CareHPV cervical cancer screening demonstration in a rural population of north India.

OBJECTIVE: To compare cervical careHPV screening in a rural community setting with other methods of cervical screening for the detection of high-grade cervical intra-epithelial neoplasia (CIN). STUDY DESIGN: Cross-sectional study. All ever-married women aged 30-59 years surveyed in an administrative area of Uttar Pradesh, India were targeted for screening by careHPV (cervical and vaginal samples), Pap test and visual inspection of the cervix following application of acetic acid (VIA). Women who screened positive were referred for colposcopy and the results were confirmed histologically. Sensitivity, specificity and predictive values for the detection of histological CINII+ and CINIII+ were assessed for each screening test. RESULTS: Sixty-five percent (5032/7704) of the women invited for cervical screening agreed to participate in the study. Screen-positive rates for cervical careHPV, vaginal careHPV, Pap test and VIA were 3%, 2%, 3% and 6%, respectively. Data for women who did not complete all screening modes, women lost to follow-up and women with missing histological results were excluded before data analysis, resulting in a final sample size of 4658. Cervical careHPV had high sensitivity (85%) for the detection of CINIII+ lesions and moderate sensitivity (53%) for the detection of CINII+ lesions. Sensitivities for the detection of CINIII+ and CINII+ were 54% and 41% for vaginal careHPV, 62% and 44% for Pap test, and 8% and 22% for VIA, respectively. CONCLUSION: Cervical careHPV testing is superior to VIA and Pap test for the detection of high-grade CIN in a rural community setting.

Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions.

OBJECTIVE: Evaluation of visual inspection of the cervix with acetic acid (VIA) for screening cervical intraepithelial neoplasia. METHODS: In this prospective study, 400 women were screened using the Papanicolaou (PAP) smear, VIA and colposcopy. Those who had positive results with any of the screening methods underwent large loop excision of the transformation zone (LLETZ). The sensitivity and specificity of each of the screening methods was analyzed. RESULTS: The sensitivity of VIA (96.7%) was much higher than that of the Pap smear (50%), and almost as high as that of colposcopy (100%). The specificity of VIA (36.4%) was lower than that of the Pap smear (97%) and colposcopy (96.9%), resulting in high false-positive rates for VIA. Two cases of endocervical lesions were missed with VIA. CONCLUSION: Visual inspection of the cervix with acetic acid is very sensitive for ectocervical lesions. The advantages of the VIA method are its low cost and ease of use (it can be used by paramedical workers), its high sensitivity and its immediate results (it is possible to "see and treat" at the first visit). Its main limitation is a high rate of false-positive results, which may lead to overtreatment if a "see and treat" policy is applied.

Amoebiasis: diagnosis by aspiration and exfoliative cytology.

The present study was undertaken to evaluate the use of fine needle aspiration and exfoliative cytology in the identification of amoebic cysts/trophozoites, and to characterize amoebiasis. The subjects consisted of 15 patients, 11 diagnosed by fine needle aspiration cytology (FNAC) as amoebic abscesses (14 liver and one pulmonary) and four women whose cervical smears contained Entamoeba histolytica cysts or trophozoites. Of 128 ultrasonographically guided FNAC of hepatic lesions over a four year period, 17 were abscesses of which 10 were diagnosed as amoebic. A single case of pulmonary amoebiasis was detected in an 18-year-old male. The case was initially diagnosed as tubercular due to deceptive symptomatology. Three cases of amoebic cysts and one trophozoite were reported on routine cervical smear screening. All four cases were unsuspected for amoebic infection. The disease may easily go undetected unless meticulous screening is exercised, and the search for cysts or trophozoites is made with clear concepts of the morphological characteristics of E. histolytica in mind.

DNA aneuploidy in invasive carcinoma of the uterine cervix.

