Marluce Bibbo

Association of Diethylstilbestrol Exposure in Utero With Cryptorchidism, Testicular Hypoplasia and Semen Abnormalities

Epididymal cysts and/or hypoplastic testes have been found in 31.5 per cent of 308 men exposed to diethylstilbestrol in utero, compared to 7.8 per cent of 307 placebo-exposed controls. Analyses of the spermatozoa have revealed severe pathological changes (Eliasson score greater than 10) in 134 diethylstilbestrol-exposed men (18 per cent) and 87 placebo-exposed men (8 per cent). Further investigation of the 26 diethylstilbestrol-exposed men with testicular hypoplasia has revealed that 65 per cent had a history of cryptorchidism. Only 1 of the 6 placebo-exposed controls with testicular hypoplasia had a history of testicular maldescent. Although none of our Diekmanns lying-in study group has had carcinoma to date one must keep in mind the reported increased risk of testicular carcinoma in testes that are or were cryptorchid. A 25-year-old man who was not part of the study group was treated recently by us for a testicular carcinoma ( mixed anaplastic seminoma plus embryonal cell carcinoma) and he had a history of diethylstilbestrol exposure in utero and cryptorchidism.

Diagnostic Accuracy of Ureteroscopic Biopsy in Upper Tract Transitional Cell Carcinoma

PURPOSE Our aim was to determine the accuracy of ureteroscopic biopsies and cytological techniques compared to open surgical specimens of upper tract transitional cell carcinoma. MATERIALS AND METHODS From 1985 to 1995, 51 cases of upper tract transitional cell carcinoma were diagnosed ureteroscopically and distal ureterectomy or nephroureterectomy was performed. Each patient underwent direct ureteroscopic inspection and biopsy. Fresh samples were delivered to the cytopathology laboratory, where they were examined using cytospin and smear. A cell block was prepared when visible tissue was present. Grades of ureteroscopic biopsies were compared to grades and stages of surgical specimens in 42 cases. RESULTS Cytological evaluation was positive for malignancy in 48 of the 51 cases (94.1%). Grading of ureteroscopic specimens was possible in 42 cases (82.4%). Transitional cell carcinoma grade on ureteroscopy accurately predicted tumor grade and stage in the surgical specimens. Of 30 low or moderate grade ureteroscopic specimens 27 (90%) proved to be low or moderate grade transitional cell carcinoma in the surgical specimens, while 11 of the 12 high grade ureteroscopic specimens (91.6%) proved to be high grade transitional cell carcinoma (p < 0.0001). Of 30 low or moderate grade ureteroscopic specimens 26 (86.6%) had a low stage (Ta or T1) tumor. In contrast, 8 of 12 high grade ureteroscopic specimens (66.7%) had invasive tumor (stage T2 or T3) in the surgical specimen (p = 0.0006). CONCLUSIONS Ureteroscopic inspection and biopsy combined with cytological techniques provide accurate information regarding grade and stage of upper tract transitional cell carcinoma.

Ureteroscopic Treatment and Surveillance of Upper Urinary Tract Transitional Cell Carcinoma

PURPOSE We determined the efficacy of ureteroscopic treatment of upper urinary tract transitional cell carcinoma. MATERIALS AND METHODS Of 92 patients diagnosed with upper urinary tract transitional cell carcinoma at our institution from 1985 to 1995, 38 (41 kidneys) underwent ureteroscopic treatment and followup. Semirigid and flexible ureteroscopes were used to examine the collecting system. Tumors were biopsied, and treated with fulguration, the neodymium:YAG laser and/or the holmium:YAG laser. Patients were treated every 6 to 12 weeks until tumor-free and then followed on a strict endoscopic protocol. RESULTS Mean and median followup was 35.1 and 26 months, respectively (range 3 to 116). Grading of ureteroscopic biopsies was possible in 40 of 41 cases. Initial grading of tumors was low (grade 1 or 1 to 2) in 21 kidneys, grade 2 in 14 and grade 3 in 5. Of 41 kidneys 28 (68%) were documented as tumor-free ureteroscopically at some time following treatment, including 8 (29%) with subsequent recurrences that were treated endoscopically and 24 (86%) with no evidence of disease at the most recent followup. No patient to date has had progression of disease during endoscopic followup. High tumor grade, size and multifocality were significantly associated with tumor persistence and recurrence. Location in the kidney versus ureter was not a significant prognostic factor. Of the recurrent tumors 75% were not identified radiographically but were only discovered endoscopically. Two of 8 kidneys removed after endoscopic treatment had no tumor stage (pT0). CONCLUSIONS Endoscopic treatment of upper urinary tract transitional cell carcinoma is a reasonable method to treat carefully select patients based on strict indications. Complete endoscopic followup at regular intervals is essential to rule out recurrences.

