[Examination of lymph nodes in resected colon segments with colorectal carcinoma]. / Hodnocení lymfatických uzlin v resekátech tlustého streva s kolorektálním karcinomem.

INTRODUCTION: Optimized staging of colorectal carcinoma (CRC) is essential for treatment planning and for estimating the prognosis of the disease. In addition to tumour size and the depth of bowel wall infiltration, the lymph node status is very important for the determination of the disease stage. For this reason, detection and assessment of the maximum number of lymph nodes is emphasized in the examination of resected segments of the large bowel. The number of lymph nodes (LNs) found in the segments resected depends on various circumstances. In our study, we focused on factors which could influence the number of pericolic LNs. MATERIAL AND METHODS: We examined two groups of CRC patients. The first group included 30 patients within the age range of 32-50 years (average: 47.5 years) and the second group consisted of 90 patients aged between 51 and 87 years (average: 68 years). The tumours were localized in various parts of the colon, predominantly in the descending colon and the sigmoid colon. Rectal tumour was present in 23 patients; 13 of them underwent preoperative chemoradiation therapy and 10 of them received no preoperative therapy. The length of the resected colon segments (radical intervention) ranged from 6 to 51 cm. The size of CRC ranged from 0.5 to 15 cm (average: 4.5 cm). The maximum tumour invasion depth reached into the subserosal tissue and pericolic adipose tissue. RESULTS: The number of LNs found in 120 resected colon segments ranged from 1 to 60 LNs per case. The number of LNs showed differences among the patients and also depended on the location of CRC within the large intestine. In the resected segments of the ceacum with CRC, the average number of LNs was 11.5, whereas it was only 7 in rectal CRC. The largest volume of pericolic adipose tissue was found in the caecum, whereas the smallest volume was seen on the rectal circumference. In CRC patients aged 50 years or younger, the number of LNs was from 2 to 60 (average: 17). In contrast, the number of LNs ranged from 1 to 46 (average: 11) in patients older than 50 years. In resected segments that were 6 to 12 cm long, the number of LNs ranged from 1 to 18 (average: 8). In resected segments that were 12 to 51 cm long, the number of LNs was from 1 to 60 (average: 13.8). In 13 cases of rectal CRC with preoperative chemoradiation therapy, small LNs of an average length of 1-3 mm predominated, and the number of LNs ranged between 1 and 13 (average: 5). The required number of 12 LNs was reached in 4 resected parts of the rectum (31%). CONCLUSION: The number of pericolic LNs found in the resected segments of the colon and the rectum with CRC depends on various factors. Besides individual differences, the number of LNs is influenced by the CRC location in the colon, the extent of the resected pericolic adipose tissue, the patients age and the length of the segment resected. In cases of rectal CRCs, it is also influenced by preoperative chemoradiation therapy.

Perineural cell differentiation in ganglioneuromas. Report of 8 cases with immunohistochemical expression of perineural cell markers.

Eight cases of ganglioneuroma were examined for a presence of perineural cell differentiation, using the immunohistochemical markers epithelial membrane antigen (EMA), claudin-1 and GLUT-1. The mean age of the patients was 42.3 years (range 26-68 years), six patients were females and two were males. Five tumors were located in the adrenal gland and 3 tumors in the retroperitoneum. Morphology of the tumors was typical, i.e., they were composed of neuroid spindle cell population and scattered mature appearing ganglion cells. Spindle cells positive for perineural cell markers claudin-1 and GLUT-1 were found in all lesions, at least focally. EMA+ cells were seen in 2 of 8 tumors. These perineural-type cells were often arranged in organoid fashion around the schwannoid bundles or around the vessels. Our findings indicate that perineural cell differentiation is commonly present in ganglioneuromas.

Immediately preoperative use of biological therapy does not influence liver regeneration after large resection--porcine experimental model with monoclonal antibody against epidermal growth factor.

