Incidence of neoplasia in patients with clinically suspicious nasal lesions and the value of computed tomography imaging in diagnosis.

BACKGROUND: There is no consensus as to whether all routine bilateral polypectomy specimens should be sent for formal histopathological diagnosis to exclude underlying neoplastic pathology. This study assessed the necessity for histopathological investigation as routine practice in cases of bilateral and unilateral nasal lesions by estimating the incidence of unexpected pathologies. It also evaluated the ability of computed tomography to predict histopathological diagnosis in patients with unilateral nasal lesions. METHODS: A retrospective analysis was conducted of 98 patients undergoing nasal polypectomy over a 12-month period. RESULTS: Five of 23 patients with a unilateral lesion on nasendoscopy had inverted papillomas on histopathological examination. None of the 75 patients with clinically bilateral lesions on nasendoscopy showed evidence of neoplasia on histopathological examination. Patients with inverted papillomas had significantly lower total Lund-Mackay scores than those with bilateral polyps. Asymmetry scores of inverted papilloma patients were significantly higher compared to both bilateral and unilateral polyps patients. CONCLUSION: The results suggest that histopathological diagnosis is only necessary in unilateral lesion patients as no unexpected histopathological diagnoses were made in bilateral lesion patients. Computed tomography imaging may have a role in predicting histopathological diagnosis by demonstrating asymmetry and less overall sinus opacification in patients with neoplastic lesions.

Evaluation of adjunct immunohistochemistry on reporting patterns of non-small cell lung carcinoma diagnosed histologically in a regional pathology centre.

Morphological sub-classification of non-small cell carcinoma in small biopsy specimens presents difficulties for pathologists and recent advances in chemotherapy have resulted in increased pressure to more robustly differentiate between squamous carcinoma and adenocarcinoma. The results of audits examining classification of non-small cell lung carcinoma by pathologists working in a specialist team within a regional centre and the effect of introducing adjunct immunohistochemistry into the reporting pathway are presented. It is concluded that the use of a limited immunohistochemical panel substantially reduces the number of cases when a specific cell type cannot be identified or 'favoured' (34% to 6%) and that the classification obtained correlates well with that found in subsequent resection specimens. In addition the introduction of immunohistochemistry substantially reduces the variability in reporting practice between pathologists.

Atypical mycobacteria in a superficial femoral artery occlusion.

There is indirect evidence that atherosclerosis may occur in association with bacterial infection. The authors report the case of a young woman who presented with right calf claudication caused by a short occlusion of the superficial femoral artery. Histological examination of the excised segment of artery revealed atheroma and atypical mycobacteria within adventitial caseating granulomata. The possible causes are discussed.

Interobserver variation in the classification of thymic tumours--a multicentre study using the WHO classification system.

AIMS: To test the reproducibility of the current World Health Organization (WHO) classification of thymic epithelial tumours and to determine the level of interobserver variation within a group of pathologists, all with experience and expertise in thoracic pathology. METHODS AND RESULTS: Ninety-five thymic tumours were circulated to a group of 17 pathologists in the UK and The Netherlands over a 1-year period. Participants were asked to classify them according to WHO criteria. The diagnoses were subjected to statistical analysis and kappa values calculated. The overall level of agreement was moderate (kappa 0.45). When the categories were reduced in number by creating two groups, (A + AB + B1 + B2 and B3 + C), the level of agreement increased to 0.62. An alternative grouping (A + AB + B1 and B2 + B3 + C) increased it slightly further. The best agreement was in tumour types A and AB. Difficulties arose in distinguishing B1 tumours from B2 tumours and B2 tumours from B3 tumours. CONCLUSIONS: Although the WHO system describes a number of well-defined tumour types with clear diagnostic criteria, the overall level of agreement was moderate and improved if some groups were amalgamated.

Is microscopic examination of hysterectomy specimens removed for clinically benign disease necessary?

The likelihood of finding significant pathology in a hysterectomy specimen undertaken for clinically benign disease is low. Some data indicate that microscopic examination of these specimens may be abandoned. While this approach may seem attractive, the authors believe that there are a number of practical and clinical governance issues associated with this. Instead a pragmatic approach is advocated, with two tissue blocks (cervix and endomyometrium) being adequate in most cases.

The role of matrix metalloproteinases-2, -7 and -9 and beta-catenin in high grade endometrial carcinoma.

AIMS: To determine the expression of matrix metalloproteinases (MMPs)-2, -7 and -9 and beta-catenin in uterine serous carcinoma (USC) and endometrioid endometrial carcinoma (EEC) and to investigate any difference in expression between EEC and USC which might explain the mechanism of invasion and aggressive behaviour of USC. METHODS AND RESULTS: Tissue microarrays were created from the viable central part and from the invasive edge of 20 cases of grade 3 EEC and 73 cases of USC. Immunohistochemistry was performed using antibodies to MMPs-2, -7 and -9 and beta-catenin. MMPs-2, -7 and -9 and beta-catenin were present in both tumour types; there was significantly higher expression of MMPs-2 and -9 in EEC compared with USC and significantly increased expression of MMPs-2 and -9 by carcinoma cells at the invasive edge of USC. CONCLUSIONS: MMPs-2, -7 and -9 and beta-catenin are present in EEC and USC. The increased expression of MMPs-2 and -9 by carcinoma cells at the invasive edge of USC is possibly due to increased binding of MMPs secreted by the stromal cells to carcinoma cells, thus equipping the USC carcinoma cells with proteases for invasion.

