Traffic pollution tracers in the lymphatic system tissue of children-possible link to chronic tonsillitis development: pilot study

The origin of metal elements in tonsillar tissues of children patients was investigated in order to establish the link between environmental pollution and tonsilitis diagnosis. The children lived either in a polluted, industrial region (Moravian-Silesian Region, North-East Czechia) or a clean, predominantly agricultural region (South Bohemian Region, South-East Czechia). Simultaneously, the distance of the address of the patients to the closest main road was assessed. The elemental content of the present particulate matter in the tonsil samples, coming from indicated tonsillectomies, was analysed using scanning electron microscopy equipped with an X-ray microprobe. No significant association of the elemental composition and the region was found using both bivariate and multivariate methods; however, an association with the distance to the closest main road was found. The study presents a novel assessment of the tonsillar tissues and supports the link between environmental factors (traffic-related particulate pollution) and the onset of chronic, idiopathic diseases in children, which has been debated recently.

Identification of the phase composition of solid microparticles in the nasal mucosa of patients with chronic hypertrophic rhinitis using Raman microspectroscopy

Solid particles, predominantly in micron and submicron sizes, have repeatedly been observed as a threat to a human health unique compared to the other textures of the same materials. In this work, the hypothesis the solid metal-based particles play a role in the pathogenesis of chronic hypertrophic rhinitis was investigated in patients who had not responded positively to medication. In the group of 40 randomly selected patients indicated for surgical mucotomy, the presence of solid micro- and submicron particles present in their nasal mucosa was assessed. For comparison, a set of 13 reference samples from patients without diagnosed chronic hypertrophic rhinitis was evaluated. The analysis was performed using Raman microspectroscopy. The advantage of this method is the direct identification of compounds. The main detected compounds in the mucosa samples of patients with chronic hypertrophic rhinitis were TiO2, carbon-based compounds, CaCO3, Ca(Fe, Mg, Mn)(CO3)2 MgCO3, Fe2O3, BaSO4, FeCO3 and compounds of Al and Si, all of which may pose a health risk to a living organism. In the reference samples, only TiO2 and amorphous carbon were found. In the control group mucosa, a significantly lower presence of most of the assessed compounds was found despite the longer time they had to accumulate them due to their higher mean age. Identification and characterisation of such chemicals compounds in a living organism could contribute to the overall picture of the health of the individual and lead to a better understanding of the possible causes not only in the chronic hypertrophic rhinitis, but also in other mucosal and idiopathic diseases.

Is autoimmune pancreatitis a risk factor for pancreatic adenocarcinoma?

Immunoglobulin G4-related diseases (IgG4-RD) are a group of diseases characterized by high serum levels of immunoglobulin G4 (IgG4), increased lymphocyte and plasma cell with IgG4 positivity in the parenchyma of some organs, and storiform fibrosis. The most frequently affected organ is the pancreas. This is an autoimmune form of pancreatitis, which can be divided into two types: Type 1, which is significantly more common than Type 2, is high in IgG4 in the pancreatic parenchyma and shows a fundamental difference in the noted presence of extrapancreatic disorders. In general, chronic inflammation is a risk factor in the development of carcinomas. Chronic pancreatitis is an accepted risk factor for the development of pancreatic cancer. The question is whether this also applies to autoimmune pancreatitis (AIP), which has some mediators of inflammation in common with sporadic pancreatitis, and what role the presence of IgG4 plays. The vast majority of the work on this topic consists of case reports, yet, even based on our own experience, we would like to say that there is a relationship between the autoimmune form of pancreatitis and pancreatic cancer, which usually occurs in the first two years after diagnosis of AIP. Also significant is the fact that the group of people with AIP, who is a clinical manifestation of IgG4-RD, was found to have an even higher incidence of extrapancreatic cancer than in the pancreas itself. Differentiating AIP from pancreatic cancer can sometimes be problematic since these diseases can both present as focal pancreatic lesions. IgG4 has been considered useful for AIP diagnosis, however, IgG4 levels can be slightly elevated, as in the case with pancreatic adenocarcinoma. IgG4 levels of over twice the upper limit are rare among patients with pancreatic adenocarcinoma. However, cases of simultaneous presentation of pancreatic cancer and AIP have been documented and should not be neglected. AIP is a condition where regular followup is mandatory, including from the perspective of possible cancerogenesis.

Metal particles in mucus and hypertrophic tissue of the inferior nasal turbinates from the human upper respiratory tract

Mucosal surfaces are the first mechanical barrier preventing the entry of foreign particles into the organism. The study addresses the detection and analysis of metal-based solid particles in cytological mucus samples from the surface of human hypertrophic tissue in the inferior nasal turbinates in patients diagnosed with chronic rhinitis. Solid particles were characterized by scanning electron microscopy and Raman microspectroscopy; all the biological samples were also subjected to vibration magnetometry. Since the upper airways are the first part of the respiratory tract, which is exposed to inhaled particles, it can be assumed that inhaled particles may be partially deposited in this region. Scanning electron microscopy revealed the presence of metal-based solid particles/clusters in the majority of the analysed cytological mucus samples and also in hypertrophic tissues; in all groups, the particles were of submicron size. Raman microspectroscopy detected the presence of particles/clusters based on amorphous carbon, graphite, calcium carbonate, anatase and barite only in the hypertrophic tissue. The obtained results show that the composition of some of the solid particles (i.e. Ba, Zn, Fe and Ti) detected in the mucus from the surface of the hypertrophic tissues resembled the particles found in the hypertrophic tissue itself. It can be assumed that after the capture of the inhaled particles by the mucus, they penetrate into the deeper layers of tissue.

