New tests for cervical cancer screening.

The Papanicolaou (Pap) smear has been used to screen women for cervical cancer since 1940. Recently, a number of new technologies have been developed to improve the detection of cervical cancer and its precursors. However, there is substantial controversy about whether the new tests offer meaningful advantages over the conventional Pap smear. Ideally, these new tests will increase the early detection of meaningful Pap smear abnormalities, reduce the number of unsatisfactory smears and provide fewer ambiguous results. It is also hoped that these new screening methods will not increase the number of false-positive results, but will improve the productivity of cytology laboratories without substantially increasing costs. The new tests include liquid-based/thin-layer preparations to improve the quality and adequacy of the Pap smear; computer-assisted screening methods to improve Pap smear interpretation; and new-generation human papillomavirus testing methods that may be useful in triaging patients with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions. Evidence on these new tests is reviewed and the advantages and disadvantages of their use are discussed.

Changing role of fine-needle aspiration in the evaluation of pediatric masses.

This study examines changes in the use of fine-needle aspiration (FNA) in the pediatric population in the past 14 yr at the University of California, Davis Medical Center. Pediatric FNAs from two 7-yr periods were compared regarding percentage of satisfactory cases and cases with a previous history of cancer, sensitivity, specificity, type of general diagnostic category, ratio of benign to malignant diagnoses, and sources of diagnostic error. Changes in the later 7-yr period included decrease in the percentage of round cell lesions with an increase in spindle cell and epithelial/epithelioid lesions, fewer patients with a prior history of cancer, and a marked increase in benign to malignant ratio. These changes illustrate that FNA is being used more commonly in the general pediatric population, and that the types of lesions seen in this population are not very dissimilar to those seen in adults.

Equivocal diagnoses in breast aspiration biopsy cytology: sources of uncertainty and the role of "atypical/indeterminate" terminology.

In 1996, a National Cancer Institute committee recommended four categories as uniform terminology for breast fine-needle aspirations (FNAs): benign, malignant, suspicious/probably malignant, and atypical/indeterminate. The latter is a controversial category. This study evaluates the usefulness of the atypical/indeterminate term, and examines sources of diagnostic equivocation in breast FNA. Eight hundred and twenty-two consecutive breast FNAs were previously classified as benign, malignant, suspicious, or unsatisfactory. Two hundred and thirteen (25.9%) cases had surgical follow-up and were classified as true positive (TP), false positive (FP), true negative (TN), false negative (FN), true suspicious (TS), or false suspicious (FS). Slides from FN, FP, TS, and FS were reviewed for interpretative error, poor clarity or preservation, obscuring material, sampling error, or insufficient malignant criteria. Cases were also evaluated as to whether classification as "atypical/indeterminate" would have improved patient care. There were 21/822 (2.6%) FN, 37/822 (4.5%) TS + FS, and 0 FP diagnoses. Seventy percent of suspicious diagnoses showed cancer on follow-up. The majority of FN and suspicious cases were due to sampling problems and insufficient criteria of malignancy. None were deemed more appropriately classified as "atypical/indeterminate" All required surgical confirmation for treatment. All equivocal breast diagnoses are due to similar problems. Splitting them into "suspicious/probably malignant" and "atypical/indeterminate" would not lower the biopsy rate. A simpler three-part terminology of benign, malignant, and suspicious/equivocal, without qualification of the latter favoring benign or malignant, would provide more effective communication and appropriate follow-up. Diagn. Cytopathol. 1999;21:217-222.

Number, size, and composition of cell clusters as related to breast FNA adequacy.

