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Huang YT, Ho CY, Ou CY, Huang CC, Lee WT, Tsai SW, Hsu HJ, Hung DSY, Tsai CS, Fang SY, Tsai ST, Hsiao JR, Chang CC, Chen CC. Evaluation of Fine Needle Aspiration Cytopathology in Salivary Gland Tumors under Milan System: Challenges, Misdiagnosis Rates, and Clinical Recommendations. Biomedicines 2023; 11:1973. [PMID: 37509612 PMCID: PMC10376957 DOI: 10.3390/biomedicines11071973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/01/2023] [Accepted: 07/09/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Salivary gland tumors are rare in the head and neck. To determine the need and extent of surgical intervention, fine needle aspiration (FNA) is a widely accepted tool to approach salivary gland lesions. However, the FNA cytology varies between entities, while the lack of uniform terminology makes diagnosis more challenging. Since establishing the Milan system for reporting salivary gland cytopathology (MSRSGC) has become an increasingly accepted reporting standard, further examination and detailed recommendations were needed. (2) Methods: Between April 2013 and October 2021, 375 cases with FNA and salivary gland resection were retrospectively collected. All FNA specimens were reclassified according to the criteria of MSRSGC. After surgical excision, the FNA data were compared with the histological diagnosis to estimate the risk of malignancy (ROM), the risk of neoplasm (RON), and the diagnostic accuracy for each diagnostic category. (3) Results: Our cohort's distribution of ROM and RON was similar to the MSRSGC's recommendation. Carcinoma ex pleomorphic adenoma (CXPA) has the highest rate (66.7%) of misdiagnosed as a nonneoplastic lesion or benign salivary gland tumor. Pleomorphic adenoma (PA) and Warthin's tumor were the most common benign salivary gland tumors, while the cytology diagnosis of Warthin's tumor seems more challenging than PAs. (4) Conclusions: Despite the convenience and effectiveness of MSRSGC, we suggest close follow-up, re-biopsy, or surgical removal for salivary lesions even in Milan IVA-Benign for possibly missing FNA of malignancy, mixed lesions, or prevention of malignant transformation.
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Affiliation(s)
- Yi-Tien Huang
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Chen-Yu Ho
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Chun-Yen Ou
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Cheng-Chih Huang
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Wei-Ting Lee
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Shu-Wei Tsai
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Heng-Jui Hsu
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - David Shang-Yu Hung
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Chien-Sheng Tsai
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Sheen-Yie Fang
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Sen-Tien Tsai
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Jenn-Ren Hsiao
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Chan-Chi Chang
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Chien-Chin Chen
- Department of Pathology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi 600, Taiwan
- Department of Cosmetic Science, Chia Nan University of Pharmacy and Science, Tainan 717, Taiwan
- Ph.D. Program in Translational Medicine, Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Department of Biotechnology and Bioindustry Sciences, College of Bioscience and Biotechnology, National Cheng Kung University, Tainan 701, Taiwan
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Ratzon F, Feliciano DL, Katabi N, Xu B, Lin O, Wei XJ. Salivary gland fine-needle aspiration biopsy: quality assurance results from a tertiary cancer center. J Am Soc Cytopathol 2023; 12:206-215. [PMID: 36792408 PMCID: PMC10563449 DOI: 10.1016/j.jasc.2023.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/13/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Fine-needle aspiration biopsy (FNAB) plays a critical role in the management of patients with salivary gland lesions. A specific diagnosis can be difficult due to the wide range of lesions with overlapping morphologic features, potentially leading to interpretation errors. We analyzed the cytologic-histologic discrepancies identified in the quality assurance program of a major cancer center in cases of salivary gland FNAB and performed a root cause analysis. MATERIALS AND METHODS Salivary gland FNAB specimens performed during a 12-year period at a major tertiary cancer center were reviewed. The inclusion criteria for this study included FNAB cases of salivary glands with subsequent histologic or flow cytometry follow up. The cytologic diagnoses for these cases were recategorized according to the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) based on the original reports. The risk of neoplasm and malignancy based on the cases with subsequent resection or flow cytometry and the most common causes of discrepancy were analyzed. RESULTS The risk of neoplasm ranged from 41% to 99% and the risk of malignancy ranged from 22% to 99% among the different MSRSGC categories. Lymphoid and myoepithelial rich lesions were the most common miscategorized lesions using the MSRSGC. Reactive changes due to inflammation were associated with overcalls. The most common malignancy in the atypical category was mucoepidermoid carcinomas. CONCLUSIONS Myoepithelial and lymphoid rich lesions arising in the salivary gland are associated with a higher risk of misclassification. The use of category IVB in the MSRSGC is appropriate for lesions with abundant myoepithelial cells. Reactive atypia seen in sialadenitis was the most common feature associated with overcall.
