İpek Işık Gönül

DGKE Variants Cause a Glomerular Microangiopathy That Mimics Membranoproliferative GN

Renal microangiopathies and membranoproliferative GN (MPGN) can manifest similar clinical presentations and histology, suggesting the possibility of a common underlying mechanism in some cases. Here, we performed homozygosity mapping and whole exome sequencing in a Turkish consanguineous family and identified DGKE gene variants as the cause of a membranoproliferative-like glomerular microangiopathy. Furthermore, we identified two additional DGKE variants in a cohort of 142 unrelated patients diagnosed with membranoproliferative GN. This gene encodes the diacylglycerol kinase DGKε, which is an intracellular lipid kinase that phosphorylates diacylglycerol to phosphatidic acid. Immunofluorescence confocal microscopy demonstrated that mouse and rat Dgkε colocalizes with the podocyte marker WT1 but not with the endothelial marker CD31. Patch-clamp experiments in human embryonic kidney (HEK293) cells showed that DGKε variants affect the intracellular concentration of diacylglycerol. Taken together, these results not only identify a genetic cause of a glomerular microangiopathy but also suggest that the phosphatidylinositol cycle, which requires DGKE, is critical to the normal function of podocytes.

Topical Cyclosporine in Thyroid Orbitopathy-Related Dry Eye: Clinical Findings, Conjunctival Epithelial Apoptosis, and MMP-9 Expression

Objectives: To evaluate the effects of topical cyclosporine A (CsA) 0.05% (Restasis) on the signs and symptoms of dry eye, on apoptosis, and on MMP-9 expression in conjunctiva epithelial cells in thyroid orbitopathy (TO)-related dry eye patients. Methods: Prospective, clinical study. Twenty-four eyes of 12 consecutive TO patients with dry eye findings instilled CsA twice daily for 2 months. Ocular surface disease index, Schirmer tear test, tear breakup time (TBUT), conjunctival apoptosis index, and conjunctival MMP-9 expression were evaluated before and after 2 months treatment. Conjunctival biopsies were harvested from all eyes at baseline and after 2 months treatment. Apoptosis was detected by the terminal deoxynucleotidyl transferase-mediated dUTP-nick end labeling (TUNEL) assay. MMP-9 expression was determined by immunohistochemistry. Results: After 2 months of topical CsA treatment, the mean OSDI score was significantly decreased from 58.08 ± 6.28 to 36.41 ± 11.75 (P = 0.001). At baseline, the mean Schirmer tear test score was 8.92 ± 5.52 mm. It was increased to 11.25 ± 4.71 mm after treatment (P > 0.05). The mean TBUT increased significantly from 3.92 ± 2.18 sec to 9.16 ± 3.34 sec (P = 0.001). The mean percentage of apoptosis index at baseline was 72.10 ± 35.82%. This was significantly decreased to 53.29 ± 34.46% after treatment (P = 0.008). The mean percentage of MMP-9 expression of the conjunctival epithelial cells was significantly decreased from 48.12 ± 28.58% to 26.66 ± 25.13% following treatment (P = 0.005). Conclusions: Topical CsA treatment appears to improve the signs and symptoms of dry eye and inhibits apoptosis and MMP-9 expression in conjunctival epithelial cells in TO-related dry eye patients after 2 months of treatment.

Comparison of 1998 WHO/ISUP and 1973 WHO Classifications for Interobserver Variability in Grading of Papillary Urothelial Neoplasms of the Bladder

Aim: Our aim was to compare the interobserver variability between the 1998 WHO/ISUP and 1973 WHO classifications. Methods: 258 consecutive papillary urothelial carcinomas were reviewed by two pathologists and assigned a tumor grade according to the 1973 WHO and 1998 WHO/ISUP without the knowledge of primary diagnosis and clinical follow-up. All cases were also histologically staged by the two pathologists separately as follows: pTa (noninvasive), pT1 (lamina propria invasion only), pT2 (muscularis propria invasion). Findings of both pathologists and degree of agreement were compared statistically by using Pearson’s χ2 test and ĸ statistics respectively. A ĸ value of 0.21–0.40 is accepted as fair, 0.41–0.60 moderate and 0.61–0.80 substantial agreement. Results: Regardless of the pathologist, tumor grades of two classifications correlated to each other and the pathological stage (p < 0.05). Overall degree of agreement between pathologists was higher in the 1998 WHO/ISUP (ĸ 0.59) than the 1973 WHO (ĸ 0.41), but both were still moderate. Papillary urothelial neoplasia with low malignant potential was the group of 1998 WHO/ISUP that showed the lowest degree of agreement and if excluded, interobserver variability of the 1998 WHO/ISUP decreased significantly (ĸ 0.84). Conclusion: The diagnosis of papillary urothelial neoplasia with low malignant potential and the criteria that differentiates it from low-grade carcinomas needs improvement in order to compare the different studies and therapies and to provide more accurate information for management.

