Ivana Mrklić

Expression of androgen receptors in triple negative breast carcinomas.

Triple negative breast cancer (TNBC) consists of a group of tumors with poor prognosis, owing to aggressive tumor biology and lack of targeted therapy. The aim of this study was to assess the immunostaining for androgen receptors (ARs) in the group of TNBC, in addition to basal-like (BL) immunophenotype, BL morphology and conventional clinicopathological factors and to demonstrate its prognostic relevance in this group of tumors. The study included 83 patients. Slides were stained immunohistochemically for estrogen and progesterone receptors, HER2, CK5/6, CK14, EGFR, Ki-67 and AR. Of the 83 TNBC samples, 32.5% showed positive immunostaining for AR, 66.3% had BL immunophenotype, and 48.2% had BL morphology. Positive AR immunostaining was inversely correlated with higher clinical stage, higher mitotic score, higher histological grade and higher proliferation index measured by Ki-67. Significantly more AR negative tumors were observed among the tumors with BL immunophenotype and BL morphology. There was no significant association between positive AR immunostaining and disease free survival or overall survival. More than one third of TNBC were AR-positive, and this represents a potential opportunity for novel targeted treatment in the group of breast tumors for which therapeutic options are currently limited.

Prospective validation of Alvarado score and Pediatric Appendicitis Score for the diagnosis of acute appendicitis in children.

Objectives The purpose of this study was to compare the results of the Alvarado and Pediatric Appendicitis Score (PAS) scoring systems and to establish which one is more reliable in setting the diagnosis of acute appendicitis in children. Methods All children operated on because of acute appendicitis from October 2011 to May 2013 were enrolled in this prospective study. Both clinical scoring systems have been compared over the same patients, and cutoff values were determined by the receiver operating characteristic curve analysis. Results A total of 311 patients were included in the study, and 265 (85.2%) of them had acute appendicitis. Mean Alvarado score for patients with appendicitis was 8.2 and 6.7 for those without (P < 0.001). Mean PAS for patients with appendicitis was of 7.8 and 6.6 for those without (P < 0.001). Based on the ROC curve analysis, a cutoff value for both scoring systems was 7. In patients with acute appendicitis and Alvarado score of 7 or higher, the correct diagnosis would have been set in 236 patients (sensitivity, 89%; specificity, 59%; positive predictive value, 93.1%), whereas in patients with acute appendicitis and a PAS of 7 or higher, the correct diagnosis would have been set in 228 patients (sensitivity, 86%; specificity, 50%; positive predictive value, 90.1%). No significant difference was found in sensitivity and specificity between the observed scoring systems. Conclusions Both scoring systems can be of assistance in setting the diagnosis of acute appendicitis, but none has adequate predictive values in assessing acute appendicitis and none can be used as an exclusive standard in setting the diagnosis of acute appendicitis in children. The final decision still remaines on the opinion of an expert pediatric surgeon.

The significance of immunohistochemical expression of merlin, Ki-67, and p53 in meningiomas.

Meningiomas are one of the most common CNS tumors whose appearance is closely linked to NF2 gene product merlin. Tumor markers Ki-67 and p53 play established role in tumor progression which should be analyzed in close association with merlin expression. The aim of this study was to investigate the immunohistochemical expression of merlin in meningiomas, correlation with Ki-67 and p53, and to determine the association of these results with histologic grade and subtype. The histologic sections of 170 patients with totally resected meningiomas, between January 2000 and December 2010, were classified according to WHO, immunohistochemically stained for Ki-67, p53, and merlin, and analyzed using light microscope. Ki-67 median was 5.6 times higher in group of patients with negative merlin than in those with positive merlin (P=0.05). Statistically significant correlation of merlin with p53 was found (P<0.001). Merlin expression between 2 combined groups (meningothelial/secretory and fibroblastic/transitional) was statistically significant (P=0.002). By comparing merlin expression and p53 levels, statistically significant difference was found (P=0.017). In the group with positive merlin and negative p53 as well as positive merlin and low p53, meningothelial/secretory subtypes of meningiomas were more common. In combination of negative merlin and negative p53 as well as negative merlin and high p53, there were more meningiomas of fibroblastic/transitional subtype. There was no statistically significant correlation between merlin and tumor grade (P=0.420). There is undeniable influence of merlin on the development and the proliferative ability of meningioma subtypes. Significant role of p53 pathway was confirmed.

