Surgical suturing-induced melanocytic nevi. A new type of eruptive melanocytic nevi?

BACKGROUND

Nevogenesis is a complex process involving several pathogenetic mechanisms, including genetic factors, hormonal influences and UV-radiation. Trauma has been described as a triggering factor for an alternative pathway of nevogenesis. Eruptive melanocytic nevi (EMN), related either to immunosuppression or to blistering disorders, represent a special type of nevi probably induced by the disruption of the dermo-epidermal junction and consequent proliferation of quiescent pigment cells during re-epithelization.

MAIN OBSERVATIONS

We report two patients with three melanocytic nevi that developed de novo along the direction of surgical suturing, following surgical operation for other reason. The lesions exhibited special dermoscopic characteristics and histology revealed features of acquired melanocytic nevi.

CONCLUSIONS

Such cases may represent a new type of eruptive nevus, the surgical suturing-induced nevus, which should be included in the differential diagnosis of new pigmentation developing within a scar.

Frontal Fibrosing Alopecia and Vitiligo: Coexistence or True Association?

Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia characterized by a progressive band-like recession of the frontotemporal hairline and frequent loss of the eyebrows. It predominantly affects postmenopausal women. Coexistence of FFA and vitiligo is rarely reported in the literature. We retrospectively studied 20 cases diagnosed with FFA in a 14-month period in our Department. Among them, there were 2 cases, a 72-year-old woman and a 48-year-old man, who developed FFA on preexisting vitiligo of the forehead. Anatomical colocalization of the two dermatoses supports the notion that a causal link may exist and their association may not be coincidental. We suggest that interrelated immunologic events and pathologic processes may underlie both these skin conditions.

Aseptic abscess syndrome associated with traveler's diarrhea after a trip to Malaysia

The first, to our knowledge, case of the aseptic abscesses syndrome as a complication of traveler’s diarrhea after a trip to Malaysia is presented. The patient failed to respond to several antimicrobials. The diagnosis was histologically confirmed and the patient only responded to immunomodulatory therapy with corticosteroids and methotrexate. Travel physicians should be aware of this entity reviewed herein in the context of traveler’s diarrhea.

Immunohistochemical Expression of p53, MDM2, and p21Wafi Oncoproteins in Endometriomas But Not Adenomyosis

OBJECTIVE

p53, MDM2, and p21Waf1 are oncoproteins that regulate the cell cycle. The purpose of this study was to examine the distribution of p53, MDM2, and p21Waf1 oncoprotein expression in endometriomas and in adenomyosis.

METHODS

Tissue samples from 25 women with pathologically confirmed endometriomas and 31 women with pathologically confirmed adenomyosis were analyzed. Expression of p53, MDM2, and p21Waf1 oncoproteins was assessed by immunohistochemical nuclear staining.

RESULTS

p53, MDM2, and p21Waf1 expression were detected in 20%, 60%, and 80% of endometrioma tissue samples, respectively. All endometrioma tissue samples expressing p53 also tested positive for both MDM2 and p21Waf1. MDM2 expression was significantly higher in the proliferative than in the secretory phase of the cycle. In contrast, all 31 adenomyosis tissue samples were negative for p53, MDM2, and p21Waf1 expression.

CONCLUSION

The expression of p53, MDM2, and p21Waf1 suggests a role for these oncoproteins in the regulation of endometrioma cell growth, but not in adenomyosis.

Giant Onychomatricoma of the Great Toenail: Case Report and Review Focusing on Less Common Variants

Onychomatricoma is a rare benign fibroepithelial filamentous tumor originating from the nail matrix. It typically presents with the clinical tetrad of xanthonychia, pachyonychia, proximal splinter hemorrhages and increased transverse overcurvature of the nail plate. The giant variant can easily confuse the clinician due to its extensive nail dystrophy that can mask the characteristic features of this tumor. Benign (fibrokeratoma, ungual fibroma, onycholytic matricoma) and malignant entities (Bowen's disease, squamous cell carcinoma, onycholytic carcinoma) are mimics of the disease. Nail surgery can facilitate the diagnosis, which should always be confirmed by histology, as rare variants do exist.

Diagnostic value of a semi-nested PCR for the diagnosis of mucormycosis and aspergillosis from paraffin-embedded tissue: A single center experience

OBJECTIVE

The main aim of our study was to investigate the diagnostic value of a molecular method for the diagnosis of mucormycosis and aspergillosis from formalin-fixed and paraffin-embedded (FFPE) tissues.

