[Experiences with telepathology in northern Afghanistan : A 10-year success story]. / Erfahrungen mit Telepathologie in Nordafghanistan : Eine 10-jährige Erfolgsgeschichte.

Afghanistan is in a military conflict lasting more than 20 years and according to recent political development, in a downhill spiral towards a failed society. This scenario faces the question of the usefulness of international medical aid, especially morphological diagnostics in crisis situations. On the basis of ten years of experience from a telemedicine project, need, feasibility and results in Afghanistan will be discussed. General and country-specific problems and the sustainability of an international partnership are discussed. In summary our experience is: (1) Telemedicine is possible and necessary even in countries with high conflict potential. It is integrated into routine care by local medical care taker, (2) Accompanying video conferences are a significant improvement in telemedical diagnostics, (3) "High level" consultations can bridge the gap between sophisticated western diagnostics and medicine in the partner country in selected cases and (4) Scientific work is possible on the basis of the medical data collected on site and the image material generated.

The Importance of Clinical Data for the Diagnosis of Breast Tumours in North Afghanistan.

BACKGROUND: This study was performed in knowledge of the increasing gap between breast disease treatment in countries with restricted resources and developed countries with increasingly sophisticated examination methods. METHODS: The authors present the analysis of a breast disease register consisting of diagnostic cases from Mazar e Sharif and Herat in 2018 and 2019. The study comprises a total of 567 cases, which were presented to experts via telemedicine for final diagnosis. 62 cases (10.9%) were excluded due to inacceptable data or insufficient image quality. These data provided by daily diagnostic classification were used for the built-up of a profile for each frequent breast disease and a breast cancer register. All images and cases were seen by at least 3 independent experts. The diagnoses were made in 60% of cases by cytology of fine needle aspiration and in 40% by histological images. RESULTS: For each entity of breast diseases (e.g., fibroadenoma), a profile of context variables was constructed allowing to assist medical decisions, as "wait and see," elective surgery or immediate surgical intervention with R0 (complete) resection. These "profiles" could be described for fibroadenoma, mastitis, galactocele, fibrous-cystic disease, and invasive breast cancer. CONCLUSIONS: The presented preliminary data set could serve as a cost-effective basis for a North Afghan breast cancer registry, with option to extent to a national model. These preliminary data are transformed in profiles of breast diseases, which are used by the local physicians in charge of breast disease patients. Each new case can be compared by the local treating physician with the profile of all preceded cases with the same diagnosis.

Experience with telepathology in combination with diagnostic assistance systems in countries with restricted resources.

INTRODUCTION: We describe the use of telepathology in countries with restricted resources using two diagnosis assistance systems (Isabel and Memem7) in addition to the diagnoses made by experts in pathology via the iPath-Network. METHODS: A total of 156 cases, largely from Afghanistan, were analysed; 18 cases had to be excluded because of poor image quality. RESULTS: Of the remaining 138 cases (100%), a responsible physician provided a tentative diagnosis for 61.6% of them. With a diagnosis from a consultant pathologist, it was then possible to make a definite diagnosis in 84.8% of cases on the basis of images taken from hematoxylin and eosin staining sections alone. The use of the diagnosis assistance systems resulted in an ordered list of differential diagnoses in 82.6% (IsabelHealth) and in 74.6% (Memem7) of cases, respectively. Adding morphological terminology reduced the list of possible diagnoses to 52.2% (72 cases, Memem7), but improved their quality. DISCUSSION: In summary, diagnosis assistance systems are promising approaches to provide physicians in countries with restricted resources with lists of probable differential diagnoses, thus increasing the plausibility of the diagnosis of the consultant pathologist.

Making cytological diagnoses on digital images using the iPath network.

