Can immunohistochemistry improve the pathological diagnosis of placenta accreta spectrum (PAS) disorders?

PURPOSE: The term of placenta accreta spectrum (PAS) disorder includes all grades of abnormal placentation. It is crucial for pathologist provide standardized diagnostic assessment to evaluate the outcome of management strategies. Moreover, a correct and safe diagnosis is useful in the medico-legal field when it becomes difficult for the gynecologist to demonstrate the suitability and legitimacy of demolitive treatment. The purposes of our study were: (1) to assess histopathologic features according to the recent guidelines; (2) to determine if immunohistochemistry can be useful to identify extravillous trophoblast (EVT) and to measure the depth of infiltration into the myometrium to improve the diagnosis of PAS. METHODS: The retrospective study was conducted on 30 cases of gravid hysterectomy with histopathologic diagnosis of PAS. To identify the depth of EVT, immunohistochemical stainings were performed using anti MNF116 (cytokeratins 5, 6, 8, 17, 19), actin-SM, HPL (Human Placental Lactogen), vimentin and GATA3 antibodies. RESULTS: Our cases were graded based on the degree of invasion of the myometrium. Ten were grade 1 (33.3%), 12 grade 2 (40%) and 8 grade 3A (26.7%). EVT invasion was best seen and evident by double immunostainings with actin-SM and cytokeratins, actin-SM and HPL, actin-SM and GATA3. CONCLUSION: The role of pathologist is decisive to determine the different grades of PAS. A better understanding of the depth of myometrial invasion can be achieved by the use of immunohistochemistry affording an important tool to obtain reproducible grading of PAS. This purpose is crucial in the setting of postoperative quality reviews and particularly in the forensic medicine field.

Human Pulmonary Dirofilariasis Due to Dirofilaria immitis: The First Italian Case Confirmed by Polymerase Chain Reaction Analysis, with a Systematic Literature Review.

Dirofilariasis is a zoonosis caused by nematodes of the genus Dirofilaria.Dirofilaria immitis is cosmopolitan as regards its distribution in animals, being responsible for human pulmonary dirofilariasis in the New World. However, human infections by Dirofilaria immitis are exceptional in Europe, and the previously reported Italian cases of pulmonary dirofilariasis were due to Dirofilaria repens. We performed a systematic literature review of the Italian cases of human dirofilariasis due to Dirofilariaimmitis according to the PRISMA guidelines. We also report the first autochthonous case of human pulmonary dirofilariasis due to Dirofilariaimmitis, confirmed by polymerase chain reaction analysis. The patient was a 60-year-old man who lived in the Po river valley and had never traveled abroad; on histological examination, the 2-cm nodule found in his right upper lung was an infarct due to a parasitic thrombotic lesion. Only one other autochthonous (but conjunctival) case due to Dirofilariaimmitis (molecularly confirmed) was previously found in the same geographic area. Climatic changes, the increasing movements of animal reservoirs and vectors, and new competent carriers have expanded the geographic distribution of the Dirofilaria species, increasing the risk of human infections. Our report demonstrates that at least some pulmonary Italian cases of human dirofilariasis are due to Dirofilaria immitis, as in the New World.

Promoter methylation and downregulated expression of the TBX15 gene in ovarian carcinoma.

TBX15 is a gene involved in the development of mesodermal derivatives. As the ovaries and the female reproductive system are of mesodermal origin, the aim of the present study was to determine the methylation status of the TBX15 gene promoter and the expression levels of TBX15 in ovarian carcinoma, which is the most lethal and aggressive type of gynecological tumor, in order to determine the role of TBX15 in the pathogenesis of ovarian carcinoma. This alteration could be used to predict tumor development, progression, recurrence and therapeutic effects. The study was conducted on 80 epithelial ovarian carcinoma and 17 control cases (normal ovarian and tubal tissues). TBX15 promoter methylation was first determined by pyrosequencing following bisulfite modification, then by cloning and sequencing, in order to obtain information about the epigenetic haplotype. Immunohistochemical analysis was performed to evaluate the correlation between the methylation and protein expression levels. Data revealed a statistically significant increase of the TBX15 promoter region methylation in 82% of the tumor samples and in various histological subtypes. Immunohistochemistry showed an inverse correlation between methylation levels and the expression of the TBX15 protein. Furthermore, numerous tumor samples displayed varying degrees of intratumor heterogeneity. Thus, the present study determined that ovarian carcinoma typically expresses low levels of TBX15 protein, predominantly due to an epigenetic mechanism. This may have a role in the pathogenesis of ovarian carcinoma independent of the histological subtype.

