Pichet Sampatanukul

Effects of clomiphene citrate on the endometrium of regularly cycling women

OBJECTIVE To study the effects of clomiphene citrate (CC) on the endometrium of regularly cycling women. DESIGN Prospective, controlled study. SETTING Department of Obstetrics and Gynaecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. PATIENT(S) Thirty healthy, regularly cycling, female volunteers. INTERVENTION(S) All volunteers were studied for two consecutive cycles, one control cycle and one CC-treated cycle. Clomiphene citrate (100 mg/d) was given on days 3-7 of the CC-treated cycles. Ultrasonography was performed daily to assess ovulation. Ultrasonography and endometrial biopsy were performed, and blood samples were obtained for determination of E2 and progesterone levels 7 days after ovulation in both the control and CC-treated cycles. MAIN OUTCOME MEASURE(S) Histologic dating, morphometric analysis, and ultrasonographic appearance and thickness of the endometrium. RESULT(S) Histologic dating and ultrasonographic appearance and thickness of the endometrium were similar in the control and CC-treated cycles, but morphometric parameters were different. The number of glands per square millimeter and the mean diameter of the glands were lower in the CC-treated cycles than in the control cycles, but the number of vacuolated cells per 1,000 glandular cells was higher. CONCLUSION(S) Clomiphene citrate has effects on the endometrium of regularly cycling women, as demonstrated by a reduction in glandular density and an increase in the number of vacuolated cells.

Recurrent Isosporiasis Over a Decade in an Immunocompetent Host Successfully Treated with Pyrimethamine

Recurrent isosporiasis in an immunocompetent host is reported. The patient suffered from chronic intermittent diarrhea for over a decade. Multiple short-term administrations of trimethoprim-sulfamethoxazole followed by pyrimethamine, or albendazole combined with tinidazole could not control the relapses. However, treatment with pyrimethamine, 25 mg/d for 20 weeks, was successful.

Proliferating ductules are a diagnostic discriminator for intrahepatic cholangiocarcinoma in FNA biopsies.

The histologic distinction of cholangiocarcinoma (CC) from metastatic carcinoma and hepatocellular carcinoma (HCC) is difficult. In particular, the distinction of CC from metastatic carcinoma on morphologic features alone is not possible and is dependent on the identification of an extrahepatic primary carcinoma. The proliferative response to many types of liver injury is characterized by a proliferation of either hepatocyte ductular clusters (HDC) or biliary ductular clusters (BDC). This study examined the presence of such ductular reactions in fine needle aspiration biopsies of 20 consecutive cases each of CC and HCC, and compared the findings to those of 20 cases of hepatic metastases from a wide variety of sites. All 18 cases of CC with adequate smears showed ductular proliferation of either HDC or BDC type, the latter being more common; in 13 cases, there were more than 10 ductular clusters per smear. In contrast, only one case of metastatic carcinoma displayed so many ductular clusters, this being a case with multiple hepatic deposits. Five cases of HCC showed more than 10 clusters. The presence of more than 10 ductular clusters associated with malignant cells is a useful discriminator to separate CC from metastatic carcinoma. Diagn. Cytopathol. 22:359–363, 2000.

Effects of initiation day of clomiphene citrate on the endometrium of women with regular menstrual cycles

OBJECTIVE To investigate the effects of initiation time of clomiphene citrate (CC) on the endometrium of women with regular menstrual cycles. DESIGN Randomized, double-blind, cross-over study. SETTING Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. PATIENT(S) Thirty-three healthy female volunteers with regular menstrual cycles. INTERVENTION(S) The volunteers were randomized to receive either 100 mg of CC on days 1-5 and placebo on days 5-9 (study group) or placebo on days 1-5 and CC on days 5-9 (control group). After a wash-out period of 1 month of CC treatment, the medication was switched in each group. Ultrasonography was performed daily after day 10 of the cycle to detect ovulation. Ultrasonography for endometrial appearance and thickness, endometrial sampling, and blood samples obtained for determination of E(2) and P levels were performed 7 days after ovulation in both groups. MAIN OUTCOME MEASURE(S) Morphometric analysis, histologic dating, and ultrasonographic appearance and thickness of the endometrium. RESULT(S) Morphometric parameters, histologic dating, and ultrasonographic appearance and thickness of the endometrium were similar in both groups. CONCLUSION(S) Starting CC on either day 1 or day 5 of the menstrual cycle did not have any differential effects on the endometrium of women with regular menstrual cycles, particularly regarding the morphometric analysis, histologic dating, or ultrasonographic appearance.

