August 2004
ANATOMIC
PATHOLOGY
A Modified Technique for the
Diagnosis of Hirschsprung Disease from Rectal Biopsies
Babu MK, Kini Usha, Das K, Alladi A, D'Cruz AJ.
A diagnosis of Hirschsprung
disease requires the demonstration of acetylcholinesterase fibres on frozen
sections obtained from snap frozen biopsies of the rectum. This histochemical
technique is generally not available in laboratories in developing countries.
Authors improvised on the methodology of tissue preservation to make the
staining technique more user-friendly, economical and reliable in demonstrating
acetylcholinesterase activity in fresh rectal mucosal biopsies for the
diagnosis of Hirschsprung disease.
Methods: Between June 1999 and May 2002 fresh rectal biopsies from 40 suspected cases of Hirschsprung disease were processed for routine frozen section (not snap frozen by liquid nitrogen) and stained by the Karnovsky and Roots method. These sections were assessed for the staining pattern of acetylcholinesterase fibres. The thickness of the nerve fibres and muscularis mucosa was assessed morphometrically. These were compared with biopsies obtained from 6 age-matched controls undergoing surgery for unrelated complaints.
Results: The sections stained for acetylcholinesterase by this improvised method of tissue fixation were good and crisp. A definite diagnosis of Hirschsprung disease was made in 25 cases and intestinal neuronal dysplasia in 1. The remaining 14 cases showed an equivocal staining pattern with no hypertrophic nerve bundles, thus excluding a diagnosis of Hirschsprung disease. The mean thickness of the submucosal nerve trunks measured in these enzyme-stained sections was found to be inversely proportional to the mean thickness of the muscularis mucosa.
Conclusion: The study on cryostat-cut sections suggests an inverse relationship between the thickness of the muscularis mucosa and the calibre of the nerve trunk--thinner the nerve trunk, thicker the muscularis mucosa and vice versa. Also, routine frozen sections, instead of snap frozen ones taken from a fresh rectal biopsy and stained by the Karnovsky and Roots method for acetylcholinesterase activity, are reliable for the diagnosis of Hirschsprung disease and are within the capability of a simple histopathology laboratory in a developing country.
Natl Med J
A side by side
Comparison of Cytology and Biomarkers for Bladder Cancer Detection
Schroeder GL, Lorenzo-Gomez MF, Hautmann SH, Friedrich MG, Ekici S, Huland
H, Lokeshwar V.
Purpose: The identification of accurate bladder tumor markers/tests
could improve diagnosis, recurrence monitoring and treatment in patients with
bladder cancer. In this study authors compared the efficacy of the hyaluronic
acid (HA)-hyaluronidase (HAase), BTA-Stat (Bard/Bion Diagnostics, Redmond,
Washington), Hemastix (Bayer Corp., Elkhart, Indiana) (hematuria detection) and
UBC-Rapid (IDL Biotech, Borlanger, Sweden) tests, and cytology to detect
bladder cancer. The HA-HAase test measures urinary HA and HAase levels, BTA-Stat
detects complement factor-H and H related protein in urine, the Hemastix
hemoglobin dipstick detects hematuria and UBC-Rapid detects cytokeratin 8 and
18 fragments in urine.
Materials And Methods: A total of 138 urine specimens from 115 patients were collected at University Hospital Hamburg-Eppendorf, including 59 with active bladder cancer and 79 with a history of bladder cancer (73) or with benign genitourinary conditions (6). Specimens were assayed by the HA-HAase test, BTA-Stat, Hemastix (hemoglobin dipstick) and UBC-Rapid. Cystoscopy and histological findings were used to make the clinical diagnosis. Cytology results were available on 92 patients.
Results: In a side by side comparison the HA-HAase test, cytology, BTA-Stat, Hemastix and UBC-Rapid had 88.1%, 70.6%, 52.5%, 50.8% and 35.6% sensitivity, and 81%, 81%, 76.7%, 78.2% and 75% specificity, respectively. The accuracy, and negative and positive predictive values of the HA-HAase test were the highest (84.1%, 90.1% and 77.6%), followed by cytology (77.2%, 82.5% and 68.6%), Hemastix (66.4%, 67.8% and 63.8%), BTA-Stat (66.2%, 67.8% and 63.3%) and UBC-Rapid (57.8%, 60% and 52.5%), respectively.
