Comparative polymerase chain reaction analysis of c-myc amplification on archival breast fine-needle aspiration materials.

The oncogene c-myc is a key regulator of cell cycle progression (from G1 to S phase). The amplification of c-myc can either induce cell proliferation or apoptosis. As a part of our ongoing effort to develop methods for multiple tumor marker analysis, this study was carried out to determine whether biomarkers such as c-myc amplification could be analyzed on genetic materials collected from archival fine-needle aspiration (FNA) smears. A novel comparative PCR analysis was used to analyze c-myc amplification semiquantitatively. Genomic DNA was prepared using cells obtained from archival FNA materials that had undergone quantitative fluorescence image analysis (QFIA) for other biomarkers. Of the 72 cases selected from 1995 for this study, 53 had an adequate amount of DNA for analysis. A novel comparative PCR analysis was used to analyze c-myc amplification quantitatively. For each batch of experiments, DNA from the high c-myc expressing cells, HL-60, and DNA from the low expressing cells, K562, were served as positive and negative controls, respectively. c-myc amplification was observed in 16 (94.1%) of 17 malignant lesions, 5 (41.7%) of 12 proliferative breast diseases with nuclear atypia, and 4 (16.7%) of 24 other benign lesions (fibroadenoma or fibrocystic disease). The overall difference of c-myc expression among these groups was highly significant by chi2 analysis (P = 0.0002). We conclude that multiple phenotypic markers and genotypic markers may be combined in a risk assessment biomarker profile on small FNA samples that can be obtained on multiple occasions relatively noninvasively from the patient. The results of this study suggest that c-myc amplification may be a biomarker of breast cancer risk. However, additional large, prospective studies are needed to confirm the current observation.

Triple test approach to inadequate fine needle aspiration biopsies of palpable breast lesions.

OBJECTIVE: To perform a retrospective study evaluating the triple test for inadequate fine needle aspiration (FNA) biopsies of palpable breast lesions with a two-year clinical follow-up. STUDY DESIGN: All aspirates were reviewed and assessed for cellular adequacy in a one-year period. Specimen adequacy was based on the most stringent criteria, the presence of six or more epithelial cell clusters composed of at least six cells each. In all cases, clinical and radiologic results were reviewed and compared with the histologic outcome. RESULTS: Aspirates from 61 of 263 (23%) patients with palpable breast lesions that yielded nondiagnostic results were examined. The study showed a misdirected FNA rate of 21% and a misinterpreted rate of 1.6%. The other 77% of cases had benign surgical biopsies and/or clinical follow-up. Three of 61 (4.9%) cases with nondiagnostic smears were found to have cancer; two were inadequate due to misdirected aspirates, and one was misinterpreted microscopically. All cancer cases underwent surgical removal of the mass as a result of clinical or radiologic suspicion. CONCLUSION: We recommend utilizing the three diagnostic parameters of cytology, clinical findings and radiology, the "triple test," to achieve the best diagnostic accuracy in breast FNAs and to enhance patient management.

Immunohistochemical evaluation of K-ras, p53, and HER-2/neu expression in hyperplastic, dysplastic, and carcinomatous lesions of the pancreas: evidence for multistep carcinogenesis.

The pathobiology of precursor lesions leading to invasive pancreatic adenocarcinoma remains a controversial area, but knowledge of the mechanisms of tumorigenesis may lead to possibly earlier detection, prevention, and treatment in the future. We hypothesize that ductal hyperplasia and dysplasia of the pancreas represent precursor lesions and are part of a continuous developmental spectrum evolving into ductal adenocarcinoma of the pancreas. To further define this sequence, we studied the immunohistochemical markers HER-2/neu, K-ras, and p53 in 15 adenocarcinomas and 15 nonmalignant specimens of the pancreas. The 15 nonmalignant specimens of the pancreas included both normal pancreas and chronic pancreatitis. Overall, HER-2/neu was positive in normal ducts, ductal hyperplasia, dysplasia, and carcinoma cells in 0 of 30, 11 of 20 (55%), 10 of 15 (67%), and 12 of 15 (80%), respectively, with progressive increase in the intensity of staining; p53 was positive in 1 of 30 (3%), 0 of 20, 3 of 15 (20%), and 13 of 15 (80%), respectively, and K-ras was positive in 1 of 30 (3%), 6 of 20 (30%), 11 of 15 (73%), and 8 of 15% (53%), respectively. These data support the hypothesis that ductal hyperplasia and dysplasia of the pancreas represent precursor lesions, and, in a fashion similar to that in colorectal tumorigenesis, pancreatic cancer seems to accumulate progressive genetic alterations.

