Gestational trophoblastic neoplasia of intermediate trophoblasts: Epithelioid trophoblastic tumor and placental site trophoblastic tumor, a study of morphologic, immunohistochemical, and next generation sequencing

Objective

Gestational trophoblastic tumors are very rare neoplasms. We determined the distinctive morphological, immunohistochemical, and clinical features of placental site trophoblastic tumors (PSTT) and epithelioid trophoblastic tumors (ETT) in our cohort.

Materials and Methods

Nine cases of PSTT and four cases of ETT were retrieved from the archives. Histomorphologic, immunohistochemical, and clinical features were noted. A molecular study was performed on one PSTT and one ETT case using next-generation sequencing.

Results

While the nodular pattern, geographic necrosis, and extracellular eosinophilic globules were peculiar to ETTs, vessel wall affinity, marked pleomorphism, intranuclear pseudoinclusion, spindle tumor cell, and vacuolar degeneration were more specific for PSTTs in our series. An immunohistochemical panel of p63, hPL, and CD146 were helpful for the exact typing of the tumor. p63 positivity supports the ETT and diffuse staining of hPL and CD146 supports the PSTT diagnosis. Three of the patients with metastatic disease (lung and brain metastasis) except one have a high mitotic count (12 and 8) and a long interval between (8 and 10 years) antecedent pregnancy and diagnosis. While KIT and TP53 mutations were observed only in PSTT, amino acid changes in KDR, APC, and SMAD4 genes were detected both in the ETT and PSTT cases.

Conclusion

In the prediction of metastasis, the long intervals between antecedent pregnancy and diagnosis, deep myometrial invasion, mitotic count, and Ki67 proliferation index were involved rather than other histomorphological parameters, but none of the parameters is an absolute predictor of the metastasis.

PROPROTEIN CONVERTASE 1/3 DEFICIENCY WITH PELVIC EWING SARCOMA

Proprotein convertase 1/3 (PC 1/3) deficiency is a rare, autosomal recessive disorder caused by mutations in the PCSK1 gene. The disease is characterized by early-onset chronic diarrhea/malabsorption, followed by severe obesity and hormonal deficiencies such as hypocortisolism, hypothyroidism, diabetes insipidus, hypogonadism, growth deficiency, and diabetes mellitus. Ewing's sarcoma is a rare tumor, usually of small dimensions of neuroectodermal origin that is difficult to distinguish pathologically from a primitive neuroectodermal tumor. A 22-year-old female patient with PC 1/3 deficiency was admitted to our clinic with recurrent urinary tract infections. Magnetic resonance imaging (MRI) revealed an 11x12 cm pelvic mass displacing the uterus. A core-needle biopsy was performed on the pelvic mass. As a result of the pathological evaluation, ıt was diagnosed with pelvic Ewing's sarcoma. The patient was started on the VAC-IE chemotherapy protocol. We report a case of pelvic Ewing's sarcoma in a patient with PC 1/3 deficiency. Further research is needed to assess malignancy risk in metabolic disorders including very rare disorders like PC 1/3 deficiency.

The expression of BMP, integrin, ZEB2 in ovarian high-grade serous carcinoma in relation with lymph node metastasis

Ovarian cancer (OC) is clinically important because it is diagnosed late and has metastasis when it is diagnosed. Mortality risk increases 2.75 times in the presence of lymph node (LN) metastasis. During metastasis, many molecules including BMPs originated from stroma, and tumor cells participate through transcription factors and integrins for cytoskeleton regulation during cell migration. We hypothesized an inverse correlation between BMP2 and BMP7 along with changes in ZEB2, and integrin α5β1 in high-grade OCs in relation to LN metastasis. The BMP2 immunoreactivity was strong along with strong ZEB2 and weak integrins' immunoreactivity in samples with LN metastasis. Strong immunoreactivity of BMP7 was accompanied by strong immunoreactivity of integrins in the samples without LN metastasis. Study results showed BMP2's strong positive immunoreactivity and weak BMP7 immunoreactivity in tumor cells with a significantly weak inverse correlation. This inverse correlation should be considered as both BMPs have different effects in the window of cancer progression and invasion.

The evaluation of laparotomy results in breast cancer patients with gynecological pathologies

AIM

The aim of the study was to evaluate the results of the laparotomies due to gynecological pathologies in breast cancer patients and to assess the distribution of gynecological pathologies and the clinical and laboratory findings contributing to the diagnosis.

METHODS

This study was conducted between years 2002 and 2011 at Hacettepe University Hospital. We obtained information about 86 consecutive breast cancer patients, including age, time of diagnosis and pathology of breast cancer, hormone receptor status, history of endocrine therapy, presenting symptoms, ultrasonography findings, CA 125 levels, endometrial biopsy results, type of gynecological surgery and pathology results. Data were analyzed with the use of SPSS software.

RESULTS

Twenty-one (24.4%) out of 86 patients had endometrial pathology, and 24 (27.9%) had adnexal pathology. Fourteen patients (16.2%) had malignant pathology, and of them, 11 had ovarian cancer 3 had endometrial cancer. There were five abnormal cytological findings: 2 ASCUS, 1 LSIL, 1 ASC-H and 1 adenocarcinoma. The patient with the cytology report of adenocarcinoma had the final diagnosis of endometrial cancer. Of the patients, 67 (77.9%) used tamoxifen, whereas 19 (22.1%) did not. Thirty-three patients (38.4%) with gynecological pathologies were detected incidentally during routine follow-up of breast cancer.

CONCLUSION

This study supports the increase of the gynecological pathology incidence in breast cancer patients and the recommendation of close gynecological follow-up in these patients. Asymptomatic patients might also develop genital cancer. The ultrasonographic appearance of the adnexal masses or endometrial thickness and any abnormal vaginal bleeding or high CA 125 levels are important parameters for evaluating breast cancer patients.

What does the Data of 354,725 Patients from Turkey Tell Us About Cervical Smear Epithelial Cell Abnormalities? - The Epithelial Cell Abnormality Rate is Increasing - Quality Control Studies and Corrective Activity are Musts

OBJECTIVE

There is no other screening program close to the success rate of PAP test. Cervical cytology constitutes a large workload so that quality control in cervical cytology is important for the quality assurance of pathology laboratories.

