Skip to main content
NCBI home page
Pathologica logoLink to Pathologica
. 2021 Oct 31;113(5 Suppl 1):S1–S74. doi: 10.32074/1591-951X-761

PROCEEDINGS OF THE ANNUAL CONGRESS OF SIAPec IAP

November 23rd-27th, 2021

PMCID: PMC9364699
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

EUROPA DONNA ITALIA E SIAPEC: ADVOCACY PER I TEST GENOMICI

R D’Antona 1

Abstract

Europa Donna Italia, tramite la sua rete territoriale, monitora costantemente la corretta applicazione delle linee di indirizzo nazionali per le Breast Unit 1 che prevedono la presenza di un anatomo-patologo specializzato all’interno dell’equipe multidisciplinare.

Il problema del mancato accesso delle pazienti italiane ai test genomici nel percorso di cura del tumore al seno è stata l’occasione per una più intensa collaborazione tra Europa Donna Italia e SIAPEC, che insieme hanno promosso l’informazione al pubblico attraverso aggiornamenti scientifici sul sito e sui social del Movimento.

Europa Donna Italia e SIAPEC hanno inoltre realizzato incontri di formazione 2 per le associazioni di pazienti sulla diagnosi personalizzata e sulla predittività e la prognostica dei test genomici nell’ambito del percorso formativo “Academy”.

Sono state svolte anche campagne di informazione e sensibilizzazione sul diritto all’equità diagnostica e una raccolta di firme virtuali per sollecitare il Ministero della Salute ad emanare il decreto attuativo necessario a sbloccare il fondo nazionale destinato alle Regioni dalla legge di bilancio 2021.

La campagna “Chemio: se posso la evito”, da gennaio a marzo 2021, ha raccolto 15.158 firme mentre da agosto a ottobre 2021 è stato svolto un monitoraggio nazionale per informare le donne sulla disponibilità dei test nelle varie Regioni a seguito dell’emanazione delle relative delibere.

È nell’interesse delle pazienti che Europa Donna Italia intende proseguire l’attività di advocacy in collaborazione con SIAPEC affinché sia assicurata un’adeguata qualità di diagnosi dei tumori al seno e a ogni paziente sia garantito il diritto di consultare il patologo della propria Breast Unit.

Bibliografia

  • 1.European Journal of Cancer The requirements of a specialist Breast Centre – aa.vv. 2013 [DOI] [PubMed] [Google Scholar]
  • 2.“Europa Donna Academy La diagnosi personalizzata e i Test genomici” - Dottoressa Donatella Santini - U.S. Patologia della Mammella e delle Ghiandole Endocrine, U.O. Anatomia Patologica, A.O.U. Policlinico Sant’Orsola, Bologna - luglio 2019; “I Test genomici prognostici e predittivi”, Professoressa Anna Sapino – Direttore scientifico Fondazione del Piemonte per l’Oncologia, Presidente SIAPEC - IAP - giugno 2021. [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

DIGITAL WORKFLOW: LA RIVOLUZIONE DEL LABORATORIO

A Caputo 1

Abstract

Le nuove raccomandazioni ESDIP 1 sottolineano l’importanza del digital workflow come uno dei pilastri della digital pathology. Molti dei benefici della digital pathology, infatti, sono da imputare ai cambiamenti nel workflow, e non allo scanner, alla telepatologia o all’uso dell’intelligenza artificiale. Esempi includono l’introduzione di checkpoint basati su barcode a ogni step del laboratorio 2, che semplificano e velocizzano drammaticamente il flusso di lavoro, oltre a identificare gli errori automaticamente permettendone una immediata correzione. Contemporaneamente, l’adozione di sistemi di gestione mutuati dall’industria 3 consente di minimizzare gli sprechi e sfruttare al massimo lo spazio, il tempo e soprattutto ciascuna mente umana presente nel laboratorio.

La spesa per implementare tali novità, apparentemente ingente, rappresenta in realtà un vantaggioso investimento. Numerose esperienze riportate in letteratura evidenziano come l’incremento della capacità produttiva del laboratorio permetta di risparmiare tempo e denaro 2,4.

Nei vecchi workflow, numerose procedure in piedi da tempo ed ormai divenute standard nascondono insidiose inefficienze che un’analisi del flusso di lavoro può smascherare e correggere. Non è raro riuscire a raddoppiare l’efficienza di un processo apportandogli poche strategiche modifiche 2,3.

Se qualche anno fa occorreva coraggio per passare alla digital pathology, nel 2021 il coraggio serve a chi resta ostinatamente aggrappato ai metodi tradizionali.

Bibliografia

  • 1.Fraggetta F, L’Imperio V, Ameisen D, et al. Best Practice Recommendations for the Implementation of a Digital Pathology Workflow in the Anatomic Pathology Laboratory by the European Society of Digital and Integrative Pathology (ESDIP). Diagnostics 2021;11:2167. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Fraggetta F, Caputo A, Guglielmino R, et al. A Survival Guide for the Rapid Transition to a Fully Digital Workflow: The “Caltagirone Example”. Diagnostics 2021;11:1916. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Zarbo RJ. Management Systems to Structure Continuous Quality Improvement. Am J Clin Pathol. 2021. [DOI] [PubMed] [Google Scholar]
  • 4.Lujan G, Quigley JC, Hartman D, et al. Dissecting the business case for adoption and implementation of digital pathology: a white paper from the digital pathology association. J Pathol Inform 2021;12. [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

ENDOMETRIOSIS: MORPHOLOGICAL ASPECTS

A Pesci 1

Abstract

Endometriosis is a benign chronic disease defined by the presence of endometrial tissue outside the uterine cavity. Endometriosis affects 2-5% of young women and 30-50% with chronic pelvic pain and infertility. Pathogenesis of endometriosis is only partially known. Diagnosis of typical endometriosis is based on the presence of endometrial glands and stroma. The appearance of endometriotic glands can range from proliferative to inactive or assume all the metaplastic appearance of the mullerian epithelium. The endometriotic stroma resembles eutopic stroma. Alterations in the typical microscopic appearance of both epithelial and/or stroma component can be challenging in the identification of endometriosis or in the differential diagnosis with others entities. Stroma can be obscured by the presence of histiocytes, foamy cells or haemosiderin. Endometriosis can elicit a fibrotic reaction which can replace the endometriotic stroma or cause adhesions or can be replaced by smooth muscle. During pregnancy or progesteron therapy endometriotic foci can exhibit progestational changes with atrophic glands and pseudodecidualized stroma. Occasionally the decidual cells exhibit cytoplasmic vacuoles with a signet ring like appearance. Peritoneal endometriosis can be subtle and all the metaplastic changes, either in the epithelial or in the stromal component can cause diagnostic problem. Stromal endometriosis can be missed or pseudodecidualized stroma with signet ring like cells can raise the suspicious of a carcinoma. Mesothelial hyperplasia, due to the presence of endometriosis, is characterized by small tubules, papillae, nests or cords in a fibrotic and/or inflammatory tissue. In florid cases those foci have a pseudoinfiltrative pattern and raise concern for an epithelioid mesothelioma. In the gastrointestinal tract endometriosis has two interesting aspects: the mass forming disease in the colon-rectum, with a huge hyperplasia of the native smooth muscle and occasionally, IBD-like feature of the overlying mucosa, and the mucinous metaplastic change of the endometriotic epithelium in the appendix which can simulates a low grade appendiceal mucinous neoplasia.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

I TUMORI DELL’OVAIO NELLA NUOVA WHO 2020

GF Zannoni 1

Abstract

Ovarian carcinoma represents the deadliest among gynecologic malignancies and is ranked as the fifth leading cause of cancer deaths in females.

The fifth edition of the World Health Organization classification of Tumors of the female genital tract divides ovarian carcinoma into five main types on the basis of morphological features, cellular origin, clinical characteristics, and molecular alterations: i) high-grade serous carcinoma, ii) endometrioid carcinoma, iii) clear cell carcinoma, iv) mucinous carcinoma, v) low-grade serous carcinomas. HGSCs generally harbor TP53 alterations, a pronounced genomic instability and, also, inherited and somatic BRCA1 and BRCA2 mutations. The other abovementioned cancer types are frequently characterized by mutations in KRAS, BRAF, PTEN, and CTNNB1 (Beta-catenin), and a relatively stable karyotype. In detail, BRAF and KRAS mutations are frequently detected in low-grade serous carcinoma. Endometrioid carcinoma are characterized by β-catenin alterations, microsatellite instability, and PTEN and POLE mutations. ARID1A mutations frequently occur in both endometrioid and clear cell carcinomas. Mucinous carcinomas are frequretly associated with copy-number loss of CDKN2A and KRAS alterations. Mesonephric-like adenocarcinoma is a recently described entity frequently associated with endometriosis or other carcinoma histotypes; this rare ovarian tumor harbours somatic KRAS mutations and is thought to arise from a malignant transformation of mesonephric ovarian remnants.

In the field of Sex cord stomal ovarian tumors, three important novelties, have been highlited in the recent Who classification: i) microcystic stromal tumor: a recently described benign ovarian tumor, characterized by alterations in beta-cathenin-APC pathway and usually arising in the setting of Familial Adenomatous Polyposis (FAP); ii) Adult ovarian granulosa cell tumor: missense mutation FOXL2 402C→G has been detected in more than 97% of adult granulosa cell tumours; therefore FOXL2 molecular testing has been suggested as a useful in tool in the differential diagnosis of sex cord stromal tumors; iii) Sertoli-Leydig Tumors: DICER1 and FOXL2 mutation status have been shown correlate with tumor clinicopathological features. In detail, DICER1 mutation are encountered in younger patients with histological evidence of retiform or heterologous elements; FOXL2 mutations are encountered in postmenopausal women without histological evidence of retiform or heterologous elements; finally, DICER1/FOXL2 wild type tumors frequently show well-differentiated histology.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

PD-L1 IN GASTRIC CARCINOMA AND GASTRO-INTESTINAL PATHOLOGY

F Galuppini 1, G Pennelli 1, A Vanoli 2, F Grillo 3, L Mastracci 3, P Parente 4, M Fassan 1,5

Abstract

The use of immunotherapy is becoming one of the mainstays of therapy for advanced gastric cancer. One of the most studied immunomodulatory systems is the PD1-PD-L1 axis. PD-1 is a member of a family of immunoglobulin co-receptors that modifies the outcome of activation of the T cell receptor by APCs or infected target cells. PD-L1, a transmembrane glycoprotein, is the primary ligand for PD1. This interaction regulates the induction and maintenance of peripheral tolerance, protects tissues from autoimmune attacks and is also involved in the attenuation of infectious and tumour immunity and in tumour progression 1. For this reason, immunohistochemical evaluation of PD-L1 protein expression in tumour cells and the microenvironment has become a key action in the pathologist’s routine. However, this action is not easy to perform due to the different scores and antibody clones used. Indeed, each of the monoclonal antibodies directed against PD-L1 (Atezolizumab and Durvalumab) or PD1 (Nivolumab and Pembrolizumab) has its own diagnostic partner.

Data collected so far have established that PD-L1 expression in gastric cancer is determined by Combined Positive Score (CPS), evaluated as summing the number of PD-L1-stained cells (tumor cells, lymphocytes, macrophages) and dividing the result by the total number of viable tumor cells, multiplied by 100. Recently, from a positivity initially given for values > or = 1, it is shifting towards a cut off of 10, precisely because of its value in predicting response to immunotherapy 2.

While agreement has been reached on the CPS, the choice of clone to be used is increasingly crucial. Several studies comparing different clones have been proposed, which also produced different results 3. In this important work by Ahn et al., the two most valid antibodies in the PD-L1 score were 22C3 and 28.8, which showed highly comparable results, thus suggesting that they may be interchangeable 4.

The assessment of PD-L1 expression in precancerous lesions is interesting: Fassan et al. analysed positivity in various degrees of dysplasia, showing that CPS is sometimes elevated even in these 5. It is therefore crucial to start from a correct anatomopathological diagnosis and above all to reaffirm the leading role of the pathologist in assessing this marker, which otherwise could be very confusing.

The expression of PD-L1 also fits into the scenario of the molecular characterisation of gastric and oesophago-gastric junction carcinoma, which has four main molecular subtypes, namely EBV-related tumours, tumours with microsatellite instability (MSI), tumours with a stable genome and tumours with chromosomal instability 6. In this regard, an interesting work by Kim et al. confirmed that PD-L1 is particularly expressed in EBV-related and MSI subtypes 7.

The assessment of PD-L1 is so important certainly because of the predictive role it has in the response to immunotherapy demonstrated in several clinical trials. The Keynote -059 study showed that pembrolizumab has a promising role in advanced gastric and oesophago-gastric junction carcinomas that have already received chemotherapy lines 8. The Keynote -061 study is a phase 3 study in which pembrolizumab shows a better safety profile than the chemotherapy paclitaxel but fairly overlapping overall survival curves 9. On the other hand, the latest Keynote -062 study in 2020 shows a better cost-benefit ratio in favour of pembrolizumab even at the first-line treatment level 10. This latest use of immunotherapeutic drugs also as first-line treatment recalls the need to assess the PD-L1 protein from the biopsy sample together with other markers such as mismatch repair system proteins and HER2 11.

Certainly, in gastric carcinoma and esophageal-gastric junction it has its greatest importance, but some studies are showing a role in other neoplasms of the gastro-enteric tract.

Knowing the increasingly important role of microsatellite instability in colorectal cancer, a number of papers are emerging on the efficacy of chekpoint inhibitor therapy, with this paper by Pientrantonio et al. showing a response in terms of RECIST in 33% of treated MSI patients 12.

But in addition to the single factor of microsatellite instability, much emphasis is also being placed on the concept of intratumoral lymphocytic inflammatory infiltrate, which has been shown to be strongly prognostic of outcome in MSI patients treated with immunotherapy.

Finally, we see that PD-L1 is also emerging in small bowel adenocarcinomas, especially in non-ampullary adenocarcinomas, and correlates with MSI status, with the density of tumour infiltrating lymphocytes and with clinicopathological features of aggressiveness. Moreover, CPS was also found to correlate with the pathological substrate, specifically it was higher in carcinomas arising in celiac disease or crohn’s disease than in sporadic carcinomas 13.

In conclusion, immunohistochemical evaluation of PD-L1 is fundamental in the diagnosis of gastric cancer and in the future also for other gastro-intestinal neoplasms and the score should be performed with the CPS method. Several clones can be use for evaluation, especially 22C3 and 28.8. Correlating the PD-L1 value with the molecular classification of the gastric cancer will become fundamental to identify the subtypes of patients most responsive to immunotherapy.

References

  • 1.Galuppini F, Dal Pozzo CA, Deckert J, et al. Tumor mutation burden: from comprehensive mutational screening to the clinic. Cancer Cell Int 2019;19:209. https://doi.org/10.1186/s12935-019-0929-4. 10.1186/s12935-019-0929-4 eCollection 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Chen K, Wang X, Yang L, Chen Z. The Anti-PD-1/PD-L1 Immunotherapy for Gastric Esophageal Cancer: A Systematic Review and Meta-Analysis and Literature Review. Cancer Control 2021; 28:1073274821997430. https://doi.org/10.1177/1073274821997430. 10.1177/1073274821997430 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Ma J, Li J, Qian M, Han W, et al. PD-L1 expression and the prognostic significance in gastric cancer: a retrospective comparison of three PD-L1 antibody clones (SP142, 28-8 and E1L3N). Diagn Pathol. 2018;13:91. https://doi.org/10.1186/s13000-018-0766-0. 10.1186/s13000-018-0766-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Ahn S, Kim KM. PD-L1 expression in gastric cancer: interchangeability of 22C3 and 28-8 pharmDx assays for responses to immunotherapy. Mod Pathol. 2021;34:1719-1727. https://doi.org/10.1038/s41379-021-00823-9. 10.1038/s41379-021-00823-9 [DOI] [PubMed] [Google Scholar]
  • 5.Fassan M, Brignola S, Pennelli G, et al. PD-L1 expression in gastroesophageal dysplastic lesions. Virchows Arch. 2020;477:151-156. https://doi.org/10.1007/s00428-019-02693-8 10.1007/s00428-019-02693-8 [DOI] [PubMed] [Google Scholar]
  • 6.Businello G, Galuppini F, Fassan M. The impact of recent next generation sequencing and the need for a new classification in gastric cancer. Best Pract Res Clin Gastroenterol 2021;50-51:101730. https://doi.org/10.1016/j.bpg.2021.101730. 10.1016/j.bpg.2021.101730 [DOI] [PubMed] [Google Scholar]
  • 7.Kim ST, Cristescu R, Bass AJ, et al. Comprehensive molecular characterization of clinical responses to PD-1 inhibition in metastatic gastric cancer. Nat Med. 2018;24:1449-1458. https://doi.org/10.1038/s41591-018-0101-z. 10.1038/s41591-018-0101-z [DOI] [PubMed] [Google Scholar]
  • 8.Fuchs CS, Doi T, Jang RW, et al. Safety and Efficacy of Pembrolizumab Monotherapy in Patients With Previously Treated Advanced Gastric and Gastroesophageal Junction Cancer: Phase 2 Clinical KEYNOTE-059 Trial. JAMA Oncol. 2018;4:e180013. https://doi.org/10.1001/jamaoncol.2018.0013. 10.1001/jamaoncol.2018.0013 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Shitara K, Özgüroğlu M, Bang YJ, et al. Pembrolizumab versus paclitaxel for previously treated, advanced gastric or gastro-oesophageal junction cancer (KEYNOTE-061): a randomised, open-label, controlled, phase 3 trial. Lancet. 2018;392:123-133. https://doi.org/10.1016/S0140-6736(18)31257-1. 10.1016/S0140-6736(18)31257-1 [DOI] [PubMed] [Google Scholar]
  • 10.Shitara K, Van Cutsem E, Bang YJ, et al. Efficacy and Safety of Pembrolizumab or Pembrolizumab Plus Chemotherapy vs Chemotherapy Alone for Patients With First-line, Advanced Gastric Cancer: The KEYNOTE-062 Phase 3 Randomized Clinical Trial. JAMA Oncol. 2020;6:1571-1580. https://doi.org/10.1001/jamaoncol.2020.3370. 10.1001/jamaoncol.2020.3370 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Nakamura Y, Kawazoe A, Lordick F, et al. Biomarker-targeted therapies for advanced-stage gastric and gastro-oesophageal junction cancers: an emerging paradigm. Nat Rev Clin Oncol. 2021;18:473-487. https://doi.org/10.1038/s41571-021-00492-2. 10.1038/s41571-021-00492-2 [DOI] [PubMed] [Google Scholar]
  • 12.Pietrantonio F, Loupakis F, Randon G, et al. Efficacy and Safety of Immune Checkpoint Inhibitors in Patients with Microsatellite Instability-High End-Stage Cancers and Poor Performance Status Related to High Disease Burden. Oncologist. 2020;25:803-809. https://doi.org/10.1634/theoncologist.2020-0014. 10.1634/theoncologist.2020-0014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Giuffrida P, Arpa G, Grillo F, et al. PD-L1 in small bowel adenocarcinoma is associated with etiology and tumor-infiltrating lymphocytes, in addition to microsatellite instability. Mod Pathol. 2020;33:1398-1409. https://doi.org/10.1038/s41379-020-0497-0. 10.1038/s41379-020-0497-0 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

EXTRA-GONADAL CHORIOCARCINOMA: PITFALLS AND PECULIARITIES OF AN INTESTINAL CASE. CASE REPORT AND REVIEW OF THE LITERATURE

E Guadagno 1

Abstract

We report the case of a 34-year-old female who presented to the emergency room with fatigue, anemia (hemoglobin of 4,7 g/dl) and amenorrhea lasting for 3 months. The most relevant finding was the evidence of high serum beta-human chorionic gonadotropin levels (400000 IU/ml). On ultrasound examination, the uterus was morphologically normal and no lesions were noted bilaterally in the adnexa. Her last pregnancy dated three years earlier. In the absence of radiological and clinical evidence of bleeding, a 99m technetium-labeled red blood cell scintigrafy was performed that showed jejunum bleeding lesions. On CT scan, multiple nodules were highlighted in the liver and the lungs. Subsequently, the patient underwent an emergency exploratory laparotomy and a jejunal resection measuring 37 cm. The final histopathological diagnosis was of jejunal extra-gonadal choriocarcinoma. After surgery, b-HCG levels reduced to 350 IU/ml and hemoglobin remained around 10 mg/dl.

Here are reported the main pifalls of diagnosis and treatment and the results of a throughout examination of literature review concerning extra-gonadal choriocarcinomas both arising from the midline or extra-midline, the gastrointestinal tract, in particular.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

INTEGRATED ONCO-HAEMATOLOGICAL DIAGNOSIS: REPORT OF A CASE OF A “TRIPLE-HIT” B CELL LYMPHOMA WITH FEATURES OF LYMPHOBLASTIC LYMPHOMA

A Filosa 1, G Goteri 2

Abstract

Recurring chromosomal abnormalities are associated with subtypes of leukemias and lymphomas that have distinct clinical, morphologic and immunophenotypic features. Both B-cell acute leukemias and high grade B-cell lymphoma may share the chromosomal translocation t(l4;18)(q32.3; q21.3) involving cMyc. In these cases, patients require different therapeutic approaches. Rarely, Tdt expression can be present in de novo high-grade B-cell lymphomas with double/triple hit. A complete workup including histopathology, immunophenotyping by flow-cytometry and FISH analysis, is necessary in such circumstances. WHO diagnostic criteria in separating these disorders are not clear-cut.

We herein report a case of a B lymphoblastic lymphoma/leukemia diagnosed in a paravertebral mass biopsy, with an immature B phenotype TdT+, CD34-, CD20-, CD79a+, PAX5+, CD10+, Bcl-2+ and c-Myc+. FISH analysis both of bone marrow aspirate and tissue sample showed IgH translocation and Bcl-2, Bcl-6 and c-Myc rearrangement with hyperdiploidy. Flow-cytometry showed absence of surface immunoglobulin. The case was difficult to classify showing that WHO classification criteria are not clear. Our final diagnosis was of a lymphoblastic lymphoma with a triple-hit. The clinical course was aggressive and the patient died in few months. Molecular studies with next-generation sequencing on such cases are needed.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

FOCUS ON NEOADJUVANT THERAPY: NEW RECOMMENDATIONS OF THE ITALIAN GROUP FOR THE STUDY OF BREAST PATHOLOGY - ITALIAN SOCIETY OF PATHOLOGY (GIPAM-SIAPEC)

N Fusco, on behalf of the GIPaM Working Group1

Abstract

Neoadjuvant therapy (NAT) plays a key role in the clinical management of patients with either early or locally advanced breast cancer with unfavorable prognostic factors. Pathological evaluation of post-NAT surgical samples is the gold standard procedure for assessing treatment response. Core biopsies before NAT should be analyzed to define the histological and biological characteristics of the tumor, allowing to set the appropriate personalized treatment protocol. The analysis of the post-NAT surgical samples is needed to assess the presence and quantify the extent of the pathological response along with the histological and biological characteristics of any residual tumor and/or lymph node metastases. Standard operating procedures involving all diagnostic phases (i.e. pre-analytical, analytical, and post-analytical phases) should be followed. It is advised to examine the sentinel lymph node(s) (SLN) on formalin-fixed paraffin-embedded (FFPE) samples. After careful mapping of the tumor bed in the surgical resection, re-evaluation of HR, HER2 status and of Ki67 labeling index is recommended in case of triple-negative status or an equivocal result on pre-treatment core biopsy, a pre-NAT biopsy performed in another institution, heterogeneous tumor, or multiple tumors with different morphology on resection, no response to therapy. During the Annual Meeting, we have provided – first preview – the updated recommendations of the Italian group for the study of breast pathology/Italian Society of Pathology (GIPaM-SIAPeC) for the analysis of breast cancer samples before and after NAT.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

LESIONI STROMALI BENIGNE DELLA MAMMELLA

Amato M 1, Campagna D 1, Costarelli L 1

Abstract

Caso 1

Uomo di 80 anni con nodulo della mammella sinistra di 2 cm, a margini espansivi, costituito da cellule fusate organizzate in corti fasci intersecati tra loro in maniera casuale; atipia nucleare assente o lieve; presenza di denso collagene eosinofilo; assenza di componente epiteliale, mitosi atipiche e necrosi. Diagnosi differenziale: miofibroblastoma (MFB), tumore fibroso solitario (SFT), leiomioma e miofibrosarcoma di basso grado. L’immunoistochimica mostra positività per SMA, desmina, hCaldesmon, CD34 e Bcl2, confermando la natura stromale. Il basso indice proliferativo (Ki67:2%) associato a CD34+ e desmina+ esclude il miofibrosarcoma di basso grado; CD34+ esclude il leiomioma; l’intensa positività per SMA rende improbabile una diagnosi di SFT. I reperti immunomorfologici depongono per MFB.

Fondamentale per confermare la diagnosi di MFB e per evitare pitfall diagnostici è l’immunoistochimica 1.

Caso 2

Uomo di 78 anni con nodulo di cm 1, traslucido,a margini ben definiti, costituito da cellule fusate organizzate in fasci, con aspetti a palizzata e presenza di collagene eosinofilo. Possibili diagnosi: neurinoma, leiomioma, pecoma ed SFT. L’immunoistochimica mostrando negatività per S100, SMA ed HMB45 esclude le diagnosi di neurinoma, leiomioma e Pecoma. La positività per CD34 suggerisce la diagnosi di SFT, confermata dall’espressione di STAT6.

SFT nella mammella è un evento molto raro. Secondo alcuni autori sarebbe analogo al MFB 2 mentre altri li considerano entità distinte, poiché SFT è di natura fibroblastica e non miofibroblastica 3.

Caso 3

Donna di 52 anni in postmenopausa con neoformazione nodulare di cm 13 della mammella destra, di aspetto omogeneo biancastro. Istologicamente caratterizzata da una complessa rete anastomotica di spazi pseudovascolari rivestiti in maniera incompleta da un monostrato di cellule fusate con citologia blanda, circondati da collagene denso e che coinvolgono lo stroma perilobulare ed intralobulare. Assenza di mitosi e necrosi. Profilo immunoistochimico: CD34+, SMA+, hCaldesmon+, ER+ e PGR+, CD31-. L’aspetto immunomorfologico caratteristico definisce l’iperplasia stromale pseudo angiomatosa (PASH).

È interessante notare come il pattern immunomorfologico faccia pensare che la PASH derivi dalla rete prelinfatica del parenchima mammario 4.

Bibliografia

  • 1.Magro M. Mammary myofibroblastoma: a tumor with a wide morphologic spectrum. Arch Pathol Lab Med 2008;132:1813-20. https://doi.org/10.5858/132.11.1813 10.5858/132.11.1813 [DOI] [PubMed] [Google Scholar]
  • 2.Damiani S, Miettinen M, Peterse JL, et al. Solitary fibrous tumour (myofibroblastoma) of the breast. Virchows Arch 1994;425:89-92. https://doi.org/10.1007/BF00193955 10.1007/BF00193955 [DOI] [PubMed] [Google Scholar]
  • 3.Magro G, Sidoni A, Bisceglia M. Solitary fibrous tumour of the breast: distinction from myofibroblastoma. Histopathology 2000;37:189-91. https://doi.org/10.1046/j.1365-2559.2000.00985-3.x 10.1046/j.1365-2559.2000.00985-3.x [DOI] [PubMed] [Google Scholar]
  • 4.Fisher CJ, Hanby AM, Robinson L, et al. Mammary hamartoma--a review of 35 cases. Histopathology 1992;20:99-106. https://doi.org/10.1111/j.1365-2559.1992.tb00938.x 10.1111/j.1365-2559.1992.tb00938.x [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

A RARE CASE OF ODONTOGENIC TUMOR

A d’Amati 1

Abstract

This study reports on a case of clear cell odontogenic carcinoma occurring in the mandible of a 84-years old woman and on its morphological, histochemical and immunophenotypical features, which may prove useful in the differential diagnosis. More than 100 cases of this rare entity have been reported in literature, with a mean age at presentation of 53 years, 63% of the cases occurring in females. The clinical manifestations usually are swelling and tooth mobility. Radiographically, these tumors appear as ill-defined radiolucent masses, associated with root resorption. As to the current case, the clinico-radiological features were in line with data from the literature. Microscopically, the neoplasm was composed of nests, cords and sheets of large epithelial cells with clear or eosinophilic cytoplasm, surrounded by a fibrocellular and hyalinized stroma. The mitotic index was very low and there was no evidence of ameloblastic differentiation, necrosis or lymphovascular invasion. Most cells contained PAS+/PASd- glycogen granules and showed immunoreactivity for cytokeratins and epithelial membrane antigen, without expression of myogenic markers. Other odontogenic (clear cell ameloblastoma, CEOT), salivary glands (mucoepidermoid carcinoma, clear cell myoepithelioma/epithelial-myoepithelial carcinoma, acinic cell carcinoma, hyalinizing clear cell carcinoma) and metastatic (renal, thyroideal, hepatic) carcinomas with prominent clear cell components should be considered in the differential diagnosis. The patient was treated with mandibular resection and remained without evidence of recurrence or metastases after 3 years of follow-up. Nevertheless, a variable clinical behavior has been reported, with possible local recurrence (40%), 1ymph node (19%) and distant metastasis (11%).

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

OSSO

M Gambarotti 1

Abstract

La nuova classificazione WHO dei tumori dell’osso e dei tessuti molli, pubblicata nel 2020, ha introdotto alcune novità nella classificazione delle neoplasie ossee; inoltre, alcuni concetti sono stati confermati.

È stata confermata la suddivisione dei tumori in benigni, intermedi (localmente aggressivi), intermedi (raramente metastatizzanti) e maligni. Rispetto alla classificazione precedente, alcune neoplasie hanno cambiato categoria (il condroblastoma, il fibroma condromixoide e la cisti aneurismatica sono ora classificati come benigni, mentre la condromatosi sinoviale e l’adamantinoma simil-displasia osteofibrosa sono classificati come intermedi, localmente aggressivi).

Non vi è un sistema di staging universalmente riconosciuto, mentre per il grading dei tumori maligni si suggerisce di basarsi sulla diagnosi di istotipo, con alcune eccezioni (es: i condrosarcomi, gradati secondo i classici criteri di Evans).

Nei tumori condrogenici è stato chiarito il concetto di tumore cartilagineo atipico, localizzato nello scheletro appendicolare, mentre con il termine di condrosarcoma grado 1 si intende un identico tumore localizzato nello scheletro assile.

Nei tumori osteogenici sono stati inseriti gli osteosarcomi secondari ad altra patologia o trattamento.

I tumori vascolari sono riclassificati in specifici istotipi, anche sulla base delle alterazioni molecolari caratteristiche degli stessi.

Nel gruppo dei tumori ricchi in cellule giganti sono scomparsi l’istiocitoma fibroso benigno e la lesione a cellule giganti delle piccole ossa, che rappresentano sempre altre lesioni, quali, ad esempio, la cisti aneurismatica con aree solide o il tumore a cellule giganti dell’osso

Sono stati introdotti due nuovi tumori: il cordoma poco differenziato e il mesenchimoma fibrocartilagineo.

Viene descritta, per ogni entità, l’eventuale presenza di alterazione molecolari di supporto diagnostico.

Infine, il sarcoma di Ewing non è più classificato all’interno dei tumori ossei, ma nel gruppo dei sarcomi indifferenziati a piccole cellule rotonde, insieme ad altri tumori in passato conosciuti come “Ewing-like”.

Bibliografia

  • 1.Editorial Board. Soft Tissue and Bone Tumours, WHO Classification of Tumours. Fifth Edition. Lyon: Iarc Press; 2020. [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

VALUTAZIONE RISCHIO PER NEOPLASIA PROSTATICA

D Onnis 1

Abstract

Caso clinico di incremento del PSA in corso di valutazione del donatore, con lo scopo di discutere come affrontare la valutazione di rischio per neoplasia prostatica, nell’ottica di delineare procedure condivise in attesa delle linee guida nazionali. Donatore multiorgano di 72aa, giunto alla nostra osservazione per rischio di neoplasia prostatica: PSA 117ng/ml (PSA libero 25ng/ml, Ratio 14,06). All’Ecografia addominale epatomegalia steatosica e 2 lesioni epatiche in S5 (2cm) e S6 (3,4cm). All’anamnesi IPB con programmata TURP e esami precedenti con valori di PSA totale intorno a 6 ng/ml e due BP nei 3 anni precedenti entrambe con diagnosi di ASAP. All’ER Prostata di volume aumentato e consistenza parenchimatosa, non noduli palpabili. L’urologo propone la prostatectomia contestuale al prelievo d’organo. La second opinion oncologica consultata dal CRT definisce il rischio pre-prelievo non standard trascurabile e non ritiene necessaria l’esecuzione della prostatectomia, purché venga eseguita una TC con mdc per le lesioni epatiche e la potenziale metastatizzazione della eventuale neoplasia epatica/prostatica. Alla TC formazione ovalare epatica sottocapsulare (mm. 34) in S6 a parziale sviluppo esofitico compatibile in prima ipotesi con angioma, diagnosi confermata dall’esame estemporaneo. Non evidenza TC di lesioni in altre sedi e nei segmenti ossei esaminati. L’urologo su specifica richiesta del paziente chiede se sia possibile ridurre il livello di rischio portandolo da rischio non standard trascurabile a rischio standard, dato che, all’esame intraoperatorio, la prostata non mostra lesioni macroscopiche. Pertanto il CRT ricontatta la second opinion che suggerisce per avvalorare l’ipotesi di assenza di neoplasia prostatica, di procedere ad un esame istologico estemporaneo su 4-5 prelievi della parete posteriore della prostata comprendenti la capsula. La diagnosi estemporanea è stata: sezioni di parenchima prostatico esenti da neoplasia. Tuttavia l’esame istologico definitivo su prostata in toto ha permesso di identificare un focolaio di cm.1,3 di adenocarcinoma acinare Gleason score 3+3 = 6, Gruppo prognostico 1, EPE-, non evidenziabile macroscopicamente e non presente nelle inclusioni random esaminate al congelatore.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

LIVER TUMORS IN A PEDIATRIC HEART TRANSPLANTED PATIENT

A Gambella 1

Abstract

Epstein-Barr-Virus-related smooth muscle tumor (EBV-SMT) is a rare neoplasm occurring in immunodeficient patients, particularly following post-transplant immunosuppression protocols. Due to its rarity and deceptive morphology, EBV-SMT could be misdiagnosed, thus critically impacting patients’ clinical management. This report presented a liver EBV-SMT case that occurred in a heart-transplanted pediatric patient four years after transplantation. Patient follow-up ultrasound examination identified two liver lesions, which were subsequently confirmed by a CT scan as hypodense nodules in S8 (3 cm) and S7 (1 cm). The major nodule was biopsied, showing features of a neoplastic lesion composed of spindle cells arranged in fascicles with interspersed vessels, whereas no hemorrhagic nor necrotic areas were observed. The lesion showed none-to-mild cytological and architectural atypia and no mitotic figures, and the proliferative index was low (mean value 7%). Neoplastic cells were negative to HHV-8 and to vascular (CD34) and GIST-related (DOG-1) immunohistochemical markers, but they resulted positive to smooth muscle actin (diffuse and intense), desmin (focal but intense), h-caldesmon (diffuse and intense), and EBER in-situ hybridization for EBV (diffuse and intense). An EBV-SMT was eventually diagnosed by combining patient clinical background and lesion histopathological features.

In conclusion, EBV-SMT represents a rare EBV-associated mesenchymal tumor that develops during immunosuppressive conditions (e.g., transplanted patient). Available studies on EBV-SMT reported it as an indolent lesion with good clinical outcome regardless of therapeutic approaches and pathological features (i.e., mitosis, necrosis, atypia) 1-3, whereas patient survival was mostly related to the overall clinical condition and the underlying immunosuppression etiopathogenesis. This report described a “typical” EBV-SMT case highlighting the relevance of clinical background and ancillary techniques (i.e., immunohistochemical and in-situ hybridization analyses) to guide the proper management and therapeutic approach to this benign lesion.

References

  • 1.Deyrup AT, Lee VK, Hill CE, et al. Epstein-Barr virus-associated smooth muscle tumors are distinctive mesenchymal tumors reflecting multiple infection events: a clinicopathologic and molecular analysis of 29 tumors from 19 patients. Am J Surg Pathol 2006;30:75-82. https://doi.org/10.1097/01.pas.0000178088.69394.7b 10.1097/01.pas.0000178088.69394.7b [DOI] [PubMed] [Google Scholar]
  • 2.Jonigk D, Laenger F, Maegel L, et al. Molecular and clinicopathological analysis of Epstein-Barr virus-associated posttransplant smooth muscle tumors. Am J Transplant 2012;12:1908-1917. https://doi.org/10.1111/j.1600-6143.2012.04011.x 10.1111/j.1600-6143.2012.04011.x [DOI] [PubMed] [Google Scholar]
  • 3.Hussein K, Rath B, Ludewig B, et al. Clinico-pathological characteristics of different types of immunodeficiency-associated smooth muscle tumours. Eur J Cancer 2014;50:2417-2424. https://doi.org/10.1016/j.ejca.2014.06.006 10.1016/j.ejca.2014.06.006 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

INTRARENAL ECTOPIC ADRENAL TISSUE IN DONOR KIDNEY TRANSPLANT

AG Bonadio 1

Abstract

Is the case of a 37-year-old man who died following a syncopal episode, already suffering from dilated heart disease and candidate as putative organ donor, in particular for liver and kidney. The risk assessment of the putative donor was standard. The surgical team sent the kidney and the liver biopsy for histopathological evaluation, which showed a disease-free liver and both kidneys in excellent condition with a Karpinski score of 2/12 and 3/12 for the right and left kidney, respectively. During surgery, a 4 mm nodule in the right kidney was identified and sent for histological evaluation. The nodule consisted of a clear cell proliferation without any cytological atypia. An immunohistochemical study with CK7, PAX8, CD10, HMB45, inhibin and sinaptophysin was performed. Negativity for CK7, PAX8, CD10 and positivity for inhibin and HMB45 allowed the diagnosis of adrenal ectopy in renal location. A clear cell lesion poses several differential diagnoses including renal cell carcinoma, PEComa and adrenal cortical lesions 1. Several cases of adrenal ectopy are described in the literature and one of the cases reported was, like ours, adrenal ectopy in a cadaveric donor 2. In conclusion, when faced with a clear cell lesion, always consider the possibility of a benign lesion.

References

  • 1.Goyal R, Gersbach E, J, Yang X, et al. Differential diagnosis of renal tumors with clear cytoplasm clinical relevance of renal tumors. Subclassification in the era of targeted therapies and personalized medicine. Arch Pathol Lab Med 2013;137:467-480. https://doi.org/10.5858/arpa.2012-0085-RA 10.5858/arpa.2012-0085-RA [DOI] [PubMed] [Google Scholar]
  • 2.Ye H, Yoon GS, Epstein JI. Intrarenal ectopic adrenal tissue and renal-adrenal fusion: a report of nine cases. Mod Pathol 2009;22:175-181. https://doi.org/10.1038/modpathol.2008.162 10.1038/modpathol.2008.162 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

DIAGNOSTIC IMAGING IN THE INTEGRATED CARE PATHWAY OF MELANOMA

A Annovazzi 1

Abstract

Imaging plays a pivotal role in the management of melanoma patients for initial staging, surveillance, and therapy planning/monitoring. In low-risk melanoma, no further investigation is necessary in the initial evaluation. As the stage of the disease increases, different imaging techniques are applied, starting from ultrasound of the peritumoral skin district and of its lymph node basin, up to total body imaging exams, eg. computed tomography (CT) or positron emission tomography with 18F-FDG (18F-FDG PET/CT) for the detection of distant metastases, integrated with brain magnetic resonance imaging (MRI). Routine imaging surveillance should be considered for the detection of asymptomatic relapses in high-risk patients, although its role is not clearly defined. The timing of follow-up and the choice of the most appropriate diagnostic tool are both influenced by initial stage and clinical practice rather than evidence-based guidance. Some studies demonstrated a better accuracy of 18F-FDG PET/CT for the detection of systemic metastases and it should be preferred starting with stage IIIb melanoma; CT may be proposed for stage IIc-IIIa surveillance instead. Finally, the correct strategy for monitoring response to immune checkpoints inhibitors is still a challenge. The use of 18F-FDG PET/CT is increasing in clinical practice, although response criteria need to be standardized.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

PDTA FIELD EXPERIENCE IN ITALY

L Festino 1, PA Ascierto 1

Abstract

PDTAs are diagnostic, therapeutic and assistance paths that allow you to outline, with respect to a pathology or a clinical problem, the best practicable path within your organization and the network in which it is inserted.

The objectives of PDTA are to standardize accessibility to the best health care and to ensure timeliness in taking charge, continuity of assistance, prescriptive and dispensing appropriateness. As part of the PDTAs, the times for taking care of patients and for carrying out the various diagnostic and therapeutic procedures are also established.

Given the large incidence of melanoma in Italy and given the annual increase of 8.8% in men and of 7.1% in women in Campania, PDTAs 1 have been drawn up that allow optimal management of these patients. The therapeutic diagnostic path was divided into 3 phases: “Path by segmentation in the initial diagnostic phase”, “Therapeutic path for people with confirmed cancer” and “Post surgery follow-up”.