Single cell multiple biomarker analysis in archival breast fine-needle aspiration specimens: quantitative fluorescence image analysis of DNA content, p53, and G-actin as breast cancer biomarkers.

Fine-needle aspiration (FNA) is a sensitive and cost-effective method for evaluating breast lesions. However, the diagnosis of early premalignant lesions is less reliable by FNA because of a lack of distinctive cytological features. Accurately defining the risk of such lesions at the individual level may have significant impact in breast cancer prevention and management. The main objective of this preliminary study was to develop a method to study multiple biomarkers on archival FNA slides using quantitative fluorescence image analysis (QFIA). Biomarkers p53, G-actin, and DNA content were labeled with an immunofluorescence technique and measured by QFIA simultaneously on a single cell basis. QFIA allows the labeling and measurement procedures to be carried out in situ, without the need to remove cells from the slide while preserving the morphology of the cells. FNA slides from 72 incident patients were obtained for this study. Fifty-six cases had an adequate number of cells for the actual analysis (25 benign breast lesions, 14 proliferative breast diseases with nuclear atypia, and 17 malignant lesions). The DNA content (> or = 5c) and G-actin (average gray mean, > 90) were positive in 81% and 88% of malignant lesions, respectively. These were significantly higher than the corresponding positive rates in benign lesions (7% and 15%, respectively; P <0.01 for both). None of the benign cases were positive for G-actin and DNA simultaneously, and none of the malignant cases were negative for G-actin and DNA together. p53 was positive in 33% of malignant lesions and 8% of benign lesions (P >0.05). Our study demonstrates the feasibility of evaluating multiple biomarkers by QFIA on archival FNA-fixed specimens. The G-actin and DNA content assayed by QFIA may be potential intermediate end point markers for breast cancer individual risk assessment.

Psammocarcinoma with an aggressive course.

BACKGROUND: Psammocarcinoma is an unusual variant of serous cystadenocarcinoma characterized by heavy deposits of psammoma bodies. This disease has been suggested to be similar to carcinomas of low malignant potential in its indolent clinical course. We present this case report of an aggressive course of this disease to alert others that psammocarcinoma may not always follow a benign course. CASE: A 66-year-old woman underwent staging laparotomy for bilateral ovarian cystadenofibromata with rare foci of borderline serous tumors and several small bowel peritoneal surface nodules showing infiltrating psammocarcinoma. She was not recommended for adjuvant therapy because of the previously reported indolent course of this disease. Eighteen months later she represented with small bowel obstruction and underwent an exploratory laparotomy that demonstrated diffuse recurrence of the psammocarcinoma. CONCLUSION: Psammocarcinoma may have a more aggressive course than has been suggested. Patients with this disease should have optimal tumor debulking. There may be a role for adjuvant therapy in its treatment.

Fine needle aspiration biopsy of solitary fibrous tumor of the pleura. A report of two cases with a discussion of diagnostic pitfalls.

BACKGROUND: The diagnosis of a peripheral pulmonary nodule presents a challenge due to many diagnostic possibilities and pitfalls. We describe the cytologic features of solitary fibrous tumor of the pleura, differential diagnoses, pertinent immunohistochemical stains and histogenesis. CASES: Two cases of solitary fibrous tumor of the pleura showed two cell populations on cytologic preparations; mesothelial cells and spindle cells. The neoplastic spindle cell component was positive for CD-34 and vimentin but not for cytokeratin. CONCLUSION: Solitary fibrous tumor of the pleura is rare but should be included in the differential diagnosis of a peripheral pulmonary nodule. Fine needle aspiration biopsy is a safe and rapid method of providing a confirmatory diagnosis.

