which immune response is mobilized in an inappropriate manner. In a previous study (A. Hildesheim et al., Cancer Epidemiol. Biomark. Prev., 6: 807-813, 1997), increasing levels of soluble interleukin 2 receptor (sIL-2R), a known proxy for general immune activation, was found to be positively associated with increasing levels of cervical neoplasia. We attempted to confirm this finding by conducting a nested case-control study of 478 women within a 10,000-woman population-based cohort in Costa Rica. We selected for the study all of the women diagnosed (at enrollment into the cohort) with: (a) low-grade squamous intraepithelial lesions (LSIL, n = 191); (b) high-grade squamous intraepithelial lesions (HSIL, n = 130); or (c) cancer (n = 37). Controls were 120 cytologically normal, HPV-negative women selected from a random sample of the entire cohort. A questionnaire was administered to participants to elicit information on cervical cancer risk factors. All of the women received a pelvic examination during which cervical cells were collected and used for HPV DNA testing by PCR. Blood samples were also collected. Plasma obtained from the blood samples was tested for sIL-2R levels by ELISA. Results indicated that sIL-2R levels increased with age. Among controls, we observed that 44.3% of women over the age of 50 had high levels of sIL-2R (defined as >735 units/ml) compared with 15.8% of women <30 years of age (P = 0.008). When women with cervical disease (LSIL+) were compared with controls, women in the upper quartile of the sIL-2R distribution had an age-adjusted odds ratio (OR) of 2.1 [95% confidence interval (CI), 1.1-4.1]. Comparing each advancing state of neoplasia with its precursor, we found that women with LSIL had higher sIL-2R levels than controls (OR for upper quartile of sIL-2R, 2.3; 95% CI, 1.1-5.2; comparing LSIL cases with controls); women diagnosed with HSIL were similar to the LSIL group (OR for upper quartile of sIL-2R, 1.1; 95% CI, 0.5-2.4; comparing HSIL cases with LSIL cases); and those with cancer had higher sIL-2R levels than subjects with an HSIL diagnosis (OR for upper quartile of sIL-2R = 1.8; 95% CI, 0.5-7.1; comparing cancer cases with HSIL cases). These data suggest that among our study subjects, sIL-2R levels most likely rise as a response to the events of infection and cancerous invasion, but that sIL-2R levels are unlikely to be predictive of disease progression among women with LSIL.

Cervicography screening for cervical cancer among 8460 women in a high-risk population

OBJECTIVE

Cervicography was evaluated as a primary screening method for cervical cancer.

STUDY DESIGN

Cervigrams of 8460 women were taken on enrollment into a population-based study of cervical neoplasia. Cervicography results were compared with a referent diagnosis determined by histologic analysis and 3 cytologic tests, and with the performance of conventional cytologic evaluation.

RESULTS

Cervicography identified all 11 cancers, whereas cytologic testing missed 1. Cervicography yielded sensitivities for detecting high-grade squamous intraepithelial lesions or cancer of 49.3% overall (specificity, 95.0%), 54.6% in women younger than 50 years of age, and 26.9% in women 50 years of age and older. Cytologic testing yielded sensitivities for detecting high-grade squamous intraepithelial lesions or cancer of 77.2% overall (specificity, 94. 2%), 75.5% in women younger than 50 years of age, and 84.6% in women 50 years of age and older.

CONCLUSIONS

Cytologic testing performed better than cervicography for the detection of high-grade squamous intraepithelial lesions. Cervicography performed marginally better than cytologic testing for the detection of invasive cervical cancer. Cervicography is not recommended for postmenopausal women.

The stability of estrogen and progesterone receptor expression on breast carcinoma cells stored as PreservCyt suspensions and as ThinPrep slides

BACKGROUND

Analysis of estrogen receptor (ER) and progesterone receptor (PR) status is an important ancillary test in the evaluation of positive breast fine-needle aspirates. This study compares the detection of ER and PR in breast carcinoma cells suspended in PreservCyt with that achieved with stored ThinPrep slides (TP).

