Diagnostic terminology for reporting thyroid fine needle aspiration cytology: European Federation of Cytology Societies thyroid working party symposium, Lisbon 2009.

A European Federation of Cytology Societies (EFCS) working party of 28 members from 14 European countries met at the European Congress of Cytology in Lisbon in September 2009, with two observers from the USA, to discuss the need for standardising thyroid FNA nomenclature in the light of the National Institute of Cancer (NCI) recommendations resulting from the State of the Science conference in Bethesda in 2007. The data were obtained through two questionnaires sent by email and a transcript of the live discussion at the congress, which is presented in full. The surveys and discussion showed that there were currently no national terminologies for reporting thyroid FNA in the different European countries except in Italy and the UK. Personal, 'local', surgical pathology and descriptive terminologies were in use. All but one of the working party members agreed that thyroid FNA reporting should be standardised. Whilst almost a third would adopt the NCI Bethesda terminology, which offers the advantages of a 'risk of cancer' correlation and is linked to clinical recommendations, more than half favoured a translation of local terminology as the first step towards a unified nomenclature, as has been done recently in the UK. There was some disagreement about the use of: a) the six-tiered as opposed to four or five-tiered systems, b) the use of an indeterminate category and c) the 'follicular neoplasm' category, which was felt by some participants not to be different from the 'suspicious of malignancy' category. The conclusions will be passed to the different national societies of cytology for discussion, who will be asked to map their local terminologies to the Bethesda classification, observe its acceptance by clinicians and audit its correlation with outcome.

A dynamic infrared imaging-based diagnostic process for breast cancer.

BACKGROUND: Dynamic infrared (IR) imaging is an emerging functional imaging modality for the detection of breast cancer without evidence of optimal imaging and diagnostic application. PURPOSE: To evaluate dynamic IR imaging in breast cancer diagnostics by comparing a stepwise diagnostic scheme to digital mammography and postoperative histopathology. MATERIAL AND METHODS: Dynamic IR imaging of breasts was undertaken preoperatively with a long-wave quantum well (QWIP) and two mid-wave photovoltaic (PV) IR cameras in 10 cases (age 34-80 years) with breast cancer size 6-45 mm on mammography. Image stabilization, two-phase frequency analysis, and two image-processing algorithms were applied. RESULTS: Combining image processing with frequency analysis proved advantageous in detecting breast cancer. The IR imaging process recognized the cancer area independently of tissue density, cancer size, and cancer appearance on mammography. Compared to histopathology, all cancers yielded abnormal analysis results, including one case of ductal carcinoma in situ. Evidence of lymphatic invasion in postoperative histopathology, imaging with PV camera, and image processing with the Wiener filtering combination correlated with highest confidence between normal and cancer tissue measured by the calculated superiority value. CONCLUSION: Dynamic IR imaging with image-processing-guided frequency analysis is a promising modality for breast cancer detection and may not have the tissue-dependent limitations of mammography. Our results encourage further work on medical IR imaging and comparison to established breast-imaging modalities.

Imaging of breast cancer with mid- and long-wave infrared camera.

In this novel study the breasts of 15 women with palpable breast cancer were preoperatively imaged with three technically different infrared (IR) cameras - micro bolometer (MB), quantum well (QWIP) and photo voltaic (PV) - to compare their ability to differentiate breast cancer from normal tissue. The IR images were processed, the data for frequency analysis were collected from dynamic IR images by pixel-based analysis and from each image selectively windowed regional analysis was carried out, based on angiogenesis and nitric oxide production of cancer tissue causing vasomotor and cardiogenic frequency differences compared to normal tissue. Our results show that the GaAs QWIP camera and the InSb PV camera demonstrate the frequency difference between normal and cancerous breast tissue; the PV camera more clearly. With selected image processing operations more detailed frequency analyses could be applied to the suspicious area. The MB camera was not suitable for tissue differentiation, as the difference between noise and effective signal was unsatisfactory.