Fine needle aspiration diagnosis of fibromatosis colli. A report of three cases.

BACKGROUND: Fibromatosis colli, a common cause of congenital muscular torticollis, should be differentiated from other neck masses in infants. Invasive diagnostic and therapeutic measures should be avoided. CASES: Three infants under the age of 2 months presented with neck masses--a clinical suspicion of malignancy, lymphadenopathy and teratoma. The cytologic findings included dyshesive multinucleated skeletal muscle fragments showing degenerative and atrophic changes within a background of scattered reactive fibroblasts. CONCLUSION: Fine needle aspiration biopsy is a safe and rapid method of providing a confirmatory diagnosis of neck masses in infants.

Studies of esophageal balloon cytology in Linxian, China.

Esophageal cancer is the second leading cause of cancer death in China. Esophageal cancer has a very poor prognosis, principally because most tumors are asymptomatic until they are unresectable. Esophageal balloon cytology is an early detection method developed by Chinese scientists to identify resectable early cancers and precursor lesions. Previous studies have reported high sensitivities for detecting esophageal cancer in symptomatic patients. The current report describes several studies evaluating this diagnostic technique in asymptomatic individuals. A comparison of Chinese and U. S. cytological diagnoses of the same esophageal samples showed that the Chinese categories of precancerous neoplasia were more inclusive than the corresponding U. S. categories. Comparisons of both Chinese and U. S. cytological diagnoses with concurrent histological findings showed low (14-36%) sensitivities for the cytological detection of biopsy-proven cancers. Prospective follow-up studies of several screened cohorts showed a consistent progression of risk for developing esophageal cancer with increasing severity of initial cytological diagnosis. These preliminary studies suggest that esophageal balloon cytology is a useful technique that can benefit from additional research to improve its optimal performance.

Progestin alone as primary treatment of endometrial carcinoma in premenopausal women. Report of seven cases and review of the literature.

BACKGROUND: The standard treatment for endometrial carcinoma is staging laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy. In an attempt to preserve childbearing potential, selected patients with endometrial carcinoma were treated with progestin alone as primary therapy. METHODS: Patients were identified through searches of tumor registries and solicitation of consulting gynecologic oncologists at the affiliated institutions of the University of California-Los Angeles Center for the Health Sciences. Only those patients with a diagnosis of endometrial carcinoma treated with progestin alone as primary therapy were included in the study. Independent pathologic review was performed by a recognized expert gynecologic pathologist to exclude cases of endometrial hyperplasia. A MEDLINE search was conducted to identify reports of similarly treated patients. RESULTS: Seven patients were treated with progestin alone for endometrial carcinoma at the study institution. Fourteen additional patients were identified through the literature search. Combining the data for all patients, 13 of 21 patients (62%) had an initial response to progestins. Three initial responders later developed recurrent disease, one of whom was found to have extrauterine disease at laparotomy. Eight of 21 patients (38%) did not respond to progestins and underwent more definitive treatment. None of these patients later developed recurrent disease. Six viable infants were delivered of three patients after therapy. Nineteen of 21 patients were alive without evidence of disease at last follow-up. CONCLUSIONS: The results of this study show that premenopausal women with endometrial carcinoma may be treated successfully with progestin therapy alone as primary therapy to preserve childbearing potential.

Mixed mesodermal sarcoma of the ovary in a young patient.

Mixed mesodermal tumors (MMT) of the ovary are rare and have a poor prognosis. This ovarian malignancy usually occurs in postmenopausal women. We report an unusual ovarian MMT in a young woman given treatment similar to one used for ovarian germ cell malignancies. We believe this is the youngest patient reported with an homologous MMT of the ovary.

Polymerase chain reaction-based K-ras mutation detection of pancreatic adenocarcinoma in routine cytology smears.