MATERIAL AND METHOD

In this study, we collected the cervical cytology results from all over Turkey and discussed the parameters influencing the quality of the PAP test. The study was conducted with Turkish gynaecopathology working group and 38 centers (totally 45 hospitals) agreed to contribute from 24 different cities. The study was designed to cover the cervical cytology results during 2013. The results were evaluated from the data based on an online questionnaire.

RESULTS

The total number of Epithelial Cell Abnormality was 18,020 and the global Epithelial Cell Abnormality rate was 5.08% in the total 354,725 smears and ranging between 0.3% to 16.64% among centers. The Atypical squamous cells /Squamous intraepithelial lesion ratios changed within the range of 0.21-13.94 with an average of 2.61. When the centers were asked whether they performed quality assurance studies, only 14 out of 28 centers, which shared the information, had such a control study and some quality parameters were better in these centers.

CONCLUSION

There is an increase in the global Epithelial Cell Abnormality rate and there are great differences among centers. Quality control studies including the Atypical squamous cells/Squamous intraepithelial lesion ratio are important. Corrective and preventive action according to quality control parameters is a must. A cervical cytology subspecialist in every center can be utopic but a dedicated pathologist in the center is certainly needed.

Diagnostic and Treatment Reproducibility of Cervical Intraepithelial Neoplasia / Squamous Intraepithelial Lesion and Factors Affecting the Diagnosis

OBJECTIVE

Inter-observer differences in the diagnosis of HPV related cervical lesions are problematic and response of gynecologists to these diagnostic entities is non-standardized. This study evaluated the diagnostic reproducibility of "cervical intraepithelial neoplasia" (CIN) and "squamous intraepithelial lesion" (SIL) diagnoses.

MATERIAL AND METHOD

19 pathologists evaluated 66 cases once using H&E slides and once with immunohistochemical studies (p16, Ki-67 and Pro-ExC). Management response to diagnoses was evaluated amongst 12 gynecologists. Pathologists and gynecologists were also given a questionnaire about how additional information like smear results and age modify diagnosis and management.

RESULTS

We show moderate interobserver diagnostic reproducibility amongst pathologists. The overall kappa value was 0.50 and 0.59 using the CIN and SIL classifications respectively. Impact of immunohistochemical evaluation on interpretation of cases differed and there was lack of statistically significant improvement of interobserver diagnostic reproducibility with the addition of immunohistochemistry. We saw that choice of treatment methods amongst gynecologists varied and overall concordance was only fair to moderate. The CIN2 diagnostic category was seen to have the lowest percentage agreement amongst both pathologists and gynecologists. We showed that pathologists had diagnostic "styles" and gynecologists had management "styles".

CONCLUSION

In summary each pathologist had different diagnostic tendencies which were affected not only by histopathology and marker studies, but also by the patient management tendencies of the gynecologist that the pathologist worked with. The two-tiered modified Bethesda system improved diagnostic agreement. We concluded that immunohistochemistry should be used only to resolve problems in select cases and not for every case.

HPV types and E6/E7 mRNA expression in cervical samples from Turkish women with abnormal cytology in Ankara, Turkey

BACKGROUND/AIM

Human papillomaviruses have been established as a risk factor for invasive carcinoma of the uterine cervix. HPV E6/E7 oncogene expression has recently emerged as a promising biomarker to determine the risk for progression to high-grade cervical lesions. The aim of this study was to evaluate HPV mRNA and DNA detection in samples with abnormal cytology.

MATERIALS AND METHODS

Cervical specimens were obtained at the Department of Obstetrics and Gynecology via cervical brushes during January-October 2011. Liquid-based cytology slides were evaluated according to the 2001 Bethesda System. Cytology specimens from a total of 81 women with abnormal cytology were included. Real-time PCR and NASBA assays were performed to detect HPV DNA and E6/E7 mRNA, respectively.

RESULTS

HPV DNA was identified in 73 samples (90.1%). HPV E6/E7 mRNA expression was observed in 45 samples (55.6%). A statistically significant difference was observed among cytological diagnosis groups. In 25 patients, a biopsy was performed during the follow-up. HPV DNA was detected in all of these patients. HPV E6/E7 expression was present only in CIN I-III diagnosed patients.

CONCLUSION

The E6/E7 mRNA test is a robust indicator of cytological atypia and correlates better with progressive lesions than DNA assays.

In vitro chemosensitivity in ovarian carcinoma: Comparison of three leading assays

OBJECTIVE

An alternative approach to the current therapy of ovarian carcinoma is the individualization of treatment by determining the sensitivity of tumoral tissue to chemotherapeutic agents before the initiation of chemotherapy. The objectives of the study are to determine the efficacy of in vitro chemosensitivity assays in ovarian carcinoma and to measure the correlation of three leading assays.

MATERIAL AND METHODS

Fresh tumoral tissue samples of 26 newly diagnosed primary ovarian cancer patients were studied with 3-(4,5-dimeth-ylthiazol-2-yl)-2,5-diphenyltetrazolyum bromide (MTT) assay, adenosine triphosphate-tumor chemosensitivity assay (ATP-TCA) and differential staining cytotoxicity (DISC) assays. Chemosensitivity of tumors were studied for paclitaxel, carboplatin, docetaxel, topotecan, gemcitabine, and doxorubicin with each of the three assays. Subgroup analysis was performed for stage, grade, and histologic type.

RESULTS

The in vitro chemosensitivity results of MTT, ATP, and DISC assays were found to be similar. The subgroups in which in vitro assays would be more useful were encountered for patients with advanced stage and serous histology ovarian carcinoma.

CONCLUSIONS

In vitro chemosensitivity can be determined in ovarian carcinoma with ATP, MTT, or DISC assays before the initiation of chemotherapy. These three assays correlate well with each other and are particularly useful for serous and advanced cancers. Large prospective studies comparing standard versus assay-directed therapy with an endpoint of overall survival are required before routine clinical utilization of these assays.

The Role of Frozen-Section in the Surgical Management of Patients with Endometrial Intraepithelial Neoplasia

OBJECTIVE

Patients with endometrial intraepithelial neoplasia may have concurrent endometrial cancer if managed surgically or develop cancer in time if managed conservatively. Therefore, intraoperative assessment of the uterus may be helpful if a surgical approach is decided on. Our study aimed to investigate the role of frozen-section examination in patients with endometrial intraepithelial neoplasia.

