[Diagnosis and grading of cervical intraepithelial neoplasias]. / Diagnose und Graduierung zervikaler intraepithelialer Neoplasien.

Diagnosing and grading of cervical intraepithelial neoplasias (CIN) are part of the routine practice of pathologists. However, discriminating between reactive changes and CIN1 and determining the different degrees of CIN may be challenging. Aim of this study was the evaluation of the proliferation markers Ki-67 and Mcm2 as well as p16 for their potential to aid in the assessment of CIN. 297 samples of normal epithelium, CIN1, CIN2, and CIN3 were assessed for expression of the above mentioned markers using tissue microarrays. There was an increase in the expression of Ki67 and Mcm2 from normal epithelium, CIN1, CIN2 to CIN3 (p<0.001 for both markers). Ki-67 was the most useful marker in differentiating between normal epithelium and CIN1. The number of p16-positive cases was 7% in CIN1, 46% in CIN2 and 86% in CIN3. There were no p16-positive cases in the group with normal epithelium. In order to grade CIN1 vs. CIN2 a combination of Ki-67 and p16 was helpful. Cases with a proliferation rate of <25% assessed with Ki-67 were most likely CIN1 (sensitivity 91.7%, specificity: 54.3%, positive predictive value: 73.3%, negative predictive value 82.6%). P16 was the most helpful marker in distinguishing between CIN2 and CIN 3 as p16 negative cases were more likely to belong into the CIN2 category. In summary, the histopathological assessment of cervical biopsies is based on H&E-stained slides. However, Ki-67 and p16 can be helpful in diagnosing and grading cervical intraepithelial neoplasia.

Fine needle aspiration cytology: a survey of current European practice.

Fine needle aspiration cytology (FNAC) is practised widely throughout Europe. The majority of countries have dedicated cytopathologists as well as histopathologists practicing cytology. Despite this, FNAC is performed mostly by clinicians and radiologists except in the larger centres with dedicated staff with a special interest in cytopathology. The advent of One-Stop diagnostic services and image-guided procedures are prompting further development of FNAC clinics where cytopathologists take their own samples, issue reports in the same clinical session and take extra material for ancillary tests to complete the diagnosis. The volume of FNAC work varies accordingly; in dedicated centres FNAC represents up to 80% of the workload whilst, in the majority of countries, it represents one quarter or less. Hence, the rate of inadequate FNAC varies widely, depending on the local sampling policies and the organ, but does not exceed 25% in any of the countries. The most sampled organs are breast and thyroid, followed by lymph nodes. Most countries have dedicated training in cytopathology for pathology trainees, the duration varying between 6 months and 2 years of the total training time. This discussion, focusing on European practices, highlights the heterogeneity of FNAC activity but also its success in many centres where it is practiced to a high standard, particularly in breast, thyroid and lymph node pathology. The relatively high rate of inadequate material in some centres reflects local policies and calls for greater uniformity of FNAC practice, particularly specimen sampling. To achieve this, the future direction should concentrate on specialist training, to include performing as well as interpreting FNAC, as part of the curriculum. Current emphasis on web-based training may not provide first hand experience of the FNAC procedure and should be supplemented by attending FNAC clinics and developing the technique to its full potential.

Differentiation and management of endometrium abnormalities and leiomyomas by hydrosonography.

Transvaginal sonography is an established method for numerous clinical indications in the assessment of endometrium pathology. The investigation of the endometrium consists of the measurement of the thickness, the visualization of the echogenity and echotexture and of the demonstration of focal masses. However, evaluation of the uterine cavity by transvaginal sonography is limited and an abnormal ultrasound of the endometrium may reflect benign or malignant conditions. Furthermore, small structures can be missed or overlooked. If indicated, hydrosonography offers various advantages compared to dilatation and curettage and hysteroscopy in terms of costs, availability and risks. Additional informations obtained after hydrosonography may influence the management before consideration of curettage or hysteroscopy.

Angiogenesis in cervical neoplasia: microvessel quantitation in precancerous lesions and invasive carcinomas with clinicopathological correlations.

