Improved cytodiagnostics and quality of patient care through double reading of selected cases by an expert cytopathologist.

Double reading may be a valuable tool for improving the quality of patient care by restoring diagnostic errors before final sign-out, but standard double reading would significantly increase costs of pathology. The aim of this study was to assess the added value of routine double reading of defined categories of clinical cytology specimens by specialized cytopathologists. Specialized cytopathologists routinely re-diagnosed blinded defined categories of clinical cytology specimens that had been signed out by routine pathologists from January 2012 up to December 2013. Major and minor discordance rates between initial and expert diagnoses were determined, and both diagnoses were validated by comparison with same-site histological follow-up. Initial and expert diagnoses were concordant in 131/218 specimens (60.1 %). Major and minor discordances were present in 28 (12.8 %) and 59 (27.1 %) specimens, respectively. Pleural fluid, thyroid and urine specimens showed the highest major discordance rates (19.4, 19.2 and 16.7 %, respectively). Histological follow-up (where possible) supported the expert diagnosis in 95.5 % of specimens. Our implemented double reading strategy of defined categories of cytology specimens showed major discordance in 12.8 % of specimens. The expert diagnosis was supported in 95.5 % of discordant cases where histological follow-up was available. This indicates that this double reading strategy is worthwhile and contributes to better cytodiagnostics and quality of patient care, especially for suspicious pleural fluid, thyroid and urine specimens. Our results emphasize that cytopathology is a subspecialization of pathology and requires specialized cytopathologists.

Fine-needle aspiration of thyroid tumors: identifying factors associated with adequacy rate in a large academic center in the Netherlands.

The goal of our study was to evaluate, and identify factors associated with, the adequacy rate of fine-needle aspiration (FNA) cytology of thyroid tumors to improve the quality of the procedure. We reviewed 1,611 cytological pathology reports of thyroid tumors of 871 patients between January 1998 and August 2008. The overall cytological adequacy rate was 53.9%. The freehand technique had significantly higher adequacy rates than the ultrasound (US)-guided technique (P < 0.001) regardless of size, tumor type, multinodularity, or location. Aspiration, performing specialist (endocrinologist versus radiologist), and size were the factors associated with adequacy rates. US-guided FNA is recommended in previous articles, but results in our clinic were in favor of freehand FNA. US guidance is a way to improve adequacy rates, but we would like to stress the importance of other factors like operator experience, education, and quality control in one's own institution before implementing techniques.

Promoter hypermethylation patterns in fallopian tube epithelium of BRCA1 and BRCA2 germ line mutation carriers.

BRCA1/2 germ line mutation carriers have a high risk of developing fallopian tube carcinoma (FTC), thought to occur through different early (p53 signatures) and later (dysplasia, intra-epithelial carcinoma) premalignant stages. Promoter hypermethylation of tumour suppressor genes is known to play a key role in (early) carcinogenesis. However, little is known about methylation in normal and (pre)malignant fallopian tube tissue. We identified 14 areas of p53 accumulation in the fallopian tubes of BRCA mutation carriers. Cells from these areas were harvested together with cells from adjacent benign appearing areas. An age-matched non-BRCA sporadic control group (n=13) and eight sporadic FTCs were included as negative and positive controls respectively. Methylation-specific multiplex ligation-dependent probe amplification was used to assess promoter methylation of 70 tumour suppressor genes in all samples. We observed a gradual increase in methylation from sporadic control tissue (median cumulative methylation index (CMI) 568.19) through normal tissue and from areas of p53 accumulation in BRCA carriers (median CMI 687.54 and 676.72) to FTC (median CMI 780.97). Furthermore, the methylation percentage of many individual tumour suppressor genes differed significantly between these groups, gradually increasing as for CMI. Between areas with and without p53 accumulation in BRCA mutation carriers no significant differences were found. In this paper, we have shown that BRCA mutation carriers display increased methylation of tumour suppressor genes in their non-malignant fallopian tube epithelium, closer to methylation levels in FTC than to normal sporadic tissue. Methylation could, therefore, play an important role in the increased risk of gynaecological malignancies in BRCA mutation carriers.

The impact of chronic endometritis on reproductive outcome.