Tailgut cysts: diagnostic challenge for both pathologists and clinicians

Retrorectal area is a well-known space for the presence of some familiar lesions, like “sacrococcygeal teratoma” in children and a low-grade malignant tumor called “chordoma” in adults. However, a variety of congenital, inflammatory, and neoplastic lesions can occur in this area, but not famous enough to the practicing pathologist to be easily familiar with. Retrorectal cystic hamartoma or “tailgut cyst” is one of them. It is a benign, developmental lesion. In addition to its nonspecific and misleading clinical presentation, it can also confuse the pathologist while giving the definitive diagnosis. Patients who had multiple, unnecessary operations before the correct diagnosis was made had been reported in the literature. The largest series of 53 cases was collected over a 35-year period by Hjermstad and Helwig at the Armed Forces Institute of Pathology, Washington, DC, USA. Unfortunately, 51 out of 53 cases were not given the correct initial diagnosis of tailgut cyst. However, most of the pathologists were aware of that they were dealing with a benign, congenital, cystic process but had difficulty in further classifying it. A 37-year-old Turkish woman was admitted to our hospital with 3 months history of weakness in her legs with an accompanying low back pain. Her medical history included an appendectomy performed approximately 20 years ago and two cesarean sections. The transrectal ultrasound showed a well-defined cystic mass with dense internal echoes in the posterior rectal area, measuring 3.5×2.5 cm. Partial, minimal lobulation was identified in its posterior part. MRI revealed a well-circumscribed cystic lesion in the presacral area at the level of lower sacrum and coccyx. Another hypodense anococcygeal cyst was also identified. The left half of the sacrum showed hypoplasia. The patient had undergone an operation with the preoperative diagnosis of rectal duplication cyst based on the radiological findings. Both cysts were excised completely. Frozen section just revealed a benign simple cyst. Gross examination showed that both cysts are thin-walled and the larger one measures 3 cm in its maximum diameter. Cyst fluid was clear in appearance. Microscopically, different types of epithelium were identified lining the cyst walls. The cysts are mostly composed of stratified squamous epithelium and ciliated columnar epithelium, but low cuboidal to flat epithelium was also present. Fibrofatty tissue was seen in the underlying stroma with accompanying focal, mild mononuclear inflammatory cell infiltrate. No remarkable specific tissue fragments were identified in the wall, like bundles of well-formed smooth muscle fibers, adnexal elements of the skin, neural elements, and heterologous mesenchymal tissue, like cartilage or bone, which are all important in the differential diagnosis. The final diagnosis was a tailgut cyst. Developmental cysts of the retrorectal area are classified according to their origin and histopathological features as epidermoid cyst, dermoid cyst, enteric or rectal duplication cyst, cystic teratoma, and tailgut cyst. The precise nature of the tailgut cysts remains controversial. Middledorpf is believed to be the first author to consider that tumors of the retrorectal area are probably derived from remnants of the postanal intestine. In 1953, Hawkins and Jackman Int J Colorectal Dis (2007) 22:1283–1285 DOI 10.1007/s00384-006-0153-2

A comprehensive morphological study for basal-like breast carcinomas with comparison to nonbasal-like carcinomas

