Double localization of keratoacantho-ma on the cutaneous and mucosal sides of the lower lip: report of a case.

The clinical course and histological features of keratoacanthoma (KA) are well recognized by dermatologists and pathologists, but they are less familiar to dental professionals. The aims of this report were to describe an unusual case of simultaneous intraoral and labial KA and to identify the most important aspects of the clinical management of this lesion.

A woman with a solitary pulmonary nodule: is it a lung cancer?

BACKGROUND: Solitary pulmonary nodules present a real challenge for physicians. Due to the clinical implications and prognosis of a certain diagnosis, it should be pursued with any cost; a clear definition is not always simple and further investigations are often necessary to exclude the possibility of a malignancy. A diagnostic path must be followed and the clinical hypothesis should be reconsidered on the basis of the new information provided by the tests, always keeping in mind their limits! Sometimes only the surgical resection permits a definitive diagnosis. A 68 year-old non-smoker female with a pulmonary solitary nodule highly suspicious to be malignant at the chest CT, performed a FBS with BAL, negative for neoplastic cells and for infective agents, and a CT guided pulmonary biopsy that was inconclusive. The patient underwent then a video-thoracoscopic atypical lung resection that demonstrated the reactive nature of the lesion, definitely excluding the presence of a malignancy.

Scedosporium apiospermum atrial mycetomas after lung transplantation for cystic fibrosis.

A 37-year-old patient with cystic fibrosis underwent double lung transplantation. She developed disseminated Scedosporium apiospermum infection 2 months after surgery. Along with multiple brain abscesses, lung infection, and chorioretinitis, a cardiac echo revealed 2 large intra-atrial mycetomas floating close to the right upper pulmonary vein orifice. The mycetomas were removed through a trans-atrial approach under cardiopulmonary by pass; histology and cultures confirmed the diagnosis. Despite intensive treatment, the patient succumbed from massive brain hemorrhage on the 10th postoperative day.

Breast tuberculosis: rare but still present in Italy--a case of mycobacterium breast infection.

Breast tuberculosis is a rare disease in highly endemic countries, and it is even rarer in Western countries, where only occasionally the local population is affected. The rarity of the disease and particularly the lack of a typical clinical-radiological presentation may cause tuberculosis to be mistaken for breast cancer or a pyogenic abscess. The authors present a case of breast tuberculosis in a 27-year-old nulliparous woman, an Italian citizen of the Caucasian race, who has never resided in a tuberculosis endemic area. She presented with painful retroareolar and para-areolar swelling in the right breast associated with cutaneous hyperemia (without fistulization), resistant to antibiotic therapy. Histopathological examination revealed features of mastitis with epithelioid histiocytes and Langhans giant cells and was characterized by the presence of caseous necrosis which suggested tuberculous inflammation. Ziehl-Neelsen staining showed the presence of acid fast bacilli. In countries where tuberculosis is non-endemic, breast tuberculosis should always be included in the differential diagnosis in cases of inflammatory breast lesions resistant to the usual antibiotic therapies. Early recognition may prevent both clinical progression and surgical excision, as breast tuberculosis usually regresses as a response to appropriate anti-tuberculosis therapy.

[Merkel cell carcinoma: an uncommon neuroendocrine cancer]. / Il carcinoma a cellule di Merkel: una rara neoplasia neuroendocrina.

Merkel cell carcinoma (MCC), firstly described by Torker in 1972, is an uncommon and aggressive neuroendocrine cancer of the skin. MCC tends to recur and precociously spread to lymph nodes. Five-year survival rate is between 35 and 75%. In literature there are not univocal criteria regarding the diagnosis and therapy of MCC, probably due to its rarity. Surgery plays an important role in the therapeutic strategy of this cancer. Surgical excision must be wide and guarantee at least 2-3 cm of free tumor margins. Sentinel lymph node biopsy is useful to identify those patients in which extensive lymph node dissection and/or adjuvant therapies (radio- and/or chemotherapy) are advisable. We hereby report a case of MCC of the left arm in a 48 year-old male. A wide excision was performed with sentinel lymph node biopsy that did not show any metastasis. Adjuvant radio therapy was administered. The patient was healthy at one year follow-up.

