Eosinophilic fasciitis: unraveling the clinical tapestry of a rare case and review of literature.

Eosinophilic fasciitis (EF) remains a diagnostic challenge due to its rarity and resemblance to scleroderma. This case report aims to provide a cohesive exploration of EF's clinical nuances, emphasizing the importance of accurate diagnosis and effective management. A 52-year-old male developed bilateral forearm and calf hardening, along with erythema, pruritus, and pain four months prior to the presentation in our Clinic. The symptoms initially debuted bilaterally in the forearms and progressed to involve the calves, distal arms, and thighs. Clinical examination revealed symmetrical plaques on forearms and calves, featuring erythematous, hyper, and hypopigmented elements extending proximally, a positive "groove sign" and a moderate difficulty in knee joint flexion. Despite these findings, the patient was generally in good condition, without any other notable clinical signs. Initial laboratory findings showed slightly increased percentual eosinophil levels, elevated C-reactive protein (CRP), normal erythrocyte sedimentation rate (ESR), and negative antinuclear and scleroderma specific antibodies. Magnetic resonance imaging (MRI) demonstrated enhanced fascial signal and thickening while the fascia-muscle biopsy revealed marked edema and inflammatory lymphoplasmacytic infiltrate, consistent with the diagnosis of EF. The patient showed a favorable response to systemic corticosteroids. EF predominantly affects males aged 30 to 60 and is characterized by a sudden onset and unclear etiological factors. Differential diagnosis requires careful exclusion of scleroderma and other mimicking conditions. Diagnostic modalities such as skin-muscle biopsy and MRI reveal characteristic findings like inflammatory infiltrate and fascial thickening. Accurate diagnosis and differentiation from scleroderma are crucial, with early intervention involving glucocorticoids and immunosuppressive agents improving long-term outcomes.

Successfully physical therapy program for functional respiratory rehabilitation after lung transplant surgery - case report.

The first lung transplant (LT) was made in Romania in 2018 at a 36-year-old male patient with chronic obstructive pulmonary disease (COPD). The study follows the first LT rehabilitation by describing the physical therapy program (PTP), the measurements of body mass and appendicular skeletal muscle mass (ASM) by bio-impedancemetry analysis (BIA) and the functional capacity assessment realized by the six-minute walk test (6MWT) and by the functional respiratory tests (FRTs) in order to evaluate the effectiveness of functional respiratory rehabilitation in this case during a period of one year. In parallel, repeated transbronchial biopsies were performed after six weeks, three months, six months and one year since the transplant. Only the first biopsies showed injuries suggesting an acute rejection, all the rest revealing mild, unspecific lesions. The patient followed 15 sessions of respiratory exercises, joints mobilizations and progressive global muscle strength started one month after LT surgery and was also instructed to perform the exercises at home, using a tablet given at discharge and under monthly guidance through telemedicine. All the measurements were performed before and after the rehabilitation cure, and it was repeated at three different evaluations for one year. The results showed that at the end of follow-up, the 6MWT was significantly increased from 59% of predicted distance at the intake in post-acute hospitalization to 166% at one year after LT, without desaturation that represent a very good evolution; the FRTs increased to normal, and the body weight increased with 18 kg (from severe underweight to normal weight) with constant increasement of skeletal muscle mass. The use of PTP after LT surgery significantly improves functional capacity and increases body mass and skeletal muscle mass.

MMP1, MMP9, MMP11 and MMP13 in melanoma and its metastasis - key points in understanding the mechanisms and celerity of tumor dissemination.

BACKGROUND: Matrix metalloproteinase (MMP)1, MMP9, MMP11, and MMP13 are overexpressed in malignant melanoma (MM), being associated with tumor invasive phase, metastases, and more aggressive neoplastic phenotypes. AIM: The main objective of the current study was to correlate the expression of the MMPs with the evolution of MM toward distant metastasis. PATIENTS, MATERIALS AND METHODS: We designed a retrospective cohort study, including 13 patients with metastatic MM. Data concerning age, sex, localization of the primary lesion and metastasis, and histological and immunohistochemical features (intensity of expression and percent of positive cells for MMPs) were statistically processed. RESULTS: The time between the diagnosis of primitive melanoma and the diagnosis of metastasis ranged between 0 and 73 months, with a mean value of 18.3 months. The metastases rich in MMP1- and MMP9-positive cells occurred earlier than the metastases with low levels of positive cells. The mean period until metastasis was shorter for the MMP1-expressing tumors than the ones without MMP1 expression. MMP13 expression in the tumor and its metastasis was significantly linked with the time until the metastasis occurrence. CONCLUSIONS: This study emphasizes the roles of MMP1, MMP9, and MMP13 in the process of metastasis in melanoma and the opportunity to use them as therapeutic targets and surveillance molecules.