Forty cases of squamous cell carcinoma and twenty cases of adenocarcinoma of the cervix were subjected to DNA ploidy analysis to find out the frequency of aneuploid DNA pattern in different types of invasive carcinoma of the uterine cervix and their possible correlation with the clinical stage and age of the patients. From the DNA analysis an increasing trend of DNA aneuploidy was observed from well differentiated (63.6%) to moderately differentiated (70.8%) to poorly differentiated squamous cell carcinoma (83.3%). However, 85% adenocarcinomas of endocervix showed aneuploid DNA pattern. It indicates that aneuploidy increases with tumour dedifferentiation and further confirms the importance of DNA ploidy as a high risk indicator.

Frequent amplification of C-erbB2 (HER-2/Neu) oncogene in cervical carcinoma as detected by non-fluorescence in situ hybridization technique on paraffin sections.

Sixty primary untreated squamous cell carcinomas were studied for C-erbB2 gene amplification by non-fluorescence in situ hybridization technique. Amplified tumour cells showed intranuclear dark brown, often paired signals under light microscopy. Twenty-two out of 60 tumours (36.6%) showed signs of amplification of different degree (+ to +). Considerable heterogeneity of C-erbB2 amplification per cell was seen within each amplified tumour. The proportion of amplified cells ranged between 10 and 90% in these tumours. The arrangement of C-erbB2 in clusters in most amplified tumours suggests that C-erbB2 amplification occurs intrachromosomally. No significant difference in the frequency of amplification was observed according to clinical stage or the histological patterns of the tumours. The results of the present study showed frequent amplification of C-erbB2 in cervical carcinoma on paraffin sections. This technique was found to be more sensitive than the Southern blot technique which could detect amplification in 14% of the tumours of the same cohort.

Immunohistochemical co-expression of human papillomavirus type 16/18 transforming (E6) oncoprotein and p53 tumour suppressor gene proteins in oesophageal cancer.

Human papillomaviruses have been widely implicated as important etiologic agents in various squamous cell carcinomas including oesophageal carcinoma. p53 mutant oncoprotein has also been implicated in various tumours. Immunohistochemical analysis was employed to detect the co-expression of HPV and p53 mutant protein in biopsy specimens of patients of cancer oesophagus as well as controls. This analysis revealed a significantly higher immunopositivity (63%) of E6 oncoprotein of HPV 16/18 in carcinoma of the oesophagus. Immunoexpression of E6 oncoprotein of HPV did not alter significantly the degree of differentiation of the tumour. Seventy-seven percent of cases of oesophageal carcinoma showed strong immuno-staining for mutant p53 protein. A higher percentage (89%) of tissues showed immunoexpression of mutant p53 protein in conjunction with E6 oncoprotein of HPV 16/18 indicating a selective degradation of key cellular protein of p53 having regulatory properties which in turn leads to uncontrolled cellular proliferation. Therefore, coexpression of oncoprotein E6 of HPV 16/18 and mutant p53 protein may be considered as a "high risk" factor for progression to oesophageal malignancy.

Ultrasound-guided fine-needle aspiration cytology diagnosis of gallbladder lesions: a study of 82 cases.

Carcinoma of the gallbladder (GB) is among the five most common forms of cancers and tops the list of gastrointestinal malignancies in females of the Delhi region. Lack of specific signs and symptoms prevents early detection of GB carcinoma. However, in recent years ultrasonographically (US)-guided fine-needle aspiration (FNA) cytology has been found to be a reliable procedure for its diagnosis. The present study was carried out during a period of 5 yr (1986-1990) in 64 female and 18 male patients to find out the diagnostic utility of US-guided FNA cytology in gallbladder lesions. Ultrasonography in these 82 cases revealed a mass in the gallbladder/GB area in 74 (90.2%), a mass in the GB/pancreas in 1 (1.2%), gallstones in 32 (39.0%), and miscellaneous gallbladder lesions in 4 (4.9%). The other findings included space-occupying lesions in liver in 18 (22.0%), portal lymphadenopathy in 12 (14.6%), and infiltration in other organs in 7 (8.5%). The initial cytodiagnosis was malignancy in 48 cases, inflammatory in 12, and inadequate in 22. Following review of the smears by one of the investigators (D.K.D.), the number of malignant cases remained 48 (58.5%). There were 10 (12.2%) inflammatory and 24 (29.3%) inadequate cases. Adenocarcinoma was the most common malignancy (83.3%), followed by squamous-cell and adenosquamous carcinoma (12.5%) and small round cell tumors (4.2%). The 10 inflammatory lesions showed slight (+) to excessive (+3) neutrophilic infiltration and included one case each of xanthogranulomatous cholecystitis and a necrotizing granulomatous lesion likely to be of tuberculous etiology.

