Evidence of latent HPV infection in older Danish women with a previous history of cervical dysplasia

INTRODUCTION

Understanding whether human papillomavirus (HPV) may establish latency in the uterine cervix is important. A better understanding of HPV natural history is useful for clinical counseling of women attending screening and to accurately inform health prevention strategies such as screening and HPV vaccination. We evaluated the extent of latent HPV infections in older women with a history of abnormal cytology.

MATERIAL AND METHODS

We conducted a cross-sectional study in Aarhus, Denmark, from March 2013 through April 2015. Women were enrolled if they underwent cervical amputation or total hysterectomy because of benign disease. Prior to surgery, women completed a questionnaire and a cervical smear was collected for HPV testing and morphological assessment. For evaluation of latency (i.e., no evidence of active HPV infection, but HPV detected in the tissue), we selected women with a history of abnormal cervical cytology or histology, as these women were considered at increased risk of harboring a latent infection. Cervical tissue underwent extensive HPV testing using the SPF10-DEIA-LipA25 assay.

RESULTS

Of 103 women enrolled, 26 were included in this analysis. Median age was 55 years (interquartile range [IQR] 52-65), and most women were postmenopausal and parous. The median number of sexual partners over the lifetime was six (IQR 3-10), and 85% reported no recent new sexual partner. Five women (19.2%) had evidence of active infection at the time of surgery, and 19 underwent latency evaluation. Of these, a latent infection was detected in 11 (57.9%), with HPV16 being the most prevalent type (50%). Nearly 80% (n = 14) of the 18 women with a history of previous low-grade or high-grade cytology with no treatment had an active or latent HPV infection, with latent infections predominating. HPV was detected in two of the six women with a history of high-grade cytology and subsequent excisional treatment, both as latent infections.

CONCLUSIONS

HPV can be detected in cervical tissue specimens without any evidence of an active HPV infection, indicative of a latent, immunologically controlled infection. Modeling studies should consider including a latent state in their model when estimating the appropriate age to stop screening and when evaluating the impact of HPV vaccination.

HrHPV testing vs liquid-based cytology in cervical cancer screening among women aged 50 and older: a prospective study

Introduction

Evidence supports high-risk human papilloma virus (HPV) testing as the primary cervical cancer screening tool. However, benefits and harms should be carefully considered before replacing liquid-based cytology. In women age 50 and older, we evaluated how a commercially available DNA amplification HPV test compares with routine liquid-based cytology.

Methods

This prospective study included 4043 patients who had a cervical sample analyzed from September 2011 to September 2012. Patients were followed between 64 and 76 months (median: 70 months). Samples were analyzed using both liquid-based cytology and the Cobas 4800 HPV DNA test. We calculated the diagnostic efficacy of liquid-based cytology and HPV, with or without the opposite test as triage, using cervical intraepithelial neoplasia (CIN2+/CIN3+) as reference.

Results

The patients had a median age of 58 years, (range; 50–90). At baseline, HPV prevalence was 8.0%: a total of 3.7% of patients had atypical squamous cells of undetermined significance or worse (ASCUS+). Positive test results were 1.9% for liquid-based cytology with HPV triage and 3.0% for HPV with liquid-based cytology triage. The cumulative incidence of CIN3+ was 1.0% (40/4043). Sensitivities for CIN3+ were: liquid-based cytology 47.5% (31.5%–63.9%); liquid-based cytology with HPV triage 45.0% (29.3%–61.5%); HPV 90.0% (76.3%–97.2%); and HPV with liquid-based cytology triage 67.5% (50.9%–81.4%). Corresponding specificities were: liquid-based cytology 96.6% (96.0%–97.2%); liquid-based cytology with HPV triage 98.5% (98.0%–98.8%); HPV 92.8% (92.0%–93.6%); and HPV with liquid-based cytology triage 97.7% (97.2%–98.1%). At baseline, HPV testing overlooked five cases of gynecological cancer other than cervical cancer. Five cervical cancers were detected, two had been overlooked at baseline by liquid-based cytology and two by HPV testing

Conclusion

HPV screening using DNA amplification is a promising alternative to liquid-based cytology in women age 50 and older, but evaluation of alternative triage methods is warranted. The risk of overlooking cancers needs consideration when replacing liquid-based cytology with HPV testing as a method for primary screening.

Whole tissue cervical mapping of HPV infection: Molecular evidence for focal latent HPV infection in humans

In this study, we aimed to provide molecular evidence of HPV latency in humans and discuss potential challenges of conducting studies on latency. We analyzed the entire cervix of two women who underwent hysterectomy unrelated to cervical abnormality. The cervices were sectioned into 242 and 186 sets respectively, and each set was tested separately for HPV using the SPF10-PCR-DEIA-LiPA25 system. To identify whether there was any evidence of transforming or productive infection, we used the biomarkers E4 and P16^INK4a to stain slides immediately adjacent to HPV-positive sections. HPV was detected in both cervices. In patient 1, 1/242 sets was positive for HPV31. In patient 2, 13/186 sets were positive for HPV18 and 1/186 was positive for HPV53. The infection was very focal in both patients, and there was no sign of a transforming or productive infection, as evaluated by the markers E4 and P16^INK4a. Had we only analyzed one set from each block, the probability of detecting the infection would have been 32.3% and 2%, respectively.Our findings support the idea that HPV may be able to establish latency in the human cervix; however, the risk associated with a latent HPV infection remains unclear.

