Objectives. We set out to evaluate Hybrid Capture (Digene Corporation, Silver Spring, MD) testing for human papillomavirus (HPV) in the management of a screening population with atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LGSIL). Methods. A total of 619 patients with ASCUS or LGSIL Papanicolaou smears were tested for high-risk HPV types. They then were followed at 6-month intervals with Papanicolaou smears and repeat HPV testing. Patients with persistent or progressive disease were referred for colposcopy. HPV results were compared to the most significant follow-up cytological or colposcopic diagnosis to determine whether Hybrid Capture HPV testing was predictive of outcome. A cost analysis was performed. Results. Follow-up of 12 to 30 months was available for 471 patients (76.1%). Outcome diagnoses for 190 patients who initially tested HPV-positive were as follows: 49% benign, 14% ASCUS, 19% LGSIL, 18% HGSIL, and 0.5% cancer. For 281 patients who initially tested HPV-negative, outcomes were 77% benign, 14% ASCUS, 6% LGSIL, 2% HGSIL, and 0.3% cancer. Twenty-six of the patients with HGSIL had two or more HPV tests, and all these patients had at least one positive result. Conclusions. Hybrid Capture testing for high-risk HPV types was predictive of which patients presenting with ASCUS/LGSIL would persist or progress to HGSIL (p < .001). The cost of adding Hybrid Capture testing was intermediate between the cost of cytological follow-up and referral of all patients with ASCUS/LGSIL to colposcopy.
We set out to evaluate Hybrid Capture (Digene Corporation, Silver Spring, MD) testing for human papillomavirus (HPV) in the management of a screening population with atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LGSIL).A total of 619 patients with ASCUS or LGSIL Papanicolaou smears were tested for high-risk HPV types. They then were followed at 6-month intervals with Papanicolaou smears and repeat HPV testing. Patients with persistent or progressive disease were referred for colposcopy. HPV results were compared to the most significant follow-up cytological or colposcopic diagnosis to determine whether Hybrid Capture HPV testing was predictive of outcome. A cost analysis was performed.Follow-up of 12 to 30 months was available for 471 patients (76.1%). Outcome diagnoses for 190 patients who initially tested HPV-positive were as follows: 49% benign, 14% ASCUS, 19% LGSIL, 18% HGSIL, and 0.5% cancer. For 281 patients who initially tested HPV-negative, outcomes were 77% benign, 14% ASCUS, 6% LGSIL, 2% HGSIL, and 0.3% cancer. Twenty-six of the patients with HGSIL had two or more HPV tests, and all these patients had at least one positive result.Hybrid Capture testing for high-risk HPV types was predictive of which patients presenting with ASCUS/LGSIL would persist or progress to HGSIL (p < .001). The cost of adding Hybrid Capture testing was intermediate between the cost of cytological follow-up and referral of all patients with ASCUS/LGSIL to colposcopy.
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Merkel cell carcinoma is an aggressive neuroendocrine tumor historically thought to arise from neural crest-derived cutaneous neuroendocrine cells. Recent evidence supports an epidermal origin. We present a case of Merkel cell carcinoma arising on the upper arm of a 94-year-old woman that had multiple morphologic patterns: small cells typical of Merkel cell carcinoma, malignant cells with squamous differentiation and malignant poorly differentiated spindle cells. Subsequent metastatic disease in regional lymph nodes showed only the small cells and the malignant spindle cells. To our knowledge, this is the first case of Merkel cell carcinoma showing these three patterns of differentiation at first presentation. This morphology raises the possibility that Merkel cell carcinomas may arise from epidermal stem cells that can differentiate along different lines.
Background: Acanthosis nigricans (AN) has been associated with insulin resistance. Individuals with type 2 diabetes are insulin-resistant and, therefore, could be expected to manifest AN. However, the prevalence and predictors of AN are unknown in this population. Objective: An outpatient population with Type 2 diabetes (DM) was compared with matched controls (C) for microscopic and clinical AN along with measurement of body habitus, insulin, glucose, and androgen levels. Methods: Twenty-four individuals with DM (12M, 12F) from a tertiary care center were compared with 24 C (12M, 12F). Fasting glucose, insulin, sex hormone binding globulin, androstenedione, dihydroepiandrosterone sulfate, and testosterone were measured. Height, weight, waist/hip measures, and a clinical survey for acanthosis were recorded. A 2-mm skin biopsy from midaxilla of the nondominant arm was taken for pathological review. Results: C and DM were matched for age and body mass index (BMI). Prevalence of microscopic AN in C was 12% (3/24) and in DM was 21% (5/24; NS). In C, AN was predicted by waist, waist/hip ratio, and fasting insulin measures, while none of the variables examined was predicative of AN in DM. Conclusions: Microscopic acanthosis nigricans was found in similar numbers of people with DM when compared with C. Fasting insulin levels most strongly predicted the presence of AN in C, while no significant predictors of AN were found in the population with DM.
