The Influence of SARS-CoV-2 Pandemic in the Diagnosis and Treatment of Cervical Dysplasia.

Background and objectives. The risk of developing invasive cancer increased during the COVID-19 pandemic, especially in Romania, where the incidence of this disease is high due to limited medical education and broad screening. This study's objective is to analyze the number of patients admitted with different types of cervical dysplasia and the treatment applied for the lesions during the SARS-CoV-2 pandemic compared to the same period for the year before the pandemic. Materials and methods: This is a retrospective study that took place in the Obstetrics and Gynecology Clinics I/II (OG I/II) of the Emergency County Hospital of Craiova during the SARS-CoV-2 pandemic (SP) (15.03.2020-14.03.2021) and in the 12 months before (non-pandemic period) (NPP) (15.03.2019-14.03.2020). The study includes 396 patients with pathological PAP smear results. All the patients included in this study were clinically examined and with colposcopy. The patients with Low-Grade Dysplasia were managed in a conservatory manner and reevaluated after six months. The patients with High-Grade Dysplasia were admitted for an excisional biopsy of the lesion. The excised fragments were sent to the Pathological Anatomy Laboratory for a histopathological examination. Results: This study reveals a decrease of more than half in the number of patients admitted with cervical intraepithelial neoplasia (CIN) lesions during the pandemic compared to the same period of the year before. The number of biopsies and excisional procedures has been decreasing by more than a factor of three during the pandemic period compared to the year before. Conclusion: During the SARS-CoV-2 pandemic, we found that the patients' admission rate, diagnosis, and treatment was almost four times lower. As hospital restrictions were not dictated for cancer/precancer management during SP, we may assume that the differences were due to the fear of becoming infected with SARS-CoV-2 due to hospitalization. In the context of poor screening performance and high cervical cancer incidence, the influence of the SP may result in a further increase of severe cases related to this condition.

Clinical and Morphological Study of Cervical Squamous Intraepithelial Lesions.

Squamous intraepithelial lesions (SILs) are cancer precursors targeted by secondary prevention of cervical cancer programs that are sometimes difficult to grade accurately. Mena is an actin regulatory protein involved in membrane protrusion, cell motility, in tumor invasion and metastasis. We studied retrospectively 68 cases of patients diagnosed with squamous intraepithelial lesions that received expedited treatment (treatment without colposcopic biopsy). We analyzed demographic, behavioral data, obstetrical and medical history, from the patients' medical charts and we studied the cervical fragments or cones harvested after the excisional procedure. Our study failed to identify a correlation between SILs and risk factors such as low socioeconomic status, combined oral contraceptive use, intrauterine device use, parity, gravity, except for the tobacco smoking habit that proved to be related to the cervical lesions' development. Mena was expressed in most of the analyzed SILs and its expression was correlated with lesions' grade in terms of both area and intensity, suggesting that Mena stains especially abnormal cells and that its expression intensity correlates with the risk of malignant transformation. Further studies are needed to validate Mena as an early stage of cervical carcinogenesis marker.

The influence of SARS-CoV-2 on the immune system elements and on the placental structure. Clinical, histological and immunohistochemical study.

BACKGROUND: The effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy remain relatively unknown. AIM: We present this original paper where we analyzed 60 parturients, at term, 30 without associated infection (C-) and 30 with associated infection (C+), present at birth. METHODS: We analyzed the blood count and placental microscopic structure through classical and immunohistochemical staining and observed the placental areas affected by the presence of SARS-CoV-2. RESULTS: SARS-CoV-2 infection was accompanied by a decrease in the number of lymphocytes, the number of platelets and the presence of placental structural changes, identifying extensive areas of amyloid deposits, placental infarcts, vascular thrombosis, syncytial knots, with a decrease in placental vascular density and the presence of infection in the cells located at decidual level, at syncytiotrophoblast level and at the level of the cells of the chorionic plate, still without overcoming this barrier and without causing any fetal infection in the analyzed cases. CONCLUSIONS: This study shows that the invasion of SARS-CoV-2 in the placenta can produce significant structural changes, with a decrease in placental vascular density that can have significant implications on proper fetal perfusion. Also, the presence of immunoreactivity at the level of decidua, the placental villi, as well as the chorionic plate proves that the virus can overcome the maternal-fetal barrier. However, in the analyzed cases there were no fetal infections at birth, which may show that local placental factors can be a protective filter for the fetus.

Clinical and pathological aspects of condyloma acuminatum - review of literature and case presentation.

