"Dum spiro spero": clinicopathologic characteristics of SARS-CoV-2 infection / "Dum spiro spero": a SARS-CoV-2-fertozés klinikopatológiája 26 eset kapcsán.

Összefoglaló. Bevezetés: A kórboncolás hozzájárul a súlyos akut légzoszervi szindrómát okozó koronavírus-2 (SARS-CoV-2-) fertozés klinikopatológiai vonatkozásainak megismeréséhez. Célkituzés: A SARS-CoV-2-fertozöttek boncolása során gyujtött tapasztalatok bemutatása. Módszer: Egymást követoen boncolt, védooltásban nem részesült, SARS-CoV-2-fertozött elhunytak klinikai adatait, makro- és mikroszkópos észleleteit összegeztük; a tüdokimetszéseket SARS-CoV-2-nukleokapszid-immunfestéssel vizsgáltuk. Eredmények: A boncolást a halálok megállapítására (n = 14), tumorgyanú (n = 9), illetve törvényi kötelezettség (n = 3) miatt végeztük. A fertozést a klinikai észlelés vagy a boncolás során (n = 4) végzett SARS-CoV-2-nukleinsav-teszt igazolta. A tünetes betegség átlagos hossza 12,9 nap volt. 21 betegnél (medián életkor 69 év; 18 férfi) állt fenn COVID-19-pneumonia, mely 16 esetben önmagában, 4 esetben bakteriális pneumoniával vagy álhártyás colitisszel szövodve okozott halált; 1 antikoagulált pneumoniás beteg heveny retroperitonealis vérzésben halt meg. 3 betegnél a halált disszeminálódott malignus tumor, 1 betegnél coronariathrombosis, 1 mentálisan retardált betegnél pedig pulmonalis emboliás szövodmény okozta. A COVID-19-pneumoniás tüdok nehezek, tömöttek és vörösen foltozottak voltak. Szövettanilag a betegség idotartamától függoen diffúz alveolaris károsodás korai exsudativ vagy késobbi proliferativ fázisa látszott atípusos pneumocytákkal; gyakori volt a microthrombosis (n = 7), a macrothrombosis (n = 5), illetve a pulmonalis embolia (n = 4). A SARS-CoV-2-immunfestés pozitívnak bizonyult az esetek 38,5%-ában, dominálóan az exsudativ fázisban. Minden elhunyt társbetegség(ek)ben szenvedett, így magasvérnyomás-betegségben (n = 17), érelmeszesedésben (n = 14), 2-es típusú diabetesben (n = 8), rosszindulatú daganatban (n = 6), krónikus obstruktív tüdobetegségben (n = 4), elhízásban (n = 3), vesetranszplantáció utáni immunszuppresszióban (n = 3). Következtetés: Az irodalmi adatokkal összhangban, halálos COVID-19-pneumonia túlnyomóan idos, társbetegség(ek)tol sújtott férfiakban alakult ki. A boncolási gyakorlatban a SARS-CoV-2-nukleokapszid-immunfestéstol a diffúz alveolaris károsodás korai fázisában várható pozitivitás. Orv Hetil. 2021; 162(45): 1791-1802. INTRODUCTION: Autopsy is an important tool for the evaluation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Objectice: The aim of this study was to present our experience with autopsies of patients diagnosed with SARS-CoV-2 infection. METHOD: Clinical data, macroscopic and microscopic findings of consecutive postmortems of non-vaccinated SARS-CoV-2 patients are summarized. Lung samples were evaluated with SARS-CoV-2 nucleocapsid immunohistochemistry. RESULTS: Autopsies were performed to determine the cause of death (n = 14), suspected tumours (n = 9) or due to legal obligation (n = 3). SARS-CoV-2 infection was verified by ante mortem (n = 22) and post mortem (n = 4) polymerase chain reaction. The mean duration of symptomatic disease was 12.9 days. Of 21 patients with COVID-19 pneumonia, 16 died of respiratory failure, 4 had additional bacterial pneumonia or Clostridioides difficile infection, and 1 developed hemorrhagic complication (n = 1). Other causes of death included disseminated malignancies (n = 3), coronary thrombosis (n = 1) and pulmonary embolism (n = 1). The affected lungs were heavy and had patchy red appearance. Exudative or proliferative phases of diffuse alveolar damage (DAD) were detected with atypical pneumocytes. Microthrombosis (n = 7), macrothrombosis (n = 5) and pulmonary embolism (n = 4) were frequent. The SARS-CoV-2 immunohistochemical reaction was positive in 38.5% of cases. All patients had co-morbidities, namely, hypertension (n = 17), atherosclerosis (n = 14), diabetes (n = 8), malignancies (n = 6), chronic obstructive pulmonary diseases (n = 4), obesity (n = 3) and immunosuppression after kidney transplantation (n = 3). CONCLUSION: Fatal COVID-19 pneumonia occurred mostly in elderly males with co-morbidities. In the autopsy practice, the SARS-CoV-2 nucleocapsid immunohistochemical reaction may confirm the infectious etiology in the early phase of DAD. Orv Hetil. 2021; 162(45): 1791-1802.