Small round cell tumors of the abdomen and thorax. Role of fine needle aspiration cytologic features in the diagnosis and differential diagnosis.

OBJECTIVE: To evaluate the role of cytomorphologic features in the diagnosis and differential diagnosis of small round cell tumor (SRCT) of the abdomen and thorax. STUDY DESIGN: During a period of six years (1985-1990), ultrasound/ computed tomography-guided fine needle aspiration cytology was performed on thoracic and abdominal/ pelvic masses in 899 cases. Slides were not available for review in 28 cases. Review of smears by one of the investigators (D.K.D.) in the remaining cases, which included 239 with intrathoracic and 632 with intraabdominal/pelvic masses, yielded 380 (43.6%) cases of malignancy. Of these, 71 (18.7%) cases were small round cell tumors. In 59 cases of SRCT the smears were found suitable for detailed assessment of cytomorphologic features. RESULTS: The 59 cases of small round cell tumors included 5 cases of neuroblastoma, 7 of hepatoblastoma, 4 of nephroblastoma, 1 of pulmonary blastoma, 2 of Ewing's sarcoma, 23 of non-Hodgkin's lymphoma (NHL), 15 of small cell anaplastic carcinoma (SCAC), 1 NHL/SCAC and 1 small round cell tumor (not otherwise specified). The frequencies of rosettes (60%) and filamentous/fibrillar matrix (100%) in neuroblastoma; acinar formation in hepatoblastoma (100%) and SCAC (93.3%); tubule formation in nephroblastoma (100%); lipid vacuoles (69.6%), exclusive noncohesive cells (95.7%) and lymphoglandular bodies (87%) in NHL; and nuclear molding (100%) and paranuclear blue inclusions (60%) in SCAC were significantly higher as compared to the rest of the SRCTs (P < .01 to < .0001). CONCLUSION: The various cytomorphologic features, alone or in conjunction with other cytologic features, and clinical/imaging findings are very useful in the diagnosis of specific types of SRCT.

Role of guided fine needle aspiration cytology in diagnosis and classification of liver malignancies.

Ultrasound or CT-guided fine needle aspiration was performed on 212 patients with space occupying lesions of the liver during a period of 5 years (1986-1990) to study the utility of fine needle aspiration (FNAC) in the diagnosis of hepatic malignancies. The initial FNAC diagnosis was malignancy in 91 cases. However, following review of the smears by one of the investigators (DKD) 93 (43.9%) cases were found to be malignant. Age of the patients with malignancy ranged from 20 days to 85 years. Male to female ratio was 57:36. The clinical diagnosis was malignancy in 58% which improved to 72% following imaging whereas nonspecific diagnosis was reduced from 34% to 20%. The primary malignancies consisted of 21 cases of hepatocellular carcinoma (HCC) and 7 hepatoblastomas. There were 61 metastatic lesions which included 43 adenocarcinomas, 6 small cell anaplastic carcinomas, 3 leiomyosarcomas, 2 cases each of malignant melanoma, paraganglioma and germ cell tumour, and one case each of squamous cell carcinoma, neuroendocrine tumour and undifferentiated carcinoma/soft tissue sarcoma. In two cases decision between HCC and secondaries was not possible. There were also two cases of non-Hodgkin's lymphoma. Thirty six percent of primary malignancies and 58% of secondaries were correctly diagnosed or suggested as one of the possibilities by combined clinical examination and imaging prior to FNAC. Thus, US/ CT guided FNAC played an important role in diagnosis and classification of malignancies of liver.

