Large loop excision of the transformation zone and cervical intraepithelial neoplasia: a 22-year experience.

AIM: To review the 22-year experience of the use of large loop excision of the transformation zone (LLETZ) for the treatment of cervical intraepithelial neoplasia (CIN). DESIGN: Retrospective observational study. SETTING: University Hospital of Ioannina, Greece. PERIOD: January 1989 until December 2011. POPULATION: Women undergoing excisional treatment with LLETZ for CIN. Women with invasive disease were excluded. INTERVENTION: Excisional treatment with LLETZ. Women had post-operative surveillance with cytology and colposcopy at 6, 12, 18 and 24 months, and yearly thereafter. OUTCOMES: We assessed the histological outcomes and margin involvement, as well as the rate of treatment failures requiring a repeat conization. RESULTS: A total of 3861 LLETZ biopsies were recorded during the study period. The histological evaluation of the cone specimens showed CIN1 in 897 (23.2%), CIN2 in 1129 (29.3%), CIN3 in 1322 (34.2%), microinvasive disease in 158 (4.1%), HPV lesions in 206 (5.3%) and normal histological findings in 149 (3.9%) women. The margins were reported as clear in 3166 (82%) cases, involved in 437 (11.3%) cases and uncertain in 258 (6.7%) cases. A total of 239 (6.2%) women underwent a second conization due to treatment failure. CONCLUSION: LLETZ remains the most popular conservative technique of treatment for women with precancerous cervical lesions. Post-treatment surveillance of these women is essential in order to detect residual or recurrent disease. New HPV biomarkers, introduced over the last two years, appear to be useful in the follow-up after treatment. A scoring system may allow for accurate prediction of women at risk of treatment failure and for tailored post-treatment surveillance.

Breast metastasis from uterine leiomyosarcoma diagnosed by fine needle aspiration: a case report.

BACKGROUND: Leiomyosarcomas of the breast are a rare subgroup of primary breast sarcomas. Even more rare is breast metastasis of an extramammary leiomyosarcoma. To date, only 4 cases have been reported in the literature. CASE: We report a case of breast metastatic leiomyosarcoma in a 58-year-old woman with a prior history of uterine leiomyosarcoma, resected 18 months earlier. The breast mass was palpable and a fine needle aspiration (FNA) was performed. The microscopic examination showed cellular smears composed of loosely structured clusters and tissue fragments of spindle-shaped and polygonal or rounded malignant cells in disorderly arrangement. The tumor cells were medium- or large-sized, with basophilic cytoplasm and enlarged, irregular, hyperchromatic nuclei with nucleoli. Tumor giant cells and multinucleation were also present. The morphologic features along with immunocytochemical positivity for desmin, muscle-specific actin and vimentin indicated the diagnosis of a metastatic leiomyosarcoma. CONCLUSION: FNA cytology can be a reliable method for the diagnosis of leiomyosarcoma. The morphologic criteria in combination Swith the clinical history and the immunocytochemical findings can indicate a definitive diagnosis and avoid additional painful and time-consuming diagnostic procedures for the appropriate patient's further clinical management.

Can circulated lung cancer cells pass to the urine without apparent urine tract metastases? A single centre series.

Urine cytology has been a useful tool for the diagnosis of urinary tract malignancies. However, the presence of tumor cells in the urine sediment without an obvious urothelial metastatic deposit is a rare phenomenon and in patients with lung cancer has never been reported. We present five cases with metastatic lung cancer and positive urine cytology. The possible mechanisms underlining this phenomenon and its implications are discussed.

Pancreatic injury after thoracoabdominal aortic occlusion in a porcine model.

