Sabato 27 ottobre 2012 - Pacini Editore

Periodico bimestrale – POSTE ITALIANE SPA - Spedizione in Abbonamento Postale - D.L. 353/2003 conv. in L. 27/02/2004 n° 46 art. 1, comma 1, DCB PISA 

Aut. Trib. di Genova n. 75 del 22/06/1949 

Journal of the Italian Society of Anatomic Pathology 

and Diagnostic Cytopathology, 

Italian Division of the International Academy of Pathology 

Società Italiana di Anatomia Patologica e Citopatologia Diagnostica, 

Divisione Italiana della International Academy of Pathology 

ISSN 0031-2983 

Cited in Index Medicus/MEDLINE, BIOSIS Previews, SCOPUS 

Vol. 104 October 2012

Benvenuto nel sito dedicato alla valutazione 

dello stato di her2. 

Che tu sia nuovo al test HER2 o tu sia un professionista esperto, questo sito 

mette a disposizione una ricca risorsa di informazioni da cui attingere nuove 

cognizioni e attraverso cui migliorare le tue conoscenze sulla determinazione dello 

stato di HER2 sia nel carcinoma mammario che nel carcinoma gastrico. 

In questo sito troverai 

una risorsa completa 

di informazioni su 

un’ampia gamma di 

argomenti correlati alla 

determinazione dello 

stato di HER2, correlate 

da una serie di esercizi 

interattivi per verificare e 

migliorare le tue capacità 

di interpretazione del 

test di HER2. 

www.her2testing.it 

DA OGGI ISCRIZIONE ATTIVA ANCHE 

PER I TECNICI DI LABORATORIO

VENTANA iScan HT 

Riconcepire le immagini in Anatomia Patologica 

Qualità 

• 

Superiore qualità delle immagini 

Scansione completa del vetrino 

Efficienza 

• 

Elevata velocità di acquisizione dell’immagine 

Caricamento in continuo (fino a 360 vetrini) 

Affidabilità 

• 

Ogni secondo 

è importante 

Gestione semplificata delle immagini grazie al software VIRTUOSO 

Algoritmi diagnostici FDA approved 

Roche Diagnostics SpA 

Roche Tissue Diagnostics 

Viale G.B. Stucchi, 110 

20900 Monza (MB) 

www.roche.it 

Materiale destinato esclusivamente ai Professionisti Sanitari

Journal of the Italian Society of Anatomic Pathology 

and Diagnostic Cytopathology, 

Italian Division of the International Academy of Pathology 

Editor-in-Chief 

Marco Chilosi, Verona 

Associate Editor 

Roberto Fiocca, Genova 

Managing Editor 

Roberto Bandelloni, Genova 

Scientific Board 

R. Alaggio, Padova 

G. Angeli, Vercelli 

M. Barbareschi, Trento 

C.A. Beltrami, Udine 

G. Bevilacqua, Pisa 

M. Bisceglia, S. Giovanni R. 

A. Bondi, Bologna 

F. Bonetti, Verona 

C. Bordi, Parma 

A.M. Buccoliero, Firenze 

G.P. Bulfamante, Milano 

G. Bussolati, Torino 

A. Cavazza, Reggio Emilia 

G. Cenacchi, Bologna 

P. Ceppa, Genova 

C. Clemente, Milano 

M. Colecchia, Milano 

G. Collina, Bologna 

P. Cossu-Rocca, Sassari 

P. Dalla Palma, Trento 

G. De Rosa, Napoli 

A.P. Dei Tos, Treviso 

L. Di Bonito, Trieste 

C. Doglioni, Milano 

V. Eusebi, Bologna 

G. Faa, Cagliari 

F. Facchetti, Brescia 

G. Fadda, Roma 

G. Fornaciari, Pisa 

M.P. Foschini, Bologna 

F. Fraggetta, Catania 

E. Fulcheri, Genova 

P. Gallo, Roma 

F. Giangaspero, Roma 

W.F. Grigioni, Bologna 

G. Inghirami, Torino 

L. Leoncini, Siena 

M. Lestani, Arzignano 

G. Magro, Catania 

A. Maiorana, Modena 

E. Maiorano, Bari 

T. Marafi oti, Londra 

A. Marchetti, Chieti 

D. Massi, Firenze 

M. Melato, Trieste 

F. Menestrina, Verona 

G. Monga, Novara 

R. Montironi, Ancona 

B. Murer, Mestre 

V. Ninfo, Padova 

M. Papotti, Torino 

M. Paulli, Pavia 

G. Pelosi, Milano 

G. Pettinato, Napoli 

S. Pileri, Bologna 

R. Pisa, Roma 

M.R. Raspollini, Firenze 

L. Resta, Bari 

G. Rindi, Parma 

M. Risio, Torino 

A. Rizzo, Palermo 

J. Rosai, Milano 

G. Rossi, Modena 

L. Ruco, Roma 

M. Rugge, Padova 

M. Santucci, Firenze 

A. Scarpa, Verona 

A. Sidoni, Perugia 

G. Stanta, Trieste 

G. Tallini, Bologna 

G. Thiene, Padova 

P. Tosi, Siena 

M. Truini, Genova 

V. Villanacci, Brescia 

G. Zamboni, Verona 

G.F. Zannoni, Roma 

Editorial Secretariat 

G. Martignoni, Verona 

M. Brunelli, Verona 

Società Italiana di Anatomia Patologica e Citopatologia Diagnostica, 

Divisione Italiana della International Academy of Pathology 

Cited in Index Medicus/MEDLINE, BIOSIS Previews, SCOPUS 

Governing Board 

SIAPEC-IAP 

President: 

C. Clemente, Milano 

Vice President: 

G. De Rosa, Napoli 

General Secretary: 

A. Sapino, Torino 

Past President: 

G.L. Taddei, Firenze 

Members: 

A. Bondi, Bologna 

P. Dalla Palma, Trento 

A. Fassina, Padova 

R. Fiocca, Genova 

D. Ientile, Palermo 

L. Resta, Bari 

L. Ruco, Roma 

M. Santucci, Firenze 

G. Zamboni, Verona 

Associate Members 

Representative: 

T. Zanin, Genova 

Copyright 

Società Italiana di Anatomia 

Patologica e Citopatologia 

Diagnostica, Divisione 

Italiana della International 

Academy of Pathology 

Publisher 

Pacini Editore S.p.A. 

Via Gherardesca, 1 

56121 Pisa, Italy 

Tel. +39 050 313011 

Fax +39 050 3130300 

info@pacinieditore.it 

www.pacinimedicina.it 

Vol. 104 October 2012

Information for Authors including editorial standards 

for the preparation of manuscripts 

Pathologica is intended to provide a medium for the communication of 

results and ideas in the field of morphological research on human diseases 

in general and on human pathology in particular. The Journal welcomes 

contributions concerned with experimental morphology, ultrastructural 

research, immunocytochemical analysis, and molecular biology. Reports 

of work in other fields relevant to the understanding of human pathology 

may be submitted as well as papers on the application of new methods and 

techniques in pathology. The official language of the journal is English. 

Authors are invited to submit manuscripts according to the following 

instructions by E-mail to: 

pathologica@pacinieditore.it, landreazzi@pacinieditore.it 

Lisa Andreazzi - Editorial Office 

Pathologica - c/o Pacini Editore S.p.A. 

Via Gherardesca 1, 56121 Pisa, Italy - Tel. +39 050 3130285 

The files containing the article, illustrations and tables must be sent 

in attachment and the following statement of Authors must also be 

enclosed: separate letter, signed by every Author, stating that the 

submitted material has not been previously published, and is not 

under consideration (as a whole or partly) elsewhere, that its content 

corresponds to the regulations currently in force regarding ethics 

research and that copyright is transferred to the Publisher in case of 

publication. If an experiment on humans is described, a statement 

must be included that the work was performed in accordance to the 

principles of the Declaration of Helsinki (1975, rev. 2000) and Authors 

must state that they have obtained the informed consent of patients 

for their participation in the experiments and for the reproduction of 

photographs. As regards the studies performed on laboratory animals, 

Authors must state that the relevant national laws or institutional 

guidelines have been observed. The Authors are solely responsible for 

the statements made in their article. Authors must also declare if they 

got funds, or other forms of personal or institutional financing from 

Companies whose products are mentioned in the article. 

Editorial standards for the preparation of manuscripts 

The article, exclusively in English, should be saved in .RTF format. Do 

not use, under any circumstances, graphical layout programmes such as 

Publisher, Pagemaker, Quark X-press, Adobe Indesign. Do not 

format the text in any way (avoid styles, borders, shading …); use only 

character styles such as italics, bold, underlined. Do not send the text in 

PDF. Text and individual tables must be stored in separate files. 

When submitting a manuscript Authors should consider the following 

points/items: 

a) Title of the work. 

b) Names of the Authors and Institute or Organization to which each 

Author belongs. 

c) Section in which the Authors intend the article to be published 

(although the final decision rests with the Editor-in-Chief). 

d) Name, address, telephone number and E-mail address of the Author to 

whom correspondence and galley proofs should be sent. 

e) 3-5 key words. 

f) Abstract, less than 250 words and subdivided into the following 

sections: Introduction, Method(s), Results, Discussion. In the 

Introduction section, the aim (or the aims) of the article must be 

clearly summarised (i.e., the hypothesis Authors want to verify); 

in the Method(s) section, the Authors must report the context of 

the study, the number and the kind of subjects under analysis, 

the kind of treatment and statistical analysis used. In the Results 

section Authors must report the results of the study and of the 

statistical analysis. In the Discussion section Authors must report 

the significance of the results with regard to clinical implications. 

g) References must be limited to the most essential and relevant, 

identified in the text by Arabic numbers and listed at the end of the 

manuscript in the order in which they are cited. The format of the 

references should conform with the examples provided in N Engl 

J Med 1997;336:309-15. The first six authors must be indicated, 

followed by “et al”. Journals should be cited according to the 

abbreviations reported on Pubmed. Examples of correct format for 

bibliographic citations: 

Journal articles: Jones SJ, Boyede A. Some morphological observations 

on osteoclasts. Cell Tissue Res 1977;185:387-97. 

Books: Taussig MJ. Processes in pathology and microbiology. Oxford: 

Blackwell 1984. 

Chapters from books: Vaughan MK. Pineal peptides: an overview. In: 

Reiter RJ, ed. The pineal gland. New York: Raven 1984, pp. 39-81. 

h) Acknowledgements and information on grants or any other forms of 

financial support must be cited at the end of the references. 

i) Notes to the text, indicated by an asterisk or similar symbol, should be 

shown at the bottom of the page. 

Tables must be limited in number (the same data should not be presented 

twice, in both text and tables), typewritten one to a page, and numbered 

consecutively with Roman numbers. 

Illustrations: Send illustrations in separate files from text and tables. 

Software and format: preferably send images in .TIFF or .EPS format, 

resolution at least 300 dpi (100 x 150 mm). Other possible formats: .JPEG, 

.PDF, .PPT (Powerpoint files). Please do not include, when possibile, 

illustrations in .DOC files. Insert an extension that identifies the file format 

(example: .Tif; .Eps). 

Drugs should be referred to by their chemical name; the commercial name 

should be used only when absolutely unavoidable (capitalizing the first 

letter of the product name and giving the name of the pharmaceutical firm 

manufacturing the drug, town and country). 

The editorial office accepts only papers that have been prepared in strict 

conformity with the general and specific editorial standards for each 

survey. The acceptance of the papers is subject to a critical revision by 

experts in the field, to the implementation of any changes requested, and 

to the final decision of the Editor-in-Chief. 

Authors are required to correct and return (within 3 days of their mailing) 

only the first set of galley proofs of their paper. Authors may order reprints, 

at the moment they return the corrected proofs by filling in the reprint 

order form enclosed with the proofs. 

Applications for advertisement space should be directed to: 

Pathologica - Pacini Editore S.p.A., Via Gherardesca, 56121 Pisa, Italy 

Tel. +39 050 3130217 - Fax +39 050 3130300 

E-mail: mmori@pacinieditore.it 

Subscription information 

Pathologica publishes six issues per year. The annual subscription rates 

for non-members are as follows: 

Italy € 105,00; all other countries € 115,00. This issue € 20,00 for Italy, 

€ 25,00 abroad. 

Subscription orders and enquiries should be sent to: Pathologica - Pacini 

Editore S.p.A. - Via Gherardesca, 56121 Pisa, Italy E-mail: abbonamenti@pacinieditore.it 

- On line subscriptions: www.pacinimedicina.it 

Subscribers’ data are treated in accordance with the provisions of 

the Legislative Decree, 30 June 2003, n. 196 – by means of computers 

operated by personnel, specifically responsible. These data are used by 

the Publisher to mail this publication. In accordance with Article 7 of the 

Legislative Decree n. 196/2003, subscribers can, at any time, view, change 

or delete their personal data or withdraw their use by writing to Pacini 

Editore S.p.A. - Via A. Gherardesca 1, 56121 Pisa, Italy. 

Photocopies, for personal use, are permitted within the limits of 15% of 

each publication by following payment to SIAE of the charge due, article 

68, paragraphs 4 and 5 of the Law April 22, 1941, n. 633. Reproductions 

for professional or commercial use or for any other other purpose other 

than personal use can be made following a written request and specific 

authorization in writing from AIDRO, Corso di Porta Romana, 108, 20122 

Milan, Italy (segreteria@aidro.org – www.aidro.org). 

The Publisher remains at the complete disposal of those with rights whom 

it was impossible to contact, and for any omissions. 

Journal printed with total chlorine free paper and water varnishing. 

Printed by Pacini Editore, Pisa, Italy - October 2012

10.00 - 12.00 

12.00 - 14.00 

Sala 

DONaTEllO 

2° piano 

GRUPPO DI STUDIO 

GISD 

CONSEGNa 

CERTIFICaTI 

DI QUalITà 

aIOm-SIaPEC-IaP 

QUADRO SINOTTICO SIAPEC-IAP 2012 

Sala 

CaRaVaGGIO 

2° piano 


GIPaD 


GISm 

Giovedì, 25 ottobre 2012 

Sala 

GIOTTO 

2° piano 


PaGine 

Sala 

BOTTICEllI 

2° piano 


GIC 

14.00 - 18.00 REGISTRaZIONE DEI PaRTECIPaNTI - 1° piano 

15.00 - 16.30 

16.30 - 18.00 

18.00 - 19.30 

08.30 - 10.30 

COmUNICaZIONI 

ORalI: 

Biologia molecolare 

Sala 

DONaTEllO 

2° piano 

PaTOlOGIa 

PEDIaTRICa NON 

NEOPla STICa 

10.30 - 12.30 TUmORI RaRI 

12.30 - 13.30 

SImPOSIO NON ECm 

DakO 

RIUNIONE 

CONSIGlIO 

DIRETTIVO 

Il PRESIDENTE 

INCONTRa I 

SEGRETaRI E I 

RESPONSaBIlI DEI 

GRUPPI 

Sala 

CaRaVaGGIO 

2° piano 

PaTOlOGIa 

GaSTRO-ENTERICa 1 

PaTOlOGIa 

GaSTRO-ENTERICa 2 

NOVITà SUlla 

NUOVa ECm 

TUmORI 

mESENCHImalI 

DEll’UTERO 

COmUNICaZIONI 

ORalI: 

Osso e parti molli 

Venerdì, 26 ottobre 2012 

Sala 

GIOTTO 

2° piano 

PaTOlOGIa 

POlmONaRE 1 

Patologie polmonari 

diffuse: una sfida 

per il patologo 

PaTOlOGIa 

POlmONaRE 2 

la diagnosi 

molecolare 

nel carcinoma 

polmonare 


aSTRaZENECa 

QIaGEN 

13.30 - 14.30 lUNCH - STaNDING BUFFET - piano inferiore 

BIOBaNCHE 

Sala 

BOTTICEllI 

2° piano 

PaTOlOGIa 

GINECOlOGICa 1 

Patologia 

dell’Ovaio 

PaTOlOGIa 

GINECOlOGICa 2 


HOlOGIC 

Sala 

BRUNEllESCHI 

4° piano 


GIUP 

COmUNICaZIONI 

ORalI: 

Gastroenterico 

Sala 

BRUNEllESCHI 

4° piano 

PaTOlOGIa 

mammaRIa: 

aGGIORNamENTI 

PaTOlOGIa 

mammaRIa 2 


ROCHE PHaRma 

Sala 

mICHElaNGElO 

piano terra 


GIPam 

COmUNICaZIONI 

ORalI: 

Interesse generale e 

Sistema nervoso 

CERImONIa DI 

aPERTURa DEl 

CONGRESSO, 

lETTURa 

maGISTRalE E 

COCkTaIl 

Sala 

mICHElaNGElO 

piano terra 

TUmORI 

NEUROENDOCRINI 

lINFOmI 

EXTRaNODalI 

Problematiche 

diagnostiche 

aSSEmBlEa 

GENERalE DEl 

COllEGIO aNaTOmO 

PaTOlOGI 

14.30 - 16.30 aSSEmBlEa SIaPEC 

16.30 - 17.00 

lETTURa 

maGISTRalE 

17.00 - 18.30 

18.30 - 19.30 

COmUNICaZIONI 

ORalI: 

Genitale maschile e 

femminile 

COmUNICaZIONI 

ORalI: 


femminile 

COmUNICaZIONI 

ORalI: 


femminile 

COmUNICaZIONI 

ORalI: 


femminile 

Endocrino 

21.00 CENa SOCIalE - PalaZZO BORGHESE, FIRENZE 

COmUNICaZIONI 

ORalI: 

Urinario 

COmUNICaZIONI 

ORalI: 

mammella 

DISCUSSIONE 

DI CaSI ClINICI 

CON TElEVOTO

08.30 - 10.30 

10.30 - 11.30 

Sala 

DONaTEllO 

2° piano 

COmUNICaZIONI 

ORalI: 

Respiratorio e 

Testa collo 

Sala 

CaRaVaGGIO 

2° piano 

CaRDIOPaTOlOGIa 

l’aorta e il Patologo 

11.30 - 12.30 TRaPIaNTI 

12.30 - 13.30 

13.30 - 14.00 

Sabato, 27 ottobre 2012 

Sala 

GIOTTO 

2° piano 

CITOlOGIa 1 

Il ruolo della 

citodiagnostica 

nell’attuale Sistema 

Sanitario Nazionale 

COmUNICaZIONI 

ORalI: 

Testa collo 

CITOlOGIa 

aGOaSPIRaTIVa IN 

TwITTER: TUTTO 

IN SEI mINUTI 

E TRE SlIDE 

Sommario 

Sala 

BOTTICEllI 

2° piano 

FaTTORI 

PREDITTIVI 

COmUNICaZIONI 

ORalI: 

Testa collo 

FaTTORI 

PREDITTIVI 

mOlECOlaRI 

Sala 

BRUNEllESCHI 

4° piano 

QUalITà E 

SICUREZZa 

NEI SERVIZI 

DI aNaTOmIa 

PaTOlOGICa 

PaRTE I 


ROCHE 

DIaGNOSTICS 

QUalITà E 

SICUREZZa 

NEI SERVIZI 

DI aNaTOmIa 

PaTOlOGICa 

PaRTE II 

Sala 

mICHElaNGElO 

piano terra 

PERCORSO 

TECNICO 

DIaGNOSTICO: 

la TRaDIZIONE 

CHE Ha GENERaTO 

l’INNOVaZIONE, 

TRa SICUREZZa E 

TECNOlOGIa 

maNaGEmENT 

SaNITaRIO: 

ORGaNIZZaZIONE, 

GESTIONE E 

COORDINamENTO 

DISCUSSIONE 

DI CaSI ClINICI 

CON TElEVOTO E 

PREmIaZIONI 

TEST DI 

ValUTaZIONE 

DEll’aPPRENDImENTO 

Relazioni ................................................................................................................................... pag. 201 

Comunicazioni orali .....................................................................................................................» 267 

Poster ............................................................................................................................................» 359 

Indice degli Autori .......................................................................................................................» 421

Pathologica 2012;104:201-265 rELAzIOnI 


Sala Botticelli – ore 15.00-18.00 

Biobanche 

Moderatori: Mattia Barbareschi (Trento), Giorgio Stanta (Trieste) 

Definizione, finalità, consenso informato e 

accesso alle biobanche. Le linee guida del 

gruppo di lavoro AIOM-SIAPEC 

M. Lavitrano, S. Casati 

Università di Milano Bicocca, Dipartimento di Scienze Chirurgiche, 

Monza 

Le definizioni di “biobanca” presentate nei documenti internazionali 

degli ultimi dieci sono molteplici, da queste emergono 

elementi ricorrenti che consentono la descrizione di biobanca, 

come unità di servizio, senza scopo di lucro diretto, finalizzata 

alla raccolta e alla conservazione di materiale biologico umano 

per scopi scientifici, al di là della tipologia dei campioni 

conservati. 

Garantendo un accesso pubblico, ben organizzato e di qualità 

alle risorse biologiche, materia prima essenziale per lo progresso 

della medicina, per la salute umana e le scienze della 

vita, la biobanca è quindi infrastruttura necessaria e un reale 

vantaggio competitivo per la ricerca traslazionale. 

Suo scopo e sua speranza principali sono lo sviluppo di una 

medicina personalizzata e la prevenzione e la cura delle malattie 

a beneficio dei cittadini. 

Il biobancaggio apre di conseguenza degli scenari rilevanti per 

il sistema sanitario, a medio-lungo termine, incrementando 

l’appropriatezza delle cure e un uso adeguato delle risorse. 

A partire da questa base condivisa si può allora consolidare 

un modello di biobancaggio che assuma concretamente la 

funzione pubblica che una biobanca svolge, sia in termini di 

standard di qualità che di attività, e la sua natura partecipativa, 

in un’ottica di reciprocità, di cooperazione tra gli attori in 

gioco e di costruzione della conoscenza scientifica. 

Il biobancaggio, generato da una donazione consapevole di 

materiale biologico a scopo scientifico, rende tangibile un 

ruolo proattivo di qualsiasi cittadino e di ciascun professionista 

della salute, alla raccolta del materiale stesso e allo 

sviluppo della ricerca. Una corretta in-formazione non solo 

è condizione di possibilità del biobancaggio, ma determina 

la qualità del dato scientifico finale, garantendo standard 

condivisi e monitorabili, dalla raccolta all’utilizzo dei campioni: 

proprio ciascun attore, che è stato reso partecipe del 

processo, permette il suo stesso svolgimento in sicurezza e 

con qualità. 

Emerge così un ruolo inatteso ma fondamentale della biobanca: 

la biobanca sin dal principio può svolgere una funzione 

in-formativa, verso i cittadini, i ricercatori e i professionisti. 

In-formando la biobanca esercita parte della sua funzione pubblica 

e allo stesso tempo consolida la sua funzione di vettore 

di conoscenza scientifica, dalla raccolta alla trasmissione dei 

risultati e brevetti eventuali generati a partire dai campioni. 

In-formando sul processo di bio-bancaggio, la biobanca esplicita 

la sua responsabilità, risponde del buon uso del campione 

e della gestione dell’informazione ivi contenuta, e il suo compromesso 

di tutela nei confronti dei diritti e gli interessi del 

singolo e di quelli della collettività: il consenso informato si 

palesa come processo complesso, con dei momenti puntuali, 

cui corrisponderanno dei documenti, che apre ad un circolo di 

condivisione della conoscenza scientifica. 

Per poter esercitare questa funzione pubblica è necessario che 

la biobanca ricopra un ruolo di indipendenza, di terzietà nei 

confronti dei cittadini, dei ricercatori e delle istituzioni stesse. 

Sotto questo aspetto è fondamentale la modalità trasparente ed 

esplicita con cui sono valutati i progetti di ricerca, cui destinare 

i campioni, e coinvolti tutti gli attori in gioco negli snodi di 

valutazione, monitoraggio e restituzione dei risultati. 

Le linee guida realizzano e allo stesso tempo manifestano 

questa dimensione pubblica e partecipativa della biobanca. 

Attraverso la modelizzazione delle buone pratiche, esse prima 

promuovono il confronto e la messa in comune di esperienze, 

saperi e valori, quando poi, nella loro elaborazione e 

diffusione, esplicitano, rendono accessibili e trasformano in 

un patrimonio di conoscenza condivisa i requisiti di qualità, 

riproducibilità e trasferibilità. 

Le linee guida sono una vera e propria infrastruttura di conoscenza, 

duttile, in evoluzione ma dirimente: qui risiede il senso 

della proposta di AIOM e SIAPEC, che a livello nazionale 

promuovono e contribuiscono alla scommessa europea di investire 

su un’infrastruttura di conoscenza di qualità, condivisa 

e accessibile per tutti i soggetti coinvolti. 

BBMRI, l’infrastruttura pan-europea per il biobancaggio e le 

risorse biomolecolari di ricerca, si propone infatti di migliorare 

l’accessibilità e l’interoperabilità tra le collezioni esistenti, 

e future, di campioni biologici provenienti da diverse popolazioni 

europee, attraverso l’attuazione di standard e linee guida 

che bilancino correttamente valori individuali, come la protezione 

della privacy e consenso informato, con valori condivisi 

di accesso agevolato ai progressi nella cura della salute e nella 

prevenzione delle malattie. 

Organizzazione, percorsi, infrastrutture, 

informatizzazione e risorse per le banche di 

campioni biologici. Una proposta di linee guida 

da condividere con il gruppo di lavoro AIOM- 

SIAPEC 

M.G. Daidone1 , A. Scarpa2 1 Fondazione IRCCS Istituto Nazionale dei Tumori, Dipartimento di 

Oncologia Sperimentale e Medicina Molecolare, Milano; 2 Università 

di Verona, Dipartimento di Patologia e Centro di Ricerca Applicata 

ARC-NET, Policlinico G.B. Rossi c/o Piastra Odontoiatrica, Verona 

Il rapido avanzamento della ricerca e delle tecnologie applicate 

alla Medicina ha portato ad un considerevole aumento di 

interesse verso le biobanche, termine con cui si definiscono 

le raccolte organizzate di materiale biologico e di dati ad esse 

associati. Le biobanche rappresentano una preziosa fonte di risorse 

per la ricerca, da quella di base fino alla sperimentazione 

di terapie innovative, in quanto permettono di avere a disposizione 

il genoma umano e i prodotti della sua espressione. 

Infatti, se processamento e conservazione del materiale sono 

stati effettuati in maniera ottimale, è possibile analizzare con

202 

gli attuali approcci multidimensionali acidi nucleici e proteine 

estratti da campioni raccolti da oltre un decennio per definire 

profili biomolecolari associati alla predisposizione a sviluppare 

tumori e ad una differente aggressività clinico-biologica e/o 

responsività/tossicità verso trattamenti specifici, e identificare 

bersagli molecolari per un trattamento selettivamente mirato 

alla popolazione cellulare neoplastica. 

Nelle patologie oncologiche (così come nella massima parte 

delle patologie in senso lato), il successo delle ricerche nel 

prossimo futuro – più di quanto sia avvenuto in passato – si 

avvarrà della possibilità di disporre di campioni biologici di 

persone affette da tumore e sottoposte a protocolli terapeutici 

controllati/randomizzati o portatrici di alterazioni molecolari 

predisponenti a specifiche neoplasie, e questo ha portato 

alla costituzione di numerose biobanche in tutto il mondo, 

grazie alle donazioni dei malati e delle loro famiglie che, 

generosamente, continuano a collaborare per lo sviluppo della 

ricerca. Gli aspetti attualmente caratterizzanti la ricerca oncologica 

sono rappresentati da: 1) possibilità di effettuare una 

caratterizzazione biomolecolare del singolo tumore in modo 

multidimensionale su larga scala; 2) elevata sensibilità e risoluzione 

degli approcci attualmente disponibili per gli studi di 

genomica e proteomica; 3) volontà di un rapido trasferimento 

di informazioni dalla ricerca di base a quella clinica per 

l’identificazione di soggetti predisposti a sviluppare tumori, 

di pazienti a rischio di progressione o non responsivi a trattamenti 

specifici, e di bersagli molecolari per un trattamento selettivamente 

mirato alla popolazione cellulare neoplastica. Di 

fondamentale importanza è quindi il materiale biologico disponibile 

per tali studi, in termini sia di qualità sia di quantità. 

Infatti, per studi su larga scala che forniscano informazioni 

robuste e clinicamente validate sono necessarie casistiche di 

dimensioni adeguate, approcci tecnologici ad elevata sensibilità 

richiedono campioni biologici opportunamente trattati, e 

il trasferimento dal laboratorio alla pratica clinica prevede 

una standardizzazione dei protocolli di campionamento tissutale 

per studi multicentrici e per garantire una comparabilità 

dei risultati tra le diverse Istituzioni. Il materiale biologico 

utilizzato per tali studi è generalmente rappresentato dal tessuto 

patologico eccedente a quello necessario per la diagnosi, 

e raccolta, campionamento, conservazione e utilizzo di tale 

materiale richiedono, all’interno di un singolo Istituto, un 

coordinamento di attività e competenze tra i Dipartimenti di 

Chirurgia, Oncologia Medica, Patologia e Oncologia Sperimentale 

per evitare frammentazione e dispersione di risorse 

di incommensurabile importanza. 

Le biobanche costituiscono quindi un importante strumento 

per la ricerca i cui risultati positivi portano benefici non tanto 

o non solo al donatore o alla sua famiglia, ma alla comunità 

umana. Questo vantaggio per la collettività è un concetto 

importante richiamato in diversi documenti, e in particolare 

nell’art. 4 della Dichiarazione sul Genoma Umano dove si 

afferma che “l’applicazione del progresso della conoscenza, 

specialmente nell’ambito della Genetica, dovrebbe migliorare 

la salute degli individui e contribuire al benessere dell’umanità 

in genere”. 

Non esistono attualmente indicazioni specifiche per l’accreditamento 

delle biobanche, anche se esistono pregresse esperienze 

sviluppate a livello regionale in Trentino e in Liguria, e 

le Regioni Lombardia e Veneto stanno promuovendo un programma 

di sostegno istituzionale, finalizzato alla creazione di 

una rete regionale di biobanche che operi con elevati livelli 

di qualità. Tuttavia, un Gruppo di Lavoro coordinato dal Comitato 

Nazionale per la Biosicurezza e le Biotecnologie della 

Presidenza del Consiglio dei Ministri ha prodotto Linee Guida 

CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012 

per la Certificazione delle Biobanche in base alle quali sono 

stati identificati criteri minimi per le biobanche di diversa natura 

e con diverse finalità, armonizzabili a livello nazionale. 

