Forensic pilot application of rehydrating solutions on human cadaveric skin: what are the effects on hemorrhagic infiltrates?

The microscopic evaluation of hemorrhagic infiltrates is crucial in forensic diagnostics, but it proves challenging in corificated and mummified cadavers. In these cases, pre-treatment with rehydrating solutions is recommended, although their effects on the hemorrhagic infiltrate are not well understood. In this pilot study, we microscopically investigated the effect of two different rehydrating solutions-Sandison's solution and fabric softener-on well-preserved human cadaveric skin samples taken from areas affected by an ecchymotic lesion, comparing them with direct fixation in formalin. Specifically, we examined the topographic distribution of the hemorrhagic infiltrate in each layer of the skin by assigning a semi-quantitative score, conducted mutual comparisons, and performed statistical analysis. Histologically, compared to direct fixation in formalin, a slight and statistically non-significant reduction in the hemorrhagic infiltrate was observed in samples pre-treated with fabric softener. On the other hand, a more pronounced and statistically significant decrease in scores was observed in samples pre-treated with Sandison's solution. This effect is likely due to the fact that Sandison's solution, due to its components, exerts an osmotic effect, partially inducing osmotic lysis of red blood cells. Overall, extensive areas of hemorrhagic infiltrates were preserved, although to a lesser extent, while smaller foci were markedly reduced, sometimes even disappearing. The findings suggest that Sandison's solution has a detrimental effect on cutaneous hemorrhagic infiltrates, emphasizing the importance of being cautious and conducting dual sampling, using both formalin and a rehydrating solution, for forensic examination of mummified or corificated skin samples.

Postmortem Diagnosis of Invasive Disseminated Aspergillosis After Tongue Piercing

ABSTRACT

Severe fungal infections caused by highly invasive fungi such as Aspergillus are not easy to diagnose and often have a poor prognosis. In these cases, the nonspecific symptoms may make clinical diagnosis challenging, and consequently, the autopsy and postmortem histological investigations acquire a crucial role. We report the case of a young man in good health who died of septic shock 3 weeks after having had a tongue piercing. Intravitam investigations did not identify the etiology of the rapidly fatal infectious condition. The autopsy revealed flaccid organs of uniformly diminished consistency with abscesses and granulomatous foci with central necrosis. Histological examination showed the presence of septate mycotic hyphae, with a dichotomous 45-degree bifurcation, typical for Aspergillus , in all the examined organs, including the tongue. The molecular identification confirmed the presence of Aspergillus fumigatus. The observed macroscopic framework and the laboratory findings made it possible to diagnose pseudomembranous invasive tracheobronchial aspergillosis and to attribute the death to fatal invasive disseminated aspergillosis. The consistency and concordance of all the findings in our possession led us to suspect the practice of piercing as the triggering cause of the man's pathology.

Visceral Microscopic Pattern From Suicidal Ingestion of Professional Lysoform® With Delayed Death

Lysoform® in the formulation of professional detergent is widely used in several fields, whereas its suicidal ingestion is an unusual occurrence. Therefore, the biological signs of this fatal poisoning remain unclear and elusive, similarly to the histological lesions induced by its main constituent, which is benzalkonium chloride (BZK). Furthermore, since all the deaths that has been reported in the literature occurred immediately, microscopic pictures of BZK lethal toxicity in subjects with prolonged survival have never been reported to date. Specifically, this brief communication reports the unique case of a woman who ingested professional Lysoform® to commit suicide, for which she died two weeks later. The autopsy examination showed either local or systemic signs of caustic ingestion; moreover, the histological analysis showed clear cellular damage of lungs, heart, and kidneys. In our case, toxicological investigations were not authorized as they were no longer considered significant. In this framework, the histological examination has therefore assumed a fundamental role in investigating and demonstrating the lethal effects caused by the systemic dissemination of BZK, which would otherwise no longer be investigable. Therefore, in cases of substance intoxication with prolonged survival where forensic toxicological investigations may be no longer possible or feasible, the histological examination may be the only resource to successfully observe and demonstrate its lethal effects.

AB1017 RADIOFREQUENCY ECHOGRAPHIC MULTI-SPECTROMETRY (REMS) AND DUAL-ENERGY X-RAYS ABSORPTIOMETRY FOR THE EVALUATION OF BONE MINERAL DENSITY IN A PERITONEAL DIALYSIS SETTING

Background

Radiofrequency echographic multi-spectrometry (REMS) is a novel ultrasound-based technique that has shown good reliability in the assessment of bone mineral density (BMD).

Objectives

The aim of this study was to compare the performance of the REMS BMD assessment with dual-energy X-rays absorptiometry (DXA) in a cohort of patients affected by end-stage renal disease undergoing peritoneal dialysis (PD).

Methods

Consecutive patients referring to the PD clinic of our hospital were enrolled. Lumbar spine and proximal femur REMS scans were performed, and lumbar spine (anteroposterior and laterolateral) and proximal femur DXA scans were performed as well. Clinical data were extracted from medical records. The risk assessment outputs of two fracture risk algorithms (FRAX and DeFRA), calculated upon the worst BMD obtained from either technique were compared as well. Analysis of variance (ANOVA) with post hoc analysis (Bonferroni) and a two-sided Student’s t-test were used to estimate the absolute differences between groups.

Written informed consent was obtained from all participants included (protocol 1483 CESC).

Results

41 total patients were enrolled (Table 1). No significant differences were documented between the BMD T-scores measured through DXA or REMS at the proximal femur. At the lumbar spine, the DXA laterolateral T-score was not significantly different from that of REMS, while the DXA anteroposterior T-score was significantly higher than both the anteroposterior DXA and the REMS measurements (Figure 1, panel A and B). When either DXA or REMS was adopted, no significant difference in the fracture risk estimate was found for both algorithms (Figure 1, panel C and D).