Conclusions: The HA-HAase test is superior to cytology, BTA-Stat, Hemastix and UBC-Rapid for detecting bladder cancer recurrence. A side-by-side comparison of tumor markers should help identify a marker for monitoring bladder cancer recurrence.
J Urol. 2004, Sep; 172(3): 1123-6
Immunohistochemical
and Molecular Markers in the Diagnosis of Hepatocellular Carcinoma
Varma, Vijay and Cohen, Cynthia
Hepatocellular carcinoma (HCC) has distinct morphologic features and can be identified in the majority of cases by routine hematoxylin and eosin (H&E)-stained formalin-fixed paraffin-embedded sections. However, distinguishing a well-differentiated HCC from normal or regenerative tissue may be very difficult in some cases, particularly in small needle aspiration or core biopsies. Furthermore, some of the unusual morphologic variants, including clear-cell, pleomorphic, and sarcomatoid variants, may be mistaken for metastases. Similarly, metastases from various primary tumors to the liver may be mistaken for primary hepatic tumors. In this overview, authors summarize the immunohistochemical and molecular markers that have been developed to address these diagnostic challenges. Among the numerous diagnostic markers studied, pCEA, HepPar 1, CD34, CK 7, CK 19, CK 20, and albumin in situ (ISH) have been found to be valuable in distinguishing HCC from metastatic neoplasms of extrahepatic sites.
Advances in Anatomic Pathology, 11(5): 239-249, September 2004
Early Detection
and Prognosis of Ovarian Cancer Using Serum YKL-40
Jakob Dupont,
Meena K. Tanwar, Howard T. Thaler, Martin Fleisher, Noah Kauff
Purpose: YKL-40 is a secreted glycoprotein (chitinase family). Authors compared YKL-40 with two ovarian cancer serum markers, CA125 and CA15-3, for the detection of early-stage ovarian cancer.
Materials And Methods: Serum YKL-40 levels were assayed by enzyme-linked immunosorbent assay for 46 healthy subjects, 61 high-risk individuals, 33 patients with benign gynecologic processes, and 50 preoperative patients subsequently diagnosed with predominantly early-stage ovarian cancer. Serum CA125 and CA15-3 values were obtained.
Results: Median YKL-40
level was 28 ng/mL (range, 15 to 166 ng/mL) for healthy subjects, 36
ng/mL (range, 9 to 69 ng/mL) for high-risk individuals without prior
cancer, 44.5 ng/mL (range, 5 to 133 ng/mL) for high-risk patients
with prior breast cancer, and 38 ng/mL (range, 5 to 67 ng/mL) for
individuals with benign gynecologic processes (P = NS).
Median preoperative YKL-40 level for ovarian cancer patients was 94
ng/mL (range, 17 to 517 ng/mL; P < .0001 compared with
normal and high-risk). YKL-40 was elevated
(
62 ng/mL) in 36 (72%) of 50 patients compared with 23 (46%) of 50
and 13 (26%) of 50 patients for CA125 and CA15-3 (P <
.008). Twenty (65%) of 31 early-stage patients had elevated serum
YKL-40 levels compared with 11 (35%) of 31 and four (13%) of 31
patients for CA125 and CA15-3 (P = .039). YKL-40 levels increased
with stage (P < .005), regardless of grade, histology, or
patient age. Patients with early-stage tumors with YKL-40 values
more than 80 ng/mL had a worse prognosis (71% recurrence v no
recurrence [P = .034]).
Conclusion: YKL-40 may represent a novel marker for the detection of early-stage ovarian cancer. YKL-40 levels in early-stage patients may also predict disease recurrence and survival. The utility of YKL-40 in detection of early-stage ovarian cancer deserves further investigation.
Journal
of Clinical Oncology, Vol. 22, No. 16 (August 15) 2004: pp. 3330-3339
Primary
Non-Hodgkin's Lymphoma of the Common Bile Duct Presenting as Obstructive
Jaundice
Joo YE, Park CH, Lee WS, Kim HS,
Primary non-Hodgkin's lymphoma of the extrahepatic bile duct presenting as
obstructive jaundice is an extremely rare disease. At this writing, a review of
the medical literature disclosed 17 reported cases of primary non-Hodgkin's
lymphoma arising from the extrahepatic bile duct. Authors, herein, report an
additional case of obstructive jaundice caused by primary non-Hodgkin's
lymphoma of the common bile duct, in a 21-year-old woman. The patient showed
clinical evidence of obstructive jaundice, and endoscopic retrograde
cholangiopancreatography and abdominal magnetic resonance imaging demonstrated
a long strictured segment of the common bile duct with proximal bile duct
dilatation. These clinical and radiological findings resembled those of
cholangiocarcinoma. Resection of the common bile duct tumor, cholecystectomy,
lymph node dissection, and Roux-en-Y hepaticojejunostomy were carried out.
