Ultrasonography and histology correlation in BI-RADS 4/5 small breast lesions among Thai patients.

Background: Ultrasonography is an important imaging tool in detection of small breast cancers, particularly in younger women with dense breasts. Among the ultrasonographic characteristics for the malignancy, it is unclear which are common or more predictive. Objective: Analyze breast ultrasonograms and determine the common and predictive characteristics of the BIRADS 4/5 small breast lesions that were correlated with histology-proved carcinoma among Thai patients. Methods: Data were collected retrospectively between November 2006 and September 2007 at King Chulalongkorn Memorial Hospital. Forty-five BI-RADS 4 or 5 small breast lesions from 41 patients were reviewed for ultrasonographic characteristics and for correlation between each of these features and histology-proved malignancy. Results: There were 15 out of 30 lesions of BI-RADS 4 and 14 out of 15 of BI-RADS 5 that were histologically proven breast carcinoma. The lesion dimension ranged from 0.27 cm to 1.5 cm (mean: 0.98 cm). The malignant signs that were common consisted of irregular shapes (70%) and posterior shadowing (35.6%). However, the most correlating signs for malignancy were vascularity of the lesion 100%, and spiculated margins 100%. The other characteristics for malignancy, in descending order, were marked hypoechoicity 88.9%, microcalcifications within mass 85.7%, echogenic halo 83.3%, shadowing 81.3%, branched pattern 77.8%, duct extension 75%, irregular shape72.2%, and taller than wide orientation 70%. Conclusion: Irregular shape and shadowing were the two most common malignant signs that characterized BIRADS 4, 5 small breast lesions by ultrasonography. However, the most predictive signs were increases in vascularity and spiculated margins.

Relationship between hybrid capture II ratios and DNA amplification of E1, E6 and L1 genes used for the detection of human papillomavirus in samples with different cytological findings.

The hybrid capture II (HCII) assay is widely used in the detection of human papillomavirus virus (HPV). However, due to the limited number of HPV genotypes, it does not permit a comprehensive typing of viruses and “grey zone” (borderline negative or positive results) are often difficult to interpret. As such, polymerase chain reaction (PCR) should be used in parallel with HCII assays, and consensus PCR detection is capable of covering a wider detection range than with the HCII method. We examined the relationship between HCII relative light unit/cut-off (RLU/CO) ratios and PCR amplification results. This was done using previously described primer sets (MY/GP) as well as with our primers for HPV E1, L1 and E6 gene amplification, and performed on samples exhibiting differ-ent cytological findings. Together, 243 samples were divided into three groups having RLU/CO ratios of < 0.4 (n = 21), 0.4-4 (n = 64) and ≥ 4 (n = 158), respectively. All samples were subjected to PCR amplification using MY/GP and the newly designed E1, L1 and E6 primers. Results were verified by direct sequencing. PCR amplification sen-sitivities were higher when using the E1 primers than for the MY/GP, E6 or L1 primers. The E1 assay can be used for HPV detection with a sensitivity of 102 copies μl-1. Samples with RLU/CO ratios exceeding 4, and grey zone samples of 0.4-4, were amplified using E1 primers in 79.74% and 26.56% of the total cases, respectively. Cytologi-cal data of grey zone samples were primarily found to be normal (77%) whereas those with RLU/CO ratios > 4 were found in any of the cytological data categories. We concluded that HPV screening by HCII for grey zone sam-ples should be analyzed together with cytological data, as well as with a PCR screening tool that incorporates the E1 primers.

Expression of E-cadherin and syndecan-1 in axillary lymph node metastases of breast cancer with and without extracapsular extension.