BACKGROUND: The aim of this work was to study the influence of isolated biological therapy administered immediately before extended liver resection on liver function and regenerative capacity of future liver remnant (FLR) in a large-animal experiment. MATERIALS AND METHODS: Nineteen piglets were included in this study (10 in the control group and 9 in the experimental group). A port-a-cath was introduced into the superior caval vein. On days 11 and 4 before liver resection, cetuximab was administered via this port at 400 mg/m2 of piglet body surface. Physiological solution was applied to the control group. Resection of the left lateral, left medial and right medial hepatic lobes was followingly performed (reduction of 50-60% of liver parenchyma). Blood samples were collected at different times before the operation and after liver resection. Serum levels of bilirubin, urea, creatinine, alkaline phosphatase, gamma glutamyltransferase, cholinesterase, aspartate aminotransferase, alanine aminotransferase, albumin, C-reactive protein and transforming growth factor-ß1 were assessed. The ultrasonographic examinations at different time points were performed pre-operatively and after liver resection in order to assess the liver volume. The biopsies from the liver parenchyma were examined for proliferative activity, binocluated hepatocytes, size of hepatocytes, and the length of the lobuli. The comparison of distribution of the studied parameters between the groups was carried out using the Wilcoxon test. The Spearman rank correlation co-efficient was used because of the non-Gaussian distribution of the parameter values. The whole development of the studied parameters over time was compared between the groups using ANOVA. RESULTS: There were no important complications of administration of biologic therapy during the operation or throughout the peri-operative period. There was no statistically significant difference in the regeneration of FLR nor were any differences in biochemical, immunoanalytical and histological parameters detected. CONCLUSION: The achieved results of comparable liver regeneration in both the experimental and control groups confirms the use of biological treatment with cetuximab in the pre-operative period for minimizing the recovery period.

Vaginal myofibroblastoma with glands expressing mammary and prostatic antigens.

A case of unusual vaginal myofibroblastoma containing glands which expressed mammary and prostatic markers is described. The tumor occurred in 70-year-old woman in the proximal third of the vagina. It showed morphology and immunophenotype typical of so-called cervicovaginal myofibroblastoma. The peripheral zone of the lesion contained a few groups of glands suggesting vaginal adenosis or prostatic-type glands on initial examination. The glands showed a surprising simultaneous expression of mammary markers mammaglobin and GCDFP-15 and prostatic markers prostate-specific antigen (PSA) and prostate-specific acid phosphatase (PSAP). Immunostains for alpha-smooth muscle actin, p63 and CD10 highlighted the myoepithelial cell layer of the glands. The finding indicates that simultaneous use of both mammary and prostatic markers for examination of unusual glandular lesions in the vulvovaginal location can be helpful for an exact diagnosis, and can contribute to better understanding of prostatic and mammary differentiations in the female lower genital tract.

Mediastinal ganglioneuroma with perineural cell differentiation. Report of a case.

An unusual case of ganglioneuroma with perineural cell differentiation is presented. The tumor was removed from the mediastinum in a 34-year-old male patient. Histologically, it contained neuroid bundles of bland spindle cells, scattered ganglion cells, and some foci of adipocytic metaplasia. Immunohistochemically, the tumor showed expected expressions of S100 protein, neurofilament protein and calretinin. In addition, many spindle cells were positive for perineural cell markers EMA, claudin-1, and GLUT-1. These cells were often arranged in an organoid fashion around the schwannoid bundles. This case indicates that the cells of ganglioneuroma can mature simultaneously towards both Schwann cell and perineural cell phenotypes.

[Caroli disease--dilatation of intrahepatic bile ducts]. / Caroliho nemoc--dilatace intrahepatálních zlucových cest.