The question of what types of parameters should be employed in establishing adequacy guidelines for fine-needle aspirations (FNAs) of palpable breast lesions remains without consensus opinion among cytopathologists. Although some investigators have suggested guidelines, based largely upon cellularity standards, these have been somewhat conflicting, and the overall issue of whether or not cellularity is an appropriate measure of adequacy is controversial. This study examines the number, size, and composition of cell clusters in FNAs of palpable breast masses which had surgical follow-up, in an effort to identify characteristics of diagnostic aspirates which could contribute to adequacy guidelines. Seventy-seven consecutive cases with surgical follow-up were selected from four quality-assurance (QA) categories (true positive, TP; true suspicious, TS; true negative, TN; and false negative, FN). All cases were evaluated in terms of overall cellularity (numbers of cell clusters), proportions of different-sized epithelial clusters (small, medium, and large), and proportions of epithelial to fibrofatty elements. Although the FN category showed the lowest average cellularity, the application of cellularity cutoff values as a condition of adequacy would have resulted in conspicuous numbers of cases from the "true" categories (TN, and to a lesser degree TS and TP) being rendered inadequate. For example, if cases with fewer than six epithelial clusters were excluded by virtue of inadequacy, 69% of the FN cases would have been affected, along with 40% of the TN, 6% of the TS, and 4.5% of the TP. In terms of composition of the aspirate, neither proportions of the differently-sized epithelial clusters nor ratios of epithelial:fibrofatty elements reliably distinguished the "true" from the "false" diagnoses. This study concluded that quantitative parameters alone are insufficient measures for determining specimen adequacy in FNA of palpable breast lesions. Rather, adequacy remains based upon factors such as confidence of needle placement, cell preservation, and correlation with clinical and mammographic findings. Diagn. Cytopathol. 1999;21:105-111.

AutoCyte Interactive Screening System. Experience at a university hospital cytology laboratory.

OBJECTIVE: To evaluate the AutoCyte Interactive Screening System (AutoCyte-Screen) as a prescreener for the cytologic detection of cervicovaginal abnormalities. STUDY DESIGN: Eight hundred fifty-six AutoCyte Preparation System from cervicovaginal samples were evaluated by AutoCyte-Screen. AutoCyte-Screen displayed 120 cell images and 6 low-power images for review by the cytotechnologist. The cytotechnologist classified the case as WNL, abnormal or unsatisfactory. AutoCyte-Screen then revealed its classification as either unsatisfactory, WNL, abnormal or undecided. These classifications were combined to form an interactive result that was compared to the diagnosis from previous manual review. RESULTS: Interactive results were as follows: 251 (29.3%) abnormal, 581 (67.9%) WNL and 24 (2.8%) unsatisfactory. The abnormal interactive result contained 15 ASCUS/AGUS and 25 SILs; the WNL interactive result contained 5 ASCUS/AGUS and 2 SILs. No ASCUS/AGUS or SILs were in the unsatisfactory interactive category. The false negative proportion was 10.5% for the interactive diagnostic method vs. 15.7% for manual review for LSIL. CONCLUSION: The interactive use of AutoCyte-Screen can effectively select those cases which are most likely to contain an epithelial abnormality and could therefore be used as a triage system to select cases for manual review. A case with an interactive result of unsatisfactory and abnormal should receive full manual review, while those classified as WNL may require a less extensive review for quality assurance purposes. This resultant decrease in the manual screening load could increase laboratory efficiency.

Preclinical evaluation of chimeric L6 antibody for the treatment of Kaposi's sarcoma with radioimmunotherapy.

L6 is a murine IgG2a monoclonal antibody with panadenocarcinoma reactivity. Chimeric L6 (ChL6), the variable region of murine L6 combined with a human IgG1 constant region, has been used in clinical trials for the delivery of radioimmunotherapy to patients with breast cancer. AIDS-associated Kaposi's sarcoma (KS), a malignancy of vascular endothelium, may be an excellent candidate for systemic radioimmunotherapy because KS is well vascularized and radioresponsive. Because ChL6 has been noted to bind vascular endothelium, our hypothesis was that ChL6 will recognize and bind KS tumors making this a potentially useful antibody for the treatment of KS with radioimmunotherapy. To test this hypothesis, 4 human KS spindle cell cultures established from cutaneous punch biopsy specimens (KS-MR, KS-NO, KS-JD and KS 6-3E) and one well-characterized human KS cell line (KS Y-1) were assessed for L6 immunoreactivity. All 5 cell cultures were L6 positive by immunohistochemistry. KS Y-1 cells grown as nude mouse xenografts were also L6 positive by immunohistochemistry. Competitive binding assays performed on the KS Y-1 and KS 6-3E cell cultures showed high density and high affinity cell binding. Biodistribution experiments performed on nude mice with KS Y-1 xenografts demonstrate tumor targeting by ChL6. These findings indicate that ChL6 may be a useful antibody for the radioimmunotherapy of KS. Future experiments will assess the therapeutic efficacy of radiolabeled ChL6 with and without concurrent systemic radiosensitizing chemotherapy.

