Advanced Merkel cell carcinoma of the lower extremity treated with surgery and isolated pelvic and limb perfusion using Melphalan: A case of unexpected long-term survival

INTRODUCTION

Merkel cell carcinoma (MCC) is a rare, neuroendocrine skin tumor, with high frequency of locoregional recurrence, metastases, and poor prognosis. Locoregional MCC recurrence in the extremities can pose considerable treatment challenges. We report a case of long-term survival in a female patient with recurrent MCC of the leg, treated with surgery and locoregional chemotherapy.

PRESENTATION OF CASE

A 73-year-old female with cirrhosis and hepatitis C, developed cutaneous MCC in the left inferior limb. This patient initially received surgical treatment, with subsequent negative sentinel lymph-node biopsy in another center, one-month prior recovery in our department, and arrived with 4 new limb nodules, cranially to the previously treated area, without distant metastases or inguinal lymph node recurrence. This patient was not eligible for immunotherapy due to active hepatitis upon treatment with NS5B inhibitors, or eligible for systemic chemotherapy or radiotherapy due to severe neutropenia and was, therefore, subjected to surgical resection combined with Isolated Pelvic and Limb Perfusion (IPLP) with Melphalan. Histological evaluation confirmed MCC diagnosis and during the following 4 months, she developed further locoregional recurrences with homolateral inguinal lymph node involvement and was subjected to two additional rounds of surgery plus IPLP.

DISCUSSION

All procedures were tolerated, systemic toxicities were temporary and subsequent clinical and radiological follow-up, following the last combined treatment, indicated that this patient was still alive and disease-free, at 56 months.

CONCLUSION

In this case, surgery combined with locoregional Melphalan chemotherapy was an effective and repeatable treatment for recurrent MMC and resulted in unexpected long-term survival.

Clinically equivocal melanocytic skin lesions with features of regression: a dermoscopic-pathological study

BACKGROUND

Benign melanocytic skin lesions may be difficult to differentiate from melanoma both clinically and dermoscopically. One of the most confounding dermoscopic features, commonly seen in melanoma but in our experience also in melanocytic naevi, is represented by the so-called blue-white structures (BWS).

OBJECTIVES

To evaluate diagnostic significance and histopathological correlates of BWS seen by dermoscopy in a series of clinically equivocal melanocytic skin lesions that were excised.

METHODS

Patients were recruited from six specialized pigmented lesion clinics in Austria, Italy and Spain over a period of 9 months. All consecutive patients showing one or more melanocytic lesions with BWS, but not classified as melanoma dermoscopically, were included. Each lesion was photographed clinically and dermoscopically. All images were reviewed by one of us and the degree, type and location of BWS evaluated for each lesion. A panel of four experienced dermatopathologists independently reviewed all specimens for diagnosis and one of them evaluated presence and degree of melanosis and/or fibrosis. The main outcome measures were the percentage and histopathological correlates of lesions with different degree, type and location of BWS.

RESULTS

All included lesions with BWS (n = 158) showed partial or focal regression histopathologically. One hundred and thirty-five (85.4%) lesions were diagnosed as melanocytic naevi (complete histopathological interobserver agreement), whereas 23 (14.6%) were defined as equivocal because at least one of four pathologists diagnosed the given lesion as melanoma. Only one lesion was diagnosed as melanoma by all four pathologists. The majority of naevi exhibited blue areas (84.4%) with a central distribution (57%) and involving < 50% of the lesion surface (89.6%). By contrast, 78.3% of equivocal lesions revealed a combination of white and blue areas with an irregular distribution (60.9%) and involving > 50% of the lesion surface (47.8%).

CONCLUSIONS

Using degree and type of BWS, an algorithm was constructed that can be applied for the management of lesions exhibiting dermoscopic features of regression.

Lack of prognostic significance in Goseki grading of gastric carcinoma

The Goseki grading system, based on intracellular mucin content and tubular differentiation, was originally created to study the influence of histologic type on the mode of extension of gastric carcinoma. The prognostic value of this grading system was subsequently proposed and even recently supported, but controversies still remain about this topic. We applied the Goseki system on 114 cases of node-negative primary gastric cancer and compared Goseki groups with the other clinicopathologic features of the patients. Statistical analysis showed a significant correlation between Goseki grading and Laurèn classification, but failed to reveal any prognostic significance for this grading system. We believe that Goseki classification should not be routinely used for prognostic purposes.

