The middle interscalene block: cadaver study and clinical assessment

BACKGROUND AND OBJECTIVES: A variety of brachial plexus block techniques via the interscalene approach have been proposed. We describe here a new middle interscalene perivascular approach to the brachial plexus. To verify its effectiveness, we studied 719 patients scheduled for shoulder arthroscopy. Furthermore, to verify the accuracy of the proposed bony landmarks to use in the case of inability to palpate the subclavian artery pulse, we simulated the block on 10 cadavers. METHODS: The aim of our technique is to cannulate the neurovascular bundle by inserting a 35-mm needle lateral to the subclavian arterial pulse near the midpoint of the upper edge of the clavicle in a horizontal or slightly cephalad direction while pointing toward the seventh cervical vertebra. If the pulse of the subclavian artery is not palpable, we localize the direction of the needle with reference to 3 bony landmarks (the middle point of the clavicle, the spinous process of C7, and the sternoclavicular joint). By connecting these 3 landmarks, we obtain an angle whose apex lies at the midpoint of the clavicle and its bisecting line points to the plexus. The needle is introduced in the transverse plane of C7. RESULTS: The block was performed successfully in 692 of 719 cases (96.2\%). Horner's syndrome occurred in 93.5\% of the cases, arterial puncture with hematoma occurred in <1\%, phrenic nerve block without respiratory impairment in 60\%, with transient respiratory failure in <1\%, and laryngeal nerve block in <1\%. The incidence of severe complications or permanent injuries was zero (upper limit 95\% confidence interval = 0.4\% or 1:250 patients). The technique performed on cadavers showed that the previously mentioned bony landmarks were reliable reference points in reaching the brachial plexus. CONCLUSIONS: Our technique via a middle interscalene approach is easy to perform and provides a high success rate. Even in the absence of a subclavian artery pulse, the easily recognizable bony landmarks reliably guide us in the insertion of the needle. Furthermore, this technique appears to avoid complications that are theoretically possible in other supraclavicular perivascular approaches (pneumothorax) and paravertebral approaches (injection into the vertebral artery and subarachnoidal injection). However, further comparative studies will be required to assess the clinical relevance of the block

Immunocytochemistry of p16(INK4a) in liquid‐based cervicovaginal specimens with modified Papanicolaou counterstaining

AIM: To evaluate the feasibility and value of a modified Papanicolaou counterstain for p16(INK4a) immunostaining in liquid‐based cervicovaginal samples. METHODS: Immunocytochemical analyses were carried out with p16(INK4a) and modified Papanicolaou counterstain on 81 liquid‐based samples, including 23 of within normal limits (WNL), 6 of low‐grade squamous intraepithelial lesion (LSIL), 20 of high‐grade squamous intraepithelial lesion (HSIL), 16 of atypical squamous cells of undetermined significance (ASC‐US) and 16 of atypical squamous cells, high‐grade lesion cannot be excluded (ASC‐H). Results were compared with histological or cytological follow‐up. For comparison, samples from 29 more cases (10 of LSIL, 10 of ASC‐H and 9 of HSIL) were immunostained with p16(INK4a) and conventionally counterstained with haematoxylin. The intensity of immunostaining in cases of squamous intraepithelial lesion (SIL) was assessed using a 0–3 scoring system. Interobserver agreement was calculated by κ statistics. RESULTS: Expression of p16(INK4a) was detected in 3 of 23 cases of WNL, 4 of 6 cases of LSIL, all cases of HSIL, 5 of 16 cases of ASC‐US and 13 of 16 cases of ASC‐H. Excluding two cases with no residual dysplastic cells in the immunocytochemistry, all cases of cervical intraepithelial neoplasia (CIN)2 or CIN3 at follow‐up expressed p16(INK4a) and none of the p16(INK4a)‐negative cases showed a high‐grade lesion at follow‐up. No evident differences in pattern or intensity of p16(INK4a) expression were observed between the specimens of the study and control groups. Interobserver agreement was significantly better in the study group than in the group with conventional immunostaining (combined κ 0.773 v 0.549; p<0.05), and still better, albeit statistically not significant, than with conventional immunostaining and cervical smear test together (combined κ 0.773 v 0.642). CONCLUSION: Immunocytochemistry with p16(INK4a) and modified Papanicolaou counterstain may add to the cervicovaginal cytology the full potentiality of p16(INK4a) without the need of a further slide and the risk of loss of dysplastic cells, yet maintaining the typical morphological features of the smear test

P16(INK4) stop expression and progression risk of low-grade intraepithelial neoplasia of the cervix uteri

