Essam Ayad

Telepathology in emerging countries pilot project between Italy and Egypt

Pathological examination includes gross & microscopic examinations at different magnification. Through the steps of examination, we obtain many images that can be used for telepathology. Telepathology is the practice of pathology at a distance, viewing images on a monitor rather than directly through a light microscope. It can be used for primary diagnosis, second opinion, quality assurance and distance learning. Telepathology is classified into Static, Dynamic, Hybrid and Whole Slide Imaging (WSI). We have a successful experience in Egypt in applying the static & dynamic techniques in a pilot project between the Italian Hospital in Cairo (NPO) and the Civico Hospital in Palermo. This project began in 2003 and continued till now. From the second year 2004, Ospedale S. Giovanni e Paolo Hospital in Venice, Charing Cross Hospital in London and the University of Pittsburgh Medical Center Health System (UPMC) in the USA participated actively in our project. During the past five years we consulted on many problematic pathological cases with these different specialized pathological centers in Italy, UK & USA. In addition to the highly specialized scientific value of consulting on the cases and exchanging knowledge, we saved a lot of time and money and succeeded in providing our patients with a better medical service.We are now in the process of establishing a Digital Telepathology Center (DTC) in the pathology department, Cairo University, using the latest technique of telepathology which is Whole Slide Imaging (WSI). We believe that it will help us to improve and extend diagnosis for our difficult pathological cases and will facilitate increased E-learning opportunities for staff and students both in Egypt and in the longer term in the wider Eastern Mediterranean.

Electron microscopy study of peripheral nerves in the uvulae of snorers and obstructive sleep apnoea patients

HYPOTHESIS The pathophysiology of snoring and obstructive sleep apnoea is still unclear. Two theories are proposed. The first is the obstructive theory, which postulates palatopharyngeal muscle hypertrophy leading to airway narrowing; there is no neural role. The second is the neurogenic theory, which postulates neural degeneration due to vibratory stretch trauma, leading to muscle atrophy and collapse. As identification of nerve fibres in the uvula and palate is difficult and time-consuming, all previous studies aiming to differentiate between these two theories have been based on indirect observation of the muscles, rather than direct study of the nerves. METHODS We conducted a prospective study to directly observe and study nerve fibres in uvular specimens from 10 cases of obstructive sleep apnoea, compared with specimens from 10 cases of simple snoring, using transmission electron microscopy. Five autopsy cases served as controls. RESULTS Obstructive sleep apnoea was associated with definite degenerative changes in myelinated and unmyelinated nerve endings. These degenerative changes were present to a lesser degree and in a smaller proportion of cases of simple snoring. CONCLUSION The events postulated by the neurogenic theory of obstructive sleep apnoea appear to play an important role in the pathophysiology of snoring and obstructive sleep apnoea.

Ultrastructural ciliary changes of maxillary sinus mucosa following functional endoscopic sinus surgery: an image analysis quantitative study.

This was a study of the effect of functional endoscopic sinus surgery (FESS) on the ciliary regeneration of maxillary sinus mucosa in patients with chronic maxillary sinusitis, using objective quantitative methods. Twenty specimens from the mucosa of both the superolateral wall and the ostium of the maxillary sinus were sampled during FESS and then six to 12 months later. They were light examined first by light microscopy and then by scanning electron microscopy in combination with image analysis software in order to study the cilia under higher magnification and to calculate proportion of the field that was ciliated. Samples were taken and studied at Cairo University hospital. This study showed that the maxillary sinus mucosa in chronic sinusitis is capable of regeneration and could return towards normal with the improvement of ventilation and drainage of the maxillary sinus following FESS. There were no significant changes in the degree of glandular hyperplasia, goblet cells or pathological glands after surgery.