METHODS

ER and PR positive mammary tumor cells (cell line ZR-75-1 spiked in PreservCyt by the American Type Culture Collection) were used to evaluate the stability of immunodetection of ER and PR under two conditions: 1) TP slides prepared immediately from PreservCyt and stored air-dried (stored TP) for up to 56 days, and 2) TP prepared from cells suspended in PreservCyt (newly prepared TP) on Days 1, 2, 5, 14, 21, 42, and 56. At each of the time periods, stored TP and newly prepared TP were analyzed for ER and PR using the same immunocytochemical staining protocol. The percentage of positive cells was calculated by counting 1000 cells/TP.

RESULTS

Positivity for ER and PR was demonstrated in both stored TP and newly prepared TP on Days 1, 2, 5, 14, 21, 42, and 56. Over the 56-day period, the number of ER positive cells ranged from 41% to 57% in stored TP and from 38% to 58% in newly prepared TP. The number of PR positive cells ranged from 31% to 41% in stored TP and from 26% to 37% in newly prepared TP. Mild, nonspecific cytoplasmic and nuclear staining occurred in all newly prepared TP (PR > ER).

CONCLUSIONS

ER and PR antigenicity was preserved in both stored TP and newly prepared TP of mammary tumor cells over a 56-day storage period. This demonstrates that ER and PR status can be evaluated in cytologic material from breast carcinoma using the ThinPrep technique.

Human leukocyte antigen class I/II alleles and development of human papillomavirus-related cervical neoplasia: results from a case-control study conducted in the United States

The host immune response to human papillomaviruses (HPVs) is believed to be an important determinant of progression of HPV-associated cervical neoplasia. Human leukocyte antigens (HLAs) are important in the presentation of foreign antigens to the immune system. Previous studies have suggested a possible association between HLA and cervical neoplasia, but the specific alleles found to be associated with disease have varied between studies. To further evaluate this issue, we conducted a nested case-control study within a 24,000-woman cohort study in the United States. A total of 711 women were selected for the study: 141 women diagnosed with high-grade squamous intraepithelial lesions (HSILs) of the cervix; 202 women diagnosed with low-grade SILs (LSILs); 166 women with no history of cervical neoplasia, but evidence of HPV-16 infection; and 202 women with no history of cervical abnormalities and who were HPV negative during follow-up as part of our cohort. Cervicovaginal lavage samples collected from participants were used for HPV testing by L1 consensus primer PCR and the Hybrid Capture tube test methods. DNA extracted from these same lavage samples were used for PCR-based HLA genotyping. Our results suggest a positive association between HLA B7 and HLA DQB1*0302 and disease. A negative association with disease was observed for HLA DRB1*1501-DQB1*0602 and DRB1*13. Associations were strongest when analyses were restricted to HPV-16-positive cases as follows. Compared with women who were cytologically normal and HPV negative, HLA B7 was associated with a 1.5-fold increased risk of HPV/LSIL [95% confidence interval (CI) = 0.95-2.5] and a 2.5-fold increased risk of HSIL (95% CI = 1.2-5.1). HLA DQB1*0302 was associated with a 1.5-fold increased risk of HPV/LSIL (95% CI = 0.94-2.4) and a 1.7-fold increased risk of HSIL (95% CI = 0.84-3.5). HLA DRB1*1501-DQB1*0602 was associated with a decreased risk of HSIL [relative risk (RR) = 0.21; 95% CI = 0.07-0.62]. HLA DRB1*13 was associated with a decreased risk of HPV/LSIL (RR = 0.78; 95% CI = 0.51-1.2) and HSIL (RR = 0.63; 95% CI = 0.30-1.3). Individuals who were either homozygous for DQB1*0302 or carriers of both B7 and DQB1*0302 were found to be at highest risk of disease (RR = 4.5, 95% CI = 1.5-14 for HPV/LSIL; and RR = 9.0, 95% CI = 2.4-34 for HSIL). No synergistic effect was observed for the alleles found to be associated with reduced risk of cervical neoplasia. Our findings support previous studies that have found HLA B7 and DQB1*0302 to be positively associated with cervical neoplasia and are consistent with those that have suggested that DRB1*13 is negatively associated with disease, but do not confirm previous assertions that DRB1*1501-DQB1*0602 increases the risk of cervical disease.