Table 1.

anthropometrics, clinical and biochemical characteristics of the enrolled sample. CKD, chronic kidney disease; PTH, parathyroid hormone; ALP, alkaline phosphatase; IQR, interquartile range; VFA, vertebral fracture assessment.

Sample size (M)41 (29)Age (y)Median [IQR]62 [52-73]Height (cm)Median [IQR]170 [165-176]Body weight (Kg)Median [IQR]74 [61-83]Body mass index (Kg/m2)Median [IQR]25 [22-27.8]Disease duration – CKD (months)Median [IQR]132 [48-140]Dialysis duration (months)Median [IQR]10 [3-24]S-calcium (mg/dL)Median [IQR]9.1 [8.6-9.4]S-phosphorous (mg/dL)Median [IQR]5.4 [4.6-6.4]PTH (pg/mL)Median [IQR]31.4 [22.8-46.8]25OH Vitamin D (nmol/L)Median [IQR]53 [36-72]Patients with morphometric fractures (VFA)15%Patients with femoral fractures2.4%Total n° of morphometric fractures12Figure 1.

comparison of the mean T-scores (error bars represent 95%CI) measured with DXA and REMS at the lumbar spine (panel A), and at the femur (panel B). Comparison between the DeFRA DXA and REMS-derived outputs (panel C) and FRAX DXA and REMS-derived outputs (panel D) raw and after correction for TBS. DeFRA, FRAX-derived risk assessment tool; FRAX, Fracture Risk Assessment tool; AP, anteroposterior; LL, latero-lateral; TH, total hip; FN, femoral neck; TBS, trabecular bone score.

Conclusion

Our data showed a good agreement, in a real-life PD setting, between the DXA and REMS-derived BMDs and in the consequent fracture risk assessment obtained with the FRAX or DeFRA tools.

Disclosure of Interests

Angelo Fassio: None declared, Stefano Andreola: None declared, Davide Gatti Paid instructor for: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB., Consultant of: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB., Matteo Gatti: None declared, Giovanni Gambaro Speakers bureau: Vifor Pharma, Maurizio Rossini Speakers bureau: Abiogen, Amgen, Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Grunenthal, MSD, Novartis, Pfizer, Sanofi, Sandoz, Theramex, UCB., Ombretta Viapiana: None declared, Giulia Zanetti: None declared, Francesca Pistillo: None declared, Valeri Messina: None declared, Giovanni Adami: None declared

AB1018 RELATIONSHIP BETWEEN AORTIC CALCIFICATIONS AND DXA AND RADIOFREQUENCY ECHOGRAPHIC MULTI-SPECTROMETRY (REMS) ACQUISITIONS

Background

Data on the relationship between peritoneal dialysis (PD), BMD and aortic calcifications (AOC) are lacking.

Objectives

to study the relationship between the degree of AOC and DXA and Radiofrequency Echographic Multi-Spectrometry (REMS) acquisitions.

Methods

Consecutive patients referring to the PD our clinic were enrolled. Lumbar spine (LS) and proximal femur REMS scans were performed, and LS (anteroposterior and laterolateral) and proximal femur DXA scans were performed as well. The degree of AOC was assessed through the semiquantitative score described by Kauppila et al, and applied to the laterolateral LS DXA scans. To test for correlations between different variables, we used the Pearson’s correlation for continuous variables and Spearman’s rho for discrete variables. Multiple regression analysis was performed to adjust for age and body mass index (BMI) the correlation between BMD and the CKD duration. Written informed consent was obtained from all participants (protocol 1483CESC).

Results

41 total patients were enrolled (29 males, 19 females). Median disease duration of CKD [IQR]: 132 months [48-140]. 15% had vertebral fractures at the DXA Vertebral Fracture Assessment (VFA). The median calcification score [IQR] was 2 [0-6] (min-max 0-20).

We found a statistically significant positive correlation of moderate strength between the total calcification score and the difference between the DXA AP T-score and the DXA LL T-score at the LS (p<0.01, Spearman’s rho = 0.402), Figure 1.

Figure 1.

scatter plot reporting the relationship between the difference between the AP and LL T-scores and the aortic calcifications score.

After adjustment for confounders, we found a significant negative between the LS and femoral neck BMD measured through REMS and CKD duration (Table 1). The same correlation was not significant then BMD was assessed with DXA.

Table 1.

multiple linear regression analysis for REMS T-score at each site after adjustment for age and BMI. BMI, body mass index; β, standardised coefficient.

REMS lumbar spine T-scoreβpCKD duration (months)-0.2280.035Age (years)-0.511<0.01BMI (kg/m2)0.566<0.01REMS femoral neck T-scoreβpCKD duration (months)-0.2100.04Age (years)-0.612<0.01BMI (kg/m2)0.484<0.01REMS total hip T-scoreβpCKD duration (months)-0.1530.219Age (years)-0.523<0.01BMI (kg/m2)0.560<0.01

Conclusion

Our study confirmed that the overestimation of DXA BMD assessed with the anteroposterior scan is indeed influenced by AOC. Furthermore, our data suggest that REMS might be an interesting tool for the investigation of bone changes in CKD.

