Duodenal Ampulla Neuroendocrine Tumor with GISTs of the Proximal Jejunum: A Case Report.

Neuroendocrine tumors (NEN) are a type of heterogenous, slow-growing tumors, that only in about half of the cases can be found in the gastrointestinal tract. Half of these is in the small intestine. The ampullary NENs are rare, accounting for less than 1% of gastroenteropancreatic NENs. Gastrointestinal stromal tumors (GIST) are a more common type of tumors of the gastrointestinal tract that consist of pacemaker cells. The occurrence of both tumors simultaneously is rare, but in patients with neurofibromatosis type 1, the co-existence of NEN and GIST is more often. Here we report a case of simultaneous occurrence of a well-differentiated NEN and a GIST in a patient without neurofibromatosis. Also, we provide a short review of the current knowledge and treatment strategies regarding these tumors.

Cellular and Molecular Profiling of Tumor Microenvironment and Early-Stage Lung Cancer.

Lung cancers are broadly divided into two categories: non-small-cell lung carcinoma (NSCLC), which accounts for 80-85% of all cancer cases, and small-cell lung carcinoma (SCLC), which covers the remaining 10-15%. Recent advances in cancer biology and genomics research have allowed an in-depth characterization of lung cancers that have revealed new therapy targets (EGFR, ALK, ROS, and KRAS mutations) and have the potential of revealing even more biomarkers for diagnostic, prognostic, and targeted therapies. A new source of biomarkers is represented by non-coding RNAs, especially microRNAs (miRNAs). MiRNAs are short non-coding RNA sequences that have essential regulatory roles in multiple cancers. Therefore, we aim to investigate the tumor microenvironment (TME) and miRNA tumor profile in a subset of 51 early-stage lung cancer samples (T1 and T2) to better understand early tumor and TME organization and molecular dysregulation. We analyzed the immunohistochemistry expression of CD4 and CD8 as markers of the main TME immune populations, E-cadherin to evaluate early-stage epithelial-to-mesenchymal transition (EMT), and p53, the main altered tumor suppressor gene in lung cancer. Starting from these 4 markers, we identified and validated 4 miRNAs that target TP53 and regulate EMT that can be further investigated as potential early-stage lung cancer biomarkers.

Techniques for digital histological morphometry of the pineal gland.

INTRODUCTION: The pineal gland is a small photo-neuro-endocrine organ. This study used human post-mortem pineal glands to microscopically assess immunohistochemical marker intensity and percentage of positivity using known and novel digital techniques. MATERIALS AND METHODS: An experimental non-inferiority study has been performed on 72 pineal glands harvested from post-mortem examinations. The glands have been stained with glial fibrillary acidic protein (GFAP), synaptophysin (SYN), neuron-specific enolase (NSE), and neurofilament (NF). Slides were digitally scanned. Morphometric data were obtained using optical analysis, CaseViewer, ImageJ, and MorphoRGB RESULTS: Strong and statistically significant correlations were found and plotted using Bland-Altman diagrams between the two image analysis software in the case of mean percentage and intensity of GFAP, NSE, NF, and SYN. DISCUSSIONS: Software such as SlideViewer and ImageJ, with our novel software MorphoRGB were used to perform histological morphometry of the pineal gland. Digital morphometry of a small organ such as the pineal gland is easy to do by using whole slide imaging (WSI) and digital image analysis software, with potential use in clinical settings. MorphoRGB provides slightly more accurate data than ImageJ and is more user-friendly regarding measurements of parenchyma percentage stained by immunohistochemistry. The results show that MorphoRGB is not inferior in functionality. CONCLUSIONS: The described morphometric techniques have potential value in current practice, experimental small animal models and human pineal glands, or other small endocrine organs that can be fully included in a whole slide image. The software we used has applications in quantifying immunohistochemical stains.

Effects of Colchicine in a Rat Model of Diet-Induced Hyperlipidemia.

