PSA Doubling Time as a Predictor of the Outcome of Random Prostate Biopsies Prompted by Isolated PSA Elevation in Subjects Referred to an Outpatient Biopsy Facility in a Routine Clinical Scenario

Aim

To assess the validity of PSA doubling time (PSADT) as a predictor of prostate sextant biopsy outcome in patients with PSA levels in the 4–10 ng/mL range.

Material and methods

A consecutive series of 355 sextant biopsies performed during 2001–2007 in subjects with negative digital rectal examination and transrectal ultrasonography was considered. Variables tested as possible predictors were age, total and free/total PSA value, PSA velocity and PSA doubling time. While PSA at time of biopsy and free/total PSA were determined with a standardized method undergoing strict quality control, previous PSA values used to assess velocity/doubling time came from other labs using different assays over widely varying intervals of time. The association with biopsy outcome (cancer vs non-cancer) was investigated by univariate and multivariate analysis.

Results

Apart from free/total PSA ratio, no other studied variable showed a statistically significant and independent association with biopsy outcome, either at univariate or multivariate analysis. No studied variable had a good performance as a biopsy indicator. Depending on the variable considered, 1.17 to 1.97 cancers would be missed to spare 10 benign biopsies.

Conclusion

When based on PSA data determined with different assays over widely varying intervals and in the absence of an underlying protocol for PSA surveillance, PSA velocity and doubling time should never discount a biopsy prompted by total PSA elevation.

Severe fibrotic changes and altered expression of angiogenic factors in maternal scleroderma: placental findings

OBJECTIVE

Pregnant women with systemic sclerosis (SSc; scleroderma) have an increased risk of premature delivery and small full-term infants. During placental development, angiogenesis and vascular remodelling are essential for a successful pregnancy outcome. An analysis was made of the pathological changes and expression of angiogenic factors in SSc placentas.

METHODS

Placenta biopsies were obtained from three patients with SSc and four healthy uncomplicated pregnancies after delivery at 34-38 weeks of gestation. The sections were stained with Masson's trichrome and phosphotungstic-acid-haematoxylin and immunostained for connective tissue growth factor (CTGF), alpha-smooth muscle actin (alpha-SMA), vascular endothelial growth factor (VEGF), placenta growth factor (PlGF) and receptors VEGFR-1 and VEGFR-2.

RESULTS

The pathological findings were signs of decidual vasculopathy, increased syncytiotrophoblast knotting, placental infarcts and villous hypoplasia. Severe and diffuse perivascular and stromal fibrosis of decidua and chorionic villi, and extensive deposition of fibrinoid material around decidual vessels and in intervillous spaces were observed. Strong CTGF expression in the vessel wall, decidual cells and fibroblasts and alpha-SMA+ myofibroblasts were found. VEGF and VEGFR-2 expression was stronger in SSc than in healthy placentas, while VEGFR-1 expression was similar to controls. PlGF immunopositivity was weaker in SSc.

CONCLUSION

In SSc placentas, severe fibrosis and abnormal vascular remodelling were detected. This may result in reduced blood flow leading to deep sufferance of maternal placenta and possible premature delivery.

Growth inhibition and differentiation of human breast cancer cells by the PAFR antagonist WEB-2086

WEB-2086 – an antagonist of platelet-activating factor receptor (PAFR) with known anti-inflammatory, antiangiogenic and antileukaemic properties – also proved to inhibit the proliferation in human solid tumour cell lines of different histology, and with much higher efficacy than in normal fibroblasts. A detailed analysis of WEB-2086 anticancer activity was then performed focusing on breast adenocarcinoma MCF-7 and MDA-MB-231 cells. WEB-2086-treated cells, either expressing (MCF-7) or unexpressing (MDA-MB-231) the oestrogen receptor (ER)α, underwent a dose-dependent growth arrest (IC₅₀=0.65±0.09 and 0.41±0.07 mM, respectively) and accumulation in G₀–G₁ phase. WEB-2086 also induced morphological and functional changes typical of mature mammary phenotype including (i) cell enlargement and massive neutral lipid deposition (best accomplished in MCF-7 cells); (ii) decrease in motility and active cathepsin D levels (mainly observed in highly invasive MDA-MB-231 cells). The expression of ERα was neither increased nor reactivated in treated MCF-7 or MDA-MB-231 cells, respectively. WEB-2086-induced differentiation in breast cancer cells involved the upregulation of PTEN, a key tumour suppressor protein opposing tumorigenesis, and was apparently independent of p53, PAFR, peripheral benzodiazepine receptor and ERα status. Overall, WEB-2086 can be proposed as an effective antiproliferative and differentiative agent with interesting translational opportunities to treat breast cancers in support to conventional chemotherapy.

[The Haemolymphopathology Italian Group (H.I.G.): an essential resource for the new technical and organization problems troubling modern haemolymphopathology diagnostics]

Recently, many progresses have been recorded in the molecular and histogenetic characterization of the haematopoietic and lymphoid tumours, resulting in important classifying changes. As a consequence, the exact definition of lymphoma subtype requires an integration between traditional morphologic "expertise" and several bio-functional data obtained from advanced and complex ancillary techniques (immunohistochemistry, molecular biology and cytogenetics). At the same time, the data provided by gene expression profiling studies are going to deeply modify the therapies in haematological cancers. These studies are expected to allow the achievement of single-patient-tailored genic therapy; for this reason it is necessary to get biological samples of good quality. Indeed, while these progresses contribute to highlight the pathologist's diagnostic role, they should make us reflect on the state of the art of the Italian haemolymphopathology diagnostics and on its ability to cope up with the new challanges. The aim of this article is to outline a realistic picture of the present condition, and to explain the reasons for setting up, inside SIAPEC-IAP, the Haemolymphopathology Italian Group (H.I.G.). The purpose of H.I.G. will be twofold: first of all, scheduling of a series of projects so as to the haemolymphopathological diagnostic standardization; secondly, building a national network among all the pathologists involved in this exciting and complex field of the anatomic pathology.

