Abnormal mismatch repair and other clinicopathologic predictors of poor response to progestin treatment in young women with endometrial complex atypical hyperplasia and well-differentiated endometrial adenocarcinoma: a consecutive case series.

OBJECTIVE: To report the response to progestin therapy in young women with endometrial complex atypical hyperplasia (CAH) or FIGO grade 1 endometrial adenocarcinoma (FIGO 1 EAC) based on clinicopathologic features, including abnormal DNA mismatch repair (MMR) by immunohistochemistry (IHC). DESIGN: Consecutive case series. SETTING: Olive View-UCLA Medical Center in Sylmar, CA, USA, and Cedars-Sinai Medical Center in Los Angeles, CA, USA. POPULATION: Women ≤55 years old with CAH or FIGO 1 EAC. METHODS: Response to progestin therapy in 84 consecutive patients was assessed based on clinicopathologic factors, including age, body mass index (BMI), initial histology, and IHC staining for MMR proteins. MAIN OUTCOME MEASURES: Rates of abnormal MMR protein expression and response to progestin therapy were determined. RESULTS: Six (7%) patients had abnormal IHC staining, of whom five (83%) had FIGO 1 EAC at initial diagnosis. Following progestin treatment, none of the endometrial lesions in patients with abnormal IHC for MMR proteins had resolution of hyperplasia or malignancy, in contrast to 41 (53%) with normal staining (P = 0.028). Age ≤40 years and initial lesion (CAH versus FIGO 1 EAC) were predictors of response to progestin; BMI was not. CONCLUSIONS: In this cohort, 7% of women ≤55 years of age with CAH or FIGO 1 EAC had loss of MMR proteins by IHC. These patients had a higher incidence of invasive cancer and a lower incidence of resolution with progestin therapy. TWEETABLE ABSTRACT: Abnormal MMR protein expression predicts poor response to progestins in young women with CAH or FIGO 1 EAC.

Foxc2 induces Wnt4 and Bmp4 expression during muscle regeneration and osteogenesis.

Proliferation and fusion of myoblasts is a well-orchestrated process occurring during muscle development and regeneration. Although myoblasts are known to originate from muscle satellite cells, the molecular mechanisms that coordinate their commitment toward differentiation are poorly understood. Here, we present a novel role for the transcription factor Forkhead box protein C2 (Foxc2) in regulating proliferation and preventing premature differentiation of activated muscle satellite cells. We demonstrate that Foxc2 expression is upregulated early in activated mouse muscle satellite cells and then diminishes during myogenesis. In undifferentiated C2C12 myoblasts, downregulation of endogenous Foxc2 expression leads to a decrease in proliferation, whereas forced expression of FOXC2 sustains proliferation and prevents differentiation into myotubes. We also show that FOXC2 induces Wnt signaling by direct interaction with the Wnt4 (wingless-type MMTV integration site family member-4) promoter region. The resulting elevated expression of bone morphogenetic protein-4 (Bmp4) and RhoA-GTP proteins inhibits the proper myoblast alignment and fusion required for myotube formation. Interestingly, continuous forced expression of FOXC2 alters the commitment of C2C12 myoblasts toward osteogenic differentiation, which is consistent with FOXC2 expression observed in patients with myositis ossificans, an abnormal bone growth within muscle tissue. In summary, our results suggest that (a) Foxc2 regulates the proliferation of multipotent muscle satellite cells; (b) downregulation of Foxc2 is critical for myogenesis to progress; and (c) sustained Foxc2 expression in myoblast cells suppresses myogenesis and alters their lineage commitment toward osteogenesis by inducing the Wnt4 and Bmp4 signaling pathways.

Predictors of invasive adenocarcinoma after conization for cervical adenocarcinoma in situ.

