Uterine effects of raloxifene in comparison with continuous-combined hormone replacement therapy in postmenopausal women

OBJECTIVE

We sought to compare the uterine effects of raloxifene with those of continuous-combined hormone replacement therapy.

STUDY DESIGN

This randomized, double-blind 24-month study involved 136 postmenopausal women who received raloxifene 150 mg/d or conjugated equine estrogens 0.625 mg/d with medroxyprogesterone acetate 2.5 mg/d. After baseline evaluations, endometrial biopsy specimens were obtained, and endometrial thickness was measured annually by means of transvaginal ultrasonography. Statistical analyses were performed with an intention-to-treat approach.

RESULTS

In the raloxifene group at the end point of the study 94.4% of biopsy specimens showed normal benign postmenopausal endometrium and 5.6% were classified as benign stimulatory endometrium. In the continuous-combined hormone replacement therapy group at the end point of the study 78.7% of biopsy specimens showed normal benign postmenopausal endometrium, 19. 1% were classified as benign stimulatory endometrium, and 2.1% showed benign abnormal postmenopausal endometrium. Mean endometrial thickness was unchanged from baseline with raloxifene and was increased significantly by 0.5 mm at 12 months with continuous-combined hormone replacement therapy.

CONCLUSION

Raloxifene 150 mg/d did not increase endometrial thickness or cause endometrial proliferation in healthy postmenopausal women.

Raloxifene HCl is not stimulatory in the endometrium as assessed by the blaustein criteria and an estrogenicity scoring system

Introduction: Raloxifene, a selective estrogen receptor modulator (SERM), acts as an estrogen agonist in the bone and on serum lipids and an estrogen antagonist in breast tissue. The effect of raloxifene on the endometrium of postmenopausal women is a key factor in determining its clinical application.Objectives: The objectives are to determine and compare the histologic outcomes of endometrial samples from healthy postmenopausal women receiving either a high dose of raloxifene or hormone replacement therapy (HRT).Design: The current study is a 24-month, multicenter, double-blind, randomized study of 136 healthy postmenopausal women randomized to receive either raloxifene 150 mg/day (RLX) or continuous combined HRT (Premarin(R) 0.625 mg/day and Provera(R) 2.5 mg/day).Materials and Methods: Endometrial samples obtained by Pipelle biopsy at baseline and endpoint were evaluated using Blaustein's criteria (Kurman RJ, editor Blaustein's pathology of the female genital tract. 1994), which is composed of descriptive diagnostic categories and a newly developed estrogenicity scoring system to quantify subtle morphologic changes in the postmenopausal endometrium (Boss et al. Am J Obstet Gynecol, in press). All subjects with adequate baseline and post-baseline endometrial samples were included in the analyses. The results from the 12-month interim analyses are reported and the Blaustein's criteria and the estrogenicity scoring system are compared.Results: Overall, 95.2% of the baseline biopsies were normal. At endpoint 30.6% of the subjects in the HRT group with normal baseline biopsies developed proliferative endometrium and 2.8% developed a polyp, while none in the RLX group developed either. Histological evaluation of stromal and glandular features revealed substantially lower estrogenicity scores in the RLX group. As shown in the table, a high degree of agreement was observed between the estrogen effect grades and the Blaustein's descriptive diagnostic categories at endpoint as shown by a Spearman correlation coefficient of 0.75 and a Kappa coefficient of 0.91.Conclusion: Results from the 12-month interim analyses reveal that, in contrast to HRT, raloxifene does not have stimulatory effects on the endometrium. Also, there is high degree of agreement between Blaustein's criteria and the estrogenicity scoring system used to evaluate endometrial histology.

Effects of raloxifene hydrochloride on the endometrium of postmenopausal women

OBJECTIVE

We evaluated subtle endometrial morphologic changes in postmenopausal women assigned to placebo, raloxifene hydrochloride 200 or 600 mg/day, or conjugated estrogens (Premarin 0.625 mg/day) according to a new estrogenicity scoring system. Raloxifene, a new selective estrogen receptor modulator, was not expected to stimulate the endometrium.

