Donatella Pacchioni

Evaluation of P53 Protein Overexpression, Ki67 Proliferative Activity and Mitotic Index as Markers of Tumour Recurrence in Superficial Transitional Cell Carcinoma of the Bladder

Objectives: To confirm the interrelationship between p53, ki67, mitotic index with others known prognostic factors such us stage, grade, multifocality, tumour size, history of recurrence in transitional cell carcinoma (TCC) of the bladder and to determine the prognostic impact of p53, Ki67 and mitotic index in predicting recurrence in superficial bladder cancer.Methods: Two hundred and fourteen patients with apparently superficial TCC of the bladder underwent TURBT and the 192 histologically Ta–T1 were divided into 104 primary lesions (group 1, mean follow–up 26 months) and 88 recurrent tumours (group 2, mean follow–up 28 months). Data concerning focality, tumour size, number of recurrences and recurrence–free survival were considered in each patients. All samples were immunohistochemically stained with p53 and Ki67 monoclonal antibodies. Mitotic index (MI) was calculated on haematoxylin and eosin stained sections.Results: Recurrence–free survival was significantly lower in superficial recurrent tumours (group 2) compared with primary tumours (group 1). P53 staining was correlated with grade and stage for both 5 and 20% positivity thresholds. Ki67 and MI were significantly different over strata defined by stage, grade and focality in both patients groups but only Ki67 showed a correlation with p53 status. Recurrence–free survival could not be predicted either by p53 status or MI. A 20% cut–off level of Ki67 staining resulted a good predictor of recurrence in group 1 Ta–T1/G1–G2 tumours (p = 0.03). Only Ki67 and multifocality were found to be independent prognostic factors of recurrence in multivariate analysis. Stratifying Ta–T1/G1–G2 patients according to these variables, Ki67 provided a useful tool to predict early recurrence in monofocal lesions from both groups.Conclusions: P53 and MI despite a fairly good correlation with traditional prognostic factors in bladder TCC seem to play no role in the prediction of tumoural recurrence. A Ki67 index over 20% predicts those single well–differentiated (Ta–T1/G1–G2) tumours which are likely to recur within one year of treatment

Diagnostic accuracy and clinical impact of imaging-guided needle biopsy of renal masses. Retrospective analysis on 150 cases.

ObjectiveTo review our method of perform needle biopsies of renal masses.MethodsWe analysed 150 consecutive imaging-guided percutaneous biopsies. The pathological diagnosis was verified on clinical outcome in 129 cases (40 surgical resection, 53 thermal ablation, two medical treatment and 34 watchful waiting). Twenty-six patients underwent fine-needle aspiration biopsy (FNAB), 45 core-needle biopsy (CB) and 58 FNAB + CB. After review by two expert pathologists, cumulative accuracy of all FNAB (84) and all CB (103) was calculated. The rate of complications and mass management other than surgery was estimated.ResultsThe final diagnosis was malignancy in 97 cases (benign mass in 32). FNAB correctly diagnosed 64/84 masses (76.2%), CB 96/103 (93.2%). Of 58 masses submitted for both FNAB and CB, CB provided a 22.5% accuracy improvement. Major and minor complications occurred in 0% and 5.3%. Renal biopsy altered clinical management in 89/129 cases (68.9%), in terms of choosing therapeutic options other than surgery.ConclusionCB is more accurate than FNAB and should be preferred in renal mass biopsy. FNAB may precede CB when an expert pathologist can immediately evaluate the samples. Renal biopsy influences renal mass management.

Utility of Flow Cytometry Immunophenotyping in Fine-needle Aspirate Cytologic Diagnosis of Non-Hodgkin Lymphoma A Series of 252 Cases and Review of the Literature

Flow cytometry (FC) immunophenotyping of fine-needle aspiration (FNA) has been reported to be useful in the diagnosis of non-Hodgkin lymphomas (NHL). The authors reviewed their 5-year experience to assess the ability that FC has in improving the diagnostic capacity of cytomorphology in the diagnosis and subclassification of NHL according to the World Health Organizations classification. FC was performed on 252 FNA specimens. These included 123 cases of NHL (89 primary and 34 recurrent lymphomas). The FC immunophenotyping included CD3, CD4, CD8, CD10, CD19, CD20, CD45, and κ/λ antibodies combinations in the screening panel and additional panels for B or T lineage in the presence of positivity for lymphoma after the screening. An immunologic diagnosis was obtained by FC in 90% (111/123) of cases identified as NHL. FC was able to improve the total number of NHL detected in 8 cases where cytomorphology had failed to do so. In 7% (9/123) of cases, FC failed to formulate a diagnostic hypothesis owing to the sample inadequacy; 2 cases (2%) were not identified as lymphomas by FC (1 of them considered only “suggestive” also by cytomorphology); 1 case was not identified neither by FC, nor by cytomorphology. In cases having a histologic follow-up, levels of diagnostic sensitivity and specificity of the combination cytomorphology/FC were 97% and 94%, respectively. FC applied to FNA enhanced the diagnostic potential of cytologic diagnosis and subclassification of NHL, thus avoiding the need for invasive surgical biopsies in many cases.