Natural history of cervical squamous intraepithelial lesions: a meta-analysis.

OBJECTIVE: To define the strengths and weaknesses of existing research on the natural history of cervical squamous intraepithelial lesions (SIL) and to estimate rates of progression and regression without treatment. DATA SOURCES: Studies of women whose cervical smears showed squamous atypia or worse and who were observed for a minimum of 6 months were identified by a search of MEDLINE from 1966 to 1996, Current Contents, the Federal Research in Progress database, and references of review articles and identified studies, and by experts in the field. METHODS OF STUDY SELECTION: Fifteen of 81 studies were eligible for data extraction. To be eligible, studies had to report a minimum of 6 months' follow-up without treatment; relate entry cytologic findings to outcomes; and report entry cytologic findings so that the study population could be stratified into categories of atypical cells of undetermined significance (ASCUS), low-grade SIL, or high-grade SIL. Studies published before 1970 were excluded. TABULATION, INTEGRATION, AND RESULTS: Eligible studies, representing 27,929 patients, were stratified according to entry cytologic findings. The following rates of progression to high-grade SIL at 24 months were found: ASCUS, 7.13% (95% confidence interval [CI] 0.8%, 13.5%); low-grade SIL, 20.81% (6.08%, 35.55%); and high-grade SIL, 23.37% (12.82%, 32.92%). The following rates of invasive cancer at 24 months were found: ASCUS, 0.25% (0%, 2.25%); low-grade SIL, 0.15% (0%, 0.71%); and high-grade SIL, 1.44% (0%, 3.95%). The following rates of regression to normal were found: ASCUS, 68.19% (57.51%, 78.86%); low-grade SIL, 47.39% (35.92%, 58.86%); and high-grade SIL, 35.03% (16.57%, 53.49%). Study heterogeneity was not explained by regression analysis of study level variables. CONCLUSION: Our findings for borderline and low-grade abnormal cervical cytologic results suggest a relatively low risk of invasive cervical cancer with observation up to 24 months and support the clinical policy of early colposcopy for high-grade lesions.

Multicenter masked evaluation of AutoCyte PREP thin layers with matched conventional smears. Including initial biopsy results.

OBJECTIVE: To compare the performance of liquid-based cell preparations from the AutoCyte PREP system (AutoCyte, Inc., Elon College, North Carolina) with the conventional cervical smear in masked, split-sample, multisite trials. STUDY DESIGN: The AutoCyte PREP system utilizes the CytoRich method, which combines liquid preservation, selective reduction of blood and inflammation, thin-layer cell dispersion and discrete staining. In an eight-site multicenter trial, 8,983 cases were evaluated. Parallel AutoCyte PREP slides and matching conventional cervical cytologic smears were screened in a masked fashion, with all abnormals reviewed in a masked, on-site pathologist review. The conventional smear was always prepared first, with the AutoCyte PREP using the residual cells on the collection device. The Bethesda System was used for reporting diagnosis and specimen adequacy. RESULTS: Of the cases, 7,805 (86.9%) had the same interpretation. In 8,750 cases (97.4%), there was agreement within one diagnostic category. The AutoCyte PREP demonstrated a statistically significant, 31% overall improvement in the detection of squamous intraepithelial lesion and invasive cancer when evaluating cases with more than one diagnostic class difference. Biopsy correlation of available data supported the improvement observed in the cytology-based comparison. Recovery of infectious organisms and endocervical component was comparable between preparations, especially in light of the split-sample study design. There was a 39% reduction in unsatisfactory slides and 44% fewer satisfactory but limited by reports. CONCLUSION: The AutoCyte PREP and CytoRich method produce excellent cellular presentations with standardized quality, superior sensitivity and improved adequacy as compared to the conventional method.

The AutoCyte preparation system for gynecologic cytology.

