Challenges and unmet needs of mothers of preschool children with autism spectrum disorders in Tunisia: a qualitative study

INTRODUCTION

Autism spectrum disorder (ASD) is a life-changing condition, not only for the child but also for the mother and the usual caregiver. In fact, a child recently diagnosed with ASD is a real challenge to mothers´ adaptation, involves their resources, and gives rise to a set of needs. This study explores the unmet needs and experiences of mothers of ASD children in the Tunisian context.

METHODS

a qualitative phenomenological design was chosen for this study and a semi-structured interview was used for eight mothers raising an autistic preschooler child.

RESULTS

the results indicate significant denial and rejection following the announcement of the diagnosis. To cope with this, reliance on religion has helped foster acceptance. Although informal support (from family and friends) has sometimes been mentioned, an increased need for training, social and financial support has been expressed and is a major concern given the high cost of TSA services.

CONCLUSION

this study provides a deeper understanding of mothers' needs following the announcement of the diagnosis of ASD. These unmet needs should be taken into account when designing interventions strategies for children with ASD to help mothers cope and parent a child with ASD.

Renal cell carcinoma with atypical metastases sites revealed by diabetes mellitus: A case report

INTRODUCTION AND IMPORTANCE

Lung, bone, lymph nodes and liver are the most common metastatic sites. This observation presents a metastatic renal cell carcinoma (RCC) with atypical secondary sites and a rare mode of revelation corresponding to diabetes mellitus.

CASE PRESENTATION

We report the case of a 64-year-old woman recently diagnosed with diabetes mellitus. A thoracic parietal nodule was palpated. An uro-CT scan had shown a renal tumor with unusual metastatic sites: pleura, pancreas, and contralateral kidney. The patient underwent a biopsy of the pleural nodule. The pathology report concluded to the diagnosis of clear cell RCC. She had a targeted therapy. Three months after admission, the patient had altered general condition and total hematuria.

CLINICAL DISCUSSION

RCC commonly metastasizes haematogenously via renal veins. Atypically, secondary lesions may involve pleura. Such a metastatic site may be of particular interest for percutaneous biopsy, as in our case. The rare metastatic invasion of the pancreas is most likely the cause of the inaugural diabetes in our patient. The controlateral kidney was involved in 1.4% of secondary lesions. For patients with poor prognosis, according to International Metastatic RCC Database Consortium classification, anti-angiogenic treatment is recommended. The median overall survival of patients with poor prognosis is 8 months.

CONCLUSIONS

Pancreas and contralateral kidney are rare secondary sites of RCC. The clinical expression of pancreas metastatic invasion can rarely fit with diabetes. Metastatic dissemination to these organs is most often associated with an unfavorable prognosis.

[Adenomatoid odontogenic tumor: about two cases]

La tumeur adénomatoïde odontogène est une tumeur épithéliale bénigne, qui touche essentiellement la femme jeune, elle siège habituellement dans la partie antérieure du maxillaire supérieur. Son diagnostic peut être suspecté cliniquement devant une formation kystique, associée à une dent incluse, mais la confirmation repose sur l'examen histopathologie. Il s'agit de deux patients précédemment de 13 et de 37 ans, sans antécédents, qui consultaient suite à une tuméfaction siégeant respectivement au niveau du maxillaire et au niveau de la mandibule. L'examen anatomo-pathologique de ces lésions avait conclu à une tumeur adénomatoïde odontogène. A travers ces deux observations, nous rapportons les caractéristiques anatomo-cliniques, l'évolution et le traitement de ce type de tumeur.

Neonatal cardiogenic shock revealing obstructive cardiac Hibernoma: case report

Background

Cardiac Hibernomas are very rare benign tumors and usually remain asymptomatic. Neonatal cardiogenic shock due to cardiac tumors is extremely very rare. Until this date a few cases of cardiac hibernoma have been reported in the literature.

Transthoracic echocardiography help in the differential diagnosis, but the definitive diagnosis is histological. The management strategy is not clearly codified.

The Aim is to report and discuss the clinical features of a cardiac Hibernoma and review the relevant literature.

Case presentation

We describe a case of a 2-day-old Caucasian full-term male neonate admitted in neonate intensive care with cardiogenic shock, having fluid resuscitation and inotropic drugs. Ventilatory support was started immediately with the subsequent reestablishment of normal blood pressure. Then he was transferred to the echocardiography laboratory.

Transthoracic echocardiography showed two echogenic masses in the right atrium and right ventricle.

The masses were extended to the pulmonary trunk. Pulmonary artery flow measurements showed the presence of pulmonary and tricuspid obstruction.

Surgery was rapidly considered since the baby was hemodynamically unstable.

Intraoperative evaluation showed a mass embedded in the interventricular septum that occupy the right ventricular cavity and the right atrium. The tumor involved also the chordae of the tricuspid. Partial resection was done. Tricuspid valve repair was performed by construction of new chordae from the autologous pericardium. The specimen was sent for histopathological analysis. The baby died immediately after surgery.

Histological examination of the surgical specimen revealed clear multivacuolated cells filled with lipid droplets and granular intense eosinophilic cytoplasm which confirms the diagnosis of Hibernoma.

Conclusion

Cardiac Hibernomas are rare benign tumors. The prognosis and treatment strategy is closely dependent on the location, initial clinical presentation and possible complications. The prognosis can be unfavorable if the tumor was obstructive and infiltrate the myocardium.

Histopathological diagnosis of strongyloidiasis hyperinfection in Tunisian patient with hodgkin lymphoma: Case report

Introduction

Strongyloides stercoralis, an intestinal nematode, is commonly dispersed throughout the tropical and subtropical regions. Strongyloides stercoralis infection typically contributes to an asymptomatic chronic disease which can remain hidden for decades. However, in immunocompromised patients, the hyperinfection can take place, causing high mortality rates.

Case presentation

A 45 year-old Tunisian women, with heavy medical history, suffering of stage 3 classic Hodgkin lymphoma under treatment; presented with complaints of epigastric pain, nausea, vomiting. Gastroduodenoscopy showed duodenal and gastric erythematous and ulcerated mucosa. Histological assessment showed chronic infiltration with a large amount of eosinophils around numerous helminth forms identified as larvae of Strongyloides stercoralis.

