Correlation between the presence of degenerated inclusion-bearing cells in voided urine samples and the occurrence of polyomavirus infection.

OBJECTIVE: The purpose of the present, prospective, cohort study was to monitor urine cytology samples from recipients of renal transplants to search for the occurrence of decoy cells and degenerated inclusion-bearing cells with an aim to correlate the existence of these cells with molecular detection of polyomavirus BK (BKV) DNA in urine. MATERIAL AND METHODS: This study included patients who underwent renal transplantation. Patients had their urine tested quarterly, during the first year post-transplantation, for the presence of decoy cells and degenerated cells, as well as by quantitative determination of BKV load in the urine and plasma. RESULTS: Three hundred and sixty-one examinations were performed on 101 patients within 12 months of attendance. Urine cytology results were: 198 (54.9%) negative and 60 (16.6%) positive for the presence of viral cytopathic effects depending on the presence of BKV infection, 72 (19.9%) positive for the manifestation of degenerated cells and 31 (8.6%) unsatisfactory for analysis. There was a subtle tendency towards the presence of degenerated inclusion-bearing cells in cases in which the virus was detected in voided urine. However, the presence of degenerated cells exhibited a tendency to BKV positivity in months 3, 6 and 9 and, exclusively in month 12, this trend was statistically significant. CONCLUSIONS: There were not enough strong morphological and staining elements to state the origin of the degenerated cells or to describe the nature of the infection (viral or bacterial), given that these cells were undergoing an apoptotic process in post renal transplant patients.

An alternative protocol for DNA extraction from formalin fixed and paraffin wax embedded tissue.

BACKGROUND: DNA extraction from paraffin wax embedded tissue requires special protocols, and most described methods report an amplification success rate of 60-80%. AIMS: To propose a simple and inexpensive protocol consisting of xylene/ethanol dewaxing, followed by a kit based extraction. METHOD: Xylene/ethanol dewaxing was followed by a long rehydration step and a kit based DNA extraction step. RESULTS: This method produced a 100% amplification success rate for fragments of 121 to 227 bp for tamponated formalin fixed paraffin wax embedded tissue. CONCLUSION: This cost effective and non-laborious protocol can successfully extract DNA from tamponated formalin fixed paraffin wax embedded tissue and should facilitate the molecular analysis of a large number of archival specimens in retrospective studies.

Helicobacter pylori eradication does not cause reflux oesophagitis in functional dyspeptic patients: a randomized, investigator-blinded, placebo-controlled trial.

BACKGROUND: The protective role of Helicobacter pylori in gastro-oesophageal reflux disease has been widely discussed. AIM: To assess the risk of reflux oesophagitis in patients with functional dyspepsia after treatment for H. pylori infection. METHODS: A randomized, placebo-controlled, investigator-blinded trial was carried out on 157 functional dyspeptic patients. Patients were randomized to receive lansoprazole, amoxicillin and clarithromycin (antibiotic group) or lansoprazole and identical antibiotic placebos (control group). Upper gastrointestinal endoscopy was performed at baseline, 3 and 12 months after randomization. The primary aim was to detect the presence of reflux oesophagitis. Analyses were performed on an intention-to-treat basis. RESULTS: A total of 147 patients (94%) and 133 (85%) completed 3 months and 12 months follow-up, respectively. The eradication rate of H. pylori was 90% in the antibiotic group (74 of 82) and 1% (one of 75) in the control group. At 3 months, reflux oesophagitis was diagnosed in 3.7% (three of 82) in the antibiotic group and 4% (three of 75) in the control group (P > 0.2). At 12 months, diagnosis was established in five new cases within the first group and in four within the second (P > 0.2). No difference was found in heartburn symptoms. CONCLUSIONS: H. pylori eradication does not cause reflux oesophagitis in this western population of functional dyspeptic patients.

Association between esophageal squamous cell carcinoma and human papillomavirus detected by Hybrid Capture II assay.