Direct notification of cervical cytology results to women improves follow-up in cervical cancer screening - A cluster-randomised trial

Up to half of all women do not receive follow-up as recommended after cervical cytology testing and are thus at increased risk of dysplasia progression. Women from lower social positions are at increased risk of not receiving follow-up. Sample takers, often general practitioners, convey results to women, but communication problems constitute a challenge. We aimed to investigate the effect of direct notification of cervical cytology results on follow-up rates. In a 1:1 cluster-randomised controlled trial, we assessed if having the pathology department convey cervical cytology results directly to the investigated women improved timely follow-up, compared with conveying the results via the general practitioner as usual. All women with a cervical cytology performed in a general practice in the Central Denmark Region (2013-2014) and receiving follow-up recommendation were included (n = 11,833). The proportion of women without timely follow-up was lower in the group with direct notifications than in the control group of women receiving usual care, regardless of age, educational status, cohabitation status and ethnicity. Among the women with the most severe cervical cytology diagnoses who are recommended gynaecological follow-up within 3 months, the percentage without timely follow-up was 15.1% in the intervention group and 19.5% in the control group (prevalence difference: -0.04 (95%CI: -0.07; -0.02)). Improved timely follow-up was also observed for women with a recommendation to have follow-up performed at 3 and 12 months. Cervical cytology results conveyed directly by letter to women increased the proportion of women with timely follow-up without raising inequality in follow-up measured by social position. Trial registration: ClinicalTrials.gov (TRN: NCT02002468) 29 November 2013.

HPV self-sampling in cervical cancer screening: the effect of different invitation strategies in various socioeconomic groups - a randomized controlled trial

Background

Participation in cervical cancer screening varies by socioeconomic status. The aims were to assess if offering human papilloma virus (HPV) self-sampling kits has an effect on screening participation among various socioeconomic groups and to determine if two invitation strategies for offering self-sampling influence the participation rate equally.

Methods

The study was based on registry data that were applied to data from a randomized controlled trial (n=9,791) measuring how offering HPV self-sampling affected screening participation. The women received either 1) a self-sampling kit mailed directly to their homes (directly mailed group); 2) an invitation to order the kit (opt-in group); or 3) a standard second reminder to attend regular cytology screening (control group). The participation data were linked to registries containing socioeconomic information.

Results

Women in the directly mailed group participated significantly more than women in the control group, regardless of their socioeconomic status, but the largest effects were observed in Western immigrants (participation difference [PD]=18.1%, 95% CI=10.2%–26.0%) and social welfare recipients (PD=15.2%, 95% CI=9.7%–20.6%). Compared with the control group, opt-in self-sampling only had an insignificant effect on participation among women who were immigrants, retired, or less educated. Western immigrants had a significantly higher increase in participation than native Danish women when kits were mailed directly compared with the opt-in strategy (PD=18.1%, 95% CI=10.2%–26.2% and PD=5.5%, 95% CI=2.9%–8.1%, respectively, P=0.01).

Conclusion

All socioeconomic groups benefited from the directly mailed strategy in terms of higher screening participation, but Western immigrants and lower socioeconomic groups seemed to benefit the most. Immigrants and some lower socioeconomic groups only had insignificant benefits of opt-in self-sampling. The directly mailed strategy might be preferable to opt-in self-sampling because it ensures that ethnic minority groups obtain benefits of introducing HPV self-sampling in an organized cervical cancer screening program.

Trial registration

Current Controlled Trials NCT02680262. Registered February 10, 2016.

Good concordance of HPV detection between cervico-vaginal self-samples and general practitioner-collected samples using the Cobas 4800 HPV DNA test

Background

Studies comparing self-samples and clinician-collected samples for high-risk human papillomavirus (HPV) detection using clinically validated PCR-based HPV DNA assays are limited. We measured the concordance of HPV detection between home-based self-sampling and general practitioner (GP) sampling using the Cobas 4800 HPV DNA test and studied women’s accept of home-based self-sampling.

Methods

Paired GP-collected samples and cervico-vaginal self-samples were obtained from 213 women aged 30–59 years diagnosed with ASC-US within the cervical cancer screening program. After undergoing cervical cytology at their GP, the women collected a self-sample with the Evalyn Brush at home and completed a questionnaire. Both samples were HPV-tested using the Cobas 4800 test. Histology results were available for those who tested HPV positive in GP-collected samples.

Results

We observed good concordance for HPV detection between self-samples and GP-collected samples (κ: 0.70, 95% CI: 0.58–0.81). No underlying CIN2+ cases were missed by self-sampling. Women evaluated that self-sampling was easy (97.2%, 95% CI: 93.9–98.9%) and comfortable (94.8%, 95% CI: 90.9–97.4%).

Conclusions

Home-based self-sampling using the Evalyn Brush and the Cobas 4800 test is an applicable and reliable alternative to GP-sampling.

SATB2 is a supplementary immunohistochemical marker to CDX2 in the diagnosis of colorectal carcinoma metastasis in an unknown primary

CDX2 is routinely used for identifying gastrointestinal origin of metastatic adenocarcinomas; but a high percentage of other carcinomas also show positivity with this antibody. SATB2 is a new immunohistochemical marker with a few studies showing that it is specifically expressed in a large majority of colorectal adenocarcinomas. We assessed SATB2 along with CDX2 in patient material with metastasis in order to determine whether the primary site could be identified as 'colon-rectum'. Metastasis in 67 liver biopsies, 108 lymph nodes from resection specimens and 36 serous effusions was analyzed retrospectively. Blinded slides stained for CDX2 and SATB2 were assessed individually by two pathologists and sensitivity, specificity and kappa statistics were calculated. Sensitivity for CDX2 in metastasis from colorectal adenocarcinomas was 93%; while in SATB2 it was 79%. The combination of CDX2 and SATB2 yielded a sensitivity of 79% and a high specificity of 93%. There was an acceptable level of agreement (κ = 0.64) between the pathologists for both the markers in case of colorectal adenocarcinoma metastasis. CDX2 is a sensitive marker compared to SATB2; while the specificity of combination of CDX2 and SATB2 is high for metastasis from colorectal adenocarcinoma. SATB2 can be used as a supplementary marker along with CDX2 to identify colorectal origin for material received from patients clinically presenting with metastasis.

Preventing cervical cancer using HPV self-sampling: direct mailing of test-kits increases screening participation more than timely opt-in procedures - a randomized controlled trial

Background

Cervical cancer screening participation remains insufficient in most countries. Our aim was to evaluate whether offering a HPV self-sampling kit, either mailed directly to the woman’s home or using timely opt-in procedures for ordering the kit, increased screening participation compared with a standard second reminder.

