Diagnostic value of conidia associated with pulmonary oxalosis: evidence of an Aspergillus niger infection.

Bronchoalveolar lavage (BAL) material is commonly received in cytopathology for the exclusion of microorganisms. When crystalline material suggestive of calcium oxalate is present in the specimen, a search for fungal elements should be undertaken. Aspergillus niger is the hyaline mold associated with the presence of oxalate crystals. Commonly fragments of hyphae and occasionally entire conidiophores may be present in BAL specimens from patients with aspergillosis. We report a case of a patient with saprophytic colonization of a bullous/cavitary lesion. The BAL consisted of abundant acute inflammation, crystalline material suggestive of oxalate, and darkly pigmented conidia. Although an extensive search was undertaken, hyphal fragments could not be found. The suspicion of an A. niger infection was confirmed by culture. We believe that even in the absence of hyphal fragments, darkly pigmented, occasionally rough-walled conidia are sufficient evidence to be highly suspicious of an A. niger infection in patients with pulmonary oxalosis.

Clinical significance of an inconclusive cytopathologic diagnosis: a five-year experience at Duke University Medical Center. II. Analysis and follow-up of specimens from the respiratory tract.

OBJECTIVE: As a follow-up of our initial report, we critically examined a selected number of cases from the respiratory tract with an original diagnosis of "atypical cells present suspicious for malignancy" in order to ascertain if any particular features of the specimen or the atypical cells were predictors of malignancy. STUDY DESIGN: From a total of 563 such cases, 31 were identified with subsequent histologic findings of a nonneoplastic pathologic process. An additional 45 cytologic cases were randomly selected to represent those with subsequent histologic findings confirming the suspicion of malignancy. All the cytologic specimens were examined without knowledge of the histologic follow-up results. RESULTS: Analysis of the cellular composition of the specimens identified no discernible difference between specimens from benign and malignant processes. Quantitative analysis of the atypical cells and qualitative assessment of the nuclear abnormalities revealed that marked nuclear hyperchromasia and a very high nuclear/cytoplasmic ratio were more likely to represent a malignant process. However, none of the parameters examined could consistently predict the presence or absence of malignancy. CONCLUSION: When a single cytologic specimen is inconclusive as to the presence or absence of malignancy, standard cytologic criteria cannot reliably predict a malignant process.

Endoscopic brush cytology of the upper urinary tract. Evaluation of its efficacy and potential limitations in diagnosis.

OBJECTIVE: To evaluate the efficacy of endoscopic brush cytology in diagnosing transitional cell carcinoma of the upper urinary tract. STUDY DESIGN: Sixty-three endoscopic brush cytology specimens from 48 patients were compared with corresponding cytologic specimens obtained by irrigation and catheterization as well as histologic specimens. RESULTS: Twenty patients (25 brushes) had histologically documented transitional cell carcinoma (TCC) or carcinoma in situ (CIS) of either the ureter or renal pelvis. Among these, 8 (32%) of the brush samples were reported as positive for TCC, 10 (40%) atypical or suspicious, and 7 (28%) negative. The seven negative cases were ultimately shown to be low grade (I-II/IV) TCC. Combining atypical and positive diagnoses, the calculated sensitivity for diagnosis of TCC by this technique was 72%. The irrigations or catheterized urines from these same patients yielded lower sensitivity, 48%, and detected only higher grade lesions. Ten patients were proven histologically to have nonneoplastic disease (hydroureter, obstruction, inflammation). Sixteen of the 17 brush specimens from these patients were negative, resulting in a specificity of 94%. In the remaining 18 patients (21 brushes) there were 17 negatives and 4 atypicals. Concomitant cytology supported the brush diagnosis in all but one sample. CONCLUSION: Brush cytology is a specific and more sensitive sampling method than irrigation or catheterized urine in detecting TCC of the upper urinary tract. Brush cytology does not appear to be successful in diagnosing dysplasia or CIS. As with urinary cytology in general, the technique is less effective in diagnosing low grade (I and II) lesions.

Metastatic lobular carcinoma of the breast diagnosed in cervicovaginal samples. A case report.

BACKGROUND: Malignant tumors with extragenital origins are rare in cervicovaginal samples. CASE: A case of metastatic lobular carcinoma of the breast was diagnosed in a cervicovaginal smear. Histologic correlation was performed. Marker studies for carcinoembryonic antigen, human milk fat globule membrane, epidermal growth factor receptor, epithelial membrane antigen and cytokeratin were positive. CONCLUSION: Recognition of extrauterine cancer in the cervicovaginal smear has important diagnostic, prognostic, and therapeutic implications.