Inflammation and hyperlipidemia play an essential role in the pathophysiology of endothelial dysfunction as well as atherosclerotic plaque formation, progression and rupture. Colchicine has direct anti-inflammatory effects by inhibiting multiple inflammatory signaling pathways. The purpose of our study was to evaluate colchicine activity in an animal model of hyperlipidemia induced by diet. A total of 24 male rats (wild type, WT) were divided into three groups: group one fed with a basic diet (BD) (WT + BD, n = 8), group two fed with a high-fat diet (HFD) (WT + HFD, n = 8)), and group three which received HFD plus drug treatment (colchicine, 0.5 mg/kg, i.p., daily administration). Total cholesterol, LDL-, HDL-cholesterol and triglycerides were determined. In addition, plasma transaminases, inflammation of oxidative stress markers, were measured. Tissue samples were evaluated using hematoxylin-eosin and red oil stain. At the end of the study, rats presented increased serum lipid levels, high oxidative stress and pro-inflammatory markers. The aortic histopathological section revealed that HFD induced signs of endothelial dysfunction. Colchicine treatment significantly resolved and normalized these alterations. Moreover, colchicine did not influence NAFLD activity score but significantly increased ALT and AST levels, suggesting that colchicine amplified the hepatocellular injury produced by the diet. Colchicine reduces plasma lipid levels, oxidative stress and inflammation markers and leads to more favorable histopathologic vascular and cardiac results. However, the adverse effects of colchicine could represent an obstacle to its safe use.

Ultrasound Image Computerized Analysis for Non-invasive Quantitative Evaluation of Hepatic Fibrosis.

BACKGROUND: Assessing the diagnostic value of liver ultrasound image computerized analysis (USICA) for hepatic fibrosis (HF) staging in respect to the "gold standard" provided by liver biopsy (LB). METHODS: Two-hundred twenty-eight patients with chronic hepatopathies were prospectively enrolled in the study. All the patients underwent LB and abdominal ultrasound (US). For quantitative US assessment of HF, an image analysis software was developed and 3 parameters were extracted by wavelet processing of the region of interest: mHLlivermHHliver, mHLlivermLLliver, and mHLlivermHLspleen. To assess the relevance of each feature, the support vector machine (SVM) classifiers were employed to discriminate between the 2 severity classes (i.e., incipient F1-F2 vs advanced F3-F4 fibrosis). The statistical significance of the HF staging was assessed using SVM classifiers, in terms of sensitivity (Se), specificity (Sp), and receiver operating characteristic (ROC) curves. RESULTS: A cut-off value of 0.342 of mHLlivermHHliver allowed the discrimination between the incipient and advanced HF with 79.5% Se and 77.4% Sp, at an area under receiver operating characteristic (AUROC) value of 0.867 (P < .001). CONCLUSION: The proposed USICA using wavelet filter parameters proved to be an innovative method that is useful for the initial noninvasive evaluation and quantification of HF, with the advantages of simplicity, short calculation time, accessibility, and repeatability. The mHLlivermHHliver parameter has demonstrated good accuracy in distinguishing incipient and advanced HF and can be considered an effective non-invasive imaging marker for the assessment of HF in patients with chronic hepatic disease.

Pharmacological Effects of Methotrexate and Infliximab in a Rats Model of Diet-Induced Dyslipidemia and Beta-3 Overexpression on Endothelial Cells.

BACKGROUND: Hyperlipidemia and inflammation are critical components in the pathophysiology of endothelial disorder, which can lead to vascular complications. Our study aimed to evaluate the effects of immunomodulatory therapy (methotrexate and infliximab) in a diet-induced hyperlipidemia rat model. METHODS: Sprague-Dawley (wild type (WT), male, n = 32) rats were divided into four groups: one group fed with standard diet (SD), one group fed with high lipid diet (HLD), and two groups that received HLD and drug treatment (methotrexate (Mtx) or infliximab (Ifx)). In order to evaluate if modifications to the endothelial cells may influence the risk of vascular complications following hyperlipidemia or treatment reactivity, each group was doubled by a rats group that overexpressed beta-3 receptors on the endothelial cells (transgenic (TG-beta 3), male, n = 32). Serum lipid profile, liver enzymes, oxidative stress, and inflammation markers were determined. Histopathologic analysis of the liver and aorta was performed. RESULTS: After 9 weeks of HLD, rats exhibited significant pathologic serum lipid profiles, elevated oxidative stress, and pro-inflammatory markers. Additionally, the aortic histopathological analysis revealed aorta media-intima thickening (p < 0.05) in the transgenic group. Methotrexate and infliximab significantly decreased inflammation and oxidative stress parameters, but presented opposing effects on lipid profiles (methotrexate decreased, whereas infliximab increased the atherosclerosis index). Drug treatment decreased the aorta media-intima thickness (p < 0.05) only in transgenic rats. CONCLUSIONS: HLD was associated with hyperlipidemia, inflammation and oxidative stress. The overexpression of beta-3 receptors on endothelial cells increased aortic thickening in response to the HLD. Methotrexate and infliximab reduced oxidative stress and inflammation in all groups, but led to favorable histopathologic vascular results only in the transgenic groups.