Sentinel node biopsy is not sensible in breast cancer patients with large primary tumours.

AIMS: We aimed to evaluate the outcome of sentinel node biopsy (SNB) in breast cancer patients with large primary tumours. METHODS: Nine hundred and eighty-four patients with invasive breast cancer and SNB were studied. The histological tumour size was larger than 3 cm in 70 patients. The advantages of SNB like avoiding axillary clearance (AC) or more accurate staging by detecting micrometastases or parasternal sentinel node metastases were evaluated in relation to the tumour size. RESULTS: Axillary metastases were detected in 351/914 patients with a tumour size of 3 cm or smaller and in 50/70 patients with larger tumours (p<<0.0001). Micrometastases or isolated tumour cells only, were observed in 134/351 node positive patients with tumours not larger than 3 cm and in 10/50 cases with larger tumours (p=0.022). Parasternal sentinel node metastases were detected in 17/914 patients with a tumour size of 3 cm or smaller and 2/70 patients with larger tumours (p=ns). AC was omitted because of tumour negative sentinel node findings 168 of the 232 patients with stage T1 a-b tumours and 281 of those 489 with T1c tumours. Twenty of the 70 patients with tumours larger than 3 cm avoided AC. CONCLUSIONS: SNB is not sensible in breast cancer patients with tumours larger than 3 cm, because of the small proportion avoiding AC after SNB.

The prevalence of non-sentinel node metastases in breast cancer patients with sentinel node micrometastases.

AIMS: The aim of the study was to estimate the prevalence of and risk factors for non-sentinel node (NSN) involvement in breast cancer patients with sentinel node (SN) micrometastases. METHODS: Eighty-four patients with SN micrometastases were included. Both the SN and NSN were examined using serial sectioning and immunohistohemistry. Various indices were evaluated as possible risk factors for NSN involvement. RESULTS: NSN involvement was found in 22/84 patients. The median size of the NSN metastases was 1.25 mm (0.01-12 mm). The NSN metastases were larger than 2 mm in 8 patients and smaller than 0.2 mm in 6 patients. NSN involvement was observed in 14/35 patients with metastatic findings in all removed SN. Three of the 23 patients with 2 or 3 tumour negative SN had NSN metastases. None of the 12 patients with 4 or more uninvolved SN had NSN metastases. NSN involvement could not excluded by other patient, tumour or sentinel node related factors. CONCLUSIONS: Every fourth patient will have residual disease in the axilla, 10% even large metastases, if axillary clearance is omitted in patients with SN micrometastases. The risk of NSN involvement seems negligible in patients with a single SN micrometastasis and four or more healthy SN harvested.

Expression of tenascin-C in intraductal carcinoma of human breast: relationship to invasion.

Tenascin-C (Tn-C) is an extracellular matrix glycoprotein that appears in areas of epithelial-mesenchymal interaction during fetal development and in neoplasia. The immunohistochemical expression of Tn-C and its relationship to histology, nuclear grade, microinvasion, oestrogen (ER) and progesterone receptors (PR), and to cell proliferation measured by Ki-67 expression were studied in 89 intraductal breast carcinomas (DCIS). Periductal Tn-C was noted in 87% and stromal Tn-C in 25% of the tumours. Stromal expression was associated with moderate to strong periductal expression and microinvasion. Periductal expression was associated with comedo-type, nuclear grade, microinvasion, Ki-67 expression, and lack of PR. The distribution of Tn-C was compared in DCIS and in the intraductal component from another series of small axillary node-negative invasive breast carcinomas (n = 44). Tn-C was present in the stroma of pure DCIS in 25% and in the intraductal component of the other series in 82%. Thus, stromal or moderate to strong periductal Tn-C expression in DCIS may relate to early invasion. DCIS with weak periductal or missing Tn-C expression may be a subgroup with benign behaviour.

Intramedullary fixation of cortical bone osteotomies with absorbable self-reinforced fibrillated poly-96L/4D-lactide (SR-PLA96) rods in rabbits.