OBJECTIVE: To assess the prevalence of chronic endometritis and the impact on the fertility of asymptomatic patients indicated for in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment. DESIGN: In the context of a randomized controlled trial, a hysteroscopy-guided endometrial biopsy was obtained and histologically examined. The live birth rate (including spontaneous pregnancies) after initiation of IVF/ICSI treatment of patients diagnosed with chronic endometritis was compared with the live birth rate of a randomly selected matched control group of patients without endometritis. SETTING: Two tertiary infertility care units. PATIENT(S): A total of 678 asymptomatic infertile women with a normal transvaginal ultrasound (TVS) who underwent diagnostic hysteroscopy before a first IVF/ICSI treatment cycle. INTERVENTION(S): Hysteroscopy guided endometrial biopsy. MAIN OUTCOME MEASURE(S): The prevalence of chronic endometritis and the live birth rate (including spontaneous pregnancies) within 3 years after initiation of the randomized controlled trial. RESULT(S): The prevalence of chronic endometritis in the 606 patients with an adequate biopsy was 2.8%. The cumulative live birth rate (including spontaneous pregnancies) did not significantly differ between patients with or without endometritis: 76% versus 54%. Also, the clinical pregnancy rate per embryo transfer was not significantly different (hazard ratio 1.456, 95% confidence interval 0.770-2.750). CONCLUSION(S): Chronic endometritis can be rarely diagnosed in a population of asymptomatic infertile patients with a normal TVS before a first IVF/ICSI treatment. Moreover, the reproductive outcome after initiation of IVF/ICSI was not found to be negatively affected by chronic endometritis. In conclusion, the clinical implication of chronic endometritis seems minimal.

Development and structure of the glandopreputial sulcus of the human clitoris with a special reference to glandopreputial glands.

The structure and development of the sulcus between the glans and prepuce of the human clitoris have hardly been investigated. Interest in its structure was raised when in the female, in contrast to the male, glands were found to develop from the solid lamella-like precursor of the glandopreputial sulcus. It prompted a further histological analysis of the sulcus in female fetuses and newborn and an extension of that study to clitorises of adult women. The investigation showed that in the clitoris, in contrast to the penis, the transformation of the glandopreputial lamella into the open sulcus was mostly incomplete and apparently remained so throughout life. As a most striking and probably exclusively female feature, two to eight eccrine glands developed from the base of the lamella in fetuses older than 14.5 weeks gestation. These glands formed secretory coils near and occasionally inside the adjacent distal corpora cavernosa. Some glands showed atresia, cystic dilatation, and squamous metaplasia. A remarkably similar picture was observed in the adult clitorises, in which the secretory coils were often found between the large blood vessels and nerves to the glans and were connected to the sulcus by long excretory ducts. All glands revealed unmistakably eccrine features. It is suggested that their secretion moistens the female glandopreputial sulcus, which is not lubricated by urethral secretion as in the male. The findings may explain the rare clitoral phimosis, cysts, and some pilonidal sinuses.

Ovarian metastasis in a transposed ovary 10 years after primary cervical cancer: the importance of histologic examination and review of literature.

Cases of cervical carcinoma metastasing to the transposed ovary are rarely reported in the literature. In this report, the authors present the case of a 53-year-old woman with a persisting, unsuspected cyst in the right transposed ovary, 10 years after treatment for adenosquamous carcinoma of the cervix. It is the first report describing a secondary ovarian malignancy originating from a cervical adenosquamous carcinoma in a transposed ovary. In addition, this is the first account of an ovarian metastasis 10 years after primary treatment for cervical cancer. Furthermore, pathologic examination with immunohistochemistry and human papillomavirus genotyping played a key role in the diagnostic process, as the case did not raise suspicion by ultrasound findings neither by cytological examination after cytological aspiration or by appearance during surgery.

The influence of the b-value combination on apparent diffusion coefficient based differentiation between malignant and benign tissue in cervical cancer.

