Malignant epithelial tumors observed in hernia sacs.

INTRODUCTION: The study of a hernia sac rarely provides the evidence of a primary or metastatic malignant epithelial tumor. METHODS: We have reviewed our institutional experience with malignant epithelial tumors found in a hernia sac with the purpose of evaluating cases present/manifesting in the sac, gross appearance, histologic type, primary tumor sites, staging, and patient outcome. RESULTS: A total of 8,435 adult patients underwent inguinal, femoral, umbilical or abdominal hernia repair in our hospitals. Twelve (0.14 %) patients had a malignant epithelial tumor in the hernia sac. Only one of these tumors was primary and the rest metastatic. Six out of twelve tumors (50.0 %), all of them metastatic, were discovered after hernia repair (0.07 %). The mean age of the 12 patients was 68.7 ± 15.2 years (range 43-90 years). Eight patients were male (66.7 %). Six tumors were located in inguinal (50.0 %), five in umbilical (41.7 %), and one in abdominal (8.3 %) hernia sacs. Gastrointestinal cases comprised 50.0 % and gynaecologic cases 25 % of tumors. In three cases (25.0 %) the hernia sac showed no gross abnormalities. All tumors were found in an advanced stage of development and ten patients died. Mean survival of these patients after hernia repair was 275.1 ± 376.4 days (range 6-1,095 days; median 68 days). CONCLUSIONS: Gravity, inflammatory oncotaxis, and chemotactic agents are probably operative phenomena in the development of metastatic lesions in hernia sacs. Routine microscopic evaluation of hernia sacs is not justified by the high cost. It should be reserved for selected cases based on the gross findings. Since subtle lesions may be overlooked on gross examination, particular caution should be taken with the examination of hernia sacs from older patients.

Cutaneous infection with Alternaria triticina in a Bilateral lung transplant recipient.

We report the case of a 60-year-old man who was receiving immunosuppressive therapy for a bilateral lung transplant and presented with a crusted, violaceous plaque on the left hand. Based on histopathology and microbiological culture the patient was diagnosed with infection by Alternaria species. Treatment with itraconazole led to complete resolution of the skin lesion. Forty months later he developed four reddish, nodular, skin lesions on the left leg. Analysis of a biopsy from one of these lesions using histopathologic and molecular techniques identified a mold that shared 98% homology with a strain of Alternaria triticina. Alternaria species belong to a group of dematiaceous fungi that cause opportunistic infections in humans. The incidence of these infections is increasing, mainly in transplant centers. To the best of our knowledge, this is the first reported case of a human infection caused by A. triticina.

C4d immunohistochemical staining is a sensitive method to confirm immunoreactant deposition in formalin-fixed paraffin-embedded tissue in membranous glomerulonephritis.

Although the diagnosis of membranous glomerulonephritis (MGN) may be suspected on routine histology of formalin-fixed paraffin-embedded tissue, fresh-frozen tissue must be used to show the immunologic nature of the process by direct immunofluorescence (IF). The efficiency of IF or immunoperoxidase (IP) detection of IgG and C3 using paraffin sections is controversial. This study was designed to evaluate whether glomerular C4d deposition using an IP method in formalin-fixed paraffin-embedded tissue may be a useful marker for MGN. We showed characteristic glomerular, granular basement membrane deposition of C4d in 31 (100%) cases of idiopathic MGN and in 5 cases (100%) of pure class V membranous lupus nephritis, in which we had a positive diagnosis of the lesions for conventional IF study. Control cases were negative. Nineteen cases of different glomerulopathies, including IgA nephropathy, primary type I membranoproliferative glomerulonephritis, focal segmental glomerulosclerosis and minimal change disease showed diverse reproducible patterns of C4d deposition, without intrinsic background. Our results indicate that staining of formalin-fixed paraffin-embedded tissue for C4d can be used for confirmation of granular basement membrane immunoreactant deposition in cases of MGN. This proved to be a reliable method that could potentially obviate the need for rebiopsy in cases with absence of glomeruli in renal frozen sections or when other adjunct IF or IP methods on paraffin sections are negative. C4d immunostaining, using an IP method, deserves a place as an adjunct method in the biopsy diagnosis of MGN.

Development and validation of I-DNA1: a 15-Loci multiplex system for identity testing.