[Creating low-power photomicrographs by digital scanning of histological sections]

The recent introduction of digital film scanners in the medical-scientific field provided everyone dealing with light-microscopy an easy method to obtain low-power photomicrographs from entire histological sections. Direct scanning of the common microscope slide allows the easy creation of high quality images. The digital images obtained may be improved or retouched using dedicated software and then printed on paper or film. The required instrumentation is relatively unexpensive and neither skilled staff nor expertise of photographic techniques is required. This reduces costs and saves time. The obtained images may be employed in histopathology, embryology, histochemistry, image analysis and telepathology, and are suitable for scientific papers, educational purposes and lecturing, as well as for daily reporting. The authors bring their personal experience in this field, making also a complete literature review on the topic.

[Recurrent abdominal pain and "chronic appendicitis"]

BACKGROUND

Chronic appendicitis may be the cause of recurrent abdominal pain. This hypothesis is the subject of controversy. The aim is to clarify the possible existence of a chronic inflammation of the appendix by a clinical and histopathologic study.

METHODS

The case history and the preoperative symptoms and serum findings of 269 patients with appendectomy have been studied. All the appendices have been histologically examined. Chronic appendicitis was diagnosed when at least two typical histological factors of chronic inflammation were present. The histological findings of the appendices have been correlated with preoperative clinical and serum findings of the patients. 14-46 months after the appendectomy, the patients have been examined.

RESULTS

Histological examination revealed 187 cases (69.5%) with acute appendicitis, 44 cases (16.3%) with non disease of appendix and 38 cases (14.2%) with chronic appendicitis. Recurrent abdominal pain and normal leukocyte count were closely correlated (chi 2 = 18.3, p < 0.001; chi 2 = 21.3, p < 0.001 respectively) with diagnosis of chronic appendicitis. 81.8% of 33 patients with chronic appendicitis who underwent follow-up had relief of all the symptoms after appendectomy.

CONCLUSION

Therefore, the study seems to confirm the existence of a clinico-pathological condition that can be defined as chronic appendicitis, resolvable with appendectomy.

N-nitroso compounds and Helicobacter pylori in the gastric remnant

AIMS AND BACKGROUND

The aims of this study were to investigate the role of N-nitroso compounds (NOC) and Helicobacter pylori (H. pylori) in gastric stump carcinogenesis.

METHODS AND STUDY DESIGN

Analyses of biochemical parameters such as pH and NOC concentration were carried out on 65 fasting gastric juice samples obtained at endoscopy from 45 patients previously submitted to partial gastrectomy for benign peptic ulcer disease (23 Billroth I, 22 Billroth II/Reichel-Polya) and 20 normal controls. Biopsy specimens were taken to determine histology and H. pylori status.

RESULTS

Significantly higher mean pH values and NOC concentrations were found in partial gastrectomies compared to normal controls. In relation to surgical methods, higher mean pH values and NOC concentrations were observed in the gastric juice of patients with Billroth II compared to Billroth I gastrectomies. Independently of the type of surgical reconstruction, higher mean NOC levels were recorded in patients with more severe histological changes and H. pylori infection.

CONCLUSIONS

All these data suggest that high levels of NOC in gastric juice and H. pylori infection could be cofactors in gastric stump carcinogenesis.