Conclusion

Early detection of Strongyloides stercoralis infection in immunocompromised patients is life saving and avoids fatality caused by hyperinfection or systemic dissemination. Routine stool examination may be negative, so histopathological identification of the parasite in tissue sections provides the definite diagnosis.

Inhabitual presentation of Sertoli-Leydig cell tumor of the ovary with xeroderma pigmentosum: Case report with review of literature

•

Sertoli-Leydig cell tumors are rare sex-cord stromal tumors of the ovary.

•

We present a case of Sertoli-Leydig cell tumors with rhabdomyomatous differentiation on the setting of xeroderma pigmentosum.

•

We describe clinical, gross and microscopic examinations for diagnosis and treatment.

Introduction

Sertoli-Leydig cell tumors (SLCTs) are rare sex-cord stromal tumors of the ovary. Heterologous components may be present, most commonly in the intermediate differentiated and poorly differentiated groups. Because of their scarcity, SLCTs with heterologous differentiation represent a challenge in both diagnosis and management, with limited available experience.

Presentation of case

We report a case of a 27-year-old, Tunisian woman, followed in the Dermatology Department since the age of six months for xeroderma pigmentosum, with a history of basal cell carcinoma of the face operated on several times. The patient presented with abdominal pain and bloating associated with a medium abundance ascites on physical exam. Ultrasound showed a large left adnexal mass associated with an elevated cancer antigen 125 on serological exam. The patient underwent unilateral salpingo-oophorectomy with resection of two omental nodules. Microscopic examination concluded to poorly differentiated Sertoli-Leydig tumor with rhabdomyomatous differentiation. Adjuvant chemotherapy was performed and there was no clinical evidence of tumor recurrence during the three years of follow-up.

Discussion

SLCTs with rhabdomyomatous differentiation on the setting of xeroderma pigmentosum are exceptional, microscopic diagnosis and management is challenging, considering the tumor scarcity.

Conclusion

Further case reports and retrospective studies are required to more understand the pathogenesis of SLCTs and to determine their optimal treatment regimen.

Investigation of Human Cytomegalovirus and Human Papillomavirus in Glioma

The study investigated the human cytomegalovirus (HCMV) and human papillomavirus (HPV) in gliomas. A retrospective study was conducted on 112 samples. HCMV was investigated by PCR, in situ hybridization (ISH) and immunohistochemistry. HPV was tested by PCR and DNA ISH. HCMV was identified in 60 gliomas, including 55 GBM. However, RNA ISH and immunohistochemistry failed to detect HCMV positivity. HPV was identified in 44 GBM. No significant relationship was identified between HCMV and HPV and tumour characteristics (p > 0.05). Our findings support the HCMV and HPV presence in gliomas. Further assays are required to more explore the potential efficient antiviral management.

Utility of the immunohistochemical analysis of DNA mismatch-repair proteins in endometrial hyperplasia

The utility of the expression lack of DNA mismatch-repair (MMR) proteins in the detection of Lynch syndrome in endometrial hyperplasia as precursor lesion of endometrial carcinoma has not been well-established. The study investigated the immunoexpression pattern of MMR proteins in endometrial hyperplasia from Tunisian patients. We carried out a retrospective study of 60 endometrial hyperplasias diagnosed among Tunisian patients. Expression of MLH1, MSH2, MSH6, and PMS2 proteins was performed by immunohistochemistry on whole-slide sections of archival tissues. Analysis of MLH1 promoter methylation and microsatellite alterations was conducted in appropriate cases. Microsatellite instability screening was assessed using the Bethesda panel, including BAT25, BAT26, D17S250, D2S123, and D5S346 markers. Expression of MMR proteins was observed in all hyperplasias without atypia as well as in 27 out of 29 atypical hyperplasias. Only two atypical hyperplasias exhibited expression loss of MMR proteins. A single case revealed MSH6 expression lack. Expression loss of MLH1 and PMS2 was identified in another atypical hyperplasia and was associated with hypermethylation of MLH1 promoter. This patient had no familial history of endometrial cancer at the diagnostic time. The two deficient MMR cases showed microsatellite stable pattern. In conclusion, only two endometrial hyperplasias displayed an altered pattern of MMR expression. Our results suggest the limited utility of the immunohistochemical analysis of MMR protein in the early detection of Lynch syndrome in Tunisian patients diagnosed with endometrial hyperplasias. Multicenter studies with larger sample size are needed to more explore these findings.

Signification of forkhead box A1 (FOXA1) expression in thyroid cancers

BACKGROUND

Forkhead box A1 (FOXA1) plays an important role in several tumors. This study investigated the potential role of FOXA1 expression in thyroid tumors. We conducted a retrospective study of 110 thyroid lesions and tumors diagnosed during 1995-2018. The expression of FOXA1 was analyzed by immunohistochemistry on archival material.

RESULTS

No FOXA1 immunostaining was observed in all cases of Graves' disease, Hashimoto's disease, multi-nodular goiter, and adenoma. FOXA1 expression was absent as well in all papillary and follicular carcinomas, Hurthle cell carcinoma, and undifferentiated sarcoma. Only three anaplastic carcinomas exhibited focally FOXA1 staining. However, FOXA1 was expressed in all medullary carcinomas. No significant correlation was found with all clinicopathological features (p > 0.05 for all). The pattern of FOXA1 staining was similar to that of calcitonin and chromogranin A (p = 0.04 and p = 0.003, respectively).

CONCLUSIONS

FOXA1 is expressed mostly in all medullary thyroid carcinomas. Hence, FOXA1 could serve as an additional marker for refining the diagnosis of medullary thyroid carcinoma.

Extranodal NK/T-cell lymphoma in Tunisia: clinicopathological features, immunophenotype and EBV infection

BACKGROUND

Extranodal NK/T-cell lymphomas (ENKTL) are rare non-Hodgkin's lymphomas with aggressive clinical behavior. ENKTL are frequently associated with the Epstein-Barr virus (EBV). Data on ENKTL in Africa and Arab world are extremely limited. The study investigated the clinicopathological characteristics, EBV infection, and immunophenotype of ENKTL in Tunisia. We conducted a retrospective study of ENKTL. Main clinicopathological features were reported. The expression of CD3, CD4, CD5, CD8, CD20, CD56, CD57, and Granzyme B were analyzed by immunohistochemistry. EBV infection was detected by IHC (LMP-1) and Epstein-Barr encoding region (EBER1/2) in situ hybridization.

