Fine needle aspiration biopsy versus sputum and bronchial material in the diagnosis of lung cancer. A comparative study of 168 patients

A group of 168 consecutive lung cancer patients in whom a definitive diagnosis of primary lung cancer was established either in a conventional cytologic specimen of sputum or bronchial material or in a specimen obtained by fine needle aspiration (FNA) biopsy was reviewed to compare the relative accuracies between the modalities of sputum and bronchial material on one hand versus FNA cytology on the other in the diagnosis of lung cancer. The patients included in the study were selected from a total of 1,093 patients who had been diagnosed and treated for lung cancer at Duke University Medical Center over the five-year period of January 1, 1980, through December 31, 1984. In 325 (29.8%) of the 1,093 patients, a definitive cancer diagnosis was established from histopathologic study alone, without any cytologic diagnoses. In 420 patients (38.4%), both histologic and cytologic material had been interpreted as being conclusively diagnostic for lung cancer. In 348 patients (31.8%), a cytologic diagnosis of lung cancer was made without a histologic confirmation. Thus, in a total of 768 (70.3%) of the 1,093 cases, a definitive cytologic diagnosis of cancer had been made. Of these 768 patients, 168 had been evaluated by both conventional respiratory cytologic methods (examination of sputum and bronchial material) and with FNA biopsy cytology. In 9 patients (5.4%), only conventional respiratory cytologic specimens were conclusively diagnostic for cancer. In 122 patients (72.6%), only the FNA biopsy specimen was diagnostic. In 37 patients (22.0%), both conventional respiratory specimens and FNA specimens yielded a definitive lung cancer diagnosis. The FNA specimen was the only positive cytologic specimen in 90.2% of large cell undifferentiated carcinomas, 79.5% of adenocarcinomas, 66.7% of small cell undifferentiated carcinomas and 58.2% of squamous cell carcinomas. In 26.5% of the patients, a diagnosis of cancer could have been established on conventional cytologic specimens, without the necessity of proceeding to percutaneous FNA biopsy. From this study, it is concluded that the techniques of conventional respiratory cytology and FNA biopsy cytology are complementary in the diagnosis of lung cancer. While the percentage of lung cancers diagnosed by FNA biopsy cytology alone is much greater than that obtained by conventional respiratory cytology alone, more than one-fourth of these cancers could be detected by the less invasive techniques of sputum collection and bronchoscopy.     

Centrifugal separation of cells in sputum specimens from patients with undifferentiated carcinoma

Ethanol-fixed cells in sputum from patients with undifferentiated carcinoma of the lung were separated in aqueous Ficoll using a discontinuous density gradient centrifugation technique. The selective enrichment of small cell undifferentiated (e.g., oat cell) or large cell undifferentiated carcinoma cells was achieved while removing most of the leukocytes (80-90%) and macrophages (65-75%) from specimen fractions containing the greatest relative frequencies of cancer cells. The maximum purity of small cell carcinoma cells (0.04%) occurs in moderate density (rho = 1.121 g/ml) gradient fractions and results in a 2.4-fold enrichment relative to unprocessed specimens. In contrast, the maximum purity of large cell carcinoma cells (0.22%) is obtained in very high density (rho = 1.172 g/ml) gradient fractions and results in a 1.2-fold enrichment in comparison with unprocessed specimens. Microscopic examination of Papanicolaou-stained specimen fractions reveals that these enrichments were achieved while retaining diagnostically significant cytomorphologic and tinctorial features necessary for cancer screening and diagnosis. Peak purity ranges of undifferentiated cancer cells significantly overlap comparable ranges for material from bronchogenic adenocarcinoma and squamous cell carcinoma.     