Osteotomies of the femoral diaphysis were fixed with absorbable self-reinforced fibrillated poly-96L/4D-lactide (SR-PLA96) intramedullary rods (4.5 mm x 50-60 mm) in 43 adult rabbits. Follow-up times varied from 3 weeks to 3 yr. After sacrifice histological, oxytetracycline-fluorescence and microradiographic studies of the bones were performed. Strength characteristics and changes in crystallinity and molecular weight of the rods were also measured. All osteotomies were evaluated radiographically. Thirty-six osteotomies (84%) healed uneventfully. The implant disappeared almost totally within 3 yr and histology showed only a minor foreign body reaction. From 6 weeks on, the bending force needed to break the osteotomy was comparable to the bending force needed to break the control bone. The shear strength of the rods displayed only minor changes for the first 24 weeks. Subsequently, the rods rapidly lost their strength and at 48 weeks there was practically no shear strength left, which is ideal for healing of an osteotomy. The present investigation demonstrated, that absorbable. fibrillated SR-PLA96-rods can be used for the intramedullar fixation of simple cortical bone osteotomies in rabbits. These results have encouraged us to continue our studies with the fixation of experimental cortical bone osteotomies in larger species.

Intramedullary fixation of femoral cortical osteotomies with interlocked biodegradable self-reinforced poly-96L/4D-lactide (SR-PLA96) nails.

Femoral diaphyseal osteotomies of adult sheep were fixed with intramedullary (i.m.) biodegradable self-reinforced poly-96L/4D-lactide (SR-PLA96) nails (Phi 10.66-10.78 mmx195-199 mm) that were interlocked with four Phi 1.5 mm metallic Kirschner (K) wires. Hollow i.m. nails used in the pilot study resulted in implant failure and only two of these sheep were followed long term (18 months and 3 years). In the main study, solid nails were used and this resulted in consolidation in 5/6 cases and in one non-union due to failure of both proximal K wires at 3 weeks. Sheep in the main study were followed for 6 and 12 months. Femurs were studied radiographically, microradiographically, histologically and by oxytetracycline labelling. Good bone healing was achieved and histology showed only a mild tissue reaction to the implant at 6-18 months. At 3 years, the implant had almost degraded and numerous foamy macrophages were ingesting the disintegrated material. No accumulations of lymphocytes implying an immunological inflammatory reaction were seen. This investigation demonstrated that absorbable SR-PLA96 i.m. nails can be used together with interlocking metallic K wires in fixation of simple cortical osteotomies in large animals weighing up to 63 kg. The long-term biocompatibility should be studied in a larger population.

The sensitivity of axillary staging when using sentinel node biopsy in breast cancer.

AIMS: We aimed to study factors, which enhance the sensitivity of sentinel node biopsy. METHODS: Three hundred and sixty-three clinically node negative breast cancer patients with successful sentinel node biopsy were studied. All focally radioactive and/or blue nodes in the axilla were harvested. All palpably suspicious lymph nodes were also removed for a similar histological evaluation. RESULTS: Sentinel node metastases were found in 129 patients. The metastasis was detected in the three first retrieved sentinel nodes in 126 cases and in the fourth or fifth node in three cases. The 'hottest' sentinel node was not the involved one in 18 cases. Five patients with tumour negative sentinel nodes had metastases in other palpably suspicious nodes. CONCLUSIONS: Harvesting all focally radioactive and/or blue nodes and other palpably suspicious nodes minimises the false negative rate in sentinel node biopsy. Removal of more than five nodes does not significantly improve the sensitivity of axillary staging.

Biodegradable semirigid plate and miniscrew fixation compared with rigid titanium fixation in experimental calvarial osteotomy.