The role of metabolic syndrome in the induction of chronic pancreatitis after a first attack of acute pancreatitis - multicenter trial

BACKGROUND

Metabolic syndrome is a serious societal problem worldwide. In the Czech Republic more than 30% of the adult population are sufferers. The role of recurrent acute pancreatitis in the induction of chronic pancreatitis, following the socalled „mechanistic definition“ of chronic pancreatitis, has been unequivocally confirmed. However, there are a number of factors that may contribute to the development of chronic pancreatitis. The first aim of the study was to determine whether the metabolic syndrome may affect the development of chronic pancreatitis. The second question we asked ourselves was whether even one acute attack of pancreatitis could be an inductive factor in chronic pancreatitis.

METHODS

Based on data obtained retrospectively from a total of 264 people diagnosed with chronic pancreatitis in 4 centers, a total of 59 people (22.3%) diagnosed within 36 months of a first attack of acute pancreatitis was obtained. Etiologies of either genetically induced pancreatitis or autoimmune pancreatitis were excluded. Diagnostics to identify the presence of metabolic syndrome were run on the 59 persons so obtained using the criteria from the socalled „harmonized“ definition of 2009 (obesity, arterial hypertension, hypertriglyceridemia, type 2 diabetes mellitus and a decreased level of HDL cholesterol).

RESULTS

Comparing the findings of the individual components of metabolic syndrome in persons with chronic pancreatitis after a 1st attack of acute pancreatitis with the metabolic syndrome and in persons with chronic pancreatitis after the 1st attack of acute pancreatitis but without metabolic syndrome, a statistically significant difference in obesity was found (82.5% vs. 28.5%), hypertriglyceridemia (82.3% vs 17.8%) and arterial hypertension (70.5% vs 21.4%). The interval during which chronic pancreatitis occurred after acute pancreatitis averaged 12 months (10-14 months) in subjects with metabolic syndrome, whereas in the group without metabolic syndrome the interval was longer, 20 months (16-29 months).

CONCLUSION

Our results show that even one attack of acute pancreatitis (regardless of etiology) can be an inductive factor in chronic pancreatitis. The presence of metabolic syndrome can accelerate the development of chronic pancreatitis after one has had acute pancreatitis.

Another case of coincidental Giardia infection and pancreatic cancer

Until now, few cases of coincidental giardiasis and pancreatic tumors have been described. Among these cases, three described giardiasis cases coincided with confirmed pancreatic cancer. We present another case of Giardia infection coexisting with pancreatic cancer in a 67-year-old man who suffered from stenosis of the distal ductus choledochus combined with a hypoechoic mass in the head of the pancreas. The diagnostic conclusion of suspicious adenocarcinoma was based on endoscopic ultrasound fine-needle aspiration (EUS-FNA) biopsy and confirmed by a partial duodenopancreatectomy. On bloody cytology smears prepared from the EUS-FNA specimen, trophozoites of Giardia intestinalis accompanying an inflammatory background and features that fulfilled the morphological criteria of malignancy were observed. In histological sections from the duodenopancreatectomy specimens, the parasites were observed attached to the epithelium, but individual Giardia parasites were also observed beneath the epithelial lining. According to conventional genotyping, the infecting Giardia belonged to sub-assemblage AII.

Idiopathic inflammatory bowel disease and the first type of autoimmune form of pancreatitis: case report

The autoimmune form of pancreatitis (AIP) is divided into the following two subtypes. The 1st subtype is characterized by the high presence of immunoglobulin G4 in the blood serum and tissue of some organs which are in the close connection to the so called IgG4 associated disorders. The typical diagnostic signs of AIP are the histomorphological changes. This type of AIP is more frequent than the 2nd type with which has however some common histomorphological signs and mainly the positive response to the administered steroids used in the initial treatment. Whilst the 1st type of AIP is typically connected to the disorders of various organs such are the biliary tract, salivary and lacrimal glands, retroperitoneal fibrosis, reins, prostate gland and the next ones, the 2nd type of AIP is significantly connected to the inflammatory bowel disease only. Inflammatory bowel diseases are rarely present in the 1st type of AIP on the contrary. In our case report we mention the first published observations performed in the Czech Republic when the 1st type of AIP is succeeded by the inflammatory bowel disease - Crohn´s disease.

