Women in Academic Pathology: Pathways to Department Chair

The Association of Pathology Chairs, an organization of American and Canadian academic pathology departments, has a record percent of women department chairs in its ranks (31%), although still not representative of the percent of women pathology faculty (43%). These women chairs were surveyed to determine what had impeded and what had facilitated their academic advancement before becoming chairs. The 2 most frequently identified impediments to their career advancement were heavy clinical loads and the lack of time, training, and/or funding to pursue research. Related to the second impediment, only one respondent became chair of a department which was in a top 25 National Institutes of Health–sponsored research medical school. Eighty-nine percent of respondents said that they had experienced gender bias during their careers in pathology, and 31% identified gender bias as an important impediment to advancement. The top facilitator of career advancement before becoming chairs was a supportive family. Strikingly, 98% of respondents have a spouse or partner, 75% have children, and 38% had children younger than 18 when becoming chairs. Additional top facilitators were opportunities to attend national meetings and opportunities to participate in leadership. Previous leadership experiences included directing a clinical service, a residency training program, and/or a medical student education program. These results suggest important ways to increase the success of women in academic pathology and increasing the percent of women department chairs, including supporting a family life and providing time, encouragement and resources for research, attending national meetings, and taking on departmental leadership positions.

Artificial Intelligence and Machine Learning in Pathology: The Present Landscape of Supervised Methods

Increased interest in the opportunities provided by artificial intelligence and machine learning has spawned a new field of health-care research. The new tools under development are targeting many aspects of medical practice, including changes to the practice of pathology and laboratory medicine. Optimal design in these powerful tools requires cross-disciplinary literacy, including basic knowledge and understanding of critical concepts that have traditionally been unfamiliar to pathologists and laboratorians. This review provides definitions and basic knowledge of machine learning categories (supervised, unsupervised, and reinforcement learning), introduces the underlying concept of the bias-variance trade-off as an important foundation in supervised machine learning, and discusses approaches to the supervised machine learning study design along with an overview and description of common supervised machine learning algorithms (linear regression, logistic regression, Naive Bayes, k-nearest neighbor, support vector machine, random forest, convolutional neural networks).

Immunohistochemical Staining of Metastatic Ductal Carcinomas of the Breast by Monoclonal Antibodies used in Imaging and Therapy: A Comparative Study

Five monoclonal antibodies (MoAbs) (L6, 170H.82, 155, BrE-3 and BR96), most of which have been previously shown to target breast cancer and not normal tissues by immunoscintigraphic imaging, were evaluated for their frequency and pattern of immunohistochemical staining in 67 to 116 metastatic lesions from patients with ductal carcinoma of the breast. Immunoperoxidase staining in 75% or more of the cells occurred in 56/116 (48%) for L6, 44189 (49%) for Br, -96, 58/102 (57%) for 155, 62/99 (84%) for 170H.82, and 65.67 (97%) for BrE-3. With the first three MoAbs, an additional 6-10% of the tumors showed staining in 50-75% of tumor cells. These results illustrate that most patients with metastatic ductal carcinoma have cancer tissue in which a high percent of cells will react to several of these selected MoAbs that target different epitopes. The high expression of the MoAb targets throughout the tumor tissue makes these antibodies potential candidates to carry immunologically directed radioimmunotherapy and is an aid in selecting patients for treatment..

Barriers to Career Flexibility in Academic Medicine: A Qualitative Analysis of Reasons for the Underutilization of Family-Friendly Policies, and Implications for Institutional Change and Department Chair Leadership

PURPOSE

Academic medical and biomedical professionals need workplace flexibility to manage the demands of work and family roles and meet their commitments to both, but often fail to use the very programs and benefits that provide flexibility. This study investigated the reasons for faculty underutilization of work-life programs.

METHOD

As part of a National Institutes of Health-funded study, in 2010 the authors investigated attitudes of clinical and/or research biomedical faculty at the University of California, Davis, toward work-life policies, and the rationale behind their individual decisions regarding use of flexibility policies. The analysis used verbatim responses from 213 of 472 faculty (448 unstructured comments) to a series of open-ended survey questions. Questions elicited faculty members' self-reports of policy use, attitudes, and evaluations of the policies, and their perceptions of barriers that limited full benefit utilization. Data were coded and analyzed using a grounded theory approach.

RESULTS

Faculty described how their utilization of workplace flexibility benefits was inhibited by organizational influences: the absence of reliable information about program eligibility and benefits, workplace norms and cultures that stigmatized program participation, influence of uninformed/unsupportive department heads, and concerns about how participation might burden coworkers, damage collegial relationships, or adversely affect workflow and grant funding.

CONCLUSIONS

Understanding underuse of work-life programs is essential to maximize employee productivity and satisfaction, minimize turnover, and provide equal opportunities for career advancement to all faculty. The findings are discussed in relation to specific policy recommendations, implications for institutional change, and department chair leadership.

Intravascular Lymphoma Clinically Mimicking Pulmonary Thromboembolic Disease

A 62-year-old man presented with a 2-week history of fatigue and easy bruising. During hospitalization he developed progressive dyspnea, which, on the basis of abormal findings from a ventilation-perfusion scan, was attributed to multiple small pulmonary emboli. Postmortem examination demonstrated intravascular lymphoma prominently involving the pulmonary interstitium and vasculature. This case is unsual in its clinical presentation as pulmonary thromboembolic disease.

The Women in Medicine and Health Science program: an innovative initiative to support female faculty at the University of California Davis School of Medicine

PROBLEM

Although more female physicians and scientists are choosing careers in academic medicine, women continue to be underrepresented as medical school faculty, particularly at the level of full professor and in leadership positions. Effective interventions to support women in academic medicine exist, but the nature and content of such programs varies widely.

APPROACH

Women in medicine programs can play a critical role in supporting women's careers and can improve recruitment and retention of women by providing opportunities for networking, sponsorship, mentorship, and career development. The University of California Davis School of Medicine established the Women in Medicine and Health Science (WIMHS) program in 2000 to ensure the full participation and success of women in all roles within academic medicine. The authors describe the components and evolution of the WIMHS program.

OUTCOMES

A steady increase in the number and percentage of female faculty and department chairs, as well as a relatively low departure rate for female faculty, strong and growing internal partnerships, and enthusiastic support from faculty and the school of medicine leadership, suggest that the WIMHS program has had a positive influence on recruitment and retention, career satisfaction, and institutional climate to provide a more inclusive and supportive culture for women.

NEXT STEPS

Going forward, the WIMHS program will continue to advocate for broader institutional change to support female faculty, like creating an on-site child care program. Other institutions seeking to address the challenges facing female faculty may consider using the WIMHS program as a model to guide their efforts.