Consistency of prostate cancer grading results in screened populations across Europe

OBJECTIVE

To assess the consistency of grading outcome among seven of eight participating centres of the European Randomised Screening Program of Prostate Cancer (ERSPC), a multicentre randomized trial intended to detect a difference in prostate cancer-related mortality between screened participants and a control group. Currently, tumour stage and grade in prostatectomy specimens represent the most predictive variables for biological behaviour. In prostate needle biopsies the tumour grade is a strong factor for deciding therapy.

PATIENTS AND METHODS

Within the ERSPC all prostate cancers detected in needle biopsies were graded according to the Gleason score system. Gleason scores were compressed in three categories of < or = 6, 7 and 8-10. Data for grading outcome were obtained from the databases from seven individual centres; in one centre the slide sets with cancer were separately reviewed.

RESULTS

Combining the data of seven ERSPC centres 66% of cancers detected in the screening arm were Gleason score < or = 6 and 92% were < or = 7. Gleason score 8-10 cancers varied from 2 to 11%. This variation in Gleason scores may be attributed to differences in the population characteristics and biopsy indications.

CONCLUSIONS

These data indicate that in the seven ERSPC centres most screen-detected cancers have favourable characteristics on biopsy. Men with these cancers are amenable for treatment with curative intent. The observed differences in Gleason score distribution in different centres may partly be attributed to geographical differences and differences in the age range of the screened populations.

Guidelines for processing and reporting of prostatic needle biopsies

The reported detection rate of prostate cancer, lesions suspicious for cancer, and prostatic intraepithelial neoplasia (PIN) in needle biopsies is highly variable. In part, technical factors, including the quality of the biopsies, the tissue processing, and histopathological reporting, may account for these differences. It has been thought that standardisation of tissue processing might reduce the observed variations in detection rate. Consensus among the members of the pathology committee of the European Randomised study of Screening for Prostate Cancer (ERSPC) concerning the optimal methodology of tissue embedding resulting in guidelines for prostatic needle biopsy processing was reached. The adoption of an unequivocal and uniform way of reporting lesions encountered in prostatic needle biopsies is considered helpful for decision taking by the clinician. The definition of parameters for quality control of prostatic needle biopsy diagnostics will further facilitate clinical epidemiological multicentre studies of prostate cancer.

Transperineal sonography guided biopsy of the prostate: critical review of 1107 cases

PURPOSE

To assess the predictive value for a positive biopsy of different indicators (rectal examination, transrectal ultrasonography, total PSA, PSA density).

MATERIAL AND METHODS

Positive predictive value was assessed on 1107 consecutive US-guided transperineal biopsies performed from 1991 to 2001 (cancer=344, dysplasia (PIN)=64, atypical hyperplasia=4, benign hyperplasia=686, inadequate=9) with univariate and multivariate analysis.

RESULTS

Increasing age (chi square for trend 52.2, p <0.001), positive rectal examination (chi square 233, df=1, p<0.001) or ultrasonography (chi square 191, df=1, p<0.001), total PSA (chi square for trend 68.9, p<0.001) and PSA density (cutoff 0.15, chi square 104, df=1, p<0.001; cutoff 0.20, chi square 104, df=1, p<0,001) were all significantly associated to the likelihood of a positive biopsy outcome. Multivariate analysis stresses the independent role of Psa density over total PSA. If the parameters studied had determined the biopsy, spared benign biopsies [positive rectal examination=505 (66%), positive ultrasonography=467 (61%), PSA>4=124 (16%), PSA>10=159 (74%), PSA density >0,15=426 (62%), PSA density >0.20=517 (75%)] would not have justified the amount of delayed cancer biopsies [positive rectal examination=103 (29%), positive ultrasonography=55 (15%), PSA>4=42 (12%), PSA>10=569 (46%), PSA density >0,15=73 (25%), PSA density >0,20=107 (37%)].

CONCLUSIONS

The parameters currently available prior to biopsy, if used alone, allow no reliable prediction of biopsy outcome. Positive predictive value, particularly for PSA density, allows a better evaluation of biopsy indication, particularly for random sextant biopsies in the 4-10 ng/ml PSA range, which are frequently negative.

Laparoscopic decapsulation of a large epidermoid splenic cyst in a child using the UltraCision LaparoSonic Coagulating Shears

Splenic cysts are rare in pediatric surgery. Congenital epidermoid cysts are exceptional representing only 2.5% of all splenic cysts in childhood. Nowadays, considering the short- and long-term complications of splenectomy in children, the management of epidermoid cyst consists of partial splenectomy or decapsulation of the cystic wall. To our knowledge, the case reported in this article describes the first successful laparoscopic decapsulation of an epidermoid splenic cyst in an 10-year-old child using the UltraCision LaparoSonic Coagulating Shears (LCS). Follow-up at six months confirms no recurrence. Laparoscopic splenic decapsulation provides minimal access and small surgical trauma for treating the cyst while preserving splenic function. The use of UltraCision LCS makes the laparoscopy safely, expeditiously, with minimal blood loss and short hospital stay.

