A rare form of hyperthyroidism leading to the diagnosis of acromegaly: A case report

Acromegaly is a rare disease, usually caused by a pituitary tumor. It typically exhibits slow evolution and can result in numerous complications. In the present case report, the patient presented with hyperthyroidism associated with ophthalmopathy and right nodular goiter. The laboratory tests revealed persistent high levels of phosphorus without an apparent cause. After ruling out common pathologies associated with this finding, a focus was placed on the clinical aspects associated with acromegaly, a rare cause of hyperphosphatemia. Laboratory tests and MRI confirmed the diagnosis. The patient underwent transsphenoidal surgery, but the disease remained active, thus medical treatment was initiated, to a poor initial response. Associated with acromegaly, two distinct thyroid pathologies were diagnosed: Toxic adenoma and Graves' disease. This case highlights the challenges in diagnosing and managing a rare endocrine pathology.

Presurgical Stratification of Thyroid Nodules - Is it really Needed? Current Guidelines versus Real Life

Background: Thyroid surgery has various benign and malignant indications. A complete pre-surgical evaluation guides the selection of cases and determines the appropriate extent of the intervention. Minimizing the number of unneeded thyroidectomies could reduce hospitalization costs, as well as post-surgery complications and iatrogenic hypothyroidism. The aim of this study was to retrospectively evaluate the presenting reasons of patients admitted to the hospital for thyroid surgeries and to estimate the need of total thyroidectomies. Methodology: The study included patients admitted in all three Surgical Departments in Timisoara Emergency County Hospital, between January 1st 2018 and December 31st 2019 (2 years). Results: A number of 1036 thyroid surgeries had been performed in 1027 patients and were retrospectively analyzed, comparing the pre-surgical diagnosis with the pathology report. Suspicion of malignancy, compression or functional autonomy was described in 326 /824 total thyroidectomy cases. Cancer was detected in 338 out of the 1027 patients (32.92%), including 39 borderline lesions. A proportion of 80.7% were papillary thyroid cancers. The current presurgical evaluation generated a number of 475 cases displaying differences between the presurgical and postsurgical diagnostic. The phenomenon was observed both in total thyroidectomy and in lobectomy interventions: 22.8% of the lobectomies were diagnosed with thyroid cancer. Conclusion: Our findings confirm that a reliable multidisciplinary approach with standardized presurgical clinical, biochemical and ultrasound evaluation is crucial in patients with indication for thyroid surgery, in order to avoid unnecessary surgeries.

Immunohistochemical expression of chemokine receptor in neuroendocrine neoplasms (CXCR4) of the gastrointestinal tract: a retrospective study of 71 cases

AIM

C-X-C motif chemokine receptor 4 (CXCR4) is expressed in many tumor entities, including gastrointestinal neuroendocrine neoplasms (GI-NENs). However, the role of CXCR4 expression in GI-NENs has been less studied. Our objective was to investigate the expression of CXCR4 in a series of GI-NENs with various clinical and pathological features.

METHODS

The immunohistochemical (IHC) expression of CXCR4 (clone UMB2) was examined in 71 GI-NENs and a semiquantitative immunoreactivity score (IRS) was calculated taking into consideration the intensity of the IHC reaction and the percentage of the tumor cells which showed positive expression. Results were compared with several clinical and pathological prognostic factors.

RESULTS

High CXCR4 expression was noted in 31 (43.7%) cases. Low IRS values were more frequent in NENs from the small intestine (66.7%) and stomach (60%). Also, all appendix tumors had IRS value of zero. High CXCR4 expression was noticed in 52.5% of liver metastases, compared to 40.4% primary tumors. A significant relationship was observed between the CXCR4 expression and the tumor grade (p=0.0216), and high IRS value was correlated with clinical stages III and IV (p=0.0142) and lympho-vascular invasion (p=0.0129). 74.1% of G1 neuroendocrine tumors (NETs) had a low IRS, G3 NETs showed minor differences between low (42.9%) and high (57.1%) expression and 66.7% of neuroendocrine carcinomas (NECs) presented high expression of CXCR4.

CONCLUSIONS

The present study highlighted that high CXCR4 expression is associated with high grade and advanced stage GI-NENs, as well as with metastatic cases. In these cases, high CXCR4 expression could serve as an important target for CXCR4 antagonists.