Tungiasis in Italy: An imported case of Tunga penetrans and review of the literature.

Tungiasis is an animal and human parasitic disease caused by fleas of the genus Tunga (Siphonaptera, Tungidae), endemic in equatorial and subtropical regions and rarely described in European countries, where clinicians and general pathologists could be not aware of this parasitic disease. To our knowledge, only 75 cases of human tungiasis (not all described in detail) were previously reported in Italy. We described a new case in a 34-year-old Italian flight attendant who developed a granuloma-like, ulcerated nodule in the subungual region of his left 5th toe, partially detaching the nail, about 20-30 days after his return from Brazil. We performed a detailed review of the literature of the Italian cases, suggesting the use of histochemical stains (especially Trichrome stain) in order to underline parasitic details. Tourism in endemic regions and globalization may result in new cases in developed countries and previously unaffected regions, therefore pathologists should consider this parasitic disease.

Suppression of invasion and metastasis of triple-negative breast cancer lines by pharmacological or genetic inhibition of slug activity.

Most triple-negative breast cancers (TNBCs) exhibit gene expression patterns associated with epithelial-to-mesenchymal transition (EMT), a feature that correlates with a propensity for metastatic spread. Overexpression of the EMT regulator Slug is detected in basal and mesenchymal-type TNBCs and is associated with reduced E-cadherin expression and aggressive disease. The effects of Slug depend, in part, on the interaction of its N-terminal SNAG repressor domain with the chromatin-modifying protein lysine demethylase 1 (LSD1); thus, we investigated whether tranylcypromine [also known as trans-2-phenylcyclopropylamine hydrochloride (PCPA) or Parnate], an inhibitor of LSD1 that blocks its interaction with Slug, suppresses the migration, invasion, and metastatic spread of TNBC cell lines. We show here that PCPA treatment induces the expression of E-cadherin and other epithelial markers and markedly suppresses migration and invasion of TNBC cell lines MDA-MB-231 and BT-549. These effects were phenocopied by Slug or LSD1 silencing. In two models of orthotopic breast cancer, PCPA treatment reduced local tumor growth and the number of lung metastases. In mice injected directly in the blood circulation with MDA-MB-231 cells, PCPA treatment or Slug silencing markedly inhibited bone metastases but had no effect on lung infiltration. Thus, blocking Slug activity may suppress the metastatic spread of TNBC and, perhaps, specifically inhibit homing/colonization to the bone.

Langer mesomelic dysplasia in early fetuses: two cases and a literature review.

In the article, we report the autoptic, histological and radiographic phenotype of two fetuses (22 and 12 weeks) with Langer mesomelic dysplasia, a homozygous deletion of the 3' enhancer of the SHOX gene, and consanguineous parents affected by Léri-Weill dyschondrosteosis, performing a literature review of the primary forms of mesomelic dysplasia. A proper identification of the type of mesomelic dysplasia is important for genetic and reproductive counseling, estimation of child growth and prevention and/or treatment of complications. A competent pathologist could provide important diagnostic information, orienting or confirming the echographic or genetic suspect, sometimes suggesting diagnostic hypothesis concerning parental unidentified congenital syndromes.

MUC5AC, cytokeratin 20 and HER2 expression and K-RAS mutations within mucinogenic growth in congenital pulmonary airway malformations.