From July 1999 to July 2000, 40 patients from the Surgical Oncology and Gastroenterology Departments of Irmandade da Santa Casa de Misericórdia de Porto Alegre were enrolled in a prospective study in order to find the frequency of human papillomavirus DNA (HPV-DNA) in esophageal squamous cell carcinoma. They were compared to 10 normal individuals (controls). Digene Inc. (Digene Corporation, Gaithersburg MD, USA) Hybrid Capture II assay, a chemoluminescent method, was used in both groups. The samples were collected from the tumor group by endoscopic biopsy in 20 cases, and by surgical specimens in the other 20 cases; the control group all underwent endoscopic biopsies. The cut-off point in the analytical assay for HPV-DNA was 1.0 pg/mL. Digene Corp. Hybrid Capture II assay tests HPV-DNA and differentiates high and low-risk for malignization virus groups. Gender, age, location of the tumor in esophagus and degree of differentiation on histology were also analyzed. There was one positive case (1.14 pg/mL), a 2.5% frequency of low-risk HPV-DNA type in the esophageal squamous cell carcinoma group (CI 95%: 0.00-7.34%). This group of patients consisted of 30 male and 10 female individuals, similar to the distribution seen in large series of such patients from the Brazilian population. The mean age was 63 years. Endoscopic samples of 10 patients who underwent endoscopic biopsy procedure for aleatory reasons, with normal looking esophageal mucosa, were tested to detect HPV-DNA, as controls. There was one positive case (1.17 pg/mL) of high-risk HPV-DNA type, resulting in a 10% positive rate. HPV-DNA is rarely found in esophageal squamous cell carcinomas: we found a 2.5% frequency, with confidence interval of 0-7.34%; and this is in the same range of controls (10% frequency, with CI: 9.1-10.9%). Both patients had a viral load quite near the 1.0 pg/mL cut-off point.

Intestinal metaplasia in the distal esophagus and correlation with symptoms of gastroesophageal reflux disease.

Barrett's esophagus is a metaplastic condition that occurs in patients with gastroesophageal reflux disease (GERD) and its importance lies in its potential to develop adenocarcinoma of the esophagus. The diagnosis of Barrett's esophagus is based on finding of intestinal metaplasia of at least 3 cm of the distal esophagus. The diagnosis of intestinal metaplasia of less than 3 cm of the distal esophagus is controversial, regarding implications with GERD, adenocarcinoma, and Helicobacter pylori. The aims of the study were to determine the prevalence of intestinal metaplasia in the distal esophagus in patients with short segments of esophageal columnar-appearing mucosa (less than 3 cm), diagnosed endoscopically, in two groups of patients, with and without symptoms of GERD. In total, 97 patients were examined, with endoscopic finding of esophageal columnar-appearing mucosa less than 3 cm. From the total, 52 patients had symptoms of GERD and 45 patients were without these symptoms. These patients were subjected to distal esophageal biopsies obtained immediately below the epithelial transition. The biopsies were stained with hematoxylin-eosin and alcian blue at pH 2.5. Urease test for H. pylori detection in two fragments of gastric antrum was carried out. The presence of intestinal metaplasia in the distal esophagus was diagnosed in 16 (30.8%) patients in the GERD group and 12 (26.7%) patients without GERD symptoms. No statistical differences were observed (P = 0.82; 95% CI: 0.61-2.17). The variables sex, mean age and positivity for H. pylori did not show statistical differences. This study diagnosed high prevalence of intestinal metaplasia in the distal esophagus with columnar-appearing mucosa, less than 3 cm, with no statistical differences in the two groups studied with and without GERD symptoms.

Karyometry in Barrett's esophagus.

OBJECTIVE: To derive a progression curve for lesions in Barrett's esophagus based on karyometric features. STUDY DESIGN: High-resolution imagery of 900 nuclei from normal gastric tissue, Barrett's metaplasia, Barrett's high grade dysplasia and adenocarcinoma of the esophagus was recorded. Karyometric features were computed, and nuclear signatures and lesion signatures for these lesions were derived. A progression curve was defined. RESULTS: Esophageal lesions were distinctly different from the normal gastric fundus tissue, with nuclei from Barrett's metaplasia deviating from normal almost as much as nuclei from high grade dysplasia and adenocarcinoma. There was considerable case-to-case variability and overlap between lesions histologically assigned to different diagnostic categories. CONCLUSION: The karyometric data suggest that Barrett's metaplasia is a more developed lesion than previously assumed.

