A rare case of myeloid sarcoma presenting as anal fissure.

Myeloid sarcoma is a tumor composed of myeloblasts occurring at an extramedullary site. It may develop in patients with acute myeloid leukemia, myeloproliferative or myelodysplastic syndrome, sometimes preceding onset of the systemic disease. Frequent sites of myeloid sarcoma are bones or various soft tissues. Gastrointestinal involvement is very rare. We report a unique case of myeloid sarcoma presenting as a painful anal fissure, in a patient with a history of acute myeloid leukemia. The diagnosis was achieved by a surgical excisional biopsy and immunoistochemical staining.

Oral lesion as unusual first manifestation of multiple myeloma: case reports and review of the literature.

Extramedullary plasmacytoma (EMP) and solitary bone plasmacytoma (SBP) represent a disease continuum through a multistage process of cell differentiation, survival, proliferation, and dissemination, strictly related to multiple myeloma (MM), the second most common hematological malignancy. Herein, we report two cases of recurrent oral plasmacytoma progressed to MM, in which the first clinical sign of a more widespread disease was limited to the mouth. Based on our experience, we recommend a strict workup for the differential diagnosis between EMP, SBP, and MM for patients with oral plasmacytoma, including radiological exam of the skeleton, magnetic resonance imaging (MRI) of the bone, and positive emission tomography (FDG-PET). MRI and possibly PET can all be used to more sensitively detect EM plasmacytoma sites.

HER2 status in advanced gastric carcinoma: A retrospective multicentric analysis from Sicily.

According to the ToGA trial, HER2 has been shown to be predictive for the success of treatment with trastuzumab in advanced gastric cancer (AGC). A number of studies have analyzed HER-2/neu overexpression in gastric carcinoma and identified the rate of HER2 positivity to be markedly varied. To date, the prevalence of HER2 overexpression in Sicilian people with AGC is unknown. Therefore, in the present study, a retrospective immunohistochemical analysis of HER2 was performed in a cohort of 304 AGC samples that were obtained from the archives of 10 Sicilian anatomopathological diagnostic units in order to verify the positive rate of HER2-positive cases. Furthermore, the characteristics of histotype, grade, stage and Ki-67 expression were also analyzed. HER2 overexpression was encountered in 17.43% of all the gastric adenocarcinomas, which was consistent with the results that have been reported elsewhere in the literature. A progressive increase in HER2 overexpression was observed, from the poorly cohesive histotype to the tubular adenocarcinomas and gastric hepatoid adenocarcinomas. HER2 overexpression was significantly associated with a high grade, advanced stage and high Ki-67 labeling index. Further investigations performed jointly by pathologists and oncologists within the geographical area of the present study should confirm that the association of trastuzumab with chemotherapy results in an improvement of survival in patients with AGC.

Morphological and biomolecular characteristics of subcentimetric invasive breast carcinomas in Sicily: A multicentre retrospective study in relation to trastuzumab treatment.

Little information from clinical trials is available regarding the efficacy of trastuzumab treatment in subcentimetric breast carcinomas (BCs). The aim of this study was to verify the existence of correlations between HER2 and hormone receptor status, Ki67 values, grade, histotype and node involvement in a cohort of pT1a,b BCs from an area not widely covered by screening campaigns. A total of 410 pT1a,b BC formalin-fixed paraffin-embedded samples collected from eight Sicilian Anatomo-Pathological Units (APUs) were classified according to the WHO classification and tumour grading was established. Estrogen and progesterone receptor status, Ki67 labelling index and HER2 status were available. Relationships between immunohistochemical data and clinicopathological characteristics were investigated using the Chi-square test; the cohort was analysed with respect to pT1a and pT1b BC as well as to node status. Ductal infiltrating carcinoma was the prevalent histotype in the pT1a and pT1b stages; G2 was a more common tumour grade, with a range between 64.6% and 70% of pT1a and pT1b, respectively. Taking into consideration the lymph node involvement of pT1a,b BC, only 17.1% cases were node-positive without a relevant difference between pT1a and pT1b. No significant differences between pT1a and pT1b BC cases emerged in relation to Ki67 LI, hormone receptors and HER2 status. T1a,b BC cases were stratified by node involvement and a significant relationship was observed with grade as well as with HER2 status. A significant relationship for pT1a cases emerged only for tumour grade, while pT1b cases showed a significant correlation exclusively with HER2 status. Our data clearly support the operative guidelines of the National Comprehensive Cancer Network. Therefore, the combined treatment with trastuzumab plus chemotherapy should be administered only to patients with pT1b or larger BCs. In small HER2-positive pT1a or microinvasive BC, this therapy should be considered on a case-by-case basis, considering tumour grade as the first characteristic.

