Acute myocardial infarction due to giant coronary artery aneurysm and arteriovenous fistula: a challenging case report and review of the literature

BACKGROUND

A coronary artery aneurysm (CAA) is an abnormal dilation of a coronary artery segment often accompanied by coronary artery fistula (CAF), leading to communication between a coronary artery and a cardiac chamber or a part of the coronary venous system. Both CAAs and CAFs can present with symptoms and signs of myocardial ischemia and infarction.

CASE PRESENTATION

We describe the case of a 46-year-old woman with non-ST-elevation myocardial infarction (NSTEMI) caused by a "giant" CAA. Various imaging modalities revealed a thrombus-containing aneurysm located at the right-posterior cardiac border, with established arteriovenous communication with the distal part of left circumflex artery (LCx). After initial treatment with dual antiplatelet therapy, a relapse of pain was reported along with a new increase in troponin levels, electrocardiographic abnormalities, reduced left ventricular ejection fraction (LVEF) and thrombus enlargement. Surgical excision of the aneurysm was favored, revealing its true size of 6 cm in diameter. Τhe aneurysm was excised without complications. The patient remained asymptomatic during follow-up.

CONCLUSIONS

Management of rare entities such as "giant" CAAs and CAFs can be challenging. Cases such as this can serve as precedents to facilitate treatment plans and develop consistent recommendations, emphasizing the importance of personalized strategies for future patients.

Targeting the epigenome in malignant melanoma: Facts, challenges and therapeutic promises

Malignant melanoma is the most lethal type of skin cancer with high rates of mortality. Although current treatment options provide a short-clinical benefit, acquired-drug resistance highlights the low 5-year survival rate among patients with advanced stage of the disease. In parallel, the involvement of an aberrant epigenetic landscape, (e.g., alterations in DNA methylation patterns, histone modifications marks and expression of non-coding RNAs), in addition to the genetic background, has been also associated with the onset and progression of melanoma. In this review article, we report on current therapeutic options in melanoma treatment with a focus on distinct epigenetic alterations and how their reversal, by specific drug compounds, can restore a normal phenotype. In particular, we concentrate on how single and/or combinatorial therapeutic approaches have utilized epigenetic drug compounds in being effective against malignant melanoma. Finally, the role of deregulated epigenetic mechanisms in promoting drug resistance to targeted therapies and immune checkpoint inhibitors is presented leading to the development of newly synthesized and/or improved drug compounds capable of targeting the epigenome of malignant melanoma.

Dermatofibrosarcoma protuberans: a case report and review of the literature

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) represents less than 0.1% of all tumors, but it is considered the most common skin sarcoma. Wide local excision (=5 cm) has been largely replaced by Mohs micrographic surgery; however, recurrence is not rare. Description of the case: A 35-year-old man presented with a large tumor on the upper side of his back and underwent local excision with the possible preoperative diagnosis of lipoma. Upon histological examination, the diagnosis of DFSP was made, and the patient underwent wide local excision with skin flap reconstruction and was referred for adjuvant radiotherapy.On twenty months follow-up, no recurrence has been observed.

CONCLUSION

DFSP is the most common cutaneous sarcoma. It originates in the dermis and tends to infiltrate underlying structures, including muscles, tendons, fascia and bone. In our case, the tumor was confined to the skin and subcutaneous tissue, however, our patient underwent adjuvant radiotherapy to avoid a possible relapse that would infiltrate deeper structures. Long-term follow-up is strongly recommended. Hippokratia 2016, 20(1): 80-83.

