Immune-related acute and lymphocytic gastritis in a patient with metastatic melanoma treated with pembrolizumab immunotherapy.

Here, we present a case of acute and lymphocytic gastritis related to therapy with pembrolizumab for metastatic melanoma. After an asymptomatic phase with moderate histological inflammation (observed at 9 months of immunotherapy), gastritis became symptomatic and severe on repeated biopsies (13 months after the beginning of pembrolizumab). Symptoms and histological lesions both improved with proton pump inhibitor and steroid therapy, as well as interruption of pembrozulimab. The interest of this case lays in the relative rarity of gastritis over small and large intestinal inflammatory lesions caused by immune checkpoint inhibitors as well as in the features of the inflammatory infiltrate, which may be purely lymphocytic (mainly T-cells, with a prevalence of CD8+ over CD4+ lymphocytes) or mixed lymphocytic and granulocytic, requiring the exclusion of other causes of disease. To our knowledge, only 7 cases of immune-related gastritis have been previously documented in the current literature, of which 4, included the current one, were exclusively associated with pembrozulimab therapy.

Caso inusual de tumor de origen desconocido detectado con 18F-FDG PET/TC: carcinoma de células claras de la glándula tiroides metastásico / Unusual case of tumor of unknown origin found by 18F-FDG PET/CT: Metastatic clear cell carcinoma of the thyroid gland

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Salivary epithelial-myoepithelial carcinoma: clinical, morphological and molecular features.

Epithelial-myoepithelial carcinoma (EMC) is a rare biphasic tumor accounting for less than 2% of all salivary gland malignancies. It presents as a slowly growing, asymptomatic small size mass, with ulceration of overlying mucosa in some cases. Microscopically, it is characterized by glands lined by the simultaneous presence of two different cell components, inner epithelial cells and outer myoepithelial cells. Immunohistochemical staining of myoepithelial cells is variably positive for vimentin, Smooth Muscle Actin (SMA), Muscle Specific Actin (MSA), S100, Smooth Muscle Myosin Heavy Chain I(SM-MHC), calponin and p63. Several molecular alterations, mainly point mutations, have been described. Mutations of HRAS, AKT1, CTNNB1 and PIK3CA were highlighted in variable percentage of EMC samples. EMC is considered a low-grade malignant tumor with a 5-year survival rate of 94% that may commonly recur locally after resection in 30-50% of cases. At the moment, adequate resection with negative margins is the minimum recommended and necessary treatment.

Detecting N-RAS Q61R Mutated Thyroid Neoplasias by Immunohistochemistry.

Recently, the immunohistochemistry (IHC) for N-RAS Q61R has been developed and commercialized for clinical practice. Here, we investigated the reliability of IHC to identify N-RAS Q61R mutated thyroid neoplasia. A series of 24 consecutive thyroid lesions undergone surgery following indeterminate cytology were enrolled. Paraffin sections were stained for IHC using the rabbit monoclonal anti-human N-RAS Q61R, clone SP174. N-RAS mutations in codon 61 were also investigated by automated sequencing. At histology, 12 cases of follicular carcinoma, cytologically defined as follicular lesions, 1 papillary cancer, 7 follicular adenomas, and 4 hyperplastic nodules were found. Of these, 4 showed a positive IHC for anti N-RAS antibody where N-RAS expression was detected mainly at cytoplasmic level with similar intensity of reaction. The remaining cases had negative IHC. A 100% concordance between IHC and molecular analysis for N-RAS Q61R was observed. In conclusion, this study shows high reliability of IHC to identify N-RAS Q61R mutated thyroid lesions with high cost-effectiveness. These data indicate the reliability of IHC to identify N-RAS Q61R mutated thyroid neoplasia and suggest to adopt this approach for a more accurate management of patients, when indicated.

Inhibition of Hedgehog signalling by NVP-LDE225 (Erismodegib) interferes with growth and invasion of human renal cell carcinoma cells.

