Maria Grazia Fiore

Down-regulated expression of transforming growth factor beta 1 mRNA in endometrial carcinoma

Transforming growth factor beta1 (TGF-beta1) is a potent modulator of cell proliferation in vitro, and recent studies have demonstrated its overexpression in several different tumours; nevertheless, the molecular mechanisms of TGF-beta1 action on cell growth and differentiation have not been fully elucidated. To clarify the role of TGF-beta and its receptor in human endometrial proliferation and differentiation, TGF-beta1 expression at both the mRNA and protein levels has been evaluated by using Northern blotting and immunohistochemistry, in both normal (atrophic, proliferative and secretory) and neoplastic (adenocarcinoma) endometrial samples. This study demonstrates that TGF-beta1 mRNA expression is dramatically reduced in endometrial carcinomas with respect to non-neoplastic tissues, whereas the immunohistochemical expression of TGF-beta1 is enhanced in the epithelial component of endometrial carcinomas compared with non-neoplastic tissues. These data suggest that TGF-beta1 acts as a paracrine regulator of endometrial cell proliferation and that it may contribute to the carcinogenic mechanisms of endometrial carcinoma.

Incidental metastases of well-differentiated thyroid carcinoma in lymph nodes of patients with squamous cell head and neck cancer: eight cases with a review of the literature

The examination of a large series of cervical lymph nodes in patients with head and neck cancer revealed the presence of incidental metastases of occult thyroid carcinoma in eight patients, of which six cases were squamous cell carcinoma of glottic and supraglottic sites of the larynx and two cases were pyriform sinus and tongue carcinomas. Three patients had two lymph nodes and the remaining patients had one lymph node each involved. The nodal chains affected were the jugular (n=5; level IV), Kuttner (level II), supraomohyoid (level III) and supraclavicular (level VI). In four cases, a subtotal thyroidectomy or unilateral lobectomy was performed during laryngectomy (for surgical reasons) or after histologic nodal examination; a minimal focus of thyroid papillary carcinoma was detected in one patient. Three of eight patients died from recurrence of the squamous cell carcinoma; no case presented clinical evidence of thyroid malignancy. The differential diagnosis from benign thyroid heterotopia was based on the presence of minimal nuclear atypia. The choice of treatment of patients with a coexisting neoplasm characterized by poor prognosis is difficult, and contrasting opinions exist regarding the use of radical thyroidectomy and the subsequent management. As reported in the literature (66 cases), the more aggressive squamous cell carcinoma will determine the prognosis of these patients; in fact, only one of the referred cases died of cerebellar metastases of the thyroid cancer. Our results emphasize the importance of an accurate re-evaluation and follow-up of patients with incidental occult metastases for detection of a primary thyroid tumor. In the general population, this incidental nodal involvement may be related to a minimal occult thyroid carcinoma.

Laparoscopic Diagnosis and Treatment of Pelvic Benign Multicystic Mesothelioma Associated with High CA19.9 Serum Concentration

We report a case of benign multicystic mesothelioma in a 20-year-old woman referred because of amenorrhea. She underwent pelvic transabdominal ultrasound, which disclosed a micropolycystic appearance of the ovaries and a fluid collection in the pouch of Douglas. Tumor serum markers revealed an increase in CA19.9. Abdominal and pelvic computed tomography scans confirmed the presence of ascites. Laparoscopy disclosed small, thin-walled, translucent cysts in the Douglas cavity. The cysts were free-floating in a yellowish, sticky, gelatinous material. Microscopically, cystic lesions showed mesothelium-lined cystic spaces surrounded by a delicate thin fibrovascular wall. With immunohistochemistry, the tumor cells were strongly positive for cytokeratin and calretinin. These aspects were suggestive of benign multicystic mesothelioma. Electron microscopy confirmed the mesothelial nature of this tumor. Serial evaluation of the CA19.9 concentration showed a progressive decrease in the serum marker in the normal range. The patient is now well and symptom-free with no recurrence 24 months after surgery. The association between benign multicystic mesothelioma and increased CA19.9 serum concentration has been described only once, in a man. To our knowledge, this is the second case of benign multicystic mesothelioma associated with increased CA19.9 serum concentration and the first diagnosed in a woman. In the present case, a minimally invasive laparoscopic approach enabled not only histologic diagnosis of benign multicystic mesothelioma but also its surgical treatment. Although benign multicystic mesothelioma is a rare pathologic entity, it is important that sonologists include it in the differential diagnosis of diseases that manifest with ascites. Furthermore, all surgeons should be aware of the macroscopic and laparoscopic appearance of the lesion, and its generally benign course.