Tali criteri comprendono: 

– Appartenenza ad un Ente pubblico o privato riconosciuto a 

livello regionale o nazionale che dia garanzie di sostenere 

tale struttura a medio/lungo termine: 

– Definizione di un documento programmatico con gli obiettivi 

della struttura in termini di: 

– specifiche funzioni da svolgere 

– tipologia del materiale conservato 

– quantità dei campioni previsti 

– modalità di processamento e conservazione dei campioni 

– Definizione di un documento programmatico con gli obiettivi 

della struttura, in riferimento alle specifiche funzioni 

da svolgere, tipologia del materiale conservato, quantità 

dei campioni previsti, modalità di prelievo, processamento 

e conservazione dei campioni, modalità di gestione delle 

informazioni, modalità di trasporto dei campioni e ricezione 

degli stessi da parte dell’ente richiedente 

– Definizione di un Regolamento per l’utilizzo dei campioni 

biologici raccolti 

– Definizione di un modello di Consenso Informato 

– Definizione della logistica e dei locali dedicati con caratteristiche 

adeguate alle specifiche funzioni e modalità di 

controllo degli accessi 

– Utilizzo di personale qualificato e dedicato con una formazione 

specifica alle funzioni da svolgere che garantisca la 

continuità del servizio 

– Identificazione del Responsabile della struttura con titoli 

adeguati alle funzioni definite nel documento programmatico 

– Utilizzo di un sistema qualità certificato 

– Identificazione di una infrastruttura informatica dedicata 

alla biobanca 

– Disponibilità di una procedura per disaster plan come misura 

preventiva in caso di disastro. 

Tali requisiti verranno presi in considerazione e discussi dal 

Gruppo di Lavoro AIOM-SIAPEC per definire tipologie e 

ruoli delle biobanche oncologiche con finalità di ricerca clinica 

e preclinica e indicare, sulla base della documentazione 

attualmente disponibile a livello nazionale e internazionale, le 

modalità per la loro istituzione e regolamentazione. 

riconoscimento istituzionale delle biobanche: 

l’esempio della regione Liguria 

M. Truini 

Si può prevedere che in un futuro non lontano la valutazione 

di diversi parametri molecolari diventerà un requisito 

indispensabile non solo per la diagnostica ma anche per il 

follow-up dei pazienti, e che lo sviluppo dei Centri di Risorse 

Biologiche diventerà parte integrante della pratica medica. 

Le biobanche costituiscono quindi un tramite tra la pratica clinica 

e l’attività di ricerca traslazionale. Per questo loro ruolo, 

le biobanche devono assicurare la qualità della conservazione 

dei materiali e delle informazioni, garantendo la tracciabilità 

degli scambi e la protezione della riservatezza dei dati sensibili 

dei soggetti, e aderire a principi etici riconosciuti a livello 

internazionale. Ciò presuppone che operino nell’ambito di un 

sistema qualità, con personale qualificato, in strutture adeguate 

che diano garanzie di sostenibilità a lungo termine, e 

svolgano una funzione di servizio per la comunità scientifica. 

Il coordinamento di queste infrastrutture a supporto della 

ricerca, nell’ottica di ottimizzare l’uso delle risorse, è prero-

RElaziONi 

gativa delle Regioni. La Regione Liguria è particolarmente 

ricca di iniziative e competenze nel campo delle biobanche, 

sia per uso di ricerca che per uso diagnostico e terapeutico. La 

Liguria è anche la prima regione italiana che abbia messo in 

atto iniziative di promozione e formale riconoscimento delle 

biobanche per diagnosi e ricerca (DRG n° 34 del 22/01/2010) 

e coordina il tavolo di lavoro sul riconoscimento delle biobanche 

della Conferenza Stato-Regioni. 

Nell’ambito della Regione Liguria è attivo un gruppo di 

lavoro che ha il compito di stabilire i principi necessari per 

rendere omogenei sul territorio regionale i regolamenti e i 

comportamenti delle banche, le condizioni di carattere generale 

richieste per l’istituzione di nuove banche, le procedure 

finalizzate all’autorizzazione delle stesse, la definizione della 

valorizzazione economica delle attività, l’elaborazione di uno 

schema-tipo di intesa Regione – Azienda sede della Biobanca, 

finalizzata alla realizzazione di un programma di azioni di 

comune interesse. 

Il riconoscimento del ruolo delle strutture attraverso un coordinamento 

a livello regionale, e la possibilità di accedere 

a finanziamenti non estemporanei dovrebbe permettere di 

estendere i servizi offerti, valorizzare il materiale raccolto, 

razionalizzare i costi ed assumere un ruolo trainante nella definizione 

delle normative nazionali di riferimento per i CRB. 

L’introduzione, in queste strutture pilota del sistema sanitario, 

di criteri di qualità tipici del farmaceutico, potrebbe consolidare 

nelle aziende sanitarie - come è avvenuto per la farmindustria 

ormai da un decennio - l’abitudine ad operare secondo 

procedure standardizzate, a curare la rintracciabilità dei dati, a 

tenere sotto controllo le diverse fasi dei processi. 

I biomateriali d’archivio: qualità dei componenti 

molecolari 

L. Annaratone, G. Bussolati, A. Sapino 

Università di Torino, Dipartimento di Scienze Biomediche e Oncologia 

Umana, Torino 

La qualità dei preparati istologici viene valutata oltre che in 

Le pieghe della storia: nuove ricerche sulla 

Famiglia Medici 

D. Lippi 

Storia della Medicina, Direttore Centro di Medical Humanities Facoltà 

di Medicina e Chirurgia Università di Firenze Dipartimento 

Anatomia, Istologia e Medicina Legale Policlinico Careggi, Firenze 

Originally farmers who had moved into the city, the Medici became 

first merchants and then bankers. The origins of their coat 

of arms, whose design was changed several times over the years, 

is not unanimously interpreted, but, according to a very suggestive 

tradition, the six red balls on a golden field could represent 

medicinal pills recalling the family’s origins as doctors or apothecaries. 

The most significant accomplishments of the Medici 

were in the sponsorship of art and architecture, mainly early and 

High Renaissance art and architecture. The Medici were responsible 

for the majority of Florentine art during their reign. Anna 

Maria Luisa de’ Medici was the last of the Medici to live in the 

Pitti Palace. She was the daughter of Cosimo III de’ Medici, 

Sala Michelangelo – ore 18.00 

203 

base al grado di conservazione strutturale, anche in relazione 

alla conservazione antigenica e all’integrità degli acidi nucleici. 

Un’ottimale conservazione dei tessuti risulta fondamentale 

per fornire accuratezza e riproducibilità di test immunoistochimici 

e di biologia molecolare, che condizionano la definizione 

e la risposta alla terapia. La determinazione precisa 

e riproducibile di un qualsiasi marcatore richiede quindi una 

standardizzazione del processo pre-analitico e analitico diagnostico. 

I punti della fase pre-analitica che devono essere 

rispettati, perché cruciali per la conservazione di antigeni 

e acidi nucleici, coinvolgono essenzialmente il trasporto e 

la fissazione del campione chirurgico. La nuova procedura 

“Under-Vacuum Sealing” (UVS) consente l’invio dei campioni 

istologici, dalle sale operatorie ai laboratori di anatomia 

patologica, in un sacchetto di plastica sottovuoto (procedura 

che evita l’essiccamento, favorisce il raffreddamento e facilita 

il trasporto), rappresentando un’alternativa all’immersione in 

formalina. Il sistema UVS conserva le caratteristiche originali 

del tessuto e consente il campionamento di tessuto fresco per 

tissue banking. Inoltre l’utilizzo del sottovuoto permette di 

standardizzare tempi e modalità di fissazione, riducendo così 

la probabilità di riportare danni nei preparati istologici a causa 

di iper/ipofissazione. La fissazione dei prelievi istologici deve 

essere effettuata mediante immersione in Formalina tamponata 

per un tempo variabile tra 12 e 24 ore, normalmente a 

temperatura ambiente. Un recente studio, condotto dal nostro 

gruppo, dimostra che la fissazione in formalina a bassa temperatura 

(4°C per 24 ore) garantisce conservazione morfologica 

e risultati immunoistochimici ottimali, con una soddisfacente 

conservazione dell’RNA, aprendo così interessanti prospettive 

di studio di espressione genica anche in tessuti d’archivio 

fissati ed inclusi. 

I dati clinici come elemento fondamentale di 

qualità 

F. Di Costanzo 

Paper not received 

Grand Duke of Tuscany and Marguerite Louise d’Orléans and 

the sister of Gian Gastone de’ Medici, the last Medici Grandduke 

of Tuscany. Anna Maria’s father unsuccessfully tried to 

engineer her ascent as Grand Duchess, when, as he came to 

expect, none of his sons or brothers produced heirs. However, 

when Gian Gastone died, she became the ruler of Florence. Her 

most notable action was to will all the personal property of the 

Medicis to the Florentine state, provided that nothing was ever 

removed from Florence: in her will she left all the Medici estate 

- palaces, villas, paintings, statues, jewellery, furniture, books 

and manuscripts - in other words all the art works assembled by 

her ancestors, to the new Grand Duke and his successors. However 

there was a condition. Nothing could ever be taken away 

from Florence, where the Medici treasures were to remain “as 

an ornament of the State, for the use of the Public and to arouse 

the curiosity of foreigners”. The last gift of the Medici Family 

to Florence and to the world is the possibility to study their 

corpses: this paleopathological study has been carrying on in the 

Medici Chapels since 2004 by different Institutions (University

204 

of Florence, University of Pisa, Soprintendenza Speciale al Polo 

Museale Fiorentino and others). Aim of the study was the identification 

of the diseases and the habits of life of the members 

of the Medici Family buried in San Lorenzo (Florence) and the 

restoration of their tombs, which had been spoiled by the Arno’s 

flood in 1966. Moreover, after the II World War a group of 

anthropologists had opened some tombs and studied the corpses 

inside, depriving them of all body tissues, in order to study the 

“naked bones” from an anthropologic point of view. In 2004 the 

Medici Project started. Apart from the lack of evidence of gout, 

traditionally believed to be the typical disease of the Family, 

which opens the field to a new rheumatologic interpretation of 

their ailments, many other disease have been documented in the 

Medici remains. 

Hovever, I would like to stress the importance of Anna Maria 

Luisa, the last Medici, whose corpse will be exhumed in the 

Approccio diagnostico al SnC nelle SIDS 



Aula Donatello – ore 08.30-10.30 

Patologia pediatrica non neoplastica 

very future. She is supposed to have died of breast cancer: 

her final illness lasted for two years. Her multiple symptoms 

included lesions on the breast and leg, pain in her arm, and 

difficulty breathing. After being greatly weakened by these 

symptoms over many months, she contracted influenza in 

1743 which then developed into bronchopneumonia and was 

probably the immediate cause of her death, aged 76. The 

exhumation of her corpse is the latest challenge of the Faculty 

of Medicine and Surgery of Florence, together with the 

Kurt Engelhorn Stiftung-REM Museen of Mannheim. If the 

diagnosis is correct, the finding of the sick tissue will provide 

the scientists with the possibility of studying the mutation of 

this disease and, hopefully, the possibility of foreseeing its 

transformation in the future. If the paleopathological evidence 

provides a different interpretation, it will be interesting to go 

deeper in the medical history of the Family as well. 

Moderatori: Anna Maria Buccoliero (Firenze), Francesco Callea (Roma) 

V. Nardini, M.E. Filice 

U.O. Anatomia Patologica 2, Azienda Ospedaliero-Universitaria Pisana 

Nei Paesi industrializzati, la Sindrome della morte improvvisa 

ed inattesa del lattante (Sudden Infant Death Syndrome – 

S.I.D.S.) rappresenta la principale causa di morte tra il primo 

mese ed il primo anno di vita. Il picco massimo di incidenza 

è tra il secondo ed il quarto mese di vita. In Italia, si stima 

un’incidenza complessiva di circa 0.2/0.4 casi per mille nati 

vivi. La diagnosi di SIDS è una diagnosi prevalentemente 

di esclusione, pertanto, può essere formulata, con certezza 

o probabilità, solo dopo esecuzione di un accurato riscontro 

diagnostico effettuato secondo quanto previsto da protocolli 

standardizzati, internazionalmente condivisi ed accettati, una 

dettagliata reportistica sulle modalità e sul luogo del decesso e 

lo studio della storia clinica del lattante. Il riscontro diagnostico 

deve essere accurato in modo da evidenziare eventuali malformazioni, 

patologie costituzionali, congenite e/o acquisite, 

tali da determinare, per se o in associazione ad altre cause, la 

morte e non può prescindere dallo studio del sistema di conduzione 

specifico del cuore e del tronco encefalico. 

Istopatologia dell’epilessia non neoplastica. 

L’esperienza fiorentina 

A.M. Buccoliero 

Anatomia Patologica AOU Anna Meyer, Firenze 

L’epilessia rappresenta uno tra i disordini neurologici più frequenti 

colpendo l’1% circa della popolazione mondiale. Essa 

è clinicamente caratterizzata dall’insorgenza di crisi parossistiche, 

motorie, sensitive, autonomiche o psichiche, causate da 

una scarica improvvisa, rapida e abnorme di una popolazione 

più meno numerosa di neuroni (focolaio epilettogeno) e comprende 

un gruppo eterogeneo di patologie a diversa eziologia. 

Alla base dell’epilessia vi possono infatti essere condizioni 

genetiche o acquisite che esitano in quadri malformativi o in 

alterazioni funzionali nella trasmissione nervosa o nella maturazione 

neuronale. 

Il trattamento chirurgico dell’epilessia cronica farmaco resistente 

è ormai una consolidata strategia terapeutica la cui 

diffusione è andata aumentando progressivamente nel corso 

degli anni con conseguente parallelo crescente interessamento 

dei patologi in generale e dei neuropatologi in particolare. 

Anomalie dello sviluppo corticale possono essere alla base 

dell’epilessia farmaco-resistente. Lo spettro istopatologico 

delle anomalie dello sviluppo corticale è molto ampio comprendendo 

quadri da prominenti, e tra questi la emimegaencefalia 

e la polimicrogiria, ad estremamente sfumati quali alcune 

forme di displasia focale corticale. 

La displasia focale corticale raccoglie molteplici quadri 

istopatologici caratterizzati da alterata laminazione corticale 

cui, in alcuni casi, si associa la presenza di elementi cellulari 

abnormi quali i neuroni dismorfici e le così dette balloon 

cells. La displasia focale corticale può inoltre presentarsi 

associata ad altre patologie malformative o acquisite tra cui 

la sclerosi dell’ippocampo, tumori, lesioni vascolari e lesioni 

ischemiche. 

La classificazione istologica dei diversi quadri di displasia 

focale corticale è andata incontro a numerosi rimaneggiamenti 

a partire dalla classificazione di Taylor del 1971 fino alla più 

recente classificazione ILAE 2010. In quest’ultima impostazione 

classificativa vengono distinti 3 diversi tipi di dispalsia 

focale corticale denominati Tipo I (Ia, Ib e Ic a seconda che 

prevalgano alterazioni architetturali corticali radiali, tangenziali 

o entrambe), Tipo II (IIa con neuroni dismorfici e IIb con 

neuroni dismorfici e balloon cells) e Tipo III (IIIa associata a 

sclerosi dell’ippocampo, IIIb associata a tumori, IIIc associata

RElaziONi 

a malformazioni vascolari e IIId ad ogni altro tipo di lesione 

acquisita durante i primi periodi di vita). 

La biopsia renale in pediatria. Ambiguità 

anatomo-cliniche e pitfall morfologici 

G. Mazzucco 


Colestasi neonatale non chirurgica 

F. Callea 

Anatomia Patologica, Ospedale Pediatrico Bambino Gesù, Roma 

L’approccio diagnostico alle colestasi neonatali richiede la 

considerazione di criteri classificativi e nomenclatura. 

Le colestasi si distinguono in extraepatiche ed intraepatiche. 

Le colestasi extraepatiche (colestasi c.d. chirurgiche) sono 

dovute a cause localizzate al di fuori dei confini anatomici 

del fegato. L’Atresia delle Vie biliari rappresenta l’entità più 

frequente e va sempre presa in considerazione nella diagnosi 

differenziale. 

Le colestasi intraepatiche (c.d. mediche) si distinguono in 

extralobulari ed intralobulari. 

Le colestasi intraepatiche extralobulari sono dovute a cause 

che agiscono a livello degli spazi portali e comprendono: la 

sindrome di Alagille (paucità dei dotti interlobulari), le malformazioni 

della lamina duttale, la sindome da bile spessa, la 

Fibrosi Cistica, la colangite sclerosante ad esordio neonatale. 

L’istologica in questo gruppo di disordini è usualmente diagnostica. 

Le colestasi intraepatiche intralobulari rappresentano il gruppo 

di maggiore difficoltà e/o complessità diagnostica poiché 

l’istologia è in genere non conclusiva per mancanza di caratteri 

di specificità. 

Le malattie metaboliche/genetiche occupano il posto maggiore, 

seguite da quelle infettive. 

Esistono alcune malattie con colestasi neonatale che pur mancando 

di caratteri specifici, presentano aspetti caratteristici. 

Tra questi figurano il deficit di alfa-antitripsina, la malattia di 

Wolman, la malattia di Niermann-Pick tipo C, la galattosemia, 

la glicogenosi di tipo IV, l’Emocromatosi neonatale. 

Aspetti suggestivi in corso di colestasi neonatali si ritrovano 

nelle mitocondriopatie (difetti della catena respiratoria, di 

beta-ossidazione degli acidi grassi). 

Le sindromi colestatiche legate a difetti di trasporti più importanti 

sono le colestasi familiari progressive intraepatiche 

(PFIC). La diagnosi morfologica di PFIC è oggi possibile con 

Tumori rari: criticità e soluzioni 

P. Dei Tos 


Sala Donatello – 10.30-12.30 

Tumori rari 

Moderatore: Paolo Dei Tos (Treviso) 

205 

l’impiego di anticorpi contro le proteine mutate (PFIC1 = difetto 

di ATP8B; PFIC2 = difetto di BSEF; PFIC3 = difetto di 

MDR3). 

Le PFIC rappresentano il gruppo di colestasi intraepatiche in 

cui il patologo sta acquistando un ruolo decisivo a seguito della 

recente introduzione di tecniche di istopatologia e genetica 

molecolare nei Laboratori di Anatomia Patologica. 

In conclusione l’istologia è in grado di distinguere tra colestasi 

intra ed extraepatica. 

L’etiologia della colestasi intraepatica è istologicamente riconoscibile 

nelle forme extralobulari. 

Nelle forme intralobulari, l’istologia è conclusiva in una 

minoranza di casi in cui sono presenti aspetti specifici o 

caratteristici, mentre rimane subordinata ad indagini immunoistochimiche, 

di Microscopia Elettronica, di biochimica e 

genetica molecolare in altre. 

L’approccio multidisciplinare e la discussione clinico-patologica 

sono essenziali nell’orientare il percorso diagnostico e 

nell’interpretazione integrata dei dati istologici, di laboratorio 

biochimici e genetica molecolare. 

Bibliografia 

1 Suchi FJ. Approach to the infant with cholestasis. In: Suchi, Sokol, 

Balistreri, eds. Liver disease in childhood. 3 rd ed. Cambridge University 

Press 2007, pp. 179-90. 

2 Portmann B, Roberts E. Developmental abnormalities and liver disease 

in childhood. In: Pathology of the Liver. 5 th ed. Churchill Livingston 

2007, pp. 147-98 

3 Portmann B, et al. Genetic and metabolic liver disease. In: Pathology 

of Liver. 5 th ed. Churcill Livingstone, pp. 199-326. 

Problematiche istopatologiche nella diagnostica 

delle coliti pediatriche 

V. Villanacci 

Anatomia Patologica, Spedali Civili Brescia 

La relazione considera i differenti aspetti istologici con cui 

può manifestarsi una colite IBD e non IBD in ambito pediatrico 

con particolare riferimento al danno allergico a livello 

colico in modo tale da poter fornire al clinico-pediatra, da 

parte del patologo, una chiara indicazione in tal senso. 

Vengono esaminate le differenti possibilità riguardanti la colite 

linfocitica, la colite collagena e l’incremento del numero 

dei granulociti eosinofili (valore superiore a 60 per 10 campi 

di visione a 40x) nei segmenti del colon SX come espressione 

di tale danno. 

Ulteriore elemento e la diagnosi differenziale con differenti 

entità in particolare le Malattie Infiammatorie Croniche Intestinali. 

rare tumors of the thoraco-pulmonary district 

G. Rossi 

Arcispedale Santa Maria Nuova/IRCCS, Anatomia Patologica, Reggio 

Emilia 

The thoraco-pulmonary region includes a broad spectrum of

206 

rare tumors with various biological behaviour (from uncertain 

to frankly malignant) and cell differentiation. Some of these 

tumors have been arbitrarily selected and here briefly mentioned 

because of uniqueness in this site or recent introduction 

as new entities. 

Epithelial tumors 

Sclerosing hemangioma: benign/low-grade biphasic tumor 

of the lung; middle-aged women; solitary or multiple welldefined 

nodules; peripheral > central site; pneumocytic/cuboidal 

(TTF-1+, napsin+, CKs+, EMA+) and stromal/interstitial 

polygonal (TTF-1+, napsin-/+, CKs-/+, EMA +) components; 

papillary, sclerotic, hemorrhagic and solid patterns intermingled 

each other. 

Pneumocytic adenomyoepithelioma: benign/low-grade double-layers 

tumor of the lung; middle-aged women; solitary 

and peripheral; inner epithelial tubulo-glandular (TTF- 

1+, low-molecular-weight CKs+, EMA+, surfactant+) and 

outer spindle myoepithelial (S100+, high-molecular-weight 

CKs+, calponin+, SMA+, p63+) components. Tubulo-glandular 

formations often show colloid-like secretions (see AJSP 

2007;31:562-8) 

Peripheral papillary/glandular neoplasm with ciliated cells 

or solitary peripheral ciliated glandular papilloma: peripheral 

nodule; adults; papillary/glandular architecture with 

fibrovascular core, endo/peribronchiolar growth, ciliated and 

mucinous cells, mucus pools, squamous epithelium, focal 

invasive growth at the periphery; TTF-1+/-, CK7+; uncertain 

malignant potential (see AJSP 2008;32:1489-94 & Histopathology 

2010;56:265-9). 

NUT midline carcinoma: undifferentiated carcinoma/poorly 

differentiated squamous cell carcinoma with rearrangement of 

the nuclear protein in testis (NUT) gene (in 2/3 NUT on chromosome 

15q14 is fused to BRD4, on chromosome 19p13.1; in 

1/3 the partner gene is BRD3 or other uncharacterised genes); 

children and young adults; p63+; lethal outcome (see J Clin 

Pathol 2010 63:492-6; AJSP 201236:1222-7) 

Mesenchymal tumors: all mesenchymal tumors are somehow 

rare in this location and might arise from pleura, lung, 

mediastinum, pericardium. They are difficult to distinguish 

from one another on the basis of imaging studies and histology 

is almost always necessary for accurate diagnosis. Imaging 

and clinical data (patient age, pain, tumor location within the 

chest wall, matrix calcification, presence of fat, and vascularity) 

can be helpful in narrowing the differential diagnosis. The 

most investigated are solitary fibrous tumor and epithelioid 

hemangioendothelioma/angiosarcoma. 

Synovial sarcoma: malignant monophasic (spindle), biphasic 

(spindle + glands) or pleomorphic tumor of uncertain cell 

lineage; young-to-adults without gender predilection; might 

arise from pleura, chest wall, heart, mediastinum, or lung; no 

asbestos-related; EMA, calretinin & CKs +/- (often patchy), 

CD56+, bcl2+, CD99+/-, demonstration of t(X;18); differential 

diagnosis with sarcomatoid mesothelioma and carcinoma 

may be very challenging. 

Glomus tumor: benign tumor of vascular origin as those conventionally 

disclosed at the extremities; 30-70 years without 

gender predilection; uniform-looking round cells with irregular 

vascular channels; central location leading to cough and 

hemoptysis; actin+, CKs-, S100-, CD34-; main differential 

diagnosis with carcinoid tumors. 

Pulmonary myxoid sarcoma: malignant sarcoma with prominent 

myxoid features recently proposed as a new entity; 25-70 

years with a slight prevalence in women; no clear-cut immunoprofile 

(focal staining with EMA); EWSR1-CREB1 fusion 

at FISH and RT-PCR; striking resemblance with myxoid 


extraskeletal chondrosarcoma (see AJSP 2011;35:1722-32) 

Angiomatoid fibrous histiocytoma: a low grade sarcoma 

recently described also in lung and mediastinum; peripheral 

cuff of lymphoid tissue, multinodular aggregates of histiocytic 

cells, blood-filled spaces and plasma cells, presence of 

clear or rhabdomyoblast-like cells; EMA+, CD99+, CD68+, 

desmin+/-, actin+/-; EWS gene rearrangement with CREB1 

or ATF1 (see Mod Pathol 2011;24:1560-70). 

Pulmonary artery sarcoma: fibroblastic/myofibroblastic sarcomas; 

intimal or mural types; often misdiagnosed as embolism. 

Pulmonary vein sarcoma: a leiomyosarcoma arising into 

the pulmonary vein, sometimes occupying the left atrium; 

middle-aged women. 

Lymphoproliferative tumors 

Lymphomatoid granulomatosis (LYG): a peculiar type of 

angiocentric, T-cell-rich large B-cell lymphoma occurring 

in immunocompromised patients; middle-aged men; EBVdriven; 

immunohistochemistry as in large B-cell lymphoma; 

prognosis depends on the number of EBV-positive large 

B-cells/mm 2 , from grade 1 (absent or rare) to 3 (large aggregates) 

(Mod Pathol 2012;25(Suppl. 1):S39-42; Am J Surg 

Pathol 2010;34:e35-48). 

Pyothorax-associated lymphoma: patients who have undergone 

artificial pneumothorax therapy for tuberculosis; 60 

years, men; soft-tissue mass or pleural thickening; immunocompromised 

condition from long-standing chronic inflammation 

due to chronic empyema, EBV-driven; B- or 

Null-cell type with immunoblastic features; most often LCA+, 

CD20+, CD30–, EBV+. 

Pleural effusion lymphoma: HHV8/Kaposi sarcoma herpes 

virus-driven, large B-cell lymphoma occurring in a setting 

of immunodeficiency (e.g., HIV); young-middle aged 

male; effusions; HHV8+, EBV+/-, LCA+, CD3-/+, CD30+/-, 

CD138+/-, pan-B -. 

Intravascular lymphoma: diffuse large B-cell lymphoma with 

intravascular growth; usually widely disseminated; adults; 

pan-B +. 

Targeted-therapy/”druggable” tumors 

Inflammatory myofibroblastic tumor: a waste-basket of lesions 

ranging from reactive to malignant neoplasms; children 

and young adult; mixture of spindle cells with myofibroblastic 

differentiation and chronic inflammatory infiltrate with histiocytes; 

about 50% express ALK1 due to the presence of ALK 

rearrangement; ALK-positive aggressive IMT are candidate 

to effective targeted therapy with Crizotinib, a specific ALK 

inhibitor (see NEJM 2010;363:1727-33). 

Thymic carcinoma: type C undifferentiated or poorly differentiated 

squamous-cell carcinomas expressing CD117 

may harbor activating c-kit mutations may be effectively 

treated with c-kit inhibitors (imatinib, sunitinib, sorafenib or 

nilotinib) depending on c-kit mutation type (see J Clin Oncol 

2011; 29:e803-5). 

Metastatic tumors 

Thoraco-pulmonary region is one of the most common site for 

metastatic malignancies mimicking primary tumors. Pathologists 

should be aware of this occurrence to prevent erroneous 

diagnoses or to introduce new exotic tumor entities. 

Tumori rari della regione capo collo 

A. Franchi 

Paper not received

RElaziONi 

Pineal parenchymal tumors 

S. Rossi 

Ospedale Regionale di Treviso 

This presentation focuses on the classification and grading of 

pineal parenchymal tumors and includes a discussion on the 

differential diagnosis with the other entities encountered in 

the pineal region. 

Pineal parenchymal tumors are histogenetically linked to the 

pineocyte, which is a cell with photosensory and neuroendocrine 

functions. During the late stages of the intrauterine life 

and the early post-natal period, the pineal gland consists of rosettes 

with abundant melanin and cilia, similar to those of the 

developing retina. Progressively the pigmented cells decrease 

and NSE-positive pineocytes accumulate, by post-natal age 

of 1 year representing the predominant cells. To some extent, 

the pineal parenchymal tumors mimic the developmental 

stages of the pineal gland, since they constitute a morphologic 

continuum from the most mature pineal tumor (pineocytoma 

WHO grade I) to pineal parenchymal tumors of intermediate 

differentiation (PPTIDs; further stratified into WHO grades II 

or III) to the highly aggressive small round cell tumor, pineoblastoma 

(WHO grade IV) somewhat reminiscent of the fetal 

pineal gland. Coherently, pineal tumors tend to express synaptophysin, 

NSE and neurofilament from diffusely in the more 

mature tumor forms to focally in pineoblastoma. They also 

may express neuronal markers and retinal S-antigen. These 

tumors may compress adjacent structures including the cerebral 

aqueduct, brain stem, and cerebellum. Signs and symptoms 

therefore relate to obstructive hydrocephalus, increased 

intracranial pressure and neuro-ophthalmologic dysfunction 

(Parinaud syndrome). On magnetic resonance imaging, they 

are T2 bright with contrast enhancement on post-gadolinium 

T1 sequences. 

PINEOCYTOMA. At the most mature/differentiated end of 

the spectrum lies the pineocytoma (1,2). Most pineocytomas 

occur in adults. At low power, they are moderately cellular 

and feature a diffuse to loosely nested-growth pattern. At high 

power, they are composed of medium-sized neoplastic cells 

resembling mature pineocytes with round to oval nuclei and a 

delicate or “salt and pepper” chromatin. Pineocytomatous rosettes 

are a distinctive feature of pineocytomas, but they vary 

in number and size. These structures are composed of neuropil 

surrounded by neoplastic cells with non-regimented nuclei 

and club-shaped terminations oriented toward the center. Notably, 

some pineocytoma feature multinucleated/bizarre cells. 

PINEOBLASTOMA. At the most malignant end of the 

spectrum, lies the pineoblastoma, a WHO grade IV tumor 

which occurs commonly in children with a mean age of 12.6 

years 1 2 . They are accompanied by leptomeningeal seeding 

in as many as 45% of cases and rarely by extracranial metastases. 

