OBJECTIVE:To exploit cervical thin layer brush samples through cytohistology in cases with invasive carcinoma with application of antibodies.STUDY DESIGN:Fourteen cases from women with carcinoma diagnosed in 2006 were selected out of 29 invasive carcinomas. From these 14 cases liquid-based cervical cytology material was available to prepare cytohistology. Eight women had squamous cell carcinoma, 4 endocervical adenocarcinoma, 1 endometrial adenocarcinoma and 1 ovarian adenocarcinoma. The residual material from the thin layer sample, collected by brushes by general practitioners, was used to prepare paraffin sections. These were stained with the Papanicolaou method and for the biomarkers Ki-67 and p16 and, if desired, for differentiation markers, including carcinoembryonic antigen, vimentin, cytokeratin 7 and cytokeratin 20 to establish the immunoprofile of the carcinoma.RESULTS:The morphologic details in the cancer nuclei in the paraffin sections were excellent, while in all cases the thin layer cytology slide contained thick epithelial fragments with blurred nuclei. In 5 of the 6 adenocarcinomas, the glandular architecture diagnostic of adenocarcinoma was visible in the cytohistology, which was highlighted in the biomarker stainings, particularly so in the Ki-67 sections. With the exception of endometrial adenocarcinoma, all p16(INK4a) stainings were positive, as they were in the ovarian adenocarcinoma case.CONCLUSION:Cytohistology is an adjunct to routine cervical cytologic examination of thin layer samples, allowing an unequivocal and refined diagnosis.

OBJECTIVE To optimize the morphology of pl6-positive atypical and (pre)neoplastic cells in paraffin cytoblock sections with the aim to minimize equivocal diagnoses on cytology samples. STUDY DESIGN Patients with negative cytology results or results within normal limits (WNL) (n=38), atypical squamous cells of undetermined significance (ASCUS) (n=25) and high grade squamous intraepithelial lesion (HSIL) (n=16) were selected. The residual material of the cervical brush samples was processed to cytoblock paraffin sections and stained for pl1. The cytohistodiagnosis of the pl1-stained paraffin sections was based on the cytologic and histologic morphology. RESULTS Of the 38 cytologically negative cases, only 4 contained afe w faintly positive pl61cells. Of the 25AS CUS cases, I 1as cytohistologically upgraded to low grade squamous intraepithelial lesion (LSIL). All 16 HSIL cases contained cells with outspoken diffuse positive immunostaining, highlighting chromatin clumping in the (pre)malignant cells. In the paraffin sections the tissue fragments showed architecture consistent with that of HSIL. The nuclear to cytoplasmic ratio in the HSIL was severely disturbed. CONCLUSION Cervical brush samples allow an unequivocal cytohistodiagnosis based on the (pre)malignant nuclear changes highlighted by the p16 staining of the paraffin sections.

The cytoblock technique, as used in our Leiden laboratory on a large scale, processes a liquid cytologic sample into a histologic paraffin slide.1 This ensures thin cell sections in which the chromatin changes are visualized in each nucleus, in contrast to cytologic specimens in which the tissue fragments show extensive nuclear blurring. Most important, however, the cytoblock technique allows the interpreter to examine the immunohistologically positive cells within the context of the tissue. We present an exemplary false negative case on which we could use our cellblock p16 technique described in this issue of Acta Cytologica.2 The cell sample, as well as brush head, was placed immediately into germand DNA-free 20 mL-volumes of BoonFix and sent by overnight mail to the testing laboratory (Leiden Cytology and Pathology Laboratory, Leiden, the Netherlands). A thin-layer slide was prepared according to liquid-based cytology methods using automated processing of cell suspensions (ThinPrep 3000 Processor, Cytyc Corporation, Marlborough, Massachusetts, U.S.A.). The original diagnosis of the