The pathology of breast cancer in Jamaica: the National Public Health Laboratory study.

OBJECTIVE: To document the pathologic features of breast cancer in Jamaica. METHODS: The pathology reports and slides of all patients diagnosed with breast cancer at the National Public Health Laboratory between January 1999 and December 2002 were reviewed. Patient age and gender side involved, number of tumours identified, tumour size, histologic type, histologic grade, degree of lymph node involvement and parish of origin of the specimens were documented. RESULTS: There were 772 patients, 762 females and 10 males; age range 21 to 96 (mean 57.9 +/- 15.9) years. There were 778 specimens (6 bilateral cases), the majority of whom originated from Kingston and St Andrew (34.7%). Manchester (22.9%), St Catherine (13.9%) and St Ann (7.3%) were the next most common sources. The left breast was involved in 50.5% of cases. Gross tumour was identified in 641 (82.4%) specimens, the number of tumours ranging from 1 - 6 (mean 1.1 +/- 0.6). The maximum gross tumour dimension ranged from 0.3 to 15 cm (mean 4.1 +/- 2.7 cm). Infiltrating duct carcinoma was the predominant histologic type (69.3 %); 13.3%, 49.5% and 37.2 % of all infiltrating tumours were well, moderately and poorly differentiated respectively. In-situ lesions (7.1% of tumours) were all of the ductal phenotype. Axillary lymph nodes were submitted in 296 (38.1%) cases; metastatic disease was identified in 224 (75.7%) of these. The total number of nodes submitted ranged from 1 - 34 (mean 10.8 +/- 6.7) with an average of 6.1 (+/- 5.8) being positive for metastases (range 1 - 29). CONCLUSIONS: The pathologic features of breast cancer documented in this series including average tumour size, histologic types and grade and the degree of lymph node involvement are consistent with patient presentation at relatively advanced stages of disease and highlight the urgent need for public health intervention including a national screening programme.

Clinicopathologic features of breast disease in Jamaica: findings of the Jamaican Breast Disease Study, 2000-2002.

OBJECTIVE: To describe the clinicopathologic profile of breast disease in Jamaica. METHODS: The Jamaican Breast Disease Study is an ongoing prospective, multidisciplinary investigation of breast disease at the University Hospital of the West Indies (UHWI). The initial phase was a prevalence survey comprising all consenting patients referred to the Surgical Outpatient Department (SOPD) UHWI, for breast disease. Demographic, clinical, radiologic and pathologic information were recorded for each patient and the data for the first three years (2000-2002) were analyzed. RESULTS: A total of 1189 patients was enrolled for the study period (28.8% of all new SOPD patients). The age range was 10 to 93 years (mean/SD = 36.5 +/- 16.4 years) with a female : male ratio of 14:1. Most patients (67.8%) presented with a palpable lump and the clinical diagnosis was benign in the majority (70.4%) of patients. Fibroadenoma was the most common benign histologic result (39.4% of all biopsies) followed by non-proliferative (fibrocystic) disease (19.3% of all biopsies). Proliferative disease without atypia, complex fibroadenoma and atypical ductal hyperplasia accounted for 6.9%, 2.6% and 0.4% of biopsies respectively. Overall, 23.4% of biopsies showed malignant histology (10.8% patients); invasive ductal carcinoma accounted for the majority of these cases (69.5%). CONCLUSIONS: The majority of patients with breast disease in Jamaica are young women with clinically benign disease. There was a low prevalence of clinically significant premalignant disease. This is the first study to prospectively describe the clinicopathologic features of breast disease in Jamaica and supports the need for advocating breast cancer screening to facilitate detection of significant premalignant disease and early stages of breast cancer.

Discrepancies between clinical and postmortem diagnoses in Jamaica: a study from the University Hospital of the West Indies.

