Biliary brush cytology for the diagnosis of malignancy: a single center experience [Citološki razmazi brisa četkicom u dijagnostici malignih promjena bilijarnog stabla: naše iskustvo]

Differentiation between benign and malignant biliary strictures is critical to the provision of adequate treatment. Brush cytology during the endoscopic retrograde cholangiopancreatography (ERCP) is the most commonly used method for obtaining tissue confirmation of the nature of biliary strictures. It’s specificity is remarkably high but reported sensitivities for the diagnosis of malignancy are low. Aim of our study was to assess sensitivity and specificity of biliary brush cytology in our institution, to find out main causes of false negative diagnoses and to confirm impression that the team approach has impact on sensitivity. Gold standard for diagnosis was definitive surgical histology or adequate clinical follow up for minimum of six month. Direct smears made by cytotechnician at the endoscopy room, and stained according to Papanicolaou and May-Grünwald Giemsa (MGG) were examined for well-recognized features of malignancy on conventional smears as a part of diagnostic routine. Cytologic diagnoses were benign, atypical/reactive, suspicious for malignancy and malignant. Of 143 brushings with available definitive diagnosis 36 (25%) had malignant cytologic diagnosis and 91(63.6%) were classified as benign, 3 were atypical/reactive and 13 suspicious for malignancy with 20 »false-negative« cases. When specimens with atypical and suspicious cytology were excluded from data analysis sensitivity was 64% and specificity was 100% and when suspicious findings were taken into account as true positives sensitivity rose to 71%. We find that biliary brush cytology, although mainly depending on the skill of endoscopist, as well as the experience of the cytologist, is a valuable method for obtaining accurate tissue diagnosis of biliary strictures, thus solving eternal diagnostic dilemma: benign or malignant

Biliary Brush Cytology for the Diagnosis of Malignancy: A Single Center Experience

Differentiation between benign and malignant biliary strictures is critical to the provision of adequate treatment. Brush cytology during the endoscopic retrograde cholangiopancreatography (ERCP) is the most commonly used method for obtaining tissue confirmation of the nature of biliary strictures. It’s specificity is remarkably high but reported sensitivities for the diagnosis of malignancy are low. Aim of our study was to assess sensitivity and specificity of biliary brush cytology in our institution, to find out main causes of false negative diagnoses and to confirm impression that the team approach has impact on sensitivity. Gold standard for diagnosis was definitive surgical histology or adequate clinical follow up for minimum of six month. Direct smears made by cytotechnician at the endoscopy room, and stained according to Papanicolaou and May-Grünwald Giemsa (MGG) were examined for well-recognized features of malignancy on conventional smears as a part of diagnostic routine. Cytologic diagnoses were benign, atypical/reactive, suspicious for malignancy and malignant. Of 143 brushings with available definitive diagnosis 36 (25%) had malignant cytologic diagnosis and 91(63.6%) were classified as benign, 3 were atypical/reactive and 13 suspicious for malignancy with 20 »false-negative« cases. When specimens with atypical and suspicious cytology were excluded from data analysis sensitivity was 64% and specificity was 100% and when suspicious findings were taken into account as true positives sensitivity rose to 71%. We find that biliary brush cytology, although mainly depending on the skill of endoscopist, as well as the experience of the cytologist, is a valuable method for obtaining accurate tissue diagnosis of biliary strictures, thus solving eternal diagnostic dilemma: benign or malignant

The Importance of Urgent Cytological Examination of Synovial Fluids in Differentiation Inflammatory and Non-inflammatory Joint Diseases