The cytologic diagnosis of pancreatic carcinoma is notoriously difficult, particularly in distinguishing benign atypia from well-differentiated adenocarcinoma. Mutation of codon 12 in the K-ras oncogene is frequently found with pancreatic cancers. Detection by polymerase chain reaction (PCR) followed by restriction endonuclease digestion can provide a powerful tool to improve and confirm diagnosis. The authors examined the utility of PCR-based detection in the diagnosis of pancreatic carcinoma using routinely obtained cytology smears that could be collected at most hospitals. Pancreatic cytology smears were collected retrospectively from 60 patients. DNA was extracted from the slides and amplified by PCR using mismatched primers that generated a Bst-N1 recognition site with the wild type codon 12 but not with the mutant allele. Results were compared with clinical follow-up. K-ras codon 12 mutations were observed in 44 of 46 (95.7%) cases of pancreatic cancer, but not in 12 benign cases nor in 2 cases of islet cell tumor. The amplification and digestion steps proved robust and sensitive, capable of detecting mutant K-ras alleles from cytology smears that contained only small foci of suspicious cells. Our results indicate that K-ras mutation analysis can be done reliably within 1 to 2 days from routine cytology slides without special handling, increasing the sensitivity of diagnosis in ambiguous cases while maintaining cost-effective and relatively noninvasive sampling strategy.

Squamous esophageal histology and subsequent risk of squamous cell carcinoma of the esophagus. A prospective follow-up study from Linxian, China.

BACKGROUND: Linxian, China, has some of the highest rates of esophageal cancer in the world. Previous authors have proposed that esophagitis, atrophy, and dysplasia may be precursor lesions of esophageal cancer in such high risk populations. METHODS: To examine the relationship between squamous esophageal histology and subsequent esophageal cancer in Linxian, the authors prospectively followed 682 participants of a 1987 endoscopic survey for 3.5 years and compared their initial biopsy diagnoses with the occurrence of squamous cell carcinoma during this follow-up period. RESULTS: Squamous cell carcinoma of the esophagus was identified in 52 (7.6%) of the participants during the follow-up period. After adjusting for potential confounding factors, relative risks (95% confidence intervals) for squamous cell carcinoma incidence by initial histologic diagnoses were as follows: normal, 1.0 (reference); basal cell hyperplasia, 2.1 (0.4-9.8); mild dysplasia, 2.2 (0.7-7.5); moderate dysplasia, 15.8 (5.9-42.2); severe dysplasia, 72.6 (29.8-176.9); dysplasia not otherwise specified, 22.9 (6.7-78.0); and carcinoma in situ, 62.5 (24.1-161.9). CONCLUSION: In this study, moderate dysplasia, severe dysplasia, and carcinoma in situ were the only histologic lesions associated with a significantly increased risk of developing squamous cell carcinoma of the esophagus within 3.5 years after endoscopy. Increasing grades of dysplasia were associated with increasing risk, but severe dysplasia were associated with increasing risk, but severe dysplasia and carcinoma in situ had similar degrees of risk, findings that suggest a continuous spectrum of esophageal intraepithelial neoplasia, without morphologically distinguishable dysplasia and in situ carcinoma. A longer follow-up will be necessary to fully evaluate the less severe diagnostic categories, which may take more than 3.5 years to affect the occurrence of squamous cell carcinoma in this high risk population.

The alcohol-fixed Diff-Quik stain. A novel rapid stain for the immediate interpretation of fine needle aspiration specimens.

A rapid alcohol-fixed Diff-Quik stain is described. The technique takes less than five minutes and results in excellent cytologic detail, comparable to that with Papanicolaou stain, as well as superb stromal definition. The stain should be very useful to pathologists and cytotechnologists for immediate interpretation of fine needle aspiration specimens.

Esophageal balloon cytology and subsequent risk of esophageal and gastric-cardia cancer in a high-risk Chinese population.

Linxian, China has some of the highest rates of esophageal/gastric cardia cancer in the world. In 1983, esophageal balloon cytology screening was performed in 3 communes in northern Linxian. Of the participants, 10,066 with no evidence of cancer were followed prospectively for 7 1/2 years to evaluate the ability of the initial cytologic diagnoses to identify individuals at increased risk for developing cancer of the esophagus or gastric cardia. A total of 747 incident cases of esophageal or cardia cancer and 322 deaths due to these tumors were identified during the follow-up period and used in this analysis. The risks for esophageal or cardia cancer incidence and mortality increased in parallel with the presumed severity of the 1983 Chinese cytologic diagnoses. After adjusting for potential confounding factors, relative risks for esophageal or cardia cancer incidence, by initial cytologic diagnosis, were normal = 1.00 (reference), hyperplasia = 1.25, dysplasia 1 = 2.20, dysplasia 2 = 4.22 and near-cancer = 5.96. Our results suggest that esophageal balloon cytology, as performed and interpreted in Linxian in 1983, successfully identified individuals at increased risk for developing cancer of the esophagus or gastric cardia.