Disclosure of Interests

Angelo Fassio: None declared, Stefano Andreola: None declared, Davide Gatti Speakers bureau: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB, Paid instructor for: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB, Matteo Gatti: None declared, Giovanni Gambaro Speakers bureau: Vitor Pharma, Ombretta Viapiana: None declared, Valeri Messina: None declared, Giulia Zanetti: None declared, Francesca Pistillo: None declared, Maurizio Rossini Speakers bureau: Abiogen, Amgen, Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Grunenthal, MSD, Novartis, Pfizer, Sanofi, Sandoz, Theramex, UCB., Giovanni Adami: None declared

Use of cadaveric vitreous humor as an innovative substrate for diatoms research and forensic diagnosis of drowning

The search for diatoms is the test that most of all may contribute to the forensic diagnosis of drowning. Diatoms can be extracted through different methods, which are all complex and long. In this preliminary study, we assessed human vitreous humor as an innovative substrate on which to research diatoms. Sampling and analyses were performed on 3 groups of 10 corpses each. The first one was composed of drowned victims. The second one of victims of traffic accidents with subsequent projection in water; based on the severe traumatic injuries reported at autopsy, we considered such victims as ideally assimilable to bodies immersed in water postmortem. The third group was composed of subjects who died for natural causes and without any relationship with water. The vitreous humor was centrifugated and cytocentrifuged and spotted on two different histological slides: one was left blank and the other one was assessed with hematoxylin and eosin staining. Microscopic observation successfully revealed diatoms in all cases of the first group; in the second group diatoms were not detected in 6 cases; in the third group, no diatoms at all were observed. Diatoms were always qualitatively and quantitatively consistent with those found in the corresponding viscera and waters, which had been investigated through classical acid digestion. Our analyses have demonstrated that the vitreous humor behaves in a completely similar way to the other viscera in cases of drowning. Although further investigations are necessary, vitreous humor has proved to be an innovative, suitable, and reliable substrate for the forensic research of diatoms.

Histotopography of haemorrhagic infiltration in the hanging cutaneous furrow: Where to look for haemorrhagic infiltration in hanging

The forensic evidence of hanging is based on the autopsy demonstration of the traces left by the noose or the ligature on the neck, as well as on the histological assessment of the hanging mark vitality. However, the specific topography of haemorrhagic infiltration in the context of the cervical damaged tissues involved in hanging is not known. We carried out an extensive microscopic examination to identify if haemorrhagic infiltration in hanging appeared in specific topographic locations that could have been considered as elective. From 102 victims of suicidal hanging, a skin fragment was sampled from the maximum compression area of the sulcus, including the skin portions immediately above and below it. The sampling was also extended to collect the subcutaneous adipose tissue and part of the striated muscle. A standard histological examination was performed on all the samples, and hematoxylin and Eosin, Weigert's resorcin-fuchsin and Goldner's Masson trichrome staining were performed. In all the cases assessed, the microscopic examination allowed the detection of haemorrhagic infiltration mainly in the deepest areas under the sulcus and especially in the deep dermis and at the transition point between the dermis and the subcutaneous adipose tissue, as well as in the context of its supporting connective tissue. Such areas could therefore be considered as regions in which the presence of haemorrhagic infiltration is more likely to be demonstrated. Accordingly, we recommend performing sampling similar to ours and focusing the search for haemorrhagic infiltration as suggested.

Paradoxal dyeing affinity's inversion of the connective tissue at Goldner's Masson trichrome staining as a peculiar characteristic of compressed and exsiccated cadaveric skin

The microscopic examination of a hanging cutaneous furrow, stained with Goldner's Masson trichrome staining, highlighted an abnormal dyeing inversion affinity of the connective tissue - red instead of green - located in the region of maximal cutaneous compression and exsiccation. To identify if this different stainability could be considered as an intrinsic characteristic of all biological tissues compressed and exsiccated, we have assessed different cadaveric skin samples that underwent traumatic detrimental phenomena that can produce such effects. We collected skin fragments from 24 corpses deceased because of gunshot injuries, electrocution, hanging, and heat-induced lesions, sampling the areas directly involved, as well as skin specimens to use as a control. The slides were stained with hematoxylin and eosin and two different protocols of Goldner's Masson trichrome staining (one homemade and one commercial kit). The inversion of the staining affinity of the connective tissue was observed in 83% of the cutaneous samples, using both the Goldner's Masson trichrome staining protocols. This phenomenon was not observed in any of the control cases. Therefore, the inversion of the staining affinity of the connective tissue dyed with Goldner's Masson trichrome staining may represent a histomorphological aspect that must be expected when the skin has been affected by specific detrimental modalities able of producing compression and exsiccation.

The frequently dismissed importance of properly sampling skin bruises

The correct interpretation of skin lesions is a crucial issue in forensic medicine. Many macroscopic and microscopic vital reaction markers and molecules have been studied in the past years in order to estimate the timing of injuries. However, literature lacks information regarding how to perform sampling to obtain a more reliable and accurate response. The present study investigates 25 bruises and analyses the different histological asset in different areas (central or marginal) and the different layers (epidermis, dermis, hypodermis and muscle) of the wound. All wounds were sampled in several areas and analysed under a 200× magnification optical microscope, simply counting the degree of haemorrhaging (i.e hematic infiltration) visible in each optical field (0 = 0%-5%; 1 = 6%-25%; 2 = 26%-50%; 3 = 51%-75%; 4 = 76%-100%). All the injuries presented some kind of infiltration in at least one area, nonetheless only 56% of the wounds were infiltrated in the entirety of the areas. Finally, in 28% the dermal layer did not show any trace of infiltration. Therefore, considering such results it seems that depth or area of sampling of a bruise may largely influence the evaluation of vitality and hence of age of a wound. Though this may seem intuitive, no studies have examined this issue in depth.

Histomorphological aspects of cadaveric skin and its possible use in forensic genetics

The skin is rarely considered as good biological material for successful DNA typing when a corpse is found in a leathery, mummified or partially skeletonised state, as bones and teeth are the gold standard in these cases. This study evaluates the histomorphological aspects of nuclear chromatin (Lillie's staining) in leathery and mummified skin samples as an indicator for possible successful DNA typing. Chromatin was found in samples that underwent mummification or partial skeletonisation but not in samples in a wet type of post-mortem transformation, such as saponification or leathery transformation. As a preliminary result, a positive detection of DNA profiles was only observed in 1-year-old mummified or partially skeletonised samples. These findings suggest that specific areas of skin, even from severely deteriorated cadavers, can show nuclear chromatin and DNA. These preliminary results raise the potential use of skin samples as an alternative source of DNA in highly degraded corpses.

