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Koiloplasia in cervical cytology
CORRESPONDENCE
Koiloplasia in Cervical Cytology
cardiomyopathy described in the J u n e 1985 issue of Human Pathology. 1 Is Keshan disease an established entity peculiar to China? T h e epidemiologic characterization of Keshan disease does not coincide with that of endemic disease in general, such as endemic goiter of thyroid. T h e geographic distribution is not nearly so definite. As mentioned above, Keshan disease was at first known to occur in the north-east part o f China, but new "endemic areas," including Tibet and Yunnan, were reported successively in the 1960s and 1970s, Furthermore, the incidence has markedly declined not only in the north-east, but also in the other reported regions. This happened when the population changed their diet from a monotonous type to that o f more variety. Even during the height o f the disease, people within the endemic area who lived on a better diet remained free from the disease. Hence, Keshan disease was virtually a disease of rural population, and most patients were children, not infrequently the next to the youngest in the family. In Shandong province, the main staple of the patients was a kind of dry roll made of sweet potato flour, which is practically devoid of water-soluble vitamins and lacks protein. In all probability, Keshan disease is a condition or syndrome related to or a result o f malnutrition, T h e marked decrease in the incidence of Keshan disease cannot be attributed to a supplement of selenium, as this procedure was only done in limited areas.
To the Editor:--The increasingly c o m m o n cytologic changes associated with infection of the uterine cervical epithelium with h u m a n papilloma virus (HPV) have taken on greater significance because of the association of HPV infection with cervical carcinoma. The characteristic appearance in cervical smears of infected cells--koilocytes (cells with irregular hyperchromatic smudged nuclei surrounded by a cytoplasmic cave)--readily permits diagnosis in most cases. However, in addition to the cytologic evidence of HPV infection, cervical smears may contain cells that have irregular hyperchromatic nuclei enlarged within the range ordinarily considered dysplastic (>150 txmz) and with a high nuclear to cytoplasmic ratio. Some cytopathologists have simply chosen to ignore the HPV-associated cellular changes and diagnosed such specimens usin~ the standard criteria for cervical squamous cell dysplasia. Another approach is to consider cells having large dysplastic-size nuclei (no matter how large or bizarre) and obvious koilocytic features as koilocytic atypia; associated cells with dysplasticsized nuclei, but no obvious koilocytic features are classified according to the ordinary criteria for dysplasia. Unfortunately, neither approach is entirely satisfactory, since the diagnosis o f dysplasia in such situations creates considerable anxiety for the patient and mandates therapeutic intervention by the gynecologist. The cytopathologist is then often placed in the uncomfortable position of being at odds with his or her surgical pathology colleagues, who find only koilocytic changes and no dysplasia in biopsies from patients whose cervical smears contained both marked dysplasia (by traditional cytologic criteria) and cells with koilocytic features. A possible solution to this dilemma would be tbr the cytopathologist to describe these cervical smears using a hybrid (but neutral) term, such as koiloplasia, that suggests the overlapping yet distinctive HPV-associated epithelial disturbance. By adopting such terminology, practicing gynecologists, cytopathologists, and surgical pathologists would be freed from the need to practice the "defensive medicine" that requires clinical management based on a traditional model for cervical epithelial neoplasia,1 and a new model based on degree of koiloplastic abnormality could be developed.
PEI-LIANGYu, MD Department o f Pathology Shandong Medical University Jinan Shandong People's Republic of China 1. Li G, Wang F, Kang D, et al: Keshan Disease: An endemic Cardiomyopathy in China. HUMPAXHOL16:602-609, 1985
A Viral Etiology in Fuchs' Corneal Dystrophy: The Authors" Reply
ROCEk A. BRUMBACK,MD Department of Pathology University of Oklahoma Health Sciences Center and Veterans Administration Medical Center Oklahoma City 1. Patten SF Jr: Diagnostic Cytopathologyof the Uterine Cervix. Basel, Karger, 1978
To the Editor.'--We agree fully with H u m a y u n and Pepose x that culture, in situ hybridization, or immunocytochemistry would be definitive in identifying the viral inclusions in the endothelium in Fuchs' corneal dystrophy. 2 However, these techniques were not available to us at the time of this publication. A viral etiology was postulated only as one of many possibilities. We considered the possibility that these structures represented mitochondria, but feel that the presence of the unencapsulated nucleocapsids is against this interpretation. Typical m i t o c h o n d r i a were identified in the endothelial cells. SANFORD I. ROTH, MD E, LEE STOCK, MD ROME JUTABHA, BSM Departments of Pathology and Ophthalmology Northwestern University Medical School Chicago
Keshan Disease: An Entity or Not To the Editor:--For decades, it has been customary to consider Keshan disease as a disease entity in China. Keshah is the name of a district in the north-east part of China, and the disease derived its name because of its prevalence in that area in the 1930s. However, in recent years, this prevalence is no longer true. As a matter of fact, people from that district object to the label, Keshan, to the type of
1. Humayun MS, PeposeJS: A viral etiologyin Fuchs' corneal dystrophy. HUMPATHOL19:245, 1988 (letter) 2. Roth SI, Stock EL, Jutabha R: Endothelial viral inclusions in Fuchs' corneal dystrophy. HUMPArHOL18:338-341, 1987
874
Koiloplasia in Cervical Cytology
cardiomyopathy described in the J u n e 1985 issue of Human Pathology. 1 Is Keshan disease an established entity peculiar to China? T h e epidemiologic characterization of Keshan disease does not coincide with that of endemic disease in general, such as endemic goiter of thyroid. T h e geographic distribution is not nearly so definite. As mentioned above, Keshan disease was at first known to occur in the north-east part o f China, but new "endemic areas," including Tibet and Yunnan, were reported successively in the 1960s and 1970s, Furthermore, the incidence has markedly declined not only in the north-east, but also in the other reported regions. This happened when the population changed their diet from a monotonous type to that o f more variety. Even during the height o f the disease, people within the endemic area who lived on a better diet remained free from the disease. Hence, Keshan disease was virtually a disease of rural population, and most patients were children, not infrequently the next to the youngest in the family. In Shandong province, the main staple of the patients was a kind of dry roll made of sweet potato flour, which is practically devoid of water-soluble vitamins and lacks protein. In all probability, Keshan disease is a condition or syndrome related to or a result o f malnutrition, T h e marked decrease in the incidence of Keshan disease cannot be attributed to a supplement of selenium, as this procedure was only done in limited areas.