RESULTS

A total of nine ENKTL were identified (mean age of 48 years and male-to-female ratio of 8:1). There were five nasal ENKTL, and the remaining four cases had extranasal involvement (palate, sub-mandibular gland, skin, and soft tissues of the ankle). The histopathology showed a lymphoid and pleomorphic proliferation characterized by images of angiocentrism. Strong and diffuse CD3 expression was observed in all cases. Tumor cells exhibited an expression of CD5 (two cases), CD8 (three cases), CD56 (six cases), CD57 (three cases), and Granzyme B (eight cases). All ENKTL cases were EBV-associated. Overall 5-year survival rate was 57%. Although six ENKTL were diagnosed at early clinical stages, the prognosis was unfavorable and associated with patient death in three cases.

CONCLUSIONS

ENKTL are exceptional in Tunisia with unfavorable outcome. Histopathological diagnosis remains challenging in clinical practice. However, a careful histopathological examination combined with a correct interpretation of immunohistochemistry and in situ hybridization results refines the ENKTL diagnosis.

Soft tissue leiomyosarcoma-diagnostics, management, and prognosis: Data of the registry cancer of the center of Tunisia

Background:

Soft tissue leiomyosarcomas are rare, accounting for almost 5%–10% of all soft tissue sarcomas; they account for almost 1% of all sarcomas. They are aggressive tumors where location, size, and management require a multidisciplinary approach. Since there are few series published, we here analyze epidemiological pattern, clinical and pathologic features of soft tissue leiomyosarcomas.

Methods:

We conducted a retrospective study of 29 consecutive cases of histologically proven soft tissue leiomyosarcoma extracted from the database of the Cancer Registry of the Center of Tunisia and the Department of Pathology of Farhat Hached University Hospital of Sousse of Tunisia, during a 10-year period (from January 1996 to December 2005). Epidemiologic details, clinico-pathological features, and treatment modalities were assessed with focus on patients’ 5-year overall survival, tumor relapse, and metastases.

Results:

Soft tissue leiomyosarcoma accounted for 17.5% of all soft tissue sarcomas diagnosed at our pathology department. Most of patients were of advanced age (median: 52 years), with extremes ranging from 12 and 87 years. There was a slight male predominance (sex-ratio = 1.07). Tumors were located mostly in the lower limbs (45%). Deep sites as retroperitoneum was found only in two cases. Tumor size was more than 5 cm in 83% of cases (average size = 9.4 cm). Five cases had metastasis on initial staging. For 24 patients, the disease was locally limited at the moment of diagnosis. Palliative chemotherapy was indicated for four patients and surgery was performed for 20 patients. Local recurrence occurred in 11 patients (55% of operated patients) and metastasis in 6 patients. Overall, 5-year survival was about 24%.

Conclusion:

Our study results highlight the scarcity of soft tissue leiomyosarcoma. Unfortunately, unusual tumor sites, disease’s advanced stages, and intralesional resection made the prognosis poorer than in other series. Clinical course of soft tissue leiomyosarcoma was highly marked by local recurrence and metastasis.

Immunohistochemical analysis of c-erbB-2, Bcl-2, p53, p21WAF1/Cip1, p63 and Ki-67 expression in hydatidiform moles

Hydatidiform moles (HM) are characterized by an abnormal proliferating trophoblast with a potential for a malignant transformation. Similar to other human tumors, trophoblastic pathogenesis is likely a multistep process involving several molecular and genetic alterations. The study was performed to investigate the expression patterns of c-erbB-2 and Bcl-2 oncoproteins, p53, p21^WAF1/CIP1 and p63 tumor suppressor proteins and Ki-67 cell proliferation marker in HM. We conducted a retrospective study of 220 gestational products, including 39 hydropic abortions (HA), 41 partial HM (PHM) and 140 complete HM (CHM). The expression of c-erbB-2, Bcl-2, p53, p21^WAF1/CIP1, p63 and Ki-67 was investigated by immunohistochemistry on archival tissues. c-erbB-2 expression was observed in three PHM and 10 CHM. Bcl-2 immunostaining was significantly higher in PHM (61%) and CHM (70.7%) compared with HA (7.7%, p =  0.001 and p <  0.0001, respectively). p53 expression was stronger in CHM (73.6%) compared with PHM (24.4%, p < 0.0001) and HA (12.8%, p < 0.0001). p21^WAF1/CIP1 staining was observed as well in molar and non-molar gestations (p >  0.05). p63 immunoexpression was significantly described in CHM (85.7%) and PHM (78%) compared with HA (10.2%, p < 0.0001 and p = 0.0001, respectively). Ki-67 was significantly expressed in CHM (72.1%) compared with HA (46.2%, p = 0.005). Altered expression of Bcl-2, p53, p63 and Ki-67 reflects the HM pathological development. Immunohistochemical analysis is beneficial to recognize the HM molecular and pathogenic mechanisms. Furthermore, it could serve as a useful adjunct to conventional methods for refining HM diagnosis.

HPV infection and p16INK4A and TP53 expression in rare cancers of the uterine cervix

Cervix cancer remains among most commonly diagnosed cancer in developing countries. Except squamous cell carcinoma and adenocarcinoma, the etiopathology and oncogenic mechanisms of rare cancers remain largely unknown. The study was performed to investigate the value of HPV infection and the expression of p16^INK4A and TP53 in rare primitive cancers of the cervix. We conducted a retrospective study of rare primitive cancers of the cervix. Main clinicopathological features were reported. HPV infection was detected by in situ hybridization. Expression of p16^INK4A and TP53 was analyzed by immunohistochemistry. Overall, seven cases were identified, including basaloid squamous cell carcinoma (BSCC, n = 2), small cell neuroendocrine carcinoma (SCNEC), granulocytic sarcoma without acute myeloid leukemia, leiomyosarcoma, primitive neuroectodermal tumor and botryoid-type embryonic rhabdomyosarcoma. The mean age of patients was 53.7 years. Four cancers were diagnosed at advanced stages. The prognosis was unfavorable and associated with patient death in five cases. HPV types 16/18 were detected in BSCCs and SCNEC. Strong and diffuse p16^INK4A overexpression was described in the nucleus and the cytoplasm of all tumor cells of BSCCs and SCNEC. The remaining cancers exhibited only scattered and focal p16^INK4A staining. Mutated TP53 protein was detected in BSCC (case 1) and GS. Rare cancers of the cervix are aggressive and associated with poor prognosis. In contrast to mesenchymal tumors, BSCCs and SCNEC are etiologically related to high-risk HPV infection and could be identified by block positive p16^INK4A overexpression as common cancers of the cervix. TP53 mutations are not a negligible genetic event in rare cervical cancers.

