Inter-observer variability in the histologic criteria of diagnosis of hydatidiform moles

@#Introduction: In the event of encountering hydropic villi in products of conception specimens, pathologists will have to distinguish complete and partial hydatidiform mole (CHM & PHM) from hydropic abortion (HA). The histological diagnostic criteria are subjective and demonstrate considerable inter-observer variability. Materials and Methods: This study evaluated the inter-observer variability in diagnosis of CHM, PHM and HA according to defined histologic criteria. Ninety abortus conception specimens were reviewed. Representative haematoxylin and eosin-stained slides were assigned independently to two pathologists who were asked to make a diagnosis of CHM, PHM or HA, and provide a report of the identified diagnostic histological criteria. Kappa value was calculated for the inter-observer agreement. Results: There was a total of 36.7% disagreement between two pathologists (K = 0.403, Strength of Agreement = moderate), of which 24.4% and 12.2%, were differentiating PHM from CHM and PHM from HA, respectively. Among defined diagnostic histological criteria, the highest rate of agreement was observed in the identification of cistern formation and hydropic changes (K = 0.746 and 0.686 respectively, Strength of Agreement = substantial). Conclusion: There was moderate to substantial agreement rate between two pathologists in identification of two essential histologic criteria for diagnosis of molar pregnancies i.e. “hydropic change” and “trophoblastic proliferation”.

Conjoined twins in a monochorionic triplet pregnancy after in vitro fertilization: a case report

Background: Monozygotic monochorionic triplet pregnancy with conjoined twins is a very rare condition and is associated with many complications

Case: In this study, we describe a monochorionic-diamniotic triplet pregnancy after in vitro fertilization with an intracytoplasmic sperm injection. At a gestational age of 6 weeks and 4 days of pregnancy one gestational sac was observed, and at a gestational age of 12 weeks and 2 days, triplets with conjoined twins were diagnosed. After consulting with the parents, they chose fetal reduction of the conjoined twins. Selective feticide was successfully performed by radiofrequency ablation at 16 weeks of pregnancy. Unfortunately, the day after the procedure, the membrane ruptured, and 1 week later, all fetuses and placenta were spontaneously aborted

Conclusion: Monochorionic triplet pregnancy with conjoined twins is very rare. These pregnancies are associated with very serious complications. Intra cytoplasmic sperm injection increases the rate of monozygotic twinning and conjoined twins. Counseling with parents before IVF is very important

Flow cytometric dna analysis and histopathologic re-evaluation of paraffin embedded samples from hydatidiform moles and hydropic abortions

Distinction of hydatidiform moles [HMs] from non-molar abortions and sub-classification of HMs are important for clinical practice; yet, diagnosis based solely on morphology is affected by interobserver variability. The objective of this study was to determine the role of DNA flow cytometry in distinguishing molar from non-molar pregnancies. This retrospective study was conducted at the Department of Pathology, Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran, between 2006 and 2010. DNA ploidy analysis and histopathologic re-evaluation were performed on paraffin-embedded tissue from 36 [17 complete and 19 partial] molar and 24 hydropic abortus [HA] cases which were previously diagnosed based on histomor-phologic study. Of the 17 cases initially diagnosed as complete HM [CHM], 9 were dip-loid, 2 were triploid, 5 were tetraploid and 1 was aneuploid. Of the 19 initial partial HMs [PHMs], 2, 8, 1 and 8 cases were diploid, triploid, tetraploid and aneuploid, respectively. In the initial HA category [n=24], 14 diploid, 1 triploid, 5 tetraploid, and 4 aneuploid cases existed. Following flow cytometry and histopathologic re-evaluation, 1 case with previous diagnosis of HA was reclassified as PHM, 2 initial PHMs were reclassified as CHM and 2 initial CHMs were categorized as PHM. The results show that correct diagnosis of PMH is the main challenge in histological diagnosis of gestational trophoblastic disease [GTD]. DNA flow cytometric analysis could be an informative supplement to the histological interpretation of molar and hydropic placentas

Histopathologic and sonographic analysis of laparoscopic removal ovarian nonendometriotic cyst: the evaluating effects on ovarian reserve

