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Liu T, Yao Y, Geng C, Guan F, Zhang G. Sarcomatoid renal pelvis carcinoma: Experience of treatment at a single-institution. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108251. [PMID: 38492258 DOI: 10.1016/j.ejso.2024.108251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVES Sarcomatoid renal pelvis carcinoma (SRPC) is a rare variant of RPC. We aimed to summarize the clinicopathological features and prognostic factors of SRPC. METHODS In this retrospective study, we collected data from 24 patients with SRPC who were treated at the Department of Urology, Affiliated Hospital of Qingdao University between 2008 and 2021. The clinicopathological features of the patients were obtained from their medical records to evaluate the diagnosis, prognostic factors, and response to systemic therapy. RESULTS Immunohistochemical staining revealed that cytokeratin was expressed in 19 patients with SRPC, while vimentin was expressed in all patients. Computer tomography showed these tumors as low-density (n = 12) or mixed-density masses, with or without necrotic areas (n = 12). All patients showed different degrees of enhancement on computed tomography. Lymph node metastasis was present in 6 patients and distant metastasis in 5. The median survival of all patients was 28 months. Patients without metastasis had a median survival of 46 months compared with 18 months in those with metastasis (P < 0.05). Necrosis had no significant influence on prognosis (P > 0.05). The median survival of patients with and without hydronephrosis was 18 and 104 months (P < 0.05). Among patients without metastasis, those without hydronephrosis survived longer than those with hydronephrosis (104 vs 18 months, P < 0.05), and necrosis had no effect on prognosis. In patients with metastasis, necrosis and hydronephrosis had no effect on prognosis (P > 0.05). CONCLUSION The prognosis of SRPC is poor, and the clinical stage, particularly the presence of distant metastasis, has a significant impact on prognosis.
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Affiliation(s)
- Tian Liu
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yu Yao
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chaoqun Geng
- Department of Pharmaceutical Analysis, School of Pharmacy, Qingdao University, Qingdao, China
| | - Fengju Guan
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guiming Zhang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China.
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Chen H, Liu S, Li X, Wang Z, Zhang C. Prognostic analysis of inflammatory response-related genes and biomarkers in patients with urothelial carcinoma of ureter. Front Genet 2023; 14:1139412. [PMID: 36936427 PMCID: PMC10017875 DOI: 10.3389/fgene.2023.1139412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/15/2023] [Indexed: 03/06/2023] Open
Abstract
Ureteral urothelial carcinoma is a common urinary system tumor, accounting for 40% to 60% of all ureteral diseases. This study attempted to analyze the prognosis of patients with urothelial carcinoma, judging ureteral urothelial carcinoma by genes and biomarkers of inflammatory response. In this paper, co-expression network analysis and gene-based image fusion evaluation methods were proposed to obtain the prognosis results of patients with ureteral urothelial carcinoma. The experimental results showed that the levels of PLR and NLR increased, and the levels of HGB and HCT decreased; high PLR and high NLR levels, low HGB and low HCT levels were all risk factors affecting bladder urothelial carcinoma, and their ratios (OR) were 1.023, 1.611, 0.961, 0.859, 1.015, 1.072, 0.979, and 0.951, respectively. However, high PLR and high NLR levels were independent risk factors for bladder urothelial carcinoma, and their OR values were 1.497 and 1.071, respectively. Through biomarker diagnosis, the area under the curve, sensitivity, specificity and Youden index of hsa-mir-17, hsa-mir-93, hsa-mir-429 and hsa-mir-20a all exceeded 0.9, indicating that this is a potential diagnostic indicators. All in all, during the treatment of ureteral cancer, in order to reduce tumor recurrence, systemic therapy should be combined with ureteral cancer. In addition, this study also analyzed the prognosis of chemotherapy patients, and the results showed that immunotherapy may increase the risk of tumor cell reperfusion during chemotherapy.