Caroli disease is a rare congenital condition characterized by a non-obstructive saccular or fusiform multi-focal segmental dilatation of the intrahepatic bile ducts and the frequent formation of the intrahepatic calculi. It can affect the entire liver with manifestations in the childhood, or only some segments, which may be an asymptomatic condition found accidentally in the adulthood. In other cases, the condition is manifested primarily with tract infections. The authors of the three case reports describe pitafalls of the diagnosis and treatment of the segmental Caroli disease, which is manifested in the adulthood. The treatment was a resection of the affected liver segments.

Pseudoglandular (adenoid, acantholytic) squamous cell carcinoma of the penis. A case report.

A case of so-called pseudoglandular (adenoid, acantholytic) squamous cell carcinoma (SCC) of the penis occurring in a 60-year-old man is described. The tumor showed, in addition to the pattern of conventional moderately to poorly differentiated SCC, a component of tubular-appearing pseudoglandular SCC. No precancerous dysplastic lesion was found near the lesion. Immunohistochemically, the tumor cells expressed pancytokeratin, p53 and p63, and they were negative for endothelial markers, carcinoembryonic antigen and p 16. Stains for mucin were negative. Metastases were found in the regional lymph nodes and spermatic cord. Four weeks after the penectomy, multiple cutaneous/subcutaneous metastases appeared and metastases in the pelvic lymph nodes were visualized through a CT scan. The advanced stage of the tumor seen in the present case further confirms that pseudoglandular SCC represents a highly aggressive tumor.

Histologic findings after sodium phosphate bowel preparation for colonoscopy. Diagnostic pitfalls of colonoscopic biopsies.

Oral sodium phosphate (NaP) has been increasingly used for bowel preparation before the colonoscopy because it shows good patients tolerance and effective bowel cleansing ability. However, new studies describe that NaP can induce colonic mucosal damage. For better characterization of these changes, we examined histologically segmental colonic biopsies from 42 patients receiving NaP bowel solution before the colonoscopy. The series includes 25 male and 17 female patients in age from 19 to 81 years (average age 46.7 ys). Clinical symptoms in 37 patients included diarrhea, constipation, bleeding and abdominal cramps. The most frequent reason for colonoscopy was suspicion of microscopic colitis. Five patients underwent endoscopy to rule out the presence of neoplasia. None of the patients took drugs before the colonoscopy. Histologically, all specimens showed mild focal edema, hyperemia and hemorrhages. In addition to edema and hemorrhage, in 26 patients (61.9%), patchy mononuclear infiltration in the upper part of lamina propria and increased epithelial cell proliferation of individual crypts were seen. Mucosal structure was normal, with partial sloughing of normal or flattened surface epithelium. In 5 patients (11.9%), some biopsy samples contained scattered neutrophilic leucocytes in the lamina propria/superficial epithelium, isolated basal cryptitis, increased proliferation and apoptosis of the crypt epithelium. In two patients with focal cryptitis (4.8%), small erosions were found. Mild basal cryptitis, increased proliferation and striking apoptosis were present in two inflammatory pseudopolyps (in two patients). In 4 patients, solitary tubular adenomas with low-grade dysplasia without any reactive changes were found. In addition, 300 hyperplastic polyps removed endoscopically after the NaP application, were examined. Two polyps (0.75%) showed cryptitis and isolated multinucleated epithelial cells in the superficial part of the crypts. Our results are similar to those previously described in other studies of colonic changes after the NaP application. It reflects probably a similarity in composition of used NaP solutions.

Cytokines and liver regeneration after partial portal vein ligation in porcine experimental model.