Pitfalls in the cytologic diagnosis of angiosarcoma of the breast by fine-needle aspiration: a case report.

This paper describes a case of angiosarcoma of the breast in a 26-yr-old female. The tumor, originally thought to be granulation tissue on fine-needle aspiration biopsy, was correctly identified as a malignant neoplasm of probable mesenchymal origin on a repeat FNA biopsy 4 mo later. A diagnosis of angiosarcoma was made on a subsequent excisional biopsy. Review of the cytologic features revealed findings that should suggest angiosarcoma, especially when correlated with the clinical history. The authors describe the cytological features seen in this case, and discuss an important pitfall in the diagnosis of angiosarcoma of the breast on FNA.

Peritoneal adenocarcinoma (serous) of Müllerian type: a subgroup of women presenting with peritoneal carcinomatosis.

Peritoneal adenocarcinoma (serous or other subtype) of Müllerian type (PAMT) is frequently misclassified as another primary tumor. Peritoneal carcinomatosis in women without evidence of a primary site may occur secondary to a number of processes. Confusion regarding the nomenclature has made it difficult to determine the incidence and natural history of this unique malignancy. Other terms used for this tumor include mesothelioma, peritoneal papillary serous carcinoma, extra-ovarian serous carcinoma, and normal-sized ovarian carcinoma syndrome. Thirty-four patients (33 serous and one endometrioid) were identified with PAMT during 1976 through 1988. One hundred and thirty-seven patients underwent primary cytoreductive surgery for a preoperative diagnosis consistent with ovarian cancer. Twenty-nine (21.2%) were classified as PAMT (5 of the 34 had their initial surgery at other institutions). The mean age was 61.4 years. The primary symptoms and signs were abdominal pain (68%) and ascites (52%). Twenty-five (73%) had a preoperative diagnosis of ovarian cancer while the postoperative diagnosis was unknown (44%), PAMT (29%), and ovarian cancer (27%). Univariate and multivariate survival analysis were performed. Survival was independent of age, residual disease, grade, ascites, type of chemotherapy, and second-look results. In patients with residual disease < 1.5 cm, extended survival was found in (hose with ascites < 1000 ml, residual disease in pelvis only, and small residual volume but statistical significance was not obtained. Twenty-eight patients received >/=4 courses of chemotherapy after primary surgery. Twelve of 21 patients (57%) who received cisplatin (CDDP) survived between 23 and 92 months, while no patient receiving other chemotherapeutic regimens survived more than 25 months. The 2 and 3 year survival rate for CDDP was 47% and 33% vs. 14% and 0% for other regimens. Optimal cytoreductive surgery was not an independent prognostic factor as found in ovarian cancer, probably secondary to unresectable peritoneal carcinomatosis. PAMT is sensitive to chemotherapy but only the use of CDDP was associated with long term survival. Based on these results, women with peritoneal carcinomatosis consistent with PAMT should receive a CDDP-based regimen after primary surgery.

Squamous dysplasia and early esophageal cancer in the Linxian region of China: distinctive endoscopic lesions.

