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Background: The accuracy of a Barrett's esophagus diagnosis is not well studied., Objective: Our purpose was to evaluate the accuracy of a clinical Barrett's esophagus diagnosis and the reproducibility of an esophageal intestinal metaplasia diagnosis., Methods: All patients with a Barrett's esophagus diagnosis between 1994 and 2005 were identified by use of International Classification of Disease (ICD) and Systematized Nomenclature of Medicine (SNOMED) coding. Subsets received manual record review (endoscopy/pathology reports), slide review by a referral pathologist (interrater reliability), and 2 blinded reviews by the same pathologist (intrarater reliability)., Setting: An integrated health services delivery system., Main Outcome Measurements: Accuracy of electronic clinical diagnosis and reproducibility of esophageal intestinal metaplasia diagnosis., Results: A total of 2470 patients coded with Barrett's esophagus underwent record review; a subgroup (616) received manual pathology slide review. Review confirmed a Barrett's esophagus diagnosis for 1533 (61.9%) patients: 437 of 798 subjects (54.8%) with a SNOMED diagnosis alone, 153 of 671 subjects (26.8%) with an ICD diagnosis alone, and 940 of 1101 subjects (85%) who had both a SNOMED and an ICD diagnosis. The same metaplasia diagnosis occurred with 88.3% of subjects (original vs referral pathologist, interrater reliability; kappa = .42, 95% CI, 0.34-0.48). The referral pathologist made the same metaplasia diagnosis twice for a given patient for 88.6% of subjects (intrarater reliability, 2 reviews by same pathologist; kappa = 0.65, 95% CI, 0.35-0.93)., Limitations: The accuracy of a Barrett's esophagus diagnosis likely represents the minimum number, given the strict criteria., Conclusions: A community pathologist's diagnosis of esophageal intestinal metaplasia is likely to be confirmed by a referral pathologist. Electronic diagnoses of Barrett's esophagus overestimate the prevalence, although they are usually confirmed in patients with both a SNOMED and ICD diagnosis of Barrett's esophagus.

Background & Aims: Little is known about the effects of alcohol use and sociodemographics on the risk of Barrett's esophagus, a precursor to esophageal adenocarcinoma. We evaluated the association between alcohol use, alcohol type, sociodemographic profiles, other lifestyle factors, and the risk of Barrett's esophagus., Methods: With the use of a case-control study within the Kaiser Permanente Northern California membership, patients with a new diagnosis of Barrett's esophagus (n = 320) diagnosed between 2002 and 2005 were matched to persons with gastroesophageal reflux disease (GERD; n = 316) and to population controls (n = 317). We collected information using validated questionnaires during direct in-person interviews. Analyses used multivariate unconditional logistic regression., Results: Total alcohol use was not significantly associated with the risk of Barrett's esophagus, although stratification by beverage type showed an inverse association for wine drinkers compared with nondrinkers (>/=7 drinks of wine per week vs none: odds ratio, 0.44; 95% confidence interval, 0.20-0.99; multivariate analysis). Among population controls, those who preferred wine were more likely to have college degrees and regularly take vitamin supplements than those who preferred beer or liquor, although adjustment for these factors or GERD symptoms did not eliminate the inverse association between wine consumption and Barrett's esophagus. Education status was significantly inversely associated with the risk of Barrett's esophagus., Conclusions: There are associations between alcohol types, socioeconomic status, and the risk of Barrett's esophagus. Although choice of alcoholic beverages was associated with several factors, multiple adjustments (including for GERD) did not eliminate the association between alcohol and Barrett's esophagus. Further research to evaluate the associations among socioeconomic status, GERD, and Barrett's esophagus is warranted.

Conditions causing high iron levels, such as hemochromatosis, are proposed risk factors for esophageal adenocarcinoma. Although this hypothesis is supported by animal models, no human data currently exist. We conducted a case-control study of persons with a new Barrett's esophagus diagnosis (cases), persons with gastroesophageal reflux disease (GERD) (without Barrett's esophagus), and population controls. Subjects completed detailed examinations and assays for hemochromatosis mutations and serum iron stores. We evaluated 317 cases, 306 GERD patients, and 308 population controls. There was no significant association between Barrett's esophagus and any hemochromatosis gene defect (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 0.95-1.84), a moderate or severe mutation (OR = 1.54, 95% CI: 0.94-2.52), or a severe mutation (C282Y homozygote or C282Y/H63D heterozygote; OR = 0.77, 95% CI: 0.24-2.48) compared with the population controls. As expected, gene defects were associated with increased iron stores. We can conclude from our findings that Barrett's esophagus was not associated with hemochromatosis gene defects, although we cannot exclude small effects.