Expression of topoisomerase II-α in triple negative breast cancer.

Triple negative breast cancer (TNBC)—defined by estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 negativity is a group with poor prognosis, due to aggressive tumor biology and lack of targeted therapy. Topoisomerase II-&agr; (topoII&agr;) protein is one of the intracellular targets for anthracycline-based therapy, and high levels of topoII&agr; expression are recently observed in TNBC. The study included 83 patients who underwent surgery between January 2003 and December 2009. Paraffin blocks were stained immunohistochemically with CK5/6, CK14, EGFR, Ki-67, and topoII&agr;. Basal-like (BL) immunophenotype was defined by positivity for ≥1 basal cell markers: CK5/6, CK14, or EGFR. Of 83 TNBC, 66.26% were of the BL immunophenotype, which was significantly associated with higher mitotic count (P=0.023), BL morphology (P=0.005), higher histologic grade (P=0.022), and higher proliferation rate assessed by Ki-67 (P<0.001). TopoII&agr; expression was significantly correlated with invasive ductal carcinoma NOS (P=0.010), higher mitotic count (P=0.001), higher histologic grade (P=0.007), and higher Ki-67 (P<0.001). In conclusion, due to lack of expression of ER, PR, and human epidermal growth factor receptor 2 receptor in TNBC, specific targeted therapies are not effective, and chemotherapy is currently the only modality of available systemic therapy. Due to expression of topoII&agr;, anthracyclines may be effective in treatment of TNBC.

P53, MAPK, topoisomerase II alpha and Ki67 immunohistochemical expression and KRAS/BRAF mutation in ovarian serous carcinomas