Comparison of PCR- and hybrid capture-based human papillomavirus detection systems using multiple cervical specimen collection strategies

This study compared the performances of three human papillomavirus (HPV) detection tests with specimens collected by three alternative procedures. The HPV tests included the Hybrid Capture Tube test (HCT), the microplate-based Hybrid Capture II test (HC II), and the MY09-MY11 L1 consensus primer PCR-based assay. Initial cervical specimens were collected from study subjects with a broom device, and after Papanicolaou smears were made, residual specimens were placed into PreservCyt (PC), a liquid cytology medium. A second specimen was collected from each subject and placed into Digene Specimen Transport Medium (STM). The device for collection of the second specimen alternated with consecutive subjects between a conical cytology brush and a Dacron swab. At the 1.0-pg/ml cutoff, the results of the HC II agreed well with those of the PCR. Specifically, when PCR data were restricted to the types found by the HC II (HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68), there was greater than 90% agreement between the HC II and PCR results with both STM and PC. At a lower cutoff (0.2 pg/ml), HC II-positive results increased further, especially when the test was applied to the PC specimens. However, false-positive HC II results were more often observed at the 0.2-pg/ml cutoff. HC II yielded the highest HPV positivity with specimens placed into PC, followed by specimens collected with a conical brush and placed into STM and, last, by those collected with a Dacron swab and placed into STM. Our results demonstrate the utility of both the STM and PC specimen collection methods and show good agreement between the HC II and PCR.

Performance of a semiautomated Papanicolaou smear screening system: results of a population-based study conducted in Guanacaste, Costa Rica

BACKGROUND

Automated cytology devices have utility in quality assurance applications, but the effectiveness of these devices in primary screening is unknown.

METHODS

Enrollment smears obtained from 7323 women participating in a population-based study sponsored by the National Cancer Institute were screened manually in Costa Rica and then evaluated independently in the U.S. with the PAPNET system (Neuromedical Systems, Inc., Suffern, NY), a semiautomated, neural network-based device. Smears with abnormal PAPNET images were microscopically rescreened and then diagnosed by a U.S. cytopathologist. ThinPrep slides (Cytyc Corporation, Boxborough, MA), prepared from rinses of the cytologic sampler, and cervigrams (National Testing Laboratories, Fenton, MO) were also evaluated. Women with any abnormal cytologic diagnosis or a positive cervigram were referred for colposcopy with biopsy and definitive therapy if indicated.

RESULTS

Based on the U.S. cytotechnologist's review of the PAPNET images, 1017 (13.9%) of 7323 smears were selected for manual screening, resulting in the selection of 492 (6.7%) possibly abnormal slides for referral to the U.S. pathologist. Ultimately, 312 smears (4.3% of the total) were diagnosed as containing squamous cells of undetermined significance or a more severe abnormality (> or =ASCUS), resulting, hypothetically, in the referral of 66.5% of women with a final diagnosis of a squamous intraepithelial lesion or a more severe abnormality (> or =SIL) and 86.0% of patients with > or =high grade SIL. Conventional microscopic screening performed in Costa Rica resulted in the hypothetical referral of 6.5% of patients with > or =ASCUS for colposcopy, including 69.5% of patients with > or =SIL and 79.8% of those with > or =high grade SIL.

CONCLUSIONS

In this study, PAPNET-assisted cytologic screening accurately identified smears obtained from women with high grade SIL or carcinoma. Determination of the clinical cost-effectiveness of PAPNET-assisted screening in routine practice awaits future study.

Performance of liquid-based, thin-layer cervical cytology: correlation with reference diagnoses and human papillomavirus testing

The performance of thin-layer cervical cytology with the use of ThinPrep (Cytyc Corporation, Boxborough, MA) was assessed by comparing the original independent diagnosis of ThinPrep slides and conventional smears prepared from 1780 split samples with the most abnormal diagnosis per patient on the basis of an independent pathologist's masked review and with the detection of cancer-associated types of human papillomavirus (HPV) DNA. Cases were selected on the basis of the original diagnoses to include all discordant pairs (those diagnosed as atypical squamous cells of undetermined significance or higher grade, n = 1017), all concordant abnormal pairs (n = 444), and a random 5% of concordant normal pairs (n = 319). In screening centers, thin-layer cytology detected 135 (70.3%) of 192 women diagnosed as having squamous epithelial lesions or a higher grade in the independent review, whereas locally read smears detected 91 (47.4%) of these patients (P < .001). In hospital-based cytology laboratories, thin-layer cytology detected 308 (86.3%) of 357 women diagnosed with SILs or a higher grade in the independent review, compared with 283 (79.3%) diagnosed with smears (P = .011). Cancer-associated types of HPV DNA were detected in a slightly higher proportion of women with smears diagnosed as SILs than in women with thin-layer cytology diagnosed as SILs, whereas the overall number of HPV-associated SILs diagnosed was higher with thin-layer cytology. These data suggest that the ThinPrep method detects a higher percentage of SILs as defined in a masked, independent review than do concurrently prepared smears and that diagnoses of SILs rendered with ThinPrep correlate with the detection of cancer-associated types of HPV.

