Microsatellite instability in metaplasia-dysplasia-adenocarcinoma sequence of Barrett esophagus: a retrospective study.

AIM: To analyze the loss of mismatch repair (MMR) system protein expression in metaplasia-dysplasia-adenocarcinoma sequence of Barrett esophagus (BE). METHODS: This study retrospectively analyzed the data from 70 patients with pathohistological diagnosis of BE or esophageal adenocarcinoma (EAC) treated at the Clinical Department of Pathology and Cytology, University Hospital Center Zagreb, from January 2009 to January 2011. Patients were divided into three groups: BE without dysplasia (22 patients), BE with dysplasia (37 patients), and EAC (11 patients). Immunohistochemical expression of MutL homologue 1 (MLH1), MutS homologue 2 (MSH2), postmeiotic segregation increased 2 (PMS2), and MutS homologue 6 (MSH6) of DNA MMR system was measured and compared with tumor protein p53 expression. RESULTS: A total of 81.8% and 81.8% patients with EAC, 32.4% and 35.1% patients with dysplasia, and 50% and 54.5% patients without dysplasia had loss of MLH1 and PMS2 expression, respectively. Patients with EAC and patients with dysplasia did not have loss of MSH2 and MSH6 expression, and 18.2% patients without dysplasia had loss of MSH2 and MSH6 expression. There was a strong positive correlation between MLH1 and PMS2 expression (Spearman ρ 0.97; P<0.001) and between MSH2 and MSH6 expression (Spearman ρ 0.90, P<0.001) in the entire sample and in all BE groups. No significant correlations of MLH1 and PMS2 with p53 expression were found, except in dysplasia group (φ 0.402, P=0.030 for MSH1; φ 0.371, P=0.042 for PMS2). CONCLUSION: Although we demonstrated considerable loss of MLH1 and PMS2 expression in BE-associated carcinoma sequence, due to the retrospective study design and low number of patients we cannot conclude that MLH1 and PMS2 can be used as biomarkers for patient surveillance and therapy-making decisions. Oxford Centre for Evidence-based Medicine level of evidence: 3.

Immunohistochemical expression of 8-oxo-7,8-dihydro-2'-deoxyguanosine in cytoplasm of tumour and adjacent normal mucosa cells in patients with colorectal cancer.

BACKGROUND: The aim of this research was to study the levels of 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG) in tumour tissue samples of colorectal carcinoma based upon immunohistochemical detection and compare those results with patients' outcome. METHODS: Tumour blocks of patients surgically treated for colorectal cancer were evaluated by 8-oxodG immunohistochemical staining. The expression was analysed in 500 tumour cells. The percentage of positive cells, as well as staining intensity, was recorded, and Allred score was calculated. For each patient, data of age, gender, tumour size and location, margin status, histologic grade, tumour stage, lymph node status, vascular invasion, overall survival, and therapy protocols were collected. Tumour grade was divided into two groups as low and high grade. RESULTS: In this study, 146 consecutive patients with primary colorectal carcinoma were included. All data were available for 138 patients, and they were included in this research. There were 83 male and 55 female patients; the median age was 64 years (range 35-87 years). The results showed shorter 5- and 10-year survival in patients with 8-oxodG positive tumour cells (5-year survival, n=138, Mantel-Cox, chi-square 4.116, degree of freedom (df)=1, p<0.05; 10-year survival, n=134, Mantel-Cox, chi-square 4.374, df=1, p<0.05). The results showed a positive correlation between Allred score and high tumour grade (two-tailed Spearman's ρ 0.184; p<0.05), as well as with non-polypoid tumour growth (two-tailed Spearman's ρ 0.198; p<0.05). There was no significant difference of 8-oxodG expression related to age, sex, blood group, size and tumour site, distance from the edge of the resected tumour margin, lymph nodes involvement, and vascular invasion. CONCLUSIONS: In this study, the positive correlation between 8-oxodG presence in the tumour cells, worse clinical outcome, higher tumour grade, and flat morphology was found.

[Clinical recommendations for diagnosis, treatment and monitoring of patients with cancer of unknown primary site]. / Klinicke preporuke za dijagnozu, lijecenje i pracenje bolesnika oboljelih od raka nepoznata primarnog podrijetla.