Extent of disease at diagnosis, extent of resection and 

radiotherapy affect the prognosis. Histologically they resemble 

CNS PNET. At low power, they look as diffuse, highly 

cellular tumors sometimes featuring either Homer-Wright or 

Flexner-Wintersteiner rosettes. Interestingly, the presence of 

the Flexner-Wintersteiner, as well as the possible expression 

of the retinal S-antigen and the rare occurrence of the trilateral 

retinoblastoma syndrome indicate the ontogenic relation with 

the retinal cells. At high power, pineoblastomas are composed 

of round cells with scant cytoplasm and high nuclear/cytoplasmic 

ratio, with frequent molding, feature high mitotic activity 

and, often, necrosis. Desmoplastic foci and anaplastic cytology 

may be encountered. Interestingly, mixed tumors with 

207 

areas of pineocytoma and areas of pineoblastomas juxtaposed 

are seldom observed. 

PINEAL TUMORS OF INTERMEDIATE DIFFERENTIA- 

TION. In between the 2 extremes of differentiation, the pineal 

parenchymal tumor of intermediate differentiation has clearly 

been the most problematic category in terms of both classification 

and treatment 1 2 . The reported incidence of these 

tumors is highly variable reflecting the difficulties in establishing 

reproducible criteria. It was first introduced by Schild 

et al. In 1993 3 . PPTIDs can have 3 different morphologic 

subtypes: a lobulated pattern, a diffuse pattern mimicking 

oligodendroglioma or neurocytoma, and a transitional form 

with lobulated and/or diffuse architecture areas intermixed 

with regions containing pineocytoma-like regions featuring 

the typical rosettes. Sometimes, they feature a papillary architecture 

4 . The tumor cells in PPTIDs generally have less cytoplasm 

than pineocytomas and show moderate nuclear atypia. 

Mitotic index is variable (0 to 16 per 10 HPFs) The average 

Ki-67-labeling index is 10.1% (range: 8%-11.8%. 

On the base of Jouvet et al’s study 5 on PPTIDs and recently 

adopted by the WHO 1 , these tumors can further be divided 

in 2 subgroups although definite criteria have yet to be established. 

In general, low-grade PPTIDs (corresponding to WHO 

grade II) consist of transitional, lobulated, or diffuse growth 

patterns, strongly express neurofilament protein, and have 

fewer than 6 mitoses per 10 HPFs. High-grade PPTIDs (WHO 

grade III) consist of lobulated or diffuse growth patterns (ie, 

no pineocytoma-like regions) with 6 or more mitoses per 10 

HPFs and limited neurofilament immunostaining. The Ki-67labeling 

index is higher in the latter group. Focal necrosis, 

leptomeningeal infiltration, and vascular proliferation may 

also be observed. 

Differential diagnosis 

The main differential diagnoses of pineocytoma include normal 

pineal gland and pineal cyst. While the pineocytomas 

generally form sheets or expanded lobules, normal pineal 

gland has small lobules and well-formed fibrovascular septae. 

In the pineal cyst 3 layers are typically identified: piloid 

gliosis with numerous Rosenthal fibers, compressed pineal 

parenchyma, and leptomeningeal tissue. 

Regarding PPTID, other entities that may occur in the third 

ventricle come to the differential, the papillary tumor of the 

pineal region, ependymoma, oligondroglioma and germ cell 

tumors. The papillary tumor of the pineal region (PTPR) 

was first described as a distinct entity in 2003 by Jouvet 

et al. 6 and formally codified in the 2007 edition of WHO 

Classification of Tumours of the Central Nervous System 1 . 

PTPR arises exclusively in the pineal region and occurs most 

commonly in adults (mean, 31.5 years). PTPRs are usually 

well-circumscribed, large (2.5-4.0 cm) lesions sometimes 

cystic. Histologically, at low power, they feature discrete 

borders and consist of papillary areas and solid cellular 

areas in variable proportion. In the papillary component, 

vessels are often hyalinized and are covered by large, paleto-eosinophilic 

cells arranged in a pseudostratified columnar 

layering. The solid areas are composed of round to oval cells 

with eosinophilic/clear/vacuolated cytoplasm or with PASpositive 

inclusions variably arranged in pseudorosettes/true 

rosettes/tubules. Pleomorphic nuclei may be seen in some 

cases. Mitotic activity varies, ranging from 0 to 10 mitoses 

per 10 HPF. Necrosis is usually found to some extent in most 

tumors. Fevre-Montange et al. 7 reviewed the prognosis of 

PTRP. Detailed follow-up information was obtained in 29 of 

31 cases. Five-year estimates of overall and progression-free 

survival were 73% and 27%, respectively. Seven patients

208 

died of disease. Incomplete resection and a mitotic index 

higher than five per 10 HPF seemed to correlate with decreased 

survival and recurrence, whereas age less than 30 

years was unassociated with risk of progression or death. 

Regarding the phenotype, the PTPR typically express AE1/ 

AE3, CAM5.2, CK18 (more evidently in the papillary part), 

EMA (usually on the cell surface, more rarely with a with 

a dot-like staining), S100, NSE and Transthyretin. When 

the solid areas predominate, the differential with pineal 

parenchymal tumors becomes crucial. To this regard, the 

expression of Synaptophysin and Chromogranin which are 

typically weak and focal in PTPR is very important for the 

differential diagnosis. When the papillary component is well 

represented, papillary ependymoma should be considered 

in the differential. Notably, GFAP and CK18 might help. 

In fact, the occurrence of an extensive GFAP staining and 

the lack of CK18 expression would favor the possibility of 

a papillary ependymoma. Importantly, CK7 and CK20 are 

usually negative, helping in the differential with most of the 

metastatic carcinomas. Notably, the choroid plexus markers, 

Kir7.1 and E-caderin, are negative in most of the cases. 

There is no standardized therapy. For both primary and 

recurrent tumors, total resection either alone or followed by 

radiotherapy is performed. For recurrent tumors, stereotactic 

radiosurgery has been proposed. Also the ependymoma 

which only rarely occurs in the third ventricle may enter in 

the differential of the PPTID. The observation of perivascular 

pseudorosettes and the extensive immunoreactivity for 

GFAP as well as dot-like EMA immunoreactivity would favor 

ependymoma. Oligodendroglioma, which is exceptional 

in the pineal region, enters in the differential when dealing 

with PPTIDs featuring a diffuse pattern. Intriguingly, olidendroglioma 

cells may express synaptophysin but its expression 

is usually focal, whereas in the pineal parenchymal 

tumors it is usually more diffuse. In this setting, GFAP is 

not always helpful, with some of the cases of oligodendroglioma 

showing the typical perinuclear immunoreactivity 

in the minigemistocytic component and other cases being 

completely negative. The distinction is easily made when the 

co-deletion 1p-19q may be demonstrated. 

For the pineoblastoma, especially when the localization of the 

tumor is not restricted to the pineal region but extends to the 

fourth ventricles or cerebellum, distinction from medulloblastoma 

may be impossible on the base of the morphology and 

immunophenotype. Sometimes the genetics may be of help 

by the detection of i17q (30-40% of medulloblastomas) and 

MYC/MYCN amplification (< 10% of medulloblastomas). 

Atypical teratoid/rhabdoid tumors (AT/RTs) can sometimes 

be seen in the pineal region and can have a predominant 

PNET-like component mimicking pineoblastoma. Age below 

3 years, the presence of carcinoma-like and sarcoma-like 

areas and a polyphenotypic immunoprofile should raise the 

suspicion of AT/RT. Notably, loss of INI1 (BAF47) immunoreactivity 

due to mutation and losses of the INI1/hSNF5/ 

SMARCB1 gene on chromosome 22q11.2 locus is seen in 

most of the AT/RTs. Germ cell tumors and metastatic carcinomas 

which may be considered in the differential when dealing 

with high grade PPTIDs and pineoblastomas might be ruled 

out by immunohistochemistry. 

references 

1 Louis DN, Ohgaki H, Wiestler OD, et al. Tumours of the pineal region. 

In: World Health Organization Classification of Tumours. WHO Classification 

of Tumors of the Central Nervous System. Lyon, France: 

IARC Press 2007,pp. 122-9. 

2 Dahiya S, Perry A. Pineal tumors. Adv Anat Pathol 2010;17:419-27. 


3 Schild SE, Scheithauer BW, Schomberg PJ, et al. Pineal parenchymal 

tumors. Clinical, pathologic, and therapeutic aspects. Cancer 

1993;72:870-80. 

4 Cohan JN, Moliterno JA, Mok CL, et al. Pineal parenchymal tumor 

of intermediate differentiation with papillary features: a continuum of 

primary pineal tumors? J Neurooncol 2010. 

5 Jouvet A, Saint-Pierre G, Fauchon F, et al. Pineal parenchymal tumors: 

a correlation of histological features with prognosis in 66 cases. 

Brain Pathol 2000;10:49-60. 

6 Jouvet A, Fauchon F, Liberski P, et al. Papillary tumor of the pineal 

region. Am J Surg Pathol 2003;27:505-12. 

7 Fevre-Montange M, Hasselblatt M, Figarella-Branger D, et al. Prognosis 

and histopathologic features in papillary tumors of the pineal 

region: a retrospective multicenter study of 31 cases. J Neuropathol 

Exp Neurol 2006;65:1004-11. 

Tumori rari: tumori rari mesenchimali: criticità e 

soluzioni 

P. Collini 

IRCCS Istituto dei Tumori, Dipartimento di Patologia Diagnostica e 

Laboratorio, Milano 

I tumori mesenchimali sono di per sé tumori rari, ed in particolare 

quelli maligni (sarcomi), con un rapporto benigni:maligni 

di 100:1 nei tessuti molli. Le sedi di insorgenza possono 

essere i tessuti molli, l’osso, la cute ed i visceri. I criteri di 

classificazione sono dipendenti anche dalla sede di insorgenza. 

Ad esempio, per la loro classificazione nei tessuti molli e 

osso viene adottata la ‘Classificazione dei tumori dei tessuti 

molli e dell’osso’ WHO 2002, che prevede l’applicazione 

di criteri anatomopatologici convenzionali (morfologia, immunocitochimica) 

e genetici. Per i tumori dei tessuti molli 

viscerali esistono regole secondo i vari organi. Ad esempio, 

per i tumori muscolari lisci di tipo ginecologico valgono regole 

proprie, presenti nella ‘Classificazione dei tumori della 

mammella e degli organi genitali femminili’ WHO 2003. Per 

classificare correttamente un tumore mesenchimale è quindi 

necessario conoscere la sede di insorgenza. Questo è mandatorio 

ad esempio nel caso dei GIST se si vuole applicare la 

classificazione di Miettinen e Lasota. Una corretta classificazione 

prevede la definizione dell’istotipo, con determinazione 

del potenziale biologico di malignità, e del grado solo nel caso 

dei tumori maligni (sarcomi). Il grado non può essere un surrogato 

dell’istotipo. Per quanto riguarda l’istotipo, la definizione 

deve essere la più precisa possibile, anche perché alcuni 

protocolli clinico-terapeutici per i sarcomi dei tessuti molli 

sono modulati sull’istotipo preciso della neoplasia. Anche la 

gradazione deve seguire regole codificate, ed in genere, se si 

tratta di tessuti molli, viene applicata la gradazione FNCLCC, 

che ha valore prognostico non per tutti gli istotipi. È sempre 

più diffuso l’uso di biopsie per definire l’istotipo ed il grado. 

Questo comporta problematiche di campionamento di grosse 

lesioni, che possono essere eterogenee. La diagnosi citologica 

è da restringere a centri altamente specializzati in questo tipo 

di metodica. Bisogna tenere inoltre conto della necessità di 

dedicare materiale per studi biologici, con la prospettiva futura 

di terapie modellate sul singolo paziente. 

Tutte queste problematiche comportano impegno di persone 

dedicate e costi di indagini sempre più sofisticate, con implicazioni 

medico-legali crescenti con necessità di second 

opinion e/o revisione da parte di un panel di esperti, che suggeriscono 

una necessità di concentrazione della gestione dei 

pazienti con tumore raro mesenchimale in centri specializzati.

RElaziONi 

Le coliti croniche non IBD 

V. Villanacci 

Anatomia Patologica, Spedali Civili Brescia 

La relazione considera i differenti aspetti istologici con cui 

può manifestarsi una colite cronica non IBD con particolare 

riferimento al danno da farmaci o allergico a livello colico in 

modo tale da poter fornire al clinico, da parte del patologo, 

una chiara indicazione in tal senso. 

Vengono esaminate le differenti possibilità riguardanti la colite 

linfocitica, la colite collagena e l’incremento del numero 

dei granulociti eosinofili (valore superiore a 60 per 10 campi 

di visione a 40x) nei segmenti del colon SX come espressione 

di tale danno. 

Ulteriore elemento e la diagnosi differenziale con differenti 

entità in particolare le Malattie Infiammatorie Croniche Intestinali. 

role of HEr2 in esophageal and gastric 

carcinogenesis and reliability of its evaluation 

in endoscopic biopsies. 

L. Mastracci1 , M. Fassan2 , S. Pigozzi1 , S. Bruno1 , F. Grillo1 1 Department of Surgical and Diagnostic Sciences (DISC), Pathology 

Unit, University of Genoa and IRCCS S. Martino-IST University 

Hospital, Genoa, Italy; 2 Department of Medicine (DIMED), Surgical 

Pathology & Cytopathology Unit, University of Padua, Padua, Italy 

The human epidermal growth factor receptor 2 (HER2) protooncogene, 

located on chromosome 17q21 1 , encodes for a 

transmembrane tyrosine-kinase receptor. HER2 gene amplification 

and HER2 protein overexpression have been identified 

in various carcinomas, including breast, lung, ovarian, 

endometrium, colon and gastro-esophageal cancer 2 3 . Several 

studies have focused on HER2 status in gastric cancer, showing 

HER2 positivity rates comprised between 10 and 30% 4 5 ; 

on the other hand less data are available for esophageal and 

junctional adenocarcinoma (ADC), where HER2 positivity 

has been reported at approximately 20-25% 6 . Similarly to 

breast cancer, HER2 overexpression and amplification in 

gastric and esophageal ADC has been associated with poorer 

prognosis and more aggressive disease 7 8 . Recently the ToGA 

trial successfully applied anti-HER2 therapy (i.e. Trastuzumab) 

in advanced gastro-esophageal cancers demonstrating a 

significant survival advantage in the Trastuzumab group with 

no significant increase in toxic side-effects 9 . These results led 

to FDA and EMEA approval of the addition of trastuzumab to 

fluoropyrimidine/platinum-based therapies in advanced HER2 

positive gastro-esophageal cancer 10 . 

Following the enthusiasm of these results in the treatment 

of a cancer that is still one of the leading causes of cancerrelated 

deaths worldwide, several studies have focused on 

the prognostic and predictive value of HER-2 expression in 

gastric and esophageal ADC. Furthermore several papers on 

the methodology of HER detection (immunohistochemistry, 


Sala Caravaggio – 08.30-10.30 

Patologia gastro-enterica 1 

Moderatori: Roberto Fiocca (Genova), Luca Saragoni (Forlì) 

209 

fluorescence in situ hybridization – FISH, chromogenic in situ 

hybridization – CISH) and the specific scoring system that has 

to be applied for evaluation, have appeared in the literature. 

Two different aspects however still deserve to be investigated: 

1) the role of HER2 in esophago-gastric cancerogenesis and 

2) the reliability of HER2 evaluation in endoscopic biopsies. 

1) Role of HER2 in esophageal and gastric carcinogenesis 

Esophageal and gastric development of ADC (intestinal-type 

ADC of the stomach and ADC in Barrett’s esophagus) depends 

on a multistep process in which the main causing factor 

is represented by a longstanding inflammation resulting in the 

replacement of native mucosa with metaplastic epithelium. In 

this setting, intestinal metaplasia (IM) has been recognized as 

the “carcinogenic field” in which neoplasia (intra-epithelial 

neoplasia and invasive ADC) can develop 11-13 . 

Few authors have focused their attention in exploring the 

HER2 status in pre-neoplastic and/or pre-invasive lesions 

and only fragmentary information is available in this setting. 

Concerning the development of ADC arising in Barrett’s 

esophagus, the group of Villanacci and Rossi, have shown in 

several reports 14-16 that HER2 overexpression/amplification is 

demonstrable in a high proportion of patients with dysplasia 

and ADC. In particular two out of five low grade dysplasias 

(LGD), four out of eight high grade dysplasias (HGD) and 

five out of thirteen ADCs have shown amplification of HER2 

by FISH, providing evidence for a possible role of HER2 

in the transition from dysplasia to ADC of the esophagus. 

On the other hand none (0/18) of the patients with Barrett’s 

esophagus (BE) showed HER2 amplification. The same field 

was explored by Hu and coll 17 who have studied a larger 

group of ADCs (116 cases), pre-invasive (18 LGD and 15 

HGD) and pre-neoplastic (34 BE) lesions as well as columnar 

cell metaplasia (CCM – 81 cases) and squamous esophageal 

epithelium (86 cases). HER2 amplification was found in only 

one case (6.7%) of HGD and in 21 (18%) ADCs compared to 

a complete negativity of all cases of LGD, CCM and BE. This 

low rate of HER2 overexpression in pre-neoplastic lesions 

may support the hypothesis that HER2 is involved in a late 

stage of esophageal carcinogenesis. 

Still less information is available for gastric carcinogenesis in 

which only the study by Lee et al. 18 has focused on this topic, 

showing HER2 positivity in 12,6% (nine out of 70 cases) of 

gastric HGDs in comparison to 20,2% of invasive carcinomas. 

The study was conducted analyzing both the pre-invasive and 

invasive component of cancer in the same patient. In 6 cases 

score 3+ immunoreactivity was identified in both dysplasia 

and carcinoma, while in three cases HER2 overexpression/ 

amplification was limited to dysplastic epithelium and not 

seen in the invasive component. 

The exhaustive study by our group 19 has finally explored 

the HER2 status in all the phenotypic alterations involved in 

gastric and esophageal carcinogenesis and in a large number 

of samples. Twenty five cases for each group were evaluated. 

Cases with extensive intestinal metaplasia (IM) of the 

distal gastric mucosa, LGD, HGD and intestinal type ADC

210 

were included in order to explore the role of HER2 in gastric 

oncogenesis while for esophageal oncogenesis non intestinal 

columnar metaplasia, IM, LGD, HGD and ADC were considered. 

HER2 amplification was observed in 1 gastric LGD, 

4 HGD and 8 ADC in the gastric spectrum of lesions. Furthermore 

amplification of HER2 was seen in 2 LGD, 5 HGD 

and 7 ADC of esophageal spectrum of lesions. No HER2 

amplification was demonstrated in native gastric and esophageal 

mucosa nor in metaplastic lesions. These results and the 

significant increase of HER2 amplification rate from LGD to 

HGD and ADC, seem to provide unequivocal evidence on the 

early involvement of HER2 dysregulation in the neoplastic 

transformation of both gastric and esophageal-metaplastic 

mucosa. 

2) Reliability of HER2 evaluation in endoscopic biopsies 

In the western world approximately half of gastric and 

esophago-gastric (junctional) cancers are diagnosed at an 

unresectable stage: these patients can potentially benefit 

from Trastuzumab therapy if HER2 overexpression and/or 

amplification is demonstrated (ie IHC score 2+ and FISH amplification 

or IHC score 3+). In such cases the only available 

material for HER2 testing is almost always represented by 

endoscopic biopsies. The well-known heterogeneity of HER2 

expression in gastric and esophageal cancer, clearly demonstrated 

on surgical material by numerous studies 4 5 20 , requires 

careful consideration of the reliability of endoscopic biopsies 

in HER2 status evaluation. Biopsies represent a minute and 

superficial portion of a tumor; moreover only around 60% 

of biopsies taken for diagnosis are effectively composed of 

invasive cancer (personal observations). Summing to this that 

intra-tumor heterogeneity has been reported in about 50% of 

HER2 IHC2+ and IHC3+ cases 18 , the hypothesis that HER2 

status on biopsy may not be truly representative should be 

considered. Few researchers, up to now, have used matched 

biopsy/surgical specimens for HER2 status evaluation and no 

one has specifically focused on the predictive role of biopsy 

in HER2 status evaluation (18,21-23). Further limits in these 

studies lie in the selection of gastric carcinomas only, in the 

use of an IHC scoring system not modified for gastric cancer 

and in the application of FISH in only a subset of cases with 

an already demonstrated amplification on surgical specimens. 

In spite of these limits, the concordance of HER2 overexpression/amplification 

between endoscopic biopsies and surgical 

specimens ranges between 74,1% and 93,2%. 

In this context we have recently analyzed 103 matched biopsy/surgical 

tissues of gastric and gastro-esophageal junction 

cancer from the same patients with the aim of evaluating and 

validating the accuracy of HER2 assessment on endoscopic 

biopsies 24 . Complete concordance between IHC results on 

biopsy and surgical samples has been reached in 80% of cases, 

while it increases up to 95% when applying FISH. This lower 

concordance rate in IHC vs FISH is mostly dependent on a relevant 

number of patients (10%) who have been underscored 

on biopsy samples (IHC 0/1+) but turned to be positive (IHC 

2+/3+) on surgical specimens. This finding is most likely due 

to tumor heterogeneity. The concordance rate between IHC 

and FISH on biopsies was as high as 89,9% and increased to 

99% in surgical specimens. In particular HER2 amplification 

was demonstrated in a quarter of patients with IHC score 1+ 

and in a third of patients with score 2+. The experience on 

breast cancer has clarified that IHC score 2+ cases have to be 

considered as “equivocal” as they are amplified by FISH in 

about 36% of cases. The modification introduced in the IHC 

scoring system applied to gastric and gastro-esophageal adenocarcinoma, 

has not led on the other hand to a modification 


in the IHC-FISH flow chart, so only IHC 2+ cases are actually 

submitted to FISH analysis. Our data suggest that also IHC 

score 1+ on biopsies should be considered “equivocal”. 

Finally, comprehensively comparing HER2 IHC and FISH 

results, it is possible to recognize three categories: 

Three quarters of patients indeed negative with a non-amplified 

FISH on the surgical specimen 

A fifth of patients indeed positive with an amplified FISH and 

IHC score 2+ or 3+ on the surgical specimen 

Approximately 10% of cases which are discordant and show a 

variable combination of IHC expression and FISH amplification 

on biopsies and surgical specimens. 

In conclusion the predictive value of HER2 assessment by 

IHC in biopsies is on the whole high. It may be increased if 

FISH is applied on both IHC 1+ and 2+ cases however, even 

with this trick, approximately 10% of cases will not be accurately 

predicted (both under or overestimated) by biopsy 

evaluation alone. 

references 

1 Normanno N, Bianco C, Strizzi L, et al. The ErbB receptors and their 

ligands in cancer: an overview. Current Drug Targets 2005;6:243-57. 

2 Tapia C, Glatz K, Novotny H, et al. Close association between HER2 

amplification and overexpression in human tumors of non-breast origin. 

Mod Pathol 2007;20:192-8. 

3 Ross JS, McKenna Bj. The HER-2/neu oncogene in tumors of the 

gastrointestinal tract. Cancer Invest 2001;19:554-68. 

4 Grabsch H, Sivakumar S, Gray S, et al. HER2 expression in gastric 

cancer: rare, heterogenous and of no prognostic value – conclusion 

from 924 cases of two independent series. Cell Oncol 2010;32:57-65. 

5 Hoffman M, Stoss O, Shi D, et al. Assessment of a HER2 scoring system 

for gastric cancer: results from a validation study. Histopathology 

2008;52:797-805. 

6 Reichelt U, Duesedau P, Tsourlakis M, et al. Frequent Homogeneus 

HER-2 amplification in primary and metastatic adenocarcinoma of the 

esophagus. Mod Pathol 2007;20:192-8. 

7 Park DI, Yun JW, Park JH, et al. HER-2/neu amplification is 

an independent prognostic factor in gastric cancer. Dig Dis Sci 

2006;51:1371-9. 

8 Walch A, BinK K, Hutzler P, et al. HER-2/neu gene amplification 

by FISH predicts poor survival in Barrett’s esophagus –associated 

adenocarcinoma. Hum Pathol 2000;31:1332-4. 

9 Bang YJ, Van Cutsem E, Feyereislova A, et al. Trastuzumab in combination 

with chemotherapy versus chemotherapy alone for treatment 

of HER2-positive advanced gastric or gastro-oesophageal junction 

cancer (ToGA): a phase 3, open-label, randomised controlled trial. 

Lancet 2010;376;687-97. 

10 EMEA, European Medicines Agency Opinion 2009. www.emea.europa.eu/pdfs/human/opinion/Herceptin_82246709en.pdf 

11 Cassaro M, Rugge M, Tieppo C, et al. Indefinite for non-invasive neoplasia 

lesions in gastric intestinal metaplasia: the immunophenotype. 

J Clin Pathol 2007;60:615-21. 

12 Correa P, Piazuelo MB, Wilson KT. Pathology of gastric intestinal 

metaplasia: clinical implications. Am J Gastroenterol 2010;105:493-8. 

13 Rugge M, Fassan M, Battaglia G, et al. Intestinal or gastric? The unsolved 

dilemma of Barrett’s metaplasia. Hum Pathol 2009;40:1206-7. 

14 Villanacci V, Rossi E, Grisanti S, et al. Targeted therapy with 

trastuzumab in dysplasia and adenocarcinoma arising in Barrett’s 

esophagus: a translational approach. Minerva Gastroenterol Dietol 

2008;54:347-53. 

15 Rossi E, Grisanti S, Villanacci V, et al. HER-2 overexpression/ 

amplification in Barrett’s oesophagus predicts early transition from 

dysplasia to adenocarcinoma: a clinico-pathologic study. J Cell Mol 

Med 2009;13:3826-33. 

16 Rossi E, Villanacci V, Bassotti G, et al. TOPOIIalpha and HER-2/neu 

overexpression/amplification in Barrett’s oesophagus, dysplasia and 

adenocarcinoma. Histopathology 2010;57;81-9. 

17 Hu Y, Bandla S, Godfrey TE, et al. HER2 amplification, overexpression 

and score criteria in esophageal adenocarcinoma. Mod Pathol 

2011;24:899-907. 

18 Lee S, de Boer WB, Fermoyle S, et al. Human epidermal growth factor 

receptor 2 testing in gastric carcinoma: issues related to heterogeneity 

in biopsies and resections. Histopathology 2011;59:832-40.

RElaziONi 

19 Fassan M, Mastracci L, Grillo F, et al. Early HER2 dysregulation in 

gastric and esophageal carcinogenesis. Histopathology 2012, in press. 

20 Kim MA, Lee HJ, Yang HK, et al. Heterogeneous amplification of 

ERBB2 in primary lesions is responsible for the discordant ERBB2 

status of primary and metastatic lesions in gastric carcinoma. Histopathology 

2011;59:822-31. 

21 Yano T, Doi T, Ohtsu A, et al. Comparison of HER2 gene amplification 

assessed by fluorescence in situ hybridization and HER2 protein 

expression assessed by immunohistochemistry in gastric cancer. Oncol 

Rep 2006;15:65-71. 

22 Yang J, Luo H, Li Y, et al. Intratumoral heterogeneity determines 

discordant results of diagnostic tests for Human Epidermal Growth 

Factor Receptor (HER) 2 in gastric cancer specimens. Cell Biochem 

Biophys 2012;62:221-8. 

23 Yan B, Yau EX, Bte Omar SS, et al. A study of HER2 gene amplification 

and protein expression in gastric cancer. J Clin Pathol 

2010;63:839-42. 

24 Grillo F, Fassan M, Ceccaroli C, et al. The reliability of endoscopic 

biopsies in assessing HER2 status in gastric and gastro-esophageal 

junction cancer: a study comparing biopsies with surgical samples. 

Submitted. 

Autoimmune gastritis 

G. Pennelli, F. Galuppini, M. Rugge 

Department of Medicine (DIMED), Surgical Pathology & Cytopathology 

Unit, University of Padua, Padua, Italy 

Autoimmune gastritis (AG) is due to an aggression targeting 

the parietal cells and affects the corpus-fundus mucosa. The 

decline incidence of Helicobacter pylori infection parallels a 

growing clinical focus on this type of gastritis. It is associated 

with serum anti-parietal cell and anti-intrinsic factor 

antibodies. Clinical signs of AG include hypo/achlorhydria, 

hypergastrinaemia, low pepsinogen I/pepsinogen II ratio and 

vitamin B12-deficient anemia. Long-standing hypo/achlorhydria 

triggers enterochromaffin-like (ECL) cell hyperplasia, 

wich may further progress to endocrine tumors as type I carcinoid 

(T I GC) 

The histology of AG typically features a chronic corpusrestricted 

inflammation that may develop into oxyntic mucosa 

atrophy. Chronic atrophyc gastritis (CAG) is an inflammatory 

condition characterized by the loss of gastric glandular 

structures which are replaced by connective tissue (nonmetaplastic 

atrophy) or by glandular structures inappropriate 

for location (metaplastic atrophy). Metaplasia includes two 

different phenotypes: pseudo-pyloric metaplasia and/or intestinal 

metaplasia. Epidemiological data suggest that CAG is 

associated with two different types of tumours: Intestinal-type 

gastric cancer (GC) and T I GC. A staging system for reporting 

gastritis histology (OLGA staging) has recently been 

proposed: by scoring atrophy histologically in both oxintic 

and antral/angular biopsy samples, the staging frame (stage 

0-IV) ranks gastritis according to its GC risk. The progression 

rate of CAG to GC fluctuates from 0% to 10% with annual 

incidence (person-year) lower than 1% and OLGA stages 

III-IV consistently feature a high GC risk. The risk of GC in 

autoimmune gastritis seems to be generally low, with annual 

incidence (person-year) evaluated between 0% and 1.20 %. 

In fact, AG is associated with corpus-restricted inflammation 

and, as a consequence, with less extensive atrophy in 

the gastric mucosa. Furthermore the cancer risk is restricted 

to high-risk gastritis stages III-IV and it is associated mainly 

with concomitant Helicobacter Pylori infection. In conclusion 

OLGA staging depicts the progression of autoimmune disease 

and provides key information for secondary gastric cancer 

prevention strategies. 

211 

references 

Rugge M, Fassan M, Pizzi M, et al. Autoimmune gastritis: histology phenotype 

and OLGA staging. Aliment Pharmacol Ther 2012;35:1460-66. 

Vannella L, Lahner E, Annibale B. Risk for gastric neoplasias in patients 

with chronic atrophic gastritis: A critical reappraisal. World J Gastroenterol 

2012;1812:1279-85. 

Rugge M, Pennelli G, Pilozzi E, et al. Gastritis: the histology report. Dig 

Liv Dis 2011;43 (Suppl. 4):S373-84. 

