Cystic change in lymph nodes with metastatic squamous cell carcinoma

A retrospective analysis was performed of the gross characteristics of aspirated material in 335 consecutive cases of metastatic squamous cell carcinoma in cervical/supraclavicular lymph nodes seen during a three-year period. In 57 cases (17.01%), 1-2 mL of fluid was obtained. Microscopic examination of cytocentrifuge smears in all cases showed malignant squamous cells. Cystic change in lymph nodes harboring metastatic squamous cell carcinoma was frequently associated with a tongue primary (21/58 cases, 36.2%) followed by an esophageal primary (4/16 cases, 25%). The frequency of cystic change varied from 9.1% to 21.5% with primaries in the oral cavity, nasopharynx, lung, uterine cervix and unknown sites.

Effect of corticosteroid treatment on various serological & bronchoalveolar lavage abnormalities in patients with sarcoidosis

Effect of daily oral prednisolone treatment was studied in 29 patients with pulmonary sarcoidosis. Twenty normal control subjects were also studied. Pretreatment absolute lymphocyte counts and proportion of lymphocytes in peripheral blood were significantly lower in patients with sarcoidosis as compared to normal controls. Total cell count and the proportion of lymphocytes in bronchoalveolar lavage (BAL) fluid were significantly higher in sarcoidosis. The proportion of CD3+ and CD4+ was significantly lower in peripheral blood and higher in BAL fluid in patients with sarcoidosis. Immunoglobulins (IgG, A and M) and complements (C3, C4 and CH50) were significantly higher both in peripheral blood and BAL fluid. Patients with sarcoidosis were treated with daily oral prednisolone (30 mg/day). Repeat studies were performed after an interval of 4-6 months in 20 patients with sarcoidosis. A significant increase in absolute lymphocyte counts in peripheral blood and decrease in the proportion of lymphocytes in BAL fluid occurred with prednisolone treatment. Proportion of CD3+, CD4+ and B cells increased in peripheral blood and decreased in BAL fluid. Complement and immunoglobulin levels revealed a significant reduction in peripheral blood and BAL fluid. It is concluded that patients with sarcoidosis have peripheral blood lymphopaenia and lymphocytic alveolitis. They have increased levels of complement and immunoglobulins both in the peripheral blood and BAL fluid. All these abnormalities show significant improvement with prednisolone treatment.

Immunologic & pulmonary function abnormalities in tropical pulmonary eosinophilia

Twenty six patients (24 males and 2 females) with tropical pulmonary eosinophilia (TPE) were studied. Arterial blood gas analysis, pulmonary functions, peripheral blood examination and bronchoalveolar lavage (BAL) were performed. Peripheral blood and BAL fluid analyses were performed in healthy volunteers. Pulmonary functions revealed a mild restrictive ventilatory defect with airways obstruction. Mild hypoxaemia was observed on arterial blood gas analysis. Serum immunoglobulins IgG (P < 0.01), IgA (P < 0.001) and IgM (P < 0.001) were significantly raised as compared to normal controls. Serum complement (C3) level was higher, however, it was not significantly different as compared to normal controls. Serum haemolytic component of the complement (CH50) was significantly higher (P < 0.001) in patients with TPE compared to normal control subjects. The immunoglobulins IgG, IgA and IgM in the BAL fluid were significantly (P < 0.001) increased as compared to normal controls. The fibronectin (FN) level was also significantly increased (P < 0.001) in the BAL fluid. It is concluded that patients with TPE have mild restrictive ventilatory defect with airways obstruction and mild hypoxaemia. They have eosinophilic alveolitis with increased levels of immunoglobulins in the peripheral blood and BAL fluid. The significance of elevated FN in the BAL fluid is not clear and serial estimations may have to be done in order to clarify its role in the pathogenesis of fibrosis in chronic TPE.