BACKGROUND: The aim of this study was to investigate pancreatic injury after 45 min of thoracoabdominal aortic occlusion in a porcine model. METHODS: Twenty-four pigs were used. Six pigs underwent sham operation and 18 intravascular balloon thoracoabdominal aortic occlusions for 45 min. The animals were randomly killed at 12, 48 and 120 h after reperfusion. After killing, all pancreata were examined macroscopically for any signs of acute pancreatitis, whereas gland specimens were harvested for histological study to evaluate pancreatic injury (haematoxylin and eosin staining) and acinar cell apoptosis (Terminal deoxynucleotidyl transferase mediated dUTP Nick-End Labelling staining). RESULTS: Pancreatic injury severity score was mildly increased in terms of oedematous features at 12 h after reperfusion, but normalized to sham levels by the second day and thereafter. Necrotic injury was not statistically significant at any time point. Acinar cell apoptotic index was mildly increased at 12 and 48 h, but showed a tendency to decrease towards sham levels by the fifth day. One animal developed acute pancreatitis. CONCLUSION: Acute pancreatitis is unlikely to occur after 45 min of thoracoabdominal aortic occlusion. However, an early, mild oedematous and apoptotic injury that occurs subclinically seems to be a constant event. This injury might have clinical significance when combined with pre-existent pancreatic pathologies.

Subcutaneous metastasis of peritoneal mesothelioma diagnosed by fine-needle aspiration.

Mesothelioma is a rare malignant neoplasm of the serosal membranes, which can give distant metastases in various organs in advanced stages of its course. Subcutaneous tissue is an unusual metastatic site. In the literature, only one case of metastatic mesothelioma to the skin of the face has been reported. We present a case of a 60-year-old female with a prior history of peritoneal malignant mesothelioma, who 6 months after the initial diagnosis presented with a subcutaneous nodule in the lateral chest wall. Cytological examination of the material obtained by FNA from the nodule revealed metastatic mesothelioma. Although subcutaneous metastasis of malignant mesothelioma is a rare entity, one must always keep this possibility in mind and proceed to further investigation of such lesions. In these cases, FNA is a simple diagnostic procedure for the identification of metastatic disease in patients with a prior history of malignancy.

Evolution of spinal cord injury in a porcine model of prolonged aortic occlusion.

BACKGROUND: Spinal cord injury and subsequent paraplegia remains an unpredictable and devastating complication of thoracoabdominal aortic surgery. The aim of this study was to investigate spinal cord injury due to prolonged thoracoabdominal aortic occlusion. MATERIALS AND METHODS: We used a highly reproducible porcine model of 45-min thoracoabdominal aortic occlusion, which was accomplished by two balloon occlusion catheters. Neurological evaluation after the end of experiment was performed by an independent observer according to the Tarlov scale. The lower thoracic and lumbar spinal cords were harvested at 10, 48, and 120 h (n = 6 animals per time point) and examined histologically with hematoxylin and eosin (H&E) stain and TUNEL method. Tarlov scores, number of neurons, and the grade of inflammation were analyzed. RESULTS: H&E staining revealed reduction in the number of motor neurons which occurred in two phases (between 0 and 10 h and between 48 and 120 h of reperfusion), as well as development of inflammation in spinal cord sections during the reperfusion period, reaching a peak at 48 h. TUNEL reaction was negative for apoptotic neurons at any time point. CONCLUSIONS: In this porcine model, we demonstrated that, after 45 min of thoracoabdominal aortic occlusion, motor neuron death seems to occur in two phases (immediate and delayed). Inflammation was a subsequent event of transient prolonged spinal cord ischemia and possibly a major contributor of delayed neuronal death. Using TUNEL straining we found no evidence of neuronal apoptosis at any time point of reperfusion.

A rare case of primary malignant melanoma of the scrotum diagnosed by fine-needle aspiration.