Implementation of the Bethesda System for Reporting Thyroid Cytopathology: observations from the 2011 thyroid supplemental questionnaire of the College of American Pathologists

CONTEXT

Although information about the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) has been widely disseminated since its inception in 2007, the extent of its implementation and impact on daily practice has not been formally evaluated.

OBJECTIVES

To assess the extent of uptake of TBSRTC across pathology laboratories and to evaluate its impact on daily practice by collating participant responses to the 2011 supplemental thyroid questionnaire of the College of American Pathologists.

DESIGN

A questionnaire was designed to gather information about various aspects of TBSRTC and mailed in June 2011 to 2063 laboratories participating in the College of American Pathologists cytopathology interlaboratory comparison program. The participating laboratories' answers were collated and summarized.

RESULTS

Seven hundred and seventy-seven laboratories (37.6%) returned the survey. Although 60.9% (n = 451) and 17.1% (n = 127) of laboratories reported using TBSRTC or planning to use it in the near future, respectively, 22% (n = 163) had no plans to implement TBSRTC. Of the latter, 32% (n = 70) stated that they were unaware of this classification system. The majority (78.3%, n = 343) of the laboratories used TBSRTC as published in the Thyroid Bethesda System atlas, whereas 21.7% (n = 95) used it with minor modifications. Most reported that the use of TBSRTC had caused either no change (n = 67, 15.2%) or only minor changes (n = 353, 80.2%) in the terminology and diagnostic criteria previously used in their laboratories.

CONCLUSIONS

According to the collected data, TBSRTC is generally well implemented in pathology laboratories. However, because approximately a third of those not using this terminology are not aware of it, additional educational efforts regarding TBSRTC are warranted.

Improving knowledge, awareness, and use of flexible career policies through an accelerator intervention at the University of California, Davis, School of Medicine

The challenges of balancing a career and family life disproportionately affect women in academic health sciences and medicine, contributing to their slower career advancement and/or their attrition from academia. In this article, the authors first describe their experiences at the University of California, Davis, School of Medicine developing and implementing an innovative accelerator intervention designed to promote faculty work-life balance by improving knowledge, awareness, and access to comprehensive flexible career policies. They then summarize the results of two faculty surveys--one conducted before the implementation of their intervention and the second conducted one year into their three-year intervention--designed to assess faculty's use and intention to use the flexible career policies, their awareness of available options, barriers to their use of the policies, and their career satisfaction. The authors found that the intervention significantly increased awareness of the policies and attendance at related educational activities, improved attitudes toward the policies, and decreased perceived barriers to use. These results, however, were most pronounced for female faculty and faculty under the age of 50. The authors next discuss areas for future research on faculty use of flexible career policies and offer recommendations for other institutions of higher education--not just those in academic medicine--interested in implementing a similar intervention. They conclude that having flexible career policies alone is not enough to stem the attrition of female faculty. Such policies must be fully integrated into an institution's culture such that faculty are both aware of them and willing to use them.

Career flexibility and family-friendly policies: an NIH-funded study to enhance women's careers in biomedical sciences

BACKGROUND

Although women receive nearly half of all doctoral degrees and show a high interest in academic careers, the pipeline is leaky. The challenge of balancing life course events with career trajectory is an important determinant leading to premature dropout or slower career advancement. This report describes the findings of the first phase of a National Institute of Health Office of Research on Women's Health (NIH ORWH)-funded study using survey and academic data for exploring satisfaction and awareness of/intent to use specific career flexibility options at the University of California, Davis (UCD).

METHODS

All men and women faculty in the UCD's Schools of Medicine (SOM) and Veterinary Medicine (SVM) and College of Biological Science (CBS) were surveyed. Data also were obtained from deans' offices on use of family-friendly benefits by faculty.

RESULTS

Three hundred twenty-five total survey responses were received from the SOM, 83 from SVM, and 64 from CBS, representing 42%, 46%, and 52% of their total faculty, respectively. In each school, large percentages of men (32%-60%) and women (46%-53%) faculty have children under 18 and a moderately high level of demand of family care responsibilities. Women were significantly more likely to be childless, particularly in the SOM (35% vs. 14%, p<0.001). For all schools, documented use of any family-friendly policy was low (0%-11.5%), as was awareness of policies, although both were significantly higher for women than for men. Significantly more women than men wanted to use policies or chose not to, particularly in the SOM (51% vs. 28%, p<0.001, and 37% vs. 23%, p=0.016, respectively), because of multiple barriers. Faculty in all schools agreed/highly agreed that policies were important to recruitment, retention, and career advancement.

CONCLUSIONS

Family-friendly policies are pertinent to men and women, as both demonstrate interest and need, linked to increased career satisfaction. A family-friendly policy is important, particularly for women in the biomedical sciences.

Imaging findings of rhinocerebral mucormycosis

BACKGROUND AND OBJECTIVES

The purpose of this study was to describe common radiographic patterns that may be useful in predicting the diagnosis of rhinocerebral mucormycosis.

METHODS

We retrospectively evaluated the imaging and clinical data of four males and one female, 3 to 72 years old, with rhinocerebral mucormycosis.

RESULTS

All the patients presented with sinusitis and ophthalmological symptoms. Most of the patients (80%) had isointense lesions relative to brain in T1-weighted images. The signal intensity in T2-weighted images was more variable, with only one (20%) patient showing hyperintensity. A pattern of anatomic involvement affecting the nasal cavity, maxillary sinus, orbit, and ethmoid cells was consistently observed in all five patients (100%). Our series demonstrated a mortality rate of 60%.

CONCLUSION

Progressive and rapid involvement of the cavernous sinus, vascular structures and intracranial contents is the usual evolution of rhinocerebral mucormycosis. In the context of immunosupression, a pattern of nasal cavity, maxillary sinus, ethmoid cells, and orbit inflammatory lesions should prompt the diagnosis of mucormycosis. Multiplanar magnetic resonance imaging shows anatomic involvement, helping in surgery planning. However, the prognosis is grave despite radical surgery and antifungals.

Adequacy evaluation of fine-needle aspiration biopsy in the breast health clinic setting

BACKGROUND

Breast health clinics (BHC) are an unfamiliar source of fine-needle aspiration biopsies (FNABs) in the U.S. and create challenges for adequacy evaluation. The current study described the experience with breast FNAB adequacy evaluation over a 2-year period, the issues that emerged, and the problem-solving employed to mitigate these issues.

METHODS

The rate of unsatisfactory FNABs and core biopsies was determined for pathologists, BHC providers, and other clinicians and compared for two different periods. Adequacy criteria during both periods required correlation of the cytologic findings with the clinical and breast imaging findings, and did not require identification of a specific number of ductal epithelial cells.