BackgroundBreast carcinomas can be classified into five subtypes based on gene expression profiling or immunohistochemical characteristics. Among these subtypes, basal-like breast carcinomas (BLBCs) are one of the most studied group, due to their poor prognosis. The aim of this study was to investigate the prevalance, morphological and immunohistochemical features of BLBCs, in Turkish population.MethodsFive hundred invasive breast carcinomas were reviewed for several morphological features and immunostained for oestrogen and progesterone receptors, c-ERB-B2, cytokeratin5/6, cytokeratin14, vimentin and epidermal growth factor receptor (EGFR). Basal-like breast carcinoma was defined as a triple negative tumor with cytokeratin5/6 and/or EGFR positive.ResultsThe prevalance of BLBC was 9.6%. All medullary carcinomas and 55.6% of metaplastic carcinomas showed basal-like immunophenotype. Patients with BLBC were younger (p=0.04) and had higher-grade tumors (p<0.0001). Morphologic features associated with BLBC included increased mitosis, nuclear pleomorphism, presence of geographic and/or central necrosis, pushing margin of invasion and stromal lymphocytic response (p<0.0001). Presence of prominent nucleoli and vesicular nuclear chromatin were the cytological features correlated with basal-like phenotype (p<0.0001). On multivariate analyses, BLBCs were associated with high mitotic number (p<0.0001), the presence of vesicular chromatin (p=0.004), high tubular grade (p=0.011), lymphocytic response (p=0.031) and the absence of carcinoma insitu (p=0.039). Vimentin was positive in 53.2% of BLBCs, while cytokeratin14 was less frequently expressed (27.7%).ConclusionsBLBCs have some distinctive, but not pathognomonical, morphological features. Paying attention to these features and adding cytokeratin14 and vimentin to the immunohistochemical panel can help the definitive diagnosis of BLBCs.Virtual slidehttp://www.diagnosticpathology.diagnomx.eu/vs/5962175467857400

Micropapillary Pattern in Urothelial Carcinoma: A Clinicopathological Analysis

Objectives: Our aim was to review our pathological archive to find out the actual incidence of micropapillary pattern (MPP) in our urothelial carcinoma patient population and determine its correlation with clinical outcome. Patients and Methods: 14 out of 170 cases with complete clinical follow-up were clinicopathologically analyzed. The extent of MPP was determined as tumor percentage. Results: 12 further cases with MPP were defined in the review. The percentage of patients with positive MPP increased in parallel to the tumor stage. There was no considerable difference between MPP-positive and MPP-negative groups according to the progression rates in non-muscle-invasive and muscle-invasive groups. Progression-free survival was much shorter in MPP cases, but again without statistical significance. Also, there was no significant relation between percentage of MPP and progression-free survival. Conclusions: Awareness of pathologists about MPP and its highly possible relation with aggressive behavior must be raised, as it may be more common than reported. A multicentric review of a large number of cases with MPP is needed for a better definition of its biological behavior. Focal MPP cases may have a better prognosis but this needs to be confirmed.

Mycophenolate mofetil treatment of crescentic Henoch-Schönlein nephritis with IgA depositions.

Mycophenolate mofetil (MMF) is considered to be a promising therapeutic agent in primary glomerulonephritis but there are no data on the use of MMF in Henoch–Schönlein nephritis (HSN). Herein we report the first adult crescentic HSN patient in whom long-term complete remission was achieved after MMF therapy.

Pauci-immune necrotizing crescentic glomerulonephritis with crescentic and full moon extracapillary proliferation: clinico-pathologic correlation and follow-up study.

The prognostic value of the type and extent of extracapillary proliferation (ECP) in pauci-immune necrotizing crescentic glomerulonephitis (PIGN) was evaluated in this study. In 141 PIGN cases, all glomeruli with ECP were grouped according to type (cellular, fibrocellular and fibrous) and extent of the lesions in Bowmans space; (segmental, semicircumferential and circumferential, which might be termed full moon-FM). Cases with cellular and fibrous lesions involving ≥ 50% of glomeruli with ECP were classified as cellular and fibrous groups, respectively, while the remaining cases were classified as fibrocellular. Cases with segmental and circumferential (FM glomerulus) lesions involving ≥ 50% of glomeruli with ECP were classified as ECPI and ECPIII (FM) groups, respectively, while the rest were classified as ECPII. All the cases were classified according to Berden et al. Significant results were only nearly obtained for the FM group, including the need for dialysis. The Cox regression model revealed a 2.6-fold risk for FM cases regarding dialysis requirement. We propose that the percentage of FM glomeruli should be noted in the pathology report, and cases with more than 50% of FM glomeruli (FM group) should be identified in the group with increased risk of dialysis requirement. Our series also suggests that classification according to Berden et al. is of clinical relevance.