PURPOSE: To analyze the influence of different b-value combinations on apparent diffusion coefficient (ADC)-based differentiation of known malignant and benign tissue in cervical cancer patients. MATERIALS AND METHODS: A total of 35 patients with stage IB1, IB2, IIA cervical cancer underwent a 3.0T MRI scan prior to radical hysterectomy and pelvic lymph node dissection. Conventional T1- and T2-weighted sequences and a diffusion-weighted sequence (b = 0, 150, 500, 1000 seconds/mm(2)) were performed. Regions-of-interest (ROI) were drawn on ADC maps derived from five different b-value combinations (0, 500; 0, 150, 500; 0, 1000; 0, 150, 500, 1000; 150, 500, 1000 seconds/mm(2)). The influence of the b-value combination on ADC-based differentiation of benign and malignant tissue was analyzed using receiver-operating-characteristics curves. RESULTS: For all b-value combinations, ADCs were significantly lower (P < 0.001) in cervical malignancies (1.15 +/- 0.21.10(-3); 1.10 +/- 0.21.10(-3); 0.97 +/- 0.18.10(-3); 0.97 +/- 0.23.10(-3) and 0.85 +/- 0.18.10(-3) mm(2)/second respectively to the aforementioned b-value combinations) than in benign cervix (2.08 +/- 0.31.10(-3); 2.00 +/- 0.29.10(-3); 1.62 +/- 0.23.10(-3); 1.54 +/- 0.21.10(-3) and 1.42 +/- 0.22.10(-3) mm(2)/second respectively). The diagnostic accuracy was high for all b-value combinations and without statistical differences between the combinations. CONCLUSION: ADC-based differentiation of benign from malignant cervical tissue is independent of the tested b-value combinations. The results support the inclusion and possible pooling of studies using different b-value combinations in meta-analyses on ADC-based tissue differentiation in cervical cancer.

Performance of EUS-FNA for mediastinal lymphadenopathy: impact on patient management and costs in low-volume EUS centers.

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of mediastinal lymphadenopathy has been shown to be a valuable diagnostic tool in high-volume EUS centers (≥ 50 mediastinal EUS-FNA/endoscopist/year). Our goal was to assess the diagnostic accuracy of EUS-FNA and its impact on clinical management and costs in low-volume EUS centers (<50 mediastinal EUS-FNA/endoscopist/year). METHODS: Consecutive patients referred to two Dutch endoscopy centers in the period 2002-2008 for EUS-FNA of mediastinal lymphadenopathy were reviewed. The gold standard for a cytological diagnosis was histological confirmation or clinical follow-up of more than 6 months with repeat imaging. The impact of EUS-FNA on clinical management was subdivided into a positive impact by providing (1) adequate cytology that influenced the decision to perform surgery or (2) a diagnosis of a benign inflammatory disorder, and a negative impact which was subdivided into (1) false-negative or inconclusive cytology or (2) an adequate cytological diagnosis that did not influence patient management. Costs of an alternative diagnostic work-up without EUS-FNA, as established by an expert panel, were compared to costs of the actual work-up. RESULTS: In total, 213 patients (71% male, median age= 61 years, range = 23-88 years) underwent EUS-FNA. Sensitivity, specificity, and negative and positive predictive values were 89%, 100%, 80%, and 100%, respectively. EUS-FNA had a positive impact on clinical management in 84% of cases by either influencing the decision to perform surgery (49%) or excluding malignant lymphadenopathy (35%), and a negative impact in 7% of cases because of inadequate (3%) or false-negative (4%) cytology. In 9% of cases, EUS-FNA was performed without an established indication. Two nonfatal perforations occurred (0.9%). Total cost reduction was €100,593, with a mean cost reduction of €472 (SD = €607) per patient. CONCLUSIONS: Mediastinal EUS-FNA can be performed in low-volume EUS centers without compromising diagnostic accuracy. Moreover, EUS-FNA plays an important role in the management of patients with mediastinal lymphadenopathy and reduces total diagnostic costs.

Müllerian serous cystadenoma of the scrotum following orchiopexy.

A 24-year-old man presented himself with a nodular lesion of about 1 cm diameter at the site of a previous orchiopexy associated with surgery for cryptorchism. Histopathology revealed the lesion to be adenomatous and confined to the scrotum. Histological and immunohistological features were not consistent neither with median raphe cysts or cutaneous adenomas nor with the intrascrotal adenomas of the rete testis, epididymis, nor with (malignant) mesotheliomas. However, the lesion did compare well with serous (papillary) cystadenomas of the testis or paratestis. These adenomas are thought to originate in remnants of the Müllerian system or of peritoneal lining altered by Müllerian metaplasia. This implies that the scrotal adenoma may have developed from an implant of such elements during orchiopexy 14 years ago. Complete excision of the lesion appears to be an adequate therapy.

Ocular adnexal lymphoma classified using the WHO classification: not only histology and stage, but also gender is a predictor of outcome.