Currently, laparoscopic cystectomy is the first-line therapy for ovarian benign cysts that are resistant to current therapies. There are different studies that point to ovarian reserve damage due to laparoscopic cystectomy. In this study, we evaluate the ovarian damage following laparoscopic cystectomy for non-endometriosis cysts using ultrasound and pathology findings. This is a prospective cohort study conducted between 7rd month of 2011 and 10th month of 2012 in Women hospital affiliated to Tehran university of medical sciences.45 non-endometriosis cysts [17 teratoma,7 mucinous, 10 simple serous and 11 simple cysts] underwent laparoscopic cystectomy with stripping technique. Amount of excised parenchyma, number of lost oocytes and cyst wall fibrosis thickness were histopathologically studied. Before and 3 months after surgery antral follicle count was evaluated by ultrasound. AFC after cystectomy for teratoma and simple serous was significantly reduced P<0.05. By larger teratomas and more parenchyma inadvertently removed during their excision [1.64, 0.255] reduced AFC was seen and in simple serous cysts with more removed parenchyma amount [1.5] reduced AFC occurred. In our study simple cysts excision led to a loss in AFC that was not associated with any other cyst parameters. Mucinous cysts resection led to no specific ovarian reserve damage. Laparoscopic cystectomy for non-endometriosis leads to reduced ovarian reserve

Alteration of the K-ras gene expression in atypical and nonatypical hyperplastic endometrium

Endometrial cancer is the most common gynecologic malignancy that has often proceeded by a premalignant phase. Modern molecular and immunostaining methods for precancerous lesions diagnosis have been expanded. One of the genetic alternations in the endometrial cancer carcinogenesis is the mutational activation of the K-ras oncogene. K-ras mutation has recognized to occur at an early stage of neoplastic progression in the endometrium. The purpose of this study is to investigate the expression pattern of K-ras gene in atypical and nonatypical hyperplastic endometrium. In a prospective study in the referral gynecologic hospital in Tehran, immunohistochemical evaluation of K-ras has performed on 72 consecutive specimens in two following groups: endometrial hyperplasia without atypia [n: 36], and endometrial hyperplasia with atypia [n: 36]. Staining of cells has evaluated in arbitrary quantitative methods in regards to both slides area staining and intensity of color reaction. K-ras immunoreactivity has seen in 3/36 [8.3%] cases of non atypical hyperplasia and in 2/36 [5.6%] cases of atypical hyperplasia [P: 0.64]. We have not establish any significant differences in K-ras expression between the atypical and nonatypical hyperplastic endometrium, and our data has supported this view that K-ras mutation is a very rare event in human endometrial carcinogenesis

[Ovarian steroid cell tumor in women with polycystic ovarian syndrome: a case report]

Steroid cell tumor is one of the rare ovarian tumors and forms 0.1% of all ovarian tumors, divided to three subgroups. Steroid cell tumor that are not otherwise specified [NOS] are the most common type and represent 60% of steroid cell tumors. One of the most known signs of this tumor is hormonal function, especially androgenic effects of it. Primary treatment consists of eradication of tumor via surgery. The patient is a 29 years old female with history of poly cystic ovarian syndrome since 10 years ago, who attended to the clinic of General Women Hospital of Tehran in January 2011. In pelvic ultrasonography, there was a 64x49 mm mass in the right adnexa consisting of homogeneous component. She underwent laparotomy and unilateral salpingoophorectomy was done. Pathological report was steroid cell tumor of ovary. The aim of this study is reporting one of the rare tumors of ovary and assessment of the correct way of diagnosis and treatment of it

[Comparison of radiological and pathological results in gestational trophoblastic diseases]