Renal Tissue Damage After Experimental Pyelonephritis: Role of Antioxidants and Selective Cyclooxygenase-2 Inhibitors

OBJECTIVES To investigate the involvement of oxidative stress in the pathogenesis of acute pyelonephritis, and to evaluate the impact of meloxicam and/or L-carnitine in addition to conventional antibiotic treatment. METHODS A total of 48 Wistar rats were divided into 4 groups according to their treatment, which was started 1 day after inoculation of all rats with Escherichia coli (ATCC 25 922, 10(10) cfu/mL). Group 1 received only antibiotic treatment with ceftriaxone (50 mg/kg, IM). Groups 2 and 3 received L-carnitine (500 mg/kg, IM) and meloxicam (3 mg/kg, IM) in addition to conventional treatment, respectively. Group 4 received combination therapy (L-carnitine and meloxicam) in addition to the first group. Rats were killed 3 and 7 days after E. coli inoculation and underwent nephrectomy. Histologic determination of tubular atrophy, acute and chronic inflammation, interstitial fibrosis and biochemical determination of superoxide dismutase and catalase activity, total thiol content, total antioxidant capacity, and malondialdehyde and protein hydroperoxide levels were measured. RESULTS Interstitial fibrosis (P = .06), chronic inflammation (P = .536), and tubular atrophy (P = 0.094) decreased in group 4 compared with the other groups, but there was a statistically significant decrease only in acute inflammation (P = .015). In addition, if the day of nephrectomy is considered, there was again a significant decrease in acute inflammation on day 7 compared with day 3 in groups 2, 3, and 4 (P = .002). Catalase significantly increased in group 2 (P = .029), group 3 (P = .02), and group 4 (P = .014), and decreased in group 1 (P = .012) in day 7. CONCLUSIONS L-carnitine and meloxicam alleviated oxidative stress, probably by decreasing lipid peroxidation and enforcing antioxidant defense system. Acute renal inflammatory injury can be prevented much more effectively by combination therapy rather than by conventional therapy alone.

Graft Inflammation and Histologic Indicators of Kidney Chronic Allograft Failure: Low-Expressing Interleukin-10 Genotypes Cannot Be Ignored

Background. Infiltration of inflammatory cells into the renal allograft interstitium is the biologic hallmark of alloimmune responses that leads to tubulointerstitial injury and subsequent interstitial fibrosis and chronic allograft failure. The proliferation, stimulation, and infiltration of these inflammatory cells are governed by various proinflammatory and regulatory cytokines. We assessed whether the differences in the genes encoding cytokines (producing low, moderate, or high expression profiles) may affect the infiltration of inflammatory cells into the renal allograft and the histologic changes characteristics of chronic allograft failure. Methods. A total of 218 kidney transplant recipients were genotyped for 15 single-nucleotide polymorphisms located in the gene promoter or exonic regions of 10 different cytokines or their receptors. Six- to 12-month posttransplant surveillance biopsies were scored using 11 individual histologic parameters and the combined grade of interstitial fibrosis and tubular atrophy (IF/TA). B-cell, T-cell, and macrophage infiltrates were quantified by immunostaining. Results. The low-expressing interleukin (IL)-10 gene promoter genotypes were found significantly associated with high IF/TA grade (IL-10 −819 TT; P=0.035; odds ratio=3.27; 95% confidence interval 1.1–9.8). At individual histologic indices, recipients carrying low-expressing IL-10 genotypes showed 2.5-fold higher scores for interstitial fibrosis, inflammation, and tubular atrophy. High infiltration of T cells and macrophages but not B cells into the renal allograft interstitium was found strongly associated with the carriage of low-expressing IL-10 genotypes. Conclusions. The results suggest that renal transplant recipients genetically predisposed to low expression of the regulatory cytokine IL-10 are more susceptible to high grades of IF/TA scores, graft inflammation, and high influx of inflammatory cells into the graft interstitium.