Is it possible to detect lead derived from gunshot residues on decalcified human bone by means of a histochemical staining with sodium rhodizonate?

In this study we have evaluated the detectability of lead deriving from Gunshot Residues (GSR) on human bone using colorimetric techniques as well as the possible interferences of decalcification on the stainability of these particles. 22 well preserved cadavers were divided into two groups: group A enlisted 11 victims deceased because of gunshot injuries (bones and soft tissues sampled in correspondence of the entry wound of the bullet)- and group B, comprehending 11 victims deceased for natural causes (specimens sampled from intact skin areas). All the samples, after decalcification processes for bone specimens with a 14 % HCl solution, underwent standard histological procedures and were stained with hematoxylin and eosin (H&E), sodium rhodizonate (Na-R) and acidified sodium rhodizonate (Na-R-HCl 5 %). Two additional slides of soft tissues for each group were pre-treated with HCl 14 % before being stained with likewise staining. In group A, 10 samples out of 11 resulted to be negative to Na-R and Na-R-HCl 5% techniques while all the corresponding soft tissues resulted to be positive for the same staining. Additional soft tissue slides processed with 14 % HCl solution were negative in 10 cases out of 11. No sample in group B showed positivity to the staining procedures neither with nor without pre-treatment with 14 % HCl. The search for GSR residues on human bone is therefore not executable with Na-R and Na-R-HCl 5 % techniques since the essential decalcifying procedure modifies the stainability of the residues therefore adulterating the results.

Lethal cardiac amyloidosis: Microscopic differential diagnosis with microfibrillar cardiomyopathy in a forensic case

In a previous study, we presented a case of an elderly woman's sudden death, in which microscopic examinations showed intramyocardial eosinophilic material suspected for amyloid, but not definable as such to the classic Congo Red staining. To overcome the arisen interpretative and diagnostic difficulties, we experimentally modified the classic Congo Red staining, using a specific one for corpse. The finding of a low-intensity positivity allowed us to formulate a very likely diagnosis of occult lethal cardiac amyloidosis. However, this low-intensity positivity obtained after having applied this experimental method for the first time and in only one case, as well as the existence of the rare pathology known as microfibrillar cardiomyopathy, which may be related to the observed microscopic findings, have forced us to investigate the correctness of the diagnosis. For this purpose, we performed in-depth investigations with sodium sulphate-Alcian Blue (SAB) staining and immunohistochemistry. Thanks to them, the amyloid nature of the intramyocardial material was confirmed and has been proved not only the reliability of our experimentally modified technique, but also the appropriateness of the diagnosis previously formulated. Therefore, the supposed involvement of the microfibrillar cardiomyopathy was excluded.

A Pilot Study on the Diagnosis of Fatal Electrocution by the Detection of Myocardial Microhemorrhages

In electrocutions, death may be caused by alterations in the heart conduction system provoking ventricular fibrillation. This study aims to identify histological cardiac markers of high- and low-voltage electrocution. Two groups of decedents were evaluated: group A included 14 fatalities caused by high- or low-voltage electrocution and group B (control) included 14 fatalities due to other traumatic or disease causes. Myocardial sampling with microscopic examination was performed on all the hearts using the hematoxylin and eosin and Masson's trichrome stains to investigate morphological characteristics that could indicate the damage caused by high- and low-voltage electrocutions. Interstitial myocardial hemorrhagic infiltration was the only differentiating finding, which was shown only in high-voltage electrocution. This pathological finding has not been previously reported, and it may be specific to high-voltage electrocution deaths. Further studies are warranted.

Pulmonary thromboembolism secondary to pelvic thrombosis related to giant ovarian tumor

Pulmonary thromboembolism (PTE) is one of the major complications in oncologic patients. The incidence of PTE in these cases is 4 to 7 times higher than in non-oncologic patients. Ovarian tumors, specifically those of large sizes, may impair the blood flow through the pelvic veins as tumor pressure over the pelvic vessels increases the incidence of thrombosis. The authors report the case of the unexpected death of a 74-year-old female due to massive pulmonary thromboembolism, associated with an ovarian tumor almost of 15 kg of weight that filled the abdominal and pelvic cavities. The compressive effect on the walls of the pudendal and periuterine veins somehow facilitated the local thrombosis. According to the histological characterization on post-mortem samples, the mass was identified as an “atypical proliferative (borderline) mucinous tumor.” The case emphasizes the important association between pulmonary thromboembolism and ovarian tumors

Excision of Oral Leukoplakias by CO2 Laser on an Out-Patient Basis: A Useful Procedure for Prevention and Early Detection of Oral Carcinomas

Several epidemiologic studies have shown that oral cancer develops among individuals with a prior diagnosis of an oral premalignant lesion. Canceration chance in these patients is 17 %, with the greatest rate occuring in the second year of observation. Based on this data, since 1981, 92 leucoplakias have been treated by out-patient laser surgery at the Istituto Nazionale Tumori of Milano. The therapeutic technique was laser excision to obtain a specimen for histology. Two groups were distinguished according to the diagnostic procedure. Thirtythree lesions (December 1981 to December 1982) were operated on without preliminary histologic examination, on the basis of a simple clinical diagnosis. Since January 1983 all leukoplakias have been biopsied in a systematic way and those negative for cancer treated with laser. Histology of the specimen showed 5 squamous cell carcinomas (15 %) in the group of patients who did not undergo preoperative biopsy. Postoperative histology showed malignancy in 6 of 59 (10.2 %) cases in spite of negative preoperative biopsies. Speckled and erosive leukoplakias had the highest canceration rate. Three of 11 patients with cancer were treated by knife excision or interstitial needle implantation because of margins in tumoral tissue or because they were unvaluable for injury by heat. Results have been satisfactory, only 2 of 54 followed leukoplakias and none of the cancers recurred during a 2 year follow-up.