Spatial distribution and life-history aspects of blackspot seabream Pagellus bogaraveo (Osteichthyes: Sparidae)

Spatial distribution and life history aspects of Pagellus bogaraveo in the eastern Ionian Sea were investigated using the data from 13 different studies carried out in the area from 1983 to 2010. The spatial patterns of the abundance, biomass and mean size showed that the species inhabits the shallow waters of the shelf (<170 m depth) as juveniles up to a certain size (<180 mm total length, LT ), moving to deeper waters of the slope (mainly 400-500 m depth) as adults. The spatial pattern of abundance indicated a continuous distribution of the species in deep waters, with hot-spot areas of high values, whereas in shallow waters distribution was more discontinuous, with higher concentrations of juveniles in estuaries and brackish waters. The study of biological aspects of the species revealed (1) a difference in the increase in mass between males and females, (2) protandrous hermaphroditism, accompanied by the presence of primary females and males that do not change sex, (3) a sex ratio in favour of females >250 mm LT , (4) the presence of hermaphrodites between 200 and 370 mm, (5) a long reproduction period from June to March, (6) a size at first maturity around 300 mm and (7) a diet composition of adults based mainly on fishes, and also on opportunistic behaviour in the food scarce environment of deep waters. The results suggest that the species' distribution and feeding strategies are the most appropriate for the oligotrophic eastern Ionian waters and that these conditions result in smaller sizes of the species in the east Mediterranean Sea compared to the west basin and the east Atlantic Ocean, with implications for the growth and reproductive biology of the species.

Perforation of Meckel's diverticulum by a wood splinter in a 4-year-old child: a case report

Perforation of Meckel's diverticulum by a foreign body represents an unusual and serious clinical occurrence. We present a case of a 4-year-old male who was admitted with symptoms of abdominal pain in the right iliac fossa, raising the suspicion of acute appendicitis. Exploratory laparotomy disclosed normal appendix and perforation of Meckel's diverticulum caused by a wood splinter. Meckel's diverticulectomy was performed and the child had an uneventful postoperative course. Preoperative diagnosis of perforated Meckel's diverticulum remains a challenging issue. Diagnosis should be considered in the presence of a right lower quadrant abdominal pain or a positive history of ingestion of a sharp foreign body.

Primary prostatic lymphoma with components of both diffuse large B-cell lymphoma (DLBCL) and MALT lymphoma

Although lymphomas involving the prostate gland are rare, they should always be considered in the differential diagnosis. We report a case of primary prostatic NHL in a 70-year-old man presented with hematuria and urinary obstructive symptoms. Routine laboratory tests were within normal limits and prostate-specific antigen (PSA) was 0,01 ng/ml. The patient underwent radical prostatectomy. Histologically, two different coexisting patterns of non-Hodgkin lymphoma, infiltrating the prostatic tissue, were identified. The diagnosis of diffuse large B-cell lymphoma (DLBCL) presenting with an associated low-grade lymphoma of MALT-type was confirmed by immunohistochemistry. The patient received chemotherapy without any complication and has been followed-up for 2 years since surgical resection with no recurrence. The clinicopathologic characteristics of prostatic lymphomas are discussed, while reviewing the current English-language literature.

Type I collagen biomarkers in the diagnosis of bone metastases in breast cancer, lung cancer, urinary bladder cancer and prostate cancer. Comparison to CEA, CA 15-3, PSA and bone scintigraphy

PURPOSE

In this study we evaluated the clinical usefulness of serum pro-I collagen peptide (PICP) and I collagen telopeptide (ICTP) as indicators of early bone metastases in patients with breast (BC), lung (LC), urinary bladder (UBC) and prostate cancer (PC).

PATIENTS AND METHODS

305 patients were examined. 145 had histologically confirmed BC (92 with bone metastases), 20 UBC (6 with bone metastases), 11 LC (3 with bone metastases) and 129 PC (68 with bone metastases). In BC patients we compared the PICP and ICTP levels with those of CA 15-3, CEA and bone scintigraphy. Patients with LC and UBC had PICP and ICTP measurements, PC patients had serum PICP, prostate specific antigen (PSA) measurements and bone scans. 104 healthy individuals served as controls.