Condyloma acuminatum (CA) is a pathology caused by the human papillomavirus (HPV). It is manifested by the appearance of warts in the vulvar, pubic, and anorectal regions, but can occur in other areas. It is a common disease that can be prevented by using measures such as condoms or vaccine. Topical, local, pharmacological, surgical, and excisional therapy options are available for this pathology. Macroscopically, it appears as a vegetative tumor, with a single implantation base that branches towards the periphery, with a cauliflower appearance. CA is defined microscopically by acanthosis, parakeratosis, papillomatosis and koilocytosis. Immunohistochemical studies can detect the presence of various HPV strains or viral antigens and can emphasize certain specific characteristics; e.g., in the case presented in this study, we observed that the tumor had a fulminant evolution due to a strong vascular base identified with anti-cluster of differentiation (CD) 34 antibody, by the existence of epithelial cells with a high degree of cell proliferation, as evidenced by the anti-Ki67 antibody, the inactivation of the tumor suppressor gene and the appearance of immunolabeling for the anti-p53 antibody, by the strong immunoreactivity for p63 which reveals the existence of cells with dysplastic and neoplastic transformation potential, but also by detecting the immunolabeling for p16INK4a that is associated with the existence of HPV. Also, the tumor was immunoreactive for cytokeratin (CK) AE1∕AE3, partially immunoreactive for CK5∕6 in the basal layer and negative for CK7, which demonstrates the squamous epithelial origin of the described tumor. Subepithelial cells of the inflammatory system have been identified, such as macrophages immunolabeled with anti-CD68 antibody, T-lymphocytes immunolabeled with anti-CD3 antibody and rare B-lymphocytes immunolabeled with anti-CD20 antibody, which demonstrates the strong cellular response to remove the virus from the structure. Surgical and excisional treatment was helpful for the patient, because she was able to resume normal sexual activity and defecation, and on the other hand, microscopic studies showed the potential for malignant transformation of CA.

Clinical and Morphological Study of Single and Twin Pregnancies Placenta.

Placental morphology is very important in both single and multiple pregnancies. It can dictate certain aspects such as: fibrin depositions, calcifications, infarctions, type of vascularization, which can be directly related to placental weight and implicitly to foetal weight, both in single and twin pregnancy. Our study highlighted the macroscopic morphological aspects and through the classical and immunohistochemical colours the microscopic placental morphological aspects, both in single and in dichorionic diamniotic twin pregnancy and showed that the placenta of the foetuses from the twin pregnancy has a higher vascular density compared to the single pregnancy, and the areas of placental fusion are poor in blood vessels, but rich in fibrin depositions, calcifications and placental infarctions. We also pointed out that maternal weight can increase with age, foetal weight can be directly proportional to maternal weight, as well as placental weight is directly proportional to foetal weight and implicitly to maternal weight, but in terms of vascularization, we observed that there is an inversely proportional connection between placental, foetal weight and vascular density.

Ovarian ectopic pregnancy: the role of complex morphopathological assay. Review and case presentation.

Ovarian ectopic pregnancy (OEP) represents the rarest type of ectopic pregnancy, accounting for 1-3% of this pathology. The diagnosis of this pathology is challenging due to the non-specific clinical aspects and the ultrasound examination hampered by the lack of visible gestational sac in the presence of hematocele and hemoperitoneum. The purpose of the extended histopathological (HP) examination was to identify particular aspects of the OEP trophoblast and to highlight potential local ovarian modifications which can determine pregnancy fixation at this level. The patient presented local favorable conditions for intraovarian nidation, conditions confirmed by the HP classical examination and by the immunohistochemical evaluation. We identified, using classical Hematoxylin-Eosin, Masson's trichrome and Periodic Acid-Schiff (PAS)-Hematoxylin, necrotic hemorrhage, accentuated vascular thrombosis and high density lymphoplasmocytary infiltrate. These modifications increased local adhesivity and cell destruction through hypoperfusion. Anti-cluster of differentiation antibodies (CD34, CD38, tryptase) revealed the low number of intravillous vessels and the high number of macrophages and mastocytes involved in the local inflammatory process heighten. We identified the presence of trophoblast tissue in the ovarian structure using anti-cytokeratin AE1∕AE3 (CK AE1∕AE3)/anti-cytokeratin 7 (CK7) antibodies. The anti-alpha-smooth muscle actin (α-SMA) and anti-vimentin (VIM) antibodies displayed the density of myofibroblasts and intravillous stromal cells and with the aid of anti-progesterone receptor (PR) antibody, we identified the corpus luteum hormonal response in the OEP. The placental villosities present a blocked multiplication process at the anti-apoptotic B-cell lymphoma 2 (BCL2) protein, confirmed by the Ki67 cell proliferation and tumor protein 63 (p63) immunomarkers. Anti-neuron specific enolase (NSE), anti-calretinin and anti-inhibin A antibodies showed the particular aspects of the granulosa and internal theca cells, which may be involved in oocyte release blockage, intraluteal and extraluteal fecundation of the OEP.

Expression patterns of aquaporins 1 and 4 in stroke.

