Uterine PEComa with aggressive behavior: A review with an additional case of spontaneous vaginal expulsion

Perivascular epithelioid cell tumor (PEComa) is a rare mesenchymal tumor originating from perivascular epitheloid cells showing melanocytic and smooth muscle differentiation. The uterus represents the second most common site of origin. A 49 years woman presented to our Hospital for a vaginal spontaneous expulsion of a mass suggestive for malignant mesenchymal tumor. The patient underwent total hysterectomy and bilateral salpingo-oophorectomy and the histopathological report was compliant with a PEComa with aggressive behavior. Medical Literature databases about PEComa were searched. The current literature identified near 90 cases of uterine PEComas and they are categorized as uncertain malignant potential or with aggressive behavior. Primary surgical excision represents the gold-standard treatment. Recently targeted therapy with mTOR inhibitors has been introduced with an important beneficial. In this paper we review the Literature about the uPEComa with aggressive behavior reporting the first case of spontaneous vaginal expulsion.

CROCC-mutated rhabdoid colorectal carcinoma showing in intercellular spaces lamellipodia and cellular projections revealed by electron microscopy

BACKGROUND

Rhabdoid colorectal carcinoma (RC) is a rare lesion localized to the proximal colon of patients with a mean age at diagnosis of around 70 years. This tumor shows an aggressive behavior with an overall survival period shorter than 12 months. The diagnostic hallmark is the presence of rhabdoid cells. Alterations in chromatin remodeling (SMARCB1) and in the centrosome structure (CROCC) are reported in RC usually BRAF^mut and MSI-H. RKO intestinal neoplastic cells culture (BRAF^mut, SMARCB1^wt, MSI-H) with CROCC knockdown exhibit rhabdoid features and develop prominent projections from the edge of the cell.

METHODS

Here, we investigated two cases of CROCC^mutSMARCB1^wt RC by scanning and transmission electron microscopy (SEM, TEM).

RESULTS

TEM confirmed the diagnostic presence of intermediate cytoplasmic filaments and nucleolar margination. SEM showed cellular protrusions (lamellipodia) in the intercellular spaces not evident at light microscopy.

CONCLUSIONS

These protrusions CROCC-related might represent the pathogenetic mechanism underlying the rhabdoid aggressive behavior, independently of tumor staging. To our knowledge, the SEM technique was applied in the study of this neoplasm for the first time.

Oil Red O Is a Useful Tool to Assess Donor Liver Steatosis on Frozen Sections During Transplantation

Oil Red O is a useful tool to assess donor liver steatosis on frozen sections during transplantation. Steatosis is a frequent finding in liver evaluation during transplantation, accounting for 9% to 26% of biopsied donor liver. The degree of macrovesicular steatosis is classified as mild, moderate, and severe; the latter is considered an absolute contraindication to liver transplantation because it is associated with poor allograft outcome. Because of the scarcity of organs, there is a debate whether livers with less severe macrovesicular steatosis are still suitable for transplant. Consequently, tools or methods that allow a more accurate intraoperative assessment of steatosis on frozen sections are mandatory. The aim of this study is to improve intraoperative evaluation of steatosis during transplantation using Oil Red O stain on liver biopsies.

METHODS

Twenty consecutive liver biopsies of donors were collected during transplantation procedures from September 2017 to February 2018 at the Institute of Pathology of the University and Hospital Trust of Verona, Italy. Each liver biopsy was cut at a different thickness (3, 5, and 8 μm) and stained with both Oil Red O and conventional hematoxylin and eosin for intraoperative consultation. The degree (percentage of hepatocytes involved) of fatty changes was recorded. The results obtained during the intraoperative consultation were finally compared with the formalin-fixed and paraffin-embedded permanent section.

RESULTS

Assessment of steatosis on hematoxylin and eosin frozen sections was reported as mild in 17 cases (85%), moderate in 2 cases (10%) and severe in 1 case (5%). Oil Red O frozen sections reported the following results: mild steatosis in 16 cases (80%), moderate in 2 cases (10%), and severe in 2 cases (10%). The percentage of liver steatosis obtained with Oil Red O was consistent in all cases with that of the permanent sections. The staining procedure for Oil Red O required approximately 18 minutes.

CONCLUSIONS

Oil Red O special stain is a fast and inexpensive tool to improve the assessment of steatosis on frozen biopsies during liver transplantation.

Interobserver Reproducibility of Immunohistochemical Her-2/Neu Assessment in Human Breast Cancer: An Update from INQAT round III

The clinical interest in HER-2/neu is related to trastuzumab, a drug used to treat patients with invasive breast carcinoma overexpressing the HER-2/neu protein. It is very important to correctly identify those patients who may benefit from trastuzumab by accurate assessment of the HER-2/neu status. Of the various methods available, the Dako Herceptest for immunohistochemical assay is considered the most reliable to reach this goal. The aim of this study was to investigate within a group of Italian laboratories the reproducibility of the results of HER-2/neu assessment by means of the Dako scoring system on slides stained with the Herceptest kit. This study was also conceived as the continuation of one of our previous studies, which was similar in its aims but different in the classification criteria adopted. Our results show that, whereas the intra-observer reproducibility was generally satisfactory, the interobserver reproducibility was not. Moreover, our findings confirm that the two extreme classes (0 and 3+) are more easy to identify than the other two and that the Herceptest does not allow to discriminate optimally between scoring classes 2+ and 3+. These findings are relevant in clinical practice where the treatment choice is based on categories defined by this assay, suggesting the need of adopting educational programs and/or new reference materials to improve the assay performance.