TROP-2 immunohistochemistry: a highly accurate method in the differential diagnosis of papillary thyroid carcinoma

We aimed to evaluate the diagnostic utility of the novel immunohistochemical marker TROP-2 on thyroid specimens (226 tumours and 207 controls). Whole slide immunohistochemistry was performed and scored by automated digital image analysis. Non-neoplastic thyroid, follicular adenomas, follicular carcinomas, and medullary carcinomas were negative for TROP-2 immunostaining. The majority of papillary thyroid carcinoma (PTC) specimens (94/114, 82.5%) were positive for TROP-2; however, the pattern of staining differed significantly between the histopathological variants. All papillary microcarcinomas (mPTC), PTC classic variant (PTC cv), and tall cell variant (PTC tcv) were TROP-2 positive, with mainly diffuse staining. In contrast, less than half of the PTC follicular variant specimens were positive for TROP-2, with only focal immunoreactivity. TROP-2 could identify PTC cv with 98.1% sensitivity and 97.5% specificity. ROC curve analysis found that the presence of >10% of TROP-2 positive cells in a tumour supported a diagnosis of PTC. The study of intratumoural heterogeneity showed that low-volume cytological samples of PTC cv could be adequately assessed by TROP-2 immunostaining. The TROP-2 H-score (intensity multiplied by proportion) was significantly associated with PTC variant and capsular invasion in encapsulated PTC follicular variant (p<0.001). None of the baseline (age, gender) and clinical (tumour size, nodal disease, stage) parameters were correlated with TROP-2 expression. In conclusion, TROP-2 membranous staining is a very sensitive and specific marker for PTC cv, PTC tcv, and mPTC, with high overall specificity for PTC.

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy for diagnosis of solid pancreatic lesions (ENES): a pilot study

Background and study aims: Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy (EUS-nCLE) has been shown to aid in the diagnosis of cystic pancreatic lesions. This is a pilot project to study its findings in patients with solid pancreatic lesions (SPLs) with a prospective single-blinded study design. Methods: Patients with SPLs undergoing trans-gastric EUS fine needle aspiration (EUS-FNA) from July 2013 to March 2014 were prospectively enrolled. The nCLE diagnoses were compared with the final diagnoses. Researchers learned about the EUS-nCLE findings from previously published studies and applied it to diagnose SPLs. In the meantime, the findings were recorded. Results: In total, 22 patients were recruited (mean age 62.7 years, SD 13.8 years; 14 men and eight women). The mean maximal tumor diameter was 36.0 mm (SD 10.9 mm). EUS-nCLE yielded satisfactory images in all patients during the first EUS procedure and diagnosed benign and malignant SPLs in 3 and 19 patients, respectively. Final diagnoses of malignant SPLs were made in 19 patients. Benign SPLs were eventually diagnosed in three patients, with confirmed the cytology and disease stability during the 12-month follow-up period. At the end of the project, based on the results of this current study, EUS-nCLE findings for malignant SPLs were dark clumping with or without dilated vessels (> 40 μm). There were two criteria for diagnosing benign lesions which were white fibrous bands and normal acini cells. The accuracy rate of EUS-nCLE was 90.9 % (20/22). One falsely diagnosed malignant SPL was an inflammatory mass from a recent acute pancreatitis. Another one with a pancreatic neuroendocrine tumor presenting with a symptomatic pseudocyst was incorrectly diagnosed as an inflammatory mass. This was likely from sampling error of the EUS-nCLE probe in an inflammatory area. Only one patient had post EUS-FNA bleeding but did not require a blood transfusion. The inter-observer agreement among three blinded endoscopists was almost perfect (Kappa 0.82). Conclusion: EUS-nCLE is a promising technique for the diagnosis of SPLs with good inter-observer agreement. Study registration‎: TCTR20140402001

Ectopic Thymoma Can Mimic Benign and Malignant Thyroid Lesions on Fine Needle Aspiration Cytology: A Case Report and Literature Review

