Reproducibility of diagnostic criteria associated with atypical breast cytology.

OBJECTIVE: The aim of this project was to assess the interobserver and intraobserver variability when identifying cytological criteria, which were found to have a statistically significant association with C3 within a workplace environment. METHODS: Sixty C3 cases with known endpoints of malignant, benign proliferative or benign non-proliferative diagnoses were blindly and independently screened by seven experienced cytologists to identify previously reported statistically significant criteria associated with the C3 category. The criteria included the presence of myoepithelial cells or bare bipolar nuclei, cohesiveness, cystic background, papillary fragments with fibrovascular cores and tubular structures. Kappa statistics were used to measure interobserver variability. Two cytologists repeated the process 6 months later to obtain intraobserver data. RESULTS: The interobserver agreement was poor for all criteria except tubules which performed badly. The intraobserver variability for the two cytologists showed that one cytologist achieved moderate intraobserver agreement for all the criteria except cohesion which was poor, whilst the second cytologist showed poor agreement for all criteria. The reasons for the variability are multifactorial and include threshold effects where criteria lack good definition or error in identifying the criteria. CONCLUSION: Interobserver and intraobserver variability remains a significant challenge for cytologists. Despite attempts to define significant criteria associated with C3, good reproducibility could not be achieved. The C3 category is imprecise and highlights the inadequacy of the current classification reporting categories for breast FNA. The impending review of reporting breast cytology by the International Academy of Cytology is timely and appropriate.

The true nature of atypical breast cytology.

BACKGROUND: Atypical breast cytology is a poorly understood heterogeneous category with limited clinical utility but significant implications for patient management. OBJECTIVE: To provide an insight into the true nature of atypical breast cytology in screening-detected (asymptomatic) and symptomatic settings, and find strategies for reducing the use of this diagnostic category. MATERIALS AND METHODS: A total of 6,415 breast cytology samples were processed between January 2004 and December 2008. An atypical cytological diagnosis was rendered in 256 (4%) of the cases. A blind microscopic review of the atypical cases was conducted and results were correlated with subsequent histological and/or clinical outcomes. RESULTS: Follow-up information by histology was available in 85.5%, by repeat fine-needle aspiration (FNA) in 3.5% and by imaging or clinical follow-up in 10.2% of the cases. Two patients (0.8%) were lost to follow-up. Of the 254 cases with follow-up, 62.6% were benign and 37.4% were malignant. The benign to malignant ratios were 1:1 and 2:1 in the screening and symptomatic groups, respectively. The atypical category in the screening population mostly yielded fat necrosis, complex sclerosing lesions and low- to intermediate-grade carcinoma on follow-up. The main outcomes in the symptomatic group were papilloma, fibroadenoma, ductal carcinoma in situ and lobular carcinoma. Preanalytical (suboptimal samples) factors were encountered in 34.8% and interpretative factors in 65.2% of the cases. Uncertainty about cellular morphology was attributed to such a diagnosis in 38 (14.8%) of the cases, architectural complexity in 137 (53.5%) and morphology and architecture in 70 (27.3%); 4.3% of cases were considered nondiagnostic. CONCLUSION: The atypical category is a necessary diagnosis but of limited use from a patient management perspective. Some preanalytical factors such as poor sample quality can be minimized by the involvement of cytopathologists in the FNA procedure. The use of the atypical category is partly dependent on the experience and confidence of the reporting pathologist. Assigning a case to this category is also likely to be unduly influenced by clinical or radiological findings. Our study indicates that the use of the atypical category can be reduced by up to 40% by appreciating these contributing factors. The practical utilization of the atypical category in breast cytology remains subjective and further study is required to identify useful objective criteria.

Can a familial gastrointestinal tumour syndrome be allelic with Waardenburg syndrome?

Familial gastrointestinal stromal tumours (GISTs) are rare but otherwise well-characterized tumour syndromes, most commonly occurring on a background of germline-activating mutations in the tyrosine kinase receptor c-KIT. The associated clinical spectrum reflects the constitutive activation of this gene product across a number of cell lines, generating gain-of-function phenotypes in interstitial cells of Cajal (GIST and dysphagia), mast cells (mastocytosis) and melanocytes (hyperpigmentation). We report a three-generation kindred harbouring a c-KIT germline-activating mutation resulting in multifocal GISTs, dysphagia and a complex melanocyte hyperpigmentation and hypopigmentation disorder, the latter with features typical of those observed in Waardenburg type 2 syndrome (WS2F). Sequencing of genes known to be causative for WS [microphthalmia transcription factor (MITF), Pax3, Sox10, SNAI2 ] failed to show any candidate mutations to explain this complex cutaneous depigmentation phenotype. Our case report conclusively expands the clinical spectrum of familial GISTs and shows a hitherto unrecognized link to WS. Possible mechanisms responsible for this novel cause of WS2F will be discussed.

Immunogold-silver staining by capillary action.

