Claudio Cacchi

The clinical significance of lymph node size in colon cancer

To date, the clinical value of lymph node size in colon cancer has been investigated only in a few studies. Only in radiological diagnosis is lymph node size routinely recognized, and nodes ≥10 mm in diameter are considered pathologic. However, the few studies regarding this topic suggest that lymph node size is not a reliable indicator of metastatic disease. Moreover, we hypothesized that increasing lymph node size is associated with favorable outcome. By performing a morphometric study, we investigated the clinical significance of lymph node size in colon cancer in terms of metastatic disease and prognosis. A cohort of 237 cases with excellent lymph node harvest (mean lymph node count: 33±17) was used. The size distribution in node-positive and -negative cases was almost identical. In all, 151 out of the 305 metastases detected (49.5%) were found in lymph nodes with diameters ≤5 mm. Only 25% of lymph nodes >10 mm showed metastases. Minute lymph nodes ≤1 mm were involved only very rarely (2 of 81 cases). In 67% of the cases, the largest positive lymph node was <10 mm. The prognostic relevance of lymph node size was investigated in a subset of 115 stage I/II cases. The occurrence of ≥7 lymph nodes that were >5 mm in diameter was significantly associated with better overall survival. Our data show that lymph node size is not a suitable factor for preoperative lymph node staging. Minute lymph nodes have virtually no role in correct histopathological lymph node staging. Finally, large lymph nodes in stage I/II disease might indicate a favorable outcome.

Methylene blue-assisted lymph node dissection technique is not associated with an increased detection of lymph node metastases in colorectal cancer

Lymph node staging is of paramount importance for prognosis estimation and therapy stratification in colorectal cancer. A high number of harvested lymph nodes is associated with an improved outcome. Methylene blue-assisted lymph node dissection effectively improves the lymph node harvest and ensures sufficient staging. Now, the effect on node positivity rate and stage-related outcome was investigated. The study cohort with advanced lymph node dissection consisted of 669 colorectal cancer cases of all stages, which were collected between 2007 and 2012. A historical collection of 663 cases investigated with conventional techniques between 2002 and 2004 served as control. Lymph node harvest was dramatically improved in the study group with mean lymph node numbers of 34±17 vs 13±5 (P<0.001) and sufficient staging rates of 98% vs 62% (P<0.001). However, neither the rate of nodal positive cases (37% vs 37%; P=0.98) nor the rate of N2 cases differed between the two groups (14% vs 13%; P=0.80). Furthermore, no differences were found concerning the outcome in both groups. The advanced lymph node dissection technique guarantees adequate histopathological lymph node staging in virtually all cases of colorectal cancer and is therefore extremely helpful. The hypothesis that it also provides a higher sensitivity in detecting metastases, however, could be not proved.

A primary cutaneous adenoid-cystic carcinoma in a young woman. Differential diagnosis and clinical implications

Primary cutaneous adenoid-cystic carcinoma (PCACC) is a rare slow-growing neoplasm of disputed histogenesis characterized by a cribriform pattern at histology and local aggressive behaviour. Up to date about 60 cases of PCACC have been reported in the literature. This tumour is most common in the scalp, affects middle-aged and older individuals (mean age 59) and has predilection for women. We describe an unexpected case of PCACC in a 32-years-old woman referred to our clinic for a subcutaneous nodule in the scalp showing a slow growth and indolent course. The differential diagnosis and the clinical management of this PCACC patient, successfully treated with a wide local excision, are presented and discussed.

Primary malignant tumour of the lung with neuroendocrine and melanoma differentiation.

Melanocytic differentiation has been described in rare cases of melanin-containing neuroendocrine tumours of the lung [1–5], thyroid [6] and thymus [7]. In some of the cases, neuroendocrine granules and melanosomes were lying free in the cytoplasm of tumour cells, thus indicating true coexpression of melanocytic and neuroendocrine differentiation. On the other hand, neuroendocrine differentiation, consisting in the presence of neuroendocrine granules at ultrastructural level and of intense immunostaining for chromogranin-A and synaptophysin, was described in three cases of cutaneous and mucosal malignant melanomas [8]. Divergent differentiation towards unrelated embryological tissue has been reported in malignant melanoma [9]. So far, cases of neuroendocrine carcinoma with associated melanomatous component in the lung have not been described. There is growing evidence that tumour development may derive from neoplastic transformation of adult stem cells [10]. In a recent publication, it was reported that in the human skin there is a SOX2-positive stem cell capable of differentiation along the neuroendocrine or melanocytic lines [11]. In the present report, we describe the first case of a malignant neoplasm of the lung showing unambiguous differentiation towards neuroendocrine carcinoma and malignant melanoma.

An unusual case of exclusive liver metastases from adenoid cystic carcinoma of the submandibular gland: A role for surgery? Report of a case

Adenoid cystic carcinoma (ACC) is a relatively rare tumor of the salivary glands, accounting for approximately 5%–10% of all salivary gland tumors. An important feature of ACCs is the long clinical course with a high rate of distant metastases, with an incidence of more than 40% for ACC of submandibular glands. The preferential sites of metastases are the lung and bone, followed by the brain and liver. Most liver metastases are derived from nonparotid ACCs, and the presentation is often related to local recurrence or metastases to other organs. We herein report the case of a patient with liver metastases treated by a hepatectomy, which occurred 18 months after the primary resection of an ACC of the submandibular gland. We furthermore review the literature concerning the management of these tumors.

