Pathological practice and management of thyroid nodules: a Thai perspective.

Although, in the thyroid field, there have been several internationally standard diagnostic and management guidelines for practitioners from every country to follow but there is still variation among physicians across the globe in taking care of patients and pathology specimens with thyroid nodules due to dissimilar backgrounds of each place. Thailand is one among several countries that tries to maintain standard of care to meet international requirements although, with some limitations, not all recommendations are followed. To understand how approaches of thyroid nodules are performed throughout the country and how the healthcare system of the whole kingdom is managed including what major current limitations, the authors conducted a survey among physicians consisting of surgeons, radiologists and pathologists who are involved in the management of the thyroid lesions by personal phone contact and custom online questionnaires. Performances of fine needle aspiration of different institutes are also evaluated by analyzing the data from available publications and compared their results with other series from the literature. Shortage of pathologists and un-equal resource allocation are the major problems concerning administrative aspect while a lack of awareness in new terminologies or diagnostic systems (e.g., NIFTP, UMP, Bethesda, TI-RADS) among physicians, particularly clinicians, are the problems of training and continuous medical education. Another point of concern is a rather poor performance in fine needle aspiration from the Thai series in which there are high rate (30.5%) of non-diagnostic category (Bethesda I) and false negativity as demonstrated by relatively high risk of malignancy (9.6%) in Bethesda II compared with other series from the literature. Regarding molecular studies, despite their usefulness in improving diagnostic accuracy, especially for cytology specimens, these ancillary tools are not routinely used in our practice since they are available in only few referral centers. This review provided a background information of the perspective on how thyroid nodules are managed in the Thai settings.

The prevalence and surgical outcomes of Hürthle cell lesions in FNAs of the thyroid: A multi-institutional study in 6 Asian countries.

BACKGROUND: Hürthle cell-rich nodules (HCNs) encompass non-neoplastic to malignant lesions. There is paucity of literature on the frequency distribution of HCNs among Bethesda categories, histologic follow-up, risk of malignancy (ROM), and risk of neoplasia (RON). The objective of this retrospective, multi-institutional study was to determine the prevalence of the cytologic diagnostic category and surgical outcomes of patients with HCN. METHODS: Nine tertiary health centers representing 6 Asian countries participated. Cases were retrieved from respective databases. The Bethesda System for Reporting Thyroid Cytopathology was used. Cytology results were correlated with surgical diagnoses. RESULTS: Of 42,190 thyroid aspirates retrieved, 760 (1.8%) had a Hürthle cell predominance. Most (61%) were categorized as atypia of undetermined significance/follicular lesion of undetermined significance, Hürthle cell type" (AUS-H); 35% were categorized as follicular neoplasm, Hürthle cell type (FN-H); and 4% were categorized as suspicious for malignancy (SFM). Histologic follow-up was available for 288 aspirates (38%). Most were benign on resection (66%), and the most common histologic diagnosis was Hürthle cell adenoma (28.5%). The ROM for AUS-H, FN-H, and SFM, as calculated on resected nodules, was 32%, 31%, and 71%, respectively; and the RON was 47%, 81%, and 77%, respectively. The 5 institutions that had an AUS-H:HCN ratio below 0.5 diagnosed HCN less frequently as AUS-H than as FN-H. CONCLUSIONS: This is the largest, contemporary, multi-institutional series of HCNs with surgical follow-up. Although there was wide interinstitutional variation in prevalence and surgical outcomes, there was no significant difference in the ROM among institutions. The categories AUS-H and FN-H had a similar ROM for resected nodules.

Current Status of Thyroid Fine-Needle Aspiration Practice in Thailand.