Histology of micro polyps in chronic endometritis.

(P = 0.065) by univariate analysis (v) (Table 1). Patients with a negative MTA3 immunohistochemical staining reaction showed better progression-free (P = 0.008), cause-specific (P < 0.001) and overall (P = 0.012) survival by univariate survival analysis (Figure 3). Cox regression resulted in just one independent term that was predictive of progression-free survival, namely FIGO stage (P < 0.001). Independent prognostic factors for cause-specific survival were FIGO stage (P = 0.004), LVSI (P = 0.025), and MTA3 positivity (P = 0.001). Overall survival was also influenced only by FIGO stage (P < 0.001) (Table 2). The data obtained revealed that MTA3 can be upregulated in human cancer cells and might contribute to a more aggressive phenotype. However, as only a few target genes of MTA3 have been identified, the consequence of MTA3 overexpression in human cancer cells is far from being understood. We here demonstrate for the first time that MTA3 is upregulated in advanced stages of uterine non-endometrial cancer, and is associated with FIGO surgical stage, lymph node involvement, and LVSI. In addition, MTA3 staining was associated with progression-free, cause-specific and overall survival of patients with non-endometrioid carcinomas. Overall, immunolabelling of MTA3 represents an independent prognostic factor for causespecific survival, suggesting that this antigen could be used as a simple and efficient parameter with which to identify high-risk patients.

Altered molecular pattern of mucosal healing in Crohn's disease fibrotic stenosis

AIM To investigate tumor necrosis factor-α (TNF-α), syndecan 1 and basic fibroblast growth factor (bFGF) balance in Crohns disease (CD) strictures. METHODS Our study was performed on 24 surgical specimens of CD fibrotic stenosis. Ten histological normal surgical samples were retrieved for both the large and small bowel from patients with benign conditions and healthy tissue represented control collection. Sex and age in controls did not differ from CD group. Three endoscopic biopsy specimens taken after informed consent in subjects with normal colon were also used as negative controls. TNF-α, syndecan 1 and bFGF were detected by both reverse transcriptase reverse transcriptase polymerase chain reaction after mRNA extraction (results expressed as fold-change) and immunohistochemistry. RESULTS TNF-α did not show any significant difference between CD and control specimens (1.54 ± 1.19; P > 0.05). Very high levels of bFGF were observed in CD (11.76 ± 4.65; P < 0.001) unlike syndecan 1 which showed a moderate increase (5.53 ± 2.18; P < 0.005). analysis of variance (ANOVA) plus Student-Neumann-Keuls showed: bFGF > syndecan 1 > TNF-α = control. Immunoreactivity for bFGF was observed in epithelial, stromal, endothelial cells and even in the muscular layer, whilst in normal tissue it was almost unexpressed. Syndecan 1 and TNF-α staining was confined to mucosal epithelial and stromal cells, while in controls syndecan 1 was found in its normal site, i.e., basolateral area of the crypts and TNF-α very poorly expressed. CONCLUSION Fibrotic stenosis of CD may be the final result of an irreversible transformation of different cells into fibrogenic phenotype no longer inhibited by post-transcriptional regulation.

Unusual Case Report of Thrombotic Microangiopathy of the Small Bowel Following Liver Transplantation, a Possible Immunosuppressant-Induced Disease with Histological and Ultrastructural Findings

Cyclosporin-A (CsA) and tacrolimus (FK-506) are immunomodulating agents used to prevent rejection in organ transplantation. They are both associated with several side effects, including nephrotoxicity and severe hypertension due to vascular injury, which often appears as a microvascular occlusive disorder (thrombotic microangiopathy, TMA). We report the first case of a microvascular occlusive disorder with the features of TMA in the small bowel of an orthotopic liver transplant (OLT) patient after immunosuppressive therapy with CsA and FK506. The patient presented with severe recurrent abdominal colics and distal subocclusion, requiring aggressive surgical treatment. Histological and ultrastructural analysis of the resected specimen disclosed intestinal TMA. Although rare, such a complication should be considered in the differential diagnosis of abdominal colics in patients undergoing immunosuppressant therapy after OLT.