Malignant hepatic vascular tumors in adults: Characteristics, diagnostic difficulties and current management

Malignant vascular tumors of the liver include rare primary hepatic mesenchymal tumors developed in the background of a normal liver parenchyma. Most of them are detected incidentally by the increased use of performing imaging techniques. Their diagnosis is challenging, involving clinical and imaging criteria, with final confirmation by histology and immunohistochemistry. Surgery represents the mainstay of treatment. Liver transplantation (LT) has improved substantially the prognosis of hepatic epithelioid hemangioendothelioma (HEHE), with 5-year patient survival rates of up to 81%, based on the European Liver Intestine Transplantation Association-European Liver Transplant Registry study. Unfortunately, the results of surgery and LT are dismal in cases of hepatic angiosarcoma (HAS). Due to the disappointing results of very short survival periods of approximately 6-7 mo after LT, because of tumor recurrence and rapid progression of the disease, HAS is considered an absolute contraindication to LT. Recurrences after surgical resection are high in cases of HEHE and invariably present in cases of HAS. The discovery of reliable prognostic markers and the elaboration of prognostic scores following LT are needed to provide the best therapeutic choice for each patient. Studies on a few patients have demonstrated the stabilization of the disease in a proportion of patients with hepatic vascular tumors using novel targeted antiangiogenic agents, cytokines or immunotherapy. These new approaches, alone or in combination with other therapeutic modalities, such as surgery and classical chemotherapy, need further investigation to assess their role in prolonging patient survival. Personalized therapeutic algorithms according to the histopathological features, behavior, molecular biology and genetics of the tumors should be elaborated in the near future for the management of patients diagnosed with primary malignant vascular tumors of the liver.

Clinical relevance and accuracy of p63 and TTF-1 for better approach of small cell lung carcinoma versus poorly differentiated nonkeratinizing squamous cell carcinoma

Lung cancer high mortality rate remains a major problem, despite the actual progress in its early detection and therapeutic design. Since lung cancer' treatment requires separation of tumors in small cell carcinoma and non-small cell carcinoma, the histopathological diagnosis focuses on this basic distinction, while immunohistochemistry contributes considerably to confirm the diagnosis accuracy. In order to check the assumption that p63 is a useful marker for squamous cellular differentiation, we used two antibodies: anti-p63 and anti-thyroid transcription factor-1 (TTF-1), based on their immunoexpression to differentiate small cell lung carcinoma (SCLC) from poorly differentiated nonkeratinizing squamous cell carcinoma (SCC). Our study included 48 cases of lung carcinoma (lung biopsies and wedge resection formalin-fixed and paraffin-embedded). The 48 cases included 23 SCLCs and 25 poorly differentiated nonkeratinizing SCC. The expressions of p63 and TTF-1, respectively, proved to be useful in distinguishing SCLC from poorly differentiated nonkeratinizing SCC, on surgical and biopsic sections. The p63 positivity and TTF-1 negative expression consequently indicated a poorly differentiated nonkeratinizing SCC, while the opposite immunostaining pattern was flagged in SCLC. Our results are useful for a targeted therapy, as long as they point out a significant role in marking of the correct diagnosis of lung tumors.

Prognostic significance of tumor immune microenvironment and immunotherapy: Novel insights and future perspectives in gastric cancer

Despite a decrease in gastric cancer incidence, the development of novel biologic agents and combined therapeutic strategies, the prognosis of gastric cancer remains poor. Recently, the introduction of modern immunotherapy, especially using immune checkpoint inhibitors, led to an improved prognosis in many cancers. The use of immunotherapy was also associated with manageable adverse event profiles and promising results in the treatment of patients with gastric cancer, especially in heavily pretreated patients. These data have led to an accelerated approval of some checkpoint inhibitors in this setting. Understanding the complex relationship between the host immune microenvironment and tumor and the immune escape phenomenon leading to cancer occurrence and progression will subsequently lead to the identification of prognostic immune markers. Furthermore, this understanding will result in the discovery of both new mechanisms for blocking tumor immunosuppressive signals and pathways to stimulate the local immune response by targeting and modulating different subsets of immune cells. Due to the molecular heterogeneity of gastric cancers associated with different clinico-biologic parameters, immune markers expression and prognosis, novel immunotherapy algorithms should be personalized and addressed to selected subsets of gastric tumors, which have been proven to elicit the best clinical responses. Future perspectives in the treatment of gastric cancer include tailored dual immunotherapies or a combination of immunotherapy with other targeted agents with synergistic antitumor effects.