Epithelial repair of the uterine cervix: assessment of morphologic features and correlations with cytologic diagnosis.

This study evaluates the morphologic features of squamous epithelial repair of the uterine cervix, a condition describing a state of regeneration, and compares them with the features of its two histologic mimics, squamous metaplasia and mild dysplasia. The materials examined were from 20 patients with a histologic diagnosis of repair, 42 with cervical biopsy specimens of acceptable quality obtained within 3 weeks of a cervical smear showing repair, and 20 each with squamous metaplasia or mild dysplasia. Specimens with repair disclosed distinctive morphologic characteristics. On low-power magnification, the stroma was chronically inflamed (100%), often floridly (55%). The nuclei were uniform with absent or minimal pleomorphism (90%). The chromatin was bland and evenly distributed (70%). Nucleoli of a bull's eye or macronucleolar appearance (45%) were easily found. Mildly dysplastic epithelium, unlike reparative epithelium, was infrequently associated with an intensely inflamed stroma (20%); its nuclei were pleomorphic (100%) and commonly displayed coarse chromatin (75%) and mitoses (60%). Metaplastic epithelium ws also infrequently associated with an intensely inflamed stroma (10%). Nuclear pleomorphism (10%) and mitotic figures were infrequent (10%), never atypical (0%), and always basally located. Most nuclei had nucleoli, but the majority were small (80%). This study indicates that most cases of repair, mild dysplasia, and metaplasia can be readily distinguished, although due to overlapping features, some cases are difficult to classify as shown by interobserver variability.

Prospective correlation of cervicovaginal cytologic and histologic specimens.

An effective, prospective, computer-guided method of correlation is reported. The mechanism for identification of cases, comparison of diagnoses, and reconciliation of discrepancies are explained. The results are similar to prior, retrospective, correlation studies. The benefits specific to this unique prospective approach include optimal capture of cases for correlation, minimization of errors before diagnoses are released to clinicians and patients, and internal standardization of diagnostic criteria. Three thousand four hundred and four consecutive paired cervicovaginal cytologies and biopsies were accessioned at the Pathology Department of Duke University Medical Center over a 43-month period. Of these, 481 paired cases (14%) had discordant diagnoses, defined as differing more than one degree of dysplasia or as dysplasia or carcinoma identified by only one modality. Additional evaluation reconciled the diagnostic differences in 35 cases. Eighteen initial diagnostic differences arose from cytologic screening errors, 16 from interpretive errors by staff pathologists, and one from superficial initial histologic sections. The remaining 446 discordances were attributed to sampling differences. The cytologic smear contained the diagnostic lesion in 40% of the cases and the biopsy the remainder, emphasizing the utility of pairing these sampling techniques in patients at risk for dysplasia.

Transthoracic fine needle aspiration biopsy. Sensitivity in relation to guidance technique and lesion size and location.

OBJECTIVE: To obtain site- and size-specific data on transthoracic fine needle aspiration (TFNA) and determine the sensitivity in relation to guidance technique and lesion size and location. STUDY DESIGN: Data on 112 patients undergoing TFNA between 1992 and 1993 were analyzed for accuracy rates, stratified according to lesion size and location within the lung. The series included 13 benign lesions, 53 metastatic neoplasms and 46 primary carcinomas. RESULTS: Overall sensitivity was 90%, with 92% specificity. There was a clear relationship between nodule size and sensitivity of TFNA, with a sensitivity of 60% for lesions < 1 cm but 93% sensitivity for nodules > or = 2 cm in diameter. Similarly, lesion location affected sensitivity. Sensitivity was 100% for peripherally located nodules but was as low as 82% for nodules in the centrobasal portion of the lung. Sensitivity was higher for fluoroscopy (97%) than computed tomography (80%). CONCLUSION: The guidance technique as well as lesion location and size affect diagnostic accuracy.

Detection of tumor cells in the bone marrow of stage IV breast cancer patients receiving high-dose chemotherapy: the role of induction chemotherapy.