Virtual telepathology in Egypt, applications of WSI in Cairo University

Telepathology, the practice of pathology at a long distance, has advanced continuously since 1986. Today, fourth-generation telepathology systems, so-called virtual slide telepathology systems, are being used for education applications. Both conventional and innovative surgical pathology diagnostic services are being designed and implemented as well. We have a successful experience in Egypt in applying the static & dynamic techniques in a pilot project between the Italian Hospital in Cairo (NPO) and the Civico Hospital in Palermo This project began in 2003 and continued till now. In 2004, centers in Venice, London and Pittsburgh participated actively in our project. During the past seven years we consulted on many problematic pathological cases with these different specialized pathological centers in Italy, UK & USA. In addition to the highly specialized scientific value of consulting on the cases and exchanging knowledge, we saved a lot of time and money and succeeded in providing our patients with a better medical service. In view of this success we have already established a new Digital Telepathology unit (DTU) in the pathology department, Cairo University, using the latest technique of telepathology which is Whole Slide Imaging (WSI) since one year. This unit is considered the first Digital pathology unit in all the universities of the whole Middle East. During the passed year we created a digital pathology library for the under graduate students using the WSI technique and changed the teaching method of the histopathology slides to be completely digital. We are building another digital pathology library (for post graduate candidates) which will be available to all pathology candidates in Egyptian universities & universities in the surrounding Arabic countries. We are also creating a digital pathology network between pathology centers in the Middle East for exchanging knowledge & telepathology.

Prevalence of extramucosal fungal elements in sinonasal polyposis: a mycological and pathologic study in an Egyptian population

OBJECTIVE AND HYPOTHESIS The objective of the study was to define the true incidence of fungal elements in the nasal and sinus mucous in cases of chronic rhinosinusitis (CRS) with bilateral polyposis compared with normal controls-in an Egyptian African population-via mycological and histologic techniques. STUDY DESIGN This study was conducted prospectively on 100 patients with the clinical diagnosis of CRS with bilateral nasal polyposis. Fifty volunteers with no history of nasal or paranasal sinus disease served as a control group. RESULTS AND CONCLUSION The postulated criteria for the diagnosis of allergic fungal sinusitis were present in 92% of CRS with polyposis, suggesting that fungi are involved in the disease process of most CRS patients.

Quantitative analysis of uvular muscles in cases of simple snoring and obstructive sleep apnea: an image analysis study

Studies on the histopathological changes of the palatine muscles in cases of obstructive sleep apnea (OSA) and simple snoring are controversial, while some authors confirm the presence of muscle hypertrophy and increase in total muscle bulk (obstructive theory), others deny this confirming the presence of muscle atrophy and decrease in the muscle bulk (neurogenic theory), but all these studies depended on subjective observer dependent methods to calculate the muscle bulk. We are carrying a unique study to calculate the muscle bulk in uvular specimens in ten cases of OSA comparing it to ten cases with simple snoring and controls using digital computer dependent software (image analysis). Cases of OSA are associated with definite increase in the total muscle bulk of the palatine muscles when compared to cases of simple snoring and controls. Uvular muscular hypertrophy and the obstructive theory seem to explain the pathophysiology of OSA.

Lymphatic obstruction: a novel etiologic factor in the formation of antrochoanal polyps.

Objectives: Antrochoanal polyps (ACPs) originate from the inner wall of the maxillary sinus and either pass through the natural sinus ostia or cause pressure-induced destruction of the medial sinus wall. Eventually, they extend into the choanae and nasopharynx. Most authors who have studied the microstructure of ACPs, including the component stromal cells and surface epithelium, have not examined the transitional area between the sinus mucosa and the pedicle of the polyp. No explanation has been given for the absence of a cystic intrasinus portion of the polyp, in many cases refuting the therapy (most accepted) that polyps are caused by a mucous gland with a blocked acinus. We noted during endoscopic removal of the ACPs that the antral part of the polyp was cystic in only 5% of patients, and polypoid in 95%. The cystic intrasinus portion of the polyp is a cornerstone of the pathophysiology of ACPs, whether caused by inflammation, cicatrization, or allergy. This finding prompted us to examine the transitional area between the sinus mucosa and the pedicle of the polyp to verify the possibility that lymphatic obstruction—whether primary (areas of higher tissue pressure) or secondary (cicatrization or inflammation)—could be an etiologic factor in the formation of ACPs. Methods: The study material consisted of 25 ACPs and 25 chronic maxillary sinusitis mucosal biopsy specimens (control group). The detection of lymphatic vessels was based on the identification of lymph vessel endothelial hyaluronic acid receptor 1 (LYVE-1) in the endothelial cells of the lymphatic capillaries. This was the first lymph-specific hyaluronic acid receptor to be characterized, and is a uniquely powerful marker for lymph vessels, differentiating them from (blood) capillaries. Results: The density of the lymphatic vessels was marked in 22 of the 25 ACP specimens, ie, 88% of the ACP cases, compared with 16% of the control group. Conclusions: This study resulted in two main findings. The first was the absence of intramaxillary cysts in the ACPs in 23 cases (92%). The second was the markedly high density of lymphatic vessels in the transitional area between the sinus mucosa and the pedicle of the ACPs, in comparison with the density in the control group. These two findings refute the “blocked acinus theory” and indicate that lymphatic obstruction, whether primary or secondary to chronic sinus infection, might play a leading role in the formation and further growth of ACPs.