Expression of E-cadherin in lung carcinoma, other than those with small cells (NSCLC)

It was suggested that the decrease and/or loss of E-cadherin expression in non-small cell lung cancer (NSCLC) is responsible for the development of the malignant phenotype. Moreover, clinical studies showed that the reduced expression of E-cadherin is associated with tumoral differentiation, with the presence of lymph node metastasis and with unfavorable diagnosis of patients with NSCLC. In order to evaluate if E-cadherin expression is involved in the NSCLC pathogenesis and significantly associated with clinicopathological parameters, we investigated the immunohistochemical (IHC) expression of E-cadherin in 47 lung carcinomas with tumoral resection pieces in the control peritumoral lung tissue, looking for possible correlations between the expression of this molecule and the clinicomorphological features and the evolutive prognosis of the patients. E-cadherin expression was preserved in 10 (21.28%) of the 47 NSCLCs immunostained with anti-E-cadherin antibody and reduced÷absent in 37 of the 47 (78.72%) NSCLCs studied. E-cadherin plays a major role in the intercellular adhesion. The reduced expression of E-cadherin indicates an unfavorable prognosis and can be a useful prognosis factor in NSCLC - for patients with reduced expression of the E-cadherin÷α-catenin complex, needing chemotherapy or radiotherapy.

Assessment of p53 and HER-2/neu genes status and protein products in oral squamous cell carcinomas

Identification of the genes involved in tumor initiation and progression has led to development of new markers and generated targets for new drugs. This study aimed to evaluate p53 and HER-2/neu genes status of and their protein products in oral cancer patients. Tumor specimens from 116 cases diagnosed with oral squamous cell carcinoma were analyzed. P53 and HER-2/neu immunoreactivity were studied. FISH analysis was performed to elucidate p53 and HER-2/neu gene status. Male cases represented 84% of the group. The majority of cases were between 51-60 years and moderately differentiated oral carcinoma had an incidence of 58.6%. Thirty-four cases showed p53 overexpression, negative immunoreaction was observed in 16.37% of cases. 66.38% of cases had p53 deletion, with an increased rate observed in neoplasms of the tongue. Immunohistochemical analysis of HER-2/neu receptor protein revealed that 76.72% were negative, 5.17% had weak immunostaining, 14.65% had +2 score, the others had +3 score. 24.1% of cases were analyzed using FISH technique, of which 25% were without amplification, but with polysomy for chromosome 17. 18.1% of total cases were amplified, with the rate HER-2/neu:CEP17 higher than 2. Of the 77 cases with a single p53 allele, 20 associated HER-2/neu amplification, 31 had positive anti-HER-2/neu immunoreaction, but did not have HER-2/neu:CEP17 rate >2. There was a significant association between HER-2/neu amplification and deletion of a p53 allele. These results could justify more extensive research to assess p53 and HER-2/neu gene status as significant prognostic factors in oral cancers.

Has the diversity of clinical and biological manifestations of systemic lupus erythematosus a correspondent in the diversity of immune mechanisms? Observations based on a Rowell's syndrome case associated with arthritis and nephritis

This paper draws attention to the relationship between the clinical and biological picture of SLE and the immune mechanisms of this disease. The presence, in the same patient, of erythema multiforme-like skin lesions and erythemato-squamous lesions specific for SLE together with a characteristic immune picture (speckled antinuclear antibodies (ANAs), positive anti-Ro antibodies, positive rheumatoid factor) raise the question of a relationship between the immune mechanisms in SLE and the clinical picture. A case of Rowell's syndrome is discussed: systemic lupus erythematosus diagnosed on the occasion of an erythema multiforme-like rash. Starting from this case, we analyse if the clinical and biological picture in SLE is an expression of the immune mechanisms involved in this disease. Our patient presented with speckled antinuclear antibodies, positive rheumatoid factor, anti-Ro antibodies, suggestive of Rowell's syndrome. The patient manifested rheumatoid-like articular pain and high titer rheumatoid factor. Clinically, we found erythema multiforme-like and erythemato-squamous lesions. The patient developed nephrotic syndrome (proteinuria 11.8g/24h), and renal failure (creatinine 3.08 mg/dl). The renal biopsy showed mesangial proliferative glomerulonephritis class II (ISN/RPS). Under treatment with prednisone the nephrotic syndrome evolved into remission (traces of proteinuria) and serum creatinine declined (1.03 mg/dl). The cutaneous syndrome had a spectacular evolution, too. The question is raised of the existence in Rowell's syndrome of immune mechanisms commonly encountered in SLE and a subset associated with the cutaneous erythema multiforme-like rash and pseudo-rheumatoid arthritis manifestations.

