Children and adolescents with ureteropelvic junction obstruction: is an additional voiding cystourethrogram necessary? Results of a multicenter study.

PURPOSE: The incidence of ureteropelvic junction obstruction (UPJO) and concomitant vesicoureteral reflux (VUR) ranges from 14 to 18 %. Therefore, different guidelines recommend a voiding cystourethrogram (VCUG) to identify cases of VUR early in the diagnostic process. Aim of this multicenter study was to reassess the incidence of concomitant VUR and the need for additional VCUG in a large cohort of patients with UPJO. Furthermore, we asked for clinical objectives that defined the need for VCUG with the intention of minimizing radiation exposure and the need for invasive diagnostic procedures. METHODS: Medical records for 266 patients (69 girls, 197 boys) with UPJO were analyzed retrospectively. Data were obtained on gender, clinical symptoms, results of pre- and postnatal ultrasound, VCUG and 99(m)Technetium-MAG3 (MAG3) scan. They were correlated with the incidence of concomitant VUR. RESULTS: One hundred and seventy-eight patients (67 %) underwent VCUG. Concomitant VUR was detected in 13 patients. Dilating VUR (dVUR) was observed in 11 patients. In our study, the overall incidence of a concomitant VUR was 7.3 %. In cases of proven VUR, we observed a positive predictive value for female gender, ureteral dilatation, renal insufficiency, and recurrent urinary tract infections (UTI). But there was no correlation between concomitant VUR and the severity of hydronephrosis. CONCLUSIONS: Our data suggest that the low incidence of concomitant VUR in cases of UPJO does not justify the routine use of VCUG as a routine diagnostic tool. Especially, ureteral dilatation and recurrent UTI have a positive predictive value for concomitant VUR.

Ferroptosis in Different Pathological Contexts Seen through the Eyes of Mitochondria.

Ferroptosis is a recently described form of regulated cell death characterized by intracellular iron accumulation and severe lipid peroxidation due to an impaired cysteine-glutathione-glutathione peroxidase 4 antioxidant defence axis. One of the hallmarks of ferroptosis is a specific morphological phenotype characterized by extensive ultrastructural changes of mitochondria. Increasing evidence suggests that mitochondria play a significant role in the induction and execution of ferroptosis. The present review summarizes existing knowledge about the mitochondrial impact on ferroptosis in different pathological states, primarily cancer, cardiovascular diseases, and neurodegenerative diseases. Additionally, we highlight pathologies in which the ferroptosis/mitochondria relation remains to be investigated, where the process of ferroptosis has been confirmed (such as liver- and kidney-related pathologies) and those in which ferroptosis has not been studied yet, such as diabetes. We will bring attention to avenues that could be followed in future research, based on the use of mitochondria-targeted approaches as anti- and proferroptotic strategies and directed to the improvement of existing and the development of novel therapeutic strategies.

Molecular characteristics and prognostic significance of Bcl-2/IgH gene rearrangement in Serbian follicular lymphoma patients.

Follicular lymphoma (FL) is characterized by the presence of a t(14;18) chromosomal translocation that results in overexpression of bcl-2 protein. Bcl-2/IgH gene rearrangement is detected in 80-90% of follicular lymphomas in Western countries. The aim of this study was to analyze the bcl-2/IgH rearrangement in FL lymphoma patients in Serbia, by PCR technique, correlate molecular findings with clinical characteristics and outcome and assess the prognostic significance of these rearrangements. One hundred-seven patients (median age, 54 years; male/female ratio:60/47) diagnosed with FL were included in the study. DNA samples were obtained from paraffin embedded lymphoid tissue of patients. Bcl-2/IgH rearrangement was assessed for the major breakpoint region (MBR), 5' MBR and the minor cluster region (mcr) breakpoints by PCR technique. We detected a t(14;18) in 81.3% (87/107) of patients. The distribution of bcl-2-IgH rearrangement was as follows: 88,5% (77/87) in MBR breakpoint, 10,35% (9/87) in 5' MBR, whereas mcr bcl-2-IgH rearrangement was observed in one patient (1.15%). No rearrangements were detected in remaining 20 patients (18.7%). This is the first analyses of the frequency of the bcl-2/IgH gene rearrangement in Serbian FL patients, as well as in Eastern European countries. There was no correlation between presence of bcl-2/IgH gene rearrangement and clinical outcome of disease. Incidence of bcl-2/IgH gene rearrangement in Serbian FL patients is relatively high, and similar to frequency in Western countries. Presence of this rearrangement in tumor tissue is not of prognostic significance.

