Living up to Life - Journal of the Italian Society of Anatomic

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Migliorare la qualità
Incrementare la produttività
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Living up to Life
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Journal of the Italian Society of Anatomic Pathology
and Diagnostic Cytopathology,
Italian Division of the International Academy of Pathology
Editor-in-Chief
Marco Chilosi, Verona
Associate Editor
Roberto Fiocca, Genova
Managing Editor
Roberto Bandelloni, Genova
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CONTENTS
Guidelines
Guidelines for autopsy investigation of sudden cardiac death
C. Basso, M. Burke, P. Fornes, P.J. Gallagher,
R.H. De Gouveia, M. Sheppard, G. Thiene, A. Van Der Wal
Although sudden cardiac death is one of the most important mode
of death in Western Countries, pathologists and public health
physicians have not given this problem the attention it deserves.
New methods of preventing potentially fatal arrhythmias have
been developed and the accurate diagnosis of the causes of sudden
cardiac death is now of particular importance. Pathologists are
responsible for determining the precise cause of sudden death but
there is considerable variation in the way in which they approach
this increasingly complex task. The Association for European
Cardiovascular Pathology developed these Guidelines, which
represent the minimum standard that is required in the routine
autopsy practice for the adequate assessment of sudden cardiac
death, including not only a protocol for heart examination and
histological sampling, but also for toxicology and molecular
investigation. Our recommendations apply to University Medical
Centres, Regional and District Hospitals and all types of Forensic
Medicine Institutes. If a uniform method of investigation is adopted
throughout the European Union, this will lead to improvements
in standards of practice, allow meaningful comparisons between
different communities and regions and most importantly permit
future trends in the patterns of disease causing sudden death to be
monitored.
Consensus document
Cytological classification of thyroid nodules. Proposal of the
SIAPEC-IAP Italian Consensus Working Group
G. Fadda, F. Basolo, A. Bondi, G. Bussolati, A. Crescenzi,
O. Nappi, F. Nardi, M. Papotti, G. Taddei, L. Palombini
In 2006-2007, a committee was established by the Italian
Societies of Endocrinology (SIE and AME) and Pathology
(SIAPEC-IAP), composed of invited endocrinologists with
special interest in thyroid diseases, endocrine pathologists and
cytopathologists. The main objectives of the committee were
to analyse current diagnostic practice and reporting of fine
needle aspiration biopsy cytology, and to define a consensus
on the definition of each individual diagnostic category. Such a
definition should include a shared, brief description of the main
cytomorphological features followed by categorisation of the
diagnosis in a five-tiered system (TIR 1 through 5). The definition should also provide a summary of clinical implications for
each cytological diagnosis.
The committee met several times to analyse the currently proposed international classification schemes. Different diagnostic
reporting approaches were discussed with clinical colleagues,
and the suggested therapeutic attitudes were recorded. This
consensus document is the final proposal.
Original article
Cytology of indeterminate cases (C3). Can this diagnostic
class be improved?
S. Fiaccavento, G. Simone
The aim of this brief report is to emphasize the need for a stronger
effort from Pathologists, to reduce the incidence of the “C3”,
Indeterminate, diagnostic class. The experience derived from
immunohistochemistry could be useful also when applied  to
cytological samples. In this study, based on immunostaining
for HMW Cytokeratin 5 (normally present in normal breast
cells and absent in malignant cells) on conventional breast
nodules aspirates, 21 out of 30 evaluated cases diagnosed as
“C3” and with histological control, have been reclassified
as “C2”, Benign or “C4”, Suspicious of malignancy.  The
Authors conclude that this immunocytochemical algorithm
could emprove the diagnosis di “C2” and “C4”, avoiding in
many cases  other presurgical, more invasive diagnostic procedures, with a positive cost/benefit ratio.
Case reports
Diffuse and extreme vacuolization of tumour cells in rectal
adenocarcinoma after neoadjuvant therapy: an unusual
finding
P. Amico, P. Greco
We report a case of diffuse and extreme cytoplasmic vacuolization of tumour cells in a rectal adenocarcinoma after neoadjuvant
treatment. A 64-year-old man with a moderately differentiated
rectal adenocarcinoma, diagnosed by endoscopic rectal biopsy,
underwent surgical treatment after chemoradiotherapy. Residual
tumour mass was represented by foci of neoplastic cells with the
morphological features of conventional type adenocarcinoma,
and surprisingly, by numerous areas consisting of several giant
vacuoles, variable in size, merging to form multilocular spaces
separated by a rim of cell membrane with a “plant-like” appearance. Cytoplasmic vacuolization may represent a distinct form of
cell death, and pathologists should carefully consider this unusual
and potentially alarming morphological change among the chemoradiotherapy-induced effects on tumour mass.
Rectal leiomyosarcoma: report on two cases and a practical
approach to differential diagnosis
N. Kourda, J. Kourda, J. Aouam, A. Zaouche,
S. Baltagi Ben Jilani, R. Zermani
Rectal leiomyosarcoma is an uncommon malignancy. Herein, we
describe the clinicopathological features and biological behaviour
of these tumours, and provide a practical approach to differential
diagnosis, particularly with gastrointestinal stromal tumours
(GIST).
We report two cases in elderly men. In the first, the lesion was
2 cm from the anal sphincter, while it was located in the rectal
ampulla in the second case. Histologically, both tumours were
characterized by pleiomorphic, large spindle cells, presenting numerous mitoses and marked nuclear atypia. Immunohistochemical analysis showed that tumour cells coexpressed both actin and
desmin, whereas CD117 and S100 protein were negative. The
final diagnosis was leiomyosarcoma. One of the patients died of
pulmonary metastasis within six months. The second patient had
bone metastasis, but was lost to follow up. This report underlines
the potential diagnostic problems raised by rectal leiomyosarcoma and emphasizes the role of immunohistochemistry in achieving correct diagnosis, which has important clinical, therapeutic
and prognostic consequences.
Extracutaneous seborrheic inclusion cyst: an unusual
presentation
T. Pusiol, M.G. Zorzi, D. Morichetti
Seborrheic inclusion cyst is an unusual variant of epidermal
cyst characterized by parietal histology similar to seborrheic
keratosis. Cysts with such changes have been called “seborrheic
keratosis-like changes in epidermal cyst” or “epidermoid cyst with
seborrheic verruca-like cyst wall” or simply “seborrheic cyst”.
To date, this lesion has been described exclusively in cutaneous
sites. We describe the first case of an extracutaneous seborrheic
inclusion cyst arising from round ligament. A 30-year-old female
was referred to our institution for abdominal pain. Ultrasonography
showed a hypoechoic heterogeneous, round mass adjacent to the
lower extremity of the left ovary, measuring 4.5 cm in maximum
diameter. Contrast-enhanced computed tomography of the pelvis in
the venous phase showed a round (4.5 cm in diameter) cystic lesion
with inhomogeneous fluid content (4.5 cm in diameter) in the side
of the left large ligament and anterior to the homolateral adnexa.
Laparoscopic resection of the mass was performed. Intraoperatively,
an extraperitoneal glistening pelvic mass was discovered: the
lesion was attached to the intrapelvic 1/3 middle portion of the left
round ligament. Macroscopically, the mass measured 6 cm x 6 cm
x 3.5 cm and exhibited a smooth and glistening external surface.
On cut sections, the mass was an unilocular cyst filled with soft,
yellow, amorphous material. Histologically, the cystic wall was
lined by a stratified squamous epithelium with a granular cell layer.
The cavity contained keratin-like material. The cystic wall showed
numerous areas with close-set basaloid cells and pseudohorn
cysts. The latter aspect consisted of cystic invaginations of the
epithelium filled with surface keratin, which in a given microscopic
section may be cut in cross-section, thereby appeared as “cysts”
within the involved epithelium. Parietal rupture was present,
accompanied by granulomatous inflammation. There were no
postoperative complications, and the patient was discharged 3
days after the procedure. The present case is unique in that it is the
first reported case of an extracutaneous seborrheic inclusion cyst
arising from a very unusual site, namely the round ligament. The
site of origin of the lesion and its cystic nature were established by
computed tomography findings. Conservative treatment with enbloc resection was possible. Histological examination confirmed
computed tomography findings. The present report described a
lesion typically found in dermatopathology practice, but which had
arisen in an extracutaneous site.
pathologica 2010;102:391-397
Guidelines
Guidelines for autopsy investigation
of sudden cardiac death
C. Basso1, M. Burke2, P. Fornes3, P.J. Gallagher4, R.H. de Gouveia5, M. Sheppard6,
G. Thiene1, A. van der Wal7
on behalf of the Association for European Cardiovascular Pathology
http://anpat.unipd.it/aecvp/
1
Department of Medical Diagnostic Sciences and Special Therapies, University of Padua, Italy; 2 Department of Histopathology,
Royal Brompton & Harefield NHS Trust, Harefield Hospital, UK; 3 Department of Pathology, Hopital Européen G. Pompidou, Paris,
France; 4 Department of Pathology, Southampton University Hospitals, UK; 5 Department of Pathology, Hospital de Santa Cruz,
Lisbona, Portugal; 6 Department of Pathology, Royal Brompton Hospital, London, UK; 7 Pathology, Academic Medical Center,
University of Amsterdam, The Netherlands
Key words
Autopsy • Guidelines • Protocol • Sudden cardiac death
Summary
Although sudden cardiac death is one of the most important mode
of death in Western Countries, pathologists and public health
physicians have not given this problem the attention it deserves.
New methods of preventing potentially fatal arrhythmias have
been developed and the accurate diagnosis of the causes of sudden cardiac death is now of particular importance. Pathologists are
responsible for determining the precise cause of sudden death but
there is considerable variation in the way in which they approach
this increasingly complex task. The Association for European Cardiovascular Pathology developed these Guidelines, which represent the minimum standard that is required in the routine autopsy
practice for the adequate assessment of sudden cardiac death,
including not only a protocol for heart examination and histological sampling, but also for toxicology and molecular investigation. Our recommendations apply to University Medical Centres,
Regional and District Hospitals and all types of Forensic Medicine Institutes. If a uniform method of investigation is adopted
throughout the European Union, this will lead to improvements
in standards of practice, allow meaningful comparisons between
different communities and regions and, most importantly, permit
future trends in the patterns of disease causing sudden death to be
monitored.
Introduction
adolescents and adults younger than the age of 30 years, the
overall risk of SCD is 1/100.000 and a wider spectrum of
diseases can account for the final event 6.
The major difficulties in interpreting epidemiological
data on sudden death are the lack of standardization in
death certificate coding and the variability in the definition of sudden death. Sudden death has been defined as “a
natural, unexpected fatal event occurring within one hour
from the onset of symptoms in an apparently healthy subject or whose disease was not so severe as to predict an
abrupt outcome” 7. This well describes many witnessed
deaths in the community or in Emergency Departments.
It is less satisfactory in pathological practice where autopsies may be requested on patients whose deaths were not
Sudden cardiac death (SCD) is the leading mode of death
in all communities of the United States and of the European
Union, but its precise incidence is unknown. Internationally accepted methods of death certification do not include
a specific category of SCD. Estimates for the United States
range from 250.000 to 400.000 adult people dying suddenly
each year due to cardiovascular causes, with an overall incidence of 1 to 2/1.000 population per year 1-3. A task force
of the European Society of Cardiology has adopted the incidence ranges from 36 to 128 deaths per 100.000 population per year 4 5. More than 60% of these are the result of
coronary heart disease. Among the general population of
Correspondence
From Virchows Arch 2008;452:11-8 with permission of the
Publisher Springer Science e Business Medica.
Gaetano Thiene, Dept. Medico-Diagnostic Sciences and Special
Therapies, University of Padua Medical School, via A. Gabelli
61, 35121 Padua, Italy - Tel. +39 049 8272283 - Fax +39 049
8272284 - E-mail: [email protected]
392
witnessed, occurred during sleep or at an unknown time
before their bodies were discovered. Under the latter circumstances it is probably more satisfactory to assume that
the death was sudden if the deceased was known to be in
good health 24 hours before death occurred 8. Moreover,
for practical purposes, a death can be classified as sudden
if a patient is resuscitated after cardiac arrest, survives on
life support for a limited period of time and then dies due
to irreversible brain damage.
Pathologists are responsible for determining the precise
cause of sudden death but there is considerable variation
in the way in which they approach this increasingly complex task. A variety of book chapters, professional guidelines and articles have described how pathologists should
investigate sudden death 9-14. However, there is little consistency between centres, even in individual countries.
In this report, we describe the minimum standard that is
required in the routine autopsy practice for the adequate
assessment of SCD in the general population, excluding
sudden infant death syndrome. Our recommendations apply to University Medical Centres, Regional and District
Hospitals and all types of Forensic Medicine Institutes.
If a uniform method of investigation is adopted throughout the European Union, this will lead to improvements
in standards of practice, allow meaningful comparisons
between different communities and regions, and most importantly, permit future trends in the patterns of disease
causing sudden death to be monitored.
C. Basso et al.
•
•
•
•
witnessed, any suspicious circumstances (carbon
monoxide, violence, traffic accident, etc.);
medical history: general health status, previous significant illnesses (especially syncope, chest pain, and
palpitations, particularly during exercise, myocardial
infarction, hypertension, respiratory and recent infectious disease, epilepsy, asthma, etc.), previous surgical
operations or interventions, previous ECG tracings and
chest X rays, results of cardiovascular examination,
laboratory investigations (especially lipid profiles);
prescription and non prescription medications;
family cardiac history: ischaemic heart disease and
premature sudden death, arrhythmias, inherited cardiac diseases;
ECG tracing taken during resuscitation, serum enzyme and troponin measurements.
The autopsy procedure
All sudden death autopsies should be sequential structured examinations. They should specifically address the
major causes of extra-cardiac and cardiac sudden death.
Principles and rules relating to autopsy procedures
should adhere to the Recommendations on the Harmonisation of Medico-Legal Autopsy Rules produced by the
Committee of Ministers of the Council of Europe 10.
A) External examination of the body
The role of the autopsy in sudden death
To establish or consider:
• whether the death is attributable to a cardiac disease
or to other causes of sudden death;
• the nature of the cardiac disease, and whether the
mechanism was arrhythmic or mechanical;
• whether the cardiac condition causing sudden death
may be inherited, requiring screening and counselling of the next of kin;
• the possibility of toxic or illicit drug abuse and other
unnatural deaths.
Clinical information relevant
to the autopsy
In practice the amount of information that is available before autopsy is variable. Any potential source of information should be interrogated (e.g. family members, general
practitioner, etc.), preferentially before autopsy is carried
out. Ideally the following information is required:
• age, gender, occupation, lifestyle (especially alcohol or
smoking), usual pattern of exercise or athletic activity;
• circumstances of death: date, time interval (instantaneous or < 1 hour), place of death (e.g. at home,
at work, in hospital, at recreation), circumstances
(at rest, during sleep, during exercise-athletic or non
athletic-, during emotional stress), witnessed or un-
• Establish body weight and height (to correlate with
heart weight and wall thicknesses 15-17).
• Check for recent intravenous access, intubation,
ECG pads, defibrillator and electrical burns, drain
sites and traumatic lesions.
• Check for implantable cardioverter defibrillator
(ICD)/pacemaker; if in situ, see MDA Safety Notice
2002 for safe removal and interrogation 18.
B) Full autopsy, with sequential approach
to the causes of sudden death
1. Exclusion of non-cardiac causes of sudden
death
Any natural sudden death can be considered cardiac
in origin after exclusion of non-cardiac causes. Thus,
a full autopsy with sequential approach should be always performed to exclude common and uncommon
extra-cardiac causes of sudden death, especially:
• cerebral (e.g. subarachnoid or intracerebral haemorrhage, etc.);
•respiratory (e.g. asthma, anaphylaxis, etc.);
•acute haemorrhagic shock (e.g. ruptured aortic aneurysm, peptic ulcer, etc.);
•septic shock (Waterhouse-Friderichsen syndrome)
2. Search for cardiac causes of sudden death
Many cardiovascular diseases can cause SCD, either
393
through an arrhythmic mechanism (electric SCD)
or by compromising the mechanical function of the
heart (mechanical SCD). These disorders may affect
the coronary arteries, the myocardium, the cardiac
valves, the conducting system, the intrapericardial
aorta or the pulmonary artery, the integrity of which
is essential for a regular heart function (Tab. I).
2.1 The standard gross examination of the heart
1. Check the pericardium, open it and explore the pericardial cavity.
2. Check the anatomy of the great arteries before
transecting them 3 cm above the aortic and pulmonary valves.
Tab. I. Substrates of SCD at postmortem.
Mechanical
Intrapericardial haemorrhage and cardiac tamponade
Ascending aorta rupture (hypertension, Marfan, bicuspid aortic valve, coarctation, others)
Post myocardial infarction free wall rupture
Pulmonary embolism
Acute mitral valve incompetence with pulmonary edema
Post myocardial infarction papillary muscle rupture
Chordae tendineae rupture (floppy mitral valve)
Intracavitary obstruction (e.g. thrombus/neoplasms)
Abrupt prosthetic valve dysfunction (e.g. laceration, dehiscence, thrombotic block, poppet escape)
Congenital partial absence of the pericardium with strangulation
Arrhythmic
Coronary Arteries (+/- Post-myocardial infarction scar)
Congenital anomalies
Origin from the Aorta
Wrong sinus (RCA from the left sinus, LCA from the right sinus)
Left circumflex branch from the right sinus or from RCA
High take off from the tubular portion
Ostia plication
Origin from the Pulmonary Trunk
Course: Intramyocardial course (“myocardial bridge”)
Acquired
Atherosclerosis
Complicated (thrombus, haemorrhage)
Uncomplicated
Embolism
Arteritis
Dissection
Others
Fibromuscular dysplasia
Intramural small vessel disease
Cardiac allograft rejection, acute or chronic
Previous surgical or interventional procedures
Coronary artery by-pass (saphenous vein, mammary and radial arteries, etc.)
Percutaneous balloon coronary angioplasty, stents
Myocardium
Cardiomyopathy, hypertrophic
Cardiomyopathy, arrhythmogenic right ventricular
Cardiomyopathy, dilated
Cardiomyopathy, inflammatory (myocarditis)
Secondary cardiomyopathies (storage, infiltrative, sarcoidosis, etc.)
Hypertensive heart disease
Idiopathic left ventricular hypertrophy
Unclassified cardiomyopathies (spongy myocardium, fibroelastosis)
Valve
Aortic valve stenosis
Myxoid degeneration of the mitral valve with prolapse
Conduction System
Sino-atrial disease
AV block (Lev-Lenegre disease, AV node cystic tumor)
Ventricular preexcitation (Wolff-Parkinson-White syndrome, Lown Ganong Levine syndrome)
Congenital Heart Disease operated and unoperated, with or without Eisenmenger syndrome
Normal Heart (“Sine materia” or Unexplained SCD or Sudden Arrhythmic Death Syndrome)
Long and short QT syndromes
Brugada syndrome
Catecholaminergic polymorphic ventricular tachycardia
Idiopathic ventricular fibrillation
AV: atrioventricular, LCA: left coronary artery, LCx: left circumflex branch, RCA: right coronary artery
394
3. Check and transect the pulmonary veins. Transect
the superior vena cava 2 cm above the point where
the crest of right atrial appendage meets the superior
vena cava (to preserve sinus node). Transect the inferior vena cava close to the diaphragm.
4. Open the right atrium from the inferior vena cava
to the apex of the appendage. Open the left atrium
between the pulmonary veins and then to the atrial
appendage. Inspect the atrial cavities, the inter-atrial
septum and determine whether the foramen ovale is
patent. Examine the mitral and tricuspid valves (or
valve prostheses) from above and check the integrity
of the papillary muscles and chordae tendineae.
5. Inspect the aorta, the pulmonary artery and the aortic and pulmonary valves (or valve prosthesis) from
above.
