The purpose of this review is to describe the clinical features, pathology and molecular biology of intraocular lymphomas, which represent a heterogenous group of malignant neoplasms; to propose an anatomical classification of these tumours according to whether they occur in the retina or uvea; and to overview laboratory investigations and highlight factors required for successful biopsy. Recent findings show that retinal lymphomas are high-grade (i.e. aggressive), B-cell malignancies and are associated with a poor prognosis, with most patients dying of central nervous system disease. Immunophenotyping and somatic mutation analyses indicate that these lymphomas are probably derived from early post-germinal centre cells. Primary choroidal lymphomas are typically low-grade (i.e. indolent), B-cell tumours with morphological, immunophenotypical and genotypic features similar to extranodal marginal zone B-cell lymphomas (EMZL) elsewhere in the body. The putative cell of origin is the post-germinal centre (memory) B cell. Primary iridal lymphomas are very rare, with an equal distribution of B- and T-cell types and with a variable clinical course, most patients succumbing to their disease as a result of systemic dissemination. Primary lymphomas limited to the ciliary body are exceptionally rare. Secondary uveal lymphomas/leukaemias occur in patients with advanced systemic lymphoma or leukaemia, respectively. In summary, the term 'primary intraocular lymphoma (PIOL)' is imprecise. It would be preferable to refer to the various forms of intraocular lymphoma according to whether they are retinal, choroidal, ciliary or iridal and whether they are primary or secondary in these locations.

Understanding intraocular lymphomas

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations.

Biliary tract brush specimens are fast becoming the method of choice in the evaluation of patients who present with biliary tract strictures. Although the specificity is high, sensitivity rates for the detection of malignancy are generally low on cytological sampling. New liquid-based preparations and ancillary tests have emerged with the intent of addressing this issue. This review focuses on the current schemata used in the diagnosis of biliary tract lesions and the current available modalities which aid in the diagnosis of cholangiocarcinoma.

Biliary brushing cytology.

Background and aims: Characterisation of the underlying molecular mechanisms that promote Barrett’s progression may ultimately lead to identification of potential predictive genetic markers that classify patients’ malignant risk. In an attempt to understand these causative pathways, fluorescence in situ hybridisation (FISH) was used in this study to determine when specific genetic alterations arise during Barrett’s associated neoplastic progression.

Methods: Endoscopic cytology brushings were obtained from 28 patients with Barrett’s metaplasia, 28 with dysplasia (20 low grade dysplasia (LGD) and eight with high grade dysplasia (HGD)), and seven with adenocarcinoma, together with paired control brushings from regions of normal proximal squamous cell epithelium. The exfoliated epithelial cells were washed and deposited onto slides. Probes specific for the centromeres of chromosomes 4, 8, 20, and Y, and locus specific probes for the tumour suppressor genes p16, p53, and Rb were subsequently hybridised.

Results: Aneuploidy was found early in progression, with metaplastic tissues displaying increased copy numbers of chromosomes 4 and 8. Chromosome 4 hyperploidy was found in 89%, 90%, 88%, and 100% of metaplasias, LGD, HGD, adenocarcinomas, respectively, while chromosome 8 hyperploidy occurred in 71%, 75%, 100%, and 100% of patients with the respective staging. Loss of the p16 tumour suppressor gene also presented in metaplastic epithelium (7%) but most other genetic aberrations were only seen in HGD.

Conclusions: Genetic instability arises well before dysplasia in Barrett’s oesophagus, with chromosome 4 and 8 hyperploidy representing the earliest and most common alterations identified. As these aberrations are widespread at all the premalignant stages, there may be genes on chromosomes 4 and 8 that are involved in both the initiation and progression of Barrett’s oesophagus.

Chromosome 4 hyperploidy represents an early genetic aberration in premalignant Barrett’s oesophagus

Symptomatic oesophageal cancer is usually advanced and the prognosis poor. Lethality of symptomatic oesophageal cancer has motivated screening for these diseases earlier in their evolution, but reliable methods for early diagnosis remain elusive. We have demonstrated that dysregulated expression of minichromosome maintenance (MCM) proteins 2-7 is characteristic of early epithelial carcinogenesis, and that these key DNA replication initiation factors can be used as diagnostic markers for cervical and genito-urinary tract cancer. In this study, we investigated whether minichromosome maintenance protein 5 (Mcm5) can be used to detect oesophageal cancer cells in gastric aspirates. Two monoclonal antibodies raised against His-tagged human Mcm5 were used in a time-resolved immunofluorometric assay to measure Mcm5 levels in cells isolated from gastric aspirates of 40 patients undergoing gastroscopy for suspected or known oesophageal carcinoma or symptoms of dyspepsia. The test discriminated with high specificity and sensitivity between patients with and without oesophageal cancer (85% sensitivity (95% confidence interval (CI)=62-97%), 85% specificity (CI=66-96%)), as demonstrated by the large area under the receiver operating characteristics curve (0.93 (95% CI=0.85-0.99)). Elevated levels of Mcm5 in gastric aspirates are highly predictive of oesophageal cancer. This simple test for oesophageal cancer is readily automated with potential applications in primary diagnosis, surveillance and screening.

/pdf/diagnosis-of-oesophageal-cancer-by-detection-of-448np68ri0.pdf

Diagnosis of oesophageal cancer by detection of minichromosome maintenance 5 protein in gastric aspirates

To evaluate ThinPrep (Cytyc, Marlborough, MA) processing of endoscopic brushing specimens for cytologic examination, ThinPrep slides and direct smears of 29 gastrointestinal (GI) and 22 bronchial brushings were compared.

Clinicians prepared the direct smears. The brush was then immersed in CytoLyt (Cytyc) and one ThinPrep slide made. All cases had corresponding biopsies. Smears and ThinPrep slides were screened and reviewed independently. Screening time per case was recorded. All slides were evaluated for cellularity, quality, cellular preservation, and quantity of diagnostic cells. A diagnosis was rendered for each case. Cytologic and histologic diagnoses were correlated. Follow up was obtained for cases with discrepant histologic and cytologic diagnosis.

Twenty-three brushings were from esophagus, 5 stomach, 1 duodenum, and 22 lung. An average of 3.6 direct smears (range 2–6) was made for each case. Average screening time per case was 12 minutes for GI direct smear, 15 minutes bronchial direct smear, 4 minutes GI ThinPrep slide, and 9 minutes bronchial ThinPrep slide. ThinPrep slides were superior to direct smears in cellularity, quantity of diagnostic cells, and quality of slides. ThinPrep slides and direct smears showed comparable cellular preservation. The sensitivity of detecting malignancy by biopsy, direct smears, and ThinPrep slides was 81%, 75%, and 75%, respectively. One false-positive diagnosis was made on cytology with both direct smear and ThinPrep slide, a case with radiation atypia.

In conclusion, ThinPrep slides are at least comparable to direct smears in cytologic examination of brushings. However, false-positive diagnosis is a possible potential pitfall.

/pdf/thinprep-processing-of-endoscopic-brushing-specimens-5a3gp7q5gr.pdf

ThinPrep processing of endoscopic brushing specimens.

Value of cytology in detecting intestinal metaplasia and associated dysplasia at the gastroesophageal junction

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ThinPrep processing of endoscopic brushing specimens.

Value of cytology in detecting intestinal metaplasia and associated dysplasia at the gastroesophageal junction