RESULTS

During the first time period, 25% of breast FNABs performed in the BHC received an inadequate evaluation versus 6% performed by pathologists and 14% performed by other clinicians. The BHC adequacy rate exceeded the 20% upper threshold recommended by the National Cancer Institute (NCI), and did not decrease after additional FNAB training. During the first time period, 24% of core biopsies received an adequacy evaluation of unsatisfactory. During the second time interval, the core biopsy volume increased and 12% received an unsatisfactory adequacy evaluation.

CONCLUSIONS

It is appropriate to use noncellular features such as clinical and imaging findings as adequacy criteria for breast FNABs rather than identification of a minimal number of ductal epithelial cells. However, the 20% upper threshold for unsatisfactory breast FNABs recommended by the NCI was not appropriate for the BHC setting because the nature of the lesions seen in this type of practice can lead to an increase in inadequate specimens and cause unnecessary concern regarding quality. The authors recommended that laboratories receiving a large number of clinician-performed FNABs from a community population, especially a BHC, define their own unsatisfactory threshold above which they will investigate for technical or other problems.

Role of Pap Test terminology and age in the detection of carcinoma invasive and carcinoma in situ in medically underserved California women

Our goals were to evaluate Pap Test findings classified by the Bethesda system, and follow up biopsies from participants in the California Breast and Cervical Cancer Control Program (Ca-BCCCP) for: 1) correlation in the detection of carcinoma in situ (CIS) and carcinoma invasive (CI), and 2) age-related trends, with discussion in the context of the 2001 ASCCP Management Guidelines. Women (n = 52,339) who had their initial screening Pap Tests with Ca-BCCCP between January 1995-December 1999 were followed for diagnostic services through December 2000. Descriptive and analytical methods were used in the analysis. Of the Pap results, 81.9% were negative, 10.6% showed infection, 4.7% showed an epithelial abnormality as defined by the Bethesda system (atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), or high-grade squamous intraepithelial lesion (HSIL)), 0.1% showed squamous-cell cancer (SCC), and 2.7% showed other or unsatisfactory. Subsequent to the initial Pap Test, follow-up results of carcinoma in situ (CIS) and carcinoma invasive (CI) accounted for 0.36% and 0.05% of the population, respectively. Among HSIL Pap Tests (n = 285), 40.7% had follow-up showing CIS. Among SCC Pap Tests, 17.9% had follow-up results of CIS and 28.6% CI. Of the 191 patients with CIS as a follow-up finding, the initial Pap smear showed: HSIL 60.7%, SCC 2.6%, LSIL 10.5%, ASCUS 13.6%, and negative or infection 9.9%. Of the 27 patients with CI, the initial Pap Test showed: HSIL 40.7%, SCC 29.6%, LSIL 7.4%, ASCUS 7.4%, and negative or infection 11.1%. Pap diagnoses of other or unsatisfactory accounted for 2.6% of the Pap results from patients with CIS and 3.7% of Pap results from patients with CI. Except for LSIL, there was an increasing age trend in the number of cases in each of Pap results, with the exception of age 65+ yr. However, the ratio of LSIL and ASCUS to negative cases decreased with age. (P < 0.0001 and 0.0293, respectively). HSIL Pap results indicate a reasonably high probability of CIS and CI. However, approximately 1/3 of patients with CIS and 1/4 of patients with CI presented with Pap diagnoses of less severity than HSIL. When a negative Pap Test result is chosen as reference group, there is a negative age trend for LSIL and ASCUS, and no age trend for other results. These findings all have important implications in the design of follow-up strategies, and support the 2001 ASCCP Consensus Guidelines for the Management of Women with Cervical Abnormalities.

Mission-based reporting in academic psychiatry

OBJECTIVE

This article describes a data entry and analysis system called Mission-Based Reporting (MBR) that is used to measure faculty and department activities related to specific academic missions and objectives. The purpose of MBR is to provide a reporting tool useful in evaluating faculty effort and in helping chairs 1) to better assess their department's performance in relation to other departments and their school as a whole, 2) to plan for the future, and 3) to reward individual faculty members.

METHODS

Mission-Based Reporting summaries, generated for each faculty member and each department, illustrate contributions to each of four missions: research, teaching, clinical service, and administrative/public service. Data from MBR can be used to evaluate whether faculty scholarly contributions are appropriate to their rank and series. That report provides data from the Department of Psychiatry and Behavioral Sciences at the University of California and the University of California Davis School of Medicine (UC Davis).

CONCLUSIONS

Mission-Based Reporting is a useful management tool for department and school administrators. Improvements in implementation are proposed.

Significance of subclassifying high-grade squamous intraepithelial lesions into moderate dysplasia/CIN II versus severe dysplasia/CIN III/CIS in the Bethesda system terminology

Recent revisions of the Bethesda System (TBS III) did not modify the original two-tiered low-grade and high-grade squamous intraepithelial lesion (LSIL/HSIL) terminology and continued to offer the option of subclassifying HSIL into moderate dysplasia/cervical intraepithelial neoplasia (CIN II) and severe dysplasia/CIN III. The purpose of this study is to evaluate the significance of the HSIL moderate dysplasia/CIN II subclassification and the causes of Pap test-biopsy discordance for this subclassification. HSIL/moderate dysplasia/CIN II Pap tests were identified from the University of California Davis Medical Center laboratory file for a 5-yr period (1997-2001) and correlated with follow-up cervical biopsies. Cervical biopsies with CIN II diagnoses were identified from the laboratory file for the same time period, and correlated with their preceding Pap test. Discordant Pap test-biopsy pairs from either group were reviewed by two pathologists for the following causes for discordance: cytologic overcall or undercall, biopsy overcall or undercall, and sampling error or possible lesion regression. During the review period, 161 of 378 total HSIL Pap tests had a HSIL/CIN II result (42%), and 81/161 (50%) had a follow-up cervical biopsy. 38/81 (47%) were concordant, and 43 (53%) were discordant; 39/43 discordant cases had both Pap test and biopsy slides available for review. CIN I was the most common discordant biopsy diagnosis. Sampling error was the most common cause of discordance and was three times more common than the other causes; 536 CIN cervical biopsies with CIN were identified in the laboratory files during this review period, and 108/536 (20%) received a diagnosis of CIN II. Sixty-seven of 108 (62%) had a preceding Pap test result available; 32 of the 67 (48%) had a concordant preceding Pap test with a HSIL/CIN II result, and 35 (52%) were discordant; 32/35 discordant cases had both Pap test and biopsy slides available for review. LSIL was the most common discordant Pap test diagnosis. Sampling error was also the most common cause of discordance, and was also three time more frequent than any other cause for discordance. HSIL/CIN II is a meaningful subclassification in our laboratory. We support the TBS III recommendation for optional subclassification of HSIL and suggest that individual laboratories may wish to monitor use of this subclassification through internal correlation studies.