Asbestos fibers and interferon-gamma up-regulate nitric oxide production in rat alveolar macrophages

The present study was undertaken to determine whether asbestos exposure induces the formation of nitric oxide (NO.) radical by rat alveolar macrophages (AM). For this purpose, AM from Sprague-Dawley rats were cultured for 48 h in the presence or absence of either chrysotile (serpentine) or crocidolite (amphibole) asbestos fibers. The effects of asbestos fibers were compared with those of nonfibrogenic carbonyl iron particles. Nitrite (NO2-), the stable oxidation product of NO. in macrophage conditioned medium, was assayed by the Griess reaction. Production of NO2- by AM was significantly increased by both chrysotile (P < 0.01) and crocidolite (P < 0.05) asbestos fibers (10 micrograms/ml). Since interferon-gamma (IFN-gamma) is known to induce NO. synthase within macrophages, and since elevated levels of intrapulmonary IFN-gamma have been noted in asbestos workers, the combined effects of asbestos and IFN-gamma also were studied in the context of NO. formation. Addition of IFN-gamma (250 to 500 IU/ml) synergistically enhanced the formation of NO2- induced by chrysotile and crocidolite. Notably, carbonyl iron had no significant effect on NO. production by AM. NO2- production was significantly attenuated by the NO. synthase inhibitor, NG-monomethyl-L-arginine (0.5 to 1 mg/ml). By contrast, superoxide dismutase (150 U/ml) significantly enhanced asbestos-induced NO2- production by AM (P < 0.001). Since superoxide anion can interact with NO. to generate the toxic hydroxyl radical, and since superoxide dismutase is known to protect against asbestos-induced injury, the induction of NO. radical by asbestos fibers may represent a novel form of asbestos-related injury.

Early inhibition of myointimal proliferation by angiopeptin after balloon catheter injury in the rabbit

PURPOSE

Coronary artery restenosis after percutaneous transluminal angioplasty occurs in more than 40% of patients. Angiopeptin, a stable synthetic octapeptide analogue of somatostatin, attenuates accelerated coronary artery myointimal thickening in rabbit cardiac allografts and myointimal thickening after arterial injury. In this study the temporal relationship between the angiopeptin treatment schedule and efficacy was explored. The relationship between inhibition of myointimal thickening by angiopeptin and inhibition of vascular cell proliferation was also examined.

METHODS

The aorta and the common and external iliac arteries of the rabbit underwent balloon injury. Angiopeptin (2 to 200 micrograms/kg/day) was administered for 1 day before injury and for 1, 5, and 21 days after injury. Morphometric studies were performed to determine measurement of intimal thickening. Inhibition of vascular cell proliferation by angiopeptin was evaluated by tritiated thymidine incorporation into the balloon-injured rabbit aorta. Thymidine was either administered intraperitoneally or added ex vivo to aorta segments of rabbits treated with angiopeptin (2, 20, or 200 micrograms/kg/day) from 1 day before injury until sacrifice 72 hours later.

RESULTS

Administration of angiopeptin (2 to 200 micrograms/kg/day) significantly reduced intimal thickening by approximately 50% in all three vessels when evaluated 3 weeks after injury. This inhibitory effect was unrelated to duration of treatment and dose. Treatment initiated at the time of injury was found to be effective, but delaying treatment for 8, 18, or 27 hours abrogated the inhibitory effect of angiopeptin on myointimal thickening. Angiopeptin treatment significantly decreased thymidine-labeled nuclei of smooth muscle cells in vitro. Angiopeptin treatment similarly inhibited thymidine uptake in vitro by balloon-injured aorta segments.

CONCLUSION

Angiopeptin significantly inhibits myointimal thickening by inhibiting vascular cell proliferation. Administration of angiopeptin for 2 days is as efficacious as 3 weeks treatment in inhibiting myointimal thickening. Delaying treatment for as little as 8 hours after injury abrogates the inhibitory effects of angiopeptin. This speaks to the importance of early events immediately after vascular tissue injury, suggesting that angiopeptin inhibits the expression of early genes causally related to the vascular injury response and thereby triggering vascular cell proliferation.