This paper presents a system for the multiplex amplification of 15 loci, known as I-DNA1, which combines mini and midiSTR technology, with amplicon sizes ranging from 49 to 297 bp. I-DNA1 analyses all the STR loci included in the CODIS and the Interpol Standard Set of loci, nine of the ten European core loci and seven of the eight German core loci, making it suitable for use in identifying humans. Moreover, its high sensitivity and the small size of its amplicons mean that I-DNA1 is potentially highly useful for analysing highly degraded and/or very small DNA samples.

An overview of the pale and clear cells of the nipple epidermis.

The stratified squamous epithelium of the nipple-areola complex may contain pale or clear cells including: Paget's disease cells (PDCs), Toker cells (TCs), and so-called clear cells (CCs). Paget's disease is an uncommon presentation of breast carcinoma. PDCs are large, atypical, have abundant, pale-staining cytoplasm that may contain mucin secretion vacuoles and bulky heterochromatic nuclei. They are commonly concentrated along the basal layer and stain for EMA, CAM5.2, cytokeratin 7, and HER2/neu oncoprotein. TCs are bland cells with roundish and scant chromatin nuclei. They are found incidentally and are reactive for EMA, CAM5.2, and cytokeratin 7, but show negativity for HER2/neu oncoprotein. So-called CCs show varied morphology, are found incidentally, and have been variably interpreted by different authors. The majority of cells that have been called epidermal CCs fit the features of pagetoid dyskeratosis. These cells are reactive for high molecular weight cytokeratin. Other CCs showing signet-ring morphology present negativity for mucins and correspond to a fixation artefact.

[Retrospective analysis of 6 cases of elastofibroma dorsi]. / Elastofibroma dorsi: estudio retrospectivo de seis casos.

Elastofibroma dorsi is a benign lesion of fibroelastic tissue. It often presents bilaterally, is frequently localized to the subscapular region, and is more common in middle-aged and elderly women. The pathogenesis is still unclear but it has been suggested to involve reactive, degenerative, or neoplastic processes. We present a retrospective study of the findings from 6 patients with elastofibroma dorsi. Elastofibroma should be included in the differential diagnosis of subcutaneous scapular tumors, as it is a benign lesion that only requires surgery when associated with symptoms or the lesion is extensive. Noninvasive techniques such as ultrasonography, computed tomography, and, above all, magnetic resonance imaging, may be sufficient to guide diagnosis. The results of histology and imaging are closely correlated, so the need for unnecessary biopsy and surgery may be avoided.

Generalized granuloma annulare and giant cell arteritis.

Granuloma annulare (Gan) and giant cell arteritis (GCA) share common histologic features. In Gan, a disease characterized by the presence of palisading granulomas usually in the dermis, the main alteration is the presence of elastic fiber degeneration and it strongly suggests that the primary target leading to the development of this disorder is the injury to the elastic tissue. On the other hand, in giant cell arteritis (GCA), a vasculitis involving large-and middle-sized blood vessels, the main histologic features are the disruption of the internal elastic lamina and the nonsuppurative granulomatous giant cell infiltrate, which seems to be focused around the disintegrated elastic fibers. Due to this, these two conditions appear to be related. However, to the best of our knowledge, only one case of association of generalized Gan and GCA is described in the literature. We herein report a new case of generalized Gan in a patient previously diagnosed with biopsy-proven GCA. Both diseases were successfully treated by oral prednisone. Although the etiology of generalized Gan and GCA remains still unknown, they seem to be immunologically mediated conditions showing predominance of T-cells in the inflammatory infiltrate.

Recall injection-site reactions associated with etanercept therapy: report of two new cases with immunohistochemical analysis.

Injection site reactions (ISRs) are the most common adverse effect reported with etanercept therapy. It has been observed that some patients treated with etanercept develop ''recall ISRs'', that are reactions at sites where etanercept was previously injected after the last injection. Etanercept-associated recall ISRs have been scarcely published. We report two patients with rheumatoid arthritis who developed recall ISRs during etanercept therapy. Biopsy specimens from ISRs demonstrated a superficial perivascular lymphocytic infiltrated with a few eosinophils. Immunohistochemical study in both cases revealed that T cells bearing a CD4+ phenotype mostly composed the inflammatory infiltrate. Our observations suggest that ISRs may be mediated by classic cellular-hypersensitivity reactions directed by CD4+ T lymphocytes.

[Microscopic polyangiitis in a patient with rheumatoid arthritis]. / Poliangeítis microscópica en paciente con artritis reumatoide.