AIMS: To analyse the expression of several mucins (MUC1, MUC2, MUC3, MUC5AC and MUC6), epidermal growth factor receptor (EGFR), v-erb-b2 erythroblastic leukaemia viral oncogene homologue 2 (HER2), thyroid transcription factor-1 (TTF-1), caudal type homeobox 2 (CDX2) and cytokeratin 20 (CK20), and the presence of mutations of EGFR, KRAS and HER2 in congenital pulmonary airway malformations (CPAM). METHODS AND RESULTS: Forty-one cases of CPAM and six pulmonary sequestrations were included. TTF-1 expression was observed in all cases but was not seen in mucinogenic growths in CPAM. CDX2 expression was completely negative. MUC1 expression was noted in 12 (29%) CPAM and in 33% sequestrations. MUC5AC was noted in only five cases (26%) by immunohistochemistry and was found in the mucinogenic proliferations of type 1 CPAM. No immunolabelling was noted for the other mucins. EGFR was expressed variably in almost all cases, while HER2 and CK20 was seen exclusively in the mucinogenic proliferations. All mucinous growths were characterized by KRAS mutations. No EGFR and HER2 gene alterations were identified. CONCLUSIONS: KRAS mutations and MUC5AC, CK20 and HER2 expression was seen in all mucinogenic proliferations, supporting the neoplastic nature of these cytologically bland growths. These findings emphasize the importance of complete surgical resection of such lesions.

Can leptin-derived sequence-modified nanoparticles be suitable tools for brain delivery?

AIM: In order to increase the knowledge on the use of nanoparticles (NPs) in brain targeting, this article describes the conjugation of the sequence 12-32 (g21) of leptin to poly-lactide-co-glycolide NPs. The capability of these modified NPs to reach the brain was evaluated in rats after intravenous administration. MATERIALS & METHODS: The g21 was linked on the surface of NPs labeled with tetramethylrhodamine by means of the Avidin-Biotin technology. The g21-labeled NPs were injected into the tail vein of rats and, after animal sacrifice, the brain localization was evaluated by confocal microscopy, fluorescence microscopy and electron microscopy. Studies to evaluate the biodistribution of the g21-modified NPs in comparison to the unmodified NPs were also carried out. Moreover, to confirm the absence of any anorectic effect of g21 linked on the surface of NPs, appropriate studies were used to assess the rats. RESULTS: After intravenous administration, the g21-modified NPs were able to cross the blood-brain barrier and to enter the brain parenchyma. The biodistribution studies of both unmodified and modified NPs pointed out an uptake at liver and spleen level, whereas only the g21-modified NPs showed brain localization. The food-intake experiments pointed out that the intravenous administration of g21 conjugated to the NP surface did not produce any anorectic effect in the rats. CONCLUSION: g21-modified NPs were able to cross the blood-brain barrier. These new modified NPs could be effectively considered as useful carrier systems for brain drug delivery.

Investigation on mechanisms of glycopeptide nanoparticles for drug delivery across the blood-brain barrier.

AIM: Nanoneuroscience, based on the use polymeric nanoparticles (NPs), represents an emerging field of research for achieving an effective therapy for neurodegenerative diseases. In particular, poly-lactide-co-glycolide (PLGA) glyco-heptapetide-conjugated NPs (g7-NPs) were shown to be able to cross the blood-brain barrier (BBB). However, the in vivo mechanisms of the BBB crossing of this kind of NP has not been investigated until now. This article aimed to develop a deep understanding of the mechanism of BBB crossing of the modified NPs. MATERIALS & METHODS: Loperamide and rhodamine-123 (model drugs unable to cross the BBB) were loaded into NPs, composed of a mixture of PLGA, differently modified with g7 or with a random sequence of the same aminoamids (random-g7). To study brain targeting of these model drugs, loaded NPs were administered via the tail vein in rats in order to perform both pharmacological studies and biodistribution analysis along with fluorescent, confocal and electron microscopy analysis, in order to achieve the NP BBB crossing mechanism. Computational analysis on the conformation of the g7- and random-g7-NPs of the NP surface was also developed. RESULTS: Only loperamide delivered to the brain with g7-NPs created a high central analgesia, corresponding to the 14% of the injected dose, and data were confirmed by biodistribution studies. Electron photomicrographs showed the ability of g7-NPs in crossing the BBB as evidenced by several endocytotic vesicles and macropinocytotic processes. The computational analysis on g7 and random-g7 showed a different conformation (linear vs globular), thus suggesting a different interaction with the BBB. CONCLUSION: Taken together, this evidence suggested that g7-NP BBB crossing is enabled by multiple pathways, mainly membrane-membrane interaction and macropinocytosis-like mechanisms. The results of the computational analysis showed the Biousian structure of the g7 peptide, in contrast to random-g7 peptide (globular conformation), suggesting that this difference is pivotal in explaining the BBB crossing and allowing us to hypothesize regarding the mechanism of BBB crossing by g7-NPs.