Triple negative, basal cell type and EGFR positive invasive breast carcinoma in Kuwaiti and British patients.

To the Editor: Geographic and ethnic variation in the incidence of various types of breast carcinoma are known to exist. We were therefore interested in finding out whether or not there are differences in the incidence of triple negative breast carcinoma and epidermal growth factor receptor (EGFR) positive tumors between patients from a Middle Eastern Country as compared with a Western Country, as this might have implications concerning health planning strategies. Eighty eight patients with invasive breast carcinoma were studied. These included 38 consecutive patients from The University of Kuwait Hospital, including one with bilateral tumors, and 50 consecutive patients from Charing Cross Hospital, London (CX). For each tumor new 5 l-thick paraffin sections were cut and stained for estrogen receptor (ER) (Novocastra, concentration 1:200), progesterone receptors (PgR) (Launch Diagnostics, 1:200), HER2 (Dako, 1:200), cytokeratin 5 ⁄ 6 (Dako, 1:200), and EGFR (Novocastra, 1:200), using standard avidin–biotin immunoperoxidase technique. Because of insufficient tumor tissue in the paraffin blocks of some cases, a few cases were stained for a limited number of these antibodies. For ER and PgR, the histochemical scoring assessment system was used (1), where the percentage of stained tumor cells was multiplied by a factor reflecting the intensity of staining (1 for weak, 2 for moderate, and 3 for strong staining). The results could thus range from 0 (no positively stained tumor cells) to 300 (strong staining of 100% of tumor cells). A minimum score of 30 is needed to consider the case positive. For HER2 and EGFR, a case is considered positive if more than 10% of tumor cells showed strong membrane staining. For cytokeratin 5 ⁄ 6, strong cytoplasmic staining of 10% of tumor cells at least was required to consider the case positive. For statistical comparison, Fisher’s exact test was used. The age of the Kuwaiti patients ranged between 30–70 years with a mean of 50.4. For CX patients the range was 31–79 and the mean 57.7 years. In particular, 16 (42%) out of the 38 Kuwaiti patients were under the age of 50, compared with 11 ⁄ 50 (22%) CX patients. The Fisher’s p-value is 0.06 which is weakly significant. The incidence of the two main histological types, i.e., invasive ductal (77% for Kuwaitis and 78% for CX) and lobular carcinoma (10% and 12% respectively), was similar in both populations. Each of the two studied cohorts included a single case of mucinous carcinoma and another of metaplastic carcinoma. However, medullary carcinoma was present in three (8%) Kuwaiti patients, (two typical and one atypical with partly infiltrative borders), and in none CX patients; while no tubular carcinomas were seen in Kuwaiti patients compared with three (6%) CX cases. The Kuwaiti patients had a higher incidence of grade III tumors (16 ⁄ 39, 56%), compared with CX patients (12 ⁄ 50, 24%); with a p-value of 0.11. Grade I tumors were less common in Kuwaiti patients (4 ⁄ 39, 10%) than in CX patients (10 ⁄ 50, 20%), but the incidence of grade II tumors was not markedly different (19 ⁄ 39; 49% versus 28 ⁄ 50; 56%, respectively). Axillary lymph node metastasis were present in 22 (59%) out of the 37 Kuwaiti patients who underwent axillary dissection, compared with 20 (40%) out of the 50 CX patients who all had axillary dissection. The Fisher’s p-value is 0.14, which is weakly positive. The incidence of ER and PgR positive tumors was similar in the Kuwaiti and CX populations (79% versus 78% for ER and 45% versus 48% for PgR; respectively), and there was no statistical difference between the incidence of cytokeratin 5 ⁄ 6 (16% versus 15%; Fig. 1) and EGFR (15% versus 12%; Fig. 2) positive tumors. HER2 positivity was higher in Kuwaiti than in CX patients (8 ⁄ 39, 21% versus 4 ⁄ 50, 8% respectively, Fisher’s p-value 0.12). Address correspondence and reprint requests to: Sami Shousha, MD, Department of Histopathology, Charing Cross Hospital, Fulham Palace Road, London W68RF, or e-mail: s.shousha@imperial.ac.uk