[Histologic microbiopsy with 14 G needle in the diagnosis of breast lesions. Experience with 1000 cases]

PURPOSE

We report our experience with large core biopsy (LCB: 14-Gauge needles) of questionable or suspicious breast lesions detected at mammography and/or US. All biopsies were performed under instrumental guidance. We also report on technique, costs, time, advantages and disadvantages of the method and, finally, give precise indications on when and why large core biopsy is needed.

MATERIAL AND METHODS

From january 1996 to may 2000 we performed 1000 microhistologic biopsies on breast lesions at the Unità Integrata di Senologia, Azienda Ospedaliera Careggi, Florence; 650 (65%) were non palpable lesions. Large core needles were used (14-Gauge caliber). In the majority of cases (70%) we used US guidance, in the others a stereotactic guidance was employed.

RESULTS

Microhistologic biopsy allowed accurate characterization in most cases. Inadequate samples were obtained in 15 cases. The false negative rate was 6%. Surgery was needed to characterize the lesion unquestionably in 13 cases only.

CONCLUSION

In agreement with literature reports, our results confirm large core biopsy as an adequate alternative to surgical biopsy and, to some extent, to FNAC, thanks to its moderate invasiveness, low costs, short execution time, little patient discomfort and high sensitivity (93.98%) and specificity (99.7%).

Epstein-Barr virus infection and P53 expression in HIV-related oral large B cell lymphoma

BACKGROUND

Head and neck non-Hodgkin's lymphomas in HIV positive patients are highly related with Epstein-Barr virus (EBV) infection. In general, viral agents can alter p53 protein levels by enhancing degradation of cellular p53 or by increasing its half-life by viral protein-p53 interaction. Moreover, it has been reported that modifications of p53 gene can modulate tumor cells' response to radio- and chemotherapy.

METHODS

To assess a possible role of EBV infection, p53 protein deregulation, and p53 gene alterations in exons 5 to 8, we have studied six cases of HIV-related primary oral large B-cell lymphoma. We used in situ hybridization (ISH) for EBV-DNA and EBV-encoded nuclear RNA-1 (EBER-1), immunohistochemistry (IHC) for EBV latent membrane protein -1 (LMP-1) and p53 proteins expression, and single strand conformational polymorphism (SSCP) analysis to screen p53 gene mutations in exons 5 to 8.

RESULTS

The EBV-DNA was present in all specimens, according to conventional DNA-ISH. No evidence for EBER-1 was found by ISH. The presence of EBV-DNA was correlated with the LMP-1 expression in all but one case. Moreover, p53 protein expression was negative in three cases and strongly positive in the others. However, mutational analysis of p53 gene in exons 5-8 showed no alteration.

CONCLUSIONS

Our data may suggest that both EBV infection and LMP-1 expression may cause p53 loss of function even in the absence of p53 gene mutations, as assessed by SSCP. We speculate that the presence of EBV-infection and p53 protein deregulation may be responsible for radio- and chemotherapy resistance, by influencing apoptosis of cancer cells.

Ethanol-induced alterations of matrix network in the duodenal mucosa of chronic alcohol abusers

Excessive consumption of alcoholic beverages may be associated with gastrointestinal symptoms, including dyspepsia and diarrhoea. It is not clear whether or not chronic alcohol ingestion damages the mucosa of the small intestine. We investigated the effect of chronic alcohol abuse on the duodenal mucosa, and particularly on its extracellular matrix (ECM) network. Duodenal biopsy specimens were obtained during upper gastrointestinal endoscopy from 50 chronic alcoholics without cirrhosis and 10 healthy subjects. Morphological studies were performed by routine histology, immunohistochemistry and electron microscopy. Morphometry of duodenal tissues was performed with a computerized image analyser. No significant duodenal epithelial changes were found in alcoholics, despite an evident reduction in the enterocyte turnover. Myofibroblast-like cells were significantly increased in the villus stroma of alcoholics in comparison to controls. These cells stained positively for desmin, alpha-smooth muscle actin and for several ECM components. In alcohol abusers the thickness of the mucosal basement membrane was greater and the staining for collagen I and III was enhanced both in the basement membrane and in the villus stroma. A higher expression of tenascin was also seen at the base of villi of alcoholics. Chronic alcohol abuse may induce fibrosis of duodenal villi which is associated with a transformation of villus juxta-parenchymal cells into active subepithelial myofibroblast-like cells able to produce different ECM components.

Persistent damage to Enterocytozoon bieneusi, with persistent symptomatic relief, after combined furazolidone and albendazole in AIDS patients

AIM

To investigate morphological changes in Enterocytozoon bieneusi and the duration of symptomatic relief after combination treatment with furazolidone and albendazole in AIDS patients.

METHODS

Four severely immunocompromised AIDS patients with symptomatic E bieneusi infection of the gut received an 18 day course of combined furazolidone and albendazole (500 + 800 mg daily). All patients were monitored for parasite shedding in stool by light microscopy at the end of treatment and monthly during follow up. At the end of treatment, duodenal biopsy specimens obtained from three patients were studied by transmission electron microscopy by two pathologists blind to the patients' treatment or clinical outcome. Duodenal biopsy specimens obtained from one of the patients two months after completion of treatment were also studied electronmicroscopically.

