An International Ki67 Reproducibility Study in Adrenal Cortical Carcinoma.

Despite the established role of Ki67 labeling index in prognostic stratification of adrenocortical carcinomas and its recent integration into treatment flow charts, the reproducibility of the assessment method has not been determined. The aim of this study was to investigate interobserver variability among endocrine pathologists using a web-based virtual microscopy approach. Ki67-stained slides of 76 adrenocortical carcinomas were analyzed independently by 14 observers, each according to their method of preference including eyeballing, formal manual counting, and digital image analysis. The interobserver variation was statistically significant (P<0.001) in the absence of any correlation between the various methods. Subsequently, 61 static images were distributed among 15 observers who were instructed to follow a category-based scoring approach. Low levels of interobserver (F=6.99; Fcrit=1.70; P<0.001) as well as intraobserver concordance (n=11; Cohen κ ranging from -0.057 to 0.361) were detected. To improve harmonization of Ki67 analysis, we tested the utility of an open-source Galaxy virtual machine application, namely Automated Selection of Hotspots, in 61 virtual slides. The software-provided Ki67 values were validated by digital image analysis in identical images, displaying a strong correlation of 0.96 (P<0.0001) and dividing the cases into 3 classes (cutoffs of 0%-15%-30% and/or 0%-10%-20%) with significantly different overall survivals (P<0.05). We conclude that current practices in Ki67 scoring assessment vary greatly, and interobserver variation sets particular limitations to its clinical utility, especially around clinically relevant cutoff values. Novel digital microscopy-enabled methods could provide critical aid in reducing variation, increasing reproducibility, and improving reliability in the clinical setting.

Much of the variation in breast pathology quality assurance data in the UK can be explained by the random order in which cases arrive at individual centres, but some true outliers do exist.

AIMS: To investigate the role of random temporal order of patient arrival at screening centres in the variability seen in rates of node positivity and breast cancer grade between centres in the NHS Breast Screening Programme. METHODS AND RESULTS: Computer simulations were performed of the variation in node positivity and breast cancer grade with the random temporal arrival of patients at screening centres based on national UK audit data. Cumulative mean graphs of these data were plotted. Confidence intervals for the parameters were generated, using the binomial distribution. UK audit data were plotted on these control limit graphs. The results showed that much of the variability in the audit data could be accounted for by the effects of random order of arrival of cases at the screening centres. Confidence intervals of 99.7% identified true outliers in the data. CONCLUSIONS: Much of the variation in breast pathology quality assurance data in the UK can be explained by the random order in which cases arrive at individual centres. Control charts with confidence intervals of 99.7% plotted against the number of reported cases are useful tools for identification of true outliers.

The interobserver reproducibility of thyroid fine-needle aspiration using the UK Royal College of Pathologists' classification system.

The overall interobserver reproducibility of thyroid fine-needle aspiration (FNA) has not been comprehensively assessed. A blinded 6-rater interobserver reproducibility study was conducted of 200 thyroid FNA cases using the UK System, which is similar to The Bethesda System for Reporting Thyroid Cytology: Thy1, nondiagnostic; Thy2, nonneoplastic; Thy3a, atypia, probably benign; Thy3f, follicular lesion; Thy4, suspicious of malignancy; and Thy5, malignant. There was good interobserver agreement for the Thy1 (κ = 0.69) and Thy5 (κ = 0.61), moderate agreement for Thy2 (κ = 0.55) and Thy3f (κ = 0.51), and poor agreement for Thy3a (κ = 0.11) and Thy4 (κ = 0.17) categories. Combining categories implying surgical management (Thy3f, Thy4, and Thy5) achieved good agreement (κ = 0.72), as did combining categories implying medical management (Thy1, Thy2, and Thy3a; κ = 0.72). The UK thyroid FNA terminology is a reproducible and clinically relevant system for thyroid FNA reporting. This study demonstrates that international efforts to harmonize and refine thyroid cytology classification systems can improve consistency in the clinical management of thyroid nodules.

Nicorandil-induced terminal ileal ulceration--a probable link.