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Warli SM, Laksmi LI, Lubis NS, Wijaya WS. Complete Response of Rare Sarcomatoid Upper Tract Urothelial Carcinoma Variant: Case Report and Literature Review. Case Rep Oncol 2023; 16:325-330. [PMID: 37187682 PMCID: PMC10176196 DOI: 10.1159/000530264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/03/2023] [Indexed: 05/17/2023] Open
Abstract
Infiltrating urothelial carcinoma sarcomatoid variant is a rare variant of urothelial carcinoma. We report a case of a 68-year-old female with a history of hematuria. CT scan with contrast showed a mass in the 1/3 distal of the right ureter. The biopsy result showed a high-grade infiltrating urothelial carcinoma. A radical nephroureterectomy was performed but at the follow-up after 3 months, there was a recurrent mass and gemcitabine-cisplatin chemotherapy was given. Since a high-grade infiltrating urothelial carcinoma sarcomatoid variant was an aggressive tumor, we need to give more attention to evaluating this tumor.
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Affiliation(s)
- Syah Mirsya Warli
- Division of Urology, Department of Surgery, Faculty of Medicine, Universitas Sumatera Utara – Haji Adam Malik General Hospital, Medan, Indonesia
- Department of Urology, Universitas Sumatera Utara Hospital, Universitas Sumatera Utara, Medan, Indonesia
| | - Lidya Imelda Laksmi
- Department of Anatomical Pathology, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Nova Sabrina Lubis
- Department of Anatomical Pathology, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - William Saputra Wijaya
- Department of Urology, Faculty of Medicine, Universitas Indonesia ‒ Haji Adam Malik General Hospital, Medan, Indonesia
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Zhu S, Yu C, Wang C, Ding G, Cheng S. Case report: Significant benefits of tislelizumab combined with anlotinib in first-line treatment of metastatic renal pelvic urothelial carcinoma with sarcomatoid carcinoma differentiation. Front Oncol 2022; 12:969106. [PMID: 36330483 PMCID: PMC9623047 DOI: 10.3389/fonc.2022.969106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background Renal pelvic urothelial carcinoma with sarcomatoid carcinoma differentiation is a very dangerous malignant tumor and extremely rare in clinical practice. In general, these tumors with a dismal prognosis, and there is no standard treatment. Case presentation In this case, an 81-year-old male patient was diagnosed with right renal pelvic carcinoma. After an open right radical nephroureterectomy, postoperative pathological examination showed infiltrating urothelial carcinoma with sarcomatoid differentiation. Overexpression of programmed death ligand-1 by immunohistochemistry. The carcinoma recurred 4.5 months after surgery. After informed, tislelizumab combined with anlotinib were used as first-line treatment. The patients showed a clinical partial response that lasted for 20 months. Conclusion This case demonstrates the efficacy of tislelizumab combined with anlotinib in patients diagnosed with metastatic renal pelvic urothelial carcinoma with sarcomatoid carcinoma differentiation. Moreover, to our knowledge, this is the first application of this treatment.
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Affiliation(s)
- Shibin Zhu
- Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chenhao Yu
- Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chongwei Wang
- Department of Pathology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guoqing Ding
- Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Guoqing Ding, ; Sheng Cheng,
| | - Sheng Cheng
- Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Guoqing Ding, ; Sheng Cheng,
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5
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Hamard A, Kerdraon R, de Pinieux G, Malka D, Ab Der Halden C, Tabareau-Delalande F. [Ossifying tumor of the urinary tract in a 81-year-old man]. Ann Pathol 2021; 42:272-275. [PMID: 34969553 DOI: 10.1016/j.annpat.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 04/09/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Aymeric Hamard
- Service de pathologie, CHR d'Orléans, avenue de l'hôpital, CS86709, 45067 Orléans Cedex 2, France
| | - Rémy Kerdraon
- Service de pathologie, CHR d'Orléans, avenue de l'hôpital, CS86709, 45067 Orléans Cedex 2, France
| | - Gonzague de Pinieux
- Service d'anatomie et cytologie pathologiques, hôpital Trousseau, CHRU hôpitaux de Tours, avenue de la république, 37170 Chambray-lès-Tours Cedex 2, France
| | - David Malka
- Service de radiologie, CHR d'Orléans, avenue de l'hôpital, CS86709, 45067 Orléans Cedex 2, France
| | - Caroline Ab Der Halden
- Service de pathologie, CHR d'Orléans, avenue de l'hôpital, CS86709, 45067 Orléans Cedex 2, France
| | - Flore Tabareau-Delalande
- Service de pathologie, CHR d'Orléans, avenue de l'hôpital, CS86709, 45067 Orléans Cedex 2, France.
