The role of breast FNAC in diagnosis and clinical management: a survey of current practice.

Most participating countries have now adopted a triple assessment approach, i.e. clinical,imaging and pathology, to breast diagnosis, with FNAC as the first-line pathological investigation in both screening and symptomatic populations, with the exception of microcalcifications. Pathologists specialized in cytopathology are best qualified to collect and interpret FNAC samples, but this is not always possible or practical. Radiologists involved in breast imaging should ensure that they have the necessary skills to carry out FNAC under all forms of image guidance. Best results are achieved by a combination of both techniques, as shown in the image-guided FNAC in the presence of the cytopathologist. The majority of European countries use similar reporting systems for breast FNAC (C1-C5), in keeping with European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis, although some still prefer descriptive reporting only. When triple assessment is concordant, final treatment may proceed on the basis of FNAC, without a tissue biopsy. ER and PR assessment can be done safely on FNAC material. However, not all institutions may have expertise in doing this. HER-2 protein expression on direct cytological preparations is insufficiently reliable for clinical use, although its use for FISH is possible, if expertise is available. The majority of participants practise a degree of one-stop diagnosis with a cytopathologist present in the out-patient clinic. Formal recognition of the importance of the time spent outside the laboratory, both for cytopathologist and cytotechnologist, is necessary in order to ensure appropriate resourcing. The use of core biopsy (CB) has increased, although not always for evidence-based reasons. CB and FNAC are not mutually exclusive. FNAC should be used in diagnosis of benign, symptomatic lesions and CB in microcalcifications, suspicious FNAC findings and malignancies where radiology cannot guarantee stromal invasion.

The future of cytopathology in Europe. Will the wider use of HPV testing have an impact on the provision of cervical screening?

The emphasis of the EFCS Congress held in Venice in October 2006 was on the future of Cytopathology in relation to events in Europe. Much of the discussion centred on the role of human papilloma virus testing and its impact on the provision of cervical screening. The following is a transcript of the discussion that took place at the Advisory Board Meeting for the journal Cytopathology, with some additional written comments received prior to the meeting. A brief summary has been provided as a conclusion by Dr A. Herbert.

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.

Human papillomavirus E6/E7 mRNA expression in women younger than 30 years of age.

OBJECTIVE: The prevalence of human papillomavirus (HPV) is high in women younger than 30 years of age, most infections being transient. It is not clear, however, to what extent the E6/E7 transcripts are being expressed. This may be of prognostic importance. In this study, we have determined the prevalence of HPV DNA and mRNA in 283 women younger than 30 years of age. METHODS: E6/E7 transcripts from HPV types 16, 18, 31, 33 and 45 were detected using PreTect HPV-Proofer, while the presence of HPV DNA was detected using Gp5+/6+ consensus PCR and type-specific PCR. RESULTS: A total of 92 women (32.5%) were positive by consensus PCR, 59 (20.8%) were positive by type-specific PCR, while 41 (14.5%) were positive by PreTect HPV-Proofer. E6/E7 mRNA expression was detected in 38 (64.4%) of the 59 HPV type-specific DNA positive women. For HPV 16, E6/E7 mRNA expression was observed in 8 (32%) of the 25 DNA positive women. No high-grade lesions were observed in the concomitant cytology. CONCLUSIONS: Among young women having a normal Pap smear, a high HPV prevalence was found. Hence, use of consensus PCR will most probably give a low prognostic value for identifying subsequent severe dysplasia. The five HPV types 16, 18, 31, 33 and 45 accounted for the majority of infections with two out of three having a detectable E6/E7 mRNA expression. Yet, repeated type-specific testing for HPV mRNA may identify young women with a persistent transforming infection being at increased risk for severe dysplasia.

Interpretation of fine needle aspiration cytology of the breast: a comparison of cytological, frozen section, and final histological diagnoses.

This study examines the performance of the preliminary, on-site interpretation by the pathologist of fine needle aspiration (FNA) cytology smears compared to the final cytology report, the frozen section diagnosis and the final histopathological report. We found that both the preliminary and the final cytology reports gave satisfactory results over the minimum standards for quality assurance required by both the Norwegian breast screening programme and the NHS BSP in the UK with the exception of the 'suspicious' rate. We noted that the preliminary report had fewer false negatives (2.1%) than the final report (4.3%). We show that an unequivocal cytological diagnosis of malignancy is a reliable diagnosis, and in cases where mammography/ultrasonography and clinical examination are in agreement with FNA, frozen section examination is unnecessary. However, cases with a suspicious or equivocal FNA should be considered for frozen section analysis.