Thyroid carcinoma is one of the leading malignancies in Thailand increasingly prevalent in the female population. Fine-needle aspiration (FNA) cytology is a widely used diagnostic tool for evaluation of thyroid nodules and thyroid cancer. Thyroid FNA is a routine procedure universally performed in Thai hospitals by a variety of clinical specialists. Manual guidance is the first-line choice complemented by ultrasound assistance in selected cases. Despite national guidelines recommendations, the diagnostic criteria and terminology of the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) was slowly adopted in the local settings. Currently, the Bethesda system is actively promoted by the local professional societies as a uniform reporting system. Experience with thyroid FNA has been rarely reported to date-only a handful of publications are available in local journals. Our review, in addition to presenting various aspects of thyroid FNA in Thailand, established for the first time national references for a certain statistical outputs of TBSRTC based on the original multi-institutional cohort. The risk of malignancy in 2,017 operated thyroid nodules collected from three tertiary thyroid cancer centers was 21.7%, 14.7%, 35.9%, 44.4%, 76.7%, and 92.6% for categories I to VI, respectively. The malignancy risk in several diagnostic categories (II to IV) was higher than the risk estimated by TBSRTC and recent meta-analysis studies. We endorse the use of uniform terminology of the Bethesda system in Thailand, which will help facilitate communication among diverse medical professionals involved in the management of patients with thyroid nodules, to share local experience with the international audience.

False-Negative Rate of Papanicolaou Testing: A National Survey from the Thai Society of Cytology.

OBJECTIVE: To evaluate the performance of Papanicolaou smear screening in Thailand at the national level, and to propose recommendations for continuing quality control. STUDY DESIGN: This study was conducted by The Thai Society of Cytology and involved 124 laboratories in 76 provinces during 2010-2014. Random sampling suggested recalling of 10% of slides defined as negative at routine screenings (10% random rescreening [R10] model) directly from the reading unit. RESULTS: Out of 330,075 smears covered by the rescreening project throughout its 5-year duration, the rates of abnormal, unsatisfactory, and normal results were 0.63, 1.82, and 97.55%, respectively. Abnormal findings were largely represented by ASC-US (54%) and L-SIL (21%). The average false-negative rate (FNR) measured at the level of L-SIL and higher was 13.8%. CONCLUSION: The national project was developed to address the accuracy of cervical cancer screening and to promote internal quality assurance based on the R10, on-site surveys, and education. The major output parameters of this study (FNR and number and distribution of abnormal cases on rescreening) improved significantly in the main phase of the project (2012-2014), after revising substantial logistics issues encountered during the first 2 years of this study. This project provided objective measurable evidence related to the quality of cytology-based cervical cancer screening in Thailand.

Human Papillomavirus infection and cervical lesions in HIV infected women on antiretroviral treatment in Thailand.

OBJECTIVES: To estimate the prevalence and factors associated with Human Papillomavirus (HPV) infection, HPV genotypes and cytological/histological high-grade (HSIL+/CIN2+) lesions. METHODS: We conducted a cross-sectional study within a prospective cohort of HIV-infected women on combination antiretroviral therapy (cART). Cervical specimens were collected for cytology and HPV genotyping (Papillocheck®). Any women with High-Risk-HPV (HR-HPV), and/or potentially HR-HPV (pHR-HPV) and/or ASC-US or higher (ASC-US+) lesions were referred for colposcopy. Factors associated with HR-HPV infection and with HSIL+/CIN2+ lesions were investigated using mixed-effects logistic regression models. RESULTS: 829 women were enrolled: median age 40.4 years, on cART for a median of 6.9 years, median CD4 cell-count 536 cells/mm3, and 788 (96%) with HIV-viral load<50copies/mL. Of 214 (26%) infected with HPV: 159 (19%) had ≥1 HR-HPV, of whom 38 (5%) HPV52, 22 (3%) HPV16, 9 (1%) HPV18; 21 (3%) had pHR-HPV, 34 (4%) low risk-HPV infection, and 56 (26%) had multiple genotypes. Younger age, low CD4 cell-counts and low education were independently associated with HR-HPV infection. 72 women (9%) had ASC-US+ and 28 (3%) HSIL+/CIN2+ lesions. HR-HPV infection was independently associated with HSIL+/CIN2+ lesions. CONCLUSION: The prevalence of HPV infection and of cervical lesions was low. The HPV genotype distribution supports the use of 9-valent vaccine in Thailand.

