Francesco Piscioli

Human nasal rhinosporidiosis: an Italian case report

BackgroundRhinosporidiosis is a disease affecting primarily the mucosa of nose, conjunctiva and urethra. It is endemic in some Asiatic regions, affecting people of any age and sex. Its manifestation is a polypoid mass growing inside the affected cavity and the only treatment is surgical excision. Rhinosporidium seeberi is the aetiological agent. Many discussions arouse regarding the taxonomic classification of the microorganism, recent studies established it is an aquatic protistan parasite. The lesion may recur and sometimes cause osteolytic bone lesions. In endemic areas it is not easy to establish if recurrent lesions are due to relapse or reinfection.Case presentationA 26-year-old male patient from India, resident in Italy since 2005, presented in March 2006 with a history of nasal obstruction of three months duration. Physical examination showed an erythematous, papillomatous mass, 3 cm in diameter, obstructing the right nasal cavity. A microscopic diagnosis of rhinosporidiosis was made. Few Italian human cases of this disease have been previously reported in the literature.ConclusionRhinosporidiosis is a condition which both clinicians and pathologists should keep in mind when managing patients from endemic countries with nasal masses. Moreover, it is very interesting in such cases to follow the clinical course: an eventual recurrence of the lesion in our patient would mean a true relapse, excluding the possibility of a reinfection, more probable in the endemic areas.

Squamous cell carcinoma with sarcoma-like stroma of the nose and paranasal sinuses: report of two cases.

Two cases of squamous cell carcinoma with sarcoma‐like stroma of the nose and paranasal sinuses are described. To the best of our knowledge, this is the first report of such a localization for this tumour type. Keratin was localized by immunocytochemistry in the epithelial cells, as well as in occasional stromal‐like elements. The importance of distinguishing these tumours from morphologically similar neoplasms is emphasized in view of their different therapeutic approach.

True sarcomatoid carcinoma of the renal pelvis: first case report with immunocytochemical study

A case of sarcomatoid carcinoma of the renal pelvis is reported. The neoplasm showed polypoid configuration and was composed exclusively of plump, spindle and pleomorphic cells. Light microscopy did not reveal any epithelial differentiation of the neoplastic cells. Immunoperoxidase staining for keratins and for epithelial membrane antigen was strongly positive in the spindle elements and showed the epithelial nature of the proliferation. The present case suggests that pleomorphic tumors, when occurring in visceral organs, should be carefully sampled and immunocytochemical markers for epithelial and sarcomatous differentiation studied, before diagnosis of carcinosarcoma or sarcoma may be accepted.

Aspiration cytology in the staging of urologic cancer

Knowledge of the status of the pelvic lymph nodes is vital for accurate staging and adequate treatment of patients with urologic cancer. Noninvasive techniques for assessing the lymphatic spread of urologic neoplasms have proved to be of limited value. Bipedal lymphangiography and percutaneous fine needle aspiration cytology under fluoroscopic guidance were performed for staging purposes in 71 patients with clinically localized bladder, prostatic and penile cancer from 257 nodal chains. The overall diagnostic accuracy was 93% and the correct aspiration of 186 lymph nodes was surgically confirmed. There were 11 (6%) false‐negative biopsy results and no false‐positive diagnoses. Aspiration cytology is a safe, well tolerated, accurate, and rapid method of determining the presence of metastatic disease in lymphangiographically visualized pelvic nodes. In the management of prostatic carcinoma, positive cytologic results are diagnostic of nodal metastatic involvement and spare the patients unnecessary surgical staging. Negative cytologic findings may be considered diagnostic of localized disease in the patients with well differentiated prostatic carcinoma (2–4 Gleasons sum). Since most surgeons are reluctant to perform a staging lymphadenectomy in the management of invasive bladder carcinoma, aspiration cytology can provide accurate staging, thus permitting an appropriate treatment plan. In patients with carcinoma of the penis, a positive aspirate permits an early and even curative lymphadenectomy in cases with clinically negative but pathologically positive nodes.

Herpesvirus 8-associated Penile Kaposi's Sarcoma in an Hiv-negative Patient: First Report Of A Solitary Lesion

&NA; Kaposis sarcoma is a neoplastic vascular lesion. Its form of onset is frequently disseminated, especially in HIV‐positive patients. Its association with the infection caused by a virus of the Epstein‐Barr family, human herpesvirus 8 (HHV‐8), has been recently demonstrated. In this article we discuss the unusual presentation of a solitary manifestation of Kaposis sarcoma on the penis of a 53‐year‐old HIV‐negative patient. Polymerase chain reaction analysis of the tumor tissue was positive for HHV‐8 in the tumor cells but not in the reactive stroma cells surrounding the tumor. The case is interesting for its unusual site of presentation, the young age of onset, the association with HHV‐8 infection, the HIV‐negative serology, and the benign course of the disease.

Value and role of percutaneous regional node aspiration cytology in the management of penile carcinoma.

The determination of the status of regional draining lymph nodes is crucial in the prognosis and treatment of penile carcinoma. Tumor staging is inaccurate without histologic examination of the nodes, but the high attendant morbidity rate of lymphadenectomy mandates careful case selection rather than routine prophylactic dissection. Since the penile and pedal lymphography opacifies all lymph nodes involved by penile carcinoma, fine needle aspiration cytology of regional nodes is an innocuous, accurate, easy, and inexpensive diagnostic procedure and alternative to surgical staging in determining the nodal extension of neoplasm. Positive cytology enables rapid, early and even curative lymphadenectomy in patients with clinically negative but microscopically positive nodes. Since radiopaque contrast medium opacifies the nodes for 6-9 months, repeated fine needle aspiration cytology may be used for accurate, careful and regular follow-up examination of patients with penile carcinoma.