Human papillomavirus oncogenic expression in the dysplastic portio; an investigation of biopsies from 190 cervical cones.

In this study, we investigated the presence of E6/E7 transcripts of seven common high-risk human papillomavirus (HPV) types in 190 cervical biopsies. The RNA-based real-time nucleic acid sequence-based amplification assay (NASBA) and type-specific PCR, both detecting HPV 16, 18, 31, 33, 45, 52, and 58, as well as consensus PCR, were performed on all 190 biopsies. High accordance between type-specific and consensus PCR confirms that the HPV types included in this study are the most common types present in cervical dysplasia. Furthermore, we see a clear increase in the incidence of HPV, both DNA and RNA, along with the histological severity of dysplasia. HPV RNA was detected in all but two PCR-positive cases, confirming that the virus exerts E6/E7 mRNA expression in cases of high-grade dysplasia. Out of 19 women given a normal or borderline diagnosis at conisation, only four were found HPV positive, which may suggest that unnecessary conisations can possibly be reduced by introducing HPV testing into the preoperative routine assessment.

TOP2A and HER-2 gene amplification in fine needle aspirates from breast carcinomas.

The TOP2A gene is located on chromosome 17 close to the HER-2 gene. It encodes an enzyme involved in the regulation of cell proliferation. Using fluorescence in situ hybridization (FISH), we have examined fine needle aspiration smears from 42 cases of breast carcinoma with probes for TOP2A, HER-2 and chromosome 17. We found that amplification of TOP2A is a frequent finding in breast cancer and is often but not exclusively accompanied by HER-2 gene amplification. It is associated with high histological grade and oestrogen receptor (ER) negativity. TOP2A deletions may also be associated with high histological grade and loss of ER. TOP2A amplification in the absence of HER-2 amplification may be associated with lower histological grade and ER positivity. Testing for TOP2A aberrations may be useful in the search for individually tailored treatment regimes for breast cancer.

Abnormal chromosome 8 copy number in cytological smears from breast carcinomas detected by means of fluorescence in situ hybridization (FISH).

Numerical change in chromosome 8 is an acquired abnormality associated with high clinical stage and may be involved in the conversion of carcinoma in situ in the breast to invasive carcinoma. Fine needle aspiration smears from 53 cases of breast carcinoma were hybridized with centromeric probes for chromosome 8 and the X chromosome. Thirty-eight cases revealed chromosome 8 copy gain. Of the 45 grade II and III tumours, 28 showed polysomy (>3 signals) and six showed trisomy. Of the eight grade I tumours, four were trisomic, none were polysomic. There were only two cases of chromosome 8 copy loss (one each of grade I and III). X chromosome polysomy was also a frequent finding although the signal counts were similar to those for chromosome 8 in only a few cases. Chromosome 8 polysomy occurs frequently in breast carcinoma and high copy number (>3) is associated with high malignancy grade.

[Can human papillomavirus testing and vaccination prevent cervical cancer?]. / Kan testing og vaksinering for humant papillomavirus forebygge livmorhalskreft?

BACKGROUND: Cervical cancer is the third most frequent cancer among women worldwide. Human papillomavirus (HPV) infection is a necessary risk factor and the first step in cervical carcinogenesis. MATERIAL AND METHODS: This article reviews the current literature concerning the possibility of preventing cervical cancer by HPV testing and vaccination. RESULTS: HPV testing cannot replace cytology, but will reduce false negative cytology and may improve the screening programme for cervical neoplasia. It has not yet been incorporated in any national cervical cancer screening program, but trials are ongoing in Scandinavia and in the Netherlands. The cost-effectiveness of HPV testing in screening has to be proven and whether it can affect the recommended screening-intervals. Therapeutic and prophylactic vaccines for HPV associated disease are in progress. Evaluating the clinical trials that are ongoing will take several years. Several anti-HPV vaccines are now in clinical trials; Norway will also participate. Therapeutic vaccines against cervical cancer have so far not been successful, but anogenital dysplasias and condylomas may be more susceptible. Prophylactic vaccines against HPV 6, 11, 16 and 18 have been evaluated in clinical phase I and II trials, and phase III trials are in progress. INTERPRETATION: HPV testing improves the specificity and sensitivity of cervical cytology and it can be used to clarify cases with atypical cells of undetermined significance (ASCUS) and low-grade intraepithelial neoplasia. In the near future it may also be included in the cervical cancer screening programme for women above the age of 30. The first results in clinical vaccine trials are encouraging, and final conclusions about the effectiveness of these vaccines may be achieved in five years' time.