Methods

In this randomized, controlled effectiveness trial, 9791 Danish women aged 30–64 who were due to receive the second reminder were equally randomized to either: 1) direct mailing of a second reminder and a self-sampling kit (directly mailed group); 2) mailing of a second reminder that offered a self-sampling kit to be ordered by e-mail, text message, phone, or webpage (opt-in group); or 3) mailing of a second reminder to attend regular cytology screening (control group). In an intention-to-treat analysis, we estimated the participation rate at 180 days post intervention, by returning a self-sample or attending regular cytology screening. We calculated the proportion of women with a positive HPV self-sample who attended for cervical cytology triage at the general practitioner within 90 days.

Results

Participation was significantly higher in the directly mailed group (38.0%) and in the opt-in group (30.9%) than in the control group (25.2%) (participation difference (PD): 12.8%, 95% CI: 10.6–15.0% and PD: 5.7%, 95% CI: 3.5–7.9%, respectively). Within 90 days, 107 women (90.7%, 95% CI: 83.9–95.3%) with a HPV-positive self-sample attended follow-up.

Conclusions

Offering the opportunity of HPV self-sampling as an alternative to regular cytology screening increased participation; the direct mailing strategy was the most effective invitation strategy. A high compliance with follow-up was seen.

Trial registration

Current Controlled Trials NCT02680262. Registered 10 February 2016.

The influence of total hysterectomy in a cervical cancer screening population: a register-based cross-sectional study

BACKGROUND

High coverage of a screening program is essential to program success. Many European screening programs cover only 10-80% of their target population. A possible explanation for the low coverage may be that some women in the screening population have had a total hysterectomy, thus they are not at risk of cervical cancer. The aim of this study was to identify the prevalence of hysterectomy in the target population of the Danish National Cervical Cancer Screening Program (NCCSP) and to recalculate coverage after excluding women with total hysterectomy. Furthermore, to analyze the association between hysterectomy and sociodemographic factors within the screening population.

METHODS

A population-based cross-sectional study using register data on all women in the target population of the NCCSP on January 12, 2012 (women born January 12, 1947, to January 12, 1986). The total coverage included women with hysterectomy in the target population whereas the recalculated coverage was calculated excluding women with total hysterectomy. To test the differences between the total coverage and the recalculated coverage, a two-sample z-test between the proportion of covered hysterectomized women and the proportion of covered non-hysterectomised women were used. A logistic regression model adjusted for age and sociodemographic characteristics was used to analyze the association between sociodemographic factors and total hysterectomy.

RESULTS

The coverage among women aged 26-49 years and 55-64 years were 77.4% and 72.7%, respectively. The recalculated coverage was 78.2% (26-49 years) and 79.4% (55-64 years). Recalculating the coverage did not result in coverage higher than 82.7% at any age. The effect of excluding women with total hysterectomy increased with age, reaching its maximum of 8 % points for the oldest women. Women with higher socioeconomic status (higher education and higher disposable income) had lower odds of being hysterectomized compared to other women. Also, immigrants and descendants had lower odds of being hysterectomized compared to ethnic Danes.

CONCLUSIONS

Excluding women with total hysterectomy only partly explained the low coverage of the NCCSP. Thus, initiatives must be made to improve acceptability of and accessibility to the NCCSP, especially in the youngest and the oldest women.

Study protocol of the CHOiCE trial: a three-armed, randomized, controlled trial of home-based HPV self-sampling for non-participants in an organized cervical cancer screening program

BACKGROUND

The effectiveness of cervical cancer screening programs is challenged by suboptimal participation and coverage. Offering cervico-vaginal self-sampling for human papillomavirus testing (HPV self-sampling) to non-participants can increase screening participation. However, the effect varies substantially among studies, especially depending on the approach used to offer HPV self-sampling. The present trial evaluates the effect on participation in an organized screening program of a HPV self-sampling kit mailed directly to the home of the woman or mailed to the woman's home on demand only, compared with the standard second reminder for regular screening.

METHODS/DESIGN

The CHOiCE trial is a parallel, randomized, controlled, open-label trial. It will include 9327 women aged 30-64 years who are living in the Central Denmark Region and who have not participated in cervical cancer screening after an invitation and one reminder. The women will be equally randomized into three arms: 1) Directly mailed a second reminder including a HPV self-sampling kit; 2) Mailed a second reminder offering a HPV self-sampling kit, to be ordered by e-mail, text message, phone, or through a webpage; and 3) Mailed a second reminder for a practitioner-collected sample (control group). The primary outcome will be the proportion of women in the intervention groups who participate by returning their HPV self-sampling kit or have a practitioner-collected sample compared with the proportion of women who have a practitioner-collected sample in the control group at 90 and 180 days after mail out of the second reminders. Per-protocol and intention-to-treat analyses will be performed. The secondary outcome will be the proportion of women with a positive HPV self-collected sample who attend follow-up testing at 30, 60, or 90 days after mail out of the results.

DISCUSSION

The CHOiCE trial will provide strong and important evidence allowing us to determine if and how HPV self-sampling can be used to increase participation in cervical cancer screening. This trial therefore has the potential to improve prevention and reduce the number of deaths caused by cervical cancer.

TRIAL REGISTRATION

Current Controlled Trials NCT02680262 . Registered 10 February 2016.

An adverse event in a well-established cervical cancer screening program: an observational study of 19,000 females unsubscribed to the program

Introduction

In Denmark, an organized approach to cervical cancer screening has had national coverage since 1998. However, in 2013, it was discovered that 19,000 females had been unsubscribed from the Danish National Cervical Cancer Screening Program and had thus not received invitations or reminders as recommended by the health authorities. The study aims to report the essence of this adverse event and describe the outcomes of reestablishing invitations in terms of participation rates and screening results. Furthermore, patient compensations to affected females diagnosed with cervical cancer and coverage in the mass media was reported.

Methods

An observational study based on information from the Danish Pathology Databank, the Department of Public Health Programs, and Infomedia (a Danish database of media coverage) was carried out.

Results

A total of 19,106 females were affected. Of those still in the screening age, 37.7% had been tested within 3 years or 5 years despite not receiving any invitation. A total of 21.6% reconfirmed their status as unsubscribed. Of the remaining females, 55.6% were tested within a year, and 94.6% of these test results were normal. Among females aged >64 years, 12.7% accepted the offer of a final screening test. Totally, 90% of these tests were normal. Nineteen females diagnosed with cervical cancer were compensated by the Danish Patient Compensation Association with a total of €693,000, ranging from €8,900 to €239,700. Coverage of cervical cancer screening in the mass media increased from 25 items in the 3 months prior to this adverse event to 590 items in the month when it became public.

