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.

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.

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.

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.

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.

Dirofilarial human cases in the Old World, attributed to Dirofilaria immitis: a critical analysis.

AIMS: To review 28 cases of human dirofilariasis reported in the last 30 years in the Old World and attributed, by their respective authors, to Dirofilaria immitis or a species of Dirofilaria other than D. repens. METHODS AND RESULTS: Each case was analysed by examining the published accounts or by discussions with the authors, who were interviewed whenever possible. CONCLUSIONS: On the basis of these analyses we conclude that there is as yet no proof demonstrating with certainty that Old World D. immitis plays a pathogenic role in humans. It remains to be explained why D. immitis causes pulmonary infections in humans in the Americas while, in the Old World, this location appears, instead, to be always associated with D.repens, even though the former species is at times more frequent than the latter both in dogs and in the vectors. To explain this apparently different pathogenic power, two hypotheses are proposed: (i) there are perhaps twin populations with different genotypes on the two sides of the Atlantic, with different infective capacity for man and dog; (ii) the infective capacity to humans of the parasite could be modified, only in the Old World, by some unidentified factor, possibly inherent to the vector, that affects the complex mechanism of the vector-parasite relationship, affecting the survival of the larvae.

Distribution of second primary malignancies suggests a bidirectional effect between breast and endometrial cancer: a population-based study.

INTRODUCTION: The aim of this study was to investigate the incidence of second primary tumors in patients with breast cancer (BC), with particular regard to bidirectional risk for endometrial cancer (EC). METHODS: A total of 7512 and 343 patients with first and second primary BC, respectively, were referenced to the expected number of cases calculated using the standardized incidence ratio (SIR) over the same period, to evaluate the observed and expected ratio between the groups. Data on tamoxifen use were also considered. RESULTS: A total of 499 women with primary BC developed a second tumor. The total SIR, that is, the ratio between observed second primary cancer among patients with BC and the expected primary cancers in the general population, was significantly higher (SIR = 1.23; 95% confidence interval, 1.12-1.34; P = 0.007), particularly for melanoma (2.25), EC (2.15), ovarian cancer (1.74), hematologic malignancies (1.36), and bilateral BC (1.25). A greater risk of BC after thyroid (2.22) and EC (1.62) was also observed. Furthermore, the risk of developing EC was higher in patients treated with tamoxifen (SIR = 2.50 vs 1.34). CONCLUSIONS: Bidirectional risk of endometrial cancer was not exclusively related to tamoxifen use.

Unexpected intrauterine fetal death in parvovirus B19 fetal infection.

Parvovirus B19 infection during pregnancy can be transmitted to the fetus through the placenta. The consequences for the health of the fetus are very variable and can be very serious. They include intrauterine fetal death (IUFD) and miscarriage, which can lead to medico-forensic questions. For the most part, cases of IUFD take place during the second trimester of gestation and present an anatomopathologic picture characteristic of fetal infection with hydrops, placental edema, serous effusion, and erythroblastosis with nuclear inclusions. Endocardial fibroelastosis, medullar and thymic hypoplasia, and hepatic hemosiderosis are frequently present. In the third trimester, the cases are less frequent, not accompanied by hydrops, and can depend more on placental compromise than on direct infection of the fetus. We present 5 cases of IUFD resulting from parvovirus B19 and we discuss the pathogenetic and anatomopathologic aspects and obstetric liability. In 4 cases, the IUFD took place suddenly, in the absence of symptoms, in women who had not previously shown any symptom of the viral infection. In one case, the patient was hospitalized following an ultrasound diagnosis of fetal hydrops and IUFD took place 5 days after admission. Of these cases 3 were verified in the second trimester and 2 in the third trimester. Only the cases of the second trimester and one of the 2 cases of the third trimester presented the characteristic aspects of fetal infection. The other case of third trimester was characterized by placental involvement.

Alveolar rhabdomyosarcoma of the uterine cervix. A case report confirmed by FKHR break-apart rearrangement using a fluorescence in situ hybridization probe on paraffin-embedded tissues.

Alveolar rhabdomyosarcoma (ARMS) is a very rare malignant soft tissue tumor found in the uterine cervix. In fact, to our knowledge, only 3 cases have previously been described in the literature. A 49-year-old premenopausal woman who had a history of vaginal bleeding underwent hysterectomy for multiple uterine nodules. Pathologic examination showed multiple leiomyomas in the uterus and ARMS in the cervix. An FKHR break-apart rearrangement by fluorescence in situ hybridization (FISH) probe on paraffin-embedded tissues identified specific chromosomal abnormalities. Systemic chemotherapy and pelvic irradiation were also performed. She remains in clinical remission from neoplastic recurrences 14 months after surgery. The literature has been reviewed; the histologic differential diagnosis of this rare lesion has been discussed and FISH has been suggested to be useful in differentiating ARMS from other poorly differentiated round cell tumors.

3-T MRI in the preoperative evaluation of depth of myometrial infiltration in endometrial cancer.