Students investigating the antiproliferative effects of synthesized drugs on mouse mammary tumor cells

The potential for personalized cancer management has long intrigued experienced researchers as well as the na?ve student intern. Personalized cancer treatments based on a tumor's genetic profile are now feasible and can reveal both the cells' susceptibility and resistance to chemotherapeutic agents. In a weeklong laboratory investigation that mirrors current cancer research, undergraduate and advanced high school students determine the efficacy of common pharmacological agents through in vitro testing. Using mouse mammary tumor cell cultures treated with "unknown" drugs historically recommended for breast cancer treatment, students are introduced to common molecular biology techniques from in vitro cell culture to fluorescence microscopy. Student understanding is assessed through laboratory reports and the successful identification of the unknown drug. The sequence of doing the experiment, applying logic, and constructing a hypothesis gives the students time to discover the rationale behind the cellular drug resistance assay. The breast cancer experiment has been field tested during the past 5 yr with more than 200 precollege/undergraduate interns through the Gains in the Education of Mathematics and Science program hosted by the Walter Reed Army Institute of Research.     

The Relevance of External Quality Assessment for Molecular Testing for ALK Positive Non-Small Cell Lung Cancer: Results from Two Pilot Rounds Show Room for Optimization

Background and Purpose

Molecular profiling should be performed on all advanced non-small cell lung cancer with non-squamous histology to allow treatment selection. Currently, this should include EGFR mutation testing and testing for ALK rearrangements. ROS1 is another emerging target. ALK rearrangement status is a critical biomarker to predict response to tyrosine kinase inhibitors such as crizotinib. To promote high quality testing in non-small cell lung cancer, the European Society of Pathology has introduced an external quality assessment scheme. This article summarizes the results of the first two pilot rounds organized in 2012–2013.

Materials and Methods

Tissue microarray slides consisting of cell-lines and resection specimens were distributed with the request for routine ALK testing using IHC or FISH. Participation in ALK FISH testing included the interpretation of four digital FISH images.

Results

Data from 173 different laboratories was obtained. Results demonstrate decreased error rates in the second round for both ALK FISH and ALK IHC, although the error rates were still high and the need for external quality assessment in laboratories performing ALK testing is evident. Error rates obtained by FISH were lower than by IHC. The lowest error rates were observed for the interpretation of digital FISH images.

Conclusion

There was a large variety in FISH enumeration practices. Based on the results from this study, recommendations for the methodology, analysis, interpretation and result reporting were issued. External quality assessment is a crucial element to improve the quality of molecular testing.     

Association of the Innate Immunity and Inflammation Pathway with Advanced Prostate Cancer Risk

Prostate cancer is the most frequent and second most lethal cancer in men in the United States. Innate immunity and inflammation may increase the risk of prostate cancer. To determine the role of innate immunity and inflammation in advanced prostate cancer, we investigated the association of 320 single nucleotide polymorphisms, located in 46 genes involved in this pathway, with disease risk using 494 cases with advanced disease and 536 controls from Cleveland, Ohio. Taken together, the whole pathway was associated with advanced prostate cancer risk (P = 0.02). Two sub-pathways (intracellular antiviral molecules and extracellular pattern recognition) and four genes in these sub-pathways (TLR1, TLR6, OAS1, and OAS2) were nominally associated with advanced prostate cancer risk and harbor several SNPs nominally associated with advanced prostate cancer risk. Our results suggest that the innate immunity and inflammation pathway may play a modest role in the etiology of advanced prostate cancer through multiple small effects.     

Primary cytodiagnosis of dually differentiated lung cancer by transthoracic fine needle aspiration

The cytologic features are described in a case of squamous cell carcinoma and small cell cancer of the lung concurrently diagnosed by a single transthoracic fine needle aspiration specimen. The value of diagnostic cytology in the detection of dually differentiated lung malignancies is discussed, and the importance of identifying the small cell component in order to direct appropriate therapy is emphasized.     

An individual level infectious disease model in the presence of uncertainty from multiple,imperfect diagnostic tests

Bayesian compartmental infectious disease models yield important inference on disease transmission by appropriately accounting for the dynamics and uncertainty of infection processes. In addition to estimating transition probabilities and reproductive numbers, these statistical models allow researchers to assess the probability of disease risk and quantify the effectiveness of interventions. These infectious disease models rely on data collected from all individuals classified as positive based on various diagnostic tests. In infectious disease testing, however, such procedures produce both false-positives and false-negatives at varying rates depending on the sensitivity and specificity of the diagnostic tests being used. We propose a novel Bayesian spatio-temporal infectious disease modeling framework that accounts for the additional uncertainty in the diagnostic testing and classification process that provides estimates of the important transmission dynamics of interest to researchers. The method is applied to data on the 2006 mumps epidemic in Iowa, in which over 6,000 suspected mumps cases were tested using a buccal or oral swab specimen, a urine specimen, and/or a blood specimen. Although all procedures are believed to have high specificities, the sensitivities can be low and vary depending on the timing of the test as well as the vaccination status of the individual being tested.     