The aim of this study was to imply the possibilities of the urgent cytological examination of synovial fluids in differential diagnosis of arthropathies and to motivate the clinicians to use this method. It gave valuable information particularly with respect to differentiate the inflammatory and non-inflammatory joint diseases. This study included 115 synovial fluids obtained by fine needle aspiration (FNA) of the swollen knee from the patients in the period between 2003 and 2008. At our department the urgent cytological examination of the synovial fluids consisted of macroscopic analysis that includes volume, colour, clarity, viscosity and mucin clot test, native microscopic analysis for crystals and tissue fragments, counting the total nucleated cell count and semiquantitative microscopic analysis for neutrophil granulocyte percentage on the slides stained with Hemacolor rapid staining. All cytological analyses were done within one hour since FNA. According to our results the clarity, viscosity, mucin clot test, the total nucleated cell count and the neutrophil granulocyte percentage enabled distinction between inflammatory and non-inflammatory diseases with statistically significant difference at the 0.01 level but we could not differentiate these two groups of illnesses according to volume and colour. In inflammation the total nucleated cell count and the neutrophil granulocyte percentage was greater than in non-inflammation, the clarity was only translucent and opaque, the viscosity was low and the mucin clot test was negative. In non-inflammatory diseases the clarity varied from transparent to opaque, the total nucleated cell count and the neutrophil granulocyte percentage was smaller than in inflammatory diseases, the viscosity was high and consequently the mucin test was highly positive in all samples. Crystals were detected in only 12 samples of synovial fluids, mostly in inflammation and they were all monosodium urate (MUS) so we could diagnose gout. We could conclude that the urgent cytological analysis of the synovial fluid is a very useful, simple and reliable basic diagnostic screening test in differentiation inflammatory and non-inflammatory joint diseases and we recommended using it as the initial test in the diagnostic procedure of these illnesses using our protocol

Clinical Cytology and Primary Health Care of Children and Adults

Clinical cytology is a diagnostic branch of medicine, best known by the Papa test in gynaecology. But, cytology can be applied in almost all fields of clinical medicine. Its advantages – high accuracy, simplicity, with little or no aggressiveness and low cost – are not used as widely as they could be. Medical practice, as well as medical research, and also medical education, are nowadays often directed at profitable use and not at the real benefit of the patient. Primary practitioners do not have enough chance to get acquainted with clinical cytology as a whole although they need true information, based on the cost-effectiveness and patient-benefit. A panel discussion on this subject was organised at the 4th Croatian Congress of Clinical Cytology, in Split, October 11–14, 2009 by the Croatian Society for Clinical Cytology-Croatian Medical Asoctiation, to inform primary practitioners about the possibilities of cytodiagnostics in the health care of children and adults. Indications for cytodiagnostics in infectious diseases (T. Jeren and A. Vince), haematology (I. Kardum-Skelin), pulmonology (S. Smojver-Je`ek), thyroid diseases (A. Kne`evi}-Obad), breast diseases (I. Kardum-Skelin), gastroenterology and urology (G. Kai}) were discussed, as well as technical procedures and the interpretation of the cytological findings. Moderator (@. Znidar~i}) opened the panel with presentation about the role of clinical cytology, particularly in the primary health care. The discussion finally pointed at the necessity of better communication between primary practitioners and cytologists. This review article presents contents of the panel discussion

POLIOMYELITIS ERADICATION – ONE STEP TO ACHIEVE THE GOAL

Dječja paraliza - bolest uzrokovana poliovirusom - poznata je od davnina. S pojavom epidemija u dvadesetom stoljeću poliomijelitis postaje globalni javno zdravstveni problem. Svjetska zdravstvena organizacija (SZO) 1988. godine započinje kampanju s ciljem eradikacije poliomijelitisa te je do danas broj slučajeva smanjen za više od 99 %. U Hrvatskoj je cijepljenje protiv dječje paralize započelo već 1961. godine i dovelo do dramatičnog smanjenja obolijevanja. Eradikacija poliomijelitisa u Hrvatskoj proglašena je 2002. godine istodobno s eradikacijom ove bolesti u Europi. Ipak, krajnji cilj - polio-free world još nije postignut. Stoga, radna skupina globalne inicijative za eradikaciju poliomijelitisa donosi „Završni strateški plan 2013-2018“ u kojem su razrađeni postupci s ciljem rješavanja: a) trajnog prijenosa divljeg soja u endemskim zemljama, b) reinfekcije područja bez poliomijelitisa i c) epidemija dječje paralize uzrokovanih cirkulirajućim sojevima proizašlim iz cjepiva (cVDPV, engl. vaccine derived poliovirus). Slijedi povlačenje oralnog, atenuiranog poliovirusnog cjepiva (OPV) i uvođenje inaktiviranog cjepiva (IPV) na globalnoj razini.Poliomyelitis is a very old disease of humans, caused by poliovirus. With appearance of the epidemics in the 20th century, poliomyelitis became a global public health issue. In 1988, the World Health Organization started a campaign for global eradication of poliomyelitis and till now poliomyelitis cases have been reduced by more than 99%. In Croatia, the introduction of vaccination in 1961 resulted in dramatic reduction of paralytic disease. The European region, including Croatia was certifi ed polio free in 2002. However, the fi nal goal of the “polio-free world” has not yet been reached. To reinforce the campaign, the global polio eradication initiative has come up with the Polio Eradication & Endgame Strategic Plan 2013-2018 with detailed program how to resolve the main challenges: (a) continued transmission of wild polioviruses in endemic reservoirs; (b) reinfection of polio-free areas; and (c) outbreaks due to the circulating vaccine-derived polioviruses (cVDPV). Global oral polio vaccine cessation will follow, with the introduction of universal use of inactivated polio vaccine

