Assessment of endometrial sampling as a predictor of final surgical pathology in endometrial cancer.

BACKGROUND: The histology and grade of endometrial cancer are important predictors of disease outcome and of the likelihood of nodal involvement. In most centres, however, surgical staging decisions are based on a preoperative biopsy. The objective of this study was to assess the concordance between the preoperative histology and that of the hysterectomy specimen in endometrial cancer. METHODS: Patients treated for endometrial cancer during a 10-year period at a tertiary cancer centre were identified from a prospectively collected pathological database. All pathology reports were reviewed to confirm centralised reporting of the original sampling or biopsy specimens; patients whose biopsies were not reviewed by a dedicated gynaecological pathologist at the treating centre were excluded. Surgical pathology data including histology, grade, depth of myometrial invasion, cervical stromal involvement and lymphovascular space invasion (LVSI) as well as preoperative histology and grade were collected. Preoperative and final tumour cell type and grade were compared and the distribution of other high-risk features was analysed. RESULTS: A total of 1329 consecutive patients were identified; 653 patients had a centrally reviewed epithelial endometrial cancer on their original biopsy, and are included in this study. Of 255 patients whose biopsies were read as grade 1 (G1) adenocarcinoma, 45 (18%) were upgraded to grade 2 (G2) on final pathology, 6 (2%) were upgraded to grade 3 (G3) and 5 (2%) were read as a non-endometrioid high-grade histology. Overall, of 255 tumours classified as G1 endometrioid cancers on biopsy, 74 (29%) were either found to be low-grade (G1-2) tumours with deep myometrial invasion, or were reclassified as high-grade cancers (G3 or non-endometrioid histologies) on final surgical pathology. Despite these shifts, we calculate that omitting surgical staging in preoperatively diagnosed G1 endometrioid cancers without deep myometrial invasion would result in missing nodal involvement in only 1% of cases. CONCLUSIONS: Preoperative endometrial sampling is only a modest predictor of surgical pathology features in endometrial cancer and may underestimate the risk of disease spread and recurrence. In spite of frequent shifts in postoperative vs preoperative histological assessment, the predicted rate of missed nodal metastases with a selective staging policy remains low.

Sentinel lymph node biopsy vs. pelvic lymphadenectomy in early stage cervical cancer: is it time to change the gold standard?

OBJECTIVE: To compare the incidence of pelvic lymph node metastases in early stage cervical cancer patients undergoing sentinel lymph node biopsy (SLN) to a matched cohort undergoing pelvic lymphadenectomy. METHODS: All patient data were entered prospectively into an ongoing cervical cancer database. Since April 2004, 87 patients with FIGO stage IA/B1 cervical cancer underwent SLN detection with identification of bilateral SLN. This cohort (cases) was compared to a matched group of patients who underwent complete pelvic lymphadenectomy (controls). The groups were matched 3:1 for tumour size (+/-5 mm), histology, depth of invasion (+/-2 mm), and presence of capillary lymphatic space invasion (CLS). Descriptive statistics were calculated for all variables of interest. The association between cases and controls and lymph node metastases was carried out using a conditional logistic regression analysis. RESULTS: 81 women in the SLN cohort were matched with 1 control, 72 cases with 2 controls, and 65 cases with 3 controls. Among cases, 14 (17%) had pelvic lymph nodes metastases vs. 15 (7%) in the controls (p=0.0059, odds ratio= 2.8, 95% CI=1.3-5.9). Among the 14 cases of SLN metastases, 11 were detected by frozen section and 3 were detected on final paraffin sectioning. All were detected by H and E stains. The size of the SLN metastases ranged from less than 1 mm to 8 mm. CONCLUSIONS: Sentinel lymph node biopsy in early cervical cancer is a more sensitive procedure in detecting pelvic lymph node metastases compared to complete lymphadenectomy.

Polypoid or non-polypoid? A novel dichotomous approach to uterine carcinosarcoma.