小细胞肺癌发生阻塞性肺炎相关因素分析

目的通过对小细胞肺癌患者是否发生阻塞性肺炎的相关因素对比分析,了解伴有阻塞性肺炎小细胞肺癌患者临床特点。方法采用回顾性分析方法,收集2003年1月至2013年1月大连医科大学附属第二医院所收治的经组织学或细胞学确诊的小细胞肺癌患者共450例。经核查资料后,进入统计学的伴有阻塞性肺炎组100例,不伴有阻塞性肺炎组112例,均为初治。对以下因素进行分析：性别、年龄、居住环境、吸烟情况、分期、肿瘤位置、病理类型、初始疗效、NSE（神经元特异性烯醇化酶）。计数资料率和构成比的比较采用卡方检验。结果本组研究中伴有阻塞性肺炎组患者100例中,吸烟患者占76%,小细胞未分化癌患者占81%,中心型癌患者占52%,广泛期患者占57%,NSE阳性率为92%,均高于不伴有阻塞性肺炎组患者。不伴有阻塞性肺炎组的小细胞癌患者初始疗效有效率明显高于伴有阻塞性肺炎组患者。两组在性别、年龄、居住环境方面差异无统计学意义。结论伴有阻塞性肺炎组的小细胞肺癌患者NSE阳性率高于不伴有阻塞性肺炎组。吸烟是小细胞肺癌患者发生阻塞性肺炎的高危因素。阻塞性肺炎降低小细胞癌患者化疗初始疗效。     

Comparison of the pick-and-smear and Saccomanno methods for sputum cytologic analysis

The two methods of preparing sputum specimens for cytologic study, the (fresh) pick-and-smear technique and the (blended) Saccomanno technique, were compared using 249 consecutive specimens. Two slides were prepared for each specimen by each technique. Of the specimens, 103 showed squamous metaplasia, carcinoma in situ or carcinoma. A semiquantitative rating system (0 to 4+) was used to determine the number of diagnostic cells for each method for those 103 cases. More diagnostic cells were found on the Saccomanno preparations (217) than on the fresh preparations (154). There were 121 diagnostic cells in the Saccomanno preparations versus 95 diagnostic cells in the fresh preparations from 63 squamous metaplasias; 7 versus 3 for the preparations from 5 carcinomas in situ; 64 versus 42 from 28 squamous cell carcinomas; 3 versus 1 from 1 large cell undiffernomas; and 12 diagnostic cells in Saccomanno preparations versus 5 in fresh preparations from 3 small cell cancers. Twelve squamous metaplasias, two carcinomas in situ, four squamous carcinomas, one adenocarcinoma and one small cell cancer had no diagnostic cells on the fresh preparations; four squamous metaplasias and one squamous carcinoma had no diagnostic cells on the Saccomanno preparations. More diagnostic information and fewer false-negative results were achieved with the Saccomanno technique.     

A simple method for the analysis of clustered binary data.

A simple method for comparing independent groups of clustered binary data with group-specific covariates is proposed. It is based on the concepts of design effect and effective sample size widely used in sample surveys, and assumes no specific models for the intracluster correlations. It can be implemented using any standard computer program for the analysis of independent binary data after a small amount of preprocessing. The method is applied to a variety of problems involving clustered binary data: testing homogeneity of proportions, estimating dose-response models and testing for trend in proportions, and performing the Mantel-Haenszel chi-squared test for independence in a series of 2 x 2 tables and estimating the common odds ratio and its variance. Illustrative applications of the method are also presented.     