Rheumatoid arthritis (RA) is a systemic disorder that primary involves joints, although renal disease has also been associated it is not common that rapidly progressive glomerulonephritis (RPGN) appears. We report the case of a patient with nodular and aggressive RA who had an acut renal failure secondary to ANCA positive RPGN due to a Microscopic polyangiitis who was not responsive to steroids and cyclophosphamide therapy.

Sclerotic fibroma-like dermatofibroma: an uncommon distinctive variant of dermatofibroma.

Dermatofibroma (DF) is a common benign cutaneous tumor with many variants based on alterations in the morphology and composition of its diverse elements. One very infrequent type is sclerotic fibroma-like DF (SF-DF). We report 7 new cases of SF-DF. In addition, their main clinicopathological and immunohistochemical features were compared with 14 unselected common DFs and with 3 sclerotic fibromas (SFs). Microscopically, the 7 cases of SF-DFs showed an unencapsulated, well-circumscribed, hypocellular central nodule with thick collagen bundles arranged in a storiform pattern with prominent clefts. The overlying epidermis was attenuated. The periphery of this nodule was more cellular with histopathologic features of common DF. The 7 SF-DFs patients were 4 women and 3 men with a mean (+/-SD) age of 44.8 (+/-15.5) years. These 7 patients were younger than those suffering from SFs [71.0 (+/-17.3) years; (p=0.04)] and older than those presenting common DFs [30.5 (+/-12.3) years; (p=0.03)]. Immunohistochemically, spindle cells in all 7 SF-DFs were negative for CD34 and CD99. On the contrary, the 3 cases of SF were positive for CD34 and CD99. All of the common DFs were negative for CD34 and only 4 (28.6%) of them were positive for CD99. In conclusion, SF-DF is an uncommon variant of DF with similar clinicopathological and immunohistochemical features. SF-DF shares certain histopathologic features with SF but they are immunophenotypically different. Therefore, both entities should be differentiated.

Markers of fibrosis in early biopsies of renal transplants.

Many factors are involved in the development of chronic allograft nephropathy (CAN). Extracellular matrix turnover depends on the balance between fibrogenic and antifibrogenic cytokines. The aim of our study was to analyze the presence of transforming growth factor beta-1 (TGF-beta1), matrix metalloproteinase-2 (MMP-2), and mast cells in 53 early transplant biopsies using immunochemistry with specific monoclonal antibodies. We divided the patients into two groups depending on graft evolution (lost due to CAN versus functioning), renal function, presence of proteinuria, and graft survival. There were no differences in the demographic or immunological data. Renal function was worse and proteinuria greater among the group with CAN. The presence of mast cells was similar in both groups, but TGF-beta1 was expressed more and MMP-2 less in the CAN group. We observed a negative correlation between donor age and mast cells, and a positive correlation between TGF-beta1 and MMP-2. Grafts from younger donors showed better renal function, less proteinuria, greater graft survival, and less frequent development of CAN. According to our experience, cytokines involved in matrix turnover are expressed in early stages, correlating with donor age. The expressions of TGF-beta1 and MMP-2 seem to be important for the development of fibrosis in CAN.

The macrophage infiltration index and matrix metalloproteinase-II expression as a predictor of chronic allograft rejection.

The presence of macrophages on renal biopsy specimens is considered an important cofactor in the development of chronic allograft nephropathy (CAN). Macrophages can activate the expression of matrix metalloproteinases (MMP), which induce glomerulosclerosis, arteriosclerosis, and interstitial fibrosis. The aim of our study was to demonstrate if they were related to the development of CAN. We analyzed matrix metalloproteinase (MMP) expression with specific monoclonal antibodies on 53 kidney biopsies performed due to the suspicion of a first acute rejection (AR) episode: 24 of the grafts have been lost due to CAN and the rest are still functioning. The group with CAN showed worse graft function and greater proteinuria from the beginning. The macrophage infiltration index (MI) expression was significantly higher in that group also (18.8 +/- 12 vs 12.5 +/- 9.15; P < .05), with a more important presence of macrophages in the interstitium and tubules. We observed a positive correlation between MI and tubular infiltration (r(2) = 0.52; P < .001) and between MMP-II and MI in the interstitium (r(2) = 0.3; P < .05) and with the global MI (r(2) = 0.3; P < 0.05). The last correlation was more powerful in the group with CAN (r(2) = 0.4; P < .05). According to our experience, global MI and tubular infiltration during an AR episode are good markers of long-term graft survival. The correlation between MI and MMP-II supports the role of macrophages in the development of CAN, although further studies are needed to clarify the nature of this relationship.