Omics sciences and precision medicine in glioblastoma

Abstract

Glioblastoma is a highly aggressive and malignant type of brain cancer with a poor prognosis, despite current treatment options of surgery, radiation therapy, and chemotherapy. These treatments have limitations due to the aggressive nature of the cancer and the difficulty in completely removing the tumor without damaging healthy brain tissue. Personalized medicine, using genomic profiling to tailor treatment to the patient's specific tumor, and immunotherapy have shown promise in clinical trials. The blood-brain barrier also poses a challenge in delivering treatments to the brain, and researchers are exploring various approaches to bypass it. More effective, personalized treatment approaches are needed to improve outcomes for glioblastoma patients. This tumor is studied using genomics, transcriptomics, and proteomics techniques, to better understand its underlying molecular mechanisms. Recent studies have used these techniques to identify potential therapeutic targets, molecular subtypes, and heterogeneity of tumor cells. Advancements in omics sciences have improved our understanding of glioblastoma biology, and precision medicine approaches have impli-cations for more accurate diagnoses, improved treatment outcomes, and personalized preventive care. Precision medicine can match patients with drugs that target specific genetic mutations, improve clinical trials, and identify individuals at higher risk for certain diseases. Precision medicine, which involves customizing medical treatment based on an individual's genetic makeup, lifestyle, and environmental factors, has shown promise in improving treatment outcomes for glioblastoma patients. Identifying biomarkers is essential for patient stratification and treatment selection in precision medicine approaches for glioblastoma, and several biomarkers have shown promise in predicting patient response to treatment. Targeted therapies are a key component of precision medicine approaches in glioblastoma, but there is still a need to improve their effectiveness. Technical challenges, such as sample quality and availability, and challenges in analyzing and interpreting large amounts of data remain significant obstacles in omics sciences and precision medicine for glioblastoma. The clinical implementation of precision medicine in glioblastoma treatment faces challenges related to patient selection, drug development, and clinical trial design, as well as ethical and legal considerations related to patient privacy, informed consent, and access to expensive treatments.

Omics sciences and precision medicine in prostate cancer

Abstract

In the last decade, Prostate Cancer (PCa) has emerged as the second most prevalent and serious medical condition, and is considered one of the leading factors contributing to global mortality rates. Several factors (genetic as well as environmental) contribute to its development and seriousness. Since the disease is usually asymptomatic at early stages, it is typically misdiagnosed or over-diagnosed by the diagnostic procedures currently in use, leading to improper treatment. Effective biomarkers and diagnostic techniques are desperately needed in clinical settings for better management of PCa patients. Studies integrating omics sciences have shown that the accuracy and dependability of diagnostic and prognostic evaluations have increased because of the use of omics data; also, the treatment plans using omics can be facilitated by personalized medicine. The present review emphasizes innovative multi-omics methodologies, encompassing proteomics, genomics, microbiomics, metabolomics, and transcriptomics, with the aim of comprehending the molecular alterations that trigger and contribute to PCa. The review shows how early genomic and transcriptomic research has made it possible to identify PCa-related genes that are controlled by tumor-relevant signaling pathways. Proteomic and metabolomic analyses have recently been integrated, advancing our understanding of the complex mechanisms at play, the multiple levels of regulation, and how they interact. By applying the omics approach, new vulnerabilities may be discovered, and customized treatments with improved efficacy will soon be accessible.

Omics sciences and precision medicine in breast and ovarian cancer

Background

Human breast carcinoma is a complex disease, affecting 1 in 8 women worldwide. The seriousness of the disease increases when the definite cause of the disease remains obscure, thus making prognosis challenging. Researchers are emphasizing on adapting more advanced and targeted therapeutic approaches to address the multifaceted impacts of the disease. Hence, modern multi-omics systems have gained popularity among clinicians, as they offer insights into the genomic, pharmacogenomic, metabolomic, and microbiomic factors, thus allowing researchers to develop targeted and personalized approaches for breast cancer prevention and early detection, and eventually improving patient outcomes.

Aim

The primary focus of this study is to elucidate, through the integration of multi-omics research findings, the inherent molecular origins of diverse subtypes of breast cancer and to evaluate the effectiveness of these findings in reducing breast cancer-related mortalities.

Methods

Thorough investigation was conducted by reviewing reputable and authoritative medical journals, e-books, and online databases dedicated to cancer research. The Mendelian inheritance in man database (OMIM) was used to scrutinize specific genes and their respective loci associated with the development of different types of breast cancer.

Results

Our present research revealed the holistic picture of sundry molecular, genomic, pharmacogenomic, metabolomic, and microbiomic features of breast cancer. Such findings, like genetic alterations in highly penetrant genes, plus metabolomic and microbiomic signatures of breast cancer, unveil valuable insights and show great potential for multi-omics research in breast oncology.

Conclusion

Further research in omics sciences pertaining to breast cancer are at the forefront of shaping precise treatment and bolstering patient survival.

Omics sciences and precision medicine in colon cancer

Abstract

Colon cancer presents a complex pathophysiological landscape, which poses a significant challenge to the precise prediction of patient prognosis and treatment response. However, the emergence of omics sciences such as genomics, transcriptomics, proteomics, and metabolomics has provided powerful tools to identify molecular alterations and pathways involved in colon cancer development and progression. To address the lack of literature exploring the intersection of omics sciences, precision medicine, and colon cancer, we conducted a comprehensive search in ScienceDirect and PubMed databases. We included systematic reviews, reviews, case studies, clinical studies, and randomized controlled trials that were published between 2015-2023. To refine our search, we excluded abstracts and non-English studies. This review provides a comprehensive summary of the current understanding of the latest developments in precision medicine and omics sciences in the context of colon cancer. Studies have identified molecular subtypes of colon cancer based on genomic and transcrip-tomic profiles, which have implications for prognosis and treatment selection. Furthermore, precision medicine (which involves tailoring treatments, based on the unique molecular characteristics of each patient's tumor) has shown promise in improving outcomes for colon cancer patients. Omics sciences and precision medicine hold great promise for identifying new therapeutic targets and developing more effective treatments for colon cancer. Although not strictly designed as a systematic review, this review provides a readily accessible and up-to-date summary of the latest developments in the field, highlighting the challenges and opportunities for future research.

