Cytology Reporting System for Lung Cancer from the Japan Lung Cancer Society and the Japanese Society of Clinical Cytology: An Extensive Study Containing More Benign Lesions

INTRODUCTION

The Japan Lung Cancer Society (JLCS) and the Japanese Society of Clinical Cytology (JSCC) have proposed a new four-tiered cytology reporting system for lung carcinoma (JLCS-JSCC system). Prior to the proposal, the Papanicolaou Society of Cytopathology (PSC) had proposed a revised reporting system (PSC system), which comprises the "neoplastic, benign neoplasm, and low-grade carcinoma" category (N-B-LG category), in addition to the 4 categories of the JLCS-JSCC system. This study aimed to evaluate the interobserver agreement of the JLCS-JSCC system with an additional dataset with more benign lesions in comparison with the PSC system.

METHODS

We analyzed 167 cytological samples, which included 17 benign lesions, obtained from the respiratory system. Seven observers classified these cases into each category by reviewing one Papanicolaou-stained slide per case according to the JLCS-JSCC system and PSC system.

RESULTS

The interobserver agreement was moderate in the JLCS-JSCC (k = 0.499) and PSC (k = 0.485) systems. Of the 167 samples, 17 samples were benign lesions: 7 pulmonary hamartomas, 5 sclerosing pneumocytomas, 2 squamous papillomas, one solitary fibrous tumor, one meningioma, and one lymphocytic proliferation. There were diverse sample types as follows: 11 touch smears, 3 brushing smears, 2 aspirations, and one sputum sample. Fourteen samples (82.3%) were categorized into "negative" or "atypical" by more than half of the observers in the JLCS-JSCC system. Conversely, 3 samples were categorized as "suspicious" or "malignant" by more than half of the observers in the JLCS-JSCC system. On the other hand, 11 samples (64.7%) were categorized into the N-B-LG category by more than half of the observers in the PSC system.

CONCLUSIONS

The concordance rate in the JLCS-JSCC system was slightly higher than that in the PSC system; however, the interobserver agreement was moderate in both the JLCS-JSCC and PSC systems. These results indicate that both the JLCS-JSCC and PSC systems are clinically useful. Therefore, both systems are expected to have clinical applications. It may be important to integrate the 2 systems and construct a universal system that can be used more widely in clinical practice.

Cytology Reporting System for Lung Cancer from the Japan Lung Cancer Society and Japanese Society of Clinical Cytology: An Interobserver Reproducibility Study and Risk of Malignancy Evaluation on Cytology Specimens

INTRODUCTION

The classification of lung carcinoma is based on small biopsies and/or cytology in 80% of patients with non-small cell carcinoma. However, there is no widely accepted classification system for respiratory cytology. The Japan Lung Cancer Society (JLCS) and Japanese Society of Clinical Cytology (JSCC) have proposed a new four-tiered cytology reporting system for lung carcinoma with the following categories: (1) "negative for malignancy," (2) "atypical cells," (3) "suspicious for malignancy," and (4) "malignancy."

OBJECTIVE

The aim of this work was to perform an interobserver reproducibility study to confirm the utility of the four-tiered reporting system on respiratory cytological samples.

METHODS

We analyzed 90 cytological samples obtained with bronchoscopy. Seven observers classified these cases into each category by reviewing one Papanicolaou-stained slide per case according to the three-, four-, and five-tiered reporting systems.

RESULTS

The interobserver agreement was fair in the three- (κ = 0.50), four- (κ = 0.45), and five-tiered (κ = 0.45) reporting systems. However, the four-tiered reporting system provided more precise information than the three-tiered reporting system in patient management. The risk of malignancy in the four-tiered reporting system was also stratified well: 19.3% for "negative for malignancy," 45.6% for "atypical cells," 74.7% for "suspicious for malignancy," and 88.1% for "malignancy."

CONCLUSIONS

The reporting system proposed by the JLCS and JSCC was designed to enhance the communication between clinicians and pathologists and among different institutions. It is simple and applicable to cytological diagnosis of any respiratory diseases. We propose establishing an international classification for respiratory cytology, harmonizing the reporting systems proposed by different countries.

P107 Predictors of increased d-dimer level at follow-up period after transcatheter aortic valve implantation.Is oral anticoagulation therapy better?

Background

Recently, there are some reports that hypo-attenuated leaflet thickening (HALT) following transcatheter aortic valve implantation (TAVI) is incidentally detected by multi-slice computed tomography. It is believed that valve thrombosis causes HALT, because oral anticoagulation therapy (OAC) is effective for HALT regression. Furthermore, it is reported that d-dimer level increases in patients with HALT, and might be a key biomarker to detect HALT.

Purpose

We sought to investigate the predictors related to increased d-dimer level at 6 months after follow-up TAVI.

Methods

We enrolled 124 consecutive patients who underwent successful TAVI between 2016 and 2018. Study patients were classified into two groups according to antithrombotic therapy resume (OAC therapy or anti-platelet therapy).We set the primary endpoint as the d-dimer levels at 6 months after TAVI. To evaluate the risks of the primary endpoint, we employed a multivariable linear regression model, setting the primary endpoint as an objective variable and patient and clinical backgrounds as explanatory variables. Furthermore, we set the secondary endpoint as one-year bleeding event.

Results

The median age of patients was 83 years old (quartile 80-87). Patients who had taken OAC at 6 months follow-up after TAVI were 29.8%. The median d-dimer level at 6 months after TAVI was 1.3 (1.0-2.2) µg/ml, and OAC group had statistically lower d-dimer level at 6 months follow-up than those in non-OAC group (p = 0.020). Uni-variable liner regression model demonstrated that increased d-dimer level at follow-up had significant relationship with large effective orifice area (EOA) (p = 0.002) and low left ventricular ejection fraction (LVEF) (p = 0.048) after TAVI. Furthermore, large EOA (p = 0.003) and OAC therapy (p = 0.027) were independently associated with increased d-dimer level in multivariate analysis. Kaplan-Meier estimates revealed that there were no significant difference regarding one-year bleeding event between OAC group and non-OAC group (long-rank p = 0.167).