Conclusion

Even though more than one-third of the affected females were tested despite not receiving regular invitations to participate in the screening program, lacking invitations were ranked alongside other adverse events in the health care system if cancer diagnoses were delayed.

Impact of opportunistic testing in a systematic cervical cancer screening program: a nationwide registry study

BACKGROUND

Systematic screening for precancerous cervical lesions has resulted in decreased incidence and mortality of cervical cancer. However, even in systematic screening programs, many women are still tested opportunistically. This study aimed to determine the spread of opportunistic testing in a systematic cervical cancer screening program, the impact of opportunistic testing in terms of detecting cytological abnormalities and examine the associations between sociodemography and opportunistic testing.

METHODS

A nationwide registry study was undertaken including women aged 23-49 years (n = 807,624) with a cervical cytology between 2010 and 2013. The women were categorised into: 1) screening after invitation; 2) routine opportunistic testing, if they were either tested more than 9 months after the latest invitation or between 2.5 years and 3 years after the latest cervical cytology and 3) sporadic opportunistic testing, if they were tested less than 2.5 years after the latest cervical cytology. Cytological diagnoses of women in each of the categories were identified and prevalence proportion differences (PPD) and 95% confidence intervals (CIs) were used to explore group differences. Associations between sociodemography and undergoing opportunistic testing were established by multinomial logistic regression.

RESULTS

In total, 28.8% of the cervical cytologies were due to either routine (20.7%) or sporadic (8.1%) opportunistic testing. Among women undergoing routine opportunistic testing, a larger proportion had high-grade squamous intraepithelial abnormalities than invited women (PPD: 0.6%, 95 % CI: 0.03-1.17%). A similar proportion of cytological abnormalities among women undergoing sporadic opportunistic testing and invited women was found. In multivariate analyses, younger age, being single or a social welfare recipient and residence region (North Denmark) were especially associated with opportunistic testing (routine or sporadic).

CONCLUSIONS

One fourth of cervical cytologies in this study were collected opportunistically. Compared to invited women, women undergoing routine opportunistic testing were more likely to be diagnosed with abnormal cytologies. Hence, routine opportunistic testing might serve as an important supplement to the systematic screening program by covering non-participating women who may otherwise be tested with a delay or not tested at all. Among women tested more often than recommended (sporadic testing), no benefits in terms of detecting more cytological abnormalities were identified.

A primary healthcare-based intervention to improve a Danish cervical cancer screening programme: a cluster randomised controlled trial

BACKGROUND

The proportion of non-attenders in cervical cancer screening is high, and should be minimised. A targeted invitation to women not participating for the last 5 years in cervical screening was evaluated to determine whether it would decrease the number of these women. Increasing general practitioners' attention to the screening programme for cervical cancer was also evaluated to determine whether it would increase participation.

METHODS

A cluster randomised controlled trial conducted in the county of Aarhus, Denmark. All women registered with a GP were randomised. Regardless of group allocation, all women received a normal invitation. In the intervention arm, GPs were visited to facilitate quality enhancements of the screening programme, combined with a special targeted invitation to women aged 23-59 registered with the GP but not attending screening for the last 5 years. The main outcome was the proportion of non-attenders and the secondary outcome was coverage rate.

RESULTS

117 129 women registered with 190 GPs were included in the study. 1737 non-attenders had a Papanicolaou smear during follow-up. The decline in non-attenders was 0.87% (95% CI 0.57% to 1.16%) after 9 months in favour of the intervention. A difference of 0.94% (95% CI 0.21% to 1.67%) in the change of coverage rate was observed at 6 months, which increased to 1.97% (95% CI 0.03% to 3.91%) at 9 months in favour of the intervention.

CONCLUSION

It is possible to decrease the proportion of non-attenders and increase the coverage rate in a screening programme for cervical cancer using a special targeted invitation to non-attenders combined with a visit to GPs. To further improve participation, other barriers must be identified and addressed.

[Adverse incidents in a cervical cancer screening programme]

INTRODUCTION

In about 10% of routine vaginal smears, pathologists recommend a repeat smear. The purpose of this paper is to describe the extent to which this recommendation is followed, reasons why this is not always the case, and possible ways of improvement.

MATERIALS AND METHODS

Data on follow-up rates were extracted from the cervical cancer screening database in Aarhus County. Through facilitator visits information was obtained about the routine procedures for informing women about the test results, reasons for lack of follow-up and suggestions for improvement of the follow-up rate.

RESULTS

One third of the recommended follow-up smears were not taken. Patients from single-handed practices were less likely to have a follow-up smear than those registered with group practices. The follow-up rate was independent of the organisation of the procedures for informing the women about the test results. Reasons at practice level for lack of follow-up included failure to convey the test results, unclear information to the women and lack of procedures to identify those who did not have the recommended test taken. To improve the follow-up rate, the general practitioners who were interviewed suggested a number of procedures to identify the women who did not receive the recommended follow-up smear.

CONCLUSION

The follow-up rate is not acceptable, and a systematic follow-up procedure is necessary to ensure that the recommended follow-up tests are carried out. This is most efficiently done at a central level.

Screening history of women with cervical cancer: a 6-year study in Aarhus, Denmark

To identify possible weaknesses in cervical screening in Aarhus County, 10 years after the programme was introduced, screening histories were examined. A major problem for the screening programme was that 31% of women were never screened and 61% under-screened, the latter group being significantly dominated by older women and high-stage tumours.

[Comparison of monolayer specimens and conventional smears]

INTRODUCTION

Monolayer specimens were compared with conventional smears in a split sample study. The quality of the specimens, sensitivity, time consumption, and costs were elucidated.

METHOD

Conventional smears and fixated residual material from 1701 women were available.