Unsuspected Carcinoma Found Histologically After Minor Anorectal Operations

The unsatisfactory results of radical operations in advanced anal cancer could be bettered by earlier diagnosis of the malignant lesion. The possibility of cancer should always be kept in mind when treating any of the common chronic anal diseases. Preliminary biopsy studies should be done more frequently if suspicious lesions are present and all tissues removed during minor anorectal operations should always be examined by a pathologist. Each surgical specimen should be labeled to show the site from which it was removed. Follow-up care of the patient would be simplified if the exact site of cancer origin could be identified.A recent ten-year survey of minor anorectal surgical procedures at the University of California Medical Center showed clinically unsuspected anal cancer found in 2 per cent of cases on tissue examination by the pathologist. The cancers were generally early and of the keratinizing squamous cell and nonkeratinizing varieties.     

Orthotopic mouse model of colorectal cancer

The traditional subcutaneous tumor model is less than ideal for studying colorectal cancer. Orthotopic mouse models of colorectal cancer, which feature cancer cells growing in their natural location, replicate human disease with high fidelity. Two techniques can be used to establish this model. Both techniques are similar and require mouse anesthesia and laparotomy for exposure of the cecum. One technique involves injection of a colorectal cancer cell suspension into the cecal wall. Cancer cells are first grown in culture, harvested when subconfluent and prepared as a single cell suspension. A small volume of cells is injected slowly to avoid leakage. The other technique involves transplantation of a piece of subcutaneous tumor onto the cecum. A mouse with a previously established subcutaneous colorectal tumor is euthanized and the tumor is removed using sterile technique. The tumor piece is divided into small pieces for transplantation to another mouse. Prior to transplantation, the cecal wall is lightly damaged to facilitate tumor cell infiltration. The time to developing primary tumors and liver metastases will vary depending on the technique, cell line, and mouse species used. This orthotopic mouse model is useful for studying the natural progression of colorectal cancer and testing new therapeutic agents against colorectal cancer.     

Heterogeneity of anticancer drug sensitivity in squamous cell carcinoma of the tongue

Heterogeneity is known to be present to varying degrees in cancer cell groups. There have been no reports, however, of studies in which a single cell clone was prepared from a cancer cell group to examine heterogeneity with respect to anticancer drug sensitivity. Thus, the authors herein report an investigation into the heterogeneity of cancer cells within the same tumor with respect to anticancer drug sensitivity. Anticancer drug sensitivity was investigated in primary tumors, metastatic lymph node tumors, recurrent tumors and established cell lines obtained from four cases of tongue cancer using an oxygen electrode apparatus. As differences were observed in anticancer drug sensitivity from one case to another, even though all four were of the same pathological tissue type, the individual differences were apparently significant. Moreover, primary tumors and recurrent tumors demonstrated different sensitivities to the anticancer drugs even in the same patient. When single cell clones were prepared from primary tumors and anticancer drug sensitivity testing was carried out, sensitivity to anticancer drugs that was not seen in the primary tumors was observed. We performed RT-PCR on cell groups derived from this single cell using MDR1, MRP1, MRP2 and ERCC1, which are primary genes that are resistant to anticancer drugs. Expression of MDR and ERCC1 was not observed in single cell clones nos. 1-10. MRP1 and MRP2, on the other hand, were expressed in all of these single cell clones. Because cells with different sensitivity levels were initially present in the cancer cell groups, even when large numbers of cancer cells died in response to anticancer drug therapy, the results suggest the possibility that recurrence and metastasis occur based on cells with differing sensitivities. After examining anticancer drug sensitivity at the single cell level, we believe that anticancer drug-resistant genes may be involved in the heterogeneity of anticancer drug sensitivity with respect to cancer cell groups.     