Expression of growth hormone-releasing hormone receptors in apocrine adnexal tumours and apocrine glands of the skin.

Encouraged by our previous finding of growth hormone-releasing hormone receptor (GHRH-R) expression in metaplastic and neoplastic apocrine breast epithelium, we examined a small series of skin adnexal tumours with various degrees of apocrine (oxyphilic) differentiation, as well as normal axillary and anogenital apocrine sweat glands, for the expression of GHRH-R. Sections of formalin-fixed paraffin-embedded tissue blocks were immunostained for gross cystic disease fluid protein-15 (GCDFP-15) and androgen receptor (AR), to prove apocrine differentiation and correlate it with areas of GHRH-R expression. All but one of 19 tumours with apocrine epithelium and all five benign apocrine glands stained with both anti-GHRH-R antibodies used, each labelling a different domain of the receptor. Non-apocrine areas of the tumours and four eccrine tumours without oxyphilic features did not stain, but most sebaceous glands and some eccrine glands were labelled. Our data suggest that anti-GHRH-R antibodies highlight apocrine differentiation at extramammary sites also. Although GHRH-R seems to have a sensitivity comparable to classic apocrine markers such as AR and GCDFP-15, it seems to be inferior in specificity. The GHRH-R labelling of apocrine glands and neoplastic epithelium might also interfere with the emerging anti-GHRH targeted treatment of some malignancies acting on these receptors.

Elastic staining does not assist detection of venous invasion in cutaneous melanoma.

The aim of the present study was to determine the benefit of orcein elastic staining of primary cutaneous melanoma specimens in detecting venous invasion. Primary cutaneous melanomas in vertical growth phase were assessed for vascular invasion. All tumour blocks were stained with haematoxylin and eosin (H&E) and orcein. The cases were reviewed by two pathologists. Vascular invasion was not identified more frequently on orcein stained slides than on H&E stained ones. Elastosis and periappendiceal elastic fibres interfered with vascular invasion detection with elastic staining. Based on our study, we conclude that elastic stains such as orcein do not improve the detection rate of venous invasion in primary cutaneous melanomas.

Incidentally discovered diffuse large B-cell lymphoma limited to the endocervical mucosa in a young female patient.

Primary high-grade non-Hodgkin lymphoma of the female genital tract is extremely rare. Vaginal bleeding, abdominal pain or urinary complaints might be its most frequent symptoms. We report a 27-year-old multipara who underwent large loop excision of the transformation zone because of the repeated finding of a low-grade squamous intraepithelial lesion identified during routine cancer screening. Incidentally, CD20-positive, primary, diffuse large B-cell lymphoma infiltrating the mucosa of the endocervix was also diagnosed from this specimen. The case is unusual because the patient had no symptoms, specific colposcopic signs or visible mass. R-CHOP 21 immunochemotherapy was introduced and resulted in complete remission without hysterectomy. The patient is without any evidence of disease after 49 months of follow-up. Primary cervical lymphomas are mainly subepithelial initially, and therefore they may be under-recognized due to the inefficiency of smears to diagnose such lesions. Early diagnosis and available targeted treatment allowed a cure in the reported example.

The case of the purple colon.

Purple discoloration of the large bowel at autopsy was related to beetroot ingestion and post-mortem changes.