Asbestos-induced nitric oxide production: synergistic effect with interferon-gamma

This study has shown, for the first time, that in vitro exposure of rat AMs to either crocidolite (amphibole) or chrysotile (serpentine) asbestos fibers induces the synthesis not only of the O2*- anion, but also of the nitrogen radical, NO*. Furthermore, this asbestos-related effect is enhanced in the presence of interferon-gamma. NO* has been implicated in several pathologic reactions, such as inflammation and immune complex-mediated cell injury. Additionally, NO* may interact with secondary amines to generate nitrosamines, which are potent carcinogens. Our findings could represent a novel type of asbestos-mediated injury, and we propose that the injurious effects of asbestos might be mediated via the interaction of NO* with O2*-, with the generation of ONOO- and other potent toxic free radicals.

Asbestos exposure stimulates pleural mesothelial cells to secrete the fibroblast chemoattractant, fibronectin

Parietal pleural plaques and visceral pleural fibrosis are well-recognized stigmata of occupational asbestos exposure. However, their pathogenesis is poorly understood. Conceivably, phagocytosis of asbestos fibers by pleural mesothelial cells may stimulate the recruitment of fibroblasts to sites of asbestos-induced pleural injury. To test this hypothesis, rat parietal pleural mesothelial cells were cultured for 6 to 96 h with or without crocidolite or chrysotile asbestos fibers (concentration range, 2 to 100 micrograms/cm2). Asbestos fibers were actively phagocytosed by pleural mesothelial cells and were incorporated within phagosomes. Conditioned medium was assayed for chemotactic activity toward RL-87 rat lung fibroblasts and for fibronectin immunoreactivity. The effects of asbestos were compared with those of alpha-cristobalite (which is strongly fibrogenic), alpha-quartz (a less fibrogenic particulate), and carbonyl iron (a nonfibrogenic agent). Both types of asbestos stimulated the secretion of fibroblast chemoattractant activity by pleural mesothelial cells in a time-dependent manner. This effect peaked at 96 h in cultures containing 4 micrograms/cm2 of asbestos (P < 0.001). alpha-Cristobalite also enhanced the secretion of the mesothelial cell-derived chemoattractant, an effect that was maximal at a concentration of 20 micrograms/cm2 (P < 0.001). Furthermore, crocidolite, chrysotile, and alpha-cristobalite stimulated pleural mesothelial cell fibronectin synthesis. In contrast, alpha-quartz and carbonyl iron particles had no noticeable effect on either immunoreactive fibronectin secretion or chemoattractant release by pleural mesothelial cells. The ability of asbestos fibers and alpha-cristobalite particles to stimulate the secretion of the fibroblast chemoattractant, fibronectin, by pleural mesothelial cells may have relevance to the induction of pleural injury by fibrogenic particulates.

Carcinoma of buccal mucosa: incidence of regional lymph node involvement

Histopathological findings in 57 surgical specimens of T3 and T4 buccal mucosa cancers are reviewed. The incidence of the well-differentiated tumours (including verrucous carcinoma) was 61%. A moderate degree of lymphocytic infiltration of the tumour was present in 37% of patients. Histologically proven cervical lymph node deposits were present in only 16% of the patients. Amongst the group of patients with clinically enlarged lymph nodes, metastatic disease was histologically demonstrated in 17.5% at level I and 14% at level II of neck nodes. Amongst group of patients with no palpable nodes in the neck, metastatic disease was histologically demonstrated in 11.7% at level I and 9% at level II of neck nodes. These findings contra-indicate an elective neck dissection and indicate the need to confirm histologically the presence of lymph node deposits doing a radical neck dissection in patients with buccal mucosa cancer. This well-differentiated tumour has a much lower tendency to metastasize than cancers in other sites of the oral cavity.