Simulation model for gynecologic specimen classification in a high-resolution prescreening system

Presentation is made of the design of a statistical model for the generation of "artificial specimens" to be used in the development and testing of a high-resolution prescreening system for gynecologic specimen classification. The model is based on two considerations: (1) the nature of the biologic material to be examined and (2) the system to be studied, which in this case is the FAZYTAN cervical prescreening system. Since gynecologic specimens that belong to the same clinical class (Papanicolaou group) have similar compositions of the different cytologic cell types, the simulation model presented is based on the close relationship between the degree of cancer suspiciousness expressed in the clinical diagnostic group and the composition of the cellular samples on a specimen. Statistically, the model considered here is based on an analysis of the single-cell classification (SCC) output process, taking the inherent system properties into account. The statistical information obtained by evaluating large sets of labelled cells is then used to produce artificially generated point distributions in the SCC decision space ("artificial specimens"), which can be used for examination of system reactions under controlled conditions. False-positive and false-negative error rates and system operation characteristics can be measured, and the effects of varying cell compositions as well as the relative performance of different specimen classifiers can be investigated. Although the "artificial specimens" thus created allow the investigation of system reactions with respect to a great variety of input processes, they cannot replace experiments on thousands of original specimens in order to measure system quality under realistic conditions.     

A mouse prostate cancer model induced by Hedgehog overexpression

Summary Hedgehog is a regulatory protein during embryonic development and its abnormal activation in adult tissues has been implicated in tumorigenesis within sites where epithelial–mesenchymal interactions take place. In the prostate, Hedgehog signaling activation was observed during advanced cancer progression and metastasis, but whether Hedgehog overexpression can initiate prostate tumorigenesis remains unknown. We introduced a Hedgehog-expressing vector by intra-prostate injection and electroporation to address the effects of Hedgehog overexpression. The manipulation caused lesions with characteristic prostatic intraepithelial neoplasia or even prostatic cancer (CaP) phenotypes within 30 days, with Hedgehog overexpression demonstrated by immunohistochemistry and Western blot detections. The tumorigenic phenotypes were confirmed by discontinuity of basal cell marker p63, mix-up of CK-8/CK-18 positive epithelial cells in the stoma as well as absence of α-SMA positive fibro-muscular sheath. Comparable Hedgehog overexpression was found in human CaP specimen. Thus, Hedgehog overexpression induced prostate tumorigenesis starting from the normal status. Furthermore, a mouse prostate cancer model induced by Hedgehog overexpression was established and may be used for testing novel therapeutical approaches targeting at Hedgehog signaling pathway.These authors have contributed equally to this work.     

吉西他滨联合顺铂序贯吉非替尼治疗晚期非小细胞肺癌

目的:观察吉西他滨联合顺铂序贯吉非替尼治疗晚期非小细胞肺癌的疗效与毒副反应。方法:71例经病理学诊断的晚期(Ⅲb-Ⅳ期)非小细胞肺癌患者,随机分成两组,观察组给予吉西他滨加顺铂化疗,序贯吉非替尼。对照组给予吉西他滨加顺铂化疗。结果:两组有效率(RR)为36.1%VS14.3%(P=0.0362);疾病控制率(DCR)比较x2=14.782,P<0.001;中位生存期(MST)为12.1月VS10.8月(P<0.05);有统计学差异;观察组除了皮疹、腹泻毒副反应较大外,其他与对照组相仿。结论:吉西他滨联合顺铂序贯吉非替尼治疗晚期非小细胞肺癌有较好的疗效和安全性,可以扩大样本继续观察。     

Prostate cancer association studies: pitfalls and solutions to cancer misclassification in the PSA era