BACKGROUND: Extracapsular extension of axillary lymph node (ECE) has significantly increased the risk of locoregional and distant recurrence in breast cancer patients. OBJECTIVE: Identify markers with high biological aggressiveness since it may serve as a prognostic indicator or adjunct to standard treatment. MATERIAL AND METHOD: The authors immunostained 115 axillary lymph nodes of invasive ductal carcinoma with syndecan-1 and E-cadherin. RESULTS: The presented data shows a significantly higher number of positive lymph node (8.48 vs. 4.15; p < 0.0001) and larger primary tumor size (3.53 vs. 2.79; p = 0.0029) in ECE patients. Sixty-one cases had node positive and without evidence of ECE, 54 cases had ECE. Syndecan-1 was found to be of significantly high expression (p = 0.001). There was no significant difference in the expression of E-cadherin during progression into extracapsular area (p = 0.12). CONCLUSION: E-cadherin displays high expression in nodal breast cancer metastases that may have re-expression and has coordinate function with syndecan-1 while invading to the surrounding fatty tissue. The protein is, therefore, likely to play a role in the invasiveness and aggressiveness.

Sensitivity of mammography and ultrasonography on detecting abnormal findings of ductal carcinoma in situ.

OBJECTIVE: To analyze the mammographic and ultrasonographic findings of ductal carcinoma in situ (DCIS) and determine the sensitivity in Thai women. MATERIAL AND METHOD: Mammograms and bilateral whole-breast ultrasonograms of 37 proven cases of DCIS were reviewed. The former was assessed for microcalcifications and soft tissue densities while the latter was evaluated for masses and thickened ducts. Ultrasonography was used to spot the areas to visualize soft tissue densities in mammogram. RESULTS: Mammography detected 22 cases of DCIS having pure microcalcifications, eight cases with mixed microcalcifications and soft tissue densities, six cases with pure abnormal soft tissue densities and one case showing negative finding. The ultrasonography detected 13 cases showing masses, seven cases as showing thickened ducts and 17 cases as negative findings. CONCLUSION: Microcalcifications are characteristic findings in mammogram accounting for 81% of DCIS in the present study. Ultrasonography shows abnormalities including mass and thickened duct lesions in 54% of DCIS. The combined modalities can give the detection of abnormalities in 97% of DCIS.

Neurovascular anatomy of the penis and pelvis in Thai males: applications to male-to-female and pelvic surgeries.

OBJECTIVE: To determine the neurovascular profiles in the pelvis and penis for applying to sex reassignment surgery. MATERIAL AND METHOD: Dissection of the pelvis and penile shaft was performed in 12 soft-preserved and 32 fresh adult male cadavers respectively. The neurovascular structures were located and documented, and the distances between anatomical landmarks were measured. Thirty-two specimens from the glans penis were obtained for immunohistochemical analysis to analyze its innervation and blood supply. RESULTS: Several anatomical variations of penile arterial supply were found. They are the presence of the accessory pudendal artery, multiple cavernous and bulbourethral arteries. The unilateral dorsal artery was observed in 10 of 32 cadavers, predominantly on the left. From the root to the neck of the penis, the dorsal nerves were divided into two groups. The first group of fibers innervating the glans coursed along the dorsolateral surface of the shaft and pierced the entire area of the corona. The other group diverged to distribute throughout the lateral surface to innervate the lateral and ventral portions. The mean distance between the left and right medial main branches that terminated in the glans was 1.18 cm. Immunohistochemical analysis revealed that the main nerves, after entering the glans, divided into terminal branches that concentrated around urethra. A mean distance from the main nerves to the epithelium was 0.71 cm. CONCLUSION: This detailed anatomy in the pelvis and along the penis should provide a valuable guide for sex reassignment surgery and intrapelvic operations.

Polymerase chain reaction for detection of Mycobacterium tuberculosis in papanicolaou-stained fine needle aspirated smears for diagnosis of cervical tuberculous lymphadenitis.