Human papillomavirus, anal squamous intraepithelial lesions, and human immunodeficiency virus in a cohort of gay men

Cross-sectional associations between human papillomavirus (HPV), anal squamous intraepithelial lesions (SIL), and human immunodeficiency virus (HIV) were studied in a cohort of gay men. HPV DNA was detected by generic and type-specific polymerase chain reaction (PCR) probes and hybrid capture assay (HC). HPV virus load was estimated by HC relative light unit (RLU) ratio. HPV prevalence, number of HPV types detected, and HC RLU ratios were each greater in HIV-positive than HIV-negative participants. Further, among HIV-positive men, HC RLU ratio was inversely associated with CD4 cell count. SIL was more frequent in HIV-positive participants, particularly those with a CD4 cell count <200/microL and was positively associated with HPV. Men with a high HC RLU ratio were nearly 3 times more likely to have SIL than were those both PCR- and HC-negative. These data support that HIV augments HPV-associated anal disease in this population.

Evidence for a common etiology for endometrial carcinomas and malignant mixed mullerian tumors

OBJECTIVE

To elucidate factors linked to the development of malignant mixed mullerian tumors (MMMT) and determine whether the risk factor profile for these tumors corresponds with that for the more common endometrial carcinomas.

METHODS

A multicenter case-control study of 424 women diagnosed with endometrial carcinoma, 29 women diagnosed with MMMT, and 320 community controls was conducted. Review of pathological reports and slides was performed to classify cases by histological type. All participants were asked to respond to a questionnaire which ascertained information on exposure to factors postulated to be linked to the development of uterine tumors.

RESULTS

Women with endometrial carcinomas and MMMTs were similar with respect to age and educational attainment. Women diagnosed with MMMTs were more likely than those diagnosed with carcinomas to be of African-American descent (28% vs 4%; P = 0.001). Weight, exogenous estrogen use, and nulliparity were related to risk of both tumor types. Marked obesity was associated with a 4.8-fold (95% CI = 3.0,7.6) increase in risk of carcinoma and a 3.2-fold (95% CI = 1.1,9.1) increase in risk of MMMT development. Use of exogenous estrogens increased the odds of developing carcinomas by 2-fold (95% CI = 1.3,3.2) and that of developing MMMTs by 1.8-fold (95% CI = 0.57,5.5). Nulliparity was associated with a 2.9-fold (95% CI = 1.9,4.8) increase in risk of carcinomas and a 1.7-fold (95% CI = 0.53,5.6) increase in risk of MMMTs. Oral contraceptive use protected against the development of both carcinomas (OR = 0.39; 95% CI = 0.26,0.58) and MMMTs (OR = 0.76; 95% CI = 0.25,2.3). Current smokers were at a reduced risk of developing endometrial carcinomas (OR = 0.34; 95% CI = 0.21,0.55) and MMMTs (OR = 0.57; 95% CI = 0.15,2.3), while former smokers were at an increased risk of MMMT (OR = 2.7; 95% CI = 1.1,6.8) but not carcinoma development (OR = 0.81; 95% CI = 0.56,1.2).

CONCLUSION

Results from this study suggest that MMMTs and carcinomas have a similar risk factor profile. This observation is compatible with the hypothesis that the pathogenesis of these two histological types of uterine tumors is similar.

