Ralph M. Richart

Endometrial precancer diagnosis by histopathology, clonal analysis, and computerized morphometry.

Management of endometrial precancers is compromised by longstanding debate over the natural history of endometrial hyperplasias and inconsistencies in their diagnosis. The recent demonstration that some hyperplasias, like cancers, are phenotypically monoclonal is useful in recognizing biological precancers. A clonal analysis has been undertaken of a series of 93 endometrial tissues and their morphology has been evaluated by subjective diagnostic classification and computerized morphometric analysis. A pathologists diagnosis of atypical endometrial hyperplasia was highly associated with monoclonal growth. Both microsatellite‐stable and microsatellite‐unstable precancers were classified as atypical hyperplasias, indicating overlapping morphologies for these two groups. Diagnosis of non‐atypical endometrial hyperplasias was not reproducible and identified a group of lesions equally likely to be monoclonal as polyclonal. Computerized morphometry resolved these lesions into monoclonal and polyclonal subgroups with a high degree of accuracy and reproducibility. The predictive value of morphometry was dominated by that fraction of the sample which consisted of stroma (volume percentage stroma). This can be measured manually and used to predict monoclonality when below the threshold value of 55%. This study shows that morphometric analysis reproducibly and precisely identifies monoclonal endometrial precancers from histological sections. It may serve, furthermore, to classify accurately lesions judged by pathologists as indeterminate (non‐atypical hyperplasias). The material from this study (available at www.endometrium.org from March 1, 2000) and precisely defined architectural diagnostic criteria provide new tools for diagnostic standardization of endometrial precancers. Copyright

Reflex human papillomavirus deoxyribonucleic acid testing in women with abnormal Papanicolaou smears.

OBJECTIVEnThe study examined interrelationships between sensitivity and specificity of reflex human papillomavirus deoxyribonucleic acid testing from liquid-based cervical cytologic specimens by means of receiver operator characteristics curves.nnnSTUDY DESIGNnA cohort study was performed on 265 women evaluated by colposcopy because of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion found on Papanicolaou smear.nnnRESULTSnAt a positive threshold of 0.2 pg/ml (1000 copies of human papillomavirus per test), human papillomavirus deoxyribonucleic acid testing detected 86% of women with cervical intraepithelial neoplasia and 93% of women with high-grade cervical intraepithelial neoplasia with a specificity of 30%. Decreasing the sensitivity of the human papillomavirus test to 1 pg/ml (5000 copies of human papillomavirus per test) improved the specificity of a positive result to 44% but decreased the clinical sensitivity to 78% for cervical intraepithelial neoplasia grade 2 or 3. Relationships between sensitivity and specificity were influenced by patient age and referral diagnosis. For example, limiting the analysis to only women with a referral for atypical squamous cells of undetermined significance found on Papanicolaou smear and a positive human papillomavirus test threshold of 0.5 pg/ml produced a sensitivity of 90% for cervical intraepithelial neoplasia grade 2 or 3 and a test specificity of 55%.nnnCONCLUSIONnHuman papillomavirus deoxyribonucleic acid testing of residual cellular material from liquid cytologic specimens appears to be more appropriate for older women (>30 years old) and women with atypical squamous cells of undetermined significance, as opposed to low-grade squamous intraepithelial lesion, on their Papanicolaou smears.

CONDITIONS INFLUENCING THE INTENSITY OF THE FEULGEN REACTION

Hydrolysis in 5 N hydrochloric acid at room temperature is preferable to the conventional Feulgen hydrolysis in 1 N HCl at 60°C. The intensities achieved are less critically dependent on time and temperature and the maximum Feulgen values obtained may be significantly higher than after the latter procedure. However, the shape of the 5 N hydrolysis curve is dependent on the fixative and preparative procedures used and it may vary from experiment to experiment. The small lymphocyte, which has previously been found by several workers to bind about 10% less Feulgen dye than other diploid cells, was found to have a similar lower Feulgen intensity after 5 N HCl hydrolysis at room temperature. Isolating leukocyte nuclei or extracting their acid-soluble nuclear proteins failed to cause a significant elevation in the amount of Feulgen dye found.

Case-control study of in situ and invasive carcinoma of the vagina

A case-control study of 41 patients with carcinoma in situ (CIS) or invasive cancer of the vagina and 97 community controls was undertaken to identify potential risk factors. Although vaginal and cervical cancers often occur as multiple primaries, only a few common risk factors prevailed. Similar to cervical cancer, low education and family income were risk factors for vaginal CIS and invasive cancer. In addition, history of genital warts was strongly related (RR = 2.9), although other sexual factors were not. Previous genital abnormalities related to subsequent cancer risk, with significant associations seen for vaginal discharge or irritation (RR = 6.1), a previous abnormal Pap smear (RR = 3.8), or an early hysterectomy (RR = 6.7). In addition, there was some evidence that vaginal trauma might be involved, with nonsignificant and independent associations relating to regular douching with preparations other than water or vinegar (RR = 2.7) and frequent washing of the genital area (RR = 2.7). Further studies are needed to determine whether our findings persist among a larger series of cases.