High-dose chemotherapy and hematopoietic support can produce long-term, disease-free remissions in selected patients with metastatic breast cancer. Occult bone marrow involvement may contribute to late relapse. We used five anti-breast cancer monoclonal antibodies and flow cytometry with cytological analysis of sorted immunostained cells to detect tumor cells in the bone marrow in two cohorts of patients. The first (Upfront) cohort was treated with a single course of high-dose chemotherapy and autologous bone marrow support (ABMS) without induction chemotherapy. The second (AFM) cohort received induction chemotherapy with doxorubicin, 5-fluorouracil and methotrexate prior to high-dose chemotherapy and ABMS. Of the 15 Upfront patients, seven (47%) had immunostained cells in the harvested bone marrow by flow cytometry and 8/15 (53%) had positive cytologies. Of the 49 AFM patients studied, nine (18%) had immunostained cells in the bone marrow, and only 1/49 (2%) had positive cytologies. Induction chemotherapy significantly decreased bone marrow contamination as detected by flow cytometry and cytology in patients with breast cancer. The detection of immunostained cells in the bone marrow did not predict for relapse or overall survival.

The current status of the Papanicolaou smear.

Since its introduction as a screen for cervical cancer in the late 1940s, the Pap smear has become one of the most widely accepted screening procedures for cancer. Numerous scientific studies have now attested to its effectiveness. However, important issues related to the Pap smear, including cytologic nomenclature, accuracy, regulatory procedures, and screening guidelines, are still being evaluated and debated. This article provides an overview of important issues related to the Pap smear.

Cervical-vaginal and intraanal human papillomavirus infection of young girls with external genital warts.

To expand information regarding the epidemiology of genital human papillomavirus (HPV) infection in young girls, girls with external genital warts were examined for the prevalence of cervical-vaginal or intraanal HPV infection. Cervical-vaginal wash specimens and biopsies of external lesions were examined for HPV genotypes 1, 2, 4, 6, 11, and 16 using Southern transfer hybridization with restriction endonuclease fragment length analysis. Exfoliated cells from cervical-vaginal and intraanal canals were processed for cytologic study. Of 18 girls, 8 (44%) had cytologic or genomic evidence (or both) of cervical-vaginal or intraanal HPV infection. Five had cervical-vaginal wash specimens that were positive for HPV genome and showed mild dysplasia. As is true for adults, young girls with external anal-genital warts are also frequently infected with HPV at internal mucosal sites. Determining the immediate and long-term prognosis of infected children and those with intraepithelial neoplasia will require appropriate prospective studies.

Vaginal administration of low-dose conjugated estrogens: systemic absorption and effects on the endometrium.

OBJECTIVE: To test the hypothesis tha a very-low-dose regimen of vaginal estrogen would provide effective relief from atrophic vaginitis without endometrial proliferation. METHODS: Twenty postmenopausal women with symptoms, signs, and cytologic evidence of atrophic vaginitis were enrolled. Each subject was treated with 0.3 mg of conjugated estrogens, administered vaginally 3 nights per week for 6 months. We examined the following outcomes: symptoms, vaginal cellular (cytologic) maturity, endometrial histology, sonographic evaluation of endometrial thickness, Doppler measures of uterine artery blood flow, and serum levels of estrone and estradiol. Pre- and post-treatment data were compared for each subject. RESULTS: Satisfactory relief of symptoms occurred in 19 of 20 cases. Vaginal cellular maturation improved significantly with therapy (P < .01). There were no significant changes in endometrial thickness, uterine artery blood flow, or serum estrogen levels. Endometrial proliferation was observed in one case. CONCLUSIONS: Relief from atrophic vaginitis can be achieved with 0.3 mg of conjugated estrogens administered vaginally three times per week. Endometrial proliferation may occur at this low dose, albeit rarely.

Clinical significance of an inconclusive cytopathologic diagnosis. I. Positive predictive value.

We retrospectively analyzed the pathology database of 1,057 patients at Duke University Medical Center who received an inconclusive cytopathologic diagnosis during the five-year period 1984-1989 in an attempt to answer the question, what is the significance of a cytopathologic diagnosis of "atypical cells are present that are suspicious for, but not diagnostic of, malignancy?" We identified 1,110 cytologic specimens from all body sites receiving this diagnosis, and of them, 805 (73%) had a follow-up specimen from the same anatomic site that was definitive as to the presence or absence of malignancy; 305 (27%) had no follow-up specimen. Of the follow-up specimens, 596 (74%) were histopathologic specimens, and 209 (26%) were cytopathologic. Specimens from the respiratory tract accounted for 51% (563) of the cases, and the positive predictive value (PPV) of an inconclusive diagnosis at this site was 85%. Of the remaining specimens, those from the urinary (10%) and genital (8%) tracts were the most common, and the PPVs of an inconclusive diagnosis at these sites were 83% and 61%, respectively. The overall PPV of an inconclusive cytologic diagnosis from all body sites was 80% and ranged between 57% and 93%, depending on the anatomic site.