Fast Chromotrope Aniline Blue Special Stain Is a Useful Tool to Assess Fibrosis on Liver Biopsy During Transplantation

BACKGROUND

Assessment of potential liver allograft donors with frozen sections has clinical relevant consequences for the transplant recipient. Several clinical risk factors have been identified that increase the risk of transplantation failure and it is critical for the pathologist to become familiar with the histologic criteria for donor liver suitability. In this setting an accurate and reliable assessment of fibrosis is crucial. We sought to report the value of the rapid chromotrope aniline blue stain (CAB) in a transplantation clinical work-flow for scoring liver fibrosis.

MATERIALS AND METHODS

Twenty consecutive intraoperative donor liver biopsy specimens were evaluated by a pathologist at the Transplant Pathology Board Room, AOUI Verona, during 24-hour on-call service. The stage of fibrosis was evaluated according to Ishak score ranging from 0 to 6 (absent to cirrhosis) using hematoxylin and eosin stain (H&E) plus rapid CAB special stain. After a 3-week washout period, only the slides stained with H&E were re-assessed for fibrosis stage by the same pathologist blinded to donor patient data.

RESULTS

Combination H&E-CAB staging fibrosis score was higher in 20%, lower in 10%, and the same in 70% of biopsy specimens as determined using only H&E stain alone. Rapid CAB stain takes 20 minutes longer than H&E stain alone.

CONCLUSIONS

CAB staining may be performed on frozen tissue from liver biopsy during a transplantation process without a significant delay in diagnosis. Combination H&E-CAB staining improves sensibility of interpretation of fibrosis.

Venous invasion detection in colorectal cancer: which approach, which technique?

Colorectal cancer is one of the most commonly diagnosed human malignancies and is a major cause of death worldwide. A high-quality macroscopic examination and histopathology report enables correct tumour staging, affects patient prognosis, and provides indications for further therapy. Although venous invasion is a stage-independent indicator of poor prognosis that identifies high-risk patients for visceral metastases, it is not a stage-influencing factor. Accordingly the use of special stains to facilitate the detection of venous invasion is not universally recommended and therefore not widely used in routine histopathological analysis. In this report based on a case presentation, the different approaches and techniques for detecting venous invasion are presented and discussed.

Acute juvenile pityriasis rubra pilaris: a case report after mononucleosis infection

A 24-year-old male boy presented dermatosis which first appeared acutely after an infection at age 17. Clinical and histopathologic examinations were consistent with a diagnosis of juvenile pityriasis rubra pilaris type III. Treatment with UVB narrow-band led to complete resolution of the dermatitis within 1 year. Pityriasis rubra pilaris is a papulosquamous disorder of unknown etiology, which can be treated with retinoids, methotrexate, cyclosporine, and narrow-band phototherapy.

Nuclear survivin is associated with disease recurrence and poor survival in patients with cutaneous malignant melanoma

AIMS

Survivin is expressed in neoplastic cells and appears to be associated with resistance to therapy and shorter survival in various types of tumours. The aim of the present study was to determine whether nuclear or cytoplasmic expression of survivin is related to disease recurrence and overall survival of patients with Stage I and II melanoma according to the American Joint Committee on Cancer (AJCC) staging system.

METHODS AND RESULTS

Immunohistochemistry was performed on formalin-fixed paraffin-embedded sections of primary cutaneous melanoma from 50 patients. Survival rates were estimated using the Kaplan-Meier method and compared using the log rank test. Association of clinical variables (gender, age, tumour location, thickness, Clark level and AJCC stage) with survivin expression was analysed by Fisher's exact test. Patients with nuclear immunoreactivity for survivin had an increased risk of disease recurrence during the first three postoperative years (P < 0.05) and of death (P < 0.05). Cytoplasmic immunoreactivity was not correlated with either survival or clinical variables.

CONCLUSIONS

Nuclear presence of survivin may be an independent biomarker for disease recurrence and overall survival in patients with Stage I and II melanoma.

Prognostic prediction of the immunohistochemical expression of p16 and p53 in cutaneous melanoma: a comparison of two populations from different geographical regions

p16INK4a and p53 are tumor-suppressor genes frequently altered in various malignancies, including cutaneous melanoma. The purpose of the study was to establish the prognostic value of immunohistochemical expression of p16INK4a a and p53 in sporadic cutaneous melanoma (CM) in two regions with a high-risk for melanoma in Italy and Ecuador. Immunohistochemical staining of p16 and p53 was performed in samples of primary CM from 82 patients with Stage I and II melanoma according to the American Joint Committee on Cancer (AJCC) staging system. Survival differences between categories of p16 or p53 expression were analyzed using the product-limit procedure (Kaplan-Meier method, log-rank test). Clinical variables (gender, age, tumor location, Clark's level, thickness) were correlated with survival and p16 or p53 expression. p16 nuclear immunoreactivity was observed in 85% of Italian patients compared to 48.7% of Ecuadorians; a small number of cases showed p53 immunoreactivity in both populations. Only nuclear p16 expression exhibited a significant correlation with survival (Italians p=0.001, Ecuadorians p=0.017) but did not appear to correlate with any clinicopathological parameter. No significant difference was observed in survival with regard to p53 expression or cytoplasmic p16. Our results demonstrate that nuclear expression of p16 can be considered a molecular prognostic factor in patients with sporadic CM and indicate its importance as a clinical marker.

Finding of conjunctival melanocytic pigmented lesions within pterygium

AIMS

Conjunctival pigmented lesions have characteristic clinical and histopathological appearances. Melanocytic pigmented lesions commonly occur in the conjunctiva, although they have not been previously reported in pterygium, a common lesion which originates from conjunctiva. Our aim was to evaluate the possibility of an association between pterygium and conjunctival melanocytic pigmented lesions.

METHODS AND RESULTS

A total of 80 samples of pterygium excised from Ecuadorian patients in 2002 were collected. Clinical data were available regarding age, sex, race and place of residence. Histological sections were evaluated for the presence of melanocytic pigmented lesions. Nine cases of conjunctival melanocytic, pigmented lesions within pterygium were found and were classified according to the histopathological criteria previously published for pigmented lesions of the conjunctiva, as naevi and primary acquired melanosis (PAM) with varying degrees of atypia. Five of the nine cases showed primary acquired melanosis without atypia, while two cases had atypia; one case showed features of compound naevus and one lesion was designated as subepithelial naevus.