AIMS: It has previously been shown that the low necropsy request rate at the University Hospital of the West Indies (UHWI) in Jamaica (35.3%) results primarily from clinicians' confidence in clinical diagnoses and laboratory investigations. This study aimed to determine the rates of discrepancy between clinical and necropsy diagnoses at the UHWI, because many previous studies from other institutions have shown persistent high rates of discrepancy, despite advances in medical investigative technology over the past several years. METHODS: Data were extracted retrospectively from consecutive necropsies performed at the UHWI over a two year period. The data were analysed to determine the categories and rates of discrepancy, and to determine the relation between discrepancy rates and age, sex, type and number of diagnoses for each patient, hospital service, and length of hospitalisation. RESULTS: Necropsies were performed on 446 patients; 348 were suitable for further analysis. The overall discrepancy rate was 48.4% and the diagnoses with the highest individual discrepancy rates were pneumonia (73.5%), pulmonary thromboembolism (68.3%), and myocardial infarction (66.7%). Males and older patients were more likely to have discrepant diagnoses. There was a high frequency of discrepancies in patients who died within 24 hours of admission, but there was no consistent relation between length of hospitalisation and discrepancy rate. CONCLUSIONS: The high discrepancy rates documented at the UHWI are similar to those reported globally. This study supports previous attestations that the necropsy remains a vital tool for determining diagnostic accuracy, despite modern modalities of clinical investigation and diagnosis.

Fatal autochthonous eosinophilic meningitis in a Jamaican child caused by Angiostrongylus cantonensis.

A fatal case of infection with Angiostrongylus cantonensis is reported in a 14-month-old Jamaican boy. Although infection with Angiostrongylus was not considered initially, sections of multiple worms were observed in the brain and lungs at autopsy and confirmed the infection. This is the first reported fatality due to this infection in the Western Hemisphere, and follows shortly after an outbreak of eosinophilic meningitis among a group of travelers to Jamaica. The source of infection in this case could not be determined.

Utility of rapid staining of fine needle aspiration smears at the University Hospital of the West Indies.

In a prospective study at the University Hospital of the West Indies, 187 fine needle aspiration cytology (FNAC) specimens, comprising 100 breast, 75 head and neck, and 12 miscellaneous specimens, were subjected to rapid Papanicolaou staining and immediate assessment. Inadequate aspirates were repeated, and all cases were also evaluated after routine Papanicolaou staining. Histologic and clinical follow-up data were obtained. The overall concordance between rapid and routine cytologic diagnoses ranged from 79% to 87% for the three specimen cohorts. Sensitivity and specificity values were similar for rapid and routine-stained slides and ranged from 80% to 100%. There were no false positive or false negative diagnoses in the cases for which the outcome was known. Rapid staining of cytologic smears is a useful adjunct to the evaluation of aspirated material, improving adequacy rates and overall performance of the FNAC service, and should also result in significant savings in time and cost to patients.

Utility of rapid staining of fine needle aspiration smears at the University Hospital of the West Indies

In a prospective study at the University Hospital of the West Indies, 187 fine needle aspiration cytology (FNAC) specimens, comprising 100 breast, 75 head and neck, and 12 miscellaneous specimens, were subjected to rapid Papanicolaou staining and immediate assessment. Inadequate aspirates were repeated, and all cases were also evaluated after routine Papanicolaou staining. Histologic and clinical follow-up data were obtained. The overall concordance between rapid and routine cytologic diagnoses ranged from 79 to 87 for the three specimen cohorts. Sensitivity and specificity values were similar for rapid and routine-stained slides and ranged from 80 to 100. There were no false positive or false negative diagnoses in the cases for which the outcome was known. Rapid staining of cytologic smears is a useful adjunct to the evaluation of aspirated material, improving adequacy rates and overall performance of the FNAC service, and should also result in significant savings in time and cost to patients

Angiomatosis of the breast in a male child. A case report with immunohistochemical analysis

