ANATOMIC PATHOLOGY

The Value Of Frozen-Section Analysis Of Ureteric Margins On Surgical Decision-Making In Patients Undergoing Radical Cystectomy For Bladder Cancer

Osman, Yasser; El-Tabey, Nasr; Abdel-Latif et al

OBJECTIVE: To prospectively investigate the value of routine frozen-section analysis (FSA) of the ureteric margin for detecting distal ureteric malignancy in patients undergoing cystectomy for bladder transitional cell carcinoma (TCC).

PATIENTS AND METHODS: In all, 100 consecutive patients had a radical cystectomy for TCC of the bladder; routine FS biopsies were obtained from the lower ureters of all. Definitive pathology with step-sectioning of the lower ureters was reviewed, and the results of paraffin-wax embedded sections and FSA were compared. The true incidence of distal ureteric malignancy was identified and correlated with different clinical and pathological variables.

RESULTS: There were 193 ureteric specimens examined; 16 ureters (8.3%) in 14 patients showed evidence of malignancy by FSA. True distal ureteric malignancy was diagnosed in 29 ureteric specimens (15%) in 24 patients. The sensitivity and specificity of the FSA were 45% and 98%, respectively, while the positive and negative predictive values were 81% and 91%, respectively. There was no significant correlation between distal ureteric malignancy and: patient age, tumour site or morphology, clinical or pathological staging, ipsilateral hydronephrosis, suspicious intraoperative ureter, biopsy or tumour grade, associated carcinoma in situ or nodal involvement. Male gender and positive intraoperative FSA were the only predictors significantly associated with distal ureteric malignancy by univariate analysis (P = 0.01 and <0.01, respectively). Both predictors remained significant on multivariate analysis.

CONCLUSION: A positive ureteric FSA during cystectomy has a high predictive value in the diagnosis of distal ureteric malignancy, and is justified as an independent predictor in male patients with bladder TCC.

BJU International. 99(1):81-84, January 2007.

 

Whole-specimen histopathology: a method to produce whole-mount breast serial sections for 3-D digital histopathology imaging

Clarke G M, Eidt S, Sun L, Mawdsley G et al

Aims: To develop a method for preparing diagnostic-quality, whole-mount serial sections of breast specimens while preserving 3-D conformation. This required supporting the fresh specimen prior to breadloafing and refining the conventional tissue processing method. The overall goal is to use digital images of whole-specimen histopathology to improve the estimation of extent of disease.

Methods and results: To maintain a 3-D conformation, the specimen is suspended in 3.5% agar at 55°C. The block is sliced at 5-mm intervals. Sectioning is performed after extended fixation in 4% formaldehyde from paraformaldehyde in 0.1 m Millonig's buffer, followed by paraffin processing using a non-routine schedule and extended paraffin infiltration. Whole-mount serial breast sections are produced with features of equal or superior quality to that which can be achieved using conventional methods. The method is compatible with some immunohistochemical stains but requires further optimization for others.

Conclusions: The technique is currently suitable for research applications. With the reduction in processing time achievable with microwave-assisted processing, there is the potential for its use as a routine clinical method. This tool may improve the accuracy of margin estimates and identification of multifocality in breast cancer; further evaluation is necessary.

Histopathology, Volume 50 Issue 2 Page 232 - January 2007

 

Histological Characteristics of Basal Cell Carcinoma of the Eyelid

Ville Paavilainen, Markku Aaltonen, Juhani Tuominen et al

Purpose: To evaluate the histological subtypes of basal cell carcinoma (BCC) of the eyelid and to determine their effect on the size, depth of invasion and need of retreatment of a nonselected patient material seen in south-western Finland.

Methods: We studied the case records and the histological characteristics of BCC of the eyelid treated at the Turku University Eye Clinic during the years 1988 through 1997. The material consisted 103 patients (103 BCC tumors of the eyelid). All tumors were surgically excised. Histological slides were reviewed by a pathologist and the material was divided into histopathological subtypes.