RESULTS

The number of inadequate/less adequate specimens was reduced significantly (p < 0.001). Diagnostic agreement was found in 1531 (90%) of the 1701 cases (kappa = 0.52, SE (kappa) = 0.026). Dysplasia (NOS) was diagnosed in seven monolayer specimens (0.4%) versus 33 smears (1.9%) and ratio atypia/low grade was reduced by 33%, which indicates greater accuracy in diagnosis in monolayers. Histological follow-up showed sensitivities of 95% (monolayers) and 94% (smears). The time consumed (laboratory work, screening) on a smear versus a monolayer specimen was 11.5 minutes versus 9.3 minutes. Utensil costs of a smear are kr. 10.69. compared to kr. 26.50 for a monolayer specimen.

CONCLUSION

The higher costs should be set against the saving in significantly improved specimen quality, improved diagnostic accuracy, and shorter time consumption. The use of the monolayer technique (direct to vial) is recommended to replace the conventional smear.

[Partial re-screening of all negative smears. A method of quality control of pathology department concerning smear screening against cervix cancer]

Partial rescreening of all negative smears is recommended as the most cost-effective method of internal quality control. The method was tested by eight cytotechnologists and the average diagnostic sensitivity, assessed upon their answering of 200 test-smears (150 negative and 50 positive) was 80%, while specificity vas calculated to 95%. Partial rescreening has here-upon been used in daily routine. After one year 21,000 smears have been re-screened. Twenty-nine cases of false negatives, 16 with atypia, eight with koilocytosis, and five cases with dysplasia have been detected, which corresponds to an overall false negative rate on 3%. In five of the 29 false negative cases with dysplasia histological follow-up has shown three cases of CIN III (two carcinoma in situ, one severe dysplasia), one case with CIN II (moderate dysplasia) and one case with CIN I (mild dysplasia). Conclusively, partial rescreening of all negative smears implies an improved quality with reduction of the number of false negative specimens.

[Bladder tumor antigen test versus urinary cytology in patients with bladder tumors]

The value of the BARD bladder tumour antigen (BTA) test for the diagnosis of bladder tumour was compared to urinary cytology. A total of 60 patients with bladder tumours (Category Ta: 39 patients and Category T1-4: 21 patients) were investigated. Urinary cytology was found to be more sensitive than the BTA test. The overall sensitivity of cytology was 0.63 compared to 0.27 for the BTA test. The sensitivity of both tests improved with increasing tumour severity. For Ta tumours and T1-4 tumours the sensitivity of cytology was 0.46 and 0.95 respectively, and for the BTA test it was 0.13 and 0.53 respectively. We conclude that urinary cytology is superior to the BTA test. The BTA test cannot be recommended either for bladder tumour screening or monitoring for recurrence because of too many false negative results. Because of its high specificity (0.93), a positive BTA test might reduce the number of flexible cystoscopies, and prepare the patient directly for tumour resection.

Cytobrush and endocervical curettage in the diagnosis of dysplasia and malignancy of the uterine cervix

BACKGROUND

The validity of cytobrush and endocervical curettage combined with colposcopically directed biopsies in the diagnosis of cervical dysplasia and malignancy has not been evaluated in randomized trials. We aimed to elucidate the diagnostic validity of the two methods.

METHODS

A prospective, randomized study of 180 consecutive patients. All patients were examined without anesthesia by colposcopically directed biopsies of the ectocervix and randomly assigned to either cytobrush or endocervical curettage. Patients with < or = CIN 1 were investigated with the alternative method three months later. Patients with > or = CIN 2 had a cone biopsy.

RESULTS

One hundred and thirty-one patients were evaluable. The sensitivity of cytobrush and endocervical curettage combined with colposcopically directed biopsies of the ectocervix was 96% and 84% (p = 0.08), respectively. The specificities of the two investigations were 95% and 88%, respectively (p = 0.78). All cytobrush specimens were evaluable but because of a low recovery of endocervical material a diagnosis could not be made in 12% of the patients examined by endocervical curettage.

CONCLUSION

The sensitivity of the combined use of cytobrush and biopsies of the ectocervix was equal to or higher than the sensitivity of endocervical curettage and ectocervical biopsies. The specificities of the two investigations were much alike. All cytobrush specimens were evaluable but a diagnosis could not be performed in 12% of the endocervical curettage specimens because of too little endocervical material. Furthermore, cytobrush is less inconvenient to the patient. Therefore, in the follow-up of patients with cervical dysplasia endocervical curettage may be replaced with cytobrush.

Significance of variations in section mounting technique for nuclear stereology and morphology in urinary bladder neoplasms

Owing to its toxicity it would be desirable to avoid xylene in the processing of histological tissue. Consequently, modifications of the section mounting technique excluding xylene have recently been suggested. Changes in tissue preparation might, however, influence histopathological structures used for malignancy grading of tumours. In the current study, we investigated the impact of alterations in the mounting process on the subjectively evaluated quality of nuclear morphology and on the stereologically obtained mean nuclear volume, vv(nuc), of urothelial neoplasms. Paraffin sections from 14 tumours were, after the haematoxylin-eosin staining, mounted with DPX and a coverslip either, 1) from the water bath, 2) after dehydration in ethanol but without clearing, or, 3) after dehydration and xylene clearing. We found that the nuclear morphology of ethanol-treated and xylene-cleared specimens was somewhat more brilliant than that of sections mounted from water. The vv(nuc) of xylene-cleared sections ranged from 142 to 751 microns3, and the mean value of 350 microns3 was not significantly different from that of ethanol-treated sections of 367 microns3 (2p = 0.67). In contrast, the mean vv(nuc) of sections mounted from water was 459 microns3, approximately 30% larger (2p < or = 0.02). Thus, although previous studies have demonstrated the prognostic value of vv(nuc) in patients with bladder cancer, the present study shows that modifications in section mounting technique may significantly influence the results, underscoring the need for standardization of tissue processing. Sections mounted from ethanol seem to be as good as routine xylene-cleared sections, whereas sections mounted from water have a less brilliant morphology and results of nuclear stereology different from those of routine sections.

