Neoplastic spread after trauma: natural death or manslaughter?

We report an unusual death of a seemingly healthy 26-year-old man due to diffuse metastasization of adrenal paraganglioma caused by rupture of the primitive tumour with subsequent massive haemorrhage after a relatively minor trauma. Our report describes the results of forensic investigation and discusses the possible mechanisms of metastasization.

Ischemic injury activates PTHrP and PTH1R expression in human ventricular cardiomyocytes.

The PTHrP/PTH1R signalling system induces calciotropic and myorelaxant effects on the vascular system and plays critical roles in the development of the cardiovascular system. In animal models, PTHrP exerts important effects on heart rate and contractility, particularly under ischemic conditions, while, in human hearts, the expression of PTHrP by cardiomyocytes remains to be defined in both normal and ischemic conditions. The present study has been conducted on 101 autoptical cases and confirmed on nine explanted hearts in order to analyze the expression of the PTHrP/PTH1R system by ventricular myocardium in respect to morphological aspects of the myocardial ischemic damage, myofiber hypertrophy and disarray, coronarosclerosis, age and sex. Immunohistochemistry showed positive cytoplasmic immunostaining for both PTHrP and PTH1R in ventricular cardiomyocytes. The expression levels of the PTHrP/PTH1R system resulted significantly increased (P = 0.0008 and P < 0.0001, respectively) in association with the myocardial ischemic damage and the presence of cardiomyocyte hypertrophy (P = 0.02 and P = 0.009 respectively). Conversely, increased expression levels of PTHrP alone were observed in myofiber disarray (P = 0.04), whereas PTH1R was augmented in coronarosclerosis (P = 0.004) and age (P = 0.001). Taken together, these results demonstrate that human ventricular cardiomyocytes express PTHrP and PTH1R and suggest that the activation of the PTHrP/PTH1R system could represent an aspect of the embryonic gene program typically reactivated by the myocardium when subjected to ischemia and/or hypertrophy.

A Fatal Mediastinitis Due to a Neck Trauma from an Undeclared Assault.

History of neck trauma should be promptly investigated in patients with severe infections of the chest as mediastinitis. We present a forensic case of a death due to a mediastinitis in a patient with an undetected fracture of the superior horn of the thyroid cartilage that was exclusively revealed at autopsy examination. Histological analyses of the neck tissues showed signs of pharyngeal mucosal microperforation caused by the fracture and surrounded by an inflammatory reaction. The fracture was caused by a not declared manual strangulation attempt, happened several days before medical evaluations. We share our experience to emphasize the importance of revealing the etiologies of fatal infections of the mediastinum both for clinical and forensic purposes.

Non-atherosclerotic coronary pathology causing sudden death.

Coronary atherosclerosis is responsible for >50% of all cases of sudden death and for 90% of sudden coronary death. Four cases encountered in routine autopsy evaluation at our institute in 2004 in which non-atherosclerotic coronary pathology was responsible for sudden cardiac death are reported. The cases of a 31-year-old man with epicardial coronary arteritis, a 57-year-old man with intramyocardial vasculitis, a 45-year-old woman with spontaneous coronary dissection and a 50-year-old man with vascular fibrosis are described. Searching for non-atherosclerotic coronary disease is relevant for both the clinician and the pathologist to prevent coronary causes of sudden death going unrecognised.

Primary renal angiosarcoma: a rare malignancy. A case report and review of the literature.

Angiosarcoma is a rare malignant tumor occurring in less than 2% of soft tissue sarcomas. Angiosarcoma involving the kidney usually represents metastasis from skin or visceral primary lesions, while angiosarcoma primarily occurring in the kidney is a very rare neoplasm. In the English literature, from 1942 to the present, only 19 cases of primary kidney angiosarcoma have been reported. A case of primary renal angiosarcoma presenting as a large kidney mass and flank pain occurring after traumatism is reported. The present case represents further evidence of a rare malignancy.

Diagnostic relevance of the immunohistochemical detection of growth factors in benign and malignant cartilaginous tumors.

The goal of this study was to evaluate the diagnostic relevance of the expression of growth factors in cartilaginous tumors and to investigate on the possible correlation with grade, local recurrence, metastatic potential, and survival. Expression of VEGF, PDGF, FGF1, TFGbeta2, TNFalpha, Ki-67, and p53 was analyzed in 21 cases of benign and malignant cartilaginous tumors using immunohistochemistry. Immunohistochemical staining was performed on sections from paraffin-embedded tissue. The correlation of these markers' expression and grading or clinical outcome was also evaluated. Immunohistochemistry revealed a high correlation between grading and VEGF-positive staining (P=0.001). In addition, a correlation with local recurrence was found in cases with a positive expression of Ki-67 (P=0.035), TGFbeta (P=0.007), PDGF (P=0.007), and p53 (P=0.0455), with a time-related association. These data suggest a progressive modification in the biologic behavior of malignant cartilaginous tumors. VEGF could be used as a marker in the preoperative surgical assessment of chondrosarcoma. New therapeutic strategies could be considered for VEGF-positive cases. Positive expression of TGFbeta and PDGF seems to be a predictor of clinical outcome.