Prognostic Factors of Prostate Cancer in Tunisian Men: Immunohistochemical Study

BACKGROUND

Prostate cancer is the second most common male cancer and remains a leading cause of cancer death worldwide. Heterogeneity regarding recurrence, tumor progression and therapeutic response reflects the inadequacy of traditional prognostic factors and underlies interest in new genetic and molecular markers. In this work, we studied the prognostic value of the expression of 9 proteins, Ki-67, p53, Bcl-2, PSA, HER2, E-cadherin, p21WAF1/Cip1, p27Kip1 and p16ink4a in prostate cancer.

MATERIALS AND METHODS

We conducted a retrospective study of 50 prostate cancers diagnosed in Pathology Department of Farhet Hached Hospital, Sousse, Tunisia, during a period of 12 months. Clinico-pathological data and survival were investigated. Protein expression was analyzed by immunohistochemistry on archived material.

RESULTS

Expression or over-expression of Ki-67, p53, Bcl-2, PSA, HER2, E-Cadherin, p21WAF1/Cip1, p27Kip1 and p16ink4a was observed in 68%, 24%, 32%, 78%, 12%, 90%, 20%, 44% and 56% of cases, respectively. Overall five-year survival was 68%. A statistically significant correlation was observed between death occurrence and advanced age (p=0.018), degree of tumor differentiation (p=0.0001), perineural invasion (p=0.016) and metastasis occurrence (p=0.05). Death occurrence was significantly correlated with the expression of p53 (p=0.007), Bcl-2 (p=0.02), Ki-67 (p=0.05) and p27Kip1 (p=0.04).

CONCLUSIONS

The p53, Bcl-2, Ki-67 and p27Kip1 proteins may be useful additional prognostic markers for prostate cancer. The use of these proteins in clinical practice can improve prognosis prediction, disease screening and treatment response of prostatic cancer.

p16INK4A expression in squamous cell carcinomas of the vagina and the vulva in Tunisian women

BACKGROUND

The role of p16INK4A expression in uterine cervix cancer is well established. In the remaining female lower genital tract cancers, the importance of p16INK4A up-regulation is less clear. In our study, we analyzed the role of p16INK4A expression and HPV infection in carcinomas of the vulva and the vagina in Tunisian women.

MATERIALS AND METHODS

We conducted a retrospective study of 30 carcinomas including 15 vulvar squamous cell carcinomas (SCCs) and 15 vaginal SCCs. Immunohistochemistry was used to determine p16INK4A expression. HPV detection and typing was by in situ hybridization.

RESULTS

p16INK4A expression was detected in 86.7% of vaginal SCCs with a strong and diffuse immunostaining in 60% of cases, and also in 73.3% of vulvar SCCs with focal immunoreactivity in 53.3% The association between p16INK4A expression and HPV infection was significant in vaginal SCCs (p=0.001) but not vulvar SCCs (p>0.05).

CONCLUSIONS

p16INK4A expression could be used as a useful marker for HPV positivity in vaginal SCCs similar to that described in uterine cervix cancers. However, our data support the presence of 2 different mechanisms for p16INK4A expression in HPV-related and HPV-unrelated vulvar carcinomas.

Om.breast cancer in very young women aged 25 year-old or below in the center of Tunisia and review of the literature

Breast cancer in very young women under 40 or 35 years attracted a widespread attention. Few studies have focused on women aged below 25 years. The aim of this study was to evaluate the situation of breast cancer in women ≤25 years in the center of Tunisia. Retrospective review from 1993 to 2013. Clinical, histopathological, therapeutic and outcome data were recorded. Cases were classified into different molecular subtypes based on the immunohistochemistry-based definitions. The series included 25 patients. The mean duration of symptoms was 7.5 months. The most common presenting symptom was a palpable mass. Four patients had at least one relative diagnosed with breast cancer. Mammography combined with ultrasound was suggestive of malignancy in 60 % of cases. Curative surgical treatment could be offered in 19 cases. The mean tumor size was 39 mm. Nodal metastases were detected in 9/18 cases. Twenty cases could be classified into: luminal A (5 cases), luminal B (6 cases), Her-2 (1 case), triple negative (6 cases) and unclassified (2 cases). Two women experienced locoregional recurrence and 6 had distant recurrence. Asynchronous contralateral breast cancer occurred in one case. The overall survival at 5 and 10 years was 85 and 75 % respectively. The survival was significantly lower in grade III tumors (p = 0.04) and triple negative tumors (p = 0.03). Breast cancer in women ≤25 years is uncommon. An adequate medical education of young women and physicians is necessary.

HER2 expression in ovarian mucinous carcinomas in Tunisia

BACKGROUND

Ovarian mucinous carcinoma has a poor prognosis in advanced stages and a poor response to conventional chemotherapy. An efficient treatment is not yet available. We heere investigated HER2 expression and the potential for trastuzumab therapy in ovarian mucinous tumors.

MATERIALS AND METHODS

Immunohistochemistry was performed in formalin-fixed, paraffin-embedded tissue from 27 ovarian mucinous tumors including 14 carcinomas and 13 borderline tumors diagnosed in the Pathology Department, Farhet Hached Hospital, Sousse, between 1993 and 2013. The HercepTest (DAKO) was used for immunohistochemistry.

RESULTS

HER2 expression was observed in only one borderline tumor (7.7%) and in 14.3% of mucinous carcinomas of the ovary.