Objective: The present study evaluated the associations among antioxidants, fruit and vegetable intake, and the risk of Barrett's esophagus (BE), a potential precursor to esophageal adenocarcinoma., Methods: We conducted a case-control study within the Kaiser Permanente Northern California population. Incident BE cases (N = 296) were matched to persons with gastroesophageal reflux disease (GERD) (GERD controls N = 308) and to population controls (N = 309). Nutrient intake was measured using a validated 110-item food frequency questionnaire. The antioxidant results were stratified by dietary versus total intake of antioxidants., Results: Comparing cases to population controls, dietary intake of vitamin C and beta-carotene were inversely associated with the risk of BE (4th vs 1st quartile, adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.26-0.90; OR 0.56, 95% CI 0.32-0.99, respectively), and the inverse association was strongest for vitamin E (OR 0.25, 95% CI 0.11-0.59). The inverse trends for antioxidant index (total and dietary) and fruit and vegetable intake were statistically significant, while most total intakes were not associated with reduced risk. The use of antioxidant supplements did not influence the risk of BE, and antioxidants and fruits and vegetables were inversely associated with a GERD diagnosis., Conclusion: Dietary antioxidants, fruits, and vegetables are inversely associated with the risk of BE, while no association was observed for supplement intake. Our results suggest that fruits and vegetables themselves or associated undetected confounders may influence early events in the carcinogenesis of esophageal adenocarcinoma.

The objective of this study was to examine the associations between dietary patterns and the risk of Barrett's esophagus, a precursor to esophageal adenocarcinoma. The authors conducted a case-control study within the Kaiser Permanente Northern California population between 2002 and 2005. Patients with a new diagnosis of Barrett's esophagus (n = 296 cases) were matched to persons with gastroesophageal reflux disease (n = 308) without Barrett's esophagus and to population controls (n = 309). Dietary information was obtained from a validated, 110-item food frequency questionnaire. A principal component analysis was used to identify major dietary patterns. Two major dietary patterns were "Western" (high in fast food and meat) and "health-conscious" (high in fruits, vegetables, and nonfried fish). When cases and population controls were compared, strong adherence to the health-conscious dietary pattern was inversely associated with Barrett's esophagus (odds ratio = 0.35, 95% confidence interval: 0.20, 0.64; fourth vs. first quartile comparison). In contrast, data suggested an adverse effect of the Western dietary pattern on the risk of Barrett's esophagus, although no dose-effect relation was found. Results suggest strong associations between a diet rich in fruits and vegetables and the risk of Barrett's esophagus.

Background: Barrett's esophagus is a strong risk factor for esophageal adenocarcinoma, but little is known about its associations with body mass index (BMI) or abdominal obesity., Methods: We conducted a case-control study within the Kaiser Permanente Northern California population. Persons with a new diagnosis of Barrett's esophagus (cases) were matched to subjects with gastroesophageal reflux disease (GERD) without Barrett's esophagus and to population controls. Subjects completed questionnaires and an anthropometric examination., Results: We interviewed 320 cases, 316 patients with GERD, and 317 controls. There was a general association between Barrett's esophagus and a larger abdominal circumference (independent of BMI) compared with population controls (odds ratio, 2.24; 95% confidence interval, 1.21-4.15; circumference, >80 cm vs <80 cm). There was a possible risk plateau, with increased risk evident only at circumferences >80 cm and no significant trend for further increases in circumference. There was a trend for association compared with patients with GERD (test for trend, P = .03). There was no association between Barrett's esophagus and BMI. Abdominal circumference was associated with GERD symptom severity (odds ratio, 1.86; 95% confidence interval, 1.03-3.38; risk of severe weekly GERD, per 10-cm circumference); adjustment for GERD partially attenuated the association between Barrett's esophagus and circumference., Conclusions: Waist circumference, but not BMI, had some modest independent associations with the risk of Barrett's esophagus. The findings provide partial support for the hypothesis that abdominal obesity contributes to GERD, which may in turn increase the risk of Barrett's esophagus.

Background: Microinvasive squamous cell carcinoma of the vulva is defined as stromal invasion < or =1 mm and is treated by wide local resection. Whether criteria for microinvasive squamous cell carcinoma can be applied to Paget's disease of the vulva is unknown because of the rarity of that disease., Cases: We initially evaluated three cases of microinvasive Paget's disease by using sentinel lymph node (SLN) analysis. The SLNs in two patients were negative; and these patients had no recurrence of invasive or metastatic Paget's disease. The other patient had a positive SLN (the only positive lymph node) and subsequently received complete lymph node dissection of the groin bilaterally., Conclusion: Evaluation of SLNs may be valid for evaluating microinvasive Paget's disease.