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Park HS. Sarcomatoid urothelial carcinoma arising in the female urethral diverticulum. J Pathol Transl Med 2021; 55:298-302. [PMID: 34058799 PMCID: PMC8353136 DOI: 10.4132/jptm.2021.04.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/23/2021] [Indexed: 01/22/2023] Open
Abstract
A sarcomatoid variant of urothelial carcinoma in the female urethral diverticulum has not been reported previously. A 66-year-old woman suffering from dysuria presented with a huge urethral mass invading the urinary bladder and vagina. Histopathological examination of the resected specimen revealed predominantly undifferentiated pleomorphic sarcoma with sclerosis. Only a small portion of conventional urothelial carcinoma was identified around the urethral diverticulum, which contained glandular epithelium and villous adenoma. The patient showed rapid systemic recurrence and resistance to immune checkpoint inhibitor therapy despite high expression of programmed cell death ligand-1. We report the first case of urethral diverticular carcinoma with sarcomatoid features.
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Affiliation(s)
- Heae Surng Park
- Department of Pathology, Ewha Womans University Seoul Hospital, Seoul, Korea
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De Lorenzis E, Albo G, Longo F, Bebi C, Boeri L, Montanari E. Current Knowledge on Genomic Profiling of Upper Tract Urothelial Carcinoma. Genes (Basel) 2021; 12:genes12030333. [PMID: 33668859 PMCID: PMC7996334 DOI: 10.3390/genes12030333] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 12/12/2022] Open
Abstract
Recent research in next-generation sequencing characterized the genomic landscape of urothelial cancer. However, the majority of the studies focused on bladder cancer (BC). Upper urinary tract urothelial carcinomas (UTUC) and BC share some histological characteristics, but, considering the differences in terms of embryologic precursors, epidemiology, genetics, medical and surgical management and response to therapy, UTUC and BC should be considered as two distinct diseases. Our objective is to analyze through a literature search the latest updates and the current knowledge about the genomics of UTUC. We also evaluate genetic differences between BC and UTUC and the potential implications for systemic therapy. Molecular subtyping and variant histology and their correlation with response to chemotherapy were also explored. In summary, the most frequent genomic variations in UTUC included FGFR3, chromatin remodeling genes, TP53/MDM2 and other tumor suppressors/oncogenes. The genomics of UTUC, integrated with clinical data, could drive the selection of patients who could benefit from targeted therapy or off-label treatment. Routine implementation of tumor genomic characterization in UTUC patients should therefore be contemplated and evaluated prospectively.
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Affiliation(s)
- Elisa De Lorenzis
- Urology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.A.); (F.L.); (C.B.); (L.B.); (E.M.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- Correspondence: ; Tel.: +39-02-55034546; Fax: +39-02-50320584
| | - Giancarlo Albo
- Urology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.A.); (F.L.); (C.B.); (L.B.); (E.M.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Fabrizio Longo
- Urology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.A.); (F.L.); (C.B.); (L.B.); (E.M.)
| | - Carolina Bebi
- Urology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.A.); (F.L.); (C.B.); (L.B.); (E.M.)
- University of Milan, 20122 Milan, Italy
| | - Luca Boeri
- Urology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.A.); (F.L.); (C.B.); (L.B.); (E.M.)
- University of Milan, 20122 Milan, Italy
| | - Emanuele Montanari
- Urology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.A.); (F.L.); (C.B.); (L.B.); (E.M.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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Ren S, Feng H, Bao Y, Wei Y, Ou Y, Wang Y, Lv Q, Zhong S, Zhou F, Fan S, Wang Q, Luo C, Chen Z, Nie Y, Wang D. Ureteral urothelial carcinoma with squamous cell carcinoma and sarcomatoid carcinoma differentiation: a case report. BMC Surg 2021; 21:96. [PMID: 33612111 PMCID: PMC7897460 DOI: 10.1186/s12893-021-01099-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/11/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Upper urinary tract urothelial carcinoma (UTUC) with multiple pathological types is extremely rare in the clinic, but the recurrence rate and mortality these patients are high. At present, there is no standard treatment for such cases. CASE PRESENTATION We reported a case of ureteral urothelial carcinoma with squamous cell carcinoma and sarcomatoid carcinoma differentiation and rapid ileal metastasis and reviewed the literature related to different pathological types of upper urinary tract tumours to explore the diagnosis, treatment and prognosis characteristics of the disease, enhance our understanding of its clinical manifestations and history of evolution and provide guidance for avoiding missed diagnosis and misdiagnosis. CONCLUSION There is no standard treatment for urinary malignant tumours with multiple pathological types; radical surgery is considered a suitable choice. Chemotherapy, targeted drug therapy and immunotherapy may be beneficial to the survival of patients. In short, these patients have a high risk of recurrence and metastasis and a poor prognosis.