Omics sciences and precision medicine in lung cancer

Abstract

Lung cancer is a complex disease, with a wide range of genetic alterations and clinical presentations. Understanding the natural and clinical history of the disease is crucial for developing effective diagnostic and treatment strategies. Omics approaches, such as genomics, transcriptomics, proteomics, and metabolomics, have emerged as powerful tools for understanding the molecular mechanisms underlying lung cancer and for identifying novel biomarkers and therapeutic targets. These approaches enable researchers to examine the entire genome, transcriptome, proteome, or metabolome of a cell or tissue, providing a comprehensive view of the biological processes involved in lung cancer development and progression. Targeted therapies that address specific genetic mutations and pathways hold promise for improving the diagnosis and treatment of this disease.

Omics sciences and precision medicine in sarcoma

Background

Sarcomas are a relatively rare but diverse group of cancers that typically develop in the mesenchymal cells of bones and soft tissues. Occurring in more than 70 subtypes, sarcomas have broad histological presentations, posing significant challenges of prognosis and treatment. Modern multi-omics studies, which include genomics, proteomics, metabolomics, and micro-biomics, are vital to understand the underlying mechanisms of sarcoma development and progression, identify molecular biomarkers for early detection, develop personalized treatment plans, and discover drug resistance mechanisms in sarcomas to upsurge the survival rate.

Aim

This study aims to highlight the genetic risk factors responsible for sarcoma-genesis, and to present a comprehensive review of multi-omics studies about sarcoma.

Methods

Extensive literature research was undertaken using reliable and authentic medical journals, e-books, and online cancer research databases. Mendelian inheritance in man database (OMIM) was explored to study particular genes and their loci that are responsible to cause various sarcomas.

Result

This in-depth research led to the finding out that omics studies provide a more comprehensive understanding of underlying molecular mechanisms of sarcomas. Through genomics, we can reveal genetic alterations that predispose to sarcoma, like mutation in TP53, NF1, and so on. Pharmacogenomics enable us to find molecular targets for specific drugs. Whereas, proteomic and metabolomic studies provide insights into the biological pathways involved in sarcoma development and progression.

Conclusion

Future advancements in omics sciences for sarcoma are on the cutting-edge of defining precision treatment plans and improved resilience of sarcoma patients.

Characterization of somatic mutations in the pathogenesis of lipedema

Background

Lipedema, a complex and enigmatic adipose tissue disorder, remains poorly understood despite its significant impact on the patients' quality of life. Genetic investigations have uncovered potential contributors to its pathogenesis, including somatic mutations, which are nonheritable genetic alterations that can play a pivotal role in the development of this disease.

Aim

This review aims to elucidate the role of somatic mutations in the etiology of lipedema by examining their implications in adipose tissue biology, inflammation, and metabolic dysfunction.

Results

Studies focusing on leukocyte clones, genetic alterations like TET2 and DNMT3A, and the intricate interplay between adipose tissue and other organs have shed light on the underlying mechanisms driving lipedema. From the study of the scientific literature, mutations to genes correlated to three main pathways could be involved in the somatic development of lipedema: genes related to mitochondrial activity, genes related to localized disorders of subcutaneous adipose tissue, and genes of leukocyte clones.

Conclusions

The insights gained from these diverse studies converge to highlight the complex genetic underpinnings of lipedema and offer potential avenues for therapeutic interventions targeting somatic mutations to alleviate the burden of this condition on affected individuals.

Targeting Mast Cells: Sodium Cromoglycate as a Possible Treatment of Lipedema

Background

Mast cells are immune cells that mediate hypersensi-tivity and allergic reactions in the body, secreting histamine and other inflammatory molecules. They have been associated with different inflammatory conditions such as obesity and other adipose tissue di-sorders. Lipedema is a chronic disease characterized by an abnormal accumulation of adipose tissue on the legs and arms, pain, and other symptoms. Mast cells may play a role in the pathology of lipedema.

Objective

Pilot study to determine levels of histamine and its metabolites in lipedema subcutaneous adipose tissue (SAT) biopsy samples, and to test sodium cromoglycate for the treatment of mast cells in women with lipedema.

Methods

Biopsies from lipedema and control SAT were collected and analyzed histologically for the presence of mast cells. Mass spec-trometry was used to measure the levels of histamine, a key marker of mast cells, and its metabolites in SAT in women with lipedema and controls, and after a group of women with lipedema were administered oral and topical doses of sodium cromoglycate for two weeks.

Results

Histological examination of biopsies from lipedema patients confirmed the presence of mast cells. Metabolomic analysis revealed high levels of histamine and its metabolites in samples from women with lipedema compared to controls. Following a two-week treatment period, lipedema tissue samples exhibited reduced levels of histamine, suggesting a reduction of mast cell activity.

Conclusion

Sodium cromoglycate has the ability to stabilize mast cells and reduce histamine levels in lipedema patients, which could be useful in lowering the symptoms of lipedema.

Steroid-converting enzymes in human adipose tissues and fat deposition with a focus on AKR1C enzymes

Adipocytes express various enzymes, such as aldo-keto reductases (AKR1C), 11β-hydroxysteroid dehydrogenase (11β-HSD), aromatase, 5α-reductases, 3β-HSD, and 17β-HSDs involved in steroid hormone metabolism in adipose tissues. Increased activity of AKR1C enzymes and their expression in mature adipocytes might indicate the association of these enzymes with subcutaneous adipose tissue deposition. The inactivation of androgens by AKR1C enzymes increases adipogenesis and fat mass, particularly subcutaneous fat. AKR1C also causes reduction of estrone, a weak estrogen, to produce 17β-estradiol, a potent estrogen and, in addition, it plays a role in progesterone metabolism. Functional impairments of adipose tissue and imbalance of steroid biosynthesis could lead to metabolic disturbances. In this review, we will focus on the enzymes involved in steroid metabolism and fat tissue deposition.