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Affiliation(s)
- Fanni Ratzon
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Nora Katabi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bin Xu
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oscar Lin
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Xiao-Jun Wei
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
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Tenney TB, Mullane PC, Viswanathan K, Shi Q, Lui SK, Lubin DJ. Does Milan affect management? A retrospective analysis of resection rate and time to surgery among Milan categories. Diagn Cytopathol 2023; 51:221-229. [PMID: 36700488 DOI: 10.1002/dc.25104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/09/2023] [Accepted: 01/09/2023] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) is an established system with reproducible risk of malignancies (ROM) for salivary gland fine needle aspiration (SGFNA). No studies have reviewed the relationship between Milan categories and the resection rate (RR) and time to resection (TTR). METHODS We searched our database (January 1, 2011 to January 4, 2021) for non-lymphoma SGFNAs and assigned appropriate MSRSGC categories. RR and TTR were calculated and compared for each category. A literature search was performed; RRs and TTRs were compared. RESULTS Seven hundred and eighty SGFNAs were identified, 333 with follow-up. RR was highest in suspicious for malignancy (SUS, V; 70.6%, n = 12/17), followed by the salivary gland neoplasm of uncertain malignant potential (SUMP, IVb; 69.6%, n = 80/115) and malignant (M, VI; 55.6%, n = 75/135). Among M, primary tumors had a higher RR (65.1%, n = 41/63) than metastases (47.2%, n = 34/72, p = .36). In literature review, SUS had the highest RR (69.3%, n = 233/336) followed by M (61.6%, n = 821/1332) and SUMP (60.2%, n = 632/1050). TTR was shorter in SUS (mean = 32.3 days, median = 25 days). Within the benign neoplasms (BN, IVa), Pleomorphic adenomas (PAs) had a higher RR than Warthin tumors (WTs) (66.3% vs. 37.2%, p < .00001), and a shorter TTR (median = 63 days vs. 90 days). CONCLUSIONS Tumors classified as SUS had higher RR and at shorter intervals than those classified as SUMP. PAs have higher RRs and more expedient surgery than WTs. Cases classified as M are less likely to undergo follow-up than SUS, perhaps due to a lower RR for metastases.
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Affiliation(s)
- Troy B Tenney
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Patrick C Mullane
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Kartik Viswanathan
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia, USA.,Winship Cancer Center, Decatur, Georgia, USA
| | - Qiuying Shi
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia, USA.,Winship Cancer Center, Decatur, Georgia, USA
| | - Shu K Lui
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Daniel J Lubin
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia, USA.,Winship Cancer Center, Decatur, Georgia, USA
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Shahi AK, Sharma S, Singh B, Tandon A, Kumar A, Chandra S. Assessment of Risk of Malignancy of Fine-needle Aspiration Cytology in Salivary Gland Lesions Using the Milan System for Reporting Salivary Gland Cytopathology Categorization: A Systematic Review and Meta-analysis. J Contemp Dent Pract 2023; 23:1039-1056. [PMID: 37073919 DOI: 10.5005/jp-journals-10024-3424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND Fine-needle aspiration cytology (FNAC) of the salivary gland is crucial in the identification of salivary gland lesions, but the variation in morphological pattern and the overlap of morphological traits can result in erroneous interpretation and affect treatment, making FNAC of the salivary gland problematic. The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) was created to address these problems. OBJECTIVES To ascertain whether the FNAC method using MSRSGC was reliable in predicting the risk of malignancy (ROM) in each category of salivary gland lesions. MATERIALS AND METHODS The databases PubMed-MEDLINE, Web of Science, Cochrane, Scopus, and Google Scholar were all searched using pertinent keywords, reference searches, and citation searches. A fixed effect model was used to determine the pooled proportion with a 95% confidence interval (CI). All statistical analyses were performed using Meta Disc and R version 4.0.2 (R Foundation for Statistical Computing). RESULTS After reviewing the submissions' abstracts and titles, 58 documents that satisfied the necessary inclusion and exclusion criteria were ultimately selected. A total of 19,652 samples from 19,408 individuals was analyzed, out of which 9,958 samples were available for histopathological follow-up. The pooled ROM for category I was 10%, category II was 5%, category III was 28%, category IV A was 2%, Category IV B was 34%, category V was 91%, and category VI was 99%. CONCLUSION Milan System for Reporting Salivary Gland Cytopathology is useful for risk stratification and quality control, confirming its validity and diagnostic utility. Widespread use of MSRSGC would improve the accuracy of salivary gland cytology and lead to better patient care and improved treatment strategies. The results of this study are in consonance with reported values as per MSRSGC except for category V. CLINICAL SIGNIFICANCE The MSRSGC which was first reported in 2018 is a very useful tool for proper stratification of ROM in salivary gland FNAC. This study allowed us to validate the ROM values in different categories as reported in MSRSGC.