Early Gastric Cancer: diagnosis, stadiation and 

clinical impact. Evaluation of 530 patients. 

new elements for an updated definition and 

classification 

L. Saragoni, P. Morgagni1 , A. Gardini1 , C. Marfisi1 , G. Vittimberga1 

, D. Garcea1 Department of Pathology, 1 the 1st Division of General Surgery, hospital 

G.B.Morgagni-L.Pierantoni, Forlì, Italy 

Abstract 

Background. The prevention and early diagnosis of gastric 

cancer permit the clinicians to discover the tumour 

in the initial phase, during which it can be completely 

eradicated, endoscopically or surgically. Since Murakami 

gave the definition of Early Gastric Cancer (EGC) in the 

1970’s, many authors identified various sub-types of EGC 

with different morphological characteristics and clinical 

behaviour. 

Methods. We evaluated retrospectively 530 patients, who 

underwent surgical treatment at the 1st Division of General 

Surgery of our hospital between 1976 and 2006, with a median 

follow-up of 9,4 years (range 1-29). All tumours were 

classified according to the macroscopic and microscopic criteria 

purposed by the Japanese Society of Gastroenterology and 

Endoscopy and Lauren, respectively. The infiltrative growth 

pattern was evaluated according to Kodama’s classification. 

Only tumour-related death was considered as an end-point of 

interest for the survival analysis. 

Results. The overall survival rates of our patients were 91.4% 

and 87% at 5 and 10 years, respectively. Only 44 patients 

(8.3%) died for the disease. Kodama’s type (p = 0.0001), 

lymph node status, both for number and pathologic stage 

according to the 6th Edition of TNM (p = 0.0001), depth of 

infiltration (p < 0.003), and tumour size (p = 0.003) were significant 

prognostic factors in univariate analysis. 

The multivariate analysis identified Kodama’s type (odds 

ratio 2.75, p = 0.0001) and lymph node status for more than 

3 positive nodes versus negative nodes (odds ratio 8.28, 

p = 0.0001), as the only independent prognostic factors in 

our series. 

Conclusion. Lymph node status, especially when more than 

3 lymph nodes are involved, is the most important prognostic 

factor in EGC. 

However, it is also important to evaluate the infiltrative 

growth pattern of the cancers in their early phase according 

to Kodama’s classification, considering PEN A type lesions 

more aggressive than the other EGC types. 

Than, we purpose new elements for an updated definition and 

classification of EGC, with an important clinical impact on 

the treatment of patients. 

Summary 

The early diagnosis of gastric cancer allows to patients to be 

radically treated by endoscopy or surgery. We report our retrospective 

surgical series of EGCs with up-dated pathological 

knowledges.

212 

Key words: EGC, Prognosis, Treatment 

Introduction 

The term “early gastric cancer (EGC)”, defined as carcinoma 

limited to gastric mucosa and or sub-mucosa regardless of 

lymph node status in 1963 by the Japanese Society of Gastroenterology 

and Endoscopy, has continued to spark controversies 

over the years 1-3 . 

Numerous studies have focused on key parameters that could 

be associated with the risk of lymph node metastases or treatment 

failure in EGC 2-6 . 

Better knowledge and increase number of EGC is due to the 

improvement and diffusion of endoscopies and the introduction 

of the new technologies, such as chromoendoscopy and 

magnifying endoscopy. 

In our area, which has an high incidence of gastric cancer, 

EGC represents about 25% of all gastric cancers treated surgically. 

This percentage of “early lesions” is to be considered 

really good for Western Countries, even though not yet comparable 

to those of Eastern Countries, where EGCs represent 

more than 50% of all tumours 7 . The presence of an active 

mass screening program 8 and different classification systems 

for gastrointestinal dysplasia and gastric carcinoma in Eastern 

and Western Countries 9 still explain the significative differences 

in the detection of EGC. 

In particular, the experience we gained by evaluating 530 patients 

affected by EGC, with a median follow-up of 9.4 years, 

has demonstrated that there is a significant worse survival 

probability in node positive and PEN A type patients, as we 

suggested in our previous reports 4-6 . 

We could also demonstrate the important clinical impact of 

size, depth of infiltration and histological type of tumours, 

with special reference to the distribution of lymph node metastases. 

According to our data, which identified sub-groups of patients 

with different prognosis, we purpose to introduce a revised 

definition of EGC, considering “early” only the tumours 

limited to the mucosal layer or, at least, minimally invading 

submucosa, and without lymph node metastases. 

Such a consideration is due, not only to the prognostic behaviour 

of the different kind of tumours, but also to the possibility 

to identify the patients who can be safely and radically treated 

with the endoscopic resection. 

Subjects and methods 

We analyzed retrospectively the data from 530 patients operated 

on at G.B.Morgagni-L.Pierantoni hospital of Forlì (Italy). 

The EGC/advanced cancer ratio was 25%. 

All the patients underwent a sub-total or total gastrectomy 

with a D2 lymphadenectomy, according to Japanese guidelines. 

The EGCs were classified according to macroscopic 

and microscopic criteria proposed by the Japanese Society 

of Gastroenterology and Endoscopy (JSGE) 10 11 and Lauren 

12 , respectively. The JSGE criteria divided the EGCs 

into type I (polypoid), type IIa (elevated), type IIb (flat), 

type IIc (depressed) and type III (ulcerated) (Tab. I). From 

the histological point of view, two main cathegories exist, 

designated intestinal and diffuse by Lauren. A third group 

includes mixed tumoral lesions. The classification of Kodama 

13 was used to define the extent and histological growth 

pattern of penetration of the cancer (Tab. II). According to 

this classification, super (superficial spreading) type is a 

tumour with a diameter of more than 4 cm, either confined 

to the mucosa (Super M) or with slight invasion of the 

submucosa (Super SM); small mucosal type is a carcinoma 


Tab. I. JSgE macroscopic classification of Egcs. 

MACROSCOPIC TYPES 

tYPE 0 i PRotRUDED 

tYPE 0 iia ElEVatED 

tYPE 0 iib flat 

tYPE 0 iic DEPRESSED 

tYPE 0 iii EXcaVatED 

with a diameter of less than 4 cm, with (small mucosal SM) 

or without (small mucosal M) slight submucosal invasion; 

and PEN (penetrating) type is a lesion with a diameter less 

than 4 cm, which invades the submucosa widely. This type 

is further subdivided into two sub-groups, according to the 

way of infiltration of the muscolaris mucosae: PEN A type, 

which invades the submucosa extensively with nodular 

masses and completely destroys the muscolaris mucosae, 

and PEN B type, which grows infiltratively, with fenestration 

of the muscolaris mucosae. The resected stomachs were 

opened along the greater curvature, pinned to a wooden 

plate, and fixed in 10% buffered formalin. The tumours in 

the surrounding gastric wall were cut into several slices, 

mainly parallel to the lesser curvature at intervals of 4-5 

mm. Five micrometer-thick sections, embedded in paraffin, 

were prepared from each slide for histologic examination. 

WHO classification was used to define the degree of tumour 

differentiation 14 . 

Follow-up analysis was performed on the 530 patients who 

were examined. The median follow-up was 9.4 years (range 

1-29 years). Survival analysis started by the day the EGC 

patients underwent surgical treatment. All the prognostic variables 

used in this analysis were measured at this time. 

Only tumour-related death was considered as an end-point of 

interest for the survival analysis. 

The chi-square test was employed to define the association 

between the sub-groups of pathological and clinical criteria 

examined. 

Tab. II. Kodama’s classification of Egcs. 

KODAMA’S TYPES 

SMall MUcoSal M iNtRaMUcoSal Egcs MEaSaURiNg 

lESS thaN 4 cm 

SMall MUcoSal SM iNtRaMUcoSal Egcs MiNiMallY 

iNVadiNG SuBmuCOSa mEaSuRiNG 

lESS thaN 4 cm 

SUPER MUcoSal M iNtRaMUcoSal Egcs MEaSURiNg 

MoRE thaN 4 cm 

SUPER MUcoSal SM iNtRaMUcoSal Egcs MiNiMallY 

iNVadiNG SuBmuCOSa mEaSuRiNG 

MoRE thaN 4 cm 

PEN (PENEtRatiNg) a Egcs MaSSiVElY iNVaDiNg 

SuBmuCOSa WitH NOdulaR pattERN 

MEaSURiNg lESS thaN 4 cm 

pEN (pENEtRatiNG) B Egcs MaSSiVElY iNVaDiNg 

SuBmuCOSa WitH SaW tEEtH 

PattERN MEaSURiNg lESS thaN 4 cm 

MiXED pENEtRatiNG tYpES (a or B) 

MEaSURiNg MoRE thaN 4 cm

RElaziONi 

Hazard ratio, in univariate analysis, was obtained using Cox 

proportional model 15 . 

All p values were based on two-sided testing, and statistical 

analyses were carried out using SAS Statistical software 16 . 

Results 

Among our patients, 305 were men and 225 women. About 

50% of the EGCs were located in the lower third of the stomach. 

We missed some topographic data, especially in the oldest 

cases. Almost all cases were monofocal (94.3%). Intramucosal 

and submucosal infiltration were observed with similar 

frequency. Macroscopic IIc and III types were more than 70% 

of all tumours (Tab. III); small mucosal M Kodama’s type 

represented about 50% of all lesions (Tab. IV). Histologically, 

the intestinal type was the most frequent findimg (78.7%), 

according to Lauren’s classification. Lymph node metastases 

affected 78 patients (14.7%). 

The lymph node status was significantly associated with 

the histologic type (p = 0.0001), infiltration of the wall 

(p = 0.0001), tumour size (p = 0.0001) and Kodama’s Type 

(p = 0.0001). In particular, the incidence of lymph node metastases 

was 30.2% for Kodama’s PEN A types, 27.4% for 

histologic diffuse types, 22.6% for submucosal lesions and 

26.6% for tumors more than 2 cm. (Tab. V). 

The tumour-related death was 8.3% (44 patients). The survival 

probability was 91.4% at 5 years and 87% at 10 years. 

On univariate analysis a significant lower survival was observed 

for patients with submucosal tumours (p = 0.03), PEN 

A type disease (p=0.0001), lesions more than 2 cm (p = 0.03) 

and node positive cancers (p = 0.0003) (Tab. VI). In particular, 

a significant worse prognosis was demonstrated for patients 

with more than 3 metastatic lymph nodes (p = 0.0001). 

Moreover, on multivariate analysis, EGC patients with more 

than 3 positive nodes had a death risk which was about 

eight times higher than in patients with with negative lymph 

nodes (HR 7.84; 95% confidence interval; CI, 3.80-16.18, 

p = 0.0001) and EGC PEN A type patients had a death risk 

of 2 times and a half (HR 2.58; 95% confidence interval; CI 

1.48-4.43, p < 0.001).These results suggest that the biological 

behaviour of EGCs depends tightly on the lymph node status 

and histologic growth pattern according to Kodama’s criteria. 

So, the patients with these findings must to be considered affected 

by an advanced gastric cancer, instead of by an “early 

lesion”, and, than, considered for a surgical standard treatment. 

Among the 78 node-positive patients, 62 were affected by 

sub-mucosal tumors and only 16 by intra-mucosal EGCs. 

Among these 16 tumors, 7 lesions had a diameter no more 

than 2 cm. and 9 measured more than 2 cm. Only 2 of the 7 

smaller EGCs were well differentiated tumors (grade 1 according 

to WHO classification) and both were ulcerated. 

Discussion 

The improvement and diffusion of endoscopic techniques 

and better knowledge of the problem have led to a significant 

increase in early gastric cancers (EGC) over the past 

few years. In our province, EGC represents about 25% of all 

resected gastric cancers 4 5 . Now, our knowledge of EGC is 

so good to permit the endoscopic treatment of some of these 

tumours. Endoscopic resection of early gastric cancers with 

no risk of lymph node metastases is a standard technique 

in Japan, probably owing to the high incidence of gastric 

cancer and the fact that more than half of Japanese gastric 

neoplasms are diagnosed at an early stage. This is due also 

to the existence of different classification systems for gas- 

Tab. III. Distribution of macroscopic types. 

tYPE i (protruded) 77 (14.5%) 

tYPE iia (elevated) 39 (7.4%) 

tYpE iiB (flat) 26 (4.9%) 

tYPE iic (depressed) 277 (52.3%) 

tYPE iii (escavated) 106 (20.0%) 

MiSSiNg 5 (0.9%) 

Tab. IV. Distribution of Kodama’s types. 

SMall MUcoSal M 251 (47.4%) 

SMall MUcoSal SM 85 (16.0%) 

SUPER MUcoSal M 18 (3.4%) 

SUPER MUcoSal SM 29 (5.5%) 

pEN B 38 (7.2%) 

PEN a 106 (20.0%) 

MiSSiNg 3 (0.5%) 

213 

trointestinal dysplasia and gastric carcinoma in Western 

and Eastern Countries 9 17-23 . Recently endoscopic mucosal 

resection (EMR) has increasingly accepted and regularly 

used in Western Countries. Notwithstanding, until now, it 

does not exist an European wide experience which has given 

us significant and useful information to be clinically applied 

and, than, comparable to the data of the Japanese authors. 

They have defined the criteria which must be evaluated by 

pathologists on the endoscopic specimen to consider EMR 

safe and radical as a treatment of EGC 9 24-29 . These criteria 

has been changed in the last ten years, also due to the introduction 

of the new endoscopic techniques, such as endoscopic 

sub-mucosal resection (ESD), which allows Japanese 

endoscopists to remove bigger lesions radically 28 30-34 . Only 

tumours less than 2cm, histologically well differentiated, 

limited to the mucosa, without ulcer and lymphatic/vessel 

invasion are suitable for endoscopic resection as a treatment 

of choice in order to remove the tumour completely 9 28 . 

When all these conditions are contemporary satisfied we can 

consider safe the endoscopic treatment of the tumors. This 

is true also in our series: the 16 intra-mucosal EGCs with 

lymph node metastases showed at least one of the unfavourable 

histologic parameters. 

The retrospective analysisis of our series of EGCs showed 

that tumour size more than 2 cm (26.6%), infiltration of the 

submucosa (22.6%), diffuse histologic type (27.4%) and Kodama’s 

PEN A type (30.2%) are important and significative 

risk factors for lymph node metastases. Moreover, univariate 

analysis demonstrated that patients with tumour size more 

than 2 cm (89% at 5 years and 83% at 10 years), submucosal 

lesions (88% at 5 years and 83% at 10 years) and Kodama’s 

PEN A type cancers (83% at 5 years and 74% at 10 years) had 

a significant worse prognosis. 

These knowledges permitted us to identify sub-groups of EGC 

patients affected by different stages of the disease, strictly 

linked to the clinical behaviour, the prognosis and, than, the 

treatment. Since 1970’s, when Murakami introduced the definition 

of early gastric cancer, the most important prognostic 

factor was considered the depth of wall invasion. 

Subsequent clinical evidence, however, consistently indicated 

nodal involvement as the most important prognostic parameter, 

so that only cancers without nodal invasion were consid-

214 

Tab. VI. univariate analysis: 5 and 10-year survival probability, the Hazard 

Ratio (HR) and their relative 95% confidence intervals (95% Ci). 

5-Year 10-Year P value 

Depth 

Mucosal 95% 90% 

Submucosal 

Size 

88% 83% 0.03 

2cm 

Kodama 

89% 83% 0.03 

PEN a 83% 74% 

Not PEN A 

Nodes 

94% 90% 0.0001 

Negative 94% 89% 

Positive 

N.nodes+ 

78% 75% 0.0003 

0 94% 89% 

1-3 86% 84% 

>3 

pN (TNM 6th Edition) 

42% 42% 0.0001 

N- 94% 89% 

N1 84% 80% 

N2 35% 25% 0.0001 

ered as early neoplasms 35 36 . By taking this into consideration, 

some authors demonstrated that the disease in patients with 

gastric cancer without lymph node metastases, but with invasion 

of the muscularis propria behaved in a similar way to the 

disease in conventional EGC patients 37 . 

We previously demonstrated that, both, invasion of submucosa 

and presence of lymph node metastases must be considered 


Tab. V. distribution of lymph node metastases. We have no information regarding the size of some older tumors. 

N-Patients N+Patients % 

Kodama 

PEN a 106 32 30.2 p = 0.0001 

Not PEN a 

Histotypes (Lauren) 

424 48 11.3 

intestinal 417 49 11.7 p = 0.0001 

Diffuse 

Macrotypes (JSGE) 

113 31 27.4 

i-iia-iib 147 17 11.6 NS 

iic-iii 

Infiltration 

383 63 16.4 

Mucosal 267 16 6.0 p = 0.0001 

Submucosal 

Size 

263 62 23.6 

< 2 cm 253 27 10.7 p = 0.0001 

> 2 cm 192 51 26.6 

unfavourable prognostic factors in EGC patients, suggesting 

to modify the definition of EGC 4 5 . 

Apart from our previous observations, few reports suggested 

to up-grade the definition of EGC, by identifying sub-groups 

of patients with nodal metastases, characterized by worse 

prognosis 2 35 37 . According to these authors, infiltration 

into the wall was not as important as lymph node status for 

establishing the biological behaviour and prognosis of the 

tumour. Again, in our actual larger series, we have shown 

that lymph node metastases and Kodama’s PEN A type still 

remain independent prognostic factors; moreover the massive 

infiltration of the submucosa in EGC patients means a 

higher risk of lymph node metastases. For this reason, we 

purpose to reconsider the definition of EGC, as Murakami 

conceived it in 1970s. According to our experience, it should 

be more appropriated to call “early” the gastric cancers 

which are limited to the mucosa, or at least do not infiltrate 

the sub-mucosal layer massively, and have no lymph node 

metastases. 

In addition, we can predict precisely the presence of lymph 

node metastases by an accurate histologic evaluation of EMR/ 

ESD specimens, which have, first of all, a diagnostic intent. 

references 

1 Japanese Research Society for Gastric Cancer. The general rules 

for gastric cancer study in surgery and pathology. Jpn J Surg 

1981;11:127-39. 

2 Abe S, Yoshimura H, Nagaoka S, et al. Long-term results of operation 

for carcinoma of the stomach in T1/T2 stages: critical evaluation 

of the concept of early carcinoma of the stomach. J Am Coll Surg 

1995;181:389-96. 

3 Sano T, Kobori O, Muto T. Lymph node metastasis from gastric cancer: 

endoscopic resection of tumour. Br J Surg 1992;79:241-4. 

4 Folli S, Dente M, Dell’Amore D, et al. Early gastric cancer: prognostic 

factors in 223 patients. Br J Surg 1995;82:952-6. 

5 Saragoni L, Gaudio M, Vio A, et al. Early gastric cancer in the province 

of Forlì: follow-up of 337 patients in a high risk region for gastric 

cancer. Oncol Rep 1998;5:945-8. 

6 Saragoni L, Gaudio M, Morgagni P, et al. The role of growth patterns, 

accordino to Kodama’s classification, and lymph node status, as 

important prognostic factors in early gastric cancer: analysisi of 412 

cases. Gastric Cancer 2000;3:134-40.

RElaziONi 

7 Sano T, Sasako M, Kinoshita T, et al. Recurrence of early gastric 

cancer. Follow-up of 1475 patients and review of Japanese literature. 

Cancer 1993;72:3174-8. 

8 Aochi K. Trends in stomach cancer mortality in Japanese women: an 

evaluation of prevention programs. Third International Gastric Cancer 

Congress, Seoul (Korea), April 27-30, 1999. Bologna: Monduzzi Editore. 

9 Gotoda T, Yamamoto H, Soetikno RM. Endoscopic submucosal dissection 

of early gastric cancer. J Gastroenterol 2006;41:929-42. 

10 Murakami T. Pathomorphological diagnosis, definition and gross 

classification of early gastric cancer. Gann Monograph Cancer Res 

1971;11:53-66. 

11 Ohta H, Noguchi Y, Takagi K, et al. Early gastric carcinoma with 

special reference to macroscopic classification. Cancer 1987;60:1099- 

106 

12 Lauren P. The two main histological types of gastric carcinoma: an 

attempt to reach a histoclinical classification. Acta Pathol Microbiol 

Scand 1965;64:31-49. 

13 Kodama Y, Inokuchi K, Soejima K, et al. Growth patterns and prognosis 

in early gastric cancer. Superficially spreading and penetrating 

growth types. Cancer 1983;51:320-6. 

14 World Health Organization. Pathology and Genetics. Tumours of the 

Digestive System. 2000, IARC Press Lyon, Edited by Stanley R. Hamilton, 

Lauri A. Aaltonen 

15 Cox DR. Regression models and life tables. JR Stat Soc 1972;34:187- 

220. 

16 th SAS Institute. SAS/STAT User’s guide, version 6. 4 ed. vol 1. Cary, 

NC: SAS Institute 1989, p. 943. 

17 Schlemper RJ, Itabashi M, Kato Y, et al. Differences in diagnostic 

criteria for gastric carcinoma between Japanese and Western pathologists. 

Lancet 1997;349:1725-9. 

18 Genta RM, Rugge M. Gastric precancerous lesions: heading for an 

international consensus. Gut 1999;(Suppl1):5-8. 

19 Kim YI. Definition, classification and epidemiology of dysplasia. 

Third International Gastric Cancer Congress, Seoul (Korea), April 27- 

30, 1999. Bologna: Monduzzi Editore. 

20 Lauwers GY, Shimizu M, Correa P, et al. Evaluation of gastric biopsies 

for neoplasia: differences between Japanese and Western pathologists. 

Am J Surg Pathol 1999;23:511-8. 

21 Lewin KJ. Nomenclature problems of gastrointestinal epithelial neoplasia. 


22 Riddell RH, Iwafuchi M. Problems arising from Eastern and Western 

Criteri di idoneità del fegato nel trapianto 

C. Mescoli 


Fine needle cytology / core needle biopsy in 

pancreatic tumors 

G. Zamboni 

Departement o Pathology, University of Verona, Ospedale Don Calabria, 

Negrar, Verona, Italy 

The extensive utilisation of imaging has increased the discovery 

of pancreatic masses. Unfortunately, most (80 to 90 percent) 

of the clinically detected masses in the pancreas are adenocarcinomas. 

With the exception of functioning endocrine tumors, 

characterised by a specific clinical picture, the other pancreatic 


Patologia gastro-enterica 2 

215 

classification systems for gastrointestinal dysplasia and carcinoma: 

are they resolvable? Histopathology 1998;33:197-202. 

23 Rugge M, Farinati F, Di Mario F, et al. Gastric epithelial displasia: 

a prospective multicenter follow-up study from the interdisciplinary 

group on gastric displasia. Hum Pathol 1991;22:1002-8. 

24 Gotoda T. Endoscopic resection of early gastric cancer: the Japanese 

perspective. Curr Opin Gastroenterol 2006;22:561-9. 

25 Rembacken BJ, Gotoda T, Fujii T, et al. Endoscopic mucosal resection. 

Endoscopy 2001;33:709-18. 

26 Soetikno R, Gotoda T, Nakanishi Y, et al. Endoscopic mucosal resection. 

Gastrointest Endosc 2003;57:567-79. 

27 Ludwig K, Klautke G, Bernhard J, et al. Minimally invasive and 

local treatment for mucosal early gastric cancer. Surg Endosc 

2005;19:1362-6. 

28 Oda I, Saito D, Tada M, et al. A multicenter retrospective study 

of endoscopic resection for early gastric cancer. Gastric Cancer 

2006;9:262-70. 

29 Eguchi T, Gotoda T, Oda I, et al. Is endoscopic one-piece mucosal resection 

essential for early gastric cancer? Dig Endosc 2003;15:113-6. 

30 Ono H, Kondo H, Gotoda T, et al. Endoscopic mucosal resection for 

treatment of early gastric cancer. Gut 2001;48:225-9. 

31 Gotoda T, Kondo H, Ono H, et al. A new mucosal endoscopic resection 

procedure using an insulated-tipped electrosurgical knife for rectal 

flat lesions. Gastrointest Endosc 1999;50:560-3. 

32 Oda I, Gotoda T, Hamanaka H, et al. Endoscopic submucosal dissection 

for early gastic cancer: technical feasibility, operation time, 

and complications from a large consecutive series. Dig Endosc 

2005;17:54-8. 

33 Yamamoto H, Kawata H, Sunada K, et al. Successful one-piece resection 

of large superficial tumors in the stomach and colon using sodium 

hyaluronate and small-caliber-tip transparent hood. Endoscopy 

2003;35:690-4. 

34 Oyama T, Kikuchi Y. Aggressive endoscopic mucosal resection in the 

upper GI tract- Hook knife EMR method. Minim Invasive Ther Allied 

Technol 2002;11:291-5. 

35 Inoue K, Tobe T, Kan N, et al. Problems in the definition and treatment 

of early gastric cancer. Br J Surg 1991;78:818-21. 

36 Kim JP, Hur YS, Yang HK. Lymph node metastasis as a significant 

prognostic factor in early gastric cancer: analysisi of 1136 early cancers. 

Ann Surg Oncol 1995;2:308-13. 

37 Adachi Y, Masafuni I, Seigo K, et al. A tumor: new criteria for vearly 

gastric cancer. Oncol Rep 1997;4:1235-8. 

Moderatori: Giovanni Lanza (Ferrara), Massimo Rugge (Padova) 

tumors manifest with either non-specific symptoms, or symptoms 

similar to pancreatitis. Although a correct diagnosis is mandatory 

to plan the therapeutic approach and establish a prognosis, accurate 

preoperative diagnosis sometimes is very difficult to achieve. 

The ideal diagnostic test, as in other disease, should be the tissue 

diagnosis with a trucut biopsy, since the tissue can be also 

used for ancillary studies. Unfortunately, diagnostic pancreatic 

tissue biopsies are not always available. The less invasive 

methods, like the FNAB with US guidance or the EUS-guided 

biopsies have a better level of safety and are considered reliable 

in detecting the presence of malignant cells, although of 

lower sensitivity. Independently on the used sampling method 

the accuracy of pathologic evaluation is higher when a pathologist 

makes the procedures or cooperates to them. 

Whether a lesion should be punctured or not it depends on 

many different aspects, and most of them are basically clinical 

and radiological ones. In many centres, if a mass is resectable

216 

the surgeons perform a pancreatectomy. A morphological diagnosis 

has to be served to all patients, either on the primary 

or secondary lesions, before to plan chemotherapy. 

In ductal carcinoma the cytologic smears are characterized by 

high celluarity, and the presence of relatively pure neoplastic 

cellular component. Major criteria of malignancy are considered: 

the presence of nuclear crowding and overlapping, 

the irregular chromatin distribution and the irregular nuclear 

contour, whereas minor criteria are the nuclear enlargement, 

the presence of single malignant cells, necrosis and mitosis. 

In the biopsy interpretation of a primary pancreatic lesion eight 

features are proposed as particularly helpful in the differential 

diagnosis with chronic pancreatitis: the loss of lobular architectural, 

resulting in a hazard distribution of glands, the variation 

in nuclear area greater than 4 to 1 from cell to cell, prominent 

and multiple nucleoli, the presence of incomplete glands, intraluminal 

necrosis, glands immediately adjacent to muscular 

artery, perineural invasion by glands and vascular invasion. 

Endocrine Neoplasms. The smears are hypercellular with 

a clean background, except for high grade neoplasia. The 

cells can be individually dispersed or arranged in clusters. 

The nuclei are frequently uniform, round to oval, with a salt 

and pepper pattern (coarse, finely distributed chromatin) but 

sometimes they can be pleomorphic and hyperchromatic. 

Acinar Cell Carcinoma. The loosely cohesive groups of cells 

show the typical acinar differentiation with a cytoplasm filled 

with deeply eosinophylic granules. The cells show signs of 

atypia, with prominent nucleoli and mitoses; necrotic debris 

are frequently found. 

To avoid the most frequent pitfalls, the pathologist should 

know in first instance all the clinical and radiological relevant 

features. The most important technical informations he has 

to know differ in solid and cystic lesions. In solid lesions the 

most important differential diagnosis is between ductal carcinoma 

and chronic pancreatitis, especially the tumor-forming 

pancreatitis, like the autoimmune pancreatitis. In cystic 

lesions, the most important bias are sampling errors. The 

recognition of gastric and duodenal epithelial contamination 

is the most important elements to be considered in the EUSguided 

FNA cytology, especially in the differential diagnosis 

of mucin-secreting low grade neoplasia. The overdiagnosis of 

carcinoma has to be avoid in the presence of cellular atypia 

due to gastritis or duodenitis. 

The immuncytochemical features of ductal adenocarcinoma, 

are the expression of MUC1 and the lack of MUC2. MU- 

C5AC, normally expressed by the gastric mucous surface 

cells, are expressed in gastric type Intraductal papillary mucinous 

neoplasms. 

In endocrine neoplasms, the diagnosis may be confirmed by 

the immunohistochemical demonstration of endocrine markers 

such as chromogranin A and synaptophysin and the detection 

of hormone production. 

In acinar cell carcinoma, the most informative immunihistochemically 

stain is the acinar marker trypsin. 


Lesioni serrate colon-rettali 

L. Novelli, M. Rotellini, C. Caporalini, C. Fondi, F. Castiglione 

Azienda Universitaria-Ospedaliera di Careggi, Dipartimento di Area 

Critica Medica-Chirurgica Università di Firenze 

Tra le lesioni polipoidi del colon-retto sicuramente le più conosciute 

e più studiate sono gli adenomi ed il loro potenziale 

quali lesioni pre-cancerose; meno dibattuto fino a qualche 

anno fa era il ruolo delle lesioni iperplastiche del colon-retto. 

Queste lesioni venivano spesso “etichettate” come polipi 

iperplastici, come polipi iperplastico-adenomatosi, oppure si 

accorpavano al gruppo degli adenomi classici. In realtà oggi 

stiamo imparando a riconoscerli ed abbiamo visto che ne 

esistono diversi tipi, sono almeno tre quelli riconosciuti dal 

WHO (polipo iperplastico, polipo/adenoma serrato sessile, 

adenoma serrato tradizionale). Oltre a differire per la loro 

morfologia queste entità hanno anche una valenza diversa 

dal punto di vista prognostico, inteso quale lesioni displastiche 

prima e pre-cancerose poi, diviene pertanto molto 

importante saperle riconoscere, classificare, identificarne 

l’eventuale grado di displasia ed indicare al clinico quali sono 

le lesioni a maggior rischio di evoluzione maligna. Alcuni 

studi hanno già evidenziato che i vari tipi di lesioni serrate 

possiedono diverse caratteristiche morfologiche, immunoistochimiche 

e biologiche e soprattutto quest’ultime giocano 

un ruolo importante nel determinare l’eventuale progressione 

in carcinoma. A questo fine abbiamo pensato innanzitutto 

di rivalutare le nostre precedenti diagnosi, per esempio i 

polipi iperplastico-adenomatosi, e di classificarle secondo 

i criteri proposti dal WHO; dopodichè di valutarne le caratteristiche 

immunoistochimiche e biologiche studiando i 

principali tipi di mutazioni che sono presenti nelle diverse 

strade che portano al cancro del colon-retto (KRAS; BRAF, 

CIMP, MLH1, MSI), confrontandole con casi di adenoma 

tradizionale e di carcinoma ex-adenoma. 