Dirofilarial infections in Europe.

Nematodes of the genus Dirofilaria are currently considered emerging agents of parasitic zoonoses in Europe. Climatic changes and an increase in the movement of reservoirs (mostly infected dogs) have caused an increase in the geographical range of these parasites from the traditionally endemic/hyperendemic southern regions, and the risk for human infection has increased. In the last several years, forecast models have predicted that current summer temperatures are sufficient to facilitate extrinsic incubation of Dirofilaria in many areas of Europe. The global warming projected by the Intergovernmental Panel on Climate Change suggests that warm summers suitable for Dirofilaria transmission in Europe will be the rule in the future decades, and if the actual trend of temperature increase continues, filarial infection should spread into previously infection-free areas. Dirofilaria repens is currently the filarial species that is most commonly reported as spreading from southern to northern areas. This article reviews the zoonotic aspects, effects of climate, and other global drivers on Dirofilaria infections in Europe and the possible implications on the transmission and control of these mosquito-borne nematodes.

Down-regulation of µ-protocadherin expression is a common event in colorectal carcinogenesis.

We have previously reported that treatment of colorectal cancer cells with mesalazine results in the up-regulated expression of a novel member of the cadherin protein superfamily, named µ-protocadherin, which is able to sequester ß-catenin on plasmatic membrane of treated cells inhibiting its proliferation signalling pathway. This finding suggests that µ-protocadherin could exert an oncosuppressive effect on colorectal epithelium. The purpose of our study was to assess whether µ-protocadherin expression is down-regulated during colorectal carcinogenesis. This issue was addressed by analyzing the messenger RNA and protein expression of µ-protocadherin in normal and tumor colorectal cell samples using a combination of quantitative real-time polymerase chain reaction, microarray analysis, and immunohistochemical examination. To better contextualize the role played by µ-protocadherin in the pathogenesis of colorectal cancer, this last assay was also extended to ß-catenin, E-cadherin, and Ki-67 proteins. The results obtained evidenced that (1) levels of µ-protocadherin transcript were down-regulated in all the analyzed colorectal cancer samples as compared with normal mucosa; (2) expression of µ-protocadherin protein was completely lost in most analyzed colorectal cancer samples (71%); (3) µ-protocadherin retains ß-catenin on the plasmatic membrane of normal colon enterocytes, which implies that ß-catenin is released from this site and translocated to the nucleus in colorectal cancer cells. Our data consequently suggest that down-regulation of µ-protocadherin expression is a common event in colorectal carcinogenesis and might therefore play an important role in this pathologic process.

Heavy metals nanoparticles in fetal kidney and liver tissues.

The proliferation of the nanotechnologies with the production of engineered nanoparticles presents a dilemma to regulators regarding hazard identification mostly for human health. We investigated the presence of inorganic micro and nanosized contamination in fetal liver and kidney tissues by Field Emission Gun-Environmental Scanning Electron Microscope (FEGESEM) innovative observations. An observational study in 16 fetuses, complicated (n=8) or not (n=8) by neural tube defects, whose mothers obtained the authorization for abortion between 21-23 weeks of gestation was carried out. Heavy metals concentrations in maternal blood were undetectable. FEGESEM assessment showed particles of iron, silicon, aluminum and magnesium in different tissues analyzed. The mean size and the number of the foreign bodies detected in kidney and liver tissues were higher in NTD fetuses as well as the number of total particles (P < 0.05, for all). The present study shows first the presence of xenobiotic, nanoscaled contamination, not detectable in maternal blood in fetuses. Data are suggestive and open-up a new clue for further investigations to elucidate the relationship between pollution at nanoscale stage and multiorgan damage.

