Aquaporin-1 expression in fluoro-edenite-induced mesothelioma effusions: An approach by cell-block procedure.

OBJECTIVE: Aquaporin 1 (AQP-1) is a water channel protein found in cell membranes, whose expression has been considered an independent favourable prognostic factor in pleural malignant mesothelioma (MM). The aim of this study was to evaluate the expression of AQP-1 and its prognostic value in a series of pleural MM effusions, from a geographical area with high concentrations of fluoro-edenite (FE). METHODS: We selected 25 MM cases from Biancavilla (Italy), an area with high environmental concentrations of FE. Cytological samples, cell-blocks (CB), clinical and follow-up data were available for all cases. Immunohistochemistry for calretinin, CK5/6, WT1, CK7 and TTF1 was used on CB sections to confirm the cytological diagnosis of MM. Immunohistochemistry for AQP-1 was performed and high expression was defined when ≥50% of tumour cells showed linear and circumferential membranous staining. RESULTS: The cohort included 16 men and nine women (median age: 67.5 years; range: 49-88 years). The median survival was 14 months (range 1.5-60 months), with a significant value (P = 0.006). All cases have been histologically confirmed and classified as epithelioid (16 cases), biphasic (seven cases) and sarcomatoid (two cases). AQP-1 high expression has been observed in 16 cases. Comparing AQP-1 high expression to the survival of corresponding patients, a significant association with a slight increased overall survival of 12 months has been demonstrated. Nine patients with a AQP-1 score less than 50% showed a shorter median overall survival (7 months). CONCLUSIONS: AQP-1 high expression is detectable on cytological samples of FE-induced MM with a prognostic value.

HER2 Status in Premalignant, Early, and Advanced Neoplastic Lesions of the Stomach.

OBJECTIVES: HER2 expression in gastric cancer (GC) has received attention as a potential target for therapy with Trastuzumab. We reviewed the current knowledge on HER2 status in premalignant gastric lesions and in early (EGC) and advanced (AGC) GC to discuss the possible pathogenetic and prognostic roles of HER2 overexpression in GC. RESULTS: HER2 overexpression was documented in gastric low-grade (LG) and high-grade intraepithelial neoplasia (HG-IEN), with higher frequency in gastric type dysplasia. HER2 overexpression was significantly associated with disease recurrence and poor prognosis in EGC representing an independent risk factor for lymph node metastases. HER2 overexpression was more frequent in AGC characterized by high grade, advanced stage, and high Ki-67 labeling index. The discordance in HER2 status was evidenced between primitive GC and synchronous or metachronous metastases. CONCLUSIONS: HER2 overexpression in premalignant gastric lesions suggests its potential involvement in the early steps of gastric carcinogenesis. The assessment of HER2 status in EGC may be helpful for the identification of patients who are at low risk for developing nodal metastases. Finally, the possible discordance in HER2 status between primary GC and its synchronous metastases support routine assessment of HER2 both in the primary GC and in its metastatic lesions.

Intraparietal esophageal leiomyomas diagnosed by endoscopic ultrasound-guided fine-needle aspiration cytology: Cytological and immunocytochemical features in two cases.

Endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) has proven to be of significant value as a diagnostic method for the evaluation of esophageal mesenchymal tumors, such as true leiomyomas. Utilizing the cell block procedure, the present study reports the diagnostic approach of EUS-FNAC in two patients affected by this lesion, describing the cytological and immunocytochemical findings. Spindle-shaped elements with elongated nuclei were appreciable; moreover, the cytoplasmatic immunohistochemical positivity for smooth muscle actin and desmin strongly supported the diagnosis of leiomyoma when also taking into account the constant negativity for CD34, CD117 and S100. The differential diagnosis between spindle cell mesenchymal tumors and leiomyomas, and the clinico-therapeutic management of the latter are also discussed in the study.

Fine needle aspiration cytology of lymphoproliferative lesions of the oral cavity.