Lethal cardiac amyloidosis: Modification of the Congo Red technique on a forensic case

Congo Red staining is usually used in diagnosing amyloidosis, a pathology characterized by the storage of abnormal proteins in several human organs. When assessed on samples fixated in formalin and embended in paraffin, this staining can undergo several artefacts, causing diagnostic and interpretative difficulties due to its weak stainability and a consequent reduced visibility of the amyloid. These complications, in time, requested several variations of this staining technique, especially in clinical practice, while in the forensic field no protocols has ever been adapted to cadaveric samples, a material that is already characteristically burdened by a peculiar stainability. In our work, studying a sudden death caused by cardiac amyloidosis and diagnosed only with post-mortem exams, we present a modified Congo Red staining used with the purpose to demonstrate amyloid in cadaveric material after the unsuccessfully use of all standard protocols.

Impact of Distal Clearance Margin on Oncologic Outcome after Restorative Resection of the Rectum

There is considerable controversy about the distal clearance margin that needs to be maintained beyond the extent of a rectal tumor in order to reduce the risk of local recurrence. We investigated the rate of local recurrence, distant metastases and survival in 87 patients who had undergone radical restorative resection of the rectum for cancer and had been followed up for a median period of over 6 years, and we analyzed the statistical relation (log-rank test for trend) with the length of the distal margin. The distal margin length was divided into three categories: 1 cm, 2 cm, and ≥3 cm.

No significant correlation was found between the length of the distal clearance margin and the oncologic outcome. Taken together, our data suggest that if the resection line distally falls on healthy tissue, there is no need to resect additional rectum in order to achieve a better outcome.

Primary Mucoepidermoid Carcinoma of the Liver. A Case Report

The authors report a case of primary mucoepidermoid carcinoma of the liver in a 66-year-old woman. Electron microscopy findings suggest an origin from the biliary epithelium as well as cholangiocarcinoma, which clinical and prognostic features are similar to those of mucoepidermoid carcinoma.

A Light Microscopic and Ultrastructural Study of Two Cases of Fibrolamellar Hepatocellular Carcinoma

We describe two cases of fibrolamellar hepatocellular carcinoma of the liver in two young women. Both patients presented with diffuse intra-abdominal metastases; nevertheless they had a survival of 28 and 32 months, respectively, which sustains the better prognosis of this neoplasm. Electron microscopy of one case confirmed the oncocytic features of the neoplastic cells and showed intra- and intercellular duct-like vacuoles with numerous microvilli containing a microfilament core that terminated in a terminal web, which represents an unusual aspect in the spectrum of differentiation of fibrolamellar hepatocellular carcinoma.

A Clinico-Pathologic Study of Clear-Cell Hepatocellular Carcinoma

We reviewed the pathologic and clinical features of 7 cases of clear-cell hepatocellular carcinomas. Tumor cells had a typical clear, empty cytoplasm due to prominent accumulation of glycogen and lipid droplets, as demonstrated by ultrastructural study in one of our cases. Follow-up of the 7 patients did not confirm the better prognosis of this tumor reported by other investigators. The clinical course of our cases was more unfavorable than that of the other 130 cases of usual hepatocellular carcinomas treated at this Institute.

Risk of Colorectal Cancer following Colonoscopic Polypectomy

Aims and Background

To follow a cohort of patients who had undergone polypectomies in order to assess the overall risk of subsequent colorectal cancer in relation with various adenomas characteristics.

Methods

A total of 1,063 patients with adenomatous polyps of the large intestine were treated between 1979 and 1996 at the National Cancer Institute of Milan, during a screening program for colorectal carcinoma. Data on patients who had undergone colonoscopies were collected prospectively. The relation between colorectal cancer and adenomas characteristics was assessed by computing the hazard ratio (HR) values and corresponding confidence intervals (95% CI), according to Cox.

Results

Of the 1,063 patients who met the eligibility requirements, 672 had single adenomas (63.2%) and 391 had multiple adenomas (36.8%). Histological examination revealed 743 cases of tubular adenoma, 196 cases of tubulo-villous adenoma, and 96 cases of villous adenoma. High-grade dysplasia was found in 3.1% of the cases. During the 8,906 persons/year of follow-up, adenocarcinomas of the large bowel developed in 11 patients. Several adenomas’ characteristics at index polypectomy were significant predictors of colorectal cancer occurrence. In univariate analysis the risk of colon cancer was significantly related with multiple adenomas (HR 4.2, 95% CI 1.1-6.5), high-grade dysplasia adenomas (HR 10.0, 95% CI 2.6-38.1) and with adenomas larger than 2 cm (HR 5.0, 95% CI 1.2-20.4). A multivariate stepwise procedure confirmed that the presence of multiple adenomas and presence of high-grade dysplasia are the most important predictors of carcinomas. Hazard ratios for colorectal cancer occurrence, from multivariate Cox's model, were 5.1 (95% CI 1.2-19.9) for multiple compared to single adenomas, and 13.0 (95% CI 3.6-50.7) for adenomas with high-grade dysplasia compared to those with low-grade dysplasia.

Conclusions

High-grade dysplasia, number and size of adenomas were confirmed as the major cancer predictors. Based on this conclusion, a subgroup of patients, who may benefit from intensive surveillance colonoscopy, can be identifiable.

Inflammatory Pseudotumor of the Liver: Report of Two Cases

Inflammatory pseudotumor of the liver is a very rare lesion. Herein we describe two cases of this entity which occurred in two women aged 22 and 49 years, respectively. Both cases were considered to be clinically malignant and only the histopathologic examination revealed the non-neoplastic nature of the disease. Ultrastructural and immunohistochemical studies further supported the evidence of a reactive disease.