A polymerase chain reaction (PCR) protocol for detecting IS6110 repetitive insertion sequence of Mycobacterium tuberculosis (MTB) was tested on archival Papanicolaou (Pap)-stained fine needle aspirated (FNA) smears from 24 patients with cervical tuberculous lymphadenopathy and 30 negative controls. The protocol involved protease digestion or phenolchloroform extraction, and simple or nested PCR, with PCR amplification of human beta-globin gene for internal control of DNA quality. Sensitivity of 50% and specificity of 100% were obtained. Sensitivity in smears showing necrosis without granuloma was 70% (7/10), whereas it was 36% (5/14) in smears with presence of granuloma. On the other hand, sensitivity of 18% (4/22) was obtained using FNA acid-fast stain, 25% (1/4) for acid-fast stain in histological section, 50% (2/4) for culture, and 100% (8/8) for PCR of fresh specimens. PCR for MTB detection in Papanicolaou-stained slides is a practical and valuable method when no fresh specimen but only Pap-stained smear is available.

Integrated criteria of fine-needle aspiration cytology and radiological imaging for verification of breast cancer in nonpalpable lesions.

OBJECTIVES: To evaluate the accuracy of using radiologic, cytologic and integrated radiologic and cytologic criteria in diagnosis of nonpalpable breast lesions. MATERIAL AND METHOD: From January 2003 to May 2004, a prospective study of performing fine-needle aspiration biopsy (FNAB) was carried out at King Chulalongkorn Memorial Hospital on female patients with nonpalpable or vaguely palpable lumps that needed ultrasound localization for the direction and depth. RESULTS: There were 162 lesions from 150 patients, consisting of 29 malignant neoplasms (17.9%) and 133 benign lesions (82.1%). Of the 107 classified as subcentimeter focal lesions (< 1 x 1 cm2 in size), two of radiological malignancy were false and two others were falsely negative by cytology. While the 23 large/ill-defined lesions (> 1.5 x 1.5 cm2 in size), one hiding malignant lesion adjacent to a prominent intraduct papilloma was missed. Two others had falsely negative cytologic diagnosis. The integrated criteria achieved accuracy and sensitivity of 97.5% and 93% compared with the cytology, 96.3% and 82.8% and the better scenario of radiology, 95.7% and 82.8% respectively. CONCLUSION: The integrated criteria provide the most accuracy rate and sensitivity rate for detection of malignancy in nonpalpable breast lesions.

A two-phase study model for the standardization of HER2 immunohistochemical assay on invasive ductal carcinoma of the breast.

OBJECTIVES: To develop and verify a standardized protocol for HER2 immunohistochemical assays on invasive ductal carcinoma of the breast in Thailand. MATERIAL AND METHOD: A two-phase study approach was employed. In the Phase One, after verifying the proposed protocol that adopted the HercepTest procedure using readily available primary antibodies, CB11 and A0485, Lab 1 performed the HER2 immunohistochemical staining for 137 cases of invasive ductal carcinoma twice with two types of the antibody. Nine pathologists from 8 centers independently examined and scored all the 2 x 137 stained slides that were blinded for antibody type. Interobserver reliability was calculated using pair-wise kappa. Following discussion of the results, the Phase Two study was planned. Lab 2 and Lab 3 independently performed the HER2 staining according to the protocol for 60 invasive breast carcinoma cases. The same group of pathologists scored 2 x 60 stained slides that were masked for laboratories. Interobserver reliability and interlaboratory agreement from each pathologist were calculated using kappa statistics. Three interpreted categories--namely negative, equivocal and positive tests were used in the analyses. RESULTS: Phase One study showed interobserver agreement between pairs varied from kappa 0.75 (95%CI, 0.68-0.82) to 0.06 (95%CI, 0-0.14) while Phase Two study obtained pair-wise kappa scores ranged from 0.84 (95%CI, 0. 80-0.89) to 0. 65 (95%CI, 0.59-0.71). Interlaboratory kappa for each pathologist was 0.67 (95%CI, 0.61-0.73). CONCLUSION: The standardization of HER2 immunohistochemical assay was achieved through this two-phase study model. It had added benefits of improving pathologists' expertise and verifying the HER2 testing protocol to be used in Thailand.

Does color Doppler ultrasound vascularity predict the response to neoadjuvant chemotherapy in breast cancer?