Hypoglycemic activity of the Anisopus mannii N. E. Br. methanolic leaf extract in normal and alloxan-induced diabetic mice.

The hypoglycemic activities of nine sub-fractions from the methanolic leaf crude extract of Anisopus mannii were investigated in normoglycemic and alloxan-induced diabetic mice. The methanolic sub-fraction M at 400 mg/kg bw showed significantly (p<0.05) high reduction in fasting blood glucose (FBG) at 27.36 and 65.57% in normoglycemic and diabetic mice, respectively. In acute toxicity test, M at 2,000 and 5,000 mg/kg bw showed reduction in blood urea nitrogen and creatinine level, elevations in aspartate transaminase, alanine transaminase and total bilirubin levels, as well as the body weights. The weight-ratios of kidney and liver to the body weight of the mice fed with these doses of M were reduced with no sign of histopathological alteration. The M at 250 mg/kg bw significantly reduced the FBG levels in a postprandial study. The hypoglycemic effect of M was eliminated when co-administered with isosorbide dinitrate or nifedipine indicating the induction of insulin secretion via K+ ATP-dependent channels. The UV/HPLC analysis of M indicated saponin at 7.7 mg/g. This study confirmed the traditional use of A. mannii for diabetes mellitus and the potential for the further development as a novel hypoglycemic drug.

Multinational comparison of diagnostic clues for uterine cervical lesions among cytotechnologists in Asian countries.

Vaccination has been underway in several countries for sexually inactive young girls or women against HPV 16 and 18 to prevent them from infection of these HPV types and concurrent cancer development. However, uterine cervical cancers may remain uncontrolled among some Asian countries, where other types of HPV infection are more frequent. A sensitive cancer screening system would remain important for detection of the earlier stage cervical cancers in Asian countries. In this study, 130 cytotechnologists (CTs) in Asian countries (Taiwan 80, Japan 18, Korea 15, Thailand 11, Singapore 3, Bhutan 2, and Mongolia 1) participated in the vote. Selected 10 cervical Pap smears that would be adequate to identify the diagnostic clues especially for atypical squamous cells (ASC) with two or three representative pictures for each case were displayed on the website. The percentages of consistent diagnosis voted by certified CTs with ≥5 years of experience were compared among 10 cervical cases or among Asian countries enrolled. As results, low consistency for ASC cases and high consistency for squamous intraepithelial lesion (SIL) were observed. Examining specimens for the diagnostic clues of ASC in TBS is crucial to maintain the high sensitivity and positive predictive value of SIL in Asian countries.

Changes in peripheral innervation and nociception in reticular type and erosive type of oral lichen planus.

BACKGROUND: Oral lichen planus (OLP) is a chronic inflammatory lesion in oral mucosa. Reticular (OLP-R) and erosive (OLP-E) types of OLP are the common forms that have been found in dental clinics. The aim of this investigation is to determine the correlation between neurogenic inflammation and nociception associated with OLP-R and OLP-E. MATERIALS AND METHODS: The oral mucosal lesions from six patients with OLP-E, four with OLP-R and three with noninflamed oral mucosa, which represent normal mucosa, were identified by morphometric analysis of nerve fibers containing immunoreactive protein gene product (PGP) 9.5. The level of inflammation was measured with hematoxylin and eosin staining and the level of nociception was analyzed with visual analog scale measurement. RESULTS: We found that 1) an increase in peripheral innervation was related to the size of the area of inflammatory cell infiltration from both OLP-R and OLP-E; 2) the pattern of PGP 9.5-immunoreactivity among OLP-R and OLP-E was not significantly different (P=0.23); and 3) the correlation between nociception and an increase in PGP 9.5-immunoreactivity was not found in OLP-E and in OLP-R. CONCLUSIONS: Our findings suggest that an increase in peripheral innervation may lead to increased inflammation, which is part of the immunopathogenesis of OLP. Differences in nociception between OLP-R and OLP-E arise from the pathogenesis of each lesion, not from the differences in peripheral innervation.

