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usually seen in one single gland or in groups of pyloric glands. The vacuoles contain fat.[2] Rubio and Kato[1] described four other different types of vacuolated cells occurring in the gastric mucosa. One type was characterized by supranuclear clear vacuoles, the other by supranuclear dark vacuoles, another by usually supranuclear vacuoles and cilia, and a fourth type by supranuclear clear vacuoles centered by a lymphocyte.[3] In our experience of 158.020 gastric biopsies, the present case is the first finding of “subnuclear empty vacuolated cell” metaplasia of the gastric mucosa. According to our knowledge, this type of metaplasia has not been reported till now.
Teresa Pusiol, Guido Mazzoleni1, Esther Hanspeter1, Doriana Morichetti, Maria Grazia Zorzi Institute of Anatomic Pathology, Rovereto Hospital, 1 Institute of Anatomic Pathology, Bolzano Hospital, Italy Address for Correspondence: Dr. Teresa Pusiol, MD, Institute of Anatomic Pathology, S. Maria del Carmine Hospital, Piazzale S. Maria 6, 38068 Rovereto (TN), Italy. E-mail
[email protected]
REFERENCES 1. 2.
3.
Rubio CA, Kato Y. Classification of vacuolated cells in the gastric mucosa. J Surg Oncol 1987;34:128-32. Torikata C, Mukai M, Kawakita H. Ultrastructure of the mucus-negative vacuolated cells in the metaplastic pyloric gland of the human stomach. Hum Pathol 1989;20:437-40. Rubio CA. Five types of pyloric cells in the antral mucosa of the stomach. Pathol Res Pract 1992;188:157-61. Access this article online Quick Response Code:
Website: www.ijpmonline.org PMID: *** DOI: 10.4103/0377-4929.97907
The association of EpsteinBarr virus infection with multiple myeloma Sir, We read with interest the recent article by Sadeghian et al. published in the last issue of this journal.[1] The etiology of multiple myeloma (MM) is poorly understood. A number of viruses have been implicated, but the findings have been 266
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Figure 1: EBER-in situ hybridiza on on a case of breast ssue showing the presence of EBV in an occasional infiltra ng lymphocyte (brown)
controversial. The study by Sadeghian et al. is yet another report exploring the possibility of a viral involvement in the pathogenesis of this malignancy. The authors examined if Epstein-Barr virus (EBV) was associated with MM. They found 10/30 MM patients and 3/30 controls to be EBV positive by polymerase chain reaction (PCR). The authors concluded that EBV is associated with MM. EBV is a B-cell lymphotropic member of the herpesviridae family. It is arguably one of the best studied human oncogenic viruses. Although the virus selectively infects B-cells using CD21/C3d receptor, the virus has been linked to the pathogenesis of a number of human malignancies of both lymphoid and epithelial origin, including Burkitt’s lymphoma, nasphopharyngeal carcinoma, and post-transplant lymphomas.[2] However, the mechanism(s) of EBV involvement in the pathogenesis of many of these malignancies is not fully understood. In recent years, the demonstration of EBV genome[3] and EBV gene expression[4] at the cellular level have become the ‘gold standards’ in studies aimed at investigating a role for this virus in the pathogenesis of human malignancies. Since EBV is ubiquitous in the healthy population, with over 90% of people seropositive worldwide, its mere detection cannot be simply equated with disease. In this context, the study by Sadeghian et al. needs to be interpreted with caution. Using PCR, the authors reported the detection of EBV in 10/30 MM and 3/30 controls. In order to imply an etiological role for EBV in the pathogenesis of MM, the authors should have performed EBV encoded RNA (EBER)-in situ hybridization and immunohistochemistry to show that the virus is present in the malignant cells and is transcriptionally active. In the absence of such data, the association between EBV and MM may be purely casual. Indeed, we have recently shown that in breast cancer, another malignancy in which EBV has been implicated, the virus can be detected in approximately 50% of the cases, but not in the malignant cells.[5] Rather the virus is localized to infiltrating inflammatory lymphocytes and therefore unlikely to be directly involved in the disease process
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[Figure 1]. Using PCR for the detection of EBV, positivity can be incorrectly interpreted to mean that the virus is associated with the disease process and this should be avoided. ACKNOWLEDGMENT
Table 1: DNA ploidy analysis of Atypical Squamous Cells (ASC) of Uterine Cervix Cytologic diagnosis ASC-US ASC-H Total
This work was support by a grant from the FMHS, UAEU.
diploid 30 3 33
DNA ploidy pa ern polyploid aneuploid 15 5 (2*) 4(2*) 3 (2*) 19 8
Total 50 10 60
* HR-HPV16 posi ve
Gulfaraz Khan Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE. Address for correspondence: Dr. Gulfaraz Khan, Department of Microbiology and Immunology,Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, PO Box 17666, United Arab Emirates. E-mail:
[email protected]
REFERENCES 1.