Predictive value of prognostic indices in patients with follicular lymphomas.

PURPOSE: The aim of this study was to compare which of three indices--International Prognostic Index (IPI), Italian Lymphoma Intergroup (ILI) index, Follicular Lymphoma adapted International Prognostic Index (FLIPI)--is the most useful in predicting outcome in follicular lymphoma (FL) patients and to identify other clinical and laboratory prognostic factors that influence survival. PATIENTS AND METHODS: Clinical and prognostic studies were carried out in 99 patients with FL. RESULTS: The distribution of patients in IPI risk groups was 44.4%, 19.2%, and 36.4% of cases classified as low, intermediate, and high risk. According to ILI, low-, intermediate-, and high-risk scores were present in 34.3%; 27.3%, and 38.4% of FL patients. After applying the FLIPI index, the patients were divided into three risk groups: low (21.2% of cases), intermediate (39.4%), and high (39.4%) of FL patients. Survival curves demonstrated a high significant difference for the low- and high-risk group according to IPI and FLIPI (log rank=91.13 and 82.17 respectively; p < 0.0001). Difference in overall survival (OS) and failure-free survival (FFS) among low-, intermediate-, and high-risk groups according to ILI was statistically significant (log rank test p < 0.0001). CONCLUSION: All three indices are important tools for prognostic evaluation of FL patients, as well as useful in identifying FL patients with poor outcome. IPI and FLIPI classify patients into two risk groups (low/intermediate- and high-risk groups) with significance difference in OS and FFS, but ILI is more reliable in stratifying patients in low-, intermediate-, and high-risk groups.

Ki-67 proliferative marker in lymph node aspirates of patients with non-Hodgkin's lymphoma.

Proliferative activity of lymphoma cells was tested by immunocytochemical staining with Ki-67 monoclonal antibody in 63 aspirates of peripheral lymph nodes sampled from patients suffering from non-Hodgkin's lymphoma. Referring to the dominant cell population in nodal aspirates, a rising trend of Ki-67 proliferative marker was noted from the small cells (X = 13.20) and small cells with notched nucleus (X = 43.52) and large cells (X = 79.47) with histopathologic equivalents corresponding to aggressive lymphoma. Statistical testing of the difference in the Ki-67 proliferative marker against demographic and clinical-laboratory characteristics of the studied patients revealed the levels of significance for the performance status, bone marrow infiltration, and albumin serum value. Correlation of cytomorphological and immunocytochemical results was tested against International Prognostic Index (IPI). Statistically significant correlation of Ki-67 with cytomorphology and REAL-immunocytochemical classification of lymphoma was confirmed, but not with the IPI index. In order to determine the prognostic importance of Ki-67 marker, the patients were classified into those with low Ki-67 (<20% of proliferating cells), mean proliferation index Ki-67 (range 20-59%), and high proliferative index Ki-67 (positive in over 60% of lymphoma cells). Testing Ki-67 with survival we have found that the low proliferative index was associated with the longest survival, median about 36 mo; for proliferative marker values ranging between 20 and 59%, the median survival was 30.4 mo; and survival of patients with the high proliferative index was only 12.9 mo.

Plasmacytoma of the lung: an indolent disease resistant to conventional myeloma treatment: report of a case.