Body growth in relation to tonsillar enlargement and tonsillectomy

Severe airway obstruction caused by tonsillar enlargement can result in disturbances in body growth. The effect of this interference and of tonsillectomy in the child with only moderate symptoms have been less satisfactoril evaluated. In this study, 122 children with symptoms and signs of tonsillar obstruction were investigated concerning the height and weight before and after tonsillectomy. None of the individuals demonstrated cardiopulmonary complications of tonsillar obstruction. Altogether 10% of the children exhibited abnormalities in body weight and/or length prior to surgery. Especially during the first postoperative year, the weight and height gain exceeded the expected in 75% of the patients. The accelerated weight gain increased with tonsil size, but there was no relation to the extent of difficulties in swallowing or sleeping disruptions. The results support the hypothesis that tonsillar hypertrophy frequently is associated with disturbances in body growth and that this is seldom demonstrable prior to tonsillectomy.

The influence of tonsillar obstruction and tonsillectomy on facial growth and dental arch morphology

Children, who were tonsillectomized because of sleep apnea were examined with respect to facial growth and dental arch morphology. Dental casts and lateral roentgencephalograms were analysed before surgery and two years after tonsillectomy. The findings were compared to data from children without tonsillary obstruction. A higher proportion of malocclusion than normal, especially open bite and crossbite, was noticed before surgery. Two years after surgery, 77% of the open bites were normalised and 50-65% of the buccal and anterior crossbites. The best results were seen in children operated before the age of 6.

Down syndrome and sleep apnea--a therapeutic challenge

This case report describes 3 patients with Down syndrome and obstructive breathing problems, ages: 5 months, 15 months, and 22 years. The youngest one had normal cardiopulmonary function at birth, but soon developed a pulmonary hypertension. The next had a severe atrioventricular defect and additional pulmonary hypertension and there was little hope for her to survive heart surgery. The oldest one had had apneas since childhood with increasing severity, but was regarded as having normal heart function. All 3 were operated to relieve their breathing obstruction. The 5-month-old boy improved only slightly after an initial UPPP and had to be tracheotomized, which solved his problems. The tracheotomy could be removed when he was one year. The 15-month-old girl was cured of her breathing problems through an A + T and survived her heart surgery one month later. Tonsillectomy and UPPP was performed on the oldest patient. Following surgery, he had an episode of life-threatening bleeding and developed a DIC syndrome, and was critically ill for 18 days. After he recovered, his sleep apnea had improved. Once a myxoedema was diagnosed and treated, he made further progress. These cases stress the significance of early recognition of sleep apnea in children with Down syndrome and the importance of a careful preoperative investigation in collaboration with cardiologists.

The effect of Xylometazoline on the mucosa of human maxillary sinus

A stuffy and running nose are two of the most expressed symptoms of acute rhinosinusitis and have made the use of decongestants very common. The medication, oral or nasal, gives relief from symptoms but its effect on the healing of the infection, positive or negative, is not clear. The effect of Xylometazoline on the blood flow, the pulse amplitude and the gas exchange in the antral mucosa of the maxillary sinus was studied in five healthy subjects. Our experiments show that the mucosal pulse amplitude and the blood flow are strongly reduced by insufflation of Xylometazoline but the gas exchange in the mucosa is only lowered to a minor extent. The reduction in gas exchange is not great enough to allow the gas mixture to be altered. The defence mechanisms in the antral mucosal lining, i.e. the mucociliary-, the immuno- and the phagocytotic mechanisms are all dependent on the blood flow and the gas exchange through narrow maxillary ostia of the pumping effect generated by the mucosal pulse wave. The reduction in blood flow and pulse amplitude in the maxillary mucosa caused by Xylometazoline leads us to consider that, although not harmful then it is at least not helpful, in healing rhinosinusitis. Since oral decongestants have almost the same effect on the mucosa as nasal decongestants, we do not think that any of the medicines faciliate the healing of infections in the upper airways even if they make the patient feel better during the infection.

Blood flow and pulse amplitude in the mucosa of the human maxillary sinus in relation to body posture

The paranasal sinuses are non-collapsible ventilated gas pockets without any known function. They should, however, be adequately ventilated to stay healthy. Persons lying in a recumbent body position compared to persons sitting or standing upright have reduced antral mucosal blood flow, a reduction of 35%, and a congested mucosa which reduces both the mucosal gas exchange and the perostial ventilation, creating a more anaerobic antral gas mixture facilitating pathogenic bacterial growth and reduced ciliary activity. It is, therefore, recommendable for patients with sinusitis to treat themselves or be treated in an upright or semi-recumbent body position.

Observer reproducibility in grading dysplasia in colorectal adenomas: comparison between two different grading systems

The two most well known and well defined grading systems for dysplasia in colorectal adenomas were compared with regard to reproducibility. The Konishi-Morson system (KMS) operates with several histological and cytological variables and grades of mild, moderate, and severe dysplasia. The Kozuka system is based on the extent of nuclear pseudostratification and also has three grades of dysplasia (III-V). As the group of severe dysplasia is very large in this system, it was extended with two higher grades, similarly based on individual histological criteria, known hereafter as the extended Kozuka system (EKS). Fifty six adenomas were graded by two observers, each observer grading twice according to the KMS criteria and twice according to EKS criteria. Intraobserver reproducibility was excellent for the KMS and moderate for the EKS, but this was not significant. The overall interobserver reproducibility was similar (moderate) for the KMS and for the EKS. Kappa values for interobserver reproducibility on individual categories were excellent for severe dysplasia according to the KMS, but low for all other categories in both systems. By simplifying both systems into two groups a high reproducibility can be obtained, but this implies that all the original grades (III-V) for the EKS must be grouped together. It is therefore recommended that a simplified KMS is used for further studies on the biological importance of dysplasia and for comparison between histological changes and other markers for colorectal neoplasia.

Histological evaluation of prostatic cancer. (II): Reproducibility of a histological grading system

The aim of this study was to evaluate the reproducibility, expressed by kappa coefficients, of the histological grading system of prostatic cancer as proposed by Schroeder, Hop, Blom and Mostofi in 1985. This grading system has five prognostic groups based on combinations of growth pattern, mitoses and nuclear anaplasia. All histological slides from 85 cases of prostatic carcinoma were blindly evaluated on two independent occasions by each of four pathologists. The overall INTER-observer agreement and mean INTRA-observer agreement regarding "prognostic group" were 0.55 and 0.69 respectively, whereas the kappa coefficients were 0.38 and 0.57 respectively. An acceptable level of INTER-observer reproducibility of prognostic group I (kappa = 0.70), of the parameter "growth pattern" (kappa = 0.60) and of "slight nuclear anaplasia" (kappa = 0.62) was found. A low overall kappa coefficient of "mitoses" and "nuclear anaplasia" was found. Based on the well reproducible parameters a simplified grading system is proposed.