Background: Ectopic cervical thymomas are rare and there are few descriptions of the cytologic findings based on fine needle aspiration. Their appearances can be misinterpreted as either benign or malignant lesions of the thyroid. The authors report such a case occurring in a patient with Sotos syndrome, a genetic disorder characterized by somatic overgrowth and cognitive impairment. Case Report: The patient developed a neck mass that was examined first by fine needle aspiration and then by pathologic examination of the resected specimen. On fine needle aspiration, a diagnosis of papillary carcinoma of the thyroid was favoured, based on the presence of large cohesive sheets of anastomosing papillary tissue fragments with fibrovascular cores. Pathologic examination of the resection specimen showed a thymoma, subtype B3. The cytologic findings correlated with the presence of nuclear palisading of tumour cells around perivascular spaces. Conclusion: To the best of our knowledge, this histologic subtype of thymoma has never been reported in ectopic cervical thymic tissue, nor these particular cytologic findings that can lead to an erroneous diagnosis of thyroid carcinoma. Moreover, this is the first description of thymoma in association with Sotos syndrome.

Primary chromoblastomycosis of the medulla oblongata: Complication of heroin addiction

A 20-year-old male heroin addict had a sudden onset of progressive medullary dysfunction and died within 12 days. Postmortem examination disclosed mycotic granulomas due to primary chromoblastomycosis strictly limited to the medulla oblongata and adjacent leptomeninges. Similar lesions were absent outside the central nervous system. Such pathologic lesions related to narcotic addiction have not been reported previously.

Clinical Epidemiology (CE) and Evidence-Based Medicine (EBM) in the Asia Pacific region (Round Table Forum)

Clinical Epidemiology (CE) and Evidence-Based Medicine (EBM) have become increasingly important in an era of rising costs, patient safety concerns and evidence-based health care. CE and EBM research in the Asia Pacific region have grown significantly. However, there are three main challenges such as linking evidence to practice and policy; developing a strong collaborative network; and a need for resources and technical expertise to produce evidence. The Cochrane Collaboration is a possible solution to resolve above challenges identified, particularly the challenge of transforming evidence to practice. In addition, training can be carried out to enhance technical expertise in the region and there is also the promising potential that collaborations could extend beyond systematic reviews. To improve the adoption of evidence-based health policy, selection of the best evidence for the right audience and focusing on the relevant issues through appropriate methodology are essential. Information on effectiveness and cost effectiveness needs to be highlighted for policy makers. The way forward to strengthen research and capacity building is to establish the Asia Pacific Consortium for CE and EBM. The consortium would help to create mutually rewarding scientific research and collaborations that will augur well for advances in CE and EBM.

Benign Aspergillus colonization (Aspergilloma) in the middle ear.

A 56-year-old Thai male presented at the ENT Department, King Chulalongkorn Memorial Hospital, complaining of a hearing loss in his right ear for 1 year. He underwent a right tympanoplasty due to chronic suppurative otitis media 21 years before, which resulted in a cure with good hearing. A year before this admission, he noticed a gradually increased hearing loss in this ear. Otoscopic examination disclosed a localized retraction of the tympanic membrane (MT) in the posterosuperior quadrant. The rest of the MT was dull and thick. A provisional diagnosis of chronic adhesive otitis media was made. The audiological examination showed a conductive hearing loss with a 55 dB speech reception threshold (SRT), 40 dB bone conduction level, and 30 dB air-bone gap. Exploratory tympanotomy was performed via a transcanal stapedectomy approach. There was a muddy clay-like substance in the middle ear cavity mixed with the thick brown fluid. The debris and granulation were evacuated, and the middle ear was lavaged with normal saline solution. The integrity of the ossicular chain appeared intact. The eustachian tube opening was cleaned, and the middle ear was closed. Histopathologic findings revealed a tangled mass of branched hyphae surrounded by numerous neutrophils (Fig 1). No invasion of fungal hyphae into the middle ear mucosa or bone was noted in the sections. The cultures for bacteria, fungus, and tuberculosis did not result in any growth. Healing of the MT was complete within 2 weeks; however, an air-bone gap of 13 dB was still present for 8 months. Because of a slight painful or uncomfortable ear, and a lack of closure of the air-bone gap, a re-exploration of the middle ear was carried out. A clear middle ear cavity without debris or fluid and a normal looking mucosa with an intact ossicular chain was observed. Postoperatively, the air-bone gap dropped to 10 dB, the earache subsided and the patient was free of symptoms during the follow-up period of 2 years.