CONCLUSIONS

Our findings suggest that conjunctival melanocytic, pigmented lesions occasionally occur in pterygium. All surgically removed pterygia should undergo careful histopathological examination.

In vivo investigation of hepatic iron overload in rats using T2 maps: quantification at high intensity field (4.7-T)

In vivo quantitation of hepatic iron content is useful in diagnosis and staging of several iron related diseases. We used an experimental model of hepatic iron overload to determine the correlation between iron content and T2 relaxation time in rat liver. Experiments were carried out at 4.7T for high signal-to-noise ratio (SNR) using a spin-echo multiecho sequence with six echoes and minimum echo-time of 5.5 msec. The liver iron content was determined ex vivo by atomic absorption spectrophotometry (AAS). T2 maps were calculated in order to evaluate the space distribution of the iron content. We found good linear correlation between the in vivo liver transversal relaxation rate and the iron content within the range explored (106-4538 microg Fe/g liver wet wt.). T2 maps revealed that the decrease in T2 is not homogeneous through the liver parenchyma. This finding represents a physiological limitation to obtaining better correlation between T2 and iron content.

Intraoperative and percutaneous radiofrequency thermal ablation in the treatment of hepatocellular carcinoma

AIMS AND BACKGROUND

The aim of the study was to evaluate feasibility, survival rate, complications and length of hospital stay in 47 patients with hepatocellular carcinoma (HCC) treated by radiofrequency thermal ablation (RFTA). Though the treatment of choice for HCC is surgical resection, the strong association of this disease with cirrhosis often rules out this procedure. Many investigations have been conducted in order to identify alternative therapies. Preliminary studies of radiofrequency thermal ablation have shown that the technique is effective and safe, achieving a predictable area of tumor tissue coagulative necrosis and sparing the surrounding cirrhotic parenchyma, without any significant side effects. In addition, this technique, which can be performed percutaneously, allows very short hospital stays.

PATIENTS AND METHODS

We report the results of a series of 47 cirrhotic patients with 52 HCC nodules (mean diameter 2.9 cm, range 1-6 cm) treated in our Institute between May 1997 and June 1999 by RFTA using an expandable needle with four hooks at its tip. All patients had hepatic cirrhosis (32 Child A, 13 Child B and two Child C). We treated patients with both unifocal (35 patients) and multifocal HCC (12 patients); 33 patients underwent percutaneous RFTA (54 passes), while in 14 cases RFTA was performed during laparotomy (22 passes).

RESULTS

The mean number of passes to achieve complete necrosis was 1.43 in 28 patients with unifocal HCC treated by percutaneous RFTA, 1.7 in 7 patients with unifocal HCC treated by intraoperative RFTA, 2.8 in 5 patients with multifocal HCC treated by percutaneous RFTA and 1.43 in 7 patients with multifocal HCC treated by intraoperative RFTA. No deaths related to the procedure or major complications occurred. Post-treatment dynamic CT was performed in all patients. All patients but one were followed-up for a mean period of 11.8 months (1-25 months). Six patients died during the follow-up (three Child A, two Child B and one Child C. The actuarial survival, computed by the Kaplan-Meier method, was 83% at 24 months. The mean hospital stay was 3.4 days in patients treated by percutaneous RFTA and 11.2 days in those treated by intraoperative RFTA.

CONCLUSIONS

In our opinion RFTA is an effective, safe technique capable of achieving good results in the conservative therapy of small HCC. We believe that curative ablation is possible for HCC nodules measuring up to 3 cm in diameter. Further studies of longer duration are necessary.

Hepatocellular carcinoma: correlation between gadobenate dimeglumine-enhanced MRI and pathologic findings

RATIONALE AND OBJECTIVES

To correlate the appearance of hepatocellular carcinoma on delayed (60 minutes) postcontrast T1-weighted gradient echo images with the mode of action of gadobenate dimeglumine (Gd-BOPTA) and the anatomic and pathologic characteristics of the lesions.

METHODS

A total of 34 patients with hepatocellular carcinoma and varying degrees of diffuse liver disease were studied. T2-weighted spin echo and T1-weighted spin echo and gradient echo images were acquired before and 60 minutes after the intravenous administration of 0.1 mmol/kg Gd-BOPTA. Qualitative and quantitative evaluations of the images were performed and correlated with histologic findings. The quantitative evaluation, performed on T1-weighted gradient echo images, looked at the percentage increase of liver enhancement after Gd-BOPTA administration, the lesion-to-liver contrast/noise (C/N) ratio before and after Gd-BOPTA administration, and the C/N variation after Gd-BOPTA administration. Qualitative assessment considered the morphologic features of the lesions as well as the visual variation of contrast before and after Gd-BOPTA administration. Finally, a histologic evaluation was made of the degree of differentiation of the lesions and of the presence of fatty metaplasia, necrosis, bile, or intratumoral peliosis.

RESULTS

Among the parameters affecting lesion identification were the extent of liver function, degree of vascularization, residual functionality of the tumor cells, and characteristics of the neoplastic tissue. Positive correlations (Spearman coefficients = 0.359 and 0.393, respectively) were observed precontrast between the degree of liver failure and the amount of contrast noise, and postcontrast between the amount of intralesional fatty metaplasia and the extent to which lesion conspicuity worsened after Gd-BOPTA administration. An inverse correlation (Spearman coefficient = -0.330) was observed between the degree of lesion differentiation and the visible appearance after Gd-BOPTA administration, with well-differentiated lesions tending toward worsened conspicuity postcontrast. A statistically significant difference (P = 0.001) was observed in the mean precontrast C/N ratio for lesions later showing unchanged conspicuity and worse conspicuity on postcontrast images, respectively. Marked variation (P = 0.019) was also observed between Child A and B cirrhotic patients for the degree of hepatic enhancement on postcontrast images.