[Thyroid cancer--the malignant lesions in the contralateral lobe]

AIM

This study analysed the frequency of the malignant lesions in contralateral thyroidian lobe after completion thyroidectomy for malignant lesions in the ipsilateral lobe, in order to establish which patients have indication of total thyroidectomy.

MATERIAL AND METHOD

There were studied retrospectively 228 patients which had completion thyroidectomy after histological confirmation of the thyroid cancer in the ipsilateral lobe.

RESULTS

Thyroid cancer in contralateral lobe was found in 94(41.2%) patients. One (4.7%) of patients with cancer < 1 cm in ipsilateral lob had malignant lesions in the contralateral lobe. In patients with ipsilateral lobe cancer > 1 cm, the frequency of malignant lesions was between 42.8% and 47.6%.

CONCLUSION

The very high frequency of malignant lesions in the patients with ipsilateral thyroid cancer > 1 cm impose total thyroidectomy in these cases.

Pseudobenign prostate carcinomas: causes of false-negative biopsy results

Prostate carcinomas are continuously surprising the pathologists through their multitude of variants and histological subtypes, some of them being recently described and characterized. Among these are individualized: atrophic carcinoma, foamy gland, pseudohyperplastic, microcystic, certain subtypes of ductal adenocarcinoma and hormone-treated adenocarcinoma, which because of minimal architectural and/or cytological atypia are often under-diagnosed, especially in small tissue fragments. This paper presents the morphological criteria, including information provided by some immunohistochemical markers for positive and differential diagnosis of these variants/subtypes of prostate adenocarcinoma with which the pathologist should be familiar and avoid their confusion with a series of similar histological structures or benign/premalignant lesions.

Prostate lesions with cribriform / pseudocribriform pattern

Prostate lesions with cribriform / pseudocribriform architecture range from normal histological structures to infiltrative carcinoma. In each group of lesions with cribriform architecture (benign, premalignant and malignant intraductal or infiltrating), there are situations in which histological classification of the lesion is difficult or impossible on routine stains. A more wide-scale application of the immunohistochemical investigation for clearing up the problematic prostate lesions led to the definition and reclassification of cribriform lesions in distinct categories and sometimes very different in terms of progression, prognosis and treatment. This paper proposes an overview of the prostate lesions with cribriform / pseudocribriform architecture, emphasizing the morpho-immunohistochemical criteria for positive and differential diagnosis.

Expression of vascular endothelial growth factor (VEGF) and assessment of microvascular density with CD34 as prognostic markers for endometrial carcinoma

INTRODUCTION

Angiogenesis plays an important role in the uncontrolled proliferation, invasion and metastasis of cancers. Increased microvessel density (MVD) is known to be associated with evolution and aggressiveness of the endometrial carcinoma (EC). The formation of new vessels depends on interactions between various hormones and growth factors. VEGF is one of the most known promoters of angiogenesis.

MATERIAL AND METHODS

In this study, we intend to evaluate the relation between MVD, the VEGF expression, and the clinicopathologic factors in patients with endometrial carcinoma. Formalin-fixed, paraffin-embedded tissue from 54 patients with EC were included. MVD was assessed with anti-CD34 in most intense areas of neovascularization. A semiquantitative scoring system was used to asses the intensity and degree of staining of VEGF.

RESULTS

MVD counts of patients with G1 EC was lower than patients with G2 and G3 EC. MVD counts of patients with stage I EC was lower as compared with stage II + III patients. There was no statistically significant difference between MVD counts in lymph node-negative and positive EC patients. The positive immunoreactions for VEGF were significantly more frequent in G1 EC in comparison to the patients with G2 + G3 EC.