Recently, angiogenic properties have been shown in preinvasive cervical lesions. Our goal was to determine the angiogenesis in cervical intraepithelial neoplasia (CIN) and the relationship between microvessel counts, histopathological parameters, and clinical outcome in invasive cervical carcinoma. One hundred thirty-eight cervical specimens were evaluated; among these 20 were designated normal epithelium, 20 low-grade CIN, 40 high-grade CIN, and 58 invasive carcinoma. Histological sections immunostained for CD31 were quantitatively evaluated for microvessel density. The tumor proliferation rate was determined by the Ki-67 Labeling Index. Comparison of microvessel counts from normal epithelium with those from CIN and invasive carcinoma showed significant increases in precancerous lesions and invasive cancer (P < 0.0001). Microvessel density was found to be associated with the overall survival in women with invasive carcinoma (P < 0.01). There was a significant correlation of microvessel density (P < 0.05) with relapse-free survival in patients with regional lymph node metastasis. A Cox stepwise regression analysis revealed microvessel density, together with depth of invasion, regional lymph node status, and vascular invasion, to be a strong independent prognostic indicator for overall survival in patients with clinical stage IB cervical carcinoma.

DNA aneuploidy, S-phase fraction, nuclear p53 positivity, and survival in non-small-cell lung carcinoma.

Inactivation of the p53 gene plays a key role in tumour biology, probably through a disturbed cell cycle control and an increased genetic instability in p53-inactivated tumours. To learn more about the relationship between p53 alterations, proliferation and genetic instability (DNA aneuploidy) in lung cancer patients, specimens of 220 surgically resected lung carcinomas with clinical follow-up information were examined by immunohistochemistry (p53; CM1) and flow cytometry. Nuclear p53 positivity--found in 49.5% of the tumours--was associated with both high S-phase fraction (SPF) and DNA ploidy aberrations. SPF was higher in p53-positive tumours (15.9 +/- 10.2) than in p53-negative tumours (10.3 +/- 8.7; P = 0.03). The rate of p53 positivity was higher in 101 DNA-aneuploid and DNA-multiploid tumours (55%) than in 27 diploid and peridiploid carcinomas (33%; P = 0.0512). These results are consistent with an in vivo role of p53 inactivation for increased proliferative activity and development of genomic instability in lung cancer. There was no association between SPF and prognosis. Although prognosis was worse in DNA-aneuploid and multiploid tumours than in diploid, peridiploid and tetraploid carcinomas (P = 0.029), DNA ploidy was not an independent predictor of poor prognosis in multivariate analysis. These data show that DNA-flow cytometry has little prognostic value for patients with resected non-small-cell lung carcinoma.

Altered expression of mdm-2 and its association with p53 protein status, tumor-cell-proliferation rate and prognosis in cervical neoplasia.

Recent results suggest that p53 inactivation is required for cervical-carcinoma development. The mdm-2 oncogene, which forms an auto-regulatory feedback loop with the normal p53 protein, has been found amplified in human carcinomas, thus abolishing the anti-proliferative function of p53. To investigate whether the mdm-2/p53 interaction plays a role in cervical neoplasms, we performed an immunohistochemical study in archival fixed, embedded specimens that included 178 pre-cancerous lesions (CIN) and invasive squamous-cell carcinomas of clinical stage IB. In addition to p53, we assessed the p53-associated protein, mdm-2, and the Ki-67 labelling index (LI). The presence of HPV was assessed by in situ DNA hybridization. Tumor expression of all nuclear proteins was scored as fraction of positive CIN or cancer nuclei. The analysis demonstrated a significant association of the Ki-67 LI with grade of atypia in cervical neoplasms. p53 accumulation and mdm-2 expression are higher in invasive carcinomas than in pre-cancerous lesions. No correlation was observed with HPV status. An inverse correlation was found between increased tumor-cell proliferation and mdm-2 expression in invasive carcinomas (p < 0.0001). mdm-2 expression was significantly associated with p53 accumulation (p < 0.02). However, the investigated nuclear proteins were not associated with overall survival in patients with invasive carcinomas. Cox stepwise-regression analysis revealed regional lymph node status and depth of invasion to be independent parameters.

Breast cancer in previously burned skin: a postburn skin adnexal malignancy?

An unstable postburn scar at the submammarian fold 6.5 months after a burn injury turned out to be breast cancer. The unexpected histological findings and a possible correlation between the burn and the malignancy are discussed. This care report emphasizes the importance of histopathologic examination and the chance of unusual findings in a postburn ulcer.