The changes of angiogenesis and immune regulations in stromal microenvironment of cutaneous melanomas

Tumour microenvironment contributes to growth and metastasis, where angiogenesis and immune alteration suppressing its effectory function belong to main factors. Our study is focused on an analysis of microvascular density (MVD), quantification of FOXP3+ T regulatory lymphocytes (Tregs) and PD-L1 lymphocytes, which are associated with a tumour-cells immune escape mechanism. We examined 95 cutaneous melanomas devided in four groups according to TNM classification - pT1 (35), pT2 (21), pT3 (21), pT4 (18) and 25 melanocytic nevi as a control group. Investigated parameters were detected on paraffin embedded tissues by indirect immunohistochemistry, and evaluated by light microscope in central (C) and at peripheral regions (P) on a 1mm2 „hot spot“ region (the area of the highest density). We found a significant MVD increase correlating with a stage of disease, mostly at the edge of tumours (p=0,0001). Lymphocytic PD-L1 expresion was increased in melanomas of pT3 and pT4 stages, also predominantly at the periphery of lesions (p=0,0001). Numbers of FOXP3 lymphocytes positively correlated with a melanoma stage, where higher values were observed in central areas (p=0,008). Our study documents that stimulation of angiogenesis and induction of an adaptive immune response correlate with a melanoma stage. The most prominent changes are at the tumour periphery confirming heterogeneity of a tumour stroma, which is more prominent in advanced tumours, and which may contribute to higher agresivity of these stages.

Settled iron-based road dust and its characteristics and possible association with detection in human tissues

Settled road dust was examined to detect the presence of non-airborne submicron and nano-sized iron-based particles and to characterize these particles. Samples were collected from a road surface near a busy road junction in the city of Ostrava, Czech Republic, once a month from March to October. The eight collected samples were subjected to a combination of experimental techniques including elemental analysis, Raman microspectroscopy, scanning electron microscopy (SEM) analysis, and magnetometry. The data thereby obtained confirmed the presence of non-agglomerated spherical nano-sized iron-based particles, with average sizes ranging from 2 down to 490 nm. There are several sources in road traffic which generate road dust particles, including exhaust and non-exhaust processes. Some of them (e.g., brake wear) produce iron as the dominant metallic element. Raman microspectroscopy revealed forms of iron (mainly as oxides, Fe₂O₃, and mixtures of Fe₂O₃ and Fe₃O₄). Moreover, Fe₃O₄ was also detected in samples of human tissues from the upper and lower respiratory tract. In view of the fact that no agglomeration of those particles was found by SEM, it is supposed that these particles may be easily resuspended and represent a risk to human health due to inhalation exposure, as proved by the detection of particles with similar morphology and phase composition in human tissues.

[Placenta percreta as a cause of massive intraabdominal bleeding]

OBJECTIVE

To inform about a rare cause of massive intraabdominal bleeding due to perforation of uterine corner by unrecognized placenta percreta.

DESIGN

Case report.

SETTING

Department of Gynecology and Obstetrics, University Hospital Ostrava.

CASE REPORT

We report a case of acute haemoperitoneum in pregnant woman at 34th week of gestation. We have detected the cause of the bleeding during emergency caesarean section - perforation of left uterine corner by placenta percreta.

CONCLUSION

Placenta percreta is the most severe form of abnormal placental villous adherence. In rare cases, chorionic villi may penetrate surrounding organs and cause acute intraabdominal bleeding. Due to increasing number of surgical interventions on uterus, these disorders are on the rise. It is crucial to anticipate an abnormal placental villous adherence in women with atypical placenta localization. These women should be thoroughly observed and referred to perinatal center with intermediary or intensive care for further management before delivery.

Histological analysis of retraction pocket pars tensa of tympanic membrane in children

AIMS

Histological and histochemical analysis of retraction pocket of pars tensa of tympanic membrane in children. Identification of morphological abnormalities in comparison with a healthy tympanic membrane as it is described in standard textbook. Identification of signs typical for cholesteatoma and support for a retraction theory of cholesteatoma formation.

STUDY DESIGN

A prospective study analysing 31 samples of retraction pockets taken during surgery.

DEPARTMENTS

University Hospital, Children's Medical Centre

METHODS

Samples of retraction pockets were processed by a standard process for light microscopy, stained by haematoxylin-eosin. Van Gieson's stain was used for differential staining of collagen, Verhoeff's stain for elastic fibre tissues, Alcian blue for acidic polysaccharides and PAS (Periodic Acid Schiff) method for basement membrane polysaccharides.

RESULTS

The following findings were observed in the samples of retraction pockets: hyperkeratosis (100%), hypervascularisations (100%), subepithelial fragmented elastic fibres (96%), myxoid changes (87%), subepithelial inflammatory infiltration (84%), rete pegs (71%), papilomatosis (71%), intraepithelial inflammatory cellularizations, (48%), intraepithelial spongiosis (16%) and parakeratosis (3%). No basement membrane continuity interruptions were observed. Thickness of retraction pocket, thickness of epidermis, occurrence of rete pegs and frequency of fragmented elastic fibres was higher in a Grade III stage RP than Grade II stage RP (according to Charachon).