Interobserver reproducibility with LiquiPrep liquid-based cervical cytology screening in a developing country.

OBJECTIVE: A modified liquid-based techniques known as the "LiquiPrep (LP) system" requires neither expensive equipment nor complicated specimen preparation. The aim of this study was to assess the applicability of the LP for use in a developing country. METHODS: Cervical cytology specimens were collected from 777 women, using the Cervex-Brush. The brush was first smeared on a glass side for conventional Papanicolaou (CP) stain, and then immersed in preservation fluid for LP preparation. Cytologic interpretations were classified into four categories: 1) no atypical cells, 2) atypical squamous epithelial cells (ASC), 3) definite epithelial cell abnormality, and 4) unsatisfactory specimen. Interobserver variability was tested using weighted kappa statistics. RESULTS: An LP specimen cost $9 per case compared to $3 per case for a conventional Pap smear. The time to learn the technique was only a few days. Forty six (5.92%) specimens by LP were unsatisfactory. The overall agreement between cytopathologists was 96.7% (weight kappa=0.62), with 95.6% (weight kappa=0.44) for the cases enrolled earlier, increasing to 97.9% (weight kappa=0.78) for the cases enrolled later. CONCLUSIONS: In summary, after a short learning curve, interobserver reproducibility of LP smear was near perfect. This feature of the LP, together with the relatively low cost and simple protocol, makes it quite suitable for cervical cytology screening in developing countries. Moreover, with this technique, some of each sample can be reserved for additional studies such as HPV detection and subtyping.

Epidemiologic study of 112 osteosarcomas in Chiang Mai University Hospital, Thailand.

OBJECTIVE: To summarize the epidemiologic features of osteosarcoma. MATERIAL AND METHOD: One hundred and twelve cases of osteosarcoma were collected retrospectively from the Pathology Department of the Chiang Mai University Hospital, Thailand between 1995 and 2005. RESULTS: From the present study, there were 14 cases in average, annually, since 2002. Seventy-seven percent of cases were from the upper north Thailand, the region serviced by Chiang Mai University Hospital. The male:female ratio was 1.3:1 and 86% of cases occurred within the first three decades of life. The majority of cancer was found in the long bones (83%) and the majority of lesion was around the knee (68%). Conventional and telangiectatic osteosarcoma accounted for 85% and 8% of cases, respectively. CONCLUSION: The authors have summarized some epidemiologic features of osteosarcoma. The authors found the relatively high frequency of telangiectatic osteosarcoma around the upper part of north Thailand These results give an initial picture to the national health provider section for planning personnel, medical and supportive equipment, and funding for the care of osteosarcoma patients. Nationwide co-operation in registering osteosarcoma patients would provide more complete data on this tumor in Thailand and promote the establishment of standardized treatment protocols.

A new mucin antibody/enzyme-linked lectin-sandwich assay of serum MUC5AC mucin for the diagnosis of cholangiocarcinoma.

We have previously used agarose gel electrophoresis and immunoblotting to qualitatively measure serum MUC5AC mucin for diagnosing cholangiocarcinoma. In this study, we developed a quantitative determination of serum MUC5AC by sandwich ELISA using MUC5AC mucin monoclonal antibody and soybean agglutinin. A cut-off value of the absorbance 0.074 was obtained from a complete statistical Receiver Operating Characteristic curves with an area under the curve=0.8141. The assay could discriminate cholangiocarcinoma patients from the controls with 71% sensitivity and 90% specificity. The test is simple to perform, reproducible, and probably used for detecting cholangiocarcinoma in a high-risk group or suspected patients.