Nicorandil, a commonly prescribed anti-anginal agent, has been reported to be associated with ulceration in various parts of the gastrointestinal tract. A 68-year-old general practitioner presented with severe rectal bleeding and abdominal pain associated with terminal ileal ulceration diagnosed by colonoscopy. Capsule endoscopy revealed no other source of bleeding and CT was normal. Diclofenac and/or aspirin were assumed to be causative factors and discontinued. Aspirin was temporarily resumed then discontinued after a second massive, but self-limiting, haemorrhage and persistent abdominal pain. Repeat colonoscopy 5 weeks later confirmed that the previously documented terminal ileal ulceration had worsened. Histopathology was consistent with localised mucosal ischaemia. Nicorandil was withdrawn, after which no further episode of bleeding occurred and his pain settled. Repeat colonoscopy 3 months later confirmed complete healing. This report implicates nicorandil as a cause of terminal ileal ulceration leading to life-threatening rectal bleeding and abdominal pain.

Barrett's oesophagus: intestinal metaplasia is not essential for cancer risk.

OBJECTIVE: Barrett's oesophagus is the main identifiable risk factor for oesophageal adenocarcinoma. It has been suggested that only patients with intestinal metaplasia are at risk of cancer, but the British Society of Gastroenterology (BSG) guidelines suggest that glandular mucosa is all that is needed. The aim of this study was to quantify the risk of adenocarcinoma in columnar-lined lower oesophagus, with or without specialized intestinal metaplasia. MATERIAL AND METHODS: All patients who had endoscopic biopsies of the lower oesophagus between 1980 and 1994 in a single-centre teaching hospital were included in the study. All histological specimens were re-examined and reported according to whether they contained columnar epithelial-lined lower oesophagus, glandular mucosa, with or without intestinal metaplasia. The primary outcome measure was the development of adenocarcinoma. RESULTS: In total, 712 patients were identified. Of these, 379 (55.1%) were found to have specialized intestinal metaplasia (SIM), and the remaining 309 (44.9%, p = NS) were reported as having glandular mucosa (GM). The median follow-up for patients was 12 years (range 8-20 years). Twenty-eight patients went on to develop adenocarcinoma (4.1%) during the follow-up period - 17 in the SIM group (4.5%) and 11 in the GM group (3.6%, p =NS). The oesophageal malignancy rate was 0.34% per year (SIM 0.37%, GM 0.30%; p =NS). CONCLUSIONS: Patients who have glandular mucosa on biopsy without intestinal metaplasia have a similar cancer risk to those with specialized intestinal metaplasia.

Making the diagnosis of coeliac disease: is there a role for push enteroscopy?

BACKGROUND: Push enteroscopy is used in the assessment of refractory coeliac disease. However, its value in making the diagnosis of coeliac disease is still not defined. METHODS: Thirty-one patients (22 females, nine males) were recruited prospectively between September 2001 and October 2002; the age range was 20-80 years (mean age, 52.7 years). All patients had symptoms suggestive of coeliac disease and positive serology but duodenal biopsy was not diagnostic. Twenty-three patients had positive IgA or/and IgG antigliadin antibodies, eight patients had positive endomysial antibodies (EMA). All patients underwent enteroscopy with repeat quadrantic duodenal and additional jejunal biopsies. RESULTS: All samples were reviewed by a single, blinded, histopathologist. There were no cases of coeliac disease diagnosed on further biopsy in patients who had a positive gliadin antibody in isolation. In the eight EMA-positive cases repeat biopsy demonstrated coeliac disease in five patients. In 3/5 cases the changes were confined to the jejunal biopsies only. CONCLUSION: EMA-positive patients with initially normal histology should have a further duodenal biopsy. In our series three of the five newly diagnosed coeliac disease patients only had villous atrophy demonstrable in the jejunum. There may be a role for push enteroscopy in making the diagnosis of coeliac disease. However, further prospective studies are needed.

Role of tumour necrosis factor gene polymorphisms (-308 and -238) in breast cancer susceptibility and severity.