OBJECTIVES: To assess the proportions of response to neoadjuvant chemotherapy of breast cancer according to color Doppler ultrasound vascularity patterns. MATERIAL AND METHOD: Prospective evaluation using gray scale and color Doppler ultrasound for number of vessels and feeding appearances of tumors as well as the changes in tumor sizes at before and after chemotherapy in 69 breast cancer patients. RESULTS: The overall response rate in 70 breast cancers was 20%. Twenty-nine lesions (41%) showed hypervascularity and 41 lesions (59%) revealed hypovascularity. There were 5 vascularity patterns and each pattern had the proportion of responders as follows; 33.3% for hypovascularity with single-vessel feeding into the tumor, 25% for hypovascularity with single-vessel feeding at periphery of the tumor, 25% for no vascular feeding to the tumor, 16.7% for hypervascularity with vascular feeding at the periphery of the tumor and 13% for hypervascularity with vascular feeding into the tumor. The highest percentage of responsive group was the pattern of hypovascularity with single-vessel feeding into the tumor (33.3%). CONCLUSION: There is a trend that tumor vascularity and patterns of vascular feeding by color Doppler ultrasound can predict the responsiveness of breast cancer to neoadjuvant chemotherapy.

The association of co-expression of CD44v4/MMP-9 with different nodal status in high-grade breast carcinoma patients.

BACKGROUND: Breast carcinoma is one of the most common tumors in female patients, and its metastasis is a major cause of death. An experimental model has recently found the association of CD44 with MMP-9 that facilitates tumor cell invasion and metastasis. MATERIAL AND METHOD: The CD44v4 and MMP-9 were performed on tissue in paraffin blocks of 50 cases of high-grade breast carcinoma with node positive and 50 cases with node negative. RESULTS: Increased expression of MMP-9(60%) significantly observed in high-grade breast carcinoma patients with node positive (p = 0. 004), whereas CD44v4 displays no significant difference between the two groups (p-value = 0.81). Significant co-expression of CD44v4+ / MMP-9+ (46%) was observed and correlated with node-positive patients whereas the CD44v4+ / MMP-9- (54%) express in node-negative patient (p-value = 0.01). CONCLUSION: The solely expression of CD44v4 does not associate with node status. MMP-9 plays an important role to enhance breast carcinoma cell invasion and associates with lymph node metastasis. The combined expression of CD44v4 (overexpression) and derangement of MMP-9 expression was significantly associated with nodal status.

Weekly rescreening of 10% of the total cervical Papanicolaou smears: a worthwhile quality assurance scheme.

BACKGROUND: In awareness of possible false negative cervical Papanicolaou tests in routine service, the authors developed and tested a new scheme that would be a practical adjunct in quality assurance. OBJECTIVE: To evaluate the value of a weekly rescreen of 10% of the total cervical Papanicolaou smears as a quality assurance scheme. DESIGN: A prospective descriptive study. RESULTS: Of 31,914 slides in the 9-month study period, a total of 3,097 slides (9.7%) were picked up in the rescreen scheme. There were 29 discordant cases (0.9%) consisting of 7 cases (0.2%) of errors from the initial reporting, 2 cases of errors from the rescreening and 20 other cases from disagreements on designating atypical squamous cells of undetermined significance. The errors of the initial reports could be further classified into 6 cases due to screening errors and one case because of interpretation error. The proper diagnoses had been revised and resent to the attending gynecologists. CONCLUSION: A weekly rescreening 10% of total cervical Papanicolaou smears scheme was worthwhile for quality assurance. It could be used for evaluating screener performance and create internal quality improvement. The detected false diagnoses were manageable.

Abnormal findings in breast imaging: a hospital-based survey in 4264 Thai women.