Cancer of unknown primary (CUP) site comprises very heterogeneous group of various malignant tumors presented in metastatic phase of the disease. Diagnosis is set when primary site remains unidentified after a thorough diagnostic evaluation in patients with histologically proven malignant metastatic disease. Despite poor prognosis in most patients, favorable prognostic clinical entities have been recognized constituting the most important group of patients for oncological treatment. The following text presents the clinical guidelines in order to standardize the diagnosis, treatment and follow-up of patients with cancer of unknown primary site in the Republic of Croatia.

[CLINICAL GUIDELINES FOR DIAGNOSIS, TREATMENT AND MONITORING OF PATIENTS WITH INVASIVE BREAST CANCER--CROATIAN ONCOLOGY SOCIETY]. / KLINICKE UPUTE HRVATSKOGA ONKOLOSKOG DRUSTVA ZA DIJAGNOZU, LIJECENJE I PRACENJE BOLESNICA/KA OBOLJELIH OD INVAZIVNOG RAKA DOJKE.

Breast cancer is the most common cancer in women. It can be diagnosed in early stage through screening, early detection and educational programs, and when diagnosed early it can be efficiently treated. Treatment modalities include surgery, chemotherapy, radiotherapy, hormonal therapy and targeted biologic therapy, according to the stage of the disease and patient condition. Treatment decisions should be made after multidisciplinary team discussion. Due to the significance of this disease it is important to define and implement standardized approach for diagnostic, treatment and monitoring algorithm as well. The following text presents the clinical guidelines in order to standardize the procedures and criteria for diagnosis, management, treatment and monitoring of patients with breast cancer in the Republic of Croatia.

[COLONIC MUCO-SUBMUCOSAL ELONGATED POLYP: A CASE REPORT AND LITERATURE REVIEW]. / IZDUZENI SLUZNICNO-PODSLUZNICNI POLIP DEBELOG CRIJEVA: PRIKAZ BOLESNIKA I PREGLED LITERATURE.

Recently a new entity has been described--a colonic muco-submucosal elongated polyp (CMSEP)--that did not fall into traditional classification of colorectal polyps. The CMSEP is endoscopically characterised by elongated, worm-like appearance with a normal overlying mucosa. Histologic characteristics of the CMSEP comprise mucosa and expanded submucosa with dilated vasculature and lymphatics. Herein, we report a case of CMSEP, that to the best of our knowledge, has not been previously described in our literature. With regard to the on-going National colorectal cancer screening programme, our intention is to draw attention of gastrointestinal pathologists and endoscopists to this distinctive and very rare phenomenon.

Extramedullary plasmacytoma imitating neoplasm of the gallbladder fossa after cholecystectomy.

Extramedullary plasmacytomas are plasma cell tumors that arise outside of the bone marrow. They account for approximately 3% of plasma cell neoplasms and are most frequently located in the head and neck region. Five months after undergoing cholecystectomy, a 69-year-old patient presented with the pain under the right costal margin and a 12 kg weight loss. Computed tomography of the abdomen demonstrated irregular, vascular mass in the gallbladder fossa that dents towards the duodenum and the pylorus and lowers caudally to the hepatic flexure. His laboratory tests indicated normocytic anemia and showed elevated sedimentation rate. During operative procedure, a tumorous mass in the gallbladder fossa was found, inseparable of the peritoneum of the hepatoduodenal ligament and the IVb liver segment. Histopathological examination and immunohistochemical staining determined the diagnosis of the plasmacytoma. Total resection of the tumor was achieved and after 24-month follow-up patient showed no signs of local recurrence or dissemination of the disease.

[Ultrasound guided breast biopsy--a retrospective study and literature review]. / Biopsija dojke pod kontrolom ultrazvuka--retrospektivna studija i pregled literature.