METHODS

A retrospective chart review identified all cases with histology reports mentioning the presence of fungi with morphological characteristics of either Aspergillus or mucormycetes, for the period 2005-2012. Paraffin blocks were retrieved from the archives of the Department of Pathology. A semi-nested PCR specific for the detection of mucormycetes and Aspergillus species was applied in FFPE tissue from the above blocks. Results were compared with those of histological (gold standard) and microbiological methods.

RESULTS

Twenty cases with fungal hyphae in tissue were revealed. Mucormycetes were detected in 9 cases (45%) by PCR, in only 4 of which culture was available. Species of Aspergillus were detected in 8 cases (40%) by PCR, two of which were co-infection with mucormycetes. Five patients had other fungi, non-detectable with this specific PCR. At least one sample per patient was positive by PCR. Seven out of 30 samples tested overall were false negative. The calculated sensitivity of this method in our setting was 79.3% (95% CI: 60.3-91.9%); specificity was 100%.

CONCLUSIONS

The specific PCR used appears to be an easy and useful tool for the prompt and accurate diagnosis of mucormycosis and aspergillosis, in combination with histology and direct examination. Mucormycosis was more frequent than aspergillosis during the study period, highlighting the importance of continuous epidemiological surveillance of these serious infections.

Immunohistochemical determination of the extracellular matrix modulation in a rat model of choline-deprived myocardium: the effects of carnitine

Choline has been identified as an essential nutrient with crucial role in many vital biological functions. Recent studies have demonstrated that heart dysfunction can develop in the setting of choline deprivation even in the absence of underlying heart disease. Matrix metalloproteinases (MMPs) are responsible for extracellular matrix degradation, and the dysregulation of MMP-2 and MMP-9 has been involved in the pathogenesis of various cardiovascular disorders. The aim of the study was to investigate the role of MMPs and their inhibitors (TIMPs), in the pathogenesis of choline deficiency-induced cardiomyopathy, and the way they are affected by carnitine supplementation. Male Wistar Albino adult rats were divided into four groups and received standard or choline-deficient diet with or without L-carnitine in drinking water (0.15% w/v) for 1 month. Heart tissue immunohistochemistry for MMP-2, MMP-9, TIMP-1, and TIMP-2 was performed. Choline deficiency was associated with suppressed immunohistochemical expression of MMP-2 and an increased expression of TIMP-2 compared to control, while it had no impact on TIMP-1. MMP-9 expression was decreased without, however, reaching statistical significance. Carnitine did not affect MMP-2, MMP-9, TIMP-1 or TIMP-2 expression. The pattern of TIMP and MMP modulation observed in a choline deficiency setting appears to promote fibrosis. Carnitine, although shown to suppress fibrosis, does not seem to affect MMP-2, MMP-9, TIMP-1 or TIMP-2 expression. Further studies will be required to identify the mechanism underlying the beneficial effects of carnitine.

Classification of endometrial lesions by nuclear morphometry features extracted from liquid-based cytology samples: a system based on logistic regression model

OBJECTIVE

To investigate the potential of a computerized system for the discrimination of benign from malignant endometrial nuclei and lesions.

STUDY DESIGN

A total of 228 histologically confirmed liquid-based cytological smears were collected: 117 within normal limits cases, 66 malignant cases, 37 hyperplasias without atypia, and 8 cases of hyperplasia with atypia. From each case we extracted nuclear morphometric features from about 100 nuclei using a custom image analysis system. Initially we performed feature selection, and subsequently we applied a logistic regression model that classified each nucleus as benign or malignant. Based on the results of the nucleus classification process, we constructed an algorithm to discriminate endometrium cases as benign or malignant.

RESULTS

The proposed system had an overall accuracy for the classification of endometrial nuclei equal to 83.02%, specificity of 85.09%, and sensitivity of 77.01%. For the case classification the overall accuracy was 92.98%, specificity was 92.86%, and sensitivity was 93.24%.

CONCLUSION

The proposed computerized system can be applied for the classification of endometrial nuclei and lesions as it outperformed the standard cytological diagnosis. This study highlights interesting diagnostic features of endometrial nuclear morphology, and the proposed method can be a useful tool in the everyday practice of the cytological laboratory.