OBJECTIVE: The objective of our study was to evaluate the diagnostic accuracy of 3-T MRI in determining the depth of myometrial infiltration in patients with endometrial cancer. SUBJECTS AND METHODS: Fifty-two patients (43 postmenopausal) with histopathologically proven endometrial carcinoma underwent preoperative 3-T MRI. The following sequences were performed: axial T1 fast spin-echo (FSE); axial, parasagittal, and paracoronal T2 FSE; paracoronal 3D T1 inversion recovery gradient-echo after contrast administration; and parasagittal fat-suppressed T1 FSE. All patients underwent a hysterectomy. The MRI findings were compared with histopathology results. The quantity and degree of artifacts were evaluated. RESULT: . MRI performed on a 3-T unit was in agreement with histopathology in assessing the depth of invasion in 86.4% (44/52) of the patients with a mean sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 83.5%, 93.9%, 77.8%, 92.2%, and 89.7%, respectively. Performance values were also assessed for single stages of myometrial infiltration. For the detection of an intramucosal lesion (MRI, 12/52; histopathology, 6/52), sensitivity was 100%; specificity, 86.9%; PPV, 50%; NPV, 100%; and accuracy, 88.5%. For the detection of myometrial infiltration that was less than 50% (MRI, 12/52; histopathology, 16/52), sensitivity was 62.5%; specificity, 94.4%; PPV, 83.3%; NPV, 85%; and accuracy, 84.6%. For the detection of myometrial infiltration that was greater than 50% (MRI, 28/52; histopathology, 30/52), sensitivity was 93.3%; specificity, 100%; PPV, 100%; NPV, 91.7%; and accuracy, 96.2%. The following artifacts were found: abdominal wall movement, nine patients (not affecting image quality); peristalsis, 16 patients (two deeply affecting, one affecting, and 13 scarcely affecting); magnetic susceptibility artifact, four patients (not affecting); chemical shift, 20 patients (four scarcely affecting and 16 not affecting); and dielectric effect, six patients (four deeply affecting and two affecting). CONCLUSION: In evaluating the depth of myometrial infiltration in patients with endometrial cancer, 3-T MRI showed high diagnostic accuracy-equivalent to that of 1.5-T MRI reported in the literature. Artifacts did not significantly affect image quality.

Periorbital subcutaneous tumor-like lesion due to Dirofilaria repens.

Dirofilariasis is a zoonotic infection, which is occasionally seen in humans and rarely found as a subcutaneous orbital swelling. The authors report a case of a 62-year-old woman presented with a 3-month history of a right periorbital subcutaneous nodule. Treatment with antibiotics and corticosteroids was not satisfactory. Magnetic resonance imaging analysis showed a nodule with a central colliquative area. The lesion displaced the eyeball superiorly but did not affect the intraorbital muscles. The patient was subjected to excisional biopsy and the nodule measured 15 mm. Histological findings showed microabscess reaction with heterogeneous lymphoid infiltration. Additional consecutive sections finally showed Dirofilaria repens, curled up in spirals with external cuticular ridges in an environment characterized by epithelioid cells. The lesion did not recur for 5 months. Periorbital swelling can be rarely caused by Dirofilaria repens; therefore, this diagnosis should be considered in all cases of subcutaneous inflammatory or tumor-like lesion of unknown etiology.

Mosquito-based survey for the detection of flaviviruses and filarial nematodes in Aedes albopictus and other anthropophilic mosquitoes collected in northern Italy.

In order to optimize resources, an assay allowing the detection of several etiological agents would be useful. This paper describes a polymerase chain reaction (PCR)-based assay for the parallel detection of different pathogens in mosquitoes (Diptera: Culicidae). The assay combines the analysis of both RNA and DNA, hence allowing the detection of both flaviviruses (Flaviviridae: Flavivirus) and filarial nematodes (Spirurida: Onchocercidae). The sensitivity of diagnostic assay for both flavivirus and nematode infections was tested by means of spiked samples and resulted adequate for the purpose of screening mosquito samples. The assay was implemented to check pathogen infections in 637 mosquitoes field-collected in Romagna, northern Italy. The integrity of RNA extracted from mosquito pools was checked by control amplifications targeting the 18 S rRNA of mosquitoes. Control amplifications were successful in 118 out of 119 pools. Flavivirus RNA was not found in any of these 118 pools, whereas DNA of Dirofilaria immitis (Leidy) was detected in one pool of Aedes albopictus (Skuse).

Spontaneous umbilical cord hematoma: an unusual cause of fetal mortality: a report of 3 cases and review of the literature.

Spontaneous hematoma of the umbilical cord represents a rare cause of fetal morbidity and mortality and the outcome is poor in half of the cases. There are many risk factors, such as infections, morphologic anomalies, alterations of the vessel walls, prolapses, twisting and traction of the cord, but in many cases the causes remain unknown. We present 3 cases of umbilical cord hematoma which took place at the end of the pregnancy and were followed by perinatal death of the fetus. In the 3 cases, which were autopsied including macroscopical and histopathologic examination of the placenta and the umbilical cord, a cordonal pathology was present; in all cases, there were alterations of the vascular wall, and in the third case inflammatory vasculopathy was found. In all 3 cases, the cause of death was attributed to acute anoxia due to the cordonal hematoma.