AIM: The purpose of this study is to determine the accuracy and clinical usefulness of ultrasound guided core biopsy for diagnosing suspicious radiologically detected breast lesions. PATIENTS AND METHODS: We retrospectively evaluated the results of percutaneous core biopsy with 14-gauge needles performed over a period of 14 months on 229 suspicious lesions detectable on mammography and/or ultrasound exam (BI-RADS 4 or 5). The imaging-histological concordance was ascertained for each lesion. In cases of discordance, repeat biopsy or surgical excision was performed. Six-month ultrasound control was recommended in cases of benign lesions. For borderline and malignant lesions a surgical excision was done. Concordance between biopsy results and subsequent examinations (surgical excision or follow-up) was also evaluated. RESULTS: Histological analysis of core biopsy samples showed 143 (62.4%) benign lesions, 21 (9.2%) borderline lesions and 65 (28.4%) malignant lesions. Follow-up, repeated biopsy, or surgical excision showed four false negative cases. Accuracy of ultrasound guided core biopsy was 98.3%. CONCLUSION: Ultrasound guided core biopsy is a safe and reliable method for diagnosing suspicious breast lesions without any significant complications as was reported in previous studies.

[Breast cancer metastases to the stomach and colon: two case reports]. / Metastaze karcinoma dojke u zeludac i debelo crijevo: prikaz dviju bolesnica.

Summary. Breast cancer has a high potential for metastasis, usually to the lungs, bones, liver and lymph nodes. Metastases in the holow organs of the digestive system are rare and mainly affectes the stomach and colon. They are characterized by very different clinical and radiological manifestations. We have warned that the initial unrecognized breast cancer can appear as a primary tumor of the stomach and colon, and onlya histopathological analysis reveales that it is a metastatic breast cancer. Metastases to the stomach or intestine involve deep layer of the mucosa and pathohistological findings of standard biopsy sample can be falsely negative, despite positive imaging technique (abdominal ultrasound and MSCT, endoscopic ultrasound) that indicate the tumor process. That's,why we emphasize the importance of endoscopic mucosal resection in the detection of malignant process of deeper layers of the gastric mucosa and deep intestinal mucosal biopsies with postoperative analysis of its walls.

[Clinical guidelines for diagnosis, treatment and monitoring of patients with non-invasive breast cancer]. / Klinicke smjernice za dijagnostiku, lijecenje i pracenje bolesnika s neinvazivnim rakom dojke.

Breast cancer is the most common malignancy in women. Early diagnosis and more effective treatment of invasive breast cancer resulted in significant mortality reduction, improvement of survival and the quality of life of the patients. The management od non-invasive breast cancer, on the contrary, is still controversial and the problem of overdiagnosis and overtreatment of patients come to evidence. In the following text a multidisciplinary team of experts brings the first consensus guidelines aimed to standardize and optimize the criteria and management in diagnosis, treatment and monitoring of non-invasive breast cancer patients in the Republic of Croatia.

[Congenital hyperinsulinism--novel insights into etiology, diagnosis and treatment]. / Kongenitalni hiperinzulinizam- -novosti o nastanku, dijagnosticiranju i lijecenju bolesti.

Congenital hyperinsulinism (CHI) is a major cause of persistent hypoglycemia in the neonatal and early infancy periods. Althought the disease is relatively rare with incidence of about 1:25 000-50 000 live births, the importance of the disease should not be underestimated. Namely, prompt recognition and management of patients with CHI is essential, if permanent neurological impairment is to be avoided. CHI is caused by mutations in one of the 7 genes involved in the regulation of insulin secretion in pancreatic beta-cells. It is important to introduce specific medical therapy as soon as diagnosis is established. Severe, neonatal forms of CHI are often resistant to medications, thus they require surgical procedure. The preoperative genetic testing and scintigraphy are indicated to distinguish histological subtypes of the disease (focal vs. diffuse CHI). Patients with focal disease are usually cured after pancreatic resection, while diffuse disease has much worse prognosis. This manuscript offers novel insights into CHI and emphasizes the role of early diagnosis as crucial for succesful treatment that was recently enriched with novel options.

Spontaneous perforation of the small intestine, a novel manifestation of classical homocystinuria in an adult with new cystathionine beta-synthetase gene mutations.