A young woman presented to the office with a history of bluish discoloration involving the superior malar region bilaterally. When the bluish discoloration became darker, she would press on her cheeks resulting in excretion of "black sweat" that temporarily lightened her skin color. Examination revealed ill-defined slightly swollen soft plaques involving both superior cheeks. Upon pressure on the cheeks, a dark brown fluid was expressed. Histologic examination revealed collections of ectopic apocrine glands within mid-reticular dermis. The diagnosis of apocrine chromhidrosis was made, an uncommon cause of chromhidrosis and one in which bilateral facial presentation is rare.
Testing for human papillomavirus (HPV) as a adjunct to the Pap smear in cervical cancer screening programs has been suggested as a means of predicting which cervical abnormality will progress to cancer. In this study, 619 women with atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesions (LGSIL) diagnosed over an 18-month period were evaluated for high-risk HPV types using first-generation Hybrid Capture testing (Digene Corporation, Silver Spring, MD). All patients were followed up conservatively at 6-month intervals with repeated Pap testing. Patients with progressive or persistent disease (three consecutive findings of ASCUS or LGSIL) were referred for colposcopy, and the colposcopic findings were compared with the results of HPV testing. At the end of the study, the most severe cytologic or histologic diagnosis was used as the final diagnosis for patients who did not undergo colposcopy. One hundred thirty-five of the 197 women with LGSIL (69 percent) were positive for HPV. One hundred seven HPV-positive and 49 HPV-negative patients in this group returned for follow-up and were available for evaluation. Fifty-six HPV-positive patients were referred for colposcopy during the course of the study. Normal or low-grade changes were found in 32 of these women, but 23 (21 percent) were diagnosed with high-grade squamous intraepithelial lesions (HGSIL). One HPV-positive woman with a smear indicating LGSIL was found to have invasive cancer at colposcopy. Seventeen of the 49 HPV-negative women were referred for colposcopy, and only 3 (6 percent) were found to have high-grade disease. Of the 422 patients with an initial diagnoses of ASCUS, 116 (28 percent) were HPV positive. Follow-up information was available for 83 patients, of whom 25 were referred for colposcopy. In this group, 7 patients were diagnosed with LGSIL, and 10 were found to have HGSIL. Cancer did not develop in any of these patients. There were 232 HPV-negative patients with ASCUS who returned for follow-up; 34 underwent colposcopy. Six women with ASCUS were negative for HPV but were diagnosed with LGSIL, and four were identified as having HGSIL. One woman who presented with a Pap smear indicating ASCUS was HPV negative but had invasive cancer. Altogether, 37.3 percent of the patients who tested positive for HPV had LGSIL, HGSIL, or cancer, compared with 8.5 percent of those who were negative for HPV (P < .001). Overall, 83 percent of the women with high-grade lesions tested positive for high-risk HPV types on their initial visit. If positive HPV results had been used as the referral criterion, 40 percent of the women would have been referred for colposcopy. When Hybrid Capture HPV testing was performed multiple times, persistent positivity was more predictive of a final diagnosis of HGSIL or LGSIL than a single positive result (P = .04). In fact, of the seven initially HPV-negative patients who eventually progressed to HGSIL, four underwent multiple HPV tests and all converted to positive. When a cost analysis of this study was performed, referral of all patients with ASCUS or higher to colposcopy had a cost of $123,800, cytologic follow-up with referral for persistent or progressive disease had a cost of $81,860, and referral based on HPV Hybrid Capture HPV positive results had a total cost of $98,795. There were no patients lost to follow-up with the immediate colposcopy strategy; 148 were lost using cytological follow-up only (actual study); and 88 would be lost to follow-up if the HPV testing triage strategy were used. J Lower Genital Tract Dis 2000;4:12–17
Nowadays it is a widespread practice to prescribe various hormonal preparations to women: contraceptives drugs to treat infertility and various diaphragms. These are prescribed by gynecologists almost in an assembly line-fashion for menstruation disorders and problems related to menopause. It has not been established if there is connection between the etiology of breast cancer and the increasing treatment of women with hormonal preparations. Different gynecologists have differing viewpoints regarding this issue. There is even a difference between male and female gynecologists since males tend to prescribe hormonal preparations more liberally in comparison to females. The proponents of hormone use argue that the period of menopause is eased by the use of various hormonal preparations; they prevent osteoporosis in old age and they reduce cardiovascular diseases and menopausal complaints. The more cautious gynecologists are less extravagant in prescribing hormonal preparations. This conflict and controversy has prompted the author to join with several women in founding a hormone group within an association of women in Finland whose goal is to organize various educational courses and meetings between doctors and women. During these sessions the issue of hormonal treatment and its putative connection to breast cancer would be elucidated especially for those who are about to decide whether to take hormonal preparations. On the one hand if hormonal preparations are taken there is possible an increased risk of breast cancer; on the other hand hormones might alleviate discomfort during the years of menopause. These educational encounters would make it possible for everyone to see this matter with more clarity.