Perinatal Arterial Ischemic Stroke in Fetal Vascular Malperfusion: A Case Series and Literature Review

Fetal vascular malperfusion includes a continuum of placental histologic abnormalities increasingly associated with perinatal brain injury, namely arterial ischemic stroke. Here, we describe the clinical-neuroimaging features of 5 neonates with arterial ischemic stroke and histologically proved fetal vascular malperfusion. All infarcts involved the anterior territories and were multiple in 2 patients. In 2 neonates, there were additional signs of marked dural sinus congestion, thrombosis, or both. A mixed pattern of chronic hypoxic-ischemic encephalopathy and acute infarcts was noted in 1 patient at birth. Systemic cardiac or thrombotic complications were present in 2 patients. These peculiar clinical-radiologic patterns may suggest fetal vascular malperfusion and should raise the suspicion of this rare, underdiagnosed condition carrying important implications in patient management, medicolegal actions, and future pregnancy counseling.

Genetics of lipedema: new perspectives on genetic research and molecular diagnoses

OBJECTIVE

The aim of this qualitative review is to provide an update on the current understanding of the genetic determinants of lipedema and to develop a genetic test to differentiate lipedema from other diagnoses.

MATERIALS AND METHODS

An electronic search was conducted in MEDLINE, PubMed, and Scopus for articles published in English up to March 2019. Lipedema and similar disorders included in the differential diagnosis of lipedema were searched in the clinical synopsis section of OMIM, in GeneCards, Orphanet, and MalaCards.

RESULTS

The search identified several genetic factors related to the onset of lipedema and highlighted the utility of developing genetic diagnostic testing to help differentiate lipedema from other diagnoses.

CONCLUSIONS

No genetic tests or guidelines for molecular diagnosis of lipedema are currently available, despite the fact that genetic testing is fundamental for the differential diagnosis of lipedema against Mendelian genetic obesity, primary lymphedema, and lipodystrophies.

Procedures and operating instructions for diagnosis in vascular anomalies and pathology

In the last 30 years a revolution has occurred in the diagnosis and management of vascular anomalies. The great changes began with Mulliken and Glowacki separation of hemangiomas and vascular anomalies. Their work has now morphed into the ISSVA classification. Subsequently the discovery of the significance of the presence of GLUT-1 in the diagnosis of the hemangiomas of infancy gave us a new marker in our quest for accurate classification. Now the genetic breakthroughs have led us into a "Star Wars" like environment in the experimental laboratory. During all these events the critical role of the pathologist has become more evident. Understanding the histopathology of anomalies has greatly aided in our approach to therapies. Moreover, genetic findings do not have full significance without the morphologic framework.

Hindbrain morphometry and choroid plexus position in differential diagnosis of posterior fossa cystic malformations

OBJECTIVE

To assess the differential diagnostic significance of a series of quantitative and qualitative variables of the cerebellar vermis in fetuses with posterior fossa cystic malformation, including Dandy-Walker malformation (DWM), vermian hypoplasia (VH) and Blake's pouch cyst (BPC).

METHODS

This was a retrospective study of confirmed cases of DWM, VH and BPC, diagnosed at the Fetal Medicine and Surgery Unit of the Federico II University between January 2005 and June 2013 or the Fetal Medicine and Surgery Unit of G. Gaslini Hospital between July 2013 and September 2017. All included cases had good-quality three-dimensional (3D) volume datasets of the posterior fossa, acquired by transvaginal ultrasound through the posterior fontanelle. The midsagittal view of the posterior fossa was the reference view for the study. We assessed brainstem-tentorium angle and brainstem-vermis angle (BVA), as well as craniocaudal (CCVD) and anteroposterior (APVD) vermian diameters and vermian area (VA), which were normalized by biparietal diameter (BPD) to take into account gestational age (CCVD/BPD × 100, APVD/BPD × 100 and VA/BPD × 100, respectively). Finally, the position of the fourth ventricular choroid plexus (4VCP) was defined as normal ('up') or abnormal ('down'), relative to the roof/cyst inlet of the fourth ventricle.

RESULTS

We analyzed 67 fetuses with posterior fossa malformations (24 cases of DWM, 13 of VH and 30 of BPC). The mean gestational age at diagnosis was 23.6 weeks. Regardless of gestational age, the BVA differed significantly between the three groups, and the VA/BPD was able to differentiate between VH and BPC. In differentiating between VH and BPC, the greatest areas under the receiver-operating characteristics curve were those for VA/BPD ratio. The 4VCP position was down in all cases of DWM and VH, while it was up in all cases of BPC.

CONCLUSIONS

Our data support the concept that VA/BPD ratio and 4VCP position may be used to differentiate between DWM, VH and BPC in the fetus. In our series, the position of the 4VCP had the highest accuracy, but a larger number of VH cases should be evaluated to confirm that an up position of the 4VCP indicates BPC while a down position indicates DWM or VH. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Histochemical Study of Mucinous Ovarian Cystomas of Intestinal and Mixed Types: O-Acetylated Sialomucin Content in Relation to Biologic Behavior

The subgroup of mucinous ovarian cystomas of intestinal type containing site 8 O-acetylated sialomucins and its relation to malignant behavior were studied. Of 75 mucinous cystomas of the ovary from the files of the Institute of Pathological Anatomy and Histology (University of Genoa), 54 were endocervical, 19 were mixed, and 2 were intestinal. As regards their histologic pattern, the 54 mucinous endocervical cystomas were benign, whereas the 19 mixed type group included 8 benign, 5 borderline and 6 malignant; the 2 intestinal type tumors were borderline. According to histochemical investigations, the frequency of tumors with goblet cells containing site 8 O-acetylated sialomucins (positive to PB/KOH/PAS) was 47% In the mixed type cystomas and 100% in the intestinal type cystomas. Twenty-five percent of benign mixed cystomas, 60 % of borderline mixed cystomas, and 67 % of mixed cystadenocarcinomas were positive to PB/KOH/PAS. One hundred percent of the borderline cystomas of intestinal type were positive. Our results confirm that among mucinous ovarian cystomas, those containing intestinal type epithelium are the most likely to fall within the borderline or malignant categories. Moreover, of all ovarian cystomas of intestinal type, those characterized by site 8 O-acetylated sialomucins seem to be more aggressive and, in general, to have a more malignant behavior than the mucinous cystic tumors of müllerian or endocervical type.