RESULTS

ICTP and CA 15-3 levels were significantly higher in patients with BC and bone metastases in comparison to patients without metastases (p <0.05), while PICP and CEA were only marginally higher. Significant correlation was observed between existence of bone metastases and ICTP levels (p <0.05). The sensitivity of PICP, ICTP, CEA and CA 15-3 was 28.1, 48.6, 42, and 78%, respectively and specificity was 83.9, 94, 65 and 86%, respectively. ICTP and CA 15-3 were the most reliable markers for early diagnosis of bone metastases in BC. PICP alone or with ICTP were not sensitive enough. Only CA 15-3 showed sensitivity 78% and specificity 86%. When combined CA 15-3, ICTP and CEA the sensitivity and specificity increased to 82% and 96%, respectively. Furthermore, PICP and PSA levels were significantly higher in patients with PC and bone metastases in comparison to patients with benign prostate hyperplasia (BPH) (p <0.0001) or in patients with PC without bone metastases (p <0.0005 for PICP and p <0.0001 for PSA). The co-evaluation of PICP and PSA improved the sensitivity (78%), specificity (96%), accuracy (97%) and positive predictive value (97%). In LC patients, ICTP levels differed significantly between patients with and without bone metastases (p=0.025). In UBC patients, PICP levels differed significantly between patients with and without bone metastases (p=0.017).

CONCLUSION

ICTP and CA 15-3 are the most reliable markers for early diagnosis of bone metastases in BC patients. PICP could be useful for diagnosing early bone metastases of PC and combined with PSA and bone scan can be an additional tool in the follow-up of PC patients. For LC patients, ICTP showed a significant difference in the discrimination of patients with and without bone metastases. In UBC patients, PICP showed a significant difference in the discrimination of patients with and without bone metastases.

High grade primary adrenal intravascular large B-cell lymphoma manifesting as Addison disease

We report a rare case of a 68 aged male who presented with adrenal failure and was diagnosed of high grade large B-cell lymphoma primarily arising in the adrenal glands. The patient was administrated with additional chemotherapy but he passed away 7 months later due to infection in the lungs. Intravascular lymphoma should be suspected in patients with bilateral adrenal masses who present with rapidly progressive adrenal insufficiency.

Association between bone scintigraphy and serum levels of procollagen (I) and PSA in the detection of bone disease in prostate cancer patients

PURPOSE

To evaluate the clinical usefulness of serum procollagen I carboxyterminal propeptide (PICP) and prostate specific antigen (PSA) in relation to bone scan results in Greek patients with prostate cancer (PC).

PATIENTS AND METHODS

108 patients (mean age 58+/-4.3 years; range 42-81) with PC and 52 healthy blood donors as control group were examined for serum PICP and PSA levels. The diagnosis of PC was confirmed histologically. Bone metastases were diagnosed in 68 of the patients with the use of (99m)Tc-MDP bone scan, while 40 patients had no bone metastases. During the one year follow-up new PICP and PSA measurements were obtained along with a new bone scan for all groups studied.

RESULTS

The levels of serum PICP and PSA were significantly higher in patients with PC and bone metastases in comparison to patients with no bone metastases. The sensitivity and specificity of the combination of PICP and PSA were 78% and 96%, respectively.

CONCLUSION

PICP could be useful for diagnosing early bone metastases of prostate adenocarcinoma and in combination with PSA and bone scan can be an additional tool in the follow-up of patients with PC.

A stromal myoid cell line provokes thymic T-cell immigration at the second and third gestational trimesters

Once lymphoid precursors enter the thymus form the blood stream, they come into contact with thymic stromal cells that guide their maturation into functionally competent T cells. Thymic myoid cells are one such cell type. They have been described as a regular constituent of the thymus of embryonic and young vertebrates and express muscle proteins including myosin, desmin, acetylcholine receptor (AChR), C-protein, MyoD, troponin T, rapsyn, and utrophin. It has been emphasized recently that the thymic myoid cells play an important role in the protection of thymocytes from apoptosis, and in the process of T-cell differentiation and maturation.