CONCLUSIONS

Our results suggest that trastuzumab therapy would be an option for patients with mucinous carcinoma when the tumor has HER2 overexpression.

Effect of chemotherapy on autoimmune hepatitis in thymoma: a case report and literature review

Autoimmune hepatitis (AIH) has rarely been described as an autoimmune paraneoplastic syndrome of thymoma. This case is the seventh case of AIH revealed by cholestasis few years after the diagnosis of thymoma and the first case treated with chemotherapy alone. We report in this paper a new approach to this rare severe condition. A 29 year-old man presented with chest pain and dyspnea with a history of thymoma surgically removed 4 years ago. CT scan showed the recurrence of an anterior mediastinal mass. Biology showed elevated liver enzymes and profound cholestasis. No sign of viral or toxic hepatitis or bile duct abnormalities were observed. Autoimmune antibodies, except for the anti-nuclear antibody, were negative. Liver biopsy showed active chronic AIH. The patient was diagnosed with recurrent thymoma with AIH and underwent 6 cycles of chemotherapy. A complete response on thymoma and cholestasis was obtained after 10 months of follow-up. Steroids and immunosuppressors are the standard treatment for AIH. The effect of chemotherapy as a specific treatment of this paraneoplastic syndrome needs to be considered.

NLRP7 mutation analysis in sporadic hydatidiform moles in Tunisian patients: NLRP7 and sporadic mole

CONTEXT

Hydatidiform mole, an aberrant human pregnancy, is commonly a nonrecurrent disease. Recently, a rare autosomal recessive form of familial and/or recurrent molar pregnancies was associated with mutations in the NLRP7 gene.

OBJECTIVE

To investigate whether NLRP7 mutations exist in Tunisian women with sporadic hydatidiform moles.

DESIGN

Genomic DNA from 38 unrelated Tunisian patients with sporadic hydatidiform moles were screened by sequencing all NLRP7 exons. A high-resolution melting curve analysis was performed on 170 DNA controls to analyze new sequence variants.

RESULTS

More than 13% of these patients were heterozygous for NLRP7 mutations. We found 2 novel missense mutations in the heterozygous state, c.544G>A (p.Val182Met) in 1 patient and c.1480G>A (p.Ala494Thr) in 2 patients, and 2 already reported mutations, c.1532A>G (p.Lys511Arg) and c.2156C>T (p.Ala719Val), in 2 patients. None of these mutations were identified in 170 controls except for 1 woman who was heterozygous for p.Val182Met.

CONCLUSION

As homozygous NLRP7 mutations are associated with recurrent hydatidiform mole or conception loss, the heterozygous state could represent a risk factor for nonrecurrent mole.

[Congenital laryngeal cyst: an uncommon cause of stridor in neonates]

Laryngeal cyst is a rare but generally benign lesion in the larynx. It may cause stridor and life-threatening airway obstruction in early infancy. We report the case of a neonate who developed respiratory distress 24h after birth in relation with materno-fetal infection. Airway obstruction was then suspected because of stridor. A laryngeal mass was discovered at the time of intubation. The infant experienced a nosocomial infection and died on day 14 of life before any surgical treatment. Autopsy concluded in an epiglottic congenital laryngeal cyst.

Colorectal cancer in Central Tunisia: increasing incidence trends over a 15-year period

INTRODUCTION

Significant variation in colorectal cancer incidence rates and trends has been observed across countries. Data from Tunisia are sparse. In this paper, we analyzed trends in incidence rates of the colorectal cancer over a 15-year period, 1993-2007, in Central Tunisia.

DESIGN

Five-year age-specific rates, crude incidence rates, world age-standardized rates, and annual percent change were calculated using annual data on population size and its estimated age structure.

RESULTS

A total of 1,443 incident cases of colorectal cancer were registered, with a male to-female sex ratio of 1.1:1. The world age-standardized rate was 10.0 per 100,000 among females and 11.7 among males. Over time, there were significant increasing trends by +2.6% (95% CI: 0.1%, 5.1%) and +5.3% (95% CI: 2.7%, 7.9%) for females and males, respectively.

CONCLUSION

The absence of a screening program for colorectal cancer could explain the increasing trends observed among males and females in Central Tunisia. Our findings point the need to plan and develop effective programs aimed at the control and prevention of the spread of colorectal cancer in Tunisia.

Breast cancer in Tunisia: clinical and pathological findings

INTRODUCTION

The aim of this study was to survey the clinical and pathological features of breast cancer in the Center of Tunisia.

DESIGN

Characteristics of all breast cancer cases diagnosed in the Pathology Department, Farhet Hached Hospital, Sousse, Tunisia during a 15-year period (1993-2007) were analyzed.

RESULTS

A total of 2,404 new cases of breast cancer were recorded, only 48 being diagnosed in men. The age-standardized incidence rate was 0.7 and 29.2 per 100,000 in men and women, respectively, with median ages of 48.0 and 64.5 years. Invasive ductal carcinoma was the most common (2,012 cases). Stage II was the most frequent (47.7%) followed by advanced stages (Stage III and IV, 41%).

CONCLUSION

Cancer of the breast remains the most common cancer in the absence of specific screening measures among Tunisian women. Our study justifies the need to plan and develop effective programs aiming at the control and prevention of the spread of breast cancer in Tunisia.

Lung cancer in central Tunisia: epidemiology and clinicopathological features

Lung cancer is the most common cancer worldwide but data from Tunisia are limited. The aim of this research was to describe the epidemiology, pathology and clinical features of lung cancer in Central Tunisia. All lung cancer cases diagnosed during a 15-year period were analyzed based on the data of the Cancer Registry of the Center of Tunisia. Five-year age-specific rates, world age-standardized rates (ASR), and annual percent change were calculated using annual data on population size and the estimated age structure. A total of 1,882 incident cases of lung cancer were registered (1,782 males, 100 females). The median age at diagnosis was 64 years for males and 61 years for females, with ASRs of 35.2 per 100,000 among males and 1.5 among females. Over time, there were significant decreasing trends by -6.5% (95% CI: -12.9%; -0.2%) for females and a stable incidence for males at an annual rate of +0.2% (95% CI: -1.6%; +1.8%). The predominant histological type was squamous cell carcinoma in males (36.9%) and adenocarcinoma in females (52%). During 2003-2007, adenocarcinoma became the most frequent (33.7%) followed by squamous cell carcinoma (30.3%) in males. The majority of tumor cases were diagnosed at advanced stages (79.9%). In conclusion, lung cancer has remained the most common cancer diagnosed at advanced stages among Tunisian men. Our findings justify the need to plan and develop effective programs aiming at the control and prevention of the spread of lung cancer in Tunisia.