MATERIAL AND METHOD

Patients with endometrial intraepithelial neoplasia who were subjected to hysterectomy with intraoperative frozen-section assessment were included. Main outcome measures were the rates of concurrent endometrial cancer and concurrent high-risk endometrial cancer as well as the efficacy of frozen-section in the detection of concurrent invasive disease and in the designation of low-risk and high-risk features.

RESULTS

The study group consisted of seventy-three patients. Permanent pathology revealed endometrial adenocarcinoma in 19.2% whereas only one patient (1.4%) had high-risk disease necessitating surgical staging. Frozen-section diagnoses were consistent with final pathology in 93.2% of patients in terms of the presence or absence of co-existent carcinoma. When frozen-section reports were further evaluated in terms of the presence or absence of high-risk endometrial carcinoma, consistency with the final pathology was seen in 98.6% of patients.

CONCLUSION

Co-existent endometrial cancer is not uncommon in endometrial intraepithelial neoplasia. Intraoperative frozen-section evaluation should therefore be considered whenever possible. Frozen-section is effective in the detection of coexistent invasive disease and in the designation of low-risk features. Although coexistent high-risk cancer is extremely rare, frozen-section assessment is not successful in determining high-risk features. Therefore, a re-staging surgery may be required on rare occasions.

Diagnostic accuracy of intraoperative consultation (frozen section) in borderline ovarian tumours and factors associated with misdiagnosis

The objective of our study was to evaluate the accuracy of frozen section (FS) in borderline ovarian tumours (BOT) and to define the factors associated with misdiagnosis during FS evaluation. We performed a retrospective review of patients who underwent exploratory laparotomy for an adnexal mass, from January 2007 to July 2012, at a tertiary oncology centre in Turkey. Patients with a diagnosis of BOT either in FS or in permanent pathology were identified. Agreement between FS diagnosis and permanent histology was observed in 37/59 patients (62.7%), which gave a sensitivity and a positive predictive value of 71.2% and 84.1%, respectively. In patients with a diagnosis of BOT by frozen section only (n = 44), the diagnosis was consistent with permanent histopathology in 37/44 patients (84.1%). Frozen section interpreted a malignant tumour as BOT (under-diagnosis) in 6/44 (13.6%) of cases and interpreted a benign lesion as BOT (over-diagnosis) in 1/44 (2.3%) of cases. Slide review of discrepant cases revealed that major pathological causes of under-diagnosis were misinterpretation and sampling errors. Univariate analysis showed that presence of bilateral tumour and positive peritoneal cytology were associated with under-diagnosis. We concluded that, despite significant risk of under-diagnosis, FS analysis is an accurate method for intraoperative diagnosis of BOTs.

Expression of p16, p53, CD24, EpCAM and calretinin in serous borderline tumors of the ovary

OBJECTIVE

According to the widely accepted pathway, a serous borderline tumor becomes invasive either by progressing into a noninvasive micropapillary tumor or directly through microinvasion. Our objective was to investigate the role of serous borderline tumors and their accompanying extraovarian lesions in pathogenesis of serous ovarian cancer using immunohistochemistry as a tool.

MATERIAL AND METHOD

An immunohistochemical panel of p16, p53, CD24, EpCAM and calretinin was applied to cutting edge matrix assembly-like tissue arrays of 46 cases consisting of typical, focal micropapillary, micropapillary, microinvasive, cystadenoma, and low-grade carcinoma cases. These tissue arrays are better choices than conventional tissue arrays to examine thin walled and heterogenous neoplasia like serous borderline tumors as they facilitate the analysis with linear sections rather than a core.

RESULTS

For two tumor supressor gene markers; no diffuse and strong expression of p53, and strong and patchy/heterogenous expression of p16 were detected in all cases. Focal and strong calretinin expression was detected in micropapillary tumors while expression of EpCAM was lost in the same areas. Strong cytoplasmic CD24 expression was detected in cases with peritoneal implants, favoring the theory that change of expression localization of cell adhesion molecules is in accordance with phenotypical changes and tumor progresssion. Furthermore, circumfrential membranous and cytoplasmic expression of CD24 and EpCAM was detected in neoplastic cells in lymph nodes and microinvasion areas.

CONCLUSION

Our results show that different levels of serous ovarian tumor progression are accompanied by changes in the immunohistochemical expression pattern of EpCAM, CD24, and calretinin.

The selective expression of ret finger protein in endometrial cancer: can RFP be a marker of serous carcinomas?

OBJECTIVE

Endometrial cancer is a common malignancy of the gynecological system and has been classified into two major groups, Types I and II. Type I tumors are estrogen-related, low-grade endometrioid tumors, whereas type II tumors are aggressive, high-grade non-endometrioid tumors. Ret finger protein is a nuclear transcription factor with a tripartite motif that is highly expressed in different tumor cells.

MATERIAL AND METHOD

To analyze the expression of ret finger protein in endometrial tissues and cancer, 18 cases of secretory and proliferative endometrium, endometrial polyp, endometrial hyperplasia and endometrial intraepithelial neoplasia and 21 cases of types I and II endometrial carcinoma were evaluated immunohistochemically.

RESULTS

Although rare cases of secretory endometrium showed a weak focal nuclear positivity, remaining proliferative endometrium, endometrial hyperplasia and type I endometrioid cancer cases were negative. In contrast, all cases of serous cancers showed strong nuclear positivity. After these strong positive results for serous endometrial cancer, 12 more cases of ovarian and endometrial serous carcinoma cases were added to the study. All of the additional cases were also strongly positive for ret finger protein.

CONCLUSION

We suggest that ret finger protein might play a role in the carcinogenesis of the serous tumors of gynecological system and can be used to differentiate serous carcinomas from other epithelial tumors.

The situation of consultation practice in pathology in Turkey

OBJECTIVE

There are some suggestions regarding the methods of consultation practice in the literature including which case will be consulted, to whom, by which transport means, the payment methods as well as the ethical issues. There are no standards for consultations in Turkey. The standardization committee of the Federation of Turkish Pathology Societies has conducted a survey to detect the current situation, determine the problematic aspects, compare the situation with international methods and offer methods specific to Turkey.