Ischemic stroke occurs through embolic or thrombotic obliteration of an artery from cerebral circulation and represents over 80% of all stroke cases. One of the fiercest complications after stroke is edema, which results from imbalanced water diffusion around the blood vessels walls. Water diffusion around blood vessel walls occurs physiologically mainly through two protein-formed pores, namely aquaporins (AQPs) 1 and 4. Here, we compare for the first time the expression patterns and colocalization degrees of the two AQPs in control brain tissue and in peri-ischemic regions, on tissue obtained from eight patients with confirmed ischemic pathology and from five control cases. Our analysis showed that AQP4 is more abundant that AQP1, especially in the cortex and in the organized scar areas. The colocalization of the two markers was high, both located on the astrocytes membranes, but the colocalization degree decreased in the scar peri-ischemic regions. Colocalization with basement membranes was also lower for AQP1 compared to AQP4, in all regions analyzed.

The performance of hyperadherence markers in anterior placenta praevia overlying the Caesarean scar.

OBJECTIVES: To assess the ultrasound (US) impact in diagnosing placenta accreta (PA) in patients with anterior placenta praevia localization, overlying a Caesarean scar. PATIENTS, MATERIALS AND METHODS: This is a prospective study between January 2016 and December 2017 that included patients with Caesarean scar and placenta praevia in the third trimester of pregnancy. By means of two-dimensional (2D) grayscale and color Doppler, we investigated the presence of the following US markers for placental invasion: intraplacental lacunae, abnormal blood vessels at the myometrium-bladder interface, thinning of the hyperechogenic uterine serosa-bladder wall interface, loss of normal hypoechoic retroplacental myometrial space. Definitive diagnosis was made at delivery. The US findings were correlated with intraoperative and histopathological (HP) evaluations. RESULTS: We found 46 cases with anterior placenta praevia overlying a Caesarean scar. Twelve patients presented US criteria for PA. The confirmation was obtained (by means of intraoperative and/or HP features) in 11 of them. The US evaluation with all markers yields a sensitivity of 100% for PA detection. Among the US markers, the association of abnormal blood vessels at the myometrium-bladder interface and the intraplacental lacunae had the highest statistical correlation in the antenatal diagnosis of PA. CONCLUSIONS: Our study suggests that the antenatal US is a useful tool in predicting PA in high-risk patients. Special attention should be given to the presence of intraplacental lacunae and abnormal myometrial vessels in cases where the placental insertion overlaps a uterine scar for best identification of PA high-risk cases.

Modern interdisciplinary monitoring of cervical cancer risk.

Currently, Romania ranks first in Europe with regard to cervical cancer mortality. A new solution proposed for optimizing cytology-based screening, before seeing the risk associated with minor abnormalities results, is the use of molecular markers. This study concerns atypical squamous of undetermined significance (ASC-US) results, the grey zone of cytology that hides up to 15% high-grade lesions, to see how dual immunocytochemistry (ICC) staining for p16INK4a∕Ki67 help to better identify and manage high-risk (HR) ASC-US patients. We included and reviewed 183 cases with ASC-US results and p16INK4a∕Ki67 double staining (DS) performed in MICOMI Clinic (Bucharest) during 2014-2016. All patients were referred for colposcopy and biopsy if appreciated as necessary and followed-up at six and 12 months. One DS(+)∕HR human papillomavirus (HPV) negative case was positive for HPV73 Group IIB International Agency for Research on Cancer (IARC). The mean age for ASC-US in our study group was 32 years, with a median of 31 years and 31% of patients were aged 25-29 years. The sensibility of p16INK4a∕Ki67 double immunostaining was 100%, the specificity 88%, the positive predictive value (PPV) was 82%, and the negative predictive value (NPV) was 100%. The use of p16INK4a∕Ki67 ICC test optimizes the medical approach towards screening or monitoring especially in ASC-US HR HPV(+) young patients, unnecessary colposcopies are avoided thus invasive gestures at nulliparous are limited.

Triple immunohistochemistry for assessing the inflammatory, vascular and progression of adenomyosis.

Adenomyosis is a benign pathology, common to both women at reproductive age as well as later during menopause. This condition is accompanied by a strong symptomatology, which has induced intense research on this topic. From a morphological point of view, it is represented by the existence of endometrial glands and, sometimes, of the periglandular stroma (endometriosis) in the structure of the myometrium, at a significant distance from the normal endometrium. Various inflammatory, vascular and mechanical factors accentuate the symptoms and evolution of this pathology. Our study included a total number of 32 patients, eight cases for each of the following histopathological subtypes: endometrium - proliferative phase, endometrium - secretory phase, myometrium with endometrial glands (adenomyosis), and myometrium with hyperplastic transformation of endometrial glands (hyperplastic adenomyosis), respectively. We have conducted clinical, morphological and morphopathological studies of the structures in question. Using the classical histological technique (Hematoxylin-Eosin), we identified the glandular structures; utilizing immunohistochemistry, we have labeled the endometrial epithelium with the anti-cytokeratin 7 (CK7) antibody and we analyzed the periglandular cell types of the immune system: T-lymphocytes using anti-cluster of differentiation (CD) 3 antibody, macrophages using anti-CD68 antibody, mast cells using anti-tryptase antibody, periglandular vascularization with the reaction using anti-CD34∕anti-CD31 antibodies, thus demonstrating their involvement in the development of adenomyosis. The interesting aspect of this study is the technique of simultaneously labeling of the inflammatory, vascular and epithelial elements.