Results: In 78.3% of the cases, the diameter of the lesion was smaller than 10 mm. The most frequent histological subtype was nodular (84.5%) followed by sclerosing (5.8%), micronodular (4.9%), keratotic (2.9%) and superficial (1.9%) types of BCC of the eyelid. Only patients of the nodular subtype showed recurrences (11 cases). The size of the tumor and the depth of invasion correlated directly with each other. However, some nodular types of BCC tumors smaller than 10 mm in diameter extended to a depth of more than 4.0 mm.

Conclusions: The nodular subtype of BCC should be regarded as a potentially invasive and recurrent tumor. Histopathological examination and subtyping of all BCC tumors is recommended.

Ophthalmic Research 2007; 39:45-48

CYTOPATHOLOGY

 The Role of Fine Needle Aspiration Cytology of the Breast in the Core Biopsy Era

Silverman, Jan .F,  Elsheikh, Tarik M., Singh et al

Since the widespread use of core needle biopsies (CNBs) for diagnosing breast lesions, fine-needle aspiration (FNA) biopsy is dramatically decreasing. Contributing factors to the decrease in FNA of breast masses include FNA's inability to separate atypical ductal hyperplasia (ADH) from ductal carcinoma in situ (DCIS) and DCIS from the invasive carcinoma, which has patient management implications. However, CNB also has some inherent limitations due to its occasional inability to make a definitive diagnosis for a number of breast lesions and discordance between ancillary studies performed on CNB versus the resected specimen results. CNB has now become the standard of care in the United States for evaluation of nonpalpable breast lesions. For palpable lesions, FNA appears currently to have the most value as completing the "triple test" for a negative diagnosis and confirming the diagnosis of locally advanced and/or inoperable carcinoma, locally recurrent breast cancer, and metastatic disease. FNA in the hands of experienced cytologists still has an important role in the diagnosis of primary palpable breast cancers. Familiarity and understanding the advantages and limitations of each biopsy technique will help select the most appropriate procedure for the workup of the patient with a breast mass.

Pathology Case Reviews. 12(1): 44-48, January/February 2007.

 Fine-Needle Aspiration Biopsy of Lymph Nodes in the Modern Era: Reactive Lymphadenopathies.

Volmar, Keith E. ,  Singh, Harsharan K. , Gong, Jerald Z.

Fine-needle aspiration (FNA) biopsy has proven to be a rapid, cost-effective, and accurate means for evaluating a wide variety of conditions in almost any organ system. In some situations, conditions resulting in reactive lymphadenopathies can be discerned on clinical grounds, and many require no specific therapy. However, cases in which an atypical presentation or a prolonged clinical course occurs warrant further investigation of the enlarged lymph nodes, often with the aim of ruling out a malignancy. In such cases, FNA biopsy can provide a rapid and accurate means of ruling out lymphoma and metastatic disease. With the aid of flow cytometry, reactive lymphoid hyperplasia can be readily assessed. Discerning the exact cause of a reactive lymphadenopathy by FNA biopsy can be problematic but can be aided with an appropriate serologic workup (ie, toxoplasma titers, Epstein-Barr virus titers). Granulomatous lymphadenitis may be caused by mycobacterial or fungal organisms, which can be grown in culture or detected by modern molecular studies performed on the aspirated material (ie, PCR). Rapid and accurate assessment of metastatic disease, particularly carcinomas and melanomas, is readily accomplished by FNA biopsy, with an overall sensitivity, specificity, and accuracy of over 90%. In these cases, cell block material can be obtained for additional useful prognostic information.

Pathology Case Reviews. 12(1):27-35, January/February 2007.

 

The Diagnostic Utility of Fine-Needle Aspiration Biopsy of Soft-Tissue Sarcomas in the Core Needle Biopsy Era