We report a case of a 55-yr-old man with malignant melanoma of scrotum. He was referred to our Hospital with a complaint of gradual focal enlargement of the scrotum in a period of 3 yr. On physical examination, a pigmented, poorly marginated mass, with central necrosis was observed. A fine-needle aspiration (FNA) of the lesion was performed. Cytological examination revealed highly cellular smears, containing malignant cells, dispersed or arranged in loose aggregates. Cellular morphology and characteristics were identical to those of malignant melanoma arising elsewhere in the skin. The immunocytochemical study revealed positivity of neoplastic cells for anti-melanoma monoclonal antibody (HMB-45) antigen. Histological confirmation finally was provided after wide excision of the lesion. We emphasize the difficulties in differential diagnosis considerations and diagnostic pitfalls of scrotal lesions.

Superiority of early relative to late ischemic preconditioning in spinal cord protection after descending thoracic aortic occlusion.

OBJECTIVE: We previously showed that ischemic preconditioning significantly reduced spinal cord injury caused by 35-minute aortic occlusion. In this study we investigated the effect of ischemic preconditioning on spinal cord injury after 45-minute aortic occlusion. METHODS: Thirty-two pigs were divided as follows: group 1 (n = 6) underwent sham operation, group 2 (n = 6) underwent 20 minutes of aortic occlusion, group 3 (n = 6) underwent 45 minutes of occlusion, group 4 (n = 6) underwent 20 minutes of occlusion and 48 hours later underwent an additional 45 minutes, and group 5 (n = 8) underwent 20 minutes of occlusion and 80 minutes later underwent an additional 45 minutes. Aortic occlusion was accomplished with two balloon occlusion catheters placed fluoroscopically after the origin of the left subclavian artery and at the aortic bifurcation. Neurologic evaluation was by Tarlov score. The lower thoracic and lumbar spinal cords were harvested at 120 hours and examined histologically with hematoxylin-eosin staining. The number of neurons was counted, and the inflammation was scored (0-4). Statistical analysis was by Kruskal-Wallis and 1-way analysis of variance tests. RESULTS: Group 5 (early ischemic preconditioning) had better Tarlov scores than group 3 ( P < .001) and group 4 (late ischemic preconditioning, P < .001). The histologic changes were proportional to the Tarlov scores, with the least histologic damage in the animals of group 5 relative to group 3 (number of neurons P < .001, inflammation P = .004) and group 4 (number of neurons P < .001, inflammation P = .006). CONCLUSION: Early ischemic preconditioning is superior to late ischemic preconditioning in reducing spinal cord injury caused by the extreme ischemia of 45 minutes of descending thoracic aortic occlusion.

Fine-needle aspiration of secondary malignancies of the penis: a report of three cases.

Metastatic malignancy to the penis is an uncommon clinicopathologic entity, with only 300 cases reported since 1870. Of the reported cases, 75% were secondary to genitourinary primary tumors. Priapism is the most frequent symptom, although dysuria, ulceration, and node formation have also been described. We report three cases of penile metastatic involvement from primary tumors in the urinary bladder (two cases) and prostate (one case), respectively. Fine-needle aspiration (FNA) cytology from the penile nodules was performed in each case. The smears in all cases were highly cellular, and atypical neoplastic cells were observed singly, in clusters, or in papillary formations. The cells were pleomorphic with hyperchromatic nuclei and prominent nucleoli. Immunocytochemistry was performed for keratin 8 and 18 and prostatic-specific antigen (PSA). In conclusion, although it has rarely been used as a diagnostic tool, FNA of the penis can be proved effective and safe in diagnosing a suspected secondary malignancy.

Early ischemic preconditioning without hypotension prevents spinal cord injury caused by descending thoracic aortic occlusion.