BACKGROUND: The iPath telemedicine platform Basel is mainly used for histological and cytological consultations, but also serves as a valuable learning tool. AIM: To study the level of accuracy in making diagnoses based on still images achieved by experienced cytopathologists, to identify limiting factors, and to provide a cytological image series as a learning set. METHOD: Images from 167 consecutive cytological specimens of different origin were uploaded on the iPath platform and evaluated by four cytopathologists. Only wet-fixed and well-stained specimens were used. The consultants made specific diagnoses and categorized each as benign, suspicious or malignant. RESULTS: For all consultants, specificity and sensitivity regarding categorized diagnoses were 83-92 and 85-93%, respectively; the overall accuracy was 88-90%. The interobserver agreement was substantial (κ = 0.791). The lowest rate of concordance was achieved in urine and bladder washings and in the identification of benign lesions. CONCLUSION: Using a digital image set for diagnostic purposes implies that even under optimal conditions the accuracy rate will not exceed to 80-90%, mainly because of lacking supportive immunocytochemical or molecular tests. This limitation does not disqualify digital images for teleconsulting or as a learning aid. The series of images used for the study are open to the public at http://pathorama.wordpress.com/extragenital-cytology-2013/.

Telecytological diagnosis of space-occupying lesions of the liver.

OBJECTIVE: In this study, the efficiency of telemedical consulting with regard to fine needle aspirates from space-occupying lesions (SOLs) of the liver is investigated for the first time. STUDY DESIGN: The study includes fine needle aspirations from 62 patients, 33 with hepatocellular carcinoma (HCC) and 29 with non-hepatic tumors. Using the Internet-based iPath system, the initial pathologist submitted 1-8 images from smears and cell block sections. One consultant assessed the cytological and another one the histological images. Both made their diagnoses independent of each other. A final diagnosis was made by immunochemistry of cell block sections. The cytological images were analyzed retrospectively for the occurrence of the most typical HCC indicators. The number of these indicators was related to the initial diagnoses of the three pathologists, and possible reasons for diagnostic errors were analyzed based on this analysis. RESULTS: The accuracy of the preliminary telemedical diagnoses regarding HCC was 82.0% for the cytological images and 87.7% for the histological images. Most of the false diagnoses occurred in tumors with unusual cytological and histological patterns. CONCLUSIONS: Telemedical consulting is a valuable tool to obtain a second opinion. However, for improvement of the diagnosis of HCC, supplementary immunochemical tests are necessary.

Co-incident BK and Epstein-Barr virus replication in a 3-year-old immunocompetent boy.

We present a unique case of infectious mononucleosis attended with transient asymptomatic BK virus (BKV) manifestation in the urine of an immunocompetent caucasian boy without kidney dysfunction. The urine sediment showed abundant decoy cells initially misdiagnosed as malignant cancer cells. This case demonstrates that the occurrence of polyoma-BKV bearing decoy cells is self-limiting and not necessarily associated with overt kidney disease in an immunocompetent child. The shedding of decoy cells into the urine might be promoted by viral co-infections modulating the host's immune response such as infectious mononucleosis.

The prognostic value of cytology and fluorescence in situ hybridization in the follow-up of nonmuscle-invasive bladder cancer after intravesical Bacillus Calmette-Guérin therapy.

Molecular markers reliably predicting failure or success of Bacillus Calmette-Guérin (BCG) in the treatment of nonmuscle-invasive urothelial bladder cancer (NMIBC) are lacking. The aim of our study was to evaluate the value of cytology and chromosomal aberrations detected by fluorescence in situ hybridization (FISH) in predicting failure to BCG therapy. Sixty-eight patients with NMIBC were prospectively recruited. Bladder washings collected before and after BCG instillation were analyzed by conventional cytology and by multitarget FISH assay (UroVysion, Abbott/Vysis, Des Plaines, IL) for aberrations of chromosomes 3, 7, 17 and 9p21. Persistent and recurrent bladder cancers were defined as positive events during follow-up. Twenty-six of 68 (38%) NMIBC failed to BCG. Both positive post-BCG cytology and positive post-BCG FISH were significantly associated with failure of BCG (hazard ratio (HR)= 5.1 and HR= 5.6, respectively; p < 0.001 each) when compared to those with negative results. In the subgroup of nondefinitive cytology (all except those with unequivocally positive cytology), FISH was superior to cytology as a marker of relapse (HR= 6.2 and 1.4, respectively). Cytology and FISH in post-BCG bladder washings are highly interrelated and a positive result predicts failure to BCG therapy in patients with NMIBC equally well. FISH is most useful in the diagnostically less certain cytology categories but does not provide additional information in clearly malignant cytology.