The authors have developed an improved method for immunogold-silver staining of paraffin sections. Using a manual capillary action staining system, they were able to simplify the technical aspects of the procedure, permitting rapid processing of large batches of slides with better reproducibility. Background staining was decreased by use of buffers containing a detergent. The use of a light-stable silver reagent permitted greater control of the enhancement stage. The method yielded a high degree of contrast with negligible nonspecific staining. Sensitivity was comparable to that obtained with conventional enzymatic immunostaining. However, the authors noted that trypsinization of sections was rendered unnecessary for those antigens for which such pretreatment was usually required, and the need for special fixatives could be eliminated. The method was also applicable to immunostaining of frozen sections. Immunogold-silver staining by capillary action deserves consideration as an alternative to existing immunohistochemical methods in diagnostic histopathology.

Use of antibodies to carcinoembryonic antigen and human milk fat globule to distinguish carcinoma, mesothelioma, and reactive mesothelium.

Antibodies raised against human milk fat globule (HMFG 1 and 2) and carcinoembryonic antigen were used in an immunoperoxidase technique to differentiate mesothelioma, carcinoma, and benign, reactive mesothelium. Sixteen mesotheliomas, 27 lung carcinomas, and 13 specimens of reactive mesothelium were examined. Staining for carcinoembryonic antigen was not seen in reactive mesothelium or mesothelioma but was present in 22 of 27 carcinomas. Mesothelioma and carcinoma usually stained with HMFG 1 and 2; reactive mesothelium did not. These three antibodies may help to distinguish carcinoma, mesothelioma, and reactive mesothelium.

CD10 positive thyroid marginal zone non-Hodgkin lymphoma.

A 72 year old woman presented with swelling of the right lobe of her thyroid gland. Fine needle aspiration and flow cytometry showed a clonal population of B cells expressing CD10 and a diagnosis of follicle centre cell lymphoma was made. Subsequent excision of the thyroid showed the typical histological features of a marginal zone non-Hodgkin lymphoma. Polymerase chain reaction showed no evidence of t (14;18). Immunohistochemistry confirmed CD10 positivity and LN1 (CDw75) expression. This is only the second report of aberrant expression of CD 10 by a marginal zone lymphoma.

A case of attempted suicide by self-hanging.

A young man arrived at the accident and emergency department after attempting suicidal self-hanging. He was cyanosed and showed severe respiratory distress. His posture, hyperreflexia and state of consciousness suggested decerebration. A dire prognosis was expected. Four days later he recovered. No residual physical or mental sequelae were found during follow up. The "post-suspension syndrome" in our case was similar to those recorded in several continental reviews. Apart from a case report of a "miraculous deliverance" following an unsuccessful judicial hanging at Oxford in 1650, no other report of this syndrome has been made in the English literature. This syndrome has an excellent prognosis and requires very little active intervention to ensure a favourable outcome.

Primary lymphoma of the central nervous system: a case report.

A 46-year-old female presented with a 1-week history of mental change, confusion and headaches. Investigations revealed evidence of sterile meningitis. CAT scanning of the brain demonstrated marked contrast enhancement around the ependyma, and later examinations showed extension of the process deep into the white matter, Cerebral biopsies were non-diagnostic and, despite ventricular drainage and treatment with antibiotics and high dose steriods, the patent died. At postmortem there was extensive tumour tissue distributed in a butterfly shape around the ventricles, and microscopy revealed typical apperances of primary CNS lymphoma. On the basis of the experience of this case and a review of recent literature, it is suggested that the CAT scan appearances of this tumour are quite typical, and that cranial irradiation may be justified in the absence of specific histological diagnosis.

alpha-1-Antitrypsin, alpha-1-antichymotrypsin, actin, and myosin in uterine sarcomas.

Fourteen cases of mixed müllerian tumour (MMT) of the endometrium, six stromal sarcomas, five uterine leiomyosarcomas, and five leiomyomas were examined, using an immunoperoxidase technique, for the presence of alpha-1-antitrypsin (A1AT), alpha-1-antichymotrypsin (A1ACT), actin, and myosin. In addition, six cases of endometrial adenocarcinoma were examined for the presence of A1AT and A1ACT. Eleven MMT were positive for A1AT and 13 for A1ACT. All stromal sarcomas, four adenocarcinomas, four leiomyomas, and three leiomyosarcomas were positive for both. All leiomyomas and leiomyosarcomas were positive for myosin as were seven. MMT and three stromal sarcomas. Four leiomyomas, four leiomyosarcomas, six MMT, and three stromal sarcomas were positive for actin. These findings are related to those in the normal uterus and their practical and theoretical significance discussed.

Immunohistochemical demonstration of alpha-1-antitrypsin and alpha-1-antichymotrypsin in normal human endometrium.