Histology and immunohistochemistry of the resected specimen confirmed a diffuse
large B-cell-type malignant lymphoma involving the common bile duct. The
patient received four courses of combination chemotherapy, including cyclophosphamide,
doxorubicin, vincristine, and prednisone (CHOP), and 3060 cGy external
irradiation. She has been well, without evidence of tumor recurrence, 17 months
after the surgery. In summary, first, primary non-Hodgkin's lymphoma of the
extrahepatic bile duct, despite its rarity, should be considered in the
differential diagnosis of causes of obstructive jaundice. Second, an accurate
histopathologic diagnosis and surgical resection, if feasible, combined with
chemotherapy with or without radiotherapy may be the approach to offer a chance
for cure.
J Gastroenterol, 2004 Jul; 39(7): 692-6
CLINICAL PATHOLOGY
Circulating
1,5-Anhydroglucitol Levels in Adult Patients With Diabetes Reflect Longitudinal
Changes of Glycemia
Janet B.
McGill, Thomas G. Cole,
1,5-Anhydroglucitol (1,5AG) is a
major circulating polyol arising primarily from ingestion and
excreted competitively with glucose. Japanese studies have
demonstrated reduced concentrations of 1,5AG in serum in
hyperglycemic patients in comparison with euglycemic subjects and a
gradual normalization of 1,5AG values for patients responding to
antihyperglycemic therapies. In this first U.S. study, authors
assessed the ability of 1,5AG measurements to monitor glycemic
control in a cohort of 77 patients with diabetes (22 with type 1
diabetes, 55 with type 2 diabetes) who presented with suboptimal
glycemic control at baseline (defined as HbA1c7%).
Research Design And Methods:
Each patient received therapies consisting of combinations of
diabetes education, nutritional counseling, and addition or dose
adjustment of various insulins or oral antihyperglycemic
medications. Therapy was targeted to reduce mean HbA1c by1.0%
over the monitoring period. 1,5AG, HbA1c, fructosamine,
and random glucose measurements were performed at baseline and at 2,
4, and 8 weeks after the initiation of therapy.
Results: 1,5AG,
fructosamine, and glucose values progressed significantly toward
euglycemia by week 2 of monitoring (Wilcoxons signed-rank test, P
< 0.05), with median changes of 93, 7, and 13% for 1,5AG,
fructosamine, and glucose, respectively. In contrast, HbA1c
values did not respond significantly to therapy until week 4. On an
individual patient basis, 89.6% of patients displayed longitudinal
changes of 1,5AG from baseline to week 8 in concordance with HbA1c.
1,5AG was also highly correlated with HbA1c and
fructosamine (Spearman
=
0.6459 and 0.6751, respectively; both P < 0.0001).
Conclusions: Authors conclude that 1,5AG responds sensitively and rapidly to changes in glycemia and monitors glycemic control in accordance with established markers.
Diabetes Care 27:1859-1865, 2004
Raised Cardiac
Troponins
Causes extend beyond acute coronary syndromes
Cardiac troponins are regulatory proteins of the thin actin filaments of the cardiac muscle. Troponin T and troponin I are highly sensitive and specific markers of myocardial injury. Serial measurement of troponin I or troponin T has become an important tool for risk stratification of patients presenting with acute coronary syndromes. Cardiac troponins, however, are raised in many patients presenting with conditions other than acute coronary syndromes (box). To ignore this fact will lead to unjustified, potentially harmful investigations and increases medical costs. In sepsis, for example, cardiac troponins are raised in up to 85% of patients in the absence of any acute coronary syndromes.
In the setting of an acute coronary syndrome raised cardiac troponins identify patients with a risk of death that is several times higher than in patients without troponin elevation in the subsequent weeks. In addition, cardiac troponins have also been reported to predict mortality in heart failure, sepsis, renal failure, stroke, pulmonary embolism, and in critically ill patients without coronary artery disease.