OBJECTIVE: To examine the impact of the polypoid morphology of uterine carcinosarcoma on clinical outcome, as well as its relationship to well-established prognostic factors. METHODS: In a retrospective study of fifty eight patients with uterine carcinosarcoma treated with hysterectomy, we correlated the polypoid status of tumors with stage, lymphatic vascular invasion, myometrial invasion, size, carcinoma to sarcoma ratio, type of carcinomatous and sarcomatous components, disease free survival and overall survival. RESULTS: By multivariate analysis, the polypoid status had no impact on disease free survival (p=0.8958), but approached significance as a positive predictor for overall survival (p=0.0569); patients in the polypoid group lived on average 14.9 months longer than those with non-polypoid tumors. Polypoid neoplasms had a smaller average size and grew to a smaller maximum size than the non-polypoid tumors. While non-polypoid tumors were either carcinoma or sarcoma predominant, polypoid tumors were mostly sarcoma predominant (p=0.0348). Polypoid carcinosarcomas also demonstrated an appreciably lesser extent of myometrial invasion (p=0.0019), a markedly lower rate of lymphatic vascular invasion (p=0.0002), and tended to present as early stage tumors (p=0.0265). Carcinomatous component in polypoid tumors tended to have pure or nearly pure (>or=90%) endometrioid histology (p=0.1608). There was no relationship between polypoid status and type of sarcomatous component (p=0.5299). CONCLUSIONS: Polypoid carcinosarcomas differ from their non-polypoid counterparts in key histological parameters such as the carcinoma to sarcoma ratio, myometrial and lymphatic vascular invasion, stage and type of carcinomatous component. Patients with polypoid tumors may have a better survival outcome than those with non-polypoid tumors.

Intraoperative margin assessment of the radical trachelectomy specimen.

OBJECTIVE: To summarize our experience in the frozen section (FS) assessment of the trachelectomy surgical margin. METHODS: All surgeries from 1994 to 2007 were performed by one surgeon. The FS examination was consistently carried out by a group of gynecologic pathologists according to the protocol described in details in this article. Cases were retrieved from the pathology files and the slides were reviewed by two pathologists. RESULTS: 132 patients were identified with complete pathology records. They ranged from 17 to 46 years old (median 31). Surgeries were performed for clinical Stages 1A (n=39) and 1B (n=93) tumors (63 adenocarcinoma, 59 squamous cell carcinoma, 7 adenosquamous and 3 others). In 78 cases, no residual tumor was seen in the trachelectomy specimens as it was resected by the preceding LEEP or cone. The margin was reported as negative in 123, suspicious in 3 and positive in 6 cases. It was revised in 16 cases (6 positive, 2 suspicious and 8 negative but <5 mm). Final margin assessment agreed with the FS diagnosis in 130 (98.5%) and showed interpretational overcall in 2 cases (1.5%); only one of which resulted in a revised margin. No false negative intraoperative assessment was found. CONCLUSIONS: We describe our FS protocol and summarize our data. This protocol is reliable since none of the patients was under-treated.

Ipsilateral open anterior hip dislocation and avulsion fracture of the greater trochanter: An unusual case report.

Approximately 3% of all joint dislocations involve the hip joint, and only 8-10% of these will be anterior. Traumatic anterior open dislocation of the hip is rare in children and prone to be associated with injuries, extensive soft tissue damage, and avascular necrosis of the femoral head. We present a case of a 13-year-old boy who had an open anterior dislocation of the hip with ipsilateral avulsion of the greater trochanter after a tractor wheel crush in an agricultural accident. Additional lesions included a diaphyseal closed fracture of the contralateral femur. We report this case because of the rarity and seriousness of this injury due to its progressive complications and difficulties related to its management.

Ramifications of protease-based liquefaction of camel semen on physical, kinematic and surface glyco-pattern of cryopreserved spermatozoa.