The diagnosis of pulmonary embolism.

The diagnosis of pulmonary embolism is challenging, and autoptic series have demonstrated that a high percentage of cases are not recognized ante-mortem. A number of predisposing factors, symptoms and signs associated with pulmonary embolism have been recognized, and should be used to raise the suspicion of the disease. These include immobilization, recent surgery, active cancer, previous thromboembolism, syncope, dyspnoea, chest pain, haemoptysis, signs of deep vein thrombosis, hypocarbic hypoxemia. Once pulmonary embolism is suspected, the clinical probability of the disease should be assessed; to this end, three clinical rules have been proposed and validated (the revised Geneva score, the Wells score and the PISA-PED score) while others await clinical validation. In case of low clinical probability, a negative a D-dimer test is sufficient to rule out the diagnosis, while if the clinical probability is high, or the D-dimer test is positive, further tests are necessary. Computer tomography angiography or perfusion lung scan are the imaging tests of choice, depending on local availability and experience. If the clinical probability and the results of the imaging test are concordant, a definitive diagnosis can be obtained; if the results are discordant, further testing is necessary. In particular, in the specific case of a small clot (i.e. segmental or subsegmental) incidentally recognized at a computer tomography obtained for other reasons in a patient without a clinical suspicion of pulmonary embolism, an occurrence whose frequency is rapidly increasing in clinical practice, a final diagnosis cannot be made without further confirmatory testing.

[Our experience in the surgical treatment of mesenchymal gastric tumors]. / La nostra esperienza nel trattamento chirurgico dei tumori mesenchimali dello stomaco.

A retrospective review on 22 patients with gastric mesenchymal tumors, who underwent surgical treatment in the period 1974-2003, is presented. The aim of the study was to review our cases in the light of the new pathologic and immunohistochemical definitions and to analyse the value of clinical signs, diagnostic methods and principles of surgical technique. The Authors conclude that no specific clinical signs have been detected. Endoscopy plays a very important diagnostic role and CT-scan is the most sensible technique in the evaluation of location, size, invasion of adjacent organs and metastasis. The aim of treatment must be the complete resection of the tumor and the prognostic prediction on the basis of histologic findings is quite difficult.

Immunolocalization of vimentin and alpha-smooth muscle actin in dysfunctional human temporomandibular joint disc samples.

The expression of vimentin and alpha-smooth muscle (alpha-SM) actin was examined in 10 human temporomandibular joint (TMJ) disc samples, with internal derangement and in two control specimens, in order to evaluate the phenotypic characteristics of TMJ disc cells in relationship to histological findings. This was accomplished by means of monoclonal antibodies specific for vimentin and alpha-SM actin and immunocytochemical technique. The study, revealed that every disc cell constantly expressed vimentin. Scattered alpha-SM actin positive cells could be appreciated in normal TMJ discs and tissues with minor pathological findings. In TMJ discs with severe alterations, i.e. tears and clefts, almost fibroblast-like cells, fibrochondrocytes and chondrocyte-like cells were strongly immunolabelled by anti-alpha-SM actin antibody. According to these findings it can be assumed that vimentin is expressed by all disc cell populations and it appears not to be influenced by any disease condition of the disc; on the other hand the up-regulation alpha-SM actin immunolabelling seems to be correlated to histopathological findings of tears and clefts. Cells, with a contractile phenotype, close to such defects, could be involved in disc tissue contraction and repair. The plasticity of disc cell populations which evolve towards a different phenotype when subjected to action of macro- and micro-environmental factors is also supported.

Histochemical study of the elastic fibers in pathologic human temporomandibular joint discs.