Poster 18. - Prevalencija infekcije uzrokovane citomegalovirusum u bolesnika koji se liječe hemodijalizom

Citomegalovirus (CMV) je važan uzročnik infekcija u imunokompromitiranih osoba, uključujući bolesnike na hemodijalizi. Analizirana je prevalencija CMV infekcije u 162 bolesnika u terminalnoj fazi bubrežne bolesti koji se liječe hemodijalizom, testiranih u razdoblju od 2010.-2012. godine. Kontrolnu je skupinu sačinjavalo 160 zdravih osoba. U 34 bolesnika na hemodijalizi praćena je dinamika titra protutijela tijekom dvogodišnjeg razdoblja. Specifična CMV IgM/IgG protutijela dokazana su pomoću komercijalnog ELISA testa (ETI‑Cytok M/ETI‑Cytok G; DiaSorin, Saluggia, Italy). U svih IgM/IgG reaktivnih uzoraka određen je indeks aviditeta (AI) IgG protutijela (Euroimmun, Lübeck, Germany) u svrhu potvrde odnosno isključenja akutne/nedavne CMV infekcije.Ukupna IgG prevalencija bila je značajno viša u osoba na hemodijalizi (90,7%; 95%CI=84,4-94,2) u odnosu na kontrolnu skupinu (81,9%; 95%CI=75,0-87,5)[OR = 2,02; 95%CI=1,05-3,89]. Seroprevalencija se nije značajno razlikovala između muškaraca (87,9%) i žena (96,3%)[OR=1,22; 95%CI=0,65-2,29]. Opažen je porast seropozitiviteta s dobi ispitanika u bolesnika na hemodijalizi (73,3-96,8%) i kontrolnoj skupini (42,9-89,3%). Usporedbom prevalencije u istim dobnim skupinama testirane i kontrolne skupine, opažena je dvostruko viša IgG prevalencija u bolesnika na hemodijalizi mlađih od 34 godine (73,3%; 95%CI=73.3) 44.9-92.2) u odnosu na kontrolne ispitanike iste dobi (42,9%; 95%CI=17.7-71.1%). Razina titra IgG protutijela nije se razlikovala između testiranih skupina (p=0,219).Akutna/nedavna CMV infekcija zabilježena je tijekom ispitivanog perioda u tri (1,9%) bolesnika na hemodijalizi te 4 (2,5%) kontrolna ispitanika. U sva tri bolesnika na hemodijalizi nađena je asimptomatska reaktivacija CMV (visok AI u rasponu 81-95%). U tri ispitanika iz kontrolne skupine dokazana je primarna CMV infekcija (nizak, odnosno graničan AI u rasponu 42-58%) te u jednog ispitanika reaktivacija (AI 83%). U jednog (0,6%) početno seronegativnog bolesnika na hemodijalizi dokazana je serokonverzija tijekom druge godine praćenja.Zbog mogućnosti prijenosa CMV putem presatka organa, poznavanje serološkog statusa prije transplantacije važno je u prevenciji ove infekcije.

The Accuracy of Fine Needle Aspiration Cytology and Flow Cytometry in Evaluation of Nodal and Extranodal Sites in Patients with Suspicion of Lymphoma

