Accuracy of p53 and ki-67 in the graduation of phyllodes tumor, a model for practical application

Background

The accurate graduation of a phyllodes tumor (PT) is critical for effective treatment as it allows correct surgical management, and avoids inadequate excision for malignant or borderline PT, or surgical overtreatment in benign PT. PTs of the breast are notoriously difficult to classify, and reliable differentiation of a benign PT from a borderline or malignant PT can be problematic, especially among relatively inexperienced pathologists. Although several authors acknowledge a strong relationship between the immunohistochemical expression of p53 and Ki-67 and the histopathological grade of PT—with potential impact on diagnostic accuracy—the literature lacks consensus about which cutoff defines a positive index test. The objective of this study is to establish a practical application score that increases the graduation accuracy of PT through the appropriate use of these auxiliary methods.

Methods

A retrospective study cohort of 146 pathology reviewed PTs surgically removed between January 2000 and December 2015. The Ki-67 test was considered positive if > 10% of neoplastic cells showed nuclear staining. The p53 test was considered positive if > 10% of neoplastic nuclear cells showed nuclear staining in a moderate or strong intensity.

Results

Of the 146 PT cases reviewed, 110 were classified as benign, 16 as borderline, and 20 as malignant. The correlation between age and size with benign, borderline, and malignant subgroups was statistically significant (p < 0.001). Significance was observed in the expression of both Ki-67 and p53 in the comparison of benign, borderline, and malignant PT with p < 0.001 and a 95% confidence interval (CI). When correlating the presence of positivity in either of the two index tests with the diagnosis of borderline or malignant PT, we reached a sensitivity of 100% and a specificity of 91.8 (p < 0.001; 95% CI).

Conclusion

We propose a practical methodology to achieve an accurate grade of PT, based on clearly defined and easy to apply cutoffs of a simple immunohistochemical panel of Ki-67 and p53. A PT positive for either of the index tests should be graded as borderline or malignant, so pathologists can use this test to improve accuracy. We hope this new approach might provide the basis for the development of standardization in using p53 and Ki-67 for grading PT.

Clinical-radiographic correlation in occlusal surfaces

The aim of the present study was to correlate clinical and radiographic diagnoses of the occlusal surfaces of the first permanent molars. A total of 56 first permanent molars with no macroscopic evidence of caries were selected from 40 children. A research worker performed the visual examination (VE) and an expert performed the radiographic analysis employing bitewing radiographs. Each professional performed diagnosis independently. The statistical analysis revealed: 1) Low correlation between both methods; Kappa: 0.03, p = 0.34; 2) Correlation between past history of caries and VE: taub Kendall 0.333, p = 0.003; no correlation between past history of caries and radiographic diagnosis: 0.002, p = 0.984; 3) No correlation between each of the methods of diagnosis and the age of the patients. The radiographic analysis showed a high revalence of radiolucid images, interpreted as caries, that failed to be detected by VE. To improve VE as a diagnostic method for pits and fissures we should combine various procedures and consider other clinical predictors.

Oral health of children from rural excluded villages (Trancas and Calchaqui valleys. Tucumán, Argentina)

The general hypothesis of the study was to evaluate strategically important rural areas to confirm their characteristics of "excluded population" and identify the priorities to allocate human and financial resources of the international co-operation project. The aim of this study was to establish the degree of development of villages in the Trancas and Calchaqui valleys, and the oral health of children living in areas involved in an integral study on excluded villages in the northwest of Argentina. These villages are considered a priority in the UNIR Project; they are thus strategically important as a link with countries of the MERCOSUR. Data on living conditions were obtained through direct inquiries (Project UNIR, W. K. Kellogg Foundation/University of Tucumán) and from data supplied by the Ministry of Economy, by the Ministry of Culture and Education and by the SIEMPRO project of the Secretariat of Social Development of the Ministry of Health. The Human Development Index (HDI) was calculated as World Bank criteria (1995), The studies on dental conditions were carried out in all the children between 12 and 14 years old, that is a total of 58 in the Trancas Valley and 212 in the Calchaqui Valley.

RESULTS

(1) The HDI was 0.731 for the province, 0.56 for the Trancas Valley and 0.51 for Calchaqui valley. (2) The results are above the values for the country in the first case, and below the average country values for the valleys. (3) The percentage of BNN families reached 92%. The results for oral health show: (4) the DMFT were 6.34 +/- 0.07 in the Trancas Valley and 7.47 +/- 0.276 in the Calchaquí valley. (5) Carious teeth (CT) were the most important component of this index. (6) The absence of a specific and preventive assistance.

CONCLUSIONS

(a) Children between 12 and 14 living in the Valleys of Trancas and Calchaqui (Tucumán, Argentina) are affected by severe levels of caries, with values above the national and province means. (b) The human development index is below that of the corresponding national and province levels. (c) Inhabitants of these valleys can be identified as socially and biologically highly vulnerable. (d) The indicators of cariogenic risk reveal the importance of introducing oral preventive care components to the health plan for the area focused on the excluded population.

[Practicability of cataract surgery at university hospitals: searching for an economic model]

Resources available for health care all over the world are not enough to cover all the demand in this sector. Cataract Free Zones conducted in many regions of the country show that only 10% to 20% of blind patients caused by senile cataract can get operated on.

PURPOSE

To demonstrate feasibility of a model for cataract surgery with intraocular lens implantation at the Clinical Hospital from the University of Campinas, Unicamp, São Paulo, when considering the remuneration payed by the government for universitary services.

METHODS

Costs with disposable material were collected for extracapsular cataract surgery, with posterior intraocular lens implant, at the Clinical Hospital, Unicamp. The model includes outpatient surgery under local anesthesia, and costs rationalization in acquisition and wear of material. University Hospitals have a different situation in the health system, where fixed costs and part of the variable costs of cataract surgery are subsidized by the State government.

RESULTS

Cataract surgery performed under the proposed methodology is economically feasible, considering disposable components only, and the price achieved was US$ 77 with government payment of US$ 474. More surgical interventions increases the efficiency of the institution, provides more surgical training to residents and better community health care.

CONCLUSION

The authors consider that it is an obligation of University Hospitals, regard their commitment with training, research and quality of eye care deliverance, to increase the number of cataract surgeries for the lowest possible price.

Screening and surgical intervention results from cataract-free-zone projects in Campinas, Brazil and Chimbote, Peru

Two cataract-free-zone projects, one in Brazil and the other in Peru, were designed to provide surgery to all those who need and want it within a defined geographic area. In-home visual acuity screening was accepted by three-fourths of the enumerated population aged 50 years or more. Those with reduced bilateral visual acuity were referred to a community health post for ophthalmic examination. Among those diagnosed as bilaterally blind (less than or equal to 20/200), comprising 5% of the screened population, two-thirds were thought to be blind from cataract. Because of other ocular pathology and general health conditions, surgery was not indicated for 30-50%. Two-thirds of those recommended for out-patient surgery accepted. Motivational efforts to convince the refusers were uniformly unsuccessful. The average age of those accepting and those refusing surgery was in the mid-seventies. Those already aphakic were 7-8 years younger. Post-operative acuity was greater than or equal to 20/50 for only one-half of those operated. A significant number of cases had previously undetected macular degeneration and other causes of decreased vision. These projects have given increased attention to cataract blindness and the need for further operational research to develop effective methods for its control using outpatient surgery.