[Micronuclei research the esophageal mucosa and its relationship with risk factors with cancer of the esophagus]. / Pesquisa de micronúcleos na mucosa esofágica e sua relação com fatores de risco ao câncer de esôfago.

PURPOSE: To demonstrate the frequency of micronucleus in esophageal mucous cells of smokers, consumers of alcoholic beverages and "maté" drinkers. METHODS: Material collected from the midlle esophagus in 250 consecutive patients submitted to upper digestive endoscopy was stained with acridine orange and the cytologist determined the number of micronuclei vizualized per each 500 cells examined. RESULTS: The frequency of micronucleated cells did not vary significantly (p > 0.05) when the following variables were considered: sex, place of residence (rural or urban), type of care (outpatient or inpatient), ingestion of alcohol. For two variables, smoking and "maté" consumption, there were significant differences in the frequency of micronuclei in the categories exposed and formerly exposed in relation to never exposed. CONCLUSION: A higher frequency of micronucleus in the esophageal mucous in smoking and "maté" drinkers was evidenced by this study.

Combined carcinoembryonic antigen and cytopathologic examination in ascites.

OBJECTIVE: To investigate use of the combined carcinoembryonic antigen (CEA) test and cytopathologic examination to improve the diagnosis of neoplastic vs. nonneoplastic ascites. STUDY DESIGN: The tests were performed prospectively on 130 patients with ascites whose effusions were submitted for cytologic examination. RESULTS: Sixty-seven patients had epithelial tumors, and the cytologic examination was positive in 39 (58.2%). The CEA level was > or = 11.0 ng/mL in 36 patients (53.73%). CEA was helpful in the diagnosis in 18 cases, increasing to 57 (85.07%) the number of positive diagnoses. Eight samples of nonepithelial tumors had low levels of CEA. In 55 patients with nonneoplasic ascites the cytopathologic examination was negative, but the CEA assay was > 11.0 ng/mL in 3 patients. CONCLUSION: The cytopathologic examination should be performed in all cases, and the CEA assay should be done in suspected cases of epithelial neoplasia in which the cytologic examination was negative, there was uncertainty about the histologic type of neoplasia, or a diagnosis of nonepithelial neoplasia was made. When ascitic leukocytosis or hepatic failure is present, one should be cautious in interpreting the CEA assay because false positivity can occur.

Pesquisa de micronúcleos na mucosa esofágica e sua relaçäo com fatores de risco ao câncer de esôfago / Research of micronuclei in the esophageal mucosa and its relationship with risk factors to esophagus cancer

Micronúcleos sao fragmentos de DNA nao incorporados ao núcleo na divisao celular e que apresentam relaçao com agentes genotóxicos (mutagênicos ou clastogênicos). Os micronúcleos podem ser detectados nas células esfoliadas dos tecidos. OBJETIVO: Determinar a freqüência de micronúcleos na mucosa esofágica, relacionando com determinados hábitos. PACIENTES E MÉTODOS: Em pacientes submetidos à endoscopia digestiva alta e sem evidências de anormalidades esofágicas, foram colhidos materiais através de escovado do esôfago médio, para pesquisa de micronúcleos. Após à endoscopia, os pacientes foram questionados sobre seus hábitos. RESULTADOS: A freqüência de micronúcleos nao mostrou diferenças significativas (p > 0,05) em relaçao ao sexo, local de residência (rural ou urbana), tipo de atendimento (ambulatorial ou hospitalizado), ingestao de álcool. Nas variáveis fumo e mate houve diferenças significativas entre as categorias expostos e ex-expostos em relaçao à categoria nunca expostos. CONCLUSAO: A freqüência de micronúcleos na mucosa esofágica foi maior nos pacientes fumantes e bebedores de mate

[High temperature "matè" infusion drinking in a population at risk for squamous cell carcinoma of the esophagus]. / Mate (chimarrão) é consumido em alta temperatura por população sob risco para o carcinoma epidermóide de esôfago.