6. Check coronary arteries:
a) examine the size, shape, position, number and patency of the coronary ostia;
b) assess the size, course and “dominance” of the
major epicardial arteries;
c) make multiple transverse cuts at 3 mm intervals
along the course of the main epicardial arteries
and branches such as the diagonal and obtuse
marginal, and check patency;
d) heavily calcified coronary arteries can sometimes
be opened adequately with sharp scissors. If this
is not possible, they should be removed intact, decalcified and opened transversely;
e) coronary artery segments containing a metallic
stent should be referred intact to a labs with facilities for resin embedding and subsequent processing and sectioning;
f) coronary artery bypass grafts (saphenous veins,
internal mammary arteries, radial arteries, etc.)
should be carefully examined with transverse
cuts. The proximal and distal anastomoses should
be examined with particular care. Side branch
clips or sutures may facilitate their identification,
particularly when dealing with internal mammary
grafts.
7. Make a complete transverse (short-axis) cut of the
heart at the mid-ventricular level and then parallel
slices of ventricles at 1 cm intervals towards the apex
and assess these slices carefully for morphology of
the walls and cavities.
8. Once emptied of blood, note the following measurements:
a) Total heart weight: assess weight of heart against
tables of normal weights by age, gender and body
weight 15-17;
b) Wall thickness: inspect endocardium, measure
thickness of mid cavity free wall of the left ventricle and right ventricle as well as of the septum
(excluding trabeculae) against tables of normal
thickness by age, gender and body weight 15-17;
c) Heart dimensions: the transverse size is best calculated as the distance from the obtuse to the acute
margin in the posterior atrio-ventricular sulcus.
C. Basso et al.
The longitudinal size is obtained from a measurement of the distance between the crux cordis and
the apex of the heart on the posterior aspect.
9. Dissect the basal half of the heart in the flow of blood
and complete examination of atrial and ventricular
septa, atrio-ventricular valves, ventricular inflows
and outflows, and semilunar valves. In case of ECG
documented ventricular preexcitation, the atrioventricular rings should be maintained intact.
2.2 The standard histologic examination of the heart
Myocardium: take mapped labelled blocks from a representative transverse slice of the ventricles to include
the free wall of the left ventricle (anterior, lateral and
posterior), the ventricular septum (anterior and posterior), and the free wall of the right ventricle (anterior,
lateral and posterior), as well as right ventricular outflow
tract and one block from each atria. Additionally, any
area with significant macroscopic abnormalities should
be sampled. H & E and a connective tissue stain (van
Gieson, trichrome or Sirius red) are standard. Other
special stains and immunohistochemistry should be performed as required.
Coronary arteries: in the setting of coronary artery disease, most severe focal lesions should be sampled for
histology in labelled blocks and stained as before.
Other cardiac samples (such as valvular tissue, pericardium and aorta) as indicated.
If the clinical history or ECG tracing suggest a conduction abnormality, conduction system investigation by serial sections technique should be performed.
2.3 Electron microscopy investigation
If there is the suspicion of rare cardiomyopathies (mitochondrial, storage, infiltrative, etc) a small sample of
myocardium (1 mm) should be fixed in 2.5% glutaraldehyde for ultrastructural examination.
2.4 Referral of Hearts to Specialised Centres
Best practice is that the entire heart is retained and sent
to specialized centres. The referring pathologist should
complete steps 2.1.1-2.1.5, make a transverse apical section of the heart and empty the heart of blood. Tissues,
blood and other fluids for toxicology and molecular pathology should be taken before fixing the heart in formalin 10% (see below 4.2). If the heart cannot be retained,
it is essential that extensive photographic documentation
is made, indicating where individual blocks are taken.
3. Other tissues for histological examination
Specimens from the main other organs should be taken
routinely and stained with H & E and a connective tissue stain.
4. Further Laboratory Tests
Molecular or toxicologic studies may be required at
some stage in the future. To this end appropriate storage
of autopsy tissues/fluids is essential in SCD autopsies. If
these laboratory tests are needed and no on site facilities
395
are available, the stored material should be sent to specialized Labs established at regional or national levels.
4.1 Toxicology
In investigating out-of-hospital deaths, the question is
almost always raised of whether toxic substances are
involved. Depending on the circumstances surrounding
the death and toxicological data, the manner of death can
be natural, accidental or criminal. Even when the heart
is found to be abnormal at gross and/or microscopic examination, and death occurred suddenly, the question
still remains of whether a substance may have triggered
the death, acting as additional factor to the anatomic substrate. During sport activity, doping is an important issue. In the young, SCD may be triggered by recreational
drugs such as MDMA (ecstasy) or other amphetaminelike substances. Moreover, SCD may be caused by medications with cardiac side effects, such as neuroleptic or
even cardiac drugs. The proper selection, collection, and
submission of specimens for toxicological analyses is
mandatory if analytical results are to be accurate and scientifically useful. The types and minimum amounts of
tissue specimens and fluids needed for toxicological evaluation are frequently dictated by the analytes that must
be identified and quantitated. For the purpose of sudden
death investigation, the following amounts are adapted
from the Guidelines of the Society of Forensic Toxicolo-
gists and the American Academy of Forensic Sciences 19
heart blood 25 mL, peripheral blood from femoral veins
10 mL, urine 30-50 mL, bile 20-30 mL (when urine is not
available). All samples are stored at 4°C. A lock of hair
(100-200 mg) should be cut from the back head (or from
the pubic hair when head hair is not available). Toxicological analyses should be quantitative.
4.2 Molecular pathology
Molecular studies of SCD include both detection of
viral genomes, in inflammatory cardiomyopathy, and
gene mutational analysis, in both structural and nonstructural genetically determined heart diseases 9 20-22.
For these purposes, 10 ml of EDTA blood and 5 g of
heart and spleen tissues are either frozen and stored at
-80°, or alternatively stored in RNA later at 4° for up to
two weeks.
5. Formulation of a diagnosis and the clinicopathological summary
The report should conclude with a clear clinico-pathological summary (epicrisis). As far as possible this should
relate the pathological findings to the clinical history,
the circumstances of the death and any investigation
performed close to the time of the death. There will be
inevitable variation in the format of the death certificate
between the states of the European Union.
Tab. II. Certainity of diagnosis in SCD autopsies.
Certain
(Highly) Probable
Massive pulmonary embolism
Stable atherosclerotic plaque with
luminal stenosis > 75% with or
Haemopericardium due to aortic or cardiac without healed myocardial infarction
rupture
Anomalous origin of the LCA from the
Mitral valve papillary muscle or chordae
right sinus and interarterial course
tendineae rupture with acute mitral valve
incompetence and pulmonary edema
Cardiomyopathies (hypertrophic,
arrhythmogenic right ventricular,
Acute coronary occlusion due to
dilated, others)
thrombosis, dissection or embolism
Myxoid degeneration of the
Anomalous origin of the coronary artery
mitral valve with prolapse with
from the pulmonary trunk
atrial dilatation or left ventricular
hypertrophy and intact chordae
Neoplasm/thrombus obstructing the valve
orifice
Aortic stenosis with left ventricular
hypertrophy
Thrombotic block of the valve prosthesis
ECG documented ventricular preLaceration/dehiscence/poppet escape
excitation (Wolff-Parkinson-White
of valve prosthesis with acute valve
syndrome, Lown Ganong Levine
incompetence
syndrome)
Massive acute myocarditis
ECG documented sino-atrial or AV
block
Congenital heart diseases, operated
Uncertain
Minor anomalies of the coronary arteries
from the aorta (RCA from the left sinus, LCA
from the right without interarterial course,
high take-off from the tubular portion, LCx
originating from the right sinus or RCA,
coronary ostia plication, fibromuscular
dysplasia, Intramural small vessel disease)
Intramyocardial course of a coronary artery
(myocardial bridge)
Focal myocarditis, hypertensive heart disease,
idiopathic left ventricular hypertrophy
Myxoid degeneration of the mitral valve
with prolapse without atrial dilatation or left
ventricular hypertrophy and intact chordae
Dystrophic calcification of the membranous
septum (+/- mitral annulus/aortic valve)
Atrial septum lipoma
AV node cystic tumor without ECG evidence
of AV block conducting system disease
without ECG documentation
Congenital heart disease, unoperated, with or
without Eisenmenger syndrome
AV: atrioventricular, ECG: electrocardiogram, LCA: left coronary artery, LCx: left circumflex branch, RCA: right coronary artery
396
C. Basso et al.
Tab. III. The Gray Zone between physiological and pathological changes in myocardial disease.
Physiological change
Fatty infiltration of the right
ventricular wall
Exercise induced left
ventricular hypertrophy
(athlete’s heart)
Focal myocardial disarray
without hypertrophy
Scattered inflammatory foci
with or without small foci of
fibrosis
Pathological
Change
Arrhythmogenic right
ventricular cardiomyopathy
Hypertrophic
cardiomyopathy
Hypertrophic
cardiomyopathy without
hypertrophy
Borderline/focal myocarditis
Comments
Massive fatty infiltration of the right ventricle, without any evidence
of replacement-type fibrosis and myocyte degeneration, should not
be considered “per se” a substrate of SCD, especially in obese and
elderly people 19, 24
An enlarged left ventricular cavity with increased wall thicknesses
up to 13-14 mm is present in more than one third of highly trained
athletes. Detailed histology essential 7
Macroscopic changes are not always present in hypertrophic
cardiomyopathy. At microscopy, the amount of fibers disarray
should exceed 5-10% of fibres for diagnosing HCM. Isolated
myocardial disarray confined to the antero-septal and postero-septal
junctions should be considered normal. For a confident diagnosis,
additional findings, such as interstitial and/or replacement fibrosis
and abnormal intramyocardial small vessels should be searched for 7
In the absence of myocyte necrosis, small foci of inflammatory cells
(even after immunohistochemistry), are not sufficient evidence of
myocarditis. Scattered small foci of fibrosis are also insignificant.
Both findings should prompt examination of additional blocks. Viral
infection should be excluded by molecular techniques 25
In the majority of SCDs a clear pathological cause can
be identified, albeit with varying degrees of confidence.
Wherever possible, the most likely underlying cause
should be stated and the need for clinical screening and
genetic analysis clearly indicated 14 23.
It is important to accept that different degrees of certainty exist in defining the cause-effect relationship between
the cardiovascular substrate and the sudden death event.
Table II lists the commonest substrates of SCD, classifying each as certain, highly probable or uncertain. In the
probable, and especially the uncertain categories, each
case should be considered on its individual merits. The
clinical history and the circumstances of death may influence the decision making process.
Finally, there are myocardial diseases in which the border
between physiological and pathological changes is poorly
defined. Some of these diagnostic “gray zones” are described in Table III 24-27. In everyday practice, pathologists
should make a detailed macroscopic and microscopic description of their findings, without implying a cause and
effect relationship. If there is real doubt as to whether the
changes are physiological or pathological, an expert opinion should be sought (see 2.3).
Deaths that remain unexplained after careful macroscopic, microscopic and laboratory investigation should be
classified as sudden arrhythmic death syndrome 23 28 29.
We strongly suspect that the numbers of these unexplained deaths have been underestimated in the past.
References
There is increasing evidence that SCD in these instances
might be due to inherited ion channel disorders, such as
long QT and short QT syndromes, Brugada syndrome
and catecholaminergic polymorphic ventricular tachycardia, which present with well-defined abnormalities
of basal or effort ECG. In this setting, the availability of
ECG tracings may be crucial for the diagnosis and molecular studies are essential. First degree relatives should
undergo clinical screening and subsequent genetic analysis when indicated.
Conclusions
Although SCD is one of the most important mode of
death in the European Union, pathologists and public
health physicians have not given this problem the attention it deserves. Ventricular fibrillation is the nightmare
of Western countries’ populations. New methods of
preventing potentially fatal arrhythmias have been developed and the accurate diagnosis of SCD is now of
particular importance. The guidelines we produced represent the minimum standards of practice that should be
adopted throughout the European Union and elsewhere.
Further detailed information on the investigation of SCD
and the diagnosis of specific entities will be available on
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pathologica 2010;102:398-404
Linee Guida
Linee Guida per lo studio autoptico
della morte improvvisa cardiaca
C. Basso1, M. Burke2, P. Fornes3, P.J. Gallagher4, R.H. de Gouveia5, M. Sheppard6,
G. Thiene1, A. van der Wal7
A nome della Association for European Cardiovascular Pathology
http://anpat.unipd.it/aecvp/
1
Dipartimento di Scienze Medico Diagnostiche e Terapie Speciali, Università di Padova, Italia; 2 Dipartimento di Istopatologia, Royal
Brompton & Harefield NHS Trust, Harefield Hospital, UK; 3 Dipartimento di Patologia, Hopital Européen G. Pompidou, Parigi,
Francia; 4 Dipartimento di Patologia, Southampton University Hospitals, UK; 5 Dipartimento di Patologia, Hospital de Santa Cruz,
Lisbona, Portogallo; 6 Dipartimento di Patologia, Royal Brompton Hospital, Londra, UK; 7 Dipartimento di Patologia, Academic
Medical Center, Università di Amsterdam, Olanda
Parole chiave
Autopsia • Linee Guida • Protocollo • Morte improvvisa cardiaca
Summary
Sebbene la morte improvvisa (MI) cardiaca sia una delle più frequenti modalità di decesso nei paesi industrializzati, a tutt’oggi
essa non ha ricevuto l’attenzione che merita. La prevenzione
delle aritmie potenzialmente fatali ha fatto notevoli progressi e
l’accuratezza diagnostica nella pratica autoptica delle MI è di
particolare importanza. Gli anatomopatologi sono responsabili
dell’esatta identificazione della causa di morte nei casi di MI,
ma l’approccio è spesso assai variabile. L’Associazione Europea
per la Patologia Cardiovascolare (AECVP) ha sviluppato delle
linee guida che rappresentano il minimo standard richiesto nella
routine della pratica autoptica per un’adeguata valutazione della
MI, che include non solo un protocollo per la valutazione macroscopica del cuore e il suo campionamento per lo studio istologico, ma anche per le indagini tossicologiche e molecolari. Tali
raccomandazioni sono rivolte a tutti i centri medici universitari,
ai centri ospedalieri regionali e distrettuali e a tutti gli istituti di
medicina legale. Se verrà adottato in tutti i paesi dell’Unione
Europea un metodo uniforme d’indagine, si potrà arrivare ad un
miglioramento della pratica standard autoptica permettendo una
comparazione dei dati tra le differenti comunità e regioni, ed
ancor più permetterà in futuro di valutare il trend delle patologie
coinvolte nella MI.
Introduzione
Nella popolazione giovanile di età inferiore a 30 anni, il
rischio totale di MI cardiaca è pari a 1/100.000 e un più
ampio spettro di patologie ne rende ragione 6.
Le maggiori difficoltà nell’interpretazione dei dati epidemiologici nella MI sono la mancata standardizzazione nel
codice di certificazione di morte e la variabilità della definizione della stessa MI. La MI è stata definita come un “evento naturale, inaspettato e fatale che avviene entro 1 ora dalla
presentazione dei sintomi in soggetti apparentemente sani o
la cui malattia cardiaca era nota ma non così severa da far
presagire una fine infausta” 7. Questo ben descrive molti decessi testimoniati che avvengono nella comunità o nei vari
servizi di Pronto Soccorso. Meno soddisfacente risulta essere nella pratica anatomo-patologica, dove le autopsie posso-
La morte improvvisa (MI) cardiaca è la modalità principale di morte nei vari Paesi dell’Unione Europea e degli
USA, ma la sua precisa incidenza non è nota. Infatti,
i metodi di certificazione di morte accettati a livello
internazionale non prevedono una categoria specifica
per la MI. La stima dei casi di MI per patologia cardiovascolare nell’adulto negli USA varia da 250.000 a
400.000 casi anno, con un’incidenza di 1 - 2/1.000 abitanti l’anno 1-3. Una task force della Società Europea di
Cardiologia ha rilevato una incidenza variabile da 36 a
128 casi/100.000 abitanti l’anno 4 5. Più del 60% di questi casi trovano spiegazione in una malattia coronarica.
CorrIspondenza
Tradotto da Guidelines for autopsy investigation of sudden cardiac
death - Virchows Arch. 2008;452:11-18, a cura di Elisa Carturan,
PhD, con la gentile autorizzazione di Springer Science e Business
Medica.
Gaetano Thiene, Dipartimento di Scienze Medico-Diagnostiche
e Terapie Speciali, Sezione di Anatomia Patologica Speciale,
Università di Padova, via A. Gabelli 61, 35121 Padova - Tel. +39
049 8272283 - Fax +39 049 827.2284 - E-mail: gaetano.thiene@
unipd.it
399
Linee Guida per lo studio autoptico della morte improvvisa cardiaca
no essere richieste in pazienti in cui la morte non è stata testimoniata, o è avvenuta durante il sonno o in un tempo non
noto prima del ritrovamento del cadavere. In tali situazioni
si può assumere che la morte è improvvisa se il deceduto si
presentava in buona salute nelle 24 ore precedenti l’evento
fatale 8. Inoltre, si può classificare come MI anche quando
un paziente viene rianimato da un arresto cardiaco, sopravvive per un tempo limitato in assistenza, e decede successivamente per un irreversibile danno cerebrale.
La responsabilità della determinazione della precisa causa di morte è dell’anatomo-patologo, ma l’approccio è
assai variabile. Numerosi capitoli di libri, linee guida ed
articoli hanno descritto come il patologo dovrebbe approntarsi allo studio nei casi di MI 9-14. Purtroppo non vi
è ancora un’uniformità tra i diversi centri, spesso anche
nello stesso paese. A tal fine in questo report si vogliono
delineare il minimo standard richiesto nella routine della
pratica autoptica per lo studio dei casi di MI escludendo
i casi di morte improvvisa in culla. Le presenti raccomandazioni dovrebbero essere recepite nei diversi centri
medici universitari, negli ospedali regionali e distrettuali ed a tutti gli istituti di medicina legale. Solo se verrà
adottato un metodo uniforme in tutti i paesi dell’Unione
Europea, si arriverà ad un miglioramento degli standard
nella pratica autoptica, permettendo una significativa
comparazione dei dati delle differenti comunità, ed ancor
più permetterà di monitorare le diverse cause della MI.
Il ruolo dell’autopsia nella morte improvvisa
Per stabilire o valutare:
• quando il decesso è attribuibile ad una patologia cardiaca o no;
• la natura della patologia cardiaca e quando il meccanismo è aritmico o meccanico;
• quando la patologia cardiaca può essere di origine
ereditaria e quindi richiedere uno screening clinicogenetico dei familiari;
• il possibile abuso di sostanze tossiche o illecite o di
altre cause di morte non naturali.
Informazioni cliniche rilevanti
per l’autopsia
Nella pratica odierna le informazioni cliniche disponibili al momento dell’autopsia sono assai variabili. Ogni
potenziale sorgente di informazione dovrebbe essere
interrogata (familiari, medico di base, ecc.), preferibilmente prima dell’autopsia. Idealmente dovrebbero essere richieste le seguenti informazioni:
• età, sesso, occupazione professionale, stile di vita (assunzione di alcool, fumo), tipo di attività fisica e/o sportiva;
• circostanze di morte: data, intervallo di tempo (istantanea o inferiore ad 1 ora), luogo del decesso (a casa,
a lavoro, in ospedale, nel tempo libero), le circostanze (a riposo, durante il sonno, durante attività fisica
o stress emozionale), con o senza testimoni, ed ogni
•
•
•
•
circostanza sospetta (presenza di monossido di carbonio, violenza, incidente stradale, ecc.);
anamnesi familiare di malattie cardiache: cardiopatia
ischemica, aritmie, cardiopatie ereditarie, morte improvvisa;
anamnesi fisiologica e patologica, remota e prossima: stato generale di salute, precedenti malattie (con
particolare attenzione a sincopi, dolore toracico e
palpitazioni soprattutto durante esercizio fisico, infarto miocardio, ipertensione, malattie respiratorie,
recenti infezioni, epilessia, asma, ecc.), precedenti
interventi chirurgici e non, precedenti tracciati ECG
e RX torace, esiti di visite cardiovascolari ed esami
del sangue (specialmente profilo lipidico);
assunzione di medicinali con e senza prescrizione
medica;
tracciati ECG ottenuti durante le manovre di rianimazione, valutazione degli enzimi sierici e della troponina.