OBJECTIVE: To evaluate the distributions of common and significant imaging findings from breast imagings at King Chulalongkorn Memorial Hospitals. MATERIAL AND METHOD: Data was collected from every mammography performed from November 1, 2001 to October 31, 2002. The reports were analyzed and imaging findings were recorded. The ACR BI-RADS category was applied to all cases. RESULTS: There were 4264 patients and all of them were female. The age range was between 19-90 years and average age was 50.1 years. The most common positive findings were cysts (39.22%), followed by focal lesions (14.76%), mass (8.69%), architectural distortion (7.83%), calcification (7.36%) and thick ducts (3.76%). According to ACR BI-RADS, most of the studies were in category 2 (42.59%), followed by category 1 (38.67%), category 3 (12.08%) category 5 (3.45%), category 4 (3.12%) and category 0 (0.09%). CONCLUSION: Breast imaging is the standard screening tool for breast cancer and can reveal different kinds of findings. Knowing the distribution of these findings helps both the radiologists to understand the scope of their work and the institution to audit their practice.

Aural aspergilloma: an unusual delayed complication of tympanoplasty.

Aural aspergilloma was first reported in 2001 by the authors. Recently the authors discovered a second case presenting with chronic otorrhea via a fistulous tract in the tympanic membrane. The patient was treated by removal of the fistulous tract and part of the tympanic membrane, cleansing the middle cavity, leaving the tympanic membrane perforated until obtaining a dry ear and followed by a tympanomastoidectomy, without the use of an antifungal agent. Because both cases of aural aspergilloma had a history of successful tympanoplasty with a long quiescent period before the symptoms appeared, the authors postulate that aural aspergilloma may be considered as an unusual delayed complication of tympanoplasty.

Role of combined fine needle aspiration and ultrasonography in the diagnosis of impalpable lesions of the breast.

OBJECTIVE: To evaluate the efficacy of combined fine needle aspiration (FNA) and ultrasonography in the diagnosis of impalpable breast lesions. METHOD: To analyze the diagnostic performance of the FNA cytology and ultrasound among female patients with impalpable breast lesions that were referred to the FNA clinic at King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand during the period of July 2001 to June 2002. The final diagnoses employed surgical pathology and 6-month follow-up of the patients. RESULT: In a-year-period of the studied frame, there were 57 studied cases (18.3% of the total FNA breast cases). To diagnose malignant lesions, FNA cytology achieved the sensitivity of 61 per cent and the specificity of 100 per cent, whereas, diagnostic radiology had a sensitivity of 100 per cent and specificity of 56.1 per cent. The FNA cytology was superior to ultrasound in the determination of inflammatory lesions while imaging was dominant in the hard-to-aspirate malignant lesions. Therefore, the combined cyto-radiology criteria could correctly diagnose malignancy in all cases (100% accuracy). CONCLUSION: The efficacy of combined FNA and ultrasonography in the diagnosis of impalpable breast lesions was highly satisfactory. The accuracy of each technique enhanced each other and gave the correct diagnosis in all cases.

Estrogen and progesterone receptors status in Thai female breast cancer patients: an analysis of 399 cases at King Chulalongkorn Memorial Hospital.

A retrospective review was performed on 576 patients who have been diagnosed breast cancer and referred to Division of Radiation Therapy, Department of Radiology, King Chulalongkorn Memorial Hospital between January 1995-September 2001. There were three hundred ninety nine cases of invasive breast cancer that available for estrogen (ER) and/or progesterone (PR) receptor status. The mean and median age in our study were 49.6 year and 49.0 year respectively. About 60.9 per cent of the patients were pre and peri-menopause and 37.8 per cent were post-menopause. Most of the histological cell type were invasive ductal carcinoma which comprised of 92.7 per cent. Histologic grading were nearly equal for moderately and poorly differentiated grade: 43.66 per cent and 40.66 per cent. The results of our study showed 53.4 per cent of 399 patients had ER positive and 42.1 per cent of 380 patients had PR positive. The proportion of ER+PR+, ER+PR-, ER-PR+, and ER-PR- were 36.31 per cent, 15.53 per cent, 5.79 per cent and 42.37 per cent respectively. Older age and post-menopause women had higher ER+. While patients with increase tumor size, poorly differentiated grading, increase positivity of axillary lymph nodes and higher stage have more chance of ER negative and PR negative.