Histological evaluation of prostatic cancer. (III): Reproducibility of assessment of tumour volume and its possible significance for prognosis

The aim of this study was to evaluate the INTER- and INTRA-observer reproducibility of prostatic cancer volume defined as the percentage of chips with carcinoma in transurethrally resected tissue. All histological slides from 80 consecutive cases of prostatic cancer were blindly evaluated on two independent occasions by each of four pathologists. The correlation was expressed by Spearman's rank correlation coefficient (R). Both the overall INTER- and mean INTRA-observer correlation of tumour volume were high with R being respectively 0.905 and 0.918. With reference to stage A1 and A2, data were transformed to an ordinal scale with 2 categories (less than = 5%, greater than 5%). The overall INTER- and mean INTRA-observer agreement of this classification were 0.926 and 0.943 respectively--the corresponding kappa coefficients being 0.68 and 0.74. It is concluded that in transurethrally resected tissue a highly reproducible index of the resected prostatic cancer volume can be given by the percentage of chips with tumour. The prognostic significance of this parameter is discussed.

The effect of physical work on the mucosal blood flow and gas exchange in the human maxillary sinus

The paranasal sinuses are lined with respiratory mucosa of principally the same structure as in the nasal mucosa but somewhat thinner. This mucosa has a rich blood flow and advanced system of blood vessels regulated mostly by the autonomous nervous system but also by other factors as acid/base balance and endocrine activity. The thickness of the nasal mucosa regulates the nasal breathing resistance and varies with among other factors, body activity. In this investigation we have studied the effect of physical work on the human maxillary sinus mucosa. The investigation shows that, as in the nose, the blood flow and the pulse amplitude are considerably reduced during physical work, in situations of heavy work falling to about half of the normal level, and probably result in the redistribution of blood from the respiratory mucosa. The gas exchange in the paranasal sinus is reduced only to a small extent, the reduction being too small to change the antral gas composition towards pathological conditions.

The relationship between body posture and pressure in occluded maxillary sinus of man

One of the most common symptoms in sinusitis is pain over the infected cavity increasing when the patient is bending forward or lying down. It is commonly thought that this increase in pain is a result of increased pressure in the paranasal cavities when bending forward. In this investigation we have found that changing the body position from sitting to recumbent or even to "head between knees" gives a manometrical pressure rise in the sinus that is too small to cause a pressure-mediated pain. The pain is probably caused by a dilation in the blood vessels of the infected mucosa when the patient is bending forward or lying down.

Reproducibility of histomorphologic diagnoses with special reference to the kappa statistic

Systems for classification and grading used in pathology should ideally be biologically meaningful and at least be reproducible from one pathologist to another. A statistical method to evaluate reproducibility (non-chance agreement) for several observers using nominal or ordinal categories has been developed and refined over the past few decades--the kappa statistic. A high level of observed agreement among different pathologists can either signify a high level of reproducibility, if agreement by chance is low, or express a low level of reproducibility, if agreement by chance is almost as high as the observed agreement. Therefore, the observed agreement says nothing in itself, unless it is low. The kappa value, however, indicates how much better the observers are compared to a throw of the dice, and therefore gives the real credit to the agreement which was found. We have developed a user-friendly computer program for calculating inter- and intra-observer agreement of 2 or more observers. By calculating associations between different categories and different observers, the statistic furthermore obtains a function close to the parameter of accuracy. We recommend the use of the above method before a set of nominal or rank scale parameters are used for deciding prognosis and treatment of patients. By submitting a diskette the computer program will be available at no cost.

Histological evaluation of prostatic cancer. 1. Reproducibility of tumour type

It has been claimed that the histological type of prostatic carcinoma bears influence on the prognosis of the patient, and that different treatments have to be considered for different types of tumours. The primary aim of this study was to evaluate the reproducibility of the histological criteria for the ordinary acinic adenocarcinoma and ductal adenocarcinoma. From 85 prospective and consecutive cases of prostatic carcinoma all histological slides were examined on two independent occasions by each of 4 pathologists. The overall inter observer agreement and mean intra observer agreement were 0.69 and 0.74, respectively. The kappa coefficients of these inter and mean intra observer agreements were 0.39 (S.E. = 0.02) and 0.48 (S.E. = 0.08), respectively. Considering a dichotomous classification of pure acinic versus all other types of prostatic carcinoma, an overall inter observer agreement of 0.78 and mean intra observer agreement of 0.84 were found. The kappa coefficients of this dichotomous classification were 0.51 (S.E. = 0.03, inter) and 0.61 (S.E. = 0.11, intra), respectively. It is concluded that the criteria for differentiation between different histological types of prostatic carcinoma need to be improved.

Immunohistochemical differentiation between lymphangiographically verified lymphatic vessels and blood vessels

In order to investigate the antigen profile in human lymphatic vessels when compared with blood vessels, postmortem retrograde lymphangiography was done via the thoracic duct on six patients. Formalin fixed, paraffin embedded tissue was stained immunohistochemically for Factor VIII-Related antigen (F VIII R:Ag), with Ulex Europaeus 1 lectin (UEA-1) and for laminin. The results show that the endothelium of blood vessels and lymphatics at all levels of the lymphatic system react positively following staining for Factor VIII-R:Ag and with UEA-1 lectin. The staining for F VIII R:Ag was generally weaker in the endothelial cells lining lymphatic vessels. Staining for the basement membrane component laminin can be used to distinguish lymphatic capillaries and smaller lymphatic collecting vessels from blood vessels.