The efficiency of incorporating different proteases in the diluent for reducing camel semen viscosity, and subsequent ramifications on morpho-functional and glycan surface properties of cryopreserved spermatozoa were investigated. Ejaculates (n = 48) were collected from three adult camels, Camelus dromedarius, during the breeding season (January - March). A portion of each raw ejaculate was evaluated for sperm physical and morphological traits, whereas the other portion was divided into three aliquots assigned for the following liquefaction treatments: control (untreated), 0.1 mg/mL papain or 5 U/mL bromelain. All samples were diluted with Tris-lactose diluent containing the anti-enzyme E-64 to neutralize both proteases before being processed for cryopreservation. Post-thaw physical and kinematic properties of spermatozoa were analyzed using a computer-assisted sperm analysis (CASA) system. The sperm surface glycocalyx pattern was evaluated with a panel of 14 fluorescent lectins. Although bromelain was more effective in elimination of semen viscosity, there was a negative correlation between bromelain supplementation and values for the variables: normal sperm, intact acrosome and intact sperm cell membrane. Bromelain supplementation, compared to papain-treated and control samples, was positively correlated with secondary sperm abnormalities, increased straight-line velocity (VSL, µm/s) and straightness (%) of spermatozoa. Results from the glycan analysis indicated that both proteases did not affect the N-linked glycan content of the entire sperm surface, whereas the treatment with proteases induced little change in N-acetylgalactosamine and fucose terminating glycans in the tail region of the sperm. Functional studies are needed to evaluate the sperm fertility rates of bromelain- and papain-treated semen for application in camel assisted reproductive technologies.

Radical vaginal trachelectomy vs. radical hysterectomy for small early stage cervical cancer: a matched case-control study.

OBJECTIVE: To determine the efficacy and outcome from radical vaginal trachelectomy (RVT) compared to a matched group of patients undergoing radical hysterectomy for small early stage cervical cancer. METHODS: All patient data were entered prospectively. Patients wishing preservation of fertility with cervical cancer, tumor <2 cm, and not meeting the definition of microinvasive cancer were offered RVT. The outcomes were compared to a matched group of patients who underwent radical hysterectomy for stage IA/IB cervical cancer. Groups were matched 1:1 for age (+/-5 years), tumor size (+/-1 mm), histology, grade, depth of invasion (+/-1 mm), presence of capillary lymphatic space invasion, pelvic lymph node metastasis, and adjuvant radiotherapy. RESULTS: A total of 137 patients underwent RVT between 1994 and 2007. Of them, 90 patients were successfully matched. Median tumor size was microscopic. Moreover, 43% and 49% were squamous and had adeno/adenosquamous histology. Median depth of invasion was 3.1 mm. Capillary lymphatic space invasion was present in 68% of cases. Of the tumors, 60% were grade 1, 29% were grade 2, and 11% were grade 3. After a median follow-up of 51 and 58 months, 5 and 1 recurrences were diagnosed in the RVT and radical hysterectomy groups, respectively. Five-year recurrence-free survival rates were present in 95% and 100% of the groups, respectively (p=0.17). In addition, 3 and 1 deaths occurred in the RVT and radical hysterectomy groups, resulting in 5-year survival rates of 99% and 100%, respectively (p=0.55). CONCLUSIONS: RVT seems to be the procedure of choice for women with small early stage cervical cancers wishing to preserve fertility.

What are the CD34+ cells in benign peripheral nerve sheath tumors? Double immunostaining study of CD34 and S-100 protein.

To determine whether CD34 expression in nerve sheath lesions was found in a unique cell population or in a subset of nerve sheath cells, we performed double immunohistochemical staining using a standard avidinbiotin complex method with 2 separate color developing systems. We studied 40 neurofibromas and 16 neurilemomas. All lesions strongly expressed S-100 in nuclei and cytoplasm. CD34 was detected in cells having ameboid dendritic cytoplasm present in greatest numbers in Antoni B zones of neurilemomas, myxoid zones of neurofibromas, at the periphery of lobules in both tumor types, and condensed in apposition to perineurium. The CD34+ cells also were detected in normal nerves. They were infrequent in Antoni A zones of neurilemomas. No dual S-100 and CD34 expression was seen. This double immunostaining confirms the presence of a CD34-reactive non-Schwannian cell type in these neural neoplasms. As the CD34+, S-100-negative cell population is present also in normal nerves and infrequently seen in the areas of cellular neoplastic Schwann cells, CD34+, S-100-negative cells in peripheral nerve sheath tumors most likely are nonneoplastic and may have a supportive function.

Polishing the posterior capsule after extracapsular extraction of senile cataract.