OBJECTIVE: Oral cavity non-Hodgkin lymphoma (OCL) is a rare condition that may be clinically and radiologically indistinguishable from other pathologies of the mouth. A complete excision or adequate biopsy of the OCL may be difficult. Fine needle aspiration (FNA) cytology has been successfully utilized in the pre-operative diagnosis of oral masses and in lymphoma involving other anatomical areas. Our experience with FNA pre-operative cytological diagnosis of 16 OCLs is reported herein. METHODS: The results of FNA cytology on 16 consecutive lymphoproliferative lesions of the oral cavity collected over an 8-year period in three institutions were retrieved. Sampled lesions were submucosal masses of different sizes bulging into the oral cavity. Rapid on-site evaluation (ROSE) and routine cytological staining were performed. Immunocytochemistry (ICC), flow cytometry (FC) and polymerase chain reaction (PCR) of the IGH (immunoglobulin heavy) locus were performed on additional passes according to ROSE. RESULTS: Fourteen OCLs, one myeloma and one florid reactive lymphoid hyperplasia (FRLH) were diagnosed by FNA. OCLs were diagnosed as large B-cell (eight cases) and small B-cell (six cases) lymphomas. Histology revealed eight diffuse large B-cell lymphomas (DLBCL), four lymphomas of mucosa-associated lymphoid tissue (MALT), two follicular lymphomas and one FRLH; no false-negative or false-positive results were diagnosed, but accurate subclassification was obtained in four cases only. CONCLUSIONS: FNA diagnosis of OCLs may be hampered by the rare incidence, anatomical context and difficulties in obtaining a sufficient amount of cells. Ancillary techniques should be used according to ROSE; a pre-operative FNA cytology diagnosis can avoid unnecessary extensive surgery and speed up the institution of therapeutic procedures.

HER2 status in advanced gastric carcinoma: A retrospective multicentric analysis from Sicily.

According to the ToGA trial, HER2 has been shown to be predictive for the success of treatment with trastuzumab in advanced gastric cancer (AGC). A number of studies have analyzed HER-2/neu overexpression in gastric carcinoma and identified the rate of HER2 positivity to be markedly varied. To date, the prevalence of HER2 overexpression in Sicilian people with AGC is unknown. Therefore, in the present study, a retrospective immunohistochemical analysis of HER2 was performed in a cohort of 304 AGC samples that were obtained from the archives of 10 Sicilian anatomopathological diagnostic units in order to verify the positive rate of HER2-positive cases. Furthermore, the characteristics of histotype, grade, stage and Ki-67 expression were also analyzed. HER2 overexpression was encountered in 17.43% of all the gastric adenocarcinomas, which was consistent with the results that have been reported elsewhere in the literature. A progressive increase in HER2 overexpression was observed, from the poorly cohesive histotype to the tubular adenocarcinomas and gastric hepatoid adenocarcinomas. HER2 overexpression was significantly associated with a high grade, advanced stage and high Ki-67 labeling index. Further investigations performed jointly by pathologists and oncologists within the geographical area of the present study should confirm that the association of trastuzumab with chemotherapy results in an improvement of survival in patients with AGC.

Gastrointestinal stromal tumours of the stomach: Cytological and immunocytochemical diagnostic features of two cases diagnosed by endoscopic ultrasound-guided fine needle aspiration.

The present study reports the diagnostic utility of endoscopic ultrasound-guided fine needle aspiration (EUS-FNAC) in two patients affected by gastrointestinal stromal tumours (GISTs) of the stomach. Clinically, the patients demonstrated skin pallor, melena, gastric discomfort and pain that had lasted three days or weeks. The cytological findings are discussed; these were strongly supported by immunocytochemical procedures that were performed on cell blocks and further confirmed following post-surgical histopathological examination. The crucial aim of GIST management is to determine a correct diagnosis in early-phase disease in order to realize an adequate curative surgical resection before the tumour becomes unresectable or metastatic. Moreover, a correct pre-surgical differential diagnosis of GISTs from other mesenchymal neoplasms may be easily made by EUS-FNAC, supported by cytological and immunocytochemical features.

Immunoexpression of lactoferrin in bone metastases and corresponding primary carcinomas.