Mixed malignant mullerian tumor with neuroendocrine features in an irradiated uterus for cervical carcinoma. A unique association? A morphological, immunohistochemisty and ultrastructural study

Chemo-radiation represents an effective therapy for carcinoma of the uterine cervix. The endometrium may however receive a consistent dose of mutagenic radiations and patients may have an increased risk of secondary malignancies. Endometrial mixed malignant mullerian tumor (MMMT) is a rare, highly aggressive disease, and neuroendocrine features are even rarer. A 68 years old woman underwent radio-chemotherapy for a squamous cell carcinoma of the cervix. Follow up was uneventful until, eight years after radio-chemotherapy, imaging exams detected a diffuse enlargement of the uterine body. Radical hysterectomy revealed a multiphasic lesion with both sarcomatous and mixed carcinomatous components. The carcinomatous, component presented neuroendocrine histologic and ultrastuctural features and an intense expression of neuroendocrine immunohistochemistry markers. No residual cervical carcinoma was documented (pR0). The patient died of disease after 9 months. Reported cases further demonstrate how the irradiation of the uterus for cervical cancer carries a not negligible risk of developing a second endometrial cancer. The second cancer may develop years after initial therapy and may have aggressive histologic and clinical features. This case underlines the importance for a long follow-up in women having received radio-chemotherapy alone.

High cellularity and mitotic activity in a primary ovarian fibro-thecomatous tumor of a young patient: a diagnostic and clinical challenge

Purpose ofInvestigation: Solid ovarian tumors represent a clinical challenge, in particular in case of young patients who require a fertility sparing treatment. The authors report a case of hypercellular mitotically active ovarian fibrothecoma in a very young woman, successfully treated with a fertility sparing surgery.

MATERIALS AND METHODS

A 21-year-old nulliparous woman presented at the present hospital with a 14-cm right ovarian mass, consisting of solid and pseudo-cystic components. There was neither an elevation of tumor markers nor evidence of metastatic disease. A laparotomic right salpingo-oophorectomy was performed. Uterus and left adnexa were preserved.

RESULTS

The neoplasm consisted of a prevalent population of spindle-shaped elements and of a minor component of cells with wider cytoplasms, attributable to a thecomatous differentiation. The mitotic activity was focally elevated. Cytological atypia was mild to focally moderate. Clear areas of coagulative necrosis were not observed. At present 48 months after surgery, the patient is alive with no evidence of recurrence.

CONCLUSIONS

The authors reported the lesion as a hypercellular and mitotically active fibrothecoma. The uneventful follow-up confirms the low malignant potential of the lesion. Caution is required reporting hypercellular stromal ovarian tu- mors, in order to avoid overdiagnosis and overtreatment, particularly in young patients.

Virtopsy in conjoined ischiopagus twins

PURPOSE OF INVESTIGATION

To propose a multidisciplinary protocol for postmortem disclosure of complex fetal malformations, comparing ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and autopsy in a case of conjoined ischiopagus twins.

MATERIALS AND METHODS

A screening second-trimester ultrasound diagnosed ischiopagus twins at 20 gestational weeks in a 31-year-old woman without any previous ultrasound examination. The couple decided for pregnancy termination. The formalin-fixed fetuses underwent full-body CT, MRI, and autopsy.

RESULTS

ultrasound accurately diagnosed ischiopagus twins. CT was very accurate in the description of bone components. MRI allowed better visualization of the visceral organs than CT. Only autopsy could disclose the aspect of the two gastrointestinal tracts and the external genitalia.

CONCLUSIONS

Prenatal ultrasound represents the standard diagnostic exam for conjoined twins. CT-MRI virtual autopsy (virtopsy) may be an option if the couple refuses to authorize necropsy or may be useful to plan a minimally invasive autopsy preserving the external phenotype.

Assessment of fetal optic chiasm: an echoanatomic and reproducibility study

OBJECTIVES

Our aims were: (1) to perform an echoanatomic correlation study, in order to confirm that the structure identified as the optic chiasm (OC) on ultrasound (US) is indeed this anatomical structure; (2) to assess and compare the reproducibility of two- (2D) and three-(3D) dimensional US in measurement of the OC in normal fetuses; and (3) to assess whether the spatial orientation of the OC changes with increasing gestational age.

METHODS

For the echoanatomic study, the OC was studied in a neonatal specimen, deceased at 29 + 4 weeks, by passing a suture around the OC and visualizing the supposed OC structure on US while pulling gently on the suture. The reproducibility study included 39 women with normal pregnancy at 20-33 weeks undergoing routine obstetric US examination. After the routine exam, the OC was visualized on 2D-US, and a 2D image and 3D volume dataset were stored for offline measurement. On the 2D images, the diameters of the OC decussation and the optic tract proximal to the transducer were measured. For the 3D volume dataset, multiplanar image correlation with volume contrast imaging (VCI) was used to measure both these diameters and the chiasmocallosal angle (CCA). Two operators each took two sets of measurements of the diameters on 2D- and 3D-US, and intra- and interoperator variability were analyzed using Cronbach's alpha intraclass correlation coefficient (ICC), while a single operator took two sets of CCA measurements for assessment of intraoperator variability. Differences in CCA with increasing gestational age were also analyzed by regression, and CCA measurements were divided into three groups according to gestational age and their means compared by one-way ANOVA.