Bibliografia 

Rex D, Ahnen D, Baqron J, et al. Serrated lesion of the colorectum: 

review and recommendations from an expert panel. Am J Gastroenterology 

2012; in press. 

Salaria S, Streppel M, Lee L, et al. Sessile serrated adenomas: hight-risk 

lesion? Human Pathology 2012; in press. 

Noffsinger A. Serrated polyps and colorectal cancer: new pathway to 

malignancy. Ann Rev Pathol Mech Dis 2009;4:343-64. 

Makinen MJ. Colrectal serrated adenocarcinoma. Histopathology 

2007;50:131-50. 

Velho S, Moutinho C, Cirnes L, et al. BRAF, KRAS, PIK3CA mutations in 

colorectal serrated polyps and cancer: primary or secondary genetic 

events in colorectal carcinogenesis? BMC Cancer 2008;8:255. 

Il patologo nello screening del CrC 

G. Lanza 

Paper not received

RElaziONi 

The pathogenesis of idiopathic pulmonary 

fibrosis: new perspectives 

M. Chilosi 

Anatomia Patologica, Department of Pathology, University of Verona 

Idiopathic pulmonary fibrosis (IPF) is the most common and 

severe form of idiopathic interstitial pneumonia, and its median 

survival is 3-4 years. New concepts have been recently 

proposed regarding the biology and pathogenesis of this 

devastating disease, focused on a sequential epithelial cell 

injury, followed by deranged activation of lung reparative 

processes 1-3 . Accumulating evidence is available that in IPF 

the abnormal re-epithelialization after injury can be related 

to a progressive and localized stem-cell exhaustion due to intrinsic 

cellular defects either related to a predisposing genetic 

background (familial IPF is a well recognized entity), or to the 

aging-related accumulation of metabolic alterations (e.g. due 

to toxic effects of smoking, pollution, metabolic abnormalities, 

or other causes) 2 . The remodeling process in this scheme 

is likely related to the abnormal triggering at sites of disease 

development of different molecular pathways crucial to lung 

tissue development and regeneration, including the wnt-betacatenin 

pathway, TGF-beta, NOTCH, and others 4 5 . 

Nevertheless, a missing point in this pathogenic scenario is 

related to the peculiar localization of IPF lesions, that typically 

start at the bases of the lower lobes, progressively extending in 

a caudal-cranial mode. Several lines of evidence suggest that 

these anatomical parts of the lung are in fact sites where mechanical 

forces can be particularly concentrated, thus triggering 

the formation of microscopic tears in the alveolar structure, 

which may result in repetitive small scarring events (fibroblast 

foci), and eventual honeycomb changes 6-8 . The microscopic 

Fig. 1. 


Sala Giotto – 08.30-10.30 

Patologia polmonare 1 

Patologie polmonari diffuse: una sfida per il patologo 

Moderatori: Camilla Comin (Firenze), Oscar Nappi (Napoli) 

217 

damages due to chronic mechanical stress located in these 

areas can in fact cooperate in a sequence of pathogenic events, 

including 1: localized accelerated pneumocyte turnover, with 

eventual increase of replicative senescence, 2: occurrence of 

a “senescence-induced hypersecretive phenotype” (SASP) 9 

within these parts of the lung parenchyma, 3: abnormal activation 

of reparative molecular pathways (e.g. wnt-pathway) 4 5 , 

leading to abnormal remodeling of the lung parenchyma. 

references 

1 Selman M, Pardo A. Idiopathic pulmonary fibrosis: an epithelial/ 

fibroblastic cross-talk disorder. Respir Res 2002;3:3. 

2 Chilosi M, Doglioni C, Murer B, et al. Epithelial stem cell exhaustion 

in the pathogenesis of idiopathic pulmonary fibrosis. Sarcoidosis Vasc 

Diffuse Lung Dis 2010;27:7-18. 

3 Chilosi M, Poletti V, Rossi A. The pathogenesis of COPD and IPF: 

distinct horns of the same devil? Respir Res 2012;13:3. 

4 Chilosi M, Poletti V, Zamò A, et al. Aberrant Wnt/beta-catenin 

pathway activation in idiopathic pulmonary fibrosis. Am J Pathol 

2003;162:1495-502. 

5 Königshoff M, Balsara N, Pfaff EM, et al. Functional Wnt signaling is 

increased in idiopathic pulmonary fibrosis. PLoS One 2008;3:e2142. 

6 Dail-DH. Pulmonary apical cap. Am J Surg Pathol 2001;25:1344. 

7 Cabrera-Benítez NE, Parotto M, Post M, et al. Mechanical stress 

induces lung fibrosis by epithelial-mesenchymal transition. Crit Care 

Med 2012;40:510-7. 

8 Leslie KO. Idiopathic pulmonary fibrosis may be a disease of recurrent, 

tractional injury to the periphery of the aging lung: a unifying 

hypothesis regarding etiology and pathogenesis. Arch Pathol Lab 

Med. 2012;136:591-600. 

9 Coppé JP, Desprez PY, Krtolica A, et al. The senescence-associated 

secretory phenotype: the dark side of tumor suppression. Annu Rev 

Pathol 2010;5:99-118. 

Smoking-related interstitial lung disease 

(Modified from Caminati et al. An integrated clinical-radiological-pathological 

approach to smoking-related interstitial 

lung disease. Eur Respir Rev, in press). 

A. Cavazza, M. Ragazzi, E. Tagliavini 

Unità Operativa di Anatomia Patologica, Ospedale S. Maria Nuova- 

IRCCS, Reggio Emilia 

In the lung, apart being the main cause of emphysema/COPD, 

carcinoma and idiopathic spontaneous pneumothorax, tobacco 

smoke is associated with several interstitial lung diseases 

(ILD) including respiratory bronchiolitis-associated ILD (RB- 

ILD), desquamative interstitial pneumonia (DIP), Langerhans 

cell histiocytosis (LCH), idiopathic pulmonary fibrosis (IPF), 

acute eosinophilic pneumonia, ILD in rheumatoid arthritis and 

pulmonary hemorrhage in Goodpasture syndrome. This talk 

will focus on the histological features of the first three diseases, 

which have the strongest epidemiological association 

with smoke. Their main clinical, radiological and histological 

features are summarized in the following table. 

Respiratory bronchiolitis. The most characteristic effect of 

tobacco smoke on lung parenchyma is respiratory bronchi-

218 

Tab. I. 

RB-ILD DIP LCH 

olitis (RB), consisting in finely pigmented, iron-containing 

(“smoker’s”) macrophages within the lumen of bronchioles 

and peribronchiolar alveoli. Frequently smoker’s macrophages 

are associated with subtle histological features of 

chronic bronchiolitis including mild lymphocytic inflammation 

and mild fibrosis of the bronchiolar wall and surrounding 

alveolar septa, sometimes with rigidity and distortion of the 

bronchiolar lumen, bronchioloectasia and mucostasis. The 

changes are patchy at low magnification with a striking bronchiolocentric 

distribution, however smoker’s macrophages 

may variably extend to the peripheral alveoli occasionally 

involving the entire lobule. 

RB is very frequent in smokers, and probably is the most sensitive 

and specific histological marker of tobacco smoke: it is 

present in almost 100% of current smokers, in about 50% of 

ex-smokers (sometimes many years after smoking cessation), 

and only exceptionally in never smokers. RB is generally an 

histological incidental finding in smokers (and the biopsy is 

obtained for another reason, for example a carcinoma), and 

only rarely RB causes an ILD. Although patients with ILD 

have in general more severe histological alterations, histology 

alone is unable to predict the presence of ILD in the single 

case. Once the clinician has established the presence of an 

ILD due to RB, the distinction between RB-ILD and DIP is 

mostly based on the extension of smoker’s macrophages: in 

RB-ILD the latter are restricted to the centrilobule, whereas 

in DIP they involve the lobule more diffusely. Moreover 

interstitial fibrosis (see below), lymphoid follicles, giant cells 

and eosinophils are more frequent in DIP than RB-ILD, and 

in some patients with DIP the number of eosinophils (both 

in tissue and BAL) is high enough to raise concern about the 

possibility of chronic eosinophilic pneumonia. However, the 

limits between RB-ILD and DIP are blurred and in practice 

the distinction can be difficult and in some cases is probably 

quite arbitrary. For these reasons some Authors suggest that 

RB-ILD and DIP should be lumped into one category. We 

share the majority’s opinion that they should be classified 

separately whenever possible, because of the differences in 


Smoking 100% 80-90% > 90% 

age 3-5th decade 3-5th decade 3-4th decade 

male/female Slight male predominance Slight male predominance 1-1 

Symptoms insidious onset of dyspnea and cough insidious onset of dyspnea 

and cough 

insidious onset of dyspnea and 

cough 

function Mixed or normal Restrictive Restrictive and/or obstructive 

Prognosis always favourable generally favourable generally favourable 

ct scan Upper-lobe predominant centrilobular Mid and lower-lobe 

Upper-lobe predominant stellate 

ground-glass opacities, centrilobular predominant ground-glass nodules, sometimes cavitated, 

emphysema and bronchial wall 

opacities, reticular opacities thick-walled and thin-walled cysts 

thickening 

with bizarre shape 

histology Smoker’s macrophages within 

Smoker’s macrophages Stellate bronchiolocentric nodules, 

bronchiolar lumens and surrounding diffusely involving the lobule, cellular in the active phase and 

alveolar spaces, frequently with mild frequently associated with fibrotic/cavitated in the chronic 

bronchiolar fibrosis/inflammation and uniform interstitial fibrosis, phase 

emphysema (centrilobular and/or lymphoid follicles and 

subpleural). Some interstitial fibrosis can 

occur, typically jaline in character and 

surrounding emphysematous holes 

increased eosinophils 

clinical-radiological presentation and prognosis, acknowledging 

that in rare cases the distinction can be impossible. 

Fibrosis and emphysema. Despite emphysema is classically 

defined as permanent airspace enlargement without “obvious” 

(macroscopic) fibrosis, in reality some microscopic 

fibrosis is quite frequent in centrilobular and particularly in 

paraseptal emphysema. Sometimes fibrosis is quite prominent, 

but generally does not produce clear clinical abnormalities 

being an incidental finding in smokers operated 

for other reasons. Reported in the literature with different 

synonymous (RB-ILD with fibrosis, airspace enlargement 

with fibrosis, smoking-related interstitial fibrosis), fibrosis 

in this setting has a typical jaline, amyloid-like character and 

is more prominent in subppleural and peribronchiolar parenchyma, 

where frequently surrounds emphysematous spaces: 

sometimes large emphysematous holes are criss-crossed by 

bands of fibrosis. Fibrosis can also occur unassociated with 

emphysema. 

In some smokers with ILD, fibrosis is so prominent to make 

the differential diagnosis between DIP and fibrotic NSIP (and 

sometimes also with UIP) difficult, both histologically and 

radiologically. Moreover, some Authors suggest that DIP can 

evolve into NSIP, and that some cases of fibrotic NSIP can be 

related to tobacco smoke. Although compelling, these hypotheses 

are unproved yet. In our practice we try to separate DIP 

and fibrotic NSIP whenever possible, particularly because 

prognosis of DIP appears to be better than fibrotic NSIP, again 

acknowledging that in occasional cases the distinction is difficult 

and probably arbitrary. 

Increase in Langerhans cells. Another common effect of 

smoking is the increase in the number of Langerhans cells, 

detectable both in lung tissue and BAL. Langerhans cells are 

characteristic both on morphology (moderate amount of pale 

cytoplasm, deeply infolded nuclei) and on immunophenotype 

(positivity for S-100 protein, CD1a and Langerin). By definition, 

in LCH Langerhans cells form clusters, but the limits 

between LCH and a simple increase in Langerhans cells in a 

smoker are conventional and sometimes blurred. LCH begins

RElaziONi 

when Langerhans cells proliferate in bronchiolar wall and 

insinuate into the surrounding alveolar septa, forming multiple 

stellate nodules centered on small airways. Together with 

Langerhans cells, these cellular nodules frequently incorporate 

a variable number of eosinophils and smoker’s macrophages, 

both in surrounding alveolar spaces and in the interstitium. 

An associated RB is almost universal and sometimes 

extensive, being visible at CT-scan as ground-glass opacities. 

With time, the center of the nodules becomes fibrotic and 

irregular cavities develop in some of the nodules, leading to 

the classical histological features of mature LCH: multiple 

stellate nodules, some of which cavitated and surrounded by 

normal lung. The fate of these lesions vary from case to case, 

probably depending on the abstinence from smoking and from 

individual predisposition. In many cases the nodules reabsorb 

completely or leave to small bronchiolocentric scars with 

paracicatricial emphysema: it is reasonable to suspect that 

some cases of centrilobular emphysema with fibrosis are in 

reality examples of healed LCH. In a minority of patients a 

progressive fibrosis develops: the stellate shape of the scars, 

their bronchiolocentric distribution with a prevalence in the 

upper lobes, and the absence/paucity of fibroblastic foci are 

characteristic of chronic LCH and are sufficient for a firm 

diagnosis in the majority of the cases, even in the absence of 

residual Langerhans cells. Occasionally, however, the histo- 

Sala Giotto 10.30-12.30 

Patologia polmonare 2 

La diagnosi molecolare nel carcinoma polmonare 

EGFr mutations in nSCLC: methods of detection 

and open questions 

N. Normanno 

Cell Biology and Biotherapy Unit, INT Fondazione “G.Pascale, Naples, 

Italy and Pharmacogenomic Laboratory, CROM – Centro Ricerche 

Oncologiche di Mercogliano, Mercogliano, Avellino, Italy 

Activating mutations of the epidermal growth factor receptor 

(EGFR) in non-small-cell lung cancer (NSCLC) have been 

discovered following analysis of the EGFR gene in patients 

that responded to the EGFR tyrosine kinase inhibitors (TKI) 

gefitinib or erlotinib in early clinical trials. Indeed, almost all 

patients who respond to EGFR-TKIs have been shown to carry 

activating mutations usually found in exons 18 through 21 of 

the TK domain of EGFR, and are either point mutations or 

in-frame small deletions or insertions. Two mutations, a single 

point mutation in exon 21, the L858R, and a series of small inframe 

deletions in exon 19, account for approximately 90% of 

all EGFR mutations. 

EGFR mutations are not frequent in unselected Caucasian 

NSCLC patients. However, they are far more frequent in 

female patients as compared with male (38.7% versus 10%); 

in adenocarcinoma as compared with other histological types 

(29.4% versus 1.8%); in non-smokers as compared with current 

smokers or former smokers (45.8% versus 7.1%); and in 

East-Asian NSCLC patients (33.4%) as compared with Non- 

Moderatori: Bruno Murer (Mestre), Luigi Ruco (Roma) 

219 

logical differential diagnosis with UIP is difficult and requires 

a strict correlation with clinical-radiological findings. As for 

RB, emphysema and fibrosis, also LCH can be an histological 

incidental finding in the lung specimen removed for another 

disease, for example carcinoma. 

Summary. As we have seen, tobacco smoke can cause in the 

lung many histological abnormalities. These abnormalities 

can be variably combined one with the others, creating a significant 

overlap among the different entities. Moreover, they 

frequently provide just a backdrop for other diseases, more 

clinically relevant. For these reasons, to establish the significance 

of histological findings a close correlation with clinical 

and radiological data is mandatory. 

Interstiziopatie fumo-correlate 

A. Cavazza 


La biopsia trans bronchiale: inquadramento 

generale e casi paradigmatici 

M. Barbareschi 


East-Asian patients (5.5%). Results of randomized phase III 

clinical trials have clearly demonstrated that administration of 

an EGFR TKI results in a prolonged progression free survival 

(PFS) as compared with chemotherapy in patients carrying 

EGFR mutations. Following these findings, treatment with an 

EGFR TKI is the recommended first line therapy for EGFR 

mutant patients. As a consequence, assessment of the mutational 

status of the EGFR has become mandatory in order to 

choose the most appropriate first-line treatment for NSCLC 

patients. 

Different techniques are currently used for the detection of 

EGFR mutations, including PCR/sequencing, pyrosequencing, 

Real Time PCR and fragment analysis. Although home 

brew methods are widely used for mutational analysis, commercially 

available kits have the advantage to provide both 

positive and negative controls. 

EGFR mutation analysis is not easy. More than 250 mutations 

in 4 different exons of the EGFR gene have been described up 

to now. Specimens available for EGFR testing are often small 

and contain a low percentage of tumor cells. Therefore, low 

sensitive techniques might lead to false-negative results. In 

contrast, high sensitive methods might lead to false positive 

results, if appropriate controls are not used. 

Gefitinib was approved in Italy for treatment of NSCLC 

patients carrying mutant EGFR in May 2010. Guidelines for 

EGFR mutational analysis in NSLC patients were prepared in 

2010 by a steering committee of members of the Italian Asso-

220 

ciation of Medical Oncology (AIOM) and the Italian Society 

of Surgical Pathology and Cytopathology (SIAPEC-IAP). 

Following the publication of the guidelines, the scientific 

societies started an educational program with presentation 

and discussion of the guidelines in several national meetings. 

AIOM and SIAPEC also organized an external quality assurance 

(EQA) program for EGFR testing that revealed that 

EGFR mutation analysis is performed with good quality in 

the majority of Italian laboratories. The activity of AIOM and 

SIAPEC has significantly contributed to improve EGFR testing 

and, more generally, molecular pathology in Italy. 

references 

1 Sharma SV, Bell DW, Settleman J, et al. Epidermal growth factor 

receptor mutations in lung cancer. Nat Rev Cancer 2007;7:169-81. 

2 Normanno N, De Luca A, Bianco C, et al. Epidermal growth factor 

receptor (EGFR) signaling in cancer. Gene 2006;366:2-16. 

3 Marchetti A, Normanno N. Recommendations for mutational analysis 

of EGFR in lung carcinoma. Pathologica 2010;102:119-26. 

ALK: how and when 

A. Marchetti 

Center of Predictive Molecular Medicine, Center of Excellence on 

Aging, University-Foundation, Chieti, Italy 

Genetic lesions that drive the proliferation of cancer cells, 

known as driver mutations, can make specific tumors sensitive 

to therapeutic inhibitors targeting the mutated pathways. 

Several target-based therapies are now available for which 

treatment optimization is based on tumor testing for specific 

mutations and direct therapies against the mutant target. In 

patients with non–small-cell lung cancer (NSCLC), inhibitors 

of the epidermal growth factor receptor (EGFR), such as 

gefitinib or erlotinib, have produced consistent responses in a 

subset of cases carrying activating EGFR mutations 1-3 . 

More recently, similarly positive outcomes have been reported 

for crizotinib in NSCLCs with rearrangement of the 

Anaplastic lymphoma kinase (ALK) gene. ALK gene rearrangements 

were described for the first time in 2007 as small 

inversions on chromosome 2p inducing a fusion of parts of 

the echinoderm microtubule-associated protein-like 4 (EML4) 

gene with parts of the ALK gene in NSCLC. The resulting fusion 

protein (EML4–ALK), with kinase activity, conferred a 

strong proliferative stimulus on the cells. 4,5 

Activating mutations or translocations of ALK have been 

identified in other types of cancer, including anaplastic largecell 

lymphoma, inflammatory myofibroblastic tumour, and 

paediatric neuroblastoma. 6-8 

Multiple distinct EML4-ALK chimeric variants have been 

identified, representing breakpoints within various EML4 

exons, all of which are transforming in vitro 9,10 . 

ALK rearrangement is present in 2-7% of NSCLC cases and it 

is associated with distinct clinicopathological features, including 

young age of onset, absent or minimal smoking history, 

and adenocarcinoma histology 4 10 11-17 . 

ALK rearrangements are in general mutually exclusive with 

EGFR and KRAS mutations 18 , consistent with the notion 

that ALK rearrangement defines a unique molecular subset 

of NSCLC. 

Preclinical and clinical studies have shown that cancer cells 

harbouring EML4–ALK and other ALK abnormalities are 

exquisitely sensitive to ALK inhibitors 11 19 . 

Crizotinib (PF-02341066; Pfizer) is a selective oral tyrosine 

kinase inhibitor of ALK and MET, which inhibits the tyrosine 

phosphorylation of ALK 20 21 . 


In a phase I clinical trial the toxicity profile and the efficacy of 

crizotinib were evaluated in a cohort of patients with NSCLC and 

ALK rearrangement 22 . The study data were recently updated. 

These data led to the accelerated approval of crizotinib, by 

the Food and Drug Administration (FDA) in the United States 

on 26 August 2011, for the treatment of NSCLC patients in a 

locally advanced or metastatic state, who are positive for ALK 

rearrangement. The use of crizotinib is restricted to patients 

whose tumors result positive to ALK alteration from a test 

approved by the FDA (currently the Abbott Vysis ALK Break 

Apart FISH Probe Kit, Abbott Molecular Inc., IL, USA) 23 . 

On 17 August 2011 the European Medicines Agency (EMEA) 

in Europe accepted the regulatory submission of crizotinib for 

the treatments of patients with advanced stage, ALK-positive, 

pretreated NSCLC. 

The analysis of molecular changes of ALK is necessary in order 

to choose the best therapeutic strategy in selected NSCLC 

patients in stages IIIB and IV which, in the presence of gene 

rearrangements, may benefit from treatment with ALK inhibitors. 

The ALK test is indicated in NSCLC patients with 

histotypes of adenocarcinoma, large cell carcinoma, mixed 

tumors with adenocarcinoma, or not otherwise specified 

(NOS) NSCLC, which present the highest probability of gene 

rearrangements. On the basis of current knowledge, the determination 

of ALK alterations may be conducted on a surgical 

specimen, or biopsy or cytological samples of the primary 

tumor and/or of metastases. 

In order to guide therapeutic decisions in NSCLC patients the 

genetic analysis of ALK runs alongside EGFR gene mutation 

research 24 25 . Various technologies have been developed in 

order to study this marker. 

Fluorescence in-situ hybridization (FISH) is currently the 

elective method for the analysis of ALK gene rearrangements. 

This method was in fact used in the clinical trials which led 

to the approval for treatment with crizotinib. The current diagnostic-therapeutic 

protocol sets a cut-off of 15% rearranged 

nuclei to consider a case as “positive” and the patient as a 

candidate for treatment. The technology is available in commercial 

kits developed for diagnostic use, among which is the 

diagnostic kit certified by the FDA, Abbott Vysis (ALK Break 

Apart FISH Probe Kit, Abbott Molecular, Inc.). Other commercial 

kits are available which are not yet FDA-approved 

(e.g. ZytoLight®SPEC ALK/EML4 TriCheckProbe, Zyto- 

Vision, Bremerhafen, Germany). 

The expression of ALK protein could represent a potential 

marker indicating gene rearrangement and/or response to 

ALK inhibitors. Introducing a user-friendly and cost-friendly 

screening method such as immunostaining, into anatomic 

pathology laboratories, is highly desirable. To this end, three 

monoclonal antibodies have been developed for research purposes 

and reported in the literature, clone 5A4 (Leica/Novocastra, 

and prediluted Abcam), clone ALK1 (Dako) and clone 

D5F3 (Cell Signaling Technology). Results obtained with 

these antibodies in comparative studies using the FISH method 

are promising, particularly those obtained with clone 5A4 

which recognizes a recombinant protein. However, results are 

insufficient to draw definitive conclusions at this time. 

RT-PCR can be performed on complementary DNA (cDNA) 

obtained by messenger RNA (mRNA) synthesis to highlight 

directly the process of fusion of ALK with EML4 or other 

proteins, using dedicated primers. The technology is extremely 

sensitive and highly specific. Nonetheless, RT-PCR has 

numerous disadvantages in its application to clinical practice. 

Further clinical studies devoted to the identification of the best 

technical procedures required are needed.

RElaziONi 

references 

1 Lynch TJ, Bell DW, Sordella R, et al. Activating mutations in the 

epidermal growth factor receptor underlying responsiveness of nonsmall-cell 

lung cancer to gefitinib. N Engl J Med 2004;350:2129-39. 

2 Paez JG, Janne PA, Lee JC, et al. EGFR mutations in lung cancer: 

correlation with clinical response to gefitinib therapy. Science 

2004;304:1497-500. 

3 Pao W, Miller V, Zakowski M, et al. EGF receptor gene mutations 

are common in lung cancers from “never smokers” and are associated 

with sensitivity of tumors to gefitinib and erlotinib. Proc Natl Acad Sci 

U S A 2004;101:13306-11. 

4 Soda M, Choi YL, Enomoto M, et al. Identification of the transforming 

EML4-ALK fusion gene in non-small-cell lung cancer. Nature 

2007;448:561-6. 

5 Rikova K, Guo A, Zeng Q, et al. Global survey of phosphotyrosine 

signaling identifies oncogenic kinases in lung cancer. Cell 

2007;131:1190-203. 

6 Chen Y, Takita J, Choi YL, et al. Oncogenic mutations of ALK kinase 

in neuroblastoma. Nature 2008;455:971-4. 

7 George RE, Sanda T, Hanna M, et al. Activating mutations in ALK provide 

a therapeutic target in neuroblastoma. Nature 2008;455:975-8. 

8 Janoueix-Lerosey I, Lequin D, Brugieres L, et al. Somatic and germline 

activating mutations of the ALK kinase receptor in neuroblastoma. 

Nature 2008;455:967-70. 

9 Choi YL, Takeuchi K, Soda M, et al. Identification of novel isoforms 

of the EML4-ALK transforming gene in non-small cell lung cancer. 

Cancer Res 2008;68:4971-6. 

10 Takeuchi K, Choi YL, Soda M, et al. Multiplex reverse transcription- 

PCR screening for EML4-ALK fusion transcripts. Clin Cancer Res 

2008;14:6618-24. 

11 Koivunen JP, Mermel C, Zejnullahu K, et al. EML4-ALK fusion gene 

and efficacy of an ALK kinase inhibitor in lung cancer. Clin Cancer 

Res 2008;14:4275-83. 

12 Mano H. Non-solid oncogenes in solid tumors: EML4-ALK fusion 

genes in lung cancer. Cancer Sci 2008;99:2349-55. 

13 Perner S, Wagner PL, Demichelis F, et al. EML4-ALK fusion lung 

cancer: a rare acquired event. Neoplasia 2008;10:298-302. 

14 Wong DW, Leung EL, So KK, et al. The EML4-ALK fusion gene is 

involved in various histologic types of lung cancers from nonsmokers 

with wild-type EGFR and KRAS. Cancer 2009;115:1723-1733. 

15 Shaw AT, Yeap BY, Mino-Kenudson M, et al. Clinical features and 

outcome of patients with non-small-cell lung cancer who harbor 

EML4-ALK. J Clin Oncol 2009;27:4247-53. 

16 Inamura K, Takeuchi K, Togashi Y, et al. EML4-ALK lung cancers are 

characterized by rare other mutations, a TTF-1 cell lineage, an acinar 

histology, and young onset. Mod Pathol 2009;22:508-15. 

17 Takahashi T, Sonobe M, Kobayashi M, et al. Clinicopathologic features 

of non-small-cell lung cancer with EML4-ALK fusion gene. Ann 

Surg Oncol 2010;17:889-97. 

18 Zhang X, Zhang S, Yang X, et al. Fusion of EML4 and ALK is associated 

with development of lung adenocarcinomas lacking EGFR and 

KRAS mutations and is correlated with ALK expression. Mol Cancer 

2010;9:188. 

19 McDermott U, Iafrate AJ, Gray NS, et al. Genomic alterations of anaplastic 

lymphoma kinase may sensitize tumors to anaplastic lymphoma 

kinase inhibitors. Cancer Res 2008;68:3389-95. 

20 Christensen JG, Zou HY, Arango ME, et al. Cytoreductive antitumor 

activity of PF-2341066, a novel inhibitor of anaplastic lymphoma 

kinase and c-Met, in experimental models of anaplastic large-cell 

lymphoma. Mol Cancer Ther 2007;6:3314-22. 

21 Zou HY, Lee JH, Arango ME, et al. An orally available small-molecule 

inhibitor of c-Met, PF-2341066, exhibits cytoreductive antitumor 

effi cacy through antiproliferative and antiangiogenic mechanisms. 

Cancer Res 2007;67:4408-17. 

22 Kwak EL, Bang YJ, Camidge DR, et al. Anaplastic lymphoma 

kinase inhibition in non-small-cell lung cancer. N Engl J Med 

2010;363:1693-1703. 

23 US Food and Drug Administration. FDA labeling information - 

Xalkori. [FDA Web site]. 2011. Available at: http://www.accessdata. 

fda.gov/drugsatfda_docs/label/2011/202570s000lbl.pdf. 

24 Marchetti A, Normanno N. Recommendations for mutational analysis 

of EGFR in lung carcinoma. Pathologica 2010;102:119-126. 

25 Pirker R, Herth FJ, Kerr KM, et al. Consensus for EGFR mutation testing 

innon-small cell lung cancer: results from a European workshop. J 

Thorac Oncol 2010;5:1706-13. 

Prospettive future e gestione del materiale: 

ruolo del patologo 

P. Graziano 


221 

Lung cancer diagnosis: from morphology 

to molecular biology through 

immunohistochemistry 

G. Rossi, G. Pelosi, M. Barbareschi, P. Graziano, A. Cavazza, 

M. Papotti 

Azienda Ospedaliera St Maria Nuova, IRCCS, Reggio Emilia (GR, 

AC); Department of Pathology and Laboratory Medicine, Fondazione 

IRCCS National Cancer Institute and University of Milan School 

of Medicine, Milan (GP); Division of Pathologic Anatomy, Forlanini 

Hospital, Rome (PG); Division of Pathologic Anatomy, Santa Chiara 

Hospital, Trento (MB); San Luigi Hospital and University of Turin, 

Orbassano (MP), Italy 

The new aspect of the recent classification of adenocarcinoma 

provides guidance for small biopsies and cytology specimens, 

non-small cell lung carcinomas (NSCLC), in patients 

with advanced stage disease, requiring to be classified into 

more specific types, such as adenocarcinoma or squamous 

cell carcinoma, whenever possible, for several reasons: (a) 

adenocarcinoma or NSCLC not otherwise specified should 

be tested for EGFR mutations, because the presence of these 

mutations is predictive of responsiveness to EGFR tyrosine 

kinase inhibitors; (b) adenocarcinoma histology is a strong 

predictor for improved outcome with pemetrexed therapy; and 

(c) squamous histology is a risk factor for life-threatening hemorrhage 

with bevacizumab therapy. NSCLC- not otherwise 

specified by light microscopy alone should be studied with 

immunohistochemistry. The advent of histology-based therapies 

have consistently changed the pathologists’ perspectives 

when diagnosing NSCLC. In fact, at the minimum the distinction 

between squamous cell carcinoma and adenocarcinoma is 

mandatory when using some new drugs, as pemetrexed, bevacizumab, 

or even molecular therapies as EGFR inhibitors. 