INTRODUCTION: Ocular adnexal lymphomas (OAL) belong to the most common malignancies of the orbit and eyelids and are now classified according to the WHO classification system. MALT lymphoma appears to be the most frequent OAL. Histology type and stage of OAL have been found predictors of patient survival. PURPOSE: To evaluate the outcome of a cohort of patients with OAL using the WHO classification and to compare outcome predictors with those of other studies using the WHO classification. DESIGN: Retrospective, cohort study. MATERIALS AND METHODS: Clinical profile at presentation, initial complaints and findings, classification and stage, treatment and outcome of 54 patients with biopsy proven and re-analyzed OAL seen between 1 January 1992 and 1 January 2002 at the UMC Utrecht, NL, were evaluated. Kaplan-Meier survival analysis and multivariate Cox-regression survival analysis were applied to assess predictors of outcome. RESULTS: Forty nine patients were found to have primary and five secondary lymphomas. Of those with primary OAL, 27 had MALT, eight diffuse large B-cell, six mantle cell and eight follicular cell lymphoma. Histology and stage showed a significant association with survival (Log-rank test: p = 0.001 and p = 0.002, respectively). A multivariate Cox-regression survival analysis showed histological type to be the only significant predictor for outcome. Looking at the dichotomy full remission versus not completely cured, gender was found to be a significant predictor (Log-rank test: p = 0.005). CONCLUSION: This study showed that not only histology type and stage, but also gender is a predictor of outcome.

The invasive front in endometrial carcinoma: higher proliferation and associated derailment of cell cycle regulators.

The aim of the study was to explore whether expression of proliferation and hypoxia-related proteins differs in the central parts and the invasive front in endometrial carcinomas. Proliferation-associated proteins Ki67 and cyclin A; cell cycle regulators p16, p21, p53, cyclin D1, cyclin E, and cdk2; and hypoxia-inducible factor 1alpha and its downstream factors glucose transporter 1, carbonic anhydrase IX, and vascular endothelial growth factor were immunohistochemically stained in paraffin-embedded specimens from endometrioid (n = 33), mucinous (n = 1), and serous (n = 5) endometrial carcinomas. The percentages of positive cells at the invasive front and central tumor parts were scored and compared. Ki67 (P < .001), cyclin E (P = .018), p16 (P = .003), and cdk2 (.001) were expressed higher at the invasive front than centrally (Wilcoxon signed ranks test). Higher expression of these antigens at the invasive front was seen in 31 of 38 cases for Ki67, in 16 of 39 cases for cyclin E, in 15 of 39 cases for cdk2, and in 11 of 39 cases for p16. The other cell cycle proteins and the hypoxia-related factors did not show significant differences in expression between the central parts and the invasive front. Endometrial carcinomas clearly show an invasive front that is characterized by higher proliferation and progressive derailment of the cell cycle regulators cyclin E, p16, and cdk2, but not by an increased hypoxic response.

Do magnetic resonance imaging and ultrasound add anything to the preoperative workup of parotid gland tumors?

PURPOSE: To assess the additional value of magnetic resonance imaging (MRI) and ultrasound (US) to physical examination (PE) and fine needle aspiration cytology (FNAC) in the preoperative determination of the location and histology of parotid gland tumors. PATIENTS AND METHODS: Prospectively, 99 patients with 77 benign and 22 malignant lesions were included; 82 underwent parotidectomy. FNAC was performed in 88 patients. On PE, the location of the tumor was predicted. Eighty-nine patients had MRI and 47 US. Various characteristics and the presumed diagnosis were assessed. Furthermore, the location of the tumor in relation to the facial nerve was predicted. The results were compared with the definite histology and the location during surgery. RESULTS: Of the MRI characteristics, incomplete demarcation from normal parotid gland tissue showed the highest positive predictive value (PPV) for malignancy of 0.48. Of the US characteristics, enlarged lymph nodes yielded the highest PPV for malignancy of 0.5. Cytology correctly predicted the benign or malignant nature of the tumor in all cases. Superficial location was well predicted on PE with a PPV of 0.8, slightly better on MRI (PPV of 0.87), and worse on US (PPV of 0.7). CONCLUSION: FNAC is the only accurate investigation for classifying a parotid gland tumor as benign or malignant. Palpation and MRI are superior to US in predicting tumor location. Because the results for palpation and MRI are almost equal, MRI should only be reserved for specific cases, and not routinely requested.