Aspects regarding nomenclature, classification and pathology of neuroendocrine neoplasms of the digestive system - a review.

Neuroendocrine neoplasms (NENs) of the digestive system are composed of cells with a neuroendocrine phenotype. These tumors produce and secrete peptide hormones and biogenic amines and they are called neuroendocrine neoplasms because of the marker proteins that they share with the neural cell system. The classification and nomenclature used to designate NENs have undergone changes over the past decades due to the accumulation of evidence related to the biological characteristics and their evolution. The European Neuroendocrine Tumor Society (ENETS) proposed a classification system based on the tumor grading and staging according to their localization. The latest internationally recognized NEN classification was published by the World Health Organization (WHO) in 2010. In accordance with the 2010 WHO criteria, the determination of the NEN malignancy potential is based on grading, depending on the mitotic activity and the Ki67 proliferation index, as well as on the tumor TNM stage. It is worth emphasizing that the terms neuroendocrine tumor (NET) and neuroendocrine carcinoma (NEC), without reference to grading or differentiation, are inadequate for prognostic assessment or the therapy determination, being inappropriate in pathology reports. The functional status of the tumor is based on the clinical findings but not on the pathological data or immunohistochemically profile. Despite the inability to establish a single system of sites, these are common features to establish the basis of most systems, documentation of these features allowing for greater reliability in the pathology reporting of these neoplasms.

Intraoperative assessment of sentinel lymph nodes in early-stage breast cancer.

The assessment of axillary lymph node (ALN) status provides heavily weighing prognostic indicators in deciding on breast carcinoma treatment. In the 6th and 7th editions of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual are evaluated the nodal metastases based on size and taking into account the number of metastatic cells. According to these Manuals, a positive node is equated to metastasis whose size reaches at least 0.2 mm or amounting to more than 200 tumor cells. The clinical significance and the therapeutic optimum of the presence of a minimal nodal involvement after axillary sentinel lymph nodes (SLNs) biopsy remain controversial. The need for further axillary treatment (ALN dissection or axillary radiation) in clinical N0 patients with early-stage breast carcinoma and SLNs metastases remains unclear. In all likelihood, the delivery of the regular adjuvant treatment in association with systemic treatment and radiation therapy results in survival rates similar to axillary treatment completion. This review also presents several assessment methods related to the SLNs at the surgical stage, such as cytological, histological, immunohistochemical and molecular diagnostic techniques, evaluating the advantages and disadvantages of each of them. More studies including larger groups of breast patients are needed to confirm which of them is the most reliable method for the evaluation of the SLNs.

Clinical, morphological and immunohistochemical survey in different types of endometriosis.

Endometriosis is a benign pathology, commonly found in women at reproductive age. It is represented by the ectopic presence of the endometrial glandular epithelium in several tissues and organs. This ectopically located tissue can display premalignant or even malignant changes under the influence of certain factors that affect cell structure, function and proliferation. Our study includes a total of 28 patients, with endometriosis of different localizations: ovarian or pelvic endometriosis, adenomyosis or endometriosis of the abdominal wall. We performed a clinical and statistical analysis upon the collected clinical and laboratory data, together with the results obtained by using classical histological and immunohistochemical (IHC) profiling. The classical staining revealed the existence of the ectopic glandular epithelium, while the IHC reactions obtained with the anti-cytokeratin (CK) 7∕anti-CK20, anti-estrogen receptor alpha (ERα)∕anti-progesterone receptor (PR) antibodies, ascertained that these tissues were of endometrial origin. The environmental, hormonal or inflammatory factors influence these areas, so that the ER∕PR scores may be modified, the cellular proliferation might be increased (Ki67+ marker), the anti-apoptotic B-cell lymphoma 2 (BCL2) protein expression and phosphatase and tensin homolog (PTEN) may also be modified. Moreover, tumor protein 53 (p53) was positive in cases with atypia, density of inflammatory cells clearly increased compared to the adjacent normal endometrium, respectively with cluster of differentiation (CD) 3+, CD20+, CD68+, CD79a+, and tryptase+ cells, all of which may influence the cellular structure, histological architecture of the surrounding microenvironment and cause premalignant or even malignant changes in endometriosis outbreaks.