CONCLUSIONS

The results suggest that liver parenchyma signal intensity is influenced by the extent to which liver function is compromised, that residual hepatocytic functionality permits Gd-BOPTA uptake by certain lesions and that this uptake might subsequently impair the observed C/N ratio on delayed images, and that the worsening of lesion conspicuity on postcontrast images is influenced also by high quantities of intralesional fatty metaplasia.

Role of iron load on fibrogenesis in chronic hepatitis C

BACKGROUND/AIMS

In chronic viral hepatitis, an enhanced iron load is related to lower response to interferon. Furthermore, iron, through the production of oxygen radicals, may stimulate hepatocyte necrosis and the activation of cells responsible for synthesis and deposition of extracellular matrix. We investigated the relationship between iron load, evaluated by serum assays, and liver fibrogenesis in chronic active viral hepatitis.

METHODOLOGY

Serum iron, ferritin, transferrin saturation and serum markers of hepatic fibrogenesis (Laminin and the amino-terminal peptide of procollagen III-NPIIIP-) were assayed in 102 patients (47 females, 55 males, mean age 42.48 years) affected by chronic hepatitis C virus and in 81 healthy controls (47 males, 34 females). In hepatitis C virus patients (studied before alpha-interferon treatment) a semiquantitative score for portal inflammation, necrosis and fibrosis was applied to liver biopsy.

RESULTS

Serum indices of iron load were higher in hepatitis C virus patients than in controls, and were higher in cirrhotic than in chronic hepatitis cases. Ferritin and serum iron were positively correlated with NPIIIP and laminin; moreover cases with ferritin levels over the normal limit for sex and age had higher levels of NPIIIP and laminin than cases with normal or poor iron status.

CONCLUSIONS

Our data suggest that even a mild increase of iron load stimulates hepatic fibrogenesis, probably adding oxygen free radical injury to the damage of viral infection.

Panniculitis induced by collagen and plexiglas microsphere injections used for aesthetic treatment

The authors report an unusual case characterised by the prompt appearance of panniculitis after injections of collagen and plexiglas microsphere for aesthetic aim and review the literature about aesthetic treatments and rheumatic disorders.

Hepatic angiomyolipoma: a clinicopathologic study of 30 cases and delineation of unusual morphologic variants

Hepatic angiomyolipoma (AML) is frequently misdiagnosed. HMB-45 is a promising immunomarker for this tumor that leads to recognition of some AMLs with unusual morphology. The purpose of this collaborative study is to better define the morphologic variations of AML. Thirty AMLs were examined, including four biopsy specimens and two fine-needle aspirates. The diagnosis was confirmed by the presence of HMB-45-positive myoid cells. Almost half the cases were originally misdiagnosed as carcinomas or sarcomas. There was marked female predominance (25:5), and the mean age was 48.7 years (range 29-68). Three patients (10%) had evidence of tuberous sclerosis and all had renal AML. According to the line of differentiation and predominance of tissue components, the tumors was subcategorized into mixed, lipomatous (> or = 70% fat), myomatous (< or = 10% fat), and angiomatous type. The mixed type was the most common (11 resected cases), comprising sheets of epithelioid muscle cells admixed with islands of adipocytes, abnormal vessels, and frequently, hematopoietic cells. Six tumors (including three from biopsy specimens) were heavily fatty and showed predominantly adipocytes with epithelioid and short spindle myoid cells webbed between fat cells. Of 10 myomatous AMLs, five tumors showed a pure sinusoidal trabecular pattern and comprised mainly epithelioid cells. Typically, mature adipocytes were absent or scanty, but fat was seen as fine droplets within cytoplasm or as occasional large globules in sinusoids. Pelioid and inflammatory pseudotumor-like patterns were identified focally. Regarding cellular features of the myoid cells, most of the epithelioid cells were either eosinophilic or clear with spiderweb cell morphology. Three AMLs showed an almost purely oncocytic appearance with scanty fat. Large pleomorphic epithelioid cells existed as small foci. Spindle cells arranged in long fascicles were uncommon. D-PAS-positive globules were common around pelioid areas. Brown pigments with staining characteristics of hemosiderin and/or melanin were noted. In conclusion, we propose HMB-45-positive myoid cells as the defining criterion of hepatic AML, which is a tumor capable of dual myomatous and lipomatous differentiation and melanogenesis. Because of its protean morphologic appearance, recognition of the various variant patterns and cell types is important for a correct diagnosis, assisted by immunohistochemical confirmation with HMB-45. Trabecular and oncocytic cell tumors appear to stand out as distinctive subtypes.

Prompt hepatitis C virus suppression following hepatitis B virus superinfection in chronic untreated hepatitis C

The natural course of chronic hepatitis C virus infection after hepatitis B virus superinfection is not clear since it is difficult to determine the chronology of the double infections. We report on a case of de novo hepatitis B virus infection in the course of chronic untreated hepatitis C, in which the time of hepatitis B virus infection is actually known. The patient eliminated HCV-RNA, both from serum and from liver tissue, soon after the clinical onset of the acute hepatitis B. Liver histology featured hepatitis with severe portal inflammation and high-grade periportal and intralobular necro-inflammatory lesions. This observation demonstrates that hepatitis C virus replication can be promptly and spontaneously suppressed by acute hepatitis B virus superinfection.