MATERIAL AND METHOD

A survey has been prepared to cover all the aspects of consultation practice using the literature and referring to the current methods used in Turkey. The survey has been announced on the internet and 83 replies were collected.

RESULTS

Multiple choice questions were evaluated in terms of percentages and open ended questions were grouped according to the answer contents. It was seen that problems could be grouped as follows: absence of written procedures covering each step, means of transport, reaching the consultant, payment, reporting and ethical issues. The absence of procedures and issues regarding the payment methods were the interfering factors for each step of consultation.

CONCLUSION

There are many problematic issues in consultation practice in pathology in Turkey. The basis of these problems is the absence of written regulations for procedural and payment methods. Regulations addressing these issues should be developed.

Pathology laboratories productivity evaluation in Turkey

OBJECTIVE

Efficiency criteria and automation in pathology laboratories have been set in a limited number of studies usually originated from the United States. A questionnaire has been prepared to determine the situation and define the criteria for adaptation in our country.

MATERIAL AND METHOD

The survey was sent to all pathology laboratories and, 302 responded. The survey questionned of pathology laboratories efficiencies, staff workloads, methods applied, devices used, and physical conditions. Work flow productivity was obtained by dividing the annual number of blocks to working hours multiplied by the number of technicians. The hospitals were categorized to 3 groups according to providing training or not and privacy, and to 4 groups according to the annual biopsy numbers. The data entered through the SPSS 16.0 statistical package program, analysis of distribution criteria, significance of the difference between means tests were used.

RESULTS

The annual biopsy numbers were significantly higher in education units, but below the limit of productivity levels for all laboratories. The device hardware and automation correlated with annual biopsy numbers. However, the laboratories of limited capacity have redundant automation. Histochemical and immunohistochemical staining numbers were high. Liquid-based cytology techniques were used more significantly in private hospitals. Archiving times were not standard. A serious shortage of working space in service hospitals was noted. Work flow productivity in education units was at the border, and low in other units.

CONCLUSION

All pathology laboratories in our country should define and improve their productivities. Formalizing of archiving times is very important for future malpractice lawsuits.

[Pathology laboratories staff workload evaluation in Turkey: a survey study]

OBJECTIVE

The workload affects the quality of the pathology report. The aim of this study was to investigate the territorial distribution and productivity of pathology laboratories around Turkey and to estimate the staff workload.

MATERIAL AND METHOD

A survey questioning the workload was sent to all Ministry of Health and university hospitals. Staff workload was questioned according to the hospital classification and educational activity to evaluate the productivity. Data were entered using SPSS 16.0 statistical software package program and the distribution criteria, t-test and one-way anova were used in the analysis to evaluate the differences between the averages.

RESULTS

An average of 2.8 pathologists worked at the pathology laboratories. A total of 5.500 biopsies and 3.750 cytology specimens were received and 20.000 blocks prepared per year. Pathologists evaluated 1.935 biopsies and 1.400 cytology specimens on average and this is equivalent to 2.718 biopsies per year. Gynecology and general surgery department materials constituted 57 percent of all biopsies. Each technician prepared 6.200 blocks, 11.500 slides and 1.000 immunohistochemistry preparations on average. An average of 3.4 paraffin blocks was prepared for each biopsy. The efficiency was low in 17% of teaching hospitals and 77.8% of non-teaching hospitals. In contrast 62.5% of teaching hospitals had work overload. The majority (70.5%) of the respondents mentioned staff shortage.

CONCLUSION

There is no pathologist shortage in Turkey and the problem is workload distribution. Pathology residents' overwork would be reduced by using pathology assistants. There is no shortage of technicians or secretaries, but uneven distribution. Pathology staff planning must be tailored taking into account the features of each hospital. Standard planning for all hospitals is not suitable.

Radiotherapy in congenital vulvar lymphangioma circumscriptum

Congenital lymphangioma circumscriptum (LC) of the vulva is a rare disorder with unknown etiology. Treatment options include ablative approaches such as laser therapy, sclerotherapy, and surgery. Radiotherapy has been shown to be effective in the management of congenital lymphangioma especially in the thoracic and abdominal lesions. In this report, we describe a patient with persistent vulvar LC despite sclerosing therapy and several surgical excisions. She was treated with a course of external radiotherapy and showed a dramatic objective response with relief of all symptoms

Maxillary ameloblastic carcinoma in a child

We report an extremely rare occurrence of ameloblastic carcinoma located in the maxilla of a pediatric patient. Wide surgical resection was done along with adjuvant radiotherapy because of involved surgical margins. Histopathological diagnosis was established with morphological features of both ameloblastoma and carcinoma.

Omentectomy for gynecologic cancer: how much sampling is adequate for microscopic examination?

CONTEXT

Detecting omental metastasis is crucial for staging and treatment of endometrial and ovarian carcinoma.

OBJECTIVE

To determine the optimal omental sampling for omentectomies to ascertain the stage of the disease in a cost-effective way.

DESIGN

We reevaluated 258 omentectomies that were performed due to ovarian or endometrial carcinoma. A total of 116 cases were retrospectively studied, and 142 cases were prospectively studied. For prospective study, 10 to 16 blocks were sampled if the omentum showed no signs of gross tumor. Mean omental block sample frequency of 2 groups with the negative macroscopy but with or without microscopic tumor have been compared using an independent samples t test.

RESULTS

Seven patients had no evidence of tumor metastasis on gross examination but had microscopic tumor metastasis. The mean numbers of blocks were 6.4 for patients having microscopic tumor without macroscopic involvement and 7.8 for patients having neither microscopic nor macroscopic involvement. Approximately twice as many samples were taken in the prospective analysis when compared with retrospective analysis. Two cases with microscopic omental metastasis that had no macroscopic involvement at first impression were reevaluated retrospectively and found to contain 0.3- to 0.5-cm white nodules. The rate of omental metastasis increased with the grade of the tumor (P = .005).

CONCLUSION

Careful macroscopic examination is the most important step in detecting small omental metastasis. For cases with gross tumor, one section is sufficient. If a macroscopic lesion is not detectable and the patient has a high-grade tumor that will necessitate an adjuvant therapy, 3 to 5 samples seem sufficient for staging. Further studies are needed to determine the optimum sample size for tumors having a low risk of metastasis.