Preliminary experience with a new cytology brush in EUS-guided FNA

BACKGROUND Despite the high diagnostic yield of EUS-guided FNA, room for technical improvements remains. Recently, the EchoBrush (Cook Endoscopy, Winston-Salem, NC), a disposable cytologic brush, was introduced to the market. To date, only 1 study, limited to 10 pancreatic cyst cases, using this device has been published. OBJECTIVE To assess the diagnostic yield of the EchoBrush in a cohort of consecutive patients, irrespective of the target lesion. DESIGN Case series. SETTING Tertiary care university hospital (Molinette Hospital, Turin, Italy). PATIENTS Thirty-nine consecutive patients (12 with solid pancreatic masses, 12 with pancreatic cysts, 7 with enlarged lymph nodes, and 8 with submucosal masses) were enrolled. INTERVENTIONS The material collected with the EchoBrush and with a standard FNA needle was double-blind evaluated by 2 cytopathologists. MAIN OUTCOME MEASUREMENTS Adequacy of the sample and sensitivity and specificity of the EchoBrush method. RESULTS Adequate material for cytologic analysis was collected in 17 of 39 patients (43.6%) with a single pass of the EchoBrush. Results were better for pancreatic lesions (for solid and cystic lesions, the adequacy was 58.3% and 50%, respectively); adequacy was low (28.6% and 25%, respectively) for lymph nodes and submucosal masses. The overall sensitivity and specificity were 57.9% and 31.2%, respectively. There were no adverse events with the procedure. LIMITATION Preliminary study. CONCLUSIONS This report suggests that the EchoBrush may provide adequate cellularity to diagnose solid and cystic pancreatic lesions. More extensive studies are needed to compare the EchoBrush and standard needles.

Cytological detection of papillary thyroid carcinomas by nuclear membrane decoration with emerin staining

Decoration of the nuclear membrane by emerin staining enhances detection of nuclear irregularities typical of papillary thyroid carcinoma (PTC). Our study aims to verify whether staining with emerin is a helpful diagnostic marker in fine-needle aspiration (FNA) cytology. We first designed a prospective study on smears, Thin Prep, and cell block specimens to prove the feasibility of the procedure; subsequently, we designed a retrospective study of 78 FNA cell blocks from cases that, after surgery, turned out to be either benign (34 cases) or malignant lesions (44, of which 31 PTC). From each sample, we obtained two slides, one stained with hematoxylin and eosin (H&E) and the other with emerin. In cases classified as Thy3, HBME-1 and galectin 3 (Gal3) stains had also been performed. Two blinded observers made the judgment concerning Thy categories (as proposed by the British Thyroid Association), first on H&E, then on emerin, HBME-1, and Gal3 stained slides. On cytological preparation, emerin staining represents an effective tool for the detection of nuclear irregularities, allowing for the identification of cases of PTC. In Thy3 cases, emerin stainings sensitivity and specificity (64% and 96%) proved higher than HBME-1s (60% and 88%) and Gal3s (61% and 68%). In conclusion, the immunohistochemical definition of the nuclear membrane, as determined by emerin stain, is a useful tool in the cytological diagnosis of thyroid lesions and can help to solve inconclusive cases by highlighting nuclear irregularities typical of PTC.

Pancreatic oncocytic endocrine tumors. Cytologic features of two cases.

BACKGROUND Oncocytoma designates a usually benign tumor consisting of oncocytes (cells rich in mitochondria). Rarely do endocrine pancreatic tumors show oncocytic transformation, and consequently their liver metastases may resemble a hepatocellular carcinoma. CASES Case 1, a 36-year-old male, presented with an 8-cm pancreatic mass with multiple liver metastases. Fine needle aspiration (FNA) biopsy was performed on the liver. The cytologic features were highly cellular material; numerous isolated cells and irregular, loose cellular aggregates; rare mitoses; round or polygonal cell shape; rosette formation; and large, granular, eosinophilic cytoplasm (suggestive of poorly differentiated hepatocellular carcinoma). Case 2, a 57-year-old female with hypoglycemia, had a 13-cm pancreatic mass. FNA material showed the same cytologic features as case 1. In situ hybridization to detect albumin mRNA was negative in both cases, while immunocytologic reactions for glandular epithelial cytokeratin and chromogranin A were positive. Case 2 was also positive for insulin. CONCLUSION Oncocytic transformation in endocrine tumors of the pancreas is a rare occurrence and must be kept in mind in the diagnostic workup of FNA material from tumors of the hepatopancreatic region.

Prognostic Factors of ‘High-Grade' Ta Bladder Cancers according to the WHO 2004 Classification: Are These Equivalent to ‘High-Risk' Non-Muscle-Invasive Bladder Cancer?