RESULTS

During the echoanatomic experiment, when the sling suture was pulled, the hyperechoic X-shaped structure just below the circle of Willis identified on 2D-US as the OC was displaced slightly and was eventually cut by the sling, confirming its identity as the OC. Intraoperator variability was low and almost identical for the two operators and the two imaging modalities for measurement of the decussation (ICC for 2D-US: 0.96 vs 0.95; 3D-US: 0.95 vs 0.96), but less so for the optic tract (ICC for 2D-US: 0.95 vs 0.91; 3D-US: 0.94 vs 0.83). Interoperator variability was low for the decussation (2D-US: 0.92; 3D-US: 0.92), but higher for the optic tracts (ICC for 2D-US: 0.80; 3D-US: 0.78). The difference between the mean measurement of the two operators was not statistically significantly different for the decussation, but it was for the optic tracts (P = 0.04). The CCA increased steadily between 20 and 30 gestational weeks and plateaued thereafter, at least until 33 weeks.

CONCLUSIONS

The hyperechoic structure evident on 2D- and 3D-US, just below the circle of Willis, is indeed the OC. 2D-US is apparently as good as 3D-US for visualization of the OC. However, only measurement of the decussation showed low intra- and interoperator variability, whereas measurement of the optic tract is of questionable variability. As gestation advances between 20 and 30 weeks, the OC becomes more oblique in orientation. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Diginyc partial hydatidiform mole with increased fetal nuchal translucency and ovarian hyperstimulation syndrome

PURPOSE OF INVESTIGATION

Hydatidiform mole (HM) is an abnormal pregnancy characterized by proliferation of cytotrophoblast and syncytiotrophoblast and vesicular swelling of placental villi. The fetus or embryo can be absent or abnormal. HMs can be complete or partial.

CASE REPORT

A case of diginyc partial HM at 12 weeks of gestational age was referred to the present center of prenatal diagnosis. The patient showed ovarian hyperstimulation syndrome. At ultrasonography, increased fetal nuchal translucency (NT) with fetal anomaly was evident, without sonographic signs of placental mole. Pregnancy was terminated with legal abortion.

RESULTS

Partial HM (PHM) was suspected by ultrasonographic fetal markers with ovarian hyperstimulation syndrome, but the diagnosis was performed only with fluorescent in situ hybridization. In particular fetal NT appeared increased also in diginyc mole.

CONCLUSION

In order to improve the detection rate of PHM, routine histological examinations may be associated to fluorescent in situ hybridization in all cases of fetal anomalies.

Sentinel node mapping with radiotracer alone in vulvar cancer: a five year single-centre experience and literature review

PURPOSE OF INVESTIGATION

The pathologic status of lymph node represents the most important prognostic factor in vulvar cancer patients, but a complete groin dissection is associated with high post-operative morbidity. Sentinel lymph node (SLN) could be representative of the totality of regional lymph nodes and consequently its biopsy might have a significant impact on clinical management in vulvar cancer patients.

MATERIALS AND METHODS

From January 2006 to December 2010 45 patients with vulvar carcinoma are evaluated. Preoperative lymphatic mapping with technetium-99m-labeled nanocolloid was performed in all patients, followed by radioguided intraoperative detection. The detection rate is 100% of patients. All the SLNs were dissected separately for histopathological evaluation and a routine inguinofemoral lymphadenectomy was performed.

RESULTS

Nine patients had positive SLNs. In the remaining 36 patients with negative SLNs, one of them showed positive non-SLNs at histological examination. It was the only false negative case in the present series.

CONCLUSIONS

Based on literature review, lymphoscintigraphy and sentinel node biopsy under gamma-detecting probe guidance offer a reliable and careful method to identify sentinel node in early vulvar cancer. Taking certain guidelines, SLN biopsy seems to be a safe alternative to inguinofemoral node dissection in order to reduce morbidity of surgical treatment.

Are there lymphatic vessels in the placenta?

The role of lymphatics in placentation has been scantily studied and the true existence of placental lymphatics is under debate. Numerous blood and lymphatic-lineage molecule markers are now available and they are expressed in human placental tissue. D2-40 expression at the placental stromal level seems to indicate that network-forming, podoplanin-expressing cells may act as a reticular-lymphatic-like conductive network. This exciting area at the intersection of perinatology and lymphology needs further investigation.

General surgery, translational lymphology and lymphatic surgery

A wide clinical experience in General Surgery has brought about a remarkable knowledge about lymphatic disorders both primary and secondary ones. Diagnostic and histopathological studies of lymphatic diseases allowed to better understand etiological aspects and pathophysiological mechanisms responsible of complex clinical features correlated to lymphatic dysfunctions. Translational lymphologic basic and clinical researches permitted to improve therapeutical approaches both from the medical and surgical point of view. Thus, strategies of treatment were proposed to prevent lymphatic injuries, to avoid lymphatic complications and to treat lymphatic diseases early in order to be able even to cure these pathologies.

Perinatal deaths and lymphatic system involvement: a diagnostic flow-chart applying immunohistochemical methods

A diagnostic flow chart is presented for use in case of perinatal death or still birth with non-immune hydrops fetalis, visceral effusions, or increased nuchal translucency. Immunohistochemical staining with CD-31, CD-34, D2-40, and smooth muscle actin is recommended.

Influence of 5-HT4 receptor activation on acetylcholine release in human large intestine with endometriosis

BACKGROUND

The 5-HT(4) receptor agonist prucalopride enhances large intestinal contractility by facilitating acetylcholine release through activation of 5-HT(4) receptors on cholinergic nerves and is effective in patients with constipation. Patients with intestinal endometriosis can present with constipation. We investigated in vitro whether large intestinal endometriotic infiltration influences contractility and facilitation of acetylcholine release by prucalopride.

METHODS

Sigmoid colon or rectum circular muscle strips were obtained at the level of an endometriotic nodule with infiltration of the Auerbach plexus, and at a macroscopically healthy site at least 5 cm cranially from the nodule, in patients undergoing laparoscopic colorectal resection because of symptomatic bowel endometriosis. Responses to muscarinic receptor stimulation and to electrical field stimulation (EFS), and the facilitating effect of prucalopride on acetylcholine release were evaluated.