Physical state of HPV16 and chromosomal mapping of the integrated form in cervical carcinomas.

Using a procedure based on restriction enzyme cleavage, self-ligation, and inverse polymerase chain reaction (rliPCR), the authors investigated 18 cervical intraepithelial neoplasia III (CIN III) cases and 37 invasive squamous carcinomas for integration of human papillomavirus type 16 (HPV16). All eighteen CIN III cases (severe dysplasia or high-grade squamous intraepithelial lesion) were found to harbor episomal HPV, but one of the samples contained mixed episomal and integrated forms. Seventeen of 37 invasive cervical carcinoma samples were identified previously as containing the completely integrated HPV16 genome by using PCR covering the entire E1/E2 gene, and this was confirmed by rliPCR in 16 cases. One case, however, showed a low level of episomal deoxyribonucleic acid in addition to the predominant integrated form. Of the remaining 20 carcinoma samples showing episomal forms in the previous analysis, 14 were found to contain integrated forms using rliPCR, and four contained multimeric episomal forms. Thus, in total, 31 of 37 of the carcinomas (84%) showed the integrated HPV16 genome. The rliPCR product from five carcinoma cases was cloned into a plasmid vector and used as a template for "primer walking" deoxyribonucleic acid sequencing to deduce human sequences flanking the integrated HPV genome. Based on this information, bacterial artificial chromosome (BAC) and P1-derived artificial chromosome (PAC) clones were obtained and used as probes in fluorescent in situ hybridization experiments on human metaphase chromosomes. The results of the fluorescent in situ hybridization experiments showed evidence for HPV16 integration in chromosome regions 1q25, 3q28, 6p25, 11p13, and 18q22. Sixteen carcinoma samples, containing episomal HPV16, were sequenced in the long control region. Evidence for changes in E2 binding or silencer YY1 sequences was found in only two samples.

A population-based five-year follow-up study of cervical human papillomavirus infection.

OBJECTIVE: The purpose of this study was to determine the long-term tendency for cervical human papillomavirus infections to persist in the general population. STUDY DESIGN: From 500 women who participated in a 1991 population-based survey, 90 healthy women with normal results of cytologic examination (women with human papillomavirus deoxyribonucleic acid detected and age-matched control women without human papillomavirus deoxyribonucleic acid detected) were interviewed and examined 5 years later colposcopically, cytologically, and with human papillomavirus serologic testing and human papillomavirus deoxyribonucleic acid testing by polymerase chain reaction with 2 different consensus primer pairs (MY09 and MY11 and GP5(+) and GP6(+)), type-specific polymerase chain reaction, and deoxyribonucleic acid sequencing. RESULTS: The 5-year human papillomavirus clearance rate was 92%. Only human papillomavirus type 16 infections persisted. Colposcopic impression of grade 2 cervical intraepithelial neoplasia was associated with persistent human papillomavirus 16 infection (P <.03). Human papillomavirus detection was associated with sexual history. Human papillomavirus type was the only determinant of human papillomavirus persistence. CONCLUSION: The high clearance rates in a population-based setting with a 5-year follow-up period imply that inclusion of human papillomavirus deoxyribonucleic acid testing in population-based cervical screening programs should target persistent infection.

The pap-smear history of women with invasive cervical squamous carcinoma. A case-control study from Sweden.

