HPV (Human Papilloma Virus) is known to be related to cancers for a long time. However it was only recently that breakthrough has been made to introduce vaccines that can prevent HPV infection. The reason for this is that HPV infections are rarely, if ever, immediately ife-threatening. Vaccination has always focused towards preventing causes of immediate death or disability.

The importance of HPV vaccination has not been recognised either by healthcare providers or recipients as most of the HPV infections are silent but at least 50 percent(1) of sexually active men and women acquire genital HPV infection at some point in their lives. By age 50, at least 80 percent of women will have acquired genital HPV infection, manifest or otherwise.

The study conducted by Professor Margaret Stanley has dealt with HPV as aetiology, primarily of cervical cancer. However, HPV is also known to have a role in the causation of colorectal cancers, bladder cancers and head and neck cancers. In a study(2) conducted by National Cancer Institute, NIH, Bethesda, Maryland, it was seen that more than 50% of patients with colorectal cancers were positive for HPV DNA, where as the controls were negative for the same. This implies that even though HPV cannot be designated as the causative factor in colorectal cancers, it does increase the risk of development of these cancers. Further, more than one-third of patients who were positive had the HPV 16 subgroup.

Though the protection provided by the vaccine is not 100%, the study has still proved a 70% efficacy of the vaccine. Vaccines that are part of the British National Vaccination Schedule vary in their efficacy. For example, the influenza vaccine(1) is only 50%- 60% effective in preventing influenza-related hospitalization or pneumonia in adults > 65 years, but it is still strongly advocated since it decreases a substantial amount of morbidity and burden of disease in the general population.

Cancer Prevention is a very important part of healthcare provided by the NHS (National Health Service) in the United Kingdom (UK). There are organised, active cancer screening programmes(3) for the prevention of colon cancer, cervical cancer and breast cancer. HPV vaccination along with screening programmes can effectively be part of a multi-modal approach to cancer prevention and treatment if introduced as a part of the British National Vaccination Schedule in the UK.

There is the question of cost-effectiveness in introducing HPV vaccination in the British National Vaccination schedule as its role is less important in males than in females. However, there have been studies which show that HPV has a role in causation of male genital warts, carcinoma in situ and invasive carcinoma of the penis(4). In addition, as the study by Professor Margaret Stanley suggests, vaccination of young boys would help in establishing herd immunity, thus helping to prevent cervical cancer. Hence, though the significance of HPV vaccination is lesser in males due to the lower incidence of penile cancer, vaccination is still important in males in preventing penile cancer and cervical cancer. Since, at present there is no effective treatment for HPV infection except for removal of warts and excision of tissue damaged by the virus where possible, in my opinion HPV infections is better dealt with before it infects the body, than after.

References:

1. Centre for Disease Control and Prevention,Sexually Transmitted Diseases.
2. Clinical Cancer Research Vol. 11, 2862-2867, April 15, 2005
3. www.cancerscreening.nhs.uk
4. International Journal of Cancer, 2005 Sep 10;116(4):606-16.

Dear Editor

The histopathological assessment of prognostic factors in rectal cancer is important in guiding management. One of these factors is the circumferential resection margin (CRM). The involvement of CRM by tumour indicates a high risk of local recurrence, and is also an indicator of the quality of surgery performed1. Eid et al2 attempted to investigate the effects of processing variability on the assessment of lateral (circumferential) resection margins in rectal cancer, however, there are several issues which raise concern.

The usefulness in measuring the longest perpendicular resection margin is dubious. Surely it is the nearest distance of tumour to the CRM, which holds the relevant prognostic information. It would have been more useful had the authors detailed whether the changes in the distance of the tumour to the CRM had made any difference to the pathological staging, and thus, were of clinical significance.

The selection of the duration of formalin fixation, in particular the longer period of 7 days, used to compare artefactual changes is a curiosity. Although there are no guidelines to indicate the optimum duration colorectal cancer specimens have to be immersed in formalin prior to dissection, with increasing pressure to improve turnaround times and meet deadlines, it would be a surprise that they languish in formalin for up to 7 days before examination by a histopathologist. It is also best to avoid over-fixation in formalin as this may cause irreversible alteration in protein structures, which may be resistant to antigen unmasking techniques, thus compromising immunohistochemical studies, when required.