Hibernoma of the para-glottic space: an unusual tumour of the larynx.

Hibernoma is an unusual tumour of brown adipose tissue. Brown adipose tissue is common in mammalian hibernating animals and acts as a thermogenic organ. A first case of hibernoma was reported in 1906 by Merkel. This tumour usually arises in the back, shoulder region, mediastinum, retroperitoneum and in the neck. The neck location of hibernomas is rare and only 18 cases of cervical hibernoma have been reported in the English literature. A 48-year-old male with hoarseness and soft voice, present for 8 months, showed a lesion involving the anterior part of the right vocal fold, with no impaired mobility. This is the first case to be reported of laryngeal hibernoma located in a vocal fold, originating from the white fat tissue of the paraglottic space. Moreover, this report could be evidence of the development of hibernoma from white adipose tissue.

[A possible cause of misdiagnosis in tumors of the axilla: schwannoma of the brachial plexus]. / Una possibile causa di errore nella diagnosi differenziale delle formazioni ascellari: lo schwannoma asintomatico dei tronchi del plesso brachiale.

The Authors report a rare case of a 57 years old man affected by a left radial nerve schwannoma that occurred as an asymptomatic lesion of the axilla. At clinical examination the lump was undistinguishable from the most common axillary lymphadenopathy. A lymphoadenopathy was erroneously diagnosed with ultrasonography (US). This mistake was due to the low specificity of the instrumental methodology and to the rarity of an asymptomatic schwannoma of the infraclavicular brachial plexus. The neoplasia was excised without using the microscope. In the early post-operative follow up, a "falling" attitude of the wrist, the hand and the fingers appeared, peculiar for a lesion of the radial nerve. Furthermore a hypoaesthesia of the skin of first finger and of the first interosseus space was associated. The sensitive and motor electromyography showed a radial nerve suffering. The "stupor" of the nerve trunk was treated with steroid therapy for 7 days and the patient underwent to some series of neuro-rehabilitative physical therapy for 12 weeks. The postoperative total body CT, showed that the lesion was unique: therefore it was possible to exclude the diagnosis of neurofibromatosis. After 28 months electromyography and axillary US were performed showing the complete resolution of the motor and sensitive deficit and the absence of local recurrence.

Preoperative anaemia does not affect the early postoperative outcome in patients with lung cancer.

AIM: Several prognostic factors like age, gender, histology, stage, type of operation, associated disorders and administration of induction therapy have been evaluated to assess the risk of postoperative complications and outcome in patients with resectable lung cancer. Anemia is a frequent condition in this subset of patients being estimated up to 50%. The aim of this retrospective study was to evaluate the effect of preoperative anemia on early outcome after lung cancer resection. METHODS: One-hundred thirty nine consecutive patients undergoing surgery for non small cell lung cancer were retrospectively considered. The mean age was 64.8+/-11.6 years. No patient received blood transfusions or administration of erythropoetin preoperatively. Overall, we performed 96 lobectomies, 14 pneumonectomies, 2 bilobectomies and 27 atypical resections. A subset of 27 patients (19.4%) (group I) had a preoperative value of Hb less than 12 g/dl (10.4+/-1.9 g/dL). Seven patients of them were stage IA (26%), 9 stage IB (33.3%), 2 stage IIA (7.4%), 6 stage IIB (22.2%), 2 stage IIIA (7.4%) and 1 stage IIIB (3.7%). Age, gender, stage, type of operation, induction chemotherapy, comorbidities were evaluated by univariate analysis comparing patients with and without preoperative anaemia. The two groups were homogenous regarding demographic characteristics. RESULTS: Three patients (11.1%) in group I and 2 (1.8%) in group II required blood transfusions after surgery (P=0.01); 4 of them received pneumonectomy (P<0.0001). The overall morbidity was 17.9% (25/139); the most frequent complication was persistent air leakage, followed by retention of secretions. No statistically significant difference was observed between the 2 groups about early mortality (1 patient-3.7% in group I and 2 patients-1.8% in group II) and postoperative complications (5 patients-18.5% in group I and 20 patients-17.9% in group II). CONCLUSION: Preoperative anaemia is not a risk factor for an increased rate of postoperative complications and should not be considered a contraindication to surgery.

