Reclassification of "atypical" diagnoses in endoscopic retrograde cholangiopancreaticography-guided biliary brushings

OBJECTIVE: To evaluate the usefulness of reclassifying "atypical" diagnoses in reporting biliary cytology using strict morphologic criteria. STUDY DESIGN: Cytologic specimens from 139 patients (direct, alcohol-fixed smears or cytocentrifuge preparations) were evaluated. Diagnoses were benign (70), atypical (36) and malignant (33). Using strict criteria--major (nuclear contour, chromatin pattern) and minor (polarity, cell types, nuclear size, nuclear grooves, nucleoli, mitosis, nuclear/cytoplasmic [N/C] ratio)--atypical cases were reevaluated and reclassified. Follow-up (F/U) was available on all cases. RESULTS: Atypical cases, (36) were reclassified as malignant (26), atypical favor benign (2)/reactive (3) and atypical, not otherwise specified (NOS) (5). Cases reclassified as malignant showed irregular nuclear contours, chromatin irregularities and rare mitosis. Nuclear enlargement, nucleoli and cellularity varied widely in all groups. N/C ratio was increased in most reclassified malignant cases. All 26 malignant reclassifications correlated with F/U of malignancy. Benign and reactive cases (5) were negative for malignancy on F/U (4), and in 1 case a metastatic carcinoma involving the biliary tree was found. In the 5 atypical (NOS) cases, F/U showed malignancy (3) and pancreatitis (2). Cytocentrifuge preparations made in our laboratory were of superior quality when compared to other methods of cell preparation. CONCLUSION: Irregularities in nuclear membrane and abnormal chromatin pattern were the most consistently useful features correlating with malignancy. The sensitivity and specificity of biliary brush cytology can be enhanced by using strict cytomorphologic criteria and proper collection and fixation, all of which decrease atypical diagnoses.     

FISHing for pancreatobiliary tract malignancy in endoscopic brushings enhances the sensitivity of routine cytology

Pancreatobiliary tract carcinoma is a lethal disease with low survival rates and limited treatment options. Diagnosis is complicated by benign conditions that can mimic malignancy on radiological studies (e.g. primary sclerosing cholangitis or PSC) and the suboptimal sensitivity of endoscopic biopsy/brushings obtained by endoscopic retrograde cholangiopancreatography (ERCP). The detection of multiple chromosomal gains by fluorescence in situ hybridization (FISH), referred to as polysomy, has demonstrated improved sensitivity over routine cytological evaluation. The evaluation of brushings by both routine cytology and FISH in our cytopathology laboratory has been in clinical practice since 2003. Strong morphological and screening skills enable cytotechnologists to become proficient in the assessment of FISH slides, which translates into cost and time savings. Multiple reports from various institutions have demonstrated the utility of FISH for patients with and without PSC. The incorporation of routine cytology and FISH results into the management algorithm for patients under suspicion for pancreatobiliary malignancy is a testament to the clinical success of these cytological assays.     

Virus penetration of examination gloves

Examination gloves worn for protection from biohazards were sampled and evaluated for their ability to exclude virus particles. We found that thin gloves manufactured from polyethylene or polyvinyl chloride are ineffective barriers while gloves of thin latex are superior but not without failure. Polyethylene and polyvinyl chloride gloves had failure rates of 40% and 22%, respectively. Following exposure to the common disinfectant, 70% ethanol, these failure rates increased to 94% and 56% for polyethylene and polyvinyl chloride gloves, respectively. Latex, although permeable to ethanol, was penetrated by virus less than 1% of the time regardless of whether the latex had been pre-exposed to disinfectant or not. This study highlights the need for caution on the part of those who rely upon examination gloves for protection from infectious agents as well as the need for establishing more adequate standards and testing procedures for their manufacture.     