MIB-1 (Ki-67) immunostaining of breast cancer cells in cytologic smears.

OBJECTIVE: The reliability of immunocytochemical evaluation of proliferation activity was tested using the monoclonal antibody MIB-1 on cytologic specimens. STUDY DESIGN: The study comprised 83 frozen tissue smears (FTSs) and 51 fine needle aspirates (FNAs) from 119 breast cancer patients. MIB-1 labeling indexes (LIs) were compared with various tumor parameters assessed on histologic material. RESULTS: MIB-1 LIs established on cytologic smears were significantly different in ductal and lobular carcinomas (P = .024) and correlated significantly with mitotic activity (P < .0001), histologic grade (P < .0001) and S-phase fraction (P < .0001). Essentially the same results were obtained on FTSs and FNAs. CONCLUSION: Proliferative activity can reliably be evaluated by FNA cytology, and the evaluation of MIB-1 LIs may complement cytologic grading of breast cancer. The evaluation of proliferation activity may, therefore, contribute to the selection of candidates for adjuvant chemotherapy.

Breast cytology. Statistical analysis and cytohistologic correlations.

OBJECTIVE: To analyze the sensitivity, specificity, positive and negative predictive values and the efficacy of fine needle aspiration (FNA) in our material, to investigate the influence of the histologic type and stage of carcinoma on the quality of the aspirates and on the detection rates of mammary carcinoma, and to investigate the rate of inadequate samples and the accuracy of cytologic diagnoses, with an emphasis on the rate of false positive diagnoses in benign mammary lesions. STUDY DESIGN: The results of 1,472 FNAs of the breast obtained over three years were subjected to a retrospective analysis. RESULTS: The cytologic diagnoses were benign in 1,003 cases (68.1%), suspicious in 49 (3.3%) and malignant in 181 (12.3%); 239 (16.2%) of the aspirates were inadequate. In 393 (26.6%) of the cases and in 85% of cytologically malignant smears, the aspirate was compared with histologic examination. The rate of false negative FNAs was 9.0%. The proportion of inadequate cases was clearly related to stage (pT): it was 9.5% in pT1, 5.0% in pT2 and 0% in pT3. Among invasive carcinomas the sensitivity was 89.9%, specificity 99.3% and overall accuracy 88.5%. Among the cases diagnosed cytologically as benign, 182 were compared with biopsies. Of these, 79.9% were true negative, 0.5% (1 case) was false positive, and 15.4% had insufficient cells for evaluation. CONCLUSION: FNA cytology has improved decision making and the selection of patients for biopsy of mammary lesions and has contributed to saving time in the clinical management of breast lumps. In no case did FNA lead to inadequate clinical measures or other disadvantages to patients. Thus, FNA cytology is an indispensible diagnostic tool in the management of breast lesions.

Association of tumor induced vascularization with clinicopathological parameters in cervical neoplasm.

Angiogenic properties have been shown in preinvasive cervical lesions. Our goal was to determine the angiogenesis in cervical intraepithelial neoplasms (CIN), the relationship between microvessel counts, histopathological parameters and the clinical outcome in invasive cervical carcinoma. Comparison of microvessel counts from normal epithelium with that from CIN and invasive carcinoma showed significant increases in pre-cancerous lesions and invasive cancer (p < 0.0001). Microvessel density, assessed by CD31 immunostaining, was found to be associated with the overall survival in women with clinical stage IB cervical carcinoma (p < 0.03). There was a significant association of microvessel density (p < 0.05) with relapse-free survival in patients with regional lymph node metastasis.

Fluorescence in situ hybridization for detecting erbB-2 amplification in breast tumor fine needle aspiration biopsies.

OBJECTIVE: To evaluate the feasibility of erbB-2 amplification analysis of fine needle aspiration (FNA) biopsies. STUDY DESIGN: FNA smears and dissociated nuclei from 58 breast cancer samples were examined by dual-labeling fluorescence in situ hybridization (FISH) with probes for centromere 17 and the erbB-2 gene. The results were compared with the outcome of erbB-2 immunohistochemistry. RESULTS: Tumors were categorized according to the erbB-2/centromere 17 signal ratio. There were 23 tumors with high-level amplification, four cases with a low-level erbB-2 gain and 27 tumors with normal erbB-2 content. Four tumors showed an erbB-2 deletion, all in patients < or = 42 years of age. ErbB-2 amplification was strongly associated with positive erbB-2 immunostaining (P < .0001). Comparison of FISH analysis on dissociated cells and on FNA biopsies showed high correspondence (P < .0001). CONCLUSION: FISH allows reliable detection of erbB-2 gene amplification on FNA biopsies.