CONCLUSIONS

MVD and VEGF are important indicators of a poor prognosis in patients with endometrial carcinoma.

Granular cell tumor of the penis shaft: case report and literature review

INTRODUCTION

Granular cell tumors (GCT) are uncommon soft tissue neoplasms of presumed neural origin that rarely involve the male external genitalia. Penile lesions are distinctly uncommon with less than 20 cases reported till now.

OBJECTIVE

In the present paper we describe the clinicopathological and immunohistochemical findings in a case of GCT of the penis shaft in a 31-years-old man.

RESULTS AND CONCLUSIONS

On physical examination the patient was found to have a small ovoid mass, 20 x 10 mm in diameter, at the left postero-lateral area of the penis' base. The mass was firm on palpation with no fixation on the neighboring tissues. The lesion was completely excised under loco-regional anesthesia. The surgical specimen was an ovoid, gray-white, elastic mass, of 10 x 5 mm. Microscopically, the tumor was moderately cellular and was composed of polygonal-shaped cells with abundant granular eosinophilic cytoplasm. Tumor cells were disposed in nests, cords, and trabeculae and showed perineural invasion. The tumor presented bland cytological features with only focal slight nucleo-megaly. Mitotic activity was undetectable. The tumor cells showed diffuse immunohistochemical expression for S100 protein. At 6 month after surgery the patient was free of persistent/recurrent disease or metastatic spread of the tumor. We discuss the clinical, histo-immunohistochemical and therapeutical features of this unusual penile tumor, the single one encountered in the Department of Pathology from Timisoara County Hospital and, to our knowledge, the only one reported in the Romanian medical literature.

Primary malignant non-Hodgkin's lymphomas of salivary glands

We evaluated the medical record of patients with salivary gland neoplasms diagnosed at Timisoara City Hospital from 2002 to 2009. A study has been carried out for seven years on 204 cases of salivary gland tumors and only two cases of salivary gland lymphomas were diagnosed. The two cases were females of 71- and 49-year-old, respectively. The formalin-fixed paraffin-embedded tissue samples were cut in 4 mum thick sections and stained with Hematoxylin and Eosin. The primary monoclonal antibodies for the immunohistochemical analysis were the followings: LCA (2B11, Dako), CD20 (L26, Dako), cytokeratin (MNF116, Dako), p53 (DQ-7, Dako), and PCNA (PC-10, Dako). The histopathology and immunohistochemistry suggested in the first case a low-grade diffuse large B-cell mucosa associated lymphoid tissue lymphoma and in the second case a high-grade extranodal marginal zone B-cell lymphoma.

Warthin tumor: a curious entity--case reports and review of literature

Warthin tumor was first described in the American literature, by Aldred Warthin, in 1929, the pathologist who named this tumor papillary cystadenoma lymphomatosum, but since than it was also knew as adenolymphoma, cystadenolymphoma, and Warthin tumor. Because of its microscopically appearance and unknown origin, this tumor entity is still fascinating head and neck surgeons and pathologist. We evaluate the histopathological aspect of Warthin tumors using Hematoxylin-Eosin stain, and immunohistochemical and histological techniques. We reviewed the medical record of patients with salivary gland tumors diagnosed at County Hospital of Timisoara from 2002-2008. In six years, 22 cases with Warthin tumor were diagnosed and among them 17 men and five women, with average age 58.47. The analysis showed that 77.27% of Warthin tumors occurred in men, and the main histopathological aspect was with 50% epithelial component. The stromal component showed a prominent B-cell population by staining with CD20, and histological techniques for mucin were positive, and reticulin fibers were revealed while using Gordon-Sweets stain. The standard and the histological and immunohistochemical techniques highlighted the complex and variable microscopical appearance of Warthin tumor that the pathologist should consider when a diagnosis for this tumor is to be considered.