AIM

To provide a quantitative estimation of thymic myoid cells and T-cell population in different stages of development. A probable interaction between these two populations could explain an additional mechanism to the active T-cell migration from the thymus that is a direct contact to a specific myoid cell line.

MATERIALS AND METHODS

Paraffin-embedded specimens from the thymus of forty five human embryos at the first, second and third trimester of gestation respectively, were investigated by conventional histology, and immunohistology for the presence in the stroma of the thymic medulla, of myosin in the myoid cells, and UCHL1 (pan T-cell) antigen in the medullary thymocytes.

RESULTS

Our results demonstrated a quantitative difference in the second and third trimester of development concerning the expression of myosin in the stromal myoid cells of the thymic medulla over the equivalent expression of the protein in the first trimester. Similar changes in the above periods were found concerning the population of medullary thymocytes expressing UCHL1 antigen.

CONCLUSIONS

Our results indicate that: (1) Thymic myoid cells play an important role in the thymic microenvironment as they are well conserved throughout species evolution. (2) The increased population of myoid cells in the medullary area during mid and late gestational age, in comparison with first trimester, probably reflects the increased demand of the growing fetus for mature T lymphocytes. Contractions of myoid cells mediated by their cytoplasmic structural proteins, including myosin which is well preserved during development, might aid the movement of thymocytes expressing UCHL1 antigen, across or out of the gland, suggesting a potential involvement of myoid cells in the thymic function. Further studies on larger series are needed to corroborate this.

Primary combined carcinoid and adenocarcinoma of the ileum associated with transitional carcinoma of the bladder. Single case report

Composite neoplasms, carcinoid and adenocarcinoma have been reported to occur in several parts of the body, including the stomach, ampulla of Vater, large bowel, lung, and urinary bladder. Here we report a case of a 74-year-old male with a composite carcinoid-adenocarcinoma of the ileum associated with a transitional cell carcinoma of the bladder. The microscopical examination of the composite tumor showed an admixture of typical carcinoid tumor and moderately a differentiated adenocarcinoma. Immunohistochemically, the two components showed clear-cut differentiations. A review of the literature revealed that this is the first reported case of composite carcinoid-adenocarcinoma of the ileum associated with transitional cell carcinoma of the urinary bladder.

Imbalance of mononuclear cell infiltrates in the placental tissue from foetuses after spontaneous abortion versus therapeutic termination from 8th to 12th weeks of gestational age