CONCLUSION

Morphological abnormalities in the structure of retraction pockets in comparison with a healthy tympanic membrane were described. The changes are typical for a structure of cholesteatoma (these changes are common in matrix and perimatrix), supporting retraction theory of its origin. Our observations show that it is inflammation that probably plays a key role in the pathogenesis of retraction pocket. The frequency of some of the changes increases with the stage of retraction pocket (II-III according to Charachon). Basement membrane continuity interruptions are not typical for retraction pockets.

[The rational diagnostic of cholangiocarcinoma]

Cholangiocarcinoma (CC) is a rare malignant tumour arising from cholangiocytes, and its prognosis is usually unfavourable, mostly as a result of late diagnosis of the tumour. The current incidence of cholangiocarcinoma in the Czech Republic is 1.4/100,000 inhabitants per year; in less than 30 % of patients with CC, one of the known risk factors can be identified, most frequently, primary sclerosing cholangitis. Only patients with early diagnosed and surgically amenable cholangiocarcinoma are likely to have a longer survival time; in their case, survival for more than five years has been achieved in 20 % to 40 %. From the perspective of the need for early diagnosis of CC, a significant part is played by imaging and histopathologic evaluation; the early diagnostic significance of oncomarkers is limited. The rational early diagnosis of CC consists in effective use of differentiated advantages of different imaging modalities - MRI with DSA appears to be the optimal method, endosonography is a sensitive method for the identification of malignancy in the hepatic hilum or distal common bile duct, MRCP (magnetic resonance cholangiopancreatography) is used to display pathological changes in the biliary tree, ERCP (endoscopic retrograde cholangiopancreatography) allows material removal for histopathological examination. Other new approaches are also beneficial, such as IDUS - intraductal ultrasonography of biliary tract or SPY-GLASS, enabling examination of the bile ducts by direct view with the possibility of taking targeted biopsies. Sensitivity and specificity of histology and cytology can be increased by using the molecular cytogenetic FISH method, i.e. fluorescence in situ by hybridization, with a specificity of 97 %.

[Hypoglycemia in a solitary fibrous tumor of the liver]

A 64-year-old patient developed sudden hypoglycemia leading to unconsciousness. Hypoglycemic episodes recurred on several occasions but were not accompanied by unconsciousness. Magnetic resonance imaging revealed a liver tumor in the right lobe sized 20.0 × 14.6 × 19.0 cm. No other masses were detected. Right hemihepatectomy was indicated but could not be performed due to heavy bleeding near the tumor. Histological examination showed a relatively cellular tumor made of elongated bland cells. The mitotic index was fewer than 4 mitoses per 10 HPF. The tumor was without necrosis or hemorrhage. The excised tumor was not encapsulated and showed no signs of invasive growth. On immunohistological examination, the tumor expressed NSE, CD34, CD99, Bcl2 and STAT6; Ki-67 was positive in approximately 20% of the cells. Both the histological pattern and immunophenotype were suggestive of solitary fibrous tumor of the liver. Given its size, cellularity and relatively high expression of the proliferation marker Ki-67, the tumor was classified as potentially malignant. The patient underwent embolization of arteries supplying the tumor with blood. The effect of the procedure on the tumor will only be assessed later. Hypoglycemia has resolved and the patient feels well.

[Hepatic pseudolesions adjacent to the falciform ligament]

INTRODUCTION

Accurate detection of hepatic pseudolesions using multi-detector CT and MRI examinations is crucial for the differentiation of benign alterations from primary and secondary malignant lesions in hepatic parenchyma.

METHOD

The authors conducted a systematic literature review in PubMed. "Liver" and "pseudolesion" were used as keywords in English and Czech, and papers/articles published from 2000 to 2014 were retrieved.

RESULTS

The authors presented a literature review. In addition, the authors performed a retrospective evaluation of a group of patients treated for liver disease at University Hospital Ostrava where this anomaly was encountered in 7 cases.In 3 of the patients, diagnostic laparoscopy was done, with visual examination of the lesion accompanied by intraoperative ultrasound exam (IOUS) and partial excision, to establish the diagnosis. Subsequent histological assessment of the specimens confirmed the diagnosis of a steatotic lesion in each of these 3 patients. Additional 2 of the 7 patients underwent liver surgery for concurrent metastatic lesions of colorectal cancer and an open-access revision of the suspected lesions was performed. Visual inspection and intraoperative ultrasound (IOUS) was followed by excisional biopsy. The histology revealed macro- and micro-vesicular steatosis and excluded malignant changes. The last 2 patients still continue to be followed-up regularly on a 6-month routine check-up basis at our hepatology unit.

CONCLUSION

The authors presented their own experience gained through inter-disciplinary cooperation at Multidisciplinary conferences. A literature overview of this unusual subject is also included. Particularly in oncologic patients, correct interpretation of these pseudolesions may help to avoid unnecessary biopsies, further imaging examinations and diagnostic laparoscopies and/or explorative laparotomies.