Gestational trophoblastic disease [GTD] is a heterogenous group of neoplastic lesions that is derived from placental trophoblastic epithelium. According to World Health Organization [WHO] classification they include: Hydatidiform mole [complete and partial], invasive mole, choriocarcinoma and placental site trophoblastic tumor. Hydatidiform mole is the most common and the diagnosis is achieved by preevacuation ultrasonographic evaluation, laboratory tests and finally histological assessment as gold standard. Since these disorders show varying potential for local invasion and metastasis, the accurate diagnosis, follow up and recommendations given to patients may differ. Consecutive cases with diagnosis of GTD from archive of pathology department of women [Mirza Kochak Khan] hospital were reviewed in whom results of clinical presentation and pre-evacuation ultrasound examination were documented. There were overall 220 cases for which the following clinical features were determined: gravidity, parity, history of previous abortion and gestational trophoblastic disease, the clinical symptoms such as vaginal bleeding and hypertension. Finally concordance between pre-evacuation ultrasonographic and histological diagnosis by kappa test is calculated. Out of 220 cases with clinically gestational trophoblastic disease diagnosis, 197 cases were confirmed by histological diagnosis. The concluding histological diagnosis includes: 98 cases of complete mole [CM], 84 partial mole [PM], 4 invasive mole and 11 cases of choriocarcinoma. Outside 98 cases with histological diagnosis CM only in 4 cases misdiagnosed by ultrasonoghraphy [4.1%] and high degree of concordance between ultrasonography and histological diagnosis is seen. Ultrasonographic examination accompanied with clinical examination, beside histological assessment as gold standard have high efficacy in diagnosing complete mole. This study did not show this finding for partial mole.

[Immunohistochemical expression of estrogen and progesterone receptors in endometrial hyperplasia and endometrioid carcinoma]

Endometrial carcinoma [EC] is the most common gynecologic malignancy; however, mechanisms underlying its pathogenesis remain obscure. Endometrial carcinoma has been classified into two major categories: type I [related to estrogen or endometrioid adenocarcinoma] and type II [unrelated to estrogen]. Estrogen is the main trigger for the abnormal proliferation in the endometrial epithelium but progesterone can inhibit this process. The aim of this study was to analyze the expression of estrogen and progesterone receptors in all types of endometrial hyperplasia in comparison to endometrioid adenocarcinoma of endometrium. Forty-seven specimens including 23 cases of histopathologically confirmed hyperplastic endometrium [12 simple hyperplasia, 5 complex hyperplasia without atypia, and 6 complex hyperplasia with atypia] and 24 cases of endometrial carcinoma were studied. Immunohistochemical staining of estrogen and progesterone receptors was performed in paraffin-embedded blocks and expression of estrogen and progesterone receptors were scored according to the proportion of positive staining cells. Overexpression of progesterone receptors was seen in 18 [75%] out of 24 cases of endometrial carcinoma and 23 [100%] of all types of endometrial hyperplasia. The aforesaid differences were statistically significant [P=0.023]. 70.8% of cases with endometrial carcinoma were 3+ for immunohistochemical staining of progesterone receptors as were 85.7% of the cases with endometrial hyperplasia; the difference being also statistically significant [P=0.02]. Considering the increased proportion of progesterone receptor expression in all types of hyperplastic endometrium in comparison to endometrial carcinoma, hormonal therapy by progestinal agents is recommended as a treatment of choice

[Determining the interobserver reproducibility of pap smears in the diagnosis of epithelial cell abnormalities]

Cancer of uterine cervix is the second cause of death in women in the world and the most common cause in developing countries. Because the majority of women with invasive cervical cancer of the uterine have not previously undergone screening, many clinicians assume that Pap smear has a high degree of accuracy; but problems such as false positive and false negative interpretations, as well as interobserver variability have questioned its validity. We retrieved 162 positive cervical smears that had been originally interpreted as ASC-US, ASC-H, LSIL, HSIL, SCC, AGC and adenocarcinoma from the cytology archives of Women's Hospital in Tehran, Iran. The slides were rescreened by an experienced pathologist and reclassified in the mentioned categories. All the 162 slides were reviewed by three more pathologists in a blind study using interpretative criteria utilized in their daily routine to evaluate interobserver reproducibility. To increase the level of interobserver agreement, the diagnostic categories were reduced to squamous Vs. glandular abnormalities and invasive [SCC and adenocarcinoma] Vs. non-invasive abnormalities. The results obtained in this study indicated slight interobserver agreement [k=0.26]. The most reproducible category was the invasive category [SCC in addition to adenocarcinoma] and the least agreement was seen for HSIL [k=0.19]. This study showed that reproducibility of cytological interpretation of conventional Pap smears varies among interpretive categories and the overall interobserver agreement is slight. Since convening on the reduction of interobserver discrepancy in Pap smear interpretations necessitates more reliable information of interpretative variability, larger studies need to be undertaken