It was not made clear why the authors chose to use fresh control specimens when their study specimens had at least 4 days of formalin fixation prior to dissection. Moreover, the authors failed to explain the rationale of sectioning the fresh control specimens into smaller pieces of 10mm lengths and why the duration of formalin fixation of these pieces was different to the study specimens. The authors also appear to investigate a different variable in their control and study specimens, longitudinal and transverse measurements, respectively. Thus, the comparison of control and study specimens is tenuous.

The paper’s title was misleading and alluded to processing variability, however, the only variable studied is the duration of formalin fixation. There are several steps involved in the preparation of a tissue sample for histological examination. Generally, it encompasses fixation (usually by formalin), processing and embedding (the paraffin wax technique is the commonest) and sectioning. Contrary to the facts presented by the authors, formalin does not cause tissue shrinkage as a result of dehydration; it works by cross-linking proteins which results in firmness of the tissue. Tissue dehydration occurs during the processing stage whereby the tissue is subjected to progressive increased concentrations of ethanol. Furthermore, the authors gave no description of the processing technique used in their study and it is unclear where the rehydration stage, as described, takes place. It is therefore impossible to critically analyse their technique and accept their unexpected finding of tissue expansion.

Last but not least, it is a concern that the assessment of CRM may be suboptimal by the very economical application of yellow ink to the specimen illustrated in Figure 1. This appears to imply that tumour growth is restricted to a particular wall, when in actuality, many rectal cancers are circumferential. It is certainly not possible to predict the location and depth of tumour invasion prior to sectioning. The practice illustrated by the authors is not in accordance with the Royal College of Pathologists minimum dataset for colorectal cancer, which recommends painting the entire CRM with silver nitrate or India ink prior to dissection.

As there is a paucity of literature that examines the effects of formalin fixation on the histopathological assessment of CRM, the authors’ effort in attempting to address this is commendable, however, the study methodology and finding do not stand up to scrutiny.

References

1. National Minimum Dataset for Colorectal Cancer. The Royal College of Pathologists 1998.

2. Eid I, El-Muhtaseb MS, Mukherjee R, et al. Histological processing variability in the determination of lateral resection margins in rectal cancer. J Clin Pathol 2007; 60:593-595.

Dear Editor

We read with interest the case report of an adenocarcinoma arising in a gastrocystoplasty [1]. The authors also mention another report of a transitional cell carcinoma developing within a gastrocystoplasty [2] . We would like to point out however that a signet ring cell variant of adenocarcinoma within a gastrocystoplasty has also been described [3]. Briefly a 36-year-old man presented with renal failure having undergone a gastrocystoplasty for the treatment of a neuropathic bladder fourteen years earlier. He was subsequently found to have an anaplastic signet ring cell carcinoma which was invading the muscularis propria of both the gastric and vesical segments at the anastomosis and extended into the intramural segment of the wall of the left ureter. These observations would suggest that tumour formation is a late, but significant complication of gastrocystoplasty. Sixty cases of carcinoma formation within augmentation cystoplasties have now been described and there is evidence to suggest that the enterocystoplasties are genetically unstable and have an inherent potential for tumour formation [4-6]. Furthermore, tumours arising within enterocystoplasties are often aggressive, have a high mortality and are not usually detected by routine follow up cystoscopy [7].

There is some evidence to indicate that histological changes characteristic of chronic inflammation, metaplasia, and dysplasia as well as benign and malignant neoplasms may be more common in gastrocystoplasties than in either colocystoplasties or ileocystoplasties [8,9]. We agree with the authors that patients with a gastrocystoplasty should be followed up long term but would suggest that such patients should be informed of the potential risks of long term malignant transformation before undergoing the procedure. We would also suggest that it may be worthwhile to determine whether chromosomal abnormalities at the gastrovesical anastomosis may be useful in identifying those patients most at risk from malignant transformation.

References:

1. Balachandra B, Swanson PE, Upton MP, Yeh MM. Adenocarcinoma arising in a gastrocystoplasty. J Clin Pathol 2007; 60: 85-7.