Singh, Harsharan K. , Volmar, Keith E. , Elsheikh, Tarik M et al

Fine-needle aspiration biopsy (FNAB) is a widely accepted and established diagnostic technique in diagnosing the presence of primary malignancies, metastatic disease, and benign nonneoplastic lesions. However, its role in the evaluation of soft-tissue sarcomas has remained controversial, especially as the primary modality for establishing an initial diagnosis. Arguments in favor of using core needle biopsies (CNB) relate to the fact that such samples provide ample "tissue" for evaluating architectural patterns, as well as a source for performing ancillary studies. However, in the hands of experienced cytopathologists, FNAB in conjunction with ancillary studies (performed on tissue obtained in the form of cell blocks) has been shown to have a diagnostic yield nearly identical to CNB, with an accuracy rate approaching 95% for the diagnosis of malignancy. Additionally, as therapy and prognosis are heavily dependent on the grade and stage of the tumor, it has been shown that approximately 90% of soft-tissue sarcomas can be successfully subtyped and even graded by FNAB. There are, however, certain limitations of FNAB, especially in the workup of low-grade myxoid and spindle cell sarcomas and in their separation from borderline and benign lesions. In these select subgroups, CNB may be more advantageous. Also, in the absence of an on-site cytopathologist for immediate evaluation of the sample and triage of materials for ancillary studies, CNB is preferred, although FNAB can still identify benign soft-tissue lesions and malignancies of nonmesenchymal origin not requiring ancillary studies. This review will focus on the more commonly encountered soft-tissue sarcomas and highlight the advantages and limitations of FNAB in establishing their diagnosis.

Pathology Case Reviews. 12(1): 36-43, January/February 2007.

 

CLINICAL PATHOLOGY

Spurious counts and spurious results on haematology analysers: a review. Part I: platelets

M. Zandecki, F. Genevieve, J. Gerard, A. Godon

The widespread use of haematology analysers (HA) has led to a major improvement of cellular haematology, because of quick and accurate results found in most instances. However, in several situations, spurious results are observed. Inadequate blood samples, situations induced by the anticoagulant(s) used, peculiar changes related to the pathology in the patient, and technical considerations about performances of the various HA must be considered. Spurious thrombocytopenia occurs in several circumstances related to the presence of ethylenediamine tetra-acetic acid (EDTA) used as the anticoagulant. Mechanism of EDTA-dependent platelet (PLT) agglutination is related to circulating (auto)antibodies directed against normally hidden epitope(s) in the glycoprotein alpha IIb/beta IIIa complex from PLT membrane exposed only in the presence of EDTA. Other spuriously low PLT counts may be related to EDTA, including PLT rosetting around white blood cells (WBC; satellitism) and PLT-WBC aggregates, but mechanisms responsible for those latter phenomena are less well known. Spurious increase of PLT count may be related to several situations, including fragmented red blood cells, cytoplasmic fragments of nucleated cells, cryoglobulins, bacteria or fungi, and lipids. Flags generated in several of these situations alert the operator on possible abnormal findings and may identify the problem. Analysing only PLT parameters is not sufficient: in many situations the WBC differential scattergram is of crucial help for flagging. Flags generated depend on the software version on the HA used, the performance in detecting the same anomalies may differ according to which analyser is used, even those from the same manufacturer. Operators must be aware of the characteristics of their analyser and be able to recognize and circumvent anomalous results.

Clinical and Laboratory Haematology, Volume 29 Issue 1 Page 4 - February 2007

 

Spurious counts and spurious results on haematology analysers: a review. Part ii: white blood cells, red blood cells, haemoglobin, red cell indices and reticulocytes

M. Zandecki, F. Genevieve, J. Gerard, A. Godon

Haematology analysers provide quick and accurate results in most situations. However, spurious results, related either to platelets (part I of this report) or to other parameters from the cell blood count (CBC) may be observed in several instances. Spuriously low white blood cell (WBC) counts may be observed because of agglutination in the presence of ethylenediamine tetra-acetic acid (EDTA). Cryoglobulins, lipids, insufficiently lysed red blood cells (RBC), erythroblasts and platelet aggregates are common situations increasing WBC counts. In most of these instances flagging and/or an abnormal WBC differential scattergram will alert the operator. Several situations lead to abnormal haemoglobin measurement or to abnormal RBC count, including lipids, agglutinins, cryoglobulins and elevated WBC counts. Mean (red) cell volume (MCV) may be also subject to spurious determination, because of agglutinins, excess of glucose or salts and technological considerations. In turn, abnormality related to one measured parameter will lead to abnormal calculated RBC indices: mean cell haemoglobin content (MCHC) is certainly the most important RBC indices to consider, as it is as important as flags generated by the haematology analysers (HA) in alerting the user to a spurious result. In many circumstances, several of the measured parameters from CBC may be altered, and the discovery of a spurious change on one parameter frequently means that the validity of other parameters should be considered. Sensitive flags now allow the identification of several spurious counts, but only the most sophisticated HA have optimal flagging and more simple HA, especially those without a WBC differential scattergram, do not possess the same sensitivity for detecting anomalous results. Reticulocytes are integrated now into the CBC in many HA, and several situations may lead to abnormal counts.