Angiomatosis is a benign vascular lesion that has been described rarely in the breast. We describe a case in a seven-year-old boy of African descent who presented with progressively increasing, unilateral breast enlargement, the first such report in a male child. The patient underwent excisional biopsy of the breast mass followed by mastectomy. Pathologic examination revealed a diffuse proliferation of variably-sized, thin-walled vascular channels lined by flattened endothelium that showed negative immunohistochemical staining for von Willebrand factor, factor VIII-related antigen, CD34 and S-100 protein. There is no evidence of recurrence after 24 months of follow-up

Histopathological findings in women with postmenopausal bleeding in Jamaica

We investigated the histopathological findings in women presenting with postmenopausal bleeding in a population predominantly of African descent by conducting a six-year retrospective study of 716 gynaecological surgical specimens from 629 women accessed in the Department of Pathology, The University of the West Indies, Jamaica. Histopathological diagnoses were correlated with patients age, specimen volume, duration of bleeding and length of postmenopausal interval at presentation using t-tests and linear regression models. The mean (SD) age was 63.6 (9.3) years. The frequency of the main causes of postmenopausal bleeding was: endometrial hyperplasia (22.3); endometrial atrophy (21.3); non-diagnostic (19.9); endometrial carcinoma (9.5); cervical carcinoma (6.8); cervical polyps (4.5); endometrial sarcoma (3.5); proliferative endometrium (3.2). Mean (SD) duration of bleeding was 6.9 (12.7) months. The percentage of women with malignant lesions was two to three times greater than those reported in the United States of America and Europe subsequent to 1980. The delay between the onset of bleeding and presentation is worrisome and suggests the need for public educatio

Causes of sudden natural death in Jamaica: a medicolegal (coroner's) autopsy study from the University Hospital of the West Indies.

Medicolegal (coroner's) autopsies are an important source of epidemiological data. A large proportion of them comprise sudden natural deaths and an analysis of such cases has never been undertaken at the University Hospital of the West Indies, the only teaching hospital in Jamaica. In a retrospective study, 841 cases of sudden natural deaths comprising 51.3% of the medicolegal autopsies conducted over the 15-year period, January 1983 to December 1997, were analyzed. There were 459 males and 382 females (M:F ratio = 1.2:1); 35 patients (4.1%) were less than 1 year of age, and the mean age of the remainder was 53.7+/-21.8 years. The peak age group was the seventh decade accounting for 21.9% of cases. The most common causes of death were cerebrovascular accidents (13.6%), pneumonia (9.4%), pulmonary embolism (7.4%), ischaemic heart disease (7.0%) and diabetes mellitus (6.1%). These findings contrasted with those from developed countries in which ischaemic heart disease is the commonest cause of sudden death. Hypertension was associated with the majority of cases of cerebrovascular accident and congestive cardiac failure (78.1 and 61.9%, respectively). Sickle cell disease represented one of the 10 most common causes of death accounting for 2.5% of cases. Documentation of autopsy-based data such as these is important in the planning of medical services in a developing country.

Necropsy request practices in Jamaica: a study from the University Hospital of the West Indies.

AIM: To investigate necropsy request practices at the University Hospital of the West Indies, Jamaica, to determine the extent to which these might influence the declining necropsy rates. This is the first such study from a developing country. METHODS: The necropsy service was audited prospectively over a six month period, and data relating to non-coroner's (hospital) necropsy requests, including the clinical service and post of the clinician involved, were documented. The reasons for non-request were recorded for deaths in which a necropsy was not requested, in addition to the reasons given by pathologists for not performing necropsies in cases that were requested but not done. The overall, non-coroner's, and coroner's necropsy rates in addition to the non-coroner's necropsy request and success rates were calculated. RESULTS: There were 364 deaths comprising 323 non-coroner's and 41 coroner's cases. The overall, non-coroner's, and coroner's necropsy rates were 29.2%, 20.2%, and 38.7%, respectively. The non-coroner's necropsy request rate was 35.3% with a success rate of 65%. Seventy five per cent of the requests were made by non-consultant clinicians and on the internal medicine service, which accounted for most of the non-coroner's deaths; necropsy requests were biased towards younger patients (p < 0.0001). Confident clinical diagnosis was the main reason for not requesting a necropsy, and the primary reason for refusing to perform a necropsy was that the request had been made too long after death. CONCLUSIONS: These findings show a relatively high necropsy success rate in the face of a comparatively low necropsy request rate, and indicate that necropsy rates can be increased if clinicians make more necropsy requests in a timely manner in patients of all ages.