Immunohistochemical detection and significance of axillary lymph node micrometastases in breast carcinoma. A study of 97 cases.

Paraffin blocks of all axillary lymph nodes from 97 patients with an initial histologic diagnosis of infiltrating ductal carcinoma and negative axillary nodes were recut and stained with two monoclonal antibodies, AE/AE3 (antikeratin) and DF3 (developed against breast cancer cells and reactive with a glycoprotein tumor-associated antigen). Immunohistochemical staining detected occult micrometastases in 20 patients (20.6%). No patient had more than three lymph nodes involved by tumor. Review of the original hematoxylin and eosin-stained sections revealed that foci of tumor were initially overlooked in nine of these cases (9.3%). In the remaining 11 cases (11.3%) the metastatic foci were encountered in the process of recutting the paraffin blocks for immunohistochemical studies. AE1/AE3 proved to be the more effective of the two antibodies in staining micrometastases. After a mean follow-up period of 5.7 years, no significant decrease in survival or increase in tumor recurrence was detected for patients with occult micrometastases as compared to those patients without micrometastases.

Application of a panel of antiganglioside monoclonal antibodies to cytologic specimens.

The cytologic evaluation of poorly differentiated tumors frequently poses a diagnostic dilemma as to the tissue of origin. To assess the diagnostic utility of monoclonal antibodies (MAbs) in these situations, we applied a panel of three highly purified MAbs specific for tumor-associated ganglioside epitopes to a diverse series of cytologic specimens. The panel was composed of DMAb-3, reactive with the epitope GalNAc beta 1-4 (NeuAc alpha 2-3)Gal- of GM2; DMAb-7, reactive with the epitope (NeuAc alpha 2-8NeuAc alpha 2-3)Gal beta 1-4(Glc or GlcNAc)- of GD3 and 3'8'-LD1; and DMAb-20, reactive with the epitope GalNAc beta 1-4(NeuAc alpha 2-8NeuAc alpha 2-3)Gal- of GD2. The cytologic material consisted of air-dried Cytospin preparations prepared predominantly from fine needle aspirates and stained with the ABC immunohistochemical method. Positive reactivity was recognized when greater than 5% of tumor cells stained with the antibody; lesser reactivity was called negative. DMAb-3 stained 9/14 (64%) glial tumors, 4/13 (31%) nonglial central nervous system tumors, 1/21 (5%) melanomas, 7/38 (18%) non-small cell carcinomas (NSCC), 1/15 (7%) small cell carcinomas (SCC), 0/9 (0%) lymphomas/leukemias, 2/10 (20%) sarcomas, 1/7 (14%) miscellaneous tumors and 2/2 (100%) reactive fluids. DMAb-7 recognized 14/14 (100%) glial tumors, 9/13 (69%) non-glial central nervous system tumors, 19/22 (86%) melanomas, 19/43 (44%) NSCC, 5/15 (33%) SCC, 2/9 (22%) lymphomas/leukemias, 6/10 (60%) sarcomas, 1/7 (14%) miscellaneous tumors and 4/4 (100%) reactive fluids. DMAb-20 stained 6/14 (43%) glial tumors, 2/13 (15%) nonglial central nervous system tumors, 1/21 (5%) melanomas, 4/38 (10%) NSCC, 0/15 (0%) SCC, 0/9 (0%) lymphomas/leukemias, 1/10 (10%) sarcomas, 1/7 (14%) miscellaneous tumors and 1/3 (33%) reactive fluids. The GD3-reactive DMAb-7 recognized a large portion of many tumor types and thus is not diagnostically useful alone. DMAb-3 and DMAb-20 were more selective and showed the strongest reactivity for glial tumors and minimal reactivity for melanomas, small cell carcinomas, and lymphomas or leukemias. DMAb-3 and DMAb-20 may be useful as components of a larger panel of MAbs in distinguishing between poorly differentiated tumors in samples derived from the central nervous system.

Evaluation of sexually abused and nonabused young girls for intravaginal human papillomavirus infection.