Cytohistological correlation as a measure of quality assurance of a cytology laboratory.

In a hospital-based cytology screening programme for the early detection of preinvasive lesions of the uterine cervix, 166 women with abnormal smears (human papillomavirus (HPV) changes, cervical intraepithelial neoplasia (CIN) and invasive carcinoma) were referred to the central colposcopy clinic between January 1989 and December 1991. The colposcopist (V.S.) was able to take a direct biopsy in 156 cases. In the remaining 10-cases, biopsy could not be taken because of unsatisfactory colposcopy. A cytohistological correlation was obtained in 121/156 (77.5%) cases, and the remaining 35 cases showed a disparity in diagnosis. These were reviewed by one of us (P.S.) and the reasons for underdiagnosis/false negatives and overdiagnosis/false-positive results were analysed. It was found that sampling error was the cause of false negativity and underdiagnosis in most cases while interpretative errors resulted in the overdiagnosis and false-positive smears. The reasons for interpretative errors were studied in detail.

Ultrasound guided percutaneous fine needle aspiration cytology of pancreas: a review of 61 cases.

The study includes 61 cases which were subjected to ultrasound (US) guided fine needle aspiration cytology (FNAC) to find out the utility of this technique in the diagnosis of pancreatic lesions. Age of the patients ranged from 23 to 85 years with a median of 50 years. Male to female ratio was 36:25. One or more clinical diagnoses were offered in 16 and in 9 of these, the disease was related to pancreas. Subsequent to US, the lesions were localized to pancreas in 57 and the nature of pathology in the pancreatic lesion could be diagnosed in 31. By FNAC, 31 cases (50.8%) were diagnosed to have pancreatic malignancy which included adenocarcinoma (23 cases), papillary cystic tumour (1), muco-epidermoid carcinoma (1), acinic cell carcinoma (1), islet cell tumor (1), and non Hodgkin lymphoma (4). FNAC of liver in 2 cases and retroperitoneal lymph node in a case of pancreatic adenocarcinoma revealed metastasis. During follow up, 1 case of non Hodgkin's lymphoma showed CSF involvement. Three cases (4.9%) were suspected to have epithelial malignancy of which one was confirmed as an adenocarcinoma following surgery and histology. Four (6.6%) were benign lesions which included nonspecific inflammation (2 cases), tuberculous pancreatitis (1) and pseudopancreatic cyst (1). The remaining 23 cases (37.7%) had normal or inadequate cytology. Of these, FNAC of liver showed metastasis in 2 cases and one case each were diagnosed as adenocarcinoma and pseudopancreatic cyst respectively following surgery. None of the patients had any complication following FNAC. We recommend US guided FNAC to be routinely used for diagnosis of pancreatic lesion.

Ultrasound guided fine-needle aspiration cytology: diagnosis of hydatid disease of the abdomen and thorax.

Eight cases of hydatid disease of the abdomen and thorax were diagnosed by fine-needle aspiration (FNA) cytology under ultrasound guidance. The age of the patients ranged from 28 to 60 yr with a median of 34.5 yr; the male to female ratio was 2:6. None of the cases were diagnosed clinically as hydatid diseases but following ultrasonography suspicion of hydatid cyst was raised in two cases. The locations of cysts were the liver in six cases, the lung in one case, and the mediastinum in one case. FNA yielded clear fluid in five cases and turbid fluid in three cases. Laminated cyst wall, scolices, and hooklets were observed in one case, scolices and hooklets were present in two cases, and laminated cyst wall along with hooklets were seen in two cases. The remaining three cases showed only laminated cyst walls which yielded positive reaction with periodic acid-Schiff reaction. Inflammatory cell reaction in the form of neutrophils was observed in four cases, including the three cases where turbid fluid was aspirated. Epithelioid cell reaction was present in one case. None of our eight cases showed any untoward allergic reaction following FNA.

