[Gastrointestinal tuberculosis as the main manifestation of systemic tuberculosis]. / Darmtuberkulose als Hauptmanifestation einer systemischen Tuberkulose.

We describe a rare case of tuberculosis with mainly gastrointestinal problems. The 52-year-aged female patient came to hospital with unclear pain in the lower abdomen and ascites that was refractory to therapy. The computed tomography of the thorax showed right-sided confluating lymphoid nodes, the CT of the abdomen showed ascites and nodular structures near the coecum. Tissue samples were taken from the mucosa of the colon, the inflammatory altered peritoneum, the left bronchus of the upper lobe and the confluating lymphoid nodes in the mediastinum during colonoscopy, diagnostic laparoscopy and bronchoscopy. The samples from the peritoneum showed granulomas with caseating necroses in histological slices. Mycobacterium tuberculosis was detected by PCR in the tissue samples from the lymphoid tissue of the mediastinum. Furthermore, Mycobacterium tuberculosis grew in cultures from samples of the abdominal ascites. The symptoms and pathological findings improved under a therapy comprising isoniazid, rifampicin, ethambutol and pyrazinamid.

[New insights into the role of estogens and their receptors in prostate cancer]. / Neue Einblicke in die Rolle der Ostrogene und ihrer Rezeptoren im Prostatakarzinom.

The present review gives a survey on the differential expression of estrogen receptors alpha and beta (ERalpha, ERbeta) and the progesterone receptor (PR) in human prostate tissue and discusses their potential implications for normal and abnormal prostatic growth. The differentiation compartment of the prostatic epithelium (secretory luminal cells) expresses high levels of ERbeta, while the ERalpha is restricted to the proliferation compartment (basal cells). In high-grade prostatic intraepithelial neoplasia (HGPIN), ERalpha gene expression extends to luminal cells and thus may mediate cancerogenic effects of estrogens on the dysplastic epithelium. Conversely, the ERbeta is downregulated in HGPIN indicating that the chemopreventive effects of phytoestrogens mediated by the ERbeta are partially lost. Irrespective of grades and stages, prostate cancer retains high levels of the ERbeta, which is partially lost in androgen-insensitive stages of the disease. In contrast with breast cancer, the presence of the ERalpha and the progesterone receptor (PR) is a late event in prostate cancer progression. At least 30% of metastatic and androgen-insensitive tumors express high levels of the PR indicating that these tumors harbor a functional ERalpha. The antiestrogen raloxifene has growth-inhibitory effects on androgen-insensitive prostate cancer cells in vitro and induces apoptotic cell death in a dose-dependent fashion. These data provide a rationale for clinical trials to study the efficiency of antiestrogens in the medical treatment of advanced prostate cancer.

Early diagnosis of mesothelioma in serous effusions using AgNOR analysis.

OBJECTIVE: To compare the results of conventional cytology, DNA image cytometry, immunocytochemistry and argyrophilic nucleolar organizer region (AgNOR) analysis for the diagnosis of malignant cells in serous effusions. STUDY DESIGN: One hundred twenty effusions, 40 with carcinoses, 40 with malignant mesotheliomas and 40 without tumor cells on follow-up were studied by conventional cytology and three adjunctive methods. RESULTS: Unequivocal tumor cells were detected in 92.5% of effusions due to carcinoses and in 45% due to mesotheliomas. Applying immunocytochemistry with BerEP-4 positivity and DNA image cytometry with aneuploidy as a marker revealed 100% of carcinoses and 71.7% of mesotheliomas. Applying the experimentally found thresholds of 2.5 AgNORs as "satellites" and 4.5 AgNORs as "satellites and clusters" together as mean values per nucleus resulted in a 95% correct rate of mesothelioma and 100% rate of carcinoma cell identification without false positive diagnoses. CONCLUSION: AgNOR analysis may be a useful adjunct to other methods in the routine diagnosis of malignant serous effusions. It seems to be the most sensitive method in early cytologic diagnosis of mesotheliomas in effusions. Seventy-three percent of malignant mesotheliomas were diagnosed cytologically at first on effusions. Forty-seven percent of patients with malignant mesotheliomas were identified at the early tumor stage T1 N0 M0.