Although the immunohistochemical presence of lactoferrin (LF) in pathological neoplastic bone and cartilage samples has previously been studied, no data concerning the distribution of LF in bone metastases of cancers that have originated from different organs are available at present. Consequently, using a monoclonal antibody, we have investigated the immunohistochemical LF pattern in 50 formalin-fixed and paraffin-embedded samples of human bone metastases and their corresponding primary carcinoma tumours (breast, 8; prostate, 4; kidney, 4; lung, 3; colon-rectum, 2 and uterus, 4). Quantification of LF immunoreactivity was performed using an intensity distribution (ID) score. LF immuno staining with a variable ID score was encountered in 11/25 (44%) metastatic lesions. In particular, the LF immunoreactivity was identified with a percentage ranging from 50 to 75% of bone metastases due to prostatic, renal, uterine and colorectal carcinomas; the positivity decreased in breast carcinomas (37.5%) and was completely absent in lung cancers. No differences in the LF-ID score were observed between primary and metastatic neoplastic localisations. Additionally, no correlations were identified between LF immunoexpression and the other parameters tested, including the age and gender of patients. Regardless of the mechanism of action of LF in human malignant tumours, we identified LF immunohistochemical reproducibility at primary and metastatic sites. Therefore, we hypothesise that the presence of LF in native neoplastic carcinomatous clones is maintained in secondary bone metastatic deposits.

Odontoameloblastoma: five years follow up of a surgical case and review of literature.

The odontoameloblastoma (OA), also known as ameloblastic odontoma, is a rare neoplasm of jaws which includes odontogenic ectomesenchyme in addition to odontogenic epithelium that resembles an ameloblastoma both in structure and in behaviour. The exact incidence is difficult to determine. Since 1944, only 24 cases have been reported in English literature which fulfill both histological and clinical features of this lesion. The Authors report a case report of an odontoameloblastoma in a 15-year-old caucasian man treated with a surgical excision. The five years follow-up shows no evidence of recurrence confirming the validity of a conservative surgery with enucleation of OA, followed by periodical clinical and radiographical controls.

Morphological and biomolecular characteristics of subcentimetric invasive breast carcinomas in Sicily: A multicentre retrospective study in relation to trastuzumab treatment.

Little information from clinical trials is available regarding the efficacy of trastuzumab treatment in subcentimetric breast carcinomas (BCs). The aim of this study was to verify the existence of correlations between HER2 and hormone receptor status, Ki67 values, grade, histotype and node involvement in a cohort of pT1a,b BCs from an area not widely covered by screening campaigns. A total of 410 pT1a,b BC formalin-fixed paraffin-embedded samples collected from eight Sicilian Anatomo-Pathological Units (APUs) were classified according to the WHO classification and tumour grading was established. Estrogen and progesterone receptor status, Ki67 labelling index and HER2 status were available. Relationships between immunohistochemical data and clinicopathological characteristics were investigated using the Chi-square test; the cohort was analysed with respect to pT1a and pT1b BC as well as to node status. Ductal infiltrating carcinoma was the prevalent histotype in the pT1a and pT1b stages; G2 was a more common tumour grade, with a range between 64.6% and 70% of pT1a and pT1b, respectively. Taking into consideration the lymph node involvement of pT1a,b BC, only 17.1% cases were node-positive without a relevant difference between pT1a and pT1b. No significant differences between pT1a and pT1b BC cases emerged in relation to Ki67 LI, hormone receptors and HER2 status. T1a,b BC cases were stratified by node involvement and a significant relationship was observed with grade as well as with HER2 status. A significant relationship for pT1a cases emerged only for tumour grade, while pT1b cases showed a significant correlation exclusively with HER2 status. Our data clearly support the operative guidelines of the National Comprehensive Cancer Network. Therefore, the combined treatment with trastuzumab plus chemotherapy should be administered only to patients with pT1b or larger BCs. In small HER2-positive pT1a or microinvasive BC, this therapy should be considered on a case-by-case basis, considering tumour grade as the first characteristic.

Neutrophil gelatinase-associated lipocalin (NGAL) immunohistochemical expression in follicular cell-derived thyroid tumors: a novel diagnostic tool?