Solitary lung plasmacytoma is a rare form of plasma cell tumors. The case of a 56-yr-old man is presented, who had a massive tumor of the right pulmonary apex. Percutaneous transthoracic lung biopsy demonstrated a tumor-cell population consisting of mature plasma cells, proplasmacytes, and rare plasmablasts. Immunohistochemically, the cells were CD79a+, kappa+, cyclin D1-, p53-, MDR-. Proliferative index was low (number of Ki-67+ tumor cells was 8%). Serum and urine immunoelectrophoresis did not show the presence of paraprotein. Screening for multiple myeloma with skeletal X-ray survey and bone marrow biopsy were negative. Radiotherapy and chemotherapy with alkylating agents were ineffective. However, the course of the disease is indolent and the patient is well, alive, and with no signs of multiple myeloma >5 yr after the diagnosis was established. Some pathogenetic aspects of tumor resistance to conventional myeloma treatment in this case are discussed.

Correlations between mitotic and apoptotic indices, number of interphase NORs, and histological grading in squamous cell lung cancer.

Proliferative activity of tumors is strongly associated with prognosis and response to therapy. The reason for faster and uncontrolled growth rate of tumors compared with normal tissue may be caused by the greater proliferation of cells, the smaller rate of cell death, or both. Cell production vs. cell loss rates, and their correlation with a grade of tumor cell differentiation (G) was estimated in 45 cases of squamous cell lung cancers (SCLC) by the use of mitotic indices (MI), number of interphase NORs, and apoptotic indices (AI) as parameters. The mitotic figures as well as apoptotic cells were observed on paraffin sections (4-microm thick) stained with haematoxylin and eosin, and with Feulgen reaction with Schiff-type reagent containing 0.5% Toluidine Blue. According to our results, all three parameters distinguish significantly (P < 0.05) between well and moderately or poorly differentiated groups, but not between the first two groups, and clearly discriminate between low- and high-grade malignancy. These results suggest classification of squamous cell lung cancers into two groups, a group of low and a group of high proliferative activity, despite their morphological appearance. Regression analysis revealed a significant (P < 0.0005) correlation between MI and AgNOR counts per cell nucleus as proliferative markers and AI as a marker of cell loss. The number of mitoses and apoptoses, especially when they are expressed as a percentage of the total number of tumor cells, are markers of tumor proliferation rate. They both can be used in biofunctional staging, based on cell kinetics, to provide more prognostic information about lung cancers than clinicopathological staging.

Acute panmyelosis with myelofibrosis: clinical, immunophenotypic and cytogenetic study of twelve cases.

The clinical, cytogenetic, and immunophenotypic features in 12 adult patients with acute panmyelosis with myelofibrosis (APMF; ICD-0-3: 9931/3; C42.1) are reported (median age: 57 years; f/m = 1.4). The white cell count (WBC) was normal in 3 patients; 9 had leucopenia. The median hemoglobin value was 64.5 g/l, and median platelet count 12 x 10(9)/l. Bone marrow biopsy showed a hypercellular marrow in 10/12 patients with a significant infiltration of pathological blasts (range: 30 - 60%). All the cases had marked reticulin fibrosis. Immunophenotyping of bone marrow blast cells showed the expression of early (CD34) and lineage-unspecified antigens (HLA-DR) in 6/7, and 7/7 patients, respectively. "Early" myeloid antigens (CD13, CD33) were seen in 6/7 and 4/6 patients respectively. Monocyte antigen (CD14) was expressed in 3/7 patients. Megakaryocyte antigen (CD61) and erythroid cell antigen (GpA) were each expressed in only 1 patient. Two patients had expression of CD34, HLA-DR and "early" myeloid antigens by their bone marrow blast cells and 1 of these also had a co-expression of the antigens from a differentiated monocytic cell proliferation (lysozyme+, CD68+). Nonspecific chromosomal aberrations were recorded in 8/10 patients. The median survival was 2 months. These findings suggest an immature myeloid phenotype of blast cells in APMF. In 6/9 patients a leukemic cell differentiation into monocytic, megakaryocytic or erythroid lineage was also demonstrated.

Primary malignant fibrous histiocytoma of the spleen and liver.