A comparative study between ciliary count and the degree of opacity of paranasal sinus CT scans in chronic sinusitis pre and post FESS.

OBJECTIVE To investigate the relationship between the extent of sinus disease in chronic sinusitis as detected radiologically by computed tomography (CT) scan and the population of cilia (ciliary area) both before and after functional endoscopic sinus surgery (FESS). In a simple way this is a trial to statistically prove that the CT scan could be a valid indicator and a mirror of the histological status of the sinus mucosa. DESIGN Twenty adult patients were enrolled in this study. Radiological extension of the sinus disease was quantitated using the classification proposed by Kennedy in 1992 and the ciliary population was studied using scanning electron microscopy and image analysis softwares. RESULTS AND CONCLUSION The more advanced the sinusitis, as evidenced by CT scans, the more the expected reduction in the ciliary area (CA) and in the ciliary count. But after FESS the degree of ciliary regeneration does not depend statistically on the radiological condition of the sinuses and the degree of opacity prior to intervention, i.e. a statistically valid inverse relationship exists between the radiological stage of sinusitis and the ciliary population pre-operatively but the same relation does not extend to the ciliary population post-operatively.

Comparative study between quantitative digital image analysis and fluorescence in situ hybridization of breast cancer equivocal human epidermal growth factor receptors 2 score 2 + cases

Background: Optimization of workflow for breast cancer samples with equivocal human epidermal growth factor receptors 2 (HER2)/neu score 2 + results in routine practice, remains to be a central focus of the on-going efforts to assess HER2 status. According to the College of American Pathologists/American Society of Clinical Oncology guidelines equivocal HER2/neu score 2 + cases are subject for further testing, usually by fluorescence in situ hybridization (FISH) investigations. It still remains on open question, whether quantitative digital image analysis of HER2 immunohistochemistry (IHC) stained slides can assist in further refining the HER2 score 2 + . Aim of this Work: To assess utility of quantitative digital analysis of IHC stained slides and compare its performance to FISH in cases of breast cancer with equivocal HER2 score 2 + . Materials and Methods: Fifteen specimens (previously diagnosed as breast cancer and was evaluated as HER 2– score 2 +) represented the study population. Contemporary new cuts were prepared for re-evaluation of HER2 immunohistochemical studies and FISH examination. All the cases were digitally scanned by iScan (Produced by BioImagene [Now Roche-Ventana]). The IHC signals of HER2 were measured using an automated image analyzing system (MECES, www.Diagnomx.eu/meces). Finally, a comparative study was done between the results of the FISH and the quantitative analysis of the virtual slides. Results: Three out of the 15 cases with equivocal HER2 score 2 + , turned out to be positive (3 +) by quantitative digital analysis, and 12 were found to be negative in FISH too. Two of these three positive cases proved to be positive with FISH, and only one was negative. Conclusions: Quantitative digital analysis is highly sensitive and relatively specific when compared to FISH in detecting HER2/neu overexpression. Therefore, it represents a potential reliable substitute for FISH in breast cancer cases, which desire further refinement of equivocal IHC results.