BACKGROUND: Multiple lines of evidence support that the Hedgehog (Hh) signalling has a role in the maintenance and progression of different human cancers. Therefore, inhibition of the Hh pathway represents a valid anticancer therapeutic approach for renal cell carcinoma (RCC) patients. NVP-LDE225 is a Smoothened (Smo) antagonist that induces dose-related inhibition of Hh and Smo-dependent tumour growth. METHODS: We assayed the effects of NVP-LDE225 alone or in combination with everolimus or sunitinib on the growth and invasion of human RCC models both in vitro and in vivo. To this aim, we used a panel of human RCC models, comprising cells with acquired resistance to sunitinib - a multiple tyrosine kinase inhibitor approved as a first-line treatment for RCC. RESULTS: NVP-LDE225 cooperated with either everolimus or sunitinib to inhibit proliferation, migration, and invasion of RCC cells even in sunitinib-resistant (SuR) cells. Some major transducers involved in tumour cell motility, including paxillin, were also efficiently inhibited by the combination therapy, as demonstrated by western blot and confocal microscopy assays. Moreover, these combined treatments inhibited tumour growth and increased animal survival in nude mice xenografted with SuR RCC cells. Finally, lung micrometastasis formation was reduced when mice were treated with NVP-LDE225 plus everolimus or sunitinib, as evidenced by artificial metastatic assays. CONCLUSIONS: Hedgehog inhibition by NVP-LDE225 plus sunitinib or everolimus bolsters antitumour activity by interfering with tumour growth and metastatic spread, even in SuR cells. Thus, this new evidence puts forward a new promising therapeutic approach for RCC patients.

Seven-Tesla micro-MRI in early detection of acute arterial ischaemia: evolution of findings in an in vivo rat model.

PURPOSE: Acute mesenteric ischaemia (AMI) is a life-threatening vascular emergency with a high mortality rate. Early diagnosis is the key to reducing its mortality rate and improving the quality of life. Although computed tomography (CT) is still the gold standard for acute intestinal disorders, over the last few years, magnetic resonance imaging (MRI) has become a useful alternative tool. An animal model of AMI was developed in order to study the effectiveness of MRI in early detection of this condition and to observe lesion evolution. METHODS: Thirty Sprague Dawley rats were randomly divided into two groups (n=15): in the first group, after laparotomy, the animals underwent ligation of the superior mesenteric artery (SMA), followed by macroscopic monitoring and histological evaluation; in the second, ischaemia was induced by squeezing a loop around the SMA 3 days before evaluation with 7-T micro-MRI. RESULTS: Macroscopically, a reflex spastic ileus followed by reflex hypotonic ileus and colour changes in some of the loops were detected. MRI evidenced luminal dilatation with air-fluid levels, free intraperitoneal fluid and bowelwall oedema. Histological analysis confirmed ischaemia and earlier damage involving the central portion of the ileum. CONCLUSIONS: This model shows the correct sequence of events during arterial AMI and demonstrates that MRI can be recommended for early diagnosis of these lesions.

Human papillomavirus (HPV) genotypes and HPV16 variants and risk of adenocarcinoma and squamous cell carcinoma of the cervix.

OBJECTIVE: Human papillomavirus (HPV) genotypes have been extensively studied in uterine cervix squamous cell carcinoma and HPV16 variants have been found to be associated with increased cancer risk, but few reports have been published on genotype distribution and HPV16 variant prevalence in adenocarcinoma tumors. The objective of this study was to analyze viral genotypes and HPV16 intratypic variants in cervical adenocarcinoma and squamous cell carcinoma of Italian women. METHODS: A total of 39 invasive adenocarcinoma and 132 squamous cell carcinoma were reviewed and classified according to the modified WHO classification. HPV sequences were detected by nested PCR, using the broad spectrum consensus-primer pairs MY09/MY11 and the GP5+/GP6+ system, and genotyped by nucleotide sequence analysis. The HPV16-positive cases were amplified with E6-specific oligonucleotides and amplimers subjected to direct nucleotide sequence for variant identification. RESULTS: The prevalence rate of any HPV infection was 72% in adenocarcinoma, and 85% in cervical squamous cell carcinoma. Among the 140 HPV-positive cancer cases, a total of nine mucosal HPV genotypes (HPV16, 18, 31, 33, 35, 39, 45, 58, 82) epidemiologically classified as carcinogenic or probably carcinogenic viruses were identified. The HPV type 16 was the most common viral type representing 64% and 73% of all infections in adenocarcinoma and squamous cell carcinoma, respectively. The E6 nucleotide sequence analysis of HPV16 isolates allowed the identification of Asian American (AA) variants in 33% of adenocarcinoma and in 20% of squamous cell carcinoma suggesting their stronger association with cancer of glandular origin. CONCLUSION: These results suggest that HPV16 has a high prevalence in both invasive adenocarcinoma and squamous cell carcinoma from Italian patients. Moreover this study confirms previous observations, summarized in a systematic review of the literature, on the increased cancer risk of HPV16 AA class in adenoglandular cancer, possibly related to their more oncogenic behavior compared to HPV16 European variants.