RESULTS

All patients had long lasting symptomatic relief, with a major decrease--or transient absence--of spore shedding in stools from completion of treatment. After treatment, changes in faecal spores were persistently found by light microscopy in all cases, and there was evidence of both a substantial decrease in the parasite load and ultrastructural damage in the parasite in all biopsy specimens. The treatment was well tolerated, and no patient had clinical or parasitological relapse during follow up (up to 15 months).

CONCLUSIONS

The long lasting symptomatic relief observed in all four treated patients correlated with the persistent decrease in parasite load both in tissue and in stool, and with the morphological changes observed in the life cycle of the protozoan. These data suggest that combined treatment with furazolidone and albendazole is active against E bieneusi and may result in lasting remission even in severely immunocompromised patients.

[Percutaneous biopsy in the definition of breast lesions: fine needle vs. 14-gauge]

INTRODUCTION

Any breast lesion/abnormality detected at mammography must be characterized as (non)-neoplastic before surgery. Fine needle aspiration cytology (FNAC) permits a precise diagnosis in over 70% of cases but exhibits many inadequate, false negatives or questionable findings. This makes surgical biopsy mandatory in many cases. An alternative is offered by fine needle biopsy (FNB: 16-18 G needles) or by large core biopsy (LCB: 14 G needles), which procedures can reduce the number of questionable diagnoses with no major discomfort or side-effects for the patient.

MATERIAL AND METHODS

January, 1996, to October, 1997, we performed 422 microhistologic biopsies on breast lesions at the Unità Integrata di Senologia, Azienda Ospedaliera Careggi, Florence, Italy. 383 of these lesions were nonpalpable. FNB was performed in 221 cases and LCB in 201. Most biopsies (65%) were carried out under US guidance and some others (25%) under stereotactic guidance.

RESULTS

Microhistologic biopsy allowed accurate lesion characterization in most cases, even though LCB obviously performed much better. Samples were inadequate in 5.88% of cases with FNB and only in 2.98% of cases with LCB. The false negative rate was 1.92% for FNB and 0.99% for LCB. Surgical biopsy was needed for an unquestionable diagnosis only in 9.5% of FNB and 3.9% of LCB cases.

CONCLUSIONS

Our results confirm the literature data on how LCB can be considered a valid alternative to surgical biopsy (and, to some extent, to FNAC); in particular, its advantages are: moderate invasiveness, little patient discomfort and high diagnostic accuracy. Moreover, the procedure is short (5-10 minutes) and costs much less than surgical biopsies (1/2 to 1/4).

Chronic cryptosporidiosis in patients with AIDS: stable remission and possible eradication after long-term, low dose azithromycin

AIMS

To investigate the effectiveness of long term, low dose azithromycin treatment for chronic cryptosporidiosis in patients with AIDS.

METHODS

Azithromycin was administered as initial daily treatment to 13 patients with AIDS: 6 patients received 500 mg for 30 to 40 days (mean 35); 3 patients received 1000 mg for 21 to 50 days (mean 37); and 4 patients received 1500 mg for 20 days. Nine of the 13 patients were also given low dose maintenance treatment with different schedules of azithromycin for 30 to 360 days (mean 129). Patients were monitored, during and after treatment, for parasite shedding in stool and for daily stool frequency and body weight. All but one patient had severe immunodeficiency.

RESULTS

Long term, low dose maintenance treatment was associated with major clinical and parasitological benefits: there was probable eradication of infection in 2 patients, and 7 patients showed a complete response with persistent high decrease (5 patients) or clearance (2 patients) of parasite in stool. The drug was well tolerated, and there was no relapse either during treatment or during follow up (up to 21 months). These results were more impressive than those observed after the short term initial course of azithromycin, which was unable at any tested dose to achieve parasite clearance in stool (except in the patient with less advanced immunodeficiency) or to prevent relapse in 3 patients who discontinued treatment. Reversible side effects occurred with the 1500 mg daily dose.

CONCLUSIONS

Long term, low dose azithromycin is well tolerated and may induce stable remission of chronic cryptosporidiosis in patients with AIDS. It may lead to probable eradication of the infection in some patients, even those with severe immunodeficiency.

The morphology of the prostatic capsule with particular regard to the posterosuperior region: an anatomical and clinical problem

The composition of the prostatic capsule is important from a clinical point of view, since it is considered to be a barrier against the spread of prostatic tumours. Clinical follow-up demonstrates that apparently intracapsular tumours, particularly in the posterosuperior region of the gland, are frequently understaged at clinical diagnosis. The morphology of the prostatic capsule was studied in 6 cadavers. In each case the prostate was obtained in one block together with the basal portion of the bladder, the seminal vesicles, the anterior wall of the rectum and the periprostatic connective tissue. Part of the material was plastinated, while the remainder was studied using histological and immunohistochemical methods. The prostate was found to be surrounded by connective tissue abundant with smooth muscle cells, and continuous with the stromal septa which subdivide the glandular tissue. A rich network of blood vessels was identifiable. In some regions, particularly in the posterosuperior region, a real capsule was not identifiable. The connective tissue seemed to constitute a continuum between the prostate gland and neighbouring organs, in particular, a connective tissue barrier between the prostate and the seminal vesicles was completely absent. Therefore, due to the absence of a capsular barrier and to the presence of a rich vascular network a prostatic tumour which begins in the posterior region of the gland should be considered as potentially extracapsular.

Enterocytozoon bieneusi in AIDS: symptomatic relief and parasite changes after furazolidone

AIMS

To investigate changes in morphology of the developmental stages of Enterocytozoon bieneusi and symptomatic relief observed in AIDS patients after treatment with furazolidone.