Histopathological determination of thin melanomas at risk for metastasis.

The current staging system for melanoma of the American Joint Committee on Cancer uses the Breslow thickness as the primary attribute; up to 1-mm-thick melanoma is defined as thin because it shows a good prognosis after surgical excision, with a 10-year survival rate of 85–90% in the case of tumor-free margin of at least 1 cm [1]. However, there is a subset of patients affected by thin melanoma, who develop nodal or distant metastases with worse prognosis. Although several clinical and histological features, such as sex, age, site, thickness, ulceration, and growth phase, have been considered over the years, the identification of a highrisk thin melanoma remains challenging [2,3]. For this reason, we have read with great interest the paper of Glazer et al. [4], in which the authors have investigated by quantitative histopathology 28 thin melanoma (18 patients with nonmetastatic disease and 10 patients with metastatic disease). Kariometric features have been used to discriminate between nuclei from indolent and potentially metastatic lesions. The results obtained by Glazer and colleagues support the hypothesis that thin melanoma contains two phenotypes of nuclei and only one type predominates in metastasizing thin melanomas. In fact, the authors conclude that kariometry may play a role in decision-making for patients affected by thin melanoma. Cutaneous melanoma generally evolves through three well-discernible progression steps. At first, transformedmelanocytes proliferate above the epidermal basement membrane (in-situ or the epidermal radial growth phase), then they invade the papillary dermis (microinvasive radial growth phase) and, subsequently, acquire the capacity to grow as a well-known malignancy (invasive vertical growth phase). In more detail, microinvasive melanoma is a nontumorigenic radial growth phase of cutaneous melanoma, which invades the superficial dermis, without forming a tumor nodule or papule, in the absence of regression [5]. In contrast, the microinvasive radial growth phase of cutaneous melanoma with regression may rarely metastasize and, for this reason, the lesion should be recognized and it could be also categorized as ‘microinvasive radial growth phase of uncertain tumorigenic potential’ [6–8]. The early vertical growth phase and the radial growth phase with regression are burdened by a statistical chance for distant metastases [9]. Therefore, thin melanoma includes four main histological subtypes, which reflect a specific biological behavior: the in-situ epidermal radial growth phase, the nontumorigenic microinvasive radial growth phase, the microinvasive radial growth phase with regression of uncertain tumorigenic potential, and the tumorigenic early vertical growth phase. In conclusion, thin melanoma can be considered a generic term and its subtypes should be histologically distinguished beyond its site of origin (acral versus nonacral) because they have a different prognostic relevance. The quantitative histopathology could be of greater utility if applied taking into account the four histopathological subtypes of thin melanoma shown here.

Aspiration Cytology of Simultaneous Bilateral Adrenal Metastases From Renal Cell Carcinoma. A Case Report and Review of the Literature

We report the computerized tomography and ultrasound-guided aspiration cytology results in the first case of renal cell carcinoma with bilateral adrenal involvement. The adrenal metastases were evident clinically 6 years after radical nephrectomy and were treated successfully by an operation. Aspiration cytology under computerized tomographic and sonographic guidance is an excellent procedure to evaluate enlarged adrenal glands in patients with renal cell carcinoma or other malignant neoplasms.

Wisely choosing thin melanomas for sentinel lymph node biopsy

To the Editor: The routine use of sentinel lymph node (SLN) biopsy (SLNB) in the management of thin melanomas is controversial. For this reason, we read with great interest the article of Wat et al in which the authors examined 1072 cases of melanoma submitted to SLNB. Among these, 171 cases were thin melanomas and 15 of them (8.8%) showed SLNB positivity. Today, the scientific community is precisely focusing on the clinical significance of different histologic subtypes of thin melanoma. The current staging system for melanoma of the American Joint Committee on Cancer uses Breslow thickness as the primary attribute and up to 1-mmthick melanoma is defined as ‘‘thin’’ because it shows good prognosis after surgical excision, with 10-year survival of 85% to 90% in case of tumor-free margin of at least 1 cm. Wat et al argued that mitotic rate does not have unequivocal utility in predicting SLNB status in thin melanomas and that there is a significant interaction between mitotic rate and Breslow depth, so the predictive value of mitotic rate on SLN positivity may be dependent on Breslow thickness. From our point of view, thin melanoma can be categorized in the following 4 histologic subtypes, which reflect specific biological attitudes: (1) epidermal (in situ) radial growth phase (RGP); (2) nontumorigenic microinvasive RGP without regression; (3) microinvasive RGP with regression of uncertain tumorigenic potential; and (4) tumorigenic early (#1.00 mm) invasive vertical growth phase (VGP). In the period 2004 to 2012, we examined SLNB of 42microinvasive RGPwithout regression, 18 microinvasive RGP with regression, and 10 early invasive VGP. Metastases to SLNwere found in only 3 cases of microinvasive RGP with regression (0.751.00 mm depth) and in 5 cases of early mitogenic invasive VGP. Therefore, ‘‘thin melanoma’’ can be considered a generic term and its subtypes should be histologically distinguished, because they have different prognostic relevance. According to our experience, SNLB should be performed in cases of microinvasive RGP with regression and early

The role of etretinate (Tegison; Tigason) in the management of keratoacanthoma

Four patients with keratoacanthomas 2 to 3 cm in size were treated with etretinate. All the patients demonstrated early response and complete regression of the lesions. Follow-up (of 24 months in one case) did not reveal any recurrence.