Malignant fibrous histiocytoma (MFH) is a distinct and pleomorphic form of sarcoma, which usually occurs in soft tissues but can be found in bones, kidney, larynx, lung, heart, and even aorta. Since the first description of MFH of the spleen by Govoni et al. in 1982, only 10 cases have been reported in the literature worldwide. We report on a 45-yr-old female with MFH of the spleen and liver, with special emphasizes on immunohistochemical findings.

Clinical, Immunophenotypic and Cytogenetic Features of Megakaryocytic Blast Crisis of Chronic Myeloid Leukemia: A Single Institution Study.

We present 15 patients with megakaryocytic (Mk) blast crisis (BC) of a Philadelphia (Ph) chromosome positive CML confirmed by immunophenotype analysis between 1989-2000. The primary aim of this study is to define clinical, immunological, cytogenetic and laboratory characteristics of Mk BC in Ph positive CML. We have done retrospective analysis regarding basic clinical findings, immunologic phenotype, cytogenetic studies and platelet functions. All patients had significant expression of CD61 (14/14) and CD34 (13/13) antigens, and a high frequency of expression of CD13 (9/12), CD33 (10/12) and CD11b (9/11). The BC in 6/15 patients was presented with thrombocytosis, 7/15 had a normal platelet count and two patients had thrombocytopenia. A grade IV myelofibrosis was present in 8/10 patients. Six patients evolved additional karyotypic abnormalities. Two patients had extramedullary BC. The serum activity of LDH (med. 1095.6) was elevated in all patients. A platelet dysfunction was documented in 4/5 patient tested. There are no clinical and hematological characteristics specific for Mk BC of CML. Normal or elevated platelet count (med. 427.4 x 109/L) in BC of CML with prominent expression of CD34 and CD61 antigens, and significant myelofibrosis (grade IV) are the most consistent clinical findings.

Survivin expression in patients with newly diagnosed nodal diffuse large B cell lymphoma (DLBCL).

Survivin is one of the inhibitors of apoptosis proteins (IAP) that might play an important role in the pathogenesis of diffuse large B cell lymphoma (DLBCL). The present study was designed to investigate the clinical and prognostic significance of survivin expression in nodal DLBCL. We analyzed lymph node biopsy specimens obtained from 56 patients with newly diagnosed nodal DLBCL, treated with immunochemotherapy (R-CHOP). The expression of survivin was analyzed using the standard immunohistochemical method on formalin-fixed and routinely processed paraffin-embedded lymph node specimens and evaluated semiquantitatively as a percentage of tumor cells. Survivin immunoexpression (>45 % positive tumor cells) was found in 22 (39.28 %) and observed as cytoplasmic staining in 15 patients, or mixed (cytoplasmic and nuclear) staining in 7 patients. A significant difference in survivin immunoexpression was noticed between the GCB and the non-GCB subtypes of DLBCL (p = 0.031). However, survivin immunoexpression had no significant association with IPI, "bulky" disease, extranodal localization, hemoglobin, Ki-67 immunoexpression or other clinicopathological parameters. A univariate analysis showed that survivin positivity was an unfavorable factor for therapy response and a predictor of shorter survival in patients with DLBCL (p = 0.048 and p = 0.034, respectively). Patients with survivin overexpression experienced a relapse more often than patients without expression of this apoptotic protein (27.3 vs. 11.8 %), but this difference did not reach statistical significance (p = 0.131). The results of this study showed that disregulation of survivin expression had an important role in the determination of the course of the disease in patients with nodal DLBCL treated with R-CHOP. Therefore, survivin represents a potential target for therapeutic intervention in DLBCL.

Littoral-cell angioma as a rare cause of splenomegaly.

We report the case of a littoral-cell angioma of the spleen, a recently described benign vascular tumour, whose imaging and pathological characteristics have been discussed only by a few authors. The diagnosis was made after elective splenectomy. The CT images, scintigraphy and histological specimens are presented, and differential diagnoses discussed.

[Argyrophilic nucleolar organizers in squamous changes in bronchial epithelium]. / Argirofilni nukleolarni organizatori (AgNOR) u skvamoznim promenama epitela bronha.