Xanthogranulomatous endometritis: a challenging imitator of endometrial carcinoma

Xanthogranulomatous inflammation is a distinguished histopathological entity affecting several organs, predominantly the kidney and gallbladder. So far, only a small number of cases of xanthogranulomatous inflammation occurring in female genital tract have been described, most frequently affecting the endometrium and histologically characterized by replacement of endometrium by xanthogranulomatous inflammation composed of abundant foamy histiocytes, siderophages, giant cells, fibrosis, calcification and accompanying polymorphonuclear leucocytes, plasma cells and lymphocytes of polyclonal origin. We present a case of a 69-year-old female complained of post menopausal bleeding and weight loss. Clinical preliminary diagnoses were endometrial carcinoma or hyperplasia and ultrasound was supposed to be endometrial malignancy, hyperplasia or pyometra by radiologist. Histopathological examination of uterus revealed xanthogranulomatous endometritis. Since xanthogranulomatous endometritis may mimic endometrial malignancy clinically and pathologically as a result of the replacement of the endometrium and occasionally invasion of the myometrium by friable yellowish tissue composed of histiocytes, knowledge of this unusual inflammatory disease is needed for both clinicians and pathologists.

Efficiency of immunohistochemical p16 expression and HPV typing in cervical squamous intraepithelial lesion grading and review of the p16 literature

Diagnosing and grading cervical cancer precursors is challenging. This study investigates the presence of HPV infection, the expression of p16, and any correlation between these two findings. H&E-stained slides of cervical loop excision materials diagnosed as LSIL and HSIL were reviewed. An immunohistochemical panel consisting of p16 as well as of all HPV types and HR-HPV types was applied. Staining of p16 was evaluated according to distribution extent and degree of intensity. All HSIL cases and 80% of LSIL cases were positive for p16. In HSIL cases, the staining distribution was as follows: 50% full thickness, 45% basal, and 5% rare. The staining intensity for the same cases was strong in 70%, variable in 20%, and weak in 10% accordingly. In LSIL cases, staining distribution was basal in 58.3% and rare in 41.7%. None of the LSIL cases showed full thickness of p16 positivity. The staining intensity of the same cases was strong in 25%, variable in 16.7%, and weak in 58.3%. Of all cases, 48.6% were positive for screening kit (all HPV types), and 31.4% of all cases were positive for HR-HPV. The distribution of this positivity was 35% for HSIL and 26.6% for LSIL cases. The total HPV-type positivity rate was 48.6%, the distribution being 50% for HSIL and 46.6% for LSIL cases. p16 is a highly sensitive marker for cervical epithelial dysplasia. Strong and full thickness staining of p16 in the cervix epithelium is highly supportive of HSIL, while weak and basal/rare staining favors LSIL. All HPV-positive cases were also p16-positive, but no statistically significant relationship between HPV infection positivity and the intensity and distribution of p16 was found. HPV is not helpful in the grading of SIL, as an unignorable rate of HR-HPV positivity (26.6%) was detected in LSIL group.

Ovarian adenomyoma following gonadotrophin treatment for infertility

An ovarian adenomyoma developed in a 38-year-old infertile patient following treatment with exogenous gonadotrophins. Laparoscopic excision was performed. Histological examination showed thick muscular bundles resembling myometrium lined with endometrial glands and stroma. Gonadotrophins might be involved in the pathogenesis of extrauterine adenomyoma.

Atypical Endometrial Stromal Cells Related With a Polypoid Leiomyoma With Bizarre Nuclei

We presented a polypoid leiomyoma with bizarre nuclei having atypical endometrial stromal cells adjacent to the leiomyoma. Although atypical stromal cells of the female genital tract have been described, to our knowledge, no lesion identical to ours has been reported thus far. These atypical cells may be mistaken for malignant cells on histologic examination, especially in small endometrial samples. To differentiate these kinds of atypical-featured lesions from sarcoma is important, especially in curettage materials. The etiology and precise nature of multinucleated giant cells and atypical stromal cells in the endometrium are unclear. To prevent radical surgery, pathologists must be familiar with these atypical cells in the female genital tract.

Activation of the canonical Wnt pathway during genital keratinocyte transformation: a model for cervical cancer progression

Cervical carcinoma, the second leading cause of cancer deaths in women worldwide, is associated with human papillomavirus (HPV). HPV-infected individuals are at high risk for developing cervical carcinoma; however, the molecular mechanisms that lead to the progression of cervical cancer have not been established. We hypothesized that in a multistep carcinogenesis model, HPV provides the initial hit and activation of canonical Wnt pathway may serve as the second hit. To test this hypothesis, we evaluated the canonical Wnt pathway as a promoting factor of HPV-induced human keratinocyte transformation. In this in vitro experimental cervical carcinoma model, primary human keratinocytes immortalized by HPV were transformed by SV40 small-t (smt) antigen. We show that smt-transformed cells have high cytoplasmic beta-catenin levels, a hallmark of activated canonical Wnt pathway, and that activation of this pathway by smt is mediated through its interaction with protein phosphatase-2A. Furthermore, inhibition of downstream signaling from beta-catenin inhibited the smt-induced transformed phenotype. Wnt pathway activation transformed HPV-immortalized primary human keratinocytes even in the absence of smt. However, activation of the Wnt pathway in the absence of HPV was not sufficient to induce transformation. We also detected increased cytoplasmic and nuclear staining of beta-catenin in invasive cervical carcinoma samples from 48 patients. We detected weak cytoplasmic and no nuclear staining of beta-catenin in 18 cases of cervical dysplasia. Our results suggest that the transformation of HPV expressing human keratinocytes requires activation of the Wnt pathway and that this activation may serve as a screening tool in HPV-positive populations to detect malignant progression.

Reactive nodular fibrous pseudotumor involving the pelvic and abdominal cavity: a case report and review of literature

There are several entities that can present with multiple nodular lesions within the peritoneal cavity, such as "disseminated peritoneal leiomyomatosis," "peritoneal fibrosis," "calcifying fibrous pseudotumor," and the recently described lesion of "reactive nodular fibrous pseudotumor of the gastrointestinal tract and mesentery." Here we present one such lesion in a 28-year-old woman with a history of dysmenorrhea and ergotamine use for migraine attacks. Intraoperative exploration of our patient disclosed numerous nodules located throughout the pelvic and abdominal peritoneum. Histopathologically, these lesions were fibrocollagenous nodules composed of sparse wavy spindle cells within hyalinized "keloid-like" collagen surrounded by an inflammatory infiltrate. Some of the nodules were associated with small foci of endometriosis. We believe this lesion is best described by the term "reactive nodular fibrous pseudotumor" and that endometriosis and the use of ergotamine derivatives may be contributing factors.