Role of immunohistochemistry in the diagnosis and staging of cutaneous squamous-cell carcinomas (Review).

Non-melanoma skin cancer (NMSC) is the most common type of neoplasm affecting Caucasian individuals, with squamous-cell carcinoma (cSCC) being the second most common type of NMSC after basal-cell carcinoma. The immunohistochemical study of cSCC is of particular importance, especially for the diagnosis of its rare forms, for which accurate and early diagnosis is crucial for survival. In the present review of the literature, the potentially significant value of immunohistochemical markers were highlighted to more accurately assess the biological behaviour, the prognosis of cSCC and to optimize case management. The immunohistochemical markers were classified from a pathophysiological point of view in order to present the mechanism by which carcinogenesis occurs with its subsequent evolution and therefore, to develop a more accurate novel risk staging criteria for this type of neoplasm.

MLH1, BRAF and p53 - searching for significant markers to predict evolution towards adenocarcinoma in colonic sessile serrated lesions.

BACKGROUND AND AIM: Colonic serrated lesions are premalignant lesions, using an alternative malignization pathway, including multiple genetic and epigenetic alterations, as: mismatch repair deficiency due to MutL homolog 1 (MLH1) promoter methylation, tumor protein p53 (TP53) mutations, activating mutations of v-Raf murine sarcoma viral oncogene homolog B (BRAF) and Kirsten rat sarcoma viral oncogene homolog (KRAS). Our study aims to evaluate MLH1, BRAF and p53 immunohistochemical (IHC) status in sessile serrated lesions (SSLs), with and without dysplasia. MATERIALS AND METHODS: This is a retrospective case-control study including 20 SSLs with dysplasia and 20 SSLs without dysplasia (matching sex and age). IHC expression of MLH1, BRAF and p53 was evaluated as the percent of nuclear loss of MLH1, cytoplasmic positivity of BRAF and nuclear positivity of p53. Data concerning age, sex, localization of the lesion, dysplasia and IHC results were statistically processed using Microsoft Excel. RESULTS: We had very polymorphous patterns of IHC expression for BRAF, MLH1 and p53, especially in the dysplastic group. Thus, two patients were BRAF+∕MLH1-∕p53+, three were BRAF+∕MLH1-∕p53-, one was BRAF+∕MLH1+∕p53- and six were BRAF+∕MLH1+∕p53+. Dysplastic lesions without BRAF mutation exhibited the following phenotype: one case BRAF-∕MLH1-∕p53+, four BRAF-∕MLH1-∕p53- and three BRAF-∕MLH1+∕p53+. In the control group (SSLs without dysplasia), there was a more homogenous distribution of cases: eight cases BRAF+∕MLH1+∕p53-, seven BRAF-∕MLH1+∕p53-, one BRAF-∕MLH1-∕p53+, two BRAF-∕MLH1-∕p53- and two BRAF-∕MLH1+∕p53+. CONCLUSIONS: There are more routes on the serrated pathway, with different mutations and time of acquisition of each genetic or epigenetic lesion with the same morphological result. These lesions should be stratified according to their risk to poor outcome and their need to further surveillance.

The differential diagnosis of ulcerative colitis versus angiodysplasia of the colon with ischemic colitis.

Ulcerative colitis and Crohn's disease are the inflammatory bowel diseases with a continuously increasing of prevalence. Their exact causes are still not well known and, more than that, they are raising up serious issues of diagnosis. The same difficulties of diagnosis are encountered in the case of the colonic angiodysplasia or ischemic colitis (IC). Colonic angiodysplasia is a common vascular abnormality of the gastrointestinal tract, being diagnosed mostly in the elderly persons, in a similar manner to the IC. For all these diseases comorbidities plays their important role both as causes of the onset and aggravating factors during the evolution. The differential diagnosis between these three conditions needs a complex and multidisciplinary approach, involving at least clinical evaluation, endoscopic and imaging assessments, and histopathological exam.

E-cadherin and aquaporin 1 co-expression analysis in hepatocellular carcinoma: a pilot study.