OBJECT: To determine the biocompatibility and suitability of resorbable plates and miniscrews, consolidation of symmetrical, bilateral frontal bone craniotomies that had been closed using various methods was studied in 20 growing lambs. METHODS: Bone fixation with a flexible, punched polylactide plate and four slowly degradable, self-reinforced poly-levolactide (SR-PLLA) or rapidly degradable, self-reinforced polyglycolide (SR-PGA) miniscrews (10 animals in each group) was compared intraindividually with rigid fixation by using a titanium miniplate and four miniscrews. Plain x-ray films, magnetic resonance images, histological studies, and histomorphometric studies were obtained at 4 to 104 weeks. CONCLUSIONS: No dislocation, instability, clinical foreign body reactions, infections, or loss of fixation were observed. Bone consolidation of the 2.35-mm-wide craniotomy lines was incomplete; connective tissue-filled defects through the bone were observed in 13 of 28 lines at 26 to 52 weeks. Statistical analyses based on histomorphometric studies showed no difference in consolidation with SR-PLLA miniscrew and titanium plate/screw fixation or between the two resorbable fixation methods. Fixation with rapidly degradable SR-PGA miniscrews resulted in less effective consolidation than on the contralateral titanium-treated side (p<0.05), but the bone segment was thicker (p<0.005). The SR-PGA miniscrews had disappeared by 6 weeks, the polyactide plate by 104 weeks, and the SR-PLLA miniscrews had been mostly resorbed at 104 weeks. Passive translocation of the titanium plates and screws into the bone tissue was seen at 52 and 104 weeks. In rapidly growing lamb frontal bone, comparable consolidation results, without complications, can be achieved with semi-rigid resorbable fixation compared with rigid metallic fixation.

SR-PLLA and SR-PGA miniscrews: biodegradation and tissue reactions in the calvarium and dura mater.

The biocompatibility and degradation of self-reinforced poly-L-lactide (SR-PLLA) and polyglycolide (SR-PGA) miniscrews, vs titanium miniscrews, was studied in frontal bone osteotomies in 20 lambs, where they were used for plate fixation. At follow-up at 4, 6, 12, 26, 52 and 104 weeks, no clinical foreign body reaction, infection or other complications had occurred. Histologically, PGA material was hydrolyzed and fragmented at 4-6 weeks and was resorbed by 12 weeks, whereas the SR-PLLA miniscrews retained their integrity and holding power for 26 weeks and were mostly resorbed at 2 years. According to histological and histomorphometric analyses and plain film radiography, the degradation of PGA miniscrews was accompanied by a typical non-specific foreign-body reaction and initial transient osteolysis with decreased osteoid formation around the screw channel, but compensatory intense osteoid formation and bone remodelling followed after resorption of the polymer. The foreign body reactions to PLLA and titanium were considerably milder. All miniscrews were commendably strong and could be satisfactorily tightened against the plate. SR-PLLA miniscrews offer fixation stability for half a year, whereas rapidly degrading SR-PGA miniscrews may be used when short-term fixation is needed.

Large-volume cytocentrifuge for processing alcohol-fixed cytologic specimens. Application in urinary cytology.

The use of a large-volume cytocentrifuge for the routine processing of urine specimens was investigated. Most specimens arrived in the laboratory mixed with 50% ethanol. Polyethylene glycol was added to the fixative supplied to the clinicians or to the cell suspension received in the laboratory. The slides used in the cytocentrifuge were coated with gelatin or poly-L-lysine to minimize cell loss. The resulting monolayers of cells, with occasional true tissue fragments, were stained by the Papanicolaou method. When indicated, immunocytochemical and histochemical stains were used. The technique gave good morphologic details, good cell yield and consistent staining quality. This method has also been applied to other cytologic specimens, such as serous fluids and fine needle aspirates, with good results. The method saves the time of cytotechnologists, and slides prepared by this technique are suitable for automatic staining.

Preparation of methacrylate-embedded cytologic smears from prefixed cells.