METHODS

Six AIDS patients with symptomatic E bieneusi infection of the small intestine were treated with a course of furazolidone. All patients had a weekly monitoring of parasite shedding in stool by light microscopy during and after treatment. At the end of the treatment, duodenal biopsy specimens obtained from three patients were studied by transmission electron microscopy by two pathologists who were unaware of the patients' treatment.

RESULTS

All patients showed both clinical and parasitological response with transient clearance or decrease of spore shedding in stool. After treatment, alterations in faecal spores were observed in all patients by light microscopy, and ultrastructural changes in E bieneusi at all stages of the life cycle were demonstrated in biopsy specimens of the three patients who underwent post-treatment endoscopy.

CONCLUSIONS

The clinical benefit seen after treatment with furazolidone in six AIDS patients with E bieneusi intestinal infection may be due to damage to the developmental stages causing a partial inhibition to reproduction of the parasite.

Morphological injury of the intestinal mucosa and infection in patients with AIDS. The role of combined tissue and stool examination

AIMS

To define the relationship between morphological injury of the intestinal mucosa and infections in AIDS patients.

METHODS

Forty-nine AIDS patients were examined by upper gastrointestinal (GI) endoscopy and 8 of them also by lower GI endoscopy. Biopsy specimens, taken from the lower duodenum, esophagus and rectum, were studied by light (L.M.) and transmission electron microscopy (T.E.M.). Stool examination for microorganisms was routinely performed in all patients.

RESULTS

Microorganisms were detected in 37 of the 49 patients (75.5%) by combined tissue and stool examination. The histological study revealed villous atrophy, inter- and intra-enterocyte oedema and epithelial degenerative changes in most of the patients whether or not they had detectable microorganisms.

CONCLUSIONS

Combined methods (endoscopy, L.M. and T.E.M., studies of tissue samples, microbiological study of stool samples) may be used to improve the documentation of infections and morphological injury of the intestinal mucosa in AIDS patients.

Chronic intestinal infection due to subgenus F type 40 adenovirus in a patient with AIDS

A case of chronic intestinal infection due to adenovirus type 40 lasting for 13 months in a patient with AIDS is described. Adenovirus particles were detected by electron microscopy in biopsy samples taken from the duodenum 3 months after the onset of diarrhoea. The virus was identified as adenovirus type 40 in stool samples by ELISA monoclonal antibodies to adenovirus group antigen (MAd-g2) and types 40 and 41 (MA 40-1 and MA 41-1). No other enteropathogens were found. These data support a causal relationship between adenovirus 40 and the gastrointestinal symptoms of the patient. This is the first reported case of intestinal infection caused by adenovirus type 40 in a patient with AIDS.

Incidence rates of leukemias, lymphomas and myelomas in Italy: geographic distribution and NHL histotypes

The annual incidence of non-Hodgkin's lymphomas is increasing by 3 to 4% in different parts of the developed world, while rates for Hodgkin's disease, myelomas and leukemias are more stable. In the case of this group of malignancies, hypothesis generation on risk factors has been limited by the use of the ICD classification in mortality and incidence statistics. We have computed incidence rates in different Italian areas after careful re-classification of diagnoses, and considering specific histotypes (Working Formulation for NHL, Rye's classification for HD). While no particularly interesting pattern is suggested for Hodgkin's disease (even after considering specific Rye subgroups), multiple myeloma and leukemias, for non-Hodgkin's lymphomas the high rate in one agricultural area (Forli) was mainly due to the A sub-group in the Working Formulation (low-grade). In a heavily industrialized area (Varese), the high incidence rate was at least partly explained by a higher proportion of cases classified in the G sub-group (intermediate grade). Excesses of non-Hodgkin's lymphomas have been observed in populations exposed to phenoxy-acetic-acid herbicides, to insecticides and to organic solvents. One can hypothesize that different risk factors act on different stem cells and induce lymphoid malignancies belonging to different histologic sub-types.

Familial AL-amyloidosis in three Italian siblings

BACKGROUND AND METHODS

Familial occurrence of immunoglobulin-related (AL) amyloidosis has occasionally been reported. In this work we describe the concomitance of systemic amyloidosis and monoclonal gammopathy (one case of Waldenström's macroglobulinemia and two cases without multiple myeloma or related diseases) in three Italian siblings, two males and one female.

RESULTS AND CONCLUSIONS

All of them showed a common pattern of polyneuropathy to different degrees; two presented a sicca syndrome and one also suffered from nephropathy. Two of them showed the same HLA typing with the same light chain type (k), but had different presenting symptoms. Polyneuropathy and a history of peptic disease in two cases was suggestive of type III familial amyloidotic polyneuropathy (FAP) occurring in the setting of a familial monoclonal component. However, immunohistochemical studies on different tissue specimens using anti-apolipoprotein A1 and anti-transthyretin antibodies were negative. Further screening of DNA samples for transthyretin (TTR) gene mutations was also negative. Clinical and laboratory investigations ruled out reactive or senile amyloidosis and immunohistochemical studies with anti-light chain antibodies on amyloidotic tissue specimens were positive. As a consequence, this family represents a new case of familial AL-amyloidosis.