2.
3.
4.
5.
Sadeghian MH, Ayatollahi H, Keramati MR, Memar B, Jamedar SA, Avval MM, et al. The association of Epstein-Barr Virus infection with multiple myeloma. Indian J Pathol Microbiol 2011;54:720-4. Kieff E, Rickinson AB. Epstein-Barr Virus and its Replication. In: Knipe DM, Howley PM, editors. Fields Virology. Philadelphia: Wolters Kluwer/Lippincott; 2007. p. 2634-54. Khan G, Coates PJ, Kangro HO, Slavin G. Epstein Barr virus (EBV) encoded small RNAs: Targets for detection by in situ hybridisation with oligonucleotide probes. J Clin Pathol 1992;45:616-20. Young LS, Deacon EM, Rowe M, Crocker J, Herbst H, Niedobitek G, et al. Epstein-Barr virus latent genes in tumour cells of Hodgkin’s disease. Lancet 1991;337:1617. Khan G, Philip PS, Al Ashari M, Houcinat Y, Daoud S. Localization of Epstein-Barr virus to infiltrating lymphocytes in breast carcinomas and not malignant cells. Exp Mol Pathol 2011;91:466-70. Access this article online Quick Response Code:
For the present report 3000 Pap smears were screened and diagnosed as per TBS 2001. A total of 60 (2%) cases were diagnosed as atypical squamous cells (ASC) consisting 50 (1.7%) cases of undetermined significance (ASC-US) and 10 (0.3%) cases of atypical squamous cells- cannot exclude hyperplasia (ASC-H) on the basis of cytomorphological features. The smears were reviewed and atypical squamous cells were marked by glass pencil on the back of glass slide and after destaining, processed for Feulgen staining and DNA ploidy analysis[2]. For control, 50 normal intermediate cells were measured and their mean DNA value was considered as ‘Diploid’. About 10-15 atypical squamous cells (ASC) of each category i.e. ASC-US and ASC-H were analyzed per smear for microphotometric DNA analysis and the cases were categorized as diploid, polyploid and aneuploid. Cervical scrapes of all ASC cases were also tested for HR- HPV 16 DNA by PCR amplification[5].
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Microphotometric nuclear DNA analysis of atypical squamous cells of the uterine cervix Sir, Pap smear is the standard screening tool, in low resource settings, INDIAN JOURNAL
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used to test for the presence of atypical cells of the uterine cervix that could become intraepithelial lesions or cancerous. The Bethesda system (TBS) 2001 has largely replaced previous classifications of Pap smears and is dividing the smears in two groups- low grade squamous intraepithelial lesions (LSIL) or high grade squamous intraepithelial lesions (HSIL).[1] A third category, atypical squamous cells (ASC) is used to classify minimal cellular changes that do not satisfy the criteria for the LSIL or HSIL. Atypical squamous cells are further divided into atypical squamous cells of undetermined significance (ASC-US) and atypical squamous cells-cannot exclude high grade lesions (ASC-H). The management of ASC-US is a triage with HR-HPV testing and colposcopy is recommended for ASC-H. Deoxy ribonucleic acid (DNA) aneuploidy is another important indicator to predict the biologic potential of squamous intraepithelial lesions. By nuclear DNA quantitation, the intraepithelial lesions could be euploid, polyploid or aneuploid. Changes having euploid or polyploid DNA distribution are most likely related to stimulated hyperplastic, non-neoplastic process secondary to infection, inflammation, repair or other unidentified agents. Those changes having an aneuploid DNA pattern are true neoplastic processes associated with significant alterations in the chromosomes and mitoses[2-4]. This study was aimed to reveal aneuploid DNA pattern of atypical squamous cells with high risk, HR-HPV DNA positivity.
The 50 cases, cytologically diagnosed as ASC-US showed intermediate squamous cells with mildly enlarged nuclei (2-3 times the size of normal intermediate cell), slightly hyperchromatic, round to oval in shape with minimal irregularities. Amongst them 30 (60%) cases had diploid, 15 (30%) had polyploid and
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