Bronchoalveolar lavage quality influences the T4/T8 ratio in sarcoidosis.

BACKGROUND: Sarcoidosis is characterised by a T-lymphocytic alveolitis with a typically increased T4/T8 ratio. The diagnostic value of this ratio is under debate. AIM OF THE WORK: We prospectively evaluated the influence of BAL pre-lavage and the impact of bronchial contamination on BAL differential cell count in 108 BAL specimens obtained from patients with histologically confirmed sarcoidosis. METHODS: BAL was performed by instilling 150-300 ml normal saline either in the middle lobe or the lingula. Fifty-one patients (47%) underwent additional pre-lavage with 50 ml normal saline. Bronchial contamination was assessed by semi-quantitative analysis of mucus, ciliated and squamous cells in the untreated BAL recovery. RESULTS: Pre-lavage did neither influence the lavage cellularity nor extend of contamination of the BAL. Content of mucus and ciliated cells, indicating bronchial contamination, showed a high correlation (Kendal's tau=0.61). Presence of either mucus or ciliated cells in the BAL recovery was associated with a significant lower T4/T8 ratio (mucus: 4.9 vs. 8.0, p=0.009; ciliated cells: 4.1 vs. 7.4, p=0.001). Squamous cells in the BAL recovery representing oropharyngeal contamination did not significantly influence the T4/T8 ratio (7.7 vs. 5.6, p=0.10). CONCLUSION: Bronchial contamination of BAL as determined by the presence of mucus and ciliated cells in the recovery decreases the T4/T8 ratio of BAL in sarcoidosis.

Nuclear and cytoplasmic Maspin expression in primary non-small cell lung cancer.

AIM: To investigate whether nuclear and cytoplasmic Maspin expression is associated with distinct clinicopathological parameters and TP53 expression in a representative series of primary non-small cell lung cancer (NSCLC). METHODS: Tissue microarrays (n=487) were used to immunohistochemically analyse expression of Maspin and TP53. Cytoplasmic and nuclear expression of Maspin was scored on the basis of the percentage of positive tumour cells. Univariate analysis of clinicopathological variables potentially affecting tumour-specific survival was performed. RESULTS: Immunohistochemical Maspin expression (nuclear and cytoplasmic) was informative in 72.3% (352/487) of cases. Cytoplasmic and nuclear Maspin immunoreactivity in >or=10% of tumour cells was detected in 37.8% (133/352) and 65.3% (230/352) of informative cases, respectively. Nuclear and cytoplasmic Maspin staining was observed more frequently in primary squamous cell carcinomas than in other lung cancer types. Only nuclear Maspin immunoreactivity was significantly associated with positive TP53 staining. Cytoplasmic or nuclear Maspin expression was not associated with tumour-specific survival. CONCLUSION: Maspin expression was found both in the nucleus and the cytoplasm of NSCLC, more frequently in squamous cell carcinomas. However, no association with tumour-specific survival could be demonstrated.

An online quiz uncovers limitations of morphology in equivocal lung cytology.

BACKGROUND: Equivocal atypia in respiratory cytology can be a diagnostic challenge. In such cases fluorescence in situ hybridization (FISH) may be used for the analysis of chromosomal aberrations and often allows a reliable distinction of benign and malignant cells. METHODS: An online picture gallery of 30 respiratory cytologic preparations comprising 23 specimens with equivocal cytology as well as 5 positive and 2 negative controls was prepared (www.unibas.ch/patho/lungenzyto/loesung). The final diagnoses were confirmed by clinical follow-up or biopsy or both. Each of the illustrated cell groups was analyzed by multitarget FISH after PAP image capturing and automatic relocalization. RESULTS: The online questionnaire was completed by 137 cytomorphologists from all continents. The control cases were assessed accurately to a significantly higher percentage than the equivocal cases. In equivocal cases participants more often made false-positive than false-negative diagnoses. In 2 patients with benign conditions (tuberculosis and pulmonary capillaritis) the rate of false-positive answers was remarkably high (31.4% and 62.8% respectively). The result of the 20 best-performing participants for the 5 cases with the highest percentage of inaccurate answers was not better than if they had chosen their answer by chance. CONCLUSIONS: These data illustrate that single cells or cell clusters of a subgroup of equivocal lung cytology are a diagnostic challenge even for highly experienced morphologists. Internet-based tests are able to reveal limitations of cytomorphology.