Children with tonsillar obstruction: indications for and efficacy of tonsillectomy

One hundred and twenty-two children between 1 1/2 and 14 years of age with symptoms suggesting tonsillar obstruction have been investigated. Each patient's history was analysed and the symptoms scored according to their incidence and severity. In addition, the size of the tonsils was evaluated. Eighty-five patients were chosen for tonsillectomy. The children with signs and symptoms of tonsillar obstruction improved greatly immediately after tonsillectomy. Severe symptoms of obstruction were observed in children with nearly normal tonsil size, as well as in those with very large tonsils. It is therefore just as important to obtain a careful history as it is to evaluate the size of the tonsils before deciding about surgery.

Bone formation induced in an infant by systemic prostaglandin-E2 administration

We report a case of long-term systemic administration of prostaglandin E2 (PGE2) to a newborn infant with ductus-dependent congenital heart disease. After 46 days of treatment, radiography showed cortical hyperostosis of the long bones. The child died 62 days after discontinuation of prostaglandin treatment. Histologic examination of tubular bones showed hyperostosis presumably due to prostaglandin-induced rapid formation of primitive bone. The additional finding of extensive resorption of the outer cortical surface and bone formation at the inner surface suggested a reversible phase after discontinuation of treatment.

Sleep apnea in children without hypertrophy of the tonsils

Two 12-year-old boys with severe sleep apnea syndrome but normal-sized tonsils were satisfactorily corrected by tonsillectomy and uvulopalatopharyngoplasty. One of the boys had muscular hypotony as contributing cause of the condition. The other had mandibular hypoplasia in combination with a long soft palate. Thorough preoperative anamnesis and examination in a sleep laboratory are necessary to determine which cases will benefit from surgery in spite of normal-sized tonsils and which surgical procedure will be most helpful.

Uvulopalatopharyngoplasty in the sleep apnea syndrome. Predictors of results

A prospective study of 34 consecutive patients with the sleep apnea syndrome was undertaken to evaluate the effectiveness and complications of, and predictors of, results in a conservative type of uvulopalatopharyngoplasty (UPPP). At six months, 65% of the patients had a 50% or greater reduction in the number of apneas and hypopneas per hour (responders). The responders to UPPP were less severely affected preoperatively regarding apneas and hypopneas, the mean number of which (+/- SD) were 32.7 +/- 20.8 compared with 64.6 +/- 26.0. They also had a lower body mass index before UPPP (31.3 +/- 4.1 vs 36.0 +/- 7.0 kg/m2). Preoperative computed tomography and cephalometry indicated that the nonresponders had narrower upper airways. It is concluded that UPPP is the treatment of choice for mild to moderate sleep apnea syndrome, but not for severely affected, heavily overweight patients with an increased tongue width.

Tumour of female paraurethral duct. Immunohistochemical similarity with prostatic carcinoma

A case of adenocarcinoma derived from a female paraurethral duct is described. Morphologically the tumour looked like a prostatic adenocarcinoma. Furthermore, the tumour cells stained positively with antibodies to prostatic specific antigen and prostatic specific acid phosphatase. The karyotype of the patient was 45,x/46,xx/47,xxx/46,xt(x;13)(p11;q22) demonstrating that the patient was not a hermaphrodite. The tumour therefore represented female homology of a prostatic adenocarcinoma.

Placental teratoma

A case of placental teratoma is presented. This is a rare tumor of disputed histogenesis. Some regard it as a separate entity while others believe it represents the extreme of a fetus amorphus. The tumor is benign and of no clinical significance.

Evaluation of commercial immunoperoxidase kits for prostatic specific antigen and prostatic specific acid phosphatase

The practical application of commercially available immunoperoxidase kits for prostatic specific antigen (PSA) and prostatic specific acid phosphatase (PSPH) were blindly evaluated on routinely formalin fixed and paraffin embedded tissue from 95 consecutive cases of prostatic carcinoma, 10 cases of metastases from prostatic carcinoma and 90 cases of primary or metastatic non prostatic carcinoma. Both Kits showed a diagnostic specificity of 100%. The diagnostic sensitivities were 94% (PSA) and 90% (PSPH) respectively, but concomitantly staining for PSA and PSPH improved the diagnostic sensitivity to 99%. Using the histologic grading system of Gleason both markers showed a tendency to less extensive staining in low differentiated prostatic carcinomas. It is concluded that both Kits are highly specific and highly sensitive, but negative reaction in medium or low differentiated adenocarcinomas does not rule out the possibility of prostatic carcinoma.

Immunohistochemical and electron microscopic study of twelve adenomatoid tumors

Twelve adenomatoid tumors were examined immunohistochemically with antibody probes to keratin and factor VIII-related antigen (FVIII-RA). None of the tumors labeled with FVIII-RA antibodies, whereas all but one labeled for keratin. Electron microscopy was done on tissue from paraffin-embedded blocks from all but one of the adenomatoid tumors. Both the immunohistochemical and electron microscopic results favor a mesothelial origin of adenomatoid tumors.

Immunohistochemical and Electron Microscopic Study of Twelve Adenomatoid Tumors

Twelve adenomatoid tumors were examined immunohistochemically with antibody probes to keratin and factor VIII-related antigen (FVIII-RA). None of the tumors labeled with FVIII-RA antibodies, whereas all but one labeled for keratin. Electron microscopy was done on tissue from paraffin-embedded blocks from all but one of the adenomatoid tumors. Both the immunohistochemical and electron microscopic results favor a mesothelial origin of adenomatoid tumors.

Prostatic carcinoma reproducibility of histologic grading

The inter- and intraobserver variations of the histologic grading systems of prostatic carcinoma proposed by Gleason and by Böcking et al. were tested by the authors. Both grading systems have previously been shown to have good correlation with prognosis. After studying 91 cases of prostatic carcinomas, the interobserver agreements of the Gleason pattern score and the Böcking combined grade were found to be 36% and 69% respectively. Both observers regraded 31 randomly selected prostatic carcinomas. With the Gleason pattern score intraobserver agreements of 65% and 42% were found, whereas the intraobserver agreements of the Böcking combined grade were 90% and 71% respectively. Since the percentages of inter- and intraobserver agreements were higher with the system of Böcking et al., this system is recommended prior to the system of Gleason as a means of evaluating the prognosis of patients with prostatic carcinoma.