To the Editor:--The increasingly c o m m o n cytologic changes associated with infection of the uterine cervical epithelium with h u m a n papilloma virus (HPV) have taken on greater significance because of the association of HPV infection with cervical carcinoma. The characteristic appearance in cervical smears of infected cells--koilocytes (cells with irregular hyperchromatic smudged nuclei surrounded by a cytoplasmic cave)--readily permits diagnosis in most cases. However, in addition to the cytologic evidence of HPV infection, cervical smears may contain cells that have irregular hyperchromatic nuclei enlarged within the range ordinarily considered dysplastic (>150 txmz) and with a high nuclear to cytoplasmic ratio. Some cytopathologists have simply chosen to ignore the HPV-associated cellular changes and diagnosed such specimens usin~ the standard criteria for cervical squamous cell dysplasia. Another approach is to consider cells having large dysplastic-size nuclei (no matter how large or bizarre) and obvious koilocytic features as koilocytic atypia; associated cells with dysplasticsized nuclei, but no obvious koilocytic features are classified according to the ordinary criteria for dysplasia. Unfortunately, neither approach is entirely satisfactory, since the diagnosis o f dysplasia in such situations creates considerable anxiety for the patient and mandates therapeutic intervention by the gynecologist. The cytopathologist is then often placed in the uncomfortable position of being at odds with his or her surgical pathology colleagues, who find only koilocytic changes and no dysplasia in biopsies from patients whose cervical smears contained both marked dysplasia (by traditional cytologic criteria) and cells with koilocytic features. A possible solution to this dilemma would be tbr the cytopathologist to describe these cervical smears using a hybrid (but neutral) term, such as koiloplasia, that suggests the overlapping yet distinctive HPV-associated epithelial disturbance. By adopting such terminology, practicing gynecologists, cytopathologists, and surgical pathologists would be freed from the need to practice the "defensive medicine" that requires clinical management based on a traditional model for cervical epithelial neoplasia,1 and a new model based on degree of koiloplastic abnormality could be developed.
PEI-LIANGYu, MD Department o f Pathology Shandong Medical University Jinan Shandong People's Republic of China 1. Li G, Wang F, Kang D, et al: Keshan Disease: An endemic Cardiomyopathy in China. HUMPAXHOL16:602-609, 1985
A Viral Etiology in Fuchs' Corneal Dystrophy: The Authors" Reply
ROCEk A. BRUMBACK,MD Department of Pathology University of Oklahoma Health Sciences Center and Veterans Administration Medical Center Oklahoma City 1. Patten SF Jr: Diagnostic Cytopathologyof the Uterine Cervix. Basel, Karger, 1978
To the Editor.'--We agree fully with H u m a y u n and Pepose x that culture, in situ hybridization, or immunocytochemistry would be definitive in identifying the viral inclusions in the endothelium in Fuchs' corneal dystrophy. 2 However, these techniques were not available to us at the time of this publication. A viral etiology was postulated only as one of many possibilities. We considered the possibility that these structures represented mitochondria, but feel that the presence of the unencapsulated nucleocapsids is against this interpretation. Typical m i t o c h o n d r i a were identified in the endothelial cells. SANFORD I. ROTH, MD E, LEE STOCK, MD ROME JUTABHA, BSM Departments of Pathology and Ophthalmology Northwestern University Medical School Chicago
Keshan Disease: An Entity or Not To the Editor:--For decades, it has been customary to consider Keshan disease as a disease entity in China. Keshah is the name of a district in the north-east part of China, and the disease derived its name because of its prevalence in that area in the 1930s. However, in recent years, this prevalence is no longer true. As a matter of fact, people from that district object to the label, Keshan, to the type of
1. Humayun MS, PeposeJS: A viral etiologyin Fuchs' corneal dystrophy. HUMPATHOL19:245, 1988 (letter) 2. Roth SI, Stock EL, Jutabha R: Endothelial viral inclusions in Fuchs' corneal dystrophy. HUMPArHOL18:338-341, 1987
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