Metastases to the breast: role of fine needle cytology samples. Our experience with nine cases in 2 years.

BACKGROUND: The increased survival due to the introduction of effective antineoplastic regimens has caused a modification of the natural history of numerous malignancies. Follow-up of neoplastic patients often includes the evaluation of masses in various body sites by fine needle cytology (FNC) in order to rule out cancer recurrence. Besides primary neoplasms, the breast can host a number of metastases: these rarely do have a typical presentation, so FNC is requested for their cytomorphological assessment. PATIENTS AND METHODS: This report describes nine consecutive cases in which a cytopathological diagnosis of metastasis to the breast was carried out on FNC samples. RESULTS: Primary sites were identified on cytomorphological and immunocytochemical bases and were represented by the ovary (three cases), melanoma (two cases), endocervix (one case), endometrium (one case), lung (one case) and prostate (one case). CONCLUSION: The cytopathological diagnosis of metastatic neoplasms to the breast is not always straightforward, especially in the absence of a clinical history of cancer. The usage of improved cytopathological criteria combined with immunocytochemistry may be of great diagnostic help in the identification of breast metastases.

Fine-needle cytology of inflammatory myofibroblastic tumor of the lung. Report of a case.

BACKGROUND: Inflammatory myofibroblastic tumor (IMT) of the lung is a rare condition that may mimic cancer. CASE: We describe a case of inflammatory myofibroblastic tumor discovered by a routine chest X-ray in a 26-year-old male patient, primarily diagnosed by fine needle aspiration biopsy. The clinical, cytopathological and differential diagnostic findings of this rare entity are briefly discussed. CONCLUSION: IMT may be diagnosed accurately on needle cytology samples, provided that other pseudoneoplastic and neoplastic entities can be excluded from its differential diagnosis.

Myxopapillary ependymoma of the ischioanal fossa.

Ependymomas outside the confines of the cranium and spinal cord are rare. Direct extension into the soft tissues of the sacrococcygeal area may occur from a primary ependymoma of the spinal cord, cauda equina or filum terminale. Alternatively they may occur as a primary pre-sacral, pelvic and abdominal tumour, or as a primary tumour of the skin and subcutaneous tissue of the sacrococcygeal area without any demonstrable connection with the spinal cord. The Authors report a case of myxopapillary ependymoma of the ischioanal fossa, demonstrated by MRI. To our knowledge, our case is the first lesion reported at this site.

Papnet-assisted cytological diagnosis intensifies the already marked variability among cytological laboratories.

OBJECTIVE: The main objective was to assess the sensitivity, specificity and reliability of PAPNET-assisted diagnosis in comparison with conventional screening. SETTING: Seven Italian and one English University or Research Institutes, and a random sample of an other 20 Italian Laboratories of the Italian National Health Service (INHS) provided the cervical smears. METHODS: During the training phase every center examined in rotation four sets of slides for a total of 300 representative slides. Afterwards, 900 "positive" slides were added to the 3,100 slides which were collected consecutively without any selection or exclusion. The eight main centers were divided into four couples and each couple of centers examined 775 slides with the PAPNET system, "blindly" to the original diagnosis. An expert cytopathologist (M.A.) of the National Institute of Health (NIH) reassessed 40% of the slides with an original negative diagnosis to evaluate the false negative rate. Two expert NIH cytopathologists (M.A., G.M.) re-examined all slides where a disagreement had been observed between the original and one or both of the study diagnoses. The main analyses concerned the following three main categories: WNL and unsatisfactory for evaluation; ASCUS, AGUS and LSIL; HSIL and carcinoma. A special algorithm was devised to define the reference diagnosis for sensitivity and specificity assessment. RESULTS: Laboratories, even belonging to the same couple, classified as "no review" a very different proportion of slides ranging from 35% to 74%. The index of kappa agreement between the members of couples examining the same sets of slides was low or very low, ranging from 0.30 to 0.03. The sensitivity of the review classification was particularly low in some laboratories. Surprisingly, only a small correlation was observed between the sensitivity of the review classification and the proportion of slides classified as "review". The "tentative" diagnosis on PAPNET tiles of the "review" slides was almost as reliable as the microscopic diagnosis. In the overall performance, there were many significant differences among the eight laboratories. The best laboratory had a sensitivity of 95% and a specificity of 96%. At least three laboratories displayed unacceptably low sensitivity and one a very low specificity. CONCLUSION: Altogether these results seem to confirm that there are wide differences among cytological laboratories per se, and that these differences are intensified by the use of an instrument like PAPNET. The huge variation in performance may be explained by differences in basic skills and by different training, but it is difficult to understand exactly what could have been done to reduce it.