BACKGROUND: Linxian, China, has one of the highest rates of esophageal cancer in the world. To design a logical biopsy strategy for large-scale endoscopic surveys in Linxian, the aim of this study was to determine whether squamous dysplasia and early squamous cancer are associated with visible lesions that can be targeted for biopsy. METHODS: Sixty-three Linxian patients with balloon cytological evidence of squamous dysplasia or early cancer of the esophagus had biopsy specimens taken every 4 cm and additional specimens taken from all visually abnormal areas. The appearance of the 398 biopsy sites was described, and abnormal-appearing areas were photographed. The endoscopic descriptions were then compared with the biopsy diagnoses. RESULTS: Twenty-five of 31 (81%) moderately dysplastic or worse specimens (including all nine specimens of invasive cancer) came from visually abnormal sites classified as friability, focal red area, erosion, plaque, or nodule. Fifteen of 16 (94%) patients with moderate dysplasia or worse biopsy diagnoses would have been identified if only these visible target lesions had been sampled. CONCLUSIONS: For surveillance in this high-risk population, random biopsy specimens may be unnecessary; sampling the target lesions described appears sufficient to detect nearly all invasive cancer and most dysplasia. Awareness of these lesion appearances may also aid in earlier detection of squamous cancers of the esophagus in lower-risk populations such as those in Europe and North America.

Malignant endometrial pathology.

This review discusses recent papers on endometrial carcinoma variants, immunohistochemical studies, and prognostic indicators. The aggressive nature of uterine papillary serous carcinoma is confirmed, even in the absence of myometrial or vascular invasion, with a comprehensive review of the histology, clinical presentation, and proposed treatment protocols. The possible etiologic role of radiation in the development of uterine papillary serous carcinoma is alluded to. The virulence of endometrial carcinomas with trophoblastic differentiation, endometrial carcinomas with a malignant giant cell component, and clear cell carcinomas of the endometrium is documented. A series of immunohistochemical studies is presented suggesting that uterine carcinosarcomas are metaplastic carcinomas derived from a common stem cell and that a shared histogenesis of endometrial stromal tumors and uterine mesoderm exists. Immunohistochemical techniques may clarify diagnostic problems of uterine tumors and their metastases and differentiate mucinous tumors of endometrium from endocervical origin. Staining of both carcinoembryonic antigen and ferritin in neoplastic endometria may be helpful in their differentiation from hyperplasias in curettage specimens. Significant prognosticators in endometrial carcinoma are depth of myometrial invasion and lymphovascular space involvement with greatest prognostic information provided by the depth of myometrial invasion above DNA index.

Histologic and immunohistochemical analysis of nine endometrial stromal tumors: an unexpected high frequency of keratin protein positivity.

Nine cases of endometrial stromal tumors were examined by light microscopy and a battery of immunostains for diagnostic purposes. Eight of the cases were originally classified as endometrial stromal tumors and one as an epithelioid leiomyoma. Three of six (50%) endometrial stromal sarcomas stained positively for keratin/cytokeratin. All of these same tumors stained for vimentin. One case originally considered an epithelioid leiomyoma on light microscopy was later diagnosed as a uterine tumor with sex cord features following strong positive immunostaining with keratin/cytokeratin antibodies and negative staining with antidesmin. These results show that immunoreactivity for epithelial differentiation may be present in endometrial stromal tumors. The diverse immunostaining patterns of the stromal tumors reflect the probable histogenesis of these neoplasms from primitive totipotential stem cells which may differentiate along epithelial and various mesenchymal cell lines.

The cytobrush for evaluating routine cervicovaginal-endocervical smears.

While the conventional wooden spatula/cotton-tipped applicator has remained the method of obtaining Papanicolaou smears for most clinicians at the University of California at Los Angeles, the Student Health Service (SHS) adopted the Zelsmyr cytobrush as its sole method of obtaining cervical samples in late 1986. A study was done to define changes in both the adequacy of sampling and the detection rate for both squamous and glandular epithelial abnormalities with the cytobrush. To accomplish this goal, 1,000 cytobrush and 244 conventionally obtained smears were analyzed prospectively, and 3,864 SHS samples obtained in 1986 prior to the change in method were reviewed retrospectively. As compared to cervical samples obtained by conventional methods, the cytobrush smears contained significantly more endocervical cells and had fewer drying artifacts. Both methods obtained equivalent squamous samples and had similar final class distributions. No case of endocervical adenocarcinoma carcinoma in situ or invasive adenocarcinoma was detected. SHS patients who had initial "no endocervical cells" samples but whose repeat sample did contain endocervical cells retained the same class in more than 75% of cases. This study confirmed that the cytobrush technique produces Papanicolaou smears with improved sampling of the squamocolumnar junction but questioned whether that results in an increased detection rate for cervical pathology.