An intelligent clinical decision support system for patient-specific predictions to improve cervical intraepithelial neoplasia detection

Nowadays, there are molecular biology techniques providing information related to cervical cancer and its cause: the human Papillomavirus (HPV), including DNA microarrays identifying HPV subtypes, mRNA techniques such as nucleic acid based amplification or flow cytometry identifying E6/E7 oncogenes, and immunocytochemistry techniques such as overexpression of p16. Each one of these techniques has its own performance, limitations and advantages, thus a combinatorial approach via computational intelligence methods could exploit the benefits of each method and produce more accurate results. In this article we propose a clinical decision support system (CDSS), composed by artificial neural networks, intelligently combining the results of classic and ancillary techniques for diagnostic accuracy improvement. We evaluated this method on 740 cases with complete series of cytological assessment, molecular tests, and colposcopy examination. The CDSS demonstrated high sensitivity (89.4%), high specificity (97.1%), high positive predictive value (89.4%), and high negative predictive value (97.1%), for detecting cervical intraepithelial neoplasia grade 2 or worse (CIN2+). In comparison to the tests involved in this study and their combinations, the CDSS produced the most balanced results in terms of sensitivity, specificity, PPV, and NPV. The proposed system may reduce the referral rate for colposcopy and guide personalised management and therapeutic interventions.

Fine needle aspiration cytology of nodular thyroid lesions: a 2-year experience of the Bethesda system for reporting thyroid cytopathology in a large regional and a university hospital, with histological correlation

OBJECTIVE

Thyroid fine needle aspiration (FNA) contributes to the appropriate management of nodular thyroid lesions. The introduced categories in the Bethesda system for reporting thyroid cytopathology (TBSRTC) are associated with an implied cancer risk, providing a clinical management guideline. This study aims to evaluate the reproducibility of this implied risk and to compare the results from two different cytopathology departments.

METHODS

Five hundred histologically confirmed FNAs, studied since the introduction of TBSRTC, were obtained from 4208 and 3587 FNAs performed in a large regional hospital in Herakleion, Crete (group A) and a university hospital in Athens (group B), respectively. Reports were issued according to TBSRTC. Aspirates were prepared with ThinPrep(®) and evaluated by two experienced cytopathologists. The reproducibility and accuracy were evaluated.

RESULTS

The proportion test for suspicious for malignancy (SFM) and malignant (M) cytology reports (P < 0.0001), and the number of malignancies on histology (P < 0.0001), were significantly higher in group A than in group B, consistent with a higher incidence of thyroid carcinomas in southern Greece. Although the malignancy rates were higher in group A than in group B for all categories, except M (A, 99.3%; B, 100%), the difference was only significant for benign aspirates (P = 0.0303). Malignancy rates for all categories in group A were above the TBSRTC recommended range, but were consistent with an increased prevalence of malignancy in that centre, differences in reporting practice and the variable ranges reported in the literature. There was lower sensitivity (P = 0.019) and overall accuracy (P = 0.003) in group A relative to group B, but no difference in specificity.

CONCLUSIONS

TBSRTC provides valuable information for the appropriate management of nodular thyroid lesions, both in a university and a large regional hospital.

Liquid based cytology and HPV DNA testing in a Greek population compared to colposcopy and histology

Screening for cervical cancer in Greece is still unorganised and based on self- motivation. The purpose of this study was to evaluate the accuracy of cytological findings from a large observational population sample, originating from Western Athens, in association with reflex DNA test, colposcopic estimation, and final histologic diagnosis. The rate of invasive carcinoma, both squamous cell and adenocarcinoma, is indicative of a largely unscreened population. In this study, the estimated overall prevalence of human papilloma virus (HPV) was 41.1%, with HPV positivity at 37.4% of cytologically normal women. HPV testing did not seem to improve sensitivity of cytology for atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LGSIL) cases in identifying CIN 2+ lesions, but outperformed cytology in detecting CIN3+ for cytological high-grade squamous intraepithelial lesion (HGSIL) cases. For HGSIL cases sensitivity of colposcopy for detecting CIN3+ was comparable to cytology.

Comparison of two commercially available methods for HPV genotyping: CLART HPV2 and Linear Array HPV Genotyping tests

OBJECTIVE

To compare the clinical efficiency of two commercially available HPV DNA detection and typing tests. The CLART HPV2 test, a novel HPV test based on DNA microarrays that can identify 35 HPV genotypes, was compared to the Linear Array HPV Genotyping (LA) test, a more widely used test able to identify 37 HPV genotypes.

STUDY DESIGN

The CLART test was evaluated by comparing the genotyping results of 538 ThinPrep Pap tests with the LA test as well as with the cytological and histological findings.