Cytologic and DNA cytometric diagnosis and therapy monitoring of squamous cell carcinoma in situ and malignant melanoma of the cornea and conjunctiva.

OBJECTIVE: To investigate the diagnostic accuracy of exfoliative cytology of the cornea and conjunctiva and DNA image cytometry for quality control and monitoring of therapy for malignant neoplasms. STUDY DESIGN: Conjunctival or corneal smears from six cases clinically suspicious for malignant melanomas and eight suspicious for carcinomas in situ were investigated. Smears from 18 cases clinically nonsuspicious for neoplastic diseases served as negative controls. Repeated smears were obtained during and after local mitomycin C (MMC) therapy. RESULTS: In none of 18 nonsuspicious cases, cytology revealed abnormal cells. DNA cytometry showed nonaneuploidy in all of these. All smears from patients with histologically proven malignant melanomas (MM) and squamous cell carcinomas in situ revealed abnormal cells. Image cytometry demonstrated DNA aneuploidy in 66.6% of patients with MM and 80% with carcinoma. Sensitivity of cytology thus was 100% for both MM and carcinoma; specificity also was 100%. DNA measurements after MMC therapy revealed euploid polyploidization of nonneoplastic squamous cells. DNA cytometry provided an objective identification of tumor cell regression. CONCLUSION: Cytologic examination of corneal and conjunctival smears is a noninvasive tool with high diagnostic accuracy for detection of epithelial neoplasms. DNA image cytometry can serve for quality control and for objective monitoring of the effect of local chemotherapy.

Early occurrence of an adenocarcinoma after allogeneic bone marrow transplantation in a patient with AML.

Several reports have showed an increased risk of secondary malignancies after bone marrow transplantation (BMT), especially after total body irradiation (TBI). We report on a 39-year-old female who underwent BMT with a matched unrelated donor because of acute myeloid leukemia in second complete remission. Previously, the patient received chemotherapy for induction, consolidation, maintenance and reinduction after diagnosis of relapse. Conditioning regimen consisted of cyclophosphamide and TBI. MTX and CSA was administered for GvHD prophylaxis. Engraftment was confirmed on day 28. Within 6 months following BMT, no complication occurred. Continuous complete remission was demonstrated by repeated bone marrow smears. On day 300 the patient complained of chest pain and dyspnea. X-ray and CT-scan showed thickening of the pleura and pleural effusion. A pleuracarcinosis was diagnosed by cytologic examination of a pleural aspirate. By an open thoracotomy a disseminated inoperable disease became apparent. Diagnosis of an adenocarcinoma was confirmed by histologic examination. The patient died 2 months later due to disseminated tumour in complete remission of AML. Solid tumours are rare as secondary malignancies after BMT. Usually the neoplasmas are late events occurring more than 10 years after BMT. In this case predisposing factors such as genetic disposition, long-term smoking, intensive pretransplant chemotherapy, TBI and immunosuppression may have lead to the early secondary malignancy.

Diagnostic accuracy of effusion cytology.

The aim of this investigation was to report on the diagnostic accuracy of conventional effusion cytology. Cytological diagnoses of 300 pleural effusions and 300 ascites were compared with clinical and/or histological follow-ups of the respective patients. Sensitivity of our cytological diagnoses on pleural effusions was 50.0%, specificity 97.0%, positive predictive value 95.7%, and negative predictive value 86.4%. Sensitivity in ascitic effusions was 62.4%, specificity 98.0%, positive predictive value 100.0%, and negative predictive value 88.3%; 5.8% of diagnoses for pleural and 4.4% for peritoneal effusions were suspicious or doubtful. The overall false-positive rate was 0.5%, while the false-negative rate was 31.5%. False-negative results were due to sampling errors in 71% of pleural and 73% of peritoneal effusions and to screening errors in 29% and 27%, respectively. Our data and those from the literature show that diagnostic accuracy of effusion cytology is still unsatisfactory and should be improved. Therefore, the use of different adjuvant methods is recommended.