A new protocol (MiCEP) for the treatment of intermediate or high-grade non-Hodgkin's lymphoma in the elderly

Age has proved to be an important prognostic factor in patients with advanced non-Hodgkin lymphoma (NHL) and these patients require intensive and extensive therapy. Dose-reduction and therapy attenuation have reduced treatment-related toxicity, but have also decreased therapeutic efficacy. Between January 1990 and December 1992, 41 previously untreated patients, 65 years with stage 2-4 intermediate- or high-grade NHL were treated with a new therapeutic scheme which included Mitoxantrone, Etoposide, Cyclophosphamide and Prednisone (MiCEP). Twenty-eight patients achieved a complete remission, ten patients partial remission (overall response rate of 93%) and two cases were resistant. The overall survival was 66% with a median follow-up of 24 months from diagnosis: three patients relapsed after a median period of 7 months. The relapse-free survival was 92% after a median follow-up of 18 months. Blood and other organ toxicity was acceptable and 12% of patients experienced a grade 4 (WHO) neutropenia. In conclusion, MiCEP was effective in inducing a good remission rate with moderate toxic effects in elderly patients with intermediate- or high-grade NHL and appears to be a useful combination to use in this group of patients.

Detection of Epstein-Barr Virus Genome in Sinonasal Undifferentiated Carcinoma by Use of in Situ Hybridization

Associations between Epstein-Barr virus and undifferentiated carcinomas of nasopharynx, parotid gland, and thymus have recently been reported. Epstein-Barr virus has also been associated with malignant lymphoma of the nose and paranasal sinuses. These findings raise the possibility that Epstein-Barr virus may additionally be linked to undifferentiated carcinoma of the nose and paranasal sinuses (SNUC), an uncommon but distinctive and highly aggressive neoplasm. Histologically, SNUC consists of small and medium cells, the precise characterization of which often requires immunocytochemical analysis. This study investigates the presence of DNA sequences of Epstein-Barr virus in biopsy specimens of 13 cases of SNUC that were defined immunocytochemically by use of previously reported criteria. In situ hybridization was used to detect Epstein-Barr virus genome in different cell types in routinely processed, paraffin-embedded tissues. Epstein-Barr virus-specific DNA sequences were detected in tumor cells of SNUC specimens from 5 of the 13 cases examined. No correlation was found between positive hybridization and primary tumor site, morphologic subtype, or disease course. Epstein-Barr virus DNA was detected in 38% (5 of 13) of the SNUC samples analyzed. This finding suggests that this virus may play a role in the pathogenesis of this rare neoplasm.

Detection of Epstein-Barr virus genome in sinonasal undifferentiated carcinoma by use of in situ hybridization

Associations between Epstein-Barr virus and undifferentiated carcinomas of nasopharynx, parotid gland, and thymus have recently been reported. Epstein-Barr virus has also been associated with malignant lymphoma of the nose and paranasal sinuses. These findings raise the possibility that Epstein-Barr virus may additionally be linked to undifferentiated carcinoma of the nose and paranasal sinuses (SNUC), an uncommon but distinctive and highly aggressive neoplasm. Histologically, SNUC consists of small and medium cells, the precise characterization of which often requires immunocytochemical analysis. This study investigates the presence of DNA sequences of Epstein-Barr virus in biopsy specimens of 13 cases of SNUC that were defined immunocytochemically by use of previously reported criteria. In situ hybridization was used to detect Epstein-Barr virus genome in different cell types in routinely processed, paraffin-embedded tissues. Epstein-Barr virus-specific DNA sequences were detected in tumor cells of SNUC specimens from 5 of the 13 cases examined. No correlation was found between positive hybridization and primary tumor site, morphologic subtype, or disease course. Epstein-Barr virus DNA was detected in 38% (5 of 13) of the SNUC samples analyzed. This finding suggests that this virus may play a role in the pathogenesis of this rare neoplasm.

Detection of human herpesvirus-6 and Epstein-Barr virus genome in childhood Hodgkin's disease

Two widespread human herpesviruses, the Epstein-Barr virus (EBV) and the Human Herpesvirus 6 (HHV-6), have been frequently associated with Hodgkin's Disease (HD) and, recently, it has been observed an HHV-6 transactivation effect on EBV replicative cycle. We studied the presence and the possible association between EBV and HHV-6 in childhood HD cases, nodular sclerosis subtype. We analyzed formalin-fixed and paraffin-embedded lymph nodes from 15 cases by PCR for HHV-6 genome, and by PCR and in situ hybridization (ISH) for EBV genome. One out 15 samples resulted positive for HHV-6 DNA PCR, while 5 resulted positive for EBV DNA PCR. Only one sample positive for HHV-6 resulted positive for both HHV-6 and EBV genome. All samples were negative in ISH. At the moment, it is not clear the exact role of EBV and HHV-6 in the lymphomagenesis, neither it is possible to establish the rate of their interaction; our data show that it does not exist in vivo an evidence of their association.

Combined surgery and chemotherapy in primary gastric non-Hodgkin's lymphoma: a retrospective study in sixty-six patients

Sixty-six consecutive patients with primary gastric non-Hodgkin's lymphoma are reported. All patients underwent surgery which consisted of radical resection in 23 patients (36%) and partial or palliative excision in the remaining 43 cases (36 and 7 respectively). Three patients died before starting chemotherapy, two refused the treatment and 61 completed the postoperative chemotherapeutic programme. We analysed this group of patients in order to assess the efficacy of chemotherapy following surgery. Chemotherapy included either CVP or the original protocols from our institution. Excluding patients who underwent radical resection, postoperative chemotherapy induced complete remission in 87% of the remaining 39 patients. After a median follow-up of 84 months (range 6-216), the 10-year cause-specific survival was 90% with a stable curve plateau after about 25 months. The survival was only influenced by response to therapy (p < 0.0001). The disease-free survival for patients who were not radically resected was 93%. We encountered only two relapses after 15 and 32 months. One of these was local and the other systemic. Our results indicate that chemotherapy following surgery induces long-term remission and survival in primary gastric lymphoma and in particular improves remission and survival, in stage II. In our opinion, surgery may also be fundamental for the treatment of gastric lymphoma in the majority of cases.