La procedura autoptica
Tutte le MI dovrebbero seguire una scaletta di esami
sequenziali. Specificatamente si dovrebbero valutare le
maggiori cause di MI extra cardiache e cardiache. Principi e regole relative alle procedure autoptiche dovrebbero rifarsi alle “Recommendation on the Harmonisation
of Medico-Legal Autopsy Rules” prodotto dal Comitato
Ministeriale del Consiglio Europeo 10.
A) Esame esterno del corpo
•Stabilire peso ed altezza del corpo per correlarli successivamente al peso del cuore ed allo spessore delle
pareti 15-17.
•Verificare recenti segni di accessi intravenosi, intubazioni, elettrodi per ECG, bruciature elettriche e da
defibrillatore, siti di drenaggio e lesioni traumatiche.
•Controllare la presenza di un defibrillatore impiantabile (ICD)/pacemaker. Per la rimozione sicura e
l’interrogazione del dispositivo medico vedere MDA
Safety Notice 2002 18.
B) Verrà effettuata una autopsia completa
con un approccio sequenziale alla ricerca
delle varie cause di MI
1. Esclusione di cause non cardiache nella MI
Tutte le MI naturali dovrebbero essere considerate di
origine cardiaca dopo aver escluso la presenza di cause extracardiache. Per tale motivo si dovrebbe eseguire
sempre l’autopsia in modo completo e con un approccio
sequenziale in modo da escludere le cause comuni e non
extracardiache, in particolare:
•cerebrale (es. emorragia subaracnoidea o intra cerebrale, ecc.);
•respiratoria (es. asma, shock anafilattico, ecc.);
•shock emorragico acuto (es. rottura aneurisma aortico, ulcera peptica, ecc.);
400
•shock settico (es. sindrome di Waterhouse-Friderichsen).
2. Ricerca di cause cardiache nella MI
Molte malattie cardiovascolari possono essere alla base di
MI, sia attraverso meccanismi aritmici (MI cardiaca elettri-
C. Basso et al.
ca) che per compromissione della funzione meccanica del
cuore (MI cardiaca meccanica). Queste patologie possono
coinvolgere le arterie coronarie, il miocardio, le valvole
cardiache, il sistema di conduzione, l’aorta intrapericardica e l’arteria polmonare, strutture tutte la cui integrità è
necessaria per una regolare funzionalità cardiaca (Tab. I).
Tab. I. Cause di MI allo studio postmortem.
Meccanica
Emopericardio e tamponamento cardiaco
Rottura dell’aorta ascendente (ipertensione, Marfan, valvola aortica bicuspide, coartazione, altre)
Rottura di cuore post infartuale nella parete libera
Embolia polmonare
Insufficienza acuta della valvola mitrale con edema polmonare
Rottura dei muscoli papillari post infartuale
Rottura corde tendinee (prolasso mitrale)
Ostruzione intracavitaria (i.e. trombo/neoplasia)
Improvvisa disfunzione della protesi valvolare (i.e. lacerazione, deiscenza, blocco trombotico)
Assenza congenita parziale del pericardio
Elettrica
Arterie coronarie (+/- cicatrice post infartuale)
Anomalie congenite
Origine dall’Aorta
Seno sbagliato (arteria coronaria destra dal seno sinistro, arteria coronaria sinistra dal seno destro)
Ramo circonflesso sinistro dal seno destro o dall’arteria coronaria destra
Origine alta dalla porzione tubulare
Plicatura ostiale
Origine dell’arteria Polmonare
Decorso intramiocardico (“ponte miocardico”)
Acquisite
Aterosclerosi
Complicata (trombo, emorragia)
Non complicata
Embolia
Arterite
Dissezione
Altro
Displasia fibromuscolare
Malattia intramurale dei piccoli vasi
Rigetto trapianto cardiaco, acuto o cronico
Precendenti interventi chirurgici o procedure interventistiche
By-pass coronarico (vena safena, arteria mammaria, arteria radiale, ecc.)
Angioplastica coronarica con palloncino, stents
Miocardio
Cardiomiopatia ipertrofica
Cardiomiopatia aritmogena del ventricolo destro
Cardiomiopatia dilatativa
Cardiomiopatia infiammatoria (miocardite)
Cardiomiopatie secondarie (accumulo, infiltrative, sarcoidosi ecc.)
Cardiopatia ipertensiva
Ipertrofia idiopatica del ventricolo sinistro
Cardiomiopatie non classificate (spongy myocardium, fibroelastosi)
Valvole
Stenosi aortica
Degenerazione mixoide con prolasso della valvola mitrale
Tessuto di conduzione
Blocco seno-atriale
Blocco atrio-ventricolare (malattia di Lev-Lenegre, tumore cistico del nodo AV)
Preeccitazione ventricolare (sindrome di Wolff-Parkinson-White, sindrome di Lown-Ganong-Levine)
Cardiopatia congenita (operata e non), con e senza sindrome di Eisenmenger
Cuore normale (MI “sine materia” o inspiegata o sindrome della MI aritmica)
Sindrome del QT lungo e corto
Sindrome di Brugada
Tachicardia ventricolare polimorfa catecolaminergica
Fibrillazione ventricolare idiopatica
MI: morte improvvisa
2.1 Esame macroscopico del cuore
1. Ispezionare il pericardio: aprirlo ed esplorare la cavità pericardica.
2. Valutare l’anatomia delle grandi arterie prima di sezionarle 3 cm sopra le valvole aortiche e polmonari.
3. Valutare e aprire le vene polmonari. Tagliare la vena
cava superiore 2 cm sopra il punto di incontro con la
cresta terminale (si preserva così il nodo del seno).
Tagliare la vena cava inferiore vicino al diaframma.
4. Aprire l’atrio destro dalla vena cava inferiore all’apice dell’auricola e l’atrio sinistro tra le vene polmonari e quindi fino all’appendice atriale. Ispezionare
le cavità atriali ed il setto interatriale, e verificare la
pervietà del forame ovale. Esaminare la valvola mitrale e tricuspide (o la protesi valvolare) da sopra, e
valutare l’integrità dei muscoli papillari e delle corde
tendinee.
5. Ispezionare l’aorta, l’arteria polmonare e le valvole
aortica e polmonare (o la protesi valvolare) dal di sopra.
6. Valutare le arterie coronarie:
a) esaminare sede, misura, forma, numero e pervietà
degli ostii coronarici;
b) valutare il calibro, il corso e la “dominanza” delle
arterie epicardiche;
c) effettuare tagli multipli trasversi ad intervalli di 3
mm lungo il corso delle maggiori arterie epicardiche e dei loro rami, come il ramo diagonale e
marginale ottuso verificandone la pervietà;
d) arterie coronarie fortemente calcifiche possono
essere aperte talora solo con le forbici. Se questo
non è possibile, si dovrebbero rimuovere in toto,
decalcificarle ed aprirle trasversalmente in un secondo momento;
e) se presente uno stent metallico, il segmento coronarico dovrebbe essere rimosso mantenendolo
intatto, per venire incluso in resina e successivamente analizzato in sezioni seriate;
f) in caso di bypass coronarico (vena safena, arteria
mammaria interna, arteria radiale, ecc.) si deve
esaminarlo attentamente con tagli trasversi. Le
anastomosi distali e prossimali vanno valutate
attentamente. Il “clips” o le suture nei rami collaterali possono facilitare la loro identificazione,
particolarmente quando si tratta di un graft con
arteria mammaria interna.
7. Fare un taglio traverso completo (asse corto) del
cuore a livello medio-ventricolare e quindi eseguire
sezioni parallele ad intervalli di 1 cm verso l’apice;
valutare queste sezioni attentamente per la morfologia dell’epicardio, delle pareti, dell’endocardio e delle cavità.
8. Una volta svuotato il cuore dal sangue, annotare le
seguenti misure:
a) peso totale del cuore: valutare il peso del cuore e
confrontarlo con la tabella di pesi normali per età,
sesso e peso corporeo 15-17;
b) spessore delle pareti: ispezionare l’endocardio, misurare lo spessore medio della parete libera del ven-
401
tricolo sinistro, ventricolo destro e del setto (escluse le trabecolature) all’altezza medio-ventricolare
e confrontarli con la tabella dei valori normali di
spessore per età, sesso e peso corporeo 15-17;
c) dimensioni del cuore: la misura trasversa andrebbe calcolata come la distanza dal margine ottuso
al margine acuto a livello del solco atrioventricolare posteriore. La misura longitudinale è ottenuta
da una misura della distanza tra la crux cordis e
l’apice del cuore nella faccia posteriore del cuore.
9. Sezionare la metà basale del cuore secondo il flusso
del sangue ed eseguire un completo esame di setti
atriale e ventricolare, delle valvole atrioventricolari,
delle zone di afflusso ed efflusso ventricolari, e delle
valvole semilunari. In caso di pre-eccitazione ventricolare documentata all’ECG, gli anelli atrioventricolari dovrebbero essere mantenuti intatti.
2.2 Istologia standard per l’esame del cuore
Miocardio: da una sezione trasversa rappresentativa
del cuore ottenere dei prelievi identificati con sigla in
modo da includere le pareti libere del ventricolo sinistro (anteriore, laterale, posteriore), il setto ventricolare (anteriore, posteriore), la parete libera del ventricolo
destro (anteriore, laterale e posteriore), il tratto di efflusso destro ed un prelievo degli atri. Inoltre si deve
campionare ogni altra area con significative anormalità macroscopiche. Le colorazioni da effettuare come
procedura standard sono l’ematossilina ed eosina (EE)
e una colorazione per il tessuto connettivo (Weigertvan Gieson, tricromica o sirius red). Altre colorazioni
speciali e l’immunoistochimica vanno eseguite in casi
particolari.
Arterie coronarie: in caso di patologia delle arterie coronarie, le lesioni focali più severe devono essere campionate per lo studio istologico in blocchetti identificati con
sigla e vanno eseguite le colorazioni standard precedentemente descritte.
Altri campioni cardiaci (i.e. tessuto valvolare, pericardio
e aorta) sono eseguiti quando indicati.
Se la storia clinica o i tracciati di ECG suggeriscono
un’anomalia del tessuto di conduzione, si deve effettuare lo studio seriato del sistema di conduzione.
2.3 Microscopia elettronica
Se vi è il sospetto di rare cardiomiopatie (mitocondriali,
d’accumulo, infiltrative, ecc.) si deve effettuare un piccolo prelievo di miocardio (1mm) fissato in glutaraldeide 2.5% per lo studio ultrastrutturale.
2.4 Invio dell’esemplare cardiaco a centri di riferimento
specializzati
In tal caso, è sempre bene che l’intero cuore venga conservato e spedito ad un centro specializzato. I patologi
dovrebbero completare le fasi da 1 a 5 dell’esame macroscopico del cuore, fare la sezione apicale trasversa
del cuore e svuotare le cavità del sangue. Prelievi di tessuto, di sangue e degli altri fluidi corporei per lo studio
402
tossicologico e molecolare dovrebbero essere effettuati
prima di procedere alla fissazione del cuore in formalina
10% (vedi le successive sezioni di Tossicologia e Patologia Molecolare). Se il cuore non può essere conservato, è essenziale una estesa documentazione fotografica
indicando dove sono stati effettuati i prelievi.
3. Altri tessuti per lo studio Microscopico
Prelievi degli organi principali dovrebbero essere effettuati routinariamente, processati e colorati con EE e colorazioni per il tessuto connettivo.
4. Ulteriori test di laboratorio
Studi molecolari o tossicologici possono essere richiesti
successivamente allo studio istologico. A tale fine una
appropriata conservazione del tessuto autoptico e dei
fluidi corporei diviene essenziale nelle autopsie della
MI. Se questi test di laboratorio sono necessari, ma non
ci sono “facilities” ad hoc nella sede dove viene fatta
l’autopsia, si deve procedere alla conservazione del materiale ed alla spedizione a laboratori riconosciuti e specializzati, regionali o nazionali.
4.1 Tossicologia
In caso di MI avvenuta in sede extra-ospedaliera, deve
essere sempre considerato l’eventuale coinvolgimento di sostanze tossiche come causa dell’evento fatale.
Dalle circostanze di morte e dal dato tossicologico deriva se la morte è di origine naturale, accidentale o criminale. Anche quando il cuore risulti essere anormale
all’esame macroscopico e/o microscopico, e la morte
sovviene improvvisamente, ci si deve porre la domanda se qualche sostanza possa avere agito come fattore addizionale al substrato anatomico. Specialmente
negli atleti e nei giovani, doping e/o farmaci possono
precipitare una MI. Inoltre la MI può essere causata
da un farmaco con effetti collaterali cardiaci, come i
neurolettici o anche farmaci cardiovascolari. Una accurata selezione, raccolta e l’invio di campioni appropriati per l’analisi tossicologica risulta essere pertanto
essenziale. A tal fine, il tipo e la quantità di tessuto e di
fluidi corporei necessari per effettuare una valutazione tossicologica, sono legati agli analiti da ricercare
e da quantificare. Nei casi di MI sono state adottate
delle linee guida delle “Society of Forensic Toxicologists” e “American Academy of Forensic Sciences” 19:
sangue cardiaco 25 ml, sangue periferico da vena femorale 10ml, urina 30-50ml, bile 20-30 ml (qualora
l’urina non sia disponibile). Tutti i campioni devono
essere conservati a 4°. Inoltre bisogna prelevare dal
retro della testa una ciocca di capelli (100-200mg) o di
pelo pubico quando non sono presenti capelli. L’analisi tossicologica dovrebbe essere sia qualitativa che
quantitativa.
4.2 Patologia molecolare
Gli studi molecolari nella MI includono l’indagine della
presenza di genoma virale dei più comuni agenti infetti-
C. Basso et al.
vi coinvolti nelle cardiomiopatie infiammatorie, ma anche lo studio genetico per le malattie cardiache ereditare,
strutturali e non 9 20-22. A tale scopo si dovrebbe procedere al prelievo di 10 ml di sangue preservato con EDTA e
5 g di miocardio e di milza congelati e conservati a -80°
o alternativamente conservati in RNA later a 4° fino a 2
settimane.
5. Formulazione della diagnosi e del sommario
clinico-patologico
Il report dovrebbe terminare con un sommario clinicopatologico (epicrisi). Questo dovrebbe correlare i reperti
patologici con la storia clinica, le circostanze di morte e
ogni indagine eseguita in prossimità della data di morte.
Ci saranno inevitabilmente variazioni nel format del certificato di morte tra i diversi stati dell’Unione Europea.
Nella maggior parte delle MI, viene identificata una
chiara causa patologica, anche se con un variabile grado
di sicurezza. Si dovrebbe riportare, ogni qual volta che
sia possibile, la causa più probabile di morte, ed indicare se è necessario uno screening clinico e genetico dei
familiari 14 23.
È importante accettare che esistono differenti gradi di
certezza nel definire la relazione causa ed effetto tra il
substrato cardiovascolare e l’evento fatale. La Tabella
II elenca i più comuni substrati di MI classificandoli
come certi, altamente probabili e possibili. Nella categoria altamente probabile ma specialmente in quella
possibile ogni caso dovrebbe essere considerato nella
sua unicità. La storia clinica e le circostanze di morte
possono influire concretamente nel processo decisionale.
Infine, ci sono malattie miocardiche nelle quali è mal
definito il confine tra alterazione fisiologica e patologica. Alcune di queste “zone grigie” diagnostiche sono
descritte nella Tabella III 24-27. Nella pratica quotidiana, i
patologi dovrebbero fare una dettagliata descrizione macroscopica e microscopica dei loro reperti senza implicare necessariamente una relazione causa-effetto. Qualora vi sia incertezza sulla natura del reperto patologico,
si dovrebbe contattare un esperto per una sua opinione
(vedi “Centri di riferimento specializzati“).
Qualora la morte rimanga inspiegata anche dopo un attento studio macroscopico e microscopico e le pertinenti
indagini di laboratorio, si dovrebbe classificarla come
sindrome aritmica 23 28 29. È altamente probabile che il
numero di morti inspiegate delle MI sia stato sottostimato nel passato. Sempre più c’è l’evidenza che queste MI
possano essere legate a patologie ereditarie dei canali
ionici come la sindrome del QT lungo e corto, di Brugada e della tachicardia ventricolare catecolaminergica
polimorfa. Tali patologie si presentano con un ben definito pattern patologico all’ECG di base o sotto sforzo. In
questi casi la disponibilità di tracciati di ECG può essere
cruciale per la diagnosi e le indagini genetiche divengono essenziali. I parenti di primo grado dovrebbero essere
sottoposti a screening clinico e successivamente genetico, quando indicato.
403
Tab. II. Grado di certezza diagnostica all’autopsia della MI cardiaca.
Certa
Embolia polmonare massiva
Rottura dell’aorta o del cuore con
emopericardio e tamponamento
cardiaco
Rottura del muscolo papillare o
delle corde tendinee della valvola
mitrale con insufficienza ed edema
polmonare acuto
Occlusione coronarica acuta da
trombosi, dissezione o embolia
Altamente probabile
Placca aterosclerotica stabile con
stenosi > 75%, con o senza infarto
miocardico cicatrizzato
Origine anomala dell’arteria
coronaria sinistra dal seno destro
e decorso interarterioso
Cardiomiopatie (ipertrofica,
aritmogena del ventricolo destro,
dilatativa, altro)
Possibile
Anomalie minori delle arterie coronarie (arteria coronaria destra dal seno sinistro, arteria coronaria sinistra
dal seno destro senza decorso interarterioso, origine
alta dalla porzione tubulare, ramo circonflesso sinistro
dal seno destro o dall’arteria coronaria destra, plicatura ostiale coronarica, displasia fibromuscolare, malattia
dei piccoli vasi intramurali)
Decorso intramiocardico di una arteria coronaria maggiore (ponte miocardico)
Miocardite focale, cardiopatia ipertensiva, ipertrofia
idiopatica del ventricolo sinistro
Origine anomala delle arterie
coronarie dall’arteria polmonare
Degenerazione mixoide della valvola
mitrale con prolasso, dilatazione
atriale, o ipertrofia ventricolare e
corde intatte
Neoplasia/trombo occludente un
orifizio valvolare
Stenosi aortica con ipertrofia del
ventricolo sinistro
Blocco trombotico della protesi
valvolare
Preeccitazione ventricolare con
diagnosi ECG (sindrome di WolffLipoma setto atriale
Parkinson-White, sindrome di LownGanong-Levine)
Tumore cistico del nodo AV, senza evidenze all’ECG di
blocco AV, patologia del sistema di conduzione senza
Blocco seno-atriale o AV
documentazione ECG
documentato all’ECG
Cardiopatia congenita non operata, con o senza sinCardiopatie congenite complesse,
drome di Eisenmenger
operate
Lacerazione/deiscenza/distacco del
poppet della protesi valvolare con
insufficienza valvolare acuta
Miocardite acuta diffusa
Degenerazione mixoide della valvola mitrale con prolasso, senza dilatazione atriale sinistra o ipertrofia del
ventricolo sinistro e corde intatte
Distrofia calcifica del setto membranoso (+/- annulus
mitrale / valvola aortica)
AV: atrioventricolare, ECG: elettrocardiogramma, MI: morte improvvisa
Tab. III. Zona grigia tra alterazioni fiologiche e patologiche nelle malattie miocardiche.