RESULTS

The exact same types and results were identified in 86.1% of the samples (kappa = 0.74). The tests showed excellent agreement in HPV positivity and identification of single and multiple infections (concordance rate 88.7%, kappa = 0.827).

CONCLUSION

The CLART test demonstrated results comparable to those of the LA test in clinical sensitivity as measured by the positive predictive value of CIN2+ in ASCUS (67.3% vs. 57.1%), while overall it exhibited higher sensitivity, specificity, positive and negative predictive values and area under curves than the LA test in all cytological and histological subgroups analyzed.

The diagnostic accuracy of two methods for E6&7 mRNA detection in women with minor cytological abnormalities

OBJECTIVE

To examine the diagnostic accuracy of nucleic acid sequence based amplification (NASBA) and flow cytometry for E6&7 human papillomavirus (HPV) mRNA detection in the triage of minor cytological abnormalities.

DESIGN

Prospective diagnostic accuracy study.

SETTING

Gynecology outpatient clinics of a university hospital.

POPULATION

472 women with low-grade squamous intraepithelial lesion (LSIL) or atypical squamous cells of undetermined significance (ASCUS).

METHODS

Residual material of the liquid-based smears was tested by NASBA and by flow cytometry for E6&E7 mRNA expression. Histological diagnosis was used as reference standard.

MAIN OUTCOME MEASURES

Accuracy indices of the two techniques and of type 16-specific NASBA for the detection of cervical intraepithelial neoplasia (CIN) 2+ and CIN3+, accuracy indices at age >35 years, correlation between NASBA and flow, comparison between integrated and episomal high-risk HPV infection for risk of CIN2+.

RESULTS

Both tests showed increased positivity rates with increasing severity of the lesion (p < 0.05, chi-squared test for trend). There was a positive correlation between NASBA and flow results (phi coefficient = 0.325). NASBA-positive cases were more likely to have CIN2+ than were NASBA-negative/DNA-positive for types 16, 18, 31, 33, 45 (25/73 vs. 4/52, p= 0.0004; Fisher's exact test). In the LSIL group the NASBA accuracy indices for CIN3+ were: sensitivity 75%, specificity 78.7% and positivity rate 20.8%, and for flow 77.8%, 64.5% and 35.9%, respectively.

CONCLUSIONS

NASBA has favorable specificity and positivity rates for triaging LSIL prior to colposcopy. A relatively low sensitivity warrants cytological surveillance of the NASBA-negative LSILs. Flow cytometry does not perform as well overall.

An unusual cutaneous tumor: African histoplasmosis following mudbaths: case report and review

African histoplasmosis, caused by Histoplasma capsulatum var. duboisii, is endemic in Africa. The disease usually involves the skin, subcutaneous tissue, and bones. A case of African histoplasmosis presenting as a cutaneous tumor and non-healing wound in a 66-year-old immunocompetent male residing in Africa, the first ever reported following mudbaths and acupuncture, is hereby reported. Diagnosis was confirmed by means of polymerase chain reaction performed on tissue material. The patient was started on long-term itraconazole therapy and he responded well. African histoplasmosis should be included in the differential diagnosis of non-healing wounds or tumor-like lesions, especially in the context of mudbaths in an endemic area.

Human epidermal growth factor receptor-2 gene amplification in gastric cancer using tissue microarray technology

AIM: To assess human epidermal growth factor receptor-2 (HER2)-status in gastric cancer and matched lymph node metastases by immunohistochemistry (IHC) and chromogenic in situ hybridization (CISH).

METHODS: 120 cases of primary gastric carcinomas and 45 matched lymph node metastases from patients with full clinicopathological features were mounted onto multiple-punch and single-punch tissue microarrays, respectively, and examined for HER2 overexpression and gene amplification by IHC and CISH.

RESULTS: Twenty-four tumors (20%) expressed HER2 immunohistochemically. An IHC score of ≥ 2+ was observed in 20 tumors (16.6%). HER2 amplification was detected by CISH in 19 tumors (15.8%) and in their matched lymph node metastases. A high concordance rate was found between HER2 positivity (as detected by IHC) and HER2 gene amplification (as detected by CISH), since 19 of the 20 IHC positive cases were amplified (95%). All amplified cases had 2+ or 3+ IHC results. Amplification was associated with intestinal phenotype (P < 0.05). No association with grading, staging or survival was found.

CONCLUSION: In gastric cancer, HER2 amplification is the main mechanism for HER2 protein overexpression and is preserved in lymph node metastases.