New tests for cervical cancer screening

The Papanicolaou (Pap) smear has been used to screen women for cervical cancer since 1940. Recently, a number of new technologies have been developed to improve the detection of cervical cancer and its precursors. However, there is substantial controversy about whether the new tests offer meaningful advantages over the conventional Pap smear. Ideally, these new tests will increase the early detection of meaningful Pap smear abnormalities, reduce the number of unsatisfactory smears and provide fewer ambiguous results. It is also hoped that these new screening methods will not increase the number of false-positive results, but will improve the productivity of cytology laboratories without substantially increasing costs. The new tests include liquid-based/thin-layer preparations to improve the quality and adequacy of the Pap smear; computer-assisted screening methods to improve Pap smear interpretation; and new-generation human papillomavirus testing methods that may be useful in triaging patients with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions. Evidence on these new tests is reviewed and the advantages and disadvantages of their use are discussed.

Changing role of fine-needle aspiration in the evaluation of pediatric masses

This study examines changes in the use of fine-needle aspiration (FNA) in the pediatric population in the past 14 yr at the University of California, Davis Medical Center. Pediatric FNAs from two 7-yr periods were compared regarding percentage of satisfactory cases and cases with a previous history of cancer, sensitivity, specificity, type of general diagnostic category, ratio of benign to malignant diagnoses, and sources of diagnostic error. Changes in the later 7-yr period included decrease in the percentage of round cell lesions with an increase in spindle cell and epithelial/epithelioid lesions, fewer patients with a prior history of cancer, and a marked increase in benign to malignant ratio. These changes illustrate that FNA is being used more commonly in the general pediatric population, and that the types of lesions seen in this population are not very dissimilar to those seen in adults.

Equivocal diagnoses in breast aspiration biopsy cytology: sources of uncertainty and the role of "atypical/indeterminate" terminology

In 1996, a National Cancer Institute committee recommended four categories as uniform terminology for breast fine-needle aspirations (FNAs): benign, malignant, suspicious/probably malignant, and atypical/indeterminate. The latter is a controversial category. This study evaluates the usefulness of the atypical/indeterminate term, and examines sources of diagnostic equivocation in breast FNA. Eight hundred and twenty-two consecutive breast FNAs were previously classified as benign, malignant, suspicious, or unsatisfactory. Two hundred and thirteen (25.9%) cases had surgical follow-up and were classified as true positive (TP), false positive (FP), true negative (TN), false negative (FN), true suspicious (TS), or false suspicious (FS). Slides from FN, FP, TS, and FS were reviewed for interpretative error, poor clarity or preservation, obscuring material, sampling error, or insufficient malignant criteria. Cases were also evaluated as to whether classification as "atypical/indeterminate" would have improved patient care. There were 21/822 (2.6%) FN, 37/822 (4.5%) TS + FS, and 0 FP diagnoses. Seventy percent of suspicious diagnoses showed cancer on follow-up. The majority of FN and suspicious cases were due to sampling problems and insufficient criteria of malignancy. None were deemed more appropriately classified as "atypical/indeterminate" All required surgical confirmation for treatment. All equivocal breast diagnoses are due to similar problems. Splitting them into "suspicious/probably malignant" and "atypical/indeterminate" would not lower the biopsy rate. A simpler three-part terminology of benign, malignant, and suspicious/equivocal, without qualification of the latter favoring benign or malignant, would provide more effective communication and appropriate follow-up. Diagn. Cytopathol. 1999;21:217-222.

Number, size, and composition of cell clusters as related to breast FNA adequacy

The question of what types of parameters should be employed in establishing adequacy guidelines for fine-needle aspirations (FNAs) of palpable breast lesions remains without consensus opinion among cytopathologists. Although some investigators have suggested guidelines, based largely upon cellularity standards, these have been somewhat conflicting, and the overall issue of whether or not cellularity is an appropriate measure of adequacy is controversial. This study examines the number, size, and composition of cell clusters in FNAs of palpable breast masses which had surgical follow-up, in an effort to identify characteristics of diagnostic aspirates which could contribute to adequacy guidelines. Seventy-seven consecutive cases with surgical follow-up were selected from four quality-assurance (QA) categories (true positive, TP; true suspicious, TS; true negative, TN; and false negative, FN). All cases were evaluated in terms of overall cellularity (numbers of cell clusters), proportions of different-sized epithelial clusters (small, medium, and large), and proportions of epithelial to fibrofatty elements. Although the FN category showed the lowest average cellularity, the application of cellularity cutoff values as a condition of adequacy would have resulted in conspicuous numbers of cases from the "true" categories (TN, and to a lesser degree TS and TP) being rendered inadequate. For example, if cases with fewer than six epithelial clusters were excluded by virtue of inadequacy, 69% of the FN cases would have been affected, along with 40% of the TN, 6% of the TS, and 4.5% of the TP. In terms of composition of the aspirate, neither proportions of the differently-sized epithelial clusters nor ratios of epithelial:fibrofatty elements reliably distinguished the "true" from the "false" diagnoses. This study concluded that quantitative parameters alone are insufficient measures for determining specimen adequacy in FNA of palpable breast lesions. Rather, adequacy remains based upon factors such as confidence of needle placement, cell preservation, and correlation with clinical and mammographic findings. Diagn. Cytopathol. 1999;21:105-111.

Preclinical evaluation of chimeric L6 antibody for the treatment of Kaposi's sarcoma with radioimmunotherapy

L6 is a murine IgG2a monoclonal antibody with panadenocarcinoma reactivity. Chimeric L6 (ChL6), the variable region of murine L6 combined with a human IgG1 constant region, has been used in clinical trials for the delivery of radioimmunotherapy to patients with breast cancer. AIDS-associated Kaposi's sarcoma (KS), a malignancy of vascular endothelium, may be an excellent candidate for systemic radioimmunotherapy because KS is well vascularized and radioresponsive. Because ChL6 has been noted to bind vascular endothelium, our hypothesis was that ChL6 will recognize and bind KS tumors making this a potentially useful antibody for the treatment of KS with radioimmunotherapy. To test this hypothesis, 4 human KS spindle cell cultures established from cutaneous punch biopsy specimens (KS-MR, KS-NO, KS-JD and KS 6-3E) and one well-characterized human KS cell line (KS Y-1) were assessed for L6 immunoreactivity. All 5 cell cultures were L6 positive by immunohistochemistry. KS Y-1 cells grown as nude mouse xenografts were also L6 positive by immunohistochemistry. Competitive binding assays performed on the KS Y-1 and KS 6-3E cell cultures showed high density and high affinity cell binding. Biodistribution experiments performed on nude mice with KS Y-1 xenografts demonstrate tumor targeting by ChL6. These findings indicate that ChL6 may be a useful antibody for the radioimmunotherapy of KS. Future experiments will assess the therapeutic efficacy of radiolabeled ChL6 with and without concurrent systemic radiosensitizing chemotherapy.