The indications of the PDTAs have been drawn up on the basis of the most recent national guidelines 2 and guarantee the patient to receive the best medical and surgical treatments available as well as the opportunity to access innovative therapies in the context of international experimental protocols thanks to the presence on the territory of oncological clinical research centers.

References

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

SINGLE CELL MULTIPLEXED IMMUNOHISTOCHEMISTRY FOR THE ANALYSIS OF THE IMMUNE LANDSCAPE IN MELANOMA. IMPLICATIONS FOR IMMUNE CHECKPOINT THERAPY RESPONSE PREDICTION

FM Bosisio 1

Abstract

Negli ultimi 10 anni il trattamento del melanoma ha subito una rivoluzione a seguito dell’introduzione dell’immunoterapia. Dal canto suo, l’anatomia patologica non è rimasta immobile a guardare ma è evoluta anch’essa andando incontro a tre diverse rivoluzioni, la prima con l’introduzione dell’IHC negli anni 80, la seconda con l’introduzione della patologia molecolare e la terza con la recente digitalizzazione del vetrino che ha aperto le porte allo sviluppo di algoritmi di intelligenza artificiale per supportare il patologo nel lavoro di tutti i giorni 1. Queste tre rivoluzioni hanno posto le basi per la cosidetta next generation pathology, basata sul next generation sequencing, sulla digitalizzazione del vetrino e sullo sviluppo di nuove tecniche di immunoistochimica che consentono la visualizzazione di più di 50 marcatori alla volta a livello delle singole cellule permettendo di fenotipizzare la quasi totalità delle cellule presenti nel tessuto. L’immunoistochimica “multiplex” fa parte di quelle tecnologie che sono esplose dal 2017 in poi inizialmente basate sulla dissociazione delle cellule per studiarne i profili di espressione genica o proteica 2. Più recenti sono le tecnologie che permettono di investigare le singole cellule in situ nella sezione tissutale, permettendo quindi di studiare non solo la citometria, cioè la composizione di cellule del tessuto ma anche la loro sociologia, come si relazionano nello spazio tra di loro in termini di vicinanza. Questo è il tipo di dettaglio che dobbiamo raggiungere per studiare adeguatamente l’ambiente infiammatorio, che è un organismo molto complesso fatto di cellule in diverso stato di attivazione e dove la vicinanza di due cellule può significare un’interazione atta a modificarne la funzionalità. Usando la tecnica “Multiple Iterative Labeling by Antibody Neodeposition” (MILAN) per analizzare in situ 500.000-1.500.000 cellule abbiamo prodotto alcuni lavori che danno una chiara idea di dove le tecnologie di multiplex ci possono fare arrivare 3-5.

References

  • 1.Salto-Tellez M, Maxwell P, Hamilton P. Artificial intelligence-the third revolution in pathology. Histopathology 2019;74:372-376. https://doi.org/10.1111/his.13760 10.1111/his.13760 [DOI] [PubMed] [Google Scholar]
  • 2.Van Herck Y, Antoranz A, Andhari MD, et al. Multiplexed immunohistochemistry and digital pathology as the foundation for next-generation pathology in melanoma: methodological comparison and future clinical applications. Front Oncol 2021;11:636681. https://doi.org/10.3389/fonc.2021.636681 10.3389/fonc.2021.636681 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Bosisio FM, Antoranz A, van Herck Y, et al. Functional heterogeneity of lymphocytic patterns in primary melanoma dissected through single-cell multiplexing. Elife 2020;9:e53008. https://doi.org/10.7554/eLife.53008 10.7554/eLife.53008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Gadeyne L, Van Herck Y, Milli G, et al. A multi-omics analysis of metastatic melanoma identifies a germinal center-like tumor microenvironment in HLA-DR-positive tumor areas. Front Oncol 2021;11:636057. https://doi.org/10.3389/fonc.2021.636057 10.3389/fonc.2021.636057 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Antoranz A, Van Herck Y, Bolognesi MM, et al. Mapping the immune landscape in metastatic melanoma reveals localized cell-cell interactions that correlate to immunotherapy responsiveness. Biorxiv https://doi.org/10.1101/2021.11.22.468617 10.1101/2021.11.22.468617 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

COVID-19 RELATED DERMATOSES. CLINICO-PATHOLOGIC CORRELATIONS

M Llamas Velasco 1

Abstract

As in Spain we were very successful joining the experiences of many hospitals in order to describe at the end of April a classification proposal with 5 types of lesions based on the findings of 375 patients, we tried to compile cases with skin biopsy in order to further study the clinico-pathological features of the skin lesions associated to COVID-19.

We have also tried to determine which ones were directly related to the SARS-CoV2 infection or to the immune hyperactivation by using RNAscope and anti-spike immunohistochemistry.

We compiled 69 biopsies, 32 from our own hospital.

Regarding maculo-papular skin eruptions, our cases, as previously published ones usually appeared concomitantly with the respiratory symptoms. Most patients were taking hydroxychloroquine, azithromycin and lopinavir/ritonavir. The ones not taking drugs were mostly as the series described by Raymundo et al. No direct viral involvement was observed. Some cases were similar to acute generalized erythematous pustulosis.

Urticariform lesions showed overlapping histopathological features when compared with maculo-papular eruptions although some cases showed similar histopathology than conventional urticaria.

We did not find truly COVID-related vesicular lesions. In patients with COVID and vesicular lesions clinico-pathologic diagnosis were vesicular Grover and herpetic infections in our series.

We had less cases childblain-lesions than other series, probably as most of patients included in the series presented with severe infection. Our cases showed similar features to the ones described by Kolivras et al.

Finally, we were not able to find direct viral involvement either by RT-PCR, RNA-scope or IHC neither in the vasculitis and occlusive vasculopathies associated to the more severe patients, requiring intensive care unit admision.

In conclusion, in our series, we found that immunostaining was not useful to determinate how the lesions were related to viremia and, as so many patterns were observed, we cannot exclude that many of them can be unspecific due to the wide range of different immune responses related to this newly emerged virus.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

“BURNING SKIN” IN LONG COVID

V Gomes 1, T Grieco 2, F Arienzo 3

Abstract

Skin manifestations are a common finding in COVID-19 patients and in the so called long COVID 1. SARS-CoV-2 is known to have neurotropism as proved by the frequent occurrence of anosmia, loss of taste and itching during COVID-19.

We present here the clinic-pathologic findings observed in four confirmed COVID-19 adult patients (3 females and 1 male, age range 36-68 ys) observed between the end of 2020 and the beginning of 2021 at the Dermatological Clinic of the Sapienza, University of Rome, who developed neuropathic pain in the long COVID. Neuropathic pain manifested as “burning skin” in all patients. Clinical evaluation failed to reveal any syndromic conditions and dermatologic lesions. Skin biopsies were performed in all patients in the region where pain occurred.

Histopathologic analysis revealed in all cases hypertrophic nerve bundles associated with vascular structures in the mid dermis. Focal nerve mucoid degeneration was also observed. In two cases the neuro-vascular complexes showed a glomeruloid appearence. The overall apperance was that of dermal hyperneury, a condition known to occur in the context of different syndromes (e.g., MEN2a, MEN2b, PTEN hamartoma tumor syndrome and NF2) or in association with skin acquired disorders (e.g., Nodular Prurigo and Notalgia Paresthetica) 2.

SARS-CoV-2 could be involved in “burning skin” through a malfunction of the myelinated A-delta and unmyelinated C primary afferent neuronal fibres, due to the activation of the immune-mediated inflammatory response and host-related factors. Further cases are required to confirm the association of dermal hyperneury with long COVID. If so, in-depth studies will be needed to clarify the underlying mechanisms.

References

  • 1.Rajan S, Khunti K, Alwan N, et al. In the wake of the pandemic: Preparing for Long COVID. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2021. (Policy Brief, No. 39.) [PubMed] [Google Scholar]
  • 2.Ieremia E, Marušić Z, Mudaliar V, et al. Expanding the clinical spectrum of dermal hyperneury: report of nine new cases and a review of the literature. Histopathology 2019;75:738-745. https://doi.org/10.1111/his.13941. 10.1111/his.13941 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

SYSTEMIC LUPUS ERYTHEMATOSUS: ROLE OF EPSTEIN–BARR VIRUS AS AN AUTO-IMMUNITY TRIGGER

A Filosa 1

Abstract

One of the viruses most frequently suspected of acting as a trigger for autoimmunity is Epstein–Barr virus (EBV). A link with EBV infection has been suspected in systemic lupus erythematosus (SLE), and the precipitation of nuclear antigens of EBV by antibodies from patients with SLE was demonstrated more than 20years ago. The suspicion that this virus is implicated in the pathogenesis of SLE was strengthened by the observation of a high titre of anti-EBV antibodies in patients affected by SLE. We report a 22-year-old woman who developed systemic lupus erythematosus immediately after an EBV-induced mononucleosis infection. The link between these two conditions has long been suspected. The close temporal relationship, the course of the pathological events and the development of immunological changes in this case provide further evidence supporting the hypothesis that EBV infection could work as a trigger in some cases of SLE, particularly if the patient is genetically susceptible.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

DERMO-HYPODERMITIS SARCOID-LIKE IN COVID

T Grieco 1, A Sernicola 1, G Carnicelli 1, N Noccioli 2, V Gomes 3

Abstract

Introduction

Since Severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2) was firstly identified in China in December 2019, various symptoms of cutaneous involvement as part of extra pulmonary manifestations have been described.

Case presentation

A 73-year-old Caucasian woman reported a mild form of Sars-Cov 2 infection in January 2021, manifested with arthromyalgias,low-grade fever,mild respiratory symptoms and received only acetaminophen. Erythema nodosum-like skin lesions first appeared early in March 2021 with spontaneous regression in the following month but recurred in June 2021, 15 days after Pfizer-BNT vaccine first dose administration. A skin biopsy was performed. Histological examination revealed the presence of non-caseating giant-cell epithelioid sarcoid granulomas surrounded with few lymphocytes, both in the papillary and in the reticular dermis. Histological staining for bacteria were all negative. Steroid therapy was administered without benefit and a second biopsy was performed with similar histology to previous. Laboratory findings were all in range, except for CRP (1,79 mg/dl), hemoglobin (11,8 g/dl). Chest X-ray, electrocardiogram and eye examination were negative. Based on laboratory and clinical findings, a diagnosis of sarcoid-like granulomatous skin reaction was made, likely induced by Sars-CoV-2 antigens.

Discussion

A granulomatous reaction is rarely described in COVID patients. Only one case is reported1 and considered a “sign of convalescence rather than a sign of acute infection itself”. A sarcoid -like reaction is possible in genetically susceptible individuals exposed to microbial antigens with activation of pathogen-associated molecular patterns (PAMPs) such as viral RNA trigger pattern-recognition receptor (PRRs). We hypothesize that COVID infection induce a transient reduction of immune capacity with evidence of hidden disease.

References

  • 1.Behbahani S, Baltz JO, Droms R, et al. Sarcoid-like reaction in a patient recovering from coronavirus disease 19 pneumonia. JAAD Case Rep 2020;6:915-917. https://doi.org/10.1016/j.jdcr.2020.07.026. 10.1016/j.jdcr.2020.07.026 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

NEFROLOGIA E MALATTIE RARE: UNA TAUTOLOGIA

S Pizzolitto 1

Abstract

Se per tautologia si intende il termine che sostanzialmente ripete quanto già significato con un altro termine, allora nefrologia e malattie rare sono una tautologia. Ma anche se utilizzassimo la forma retorica che esprime concetti contrari, ossia l’ossimoro, la nefrologia e le malattie rare rappresentano proprio un ossimoro, perché molte nefropatie mediche sono anche “frequentemente rare”. Ad esempio l’ossimoro della glomerulonefrite (GN) a depositi mesangiali di IgA, la più frequente GN nel mondo, ma con un’incidenza tra 0.63 e 1,22/1000.000/anno. In ogni caso escludendo diabete e ipertensione, il nefrologo si confronta prevalentemente con malattie rare, dove si rendono sempre più necessari approcci multidisciplinari: reumatologo, dermatologo, oculista, ORL, cardiologo e soprattutto genetista. Tuttavia il più importante modo di contribuire efficacemente alla diagnostica di queste malattie, rimane ancora la Biopsia Renale e la diagnosi anatomo-clinica.

Ma quanto sono rare le malattie rare? Si intende come MR una malattia con prevalenza inferiore a 5 persone ogni 10.000. Sono riconosciute circa 6.000-8.000 malattie rare. Globalmente rappresentano il 6% della popolazione EU (30 ml persone). La definizione basata sulla sola prevalenza fa sì che il termine includa patologie di origine assai diversa: congenite, infettive, tumorali, genetiche, degenerative, dismetaboliche. Tuttavia l’80% sono forme ereditarie legate a mutazioni geniche. Il 95% delle MR non ha terapia. Pertanto c’è estremo bisogno di sviluppare nuove terapie orfane per malattie orfane. Prima di ricevere una diagnosi corretta di malattia rara passano da 5,6 a 7,6 anni, in cui il paziente vede in media 8 medici tra MMG e specialisti, ricevendo da 2 a 3 diagnosi, il più delle volte mis-diagnosi: l’odissea delle malattie rare!

Finalmente oggi l’Italia ha una legge/testo unico dedicata alle MR approvata dal Senato nel novembre 2021 che garantisce sull’intero territorio nazionale l’uniformità della presa in carico diagnostica, terapeutica e assistenziale dei malati rari e disciplina in modo sistematico ed organico gli interventi dedicati al sostegno della ricerca, sia sulle malattie rare sia sui farmaci orfani.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

LA BIOPSIA RENALE COME CHIAVE D’ACCESSO ALLA DIAGNOSI: L’APPROCCIO ANATOMO-CLINICO

S Pizzolitto 1

Abstract

Il modo più importante di contribuire efficacemente alla diagnostica delle nefropatie mediche rimane ancora la Biopsia Renale, che rappresenta davvero la chiave di accesso (Clavis et Clavus Medicinae, GB Morgagni 1886) alla diagnosi attraverso l’approccio anatomo-clinico.

In questo contesto di fondamentale importanza appare il ruolo svolto dal Nefrologo e dal Patologo in quello che definiremo “the first minidisciplinar team approach”. La prima ipotesi diagnostica (“prebiopsy diagnosis”), è quella che si forma nel cosiddetto “prebiopsy planning”, ove il Clinico Nefrologo deve confrontarsi con il Patologo discutendo l’indicazione clinica alla procedura bioptica, informandolo sulle modalità della procedura stessa e condividendo la tipologia del materiale necessario al successivo miglior approccio tecnico dei frammenti raccolti. In ogni caso i tre punti fondamentali per un efficacie approccio anatomo-clinico rimangono sempre: 1) una approfondita conoscenza clinica del Patologo 2) la capacità di dialogo fra Nefrologo e Patologo e soprattutto 3) la qualità dei preparati istologici, delle colorazioni ancillari, dell’immuofluorescenza e della microscopia elettronica. Qualità che deve tendere sempre all’eccellenza.

Molte nefropatie mediche sono «frequentemente rare»: è necessario pertanto conoscerle per andarle a cercare, ma anche cercarle per conoscerle meglio. E solo attraverso l’approccio multidisciplinare fra Nefrologo e Patologo sarà possibile coniugare esperienza, conoscenza e curiosità clinica.

Conclusion for Clinicians

  • Make a biopsy early!

  • Make a biopsy early with a thick needle!

  • Make a biopsy early with a thick needle and provide sufficient clinical information through an accurate prebiopsy planning!

Conclusion for Pathologist

  • The highest possible quality is the goal

  • Strive for technical excellence and high diagnostic expertise!

Pochi millimetri cubi di tessuto sono necessari (…e possono essere sufficienti!) per una completa caratterizzazione patologica della lesione: trattiamoli bene e sfruttiamoli tutti al meglio.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

IMPATTO DELLA DIAGNOSI ANATOMO-PATOLOGICA SU UN HUB DI COORDINAMENTO TRAPIANTI

TM De Feo 1

Abstract

L’attuale rete nazionale donazione-trapianto di organi e tessuti è strutturata su 3 livelli operativi variamente coinvolti in ogni processo donativo. Un livello nazionale coordinato dal Centro Nazionale Trapianti Operativo (CNTo) che gestisce i programmi nazionali; un livello regionale coordinato dal Centro Regionale Trapianti presente in ogni regione e un livello locale costituito dai Coordinamenti Locali dei presidi ospedalieri regionali attivi nel procurement dei donatori e dai centri trapianto. Il Centro di Riferimento Regionale del Nord Italia Transplant program (CRR NITp) rappresenta una realtà unica nel panorama italiano poiché funge da “hub di coordinamento del processo donazione-trapianto” di 6 regioni in cui si svolge oltre il 40% dell’attività nazionale di donazione e trapianto. Tra le attività affidate al CRR NITp una delle più critiche è la valutazione di sicurezza della donazione per offrire ai riceventi organi funzionalmente idonei ed evitare il rischio di trasmettere patologie da donatore a ricevente. La rete nazionale è supportata in questa delicata attività dalle Linee Guida Nazionali che indicano quali valutazioni cliniche, strumentali e di laboratorio devono essere eseguite per evidenziare eventuali fattori di rischio per patologie trasmissibili tenendo conto di un fattore limitante ineludibile: il brevissimo tempo a disposizione. L’innalzamento dell’età media dei donatori, attualmente oltre i 65 anni, rende più elevata la probabilità di evidenziare patologie neoplastiche non note nei donatori durante il processo di valutazione di idoneità o in sala operatoria durante il prelievo degli organi. Poter contare sulla professionalità dell’anatomo-patologo diventa cruciale per definire idoneo o non idoneo un donatore e/o un organo per ridare una speranza di vita ad uno o più pazienti in lista d’attesa. Il contesto in cui questa specifica professionalità viene richiesta è però profondamente diverso da quello ospedaliero/ambulatoriale routinario poiché il fattore tempo è cruciale e limitante. Compito della rete è quello di informare, formare e aggiornare questi professionisti per renderli consapevoli del ruolo sempre più cruciale che ricoprono nel processo di valutazione di idoneità e sicurezza.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

ANATOMIA PATOLOGICA SU PIÙ SEDI: GESTIONE DEL RISCHIO E DELLA QUALITÀ

G Mazzoleni 1

Abstract

L’azienda sanitaria di Bolzano ha un’unica Anatomia Patologica che serve tutta la provincia (7 strutture Ospedaliere, utenti 550.000 circa). Le principali problematiche riguardano fissazione e problematica formalina, identificazione campioni ed etichettatura, invio campioni e fogli di richiesta, trasporto campioni e gestione estemporanee. Le indicazioni operative per la maggior parte dei problemi sono indicate nelle Linee Guida Ministeriali edite nel 2015. Sono state pubblicate ad uso interno le procedure per ogni attività operativa con aggiornamento biennale. Manca ad oggi un sistema di trasporto formalin-free tipo Regione Toscana USL Nord Ovest. Oltre alla tracciabilità nel servizio di anatomia patologica, è stata realizzata una prima sperimentazione di order-entry con il Servizio di gastroenterologia che permette la diretta identificazione dei campioni nel reparto inviante, la visione di tutta la documentazione direttamente sul gestionale della gastroenterologia e l’invio delle risposte direttamente al gestionale. Essendo sprovvisti di anatomia patologica, originariamente l’esecuzione degli esami intraoperatori in quelle sedi prevedeva che un patologo ed un tecnico dell’ospedale di Bolzano vi si recassero di persona con un congelatore portatile. Dal 2003 è iniziata l’elaborazione di un progetto per l’utilizzo di una piattaforma digitale che consentisse la lettura dei preparati estemporanei al congelatore da remoto, evitando i trasferimenti del personale della Anatomia Patologica di Bolzano.

Il progetto si è concretizzato nel 2008, con la risoluzione di diverse problematiche strutturali ed organizzative e la collaborazione di tecnici, chirurghi e patologi. Nel 2014 il sistema è stato rinnovato con miglioramento della qualità delle immagini scansionate e della trasmissione. È stato introdotto un sistema di congelamento automatizzato per migliorare la tecnica di congelamento del materiale da esaminare, orientare in maniera adeguata il pezzo e tagliare anche tessuti adiposi in estemporanee. Contemporaneamente è stato adottato un coloratore automatico per standardizzare le colorazioni in periferia. Viene illustrato il percorso per la realizzazione del progetto, gli studi di validazione effettuati, e l’attività di diagnostica intraoperatoria da remoto effettuata in questi anni.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

MUMMIES OF SAINTS: DISTINGUISHED RELICS, WHERE HISTORY, SCIENCE AND DEVOTION MEET

E Fulcheri 1,2

Abstract

An introduction justified by two noteworthy novelties seems appropriate at the start of the Paleopathology session of the G-Paleo study group.

It is indeed the first time that a conference on Pathological Anatomy or Paleopathology deals with the topic of Recognition of the Relics of Saints, Blesseds, Venerables and Servants of God.

As a matter of fact, paleopathology is successfully applied to investigate the mummies of notables and nobles, politicians, artists and even clergymen, by studying diseases in ancient times. Professor Gino Fornaciari, while still a recognised master in this field, was undoubtedly also a pioneer.

In parallel to this great theme, some interest has gradually developed in the remains of people who were outstanding examples of faith, wisdom, piety, and charity within the Church.

The whole process was initiated thirty years ago, in 1991, by the journal Pathologica in an attempt to outline the issues and procedures to be followed by pathologists when appointed to perform Canonical Recognitions.

In 1995, this systematisation work produced the first cataloguing survey aimed at identifying the number of mummified bodies - the so-called Distinguished Relics -, the types of mummification, as well as the distribution of cases throughout Italy. In addition to compiling a very detailed catalogue, a number of artificially mummified subjects were also identified, thus documenting embalming practices that had flourished in a well circumscribed geographic area and within a particular religious and cultural context.

In 2000, hosted by the young Luca Ventura, we organized a conference in L’Aquila entitled: “The distinguished relics of the Saints: where history, science and devotion meet” with the aim to emphasize the great importance of distinguished relics, not only for the Church, but also for the scientific world and Paleopathology in particular.

Participants in this wide-ranging conference included leading palaeopathologists and representatives from the Ministry of Cultural Heritage, experts in the preservation of bodies, historians and also Msgr. Saraiva Martins, Prefect of the Congregation for the Causes of Saints, who shortly afterwards would be appointed Cardinal.

Not to forget them, it is worth mentioning the titles of the papers that were presented: Fulcheri E.: Protection of Cultural heritage: Biological Archives; Saraiva Martins J.: Saints’Relics: Meaning and Tradition; Capasso L.: The Ministry of Cultural Heritage in the preservation of the Relics of the Saints; Grilletto R.. Between Natural and Artificial Mummies; Fornaciari G.: Embalming Practices in the Monastic Environment of Umbria in the Late Middle Ages; Ventura L.: Histopathology of Mummified Tissues; Fulcheri E.: The Recognition of the Relics of the Saints; Gabrielli N.: Treatments on the Bodies and Relics of the Servants of God; Fulcheri E.: Future Perspectives and Closing of the Session.

Hence, after 20 years of work, the current session is not a point of arrival, but a starting point to develop, within a scientific environment, a theme characterised by two adjectives: ‘relevant and sensitivè.

The second novelty worth mentioning refers to this very approach.

In 2017, the Instructions of the Congregation for the Causes of Saints on “Relics in the Church: Authenticity and Preservation” were published. They contain some very important regulations and some particularly interesting novelties for our scientific-disciplinary field.

In PART II, Diocesan or Eparchial Phase of the specific operations that can be carried out, in Title I, Initial Acts, in Article 9 we read:

“The Bishop or the Episcopal Delegate is to nominate a medical expert (anatomical pathologist, medical examiner or another specialized doctor) and, if necessary, an assistant medical expert (autopsy technician), as well as others charged with performing the technical aspects of the work”

This is the first time that the role of the pathologist is expressly recognised in carrying out investigations aimed at diagnosing the state of disease, thanatology, and preservation conditions. This article also expressly mentions the role of the assistant medical expert (Autopsy Technician) with specific dissection skills.

In Title II, Specific operations, Chapter I: Canonical examination, Article 16 reads as follows:

Ҥ1. When these procedures have been completed, the anatomical experts are to inspect carefully the relics of the Blessed or of the Saint or the mortal remains of the Servant of God or of the Venerable.

§ 2. Furthermore, they are to identify analytically all the parts of the body, to describe in a detailed manner their state, and they are to put their findings down in a Report signed by them and attached to the acts.”

Under these provisions, a comprehensive report of the examination must be produced, similar to a detailed post-mortem report.

Article 17 then covers the issue of conservative treatment and any necessary histopathological and laboratory investigations in a broader sense.

“Whenever the canonical recognition makes evident the necessity or the opportuneness of performing treatments for their preservation, after having obtained the consent of the Bishop, such treatments are to be performed by applying the most accredited techniques in that place and in the ways which the anatomical experts or other experts shall establish.”

At the end of Title III, Final Acts, we read in Article 30:

“The images and information, taken from the anatomical treatments and all the procedures performed, must not be divulged or made public without the written authorization of the competent Bishop and that of the possible heir”.

Although this document is only briefly quoted here, it offers us a great opportunity to think about the objectives, required skills, and the procedures to be implemented during the recognition of the relics of Saints, Blesseds, Venerables and Servants of God.

It should also be mentioned here that in many cases canonical recognitions, carried out to ensure the authenticity and preservation of mortal remains, are also an opportunity for research studies. When properly authorised, they are going to shed light on unique, sometimes still little known aspects of the life of the investigated individual, with confused hagiographic descriptions that have somehow blurred the contours of the human, anthropological and pathological profile affecting their health conditions.

The role of pathologists and their specific expertise in modern pathology and the study of diseases of the past are now well defined even in this delicate and fascinating field. While for believers this field of research enriches the history of the Church in its path of faith and charity, for agnostics it stimulates interesting and unique cultural insights.

References

  1. Fulcheri E. Il patologo di fronte al problema della perizia in corso di ricognizione sulle reliquie dei Santi. Pathologica 1991;83: 373-397. [PubMed] [Google Scholar]
  2. Fulcheri E. Mummies of Saints: A particular category of Italian mummies. In: Spindler K, Wilfing H, Rastbichler-Zissernig E, Zur Nedden D, Nothdurfter H, eds. The Man in the ice, Vol 3. Human Mummies. Berlin: Springer Verlag; 1995. [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

RICOGNIZIONE CANONICA E STUDIO INTEGRATO MULTIDISCIPLINARE SUL CORPO MUMMIFICATO DI SANT’ATTO DA PISTOIA (M. 1153)

A Lunardini 1,2,3, R Gaeta 1

Abstract

The canonical recognition and the integrated multidisciplinary study, performed on the natural mummy of Saint Atto (+1153), reveal some aspects of the lifestyle and the pathologies that afflicted the subject in life, not reported in his biography or in the contemporary chronicles. He was in life monk, abbot and bishop of Pistoia (Tuscany). The study included macroscopy, conventional X-ray and CT examination, paleonutritional analysis, histological examination, paleopathology and radiometric dating. The natural mummy, with stature of 169 cm, is in secondary lying position and in a good state of preservation. After undressing, the skin presents an almost homogeneous brown coloration, with some lacunae and evident signs of remodelling, especially on the lower part of the face, at the level of the right shoulder, on the back and on the abdomen. Imaging studies reveal that he was suffering from Mediterranean anaemia, caries and arthrosis. Isotopic values of δ13C and δ15N suggest a paleonutritional profile based on consumption of terrestrial protein (meat and dairy) and sugar, without supplementation of fish-based foods. Preliminary histological examinations show the excellent general state of preservation of the microscopic characteristics of biological tissues. The major pathological conditions are not present in the samples, but the extensive and marked deposition of anthracotic pigment, in the bronchial and alveolar areas, is evident. This pathological condition is compatible with the habit of living in smoky environments due to the use of fires to heat the rooms and cook the food. The synthesis of the scientific study of Saint Atto has revealed that the subject, who lived between the 10th and 12th centuries, was an adult male, rather tall and long-limbed, who was devoted to the practice of horseback riding. The individual was, moreover, well fed and belonged to a high social class, compatible with the status of Bishop.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

BLESSED RANIERI DA BORGO (D. 1304), A NEW POTENTIAL CASE OF MEDIEVAL EMBALMING

M Mandarano 1, A Czortek 2, L Ventura 3,4

Abstract

In the Middle Ages, the lack of the natural corpse decay was considered a prodigious sign. The body was sometimes artificially mummified to confer it incorruptibility, not only as an essential requirement during Canonization trials, but also as a source of profit. However, only 10 cases of artificially embalmed Holy Bodies have been known from 1297 to 1482.

Ranieri da Borgo San Sepolcro was a lay brother of the Conventual Franciscans, who was dead on November 1st, 1304 and immediately embalmed. The local Municipality played a significant role after his death, obtaining from a Roman cardinal the balm for preservation, and allowing the construction of the main altar in S. Francesco’s church, just above the crypt in which Ranieri’s body has been kept.

The last documented Canonical Recognition of the body dates back to 1954, but related documents were not found in the bishopric archive. According to historical sources, previous inspections were carried out in 1740 and in 1761.

In order to plan a new recognition, we performed a preliminary survey of Ranieri’s body: probably in his original clothes, it was lying inside a wooden casket dating to XVI Century. Signs of past burglary were noted, and Ranieri’s right arm was lacking. Left hand and feet were in excellent state of preservation. The face was almost entirely covered with homogeneous brownish matter, suggesting embalming. Moreover, small defects in this material allowed to visualize portions of eyebrows, mustache, and beard.

Intentionally preserved bodies of charismatic religious people are considered the most ancient examples of body embalming in Europe. This practice arose in a specific area of Central Italy and was used to reach civic independence. In this context, Ranieri could represent the eleventh and oldest male example of an embalmed Holy Body. Further analyses are needed to confirm this historical assumption, to better understand the socio-political scenario of Central Italy during the Middle Ages.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

SCIENTIFIC INVESTIGATIONS ON THE BODY OF THE BLESSED ANTONIO DA FANO (D.1435)

M Traversari 1, L Ventura 2,3, F Tei 4, E Petrella 5, A Biselli 6, C Milani 7, G D’Altri 8, M Turla 2, S Ciocca 2, D Luiselli 9

Abstract

Antonio da Fano was a Franciscan friar, Confessor to the King Alphonso V of Aragon and Ambassador of the Pope Martin V. His body was found during restoration works in the Church of Santa Maria Nuova in Fano.

The skeletonized natural mummy underwent digital radiology and CT scanning, anthropometric survey, and representative sampling for laboratory analyses.

The anthropological analysis confirmed a male individual, with an estimated age at death of 45-49 years, and a height of 168 cm. Lower limbs showed a high robusticity index, with a low/middle value in the upper ones. The study of occupational activities suggested a commitment to the shoulders. Abdominal and thigh skin folds indicate an overweight subject, as confirmed by the osteoarthritic sacralization of L5 and the osteophytic bridges of lower thoracic vertebrae. Schmorl’s nodes with focal signs of herniation were observed in the thoracic tract.

Teeth were well preserved with good occlusion, caries of inferior molars, and widespread tooth grinding or bruxism without apical periodontitis. CT evidence and high density of the lower limb arteries in a plump subject could be reliably referred to atherosclerosis. Gross and histologic evidence of adipocere in the abdomen, also within muscle fibres indicate an obese subject.

Amorphous material, textile fragments and bony remnants of rodents were found endocranially. Textiles were composed of animal and vegetable fibers, namely silk and linen. probably belonging to the primary burial.

The good bone trophism combined with caries and atherosclerosis lead to hypothesize that Antonio had a diet rich in sugars and fats, as expected at the Royal Court of Aragon.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THE SKULL OF THE BLESSED MARIA LORENZA LONGO (D. 1539) FOUNDER OF THE “OSPEDALE DEGLI INCURABILI” IN NAPLES

C Bellevicine 1, A Brunetti 2, G Troncone 1, L Ventura 3,4, M Traversari 5

Abstract

Maria Lorenza Requenses was born in 1463 (although the birthyear was uncertain, ranging from 1463-1473) to a noble family in Lleida (Spain). In 1506, she followed her husband Joan Llonc (translated in italian as Giovanni Longo) who was chancellor of King Fernando of Aragon, in Naples; the husband died in Naples three years later. Maria Longo suffered from a disabling disease that was attributed either to poisoning or syphilis or rheumatoid arthritis. However, she succeeded in establishing the hospital of Santa Maria del Popolo degli Incurabili, also founding the Order of the Capuchin Poor Clares. She died on 21 December 1539 and was beatified 9 October 2021.

The relic attributed to Blessed Maria Lorenza Longo is represented exclusively from a completely skeletonized calvarium lacking right temporal bone, part of the large sphenoidal wing, lacrimal bone and orbital lamina of ethmoid bone. A large fracture of the right parietal bone was recorded during the previous recognition and attributed to an accidental fall.

The skull underwent visual inspection and digital radiology on different projections using a GMM Opera device. Computed tomography (CT) scanning was performed using a Toshiba Astelion 16-slice scanner with multiplanar reconstructions (MPR) and volumetric (3D) rendering.

Determination of sex tended to female, whereas the age at death was referred to a mature individual. No obvious indicators of vitamin deficiencies were found. The slight cribrosity on the glabella observed could be associated either with osteoporosis or osteitis. A moderate inflammatory process is active along the orbital frame of the zygomatic bone, with slight reactions of a periostitic nature. The endocranium is characterized by strong vascular impressions, with rather deep Pacchioni granulation, somewhere almost passing through the entire thickness. A small rounded osteoma was present on the endocranial surface of the frontal bone. An artificial postmortem hole was clearly visible at the top of the calvarium, probably made for suspending the relic by a small rope. From a morphologic viewpoint, the tertiary syphilis hypothesized by some textual sources could not be confirmed.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74. [Article in Italian]

IL MUSEO MORGAGNI DI ANATOMIA PATOLOGICA DI PADOVA: NUOVE TECNOLOGIE AL SERVIZIO DELLA DIDATTICA

A Zanatta 1

Abstract

Il Museo Morgagni di Anatomia Umana, sezione Anatomia Patologica dell’Università di Padova, fondato nel 1860 da Lodovico Brunetti (1813-1899), è stato recentemente ristrutturato e riaperto al pubblico nel 2018 per migliorare la fruibilità degli esemplari soprattutto per scopi didattici e scientifici. Attualmente il museo conserva una collezione databile tra la fine del 1700 e la prima metà del 1900 di oltre 1300 esemplari patologici umani, conservati in liquido, a secco o mummificati artificialmente con la tecnica della tannizzazione, inventata da Brunetti stesso 1.

La ristrutturazione del Museo nel 2018 ha previsto un nuovo sistema di allestimento con moderne vetrine e un rinnovato sistema di supporto didattico museale, con nuove tecnologie digitali come codici QR e Realtà Aumentata, utilizzati anche per applicazioni interattive durante le attività didattiche con le scolaresche o gli studenti di medicina. Sono stati inoltre realizzati percorsi virtuali, dedicati alla storia della medicina e alla città di Padova o per migliorare la capacità di osservazione degli studenti, fondamentale nella diagnosi delle patologie.

La visita del Museo Morgagni mira anche a portare nuovo interesse al grande pubblico su varie tematiche, come le patologie umane e le condizioni di vita della popolazione veneta tra Ottocento e primo Novecento, facendo così capire i progressi che la medicina ha compiuto negli ultimi anni. Al fine di promuovere un dialogo scientifico tra il visitatore e il ricercatore, le visite al museo sono tutte guidate proprio da personale qualificato. A questo vanno inoltre aggiunte nuove modalità digitali per arricchire il percorso museale con diversi livelli di approfondimento:

  • Codici QR (Quick Response Codes);

  • Realtà Aumentata;

  • Itinerari virtuali.

Rimangono comunque presenti didascalie testuali “tradizionali”, a muro e cartacee, disponibili per la consultazione durante e dopo la visita guidata. Infine, per favorire l’inclusività internazionale, sia le visite che la didattica digitale sono fornite in doppia lingua.

L’utilizzo di nuove forme digitali per il potenziamento dell’apprendimento nel Museo Morgagni di Anatomia Patologica hanno fornito risultati positivi in termine di didattica, sostenibilità, inclusività ed accessibilità, portando così all’obiettivo di un continuo miglioramento delle attuali forme per fornire una visita sempre più ricca di contenuti educativi e culturali.

Bibliografia

  • 1.Zanatta A, Zampieri F. Origin and Development of Medical Museum in Padua. Curator 2018;61;401-414. https://doi.org/10.1111/cura.12273 10.1111/cura.12273 [DOI] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THE PATHOLOGY SPECIMENS IN THE FLAJANI COLLECTION OF THE NATIONAL HISTORY MUSEUM OF SANITARY ART IN ROME

L Ferrari 1, PP Visentin 2, G Iacovelli 2, L Ventura 3,4

Abstract

The Academy of Sanitary Art History was established in 1922 in the monumental complex of Santo Spirito in Sassia hospital, dating back to 1205. Here, the Flajani Hall hosts the specimens from the Anatomical Museum of the Santo Spirito hospital, founded in 1772 by the great surgeon Giuseppe Flajani (1739-1808) to serve as teaching to the students. Aim of the present study is the preliminary survey of the pathological specimens held in the Museum in order to plan a detailed paleopathological investigation of the collection.

Information about the specimens was retrieved from the official catalogue of the Museum. An extensive photographic documentation of the specimens was performed.

The collection in the Flajani Hall consists of anatomy and obstetrics wax models, as well as pathology wet and dry specimens. Pathology specimens are currently showed in three wooden closets. Two of them date back to the 18th Century and hold dry specimens including aneurysms, congenital anomalies, and soft tissue swellings, as well as bone preparations including fractures, syphilitic gummas, and rickets/osteomalacia. An additional small closet holds thirty glass jars with gall, kidney, and bladder stones, five wet and three dry specimens of fetal malformations, dry preparations from skull and long bones. Seven additional wet specimens of fetal malformations are kept out of the closets. Few artworks may undergo pathographic studies.

Dry specimens are in good preservation conditions. Wet specimens appear well-preserved, but their conditions need to be checked. A scientific project for the recovery, study and rearrangement of the entire museum material is on the way.

References

  1. Fulcheri E. Saints and illnesses in faith and paleopathological evidences. Journal of History of Medicine 2006;18/3:815-830. [PubMed] [Google Scholar]
  2. Fulcheri E. Ricognizioni canoniche ed indagini scientifiche sulle mummie dei Santi. Medicina nei secoli: arte e scienza 2013;25(1):139-166. [PubMed] [Google Scholar]
  3. Istruzione della Congregazione delle Cause dei Santi su “Le reliquie nella Chiesa: Autenticità e Conservazione”. Bollettino Sala Stampa della Santa Sede. n° 0905. Roma 2017. [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

COMPETENZE PROFESSIONALI NEL CONTESTO LAVORATIVO

A Esposito 1, M Cadei 2, M Canepari 3, F Pagano 4, E Stigliano 5, M Torboli 6, L Tarter 7, M Bonardi 8, S Salvatore 9, F Colonna 10

Abstract

Summary

Nel contesto del Servizio Sanitario Nazionale (SSN) si sta assistendo ad una significativa evoluzione delle componenti organizzative-assistenziali conseguenti all’oggettivo manifestarsi di diversi fenomeni di evoluzione scientifica e tecnologica anche nell’ambito dell’Anatomia Patologica (AP). Le norme in merito, i percorsi formativi specifici e le esperienze già in essere in differenti realtà italiane ne hanno evidenziato la “necessità” di definizione ministeriale per Tecnico di Laboratorio Biomedico (TSLB) “specialista” in AP. La Società Scientifica SIAPeC-IAP e la Società Tecnico Scientifica AITIC si sono confrontati, al “Virtual Congress” di SIAPeC-IAP 2021, in una Sessione dedicata per definire una Proposta attuativa.

Introduzione

Nel contesto del SSN si sta assistendo ad una significativa evoluzione delle componenti organizzative-assistenziali conseguenti all’oggettivo manifestarsi di alcuni fenomeni come l’Epidemiologia della Popolazione italiana, la maggiore attenzione alla Prevenzione, la costante e profonda evoluzione scientifica e tecnologica applicabile nei Laboratori di AP ed il recente PNRR 1 con le Missioni 4 e 6 (Istruzione- Formazione e Salute).

Il generarsi con forza di nuove esigenze rende peculiare, pertanto, la costante trasformazione del Ruolo professionale dato dal “Sapere, Saper fare e Saper essere” delle 22 Professioni Sanitarie e, nel caso specifico, del TSLB operante in AP.

Prossimità, Innovazione e Formazione, infatti, sono alcuni dei principali temi che guideranno la grande stagione di investimenti che attende la nostra Sanità pubblica e privata nei prossimi anni 1.

La ridefinizione degli ambiti, quindi, con modalità multi professionale presuppone che alle Competenze e Responsabilità acquisite dal TSLB nel percorso formativo di base facciano seguito specifiche esigenze formative post base nel rispetto della Normativa vigente.

In tale contesto si rende necessario definire Competenze “distintive” anche del TSLB operante in AP che possano garantire un giusto “value” ai Processi di Cura ed Assistenza 2,3.

