Combination of cytologic evaluation and quantitative digital cytometry is reliable in detecting recurrent disease in patients with urinary diversions

BACKGROUND: Detecting recurrent bladder carcinoma early is important because it is a multifocal disease that may affect the bladder mucosa, ureters, urethra, and renal pelvis and is associated with high morbidity and mortality rates. However, specimens from patients who have undergone cystectomy with urinary diversion can be difficult to interpret by cytologic evaluation because they often contain degenerated epithelial cells, histiocytes, acute inflammatory cells, bacteria, and cellular debris. In this retrospective study, the reliability of quantitative digital cytometry (QDC) in conjunction with cytologic evaluation in detecting recurrent disease was determined in these patients. METHODS: In all, 116 specimens were identified from the cytology files from 83 patients who had undergone radical cystectomy with urinary diversion for bladder carcinoma at the study institution between 2002 and 2005; all specimens underwent cytologic evaluation and 105 underwent QDC. Two cytospin slides were prepared for cytologic evaluation and 1 for QDC. At least 100 of the most atypical cells were interactively digitized and evaluated for ploidy, the percentage of proliferating cells, and the percentage of cells with a DNA content greater than 5c. Based on these parameters, the DNA histograms were grouped by pattern: diploid, abnormal diploid, tetraploid, and aneuploid. The cytologic evaluation and QDC results were compared with the clinical follow-up data. RESULTS: In all, 103 specimens were negative for recurrent disease or had atypical cells on cytologic examination and were found to have diploid or abnormal diploid patterns on QDC. None of these cases had clinical evidence of upper urinary tract disease at the time the first specimen was obtained. However, recurrent urothelial carcinoma was found in subsequent conduit specimens from 2 patients. Thirteen specimens from 9 patients were suspicious or positive for malignancy by cytology. Five of these patients had an upper urinary tract recurrence and their specimens were found to be abnormal on cytologic evaluation and QDC, with 15% of cells with a DNA content greater than 5c. CONCLUSIONS: Combined cytologic evaluation and QDC is a reliable method of detecting recurrent disease in patients with urinary diversions and can be used to regularly monitor these high-risk patients.     

The fate of transplanted xenogeneic bone marrow‐derived stem cells in rat intervertebral discs

Intervertebral disc degeneration is a major cause and a risk factor for chronic low back pain. The potential of using stem cells to treat disc degeneration has been raised. The aims of our study were to assess whether xenogeneic bone‐marrow derived stem cells could survive in a rat disc degeneration model and to determine which cell types, if any, survived and differentiated into disc‐like cells. Human bone‐marrow derived CD34⁺ (hematopoietic progenitor cells) and CD34^? (nonhematopoietic progenitor cells, including mesenchymal stem cells) cells were isolated, fluorescent‐labeled, and injected into rat coccygeal discs. The rats were sacrificed at day 1, 10, 21, and 42. Treated discs were examined by histological and immunostaining techniques and compared to control discs. The survival of transplanted cells was further confirmed with a human nuclear specific marker. Fluorescent labeled CD34^? cells were detected until day 42 in the nucleus pulposus of the injected discs. After 3 weeks these cells had differentiated into cells expressing chondrocytic phenotype (Collagen II and Sox‐9). In contrast, the fluorescent labeled CD34⁺ cells could not be detected after day 21. No fluorescence‐positive cells were detected in the noninjected control discs. Further, no inflammatory cells infiltrated the nucleus pulposus, even though these animals had not received immunosuppressive treatment. Our data provide evidence that transplanted human BM CD34^? cells survived and differentiated within the relative immune privileged nucleus pulposus of intervertebral disc degeneration. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:374–379, 2009     

Hexylaminolaevulinate ‘blue light’ fluorescence cystoscopy in the investigation of clinically unconfirmed positive urine cytology

OBJECTIVE

To investigate the value of photodynamic diagnosis (PDD) using hexylaminolaevulinate (Hexvix®, PhotoCure, Oslo, Norway) in the investigation of patients with positive urine cytology who have no evidence of disease after standard initial investigations.

PATIENTS AND METHODS

Twenty‐three patients referred with positive urine cytology but no current histological evidence of cancer were investigated between April 2005 and January 2007 with PDD, using Hexvix and the d ‐light system (Karl Storz, Tuttlingen, Germany) to detect fluorescence. The bladder was mapped initially under white light and then under ‘blue‐light’. Biopsies were taken from abnormal urothelium detected by white light, fluorescence, or both. All cytological specimens were reviewed by a reference cytopathologist unaware of the result of the PDD.

RESULTS

Twenty‐five PDD‐assisted cystoscopies were carried out on 23 patients (20 men/3 women; median age 64 years, range 24–80 years). Of the 23 patients, 17 (74%) were previously untreated for transitional cell carcinoma (TCC), whilst six were under surveillance for previous TCC. Nineteen of the 23 (83%) cytology specimens were confirmed as suspicious or positive by the reference pathologist. TCC of the bladder or preneoplastic lesions were diagnosed in six patients, i.e. six (26%) of those investigated and six of 19 (32%) with confirmed positive cytology. Four of the six were under surveillance for previous bladder tumour. Additional pathology was detected by fluorescence in five of the six patients, including two carcinoma in situ (CIS), one CIS + G3pT1 tumour, and two dysplasia. Diagnoses in PDD‐negative cases included one upper tract TCC and four patients with stones. In addition, one patient had CIS diagnosed on both white light and PDD 6 months later.

CONCLUSION

Additional pathology was detected by HAL fluorescence cystoscopy in 32% of patients with confirmed positive urinary cytology. PDD is a key step in the management of patients with positive urinary cytology and no evidence of disease on conventional tests.     

Meniscal ossicle

Meniscal ossicle, or bone within the substance of meniscus, is a rare entity and commonly confused with a loose body both clinically and radiologically. MRI is the modality that can definitely diagnose meniscal ossicle and avoid unnecessary diagnostic arthroscopy. Here we report one such case diagnosed using MRI; this patient is doing well without surgery one year after diagnosis.     

Technical aspects of the use of dynamic condylar screw in biological fixation of comminuted subtrochanteric fractures

Background  Indirect reduction and biological internal fixation using dynamic condylar screw (DCS) yield acceptable results in comminuted subtrochanteric fractures. An analysis of the technical difficulties of the procedure with the tricks to prevent these is presented. Materials and methods  Forty-eight consecutive patients with the mean age of 44.5 years with comminuted subtrochanteric fractures were treated with a DCS and biological reduction methods. Results  All fractures united without bone grafting at average union time of 16.16 weeks. Average Harris hip score was 87.97 points. We observed technical difficulties in six patients like inaccurate placement of guide pin in two; difficulty in sliding the plate due to obesity in one; difficulty in gliding barrel plate over condylar screw in one; and technical failure in two patients. Malunion (coxa vara) leading to limp occurred in one patient. A mean limb length discrepancy of 1.46 cm was detected in 5 patients at last follow up. We improvised the technique to overcome these difficulties. Conclusions  Accurate placement of the guide pin is the key to avoid technical difficulties during the procedure. Surgeon should not proceed further until completely satisfied with the position of the guide pin. Few tricks in the technique make use of dynamic condylar screw in biological fixation of comminuted subtrochanteric fractures easier.