Posterior capsular polishing is performed to delay or prevent capsular opacification. To study its effectiveness, a prospective study of 412 patients with bilateral senile cataracts was conducted. Each patient had bilateral extracapsular cataract extraction with laser ridge, posterior chamber lens implantation. The right eye of each patient had posterior capsular polishing using the Tennessee-Freeman polisher. The posterior capsule in the left eye was not polished. All patients above the age of 80 years (22 patients) had bilateral opacification within 16 months postoperatively. For patients less than 80 years old (390 patients), the cumulative capsulotomy rate in the polished capsule group was 9.2% (36 eyes); in the unpolished capsule group the rate was 12.0% (47 eyes) for the same follow-up time (average 30 months). There was no statistical difference in the incidence of posterior capsular opacification between the polished and unpolished groups. Polishing the posterior capsule after lens cortex cleaning had no significant role in delaying or preventing capsular opacification.

The occurrence of endometrial adenocarcinoma in a patient with basal cell nevus syndrome.

Basal cell nevus syndrome is rare multisystem disorder. Its genital implications in female patients is thought to be limited to ovarian fibroma. This article describes endometrial adenocarcinoma in association with basal cell nevus syndrome in a 37-year-old female with multiple basal cell carcinomas, mandibular and maxillary bone cysts, right ovarian fibroma, and scoliosis. Histopathologic examination of her endometrial biopsy, performed for irregular uterine bleeding, revealed endometrial hyperplasia. Her bleeding failed to respond to progestin therapy, and a repeat endometrial biopsy revealed a well differentiated endometrial adenocarcinoma. Health-care providers are encouraged to refer these patients to gynecologists. Regular gynecologic examination as well as appropriate evaluation of abnormal menstrual bleeding should be emphasized.

Interpretation of multiple isolate urine cultures in adult male patients.

A retrospective analytical study examined the records of 220 adult males (mean age 64.9 years) to determine the relative probability that multiple urine culture isolates (MUI) represent urinary tract infection (UTI) versus contamination or colonization. Nonculture laboratory data were used to determine the likelihood of UTI. Patients were classified into three categories: group 1 (those with single isolate cultures; n = 110), group 2 (those with MUI and either symptomatic UTI or an underlying pathologic condition; n = 71) and group 3 (those with MUI and either surgically altered urinary passages or absence of UTI symptoms; n = 39). Nonculture laboratory data suggested UTI in 48.2% of patients in group 1, 46.5% in group 2, and 23.1% in group 3. Patients in groups 1 or 2 with cultures yielding isolate counts of 10(5) colony forming units/mL were 6.2 times more likely to be classified as having a UTI (by nonculture laboratory data) compared with patients having only one or more of these two criteria. This study proposes a more objective approach to interpretation of MUI cultures using the results of nonculture laboratory data, clinical profiles, and colony counts.

Tympano-cartilago-stapediopexy: a method to improve hearing in open technique tympanoplasty.

Canal wall-down technique tympanoplasty was indicated in about 41 per cent of our cases with chronic suppurative otitis media. In this series done during the last four years, of 576 tympanoplasties, 240 cases needed type III tympanoplasty. In 145 cases, myringostapediopexy was carried out using temporalis fascia grafting over the head of the stapes. Tympano-cartilago-stapediopexy was performed in the other 95 cases by using tragal cartilage and perichondrium over the stapes. A comparison between the results of both methods of grafting is discussed. Improvement in hearing was achieved after tympano-cartilago-stapediopexy. This method proved to be suitable for those cases which need open technique tympanoplasty.

Interobserver agreement for endometrial cancer characteristics evaluated on biopsy material.

A shift toward a disease-based therapy designed according to patterns of failure and likelihood of nodal involvement predicted by pathologic determinants has recently led to considering a selective approach to lymphadenectomy for endometrial cancer. Therefore, it became critical to examine reproducibility of diagnosing the key determinants of risk, on preoperative endometrial tissue samples as well as the concordance between preoperative and postresection specimens. Six gynaecologic pathologists assessed 105 consecutive endometrial biopsies originally reported as positive for endometrial cancer for cell type (endometrioid versus nonendometrioid), tumor grade (FIGO 3-tiered and 2-tiered), nuclear grade, and risk category (low risk defined as endometrioid histology, grade 1 + 2 and nuclear grade <3). Interrater agreement levels were substantial for identification of nonendometrioid histology (κ = 0.63; SE = 0.025), high tumor grade (κ = 0.64; SE = 0.025), and risk category (κ = 0.66; SE = 0.025). The overall agreement was fair for nuclear grade (κ = 0.21; SE = 0.025). There is agreement amongst pathologists in identifying high-risk pathologic determinants on endometrial cancer biopsies, and these highly correlate with postresection specimens. This is ascertainment prerequisite adaptation of the paradigm shift in surgical staging of patients with endometrial cancer.