Discrimination of follicular cell-derived benign and malignant tumors of the thyroid is one of the major problems encountered in surgical pathology. In the present study, we evaluated the immunohistochemical expression of NGAL, an iron-binding protein involved in the infiltrative potential of cancer cells, in a cohort of tumors including 8 follicular adenomas (FA), 2 Hurthle cell adenomas (HA), 2 atypical adenomas (AA), 8 minimally invasive follicular carcinomas (MIFC), 9 widely invasive follicular carcinomas (WIFC), 3 Hurthle cell carcinomas (HC) and 8 papillary carcinomas (PC) with 5 follicular-variant PC (FVPC) and 3 not otherwise specified (PC-NOS). Our goal was to test whether evaluation of NGAL immunoexpression may be of use in the differential diagnosis of benign and malignant thyroid neoplasias. 92% of benign tumors (specificity) were negative for NGAL, whereby NGAL immuno-expression was found in 82% (sensitivity) of malignant tumors, and, specifically, in 100% of MIFC, in 87% of WIFC, in 100% of HC, in 80% of FVPC. None of the PC-NOS displayed NGAL staining. When only tumors with a follicular architecture were considered, NGAL specificity for malignant lesions was 92%; sensitivity, positive predictive value and negative predictive value were 92%, 96% and 85%. Diagnostic accuracy of NGAL expression in the differential diagnosis between benign and malignant follicular tumors was 92%. In conclusion, NGAL protein seems to represent a marker of malignant follicular cell-derived thyroid tumors, and especially of those with follicular architecture. Hence assessment of its expression might be of use with respect to differential diagnosis from follicular benign neoplasias.

Hematopoietic progenitor cells (HPCs) in node-negative invasive breast carcinomas: Immunohistochemical analysis and clinico-pathological correlations.

Using immunohistochemistry, we investigated 603 negative lymph nodes from 51 patients affected by invasive breast cancer (BC) to recognize bone marrow-derived hematopoietic progenitor cells (HPCs). HPC aggregates, revealed by CD34, CD133, VEGFR1, and CD117 antisera, were determined by an intensity-distribution score (ID). Cases with an ID-score >3 at least for one marker were considered to strongly express HPCs. Twenty-five of 51 (49%) high expressor patients were identified by CD34 antiserum, while 24/51 (47.1%), 17/51 (33.3%), and 15/51 (29.4%) were identified by CD117, CD133, and VEGFR1, respectively. No significant relationships were found between HPCs status and histotype, tumor grade, stage, and hormone receptors, as determined at the moment of the first diagnosis. A significant correlation was recorded for Ki-67 values, as well as for death from invasive BC. No statistical significance was achieved regarding HER2 status, although a tendency toward a statistically significant P value was obtained. A significant relationship (P<0.001) was found between high expressors of HPC and progression of disease, documented by the development of distant metastases. An equivalent P value was ascertained for osseous localizations, with a lesser value in other metastatic sites. Regarding the appearance of distant metastases, the greatest efficiency value was obtained by CD133 (85.7%). Overall survival (OS) and distant metastases-free survival (DMFS) revealed a high statistical significance for HPC expression, Ki-67 values, and HER2 status. By multivariate analysis, HPC expression and Ki-67 values emerged as the higher independent prognostic variables in the analysis of DMFS and OS, respectively.

Osteoblastic meningiomas: clinico-pathological and immunohistochemical features of an uncommon variant.