Evaluation of 36 patients from Turkey with neuronal ceroid lipofuscinosis: clinical, neurophysiological, neuroradiological and histopathologic studies

Neuronal ceroid lipofuscinosis (NCL) is one of the most common progressive neurodegenerative diseases seen in childhood. NCL is inherited as autosomal recessive trait, and is characterized by the accumulation of 'ceroid lipofuscin' in neuronal and extraneuronal cells. Clinical features include seizures, ataxia, myoclonus, loss of vision, and mental and motor deterioration. Although the disease is widely seen across the world, there seems to be an information gap in Asian countries. To date, no comprehensive and detailed studies on NCL have been carried out in Turkey. However, one could predict that the disease is rather frequent in Turkey due to high rates of consanguineous marriages. Thirty-six Turkish patients were evaluated in this study. Sixteen (44.5%) patients were girls, and 20 (55.5%) were boys. Parents were consanguineous in 25 families (80%). In five families (14%), the disease was seen in two sibs. The diagnosis was based on clinical evaluation, and neurophysiological, neuroradiologic, enzymatic, and histopathological studies. Electron microscopic study was the main diagnostic laboratory test. Three patients were classified as infantile NCL, 11 were late infantile NCL, 5 were juvenile type NCL and 17 patients were Turkish variant NCL. In juvenile type, major initial symptom was visual impairment, whereas in all other types seizures were predominantly the first symptom at the onset of the disease. The initial symptoms of Turkish variant NCL were similar to those of late infantile type. Similar age at clinical symptoms and the presence of visual symptoms were common features of Turkish variant and juvenile NCL. Compared to late infantile NCL, Turkish variant, showed a more severe course regarding seizures. Electroencephalogram (EEG) showed abnormal features predominantly in Turkish variant, and were remarkable for occipital spikes. In patients with Turkish variant magnetic resonance imaging of the brain showed brainstem involvement, especially pons, in all patients except one; cerebral and cerebellar atrophy were seen with a slower course compared to late infantile NCL. Clinical picture of NCL in advanced stages of the disease was similar regardless of the subtype.

Epidermolysis bullosa acquisita: clinical manifestations, microscopic findings, and surgical periodontal therapy. A case report

BACKGROUND

Epidermolysis bullosa acquisita (EBA) is an uncommon, acquired, chronic subepidermal bullous disease. This report describes a case of EBA with gingival involvement. A 43-year-old woman with EBA was referred to our clinic for periodontal therapy because of gingival tenderness and bleeding. She has been on cyclosporin A therapy for the last 2 years.

METHODS

Clinical findings were analyzed. Anterior gingivectomy operations were performed in 2 stages. The samples obtained during the surgery were examined using histopathologic, immunohistologic, and electronmicroscopic methods. Long-term effects of the surgical periodontal treatment on gingiva were evaluated both clinically and microscopically.

RESULTS

The dentition displayed minimal enamel hypoplasia. Decayed, missing, and filled surfaces score was found to be elevated. Periodontal examination showed generalized diffuse gingival inflammation and gingival enlargement localized mainly to the anterior region. Nikolsky's sign was positive. However, wound healing was uneventful after the operations. Microscopic findings were similar to those obtained from the skin. Twenty-one months after the operations, Nikolsky's sign was negative and no remarkable gingival inflammation was noted. Microscopic examination revealed that the blisters were fewer in number and smaller in size.

CONCLUSIONS

These results indicate that gingival tissues may also be involved in EBA. Uneventful wound healing after periodontal surgery in this case suggests that periodontal surgery can be performed in patients with EBA. Moreover, both our clinical and histopathologic findings imply that gingivectomy proves useful in maintaining gingival integrity in these patients. Our data may also suggest that the patients with EBA are highly likely to develop dental caries.

Search for problem areas in endometrial biopsies to achieve quality assurance

The aim of this study was to underline the frequently seen problems in diagnosing the lesions seen in the hyperplasia-carcinoma sequence by evaluating the variances between the observers. Four pathologists re-evaluated 137 endometrial biopsies and grouped them into diagnostic categories. The results were analyzed by Kappa statistics. Full agreement was reached in 89 cases (64.96%), with Kappa values ranging between 0.63-0.74. Three observers rendered the same diagnosis in 34 (24.81%) cases, and only one pathologist disagreed. Two or more observers held different views in 16 cases (10.95%). The problem areas were as follows: criteria distinguishing simple hyperplasia from other benign lesions, discrimination between atypical hyperplasia and carcinoma, and decision-making regarding the presence of atypia. There was a tendency towards overdiagnosis of hyperplasia in our department. Since the progression to carcinoma is a sequential event, borderline cases will exist if categories based on simple and clear cut off points are not defined.

Renal tubular apoptosis after complete ureteral obstruction in the presence of hyperoxaluria

Hyperoxaluria is a well-known cause of renal stone disease and in vitro studies have shown that oxalate crystals have a stimulatory effect on apoptosis of renal tubular epithelial cells. Total and partial ureteral obstruction also have an accelerating effect on apoptosis of renal tubular epithelial cells. The aim of the present study was to investigate the apoptotic effect of unilateral ureteral obstruction in the presence of hyperoxaluria on the rat kidney. Twenty-eight male Wistar rats were divided into four groups, with seven rats in each. The groups were named G1 (control), G2 (hyperoxaluric), G3 (obstructive) and G4 (hyperoxaluric + obstructive). G2 and G4 rats were given 1% ethylene glycol (a precursor for oxalates) in their drinking water. G1 and G2 rats underwent sham operation, while left proximal ureteral ligation with a 5-zero silk suture was performed on G3 and G4 animals. The rats were sacrificed 2 weeks after the operation; left nephrectomy was then performed. We searched for the apoptotic cells by direct immuno-peroxidase detection of digoxigenin-labeled genomic DNA. The mean +/- SD values of the apoptotic cell count was 0.86+/-0.90 in G1 and 4.33+/-3.81 in G2. The values for G3 and G4 were 30.17+/-16.85 and 302.67+/-184.45, respectively. We found a statistically significant difference between all groups (P < 0.001). When compared with the control group (G1), the mean apoptotic cell count was fivefold that of G2 and 35- and 351-fold those of G3 and G4, respectively. Our study demonstrated that hyperoxaluria with complete ureteral obstruction induces an excessive level of apoptosis, which is responsible for renal damage, and that ureteral obstruction is a more important factor for apoptosis than hyperoxaluria. Considering these data, we also believe that research studies for medical preventive measures must be considered for patients with ureteral obstruction and/or hyperoxaluria.