STUDY DESIGN

Baseline and end point endometrial biopsies were performed during this double-blind, placebo-controlled 8-week study. A scoring system that was based on standard glandular and stromal morphologic criteria was used to quantitate estrogen-induced effects. Baseline, end point, and baseline-to-end point changes were analyzed for treatment differences.

RESULTS

Treatment groups were similar at baseline with most women showing no estrogenic effects. At end point, statistically significant moderate and marked estrogenic effects were noted in 77% of estrogen-treated women versus 15% of placebo-treated women versus 0% of raloxifene-treated women.

CONCLUSIONS

As expected, estrogen treatment stimulated postmenopausal endometrium. In contrast, raloxifene did not induce histopathologic evidence of endometrial stimulation in healthy postmenopausal women.

Fine-needle aspiration biopsy of salivary duct carcinoma: report of five cases

Salivary duct carcinoma is a high grade malignancy which histologically strongly resembles ductal carcinoma of the breast. The findings from five cases of histologically proven salivary duct carcinoma sampled by preoperative fine-needle aspiration (FNA) cytology are presented. Characteristic cytomorphologic features include cohesive clusters and flat sheets of epithelial cells which display a cribriform pattern with eccentrically located, hyperchromatic nuclei, abundant finely granular cytoplasm, and necrosis in the smear background.

Fine-needle biopsy of pediatric lesions: a three-year study in an outpatient biopsy clinic

Diagnostic Cytology Laboratory, Inc., has an outpatient Fine Needle Biopsy Clinic, which evaluated 7,487 fine-needle biopsies (FNB) from January 1989 to February 1992. Two hundred eighty-eight (3.8%) of these specimens were collected from patients 19 years old or younger and this represents the largest study of this population in the scientific literature. The majority of these specimens were obtained from palpable masses in the head and neck region [lymph nodes (58.3%), thyroid (7.6%), and salivary gland (5.2%)] while a smaller number were collected from miscellaneous soft tissue (18.8%) and breast masses (10.1%). Thirteen (4.5%) (from 12 patients) were diagnosed as malignant by FNB and 275 (95.5%) (264 patients) were benign by FNB. This benign:malignant ratio (22:1) is significantly higher than has been reported from tertiary care institutions and is a reflection of the difference of this outpatient population. Two hundred nine of 276 patients (75.7%) had adequate follow-up, including 137 (49.6%) patients followed by observation, 48 (17.4%) patients followed by surgical biopsy, and 24 (8.7%) patients followed by some other modality: imaging studies, flow cytometry, or treatment. There was a single false positive diagnosis (a pilomatrixoma) and one (1) false negative interpretation (a cystic acinic cell carcinoma) resulting in a diagnostic sensitivity of 92.3% and a specificity of 99.6%. The positive predictive value was 92.3%, the negative predictive value was 99.6%, and the test efficiency was 99.3%. The utility, cost-effectiveness and uniqueness of the clinic population is discussed.

Thoracic needle biopsy. Improved results utilizing a team approach

Transthoracic needle aspiration biopsy (TNAB) is a useful diagnostic technique in the evaluation of thoracic disease. Previous reports have shown that this technique has a high positive but a low negative predictive value. The latter has limited the clinical usefulness of a negative biopsy. To improve the reliability of a negative TNAB, a series of thoracic needle biopsies was done using a team approach, having a cytopathologist, with the necessary equipment to examine the biopsy specimens, in attendance at the biopsy. As biopsy specimens were obtained, they were reviewed to ensure an adequate and representative sampling. The positive predictive value was 98.6 percent and the negative predictive value was 96.7 percent. The high negative predictive value obtained using this approach allows clinical decisions to be based on the results of a negative TNAB.