Microscopic observation drug susceptibility assay in the diagnosis of multidrug-resistant tuberculosis.

BACKGROUND: Early detection of multidrug-resistant Mycobacterium tuberculosis (MDR-TB) is of primary importance for both patient management and infection control. Optimal methods for identifying MDR-TB in a timely and affordable manner in resource-limited settings are not yet available. OBJECTIVES: To evaluate the performance of a low-technology but rapid drug susceptibility testing method, the microscopic observation drug susceptibility assay (MODS), in the concurrent detection of M. tuberculosis and its susceptibility to isoniazid (INH) and rifampin (RMP) directly from sputum specimens. METHODS: A total of 115 smear-positive TB patients admitted to Abbasia Chest Hospital, Cairo, Egypt, were simultaneously tested using MODS and the BACTEC MGIT 960 mycobacterial detection system for the detection of M. tuberculosis and the identification of MDR-TB samples. RESULTS: MODS detected 112 (97.4%) samples and BACTEC MGIT detected 115 (100%). Of the 115 isolates tested for susceptibility to INH, RMP and MDR-TB, complete agreement between MODS and MGIT results was found among respectively 92.9%, 95.5% and 97.3% of samples. The sensitivity, specificity, and positive and negative predictive values of MODS in the detection of MDR-TB were respectively 95.3%, 98.6%, 97.6% and 97.1%. MODS results were obtained in a median of 8 days (range 5-21). CONCLUSION: MODS is an optimal alternative method for timely and affordable identification of MDR-TB in resource-limited settings.

Androgenetic complete mole with trisomy 13: report of a case with microsatellite genotyping and review of the literature.

Hydatidiform moles are gestational diseases with abnormal development of the villous trophoblast and characterized by an excess of paternal to maternal genetic material. Complete moles are usually diploid and androgenetic, and are thought to develop after the fertilization of an "empty ovum" by either a haploid spermatozoon or two spermatozoa. We report a case of a complete mole in which fluorescence in situ hybridization (FISH) incidentally disclosed trisomy 13. Microsatellite genotyping showed a single allele at each of the markers tested on the chorionic villi, and comparison with parental peripheral blood specimens revealed that the markers were all of paternal origin. These results confirmed the paternal origin of all three copies of chromosome 13, and the isodisomy for each chromosome was consistent with duplication of a monospermic fertilization event and subsequent non-disjunction. To the best of our knowledge, this is the only case of an androgenetic complete mole with trisomy 13 described in the scientific literature. We present a review of the literature and hypothesize that the trisomy 13 in our case likely resulted from non-disjunction of chromosome 13.

Peripheral blood candidosis infection leading to spurious platelet and white blood cell counts.

We report a patient with thrombocytopenia secondary to disseminated stomach adenocarcinoma and sepsis whose platelet and white blood cells were falsely enumerated by two automated haematology analyzers. The cause of the spurious counts became obvious when numerous yeast forms were observed on the peripheral blood smear. Artefactual automated analyzer results are detailed.

Detection of local failures after management of nasopharyngeal carcinoma: a prospective, controlled trial.