Deoxyribonucleic acid content of presumed precursors of endometrial carcinoma

Microspectrophotometric measurements of Feulgen‐stained gland cell nuclei were carried out in 16 cases of presumed precursors (six cystic glandular hyperplasias, ten adenomatous hyperplasias) and six adenocarcinomas of the endometrium. In all cases of cystic glandular hyperplasia a diploid to tetraploid DNA‐distribution was found which was indistinguishable from that of a normal proliferating epithelium. The same diploid to tetraploid DNA distribution was found in eight of the ten adenomatous hyperplasias. Only two cases of adenomatous hyperplasia had an aneuploid DNA‐distribution pattern and this pattern was similar to that of the invasive carcinomas. In both of these aneupolid hyperplasias there were two different types of glands which could be distinguished by their cytomorphology. The six cases of adenocarcinoma of the endometrium had aneuploid DNA‐distributions. Since every group of precursor lesions in other organs studied by microspectrophotometry have been reported to have aneuploid DNA‐distribution patterns, the results of this study suggest that most of the lesions now diagnosed as precursors of endometrial carcinoma either deviate from the pattern of other epithelia or that the morphologic criteria which traditionally are used in the diagnosis of these lesions are insufficiently precise.

Influence of diagnostic and therapeutic procedures on the distribution of cervical intraepithelial neoplasia

Patients with colpomicroscopically visible lesions of dysplasia or CIS were biopsied systematically and then were followed by direct observation using colpomicroscopy and by cytology. These observations indicate that under certain circumstances a single punch biopsy may produce an immediate cure, a delayed cure or a change in the distribution of an area of cervical intraepithelial neoplasia (dysplasia or carcinoma in situ). These sequelae may reflect the dependence of areas of CIN on contiguity with the squamo‐columnar junction for their continued survival. The delayed influence of biopsy procedures on the distribution and natural history of CIN militates against their being used as part of long‐term follow‐up studies of the course of these lesions.

Underwear: contamination by human papillomaviruses.

Genital human papillomavirus-related lesions occurring in 74 patients and cellular swab samples taken from their underwear were analyzed with a filter hybridization technique (ViraPap-ViraType, Life Technologies Inc., Gaithersburg, Md.) for human papillomavirus deoxyribonucleic acid. Human papillomavirus deoxyribonucleic acid was found in 54 of 74 (72%) lesional tissues and 13 of 74 (17%) swabs from the underwear. Recurrence rates in patients with and without positive underwear swabs were 61% and 29% (p less than 0.05), respectively.

Colpomicroscopic studies of cervical intraepithelial neoplasia

This paper reports colpomicroscopic observations on 750 patients with abnormal Papanicolaou smears and delineates the diagnostic criteria used in colpomicroscopy. The detection rate in a prospective series of 100 women was 84% and the diagnostic accuracy 68%. Of special interest in this study was a group of patients who had a minute area of mild dysplasia found on the squamous side of the squamo‐columnar junction. Each of these areas was unifocal and was associated with a smear in which the abnormal cells were derived from the superficial and upper intermediate layers.

Endometrial morphologic response to hormonal environment

Abstract In the preovulatory phase 17-β estradiol promotes endometrial growth by stimulating endometrial cellular metabolism; after ovulation, progesterone acts as a growth inhibitor, stimulates secretory conversion, and induces lysosomal hydrolytic activity in the estrogen-primed endometrium. Persistent (anovulatory) proliferative endometrium, endometrial polyps, and cystic and simple adenomatous glandular hyperplasia are morphologically similar to proliferative endometrium but there is a more pronounced cellular response to hormonal stimuli in these abnormal states than is seen in the normal proliferative endometrium. There is a gradual increase in estrogen-related cellular specialization as one goes from persistent proliferative endometrium through adenomatous hyperplasia which seems to reflect a spectrum of progressive epithelial changes mediated by exogenous estrogenic stimulation. These specialized cellular alterations are comparatively reduced in severe adenomatous hyperplasia (carcinoma in situ ) and well-differentiated adenocarcinoma, and are absent in less well-differentiated endometrial cancers. The gradual failure to express estrogen-influenced cellular characteristics in these lesions is thought to be related to neoplastic dedifferentiation rather than to reduced estrogenic influence. The morphological effects of progesterone or synthetic progestins on hyperplastic or well-differentiated endometrial adenocarcinoma are similar to those occurring in the normal postovulatory endometrium. The subcellular dynamics of epithelial regression in normal, as well as abnormal, endometrial tissues are related to secretory activity followed by autophagocytosis and apoptosis. These observations support the concept that progestogens act upon endometrial hyperplasia and neoplasia by a direct, nonimmunologic, cellular effect.

DNA content of condyloma acuminatum

Female genital condylomata acuminata were examined for DNA content. Diploid and polyploid DNA distributions, including tetraploidy and octaploidy, were found. These findings are in clear counter‐distinction to squamous intraepithelial lesions, which have been found to be aneuploid. DNA quantitation, therefore, can be used in difficult cases to distinguish between condylomatous and neoplastic epithelium.