Glycogen-rich clear cell carcinoma of the urethra: an ultrastructural study

A 49-year-old black woman developed a urethral glycogen-rich clear cell carcinoma. She was treated with anterior pelvic exenteration. The resected lymph nodes, vagina, uterine cervix, endometrium, ovaries, and urinary bladder were free of neoplasm. Histologically the neoplasm consisted of clear cells growing in sheets and occasional papillary structures. In some areas, hobnail cells were present. Ultrastructurally, the cells had apical caps, short microvilli, and complex cell bases, and contained abundant glycogen. These features were identified in one, but not the other of two previously reported cases. Because glycogen-rich clear cell carcinomas of the lower urinary tract do not resemble ultrastructurally mesonephric remnants or carcinomas known to arise from them, these glycogen-rich clear cell carcinomas should not be called "mesonephromas" as has been the practice.

The role of fine needle aspiration cytology in the management of gynecologic malignancies

Between 1978 and 1983, 317 diagnostic fine needle aspirations (FNA) were procured at Indiana University by the Cytology, Radiology or Gynecology services for initial evaluation or follow-up of proven gynecologic malignancies. The primary sites of the neoplasms included the cervix, uterus, ovary, vagina and vulva. Totals of 199 samples were procured from superficial sites, including parametrium, vagina, subcutaneous tissue and superficial lymph nodes, and 118 were obtained from deep soft tissues, abdominal organs, pelvis and deep lymph nodes. Of the FNA specimens, 146 (46%) were cytologically diagnosed as malignant and 171 (54%) were reported as benign. Of the specimens initially given negative diagnoses, 35 (11%) were inadequate samples. No complications occurred as a result of FNA biopsy. All cases were reclassified using strict criteria for an inadequate specimen. After review, 79 biopsies were considered either scant (22%) or inappropriate (0.03%) for the target lesion. Scant specimens were obtained more often in superficial than in deep sites. No significant differences were found in the false-negative rate between superficial and deep sites; all false positives were from superficial sites. The use of strict criteria for adequacy of a sample (two groups of appropriate cells on two separate slides) yielded a specificity of 95%, an increased sensitivity from 73% to 91%, a predictive value for a positive result of 98% and a predictive value for a negative result of 84%. Use of strict criteria for specimen adequacy served to reemphasize two points regarding negative FNA results: that rebiopsy should be suggested and that on-site assessment of the specimen adequacy should be made during the aspiration.

Parathyroid cytopathology

Cytologic criteria for diagnosing parathyroid adenomas and hyperplasia have not been elucidated. This report will present the cytomorphology of parathyroid tissue in the spectrum of normal, hyperplastic, and neoplastic states. We examined clinical needle aspirates from three patients with parathyroid lesions as well as 15 needle aspirations or touch preparations from surgical specimens. The series included three with hyperparathyroidism secondary to chronic renal failure, four with primary chief cell hyperplasia, nine with typical adenomas, and two with atypical adenomas. Normal parathyroid glands were also studied. Most parathyroid lesions could be distinguished from thyroid lesions by frequent thick fragments of cohesive cells with frayed edges and typical nuclear features. In general, the nuclei were small (6-8 mu) and round with regular coarse granular chromatin. Occasional larger nuclei (10-30 mu) with similar chromatin were observed in some cases. Oxyphil cells with abundant granular cytoplasm were present in some cases; one case with mostly oxyphil cells was difficult to differentiate from a thyroid neoplasm. Pseudocolloid was found in seven cases. Criteria for the differentiation between parathyroid hyperplasia and adenomas were not discovered. In addition, the cytology and differential diagnosis of atypical parathyroid adenomas are described and illustrated.

Intranuclear cytoplasmic inclusions in aspirates of follicular neoplasms of the thyroid. A report of two cases

Two cases are reviewed in which the presence of intranuclear cytoplasmic inclusions in fine needle aspiration biopsy specimens of the thyroid suggested a diagnosis of papillary carcinoma. Subsequent surgical specimens were consistent with diagnoses of microfollicular adenoma and follicular carcinoma. These cases suggest that the presence of intranuclear inclusions in epithelial thyroid cells is not limited to papillary and medullary carcinoma, as some authors have suggested.