New masses in the head and neck region of previously treated patients with cancer are considered suggestive of potential recurrence. Fine-needle aspiration is an excellent primary tool for evaluating these masses but may show atypical squamous cells that mislead clinicians to pursue aggressive treatment. We describe 3 patients in whom submandibular gland masses developed after radiation therapy for squamous cell carcinoma and for whom subsequent excisional biopsy findings showed benign squamous metaplasia. We review distinguishing clinical and histopathologic features that may allow these lesions to be identified. We also propose a treatment algorithm for this uncommon clinical scenario.

Parathyroid carcinoma is a rare disease. The first report of parathyroid carcinoma with sarcomatous differentiation is presented. A parathyroid mass measuring 6 x 8 x 9 cm was surgically excised from the left side of the neck in a 54-year-old man who had mild hypercalcemia. Light microscopic examination of the mass showed carcinoma with areas of rhabdomyosarcoma and chondrosarcoma. Immunohistochemical studies confirmed the light microscopic impression. Resolution of hypercalcemia followed excision of the mass, but multiple pulmonary and adrenal masses subsequently developed and led to the patient's death despite aggressive trials of chemotherapy with doxorubicin, ifosfamide, and cisplatin. The sarcomatous elements of the mass excised from this patient are presumed to represent aberrant cellular differentiation previously described in uterine and other tissue but not in parathyroid glands. Sarcomatous differentiation itself appears to be a poor prognostic factor in parathyroid carcinoma.

Objectives: Diagnostic accuracy of the ThinPrep process (Cytyc, Boxborough, MA) was compared with that of conventional (smear) cytopreparation for fine-needle aspiration (FNA) of head and neck masses., Methods: In a prospective, randomized, single-blinded study, 209 patients served as their own controls and underwent 236 FNAs using ThinPrep and conventional (smear) cytopreparatory techniques., Results: ThinPrep produced less air-drying artifact and less mechanical distortion than the conventional method. The conventional technique was diagnostic in 63% of samples; the ThinPrep technique was diagnostic in 55% of samples. When all results were combined, pathologists subjectively preferred the conventional technique but accepted use of ThinPrep as the only cytopreparatory technique for most head and neck masses., Conclusions: For adequately experienced cytopathologists, ThinPrep is acceptable for FNA of salivary masses, neck cysts, metastatic lymph nodes, and thyroid lesions. Conventional smear technique should be used for FNA of nonmetastatic lymphoid lesions. Use of ThinPrep can complement use of the conventional (smear) cytopreparatory technique when aspirate is nondiagnostic or bloody, when the patient has a blood-borne infectious disease, when the clinician is inexperienced, or when aspirate has entered the syringe.

Metastatic tumors to the head and neck are uncommon. We report a case of renal cell carcinoma that presented as an epidermal inclusion cyst on the forehead. The forehead is an exceedingly uncommon site for renal cell metastases. We review the biology of tumor metastases and explore the pathways by which infraclavicular tumors spread to the head and neck. We then discuss the clinical appearance and management of metastatic renal cell carcinoma.

Objective: To perform a cost-benefit analysis of screening for hereditary hemochromatosis., Patients and Methods: A total of 3,977 consecutive men > or = 30 years of age who presented for routine health checkups at a health maintenance organization medical center were screened for hereditary hemochromatosis by measuring transferrin saturation. Subjects with repeated transferrin saturation > or = 62% and ferritin level > or = 500 ng/mL (> or = 500 micrograms/L) were referred for liver biopsy. Subjects with transferrin saturation < 15% were referred for evaluation. Laboratory testing, screening, and abnormal screening test evaluation procedures were identified by chart review., Results: Forty patients had transferrin saturation > or = 62%. One hundred seventy-two had transferrin saturation < 15%. Eight patients with hemochromatosis were identified. The 3 patients most seriously affected had hepatic iron concentrations > 250 mumol/g dry weight. Two of them had hepatic fibrosis. Seven cases of hemochromatosis were found among 1,974 white subjects who were screened. Only 1 case was found among the remaining subjects., Conclusions: Our observations support routine screening with transferrin saturation for white men > or = 30 years of age.

The change toward breast-conserving surgery for cancer has altered the role of the initial biopsy. We retrospectively analyzed two methods, traditional excisional biopsy (n = 47) and lumpectomy (n = 44) to evaluate their usefulness as the initial procedure for breast-conserving surgery. Lumpectomy required more time (mean +/- SEM, 53 +/- 3 minutes) than traditional biopsy (37 +/- 2 minutes). Margins were verified by microscopic examination to be clear in 73% of the patients in the lumpectomy group and in only 17% of patients in the traditional biopsy group. Patients in the lumpectomy group subsequently underwent more axillary dissections than patients in the traditional biopsy group (31% vs 4%, respectively) and fewer modified radical mastectomies (49% vs 71%, respectively). A correlation between extensive intraductal components and positive margins was found in the lumpectomy group. These data suggest that as the initial biopsy method, lumpectomy more often provides adequate margins and may decrease the number of subsequent procedures on the breast for breast-conserving surgery.