OBJECTIVE: To determine if thin-layer processing of cervicovaginal samples improves detection of cytologic abnormalities by reducing problems related to direct smear preparation. STUDY DESIGN: Eight hundred fifty-two cervical samples were collected as part of a multicenter trial of the CytoRich/AutoCyte system. The Cervex Brush was used for specimen collection. Following preparation of a conventional Papanicolaou smear, the brush was placed in a vial of fixative. A thinlayer CytoRich preparation was prepared by sedimentation following centrifugation through a density gradient and then stained by the AutoCyte Preparation System according to the manufacturer's guidelines. The two preparations were masked and screened, and a diagnosis was rendered. Abnormal results from were reviewed by a pathologist. The specimens were later unmasked and the diagnoses compared. RESULTS: CytoRich and conventional cervical cytologic smears detected an equivalent number of squamous intraepithelial lesions (SILs) (27 vs. 29) and atypical squamous cells of undetermined significance (ASCUS) (19 vs. 21). Both methods missed an equivalent number of SILs (four vs. five). CytoRich detected more infections (151 vs. 115) and had 66% fewer nonspecific inflammatory diagnoses. CytoRich also had fewer "limited" adequacy evaluations (211 vs. 236). CONCLUSION: CytoRich preps improve adequacy; increase detection of infections, such as candidiasis and trichomoniasis; and are accurate in the diagnosis of SILs. CytoRich appears to be an equivalent and possibly better preparation for cervicovaginal cytology.

Fine-needle aspiration cytology of sarcoma: retrospective review of diagnostic utility and specificity.

Fine-needle aspiration cytology (FNA) is useful because of its low cost, quick turn around time, and low incidence of complications. This study investigates the role FNA plays in the evaluation of sarcoma. We reviewed all the pathologic material from patients with sarcoma or a FNA diagnosis suggestive of sarcoma at the University of California-Davis Medical Center (1985-1994). Fifty-two of 196 patients identified (26.5%) were evaluated with FNA exhibiting 46 soft tissue and 6 bone lesions located in the extremities (19), trunk (19), head and neck (8), retroperitoneum (3), and abdominal cavity (3). Among 196 patients identified, those evaluated by FNA had soft tissue rather than bone lesions (P < .001) and primary sites other than in the extremities (P < .001). The primary neoplasms for the 52 FNA patients included 47 sarcomas (10 malignant fibrous histiocytomas and 16 other types), 1 intramuscular myxoma, 2 lymphomas, and 2 spindle cell (sarcomatoid) carcinomas. In 43 patients (22% of total), FNA was used first, before a primary diagnosis. The FNA report showed the correct specific neoplasm in only 20.9%. However, the FNA reports reflected an effective positive diagnosis leading to appropriate diagnostic biopsy in 88.4%, while only 7.0% were misleading (benign or inflammatory) and 4.6% inadequate. Review of FNA slides for 32 of 43 patients in which FNA was used first, in a blinded fashion, exhibited 21.9% specificity for the specific neoplasm, and 88.4% effective positive diagnoses. In 9 patients, FNA was utilized to investigate recurrence. Five out of 5 instances of recurrent sarcoma were identified by FNA. However, FNA misidentified recurrence in 3/4 instances, exhibiting suspicious cells from regenerating skeletal muscle (2) and a traumatic neuroma (1). The specific diagnosis for sarcomas is challenging even with surgical material. FNA usually does not provide a specific diagnosis (only in 20.9% of cases) and review of routinely prepared slides showed the same specificity as reflected by the original FNA report, at times formulated with the benefit of immunohistochemistry or electron microscopy. FNA effectively evaluated lesions in 45 of 52 patients (86.5%), confirming the useful screening role for this technique in sarcomas.

Relationship of p53 and bcl-2 to prognosis in muscle-invasive transitional cell carcinoma of the bladder.