Objective: To determine the impact of prognostic factors of a series of high-grade Ta non-muscle-invasive bladder cancers (NMIBCs) according to the new International Society of Urological Pathology (ISUP) 1998/WHO 2004 grading system (previously classified as either TaG2 or TaG3). Methods: One hundred and thirty-one high-grade Ta (105 G2 and 26 G3) cases were identified after independent review by two pathologists. Univariable and multivariable Cox regression models addressed recurrence and progression-free survival. Progression was defined as appearance of any T ≥1 recurrence after complete TUR (type 1) or occurrence of T ≥2 (type 2). Results: Ten-year recurrence, type-1 and type-2 progression-free survival were 60, 75 and 95%, respectively. The previous grading system (G3 vs. G2) significantly predicted type 1 progression in the univariate model only. In the multivariate model, Ki67 was the only independent predictor of progression according to both definitions (HR = 5.25, p = 0.002 and HR = 6.16, p = 0.03, respectively). Conclusions: High-grade Ta NMIBC as defined by the WHO 2004 grading system cannot be equated with high-risk NMIBC. The risk of progression to muscle-invasive disease (type 2) is low, more in keeping with an intermediate-risk category of NMIBC. The previous WHO 1973 subcategorization into G2 and G3 is of little help in the prediction of outcome. Ki67 is a strong independent predictor of progression worthy of consideration for a clinical setting.

Prognostic Factors Including Ki-67 and p53 in Bacillus Calmette-Guérin-Treated Non-Muscle-Invasive Bladder Cancer: A Prospective Study

Objectives: To prospectively evaluate the prognostic utility of the traditional prognostic factors and molecular markers p53 and Ki-67 in a homogeneous series of patients with non-muscle-invasive bladder cancer (NMIBC) treated with Bacillus Calmette-Guérin (BCG). Patients and Methods: 192 intermediate- and high-risk NMIBC cases were enrolled. The variables in study were age, stage, grade, focality, tumour size, presence of associated carcinoma in situ, recurrence rate before BCG, maintenance for BCG, Ki-67 and p53. The endpoints considered were recurrence-free survival, progression-free survival, cancer-specific survival (CSS) and overall survival (OS). Results: T stage resulted in being associated with CSS, whereas age with OS. BCG maintenance was a significantly favourable independent predictor of OS, CSS, recurrence and progression. In univariate analysis, the labelling index of Ki-67 was significantly associated with OS, CSS and progression. Multivariate analysis, however, confirmed this association only for OS. On the contrary, the labelling index of p53 was a significant predictor of recurrence, both in uni- and multivariate analyses, but with a HR inferior to 1. Conclusions: Ki-67 was an independent predictor of survival. p53 overexpression showed a significant yet inverse correlation with recurrence, thus showing little clinical utility. Age, stage and maintenance were confirmed as independent predictors of BCG response.

Epstein-Barr Virus Detection by In Situ Hybridization in Fine-Needle Aspiration Biopsies

Metastasis to neck lymph nodes is often the presenting symptom of occult head and neck tumors, including undifferentiated nasopharyngeal carcinoma (UNPC). The diagnosis of the primary site of the tumor by conventional cytological analysis of tissue obtained by fine-needle aspiration (FNA) may be difficult. As Epstein-Barr virus (EBV) infection is consistently associated with UNPC, we evaluated the diagnostic significance of EBV detection using a nonradioisotopic in situ hybridization assay. The data obtained by FN A from metastatic head and neck tumors was correlated with the histology of the corresponding surgical specimens. In a series of 25 FN A specimens of cervical lymph node metastases of tumors of unknown origin, EBV was found expressed in all seven metastases of UNPC but in none of 18 metastases of tumors of different types. Therefore, detection of EBV in cervical metastatic adenopathy may be successfully used to identify the presence of occult UNPC

Diagnosis of Biliary Tract Lesions by Histological Sectioning of Brush Bristles as Alternative to Cytological Smearing

AIM:To increase the diagnostic potential of endoscopic biliary tract brushing, we devised an approach alternative to cytological smearing, leading to the preoperative histological examination of the collected material.METHODS:One hundred twelve consecutive biliary brush specimens were included. All patients presented a stricture of the biliary tract, leading to a diagnostic procedure by brushing. Immediately following brushing, the endoscopist immersed the brush into methanol and sent it to the pathology laboratory. The brush was introduced into a cassette for paraffin embedding and sections parallel to the long axis of brush were cut until the metal wire was almost reached, then the block was rotated and new sections were obtained from the opposite side. Samples of the mucosa, inflammatory cell aggregates, small fragments of carcinomas, or isolated cells were observed, and displayed an optimal fixation, allowing a definite diagnosis that proved mandatory for therapy in the vast majority of cases (99.1%).RESULTS:The results obtained in 112 consecutive cases using such technique compared with final histological diagnosis proved: 91% sensitivity, 100% specificity, 100% positive predictive value (PPV), and 87% negative predictive value (NPV) (P < 0.001). In nonoperated patients, the clinical diagnosis after at least 6 months of follow-up showed: 95.5% sensitivity, 100% specificity, 100% PPV, and 88.2% NPV (P < 0.001).CONCLUSION:Such novel approach to the preoperative diagnosis of biliary tract lesions proved to be highly sensitive and specific, limiting the inadequate preoperative diagnoses to less than 1%.