Different risk factor patterns for high-grade and low-grade intraepithelial lesions on the cervix among HPV-positive and HPV-negative young women

Risk factors for cervical intraepithelial neoplasia have most often been studied in high-grade lesions. Furthermore, in a high proportion of the studies, human papillomavirus (HPV), the most significant risk determinant of cervical neoplasia, was not taken into account when evaluating other risk factors. To compare risk factors for ASCUS (atypical cells of undetermined significance), LSIL (low-grade squamous intraepithelial lesion) and HSIL (high-grade squamous intraepithelial lesion), we conducted a case-control study among 20 to 29 year-old women participating in a prospective cohort study in Copenhagen. It included 131 women with ASCUS, 120 women with LSIL, 79 women with HSIL and 1,000 randomly chosen, cytologically normal, control women. All participants had a personal interview and a gynecological examination including a Pap smear and cervical swabs for HPV DNA detection using general primer-mediated polymerase chain reaction. The most significant risk determinant of all 3 disease categories was the presence of genital HPV DNA. The risk factor pattern was nearly identical for ASCUS and LSIL, but differed significantly from that for HSIL. Stratified analysis by HPV-status showed that, apart from, respectively, smoking and parity among HPV-positive women, and smoking and number of sex partners among HPV-negative women, no additional risk factors were observed for ASCUS and LSIL. In contrast, among HPV-negative women with HSIL, long-term use of oral contraceptives was the most important risk factor. However, our result should be taken with great caution as it is based on very small numbers, and as it is unknown whether the HPV-negative lesions constitute a true entity. Among HPV-positive women, the risk of HSIL was associated with e.g., years of sex life without barrier contraceptive use, early age at first genital warts and smoking. Whether the risk factors that are applicable only to HSIL represent factors related to progression remains unknown.

A nested case-control study of dietary factors and the risk of incident cytological abnormalities of the cervix

Several earlier case-control studies reported inverse associations of cervical squamous intraepithelial lesions (SIL) with high dietary or biomarker levels of carotenoids, folate, and vitamins C and E. However, most studies did not measure the primary causal factor, cancer-associated genital human papillomaviruses (HPV), now detected by sensitive viral DNA tests. This nested case-control study assessed whether high dietary intakes of these nutrients, plus zinc and vitamin A, reduced SIL risk in cancer-associated HPV DNA-positive women. Using a 60-item food-frequency questionnaire, nutrient estimates were obtained for 33 incident cases with high-grade lesions, 121 with low-grade lesions, 97 with equivocal SIL, and 806 cytologically normal controls sampled from a large prospective cohort study. Baseline cervicovaginal lavages were tested for HPV DNA by the polymerase chain reaction. Among DNA-positive cases (n = 68) and controls (n = 69), age-adjusted odds ratios (ORs) of SIL in the highest vs. the lowest nutrient quartiles were 1.4 [95% confidence interval (CI) = 0.5-4.2] for vitamin A, 0.6 (CI = 0.2-2.0) for beta-carotene, 1.3 (CI = 0.4-3.6) for vitamin C, 1.0 (CI = 0.4-3.6) for vitamin E, 0.7 (CI = 0.3-2.1) for folate, and 0.8 (CI = 0.3-2.2) for zinc. ORs in HPV DNA-negative women approximated 1.0, with the exception of vitamin E (OR = 0.5, CI = 0.3-0.9). These results do not support a protective role for the above nutrients against low-grade or equivocal SIL, which constituted the majority of diagnoses in this study.

Morphologic and immunophenotypic characterization of foam cells in endometrial lesions

The detection of foam cells in cervicovaginal smears obtained from postmenopausal women suggests the possibility of an endometrial lesion. Ultrastructural studies have suggested that foam cells represent endometrial stromal cells but the histogenesis of these cells has not been firmly established. To investigate the origin and diagnostic significance of foam cells, we analyzed the morphology and immunophenotype of these cells in endometrial tissue specimens and correlated the findings with cervical smears obtained within the preceding 6 months. Selected biopsies containing foam cells were evaluated using four well-characterized macrophage markers: KP-1(CD68), HAM 56, MAC 387, and lysozyme. Foam cells were found in 11 (38%) of 29 simple hyperplasias, 7 (50%) of 14 complex hyperplasias, 6 (50%) of 12 complex atypical hyperplasias, 21 (70%) of 30 adenocarcinomas, 1 (4%) of 25 samples with stromal breakdown, and 0 of 30 specimens showing normal cycling endometrium. Foam cells were also found in smears preceding the histologic diagnosis of 2 (13%) simple hyperplasias, 2 (25%) complex hyperplasias, 3 (43%) complex atypical hyperplasias, 5 (28%) adenocarcinomas, 5 (28%) cases of stromal breakdown, and 0 of 8 normal tissue specimens examined. Foam cells were immunoreactive with at least 2 of the 3 macrophage-specific antibodies in all 21 biopsies studied. Our results suggest that foam cells phenotypically represent macrophages and not endometrial stromal cells. Foam cells are identified in a significant percentage of cervical smears and endometrial tissue specimens obtained from women with endometrial pathology. The morphology and immunophenotype of foam cells, however, does not appear to be useful in distinguishing benign endometrial stromal breakdown, endometrial hyperplasia, and endometrial adenocarcinoma.