[Agranular CD4+/CD56+ haematodermic neoplasm (Precursor haematologic neoplasm)]. / Agranularis CD4+/CD56+ haematodermiás daganat (Prekurzor hematológiai daganat).

The agranular CD4+/CD56+ haematodermic neoplasm (so-called blastic NK-cell lymphoma) represents a distinct clinicopathologic entity and it is characterised by its clinical presentation (skin tropism, bone marrow involvement with or without leukemic phase, very poor prognosis) and the common expression of the T helper CD4 as well as the NK cell marker CD56. The authors present an 86 year old male patient with hemorrhagic macules, plaques and hemorrhagic flat nodules mainly on the trunk without any complaints. The skin biopsy revealed an agranular CD4+/CD56+ hematodermic tumor. During the medical check-up and the 18 months long follow-up they did not find any internal involvement including the bone marrow. In their case they revealed the cutaneous form of the hematodermic tumor which is considered to be a new and interesting manifestation of aleukemic leukemia cutis.

Use and limitations of a nomogram predicting the likelihood of non-sentinel node involvement after a positive sentinel node biopsy in breast cancer patients.

After a positive sentinel lymph node (SLN) biopsy, some patients may be considered to have a very low risk of non-SLN involvement and could be candidates for axillary sparing. The aim of this study was to validate the nomogram created at the Memorial Sloan-Kettering Cancer Center (MSKCC) for the prediction of non-SLN involvement in an independent set of 140 patients with both positive SLNs and axillary dissection. The predicted proportions of positive non-SLNs were compared with the observed percentages of non-SLN metastasis. Although the SLN metastasis size and tumor size did influence the risk of non-SLN involvement, the correlation between the predicted and observed proportions was weaker for our patients (R: 0.84) than for the patients assessed at the MSKCC (R: 0.97). Differences were noted in the intraoperative assessment and in the final histology of the SLNs (imprints vs frozen sections and more detailed vs less detailed, respectively), and these could partly explain the lower level of the correlation. The nomogram could not be validated and was found to be of only limited use for the prediction of non-SLN involvement in patients operated on under similar, though not fully identical conditions. We therefore warn against the unvalidated use of this prediction tool.

Axillary sentinel node and tumour-related factors associated with non-sentinel node involvement in breast cancer.

BACKGROUND: After completion of axillary dissection, many breast cancer patients with axillary sentinel nodal involvement are found to have regional disease limited to the sentinel nodes. These patients are exposed to the morbidity of axillary clearance without any expected therapeutic benefit. METHODS: Sentinel node biopsy was performed either with Patent blue dye or with a combined dye, radiocolloid and gamma-probe-guided method involving peritumoral tracer administration. For a series of 150 consecutive patients with involved axillary sentinel nodes and axillary dissection, factors associated with non-sentinel nodal involvement were analysed in a multivariate analysis based on logistic regression with the use of fractional polynomials. RESULTS: The following variables were found to be potentially associated with non-sentinel node metastases: tumour size, sentinel node metastasis size, number of examined sentinel nodes, percentage of involved sentinel nodes (the latter two were found to be significant only when in combination), and extracapsular perinodal spread. CONCLUSIONS: Isolated tumour cells and micrometastases in axillary sentinel nodes carry a low risk of non-sentinel node metastasis. The risk of metastasis to further echelon nodes is higher with macrometastases, especially if there is extracapsular growth and the proportion of involved sentinel nodes is high.

Endometrial adenocarcinoma with coexisting adenomatoid tumor of the uterus.

BACKGROUND: Uterine adenomatoid tumors may be present in up to 1% of hysterectomy specimens, and their infiltrative pattern may simulate that of adenocarcinomas. CASE: This is a report on the coexistence of a uterine adenomatoid tumor and an endometrial adenocarcinoma, both chance findings in a 41-year-old woman undergoing hysterectomy because of a preoperative diagnosis of metrorrhagia due to leiomyomas. CONCLUSION: Although uterine adenomatoid tumors are believed to be rare, they may pose a differential diagnostic problem in the pathologic staging of endometrial carcinomas, because they form gland-like lumina and infiltrate the myometrium. To our knowledge, no previous coexistence of these two tumors has been reported.