Alterazioni fisiologiche
Infiltrazione di grasso nella parete
del ventricolo destro
Alterazioni patologiche
Cardiomiopatia aritmogena
del ventricolo destro
Ipertrofia del ventricolo sinistro
da esercizio fisico
(cuore d’atleta)
Disarray focale miocardico
senza ipertrofia
senza ipertrofia
Rare cellule infiammatorie,
con e senza piccoli foci di fibrosi
Miocardite borderline/focale
Commenti
Infiltrazione massiva di grasso nel ventricolo destro, senza evidenza di sostituzione fibrosa e degenerazione miocitaria, non
dovrebbe essere considerata un substrato di MI, specialmente
in obesi o persone anziane 19 24
Un ingrandimento della cavità del ventricolo sinistro con aumento dello spessore della parete fino a 13-14 mm è presente
in più di un terzo degli sportivi con un elevato livello di allenamento. L’indagine istologica dettagliata è essenziale 7
Alterazioni macroscopiche non sono sempre presenti nella
cardiomiopatia ipertrofica. All’esame microscopico, la quantità
di fibre con “disarray” dovrebbe eccedere il 5-10% delle fibre
per essere diagnostico. Un disarray miocardico confinato alla
giunzione antero-settale e postero-settale dovrebbe essere
considerato fisiologico. Per una diagnosi sicura dovrebbero
essere ricercati reperti addizionali quali fibrosi interstiziale e/o
sostitutiva e malattia dei piccoli vasi intramiocardici 7
In assenza di necrosi miocitaria, foci isolati di cellule infiammatorie (anche dopo immunoistochimica), non sono sufficienti per una diagnosi di miocardite. Piccoli foci sparsi di fibrosi sono pure insignificanti. Entrambi i reperti dovrebbero
indurre l’esecuzione e l’analisi di ulteriori prelievi. La presenza
di agenti infettivi cardiotropi dovrebbe essere esclusa con tecniche molecolari 25
404
Conclusioni
Sebbene la MI cardiaca sia una delle più frequenti modalità di morte nell’Unione Europea, questo problema
non ha ricevuto in passato la necessaria attenzione da
parte dei Patologi e dei Medici della Salute Pubblica.
La fibrillazione ventricolare è divenuta un incubo nelle
popolazioni dei paesi industrializzati. Sono state sviluppate nuove metodiche per la prevenzione di aritmie po-
C. Basso et al.
tenzialmente fatali e l’accuratezza diagnostica nei casi
di MI risulta di particolare importanza. Le nostre linee
guida rappresentano il minimo standard nella pratica autoptica e dovrebbero essere adottate in tutti i paesi della
Comunità Europea e altrove. Ulteriori dettagliate informazioni per lo studio della MI e la diagnosi di specifiche
entità saranno disponibili nel sito web dell’Associazione
per la Patologia Cardiovascolare Europea (http://anpat.
unipd.it/aecvp/).
Bibliografia
765 specimens from subjects 20 to 99 years old. Mayo Clin Proc
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pathologica 2010;102:405-406
Consensus document
Cytological classification of thyroid nodules.
Proposal of the SIAPEC-IAP Italian Consensus
Working Group
G. Fadda, F. Basolo, A. Bondi, G. Bussolati, A. Crescenzi, O. Nappi, F. Nardi, M. Papotti,
G. Taddei, L. Palombini
Divisions of Anatomic Pathology and Histology of the Catholic University of Rome, University of Pisa, Maggiore Hospital
of Bologna, University of Turin, Regina Apostolorum Hospital of Albano Laziale, Cardarelli Hospital of Naples, La Sapienza
University of Rome, University of Turin, University of Florence, Federico II University of Naples, Italy
Foreword
In 2006-2007, a committee was established by the Italian
Societies of Endocrinology (SIE and AME) and Pathology (SIAPEC-IAP), composed of invited endocrinologists with special interest in thyroid diseases, endocrine
pathologists and cytopathologists. The main objectives
of the committee were to analyse current diagnostic
practice and reporting of fine needle aspiration biopsy
cytology, and to define a consensus on the definition of
each individual diagnostic category. Such a definition
should include a shared, brief description of the main cytomorphological features followed by categorisation of
the diagnosis in a five-tiered system (TIR 1 through 5).
The definition should also provide a summary of clinical
implications for each cytological diagnosis.
The committee met several times to analyse the currently proposed international classification schemes. Different diagnostic reporting approaches were discussed
with clinical colleagues, and the suggested therapeutic
attitudes were recorded. The following consensus document is the final proposal.
Introduction
The term FNC is an acronym for “fine needle cytology”.
This technique provides a cytological sample using 22G
(or thinner) needles with or without aspiration. In the
cytological report, the needle gauge used to collect the
sample should be indicated. In case of solid and vascularized nodules, sampling without aspiration is recommended. Ultrasonography can be useful for multinodular glands and for cystic lesions with solid component
filling their cavities. The presence of the cytopathologist on-site is recommended for evaluating sampling adequacy. Aspirated material should be smeared on a glass
slide. Liquid-based cytology techniques (LBC) have not
shown any substantial advantages compared with traditional methods; therefore, they should be performed only in reference centres by experienced cytopathologists.
The use of a cell block is an additional technique, and
can be helpful when further investigations are required.
The main goal of FNC is to identify patients who may
benefit from medical treatment from those who should
undergo surgery. In non-functioning thyroid nodules, the
diagnostic accuracy of FNC is 95%. Ideal parameters of
quality recommend less than 2% of false negative results
and less than 3% of false positive results. The cytological report should be descriptive and, whenever possible,
a definitive diagnosis should be made. A numerical code
identifying a category of lesions homogeneous for malignancy risk and therapeutic options can be added to
the cytological report. The clinical request form should
contain essential clinical information, including the sampling site and the modality of the corresponding FNA.
The diagnostic categories are the following:
TIR 1. Non-diagnostic
The “non-diagnostic” reports should not exceed 20%
of the FNC (it is advisable they account for no more
than 15%). They can be classified as inadequate and/or
non-representative. The rate of non-diagnostic results
varies depending on technical factors. By definition, a
sample is inadequate when biased by smearing and/or
fixing and/or staining errors, whereas a sample is defined “non-representative” when an insufficient number of cells for a definitive diagnosis is collected from
the lesion.
The pathologist should specify the inadequacy or nonrepresentativeness of the sample in the cytological report and, if possible, the causes should be detailed. A
Correspondence
Guido Fadda, Catholic University of Sacred Heart, largo Francesco
Vito 1, 00168 Rome, Italy - Tel. +39 06 30154433 - Fax +39 06
30157008 - E- mail: [email protected]
406
sample correctly smeared, fixed and stained is defined
as adequate.
A sample with at least 6 groups of 10-20 well-preserved
epithelial cells from the lesion can be considered representative. Cytological diagnosis should be made only on
representative and adequate samples.
Action. Repetition of FNC at least one month after the
previous, according to the clinician’s judgement. Some
cases that are morphologically defined as non-representative should be evaluated according to the clinical setting. These cases include the following:
a) abundant and homogeneous colloid with scattered follicular cells aspirated from colloid nodules or cysts;
b) only lymphocytes in clinically diagnosed Hashimoto
thyroiditis;
c) erythrocytes, necrosis and macrophages from haemorrhagic pseudocysts.
If a solid portion remains after emptying a cystic lesion
under ultrasonographic guidance, it should be immediately re-aspirated. Ultrasonography is fundamental in
order to guide the needle to the solid component.
TIR 2. Negative for malignant cells
This category accounts for 60-75% of cytological reports. It includes colloid goiter, autoimmune thyroiditis
(Hashimoto’s) and granulomatous thyroiditis (de Quervain’s).
Action. Follow-up or FNC repetition, according either to
the clinician’s or cytopathologist’s judgement may reduce the number of false negative results.
TIR 3. Inconclusive/indeterminate
(Follicular proliferation)
This category encompasses all follicular-patterned lesions: adenomatoid hyperplasia, adenoma, oxyphilic
cells lesions, some cases of follicular variant of papillary
carcinoma and microinvasive follicular carcinomas. In
these cases only histology (and not cytology alone) can
provide a definitive diagnosis. This category accounts
approximately for 20% of cytological reports. About
80% of TIR 3 diagnoses are benign lesions, whereas
only 20% of are malignant tumours after histological
examination.
Immunohistochemical markers such as galectin-3,
HBME-1, cytokeratin 19 may improve the accuracy of
Selected references
1
Autori Vari. Gestione clinica del paziente con patologia nodulare
tiroidea: Consenso Italiano. L’Endocrinologo 2008;9(Suppl.4):S1S16.
G. Fadda et al.
cytological diagnosis. Although they do not have a well
established predictive value, they can be used following
strict diagnostic protocols to discriminate positive cases
(surgical option) from negative ones (follow-up).
Some cases characterized by too mild cytological alterations to be included in TIR 4 but which, on the other
hand cannot be included in the benign category (TIR 2),
can be classified as TIR 3. The choice of including these
samples in the “low risk” category must be supported by
an appropriate description in the medical report.
Action. Surgical excision of the lesion and histological
examination. Intraoperative histological examination is
not recommended. The surgical option should be evaluated in the clinical and imaging setting.
TIR 4. Suspicious for malignancy
This is a heterogeneous group of lesions. Samples with
insufficient malignant neoplastic cells and samples
without sufficient cytological atypia to make a diagnosis
of cancer are included. This category almost always includes suspicious papillary carcinomas, and accounts for
about 5% of cytological diagnoses.
Action. FNC repetition, according to the clinician’s or
cytopathologist’s judgement. Surgery with intraoperative histological examination is recommended.
TIR 5. Diagnostic of malignancy
All cases with a definitive diagnosis of malignant neoplasm (papillary, medullary and anaplastic carcinomas,
lymphomas and metastasis) are included in this category. It accounts for 5-15% of cytological diagnoses. The
medical report should contain an adequate cytological
description.
Action Surgery for differentiated carcinomas. The surgical option should be evaluated in the clinical setting and
on the basis of the cytological report.
For anaplastic carcinomas, lymphomas and metastatic
lesions, continuation of diagnostic/therapeutic procedures is recommended.
Conclusions
FNC is a screening test. A definitive diagnosis can be
made only after histological examination of the nodule.
2
British Thyroid Association. Guidelines for the Management of
Thyroid Cancer. Second Edition. London: Royal College of Physicians 2007.
pathologica 2010;102:407-408
Consensus document
Classificazione citologica dei noduli tiroidei.
Proposta del Consensus Working Group italiano
della SIAPEC-IAP
G. Fadda, F. Basolo, A. Bondi, G. Bussolati, A. Crescenzi, O. Nappi, F. Nardi, M. Papotti,
G. Taddei, L. Palombini
Divisioni di Anatomia Patologica e Istologia dell’Università Cattolica del Sacro Cuore di Roma, Università di Pisa, Ospedale
Maggiore di Bologna, Università di Torino, Ospedale Regina Apostolorum di Albano Laziale, Ospedale Cardarelli di Napoli,
La Sapienza Università di Roma, Università di Torino, Università di Firenze, Università Federico II di Napoli
Introduzione
Sotto il termine di Fine-Needle Cytology (FNC) si intende un prelievo citologico mediante ago sottile che
può essere effettuato con o senza aspirazione, preferibilmente con un ago di 22G o più sottile. È opportuno
che il calibro dell’ago sia riportato in referto. In presenza
di noduli solidi e vascolarizzati è consigliato il prelievo
senza aspirazione. Il prelievo va effettuato preferibilmente con l’ausilio dell’esame ecografico soprattutto in
caso di multinodularità e di cisti con componenti solide
aggettanti nel lume. Si consiglia, ove possibile, la presenza del citopatologo per la valutazione dell’idoneità
del prelievo. Lo striscio diretto su vetrino portaoggetti
del materiale aspirato è il metodo di base consigliato.
Le tecniche in strato sottile (Liquid Based Cytology,
LBC), che al momento non hanno dimostrato un reale
vantaggio sulla metodica tradizionale, dovrebbero essere praticate solo in centri con collaudata esperienza o
da citopatologi con uno specifico training. Il citoincluso
(cell block) è considerato supplementare ed è utile quando siano necessarie ulteriori indagini.
Lo scopo principale della FNC è quello di selezionare i
pazienti con patologia nodulare della tiroide in funzione della terapia medica o chirurgica. La sua accuratezza
nella diagnostica del nodulo tiroideo non funzionante è
del 95%. I parametri ideali di qualità prevedono una percentuale di falsi negativi < 2%, e di falsi positivi < 3%.
Il referto citologico deve essere descrittivo e, ove possibile, porre una conclusione diagnostica, preferibilmente
individuata da un codice numerico che indica una categoria di lesioni omogenee per rischio di malignità e
opzione terapeutica. Quest’ultima rappresenta una indicazione di massima in quanto la diagnosi citologica
deve essere valutata nel contesto degli esami clinici e
strumentali. I moduli di richiesta dovrebbero contenere
le notizie cliniche essenziali, la sede e la modalità del
prelievo.
Le categorie diagnostiche sono le seguenti:
TIR 1. Non diagnostico
I referti “non diagnostici” non dovrebbero superare il
20% delle FNC (e comunque è opportuno che siano al
di sotto del 15%). I referti non diagnostici possono essere inadeguati e/o non rappresentativi. Tale percentuale
varia essenzialmente in relazione a fattori tecnici.. Viene definito inadeguato un campione mal strisciato e/o
mal fissato e/o mal colorato, mentre viene definito non
rappresentativo un campione che non abbia un numero
sufficiente di cellule appartenenti alla lesione per effettuare la diagnosi. Il giudizio di non adeguatezza e/o non
rappresentatività andrebbe riportato nella refertazione
con indicazione della causa. Viene definito adeguato un
campione ben strisciato fissato e colorato. Viene definito rappresentativo un preparato che contenga di norma un minimo di 6 gruppi di 10-20 cellule epiteliali ben
conservate appartenenti alla lesione. La diagnosi citologica è effettuata solamente su campioni rappresentativi
e adeguati.
Suggerimento operativo. Ripetizione dell’FNC a giudizio del clinico, trascorso almeno un mese. Alcuni casi
non rappresentativi devono essere valutati nel contesto
clinico:
a) strisci costituiti da abbondante colloide omogenea con
rari tireociti da noduli o cisti colloidi;
b) strisci costituiti esclusivamente da linfociti in tiroiditi
di Hashimoto clinicamente diagnosticate;
c) strisci costituiti da emazie, materiale necrotico e macrofagi da pseudocisti emorragiche.
Se dopo lo svuotamento residua una parte solida, questa deve essere immediatamente riaspirata. L’ecografia
Corrispondenza
Guido Fadda, Università Cattolica del Sacro Cuore, largo
Francesco Vito 1, 00168 Roma - Tel. +39 06 30154433 - Fax +39
06 30157008 - E- mail: [email protected]
408
è comunque fondamentale per guidare l’ago nella componente solida.
TIR 2. Negativo per cellule maligne
Costituisce circa il 60-75% degli esami citologici. Include il gozzo colloido-cistico, la tiroidite autoimmune
(di Hashimoto) e la tiroidite granulomatosa (di De Quervain).
Suggerimento operativo. Ripetizione dell’FNC a giudizio del clinico o su suggerimento del citopatologo, per
ridurre la possibilità di falsi negativi.
TIR 3. Inconclusivo/indeterminato
(Proliferazione follicolare)
È costituita da tutte le lesioni follicolari: iperplasia adenomatoide, adenoma, carcinoma follicolare microinvasivo,
lesioni a cellule ossifile e alcuni casi della variante follicolare del carcinoma papillare. In questi casi la citologia
non è in grado di fornire una conclusione diagnostica che
è possibile solo con l’esame istologico. Questa categoria
costituisce circa il 20% degli esami citologici. In circa
l’80% dei casi si tratta di lesioni benigne ed il 20% risulta maligno all’esame istologico. Alcuni marcatori immunoistochimici Galectina-3, HBME-1, citocheratina-19
possono aumentare l’accuratezza diagnostica, sebbene
non abbiano ancora un soddisfacente valore predittivo.
Possono essere utilizzati seguendo rigorosi protocolli diagnostici finalizzati ad una definizione alternativa tra casi
positivi ai marcatori (da avviare alla verifica chirurgica) e
casi negativi, meritevoli di follow-up.
In questa categoria possono rientrare anche alcuni casi con alterazioni citologiche troppo lievi per includerli
nella categoria TIR 4, ma che non possono essere considerati sicuramente benigni (TIR 2). L’inclusione di
questi casi nella categoria “a basso rischio” deve essere
giustificata da un’adeguata descrizione nel referto.
Bibliografia di riferimento
1
Autori vari. Gestione clinica del paziente con patologia nodulare
tiroidea: Consenso Italiano. L’Endocrinologo 2008;9(Suppl.4):
S1-S16.
G. Fadda et al.
Suggerimento operativo. Asportazione chirurgica della
lesione ed esame istologico. L’esame istologico intraoperatorio è sconsigliato perché non utile in questi casi.
La decisione operativa deve comunque sempre tenere
conto del contesto clinico-strumentale.
TIR 4. Sospetto di malignità
Costituisce un gruppo eterogeneo di lesioni che presentano atipie citologiche che non sono sufficienti a porre
con sicurezza la diagnosi di malignità. Per lo più, si tratta di sospetti carcinomi papillari. Questa categoria costituisce circa il 5% degli esami citologici.
Suggerimento operativo. Eventuale ripetizione della
FNC a giudizio del clinico o su suggerimento del citopatologo. Intervento chirurgico con esame istologico
intraoperatorio.
TIR 5. Positivo per cellule maligne
Comprende tutti i casi con citologia sicuramente diagnostica di neoplasia maligna (carcinoma papillare, midollare, anaplastico, linfoma e neoplasia metastatica). Costituisce il 5-15% dei risultati citologici. Il referto deve
contenere un’adeguata descrizione citologica.
Suggerimento operativo. Intervento chirurgico per i carcinomi differenziati. L’opzione chirurgica deve sempre
tenere conto del contesto clinico e del referto citopatologico.
Va raccomandata la prosecuzione dell’iter diagnosticoterapeutico in caso di carcinoma anaplastico, linfoma o
neoplasia metastatica.
Conclusione
La FNC è un test di screening. La diagnosi definitiva è
comunque basata sull’esame istologico del nodulo.
2
British Thyroid Association. Guidelines for the Management of
Thyroid Cancer. Second Edition. London: Royal College of Physicians 2007.
pathologica 2010;102:409-413
Original article
Cytology of indeterminate cases (C3).
Can this diagnostic class be improved?
S. Fiaccavento, G. Simone*
Servizio di Anatomia Patologica- Settore Citodiagnostica, Istituto Clinico Città di Brescia; * Unit of Cytopathology, Istituto Tumori
“Giovanni Paolo II”, Department of Histopathology and Cytopathology IRCCS, Bari, Italy
Key words
Cytology • Breast FNA • Breast cancer • Cytokeratins • Indeterminate
Summary
The aim of this brief report is to emphasize the need for a stronger effort from Pathologists, to reduce the incidence of the “C3”,
Indeterminate, diagnostic class. The experience derived from
immunohistochemistry could be useful also when applied to
cytological samples. In this study, based on immunostaining for
HMW Cytokeratin 5 (normally present in normal breast cells
and absent in malignant cells) on conventional breast nodules
aspirates, 21 out of 30 evaluated cases diagnosed as “C3” and
with histological control, have been reclassified as “C2”, Benign
or “C4”, Suspicious of malignancy. The Authors conclude that
this immunocytochemical algorithm could emprove the diagnosis di “C2” and “C4”, avoiding in many cases other presurgical, more invasive diagnostic procedures, with a positive cost/
benefit ratio.
Introduction
tive lesions into: a) without atypia (with a risk of 1.5 – 2
times); and b) with atypia (with a risk of 2-4 times) 4.
As a consequence, in the interest of patients and to improve the cost/benefit ratio of pre-operative investigations, it seems necessary to reduce as much as possible
the use of such a diagnostic class.
This possibility is based on the reliability of differential
diagnosis using cytological and morphological aspects
such as cellularity, atypia, the presence of myoepithelial
cells, monomorphic cell population, non-cohesive, singularly dispersed cells, and the different morphological
features of cellular aggregates.
However, morphological evaluation is still subjective
and would be not able to eliminate the problem, leading again to the necessity of performing a core needle
biopsy.