Spectrum of bone tumors in Chiang Mai University Hospital, Thailand according to WHO classification 2002: A study of 1,001 cases.

OBJECTIVE: The aim of the present study was to determine the spectrum, frequency and demographics of bone tumors. MATERIAL AND METHOD: A retrospective study of the 1,001 bone tumor specimens from the files at the Pathology Department of the Chiang Mai University Hospital, Thailand from 2000 to 2004. RESULTS: From the study, 41 were non-neoplastic mass lesions, and 960 were neoplastic, with 856 (89%) as primary and 104 (11%) as metastatic tumors. In the primary tumor group, 654 (76%) cases were of hematologic origin, and 202 (24%) were non-hematologic. The most common benign bone tumors were giant cell tumor (n = 37), osteochondroma (n = 25), and chondroma (n = 15). The most common malignant bone tumors were lymphoma-leukemia (n = 583), metastatic malignancy (n = 104), plasma cell myeloma (n = 71), and osteosarcoma (n = 58). CONCLUSION: The present study showed a higher frequency of osteosarcoma (68%), lower frequencies of chondrosarcoma (12%) and Ewing sarcoma (4%) among primary non-hematologic malignant bone tumors when compared with similar studies based on Western patients. Whether these differences reflect differences in the ethnic population or in practice patterns remains to be determined

Why were limbs amputated? An evaluation of 216 surgical specimens from Chiang Mai University Hospital, Thailand.

INTRODUCTION: Limb loss has a devastating effect on patients. To know the underlying causes of limb amputation would be helpful in planning public health strategies in the country. The objectives of this study are (1) to identify the primary causes and the feature of limb amputations in the setting of a university hospital, and (2) to study the time trends of the causes of limb amputation over a period of 5 years. MATERIALS AND METHODS: The clinical and pathological data from 216 amputated limbs submitted to the Pathology Department of Chiang Mai University Hospital from 2000 to 2004 were reviewed. RESULTS: Of these, 188 cases were first time amputations, and 28 cases were repeat amputations. The 188 first amputated specimens included 23 upper limbs (12%) and 165 lower limbs (88%), from 115 male (61%) and 73 female (39%) patients. Dysvascular (46%), tumor-related (36%), and infection-related (10%) amputations were the three most common scenarios. The rate of amputation was high in 2004 (32%) owing to an unexpected increase in the numbers of dysvascular amputation. Atherosclerosis accounted for at least 52% of dysvascular amputations. The leading cause of tumor-related amputations was sarcoma (72%), almost half of which were osteosarcomas. The major cause of lower limb amputation was dysvascular (51%) whereas that of upper limb amputation was tumor related (61%). Subgroup analysis of the major limb amputations revealed that 44% were tumor related, 39% were dysvascular, and 8% were infection-related causes. The proportion of major limb losses in the tumor-related group (87%, 59/68) was significantly higher than those in the dysvascular group (62%, 53/86) (P = 0.001). In addition, the proportion of upper limb losses in the tumor-related group (21%, 14/68) was significantly greater than those in the dysvascular group (2%, 2/86), (P < 0.001). The causes of 28 repeat amputations were similar, i.e., dysvascular (61%), tumor related (29%), and infectious related (7%). CONCLUSION: (1) Atherosclerosis, a potentially preventable disease is responsible for the great proportion of limb losses in Northern Thailand; (2) the numbers of dysvascular amputation seem to be increasing; (3) tumor, especially sarcoma, is the most common cause of major limb amputations as well as upper limb loss.

Global gene expression profile of nasopharyngeal carcinoma by laser capture microdissection and complementary DNA microarrays.