Clinicopathological features of prostate cancer in Jamaican men.

OBJECTIVE: To document the clinicopathological features of prostate cancer in a cohort of Jamaican men, and to determine which of these features are of prognostic significance in this population. PATIENTS AND METHODS: The clinical and pathological findings in 99 patients with prostate cancer (diagnosed consecutively after biopsy, in the Department of Pathology at the University of the West Indies) between 1993 and 1997 were reviewed retrospectively. Biopsy specimens included 74 needle biopsies and 25 transurethral resection (TUR) specimens. RESULTS: The mean age at diagnosis was 72.3 years and 79 patients (80%) were symptomatic. The median (range, interquartile range) serum prostate-specific antigen (PSA) value at diagnosis was 37 (1-2100, 2-750) ng/mL; 63% of the patients had clinical stage T1 or T2 disease. Most (60%) of the cancers had a Gleason score of 8-10. Perineural invasion was present in a third of cases overall; high-grade prostatic intraepithelial neoplasia and periprostatic involvement were present in 18% and 8% of biopsies, respectively. The median percentage involvement of all biopsy samples was 37%, that for needle biopsies 47% and for TUR specimens 14%. Of the 90 patients with complete follow-up data, 37 (41%) died; the cause was progressive disease in 19 (51%). The mean (sd, range) survival was 41.3 (19.7, 1-73) months. On univariate analysis, age, PSA level, tumour stage, Gleason score, perineural involvement and periprostatic involvement were significantly associated with an increased risk of dying from prostatic cancer; in a multivariate model, PSA and tumour stage (4 vs. 1) were the only independent factors. CONCLUSIONS: The mean PSA values at the time of diagnosis, the median percentage of biopsy involvement by cancer and the number of patients with tumours of high histological grade were comparatively high, probably reflecting the patients' relatively late clinical presentation. Established prognostic markers were predictive of the risk of death from prostate cancer.

Histopathological findings in women with postmenopausal bleeding in Jamaica.

We investigated the histopathological findings in women presenting with postmenopausal bleeding in a population predominantly of African descent by conducting a six-year retrospective study of 716 gynaecological surgical specimens from 629 women accessed in the Department of Pathology, The University of the West Indies, Jamaica. Histopathological diagnoses were correlated with patients age, specimen volume, duration of bleeding and length of postmenopausal interval at presentation using t-tests and linear regression models. The mean (SD) age was 63.6 (9.3) years. The frequency of the main causes of postmenopausal bleeding was: endometrial hyperplasia (22.3%); endometrial atrophy (21.3%); non-diagnostic (19.9%); endometrial carcinoma (9.5%); cervical carcinoma (6.8%); cervical polyps (4.5%); endometrial sarcoma (3.5%); proliferative endometrium (3.2%). Mean (SD) duration of bleeding was 6.9 (12.7) months. The percentage of women with malignant lesions was two to three times greater than those reported in the United States of America and Europe subsequent to 1980. The delay between the onset of bleeding and presentation is worrisome and suggests the need for public education.

Angiomatosis of the breast in a male child. A case report with immunohistochemical analysis.

Angiomatosis is a benign vascular lesion that has been described rarely in the breast. We describe a case in a seven-year-old boy of African descent who presented with progressively increasing, unilateral breast enlargement, the first such report in a male child. The patient underwent excisional biopsy of the breast mass followed by mastectomy. Pathologic examination revealed a diffuse proliferation of variably-sized, thin-walled vascular channels lined by flattened endothelium that showed negative immunohistochemical staining for von Willebrand factor, factor VIII-related antigen, CD34 and S-100 protein. There is no evidence of recurrence after 24 months of follow-up.