Metal-based particles in human amniotic fluids of fetuses with normal karyotype and congenital malformation--a pilot study

This study explores the inorganic composition of amniotic fluid in healthy human fetuses and fetuses with congenital malformation with a special attention to presence of metal-based solid particles. Amniotic fluid originates from maternal blood and provides fetus mechanical protection and nutrients. In spite of this crucial role, the environmental impact on the composition of amniotic fluid remains poorly studied. The samples of human amniotic fluids were obtained by amniocentesis, including both healthy pregnancies and those with congenital malformations. The samples were analysed using several techniques, including Raman microspectroscopy, scanning electron microscopy with energy-dispersed spectrometry (SEM-EDS), Fourier transform infrared spectroscopy (FTIR) and X-ray diffraction (XRD) analysis. Several metal-based particles containing barium, titanium, iron, and other elements were detected by SEM-EDS and Raman microspectroscopy. XRD analysis detected only sodium chloride as the main component of all amniotic fluid samples. Infrared spectroscopy detected protein-like organic components. Majority of particles were in form of agglomerates up to tens of micrometres in size, consisting of mainly submicron particles. By statistical analysis (multiple correspondence analysis), it was observed that groups of healthy and diagnosed fetuses form two separate groups and therefore, qualitative differences in chemical composition may have distinct biological impact. Overall, our results suggest that metal-based nanosized pollutants penetrate into the amniotic fluid and may affect human fetuses.

[Autoimmune pancreatitis - diagnostic consensus]

The autoimmune type of pancreatitis represents the specific disease of pancreas, with significant contribution of autoimmune processes in its etiopathogenesis. Currently, there are two proved subtypes of this particular pancreatopathy, which are defined clinically, histomorphologically and serologically. They have many histomorphological signs in common, but differ in the presence of so-called granulocytic epithelial lesions (GEL), which are absent in subtype 1. The subtype 1 is characterized by the presence of gammaglobulines, esp. immunoglobuline G4 and IgG4 positive extrapancreatic lesions. The subtype 2 is typically associated with the inflammatory bowel diseases, esp. ulcerative colitis. But the common characteristic of both subtypes is the fact response to applied steroid treatment. Due to diverse diagnostic criteria in the past, in 2011 the consensus for the diagnosis of autoimmune pancreatitis was announced. It is based on clinical symptoms, biochemical results, the results got by using of imaging methods, histomorphology and positive response to steroid treatment. The matter to be solved is the question of early differential diagnosis between focal autoimmune pancreatitis and adenocarcinoma of pancreatic head. From imaging methods are MRI/CT, MRCP (in Asia ERCP), EUS with targeted biopsy of the gland (under EUS control), are recommended as the methods of choice.

Immunoglobulin G4, autoimmune pancreatitis and pancreatic cancer

BACKGROUND

Immunoglobulin G4 (IgG4)-related diseases are a group of diseases characterized by enlargement of the affected organs, elevation of serum IgG4, massive infiltration of affected organs with lymphocytes and plasma cells with IgG4 positivity and tissue fibrosis. Type I autoimmune pancreatitis is one form of IgG4-related disease. For IgG4-related diseases, various localizations are described for up to 10% of malignancies. The aim of our study was to examine IgG4 serum levels and pancreatic tissue with respect to the simultaneous presence of autoimmune pancreatitis in patients with pancreatic cancer.

METHODS

IgG4 serum levels were examined In 106 patients with histologically confirmed pancreatic cancer. The level of 135 mg/dl was considered as the normal value. Pancreatic tissue was histologically examined with respect to the presence of markers of autoimmune pancreatitis.

RESULTS

A higher IgG4 level than the cut-off value of 135 mg/dl was proven in 11 patients with pancreatic cancer. Of these 11 patients, 7 had levels twice the normal limit (65.6%). Autoimmune pancreatitis was diagnosed in these individuals. In the case of 1 patient, it was basically an unexpected finding; another patient was initially diagnosed with autoimmune pancreatitis. Repeated biopsy of the pancreas at the time of diagnosis did not confirm the presence of tumour structures, therefore steroid therapy was started. At a check-up 6 months after starting steroid therapy, the condition of the patient improved subjectively and IgG4 levels decreased. However, endosonographically, malignancy was suspected, which was subsequently confirmed histologically. This patient also demonstrated an IgG4 level twice the normal limit.

CONCLUSION

IgG4-related diseases can be accompanied by the simultaneous occurrence of malignancies, which also applies to autoimmune pancreatitis. Chronic pancreatitis is considered a risk factor for pancreatic cancer. It cannot be reliably confirmed whether this also applies to autoimmune pancreatitis. In accordance with other works, however, it is evident that, despite the described high sensitivity and specificity for IgG4 elevation in the case of autoimmune pancreatitis, even levels twice the normal limit are demonstrable in some individuals with pancreatic cancer, without the presence of autoimmune pancreatitis. We believe that patients with IgG4-related disease, including autoimmune pancreatitis, must be systematically monitored with respect to the potential presence of malignancy.

[Risk factors and progression predictors of Barrett´s oesophagus to adenocarcinoma]

Gastroesophageal reflux disease is a quite common disorder, and the condition affects some 40 per cent of population in the course of their lifetime. Fortunately, about half of the patients examined due to clear symptoms do not manifest macroscopic damage of the oesophageal mucosa, and serious endoscopic findings (Barrett's oesophagus) are observed in only a small percentage of patients (10%). Barrett's oesophagus is a serious complication - precancerous condition with a 30-fold higher risk of development of oesophageal adenocarcinoma when compared with patients without this condition. The article presents risk factors and predictors of progression of the Barrett's oesophagus into the stage of adenocarcinoma. The main risk factors associated with oesophageal adenocarcinoma are male sex, white race, gastroesophageal reflux.