A good agreement between pathologists (K = 0.48-0.88) has 

been observed in differentiating squamous and non-squamous 

cell carcinoma based just on morphology and in some recent 

papers highlighting the accuracy of cytology in subtyping 

NSCLC. A definitive diagnosis of NSCLC subtype was obtained 

in 88% preoperative cytology samples. In addition, a 

diagnosis of favored histologic type was made in another 8%, 

then leaving unclassified 4% of NSCLC. The concordance between 

cytology and histology was > 90% (Rekhtman N, et al. 

J Thorac Oncol 2011; Nizzoli R, et al. J Thorac Oncol 2011). 

Finally, Pelosi et al (J Thorac Oncol 2012) recently showed 

that the correct morphologic diagnoses on small biopsies of 

NSCLC arose from 67% to 84% when slides were reviewed 

by expert pulmonary pathologists. Several papers have investigated 

the role of immunohistochemistry on NSCLC 

subtyping. Immunohistochemistry is the less expensive and 

most quick ancillary technique in subtyping NSCLC. As 

matter of fact there are various commercially available antibodies 

with different sensitivity and specificity that can find 

out squamous, glandular as well as neuroendocrine differentions. 

Among many immunomarkers, high-molecular-weight 

cytockeratins (HMWCK), CK5/6 and p63 are considered 

more specific for squamous differentiation, while positivity 

for TTF-1, CK7 and Napsin A is generally used to confirm 

adenocarcinoma. Finally, chromogranin A, synaptophysin

222 

and CD56 are the best immunostains for neuroendocrine 

tumors. Of note, when singly considered all these antibodies 

may show aberrant expression among various differentiations 

(i.e., p63 may stain about 20-30% of adenocarcinomas). Said 

that, combination of these markers may display tumor differentiation 

in more than 90% of poorly differentiated NSCLC. 

Overall, there is agreement in considering the coordinated 

expression for TTF-1 and p63 as the most reasonable panel 

in terms of sensitivity and specificity. Despite a limited but 

consistent body of evidence, p40 (an antibody reacting only 

with truncated dominant-negative isoforms - DeltaN-p63 of 

p63) seems to have a higher specificity than conventional 

transactivated p63 in distinguishing squamous cell carcinoma, 

and p63-positive adenocarcinomas turned-out negative 

when exploiting p40 (Pelosi et al. J Thorac Oncol 2012; 

Bishop et al. Mod Pathol 2012). Of interest, on molecular 

ground miRNA-205 expression parallels results obtained 

by conventional morphology and/or immunohistochemistry. 

Considering the high cost and laboratory equipment required 

for miRNA-205 determinations, however, it is our opinion 

that miRNA expression should not be considered a practical 

substitute for more conventional characterization of NSCLC 

by either immunohistochemistry or morphology. Whenever 

there is any doubt about the histologic type, it is correct to ask 

for immunostains. At the moment TTF-1 plus p63 is probably 

the best panel, but it is important to follow some basic rules 

to limit the need for further immunostains or misleading diagnoses, 

then preserving tissue for molecular analyses. In any 

case, histologic type plays a major role and it is also helpful 

in guiding molecular analyses. Napsin A for adenocarcinoma 

and p40 and desmocollin-3 for squamous cell carcinoma are 

the most appropriate choices if further stains are necessary. 

CK7 and 34betaE12 are less specific because they are shared 

by squamous cell carcinoma and adenocarcinoma in up to 50- 

60% of cases. While no specific immunostains are available 

in determining the origin of a squamous cell carcinoma, in 

case of a clear-cut adenocarcinoma on morphology immunostains 

should be advised only if a differential diagnosis with 

metastatic extrapulmonary adenocarcinoma is concerned. In 

general, the more stains you demand, the more complicated 

the case becomes, considering that some clear-cut pulmonary 

adenocarcinomas express a complex phenotype with multiple 

markers simultaneously present. 

references 

Travis WD, et al. J Thorac Oncol 2011;6:244-85. 

Bishop JA, et al. Clin Cancer Res 2010;16:610-9. 

Matoso A, et al. Appl Immunohistochem Mol Morphol 2010;18:142-9. 

Mukhopadhyay S, Katzenstein ALA. Am J Surg Pathol 2011;35:15-25. 

Lebanony D, et al. J Clin Oncol 2009;27:2030-7. 

Del Vescovo V, et al. Am J Surg Pathol 2011;35:268-75. 

Pelosi G, et al. J Thorac Oncol 2012;7:281-90. 

Bishop JA, et al. Mod Pathol 2012;25:405-15. 

Righi L, et al. Cancer 2011;117:3416-23. 

Nizzoli R, et al. J Thorac Oncol 2011;6:489-93. 

Reckthman N, et al. J Thorac Oncol 2011;6:451-8. 

Reckthman N, et al. Clin Cancer Res 2012;18:1167-76. 


Molecular diagnosis in cytological samples of 

nsclc: appropriateness and reliability 

G. Fontanini 

Department of Surgery, University of Pisa 

Molecular test are mandatory in non-small cell lung cancer 

(NSCLC) to identify the patients most likely to benefit from 

therapies with EGFR inhibitors. In the approximately 70% of 

patients with NSCLC the only pathologic material guiding 

systemic therapy may be small biopsy or cytology specimens; 

the performance characteristics of cytology in NSCLC predictive 

marker testing are not well established. In this study we 

showed the accuracy of cytologic specimens submitted for 

EGFR molecular testing. 

Within most advanced laboratory it is now common to see 

a fusion of cytological and molecular analysis such as DNA 

sequencing with a significant impact on how diseases are diagnosed 

and treated in clinical practice. 

DNA sequencing technique offers a higher genetic resolution 

showing small variations in their nucleotide content. The 

clinical use of these variations is fully recognized in pharmacogenetics 

where variations in genes predict whether a patient 

will have a good response to a drug, a bad response to a drug, 

or no response at all. 

Molecular cytology is influenced by an increase in the technical 

sophistication of next generation techniques impacting on the 

overall sensitivity of genetic testing maximizing accuracy and 

reproducibility and providing a wide range of testing options. 

The key warning of molecular cytology regards the quality of 

specimens that has an important impact on diagnostic results. 

In fact, cytological samples are exposed to some criticisms as 

low cellularity and cellular heterogeneity that may have an 

effect on the downstream molecular results. Optimization and 

standardization of cytological sample preparation methods is 

necessary to preserve bio-molecular integrity and to ensure a 

correct molecular result. 

As a consequence, the major contribution to obtain adequate 

material for molecular diagnostic is the correct and appropriate 

sampling: stained smears from the aspirate are evaluated by a 

cytopathologist for cellularity and diagnostic yield. Molecular 

testing is feasible if: the number of neoplastic cells is higher than 

100 (for instance the proportion of neoplastic cells versus non 

neoplastic cells will determine which sequencing techniques will 

be used and the type of cell dissection) and 2) the sample yielded 

sufficient quantity and quality of DNA for mutational analysis. 

Moreover each laboratory should take into account a further 

internal validation, analyzing in parallel a large number of 

cytological samples together with the matching histological 

samples. A sequencing technique is suitable for molecular 

cytology if the mutations detected in cytological specimens 

are the same to that find in surgical specimens in each case. 

In our experience the genotyping techniques with a higher 

level of accuracy in molecular cytology are pyrosequencing 

and real-time PCR based genotyping. In fact, both these techniques 

have a sensitivity ranging from 1 to 5% and are able 

to identify almost all gene mutational variants. Using these 

techniques the overall percentage on neoplastic cells is not 

a limit if a strictly selected cell microdissection (cell enrichment) 

is performed. Definitely the major limitation for an 

adequate molecular test on a cytological sample is the number 

of available cells and as a consequence the low concentration 

and overall quality of DNA; the use an extremely sensitive 

techniques (for instance real-time PCR based genotyping) 

could minimize but not completely avoid this issue.

RElaziONi 

nuove teorie di patogenesi: l’impatto sulle 

nostre diagnosi 

L. Resta 


I tumori ovarici borderline 

M. De Nictolis 

Azienda Ospedaliera Marche Nord 

I tumori ovarici borderline più frequenti e meglio conosciuti 

sono i tumori sierosi e quelli mucinosi con epitelio intestinale. 

I borderline sierosi hanno caratteristiche morfologiche e molecolari 

ben definite. La prognosi è in genere ottima e solo le 

forme associate ad impianti invasivi mostrano un comportamento 

biologico aggressivo. Nell’ambito di un tumore sieroso 

borderline si possono sviluppare aree di carcinoma sieroso di 

basso grado in situ (carcinoma micropapillare con il pattern 

della “medusa”) o carcinomi sierosi di basso grado invasivi, 

che più raramente possono comparire de novo. 

I tumori mucinosi borderline sono neoplasie di grandi dimensioni, 

tipicamente polimorfe. Aree morfologicamente 

benigne si alternano con aree borderline; in alcuni casi l’epitelio 

è atipico realizzando aspetti di carcinoma intraepiteliale; 

quando l’atipia citologica si associa ad un pattern di crescita 

complesso si parla di carcinoma mucinoso di tipo espansivo. 

In rari casi il carcinoma mucinoso infiltra in modo distruttivo 

lo stroma alla stregua di un carcinoma del colon realizzandosi 

il quadro di un carcinoma mucinoso infiltrante. Il fattore prognostico 

principale di queste lesioni è lo stadio; le forme infiltrative 

in stadio avanzato sono in pratica le uniche in grado di 

progredire rapidamente e sono insensibili alla chemioterapia 

abitualmente utilizzata per i carcinomi ovarici. Un’accurata 

diagnosi di queste complesse neoplasie è alla base della prognosi, 

della terapia e degli studi molecolari. 

The frozen section in ovarian pathology 

G.F. Zannoni 

Istituto di Anatomia Patologica, Policlinico A. Gemelli, Università 

Cattolica del Sacro Cuore 

Frozen sections (FS) of ovarian tumors are the most common 

ones seen in gynecological pathology, accounting for the largest 

number of discrepancies between the intraoperative and 

the final diagnosis. In this context these FS should only be 

requested if the result will influence the surgical procedure. 

The most common scenario is that of an adnexal mass with 

clinical and radiological features that suggest a non benign 

tumor. The differential diagnosis between a borderline tumor 

and an ovarian carcinoma may be difficult. 

Most of the mistakes at the time of frozen section are due 

to either poor quality of the frozen section slide or sampling 


Sala Botticelli – 08.30-10.30 

Patologia Ginecologica 1 

Patologia dell’ovaio 

Moderatori: Luigi Resta (Bari), Gian Franco Zannoni (Roma) 

223 

error. Poor quality can be caused by problems on the frozen 

section, fixation or staining. 

A common problem is the finding of a solid tumor on the FS 

that cannot be classified under any of the common ovarian epithelial 

types. Features that favor a serous carcinoma include: 

presence of isolated large nuclei more than two time larger 

than the average (averaging 15-16 microns): multinucleated 

tumor cells (defined as having more than 2 nuclei); macronucleoli 

(defined as measuring at least 3 microns); psammomatous 

calcifications; and lack of uniformity in size of the nuclei. 

Sampling errors are more commonly seen in mucinous tumors 

due to their heterogeneity. Once tumor is identified as mucinous, 

it is better submit 2 or 3 frozen sections from grossly 

different areas. It is useful keep in mind that mucinous carcinomas 

are very rare and, as a rule, they contain less mucin that 

in the bening or borderline ones. Most tumor that look infiltrative 

and have abundant mucin are metastases. Most common 

sites being appendix, pancreatic-biliary, large intestine and 

cervix. The presence of large pools of mucin either within the 

ovarian parenchyma or on the ovarian surface should prompt 

a possible diagnosis of metastatic appendical carcinoma 

(pseudomyxoma peritonei type). Some of these cases may be 

metastatic but have a grossly normal appendix. Nevertheless, 

in these cases an appendectomy should be performed to rule 

out this possibility. 

The differential diagnosis between a primary ovarian carcinoma 

and a metastasis can be challenging at the time of FS. 

The gross appearance of the tumor can also help. Bilaterality 

and the presence of deposits of tumor of the ovarian surface 

favor metastases. If the tumor has endometrioid features, features 

that favor a primary tumor of the ovary include: an adenofibroma 

component, endometriosis, squamous or morular 

metaplasia, a sertoliform component (sex-cord like areas), and 

a spindle cell component. Features that favor metastasis in endometrioid 

like tumors include: extensive necrosis, extensive 

desmoplasia, cribriforming with central dirty necrosiss, segmental 

distruction of the glands and diffuse lynphovascular 

involvement. Metastatic tumors that can have endometrioidlike 

feautures include colon, endometrium, gallbladder, bile 

ducts and cervix. 

In one personal study we analyzed the impact of a specialized 

pathologist on the accuracy of frozen section analysis for adnexal 

masses.We included women who underwent frozen section 

diagnosis for adnexal mass surgery. A specialized and a 

general pathologist read the sections. We calculated sensitivity, 

specificity, positive and negative predictive values, and accuracy 

for the whole series, as well as for the specialized and 

general pathologist groups. We included 325 patients; in 103 

patients (31.7%), frozen section diagnosis was performed by 

the specialized and in 222 (68.3%), by the general pathologist. 

There was a significant difference in terms of correspondence 

between the specialized and the general pathologist groups(P 

¼ 0.024). We registered four overdiagnoses (both performed

224 

by the general pathologist [1.8% vs 0%])and 56 underdiagnoses 

of which 14 (13.6%) were made by the specialized 

pathologist and 46 (20.7%) by the general pathologist. In 14 

cases (4.3%), diagnosis could not be made on frozen section 

and was postponed to final histology for definitive diagnosis 

(1/103 [0.9%] for the specialized pathologist and 13/222 

[5.8%] fort he general pathologist). Our data confirm previous 

reports on the accuracy of frozen section analysis of adnexal 

masses and show a significant positive impact of the specialized 

pathologist as opposed to the general pathologist. 

references 

Baker P, Oliva E. A pratical approach to intraoperative consultation in 

gynecological pathology. Int J Gynecol Pathol 2008;27:353-65. 

Fanfani F, Zannoni GF, Fagotti A, et al. Importance of a specialized pathologist 

for theexamination of frozen sections of adnexal masses. Int 

J Gynecol Cancer 2007;17:1034-9. 

Patologia dell’ovaio: ruolo 

dell’immunoistochimica 

M.R. Raspollini 

Istologia Patologica e Diagnostica Molecolare, Azienda Ospedaliera 

Universitaria Careggi, Firenze 

L’immunoistochimica ha dimostrato essere un ausilio prezioso 

alla valutazione convenzionale nell’identificazione delle 

metastasi ovariche. L’ovaio è sede frequente di metastasi. In 

alcuni casi è noto il tumore primitivo, e in tal caso la valutazione 

di peculiari aspetti istologici sospetti per neoplasia 

secondaria può essere agevole alla luce della storia della 

paziente. In altri casi, la neoformazione ovarica si manifesta 

senza una storia nota di precedente tumore. In sede ovarica si 

può documentare metastasi da un’ampia varietà di neoplasie 

da differenti organi. Le sedi primitive di tumori che più frequentemente 

sono metastatici all’ovaio sono l’intestino, lo 

stomaco, e la mammella. 

L’identificazione della natura metastatica di un tumore ovarico 

non è sempre agevole. Talvolta è necessario integrare i dati 

clinici, radiologici, sierologici, e patologici per giungere alla 

corretta diagnosi. È importante avere in mente la frequenza 

dei differenti tumori che metastatizzano all’ovaio, e inoltre 

è importante conoscere i confondenti aspetti istologici dei 

tumori metastatici che possono simulare l’ampia varietà dei 

tumori primitivi ovarici. Le caratteristiche a favore per una 

metastasi e per l’esclusione di tumore primitivo ovarico sono 

la bilateralità, il pattern infiltrativo, gli impianti tumorali 

microscopici superficiali, il pattern di crescita nodulare, l’invasione 

prominente degli spazi linfovascolari, così come le 

caratteristiche specifiche di alcuni tumori quali per esempio 

la presenza di cellule ad anello con castone. In alcuni casi, il 

tumore primitivo che metastatizza all’ovaio può essere di difficile 

identificazione, persino all’esame autoptico; e l’utilizzo 

dell’immunoistochimica è di ausilio nella diagnosi differenziale. 

La colorazione con specifiche citocheratine (citocheratina 

7 e citocheratina 20) è usata nella diagnosi differenziale 

di tumore primitivo e metastatico. La combinazione di una 

colorazione positiva per citocheratina 20 con una colorazione 

negativa per citocheratina 7 è sospetta per metastasi da 

un’adenocarcinoma primitivo del colon, anche se ciò non è 

completamente patognomonico. Un tumore che dimostra la 

citocheratina 7 positiva e la citocheratina 20 negativa è indicativo 

di carcinoma primivo ovarico, ma non esclude tuttavia 

una metastasi di adenocarcinoma del pancreas, o del tratto 

biliare, o dello stomaco. È stato suggerito l’utilizzo anche di 

altri anticorpi. CDX2, e CEA possono essere di ausilio nella 


valutazione di sospette metastasi dal tratto gastroenterico. 

I recettori degli estrogeni e del progesterone sono espressi 

nella maggioranza dei tumori della mammella metastatici e 

nei tumori primitivi ovarici. Mammoglobina e GCDF15 sono 

abbastanza indicativi di carcinoma mammario metastatico, ma 

la loro sensibilità non raggiunge il 100%. Il TTF-1 è un buon 

marker per le metastasi da carcinoma polmonare, ma il TTF-1 

può essere espresso anche da altri tumori. 

Come ulteriore ausilio alla diagnostica differenziale fra neoplasia 

primitiva e secondaria va considerata la valutazione 

dell’espressione genica che può giocare un ruolo nell’assistere 

la valutazione patologica convenzionale e l’immunoistochimica 

nella determinazione della sede di origine di neoplasie 

ovariche. 

Sebbene la valutazione delle caratteristiche istopatologiche 

e immunoistochimiche rimanga uno strumento buono per 

determinare la natura primitiva o metastatica, la valutazione 

dell’espressione genica può essere di ausilio in alcuni casi 

difficili. 

Bibliografia 

1 Young RH. From Krukember to today: the ever present problems 

posed by metastatic tumors in the ovary: part I. Adv Anat Pathol 

2006;13:205-27. 

2 Young RH. From Krukember to today: the ever present problems 

posed by metastatic tumors in the ovary: part II. Adv Anat Pathol 

2007;14:149-77. 

3 Prat J. Ovarian carcinomas, including secondary tumors: diagnostically 

challenging areas. Mod Pathol 2005(Suppl. 2):S99-111. 

4 Baker PM, Oliva E. Immunohistochemistry as a tool in the differential 

diagnosis of ovarian tumors: an update. Int J Gynecol Pathol 

2005;24:39-55. 

5 McCluggage WG, Wilkinson N. Metastatic neoplasms involving the 

ovary: a review with emphasis on morphological and immunohistochemical 

features. Histopathology 2005;47:231-47. 

6 Lagendijk JH, Mullink H, van Diest PJ, et al. Immunohistochemical 

differentiation between primary adenocarcinomas of the ovary and 

ovarian metastaes of colonic and breast origin. Comparison between 

a statistical and an intuitive approach. J Clin Pathol 1999;52:283-90. 

7 Park SY, Kim BH, Lee S, et al. Panels of immunohistochemical markers 

help determine primary sites of metastatic adenocarcinoma. Arch 

Pathol Lab Med 2007;131:1561-7. 

8 Azueta A, Maiques O, Velasco A, et al. Gene expression microarraybased 

assay to determine tumor site of origin in a serioes of metastatic 

tumors to the ovary and peritoneal carcinomatosis of suspected gynecologic 

origin. Hum Pathol 2012; In press. 

La diagnosi e le strategie terapeutiche 

D. Lorusso 

Il carcinoma epiteliale dell’ovaio rappresenta la prima causa 

di morte tra le neoplasie ginecologiche; negli Stati Uniti è 

stato calcolato che circa 26000 donne si ammalano ogni anno 

di questa malattia e 12000 ne muoiono. Circa l’80% delle 

pazienti affette da carcinoma ovarico risponde al trattamento 

primario rappresentato dalla combinazione della chirurgia 

citoriduttiva di prima istanza, il cui fine è l’asportazione 

della massima parte della malattia allo scopo di ottenere un 

residuo tumore ottimale (≤ 1 cm), seguita da una chemioterapia 

di prima linea a base di carboplatino e paclitaxel. Pur 

essendo stato registrato negli ultimi 10 anni un significativo 

incremento della sopravvivenza, il 60-70% circa delle pazienti 

con tumore ovarico che hanno risposto al trattamento 

primario sviluppa una recidiva di malattia e la sopravvivenza 

a 5 anni dalla diagnosi rimane mediamente nell’ordine del 

15-30%; diviene pertanto necessario individuare innovative 

strategie terapeutiche al fine di diminuire la percentuale di 

recidive. Recenti dati sembrano individuare nell’antiangio-

RElaziONi 

genesi il target per incrementare la sopravvivenza libera da 

progressione delle pazienti con carcinoma dell’ovaio alla 

prima diagnosi. 

Sempre piu’ spesso oggi le caratteristiche biologiche e biomolecolari 

del tumore dell’ovaio rendono questa patologia 

quanto mai variegata e indirizzano i successivi trattamenti 


Patologia ginecologica 2 

Patologia vulvare 

Moderatori: Alfredo Fabiano (Roma), Domenico Ientile (Palermo) 

Approccio clinico alla patologia vulvare 

L. Micheletti, M.C. Zanotto Valentino, O. di Pumpo, E. Palmese, 

V. Frau, C. Bondi, F. La Monica 

Dipartimento di Discipline Ginecologiche e Ostetriche dell’Università 

di Torino 

Introduzione 

In linea generale una superspecialità, (subspecialty in lingua 

inglese), prende corpo e diviene ufficialmente accettata nel 

momento in cui si riconosce la necessità di organizzare dal 

punto di vista terminologico e metodologico una massa di 

conoscenze, talora pertinente ad ambiti specialistici differenti, 

ma riguardante uno specifico organo od apparato. 

La vulva, per le sue caratteristiche embriologiche, anatomiche 

e funzionali, rappresenta un organo di interesse sia ginecologico 

che dermatologico e richiede anche una specifica 

competenza istopatologica. Dal punto di vista clinico-pratico 

sicuramente la donna affetta da disturbo vulvare consulterà 

preferibilmente il ginecologo ed è pertanto utile che questo 

riceva una specifica preparazione di tipo interdisciplinare. 

La “Vulvologia”, da alcuni anni identificata come una vera e 

propria superspecialità a carattere interdisciplinare specificatamente 

dedicata allo studio e all’approccio clinico-terapeutico 

delle malattie della vulva 1 , riveste un ruolo utile nella 

formazione del ginecologo e di altri specialisti che per pratica 

clinica si interessano di malattie vulvari. 

Grazie alla vulvologia è possibile oggi fornire delle indicazioni 

più precise sulla metodologia dell’approccio diagnostico 

alle malattie vulvari eliminando metodiche ed atteggiamenti 

radicati nella pratica clinica soprattutto ginecologica e ritenuti 

ormai inadatti e talvolta fuorvianti. 

Anamnesi generale 

L’anamnesi generale deve essere rivolta ad evidenziare tutte 

quelle situazioni che possono avere ricadute vulvari specifiche. 

Tra queste vanno ricercate diatesi allergiche, presenza di malattie 

dermatologiche con loro localizzazione in altri distretti 

corporei, presenza di malattie sistemiche e metaboliche, ecc. 

Utile investigare anche sulla presenza di malattie sessualmente 

trasmesse, sia della paziente che del partner, su eventuali terapie 

mediche topiche pregresse o in atto, sull’uso di prodotti 

per l’igiene personale e su abitudini igienico-comportamentali 

(uso di salva-slip, biancheria intima sintetica e colorata, collant, 

pantaloni stretti, ecc.). 

225 

medici e chirurgici. Appare sempre piu’ evidente come oggi 

il tumore dell’ovaio sia una miscellanea di malattie completamente 

diverse che condividono il sito anatomico di origine e 

la clinica e la chirurgia si vanno sempre piu’ orientando verso 

trattamenti personalizzati in base anche solo alla caratteristica 

piu’ “ banale” rappresentata dall’istologia della malattia. 

Anamnesi sintomatologica 

L’anamnesi sintomatologica, a causa della aspecificità dei 

sintomi vulvari, deve essere rivolta ad evidenziare le caratteristiche 

peculiari. 

Infatti dal punto di vista soggettivo tutte le malattie vulvari si 

esprimono attraverso due fondamentali sintomi, il prurito e il 

dolore, che possono assumere differenti connotazioni. Sia per 

il dolore che per il prurito esiste una rielaborazione corticale 

che influenza la percezione e la modulazione di questi sintomi. 

Pertanto particolare attenzione deve essere posta nel separare 

la componente emozionale da quella più strettamente organica 

legata ad una vera e propria lesione vulvare correlabile 

al sintomo riferito (ad esempio, una condilomatosi florida, 

di per sé lesione asintomatica, in un soggetto con particolare 

labilità emotiva, può essere associata ad una sintomatologia 

pruriginosa o dolorosa di origine reattivo-emozionale e non 

direttamente correlabile alla lesione). 

Ispezione clinica 

L’ispezione clinica deve essere condotta ad occhio nudo, con 

eventuale buona illuminazione, e seguire una metodologia 

standardizzata. 

Una modalità può essere iniziare ad ispezionare l’area vestibolare, 

le piccole labbra, il cappuccio clitorideo, lo spazio 

interlabiale, per poi procedere verso l’esterno ispezionando 

le grandi labbra, le pieghe genito-crurali, la regione pubica 

e quella inguinale; non va dimenticata la regione perineale e 

perianale sino ad una parte del solco intergluteo. L’ispezione 

ricerca eventuali alterazioni cromatiche sotto forma di macchie 

rosse, bianche o pigmentate, la presenza di rilievi sulla 

superficie quali papule, placche, noduli, vegetazioni, vescicole, 

pustole e perdita di sostanza quali ulcere e fissurazioni. 

All’ispezione va associata una delicata palpazione tesa a rilevare 

spessore, infiltrazione, fissità, dolorabilità delle lesioni 

vulvari. 

Generalmente l’ispezione vulvare viene definita in letteratura 

ginecologica come vulvoscopia intendendo con ciò l’ispezione 

colposcopica della vulva dopo applicazione di acido 

acetico al 3-5%. Tuttavia l’utilizzo dell’acido acetico risulta 

scarsamente utile nella diagnostica delle malattie vulvari ed 

in alcuni casi addirittura fuorviante, in quanto il rivestimento 

mucoso e cutaneo della vulva non possiede epitelio di trasformazione 

ed è nettamente diverso dall’epitelio mucoso cervico-vaginale. 

Pertanto per vulvoscopia non si deve intendere 

l’ispezione colposcopica della vulva ma l’ispezione ragionata 

e consapevole, condotta ad occhio nudo e con eventuale buo-

226 

na illuminazione, da un vulvologo, ovvero da uno specialista 

fornito di specifica preparazione multidisciplinare ginecologica, 

dermatologica ed anatomo-patologica 2 . 

L’utilizzo del colposcopio deve essere limitato a quello di fonte 

luminosa o, in particolari situazioni, a quello di strumento 

di ingrandimento eventualmente collegato a sistema video per 

fini didattici. 

Il test al blu di toluidina, noto anche come test di Collins, 

viene ancora ampiamente utilizzato ma va sottolineato che 

è gravato da una elevata percentuale di falsi positivi (lesioni 

infiammatorie ed ulcerazioni) e da una non trascurabile percentuale 

di falsi negativi soprattutto su lesioni neoplastiche intraepiteliali 

3 4 . Per tutti questi motivi in un moderno approccio 

diagnostico alle malattie vulvari questo test non dovrebbe più 

essere utilizzato in quanto, rispetto ad una accurata ispezione 

consapevole ad occhio nudo, non fornisce alcun elemento 

diagnostico aggiuntivo. 

Al termine dell’ispezione vulvare e della descrizione del 

reperto su cartella vulvologica è molto utile documentare 

l’aspetto clinico mediante una fotografia. Infatti anche la più 

accurata descrizione risulta spesso ancora troppo soggettiva e 

notevolmente variabile da una volta all’altra anche se eseguita 

dallo stesso medico. 

La biopsia 

La biopsia va considerata come un ausilio alla diagnosi e non 

un sostituto della capacità diagnostica del clinico. 

Di qui nasce la necessità di corredare il prelievo bioptico con 

una documentazione clinica riguardante l’anamnesi, la descrizione 

dell’ispezione clinica (con eventuale documentazione 

fotografica) e le ipotesi diagnostiche. Tutto ciò è indispensabile 

per il patologo nell’interpretazione delle lesioni dermatologiche 

vulvari, che solo raramente mostrano un quadro 

morfologico patognomonico. 

In questi casi il colloquio interdisciplinare tra patologo, ginecologo 

e dermatologo è fondamentale per superare eventuali 

limiti ed incomprensioni. 

Dal punto di vista tecnico le biopsie possono essere sia di tipo 

incisionale che escissionale. Nel primo caso mantengono un 

significato puramente diagnostico, mentre nel secondo possono 

assumere anche un ruolo terapeutico. La pinza a morso, 

utile sulla mucosa cervicovaginale, non deve essere utilizzata 

in sede vulvare in quanto fornisce un prelievo inadeguato per 

una accurata valutazione istologica, in ragione della superficialità 

ed esiguità del prelievo ed irregolarità dei margini. 

Il Keye’s punch ed il bisturi a lama fredda rappresentano gli 

strumenti più adatti per un corretto prelievo bioptico vulvare. 