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Affiliation(s)
- Ajoy Kumar Shahi
- Department of Oral and Maxillofacial Surgery and Oral Implantology, Dental College, Rajendra Institute of Medical Sciences and Hospital, Ranchi, Jharkhand, India
| | - Swati Sharma
- Department of Pedodontics and Preventive Dentistry, Dental College, Rajendra Institute of Medical Sciences and Hospital, Ranchi, Jharkhand, India, Phone: +917562048287, e-mail:
| | - Bishnupati Singh
- Department of Prosthodontics, Dental College, Rajendra Institute of Medical Sciences and Hospital, Ranchi, Jharkhand, India
| | - Ankita Tandon
- Department of Oral Pathology and Microbiology, Dental College, Rajendra Institute of Medical Sciences and Hospital, Ranchi, Jharkhand, India
| | - Amit Kumar
- Department of Laboratory Medicine, Rajendra Institute of Medical Sciences and Hospital, Ranchi, Jharkhand, India
| | - Subhash Chandra
- Department of Orthodontics and Dentofacial Orthopedics, Dental College, Rajendra Institute of Medical Sciences and Hospital, Ranchi, Jharkhand, India
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Wang H, Liang J, Belcher R, Compton M, Weiss VL, Ely K, Johnson J, Coogan A. Nondiagnostic category of Milan System for Reporting Pediatric Salivary Gland Cytopathology: outcomes and root cause analysis. Cancer Cytopathol 2022; 130:609-619. [PMID: 35298098 PMCID: PMC10030067 DOI: 10.1002/cncy.22571] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/10/2022] [Accepted: 02/21/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fine-needle aspiration (FNA) results classified as the nondiagnostic category of the Milan system for reporting salivary gland cytopathology (MSRSGC) may be infrequently encountered in children. Clinical management may be challenging due to lack of data regarding outcomes and underlying causes. METHODS We retrospectively analyzed 106 consecutive pediatric salivary gland FNAs (2000-2020; 45% performed under image guidance). The outcomes of patients with nondiagnostic results were analyzed. Clinical parameters, FNA procedural parameters, and histopathologic parameters were compared between diagnostic and nondiagnostic cases. A root cause analysis was performed using the fishbone diagram and the 5 Whys method. RESULTS A total of 103 initial FNAs were identified. The nondiagnostic rates for initial and repeat biopsy were 16% (16/103) and 67% (2/3), respectively. Initial nondiagnostic FNAs were most frequently managed by clinical/radiologic follow-up only (56%, 9/16), followed by direct surgery (19%, 3/16) and repeat FNA (19%, 3/16). By histologic and clinical/radiologic follow-up, the risk of malignancy for nondiagnostic cases was zero. Palpation guidance (P < .05), inadequate sampling determined by rapid on-site evaluation (P < .01), and lesions with cystic, vascular, or diffuse nature (P < .05) were significantly associated with nondiagnostic results. By root cause analysis, proceduralist sampling error and lack of ultrasound guidance were the most common primary and secondary causes, respectively. CONCLUSIONS Pediatric salivary gland lesions of the nondiagnostic MSRSGC category have minimal risk of malignancy and may be successfully managed by clinical/radiologic follow-up. The root causes for nondiagnostic results were often multifactorial and primarily related to proceduralist sampling, characteristics of the lesions, and lack of ultrasound guidance.
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Affiliation(s)
- Huiying Wang
- Department of Pathology, Microbiology and Immunology
| | | | - Ryan Belcher
- Department of Otolaryngology, Vanderbilt University Medical Center
| | | | | | - Kim Ely
- Department of Pathology, Microbiology and Immunology
| | - Joyce Johnson
- Department of Pathology, Microbiology and Immunology
| | - Alice Coogan
- Department of Pathology, Microbiology and Immunology
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Hindi I, Simsir A, Szeto O, Hernandez O, Sun W, Zhou F, Brandler TC. The Milan System for Reporting Salivary Gland Cytopathology. Am J Clin Pathol 2022; 158:583-597. [PMID: 35849113 DOI: 10.1093/ajcp/aqac075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/11/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Our study assesses whether the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) offers any benefit over the original cytology classification, and measures interobserver agreement. METHODS Four cytopathologists retrospectively blindly classified preoperative cytology by MSRSGC from 101 resected salivary tumors. Consensus MSRSGC diagnoses were correlated with surgical pathology diagnoses and compared with the original cytology classification. Diagnostic parameters were calculated for both systems. Interobserver variability was assessed. RESULTS The original cytology classification vs MSRSGC had sensitivity, specificity, positive predictive value, and negative predictive value of 75.0% vs 78.3%, 97.1% vs 98.0%, 91.2% vs 94.7%, and 90.1% vs 90.0%, respectively. The original cytology classification risk of neoplasm (RON) was 91.7% for "negative for malignancy" and 100.0% for other categories. The MSRSGC RON was 71.4% in category II (nonneoplastic) and 100.0% in all other categories. The original cytology classification risk of malignancy (ROM) ranged from 0.0% for "atypical" to 100.0% for "positive for malignancy." The MSRSGC ROM ranged from 0.0% in categories I (nondiagnostic) and III (nonneoplastic) to 100.0% in category VI (malignant). Weighted agreement using the MSRSGC was 92% (Gwet AC1, 0.84); unweighted agreement was 69% (Gwet AC1, 0.64). MSRSGC category IVA (benign neoplasm) was most likely to show interobserver agreement, with complete agreement in 67% of cases. CONCLUSIONS The MSRSGC performs similarly to the original cytology classification and shows relatively high interobserver agreement.
