Morphological variability of the renal artery branching pattern: a brief review and an anatomical study.

The segmental branches of the renal artery vary in number and origin. The 1998, Terminologia Anatomica homologates two branches of the renal artery (anterior, posterior) and five segmental arteries: four from the anterior branch and one from the posterior one. The purpose of this study is to evaluate the renal artery branching pattern, the number and origin of the segmental arteries, as well as to review data from similar studies. The study material consisted of 60 formalin-fixed adult kidneys. Dissections and microdissections were performed on the renal arteries and their branches. The branching of the renal artery was prehilar in 81.67% of cases, hilar in 10% and intra-sinusal in 8.33%. The number branches varied as follows: two branches in 42 cases (70%), three branches in 14 cases (23.33%) and four branches in four cases (6.67%). We subsequently analyzed the origin of the segmental arteries and found that in 53% of the cases the segmental arteries arose independently from the renal artery's branches, while in 47% of the cases they derived from common trunks of type I (85%) or II (15%). Type I trunks are those that originate directly from the main renal artery. They divide either into 2-3 segmental branches, or into just 1-2 branches and a smaller trunk (type II). The type II trunks further divide into 2-3 other segmental branches. These common trunks must be taken into account to avoid confusion with the segmental arteries. Knowledge of these variations is useful not only morphologically, but also clinically.

Atypical variant of lichen planus mimicking normal skin histology.

We present the case of a 69-year-old Caucasian and non-smoker patient with erythematous, itchy, violaceous lesions on the ankles, wrists, lower legs, forearms and trunk developed within 15 months. Her condition was diagnosed as prurigo and she was treated for a long period of time with antihistaminic drugs, with no resolution of lesions. In October 2008, she presented to a Private Practice of Dermatology in Timisoara. The dermatologist noticed the development of violaceous lesions on her trunk. The patient had similar lesions on the ankles, wrists, lower legs, and forearms for the last eight months. At physical examination many hyperpigmented, 1 to 6 cm, thin plaques were present on the flanks, shoulders, and infra-mammary area. There was no vaginal involvement. This eruption had a good response to topical glucocorticoids, but recurred multiple times after discontinuation of treatment. A biopsy specimen showed some histopathological features of lichen planus.

The diagnostic value of EMA expression in the renal parenchyma tumors.

Renal parenchyma tumors are a heterogeneous group of malignancies that are difficult to diagnose and classify. Immunohistochemistry begun to be routinely used for the diagnosis of these tumors. Panels of antibodies are developed for the diagnostic assessment of these tumors, which include cytokeratins, epithelial membrane antigen and vimentin. Epithelial membrane antigen (EMA) is expressed by most of the tumor cell types. Forty-seven specimens of renal parenchyma tumors were studied immunohistochemically for the expression of EMA. In the majority of the cases, clear cells carcinoma was positive for EMA (25/33, 75.70%). All of the papillary carcinomas were positive, with different staining patterns between the two subtypes. The two cases of chromophobe cells carcinomas were intensely positive with a granular cytoplasmic staining pattern. The mixed epithelial-stromal tumor was negative for EMA in both of the components. Out of the three cases of sarcomatoid carcinomas, one was negative, one was weakly positive (+1) and the last was positive (+2). Intensely positive normal tubes were caught by the tumor proliferation in the negative case and in the negative stained areas of the weakly positive case.

The diagnostic value of VEGF expression in the renal parenchyma tumors.

Tumor angiogenesis emerged as an important concept in cancer therapy over two decades ago, and was extensively studied by the discovery of VEGF family members. VEGF, also known as vascular permeability factor, is a generic name for VEGF-A, which is one of the members involved in angiogenesis. VEGF is the most important angiogenic factor, with significant effects on tumor angiogenesis. Tumor expression of VEGF was not the first angiogenesis indicator, but a growing number of studies have demonstrated that VEGF could be a prognostic factor, independent even from microvascular density, which is increased by its expression. Renal parenchyma tumors are a heterogeneous group of malignancies, difficult to classify or monitor, which prompts for the assessment of novel markers useful for the investigation of tumor histogenesis or prognostic assessment. VEGF expression in renal parenchyma tumors is poorly studied, with most of the articles published so far focusing on antiangiogenic usage in renal carcinoma therapy. The aim of this study is to detect the expression pattern of VEGF in renal parenchyma tumors by immunohistochemistry.

Ectopic kidney with malrotation and bilateral multiple arteries diagnosed using CT angiography.