4-Aminobiphenyl-DNA adducts in laryngeal tissue and smoking habits: an immunohistochemical study

4-Aminobiphenyl (4-ABP)-DNA adducts and p53 overexpression were evaluated in laryngeal biopsies from 38 patients by immunohistochemical methods. Samples were categorized as tumors (n = 9), polyps (n = 28) or normal tissue (n = 1). 4-ABP-DNA adducts were evaluated with a quantitative immunoperoxidase method using monoclonal antibody 3C8 in both the lesion and adjacent tissue. Relative staining intensity data showed a log-normal distribution and values found in adjacent tissue from smokers were significantly higher (median: 173.5, geometric mean: 159.9) than those measured in adjacent tissue from non-smokers (median: 75.5, geometric mean: 7.40). Statistical significance was assessed both by non-parametric testing on raw data (P = 0.0007 on rank sum test) and by parametric testing on log-transformed data (P = 0.0002 on an unpaired t-test). Furthermore, relative staining intensity in the lesional tissue showed the same significant difference between smokers and non-smokers in patients affected by polyps, whereas no significant difference was detected in patients with laryngeal tumors. Overexpression of p53, also measured with an immunoperoxidase method, was observed in 44% of the malignant tumors and in 3.5% of the polyps. This work demonstrates that 4-ABP-DNA adducts can be evaluated in laryngeal tissue and are related to smoking exposure.

Unicentric angiofollicular hyperplasia (Castleman's disease) of the parotid: a case report

Angiofollicular lymph node hyperplasia, or Castleman's disease, is a condition of uncertain cause usually presenting with mediastinal lymphadenopathy. Occasionally other lymph node groups may be involved with or without associated systemic manifestations. A case of Castleman's disease involving parotid lymph nodes is reported in a 16-year-old female patient who presented with a painless swelling that initially was noticed at the age of 3 years. Diagnosis was established by histopathologic examination of the respected specimen. Histologic and clinical features of Castleman's disease are also discussed.

[Epidermoid carcinoma of the oral cavity. Considerations of the role of the papillomavirus]

Human papilloma virus (HPV) may have an important role in oral carcinoma etiology. Our work compares the presence of HPV in the epithelium of oral mucosa of patients with oral carcinoma with other factors of risk (smoking, alcohol, chronic mucosal trauma). We studied 33 patients operated for oral cancer at St. Salvatore Hospital in l'Aquila, in January-December 1990. The presence of HPV was proved by a direct valuation of morphological signs (coilocytosis, nuclear inclusions, etc.) and by immunohistochemical technique with primary antibodies against structural virus antigens. Among the 33 patients 19 (57.6%) were positive for HPV and 14 (42.4%) were negative. Among the HPV positive subjects 13 were smokers, 11 usually assumed alcohol and 6 had chronic mucosal trauma. Among the HPV negative subjects 9 were smokers, 7 assumed alcohol and 3 had chronic mucosal trauma. The statistical evaluation of data showed the lack of significance of viral infection compared to other factors of risk. In spite of a few cases examined, we suppose that HPV doesn't play a primary role in oral cancerogenesis, but is a concomitant cause with other factors of risk.

Is Early Gastric Cancer, Diffuse Type, a Forerunner of Advanced Gastric Cancer?

Aims and Background

Gastric cancer (GC) represents one of the most Important causes of death by malignancy world wilde. Our retrospective study was carried out on surgical stomach specimens obtained from a series of 552 consecutive cases of GC observed in the Departments of Surgical Pathology of the Public Hospitals of L'Aquila and Atri which cover the 17 % of the entire population of the Italian Region Abruzzo. The aim of the study was to compare the anatomo-clinical characteristics of early GC (EGC) and advanced GC (AGC).

Methods

The diagnosis was achieved by the criteria of the Lauren's histopathological classification (intestinal and diffuse types). Our study also stratified the cases by sex, age, lymph node metastases and associated lesions such as chronic atrophic gastritis, intestinal metaplasia and dysplasia.

Results

On an average, patients affected by EGC were 8.1 years younger than those with AGC. This age gap could support the hypothesis that early lesions represent the first stage of AGC. However, when patients were subdivided according to Lauren's classification, the mean age of patients with EGC, diffuse type, was 12.2 years less than that of AGC patients of the corresponding histological type. Furthermore, the subset of patients with EGC, diffuse type, and lymph node metastases was 17.8 years younger than patients affected by AGC diffuse type, with lymph node metastases.

Conclusions

The present study offers an original survey on GC in a defined Italian population. As far as the intestinal histotype is concerned, the slight age difference between EGC and AGC suggests that these tumors are different steps of the same process. On the contrary, the age distribution suggests that EGC, diffuse type, has a different biological behaviour.