BACKGROUND: Screening by cytology is a potentially highly effective procedure for preventing carcinoma of the uterine cervix. To elucidate any weaknesses in the screening procedure in a Swedish county where screening started many years ago, the detection of invasive cervical squamous cell carcinoma was compared to the prior cytological screening. METHODS: On the basis of the complete Pathology data files, including cytology and histology, all 112 women with invasive cervical squamous carcinoma were compared to 112 matched controls from the Swedish Population Register, regarding attendance rate and results of Pap-smears prior to the date of discovery of an invasive carcinoma in the case. RESULTS: Almost as many cases as controls had a history of pap-smear testing, but the cases had significantly more prior atypias registered. Only 16% of women with cervical carcinoma and younger than 60 years were lacking Pap-smear tests prior to the carcinoma diagnosis, but 46% had former atypias registered. More than half of them presented, however, a negative Pap-smear test less than three years before the diagnosis. Among the controls, 10% were lacking prior Pap-smears and only 9% had former atypias registered. CONCLUSION: The policy for follow-up and treatment of cervical dysplasias has to be improved in order to achieve a further reduction of the incidence of invasive carcinoma.

Fine needle aspiration biopsy in selecting treatment for inconclusive intraocular disease.

PURPOSE: To evaluate the fine needle aspiration biopsy (FNAB) as a diagnostic tool in cases where it was impossible to make a definitive diagnosis with noninvasive techniques. METHOD: 80 consecutive patients with inconclusive diagnoses were examined by FNAB prior to decision of treatment. Biopsies were performed through a transscleral route in 50 eyes, an anterior chamber route in 16 eyes and a transvitreal approach in 14 eyes. The consequences of FNAB were analysed retrospectively. RESULTS: FNAB confirmed malignancy in 59 eyes. Inconclusive material was obtained from 5 eyes judged clinically to be malignant disorders. One melanoma was misinterpreted as being a metastasis. In 47.5% of our patients this procedure altered the therapeutic plan and 25 patients were spared enucleation. The biopsy material was correctly diagnosed as benign in 16 cases. CONCLUSION: In eyes where the diagnosis remained uncertain after non-invasive tests, FNAB gave important information which greatly influenced our choice of treatment. FNAB contained sufficient tissue elements for cytological diagnosis in 77 eyes. Cytopathological interpretation failed once in relation to tumour type. The procedure of FNAB can be recommended for use in ambiguous tumour cases of the eye. Probably it should only be used in tumour centres with adequate cytology service.

High risk genital papillomavirus infections are not spread vertically.

The Medline-indexed literature on risk factors for HPV infection and HPV transmission is critically reviewed. Principles for assay validation and interpretation, reliability of different study designs and principles for interpretation of conflicting reports are discussed. The conclusions arrived at can be summarised as: (1) There is overwhelming epidemiological evidence that the only quantitatively important mode of transmission of infection with oncogenic genital HPV types is sexual. (2) There is also evidence that benign genital HPV types can be transmitted sexually, but the epidemiological data on the benign virus types are less extensive and less clear. (3) Perinatal HPV transmission is unequivocally demonstrated only for the rare disease juvenile respiratory papillomatosis.

Low detection rate of HPV in oral and laryngeal carcinomas.

The presence of human papillomaviruses (HPVs) in 38 oral and 16 laryngeal lesions (verrucous hyperplasia, carcinoma in situ and carcinomas) was investigated using the polymerase chain reaction (PCR) technique. All biopsies were fresh frozen and a set of consensus and type-specific primers was used for PCR detection and HPV typing. In oral biopsies a low proportion of HPV-positive cases was found, despite the sensitive techniques. Only one case out of 38, a carcinoma in situ was positive (2.6%). It is thought that this finding reflects a minimal presence of HPV in the oral lesions, but a transient role of virus in the induction of carcinomas cannot be ruled out. Differences in relation to other studies may be geographical and/or methodological. In laryngeal carcinomas (and dysplasias), 3 out of 16 cases were HPV positive. This frequency (19%) concurs with most other studies.

Disruption of the E1 and E2 reading frames of HPV 16 in cervical carcinoma is associated with poor prognosis.