Moreover, it should be highlighted that the difficulties
in cytological interpretation of proliferative lesions are
not only related to intrinsic difficulties in cytological
evaluation, but also to the absence, in such lesions, of
histological reference points as previously observed by
Rosai 5. Indeed, Rosai commented that “The concept of
borderline epithelial lesions of the breast remains a controversial one … The degree of inter observer variability
in this field remains unacceptably high”.
Fine Needle Cytology (FNC) is an accepted method that
consents a correct preoperative diagnose in a large number of benign and malignant breast tumours. However,
its role in proliferative lesions is not yet clearly established, particularly in classifying a number of such lesions within the classification that the ‘Consensus Conference on Breast FNA of the National Cancer Institute
(NCI) recommended in 1996 1.
In fact, according to European guidelines 2, cases of highly suspected malignant neoplastic evolution are placed in
the C4 category, whereas the proliferative lesions, which
are usually classified as “atypical, indeterminate “class
C3, are not in the same category. However, following a
C3 diagnosis, a malignant neoplasia is expected in less
than 20% of cases, leading to more aggressive presurgical investigations for this diagnostic class (Core Biopsy,
Mammotome), even if it could result unnecessary, after
surgery 3. Thus, the risk that lesions defined as C3 could
mask a carcinoma, usually in situ, but also low grade or
invasive lobular carcinomas, is not negligible.
Therefore, the possibility that carcinoma might develop
after a proliferative lesion supports the proposal of some
Authors of a cytological sub-categorisation of prolifera-
Aknowledgements
We thank Mrs Rosangela Cordoni, Cytotechnologist, for the very
qualified help in immunocytochemical assays, for this study.
Correspondence
Sergio Fiaccavento, Servizio di Anatomia Patologica, Settore
Citodiagnostica, Istituto Clinico Città di Brescia, via Gualla,
25123 Brescia - E-mail: [email protected]
410
Thus, for lesions that are histologically borderline, cytological diagnosis can appear even more problematic
with regards to the overlap of different features present
in proliferative benign and atypical lesions, papillary
patterns, in situ or low grade and invasive carcinomas.
Thus, based on previous cytological observations 6 and
by applying in cytology recent experience derived from
histology, it should be useful to apply the same immunocytochemical algorithm used for histological samples to
increase the sensitivity of traditional morphology.
In histology, the use of antibodies against cytokeratin
5/14 and 5/6 has recently been proposed in the differential diagnosis between benign ductal hyperplasia, which
are immunoreactive, and atypical ductal hyperplasia
(ADH) and/or in-situ carcinoma, which are not.
As already known, during differentiation, epithelial
CK5/14 positive stem cells can modify their characteristics, gradually losing this character and progressively
gaining immunoreactivity for Ck8/18. Also, the myoepithelial cell line can acquire antigenicity for SMA, p63
and calponin 7.
Therefore, a ‘normal’ breast cell population is heterogeneous with luminal cells, predominantly of intermediate type, stem cells and differentiated ductal cells; the
greatest heterogeneity is present in terminal ducts and
tubular-lobular units.
This knowledge is therefore useful for better understanding of the functional organization of the different
cell components of the ductal and lobular tree, and can
be applied to the diagnostic field.
In fact, in normal glandular tissue and in usual ductal
hyperplasia, the cell population shows is heterogeneous,
with positivity for Ck 5/14 and Ck8/18 Cytokeratins,
whereas a monotone positive Ck8/18 cellularity associated with negativity for Ck 5/14 is present in atypical
proliferation processes and in-situ carcinoma.
Aim of the study
To apply the experiences acquired in histology related
to antibodies against cytokeratin 5 (Ck5) to breast FNC,
with the aim of reducing the diagnoses of C3 and, consequently, the number of cases to be referred for more
aggressive diagnostic tools such as Core Biopsy and
Mammotome.
C3, with histological controls, were observed (Group B).
The cases were included when at least two conventional
smears showed sufficient cellularity, also for immunocytochemical assays.
Results
Group A
With one only exception, all malignant cases examined
showed similar immunostaining in both cytology and
histology, characterized by negativity for CK5 (Fig. 1).
A discordant case showing CK5+ in histology was characterised by highly malignant cancer cells consistent
with carcinoma with basal cell features.
All 10 benign cases examined presented immunoreactivity for CK5 in both cytological and histological samples
(Fig. 2).
Group B
The cytological diagnosis of category C3 was based on
the presence of a high number of cellular clusters with
large, irregular profiles, sometimes multilayered and
showing a central fenestration, in the presence of only
mild or moderate nuclear irregularities. This cytological
finding suggests a proliferative lesion with undetermined significance, probably benign.
Criteria used in clinical reports to change
the diagnostic category C3
In this early phase of the new diagnostic approach, rigorous criteria to change the diagnostic category C3 was
used. Only cellular areas easily assessable and absoluFig. 1. a) Breast cancer classified as CK5 - Pap Stain. b) Corresponding histological sample, haematoxylin and eosin. c) Absence of immunoreactivity in both the cytological and d) histological sample.
a
b
c
d
Material and methods
Before to transfer the investigation to cytologically indetermined FNCs (C3) the immunoreactivity in benign
or malignant histologically-confirmed cases was evaluated. Therefore, a preliminary analysis was performed
on 10 cases cytologically diagnosed as malignant (C5)
and 10 cases cytological classified as Benign (C2), the
cytological diagnoses of which were confirmed at histology following local or radical surgery (Group A).
Successively, 30 consecutive breast FNCs diagnosed as
411
Cytology of indeterminate cases (C3). Can this diagnostic class be improved?
Fig. 2. a) Breast proliferative lesion classified as C3, Pap Stain. b)
CK5 staining in the histological and c) cytological samples. a
b
c
d
C3 diagnosis was changed to C4, suspect of malignancy,
when immunoreactivity for CK5 was absent, but in the
presence of weakly cytological moderate atypia.
The C3 category was confirmed in cases with mixed or
equivocal morphological or immunocytochemical features, such as when focal or heterogeneous distribution
was detected in association with moderate cell atypia or
when immunostaining in mild cell atypia was not evaluable.
Fig. 4. a) Breast proliferative lesion classified as C4, Pap Stain. b)
Absence of immunoreactivity for CK5 in cytological sample. c)
Corresponding histological sample, haematoxylin and eosin : low
grade breast carcinoma.
a
b
Fig. 3. a) Breast proliferative lesion classified as C3, Pap Stain.
b) Immunoreactivity for CK5 in the cytological sample. c) Corresponding histological sample, haematoxylin and eosin.
a
b
c
tely consistent with the presence or absence of CK5 immunoreactivity were considered.
The results obtained from the survey allowed for the cases to be placed in three sub-groups as shown in Table I,
which clearly shows that diagnosis in 21 of 30 cases had
to be modified.
In particular, in 13 cases the diagnosis was changed from
C3 to C2, whereas in 8 cases it was changed from from
C3 to C4. In 9 cases, the immunocytological features
could not clarify the morphological uncertainty.
C3 diagnoses were changed to C2, benign when “mosaic”
immunoreactivity for CK5, was uniformly present in the entire cell population, suggesting that the lesion was benign.
c
Fig. 5. a) Breast proliferative lesion classified as C3, Pap Stain.
Equivocal, non-homogeneous CK5 immunoreactivity characterized CK5+areas, typical of benign lesions. c) CK- areas, generally
associated with carcinoma (probably low grade). d) Histology showed a complex lesion with flat atypia associated with usual atypia
and micropapillary ADH.
a
b
c
d
412
Fig. 6. Two different cytological and immunocytochemical patterns are present: one was coherent with usual hyperplasia (CK+)
a) and b), while the other was consistent with tubular carcinoma
(CK5-), c) and d).
a
c
b
d
Fig. 7. Histology of the same case. Epithelial atypical clusters
showing focal, CK+ immunostaining at borders. The feature could
be present in in situ carcinoma as well as in ADH. The histological
control, a) and b) confirmed ADH diagnosis.
a
b
Discussion
The present modifications for preoperative diagnosis are
based on preliminary data, and require further confirmation based on a larger number of cases.
However, based on our preliminary experience, we believe that the application of immunocytochemical methods can substantially reduce substantially the number
of C3 cases and translate many diagnoses into C2 and
C4. Therefore, the methodological approach described
should always consider FNC as a preliminary diagnostic tool, whereas more aggressive investigation methods
Tab. I. Reclassification of C3 Breast FNA.
C3 → C2
C3 → C4
C3 → C
Total
13
8
9
30
such as Core Biopsy and Mammotome could be applied
only in unsolved cases.
We also believe that the results of the present study can
enhance the variety of criteria that determine the preoperative choice between FNC and Core Biopsy/ Mammotome 8.
Moreover, the use of this algorithm might also favourably influence the other diagnostic categories, with particular reference to C4.
In fact, in our opinion, microcalcifications should not be
still the decisive parameter for a macrobiotic, histological evaluation.
Example giving, it is probable that the C3 diagnostic category could be characterized by microcalcific lesions in
a prevalent number of cases, however, the presence of
microcalcifications in not palpable breast lesions, could
not be still the decisive criteria for a macrobiotic, histological evaluation.
The study suggests that in experienced hands, immunocytochemistry is a valuable tool in both conventional cytology and tissue samples. Therefore, the need to use biopsy
to obtain samples for immunocytochemical assays (as
claimed in biological characterization of breast cancer) is
without a well-founded scientific and technical basis.
Fine needle aspiration cytology is an operator dependent
tool that reflects the professional skill and the the ability of the pathologist to participate in an interdisciplinary team in order to establish an appropriate diagnostic
procedure.
Screening programs have improved the number of borderline breast lesions and in situ or low histological
grade carcinomas; they are however a major cause of
inconclusive diagnoses similar to the C3 classification.
Considering these results, the reduction in the incidence
of this diagnostic class could be related to systematic use
of immunocytochemistry on cytological samples.
New techniques such as liquid based cytology, where
the aspirate is not directly performed by the pathologist
or when cytoassistance is not available, could lead, at
least in some situations, to a reduction in the number of
inadequate and inconclusive FNCs, also by increasing
the availability of cytological samples for immunocytochemistry.
413
Cytology of indeterminate cases (C3). Can this diagnostic class be improved?
References
1
EWGBCSP. European Guidelines for quality assurance in Mammography Screening. 2nd edition, June 1996.
2
Sapino A, Bianchi S, Bussolati G. Breast cytology guidelines
for a mammographic screening program. Report edited by the
working group on “Breast Pathology in the Mammographic
Screening Program” of the European Union. Pathologica
1999;91:203-8.
3
Kooistra B, Wauters C, Strobbe B. Indeterminate breast fine needle aspiration: repeat aspiration or core biopsy? Ann Surg Oncol
2009;16:281-4.
4
Zhao C, Raza A, Martin SE, Pan J, Greaves TS, Cobb CJ. Breast
fine-needle aspiration samples reported as “proliferative breast
lesion”: clinical utility of the subcategory “proliferative breast lesion with atypia”. Cancer Cytopathol 2009;117:137-47.
Rosai J. Borderline epithelial lesions of the breast. Am J Surg
Pathol 1991;15:209-21.
5
Bankfalvi A, Ludwig A, De-Hesselle B, Buerger H, Buchwalow
IB, Boecker W. Different proliferative activity of the glandular
and myoepithelial lineages in benign proliferative and early malignant breast disease. Mod Pathol 2004;17:1051-61.
6
Wauters CAP, Kooistra B, Strobbe LJA. The role of laboratory
processing in determining diagnostic conclusiveness of breast fine
needle aspirations: conventional smearing versus a monolayer
preparation. J Clin Pathol 2009;62:931-4.
7
Simone G. Core biopsy Fine Needle Aspiration and: fit modus in
rebus! Int. J Surg Pathol 2005;13:121-2.
8
pathologica 2010;102:414-416
Case report
Diffuse and extreme vacuolization of tumour cells
in rectal adenocarcinoma after neoadjuvant therapy:
an unusual finding
P. Amico, P. Greco
Dipartimento G.F. Ingrassia, Azienda Ospedaliero-Universitaria Policlinico-Vittorio Emanuele, Anatomia Patologica,
Università di Catania, Italy
Key words
Rectal cancer • Vacuolization • Neoadjuvant therapy • Signet ring-like cells
Summary
We report a case of diffuse and extreme cytoplasmic vacuolization of tumour cells in a rectal adenocarcinoma after neoadjuvant
treatment. A 64-year-old man with a moderately differentiated
rectal adenocarcinoma, diagnosed by endoscopic rectal biopsy,
underwent surgical treatment after chemoradiotherapy. Residual
tumour mass was represented by foci of neoplastic cells with the
morphological features of conventional type adenocarcinoma, and
surprisingly, by numerous areas consisting of several giant vacuoles, variable in size, merging to form multilocular spaces separated by a rim of cell membrane with a “plant-like” appearance.
Cytoplasmic vacuolization may represent a distinct form of cell
death, and pathologists should carefully consider this unusual and
potentially alarming morphological change among the chemoradiotherapy-induced effects on tumour mass.
Introduction
and chemotherapy treatment has been described in prostatic 7 and breast carcinoma 8 9 (Tab. I). Extreme vacuolization of tumour cells with a lipoblast-like appearance
has been described after neoadjuvant treatment in a case
of adenocarcinoma arising in Barrett’s mucosa 10 (Tab. I).
Herein, we expand on previous observations by illustrating a case of post-neoadjuvant therapy rectal adenocarcinoma in which tumour cells showed a diffuse and extreme
cytoplasmic vacuolization with a “plant-like” appearance.
To the best of our knowledge, this unusual finding has not
been reported in rectal cancer to date.
Correct management of rectal cancer is based on preoperative chemoradiotherapy, which represents the treatment of choice for cT3, T4 and N+ cancers 1-4. Chemoradiotherapy-induced effects on both tumour mass and
non-neoplastic tissue are well known, and pathologists
have become increasingly familiar with these histological
changes. These latter include stromal fibrosis, tumour necrosis, mucin pools, hemosiderin-laden and foamy macrophages, granulomatous reaction, foci of calcification,
ulceration and cytomorphological changes as prominent
nucleoli, hyperchromatic nuclei, nuclear membrane irregularities, chromatin clumping and bizarre multinuclear
giant cells. After preoperative treatment, residual neoplastic cells may sometimes acquire a well defined oncocytic
and/or endocrine phenotype as a result of modifications at
the genetic level 5 6, and the extent of these morphological
changes are related to the degree of treatment response 6.
A prominent cytoplasmic vacuolization after hormonal
Tab. I. Cases of vacuolization of tumour cells after hormonal and/or
chemotherapy treatment reported in literature.
Authors
Civantos F et al. 7
Aktepe F et al. 8
Kennedy S et al. 9
Weiss SW 10
Organ
Prostate
Breast
Breast
Oesophagus
Treatment
Hormonal Therapy
Chemotherapy
Chemotherapy
Chemotherapy
Correspondence
Paolo Amico, Dipartimento G.F. Ingrassia, Azienda OspedalieroUniversitaria “Policlinico-Vittorio Emanuele”, Anatomia
Patologica, Università di Catania, via Santa Sofia 87, 95123
Catania - Tel. +39 095 3782022 - Fax +39 095 3782023
415
Diffuse and extreme vacuolization of tumour cells
Case report
A 64-year-old man with a moderately differentiated rectal adenocarcinoma, diagnosed by endoscopic rectal biopsy, was staged by endorectal ultrasound and abdominopelvic CT scan as cT3 N0. Surgical treatment (rectal
anterior resection with total mesorectal excision) was
carried out six weeks after chemoradiotherapy. Upon
examination of the rectal specimen, an ulcerated and
partially fibrotic area was identified at 2 cm from distal margin. This area was entirely sampled. Histological
examination showed dominant fibrosis with more than
50% of tumour regression. Residual tumour mass was
represented by foci of neoplastic cells that extended into
the mesorectum (ypT3 N0) with the morphological features of a moderately differentiated, conventional type,
adenocarcinoma, and surprisingly, by numerous areas
(about 70% of entire residual tumour mass) consisting,
at low-power magnification, of several giant vacuoles,
variable in size, merging to form multilocular spaces
separated by a rim of cell membrane with a “plant-like”
appearance (Fig. 1). At medium magnification, it was
possible to recognize infiltrating solid nests of residual
tumour cells with a cribriform growth pattern, punctuated by giant vacuoles that displaced the hyperchromatic
and atypical nuclei, where present, toward the periphery
of the cells (Fig. 2). Focally, these vacuolated cells had
a signet ring-like appearance (Fig. 3). Interestingly, intracytoplasmic large vacuoles were all positive for PAS
and PAS-diastase (Fig. 4) and alcian blue negative, as
a result of accumulation of glycogen admixed with cellular debris.
Fig. 1. At low-power magnification, the residual tumour mass
showed a diffuse vacuolated pattern with a gland-in-gland architecture and an unusual “plant-like” appearance.
Fig. 2. At medium magnification, residual atypical nuclei are visible at the periphery of some vacuoles.
Fig. 3. Some tumour cells show a signet ring-like appearance.
Fig. 4. All vacuoles were PAS positive.
416
Discussion
Despite the fact that neoadjuvant therapy for rectal cancer has entered into routine clinical practice for many
years 1-4, to the best of our knowledge such an extreme
and intriguing vacuolization has never been reported in
P. Amico, P. Greco
the literature. In this regard, there is some evidence to
suggest that cytoplasmic vacuolization may represent a
distinct form of cell death, different from the conventional lytic and apoptotic modes 11, supporting our hypothesis that it represents an unexpected effect related to
cytotoxicity induced by treatment.
References
Increased endocrine cells in treated rectal adenocarcinomas:
a possible reflection of endocrine differentiation in tumor cells
induced by chemotherapy and radiotherapy. Am J Surg Pathol
2002;26:863-72.
1
Minsky BD. Is preoperative chemoradiotherapy still the treatment
of choice for rectal cancer? J Clin Oncol 2009;27:5115-6.
2
Roh MS, Colangelo LH, O’Connell MJ, Yothers G, Deutsch M,
Allegra CJ, et al. Preoperative multimodality therapy improves
disease-free survival in patients with carcinoma of the rectum:
NSABP R-03. J Clin Oncol 2009;27:5124-30.
7
3
Lombardi R, Cuicchi D, Pinto C, Di Fabio F, Iacopino B, Neri
S, et al. Clinically-staged T3N0 rectal cancer: is preoperative
chemoradiotherapy the optimal treatment? Ann Surg Oncol
2010;17:838-45.
8
4
Lim YK, Law WL, Liu R, Poon JT, Fan JF, Lo OS. Impact of
neoadjuvant treatment on total mesorectal excision for ultra-low
rectal cancers. World J Surg Oncol 2010;8:23.
5
6
Ambrosini-Spaltro A, Salvi F, Betts CM, Frezza GP, Piemontese A, Del Prete P, et al. Oncocytic modifications in rectal adenocarcinomas after radio and chemotherapy. Virchows Arch
2006;448:442-8.
Shia J, Tickoo SK, Guillem JG, Qin J, Nissan A, Hoos A, et al.
Civantos F, Marcial MA, Banks ER, Ho CK, Speights VO, Drew
PA, et al. Pathology of androgen deprivation therapy in prostate carcinoma. A comparative study of 173 patients. Cancer
1995;75:1634-41.
Aktepe F, Kapucuoğlu N, Pak I. The effects of chemotherapy on
breast cancer tissue in locally advanced breast cancer. Histopathology 1996;29:63-7.
Kennedy S, Merino MJ, Swain SM, Lippman ME. The effects of
hormonal and chemotherapy on tumoral and nonneoplastic breast
tissue. Hum Pathol 1990;21:192-8.
9
Weiss SW. Criteria and importance of lipoblasts. In: Weiss SW,
Goldblum JR, eds. Enzinger and Weiss’s Soft Tissue Tumors. Philadelphia: Elsevier 2008, pp. 478-483.
10
Henics T, Wheatley DN. Cytoplasmic vacuolation, adaptation
and cell death: a view on new perspectives and features. Biol Cell
1999;91:485-98.