Microleakage comparison of thermafil versus vertical condensation using two different sealers.

The effect of two different sealers on the quality of the apical seal in roots obturated with Thermafil obturators (Tulsa Dental Products, Tulsa, Okla.) and vertical condensation was tested. Fifty extracted human maxillary anterior teeth were treated with the use of a step-back technique. Teeth were placed into five groups of 10 teeth each. One group served as the positive control. The root canals were obturated using either Thermaseal (Tulsa Dental Products) or Kerr (Kerr Manufacturing Co., Romulus, Mich.) sealer, and Thermafil or vertical condensation. All roots were placed in 1% methylene blue dye for 2 weeks. The roots were cleared, and the degree of linear dye penetration was measured using a Unitron light microscope with a Microcode II digital readout (Boeckeler Instruments, Tucson, Ariz.). The study showed that under in vitro conditions, the Thermafil technique was equivalent in linear leakage to vertical condensation. There were no statistical differences in the mean apical dye penetration between the two sealers or the two obturation techniques.

Tissue reactions to endodontic materials implanted in the mandibles of guinea pigs.

Teflon, Intermediate Restorative Material, and Prisma VLC Dycal were implanted in the mandibles of 16 guinea pigs. After experimental periods of 4 and 12 weeks, the animals were killed and tissue sections were prepared. No severe inflammatory response was noted in any of the groups except for a persistence of moderate inflammation in the poorly condensed Teflon group. Bone apposition occurred in the Prisma VLC Dycal group; none-to-mild inflammation and a thin fibrous capsule characterized the IRM group; and the Teflon group had a thick fibrous encapsulation except for samples where the Teflon material appeared to be poorly condensed and dispersed into the bony tissue. In areas where the teflon was loosely condensed, chronic inflammation and active phagocytosis were seen along the surface of the material.

Fine needle aspiration cytology of oral and pharyngeal lesions. A study of 45 cases.

Forty-five patients with oral or pharyngeal swellings were subjected to fine needle aspiration cytology (FNAC) of the mucosal surface over eight years. The age of the patients ranged from 2 to 85 years. The male:female ratio was 25:20. The common sites of involvement were palate (16 cases), cheek (9), pharynx (7) and tonsillar/peritonsillar area (6). Tongue, maxilla, alveolus and lips were less frequently involved. FNAC played an important role in differentiating inflammatory from neoplastic lesions and also benign from malignant neoplasms. Fifteen cases were cytologically diagnosed as benign neoplasms and included pleomorphic adenoma (11 cases), schwannoma (2), odontogenic tumor (1) and benign neoplasm not otherwise specified (1). Sixteen cases were diagnosed as malignancies. There were seven cases of malignant salivary gland tumors and 6 of squamous cell carcinoma. Two cases were high grade non-Hodgkin's lymphomas, and one was malignant odontogenic tumor. Of the 11 inflammatory or reactive lesions, 4 were found to be harboring Actinomyces. The rate of inadequate sampling was 6.7%. Histopathology reports on excised tissue were available for 10 cases only. Seven of nine cases with adequate cytology (77.88%) showed complete agreement with histology.

Treatment and prognosis of avulsed teeth. A discussion and case report.

A documented case that involves avulsion of an incisor is reported. Calcium hydroxide failed to prevent progressive irreversible root resorption. The importance of extraoral time, transport media, duration and type of splinting, as well as the rationale for the use of calcium hydroxide in the treatment of avulsed teeth are discussed. This case could serve as a reminder to practitioners, that patient compliance, timing and sequencing of endodontic therapy, and regular recalls is critical in the prevention or treatment of root resorption in avulsed teeth. It also emphasizes the frustration of many clinicians in treating avulsed immature teeth. The reporting of long-term documented cases should be encouraged so that replantation techniques may be evaluated.