ThinPrep slide in the false negative case we describe was within normal limits in December 2006. In February 2007 the patient was referred to the Leiden University Hospital for complaint of postcoital bleeding, and a cervical polyp was removed in which (histologically) high grade squamous intraepithelial lesion and adenocarcinoma were detected. A hysterectomy was performed. The general practitioner informed us that we had missed the diagnosis of cancer in the thin-layer slide of December 2006. We keep the vials with the rest of the material after the ThinPrep slide is made, and thus we could retrieve it from the archive. We could observe that some reddish material was still in the endocervical part of the brush. We decided to place the vial with the brush head in the paint shaker again to remove all material left behind in the bristles of the brush and enrich the sample with possibly valuable diagnostic material. This enriched sample was histoprocessed in the Pathos (Milestone, Sorisole [BG], Italy), applying microwave technology. From each block, several 4-mm sections were cut and stained for p16 as described in this issue of Acta Cytologica.2 In the sections we encountered, numerous small tissue fragments from cancerous epithelium with p16-positive nuclei in which the chromatin changes were highlighted (Figure 1A and B). Also, the cytoplasm of these cells stained strongly positive. Accordingly, it was easy to identify the malignant nature of these minibiopsy specimens. In our present screening practice of 70,000 cases per year, when we encounter such undiagnosable clusters LETTERS TO THE EDITORS

OBJECTIVE:Carcinoid of the lung is considered low-grade malignancy, and less invasive treatment may therefore be considered. We analyzed the long-term outcome of initial bronchoscopic treatment in patients with intraluminal bronchial carcinoids.METHODS:Initial bronchoscopic treatment was applied to improve presurgical condition, to obtain tissue samples for proper histologic classification, and to enable less extensive parenchymal resection. For intraluminal bronchial carcinoid, complete tumor eradication with initial bronchoscopic treatment was attempted. High-resolution computed tomography in addition to bronchoscopy was used to determine intraluminal versus extraluminal tumor growth. Surgery followed in cases of atypical carcinoid, residue, or recurrence.RESULTS:Seventy-two patients, 43 of them female, have been treated (median age 47 years, range 16-80 years). Median follow-up has been 65 months (range 2-180 months). Fifty-seven (79%) had typical carcinoids and 15 (21%) had atypical carcinoids. Initial bronchoscopic treatment resulted in complete tumor eradication in 33 of 72 cases (46%), 30 typical and 3 atypical. Thirty-seven of 72 cases (51%), 11 atypical, required surgery (2 for late detected recurrences). Two patients had metastatic atypical carcinoid, 1 already at referral. Of the 6 deaths, 1 was tumor related.CONCLUSIONS:Initial bronchoscopic treatment is a potentially more tissue-sparing alternative than immediate surgical resection in patients with intraluminal bronchial carcinoids. For successful tumor eradication with initial bronchoscopic treatment in central carcinoids, assessment of intraluminal versus extraluminal growth may be of much more importance than histologic division between typical and atypical carcinoid. Disease-specific mortality is low, and long-term outcome has been excellent. Implementation of initial bronchoscopic treatment had no negative impact on surgical treatment outcome.