KEY RESULTS

The EC50 and E(max) of the contractile responses to the muscarinic receptor agonist carbachol did not differ between healthy and lesioned strips. EFS-induced on-contractions were not different between the healthy and lesioned strips, while the non-nitrergic relaxant responses induced by EFS were decreased in the lesioned strips. The facilitating effect of prucalopride on acetylcholine release in healthy strips was similar to that reported before in macroscopically healthy colon tissue of patients with colon cancer; in lesioned strips, the effect of prucalopride was fully maintained in 6/8 patients and absent in two.

CONCLUSIONS & INFERENCES

Large intestinal endometriosis does not lead to a systematic interference with the cholinergic facilitating effect of prucalopride.

Selective D2-40 lymphatic endothelium immunoreactivity in developing human fetal skin appendages

D2-40 is a novel monoclonal antibody that recognizes a 40,000 Da O-linked sialoglycoprotein podoplanin. Although its use is becoming more common, little work has been done with human foetuses. We initiated an evaluation of D2-40 antibody immunoreactivity in developing cutaneous adnexa of human fetuses at various gestational ages. Starting from a retrospective cohort of 1,098 human fetal autopsies we identified and selected a total of 48 fetuses ranging from the 12th week gestational age to term appropriate for this study. We demonstrated that the gems of the hair follicles were D2-40 negative in fetuses from the 12th to 15th week gestation, positive in fetuses between the 16th and 20th week of gestation, negative in fetuses from the 21st week gestation to term. Normal adult controls were also negative. This is the first report to demonstrate intense D2-40 immunoreactivity in the gems of hair follicles of developing human skin.

Massive ovarian edema: a case of over 30 cm ovarian mass in young woman

Massive ovarian edema is a rare entity that can be confused with ovarian neoplasm. A 20-year-old nulligravid woman presented with a large solid pelvic mass and abdominal mass. On examination a solid mass was found which extended from the pelvis until over the umbilical transversal line. Abdominal ultrasound revealed a solid non-homogenous mass originating from the right ovary with largest diameter of over 30 cm, fine internal echoes, regular margins, and poor vascularization. The abdominal computed tomography (CT) image was non-contributory. Blood work including hematology and biochemistry was normal. There was no sign of systemic infection and the tumour markers are negative. Unilateral adnexectomy was performed during exploratory laparotomy. Histological examination demonstrated massive ovarian edema. The adnexa weighted 1,585 g. Massive edema of the ovary remains difficult to diagnose before surgery because it may clinically and radiologically mimic an ovarian neoplasm. The majority of cases present with recurrent abdominal pain or a palpable adnexal mass. Nausea with or without vomiting can be present. Menstrual irregularities are common. Some patients have signs of masculinization including hirsutism, clitoromegaly, voice deepening, precocious puberty. However, this entity should be considered in young women presenting with an ovarian mass and abdominal pain. Treatment of massive ovarian edema is controversial.

Immunohistochemical studies in a hydroptic fetus with pulmonary lymphangiectasia and trisomy 21

This case report presents a hydroptic trisomy 21 fetus affected by lymphatic dysplasia with no other malformations. Our studies using CD31, CD34, smooth muscle actin, desmin, and D2-40 antibodies immunohistochemistry confirm the diagnosis of severe pulmonary lymphangiectasia associated with lymphangiectasia ih the mediastinum and small bowel.

The risk of premalignant and malignant pathology in endometrial polyps: should every polyp be resected?

AIM

There is no wide consensus in the literature on the clinical significance and management of symptomatic and asymptomatic polyps. Aims of the study are to evaluate frequency of premalignant and malignant histo-pathologic features in endometrial polyps resected hysteroscopically and identify clinical parameters able to predict final histopathologic diagnosis.

METHODS

Clinical data and pathologic report of 90 consecutive operative hysteroscopies performed on women with endometrial polyps were collected. Frequency of premalignant and malignant histopathologic features on the polyps were calculated and relation to clinical risk factors analyzed.

RESULTS

The frequency of premalignant and malignant histopathologic features in polyps was 6.7% and 2.2% respectively. Owing to the small sample size no statistical analysis to detect clinical risk factor for premalignant or malignant histopathologic features could be performed.

CONCLUSION

Frequency of premalignant and malignant histopathologic features in symptomatic and asymptomatic patients is not negligible. Reported clinical risk factors for malignant degeneration of endometrial polypoid lesions are the same as those reported for endometrial cancer and are very common in patients with endometrial polyps. Every endometrial polyp should be resected.

Lymphatic microsurgery for the treatment of lymphedema

One of the main problems of microsurgery for lymphedema consists of the discrepancy between the excellent technical possibilities and the subsequently insufficient reduction of the lymphoedematous tissue fibrosis and sclerosis. Appropriate treatment based on pathologic study and surgical outcome have not been adequately documented. Over the past 25 years, more than 1000 patients with peripheral lymphedema have been treated with microsurgical techniques. Derivative lymphatic micro-vascular procedures has today its most exemplary application in multiple lymphatic-venous anastomoses (LVA). For those cases where a venous disease is associated to more or less latent or manifest lymphostatic pathology of such severity to contraindicate a lymphatic-venous shunt, reconstructive lymphatic microsurgery techniques have been developed (autologous venous grafts or lymphatic-venous-Iymphatic-plasty - LVLA). Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Subjective improvement was noted in 87% of patients. Objectively, volume changes showed a significant improvement in 83%, with an average reduction of 67% of the excess volume. Of those patients followed-up, 85% have been able to discontinue the use of conservative measures, with an average follow-up of more than 7 years and average reduction in excess volume of 69%. There was a 87% reduction in the incidence of cellulitis after microsurgery. Microsurgical lymphatic-venous anastomoses have a place in the treatment of peripheral lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. Improved results can be expected with operations performed earlier at the very first stages of lymphedema.