The aim of the study was to evaluate the immunohistochemical expression of p16(INK4a) as a marker of progression risk in low-grade dysplastic lesions of the cervix uteri. p16(INK4a) immunohistochemistry was performed on 32 CIN1 with proven spontaneous regression of the lesion in the follow-up ( group A), 31 ( group B) with progression to CIN3 and 33 ( group C) that were randomly chosen irrespective of the natural history of the lesion. p16(INK4a) staining pattern was scored as negative ( less than 5% cells in the lower third of dysplastic epithelium stained), as focally positive ( less than or equal to 25%) and as diffuse positive (> 25%). A diffuse staining pattern was detected in 43.8% of CIN1 of group A, 74.2% of group B and 56.3% of group C. No p16(INK4a) staining was detected in 31.3% and 12.9% CIN1 lesions of groups A and B, respectively. Overall, 71.4% and 37.8% of p16(INK4a)-negative and diffusely positive CIN1 had regressed at follow-up, whereas 28.6% and 62.2% negative and diffusely positive CIN1 were progressed to CIN3, respectively (P< 0.05). All CIN3 lesions analyzed during follow-up of group B were diffusely stained for p16(INK4a). Although p16(INK4a) may be expressed in low-grade squamous lesions that undergo spontaneous regression, in this study, CIN1 cases with diffuse p16(INK4a) staining had a significantly higher tendency to progress to a high-grade lesion than p16(INK4a)-negative cases. p16(INK4a) may have the potential to support the interpretation of low-grade dysplastic lesions of the cervix uteri

Usefulness of p16ink4a, ProEX C, and Ki-67 for the diagnosis of glandular dysplasia and adenocarcinoma of the cervix uteri

Although the diagnostic criteria of in-situ and invasive adenocarcinomas of the cervix uteri are well established, the differentiation from benign mimics may be difficult and the morphologic features of the precursors of endocervical adenocarcinoma are still debated. In this study, we evaluated the usefulness of p16ink4a (p16), ProEX C, and Ki-67 for the diagnosis of endocervical adenocarcinoma and its precursors. Immunohistochemistry with p16, ProEX C, and Ki-67 was performed in 82 glandular lesions including 15 invasive adenocarcinomas, 29 adenocarcinomas in situ (AIS), 22 non-neoplastic samples, and 16 cases of glandular dysplasia (GD), which showed significant nuclear abnormalities but did not meet the diagnostic criteria for AIS. The immunohistochemical expression pattern was scored according to the percentage of the stained cells (0, 1+, 2+, and 3+ when 0% to 5%, 6% to 25%, 26% to 50%, and more than 50% of the cells were stained, respectively) and was evaluated for each antibody. p16 was at least focally expressed (1+ or more) in 14 of 15 invasive adenocarcinomas, in all AIS and in 7 negative samples. ProEX C and Ki-67 both scored 1+ or more in all adenocarcinomas and AIS and in 8 and 6 negative samples, respectively. Of the GD 15, 14, and 15 expressed p16, ProEX C, and Ki-67, respectively. The score differences between neoplastic and non-neoplastic samples were highly significant for each marker (P<0.001); however, the score distribution by marker differed significantly only in GD (P=0.006) in which, compared with the other markers, p16 showed more often a 3+ pattern. Our study shows that p16, Ki-67, and ProEX C may be helpful for the diagnosis of glandular lesions of the cervix uteri and may also improve the diagnostic accuracy of endocervical GD. In particularly problematic cases, the combination of p16 and a proliferation marker can provide additional help for the interpretation of these lesions

p16 ink4a and HPV L1 immunohistochemistry is helpful for estimating the behavior of low-grade dysplastic lesions of the cervix uteri.

As only a minority of low-grade dysplastic lesions of the cervix uteri will eventually progress to carcinoma, predicting the behavior of these lesions could be of high value in clinical practice. The aim of the study was to evaluate p16 ink4a and L1 as immunohistochemical markers of the biologic potentiality of low-grade dysplasia of the uterine cervix. The study included 38 conization specimens with coexisting cervical intraepithelial neoplasia grade 1 (CIN1) and 3 (CIN3) (group A) and 28 punch biopsies from women with CIN1 and proven spontaneous regression in the follow-up (group B). In group A, all CIN3 were p16 ink4a positive (p16+) and L1 negative (L1-). The CIN1 of this group were p16+L1- and p16+L1+ in 68.42% and 31.57%, respectively. No other expression pattern was found in this group. In group B, the p16+L1-, p16+L1+, p16-L1+, and p16-L1- patterns were found in 3.57%, 25%, 14.29%, and 57.14%, respectively. Overall, 96.29% p16+L1- CIN1 were found in group A, whereas all the p16-L1+ and p16-L1- CIN1 were found in group B. A significant difference between staining pattern distributions of group A and B was observed (P<0.0001). The results of the study show that p16 ink4a and L1 immunohistochemistry can be helpful for estimating the biologic potentiality of low-grade squamous cervical lesions. Particularly in cases in which the grade of the lesion is morphologically difficult to assess, the p16/L1 expression pattern could be useful for planning the clinical management of these women