859 Consensus statement on mandatory registration of clinical trials 861 Stentless mitral valves ▲ R. W. M. Frater 865 Case complexity scores in congenital heart surgery: A comparative study of the Aristotle Basic Complexity score and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) system O. O. Al-Radi, F. E. Harrell Jr, C. A. Caldarone, B. W. McCrindle, J. P. Jacobs, M. G. Williams, G. S. Van Arsdell, and W. G. Williams 876 Aortic valve–sparing reimplantation for dilatation of the ascending aorta and aortic regurgitation late after repair of congenital heart disease M. Ono, H. Goerler, K. Kallenbach, D. Boethig, M. Westhoff-Bleck, and T. Breymann 880 A randomized clinical trial of regional cerebral perfusion versus deep hypothermic circulatory arrest: Outcomes for infants with functional single ventricle C. S. Goldberg, E. L. Bove, E. J. Devaney, E. Mollen, E. Schwartz, S. Tindall, C. Nowak, J. Charpie, M. B. Brown, T. J. Kulik, and R. G. Ohye 888 Aberrant subclavian artery and Kommerell aneurysm: Surgical treatment with a standard approach N. T. Kouchoukos and P. Masetti 893 Midterm outcomes and predictors of reintervention after the Ross procedure in infants, children, and young adults S. K. Pasquali, D. Shera, G. Wernovsky, M. S. Cohen, S. Tabbutt, S. Nicolson, T. L. Spray, and B. S. Marino 900 Risk factors for cardiac arrhythmias in children with congenital heart disease after surgical intervention in the early postoperative period J. Rękawek, A. Kansy, M. Miszczak-Knecht, M. Manowska, K. Bieganowska, M. Brzezinska-Paszke, E. Szymaniak, A. Turska-Kmieć, P. Maruszewski, P. Burczyński, and W. Kawalec 905 Early childhood health, growth, and neurodevelopmental outcomes after complete repair of total anomalous pulmonary venous connection at 6 weeks or younger G. Y. Alton, C. M. T. Robertson, R. Sauve, A. Divekar, A. Nettel-Aguirre, S. Selzer, A. R. Joffe, I. M. Rebeyka, D. B. Ross, and the Western Canadian Complex Pediatric Therapies Project Follow-Up Group 912 Transcatheter creation and enlargement of ventricular septal defects for relief of ventricular hypertension J. Meadows, F. Pigula, J. Lock, and A. Marshall 919 Effect of profound hypothermia during circulatory arrest on neurologic injury and apoptotic repressor protein Bcl-2 expression in an acute porcine model O. G. Ananiadou, K. Bibou, G. E. Drossos, A. Charchanti, M. Bai, S. Haj-Yahia, C. E. Anagnostopoulos, and E. O. Johnson 927 Myocardial regeneration therapy for ischemic cardiomyopathy with cyclin A2 Y. J. Woo, C. M. Panlilio, R. K. Cheng, G. P. Liao, E. E. Suarez, P. Atluri, and H. W. Chaudhry 934 Inhibition of the MEK/ERK pathway reduces microglial activation and interleukin-1-beta expression in spinal cord ischemia/reperfusion injury in rats K. Lu, C.-L. Cho, C.-L. Liang, S.-D. Chen, P.-C. Liliang, S.-Y. Wang, and H.-J. Chen 942 Controlled low-pressure perfusion at the beginning of reperfusion attenuates neurologic injury after spinal cord ischemia E. Shi, X. Jiang, T. Kazui, N. Washiyama, K. Yamashita, H. Terada, and A. H. M. Bashar 949 A novel instrumented retractor to monitor tissue-disruptive forces during lateral thoracotomy G. Bolotin, G. D. Buckner, N. J. Jardine, A. J. Kiefer, N. B. Campbell, M. Kocherginsky, J. Raman, and V. Jeevanandam 955 Pulmonary sequestration: A single-institutional series composed of 27 cases S. Gezer, İ. Taştepe, M. Sırmalı, G. Fındık, H. Türüt, S. Kaya, N. Karaoğlanoğlu, and G. Çetin 960 Awake pulmonary metastasectomy E. Pompeo and T. C. Mineo 967 Prognostic role of lymph node involvement in lung metastasectomy G. Veronesi, F. Petrella, F. Leo, P. Solli, P. Maissoneuve, D. Galetta, R. Gasparri, G. Pelosi, T. De Pas, and L. Spaggiari 973 Initial bronchoscopic treatment for patients with intraluminal bronchial carcinoids H. A. P. Brokx, E. K. Risse, M. A. Paul, K. Grünberg, R. P. Golding, P. W. A. Kunst, J.-P. Eerenberg, J. C. van Mourik, P. E. Postmus, W. J. Mooi, and T. G. Sutedja 979 Electromechanical characterization of a tissue-engineered myocardial patch derived from extracellular matrix T. Ota, T. W. Gilbert, S. F. Badylak, D. Schwartzman, and M. A. Zenati 986 Acute in vivo evaluation of a new stentless mitral valve ▲ J. L. Navia, K. Doi, F. A. Atik, K. Fukamachi, M. W. Kopcak Jr, R. Dessoffy, P. Ruda-Vega, M. Garcia, P. L. Houghtaling, M. Martin, E. H. Blackstone, P. M. McCarthy, and B. W. Lytle 995 Long-term clinical results of mitral valvuloplasty using flexible and rigid rings: A prospective and randomized study B.