Placental macrophages (Hofbauer cells) are located close to trophoblastic cells and foetal capillaries, which make them perfect candidates for involvement in regulatory processes within the villous core. Their capacity of producing several cytokines and prostaglandin-synthesising enzymes, and expressing vascular endothelial growth factor, indicate a possible role in placental development and angiogenesis in order to support pregnancy. Common cells to Hofbauer macrophages sharing similar cell surface markers (HLA-A, -B, -C and leukocyte common antigen) have been reported in the stroma, decidua and amnion, indicating additional foetal protection. Yet this is not always the case. Most spontaneous abortions occur before 12 weeks' gestation, and most are due to chromosomal errors in the conceptus. Relatively few truly spontaneous abortions take place between 12 and 20 weeks' gestation. Thereafter, between 20 and 30 weeks, another type of premature spontaneous termination becomes prevalent, which is due to ascending infection. The numbers of cells expressing the various markers of the monocytemacrophage lineage change throughout pregnancy. In the present study, we investigated the immunohistochemical expression of mononuclear infiltrations in paraffin-embedded placentas, from foetuses after spontaneous abortion (8th, 10th and 12th weeks of gestational age), and those after therapeutic abortion at the same time, using a panel of monoclonal antibodies for the identification of leukocytes (CD45/LCA), B-lymphocytes (CD20/L-26), T lymphocytes (CD45RO/UCHL1), CD68 and CD14 cells. Immunologic factors in human reproductive failure are plausible mechanisms of infertility and spontaneous abortion. Approximately 25% of cases of premature ovarian failure appear to result from an autoimmune aetiology. Unfortunately, current therapeutic options for these women are limited to exogenous hormone or gamete substitution. Local inflammations at the sites of endometriosis implants are postulated to mediate the pain and reduced fecundability associated with this clinical syndrome. The recruitment of immune cells, particularly monocytes and T-cells, neovascularisation around foci of invading peritoneal lesions, and the possible development of antiendometrial autoantibodies support an immunologic basis of this disorder. To date, treatment of pain and infertility associated with endometriosis is primarily surgical, although immune-based adjuvants are theoretical possibilities for the future. Finally, although hypotheses supporting immunologic mechanisms of recurrent pregnancy loss have been popular over the past decade, most clinical investigations in this area do not provide compelling evidence for this position. Reputable specialists in reproductive medicine use experimental immunotherapies judiciously in selected cases of repetitive abortion. For example, the use of anticoagulation therapy can be beneficial in cases with documented antiphospholipid antibodies. At present, however, efficacious immunotherapy protocols for general application have not been established. Despite these caveats, continued strides in our understanding of human reproductive immunology should yield considerable future progress in this field. During the physiological changes that occur in the first and in the beginning of the second trimester of pregnancy, spiral arteries of the placental bed are converted into the uteroplacental arteries. The essence of this conversion consists of losing the muscular elements in the vessel walls, making them unable to respond to vasomotor influences. Cells that infiltrate the walls of spiral arteries and replace their normal elements are called migratory, non-villous or intermediate trophoblastic cells. Besides infiltrating and replacing the anatomic structures of spiral arteries, intermediate trophoblastic cells also penetrate into the lumina of these vessels forming endovascular plugs. These plugs are one of the reasons why early uteroplacental blood flow cannot be visualised, even with transvaginal ultrasound, during the first 12 weeks of gestation. In uncomplicated pregnancies, the endovascular trophoblast is bound to disappear by the end of the second trimester of pregnancy, but the literature on this topic is scarce. Here we describe the detection, isolation and characterisation of CD45RO-, L26- and CD68/CD14-positive cells from human early pregnancy deciduas. These cells were found in close vicinity to endometrial glands, with preference to the basal layer of the decidua. We conclude that (1) maternal cells, apparently CD45RO/UCHL1-positive cells, cross the maternofoetal barrier and participate in spontaneous (involuntary) abortions, and (2) a small proportion of maternal cells (approximately 30%), apparently CD68/CD14-positive cells, also cross the maternal-foetal barrier and cause growth delay and recurrent reproductive failure. Further investigation of involvement of the intercellular adhesion molecules 1 and 2, platelet endothelial cell adhesion molecule, vascular cell adhesion molecule and E-selectin in leukocyte accumulation will be needed to support the passage of maternal cells to the foetus. The results were statistically significant (P<0.0001, Student's t-test).

Spontaneous abortions with increased CD5 positive cells in the placental tissue during the first trimester of gestation