11
pathologica 2010;102:417-419
Case report
Rectal leiomyosarcoma: report on two cases
and a practical approach to differential diagnosis
N. Kourda, J. Kourda, J. Aouam, A. Zaouche*, S. Baltagi Ben Jilani, R. Zermani
Pathology Department, * Surgery Department, Charles Nicolle Hospital Tunis. Tunisia
Key words
Leiomyosarcoma • Rectum • Differential diagnosis • GIST • Immunohistochemistry • CD117 • Desmin
Summary
Rectal leiomyosarcoma is an uncommon malignancy. Herein, we
describe the clinicopathological features and biological behaviour of
these tumours, and provide a practical approach to differential diagnosis, particularly with gastrointestinal stromal tumours (GIST).
We report two cases in elderly men. In the first, the lesion was
2 cm from the anal sphincter, while it was located in the rectal
ampulla in the second case. Histologically, both tumours were
characterized by pleiomorphic, large spindle cells, presenting
numerous mitoses and marked nuclear atypia. Immunohistochem-
ical analysis showed that tumour cells coexpressed both actin and
desmin, whereas CD117 and S100 protein were negative. The
final diagnosis was leiomyosarcoma. One of the patients died of
pulmonary metastasis within six months. The second patient had
bone metastasis, but was lost to follow up. This report underlines
the potential diagnostic problems raised by rectal leiomyosarcoma
and emphasizes the role of immunohistochemistry in achieving
correct diagnosis, which has important clinical, therapeutic and
prognostic consequences.
Introduction
3 cm in diameter. No metastases were found. Two biopsies were obtained, but both showed necrotic tissue.
Leiomyosarcoma is a rare malignant smooth muscle
tumour that, in the gastrointestinal tract, occurs most
frequently in the oesophagus and rectum 1 2. Rectal leiomyosarcoma accounts for less than 0.5% for all malignancies of the colon and rectum. The main differential
diagnosis is gastrointestinal stromal tumour (GIST). We
report two cases of rectal leiomyosarcoma and discuss
the clinical, histological and immunohistochemical findings that distinguish this entity from GIST.
Clinical history
Case 1
A 77-year-old man presented with rectal bleeding, abdominal pain and weight loss for three months. Rectal
examination revealed a firm polypoid mass at 2 cm from
the anal sphincter. Abdominal ultra-sonography and CT
scan showed a polypoid mass in continuity with the rectal wall, showing an intramural necrotic area, measuring
Case 2
A 65-year-old man presented with rectal bleeding, abdominal pain and a clinical history of diarrhoea and constipation
for five months. Rectal examination revealed a circumferential ulcerative mass in the rectal ampulla. Abdominal ultra-sonography and CT revealed a circumferential inhomogeneous mass in continuity with the rectal wall, showing
an intramural necrotic area. No metastases were found. The
patient underwent urgent surgical intervention for intestinal
obstruction before a biopsy could be taken. An abdominoperineal resection was performed in both cases.
Macroscopic features
In the first case, the polypoid, ulcerated tumour measured 3 cm in its greatest dimension. On cross sections,
necrotic and haemorrhagic foci were occasionally observable. The tumour extended to the mucosa, the proper
muscle layer and the serosa.
Acknowledgements
Correspondence
Written consent of the patients was obtained for publication of
this case report.
Jihene Kourda-Boujemâa, Hopital Charles Nicolles, Boulevard
9 Avril 1938, Tunis 1006, Tunisie - E-mail: jiheneboujemaa@
yahoo.fr
418
In the second patient, the tumour was ulcerated and circumferential with foci of necrosis on the cut surface. It
measured 9 cm in diameter. The tumour diffusely infiltrated the outer layers of the rectal wall.
Microscopic features
Histologically, both tumours were composed of spindle
cells arranged in fascicles (Figs. 1, 2). The cytoplasm of
the tumour cells was eosinophilic or clear. Cellular and
nuclear atypia were severe, and marked mitotic activity
was observed (> 19 mitosis/10 HPF) (Fig. 2), supporting
the diagnosis of a high grade sarcoma. There were areas
of broad necrosis and haemorrhage. Mucosal involvement was noted in some areas (Fig. 1). Surgical margins
were microscopically negative. Immunohistochemical
analysis showed positive immunostaining for vimentin,
α-smooth muscle actin and desmin, whereas cytokera-
Fig. 1. Leiomyosarcoma: tumour infiltrating rectal mucosa (haematoxylin and eosin, x20).
Fig. 2. Tumour cells were composed of fusiform cells with nuclear pleomorphism and mitotic figures (haematoxylin and eosin,
x400).
N. Kourda et al.
tin, EMA, PS100 and CD117 were negative. The tumour
cells showed a high Ki-67-proliferative index in both
cases.
Follow-up
The first patient died from pulmonary metastasis after 6
months, whereas the second patient had bone metastasis
one year after initial diagnosis but was lost to follow up.
Discussion
Rectal leiomyosarcoma is rare 2. The main differential
diagnosis is with the gastrointestinal stromal tumours
(GIST). Both leiomyosarcoma and GIST have a predilection for adults older than 50 years, with a medium
age, in the largest series, of around 63 years 3. There is
no clear sex predilection, but malignant GISTs may be
slightly more common in men. The most common clinical presentation of leiomyosarcoma is gastrointestinal
bleeding. This may be acute (melena or haematemesis)
or chronic insidious bleeding leading to anaemia.
Tumour rupture, gastrointestinal obstruction, or appendicitis-like pain can cause acute abdominal symptoms 4.
Rectal leiomyosarcoma typically presents as a small
polypoid intraluminal mass measuring between 1 and 5
cm 5. It tends to be diagnosed earlier and is more accessible to physical, proctoscopic and sonographic examinations. It is almost invariably an incidental finding that
can be removed endoscopically. It may also present as
a circumferential ulcerative mass 5. The most common
location of GISTs is the stomach (60-70%), but they are
less common in the colorectum. On sectioning, leiomyosarcomas are greyish-white, cream-coloured, or brownish-green and soft. On the other hand, small GISTs often form solid, nodular, sub-serosal, intramural, or less
commonly polypoid intraluminal masses. The majority
of larger GISTs form external, sometimes pedunculated
masses attached to the outer layers of the gut involving
the muscular fascia 5.
Microscopically, leiomyosarcoma is composed of bundles of spindle cells intersecting at right angles; the tumour cells are eosinophilic often with blunt ended nuclei. They frequently show focal pleomorphism and high
mitotic activity (> 100 mitoses per 50 HPFs) 1 3 5 6. These
tumours are usually ulcerated, and show mucosal infiltration. Coagulative necrosis may be also present 3 5 6.
Serosal fat infiltration is reported in some cases. On
immunostaining, leiomyosarcoma tumour cells are
typically negative for c-KIT (CD117) and keratin,
but are positive for smooth muscle markers such as
α-smooth muscle actin and especially desmin. GISTs
are immunoreactive for CD117, usually associated with
CD34 expression in 60-70% of cases 3 5 and actin in
30% of cases, but negative for desmin. Approximately
5% of typical GISTs are negative for CD117 on immunohistochemistry and pose a diagnostic challenge.
419
Rectal leiomyosarcoma: practical approach to differential diagnosis
The detection of mutations in target genes (either PDGFR or c-kit) can be helpful, but is required only in cases
that are histologically suggestive of GIST but are KITnegative upon immunochemistry; beyond this, mutational screening is only undertaken in research investigations 7 8. Some studies have reported a widespread
KIT positivity in sarcomas other than GISTs 9. Most of
the positive cases show focal staining. The positivity
in non-GIST sarcomas in many instances represents an
artefact, possibly related to a poor specificity or to high
dilutions of polyclonal KIT antibodies 8.
Differential diagnoses mainly include GISTs, but also
other spindle cells tumours such as sarcomatoid carcinoma; accordingly, good sampling of the tumour is essential to determine epithelial differentiation. In sarcomatoid carcinoma, tumour cells are positive for keratin and
may express actin or c-KIT, but not desmin or CD34. In
contrast to leiomyosarcoma which are characterised by
very poor prognosis, only 10-30% GISTs behave aggressively and necessitate targeted therapy with the kit-tyrosine kinase inhibitor imatinib mesylate 1. Lymph nodes,
bone and pulmonary metastases are often described in
leiomyosarcoma, whereas liver and mesenteric metastases are more common in GIST 1 4 10.
The treatment of choice for both GIST and leiomyosarcoma is radical surgical excision 10. Pre-operative ultrasound is useful in assisting the surgical decision by
defining malignant features of the tumour 1 3 4. An aggressive surgical approach is often required to guarantee
complete clearance of the tumour. Adjuvant radiotherapy has been shown to improve survival 10.
Histopathological grading is important to establish prognosis and decide upon the most appropriate therapeutic
strategy. Grading is based on a summation of points derived from differentiation, mitotic index and tumour-necrosis 1 2 4 5 6. Non-curative resection, high tumour grade
and size > 10 cm, tumour necrosis and high mitotic
rate are unfavourable prognostic factors 3 4. The staging of GISTs is based only on tumour size and mitotic
index 1 5 6. The survival rates of patients with leiomyosarcoma varies between 18 months to 15 years 5. Some
authors report that polypoid intraluminal leiomyosarcomas can have a better prognosis than GISTs with similar
tumour size and mitosis parameters provided that they
are completely excised 5.
Conclusion
Achieving correct diagnosis of rectal leiomyosarcoma
has important clinical, therapeutic and prognostic consequences. It is essential to perform immunohistochemical characterization using a panel of antibodies including cytokeratin, CD117, desmin, smooth muscle actin
(AML), and CD 34 to distinguish leiomyosarcoma from
GISTs. The treatment of leiomyosarcoma is primarily
surgical, and whenever possible should ensure complete
clearance of the tumour.
References
1
Michalopoulos A, Papadopoulos VN, Basdanis G, Haralabopoulos
E, Zatagias A, Netta S, et al. Colorectal gastrointestinal mesenchymal tumours. Report of a stromal case of the rectum (GIST)
and a leiomyosarcoma of the transverse colon. Tech Coloproctol
2004;(Suppl 1):155-7.
2
Miettinen M, Sarlomo-Rikala M, Sobin LH. Mesenchymal tumors
of the muscularis mucosae of colon and rectum are benign leiomyomas that should be separated from gastrointestinal stromal
tumors -a clinicopathologic and immunohistochemical study of 88
cases. Mod Pathol 2001;14:950-6.
3
Markku M, Lasota J. Gastrointestinal stromal tumors. review on
morphology, molecular pathology, prognosis, and differential diagnosis. Arch Pathol Lab Med 2006;130:1466-78.
4
Emory TS, Sobin LH, Lukes L, Lee DH, O’Leary TJ. Prognosis of
gastrointestinal smooth-muscle (stromal) tumors: dependence on
anatomic site. Am J Surg Pathol 1999;23:82-7.
5
Miettinen M, Furlong M, Sarlomo-Rikala M, Burke A, Sobin LH,
Lasota J. Gastrointestinal stromal tumors, intramural leiomyomas,
and leiomyosarcomas in the rectum and anus a clinicopathologic,
immunohistochemical, and molecular genetic study of 144 cases.
Am J Surg Pathol 2001;25:1121-33.
Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley
BJ, et al. Diagnosis of gastrointestinal stromal tumors: A consensus approach. Hum Pathol 2002;33:459-65.
6
Rossi G, Valli R, Bertolini F, Marchioni A, Cavazza A, Mucciarini C, et al. PDGFR expression in differential diagnosis between
KIT-negative gastrointestinal stromal tumours and other primary
soft tissue tumours of the gastrointestinal tract. Histopathology
2005;46:522-31.
7
Miettinen M, Lasota J. KIT (CD117): a review on expression in
normal and neoplastic tissues, and mutations and their clinicopathologic correlation. Appl Immunohistochem Mol Morphol
2005;13:205-20.
8
Sabah M, Leader M, Kay E. The problem with KIT: clinical implications and practical difficulties with CD117 immunostaining.
Appl Immunohistochem Mol Morphol 2003;11:56-61.
9
Gutierrez JC, Perez EA, Franceschi D, Moffat FL, Livingstone AS,
Koniaris LG. Outcomes for soft-tissue sarcoma in 8249 cases from
a large state cancer registry. J Surg Res 2007;141:105-14.
10
pathologica 2010;102:420-422
Case report
Extracutaneous seborrheic inclusion cyst:
an unusual presentation
T. Pusiol, M.G. Zorzi, D. Morichetti
Institute of Anatomic Pathology, S. Maria del Carmine Hospital, Rovereto (TN), Italy
Key words
Seborrheic inclusion cyst • Epidermoid cyst with seborrheic verruca • Like cyst wall • Epidermoid cyst
Summary
Seborrheic inclusion cyst is an unusual variant of epidermal cyst
characterized by parietal histology similar to seborrheic keratosis.
Cysts with such changes have been called “seborrheic keratosislike changes in epidermal cyst” or “epidermoid cyst with seborrheic verruca-like cyst wall” or simply “seborrheic cyst”. To
date, this lesion has been described exclusively in cutaneous sites.
We describe the first case of an extracutaneous seborrheic inclusion cyst arising from round ligament. A 30-year-old female was
referred to our institution for abdominal pain. Ultrasonography
showed a hypoechoic heterogeneous, round mass adjacent to the
lower extremity of the left ovary, measuring 4.5 cm in maximum
diameter. Contrast-enhanced computed tomography of the pelvis
in the venous phase showed a round (4.5 cm in diameter) cystic
lesion with inhomogeneous fluid content in the side of the left
large ligament and anterior to the homolateral adnexa. Laparoscopic resection of the mass was performed. Intraoperatively, an
extraperitoneal glistening pelvic mass was discovered: the lesion
was attached to the intrapelvic 1/3 middle portion of the left round
ligament. Macroscopically, the mass measured 6 cm x 6 cm x 3.5
cm and exhibited a smooth and glistening external surface. On cut
sections, the mass was an unilocular cyst filled with soft, yellow,
amorphous material. Histologically, the cystic wall was lined by
a stratified squamous epithelium with a granular cell layer. The
cavity contained keratin-like material. The cystic wall showed
numerous areas with close-set basaloid cells and pseudohorn
cysts. The latter aspect consisted of cystic invaginations of the
epithelium filled with surface keratin, which in a given microscopic section may be cut in cross-section, thereby appeared as
“cysts” within the involved epithelium. Parietal rupture was present, accompanied by granulomatous inflammation. There were
no postoperative complications, and the patient was discharged 3
days after the procedure. The present case is unique in that it is the
first reported case of an extracutaneous seborrheic inclusion cyst
arising from a very unusual site, namely the round ligament. The
site of origin of the lesion and its cystic nature were established by
computed tomography findings. Conservative treatment with enbloc resection was possible. Histological examination confirmed
computed tomography findings. The present report described a
lesion typically found in dermatopathology practice, but which
had arisen in an extracutaneous site.
Introduction
was reported in the paper of Brown and Youngberg in
1991 3. These authors reported the development of an
epidermoid cyst with seborrheic keratosis-like linings
following the excision of a typical seborrheic keratosis. The search for human papillomavirus infection by
PCR was performed in a case of seborrheic inclusion
cyst by Flores 4. This author found no evidence of human papillomavirus, and hypothesized that seborrheic
inclusion cyst might result from a non-viral, epidermal, seborrheic-like change. Reviewing the literature
for seborrheic inclusion cyst, no case has been reported
in an extracutaneus site to date. We describe the first
case of extracutaneus seborrheic inclusion cyst, arising
from the round ligament, with emphasis on radiologic
findings in the preoperative determination of the benign nature of the lesion.
Seborrheic inclusion cyst is an unusual variant of epidermal cyst characterized by parietal histology similar to seborrheic keratosis (Tab. I) 1-4. Cysts with such
changes have been called “seborrheic keratosis-like
changes in epidermal cyst” or “epidermoid cyst with
seborrheic verruca-like cyst wall” or simply “seborrheic
cyst”. The first accurate description of a seborrheic inclusion cyst was reported by Rahbari in 1982 in a series
of five cases 1. Rahbari’s report showed a trichoblastic
infundibular cyst according to Ansai et al. 5 diagnostic
criteria. In 1990, Chun and Im 2 reported an epidermoid
cyst with a seborrheic verruca-like cyst wall in the subcutaneous tissue of the left buttock in a 24-year-old female. The terminology of “seborrheic inclusion cyst”
Correspondence
Teresa Pusiol, Institute of Anatomic Pathology S. Maria del
Carmine Hospital Rovereto (TN), Italy - Tel. +39 0464 403502 Fax +39 0464 403029 - E-mail: [email protected]
421
Extracutaneous seborrheic inclusion cyst: an unusual presentation
Tab. I. Seborrheic inclusion cysts. A review of the literature.
Nr.
1
6
7
8
Author
Rahbari 1
Chun, Im 3
Brown, Youngberg 4
Fernandez-Flores 5
Age/sex
68/M
46/M
61/M
58/M
55/M
24/F
81/M
84/M
Location
Size (cm.)
Duration of symptoms
Left, anterior part of chest
1x0.9x0.6
Not specified
Left, posterior part of neck
Not specified
10 years
Left buttock
Not specified
Not specified
Back to middle of shoulders
Not specified
Not specified
Right shoulder
Not specified
years
Left buttock
1.2 cm. maximum diameter.
One year
Under left eye
0.6x0.5x0.2
One year
Left thigh
1.9 cm. maximum diameter
Not specified
Case report
A 30-year-old female was referred to our institution for
abdominal pain. Ultrasonography showed a hypoechoic
heterogeneous, round mass adjacent to the lower extremity of the left ovary, measuring 4.5 cm in maximum
diameter. Contrast-enhanced computed tomography of
the pelvis in the venous phase showed a round 4.5-cm
in diameter cystic lesion with inhomogeneous fluid content, in the side of the left large ligament and anterior to
the homolateral adnexa (Fig. 1). Laparoscopic resection
of the mass was performed. Intraoperatively, an extraperitoneal glistening pelvic mass was discovered: the
lesion was attached to the intrapelvic 1/3 middle portion of the left round ligament. Macroscopically, the
mass measured 6 cm x 6 cm x 3.5 cm and exhibited a
smooth and glistening external surface. On cut section,
the mass was an unilocular cyst filled with soft, yellow,
amorphous material. Histologically, the cystic wall was
lined by a stratified squamous epithelium with a granular cell layer. The cavity contained keratin-like material.
The cystic wall showed numerous areas with close-set
basaloid cells and pseudohorn cysts. The latter aspect
consisted of cystic invaginations of the epithelium filled
with surface keratin, which in a given microscopic section may be cut in cross-section, thereby appearing as
Fig. 1. Contrast-enhanced computed tomography of the pelvis
in the venous phase revealed a round (4.5 cm in diameter) cystic
lesion (arrow head) with inhomogeneous fluid content (4.5 cm in
diameter) in the side of the left large ligament and anterior to the
homolateral adnexa (*). Minimal fluid in the pelvis was found.
“cysts” within the involved epithelium (Fig. 2). Parietal
rupture was present, accompanied by granulomatous
inflammation. There were no postoperative complications, and the patient was discharged 3 days after the
procedure.
Discussion
The round ligament extends from the uterus through the
inguinal canal to terminate in the region of the mons pubis and labia majora. Common round ligament lesions are
leiomyoma (including epithelioid and bizarre types) 6,
endometriosis and mesothelial cyst. Other rare tumours
such as leiomyosarcoma 7, malignant perivascular epithelioid cell tumour 8, “fibromas”, benign mesenchymomas, angiomyolipomas, dermoid cyst, haemangioma
and nodular fasciitis have been reported. Only one case
of epidermoid cyst of round ligament has been reported in the literature to our knowledge 9. In 1968, Lecca
and Belvederi described a peduncolated mass arising
from the left round ligament in a 23-year-old woman.