AutoCyte Interactive Screening System. Experience at a university hospital cytology laboratory

OBJECTIVE

To evaluate the AutoCyte Interactive Screening System (AutoCyte-Screen) as a prescreener for the cytologic detection of cervicovaginal abnormalities.

STUDY DESIGN

Eight hundred fifty-six AutoCyte Preparation System from cervicovaginal samples were evaluated by AutoCyte-Screen. AutoCyte-Screen displayed 120 cell images and 6 low-power images for review by the cytotechnologist. The cytotechnologist classified the case as WNL, abnormal or unsatisfactory. AutoCyte-Screen then revealed its classification as either unsatisfactory, WNL, abnormal or undecided. These classifications were combined to form an interactive result that was compared to the diagnosis from previous manual review.

RESULTS

Interactive results were as follows: 251 (29.3%) abnormal, 581 (67.9%) WNL and 24 (2.8%) unsatisfactory. The abnormal interactive result contained 15 ASCUS/AGUS and 25 SILs; the WNL interactive result contained 5 ASCUS/AGUS and 2 SILs. No ASCUS/AGUS or SILs were in the unsatisfactory interactive category. The false negative proportion was 10.5% for the interactive diagnostic method vs. 15.7% for manual review for LSIL.

CONCLUSION

The interactive use of AutoCyte-Screen can effectively select those cases which are most likely to contain an epithelial abnormality and could therefore be used as a triage system to select cases for manual review. A case with an interactive result of unsatisfactory and abnormal should receive full manual review, while those classified as WNL may require a less extensive review for quality assurance purposes. This resultant decrease in the manual screening load could increase laboratory efficiency.

Natural history of cervical squamous intraepithelial lesions: a meta-analysis

OBJECTIVE

To define the strengths and weaknesses of existing research on the natural history of cervical squamous intraepithelial lesions (SIL) and to estimate rates of progression and regression without treatment.

DATA SOURCES

Studies of women whose cervical smears showed squamous atypia or worse and who were observed for a minimum of 6 months were identified by a search of MEDLINE from 1966 to 1996, Current Contents, the Federal Research in Progress database, and references of review articles and identified studies, and by experts in the field.

METHODS OF STUDY SELECTION

Fifteen of 81 studies were eligible for data extraction. To be eligible, studies had to report a minimum of 6 months' follow-up without treatment; relate entry cytologic findings to outcomes; and report entry cytologic findings so that the study population could be stratified into categories of atypical cells of undetermined significance (ASCUS), low-grade SIL, or high-grade SIL. Studies published before 1970 were excluded.

TABULATION, INTEGRATION, AND RESULTS

Eligible studies, representing 27,929 patients, were stratified according to entry cytologic findings. The following rates of progression to high-grade SIL at 24 months were found: ASCUS, 7.13% (95% confidence interval [CI] 0.8%, 13.5%); low-grade SIL, 20.81% (6.08%, 35.55%); and high-grade SIL, 23.37% (12.82%, 32.92%). The following rates of invasive cancer at 24 months were found: ASCUS, 0.25% (0%, 2.25%); low-grade SIL, 0.15% (0%, 0.71%); and high-grade SIL, 1.44% (0%, 3.95%). The following rates of regression to normal were found: ASCUS, 68.19% (57.51%, 78.86%); low-grade SIL, 47.39% (35.92%, 58.86%); and high-grade SIL, 35.03% (16.57%, 53.49%). Study heterogeneity was not explained by regression analysis of study level variables.

CONCLUSION

Our findings for borderline and low-grade abnormal cervical cytologic results suggest a relatively low risk of invasive cervical cancer with observation up to 24 months and support the clinical policy of early colposcopy for high-grade lesions.

The AutoCyte preparation system for gynecologic cytology

OBJECTIVE

To determine if thin-layer processing of cervicovaginal samples improves detection of cytologic abnormalities by reducing problems related to direct smear preparation.

STUDY DESIGN

Eight hundred fifty-two cervical samples were collected as part of a multicenter trial of the CytoRich/AutoCyte system. The Cervex Brush was used for specimen collection. Following preparation of a conventional Papanicolaou smear, the brush was placed in a vial of fixative. A thinlayer CytoRich preparation was prepared by sedimentation following centrifugation through a density gradient and then stained by the AutoCyte Preparation System according to the manufacturer's guidelines. The two preparations were masked and screened, and a diagnosis was rendered. Abnormal results from were reviewed by a pathologist. The specimens were later unmasked and the diagnoses compared.

RESULTS

CytoRich and conventional cervical cytologic smears detected an equivalent number of squamous intraepithelial lesions (SILs) (27 vs. 29) and atypical squamous cells of undetermined significance (ASCUS) (19 vs. 21). Both methods missed an equivalent number of SILs (four vs. five). CytoRich detected more infections (151 vs. 115) and had 66% fewer nonspecific inflammatory diagnoses. CytoRich also had fewer "limited" adequacy evaluations (211 vs. 236).

CONCLUSION

CytoRich preps improve adequacy; increase detection of infections, such as candidiasis and trichomoniasis; and are accurate in the diagnosis of SILs. CytoRich appears to be an equivalent and possibly better preparation for cervicovaginal cytology.

Multicenter masked evaluation of AutoCyte PREP thin layers with matched conventional smears. Including initial biopsy results

OBJECTIVE

To compare the performance of liquid-based cell preparations from the AutoCyte PREP system (AutoCyte, Inc., Elon College, North Carolina) with the conventional cervical smear in masked, split-sample, multisite trials.

STUDY DESIGN

The AutoCyte PREP system utilizes the CytoRich method, which combines liquid preservation, selective reduction of blood and inflammation, thin-layer cell dispersion and discrete staining. In an eight-site multicenter trial, 8,983 cases were evaluated. Parallel AutoCyte PREP slides and matching conventional cervical cytologic smears were screened in a masked fashion, with all abnormals reviewed in a masked, on-site pathologist review. The conventional smear was always prepared first, with the AutoCyte PREP using the residual cells on the collection device. The Bethesda System was used for reporting diagnosis and specimen adequacy.

RESULTS

Of the cases, 7,805 (86.9%) had the same interpretation. In 8,750 cases (97.4%), there was agreement within one diagnostic category. The AutoCyte PREP demonstrated a statistically significant, 31% overall improvement in the detection of squamous intraepithelial lesion and invasive cancer when evaluating cases with more than one diagnostic class difference. Biopsy correlation of available data supported the improvement observed in the cytology-based comparison. Recovery of infectious organisms and endocervical component was comparable between preparations, especially in light of the split-sample study design. There was a 39% reduction in unsatisfactory slides and 44% fewer satisfactory but limited by reports.