Hepatocellular carcinoma (HCC) is the main primary liver malignancy, being associated with both health and economic burden worldwide. Recently, novel molecular markers and possible therapeutic targets were identified. Different adhesion molecules, as well as possible angiogenesis-associated targets can be prime candidates when investigating novel therapies. Considering these premises, our goal was to study the co-existence of E-cadherin and aquaporin 1 (AQP1) in a series of HCC diagnosed patients. Utilizing archived tissue fragments from 17 patients diagnosed with well-to-moderate and poorly differentiated HCC, as well as four samples of normal liver tissue and using a highly specific biotin-free tyramide amplification technique, we have assessed here the expression of E-cadherin and AQP1 during HCC carcinogenesis. Moreover, as we have observed that some of the AQP1 expression seems membrane-bound, we have sought to evaluate their co-localization. Our data showed, as expected, that E-cadherin decreases from control tissue to low-grade and respectively, high-grade HCC. AQP1 was expressed, also as already known, at the level of endothelial blood vessels and bile ducts epithelia, however, we have showed here for the first time that this water pore is also expressed in the cytoplasm and membranes of hepatocytes, both in control and HCC tissue. Moreover, AQP1 expression parallels the decrease of E-cadherin expression during carcinogenesis, but together with this downregulation, we have also found a spatial decrease in the colocalization of the two proteins. Altogether, utilizing a biotin-free tyramide signal amplification technique, this study shows for the first time that AQP1 is expressed at the level of liver epithelia, in both control and HCC tissue.

Efficacy of methotrexate as anti-inflammatory and anti-proliferative drug in dermatology: Three case reports.

Methotrexate (MTX) is a folic acid analog with anti-proliferative (anti-neoplastic, cytotoxic), immunosuppressive and anti-inflammatory properties, which has been used in the treatment of various cutaneous disorders, such as psoriasis, keratoacanthoma, pityriasis rubra pilaris, atopic dermatitis, mycosis fungoides, bullous skin diseases, systemic sclerosis, morphea, lupus erythematosus, dermatomyositis and crusted scabies. Inhibition of cell proliferation is explained through its role in blocking DNA/RNA synthesis, by inhibiting dihydrofolate reductase, necessary for the production of pyrimidine and purine nucleotides. An anticancer effect can be related to α-oxoaldehyde metabolism (MTX increases methylglyoxal levels). Its anti-inflammatory property is based on the inhibition of 5-aminoimidazole-4-carboxamide ribonucleotide transformylase, thus increasing intracellular and extracellular adenosine, a purine nucleoside with anti-inflammatory effect. This drug can limit inflammation by scavenging free radicals and decreasing malondialdehyde-acetaldehyde protein-adduct production. Moreover, the anti-proliferative and anti-inflammatory effects can also be related to inhibition of the DNA methylation pathway, thus inhibiting methionine formation. The aim of the present study was to report various dermatological cases from our daily practice that demonstrate the efficacy of MTX in the treatment of cutaneous diseases, highlighting different mechanisms of action: its anti-inflammatory effect in psoriasis and its anti-proliferative, and anti-neoplastic effect in well-differentiated squamous cell carcinoma or in keratoacanthoma. Moreover, different administration pathways and doses are addressed. Assessment of the treatment plan, clinical improvement of cutaneous lesions, biologic evaluation, final aesthetic result, quality of life, as well as potential adverse effects and drug tolerance related to each case mentioned.

Tumor infiltrating lymphocytes: The regulator of melanoma evolution.

Melanoma is the most severe type of skin cancer and its incidence has increased in the last decades. In the United States, it is the 6th most common cancer in both men and women. Prognosis for patients with melanoma depends on the stage of the disease at the time of diagnosis and it can be influenced by the immunologic response. Melanoma has been historically considered an immunogenic malignancy. It often contains great amount of immune cells (different subsets of T-cells, dendritic cells, macrophages, neutrophils, mast cells, B lymphocytes), which may reflect a continuous intercommunication between host and tumor. It is not established if tumor-infiltrating lymphocytes (TILs) are induced by tumor cells or by other components of the microenvironment or when they are a host direct immunologic reaction. It has been observed that in many cases, the presence of a dense TIL is associated with good prognosis. The pattern and activation state of the cells which constitute TIL is variable and modulates the clinical outcome. An important step in the understanding of tumor immunobiology is the analysis of the populations and subsets of immune cells that form TIL. Besides its prognostic significance, after approval of cytotoxic T lymphocyte antigen 4, programmed cell death-1 and programmed death-1 ligand antibodies for the treatment of melanoma, the assessment of immune infiltrate composition has become even more captivating, as it could provide new target molecules and new biomarkers for predicting the effect of the treatment and disease outcome in patients treated with immunotherapy. In this review we discuss current state of knowledge in the field of immune cells that infiltrate melanoma, resuming the potential of TIL components to become prognostic markers for natural evolution, for response to drugs or valuable targets for new medication.