2. Qiu H, Kordunskaya S, Yantiss RK. Transitional cell carcinoma arising in the gastric remnant following gastrocystoplasty: a case report and review of the literature. Intl J Surg Pathol 2003; 11: 143-7

3. Baydar DE, Allan RW, Castellan M, Labbie A, Epstein JI. Anaplastic signet ring cell carcinoma arising in gastrocystoplasty. Urology 2005; 65: 1226

4. Ivil KD, Jenkins GJ, Parry EM, Parry JM, Stephenson TP. Identification of early p53 mutations in clam ileocystoplasties using the restriction site mutation assay. J Urol 2003; 169 (Suppl 4): 139.

5. Ivil KD, Doak SH, Jenkins SA, Parry EM, Kynaston HG, Parry JM, Stephenson TP. Fluorescence in-situ hybridisation on biopsies from clam ileocystoplasties and on a clam cancer. Br J Cancer 2006; 94: 891-89.

6. Appanna TC, Doak SH, Jenkins SA, Kynaston HG, Stephenson TP, Parry JM. Comparative genomic hybridization (CGH) of augmentation cystoplasties. Int J Urol 2007. In Press.

7. Filmer RB, Spencer JR. Malignancies in bladder augmentations and intestinal conduits. J Urol 1990; 143: 671-8.

8. Buson H, Diaz DC, Manivel JC, Jessurun J, Dayanc M, Gonzalez R. The development of tumors in experimental gastroenterocystoplasty. J Urol 1993; 150: 730-3.

9. Little JS, Klee LW, Hoover DM, Rink RC. Long-term histopathological changes observed in rats subjected to augmentation cystoplasty. J Urol 1994; 152: 720-4.

Dear Editor

The world literature clearly recognises the role of the bone marrow trephine (BMT) biopsy in the investigation of haematological disorders and its flexibility in providing both diagnostic and prognostic information, an example of which appeared in the August edition of this journal This article gives an excellent account of the methodology employed and the accompanying illustrations clearly demonstrate the results of the wide array of investigations undertaken.

The authors talk about the use of resin embedding media noting that ‘resin embedding and semi-thin sections provide the best morphology; there have been questions on preservation of antigens and nucleic acids. However, RNA preservation and suitability for ISH analyses of mRNA is not clear’. They also discuss the need for specialised technology and skill and the additional associated costs. For these reasons the authors felt that the wax embedding would be their method of choice, the principles of their approach being that the results gave excellent morphology without compromising preservation of antigens and nucleic acids. They also required the method to be simple and integrated with standard processing schedules and for it to be inexpensive and non-toxic.

We have been able to meet all of these criteria with the added benefit of superior morphology by using Methyl Methacrylate (MMA) as the embedding medium. The reagent is cheap (<£8.00 for 500ml), easy to dispose of safely as an inert solid, and easily sectioned using disposable glass knives. There are several advantages to this practice in that the need for decalcification is greatly reduced and greater support of the tissue facilitates the routine production of 1-2ìm sections, thereby improving the quality of cell morphology on histological sections, within 24 hours of receipt.

The choice of resin is critical. Methyl methacrylate provides a stable and reliable embedding medium which has the added benefit of being readily removed from sections and thus does not inhibit the use of either conventional or immunohistochemical staining methods. We reciprocate in regular use, the range of antibodies demonstrated by Naresh et al. We also can demonstrate kappa and lambda light chains using ISH in trephines embedded in MMA.

As they authors rightly conclude, the ideal method for handling BMT specimens should be worked out at each institution. In Aberdeen we have found that initial fixation in 10% NBF followed by six hours in EDTA-NBF provides excellent morphology. Specimens are dehydrated overnight on an automated tissue processor, which is also has the facility to process specimens for EM, and embedded the following morning in fresh MMA. Polymerisation takes three hours thus specimens received late afternoon are embedded, cut and sectioned by the following lunch time. Urgent requests for ICC can be dealt with the same day and the results available within forty eight hours.

We also find that technical staff easily adapt to sectioning resin embedded material and the staining methods, dye based and immunohistological, are identical to those employed for wax embedded tissue. Antigen retrieval methods do not need to be changed and the ISH techniques required only minimal adaptation to the manufacturer’s instructions.

The results of both the Hammersmith protocol and that used in Aberdeen are comparable; the biggest advantage of our method must be the reduction in turnaround time of BMT specimens.