Pathological Seman and Anatomical Abnormalities of the Genital Tract in Human Male Subjects Exposed to Diethylstilbestrol in Utero

The in utero effects of diethylstilbestrol on the human male genital tract are reported in our followup study of male offspring of mothers treated with diethylstilbestrol. Anatomical and functional abnormalities were significantly greater in male patients exposed to diethylstilbestrol compared to male controls whose mothers were all participants in a prospective, randomized double-blind study on the effects of diethylstilbestrol on pregnancy at our hospital during the early 1950s. Epididymal cysts, hypotrophic testes and capsular induration of the testes were among the more common genital lesions found in more than 25 per cent of 159 male patients exposed to diethylstilbestrol compared to a 6.8 per cent incidence in 161 male controls. Spermatozoal analysis revealed severe pathological changes (Eliasson score more than 10) in 32 per cent of 31 patients exposed to diethylstilbestrol and 0 per cent of 20 male controls. Abnormal findings on physical examination combined with severe sperm abnormalities (Eliasson score more than 10) were found in 23 per cent of the male patients exposed to diethylstilbestrol versus none of the male controls. Cytologic examinations revealed no malignant cells from urine samples before and after prostatic massage or ejaculation, prostatic fluids and aspirates from epididymal cysts.

Procedure for immunocytochemical detection of P16INK4A antigen in thin-layer, liquid-based specimens.

OBJECTIVE To develop a procedure for the immunocytochemical detection of P16INK4A in ThinPrep specimens. STUDY DESIGN Archived ThinPrep, liquid-based cervical/endocervical cytology specimens (Cytyc Corp., Boxborough, Massachusetts, U.S.A.) diagnosed as LSIL, HSIL and WNL were resampled and fixed in 95% ethanol for at least three days. Rehydration and endogenous peroxidase blocking of both ThinPreps and formalin-fixed, paraffin-embedded tissues were accomplished on a Leica Autostainer (Leica, Deerfield, Illinois, U.S.A.). Microwave antigen retrieval with CitraPlus (Biogenex, San Ramon, California, U.S.A.) was performed using a Panasonic microwave oven (Matsushita Cooking Appliances, Franklin Park, Illinois, U.S.A.) on the high setting twice for five minutes each. After cooling for 20 minutes and undergoing a buffer rinse, the slides were placed in a Dako autostainer (Dako-USA, Carpinteria, California, U.S.A.). The P16INK4A primary antibody, clone E6H4 (MTM Laboratories, Heidelberg, Germany) was diluted 1:200 in antibody diluent buffer. Detection was accomplished with a mouse non-avidin-biotin EnVision+ polymer (Dako). The expression of P16INK4A in ThinPreps and corresponding biopsies were scored by two pathologists. A ThinPrep case was scored as positive if it contained > 10 abnormal cells with nuclear and cytoplasmic immunocytochemical staining. Corresponding biopsies were scored as exhibiting negative, sporadic, focal or diffuse staining, as described by Klaes et al, Overexpression of P16INK4A as specific marker for dysplastic and neoplastic epithelial cells of the cervix uteri (Int J Cancer 2001;92:276-284). RESULTS The P16INK4A antibody assay was positive in 14 of 19 (73.68%) LSIL ThinPrep cases and in 25 of 26 (96.15%) HSIL ThinPrep cases. Thirty-eight of the 39 (97.44%) biopsies corresponding to the positively stained ThinPreps also were positive, with a staining score of at least focal positivity in the dysplastic regions. The P16INK4A antibody assay was negative in 5 of 19 (26.32%) LSIL ThinPrep cases and negative in 1 of 26 (3.85%) HSIL ThinPrep cases. The six biopsies corresponding to the negative ThinPreps were similarly negative. The two cytologic specimens diagnosed as WNL were negative for P16INK4A, as were two tissue control cases with benign diagnoses. Nondysplastic squamous epithelium, identified in 17 biopsy cases, did not stain, nor did nondysplastic squamous cells identified in ThinPrep cases. Sporadic staining of bacteria, inflammatory cells and occasional endocervical glandular cells was identified. CONCLUSION P16INK4A expression in ThinPrep specimens correlates with tissue expression of P16INK4A, as implemented in the above protocol. P16INK4A may thus serve as a surrogate marker in gynecologic cytology for high-risk HPV infection and for the development of cervical neoplasia.