An acephalus acardius amorphous fetus in a monochorionic pregnancy with sex discrepancy.

Acephalus acardia is among the most severe malformations described in fetuses, with an incidence of about 1 in 35,000 births and is due to twin-to-twin transfusion syndrome, frequently occurring in monochorionic twin pregnancies. The severity of the syndrome depends upon the type of the anastomoses arising between the vascular networks of the two fetuses, usually configuring the 'twin reverse arterial perfusion syndrome'. No clear and univocal etiological explanation is known, though few cases with chromosomal abnormalities have been reported so far. In some cases the fusion of two or more separate placentae of dizygotic fetuses occurs, leading to monochorionic twinning. Few cases of acardius amorphous with complete autoptical examination have been described so far. We report a case of acephalus acardius amorphus fetus, showing features of extremely severe sistemic immaturity with very few structured organs. Defined external and autoptic examinations have been performed on the dismorphic twin, along with the histological examination of tissue samples. Kariotype analysis showed sex discrepancy between the twins, as a normal female kariotype had been detected in the acephalus acardius while the living co-twin was a normal healthy male. The analysis of the placenta showed the vascular anomalies leading to the twin-to-twin transfusion syndrome.

Diagnostic efficacy of immunocytochemistry on fine needle aspiration biopsies processed by thin-layer cytology.

OBJECTIVE: To evaluate the efficacy of immunocytochemistry (ICC) performed on smears processed by thin-layer cytology (TLC). STUDY DESIGN: During the period January 2001-September 2003, 3,573 consecutive fine needle aspiration biopsies were processed with both conventional smears (CSs) and TLC diagnosed by a single pathologist; 113 required immunocytochemical study. CSs were fixed in ethanol whereas TLC slides were processed with the ThinPrep 2000 method (Cytyc Co., Marlborough, Massachusetts, U.S.A); both were stained with Papanicolaou stain. ICC staining was carried out on only TLC slides. RESULTS: The 113 cytologic cases were grouped as follows: 32 thyroid nodules with 16 histologic controls (HCs), 24 lymph nodes (regardless of location) with 15 HCs, 18 liver and pancreatic lesions (3 HCs), 11 lung nodules (6 HCs), 5 kidney and adrenal gland lesions (1 HC), 6 abdominal (2 HCs) and 4 mediastinal masses (1 HC), 6 salivary gland tumors (3 HCs), 4 bone masses (2 HCs) and 3 subcutaneous lesions (1 HC). ICC contributed to the diagnosis in 104 cases (92%), whereas it was inconclusive in 9. The cytologic diagnoses were histologically confirmed in 46 of 50 cases (92%). CONCLUSION: ICC can be successfully applied on TLC slides with better results than on CSs, and its yield can be useful in making the correct diagnosis on fine needle aspiration biopsy.

Exercise-unrelated sudden death as the first event of anomalous origin of the left coronary artery from the right aortic sinus.

Congenital anomalous origins of the coronary arteries represents a rare but well-described cause of myocardial ischemia and sudden death. Left coronary artery (LCA) arising from the right sinus of Valsalva is a rare congenital coronary anomaly that seems to be commonly associated with sudden death in young trained athletes. The possibility of a coronary artery anomaly should always be considered in young individuals with a history of chest pain or syncope, particularly if the episodes are triggered by exercise. We describe a case of congenital LCA anomaly in an asymptomatic 10-year-old girl with no family history of sudden death; no previous unexplained syncopal episodes or exercise-induced symptoms were reported. She experienced a cardiac arrest while she was resting at school and was not recoverable despite early emergency department admission and intensive prolonged cardiopulmonary resuscitation attempts. Post-mortem pathological findings revealed a single origin from the right sinus of Valsalva for both right and left coronary arteries. The LCA was compressed between the aorta and the pulmonary trunk. Histologic features suggested recent ischemia. Although sudden death can be the first manifestation of this condition, it is important to be particularly aware of prodromic symptoms: exertional dyspnea, chest pain, syncope or dizziness. Recognition during life of this coronary anomaly is mandatory to prevent the risk of sudden death and to plan surgical correction if clinically indicated.