Myofibroblast and elastic and collagen fiber hyperplasia in the bronchial mucosa: a possible basis for the progressive irreversibility of airway obstruction in chronic asthma

Considering the role proposed for myofibroblasts in inflammatory and hyperelastotic lung diseases, the possibility arises that these cells are involved in bronchial pathology, including asthma. To address this issue, we have analyzed by light microscopy, histochemistry and immunohistochemistry the structure of extra- and intra-pulmonary bronchi of patient died of asthma. We have demonstrated hyperplasia of connective tissue cells and fibers in the mucosa, all around the lumen of extra- and intra-pulmonary bronchi. The cells were thin and elongated, labeled by anti-actin and anti-vimentin antibodies and interspersed with many elastic and collagen fibers, therefore they were interpreted as myofibroblasts. These findings may explain the rigidity of the bronchial wall in patients with asthma, which causes the progressively more limited resolution of airway obstruction upon pharmacological treatment and the gross anatomical finding of bronchial stiffness at inspection of the lungs. The possibility should also be considered that myofibroblasts and elastic--not collagen--fibers have contributed to bronchial hyperreactivity at an early stage of the disease.

Unusual clinical aspects of oral non-Hodgkin lymphomas in patients with HIV infection

Patients with HIV infection are at greater risk of developing malignancies. We report two HIV-seropositive patients with primary oral manifestation of a B-cell non-Hodgkin lymphoma (NHL). Localisations of tumours were the palate, with an unusual bifocal origin, and the tongue which is rarely the primary site of NHL. Ulcerations and extensive tissue necrosis were observed. Histologically both cases were high grade malignant lymphomas, immunoblastic. Epstein-Barr virus DNA was detected with in situ hybridisation in 1 patient.

[CT-guided thoracic biopsy. Personal experience with DBNH Haaga 20 G needles]

CT-guided fine-needle biopsy of the chest is nowadays a conventional diagnostic procedure, which can be furtherly improved so as to increase its diagnostic sensitivity and to reduce complications. We studied a series of possible improvements over a 2-year period (1990-1992). In our radiology department 164 CT-guided biopsies were performed in 130 men and 34 women. DBNH Haaga 20-G (15 cm) needles (Cook, Denmark) were used. This kind of needle is a coaxial cutting-edge needle used for simultaneous cytological and histological sampling. Exams were performed with a Philip Tomoscanner CX-S (scanning time: 2.8 seconds). Of 164 tissue samples, 153 (93.4%) were adequate for histological diagnosis. As for suspected neoplastic disease, our results demonstrated 108 true positives, 27 true negatives, 18 false negatives and no false positive. Sensitivity, specificity and diagnostic accuracy were 85.7%, 100% and 88.2%, respectively. In 24 cases there were minor complications--i.e., 5 cases of parenchymal hemorrhage and 19 cases of minor pneumothorax. In one case only there was major pneumothorax which required surgical drainage. On the basis of our experience, we suggest the use of such coaxial catheters as the DBNH Haaga type for the collection of both histological and cytological material because this needle reduces the need for repeated invasive and potentially dangerous maneuvers.

Identification of hematopoietic progenitor cells in human amniotic fluid before the 12th week of gestation

Due to technical difficulties in performing amniocentesis before the 12th week of pregnancy, very little is known about the components of human amniotic fluid before that time. Amniocentesis was performed between the 7th-11th week of gestation in 25 informed and consenting patients, who had to undergo therapeutic interruption of pregnancy. The cells from the amniotic fluid were stained, counted on a hemocytometer, and checked for vitality. The origin of these cells was determined from cellular cultures the intracellular content of the hemoglobin and the chloroacetate esterase content of the hemoglobin and the chloroacetate esterase contents were also studied. Taking advantage of the "in vitro" adhesive properties of these cells to the bone marrow stromal feeder layer, we obtained clonal growth of an erythroid nature from 18 out of 33 samples. At the 17th week of gestation, an increased number of cells and a decrease in their vitality was found. Between the 7th and 12th week, the cellular composition of the fluid was totally different from that found later in the pregnancy. Small nucleated, round cells were identified as hematopoietic progenitor cells. At the beginning of the 11th week, a cellular population, typically used to perform prenatal diagnosis of chromosomal abnormalities from the 14th week of pregnancy appeared. Since hematopoietic progenitor cells were found in the amniotic fluid before the 12th week of gestation, these cells most probably come from the hematopoietic cells of the yolk sac through the thin membrane of the yolk sac at this time.

Actinomycosis of the tongue: a diagnostic challenge

Actinomycotic infections of the cervicofacial area are rare and frequently show a confusing clinical picture. We report a case of actinomycosis that mimicked a neoplasm of the tongue. The clinical and pathologic features and the differential diagnosis of this unusual oral infection are discussed.