Gli elettrodi ad ansa o a microago per elettrochirurgia, unitamente 

al laser CO2, sono validi strumenti che permettono, in 

analogia al bisturi a lama fredda, di modulare la profondità e 

l’estensione perimetrica del prelievo bioptico, ma possono essere 

causa di danni termici che inficiano la lettura istologica. 

Riflessioni conclusive 

La Vulvologia, per la sua recente istituzione e riconoscimento, 

rappresenta una superspecialità in cui sono ancora attivi ed 

in evoluzione dibattiti interdisciplinari su tematiche di tipo 

terminologico, classificativo e metodologico tese a superare 

l’approccio settoriale ai problemi vulvari, al fine di una migliore 

gestione clinica delle donne affette da disturbi vulvari 

unitamente ad una più accurata formazione della figura del 

vulvologo. Si può comunque affermare che le linee comportamentali 

in Vulvologia presentate in questo scritto rappresentano 

il corpo di conoscenze di base unanimemente accettate dai 

vulvologi odierni anche di differente estrazione specialistica e 


che se applicate garantiscono un corretto approccio clinico di 

primo livello alla donna con disturbo vulvare. 

Bibliografia 

1 Micheletti L, Preti M, Bogliatto F, et al. Vulvology. A Proposal for a 

Multidisciplinary Subspecialty. J Reprod Med 2002;47:715-7. 

2 Micheletti L, Bogliatto F, Lynch PJ. Vulvoscopy. Review of a Diagnostic 

Approach Requiring Clarification. J Reprod Med 2008;53:179-82. 

3 Micheletti L, Barbero M, Trivelli MR, et al. Unreliability of toluidine 

blue test in the early diagnosis of vulvar neoplasia. Cervix and l.f.g.t. 

1985;3:171-4. 

4 Joura EA, Zeisler H, Losch A, et al. Differentiating vulvar intraepithelial 

neoplasia from nonneoplastic epithelial disorders: the toluidine 

blue test. J Reprod Med 1998;43:671-4. 

La diagnostica delle lesioni dell’epitelio vulvare 

B. Ghiringhello, S.S. Privitera 

A.O. OIRM-S.ANNA, Dipartimento Diagnostica e Servizi, SC Anatomia 

Patologica, Torino 

Jeffcoate e Woodcock (1961) 1 propongono il termine “distrofia” 

per raggruppare tutte quelle situazioni di “difficile” o 

“cattivo” (dis-) “nutrimento” (trofè) della vulva, cioè di disordine 

della crescita epiteliale o di alterazione dell’architettura 

epiteliale e dermica che si manifesta come lesione bianca; 

però il problema della terminologia viene affrontato negli 

anni ’70 dalla società multidisciplinare ISSVD con lo scopo 

di uniformare la terminologia e raggruppare le lesioni preneoplastiche, 

analogamente a quanto fatto per la cervice uterina 

(New Nomenclature for Vulvar Disease, 1976) 2 ; ne nasce la 

classificazione che prevede il raggruppamento delle lesioni in: 

lichen sclerosus 

distrofia iperplastica con o senza atipia 

distrofia mista con o senza atipia 

La definizione delle VIN è stata accettata, in sostituzione della 

definizione “distrofia iperplastica con atipia”, nel 1986 dalla 

ISSVD e nel 1994 dalla WHO. 

In analogia alla classificazione delle lesioni displastiche della 

cervice uterina è stata proposta una classificazione in tre gradi 

della lesione displastica vulvare. 

Attualmente risulta chiaro che esistono forme morfologicamente 

e biologicamente diverse di VIN 3 che giustificano la 

suddivisione terminologica di Abell in VIN classica e VIN 

differenziata 4 5 . 

Nella VIN classica (indifferenziata) si fanno rientrare le varianti 

basaloide e condilomatosa, correlate con l’infezione da 

HPV (più spesso il ceppo 16) e frequentemente concomitanti 

con lesioni cervico-vaginali. La VIN differenziata non sembra 

essere correlata con infezione da HPV. 

Nella VIN classica si fa rientrare anche la Papulosi Bowenoide, 

una lesione che colpisce entrambi i sessi, che è caratterizzata 

dalla multifocalità e che non sembra avere rischio di 

progressione neoplastica. La forma condilomatosa della VIN 

classica è caratterizzata da marcata proliferazione, paracheratosi 

e ipercheratosi con aspetto ondulato dell’epitelio che 

rende conto degli aggettivi “condilomatoso” o “verrucoso”. 

Sebbene la proliferazione cellulare sia marcata con presenza 

di numerose figure mitotiche anche atipiche, in questa forma 

di VIN rimane una certa capacità di maturazione superficiale. 

Le cellule, di grandi dimensioni e con citoplasma eosinofilo, 

mostrano nuclei ingranditi con cromatina grossolana,spesso 

con plurinucleazioni e con evidente coilocitosi. La creste 

epidermiche mostrano base larga che si approfonda nel derma 

e sono separate da sottili papille dermiche che si spingono 

verso la superficie. Frequente è l’interessamento degli annessi 

pilo-sebacei.La VIN classica basaloide è caratterizzata da un

RElaziONi 

epitelio spesso con superficie relativamente liscia e piatta e 

con grado variabile di ipercheratosi ma mai tanto marcata 

come nella forma condilomatosa. L’epitelio è caratterizzato 

dalla presenza di cellule atipiche immature di tipo parabasale 

(similmente a quanto avviene nel carcinoma in situ della 

cervice) con bordi citoplasmatici indistinti, scarso citoplasma 

e nucleo ingrandito, ipercromatico. Le mitosi anche atipiche 

sono numerose e la coliocitosi, presente in superficie, è meno 

evidente che nella forma condilomatosa. Al pari della forma 

condilomatosa è frequente l’interessamento degli annessi 

cutanei.La VIN differenziata interessa prevalentemente donne 

anziane e si presenta come lesione unica. Dal punto di vista 

morfologico si osserva aumento di spessore dell’epitelio 

con paracheratosi e allungamento delle creste epidermiche 

che tendono anche ad anastomizzarsi. L’atipia citologica, 

assente o lieve, è limitata agli strati basale e parabasale, 

mentre sono presenti cheratinociti di grandi dimensioni con 

citoplasma eosinofilo, con nucleo vescicoloso e con evidenti 

ponti intercellulari. Queste cellule, al pari delle perle cornee, 

possono essere presenti anche nella parte più profonda delle 

creste epidermiche. Le cellule degli strati basale e parabasale 

generalmente appaiono di piccole dimensioni con cromatina 

nucleare densa e con nucleolo evidente.La VIN differenziata è 

spesso associata con lichen sclerosus o con iperplasia di cellule 

squamose ed è caratterizzata dalla positività delle cellule di 

tutti gli strati per la proteina p53, al contrario di quanto accade 

nelle VIN indifferenziate nelle quali non si osserva positività 

per questa proteina. Questa forma di VIN evolve verso una 

neoplasia invasiva in una bassa percentuale di casi (stimata in 

percentuali variabili dal 3-4% al 20% a seconda del lavori) e 

quasi sempre sottoforma di microinvasione. 

Delle lesioni in situ merita un cenno anche la malattia di 

Paget, relativamente semplice dal punto di vista diagnostico 

anche perché certamente meno rara dell’altra lesione che può 

entrare in diagnosi differenziale e cioè il melanoma in situ. 

Tuttava alcuni recenti lavori hanno descritto una forma di 

displasia con caratteristiche morfologiche simili alla malattia 

di Paget e che vengono definite come VIN pagetoidi 6 7 . Inoltre 

non va dimenticata la possibilità che la malattia di Paget sia 

secondaria a neoplasie ghiandolari di altri distretti viciniori 

alla vulva, nel qual caso la conoscenza della storia clinica e 

i risultati delle indagini strumentali rappresentano fattori imprescindibili 

per la diagnosi. 

Per quanto riguarda le lesioni non neoplastiche, nel 1987 la 

ISSVD propone una nuova classificazione delle lesioni vulvari 

definendole “ alterazioni epiteliali vulvari non neoplastiche 

“ comprendenti: 

- lichen sclerosus; 

- iperplasia di cellule squamose; 

- altre dermatosi. 

La successiva revisione della classificazione è del 1989 e 

nasce dalla collaborazione della ISSVD con la ISGP. Questa 

classificazione è sovrapponibile a quella del 1987 ma 

prevede l’aggiunta dei termini “atroficus” al lichen sclerosus 

e “non altrimenti specificata” all’iperplasia di cellule 

squamose.L’aggiunta della precisazione “non altrimenti 

specificata” all’iperplasia di cellule squamose è finalizzata a 

definire come tali soltanto quelle lesioni iperplastche aspecifiche 

che non rientrano in altri quadri anatomo-clinici noti; 

la diagnosi di iperplasia di cellule squamose diventa cioè 

una diagnosi di esclusione. Tuttavia questa aggiunta rischia 

di creare una zona d’ombra nella quale confinare quadri 

anatomo-clinici che patologi poco esperti non riescono a 

classificare in modo corretto. Probabilmente una revisione 

critica della terminologia sarà alla base di una rivisitazione 

227 

della classificazione oggi in uso.Anche l’aggiunta del termine 

“atrofico” al lichen sclerosus non trova tutti d’accordo dal 

momento che pare dimostrato come il lichen sclerosus sia 

una lesione evolutiva e non “atrofica” (come viene descritto 

in altri distretti cutanei) e con potenzialità di sviluppare una 

neoplasia.L’etiologia dell’iperplasia di cellule squamose e del 

lichen sclerosus è ancora sconosciuta. L’iperplasia di cellule 

squamose rappresenta forse una risposta aspecifica a patologie 

sistemiche (diabete, epatopatie, linfomi, ecc.) e/o a fattori esogeni 

(infettivi, fisici, chimici, ecc.) che innescano un circolo 

vizioso: prurito- grattamento-iperplasia epiteliale. Lesioni 

specifiche (psoriasi, infezioni da Candida, lichen planus, ecc.) 

che comportano iperplasia cellulare non dovrebbero pertanto 

essere incluse in questa categoria. 

Nel gruppo delle altre dermatosi vengono inserite lesioni infiammatorie, 

bollose, ecc. riscontrabili in altri distretti cutanei 

e mucosi.La più recente classificazione del 2006 è totalmente 

diversa dalle precedenti in quanto basata esclusivamente 

sull’aspetto morfologico della lesione, raggruppando lesioni 

con pattern spongiotico, acantotico, lichenoide, con omogeneizzazione 

o sclerosi del derma, vescicolo-bolloso, acantolitico, 

granulomatoso, vasculopatico 8 9 . 

Per il lichen sclerosus l’ipotesi più accreditata è che si tratti 

di una lesione autoimmunitaria sostenuta da una variazione 

genetica sul sistema HLA anche se ancora non è dimostrata 

la presenza di un anticorpo specifico.La letteratura più recente 

dimostra una stretta associazione tra lichen sclerosus e 

carcinoma squamoso non correlata ad infezione da HPV ma 

passando per la fase di VIN differenziata. La flogosi cronica e 

i processi cicatriziali, in un particolare assetto immunogenetico, 

sarebbero responsabili dello sviluppo del carcinoma [10]. 

Una paziente affetta da lichen sclerosus mostra un rischio di 

sviluppare un carcinoma 300 volte maggior erispetto ad una 

donna non affetta da lichen. Tuttavia la diagnosi precoce, le 

terapie farmacologiche e l’escissione di lesioni ispessite certamente 

riducono il rischio di progressione. Alla luce di questi 

dati è opportuno identificare dei marcatori di progressione: 

utili Mib 1 (LI > 50%) e p 53 (mutazione della p 53 è stata 

dimostrata nel 40% di lichen non associato a carcinoma e nel 

90% di lichen associati a carcinoma), mentre non ha alcun 

significato statistico la p 16 11 12 . Anche fattori che regolano 

l’angiogenesi e gli enzimi della ciclossigenasi sembrano 

svolgere un ruolo nella patogenesi del carcinoma in contesto 

di lichen sclerosus (aumento della densità microvascolare e 

espressione di VEGF e di COX-2) 13 . 

Bibliografia 

1 Jeffcoate TN, Woodcock AS. Premalignant conditions of the vulva, 

with particular reference to chronic dystrophies. Br Med J 

1961;2:127-34. 

2 New nomenclature for vulvar diseas. Am J Obstet Gynecol 

1976;124:325-6. 

3 Preti M, et al. Inter-observer variation in histopathological diagnosis 

and grading of vulvar intraepithelial neoplasia: results of an European 

collaborative study. Br J Obstet Gynecol 2000;107:594-9. 

4 Hart WR. Vulvar intraepithelial neoplasia: historical aspects and current 

status. Int J Gynecol Pathol 2001;20:16-30. 

5 Sideri M et al. Squamous vulvar intraepithelial neoplasia: 2004 modified 

terminology, ISSVD Vulvar Oncology Subcommittee. J Reprod 

Med 2005;48:845-61. 

6 Raju RR, et al. Pagetoid squamous cell carcinoma in situ (pagetoid 

Bowen’s disease) of external genitalia. Int J Gynecol Pathol 

2003;22:127-35. 

7 O’Neil CJ, et al. p16 expression in the female genital tract and its 

value in diagnosis. Adv Anat Pathol 2006;13:8-15. 

8 Lynch PJ. 2006 International Society for the Study of Vulvovaginal 

Disease classification of vulvar dermatoses: a synopsis. J Low Genit 

Tract Dis 2007;11:1-2.

228 

9 Lynch PJ, Moyal-Barocco M, Bogliatto F, et al. 2006 ISSVD classification 

of vulvar dermatoses: pathologic subsets and their clinical 

correlation. J Reprod Med 2007;52:3-9. 

10 van de Niewenhof HP, van der Avoort I, de Hullu JA. Review of squamous 

premalignant vulvar lesions. Critical Reviews in Oncology/ 

Hematology 2008. 

11 van der Avoort I, van der Laak J, Paffen A, et al. MIB1 expression in 

basal cell layer: a diagnostic tool to identify premalignancies of the 

vulva. Modern Pathology 2007;20:770-8. 

12 Hantschmann P, Sterzer S, Jeschke U, et al. p53 expression in vulvar 

carcinoma, vulvar intraepithelial neoplasia, squamous cell hyperplasia 

and lichen sclerosus. Anticancer Research 2005;25;1739-45. 

13 MR Raspollini, G Asirelli, G Taddei. The role of angiogenesis 

and COX-2 expression in the evolution of vulvar lichen sclerosus 

to squamous cell carcinoma of the vulva. Gynecologic Oncology 

2007;106:567-71. 

Tumori dello stroma vulvo-vaginale: 

inquadramento clinico-patologico 

G. Magro 

Dipartimento G.F. Ingrassia, Università di Catania, Sezione di Anatomia 

Patologica, Catania 

I tumori mesenchimali dello stroma vulvo-vaginale comprendono 

lesioni benigne e maligne che possono originare comunemente 

in tutti i tessuti molli, nonché tumori che sono sedespecifici, 

quali l’angiomixoma aggressivo (AAM), l’angiofibroma 

cellulato (CAF), l’angiomiofibroblastoma (AMFB) e il 

miofibroblastoma (MFB). Il primo, a dispetto di una citologia 

piuttosto blanda, ha il comportamento clinico di neoplasia a 

“malignità intermedia”, data l’elevata capacità di recidivare 

localmente in modo infiltrativo/destruente e la rarità di metastatizzare 

a distanza. Verrà presentata una casistica di 27 casi di 

AAM, enfatizzandone gli aspetti morfologici caratteristici e anche 

quelli più inusuali che possono rappresentare dei “diagnostic 

pitfalls” per il patologo. A tal proposito verranno discussi alcuni 

casi che, nel corso degli anni, hanno presentato recidive locali 

multiple, caratterizzate da uno stroma tumorale diffusamente 

fibro-sclerotico, morfologicamente difficile da distinguere da 

un processo fibrotico reattivo post-chirurgico. Verrà presentato 

il profilo immunoistochimico di questi tumori, con particolare 

attenzione all’espressione del marker HMGA2, considerato 

altamente sensibile ma non tumore-specifico. L’espressione 

variabile dei recettori estro-progestinici suggerisce che l’AAM 

sia un tumore ormono-responsivo che potrebbe beneficiare di 

terapie anti-ormonali, soprattutto nei casi di tumori localmente 

molto avanzati. 

La chirurgia della mammella 

L. Cataliotti 

Oggigiorno è ormai evidente che il tumore della mammella 

può essere più o meno aggressivo e che molti fattori prognostici 

e predittivi possono giocare un ruolo importante 



Sala Brunelleschi – 08.30-10.30 

Patologia mammaria: aggiornamenti 

Il CAF, l’AMFB ed il MFB sono, invece, dei tumori benigni 

costituiti da fibroblasti/miofibroblasti, che possono presentare 

un “overlapping morfologico ed immunoistochimico” 

che, talora, rende difficile una netta separazione tra queste 

entità. Verrà presentata una casistica di 3 casi di CAF, 10 

casi di AMFB e 10 casi di MFB vulvo-vaginale. Per ciascuna 

categoria tumorale verranno enfatizzati gli aspetti morfologici 

ed immunoistochimici tipici, nonché le varianti più 

inusuali che possono aiutare nella diagnostica differenziale. 

Questi tumori stromali benigni sono stati anche studiati, 

con metodica FISH, per la delezione (monosomia) della 

regione 13q14, alterazione cromosomica originariamente 

identificata nel lipoma a cellule fusate dei tessuti molli 

e, successivamente, anche nel MFB mammario, nel MFB 

dei tessuti molli, ed in alcuni casi di CAF vulvo-vaginali. 

Questo studio ha dimostrato che la maggior parte dei MFB 

vulvo-vaginali, al pari di quelli mammari, condividono con 

il CAF la delezione della regione 13q14. Al contrario, tale 

marker citogenetico non è stato riscontrato in nessun caso 

di AMFB. Questi dati suggeriscono che il MFB e il CAF 

vulvo-vaginale probabilmente appartengono alla stessa categoria 

tumorale, rappresentandone soltanto una variazione 

morfologica sul tema. È possibile ipotizzare che esiste una 

cellula dello stroma vulvo-vaginale a profilo staminale che, 

sotto stimoli (ambientali? genetici?) ancora sconosciuti, dà 

origine a tumori che esibiscono una variabile differenziazione 

fibroblastica/miofibroblastica. Tutti i dati morfologici, 

immunoistochimici e quelli relativi alla FISH per la delezione 

della regione 13q14 suggeriscono al patologo che: 

i) è cruciale distinguere l’AAM dagli altri tumori benigni, 

con o senza stroma mixoide, della regione vulvo-vaginale, 

per il diverso comportamento clinico; ii) la distinzione tra 

l’AMFB, il CAF e il MFB, laddove possibile sulla base dei 

dati morfologici ed immunoistochimici, è auspicabile per 

un corretto inquadramento nosologico; iii) una distinzione a 

tutti i costi tra l’AMFB, il CAF e il MFB, soprattutto in quei 

casi che mostrano un”overlapping morfo-immunoistochimico”, 

appare piuttosto accademica e priva di significato clinico. 

A tal fine si suggerisce l’utilizzo del termine “tumore 

stromale benigno vulvo-vaginale, N.A.S (non ulteriormente 

specificato). 

La diagnostica delle lesioni pigmentate vulvari 

G. Massi 


Moderatori: Simonetta Bianchi (Firenze), Anna Sapino (Torino) 

nella scelta della terapia più appropriata e dei risultati 

finali. L’imaging moderno, la caratterizzazione morfologica 

e biologica della lesione (oltre a molti altri fattori 

quali l’età, la buona salute e l’ atteggiamento della paziente 

nei confronti della diagnosi di cancro), richiedono un 

atteggiamento più flessibile da parte di tutti gli specialisti

RElaziONi 

coinvolti nell’ approccio multidisciplinare al tumore della 

mammella. 

Lo studio del tumore primario e delle sue caratteristiche patologiche, 

insieme ad un profilo molecolare basato su modelli 

di espressione genica, porterà senza dubbio ad una migliore 

comprensione dei tumori della mammella. 

Oltre a questo, il chirurgo non dovrebbe mai dimenticare che, 

oggi giorno, il corretto trattamento è il risultato del corretto 

bilanciamento tra le tecniche chirurgiche, radioterapiche e 

farmacologiche disponibili. 

Tuttavia questo richiede una conoscenza approfondita dei problemi 

e l’abilità di affrontare situazioni diverse e di valutare 

ogni singola situazione nella sua totalità. 

In un futuro prossimo si avrà sicuramente un ulteriore miglioramento 

della qualità nella diagnosi e nel trattamento del 

tumore della mammella ed una più attenta considerazione 

delle singole situazioni. Ogni fase del percorso chirurgico 

deve essere accuratamente registrata, per favorire il controllo 

di qualità, per assicurare la completezza dell’escissione, per 

evitare il trattamento eccessivo delle donne con lesioni a 

prognosi favorevole, assicurandosi di aver raccolto tutti i dati 

necessari al fine di decidere sull’eventuale radioterapia adiuvante 

o terapia sistemica adiuvante. 

nuove linee guida ASCO 

G. Viale 


“nomogrammi” per la predittività del linfonodo 

sentinella sullo stato del cavo ascellare 

I. Castellano 

Dipartimento di Scienze Mediche, Università di Torino 

La biopsia del linfonodo sentinella (LS) rappresenta il trattamento 

chirurgico standard nella stadiazione del carcinoma 

mammario in pazienti con ascella clinicamente negativa. 


Patologia mammaria 2 

Moderatori: Generoso Bevilacqua (Pisa), Eugenio Maiorano (Bari) 

Problematiche della fase pre-analitica nella 

determinazione dello status di HEr2/neu 

Preanalytical variables in HEr2/neu testing 

C. Doglioni 

U.O. Anatomia Patologica, Istituto Scientifico San Raffaele, Università 

Vita-Salute San Raffaele, Milano 

The process of HER2 testing is composed by several steps 

including a preanalytical phase, immunostaining or FISH/ 

CISH preparation and microscopic evaluation. In the preanalytical 

phase, several factors may affect the final results: these 

factors include the interval from sampling or surgical excision 

to fixation, the type and quality of fixative, the length of 

fixation, the processing protocols, the quality of microtome 

sectioning and the time from sectioning to immunostaining or 

229 

Dopo 20 anni di applicazione routinaria di questa metodica, 

numerosi studi di follow up hanno dimostrato come, anche 

in presenza di coinvolgimento metastatico di LS, le recidive 

ascellari siano rare e con scarso impatto sulla sopravvivenza. 

È stato inoltre documentato che LS può nel 50-70% dei casi 

essere l’unico linfonodo ascellare interessato dalla metastasi 

del carcinoma mammario, rendendo la dissezione dell’intero 

cavo inutile e dannosa per la maggior parte delle pazienti. 

In seguito a queste osservazioni sono stati proposti in letteratura 

numerosi nomogrammi, alfine di predire lo stato del 

cavo ascellare, in pazienti con LS positivo per micro o macro 

metastasi. Questi sistemi si basano su (i) caratteristiche cliniche 

della paziente, quali l’età; (ii) caratteristiche anatomopatologiche 

del tumore primitivo, quali la dimensione, il 

grading istologico, l’invasione vascolare, la multifocalità (iii) 

caratteristiche del LS, quali l’estensione dell’interessamento 

metastatico, il coinvolgimento extracapsulare ed il numero di 

LS positivi. Nonostante la loro potenziale utilità nel discriminare 

pazienti a rischio di metastasi ascellari, l’applicazione 

routinaria dei nomogrammi è oggetto di discussione. In primo 

luogo la loro numerosità crea una certa confusione su quale 

sia il nomogramma più idoneo da applicare alla propria casistica. 

Inoltre, basandosi su parametri talvolta scarsamente 

riproducibili dal punto di vista anatomo-patologico, quali ad 

esempio l’invasione vascolare o il grado istologico del tumore 

primitivo, lasciano una certa perplessità circa la loro affidabilità 

e riproducibilità. Inoltre, data la loro costruzione basata 

su modelli statistici complessi, risultano talvolta difficili da 

utilizzare quotidianamente e mancano quindi di validazioni 

multicentriche. Ci si chiede infine quale possa essere in futuro 

l’indicazione all’utilizzo dei nomogrammi, dati i recenti 

risultati del famoso trial coordinato dal Prof Giuliano (JAMA 

2011;305:569-75). 

Lesioni B3: aggiornamenti 

S. Bianchi 


FISH/CISH. The interval from surgical excision and fixation 

(cold ischemia) and length of fixation are probably the most 

relevant steps. A few studies addressed the effects of cold 

ischemia, showing in some case deleterious results. The 2007 

ASCO guidelines indicate a fixation time of 6 to 48 h for surgical 

specimens. This interval was considered the best compromise 

in order to avoid false positive results with too short 

fixation and false negative results with specimen overfixation; 

however formal and rigorous studies on this specific topic are 

lacking. Furthermore the length of fixation for core biopsies 

was not addressed in 2007 guidelines. A recent update of 

ASCO guidelines indicated in 6 hours the adequate fixation 

time for needle biopsies. Utilizing breast cancer cell lines with 

known Her2 status and surgical specimens, we analyzed the 

effects of different fixation times on Her2 immunohistochemical 

evaluation.

230 

Procedure di analisi del linfonodo sentinella: 

esame morfologico vs biologia molecolare 

A.G. Naccarato 


Carcinoma invasivo duttale vs lobulare: distinte 

entità o facce della stessa medaglia? 

E. Orvieto 


La rilevanza dei cloni focali con iperespressione 

di HEr2 nella pratica clinica 

S. Dellapasqua 

Istituto Europeo di Oncologia, Dipartimento di Medicina, Divisione 

di Oncologia Medica, Unità di Ricerca in Senologia Medica, Milano 

Negli ultimi decenni numerosi passi avanti sono stati compiuti 

in campo oncologico nella diagnosi e nella terapia del 

carcinoma mammario HER2 positivo. Tali progressi sono 

stati possibili grazie alla estensiva esperienza di tecniche di 

immunoistochimica (IHC) e di ibridazione in situ (ISH), la 

disponibilità di reagenti e kit standardizzati, e la pubblicazione 

di linee guida e raccomandazioni che descrivono il modo 

ottimale di condurre tali test e valutare e dare uno score ai 

risultati. Nonostante questi progressi, diversi aspetti sono 

tuttora altamente controversi nell’ambito della determinazione 

di HER2 nel carcinoma mammario: tra questi, aspetti 

metodologici, quali l’accuratezza e la riproducibilità dei 

risultati dei test, la definizione di soglie ottimali per le analisi 

di IHC che di ISH, e la concordanza tra IHC e ISH, e aspetti 

legati alla biologia del tumore, in particolare le implicazioni 

cliniche della eterogeneità intratumorale dello stato di HER2, 

la discordanza tra espressione di HER2 nel tumore primitivo e 

nelle metastasi, ed il ruolo della polisomia del cromosoma 17. 

Per poter risolvere almeno in parte tali aree di controversia, 

la comunità scientifica dovrebbe essere pronta a riconsiderare 

almeno alcuni dei presupposti su cui sono basati i test attuali 

e lo scoring system. Affrontando tali aree di controversia, 

potremmo migliorare la nostra comprensione sulla biologia, il 

decorso clinico e la responsività alle terapie target anti-HER2 

nel carcinoma mammario, migliorando così l’accuratezza 

nella selezione dei pazienti che sono candidati a terapie target 

anti-HER2, in modo da identificare i pazienti responsivi alle 

diverse opzioni terapeutiche. 

Clonalità nei carcinomi duttali in situ 

multipli della mammella: possibili aspetti di 

cancerizzazione a campo 

M.P. Foschini 

Dipartimento di Scienze Biomediche e Neuromotorie, Università di 

Bologna, Sezione di Anatomia Patologica, “M.Malpighi”, Ospedale 

Bellaria, Bologna 

Le macrosezioni (MS) consentono di visualizzare istologicamente 

una sezione completa dell’organo in esame. Tale tecnica 

è nota fin dai primi anni del 1900, ma solo nelle ultime due 

decadi il suo utilizzo è andato aumentando. Nell’ambito della 

patologia mammaria le MS hanno permesso di approfondire 

le nostre conoscenze sia riguardo l’anatomia normale, sia re- 


lativamente alle correlazioni con le immagini radiologiche 3 8 . 

Sulla base delle osservazioni su MS, Tot ha proposto la teoria 

del “lobo malato” 6 . Secondo questa teoria il carcinoma 

mammario insorge nell’ambito di un lobo geneticamente 

predisposto. 

Recentemente studi eseguiti su MS hanno evidenziato che la 

multifocalità nel carcinoma mammario è un evento tutt’altro 

che raro e che comporta un peggioramento prognostico 7 9 . 

In uno studio in precedenza svolto presso il nostro istituto, 

si è visto che il carcinoma duttale in situ (DCIS\DIN) ben 

differenziato, di grado 1, è frequentemente una neoplasia 

molto estesa, che può interessare anche più di un quadrante 

mammario. Al contrario DCIS\DIN di grado 2 e 3, anche se 

presentano foci multipli, in genere presentano un’estensione 

inferiore 2 . In uno studio basato su 574 casi di carcinoma 

mammario, tutti studiati con macrosezioni, Tot et al. 7 hanno 

dimostrato che la multifocalità nel carcinoma mammario è un 

evento frequente. 

In caso di DCIS\DIN multifocale è difficile capire se si tratta 

di neoplasie multiple indipendenti oppure se si tratta della 

stessa neoplasia che si estende lungo un unico lobo. 

Per capire meglio la relazione clonale tra i foci multipli di 

DCIS\DIN li abbiamo studiati valutando le mutazioni puntiformi 

della regione D-loop del DNA mitocondriale. Tale 

tecnica ha dimostrato che nel DCIS\DIN di grado 1 tutti i foci 

erano neoplasie indipendenti, prive di correlazione clonale tra 

loro. Al contrario i foci multipli del DCIS\DIN di grado 3 erano 

più frequentemente clonalmente correlati tra loro. Questi 

dati confermano la teoria del lobo malato. Infatti nei casi di 

DCIS\DIN di grado 3, i foci multipli sono probabilmente dati 

da cellule neoplastiche che si estendono nelle diramazioni di 

un singolo lobo. Nei casi di DCIS\DIN di grado 1, si tratta 

più probabilmente di neoplasie multiple ed indipendenti. 

L’insorgenza di neoplasie a carico di una (o di entrambe le 

mammelle) può essere correlato all’esposizione a carcinogeni 

di più lobi mammari geneticamente predisposti. Un fenomeno 

simile è ben conosciuto nel tratto aero-digestivo ed urinario 

ed è definito “cancerizzazione a campo” 5 . Tale concetto è 

applicabile anche in patologia mammaria 1 4 . 

references 

1 Dworkin AM, Huang TH, Toland AE. Epigenetic alterations in the 

breast: Implications for breast cancer detection, prognosis and treatment. 