OBJECTIVE: Modified radical hysterectomy has been advocated for the definitive treatment of patients with cervical adenocarcinoma in situ (ACIS) with positive conization margins due to the risk of a co-existing invasive cervical adenocarcinoma (ICA). We sought to identify patients who can be safely managed with an extrafascial hysterectomy based on predictors of invasion in the conization specimen. METHODS: Between 1996 and 2010, we identified 33 patients who had definitive surgical management for cervical ACIS following conization with positive margins and/or positive endocervical curettage (ECC). Demographic and pathologic characteristics were collected by chart review. Statistical analysis was performed using Fisher's exact test. RESULTS: Among 33 patients, 4 (12%) had ICA in the hysterectomy specimen. Predictors of ICA included pathologic suspicion of invasion (PSI) in the conization specimen and positive ECC. In patients with ICA at hysterectomy, PSI and ACIS-positive ECC were found in 75% (p=0.32) and 100% (p=0.09) respectively. When PSI was present and the ECC was positive, the positive predictive value (PPV) for ICA was 33% (2 of 6). When PSI was absent, the negative predictive value (NPV) for ICA was 94% (1 of 16). When both PSI and ECC were negative, the NPV for ICA was 100% (0 of 6). CONCLUSIONS: Women with cervical ACIS have the highest risk for ICA in the setting of positive cone margins, positive ECC, and presence of PSI in the conization specimen. Extrafascial hysterectomy remains a viable option for women with positive cone margins when ECC is negative and PSI is absent.

Evidence-based evaluation of the risks of malignancy predicted by thyroid fine-needle aspiration biopsies.

A National Cancer Institute (NCI) "Thyroid Fine-Needle Aspiration (FNA) State of the Science Conference" recently proposed standardized nomenclature and "risks of malignancies" associated with various diagnostic categories. We evaluated the evidence levels of the data used by NCI to predict malignancy risks and whether those estimates had clinical validity in our patient population.Eight hundred seventy-nine patients underwent thyroid FNA during 2006. FNA diagnoses were translated into NCI diagnostic categories, and 2-year follow-up retrospective information was obtained. Four percentages of malignancies were calculated for each diagnostic category using follow-up information from FNA, thyroidectomy, both, and all patients as denominators. 95% confidence intervals (CI) were estimated for all proportions, and results were analyzed with chi-square statistics. "Relative risk" calculations were performed using the percentage of malignancies in the entire population under study as a denominator.Most of the studies cited by the NCI provided incomplete and variable level III evidence based mainly on surgical follow-up. Among our patients, the percentages of malignancies calculated with follow-up data from all patients as the denominator were similar to the "risk estimates" proposed by the NCI, but estimates based on surgical follow-up overestimated the probability of thyroid malignancy for patients with FNA diagnosis of "benign" and "follicular lesions of undetermined significance" (FLUS). Relative risk and 95% CI calculations suggested that the NCI classification could be simplified into three categories: "benign," "FLUS + neoplasm," and "suspicious + malignant."

Anal cytology: is there a role for reflex HPV DNA testing?

There is an increased incidence of anal squamous carcinoma and its precursor lesions (anal intraepithelial neoplasia [AIN]) among persons who engage in anal-receptive sex. Analogous to cervical cancer screening, anal Papanicplaou (Pap) smears currently are used to screen these high-risk populations. Human papilloma virus (HPV) has been implicated in anal carcinoma pathogenesis and this study was performed to assess the potential role of HPV DNA testing as an adjunct to anal cytology. We correlated cytological diagnoses and HPV DNA (Digene Hybrid Capture [HC II] assay) in anal specimens collected in SurePath liquid medium from 118 patients; 54.8% of cases diagnosed as atypical squamous cells of undetermined significance (ASC-US) and 87.8% diagnosed as low-grade squamous intraepithelial lesion (LSIL) or above tested positive for high- risk HPV DNA (B+). High-grade SIL (HSIL) was present in 31 of the 51 patients with follow-up. Although a cytological diagnosis of ASC-US or above was a reliable indicator for AIN, cytology frequently did not accurately predict the grade of SIL in subsequent biopsy. Our findings suggest that reflex HPV DNA testing would be helpful in triaging patients diagnosed with ASC-US. However, patients diagnosed with LSIL or above should go directly to ansocopic biopsy.

Pseudallescheria: an underdiagnosed fungus?