[Assessment of cervical dysplasia with DNA image cytometry]. / Abklärung zervikaler Dysplasien mittels DNA-Bild-Zytometrie.

Dysplastic epithelia represent potentially precancerous conditions in which the risk of progression to cancer is unknown in the individual case. The positive predictive value of mild and moderate dysplasias of the uterine cervix is only about 13%. Using DNA image cytometry on restained, conventional Papsmears the cytometric equivalent of chromosomal aneuploidy can be detected as marker for neoplastic transformation of cells. The identification of DNA aneuploidy in dysplastic squamous epithelia can increase the predictive value for malignant transformation to over 90%. DNA aneuploidy qualifies squamous intraepithelial lesions as high grade (H-SIL) which have to be treated whereas lack of DNA aneuploidy characterizes low grade squamous intraepithelial lesions (L-SIL) which have only to be controlled. The methodology is meanwhile internationally standardized concerning performance and diagnostic interpretation.

Semiautomated monolayer preparation of bronchial secretions using AutoCyte PREP.

OBJECTIVE: Development of a method for semiautomated preparation of purified, representative and conventionally stained monolayer smears from bronchial secretions suitable for subjective and/or automated cytodiagnosis. STUDY DESIGN: Bronchial secretions from 50 patients with and 48 without carcinoma cells of different types were collected in Saccomanno's fixative. After routine pick-and-smear processing, residual material was subjected to a mucolytic agent (ammonium thioglycolate). Separation of cells was performed by differential centrifugation through aqueous sucrose. The pellet was automatically processed by the AutoCyte PREP system. RESULTS: Slides revealed well-preserved, slightly shrunken, homogeneously distributed cells devoid of mucus, cellular debris and bacteria in monolayer arrangement nearly without overlap. Granulocytes were eliminated to a large extent. Comparison with pick-and-smear specimens showed more tumor cells per square centimeter of slide surface in 100% of AutoCyte PREP slides. The number of tumor cells per AutoCyte PREP slide was higher in 46% and lower in 54%. Selecting slides at random and requiring at least 10 abnormal cells to establish a tumor diagnosis were achieved in 82.7% if only one, in 88.0% if two and 94.0% if seven or eight AutoCyte PREP slides were investigated. CONCLUSION: The semiautomated method yielded conventionally stained, purified monolayer smears from bronchial secretions with cellular morphology suitable for evaluation by cytologists and screening machines. Representativity of AutoCyte PREP monolayers was superior to that of pick-and-smear slides.

DNA aneuploidy as a specific marker of neoplastic cells in FNAB of the thyroid.

OBJECTIVE: To investigate whether DNA image cytometry (ICM) could be of value in the specific identification of neoplastic cells in cytologic specimens of the thyroid. STUDY DESIGN: FNABs of thyroid from 162 patients with different benign and neoplastic diseases were investigated. Nuclear DNA content in thyroid cells was measured after Feulgen staining using a TV image analysis system. Data were correlated with clinical and histologic patient follow-up. The occurrence of abnormal DNA stemlines was used as a marker for aneuploidy and thus for neoplasia. RESULTS: None of the 89 cases without tumor cells revealed DNA aneuploidy. An abnormal DNA stemline was found in 55% of histologically proven benign thyroid tumors (follicular or oncocytic adenomas) and in 59.5% of malignant tumors. The positive predictive value of DNA aneuploidy in FNABs of the thyroid for neoplasms was 100%. The negative predictive value of DNA nonaneuploidy for the prediction of tumor-free histologic or clinical follow-up was 79.4%. CONCLUSION: DNA image cytometry may be helpful in the specific identification of neoplastic follicular cells. DNA ICM on FNABs of the thyroid is an additional tool to achieve early identification of patients with nodular lesions of the thyroid that have to be operated on. DNA euploidy excludes the presence of neither malignancy nor neoplasia.