Conditions associated with raised cardiac troponins (analytical causes excluded)
Non-cardiac diseases
Critically ill patients
High dose chemotherapy
Primary pulmonary hypertension
Pulmonary embolism
Renal failure
Subarachnoid haemorrhage
Scorpion envenoming
Sepsis and septic shock
Stroke
Ultra-endurance exercise (marathon)
BMJ 2004; 328:1028-1029 (1 May) - Editorial
Serum
Concentrations of Cardiac Troponin T in Sudden Death
Ellingsen, Christian Lycke and Hetland, Oyvind
Ischemic heart disease is the most common cause of sudden death of natural
causes. By autopsy, there may be no gross or histologic evidence of acute
myocardial damage unless the patient survived for several hours following the
event. Cardiac troponin in serum has become the recommended biochemical marker
for myocardial injury in the clinical setting.
Authors made a prospective study on 102 autopsied subjects at the Central Hospital of Rogaland, Stavanger, Norway. Femoral blood was sampled for subsequent analysis of cardiac troponin T (cTnT). In the subjects with morphologic evidence of recent myocardial injury (n = 34), the mean serum cTnT level was 1.95 [mu]g/L compared with 0.16 [mu]g/L in the subjects with a noncardiac cause of death (n = 35) and 0.61 [mu]g/L in the group with probable sudden cardiac death without morphologic signs of acute myocardial injury (n = 33). The observed differences in mean serum cTnT levels between the groups were statistically significant (P < 0.0001). These data suggest that elevated postmortem serum concentration of cTnT reflects ongoing myocardial damage and may support a diagnosis of cardiac-related death in cases associated with sparse or inconclusive morphologic findings postmortem.
American Journal of Forensic Medicine & Pathology, 25(3): 213-215, September 2004
MICROBIOLOGY
Prevalence of
Methicillin-resistant, Coagulase-negative Staphylococci in Neonatal Intensive
Care Units: Findings from a Tertiary Care Hospital in India
Amita Jain, Jyotsna Agarwal and Seema Bansal
This study was undertaken to determine the antimicrobial resistance pattern and species of coagulase-negative staphylococci (CNS) isolated from the blood and skin of neonates with clinical suspicion of late-onset septicaemia (>72 h post-delivery) admitted to neonatal intensive care units, with particular reference to the phenotypic and genotypic expression of methicillin resistance. Blood culture specimens were collected by venipuncture from 660 such neonates in brain heart infusion broth. Skin swabs from axillae were obtained from 60 neonates and inoculated on mannitol salt agar. All CNS thus obtained were further identified and antibiotic sensitivity was performed according to NCCLS recommendations. PCR for the mecA gene was carried out on 54 randomly selected isolates. Staphylococcus haemolyticus was the commonest species (34 %) followed by Staphylococcus epidermidis (24 %) amongst blood isolates. All blood isolates were sensitive to glycopeptides. Resistance to penicillin and methicillin was 94 and 66 %, respectively. Similar biotypes and antimicrobial resistance patterns were observed in skin isolates. All phenotypically methicillin-resistant isolates had the mecA gene and two of the phenotypically methicillin-sensitive isolates were also positive for mecA. A PCR assay for detection of the mecA gene in CNS may be a beneficial adjunct to standard susceptibility testing for timely and reliable detection of methicillin resistance. Given the large number of methicillin-resistant CNS, inclusion of vancomycin in empiric therapy for neonates with late-onset septicaemia may be justified.
J Med Microbiol, 53 (2004), 941-944
END PIECE
Errors by
Surgical Pathologists in India: Results of a Questionnaire Survey
Sanjay A. Pai
Background: Data from the United Kingdom show that most surgical
pathologists are aware of about one serious mistake in their reports every
year. There are no corresponding data from India or the developing world. The
author made an attempt to determine the rate of error made by Indian
pathologists.
Methods: A postal questionnaire was sent to 96 pathologists and 71 clinicians in different cities. The questions included some related to their experience with error in histopathology, as well as a few on the respondents' views on the legal and ethical aspects in the case of medical error.
Results: Fifty pathologists and 47 clinicians responded. Of the evaluable responses, 32 pathologists were aware of 86 errors in the past 5 years, while 30 clinicians recalled 162 errors. Most mistakes that pathologists remembered were cases related to lymphoid disease (n = 15) while for clinicians, gastrointestinal tract (n = 12) and lymphoid tissue (n = 9) were common sites of error. Benign-malignant errors were the most common type of error.
Conclusion: The discrepancy between the rates of error between the two groups suggests that better pathologist-clinician communication is required.
Natl Med J India, 2003; 16(4):
204-6