Pseudallescheria has been identified as one of the "clinically significant emerging mycoses" but has received little attention in the cytology literature. Recognition of this fungus is of particular importance clinically, because unlike most other fungi (including Aspergillus, with which it is most frequently confused), Pseudallescheria is not effectively treated with amphotericin B, the most frequently and often the only antifungal agent administered. Features helpful in the diagnosis of Pseudallescheria in cytologic material are presented.

Optimization of the peritoneal lavage.

Review of 275 consecutive peritoneal lavages and concurrent histologic material from gynecologic operations suggested that cytologic evaluation was clinically indicated for only 60.7% of the lavages, representing 46% of the patients in the study. More than one concurrent lavage was received from 21.6% of all patients in the study, comprising 50% of patients with malignant lavages, 18.7% of patients with benign lavages, and 5.3% of patients for whom cytologic evaluation of peritoneal lavage was not clinically indicated. Malignant cells were diagnosed in 15% of the 167 lavages for which cytologic examination was clinically indicated. In this series of patients, identification of malignant cells in peritoneal lavages did not increase the tumor stage beyond that obtained solely from examination of the concurrent histologic material. There were no false-positive cytologic diagnoses and no lavages in which neoplastic cells were misinterpreted as benign. A significant number of lavages, including several from patients with histologically confirmed peritoneal tumor, were sparsely cellular and/or excessively bloody. It is suggested that although peritoneal lavages might be collected during all gynecologic operations, only specimens from selected cases should be submitted for cytologic evaluation, and greater attention should be given to specimen collection to ensure that only well-preserved and representative material from the peritoneum is submitted for cytologic evaluation.

Toward optimal use of the cytology laboratory: quality improvement and cerebrospinal fluid specimens.

Review of 203 consecutive cerebrospinal fluid (CSF) specimens submitted concurrently to the cytology and hematology laboratories identified several quality improvement (QI) opportunities. Clinician/laboratory, interlaboratory, and intralaboratory issues are addressed. Data are utilized to formulate a multifaceted approach that would decrease patient expenditure, conserve laboratory resources, and improve the clinical value of CSF reports.

Pulmonary cysticercus.

Cysticercus cellulosae, the encysted larva of Taenia solium, is reported in a solitary granulomatous lesion excised from the lung of a 61-year-old woman from Thailand. No extrapulmonary signs of cysticercosis were manifest preoperatively, and the diagnosis was not suspected clinically. Pulmonary cysticercus is rarely diagnosed histologically. When unaccompanied by extrapulmonary disease, a single cysticercus lung lesion may be clinically and radiologically indistinguishable from other granulomata and malignancy.

Neural networks as an aid in the diagnosis of lymphocyte-rich effusions.

Neural network (NN) technology was applied to digital image analysis data for 112 Papanicolaou-fixed and -stained smears of lymphocyte-rich effusions (LREs). The smears were analyzed with an inexpensive image analysis system assembled in our laboratory. Several models were developed using backpropagation NN development software in an effort to optimize classification of the LREs as reactive lymphocytosis or malignant lymphoma and to analyze the effects of various parameters on classification rates. The greatest specificity and sensitivity of LRE classification were achieved with NN models that consisted of 7 input neurons, including 5 morphometric and 2 densitometric variables, 10 hidden-layer neurons and 1 output neuron. This NN architecture with a sigmoidal transfer function provided a true cross-validation rate of 89.3% of testing data, with a sensitivity of 76.9%, specificity of 93.0% and shrinkage of 10.7%. The same NN architecture with a step transfer function provided a true cross-validation rate of 95.3%, sensitivity of 85.7%, specificity of 97.6% and shrinkage of 0%. The effects of various parameters, such as network size, shrinkage and ratio of sample size to input layer size, on NN accuracy are discussed.