I nuovi Modelli hanno sempre di più bisogno di un esercizio professionale flessibile, dinamico ed integrato che renda necessario sia l’innovazione dei rapporti fra le professionalità Medico/Tecnico sia la riorganizzazione dei processi produttivi dei Laboratori attraverso la ridefinizione “in progress” di spazi ed attività “integrative-specialistiche” al fine di garantire sostenibilità, equità, appropriatezza, efficacia ed efficienza.

La ridefinizione, pertanto, degli ambiti di attività con modalità multi professionali e la conseguente rimodulazione ed ampliamento delle competenze/responsabilità acquisite nei Percorsi formativi (di Primo e Secondo Livello), Master (di Primo e Secondo livello), integrati da Percorsi modulari strutturati dalle Regioni in base a specifiche esigenze, nel rispetto dei requisiti da (ri)definire a livello nazionale, costituiscono l’ambito di azione e lo spazio istituzionale, sul “modello europeo”, in cui proporre le necessarie modifiche con l’attuazione del PNRR.

Diviene fondamentale, quindi, che:

  • il Sistema-Paese orienti azioni programmatiche e piani di studio che valorizzino i concetti precedentemente illustrati;

  • che i Ministeri della Salute e dell’Università e Ricerca, in condivisione con le Regioni e Società Scientifiche, producano atti e strumenti di “pianificazione, attuazione e valutazione” dell’impatto Formativo sia sulla Salute dei Cittadini sia nel rispetto delle specifiche Competenze professionali.

Dal 2006, anno di emanazione della L. 43, abbiamo assistito ad una offerta formativa universitaria post base “free” e non “appetibile” ai Professionisti TSLB operanti in AP in quanto carente della dovuta valorizzazione da riconoscere nelle singole realtà lavorative4.

La “quadratura del cerchio” è finalmente avvenuta con la sigla del CCNL del Comparto Sanità – Periodo 2016-2018 in cui, con Art. 14 e seguenti - Definizione degli incarichi di funzione -, sono stati istituiti, nei ruoli sanitario, tecnico, amministrativo e professionale, i seguenti incarichi di funzione:

  • di organizzazione;

  • professionale,

con la relativa introduzione delle figure di “Professionista specialista” e di “Professionista esperto”.

Ne deriva, di fatto, la necessità di definire le tipologie di Master di I livello necessarie a garantire la migliore formazione post-base nell’Area di AP 2.

Metodi

Sono stati analizzati, nel dettaglio, gli Obiettivi/Ordinamenti Didattici dei Master di I livello di ambito AP già attivati sul territorio nazionale nei diversi anni. Contestuale attenzione è stata dedicata al rapporto storico, dal 2002, tra la Società Scientifica SIAPeC-IAP e la Società Tecnico Scientifica dei Tecnici di Istologia e Citologia (AITIC). Scopo di questo lavoro, quindi, è quello di delineare il superamento definitivo del concetto di TSLB operante in AP come Professionista “astratto”, attraverso una ri(e)voluzione, in “tangibile”, ovvero proiettare il TSLB nel presente/futuro scientifico, tecnologico ed organizzativo così come già accade nei Paesi dell’UE e nel panorama anglosassone. Tale Processo è possibile, a nostro avviso e nel nostro Sistema Paese, unicamente attraverso un approccio “sinergico” 5 tra le due Società Scientifiche con la conseguente istituzione di Tavoli tecnici dedicati. L’occasione, fornita dalla Sessione del “Virtual Congress” di SIAPeC-IAP 2021, ha permesso alle Presidenti delle due Società di ascoltare e verificare tutti gli aspetti sia “formativi/normativi” sia “esperienziali sul campo” di diverse realtà italiane:

Pathologists’Assistant – PathA:

  • Master in Tecniche istopatologiche in AP - UNIMORE - M. Canepari;

  • UOC Anatomia Patologica ASSP multizonale - Trento - M. Torboli, L. Tarter.

Specialista in Citologia e Screening di Popolazione:

  • European Advisory Committee of Citotecnology (EACC) – F. Pagano;

  • ◊ UOC Anatomia Patologica ASST “Spedali Civili” – Brescia - M. Bonardi.

Specialista in Sala Settoria:

  • Master in Tecniche Diagnostiche Autoptiche e Forensi – UNICATT - E. Stigliano;

  • UOC DMO “SS. Annunziata” Chieti - ASL 02 Abruzzo - S. Salvatore.

Risultati e conclusioni

Dopo 1 anno di confronto si è convenuta la proposta di individuare n°3 figure “specialistiche” in:

  • Scienze Tecniche Diagnostiche Autoptiche e Forensi;

  • Scienze Tecniche Diagnostiche di Citologia e Screening di Popolazione;

  • Scienze Tecniche Diagnostiche di Istopatologia (Pathologists’Assistant – PathA).

Tale metodo di lavoro ha, inoltre, permesso di individuare anche gli Obiettivi formativi e le conseguenti abilità da conseguire per lo Specialista:

Scienze Tecniche Diagnostiche Autoptiche e Forensi:

  • Scienze Tecniche e di Management:

    • ◊ Collaborazione con il Patologo e/o Medico Legale;

    • ◊ Management dell’evento decesso;

    • ◊ Management della Sala Settoria;

    • ◊ Management Biobanca in ambito Medico Legale e Forense;

    • ◊ Consulente Tecnico del Giudice o delle Parti (CTU/P).

Scienze Tecniche Diagnostiche di Citologia e Screening di Popolazione:

  • Scienze Tecniche e di Management:

    • ◊ Collaborazione alla lettura di preparati citologici di triage;

    • ◊ Management degli Screening di popolazione.

Scienze Tecniche Diagnostiche di Istopatologia (Pathologists’Assistant – PathA):

  • Scienze Tecniche e di Management:

    • ◊ Collaborazione con il Patologo per:

    • ◊ Riconoscere, descrivere e campionare;

    • ◊ Management del Laboratorio di istopatologia.

SIAPeC-IAP ed AITIC invieranno, dopo la condivisione nei rispettivi Consigli Direttivi, la Proposta complessiva ai Ministeri di pertinenza al fine di “accelerare” i processi istituzionali di riconoscimento, consapevoli che l’evoluzione del TSLB in AP non è determinata solo dal percorso normativo/formativo ma da un “convinto e partecipato” cambiamento culturale dello stesso.

In contesti lavorativi “multi professionali” ad alto tasso di specializzazione ed innovazione tecnologica 3, come il nostro Ambito di AP, deve essere sviluppata, quindi, la capacità di verificare, quotidianamente, il sapere/saper fare/saper essere “individuale e di gruppo” proiettando l’agire professionale verso la centralità del Sistema, il Cittadino.

Bibliografia

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

WHAT IS AN NGO. THE ROLE OF LABORATORY TECHNICIANS IN THE EVOLUTION OF APOF

F Acciai 1

Abstract

A Non-Governmental Organization (NGO) is a non-profit organization that is independent of states and their policies that obtain a significant portion of their income from private sources, mostly donations, engaged in a wide range of activities, often of a humanitarian or social nature, taking different legal forms. NGOs in Italy began to develop from the 60s and 70s, finding the first regulatory recognition in Law 38/1979 which defined the requirements to obtain the suitability to operate in development cooperation. Law 125/2014,currently in force, instead exceeds the category of Non-Governmental Organization (NGO) to introduce Civil Society Organizations (CSOs),including the previous but much broader. During over fifteen years of activity Patologi Oltre Frontiera (APOF) has carried out projects in Africa (Tanzania, Zambia, Madagascar, Uganda, Nigeria, Djibouti, Congo, Somalia), Latin America (Cuba), Europe (Kosovo) and the Middle East (Palestine) aimed at achieving (and maintaining) an accurate and timely diagnostic activity with the participation of various professional figures in the health and logistics field. Among them over the years has carved out a particularly important role for the Laboratory Technician who works in the Pathological Anatomy Services, who has in particular the task of dealing with the choice of equipment but above all of following the training of local technicians. The training follows the classic process of lectures with final exam and practical part with the support of expert staff. Lately, due to the impossibility of finding medical personnel of Pathological Anatomy in the training, a part dedicated to macro pathology (pathology assistant) and digital pathology are also planned. In some laboratories (Djibouti) there are already local technicians able to process the material from the arrival in Anatomy to the digitization of the finished slide. However, the problems are still many and range from the need to increase the ranks of technical volunteers to the need to support the various laboratories even in the absence of our staff. The assistance is mainly linked to the preparation but also to the maintenance of the instrumentation that in recent years has undergone a necessary implementation and modernization.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

FINE NEEDLE CYTOLOGY IN THE MANAGEMENT OF LYMPH NODE METASTASES: 1-YEAR EXPERIENCE

G Acanfora 1, E Vigliar 2, C Bellevicine 2, G Troncone 2

Abstract

Objectives

Fine needle cytology (FNC) is a useful technique in the analysis of lymphadenopaties. This study aimed to address FNC accuracy in lymph node metastases analysis and the role of immunocytochemistry (ICC).

Material and Methods

This is a 1-year retrospective study; all FNCs diagnoses of metastasis and cases in which histology revealed a metastasis were included. To assess diagnostic accuracy, histopathologic controls were correlated with FNC diagnoses; when no biopsy was performed, clinical follow up was checked. ICC data were reviewed. Then, the origin of the primary neoplasm was assessed, when feasible.

Results

Out of 300 lymph nodes FNCs performed during 2019, 86 cases were included; of these 41,8% had a previous diagnosis of malignancy. Cervical lymph node group was the most sampled (47,6%), followed by the axillary group (27,9%). Eighty-five FNCs were diagnosed as metastasis; of these, 68 were histologically/clinically confirmed; in one case a FNC benign diagnosis, histology showed a breast cancer micrometastasis. Seventeen cases were lost during the follow-up. Overall, the concordance rate was 98,5%.

ICC was performed in 60% of FNCs, with a mean of 3 immunomarkers per case. The most common immunostainings were TTF1 (17,4%) and GATA3 (9%).

The primary neoplasm was stated in 76,7% of FNCs; the most common was breast cancer (34,8%).

Conclusion

FNC is a very useful tool in lymph node metastases diagnosis. Cytomorphological features and ICC findings are proven to be helpful to identify the primary neoplasm, even with a limited number of immunomarkers.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

IMPACT OF IMPLEMENTING THE PARIS SYSTEM FOR REPORTING URINARY CYTOLOGY IN THE PERFORMANCE OF URINE CYTOLOGY

A Amico 1, I Bagni 1, G Lanza 1, C Buriani 1

Abstract

Objectives

The Paris System (TPS) has recently been proposed as a method to standardize urinary cytology reporting. In this study, we evaluated the impact of implementing TPS compared to the traditional reporting system.

Materials and methods

We performed a pathology database search for urinary cytology cases reported within 15 months periods, from January 1, 2019 to March 31, 2020 (pre-TPS, 5548 cases) and from June 1, 2020 to August 30, 2021 (post-TPS, 5383 cases).

We evaluated the frequency of cytological diagnostic categories NUC/NHGUC (Negative for Urothelial Carcinoma/Negative for High-Grade UC), AUC (Atypical Urothelial Cells), SHGUC/HGUC (Suspicious for High-Grade UC/High-grade UC) in the pre-TPS and post-TPS period and correlated cytological and histological diagnoses. Biopsies were classified as benign, LGUN (Low-grade Urothelial Neoplasm), and HGUC (including CIS). Surgical follow-up information was available for 143 patients in the pre-TPS period and 229 patients in the post-TPS period.

Results

Comparing the pre-TPS and post-TPS periods AUC diagnoses decreased from 9.5% to 6.6%, increasing the prediction of subsequent high-grade urothelial carcinoma (pre-TPS AUC sensitivity 36.8% and specificity 85.7%; post-TPS AUC sensitivity 60% and specificity 91.2%). Diagnostic accuracy for HGUC was also improved: sensitivity, specificity, PPV, NPV pre-TPS were 81,8%, 80%, 85,7%, 75% while post-TPS were 82.6%, 90.1%, 87.72%, 85.9%.

Conclusions

In our study TPS implementation reduced atypia rates and improved diagnostic accuracy for high-grade tumors.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THE ROLE OF INTERVENTIONAL CYTOPATHOLOGIST IN THE DIAGNOSIS OF PARAGANGLIOMA ON FINE-NEEDLE ASPIRATION

AM Carillo 1, P Pisapia 1, E Vigliar 1, G Troncone 1, C Bellevicine 1

Abstract

Background

Paragangliomas are rare tumors often diagnosed during imaging procedures performed for other medical reasons and frequently misdiagnosed.

Presentation

A 51-year-old man noticed a growing mass in the right side of the neck and the US hypothesized a parotid origin. The CT and MRI scans revealed a heterogeneous mass almost indissociable from the jugular-carotid vascular bundle and featuring discrete contrast enhancement. An US-guided FNA was performer by an interventional cytopathologist. The ROSE revealed epithelioid cells arranged in trabecular and pseudofollicular aggregates. The Diff-Quik staining highlighted reddish metachromatic granules within the cytoplasm of several cells and intranuclear cytoplasmic inclusions. An additional pass was performed in order to obtain a cell-block preparation. H&E stained CB sections revealed round cell groups similar to the Zellballen observed in the histological preparations of paragangliomas. Chromogranin and synaptophysin immunocytochemical staining were diffusely positive in the main cells whereas the S100 immunostain hightlighted the sustentacular ones. A final diagnosis of paraganglioma was rendered.

Discussion

Histological biopsy is not always indicated when a paraganglioma is suspected. The less invasive FNA followed by the ROSE and the proper triaging of the aspirated material performed by the interventional cytopathologist allow a definitive diagnosis.

Conclusion

The introduction of FNA in the diagnostic practice of head and neck paragangliomas represent an important diagnostic tool in particular when the FNA is performed by an interventional cytopathologist.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

EVALUATING PDL-1 IN ONCOCYTIC THROID LESIONS. INSIGHTS ON ITS DIAGNOSTIC AND PROGNOSTIC ROLE.

M Dell’Aquila 1, V Fiorentino 1, G Fadda 2, LM Larocca 1, ED Rossi 1

Abstract

Objectives

PDL-1 expression is emerging as a predictive biomarker in cancer immunotherapy. Its role has been studied in several neoplasms, associating it to a more aggressive biological behaviour. Its role in thyroid cancers is still not completely clear: very few authors addressed the issue of its evaluation and role in fine needle aspiration cytology. Our group already demonstrated the correlation of pdl-1 expression with papillary thyroid carcinoma, however oncocytic neoplasms yielded uncertain results. In this study we examined pdl-1 expression in oncocytic neoplasms from cytological samples in order to clarify the pattern of immunostaining and the eventual correlation with aggressiveness.

Materials and methods

We collected 60 thyroid oncocytic neoplasms from January 2018 to March 2021 immunostained for pdl-1 on both LBC samples and on their histological equivalent.

Results

We included 50 tir2 controls, 5 tir3a, 53 tir3b, 2 tir4, with the histopathological complement in 39 cases. Overall we found an increase in pdl-1 membrane and cytoplasm expression in 33 cytology cases; while histologically 52% of oxyphilic adenomas and 66% of oxyphilic carcinomas showed pdl-1 expression. Hyperplastic oncocytic cells in hashimoto thyroiditis were negative for pdl-1.

Conclusions

Overall our data suggests that PDL-1 expression is associated with oncocytic lesions. PDL-1 expression appears to be independent from benignity or malignancy in oncocytic lesions.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THE ONGOING EFFECTS OF COVID-19 ON CYTOPATHOLOGY PRACTICE: RESULTS FROM AN INTERNATIONAL SURVEY

F Dello Iacovo 1, E Vigliar 2, P Pisapia 2, G Troncone 2

Abstract

Objectives

The aim of this study was to evaluate how cytopathology practice changed during the post-lockdown period, appraising data from 29 laboratories all over the world.

Materials and methods

Each laboratory collected data over 12 weeks, grouped into four 3-week periods, and then compared it to the corresponding period in 2019. The following data were recorded: total number and types of specimens, sample sites, number of suspicious and malignant diagnoses of non-gynecological samples and trends in sample workload.

Results

The sample workload was overall lower than 2019 (n=239,266 vs 319,315), with an average volume reduction of 26%.

A decrease of samples from thyroid (-48%), cervicovaginal tract (-44%), breast (-26%), serous cavities (-20%), respiratory tract (-14%) was observed. Conversely, a slight increase in volume of samples from bone marrow (+18%), gastrointestinal tract (+13%), central nervous system (+7%) was observed.

The overall malignancy rate was significantly increased during the post-lockdown compared to the corresponding period in 2019 (6.54% vs 4.98%: p value < 0.001).

Most laboratories (n=19/29, 65,5%) experienced a steady increase of samples workload over the 4 periods.

Conclusion

During the COVID-19 post-lockdown more samples were progressively collected. Although the malignancy rate increased, confirming that patients at higher oncological risk were still prioritized, a significant volume reduction (-26%) was still observed. Therefore, a continuous monitoring of the effects of COVID-19 on cytopathology worldwide is advisable.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THYROID CYTOLOGY IN THE COVID-19 PANDEMIC ERA

C Pizzimenti 1,2, C Petracca 3, T Ientile 3, A Ieni 1, G Fadda 1

Abstract

Objectives

The fine-needle aspiration (FNA) of thyroid performed in 3 reference periods at a single Institution are reviewed, to evaluate the effects that Covid-19 pandemic had on the amount of examinations and on the distribution of the diagnoses.

Materials and methods

In 3 semesters of 2019 (349 cases), 2020 (118 cases) and 2021 (219 cases), a total number of 686 cases were diagnosed at G. Martino University Hospital of Messina. In 2021, the Liquid-based Cytology (LBC) method was introduced making the immunocytochemical (ICC) tests on the cytological material possible.

Results

TIR1 diagnoses were 15% in 2019, 12.7% in 2020 and 12.2% in 2021, respectively; TIR2 75% in 2019, 71% in 2020 and 74.5% in 2021, TIR3 A 5.7% in 2019, 8.5% in 2020 and 5.9% in 2021; TIR3 B 0.6% in 2019, 0.8% in 2020 and 3.6% in 2021; TIR4 0.6% in 2019, 5% in 2020 and 3.2% in 2021; TIR5 2% in 2019, 1.7% in 2020 and 0.45% in 2021.

23 cases had a histological examination (3,4% of cases). ICC stainings were carried out in 15 LBC cases (mostly indeterminate, 6,8% of cases).

Conclusions

Covid-19 pandemic reduced the number of patients submitted to FNA of the thyroid which was performed on those who had a high clinical suspicion of a thyroid tumor. The introduction of LBC allowed the execution of ICC tests on the aspirated material.

References

  • 1.Vigliar E, Cepurnaite R, Alcaraz-Mateos E, et al. Cancer Cytopathol 2020;128:885-894. https://doi.org/10.1002/cncy.22373 10.1002/cncy.22373 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

FINE NEEDLE ASPIRATION IN METASTATIC MELANOMA AT FEDERICO II ACADEMIC HOSPITAL

F Puccio 1, M Nacchio 1, E Vigliar 1, G Troncone 1, C Bellevicine 1

Abstract

Objectives

Melanoma can metastasize at any body site. Fine-needle aspiration (FNA) is minimally invasive, fast and cheap in tracking disease evolution. Interventional cytopathology can properly triage the FNA providing sufficient material for the microscopical evaluation, immunocytochemistry (ICC) and molecular assessment. In fact, 45-50% of melanomas show a BRAF V600E mutation, an important predictive marker for thyrosine-kinase inhibitors (TKI) therapy.

Material and methods

We retrieved from our database 56 metastatic melanomas diagnosed by FNA. Records regarding age, sex, anatomic location, main cytomorphological features, ICC and molecular test performed were collected.

Results

Out of the 56 cases, 27/56 (48%) were females and 30/56 (53%) males. 34/56 (62%) of FNA were performed on lymph nodes, 15/56 (27%) on soft tissues, 3/56 (5%) on the liver, 2/56 (3%) on parotid gland, 1/56 (2%) in the orbit. The epithelioid cell morphology was the most frequent microscopic feature (22/56; 39%). In 45/56 (80%) FNA, ICC was performed on cell blocks; the S100 staining was the most frequently employed ICC marker (40/56; 71%). On the overall, 40 out of 56 FNA (71%) underwent molecular test by next-generation sequencing or RT-PCR technology: 22/56 (39%) revealed a BRAFV600E mutation, 3/56 (5%) an NRAS mutation.

Conclusions

FNA represents a first and rapid approach to diagnose a suspected melanoma metastasis, providing sufficient material for molecular tests in the majority of cases.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

FINE-NEEDLE ASPIRATION (FNA) OF SECONDARY NEOPLASM TO THYROID (SNTGS) AT FEDERICO II HOSPITAL

M Salatiello 1, E Vigliar 1, P Pisapia 1, G Troncone 1, C Bellevicine 1

Abstract

Objectives

SNTGs are rare and fine-needle aspiration (FNA) are often the only sample available. This study reports our Institutional experience of SNTGs diagnosed on FNA.

Materials and methods

We performed a retrospective study of patients with SNTGs diagnoses on FNA from 2003 to 2021. We queried our database employing as keywords: thyroid; FNA; malignant; suspicious; TIR5; TIR4; metastasis.

Results

Out of 59,951 thyroid FNA, 1500 (2.5%) were diagnosed as TIR4 or TIR5. 29/1500 (1.9%) of these latter were SNTGs, representing the 0.05% (29/59,951) of all thyroid FNA and 1.9% of thyroid malignancies. In 22/29 cases (75%) immunocytochemical staining on cell-block preparations were performed, whereas in 2/29 (7%) FNAs featuring atypical lymphoid cells part of the aspirated material was triaged for flow cytometry. The most common sites of primary tumour were the kidney, the skin, gastrointestinal tract and the lung, each one showing a similar incidence (5/29; 17%), respectively, followed by breast 4/29 (14%), gynaecological and haematological malignancies 2/29 (7%), head and neck 1/29 (3%). Interestingly our series revealed two metastases from uterine leiomyosarcomas, rarely described as SNTGs.

Conclusions

This retrospective study confirms the rarity of SNTGs with an incidence of 1.9% in our series and the accuracy of FNA for the diagnosis of SNTGs, in particular when coupled with ancillary technique, that are useful not only to refine the morphological diagnosis but also to provide relevant predictive information.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

A STRANGE INFECTION RESISTANT TO EVERYTHING

V Caputo 1, A Citterio 2, FW Baruffaldi-Preis 2, E Bonoldi 1

Abstract

Objectives

highlight the role of the pathologist in a multidisciplinary context, in the management of non neoplastic dermatoses.

Materials and methods

A 33-year-old woman came to the observation for the appearance for several months of deep skin ulcerations with loss of substance, that undergo spontaneous scarring on the face and trunk.

The patient had lived in Spain since 2017 to 2019 and in 2018 had been in Africa for a journey. In 2019 in Spain she underwent surgery for a mammary fibroadenoma. Upon returning to Italy, she developed skin lesions. Despite the different and numerous dermatological consultations, biopsies and therapies, the lesions persisted.

All microbiological examinations, to exclude infectious disease, gave negative results.

During hospitalization, she underwent also rheumatological, haematological, neurological and psychiatric consultation that did not show pathologies.

On the basis of the clinical aspect, in a multidisciplinary context, it was decided to re-perform biopsies on lesions both ulcerated and in scarring phase.

Tissue samples were formalin fixed and paraffin embedded, then slides were stained with Haematoxilin-Eosin (EE), PAS, PAS-D, Grocott and Ziehl-Neelsen.

Results

Skin samples were characterized by pseudoepitheliomatos hyperplasia of the epidermis, which was sometimes abruptly ulcerated, with sharp demarcation. The dermis was replaced by a scar-like fibrosis, with scattered lympho-monocytes and foreign body type giant-cells.

At high magnification it was possible to observe, on the surface and in depth of the lesions, numerous fibers of varying colors, from dark grey to blue, birefringent to polarized light.

Stains for opportunistic pathogens were all negative.

The diagnosis was coherent with Morgellons Disease (MD).

MD is a rare, poorly understood dermatosis characterized by fibers appearing underneath the skin or emerging from slow-healing skin sores.

Symptoms can be painful and long-lasting affecting quality of life.

The general medical consensus is that is a form of delusional parasitosis, even if recently a group of investigators supported the notion that is an infectious disease and demonstrated in a large series of patients an association with Lyme disease.

Conclusions

Sierology for Borrelia was negative.

The patient spontaneously tampered the dressings, preventing healing.

She underwent another psychiatric observation and specific therapy is set with lorazepam, sertraline and quetiapine, with apparent benefit.

References

  1. Middleveen MJ, Stricker RB. Morgellons disease: a filamentous borrelial dermatitis. IInt J Gen Med 2016;9;349-354. https://doi.org/10.2147/IJGM.S116608 10.2147/IJGM.S116608 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Middleveen MJ, Fesler MC, Stricker RB. History of Morgellons disease: from delusion to definition. Clin Cosmet Investig Dermatol 2018;11:71-80. https://doi.org/10.2147/CCID.S152343 10.2147/CCID.S152343 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Suh KN. Delusional infestation: Epidemiology, clinical presentation, assessment and diagnosis. UpToDate, 2020. [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

ATYPICAL FIBROXANTHOMA-LIKE AMELANOTIC MELANOMA: A DIAGNOSTIC CHALLENGE

G Cazzato 1, A Colagrande 1, A Cimmino 1, L Resta 1, G Ingravallo 1

Abstract

Objectives

Atypical fibroxanthoma-like amelanotic melanoma is a very rare variant of melanoma that can, if not correctly recognized and framed, lead to diagnostic errors that can potentially cause problems of extreme relevance to patients. Correct knowledge of this entity and the execution of adequate immunohistochemical investigations are the basic conditions for the correct management of this lesion. We report on a case of atypical fibroxanthoma-like amelanotic melanoma, which clinically simulated a fibrohistiocytic lesion, and which created differential diagnostic problems, and finally, we conduct a short review of the literature.

Materials and methods

A 93-year-old man came to the University Dermatology and Venereology Department following the identification of a lesion to the right auricle of approximately 1 cm in diameter that had been present for about 2 years. The lesion had been interpreted by the dermatologist as a benign fibrohistiocytic tumor without suspicious dermoscopical appearance. The lesion was excised, formalin-fixed, and paraffin-embedded. Histopathological examination of hematoxylin and eosin-stained sections revealed a lesion centered in the dermis, ulcerated, and composed of epithelioid and sometimes spindle cells with pleomorphic, hyperchromatic, and nucleolated nuclei, with moderate to abundant eosinophilic cytoplasm and arranged in a fascicular and occasionally random fashion. There were also giant multinucleated cells, especially in the superficial part of the lesion. At a higher magnification, both typical and atypical mitotic figures were observed. There were clusters of peritumoral inflammatory lymphocytic infiltration. Phenomena such as necrosis and hemorrhage were not evident. There was no melanin pigment present, and the dermoepidermal junction did not present any junctional melanocytic growth, without significant alterations. The lesion was noted to make contact with the nerves, surrounding them, without evidence of invasion.

Results

Based on these morphological features, the differential diagnosis included, initially, sarcomatoid squamous cell carcinoma, or atypical fibrohistiocytic lesion, or finally, a variant of melanoma. Therefore, some immunohistochemical tests were carried out in order to confirm this clinical and pathological diagnosis.

The immunohistochemical tests for p40, p63, vimentin, CD34, and CD31 were negative (not shown), and immunostaining for CD68 was focally positive in rare giant cells. Immunostainings for SOX-10 and S-100 proteins were strongly positive, including in some giant cells, and S-100 protein also stained some nerves present at the base of the lesion.

Reactions for melan-A and HMB-45 were negative (not shown). Immunostaining for CD10 (positive in many AFXs) was strongly positive.

Based on the strong SOX-10 and S-100 expressions, the lesion was diagnosed as melanoma with morphological features of AFX, measuring to a Breslow depth of 3.1 mm and a Clark level of IV. The patient subsequently underwent PD-1 immunotherapy.

Conclusions

In conclusion, we have described the sixth rare case of AFX-like amelanotic malignant melanoma, which is a very rare entity that can be difficult to diagnose. Pathologists should be aware of this rare melanoma variant and utilize appropriate immunohistochemical testing to avoid a diagnostic pitfall.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

UNUSUAL VARIANTS OF CUTANEOUS MELANOMA: TWO EMBLEMATIC CASES

RM Di Crescenzo 1, S Varricchio 1, Paola Moretta 1, D Russo 1, S Staibano 1

Abstract

Objectives

Cutaneous Melanoma (CM) is considered the great mimicker in dermatopathology.

Besides the main melanoma categories identified in the last WHO classification, many rare histological variants have been described 1. Herein, we report two unusual variants of CM with a particularly aggressive biological behavior.

Cases presentation

The first case occurred in a 91-year-old male patient with a nodular pedunculated back lesion, histologically consistent with an ulcerated balloon cell CM with a Breslow thickness of 11 mm. At molecular analysis, tumor cells presented BRAFv600E mutation. After six months, the patient developed painless papules around the surgical scar, histologically diagnosed as satellite metastasis.

The second case was from a 60 years-old male patient with irregular exophytic multiple lesions of the right arm, which occurred on a surgical scar of a previous thin CM. Histologically, lesions appeared as a dermal nodular proliferation of epithelioid and signet-ring cells, diagnosed as recurrent melanoma with BRAFV600E mutation. Sentinel node biopsy examination revealed a metastatic deposit of signet-ring melanoma.

Conclusions

CM is an aggressive neoplasia with an impressive variety of morphological patterns. Amongst the most unusual variants are balloon-cell and signet-ring cell CM. Despite molecular advances in dermatopathology, histopathological examination is crucial for the diagnosis of CM. Therefore, knowledge of unusual variants is essential for a correct diagnostic approach.

References

  1. Saggini A, Cota C, Lora V, et al. Uncommon Histopathological Variants of Malignant Melanoma. Part 2. Am J Dermatopathol 2019;41:321-342. [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

IN VIVO RCM FEATURES OVERLAP WITH HHS IN MOLLUSCUM CONTAGIOSUM

J Farina 1, G Broggi 1, GM Vecchio 1, G Magro 1, R Caltabiano 1

Abstract

Objectives

The aim of the study was to correlate in vivo reflectance confocal microscopy (RCM) images to horizontal histopathological sections (HHS) 1 features in molluscum contagiosum (MC) to further demonstrate RCM diagnostic accuracy 2.

Materials and methods

Six patients with MC typical lesions were enrolled in the study. One lesion was examined using the handled RCM device (Vivascope 3000, Caliber I.D., Rochester, New York), excised and processed to obtain HHSs. Images were digitalised by using Scan-Scope Digital Slide Scanner (Aperio, Vista, California).

Results

6/6 RCM images showed well-defined lobules filled with bright round cells at epidermis level. HHS showed lobulated squamous epithelial hyperplasia surrounded by fibrous septa of large keratinocytes with intracytoplasmic viral inclusions (Henderson-Paterson bodies).

Conclusions

RCM images perfectly overlap HHS findings, particularly the well-defined lobules and the bright cells seen with RCM match with the lobulated epithelial hyperplasia and keratinocytes with viral inclusions seen with HHS, respectively. It demonstrates how HHSs better correlate with RCM images than conventional histopathology, since both techniques share the same point of view of the skin.

References

  • 1.Broggi G, Verzì AE, Caltabiano R, et al. Correlation Between In Vivo Reflectance Confocal Microscopy and Horizontal Histopathology in Skin Cancer: a Review. Front Oncol 2021;11:435. https://doi.org/10.3389/fonc.2021.653140 10.3389/fonc.2021.653140 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Scope A, Benvenuto-Andrade C, Gill M, et al. Reflectance confocal microscopy of molluscum contagiosum. Arch Dermatol 2008;144:134. https://doi.org/10.1001/ARCHDERM.144.1.134 10.1001/ARCHDERM.144.1.134 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

PARAOXONASE-2 IN CUTANEOUS T-CELL LYMPHOMAS

A Filosa 1, E Molinelli 2, E Morsia 3, M Emanuelli 4, G Goteri 5

Abstract

Objectives

Paraoxonase-2 (PON2) is an intracellular membrane protein that belongs to PON gene family. PON2 is ubiquitously present in all human tissues and localized within the cell, exerting a crucial role against production of reactive oxygen species (ROS) associated with mitochondrial respiratory chain. ROS regulates numerous signalling events, such as gene expression and cell differentiation, including hematopoietic stem cell differentiation. Based on investigations in different types of malignancy, it seems that solid neoplasms show PON2 overexpression, potentially correlated with unfavourable prognosis, whereas haematological malignancies exhibit enzyme downregulation. In particular, acute myeloid leukaemia and B-cell lymphomas are characterised by low PON2 levels with deletion of the respective gene, and the aberrant level of PON2 expression seems to correlate with favourable prognosis. The aim of this study was to investigate PON2 expression in skin lesions from primary cutaneous T cells lymphomas (CTCL), specifically Mycosis Fungoides (MF) at different stage of evolution and the leukemic counterpart Sezary Syndrome (SS).

Materials and methods

We performed immunohistochemistry analyses to investigate PON2 protein expression in skin biopsies from stage I (n = 3) and stage II (n = 6) MF and stage III/IV (n = 5) SS, as well as control tissues represented by cases of chronic inflammatory dermatitis (n = 6). We evaluated the percentage of PON2-positive lymphocytes in controls and atypical lymphocytes of MF and SS cases. Subsequently, the intensity of immunostaining (from negative to strong) in the lymphoid infiltrate was scored. Statistical analysis was performed to explore the existence of a different expression in tumoral and inflammatory lesions, as well as between MF and SS cases.

Results

In our preliminary study, we observed a statistically significant lower PON2 expression in SS skin biopsies compared to controls. PON2 lymphocytes expression was significantly higher in MF compared to SS lesions. Moreover, we found no significant differences in immunohistochemical expression between MF patients and controls.

Conclusions

Our study is the first to suggest an intra-tumoral down-regulation of PON2 expression in SS compared with MF patients. These findings seem to suggest that PON2 could be involved in the leukemic phase of CTCL.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

A RARE CASE OF SUPERFICIAL SOLITARY FIBROUS TUMOR

S Squillaci 1, F De Trovato 1, M Piccolomini 1, M Chiudinelli 1, R Marchione 1

Abstract

Objectives

Most extrathoracic solitary fibrous tumor (SFT) occur in a deep location and only rarely in the subcutis or dermis.

Material and Methods

We describe a SFT in the subcutis on the thigh of a 54-year old male, who is free of disease 10 months after surgery.

Results

The patient presented a 6 cm right upper thigh, tan to whitish, lobulated mass. Microscopically, it consisted of a well circumscribed nodule that was variably cellular with irregular fascicles of ovoid to spindled cells with moderate pleomorphism, sometimes arranged in vaguely storiform to whorled pattern with variable amounts of hyalinized collagen. Hypercellular areas frequently alternated with hypocellular ones, in which cells were interspersed within an edematous to myxoid stroma with focal dilated blood vessels, often with staghorn-like profile. Mitotic count was 1-2 in 10 HPF. There was no necrosis. The tumor cells were diffusely reactive to vimentin, CD34 and STAT-6, focally to α-SMA and did not stain for S-100 and desmin. Furthermore, the tumor had a Ki67 index of about 5%.

Conclusions

Differential diagnosis of superficial SFT includes spindle cell lipomas, mammary-type myofibroblastoma, cellular angiofibroma, fibrous histiocytoma, DFSP and monophasic synovial sarcoma 1. A number of risk stratification models have been proposed based on parameters such as mitotic activity, tumor size, patient age and extent of necrosis; using one such model our neoplasm falls in the low-risk category, indicating an excellent prognosis.

References

  1. Feasel P, Al-Ibraheemi A, Fritchie K, et al. Superficial solitary fibrous tumor. A series of 26 cases. Am J Surg Pathol 2018;42:778-785. https://doi.org/10.1097/PAS0000000000001027 10.1097/PAS0000000000001027 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THE APPLICATION OF DIGITAL PATHOLOGY FOR HISTOLOGICAL DIAGNOSIS IN THE ATS INSUBRIA’S AREA

F Crivelli 1, F Sessa 2,3, M Cerati 3, S Zannella 4, C Patriarca 4

Abstract

Due to the improvement of digitalization technologies, Digital Pathology has now become a very important tool for histological diagnosis.

The possibility to share digital slides via the web favours the development of real time diagnostic networks and support the improvement of diagnostic quality.

In 2018 the Region of Lombardy approved different innovative projects, among which a project whereby the Pathology Departements in the ATS Insubria’s are started to exchange digital slides. This has improved improved the quality of diagnosis by facilitating discussion among different expert pathologists. The project is still ongoing.

Objectives

The principal goals of the project are:

To assess of the impact of digital pathology on the organization of the pathology Departement;

To verify the effectiveness of histological diagnosis on a digital image vs diagnosis through microscope;

To verify the usefulness of sharing diagnoses in particular for the more difficult cases;

To improve the quality of Surgical Pathology wards in the area by facilitating access to expert physicians across the network

To improve diagnostic quality and ability through sharing and discussing among pathologists.

Conclusions

After four months from the project’s beginning, preliminary results aligns perfectly to the goals: a marked improvement in diagnistic quality has been evidenced, particularly for pigmented skin lesions and breast carcinoma biopsis.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

NAMED ENTITY RECOGNITION TO EXTRACT CLINICAL INFORMATION FROM BREAST PATHOLOGY REPORTS.

A Lozupone 1, M Sonnessa 1, MA Botticella 1, MI Pastena 1, FA Zito 1

Abstract

Objectives

Named Entity Recognition (NER) is a process of extraction of information that seeks to detect key words into a text in natural language, extracting and importing them in a list of named entities usable for query search. NER is used in Natural Language Processing that tries to solve the problems related to unstructured information. The majority of clinical data in health field are free text helpful for single cases but not useful for analytical investigation. The aim of this study was to determine the feasibility of using NER to extract clinical information from breast pathology (BP) reports from thousands of cases.

Methods

A total of 369.755 record of pathological reports from 2006 to 2020 of two different Hospitals were imported in a single database created with filemaker (FM) 18 (Claris inc.). From all record, a query of 14,313 reports of the BP has been selected and imported in a dedicate FM database. A single field, which collected different biological and pathological data, was elaborated with a specific algorithm to extract key words from diagnostic texts. A random cohort of 2000 BP diagnosis has been examined by different pathologists to verify the concordance with the original file.

Results

The experimental results showed that this approach achieves the 98% of exact concordance for numerical variables (ER, PgR, HER2, Ki67, grading and pTNM). The concordance was reduced for angiogenesis and margins (80% and 85% respectively).

Conclusions

This approach is essential to obtain structured data with a good feasibility in the era of Big Data to avoid to forget important data and to make them available for analytical investigations.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

IMPACT OF DIGITAL ON KIDNEY PRE-IMPLANTATION BIOPSIES DIAGNOSIS

S Marletta 1, MG Mastrosimini 1, I Girolami 2, M Brunelli 1, A Eccher 3

Abstract

Objectives

Lack of organs leads kidneys from Extended Criteria Donors (ECD) to be used to increase the donor pool. Pre-transplant biopsies are routinely evaluated through the Remuzzi-Karpinski score but consensus on its correlation with graft survival is controversial. Thus, we sought to test a digital diagnostic approach for evaluation of pre-transplant biopsies and to correlate it with graft outcome.

Material and methods

Pre-transplant biopsies from 78 ECD utilized as single kidney transplantation were scanned, converted to whole-slide images (WSIs) and reassessed by two experienced renal pathologists using the Remuzzi-Karpinski score. The correlation between graft survival and parameters assigned by either WSI or glass slide score (GSL) by the on-call pathologist was evaluated, as well as agreement between the GSL and the WSIs score.

Results

While no relation was found between the GSL and graft survival (p = 0.413), the WSI score assigned by the renal pathologists strongly correlated with graft loss probability, as confirmed by the ROC curves analysis (DeLong test p = 0.046).

Conclusions

Digital pathology allows to share expertise in the transplant urgent setting, ensuring higher accuracy and favoring standardization of the process. Its employment may significantly increase predictive capability of the pre-transplant biopsy evaluation for ECD, improving quality of allocation and patient’s safety.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

PATHOMICS IN STAGE III NSCLC: PREDICTIVE INFORMATION HIDDEN BEHIND IMAGES

L Nibid 1, G Sabarese 1, S Ramella 2, P Soda 3, G Perrone 1

Abstract

Objectives

Through Radiomics it is possible to obtain prognostic and predictive information combining quantitative analysis of digitalised images and machine learning methods 1. Similarly, Pathomics is a predictive and prognostic analysis based on histological digitalised images combined with Artificial Intelligence (AI). Here we provide an exploratory Pathomics analysis in stage III NSCLC to predict response to chemoradioterapy.

Materials and methods

91 patients affected by stage III NSCLC whose TC scans have undergone a Radiomic analysis classifying patients in “adaptive” or “non-adaptive” depending on target reduction after chemoradiotherapy 2. 35/91 patients were enrolled based on availability of tissue sample and H&E tissue slides were digitalized and segmented outlining tumor areas. Overall, 1303 tumor areas were manually segmented and a training and prediction set were performed.

Results

Image analysis approach correctly classified 30 out of 35 patients (AUC: 0,85) in terms of radiotherapy response. Despite the small size of our sample, we obtained similar results to those of Radiomics approach (AUC: 0,82) 2.