The protective effect of taurine against gentamicin-induced acute tubular necrosis in rats

BACKGROUND

Taurine, which is the major intracellular free beta-amino acid, is known to be an endogenous antioxidant and a membrane-stabilizing agent. In this study, we wished to know whether taurine altered the concentration of gentamicin in kidney tissue and could protect against gentamicin-induced acute proximal tubular injury.

METHODS

Wistar albino rats of both sexes were assigned to three groups, which all received one of the following daily intraperitoneal injections for 8 days: (i) 0.9% sodium chloride (NaCl) alone at the same volume as gentamicin treated rats (group C; n=8); (ii) 100 mg/kg/day gentamicin alone (group G; n=8, four male, four female); or (iii) 100 mg/kg/day gentamicin plus 7.5 ml/kg/day taurine (group G+T; n=9, five male, four female). Urine was collected for 24 h for the determination of urine volume and creatinine. Intracardiac blood was collected for blood urea nitrogen (BUN) and serum creatinine determination. The kidneys were removed, weighed, and the left kidneys were subjected to biochemical analysis for the determination of thiobarbituric acid-reactive substance (TBARS) and lactate levels, and glutathione peroxidase (Gpx) and superoxide dismutase (SOD) activities. The right kidneys were divided vertically in half. The upper halves were used for histopathological examination, by light and electron microscopy. The lower halves were used to detect the gentamicin concentration within the kidney tissue, by high-performance liquid chromatography (HPLC). Changes in body weight and normalized kidney weight were recorded.

RESULTS

Taurine treatment reduced gentamicin-induced increases in serum creatinine, 24 h urine volume, BUN and tissue lactate and TBARS levels (0.57+/-0.02 vs 1.06+/-0.08 mg/dl, P<0.001; 9.00+/-1.46 vs 20.9+/-2.73 ml, P<0.001; 25.3+/-1.87 vs 54.1+/-6.99 mg/dl, P<0. 001; 2.56+/-0.10 vs 3.44+/-0.08 micromol/g wet tissue, P<0.001; and 66.4+/-3.41 vs 79.5+/-5.07 nmol/g wet tissue, P>0.05, respectively). Taurine reduced the accumulation of gentamicin within the kidney tissue (233+/-29 vs 494+/-93 microg/g wet tissue, P<0.05). Taurine treatment also prevented body weight loss due to gentamicin administration (17.8+/-1.64 vs -10.0+/-7.08 g, P<0.01) and normalized reduced Gpx and SOD activities (3.46+/-0.16 vs 2.37+/-0. 15 U/g wet tissue, P<0.01; and 15577+/-377 vs 12662+/-577 U/g wet tissue, P<0.01, respectively). Light microscopic examination of the renal tissues from gentamicin-treated rats revealed severe histopathological changes, whereas specimens obtained from taurine-treated rats revealed only mild changes. This finding was supported by electron microscopic examination.

CONCLUSIONS

Our observations suggest that taurine treatment attenuates the accumulation of gentamicin within kidney tissue and counteracts the deleterious effect of gentamicin on renal tubular function. They may have potentially important clinical implications.

Disseminated peritoneal leiomyomatosis. A benign entity mimicking carcinomatosis

Disseminated peritoneal leiomyomatosis (DPL) is a rare entity, occurring primarily in premenopausal women. The lesion is characterized by numerous subperitoneal nodules of benign smooth muscle proliferations which usually mimics the macroscopic appearance of the peritoneal carcinomatosis. We report a case of DPL and multiple uterine leiomyomas, occurring in a 50 year old premenopausal woman who was on oral contraceptives for the last three years. In order to diagnose this entity clinicians and pathologists have to be alert and collaborative during the intraoperative frozen section consultation.

Fibroadenoma of the vulva

A well-circumscribed mass was excised from the vulva of a 37-year-old woman. Histological and immunohistochemical findings showed the characteristic features of fibroadenoma of breast. The concepts about the histogenesis of this lesion were discussed.

Prognostic factors and the role of nephrectomy in metastatic renal cell carcinoma

The objective of this study is to evaluate the prognostic factors and the role of nephrectomy in metastatic renal cell carcinoma. We reviewed 62 cases of metastatic renal cell carcinoma to document the factors influencing survival and to evaluate the role of nephrectomy. Sex and age of patients, size of primary tumor, site and number of metastases, nephrectomy, cell type and grade of tumor and medical treatment were analyzed as prognostic factors. Age and sex, cell type and type of medical treatment cannot be considered reliable predicting factors. However, improved survival was correlated with tumor size < or = 7 cm in diameter, low grade histology, metastasis limited to single organ and removal of the primary tumor. When these parameters were analyzed in a multivariate model, the presence of nephrectomy was the sole significant parameter. We therefore suggest that nephrectomy should be considered in all patients with metastatic renal cell carcinoma, as long as the morbidity of the operation is acceptable.

Prognostic factors and the role of nephrectomy in metastatic renal cell carcinoma

The objective of this study was to evaluate the prognostic factors and role of nephrectomy in metastatic renal cell carcinoma. We reviewed 62 cases of metastatic renal cell carcinoma (RCC) at presentation to document the factors influencing the survival and to evaluate the role of nephrectomy. Sex and age of the patients, size of the primary tumour, site and number of the metastases, nephrectomy, cell type and grade of the tumour and type of the medical treatment were analyzed as prognostic factors. The age and sex of the patients, cell type and type of the medical treatment did not appear to be significant predictors of prognosis. However, improved survival was correlated with tumours < or =7 cm in diameter, low grade tumours, metastasis limited to single organ and removal of the primary tumour. When these parameters were analyzed in a combined manner patients who had undergone nephrectomy showed consistently longer survival. We suggest that nephrectomy should be considered in all patients with metastatic RCC, as long as the morbidity of the operation is predicted to be acceptable.