The clinical picture of classical homocystinuria is diverse. This is the first report of an adult homocystinuric patient with non-traumatic spontaneous small bowel perforation. A 47-year old man presented with abdominal rebound tenderness, hypotension and tachycardia, anemia, and elevated markers of inflammation. Other routine laboratory tests were normal. Abdominal x-ray showed no free air. An emergency laparotomy revealed jejunal perforation in the left upper quadrant. Histologic specimen showed full-thickness nonspecific inflammation of the intestinal wall with granulocytic infiltration, hemorrhage and necrosis. Tuberculosis, actinomycosis and typhus were histologically and clinically excluded. After excluding all known possible causes of perforation, we presumed a causative relationship between homocystinuria and small bowel perforation. It could be hypothesized that connective tissue weakness in homocystinuria is a result of homocysteine interference with recombinant human fibrillin-1 fragments or cross-linking of collagen through permanent degradation of disulfide bridges and lysine amino acid residues in proteins. DNA analysis showed three detectable mutations in the cystathionine beta-synthetase gene, 1278T:c.833T>C, and two new mutations, V372G:c.1133T > G, and D520G:c.1558A > G in the aternatively spliced exon 15.

[The role of KRAS gene mutation testing in colorectal cancer--a predictive biomarker of response to EGFR inhibitors therapy]. / Uloga mutacije gena KRAS u kolorektalnom karcinomu--prediktivni cimbenik odgovora na lijecenje inhibitorima EGFR-a.

Activation of KRAS oncogene has been implicated in colorectal carcinogenesis. KRAS mutations can be detected in more than 30% of all patients with colorectal cancer (CRC). Most recently, regimens that include anti-epidermal growth factor receptor (EGFR) targeted antibodies, cetuximab and panitumumab, for metastatic CRC have been developed. Several recent studies have shown that patients with KRAS mutations in codons 12 and 13 in metastatic CRC do not benefit from anti-EGFR therapy. With the aim to determine KRAS status as predictive biomarker, 7 known mutations ofKRAS gene in codons 12 or 13 on 44 CRC samples were tested. After DNA extraction from paraffin-embedded tumor tissue blocks, KRAS mutations were analysed using quantitative real-time PCR with internationally certified method, for the first time in Croatia. Mutations were detected in 12 tumor samples: five patients with Gly12Val (GGT>GTT), three with Gly12Asp (GGT>GAT), two patients with Gly13Asp (GGC>GAC), one patient with Gly12Ser (GGT>AGT) and one with Gly12Cys (GGT>TGT) mutation in tumor. Our data about KRAS mutational status in the sample of Croatian population diagnosed with CRC have shown that incidence of KRAS mutation is 27%, which is consistent with results already reported worldwide. The final result must be a proper selection of the correct therapy with EGFR inhibitors for the patients with CRC which is critical for improving clinical outcomes, unnecessary toxicities, side effects and financial cost.

[Consensus guidelines for diagnosis, treatment and follow-up of patients with gastrointestinal stromal tumors]. / Prijedlog postupnika za dijagnostiku, lijecenje i pracénje oboljelih od gastrointestinalnih stromalnih tumora.

Gastrointestinal stromal tumors are the most common mesenchymal tumors in gastrointestinal tract. They are often asymptomatic and discovered incidentally during endoscopic or barium studies. About 80% GISTs have a KIT (CD 117 antigen) gene mutation. Most affect exon 11, less commonly exon 9,13 or 17, that results in uncontrolled KIT signaling. This led to effective systemic therapies in the form of small molecule inhibitors of the receptor tyrosine kinase such as imatinib mesylat. With the purpose of providing standardized approach to rational and effective diagnostic and treatment algorithm in Croatia, a multidisciplinary session was organized. Results of the session are given in the form of Consensus guidelines.

Expression of E26 transformation specific-1 (ETS-1) in tumour-infiltrating lymphocytes (TILs) is adverse prognostic factor in invasive breast cancer.