Conclusions

Our results suggest that digital pathology combined with machine learning could represent a new approach for the prediction of therapy response.

References

  • 1.Avanzo M, Stancanello J, El Naqa I. Beyond imaging: The promise of radiomics. Phys Medica 2017;38:122-139. https://doi.org/10.1016/j.ejmp.2017.05.071 10.1016/j.ejmp.2017.05.071 [DOI] [PubMed] [Google Scholar]
  • 2.Ramella S, Fiore M, Greco C, et al. A radiomic approach for adaptive radiotherapy in non-small cell lung cancer patients. PLoS One 2018;13:e0207455. https://doi.org/10.1371/journal.pone.0207455 10.1371/journal.pone.0207455 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

IMPACT OF MOBILE DEVICES ON CANCER DIAGNOSIS IN CYTOLOGY

N Santonicco 1, S Marletta 1, I Girolami 2, A Eccher 3, M Brunelli 1

Abstract

Objectives

Digital pathology has widened pathologists’ opportunities to examine cytological samples. Recently, mobile devices like tablets and smartphones have been tested for application in digital pathology. The aim of this study was to review the published literature on the impact of mobile devices on cancer diagnoses in cytology.

Materials and methods

A systematic search was carried out, including studies dealing with the application of mobile devices for diagnosing cancer on cytological specimens. The quality of these studies was assessed with the QUADAS-2 tool. The main themes addressed were the comparison of light microscopy and mobile tools for assessing primary diagnosis. The technical features of smartphones and tablets, softwares and adapters were also studied in terms of feasibility and costs-analysis.

Results

Eighteen articles were included. Correlation coefficients with light microscope assessment were good and diagnostic performance of portable devices was comparable with an expert pathologist’s diagnosis. The mobile device models studied differed, sometimes significantly, in terms of speed and cost. Utility was improved by employing designed adapters.

Conclusion

The use of mobile devices demonstrated promising results regarding digital evaluation of cytological samples. Widespread adoption even in underserved areas is anticipated following validation studies, technology improvements and reduction in the cost of investing in mobile platforms.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

LEISHMANIA LYMPHADENITIS IN A PATIENT WITH PRIMARY IMMUNODEFICIENCY

E Beccaria 1, G Di Stefano 1, R Santi 1

Abstract

Objectives

According to Azadeh classification, Leishmania lymphadenitis may exhibit various histological patterns, the most common being a granulomatous reaction with or without necrosis. Intact (anergic) histiocytic response characterized by numerous Leishman bodies, no necrosis and inconspicuous plasma cells is extremely rare.

Materials and methods

A 47-year-old male, diagnosed 12 years previously with visceral leishmaniasis, complained of fever and bilateral laterocervical lymphadenopathies. One right cervical lymph node measured 4 cm in the greatest diameter and the patient underwent excisional biopsy on suspicion of malignancy.

Results

Histological examination revealed a diffuse collection of epithelioid histiocytes, with no necrotizing granulomas and a residual minimal lymphoid tissue with sparse plasma cells. At higher magnification, the histiocytes displayed intracytoplasmic, ovoid 2-3 μm bodies compatible with Leishman bodies. The overall picture excluded lymphoid neoplasms and was suggestive of Leishmania lymphadenitis.

Conclusions

At first presentation of visceral leishmaniasis the patient was diagnosed with primary immunodeficiency. Visceral leishmaniasis can cause lymphadenopathy and pyrexia and may be considered the first step toward diagnosing immunodeficiency of unknown origin.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

ASSESSMENT OF TIGIT MRNA EXPRESSION IN CLASSIC HODGKIN LYMPHOMA BY IN SITU HYBRIDIZATION WITH RNASCOPE

A Bianchi 1, M Verri 1, O Annibali 2, A Crescenzi 1

Abstract

Objectives

T cell Ig and ITIM domains (TIGIT) has been recently recognized as an immune checkpoint receptor that negatively regulate T cell functions in Hodgkin’s lymphoma (HL) 1. Our group demonstrated the expression of TIGIT in HL microenvironment and proposed a scoring system for TIGIT immunohistochemistry 2. Based on that, we systematically investigated the mRNA expression dynamic of TIGIT in order to find a correlation with our proposed scoring system.

Materials and methods

TIGIT expression was evaluated in 34 consecutive patients with HL. TIGIT expression in T lymphocytes surrounding Hodgkin Reed-Sternberg (HRS) cells was assessed by RNAscope, a novel in situ RNA analysis platform for formalin-fixed paraffin-embedded tissues 3.

Results

Among 34 enrolled cases, 15 didn’t show any mRNA TIGIT expression on lymphocytes within the tumor environment and can match to score 0. Ten cases showed very low mRNA TIGIT expression in a sparse non-tumoral lymphocytes within the tumor environment near the HRS cells, these can be associated with score 1. Five cases showed the presence of a discrete number of non-tumoral lymphocytes with moderate mRNA TIGIT positivity around the HRS cells and can match to score 2. Four cases showed evidence of a circle of non-tumoral lymphocytes with intense mRNA TIGIT expression surrounding the HRS cells, these can be associated to the score 3.

Conclusions

Our results confirm that the expression of TIGIT in peritumoral T lymphocytes has a similar rate as the immunohistochemistry evaluation. According to the TIGIT scoring system, we demonstrated the existence of neoplastic induction mechanism.

References

  • 1.Manieri NA, Chiang EY, Grogan JL. TIGIT: A Key Inhibitor of the Cancer Immunity Cycle. Trends Immunol 2017;38:20-28. https://doi.org/10.1016/j.it.2016.10.002. Epub 2016 Oct 25 10.1016/j.it.2016.10.002 [DOI] [PubMed] [Google Scholar]
  • 2.Annibali O, Bianchi A, Grifoni A, Tomarchio V, Tafuri M, Verri M, Avvisati G, Crescenzi A. A novel scoring system for TIGIT expression in classic Hodgkin lymphoma. Sci Rep 2021;11:7059. https://doi.org/10.1038/s41598-021-86655-8 10.1038/s41598-021-86655-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Bingham V, McIlreavey L, Greene C, O’Doherty E, Clarke R, Craig S, Salto-Tellez M, McQuaid S, Lewis C, James J. RNAscope in situ hybridization confirms mRNA integrity in formalin-fixed, paraffin-embedded cancer tissue samples. Oncotarget 2017;8(55):93392-93403. https://doi.org/10.18632/oncotarget.21851 10.18632/oncotarget.21851 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

ANALYSIS OF THE LEUCOCYTE PROFILE OF 1592 HOSPITALIZED COVID-19 PATIENTS: SECOND VS. THIRD WAVE

A De Vito 1, F Del Ben 2, M Comar 2, C Di Loreto 1,2, D Cesselli 1,2

Abstract

Objectives

COVID-19 can present with a wide range of manifestations. Especially in severe, critical cases were described lymphocytopenia and immunoparalysis. Aim of the present study was to analyze 1592 consecutive patients, undergoing leukocyte immunophenotype by FACS upon admission to the University Udine Hospital for COVID-19, and comparisons were made based on the wave of belonging (second or third, being the last one characterized by the so called UK variant), age, outcome and survival time. Finally, an attempt was made to identify possible prognostic factors.

Methods

Laboratory data were collected from 1592 patients hospitalized between 29 September 2020 and June 28, 2021. The following data were collected: absolute number of leukocytes, lymphocytes and monocytes. Absolute and relative number of T, Th, Tc, NK, B, NK-like cells, as well as recent thymic emigrants (RTE), Th-HLA-DR, Tc-HLA-DR, expression of HLA-DR on monocytes. Overall survival was defined as the time from the first typization and the death.

Results

Of the 1592 hospitalized COVID-19 patients, 967 belong to the second wave and 625 to the third. Waves did not differ in gender distribution (63,5% of males), mortality (19%) and median survival time of deceased patients (12 days). Compared to wave 2, wave 3 patients presented: lower median age, greater activation of T lymphocytes, higher absolute and relative number of B lymphocytes and a lower absolute and relative number of NK cells. At the hospital admission, deceased patients presented a higher lymphopenia, a reduced RTE number and monocytes were characterized by reduced expression of HLA-DR. Similar results were seen comparing patients with age ≥ 65 years vs. those < 65 years of age. Univariate and multivariate Cox analyses were used to identify a score predictive of survival.

Conclusions

We identified statistically significant differences in terms of leukocyte parameters by comparing patients based on wave, age, outcome and survival time. These data will be now implemented with other clinical and laboratory data to improve their clinical utility.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

MORPHO-PHENOTYPICAL CHANGES OF HUMAN BONE MARROW ADIPOCYTES IN MARROW METASTASIS AND MYELOFIBROSIS.

M Dello Spedale Venti 1, B Palmisano 1, S Donsante 1,2, A Corsi 1, M Riminucci 1

Abstract

Objectives

Bone marrow adipocytes (BMAds) are involved in the growth of non-hematological and hematological marrow malignancies. Aim of this study was to analyze the morpho-phenotypical changes of BMAds in two different types of marrow tumors.

Materials and methods

Iliac crest bone biopsies were obtained from 8 patients with BM metastasis (MET, age 27-73 years), 8 with chronic myeloid neoplasia with grade-3 myelofibrosis (CMN-MF, age 39-81 years) and 8 age-matched controls (CONTR, age 41-68 years). Paraffin sections were stained with HE or immunostained for perilipin, FABP4, AdipoQ, phosphorylated hormone sensitive lipase (pHSL). Statistical analysis was performed by GraphPAD Prism 8 software.

Results

Compared to CONTR, the number of BMAds/marrow and the mean diameter and area of BMAds were significantly reduced in both MET and CMN-MF. In the same groups, the percentage of AdipoQ- and pHSL-positive BMAds were significantly reduced and increased respectively. No statistically significant difference was found between MET and CMN-MF. Interestingly, in some MET samples, some AdipoQ-positive BMAds showed a large lipid vacuole and multiple, smaller and polarized lipid droplets.

Conclusions

Our data indicate that, in non-hematological and hematological marrow malignancies, a) the reduction in BM Adipose Tissue depends on changes in number and size of BMAds and b) BMAds undergo morphological and phenotypic changes that may contribute to the neoplastic cell growth and tumor progression.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

LYMPHOID INFILTRATE AND P53 ELEMENTS AS PREDICTIVE MARKERS IN MDS TREATED WITH AZACITIDINE

C Pescia 1,2, F Boggio 1, G Croci 1,2, E Sabattini 3, U Gianelli 1,2

Abstract

Objectives

High risk myelodysplastic syndromes (MDS) represent clinical challenges and are managed with hypomethylating agents such as Azacitidine. Our purpose was to identify histological changes induced by therapy or correlations between therapy response and pre or post-treatment features.

Materials and methods

We enrolled 57 high risk MDS treated with Azacitidine. For each patient, clinical and histological data were collected together with peripheral blood and bone marrow aspirate blast count.

Results

Azacitidine treatment had no impact on bone marrow morphological features. However, we observed a slight decrease in CD34+/CD117+ blasts and p53+ cells after treatment. Pre-treatment IPSS-R cytogenetic score, lymphoid infiltrate and p53+ elements correlated with leukemic progression (p < 0.05). Pre-treatment lymphoid infiltrate portended better therapy response (p = 0.004). Post-treatment blast count impacted negatively on overall survival and risk of leukemic progression, while post-treatment lymphoid infiltrate and p53+ elements correlated with treatment response (all p < 0.05). Higher post-treatment p53+ elements correlated with leukemic progression (p = 0.013).

Conclusions

We suggest the possible role of lymphoid infiltrate and p53+ elements as predictive markers in MDS treated with Azacitidine.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

CANCERS OF UNKNOWN PRIMARY (CUPS): PROPOSAL FOR A SMART HISTOLOGY-DRIVEN DIAGNOSTIC ALGORITHM.

E Cascardi 1,2, I Sarotto 1, E Berrino 1,2, A Pisacane 1

Abstract

Objectives

CUPs represent a frustrating event due to undetectable primary lesions (PR).

The need of site-specific or personalized therapies in the absence of specific immunohistochemical (IHC) CUP markers forces the pathologist to utilize wide IHC panels in the attempt to identify the tissue of origin (ToO). Our study proposes a practical tool for CUP understanding and classification.

Materials and methods

A series of 66 bona fide CUPs were classified according to classic morphologic criteria. A panel of 10 IHC markers (CKAE1/AE3, CK7, CK20, PAX8, ER, GATA3, TTF1, CDX2, p40, Synaptophysin), was systematically used to dissect the corresponding ToO.

Results

The algorithm enabled us to unravel the PR in 14/66 cases (6 breast, 3 bilio-pancreatic, 2 lung, 1 stomach, 1 melanoma and 1 thyroid). Out of the remaining 52 true CUPs, 27 were morphologically adenocarcinomas (AC), 18 of which with specific IHC phenotypes (6 bilio-pancreatic, 7 genital, 4 lung and 1 intestine), and 9 undefined. Eleven CUPs were squamous carcinomas (Ca); 5 sarcomatoid Ca, 4 neuroendocrine Ca and 5 were classified as “not otherwise specified (NOS)” Ca.

Conclusions

Our algorithm proved to be effective in detecting PR in 14/66 possible CUPs and in identifying the ToO in 42/52 true CUPs. Of the five histologic types observed, the algorithm confirmed squamous, neuroendocrine and sarcomatoid Ca using no more than 3 antibodies; in addition, in 18 AC an IHCphenotypic line of differentiation could be suggested. Only 5 CUPs could not be further refined beside the definition of NOS Ca probably due to their low level of differentiation.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

E-CADHERIN EXPRESSION ON PLASMACYTOID DENDRITIC CELLS

C Metelli 1, L Lorenzi 1, M Bugatti 1, L Cerroni 2, F Facchetti 1

Abstract

Objectives

E-cadherin (EC) expression on circulating plasmacytoid dendritic cells (PDCs) was described by Cella et al. (PMID:10426316). This study aims to evaluate EC expression on PDCs in normal tissues (lymph nodes, LN; tonsils, TN; bone marrow, BM), in Castleman Disease (CD), Kikuchi-Fujimoto Lymphadenitis (KFL) and Cutaneous Lupus Erythematosus (CLE), as well as in neoplastic samples including PDC nodules associated with Chronic Myelo-monocytic Leukemia (CMML), Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN) and Leukemia cutis (LC).

Materials and methods

Double immunohistochemistry E2.2+EC or BDCA2+EC was performed on a total of 109 samples: 6 normal BM, 5 reactive LN, 5 TN, 5 KFL, 5 CD, 31 CLE, 49 BPDCN (33 skin, 13 BM, 2 LN, 1 spleen), 3 BM with CMML and 30 LC.

The fraction of EC positive PDCs was calculated on 5 HPF, counted manually, on digitalized slides.

Results

The vast majority of PDCs in reactive LN and TN (89%,84%) expressed EC, as well as in KFL and CD (91%,91%). In contrast, EC was negative in PDC in normal BM and in CMML aggregates. Notably, in CLE, PDCs at the dermal-epidermal junction were invariably negative for EC (0%). The majority of BPDCN was positive, particularly in cutaneous localizations (skin: 31/33, 94%; BM 5/13, 38%;LN and spleen 3/3, 100%). Notably EC was negative in all LC samples.

Conclusions

Heterogeneity of EC expression in PDC might be related to different subsets of these cells. EC support the diagnosis of BPDCN in the differential with LC. Furthermore, the study indicate that PDCs may modulate EC expression depending on the residing tissue and on IFN-I production(PMID:34081040). In vitro studies are warrant to confirm this hypothesis.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

IS WT1 JUST A MARKER OF ADNEXAL ORIGIN NEOPLASMS? A SYSTEMATIC REVIEW AND META-ANALYSIS

Q Zhang 1,*, D Arciuolo 1,*, N D’Alessandris 1, G F Zannoni 1, F Policardo 1

Abstract

Objective

Wilm’s tumor 1 (WT1) is considered a specific marker for serous histotype and adnexal origin neoplasms. Recently, it’s oncogenic role has been hypothesized in many cancers, consequently it is been considered a promising targetable antigen for immunoterapy. However we noticed that WT1 could be expressed differently among different uterine histotypes carcinoma. The goal of the corrent meta-analysis is to investigate the diagnostic and prognostic role of WT1 expression in patiens with uterine carcinoma.

Materials and methods

We performed a literature search using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the PICOS (Participants, Intervention, Comparison, Outcomes, Study Design) model through PubMed, Scopus and Web of Science databases to identify English-language studies published from January 2000 to April 2020, wich evaluated the WT1 expression in uterine carcinoma.

Results

The 35 articles that match our criteria provided data about 1616 patients. The overal rate of WT1 expression in uterine carcinoma was 25% and different histotypes (endometrioid, clear cell, serous carcinoma and carcinosarcoma) expressed variably WT1.

Conclusions

Our research revealed that a significant proportion of endometrial hystotype adenocarcinomas could express WT1. Therefore WT1 is not a prerogative of serous histotype and adnexal origin neoplasms. Our analysis also suggest a potential prognostic value of WT1 in patient with uterine cancer, but more studies are needed to confirm this role.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

HORMONAL ENVIRONMENT IN EXTRA-MAMMARY PAGET’S DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Q Zhang 1,*, F Inzani 1,*, D Arciuolo 1, A Travaglino 1, F Policardo 1

Abstract

Objectives

Extra-mammary Paget’s disease (EMPD) is a rare cutaneous carcinoma that typically affect genital skin. A hight percentage of EMPD are adenocarcinoma in situ, confined in epidermis, but rare cases of dermal invasion are seen and correlated with lymph node and distant metastasis. We had evaluated, in both female and male patients, the immunohistochemically expression of many factors, in order to identify markers with potential prognostic/therapeutic role.

Materials and methods

A systematic review and meta-analysis was performed trough a literature search of the PubMed, Scopus, and Web of Science databases for English-language studies published from January 2000 to June 2020. All selected studies assessed the role of human epidermal growth factor receptor 2 (HER2/neu), Estrogen Receptor (ER), Progesterone Receptor (PR), and Androgen Receptor (AR) in vulvar (VPD) and extra-mammary Paget›s disease (EMPD). 27 studies matched all our criteria and provided data about 713 patients.

Results

The overall rate of HER2/neu expression was 30%, ER was 13%, AR was 40% and PR was 8% with p < 0.05. The analyses indicated that the expression of HER2/neu in female and male patients was 32% and 26%; of ER was 12% in female and 9% in male; of AR was 40% in female and 40% in male; of PR was 9% in female and only one study involved five male patients and the rate observed was 2%.

Conclusions

The current meta-analysis demonstrates that AR status and HER2/neu overexpression/amplification have been shown as two fundamental pathogenic pathways in both female and male patients affected by EMPD.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

MICROSATELLITE INSTABILITY AND ALTERATIONS OF THE PROTEINS OF THE MISMATCH REPAIR DNA SYSTEMS IN NEWLY DIAGNOSED GLIOBLASTOMA

F Antoniazzi 1, E Pegolo 1, M Bulfoni 2, C Di Loreto 1,2, D Cesselli 1,2

Abstract

Objectives

The literature regarding the state of the MMR system and instability of microsatellites (MSI) in primitive glioblastomas (GBMs) is not yet fully elucidated. However, in many cancers MSI and deficiency of the MMR system (dMMR) represent prognostic and predictive factors. The present study aims at evaluating: 1. frequency of dMMR and MSI in newly diagnosed GBM; 2. correlation between dMMR and MSI; 3. Of MSI and dMMR correlation with the anatomo-pathological characteristics of GBM; 4. prognostic role of dMMR and MSI.

Materials and methods

MMR status was evaluated in 106 FFPE samples by evaluating MLH1, PMS2, MSH2 and MSH6 (Ventana). DNA was extracted from FFPE section of 40 GBM and corresponding healthy tissues. MSI was evaluated with the kit AlphaCapillary MSI (Alphagenics Biotech) analyzing 13 microsatellite sequences.

Results

dMMR were identified in 8 out of 106 GBM, being MLH1 and PMS2 the most interested proteins. dMMR differed from pMMR only for the patient age and it was not endowed with a prognostic value. Elettropherograms obtained from MSI testing showed that many GBM were characterized not by instability but by allelic loss. 44% of GBM were MSS, 40% MSI-L and 16% MSI-H. The association between MMR status and MSI was moderate. MSS and MSI gliomas significantly differ in terms of age, dMMR status, and presence of previous cancer in another site, being MSS gliomas characterized by younger age, pMMR status, absence of previous cancer. Not a clear prognostic role of MSI was demonstrated.

Conclusions

Only a small fraction of newly diagnosed GBM are dMMR or are MSI-H. Although dMMR and MSI-H seems not to have a prognostic role, they define cancers with different clinicopathological features.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

ELESCLOMOL IMPAIRS GLIOBLASTOMA STEM-LIKE CELLS SURVIVAL

V Fiorentino 1, L Ricci Vitiani 2, G Fadda 3, M Martini 1

Abstract

Objectives

Glioblastoma (GBM) is the most aggressive primary malignant brain tumor in adults 1. Glioblastoma stem-like cells (GSCs) contribute to neoplastic neovascularization processes through different mechanisms including the transdifferentiation into GSC-derived endothelial cells (GdECs) 2.

We therefore aimed to identify compounds counteracting the survival pathways of both GSCs and GdECs.

Materials and methods

We assessed the effect of 349 compounds on both GSCs and GdECs and we selected elesclomol as the most effective in inducing cell death.

Results

Our in vitro data revealed that combining elesclomol with temozolomide (TMZ) enhances the cytotoxicity compared to TMZ alone. Elesclomol, in fact, induces reactive oxygen species in cancer cells, leading to a non-apoptotic cell death. Our in vivo model confirmed these results.

Conclusions

Targeting oxidative stress could represent a valuable strategy for novel therapies in GBM.

References

  • 1.Cloughesy TF, Cavenee WK, Mischel PS. Glioblastoma: from molecular pathology to targeted treatment. Annu Rev Pathol 2014;9:1-25. https://doi.org/10.1146/annurev-pathol-011110-130324 10.1146/annurev-pathol-011110-130324 [DOI] [PubMed] [Google Scholar]
  • 2.Ricci-Vitiani L, Pallini R, Biffoni M, et al. Tumour vascularization via endothelial differentiation of glioblastoma stem-like cells. Nature 2010;468(7325):824-8. https://doi.org/10.1038/nature09557 10.1038/nature09557 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THE ANCIENT TERATOLOGICAL COLLECTION OF THE ANATOMICAL PATHOLOGY MUSEUM OF PALERMO

L Ferrari 1, E Formisano 2, AG Giannone 2, E Maresi 2, AM Florena 2

Abstract

Introduction

The Pathology Museum of Palermo has a great relevance for the high number of specimens and their typology.

The Museum was founded by G.Gorgone, reaching 1300 specimens in 1872. Finally in 1937 the collection was moved to the new University Polyclinic in a wide suitable museum where the collection currently is.

Materials and methods

Specimens nowadays are about 400, especially of fetal-perinatal pathology, cases of myocarditis, about 100 bladder stones of ruminants, a case of two-headed lamb and a human acromegalic.

The wet specimens are in original glass jars often with original labels. Some teratologic cases were selected for the study; a case of cyclopia and cases of conjoined twins, which today are no observable.

The possibility to study these ancient specimens by conservative approach with safe sampling methods as well as with radiological techniques, especially for delicate cases difficult to manipulate, allows to improve the knowledge about these malformations.

Moreover, we plan a photogrammetry acquisition of the specimens with digitalization of the obtained images for a 3D reconstruction, with the further possibility of 3D printing for learning purposes.

Results

A cognitive survey of the consistency of the materials and a real census of the specimens are necessary to understand the composition and specificity of the collection and for the creation of a museum itinerary.

Conclusions

Specimens of particular interest could continue to be collected, forming a sort of biological archive with an accessible database to establish a network between anatomical museums.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

INTRA-DUCTAL FAT INFILTRATE AS BREAST CANCER PROGNOSTIC BIOMARKER

R Bonfiglio 1, A Palumbo 1, G Solidani 1, M Scimeca 1, E Bonanno 1

Abstract

Objectives

Recent studies showed a correlation between body mass index and both breast cancer occurrence and progression 1,2. Nevertheless, no study reported an accurate evaluation of intra-ductal fat infiltrate. Therefore, the main aim of this study was to evaluate the putative association between intra-ductal fat infiltrate (IDFi) and breast cancer subtypes by using digital pathology.

Materials and methods

We retrospectively collected 220 breast biopsies. Paraffin serial sections were used for haematoxylin and eosin staining and immunohistochemical evaluation of the following markers: estrogen receptor (ER), progesterone receptor (PR), Ki67 and c-erb2. Three haematoxylin and eosin sections for each paraffin block were digitalized. Digital slides were used to evaluate the areas of IDFi. Five randomized areas were evaluated for each slide. IDFi areas were analyzed by using GraphPad software and correlated with a) breast cancer histotype, b) presence of microcalcifications and c) biomarkers expression.

Results

Breast biopsies were classified as follow: 20 normal breast tissues, 50 benign lesions and 150 malignant lesions (85 ductal in situ carcinomas; 65 ductal infiltrating carcinomas). Statistical analysis showed a significant increase of IDFi in malignant lesions as compared to both normal breast and benign lesions. We noted higher IDFi in breast ductal carcinomas as compared to lobular lesions. Significant differences were observed between breast lesions with microcalcifications respect to lesions without calcifications. Noteworthy, we also found a positive association between IDFi and the expression of both ER and Ki67.

Conclusions

Results of our study highlighted the possible role of adipose tissue in breast cancer progression suggesting a negative prognostic value of IDFi.

References

  • 1.Liu YS, Wu PE, Chou WC, et al. Body mass index and type 2 diabetes and breast cancer survival: a Mendelian randomization study. Am J Cancer Res 2021;11:3921-3934. [PMC free article] [PubMed] [Google Scholar]
  • 2.McCarthy AM, Friebel-Klingner T, Ehsan S, et al. Relationship of established risk factors with breast cancer subtypes. Cancer Med 2021;10:6456-6467. https://doi.org/10.1002/cam4.4158 10.1002/cam4.4158 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

IS IT POSSIBLE TO INCREASE THE REPRODUCIBILITY OF KI67 IN BREAST CANCER?

L Costarelli 1, D Campagna 1, M Amato 1, M Lombardi 1, G Coppola 1

Abstract

Objectives

Ki67 is a prognostic factor in Breast Cancer (BC) and a predictor of response to therapies 1. Intermediate values have been suggested to represent an indication for further genetic analysis. However, a moderate/low reproducibility has been reported (CI 95% = 0.47-0.78) 2. Aim of this study is to compare the Ki67 as assessed by three expert pathologists, through manual count on digital images and automatic evaluation on digital specimens.

Material and methods

Ki67 was evaluated, according to Nielsen et al. 3, by three pathologists of the same group experienced in Breast Pathology (CL, CD and AM) on 100 consecutive cases of BC. Five high magnification images from each case were evaluated through manual computer counting. Then, the digital slides were automatically evaluated (Nikon Hamamatsu©, Visiopharm Ki67 App©). Ki67 ≤15%, 15-35% and > 35% were considered low, intermediate and high, respectively.

Results

The agreement between the three pathologists was 77%, with the same median value and no differences between the means (p < 0.01). The agreement between microscopic evaluation and manual count on the digital images and the automatic evaluation on digital specimens was 80% and 90% respectively, with no differences between the means (p < 0,05).

Conclusions

The agreement for Ki67 among pathologists of the same group is high. The evaluation should involve at least two pathologists. In case of discrepancy, either evaluation by a third pathologist or manual computer counting on high magnification images or automatic counting on digital slides is useful.

References

  • 1.Yerushalmi R, Woods R, Ravdin PM, et al. Ki67 in breast cancer: prognostic and predictive potential. Lancet Oncol 2010;11:174-183. https://doi.org/10.1016/S1470-2045(09)70262-1 10.1016/S1470-2045(09)70262-1 [DOI] [PubMed] [Google Scholar]
  • 2.Polley MY, Leung SC, McShane LM, et al. International Ki67 in Breast Cancer Working Group of the Breast International Group and North American Breast Cancer Group . An international Ki67 reproducibility study. J Natl Cancer Inst 2013;105:1897-1906. https://doi.org/10.1093/jnci/djt306 10.1093/jnci/djt306 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Nielsen TO, Leung SCY, Rimm DL, et al. Assessment of Ki67 in Breast Cancer: Updated Recommendations From the International Ki67 in Breast Cancer Working Group. J Natl Cancer Inst 2021;113:808-819. https://doi.org/10.1093/jnci/djaa201 10.1093/jnci/djaa201 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

DERMATOFIBROSARCOMA PROTUBERANS OF THE BREAST: A CASE REPORT AND REVIEW OF THE LITERATURE

A D’Amuri 1, M Pellegrino 1, L Fiorentino 1, M Capodieci 2, S Burlizzi 3

Abstract

Objectives

Dermatofibrosarcoma protuberans (DFSP) was first described by Darier and Ferrand in 1924. It is a rare, locally aggressive but rarely metastasizing tumor of the deep dermis and subcutaneous tissue. It may occur at almost any site but is more common in the trunk and extremities. DFSP of the breast has been rarely reported.

Material and methods

A 55-year-old woman without a significant medical history presented with a left breast mass that had been present for more than 2 years. Recently, progressive enlargement of the mass was noted. Physical examination showed a firm, well-defined, non-tender, mobile, erythematous 10 x 6 cm multinodular mass in all quadrants of the left breast. Ultrasound, mammography and breast MRI showed a well-circumscribed, round to oval homogeneous mass, with multilobulated borders with uneven anterior contours located in the dermal layer, highly suggestive of a dermal and parenchymal lesion. Core-biopsy first and subsequently mastectomy was performed. Histological examination showed a hypercellular tumor with infiltrative growth pattern, centered in the breast parenchyma. It was composed of spindle-shaped cells arranged in a prominent storiform growth pattern. Mild nuclear atypia and a low mitotic index (3 mitoses/10 HPF) were observed. Necrosis and atypical mitoses were absent. The neoplastic cells entrapped mammary ducts/lobules and infiltrated the mammary fat with focal honeycomb pattern. A wide panel of antibodies for immunohistochemistry were tested, including vimentin, cytokeratins, desmin, alpha-smooth muscle actin, ALK1, CD34, EMA, S-100 protein, Ki67, calponin, p63 and Bcl-2. Immunohistochemical analyses showed diffuse staining only with vimentin and CD34. Tumor was negative for all the other antibodies tested. The final histological diagnosis was DFSP. After this diagnosis, the patient underwent immediate reconstruction using breast implant. Postoperative outcome was regular and without pain. The patient is well with no local recurrence at 1-years of follow-up.

Results

DFSP is a rare, locally aggressive tumor arising from the skin. It has an indolent growth and a strong tendency towards local recurrence after excision. DFSP is usually characterized by painless, atrophic plaques and occasionally presents as red plaques with irregular borders, mimicking hemangioma. It is not easy to make a correct diagnosis merely by examination of the lesion and the tumor may be confused with localized scleroderma or congenital solitary fibromatosis. The reported case presented as a breast mass and sonography showed a mass that was highly suggestive of a dermal lesion. We thus believe sonography to be an important tool for the differentiation of a dermal lesion like DFSP from a primary breast lesion. The standard treatment of DFSP is wide excision. The recurrence rate after local excision has been claimed to decrease as the excision margin increases. Arnaud et al. suggested that the surgical margin should not be less than 3.5-5 cm for a minimal recurrence rate. The use of Mohs micrographic surgery has been advocated by some authors to minimize the amount of tissue resected, especially in more visible areas. Adjuvant radiation therapy has been recommended after a planned marginal excision in critical anatomic sites or as the sole treatment in advanced cases where surgery is no longer feasible. A number of neoplasms should be taken into account in the differential diagnosis of DFSP. These include fibromatosis-like metaplastic carcinoma, fibromatosis, inflammatory myofibroblastic tumor, phyllodes tumor and periductal stromal hyperplasia or tumor. The present tumor was negative for a broad panel of cytokeratin antibodies as shown by immunohistochemistry, excluding the possibility of a fibromatosis-like metaplastic carcinoma. Its typical storiform pattern and CD34 immunoreactivity were also against the diagnosis of a fibromatosis. The histology of the tumor did not support an inflammatory myofibroblastic tumor because of the lack of a conspicuous inflammatory infiltrate and the negative smooth muscle markers and ALK1 immunoreactivity. Both phyllodes tumor and periductal stromal hyperplasia/tumor are spindle cell neoplasm but they show a biphasic pattern composed of spindle cells around tubular or ductal structures that was not present in the present tumor.

Conclusions

The present case confirms that DFSP can arise primarily in the breast parenchyma, posing differential diagnostic problems with other benign and malignant bland-looking spindle cells lesions of the breast. As radiological features of DFSP of the breast are not specific, histological examination and diffuse staining for CD34 remain the diagnostic gold standard for a correct diagnosis. In summary, breast DFSP is very rare, its characteristic location in the subcutaneous mesenchymal tissue, and imaging findings may suggest the diagnosis, while the final diagnosis should be made based on pathological examination. Comprehensive imaging, especially CT and MRI can help delineate the tumor location, size, shape, margins, internal structure, skin infiltration and associations of the surrounding tissue, for preoperative assessment as well as for evaluation of post-operative recurrence.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

METASTATIC TUMORS TO THE BREAST. REPORT OF FOUR CASES

A D’Amuri 1, A Scivetti 1, F Floccari 2, L Fiorentino 1, M Capodieci 3

Abstract

Objectives

We report our experience on metastatic tumors to the breast emphasizing their incidence, clinical, pathologic and immunohistochemical features as documented in the last 2 years (2019-2021). When evaluating metastatic lesions, clinical history, radiologic findings and review of prior slides are most important and more helpful than any special studies in distinguishing breast from on-breast tumor. However, the clinical history may not be revealing, and the prior slides may not always be available for review. In such situations, selected use of immunohistochemistry (IHC) markers may provide an invaluable diagnostic adjunct in elucidating the primary site. The aim of our study is to describe few unusual sites of metastatic to the breast and provide an insight to IHC markers that aid in the identification of the primary tumor.

Material and methods

Cases search was conducted through the archives of the electronic files of the Pathology Unit between 2019-2021, retrieving the cases of metastatic tumors to the breast and the incidence thereof. We identified 4 patients who underwent breast core needle biopsies for suspicious of primary mammary tumors. All the patients were women.

Results

Case 1. The patient was 68 years old and had history of adenocarcinoma carcinoma of lung. In July 2019, a bronchial biopsy was deemed consistent with NSCLC of the lung. In October of the same year, the left lower lobe was resected showing evidence of adenocarcinoma of the lung, pT1N1Mx. In January 2021 a nodule was discovered in the superior sector of the left breast: the mammary tumor measured 7 mm. A core needle biopsy was performed and routine and immunohistochemical (TTF-1 and CK7 positivity; GATA-3, ER, PR, mammaglobin and GCDFP-15 negativity) examination of the breast tumor were deemed consistent with a metastatic adenocarcinoma from primary in lung. Case 2-3. The first patient was 49 years old and had history of melanoma of back and a core needle biopsy of right inferior extern quadrant of breast was done. The second patient was 32 years old and had history of melanoma of the arm and a core needle biopsy of left extern quadrant of breast was done. The breast tumor in both cases showed a metastatic melanoma. Tumor cells were negative for broad spectrum keratins, estrogen receptors, progesterone receptors, GATA-3, mammaglobin, GCDFP-15 and positive for S100 protein, HMB45 and Melan A. Molecular BRAF mutations was performed and follow-up until now is negative for tumor recurrence or metastatic disease. Case 4. The patient was 73 years old and had history of renal cell carcinoma. In 2015 radical left nephrectomy had been performed for renal cell carcinoma (clear cell), stage III. In November 2020, a biopsy of a 1 cm nodule of left superior internal quadrant of breast revealed a metastatic carcinoma consistent with renal primary. At the immunohistochemistry findings the tumor cells were positivity for PAX-8, CD10, vimentin antibodies and negativity for GATA-3, ER, PR, mammaglobin and GCDFP-15 antibodies. The patient is currently alive, symptom free with evidence of minimal metastatic tumor.

Conclusions

In our series the incidence of metastatic tumors to the breast is comparable to published data, with 4/1500 cases (0.26% vs 0.2-1.3% of literature). The spectrum of tumors capable to metastasize to the mammary gland is likewise consistent with available reports addressing the subject, namely melanoma, renal cell carcinoma, neuroendocrine carcinoma, lung carcinoma and ovarian carcinoma. We have documented only cases of metastases to the female breast. Published cases of metastases to male breast, although available, are very rare. In one of our 4 cases, the breast metastasis was the first clinical evidence of the neoplastic disease, whereas in case 3 the melanoma was initially neglected. The interval between the diagnosis of the primary tumor and the breast metastasis varies although it can be as long as 5 years (case of renal cell carcinoma) or 2 years (case of lung adenocarcinoma). Metastases to the breast from an extramammary neoplasm usually indicates a disseminated metastatic disease and a poor prognosis, localized metastatic disease may be encountered yet. In addition to evaluation of the proper clinical context, metastatic tumor to the breast may be suspected in cases of preponderant lymphatic breast infiltration, along to appropriate immunohistochemical evaluation especially of apparently “triple negative” breast carcinoma.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

BREAST GRANULAR CELL TUMOR: DESCRIPTION OF A CASE

LR Grillo 1, A Tornese 1, L Stortoni 2, MT Ramieri 1

Abstract

Objectives

The aim of the study is to describe a case of rare breast tumor often mimicking clinically an epithelial malignancy.

Materials and methods

A 45-years old woman came to our observation for right breast nodule suspected of cancer; there was no family history of breast cancer. Mammography showed a spiculated mass at the lower outer quadrant of right breast. Ultrasound demonstrated an 8 mm irregularly delineated hypoechoic lesion (BIRADS 5). No pathological axillary lymph nodes were found. An ultrasound- guided core biopsy was performed.

Results

Histological examination revealed a mesenchymal benign epithelioid neoplasia consisting of aggregates of cells with large, foamy cytoplasm, arranged in nests and cords. Immunohistochemistry was positive for S100 and CD68 and negative for cytokeratin. A diagnosis of Granular cell tumor (GCT) was made. The tumor was fully excised and final pathology did not exhibit any malignant features according to Fanburg-Smith and Nasser histological criteria 1.

Conclusion

In our case, a complete excision and histopathological examination allowed the correct diagnosis of GCT; the clinical behavior of these lesions, however, is still unpredictable only the finding of a metastasis providing an unequivocal sign of malignancy 2.

References

  • 1.Machado I, Cruz J, Lavernia J, et al. Solitary, multiple, benign, atypical, or malignant: the “Granular Cell Tumor” puzzle. Virchows Arch 2016;468:527-38. https://doi.org/10.1007/s00428-015-1877-6 10.1007/s00428-015-1877-6 [DOI] [PubMed] [Google Scholar]
  • 2.Corso G, Di Nubila B, Ciccia A, et al. Granular cell tumor of the breast: Molecular pathology and clinical management. Breast J 2018;24:778-782. https://doi.org/10.1111/tbj.13036.29 10.1111/tbj.13036.29 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

BENIGN SQUAMOUS EPITHELIAL INCLUSIONS IN AXILLARY LYMPH NODES. REPORT OF TWO CASES

E Lemmi 1, G Di Stefano 1, V Vezzosi 1, S Bianchi 1, R Santi 1

Abstract

Objectives

Benign squamous epithelial inclusions in lymph nodes are rare and may constitute a diagnostic challenge. In this paper, we aimed to report our experience and contribute two further cases to the existing literature.

Materials and methods

The first case concerned a 67-year-old female who underwent left axillary lymph node core biopsy on suspicion of malignancy at ultrasonography (U4). The second case regarded a 52-year-old woman subjected to left mastectomy for invasive breast carcinoma and intra-operative sentinel lymph node biopsy.

Results

In both cases, in the interfollicular areas, histology showed millimetric cystic lesions lined by a multilayered cubic epithelium with no myoepithelial cell layer. Desmoplastic reaction was not documented. Absence of cytological atypia or mitoses in the epithelial lining, parenchymal location, and presence of keratin debris in the cystic cavity supported the benign nature of the epithelial inclusions.

Conclusions

Immunohistochemistry plays a marginal role in evaluating these lesions, since it can only confirm squamous differentiation but not rule out malignancy. Morphological criteria enable confident diagnosis of benign squamous epithelial inclusions also in core biopsies.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

TNBCS: INTERACTIONS WITH TIL AND EVALUATION OF IL1B, PML AND TUMOR ASSOCIATED MACROPHAGES

M Pedriali 1, A Scialdone 2, C Giorgi 2, B Vezzani 2, P Querzoli 3

Abstract

Objectives

Cancers microenvironment is a complex entity with possible pro and anti neoplastic factors. In this study we better define its possible role as prognostic and predictivity factor in triple negative breast cancers (TNBCs).

Materials and methods

105 TNBCs were studied to evaluate the role of TILs. In 50 TNBCs we evaluate CD68+ elements and correlate them with OS/DFS. We perform a preliminary analysis in a sub-cohort of 20 patients (10 poor and10 good prognosis) of the expression of IL1b, PML NBs CD68.