Fulminant necrotizing streptococcal myositis with dramatic outcome - a rare case report.

Necrotizing myositis represents a rare, aggressive form of bacterial-induced soft tissue necrotizing infection. We present a fulminant case of a 44-year-old patient with a necrotizing soft tissue infection and a history of rheumatoid arthritis transferred to our service, Cluj-Napoca Emergency County Hospital, from a local hospital where he had been admitted two days before with chills and light-headedness after an accidental minor blunt trauma in the right thigh region. After admission to our hospital and first assessment, broad spectrum antibiotherapy was started with Meropenem, Vancomycin and Metronidazole along with surgical debridement. The evolution was fulminant with rapid development of multiple organ dysfunction syndrome, therefore he was transferred to the intensive care unit, intubated, and started the volemic resuscitation and vasopressor therapy. The blood culture was positive for group A beta-hemolytic streptococcus (GAS) and high dose Penicillin G was added to the therapeutic scheme. Despite all efforts, the patient developed disseminated intravascular coagulation syndrome and died in the next hours. The clinical picture together with the findings from the autopsy were suggestive for a streptococcal toxic shock syndrome developed as a complication of GAS induced necrotizing myositis.

Transesophageal endoscopic ultrasound fine needle aspiration of vertebral body osteolytic tumors - a novel diagnostic approach. Case series.

AIMS: Vertebral lesions, either primary or more frequently metastasis, are difficult targets for percutaneous guided biopsies and surgical biopsies and are associated with greater risks of complications. We investigated the feasibility of endoscopic ultrasound (EUS) fine needle aspiration (FNA) biopsy in the assessment of vertebral osteolytic tumors as an alternative to CT guided biopsy which is the technique currently used. MATERIAL AND METHODS: Four patients with osteolytic tumors of the vertebral bodies identified by imaging methods (CT or MRI) - 3 patients, and one with a tumor detected primarily during EUS procedure were included in order to evaluate the feasibility of the procedure. The lesions were located either at the dorsal or lumbar vertebrae. In all cases we performed EUS FNA of the osteolytic vertebral body lesions with 22G needles using the transesophageal or transgastric approach. RESULTS: In all cases EUS FNA provided enough tissue for an accurate histopathological report, with no procedural complication. We diagnosed lung adenocarcinoma, hepatocarcinoma and a pancreatic adenocarcinoma vertebral metastasis and one case of lymphoma. CONCLUSIONS: EUS FNA is a valuable technique which should be considered in selected cases, when a "traditional approach" is not applicable or associated with a higher risk. Treatment guidelines are based on the histology of the tumor, histopathological examination being nowadays mandatory. Therefore, we propose for selected cases a feasible technique, with significantly lower procedural risks, as an alternative for open surgical biopsies or computed tomography guided biopsies.

Transthoracic ultrasound: an essential diagnostic tool in a very rare case of thoracic lymphangiomatosis.

Thoracic lymphangiomatosis (proliferation of anastomosing lymphatic vessels, of different sizes, in pulmonary, pleural and mediastinal regions) is an extremely rare disorder occurring mostly in childhood. We present a diffuse pulmonary lymphangiomatosis (DPL) case in a young adult female patient in which repeated surgical biopsies were inconclusive and transthoracic ultrasound-guided (TUS) biopsy led to the diagnosis. Even histologically, DPL is very difficult to differentiate from other lymphatic diseases such as lymphangioma and lymphangiomyomatosis, requiring an experienced pathologist and proper immunohistochemistry staining. This case highlights the importance of TUS-guided biopsies in the armamentarium of imagistic techniques in this very rare case.