Prospective comparison of the value of brushings before and after biopsy in the endoscopic diagnosis of gastroesophageal malignancy

The hypothesis that the cytodiagnostic results on endoscopic brushings obtained before biopsy may be superior to those brushings obtained after biopsy, but with the accuracy of the subsequent biopsy reduced, was examined for 300 consecutive patients, including 256 with esophageal or gastric carcinomas. Following stratification by site and endoscopic appearance of their lesions, the patients were randomized to undergo brushing either before or after forceps biopsy. The accuracy of brushing cytology in patients with carcinoma was significantly higher when the brushing was performed before biopsy than after biopsy (93.5% versus 82.6%; P less than .01). The diagnostic yield of the biopsy was not significantly different whether the lesions were brushed before or after the biopsy (92.7% versus 93.2%; P less than .5). The diagnostic superiority of brushings obtained before biopsy did not relate to the site or endoscopic appearance of the tumor. There were no false-positive cytologic or histologic reports. For all 256 carcinomas, the cumulative accuracy (brushing cytology plus biopsy) reached 98.8% and was significantly better (P less than .001) than that of biopsy alone (93.9%) or cytology alone (87.9%). Apart from reinforcing the belief that the combined application of brushing and biopsy is mandatory for achieving optimal results, this study indicated that the brushing should be performed before the biopsy.     

Role of gastric mucosa prostaglandins in the development of ulcer lesions in liver cirrhosis]

The amount of prostaglandins (PD) E, F2 alpha and I2 (measured as 6-keto-Pg F1 alpha) in endoscopic biopsy specimens of gastric corpus' mucosa also as the concentration of Pg E and F2 in gastric juice of cirrhotic patients without or with gastric and duodenal ulcer were measured by radioimmunoassay. Release of Pgs with gastric juice (in the basal state and after histamine stimulation) was also significantly less in these patients. It was concluded that the severe disturbance of endogenous biosynthesis Pgs in gastroduodenal mucus of cirrhotic patients may play an important role in the development of ulcer disease in these patients.     

Cytodiagnosis of Campylobacter pylori in Papanicolaou-stained imprints of gastric biopsy specimens.

The use of Papanicolaou-stained touch preparations of gastric antral biopsies for the identification of Campylobacter pylori was examined using specimens obtained from 63 consecutive patients with endoscopic evidence of antral gastritis, with the results compared to routine histologic examination and Warthin-Starry silver staining. Organisms were readily identifiable in the Papanicolaou-stained imprints of the gastric mucus. The sensitivity in detecting organisms was 92.5% for the Warthin-Starry-stained sections, 71.4% for the Papanicolaou-stained imprints and 100% for both techniques combined. False-negative imprints were attributed to poor smears and/or the submission of duodenal tissue rather than antral biopsies. Properly performed touch preparations stained by the Papanicolaou method are a cost-effective adjunct to Warthin-Starry-stained section for improving the sensitivity of gastric biopsies for the diagnosis of C pylori.     

Endothelin-1-induced gastric ulcer is attenuated by cetraxate

We investigated the effect of the anti-ulcer drug cetraxate on the development of the gastric ulcer induced by the submucosal injection of endothelin-1 in the rat gastric body, and its effects on gastric mucosal hemodynamics and tissue oxygenation by Laser doppler flowmetry and tissue spectrophotometry. Endothelin-1 induced gastric ulcer (ulcer length: 11.85 ± 0.89 mm, mean ± SEM, n = 4) which was strongly attenuated by cetraxate (ulcer length: 3.27 ± 0.3 mm, mean ± SEM, n = 8, p < 0.0001). Cetraxate maintained also tissue oxygenation without causing any significant effect on the endothelin-1 induced changes in gastric mucosal blood flow and volume. These results show that cetraxate exerts its cytoprotective action partly by maintaining mucosal oxygenation.     

Cytodiagnosis of bone tumors by fine needle aspiration

A retrospective study was undertaken of bone lesions examined by preoperative fine needle aspiration (FNA) cytology in our hospital during the ten-year period from 1970 to 1979. The 430 cytologically examined lesions were classified into three groups: inflammatory lesions, tumorlike lesions and tumors. A total of 54 patients had undergone surgery, with most of the lesions in those cases proven to be tumors or tumorlike by histologic study. Correlation between the histologic and FNA cytologic findings showed complete compatibility in 76% of the cases, partial compatibility in 13% and incompatibility in 11%. It is concluded that FNA biopsy is appropriate for identifying bone tumors and tumorlike lesions if sufficient numbers of tumor cells are obtained for morphologic examination. Although aspiration cytodiagnosis can be of considerable value in the recognition of certain bone lesions, it cannot replace formal tissue biopsy in the diagnosis of primary bone neoplasms. The morphology of several common bone tumors is described in detail and their differential diagnosis is discussed.