Conclusions

This study suggests that large EOA after TAVI is associated with increased d-dimer levels at 6 months after TAVI, and OAC therapy might have a potential to decrease d-dimer level after TAVI without increase of bleeding events.

Abstract P107 Figure: One-year bleeding event

P3693Self-expandable transcatheter aortic valve implantation is associated with frequent periprocedural stroke detected by diffusion-weighted magnetic resonance imaging -Insight from propensity score match

Background

Little evidence is available regarding the risk of peri-procedural stroke detected by diffusion-weighted magnetic resonance imaging (DW-MRI) after transcatheter aortic valve implantation (TAVI). Our purpose was to evaluate stroke risk after TAVI using DW-MRI by enrolling consecutive patients who underwent transfemoral TAVI and post-procedural DW-MRI.

Methods

We prospectively enrolled 113 consecutive patients who underwent transfemoral TAVI and post-procedural DW-MRI. We used balloon-expandable valves as first-line therapy and selected self-expandable valves only for patients with narrow sinotubular junctions or annuli. We set the primary endpoint as the number of high intensity areas (HIA) detected by DW-MRI regardless of the size of the area. To evaluate the risks of the primary endpoint, we employed a multivariable linear regression model, setting the primary endpoint as an objective variable and patient and clinical backgrounds as explanatory variables. In addition, the relationship between valve type and the number of HIAs on DW-MRI was also confirmed by the propensity score matching analysis to evaluate the robustness of the result, using a multivariable linear regression model with the protocol described in the previous manuscript. Shortly, the propensity score was calculated with a logistic regression model by setting the treatment as the response variable and baseline characteristics and procedural information that were significantly different between 2 groups (balloon expandable and self-expandable) as explanatory variables, which included age, estimated glomerular filtration rate, oversizing rate, and BAV before THV deployment.

Results

Median patient age was 84 years, and 36.3% were men. Ninety-three patients underwent balloon-expandable TAVI and 20 underwent self-expandable TAVI. Symptomatic stroke occurred in 6 (5.3%) whereas asymptomatic stroke occurred in 59 (52.2%) patients. The incidence of symptomatic and total stroke was higher in patients who underwent self-expandable TAVI than those who underwent balloon-expandable TAVI (30.0% vs 0.0%, p<0.001 and 90.0% vs 50.5%, p=0.001, respectively). A multivariable linear regression model demonstrated an increased primary endpoint when self-expandable TAVI was performed (p<0.001). The other covariates had no significant relationship to the primary endpoint. Akaike information criterion-based stepwise statistical model selection revealed that valve type was the only explanatory variable for the best predictive model. This result was also confirmed with the propensity score matching analysis (estimate, 2.359; 95% CI, 0.426–4.292; p=0.019) after adjustments of propensity score, in which 28 patients were matched (n=14 in each group).

Conclusions

Self-expandable valves were associated with increased numbers of HIA on DW-MRI after TAVI in patients with severe aortic stenosis.

[Granulocyte colony-stimulating factor producing undifferentiated carcinoma of urinary bladder: a case report]

A case of bladder cancer producing granulocyte colony-stimulating factor (G-CSF) is reported. A 94-year-old woman with a progressive, grade 3 undifferentiated carcinoma, showed marked leukocytosis (maximum 29,780/mm3) with an elevated G-CSF (420 pg/ml). Immunohistochemical examination with monoclonal antibody specific for G-CSF revealed positive staining. Further examination for epidermal growth factor receptor (EGF-R) and p53 were both positive and Ki67 index were 40.7%. These data suggested that this tumor had extremely aggressive growing nature, as the biological character is this.

[Clinical features of transurethral anterior sphincterotomy and urological management of patients with cervical spinal cord injury]

BACKGROUND

The ideal urological management for the patients with cervical spinal cord injury (CSCI) is to obtain catheter free urination and to prevent urinary tract complications. We have evaluated cases that had undergone transurethral anterior sphincterotomy from the view-point of the operative indications and the efficacy.

METHODS

We carried out sphincterotomy 166 times on 133 male patients with CSCI in our Center. Before the operations were performed, all patients suffered from urinary incontinence, and they were unable to catheterize themselves for low level activity of daily life. Before and after the operation, their detrusor functions with sphincter reactions were assessed by urodynamic study. In principle we have followed up these cases by cystogram combined with cystometry, cystogram and excretory-pyelography or abdominal ultrasonography.

RESULTS

In post-operative evaluations, more than 80% of cases attained hypotonic detrusor contractions and residual urine was significantly decreased. In long term follow-up, 96% of patients had obtained catheter free urination and about 85% of patients had no urinary tract complications, such as bladder deformity, vesicoureteral reflux, or hydronephrosis, with the exception of common unavoidable urinary infections. About 20% of cases had to be re-operated upon, and some cases showed hypertonic detrusor contractions or detrusor-sphincter-dyssynnergia during follow-up.

CONCLUSION

The operative indications of sphincterotomy should be decided when the CSCI patients is unable to perform self-catheterization, and when due to the dysfunction of the urethral sphincter, these patients suffered from voiding difficulties or autonomic dysreflexia, or when the urinary tract complications might occur. In the majority of cases the aims of the sphincterotomy were achieved but some cases underwent another operation or had recurrent dysfunction of the urethral sphincter, indicating the need for careful follow-up.