Analysis of histopathological features of endometrioid uterine carcinomas and epidemiologic risk factors

A large case-control study was performed to determine whether risk factors for endometrioid carcinoma, the most common type of endometrial cancer, vary according to the histological features of the tumor. Study subjects consisted of 328 women with newly diagnosed endometrioid adenocarcinoma and 320 population-based control subjects. Variables studied included age at menarche, menopausal estrogen use, weight, parity, cigarette smoking, and oral contraceptive use. The risk factor profile for endometrioid carcinomas with and without squamous differentiation was very similar. No striking differences in risk factors were observed between endometrioid cancers with and without adjacent endometrial hyperplasia. Finally, none of the risk factors varied substantially between early-stage and late-stage tumors or low-grade and high-grade tumors. In summary, this study indicates that risk factors for endometrioid carcinomas are not related to the morphological features of the tumor.

Utility of thin-layer preparations in thyroid fine-needle aspiration: diagnostic accuracy, cytomorphology, and optimal sample preparation

BACKGROUND

The efficacy of preparing thyroid fine-needle aspirations (FNAs) as thin-layer slides has not been evaluated extensively.

METHODS

To evaluate the efficacy of thin-layer cytology, the authors examined thyroid FNAs from 135 unselected palpable lesions that were aspirated using uniform procedures and prepared as air-dried, Diff-Quik-stained direct smears (DS) and Papanicolaou-stained thin-layer slides (TL). Diagnoses rendered independently on masked slides from each thyroid nodule were compared with the reported final cytologic or histologic diagnoses based on all available pathologic material. Slides were analyzed for diagnostically important cytologic features and the optimal number of TL slides per sample was assessed.

RESULTS

TL diagnoses agreed with final diagnoses in 85% of cases compared with 96% for DS. All 11 neoplasms were recognized in both preparations. A final diagnosis of chronic lymphocytic thyroiditis (CLT) was missed in 10 of 26 TL (39%) compared with 2 of 26 DS (8%) (P = 0.013, McNemar's test). Cytologic features appreciated less often in TL than DS (McNemar's test) included diffuse colloid, spherules, tissue fragments, and lymphocytes. Multinucleated giant cells were identified more often in TL than DS. Two TL slides were sufficient for diagnosis in 83% of cases.

CONCLUSIONS

The diagnostic accuracy of TL was 85% compared with 96% for DS. CLT was diagnosed accurately in 62% of TL compared with 92% of DS. Cytologic features in TL and DS may differ. Preparation of only two TL slides is adequate for definitive diagnosis in most cases.

Prospects for a prophylactic HPV vaccine: rationale and future implications for cervical cancer screening

Cytologic screening in combination with ablative therapy has helped reduce cervical cancer mortality in the developed world. Despite the success of this approach, cervical cancer remains a major cause of death, especially among women with limited access to health care. Recognition that human papillomaviruses (HPVs) are the main etiologic agent in cervical cancer suggests that a prophylactic vaccine could reduce the incidence of HPV infection and, therefore, achieve cancer control with reduced reliance on costly screening programs. In this review, the rationale for developing a prophylactic HPV vaccine and the potential impact that vaccination would have on cervical cancer screening are discussed.

Inhibin and epithelial membrane antigen immunohistochemistry assist in the diagnosis of sex cord-stromal tumors and provide clues to the histogenesis of hypercalcemic small cell carcinomas