Cancer of corpus uteri in Tunisia: epidemiological and clinicopathological features

INTRODUCTION

The aim of this study was to survey for the first time the burden and characteristics of corpus uteri cancers in Central Tunisia.

DESIGN

Characteristics of all cancer cases diagnosed during a 15-year period were analyzed based on the data of the Cancer Registry of the Center of Tunisia. Five-year age-specific rates, crude incidence rates, world age-standardized rates (ASR), and annual percent change (APC) were calculated using annual data on population size and its estimated age structure.

RESULTS

A total of 218 new cases of corpus uteri cancer were recorded. The ASR was 3.1 per 100,000 with a significant increase over time (APC: +7.1%; 95% CI: 3.1%, 11.1%). The median age at diagnosis was 60 years and only 20.6% of patients were less than 50 years old. The tumor size was higher than 2 cm in 83.5% of cases. Stage I was the most frequent (59.9%) followed by advanced stages (23.2%). Endometrial adenocarcinoma was the most frequent histological type (62.8%) with grade II accounting for 48.5% of cases.

CONCLUSION

Corpus uteri cancer is an important female cancer with increasing trend over time. These findings justify the need to plan and develop effective programs aiming at the control of the spread of cancer in Tunisia.

Childhood cancer frequency in the center of Tunisia

OBJECTIVE

In this paper, we analyzed the frequency of childhood cancer in the Center of Tunisia during 1993-2006.

DESIGN

The different types of cancer were grouped according to the International Classification for Cancer in Children. The general and specific frequencies by age and by sex were analyzed.

RESULTS

A total of 727 new cases of childhood cancer were registered, with a male to-female sex ratio of 1.7/1. Leukemias had the highest frequency (27%) and, of these, lymphoid leukemias were the most prevalent (73.5%). Thereafter, in descending order of frequency, were lymphomas (25.7%), tumors of the central nervous system (CNS, 9.2%), neuroblastomas (7.7%), sarcomas (6.9%), carcinomas (6.3%), bone tumors (5.8%), nephroblastomas (5.5%), and germinal cell tumors (2.6%). The highest frequency of cancer was found at age 10-14 years (34.9%). Leukemias were the most frequent in age groups 1-4 and 5-9 years, whereas, neuroblastomas and lymphomas were the most frequent at age under one year and 10-14 years, respectively. Of those cases of solid tumors, 55.8% were diagnosed as having advanced stages of the disease.

CONCLUSION

Leukemias, lymphomas, and CNS tumors were the principal cancers in the Center of Tunisia. A childhood cancer registry with high-resolution data collection is advocated for in-depth analysis of pediatric malignancies.

Promoter hypermethylation of CDH13, DAPK1 and TWIST1 genes in precancerous and cancerous lesions of the uterine cervix

Aberrant DNA methylation is an early event in carcinogenesis and could serve as an additional molecular marker for the early diagnosis. The study was performed to investigate the promoter methylation of DAPK1, CDH13, and TWIST1 genes in uterine cervix lesions in an effort to examine whether this epigenetic event is involved in the process of cervical carcinogenesis, and whether it might be used as a molecular marker of cervical lesions. We conducted a retrospective study of 60 uterine cervix specimens, including 8 normal tissue samples, 10 benign lesions, 28 precancerous lesions (CIN1-3), and 14 squamous cell carcinomas (SCC). DNA hypermethylation was investigated using methylation-specific PCR. Immunohistochemistry was used to find p16(INK4A) overexpression. No hypermethylated promoters were detected in normal tissues and benign lesions. However, promoter hypermethylation of CDH13, TWIST1, and DAPK1 increased progressively from CIN1 to cancer, reaching values higher than 50% for cancer. DAPK1 and CDH13 displayed a significantly increased frequency of promoter methylation with progressively more severe cervical neoplasia (p<0.05). A statistically significant association was observed between p16(INK4A) expression and hypermethylation of DAPK1, TWIST1, and CDH13 (p<0.0001). Hypermethylation of CDH13, DAPK1, and TWIST1 promoters is an early event in the initiation and progression of cervix neoplasia. CDH13, DAPK1, and TWIST1 genes are potential biomarkers of cervical cancer risk.

Trends in the incidence of cancer in the Sousse region, Tunisia, 1993-2006

In this article, we analyzed trends in incidence rates of the major cancer sites for a 14-year period, 1993-2006, in the Sousse region localized in the centre of Tunisia. Five-year age-specific rates, crude incidence rates (CR), world age-standardized rates (ASR), percent change (PC) and annual percent change (APC) were calculated using annual data on population size and its estimated age structure. A total of 6,975 incident cases of cancer were registered, with a male to-female sex ratio of 1.4:1. ASRs showed stable trends (-0.1% in males, and +1.0% in females). The leading cancer sites in rank were lung, breast, lymphoma, colon-rectum, bladder, prostate, leukemia, stomach and cervix uteri. For males, the incidence rates of lung, bladder and prostate cancers remained stable over time. While, cancers of colon-rectum showed a marked increase in incidence (APC: +4.8%; 95% CI: 1.2%, 8.4%) and non-Hodgkin's lymphoma (NHL) showed a notable decline (APC: -4.4%; 95% CI: -8.2, -0.6). For females, cancers of the breast (APC: +2.2%; 95% CI: 0.4%, 4.0%) and corpus uteri (APC: +7.4%; 95% CI: 2.8%, 12.0%) showed a marked increase in incidence during the study period, while the cervix uteri cancer decreased significantly (APC: -6.1%; 95% CI: -9.2%, -3.0%). The results underline the increasing importance of cancer as a cause of mortality and morbidity in Tunisia. Our findings justify the need to develop effective program aiming at the control and prevention of the spread of cancer amongst Tunisian population.