Appendicitis associated with presence of Schistosoma haematobium eggs: an unusual pathology for Europe. Report of three cases.

Three cases of appendicitis associated with presence of Schistosoma haematobium eggs in the appendix tissue are reported. The patients (two males and one female) were all from Ghana and had immigrated to Italy a few years previously. It is difficult to attribute the cause of the appendicitis to the parasite; it is more probable that the appendicular location of the eggs occurred accidentally many years earlier in an endemic zone of the country of origin, and that recently bacterial agents were able to provoke the present appendicitis. Since it is probable that with the increase in the number of immigrants to Europe from endemic countries (sub-Saharan Africa in particular) other similar cases may occur, it is important that the surgeon and the pathologist be aware of this pathology, which has so far been considered unusual.

Detection of Dirofilaria (Nochtiella) repens DNA by polymerase chain reaction in embedded paraffin tissues from two human pulmonary locations.

We here report two new cases of human pulmonary dirofilariasis in men aged 62 and 64 from Northern and Central Italy, respectively. Both were asymptomatic and the infections were discovered incidentally when chest radiographs taken for another reason revealed the presence of a coin lesion. The initial clinical diagnosis was oriented towards a lung tumour, and an excisional lung biopsy after thoracotomy was necessary for the final diagnosis. Pathologically, the lesion consisted of a roundish subpleural infarct with a central thrombotic artery containing sections of an immature nematode: Dirofilaria repens was diagnosed histologically in one case, the necrotic condition of the worm allowing only genus identification, Dirofilaria, in the other case. In both samples, PCR analysis amplified a 246 bp product, specific for the IpS insert 11 of D. repens. The authors stress the role of PCR in the diagnosis of this parasite from paraffin samples, also in cases in which identification of the species was not possible by conventional morphology due to poor conservation of the worm. These cases represent the first PCR-based diagnosis of D. repens in a human pulmonary dirofilariasis on samples embedded in paraffin.

Nanoparticulate drug carriers based on hybrid poly(D,L-lactide-co-glycolide)-dendron structures.

We describe a general method for incorporating target moieties in a well-defined arrangement into the surface of biocompatible polyester poly(D,L-lactic-co-glycolic acid) (PLGA) materials using dendrons. In this way it is possible to obtain nanoparticles (NPs) with a high degree of surface coverage. This new strategy was successfully applied to the preparation of peptide- and beta-D-glucose-covered NPs. The first application is based on the discovery of NPs made of conjugates between PLGA and short peptidic sequences able to cross the blood-brain barrier (BBB) after systemic administration. In this paper, we used a branched structure (dendron) in order to prepare a derivative of PLGA able to form, by simple nanoprecipitation, NPs with a higher degree of surface coverage than previously reported by us, characteristic that could influence the uptake by the liver and spleen. The NPs thus obtained retain the ability to cross the BBB and possess a core-shell structure, as evidenced from zeta-potential, X-ray photoelectron (ESCA) spectroscopy and elemental analyses. These results are comparable with the NPs obtained by the derivatization of preformed NPs. The same strategy, namely the use of a branched spacer (a dendron or a G1 dendrimer) inserted between one end of the PLGA chain and a derivatizing molecule, was also successfully applied to obtain beta-D-glucose-covered NPs; in this case, the surface analysis of the NPs was performed by using high resolution magic angle spinning (HRMAS) NMR spectroscopy and zeta-potential measurements.

Vegetable cells in Papanicolaou-stained cervical smears.

Vegetable cells are unusual findings in Papanicolaou-stained cervical smears; these structures could be wrongly mistaken for abnormal human cells, worm eggs, or spores by a cytologist encountering the possibility of meeting those elements in cytological analysis. Five cervicovaginal smears showing similar vegetable cells have been detected over a 3-yr period (2002-2004) in the course of a population screening program for cancer of the uterine cervix in Modena (Italy) involving 32,500 women. According to the clinical histories of the patients, the vaginal pharmaceutical drugs or appliances used were of different types: vaginal lavages, pessaries, and vaginal creams. Following a careful investigation, the only substance that can lead to vegetal elements has been identified as polysaccharide galactomannan, which is one of the excipient present in the drugs used. The authors have identified the origin of these contaminants and the means of pollution, using cytological and pharmaceutical investigation.

Sudden death from tubercular myocarditis.

Tuberculous myocarditis is a rare finding. We present the case of a 33-year-old woman who was in good health and who died suddenly at home. Autopsy and histopathologic examinations revealed granulamatous lesions in the myocardium, lungs, lymph nodes, liver, and spleen. No fast acid bacilli were demonstrated on histological examination. The presence of a Mycobacterium tuberculosis DNA complex was identified using a polymerase chain reaction (PCR) on formalin-fixed paraffin-embedded histological samples. An HIV test carried out on the blood obtained during the autopsy was negative according to the DNA amplification technique (PCR) and enzyme-linked immunosorbent assay serological test. We hypothesize that the mechanism of death was severe ventricular arrhythmia due to granulomatous proliferation in the structures of the interventricular septum.

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.