Immunocytochemistry and DNA-image cytometry in diagnostic effusion cytology I. Prevalence of markers in tumour cell positive and negative smears.

To determine the prevalence of immunocytochemical positivities for a panel of antibodies in benign and malignant cells in effusions with known follow-up in order to use these as diagnostic markers. Besides their ability to identify malignant epithelial cells their contribution to the differential diagnosis between carcinomatoses and mesotheliomas was investigated. 101 tumour cell positive and 53 negative effusions were stained with 12 different antibodies. Results were scored semiquantitatively per cell type. Furthermore, DNA-image cytometry was performed. While prevalence of Ber-EP4 positivity was 95.4% in metastatic carcinoma cells, it was 0% in those from mesotheliomas. No cell type reacted with this marker in benign effusions (0%). Ber-EP4 correctly differentiated between metastatic carcinoma and mesothelioma in 98.0%. Prevalence of DNA-aneuploidy was 95.4% in metastatic carcinomas, 57.1% in mesotheliomas and 0% in reactive effusions. Combining immunocytochemistry (Ber-EP4 positivity) and DNA-image cytometry (aneuploidy) results in a 100% detection of metastatic carcinomatoses and 57.1% of mesotheliomas. Both markers furthermore allowed a correct differentiation of these entities in 98%.

Immunocytochemistry and DNA-image cytometry in diagnostic effusion cytology. II. Diagnostic accuracy in equivocal smears.

To determine sensitivity and specificity of different antibodies for the immunocytochemical detection of malignant cells in diagnostically equivocal effusions in comparison with those achieved by DNA-image cytometry. 65 cytologically doubtful effusions of the serous cavities were stained with twelve antibodies. Furthermore, DNA-image cytometry was performed. Data were correlated with patient follow-up. Sensitivity of cellular staining of Ber-EP4 for the identification of malignant cells was 77.8%, specificity of absent staining for benign cells was 100%. Positive predictive value for the identification of malignant cells was 100%, negative value 65.5%. Sensitivity of DNA-aneuploidy for the identification of malignancy was 82.9%, specificity of DNA-non-aneuploidy for benignity 94.7%. The positive predictive value of DNA-aneuploidy for the occurrence of malignant cells was 96.7%. Negative predictive value of DNA-non-aneuploidy was 72.0%. Combining immunocytochemistry applying Ber-EP4 only and DNA-cytometry in equivocal effusions resulted in a sensitivity of 88.9% for the identification of malignant cells associated with a 95.0% specificity. Positive predictive value was 97.7%, the negative one 79.2%.

Pleural carcinosis confirmed by adjuvant cytological methods: a case report.

We describe a case of a 43-yr-old woman presenting a progressive pleural effusion. The patient was known to have an acute myeloid leukemia in complete remission after allogenic bone marrow transplantation. Suspicion of pleural carcinosis was raised cytologically and confirmed by immunocytochemistry, DNA-cytometry, and atomic force microscopy. We emphasize the use of these additional methods for the distinction of adenocarcinoma cells in effusions from reactive mesothelial cells.

Static DNA cytometry as a diagnostic aid in effusion cytology: I. DNA aneuploidy for identification and differentiation of primary and secondary tumors of the serous membranes.