May the assessment of baseline mucosal molecular pattern predict the development of gluten related disorders among microscopic enteritis

AIM To evaluate mucosal baseline mRNA expression of tissue transglutaminase 2 (tTG2), interferon gamma (IFNγ), toll-like receptor 2 (TLR2) and Myeloid Differentiation factor 88 (MyD88) in patients with microscopic enteritis (ME). METHODS We retrospectively enrolled 89 patients with ME of different etiology, which was defined within a 2-year mean period of follow-up. Baseline histological examination was performed on Hematoxylin-Eosin stained sections and CD3 lymphocyte immunohistochemistry was used for intraepithelial lymphocyte count (IELs). ME was defined according to the criteria of Bucharest Consensus Conference. For each patient, formalin embedded biopsy samples of the duodenum referred to the period of ME diagnosis were retrieved. Real-time polymerase chain reaction (RT-PCR) was used to detect the amount of mRNA coding for tTG2, IFNγ, TLR2 and MyD88, and the quantity was expressed as fold change compared to controls. Control group was represented by duodenal normal specimens from 15 healthy subjects undergoing endoscopy for functional symptoms. Comparisons among continuous variables were performed by One way analysis of variance (ANOVA) and Bonferroni’s test. The χ2 test was used for categorical variables. Pearson’s test was used to evaluate correlations. Receiver operating curves were drawn for all four markers to estimate sensitivity and specificity in discriminating the development of CD and GS. RESULTS After a period of follow up of 21.7 ± 11.7 mo, the following diagnoses were achieved: gluten related disorders in 48 subjects (31 CD; 17 GS) and non-gluten related ones in 41 (29 Irritable Bowel Syndrome - IBS; 12 Others). CD patients had the highest tTG2 levels (8.3 ± 4.5). The ANOVA plus Bonferroni analysis showed that CD > Other ME > GS = IBS > negative controls. A cut off value of 2.258 was able to discriminate between CD and GS with a sensitivity of 52.94% and a specificity of 87.1%. Additionally, CD patients had the highest IFNγ levels (8.5 ± 4.1). ANOVA plus Bonferroni demonstrated CD > Other ME > GS = IBS > negative controls. A cut off of 1.853 was able to differentiate CD and GS with a sensitivity of 47.06% and a specificity of 96.77%. Patients with non gluten-related causes of ME exhibited the highest TLR2 levels (6.1 ± 1.9) as follows: Other ME > CD = GS = IBS > negative controls. TLR2 was unable to discriminate CD from GS. Patients with CD overexpressed MyD88 levels similarly to non gluten-related causes of DL (7.8 ± 4.9 and 6.7 ± 2.9), thus CD = Other ME > GS = IBS > negative controls. A cut off of 3.722 was able to differentiate CD from GS with a sensitivity of 52.94% and a specificity of 74.19%. IELs count (15-25 and more than 25/100 enterocytes) strongly correlated with mRNA levels of all tested molecules (P < 0.0001). CONCLUSION Our results confirm that a single marker is unable to predict a discrimination among ME underlying conditions as well as between CD and GS. Mucosal high levels of tTG and IFNγ mRNA may predict the development of CD more than GS with high specificity, despite an expected low sensitivity. TLR2 does not discriminate the development of CD from GS. MyD88 levels indicate that intestinal permeability is more increased when a severe intestinal damage underlies ME in both gluten related and unrelated conditions. Therefore, the results of the present paper do not seem to show a clear translational value.