BackgroundWe investigated the immunohistochemical expression of p53, MAPK, topoisomerase II alpha (topoII alpha) and Ki67 in ovarian serous carcinomas (OSCs) along with mutational analysis for KRAS and BRAF.MethodsEighty one cases of OSCs were reviewed and examined immunohistochemically using antibodies against p53, MAPK, topoII alpha and Ki67. Staining was evaluated as a percentage of immunopositive cells with cut-off levels at 10% for p53 and topoII alpha, and 5% for MAPK. The Ki67 immunoexpression was assessed by means of Olympus Image Analysis System as a percentage of immunopositive cells in 1000 tumor cells. KRAS and BRAF mutational analysis was performed on 73 available microdissected samples.ResultsOf 81 cases of OSCs 13.6% were of low-grade and 86.4% were of high-grade morphology. In the high-grade group there was a significantly higher immunoexpression of p53 (P < 0.001) and topoII alpha (P = 0.001), with Ki67 median 56.5 vs. 19 in low-grade group (P < 0.001). The difference in immunoexpression of active MAPK between low- and high-grade group was also significant (P = 0.003). MAPK positive immunostaining was detected in 63.6% of low-grade vs. 17.1% of high-grade OSCs. The frequency of KRAS mutation was significantly higher in low-grade as compared to high-grade group (P = 0.006). None of the samples had BRAF mutation. In addition, we detected positive MAPK immunoexpression in 13/59 samples with wild-type KRAS, suggesting that activation of MAPK pathway is not ultimately related either to KRAS or BRAF mutation. Seven morphologically high-grade samples (11.7%) showed both KRAS mutation and p53 immunopositivity.ConclusionsAlthough this study is limited by its humble number of low-grade samples, our data fit the proposed dualistic pathway of ovarian carcinogenesis. Mutational analysis for KRAS and BRAF discloses some possible interactions between different tumorigenic pathways of low- and high-grade carcinomas. Immunohistochemical staining for MAPK was not sufficiently sensitive, nor specific, to precisely predict the KRAS mutation. However, it appears to be quite reliable in ruling out a KRAS mutation if the staining is negative.Virtual SlidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/9283563368804632ZusammenfassungHintergrundWir untersuchten die Immunohistochemische Expression der p53, MAPK, topoisomerase II alpha (topoII alpha) und Ki67 in Ovarialkarzinomen (OSCs) anbei mit Mutationsanalyse für KRAS und BRAF.Methode81 OSCs Fälle wurden analysiert und Immunohistochemisch untersucht mit Antikörper gegen p53, MAPK, topoII alpha und Ki67. Die Färbung war ausgewertet als der Prozent von immunopositiven Zellen mit den “cut-of” Niveau an 10% für p53 und topoII alpha und 5% für MAPK. Die Ki67 Expression war bewertet mittels Olympus Image Analysis System als der Prozent von immunopositiven Zellen in 1000 Tumorzellen. KRAS and BRAF Mutationsanalyse wurde in 73 verfügbaren microdissections Stichproben aufgeführt.ErgebnisseVon 81 OSCs Fälle 13.6% zeigte “low-grade” und 86.4% “high-grade” Morphologie. In der “high-grade” Gruppe war eine statistisch bedeutende höhere Expression von p53 (P < 0.001) und topoII alpha (P = 0.001) mit Ki67 median von 56.5 im Gegensatz zu 19 in der “low-grade” Gruppe (P < 0.001). Die Differenz in Immunoexpression von aktiver MAPK zwischen der “low-grade” und “high-grade” Gruppe war statistisch bedeutend (P = 0.003). MAPK positive Expression war in 63.6% der “low-grade” im Gegensatz von 17.1% der “high-grade” Karzinoms bemerkt. Die Häufigkeit der KRAS Mutation war bedeutend höher in “low-grade” im Verglich zu der “high-grade” Gruppe (P = 0.006). Keiner der Stichproben hate BRAF Mutation. Wir haben auch eine positive MAPK Expression in 13/59 der Stichproben mit “wild-type” KRAS bemerkt, was sugeriert das die Aktivation des MAPK Pfads ist nicht letztmalig mit KRAS oder BRAF verbunden. Sieben der “high-grade” Stichproben (11.7%) waren KRAS Mutation und p53 Expression positive.SchlussworteObwohl diese Studie mit bescheiden Nummer von “low-grade” Stichproben limitiert ist, unsere Daten passen in das dualistische Modell von Ovarial Karzinogenesis. Mutationsanalyse für KRAS und BRAF enthüllen einige mögliche Interaktionen zwischen verschieden tumorigenen Wege von “low”- and “high-grade” Karcinomen.Die Immunohistochemische Expression für MAPK war nicht empfindlich oder spezifisch genüg um den KRAS mutations Status des Tumor genau vorauszusagen.Es scheint das die MAPK Expression ziemlich verlässlich ist in ausschließen der KRAS Mutation, wenn die Expression negative ist.

Unusual cause of small intestine obstruction in a child Small intestine anisakiasis: report of a case

Introduction Anisakiasis is caused by human infection by the anisakis larvae, a marine nematode found in undercooked or raw fish. Infection with the parasite Anisakis simplex is common in Japan and northern European countries. With the increased popularity of eating sushi and raw fish infection with anisakis is expected to rise. Case presentation We present the case of a 14-year-old boy who had eaten sushi 3 days before the onset of symptoms and had small bowel obstruction caused by enteric anisakiasis. To the best of our knowledge this is the first reported case of intestinal anisakiasis presenting as a bowel obstruction in a child. Conclusion Enteric anisakiasis is very rare, and its diagnosis is usually made after laparotomy. Nevertheless, when signs of acute abdomen develop after the ingestion of raw fish, such as sushi or sashimi, the possibility of enteric anisakiasis should be considered.

Prognostic value of Ki-67 proliferating index in triple negative breast carcinomas

The aim of this study was to assess Ki-67 in the triple negative breast cancer group (TNBC) in addition to basal like (BL) immunophenotype, BL morphology and conventional clinicopathologic factors, and to demonstrate their prognostic relevance in this group of tumors. Immunohistochemical staining for CK5/6, CK14, EGFR and Ki-67 was performed on 83 formalin-fixed, paraffin-embedded tumor sections. Correlations between categorical variables were studied using the chi-square and the Mann-Whitney U test. For survival analysis, the Kaplan-Meier method, the log-rank test and the Cox proportional hazard regression model were used. The optimal cut-off values for Ki-67 and mitotic count were selected using the ROC (receiver operating characteristic) method. Of the 83 TNBC, 55 (66.3%) had the BL immunophenotype, and 40 (48.2%) had BL morphology. Clinical stage and Ki-67 proliferation index were significantly associated with shorter disease-free survival (DFS) (p=0.002 and p<0.001) and overall survival (OS) (p=0.05 and p=0.025). An independent prognostic relevance regarding DFS and OS was found for clinical stage (p<0.001 and p<0.001), Ki-67 (p=0.008 and p=0.055) and BL morphology concerning DFS (p=0.011). Cellular proliferation measured by Ki-67 has prognostic relevance in TNBC, but further validation of its clinical significance, standardization of assessment and determination of optimal cut-off points is essential for this group of breast tumors.