UNLABELLED: "Matè", a popular hot infusion of a herb (Ilex paraguayensis) drunk in large volumes, is a known risk factor for squamous cell carcinoma of the esophagus and there is a suspicion that high temperature of boiled water used for the infusion may contribute for carcinogenesis. METHODS: We measured the temperature of "matè" infusion drunk by a sample of the population at risk for this carcinoma in Taquara, southern Brazil. We interviewed inhabitants for drinking habits and the temperature of the infusion was measured with high precision thermometers. Temperature of the infusion was asked to consumers and their estimate compared to our measurements. We considered 60 degrees C or higher as "hot". RESULTS: In 36 residencies, 107 individuals were drinking "matè". Most individuals drank it daily (97.2%), and the medium daily volume was 1,265 ml (SD +/- 1,132 mL) ranging from 250 to 6,000 mL. The measured temperature was 60 degrees C or higher in 72% of residencies with medium of 63.4 degrees C (51-78 degrees C) and median 64.4 degrees C. CONCLUSION: In this study, "matè" was consumed in large volumes at high temperature and individuals did not estimate correctly the temperature of infusion. High temperatures of "matè" may contribute to carcinogenesis in this population.

Clinical and endoscopic aspects in the evolution of patients with bleeding peptic ulcer--a cohort study.

BACKGROUND: Bleeding ulcers are a major problem in public health and represent approximately half of all the cases of upper gastrointestinal hemorrhage in the United States. This study aims to determine the prognostic value of factors such as clinical history, laboratory and endoscopic findings in the occurrence of new episodes of bleeding in patients who have upper gastrointestinal hemorrhage caused by gastric or duodenal peptic ulcer. METHODS: A cohort study with 94 patients was designed to investigate prognostic factors to the occurrence of new episodes of bleeding. RESULTS: From the 94 patients studied, 88 did not present a new bleeding episode in the 7 days following hospital admission. The incidence of rebleeding was significantly higher in those patients with hemoglobin < 6 g/dL at the admission (P = 0.03, RR = 6.2). The localization of the ulcers in bulb was positively associated to rebleeding (P = 0.003). The rebleeding group needed a greater number of units transfunded (P = 0.03) and the time of hospitalization was longer than the time of the hemostasia group (P = 0.0349). CONCLUSIONS: The identification of patients with risk of death by bleeding peptic ulcer remains as a challenge, once few factors are capable of predicting the severity of the evolution. The identification of such factors will allow the choice of the better therapeutic conduct improving the diagnosis and decreasing the rate of rebleeding and the mortality.

[Prevalence of adenocarcinoma of the esophagus and esophagogastric junction in a 10 year period at a cancer referral center in southern Brazil]. / Prevalência de adenocarcinoma do esôfago e da junção esofagogástrica durante 10 anos num centro de referência para câncer no sul do Brasil.

UNLABELLED: There is increasing incidence of adenocarcinoma of the esophagus and esophagogastric junction in the USA and Europe, however, data in Brazil are scanty. OBJECTIVE AND METHODS: We reviewed all histology confirmed esophageal and esophagogastric junction cancer reports during a 10-year period (1987-1996) obtained by upper digestive endoscopy biopsies at a cancer referral center in Southern Brazil. Cancer cases were classified in three categories: adenocarcinoma, squamous cell carcinoma, and others. RESULTS: Among 349 cases, adenocarcinoma was found in 53 (15.2%), squamous cell carcinoma in 283 (81.1%) and others in 13 (3.7%). CONCLUSIONS: In this study, the prevalence of adenocarcinoma was 15%.

Esophageal dysplasias are detected by endoscopy with Lugol in patients at risk for squamous cell carcinoma in southern Brazil.

Diagnosis of squamous cell carcinoma of the esophagus is usually late. Staining of the mucosa with Lugol's solution during endoscopy has been suggested to identify early cancer/dysplasia and may improve prognosis. Lugol was tested during endoscopy in 96 asymptomatic subjects at risk for this tumor, who were found to have atypias after exfoliative cytology in southern Brazil. Biopsies were obtained in Lugol's 'stained' and 'unstained' areas in the esophageal mucosa and the histologic results were compared. 'Unstained' areas were present in 64 (66.7%) instances: 44 'unstained' areas over mucosa with normal appearance revealed seven dysplasias (four high and three low grade), whereas 20 'unstained' areas with visible lesions contained only one dysplasia (low grade). 'Stained' areas in 96 (100%) subjects showed two additional dysplasias (one high and one low grade). In this study, Lugol 'unstained' areas were of great value for detection of dysplasias (sensitivity = 80%; specificity = 63%; p = 0.01, Fisher's exact test; CI = 95%; odds ratio = 6.7).