Uterine tumors resembling ovarian sex cord tumors (UTROSCT). Report of a case with lymph node metastasis

Uterine tumors resembling ovarian sex cord tumors (UTROSCT) have an uncertain histogenesis. Although generally considered to be benign, they metastasize in some cases. We report the case of a 53-year-old woman who presented with vaginal bleeding. Clinical examination revealed a tumor sized 1.5 cm in diameter localized in the subendometrial region of the uterine wall. Histologically, the tumor consisted of epithelioid oval cells arranged in solid nests, trabeculae and ribbons. Immunohistochemically, approximately 1% of tumor cells expressed strong desmin positivity, calponin in 10% of cells, WT1 in 80% cells, and Ki-67 was positive in about 5 % of tumor cells. All the other immunohistochemical reactions applied including anti-cytokeratin antibodies were negative. The RT-PCR method for identification of the JAZF1-JJAZ1 fusion transcript was negative. In one lymph node in the right iliac artery region, a metastasis of UTROSCT was found. This finding adds to the previously reported UTROSCT cases with metastatic spread.

KEYWORDS

uterine tumors resembling ovarian sex cord tumors - UTROSCT - metastasis - lymph node.

An isolated metastasis to the heart from a malignant phyllodes tumor with osteosarcomatous differentiation

A 74-year-old woman was admitted in a serious condition due to the failing right heart. A CT scan revealed a tumor infiltration through the interventricular septum in the right heart, spreading from the apex as far as under the tricuspid valve. The tumor penetrated into the conus of the pulmonary artery, bulging and markedly narrowing the lumen. As a result of the tumor infiltration, the patient died from cardiac failure. Histological examination of the tumor revealed atypical elongated cells and areas of large cells with significantly enlarged hyperchromatic and lobulated nuclei. In some portions, the tumors had a biphasic appearance. The tumor cells resembled epithelial tissue but immunohistological analyses to detect cytokeratins yielded negative results. The elongated cells expressed desmin and smooth muscle actin. A vast majority of the tumor was solid or hard, histologically corresponding to osteosarcoma. Later, it was found that the patient undergone right-sided mastectomy for a malignant phyllodes tumor with osteosarcomatous differentiation three years previously. The metastasis to the heart was the only metastasis detected by the autopsy.

[Improving the quality of histopathological examination of colorectal cancer specimens through standard protocol implementation]

INTRODUCTION

Detailed, high-quality histopathological examination of colorectal carcinoma is an essential component of accurate disease staging. The aim of this study was to evaluate the influence of standard pathological protocol implementation on the quality of colorectal cancer specimen evaluation.

MATERIAL AND METHODS

The standard protocol for colorectal cancer specimens evaluation was created on the basis of the NCCN guidelines for colorectal carcinoma and in accordance with the American Joint Committee on Cancer (AJCC) recommendations. The protocol has been implemented into the practice of University Hospital Ostrava since 1 January 2013. All patients who underwent resection for colorectal cancer in University Hospital Ostrava between 1 January 2011 and 30 June 2013 were included into the study. Histopathological reports (before and after protocol implementation) were analysed with a focus on the presence of the parameters being monitored; the differences underwent statistical analysis.

RESULTS

In total, 235 patients who underwent resection of colorectal cancer (184 patients before and 51 patients after protocol implementation) were included into the study. The mean number of investigated lymph nodes was 12.5±6.3 (colon) and 12.6±6.2 (rectum) before protocol implementation. The mean number of lymph nodes was 15.0±4.6 (colon) and 16.8±6.7 (rectum) after protocol implementation; the differences are statistically significant. Before protocol implementation, the limit of 12 investigated lymph nodes was not reached in 49 patients with colon carcinoma (43.8%) and in 32 patients with rectal carcinoma (44.4%). Statistically significant improvement was noted after protocol implementation - the limit of 12 lymph nodes was not reached in 5 patients (18.5%) with colon and 4 patients (16.7%) with rectal carcinoma. There were also differences in the number of macroscopic mesorectal excision quality evaluation, circumferential resection margin reports and signs of microscopic tumour aggressiveness, in favour of histopathological reports after standard protocol implementation.

CONCLUSIONS

Our retrospective study proved that the implementation of the standard protocol for colorectal cancer resection specimens leads to an improved quality of definitive histopathological reports.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: case report and review of literature

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia is a rare condition affecting mostly women in the fifth and sixth decades of life. Here we present a case of its accidental finding in the lung parenchyma of a 56-year-old non-smoker female. In the periphery of the right middle lobe, linear and nodular proliferations were detected in the wall of the small bronchi and terminal and respiratory bronchioles. Under the pleura, several tumorlets were located. Immunohistologically, neuroendocrine cells were positive with antibodies against chromogranin A, synaptophysin, CD56, serotonin (weak positivity of some cells only), calcitonin, GRP/bombesin, cytokeratin 7 and TTF-1.