Prognostic importance of DNA-ploidy and S-phase fraction in endometrial cancer.

On fresh frozen tumor tissue from 161 patients with endometrial cancer DNA-ploidy and S-phase fraction were measured in a prospective study to evaluate their prognostic and predictive value. All FIGO stage I or II patients had surgery and were included in an adjuvant trial comparing tamoxifen 30 mg p.o. versus medroxyprogesterone acetate 500 mg p.o. for 2 years versus no therapy. Diploid (DNA index (DI) 5%) in 46 (30%) of the patients. Significant correlations of DNA-ploidy and S-phase fraction were found with classical parameters such as stage, grade, histologic type and estrogen and progesterone receptor status. Patients with FIGO stage I aneuploid tumors showed significantly shorter disease-free interval (DFS) and overall survival (OAS). Recurrences and deaths occurred more often in tumors with raised S-phase fraction. In these early stages clinical outcome was worst if both factors were unfavorable. In multivariate analysis of stage I tumors DNA-ploidy and S-phase fraction were independent of grade, type and estrogen receptor status. Patients whose tumors had elevated S-phase fractions (>5%) gained more benefit from endocrine treatment than patients with low S-phase fractions. Patients with diploid and aneuploid tumors had prolonged DFS and improved OAS, if they had received adjuvant hormonal therapy. In endometrial cancer, DNA-ploidy and S-phase fraction are objective and reliable prognostic and predictive parameters which should be integrated into the clinical management.

Clinical and pathological features of highly malignant prostatic carcinomas with metastases to the penis.

Since 1885, 73 penile metastases of a primary carcinoma of the prostate have been reported. There is no standardized therapy as various therapeutic methods have produced variable results. The authors present their experiences with 2 recent cases. In some cases, total penectomy can relieve untolerable pain. Immunohistochemistry and flow cytometry for various prognostic factors showed a high malignant potential of carcinomas of the prostate metastasizing to the penis. Screening for various prognostic factors could favor an initial, more radical surgical approach in some cases, thus avoiding later tumor progression.

[Sarcoma of the breast: what is the contribution of immunohistochemistry and flow cytometry?]. / Sarkome der Mamma: Was bringen Immunhistochemie und Flowzytometrie?

Only 0.2-1% of all mammary malignancies are sarcomas of the breast. This study includes 4 cases: 2 osteosarcomas, 1 fibrosarcoma, and 1 malignant undifferentiated stromal sarcoma. The therapy was mastectomy in 3 cases with dissection of axillary lymph nodes and simple mastectomy in one case. One patient demonstrated local recurrence and died. The remaining 3 patients developed neither metastases nor local recurrence. They are still alive after a follow-up period of between 18 months and 17 years. As first-line treatment, wide local excision or simple mastectomy is recommended. Dissection of the axillary lymphatics, adjuvant radiotherapy, or chemotherapy have no established value in the treatment of breast sarcoma. In our 4 cases, flow-cytometric analysis does not always agree with the biological properties of the tumour and the clinical behaviour, in contrast to the results obtained in respect of carcinomas.

Comparative analysis of the expression of tenascin and established prognostic factors in human breast cancer.

Tenascin is an extracellular matrix glycoprotein expressed during morphogenesis in embryonal life. It reappears in the stroma of benign and malignant tumors. The distribution of tenascin in variants of fibrocystic disease and infiltrating breast carcinoma was assessed in cryostat sections by immunofluorescence using a polyclonal antibody. The tenascin immunoreactivity was compared with various prognostic factors. In fibrocystic disease (n = 10), tenascin appeared as periductal and periacinar bands. In infiltrating carcinomas (n = 32) the tenascin expression was markedly increased. Tenascin immunoreactivity was noted around the ducts (78%), extended into the distal stroma (56%), or was distributed in smaller (reticular) septa around and within tumor-cell nests (34%). Nineteen percent of infiltrating carcinomas did not express tenascin. None of the patterns correlated with prognostic factors such as nodal metastasis, tumor necrosis, invasion of blood vessels, or with flow cytometry results, such as ploidy and S-phase fraction. However, a significantly higher reticular and periepithelial tenascin expression was noted in cases with increased stromal inflammatory reaction. These findings indicate that the appearance of tenascin is neither an indicator of malignancy nor predictive of invasiveness or metastasis but that it is related to local inflammatory response.