Argyrophil technique for presentation of interphase nucleolar organiser regions (AgNOR) is becoming an important method in tumour pathology which is used in diagnosis and prognosis. The number of interphase AgNOR is in the strict correlation with the degree of cell proliferation. We have used this technique in evaluation of degree of differentiation and proliferation of squamous changes of the epithelium of the bronchial mucosa. The statistically significant differences were found (p < 0.01) in the number of AgNOR by nucleus in cells of benignant squamous metaplasia (3.31) and epidermoid bronchial carcinoma (5.34). On the basis of numerical values of AgNOR epidermoid bronchial carcinomas could be divided into the group with low proliferative capability (AgNOR < 5.34) and in the group with high degree of proliferation (AgNOR > 5.34). Prognosis of patients with tumours with the high AgNOR value is poorer and they require additional systemic chemotherapy regardless of the clinical state of the disease at the moment of surgical intervention.

[Teratogenic tumors of the mediastinum]. / Teratogeni tumori medijastinuma.

Primary teratogen tumors of the mediastinum are rarities in clinical and pathological practice. Their polymorphic histological picture and their enormous size provoke a great diagnostic difficulty. We analyze 85 primary teratogen tumors of the mediastinum (except those that were localized in thymus) which have been diagnosed in Institute for pulmonary diseases and tuberculosis, Clinical center of Serbia, between 1973 and 1991. Material for pathohistological evaluation was obtained by surgical resection of the whole tumor in 58 patients or by percutaneous needle aspiration biopsy in 47 patients. Malignant (immature or teratomas with malignant transformation) were present in 49 (57.65%) patients and benign (mature) teratomas in 36 (42.35%). The majority of benign (mature) teratomas (83.33%) were composed of a variety of tissue elements derived from all three germ layers and 16.67% show only ectodermal and mesodermal derivates. Malignant (immature) teratomas contained both epithelial and mesenchymal incompletely differentiated elements in 67.35% of cases and in 22.45% of cases only epithelial component undergoes malignant transformation. In our series there were two cases of primary seminoma of the mediastinum and one case of primary embryonal carcinoma, primary yolk sac tumor and primary choriocarcinoma of the mediastinum.

Diffuse primary plasmacytoma of the lung.

Primary plasmacytoma of the lung is a rare tumor, thus presenting a diagnostic challenge to the clinician. So far, approximately 20 cases have been verified by immunohistochemistry. We describe an elderly patient presenting with progressive dyspnea on exertion, dry cough, weight loss and malaise. The main finding on plain chest radiography was a diffuse infiltration of pulmonary parenchyma in the lower parts of both lungs and in the middle part of the right lung. The histology of the open lung biopsy of the right middle lobe revealed massive and diffuse infiltration by well differentiated plasma cells with extracellular deposits of amyloid. The plasma cells and amyloid expressed a monoclonal lambda light chain. No monoclonal spike was shown by serum and urine immunoelectrophoresis. A skeletal survey and bone marrow biopsy specimen excluded a disseminated disease and a diagnosis of extramedullary plasmacytoma was made. The patient was considered for VI courses of VMCP chemotherapy after which a complete regression on chest roentgenography was evident. Almost five years after the diagnosis the patient is still alive without any evidence of disease recurrence or dissemination.

[Angioblastic lymphadenopathy--its course and prognosis]. / Angioimunoblastna limfadenopatija--tok i prognoza.