A number of genetic and epigenetic changes underlying the development of nasopharyngeal carcinomas have recently been identified. However, there is still limited information on the nature of the genes and gene products whose aberrant expression and activity promote the malignant conversion of nasopharyngeal epithelium. Here, we have performed a genome-wide transcriptome analysis by probing cDNA microarrays with fluorescent-labeled amplified RNA derived from laser capture microdissected cells procured from normal nasopharyngeal epithelium and areas of metaplasia-dysplasia and carcinoma from EBV-associated nasopharyngeal carcinomas. This approach enabled the identification of genes differentially expressed in each cell population, as well as numerous genes whose expression can help explain the aggressive clinical nature of this tumor type. For example, genes indicating cell cycle aberrations (cyclin D2, cyclin B1, activator of S-phase kinase, and the cell cycle checkpoint kinase, CHK1) and invasive-metastatic potential (matrix metalloproteinase 11, v-Ral, and integrin beta(4)) were highly expressed in tumor cells. In contrast, genes underexpressed in tumors included genes involved in apoptosis (B-cell CLL/lymphoma 6, secretory leukocyte protease inhibitor, and calpastatin), cell structure (keratin 7 and carcinoembryonic antigen-related cell adhesion molecule 6), and putative tumor suppressor genes (H-Ras-like suppressor 3, retinoic acid receptor responder 1, and growth arrested specific 8) among others. Gene expression patterns also suggested alterations in the Wnt/beta-catenin and transforming growth factor beta pathways in nasopharyngeal carcinoma. Thus, expression profiles indicate that aberrant expression of growth, survival, and invasion-promoting genes may contribute to the molecular pathogenesis of nasopharyngeal carcinoma. Ultimately, this approach may facilitate the identification of clinical useful markers of disease progression and novel potential therapeutic targets for nasopharyngeal carcinoma.

Cytological diagnosis of lung cancer in Chiang Mai, Thailand: cyto-histological correlation and comparison of sensitivity of various methods.

To evaluate the role of cytology of sputum, bronchial brushing (BB), bronchial washing (BW), bronchoalveolar lavage (BAL) and fine needle aspiration cytology (FNA) in the diagnosis of lung cancer using histological material as a gold standard, a retrospective study was performed on cytological materials obtained from 243 patients with possible lung cancer. Of these, 160 had been confirmed histologically to have lung cancer. Cytological materials included in the study were 31 sputa, 123 BWs, 11 BBs and 36 BALs. Meanwhile, FNAs and concurrent gun biopsies (GBs) were performed on 23 patients clinically and histologically proved to have lung cancer. The overall sensitivity of sputum, BW and BAL was 0.222, 0.455 and 0.361, respectively. BB provided a significantly far superior sensitivity (0.800) than those of three former methods with p<0.05 by Fisher's exact test. FNA and GB seemed to provide greater sensitivity of 0.913 and 0.783, respectively. Although the complimentary role of various conventional cytological techniques is well recognized, bronchial brushing is the only single technique that significantly improved diagnostic yield. FNA and GB techniques should be encouraged due to their superior sensitivity.

Lymphadenopathy due to Penicillium marneffei infection: diagnosis by fine needle aspiration cytology.

Penicillium marneffei is an opportunistic fungal infection that usually causes disseminated disease, mainly in immunocompromised individuals, especially those with HIV infection. Untreated cases are usually fatal. Diagnosis is traditionally made by biopsy and/or culture; successful diagnosis by fine needle aspiration (FNA) has only been reported once. We present eight cases of HIV-infected patients with lymphadenopathy caused by P. marneffei infection, in which the diagnosis was made by FNA. In all cases, intracellular and extracellular yeast forms were visualized, and the characteristic cross-septation of P. marneffei was highlighted by GMS staining. All diagnoses were confirmed by culture. Anti-fungal treatment for P. marneffei was initiated, resulting in marked clinical improvement. We conclude that a diagnosis of lymphadenopathy caused by P. marneffei can reliably be made by FNA. The diagnosis is more rapid than biopsy or culture, allowing rapid institution of therapy, particularly important in immunocompromised patients. In all our cases, not only were lymphoma and other causes of lymphadenopathy ruled out, but also the necessity for an open surgical biopsy was obviated. This can be especially beneficial to patients (e.g., three in our study) in which lymphadenopathy is confined to deep intra-abdominal nodes.