Her-2/neu assessment for gastric carcinoma: validation of scoring system.

BACKGROUND/AIMS Gastric cancer is the second leading cause of cancer mortality in the world. Amplification of HER-2/neu oncogene has become an important biomarker for identifying patients who respond to HER-2 targeting therapy. A number of studies have analyzed HER-2/neu overexpression in gastric carcinoma, and the rate of HER2 positivity is variable, ranging from 6% to 35%. METHODOLOGY In our study HER-2/neu expression was assessed on 73 samples of primary gastric cancer, using immunohistochemistry. For 19 patients preoperative biopsy samples and resected specimens were available. Additionally, internal ring study was performed to estimate intraobserver variability of IHC scoring among pathologists at our department. RESULTS HER-2/neu overexpression was found in 10 (13.6%) of the tested samples, and it was more common in intestinal (22.5%) than the diffuse type (3.7%). Not one of the 6 analyzed mixed type tumors showed HER-2/neu expression. For the paired samples (preoperative biopsy samples and resected specimens) the concordance rate for HER-2/neu expression was 94.7%. CONCLUSIONS According to high concordance rate in paired samples we consider it appropriate to evaluate HER2 expression on biopsy specimens, especially in unresectable cases, and to re-evaluate it on resected specimens if available, due to high heterogeneity of a gastric cancer.

Acute appendicitis as a complication of varicella.

INTRODUCTION Obstruction of the appendiceal lumen is the primary cause of appendicitis. The most common causes of luminal obstruction are fecaliths and lymphoid follicle hyperplasia. Additionally, bacterial infections or enteric and systemic viral diseases can cause a reaction of the lymphoid follicle. CASE PRESENTATION An 11-year-old boy with active phase of chickenpox presented on our Pediatric surgery emergency department under the impression of acute appendicitis. An appendectomy was performed on the same day. An inflamed and edematous retrocecal appendix was removed during surgery. Histological investigation of the appendix revealed transmural acute inflammation, with diffuse proliferation of inflammatory cells, with characteristic intranuclear inclusion surrounded by a clear halo. The PCR analysis of peripheral blood and appendix tissue specimen revealed positive VZV DNA. CONCLUSION We have shown that varicella-zoster virus infection of the appendix is associated with acute appendicitis and possibly also with severity of the disease.

A Comparison of Endoloop Ligatures and Nonabsorbable Polymeric Clips for the Closure of the Appendicular Stump During Laparoscopic Appendectomy in Children

BACKGROUND The aim of this prospective trial was to evaluate the clinical outcomes of nonabsorbable polymeric clips in laparoscopic appendix stump closure in children by comparing the endoloop ligature. PATIENTS AND METHODS From June 2011 to June 2016, 277 children who underwent laparoscopic appendectomy were included in the study. The patients were divided into two groups based on the technique used for appendiceal stump closure: there were 101 patients in the polymeric clips group and 176 in the endoloop group. The risk of intraoperative and postoperative complications was investigated for two different techniques to close the appendiceal stump. RESULTS Among the 277 patients who underwent laparoscopic appendectomy, no intraoperative complications and 17 (6.1%) postoperative complications were recorded. There were no significant differences between the groups with respect to the postoperative complications (P = .546). The median length of the operation was 10 minutes shorter when the polymeric clips were used (P < .001). The median hospital stay was also shorter in the polymeric clips group (P = .008). Costs of polymeric clip were significantly lower (€ 17.64) compared to endoloop (€ 34.16). CONCLUSIONS Closure of the appendix stump with polymeric nonabsorbable clips in laparoscopic appendectomy reduces operative time and may be a cost-effective and simpler alternative to widely used endoloops.