Disseminated Superficial Porokeratosis with Dermal Amyloid Deposits

Only 6 cases with an association of disseminated superficial porokeratosis with dermal amyloid deposits are reported in the literature. We present the case of a 76-year-old woman who presented with a disseminated superficial porokeratosis. Histological examination revealed amyloid deposits in the upper dermis, which were typed with routine HE stains, Congo red stains and anticytokeratin antibodies (AE1-AE3 and CK5). Positive staining with Congo red and, moreover, with CK5 (a cytokeratin strongly represented in the basal cell layer of the epidermis) indicates an epidermal origin of this protein.

Primary Adenocarcinoma of the Renal Pelvis Histologic Features of a Stepwise Process From Intestinal Hyperplasia to Dysplasia in a Patient With Chronic Renal Abscess

Pure adenocarcinomas of the urothelium are very rare and their location in the pelvis is uncommon. Although their pathogenesis is not well defined, adenocarcinomas are likely to originate from neoplastic transformation of the glandular cells of the urothelial intestinal metaplasia usually arising in response to chronic irritating stimuli, such as long-duration inflammation, urolithiasis, and hydronephrosis. We report a case of an 81-year-old woman who underwent right nephrectomy for relapsing renal abscess due to a staghorn calculus. Histological examination disclosed an infiltrating adenocarcinoma arising from a tubulovillous adenoma with the surrounding pelvic mucosa showing a sequence of intestinal metaplasia, low- and high-grade villous adenoma, and invasive adenocarcinoma, supporting the hypothesis of cancer progression due to chronic inflammation from the urothelium through the metaplasia step.

A very unusual thyroid tumor: a nodule with mature fat papillary hyperplasia and focal atypia

Fat-containing lesions of the thyroid are rare, encompassing several clinical-pathological conditions such adenolipomas, thyrolipomatosis and lipomotous tissue in case of amyloidosis. Furthermore, cases of papillary thyroid carcinoma have been identified in association with thyrolipomatosis. We report a case of 51 years old man referred to surgery for a multinodular goiter, showing multiple cystic and hemorrhagic nodules of up to 3 cm. One of these lesions showed features of papillary hyperplasia with focal cytological atypia and mature fat. Here, we describe and discuss the histological and immunophenotypical features of this rare lesion.

A Case of Ketron-Goodman Disease

Pagetoid reticulosis (PR) is a rare form of cutaneous T-cell lymphoma [Mod Pathol 2000;13:502–510]. Two variants of the disease are described: the localized type Woringer-Kolopp disease (WKD) and the disseminated type Ketron-Goodman disease (KGD). KGD may have disseminated lesions, high rate of recurrence and a guarded prognosis [Mod Pathol 2000;13:502–510]. In patients with KGD, therefore, long-term observation is necessary. Disappearance of cutaneous lesions does not mean resolution of the disease [J Am Acad Dermatol 2002;47:183–186]. Herein we report the case of an 84-year-old man with erythematous patches of the trunk and the upper and lower extremities in whom the diagnosis of KGD was made. We describe this case for the rarity of this pathology and for the good response to therapy (IFN).

Hyperbaric oxygen therapy in a case of cholesterol crystal embolization.

Cholesterol crystal embolism (CCE) is a multiorgan disease, with a high morbidity and mortality rate. This syndrome may occur spontaneously, but more often is a severe iatrogenic complication of an invasive vascular procedure. It is an increasing and still underdiagnosed disease; in fact, its real incidence is unknown. Skin and kidneys are most frequently involved, but any organ can be affected. Biopsy of the ischemic lesions is essential for diagnosis. There is still no established standard treatment of CCE. We report the case of a 56-year-old man who developed CCE with involvement of skin and kidneys 2 weeks after coronary angioplasty. After a long, unsuccessful treatment with high-dose statins, prednisone, and iloprost, hyperbaric oxygen therapy was effective to improve ischemia of distal extremities and renal function and to relieve pain. This is the first case in which the efficacy of hyperbaric oxygen in CCE was tested. Cholesterol crystal embolism (CCE) syndrome is a multisystemic disorder that may occur either spontaneously or as a potential complication after coronary artery bypass grafting, arterial catheterization, or anticoagulant and fibrinolytic therapy. This syndrome is a multiorgan disease due to the displacement of atheromatous material dislodged from unstable plaque to arteriolar vessels, resulting in local ischemia and end-organ damage. Cholesterol crystal embolism was first described by Panum in 1862 [1]. Clinical manifestations of CCE are various, depending on sites of embolization, and may include cutaneous manifestations with livedo reticularis, acrocyanosis and ecchymotic nodules, renal failure, neurologic defects, pancreatitis, gastrointestinal ischemia, and visual defects. It is often associated with hypereosinophilia and with increased level of the markers of inflammation. The real incidence of CCE is unknown. The diagnosis is difficult, and histologic confirmation is essential. Biopsy specimen characteristically shows presence of cholesterol crystal within the lumen of blood vessels. Today, the optimal therapy is still not 0735-6757/