Endobronchial ultrasound-guided fine-needle aspiration and liquid-based thin-layer cytology.

BACKGROUND: Optimal management of patients with lung cancer requires accurate cell typing of tumours and staging at the time of diagnosis. Endobronchial ultrasound-guided lymph node aspiration as a method of diagnosing and staging lung cancer is a relatively new technique. AIM: To report the use of liquid-based-thin-layer cytology for the processing and reporting of these specimens. METHODS: The specimens obtained from 80 patients were processed using the ThinPrep system, with the remainder of the samples being processed as a cell block. RESULTS: 40 of the 81 procedures yielded malignant cells (30 non-small cell carcinoma, 8 small-cell carcinoma and 2 combined small-cell carcinoma/non-small-cell carcinoma). The cell blocks were found to contain sufficient material to allow the immunohistochemical characterisation of tumour cells with a range of antibodies. CONCLUSION: The use of liquid-based-thin-layer cytological techniques provides high-quality specimens for diagnostic purposes. When used in conjunction with cell blocks, sufficient material may be obtained to allow immunohistochemical studies to confirm the tumour cell type. Given the current move towards centralisation of pathology services, this approach gives the pathologist high-quality specimens without the need for direct onsite support at the time of the procedure.

A review of the pathology and management of uterine papillary serous carcinoma and correlation with outcome.

Uterine papillary serous carcinoma (UPSC) accounts for 10% of endometrial carcinomas but a higher proportion of deaths due to its aggressive nature and poor response to chemotherapy and radiotherapy. In order to add to the knowledge of UPSC in the literature and to review our local practices, we examined the pathology, medical records, and management of all cases of UPSC (67 patients) treated in South East Scotland over a 10-year period and also evaluated the prognostic significance of the percentage of UPSC in endometrial pipelle and hysterectomy specimens. Although only 63% of initial diagnostic biopsies were reported to contain UPSC, rereview of the cases revealed UPSC in 98.5% of the preoperative biopsies. The percentage of UPSC in the tumors did not affect the outcome. Stage, positive omentum, and treatment with external-beam +/- intracavitary radiotherapy were significantly correlated with overall survival and progression-free survival by univariate analysis, but only stage (P < 0.01) was correlated with outcome on multivariate analysis. Chemotherapy did not affect outcome. UPSC may be difficult to diagnose in preoperative biopsies, particularly when present as part of a mixed tumor. Even a small percentage of UPSC in a diagnostic biopsy or hysterectomy specimen is correlated with a poor prognosis. This study emphasizes the need of a cooperative, prospective study on this distinct uterine carcinoma.

Sampling the omentum in ovarian neoplasia: when one block is enough.

Infracolic omentectomy should be performed on all patients as part of the surgical management of suspected ovarian neoplasia to allow accurate pathologic staging. Unlike the primary ovarian lesion, no guidelines exist as to how the pathologist should sample the omentum. We retrospectively examined pathology reports from 692 cases of primary ovarian neoplasia and demonstrated a high positive predictive value for omenta described as macroscopically involved (98.4%). We propose a system of sampling omenta in which block taking is minimized in cases where the ovary appears benign and the omentum normal or where the ovary appears malignant and correspondingly the omentum appears involved. Thorough sampling should be focused on those cases where the ovary appears malignant or borderline and the accompanying omentum normal. This will allow a reduction in departmental workload without a reduction in quality of pathologic staging.

The use of P53, PTEN, and C-erbB-2 to differentiate uterine serous papillary carcinoma from endometrioid endometrial carcinoma.

Endometrial adenocarcinoma is the most common pelvic genital malignancy in the western world. The most common subtype of endometrial cancer is endometrioid endometrial carcinoma (EEC), which has a relatively good prognosis. Uterine serous papillary carcinoma (USPC) is also a subtype of endometrial carcinoma. This is an aggressive carcinoma with the majority of patients presenting at stage 3-4 and has a worse prognosis stage for stage when compared with EEC. In addition, the treatment of USPC is more extensive than that of EEC, and therefore definitive diagnosis before surgery ensures the optimum management for the patient. This study aims to determine whether P53, C-erbB-2, and PTEN antibodies have a use in the diagnosis and distinction of these cancers. We created tissue microarrays for 35 cases of EEC and 25 cases of USPC, and then we assessed the immunohistochemical expression of P53, C-erbB-2, and PTEN. There was significantly greater expression of P53 in USPC than that in EEC. However, neither C-erbB-2 nor PTEN showed any significant difference in expression between the two carcinomas. P53 may have a role in the diagnosis of USPC, but neither C-erbB-2 nor PTEN would be useful as part of a diagnostic panel.