[Isosporiasis and sarcocystosis. The current findings]

A review on infections by Isospora belli and Sarcocystis spp. both in healthy and in AIDS patients is done on the basis of literature and personal data. In this view a special focus is made on isospora belli infection in AIDS because of its high recurrence after successful attack therapy. Consequently the most recent protocols for maintenance and attack therapy in these patients are reported. At the end, concerning ultrastructural pathology, the features of some Isospora belli developing stages are described by means of electron microscopy on duodenal biopsy specimens from a patient.

Localization of the pathological process in Miller Fisher syndrome

A 64 year old woman died at the third attack of MFS. Histological examination demonstrated segmental demyelination and axonal swelling of the peripheral nerves studied, oculomotor included. In the C.N.S. only mild chromatolytic changes and rare pyknosis of the nerve cells in the midbrain were found without signs of primary inflammation. We reviewed the findings in all the 4 anatomoclinical cases of MFS and in 2 cases of GBS with ophthalmoplegia or ataxia. With one exception, they appear to be concordant with those of our case. As the histological examination showed CNS involvement consequent upon peripheral nerve impairment, we are bound to change our opinion on the nosological position of MFS. Any small CT enhancements in the brain in MFS may be due, as in some cases of demyelinating polyneuropathy, to focal rupture of the blood-brain barrier.

[Proctocolitis caused by Schistosoma mansoni in AIDS. A clinical and immunohistochemical study of a case]

An imported case of intestinal schistosomiasis in AIDS is analysed by the relationships between immune response, diagnostic methods, pathogenetic mechanisms. The inconclusiveness of negative results from both serology and stool parasitology is remarked whereas the efficacy of associated histological, histochemical and immunohistochemical methods is emphasized in order to get better data on aetiological diagnosis and on cell types and size of reactive granulomas. In the case studied, negative serology, absent fecal egg excretion and uneffective granulomatous response with scarcity of T and B lymphocytes have been documented by means of the above methods.

[Intestinal microbial pathology in AIDS. A clinical case series]

Microbial isolates from 60 diarrheic AIDS patients hospitalized to the Infectious Disease Division of Careggi hospital (Florence) are described. Clinical, microbiological and diagnostic features of each case are discussed with emphasis to some rare or underestimated entities in Europe: Campylobacter laridis bacteremia, Whipple-like disease by atypical Mycobacteria, Schistosoma mansoni proctocolitis. Results regarding newly AIDS-related microorganisms are also stressed.

[Pseudo-Whipple disease caused by atypical mycobacteriosis in AIDS: a clinical and electron microscopic study of 2 cases]

The Authors focus on two cases, studied by electron and light microscopy, of Whipple-like disease caused by atypical mycobacteria in AIDS. Differential characteristics between the cases and classical Whipple's disease are analyzed with regard to the diagnostic and therapeutical peculiarities of Mycobacterium avium-intracellulare infection which accounts for over 80% of atypical mycobacterial infections in AIDS. In this regard the Authors stress the role of histological findings of pale blue striated histiocytes as a marker of Mycobacterium avium-intracellulare infection.

In situ immunologic characterization of cutaneous involvement in Hodgkin's disease

The current study assesses in situ the antigenic phenotype of cutaneous infiltrate in two cases of Hodgkin's disease affecting the skin. Immunostaining utilized monoclonal antibodies for T-lymphocyte and B-lymphocyte and mononuclear phagocyte markers. The same immunophenotypic pattern of cutaneous infiltrate was observed in both cases, despite a different histopathologic subtype (mixed cellularity in case one, nodular sclerosis in case two). The majority of infiltrating cells expressed T-lymphocyte markers, with a predominance of CD8+ phenotype. Few cells bore B-lymphocyte markers or had DRC-1+ phenotype. No CD1a+ dendritic cell was found in the dermal infiltrate. Variable numbers of cells reacted with mononuclear phagocyte markers. The authors believe that the antigenic phenotype of cutaneous Hodgkin's disease has not previously been reported. The immunophenotypic pattern of skin infiltrate is different from that described in lymphoid tissues. Such findings could be related to the previous therapy or to the possible influence of skin microenvironment.

[CT-guided percutaneous fine-needle biopsy in the histological characterization of mediastinal-pulmonary lesions]

CT-guided percutaneous fine-needle biopsy (FNB) is the method of choice in the histological characterization of mediastinum and lung lesions in which a diagnosis could not be reached through noninvasive methods such as cytology of the sputum, or biopsy during bronchoscopy. FNB represents an alternative to diagnostic thoracotomy: it is, in fact, less invasive, it can be carried out with no need for hospitalization, and has a low incidence of complications. FNB diagnostic accuracy is very high, as our results prove: accuracy 89.6%, sensitivity 87.6% and specificity 98%. Our series includes 419 percutaneous fine-needle biopsies.

Magnetic resonance imaging and high-resolution computed tomography in tumors of the lung and the mediastinum

Magnetic resonance (MR) imaging and high resolution computed tomography (CT) have been compared in 37 patients who had expansive processes of the lung and the mediastinum. MR imaging and CT scanning gave identical results in 32 patients; in 5 patients, CT scanning has proved more useful in evaluating the stag e of primary lung tumors. MR imaging often gives more information about the actual size of the tumor, and the involvement of close structures, although it does not modify staging of the tumor. MR imaging has the advantage to differentiate hilar adenopathy from blood vessel structures. Evaluation of T2 relaxing time (that we have performed in the same location of thin-needle biopsy aspiration), however, did not prove to be of diagnostic significance; this indicates that MR imaging at the moment is not suitable for tissue typification.