An international telecytologic quiz on urinary cytology reveals educational deficits and absence of a commonly used classification system.

Urinary cytology is limited by high interobserver variability in the evaluation of cells with little atypia. We set up an online quiz on urinary cytology and tested the performance of 246 international participants. The quiz consisted of still images of 42 urinary specimens with equivocal morphologic features and 10 control cases with an unequivocal cytologic diagnosis. The nature of the cells on the 292 quiz images had been verified by multitarget fluorescence in situ hybridization in addition to the information obtained by cystoscopy, clinical follow up, and/or histologic examination. The original quiz cases and the percentage of answers given by the participants can be viewed at: http://kathrin.unibas.ch/urinzyto/. High-grade cancers were diagnosed correctly in 76.0% and low-grade cancers in only 33.9%. Remarkably, 54.5% of all participants misclassified decoy cells as malignant. This study shows that large-scale international online quizzes may be used to find educational deficits in cytopathology.

Multitarget FISH analysis in the diagnosis of lung cancer.

The aim of the present study was to explore the diagnostic usefulness of the multitarget fluorescence in situ hybridization (FISH) test, LAVysion (Vysis, Downers Grove, IL), for the detection of lung cancer cells in cytologic specimens. Specimens from bronchial washings, bronchial brushings, and transbronchial fine-needle aspirates (TBNAs) from 100 patients with suspected lung cancer and from a control group of 71 patients with nonneoplastic lung disorders were analyzed. FISH positivity was defined as more than 5 cells with gains of at least 2 chromosomes or gene loci. FISH significantly improved the sensitivity of bronchial brushings from 49% to 73%. The specificities of FISH and cytologic examination were 87% and 100%, respectively. In contrast, FISH provided no additional diagnostic information in TBNAs and bronchial washings. There was no increased prevalence of genetic changes in contralateral bronchial washings from patients with lung cancer compared with the control group. The quantity of previous smoking had no effect on the prevalence of chromosomal changes.

Differential diagnosis of kidney transplant rejection and cyclosporin/tacrolimus nephropathy using urine cytology.

A total of 9000 urine samples from 69 kidney transplant recipients were studied for differential diagnoses of transplant rejection and cyclosporin/tacrolimus toxicity. New-Sternheimer and Papanicolaou staining were used to differentiate cells in urine. We also employed an immunocytochemical technique for further identification of exfoliated cells. With New-Sternheimer and Papanicolaou staining, the predominance of proximal tubular cells was useful to differentiate cyclosporin/tacrolimus toxicity from acute rejection in cases of increased serum creatinine level. During rejection episodes, an increased number of mononuclear cells and renal epithelial cells were found. Immunocytochemical analysis showed a significant increase of CD2-, CD4- CD8-, CD25- and HLA-DR-positive cells with rejection. However, there was no relationship between Banff criteria rejection grade and the increase of mononuclear cells.

DNA image cytometry and fluorescence in situ hybridization for noninvasive detection of urothelial tumors in voided urine.

BACKGROUND: Cystoscopy and histologic examination remain the standard methods for initial tumor diagnosis and monitoring for early detection of recurrences, since the sensitivity of conventional urinary cytology for the detection of urothelial tumors in urinary specimens is low. DNA image cytometry (ICM) and fluorescence in situ hybridization (FISH) have been suggested as ancillary tools. The goal of the current study was to compare the diagnostic value of DNA image cytometry and FISH for the noninvasive detection of urothelial tumors in voided urine. METHODS: Cytospin preparations were prepared from voided urine collected prior to the resection of 26 noninvasive (pTa) and 11 invasive (pT1-2) tumors. Specimens from 14 patients with benign prostatic hyperplasia were used as negative controls. DNA ICM was performed using the AUTOCYTE trade mark cell analytical system on Feulgen-stained cytospin specimens. The commercially available UroVysion trade mark FISH multiprobe was used to analyze chromosomes 3, 7, and 17, and 9p21. RESULTS: The overall sensitivity of cytology improved from 24% to 54% and to 78% if supplemented by ICM or FISH, respectively. Image cytometry detected all invasive tumors (pT1-2), while FISH missed one; FISH identified 19 of 26 (73%) pTa tumors, while only 9 (35%) of these tumors were aneuploid by ICM. The results of ICM and FISH were concordant in 37 of 51 (72%) cases. CONCLUSIONS: The current study shows that both FISH and ICM can successfully be used as supplementary methods to detect the clinically most relevant group of invasive bladder carcinomas. However, UroVysion FISH is more sensitive in the detection of pTa tumors than ICM, as it recognizes individual chromosomal alterations that frequently prevail in urothelial tumors.