Immunohistochemical Study of Ten Cases of Argyrophilic Carcinoma (Carcinoid) of the Breast

The significance of argyrophilia in human breast cancer is still a controversial issue. We tested immunohistochemically 10 cases of argyrophilic carcinomas of the breast and found evidence of immunoreactivity with neuroendocrine markers: chromogranin, NSE, gastrin, insulin and bombesin. Argyrophilia was demonstrated in breast cancers of the usual types and was found to be related to the secretory activity of neoplastic cells. Unfortunately, no adequate follow-up data are available to clarify the natural history of argyrophilic breast cancer. A clinical treatment different from that of conventional breast cancer is not at present justified.

Abnormal Pattern of Mucin Secretion at the Resection Margin of Colorectal Carcinomas

In a retrospective study, we investigated 56 consecutive patients who had undergone radical intestinal resection for colorectal adenocarcinoma and who had developed local or distant recurrences of the disease. We found that the presence of a predominant sialomucin pattern at the margins of resection of the surgical specimen was correlated with a high percentage of local, endoluminal recurrence in the anastomotic mucosa. In contrast, no correlation could be found when the recurrences occurred in the outer tissues around the anastomosis or at some distance from it.

Monoclonal Antibodies MBr1 and MBr8 as Predictors of Response to Oophorectomy in Advanced Breast Cancer

The response to oophorectomy in 40 patients with advanced breast cancer was evaluated as a function of the presence or absence of the antigens recognized by the monoclonal antibodies MBrl, MBr8, and MOv2 on the cell surface of the primary tumor. Two groups (20 patients alive 5 years after oophorectomy and 20 patients who died within 5 years) were evaluated. These groups had a) the same distribution of lymph node status, diameter of the primary, and the presence of estrogen receptors at the time of first treatment and b) a comparable extent of the disease at the time of oophorectomy. The frequency of complete response after oophorectomy was significantly higher in patients whose tumors did not express the antigens recognized by antibodies MBrl and MBr8. Fourteen of the 22 patients with tumors not reacting with MBrl and 11 of the 18 negative to MBr8 had a complete response. There was no correlation with response and the monoclonal antibody MOv2. Both MBrl and MBr8 were present in 11 patients and both were absent in another 11. The simultaneous absence of the two antigens was related to the highest complete response rate (9 out of 11 patients).

Ileal Carcinoid Metastatic to the Breast. Report of a Case

We report a case of ileal carcinoid which clinically presented as a primary breast carcinoma. Review of the literature demonstrated only 9 cases of carcinoids metastatic to the breast. In spite of the rarity of this event, the differential diagnosis between primary and metastatic carcinoid of the breast should be considered in view of the different clinical management of these two settings.

Prognostic Effects of Lymph Node Micrometastases in Patients Undergoing Curative Gastrectomy for Cancer

Aims & background

It is not known whether the presence of micrometastases in the regional lymph nodes has an impact on the oncologic outcome of patients undergoing a curative (Ro) gastrectomy for cancer. The aim of the study was to assess the effects of the presence of micrometastases on survival.

Methods

We reviewed 29 patients operated on for curative (Ro) gastrectomy, with a final diagnosis of pN0, 16 or more lymph nodes in the specimen, and a follow-up of at least 4 years. The original hemotoxylin and eosin slides were reviewed, and a new section was cut from the lymph nodes and immunostained with a pool of antibodies against different types of cytokeratins. Micrometastases were detected in 5 patients (27.5% of the series) and 11 lymph nodes (1.51% of all removed lymph nodes).

Results

Mortality due to cancer progression occurred in 3 patients from the pN0 group (14.2%) and 1 patient from the pN1 group (12.5%).

Conclusions

There was no suggestion from the data that the presence of micrometastases carries an ominous prognosis in terms of survival.

Hormonal and Receptor Status in Postmenopausal Women with Endometrial Carcinoma before and after Treatment with Tamoxifen

Twenty-four patients with endometrial carcinoma received tamoxifen (Nolvadex) for 7 days. Before and after administration, circulating hormones (estradiol, testosterone, progesterone, gonadotropins FSH and LH) were evaluated. Estrogen (ER) and progesterone receptors (PgR) in neoplastic tissue were also assayed. Our results show a net increase in PgR content and a signicant decrease in gonadotropin levels after the treatment. The authors suggest that clinical trials be conducted using tamoxifen and progestins for adjuvant therapy after surgery of endometrial carcinoma and for the therapeutic approach of advanced carcinoma.

Topical Administration of Tetrasodium-Mesotetraphenyl-Porphinesulfonate (TPPS) and Red Light Irradiation for the Treatment of Superficial Neoplastic Lesions

In photodynamic therapy, systemic administration of photosensitizing agents induces cutaneous photosensitization in patients. This side-effect can be avoided by topical administration of the agents when only surface lesions are involved. A hydroalcoholic solution of tetrasodium-meso-tetraphenylporphinesulfonate (TPPS) containing Azone, a percutaneous penetration enhancer, was investigated to evaluate its photosensitizing potential in the treatment of 33 primary and recurrent neoplastic lesions of the skin. A complete remission was obtained of lesions with clinical thickness of less than 2 nun. Treatment effectiveness depends on both light and drug penetration through skin. Further studies are in progress to optimize treatment parameters.

Histopathological Characterization of a Novel Monoclonal Antibody, MLuC1, Reacting with Lung Carcinomas

A monoclonal antibody (MoAb), MLuC1, derived from the fusion of P3 - X63 - Ag 8 - U1 mouse myeloma cells with spleen cells from an HR mouse immunized with the carcinoma cell line SW626, was studied to define its reactivity profile on normal and neoplastic human tissues and its potential clinical applications in lung cancer. Evaluation of paraffin sections using the ABC immunoperoxidase method showed a « pan-epithelial » reactivity; a large majority of epithelial components of organs in the respiratory, digestive and urogenital systems (except liver, rectum and ovary) were immunostained. As regard to neoplastic tissues MLuC1 recognized 84 % of lung carcinomas (82 % of small cell, 100 % of squamous cell, 74 % of adenocarcinomas), 86 % of breast and 62 % of ovarian carcinomas. On the contrary, MLuC1 was non-reactive with the other normal and tumoral non-epithelial tissues. Due to its spectrum of reactivity this MoAb could be useful for different diagnostic purposes such as differential diagnosis and lung cancer cytology.