Ponto-cerebellar hypoplasia with dystonia: clinico-pathological findings in a sporadic case

Microcephaly, absent psychomotor development and dystonic limb movements were the main clinical features of a 3-year-old girl affected by hypoplasia of the pontocerebellar structures. As in the few previously reported cases there are discrepancies between the severity of lesions in the supratentorial and infratentorial compartments. Pathological features such as size reduction of the ventral pons, inferior olive atrophy, dentate nucleus fragmentation, and thinning of the cerebellar cortex suggest an impaired maturation of the involved structures due to a prenatal condition (dated at about 20-28 weeks of gestation). Somatotopic analysis failed to provide conclusive evidence on the primary target of the disease. The affected structures originate from the dorsal rhombencephalic region at about the same gestational age, and their maturation is probably under the control of sets of genes which regulate pattern formation. Early abnormal functioning of such genes might lead to the selected morphogenetical alterations observed in ponto-cerebellar hypoplasia. The normal morphogenetic pattern of the supratentorial structures and the mild lesions observed suggest that their late involvement can be related to a different pathogenetic process.

Serum laminin and type III procollagen in chronic hepatitis C. Diagnostic value in the assessment of disease activity and fibrosis

Laminin P1 (pepsin-resistant fragment of laminin) and aminoterminal peptide of type III procollagen are measurable in serum and are now considered useful serum markers of fibrogenesis and inflammation in chronic liver diseases. However, very few studies thus far have focused on assessing the diagnostic value of these markers in detecting fibrosis and necro-inflammatory activity in chronically diseased liver. The aim of the present study was therefore to investigate the correlations of laminin and type III procollagen with liver histology and to compare their diagnostic value in detecting the degree of liver fibrosis and necro-inflammatory activity in a homogeneous group of 99 patients suffering from chronic hepatitis C, and lacking other factors which can directly affect the serum levels of the two markers. Both these serum markers were measured by radioimmunoassay, employing commercially available kits. The three main aspects of liver pathology, i.e. portal-periportal activity, lobular activity and fibrosis, were histologically evaluated and semiquantitatively expressed by numerical scores. The results of this study show that laminin and type III procollagen were both positively correlated with the histological scores for portal-periportal activity and with those for fibrosis, whereas no significant correlation was observed between each of the two serum markers and the histological scores for lobular activity. The sensitivity and specificity of laminin and type III procollagen in detecting histological aspects of fibrosis and disease activity in liver, computed at various cut-off levels, showed overlapping trends for the two markers; however, the diagnostic value was in general rather low, whatever the cut-off considered. We therefore conclude that the 'static' measurement of both serum laminin and type III procollagen is of limited value for individual diagnosis of liver damage.

Inflammatory pseudotumor of the liver: case report and review of the literature

Inflammatory pseudotumors of the liver (IPL) are extremely rare focal lesions of the parenchyma. Up to now, the ethology of IPL has not been completely understood. Usually the clinical presentation is with fever, chills, hepatic mass. The fine needle biopsy shows a large amount of inflammatory cells, while the most common imaging techniques are not specific and do not reach a definitive preoperative diagnosis between a benign and a malignant tumor. From the examination of the Literature, the Authors found a mortality rate of 40% among patients treated by antibiotic therapy, while surgical procedures were successful in all but one case. Moreover, in Authors' case, successfully treated by hepatic resection, the preoperative diagnostic procedures were not helpful in differential diagnosis with a malignant lesion. For these reasons, the Authors believe surgery is the best therapeutic choice in case of a suspected IPL without an early clinical resolution after antibiotic therapy.

Sjögren's syndrome associated with autoimmune hepatitis. A case report

Liver involvement in patients with primary Sjögren's syndrome is rare, usually without clinical significance and histologically characterized by a feature like stage 1 primary biliary cirrhosis. We describe herein a case of acute and severe autoimmune hepatitis in a patient suffering from primary Sjögren's syndrome. The diagnosis of Sjögren's syndrome was performed in 1989. In June 1995 the patient presented severe weakness, jaundice and elevation of transaminases; moreover IgG raised to 5560 mg/dl and ANA titre increased to 1:20480. The patient denied alcohol and drug use and a viral hepatitis was excluded. Antimitochondrial antibodies, anti-smooth muscle antibodies and antibodies against liver kidney microsomes were negative. An abdomen ultrasound examination revealed hepatomegaly, with irregular echogenic structure and lymphoadenomegaly near the celiac tripod. Liver biopsy demonstrated a picture of autoimmune hepatitis. The patient was treated with prednisone 50 mg/day and azathioprine 50 mg/day, with improvement in clinical and liver function indices. At present, the patient is given only 10 mg/day of prednisone. The association of Sjögren's syndrome with autoimmune hepatitis is very rare: in the literature only one other similar case has been reported.

Serum laminin P1 in chronic viral hepatitis: correlations with liver histological activity and diagnostic value

Laminin is a major basement membrane-associated, non-collagenous glycoprotein of the extracellular matrix and is deposited in the space of Disse during sinusoidal capillarisation. Laminin P1, a pepsin-resistant fragment originating from the central portion of the cross-shaped laminin molecule, is detectable in serum and has been related to liver fibrosis and portal hypertension. In this study we investigated the behaviour of serum laminin P1, measured by radioimmunoassay, in a homogeneous group of 95 patients suffering from chronic viral hepatitis, types C or B, in order to determine the relationships between serum laminin P1 and each of the main histological aspects of the disease process (i.e. portal-periportal activity, lobular activity and fibrosis), which were assigned numerical scores. Moreover, we computed, at several cut-off levels, the sensitivity, specificity and positive and negative predictive values of laminin P1 in detecting both necroinflammatory activity and fibrosis in the liver. The results show that serum laminin P1 levels parallel the severity of liver disease, the highest laminin concentrations being observed in cirrhotic patients. They suggest also that serum laminin P1 should be considered a marker of the liver disease process as a whole, rather than a marker exclusively linked to fibrosis. Nevertheless, the usefulness of serum laminin P1 measurement, as investigated in this study, seems too limited to be recommended for routine clinical practice.