Rapid rescreening of cervical smears for internal quality control.

OBJECTIVE: To assess the performance of quick rescreening as an internal quality control for cervical smears previously screened as negative and to compare this method with clinically indicated rescreening of negative smears and with further 10% random rescreening. STUDY DESIGN: In a small-workload laboratory with many different types of indications for cytology, during a three-month period, all gynecologic cytology smears considered negative for significant findings (anything above atypical squamous cells of undetermined significance (ASCUS)/atypical glandular cells of undetermined significance (AGUS) in the Bethesda System) or inadequate were quickly rescreened using a 10 x objective. RESULTS: Of the total 2,188 smears processed, 164 (7.5%) were excluded from rapid review because they were positive on routine screening, and 2,024 cases were subjected to rapid rescreening: 1,925 (95.1%) cases were considered negative and 99 (4.9%) positive for significant findings; 58 of the latter were confirmed and 41 not confirmed by the cytopathologist's detailed examination. The 58 confirmed cases were classified as: 43 ASCUS/AGUS, 14 of low grade squamous intraepithelial lesion and 1 of invasive cancer. No cases of high grade squamous intraepithelial lesion were detected. CONCLUSION: Considering that the routine screening and internal quality control of the laboratory had detected 117 positive cases, the additional 58 represent a definite increase in the efficiency of a small-workload laboratory. In such a clinical setting, no additional case of a high grade lesion was detected by rapid rescreening. The increase in cost and time was considered very reasonable, and the method was incorporated as quality control for the laboratory. Clinically indicated rescreening of negative smears and random 10% rescreening after random rescreening did not add significantly to quality assurance.

Esophageal dysplasia and chronic esophagitis: detection at upper gastrointestinal tract endoscopy.

UNLABELLED: Cancer of the esophagus becomes symptomatic at an advanced phase with a late diagnosis, when the tumor is already incurable. Early diagnosis has been shown to improve the survival rates. Conventional esophagoscopy is largely available but its sensitivity to detect early cancer or precancerous lesions remains controversial. In this study we tested the sensitivity of conventional esophagoscopy to identify suspicious areas and compared to histopathology of endoscopic biopsies to detect dysplasia and chronic esophagitis in a population at risk for cancer in southern Brazil. Adult males scheduled to have outpatient endoscopy were examined by two experienced endoscopists and any small (< 5 mm) plaque, nodule, erosion, hyperemia and or friable areas of the mucosa were biopsied and looked for the presence of early cancer or precancerous lesions. Normal appearing mucosa at the middle third of the esophagus was also biopsied and results compared for sensitivity, specificity, positive and negative predictive value. Of the 89 individuals with satisfactory biopsies, 3 had dysplasias, 29 moderate or severe chronic esophagitis and 57 normal findings at the histopathological study. We found no early cancer. We found two large, vegetating lesions confirmed to be advanced squamous cell carcinoma but they were excluded from analysis. To detect dysplasia or moderate/severe chronic esophagitis conventional esophagoscopy had a sensitivity of 40.6%, specificity of 78.9%, positive predictive value of 52% and negative predictive value of 70.3. CONCLUSIONS: In this study, conventional esophagoscopy had a low sensitivity to detect dysplasias and/or chronic esophagitis and techniques to improve endoscopic identification of these lesions in individuals at risk for cancer are much needed.

Imagequest. A model self-assessment and self-teaching program for cytopathology.

OBJECTIVE: To develop a low-cost program for providing self-assessment and training for cytopathologists. STUDY DESIGN: Using an optical microscope with a color charge coupled device connected to a personal computer equipped with an ISA bus frame grabber, images were digitized. After the selection of proper images, they were attached to 100 questions with a single answer and five options each. For every question, references accompanied the answer. A colorful score and sounds were played while each question and its corresponding answer were on the screen in order to stimulate the learning process. RESULTS: A low-cost, attractive, effective program for providing self-assessment and training for cytopathologists was developed. CONCLUSION: The use of a high-level programming language permits the creation of a simple, assisted, programmable interface with accessibility for upgrades and customization for every pathologist. This feature permits the insertion of new questions, an essential feature to preserve the usefulness of the program for the future.