Clinical and Laboratory Haematology, Volume 29 Issue 1 Page 21 - February 2007

 

MICROBIOLOGY

Mycobacteriuria – Whether a Forerunner of Manifest Tuberculosis?

Correspondence

 VM Bapat, AM Bal, Rakhi S Bhuta, DR Salvi
Department of Pathology, Jehangir Hospital, Pune, India.

Sir,
Diagnosis of tuberculosis continues to be a challenge. Difficulty in localization of the active lesion and its inaccessibility for appropriate sampling – account for the diagnostic uncertainty. At present, diagnosis of Tuberculosis relies upon tissue diagnosis, mycobacterial culture, polymerase chain reaction (PCR –tuberculosis) and detection of acid fast bacilli (AFB) in appropriate diagnostic material.

Sputum smear for AFB has been a standard diagnostic method for pulmonary tuberculosis, while detection of AFB in urine has been equated to urinary tract tuberculosis in the textbooks. In our experience, a case has been encountered with AFB in urine without evidence of urinary tract tuberculosis. Conversely, detection of AFB in urine without any evidence of tuberculosis at that time has been harbinger of extra pulmonary tuberculosis eventually. A purposive follow-up of two proven cases of tuberculosis showed urine positive for AFB. With this background, 607 cases suspected/proven to be tuberculosis, were followed up with various investigations including 24 Hour urine analysis for AFB. The results indicate that the latter has high predictive value for tuberculosis at varied sites in body. There appears to be a justification to consider this investigation as confirmatory or predictive of tuberculosis.

Urine AFB has conventionally been equated with urinary tract tuberculosis in textbooks. It was fortuitous for us to be able to examine both kidneys and both ureters with no tuberculosis in a urine AFB and PCR positive case (Case - I) suggesting non-renal tuberculosis showing AFB in urine. This was further substantiated by Case – II that was urine AFB positive for 4 months prior to being symptomatic for Pott’s spine as also by one apparently healthy volunteer developing pulmonary tuberculosis 2months after urine testing positive for AFB.

With evidence based clinical practice, a definitive diagnosis of tuberculosis has become imperative for starting anti- tubercular chemotherapy. Besides biopsy and AFB culture, the other diagnostic methods accepted widely are PCR and serological methods (anti-Tuberculosis IgG, IgM and IgA). However, the costs of PCR and serological tests are prohibitive for patients of tuberculosis in developing countries. Accessibility is a limitation for biopsy of imaging detected lesion. Time required for culture report makes it impracticable investigation for starting therapy. On this background, a simple test as urine deposit smear may be a boon to the poor patients in developing countries.

Recovery of etiological organism from urine in systemic infection is a well-established phenomenon, exemplified by salmonella and leptospira. However the detection of AFB in urine attains far more importance especially for extra pulmonary tuberculosis because the yield of AFB from CSF, effusions, aspirates or joint fluids is very low and lesion accessibility for biopsy may be a severe limitation for tissue diagnosis.

As to the identity of AFB in urine, a 96% concordance of PCR-tuberculosis with smear asserts the observed AFB as Mycobacterium tuberculosis and rules out Mycobacterium smegmatis. Contrary to the groundless yet widely heldbelief1, M. smegmatis is a rare contaminant in urine.2Webster3 had observed AFB in urine from cases of skeletal tuberculosis while Munro4 cultured M. tuberculosis from urine of cases without evidence of renal disease. However, in subsequent years these findings were probably lost in cloud of doubt about contamination by M. smegmatis.