Pediatric rhabdomyosarcomas in Tunisia

INTRODUCTION

Rhabdomyosarcoma is the most common soft tissue sarcoma in the first two decades of life. Since there is a paucity of reports on the pattern of its occurrence in Tunisia, we here analysed the epidemiological pattern, clinical features, and pathology.

DESIGN

We retrospectively studied 30 consecutive cases of histologically proven rhabdomyosarcoma in children aged 0-15 years extracted from the database of the Cancer Registry of the Center of Tunisia for the period 1993-2007.

RESULTS

Rhabdomyosarcomas represented 53.6% of soft tissue sarcomas and 3.8% of all children cancer cases registered during this period. The male/female ratio was 2.7 with a mean age at diagnosis of 5.9 years. The embryonal subtype was the most frequent (60%) and the two most common sites of disease were the head and neck (50%) and genito-urinary tract(23.3%). Chemotherapy was used in 90% of patients; 43.3% of patients had radical surgery and 26.7% of patients received radiation therapy.

CONCLUSION

The epidemiology, pathology and clinical features of rhabdomyosarcoma in Tunisian children are close to those reported from other countries.

Global DNA methylation in precancerous and cancerous lesions of the uterine cervix

INTRODUCTION

Persistent human papillomavirus (HPV) infection is the primary causal agent in the development of the uterine cervix carcinoma. Nevertheless, only a minority of high-risk HPV-associated lesions progress to cervical cancer, suggesting involvement of other molecular alterations. Among putative changes, aberrant methylation might be a crucial event.

DESIGN

Paraffin-embedded samples of benign lesions, cervical intraepithelial neoplasia (CIN) and invasive squamous cell carcinomas (SCC) were analyzed for DNA 5-methylcytosine content by immunohistochemistry with anti-5-methylcytosine antibodies and by high-performance liquid capillary electrophoresis (HPCE).

RESULTS

No significant difference of DNA 5-methylcytosine content was observed between normal tissues, benign lesions, low-grade lesions and high-grade lesions (p=0.6). In contrast, DNAs extracted from invasive SCC were hypomethylated when compared with normal and preneoplastic lesions (p=0.0004). An association between global DNA hypomethylation and the SCC stage was confirmed by HPCE.

CONCLUSIONS

The transition from CIN lesions to invasive carcinoma seems to be closely linked to global DNA hypomethylation, which could be a useful marker of invasive uterine cervical lesions.

Cervix cancer in Tunisia: clinical and pathological study

INTRODUCTION

Uterine cervix cancer is the second most commonly diagnosed cancer among women worldwide.

DESIGN

In order to review the clinical and pathological features of cervix cancer in the center of Tunisia, a retrospective study was carried out on 410 cancer cases diagnosed in the Pathology Department, Farhet Hached University Hospital, Sousse, Tunisia (1993-2006).

RESULTS

The mean age was 52.1 years. Of the 410 patients, 90.5% had squamous cell carcinoma and 7.3% had adenocarcinoma. One hundred thirty-eight patients were identified as being in early stages (0 and I) (33.6%) and 58.2% in advanced stages (II-IV). Therapy consisted mainly in combination of radiotherapy and surgery in early stages (28.8%), and radiotherapy alone or associated with the chemotherapy in advanced stage (29.7%). Surgery was the only treatment in 29.5% of cases.

CONCLUSION

A relatively large proportion of patients presented in stages II to IV, as compared to only 36% with early stages, emphasizing the need to reinforce the early detection of this cancer and its precursor lesions in the center of Tunisia.

Cervical adenocarcinoma and squamous cell carcinoma incidence trends among Tunisian women

INTRODUCTION

Uterine cervix cancer is an important public health problem in Tunisia. In this study, we report trends in the incidence of adenocarcinoma and squamous cell carcinoma of the cervix uteri in the central region of Tunisia during 1993-2006.

DESIGN

Data were obtained from the Cancer Registry of the Center of Tunisia which registers invasive cancer cases by active methods. Five-year age-specific rates, crude incidence rates (CR), world age-standardized rates (ASR), percent change (PC) and annual percent change (APC) were calculated using annual population data.

RESULTS

Among all women cancers, cervix uteri cancer accounted for 5.9% and ranked the fourth during the study period with an ASR of 6.9 per 100,000. The ASRs decreased notably with an APC of -6.7% over the whole period. However, incidence rates of adenocarcinomas have increased during the last years (APC: +14.4%).

CONCLUSION

The introduction of cytological screening programs has led to a marked decrease of the incidence rates of cervix uteri cancer among Tunisian women. The data underline the fact that the population-based cancer registry is an indispensable tool for providing data for planning and evaluation of programs for cancer control.

Clinicopathological patterns of colorectal cancer in Tunisia

INTRODUCTION

Colorectal cancer is the third most commonly diagnosed cancer worldwide.

DESIGN

In order to review the clinical and pathological features of colorectal cancer in Tunisia, a retrospective study was carried out on 1,443 cancer cases diagnosed in the Pathology Department, Farhet Hached University Hospital of Sousse, for a 15-year period (1993-2007).

RESULTS

The median age was 61 years. Adenocarcinoma was the most frequent (90.9%) with moderately differentiated tumors accounting for 76.7% of cases. Only eighty patients were identified as being in early stages (0 and A) and 85.8% in advanced stages (B-D). Over time, we observed a significant decrease of stage B (p=0.02) and a significant increase of stage D (p=0.002). The tumor size was larger than 5 cm in 67.5% of cases.

CONCLUSION

The large proportion of patients presented at advanced stages, compared to only 5.5% of patients at early stages, emphasizes the need to plan and develop a screening program for the early detection of this cancer and its precursor lesions in Tunisia.

Renal mucinous tubular and spindle cell carcinoma

We report a case of mucinous tubular and spindle cell carcinoma in a 66-year-old woman. The tumour, located on the left kidney, was well circumscribed. Microscopically, the tumour was composed of cuboidal cells arranged in tubules and making abrupt transitions to spindle cell morphology in a myxoid stroma. Tumour cells were strongly positive for cytokeratin 7 and epithelial membrane antigen. Because of the favourable prognosis with this type of tumour, mucinous tubular and spindle cell carcinoma must be differentiated from papillary renal cell carcinoma, especially that with sarcomatoid change. No tumour recurrence or metastasis were reported with a follow-up of 23 months.