A twenty-five-year follow-up study of women exposed to diethylstilbestrol during pregnancy.

Abstract To assess the long-term effects of diethylstilbestrol we conducted a health survey among 693 mothers who had taken the drug during pregnancy and a comparable group of 668 who had not. These women had participated in a study during 1951–52 to evaluate the drug. There were 32 (4.6 per cent) breast cancers among the 693 exposed and 21 (3.1 per cent) among the 668 unexposed, but the difference was not statistically significant (P = 0.16). No statistically significant differences occurred between the groups in any of the other categories of disease. The occurrence of breast cancer in both groups was compared to the Connecticut State Tumor Registry for 1963–65. Compared to the registry data, a significantly (P<0.01) higher incidence of breast cancer occurred in both the exposed and unexposed groups at ages over 50. The reason for this increase is not known, but effects linked to the selection of mothers participating in the original clinical study cannot be excluded. (N Engl J Med 298:763–767, 1978)

Targeted cyst wall puncture and aspiration during EUS-FNA increases the diagnostic yield of premalignant and malignant pancreatic cysts

BACKGROUND Characterization of pancreatic cysts by using EUS-FNA includes chemical and cytologic analysis. OBJECTIVE To evaluate whether material obtained from FNA of the cyst wall increases diagnostic yield. DESIGN Prospective series. SETTING Tertiary referral center. PATIENTS Consecutive patients with pancreatic cysts referred for EUS-FNA between March 2010 and March 2011. INTERVENTION FNA was performed with aspiration of cyst fluid for carcinoembryonic antigen (CEA) and cytology, followed by cyst wall puncture (CWP). CWP is defined as puncturing the far wall of the cyst and moving the needle back and forth through the wall to sample the wall epithelium. MAIN OUTCOME MEASUREMENTS The diagnostic yield for mucinous cystic pancreatic neoplasms by CEA and cytology obtained from cyst fluid compared with cytology obtained from CWP. CEA ≥192 ng/mL was considered mucinous. RESULTS A total of 69 pancreatic cysts from 66 patients were included. Adequate amounts of fluid were aspirated for CEA, amylase, and cytology in 60 cysts (81%). Cellular material adequate for cytologic assessment from CWP was obtained in 56 cysts (81%). Ten (30%) of 33 cysts with CEA <192 ng/mL and negative results of cyst fluid cytology had a mucinous diagnosis from CWP; 6 of 9 (67%) cysts with an insufficient amount of fluid for CEA analysis and cyst fluid cytology had a mucinous diagnosis from CWP. Furthermore, 4 malignant cysts were independently diagnosed by CWP cytology. The incremental diagnostic yield of CWP for mucinous or malignant cysts was therefore 29% (20 of 69 cysts, P = .0001). An episode of pancreatitis (1.45%) occurred. LIMITATION Lack of surgical criterion standard. CONCLUSIONS CWP during EUS-FNA is a safe and effective technique for improving the diagnostic yield for premalignant and malignant pancreatic cysts.