[Embryo and fetal pathology in routine diagnostics: what has changed and what needs to be changed]

The Authors have focused on the most important feto-neonatal and placental diseases in order to develop modern diagnostic tools which can meet the needs of clinicians (obstetricians, gynecologists, and neonatologists) for the best possible management of both the mother and the newborn. Although far from being operational instructions, it should be intended as a programmatic document providing a guideline on the issues that have cropped up in eight years of work of the APEFA group, as well as during several residential and practical classes. First of all, a synopsis is provided of the main issues concerning placental diagnosis in the newborn, as well as in case of fetal loss. A reasoned review is then provided of the main diagnostic criteria in placental pathology, in the light of therapeutical measures toward the mother (monitoring of future pregnancies) and the newborn (management of newborns at risk or with infectious disease). Legal issues in case of fetal distress at the end of pregnancy, neonatal damage and peripartum death have also been discussed with particular attention. Early and late miscarriages have also been separately examined, as well as fetal deaths. For each of these categories, a critical analysis is presented of current issues, followed by some considerations on the development of diagnostic methods and technology, and a modern diagnostic process is then outlined. Reference tables are also provided for diagnostic, auxological parameters, as well as on essential procedures. Issues concerning legal abortions and terminations of pregnancies have also been considered, with particular reference to tests and supplemental genetic and ultrasound examinations, diagnostic questions about malformations and forensic medicine assessments that are often involved with these specific categories. Malformations, fetal distress and growth retardation, sudden fetal and neonatal death, as well as embryo-pathology are all briefly dealt with also with synoptic tables. Diagnostic criteria are thus optimized and specially aimed at solving "human reproduction pathology" issues.

Is there a role for microsurgery in the prevention of arm lymphedema secondary to breast cancer treatment?

The secondary lymphedema of the upper limb (post-mastectomy lymphedema) has an incidence, in patients who underwent axillary lymphadenectomy for breast cancer, between 5 to 25%, up to 40% after radiotherapic treatment. We studied 50 patients treated for breast cancer. The patients were divided in two groups of 25 each, comparable for age, sex, pathology and treatment and followed up to 5 years after operation for breast. One group of 25 patients was controlled only clinically (physical examination, water volumetry) at 1-3-6 months and 1-3-5 years from breast cancer treatment. The other group of 25 patients was followed also by lymphatic scintigraphy performed pre-operatively and after 1-3-6 months and 1-3-5 years from operation. In the first group, followed only clinically, lymphedema appeared in 9 patients after a period variable from 1 week to 2 years, with highest incidence between 3 and 6 months. In the second group of 25 patients, the preventive therapeutic protocol allowed to have a clinically evident arm lymphedema only in 2 patients. The comparison of the two groups of 25 patients proved a statistically significant difference in the appearance of arm secondary lymphedema (p = 0.01, using Fisher's exact test). The diagnostic and therapeutic preventive procedures allow to reduce the incidence rate of lymphedema significantly, in comparison with patients who did not undergo this protocol of prevention.

Placental lesions in a case of DiGeorge sequence

This work describes some placental alterations found in a partial form of DiGeorge sequence, namely, hypoplasia of a cord artery with internal calcification of an extensive endoluminal thrombosis, and widespread calcification of microthrombi in the arteries of the second and third order villous branches. Hypoplasia of a cord artery is a relatively rare event, and is also associated with malformations of the gastroenteric and cardiovascular system, as sometimes described in the DiGeorge sequence. Interesting placental alterations are reported and their likely physiopathologic basis and pathogenic correlation discussed in order to give a better and more comprehensive picture of the DiGeorge sequence in which the correlated placental alterations are not sufficiently known.

A newly described thoracic vascular malformation in fetuses with Down syndrome

OBJECTIVES

To report the association between thoracic vascular malformations observed in the first trimester of pregnancy and Down syndrome.

METHODS

The clinical features were reviewed of seven fetuses undergoing chorionic villus sampling (CVS) for increased nuchal translucency (NT) thickness, in which color Doppler ultrasonography revealed a vascular malformation in the fetal thorax.

RESULTS

The crown-rump length of the fetuses ranged from 58 to 78 mm and NT measurements ranged from 2.9 to 10.0 mm. Color Doppler allowed the identification of a highly vascular structure in the posterolateral portion of the fetal thorax, in proximity to the costovertebral angle, at the level of a four-chamber view of the heart. The lesions had a globular shape and were 4-6 mm in diameter, occupying almost one third of the hemithorax. Down syndrome was diagnosed in five out of the seven cases. In the only affected case that underwent postmortem examination, a hemangioma of the chest wall was demonstrated. In the two fetuses with normal karyotype, the lesion disappeared by mid-gestation.

CONCLUSION

We report an association between the prenatal Doppler finding of a vascular tumor in the fetal chest and Down syndrome.

How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study

BACKGROUND

This study aims to evaluate the completeness of full thickness disc resection in the treatment of deep endometriotic bowel lesions.

METHODS

This study comprised 16 women with bowel endometriotic lesions requiring segmental resection. For the purpose of the study, before intestinal resection, nodulectomy was performed. The presence of endometriotic infiltration in direct continuity with the removed nodule and the presence of fibrosis in the area surrounding the nodule were histologically evaluated.

RESULTS

In seven out of 16 cases (43.8%; 95% CI, 19.8-70.1), endometriosis was found in the bowel wall adjacent to the site of nodulectomy; the infiltration was visible in the muscular layer in all cases. In cases of incomplete nodulectomy, the muscular layer of the bowel segment surrounding the endometriotic nodule contained limited or no fibrosis.

CONCLUSIONS

Full thickness disc resection is not complete in > or =40% of women with bowel endometriosis. Our finding that fibrosis in the muscular layer, the main landmark during surgical resection, does not always surround bowel endometriotic lesions might explain why incomplete resection may occur.

Cytological analysis of the distension fluid used during diagnostic office hysteroscopies in patients with suspected endometrial pathology

OBJECTIVE

Evaluation of the feasibility and usefulness of cytological analysis of the distension fluid used during diagnostic office hysteroscopy in patients with suspected endometrial pathology.

METHODS

In 243 consecutive patients undergoing diagnostic hysteroscopy for suspected endometrial pathology a few milliliters of the distension medium used for uterine visualization were collected and sent for cytological analysis. Findings of these "endometrial washings" were compared to visual hysteroscopic impression, endometrial biopsy and uterine histology--when available.