Today lymphomas are defined according to a combination of morphology, immunophenotype, genetic features and clinical presentation, so beside the pure cytomorphologic analysis in diagnosis of lymphoma ancillary techniques such as cytochemistry, immunocytochemistry, molecular diagnosis and flow cytometry (FC) are often used. Our goal was to determinate how is information given by fine-needle aspiration cytology (FNAC) and FC correlated with pathohistologic diagnosis and to evaluate ability to diagnose and subclassify malignant lymphomas by FNAC and FC. This study is a retrospective chart review of patients with suspicion of lymphoma processed at University Hospital Dubrava in Zagreb. After analysis 50 patients fulfilled inclusion criteria for this study (FNAC diagnosis with or without FC and consecutive confirmatory pathohistological diagnosis). When analyzing accuracy of FNAC according to suspicion of lymphoma or NHL and differential diagnosis lymphoma sensitivity was 97.7%, specificity 85.7% and the diagnostic accuracy was 96%. When analyzing accuracy of FNAC according to the subclassification of lymphoma, sensitivity was 74.4%, specificity 85.7% and the diagnostic accuracy 76%. Combined FNAC and FC improved sensitivity, positive predictive value, negative predictive value and diagnostic accuracy. Sensitivity was 79.1% and the diagnostic accuracy 80%. We have shown that these methods can distinguish benign lymphadenopaties from lymphomas and also subclassify lymphomas and quickly provide clinicians with that information

Poster 18. - Prevalencija infekcije uzrokovane citomegalovirusum u bolesnika koji se liječe hemodijalizom

Citomegalovirus (CMV) je važan uzročnik infekcija u imunokompromitiranih osoba, uključujući bolesnike na hemodijalizi. Analizirana je prevalencija CMV infekcije u 162 bolesnika u terminalnoj fazi bubrežne bolesti koji se liječe hemodijalizom, testiranih u razdoblju od 2010.-2012. godine. Kontrolnu je skupinu sačinjavalo 160 zdravih osoba. U 34 bolesnika na hemodijalizi praćena je dinamika titra protutijela tijekom dvogodišnjeg razdoblja. Specifična CMV IgM/IgG protutijela dokazana su pomoću komercijalnog ELISA testa (ETI‑Cytok M/ETI‑Cytok G; DiaSorin, Saluggia, Italy). U svih IgM/IgG reaktivnih uzoraka određen je indeks aviditeta (AI) IgG protutijela (Euroimmun, Lübeck, Germany) u svrhu potvrde odnosno isključenja akutne/nedavne CMV infekcije.Ukupna IgG prevalencija bila je značajno viša u osoba na hemodijalizi (90,7%; 95%CI=84,4-94,2) u odnosu na kontrolnu skupinu (81,9%; 95%CI=75,0-87,5)[OR = 2,02; 95%CI=1,05-3,89]. Seroprevalencija se nije značajno razlikovala između muškaraca (87,9%) i žena (96,3%)[OR=1,22; 95%CI=0,65-2,29]. Opažen je porast seropozitiviteta s dobi ispitanika u bolesnika na hemodijalizi (73,3-96,8%) i kontrolnoj skupini (42,9-89,3%). Usporedbom prevalencije u istim dobnim skupinama testirane i kontrolne skupine, opažena je dvostruko viša IgG prevalencija u bolesnika na hemodijalizi mlađih od 34 godine (73,3%; 95%CI=73.3) 44.9-92.2) u odnosu na kontrolne ispitanike iste dobi (42,9%; 95%CI=17.7-71.1%). Razina titra IgG protutijela nije se razlikovala između testiranih skupina (p=0,219).Akutna/nedavna CMV infekcija zabilježena je tijekom ispitivanog perioda u tri (1,9%) bolesnika na hemodijalizi te 4 (2,5%) kontrolna ispitanika. U sva tri bolesnika na hemodijalizi nađena je asimptomatska reaktivacija CMV (visok AI u rasponu 81-95%). U tri ispitanika iz kontrolne skupine dokazana je primarna CMV infekcija (nizak, odnosno graničan AI u rasponu 42-58%) te u jednog ispitanika reaktivacija (AI 83%). U jednog (0,6%) početno seronegativnog bolesnika na hemodijalizi dokazana je serokonverzija tijekom druge godine praćenja.Zbog mogućnosti prijenosa CMV putem presatka organa, poznavanje serološkog statusa prije transplantacije važno je u prevenciji ove infekcije.

Misleading Presentations of Malignant Breast Diseases – Role of Clinical Cytology

We described two examples with misleading presentations to draw attention to the role of clinical cytology as a part of multidisciplinary approach to breast lesions. In the first case – Paget’s disease of the nipple, there was no obvious clinical and radiological evidence of breast cancer, while the second case – primary non-Hodgkin lymphoma of the breast imitated advanced breast carcinoma. The question is whether accurate and fast diagnoses can be made without cytological examinations. It must be kept in mind that first-hand clinical information and contact with the patient is necessary in rendering accurate cytological diagnoses