AIM OF THE STUDY: The microenvironment depicts the relationship between tumour cells and immune response, and every insight into stromal lymphocytes could contribute to explain their role and activity. E26 transformation specific-1 (ETS-1) is a transcription factor that is active in cell proliferation. We analysed its immunohistochemical expression in tumour infiltrating lymphocytes (TILs) in invasive breast cancer and correlated its immunohistochemical score (IHS) to traditional predictive and prognostic factors and survival. MATERIALS AND METHODS: The sample contains data of 121 patients with invasive breast cancer, not otherwise specified (NOS) who underwent mammectomy and lymphadenectomy in 2002 at the Clinical Hospital Centre Zagreb, Croatia. Paraffin blocks of the tumour tissue were collected from the pathological archive. Three representative areas of every patient were chosen and multiple tissue samples were made. Immunohistochemical staining with rabbit anti-ETS-1 (Novocastra, UK) and the ABC method was performed on a DAKO Autostainer. The expression of ETS-1 in stromal TILs was analysed on an Olympus 41 microscope. The IHS score was calculated and correlated with clinical and pathological parameters, as well as disease-free survival (DFS) and overall survival (OS). RESULTS: In almost all patients (95%), some expression of ETS-1 in TILs was found. A moderate/high score of ETS-1 correlated with larger tumour size and higher histological grade, high proliferation index and low progesterone receptors (PgR). The patients with moderate/high ETS-1 expression in TILs had shorter DFS than patients with weak/negative ETS-1 expression. CONCLUSION: In invasive breast cancer NOS, expression of ETS-1 in TILs is an adverse prognostic factor.

Morphometry of tumor cells in different grades and types of breast cancer.

The aim of the study was to compare morphometric characteristics of different types and grades of breast cancer. Morphometric analysis was performed using the SFORM software (Vamstec, Zagreb) on the May-Grünwald-Giemsa stained fine needle aspiration cytology (FNAC) breast tissue specimens. The study included 42 patients diagnosed with breast carcinoma by breast smear FNAC at Merkur University Hospital during the 2001-2005 period. Postoperative tumor histopathology and semi-quantitative tumor grading by the method of Elston and Ellis' showed invasive ductal carcinoma grade I in 10, invasive ductal carcinoma grade II in 9, invasive ductal carcinoma grade III in 13, and invasive lobular carcinoma in 13 patients, the latter also including a subtype of invasive tubulolobular carcinoma. The following parameters were assessed by use of Statistica 7.1 and chi2-test: tumor area, circumference, maximal radius, minimal radius, convexity, length, width, elongation, nucleus/cytoplasm ratio, and shape factor. Morphometric analysis yielded statistically significant differences among all study groups (p < 0.001). Morphometric parameters showed significant individual correlation with tumor type and grade, whereby the area, convexity and circumference were most significant at both nuclear and cellular level.

A case report of breast angiosarcoma.

Angiosarcoma is a rare disease of the breast with the reported incidence of only 0.04% of all breast malignancies. The etiology of angiosarcoma remains unknown. It occurs post-mastectomy, in association with chronic lymphedema (Stewart-Treves syndrome), or after radiotherapy. We present a patient with angiosarcoma which developed 12 years of the diagnosis of breast carcinoma and 8 years of the operative procedure and radiotherapy for disease recurrence. A small angiomatous lesion of a few mm in size, cytologically suspect of vascular tumor (hemangioma or hemangiopericytoma) and histopathologically verified to be an atypical vascular lesion, was detected two years before breast enlargement and cytologic and histologic diagnosis of angiosarcoma. The patient died 15 months of the diagnosis of angiosarcoma, after two tumor recurrences and intrathoracic cavity invasion.

[Consensus guidelines for diagnosis, treatment and follow-up of patients with pancreatic neuroendocrine tumors]. / Postupnik za dijagnostiku, lijecenje i pracenje oboljelih od neuroendokrinih tumora gusterace.

Pancreatic neuroendocrine tumors (PETs) are increasingly recognized. In order to assure an optimal treatment of patients and to propose an efficient diagnostic algorithm we were prompted to organize meetings, with participating experts, specialists in different fields of expertise. The idea for the meetings was to try to give a standardized approach, which would in future help in stratification of PET patients. Results of meetings are given in a form of Consensus guidelines for diagnosis, treatment and follow-up of patients with pancreatic neuroendocrine tumors.

[Pulmonary Langerhans' cell histiocytosis--case report]. / Plucna histiocitoza Langerhansovih stanica--prikaz bolesnika.

Authors report a case of a 29-year old patient with pulmonary Langerhans' cell histiocytosis who presented with chest pain as a consequence of rib osteolytic process. We carried out a diagnostic work-up which included laboratory and radiographic analysis, lung function tests, bronchoscopy, cytologic and pathologic analysis. After reaching the diagnosis, corticosteroid therapy was introduced with long-term follow-up. In this report, we included a brief review of pulmonary Langerhans' cell histiocytosis.