RESULTS

Endometrial washings were considered adequate in 227 patients (93.4%). In 12 cases (5.3%) atypical cells were detected: all of these presented either atypical complex hyperplasia or endometrial cancer at the final histological evaluation of the uterus. Four of the 16 (25%) patients diagnosed with endometrial cancer or atypical complex hyperplasia at the final histopathological analysis of the uterus had inadequate washings. No patient with cancer or atypical hyperplasia had negative cytology.

CONCLUSIONS

Collection and analysis of the distension fluid is feasible and, when positive, has a remarkable value in the diagnosis of endometrial cancer and its precursors.

The involvement of the interstitial Cajal cells and the enteric nervous system in bowel endometriosis

BACKGROUND

Our aim was to investigate the relationships between gastrointestinal symptoms and histological findings in women with bowel endometriosis.

METHODS

The gastrointestinal symptoms of 362 women with endometriosis were classified according to the subgroups of the Rome II criteria. All visible endometriotic lesions of the bowel were removed; the patients were prospectively followed up for 2 years. The interstitial Cajal cells (ICC) and the enteric nervous system were immunohistochemically evaluated.

RESULTS

Sixty-eight (18.8%, 95% CI 14.9-23.2) women had bowel lesions. The endometriotic lesions infiltrated the serosal layer and surrounding connective tissue in 45 cases; the subserous plexus in 11 cases; the Auerbach plexus in eight cases; the Meissner plexus in four cases. Whenever the subserous plexus was interrupted by the endometriotic lesions, the ICC were damaged. All women with endometriotic lesions reaching at least the subserous plexus reported bowel complaints. The level of infiltration into the bowel wall was correlated with severity of symptoms. Removal of lesions resulted in improvement of symptoms.

CONCLUSIONS

Endometriosis-induced damage of ICC, even before muscular infiltration, may cause bowel symptoms.

Sclerosing stromal tumor of the ovary in pregnancy: clinical, ultrasonography, and magnetic resonance imaging findings

We report a case of sclerosing stromal tumor of the ovary in a 30-year-old pregnant patient presenting with pelvic pain, dysuria, and metrorrhagia. Very few reports of sclerosing stromal tumor of the ovary during pregnancy have been presented. The purpose of our work is to present the findings at physical examination, ultrasonography, magnetic resonance imaging, and histopathology, to review the literature regarding this uncommon neoplasm, and to show the usefulness of magnetic resonance imaging in the assessment of pelvic masses during pregnancy.

[Expression of the cdx2 gene in benign intestinal-type mucinous ovarian tumors]

INTRODUCTION

Cdx2 gene belongs to the homeobox caudal gene family and it is located, in humans, on the 13q12.3 chromosome; in particular it codifies for a specific nuclear transcription factor which induces intestinal epithelium development, differentiation and preservation. Cdx2 expression in the human embryo can be observed in the intestinal epithelium starting from the sixth week of gestation. In the foetus and in adults it is observed in the whole enteric tube from the duodenum to the anal canal. Because of its organ specificity, cdx2 is an important marker for metastatic neoplastic lesions. Cdx2 is expressed in intestinal metaplasia and it is focally positive in adenocarcinomas of intestinal type of the stomach, pancreas and gall bladder as well as in ovarian mucinous adenocarcinomas. FINALITY OF THE STUDY: The aim of our study is to detect cdx2 positivity, with evaluation of its characteristics and expression, in ovarian mucinous cistoadenomas.

MATERIALS AND METHODS

We examined cdx2 expression in 50 ovarian mucinous cistoadenomas (mean age between 17 and 85), 19 of which were localised in the right ovary while 31 in the left one. Standard staining techniques (H&E), histochemistry (AB-PAS) ed immunohistochemistry with monoclonal antibodies against cdx2 (Biogenex/Menarini cdx2-88, batch MU3920402XS) were performed on formalin fixed and paraffin embedded material. For each case two samples were analysed.

RESULTS

Morphological evaluation of the 50 benign mucinous tumours distinguished 47 of endocervical type and 3 of intestinal type. These data were also confirmed by characterisation of mucin profile by AB-PAS staining. Using anti-cdx2 antibodies tumours of endocervical type were negative, while 3 intestinal type tumours were positive. In particular 2 cases presented diffuse nuclear positivity, while in one positivity was only focal.

DISCUSSION

Until today only two studies deal with cdx2 expression in mucinous ovarian tumours: 5 and 14 cases strong respectively. In the former, cdx2 expression was positive in all cases (100% positivity--5/5), in the latter cdx2 expression was positive in 64% of cases (9/14). In order to explain the lack of consistency in these data one must analyse ovarian mucinous tumours in detail. These neoplasms are divided into two subtypes: endocervical type and intestinal type. Distinction between these two types is near to impossible in malignant tumours, difficult in borderline tumours while it becomes easy in benign ones. Among benign tumours, endocervical type tumours are the majority, while intestinal type are much more infrequent. Our 50 case strong casistic is sufficiently ample to include 3 cases of intestinal type, all of which are cdx2 positive, compared to a complete negativity in the remaining 47 tumours clearly of endocervical type. We believe that the lack of consistency between the aforementioned studies is probably due to the fact that neither work contemplates the subdivision in intestinal and endocervical types. It is hence possible to hypothesise a selective and specific correlation between cdx2 positivity and the intestinal type epithelial component of ovarian tumours.

Cranial trepanation in two skulls of early medieval Italy

Cranial trepanation is a practice known since prehistory in various, often geographically distant populations. In this work are presented two early medieval trepaned skulls. The first skull comes from Canosa in Apulia (6th-7th c. AD; according to radiocarbon dating), the second is from Ticineto Alessandrino (5th-8th c. AD). The skull of Canosa shows a single perforation on the bregmatic quadrant of the right parietal, whereas the Ticineto skull presents three lesions of different shapes and sizes. Two perforations are on the left parietal and the other is on the right parietal. The lesions of the Ticineto skull can be referred to a therapeutic operation following a trauma, with survival of the individual. In the Canosa skull the absence of a healing reaction suggests a pathological process, without survival of the subject. Moreover, a particular ritual practice cannot be excluded (i.e. a post-mortem trepanation).