[Primary large cell neuroendocrine carcinoma of the urinary bladder]

Large cell neuroendocrine carcinoma of the urinary bladder is rare. In the last five years, we have had the opportunity to see this type of cancer in an 88-year-old and in a 66-year-old males. In both cases, transurethral resection of carcinoma of the bladder was carried out. In the first case, urothelial carcinoma was detected and deeper in the bladder wall, large cell neuroendocrine carcinoma structures were found. In the second case, the bladder was only infiltrated with large cell neuroendocrine carcinoma. Both tumors expressed NSE, CD56 and synaptophysin. Other markers, such as those against calcitonin, chromogranin, PP, VIP, serotonin, gastrin, glucagon and somatostatin did not react with the tumor. In the first case, no tumor dissemination was found; in the second case, clinical methods confirmed dissemination into the liver, left adrenal gland, spleen and paracaval lymph nodes. Given his age, the first patient only received symptomatic therapy. The other patient underwent chemotherapy and his condition is stable. Paraneoplastic manifestations of the tumors were not clinically found. Histogenetic origin of neuroendocrine tumors is not fully clarified. In some cases, tumor development is thought to be associated with Brunns nests, cystitis cystica and urothelial carcinoma stem cells.

[Lung metastases as the first manifestations of occult medullary microcarcinoma]

The article is concerned with medullary microcarcinoma of the thyroid. Similarly to medullary macrocarcinoma, this may metastasize to distant sites. Reported is a case of a 54year- old male who had suffered from chest tightness and dry irritating cough. Chest Xray showed small nodules with poorly- defined borders of unknown etiology. Lung biopsy was performed, which detected amyloid- rich neuroendocrine carcinoma. Examination of the thyroid was recommended to confirm or rule out suspected medullary carcinoma. The biopsy examination also suggested G1 and G2 primary neuroendocrine carcinoma of the lung or diffuse idiopathic pulmonary neuroendocrine cell hyperplasia. Numerous examinations using imaging methods (CT, MRI, PET- CT) were carried out with no positive results in the thyroid. Despite that, thyroidectomy was performed. Subsequent biopsy examination revealed medullary microcarcinoma sized 0.6 cm. Apart from lung metastases, tumor lesions were found in cervical lymph nodes. This case is an example of a close cooperation between a pathologist and a clinician -  endocrinologist. Based on serum calcitonin levels, this may aid in differential diagnosis.

[Nanopathology as a new scientific discipline. Minireview]

The detection of metal particles in the pathologically altered tissues (eg. in inflammatory lesions or tumors) led to the idea that they might be associated with emergence of some idiopathic diseases. To understand the etiopathogenesis of diseases associated with the presence of nanoparticles in the tissue there is a new area of pathology - nanopathology. Numerous studies have shown that nanoparticles can enter the human body through inhalation or ingestion. Through the pulmonary alveoli, skin and intestinal mucosa, the nanoparticles may reach the blood and lymphatic system, which subsequently distributes them to other target organs. Epithelial surfaces of conjunctiva and skin represent another potential way of penetration of nanoparticles into the body. There is a number of studies, which described the adverse effects of ultrafine particles on respiratory and cardiovascular system. Recent studies have also shown that some nanoparticles are able to pass through the pores of the nuclear membrane, where they may pose a risk of damage to cells and genetic information and they are also potentially capable to cross the placental and hematoencephalic barriers. Further, their role in the induction of oxidative stress is significant in relation to the mutagenesis. Scanning electron microscopy with energy disperse spectroscopy (SEM-EDS) represents a suitable tool for identification of metal-based particles in tissues and body fluids. Importance of nanopathology can be seen in the elucidation of the etiopathogenesis of many diseases, not only of respiratory and cardiovascular systems, but also of many other organ systems.

[A giant gastrointestinal stromal tumour - a case report]

Gastrointestinal stromal tumours represent a group of non-epithelial gastrointestinal tumours that have both benign and malignant character. Most frequently, they occur in the stomach and the intestine; however, as regards their overall incidence, they are rather infrequent tumour lesions. The present case report describes a rare bulky extragastrointestinal stromal tumour originating from the mesenterium in a young patient. Its anatomical and histological picture, diagnosis and treatment are described. Our work points to the necessity for physicians to also bear in mind the less likely options and highlights the role of surgery in the treatment of such voluminous findings.