Follicular variant of papillary carcinoma: cytologic findings on FNAB samples-experience with 16 cases.

Between January 1, 1992 and December 31, 1997, a cytopathological diagnosis of follicular variant of papillary thyroid carcinoma (FVPC) was made on a series of 16 out of 18 patients with palpable nodules who underwent fine-needle aspiration biopsy (FNAB) in our Department. The results of aspiration biopsy were followed by histopathological examination of the surgically excised tissues. There were three false-negative aspirations (16.6%), of which two were probably bound to fine-needle sampling and one due to a mixture of benign and malignant cells which had originally gone unrecognized. The accuracy of the cytopathologic diagnosis in this variant was 88.8%. An analysis of the diagnostic cytopathological criteria was performed, which demonstrated the importance of both architectural features (monolayered and branching sheets, microacinar structures, and their combinations) and nuclear features (presence of nuclear grooves). Background -bound features were mainly represented by dense, nonfilamentous colloid. The cytopathologic findings in FVPC were compared to those found in a series of 10 usual papillary carcinomas (UPC) and 10 follicular neoplasms (FN). These latter had originally been diagnosed by FNAB and were subsequently classified histologically as follicular adenoma (n = 6), follicular carcinoma (n = 3), or adenomatoid colloid nodule (n = 1). Statistical evaluation was performed on the cytopathological findings in the three classes of lesions (FVPC, UPC, and FN) as to their presence and relative frequency or absence by using a nonparametric one-way ANOVA (Kruskall-Wallis) and, where necessary, a Mann-Whitney U test. Papillary cellular fragments and multinucleated giant cells (P < 0.005), nonfilamentous dense colloid, squamoid cells, and syncytia were significantly more represented in UPC than in FVPC (P < 0.05), while histiocytes were significantly more frequent in FVPC (P < 0.005). Other nuclear and/or background features were significant only in the distinction between papillary carcinomas as a group and FN. The cytological differential diagnosis of the FVPC is briefly discussed with relevance to the possible pitfalls caused by its peculiar cyto- and histomorphology.

Quantitative assessment of oxyphilic cell lesions of the thyroid gland on fine needle aspiration samples.

OBJECTIVE: To assess the possible contribution by a multiparametric quantitative approach to the cytologic diagnosis of oxyphilic cell (OC) thyroid lesions. STUDY DESIGN: Ten cases of chronic lymphocytic (Hashimoto) thyroiditis and 10 nodular goiters containing oxyphilic cells plus 20 cases of tumors subsequently classified as oxyphilic cell adenomas (10 cases) or oxyphilic cell well-differentiated carcinomas (10 cases) were evaluated. The study was performed on May-Grünwald-Giemsa-stained smears for planimetric measurements. The same smears were destained and Feulgen restained for densitometric measurements. The latter were performed using static cytometry equipment measuring 100 and 20-30 lymphocytes per case for the determination of integrated optical density (IOD). The following parameters were considered: nuclear area, perimeter, maximum diameter, form ELL, form PE, IOD, 5c exceeding rate (5cER) and visual classification of histograms as euploid, polyploid and aneuploid. RESULTS: Mean nuclear area of carcinomas was smaller than that of adenomas, goiter and thyroiditis. Nuclear area was larger in adenomas than in other benign lesions and carcinomas. All the other planimetric parameters were similar in the lesions examined. Four carcinomas and three adenomas were aneuploid, and all the rest were euploid. All the cases of thyroiditis and goiter were euploid or polyploid; four thyroiditis cases showed polyploid histograms and 5cER values > 1. CONCLUSION: Morphometric and densitometric procedures have a limited role in the discrimination of OC lesions, but small nuclear area values may be useful in distinguishing OC carcinoma from other lesions. The role of densitometry seems even more limited because aneuploid histograms may be found among adenomas and carcinomas. Further studies are needed to explain polyploidy and 5cER > 1 in Hashimoto thyroiditis.