Right renal ectopia with malrotation was seen on a CT angiography in a 64-year-old male patient. Bilateral triple renal arteries were also revealed: one main (superior) renal artery and two accessory arteries (middle and inferior), all originating in the abdominal aorta. The renal arteries are disposed symmetrically. The main arteries and the accessory ones are of equal caliber. Simple renal ectopia is a congenital malformation with an incidence of 1-2 cases in 1000 births; of these, only one of 10 cases is diagnosed. Like our case, many such cases are diagnosed by accident, during investigations of causes that have no connection with renal ectopia. Variations in kidney position and renal vascular variants are very important clinically, for both the complications they may generate and the technical difficulties of certain surgical interventions. CT angiography is a minimally invasive method that allows the identification of malformations or anatomic variations, providing accurate information on position, size and anatomic ratios, which are very useful in diagnosing and treating various affections.

Clinical significance of Her2/neu overexpression in urothelial carcinomas.

HER2/neu is a defective transmembrane tyrosine kinase receptor, homologue to the epidermal growth factor receptor, showing overexpression in a large variety of tumor cells. There are no studies published so far regarding HER2/neu overexpression and sensitivity of the urothelial tumors of the urinary bladder to anti-HER2/neu therapy. There are a relatively high number of articles in the literature referring to HER2/neu expression in urothelial tumors of the urinary bladder, but only two of them had investigated HER2/neu expression in patients with urothelial tumors of the upper urinary tract. We have studied HER2/neu overexpression in 59 patients with urothelial carcinomas of the urinary tract by immunohistochemistry. Normal urothelium and the elements of the neighboring renal parenchyma were negative. Out of the 59 cases of urothelial carcinomas, 38 were negative (0 and +1) and 21 were positive: eight were moderately and 13 were intensely positive (+2 and +3). The percentage of positive cases was 35.59%. The negative cases were mostly well-differentiated, G1 tumors, no matter the T-tumor stage. Most of the cases were diagnosed as papillary or, rarely, infiltrative. There is no correlation between HER2/neu overexpression and the tumor stage. The same was true for the lymph node status. The expression intensity, however, was significantly correlated with the differentiation grade. Overexpression was most likely present in tumors with high differentiation grade (p<0.05).

The diagnostic value of cytokeratins expression in the renal parenchyma tumors.

Renal carcinomas are a heterogeneous group of tumors, difficult to classify and identify precisely. Since their prognosis depends very much upon their type, precise diagnosis might mean the difference between therapeutic success and patient death. Cytokeratins are particularly useful for the identification of the epithelial nature of the tumors, because their expression is maintained even in poorly differentiated tumors. Monoclonal cytokeratins such as CK7 and CK20 stain different components of the renal tubular system and are a useful duo for the identification of the origin of the different tumors that might arise in the kidney. Along with polyclonal cytokeratins such as AE1/AE3 and high molecular weight cytokeratin antibodies (34betaE12, Cam 5.2), epithelial membrane antigen (EMA) and vimentin, they are included in every diagnostic panel for renal tumors. We have selected 138 renal parenchyma tumor specimens, performed morphological diagnosis and then stained them with polyclonal cytokeratin antibody AE1/AE3, and monoclonal antibodies to CK7 and CK20. AE1/AE3 was expressed in 61.7% of the renal parenchyma tumors, with high intensity and percentage of positive cases in the papillary carcinomas (100%), and with rare and weakly positive cells in chromophobic cells carcinomas, clear cells carcinomas and sarcomatous carcinomas. CK7 was positive in 68% of the renal parenchyma tumors, with positive reaction in 100% of the cases of chromophobic cells and sarcomatous carcinomas. Clear cells carcinomas had the less percentage of positive cells, whereas papillary carcinomas were positive in seven out of eight cases. No difference in the staining pattern was noticed between type I and type II papillary carcinomas. CK20 was negative in all cases studied.

The value of the reprocessing method of paraffin-embedded biopsies for transmission electron microscopy.

Transmission electron microscopy (TEM) implies an elaborate preparation protocol that includes: fixation in glutaraldehyde followed by osmium tetraoxide postfixation, specimen dehydration, infiltration, resin embedding, ultrathin sectioning and staining with heavy metal salts. The aim of TEM is to examine the ultrastructure of specimens in ways that cannot be examined using other equipments or techniques. In some cases, when the requirement for TEM were made after tissue collection, useful information can be obtained from reprocessing the formalin-fixed, wax-embedded tissue used for light microscopy.