Accuracy of endoscopic ultrasound-guided biopsy of focal liver lesions.

AIM: Endoscopic ultrasound (EUS) has become an indispensable method for diagnosis in gastroenterology and new indications for EUS continue to emerge. However, there are limited data regarding the accuracy of EUS-guided biopsy of hepatic focal lesions. The aim of this study was to assess the diagnostic yield of EUS-guided fine needle aspiration (FNA) of focal liver lesions. MATERIAL AND METHODS: We conducted a prospective study in which patients with focal liver lesions, detected by transabdominal ultrasound and computed tomography or magnetic resonance imaging, underwent EUS-guided FNA to determine the diagnostic yield of the procedure. RESULTS: In 47/48 of patients, the results of EUS-FNA were positive for malignancy, while in one case the acquired fragment was insufficient for appropriate histological analysis. Diagnostic yield was 0.98. In 83% of the cases biopsies were taken from the left lobe and in 17% from the right lobe with the same technical success rate. The most common diagnosis was metastatic adenocarcinoma of the pancreas (26% cases) followed by cholangiocarcinoma (17% cases). Concurrent sampling of other sites in addition to the liver and/or primary tumor was realized in 35% of the cases, with results that correlated with the liver biopsy and with the primary tumor biopsy. We reported no immediate or long-term complications in any of the patients. CONCLUSIONS: EUS guided fine needle aspiration/biopsy of focal liver lesions is safe, provides a very high diagnostic accuracy and should not be considered only as a rescue method after failure of percutaneous guided biopsies.

Different patterns of p16INK4a immunohistochemical expression and their biological implications in laryngeal squamous cell carcinoma.

INTRODUCTION: p16INK4a immunohistochemistry (IHC) is widely used to facilitate the diagnosis of human papillomavirus (HPV)-associated neoplasia, when ≥70% of cells show strong nuclear and cytoplasmic positivity. In this study, we aim to compare partial expression patterns that do not fulfill the above criteria and seek biological implications in laryngeal squamous cell carcinoma (LSCC). MATERIALS AND METHODS: p16INK4a IHC staining was conducted on representative sections of archived tissue from 88 LSCCs. Immunoreactivity was described based on four parameters: intracellular localization of immunostaining, intensity of immunostaining, distribution pattern and percentage of positive cells. RESULTS: Six patterns of p16INK4a immunoexpression were observed and defined as: strong diffuse (strong immunostaining, expression in cytoplasm and nucleus in >70% of tumor cells), weak diffuse (moderate or weak immunostaining, expression in cytoplasm in >70% of tumor cells), marginal (strong cytoplasmic immunostaining, limited to the periphery of tumor islets), strong scattered (strong immunostaining, expression in cytoplasm and nucleus in <50% of tumor cells), weak scattered (moderate or weak immunostaining, expression in cytoplasm in <50% of tumor cells), negative (no expression). The pN stage of the patients was associated with p16INK4a immunoexpression patterns, the marginal pattern was only found in the pN0-Nx stages, while the weak diffuse pattern was more frequently observed in pN2-N3 stages. CONCLUSIONS: Partial immunostaining with architecturally distinct p16INK4a immunoexpression patterns may prove significant in stratifying characteristic clinicopathological subgroups among LSCC. Our observations may support the hypothesis that p16INK4a has different roles in different subcellular locations, with tumorigenic molecular pathways unrelated to HPV infection.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of paraesophageal lung tumors - diagnostic yield and added value.