CONCLUSION

The AutoCyte PREP and CytoRich method produce excellent cellular presentations with standardized quality, superior sensitivity and improved adequacy as compared to the conventional method.

Fine-needle aspiration cytology of sarcoma: retrospective review of diagnostic utility and specificity

Fine-needle aspiration cytology (FNA) is useful because of its low cost, quick turn around time, and low incidence of complications. This study investigates the role FNA plays in the evaluation of sarcoma. We reviewed all the pathologic material from patients with sarcoma or a FNA diagnosis suggestive of sarcoma at the University of California-Davis Medical Center (1985-1994). Fifty-two of 196 patients identified (26.5%) were evaluated with FNA exhibiting 46 soft tissue and 6 bone lesions located in the extremities (19), trunk (19), head and neck (8), retroperitoneum (3), and abdominal cavity (3). Among 196 patients identified, those evaluated by FNA had soft tissue rather than bone lesions (P < .001) and primary sites other than in the extremities (P < .001). The primary neoplasms for the 52 FNA patients included 47 sarcomas (10 malignant fibrous histiocytomas and 16 other types), 1 intramuscular myxoma, 2 lymphomas, and 2 spindle cell (sarcomatoid) carcinomas. In 43 patients (22% of total), FNA was used first, before a primary diagnosis. The FNA report showed the correct specific neoplasm in only 20.9%. However, the FNA reports reflected an effective positive diagnosis leading to appropriate diagnostic biopsy in 88.4%, while only 7.0% were misleading (benign or inflammatory) and 4.6% inadequate. Review of FNA slides for 32 of 43 patients in which FNA was used first, in a blinded fashion, exhibited 21.9% specificity for the specific neoplasm, and 88.4% effective positive diagnoses. In 9 patients, FNA was utilized to investigate recurrence. Five out of 5 instances of recurrent sarcoma were identified by FNA. However, FNA misidentified recurrence in 3/4 instances, exhibiting suspicious cells from regenerating skeletal muscle (2) and a traumatic neuroma (1). The specific diagnosis for sarcomas is challenging even with surgical material. FNA usually does not provide a specific diagnosis (only in 20.9% of cases) and review of routinely prepared slides showed the same specificity as reflected by the original FNA report, at times formulated with the benefit of immunohistochemistry or electron microscopy. FNA effectively evaluated lesions in 45 of 52 patients (86.5%), confirming the useful screening role for this technique in sarcomas.

Relationship of p53 and bcl-2 to prognosis in muscle-invasive transitional cell carcinoma of the bladder

PURPOSE

We examined the presence of the p53 and Bcl-2 oncoproteins, as detected by immunohistochemistry, in muscle-invasive bladder cancer and correlated this with survival.

MATERIALS AND METHODS

Formalin-fixed cystectomy specimens from 41 consecutive patients with mean follow-up of 52 months were used. Five patients were either lost to follow-up or died of other diseases and were not included in the survival evaluation.

RESULTS

Eighteen of 36 patients died of metastatic transitional cell carcinoma. p53 immunostaining was found in 61% of patients. In 21 of 23 this staining was homogeneous, with more than 75% of cancer cells staining using a DO-1/DO-7 antibody cocktail. p53 staining was not correlated with stage (p>0.25) or grade (p<0.10) in these invasive cancer specimens. Contrary to recent studies p53 immunostaining was not correlated with disease-specific survival. Bcl-2 immunostaining was found in 28% of patients and was not correlated with grade (p>0.25) or disease-specific survival. No combination of p53 and Bcl-2 staining gave added predictive information.

CONCLUSIONS

Cytoplasmic Bcl-2 is found in a small percentage of these cancers and does not correlate with prognosis. Further, p53 molecular overexpression is detected in the majority of muscle-invasive bladder tumors as a field defect. However, in patients undergoing cystectomy, it does not correlate with prognosis.

Follow-up of Papanicolaou smears diagnosed as atypical squamous cells of undetermined significance

In the first year since the institution of the Bethesda system at UCDMC, 549/7,388 (7.43%) Papanicolaou (Pap) smears were diagnosed as having an epithelial abnormality. One hundred ninety-three of the 549 (35.1%) of the abnormal smears received an ASCUS diagnosis, representing 2.61% of the total volume. Follow-up was obtained on 124/193 (64.2%) and consisted of colposcopy with biopsy in 38.3%, one repeat Pap smear in 51.2%, and two or more repeat Pap smears in 10.5%. Follow-up revealed a squamous intraepithelial lesion (SIL) in 29.1%, ASCUS in 12.9%, and no evidence of an epithelial lesion in 58.0%. Review of the original ASCUS Pap smear from the group with no epithelial lesion on follow-up showed increased inflammation plus metaplasia and/or reactive changes in 69.5% and ASCUS in 19.5%. This study demonstrates that a significant percentage of ASCUS Pap smears represent SIL. However, many Pap smears with reactive, inflammatory changes are misclassified as ASCUS and would be best diagnosed under "Reactive/Reparative Changes" in the Bethesda system. Careful attention to criteria for ASCUS and inflammatory and reactive atypia is recommended to avoid misclassification and to make this category more meaningful to the clinician.

Fine needle aspiration cytology of pulmonary Wegener's granulomatosis with biopsy correlation. A report of three cases

BACKGROUND

Pulmonary Wegener's granulomatosis frequently presents clinically as ill-defined nodules on chest radiographs or computed tomographic scans. With refinement of fine needle aspiration (FNA) cytology as a diagnostic tool, pathologists are sometimes asked to render this diagnosis on cytologic material rather than on the more invasive open lung biopsy. Experience is currently limited to a few case reports in the cytopathology literature. We add to this by reporting the findings from five FNA biopsies performed on three patients, with open lung biopsy correlation.

CASES

The cytologic findings included a background of necrotic debris, acute and chronic inflammatory cells, multinucleate giant cells and, in one case (case 2), numerous clusters of atypical epithelioid cells mimicking carcinoma. Correlation of the respective open lung biopsy specimens with the FNA material was instructive in revealing the nature of the findings on cytologic preparations. Two cases showed classic histopathologic findings. Case 3 showed a less common presentation, pulmonary hemorrhage, which was reflected in the FNA specimen.

CONCLUSION

FNA biopsy cytology is a useful alternative to open lung biopsy in the diagnosis of pulmonary Wegener's granulomatosis but requires careful correlation with the clinical and laboratory findings.