Forty-five specimens of endometrium, consisting of 10 proliferative, 10 each of early, mid-, and late secretory, and five menstrual phase, were examined with antibodies to alpha-1-antitrypsin (A1AT), alpha-1-antichymotrypsin (A1ACT), muramidase, and serum 22, using an indirect peroxidase-antiperoxidase immunoperoxidase technique. Five postmenopausal and 10 pregnancy endometria were also examined. Very few macrophages were detected. Other stromal cells, however, in premenopausal, nonpregnant endometrium, stained strongly for A1AT and A1ACT but not with the other two antisera. Stromal cells following the menopause did not stain nor did the decidual cells of pregnancy. Only rare, isolated epithelial cells or whole glands stained for A1AT and A1ACT. The function of these antiproteases in endometrium may be to regulate the protease activity of the implanting blastocyst or the immunological response to it.

Annular subvalvular left ventricular aneurysm mimicking a pericardial effusion on echocardiogram.

Annular subvalvular left ventricular aneurysms are a rare form of herniation of the left ventricle, reported usually in negroes. These aneurysms are situated beneath the mitral or aortic valves and extend along the line of the valvular annulus. The aetiology remains speculative but is not associated with coronary artery disease. Our patient was Caucasian and a review of the literature reveals only four other documented cases in Caucasians. Our case corresponds completely in pathological detail with previous cases. This condition has never been reported in Australia. The echocardiographic features have not been described before. These are the presence of a large echo free space behind the left ventricle, without an interior free space. These features are not specific but this type of aneurysm should be considered in the differential diagnosis of a loculated posterior pericardial effusion, along with a large left atrium and a hernia through a patent foramen of Morgagni.

Dermal cylindromas originate from the eccrine sweat gland.

Ten dermal cylindromas have been studied using histological, ultrastructural and immunocytochemical techniques. The clinical data from the ten patients have also been reviewed. The results indicate histogenesis from the intradermal coiled duct region of the eccrine sweat gland.

Leiomyosarcoma of the uterus with giant cells resembling osteoclasts.

A case of leiomyosarcoma of the uterus with osteoclast-like giant cells was examined by light and electron microscopy, histochemistry, and immunoperoxidase techniques. A panel of antibodies was used, including monoclonal antibodies raised against various macrophage determinants and PD 7/26, which detects a leucocyte-common antigen. The giant cells contained nonspecific esterase, stained with PD 7/26 and with two antimacrophage antibodies. These findings strongly suggest that these giant cells are derived from macrophages.

Changes in blood flow, portal pressure and shunting during the development of cirrhosis in response to beta-blockade.

An experimental model of cirrhosis was developed in the rat to assess the effect of disease and pharmacological manipulation on blood flow, shunting and portal pressure. With progression in the severity of histological cirrhosis there was a steady fall in effective liver blood flow as measured with radioisotope labelled colloid. This corresponded to a rise in portal pressure and shunting with a close correlation between the two (r = 0.7, p less than 0.01). In control animals and when portal hypertension was caused by extrahepatic obstruction, beta-blockade with propranolol, but not selective beta 2 blockade, significantly decreased liver blood flow. With cirrhosis there was a variable response to propranolol depending on the histological severity of disease, the height of portal pressure and degree of shunting. There is a possibility therefore that a potential may exist for lowering portal pressure by manipulating intrahepatic shunting.

Antigen-dependent progression of mucosa-associated lymphoid tissue (MALT)-type lymphoma in the stomach. Effects of antimicrobial therapy on gastric MALT lymphoma in mice.

In humans, low-grade B-cell mucosa-associated lymphoid tissue (MALT) lymphomas of the stomach regress when Helicobacter pylori infection is cured by antimicrobial therapy. Using an animal model of human gastric MALT lymphoma, we observed the effects of Helicobacter felis eradication and the relationship between infection and disease progression. Antimicrobial therapy was given to one-half of the BALB/c mice infected with H. felis for 20 months. Groups of antibiotic-treated and untreated mice were killed 2, 3, and 4 months after antimicrobial therapy (ie, 22, 23, and 24 months after infection). The numbers of mice with MALT decreased after H. felis eradication with no lymphoid follicles seen 4 months after treatment. MALT lymphoma was present in a total of 23% (11/48) of antibiotic-treated infected mice compared with 75% (27/36) in untreated infected mice. These lymphomas were further graded into low-, intermediate-, and high-grade lymphoma. In the untreated mice, lymphoma development was more advanced with 36% low-grade (13/36), 39% intermediate-grade (14/36), and 6% high-grade (large B-cell) lymphoma (2/36) whereas in the treated mice the incidence was 21% (10/48), 6% (3/48), and 0% (0/48), respectively. These observations suggest that antigenic stimulation by H. felis sustained growth and progression of low-grade MALT lymphoma and that primary high-grade gastric lymphomas can evolve from the transformation of these tumors. Eradication of the organism caused low-grade tumors to regress, with inhibition or slowing down of lymphoma development toward high-grade lymphoma. The H. felis mouse model of gastric MALT lymphoma presents an opportunity to address the issues arising from antimicrobial treatment of these tumors in humans.