AIMS: There are few data on the use of endoscopic ultrasound (EUS) for the biopsy of suspected malignant lesions of the lung. The main objective of this study was to evaluate the performance of transesophageal EUS fine needle aspiration (EUSFNA) for the diagnosis of paraesophageal lung tumors and also for the confirmation of metastatic sites of lung cancer during the same procedure. MATERIAL AND METHODS: We performed a retrospective study in a tertiary care unit including 19 patientswith paraesophageal lung tumors referred to our department for a lung biopsy. Transesophageal EUS-FNA was performed using a linear echoendoscope and 22G needles. RESULTS: In all 19 patients with suspected lung tumors the confirmation of the malignant disease was achieved. Pathological examination revealed 16 cases of non-small cell lung cancers, 2 small cell lung cancers and one case of lung metastases. Diagnostic yield of lung EUS-FNA was 1, with no post-procedural complications. In 7 cases, we performed also biopsies of suspected metastasis and all biopsies revealed the same histopathological type as the primary tumor. CONCLUSIONS: Our study supports the use of this minimally invasive technique for paraesophageally locatedlung tumors and demonstrates that EUS-FNA is safe and has an excellent diagnostic yield.

Molecular markers in the diagnosis of invasive pituitary adenomas - an immunohistochemistry study.

Pituitary adenomas are benign tumors of the brain, with a relatively high prevalence in the general population, being responsible for 14.4-16.7% from all brain tumors. These tumors, although benign, have a local invasive behavior in approximately 35% of the cases. The aim of this study was to identify the differences in expression of molecular markers between primary and relapsed pituitary adenomas (as an aggressiveness indicator), as well between secreting and non-secreting pituitary adenomas. Tumor fragments were collected from 51 patients with invasive pituitary adenomas. Of these, 10 cases were operated a second time due to tumor recurrence. The tumor fragments were retrieved from the archives of the Department of Pathology, Emergency County Hospital, Cluj-Napoca, Romania. Immunohistochemical staining was performed for nine markers on 51 invasive pituitary adenomas: Ki-67, ß-catenin, E-cadherin, Bcl-2, galectin-3, p53, p27, CD117, and CD44. We compared the expression differences between two groups: the first one including primary and relapsed invasive pituitary adenomas, and another one including prolactin (PRL)-secreting and non-secreting invasive pituitary adenomas. Ki-67, p53 and Bcl-2 expressions were found significant in the PRL-secreting group. CD44 immunostaining was significant only in relapsed invasive pituitary adenomas. For the ß-catenin, E-cadherin, galectin-3, p27 and CD117 expression levels were not registered statistically significant differences between our groups. Our study is the first one to report a statistically significant difference between the expression of CD44 in primary and relapsed invasive pituitary adenomas and it could be used as a negative impact prognostic marker.

Unusual multiple metastatic localisations in adult Burkitt's lymphoma. A case report.

Burkitt's lymphoma is an aggressive B-cell non-Hodgkin lymphoma. It is less common in adults accounting for less than 5% of non-Hodgkin lymphoma cases. Radiological methods (ultrasonography, computed tomography) are indispensable for the initial evaluation and appreciation of organ extension; complete diagnosis is confirmed by the histopathological examination.We present the clinical case and ultrasound imaging particularities of a young patient diagnosed with multisystem involvement Burkitt's lymphoma, with rapid progressive evolution towards exitus.

Diagnostic reevaluation of 17 cases of pheochromocytoma - a retrospective study.

A rare neuroendocrine tumor, the pheochromocytoma (PCC) raises problems due both the limited experience of the researchers in this field and its pathogenic mechanisms, still not fully elucidated. The malignant potential of this tumor cannot be predicted based on its macro- or microscopic aspects, but on the presence of metastases. The aims of this study were: (1) the reevaluation of data for a pertinent and complete tumor diagnostic and prognostic pattern; (2) the statistical correlation of all investigated parameters with the malignant form and the survival rate in order to obtain a possible predictor of malignancy; (3) the potential identification of initially diagnosed benign tumors that become malignant in time. The retrospective study was conducted on 17 patients diagnosed with pheochromocytoma. We investigated: the personal data, the associated neuroendocrine syndromes, the clinical, the laboratory, the macro- and microscopic data [location, size, Hematoxylin-Eosin (HE) pheochromocytoma of the adrenal gland scaled score (PASS score), and immunohistochemical aspects] and the survival rate (analyzed by Kaplan-Meier method and Log-Rank test). The influence of diagnostic parameters on malignancy was calculated taking into consideration the survival rate. By reevaluation of the 17 cases, we tried to emphasize the value of a complex diagnosis pattern for PCCs, based on the correlation between clinical data, laboratory findings and microscopic features. A significant statistical difference between benign and malignant forms was not registered, but there were parameters as age, association with neuroendocrine syndromes, PASS score and specifically Ki-67 mitotic index that had a powerful impact on the survival rate and could be consider as possible predictors of malignancy. The potential of PCC malignant transformation was revealed in our study, by two cases that have metastasized in time.