Malignancies following lung transplantation.

During the last 2 decades, long-term survival after lung transplantation has significantly improved. However, among the complications related to the continuous administration of immunosuppressive drugs, malignancy plays an important role. We retrospectively revisited our series of patients to report our experience. From January 1991 we performed 134 lung transplantations in 128 recipients (mean age, 33.4 +/- 13.5 years). In all patients the first-line immunosuppressive regimen was based on a calcineurin inhibitor (cyclosporine or tacrolimus), an antimetabolic agent (azathioprine), and steroids. Five patients (4.2%) developed malignancy and the mean time of occurrence after the transplantation was 46.4+/-23 months. The mean age was 41 +/- 16 years (P = not significant [ns]). The tumors were as follows: laryngeal cancer (radiotherapy), colon cancer (surgery plus adjuvant chemotherapy), gastric cancer (surgery plus adjuvant chemotherapy), endobronchial non-Hodgkin lymphoma (NHL) (endoscopic resection plus chemoradiotherapy), and cutaneous and visceral Kaposi's sarcoma (KS) (chemotherapy). All patients have reduced the dose of immunosuppressive drugs; in 1 of them, tacrolimus was changed to rapamycin. Two patients died because of neoplastic dissemination, another 1 due to obliterans bronchiolitis. The 2 patients with NHL and KS are alive at 6 and 9 months, respectively, without signs of recurrence. Malignancies after lung transplantation represent an important problem. A multidisciplinary approach is mandatory to obtain satisfactory results in terms of improved quality of life and long-term survival.

A clinical radiographic and histologic revaluation of a 10 years sample of surgically treated cysts of the jaws, with special emphasis on keratocysts.

AIM: The aim of this study was to compare the histologic features of the cysts as regards their radiographic and clinical aspects, in order to assess the accuracy of the diagnosis, the appropriateness of the treatment and the reliability of the follow-up. METHODS: A sample of 173 cysts of the jaws was reviewed in accordance with the 1992 WHO histological classification. RESULTS: Of these cysts, 77.44% were inflammatory, 12.71% follicular and 8.67% keratocysts. The cysts were slightly more frequently located in the mandible (52.60%) than in the maxilla (47.39%) and they affected men more frequently (60.11%) than women (39.88%). However keratocysts and nasopalatine cysts were twice as frequent in women than in men. No recurrence of keratocysts was found, either in those correctly diagnosed at the moment of the first histologic examination, or in those firstly erroneously diagnosed as an other type of cysts. CONCLUSION: On the basis of the fairly high percentage of non-inflammatory cysts in adult patients, it can be suggested to perform an orthopantomography as a preventive measure, every 5 years, particularly when impaired teeth are present.

Neutropenic enterocolitis in acute leukemia: diagnostic and therapeutic dilemma.

The main purpose of this report is to focus on the importance of an accurate etiologic diagnosis of gastrointestinal complications during chemotherapy for acute myeloid leukemia, taking into account that a syndrome characterized by bowel wall thickening associated with diarrhea and abdominal pain may have etiologies different from neutropenic enterocolitis (NE) and in such a case necessitate a different treatment approach. We describe a case of a 46-year-old woman affected by acute myeloid leukemia presenting the onset of a syndrome with clinical features of NE. Supportive therapy for NE was instituted, but during treatment the patient presented a life-threatening gastrointestinal bleeding and was submitted in emergency to hemicolectomy. Following surgery, the patient recovered completely and she is currently alive in complete remission after receiving allogeneic bone marrow transplantation. Histological examination of the surgical specimens showed that the acute abdominal syndrome was related to massive infiltration of the bowel by leukemia cells. A correct baseline evaluation and a prompt diagnosis of the complication may help in making the therapeutic decision, which in our case led necessarily to a surgical procedure, because the bleeding was due to post-chemotherapy necrosis of the leukemic infiltrating tissue. A close collaboration between the hematologist and the surgeon may provide guidelines for behavior in such cases, giving these patients the possibility of survival and the opportunity to carry on the treatment planned for the primary disease.