Ovarian sex cord-stromal tumors are a morphologically diverse group of neoplasms that can mimic the appearance of other ovarian tumors. Because the treatment and prognosis of sex cord-stromal tumors differs substantially from those of other ovarian neoplasms, the development of an immunohistochemical panel to support the diagnosis of the former group of tumors would be useful. In this report, the utility of immunostaining for inhibin alpha, epithelial membrane antigen, MIC2 gene protein product, and keratin in the differential diagnosis of sex cord-stromal tumors was assessed in formalin-fixed, paraffin-embedded sections. In addition, the immunohistochemical staining pattern of ovarian small cell carcinomas (SCCs), hypercalcemic type, was analyzed in an attempt to clarify the histogenesis of these tumors. Thirty-two (97%) of 33 granulosa cell tumors (GCTs), 10 (91%) of 11 Sertoli-Leydig cell tumors (SLCTs), and 4 (8%) of 51 carcinomas showed inhibin alpha immunopositivity. None of the 3 lymphomas, 5 carcinoids, 6 dysgerminomas, or 12 SCCs showed inhibin alpha positivity. Eighteen (55%) GCTs, 6 (55%) SLCTs, 6 (12%) carcinomas, and 7 (58%) SCCs showed MIC2 gene expression. None of the GCTs and only one SLCT showed epithelial membrane antigen (EMA) positivity, although 92% of surface epithelial carcinomas and 75% of SCCs were immunoreactive. These data suggest that detection of inhibin immunoreactivity in an ovarian tumor that is EMA-negative provides both sensitive and specific support for the diagnosis of a sex cord-stromal tumor. Because SCCs generally stain for EMA but not for inhibin, it appears that SCCs probably represent a variant of surface epithelial tumor rather than a type of sex cord-stromal tumor.

Accuracy of grading gliomas on CT-guided stereotactic biopsies: a survival analysis

The accuracy of using a combination of cytopathologic and histopathologic techniques to diagnose stereotactically guided brain biopsies was investigated in 74 patients. Diagnostic accuracy was assessed by determining whether classification of the biopsies as gliosis, astrocytoma (A), anaplastic astrocytoma (AA), or glioblastoma multiforme (GBM) predicted survival. The utility of on-site evaluation using Diff-Quik-stained crush preparations was also assessed. The patients ranged in age from 5 to 88 years (mean, 55 years) and were followed for over 2 years in most cases. Four cases (5%) were classified as gliosis (G), 7 (9%) as atypical gliosis (AG), 4 (5%) as high-grade mixed oligodendroglioma/astrocytoma (OA), 11 (15%) as astrocytoma (A), 21 (28%) as anaplastic astrocytoma (AA), and 27 (36%) as glioblastoma multiforme (GBM). Median survival was 11 months in patient with OA, 57 months in patients with A, 10 months in patients with AA, and 5 months in patients with GBM. Diagnosis of Diff-Quik-stained crush preparations made during the biopsy procedure was highly correlated with the final diagnosis and survival. We conclude that the diagnosis of stereotactic brain biopsies using cytopathology with on-site evaluation in combination with histopathological evaluation of needle cores is accurate based on a survival analysis. However, A and G may be difficult to distinguish.

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

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

Determinants for genital human papillomavirus (HPV) infection in 1000 randomly chosen young Danish women with normal Pap smear: are there different risk profiles for oncogenic and nononcogenic HPV types?

Most studies of risk factors for human papillomavirus (HPV) DNA detection have focused on overall HPV positivity and have not examined determinants for high-risk and low-risk HPV types separately. We studied risk determinants for genital HPV infection in 1000 randomly chosen women (20-29 years) with normal cervical cytology from Copenhagen, Denmark. All women had a personal interview, a Pap smear, and cervical swabs for HPV DNA detection using a PCR technique. On the basis of their association with cervical cancer, the HPV types were categorized as belonging to a high-risk group ("oncogenic types") or a low-risk group ("nononcogenic types"). The overall HPV detection rate was 15.4%. Of HPV-positive women, 74% had oncogenic HPV types, and 30% had nononcogenic HPV types. Younger age and lifetime measures of sexual activity (notably, number of partners) were the main risk factors for the oncogenic HPV types. Furthermore, a previous Chlamydia infection was associated with the high-risk HPV types. In contrast, the most important determinants for nononcogenic HPV infection were contraceptive variables related to the physical protection of the cervix (condom or diaphragm) and number of partners in the last 4 or 12 months. Our study confirms the venereal nature of HPV infection. We hypothesize that the low-risk HPV infection, which correlates with recent sexual behavior, may be more transient than infection with the oncogenic HPV types, which correlates with lifetime exposure measurements of sexual habits.