Reversal of chloroquine resistance with verapamil in P. berghei in vivo.

The effects of verapamil on the parasite susceptibility to chloroquine were examined in mice infected with chloroquine-sensitive and chloroquine-resistant lines of Plasmodium berghei. Verapamil in a dose of 10-50 mg/kg daily s.c. for 4 days did not affect the growth of both sensitive and resistant parasites. When verapamil in the same dose range was combined with 1.5 mg/kg chloroquine diphosphate, the chloroquine-sensitive parasites became more susceptible to chloroquine. Similarly, verapamil severely suppressed the growth of chloroquine-resistant parasites in combination with 3 mg/kg (base) of chloroquine, but the reversal of resistance was not complete. Thus, still higher doses of verapamil, which are not tolerated by the host, are required for the complete reversal of resistance.

Superficial and deep-seated tuberculous lesions: fine-needle aspiration cytology diagnosis of 574 cases.

Over a period of 2 yr (1987-1988), FNA smears in 574 cases were found to have cytologic features suggestive of or consistent with tuberculous lesions. The age of the patients ranged from 6 mo to 75 ye, with a median of 24 yr. The male to female ratio was 273:301. Sites of FNA were superficial lymph nodes (SLN) in 440 (76.7 percent) cases, superficial extranodal sites (SENS) in 50 (8.7 percent), both SLN and SENS in 7 (1.2%), the thoracic cavity in 16 (2.8%), and the abdominal cavity in 61 (10.6%). Cytologic features were described under 3 major cytologic patterns, i.e., type I: epithelioid granuloma without necrosis, type II: epithelioid granuloma with necrosis, type III: necrosis without epithelioid granuloma. Type I, II, and III reactions were observed in 181 (31.5%), 183 (31.9%), and 210 (36.6%) cases, respectively. The overall AFB positivity was 30.8%. The AFB positivities for type I, II, and III cytologic reactions were 5.4%, 32.0%, and 48.5%, respectively. The AFB positivity was low (less than 30.0%) in swellings of the body surface (23.8%) and abdominal organs (18.9%). High positivity (greater than 60.0%) was observed in lesions of the thorax (63.6%) and thyroid (62.5%).

Supportive role of image analysis and DNA ploidy pattern in the diagnosis of thyroid tumors.

To evaluate the supportive role of image cytometry and DNA ploidy pattern in the diagnosis of thyroid tumors, a preliminary study was performed on fine needle aspirates of 30 cases. Of these, 10 cases each were of colloid goiter, follicular neoplasm, and papillary carcinoma. The nuclear area and DNA value of 50 cells in each case were measured. The mean nuclear area in colloid goiter (69.50 + 12.62 sq.microns) was significantly lower than the mean nuclear area in a follicular neoplasm (88.71 + 15.51 sq.microns) (P less than 0.05). Similar differences between the mean nuclear area in colloid goiter and papillary carcinoma (124.0 + 12.27 sq microns) was also highly significant (P less than 0.001). The results obtained by image cytometry were compared with estimated DNA ploidy pattern of follicular cells from the same cases. All colloid goiter had mean nuclear area below 100 sq.microns with diploid DNA value. However, papillary carcinoma showed aneuploid DNA pattern in eight cases (80.0%), but mean nuclear area was above 100 sq.microns. A diagnostically useful finding obtained in two of the 10 cases of follicular neoplasm was the association of aneuploid DNA pattern with mean nuclear area of the follicular cells above 100 sq.microns indicating a high probability of carcinoma and thus demanding an urgent open biopsy. These cases were readily distinguished from other cases of the same category showing diploid DNA pattern and mean nuclear area of follicular cells below 100 sq.microns.