[Recurrent hydatidiform mole. Case report of 9 successive molar pregnancies]

The recurrent hydatiform mole is rare, its frequency is lower to 1%. We report the observation of a 28 years old women. without antecedents of molar pregnancy in the family and without considerable pathological antecedents. She had 9 successive molar pregnancies, without inset normal pregnancies and without living children. The delay of at least 1 year between the gestations has been respected in 6 pregnancies. The etiologic balance in particular the caryotypes of parents is normal. The authors debate the étiopathogénic and prognostic factors of this pathology.

[Lobular idiopathic granulomatos mastitis. About 10 cases]

Our retrospective study was performed on 10 cases of granulomatous mastitis registered in Obstetric Gynaecology Department and Pathology Department of CHU F. Hached, Sousse, during 8 years period. The mean age was 36.4 years (range 32-59). Among these 10 cases. 8 were observed in reproductive-age women and 2 were noted in menopausal women. Clinical findings showed unilateral breast nodule associated with inflammatory signs in 4 cases, mammelonary retraction in 2 cases and serous or sero-purulent mamelonnary flow in 4 cases. Mamnmographic examination suggested a malignant tumor in 5 patients. In all cases, the diagnosis is made by histopathology. Surgical treatment consisted in wide excision with drainage or radical mastectomy, eventually with combination with antibiotic therapy and non steroid anti-inflammatory drugs. Prognostic features showed a good cicatrization in 4 cases, local recurrence and cutaneous fistulization in one patient. Granulomatous mastitis aetiology is still unclear, auto-immune aetio-pathogenesis appears more interesting and should be clarified.

[Ovary teratoma. Report of 91 cases]

OBJECTIVE

To analyse the clinical and anatomic aspects of cystic teratomas of the ovary, caracteristics of patients having cystic teratomas and the management trends at our institution.

STUDY DESIGN

Retrospective study of 91 cases of cystic teratomas of the ovary diagnosed and treated at Farhat -Hached Hospital (Sousse) between 1 january 1995 and 30 june 2003.

RESULTS

Cystic teratomas constituted 12.13% of all ovarian tumors diagnosed and treated at our institution during the study period. The median of age was 33.35 ans. Abdominal or pelvic pain was the most frequent symptom for presentation in 67% of the cases. In addition; incidental finding was noted in 25.3% of the cases and swelling in 23% of the cases. The mean tumor diameter was 10 cm. The rate of bilateral cystic teratomas of the ovary was 14.3%. 19.8% of cystic teratomas has occurred in pregnancy. The operative video-laparoscopy was employed in 9 cases, laparotomy was employed in82 cases. Histopathological evaluation has detected 96.7% cases of mature teratomas, and 3.3% cases of immature teratomas.

CONCLUSION

Cystic tertomas are the most common ovarian neoplasms, that occurs most commonly during the reproductive years. The operative laparoscopy is the most common modality of treatment of mature cystic teratomas. Immature teratomas must be treated by laparotomy associated if necessary to chimiothrapiy.

[Prevalence of high risk oncogen HPV by in situ hybridization and by PCR in condyloma acuminata in the region of the Tunisian Center]

The aim of this study was to evaluate the frequency of "high-risk" HPV types in condyloma acuminata in patients from Tunisian Center. Thirty two paraffin-embedded biopsies were analysed for the presence and type of HPV DNA by means of in situ hybridization (ISH) and polymerase chain reaction (PCR) techniques. ISH was done using a broad spectrum HPV biotinylated DNA probe for the detection of HPV DNA. HPV typing was carried out using specific probes for HPV types 6/11, 16/18 and 31/33. HPV DNA was amplified by PCR using the degenerate primers E1350L/E1547. HPV were typed by pU-1M/PU-2R primers for the oncogenic HPV types 16, 18, 31 and 33, and PU-31B/PU-2R for "low-risk" group (6 and 11). Using ISH, HPV was detected in 27 out 32 cases (84.4%). All were HPV 6/11 positive. Co-infection with oncogenic HPV was found in one case that reacted with 16/18 and 31/33 probes. Good quality DNA was obtained in 13 cases. HPV was detected by PCR in 11 of 13 specimens (80.6%) when E1350L/E1547 primers were used. HPV 6/11 were present in all cases. The results of this study provide specific confirmation of the predominance of HPV6/11 and low rate of co-infection in patient from Tunisian Center. Because of the difficulty of DNA extraction, risk of DNA degradation and contamination associated with PCR, the ISH remains more adapted to archival materiel especially in routine clinical practice.

p16INK4A overexpression and HPV infection in uterine cervix adenocarcinoma

Human papillomaviruses (HPVs) are causally involved in the genesis of cervical carcinomas and their precursors, and there is a strong relationship between the cyclin-dependant kinase inhibitor p16INK4A and HPV infection. This study was carried out to assess the correlations between p16INK4A expression as an early biomarker of the endocervical adenocarcinoma and HPV infection. p16INK4A expression and HPV typing were performed on 46 samples including 5 normal endocervix, 9 benign lesions of the endocervix, 25 endocervical adenocarcinomas, and 7 endometrioid adenocarcinomas of the uterine corpus. A semiquantification of the p16INK4A immunostaining was realized (using both the staining intensity and the percentage of positive cells) and was graded from 0 to 15. All of the 25 endocervical adenocarcinomas overexpressed p16INK4A; the adjacent epithelium and the connective tissue were strictly negative. No p16INK4A was detected in nine benign endocervical lesions and in five normal endocervix. Few endometrioid adenocarcinomas of the uterine corpus that infiltrate the endocervix exhibited a low immunoreactivity (score 0/15 or 1/15). This pattern of expression is significantly associated with HPV infection (p<10(-3)), mainly high-risk HPV types (p=0.02). Our results suggest that p16INK4A is a putative molecular biomarker that consistently discriminates uterine cervix adenocarcinomas from benign lesions and from endometrioid adenocarcinomas of the uterine corpus.