PURPOSE: We examined the presence of the p53 and Bcl-2 oncoproteins, as detected by immunohistochemistry, in muscle-invasive bladder cancer and correlated this with survival. MATERIALS AND METHODS: Formalin-fixed cystectomy specimens from 41 consecutive patients with mean follow-up of 52 months were used. Five patients were either lost to follow-up or died of other diseases and were not included in the survival evaluation. RESULTS: Eighteen of 36 patients died of metastatic transitional cell carcinoma. p53 immunostaining was found in 61% of patients. In 21 of 23 this staining was homogeneous, with more than 75% of cancer cells staining using a DO-1/DO-7 antibody cocktail. p53 staining was not correlated with stage (p>0.25) or grade (p<0.10) in these invasive cancer specimens. Contrary to recent studies p53 immunostaining was not correlated with disease-specific survival. Bcl-2 immunostaining was found in 28% of patients and was not correlated with grade (p>0.25) or disease-specific survival. No combination of p53 and Bcl-2 staining gave added predictive information. CONCLUSIONS: Cytoplasmic Bcl-2 is found in a small percentage of these cancers and does not correlate with prognosis. Further, p53 molecular overexpression is detected in the majority of muscle-invasive bladder tumors as a field defect. However, in patients undergoing cystectomy, it does not correlate with prognosis.

Follow-up of Papanicolaou smears diagnosed as atypical squamous cells of undetermined significance.

In the first year since the institution of the Bethesda system at UCDMC, 549/7,388 (7.43%) Papanicolaou (Pap) smears were diagnosed as having an epithelial abnormality. One hundred ninety-three of the 549 (35.1%) of the abnormal smears received an ASCUS diagnosis, representing 2.61% of the total volume. Follow-up was obtained on 124/193 (64.2%) and consisted of colposcopy with biopsy in 38.3%, one repeat Pap smear in 51.2%, and two or more repeat Pap smears in 10.5%. Follow-up revealed a squamous intraepithelial lesion (SIL) in 29.1%, ASCUS in 12.9%, and no evidence of an epithelial lesion in 58.0%. Review of the original ASCUS Pap smear from the group with no epithelial lesion on follow-up showed increased inflammation plus metaplasia and/or reactive changes in 69.5% and ASCUS in 19.5%. This study demonstrates that a significant percentage of ASCUS Pap smears represent SIL. However, many Pap smears with reactive, inflammatory changes are misclassified as ASCUS and would be best diagnosed under "Reactive/Reparative Changes" in the Bethesda system. Careful attention to criteria for ASCUS and inflammatory and reactive atypia is recommended to avoid misclassification and to make this category more meaningful to the clinician.

Fine needle aspiration cytology of pulmonary Wegener's granulomatosis with biopsy correlation. A report of three cases.

BACKGROUND: Pulmonary Wegener's granulomatosis frequently presents clinically as ill-defined nodules on chest radiographs or computed tomographic scans. With refinement of fine needle aspiration (FNA) cytology as a diagnostic tool, pathologists are sometimes asked to render this diagnosis on cytologic material rather than on the more invasive open lung biopsy. Experience is currently limited to a few case reports in the cytopathology literature. We add to this by reporting the findings from five FNA biopsies performed on three patients, with open lung biopsy correlation. CASES: The cytologic findings included a background of necrotic debris, acute and chronic inflammatory cells, multinucleate giant cells and, in one case (case 2), numerous clusters of atypical epithelioid cells mimicking carcinoma. Correlation of the respective open lung biopsy specimens with the FNA material was instructive in revealing the nature of the findings on cytologic preparations. Two cases showed classic histopathologic findings. Case 3 showed a less common presentation, pulmonary hemorrhage, which was reflected in the FNA specimen. CONCLUSION: FNA biopsy cytology is a useful alternative to open lung biopsy in the diagnosis of pulmonary Wegener's granulomatosis but requires careful correlation with the clinical and laboratory findings.

Immunohistochemical staining of metastatic ductal carcinomas of the breast by monoclonal antibodies used in imaging and therapy: A comparative study.

Five monoclonal antibodies (MoAbs)(L6, 170H.82, 155, BrE-3 and BR96), most of which have been previously shown to target breast cancer and not normal tissues by immunoscintigraphic imaging, were evaluated for their frequency and pattern and immunohistochemical staining in 67 to 116 metastatic lesions from patients with ductal carcinoma of the breast. Immunoperoxidase staining in 75% or more of the cells occurred in 56/116 (48%) for L6, 44/89 (49%) for Br, -96, 58/102 (57%) for 155, 62/99 (84%) for 170H.82, and 65.67 (97%) for BrE-3. With the first three MoAbs, an additional 6-10% of the tumors showed staining in 50-75% of tumor cells. These results illustrate that most patients with metastatic ductal carcinoma have cancer tissue in which a high percent of cells will react to several of these selected MoAbs that target different epitopes. The high expression of the MoAb targets throughout the tumor tissue makes these antibodies potential candidates to carry immunologically directed radioimmunotherapy and is an aid in selecting patients for treatment.