Hepatoblastoma in adult age: a report of two cases

Hepatoblastoma in adults is a rare malignancy that presents in the epithelial or mixed epithelial-mesenchymal variants. We report two cases, the former representing the epithelial and the latter the mixed type. A 21 year-old woman with epigastric pain had abdominal ultrasound and CT scans showing a large hepatic mass. A right trisegmentectomy was performed. The first and second recurrences were treated by resection. The third recurrence was treated by hepatic transarterial chemo-embolization, systemic chemotherapy and 19 percutaneous alcohol injections. A careful follow up by abdominal ultrasound and CT scans was able to detect the recurrence at an early stage. The patient is well at 151 months. A 39 year-old man with epigastric pain and dyspepsia had upper-GI series and abdominal CT scan showing a left hepatic mass involving the stomach. Liver resection and Billroth II hemigastrectomy were performed. A recurrence involving the left hepatic lobe, the spleen and the remaining stomach occurred 15 months later and the patient died from multi organ failure. Surgery is the treatment of choice of hepatoblastoma in adults. Recurrences can also be treated aggressively by surgical resections if no extrahepatic organs are involved. Other therapeutic modalities can be attempted whenever surgery is not possible.

Long-term variations of serum laminin and procollagen III peptide in chronic HCV hepatitis after alpha-interferon therapy

Twenty-three out of 40 patients affected by chronic HCV hepatitis responded (i.e. aminotransferases returned to normal) after 6-month treatment with 6 MU tiw of recombinant alpha-interferon 2a (IFN); in 11 (Group 1), the remission was maintained for a mean observation time of 33.15 months (range 20-50) after withdrawal of therapy; 12 (Group 2) relapsing after IFN withdrawal, were treated again obtaining in 10 a second response. Seventeen did not respond (Group 3). Serum markers of connective tissue metabolism (laminin and aminoterminal peptide of type III procollagen -NPIIIP-) were assayed in all patients before treatment and every 6th month, to evaluate long-term effects of IFN therapy. In non-responders, NPIIIP after treatment was not different from baseline, while laminin significantly increased at 6 and 12 months; in responders, NPIIIP decreased significantly after therapy, maintaining values lower than baseline on long-term observation. Laminin decreased significantly six months after the end of therapy and remained lower than baseline in all sustained responders. In this group, the drop in laminin was progressive, whereas in Group 2, laminin showed only a slight decrease on long-term control. Our data show that these serum markers persistently decrease in sustained responders to IFN, while in relapsed cases, prolonged therapy is needed to obtain minor effects on laminin; on the contrary, in non-responders, NPIIIP remains unchanged and laminin significantly increases, suggesting a persistence of active fibrogenesis.

HCV RNA detection in parotid gland biopsy in a patient with chronic hepatitis C virus liver disease

We report a case of a 75-year-old woman admitted to our Unit for chronic sialadenitis, characterized by histologic evidence of B and T lymphocyte infiltrate; laboratory and histologic tests revealed chronic hepatitis C, without autoimmune markers. We found hepatitis C virus (HCV) RNA in liver, in parotid gland, in saliva and in peripheral blood mononuclear cells, but not in serum. HCV RNA was detected by PCR technique. To our knowledge this is the first case of detection of HCV RNA in parotid gland. This finding raises the question about the relationship between sialadenitis and viral HCV infection.

alpha-Interferon treatment of chronic hepatitis C: a controlled, multicentre, prospective study

This prospective, controlled study was designed in order to evaluate the response rate to alpha-interferon (IFN) versus no treatment in 63 patients affected by chronic hepatitis C. Fifty-two patients were randomly chosen to receive no treatment of IFN alfa-2b (6 MU 3 times weekly for the first month and 3 MU for the next 11 months). Eleven additional patients were crossed to active treatment after a 1-year control period without any change of serum pattern and were therefore enrolled both as controls and cases. Four patients had to be withdrawn from the active treatment for adverse effects. Sixteen out of the remaining 23 had normal alanine aminotransferase (ALT) values at the end of the treatment, and 14 were still normal 12 months later. A liver biopsy, taken 6 months after the end of the treatment, showed improvement in 12 patients and normalization in 1. Only 1 out of the 25 controls had transaminase normalization and 5 a decrease. One of them showed also a histological improvement. Eight of the 11 case/control patients showed ALT normalization after IFN administration, 5 of them histological improvement and 2 liver normalization. Hepatitis C virus (HCV) RNA became negative in 13 of 17 cases in whom the assay was carried out. Therefore this study confirms that the longterm administration of alpha-IFN induced a prolonged remission of disease activity in over 50% of the patients and the clearance of HCV RNA in the majority of the responders.

[Postoperative ischemic ileocolitis in the elderly. Suggested therapy with intraluminal administration of oxygen and glutamine]

Ischaemic ileocolitis in postoperative course of major abdominal surgery is a great challenge for the surgeon: the mortality rate is very high, and therapeutic choices are poor. In the elderly patients ischaemic bleeding ileocolitis is often determined by low flow: sepsis and cytologic damage are primed by activation of endotoxins and chemical mediators, and bacterial translocation could develop across intestinal wall. In our case the patient (male, caucasian, 68 years old) underwent bilio-hepatic resection for hilar cholangiocarcinoma. In the postoperative period continuous enteric haemorrhage was determined by an ischaemic ileocolitis demonstrated by colonoscopy. Abdominal angiography did not show stenosis or occlusion of mesenteric vessels. We administered dopamine and dobutamine as vasodilator drugs for splanchnic circulation without any positive response. Surgical removal of the colon was unsuccessful to stop bleeding. ileostomy and sigmostomy were performed. Histologic samples of the specimen showed ischaemic ileocolitis. After a few days the patient bled again. As last therapeutic choice, we bubbled oxygen in a solution of L-glutamin 500 mml (3 liters/min for 5 min). We administered 500 mml of this solution three times a day by enteral sond, and 100 mml twice a day by sigmoidostomy and endoluminal oxygenation was performed twice a day (1l/min for 1-2 minutes) under continuous control. Bleeding was reducing during the next five days, until stopping. If glutamine and O2 can be considered the fuel of enterocytes, we hypothesized endoluminal oxygenation and glutamine enteral supply of the small intestine could feeding enterocytes, until a complete restoration of enteral mucosa and stopping of the haemorrhage.