Results

High TIL correlates with lower pT, pN0, long DFS, higher OS; a high CD8 +TIL expression correlates with a highTIL value, pN0, higher DFS and OS, reduced expression of IL1beta and CD68. Reduced IL1be associates with elevated CD8 + TIL, increased OS and DFS; low CD68 correlates with elevated CD68 +TIL and increased DFS. PML does not correlate with the markers evaluated

Conclusions

The role of the tumor microenvironment and inflammatory component, capable of promoting immune-escape or, on the contrary, cytotoxic processes is increasingly evident and seems to have an important role as prognostic and predictive factor.

IL1beta is an important pro-inflammatory, pro-tumorigenic and pro-metastatic cytokine. To better understand TAM is necessary to characterize macrophages polarization, evaluate the correlation between subpopulations of CD68 elements (M1 and M2) and prognosis. PML NBs involved in the regulation of gene expression and DNA repair could be a potential prognostic markers and therapeutic targets.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

BREAST METASTASIS FROM RENAL CELL CARCINOMA: REPORT OF 2 CASES

E Piombino 1, L Memeo 1, F Motta 2, A Rizzo 2

Abstract

Objectives

The breast is a rare site of metastasis. We report two cases of breast metastases from renal cell carcinoma, one of which had no history of renal malignancy.

Materials and methods

Case 1: a 56-year-old woman with a history of right NST infiltrating breast cancer 4 years before and clear cell carcinoma of the left kidney 10 years before, was admitted to our institution to perform mammography that revealed a nodule located in the upper-external quadrant of the right breast.

Case 2: of a 78-year-old woman was admitted to our institution to perform a routine mammography that showed a nodule between the upper quadrants of the right breast and a nodule with expansive margins in the upper outer quadrant of the left breast.

Results

Case 1 Histological examination showed a clear cell neoplastic proliferation. Immunohistochemical investigations revealed immunoreactivity for PAX8, CD10 and RCC. The diagnosis of breast metastasis of clear cell renal cell carcinoma was rendered.

Case 2 Histological examination revealed NST infiltrating carcinoma in the right breast with metastasis to the axillary lymph node. The needle biopsy of the left breast nodule showed a clear cell neoplastic proliferation that showed immunoreactivity for CD10, RCC, and PAX8. The diagnosis of breast metastasis of clear cell renal cell carcinoma was rendered.

Conclusions

Our cases emphasize that histology remains essential for a correct diagnosis. The hypothesis of renal cell carcinoma metastases must be considered in cases with suggestive morphology even in the absence of a positive history of renal neoplasm.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

BREAST CARCINOMA SENTINEL LYMPH NODES UNVEILING HEMATOLOGICAL MALIGNANCIES

MT Ramieri 1, A Di Napoli 2, LR Grillo 1

Abstract

Objectives

The aim of the study is to describe the unusual findings in axillary lymph nodes draining a breast carcinoma.

Materials and methods

A 75-years old woman with a history of right invasive breast carcinoma underwent a left mastectomy and axillary sentinel lymph node plus additional lymph nodes excision for multifocal tumor.

Results

Both the sentinel and non-sentinel lymph nodes were free from metastasis and were partially involved by CD20+, CD5+, CD23+ chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). In the axillary lymph nodes occasional germinal centers showed necrotic foci. Stainings for Ziehl Neelsen, HVS1, HVS2, HHV8 were all negative, whereas in situ hybridization (ISH) for Epstein-Barr Virus (EBV) showed nuclear positivity in CD20+, CD30+ proliferating large cells associated with the necrotic foci, suggestive for EBV re-activation in reservoir B cells.

Conclusions

Superimposed viral infection in lymph nodes involved by CLL is an infrequent complication mainly associated with Herpes Simplex. Increased serum EBV DNA copies has been associated with severe CLL and secondary immunodeficiency; however, only rare EBER-positive cells have been detected in affected tissues 1. Careful examination of sentinel and axillary lymph nodes draining breast carcinoma could disclose lymphoid diseases and their unexpected complications.

References

  • 1.Salem A, Loghavi S, Khoury JD, et al. Herpes simplex infection simulating Richter transformation: a series of four cases and review of the literature. Histopathology 2017;70:821-831. https://doi.org/10.1111/his.13137 10.1111/his.13137 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THE PROGNOSTIC SIGNIFICANCE OF LYMPHOVASCULAR INVASION IN INVASIVE BREAST CANCER

SM Rossi 1, G Gullotta 1, D Righi 1, G Sabarese 1, G Perrone 1

Abstract

Objective

The aim of this study was to assess a possible correlation between lymphovascular invasion (LVI) in breast cancer and intrinsic molecular subtype according PAM50/PROSIGNA in terms of histological features and disease relapse risk (ROR score).

Materials and methods

The study retrospectively included 82 patients with ER + Her2- breast cancer with negative or positive lymph nodes (1 to 3) treated in our institution. LVI was evaluated using ASCO-CAP 2020 criteria and Rosen P instructions1. Correlation between LVI status, clinical-pathological variables and ROR score are obtained using Anova test, whereas Fisher’s exact test was used for comparison between LVI and intrinsic molecular subtype.

Results

A significant correlation between the LVI subgroups (absent, present) and the ROR score was found (p = 0,07): LVI is frequently demonstrated in tumor with higher ROR score value. Instead, no correlation was found between LVI subgroups and tumor size, age, Ki67, ER/PR, in line with previous studies2.

Conclusion

The correlation between high-risk values according PROSIGNA and LVI positivity indicates that genetic signature plays a role in lymphovascular invasion development. Future analyses are necessary to determine tumor genes involved in LVI to suggest new diagnostic and/or therapeutic target.

References

  • 1.Rosen PP. Tumor emboli in intramammary lymphatics in breast carcinoma: pathologic criteria for diagnosis and clinical significance. Pathol Annu. 1983;18 Pt 2:215-32. [PubMed] [Google Scholar]
  • 2.Elkablawy MA, Albasri AM, Mohammed RA, et al. Ki67 expression in breast cancer. Correlation with prognostic markers and clinicopathological parameters in Saudi patients. Saudi Med J 2016;37:137-41. https://doi.org/10.15537/smj.2016.2.12285 10.15537/smj.2016.2.12285 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

DOWNSTREAM SIGNALING OF INFLAMMASOME PATHWAY IN MOLECULAR BREAST CANCER SUBTYPES

C Saponaro 1, A Fanizzi 2, P Mondelli 1, R Massafra 2, L Schirosi 1

Abstract

Objectives

We examined the possible interaction between inflammasome proteins (NLRP3 and PYCARD) and two of major oncogenic protein CyclinD1 and Myc, which are involved in the cancer onset and progression, and their potential impact on patients’clinical outcome in the principal molecular breast cancer (BC) subtypes.

Methods

We evaluated 240 primary BC samples by immunohistochemistry (IHC). Statistical evaluations were performed with the Prism version 5.00 software package, with the statistical significance set at p < 0.05.

Results

A positive correlation between NLRP3 and PYCARD versus Cyclin-D1 expression (rs = 0.36 p < 0.0001, rs = 0.28 p < 0.0001, respectively) was found. NLRP3 and PYCARD were more expressed in the Luminal A and B- subtypes respect to TNBCs (p = 0.01 and p = 0.0015). No statistical differences were reported for Cyclin-D1 expression in the different subtypes. While, Myc was more expressed in the Luminal B- group. Univariate analyses showed that patients with lower NLRP3 and PYCARD expression had better 5-year progression free survival (PFS) compared to patients with higher expression (p = 0.05 and p = 0.017, respectively). High Myc expression was associated to a worst overall survival (OS), (p = 0.041). Not impact was found on patients’ PFS and OS, when NLRP3 or PYCARD were considered combined with Cyclin-D1 or Myc expression.

Conclusions

Our study proved a positive correlation between NLRP3 and PYCARD and Cyclin-D1 expression, which however does not impact on the survival of patients, where other pathways certainly are involved. Further, NLRP3 and PYCARD expression seems involved in luminal subtypes development, assuming a potential role as clinical markers.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

ROLE OF BMP-2 ISOFORMS IN THE FORMATION OF BREAST MICROCALCIFICATIONS

M Scimeca 1, MP Scioli 1, G Solidani 1, R Bonfiglio 1, E Bonanno 1

Abstract

Objectives

This study aims to investigate the possible different roles of the BMP-2 variants in both epithelial to mesenchymal transition and in microcalcifications origin in human breast cancers.

Materials and methods

The in situ expression of cytoplasmic and nuclear BMP-2 was associated with the expression of the main epithelial to mesenchymal transition biomarkers (e-cadherin and vimentin) and molecules involved in bone metabolisms (RUNX2, RANKL, SDF-1) by immunohistochemistry. In addition, the expression of cytoplasmic and nuclear BMP-2 was associated with the presence of microcalcifications.

Results

Our data showed a significant association among the number of cytoplasmic BMP-2-positive cells and the number of both vimentin (positive association) and e-cadherin (negative association) positive breast cells. Conversely, no associations were found concerning the nuclear BMP-2-positive breast cells. Surprisingly, the opposite result was obtained by analyzing the variants of BMP-2 and both the expression of RANKL and SDF-1 and the presence of microcalcifications. Specifically, the presence of microcalcifications was related to the expression of nuclear BMP-2 variant rather than the cytoplasmic one, as well as a strong association between the number of nuclear BMP-2 and the expression of the main bone biomarkers.

Conclusions

Data here reported confirmed the association between the nBMP-2 expression and both RANKL and SDF-1. The data supports the idea that whilst cytoplasmic BMP-2 can be involved in epithelial to mesenchymal transition phenomenon, the nuclear variant is related to the essential mechanisms for the formation of breast microcalcifications. In conclusion, from these experimental and translational perspectives, the complexity of BMP-2 signaling will require a detailed understanding of the involvement of specific BMP-2 variants in breast cancers.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

UNDIFFERENTIATED RHABDOID CARCINOMA IN THE JEJUNUM: PRIMARY OR SECONDARY? THAT IS THE QUESTION!

L Carlin 1, L Valle 1, F Grillo 1-2,1-2, L Mastracci 1-2,1-2

Abstract

Objectives

Small bowel tumors are uncommon in surgical pathology practice. When facing a poorly differentiated neoplasm, the assessment of primary versus metastatic disease may pose a challenge even to expert pathologists.

Materials and methods

A 54-year old female patient, with subocclusive crises and anemia, was resected for a jejunal PET positive mass. She had a known history of immunotherapy treated stage IV PD-L1 positive lung adenocarcinoma diagnosed 3 years prior at another center.

Results

Grossly, a flat whitish lesion, with transmural extension and adjacent satellite nodules, was observed. A solid, undifferentiated neoplasm was seen, with marked cytologic anaplasia and rhabdoid features, necrosis and vascular invasion. Immunostaining was focally positive for cytokeratins (CK) AE1/AE3, CAM 5.2, 7 and 19, EMA and WT1, and positive (> 50%) for PD-L1. Differential diagnosis included an undifferentiated jejunal primary or metastases from her known lung adenocarcinoma (CK7+, TTF1-); to help in this distinction, the lung cancer biopsy was retrieved and reviewed and this showed overlapping cytological features.

Conclusions

This case is a perfect example of the peculiar finding of metastatic undifferentiated rhabdoid carcinoma presenting in the intestines of patients with concurrent/recent non-small cell lung cancer as recently described (Virchows Archiv (2021) 479:157–167). Obtaining detailed clinico-pathological history about the primary tumor and reviewing the original slides whenever possible is of utmost importance.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

GIANT GIST ARISING FROM MECKEL’S DIVERTICULUM

F Farci 1, MC Botta 1, A Garau 1, A Campiglio 1, G Gramignano 1

Abstract

Introduction

Meckel Diverticulum (MD) is a congenital defect present in about 2% of the population, 3.2% of them can harbor neoplastic tissue 1 a rare minority being gastrointestinal stromal tumor (GIST) 2.

Case report

A 52 year-old woman presented for fever and abdominal pain. Abdominal CT-scan showed a lesion of 187 mm adherent to the ileal wall. The lesion ruptured upon intraoperatory detachment maneuvers. At gross examination the external surface was smooth with a large laceration (7 cm), a whitish cut surface and central cavitation with necrotic exudate. Histological examination revealed a neoplasm originating from the submucosa of the MD, infiltrating the omentum through the visceral peritoneum. The neoplasm had a solid growth pattern, epithelioid and spindled cells, a mitotic index of 2/50HPF and a Ki-67 of 5%. The neoplastic cells only expressed CD117 being negative for DOG1, CKpan, CK7, EMA, desmin, myogenin, SMA, MART1, S100, CD10, CD99, synaptophysin, CD56.

Conclusions

We describe a rare GIST arising from a MD. The patient has been treated with Imatinib and is currently free of disease at 1 year of follow-up.

References

  • 1.Van Malderen K, Vijayvargiya P, Camilleri M, et al. Malignancy and Meckel’s diverticulum: A systematic literature review and 14-year experience at a tertiary referral center. United European Gastroenterol J 2018;6:739-747. https://doi.org/10.1177/2050640617752771 10.1177/2050640617752771 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Hashizume N, Sakamoto S, Fukahori S, et al. Gastrointestinal stromal tumor in perforated Meckel’s diverticulum: a case report and literature review. Surg Case Rep 2020;6;265. https://doi.org/10.1186/s40792-020-01038-x 10.1186/s40792-020-01038-x [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

ACUTE ILEITIS: SOMETHING ELSE? GUESS WHAT. FROM A TRICKY BIOPSY TO A TRUE DIAGNOSTIC SURGICAL SPECIMEN

A Filosa 1,2,3, G Macarri 1,2,3, S Traini 1,2,3, G Collina 1,2,3, S Guerriero 1,2,3

Abstract

Objective

Endometriosis is a condition in which the endometrium is observed outside the uterus. It frequently occurs in the pelvis but can affects extrapelvic organs including the intestines and urinary tracts. Generally, endometriosis is treated with medication but surgery is indicated when the initial conservative approach fails. Nevertheless, the intestinal endometriosis is mainly treated surgically due to the difficulty of preoperative diagnosis. The etiology of endometriosis is still undetermined. The most important hypothesis was proposed by Sampson in 1927, who observed menstrual bleeding flow back from the fallopian tube during operation, concluding that it causes implantation onto the nearby peritoneum. The other is the coelomic metaplasia theory, explaining that the peritoneum directly causes meta-plasia to become ectopic endometrial tissue on the grounds that endometriosis can occur even for patients who congenitally lack a uterus. The occurrence rate of endometriosis in women of reproductive age is approximately 10%. The most affected site is the ovary, the pouch of Douglas, and the rectum, due its proximity to the fallopian tube. In contrast, endometriosis in the ileum and appendix is relatively rare. Endometriosis affecting the appendix and/or ileum shows various symptoms, such as bowel obstruction, perforation, acute appendicitis, and intussusception. However, the preoperative diagnosis is difficult since the symptoms, laboratory studies, and imaging studies are all non-specific.

Material and methods

We report the case of a women of reproductive age show chronic abdominal symptoms who underwent an ileocolic endoscopy which revealed erosions of the ileo-cecal junction with edema and hyperemia of the terminal ileal mucosa. The endoscopic aspects where suggestive of an idiopatic inflammatory bowel disease and the histology was not in contrast with that diagnosis, even if without granulomas or giant cells suggesting Crohn disease. Soon after the final bioptic histological report the patient was admitted to the Emergency Room for a bowel obstruction and was treated with a laparoscopic bowel resection.

Result

At microscopy the deeper portion of the ideal muscle wall revealed endometriotic glands surrounded by endometrial stroma, so that a final diagnosis of endometriosis was made.

Conclusion

Exclusive endometriosis localization on the ileum is very rare (1%-7%). Endometriosis of the distal ileum is an infrequent cause of intestinal obstruction. We report a case in which endometrial infiltration of the small bowel caused acute obstruction requiring emergency surgery, in a woman whose symptoms were suggestive for IBD.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

NGS ANALYSIS OF DNA DAMAGE RESPONSE (DDR) GENES IN LOCALLY ADVANCED RECTAL CANCER TREATED WITH NCRT

A Montori 1, A Germani 1, M Piane 1, E Pilozzi 1

Abstract

Objectives

Identifying the molecular mechanism underlying tumor chemoradioresistance in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (nCRT) remains a challenge.

Molecules directly involved in DNA damage response (DDR) induced by radiation are excellent candidates as radiosensitivity biomarkers. The aim of this study is to evaluate DDR genes mutational status in LARC to assess them as potential predictive factors of radiosensitivity.

Materials and methods

26 patients diagnosed with LARC who received nCRT followed by surgical resection, were included in this study. According to Tumor Regression Grade (TRG) score system, 13 were classified pathological complete responders (pCR/TRG0) and 13 partial pathological responders (pPR/TRG1-3). Tumor somatic mutations were investigated on pre-treatment LARC biopsies by target sequencing using a custom NGS panel specifically designed for FFPE tissue including 5 genes involved in DDR (MRE11A, RAD50, NBN, ATM and ATR).

Results

Among the 26 cases, NGS analysis revealed 5 unique variants in 4/26 (15,4%) patients, 4 classified as variants of uncertain significance (VUS) and 1 (3,8%) as pathogenic mutation. The pathogenic one, a nonsense mutation causing Loss of Function of RAD50 gene, was detected in a pCR/TRG0 patient and has not been previously reported.

Conclusions

Our data show that genes involved in DDR pathway are rarely mutated in LARC. However, the identification of a nonsense mutation in RAD50 in one case of pCR/TRG0 suggests a possible predictive biomarker for nCRT in LARC.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THE AID OF MOSE TO IMPROVE DIAGNOSTIC QUALITY IN FNB OF PANCREATIC NEOPLASMS

F Motta 1, C Bonanno 1, G Leone 1, A Giorlandino 1, A Rizzo 1

Abstract

Objectives

Evaluate diagnostic improvement of pancreatic neoplasms using Macroscopic On Site Evaluation (MOSE) during EUS-FNB tissue acquisition. This allow to provide real-time information in order to assesses tissue’s adequacy. The materials were handled with dedicated protocol in order to obtain samples comparable to conventional biopsies

Materials and methods

We assessed 90 EUS-FNB procedures, performed with MOSE, in 2020 and compared with those, of the previous year, performed without MOSE. Specific laboratory protocol was made up consisting in spin the samples liquid containing microcores, then strain the pellet in a particular filter in order to catch even small fragments

Results

The average reporting time was respectively 8 days without and 3 days with MOSE. 62% of procedures performed with MOSE were reported as neoplasms, with significant gain if compared with 49% without MOSE; 11% as non-diagnostic (15% without MOSE)

Conclusions

The use of dedicated laboratory protocol allowed the halving of the average reporting from 8 days to 3 days. Also neoplastic diagnosis increased significantly, from 49% to 62%, gaining more than 10% in diagnostic accuracy. The repeated procedures due to non-diagnostic report was reduced, with consequent decrease in risk of possible complications. Furthermore real-time MOSE, combined with specific laboratory protocol, allowed to obtain more tissue than before with consequent possibility of immunohistochemistry studies for challenging cases, and molecular biology and prognostic factor investigations that could open new prospectives for future studies on this neoplasms

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

AN UNUSUAL TUMOR OF LIVER

M Pace 1, A Di Cicco 1, RA Franca 1, P Cretella 1, M D’Armiento 2

Abstract

Objectives

Mesenchymal hamartoma of the liver (MHL) had always been regarded as a benign pediatric malformative lesion due to an error in development and transformation of the mesoderma of the ductal plate consisting of a mixture of mesenchymal and endodermal elements with variable histological differentiation. Recent molecular evidence showed its true neoplastic nature.

Materials and methods

We reviewed the international literature to ensure the correct interpretation of a rare and unexpected lesion.

Results

As a consequence of rapidly worsening hyperbilirubinemia, a 42-year-old female undergoes a partial hepatectomy with hepatic sub-segmentectomy, performed to resect multiple intrahepatic masses that come to our attention with the clinic-radiologic suspicion of choriocarcinoma. On cut surface the masses appear whitish, with clear margins and calcified consistency. In the larger one, the nodules are mixed with cystic spaces of varying sizes, devoid of content and with thickened walls that microscopically, correspond to large biliary ducts, immersed in an immature loose stroma that contains small biliary ducts with a serpiginous course and numerous vascular structures. The solid areas are made up of calcified bone matrix and of lipoblastic-like cells nodules. The adjacent liver parenchyma shows large regenerative nodules/ focal nodular hyperplasia-like.

Conclusions

We present a rare case of MHL manifested in adulthood, with not usual differentiation of the mesenchymal component.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

A CASE OF “INCIDENTALOMA”: NEUROENDOCRINE TUMOUR IN A LONG-STANDING IN TAILGUT CYST

M Pace 1, RA Franca 1, MC Sibillo 1, ML Del Basso De Caro 1, M D’Armiento 2

Abstract

Objectives

Tailgut cyst, also known as retrocecal hamartoma, is a benign cystic lesion of the presacral space derived from persistence of tailgut remmants. It is regarded as a congenital malformation and represents the most frequent presacral tumor in adult life. Neoplastic transformation of the lining epithelium is rare event and often occurs in the form of adenocarcinoma or neuroendocrine neoplasia.

Materials and methods

The clinico-radiological and morphological suspicion led us to carry out a review of the literature in order to define the diagnostic criteria of this unusual surgical case.

Results

An excisional biopsy was sent to our institute with the diagnostic suspicion of pelvic floor cyst presented as an expansive process of the mesorectum. The surgical specimen consists of a multiloculated cyst comprising a white solid-looking area that shows histological and immunophenotypical features of a well differentiated neuroendocrine tumor with a KI-67/MIB-1 Labelling Index of 5% -10%, favoring the diagnosis of well differentiated neuroendocrine tumor (G2).

Conclusions

A recent review of the english literature reports only 29 cases of neuroendocrine tumors arised in a retrocecal hamartoma and the rarity of its occurrence leads to a wide variability in the pathological reporting and in the type of surgical and pharmacological management.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

FERROPTOSIS IN INTRAHEPATIC CHOLANGIOCARCINOMA: AN IMMUNOHISTOCHEMICAL STUDY

S Sarcognato 1, D Sacchi 1, L Fabris 2, G Zanus 3, M Guido 1,4

Abstract

Objectives

Intrahepatic cholangiocarcinoma (iCCA) has a dismal prognosis and a demonstrated anti-apoptotic landscape, which is a key step to chemotherapy resistance. Ferroptosis is a regulated iron-mediated cell death induced by glutathione peroxidase4 (GPX4) inhibition. GPX4 is overexpressed in aggressive cancers and directly inhibited by ferroptosis inducer drugs.

We investigated ferroptosis markers in iCCA.

Materials and methods

Sixty-two patients, who underwent hepatic resection for iCCA, were enrolled. Immunostaining for transferrin-receptor1 (TFR1) and GPX4, and Pearls’ stain for iron deposition were performed to evaluate ferroptosis. Immunostaining for STAT3 was performed to investigate anti-apoptotic landscape.

Results

STAT3 was expressed in 89% of cases, confirming an anti-apoptotic milieu in iCCA. A high STAT3 expression correlated to a worse prognosis (DFS p = 0.001; OS p = 0.006). None of cases showed iron deposition; a complete TFR1 loss was observed in 94% of cases. GPX4 overexpression was seen in 73% of cases and related to poor histological prognostic factors (p < 0.005 for all) and worse prognosis (DFS p = 0.0002; OS p = 0.005).

Conclusions

Our study firstly demonstrates that ferroptosis is not active in iCCA. GPX4 overexpression is seen in most cases and correlates with poor outcome. These data pave the way to a possible therapeutic use of ferroptosis inducers in iCCA to overcome cancer cell drug resistance.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

EBV PERSISTENCE IN GASTRIC CANCER CASES CONVENTIONALLY CLASSIFIED AS EBER-ISH NEGATIVE

MC Siciliano 1,*, S Tornambè 1,*, L Leoncini 1, L Mundo 1,2, S Lazzi 1

Abstract

The Epstein-Barr virus (EBV) causes various B-cell lymphomas and epithelial malignancies, including gastric cancer (GC) at frequencies ranging from 5-10% in adenocarcinomas (ADK) to 80% in GC with lymphoid stroma (GCLS). Using high-sensitivity methods, we recently detected EBV traces in a large cohort of EBV-negative B-cell lymphomas, suggesting a “hit-and-run” mechanism. Here, we used routine and higher-sensitivity methods (ddPCR for EBV segments on microdissected tumour cells and EBNA1 mRNA by RNAscope) to assess EBV infection in a cohort of 40 GC (28 ADK and 12 GCSL). ddPCR documented the presence of EBV nucleic acids in rare tumour cells of several cases conventionally classified as EBV-negative (ADK, 8/26; GCSL, 6/7). Similarly, RNAscope confirmed EBNA1 expression in rare tumour cells (ADK, 4/26; GCSL, 3/7). Finally, since EBV induces epigenetically changes that are heritable and retained after complete loss of the virus from the host cell, we studied the methylation pattern of EBV-specifically methylated genes (Timp2, Eya1, Mgmt) as a mark of previous EBV infection. Cases with EBV traces showed a considerable level of methylation in Timp2 and Eya1 genes that was similar to that observed in EBER-ISH-positive cases and greater than cases not featuring any EBV traces. These findings suggest that: a) EBV may contribute to gastric pathogenesis more widely than currently acknowledged and b) indicate the methylation changes as a mechanistic framework for how EBV can act in a “hit-and-run” manner.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

SCHWANN CELL HAMARTOMA OF THE RECTAL MUCOSA. A CASE REPORT

S Squillaci 1, M Chiudinelli 1, F De Trovato 1, M Piccolomini 1, R Marchione 1

Abstract

Objectives

Mucosal schwann cell hamartomas (MSCHs) are a rare pathological entity. They often present as incidental colonoscopic discovery of solitary, small, sessile polyps (< 1 cm), usually located on the left side of the colon and predominantly seen in middle-age female patients.

Material and methods

A 60-year-old man underwent follow-up colonoscopy after resection of colonic tubular adenomas and hyperplastic polyps. Colonoscopy revealed a 2 mm erythematous polyp at the rectum and an additional 2,8 mm rectal sessile polyp. Both were removed by excisional polypectomy and the latter was subsequently pathologically diagnosed as hyperplastic polyp.

Results

Microscopically, the lamina propria was hypercellular and slightly expanded for multiple small round to oval structures, well-delimitated and composed of uniform and bland spindle cells with indistinct cell borders and tactoid body features 1. The cytoplasm was dense and eosinophilic. Spindle cells were strongly and diffusely reactive to S-100 protein and collagen-IV without expression of other markers as GFAP, neurofilaments, CD117, Claudin-1, CD34 and EMA.

Conclusions

MSCHs are sporadic and have not been associated to inherited syndromes as NF type 1 or MEN type 2b. Differential diagnosis of rectal MSCHs includes neurofibromas, ganglioneuromas, schwannomas, perineuriomas, gastrointestinal stromal tumors and mucosal prolapse syndrome. Due to the benign nature of these lesions, a long- term follow-up is not needed.

References

  • 1.Ferro de Beca F, Lopes J, Maḉoas F, et al. Tactoid body features in a schwann cell hamartoma of colonic mucosa. Int J Surg Pathol 2014;22:438-441 https://doi.org/10.1177/1066896913501384 10.1177/1066896913501384 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

INTRA-AMPULLARY PAPILLARY TUBULAR NEOPLASM (IAPN) – A RARE TUMOR IN A MESSY SITE!

L Valle 1, L Carlin 1, L Mastracci 1, F Grillo 1

Abstract

Objectives

The ampullary region gives rise to various types of tumors with peculiar morphologic and immunohistochemical aspects.

Materials and methods

We report a case of a 67 year old man who underwent pancreatoduodenectomy with radical lymphadenectomy. The resected specimen was submitted to pathology, where it was abundantly sampled after formalin fixation using a standardized protocol.

Results

The neoplasm, submitted in its entirety, was actually localized within the ampulla of Vater forming an exophytic solid mass. Microscopically, the tumour showed a predominant tubular (focally papillary) architecture, associated with areas of high-grade dysplasia, in the absence of invasion. At immunohistochemistry the neoplasm stained for CK7, MUC6, but negative for MUC5AC and trypsin, showing a pancreato-biliary phenotype.

Conclusions

The lesion was classified as an intra-ampullary papillary tubular neoplasm (IAPN) – pancreato-biliary subtype. These lesions are similar to the pancreatic intraductal tubulo-papillary neoplasms and also require distinction from intraductal acinar carcinomas¹. This specific subtype of IAPN requires in depth morphologic evaluation; on this basis future specific molecular analysis may yield interesting results.

References

  • 1.Ohike N, Kim GE, Tajiri T, et al. Intra-ampullary papillary-tubular neoplasm (IAPN): characterization of tumoral intraepithelial neoplasia occurring within the ampulla: a clinicopathologic analysis of 82 cases. Am J Surg Pathol 2010;34:1731-48. https://doi.org/10.1097/PAS.0b013e3181f8ff05 10.1097/PAS.0b013e3181f8ff05 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

INFLAMMATORY CELLS AND OXIDATIVE STRESS CORRELATION IN GIANT CELL ARTERITIS

V Nistri 1, DSM Araújo 1, LF Iannone 2, C Ammatuna 1, G Nesi 1

Abstract

Objective

Giant cell arteritis (GCA) pathogenesis remains largely unknown. However, areas of pronounced tissue derangement show increased levels of reactive oxygen species (ROS), suggestive of their role in mediating tissue injury. This study aimed to i) assess the inflammatory infiltrate in GCA tissue samples; ii) estimate the end-product of oxidative stress, i.e. 4-hydroxynonenal (4-HNE), and iii) correlate inflammation with 4-HNE content.

Materials and methods

Thirty formalin-fixed and paraffin-embedded temporal artery biopsies performed between 1995 and 2014 were retrospectively selected (25 females, 5 males; mean age, 74 years). All biopsies were stained with anti-CD3, anti-CD68, and anti-CD163 antibodies. Inflammatory cell infiltration in each layer of the arterial wall was scored as “negative”, “mild”(+), “moderate”(++), and “marked”(+++). By immunofluorescence staining, 4-HNE content was assessed in each layer of the artery.

Results

Histopathologic features included giant cells (24/30), intimal hyperplasia (29/30), fragmented internal elastic lamina (29/30), calcifications (4/30), and necrosis (2/30). CD3+ cells in the intima significantly outnumbered CD68+ and CD163+ cells, which were mainly distributed in the media and adventitia. Increased macrophage (CD68+) score was associated with higher 4-HNE levels in the intima and media. Similar results for CD163+ cells and 4-HNE content were observed in the media.

Conclusions

Correlations of increased CD68+ and CD163+ cells with higher 4-HNE levels indicate a potential role of macrophage activation and ROS-induced inflammatory signaling in GCA pathogenesis.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

EFFECT OF MICRO- AND MACRO-CALCIFICATIONS IN CAROTID ATHEROSCLEROSIS

M Scimeca 1, M Montanaro 1, R Bonfiglio 1, F Servadei 1, A Mauriello 1

Abstract

Objectives

this study aims to investigate the possible association among the histopathologic features of carotid plaque instability, the presence of micro- or macrocalcifications, the expression of in situ inflammatory biomarkers, and the occurrence of the major risk factors in this process in a large series of carotid plaques.

Materials and methods

a total of 687 carotid plaques from symptomatic and asymptomatic patients were collected. Histological evaluation was performed to classify the calcium deposits in micro or macrocalcifications according to their morphological features (location and size). Immunohistochemistry was performed to study the expression of the main inflammatory biomarkers.

Results

results here reported demonstrated that calcifications are very frequent in carotid plaques, with a significant difference between the presence of micro- and macrocalcifications. Specifically, microcalcifications were significantly associated to high inflamed unstable plaques. Paradoxically, macrocalcifications seem to stabilize the plaque and are associated to a M2 macrophage polarization instead.

Conclusions

the characterization of mechanisms involved in the formation of carotid calcifications can lay the foundation for developing new strategies for the management of patients affected by carotid atherosclerosis. Data of this study could provide key elements for an exhaustive evaluation of carotid plaque calcifications allowing to establish the risk of associated clinical events.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

PLEOMORPHIC HYALINIZING ANGIECTATIC TUMOR (PHAT): REVIEW OF THE LITERATURE WITH CASE PRESENTATION

G Cazzato 1, A Colagrande 1, A Cimmino 1, L Resta 1, G Ingravallo 1

Abstract

Objectives

Pleomorphic hyalinizing angiectatic tumor (PHAT) is a very rare entity of soft tissue considered a “neoplasm of uncertain behaviour of connective or other soft tissue” by the World Health Organization (2020). It develops in subcutaneous tissue of the lower extremities, more frequently in the region of the ankle and foot, and rarely as a deep-seated soft tissue mass in locations such as the perineum, buttock, arms, head and neck, and viscera. Although inconsistent cytogenetic data have been reported on PHAT so far, there are potential morphological and genetic overlaps with hemosiderotic fibrolipomatous tumor (HFLT) and myxoinflammatory fibroblastic sarcoma (MIFS). Here we report a case of PHAT at the level of the upper third of the right thigh in a 48-year-old patient and we also focus on the differential diagnoses of these entities and conduct a literature review of reported cases.

Materials and methods

A 48-year-old woman was referred to the U.O.C. of Plastic Surgery for a volumetric increase in a mass at the level of the right thigh, present for about 15 years and which in recent months had begun to cause functional discomfort. An echography (US) had confirmed the presence of an intensely vascularized subcutaneous lesion and in agreement with the patient it was decided to opt for the surgical option. The patient underwent a wide surgical excision with histologically confirmed margins free from neoplasm.

The sample had therefore been sent to our laboratory and it appeared as a lesion of 6 × 5.5 × 5 cm, with a multiple chambered and collated appearance when cut and a greyish color.

Results

After sampling, processing, inclusion in paraffin and microtome cutting, 5-micron thick sections were prepared and stained with routine staining (Hematoxylin-Eosin) and other sections were prepared by immunostaining with anti-CD34, Desmin, Vimentin, Actin Smooth muscle, Ki67 (MIB1), and S-100 protein.

Microscopically, the lesion was composted of clusters of variably sized, thin walled, ectatic blood vessels scattered and surrounded by a thick rim of amorphous eosinophilic material, with fibrosis. There were also organizing thrombi within blood vessels and the tumour cells were arranged in fascicles or, less frequently, sheets with spindle morphology, sometimes hemosiderin pigment, and nuclear pseudo inclusions. At the periphery, the lesion showed a pseudo infiltrative pattern of growth. There were not cytological atypia and mitotic figures. From the immunohistochemical point of view, we found that the lesion was positive for CD34 and Vimentin, while it was negative for Desmin, S-100 protein and smooth muscle actin. The fraction of neoplastic proliferation (valued by KI67) was < 5%. After a second opinion consultation with a soft tissue expert pathologist, PHAT diagnosis was placed. At the follow-ups of 6 months and 12 months, the patient showed no local recurrence.

Conclusions

We, herein, described another case of PHAT occurring in a middle-aged woman at the root of the right thigh.We have conducted a careful and detailed review of the literature but, considering the rarity of the lesion, future studies with large case series are needed to confirm or possibly deny the hypotheses of histogenesis formulated to date, and to further clarify which common precursor underlies the development of these particular types of lesions.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THORACIC MYELOLIPOMA: A RARE SITE FOR EXTRA-ADRENAL MYELOLIPOMA

E Hamiti 1, S Bongiolatti 2, IC Galli 1, R Santi 1

Abstract

Objectives

Myelolipomas are uncommon benign lesions composed of mature adipose tissue and hematopoietic cells, occurring primarily in the adrenal glands. Extra-adrenal locations are rare with approximately 3% of myelolipomas arising in the thorax. The purpose of this report is to raise awareness of this unusual tumor when formulating a differential diagnosis for intrathoracic masses.

Materials and methods

A 59-year-old man on follow-up for laryngeal squamous cell carcinoma underwent a CT scan, which revealed a solid 3 x 2.8 x 2 cm mass in the right paravertebral region (T10) suggestive of schwannoma. The lesion was surgically removed.

Results

Histologically, the mass consisted of mature adipocytes mixed with islands of hematopoietic cells. Trilineage hematopoiesis was evident, including nucleated red blood cells and megakaryocytes at numerous stages of differentiation. There were extensive hemorrhagic areas, but there no signs of malignancy. Pathological diagnosis was consistent with myelolipoma.

Conclusions

This case illustrates an atypical location of myelolipoma and the essential role of histopathology in determining the correct diagnosis.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

SCLEROSING MESENTERITIS A RARE CAUSE OF MESENTERIC MASS IN YOUNG ADULT

E Piombino 1, C D’Agata 2, C Colarossi 1, G Magro 3, L Memeo 1

Abstract

Objectives

Sclerosing mesenteritis (SM) is a rare fibroinflammatory disorder that involves mesenteric adipose tissue, with an insidious clinical presentation having symptoms, usually resulting in bowel obstruction, mesenteric ischemia, as well as rapid weight loss.

Materials and methods

A 23-year-old male was admitted to our institution with a history of rapid weight loss. A CT scan was performed. An oval-shaped mass were observed in the mesenter. Laparotomic excision of the mass, with small bowel resection and primary anastomosis were performed.

Results

Histologically, it was composed of a proliferation of bland-looking spindle cells with mild nuclear atypia, haphazardly set in a collagenized stroma; fat necrosis and inflammatory cells were also evident. Immunohistochemical analyses, showing a diffuse staining for vimentin and smooth muscle actin; desmin, CD117, CD34, DOG1, β-catenin, S100 protein, pancytokeratins, and EMA were negative. The plasma cell component was negative for IgG4.

Conclusions

Our case emphasizes that histology remains prominent for a correct diagnosis of SM, as preoperative radiological-based diagnosis is non-specific. SM should be included in the differential diagnosis, in view of its benign clinical behavior and different management, compared to the most common neoplasms arising in the same site.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

ISCHEMIC ALTERATIONS IN KIDNEYS FROM DCD DONORS AND CORRELATION WITH POST-TRANSPLANT RENAL FUNCTION

M Zagni 1, A Del Gobbo 1, SM Passamonti 2, A Cannavò 2, U Gianelli 1

Abstract

Objectives

Kidneys retrieved from donors after cardiac death (DCD) pose significant challenges, undergoing a variable degree of ischemia-reperfusion injury (IRI). In this study, we hypothesize that the evaluation of IRI-related lesions in DCD kidneys could represent a useful tool to assess donors’ terminal renal function and to predict functional recovery in recipients.

Materials and methods

We performed a detailed assessment of kidney biopsies both from DBD and DCD donors, which included calculation of Karpinski score and quantification of ischemic lesions as previously described by literature. Morphologic data were later correlated with donors’ terminal serum creatinine and with follow-up data of the recipients.

Results

DCD biopsies (n = 47) show necrosis of epithelium, shedding and loss of PAS-positive brush border and vacuolization of cytoplasm (respectively in 18,4%, 21,3% and 27,5% of observed tubules). These alterations are more frequent in DCD than DBD biopsies (n = 72; t-test, p value range 0,0001-0,0010) and are correlated both with donors’ terminal serum creatinine (r coefficient range 0,3506-0,5029) and with functional recovery of the organ, with a higher incidence of primary non-function (PNF) in recipients of kidneys with brush border loss present in more than 16% of observed tubules (ROC curve, AUC = 0,68).

Conclusion

Quantification of ischemic tubular lesions in biopsies of kidneys from DCD donors is a useful tool for predicting post-transplant renal function and a valid parameter for assessing the quality of the graft.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

A UNIQUE CASE OF ADRENOCORTICAL CARCINOMA WITH PECOMA-LIKE FEATURES.

F Di Giovanni 1, P Calamaro 2, M Volante 3, G De Rosa 2

Abstract

Objectives

To describe the pathological characteristics of a peculiar cases of malignant adrenal tumor with equivocal features of adrenal cortical derivation and PEComa-like morphology.

Materials and methods

A wide panel of immunohistochemical (IHC) markers was applied. TFE3 gene status was assessed by FISH.

Results

A left adrenal mass of 10 cm was discovered in a female patient, aged 70 yrs, with mild increase of cortisol secretion. At histopathology, the lesion had a solid/alveolar growth with a delicate vascular network, epithelioid cell morphology with clear and eosinophilic cytoplasm, marked nuclear atypia with scattered multinucleated cells, and no capsular/vascular invasion. Necrosis was extensive, mitotic index was 30/10 mm2 with atypical figures. Among adrenocortical markers, Melan A only was positive. SF-1 was inconclusive because of technical artifacts. FISH was negative for TFE3 rearrangement. Cathepsin K was markedly positive, thus supporting a differential diagnosis with a PEComa primary of the adrenal. Salivary cortisol levels decreased after operation. Eight months later, the lesion recurred (together with a new increase of cortisol levels) and a fine-needle aspiration biopsy was performed showing overlapping features with the surgical sample, including strong cathepsin K expression and a weak and focal positivity for SF-1. The patient died 2 months after recurrence.

Conclusions

The overall clinical and pathological picture of this case supports its adrenocortical derivation, thus widening the morphological spectrum of adrenocortical carcinoma.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

GATA-3 PROTEIN EXPRESSION IN ADRENOCORTICAL CARCINOMA.