Surgical Treatment of Gastric Metastases from Cutaneous Melanoma: Experience of the National Cancer Institute of Milan

Aim

To evaluate the role of a surgical approach in patients affected with gastric metastases from cutaneous melanoma.

Methods

A retrospective review of our local melanoma database of 2100 patients identified 31 cases with gastric metastatic deposits. Nine of them were considered candidates for surgical resection.

Results

Median overall survival of the 9 patients who underwent surgery was 14.2 months. Six (67%) underwent a local radical resection of disease, and 3 (33%) had a simple exploratory laparotomy. The median survival was 21.6 months (range, 4-32 months) for the subset receiving radical surgery and 3.6 months (range, 2-6 months) for the patients who had no resection. Median follow-up was 14.2 months. No specific correlation of serologic LDH levels and final outcome, as documented elsewhere, was observed. A marked decreased or substantial remission of symptoms with an improvement in quality of life was observed in all radically resected patients.

Conclusions

Patients with gastric metastases from melanoma may benefit from surgery if all macroscopic disease can be removed. In addition, gastric resection in patients with symptomatic melanoma spread to the stomach provides important symptomatic palliation.

A Clinical and Pathologic Study of 34 Sarcomas of the Uterus

The clinical and pathologic features of 34 uterine sarcomas were studied to determine the natural history of the disease. Sixteen patients had leiomyosarcoma, five mixed mesodermal sarcoma, ten endometrial stromal sarcoma, two carcinosarcoma and one endolymphatic stromal myosis. The patients were treated without an unique protocol. At 3 years the actuarial relapse-free survival was 53.6 %: 68.4 % in stage I-II patients and 22.2 % in stage III-IV patients. As regards the histologic subtype mixed mesodermal sarcomas had the best prognosis; endometrial stromal sarcomas the worst. The necessity of a uniform clinical and histologic classification as well as the importance of controlled clinical trials are pointed out.

Preoperative Endoscopic Ultrasonography in Patients with Gastric Cancer

Aims and background

There is a need to assess the accuracy of endoscopic ultrasonography (EUS) in the diagnosis and staging of gastric cancer, especially in the early and very advanced stages of the disease when the therapeutic approach is still controversial.

Methods

A retrospective study was performed on 79 patients with gastric cancer in order to compare the stage defined by preoperative EUS with that assessed histopathologically. All patients underwent laparotomy for final diagnosis, staging, and eventually treatment. The results of EUS were correlated with the histologic findings of the resected specimens.

Results

In the uT1 group, which corresponds to early gastric cancer, the diagnosis was histologically confirmed in 85.7% of the cases. In patients with advanced tumors defined as uT3-uT4, i.e., tumors infiltrating the serosa or neighboring structures, the diagnostic concordance was 91.1%. In contrast, concordance for less advanced lesions confined to the muscular layer was only 31.2%. As regards the lymph nodes, they were defined metastatic in 31 patients and confirmed to be histologically involved in 77.4%. In contrast, when the lymph nodes were assessed as negative at EUS, they proved to be metastatic in more than half the cases.

Conclusions

From the data it appears that EUS has proven to be valuable in correctly staging most of the patients. EUS shows not only tumor depth and local spread but also the passage from a pathologic to a normal wall and lymph node metastasis. EUS appears to represent an important advance in the staging and follow-up of patients with gastric cancer. Instruments and techniques will continue to evolve, but the next level of research should be designed to show that the improved staging provided by EUS has clinical utility and can affect patient outcome. It is noteworthy that the highest accuracy of EUS has been shown in those conditions (uT1 and uT3-4) which currently are under consideration for a therapeutic approach that differs from the standard one.

Topical Administration of Tetrasodium-Mesotetraphenyl-Porphinesulfonate (TPPS): Correlation between Drug Penetration and Depth of Necrosis in Skin of Nude Mice following Red Light Irradiation

The main side effect in photodynamic therapy is photosensitization of the patient's skin following systemic administration of the photosensitizing agent. In the case of superficial lesions, this problem can be avoided by topically applying the drug: in this way a local treatment can be performed. We tested the photosensitizing properties of a 2 % solution of TPPS (tetrasodium-tetraphenylporphinesulfonate) in a vehicle containing a penetration enhancer, Azone, on skin of nude mice. An aliquot of 0.1 ml/cm2 of the solution was painted on the skin overlying an s.c. implanted NMU-1 tumor. Subsequently, animals were sacrificed at different times after application. Fluorescence microscopy revealed that TPPS penetration depth was related to time elapsed after application and to painting modalities. Solution penetration was enhanced by wiping with ether immediately before painting. Irradiation at 80 mW/cm2 for 20 min with a dye laser emitting at 640 am, 4 h after TPPS application, produced necrosis of the upper skin layers, up to 0.2 mm in depth. These findings suggest that topical TPPS administration, followed by laser irradiation, may be a suitable treatment modality for skin lesions involving epithelial layers, even though several aspects of this metodology need further investigation.

Double-Contrast Barium Enema and Computerised Tomography in the Pre-Operative Evaluation of Rectal Carcinoma: Are they Still Useful Diagnostic Procedures?

Purpose

In modern management of rectal carcinoma, the preoperative evaluation of disease parameters is important for selection of therapeutic options. Such parameters are currently defined through endorectal ultrasonography or endoscopic ultrasonography. A retrospective analysis of the parameters obtained with double-contrast barium enema (DCBE) and endorectal balloon computed tomography (CT) was conducted to verify the diagnostic reliability of the radiological techniques and to establish whether there is still an indication for their use.