THE AIM OF STUDY: The limits of liver surgery are restricted today by the functional reserves of remnant parenchyma. The aim of this article was to acquaint the general surgical and medical public with the results of experimental liver regeneration stimulated by cytokines and thus to enhance their effort to carry on with implementing the research results in clinical practice. METHODS: Authors present their experimental model of liver regeneration after ligation of portal branches for caudate and right lateral, and right medial liver lobes. The regeneration was induced by application of TNF-alpha and IL-6 into the non-occluded portal branches, and compared with the results of other experimental teams. RESULTS AND CONCLUSION: The absolute volume of hypertrophic lobes increases after application of TNF-alpha more rapidly, whereas in the control group, practically no changes were recorded in hypertrophic liver lobes volumes in first three days. The achieved acceleration of growth of hypertrophic liver lobes after application of TNF-alpha and IL-6 confirmed the key role of studied pleiotropic cytokines in the priming of liver parenchyma regeneration after portal vein ligation (Fig. 3, Ref. 26).

Giant cell fibroblastoma in a 62-year-old patient. A case report.

A case of giant cell fibroblastoma in a 62-year-old male is described. The 2 x 1.5 x 1.5 cm tumor was excised from the right supraclavicular area. Histologically, it was typical with exceptions that the typical pseudovascular spaces were seen only focally and the neoplastic cells were closely spatially associated with lymphocytes and plasmocytes. This association was suggestive of emperipolesis. The unusual clinicopathologic features caused some diagnostic difficulty.

[Pseudomembranous colitis]. / Pseudomembranózní kolitida.

For some thirty years it has been known that pathologic proliferation oftoxigenic Clostridium difficile may lead to inflammation of colonic mucosa which, in its fully developed form, manifests as pseudomembranous colitis. CDAD (Clostridium difficile - Associated Disease or Diarrhoea) is the term which is generally and quite aptly used for the disease in literature on the subject. In most cases, the disease develops after the administration of broad-spectrum antibiotics, yet there are also other important pathogenetic factors involved which should not be ignored. The disease has grown in significance over recent years due to the occurrence of serious epidemics in a number of advanced countries provoked by a highly virulent strain characterised as ribotype 027, toxinotype III, pulsovar NAP1. CDAD is a potentially fatal disease, yet it can be effectively cured if diagnosed on time. Stool toxin testing plays a crucial role in the diagnostics of the disease, and the use of endoscopy has been on the rise. Administration of targeted antibiotics is of critical importance for successful therapy, metronidazol or orally administered vankomycine being considered the most reliable, and there are also other drugs with promising effects. However, the rate of recurrence of the disease is as high as 25%. In view of the realistic threat of propagation of the highly virulent strain in the territory of the Czech Republic, preparations have started for the setting up of a national reference laboratory for Clostridium difficile typification.

Histopathologic changes in gastroesophageal reflux disease. A study of 126 bioptic and autoptic cases.

The histologic diagnosis of reflux esophagitis is still complicated by the lack of a consensus opinion on what is the normal mucosa in the area of the gastroesophageal junction (GEJ). Most authors consider GEJ as the junction between the squamous and the cardiac epithelium. The cardiac mucosa is composed of mucinous or mixed mucinous-oxyntic glands. These glands are in fact indistinguishable from metaplastic mucosa that arises in the distal esophagus in consequence of gastroesophageal reflux (GER). The cardiac mucosa shows invariably chronic inflammatory changes referred to as "carditis". The cause of "carditis" is GER and/or Helicobacter pylori (HP) infection. In our series of 120 endoscopic biopsies of the GEJ and distal esophagus the cardia type mucosa (CM) was always present. In 15 cases, it was accompanied by oxyntocardiac mucosa. Both mucosa types showed chronic inflammation that is after exclusion of HP infection regarded as a strong diagnostic sign of the gastroesophageal reflux disease (GERD). In two cases with clinical symptoms of GERD, a few HP were found on the CM. Therefore we diagnosed them as GERD with secondary HP infection. In 17 cases, CM displayed intestinal metaplasia (IM) predominantly of incomplete type and no dysplasia. This IM expressed MUC6 in the glandular zone of the mucosa like it did in the neighboring glands, whereas in the surface and foveolar epithelium the MUC6 was negative or only slightly and focally positive. On the other hand, IM in the surface and foveolar epithelium was reactive for MUC5AC. The positivity and distribution of CK7 and CK20 was very similar in the Barrett's mucosa, cardiac mucosa and antral mucosa. In one specimen of esophagus resected for adenocarcinoma, CM with incomplete IM was found in the vicinity of the tumor. Squamous metaplastic epithelium was often seen near the orifices of submucosal esophageal glands in these areas, indicating the metaplastic nature of the glandular mucosa in the distal esophagus. In the GEJ of 5 autopsy cases of children with spastic quadriplegia (age range 7-10 years) CM in a short segment (0.5-3 mm in length), probably of metaplastic origin was identified, showing chronic inactive inflammation.