Detection of TT virus in lymph node biopsies of B-cell lymphoma and Hodgkin's disease, and its association with EBV infection.

Human TT virus (TTV) recently isolated from the serum of a patient with post-transfusion hepatitis does seem to have only hepatopathic effect. The virus can also infect the serum, peripheral blood mononuclear cells (PBMC) and bone marrow cells (BMC ). Additional evidence has indicated that TTV is also present in the serum of people with hematopoietic malignancies. A significant increase in the incidence of lymphoma has recently been observed worldwide. We have investigated the presence of TTV DNA in lymph node biopsies of Italian patients affected with the most common lymphoma types in Western Countries: follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL) and nodular sclerosis Hodgkin's disease (NS-HD). The possible role of a co-infection with Epstein-Barr virus (EBV) has also been investigated. DNA was extracted from 73 paraffin-embedded and 38 snap-frozen tissue specimens. From these, only 67 samples (29 paraffin-embedded and 38 snap-frozen tissues) from a total of 56 patients, were suitable for PCR analysis. TTV and EBV were detected by PCR using primers from two different conserved region in TTV and EBV genomes respectively. TTV DNA was detected in 30.0-50.0% of FL, 30.8% of DLBCL and 30.0-50.0% of NS-HD cases, depending on the primers used. All cases of non-specific reactive lymphoid hyperplasia (RLH), used as a putative control, were negative. The two major TTV genotypes circulating in Italy (G1 and G2) were detected in the analysed lymphoid neoplasms. EBV DNA was detected in 40.0% of FL, in 72.7%of DLBCL, in 80.0% of SN-HD and in 40.0% of RLH cases. EBV co-infection was found in 90% of TTV positive cases. The in situ hybridization assay was performed in TTV positive frozen samples. The significant prevalence of TTV DNA in lymphocytes circulating in the lymph nodes of both B-cell lymphomas and HD reported herewith suggests an implication of TTV infection in the development of these lymphoproliferative disorders.

Laminin alpha2 chain (merosin M chain) distribution and VEGF, FGF(2), and TGFbeta1 gene expression in angiogenesis of supraglottic, lung, and breast carcinomas.

The prognostic significance of vessel quantification in human solid tumours is still debated, due to the presence of multiple factors modulating neoangiogenesis and the invasiveness of neoplastic cells. This study examined ten supraglottic squamous carcinomas, ten non-small cell lung carcinomas (three squamous, five bronchioloalveolar, two adenocarcinomas), and nine classic (NOS) invasive ductal breast carcinomas. The properties studied in these tumours were vascularity; the immunohistochemical distribution of adhesion molecules such as alpha2beta1, alpha3beta1, alpha4beta1, alpha5beta1, alpha6beta4, and ICAM-1 in endothelial cells; extracellular matrix proteins (ECMPs) and laminin alpha2 chain (merosin M chain) in basal membranes of vessels; and gene expression of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (FGF2), and transforming growth factor beta1 (TGFbeta1), by in situ hybridization. Independently of tumour type and vascularity, laminin alpha2 chain expression was observed in the basal membranes of a limited proportion of vessels. In vitro experiments demonstrated laminin alpha2 chain expression mainly in early endothelial cell cultures, suggesting that laminin alpha2 chain expression in vivo can be considered a marker of early angiogenesis. Stromal and parenchymal vascularity was associated with laminin alpha2 chain expression in supraglottic carcinomas, whereas in the other tumours, laminin alpha2 chain-positive vessels were observed only in the stroma. In supraglottic carcinomas, VEGF-positive cells were mainly represented by neoplastic cells, whereas in the other tumours, the great majority of VEGF-positive cells were macrophages and fibroblasts. FGF2- and TGFbeta1-positive cells were macrophages and fibroblasts in all tumours. These observations suggest that in addition to the quantification and distribution of vessels, evaluation of their maturation may contribute to a better understanding of the role of angiogenesis in the growth and spread potential of solid tumours. In this regard, in supraglottic carcinomas, parenchymal angiogenesis seems to be regulated mainly by neoplastic cells, which may help to explain their high metastatic potential; in solid tumours of different histogenesis, different cells might be responsible for modulating tumour angiogenesis.