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Affiliation(s)
- Issa Hindi
- Department of Pathology, New York University Langone Health, New York, NY, USA
| | - Aylin Simsir
- Department of Pathology, New York University Langone Health, New York, NY, USA
| | - Oliver Szeto
- Department of Pathology, New York University Langone Health, New York, NY, USA
| | - Osvaldo Hernandez
- Department of Pathology, New York University Langone Health, New York, NY, USA
| | - Wei Sun
- Department of Pathology, New York University Langone Health, New York, NY, USA
| | - Fang Zhou
- Department of Pathology, New York University Langone Health, New York, NY, USA
| | - Tamar C Brandler
- Department of Pathology, New York University Langone Health, New York, NY, USA
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Gubbiotti MA, Jalaly J, Baloch Z. Making a case for the success of Milan system for reporting salivary gland cytopathology. Diagn Cytopathol 2022; 50:451-455. [PMID: 35801712 DOI: 10.1002/dc.25010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Maria A Gubbiotti
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jalal Jalaly
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zubair Baloch
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Tommola E, Kalfert D, Hakso-Mäkinen H, Kholová I. The Contributory Role of Cell Blocks in Salivary Gland Neoplasms Fine Needle Aspirations Classified by the Milan System for Reporting Salivary Gland Cytology. Diagnostics (Basel) 2021; 11:diagnostics11101778. [PMID: 34679476 PMCID: PMC8534546 DOI: 10.3390/diagnostics11101778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/14/2022] Open
Abstract
(1) Background: The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) was introduced in 2018, bringing an organ-specific classification system for salivary gland cytopathology. The aim of present study is to evaluate the MSRSGC prospectively, based on a two-year experience in the tertiary care center pathology department, and evaluate the role of routine cell block (CB) preparation in salivary gland cytopathological diagnostics. (2) Methods: In our institution, the Department of Pathology, Fimlab Laboratories, Tampere, Finland, the MSRSGC has been implemented in salivary gland cytopathology since January 2018 and, over a two-year period (January 2018–December 2019), there were 365 fine-needle aspirations, of which 164 had a surgical follow-up. The CB methods used were Plasma-thrombin, the collection of visible fragments, and the Shandon and in-house methods. (3) Results: The MSRSGC diagnostic figures were as follows: accuracy 87.5%, sensitivity 45.8% and specificity 98.9%. For diagnostic categories of MSRSGC (non-neoplastic, benign neoplasm and malignant neoplasm) (n = 63) diagnostic accuracy was 98.4%, and for undetermined categories (atypia of undetermined significance, salivary gland neoplasm of uncertain malignant potential and suspicious for malignancy) (n = 49) diagnostic accuracy was 73.5%. Non-contributory cell blocks resulted more often in a false negative diagnosis (25%, 3/12) than a true negative diagnosis (10%, 7/73, p < 0.001), and is, most likely, an insufficient cytological diagnosis (86%, 18/21, p < 0.001). (4) Conclusion: The application of MSRSGC and CBs are beneficial in salivary gland cytological diagnosis, increasing diagnostic accuracy and, thus, patients’ management and treatment.
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Affiliation(s)
- Erkka Tommola
- Fimlab Laboratories, Department of Pathology, Tampere University Hospital, 33520 Tampere, Finland; (E.T.); (H.H.-M.)
- Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland
| | - David Kalfert
- Department of Otorhinolaryngology and Head and Neck Surgery, First Faculty of Medicine, University Hospital Motol, Charles University, 15006 Prague, Czech Republic;
| | - Heli Hakso-Mäkinen
- Fimlab Laboratories, Department of Pathology, Tampere University Hospital, 33520 Tampere, Finland; (E.T.); (H.H.-M.)
| | - Ivana Kholová
- Fimlab Laboratories, Department of Pathology, Tampere University Hospital, 33520 Tampere, Finland; (E.T.); (H.H.-M.)
- Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland
- Correspondence: ; Tel.: +358-3-311-74851
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