Fatal pulmonary arterial dissection and sudden death as initial manifestation of primary pulmonary hypertension: a case report.

We report a rare case of sudden death due to cardiac tamponade following intrapericardial rupture of a main pulmonary artery dissecting aneurysm. On pathology examination, the pulmonary artery showed an intimal tear in an arterial wall area with reduced thickness. However, no degenerative, inflammatory or necrotic processes were evident within the vessel wall. Hypertrophy of the wall of vasa vasorum in the adventitia of the pulmonary artery was found, as well as bilaterally diffuse myointimal arterial hyperplasia of the lung vasculature. According to these findings, we conclude that pulmonary artery rupture occurred in a patient with chronic unrecognized primary pulmonary hypertension.

Adrenal Schwannoma. Report of two cases.

Adrenal tumours are frequently incidental discoveries, and their therapy is a subject of controversial discussions. Herein we describe two cases of adrenal schwannoma discovered during autopsy. The accidental observation of two benign schwannomas of the adrenal gland on asymptomatic patients led to the hypothesis that the real frequency of this type of lesion was underestimated. Furthermore, the adrenal origin of the superior retro-peritoneum schwannomas represents a diagnostic hypothesis to be considered when the original structure of the neoplasia can't be established.

Histological classification of lung cancer.

A histological classification should provide guidelines for tumor diagnosis in order to evaluate patient prognosis and therapy. Pre-invasive lesions identified as precursors of invasive lung carcinoma are: squamous dysplasia/carcinoma in situ, atypical adenomatous hyperplasia and idiopatic pulmonary neuroendocrine cell hyperplasia. Squamous carcinoma and adenocarcinoma are the commonest types of lung carcinoma with the latter increasing in many countries mainly for changed smoking habits. Bronchioloalveolar carcinomas include exclusively noninvasive mucinous or non-mucinous tumors. Neuroendocrine tumors range from well differentiated neuroendocrine carcinoma (typical carcinoid) to intermediate grade (atypical carcinoma) to very aggressive poorly differentiated lesions (large cell neuroendocrine carcinoma and small cell carcinoma).

The role of forensic botany in crime scene investigation: case report and review of literature.

Management of a crime is the process of ensuring accurate and effective collection and preservation of physical evidence. Forensic botany can provide significant supporting evidences during criminal investigations. The aim of this study is to demonstrate the importance of forensic botany in the crime scene. We reported a case of a woman affected by dementia who had disappeared from nursing care and was found dead near the banks of a river that flowed under a railroad. Two possible ways of access to crime scene were identified and denominated "Path A" and "Path B." Both types of soil and plants were identified. Botanical survey was performed. Some samples of Xanthium Orientalis subsp. Italicum were identified. The fall of woman resulted in external injuries and vertebral fracture at autopsy. The botanical evidence is important when crime scene and autopsy findings are not sufficient to define the dynamics and the modality of death.

A case of sudden infant death due to a primary cardiac sarcoma.

The case reported herein concerns the unexpected death of a 3-month-old female newborn who suddenly collapsed in her mother's arms and was dead on arrival at the hospital. The clinical histories of the baby and her parents were negative for symptoms or signs of illness, even those of cardiovascular origin. Furthermore, no clinical appearance of a pathologic status was noted by pediatricians after the birth until the last emergency recovery. The autopsy excluded external and internal signs of violence but revealed a large primary cardiac tumor arising from the free wall of the left ventricle, which had totally invaded the heart causing mitral valve deformation. Histological examination showed a low-grade sarcoma that completely infiltrated the myocardial tissue. The pathogenesis of this sudden infant death was postulated as being owing to a fatal ventricular fibrillation combined with a tumor-related restrictive cardiomyopathy obstructing left ventricular filling.

Venous air embolism after cardiopulmonary resuscitation: the first case with histological confirmation.

We report a case of intracerebral air embolism after cardiopulmonary resuscitation in a patient with a fatal myocardial infarct. Cases of cerebral air embolism rarely occur as a result of cardiopulmonary resuscitation in cases of cardiopulmonary arrest on arrival. This is the first case with postmortem histological confirmation.

Hypoplastic coronary artery disease causing sudden death. Report of two cases and review of the literature.

Congenital coronary anomalies represent a condition often unrecognized in the living and in the dead. Investigating this condition is relevant for both clinicians and pathologists in order to identify potentially unrecognized coronary causes of sudden death. Hypoplastic coronary artery disease (HCAD) is a rare congenital abnormality reported to be associated with sudden death. We report two additional cases of previously apparently healthy people who died suddenly and were found to have HCAD at postmortem evaluation. The clinicopathologic findings are discussed along with a review of the literature.