OBJECTIVE: To determine whether DNA aneuploidy is a sensitive and specific marker for the identification of tumor cells in effusions and whether the pattern of DNA aneuploidy can provide important information for the differential diagnosis of primary and secondary tumors of the serous membranes. STUDY DESIGN: One hundred eight malignant mesotheliomas as well as 102 metastatic carcinomas of the serous membranes were obtained from routine cytologic and histologic material. One hundred reactive effusions were investigated as controls. Nuclear DNA contents were measured after Feulgen staining using a TV image analysis system. RESULTS: DNA aneuploidy was assumed if abnormal DNA stemlines, a coefficient of variation of the first DNA stemline > or = 10%, or cells > 9c were observed. On this basis the prevalence of DNA aneuploidy in mesotheliomas was 83% for cytologic and 84% for histologic material. In effusions of metastatic carcinomas it was 100%. None of the 100 reactive effusions revealed DNA aneuploidy (prevalence, 0%). Positive predictive value for mesotheliomas was 100%; negative predictive value was 88% for cytologic and 82% for histologic material. Positive predictive value for metastatic carcinomas was 100%; negative predictive value was 100%. Seventy-two percent of the mesotheliomas revealed their greatest stemline within the range 1.80c-2.20c, whereas none of the metastatic carcinomas showed this stemline position. CONCLUSION: DNA image cytometry might be a very sensitive and highly specific, additional tool for identification of neoplastic cells in effusions as well as for the differential diagnosis of mesothelioma vs. metastatic carcinoma of the serous membranes.

Static DNA cytometry as a diagnostic aid in effusion cytology: II. DNA aneuploidy for identification of neoplastic cells in equivocal effusions.

OBJECTIVE: The sensitivity of conventional cytology for identification of neoplastic cells in effusions is unsatisfactory, about 58%. The rate of diagnostically equivocal effusions in routine cytology is about 6%. DNA aneuploidy has previously been proven to be a sensitive and specific marker for the identification of tumor cells in effusions. In the present study we determined if malignancy can be identified in cytologically equivocal cells in effusions using DNA aneuploidy as a marker, thus decreasing the rate of cytologically equivocal diagnoses in effusions. STUDY DESIGN: One hundred cytologically equivocal effusions of the serous cavities were obtained from routine diagnostic material. Nuclear DNA content was measured after Feulgen staining using a TV image analysis system. Data were correlated with patient follow-up. RESULTS: DNA aneuploidy was assumed if abnormal DNA stemlines, a coefficient of variation of the first DNA stemline > or = 10% or cells > 9c were observed. The sensitivity of DNA aneuploidy for the identification of malignancy was 55.9%. Specificity of DNA nonaneuploidy for benignity was 94.1%. The positive predictive value of the marker DNA aneuploidy for the occurrence of malignant cells was 97.9% since all but one DNA aneuploid case showed malignancy in follow-up. CONCLUSION: Image cytometry applying DNA aneuploidy as a parameter is able to detect the occurrence of malignant cells in cytologically equivocal effusions in about every second case. Thus, this method is able to increase diagnostic accuracy of conventional effusion cytology by decreasing the rate of diagnostically equivocal effusions.

Atomic force microscopy in effusion cytology.

OBJECTIVE: To investigate whether atomic force microscopy (AFM) in combination with classical light microscopy allows simple identification of surface structures of cells from pleural and ascitic fluids for diagnostic purposes in place of scanning electron microscopy (SEM). STUDY DESIGN: We examined a total of 180 cells obtained from 9 reactive pleural or peritoneal effusions, 14 associated with carcinomatosis from histologically confirmed tumors and 5 from mesotheliomas. Cells of interest were selected in air-dried, uncovered, May-Grünwald-Giemsa (MGG)-stained smears and subsequently investigated by AFM. Incorporation of a very compact AFM scanner into the nose piece of a conventional Axioscope light microscope allowed alternating application of both techniques. RESULTS: AFM was able to detect cell surface structures, such as microvilli, phagocytic pits, secretory blebs and lytic holes. The image resolution was sufficient but not as good as that with SEM. We found differences in number, length and diameter of microvilli between cells from mesotheliomas and from metastatic adenocarcinomas. CONCLUSION: As AFM can be carried out in combination with light microscopy quickly and easily on uncovered, MGG-stained smears, we propose this method as a suitable tool for obtaining additional useful information in routine cytologic diagnosis of effusions.