Matrix metalloproteinases expression in lentigo maligna∕lentigo maligna melanoma - a review of the literature and personal experience.

Cutaneous melanoma is the most aggressive type of skin cancer, with high invasive potential. Lentigo maligna melanoma (LMM) is a relatively rare type, accounting for about 10% of all melanomas, while the most common subtype of melanoma on the face, typically on chronically sun-exposed skin of elderly people. Its in situ stage is lentigo maligna (LM). During the process of transformation from LM to LMM, tumor cells secrete or induce the release from neighboring cells of large amounts of matrix metalloproteinases (MMPs) that degrade the extracellular matrix. Some MMPs, as MMP3 and MMP9 expressed melanoma cells is associated with statistical significance in both in vitro and in vivo studies, with an invasive phenotype. Unfortunately, there is scarce data published about MMPs expression in LM∕LMM, as majority of research on melanoma refer to superficial spreading and nodular melanoma. Our personal, unpublished yet fully data is an attempt to complete a specific panel of immunohistochemical markers that could explain the slow growing rate of LMM.

Novel perspectives on gastrointestinal stromal tumors (GISTs).

Since they were described, gastrointestinal stromal tumors (GISTs) are, for pathologists and not only for them, a subject of controversy regarding histological origin, differentiation, nomenclature, malignant potential and prognosis. Before 1998, there were no certainties that GISTs were fundamentally different from other types of abdominal cancers in the big family of mesenchymal tumors. Before the discovery of KIT gene mutations, GISTs were most often classified as leiomyoma, leiomyosarcoma, leiomyoblastoma, and gastrointestinal autonomic nerve tumor. When a tumor is discovered, the first data obtained are initially assessed by one or more imaging tests, such as an ultrasound, computed tomography scan or magnetic resonance imaging. The imaging results define the size of the lesion and its anatomic location, which in the case of GIST is usually within the wall of the stomach or intestine. Depending on the experience of the medical team - radiologist, gastroenterologist or surgeon - reviewing the imagistic tests and correlating them with the general patient profile, the differential diagnostic is reduced and GIST may become the main suspect.

Unusual triple combination of prostate, lung and skin cancer.

Multiple malignancies are an increasing combination in the recent years in cancer patients, due to prolonged survival rate and to the advances in diagnostic techniques and therapeutic management. We present the case of a patient diagnosed with prostate cancer and metachronous in one year with basal cell carcinoma of the skin and small lung cell carcinoma with lymph nodes and pararectal metastasis. To our best knowledge, this is the only case presented in the medical literature with these three different types of primary malignancy. In conclusion, multiple malignancies in the same patients are a real challenge to the physician, because an early diagnosis and specific treatment modalities are essential for successful patient management and increasing life expectancy.

Sinonasal non-Hodgkin's malignant lymphoma - review of a clinical case.

Malignant lymphomas represent one of the most important problems of modern medicine, with a constant increase in the last decades, becoming the most frequent tumor among young people. Sinonasal localization is a particular site of malignant lymphomas, representing the second most frequent among ear, nose and throat (ENT) tumors. In this paper, authors present the clinical, diagnostic and therapeutic aspects of a malignant sinonasal lymphoma, which despite an aggressive histological subtype and important regional extension had a favorable clinical outcome. The patient presented to the ENT specialist with an important deformity of the nasal pyramid developed in the last two months. The anatomopathological exam and immunohistochemical analysis were conclusive for non-Hodgkin's lymphoma. The therapeutic course was cytostatic chemotherapy (in spite of the surgical approach) with beneficial oncological outcomes, which determined complete remission of the tumor. Computed tomography (CT) scan revealed a nasoethmoidal tumor with destruction of the nasal pyramid.

Vascular endothelial growth factor - key mediator of angiogenesis and promising therapeutical target in ulcerative colitis.

Ulcerative colitis (UC) is an inflammatory bowel disease, triggered by an inappropriate immune response of colonic mucosa. Angiogenesis is an important part of inflammatory process, enhancing inflammation in a vicious circle that aggravates mucosal damage and remodeling. The most important pathway for angiogenesis in ulcerative colitis involves vascular endothelial growth factor (VEGF) and endoglin (CD105) and can be used as target for adjuvant therapy in order to improve patients' outcome. We present a retrospective cohort study evaluating mucosal expression of VEGF and CD105 and their correlation with patients' evolution and risk of relapse. In our study, patients with UC have correlated increases of VEGF expression and microvessel density (evaluated with CD105 staining), sustaining the hypothesis that angiogenesis is not just a passive process driven by inflammation, but an active player of mucosal lesions in ulcerative colitis.