Osteoblastic meningioma is a rare variant of meningioma characterized by the presence of a variable number of bone spicules within the tumor parenchyma. Its histogenesis has not been yet fully clarified. Herein we report clinical and histological findings and expression of bone matrix proteins (osteocalcin and ostepontin) observed in seven osteoblastic meningiomas. None of the cases displayed recurrences or significant re-growth after partial resection. In 5/7 cases the osseous component occurred in association with psammoma bodies and dystrophic calcification. Interestingly, foci composed of immature bone trabeculae, mineralized chondroid matrix, and osteoclasts were found in one of the two cases with no psammoma bodies or calcification, suggesting enchondral ossification. Positive staining for osteocalcin, which is a marker of terminal osteoblastic differentiation, was observed within the bone spicules in all meningiomas, but not in the chondroid mineralized matrix. On the other hand, immuno-expression of osteopontin, an early osteogenic marker, was observed in the osteoclasts and in mature and immature bone spiculae, calcification, and psammoma bodies. Even more, osteopontin was extensively expressed by the neoplastic cells of cases without calcification or psammoma bodies, suggesting acquisition of osteoblastic phenotype in these meningiomas. In conclusion, osteoblastic meningioma seems to be an indolent variant of meningiomas characterized by a slow growth and good prognosis. Our histological and immunohistochemical findings suggest that bone formation may occur through two different pathways, i.e., as the final step of calcification or through a metaplastic mechanism in cases with absent calcification or psammoma bodies.

Prognostic impact of CD133 immunoexpression in node-negative invasive breast carcinomas.

BACKGROUND: Hematopoietic progenitor cells (HPCs) are able to prepare the site for incoming neoplastic cells. Among different markers of HPCs, which one should be considered the most efficient was investigated. PATIENTS AND METHODS: Five hundred and seventy-nine non-metastatic lymph nodes from 49 patients affected by invasive breast cancer were submitted to an immunohistochemical comparative analysis of hematopoietic (CD34), endothelial (CD133), mesenchymal (CD117) progenitors and vascular endothelial growth factor receptor 1 (VEGFR1, also known as Flt1). The cases with an intensity-distribution score >3 were considered as high HPC expressors. Survival univariate and multivariate analyses were performed. RESULTS: Fifteen out of the 49 patients were recorded as HPC high expressors based on the immunohistochemical VEGFR1 staining. A highly significant relationship was found between high HPC immunoexpression and the development of distant metastasis as well as the occurrence of bone localization (p<0.001). By univariate analysis, CD133 showed a highly significant value regarding metastatic localizations in the bone; by multivariate analysis, CD133 emerged as the only independent prognostic variable. CONCLUSION: CD133 expression shows a potential predictive role, thus representing a helpful tool for the management of breast cancer.

Redefining the intraepithelial lymphocytes threshold to diagnose gluten sensitivity in patients with architecturally normal duodenal histology.

BACKGROUND: Accuracy of intraepithelial lymphocytes counts for diagnosing mild enteropathy coeliac disease in absence of villous atrophy can be limited by inappropriate controls included in the studies. AIM: To determine the diagnostic accuracy of intraepithelial lymphocytes counts utilising controls lacking HLA coeliac disease-associated alleles. METHODS: Intraepithelial lymphocytes counting at villus tip and per 100 enterocytes was performed at haematoxylin and eosin (H&E) and CD3-stainings in: 29 cases (21 with potential coeliac disease and 8 affected by latent coeliac disease) representing the patient population and 14 noncoeliac controls lacking HLA-DQ2/DQ8 alleles. RESULTS: Threshold (mean+2 s.d.) of duodenal intraepithelial lymphocytes at villus tip and per 100 enterocytes in noncoeliac controls was respectively: 3.5 and 18 at H&E, 3.2 and 17 following CD3-staining. Considering the whole patient population, the sensitivity of tip intraepithelial lymphocytes in detecting mild enteropathy coeliac disease was 90% (95% CI=72.6-97.8) both at H&E and CD3-stainings. The sensitivity of intraepithelial lymphocytes per 100 enterocytes was 93% (95% CI=77.2-99.2) both at H&E and CD3-staining. Specificity of both intraepithelial lymphocytes counts was 100% (95% CI=76.8-100). Using a threshold of 25 intraepithelial lymphocytes per 100 enterocytes could miss 59% of cases at H&E and 48% following CD3-staining. CONCLUSIONS: Intraepithelial lymphocytes counts are diagnostic feasible tools to detect mild enteropathy coeliac disease. Threshold of duodenal intraepithelial lymphocytes may be lower than currently accepted.

MMP-9 expression in meningiomas: a prognostic marker for recurrence risk?