The observations of – (a) absence of tubercular lesions in Case – I, (b) presence of AFB in urine months ahead of Pott’s spine in Case – II as well as in apparently healthy volunteer, (c) biopsy confirmed cases of non-renal tuberculosis showing AFB in urine and (d) PCR proven identity of M. tuberculosis in their urine being positive for AFB – taken collectively indicate that acid-fast bacilluria may (i) confirm tuberculosis in localized indicative lesions; (ii) may corroborate with the clinical diagnosis of Tuberculosis with classical symptoms (iii) may be used as a second line investigation in cases of PUO or backache with equivocal results of first line investigations of routine blood, urine, stools & sputum examination (iv) may herald manifest tuberculosis –particularly in case of contacts of diagnosed cases of tuberculosis. Urine deposits tested positive for AFB in asymptomatic case later on turning negative may have a prognostic value superior at least to ESR that is relied upon today.

Tubercular bacillemia with acid-fast bacilluria appears to be the mechanism that can be hypothesized to explain these findings. Thus, there appears to be a strong case for multi-centric trials for cohort studies for24 hour urine deposit for AFB as a predictor of tuberculosis. Also, sensitivity, specificity and predictive value for a positive test needs to be worked out with appropriate case-control studies.

JAPI, vol.54, July 2006, pp. 588-590

New Culture Method for Hepatitis C Virus Uses Primary Hepatocytes and Patient Serum

SEATTLE, WA -- January 23, 2007 -- Researchers open the way for improved study of hepatitis C virus by devising a novel virus culture system that allows replication of patient-isolated virus in nontransformed hepatocytes, instead of culture-adapted virus strains in transformed cell lines.

The related report by Lázaro et al, "Hepatitis C virus replication in transfected and serum-infected cultured human fetal hepatocytes," appears in the February issue of The American Journal of Pathology.

Hepatitis C virus (HCV) infection affects approximately 170,000,000 people worldwide. HCV liver disease, which may induce liver inflammation, cirrhosis, and/or hepatocellular carcinoma, represents the foremost reason for liver transplantation in much of the U.S.

Study of HCV replication within liver cells, or hepatocytes, has been hampered by a lack of adequate virus culture systems. Some systems allow the virus to infect cells but do not permit prolonged replication and production of virus, while other systems rely on derivatives of permissive virus isolates for efficient replication in transformed (mutated) cell lines. Still lacking has been a system to sustain replication of novel virus isolates from patients using nontransformed hepatocytes.

Nelson Fausto of the University of Washington School of Medicine has crossed this hurdle using a human fetal hepatocyte culture system that was previously developed in his lab. Using this system, his group has demonstrated sustained replication and production of virus particles for at least 2 months, with these virus particles able to infect new cells.

In their first experiments, Fausto and colleagues transfected hepatocyte cultures with HCV genomic RNA and found replication of HCV RNA genomes and production of core protein (for virus particle formation). Release of infectious virus particles was confirmed, as media from these cells were able to infect naive hepatocytes. Finally, virus particles were examined by electron microscopy and shown to possess the expected size and shape of HCV virus particles.

Once the system was established, the group examined whether sera from patients carrying HCV could infect the human fetal hepatocytes. When sera from patients infected with different HCV strains were added to the hepatocyte culture system, viral replication occurred and new virus particles were produced.

In both transfection and infection models, virus particles were released in a cyclical manner, with bursts of virus produced every 10-14 days. This is similar to what has been reported during clinical HCV infection, possibly due to the host's natural defenses. Interestingly, cultured hepatocytes responded to viral replication by displaying signs of distress and cell death and by expressing interferon-beta, a cellular antiviral, in an effort to control the infection.

This culture system provides a breakthrough in studying HCV replication in nontransformed hepatocytes, the natural target of the virus. By allowing infection by patient serum containing a wide array of virus strains, this system may allow better understanding of the differences between different strains, further improving treatment strategies.

REFERENCE:
Lázaro CA, Chang M, Tang W, Campbell J, Sullivan DG, Gretch DR, Corey L, Coombs RW, Fausto N. Hepatitis C virus replication in transfected and serum-infected cultured human fetal hepatocytes. Am J Pathol 2007 170: 478-489.

SOURCE: American Society for Investigative Pathology