OBJECTIVE: Postoperative neurologic deficits after thoracic aortic reconstruction vary widely. Our previous study showed that delayed ischemic preconditioning could prevent spinal cord injury caused by occlusion of the descending thoracic aorta in pigs. We investigated early ischemic preconditioning in the same model. METHODS: Twenty-eight pigs were divided into 4 groups: group 1 (n = 6) underwent a sham operation, group 2 (n = 6) underwent aortic occlusion for 20 minutes, group 3 (n = 8) underwent aortic occlusion for 35 minutes, and group 4 (n = 8) underwent aortic occlusion for 20 minutes and underwent aortic occlusion 80 minutes later without hypotension for 35 minutes. Aortic occlusion was accomplished by using 2 balloon occlusion catheters placed fluoroscopically at T6 to T8 above the diaphragm and at the aortic bifurcation. Neurologic evaluation was performed by an independent observer according to the Tarlov scale (0-4). The lower thoracic and lumbar spinal cords were harvested at 120 hours and examined histologically with hematoxylin-and-eosin stain. Histologic results (number of neurons and grade of inflammation) were scored (0-4) and were similarly analyzed. Statistical analysis was by means of the Kruskal-Wallis test. RESULTS: Group 4 had a better neurologic outcome at 24, 48, and 120 hours in comparison with group 3 (P <.001). The histologic changes were proportional to the neurologic test scores, with the more severe and extensive gray matter damage in animals of group 3 (number of neurons, P <.001; grade of inflammation, P <.001). CONCLUSION: Early ischemic preconditioning without hypotension protects against spinal cord injury after aortic occlusion, as confirmed by using the Tarlov score and histopathology.

Does ischemic preconditioning reduce spinal cord injury because of descending thoracic aortic occlusion?

OBJECTIVE: Ischemic preconditioning has been found to protect various organs from a subsequent longer ischemic insult. We investigated whether the late phase of ischemic preconditioning reduces spinal cord injury from occlusion of the descending thoracic aorta. METHODS: Twenty-four pigs (27 to 30 kg) were randomly divided in four groups: group I (n = 4) underwent a sham operation, group II (n = 4) underwent aortic occlusion for 20 minutes, group III (n = 8) underwent aortic occlusion for 35 minutes, and group IV (n = 8) underwent aortic occlusion for 20 minutes and, 48 hours later, aortic occlusion for 35 minutes. Aortic occlusion was accomplished with two balloon occlusion catheters placed fluoroscopically at T(6) to T(8) above the diaphragm and at the aortic bifurcation. Neurologic evaluation was performed by an independent observer according to Tarlov's scale (0 to 4, with 4 as normal). The lower thoracic and lumbar spinal cords were harvested at 120 hours and examined histologically with hematoxylin and eosin stain. Histologic results (number of neurons and grade of inflammation) were scored 0 to 4 (4, intact spinal cord; 0, no neurons and high inflammation) and were similarly analyzed. Results were expressed as the mean +/- the standard error of the mean, and statistical analysis used the Kruskal-Wallis test. RESULTS: Group IV had a better neurologic outcome at 24, 48, and 120 hours in comparison with group III (P <.001), although 120 hours after the end of the experiment, the neurologic outcome in group IV was worse than at 24 hours (P =.014). The histologic changes were proportional to the neurologic test scores, with the more severe and extensive gray matter damage in the animals of group III (number of neurons, P <.001; and grade of inflammation, P <.001). CONCLUSION: Ischemic preconditioning (late phase, 48 hours after the first occlusion) reduces spinal cord injury after aortic occlusion, as estimated with Tarlov's score and histopathology.

Sudden death due to an unrecognized cardiac hydatid cyst.

Echinococcosis is an endemic disease, most common in sheep-raising communities, usually caused by the larval or cyst stage of the tapeworm Echinococcus granulosus. Isolated cardiac hydatid cyst is uncommon at any age, occurs through the coronary circulation, and accounts for less than 3% of all hydatid disease. We describe a case of an 1%-year-old female, who died suddenly. The post-mortem examination revealed an isolated cyst in the left ventricle of the heart with intact wall. The cytologic examination of the cyst fluid demonstrated the presence of the characteristic scolices and hooklets and established the diagnosis of cardiac hydatid cyst. The present case is of special interest because of the rare primary localization and the onset of sudden death in a young person as the initial manifestation of the disease.