Reproducibility of the histologic diagnosis of pneumonia among a panel of four pathologists: analysis of a gold standard.

STUDY OBJECTIVE: To establish a histologic diagnosis of pneumonia by consensus of a panel of pathologists, to test the interobserver and intraobserver variation in the histologic diagnosis of pneumonia, to compare the diagnostic accuracy of diagnosing pneumonia with and without preselected histologic criteria, and to establish more specific histologic criteria for the diagnosis of pneumonia. METHODS: The study group consisted of 39 patients who died after a mean of 14 days of mechanical ventilation. A postmortem open lung biopsy was performed on all patients. The tissue was reviewed independently by four pathologists who categorized the slides from each patient as showing or not showing pneumonia. Interobserver variation was calculated using the kappa statistic. Six months following the initial evaluation, the same slides were resubmitted to one of the pathologists for reevaluation to look for intraobserver error. Finally, the slides were reviewed and categorized by the criteria of Johanson et al into no pneumonia, mild, moderate, or severe bronchopneumonia. A comparison was made of the patients selected as demonstrating histologic pneumonia by each of the examinations. RESULTS: The reliability coefficient (kappa) measuring agreement among the four pathologists was good at 0.916. However, the prevalence of pneumonia as determined by each of the four pathologists varied; pathologist A, 15 of 39 (38%); pathologist B, 12 of 39 (31%); pathologist C, 9 of 39 (23%); and pathologist D, 7 of 39 (18%). Resubmitting the same slides to the same pathologist 6 months later resulted in reclassification of 2 of 39 patients. Using the histologic criteria of Johanson and colleagues, 14 patients were selected as having pneumonia compared with only nine patients selected by consensus of three of four pathologists. CONCLUSIONS: Recognition of histologic pneumonia varies among pathologists. The preselected criteria of Johanson and colleagues detected histologic pneumonia in eight of nine patients picked by consensus of pathologists, but six additional patients classified as "no histologic pneumonia" by the consensus of pathologists were judged to have histologic pneumonia by these criteria. The results established the necessity for standardization of histologic criteria for studies using biopsy as the gold standard for bacterial pneumonia. An atlas showing the criteria used in our selection was developed.

The role of fine-needle aspiration in the management of solid breast masses.

Fine-needle aspiration cytology is a safe, inexpensive, rapid method of establishing the diagnosis of breast cancer in patients with solid, palpable masses. The pathologist must be conservative in his interpretation of malignancy so that positive study results occur only in patients with cancer. We compared the cytologic diagnosis of 140 breast masses with the histologic diagnosis. Seventy of 98 breast cancers were diagnosed by this technique. Because 28 cancers could not be diagnosed with certainty, open biopsy should be performed on all breast masses with nonmalignant cytologic findings.

Prognostic significance of hormone receptors in early recurrence of breast cancer.

A retrospective analysis of 155 patients with primary infiltrating breast cancer was carried out to determine the prognostic significance of hormone receptor values and analyze the effect of adjuvant chemotherapy. Estrogen receptor-negative patients were found to have a significantly higher recurrence rate than estrogen receptor-positive patients (p less than 0.005). No difference was found based on the progesterone receptor value. The data strongly suggest a favorable response to adjuvant chemotherapy administered on the basis of the estrogen receptor value alone.

Angioimmunoblastic lymphadenopathy: clinical spectrum of disease.

The clinical features of 13 patients with angioimmunoblastic lymphadenopathy were analyzed to determine prognostic factors and response to therapy. Eleven patients presented with sudden onset of fever, weight loss, generalized lymphadenopathy, and hepatosplenomegaly. Laboratory features included autoimmune hemolytic anemia and polyclonal hypergammaglobulinemia. Pulmonary involvement was seen in six cases and skin rash in four. Two patients had localized lymphadenopathy without systemic symptoms. Both are alive at 5.5 and 2.5 years, respectively, after diagnosis, although the latter patient has required intermittent prednisone for recurrent lymphadenopathy. An additional patient is alive on treatment for months following diagnosis. The remaining ten have died, nine of sepsis and one of cerebral hemorrhage. The immunosuppression and myelosuppression of combination chemotherapy may have hastened their deaths. An individualized, conservative treatment approach is recommended.

Endometrial carcinoma: histopathology, survival, and exogenous estrogens.