PURPOSE: This study investigated histochemically the elastic fibers in human temporomandibular joint (TMJ) discs with varying degrees of tissue degeneration/regeneration to determine whether there are differences that correlate with the histologic findings. MATERIALS AND METHODS: Ten diseased human TMJ discs and 2 control specimens were studied histochemically by staining with Weigert's resorcin-fuchsin after oxidation with peracetic acid. This technique selectively stains elastic, elaunin, (pre-elastic), and oxytalan fibers. RESULTS: In TMJ discs with an abnormal collagen fiber arrangement, an increased number of oxytalan fibers could be observed, contrary to discs with scar-like tissue transformation in which oxytalan fibers were decreased in number. In discs showing tears and clefts, the oxytalan fibers run perpendicular to the defects, whereas elaunin and elastic fibers were mainly circumferentially arranged. In discs with chondroid metaplasia, elastic, elaunin, and oxytalan fibers were extensively detected. CONCLUSIONS: It is hypothesized that the elastic, elaunin, and oxytalan fibers found in severely damaged discs appear to ensure biomechanical compliance by reinforcing regions devoid of collagen bundles and thus function as shock absorbers of stretch and compression.

Hodgkin's disease as a second malignant neoplasm in childhood: report of a case and review of the literature.

There is a known association between lymphoid malignancy and Hodgkin's disease (HD), but the development of HD in children who have been treated for leukemia or lymphoma is very uncommon. Hodgkin's disease is, after retinoblastoma, the most common primary tumor that is associated with development of second malignant neoplasm. For reasons that remain to be determined, HD is very rare as a second malignancy [1, 2, 3]. We report the case of a eight-year-old girl who developed HD 6 years after treatment for common acute lymphoblastic leukemia (ALL). This case prompted us to review the published literature for cases of secondary HD in childhood. Our experience suggests that we should follow strictly our patients with ALL and be ready to intervene with invasive diagnostic procedures at the least suspicion of a second or recurrent neoplasm. The most frequent causes of second tumors are radiotherapy, genetic susceptibility and prior treatment with certain chemotherapeutic agents, such as nitrogen mustards. It is likely that any type of immunodeficiency, even without symptoms, might play a role in the development of second tumors in childhood.

Heat shock protein 27 expression in the epithelium of periapical lesions.

Heat shock protein (HSP) 27 is a member of the small HSP family that plays a part in the regulation of epithelial cell growth and differentiation, wound healing, apoptosis and cell protection against inflammatory cytotoxicity mediators. Thus the expression of HSP27 was investigated immunohistochemically in periapical granulomas with epithelial rests of Malassez and in radicular cysts. Anti-HSP27 mouse monoclonal antibody and peroxidase-labeled streptavidin-biotin standard technique were used to study the expression of HSP27. Proliferating epithelial cell rests, and islands of epithelium and epithelial lining of microcysts strongly reacted throughout all layers, whereas radicular cysts epithelial lining presented mainly a moderate suprabasal staining pattern. However both the proliferating epithelial cell rests and the radicular cysts shared an over-expression of HSP27 immunostaining intensity in coincidence with the presence of local infiltration of immune cells. HSP27 may play several roles in periapical lesions that include contributing to the migration of epithelial cell rests and an increased resistance both to necrotic and apoptotic cell deaths.

Late sequelae of pontine lesions by acute uncal herniation.

The authors report the late macro- and microscopic aspects of the brainstem lesions found in two patients who survived an acute uncal herniation, respectively, 176 and 62 days. They also describe the evolution of the clinical picture characterized by the complete disappearance of initially present neurological signs but by a persistent comatose state.

Thymic carcinoma, systemic lupus erythematosus, and hypertrophic pulmonary osteoarthropathy in an 11-year-old boy: a novel association.

Thymic carcinoma is exceptionally rare in children and it has never previously been associated with autoimmune disorders. The authors report the case of an 11-year-old boy with thymic carcinoma, hypertrophic pulmonary osteoarthropathy, and an autoimmune disease that resembled systemic lupus erythematosus. To their knowledge, this is the first case of such complex clinical findings. The tumor was of high grade histologically and the boy died after 1 year, in spite of chemotherapy and radiotherapy. A review is presented of the available medical literature on thymic malignancy in childhood.

CD44 standard form (CD44H) expression and distribution in dysfunctional human temporomandibular joint discs.