Paragangliomas--a diagnostic dilemma on fine needle aspirates

Paragangliomas are uncommon tumours arising from the neural crest and are widely distributed throughout the body. Because of the morphologic diversity of these tumours fine needle aspirate (FNA) diagnosis is not very accurate in identifying these neoplasms. Review of FNA from seven paragangliomas (three extra-adrenal, three carotid body and one multicentric in location) was conducted to find any diagnostic criteria. On initial morphologic diagnosis five of the seven paragangliomas were considered malignant (four undifferentiated and one adenocarcinoma). Review of these cases in our series made us wiser. Pleomorphic nuclei, prominent nucleoli, clumped chromatin with finely granular cytoplasm and occasional intranuclear cytoplasmic inclusions were characteristically seen and these were probably the cause for misdiagnosis. This lesion must be entertained in an aspirate from the neck or retroperitoneum which contains cells showing marked nuclear pleomorphism with naked nuclei and have a tendency to spindle or from acini. To confirm these cases argyrophilic granules were demonstrated in two of the four cases studied. However, neuron specific enolase and calcitonin were found to be non-contributory. Ultrastructural examination was helpful and done in one case showed abundant neurosecretory granules.

Inquiry-driven strategies for innovation in medical education: experiences in India

Four medical institutes, viz, AIIMS, New Delhi; CMC, Vellore; JIPMER, Pondicherry and IMS-BHU, Varanasi formed a consortium to introduce reforms in undergraduate medical education. A detailed inquiry was conducted by administering questionnaires to the faculty, recent graduates and patients to identify the deficiencies in the present system. Morbidity patterns prevalent in the community at primary, secondary and tertiary care levels were determined. These were matched with the actual curricula being followed and the assessment patterns. The main findings were: inadequate emphasis on practical skills (including communication), insufficient coverage of common diseases; and neglect of behavioral, social and ethical aspects in the curriculum. Based on these findings certain corrective programmes are being introduced. The content areas in the curriculum have been classified in to 'must know', 'good to know' and 'need not know'. A list of essential skills have been identified. Steps are on to ensure that these skills are acquired by the graduates. A modular approach to the teaching was suggested and modules on some of these topics are under preparation.

A hospital-based study on the use of paramedical personnel for clinical downstaging of cancer cervix

Two auxiliary nurse midwives (ANMs) were recruited and trained to recognize normal and different types of abnormal cervices. A total of 2102 women were examined by a gynaecologist and ANM independently and their findings were noted. Comparison of their findings showed an overall agreement of 89.6 per cent (Kappa 0.84 with standard error of 0.015 and a significantly large Z value of 55.6). Gross examination of 4679 women attending the Gynaecology OPD revealed normal cervix in 49.6 per cent and suspected lesions or malignant cervix in 3.4 per cent of women. Cytology smears were taken in 3608 women. Adequacy of smears was 97 per cent. Comparing the group clinically diagnosed as highly suspected or malignant to the cytologically diagnosed suspected group (atypical and malignant), clinical examination had a sensitivity of 81.7 per cent and specificity of 97.3 per cent; while comparison of the group clinically diagnosed as abnormal cervix to abnormal cytology (all grades of dysplasia, atypical and malignant cells), the clinical examination had a sensitivity of 92.5 per cent and specificity of 37.4 per cent. It was concluded that paramedical staff (ANMs) can be relied upon to do speculum examination in women in the community and take cytology smears in selected cases.

Detection of human papilloma virus types 16 & 18 DNA in cervical lesions of Indian women using in situ hybridization

Fifty one biopsies from women with malignant lesions of the uterine cervix and 9 biopsies fron non-malignant lesions were examined for the presence of HPV 16 and 18 DNA sequences by in situ hybridization method using 35S-labelled DNA probes. HPV 16 DNA sequences were detected in 82.4 per cent biopsies from women with malignant lesions, whereas HPV 18 DNA was detected in only 3 biopsies which were also positive for HPV 16 DNA. Two biopsies from non-malignant lesions were positive for HPV 16 DNA only. Data were also analysed according to the histologic type of cancer. It was observed that no significant correlation existed between HPV types and different histologic types of cervical cancer.