Despite total macroscopic resection of meningiomas relapses do occur in these tumours, possibly because of microscopic clusters of neoplastic cells left in the dura mater or in the arachnoid membrane. The invasiveness of the neoplastic cells of human meningiomas has been related to expression of matrix-metalloproteinase-9 (MMP-9), a peptidase actively implicated in the degradation of the extracellular matrix; nonetheless, the prognostic value of MMP-9 in the risk of recurrence of meningiomas has not been sufficiently investigated. Herein, we analysed MMP-9 expression in a series of meningiomas of different histotype and histological grade and assessed its correlation with various clinico-pathological indicators and with the clinical outcome of these tumours. We also tested the eventual pro-angiogenic role of MMP-9 expression in meningiomas through its correlation with vascular endothelial growth factor (VEGF) and microvessel density (MVD) revealed in the same cases. MMP-9 expression was observed in 64% of cases; high expression of this protein was significantly associated with high histological grade and proliferation index, but not with high MVD, of the tumours. A trend towards correlation between MMP-9 and VEGF expression was found, although statistical significance was not reached. In addition, high MMP-9 expression was a negative independent prognostic factor associated with higher recurrence risk in totally resected meningiomas. In conclusion, we demonstrated for the first time the potential prognostic value of MMP-9 expression in meningiomas. Inhibition of MMP-9 may be a new therapeutic strategy to prevent recurrences of meningiomas, particularly the high-grade type.

Comparison of the Marsh-Oberhuber classification with a new grading system in identifying patients with latent celiac disease.

AIM: The diagnosis of celiac disease (CD) is still mainly based on pathological description. However, these descriptions are often unable to identify latent CD. The aim of this study was to evaluate whether the Marsh-Oberhuber classification and a recently proposed classification may help to identify patients with latent CD. METHODS: Biopsy samples from twelve patients with latent CD (age range 3-32 years) defined as having normal duodenal mucosa when ingesting a free diet, and subsequently developing severe villous atrophy, were retrospectively reviewed in blind according to the Marsh-Oberhuber classification and the new grading system. RESULTS: In 67% of patients the Marsh-Oberhuber and the new classification could have yielded a diagnosis of CD soon after the first biopsy (3a-3c score when reviewed according to this classification, and B2 score when reviewed according to the new grading system), thereby avoiding further (up to two more in four cases) unnecessary endoscopic procedures. CONCLUSION: Both the Marsh-Oberhuber and the new classification allow to discriminate latent CD from patients with normal mucosa. Thus, these classifications may help in identifying and treating patients at an early stage.

NGAL immunohistochemical expression in brain primary and metastatic tumors.

A significant association has been recently shown between the expression of neutrophil gelatinase-associated lipocalin (NGAL) in tumors and its urinary levels. Thus NGAL urinary detection has been proposed as a method for the early diagnosis of brain tumors. In view of this, the objective of this study was to investigate whether NGAL expression differs according to brain tumor type or in primary vs. metastatic brain neolasias. 42 surgically resected formalin fixed and paraffin embedded neoplasias, including 15 cases of brain metastasis and 27 cases of primary central nervous system (CNS) tumors (11 meningiomas; 1 pilocytic astrocytoma, 2 diffuse astrocytomas, 2 oligoastrocytomas, 2 oligodendrogliomas, 1 anaplastic oligoastrocytoma, 7 glioblastomas, 1 ependymoma) were submitted to the immunohistochemical procedure. Sections were incubated overnight with the primary antibody against NGAL. NGAL staining was found in all the analyzed glioblastomas and in the anaplastic oligoastrocytoma. No NGAL immuno-expression was evidenced in all the other cases. A statistically significant correlation was demonstrated between NGAL presence and high proliferation index in the primary tumors. In conclusion, our findings suggest that NGAL expression is restricted to high grade gliomas among primary brain tumors, and that brain metastases do not express this protein. Considering the correlation between NGAL expression in tumors and its urinary levels, if our observations will be further validated, NGAL urinary detection might be used as an additional tool in the pre-surgical definition of brain lesions involving difficult differential diagnosis.