Sessile serrated adenomas of the large bowel. Clinicopathologic and immunohistochemical study including comparison with common hyperplastic polyps and adenomas.

Sessile serrated adenoma (SSA) is a newly characterized type of the large bowel adenoma. It arises in hyperplastic polyp (HP) and represents a precursor lesion of colorectal carcinoma with microsatellite instability. SSAs differ from common HPs by abnormal proliferation of the crypt epithelium and by nuclear atypia. We examined 15 SSAs from 15 patients. The age range was 25-80 years (average 60 years). Six patients were females and 9 were males. For comparison, we examined 10 conventional tubular adenomas and 10 common HPs with vesicular cells. The sites of SSAs were as follows: 8 in rectum, 4 in rectosigmoid colon, 1 in transverse colon, 1 next to mucinous carcinoma of ascending colon, 1 in anastomosis after resection of the transverse colon adenocarcinoma. The diameter of the lesions ranged from 5 to 12 mm. Histologically, SSAs showed asymmetrical proliferation of the epithelium, irregular shape of the crypts with their branching and some crypt dilatations especially in the basal parts of the crypts. Cellular atypia (dysplasia) was usually low. In 5 cases the nuclei were focally stratified and localized in the lower part of the cells. High-grade dysplasia was found only in SSA adjacent to mucinous adenocarcinoma. Immunohistochemically, SSAs showed secretion of gastrointestinal mucin expressing MUC2 and MUC5A. Both MUC2 and MUC5A were also positive in mucinous carcinoma. In previous studies these expressions were considered specific for serrated type of carcinogenesis. However, our study found positivity of MUC2 and MUC5A also in conventional adenomas. Expression of p53 in SSAs was minimal. SSAs have malignant potential comparable with conventional adenomas and for this reason they must be distinguished from HPs.

Autoimmune gastritis. A clinicopathologic study of 25 cases.

The histopathological diagnosis of autoimmune gastritis (AG) in its early stages can be a diagnostic challenge. Even some advanced cases with complete atrophy of the corpus mucosa may be difficult to recognize. To establish the diagnosis of autoimmune gastritis, several histological features should be assessed and combined with immunostains for enterochromaffin cell-like (ECL) cells and G-cells. The main histological criteria include a mononuclear infiltrate within the lamina propria, foci of destruction of oxyntic glands, intestinal metaplasia (IM), pyloric metaplasia, and parietal cell pseudohypertrophy. These criteria were evaluated in our series of 25 patients with achlorhydria and/or megaloblastic anemia. Some of our patients presented with nonspecific gastrointestinal symptoms. The age ranged between 46 and 79 years; one male patient was only 31 years old. Histologically, the corpus mucosa displayed in all cases chronic inflammation with focal complete IM and advanced pyloric metaplasia. In 4 patients, oxyntic glands were destructed in some sites. There was a pancreatic metaplasia of acinar type in 2 patients and a minimal focal pseudohypertrophy of parietal cells in the 31-year-old man. A tubular adenoma with a low-grade dysplasia was found in one female patient. Immunohistochemically, chromogranin-A highlighted linear or nodular hyperplasia of ECL cells in 19 patients, and adenomatoid ECL hyperplasia in one case (80%). In the remaining cases hyperplasia of ECL cells could not be recognized from their normal count. In 13 cases (52%) a few ECL cells were seen also in IM. Regarding associated pathology, in one woman with nodular ECL cell hyperplasia, a gastric carcinoid was removed endoscopically. The reaction with gastrin antibody revealed in 11 cases (44%) a small number of G cells in IM in the corpus mucosa. In 18 patients, antral mucosa was examined as well. In 8 patients, the mucosa was normal; in 10 cases, a mild chronic inactive gastritis was diagnosed, and in 15 patients G-cell hyperplasia was found. In accordance with other studies, we show that the diagnosis of AG may be established microscopically in endoscopic specimens of the gastric body mucosa when histologic features and immunohistochemical detection of ECL and G cell hyperplasia are combined.