Laparotomic resection of the lesion was performed. The
Fig. 2. The cystic wall showed numerous areas with close-set
basaloid cells and pseudohorn cysts. The latter aspect consisted
of cystic invaginations of the epithelium filled with surface keratin, which in a given microscopic section may be cut in cross-section, thereby appearing as “cysts” within the involved epithelium
(H&E; 40X).
422
T. Pusiol et al.
mass weighted 60 gr, measured 6 cm in maximum diameter and was an unilocular cyst, lined by keratinized
squamous epithelium with keratin-like content. A diagnosis of “epidermoid cyst” was made.We are not aware
of reports of any similar lesions 9. Only a few cutaneous epidermoid cysts exhibit seborreheic keratosis-like
changes in their wall 1-4. In all reported extracutaneous
epidermoid cysts, these features have not been found.
The present case is unique in that it is an extracutaneous
epidermoid cyst with seborreheic keratosis-like changes
in the cystic wall arising from a very unusual site, namely
the round ligament. The origin site of the lesion and its
cystic nature were established by computed tomography
findings. Conservative treatment with en-bloc resection
was possible. Histological examination confirmed the
computed tomography findings.
References
6
Bakotic BW, Cabello-Inchausti B, Willis IH, Suster S. Clearcell epithelioid leiomyoma of the round ligament. Mod Pathol
1999;12:912-8.
1
Rahbari H. Epidermoid cysts with seborrheic verruca-like cyst
walls. Arch Dermatol 1982;118:326-8.
7
2
Ansai S, Tsuda M, Nagato H, Nishimaki K, Wako M, Manabe
M, et al. Trichoblastic infundibular cyst. Am J Dermatopathol
2006;28:507-9.
8
3
Chun SI, Im S. An epidermoid cyst with a seborrheic verruca-like
cyst wall. J Dermatol 1990;17:260-3.
4
Brown EJ, Youngberg GA. Seborrheic inclusion cyst. J Tenn Med
Assoc 1991;84:587-8.
5
Fernandez-Flores A. Seborrheic inclusion cysts: a study of human
papillomavirus infection by polymerase chain reaction. Am J Dermatopathol 2009;31:310-2.
Kirkham JC, Nero CJ, Tambouret RH, Yoon SS. Leiomyoma and
leiomyosarcoma arising from the round ligament of the uterus. J
Am Coll Surg 2008;207:452.
Pattamapaspong N, Khunamornpong S, Phongnarisorn C, Pojchamarnwiputh S. Malignant perivascular epithelioid cell tumour
of the round ligament mimics leiomyoma on computed tomography. Singapore Med J 2009;50:e239-42.
Lecca U, Belvederi GD. Considerations on a case of epidermoid
cyst of the round ligament. Minerva Ginecol 1968;20:1782-3.
9
Pathologica 2010;102:423-426
5th Triennial Congress of the Italian Society of Anatomic Pathology
and Diagnostic Cytopathology - September 2010
Ematopathology – ROTARY BOLOGNA AWARD
to
Maria Rosaria Sapienza
U.O. di Emolinfopatologia, Istituto di Ematologia e Oncologia Medica
“L. e A. Seragnoli”, Bologna
Identification of novel cryptic chromosomal
abnormalities in primary myelofibrosis
by single-nucleotide polymorphism
oligonucleotide microarray
M.R. Sapienza1, G. Visani2, A. Isidori2, S. Righi1,
A. Laginestra1, C. Agostinelli1, E. Sabattini1, M. De Nictolis3,
M. Valentini4, M. Donati4, R. Emiliani4, A. Gazzola1,
C. Mannu1, M. Rossi1, C. Finelli1, N. Vianelli1, S.A. Pileri1,
P.P. Piccaluga1
Department of Hematology and Oncology “L. e A. Seràgnoli”, Hematopathology and Hematology Sections, Molecular Pathology Laboratory,
Sant’Orsola-Malpighi Hospital, University of Bologna, Italy; 2Hematology
and Hematopoietic Stem Cell Transplant Center, San Salvatore Hospital, Pesaro, Italy; 3Department of Pathology, San Salvatore Hospital, Pesaro, Italy;
4
Clinical Pathology Laboratory, San Salvatore Hospital, Pesaro, Italy
1
Background.
The
molecular
genetics
of
primary myelofibrosis (MF) is poorly known at present.
In this study we performed high resolution karyotyping by SNP oligonucleotide microarray by using the most updated Affymetrix array (Genome-Wide Human SNP Array 6.0) in 20 cases of myelofibrosis (MF) in order to identify novel cryptic genomic aberrations.
Methods. DNA was extracted from lymphocytes-depleted PBMNC of 14 primary and 6 secondary MF patients. DNA was
then processed and hybridized to the Affymetrix SNP arrays 6.0
as for manufacturer instruction. A whole-genome copy number
variation (CNV), was performed using the Partek Suite 6.0. Ten
lab-specific as well as 90 HapMap samples relative to Caucasian
healthy donor were used as control reference. Genomic abnormalities were defined as recurrent when occurring in at least 25%
of cases. JAK2 mutational status was assessed by alle-specific
PCR. Clinical information and complete follow-up were retrieved
for all cases. Direct sequencing, FISH, qPCR and immunohistochemistry (IHC) has been chosen for validation.
Results. In all patients we could detect several CNV. The median
number of CNV was 60 (range, 34-72), including 46 amplifications
(A) and 14 deletions (D). All commonest previously described abnormalities were detected. In addition, several formerly uncovered
recurrent lesions were identified, mainly involving 1p, 1q, 2p, 4p,
4q, 5q, 6p, 6q, 7q, 8p, 9q 10q, 11p 11q, 12p, 14q, 15q, 16p, 16q,
17q, 18q, 19q, 20p, 22q. Of note, numerous definite aberrations (A
or D) distinguished JAK2+ vs. JAK2- cases, specifically affecting
16q23.1, 1p36.13, 3q26, 14q13.2, 5q33.2, 6q14.1, 7q33, 8p23.1,
and 9p11.2.Grippingly, several genes of potential interest for PMF
pathogenesis were identified within the involved loci, including
RET, SCAPER, WWOX and SIRPB1. Among others, the product of
such genes has been selected for validation by IHC. Similarly, many
miRNA were recognized, which may deserve further investigation.
Conclusions. By using a newly developed highly sensitive array
we identified novel cryptic lesions in patients affected by MF.
Future studies on larger series, as well as functional analyses will
definitely assess their role in the pathogenesis of the disease. Of
note, consistent differences were recorded in JAK2+ vs. JAK2-,
supporting the hypothesis of different genetic mechanisms occurring in the two sub-groups.
Publications
Piccaluga PP, et al. Biology and treatment of follicular lymphoma. Expert Review of Hematology 2009;2:533-47.
Gazzola A, et al. Partial nodal involvement by marginal zone
lymphoma. Use of IGK gene rearrangement analysis in the diagnostic work-up. Case Report 2009, submitted.
Piccaluga PP, et al. Gene expression analysis uncovers similarity
and differences among Burkitt lymphoma subtypes. Blood 2010,
submitted.
Gazzola A, et al. CDKN1B/p27 expression in Peripheral T-cell
Lymphoma not otherwise specified. J Clin Pathol, in press, 2010.
Piccaluga PP, et al. Pathobiology of Hodgkin lymphoma. Advances in Hematology 2010,submitted.
Abstracts
Piccaluga PP, et al. Genomic profiling in T-cell lymphoma. T-cell
Lymphoma Forum Lahaina, Maui, Hawaii, 25-28 January, 2010.
Rossi M, et al. BCL10 expression in pheripheral T-cel Lymphomas. EAHP, Uppsala, 25-30 September 2010.
Visani G, et al. Identification of novel cryptic chromosomal
abnormalities in primary myelofibrosis by single nucleotide
polymorphism oligonucleotide microarray. Poster presentation.
American Society of Hematology, New Orleans, 5-8 December,
2009.
Piccaluga PP, et al. Gene expression profiling of Peripheral Tcell lymphoma: from bench to bedside. Now we Know of T-Cell
Lymphoma, Bologna, 16-18 March, 2009.
Piccaluga PP, et al. Molecular biology of childhood and adolescent lymphomas. Innovative Strategies in Pediatric Oncology:
for a Proactive Surgical and Clinical Approach. Bologna, 12-14
November, 2009
424
BREAST PATHOLOGY – SUSAN G. KOMEN AWARD
to
Paola Mazzarelli
Biopatologia, Policlinico Tor Vergata, Roma
HER2-mediated epigenetic control in human
breast cancer: CPT1A as a novel biomarker
and target for therapy
P. Mazzarelli1, S. Pucci2, M.J Zonetti3, L.G. Spagnoli4
Biopatologia, Policlinico di Tor Vergata, Roma, Italia; 2 Biopatologia,
Policlinico di Tor Vergata, Roma, Italia; 3 Biopatologia, Policlinico di Tor
Vergata, Roma, Italia; 4 Biopatologia, Policlinico di Tor Vergata, Roma,
Italia
1
Background. The altered metabolism of tumor cells may be a
potential means by which these cells evade programmed cell
death, favoring survival and tumoral growth. In particular,
lipid metabolism is markedly altered in the tumoral context.
Fatty acids synthase (FASN), the major enzyme required for
the synthesis of fatty acids, is up-regulated in a wide array of
solid tumors and ErbB2 (HER2) receptor, amplified in 25%
of breast cancers, has been recognized as activator of FASN
promoter. On the other hand, fatty-acids b-oxidation is inhibited in the tumoral context. We previously showed that the
carnitine palmitoyl transferase I (CPT I), rate-limiting enzyme
in the transport of long-chain fatty acids for b-oxidation, was
significantly decreased in the mitochondria and it strikingly
localized in the nuclei of tumor samples, where it could be
implicated in the epigenetic regulation of transcription by its
link to HDAC1.
Methods. Here we analyze human breast carcinomas and breast
cancer cell lines (SK-BR3, BT474, MCF7) correlating the HER2
status with FASN protein expression. Moreover, we transfected
MCF7 cells with small interfering RNAs (siRNAs) to silence
CPT1A nuclear expression and analyzed the histone and non
histone acetylation and the gene expression downstream effects,
by microarray analysis.
Results. We confirmed that FASN was over-expressed in a high
percent of breast cancer samples and it could be indicator of
HER2 transduction activity. Then we displayed that the silencing of nCPT1A was a sufficient condition to induce apoptosis
in MCF7 cells. The cell death triggered by RNA interference
correlated with decreased HDAC activity and hyperacetylation
of histone- and non histone-proteins involved in cancer-relevant
death pathways. Gene array studies showed that pro-apoptotic
genes such as BAD and CASP9 were up-regulated, whereas
invasion and metastasis-related genes were down-modulated at
transcriptional level. In breast cancer, the activation of Her2/Neu
signaling and the altered metabolism indirectly induce nCPT1A
that regulates pro-survival genes at epigenetic level, representing
a potential target for anti-cancer therapy.
Publications
Original Research Articles
Pucci S, et al. Interleukin-6 affects cell death escaping mechanisms acting on Bax-Ku70-Clusterin interactions in human colon
cancer progression. Cell Cycle 2009;8:1-9.
Pucci S, et al. Clusterin in stool: a new biomarker for colon cancer screening? Am J Gastroenterol 2009;104:2807-15.
Mazzarelli P, et al. Carnitine palmitoyl transferase I in human
carcinomas: a novel role in histone deacetylation? Cancer Biol
and Therapy 2007;6:1606-13.
Parrella P, et al. Expression and heterodimer-binding activity
of Ku70 and Ku80 in human non-melanoma skin cancer. J Clin
Pathol 2006;59:1181-5.
Mazzarelli P, et al. DNA end binding activity and Ku70/80 heterodimer expression in human colorectal tumor. World J Gastroenterol. 2005;11:6694-700.
Pucci S, et al. ApoJ-Ku70-Bax interaction regulated Bax dependent apoptosis. FEBS Journal 2005;272:1.
Pucci S, et al. The expression and the nuclear activity of the caretaker gene ku86 are modulated by somatostatin. Eur J Histochem
2004;48:103-10.
Mazzarelli P, et al. Differential modulation of Ku70/80 DNAbinding activity in a patient with multiple basal cell carcinomas.
J Invest Dermatol 2003;121:628-33.
Parrella P, et al. Mutations of the D310 mitochondrial mononucleotide repeat in primary tumors and cytological specimens.
Cancer Lett 2003;90:73-7.
Parrella P, et al. Detection of mitochondrial DNA mutations in
primary breast cancer and fine needle aspirates. Cancer Res
2001;61:7623-6.
Sanchez-Cespedes M, et al. Identification of a mononucleotide
repeat as a major target for mitochondrial DNA alterations in
human tumors. Cancer Res 2001;61:7015- 9.
Marino M, et al. Constitutive and cytokine-induced expression of
MHC and intercellular adhesion molecule-1 (ICAM-1) on human
myoblasts. J Neuroimmunol 2001;116:94-101.
Pucci S, et al. Tumor specific modulation of Ku70/80 DNAbinding activity in breast and bladder human tumor biopsies.
Oncogene 2001;20:739-47.
Mazzarelli P, et al. Effect of transforming growth factor b1 on
secretion of interleukin-6 in human myoblasts. J Neuroimmunol
1998;87:185-8.
Gallucci S, et al. Myoblasts produce interleukin-6 in response to
inflammatory stimuli. Int Immunol 1998;10:267-73.
Books
Pucci S, Mazzarelli P, Spagnoli LG. From normal to malignant
phenotype: survival and cell death escaping mechanisms. Tumorigenesis Research Focus. In: Wong DK, ed. Tumorigenesis
Research Advances. USA: Nova Science Publishers 2007.
Pucci S, Mazzarelli P, Nucci C, Ricci F, Spagnoli LG. CLU “in
and out”: looking for a link. Adv Cancer Res 2009;105:93-113.
Mazzarelli P, Pucci S, Spagnoli LG. CLU and colon cancer.
The dual face of CLU: from normal to malignant phenotype.
Adv Cancer Res 2009;105:45-61.
425
MOLECULAR PATHOLOGY – PATHOLOGICA AWARD*
to
Dario de Biase
Dipartimento di Ematologia e Scienze Oncologiche “L. e A. Seragnoli”,
Sezione di Anatomia Patologica, Ospedale Bellaria, Università di Bologna
Polyoma virus dna integration in extracutaneous
merkel cell-like carcinoma
D. de Biase1, M. Ragazzi2, S. Asioli3, V. Eusebi4
Sezione di Anatomia Patologica, Ospedale Bellaria, Università di Bologna, Italia; 2 Dipartimento di Ematologia e Scienze Oncologiche “L. e A.
Seragnoli”, Sezione di Anatomia Patologica, Ospedale Bellaria, Università di Bologna, Italia; 3 Dipartimento di “Scienze Biomediche e Oncologia Umana”, Università di Torino, Italia; 4 Dipartimento di Ematologia e
Scienze Oncologiche “L. e A. Seragnoli”, Sezione di Anatomia Patologica, Ospedale Bellaria, Università di Bologna, Italia
1
Background. Merkel cell carcinoma (MCC) is a neuroendocrine
tumour, with typical morphological features. Originally reported
as primary carcinoma of skin, it has been described in numerous
other sites such as lymph-nodes, breast and salivary glands.
Cytogenetic studies have shown trisomy of chromosome 6 in
about 50% of MCC of both skin and lymph nodes indicating a
strict similarity of these two forms. Recent molecular studies revealed in up to 80% of cases a clonally integrated polyomavirus,
named Merkel cell polyomavirus (MCPV). It seems that MCPV
is restricted to MCC as no positivity was found in 74 cases of
visceral neuroendocrine carcinomas [Am J Surg Pathol. 2009
Dec;33(12):1771-7]. Aim of the present study was to verify
the presence of MCPV in MCC of lymph nodes and parotid to
further investigate similarities and differences between the two
groups.
Methods. Cases of primary MCC studied were: 7 of lymph
nodes, 2 of parotid, 13 of skin. 13 cases of small cell carcinoma
(SCC) of lung (11 primaries and 2 brain metastases) were also
analyzed. Immunohistochemistry for keratin 20, chromogranin,
synaptophysin and TTF1 was obtained in all cases. Tumour cells
were microdissected and DNA extracted. Viral DNA was studied
with PCR assay using primers previously described by Duncavage et al. [Mod Pathol. 2009 Apr;22(4):516-21]. The PCR products were evaluated in a 3% agarose gel and sequenced.
Results and conclusions. MCPV was detected in 4 cases of
MCC primary of lymph node (in 3 cases DNA was not evaluable) and in all cases of parotid and cutaneous MCC. Keratin
20 was positive in all cases of MCC. On the contrary, all cases
of pulmonary SCC were negative for both MCPV and CK20. It
appears that cutaneous and extracutaneous MCC share similar
histological, immunohistochemical and molecular features. This
is a further evidence that Merkell cell origin is no longer tenable
as Merkel cells have not been described in lymph nodes and
parotid glands.
Publications
Grifoni D, et al. aPKCzeta cortical loading is associated with Lgl
cytoplasmic release and tumor growth in Drosophila and human
epithelia. Oncogene 2007;26:5960-5.
Foschini MP, et al. E-cadherin loss and Delta Np73L expression
in oral squamous cell carcinomas showing aggressive behavior.
Head Neck 2008;30:1475-82.
de Biase D, et al. NCOA4 (Nuclear Receptor Coactivator 4). Atlas Genet Cytogenet Oncol Haematol. October 2008. URL: http://
AtlasGeneticsOncology.org/Genes/NCOA4ID218ch10q11.html
de Biase D, et al. PAX8 (paired box 8). Atlas Genet Cytogenet
Oncol Haematol October 2008. URL: http://atlasgeneticsoncology.org/Genes/PAX8ID382ch2q13.html
Righi A, et al. Adenoid cystic carcinoma of the breast associated
with invasive duct carcinoma: a case report. Int J Surg Pathol
2009 Feb 19 [Epub ahead of print].
de Biase D, et al. p63 short isoforms are found in invasive carcinomas only and not in benign breast conditions. Virchows Arch
2010;456:395-401.
Morandi L, et al. Promoter methylation analysis of O6-methylguanine-DNA methyltransferase in glioblastoma: detection by
locked nucleic acid based quantitative PCR using an imprinted
gene (SNURF) as a reference. BMC Cancer 2010;10:48.
Geyer FC, et al. Molecular analysis reveals a genetic basis for the
phenotypic diversity of metaplastic breast carcinomas. J Pathol
2010;220:562-73.
Ragazzi M, et al. Oncocytic carcinoma of the breast: frequency,
morphology and follow up. Hum Pathol 2010 Nov 25 [Epub
ahead of print].
*
Sponsored by Menarini Diagnostics
426
SURGICAL PATHOLOGY – VIRCHOWS ARCHIV AWARD
to
Barbara Dal Bello
Anatomia Patologica, Fondazione IRCCS Policlinico San Matteo, Pavia
A survey of human papillomavirus (HPV) type
distribution and multiple infections entering
into the vaccine era
B. Dal Bello1, S. Cesari2, P. Alberizzi3, B. Gardella4,
D. Iacobone5, A. Spinillo6, E.M. Silini7
1
Anatomia Patologica, Fondazione Irccs Policlinico San Matteo, Pavia,
Italia; 2 Anatomia Patologica, Fondazione Irccs Policlinico San Matteo,
Pavia, Italia; 3 Anatomia Patologica, Fondazione Irccs Policlinico San
Matteo, Pavia, Italia; 4 Ostetricia e Ginecologia, Fondazione Irccs Policlinico San Matteo, Pavia, Italia; 5 Ostetricia e Ginecologia, Fondazione
Irccs Policlinico San Matteo, Pavia, Italia; 6 Ostetricia e Ginecologia,
Fondazione Irccs Policlinico San Matteo, Pavia, Italia; 7 Anatomia Patologica, Azienda Ospedaliero-Universitaria di Parma, Italia
Background. A large proportion of HPV infections is sustained by
genotypes that are not targeted by currently available multivalent
vaccines and/or by multiple viral types. The impact of HPV type
distribution and multiple infections on the potential efficacy of current vaccines is controversial. We investigated the type and number
of HPVs present in women referred to colposcopy in a single tertiary
institution and we evaluated their clinicopathologic correlations.