INTRODUCTION: In recent years important advances have been made in the understanding of angioimmunoblastic lymphadenopathy since substantial controversy has been related to the name, course, prognosis and therapy of the disease. It was first recognized in the Kil Classification as a low risk T-cell lymphoma [5], and omitted from the most widely used Working Formulation for clinical purposes. According to the criteria of REAL (Revised European American Lymphoma), classification angioimmunoblastic lymphadenopathy (AILD) is one of peripheral postthymic T cell lymphomas that are an immunologically defined category of non-Hodgkin's lymphomas originating from the peripheral lymphatic tissues. Morphologically, AILD is characterized by partially or completely obliterated sinuses and frequent infiltration of the pericapsular tissue and substantial proliferation of epithelioid, postcapillary venules. Cytologically, polymorphous cellular infiltration with immunoblasts, transformed lymphoid cells, polyclonal plasma cells, eosinophils and epithelioid cells are found. Clinically, rapid occurrence of systemic symptoms in elderly individuals (sixth and seventh decades of life) with generalized lymphadenopathy, hepatosplenomegaly and cutaneous maculo-papulous or erythematous rash is noted. The patients are characterized with hyperimmune condition in the form of Coombs' positive haemolytic anaemia, polyclonal hypergamma-globulinaemia and liability to infections [8, 9]. In spite of numerous suggestions, therapeutic consensus has not been achieved, and the reported survival ranges from 1 to 30 months [10, 11]. Therefore, this information suggests an aggressive form of the disease with the 60% mortality rate. METHODS: At the Institute of Haematology of the Clinical Centre of Serbia in Belgrade in the last five years, from 1993 through August 1998, nine patients were diagnosed with AILD according to the results of pathohistological examination of the extirpated peripheral lymph nodes and the correlation with clinical picture and relevant laboratory findings. RESULTS: Clinical characteristics of nine patients in whom AILD was diagnosed after lymph node biopsy are given in Table 1. The group consisted of 6 men and 3 women, mean age 53. Eight patients were in advanced stage of the disease at the time of the diagnosis (III and IC CS), while the patient in II CS stage had a large tumorous mass (M+). All patients had initial systemic symptoms. Five of them developed fever with chills. Three patients had evidence of extranodal infiltration of the bone marrow. Infiltration of the liver was suspected in two patients according to aberrant hepatogram values, although pathohistological verification was not obtained. In one patient lung infiltration was histologically verified in addition to bone marrow and liver infiltration. All patients had peripheral lymphadenopathy, and most of them hepatosplenomegaly, as well. Three patients had the so called bulky form of the disease since the diameter of the largest tumour exceeded 10 cm. On admission, most were in poor overall condition, and only two were apparently healthy. Knowing that AILD is basically an immunoregulatory disease and that the described cases of association with systemic diseases of the connective tissue and some drugs were implied in the triggering of AILD, Table 2 shows important information obtained form histories of these patients. Namely, 7 of 9 patients had cutaneous changes suggestive of erythematous or maculopapular rash, while three had received corticosteroid therapy for months before AILD was diagnosed since toxoallergic exanthema had been incorrectly suspected. Three patients received gold sodium thiosulfate therapy for rheumatoid arthritis, while four had history of allergy to drugs and pollen. Table 3 shows laboratory results: anaemia was present in 8 of 9 patients, it was severe in three with haemoglobin values of 67 g/L, 72 g/L and 50 g/L, respectively. Five patients had haemolysis. A

Monocytoid B cell lymphoma associated with antibodies to myelin-associated glycoprotein and sulphated glucuronyl paragloboside.

Monocytoid B cell lymphoma (MBCL) is an immunologically and morphologically well-defined low-grade lymphoma with a predilection for lymph nodes of the parotid region. We describe an association of MBCL with anti-myelin-associated glycoprotein (MAG) polyneuropathy in a 53-year-old male. The diagnosis of stage IV MBCL with nodular bone marrow infiltration, Sjögren's syndrome and sensorimotor polyneuropathy was made in October 1996. Serum immunoelectrophoresis demonstrated IgMkappa paraprotein. This was then cross-reacted with epitopes of MAG and sulphated glucuronyl paragloboside (SGPG) on myelin sheaths, and detected by thin layer chromatography and Western blot. Direct immunofluorescence of a sural nerve biopsy showed loss of myelin fibres, segmental demyelinization and IgM deposits on the myelin sheaths. The cerebrospinal fluid was normal. After six cycles of chemotherapy (ChlVPP protocol), all the patient's haematological parameters normalized accompanied by an improvement in neurological signs. The improvement of the polyneuropathy after chemotherapy indicates that the autoimmune anti-MAG and anti-SGPG antibodies resulted from the neoplastic lymphoid proliferation.