Gastrointestinal stromal tumor (GIST) with glandular component. A report of an unusual tumor resembling adenosarcoma.

A case of gastrointestinal stromal tumor (GIST) with an unusual glandular component is reported. The tumor was found in the gastric fundus of a 93-year-old woman. Histologically, the lesion showed a biphasic adenosarcoma-like structure. Typical low-grade spindle cell patterns of GIST were intermingled with numerous and partly cystic glands. The glandular epithelium had pyloric/foveolar-like appearance, with foci of intestinal metaplasia and low-grade dysplasia. The stromal component was immunoreactive for CD117 (c-kit) and CD34, and negative for myoid and neuroid markers. The ultrastructural examination found nondescript and undifferentiated spindle cells. The gastric mucosa and submucosa near the tumor contained a small area with features of gastritis cystica profunda, with glands similar to those present inside the tumor. Therefore, a collision of GIST and gastritis cystica profunda is suggested in the histogenesis of the lesion.

The histological findings in the gastroesophageal junction of fetuses.

The development of the esophageal and gastric mucosa in the gastroesophageal junction was studied in 61 fetuses of 13-41 weeks of the gestational age. During the 13th-15th week, the esophageal multilayered epithelium was covered by a continuous layer of columnar mucous ciliated cells which were present only focally till the 25th week and disappeared later. Before the 15th week, the gastric mucosa was formed by pits only. The glands started as proliferating tubules in the basal parts of the pits in the 15th week. Further, they differentiated into oxyntic glands. The mucosa of the corpus was fully developed in the 27th week. The cardiac mucosa was absent in all the 10 fetuses examined between the 27th and 41st week of gestation. This supports the view that the gastric cardiac mucosa is not a physiological structure but that it results from glandular metaplasia of the distal esophageal mucosa due to gastroesophageal reflux.

[Ulcerative colitis--contemporary morphological criteria]. / Ulcerózní kolitida--soucasná morfologická kritéria.

Regular bioptical examinations of patients with ulcerative colitis (UC) performed in recent years show that the inflammatory changes of the mucosa of the large intestine are not necessarily diffuse, and that their extent may vary in the course of the disease. To establish the diagnosis of UC and to assess the treatment efficacy it is important to examine histologically multiple mucosal specimens from different levels of the large intestine. In our series of 27 patients with ulcerative colitis (18 men and 9 women at the age of 17 to 76 years), active or active and inactive pancolitis was diagnosed in 25 cases (93%). In 11 of these, the whole of the large intestine was affected. Two patients showed diffuse pancolitis without caecal involvement, in 5 cases there was inactive inflammation in the rectum or in the sigmoid colon. Seven patients had active colitis of the rectum and sigmoid. In another 2 patients (7%), the inflammation was limited to several segments of the large intestine only (the descending colon, and the descending and transverse colon). On bioptical examination of 6 patients repeated after 2-29 months (mean 14 months), there were changes in the distribution and appearance of the inflammation. Thus our findings correspond with the results of previous studies: UC does not always affect the mucosa of the large intestine diffusely. Further, the extent and distribution of inflammatory changes vary in the course of the disease.