Fatal head trauma from tree related injuries.

Two cases of death following tree related injuries are presented. Two females, an elderly woman and a child, suffered severe head trauma from falling objects from trees--a falling coconut and a falling branch respectively. Although this mode of injury has been previously documented, there have been no prior reports of in-hospital deaths in such patients. This uncommon cause of death is reviewed and recommendations made concerning its prevention.

Vaginitis emphysematosa associated with an abnormal Pap smear

Vaginitis emphysematosa is an uncommon inflammatory condition that is aetiologically linked to trichomonal or gardnerella infection, and has been associated with immunosuppressive disorders. The disease does not have deleterious sequelae and resolves on treating the underlying infection. We describe a case in which the disease predominantly affected the cervix leading to an abnormal pap smear and colposcopic investigation.

Vaginitis emphysematosa associated with an abnormal Pap smear.

Vaginitis emphysematosa is an uncommon inflammatory condition that is aetiologically linked to trichomonal or gardnerella infection, and has been associated with immunosuppressive disorders. The disease does not have deleterious sequelae and resolves on treating the underlying infection. We describe a case in which the disease predominantly affected the cervix leading to an abnormal pap smear and colposcopic investigation.

Severe pulmonary barotrauma

Pulmonary barotrauma is a well-known but rarely seen complication of mechanical intermittent positive pressure ventilation. It is thought to be related to raised pressures within alveoli which lead to their eventual rupture and the subsequent development of respiratory embarrassment. Mishaps related to faulty one-way valves in the self-inflating, bag-ventilation devices commonly used in cardiopulmonary resuscitation (CPR) can, although rarely, lead to severe barotrauma. In this report, we describe a case of pulmonary barotrauma that appeared to be related to the "locking" of the "Ambu" bag's one-way valve in the inspiratory position during routine CPR.

Autopsy rates at the University Hospital of the West Indies, 1968-1997.

Autopsy rates have not been reported at the University Hospital of the West Indies (UHWI) for more than three decades. Declining rates have been documented worldwide, and so we sought to define autopsy rates over the past three decades at UHWI. We conducted a retrospective analysis of the numbers and types of autopsies performed on deaths occurring in the institution, and calculated the relevant autopsy rates. The overall autopsy rate for the study period was 52.7%, with a statistically significant decline from 65.3% in the first decade to 39.3% in the third. The non-coroner's autopsy rate showed a concomitant decline from 57.5% to 31.5%, while the coroner's autopsy rate remained stable with a slight increase from 28.1% to 29.1%. The factors that might have led to the decline of the autopsy are discussed.

Severe pulmonary barotrauma.

Pulmonary barotrauma is a well-known but rarely seen complication of mechanical intermittent positive pressure ventilation. It is thought to be related to raised pressures within alveoli which lead to their eventual rupture and the subsequent development of respiratory embarrassment. Mishaps related to faulty one-way valves in the self-inflating, bag-ventilation devices commonly used in cardiopulmonary resuscitation (CPR) can, although rarely, lead to severe barotrauma. In this report, we describe a case of pulmonary barotrauma that appeared to be related to the "locking" of the "Ambu" bag's one-way valve in the inspiratory position during routine CPR.

Testicular metastases from carcinoma of the prostate.

Secondary testicular tumours are uncommon and most originate from prostatic carcinoma. A retrospective study of the clinico-pathological features of prostatic carcinoma metastatic to the testes was conducted in the Department of Pathology, University of the West Indies, Jamaica, for the period June 1958 to January 1998. Metastatic prostatic carcinoma was seen in 1.4% of the 284 orchiectomy specimens examined. A brief review of the literature related to this entity was undertaken.