Cervical pathology--the Bethesda System and the 'atypical squamous cells of undetermined significance' controversy

The Council on Scientific Affairs of the California Medical Association presents the following epitomes of progress in pathology. Each item, in the judgment of a knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and clinical importance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, and scholars to stay abreast of progress in medicine, whether in their own field of special interest or another. The epitomes included here were selected by the Advisory Panel to the Section on Pathology of the California Medical Association, and the summaries were prepared under the direction of Yutaka Kikkawa, MD, and the panel.

Remission of sarcoidosis following removal of silicone gel breast implants

We report herein a patient with debilitating multisystem sarcoidosis. Interestingly, dermal lesions and enlarged lymph nodes resolved and her clinical condition dramatically improved following removal of silicone gel breast implants. Of note, the capsular tissue surrounding the breast implant demonstrated a granulomatous foreign-body response. The potential harmful effects of silicone may include an acceleration of an already existing hypersensitivity response.

Application of the Scarff-Bloom-Richardson tumor grading system to fine-needle aspirates of the breast

Assigning a tumor grade to breast cancers provides important prognostic information. This study evaluated the applicability of the Scarff-Bloom-Richardson (SBR) breast cancer grading system to aspiration biopsy cytology. Thirty-five consecutive breast cancer fine-needle aspirates and their surgical specimens were reviewed by two pathologists. An SBR grade of 1-3 was assigned by each pathologist to both the fine-needle aspirate and biopsy specimen, based on the sum of scores given to each of three features: tubular differentiation, nuclear pleomorphism, and mitotic index. Both pathologists assigned the same SBR score to 74.3% of biopsy specimens and 65.7% of fine-needle aspirates. The cytologic grade could be used to predict the histologic grade in as many as 57.1% of cases. The wide disparities in the cytologic and histologic grades in some cases were chiefly due to difficulties in detecting mitoses or tubules in the cytology.

Fixation method useful for cytologic examination and DNA flow cytometry of exfoliated bladder cells

Single-institution studies have shown that DNA flow cytometry is superior to routine cytologic evaluation of following patients for bladder cancer recurrence. For 15 urine and 15 bladder washing specimens, we evaluated a fixative employing methanol plus acetic acid (MA), freshly mixed 20:1 (vol/vol). Routine cytologic evaluation following Papanicolaou staining, and DNA flow cytometry were performed. Paired aliquots from the same washings and urines were processed as fresh spray-fixed samples and MA-fixed samples. The majority of the MA-fixed specimens showed good nuclear preservation when assessed for chromatin texture, presence of distinct nuclear envelope, and clarity of nucleolus, while only a minority of the fresh urine and washing samples showed these features. Cytoplasmic degeneration was seen only in fresh specimens. The presence of aneuploidy and the percentage of hyperdiploid cells could be reliably determined in the MA-fixed samples. This fixation protocol is recommended for the transport of urine and bladder washing specimens to centralized laboratories for both cytologic and flow cytometric evaluation.

Intraoperative cytology as an elective surgical procedure. Analysis of 57 cases

Fifty-seven consecutive cases submitted by surgeons for intraoperative cytology were reviewed. In 47 cases there was a concomitant biopsy from the same anatomic site; among them, the cytologic and surgical diagnoses agreed in 44 (94%). The three discordant cases (6%) represented false-negative frozen sections. In the remaining 10 cases the cytologic and surgical biopsy sites differed in 5, 4 were considered inadequate for cytologic interpretation, and 1 did not have a corresponding surgical biopsy. Attitudes toward the use of intraoperative cytology were assessed with questionnaires sent to surgeons from all specialties represented at the University of California, Davis, Medical Center. Fifty-three percent of the respondents reported use of this procedure. At our institution thoracic surgeons and otorhinolaryngologists were more apt than others to use intraoperative cytology as an adjunct to frozen section analysis. Factors influencing their selection of intraoperative cytology are discussed.

The cytology of pediatric masses: a differential diagnostic approach

In the United States, fine-needle aspiration biopsy (FNAB) and other cytodiagnostic methods have been underutilized in the evaluation of masses in the pediatric age group. Cytopathologists and cytotechnologists are therefore relatively unfamiliar with the cellular features of lesions that occur in children. On the basis of the cytologic findings from 64 pediatric cases, including 56 FNABs and 8 intra-operative imprints, a differential diagnostic approach to lesions in this age group is presented. The majority of cases can be placed into 1 of 5 cytomorphologic categories: (1) round-cell pattern, (2) mixed inflammatory pattern, (3) spindle-cell pattern, (4) epithelial pattern, and (5) cystic pattern. Once a cytomorphologic category is determined, evaluation for unique cellular features, special studies, and clinical correlation allows a specific diagnosis to be made in most cases. Pitfalls in pediatric cytopathology are illustrated by discussion of the following cases: a renal Burkitt's lymphoma mimicking a Wilms' tumor, a traumatic neuroma masquerading as a recurrent malignant schwannoma, Langerhans-cell histiocytosis resembling granulomatous inflammation, and a cystic granuloma that mimicked a branchial cleft cyst. Consideration of these problems and use of the recommended diagnostic approach will aid in interpretation in this difficult area.

Cytodiagnosis of classic lobular carcinoma and its variants

The well-known cytologic features of lobular carcinoma traditionally consist of modest cellularity and small, atypical cells lying singly or in small groups. However, lobular carcinoma is a common pitfall in the cytodiagnosis of breast lesions. Knowledge of its varied histologic appearance can help to prevent diagnostic difficulties. Among 55 consecutive cases of breast needle aspirates with histologic follow-up, 9 lobular carcinomas were identified. The surgical material was examined for the following histologic variants: (1) classic, (2) solid, (3) alveolar, and (4) mixed; it was correlated with the cytologic findings. Pure, classic lesions were the most likely cause of false-negative diagnoses. Two of nine lobular carcinomas were diagnosed as benign due to scant cellularity and cell smallness. Four of nine were cytologically misclassified as ductal type due to more abundant cellularity and larger cells. This could be attributed to the predominant alveolar or solid patterns present in three cases. Only three of nine were accurately classified as lobular carcinoma, and all had a significant classic histologic element. Another important feature that is highly suggestive of lobular carcinoma is the presence of cytoplasmic vacuoles. They were overlooked in three of four cases. This study suggested that the traditional cytologic features of lobular carcinoma are present only in tumors with a predominantly classic histologic pattern. Awareness of the variant patterns and their cytologic features, including more abundant cellularity, larger cells and clusters, and cytoplasmic vacuoles, will aid in correct classification.

Fine needle aspiration biopsy of superficial masses in children

Fine needle aspiration biopsy (FNAB) is an underused diagnostic procedure in children, particularly in the evaluation of superficial masses. A total of 54 FNABs of superficial masses were performed in children aged 1 month to 15 years. Adequate material for diagnosis was obtained in 50 attempts. The cytologic diagnosis increased clinical understanding and provided a guide for treatment in 46 of the 50 cases. The cytologic diagnosis was confirmed in 15 of 19 patients who underwent an operation. Surgical intervention was obviated in 31 patients. There was one false-positive diagnosis of cancer. We describe the role of FNAB in children and its technique, accuracy, and diagnostic problems.