Malignant melanoma of the left nasal fossa - case report.

Mucosal malignant melanoma is an extremely rare tumor of the nose, with an aggressive character, low prognosis and frequent recurrences. The authors present a case of a 60-year-old male patient, diagnosed five years ago with adenoid cystic carcinoma, for which he had surgery and radiotherapy, who was admitted in our Clinic with unilateral epistaxis and obstruction of the nasal cavity. Clinical exam revealed an obstructive polypoidal bleeding mass of the left nasal cavity. Biopsy was performed and the histopathological exam showed malignant mucosal melanoma. Wide local endoscopic surgery was practiced for two times in the last two years, and for now, there is no recurrence. Malignant melanomas are tumors with high mortality rate, which necessitate an early diagnosis and immediate treatment.

Histological assessment of fracture healing after reduction of the rat femur using two different osteosynthesis methods.

Osteosynthesis using Kirschner (K) wires and plates with screws were compared on the same subject in a previous experimental protocol, but none of them led to fracture healing. We designed a new murine study in order to compare this two methods on different subjects in order to obtain histological proofs of which one is better and to see how limited periosteum removal influence fracture healing. Divided in two equal groups, femoral osteotomies were performed on 30 Brown Norway rats, then reduced using plates and screws in the OPS (osteosynthesis using plates and screws) group and using K-wires in the OIKW (osteosynthesis using Kirschner wire) group. The animals underwent clinical, radiological and histological assessment for eight weeks. The quality of the fracture healing was associated with a higher number of osteocytes/microscopic field at eight weeks. The difference between the groups regarding the number of osteocytes inside lacuna was statistically significant (t-test for equal variances not assumed, p=0.001), which confirms a mean difference of 32 cells÷microscopic field (mf) with a 95% confidence interval of 15-50 cells÷mf. In conclusion, limited periosteum removal did not influence negatively fracture healing. Therefore, we considered that osteosynthesis using plates and screws led to better results compared to fracture fixation using K-wires.

Correlations Between the Density of Tryptase Positive Mast Cells (DMCT) and that of New Blood Vessels (CD105+) in Patients with Gastric Cancer.

Mast cells proteases, tryptase and chymase are directly involved in the growth and progression of solid tumors due to their important role in tumor angiogenesis. We examined the density of tryptase positive mast cells and the mean density of new blood vessels in gastric malignant tumors of patients with and without Helicobacter pylori infection, using immunohistochemical staining for tryptase (for mast cells) and CD 105 (for new vessels). Tryptase and CD 105 expression was detected in gastrectomy specimens. In this study, mast cell density correlates with angiogenesis and the growth and progression of gastric cancer. It also shows that the participation of Helicobacter pylori infection in the growth and progress of gastric neoplasia is due to an increase of peritumoral angiogenesis, with subsequent local and distant tumor spread and perivascular growth, but without perineural and nodal involvement.

A rare case of concomitant tuberculosis of the nose, paranasal sinuses and larynx: clinical, histological and immunohistochemical aspects. A case report.

Extrapulmonary tuberculosis is a rare condition determined by Mycobacterium tuberculosis. It can affect any organ, and has a higher incidence with the increase of HIV infection, or in countries with high pulmonary tuberculosis. Diagnosis is difficult, mostly because of non-specific symptoms and a low rate of presentation for medical consult when symptoms do occur. Complete diagnosis is usually set by histological, immunohistochemical examinations, and also with Polymerase Chain Reaction (PCR) in selected cases. The authors present a case of concomitant tuberculosis of the nose, paranasal sinuses and subglottic larynx, without primary involvement of the lungs. The diagnosis was imposed by histological examination and immunostaining of probes obtained in surgery. The treatment was surgical debridement followed by specific antituberculosis medication.

Vagus nerve schwannoma in the parapharyngeal space: surgical, histological and immunohistochemical aspects. A case report.

Tumors of the parapharyngeal space are rare accounting approximately for 0.5% of all head and neck tumors. In the retrostyloid space, schwannomas are a more common finding, in contrast to other tumors. Usually, they present with a variety of slight symptoms until they grow in size and compress surrounding organs. Surgical treatment of parapharyngeal space tumors is difficult; due to the anatomical complex area, they develop in, and include several approaches, according to its size and relations. In this paper, we present a case of a 63-year-old female with a vagus nerve schwannoma in the parapharyngeal space. Beside the surgical difficulties, the resected tumor had a peculiar histopathological aspect (large areas of degeneration and atypia and little typical palisading) that compelled a thorough histological and immunohistochemical evaluation for positive and differential diagnosis.