Reversal of IgM deficiency following a gluten-free diet in seronegative celiac disease

Selective IgM deficiency (sIGMD) is very rare; it may be associated with celiac disease (CD). We present the case of an 18-year-old man with sIGMD masking seronegative CD. Symptoms included abdominal pain, diarrhea and weight loss. Laboratory tests showed reduced IgM, DQ2-HLA and negative anti-transglutaminase. Villous atrophy and diffuse immature lymphocytes were observed at histology. Tissue transglutaminase mRNA mucosal levels showed a 6-fold increase. The patient was treated with a gluten-free diet (GFD) and six months later the symptoms had disappeared, the villous architecture was restored and mucosal tissue transglutaminase mRNA was comparable to that of healthy subjects. After 1 year of GFD, a complete restoration of normal IgM values was observed and duodenal biopsy showed a reduction of immature lymphocytes and normal appearance of mature immune cells.

A Rare Case of Primitive Epithelioid Leiomyosarcoma of the Conjunctiva

Purpose: To describe a rare case of conjunctival leiomyosarcoma initially diagnosed as a poorly differentiated squamous cell carcinoma. Methods: Clinical, light microscopic, immunohistochemical, and ultrastructural findings are reported. Results: A 56-year-old Caucasian woman was referred with a history of a progressive, rapidly growing mass in her left eye. Biopsy of the mass and histology yielded a first diagnosis of a poorly differentiated conjunctival squamous cell carcinoma. Orbital exenteration was performed 2 weeks later. Macroscopically, the exenteration specimen showed a soft mass completely involving the conjunctiva and extending to the eyelids and orbital structures. Histological examination revealed a malignant tumour composed of atypical, predominantly epithelioid large cells. Immunohistochemical and ultrastructural studies combined with the light microscopic findings contributed to clarify the diagnosis of epithelioid leiomyosarcoma. The patient was started on chemotherapy and radiotherapy, but died a few months later from widespread metastases. Conclusions: primary involvement of the orbit by a leiomyosarcoma is rare, but this eventuality should be considered in the differential diagnosis of rapidly growing orbital and conjunctival masses.

Synchronous Presentation of B-Cell Chronic Lymphocytic Leukemia/Small-Cell Lymphoma and Colon Adenocarcinoma Within the Same Mesenteric Lymph Nodes and a Single Liver Metastasis

An 86-year-old man with hypertension and chronic fibrillation presented with worsening abdominal pain and a 2-month history of persistent disturbed alvus. No other systemic symptoms were reported. At the admission he had mild tenderness and fullness in the right lower quadrant. The remainder of the general examination was unremarkable with no lymphadenopathy. Laboratory findings showed a hemoglobin concentration of 12.4 g/dL, WBC count of 750/ L with 78.8% lymphocytes, and platelet count of 135,000/ L. A peripheral-blood flow cytometry revealed a CD5 , CD19 , CD23 monoclonal B-cell population. Immunoglobulin levels and renal and liver tests were normal. Hepatitis markers were negative. Serum carcinoembryonic antigen and CA 19-9 levels were 82 ng/mL and 328 ng/mL, respectively. A computed tomography scan of the abdomen and pelvis revealed mesenteric lymphadenopathies associated with a partial obstructive mass in the right colon and a single focal area of increased liver opacity of approximately 14 mm within segment IV consistent with liver metastasis (Fig 1). Computed tomography scan of the thorax showed no evidence of metastases. A complete colonoscopy showed a constricting lesion of the right colon, and multiple biopsies were performed showing moderately differentiated colon adenocarcinoma. The consideration of high risk of bowel obstruction associated with the low aggressiveness of myeloproliferative disease and the absence of significant comorbidities of our patient prompted us to perform a right hemicolectomy associated with locoregional lymphadenectomy and liver metastasectomy. The pathologic assessment of the resection specimen showed a moderately differentiated adenocarcinoma extending through the muscularis propria. Extramural vascular invasion was present. Microscopic evaluation of the 45 regional lymph nodes isolated from mesenteric fat revealed lymph node architecture predominantly effaced by a diffuse infiltrate of small lymphocytes; in four lymph nodes, an adenocarcinoma metastasis was also present (Fig 2). Liver specimen microscopically revealed subcapsular metastasis of adenocarcinoma with central necrosis; the peripheral hepatic parenchyma showed portal and periportal involvement by infiltration of monomorphic small lymphocytes (Fig 3). By immunohistochemistry, the cells were positive for CD20 (Fig 3, insert), CD5, CD23, and Bcl2 and negative for CD10, CD23, Fig 2.