The use of diagnostic bronchoscopy in lung cancer

BACKGROUND

The role of fibreoptic bronchoscopy in the diagnosis of bronchogenic carcinoma is well established. However, in developing countries, where the burden of illness is large and diagnostic facilities are limited, only a small number of patients are diagnosed at a stage when they might benefit from operation. We felt it would be desirable to identify subsets of patients suspected of harbouring lung cancers, in whom bronchoscopy would have not only a high diagnostic yield but also provide useful information which might influence treatment, the patient's quality of life and duration of survival.

METHOD

We analysed the records of 588 patients, who had been bronchoscoped for suspected lung cancer, over a period of 8 years at a tertiary referral centre in north India. The patients were divided into different clinical subgroups on the basis of their clinical and radiological presentation, and the diagnostic yield from bronchoscopy in each group was calculated. A decision analysis model was constructed and the expected value of clinical information was determined for each group.

RESULTS

A tissue diagnosis was established by bronchoscopy in 177 (30%) patients and by additional investigations in 43 (7.3%) patients. A positive tissue diagnosis was obtained most often in patients with clinical and radiological evidence of pulmonary collapse (50%) and mass lesions (38-42%). Only 12% of patients with malignancy underwent resection and 70% of them belonged to the above two groups. The expected value of clinical information was greatest in patients with collapse (0.077) or mass lesions (0.067-0.065).

CONCLUSIONS

A diagnostic work-up including fibreoptic bronchoscopy is indicated early in patients with collapse or mass lesions of the lung. Patients with non-resolving pneumonia, pleural effusion, metastatic disease and non-specific lesions on chest X-ray should receive a low priority for bronchoscopy.

Pulmonary function and immunologic abnormalities in miliary tuberculosis

In a group of 33 patients with miliary tuberculosis (MTB), pulmonary function testing and bronchoalveolar lavage (BAL) were each performed in 31. The arterial blood gas analysis was done in 13 patients. Mild restrictive ventilatory defect, hypoxemia, and hypocapnia were observed. BAL revealed lymphocytic alveolitis. The lymphocyte subsets were measured in the BAL fluid and peripheral blood in 10 patients. The helper lymphocytes were decreased in the peripheral blood and increased in the BAL fluid. The immunoglobulins (IgG, IgA, and IgM) were significantly increased in the peripheral blood and BAL fluid in 18 patients. Serum complement (C3) (n = 23) and BAL fluid fibronectin (n = 22) were also significantly increased. Lymphocytic alveolitis and the raised levels of IgG and IgA in the peripheral blood and BAL fluid persisted at the end of 9 months of standard chemotherapy for tuberculosis. Long-term studies with larger numbers of patients are required to monitor the course of alveolitis in MTB. An addition of corticosteroids to the antituberculosis drug regimen may be considered in the treatment of these patients.

Medullary carcinoma of the thyroid: a cytological, immunocytochemical, and ultrastructural study

The cytomorphological features of 38 cases of medullary carcinoma of the thyroid on FNAC were studied. These cases were retrieved from the files of the cytopathology laboratory. In addition, staining for calcitonin (19 cases), thyroglobulin (5 cases), neurone specific enolase (7 cases), and carcinoembryonic antigen (8 cases) was done. Electron microscopy was done in two cases. On morphology, the presence of amyloid together with cytoplasmic granules was found to be diagnostic. The plasmacytoid cell type and the mixed cell populations were most commonly observed. Pseudononuclear inclusions were seen in 58% of cases. Calcitonin was present in 74% of cases. NSE was noncontributory, whereas CEA was positive in one of the calcitonin negative cases.