Angiostrongylus cantonensis infection mimicking a spinal cord tumor.

Angiostrongylus cantonensis is the most common cause of eosinophilic meningitis and meningoencephalitis. Almost all cases are self-limiting and are diagnosed by cerebrospinal fluid eosinophilia and enzyme-linked immunosorbent assay; pathology reports are restricted to postmortem samples from lethal cases. We report on what we believe is the first case of A. cantonensis infection diagnosed by biopsy in a living patient. The spinal cord was biopsied because of the unusual clinical presentation of a myelopathy without meningeal symptoms, together with a mass lesion that was clinically and radiologically diagnosed as a spinal cord tumor.

Intraosseous proliferative sparganosis: a case report and review of the literature.

Intraosseous proliferative sparganosis is an extremely rare parasitic disease in which the larvae of incomplete differentiated sparganum proliferate in the human bone. We present the first case of intraosseous proliferative sparganosis arising in the long bone. The patient was a 51-year-old man who complained of a slow growing painful mass on his right leg. The radiographic findings showed an infiltrative osteolytic lesion with speckled calcification at the proximal tibia the clinical diagnosis of which favored chondrosarcoma. Incisional biopsy revealed an innumerable number of small globular shapes, whitish parasites. Histologically, the parasites were composed of a few layers of smooth muscle and several calcerous bodies that were enclosed within a single row of tegumental cells. The latter exhibited a wavy appearance and coated with microvilli. These morphologic findings confirmed the nature of these maldifferentiated larvae. The patient was treated by partial resection of the lesion. This should remind clinicians that parasitic infection of the bone can produce a tumor-like lesion.

Carcinoma of the breast with unusual clinical presentation: a case report.

A common presentation of breast cancer is a palpable or non-palpable breast mass that might or might not demonstrate clinical signs of skin and/or nipple involvement. These malignant lesions frequently receive correct diagnosis only by physical examination under modestly experienced observers. We, hereby, reported the case of a 66-year-old woman who presented with a rapidly growing skin lesion at the left breast for three months. A 3.6x3x2.5 cm reddish, shiny, rubbery, sessile mass was seen on the upper outer quadrant of her left breast. The cytologic and histologic features of the tumor were typical for infiltrating ductal carcinoma. This case demonstrated a very unusual clinical presentation of breast cancer. No similar clinical feature of such cancer was mentioned in the reviewed literature.

Effectiveness of fine-needle aspiration cytology of breast: analysis of 2,375 cases from northern Thailand.

At the Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand, 2,375 cases of breast lesions were sampled by fine-needle aspiration (FNA) from 1994-1999. Cytologic diagnoses were: benign (48%), suspicious for malignancy (5%), malignant (15%), and unsatisfactory (32%). Comparison with histology was possible in 721 cases. The diagnoses obtained by FNA showed a sensitivity of 84.4%, specificity of 99.5%, positive predictive value of 99.8%, negative predictive value of 84.3%, false-negative rate of 16.7%, false-positive rate of 0.5%, and overall diagnostic accuracy of 91.3%. We conclude that, in experienced hands, FNA of breast masses is reliable for diagnosis. Assessment of samples at the time of aspiration can reduce the number of inadequate specimens to near zero. Correlation of FNA results with clinical and radiologic findings can identify false-negatives and false-positives, ensuring optimal patient management. Many centers now recommend needle core biopsy instead of FNA. For regions such as ours, the added cost of this test would make it unavailable to many patients, which could delay a diagnosis of breast cancer. We advocate keeping FNA as a first-line diagnostic procedure, at least in areas under economic restrictions, in order to maximize the availability of health care to women with breast disease.