A new method of preparing smears of alcohol-fixed cytologic material by using methacrylate embedding medium to make the cells adhere on plain glass slides is presented. After centrifugation, the cytologic material was mixed with Lowicryl K4M embedding medium and smeared on slides. The polymerization process was achieved by exposing the slides to ultraviolet light. The morphology in such smears was similar to that of specimens prepared by the filter technique. The methacrylate method does not have the most common disadvantages of the filter technique--the development of air bubbles over time and the visually disturbing presence of the filter.

Dynamic infrared imaging in identification of breast cancer tissue with combined image processing and frequency analysis.

Five combinations of image-processing algorithms were applied to dynamic infrared (IR) images of six breast cancer patients preoperatively to establish optimal enhancement of cancer tissue before frequency analysis. mid-wave photovoltaic (PV) IR cameras with 320x254 and 640x512 pixels were used. The signal-to-noise ratio and the specificity for breast cancer were evaluated with the image-processing combinations from the image series of each patient. Before image processing and frequency analysis the effect of patient movement was minimized with a stabilization program developed and tested in the study by stabilizing image slices using surface markers set as measurement points on the skin of the imaged breast. A mathematical equation for superiority value was developed for comparison of the key ratios of the image-processing combinations. The ability of each combination to locate the mammography finding of breast cancer in each patient was compared. Our results show that data collected with a 640x512-pixel mid-wave PV camera applying image-processing methods optimizing signal-to-noise ratio, morphological image processing and linear image restoration before frequency analysis possess the greatest superiority value, showing the cancer area most clearly also in the match centre of the mammography estimation.

Sentinel node biopsy with intraoperative diagnosis in patients undergoing skin-sparing mastectomy and immediate breast reconstruction.

AIMS: False negative cases in the intraoperative assessment of sentinel node (SN) metastases in breast cancer prompt for a secondary axillary lymph node dissection (ALND). Such ALND is technically demanding and prone to complications in patients with immediate breast reconstruction (IBR) if there is a microvascular anastomosis or the thoracodorsal pedicle of a latissimus dorsi flap in the axilla. This study aims to evaluate the feasibility of the intraoperative diagnosis of sentinel node biopsy (SNB) in breast cancer patients undergoing IBR. METHODS: Sixty-two consecutive breast cancer patients undergoing SNB with the intraoperative diagnosis of SN metastases simultaneously with mastectomy and IBR between 2004 and 2006 were included in this study. Results of the SNB and especially the false negative cases in the intraoperative diagnosis were evaluated. RESULTS: Eleven patients had tumor positive SN. Nine of these cases were detected intraoperatively. The two false negative cases in the intraoperative diagnosis constituted of isolated tumor cells only. CONCLUSIONS: Our present study suggests that SNB with intraoperative diagnosis of SN metastases is feasible in patients undergoing IBR if the risk of nodal metastasis is low and the sensitivity of intraoperative SNB diagnosis is high.

Reactive oxygen species induce signals that lead to apoptotic DNA degradation in primary CD4+ T cells.

Reactive oxygen species are toxic to cells but they may also have active roles in transducing apoptotic events. To study the role of reactive oxygen species in growth factor depletion induced apoptosis of human primary CD4+ T cells, we used a synthetic manganese porphyrin superoxide dismutase mimetic to detoxify superoxide anions formed during apoptosis. Apoptosis of primary CD4+ T cells was characterized by generation of superoxide anions, plasma membrane phosphatidyl-serine translocation, loss of mitochondrial membrane potential, activation of caspase 3, condensation of chromatin, as well as DNA degradation. The detoxification of superoxide anions did not influence plasma membrane phosphatidyl-serine translocation, or chromatin condensation, and only marginally inhibited the loss of mitochondrial membrane potential and the formation of DNA strand breaks. In contrast, the detoxification of superoxide anions significantly reduced caspase 3 activity and almost completely inhibited the apoptotic decrease in total cellular DNA content as measured by propidium iodide staining. Our results indicate that reactive oxygen anions induce signals leading to efficient DNA degradation after the initial formation of DNA strand breaks. Thus, reactive oxygen anions have active roles in signaling that lead to the apoptotic events.