-C. Chang, Y.-N. Youn, J.-W. Ha, S.-H. Lim, Y.-S. Hong, and N. Chung 1004 Chordal “translocation” for functional mitral regurgitation with severe valve tenting: An effort to preserve left ventricular structure and function M. Fukuoka, M. Nonaka, S. Masuyama, T. Shimamoto, K. Tambara, H. Yoshida, T. Ikeda, and M. Komeda 1012 Association between indices of prosthesis internal orifice size and operative mortality after isolated aortic valve replacement C. R. Bridges, S. M. O’Brien, J. C. Cleveland, E. B. Savage, J. S. Gammie, F. H. Edwards, E. D. Peterson, and F. L. Grover 1022 Superiority of cut-and-sew technique for the Cox maze procedure: Comparison with radiofrequency ablation J. M. Stulak, J. A. Dearani, T. M. Sundt III, R. C. Daly, C. G. A. McGregor, K. J. Zehr, and H. V. Schaff 1028 Expression of matrix metalloproteinases and endogenous inhibitors within ascending aortic aneurysms of patients with bicuspid or tricuspid aortic valves J. S. Ikonomidis, J. A. Jones, J. R. Barbour, R. E. Stroud, L. L. Clark, B. S. Kaplan, A. Zeeshan, J. E. Bavaria, J. H. Gorman III, F. G. Spinale, and R. C. Gorman 1037 Comparison of standard Maze III and radiofrequency Maze operations for treatment of atrial fibrillation J. R. Doty, D. B. Doty, K. W. Jones, J. H. Flores, M. Mensah, B. B. Reid, S. E. Clayson, G. Snow, E. Righter, and R. C. Millar 1045 A randomized comparison of the Cryolife O’Brien and Toronto stentless replacement aortic valves J. B. Chambers, H. M. Rimington, R. Rajani, F. Hodson, and F. Shabbo 1051 The reduction of hemodynamic loading assists self-regeneration of the injured heart by increasing cell proliferation, inhibiting cell apoptosis, and inducing stem-cell recruitment R. Suzuki, T.-S. Li, A. Mikamo, M. Takahashi, M. Ohshima, M. Kubo, H. Ito, and K. Hamano 1059 Chronic ischemic cerebral white matter disease is a risk factor for nonfocal neurologic injury after total aortic arch replacement R. Lin, L. Svensson, R. Gupta, B. Lytle, and D. Krieger 1066 Avoiding vascular complications during minimally invasive, totally endoscopic intracardiac surgery H. Jeanmart, F. P. Casselman, Y. De Grieck, I. Bakir, J. Coddens, L. Foubert, G. Van Vaerenbergh, Y. Vermeulen, and H. Vanermen 1071 Predictors of independent lung ventilation: An analysis of 170 single-lung transplantations D. V. Pilcher, G. M. Auzinger, B. Mitra, D. V. Tuxen, R. F. Salamonsen, A. R. Davies, T. J. Williams, and G. I. Snell 1078 Gastroesophageal reflux in patients with idiopathic pulmonary fibrosis referred for lung transplantation M. P. Sweet, M. G. Patti, L. E. Leard, J. A. Golden, S. R. Hays, C. Hoopes, and P. R. Theodore 1085 Intramural hematoma and thoracic aortic aneurysm with syphilis M. Asano, O. Hiroshi, Y. Hanafusa, H. Kazuma, and M. Tanji 1086 Purse-string deformity of the right coronary artery: A pitfall in de Vega tricuspid annuloplasty P. Symersky, A. P. de Jong, K. T. Koch, E. M. de Beaumont, and B. A. J. M. de Mol 1088 Ross procedure with a tissue-engineered heart valve in complex congenital aortic valve disease D. Gabbieri, P. M. Dohmen, J. Linneweber, A. Lembcke, J. P. Braun, and W. Konertz 1090 Pulmonary and aortic root translocation in the management of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction S.-s. Hu, S.-j. Li, X. Wang, L.-q. Wang, H. Xiong, L.-h. Li, F.-x. Yan, and X. Wang 1092 Interruption of the aorta with multilobulated arch aneurysms: A new clinicopathologic entity V. T. Tsang, P. J. Kilner, T.