OBJECTIVES: To conduct a prospective study (1) to evaluate and compare the efficacies of nasopharyngeal endoscopy and computed tomography in the diagnosis of local failure of external beam radiotherapy for nasopharyngeal carcinoma, and (2) to assess whether multiple endoscopic nasopharyngeal biopsies are superior to a single, targeted biopsy, for the same purpose. METHODS: Forty-six patients who had been treated with external beam radiotherapy for primary nasopharyngeal carcinoma were enrolled in the study. For every patient recruited, computed tomography, rigid nasopharyngeal endoscopy and nasopharyngeal biopsies were performed 12 weeks after radiotherapy. RESULTS: Twelve weeks after treatment, six patients (13 per cent) had evident disease on histological examination of biopsies. Nasopharyngeal endoscopy showed a sensitivity, specificity, positive predictive value and negative predictive value of 66.6, 95, 66.6 and 95 per cent, respectively. There was statistically significant agreement between the endoscopic findings and the histological findings (Kappa reliability coefficient = 0.617, p < 0.01). Computed tomography showed a sensitivity, specificity, positive predictive value and negative predictive value of 50, 45, 12 and 85.7 per cent, respectively. There was no statistically significant agreement between the computed tomography findings and the histological findings (Kappa reliability coefficient = 0.021, p > 0.05). A targeted, single biopsy performed under endoscopic control demonstrated excellent sensitivity, specificity, positive predictive value and negative predictive value, being 83.3, 100, 100 and 97.5 per cent, respectively. The Kappa test showed a very statistically significant agreement between the histological findings for the single and the multiple endoscopic biopsies (Kappa reliability coefficient = 0.897, p < 0.001). CONCLUSIONS: Rigid nasopharyngeal endoscopy should be considered the primary follow-up tool after radiotherapy treatment of nasopharyngeal carcinoma, with computed tomography being reserved for patients with histological or symptomatic indications. Routine postnasal biopsies are not necessary, given the excellent specificity and negative predictive value of rigid nasopharyngeal endoscopy. Single, targeted endoscopic biopsy provides an excellent alternative to the usual multiple biopsies. In addition, it reduces cost, time, morbidity and patient discomfort.

Immunohistochemical characterization of endocervical papillary serous carcinoma.

Endocervical adenocarcinomas are rare and aggressive neoplasms. Papillary serous endocervical adenocarcinomas are the rarest form of endocervical adenocarcinomas. This tumor exhibits morphologic similarities to its counterparts commonly seen in the endometrium, fallopian tubes, ovaries, and peritoneum, which are known to have an aggressive behavior. Because of the rarity of this tumor, little is known about its immunophenotyping. In this study, we included ten cases of papillary serous carcinomas arising from the uterine cervix (PSCC) diagnosed in the absence of a primary endometrial malignancy. We studied their immunohistochemical profile, using a panel of antibodies against Ki67, bcl-2, p53, carcinoembryonic antigen (CEA), and CD10, and compared them to 20 consecutive cases of cervical adenocarcinoma of conventional cell subtypes (CAC) (15 mucinous, 3 adenosquamous, and 2 endometrioid). Immunostaining was recorded semiquantitatively. Patients with PSCC ranged in age from 27 to 79 years (mean = 51.6 +/- 19.1), while the conventional cell subtypes control group were 28-90 years old (mean = 47.5 +/- 16.9). Only p53 and CEA immunostaining significantly correlated with the PSCC morphology (P= 0.001 and P= 0.016, respectively) as shown by Cochran-Mantel-Haenszel Statistics (Modified Ridit Scores). PSCC is a distinctive immunophenotypic subtype of endocervical adenocarcinoma with significantly higher p53 and lower CEA reactivity than other more common histologic subtypes.

Age pattern of fertility in the Sudan.

PIP: Birth registration in the Sudan as in many other developing countries is incomplete and far from accurate. Estimates are based on census or sample survey data. Methods of analysis are applied which are suitable to the kind and quality of the collected information, and data provided by the World Fertility Survey is used. The number of children everborn tabulated by the duration of marriage is used to derive an estimate of the age pattern of fertility. These observed average parities are here used for the estimation of the age specific fertility schedule. The advantages of applying this method to the Sudanese data are mainly due to the greater confidence in the reports of the duration of marriage than in reports of age. It is believed that sociocultural factors in the Sudan help to sustain a high level of fertility. A few of these factors are the high infant mortality rate, the high economic and psychological value of children, and the large preferred family size. In spite of the evidence of some contraceptive use, the effectiveness of such use in reducing fertility is low. Yet the present analysis shows that the level of marital fertility is only 78% of the natural model schedule, a level which is lower than expected. A possible explanation may lie in the high level of maternal morbidity, poor nutritional and hygienic conditions in general and the substantial amount of pregnancy wastage and number of stillbirths, especially for young wives. Adequate antenatal care is lacking or even absent in some areas. These factors may have a negative effect on fecundity. However, the crude birth rate is high. This may be due to the prevalence of the traditional pattern of 1st marriage characterized by early and almost universal marriage of females. The calculated crude birth rate is consistent with the rate calculated by other methods using different data.^ieng