Comparison of conventional microscopy and digitized imaging for diagnosis in serous effusions.

OBJECTIVE: To compare diagnoses made from conventional microscopy and digitized imaging in preparation for teleconsultation cytopathology services that are affordable and efficient. STUDY DESIGN: One hundred six consecutive serous effusions received in the cytopathology laboratory of a general hospital in Porto Alegre, RS, Brazil, were studied. The diagnoses by the senior cytopathologist at the conventional microscope were considered the standard and identified 61 cases negative and 45 positive for malignant cells (40 epithelial and 5 nonepithelial). The same pathologist digitized 461 selected fields for analysis by a second experienced cytopathologist (observer A) and a senior cytotechnologist (observer B) without knowledge of the standard diagnoses. Ten cases were studied in daily sessions of one hour each. The diagnoses were negative for malignant cells, positive for malignant cells (epithelial) and positive for malignant cells (nonepithelial). RESULTS: The following kappa values were found: 0.91 (observer A and observer B versus standard) and 0.86 (observer A versus observer B). CONCLUSION: Remote digitized imaging diagnosis in serous effusions is possible and has a high degree of concordance with diagnosis by conventional microscopy. Similar studies involving a larger group of cytopathologists and cytotechnologists should be done to identify interobserver variability.

Correlation of endoscopic cytology and histology in oesophageal cancer: results in Porto Alegre, RS--Brazil.

A retrospective study of oesophageal cytopathology at the Hospital de Clinicas de Porto Alegre (HCPA), RS, Brazil, from 1989 to 1992 was made assess the sensitivity, specificity, predictive values and accuracy of endoscopic cytology and biopsy; and study the correlation between cytopathological and histopathological diagnosis. Specimens from 94 patients were available for review. The final diagnosis was based on surgical pathology and follow up. The 81 patient with cancer of the oesophagus had the following sex distribution: 64 males and 17 females(a 3.7-1 ratio). No tumour was found in 13 patients. The following conclusions were made: (i) there is excellent correlation between cytology and histology in oesophageal lesions sampled by endoscopy; (ii) a correct positive cytologic report was obtained in 77 (95%) of the 81 proven oesophageal cancers; a false-negative or unsatisfactory result was given in four patients. A false-positive diagnosis of cancer was not made. There were 13 true-negative reports. These findings result in a sensitivity of 83% with 95% CI of 74.82-91.18%; a specificity of 100% (CI of 98.5-100%) a positive predictive value of 100% (CI of 99.25-100%); a negative predictive value of 48% (CI of 29.16-64.84%); (iv) of 81 patients with proven cancer, in 79 (98%) at least one of the methods was positive. In only two patients with cancer were both methods negative. These finding result in a combined sensitivity of 98% (CI of 94.92-100%); a specificity of 100% (CI of 98.5-100%); a positive predictive value of 100% (CI of 99.31-100%); and a negative predictive value of 87% CI of 70-100%). Our series confirms the value of the combined use of cytology and biopsy for the investigation of oesophageal lesions.

Pleural fluid adenosine deaminase and lymphocyte proportion: clinical usefulness in the diagnosis of tuberculosis.

Adenosine deaminase (ADA) and lymphocyte proportion are known to be independently elevated in tuberculous effusions, but are non-specific, and false positive results are frequent. To overcome this problem the combined use of both parameters was prospectively studied in 276 patients with pleural effusion seen at Porto Alegre, Brazil. Using a cut-off level of 40 U/l at 37 degrees C (method of Giusti19) for ADA activity and lymphocyte proportion of more than 50%, the correct diagnosis of tuberculosis (sensitivity) was made in 90.7% (CI 87.3-94.1%) of 54 patients. A specificity of 97.7% (CI 95.9-99.5%) was recorded. Five false positive diagnoses of tuberculous effusion were made. Five false negative diagnoses were made: three cases with haematogenous tuberculous dissemination with low ADA levels, and two other patients with low lymphocyte proportion. The combined use of ADA activity determination and lymphocyte proportion is a highly efficient diagnostic strategy of low cost, that merits wider use.