Hypoxia and angiogenesis in endometrioid endometrial carcinogenesis.

BACKGROUND: Hypoxia-inducible factor 1alpha (HIF-1alpha) plays an essential role in the adaptive response of cells to hypoxia, triggering biologic events associated with aggressive tumor behavior. METHODS: Expression of HIF-1alpha and proteins in the HIF-1alpha pathway (Glut-1, CAIX, VEGF) in paraffin-embedded specimens of normal (n=17), premalignant (n=17) and endometrioid endometrial carcinoma (n=39) was explored by immunohistochemistry, in relation to microvessel density (MVD). RESULTS: HIF-1alpha overexpression was absent in inactive endometrium but present in hyperplasia (61%) and carcinoma (87%), with increasing expression in a perinecrotic fashion pointing to underlying hypoxia. No membranous expression of Glut-1 and CAIX was noticed in inactive endometrium, in contrast with expression in hyperplasia (Glut-1 0%, CAIX 61%, only focal and diffuse) and carcinoma (Glut-1 94.6%, CAIX 92%, both mostly perinecrotically). Diffuse HIF-1alpha was accompanied by activation of downstream targets. VEGF was significantly higher expressed in hyperplasias and carcinomas compared to inactive endometrium. MVD was higher in hyperplasias and carcinomas than in normal endometrium (p<0.001). CONCLUSION: HIF-1alpha and its downstream genes are increasingly expressed from normal through premalignant to endometrioid adenocarcinoma of the endometrium, paralleled by activation of its downstream genes and increased angiogenesis. This underlines the potential importance of hypoxia and its key regulator HIF-1alpha in endometrial carcinogenesis.

Possible link between unique chemokine and homing receptor expression at diagnosis and relapse location in a patient with childhood T-ALL.

Childhood acute lymphoblastic leukemia (ALL) is often associated with extramedullary infiltration by leukemic cells at diagnosis or at relapse. To understand the mechanisms behind the dissemination of T-cell ALL (T-ALL) cells this study investigated the homing receptor expression on the blast cells of 11 pediatric T-ALL patients at diagnosis. One patient revealed a unique profile with high expression of the chemokine receptor CCR9 and the integrin CD103 on the T-ALL cells. Both of these molecules are specifically associated with homing to the gut. This finding was clinically significant as the patient later suffered a relapse that was confined to the gut. Immunohistochemistry revealed that the leukemic cells in the gut still expressed CCR9 and colocalized with a high expression of the CCR9 ligand, CCL25. These findings suggest that the original expression of CCR9 and CD103 on the leukemic cells contributed to the relapse location in the gut of this patient.

The prognostic value of immunohistochemically detected CD44v3 and CD44v6 expression in patients with surgically staged vulvar carcinoma: a multicenter study.

BACKGROUND: Isoforms of the adhesion molecule CD44 are involved in carcinogenesis and the metastatic cascade of tumor cells by increasing the affinity of malignant cells to their extracellular matrix. Preliminary data with respect to the prognostic value of the CD44 isoforms CD44v3 and CD44v6 in patients with vulvar carcinoma showed promising results. The current multicenter study aimed to determine the prognostic value of CD44v3 and CD44v6 in patients with surgically staged vulvar carcinoma. METHODS: Expression of CD44v3 and CD44v6 in vulvar carcinoma tissue was assessed by immunohistochemistry. Immunohistochemical staining was performed according to established protocols. Results were correlated to clinical data. RESULTS: A positive CD44v3 and CD44v6 staining was detected in 33.3% (33 out of 99) and 39.4% (39 out of 99) of the tumor samples, respectively. Overexpression of CD44v6 was associated with an impaired prognosis with respect to disease-free survival (P = 0.01) and overall survival (P = 0.04). Multivariate analysis showed that CD44v6 provided prognostic information with respect to disease-free survival (P = 0.001) and overall survival (P = 0.005) independently of the two established prognosticators, tumor stage and groin lymph node involvement. Overexpression of CD44v3 had no impact on patient survival. CONCLUSIONS: The current multicenter study, involving a large series of patients with surgically staged vulvar carcinoma, allowed for multivariate survival analysis and showed that CD44v6 confers prognostic information in addition to that provided by the established clinicopathologic parameters of tumor stage and lymph node status.