Valved and nonvalved right ventricular--pulmonary arterial extracardiac conduits. An experimental comparison

Extracardiac conduits are essential in operations for congenital discontinuity between the right ventricle and the pulmonary artery. The disturbing degree of obstruction reported in clinical series of extracardiac conduits containing porcine valves has been attributed in part to early valve deterioration and the development of a thick neonintimal lining within the Dacron graft. This study compares the hemodynamic differences and the thickness of the neointimal lining in right ventricular extracardiac conduits with and without a porcine valve. Woven Dacron conduits (16 mm) were implanted in 15 adult mongrel dogs, and then the proximal pulmonary artery was occluded with Dacron tape. In six dogs, the extracardiac conduit contained a porcine valve, whereas in the other nine it did not. Cardiac output, transconduit gradient, and resistance were measured at operation and 6 and 12 months postoperatively in both groups. No hemodynamic differences were noted. After 1 year, the thickness of the neointimal lining was threefold greater in valved conduits (1,370 +/- 313.1 mu versus 367 +/- 28.07 mu, p less than 0.005). The neointima along the Dacron graft was thickest proximal and distal to the porcine valve. The luminal peel in valved conduits contained fenestrations and intimal flaps, similar to those observed clinically. In our model, a porcine valve in a right ventricular extracardiac conduit is associated with intimal hyperplasia not seen in nonvalved conduits. If the pulmonary vascular resistance is normal, then the absence of a valve within the conduit does not significantly change hemodynamics and may warrant clinical application to prevent late conduit obstruction.

Aminoglycoside accumulation kinetics in rat renal parenchyma

To test the hypotheses that the renal parenchymal accumulation kinetics of aminoglycosides can predict nephrotoxicity, we measured renal parenchymal concentrations in rats receiving gentamicin and tobramycin. In addition to comparing the drugs as single daily injections, we also examined the effect of multiple doses versus a single daily dose. Gentamicin accumulated to much greater concentrations in the kidney than did tobramycin. Gentamicin given twice daily accumulated more rapidly and to greater concentrations than did the same total dose given once daily. We conclude that aminoglycoside accumulation in the kidney depends on the drug and dose regimen. These differences may explain relative nephrotoxicities.

Effects of vancomycin on renal function in rats

To assess the effects of vancomycin on the kidney, we gave rats doses of 10, 50, 100, 200, and 400 mg/kg per day. Creatinine clearance and urine protein excretion did not differ significantly from the control values. Urine osmolality was unchanged. Mild histological changes occurred in rats given the highest dose. We conclude that although histopathological changes occurred at high doses, vancomycin does not alter renal function in rats.

Retroperitoneal leiomyosarcoma: a light and electron microscopic study

Retroperitoneal leiomyosarcoma arising in a spermatic blood vessel is described. In addition to typical leiomyosarcoma, areas of atypical histiocyte-like cells and storiform pattern bearing a close resemblance to malignant fibrous histiocytoma, were seen. Ultrastructurally, cells with features of smooth muscle, partially differentiated cells with marginal densities and basal lamina and histiocyte-like giant cells were present. Phagocytosis of inflammatory cells by tumour cells with marginal densities and an investment of basal lamina was observed. It is suggested that the precursor cell in this lesion was a primitive mesenchymal cell showing varying degrees of smooth muscle differentiation and giant cell formation.

Endobronchial granular cell tumor. Cytology of a new case and review of the literature

We report the 45th case of endobronchial granular cell tumor in the literature and describe in detail the cytologic findings in bronchial brushings and post-brush washings. Our findings differ from those of the only other cytologic report of such a lesion. We review the literature and summarize the clinical and pathologic findings of endobronchial granular cell tumors. Cytologically the differential diagnosis is between granular cells, respiratory epithelial cells and macrophages. We feel that our criteria make the distinction between them easy. However, most importantly, one must suspect the lesion; otherwise, these "benign cells" will be passed over by the screening cytotechnologist.