[Rare breast tumors]. / Seltene Mammatumoren.

The cystosarcoma phylloides, like the sarcoma, represents 0.3 to 0.9% of all tumors of the breast. The clinical features include two different developments, one phase with increase and the other without. After removal of tumors, there are frequent recurrences. The unique therapy is for that reason to remove the lump with a margin in healthy tissue. The sarcoma of the breast represents only 0.2 to 1% of all mammary malignancies. This study reports four cases, including two osteosarcomas, one fibro- and one malignant fibrous sarcoma. The treatment of choice was mastectomy in three cases with dissection of axillary lymph nodes. The remaining patient was treated by simple mastectomy only. One patient demonstrated local recurrence and died. The remaining three patients developed neither metastases nor local recurrence. They are still alive with periods of observation between 18 months and 17 years. As first-line treatment wide local excision or simple mastectomy is recommended. Dissection of the axillary lymphatics, adjuvant radiotherapy or chemotherapy have no proven value in the treatment of breast sarcoma.

[Cytology and cytometry of breast cancer]. / Zytologie und Zytometrie des Mammakarzinoms.

The cells of mammary carcinoma are obtained by means of fine-needle aspiration (FNA) and assessed by light microscopy. The cytologic diagnosis is supplemented by a steadily increasing series of various cytologic methods such as cytometry (morphometry and flow cytometry) as well as immunocytochemistry. This article deals with the basic principles of a correct FNA technique, its sources of error, and the pitfalls of cytologic differential diagnosis. The additive methods and some of their applications are presented briefly.

Immunocytochemistry in diagnostic cytology.

As the decision for immunocytochemistry is usually made on the basis of findings in Papanicolaou-stained smears and uncovering of the smears takes time, the immunocytochemical results are often reported with some delay. But they are of clinical interest only if reported within a short time. Therefore, immunocytochemistry on cytologic preparations must be carefully organized. The decision for immunocytochemistry must be made before the mounting medium has completely hardened to keep the time of uncovering short. The method of immunocytochemistry should fulfill the following prerequisites: 1. Cell sampling and fixation should be easy to handle for the clinician who sends the specimen to the laboratory. 2. Unspecific background staining, especially in cytologic preparations rich in blood and protein, should not occur. 3. The immunostaining method should be applicable to all kinds of cytologic material, fixed and stained smears included. 4. The nuclear structure of tumor cells should not be destroyed by the immunocytochemical procedure so that tumor cells after incubation are clearly distinguishable from normal cells showing a similar reaction as the tumor cells. There has hitherto been no such all-round method fulfilling all these prerequisites since the properties of the antigenic epitopes of the cells and of the antibodies recognizing them are too heterogeneous. Therefore several methods have to be considered and a variety of technical aspects such as fixation, storage of cytologic material, properties of tinctorial stains, of antibodies and of the antigenic epitopes must be studied to find out the two or three standard methods which meet the requirements in most cases. We recommend the ABC method for Papanicolaou-stained smears and the APAAP method for demonstration of lymphocyte markers. The indication of immunocytochemistry in diagnostic cytology is restricted by the limited number of specimens. Therefore, the following rules have to be observed: 1. The conventional light-microscopic examination must have priority over the immunocytochemical examination. 2. The cytologic specimens assigned for immunocytochemical examination must have been adequately fixed and stored. 3. As the number of smears is limited, the immunocytochemical examinations must be carefully planned and restricted to the absolutely necessary incubations. If possible, an informative smear has to be spared for documentation and future training of cytologists and cytotechnicians. 4. Immunocytochemical examinations in cytology are only justified if the diagnostic problem can be clearly defined. 5. The panel of antibodies should be selected carefully so that the results may give an answer to alternative questions. At least two antibodies should be applied.(ABSTRACT TRUNCATED AT 400 WORDS)