A case of human conjunctival dirofilariosis by Dirofilaria immitis in Italy.

This short communication describes a case of human conjunctival dirofilariosis by Dirofilaria immitis. A 51-year-old man from the Emilia-Romagna region of northeastern Italy referred for ocular foreign body sensation in his right eye. A slight swelling of the bulbar conjunctiva was observed. A live, whitish, 10-cm-long nematode was extracted from the subconjunctival space. Histology revealed typical features of a filarioid nematode belonging to the genus Dirofilaria sp. Molecular analysis with polymerase chain reaction confirmed that the extracted nematode was a male of D. immitis. The removal of the parasite leads to complete resolution of symptoms. Ocular human dirofilariosis caused by infection with the filarioid nematode D. immitis is extremely rare, but should be considered in humans living in Italian endemic areas.

Fatal Aspergillus flavus infection in a neonate.

Aspergillosis is an uncommon perinatal infection diagnosed with increasing frequency in recent years. We report a premature infant who required both nutrition and ventilation artificially assisted and developed a disseminated invasive nosocomial infection from Aspergillus flavus. Autopsy revealed marked hypotrophy of the thymus and multisystem invasive aspergillosis chiefly involving the vascular and alimentary systems and also the respiratory tract, the central nervous system, and the skin. From what we know, this is the first case of the literature with a misleading initial clinical presentation involving the alimentary tract (hepatomegaly, ingravescent cholestatic icterus) and evolving in intestinal occlusion.

Organising pneumonia mimicking invasive fungal disease in patients with leukaemia.

Clinical charts from 63 consecutive highly immunocompromised haematologic patients presenting with pulmonary nodular lesions on CT scan, classified as either probable or possible invasive fungal disease (IFD) according to the revised EORTC/MSG classification, were retrospectively studied. Histopathological analysis of lung tissues, available for 23 patients, demonstrated proven IFD in 17 cases (14 invasive aspergillosis and 3 invasive zygomycosis), diffuse alveolar damage in one and organising pneumonia (OP) in five cases. In the OP cases, three of which have been defined as probable IFD according to EORTC/MSG classification, extensive immunohistochemical, molecular and immunological analyses for fungi were negative. Our case descriptions extend the notion that OP may be encountered as a distinct histopathological entity in pulmonary nodular lesions in patients with leukaemia with probable/possible IFD.

Mature solid teratoma of the fallopian tube mimicking metastasis of endometrial adenocarcinoma: a case report.

We report a mature solid teratoma of the fallopian tube in an elderly woman. This mass was noted on CT scan and considered metastatic in nature since following a bioptical diagnosis of endometrial adenocarcinoma. Hysterectomy and bilateral salpingectomy and ovariectomy were performed and a second minor mature solid teratoma was discovered inside the right ovary. Neoplasms of the fallopian tube are very uncommon and this is the first Italian case to be added to about other 60 of the literature. Moreover it joins minimum teratomatous diameter with maximum recorded age.

Enterobiasis in ectopic locations mimicking tumor-like lesions.

Both the clinical and the histopathological diagnostic difficulties of oxyuriasis in unusual sites and their importance from a clinical point of view are pointed out. The authors report two ectoptic cases of enterobiasis observed in Northern Italy, one located in a fallopian tube of a 57-year-old woman and the other in a perianal subcutaneous tissue of a 59-year-old man, mimicking tumor-like lesions. The authors take advantage of the occasion to focus the attention of the medical world on this subject, lamenting the scarce importance given to this parasitosis in university courses of medical schools and in medical textbooks as it is incorrectly considered "out-of-fashion."