Pathology of the cervix: recent developments.

In the UK, cervical carcinoma is still the eleventh most common cause of cancer in women--it comprises 2% of all female cancers, and accounts for 927 deaths in 2002 alone. The most effective treatments to date are surgery in the form of loop excision of the transformation zone (LLETZ) for pre-invasive disease, LLETZ or simple hysterectomy with laparoscopic pelvic lymphadenectomy for International Federation of Gynecology and Obstetrics (FIGO) Stages IA1 and IA2 microinvasive carcinomas, and Wertheim's hysterectomy or Coelio-Schauta for FIGO Stage IB disease along with concurrent chemoradiotherapy in patents with at least FIGO Stage IB disease. However, radical trachelectomy, which involves a radical excision of the cervix with simultaneous laparoscopic or extraperitoneal lymphadenectomy, may be used selectively in patients with up to FIGO Stage IB1 cancers, as this may preserve fertility in younger women. This paper briefly discusses the role of human papilloma viruses (HPV) and human immunodeficiency virus (HIV) in the development of cervical pre-cancer, and some of the improvements in the techniques used in the cervical carcinoma screening programme. In addition, the diagnosis, staging, spread and prognostic factors involved in invasive cervical carcinoma are mentioned. We will also discuss the role of immunohistochemistry in the diagnosis of invasive cervical carcinoma and recent advances in the molecular pathology of cervical carcinomas.

Galectin-3: differential expression between small-cell and non-small-cell lung cancer.

AIMS: To compare the histological expression of galectin-3 in different lung cancers, including small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC). Lung cancer is the leading cause of cancer deaths in the UK. Galectin-3 is a beta-galactoside binding protein with a controversial role in malignant transformation. SCLC metastasizes early and is initially chemosensitive; NSCLC metastasizes later, offering the chance of surgical cure, but is much less chemosensitive. Mixed tumours present a diagnostic and therapeutic problem, with a poorer response to therapy. Insight into the cellular mechanisms that govern metastasis and chemoresistance will profoundly influence the future management of this disease. METHODS AND RESULTS: In this study the histological expression of galectin-3 was assessed in a panel of lung tumour specimens, using the indirect streptavidin-biotin method. A striking difference in galectin-3 expression was observed between tumours, with high expression in NSCLC (42/47 samples) and low expression in SCLC (negative in 13/18, weak in 5/18). CONCLUSION: This differential expression of galectin-3 between histological types of lung carcinoma suggests that galectin-3 may have an important influence on tumour cell adhesion, apoptosis and the response of tumours to chemotherapy.

Efficacy and pattern of use of sputum cytology as a diagnostic test.

Sputum cytology is regarded by many clinicians as a noninvasive, cheap and simple test for the diagnosis of bronchogenic carcinoma. Since the introduction of fibre-optic bronchoscopy and more easily obtained bronchial biopsies reliance on sputum cytology has diminished. However, in Edinburgh it was perceived that sputum samples were still being sent as well as, rather than instead of, bronchoscopic specimens. This retrospective study was undertaken to determine whether or not cytological examination of sputum is an efficient and sensitive test in the investigation of patients with suspected bronchogenic carcinoma. It demonstrated that the Lothian University Hospitals NHS Trust Pathology Directorate receives many sputa from departments not specializing in respiratory disease when there is no indication for the test. In addition, we have shown that the absolute sensitivity of the test is only 5% and that when there is a strong clinical suspicion of bronchogenic carcinoma the results of sputum cytology do not play a significant role in the management of the patient. We recommend that sputum cytology is restricted to those patients under the care of Respiratory Units in whom bronchoscopy is inappropriate or unsuccessful.

Intra-uterine death resulting from placental metastases in adenocarcinoma of unknown primary.

A thirty-five year old woman presented with bilateral neck, chest wall and back masses. She was 16 weeks pregnant. Lymph node excision revealed metastatic poorly differentiated adenocarcinoma of unknown primary. Abdominal ultrasound showed a mildly enlarged spleen and a 2-3 cm porta hepatis node. All other investigations were negative. The lymph node and cutaneous metastases progressed rapidly so it was decided to initiate systemic chemotherapy with a view to delivery at 28 weeks gestation by Caesarean section. Shortly after the second 3-weekly cycle of cisplatinum chemotherapy the patient suffered severe lower back and hip pain with MRI scan showing multiple bony metastases in the pelvic girdle. Ultrasound revealed the fetus to have been dead for at least 10 days. The products of conception were delivered following medical induction of labour. Two days later the patient suffered a cardiac arrest from which she could not be resuscitated. Placental histology revealed extensive metastases. With the exception of melanoma this has rarely been reported in solid adult malignancy. As a cause of fetal death, placental metastases are extremely rare.