Possible role of nano-sized particles in chronic tonsillitis and tonsillar carcinoma: a pilot study

This study aimed to evaluate the palatine tonsils of patients with chronic tonsillitis and spinocellular carcinoma to determine the presence of nano-sized particles. Tonsil samples from adult patients with chronic tonsillitis and spinocellular carcinoma of the palatine tonsil were dried and analyzed using a scanning electron microscope with the X-ray microprobe of an energy-dispersive spectroscope. Demographic data and smoking histories were obtained. The principal metals found in almost all tissues analyzed were iron, chromium, nickel, aluminum, zinc, and copper. No significant difference in elemental composition was found between the group of patients with chronic tonsillitis and the group with spinocellular carcinoma of the palatine tonsil. Likewise, no significant difference was found between the group of smokers and the group of nonsmokers. The presence of various micro- and nano-sized metallic particles in human tonsils was confirmed. These particles may potentially cause an inflammatory response as well as neoplastic changes in human palatine tonsils similar to those occurring in the lungs. Further and more detailed studies addressing this issue, including studies designed to determine the chemical form of the metals detected, studies devoted to quantitative analysis, biokinetics, and to the degradation and elimination of nanoparticles are needed for a more detailed prediction of the relation between the diagnosis and the presence of specific metal nanoparticles in tonsillar tissue.

[Primary hepatic neuroendocrine carcinoma]

Primary neuroendocrine carcinoma of the liver is a rare tumour, probably arising from scattered neuroendocrine cells of the bile duct. We present the case of a 72-year-old male who experienced gradual weight loss and diarrhoea. Given the fact that he had stayed in the Dominican Republic, a parasitic disease was initially suspected. However, this was not confirmed. Further examination showed tumour infiltration of the liver. Fine needle aspiration cytology of the tumour site was performed. The diagnostic procedure revealed neuroendocrine carcinoma. The tumour cells expressed the following neuroendocrine markers (chromogranin, synaptophysin, CD56 and NSE) as well as the epithelial marker AE1-AE3. The tumour was considered metastasis of the primary tumour located in the gastrointestinal tract. A thorough clinical examination was performed including gastroscopy, colonoscopy, In-111 Octreoscan scintigraphy, computed tomography and magnetic resonance imaging. These methods revealed metastases in the vertebrae, pelvis, long bones and skull. No other tumour sites were found in the lungs, gastrointestinal tract or pancreas. The patient became increasingly cachexic and later died. An autopsy showed massive multicentric tumour infiltration of the liver. Histological examination revealed well differentiated neuroendocrine carcinoma which transformed into intermediate and small cells. The autopsy found no tumour sites in the gastrointestinal tract, lungs or pancreas. The results were suggestive of primary neuroendocrine carcinoma of the liver.

KEYWORDS

neuroendocrine carcinoma - liver - primary tumour.

Transfusion-related Acute Lung Injury: Report of Two Cases

Transfusion-related acute lung injury (TRALI) is a severe life-threatening complication of blood transfusion, characterized by acute lung injury developing within 2–6 h of transfusion. However, TRALI is difficult to diagnose, and the initial report or suspicion of TRALI depends on close collaboration between clinical departments and transfusion centres. A total of 17 adverse post-transfusion reactions were reported to the Blood Centre of the University Hospital Ostrava as suspected TRALI between 2005 and 2010. We report two cases of serious TRALI with different pathogenetic mechanisms.

[Bronchobiliary fistulae as a complication of hepatic cystic echinococcosis]

Cystic hydatid disease or cystic echinococcosis (CE) rarely occurs in the Czech Republic. In 2005 - 2009, eleven cases were recorded, mostly among immigrants from the Balkans. Presented here is a case report of a 38-year-old patient with hepatic CE complicated by bronchobiliary fistulae. Ten days before surgical removal of the hydatid cysts, treatment with mebendazole was started. During surgery the affected part of the lungs was resected and the liver cysts were drained using transthoratic access. The follow-up was complicated by leakage of bile into the pleural cavity. The leakage was associated with continued communication between the liver cyst and the pleural cavity which did not close spontaneously after removal of the drain. Endoscopic nasobiliary drainage decreased pressure in the bile duct and within 14 days, it led to the spontaneous closure of the communication between the liver cyst and the pleural cavity. Seven months after the operation, the patient was in a very good clinical condition.

Ultrasonographic and perioperative macroscopic findings in acute carotid artery occlusion

BACKGROUND AND PURPOSE

acute ischemic stroke (AIS) may occur both in the acute and chronic internal carotid artery occlusion (ICAo). Thus, it is important to assess the ICAo character when considering the recanalization method. The aim was to assess the agreement between the ultrasonographic (US) and perioperative macroscopic (PM) finding in AIS patients with acute ICAo, undergoing an emergent carotid endarterectomy.

METHODS

in a retrospective, hospital-based study, the set consisted of 47 patients (36 males; age 49-79, mean 63.7 ± 8.5 years). ICAo character was classified as an acute thromboembolus either isolated or in combination with atherosclerotic plaque using the US (B-mode) and the PM evaluation. Cohen's Kappa and AC(1) coefficient were applied to assess the methods agreement.

RESULTS

an acute ICAo character diagnosed by US was confirmed by the PM evaluation in all cases. US and PM findings were consistent in 41 cases. The agreement between both methods in the classification of acute ICAo was 87.2% [95% confidence interval (CI): 77.7-96.8%], κ= .589 (95% CI: .293-.885) (P < .0001), AC(1) = .815.

CONCLUSIONS

US is a reliable method in the diagnostics of the acute character of ICAo and it has a good agreement with PM finding regarding a differentiation of atherosclerotic plaque and fresh thromboembolus.