Methods

53 consecutive patients with adenocarcinoma of the distal half of the rectal ampulla underwent double contrast barium enema examination and CT of the pelvis with endorectal balloon. On the basis of the DCBE and CT assessment we evaluated: 1) the distance between the cranial extremity of the anal canal and the distal margin of the neoplasm; 2) the radial diffusion of the tumor; 3) the metastatic involvement of the perirectal and inferior mesenteric lymph nodes.

Results

1) CT and DBCE measurements of the distal margin tended to coincide, but both tended to overestimate the measurement when compared to the pathologic examination; 2) in the identification of neoplastic infiltration of perirectal fat (T3) CT had 100% sensitivity, 78.7% specificity and 86.8% accuracy; 3) the CT sensitivity for detecting lymph node metastasis was 52.6%, specificity 85.3% and accuracy 73.6%.

Conclusions

The diagnostic information provided by the radiological examinations is comparable to that of clinical and instrumental methods currently employed for staging of rectal carcinoma, although the latter are preferred because they are more readily accessible and less costly. DCBE and CT can therefore be usefully employed for staging of cancer of the rectum in those cases in which there are limitations of the current standard methods.

A Light Microscopic and Ultrastructural Study of Spindle-Shaped Hepatocellular Carcinoma

Spindle-cell hepatocellular carcinoma is an unusual morphologic variant of hepatocellular carcinoma with a typical sarcomatous appearance. The exact diagnosis of this tumor may be difficult when only small biopsies are available and in the absence of ultrastructural studies. We describe two cases of hepatocellular carcinoma: one was entirely composed of spindle-shaped cells, and the other was a typical hepatocellular carcinoma with only a small area of sarcomatous, fusiform cells. In the first case, ultrastructural studies demonstrated desmosomes and many Mallory bodies and confirmed the epithelial nature of the neoplasm. In the second case, no ultrastructural studies were available, but the presence of gradual transition from liver cell carcinoma to spindle-cell carcinoma excludede the diagnosis of carcino-sarcoma.

Spontaneous Massive Necrosis of a Hepatocellular Carcinoma

A case of hepatocellular carcinoma that underwent total necrosis without previous chemotherapy is described. Histologic examination of the neoplasm revealed massive thrombosis of numerous peritumoral venous vessels in the adjacent normal liver. Although the importance of a newly formed arterial blood supply for the maintenance of the viability of hepatocellular carcinoma is unquestionable, this case suggests a similar importance of the venous drainage of the surrounding liver.

Hyperthermic Antiblastic Perfusion in the Treatment of Cancer of the Extremities

From February 1982 to December 1983, 42 patients affected by neoplasms of the limbs were treated at the Istituto Nazionale Tumori of Milan by hyperthermic antiblastic perfusion in extracorporeal circulation at the temperature of 40-41 °C for 1 h. Thirty-two were affected by melanoma, 4 by osteogenic sarcoma, 2 by squamous-cell carcinoma, 1 by liposarcoma, 1 by hemangiopericytoma, 1 by clear-cell sarcoma and 1 by Kaposis's sarcoma. As regards the immediate response, a complete plus partial remission rate of 88 % without any major complication was obtained. The follow-up period is too short for any considerations about overall survival. However, because of these good clinical results we consider this method able to locally control the evolution of neoplasms of the extremities, allowing in many cases a limb salvage.

Limb-Salvage Procedure in Two Patients with Spindle Cell Carcinoma of the Lower Extremities using Isolation Perfusion

Two patients with extensive squamous cell carcinoma of the lower extremities, candidate for demolitive surgery, were treated by hyperthermic antiblastic perfusion in extracorporeal circulation. The temperature reached was 41 degrees C and the drug used was methotrexate at the dosage of 500 mg. Radical excision of the ulcer was possible in the 2 patients. Both tumors underwent extensive necrosis, and histology done 1 month after perfusion on surgical specimens showed limited areas of residual malignancy. These 2 patients suggest that hyperthermic antiblastic perfusion may be a limb salvage procedure in the multimodal management of extended squamous cell carcinoma of the extremities.

A Retrospective Analysis of 53 Patients with Pathologic Stage II and III Endometrial Carcinoma

From 1969 to 1977, 53 patients with surgical-pathologic stages II and III endometrial carcinoma were seen at the Istituto Nazionale Tumori of Milan. The treatment was individualized. The 5-year survival was 68.8% in stage II and 75.3% in stage III. The relapse-free survival was 68.9% and 69.4%, respectively. Adjuvant type of radiotherapy, degree of differentiation, depth of myometrial invasion, and especially sites of disease were the factors influencing survival.

Decomposition and entomological colonization of charred bodies - a pilot study

Aim

To use forensic entomological approach to estimate the post mortem interval (PMI) in burnt remains.

Methods

Two experiments were performed in a field in the outskirts of Milan, in winter and summer 2007. Four 60-kg pigs were used: two for each experiment. One pig carcass was burnt until it reached the level 2-3 of the Glassman-Crow scale and the not-burnt carcass was used as a control. In order to describe the decomposition process and to collect the data useful for minimum PMI estimation, macroscopic, histological, and entomological analyses were performed.

Results

In the winter part of the experiment, the first insect activity on the burnt carcass began in the third week (Calliphora vomitoria) and at the beginning of the fourth week an increase in the number of species was observed. In the summer part, adult flies and first instar maggots (Phormia regina) appeared a few minutes/hours after the carcass exposure. Both in winter and summer, flies belonging to the first colonization wave (Calliphoridae) appeared on burnt and control pigs at the same time, whereas other species (Diptera and Coleoptera) appeared earlier on burnt pigs.

Conclusion

In forensic practice, burnt bodies are among the most neglected fields of entomological research, since they are supposed to be an inadequate substratum for insect colonization. Entomological approach for PMI estimation proved to be useful, although further studies on larger samples are needed.