Most spontaneous abortions occur before 12 weeks' gestation, and most are due to chromosomal errors in the conceptus. Relatively few truly spontaneous abortions take place between 12 and 20 weeks' gestation. Thereafter, between 20 and 30 weeks another type of premature spontaneous termination due to ascending infection becomes prevalent. The number of cells expressing the various lymphocytic markers changes throughout pregnancy. In the present study, we investigated the immunohistochemical expression of mononuclear infiltrations in paraffin-embedded placentas, from fetuses after spontaneous abortion (8th, 10th, and 12th week of gestational age), and those after therapeutic abortion at the same time, using a panel of monoclonal antibodies for the identification of leukocytes (CD45/LCA), B-lymphocytes (CD20/L-26), T-lymphocytes (CD45RO/UCHL1) and CD5 cells. Immunologic factors in human reproductive failure are plausible mechanisms of infertility and spontaneous abortion. Approximately 25% of cases of premature ovarian failure appear to result from an autoimmune etiology. Unfortunately, current therapeutic options for these women are limited to exogenous hormone or gamete substitution. Local inflammation at the sites of endometriosis implants are postulated to mediate the pain and reduce fecundability associated with this clinical syndrome. The recruitment of immune cells, particularly monocytes and T cells, neovascularization around foci of invading peritoneal lesions, and the possible development of antiendometrial autoantibodies support an immunologic basis of this disorder. To date, treatment of pain and infertility associated with endometriosis is primarily surgical, although immune-based adjuvants are theoretical possibilities for the future. Finally, although hypotheses supporting immunologic mechanisms of recurrent pregnancy loss have been popular over the past decade, most clinical investigations in this area do not provide compelling evidence for this position. Reputable specialists in reproductive medicine use experimental immunotherapies judiciously in selected cases of repetitive abortion. For example, the use of anticoagulation therapy can be beneficial in cases with documented antiphospholipid antibodies. At present, however, efficacious immunotherapy protocols for general application have not been established. Despite these caveats, continued strides in our understanding of human reproductive immunology, should yield considerable future progress in this field. We conclude that, 1) maternal cells, probably CD45RO/UCHL1 positive cells, cross the maternofetal barrier and participate in spontaneous (involuntary) abortions, 2) a small proportion of maternal cells (approximately 30%), probably CD5 positive cells, also cross the maternal fetal barrier and cause growth delay and recurrent reproductive failure. The results were statistically significant (p < 0.0001, Student's t-test).

Human decidual cells can express the Hodgkin's cell-associated antigen Ki-1 (CD30) in spontaneous abortions during the first trimester of gestation

CD30 (Ki-1) antigen has been considered to be expressed on hematopoietic cells including the ones of the recently described anaplastic large cell lymphoma (ALCL), the Reed-Sternberg (RS) cells of Hodgkin's disease and the scattered large parafollicular cells in normal lymphoid tissues. Since then, several reports have been published describing CD30 expression in non-hematopoietic and malignant cells, such as cultivated human macrophages, human decidual cells, histiocytic neoplastic cells, mesothelioma cells, embryonal carcinoma, and seminoma cells. In the present study, we investigated the immunohistochemical expression of CD30 antigen in 15 paraffin-embedded placentas from fetuses after spontaneous abortion in the first trimester of gestation (8th, 10th, and 12th week, respectively) using the monoclonal antibody Ber-H2. All the pregnant patients had been given hormonal medication to support gestation. In addition, a panel of monoclonal antibodies for the identification of leukocytes (CD45/LCA), B-lymphocytes (CD20/L-26), and T-lymphocytes (CD45RO/UCHLI) was performed. Our findings were correlated with those found in 15 placentas obtained from 15 fetuses at the same time, after therapeutic or voluntary abortions. This study demonstrates that, 1) decidual endometrial stromal cells are able to express the CD30 (Ki-1) antigen, 2) the expression of CD30 in decidual cells is higher in cases of hormonal administration (to support gestation), than that found in normal gestation. In the former cases (hormonal support of gestation), a mild mononuclear infiltration of the decidua by UCHLI (T marker) positive cells, accompanies the CD30 positive cells.

Expression of fibrillar proteins and vimentin in developing chorionic villi is related to fetal maturation

Using an immunocytochemical technique, the extracellular matrix components fibronectin, vimentin, laminin and collagen type IV were investigated in human chorionic villi of various stages of development. Fibronectin and laminin were consistently positive throughout embryonic development. Vimentin and collagen type IV were negative in first and second trimester chorionic villi, but became positive in term placentas. With the exception of laminin, all extracellular matrix molecules were detected in the villous stroma and, with the exception of vimentin, they were localized in the basement membranes. Our data suggest that fibronectin and laminin are essential components of the villous structure, while the presence of vimentin and collagen type IV in the chorionic villi should be regarded as an indicator of fetal maturation.