Is immunoreactivity for p53 useful in distinguishing benign from malignant effusions? Localization of p53 gene product in benign mesothelial and adenocarcinoma cells.

p53 protein is a "natural tumor suppressor" that plays an important role in controlling cell proliferation. Alterations resulting in overexpression of this gene product have been described in a wide variety of human malignancies. We utilize two commercially prepared monoclonal antibodies to assess the potential role of immunoreactivity for p53 protein in distinguishing benign mesothelial from adenocarcinoma cells in effusion smears. p53 protein was detected in adenocarcinoma cells in 78% of the malignant fluids studied. Benign mesothelial cells in 14% of these fluids and in 73% of the benign fluids also stained for p53. Differences in staining were observed with the Bp-53-12-1 and the 1801 antibodies. Intensity, intracellular distribution, and frequency of immunoreactivity within each cell population are described. Observations are discussed in relation to sensitivity and specificity of the monoclonal antibodies for different configurational forms of p53 protein, configurational modifications of p53 protein during the cell cycle, and diagnostic evaluation of effusion smears for the presence of malignant cells. Immunoreactivity for p53 does not correlate with site of primary tumor. Although overexpression of p53 is more frequent in adenocarcinoma cells than in reactive mesothelial cells, p53 protein overexpression is not necessarily indicative of malignancy.

Lymphoid-rich effusions. Diagnosis by morphometry using the CAS 200 System.

Lymphoid-rich effusions frequently present diagnostic problems in clinical cytology. In the authors' previous studies, most lymphoid-rich effusions had been correctly classified as benign lymphocytosis or malignant lymphoma by an experimental computerized interactive morphometry system, in which randomly selected lymphoid nuclear profile images were measured in Papanicolaou fixed and stained cytospin smears. The present study used the CAS 200 System and criteria from the previously described rule-based expert system to classify similar preparations of 134 lymphoid rich pleural, peritoneal, and pericardial effusions (90 benign lymphocytoses, 36 malignant lymphomas, and 8 chronic lymphocytic leukemias). A total of 98.9% of the benign lymphocytoses and 88.9% of the malignant lymphomas were correctly classified (predictive values of correct diagnoses 95.7% and 97.3%, respectively). Chronic lymphocytic leukemias could not be distinguished from benign lymphocytoses by nuclear profile areas. Optical density histograms of benign, lymphomatous, and chronic lymphocytic leukemias effusions are described. Advantages and limitations of image analysis and immunocytochemistry are discussed.

Localization of p53 protein and human papillomavirus in anogenital squamous lesions: immunohistochemical and in situ hybridization studies in benign, dysplastic, and malignant epithelia.

p53 Protein is a 53-kd nuclear phosphoprotein believed to play an important role in controlling proliferation of neoplastic and normal cells. This "natural tumor suppressor" can be rendered ineffective (or oncogenic) by mutations in the p53 gene or by interactions with proteins synthesized by DNA-transforming viruses, including specific subtypes of human papillomavirus (HPV). We describe the localization of p53 protein in association with HPV in paraffin sections of a spectrum of benign, dysplastic, and malignant anogenital squamous epithelia using immunohistochemical and in situ hybridization techniques. p53 Was detected in 81% of the 48 cases studied. Immunoreactivity for p53 was seen in 83% of the benign and low-grade squamous intraepithelial lesions (SILs), in 73% of the high-grade SILs, and in 86% of the infiltrating squamous carcinomas. In high-grade SILs p53 staining was frequently observed in individual nuclei at various levels of the abnormal epithelium and in the basal layer of the adjacent epithelium, while in squamous metaplasia and low-grade SILs immunostaining for p53 was limited to the basal layer of the epithelium. p53 Was detected in a slightly higher percentage of HPV-positive than HPV-negative epithelia as determined by in situ hybridization. No correlation was observed between p53 immunoreactivity and HPV subtypes. p53 Protein and HPV were detected in anal lesions from a small group of human immunodeficiency virus-positive individuals. Antibodies currently available mainly demonstrate mutant forms of p53 protein that are associated with longer half-lives than the wild-type protein, but demonstration of p53 protein overexpression is not necessarily indicative of malignancy.

Computerized interactive morphometry and the diagnosis of lymphoid-rich effusions.