Co-localization of multiple ErbB receptors in stratified epithelium of oral squamous cell carcinoma.

The expression of all four ErbB receptors was compared by immunohistochemistry, using receptor-specific polyclonal antisera, in 32 invasive, 11 in situ carcinomas, six benign lesions, and 22 samples of histologically normal mucosa adjacent to specimens of carcinoma originating from oral cavity epithelium. Among invasive and in situ carcinoma, EGFR expression was the most prevalent (in 29/32 and 8/11 cases, respectively) followed by ErbB2 (17/32 and 2/11) and ErbB4 (9/32 and 1/10), while ErbB3 was only detected in invasive tumours (12/32). Specific patterns included invasive tumours with expression of EGFR (8/32) or ErbB4 (1/32) alone, as well as different receptor combinations (EGFR+ErbB2, EGFR+ErbB4, EGFR+ErbB2+ErbB3, EGFR+ErbB2+ErbB4, and all four receptors). Simultaneous expression of three or four ErbB receptors correlated with tumour invasion (p=2.2x10(-4)) and localized in the intermediate epithelial cell layer of well and moderately differentiated tumours. No other significant correlation with clinico-pathological features was noticed. Some benign lesions and histologically normal mucosa adjacent to carcinomas showed weak immunostaining of EGFR (10/28), ErbB2 (4/28) or ErbB4 (3/28). By comparison, overexpression, as indicated by increased staining intensity, was observed in invasive tumours for EGFR (18/32), ErbB2 (8/32), ErbB4 (3/32), and ErbB3 (3/32). Statistical evaluation demonstrated a significant association of EGFR or ErbB2 overexpression with invasive carcinoma when compared with benign lesions and apparently normal epithelium (p=5.2x10(-7) and p=5x10(-3), respectively). Tumour-specific overexpression of ErbB receptors and their co-expression, most frequently involving EGFR and ErbB2, in the same cell layer of neoplastic epithelium, implicate receptor heterodimers in the pathogenesis of oral squamous carcinoma.

Salvage resection after previous laryngeal surgery: total laryngectomy with en bloc resection of the overlying cervical skin.

OBJECTIVE: To evaluate the effectiveness of extended total laryngectomy for the treatment of recurrences of laryngeal cancer. DESIGN: We conducted a retrospective clinical study of patients who had undergone extended total laryngectomy and were seen over a 15-year period. The follow-up period ranged from 3 to 15 years. SETTING: Academic tertiary referral medical center. PATIENTS: We observed 15 patients who were affected by a recurrence of laryngeal cancer that extended to the overlying soft tissue. All patients were male. The mean age was 61.5 years. Thirteen patients had previously undergone partial laryngeal surgery, and 2 patients had undergone radiation therapy, without success. INTERVENTION: All patients underwent total laryngectomy extending to the soft tissue, including the overlying skin. RESULTS: Five of the 15 patients died of local recurrence, and 1 patient died of massive postoperative hemorrhaging. An actuarial survival rate of 60% was observed at 5 years. CONCLUSION: Total laryngectomy extending to the soft tissues seems to be an effective procedure for treating local recurrences of laryngeal cancer after partial laryngectomy or failure of radiation therapy.

Interleukin-12-related cytokine gene expression in carcinomas of the breast, lung, and larynx: a study at tissue level.

Tumor-infiltrating lymphocytes (TIL) consist of T helper 1 (Th1) and T helper 2 (Th2) cells producing interferon-gamma (IFN-gamma) and interleukin4 (IL-4), respectively. Interleukin-12 (IL-12) induces Th1 and Th2 differentiation. Therefore, IL-12, IFN-gamma, and IL-4 gene expression were evaluated by reverse transcriptase-polymerase chain reaction in carcinomas of the breast (n = 10), lung (n = 17), and larynx (n = 13) to investigate whether TIL activation is IL-12-related. IL-12 and IFN-gamma were codistributed in breast carcinomas, and IL-4 was demonstrated in three instances. IL-12 and IFN-gamma were detected in 15 and 13 lung carcinomas, respectively, and were codistributed in 11 cases; IL-4 was observed in 9 cases and was codistributed with IL-12 and IFN-gamma in 7 instances. IL-12 and IFN-gamma expression was observed in five and nine larynx carcinomas, respectively, and were codistributed in four cases; IL-4 was detected in five instances. These data indicate that breast, lung, and larynx carcinomas are characterized by different patterns of IL-12, IFN-gamma, and IL4 gene expression and suggest that Th1 activation may be induced, at least in part, by the neoplastic microenvironment.