Chronic hepatitis in multiple virus infection: histopathological evaluation

The frequency and histological pattern of multiple hepatitis virus infection was studied in 161 Italian patients who had consecutively undergone liver biopsy from 1989 to 1991. The histological features were compared with that of infection with a single virus. Thirty-nine per cent of patients had evidence of past or present multiple infection, the commonest of which was hepatitis C virus (HCV) in patients with evidence of previous infection with hepatitis B virus (HBV). In general, the severity of the histological pattern of each viral infection was maintained even when more than one virus was involved; there was neither exacerbation nor diminution of the histological changes. The delta-virus (HDV) was not associated with severe necro-inflammatory lesions, but HDV-positive patients were few in this cohort. Lymphoid follicle formation (a putative histological marker of HCV infection) was also found in a high proportion of HCV-negative patients but expressing much HBcAg or HDAg in liver tissue. Possible explanations for this finding are that follicles are relatively non-specific for HCV infection, or that these cases represent HCV infection with false-negative serology. The results of this study suggest that multiple hepatitis virus infection is common in the population investigated and that HBV and HCV co-infection cannot be reliably diagnosed histologically. Whether double infection with these viruses influences the cirrhotic evolution of the liver lesion remains unclear.

alpha-Interferon in the treatment of chronic viral hepatitis: effects on fibrogenesis serum markers

Forty patients with chronic viral hepatitis or active cirrhosis (33 anti-HCV positive) entered a recombinant human alpha 2A interferon randomized trial. Twenty-one subjects were treated with 6 million units (MU) three times per week for 6 months. Nineteen were not treated. Six months later in 12 patients of the treated group (60% of the evaluable 20) with normalized serum aminotransferases levels (responders), fibrogenesis serum markers (NPIIIP and laminin) were significantly lower than baseline. In the untreated patients and in non-responders NPIIIP and laminin were unchanged. Semi quantitative histological evaluation (allotting scores for inflammation, necrosis and fibrosis) confirmed a significant improvement of necro-inflammation in the responders. These data suggest that alpha-IFN treatment may decrease stimuli for fibrogenesis by reducing liver inflammation and necrosis, thus preventing evolution to cirrhosis.

An immunohistochemical study of the blood vessels within primary hepatocellular tumours

We studied the blood vessels in routinely formalin-fixed and paraffin-processed tissue from 18 hepatocellular carcinomas, three "small" hepatocellular carcinomas, and 15 benign nodular lesions representing a spectrum of conditions with which liver cell carcinomas may be confused. These were stained for a basement membrane component (collagen IV) and endothelial markers (Factor VIII-related antigen, Ulex europaeus lectin binding, and QBEnd10). The staining pattern of normal and cirrhotic liver was also examined in tissue removed with these tumours. There was an increased expression by small blood vessels for collagen IV in carcinomas and benign lesions compared with cirrhotic nodules. All endothelial markers (Factor VIII-related antigen, QBEnd10, and Ulex europaeus binding) were best expressed in liver cell carcinomas. These differences were of degree and pattern, and no single marker distinguished benign from malignant lesions. The differences in staining pattern taken together with other clinical and pathological information should be useful in diagnosis particularly of small liver cell carcinoma. The differences between benign and malignant lesions support the idea that malignant neoplastic blood vessels in the liver are of a different basic biological type from normal hepatic sinusoids, and this difference could be exploited further in future therapy.

Merkel-cell carcinoma of the skin

Three cases of Merkel-cell carcinoma of the skin have been presented. The need for a correct clinical and histologic diagnosis has been highlighted. Rapid widespread growth of the tumor occurs when surgical treatment is delayed. Immunohistochemistry is essential for accurate differential diagnosis.

Melanocyte-marker-HMB-45 is regularly expressed in angiomyolipoma of the kidney

HMB-45 (melanocytic cell-specific monoclonal antibody) immunoreactivity was investigated in 10 cases of angiomyolipoma (AML) (1 with massive regional lymph node involvement) of the kidney and detected in all of them. No HMB-45 immunoreactivity was found in other tumors of the region which can occasionally be confused with AML, such as renal cell carcinoma, Wilms' tumor, and retroperitoneal sarcoma (leiomyosarcoma and liposarcoma). These findings indicate that HMB-45 is not a melanocyte-restricted marker and suggest that its expression might be useful in distinguishing AML from other tumors of the kidney and retroperitoneum.

False-positive immunostaining of normal epithelia and carcinomas with ascites fluid preparations of antimelanoma monoclonal antibody HMB45

HMB45 is a melanoma-specific monoclonal antibody that has found widespread use in diagnostic pathology. Recent reports, however, have suggested that this antibody may cross-react with a small number of carcinomas and other epithelial cells. The authors tested the hypothesis that these latter reports represent examples of false-positive immunostaining by comparing the immunostaining on breast, salivary gland, and lung tumors with the following: (1) a commercial ascites preparation of this monoclonal antibody; (2) a protein A-purified antibody preparation derived from ascites fluid; and (3) supernatant fluid obtained from the hybridoma cell line. The authors found that all examples of nonmelanoma immunostaining in the carcinomas tested were eliminated with the nonascites fluid preparations, whereas strong immunostaining of melanomas was retained. The authors conclude that contaminated commercial ascites fluid preparations of HMB45 may account for most, if not all, of the reports of nonmelanoma immunostaining with HMB45.