F Di Giovanni 1, S Shahpouri Arani 1, F Massa 2, E Bollito 2, M Volante 2

Abstract

Objectives

GATA-3 expression has been reported in adrenocortical carcinoma (ACC) in a few reports in the literature, and suggested to be associated with aggressive behavior. Since its expression might represent a relevant diagnostic pitfall in the differential diagnosis with other adrenal (such as pheochromocytoma) and urological tumors, we aimed at testing the prevalence and pattern of expression of GATA-3 in a series of ACC.

Materials and methods

GATA-3 protein expression was assessed in 40 ACC, and intensity and percentage of positive tumor cells were recorded. The immunohistochemical results were correlated with major clinical and pathological information available.

Results

GATA-3 protein expression was detected in 3/40 cases (8%), all cases showing a weak intensity and a percentage of tumor cells ranging from 10 to 30%. In 2/12 (17%) cases of normal adjacent adrenocortical tissue, a focal staining was observed in the fascicular zone. GATA-3 expression in ACC was associated with non-conventional histology (1 case of oncocytic, myxoid and sarcomatoid variant, each), high Weiss score (mean 8.7 vs 6.7 in GATA-3 negative cases; p = not significant), high Helsinki score (51 vs 26; p = 0.007) and high Ki-67 index (43% vs 20; p = 0.014).

Conclusions

GATA-3 protein expression is rare in ACC and usually weak and focal, thus not representing a relevant pitfall in the differential diagnosis with other adrenal or urological neoplasms. Its positive expression in cases with aggressive features is probably the result of an aberrant expression associated with loss of differentiation.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

DOG1 EXPRESSION IN NEUROENDOCRINE NEOPLASMS: AN USEFUL DIAGNOSTIC TOOL

A Marando 1, E Di Blasi 2, E Bonoldi 1, MC Aquilano 1

Abstract

Objectives

DOG1 expression has been rarely described in neuroendocrine neoplasia (NEN). So, we performed DOG1 immunostain in NEN from different sites.

Materials and methods

We studied 197 cases: 131 neuroendocrine tumors (NET), 41 neuroendocrine carcinomas (NEC) and 25 thyroid medullary carcinomas (MC). We considered positive a moderate/strong reaction in up 5% of the cells.

Results

NET were DOG1 positive in 53/131 cases: 19/22 (86%) gastric NET, 17/20 (85%) NET of the ileaus, 6/10 duodenal NET, 1/3 NET of the Vater papilla, 2/28 (7%) pancreatic NET 1/2 NET of the ileocecal valve, 3/5 NET of the appendix, 3/4 colic NET and 1/37 (3%) lung carcinoid.

In NEC series, the immunoreactive cases were 12/41: 1/2 gastric NEC, 1/3 carcinomas of the Vater papilla, 1/1 duodenal NEC, 1/4 NEC of the colon, 1/1 carcinoma of the pharynx, 5/22 (23%) lung NEC and 2/2 NEC of the urinary bladder. Negative a case of galbladder NEC, 1 breast NEC, a Merkel carcinoma, a NEC of the paranasal sinus and 2 cases of prostatic NEC.

1/25 thyroid MC was positive.

Conclusions

NET can be immunoreactive for DOG1 and expression is more frequent in gastrointestinal NET (68%) and it is rare in pancreatic NET (7%) and in pulmonary carcinoids (3%). The expression is most frequent in gastric and ileal NET.

In NEC the expression is superior in gastrointestinal NEC (58%), than in NEC of the lung (27%).

In biopsies of the gastrointestinal tract, DOG1 stain can represent a pitfall in the differential diagnosis with GIST. DOG1 can help to establish a primary site of a metastasis of a NET and it will be able to represent a possible target for future therapies.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

CORRELATION BETWEEN BRAF STATUS AND RESPONSE TO THERAPY IN MULTIFOCAL PAPILLARY THYROID CARCINOMA

C Pizzimenti 1,2, G Giacoppo 1, H Rosarno 1, G Tuccari 2, G Fadda 2

Abstract

Objectives

The aim of this study is to examine BRAF expression in a cohort of multifocal papillary thyroid carcinoma (PTC) and its correlation with the ATA response-to-therapy categories (RTT)

Materials and methods

46 multifocal PTCs treated with surgery and radioactive iodine (RAI) from 2012 to 2019 were retrospectively reviewed. Clinical and pathological parameters as well as response-to-therapy data were collected. The mutational analysis of BRAF (immunohistochemical and molecular) were conducted for each case. The response to the RAI treatment was graded in excellent (ER), incomplete biochemical (BIR) and structural (SIR).

Results

The median age of patients is 33 yrs, with 31 females (63%) and 15 males (32%). The BRAF V600E mutation was detected in 60,8% of PTC (28/46), the majority of them being classical variants. Excluding 1 diffuse sclerosing variant (DSV) and 6 solid variants, 39 cases were evaluated for the RTT. 29 cases had a ER whereas, of the remaining 10 with incomplete (biochemical or structural) response, 9 were BRAF mutated and only 1 wt.

Conclusions

The BRAF mutation, even on immunohistochemistry, may predict the response to the RAI treatment in multifocal PTC, except for the solid and DSV variants.

References

  1. Haugen BR, Alexander EK, Bible KC, et al. Thyroid 2016;26:1-133. https://doi.org/10.1089/thy.2015.0020 10.1089/thy.2015.0020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Parker KG, White MG, Cipriani NA. Head Neck Pathol 2020;14:1067-1079. https://doi.org/10.1007/s12105-020-01166-8 10.1007/s12105-020-01166-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THE ROLE OF TLR-4 IN PAPILLARY THYROID CANCER (PTC)

PATHOGENETIC RELATIONSHIPS BETWEEN INNATE IMMUNE SYSTEM AND ACTIVATION OF INFLAMMATORY PATHWAYS IN ENDOCRINE PATHOLOGY

M Ramunno 1, NS Losito 2, F Collina 2, A Pennella 1, G Pannone 1

Abstract

Activated TLR signals on cancer cells may promote cancer progression, anti-apoptotic activity and resistance to host immune responses. We carried out an immunohistochemical study on TLR4 expression in PTC in order to investigate the pathogenetic relationship between innate immunity and activation of pro-tumorigenic inflammatory pathways. In addition TLR-4 expression was compared with BRAFV600E status of PTC samples.

TLR-4 expression has been evaluated on PTC by standard LSAB-HRP IHC technique using monoclonal Ab (clone - 76B357.1 Novus Biological). Using Detre S. et al. method a combined score (CS) has been calculated multiplying staining intensity by percentage of stained cells. Neoplastic Immuno-score (NIS) was considered positive when TLR4 was overexpressed in greater than 50% of neoplastic cells (High-NIS), and negative in those with a percentage of stained cells less than 50% (Low-NIS). Statistical analysis was performed using IBM SPSS software, with value < 0.05 considered as statistically significant.

Statistical analysis showed TLR4 upregulation in neoplastic PTC cells if compared with non neoplastic thyroid and chronic thyroiditis (p < 0,05) and TLR4 Hight-NIS was significantly associated with PTC samples harboring the BRAFV600E+ mutation (p < 0,05).

Understanding the role of TLR4 in the development and progression of PTC could provide new therapeutic alternatives in the field of immunotherapy for a subset of tumors potentially more aggressive.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

SARS-COV-2 AND PLACENTA: NEW INSIGHTS AND PERSPECTIVES

G Cazzato 1, A Colagrande 1, G Ingravallo 1, R Rossi 1, L Resta 1

Abstract

Objectives

At the end of December 2019, Chinese doctors in Wuhan, in the province of Hubei, China, started to report the first cases of an anomalous pulmonary infection not directly attributable to known infectious. By the start of January 2020, the World Health Organization (WHO) had confirmed that the etiological agent in the cases of pneumonia was a new strain of Coronavirus, denominated SARS-CoV-2 (Severe Acute Respiratory Syndrome due to Coronavirus-2), and within just a few months, the pandemic still unfolding today had developed. In February, after the first infections that developed in Codogno (Lombardy), many other infection foci emerged, firstly mainly in northern Italy, in the Lombard provinces of Brescia, Bergamo and Milan, but then spreading all over the peninsula. By 11 February 2021, all the Italian regions had been infected by COVID-19 and more than two million positive cases had been recorded.

As regards placental disease in virus-positive pregnant women, only case reports or small, limited case series were reported in the first months of the pandemic. However, as time passed, more and more cases of placental infection by SARS-CoV-2 were described, and there can be no doubt that with the progressive reduction in age of patients affected, the question of placental involvement and of potential maternal–fetal transmission has become an important matter of debate.

A study of the current literature seems to show that neonatal transmission is very rare, and that there are no specific SARS-CoV-2 histopathologic placental modifications observed in adverse perinatal outcomes, nor is there any evident greater risk of spontaneous abortion, preeclampsia, pre-term delivery or stillbirth. However, few large case series have yet been reported owing to the obvious technical instrumental difficulties. The present case–control study aimed to report the analysis of a large series of placentas from SARS-CoV-2-positive mothers observed at a COVID-19 reference center during the pandemic, and to compare them with a control group in order to highlight any histopathological alterations attributable to SARS-CoV-2. The research is documented by histopathological, ultrastructural and immunohistochemical findings, which are compared with other literature data.

Materials and methods

The study was made of 83 placentas from 81 pregnant mothers (2 twin pregnancies) followed at the Gynecology and Obstetrics Operative Unit from 15 September 2020 to 31 January 2021, identified through electronic clinical records. All the women who presented during labor and delivery underwent testing with GeneXpert Dx Xpress SARS-CoV-2 RT-PCR (Cepheid). The analytical sensitivity and specificity of this test are reported by the manufacturers as 100% (87/87 samples) and 100% (30/30 samples), respectively, with a detection limit of 250 copies/mL or 0.0100 plaque-forming units per milliliter. Positivity to the SARS-CoV-2 test was an independent criterion for the histopathologic analysis of the placentas. Among the positive SARS-CoV-2 group, twelve cases were excluded because they were related to unavoidable abortions due to maternal pathologies, which occurred in the 2nd trimester of the pregnancy, and to endo-uterine fetal deaths (EUFD) unrelated to SARS-CoV-2 positivity. The final sample included 71 placentas.

The SARS-CoV-2 group was compared with a control group of 142 placentas (1:2), selected from a population of pregnancy with physiological outcome, matched by gestational age and maternal age. Historical controls were selected from an archive of 500 placentas of women who had given birth between 2013 and 2018, of which 214 had a physiological fetal outcome. In accordance with the Amsterdam criteria, the parameters considered were: early maternal malperfusion, late maternal malperfusion, fetal malperfusion, placental infection/inflammation, villitis of unknown origin, delayed maturation of the villi; in addition, placental alterations (excluded from the Amsterdam criteria), including intravenous and chorangiotic hemorrhage, were taken into account. All records were retrieved from the electronic archives of our laboratory.

The placentas were fixed in Formalin buffered at 10%, and photographs of the maternal and fetal surfaces were taken; they were then weighed, sampled and examined along the cut surface. The samples obtained included 2 rolls of amnio-chorial membrane, at least 2 samples from the umbilical cord, 3 from the maternal surface, 2 full-thickness sections and representative samples of any lesions presents. All samples were subjected to routine treatment, inclusion, 5 μm sectioning and hematoxylin–eosin staining (H&E). They were observed with an Olympus BX-51 Optical Microscope equipped with the Olympus DP80 image acquisition system. To randomly chosen sections of 51 placentas, the anti-SARS-CoV-2 spike S1 glycoprotein monoclonal antibody, Thermofisher, Rabbit, was added, at pH 6, diluted 1:800, and the antigenic unmasking heat-induced citrate buffer epitope retrieval, for enzymatic immunohistochemical (IHC) analysis. In addition, electronic microscopy analysis was performed for 30 of the 83 placentas. At the moment of delivery, random placental parenchyma samples were immediately fixed in 2.5% Gluteraldehyde for 4 h at 4 °C, and after overnight immersion in phosphate buffer, post-fixed with Osmium Tetroxide in PBS for 2 h at a temperature of 4 °C. The prepared samples were processed for inclusion in araldite epoxy resin (M) CY212 (TAAB, Aldermason, UK). Semifine sections 0.5 μm thick were stained with Toluidine Blue for microscopic analysis. Ultrafine sections were mounted on nickel grilles with uranium acetate and lead citrate contrast. The semifine sections were observed with a Nikon photomicroscope equipped with a Nikon Coolpix DS-U1 Digital Camera (Nikon Instruments SpA, Calenzano, Italy). The ultrafine sections were observed with a Morgagni 268 electron transmission microscope (FEI Company, Naples, Italy). All cases were examined independently under double-blind conditions by two pathologists with expertise in the field of perinatal pathology, to confirm the diagnoses.

Results

All the SARS-CoV-2-positive pregnant women who presented to the Gynecologic and Obstetrics Clinic in the period between 15 September 2020 and 16 January 2021 were enrolled in the study. Of the 83 placentas in the SARS-CoV-2 -positive group, 6 were from unavoidable abortions due to maternal disease that developed in the second trimester of pregnancy and 6 from endo-uterine fetal deaths (EUFD) in the third trimester; all these placentas were excluded from the statistical analyses. The final sample included 71 placentas; 62 women had delivered at term (37-42 weeks) and 7 preterm (≤37 weeks). The mean gestational period was 38.5 ± 2.9 (20-42) weeks. The gravidae were aged 19 to 46 years, with a mean age 33.1 ± 6.1 years; 37 had a spontaneous vaginal delivery, 32 underwent cesarian section, urgent or elective; 31 were primiparous, 25 at their second pregnancy and 13 multiparous. No prior disease before or during pregnancy was reported by 54 women, while 3 were carriers of the methylenetetrahydrofolate-reductase gene (MTHFR), 1 of which was in association with a PAI-1 deficit, 4 were in treatment for hypothyroidism, 5 were affected by gestational diabetes treated with a special diet (in 1 case the metabolic disease was associated with hypertension and in 1 with allergic asthma), and 6 women were affected by hypertension; finally, 2 women had developed hepatogestosis. All these women were positive for SARS-CoV-2 at the moment of delivery; 42 patients (60.9%) were asymptomatic while 24 (34.8%) had a flu-like syndrome with one or more of the following symptoms: slight fever, headache, cough, myalgia, anosmia and ageusia. Of these, 13% required treatment. Finally, three (4.3%) patients had moderate/severe symptoms (two patients needed oxygen in cannula ventilation and one patient mechanical non-invasive ventilation). The Apgar scores of liveborn infants at 1 min were 8 or 9. All Apgar scores at 5 min were 9 or 10. No neonatal deaths occurred. All the infants were negative for SARS-CoV-2 at nasopharyngeal and/or pharyngeal swab. In accordance with the matching, there were no significant differences in maternal and gestational age between SARS-CoV-2-positive and control mothers (p > 0.05). Maternal diseases were equally distributed in the two groups. PROMs were significantly less prevalent in the cases than the controls (8.4% vs. 23.9% p = 0.017), as were IUGR (0% vs. 12.7% p = 0.003) and oligohydramnios (1.4 vs. 9.2 p = 0.05). There were no differences for polyhydramnios (p = 0.61). Apgar scores at 1 min and 5 min were not significantly different (p = 0.83).

The mean placental weight was not significantly different between the two groups (p = 0.48). No differences in the percentage of maternal vascular malperfusion were observed in the cases compared to controls (54.3% vs. 43.7% p = 0.19), whereas the differences with regard to fetal vascular malperfusion (21.1% vs. 4.2% p < 0.001) were significant. The same applied for decidual arteriopathy (40.9% vs. 1.4% p < 0.0001), decidual inflammation (32.4% vs. 0.7% p < 0.0001), perivillous fibrin deposition (36.6% vs. 3.5% p < 0.0001) and fetal vessel thrombi (22.5% vs. 0.7% p < 0.0001). In contrast, a lower percentage of villous hypervascularization (12.7% vs. 34.5% p < 0.001) was observed in the SARS-CoV-2-positive group compared to controls. No significant differences in the percentage of terminal villous hyperplasia and chorioamnionitis were observed between the two groups (Table 2). The anti-SARS-CoV-2 spike-S1 glycoprotein antibody’s results were significantly different, with 33/51 cases (65%) of diffuse positivity throughout the examined section and 18/51 cases (35%) of localized positivity, the expression being prevalent in the cytoplasm of the villi trophoblasts. We also observed positivity in 13/51 (25%) cases in the endothelium of the villi capillaries in sites of thrombosis; 14/51 cases (28%) showed positivity in the maternal decidual cells and in the intervillous histiocytes from maternal blood.

Conclusions

Our study, conducted on a large number of placentas, shows that in cases of SARS-CoV-2-positive pregnant women without transmission of the disease to the fetus, the placentas are largely unaffected by the inflammatory process. However, there are some more frequent characteristics in the placentas of infected women, in particular, maternal thrombosis and deciduous, increased intervillous fibrin, and, in rare cases, fetal thrombosis. The immunohistochemical investigation demonstrates positivity for the anti-SARS-CoV-2 spike glycoprotein antibody both among maternal cells (including inflammatory intervillary cells) and in the trophoblast, and rarely in the endothelium. The ultrastructural investigation demonstrated both the suffering of fetal endothelia and the presence of particles attributable to SARS-CoV-2 in the trophoblast, in conjunction with its degeneration.

As the pandemic continues, these studies will become more urgent for clarifying the possible mechanism of the maternal–fetal transmission of the virus.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

A STUDY ON THE PLACENTA IN THE IUFD: AN EVALUATION OF MOLECULAR ALTERATIONS THROUGH NGS

E Nardi 1, V Seravalli 2, D Massi 1, M Di Tommaso 2, F Castiglione 1

Abstract

Objectives

Placental dysfunctions are among the most common causes of Intrauterine Fetal Demise (IUFD).

Due to its characteristics, the placenta acquires the value of target organ, through which it is possible to carry out molecular research and predictive analyses of IUFD. The aim of this study was to identify the presence of gene mutations in placental tissues in a series of cases of IUFD and to evaluate any potential correlations with the continuation of pregnancy.

Materials and methods

49 samples of formalin-fixed and paraffin-embedded placental tissue were retrospectively selected from pregnancies ending in IUFD at different gestational periods from patients aged 18 to 45, as well as 6 control placentas of physiological pregnancies. After sampling, made according to standardized protocol and conventional histopathological examination, the tissues were subjected to DNA extraction and sequencing by means of NGS with a 56-gene panel.

Results

The most frequent mutation was in c-KIT gene. Such mutation was present in 44/49 cases of IUFD and not observed in any of the 6 control placentas.

Conclusion

In mouse models, the c-KIT mutation was identified as capable of altering the placental structure, leading to abnormal tissue differentiation with negative consequences on vascularization and placental functionality (Kaiser 2020). These observations allow us to hypothesize that the advanced molecular characterization of placental tissues in the early prenatal phase could predict the onset of IUFD and potentially prevent its occurrence.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

RELATIONSHIP BETWEEN SARS-COV-2 INFECTION AND PLACENTAL PATHOLOGY

M Onorati 1, F Di Nuovo 1, V Toto 2, G Bulfamante 2

Abstract

Objectives

Our aim is to add pathological information about correlations between Sars-Cov 2 maternal infection and histopathological features occurring in placenta.

Material and Methods

We analysed 6 placentas: 1 patient with previous asymptomatic Sars-Cov-2 infection, 5 asymptomatic patients with positive nasal swab at delivery (median age 28 years; no other maternal complications during pregnancy).

Results

6 third trimester term placentas were examined. We found aspecific inflammatory lesions (acute subchorionitis and chronic villitis of unknow origin, low grade) in two placentas and some aspects of maternal vascular malperfusion in other two placentas.

Conclusions

Up to date the only specific sign of Sars-Cov-2 infections, chronic histiocytic intervillositis 1, has been found in high symptomatic patient and has been confirmed by the presence of Sars-Cov-2 virus. A large variety of lesions have been found, however a direct connection to Sars-Cov-2 infection cannot still be made, as they can be related to other clinical, or even subclinical, pregnancy complications.

Nevertheless describing also negative events is crucial, considering also that our cases confirm literature data of aspecific placental lesions in young, complete asymptomatic patients.

References

  • 1.Schwartz DA, Baldewijns M. Hofbauer cells and coronavirus disease 2019 in pregnancy: molecular pathology analysis of villous macrophages, endothelial cells, and placental findings from 22 placentas infected by severe acute respiratory syndrome coronavirus 2 with and without fetal transmission Arch Pathol Lab Med 2021. Jul 23. [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

COMPLETE MOLAR PREGNANCY WITH TRANSFORMATION TO INTRAPLACENTAL CHORIOCARCINOMA IN THE FIRST TRIMESTER

M Orsaria 1

Abstract

Objectives

Intraplacental choriocarcinoma (IC) is a rare variant of gestational choriocarcinoma diagnosed after an abortion, a term or preterm pregnancy or hydatidiform mole; due to its rareness, the information available on this entity is still limited. It is generally found on examination of third trimester placentas. Here I describe a case in a first trimester pregnancy in order to highlight the importance of its identification.

Materials and methods

Secundigravida, 29 years old, previous pregnancy with a gestational hypertension, presented in June 2021, with vaginal bleeding and an 8-week amenorrhea. The ultrasound showed a placenta with hypoechogenic vesicular formations with no embryo. The serum hCG level was 403.242 U/L. An aspirative curettage was performed.

Results

The placental pathology reviewed at our institution showed microscopic foci of choriocarcinoma arising in a complete hydatidiform mole.

Immunohistochemistry showed loss of nuclear p57 expression in both the components, mole and choriocarcinoma. A diagnosis of IC in complete molar pregnancy was rendered. Following the curettage, ultrasound and CT showed an enlarged uterus, containing residual trophoblastic disease, with suspicious myometrial invasion. The Score GTN-FIGO was 6 (low risk). At the end of July chemotherapy with Methotrexate was started and the fifth cycle is still going at this time. The whole body CT scan showed no metastasis and the serum hCG levels are decreasing (actual level at 2523.2 U/L).

Conclusions

IC is an important lesion to recognize and report to the clinicians, as the biological behavior is variable and there may be metastatic disease in both mothers and infants, that needs prompt treatment.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

INDICATIONS AND CLINICAL CONSEQUENCES OF FROZEN SECTION EXAMINATION OF THE PLACENTA

V Parrella 1, M Paudice 1, M Pittaluga 1, C Arioni 2, VG Vellone 1,3

Abstract

Introduction

Neonatal sepsis represents a relevant clinical problem but the empirical administration of antibiotics can impair the formation of the microbiota with relevant consequences in later life. Frozen sections examination (FSE) of the placenta allows a prompt diagnosis reducing unnecessary use of antibiotics.

Materials and methods

Retrospective study on frozen section examination of the placenta from 2019 to 2021

Results

59 at term new-borns at high risk for sepsis were considered. The indications for the FSE were divided into absolute (PROM, positive or absent vagino-rectal swabs, maternal fever) and minors (foul-smelling amniotic fluid, preeclampsia, CTG anterations, others). The results showed funisitis (5) and chorionamnionitis (18); based on it, we divided the study population into three categories: high Risk (HR = 5; funisitis±chorionamnionitis), which required prompt antibiotic therapy; intermediate Risk (IR = 1; no funistis, severe chorionamnionitis), treated with watchful waiting; low Risk (LR = 53 no funisitis, mild/no chorionamninitis), not treated. All the newborns did well and 43 babies avoided antibiotic therapy. LR required antibiotic therapy significantly less than the HR (p = 0.0006); only 11 LR requiring subsequent therapy and hospitalization.

Conclusions

The FSE of the placenta, integrated with the clinic, is simple, reliable and safe for the management of the newborn with suspected sepsis and can reduce the use of antibiotic therapy.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

FETAL AUTOPSY BEYOND THE 28TH GESTATIONAL WEEK. A CRITICAL REVIEW OF OUR CASES

V Parrella 1, M Paudice 1, F Todeschini 1, E Fulcheri 1,2, VG Vellone 1,3

Abstract

Introduction

Fetal losses beyond the 28th wks are uncommon events with clinical and medico-legal consequences. These cases are challenging, requiring a specific expertise.

Materials and Methods

Retrospective study on fetal autopsies > 28 wks performed at San Martino Hospital (Genoa) from 2011 to 2020 reported with an institutional check-list based protocol. Causes of death ware classified according to ReCOGE.

Results

During 2011-2020 724 autopsies were made, 439 fetal (60.6%), 36 > 28wks (5%). Alterations consistent with asphyxial endouterine death were evident in almost all cases (n = 34). Overall, the main cause of death was assessed as placental in 29 cases, fetal in 3 cases, and maternal in 3 cases. In most cases the maternal history was silent (n = 18) with a regular course of pregnancy (n = 23). Placental alterations were frequent: underweight (n = 10); dysmaturity (n = 4); chorionamnionitis (n = 14). According to ReCOGE classification the most relevant conditions of death groups were: funiculus (B2-4; n = 16)), placenta (C1,4,5; n = 9), amnionic fluid (D1; n = 4), fetal (A1; n = 3), and maternal (F1,8; n = 3). Only in 1 case was not possible to identify the cause of death for a prolonged in utero retention (8 wks).

Conclusions

Examining the whole feto-placental unit with a check-list based protocol allowed us to establish the cause of death in the vast majority of cases and an increased attention on funiculus pathology appear crucial.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

IMMUNOMORPHOLOGICAL AND MOLECULAR CHANGES IN SQUAMOUS CARCINOMA OF THE VULVA

M Concardi 1, V Parrella 1, N Piol 1, B Spina 1, VG Vellone 1,2

Abstract

Introduction

Vulvar SCC recognize two pathogenetic pathway: HPV-dependent and HPV-independent. The differences between the two pathways and in the transition from normal epithelium (N) to pre-neoplasia (PRE) to invasive cancer (K) is investigated.

Material and methods

16 vulvar excisions from 2014 to 2016 were considered. We compared the expression of different IHC markers (p16, p53, Ki67, CyclinD1), hormone receptors (ERα, PgR, AR) and ISH HPV HR

Results

N confirmed to be ISH HPV HR-, p16-, p53 wild type, low Ki67, intermediate Cyclin D1, low ERα, low PgR, high AR. In PRE: HPV HR- in 12 cases, HPV HR+ in 4; p16- in 12 cases and p16+ in 4, p53abn in 3 cases, Ki67 intermediate, low Cyclin D1, low ERα, low PgrR, intermediate AR. In K: ISH HPV HR- in 12 cases and spotty in 4; p16- in 11 cases and p16+ in 5; p53abn in 5 cases, Ki67 high, Cyclin D1 intermediate, low ER, low PgR, low AR. The transition between N and PRE showed a significant increase in Ki67 and p53 and a significant decrease in AR and Cyclin D1. The transition to K showed a further increase in Ki67 and p53 and a decrease of AR. HPV+ neoplasms show lower p53, higher Ki67, lower Cyclin D1 and higher AR.

Conclusions

Globally Vulvar SCC was confirmed to be a hormone-insensitive neoplasm, with relevant differences between the pathogenetic pathways. None of the proposed markers is able alone to determine the specific pathway and a panel of molecular tests including IHC for p16, ki67, p53 and ISH HPV HR is required.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

NEOVAGINAS AND THE RISK OF SUBSEQUENT MALIGNANCIES. SQUAMOUS CELL CARCINOMA 20 YEARS AFTER SEXUAL REASSIGNMENT: A CASE REPORT.

A Filosa 1, L Leone 2, C Guicciardino 3, G Collina 1

Abstract

Objective

Carcinoma of the neovagina is extremely rare. Malignancies arising in a neovagina seem to be dependent on the original tissue and are thought to be associated with HPV infection or chronic irritation. It is conceivable that the heterotopic glans and prepuce may be at increased risk of developing squamous cell carcinoma as a result of environmental factors, especially if there is a personal history of venereal warts, caused by high-risk human papillomavirus (HPV), leading to anogenital and penile malignancies. Symptoms include clear or bloody discharge and postcoital bleeding. Carcinoma may develop many years after creation of a neovagina, with one squamous cell carcinoma 20 years after neovaginal creation.

Materials and methods

We report a case of squamous cell carcinoma of the neovagina occurred 20 years after a male-to-female reassignment.

Results

A 53-year-old male-to-female transsexual was referred to the Urology Unit with a recent history of vaginal discharge. He had undergone gender reassignment at the age of 34 years. The vagina was constructed using penile and scrotal skin inversion. After an uneventful period of 18 years, the patient presented with an increasing vaginal discharge, which was initially treated with antibiotics for more than 4 weeks. The scar-related tightness of the neovagina did not permit a conclusive manual examination. A vaginoscopy was performed and revealed a blind-ending fistula. She had been on estrogen therapy from 20 years of age, and at age 34, she underwent sex reassignment. Initially, a neovagina was formed using penile and scrotal skin; however, an abdominoperineal vaginoplasty was performed 12 months later with a skin graft from her left thigh to create a deeper cavity. After an uneventful 20-year period since initial surgery, the patient presented with a 4-month history of initially clear and then bloody, foul-smelling vaginal discharge. The patient was not sexually active at the time of presentation. Examination under anesthesia revealed a 4-cm necrotic mass at the apex of the neovagina. The tissue was highly friable and histopathology determined this to be due to a poorly differentiated squamous cell carcinoma arising from the skin. Neoplastic cells formed large nests of basaloid cells, sometimes with central necrosis and infiltrated the soft tissues. Immunohistochemistry showed diffuse positivity for p16 and both low and high risk HPV staining was positive in neoplastic cells by in situ hybridization

Conclusion

Carcinoma may develop many years after creation of a neovagina, with one squamous cell carcinoma 20 years after neovaginal creation [7,8]. Carcinoma of the neovagina may be treated by surgery with reconstruction, although this is a significant undertaking. Radiation has been used but may result in vaginal stenosis, already an underlying potential problem in neovaginas.

References

  1. Fernandes HM, Manolitsas TP, Jobling TW. Carcinoma of the neovagina after male-to-female reassignment. J Low Genit Tract Dis. 2014. Apr;18(2):E43-5. [DOI] [PubMed] [Google Scholar]
  2. Heller DS. Lesion of the neovagina- a review. J Lower Gen Tract Dis 2015;19: 267-270. [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THREE SHADES OF HPV-RELATED LESIONS IN UTERUS: FROM SIL TO CARCINOSARCOMA IN A SINGLE PATIENT

A Morrone 1, D Filip 1, M Viola 1, C Provenza 2, C Manini 2

Abstract

Objectives

To date few cases of multiple HPV-related neoplasms arising in a single uterus have been described. Our report prompts a particular atlas of HPV-related uterine lesions and consequent p16 expression variation on immunohistochemistry.

Materials and methods

Trans-vaginal ultrasound due to vaginal blood loss, in a post-menopausal 59 yo woman led to biopsy of a lesion of the uterine isthmus. Pathological report was of a poorly differentiated adenocarcinoma. A total laparoscopic hysterectomy with bilateral sentinel lymph node resection was then performed.

Results

On macroscopic evaluation the uterus showed wide erosion of exocervix and a hemorrhagic lesion involving corpus and fund. Microscopical analysis revealed carcinosarcoma with poorly differentiated glandular epithelial component, while the sarcomatous one showed bony and cartilaginous differentiation. In situ adenocarcinoma (AIS) endocervical-type of the cervix in direct continuity with infiltrative lesion, and low-grade squamous intra-epithelial neoplasia (L-SIL) were detected. Immunohistochemical staining for p16 showed all its nuances and distribution: focal with low intensity in L-SIL, diffuse and highly intense in AIS and epithelial component of carcinosarcoma. Due to coexistence of different HPV-related lesions, the cervix was considered the tumor site of origin and HPV the main tumorigenesis factor.

Conclusions

this case prompted a full atlas of uterine malignancies and p16 positivity variation, suggesting further study on HPV role among epithelial-mesenchymal transition.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

PATHOLOGICAL CHEMOTHERAPY RESPONSE SCORE IN TUBO-OVARIAN HIGH-GRADE SEROUS CARCINOMA: CLINICOPATHOLOGIC AND GENETIC FEATURES

E Olmeda 1, F Locatelli 2, D Santini 3, G Tallini 1, A De Leo 1

Abstract

Objective

The chemotherapy response score (CRS) is used to score histopathological response to neoadjuvant chemotherapy (NACT) of patients affected by tubo-ovarian high-grade serous carcinoma (HGSC). CRS stratifies NACT response into complete/near-complete (CRS3), partial (CRS2), and absent/minimal (CRS1).

The aims of this study were: (I) to investigate the correlation of CRS and clinicopathological features (including BRCA status), (II) to evaluate the prognostic-predictive impact of the CRS in a single institution cohort.

Materials and methods

CRS has been retrospectively determined in 190 consecutive cases of patients with tubo-ovarian HGSC that had undergone interval debulking surgery (IDS) between 2011-2021. Comprehensive clinico-pathological features were collected, and univariate and multivariate analyses were conducted.

Results

Omental CRS: 1 (48 cases, 25.3%), 2 (51 cases, 26.9%), and 3 (91 cases, 47.9%). CRS correlates with (1) laparoscopic score of abdominal disease (peritoneal cancer index – PCI), (2) CA-125 levels after NACT, and (3) cytoreduction (CC) score at the end of the surgery. Kaplan-Meir survival curves showed a significantly longer progression-free survival (PFS) and overall survival (OS) for patients with CRS 3 (median PFS = 17 months for CRS1 and CRS2, 24 months for CRS 3; median OS = 23,5, 25 and 48 months for CRS1, 2 and 3, respectively). Multivariate analysis showed that CRS was the only parameter significantly correlated with progression free survival (PFS) and overall survival (OS).

Conclusions

CRS3 was significantly associated with improved PFS and OS compared to CRS1/2. The CRS is a cost-effective, reproducible, and robust pathological parameter with strong prognostic impact in assessing response to neoadjuvant chemotherapy in patients with advanced tubo-ovarian HGSC carcinoma. Therefore, it should be incorporated into therapeutic decision-making and clinical trial design.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

INTRAFALLOPIAN TUBE ADRENOCORTICAL CELLS: A PATHOLOGICAL SURPRISE

M Onorati 1, M Nicola 1, F Di Nuovo 1

Abstract

Objectives

Adrenocortical cells can be aberrantly located around kidney, spermatic cord and rarely in the fallopian tube. It is discovered incidentally in surgical specimens and its incidence is very low in females. We report a case of the aforementioned entity because of its rarity and its surprising and unexpected detection.

Material and methods

A 39 years old woman presented for uterine bleeding, undergoing surgical hysterectomy and bilateral adnexectomy. The histological examination revealed a leiomyoma of the uterine body and an unforeseen finding only in the left fallopian tube.

Results

Microscopically the left tube revealed a well demarcated nodule located into the smooth muscle wall, composed of cells with clear and abundant lipid-rich cytoplasm showing strong positivity for alpha-inhibin and melan-A and negativity for CD10, CD68 and CD163. Malignant features, such as atypia, necrosis or mitoses, were absent. These results confirmed the presence of adrenocortical ectopic cells in fallopian tube.

Discussion

After the initial surprise, the pathologist must keep in mind the main differential diagnoses, particularly metastatic renal clear cell carcinoma, cluster of foamy histiocytes, heterotopia of ovarian hilus cells, Walthard cell nests, ovarian luteinized theca cells and, finally, ectopic adrenocortical tissue. The ectopic adrenal rests despite their indolent course, should be excised and histologically diagnosed because they could become functional or unfortunately malignant.

References

  1. Tzigkalidis T, Skandalou E, Manthou ME, et al. Adrenal Cortical Rests in the Fallopian Tube: Report of a Case and Review of the Literature. Medicines (Basel). 2021;8(3):14. [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

MOLECULAR CHARACTERIZATION OF ENDOMETRIAL CANCER

M Paudice 1, M Ingaliso 1, D Rivera 2, L Varesco 2, VG Vellone 1,3

Abstract

Objectives

in light of the ESGO/ESTRO/ESP 2020 guidelines, the study aims to evaluate the clinical applicability of NGS analysis to define an appropriate risk class for a better diagnostic and prognostic definition of endometrial carcinoma.

Materials and methods

cases of serous endometrial carcinoma (SEC), high (HGEC) and low (LGEC) grade endometrioid carcinoma (period 2018-2020) were considered. After a standardized pre-analytical phase, the tumour DNA was semi-automatically extracted and analyzed by NGS with Oncomine On Demand Tumor Specific custom panel on 14 genes (BRIP, CTNNB1, KRAS, MLH1, MLH3, MSH2, MSH6, PALB2, PMS2, POLE, PTEN, TP53, RAD51C e RAD51D).

Results

31 cases were considered (n = 8 HGEC, n = 8 SEC, n = 15 LGEC) and NGS analysis gave good analytical results. Cases were classified according to the new diagnostic algorithm: POLEmut (n = 2), MMRd (n = 3), NSMP (n = 17), TP53mut (n = 9); among the HGECs: 2 POLE, 4 NSMP, 2 TP53mut.

Conclusions

the study showed that the protocols of the pre-analytical and analytical phases used are robust and can lead to molecular results that fall within the standards required for use in clinical practice for a more precise diagnostic-therapeutic management of patients. The implementation of the molecular classification is particularly relevant for better prognostic stratification of HGECs.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

IMMUNOPHENOTYPICAL PROFILING OF ENDOMETRIAL CLEAR CELL CARCINOMA: ANALYSIS OF 45 CASES

F Policardo 1,*, N D’Alessandris 1,*, A Santoro 1, G F Zannoni 1, Q Zhang 1

Abstract

Objectives

A rare subtype of endometrial tumor is represented by endometrial clear cell carcinoma (ECCC), accounting for only 2% to 5.5% of all endometrial malignancies. Postmenopausal women are mainly affected and it is well known that ECCC is poorly responsive to platinum-based chemotherapy and radiation therapy.

Our aim was to provide new data about the molecular profile of pure clear cell carcinoma of endometrium (ECCCs), by studying it from an immunohistochemical and molecular prospective.

Materials and methods

45 cases of endometrial clear cell carcinoma, according to WHO criteria, were included. We have analyzed the immunohistochemical expression of mismatch repair (MMR) proteins (MLH1, MSH2, MSH6, PMS2), estrogen, progesterone receptors, alfa-methylacyl-coenzyme-A racemase, Napsin A, p16 and p53 by immunohistochemistry with the labeled streptavidin-biotin peroxidase detection system using the Ventana automated immunostainer (Ventana Medical Systems, Tucson, AZ).

We have also investigated the status of KRAS, BRAF and PIK3CA mutations by the PyroMark Q24 system (Qiagen GmbH, Hilden, Germany), used for pyrosequencing analysis of the hot spot regions.

Results

15 patients (33.3%) had loss of 1 or more MMR proteins. In all cases, ER and PR were negative, p16 showed a “patchy” pattern and p53 exhibited a “wild-type” staining pattern. Immunohistochemical expression of alfa-methylacyl-coenzyme-A racemase and Napsin A, to support the diagnosis of ECCCs, showed a positivity of all cases for at least 1 of these two markers. Mutations of KRAS and PIK3CA were found in 5/45 patients (11%) and 5/45 patients (11%), respectively and also two synchronous mutations affecting PIK3CA and KRAS were showed. No mutations were detected in the hot spot region of BRAF.

Conclusions

We have provided an immunohistochemical and molecular profile of the ECCC, demonstrating the high incidence (33%) of MMR protein loss and the synchronous mutation of PIK3CA and KRAS genes. By the way this is the first step to provide a complete genomic profile of the ECCC, useful to find molecular alterations that are unique to, or significantly enriched in clear cell tumors compared to other subtypes.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

DETECTION OF SENTINEL LYMPH NODE METASTASIS IN EARLY STAGE CERVICAL CANCER: ULTRASTAGING VS OSNA ASSAY

F Policardo 1,*, G Scaglione 1, M Valente 1, G F Zannoni 1, Q Zhang 1

Abstract

Objectives

Cervical cancer is a very frequent gynecological neoplasm, being the fourth diagnosed tumor and the fourth cause of death in women.

We compared ultrastaging and one-step nucleic acid amplification (OSNA) examination of sentinel lymph nodes in two similar groups of patients with a diagnosis of early stage cervical cancer. Our aim were:

  • firstly to identify the type and the rate of lymph node metastasis detected by ultrastaging and OSNA assay

  • to define the sensitivity and the negative predict value of sentinel lymph node biopsy

  • to define the role of sentinel lymph node assessment in predicting non-sentinel lymph node status.

Materials and methods

116 patients with an early stage of cervical cancer, who underwent surgery (radical hysterectomy or trachelectomy or cevical conization) had a sentinel lymph node assessment with ultrastaging (n = 53) or OSNA (n = 63). Overall, 531 and 605 lymph nodes were removed in the ultrastaging and OSNA groups, respectively. 140 and 129 sentinel lymph nodes were analysed in the ultrastaging and OSNA groups, respectively. Clinical data were compared using the χ2 test and Fisher’s exact test. A κ coefficient was determined with respect to lymph node assessment. A p value < 0.05 was considered statistically significant.

Results

22 patients had metastatic sentinel lymph nodes: 6 (11.3%) of 53 patients in the ultrastaging group and 16 (25.4%) of 63 patients in the OSNA group.