Risk factors and hormone levels in patients with serous and endometrioid uterine carcinomas

We performed a multi-institutional, incident case-control study of 328 endometrioid and 26 serous carcinomas to assess whether risk factors and circulating hormone levels in women with serous carcinoma differ from the expected profile for endometrial carcinoma We also evaluated exposures potentially related to endometrial cancer risk, anthropometric measurements, and circulating levels of sex hormones and related carrier proteins. Histopathologic specimens were reviewed without knowledge of the other data. As expected, a statistically significant association was observed for high body mass index (BMI) (relative risk, 3.5) and use of menopausal estrogens (relative risk, 2.4) in the endometrioid carcinoma cases, whereas serous carcinomas were not strongly associated with these factors. Smoking and oral contraceptive use decreased risk for both tumor types. For five of six sex hormones tested, age-adjusted mean serum levels in patients with serous carcinoma were significantly lower than those in women with endometrioid carcinoma. After adjustment for BMI, these differences were narrowed, but levels of albumin-bound estradiol and estrone remained significantly lower in the serous cases. Age and BMI-adjusted levels of sex hormone-binding globulin were significantly higher in patients with serous carcinoma than in women with endometrioid carcinomas. In conclusion, risk factors and sex hormone levels in patients with uterine serous carcinoma seem to differ from those in women with endometrioid carcinoma, suggesting that there may be at least two different pathways of endometrial carcinogenesis.

Immune activation in cervical neoplasia: cross-sectional association between plasma soluble interleukin 2 receptor levels and disease

In a previous study (Tsukui et al., Cancer Res., 56: 3967-3974, 1996), we observed an inverse association between degree of cervical neoplasia and interleukin (IL) 2 production by peripheral blood mononuclear cells in response to human papillomavirus (HPV) 16 E6 and E7 peptides in vitro. This suggested that a Th1-mediated cellular immune response might be important in host immunological control of HPV infection and that a lack of such a response might predispose to progression of cervical disease. To follow up on these findings, we have conducted a cross-sectional study of women with various degrees of cervical neoplasia to investigate the association between overall immune activation and cervical disease. A total of 235 women were recruited into our study; 120 of these women were participants in our previous study in which IL-2 production in response to HPV-16-specific peptides was measured. The study population included 34 women with invasive cancer, 62 women with high-grade squamous intraepithelial lesions (HSILs), and 105 women with low-grade squamous intraepithelial lesions (LSILs). In addition, 34 cytologically normal women with no past history of squamous intraepithelial lesions despite confirmed HPV-16 infection in the 5 years preceding the study were selected as controls. As our measure of overall immune activation, serum samples obtained from study participants were tested for soluble IL-2 receptor (sIL-2R) level using an ELISA method. The mean sIL-2R levels were found to increase with increasing disease severity (Ptrend = 0.0002). Among cytologically normal, HPV-exposed women, the mean receptor level in serum was 465.8 units/ml compared to 467.6 units/ml among LSIL subjects, 514.9 units/ml among HSIL subjects, and 695.5 units/ml among women with invasive cervical cancer. Similarly, the proportion of women with elevated sIL-2R levels (defined as > or = 450 units/ml) increased with increasing disease severity from 35.2% among normal study subjects to 70.6% among cancer patients (Ptrend = 0.003). Among the subgroup of subjects for whom in vitro IL-2 production in response to HPV-16-specific peptides was measured, we examined the association between in vitro IL-2 production and serum levels of sIL-2R. sIL-2R levels were higher, on average, among those women who were positive in our IL-2 production assay compared to those who were negative, but the differences did not reach statistical significance (P > 0.05). We also observed a trend of increasing sIL-2R level with increasing disease severity both in women who were positive and in women who were negative for our IL-2 production assay, but the trend was only significant among those who were negative for IL-2 production (Ptrend = 0.01). Results from our studies suggest that although the immune system of women with cervical neoplasia is nonspecifically activated as disease severity increases, the ability of those women with HSILs or cancer to mount a Th1-mediated immune response to HPV peptides appears to decrease compared to women with LSILs or normal women infected with HPV. Increased overall activation along with decreased Th1 immune response among women with increasing cervical disease severity might be explained by an increased Th2-mediated immune response, a response that we hypothesize is ineffective in controlling the viral infection and its early cytological manifestations. Future studies should directly assess Th2-mediated responses to confirm this hypothesis. Also, future efforts should be aimed at determining whether the associations observed are causally related to disease progression or an effect of the disease.