Myofibroblasts reaction in urothelial carcinomas.

The myofibroblast is a connective tissue cell with intermediate features between the fibroblast and the smooth muscle cell and unknown origin, which normally is present in only a few organs, but with increased incidence in malignancies. The patterns of myofibroblastic reaction may be synchronous, metachronous and mixed. The presence of the myofibroblasts has been demonstrated into the stroma of breast carcinomas, particularly in firm, retracted tumors with no inflammatory infiltrate. The present literature lacks data regarding the presence and the behavior of the myofibroblasts in urothelial carcinomas. Fifty-nine urothelial carcinoma specimens from patients admitted into the Urology Clinic of the Emergency County Hospital of Timisoara between 1999 and 2004 were stained with usual HE stain for the morphological diagnosis and immunohistochemically stained with smooth muscle actin, vimentin, and desmin for the detection of myofibroblasts. In biopsies sampled from normal urinary bladder and in urothelial carcinomas of the superior urinary tract Ta, we have not noticed any cells with myofibroblast morphology or immunophenotype. In Ta tumors, no matter the differentiation grade, we have not noticed myofibroblasts neither between the tumor cells nor at distance. The myofibroblasts were identified in seven of the 26 (26.92%) tumors in T1 stage. In T2 and T3 stage tumors the number of myofibroblasts differs from case to case, being significantly higher in tumors with high differentiation grade, G3.

Analysis of the immunohistochemical expression of mammaglobin A in primary breast carcinoma and lymph node metastasis.

Mammaglobin A is a specific marker of the normal and neoplastic mammary tissue that usually is detected by RT-PCR. Few data are available about the immunohistochemical expression of this marker in mammary carcinoma and about the significance of the positive reaction. Our purpose was to investigate the sensitivity of the mammaglobin expression in breast cancer and to determine its correlations with conventional prognostic parameters. There were investigated 47 patients with breast carcinoma, and slides from paraffin blocks were stained with an antibody against mammaglobin. The immunohistochemical reaction was scored based on the percentage of positive tumor cells in both primary tumors and lymph node metastasis. Positive reaction for mammaglobin was found in the normal mammary tissue adjacent to the tumor in all cases, in 78.72% primary breast carcinoma, and in 58.06% of cases with lymph node metastases. A significant correlation was found between the mammaglobin expression in the primary tumor, grade, and lymph node status, but not with the age of the patient, pathologic subtype of carcinoma and stage of the tumor. The ductal in situ carcinoma associated to the invasive tumor did not influence significantly the prognostic value of mammaglobin expression. Out results suggest that mammaglobin is a sensitive marker of breast carcinoma, it defines a subgroup of patients with better prognosis and is a useful method to detect breast cancer metastases.

Schwannoma of the lip: case report and review of the literature.

Schwannomas of the lip are rare, benign neoplasms which vary in size. The diagnosis is typically made at the time of surgery following biopsy and surgical resection is the mainstay of treatment. We present one case of lip schwannoma: the patient was 25-year-old and he has presented to otorhinolaryngologist for a non-dolorous tumor on the mucosal side of his inferior lip, which was increasing in size for the last six months. The tumor had a superficial ulceration and infection. Initially it was suspected to be a papilloma. The tumor was radically removed, and the sections were stained with Hematoxylin-Eosin. The tumor was encapsulated and showed two different pattern of growth. Antoni A areas displayed spindle cells closely packed together with palisading of nuclei. Verocay bodies, which were presented in Antoni A areas, are whorled formations of palisading tumor cells. The cells of neoplasm were monotone. Only few spindle cells were moderately pleomorphic, but mitotic figures were unusual. In addition, immunohistochemical labeling was performed for S-100 protein, vimentin, GFAP and NSE and confirmed the diagnosis. This report describes a case of lip schwannoma, which was correctly diagnosed by routine staining and confirmed by immunohistochemical staining for S-100 protein, vimentin, GFAP and NSE.

Amelanotic vulvar melanoma: case report and review of the literature.