-Y. Hsia, S. Hughes, and M. Yacoub 1094 The negative impact of Alagille syndrome on survival of infants with pulmonary atresia G. M. Blue, J. M. Mah, A. D. Cole, V. Lal, M. J. Wilson, R. B. Chard, G. F. Sholler, R. E. Hawker, M. C. Sherwood, and D. S. Winlaw 1096 Infant arch reconstruction during total system perfusion A. B. Gardner and P. Eghtesady 1098 Thoracic aortic aneurysm in a young infant with congenital aortic stenosis D. Picarelli, S. Antunez, C. Kreutzer, G. Touyá, D. Abdala, L. Ligüera, and G. Echegaray 1100 Main pulmonary artery translocation for left pulmonary stenosis M. Yoshida, Y. Oshima, C. Shimazu, H. Matsuhisa, T. Higuma, and Y. Okita 1101 Immunohistologic examination of pedicled autologous pericardium 9 years after implantation for an extracardiac conduit in Fontan pathway: Comparison with in situ pericardium and pulmonary arterial tissue from the same patient I. Adachi, H. Ishibashi-Ueda, T. Yagihara, K. Kagisaki, I. Hagino, T. Ishizaka, and H. Uemura 1103 Closure of tracheogastric fistula by video-assisted tracheoscopy, direct repair, and self-expandable titanium stent in a patient with total laryngopharyngoesophagectomy S. Fayoumi and S. Sawalhi 1105 Hemodynamic instability during superior vena cava crossclamping: Predictors, management, and clinical consequences F. Leo, L. Della Grazia, M. Tullii, R. Gasparri, A. Borri, M. Venturino, and L. Spaggiari 1106 Massive hemoptysis: Successful treatment with surgical ligation of the thyrocervical artery B. Planquette, P. Bagan, A. Cox, J. Valcke, and M. Riquet 1108 Liposarcoma of the pleural cavity: A case report C. Peng, X. Zhao, X. Dong, and X. Jiang 1110 An uncommon extrapulmonary sequestration located in the upper posterior mediastinum associated with the azygos lobe in a child Y. Koksal, E. Unal, O. K. Aribas, and B. Oran 1112 The combination of multiple materials in the creation of an artificial anterior chest cage after extensive demolition for recurrent chondrosarcoma G. Rocco, F. Fazioli, F. Scognamiglio, V. Parisi, C. La Manna, A. La Rocca, R. Cerra, R. Accardo, and E. De Lutio 1114 Mediastinal mature teratoma with complex rupture into the pleura, lung, and bronchus complicated with mycoplasma pneumonia C.-W. Yu, M.-J. Hsieh, K.-P. Hwang, C.-C. Huang, S.-H. Ng, and S.-F. Ko 1116 Definitive diagnosis and surgical planning of H-type tracheoesophageal fistula in a critically ill neonate: First experience using air distension of the esophagus during high-resolution computed tomography acquisition P. Ou, E. Seror, W. Layouss, Y. Révillon, and F. Brunelle 1118 Letters to the Editor 1126 Events of Interest 1128 Announcements 864 Notice of Correction 35A Reader Services 941 Change of address 959 Interactive eLearning Activities Full-text online access to The Journal of Thoracic and Cardiovascular Surgery is now available for all print subscribers. See page 1011 for details.The Journal of Thoracic and Cardiovascular Surgery online is sponsored by St. Jude Medical. Full-text online access to The Journal of Thoracic and Cardiovascular Surgery is now available for all print subscribers. See page 1011 for details. The Journal of Thoracic and Cardiovascular Surgery online is sponsored by St. Jude Medical. Earn CME credits at http://cme.ctsnetjournals.org Supplemental material is available online Video clip is available online Earn CME credits at http://cme.ctsnetjournals.org Supplemental material is available online Video clip is available online Cover PhotographFigure 1 shows a massive lesion of fat density that completely fills the left pleural space and shifts the mediastinum to the right. The left lung cannot be identified, and the great vessels and bronchus are obviously displaced. Figure 2 shows a well-differentiated liposarcoma; the capillary network, different sizes of lipocytes, fibrous intervals, and scattered lipoblasts are visible.Peng et al 2007Peng C. Zhao X. Dong X. Jiang X. Liposarcoma of the pleural cavity: a case report.J Thorac Cardiovasc Surg. 2007; 133: 1108-1109Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Figure 1 shows a massive lesion of fat density that completely fills the left pleural space and shifts the mediastinum to the right. The left lung cannot be identified, and the great vessels and bronchus are obviously displaced. Figure 2 shows a well-differentiated liposarcoma; the capillary network, different sizes of lipocytes, fibrous intervals, and scattered lipoblasts are visible.Peng et al 2007Peng C. Zhao X. Dong X. Jiang X. Liposarcoma of the pleural cavity: a case report.J Thorac Cardiovasc Surg. 2007; 133: 1108-1109Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar

Purpose: To study the natural history of preneoplastic lesions in the bronchial mucosa of the individuals at risk. Patients and Methods: White light and autofluorescence bronchoscopy examinations have been done in 52 individuals harboring 134 preneoplastic lesions (WHO criteria). End points were the development of carcinoma in situ (CIS) or squamous cell cancer (SCC) or the highest category of dysplasia up until March 1, 2003 for the remaining preneoplastic lesions. Results: Distribution and outcome of preneoplastic lesions have been found to be unrelated to various risk factors such as smoking history, past history of cancer, or chronic obstructive pulmonary disease. Nonstepwise changes of preneoplastic lesions are seen. Regression rate has been 54%. Progression to CIS/SCC has been 13.4% (18 of 134) and was for severe dysplasia, significantly higher (P < 0.003) than preneoplastic lesions showing lower-grade dysplasia (squamous metaplasia, mild and moderate dysplasia). Time to progression was not significantly different. However, when analyzed per individual, no significant difference of progression rate between individuals with or without severe dysplasia was seen (39% versus 26%; P = 0.36). Conclusions: The 54% regression rate of all preneoplastic lesions, 26% to 39% progression rate to CIS/SCC of individuals with lower-grade dysplasia or severe dysplasia with no significant difference in progression rate and time to progression combined with nonstepwise histologic changes unrelated to the initial histologic grading indicate that one cannot differentiate the potentially more malignant preneoplastic lesions among the many preneoplastic lesions present in the bronchial mucosa. The initial WHO classification of any preneoplastic lesion cannot be reliably used for accurate risk assessment of field carcinogenesis.

The risk to develop lung cancer has been shown to decrease after smoking cessation and compared to non-smokers, the higher risk seems to persist for several years after smoking abstinence in the population at risk [1,2]. Exposure to carcinogens leads to a series of morphological and genetic changes towards the development of multiple intraepithelial pre-invasive lesions. These cumulative genetic events are more frequently observed in high-grade compared to low grade lesions [3]. It remains as yet unclear whether spontaneous regression of pre-invasive lesions does occur [4,5]. The aim of this study is to analyze whether smoking behavior may have any influence on the natural course of pre-invasive lesions in the population at risk. The data from 52 high risk individuals who underwent autofluorescence bronchoscopy (AFB) in our institute in the period November 1995—March 2003, with histologically confirmed pre-invasive lesions at baseline (WHO criteria) and a follow-up pe-

BACKGROUND:Penile lesions and pearly penile papules (PPP) are frequently found in male sexual partners of women with cervical intraepithelial neoplasia (CIN). The former have been associated with human papillomavirus (HPV).OBJECTIVES:We estimated the prevalence of PPP in male sexual partners of women with CIN, and investigated the association between PPP and flat and papular penile lesions found in these men. We further evaluated a possible association between PPP and HPV, age, and CIN grade of the female partner.METHODS:We evaluated by penoscopy the presence of HPV-associated penile lesions and PPP in 226 male sexual partners of women with CIN. HPV was tested by polymerase chain reaction-enzyme immunoassay and in situ hybridization.RESULTS:The prevalence of PPP was 34% and was not associated with the presence of penile lesions or a positive HPV test. Age and CIN grade of the female partner were not related to the presence of PPP.CONCLUSION:The prevalence of PPP in male sexual partners of women with CIN is comparable with the prevalence described in men of more diverse populations. Our data do not support a causative role for HPV in the genesis of PPP.