The total amount of positive SLNs was 7 (5%) of 140 in the ultrastaging group and 21 (16.3%) of 129 in the OSNA group, respectively (p = 0.0047). Pelvic lymphadenectomy was performed in 26 (49.1%) of 53 patients in the ultrastaging group and in 34 (54%) of 63 patients in the OSNA group due to comorbidities. Metastatic non-sentinel lymph nodes were found in 4 patients: 2 (7.7%) of 26 patients in the ultrastaging group and 2 (5.9%) of 34 patients in the OSNA group, respectively. The total amount of positive pelvic lymph nodes was 3 (0.6%) of 531 in the ultrastaging group and 4 (0.7%) of 605 in the OSNA group (p = 0.61). In the OSNA group, only 2 patients with negative sentinel lymph nodes had metastatic disease in the pelvic lymph nodes.

By contrast, no patients with OSNA-positive sentinel lymph nodes had metastasis in the pelvic lymph nodes. In the ultrastaging group, all patients with negative sentinel lymph nodes did not have metastatic disease in other pelvic lymph nodes.

Conclusions

A negative predictive value of 91% was associated with the assessment of sentinel lymph node by OSNA but the reliability in detecting node metastasis in non-sentinel lymph nodes is poor. On the other hand, ultrastaging protocol demonstrated higher sensitivity and more reliability in providing pelvic non-sentinel lymph node status.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

NOVEL IMMUNOHISTOCHEMICAL MARKERS (SST2-SST5) IN NEUROENDOCRINE CARCINOMA OF THE UTERINE CERVIX

F Policardo 1,*, A Travaglino 1, M Valente 1, G F Zannoni 1, Q Zhang 1

Abstract

Objectives

Gynaecological NENs are extremely rare tumors, accounting for 1.2-2.4% of all the NENs, because of that the identification of new markers for diagnosis and target therapy of cervical NENs could be very useful.

Materials and methods

16 poorly differentiated neuroendocrine carcinomas (NECs) (10 small cell types, 6 large cell types) were tested with the following immunohistochemical markers: chromogranin A, synaptophysin, CD56, CDX2, TTF1, proteins p40, p63, p16INK4a, and p53, SST2-SSt5 and Ki67.

Results

At least 2 of the 3 neuroendocrine markers (chromogranin A, synaptophysin, CD56) were expressed by the cancer cells. 14 cases expressed p16 intensely. The expression of the somatostatin receptors was found in 11 (SST5) and 8 (SST2), CDX2 in 8, TTF1 in 5 and p53 in 1 case. The expression of p40 and p63 was negative, except for 1 case in which p63 expression was moderate.

Conclusions

From our study, SST2 and SST5 appear consistently expressed in cervical NEC therefore somatostatin analogues could have a potential both diagnostic and therapeutic role in these neoplasms. The negativity for p40 rather then p63 is more useful for the differential diagnosis with squamous cell carcinoma. CDX2 and TTF1 couldn’t help to differentiate NEC from possible cervical metastasis from digestive system and lung, respectively. P16 may suggest a cervical origin.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

A RARE CASE OF DEEP AGGRESSIVE ANGIOMYXOMA OF THE VULVA

S Squillaci 1, A Pitino 2, C Spairani 2, M Farina 3, R Tumino 2

Abstract

Objectives

Deep aggressive angiomyxoma (DAM) is a locally infiltrative and non-metastasizing tumor most commonly arising in the lower genital tract.

Material and Methods

A 48-year-old woman was admitted at Hospital “Umberto I”, Siracusa for a mass attached through a stalk to the right labia majora.

Results

Gross examination showed a 9x7x5,5 cm mass, with white-grayish color cut surface and soft elastic texture. A hypocellular mass, composed of bland spindle to stellate cells and medium/large sized vessels with thick hyalinized walls, was seen. The stroma appeared myxo-edematous to frankly myxoid, with focal collagenized areas. Tumor cells involved the excision margin and were positive for vimentin, and oestrogen and progesterone receptors. S-100, CD34, SMA, desmin and CD117 were negative. Ki67 was low (< 2%).

Conclusions

DAM needs to be distinguished from angiomyofibroblastoma, cellular angiofibroma and myofibroblastoma. Although diagnosis of DAM is usually straightforward, diagnostic problems may arise in cases with uncommon features, especially hypercellularity, extensive collagenous stroma and neurofibroma-like appearance 1. HMGA2 positivity on immunohistochemistry helps to confirm diagnosis and margin status. Hormone-positive recurrent DAMs have been successfully treated with surgery and therapy with GnRH analogues.

References

  • 1.Magro G, Angelico G, Michal M, et al. The wide morphological spectrum of deep (aggressive) angiomyxoma of the vulvo-vaginal region: a clinicopathologic study of 36 cases, including recurrent tumors. Diagnostics 2021;11:1360 https://doi.org/10.3390/diagnostics11081360 10.3390/diagnostics11081360 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

ENDOMETRIOSIS-RELATED TUMORS: A CASE OF STROMAL AND EPITHELIAL NEOPLASIA IN A POST-MENOPAUSAL WOMAN

Q Zhang 1,*, A Santoro 1,*, F Inzani 1, G F Zannoni 1, F Policardo 1

Abstract

Introduction

The presence of endometrium tissue outside the uterine cavity is defined as endometriosis. Generally it has a good behavior and a malignant transformation is an uncommon event. The most frequent neoplastic histotype occurring in an endometrial cyst are clear-cell, endometrioid and serous carcinoma. Rarely it has been reported neoplastic transformation of the stromal tissue. Here we report the first case with the presence of two lesions, a clear cell carcinoma and a low grade stromal sarcoma, both arising in the same patient and in relation to endometriosis.

Case presentation

A 62-year-old woman, with a history of endometriosis, pelvic pain and uterine bleeding, underwent exploratory laparotomy that showed an ovarian mass of 18 cm in largest diameter. Therefore hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with pelvic lymph-node sampling were carried out. The histopathological examination of ovarian mass revealed a clear-cell carcinoma arising from an endometrial cyst. In a background of conventional leiomiomas and diffuse adenomiomas, a yellow lesion measured 1.5 cm was found. Histologically, it showed a round to fusiform cells with oval hyperchromatic nuclei and moderate cytological atypia, the cells were positive for CD10, ER and PR and negative for Cyclin D1, Caldesmon and Desmin. The latter lesion was signed out as low-grade endometrial stromal sarcoma. In this context, admixed with neoplastic LGSS’s cells, we found the presence of endometrial glands with proliferative features and with atypical differentiation. The surgical resection was followed by chemotherapy and radiation therapy. After 9 months of follow-up, the patient was alive without relapse.

Conclusions

The endometriosis’s maglinant trasformation is an uncommon event. Several mutations of different genes (TP53, KRAS, PTEN, PIK3CA, and ARID1A) or the alteration in the mismatch repair system were implicated in the cancer development of the endometriosis. To the best of our knowledge, We report the first case of the simultaneous occurrence of clear-cell carcinoma and low-grade endometrial stromal sarcoma arising from an endometiotic cyst and uterine endometriotic foci, respectively.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

NEUROENDOCRINE TUMOR (NET) OF THE VAGINA: THE FIRST CASE REPORTED IN THE LITERATURE

Q Zhang 1,*, G Scaglione 1, A Mulè 1, G F Zannoni 1, F Policardo 1

Abstract

Objectives

Neuroendocrine tumours (NETs) are a group of neoplasms with heterogeneous malignancy, that arise from the diffuse neuroendocrine system. The gastroenteropancreatic tract and the bronchopulmonary tree are the most frequent origin sites and are rarely observed in the female genital tract where, according to the last WHO classification, are divided in a two-tier system in well-differentiated tumors (NETs) and poorly differentiated carcinomas (NECs).

Case presentation

We report a rare case of a vaginal well-differentiated neuroendocrine tumour (NET). A 2-cm vaginal nodule, histologically constituted by nests of eosinophilic epithelioid cells, that showed positivity for CK (AE1/AE3), chromogranin A, and synaptophysin, focal positivity for CDX2, and negativity for PAX8 and TTF1. The radiological imaging and the presence of benign mucinous glands in the surgical specimen oriented for a primary vaginal tumour. The absence of tumor cell necrosis, the mitotic index (8 mitoses/2 mm) and Mib1/Ki67 (> 20%) determined the diagnosis of vaginal NET G2, according to the WHO 2020 grading system for the gynecologic neuroendocrine neoplasms (NENs).

Conclusions

Gynecologic NENs still represent a diagnostic challenge. A clinico-radiologic workup and an appropriate diagnostic path ruling out the metastatic nature are mandatory to achieve the diagnosis.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

MICROSATELLITE STATUS DETECTION IN GASTROINTESTINAL CANCERS: IHC VERSUS PCR

M Amato 1, I Panarese 1, A Ronchi 1, F Zito Marino 1, R Franco 1

Abstract

Objectives

Microsatellite instability (MSI) is a predictive biomarker for immune checkpoint inhibitors in gastrointestinal cancers. Standard methods for determining microsatellite status are IHC and PCR. The main goal of this study was to investigate the discordance between IHC and PCR for MSI detection in colorectal cancer (CRC) and gastric cancers (GC).

Materials and methods

A series of 444 CRC and 176 GC was analyzed through IHC evaluating the mismatch repair system proteins (MMRP) (MLH1- PMS2-MSH2-MSH6 Roche-Ventana) and PCR using EasyPGX-ready-MSI-kit. Cases with instability at least two markers were classified as MSI-high (MSI-H), at one marker as MSI-low (MSI-L) and without instability as microsatellite-stable (MSS).

Results

In CRC cohort, 61 out of 444 cases (14%) showed the loss of MMRP, 15 cases the loss of a heterodimer and 46 cases the loss/patchy expression of one MMRP. Among 15 cases harbouring the loss of a heterodimer, 13 were MSI-H and 2 MSS by PCR. Among 46 cases showing negative/patchy expression of only one MMR, 13 were MSI-H and 33 were MSS by PCR. In GC cohort, 19 out of 176 cases (11%) showed the loss of MMRP, 13 cases showed the loss of a heterodimer and 8 cases the loss/patchy expression of only one MMRP. Only one case out of 19 was MSI-H by PCR, all the others were MSS.

Conclusion:

Our findings showed discordant results between IHC negative/patchy expression and PCR. A possible diagnostic flow chart to identify MSI status could include IHC as a screening test and an additional molecular analysis exclusively in cases carrying negative/patchy MMR IHC.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

GENE FUSIONS WITH KNOWN AND UNKNOWN PARTNERS DETECTED BY NGS: A SINGLE-CENTER EXPERIENCE WITH METHODOLOGIES’ INTEGRATION

A Ambrosini-Spaltro 1, A Farnedi 1, P Ulivi 2, C Rengucci 2, G Rossi 3

Abstract

Objectives

Next-generation sequencing (NGS) is becoming the new gold standard in the determination of up-front molecular predictive biomarkers, unraveling mutations, amplifications and gene fusions of dozens-to-hundreds genes in a single run. However, the most widely used amplicon-based DNA/RNA NGS assays may fail to identify the specific fusion partner of some gene fusions, leading to indeterminate results with unknown partners and requiring further confirmation with a second method.

This study aims to retrospectively collect all gene fusions from a consecutive case series using an amplicon-based DNA/RNA NGS platform, to examine the differences between gene fusions with known and unknown (indeterminate) partners, and to further characterize them by immunohistochemistry (IHC) and fluorescent in situ hybridization (FISH).

Materials and methods

We considered 777 consecutive cases routinely examined by DNA/RNA NGS platform (Oncomine Focus Assay, Thermo Fisher Scientific Inc., Waltham, MA, USA) from January 2019 to April 2021 from the Molecular Diagnostics Laboratory of IRST-Meldola, serving 4 different Oncology Institutions of the “Azienda Unità Sanitaria Locale della Romagna”, and analyzed the results of gene fusions. An external laboratory examined 397 additional cases, using the same NGS platform. Sequencing analyses were performed by using the Ion Reporter v 5.16 software (Thermofisher). All gene fusions detected by NGS were subdivided into 2 main groups, namely gene fusions with a known (or specific) partner and gene fusions with an unknown (or indeterminate) partner.

Gene fusions detected by NGS and involving ALK, ROS1 and RET were also examined by FISH and/or by IHC, as follows: ALK gene fusions detected by NGS were directly confirmed as rearranged if IHC was definitely positive, but underwent FISH analysis if IHC was negative; all RET and ROS1 gene fusions detected by NGS were subsequently tested by FISH.

The following probes were used for FISH: Vysis 10q11 RET Break-Apart FISH Probe Kit; Vysis Alk Break Apart FISH; Vysis ROS1 Break Apart FISH Probe Kit (Abbott Molecular Inc., Des Plaines, IL, USA). The following antibodies were used for IHC using an automated immunostainer (ULTRA, Ventana Medical Systems/Roche, Tucson, AZ, USA): anti-ALK (D5F3) Rabbit Monoclonal Primary Antibody (Ventana Medical Systems) and ROS1 (D4D6) Rabbit Monoclonal Antibody (Cell Signaling Technology, Inc., Danvers, MA, USA).

We examined differences between gene fusions with known and unknown (indeterminate) partners detected by NGS using the following statistical tests: t-test, Mann-Whitney (SPSS software, IBM, Armonk, NY, USA).

Results

Overall, 1174 consecutive cases of metastatic/advanced malignancies of different primaries and cell differentiation underwent DNA/RNA NGS testing. NGS detected gene fusions in 62 cases (overall, 5.3%), further subdivided in 38 (61.3%) with a known partner and 24 (38.7%) with an unknown partner (indeterminate cases). Gene fusions were predominantly found in non-small cell lung carcinomas (46 cases), followed by 3 cutaneous melanomas, 3 neuroendocrine tumors (2 from the lung, 1 from the larynx), 2 medullary thyroid carcinomas, 2 intrahepatic cholangiocarcinomas, 1 case each of breast carcinoma, intestinal adenocarcinoma, anal squamous cell carcinoma, adrenal cell carcinoma, dermatofibrosarcoma protuberans and pancreatic adenocarcinoma.

By NGS, gene fusions with a known partner (38) predominantly involved ALK (16, 42.1%) and MET (10, 26.3%), followed by ROS1(5), RET (3), FGFR3(2), ERG (1), NTRK (1), while indeterminate cases of gene fusions with an unknown partner (24) predominantly involved RET (18, 75.0%), followed by ALK (5) and ROS1(1).

By statistical analysis, age (p = 0.068) and sex (p = 0.775) were similarly distributed between gene fusions with known and unknown partners. Conversely, rearrangement status by FISH/IHC was more frequent in gene fusions with a known partner (19 out of 22; 86.4%) than in gene fusions with an indeterminate unknown partner (1 out of 19; 5%), resulting in a statistically significant difference (p < 0.001).

Conclusions

Overall, NGS identified 62 gene fusions in 1174 cases (5.3%), further subdivided in 61.3% with a specific gene fusion partner and 38.7% with an indeterminate gene fusion partner.

Fusion genes with a known partner detected by NGS were usually confirmed by FISH/IHC in the vast majority (19/22; 86.4%), while fusion genes with an unknown partner detected by NGS were confirmed by FISH/IHC only rarely (1/19; 5%) (p < 0.001).

Among NGS-based rearranged fusion genes with indeterminate results (unknown partner), RET represents the most frequently involved gene and further analyses (especially FISH) are necessary to confirm NGS-derived results.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

MICRORNA PROFILES OF POST-TRANSPLANT LIVER BIOPSIES ALLOW TO STUDY THE GRAFT REINFECTION PROCESS

M Bulfoni 1, U Baccarani 1,2, Pravisani 1,2, C Di Loreto 1,3, D Cesselli 1,3

Abstract

Objectives

The Introduction. of direct-acting antiviral agents (DAAs) against HCV has significantly improved the prognosis of HCV infected patients undergoing liver transplantation for end stage liver disease. However, DAA treatment does not completely normalize immune and liver functions as well as the risk of hepatocellular carcinoma. Here, we assayed the miRNA profile of formalin-fixed paraffin-embedded (FFPE) liver biopsies obtained 6 months after transplantation, a unique model able to get insights into the reinfection process.

Materials and methods

miRNA isolated from liver biopsies (LB) of 3 healthy livers and 3 transplanted grafts were sequenced by illumina HiSeq2500 platform. Analyses were conducted taking advantage of DIANA-miRPath v3.0 web-server, DIANA-microT-CDS algorithm (v5.0), KEGG and Gene Ontology-Biological Process databases.

Results

6 months after transplantation, liver biopsies obtained from infected patients were already characterized by a miRNA profile strictly related to immunological and apoptotic processes and extracellular matrix remodeling.

Conclusions

FFPE liver biopsies are suitable to study early changes in miRNA profile by NGS. Further studies are necessary to establish whether detected differentially expressed miRNAs can play a role as prognostic markers or could represent actionable targets.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

OPTIMIZATION OF A GENE PANEL FOR THE STRATIFICATION OF TRIPLE-NEGATIVE BREAST CANCERS (TNBC)

M Bulfoni 1, A Lugli 2, E Dalla 1, D Cesselli 1,2, C Di Loreto 1,2

Abstract

Objectives

In 2011, the group of Lehmann proposed the subdivision of TNBC into six molecular subtypes each characterized by potentially new therapeutic targets: 2 forms of basal-like (BL1 and BL2), an immunomodulatory group (IM), a mesenchymal (M), a mesenchymal stem-like (MSL) ) and a positive subtype for the androgen receptor (Luminal Androgen Receptor, LAR). Objective of this study was to develop and evaluate the feasibility of a gene panel for the classification of TNBC into the 6 molecular classes.

Materials and methods

RNA was extracted from FFPE sections of 40 TNBC. The characterization of the different molecular subtypes of TNBC was performed by multiplex Real Time qPCR analyzing the following transcripts: PARP1, RAD51, TTK, AURK_A, EGFR, mTOR, MET, EPHA2, PIK3CA, IGF1R, SRC, PDGFRA, mTOR, AR, FGFR4, JAK1/2, LYN, IRF1, NFKB, SRC, IGF1R, PIK3CA, NFKB, mTOR, PDGFRa. For the analysis of real-time qPCR data, “gplots” and “stats” packages of the “R” statistical software were used. Hierarchical clustering was performed by Distance “Euclidean” and Hierarchical clustering “Complete linkage”.

Results

Adopting the developed gene panel it was not possible to clearly identify the 6 subgroups. Therefore, we decided to cluster using the “R” software on the basis of genes and samples without seeking correspondences with the 6 expected subgroups. In this way, it was possible to identify 4 subgroups with a gene profile predicting different therapies.

Conclusions

this preliminary study indicates the feasibility of implementing TNBC diagnostics with gene panels. Further studies are requested to validate the gene panel in a larger case study.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

FISH CHROMOSOME ANOMALIES IN HEMATOLOGICAL DISEASES: A STUDY OF 2586 PATIENTS

R Fumo 1, A D’Ardia 1, C Picariello 1, S Gaeta 1, A D’Antonio 1

Abstract

Objectives

Cytogenetic anomalies have an important diagnostic, prognostic and predictive role in the hematological tumors 1. Fluorescence in-situ hybridization (FISH) contribution is important for the genetic characterization of corresponding patients.

Methods

2586 hematologic samples were analyzed by FISH in ten years: corresponding entities were LLC (18%), MDS (39%), MM (21%), LMC (12%), LNH (3%), LMA (6%) and LLA (2%); different probe panels were used.

Results

Detected anomalies in LLC were del13q14.3 (32%), del17p13.1 (17%), +12 (14%) and del11q22.3 (9%). Detected anomalies in MDS were del20q (7%), del5q (6%), del7q (3%), +8 (4%), del17p13.1 (1%) and more of 3 anomalies in 1% of nuclei. Detected anomalies in MM were del13q14.3(9%), del17p13.1 (9%), locus IGH break (6%). In LMC and LLA, BCR-ABL translocation was detected in 14% and 13% of nuclei respectively. Detected translocation in NHL were: IGH-BCL2 (5%), IGH-CCND1 (4%) and IGH-MYC (1%); detected translocations in LMA were PML-RARA (10%), AML-ETO (5%) and BCR-ABL (3%).

Conclusions

FISH is a fundamental tool to detect genomic aberrations that are important independent predictors of disease progression and survival and have implications for the design of risk-adapted treatment strategies 2.

References

  • 1.Lai YY, Huang XJ, Cai Z, et al. Prognostic power of abnormal cytogenetics for multiple myeloma: a multicenter study in China. Chin Med J (Engl) 2012;125:2663-70. [PubMed] [Google Scholar]
  • 2.Döhner H, Stilgenbauer S, Benner A, et al. Genomic aberrations and survival in chronic lymphocytic leukemia. N Engl J Med 2000;343:1910-6. https://doi.org/10.1056/NEJM200012283432602 10.1056/NEJM200012283432602 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

NEXT GENERATION SEQUENCING STUDY OF A RENAL EWING’S SARCOMA/PRIMARY NEUROECTODERMAL TUMOR (ES/PNET)

R Lobrano 1, P Paliogiannis 1, G Palmieri 2,3, MC Sini 3, A Cossu 1

Abstract

Objectives

Ewing’s sarcomas/primary neuroectodermal tumor (ES/PNET) of the kidney is a rare malignancy with poor prognosis. ES/PNET were described in 1975 by Seemayer et al., and since then approximately 200 cases have been reported in the scientific literature. The aim of this study was to investigate the molecular landscape of this rare tumor using a next generation sequencing approach.

Materials and methods

DNA extraction was performed by GeneRead DNA FFPE Kit. Next generation sequencing (NGS) was performed using Ion GeneStudio S5 systems and carried out by Ion AmpliSeq™ Comprehensive Cancer Panel which provides highly multiplexed target selection of 409 genes implicated in cancer research. For NGS-based somatic mutation screenings were evaluated coverage of > 200 reads and frequency of mutated alleles > 3% for gene amplicon. Tumor Mutation Burden (TMB) and MSI values were directly calculated by the Ion Reporter™ Software using the specific panel analysis workflow.

Results

Mutations with known pathological significance have been detected in four driver genes: ARID1A, BARD1, POLE, and AURKA. The tumor showed a consistent tumor molecular burden, microsatellite stability, numerous VUS and likely pathogenic alterations.

Conclusions

Pathogenic mutations in driver genes, microsatellite stability and significant tumor molecular burden were found in the ES/PNET described in our study. These data are essential for establishing a tailored therapeutic strategy.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

AN INTEGRATED HISTOLOGICAL, IMMUNOHISTOCHEMICAL AND MOLECULAR APPROACH, IDENTIFYING NEW SMAD4 PATHOGENIC MUTATIONS, FOR THE DIAGNOSIS OF A CASE OF JUVENILE POLYPOSIS

A Mafficini 1, P Mattiolo 2, Lodewijk A A Brosens 3, C Luchini 2

Abstract

Objectives

Juvenile polyposis (JP) is a rare familial syndrome characterized by the development of numerous hamartomatous polyps of the gastrointestinal tract and by an increased risk of developing gastrointestinal cancers. It follows a pattern of autosomal dominant inheritance and is associated with germline mutations of SMAD4 or BMPR1A genes. Differential diagnosis may be difficult based on histology alone, due to morphological similarities to other familial syndromes. Here we report a case of familial JP diagnosed in a woman of 50 years with a familial history positive for gastrointestinal cancers and other tumor types.

Materials and methods

The patient presented with severe iron deficiency anemia and showed numerous polyps in the stomach and jejunum according to endoscopy and imaging. She underwent an intra-gastric laparoscopic removal of the major gastric polyp, followed by jejunal exploration and resection of a segment with multiple neoformations. Histological examination revealed the presence of hamartomatous polyposis. Gastric and intestinal samples were analyzed with next-generation sequencing.

Results

Molecular analysis showed that the patient harbored a germline splicing site variant of SMAD4, c.1139+3A > G, which was complemented by different somatic mutations of the same gene in the different polyps. Immunohistochemistry for SMAD4 confirmed loss of protein expression in the polyps, while regular expression was retained in normal cells.

Conclusions

We thus definitively diagnosed the woman as having JP thanks to an integrated approach based on histology, immunohistochemistry and molecular analysis. The identified mutations, all previously reported as variants of unknown significance, were classified as pathogenic as they complemented each other leading to SMAD4 loss.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

HISTO-MOLECULAR CHARACTERIZATION OF PANCREATIC CANCER WITH MICROSATELLITE INSTABILITY

P Mattiolo 1, A Mafficini 1,2, RT Lawlor 2, A Scarpa 1,2, C Luchini 1

Abstract

Objectives

Pancreatic ductal adenocarcinoma (PDAC) with microsatellite instability (MSI) / defective mismatch repair (dMMR) represents the only subtype of pancreatic cancer with potential response to immunotherapy.

Materials and methods

Here we report the histo-molecular characterization of MSI/dMMR PDAC with immunohistochemistry, MSI-based PCR and next-generation sequencing. Five paradigmatic cases have been identified.

Results

The main results include the first report in pancreatic cancer of MSI/dMMR intra-tumor heterogeneity, the presence of microsatellite-stable metastases from MSI/dMMR primary and the recurrent B2M gene inactivation, which may confer resistance to immunotherapy. In addition to the classic PDAC drivers, ARID1A was the most commonly mutated gene in the cohort.

Conclusions

Intra-tumor heterogeneity, B2M inactivation and metastatic sites should be carefully considered in MSI/dMMR PDAC, which should be investigated also in routine diagnostic practice with specific molecular analysis. The chromatin remodeler ARID1A represents another potential driver gene in this context.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

MOLECULAR ANALYSIS OF AN INTESTINAL NEUROENDOCRINE/NON-NEUROENDOCRINE NEOPLASM (MINEN) REVEALS MICROSATELLITE INSTABILITY AND A MONOCLONAL ORIGIN: DIAGNOSTIC AND CLINICAL IMPLICATIONS

P Mattiolo 1, C Sciammarella 2, A Mafficini 2, RT Lawlor 2, C Luchini 1

Abstract

Objectives

Mixed neuroendocrine-non neuroendocrine neoplasms (MiNEN) are rare mixed epithelial neoplasms in which a neuroendocrine component is combined with a non-neuroendocrine component. Here we provide the clinical, pathological and molecular report of a 73 years-old-men presenting with an intestinal MiNEN.

Materials and methods

The lesion was composed of a well-differentiated G3 neuroendocrine tumor and a colloid adenocarcinoma. The molecular characterization was performed using a multigene next-generation sequencing panel.

Results

The neoplasm displayed microsatellite instability (MSI) due to MLH1 promoter methylation. The extended molecular profile documented the same mutations affecting ARID1A, ASXL1, BLM, and RNF43 genes in both components, indicating a monoclonal origin of the tumor. Regarding component-specific gene mutations, BRCA2 was specifically altered in the neuroendocrine area.

Conclusions

It may represent a new actionable target for precision oncology in MiNEN, but the lack of its alteration in the colloid component calls for further considerations on intra-tumor heterogeneity. The most important finding with potential immediate implications regards the presence of MSI: it indicates that this molecular alteration should become part of the diagnostic algorithm for these rare neoplasms.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

COMPARISON BETWEEN THREE TECHNIQUES FOR THE DETECTION OF EGFR T790M MUTATIONS IN LIQUID BIOPSIES

P Paliogiannis 1, G Palmieri 2,3, M Colombino 3, R Lobrano 1, A Cossu 1

Abstract

Objectives

T790M mutation is the most common mechanism of acquired resistance to Epidermal Growth Factor Receptor (EGFR) tyrosine kinase inhibitors in patients with advanced lung adenocarcinoma. The aim of this study was to compare three laboratory techniques for EGFR T790M detection in liquid biopsies.

Methods

Fifty-four liquid biopsy samples from 48 patients were tested for T790M and other relevant EGFR mutations with the Therascreen® EGFR Plasma RGQ PCR Kit on the Rotorgene Q platform (CE-IVD; Qiagen). Samples were subsequently tested with two different technologies: the real-time PCR based assay Idylla™ ctEGFR Mutation Assay (Biocartis), and a next generation sequencing (NGS) system with the Ion AmpliSeq Cancer Hotspot targeted Panel (Life Technologies), with the aim to compare the detection rates.

Results

The T790M concordance rate between Idylla™ and Therascreen® was 100%, while the NGS method identified only 37.5% of those detected with Therascreen®. Concordance rates for other druggable EGFR alterations were high between Idylla™ and Therascreen® (EGFR Del Ex19: 85.2%, p = 0.562; EGFR L858R: 94.4%, p = 1.000), and lower between Idylla™ and NGS (EGFR Del Ex19: 74.1%, p = 0.244; EGFR L858R: 94.4%, p = 0.822).

Conclusions

An equivalent detection ability of EGFR T790M mutations between PCR-based techniques (Therascreen® and Idylla™) was evidenced. NGS detected a wider range of EGFR and additional gene mutations, but showed a poor ability to detect T790M.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

TLR-MEDIATED IMMUNO-ESCAPE OF CANCER CELLS IN HR-HPV INTEGRATED TUMORS

COMPARATIVE RESEARCH IN HEAD AND NECK (OSCC/OPSCCS), AND CERVICAL SQUAMOUS CELL CARCINOMAS (CSCCS) – PRELIMINARY REPORT

G Pannone 1, MC Pedicillo 1, NS Losito 2, RA Rega 2, A Pennella 1

Abstract

Objectives

TLRs may be involved in immunity against virus-transformed cancer cells. Correlation between TLR4 and HPV is an important factor to study immuno-escape. Our aim was to evaluate whether TLR4 expression be related with HR-HPV integration, and virus type in OSCC/OPSCCs, CSCCs.

Materials and methods

TLR4 levels in OSCC/OPSCCs, HSIL, and CSCCs was studied by IHC, HR-HPV viral integration (HR-HPV-int) by ISH, and viral typing (HPV-type) by RT-PCR-based assay. TLR4 expression has been evaluated by staining intensity (TLR4-SI) and Combo Score (TLR4-CS).

Results

OSCC/OPSCCs. ISH HPV+ OSCC/OPSCCs showed lower levels of TLR4 intensity than negative ones (p = 0.002). Statistical correlation revealed a significant inverse relationship between TLR4-SI and HR-HPV-Int (p = 0.0001; r = -0,41), between TLR4-CS and HR-HPV-Int (p = 0.001; r = -0,35), segregating with basaloid histotype of HPV+ SCCs. ROC curve analysis showed good accuracy, when a cut-off of TLR-4 negative staining has been used to identify HR-HPV-int tumors (p = 0,002). HSIL/CSCCs. TLR-4 expression is downregulated in HSIL and in CSCCs if compared with normal cervix.

Conclusions

TLR4 down-regulation is strongly associated with HR-HPV integration into the host DNA in OSCC/OPSCCs and in a subgroup of CSCCs. Regardless of its anatomic site, HR-HPV-int SCCs are characterized by TLR4 downregulation, which is an important step for immuno-escape. HPV16, the most oncogenic HPV-type, showed greatest tendency to down-regulate TLR-4 in OPSCCs and in CSCCs. This study reveals important implications for diagnostic approach, immuno-target therapy, and vaccination strategies.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

REAL-LIFE, SINGLE CENTRE, GENOMIC ANALYSES OF LUNG CANCER

G Sciacca 1, A Morrone 2, I Rapa 1, S Novello 1, L Righi 1

Abstract

Objectives

Somatic genomic analysis has remarkably changed the therapeutic strategies of advanced lung cancer patients. Furthermore, PD-L1 determination allows to identify those patients who can benefit of immunotherapy.

Materials and methods

the real life of molecular analyses in a consecutive series of lung cancer samples is described. By means of next generation sequencing (Ion Torrent platform), 1226 tumour samples from 1152 patients (79 had multiple molecular analyses) were analysed over a 3-year period (2018-2020).

Results

Males/Females ratio was 722/437; mean age was 68 (30-91). 779 were lung primary, 447 were metastatic sites. The most common specimen was core biopsy (47%), the most common histotype was adenocarcinoma (77%). All samples were adequate for sequencing with mean tumor cellularity of 43% (2-80%). Oncogene addicted carcinomas were 709 (61%). Most frequent mutated genes were: KRAS (29%, of which 39% G12C), EGFR (19%), BRAF (5%, of which 28% V600E), ALK (3%), ROS1 (2%) and RET (1%). Among non-oncogene addicted carcinoma PD-L1 was > 50% in 73/443 cases (16%). Higher mean PDL1 expression was significantly associated to KRAS as compared to EGFR mutated cases (p < 0.0001). Patients with ALK, ROS1 and RET fusions were significantly younger (p < 0.0001, p < 0.0001, p = 0.0056, respectively) and ROS1 translocation was significantly associated with the female sex (p = 0.0083).

Conclusions

oncogene addicted carcinomas require accurate and deep analyses to select patients that could benefit from target therapy.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

BETA2-MICROGLOBULIN MUTATION IN MISMATCH REPAIR-DEFICIENT COLORECTAL ADENOCARCINOMAS

V Tagliatti 1, I Maestri 1, R Gafà 1, G Lanza 1

Abstract

Objectives

Beta2-microglobulin (B2M) is a component of the human leucocyte antigen (HLA) class I complex. Recent studies demonstrated that B2M mutations occur frequently in mismatch repair-deficient colorectal cancer (dMMR CRC). Moreover, in the QUASAR trial B2M mutation was associated with lack of recurrence in stage II dMMR tumors. Aim of the present study was to investigate B2M mutations in a series of patients with dMMR CRC.

Materials and methods

The study included 56 patients with dMMR CRC surgically resected in the years 2019-20. MMR status was determined by immunohistochemical analysis of MLH1-MSH2-MSH6-PMS2 proteins expression and by microsatellite instability analysis. B2M mutations were investigated by Sanger sequencing of the three coding exons.

Results

Of the 56 tumors examined 18 (32,1%) demonstrated B2M mutations, 5 tumors showing double mutations. B2M mutations were detected at higher rate in exon1 (65,2%) than in exon2 (21,7%) and exon3 (13,1%), and the most common mutation was a specific frameshift mutations affecting signal peptide in exon 1. No significant relationship was found between B2M mutational status and clinico-pathological parameters, BRAF status and MMR proteins pattern of expression.

Conclusions

Our data confirm that B2M mutations are common in dMMR CRC. B2M mutational status seems to be unrelated to clinico-pathological and molecular parameters. The prognostic relevance of B2M mutation in dMMR colon cancer deserves further investigation.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

DIAGNOSTIC UTILITY OF WT1 AND CYCLIN D1 IN PEDIATRIC SMALL ROUND BLUE CELL TUMORS

G Broggi 1, L Salvatorelli 1, G Attanasio 1, R Garro 1, G Magro 1

Abstract

Objectives

Pediatric small round blue cell tumors (SRBCTs) are a wide group of tumors with similar morphological features. Over time, the diagnosis of these tumors has become more difficult due to the increasing use of small biopsies. However, the use of a series of immunomarkers allowed to make, in most cases, a correct differential diagnosis. Recently, our research group demonstrated the utility of WT1 and Cyclin D1 in the differential diagnosis of these neoplasms on surgically-resected specimens. Based on these results, we investigated the expression of WT1 and Cyclin D1 on a series of 106 cases of small biopsies.

Materials and methods

The following tumors were selected: 14 cases of extra-skeletal Ewing sarcoma (EWS), 34 cases of rhabdomyosarcoma, 44 cases of neuroblastoma, 11 cases of lymphoblastic lymphoma and 3 cases of renal Wilms’ tumor.

Results

Among SRBCTs, all cases of rhabdomyosarcomas (34/34) showed a diffuse and strong cytoplasmic staining for WT1, while the remaining tumors were completely negative; none of the tested cases showed nuclear immunostaining positivity, except for Wilms’ tumors (3/3). All cases of EWS (14/14) displayed a strong and diffuse nuclear staining for Cyclin D1. Similarly, all cases (44/44) of undifferentiated and poorly differentiated neuroblastomas showed a diffuse (> 70% positive cells) nuclear expression of Cyclin D1. No immunoreactivity was observed in the other SRBCTs tested.

Conclusions

We propose to include WT1 and Cyclin D1 into the list of the immunohistochemical antibodies as adjunct immunomarkers to confirm the diagnosis of rhabdomyosarcoma or EWS/neuroblastoma, respectively.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

A DIAGNOSTIC CHALLENGE IN A NEWBORN WITH TESTICULAR TORSION

E Kuhn 1,3, L Runza 3, U Gianelli 2,3

Abstract

Objectives

Orchiectomy specimens for testicular torsion are not uncommon routine surgical pathology specimens, particularly from newborns. We present an exceptional case of a paratesticular extramedullary hematopoiesis (EMH) in a newborn that caused a diagnostic challenge.

Materials and methods

Orchiectomy specimen from a newborn was evaluated and immunohistochemistry performed.

Results

Macroscopically, the orchiectomy measured 2,5 cm and was hemorrhagic. Microscopically, the testis was extensively congested and necrotic. Also, the paratesticular structures were congested and necrotic, with numerous siderophages and other inflammatory cells, together with many clusters (of variable size until to 1 mm) of dark small cells with scanty cytoplasm and appreciable mitotic figures, suspicious for a small cell cancer. Immunohistochemical stainings for many epithelial/neuroendocrine, germinal, mesenchymal and, lymphoid markers were negative, including CK8/18,AE1/AE3,CD56,NSE,chromogranin A,synaptophysin,S100,PLAP,a-FP,HMB45,CD1a,CD2,CD3,CD10,CD30,CD34,CD68, CD79a,CD99,CD117 and,TdT. Therefore, the possibility of EMH foci was taken into consideration and confirmed by the positivity for glycophorin A, E-cadherin (erythroid precursors), MPO (myeloid precursors) and, CD61 in rare cells (megakaryocytes).

Conclusions

We present this case of extensive paratesticular EMH to warn general surgical pathologist against overinterpreting it as a malignant neoplasm.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

UNUSUAL CLINICAL PRESENTATION OF PLEURAL MESOTHELIOMA ASSOCIATED WITH RECURRENT SPONTANEOUS PNEUMOTHORAX

DP Filip 1, U Mortara 1, F Leo 2, M Volante 2, L Righi 2

Abstract

Objectives

Patients with malignant pleural mesothelioma (MPM) typically present with non-resolving pleural effusions, with or without pleural plaques. Visceral pleural involvement is usually secondary to disease dissemination.

Materials and methods

We report a 63-year-old man, former smoker with no history of asbestos exposure, who presented with recurrent left pneumothorax. After the third recurrence in 3 months, the patient underwent a left upper lobe bullectomy. Thoracoscopic findings were negative for pleural effusion or for parietal pleural nodules.

Results

Pathological examination of the resected lung tissue showed subpleural emphysematous alterations, along with an atypical mesothelial proliferation involving the visceral pleura with predominant superficial growth and foci of lung parenchymal invasion, morphologically and immunophenotypically consistent with MPM. Loss of BAP1 expression was detected in both superficial and invasive components. The disease progressed after 4 months with diffuse parietal pleural nodules without effusion, and a chemotherapeutic treatment was started.

Conclusions

The association of recurrent spontaneous pneumothorax and MPM is rare. In the present case, the clinical history (negative thoracoscopy at diagnosis) and pathological findings (predominant superficial spread) suggest that MPM developed primary in the visceral pleura in the context of fibro-inflammatory changes, suggesting a potential causative relationship between emphysematous changes and MPM.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

CLAUDIN-4 AND BAP1 IMMUNOHISTOCHEMISTRY IN DISCRIMINATING SARCOMATOID MESOTHELIOMA FROM SARCOMATOID CARCINOMA OF DIFFERENT PRIMARIES

G Gallo 1, T Bizzarro 2, D Caruso 3, G Rossi 2,3, A Ambrosini-Spaltro 4

Abstract

Objectives

The distinction between sarcomatoid mesothelioma and metastatic sarcomatoid carcinoma from lung and extra-pulmonary sites may be extremely difficult. No study has ever evaluated the role of coordinated expression of claudin-4 and BAP1 in the differential diagnosis between sarcomatoid mesothelioma and sarcomatoid carcinoma, while it is a formidable panel in discriminating epithelioid mesothelioma from conventional carcinoma.

The study aims to determine sensitivity, specificity, positive predictive value, negative predictive value and accuracy of claudin-4 and BAP1 in distinguishing sarcomatoid mesothelioma from sarcomatoid carcinoma of various origins.

Materials and methods

We collected 33 surgical specimens of sarcomatoid mesothelioma and 36 surgically-resected sarcomatoid carcinomas of different primaries. All cases were tested by immunohistochemistry with Claudin-4 (monoclonal antibody 3E2C1, Thermo-Fisher Scientific, Rockford, IL, USA) and BAP1 (monoclonal antibody C4/sc-28383, Santa Cruz Technology Inc., Dallas, TX, USA) in an automated immunostainer (ULTRA, Ventana Medical Systems, Tucson, AZ, USA). Statistical calculations of sensitivity (the number of true-positives/true-positives + false-negatives), specificity (the number of true-negatives/true-negatives + false-positives), positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy (DA), and P value were performed for each antibody alone and for the combined immunopanel. Comparison of categorical variables was performed using the chi-square statistic with the Fisher exact test.