A rare case of amelanotic vulvar melanoma is presented. The patient was a 71-year-old woman complaining of vulvar itching and yellowish vaginal discharge who underwent a complete gynecological evaluation during which a suspicious grey-whitish mass on her vulva was observed. The tumor presented superficial ulceration and was located in the upper half of the labia minora and clitoris. Initially it was suspected to be a vulvar carcinoma. A biopsy was taken and a histopathological suspicion of amelanotic melanoma was rendered. The mass was radically excised and the diagnosis was confirmed using HMB-45, Melan-A and anti-S-100 protein antibodies. Malignant melanoma is readily diagnosed by the presence of melanin granules. Although amelanotic melanoma contains a few melanin granules, it is often difficult to differentiate it from other non-epithelial malignant tumors. This report describes a case of amelanotic melanoma of the vulva, which was correctly diagnosed by immunohistochemical staining with the HMB-45, Melan-A antibody and for the S-100 protein.

Immunohistochemical expression of vascular endothelial growth factor (VEGF) in intestinal type gastric carcinoma.

BACKGROUND: Gastric cancer still represents a difficult problem in the field of oncology, in terms of morbidity and mortality. The local progression and systemic spread is significantly influenced by tumor angiogenesis and lymphangiogenesis. In spite of many studies on the topic, data about the significance of growth factors in gastric cancer is controversial. AIM: to investigate the immunohistochemical expression of VEGF and to evaluate the relationships with the tumors stage and grade. MATERIAL AND METHODS: The immunohistochemical expression of VEGF was investigated on 80 patients with intestinal type gastric carcinoma. Specimens were fixed in buffer formalin, embedded in paraffin, and sections were stained with Hematoxylin-Eosin and immunohistochemistry was performed for VEGF (clone VG-1). Evaluation was performed using the VEGF score, based on the intensity of reaction and percent of positive cells. RESULTS: The reaction for VEGF was positive in 52 from 80 cases (70%). The final product of reaction was found in the cytoplasm of tumor cells, with granular pattern. Positive reaction was also found in eight from 28 cases with associated intestinal metaplasia, and in six from nine cases with gastric dysplasia. In the adjacent apparently normal mucosa, the reaction was positive in hyperplastic gastric pits and parietal cells. A strong correlation was found between VEGF expression and lymph node status and grade of the primary, but not with the stage of the tumor. CONCLUSIONS: The investigation of the immunohistochemical expression of VEGF in the intestinal type of gastric carcinoma showed positive reaction in 70% of the cases. It was demonstrated the expression of VEGF in intestinal metaplasia and gastric dysplasia, which could signify an early angiogenic switch during tumorigenesis.

Immunohistochemical expression of VEGF in normal human renal parenchyma.

In the normal kidney, VEGF is constitutively expressed in podocytes and tubular epithelial cells of the renal cortex and medulla. The aim of this study was to determine distribution of VEGF in normal renal parenchyma using immunohistochemical methods. The study was retrospective, using normal kidneys samples taken from 28 patients with nephroureterectomy for different types of renal cell carcinomas. Sections were stained with routine Hematoxylin-Eosin method and immunohistochemically with anti-VEGF polyclonal antibody. All cases presented an intense immunoreaction in the cells lining the nephron tubular system, the higher immunoreaction intensity in the collecting and distal tubules, but weak or moderate in the proximal tubules. The Henle loop cells showed a negative immunoreaction. The immunoreaction was absent in most cells of the renal corpuscle. The cells lining the same tubule presented some variation of intensity, with large polygonal epithelial cells, bulging in the tubular lumen showing an intense cytoplasmic immunoreaction for VEGF. In the renal parenchyma adjacent to the tumor, we observed the same pattern of positive reaction distribution as in the nephron's epithelial tubular cells situated far from the tumor. Adjacent to the tumor proliferation front and in those cases with massive invasive features, we observed a partial depletion of VEGF in distal tubules, while the majority of collecting ducts remained intense positive. The VEGF immunostaining was significantly higher in the renal cortex than in the outer and respectively the inner medulla.

Angiogenesis in urothelial tumors of the upper urinary tract.

Angiogenesis is an essential process in the progression of malignant tumors. Tumors of the ureter and renal pelvis account for 5% of all urinary tract neoplasms. Little is known about angiogenesis in upper urinary tract urothelial tumors. We tried to demonstrate angiogenesis by using three endothelial markers CD31, CD34, von Willebrand factor and one pericytes marker (alpha-smooth muscle actin) in 26 cases. The pattern of CD31 immunolabelling was more complex and extensive than the vessel pattern shown by CD34 or factor VIII staining. In non-invasive tumors we observed that angiogenesis process is limited to connective tissue of tumor stroma. In the tumor area, the blood vessels stained with anti-CD31 had large lumen, thin walls and numerous branches, some of them being very thin. Pericyte covered vessels were branching of frequently into smaller, pericyte negative vessels.