Pathologic material was reviewed and survival data were obtained on 182 of the endometrial cancer patients reported in our previous study (1975) to compare histopathologic characteristics and clinical behavior (survival) between endometrial adenocarcinoma in estrogen users and nonusers. In addition, relative risk estimates of estrogen-associated endometrial carcinoma were calculated from review results. This work identifies estrogen users as having a significant higher frequency of low-grade tumor with an associated improved survival even when numerous clinical parameters are taken into account. Other histologic or clinical characteristics of the disease did not relate significantly to estrogen use after taking account of histologic grade. The marked increase in endometrial cancer risk among estrogen users was confirmed by the pathology review (relative risk 6.44) and is evident even when attention is restricted to disease that has invaded the myometrium (relative risk 6.09).

The role and limitations of frozen section and needle aspiration biopsy in breast cancer diagnosis.

Frozen section of breast biopsy specimens, and cytologic smears of breast mass aspirates, are both acceptable methods in the initial evaluation of palpable breast masses. The latter method is an outpatient procedure without significant morbidity. Interpretation may be made immediately; however, the diagnostic information obtained is limited to "malignant" or "negative." Frozen section may be applied to open biopsy or needle core biopsy specimens. In either case, the false-negative rate is less than that experienced with needle aspiration, and additional information is obtained regarding the histologic characteristic of the neoplasm. Although open biopsy is an operating room procedure, needle core biopsy may be performed in the office; however, local anesthetic is required and the patients do experience more pain than with fine-needle aspiration. The selection of the proper procedure must be individualized, depending on the clinical situation and the amount of diagnostic information required. It is essential to remember that although a positive result may be considered diagnostic, a negative report is always tenuous and should not lead to definitive therapy.

Langerhans cells and serum precipitating antibodies against fungal antigens in bronchioloalveolar cell carcinoma: possible association with pulmonary eosinophilic granuloma.

In an ultrastructural study of 37 cases of bronchioloalveolar cell carcinoma (BAC), we identified seven cases (19%) in which Langerhans cells (LC) were closely associated with tumor cells. Serum precipitating antibodies against Aspergillus species and/or thermophilic actinomyces were present in five BAC patients whose tumors contained LC and in six patients whose tumors lacked LC. In a simultaneous study we identified marked atypical bronchiolar and alveolar lining cell hypertrophy and hyperplasma in pulmonary eosinophilic granuloma (PEG). Our data plus current information suggesting that PEG is a form of hypersensitivity pneumonitis support our hypothesis that those cases of BAC in which LC are present may rise in localized or diffuse pulmonary scars caused by PEG.

Cytologic, histologic and electron microscopic correlations in poorly differentiated primary lung carcinoma. A study of 43 cases.

For 43 poorly differentiated lung carcinomas we compared cytopathologic diagnoses made on specimens obtained prior to biopsy with histologic and electron microscopic diagnoses. Tissues were obtained by transbronchial biopsy, mediastinoscopy o pulmonary resection. Cytologies, tissues and electron micrographs were reviewed independently and blindly by five pathologists and one cytotechnologist. The cytologic, histologic and electron microscopic diagnoses agreed in 27 cases (62.7%), including adenocarcinoma (12), squamous carcinoma (five), oat cell carcinoma (six), mesothelioma (two) and adenosquamous carcinoma (two). In 14 cases the cytopathologic diagnoses had more accurately reflected the cell type ultimately diagnosed by electron microscopy than had the histologic diagnoses. Of ten poorly differentiated adenocarcinomas, eight had been interpreted as large-cell undifferentiated carcinomas, one as squamous carcinoma and one as poorly differentiated carcinoma histologically. Four poorly differentiated squamous carcinomas had been histologically diagnosed as giant cell, oat cell, undifferentiated carcinoma and adenocarcinoma. In these cases the previous cytologic diagnoses had been in agreement with the ultimate electron microscopic interpretation. The accuracy of cytodiagnoses may exceed that of histologic diagnoses in poorly differentiated lung cancer.

Diagnostic laparoscopy from the pathologist's viewpoint.

In conclusion, laparoscopy provides an easy approach to the diagnosis of various intraabdominal diseases. Because biopsy specimens are often small, adequate sampling is essential for accurate diagnosis. It is important for the laparoscopist to understand the basic pathologic anatomy of the diseases under consideration in order to provide the pathologist with adequate diagnostic material. The use of special techniques, including electron microscopy, may be helpful in establishing specific diagnosis in selected difficult cases.