Small-cell neuroendocrine carcinoma of the ampullary region. A clinicopathologic, immunohistochemical, and ultrastructural study of three cases

We report the clinicopathologic, immunohistochemical, and ultrastructural features of three small-cell neuroendocrine carcinomas of the ampullary region of the duodenum. All patients were men; their ages were 51, 62, and 66 years. The therapy consisted of pancreatoduodenectomy. All patients died of the disease; median survival was 10 months from the diagnosis. The histological appearance was identical to pulmonary and extrapulmonary small-cell carcinoma. The neuroendocrine differentiation was demonstrated ultrastructurally by the presence of dense-core granules, and by the positive immunoreaction for neuron-specific enolase and Leu-7 in each case. One case expressed a focal positivity for chromogranin A (PHE-5) and argyrophilic granules. The same case showed the presence of neurofilaments on frozen material. Neurofilament proteins could not be demonstrated in any case in paraffin sections. Neoplastic cells exhibited cytoplasmic immunostaining for cytokeratins (CAM 5.2) in all cases. In one case, a large number of neoplastic cells (60-70%) exhibited nuclear Ki-67 positivity. We postulate that the disease's histogenesis was from epithelial stem cell expressing both epithelial and neuroendocrine characteristics. The clinical behavior of small-cell neuroendocrine carcinomas of the ampullary region appears to be extremely aggressive, with early metastases and fatal outcome.

[Microcystic adnexal carcinoma. A case report]

Microcystic adnexal carcinoma (MAC) is a rare cutaneous neoplasm, locally aggressive, recently recognized as a clinicopathologic entity. Histologically, MAC shows both ductal and pilar differentiation. In this article we discuss a case of 52-year-old woman with MAC on the inferior lip, early recurred after initial excision.

Breast carcinoma with positive results for melanoma marker (HMB-45). HMB-45 immunoreactivity in normal and neoplastic breast

HMB-45 (melanocytic cell-specific monoclonal antibody) immunoreactivity has been detected by the immunoperoxidase technique in the cytoplasm of 2 of 100 breast carcinomas. In addition, normal breast lobules and ducts were occasionally found to have positive results in 6 of 100 cases. These findings indicate the need to exercise caution in the interpretation of HMB-45 immunoreactivity for immunohistochemical characterization of neoplasms.

Preoperative embolization of arteriovenous malformations with polylene threads: techniques with wing microcatheter and pathologic results

The technique with a wing microcatheter system and the pathologic aspects of 11 cerebral arteriovenous malformations (AVMs) surgically resected after embolization with polylene threads are reported. Embolization was performed once in eight patients and twice in three patients. Resected AVMs were submitted both to routine hematoxylineosin examination and to immunohistochemical workup in order to detect the type of immunologic response to thread emboli. In nine cases, 50% or more of the nidus was obliterated by the embolization. After embolization two patients developed reversible neurologic deficits. Pathologic specimens of resected AVMs demonstrated no vascular necrosis; however, a moderate inflammatory response could be seen, characterized by the presence of both mononuclear cells and foreign-body giant cells, associated with the absence of polymorphonuclear infiltrates. A granulomatous fibrotic process was identified that was present from the first month after embolization. Immunohistochemistry indicated that the immunologic response to thread emboli was cell-mediated, not humoral. Embolization with the wing microcatheter with the use of polylene threads proved to be a safe and efficient system of embolization, as a preoperative procedure. Polylene threads are a nontoxic and biocompatible material that can be used as an embolic agent for brain AVMs.

Establishment and Characterization of a New Human Melanoma Cell Line (HU 214) with a High Growth Potential and Stable Properties

A human melanoma cell line (HU 214) with high growth potential was established from a lymph node metastasis of a patient with advanced cutaneous melanoma. The cells of this line were able to grow in monolayer (according to the Rosenblum technique) and in agar (according to the Courtenay-Mills method), and formed tumors when injected in nude mice. The line has been maintained in culture for more than 47 passages. The cell cultures were periodically characterized (every 6-8 passages) by immunohistochemistry using a panel of monoclonal antibodies (MoAbs) including MoAbs against tumor-associated antigens (antimelanoma, antiglioma and anti-LLA), against vimentin, and against major histocompatibility antigens, and including also Ki 67, a MoAb which reacts with a nuclear antigen associated with cell proliferation. The results of this characterization indicate that we have established a human melanoma cell line with a stable antigenic phenotype during subculturing, poorly differentiated cells, and a high growth potential.

Distribution of melanoma specific antibody (HMB-45) in benign and malignant melanocytic tumours. An immunohistochemical study on paraffin sections

The distribution of a recently produced melanoma specific antibody (HMB-45) has been evaluated histochemically on paraffin sections in a large panel of melanocytic and non melanocytic tumours. Results have been compared with the presence of S-100 protein. HMB-45 was shown to be a highly specific antibody being present only in melanomas, junctional melanocytes and histogenetically related neoplasms such as melanocytic neuroectodermal tumour of infancy and, at low levels, on a proportion of peripheral nerve sheath tumours. The high specificity of HMB-45 antibody, coupled with the greater sensitivity of S-100, makes the combined use of these markers practical in the differential diagnosis of skin tumours and of metastatic lesions of uncertain primary site.

Secondary amyloidosis and cystic fibrosis. A morphological and histochemical study of five cases

The pathological findings of five cases of amyloidosis associated with Cystic Fibrosis are reported. Rectal biopsy led to the diagnosis of amyloidosis in four patients. In three cases the diagnosis was confirmed at autopsy, with involvement of spleen, liver, kidneys, adrenal glands, thyroid and other organs. It seems that Secondary Amyloidosis provokes a significant, although rare, complication of Cystic Fibrosis as greater numbers of these patients survive into adulthood.