Cyclin-dependent kinase inhibitor p27(Kip1) expression in thyroid cells obtained by fine-needle aspiration biopsy: a preliminary report.

Recent studies on paraffin-embedded tissue have shown that the cyclin-dependent kinase inhibitor p27(Kip1) is expressed in normal thyroid cells, whereas it is downregulated in neoplastic cells. This prospective study was undertaken to assess whether p27(Kip1) staining may also be applied to fine-needle aspiration biopsy (FNAB) samples of the thyroid. We present here our preliminary results on 100 FNABs examined for p27(Kip1) expression. p27(Kip1) expression was assessed by immunocytochemistry; the technique was optimized on smears prepared from a normal thyreocyte cell line (TL5), which conspicuously expresses p27(Kip1), and then applied to FNAB samples prospectively collected from 80 cases of nodular goiter and 20 cases of thyroid neoplasms (10 papillary carcinomas and 10 follicular neoplasms). The TL5 cell culture smears showed that methanol fixation, followed by heat-induced antigen retrieval, is the most suitable technique for p27(Kip1) staining on cytological samples. The FNAB smears similarly treated showed high p27(Kip1) expression (75%) in goiter and a significantly lower expression (35%) in neoplasms (P < 0.0001). Our preliminary results show that: 1) p27(Kip1) protein expression can be reliably assessed on cytological samples; and 2) p27(Kip1) stains nonneoplastic and neoplastic samples in a different fashion, and thus is a useful tool in thyroid cytology.

Retrospective evaluation of DNA ploidy of hepatocarcinoma on cytologic samples.

DNA ploidy was evaluated by image cytometry in a series of 84 hepatocellular carcinomas diagnosed by fine-needle aspiration biopsy. In the series were included eight cases originally diagnosed as suspect and reclassified as well-differentiated hepatocarcinoma. The study was retrospectively performed on Papanicolaou-destained, Feulgen-restained smears. The 5c exceeding rate and the visual interpretation of the corresponding histograms were evaluated and compared with size of the tumors, serum alpha-fetoprotein values, hepatic functional staging, and patient survival. Sixty-eight cases were aneuploid and 16 euploid (9 diploid and 7 polyploid). Four of the eight cytologically suspect cases were aneuploid. Statistical analysis showed an association between size and cytologic grading, 5c exceeding rate and cytologic grading, and between aneuploidy and multiple tumors; in a Cox multivariate DNA content analysis, aneuploidy and multiple tumors were the two prognostically significant variables. DNA ploidy evaluation by static cytometry of hepatic tumors may be useful in the diagnosis on cytologic samples and could represent an independent prognostic parameter in predicting the survival outcome of patients with hepatocellular carcinoma.

Beta- and gamma-catenin expression in thyroid carcinomas.

Cadherins are calcium-dependent cell-cell adhesion molecules whose intracellular domain forms a complex with proteins required for their function, called catenins. Down-regulation of cadherins has frequently been detected in many types of human carcinomas, being associated with tumour progression. The present study investigates the immunohistochemical expression of E-cadherin and beta- and gamma-catenin in 27 human thyroid carcinomas. E-cadherin immunoreactivity was found to be decreased at cell-cell contacts in 8/15 (53 per cent) papillary, 5/7 (71 per cent) follicular, and 5/5 (100 per cent) anaplastic carcinomas. Beta-catenin membrane localization was found to be decreased in 6/15 (40 per cent) papillary, 2/7 (28 per cent) follicular, and 5/5 (100 per cent) anaplastic carcinomas. Gamma-catenin expression was partially or totally lost in 13/15 (86 per cent) papillary, 6/7 (85 per cent) follicular, and 5/5 (100 per cent) anaplastic carcinomas. A normal pattern of expression for these three molecules was observed in areas of normal tissue in each sample. These data indicate that in addition to E-cadherin, catenins are also down-regulated at cell-cell junctions in thyroid tumours and could represent potentially useful differentiation and/or transformation markers. The high frequency of alterations of gamma-catenin expression found in thyroid carcinomas suggests an important role for this gene product in thyroid carcinogenesis.