The expression pattern of the cell adhesion molecule CD44 standard form (CD44H) in dysfunctional human temporomandibular joint (TMJ) discs was studied immunohistochemically and compared with normal disc pattern in order to evaluate the expression of this adhesion molecule and correlate it to histopathological changes. Immunohistochemistry with anti-CD44H antibodies was performed on paraffin sections of pathological and normal discs. In normal TMJ discs, a moderate immunolabelling with anti-CD44H antibodies was detectable in fibroblastlike cells, in the few fibrochondrocytes and in chondrocytelike cells. In dysfunctional discs, the staining pattern and intensity varied according to the histopathological findings of the specimens. The TMJ discs showing abnormal collagen arrangement or fragmentation of collagen fibres presented overall the same immunolabelling pattern of normal discs. In the discs showing areas of fibrocartilaginous metaplasia, CD44H expression was upregulated in fibrochondrocytes and fibroblastlike cells, especially around the chondroid tissue. Overall, these results suggest that CD44H mediates the binding of some ECM proteins in TMJ disc cells. The up-regulation of CD44H observed in some dysfunctional TMJ discs seems to indicate a prevention of apoptosis in fibroblastlike cells and an important role in phenotypical change of fibrochondrocytes into chondroblastlike cells, enabling the aggregation of chondroid tissue pericellular matrix components.

Cellular S-100 protein immunostaining in human dysfunctional temporomandibular joint discs.

S-100 protein was detected immunohistochemically in diseased human temporomandibular joint discs with different degrees of pathology, and the findings compared with those of normal discs. In normal discs, large nerve trunks in the posterior ligament were strongly stained by anti-S-100 antiserum; the very few chondrocyte-like cells sometimes showed faint staining, while no staining was observed in any fibrochondrocyte-like or fibroblast-like cell. In dysfunctional discs, S-100 protein immunostaining seemed to correlate with structural pathological findings. The discs showing an abnormal collagen arrangement or fragmentation of collagen fibres presented overall the same immunolabelling pattern as normal discs. In discs with fibrocartilaginous metaplasia and dystrophic cartilage formation, fibrochondrocyte cells showed a very strong immunoreaction for S-100 protein and fibroblast-like cells in some instances were also positive. These findings suggest that S-100 upregulation in disc cells can be considered an attempt at tissue repair by chondroid metaplasia following an injury in that it enables fibroblast-like cells and fibrochondrocytes to acquire a chondrogenic phenotype.

Distribution of extracellular matrix glycoproteins in the human mesonephros.

We analyzed the expression and distribution of collagen types IV and VI, laminin and fibronectin during the development and regression of the mesonephros in human embryos and fetuses ranging from 6 to 12 weeks of gestation by indirect immunoperoxidase methods. Type IV collagen, laminin and fibronectin were detected along the glomerular, tubular and capsular basement membranes of developing and mature nephrons. Only type IV collagen and fibronectin were found in the mesangium. Type VI collagen formed a delicate interstitial fibrillar network and a continuous basement membrane-like structure along the mesonephric nephrons. Basement membranes (GBM) of developing and mature glomeruli showed a distinct continuous staining for this collagen. The mesangial matrix was rich in type VI collagen. Mesonephric involution started during the 8th week of gestation and coincided with a moderate expansion of mesangial matrix and progressive collapse of the capillary walls, while the tubules became thinner and shorter. Staining for all extracellular matrix glycoproteins studied showed GBM wrinkling, gradual disintegration of some capillary loops and glomerulosclerosis. The sclerotic glomeruli were strongly positive for type IV collagen and less positive for type VI collagen and fibronectin. Laminin was absent. Our results indicate that collagen types IV, VI, laminin and fibronectin may be involved in the development and regression of the human mesonephros.

Effects of GABAergic drugs on ethanol-induced gastric lesions.

Different classes of GABAergic drugs--baclofen, GABA, muscimol, Na-valproate, Mg-valproate and diazepam--were tested per os on ethanol-induced gastric lesions in rats. The GABAB agonist baclofen failed to affect gastric susceptibility to ethanol damage, while all the other compounds exerted a dose-dependent inhibition on haemorrhagic-necrotic lesions. This effect was not significantly reversed by the specific GABAA antagonist bicuculline, suggesting it to be independent from GABAA receptors. The blockade of prostaglandin synthesis by indomethacin significantly decreased the gastroprotective action of GABA, Na- and Mg-valproate, but did not antagonize the effect of muscimol and diazepam. Gastric juice volume and pH showed remarkable differences between the various treatments.