Cytologic interpretation of fine-needle aspiration biopsies from clinically occult breast masses

Fine-needle aspiration biopsy (FNAB) was performed on 39 occult breast masses of soft tissue density using standard mammographic guidance. All malignant tumors were diagnosed as either positive or suspicious for carcinoma, and there were no false-positive or false-suspicious diagnoses. These excellent results can be attributed to accurate cytologic interpretation based on consideration of problems unique to these lesions and the sampling method, such as scantier cellularity, potentially less confidence in needle placement, and the nature of the occult mass itself. The team approach between pathologist, radiologist, and clinician is emphasized.

Aspiration biopsy cytology of the prostate in young adult men

The aspiration biopsy cytology of 11 prostates obtained at autopsy from men younger than 40 yr old were studied to define the cytologic criteria of benign changes in this age group. Cytologic features that differ from those of older men with benign prostatic enlargement include abundant cellularity, the presence of large and small cell groups (which would otherwise suggest dyshesion), and a predominantly columnar cell shape. These differences can be attributed to age-related changes in the prostate. A case of a prostatic nodule in a 22-yr-old that was evaluated by fine-needle aspiration biopsy is presented to illustrate the diagnostic difficulties that can arise when the interpreter is unaware of differences in cytologic patterns due to age.

Medullary carcinoma of the breast. An unusual cytologic finding in cyst fluid aspirates

Cystic medullary carcinoma of the breast is unusual. This report describes five patients with medullary carcinoma who presented clinically with a breast cyst. Fine-needle aspiration biopsy (NAB) was performed as part of the initial physical examination and the retrieved cyst fluid was examined cytologically. Four of the five patients were premenopausal, more typical of benign cystic disease and significantly younger than the average (60+ years) for other forms of cystic breast carcinoma. Only three of the five patients demonstrated suspicious findings of hemorrhagic cyst fluid, a residual mass after NAB, or refilling of the cyst. Due to the relatively young age of most patients, the innocuous clinical presentation, and the abundant inflammatory component noted in the aspiration biopsy cytologic study (ABC), misinterpretation as an inflamed cyst is possible. The ABC of cystic medullary carcinoma is presented with histologic correlation.

Papillary carcinoma of prostatic ductal origin: a cytologic case report with immunohistochemical and quantitative DNA correlation

This report describes the aspiration biopsy cytology (ABC) of a case of papillary carcinoma of ductal origin, an uncommon malignant tumor of the prostate. Only one case has been previously reported in the cytology literature. Atypical papillary fragments are the distinctive cytologic findings. Similar to well-differentiated acinar carcinoma of the prostate, the cytologic features of malignancy in this lesion may be subtle, and diagnosis is based on the presence of the cytologic pattern. Positive immunohistochemical staining with prostate-specific acid phosphatase confirms the prostatic origin. Application is made of quantitative DNA analysis for prognostic determination.

Cytodiagnosis of extrahepatic biliary duct tumors from specimens obtained during cholangiography

Two cases of cholangiocarcinoma of the extrahepatic biliary ducts, one case of bile duct adenoma, and one case of pancreatic carcinoma involving the common bile duct are presented to illustrate cytologic diagnoses from specimens obtained during endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. Obtaining specimens during these procedures can be advantageous because the cells retrieved are well-preserved, surgery is not required, and patients with advanced disease can be managed conservatively once a diagnosis is rendered. Cytologic diagnosis can be difficult, since malignancies of the extrahepatic bile ducts are often well-differentiated. Cytologic findings with histologic correlation are presented to emphasize the subtle cellular features of these uncommon lesions.

A gastrointestinal-specific monoclonal antibody that may be of clinical value in cytologic material

A new monoclonal antibody (MAb), 29-10, produced by immunization of mice with cells from the SW 1116 colorectal carcinoma cell line, detected an antigen present in cytologic touch imprints of surgically resected normal and neoplastic gastrointestinal (GI) tissue, including specimens from the stomach and the colon. These imprints were fixed in 95% ethanol and stained with the avidin-biotin immunoperoxidase technique. In tested cases, 22 (100%) of 22 imprints from GI adenocarcinomas and from normal GI tissue, as well as 13 (56.6%) of 23 imprints from colonic polyps, stained positively while no staining was demonstrable in imprints from other tissues. In histologic sections, only 4 (23%) of 17 colonic adenocarcinomas and 3 (11.5%) of 26 polyps stained positively. The staining ability of MAb 29-10 was compared to that of MAb 19-9, another colorectal antibody, and was found to be markedly superior for binding of the antigen in cytologic preparations. This tissue-specific antibody may be useful in identifying malignant cells of metastatic carcinoma as to their GI tract origin.

Cytodiagnosis of in situ and early carcinoma of the upper gastrointestinal tract

Three cases of adenocarcinoma of the stomach, two in situ and one superficially invasive, and one of superficially invasive squamous-cell carcinoma of the esophagus are presented to illustrate the problems encountered in the diagnosis of early lesions of the upper gastrointestinal (GI) tract and the contribution that cytodiagnosis can make. The symptomology and roentgenographic findings in these cases were largely nonspecific. While endoscopic biopsies were repeatedly negative in three of the four cases, endoscopic brushing cytology consistently indicated the presence of a malignancy. Surgery was finally performed on the basis of the cytologic findings, confirming the presence of early malignancy. The cytologic findings, with histologic correlations, are presented in an effort to define some specific criteria for the diagnosis of early malignancy of the upper GI tract.

Nifedipine-induced gingival hyperplasia. A histochemical and ultrastructural study

Gingival hyperplasia induced by nifedipine (Procardia), a calcium channel-blocking agent used as an anti-anginal drug, was studied. In recent months, the role of nifedipine in the etiology of gingival hyperplasia has attracted interest. The purpose of this study was to determine the causal relationship and compare nifedipine to other drug-induced (phenytoin) and nondrug-induced gingival hyperplasias. Histochemical studies revealed increased numbers of fibroblasts containing strongly sulfated mucopolysaccharides in the nifedipine- and phenytoin- (Dilantin) induced gingival hyperplasias as compared to the nondrug-induced cases. Numerous secretory granules were also noted in the fibroblast cytoplasm in the nifedipine-treated case studied by electron microscopy. These results imply that there is an increase in acid mucopolysaccharide production in the nifedipine- and phenytoin-induced gingival hyperplasias. The potential significance and comparisons of the drugs' effects at the cellular level are discussed.