[An unusual splenic tumor. Littoral cell angioma]

Littoral cell angioma is a rare splenic tumor which develops from specialised endothelial cells of the splenic red pulp. Numerous papers published since 1991 when the tumor was firstly described till now were focused on the radiologic characteristics of the lesion. This paper presents the clinical, imaging and morpho-immunohistochemical features of a littoral cell angioma diagnosed in a 51 year - old woman, to our knowledge, the first documented case in the Romanian medical literature. The lesion might be suspected on the basis of the clinical and imaging signs, but the diagnosis of certitude is provided by the gross and microscopic examination supplemented with immunohistochemical methods.

The expression of p53 protein in salivary gland carcinomas

The p53 suppressor gene is the most frequently altered gene in solid human malignancies. It is located on the short arm of chromosome 17 in the region 17p13 and encodes a 53kD nuclear phosphoprotein containing 393 amino acids with specific DNA binding properties and a short life span. The wild p53 protein has been classified as a tumoral suppression gene with a determining role in controlling cellular proliferation and differentiation and can be inactivated through mutation in the protein sequence encoding the gene, leading to neoplastic transformation. In this study we analyzed the expression of p53 protein in a variety of salivary gland malignant tumors fixed in formalin and included in paraffin, using the method of immunohistochemical coloring with the anti-p53 DO-7 antibody. The evaluation of the immunoreactivity with p53 proved a significantly more intense coloring in salivary gland high-grade malignant tumors and the observed immunomarking of over 50% of the tumoral cells is correlated with the weak differentiation of the tumors, giving a predictive factor for the evolution of the disease.

Immunohistochemical markers in the morphological diagnosis of lung carcinoma

Conventional histopathological criteria based on light microscopy are used in pulmonary oncologic pathology in order to establish the diagnosis of tumor, but most frequently they are insufficient, accurate diagnosis requiring ultrastructural and immunohistochemical investigations. The method of immunostaining allowed some molecular marker to be evaluated. Some of them seem to be important in carcinogenesis as a general process, while others have high specificity for lung tumors. Estimation of EGFR and c-erbB-2 protein immunoreactivity showed a significantly stronger staining with NSCLC and was correlated to the poor differentiation of the tumors, undergoing an aggressive biological behavior and an unfavorable prognosis. The expression of p53 protein was found in 19 cases by immunostaining with DO-7 antibody. Immunotracing of more than 50% of the tumoral cells was a predictive factor for the progression of the disease. The growing rate of tumoral proliferative activity was evaluated by immunotracing technique (MIB-1), allowing the Ki-67 index of labeling to be calculated.

Carcinoid tumor with uterine location. Case report

A carcinoid is defined as a tumor arising from endocrine cells with neurosecretory characteristics belonging to the APUD system. These cells are most frequently observed in the digestive tract and lungs. Uterine location is rare. This paper presents the case of a 21-year old patient with uterine carcinoid tumor. In order to establish the histopathologic diagnosis of the carcinoid tumor, we used optical microscopy examination in haematoxylin-eosin, argentic impregnation in Fontana-Masson staining and an immunohistochemical reaction using monoclonal antibody to the S100 protein. Due to the intracytoplasmatic granulations shown in Fontana-Masson staining and in the immunohistochemical reaction to S100 protein which confirm the neurosecretory character of the tumoral cells, we included this tumor in the group of tumors with neuroendocrine differentiation.

Expression and significance of tumoral suppressor p53 gene in lung adenocarcinomas

The mutations of p53 tumoral suppressor gene are the most frequent genetic modifications identified till now in lung cancer, suggesting that these alterations represent critical stages in malignant cellular transformation of respiration ways. Conformational changes induced by these mutations are associated with stabilisation of the product of p53 gene and the accumulation of the mutant protein in malignant cells' nuclei, in quantities that can be immunohistochemically detected: immunohistochemistry can be used as an indirect indicator of the genome alteration. Eight cases of lung adenocarcinoma were immunohistochemically analysed (formalin-fixed and paraffin-embedded specimens), in order to find the p53 suppressor expression. The overexpression of p53 protein was detected using an antigenous system and Monoclonal Mouse Anti-Human p53 protein, and it was detected in 5 (62.5%) of the 8 examined adenocarcinomas. In the examined cases, p53 overexpression was limited only to neoplastic cells, the nuclear staining being considered specific. p53 high level was correlated to: histological differentiation degree, smoking, the stage of the tumor and to the survival rate of the patients. The association of smoking with p53 overexpression suggests that p53 gene is a target of specific mutagenes in smokers.