Immunohistochemical detection of insulin at the injection site in a case of suspected murder with the suicide of the perpetrator

In medicolegal practice, rare cases involving suicidal, criminal, or accidental insulin overdose are both analytically and forensically challenging. The aim of this study is to present a model procedure in such cases, developed at the Department of Forensic Medicine and Toxicology of the Medical University of Silesia in Katowice, with particular emphasis on the possibility of additional confirmation of insulin intake by its immunohistochemical detection at the injection site. In the example case presented here, an immunohistochemical examination using FLEX Polyclonal Guinea Pig Anti-Insulin antibody (code IR002, Dako) confirmed the presence of insulin in the subcutaneous tissue of the victims. In our opinion, the method of immunohistochemical detection of insulin at the injection site can and should be used routinely in such cases. Immunohistochemiczna detekcja insuliny w miejscu wkłucia w przypadku podejrzenia zabójstwa z samobójstwem sprawcy W praktyce medyczno-sądowej przypadki związane z samobójczym, zbrodniczym lub przypadkowym przedawkowaniem insuliny są rzadkie i należą do trudnych pod względem analitycznym i opiniodawczym. Celem pracy jest przedstawienie modelowego postępowania w tego typu przypadkach opracowanego w Katedrze i Zakładzie Medycyny Sądowej i Toksykologii Sądowo-Lekarskiej w Katowicach, ze szczególnym uwzględnieniem możliwości dodatkowego potwierdzenia podania insuliny przez jej immunohistochemiczną detekcję w miejscu wkłucia. W zaprezentowanym przypadku badanie immunohistochemiczne z wykorzystaniem przeciwciała Polyclonal Guinea Pig Anti-Insulin FLEX IR002 (Dako) potwierdziło obecność insuliny w tkance podskórnej obu ofiar. Naszym zdaniem metoda immunohistochemicznej detekcji insuliny w miejscu wkłucia może i powinna być stosowana w każdym tego rodzaju przypadku.

The Usefulness of Spectral Mammography in Surgical Planning of Breast Cancer Treatment-Analysis of 999 Patients with Primary Operable Breast Cancer

Contrast-enhanced spectral mammography (CESM) is a promising, digital breast imaging method for planning surgeries. The study aimed at comparing digital mammography (MG) with CESM as predictive factors in visualizing multifocal-multicentric cancers (MFMCC) before determining the surgery extent. We analyzed 999 patients after breast cancer surgery to compare MG and CESM in terms of detecting MFMCC. Moreover, these procedures were assessed for their conformity with postoperative histopathology (HP), calculating their sensitivity and specificity. The question was which histopathological types of breast cancer were more frequently characterized by multifocality–multicentrality in comparable techniques as regards the general number of HP-identified cancers. The analysis involved the frequency of post-CESM changes in the extent of planned surgeries. In the present study, MG revealed 48 (4.80%) while CESM 170 (17.02%) MFMCC lesions, subsequently confirmed in HP. MG had MFMCC detecting sensitivity of 38.51%, specificity 99.01%, PPV (positive predictive value) 85.71%, and NPV (negative predictive value) 84.52%. The respective values for CESM were 87.63%, 94.90%, 80.57% and 96.95%. Moreover, no statistically significant differences were found between lobular and NST cancers (27.78% vs. 21.24%) regarding MFMCC. A treatment change was required by 20.00% of the patients from breast-conserving to mastectomy, upon visualizing MFMCC in CESM. In conclusion, mammography offers insufficient diagnostic sensitivity for detecting additional cancer foci. The high diagnostic sensitivity of CESM effectively assesses breast cancer multifocality/multicentrality and significantly changes the extent of planned surgeries. The multifocality/multicentrality concerned carcinoma, lobular and invasive carcinoma of no special type (NST) cancers with similar incidence rates, which requires further confirmation.

Clear cell carcinoma derived from an endometriosis focus in a scar after a caesarean section--a case report and literature review

Endometriosis is defined as the occurrence of endometrial glands and endometrial stromal cells outside their typical localization within the uterus. Malignant transformation of endometriosis foci in a scar after a caesarean section (cc) is very rare--until 2013 (in a span of 40 years), about 40 such cases have been described. In our article, we describe a case of a 42-year-old woman with a tumour localized in a scar after a caesarean section. The tumour was diagnosed as clear cell carcinoma derived from an endometriosis focus. The long time interval--17 years in average (from 3 to 39 years) between the surgery (cesarean section in most cases) and the tumor diagnosis is characteristic. In the case we describe, the patient was diagnosed 16 years after the endometriosis focus in the scar had arised. Even though endometriosis is a benign lesion, it has many features distinctive for invasive carcinoma; it may itself undergo a malignant transformation as well as increase the risk of endometrial carcinoma or clear cell ovarian carcinoma. Maybe in future, more exhaustive studies will allow establishing a therapeutic protocol in patients with extra-ovarian malignant transformation of endometriosis foci.

Inflammatory myofibroblastic tumor of the bladder - an unexpected case coexisting with an ovarian teratoma

Inflammatory myofibroblastic tumors (IMTs) mainly occur in children and young adults, usually in the first two decades of life. IMT-type tumors belong to neoplasms of an intermediate biologic potential with considerable rate of local recurrence and in some cases that able to create metastases. Presented case is the first IMT coexisting with the other neoplasm. In our paper we are going to present a peculiar case of an IMT of the bladder coexisting with an ovarian teratoma, and to discuss its pathogenesis, histological picture and differential diagnosis. A 19-year-old female was admitted to the Gynecological Department and during the surgery, two independent, non-adjacent tumors were found. To settle the diagnosis, a FISH examination with the ALK1 break apart probe was carried out. It confirmed the rearrangement of the chromosome 2p23. Morphologic and immunophenotypic similarities between an IMT and other malignant tumors of the bladder may lead to diagnostic errors and an unnecessary radical cystectomy as a result. The therapy of choice is only total excision of the tumor.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1937487606122622.

An atypical leiomyoadenomatoid tumor of the uterus--a case report and literature review

In this study, we describe morphological and immunohistochemical features of a mixed tumor (atypical leiomyoadenomatoid tumor - LMAT) localized in the body of the uterus.

AIM OF STUDY

LMAT-type tumors are very rare and only 5 cases have been described in the literature so far therefore this case report seems particularly noteworthy.

MATERIALS AND METHODS

A 57-year-old patient was admitted to the Gynecology and Obstetrics Unit, Brothers of Mercy Hospital in Katowice for hysterectomy with bilateral salpingo-oophorectomy due to uterine myomata. The macroscopic examination of the surgical material revealed a polycystic tumor 5 cm in diameter with gelatinous contents and grey fibrous areas. The patient was discharged on postoperative day 4, in good general condition. A histological diagnosis of an atypical leiomyoadenomatoid tumor was established on the basis of the tissue material.

Primary undifferentiated small cell carcinoma (Merkel cell carcinoma) in a patient after heart transplantation--case report

Here we report a case of a 48-year-old man after heart transplantation in whom two years after the procedure an appendage germ tumour was diagnosed and a year after its removal in the same area a primary undifferentiated small cell carcinoma (Merkel cell carcinoma) with metastases to the axillary lymph nodes was detected. The diagnosis of Merkel cell carcinoma was confirmed by immunohistochemical staining showing a typical perinuclear expression of cytokeratin 20 with the absence of reactivity with wide spectrum cytokeratin and the presence of neuroendocrine markers of neurone-specific enolase and chromogranin. Primary undifferentiated small cell carcinoma occurs more frequently in patients receiving immunosuppressive treatment as compared with a general population and occurs much more frequently in those below 50 years of age.