Methods. Viral typing was performed by SFP10-LIPA on a consecutive series of cervical scrapings from 3166 women (mean age
37 yrs, 4.4% HIV+) undergoing colposcopy for abnormal cytology over a four years period (2005-2009). 62% of the women had
targeted and/or cone cervical biopsy. CIN severity was correlated
with the type and number of HPVs.
Results. Overall prevalence of HPV-DNA was 70%, 98% in
CIN1 and 98,6% in CIN≥2; specific HPV types were identified
in 89% of cases. Twenty-eight different types were detected,
HPV16 (34%), 31 (20%), 52 (23%) and 51 (15%) being the most
frequent. Frequencies of HPV-6, 11 and 18 were 17%, 9% and
12% respectively. Other types were HPV-53 (9%), 33 (6%), 39
(7%) and 56 (5%). Multiple types were detected in 57.2% of
women, of whom 41.6% had CIN1 and 48% CIN ≥ 2. Overall,
multiple infections were diagnosed in 54.1% of CIN1, 78.4% of
CIN≥2 and 44.5% of negative biopsies (p < 0.001). Infections
by HPV-16 or 18 occurred in 43.3% of CIN, including 33.9% of
CIN1 and 56% of CIN ≥ 2. Infections by HPV-6, 11, 16 or 18
occurred in 55.1% of CIN, including 48.4% of CIN1 and 64.2%
of CIN ≥ 2. Finally, 44.9% of CIN and 35.8% of CIN ≥ 2 were
entirely sustained by HPV types that are not targeted by currently
available multivalent vaccines
In conclusion, the distribution of HPV types and the risk of CIN
correlated with multiple viral infections highlight the importance
of genotyping in the clinical management of women with abnormal cytology and point to potential limitations in current vaccine
strategies.
Publications
Original Articles
Arbustini E, et al. Am Heart J 1995;130:528-36.
Arbustini E, et al. Am J Cardiol 1996;78:795-800.
Arbustini E, et al. J Heart Lung Transplantation 1997;16:982-4.
Dal Bello B, et al. Transplant Proc 1998;30:2086-90.
Arbustini E, et al. Transplant Proc 1998;30:1922-4.
Arbustini E, et al. J Am Coll Cardiol 1998;31: 645-53.
Arbustini E, et al. Heart 1998;80: 548-58.
Arbustini E, et al. Am J Pathol 1998;153:1501-10.
Pastoris O, et al. Pharmacological Research 1998;37:115-22.
Castello A, et al. Transplantation 1999;67: 840-6.
Narula J, et al. Proc Natl Acad Sci USA 1999;96:8144-9.
Arbustini E, et al. Am Heart J 1999;138:S55-S60.
Arbustini E, et al. Heart 1999;82:269-272.
Arbustini E, et al. Heart 2000;83:86-90.
Arbustini E, et al. Transplantation 2000;69:1095-101.
Arbustini E, et al. J Am Coll Cardiol 2000;35:1760-8.
Prati F, et al. Z Kardiol 2000;89(Suppl 2):117-23.
Gavazzi A, et al. Eur Heart J 2001;22:73-81.
Sangiorgi G, et al. Cardiovasc Intervent Radiol 2001;24:260270.
Prati F, et al. Heart 2001;85:567-70.
Repetto A, et al. Eur Heart J 2005;26:1519-27.
Serraino D, et al. Transplantation 2005;80:1656-7.
Serraino D, et al. Methods Mol Biol 2009;471:409-19.
Vetro A, et al. Prenat Diagn 2008;28:1171-3.
Celant A, et al. Rheumatol Int 2008;29:111-2.
Rossi S, et al. Eur Radiol 2008;18:1749-56.
Dal Bello B, et al. Gynecol Oncol 2009;115:262-6.
Dal Bello B, et al. J Clin Microbiol 2009;47:2175-80.
Spinillo A, et al. Virus Res 2009;142:154-9.
Dal Bello B, et al. J Med Virol 2009;81:703-12.
Spinillo A, et al. Gynecol Oncol 2009;113:115-9.
Dal Bello B, et al. Clin Cancer Res 2010;16:2157-66.
Pathologica 2010;102:427-429
This issue of Pathologica publishes the lecture “Marcello Malpighi (1628-1694): the forgotten ancestor of Surgical Pathology”, erroneously omitted in Pathologica vol. 102, August 2010 - 5th Triennial
Congress of the Italian Society of Anatomic Pathology and Diagnostic Cytopathology and the correct
version of some oral communications and posters. The Publisher regrets for the inconvenience.
Marcello Malpighi (1628-1694):
the forgotten ancestor of Surgical Pathology
P. Scarani
Bologna University, Italy
Introduction. In a 1994 paper 1, Marcello Malpighi was considered to be the founding father of modern pathology. The
foundations of such a suggestion appeared to be shaky, because
the use of the microscope to study pathological lesions does not
clearly emerge from Malpighi’s records. In the years to follow,
a review of Goethe’s scientific papers 2 showed the importance
of Malpighi’s rediscovery as a fundamental cause of the 19th
century second great revolution in microscopy, preluding to the
discovery of the cell and to the foundation of cell pathology by
Robert Remak (1849). On the other hand, a recent revisitation
of Morgagni’s anatomic papers 3, showed the role of that great
scholar in removing Malpighi an the microscope from medical
research and practice for more than a century.
In this report, Malpighi’s role in natural sciences and medicine is
summarized. Moreover, his ideas antedating Morgagni’s classical
definition of pathology are stressed.
Malpighi’s achievements. Marcello Malpighi is the founding father of microscopic anatomy. He achieved a series of sensational
breaktroughs during his scientific career. He discovered the capillary circulation of the lung, the structure of the renal glomerulus
and of other parts of the nephron, the structure of the spleen, of
the lymph nodes, of many glands and of the skin.
Malpighi also discovered the microscopic structure of plants,
being thus considered the founder of modern plant morphology.
Moreover, although Malpighi was not able to conceive the existence of cells, he was probably the first to identify the red blood
cells.
Nevertheless, Malpighi found a lot of hostility in his country, being instead firmly supported by the members of the Royal Society
of London, who took in charge the publication of his “Opera
omnia” and “Opera posthuma”.
Morgagni & Malpighi. Giovanbattista Morgagni (1682-1771),
usually considered to be the founder of modern pathology, was
initially a strong supporter of Malpighi’s discoveries. Such an attitude is expressed very elegantly and convincingly in many parts
of the Adversaria anatomica, where Morgagni’s main anatomic
discoveries are reported 3.
In a second time, however, Morgagni profoundly changed his
favourable attitude to microscopy, apparently with no plausible
reason. Probably, he was influenced by the growing criticism
of Malpighi’s discoveries and of the microscope’s reliability by
Hermann Boerhaave (1668-1738), the ruler of the 19th century
medical science, more inclined to the value of the injection studies performed by Frederik Ruysch (1638-1731).
Therefore, it is not surprising that the microscope appears to be
practically absent from Morgagni’s “De sedibus et causis morborum per anatomen indagatis”. Until 1920, that great treatise
was just read by the clinicians, still in charge of autopsy practice
until Rudolf Virchow’s (1821-1902) reform was universally accepted 4. Such an attitude explains why Morgagni’s masterpiece
was substantially forgotten by the new-generation pathologists
(1850s), who created the background of the 20th century surgical pathology. Probably, the birth of modern surgical pathology,
founded in 1850 by Robert Remak (1815-1865) and ardently supported by people such as Theodor Billroth (1829-1894) and James
Paget (1814-1899), was delayed for more than a century 5, due to
Boerhaave’s and Morgagni’s unfortunate misconceptions 3.
“sedes et causae morborum” 100 years before Morgagni.
Apart from the very brilliant and modern use of the newborn
microscope, there is something more in Malpighi that should
induce us to consider him as the founding father of pathology.
Although more inclined to pure research, Malpighi was a prominent
clinician who also performed autopsies. A manuscript autopsy
record was discovered in Bologna in the 19th century appearing to
be no less sophisticate than Morgagni’s “De sedibus”. Although the
manuscript appears just to be a notebook, never printed by Malpighi,
nevertheless, the strict relationship of clinic to morphology is very
well defined. Moreover, as Adelmann stated 6, in a 1693 letter
to the Geneva publisher Jean-Antoine Chouet, Malpighi wrote:
“... Cum enim hac nostra aetate Anatomes pomeria adeo prolata sint,
et Phylosophia mechanica Medicinae associata sit, frequentibusque
cadaverum sectionibus morborum sedes in chronicis praecipue morbis
innotuerint, animalis oeconomia naturalis, et morbosa ita patere
videtur, ut Medicina a priori, et a posteriori instaurari, firmarique
possit. Quapropter ex collecta feraci sectionum cadaverum segete,
et ex mechanico fluidorum analogo examine, additisque remediorum
auxilijs Medicina practica locupletari potest …”.
In the sentence reported, the profound sense of the title of
Morgagni’s masterpiece “de sedibus et causis morborum per
anatomen indagatis” is clearly defined long before Morgagni
elaborated it. Such a title is usually considered to be the most appropriate definition of modern pathology.
Conclusion. Of course, the sentence quoted above does not
diminish the importance of Morgagni’s studies in pathology: it
does just show that they did not arise in a cultural vacuum, but
were intimately connected with the really volcanic activity of
Marcello Malpighi. Large parts of the vast Malpighian studies
are still incompletely explored (botany especially) and very often
continue to be misinterpreted, just as in the 17th century, when
Malpighi was still alive. Nevertheless, the reading of his works is
still extremely exciting. One should not be surprised by such an
impressive actuality of Malpighi’s studies after so many years.
In fact, Malpighi was not really an exception, but just an example
of the extraordinary (probably still unparalleled) levels achieved
by top western scientists in the 17th century.
428
References
1
2
3
4
5
6
Scarani P, Salvioli GP, Eusebi V. Marcello Malpighi (16281694). A founding father of modern anatomic pathology. Am
J Surg Pathol 1994;18:741-6.
Scarani P. Johann Wolfgang Goethe (1749-1832): il creatore del termine e del concetto di morfologia. Pathologica
2000;92:45-9.
Scarani P. The men who influenced Morgagni as anatomist.
Florence, September 2009, XXII European Congress of Pathology.
Scarani P, Lacchini G. L’autopsia clinica dell’ottocento a
Bologna. Nuove prospettive. Pathologica 1999;91:128.
Scarani P. Il Dio di Einstein: la rivoluzione tardiva del microscopio … ed altro. Pathologica 2001;93:696-9.
Adelmann H.B. Marcello Malpighi and the evolution of embryology. Cornell University Press 1966.
Pathologica 2010;102:262
Left ventricular hemangioma
F. Bondi1, M. Del Giglio2, M. Puccetti3
Endocrinologia, Ospedale S. Maria delle Croci, Ravenna, Italia;
Dipartimento di Chirurgia cardiovascolare, Ospedale Villa Maria
Cecilia, Cotignola, Lugo, Italia; 3 Anatomia ed Istologia Patologica,
AUSL Ravenna, Italia
1
2
Background. Primary cardiac tumors are rare. The large majority
of cardiac tumors are benign; hemangiomas account for < 10%
of all primary cardiac tumors in children and they are usually asymptomatic when diagnosed after infancy. Cardiac hemangiomas
are often found incidentally at autopsy or with imaging, usually
hocardiography.
Methods. A 16-year-old previously healthy boy presented with a
heart murmur and was found by transthoracic echocardiography
to have a single mobile tumor in the left ventricular. A diagnosis
of probable cardiac hemangioma was made on the basis of its
MRI signal intensity characteristics indicating high vascularity.
The polipoid mass appeared to be localized in the left ventricle
and its implant base was in the lateral border of the posterior
papillary muscle. The tumor was surgically excised.
Results. At gross inspection, tumor consisted of exophytic
polypoid mass. The size was 1.7 x 1.5 x 1 cm. On cut section,
tumor had microcytic appearance with areas of hemorrhage.
Histopathological features were consistent with an unusual type
of hemangioma composed of large, endothelial-lined, thin-walled
channels and intervening dense proliferation of capillary-sized
vessels. Although hemangioma was predominantly exophytic,
there was infiltration of superficial myocardium. No evidence of
atypia, cellular pleiomorphism, high mitotic count, or necrosis
were found. Immunohistochemical profile of tumor consistent
with with strong staining for CD31 and factor VIII. The diagnosis
of cardiac hemangioma, capillary type, was made.
Conclusions. Cardiac hemangiomas are rare tumors therefore
it is difficult to make a definitive preoperative diagnosis. Other
cardiac tumors that may have strong gadolinium enhancement
include pheochomocytoma, angiosarcoma, myxoma, and rhabdomyosarcoma. Cardiac angiosarcomas are exceptionally aggressive, are usually large, centrally necrotic, and frequently extend
into the pericardium.
The cell blocks: it could be a real-biopsy
F. Bondi1, V. Salerno2, M. Puccetti3
Endocrinologia, Ospedale S. Maria delle Croci, Ravenna, Italia;
Oncologia, Ospedale Umberto I, Lugo, Italia; 3 Anatomia ed
Istologia Patologica, AUSL Ravenna, Italia
1
2
Background. For pathologist, an essential step in the mastery of
aspiration cytology is the ability to translate the cytologic patterns
into histologic tissue patterns of diagnostic value.
The fine needle aspiration cytology (FNAC) in nodular lesions
has a limited diagnostic use for the impossibility to obtain multiple sections for an immunohistochemical analysis.
Methods. Often from standard FNA is possible to obtain thin
cores or multiple tissue fragments, especially in tissue rich of cell
as lymph node and solid tumours. The FNA samples, previously
centrifugation, are assembled with a drop of tromboplastina to
produce a clot. The clot is fixed in 10% solution of buffered isotonic formalin and processed as for routine histology. Cell blocks
may give some idea of tissue architecture and allow multiple section for immunohistochemistry.
Results. We always prepare the cell blocks and a cytologic
smearing from fresh material in FNA of neoplastic lesions from
different organs and tissues. This gives us tissue fragments for
value histologic pattern of the lesions and on which perform
immunohistochemistry and/or the molecular pathology (FISH,
EGFR, K-ras ecc). In the review of our series we have observed
that the cell blocks is useful to differentiate tumoral histotypes
(in particular of the parotid gland and of the lung), primary from
metastatic tumours, lymphomas, undifferentiated carcinomas
from sarcomas and melanomas, neuroendocrine tumours and it
was essential to diagnose: parotid gland melanoma metastasis,
lymph node alveolar rhabdomyosarcoma metastasis, lymph
node gastric leiomyosarcoma (GIST) metastasis, thyroid gland
colic ADK metastasis, adrenal gland leiomyosarcoma, giant cells
MFH, pulmonary angiosarcoma.
Significance of egfr expression in de novo and
progressed atypical and anaplastic meningiomas:
an immunohistochemical and fluorescence in situ
hybridization study
R. Caltabiano1, G.M. Barbagallo2, V. Albanese3, M. Castaing4,
S. Lanzafame5
Dipartimento G.F. Ingrassia Anatomia Patologica, Azienda Ospedaliero-Universitaria Policlinico-OVE, Catania, Italia; 2 Dipartimento di
Neurochirurgia, Azienda Ospedaliero-Universitaria Policlinico-OVE,
Catania, Italia; 3 Dipartimento di Neurochirurgia, Azienda Ospedaliero-Universitaria Policlinico-OVE, Catania, Italia; 4 Dipartimento G.F.
Ingrassia Istituto di Igiene, Catania, Italia; 5 Dipartimento G.F. Ingrassia
Anatomia Patologica, Azienda Ospedaliero-Universitaria PoliclinicoOVE, Catania, Italia
1
Background. The gene encoding EGFR is located on chromosome 7. It encodes a 170 kD protein, which is a transmembrane
receptor responsible for sensing its extracellular ligands, such
as EGF and TGF-a and for transducting this proliferation signal. The purpose of this study is to assess the EGFR protein
expression and the EGFR gene amplification in meningiomas
of different grade. We investigated whether there is a difference
in the EGFR protein expression and the EGFR gene amplifica-
429
tion between the so called de novo malignant meningiomas and
meningiomas with malignant progression. We also assessed the
prognostic value of the EGFR expression on overall survival in
different groups of meningiomas.
Methods. All cases of meningiomas diagnosed from year 2000
to 2009 at the Pathology Department of the University of Catania
were reviewed. Five meningiomas with recurrences and progression were selected. They were compared with fifteen meningiomas without recurrences.
Results. The group of G I-II meningiomas without progression
showed a tendency to a better survival than the group of G I-II
meningiomas with recurrences and progression. The group of
G III meningiomas without progression showed a tendency to a
better survival than the group of G III meningiomas with recurrences and progression. The comparison between EGFR expression at baseline and after progression have showed an increased
expression of EGFR protein in the last group. The progression
from benign to atypical or anaplastic meningiomas may be due to
the increased expression of EGFR protein. However there was no
difference in the EGFR expression between the group of G I-II
de novo meningiomas and the group of G I-II progressed meningiomas. The comparison between the group of G III de novo and
progressed meningiomas and EGFR expression was not statistically significant. Our FISH study demonstrated an increase in the
number of EGFR gene copies in only 1 of the 20 meningiomas.
Management of histopathology laboratory in
Africa: the St Raphael, St Francis and Nsambya
Hospital experience
G. Dell’Antonio1, A. Colantoni2, E. Bonanno3, E. Othieno4, F.S.
Aloi5
Anatomia Patologica, San Raffaele, Milano, Italia; 2 Anatomia Patologica, Policlinico Universitario Tor Vergata, Roma, Italia; 3 Anatomia
Patologica, Policlinico Universitario Tor Vergata, Roma, Italia; 4 Anatomic Pathology, Nsambya Hospital, Kampala, Uganda; 5 Aispo, Nsambya
Hospital, Kampala, Uganda
1
Background. Nsambya Hospital in Kampala (Uganda), accredited by the Uganda Catholic Medical, is a tertiary child-maternal
referral hospital with a capacity of 361 beds which has played a
pioneering role in HIV/AIDS activities. It is involved in patient
care, research and teaching for graduates of any of Uganda’s four
medical schools. Here they spend a year of internship in Surgery,
Internal Medicine, Pediatrics and Obstetrics-Gynecology under
the supervision of local specialists and consultants.
A modern histopathology laboratory (HL) has special challenges because prevention, diagnosis and clinical practice relies
on morphological and qualitative (biomarkers) characteristic of
pathological tissues and more and more therapeutics decisions
are based on specific immunostainings (IHC) (i.e.hormonal receptors).
Methods. In Nsambya HL are mainly processed cytologic samples (PAP test and fine needle aspirates), biopsies and surgical
specimen from gynecologic pathologies. The human resources
are a pathologist and two technologists with expertise in cyto/
histopathology. Existing procedures have been reviewed and formalized as guide lines, some new procedures, such as “thin layer
cytology”, histochemistry and IHC have been introduced.
Results. In the first five months of 2010 in the HL were performed
about 500 PAP test, 30 fine needle aspirations, 680 histological
specimens some of which combined with IHC improving both the
number and the quality of specimens examined. In march 2010
AISPO, with APOF and Tor Vergata University counselling,
has opened a new HL with western standards and machineries.
The most critical issues are technicians’ training made inside the
lab, the written protocols approved by the pathologist to ensure
the continuity and a quality control in sample preparation and
diagnosis. We think that telepathology with internet broad band,
as demonstrated by other experiences done by APOF, will be the
best solution to these problems.
Printed in December 2010
by Industrie Grafiche Pacini Editore S.p.A.
Via A. Gherardesca • 56121 Ospedaletto • Pisa • Italy
Tel. +39 050 313011 • Telefax +39 050 3130300
www.pacinieditore.it

Living up to Life - Journal of the Italian Society of Anatomic

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