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Affiliation(s)
- Shangqing Ren
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Hualin Feng
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Yige Bao
- Departments of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Wei
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Yong Ou
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Yaoqian Wang
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Qian Lv
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Shan Zhong
- Department of Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Fang Zhou
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Shida Fan
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Qiang Wang
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Cheng Luo
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Zhengjun Chen
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Yu Nie
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Dong Wang
- Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China.
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Attia A, Siriwardana A, Desai D. Sarcomatoid urothelial carcinoma of the ureter with heterologous elements of chondrosarcoma and osteosarcoma, and concurrent divergent squamous differentiation: A rare case report. Urol Case Rep 2020; 34:101484. [PMID: 33224730 PMCID: PMC7662845 DOI: 10.1016/j.eucr.2020.101484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 11/04/2022] Open
Abstract
Primary sarcomatoid urothelial carcinoma of the ureter with heterologous elements is rare and carries a poor prognosis. Although there is some literature on primary bladder sarcomatoid urothelial carcinoma, ureteric involvement has been reported infrequently, and this case report describes this unusual histological finding with concurrent divergent squamous differentiation. Despite laparoscopic radical nephroureterectomy, our patient died within six months of diagnosis with local recurrence and metastatic spread. A more thorough understanding of this disease process and consideration of standardised guidelines for treatment are needed to improve patient outcomes.
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Affiliation(s)
- Arsany Attia
- Department of Urology, Ipswich Hospital, Ipswich, Queensland, Australia, 4305
| | - Amila Siriwardana
- Department of Urology, Ipswich Hospital, Ipswich, Queensland, Australia, 4305
| | - Devang Desai
- Department of Urology, Toowoomba Hospital, Toowoomba, Queensland, Australia, 4350.,Faculty of Medicine, Griffith University, Mount Gravatt, Queensland, Australia, 4122.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia, 4006.,Toowoomba Urology, Toowoomba, Queensland, Australia, 4350
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Cimadamore A, Scarpelli M, Santoni M, Cheng L, Lopez-Beltran A, Montironi R. Upper urinary tract urothelial carcinoma and its variants: transition from morphology to personalized molecular characterization in diagnosis, prognosis, and therapy. Expert Rev Mol Diagn 2018; 18:1021-1028. [PMID: 30452305 DOI: 10.1080/14737159.2018.1549490] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Upper tract urothelial carcinoma (UTUC) accounts for 5% of urothelial carcinomas (UCs), the estimated annual incidence being 1-2 cases per 100,000 inhabitants. The aim of this review was to summarize the main morphologic features of UTUC as well as the current status and future role of its molecular characterization in diagnosis, prognosis, and therapy. Areas covered: Several studies on the UTUCs have shown the diagnostic, prognostic, and therapeutic significance of standard pathological features, such as tumor stage, grade, and lymph node metastasis. Investigations have also identified novel factors, in particular, variant histologies, and molecular biomarkers. Based on these, predictive tools have been developed. Expert commentary: The morphology of the UTUC has been considered to be the same as that of Bladder Urothelial carcinoma (BUC). Molecular characterization studies, including genomics, have shown changes in UTUC occurring at differing frequencies in comparison with BUC, the former with unique molecular subtypes and different responses to treatment.
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Affiliation(s)
- Alessia Cimadamore
- a Section of Pathological Anatomy, School of Medicine, United Hospitals , Polytechnic University of the Marche Region , Ancona , Italy
| | - Marina Scarpelli
- a Section of Pathological Anatomy, School of Medicine, United Hospitals , Polytechnic University of the Marche Region , Ancona , Italy
| | | | - Liang Cheng
- c Department of Pathology and Laboratory Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
| | | | - Rodolfo Montironi
- a Section of Pathological Anatomy, School of Medicine, United Hospitals , Polytechnic University of the Marche Region , Ancona , Italy
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