RGC-32 is expressed in the human atherosclerotic arterial wall: Role in C5b-9-induced cell proliferation and migration.

The complement system is an important player in the development of atherosclerosis. Previously reported as a cell cycle regulator, RGC-32 is an essential effector of the terminal complement complex, C5b-9. In this study, our aims were to determine the expression of RGC-32 in the human atherosclerotic arterial wall and to delineate the mechanisms through which RGC-32 affects C5b-9-induced endothelial cell proliferation and migration. We now demonstrate that RGC-32 is expressed in human aortic atherosclerotic wall and that RGC-32 expression increases with the progression of atherosclerosis. Furthermore, silencing of RGC-32 expression abolished C5b-9-induced human aortic endothelial cell (HAEC) proliferation and migration. Of the 279 genes differentially expressed in HAECs after RGC-32 silencing, the genes involved in cell adhesion and cell cycle activation were significantly regulated by RGC-32. RGC-32 silencing caused a significant reduction in the expression of cyclin D1, cyclin D3, Akt, ROCK1, Rho GDP dissociation inhibitor alpha and profilin. These data suggest that RGC-32 mediates HAEC migration through the regulation of RhoA and ROCK1 expression and is involved in actin cytoskeletal organization. Thus, RGC-32 has promising therapeutic potential with regard to angiogenesis and atherosclerosis.

Computerized ultrasound image analysis for noninvasive evaluation of hepatic steatosis.

OBJECTIVE: To assess the diagnostic value of a particular set of local intensity parameters extracted from ultrasound liver images in conjunction with support vector machine (SVM) classifiers for liver steatosis grading in respect to the "gold standard" provided by liver biopsy. MATERIAL AND METHODS: We prospectively enrolled in the study 228 patients with chronic hepatopathies. All the patients underwent liver biopsy and abdominal ultrasound examination. For quantitative ultrasound assessment of liver steatosis, an image analysis software was developed, which extracts three local intensity parameters from regions of interest (ROI) in the ultrasound section and analyzes their depth variation: the coefficient of variation of luminance (CVL), the median luminance (ml ), and the hepato-splenic attenuation index (HSAI). For steatosis grading, SVM classifiers were trained on the input feature spaces provided by the above mentioned parameters. The statistical significance of the steatosis grading was assessed on a significant test set using SVM classifiers, in terms of sensibility, specificity and through the ROC curves. RESULTS: A cut-off value of 0.362 of the CVL of the liver performed the liver steatosis grading with an accuracy of 89.17% (p<0.0001). A cut-off value of 0.27 of the HSAI performed the prediction of the moderate-severe liver steatosis with an accuracy of 87%. CONCLUSIONS: The proposed computer analysis method of ultrasound images proved innovative and useful for the initial non-invasive assessment and grading of liver steatosis, with an additional advantage of reduced computational complexity and accessibility. The CVL provided a very good accuracy (89.17%) for an AUROC of 0.923 for the classification of liver steatosis in two severity categories (mild versus moderate-severe).

Endobronchial ultrasound EBUS--a new method for the diagnosis and staging of lung cancer.

In this paper we present a new method, endobronchial ultrasound (EBUS), which appeared recently among the tools of the pulmonologist for the diagnosis and staging of lung cancer. Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) provides the opportunity for obtaining tissue samples required for the histologic and cytologic diagnosis of lung cancer. The advantages of EBUS have to be made popular as it is a minimally invasive method, safe, simple, fast, also with a superior cost/benefit ratio compared to any previously used methods.