INTRODUCTION: Genetic polymorphisms in the promoter region of the tumour necrosis factor (TNF) gene can regulate gene expression and have been associated with inflammatory and malignant conditions. We have investigated two polymorphisms in the promoter of the TNF gene (-308 G>A and -238 G>A) for their role in breast cancer susceptibility and severity by means of an allelic association study. METHODS: Using a case-control study design, breast cancer patients (n = 709) and appropriate age-matched and sex-matched controls obtained from the Breast Screening Unit (n = 498) were genotyped for these TNF polymorphisms, using a high-throughput allelic discrimination method. RESULTS: Allele frequencies for both polymorphisms were similar in both breast cancer cases and controls. However, the -308 polymorphism was found to be associated with vascular invasion in breast tumours (P = 0.024). Comparison with other standard prognostic indices did not show any association for either genotype. CONCLUSIONS: We demonstrated no association between the -308G>A polymorphism and the -238G>A polymorphism in the promoter region of TNF and susceptibility to breast cancer, in a large North European population. However, the -308 G>A polymorphism was found to be associated with the presence of vascular invasion in breast tumours.

Analysis of colorectal tumor progression by microdissection and comparative genomic hybridization.

This investigation aimed to identify patterns of copy number change in colorectal tumor progression from adenoma to liver metastasis. Fifty-three microdissected sub-regions from 17 cases of colorectal cancer were assigned to one of six histopathologically defined categories: coexisting adenoma, tumor above the muscularis layer, tumor within the muscularis layer, tumor extending through the bowel wall to serosal fat, lymph node metastasis, and liver metastasis. Microdissected samples were treated by a microwave processing step and then used as templates for universal PCR amplification. PCR products were fluorophore labeled and subjected to comparative genomic hybridization. Copy number changes were found in all samples, and every chromosome arm (excluding acrocentric short arms) was affected. More losses than gains were detected, but there were no significant differences between the numbers of changes seen in each category. Each individual sample revealed unique changes, additional to those shared within each case. The most frequently observed gains were of X and 12q. The most common losses were of 8p, 16p, 9p, 15q, 18q, and 10q. Nominally significant associations were observed between metastatic tumor and loss of 12q24.1 or 10p13-14, non-metastatic tumor and loss of 8q24.1, tumor extending to serosal fat and loss of 6q24-25 or gain of 4q11-13, tumor extending to serosal fat and metastatic lesions and loss of 4q32-34 or 22q11-12, and adenoma and loss of 15q24. Loss of 4q32-34 remained highly significant after correction for multiple testing. Adenoma was the only category not to show loss of 17p. These data reveal a genetically heterogeneous picture of tumor progression, with a small number of changes associated with advanced disease.

A primary care cross-sectional study of undiagnosed adult coeliac disease.

OBJECTIVES: To establish the prevalence of coeliac disease in the general population and in specific conditions, such as irritable bowel syndrome, iron deficiency anaemia, fatigue and other coeliac-related conditions. METHODS: Primary-care-based cross-sectional study using immunoglobulins, IgA/IgG antigliadin antibodies and endomysial antibodies to initially recognize coeliac disease. A total of 1200 volunteers were recruited from January 1999 to June 2001 from five general practices in South Yorkshire, UK. Any participant with a positive IgA antigliadin antibody, positive endomysial antibody, or only IgG antigliadin antibody in the presence of IgA deficiency was offered a small-bowel biopsy to confirm the diagnosis of coeliac disease. RESULTS: Twelve new cases of coeliac disease were diagnosed from 1200 samples. The prevalence of coeliac disease in this primary care population sample is 1% (95% CI 0.4-1.3%). The prevalence of coeliac disease was 3.3% (4/123) in participants with irritable bowel syndrome, 4.7% (3/64) in participants with iron deficiency anaemia, and 3.3% (3/92) in participants with fatigue. CONCLUSIONS: This study describes the prevalence of undiagnosed adult coeliac disease in primary care patients with irritable bowel syndrome, iron deficiency anaemia and fatigue. Underdiagnosis of coeliac disease is common in primary care. A case-finding approach would avoid delays in diagnosis and the associated morbidity or potential complications of coeliac disease. A low threshold for serological screening of patients with coeliac-associated symptoms or conditions would be an optimal strategy.