Results

Claudin-4 was completely negative in normal mesothelium, benign reactive mesothelial hyperplasia and sarcomatoid mesotheliomas, while 36.1% (13 out of 36) of sarcomatoid carcinomas showed some staining (3 diffusely, 10 focally). Of note, all sarcomatoid carcinomas with biphasic appearance showed consistent expression of Claudin-4 in conventional epithelial components. All normal and reactive mesothelium and all carcinomas were immunoreactive for BAP1, while loss of BAP1 was noted in 15 out of 33 mesotheliomas (45.5%). When present, Claudin-4 staining excluded a diagnosis of mesothelioma, but its expression was observed only in 36.1% of sarcomatoid carcinomas. Although statistically significant (p < 0.0001) with a complete specificity and positive predictive value (both 100%), staining with BAP1 and Claudin-4 has a low sensitivity in discriminating sarcomatoid mesothelioma from sarcomatoid carcinoma (45.5% and 36.1%, respectively).

Conclusions

Coordinated staining with Claudin-4 and BAP1 showed low sensitivity in the differential diagnosis between sarcomatoid mesothelioma and sarcomatoid carcinoma (overall sensitivity of 40.6%), but very high specificity: Claudin-4 is expressed only in sarcomatoid carcinomas and BAP1 loss was noted only in sarcomatoid mesotheliomas.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

CYTOLOGICAL DIAGNOSIS OF A LETHAL CASE OF PRIMITIVE PULMONARY EPITHELIOD ANGIOSARCOMA

M Onorati 1, M Nicola 1, F Di Nuovo 1

Abstract

Objectives

Primary pulmonary angiosarcoma (MPPA) is an exceedingly rare neoplasm characterized by fatal clinical course. It is infrequently described, therefore we report a deceptive case because of its rarity, the paucity of literature and the limited knowledge.

Material and methods

A 57 year old, never-smoker, Philippine woman presented with cough, haemoptysis, dyspnea, asthenia and weight loss. A chest CT scan revealed bilateral nodules with ground glass opacity. A transbronchial FNA was performed and a cell block was obtained. Cytology showed microaggregates of epithelioid malignant cells with intracytoplasmatic empty vacuoles, positive for vimentine, CD34, CD31 and ERG in a background of hemorrhage and necrosis. The cytological findings, in particular the presence of intracytoplasmic vacuoles and the immunoistochemical results pointed to a vascular origin of the neoplasm.

Results

In absence of other neoplasms a diagnosis of MPPA was performed. The patient did not undergo surgery due to sudden deterioration in her conditions and she died a month after the diagnosis.

Discussion

MPPA is a high grade malignancy with only a few reported cases 1. It represents a diagnostic challenge for pathologists and requires a meticulous cytological examination and a specific immunohistochemical panel to perform a correct diagnosis. Our experience with this troubled case suggests that, despite its rarity, pathologists should be suspicious in order to achieve an early diagnosis and try to improve its poor prognosis.

References

  • 1.Faiek S, Tariq H, Upparapalli D, et al. Primary pulmonary epithelioid angiosarcoma: a rare case presentation of bilateral pneumothoraces. Cureus. 2019;11:e6514. https://doi.org/10.7759/cureus.6514 10.7759/cureus.6514 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

IMPACT OF RAPID ON-SITE EVALUATION IN THE MANAGEMENT OF CORE-NEEDLE BIOPSY SAMPLES: A REAL-LIFE EXPERIENCE

M Vanzino 1, G Trucco 1, L Righi 2, A Veltri 2, M Volante 2

Abstract

Objectives

The role of rapid on-site evaluation (ROSE) for the assessment of adequacy and sample management in fine-needle aspiration biopsies is well-established. Differently, although suggested by the current guidelines, the role of ROSE in core-needle biopsies (CNB) using tissue-core imprinting remains unclear and should be assessed in a multidisciplinary approach.

Materials and methods

We retrospectively selected 646 consecutive CNB samples, and compared those with or without ROSE (ROSE+ [N = 549] vs. ROSE- [N = 97]) in terms of imaging-based procedure and operator, characteristics of lesions and cores, previous FNA and adequacy. Among those, histological slides from 409 cases were reviewed to assess core number and length, core fragmentation and tumor cellularity.

Results

Use of ROSE was influenced by operative procedure, location and size of lesion, and operator. Final adequacy of paraffin-embedded material was significantly higher in ROSE+ (97%) as compared to ROSE- (92%) cases. None of the procedures or sample characteristics were associated with inadequate material. Number of overall cores - but not overall core length - was higher in ROSE+ samples, whereas sample fragmentation was higher and tumor cellularity lower.

Conclusions

ROSE in CNB procedures may increase the percentage of adequate samples, but to a lesser degree than in fine-needle aspiration biopsies. Additionally, it may interfere with integrity and quantity of diagnostic tissue, thus potentially limiting availability of tissue material for ancillary studies.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

MORPHOLOGICAL AND IMMUNOPHENOTYPICAL CHARACTERIZATION OF NON-INVASIVE PLEURAL LESIONS

G Witel 1, F Leo 2, F Napoli 2, M Volante 2, L Righi 2

Abstract

Objectives

The WHO 2021 classification describes mesothelioma in situ (MPMis) as a pre-invasive single-layer surface mesothelial proliferation with or without cytologic atypia. Its differential diagnosis from benign pleural lesions is a challenging topic.

Materials and methods

56 consecutive thoracoscopic pleural biopsies (from 2012 to 2020) with non-invasive mesothelial lesions, and clinical and follow up data, were reviewed. Immunohistochemistry (IHC) for BAP1 and MTAP was performed.

Results

11/56 (20%) patients had known asbestos exposure; all but 5 (91%) presented with recurrent pleural effusion. 13/56 patients (23%) have died due to MPM progression (38% with asbestos exposure). In these 13 cases, histological re-evaluation revealed variable degrees of superficial mesothelial proliferation (11/13, 85%), fibrosis (10/13, 77%) and inflammation (9/13, 69%). All 13 cases showed cytologic atypia (6 of low and 7 of moderate grade), associated with progression as compared to non-progressed cases (p = 0.04). BAP1 and MTAP were mutually exclusively lost in 5/13 (38%) and 2/13 (15%) cases, respectively. Integrated morphological and IHC features were suggestive of MPMis in 9/13 (69%) of the progressed and in 10/43 (23%) of non-progressed cases.

Conclusions

further efforts are needed to accurately predict the risk of progression among non-invasive pleural lesions to identify those with a malignant potential. BAP1 and MTAP IHC are specific but not sensitive markers in this context.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

SPIKE AND ORF1AB RNA LEVELS IN AUTOPSY LUNG SAMPLES OF POSITIVE DECEASED SUBJECTS: ISH VS RT-PCR

G Zannini 1, A Ronchi 1, M Montella 1, F Zito Marino 1, R Franco 1

Abstract

Objectives

Post-mortem examination plays a pivotal role in understanding the pathobiology of the SARS-CoV-2, thus the optimization of virus detection on the post-mortem formalin-fixed paraffin-embedded (FFPE) tissue is needed. The main aim of this study is to compare in situ hybridization (ISH) versus reverse transcription polymerase chain reaction (RT-PCR) to detect SARS-CoV-2 on post-mortem lung samples of positive deceased subjects.

Materials and methods

A total of 27 samples were analyzed by RT-PCR targeting different viral RNA sequences of SARS-CoV-2, including envelope (E), nucleocapsid (N), spike (S), open reading frame (ORF1ab) genes and ISH targeting S and Orf1ab.

Results

All 27 cases showed the N gene amplification, 22 out of 27 the E gene amplification, 26 out of 27 the S gene amplification and only 6 the ORF1ab gene amplification. The S ISH was positive only in 12 out of 26 cases positive by RT-PCR. The S ISH positive cases with strong and diffuse staining showed a correlation with low values of the number of the amplification cycles by S RT-PCR suggesting that ISH is a sensitive assay mainly in cases carrying high levels of S RNA.

Conclusions

Our findings demonstrated that ISH assay has lower sensitivity to detect SARS-CoV-2 in FFPE compared to RT-PCR, however it is able to localize the virus in the cellular context since it preserves the morphology.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

ELECTRICAL DC TENSIONS (800 MV/MM) CAN IMPLEMENT MORPHOLOGIC PATTERNING IN CHICK EMBRYO MODEL INDUCING LARGE OMPHALOCELES.

A Capuani 1, M Nistri 1, D Pisani 2, A Poli 3

Abstract

Background

Electrotaxis and Polarity play an important role in embryogenesis. The genes pathways expression normally leads to specific phenotypes under chemical and physical laws.

Purpose

Does the 800 mV/mm electrical field (EF) interfere with the ongoing embryogenetic processes?

Methods

We designed a two terminal condenser storing a uniform 800 mV/mm electric field between two aluminum plates 13.5x25 cm faraway 6 cm connected to the poles of 48/V battery with possible polarity reversal. Inside the EF is positioned a two wood shelfs container of 6 horizontal fertilized eggs simultaneously laid. We adapted a large incubator to settle the electrical device with temperature and humidity sensors.

With the device we have treated for 52 hours after laying (gastrulation looping septation periods) 30 fertilized eggs in series of horizontal and vertical position inverting polarity in each group. In vertical position the EF forces act perpendicular to the embryo’s primitive streak

Results

We observed 4 giant defects of the anterior abdominal wall (13.3%). One embryo born alive died after few hours, three died almost at the end of the development. 8 eggs (26.6%) did not develop. The research is ongoing with micro-TAC and stereoscopic microscopy.

Conclusions

DC electrical forces 800 mV/mm affect the endogenous fields leading to abnormal mid gut rotation.

We speculate a similar pathological heart looping.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

DEVELOPMENT OF AN IN VITRO MODEL TO STUDY GLIOMA CELLS’ MIGRATION AND TO SCREEN DRUGS

IG Rolle 1, P Del Mestre 1, Miran Skrap 2, A Magistrato 3, D Cesselli 1,2

Abstract

Objectives

Glioblastoma multiforme (GBM) represents the most aggressive primary malignant brain tumor characterized by a poor prognosis. Two are the major causes of GBM aggressiveness: its highly infiltrative nature, supported by a hydrodynamic process possibly involving Rho GTPases, and the rapid development of drug resistance. Therefore, it is considered fundamental to develop new drugs able to interfere with glioma cell migration and to evaluate their possible effectiveness in in vitro assays. Objectives of the present study were to develop either algorithms to identify new drugs or patient-based in vitro model to assess drug efficacy.

Materials and methods

In silico analysis, based on the known structure of targets, identified possible inhibitors of Rho GTPases. In vitro assays were designed to evaluate the ability of tumor cells to pass through narrow pores (3μM) taking advantage of fluorescence microscopy and transwell assays. Experiments were initially performed using the commercially available U87 MG cell line and, subsequently, glioma stem cells (GSC) isolated from human tumors.

Results

In silico analysis identified 21 compounds that could act on Rac1 and Cdc42 GTPases, either drugs already used for other diseases (repositioning) or new molecules (lead compounds). Of the 21 compounds selected for the in vitro analysis, 2 showed a 50% reduction of U87 cells migration, while 3 a 30% reduction. Use of tested inhibitors on GSC showed a more variable effects underlying the biological diversity characterizing patient tumors.

Conclusions

5 molecules predicted to bind Rho GTPases, were indeed able to efficiently interfere with the migration capability of glioma cells. However, further experiments are ongoing to confirm the selectivity of these compounds and to determine if it is possible to identify gliomas that could be effectively targeted by these drugs.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

TUMOUR-INFILTRATING LYMPHOCYTES IN SINONASAL INTESTINAL-TYPE ADENOCARCINOMA: PRELIMINARY REPORT

L Alessandrini 1, M Ferrari 2, E Savietto 2, Diego Cazzador 2, M Sbaraglia 1

Abstract

Objectives

To evaluate the prevalence and potential prognostic role of tumor-infiltrating lymphocytes (TILs) in 52 cases of Sinonasal Intestinal-Type Adenocarcinoma (ITAC) treated in our Institution (2008-2020).

Materials and methods

Each case was categorized according to Barnes and Kleinsasser/Schroeder classifications. CD3/CD8-immunostained slides from the most representative formalin-fixed, paraffin-embedded tissue block were scanned and the corresponding digital images validated by pathologists. Image analysis was performed by Visiopharm™ software, version 4.5.6.5 (Hoersholm, Denmark). The whole tumor area was considered for the analysis. The density of CD3+/CD8+ TILs per mm2 was counted and correlated with clinicopathological data.

Results

The mean density of CD3+ TILs was 194.5 (range 18-760), whereas the mean density of CD8+ TILs was 202.1 (range 17-846). Optimal TILs cutoff values in terms of overall survival (OS) were 219 for CD3+, and 176 for CD8+ cells. Categorized CD3+/CD8+ density was associated with OS (p = 0.059 and p = 0.061, respectively). Pathological high T category, involved margins and treatment not including adjuvant radiotherapy were inversely related with OS (p = 0.009, p = 0.006, p = 0.001, respectively). No other variable showed statistical associations with TILs density.

Conclusions

TILs assessment in ITAC could provide relevant prognostic information beyond that predicted by conventional clinicopathological data and be used for immunotherapy.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

IS TUMOR BUDDING A USEFUL PROGNOSTICATOR FOR TEMPORAL BONE SQUAMOUS CELL CARCINOMA? AN EXPLORATORY STUDY

L Alessandrini 1,*, E Zanoletti 2,*, A Mazzoni 2, G Marioni 2, M Sbaraglia 1

Abstract

Objectives

To investigate the role of tumor budding (TB) in primary temporal bone squamous cell carcinoma (TBSSC) prognosis and in its loco-regional aggressiveness analyzed according to the revised Pittsburgh staging system.

Materials and methods

32 patients treated by en bloc surgical resection were considered. For each case, a pancytokeratin-immunostained slide from the most representative formalin-fixed, paraffin-embedded tissue block was evaluated. Peri-tumoral budding (PTB) and intra-tumoral budding (ITB) were counted at 200x total magnification in the ‘hotspot’. For risk stratification purposes, along with the absolute count, a three-tier scale was applied, using a cut-off of five and ten and a two-tier system was also adopted, using a cut-off of five, as frequently used in head and neck SCC.

Results

Advanced (T3-4) TBSCC correlated with high risk ITB at two-tier risk grading (p = 0.0361). N+ status was associated with intermediate-high risk PTB (p = 0.0382). PTB two-tier risk grading was associated with disease-free survival (p = 0.0463). PTB absolute count, PTB three-tier risk grading, and PTB two-tier risk grading were associated with overall survival (p = 0.0341, p = 0.0359, p = 0.0132, respectively).

Conclusions

TB in TBSCC, regardless of its localization, may be a reliable predictor of neck lymphnode metastasis and poor prognosis. Larger series could confirm this evidence both in post-operative specimens and in preoperative biopsies.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THE IMMUNOHISTOCHEMICAL EXPRESSION OF SRSF1 HAS A POOR PROGNOSTIC VALUE IN UVEAL MELANOMA

M Failla 1, R Caltabiano 1, L Salvatorelli 1, L Puzzo 1, G Broggi 1

Abstract

Objectives

Serine and Arginine-Rich Splicing Factor 1 (SRSF1) is an RNA-binding protein that among other proto-oncogenic functions, promotes the alternative splicing of the pro-angiogenic form of VEGF-α.

We studied its expression on a series of 85 cases of primary Uveal Melanomas (UMs) to assess its potential prognostic role.

Materials and methods

Histologic specimens of 39 metastasizing UMs and 46 non-metastasizing UMs were retrospectively collected along with their clinicopathologic data.

The immunohistochemical expression of SRSF1 was semi-quantitatively analyzed, according to the Intensity of Staining (IS) and the Extent Score (ES) The Immunoreactivity Score (IRS) was obtained by multiplying IS and ES and we considered the immunohistochemical expression of SRSF1 as low if IRS was ≤ 6 (L-IRS), and as high if IRS > 6 (H-IRS).

Results

Among 46 primary non-metastatic UMs, SRSF1 L-IRS was found in 39/46 cases (84.8%) while SRSF1 H-IRS was observed in the remaining 7/46 cases (15.2%). Among the primary metastatic UMs, 5/39 (12.8%) exhibited SRSF1 L-IRS, while 34/39 (87.2%) showed SRSF1 H-IRS. A significant correlation was found between higher SRSF1 expression and lower metastasis-free survival times in our cohort.

Conclusions

Our results indicate a negative prognostic role of SRSF1 in UM patients, as higher immunohistochemical expression of this protein was associated with a higher risk of metastases and lower metastasis-free survival times; contrarywise, the cases from our cohort that exhibited lower SRSF1 levels showed both lower metastatic risk and longer metastasis-free survival.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

INTERACTION BETWEEN IMMUNE-CONTEXTURE AND INFLAMMATORY MICROENVIRONMENT

HEAD AND NECK PATHOLOGY. ANALYSIS IN ORAL SQUAMOUS CELL CARCINOMA (OSCCS)

G Pannone 1, G Aquino 2, G Villani 1, I De Stefano 1, M Ramunno 1

Abstract

Objectives

OSCCs is a devastating disease with an incidence of approximately 540,000 new cases annually worldwide. Despite promising improvements in conventional therapeutic approaches currently available, overall survival is still poor. A role of PD-L1 in OSCCs has been established since PD1/PD-L1 targeting has been confirmed in clinical setting. However, relationship between immune-contexture and phlogistic microenvironment need further studies. Aim of this research was to investigate the level of PD-L1 (22C3) expression (PD-L1 Expr) in OSCCs compared to COX-2 (SP21) expression (COX-2 Expr) and different clinic-pathological features.

Materials and methods

We built a prognostic TMA with 119 OSCCs, representative of superficial part and deep invasive front of the tumor, to investigate, COX-2 Expr and PD-L1Expr, correlating with clinic-pathological parameters and outcome. Statistical tests (Chi-square test and Pearson’s correlation) were performed using SPSS software.

Results

PD-L1 Expr in lymphocytes has been significantly related to COX-2 Expr plasmacells (P = 0,001). PD-L1 Expr in lymphocytes has been significantly correlated to COX-2 positive TIL (P = 0,048). PD-L1 distribution is related with COX-2 intensity of expression (P = 0.02).

Conclusions

Our results revealed a co-expression of the PD-L1 and COX-2, suggesting that they play complementary roles during oral carcinogenesis. This relationship emphasizes their clinical relevance in the era of precision medicine.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

HISTOPATHOLOGICAL DIAGNOSIS OF “IGG4-RELATED DISEASE” IN THE LACRIMAL AND SALIVARY GLANDS

ASSESSMENT OF THE ACCURACY OF THE IGG / IGG4 RATIO

G Pannone 1, IS De Stefano 1, E Leggieri 1, MC Pedicillo 1, A Pennella 1

Abstract

Objectives

Primary endpoint is verifying the diagnostic criteria according for the histolopathological diagnosis of the “IgG4-Related Disease”, evaluating the values of the IgG4 +, IgG + plasma cells and their ratio; secondary endpoint is studying the possible involvement of the MUM1 + plasma cells in the diagnosis of “IgG4-RD”.

Materials and methods

Histopathological material from 30 cases was selected, immunohistochemical technique with biotin-labeled avidin modified with monoclonal antibodies was used. Plasma cells were counted with CelleSens image analysis software and Image Pro Premier analysis software to obtain Digital Pathology images; data was analyzed by Sofa Statistics software.

Results

Results consist not only in outlining the correlation between the IgG4 + and IgG + plasma cells, but also in checking the accuracy of the ratio between the IgG4 / IgG plasma cells, useful criteria for the diagnosis of the “IgG4-RD “. An important result was also to highlight the role of the MUM1 + plasma cells in the “IgG4-RD”, obtaining statistically significant results. There is a positive linear correlation between the IgG4 + and MUM1 + plasma cells and between the IgG + and MUM1 + plasma cells.

Conclusions

Results made it possible to verify the accuracy of the diagnosis of “IgG4-Related Disease” and to demonstrate the sensitivity and specificity of the test allowing the differential diagnosis with other non-specific pathologies, to classify Mikulicz Syndrome and Kuttner’s Pseudotumor as “IgG4-Related Disease”.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

ROLE OF HPV IN THE PATHOGENESIS OF HNSCC

G Pannone 1, IS De Stefano 1, M Ramunno 1, MC Pedicillo 1, A Pennella 1

Abstract

Objectives

Study the distribution frequency of HPV in squamous carcinomas of the head and neck area, for better therapeutic and prognostic management of the patient; study the prevalence of HPV also in potentially malignant lesions (PMD) of the head and neck area, to be able to make increasingly early diagnoses; identify the presence of the virus that is actually oncogenic and not simply episomic HPV DNA.

Materials and methods

Study includes 220 cases from the otolaryngology department. 75% of cases are made up of potentially malignant lesions, which include squamous papillomas, epithelial hyperplasia, verrucous hyperplasia, leukoplakia, hyperplastic nodules, dysplasia and carcinomas in situ. Remaining 25% are squamous carcinomas from the various locations in the district. ISH technique was used.

Results

Frequency of distribution of LR-HPV in all lesions in the district is 5%, and of HR-HPV is 5.5%, with greater positivity in the male sex. LR-HPV was not positive in any squamous carcinoma and was positive in 2 out of 22 squamous papillomas. HR-HPV was found in 2.6% of all potentially malignant lesions and in 11.7% of HNSCC. No cases of squamous laryngeal carcinoma were associated with HPV infection.

Conclusions

Positive finding of HR-HPV in HNSCC confirms and strengthens the role of the virus in carcinogenesis and the evident prevalence of incidence in males. Presence of HR-HPV in PMD suggests the possibility of setting up less invasive screening for the identification of the virus, to allow the diagnosis of carcinoma in the early stages and/or prevent progression towards malignant transformation.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

LIMITS AND EFFICIENCY OF POP-OFF TECHNIQUE IN THE ROUTINE ULTRASTRUCTURAL ANALYSIS OF KIDNEY DISEASES

S Valente 1, E Giampieri 1, G Comai 2, G La Manna 2, G Pasquinelli 1,3

Abstract

Objectives

The pop-off technique was introduced by Bretschneider in 1981 to recover samples from histological sections. It could be useful when the dedicated tissue for ultrastructural analysis is not available. Here, we apply the pop-off technique on routine kidney biopsies and we report on its limitation and effectiveness.

Materials and methods

Histological stained sections of renal biopsies fixed in Serra’s solution were recovered for electron microscopy (EM) using the pop-off method. The glomerular basal membrane (GBM) thickness was measured in retrieved samples and in the same glutaraldehyde fixed samples. Data were analyzed with robust linear model.

Results

The pop-off method was successful performed; tissue artifacts were observed and related to the Serra’s fixation and to the recovering procedure itself. Structures of diagnostic significance such as presence and localization of electron dense deposits, fusion of the podocyte foot processes were identified; GBM structure was maintained even though a general reduction of GBM thicknesses was recorded in recovered samples. A correction factor useful in estimating how much GBM thickness varies was elaborated.

Conclusions

Albeit with some limitations, the pop-off technique represents a quick recovery method applicable to renal biopsies when the EM tissue is not allocated providing useful information for ultrastructural diagnosis of glomerular diseases.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

REASONS FOR DROPPING OUT OF SCHOOLS IN PATHOLOGY: WEB SURVEYS FOR STUDENTS AND RESIDENTS.

WEB SURVEYS FOR STUDENTS AND RESIDENTS ABOUT PATHOLOGY

G D’Abbronzo 1, S Lucà 1, E Clery 1, R Franco 1, A Ronchi 1

Abstract

Objectives

In Italy, the shortage of pathologists is a serious problem that affects the quality of the national health system. According to Italian Pathologist Society (SIAPEC), lack of pathologists will exceed 200 units in 2025. In part, shortage of pathologists is due to the dropping out of post-graduate medical schools. We set out to investigate the reasons for dropping out of pathology schools.

Materials and methods

We have developed and proposed on Facebook two surveys, one dedicated to students enrolled in the 4th to 6th year of medicine course and one to pathology residents. Survey for medical students consisted of 10 questions that provided perception of students about pathology; survey for pathology residents consisted of 8 questions and investigated the most appreciated and least appreciated aspects of Italian pathology postgraduate medical schools.

Results

We obtained 500 responses to the student’ survey and 51 responses to resident surveys. Concerning students, our results show that reasons for a lack of interest of the students may be due to their incomplete knowledge of the discipline. Concerning pathology residents ‘answers show that some aspects of teaching should be improved.

Conclusions

Our surveys showed that students have poor knowledge about the real clinical significance of pathology and residents believe that teaching offered by graduate schools needs to improve in some respects.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

RENAL ONCOCYTIC TUMORS OF LOW MALIGNANT POTENTIAL: A MONO-INSTITUTIONAL EXPERIENCE WAITING FOR WHO

A Bressan 1, M Valeri 1, M Cieri 1, S Pancetti 1, P Colombo 1

Abstract

Objectives

Low and High grade oncocytic tumors (LOT and HOT) have been proposed as distinct novel entities with uncertain prognosis in the spectrum of renal oncocytic neoplasms. We report 7 further cases of these controversial categories with clinico-pathological description.

Materials and methods

Renal oncocytomas (RO) diagnosed in our Institution from 2015 to 2021 were retrospectively reviewed. Expression of CD117 and CK7 was performed or re-evaluated to identify LOT and HOT. Morpho-phenotypical and clinical features were recorded.

Results

Of 286 RO selected for analysis for CD117 and CK7, five LOT and two HOT were identified (2.4%). Tumor size was 1-4.5 cm and two LOT presented hemorrhages on cut surface. Mean age was 49yrs; male/female ratio was 1,5:2. Histologically, LOT overlapped RO with some features of Chromophobe carcinoma (ChRCC) (perinuclear halos). Immunophenotype was: CK7+ (diffuse), CKpan+, CD63+, AMACR+, ECAD+, CD15+ (2/5 pts), PAX8+, CD10-, CKIT-, p63-, CAIX-, TFE3, Vimentin-; low Ki67. Overall, LOT behaved indolently (follow-up 9-72 months); only in one patient the tumor doubled its size in two years. In comparison, HOT showed atypical nuclei with prominent membranes and nucleoli. HOT showed CKIT+ and CK7- or focally+, AMACR+ and CD10+, as opposed to LOT, RO and ChRCC. Interestingly, CKpan immunoreactivity reflected a biphasic cellularity.

Conclusions

LOT and HOT are emerging entities with a peculiar phenotype that will be reported in the upcoming Genitourinary WHO. However, further clinico-pathological studies are needed for promoting the awareness and improving classification.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

THREE CASES OF UNUSUAL RENAL ENTITIES

F Cabutti 1, SS Arani 1, F Di Giovanni 1, C Manini 2

Abstract

Objectives

To describe the microscopic characteristics of a renal cell carcinoma with fibromyomatous stroma (RCC FMS), an eosinophilic vacuolated tumor (EVT) and a pigmented microcystic chromophobe renal cell carcinoma (PMChRCC).

RCC FMS are composed of clear cells arranged in elongated and branched tubules admixed to a stromal fibromuscular component that resembles leiomyomata.

EVT are composed of eosinophilic tumor cells with large intracytoplasmic vacuoles and prominent nucleoli (ISUP G3) arranged in solid sheets and nests.

PMChRCC are composed of eosinophilic and pale cells with raisinoid nuclei with perinuclear halo arranged in tubules and microcysts with pigment deposition.

All three entities are considered indolent tumors.

Matherials and methods

Histological specimens were obtained from a radical nephrectomy (RCC FMS) and two enucleoresections (EVT, PMChRCC).

Discussion

Our case of RCC FMS was a non-encapsulated nodule composed of pale cells with fibromuscular stroma and papillary growth. Stromal cells were positive for actin.

The EVT was composed of large oncocytic cells with vacuolated cytoplasm and prominent nucleoli arranged around small and big cystic spaces. The cells were positive for PAX8, CD117, AE1/AE3 and CD10.

The PMChRCC was composed of eosinophilic cells with perinuclear haloes arranged in tubules with heavy intra- and extracytoplasmic deposition of pigment. The cells were positive for Ck7 and Hale colloidal iron.

Conclusion

Even if these types of renal neoplasms are rare, it is useful to know about them because of the different prognosis than the more common variants.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

LOW METASTATIC POTENTIAL TO LYMPH-NODES OF ISOLATED CELLS AND CLUSTER-CORDS IN ISUP 5 PROSTATE ADENOCARCINOMA: A MORPHOLOGICAL ANALYSIS

M Cieri 1, V Belsito 1, A Bressan 1, G Elefante 1, P Colombo 1

Abstract

Objective

The definition of Gleason pattern 5 (GP5) in prostate adenocarcinoma (PC) includes four distinct morphologies: undifferentiated solid pattern (US), cribriform with necrosis (CN), cluster and cord cells (CC), and isolated single tumor cells (ISTC). We histologically characterized PC within a mono-institutional series of radical prostatectomy with lymph node metastases (LNM) to better understand these subpopulations of GP5.

Materials and methods

ISUP5/LNM+ cases were collected from 2784 consecutive pts. Subtypes of GP, volume, and topographical distribution were determined both for LNM and primary tumor. ISTC/CC, cribriform pattern (CR), and intraductal component in the primary tumor were recorded.

Results

We identified 79 ISUP5/LNM+ cases. GP5 was documented in 22/79 cases, either alone or in combination with other patterns. US, CN, ISTC and CC were documented in 16.4%, 10%, 6.3%, and 5% cases, respectively. Primary PC harbored ISTC in 35/79 cases, but it was rare in the associated LNM (3/35), and only as minor component (alone in one, with CC in one, with US in one). ISTC in LNM did not show differences in distribution (parenchymal, capsular, extra-capsular) compared with other patterns. Overall, 67% LNM were dominated by cribriform GP4. The presence of ISTC/CC did not correlate with pathological parameters analyzed.

Conclusions

ISTC/CC patterns are unfrequently observed in LNM, suggesting a different spreading way to disseminate when compared with CR. This low capability to spread into lymph nodes could be modulated on a genomic level, and further studies are ongoing to better understand the biology of these subtypes of GP5.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

SPOP MUTATIONS AND PD-L1 EXPRESSION IN PROSTATE CANCER

V Fiorentino 1, M Dell’Aquila 1, F Pierconti 1, G Fadda 2, M Martini 1

Abstract

Objectives

Anti-PDL-1 therapy in advanced prostate cancer has limited success to date. Recently, an inactivating mutation of SPOP gene has been demonstrated to determine a significant upregulation of PD-L1 expression in neoplastic cells 1. We therefore aimed to investigate SPOP mutations in a series of prostate carcinomas, correlating our results with PD-L1 expression, with clinical and pathological features.

Materials and methods

We retrospectively selected 153 prostate cancers, including a subset of 35 metastatic cases. We evaluated PD-L1 expression using the CPS and searched for SPOP mutations using an exone-sequencing. We also analyzed the functional effect of SPOP silencing on PD-L1 expression in two prostate cancer cell lines.

Results

PD-L1 was expressed in 21 cases with a significant association with metastatic disease and high Gleason grade. SPOP missense mutations were identified in 14 samples and 6 mutated samples showed a higher PD-L1 expression and a significant association with high Gleason grade group. After SPOP silencing in the two cancer cell lines, we found a significant higher expression of PD-L1 in comparison to control.

Conclusions

Our analysis identifies SPOP mutations as a cofactor in the high PD-L1 expression in prostate cancer, identifying a possible marker in the immunotherapy patients’ selection.

References

  • 1.Zhang J, Bu X, Wang H, et al. Cyclin D–CDK4 kinase destabilizes PD-L1 via cullin 3-SPOP to control cancer immune surveillance. Nature 2018;553:91-95. https://doi.org/10.1038/nature25015 10.1038/nature25015 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

VALIDATION OF A NOVEL THREE-DIMENSIONAL (3D Fusion) GROSS SAMPLING PROTOCOL FOR CLEAR CELL RENAL CELL CARCINOMA TO OVERCOME INTRATUMORAL HETEROGENEITY.

S Gobbo 1, M Brunelli 2,3, A Caliò 2, E Munari 4, G Martignoni 2,5

Abstract

Objective

Intratumoral heterogeneity in clear cell renal cell carcinoma (CCRCC) samples frequently results in bias when assessing morphological and molecular profiles of tumors.

We aimed to develop a novel method of sampling CCRCC to overcome heterogeneity.

Materials and Methods

100 cases of CCRCC were sampled utilizing three methods. 1: Standard sampling (1 block/cm of tumor). 2: The whole tumor was then sampled and cores were taken from each block to construct a tissue microarray. 3: The residual tissue was mapped in order to allow the reconstruction of the entire tumor mass and blocks 0.5 x 0.5 cm were taken. Six randomly derived blocks were placed in each cassette with the number of cassettes being based upon the diameter of the tumor in centimeters. Additional molecular drivers CD31/CD34 and PD-L1 were evaluated on 3D masses as Cohen’s kappa-statistics as a measure of interrater agreement.

Results

Tissue blocks taken per case ranged 33-198 and in total 5231 blocks were sampled. Immunohistochemical staining showed a mean of 90 vessels/mm2 for CD31 and 114 vessels/mm2 for CD34. Similar indices were obtained for 3D Fusion multisite sampling versus TMA cores, whereas poor concordance in between values from routine sampling versus TMA cores or 3D Fusion multisite samples (0.3 k-Cohen). 3D Fusion sections revealed three patterns: pattern A, homogeneous high vascular density (10%); pattern B, low density vascular profile (8%); pattern C, characterized by mixed heterogeneous angiogenetic signature (82%). PD-L1 expression was seen diffuse (7%), low (33%) and absent (60%) of cases after in toto 3D tumor inclusion. The Firehose and PanAtlasCancer databases, as well as the mRNA levels based on the large CCRCC cohort from The Cancer Genome Atlas, confirmed the relevance of antibodies tested.

Conclusions

Easy to apply 3D Fusion sampling negates bias due to tumor heterogeneity in CCRCCs.

References

  1. Gerlinger M, Rowan AJ, Horswell S, et al. Intratumor heterogeneity and branched evolution revealed by multiregion sequencing. New Eng J Med 2012;366:883-892. https://doi.org/10.1056/NEJMoa1113205 10.1056/NEJMoa1113205 [DOI] [PMC free article] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

PD-L1 EXPRESSION IN PAPILLARY RCCS VERSUS OTHER HISTOTYPES OF RCCS WITH PAPILLARY FEATURES

S Gobbo 1, P Mattiolo 2, A Caliò 2, G Martignoni 2,3, M Brunelli 2,4

Abstract

Objectives

Discordant data are reported on PD-L1 expression in papillary RCCs sec. WHO 2016. Major discordances are due to erroneous inclusion of other histotypes with papillary features. We aimed to report PD-L1 expression in papillary RCCs versus other histotypes with papillary features. Clinical implications may impact to patient prognostication and predictiveness.

Materials and methods

A series of consecutive papillary RCCs and other histotypes of RCCs with papillary features have been tested by both sp263 and E1L3N clones. Percentages of expression have been scored.

Results

Only 7% (3/42) of papillary RCCs did show PD-L1 expression. Both clones are positive in the same tumours. Only one out of three positive tumours showed > 50% of positive neoplastic cells. 17/20 (85%) collecting duct carcinoma with areas showing papillary features did show positive PD-L1 expression, such as most fumarate hydratase-deficient RCCs (3/5 positive tumours). 12 clear cell RCCs with areas picturing pseudo/papillae did not show any positive stains. Xp traslocation RCCs with diffuse pseudopapillae and papillary features showed and high percentages of positive cases (5/9, 56%).

Conclusion

1) papillary RCCs does show few cases with PD-L1 expression; 2) clear cell RCCs with papillary or pseudopapillae do not show PD-L1 expression; 3) other histotypes with papillary features such as collecting ducts with papillae, fumarate hydratase-deficient RCCs and Xp11 traslocations RCCs with diffuse papillae show high percentages of PD-L1 positive cases; 4) PD-L1 appears to be expressed in histotyopes of RCCs with papillary features harboring worse prognostication per se versus papillary RCCs which does rarely show expression.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

C-MYC DEREGULATION IN PENILE SQUAMOUS CELL CARCINOMA

S Lucà 1, A Ronchi 1, F Pagliuca 1, F Zito Marino 1, R Franco 1

Abstract

Objectives

The aim of this study is to investigate the eventual involvement of c-MYC in penile squamous cell carcinoma, testing the overexpression of c-MYC by immunohistochemistry and c-MYC rearrangements by fluorescence in situ hybridization (FISH).

Materials and methods

Our series included twenty-nine histologically diagnosed penile SCC. We performed an evaluation of c-MYC expression by immunohistochemical staining with anti-c-MYC (Y69) and c-MYC rearrangements with FISH (Kreatech KBI-XL006 probe).

Results

Of the twenty-nine penile SCCs: twenty-one (73%) were diagnosed as usual type SCCs, four (14%) were basaloid carcinomas, two (7%) were Warty carcinomas, one (3%) was verrucous carcinoma, and one (3%) was a Warty-basaloid carcinoma. By in situ hybridization (ISH) we have shown that most cases (20/29, 69%) were unrelated to chronic HPV infection.

Twenty-four (83%) penile SCCs were c-MYC positive by immunohistochemical staining and they were mostly non HPV-related SCCs (16/24, 66,6%). Evaluation by FISH showed a clear majority of non-rearranged penile SCCs (27/29, 93%) and the two rearranged cases showed a copy number gain.

Conclusions

In our penile SCCs series c-MYC protein is overexpressed by immunohistochemistry but c-MYC gene rearrangements have not been demonstrated by FISH. Therefore, c-MYC protein overexpression may be related to epigenetic alterations.

Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

PD-L1 EXPRESSION IN A SERIES OF PENILE CARCINOMAS: A NEW POTENTIAL PREDICTIVE BIOMARKER

R Sabetta 1, M Montella 1, F Pagliuca 1, F Zito Marino 1, R Franco 1

Abstract

Objectives

Penile Carcinoma (PC) is an extremely rare malignancy. While primary penile cancer can be managed surgically, patients at advanced stages have currently limited treatment options with disappointing results. Immune checkpoint inhibitors anti-programmed cell death 1 (PD-1)/programmed cell death ligand 1 (PD-L1) are currently changing the treatment of several tumors. To date, few data have been reported related to PD-L1 expression in PC 1. Our main aim was the evaluation of PD-L1 expression in tumor cells and tumor-infiltrating immune cells (TILs).

Materials and methods

A series of 73 PC, including 62 usual squamous cell carcinoma (USCC), 2 papillary types, 3 verrucous, 4 basaloid, 1 warty and 1 mixed (warty-basaloid) was collected. The immunohistochemistry was performed to assess PD-L1 expression using two different anti-PD-L1 antibodies (clone SP263 and SP142 Ventana).

Results

PD-L1 SP263 expression in tumor cells was found in 45 out of 73 cases (62%). PD-L1 SP142 expression in tumors cells was found in 9 out of 73 cases (12%). Furthermore, 47 out of 73 cases (64%) showed PD-L1 SP142 staining exclusively in TILs.

Conclusions

Our results showed a high incidence of PD-L1 expression in PC both in tumor cells and in TILs. Our findings provide a rationale for a new frontier in the treatment of PC patients based on the immune checkpoint inhibitors anti-PD-1/PD-L1.

References

  • 1.Davidsson S, Carlsson J, Giunchi F, et al. PD-L1 Expression in Men with Penile Cancer and its Association with Clinical Outcomes. Eur Urol Oncol 2019;2:214-221. https://doi.org/10.1016/j.euo.2018.07.010 10.1016/j.euo.2018.07.010 [DOI] [PubMed] [Google Scholar]
Pathologica. 2021 Oct 31;113(5 Suppl 1):S1–S74.

OVARIAN METASTASIS FROM RENAL CELL CARCINOMA: A CASE REPORT

S Squillaci 1, F De Trovato 1, M Chiudinelli 1, M Piccolomini 1, R Marchione 1

Abstract

Objectives

Renal cell carcinoma (RCC) accounts for approximately 2-3% of adult malignancies, with less than 55 cases of ovarian metastases of this tumor to date. Most of the RCCs spreading into the ovaries were clear cell types and presented as metachronous lesions. Differential diagnosis includes primitive ovarian neoplasms, as clear cell carcinoma, steroid cell tumors, disgerminomas and clear cell variants of struma ovarii.

Material and Methods

A 65-year-old woman was referred for a right ovarian mass. She had been treated, ten years before, with right nephrectomy for clear cell RCC and a local recurrence had been resected one year after. Her past medical history also included left mammary quadrantectomy for infiltrating NST ductal carcinoma in 2004. Abdominal CT showed a 55x40 mm right-sided hypervascular cystic mass with solid components.

Results

Gross examination showed a 8x6x4 cm hemorrhagic solid to cystic white-yellowish right ovarian mass. It was composed of cystic to compact and alveolar growth of large polygonal cells with clear cytoplasm, distinct cell boundaries, round nuclei and small nucleoli. The tumor cells were positive for CD10, vimentin, PAX8 and Cam.5.2 with negativity for CK7, CKHW, Sall-4, Napsin-A and glypican-3, thus confirming the morphological findings.

Conclusions

Metastasis from clear cell RCC to the ovary should be considered in the differential diagnosis of ovarian clear cell neoplasms. An additional troublesome problem is represented by rare aggressive variants of epithelial ovarian carcinomas with yolk sac tumor (YST) component that should be suspected when an unusual clear cell morphology and a heterogeneous immunohistochemical profile are seen.

Articles from Pathologica are provided here courtesy of Pacini Editore

RESOURCES