Cervical pathology--the Bethesda System and the 'atypical squamous cells of undetermined significance' controversy.

The Council on Scientific Affairs of the California Medical Association presents the following epitomes of progress in pathology. Each item, in the judgment of a knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and clinical importance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, and scholars to stay abreast of progress in medicine, whether in their own field of special interest or another. The epitomes included here were selected by the Advisory Panel to the Section on Pathology of the California Medical Association, and the summaries were prepared under the direction of Yutaka Kikkawa, MD, and the panel.

Remission of sarcoidosis following removal of silicone gel breast implants.

We report herein a patient with debilitating multisystem sarcoidosis. Interestingly, dermal lesions and enlarged lymph nodes resolved and her clinical condition dramatically improved following removal of silicone gel breast implants. Of note, the capsular tissue surrounding the breast implant demonstrated a granulomatous foreign-body response. The potential harmful effects of silicone may include an acceleration of an already existing hypersensitivity response.

Application of the Scarff-Bloom-Richardson tumor grading system to fine-needle aspirates of the breast.

Assigning a tumor grade to breast cancers provides important prognostic information. This study evaluated the applicability of the Scarff-Bloom-Richardson (SBR) breast cancer grading system to aspiration biopsy cytology. Thirty-five consecutive breast cancer fine-needle aspirates and their surgical specimens were reviewed by two pathologists. An SBR grade of 1-3 was assigned by each pathologist to both the fine-needle aspirate and biopsy specimen, based on the sum of scores given to each of three features: tubular differentiation, nuclear pleomorphism, and mitotic index. Both pathologists assigned the same SBR score to 74.3% of biopsy specimens and 65.7% of fine-needle aspirates. The cytologic grade could be used to predict the histologic grade in as many as 57.1% of cases. The wide disparities in the cytologic and histologic grades in some cases were chiefly due to difficulties in detecting mitoses or tubules in the cytology.

Intraoperative cytology as an elective surgical procedure. Analysis of 57 cases.

Fifty-seven consecutive cases submitted by surgeons for intraoperative cytology were reviewed. In 47 cases there was a concomitant biopsy from the same anatomic site; among them, the cytologic and surgical diagnoses agreed in 44 (94%). The three discordant cases (6%) represented false-negative frozen sections. In the remaining 10 cases the cytologic and surgical biopsy sites differed in 5, 4 were considered inadequate for cytologic interpretation, and 1 did not have a corresponding surgical biopsy. Attitudes toward the use of intraoperative cytology were assessed with questionnaires sent to surgeons from all specialties represented at the University of California, Davis, Medical Center. Fifty-three percent of the respondents reported use of this procedure. At our institution thoracic surgeons and otorhinolaryngologists were more apt than others to use intraoperative cytology as an adjunct to frozen section analysis. Factors influencing their selection of intraoperative cytology are discussed.

Fixation method useful for cytologic examination and DNA flow cytometry of exfoliated bladder cells.

Single-institution studies have shown that DNA flow cytometry is superior to routine cytologic evaluation of following patients for bladder cancer recurrence. For 15 urine and 15 bladder washing specimens, we evaluated a fixative employing methanol plus acetic acid (MA), freshly mixed 20:1 (vol/vol). Routine cytologic evaluation following Papanicolaou staining, and DNA flow cytometry were performed. Paired aliquots from the same washings and urines were processed as fresh spray-fixed samples and MA-fixed samples. The majority of the MA-fixed specimens showed good nuclear preservation when assessed for chromatin texture, presence of distinct nuclear envelope, and clarity of nucleolus, while only a minority of the fresh urine and washing samples showed these features. Cytoplasmic degeneration was seen only in fresh specimens. The presence of aneuploidy and the percentage of hyperdiploid cells could be reliably determined in the MA-fixed samples. This fixation protocol is recommended for the transport of urine and bladder washing specimens to centralized laboratories for both cytologic and flow cytometric evaluation.