Study of viral integration of HPV-16 in young patients with LSIL.

Aims: To investigate the physical status of human papillomavirus 16 (HPV-16) in low grade squamous intraepithelial lesions (LSILs) as a means of determining the percentage of viral integration. Methods: Ninety two LSIL/HPV positive Thin Prep™ samples were initially tested for the E6 gene by the polymerase chain reaction (PCR) to identify the HPV-16 virus. To avoid false positive results, the specificity of the bands obtained from PCR was confirmed by Southern blot hybridisation with internal oligonucleotide probes. Next, a PCR screen for the E2 gene was performed to identify those samples in which the virus was integrated. Viral integration was detected in just over half of them. Results: Twenty of the 92 samples were HPV-16 positive, as shown by PCR for the E6 gene. Southern blot analysis confirmed that 13 of these samples were positive for the viral E6 gene. Thus, viral integration was detected in just over a half of the samples positive for HPV-16. Conclusions: These data show that HPV-16 integration occurs in a subset of LSILs. The measurement of HPV-16 integration would be a helpful complementary tool for cytological evaluation in primary cervical screening to identify those patients at risk of developing high grade squamous intraepithelial lesions and cervical cancer.

Classification of the four main types of lung cancer using a microRNA-based diagnostic assay.

For patients with primary lung cancer, accurate determination of the tumor type significantly influences treatment decisions. However, techniques and methods for lung cancer typing lack standardization. In particular, owing to limited tumor sample amounts and the poor quality of some samples, the classification of primary lung cancers using small preoperative biopsy specimens presents a diagnostic challenge using current tools. We previously described a microRNA-based assay (miRview squamous; Rosetta Genomics Ltd., Rehovot, Israel) that accurately differentiates between squamous and nonsquamous non-small cell lung cancer. Herein, we describe the development and validation of an assay that differentiates between the four main types of lung cancer: squamous cell carcinoma, nonsquamous non-small cell lung cancer, carcinoid, and small cell carcinoma. The assay, miRview lung (Rosetta Genomics Ltd.), is based on the expression levels of eight microRNAs, measured using a sensitive quantitative RT-PCR platform. It was validated on an independent set of 451 samples, more than half of which were preoperative cytologic samples (fine-needle aspiration and bronchial brushing and washing). The assay returned a result for more than 90% of the samples with overall accuracy of 94% (95% CI, 91% to 96%), with similar performance observed in pathologic and cytologic samples. Thus, miRview lung is a simple and reliable diagnostic assay that offers an accurate and standardized classification tool for primary lung cancer using pathologic and cytologic samples.

Utility of the BTA stat test kit for bladder cancer screening

Our study evaluated the BTA (bladder tumor antigen) stat test kit as a primary screening device for the detection of transitional‐cell carcinoma (TCC) of the bladder, with direct comparison by voided urine cytology (VUC) on the same specimens. The unfixed voided urine of 100 patients with no history of bladder cancer who had signs and symptoms of dysuria, incontinence, and gross hematuria and microhematuria were tested using the one‐step BTA stat test kit before processing via the cytospin technique for fluid cytological evaluation. The patients in the study were followed for up to 12 mo with repeated urine cytological testing, cystoscopy, and bladder biopsy when clinically indicated. Nineteen cases tested positive, and 81 cases tested negative on the BTA stat test. VUC diagnosed three cases as unequivocally positive for TCC, 93 cases as negative, and four cases in which unqualified atypical urothelial cells were noted. TCC was confirmed by cystoscopy and bladder biopsy in three of three cases diagnosed by VUC and in three of 19 cases that tested positive by the BTA stat test. These findings resulted in an 84% false‐positive rate for the BTA stat test and no false‐positive cases for VUC during the 12‐mo follow‐up period. The results indicate that the sensitivity and specificity of BTA stat test are comparable to those of VUC; however, owing to a relatively high false‐positive rate, it can at best act as an adjunct to urine cytological study for bladder cancer screening. Diagn. Cytopathol. 1999;21:27–29.