The E1 and E2 reading frames of 158 cervical carcinoma samples containing human papillomavirus (HPV) 16 were mapped using polymerase chain reaction (PCR). The reading frames were amplified using primers spanning the entire genes. Of the analyzed samples, 23% showed no amplification with the E1 primers and 29% showed no amplification with the E2 primers. There was an overlap, but not complete identity, between the E1- and E2-disrupted groups. All E1- and E2-negative samples were further analyzed with primers spanning subsections of the E1 and E2 reading frames, which together covered the entire genes. Of the 35 samples negative for E1, 11 were positive in specific amplification of the 3' end of the E1 gene. Several different subsections of E2 could be amplified from most samples negative for the entire gene (37/46). Five classes of patterns were found, in which either all subsections of the E2 gene or subsections in the 5', middle, or 3' end were disrupted. Although a variable pattern of disruption/deletion in the E1-E2 area of the HPV 16 genome was found in cervical carcinoma, the 5' end disruption was the most common one in both E1 and E2. Patients with carcinomas showing disruptions in E1/E2 had a poorer survival than those without such changes, and E1 disruptions were the most important prognostically.

Human papillomavirus findings in relation to cervical intraepithelial neoplasia grade: a study on 476 Stockholm women, using PCR for detection and typing of HPV.

Among human papillomavirus (HPV) types found in humans, there is a strong association between HPV 16, 18, 31, and 33, and cervical cancer. The relationship between various grades of dysplasia and HPV type is less clear. To elucidate this point, the authors tested 476 cytological and histological samples from cervix with polymerase chain reaction (PCR) for HPV using consensus primer My 09-11 and type-specific primers. All cases were divided into groups on the basis of cytology: "normal cases" (ie, women with other disease than cervical intraepithelial neoplasia [CIN]), and CIN I, II, and III. Out of the "normal cases," in which women with a previous history of condyloma and dysplasia were included, 69% had HPV with type 6 as the most common one. Of all CIN I cases, 71% were HPV positive, and HPV type 6 and 16 were equally common. In CIN II cases, HPV 16 was the most common type, whereas HPV 6 accounted for only 7.5% of cases in this group as single virus type. HPV 16 was also the most common type in the CIN III group, followed by type 33. Double and even multiple infections occurred in all groups.

[Sexuality and STD infections among teenage girls. "Unprotected sex" is common in spite of sufficient knowledge about the risks]. / Sexualitet och STD-infektioner bland tonårsflickor. "Osäkert sex" vanligt trots goda kunskaper.

A 2-year prospective study of sexual behaviour transmitted diseases (STDs) in 98 healthy 16-year-old schoolgirls showed human papillomavirus (HPV) infections to have spread rapidly among sexually active girls, whereas none of the virgins manifested HPV DNA in the cervix or anti-HPV 16 or anti-HPV33 antibodies in serum. A high level of knowledge of STDs and their prevention failed to induce appropriate behaviour among the sexually active.

Use of multiple PCR primer sets for optimal detection of human papillomavirus.

Using multiple PCR primer sets, we tried to optimize the detection of human papillomavirus (HPV) in DNA samples isolated from 361 frozen biopsy specimens from patients with invasive cervical carcinomas. The HPVs detected were placed into three distinct groups, including group I/Inex at Telelab (Skien, Norway) and group Ineg and group II at the Norwegian Radium Hospital (Oslo, Norway). The consensus primer sets were Oli-1b-oli-2i, My09-My11, Gp5-Gp6, and Gp(5+)-Gp6+ from the HPV L1 gene and CpI-CpIIG from the E1 gene. Using these consensus primers together with the type-specific primers from E6-E7, we found that 355 patients (98%) were HPV positive. Type-specific primers for HPV types 11, 16, 18, 31, 33, and 35 detected more HPV-infected patients than the most sensitive consensus primer set, while the three consensus primer sets My, Gp/Gp+, and Cp together detected more HPV-positive patients than the type-specific primers. Testing of sensitivity of the PCR with SiHa cells serially diluted in lymphocytes (HPV-negative cells) indicated a detection limit of 6,300 HPV type 16 DNA copies with consensus primers (My, Gp+, and Cp) and 126 original HPV type 16 DNA copies with type-specific primers. Comparison of the amplification results for consensus L1 primers and type-specific E6-E7 primers indicated the presence of L1 deletions in 23 of 56 samples. The conclusion is that in PCR detection systems, multiple consensus primers and type-specific primers should be used in order to detect all patients harboring HPV.