OBJECTIVE: The objective of this study was to compare the prevalence of intravaginal human papillomavirus-associated disease in two groups of girls to develop information regarding the means of transmission of anal-genital human papillomavirus disease. DESIGN: A pair of parallel studies of prevalence of human papillomavirus infections in two populations of prospectively enrolled girls. PATIENTS: Index patients consisted of 15 consecutive girls aged 11 years or younger who were confirmed to have been sexually abused, had signs or symptoms of vaginal disease, and required generalized anesthesia for evaluation. Selection of nonabused control patients was based on negative findings from screening evaluations and physical examinations. MAIN OUTCOME MEASURES: Prevalences of cervical-vaginal human papillomavirus infections in the two populations were compared. Vaginal wash samples from index and control patients were assayed for human papillomavirus 1, 2, 4, 6, 11, and 16 by reverse-blot and Southern transfer hybridization methods. Papanicolaou smears were examined from index patients. RESULTS: Vaginal wash samples from five (33%) of 15 index patients were positive for human papillomavirus 6, 11, or 16, compared with none of 17 controls. The presence or absence of external anal-genital warts was not correlated with results from the assay of intravaginal samples. Blinded readings of vaginal exfoliative cytologic findings of the index patients showed koilocytosis, atypia, or inflammatory reactions in four of five human papillomavirus-positive girls, and normal cytologic findings in one human papillomavirus-positive girl. CONCLUSION: These findings support other studies that indicate that sexual contact is a major route in the transmission of anal-genital human papillomavirus-related disease in children. Evaluation of intravaginal specimens was required to identify human papillomavirus-infected girls since the results of the wash samples were not correlated with the presence or absence of external anal-genital warts.

CA 72-4 radioimmunoassay in the diagnosis of malignant effusions. Comparison of various tumor markers.

We evaluated the utility of the CA 72-4, CEA, CA 125, CA 19-9 and CA 15-3 radioimmunoassays for the detection of tumor-associated antigens (TAAs) in effusions of malignant vs. benign origin. Fluids were obtained from 51 patients with adenocarcinomas, 27 with non-epithelial malignancies, and 68 with benign disorders. The CA 72-4 radioimmunoassay (cut-off value 8.5 U/ml) detected the TAG-72 antigen in 51% of adenocarcinoma patients' effusions, while only 1 of 68 benign specimens had an elevated TAG-72 level. Similarly, CEA levels above 5 ng/ml were found in 55% of the fluids from patients with adenocarcinoma and 3.2% of effusions from patients with benign disease. CA 19-9 (cut-off value 37 U/ml) exhibited a lower degree of sensitivity, with positive values in 23.5% of the effusions due to adenocarcinomas and in 4.5% of the effusions due to benign disease. At a cut-off value of 29 U/ml, CA 15-3 was positive in 49% of fluids from patients with adenocarcinoma and in 3.0% of the benign fluids. The CA 125 RIA failed to show any specificity using the established cut-off value of 35 U/ml, with approximately 80% of all the effusions giving positive results. The specificity of the assay was increased by using a cut-off value of 3000 U/ml, but with a substantial loss in sensitivity (23.5%). Using a combination of the CA 72-4 and CEA RIAs the sensitivity for malignant effusions was increased to 73.5%. No additional improvement in the overall sensitivity was observed when using the CA 72-4 assay in combination with assays for the other markers, except in the case of 1 effusion. We conclude that the CA 72-4 RIA, possibly in combination with other assays such as CEA, may be useful in distinguishing between adenocarcinomatous and benign effusions.

Detection of breast carcinoma cells in human bone marrow using fluorescence-activated cell sorting and conventional cytology.

Flow cytometry has been compared with conventional cytology as a method for detecting breast carcinoma cells in human bone marrow. Breast cancer cells from patient effusion fluids or from established cell lines were mixed with normal human bone marrow at dilutions ranging from 1:10 to 1:100,000. Cells were labeled with five directly fluoresceinated murine monoclonal antibodies reactive against epithelial cell surface determinants of 42, 55, 72, 200, and more than 200 kD. Fluorescence of tumor cells within the mixtures was then analyzed with the use of a fluorescence-activated cell sorter. In multiple experiments, one tumor cell in 10,000 nucleated marrow cells could be detected by flow cytometry. In addition, a linear correlation was observed over approximately 3 logs between the number of tumor cells added and the number of tumor cells detected. In a double-blind study comparing flow cytometry and cytology, flow cytometric analysis detected one tumor cell among 10,000 marrow precursors in 14 of 15 instances, whereas standard cytologic methods detected similar tumor contamination in 9 of 15 instances. Neither technique used individually could detect one tumor cell in 100,000 bone marrow cells. Used in combination, however, flow cytometry and cytology could detect one breast cancer cell among 100,000 normal marrow progenitors.