Clinical and histopathologic findings of iris nevus (Cogan-Reese) syndrome

PURPOSE

To report a case of Cogan-Reese syndrome.

METHOD

Case report. A 37-year-old man presented with Cogan-Reese syndrome.

RESULTS

Visual acuity was 0.5 in the right eye and 1.0 in the left eye. There were corneal edema and pigmented nodules on the anterior surface of the iris, iris atrophy and ectropion uvea in the right eye. The intraocular pressure was 42 mmHg in the right eye and there was glaucomatous optic atrophy of the optic disk. Trabeculectomy with mitomycin C has been performed as the intraocular pressure did not decrease with the maximum medical treatment. Electron microscopic examination of the trabeculum and the iris tissue revealed a lot of melanocytic cells in the stroma.

CONCLUSION

Trabeculectomy with mitomycin C might be effective in Cogan-Reese cases with glaucoma resistant to medical treatment.

Kindler syndrome: absence of definite ultrastructural feature

Kindler syndrome is characterized by congenital blister formation, photosensitivity, poikiloderma, and cutaneous atrophy in later life. There are few reports about the ultrastructural features of this syndrome, but still there is no consensus about the basic disease. Here we report a case of Kindler syndrome with ultrastructural findings.

Comparison of grading systems for estimating the prognosis of renal cell carcinoma

In this study histologic slides of 165 patients who were diagnosed as RCC between 1983 and 1993 were re-evaluated and each tumour was graded according to Thoenes, Fuhrman, Arner and Skinner's grading systems. According to Thoenes' system, patients with grade (G) 2 and 3 tumours had significantly shorter survival compared to patients with G 1 tumours. The survival difference between the subgroups of Fuhrman and Skinner's grading systems did not reach statistical significance. When the histologic differentiation was grouped as low grade (G 1&2) and high grade (G 3&4) tumours in Fuhrman and Skinner's systems, a statistically significant difference was noted between the groups in terms of survival.

The value of intraoperative consultation (frozen section) in the diagnosis of ovarian neoplasms

BACKGROUND

Frozen Section is an important diagnostic tool to determine the nature of ovarian masses. However, like other diagnostic tools, frozen section also has some pitfalls. We aimed to discuss the source and the nature of inaccuracies associated with this procedure.

METHODS

In this retrospective study 360 cases of ovarian masses examined by frozen section were re-evaluated. The sensitivity, specificity and predictive values of frozen section diagnosis of ovarian tumors were calculated. The reasons for the erroneous frozen-section diagnoses were discussed.

RESULTS

Overall diagnostic agreement for ovarian lesions was 94.2%. Disagreements were found in nine cases (2.5%). Diagnosis was deferred to permanent sections in 12 cases (3.3%). The sensitivity for malignant tumors was 93.1% and specificity was 99.2%. The sensitivity for benign tumors was 99.2% and specificity was 92.1%. Most problematic cases were mucinous tumors, followed by tumors resembling fibrothecomas, in addition sections without viable tissue fragments or presence of extensive hemorrhage and necrosis also obscured the frozen diagnosis. Another factor was the lack of an effective communication between the surgeon and the pathologist.

CONCLUSIONS

For an effective usage of this method not only the pathologist but also the surgeons must know the pitfalls of this method and also there must be good communication between the pathologist and the surgeon. Especially deferred cases should be minimized by good communication. In fact it's an intraoperative consultation method that enables the pathologist to gather all the preoperative, intraoperative findings and to be familiar with the further treatment plan of the patient.

nm23 protein expression in renal cell tumors: the role of the cell type

This study investigated nm23 protein expression in renal cell carcinomas to determine the relationship between nm23 protein expression and grade, stage, prognosis and the cell type. 89 cases were examined by immunohistochemistry. Tubular epithelia were homogeneously stained. Cytoplasmic nm23 protein levels were reduced in renal cell carcinoma. nm23 protein levels persisted in oncocytomas, which are accepted to be benign. Cytoplasmic nm23 staining intensity did not show any correlation with stage and grade of tumor nor prognosis. Reduction in nm23 protein levels may have a role during renal cell carcinoma pathogenesis but not in progression or metastasis suppression.

Prognostic factors in renal cell carcinoma

In this study we evaluated some morphological and clinical prognostic factors in 166 patients with renal cell carcinoma (RCC). Patients' ages, sex and localization of the tumor had no effect on survival. Tumor diameter and the weight of the nephrectomy specimen revealed prognostic value. Stage of the tumor, especially the presence of metastasis, is the most important prognostic factor for RCC (p < 0.001). Tumor grade had prognostic value (p = 0.0146). The survival difference between cell types was not significant (p > 0.05). Renal vein invasion, the presence of pseudocapsules and tumor in the intravascular space, mitotic rate, the presence and the number of lymphocytes and macrophages, along with the presence of calcifications had no prognostic value (p > 0.05). The presence of necrotic areas was significant (p = 0.0102). The patients with "infiltrative growth pattern" showed poorer prognosis than patients with "pushing type growth pattern", regardless of the existence of a pseudo capsule (p = 0.0045).

Six chromophobe cell carcinomas and one mixed renal cell carcinoma with chromophobe cell features: clinical and pathological implications

OBJECTIVE

To determine the incidence and clinical and pathological features of chromophobe cell carcinoma (CCC) among renal cell carcinomas (RCCs).

MATERIALS AND METHODS

The records and nephrectomy samples from 166 patients who were operated on and followed up thereafter with a diagnosis of RCC were re-evaluated. New sections were cut and specific staining performed when deemed necessary.

RESULTS

Of 166 patients with RCC, six were diagnosed as having CCC and, unusually, one patient had a mixed RCC with areas of CCC. Neither the symptoms nor radiological features of these seven patients differed from those of the patients with RCC; the serum ferritin levels of these seven patients were also within the normal range. These patients appeared to have a favourable clinical course.

CONCLUSION

Chromophobe cell carcinoma is a distinct entity and must be distinguished particularly from oncocytoma and other variants of RCC. Although it seems to have a low malignant potential, metastatic CCC may have a worse prognosis.