Widespread screening of American men for elevated PSA has changed the characteristics of prostate cancer cases in the U.S. The influence of the changed nature of prostate cancer cases in the PSA era and the need for careful consideration of who is a "case" and who is a "control" on the ability to detect associations of risk factors with prostate cancer in etiologic epidemiologic studies merits discussion. Issue 1: prostate cancer cases diagnosed in the PSA era are enriched with a pool of early lesions, which may differ in etiology, and are deficient in advanced lesions, which are the most likely to be the product of promotion and progression events. By admixing the two types of cases (i.e., imperfect specificity), the associations previously detected using epidemiologic designs when the majority of cases were clinically detected may no longer be apparent in the PSA era when the majority of cases are now detected in the pre-clinical phase. Researchers must now tailor hypotheses such that they are testable using early stage cases or specifically augment the number of advanced cases when testing hypotheses related to extraprostatic growth and progression. Issue 2: even when controls are screened for elevated PSA to rule out the presence of prostate cancer, some proportion of those controls currently will have one or more foci of prostate cancer. The imperfect sensitivity of the PSA test coupled with diagnostic work-up may in part result from (a) lack of PSA elevation in some men with prostate cancer or (b) failure of biopsy to sample the tumor focus in men with elevated PSA. Misclassification of men with undetected prostate cancer as controls usually produces a bias that tends to deflate associations. Given this type of disease misclassification, whether an association still can be statistically detected depends on the extent of misclassification, the magnitude of the true association, the prevalence of the exposure in the true controls, and the sample size, although in general moderate nondifferential misclassification does not lead to profound attenuation. However, under the same scenario attenuation does not occur in cohort or case-cohort studies in which the rate or risk ratio (RR) is calculated. That prostate cancer cases diagnosed in the PSA era are enriched with early stage, minimally invasive disease in our opinion is likely to pose a far more serious obstacle to epidemiologic research on the etiology of clinically important prostate cancer than the issue of inclusion as controls some men who have undiagnosed prostate cancer because of imperfect sensitivity of PSA screening and biopsy sampling error.     

Predictive Modeling for Diagnostic Tests with High Specificity,but Low Sensitivity: A Study of the Glycerol Test in Patients with Suspected Menière’s Disease

A high specificity does not ensure that the expected benefit of a diagnostic test outweighs its cost. Problems arise, in particular, when the investigation is expensive, the prevalence of a positive test result is relatively small for the candidate patients, and the sensitivity of the test is low so that the information provided by a negative result is virtually negligible. The consequence may be that a potentially useful test does not gain broader acceptance. Here we show how predictive modeling can help to identify patients for whom the ratio of expected benefit and cost reaches an acceptable level so that testing these patients is reasonable even though testing all patients might be considered wasteful. Our application example is based on a retrospective study of the glycerol test, which is used to corroborate a suspected diagnosis of Menière’s disease. Using the pretest hearing thresholds at up to 10 frequencies, predictions were made by K-nearest neighbor classification or logistic regression. Both methods estimate, based on results from previous patients, the posterior probability that performing the considered test in a new patient will have a positive outcome. The quality of the prediction was evaluated using leave-one-out cross-validation, making various assumptions about the costs and benefits of testing. With reference to all 356 cases, the probability of a positive test result was almost 0.4. For subpopulations selected by K-nearest neighbor classification, which was clearly superior to logistic regression, this probability could be increased up to about 0.6. Thus, the odds of a positive test result were more than doubled.     

Frequent detection and immunophenotyping of prostate-derived cell clusters in the peripheral blood of prostate cancer patients

BACKGROUND: Recent scientific studies have failed to determine parameters for the assessment of prostate cancer aggressiveness. The present study deals with the detection of blood-borne cancer cells based on polymerase chain reaction (PCR) and cell enrichment methods. The contradictory results reported in the literature have called into question the clinical usefulness of this diagnostic method in the preoperative staging of clinically localized prostate cancer. METHODS: We established a combined method of density gradient centrifugation and immunomagnetic separation using epithelium-specific antibodies, i.e. cytokeratins, to isolate prostate-derived circulating cells from the peripheral blood of patients with prostate cancer. Isolated cells were characterized by DNA staining and immunocytochemistry using antibodies for the detection of prostate-specific antigen (PSA), proliferation-associated proteins (MIB-1, H1 and H3) and apoptosis-associated proteins (M30, c-FasR). RESULTS: We applied these methods to 68 prostate cancer patients and were able to isolate cell clusters in 98%. Immunophenotypic and morphological characterization of PSA-positive prostate-derived cell clusters found in the peripheral blood of prostate cancer patients showed two main populations: 1) in 35% of the investigated prostate cancer patients we detected rounded cell aggregates of probable cancer cells expressing proliferation-associated proteins and lacking apoptosis-associated protein expression; 2) in all cases there was a high frequency of circulating dysmorphic cell clusters positive for apoptosis-associated protein expression. CONCLUSION: Our results demonstrate the existence of at least two different types of blood-borne prostate-derived circulating cell clusters. Of these, only the less frequent, round, small cell clusters harbor features that are probably necessary for the cells to survive for metastatic spread.