Interleukin-12 related cytokine gene expression at a tissue level in carcinomas of the larynx.

Head and neck squamous cell carcinomas are highly immunogenic tumors in which tumor-infiltrating lymphocytes (TIL) consist largely of CD4, Th1, and Th2 lymphocytes and a minor proportion of other immune effector cells, such as macrophages and B cells. Interleukin (IL)-12 release and antigen presentation from macrophages induce Thl and Th2 differentiation. Gene expression for IL-12, interferon (IFN)gamma, IL-4, and other cytokines was studied by reverse transcriptase-polymerase chain reaction in tissue sections from laryngeal carcinomas to evaluate the mechanisms of Th1 and Th2 lymphocyte differentiation. Local effects of cytokines were probed evaluating immunohistochemically the presence of inducible nitric oxide synthase positive tumor-infiltrating macrophages in 13 cases of laryngeal carcinomas. IL-12 gene expression was observed in five cases and that for IFNgamma in nine cases. These cytokines were coexpressed in four specimens. IL-4 and transforming growth factor-beta1 were detected in 5 and 11 cases, respectively. These findings show that IL-12, IFNgamma, IL-4, and IL-6 in laryngeal carcinomas have different patterns of gene expression, suggesting distinct pathways of Th1 and Th2 lymphocyte differentiation to indicate that their exogenous modulation might be utilized in adoptive immunotherapy.

alpha5 integrin distribution and TGFbeta1 gene expression in supraglottic carcinoma: their role in neoplastic local invasion and metastasis.

BACKGROUND: Head and neck carcinomas are characterized by tumor-infiltrating lymphocytes (TIL) producing cytokines. Adhesion molecules, extracellular matrix proteins (ECMPs), and cytokines regulate cell-cell and cell-ECMPs interactions. We investigated the distribution of these proteins to contribute to better understanding of their role in local tumor invasion and metastasis. METHODS: Distribution of integrins, laminin, type IV collagen, tenascin, and fibronectin was immunohistochemically evaluated in 13 supraglottis carcinomas. Cytokines gene expression was assessed by reverse-transcriptase-polymerase chain reaction (RT-PCR). RESULTS: Neoplastic cells were alpha2beta1, alpha3beta1, alpha4beta1, alpha5beta1 and alpha6beta1 positive. Normal and metaplastic epithelium was alpha5beta1 negative; the stroma of primary and metastatic tumors was tenascin and fibronectin positive. TGFbeta1 and IFNgamma gene expression was observed in the majority of tumors. CONCLUSIONS: Because TGFbeta1 is known to down-modulate immune processes and to increase alpha2beta1, alpha5beta1, and tenascin distribution, we propose that their expression in neoplastic cells of supraglottis carcinoma might represent an immune-related process able to help tumor growth and progression.

Management of abdominal lymphoproliferative diseases in the era of laparoscopy.

BACKGROUND: The treatment of lymphoproliferative diseases requires extensive histological, immunohistochemical, and cytogenetic diagnosis. The aim of this study was to analyze the results of 66 laparoscopic procedures in the diagnosis, staging, and restaging of hematological malignancies localized in the abdominal cavity. METHODS: Between July 1993 and March 1998, 64 consecutive patients (28 male and 36 female; mean age 46.6 years, range 7 to 69) with diagnosed or suspected lymphoproliferative diseases were referred for primary diagnosis or reassessment and for staging/restaging. RESULTS: Sixty-two out of 66 procedures (93.9%) were completed laparoscopically. CONCLUSIONS: The minimally invasive approach, in the management of lymphoproliferative diseases, is able not only to provide an adequate specimen for proper diagnostic techniques, but also, when compared with open surgery, to offer a large number of advantages.