An experimental computerized interactive morphometry system for the classification of lymphoid-rich effusions is presented. The relatively inexpensive microcomputer-based system was assembled in our laboratory with commercially available hardware and software. One hundred twenty-two effusions (86 benign lymphocytoses, 26 lymphomas, and 10 chronic lymphocytic leukemias) were studied. Lymphoid cells were selected randomly by the system from real-time images of Papanicolaou-fixed and stained cytospin smears of pleural, peritoneal, and pericardial effusions. Parameters of nuclear shape, area, and optical density were measured automatically. Multiparameter statistical procedures of discriminant classificatory analysis analyzed the distribution of lymphoid nuclear profile integrated optical density to yield three groups of effusions, each with a predictive value of diagnosis of 100%. Neither these statistical procedures nor a simple rule-based expert system accurately classified chronic lymphocytic leukemia effusions based on the distribution of lymphoid nuclear profile area. When chronic lymphocytic leukemia effusions were excluded, however, the predictive values of a diagnosis of lymphoma by statistical analysis and by rule-based expert system were 92.3% and 88.9%, respectively, whereas the predictive values of a diagnosis of benign lymphocytosis were 97.7% and 91.3%, respectively. Potential applications and limitations of this technology for the diagnosis of lymphoid-rich effusions are discussed.

The severity of atherosclerosis at sites of plaque rupture with occlusive thrombosis in saphenous vein coronary artery bypass grafts.

Atherosclerotic plaque rupture with superimposed thrombosis is recognized as the lesion causing late, acute, thrombotic saphenous vein coronary artery bypass graft (CABG) occlusion. To determine the severity of atherosclerosis at the site of plaque rupture, 68 saphenous vein CABGs removed at the time of reoperation or at autopsy were studied. The study population consisted of 57 men, 64 +/- 9 years old, and nine women, 70 +/- 10 years old. The duration of graft implantation was 7.9 +/- 2.7 years (mean +/- S.D.). All CABGs were dissected from the hearts, fixed, decalcified, cut at 2 to 3 mm intervals, and processed routinely for histologic examination. A planimeter was used to measure total vessel, plaque, thrombus, and luminal cross-sectional areas at the site of plaque rupture with thrombosis in sections projected at 13.8 power magnification. At the site of atherosclerotic plaque rupture with superimposed thrombosis, the degree of stenosis due to plaque was: 90 +/- 11% for the right coronary artery grafts (n = 19); 94 +/- 7% for the left anterior descending artery grafts (n = 41), and 90 +/- 14% for the left circumflex artery (n = 8) grafts. Thus in saphenous vein CABGs, atherosclerotic plaque rupture with thrombosis usually occurs at sites of severe narrowing (mean = 93%) by preexisting atherosclerotic plaque.

Pulmonary cytology in lung transplant recipients: recent trends in laboratory utilization.

The value of bronchoscopy for the diagnosis of rejection and opportunistic infection in lung transplant recipients is controversial. We review our experience with pulmonary cytology obtained from 10 lung transplant recipients during the first 15 mos of the transplantation program at Cedars-Sinai Medical Center and compare the efficacy of pulmonary cytology for the diagnosis of opportunistic infectious agents with that of histology and microbiology. Our study encompasses 1,465 post-transplant days during which 70 bronchoscopies were performed yielding 94 cytologic specimens (44 bronchial washes, 25 bronchial brushings, and 25 bronchoalveolar lavages) and 55 transbronchial biopsies. The major advantages of cytology in this setting are short turn around time and high specificity for nonbacterial agents. All of the patients experienced episodes of bacterial pneumonia as well as fungal and viral infections. None developed Pneumocystis carinii infection during the study period. Simultaneous and concurrent infections were diagnosed. The initial diagnosis of bacterial pneumonia and herpes simplex virus preceded the diagnosis of cytomegalovirus; the former infections tended to persist and/or recur. Cytology was more effective than histology in establishing the diagnosis of Candida sp. and herpes simplex virus, while histology was more effective in establishing the diagnosis of cytomegalovirus. Increased numbers of polymorphonuclear cells did not constitute a consistent finding in cytologic or histologic samples during episodes of bacterial infection; cultures were most sensitive for detection of bacterial infection. Histochemical and immunohistochemical stains as well as in situ hybridization studies confirmed diagnoses rendered on routine Papanicolaou and hematoxylin and eosin stained material but did not provide additional diagnoses.(ABSTRACT TRUNCATED AT 250 WORDS)