Tissue microarray evaluation of Melanoma antigen E (MAGE) tumor-associated antigen expression: potential indications for specific immunotherapy and prognostic relevance in squamous cell lung carcinoma.

OBJECTIVE: To evaluate MAGE tumor-associated antigen (TAA) expression in an extensive panel of normal and neoplastic tissues. SUMMARY BACKGROUND DATA: TAAs of the MAGE family represent targets of active specific immunotherapy. Limited-size studies indicate that they are expressed in normal testis and tumors of different histologies. High-throughput tissue microarray (TMA) technology and MAGE TAA-specific monoclonal antibodies now allow us to comprehensively evaluate their expression in large numbers of tissues and to address clinical correlations. METHODS: A TMA containing 3,520 samples from 197 different tissues and a non-small-cell lung cancer TMA including 301 specimens were stained using the MAGE TAA-specific monoclonal antibody 57B. For patients with squamous cell carcinoma of the lung, the dichotomous result (positive vs. negative) of MAGE TAA staining was used as a predictor variable along with other covariates in proportional hazard regression analysis of tumor-specific survival. RESULTS: MAGE TAAs are expressed with frequencies ranging between 22.7% (larynx) and 50% of cases (lung) in squamous cell carcinomas from different anatomic areas and in large cell carcinomas of the lung (37.9%). The authors provide here the first description of MAGE TAA expression in basalioma (48.1%). To investigate the clinical significance of MAGE expression in a frequently positive tumor type, a non-small-cell lung cancer, TMA was then studied. In this TMA 43.2% of tumors were 57B positive. In patients with squamous cell carcinoma, MAGE TAA positivity was significantly correlated with a shorter tumor-specific survival in the proportional hazard regression analysis model. CONCLUSIONS: These data suggest novel potential therapeutic indications in different types of cancers. In lung squamous cell carcinoma, the significant association of MAGE TAA expression with poor prognosis suggests that patients with 57B-positive tumors may benefit from early, specific immunotherapy procedures.

A fluorescence in situ hybridization-based assay for improved detection of lung cancer cells in bronchial washing specimens.

BACKGROUND: Interphase fluorescence in situ hybridization (FISH) is a powerful tool for detecting chromosome and locus-specific changes in tumor cells. We developed a FISH-based assay to detect genetic changes in bronchial washing specimens of lung carcinoma patients. METHODS: The assay uses a mixture of fluorescently labeled probes to the centromeric region of chromosome 1 and to the 5p15, 8q24 (site of the c-myc gene), and 7p12 (site of the EGFR gene) loci to assess cells in bronchial washing specimens for chromosomal abnormalities indicative of lung carcinoma. The FISH assay was performed on 74 specimens that had been assessed previously for evidence of malignancy by routine cytology with Pap staining. RESULTS: Forty-eight patients had histologically confirmed lung carcinoma and 26 patients had a clinical diagnosis that was negative for lung carcinoma. FISH analysis was performed without knowledge of the patient's clinical information. The finding of six or more epithelial cells with gains of two or more chromosome regions was considered a positive FISH result (i.e., evidence of malignancy). The sensitivity of FISH for the detection of lung carcinoma was 82% in this set of specimens compared with a 54% sensitivity by design for cytology (FISH vs. cytology, P = 0.007). FISH detected 15 of 18 specimens that were falsely negative by cytology. The specificities of FISH and cytology were 82% and 100%, respectively, and were not significantly different (P = 0.993). CONCLUSIONS: The data indicate a potential utility of the FISH assay as an adjunct to bronchial washing cytology in routine clinical practice.