The prognostic significance of ploidy analysis in operable breast cancer

The nuclear DNA content of 98 operable breast cancers was determined by flow cytometric analysis using paraffin-embedded tissue. All patients were on follow-up and failure of treatment or recurrences were identified. DNA ploidy data in the form of ploidy status and DNA index (DI) has been correlated with various clinical and histopathologic factors. The only significant correlation using univariate analysis exists between the histologic grade and DI (P less than 0.025), recurrence of the disease and ploidy status (P less than 0.005), and recurrence of the disease and DI (P less than 0.005). The absence of correlation of ploidy status with other tumor derived factors indicates the independent nature of ploidy as a prognostic factor. Multivariate analysis showed that in the whole-group ploidy (P less than 0.01), tumor margin (P less than 0.01), and menopausal status (P less than 0.01) were significant factors in the order mentioned. DI with a cut of at 1.29 is not found to be a significant factor in the multivariate analysis. The maximum prognostic value of ploidy status was observed in the postmenopausal group (P less than 0.0005). In the node-negative group ploidy status (P less than 0.05) is the only independent significant factor predicting for early relapse. It is concluded that ploidy status is an independent prognostic factor predicting for recurrence of the disease. In the node-negative subgroup this could be used to identify the subset of patients who may benefit from adjuvant treatment.

Laparoscopic & histological features of hepatocellular carcinoma

Laparoscopic findings in 17 patients of proven hepatocellular carcinoma are reported. The laparoscopic appearance was of two types viz., solitary mass (in 12) and a multinodular lesion (in 5). Five patients with a solitary lesion involving the right lobe of the liver had associated satellite lesions. There was no evidence of cirrhosis in 8 (47%) patients. Ascites, peritoneal metastasis and splenomegaly were observed in 24, 12 and 17 per cent patients respectively. The commonest histological pattern seen was trabecular (65%) followed by anaplastic (17%), acinar (12%) and fibrolamellar (6%).

Cytomorphology of metastatic melanoma--use of S-100 protein in the diagnosis of amelanotic melanoma

The cytomorphological features of cells from 52 cases of metastatic melanoma obtained by fine needle aspiration cytodiagnosis were studied. Morphologically, 11, 19 and 22 cases were classified as spindle, epithelial, and mixed cell types of metastatic melanoma respectively. There were 34 melanotic and 18 amelanotic melanomas. Besides melanin, the presence of intranuclear cytoplasmic inclusions, eosinophilic macronucleoli and giant cells were helpful in the diagnosis of a melanoma. Where attempted, staining for S-100 protein was positive in all the 19 cases (eight amelanotic and 11 sparsely pigmented melanomas). In addition eight cases of metastatic tumour where a differential diagnosis of poorly differentiated carcinoma or large cell lymphoma was entertained, were also studied for localization of S-100 protein and all were found to be negative. Electron microscopy was performed in five cases and showed the presence of melanosomes and/or premelanosomes.

Extramedullary involvement in acute lymphoblastic leukemia and its relation to therapy

Extramedullary involvement (EMI) of various body sites was studied by doing CSF cytology anu FNAC of testes and lymph nodes in 82 children with acute lymphoblastic leukemia (ALL). Forty-five patients had received no therapy (group I) and 37 had been diagnosed and treated earlier and were now in remission (36) or relapse (group II). EMI was documented in 48.9% and 32.4% of patients of group I and II respectively. EMI was seen more frequently in patients with FAB-L 2 subtype (66.6%) as compared to FAB-L1 subtype (34.6%) in group I. Lymph nodes and testes were commonly involved in group I and II patients respectively. Successful remission after complete chemotherapy was achieved in 82.5% of group I patients. However, successful remission rates were 95.2% in patients without any evidence of EMI versus 68.4% in those with EMI. These differences were also observed when response to therapy was analysed separately for patients with FAB-L1 and FAB-L2 subtypes.