Semin Cancer Biol 2009;19:165-71. 

2 Foschini MP, Flamminio F, Miglio R, et al. The impact of large sections 

on the study of in situ and invasive duct carcinoma of the breast. 

Human Pathology 2007;38:1736-43. 

3 Going JJ, Moffat DF. Escaping from flatland: clinical and biological 

aspects of human mammary duct anatomy in three dimensions. J 

Pathol 2004;203:538-44. 

4 Heaphy CM, Griffith JK, Bisoffi M. Mammary field cancerization: 

molecular evidence and clinical importance. Breast Cancer Res Treat 

2009;118:229-39. 

5 Slaughter DP, Southwick HW, Smejkal W. Field cancerization in oral 

stratified squamous epithelium; clinical implications of multicentric 

origin. Cancer 1953;6:963-8. 

6 Tot T. DCIS, cytokeratins, and the theory of the sick lobe. Virchows 

Arch 2005;447:1-8. 

7 Tot T, Gere M, Pekàr G, et al. Breast cancer multifocality, disease 

extent, and surviaval. Hum Pathol 2011;42:1761-9. 

8 Tot T, Tabàr L. The role of radiological–pathological correlation in 

diagnosing early breast cancer:the pathologist’s perspective. Virchows 

Arch 2011;458:125. 

9 Weissenbacher TM, Zschage M, Janni W, et al. Multicentric and 

multifocal versus unifocal breast cancer: is the tumor-node-metastasis 

classification justified? Breast Cancer Res Treat 2010;122:27-34.

RElaziONi 

La classificazione dei GEP nET 


Sala Michelangelo – ore 8.30-10.30 

Tumori neuroendocrini 

Moderatori: Luca Messerini (Firenze), Giuseppe Zamboni (Verona) 

G. Rindi 

Istituto di Anatomia Patologica, U.C.S.C. Policlinico A. Gemelli, 

Roma 

I tumori neuroendocrini (NET) del tratto gastroenteropancreatico 

(GEP) sono un gruppo di lesioni epiteliali neoplastiche 

originalmente note come “carcinoidi”. In base alle indicazioni 

fornite dell’organizzazione mondiale della sanità (WHO 

2010) i NET sono raccolti sotto la definizione ombrello di 

“neoplasia”, comprendente lesioni a grado istologico basso, 

intermedio ed alto. La corrente classificazione WHO 2010 

introduce i due nuovi strumenti classificativi del grading 

(G1-G3) e dello staging TNM (Tumor, Node, Metastasis). 

Il sistema di grading definisce tre categorie (G1-G3) in base 

alla conta mitotica ed all’indice di proliferazione per Ki67. 

Si identificano tre classi WHO, la classe 1 WHO, definita 

tumore neuroendocrino NET G1; la classe 2 WHO, NET 

G2 e la classe 3 WHO definita carcinoma neuroendocrino 

(NEC), per definizione G3. Il TNM WHO è sostanzialmente 

sovrapponibile allo schema classificativo per organo proposto 

dalla Società Europea dei Tumori Neuroendocrini (ENETS). 

Tuttavia la WHO 2010 ne limita l’applicazione solo ai NET 

G1 -G2 (“carcinoidi”) e sono presenti differenze significative 

per il pancreas, adottando quello delle neoplasie esocrine, 

e per l’appendice, con un T basato esclusivamente sulla dimensione 

della neoplasia. Lo schema di staging è comune e 

definito a gravità progressiva di malattia come segue: stadio 

I, neoplasie a crescita limitata locale, stadio II, neoplasie di 

maggiori dimensioni o maggiormente invasiva localmente, 

ma sempre in assenza di metastasi, stadio III neoplasie che 

invadono in profondità o con metastasi loco-regionali e stadio 

IV con metastasi a distanza. Lo schema classificativo TNM 

WHO è peraltro quello raccomandato dall’American Joint 

Cancer Committee (AJCC) e dall’Union for International 

Cancer Control (UICC). Le linee guida oncologiche correnti 

per il trattamento dei pazienti con neoplasie neuroendocrine 

si basano largamente sugli schemi classificativi di grading e 

staging della WHO 2010 per la scelta di specifiche opzioni 

terapeutiche. 

Bibliografia 

Bosman F, Carneiro F, Hruban RH, et al. WHO Classification of Tumours 

of the Digestive System. Lyon, France: IARC Press 2010. 

neuroendocrine tumors of the stomach 

S. La Rosa 

Anatomia Patologica, Ospedale di Circolo-Fondazione Macchi, Varese 

Gastric neuroendocrine tumors (NETs) are a heterogeneous 

group of neoplasms that differ considerably in clinicopathologic 

background, degree of histologic differentiation and 

prognosis. In the past, they have been reported with an annual 

incidence of 0.002 per 100.000 population, accounting 

231 

for about 2-3% of all gastrointestinal NETs 1 and 0.3% of all 

gastric neoplasms 2 . However, more recent studies have suggested 

a higher incidence reaching 11-41% of all gastrointestinal 

NETs 3 . Recent population-based studies showed that the 

annual incidence of gastric NETs was 0.18-0.24 per 100.000 

among Caucasian 4 with an incremental trend in the last three 

decades 5 . This may be probably due to the increased use of 

endoscopic techniques and to the increased awareness of such 

pathology. 

The current WHO classification of digestive tumors distinguishes 

gastric neuroendocrine neoplasms in different 

categories on the basis of the proliferative criteria common 

to all gastrointestinal and pancreatic neuroendocrine tumors: 

G1 NET, G2 NET, G3 neuroendocrine carcinoma (NEC) and 

mixed adenoneuroendocrine carcinoma (MANEC) 6 7 . However, 

in addition to proliferation, tumors arising in the stomach 

represent a peculiar entity for which neoplastic cell type 

and clinicopathologic background can influence the biological 

aggressiveness and patients prognosis 8 9 . 

Although up to five neuroendocrine cell types have been morphologically 

and functionally characterized in the human normal 

gastric mucosa, most gastric NETs are enterochromaffinlike 

(ECL)-cell neoplasms 8 9 . These may be multiple arising 

in a background of long-standing hypergastrinemia due to 

gastric body atrophic gastritis and achlorhydria (clinico-pathologic 

Type 1) or to combined multiple endocrine neoplasia/ 

Zollinger-Ellison syndrome (MEN/ZES) with hypertrophic 

gastropathy (Type 2). In some cases they appear sporadically 

in normal mucosa (Type 3) 10 . Recently, a so called 

“type 4” ECL-cell NET has been identified: it is multiple and 

characterized by hypertrophic gastropathy, hypergastrinemia, 

G-cell hyperplasia, and absence of MEN/ZES 11 12 . In addition 

to the above listed ECL-cell NETs, rare NETs composed of 

serotonin-producing EC-cells, gastrin-producing G-cells and 

somatostain-producing D-cells have been also described in the 

stomach with a predilection for the antral mucosa 9 . 

Type 1 ECL-cell NET 

Type 1 ECL-cell NETs are frequently multiple, localized 

in atrophic oxyntic mucosa and show a female predilection 

(female to male ratio, 2.5:1). They are small in size: about 

70% are < 1cm and about 95% are

232 

are classified as G1 NETs, following the 2010 WHO Classification 

6 . Tumors are strongly positive for chromogranin 

A, synaptophysin and vesicular monoamine transporter 2 

(VMAT2) and are associated with excellent prognosis in most 

cases. Low grade malignant behavior has been only observed 

in large tumors (more than 2 cm) deeply infiltrating the gastric 

wall. In a recently published series, type-1 NETs were all G1 

with a well differentiated morphology and were associated 

with excellent prognosis. All but one patient were alive at 

follow-up control. The only patient died had a large and deep 

infiltrative neoplasm 9 . For this reason the therapeutic choice 

is endoscopic resection, while surgical resection must only be 

restricted to the rare large tumors showing infiltration beyond 

the submucosa at ECO-endoscopic examination. 


Type 2 ECL-cell NETs are less frequent than type 1 and account 

for about 8% of all gastric NETs. They are multiple 

and frequently of small size (about 80% are < 2cm). Unlike 

type 1 NETs, this category of tumors does not show a female 

prevalence, with equal incidence between men and women. 

Similarly to type 1 NETs hypergastrinemia plays a pivotal 

role in tumor pathogenesis. Gastrin hypesecretion depends 

on functioning duodenal or pancreatic gastrinomas associated 

with Zollinger-Ellison syndrome (ZES) in the context 

of MEN1 syndrome (MEN/ZES). Interestingly, patients with 

ZES but without MEN1 very rarely develop a type 2 ECLcell 

NET. Indeed, it has been reported that 13-37% of patients 

with MEN1 presented type 2 NETs, whereas only 0-2% of 

ZES patients without MEN1 developed such tumors 13 . Conversely 

to type 1 NETs, in type 2 NETs the gastric mucosa is 

hypertrophic with ECL-cell hyperplasia or dysplasia. Tumors 

are morphologically well differentiated following the criteria 

recently proposed 9 . However, respect to type 1 NETs they are 

more frequently larger and infiltrating the submucosa, despite 

a low proliferation. Most cases are G1, while a few cases 

show a Ki67% proliferative index slightly higher than 2% 9 . 

These aspects influence the clincopathologic behavior that appears 

to occupy an intermediate position between type 1 and 

type 3 NETs. Lymph node metastases have been observed in 

30% of patients, while distant metastases in 10% 10 , with a 

tumor-related death observed in 7.7% of patients 9 . 


Type 3 ECL-cell NETs have been traditionally defined as 

“sporadic tumors” because they arise in normal gastric mucosa 

without any known precursor lesion 10 . These tumors are single 

and show a prevalence in males (male/female ratio: 2.8:1) with 

a mean age of about 50 years. They are usually considerably 

larger than other ECL-cell NETs and often show deep infiltration 

of the gastric wall including the muscularis propria or 

beyond. Several cases are well differentiated in morphology 

like type 1 and 2 NETs. However, cases showing a moderate 

histologic differentiation characterized by large and disordered 

cell aggregates with large and poorly aligned nuclei with moderate 

atypia, less regularly distributed chromatin, evident but 

not prominent nucleoli and sometimes focal necrosis have been 

described 9 . Neoplasms with this histological feature display a 

relative high proliferation fitting the current G2 class 6 . Moreover, 

a few cases can show more than 20% Ki67 and for this 

reason they should be classified as G3 NEC, despite the less 

atypical morphology. However, these latter tumors are associated 

with a better prognosis than that of typical NECs showing 

poorly differentiated histology and very high proliferation. 

In general, type 3 ECL-cell NETs have a worse behavior 

than that of type 1 and 2 NETs and this probably depends on 

the group of high proliferative tumors above described. At 


diagnosis local spread is present in about 15% of cases and 

liver metastases in about 50%. While type 1 and 2 NETs are 

endocrinologically silent tumors, a subset of type 3 ECL-cell 

NETs can be associated with the atypical carcinoid syndrome, 

characterized by cutaneous flushing, profound itching, bronchospasm, 

and lacrimation 14 . 


In addition to the three previously described ECL-cell NETs, 

a fourth category can be included in the spectrum of gastric 

neuroendocrine tumors. This “type 4” ECL-cell NET is very 

rare accounting for about 4 described cases 9 11 12 . These tumors 

are multiple with well differentiated morphology and 

arise in a hypertrophic mucosa in which marked ECL-cell 

proliferation including linear and micronodular hyperplasia 

is present. These patients have marked reduction of acid secretion, 

hypergastrinemia, antral G-cell hyperplasia but lack 

MEN/ZES. The natural history of these NETs is not completely 

clear due to the very small number of cases described. 

Basing on the reported information they seem to have good 

prognosis like type 1 NETs 12 . The pathogenetic mechanism of 

such tumor is not clear. Experimental findings suggest that an 

intrinsic block in acid secretion from parietal cells may play a 

role, although the etiology of this defect is not known 12 . 

Antral non ECL-cell NET 

In addition to ECL-cell NETs, rare tumors composed of different 

cell types have been reported 7 9 . They are generally 

located in the antral mucosa and can be composed of different 

cell types: gastrin-producing G-cells, serotonin-producing 

EC-cells, or somatostatin-producing D-cells. Most tumors 

were clinically nonfunctioning, unexpectedly found at endoscopy 

or surgery, well differentiated, small in size and confined 

to the mucosa or superficial submucosa. However, two large 

G-cell NETs infiltrating the muscolaris propria and associated 

with the gastrinoma syndrome have been described. In a 

recent published series no tumor-related death was observed 

after a mean follow-up time of 10 years 9 . 

NEC 

Neuroendocrine carcinomas (NECs) are aggressive neoplasms 

associated with poor prognosis. They can arise everywhere in 

the gastric mucosa even if they are more frequent in the antral 

and cardial region. Histologically, they are characterized by 

poorly formed large trabeculae or diffuse sheets of poorly 

differentiated neuroendocrine cells with abundant necrosis. 

Two main different cell types have been identified. Small 

cell NECs are characterized by small to intermediate sized 

cells with scanty cytoplasm and fusiform nuclei with granular 

chromatin and inconspicuous nucleoli. The mitotic rate is 

brisk, generally ranging from 50 to 80 mitotic figures per 10 

high-power fields. The large cell NEC, or high grade NEC 

(HGNEC) non small cell type 15 , is formed by cells with abundant 

cytoplasm showing more vesicular nuclei with prominent 

nucleoli as well as more prominent organoid, trabecular and 

palisading pattern. Most NECs are deeply infiltrative with 

metastatic spread at the time of diagnosis and show a very 

ominous outcome, much more severe than any type of ECLcell 

NET. Due to the poor morphological differentiation, the 

neuroendocrine nature of such carcinomas must be confirmed 

using immunohistochemistry. NECs are positive for synaptophysin, 

neuron specific enolase, CD56 and chromogranin A. 

Conversely to well/moderately differentiated NETs, NECs are 

also frequently positive for p53 which reflects the frequent 

p53 gene mutation 16 . 

MANEC 

Mixed exocrine-neuroendocrine carcinomas, now classified 

as mixed adenoneuroendocrine carcinomas (MANECs), are

RElaziONi 

by definition neoplasms in which each component represents 

at least 30% of the lesion 6 . It is now well known that there 

is a wide spectrum of combination of exocrine and neuroendocrine 

components which can show different morphological 

features ranging, for the former, from adenoma to adenocarcinoma 

with different degrees of differentiation and, for the 

latter, from well differentiated to poorly differentiated neuroendocrine 

tumors. Basing on these morphological criteria 

they can also be stratified in different prognostic categories 17 . 

Most gastric MANECs are high grade malignant neoplasms 

formed by an adenomatous or adenocarcinomatous component 

and by a poorly differentiated (small to intermediate or 

large cell type) NEC 9 18-22 . They show an equal distribution 

in the upper and lower part of the stomach 9 23 24 . Prognosis 

of gastric high grade MANECs depends on stage and tumor 

type at presentation. A better survival was registered for patients 

with loco-regional disease compared to patients with 

distant metastases. In general, patients with gastrointestinal 

MANECs seem to have a better median overall survival than 

patients with pure NECs and this seems to be mainly due to 

the higher stage at the time of diagnosis of pure NECs compared 

with that of MANECs 9 . 

Intermediate grade gastric MANECs are composed by areas 

of tubular, papillary adenocarcinoma, mucinous adenocarcinoma 

or diffuse signet ring cell carcinoma and areas of grade 

1 or 2 NET in both primary and metastatic sites 20 25-28 . Interestingly, 

at least five adenocarcinoma-NETs of the stomach 

were associated with autoimmune chronic atrophic gastritis 

and with multiple proliferative neuroendocrine lesions such as 

intramucosal ECL-cell micro-NETs (microcarcinoids) 25 29-31 . 

MANECs composed of diffuse signed ring cell carcinoma and 

NET are combined neoplasms characterized by nonchoesive 

signet ring cells diffusely admixed with neuroendocrine cells. 

According to Tahara et al. 26 they appear at a mean age of 53 

years and in the majority of cases involve the entire stomach 

with a pattern of linitis plastica. 

Tumor Staging 

The prognostic value of the TNM staging system for gastric 

neuroendocrine neoplasms proposed by ENETS 32 has been 

recently confirmed 9 33 . However, a prognostic amelioration of 

such TNM scheme has been recently proposed 9 . It includes 

the distinction of the T1 stage into T1 a (intramucosal or superficial 

submucosa extension) and T1 b (deep submucosal 

invasion) categories. In addition, useful prognostic information 

derives from the distinction of the N1 category into N1 

(≤ 3 metastatic lymph nodes) and N2 (> 3 metastatic lymph 

nodes) subtypes. Interestingly, tumors showing more than 3 

metastatic lymph nodes, but without distant metastases, show 

an aggressive behavior like tumors in stage IV. These findings 

suggest that a careful investigation of the wall infiltration 

and the number of metastatic lymph nodes is of prognostic 

relevance. 

references 

1 Godwin JD. Carcinoid tumors. An analysis of 2,837 cases. Cancer 

1975;36:560-9. 

2 McDonald RA. A study of 356 carcinoids of the gastrointestinal 

tract; report of four new cases of the carcinoid syndrome. Am J Med 

1956;21:867-78. 

3 Sjoblom SM. Clinical presentation and prognosis of gastrointestinal 

carcinoid tumours. Scand J Gastroenterol 1988;23:779-87. 

4 Hauso O, Gustafsson BI, Kidd M, et al. Neuroendocrine tumor 

epidemiology: contrasting Norway and North America. Cancer 

2008;113:2655-64. 

5 Yao JC, Hassan M, Phan A, et al. One hundred years after “carcinoid”: 

epidemiology of and prognostic factors for neuroendocrine tumors in 

35,825 cases in the United States. J Clin Oncol 2008;26:3063-72. 

233 

6 Rindi G, Arnold R, Bosman FT, et al. Nomenclature and classification 

of neuroendocrine neoplasms of the digestive system. In: Bosman FT, 

et al., editors. WHO classification of tumours of the digestive system. 

Lyon: IARC Press 2010, pp. 13-4. 

7 Solcia E, Arnold R, Capella C, et al. Neuroendocrine neoplasms of the 

stomach. In: Bosman FT, et al, editors. WHO classification of tumours 

of the digestive system. Lyon, France: IARC Press 2010. pp. 64-8. 

8 Rindi G, Azzoni C, La Rosa S, et al. ECL cell tumor and poorly differentiated 

endocrine carcinoma of the stomach: prognostic evaluation 

by pathological analysis. Gastroenterology 1999;116:532-42. 

9 La Rosa S, Inzani F, Vanoli A, et al. Histologic characterization and 

improved prognostic evaluation of 209 gastric neuroendocrine neoplasms. 

Hum Pathol 2011;42:1373-84. 

10 Rindi G, Luinetti O, Cornaggia M, et al. Three subtypes of gastric 

argyrophil carcinoid and the gastric neuroendocrine carcinoma: a 

clinicopathologic study. Gastroenterology 1993;104:994-1006. 

11 Ooi A, Ota M, Katsuda S, et al. An unusual case of multiple gastric 

carcinoids associated with diffuse endocrine cell hyperplasia and 

parietal cell hypertrophy. Endocr Pathol 1995;6:229-37. 

12 Abraham SC, Carney JA, Ooi A, et al. Achlorhydria, parietal cell hyperplasia, 

and multiple gastric carcinoids. A new disorder. Am J Surg 

Pathol 2005;29:969-75. 

13 Jensen R. Management of the Zollinger-Ellison syndrome in patients 

with multiple endocrine neoplasia type 1. J Int Med 1998;243:477-88. 

14 Modlin IM, Lye KD, Kidd M. Carcinoid tumors of the stomach. Surg 

Oncol 2003;12:153-72. 

15 Shia J, Tang LH, Weiser MR, et al. Is nonsmall cell type high-grade 

neuroendocrine carcinoma of the tubular gastrointestinal tract a distinct 

disease entity? Am J Surg Pathol 2008;32:719-31. 

16 Furlan D, Cerutti R, Uccella S, et al. Different molecular profiles 

characterize well-differentiated endocrine tumors and poorly differentiated 

endocrine carcinomas of the gastroenteropancreatic tract. Clin 

Cancer Res 2004;10:947-57. 

17 La Rosa S, Marando A, Sessa F, et al. Mixed adenoneuroendocrine 

carcinomas (MANECs) of the gastrointestinal tract: an update. Cancers 

2012;4:11-30. 

18 Matsui K, Jin XM, Kitagawa M, et al. Clinicopathologic features of 

neuroendocrine carcinomas of the stomach: appraisal of small cell 

and large cell variants. Arch Pathol Lab Med 1998;122:1010-7. 

19 Kim KM, Kim MJ, Cho BK, et al. Genetic evidence for the multi-step 

progression of mixed glandular-neuroendocrine gastric carcinomas. 

Virchows Arch 2002;440:85-93. 

20 Lee EJ, Park SM, Maeng L, et al. Composite glandular-endocrine cell 

carcinomas of the stomach: clinicopathologic and methylation study. 

APMIS 2005;113:569-76. 

21 Rayhan N, Sano T, Qian ZR, et al. Histological and immunohistochemical 

study of composite neuroendocrine-exocrine carcinomas of 

the stomach. J Med Invest 2005;52:191-202. 

22 Li AF, Li AC, Hsu CY, et al. Small cell carcinomas in gastrointestinal 

tract: immunohistochemical and clinicopathological features. J Clin 

Pathol 2010;63:620-25. 

23 Matsui K, Kitagawa M, Miwa A, et al. Small cell carcinoma of the 

stomach: a clinicopathologic study of 17 cases. Am J Gastroenterol 

1991;86:1167-75. 

24 Rindi G, Bordi C, Rappel S, et al. Gastric carcinoids and neuroendocrine 

carcinomas: pathogenesis, pathology, and behavior. World J 

Surg 1996;20:168-72. 

25 Caruso ML, Pilato FP, D’Adda T, et al. Composite carcinoid-adenocarcinoma 

of the stomach associated with multiple gastric carcinoids 

and nonantral gastric atrophy. Cancer 1989;64:1534-9. 

26 Tahara E, Ito H, Nakagami, K, et al. Scirrhous argyrophil cell carcinoma 

of the stomach with multiple production of polypeptide hormones, 

amine, CEA, lysozyme and HCG. Cancer 1982;49:1904-15. 

27 Yang GC, Rotterdam H. Mixed (composite) glandular-endocrine cell 

carcinoma of the stomach. Report of a case and review of the literature. 


28 Fujiyoshi Y, Kuhara H, Eimoto T. Composite glandular-endocrine 

cell carcinoma of the stomach. Report of two cases with goblet cell 

carcinoid component. Pathol Res Pract 2005;200:823-9. 

29 Pasquinelli G, Santini D, Preda P, et al. Composite gastric carcinoma 

and precursor lesions with amphicrine features in chronic gastritis. 

Ultrastruct Pathol 1993;17:9-24. 

30 Adhikari D, Conte C, Eskreis D, et al. Combined adenocarcinoma 

and carcinoid tumor in atrophic gastritis. Ann Clin Lab Sci 

2002;32:422-7.

234 

31 Nugent SL, Cunningham SC, Alexiev BA, et al. Composite signet-ring 

cell/neuroendocrine carcinoma of the stomach with a metastatic neuroendocrine 

carcinoma component: a better prognosis entity. Diagn 

Pathol 2007;2:43-50. 

32 Rindi G, Kloppel G, Alhamn H, et al. TNM staging of foregut (neuro) 

endocrine tumors: a consensus proposal including a grading system. 

Virchows Arch 2006;449:393-401. 

33 Pape UF, Jann H, Muller-Nordhorn J, et al. Prognostic relevance of 

a novel TNM classification system for upper gastroenteropancreatic 

neuroendocrine tumors. Cancer 2008;113:256-265. 

I tumori neuroendocrini del pancreas 

P. Capelli 


Aspetti neuroendocrini di tumori nonneuroendocrini 

M. Milione, P. Gasparini, A. Aiello, A. Testi, F. Perrone, F. 

Melotti, S. Pilotti, G. Sozzi, G. Pelosi 

Fondazione IRCCS Istituto Nazionale dei Tumori, Dipartimento di 

Patologia Diagnostica e Laboratorio 

Intraspinal Ewing’s sarcoma ES and/or primitive neuroectodermal 

tumors (PNET) arise in the soft tissue. These pPNET 

originate in the neural crest region and are considered a very 

rare and aggressive neoplasm which develops locally in the 

chest wall and lower extremities. Histologically, pPNETs 

are composed of undifferentiated small round cells that may 

form Homer Wright or Flexner–Wintersteiner rosettes and 

perivascular pseudo-rosettes. Moreover, histological differentiation 

of ES/pPNET from carcinoid tumor, small cell undifferentiated 

carcinoma, neuroblastoma, rhabdomyosarcoma, 

fibrosarcoma or malignant peripheral nerve sheath tumor, is a 

diagnostic challenge due to similarity in histology and clinical 

presentation among these tumors. An essential tool in diagnosing 

ES/pPNET is immunohistochemistry (IHC). In particular 

CD99 (MIC2), which recognizes a 30/32 kDa surface 

glycoprotein a, is expressed in more than 90% of ES/pPNET 

Also, CD99 expression may be seen in several tumors such 

as malignant lymphoma, leukemia and small cell carcinoma 

(Kushner BH, Riopel M, Menasc LP Lumadue JA). 

Non-random chromosomal aberrations, in particular translocations, 

often characterize a number of neoplasms including 

bone and soft tissue tumors. ES/pPNET is a solid tumor 

characterized by the presence of chromosomal translocations 

involving the gene EWS, located at 22q12 and a gene of the 

ETS family. In particular, 85% of cases possess the EWS- 

FLI1 fusion protein created by a chromosomal translocation 

t(12;22)(q24;q12), in which the DNA-binding domain of the 

ETS transcripts fuses to the transactivation domain of FLI1. 

However, EWS-FLI1 is not the only fusion transcript responsible 

for ES/pPNET as the second most common partner gene 

which forms a chimeric fusion with EWS is ERG, formed 

by a chromosomal rearrangement t(22;21) (q22;q12) and accounting 

for approximately 10% of cases. Other fusion genes 

with EWS are less frequent but still present in ES/pPNET 

are EWS-ETV1 t(7;22), EWS-ETV4 t(7;22), and EWS-FEV 

t(2;22) (REF. Sankar et al). 


Overall, in soft-tissue tumors, the incidence of ES/PNET is 

of 4%. Literature describes the occurrence of pPNET anywhere 

in the body, with the most affected site being thoracopulmonary, 

followed by pelvis, retroperitoneum or abdomen, 

limbs, neck and other unknown origins (Kushner et al). 

Moreover, literature reports isolated cases of pPNET also in 

pancreas, heart, kidney, ovary, uterus, testis, urinary bladder 

and parotid gland (REF). The ileo-cecal site is an even rarer 

location for this neoplasm and literature describes only single 

case reports. Regardless the origin of this aggressive and rare 

neoplasm, ES/pPNET has an overall unfavorable prognosis. 

Unfortunately, despite the combined approaches used such as 

therapy with surgery and chemotherapy with radiations, only 

25% of patients with tumors greater than 5 cm were alive at 

24 months. Moreover, molecular events of tumorigenisis in 

ES/pPNETs are still poorly understood but critical in order 

to identify novel molecular markers for new target therapy. 

Yearly, our institution diagnoses about 100ES/pPNET cases 

of different origin site. Interestingly, over the past year, we diagnosed 

5 ES/pPNET cases with primary site in the ileo-cecal 

region. We here describe how an accurate histological differentiation, 

associated with IHC and molecular cytogenetic 

characterization of the specimen, were able to give an accurate 

diagnosis and prognosis. 

Over the past 15 years we treated 5 patients with ES pNET 

with a primary in the ileocecal region. Interestingly, all cases 

presented a similar clinical presentation and identical morphologic 

and immunophenotypical characterization. 

Microscopically, the 5 specimens showed a sheet-like proliferation 

of spindle-to-polygonal cells with large vesicular 

nuclei with thin vascular stroma. Focally, the tumor formed 

ribbon-like or rosette structures, with moderate mitosis (10/50 

high-power field). Moreover, neither invasive growth nor 

metastasis to lymph nodes was identified. 

Prior to IHC, all cases were identified as poorly differentiated 

epithelial neoplasm. In order to define the proper histotype a 

series of antibodies, summarized in table 1, were utilized for 

IHC. All five cases presented an identical IHC pattern: a) focal 

positivity for the cytokeratin (CK) AE1/AE3, CAM 5.2, 

synaptophisin (SYN), and chromogranin A (CgA); b) strongly 

diffuse positivity for CD 117,vimentin,CD 99, FlI-1; c) negative 

for epithelial membrane antigen (EMA), S100, leucocyte 

common antigen (LCA), CD 34, smooth muscle actine 

(SMA), carcinoembryonic antigen (CEA), desmin and WT-1 

(C19 and C180). Proliferative index of neoplasia valued with 

MIB-1/Ki-67 immunostaining was about 30%. 

A molecular and molecular cytogenetics analysis, such as RT- 

PCR, FISH, and SKY were performed as complementary tests 

to IHC to better characterize the histotype. 

In details no KIT mutations were found in any of the 5 cases, 

therefore excluding the possibility of being a GIST. On the 

other hand, FISH confirmed rearrangemnts of EWS for all 

five cases, confirming the dignosis of a pNET. 

Presentazione gruppo di studio GIPE 

C. Capella 

Paper not received

RElaziONi 

Infezioni batteriche e linfomi extranodali 

M. Ponzoni 

U.O Anatomia Patologica, Area Diagnostica di Emopatologia, Istituto 

Scientifico Ospedale San Raffaele, Milano 

Il rapporto tra agenti infettivi e sviluppo di processi linfoproliferativi, 

tradizionalmente rappresentato dai virus, si è 

arricchito negli ultimi 25-30 anni grazie al contributo offerto 

dai batteri. Tale legame è particolarmente evidente per le forme 

extranodali a basso grado, soprattutto a istotipo MALT. 

Al di là del ruolo storicamente rappresentato dal rapporto 

patogenetico tra infezione da Helicobacter pylori e il linfoma 

di tipo MALT gastrico, altri agenti infettivi di tipo batterico 

sono stati variabilmente associati ad altri tipi di linfomi, con 

livelli differenti di evidenza di tale associazione. Nel corso 

della presentazione verrà effettuata un’analisi critica dei vari 

agenti proposti e delle più recenti acquisizioni sul piano 

patogenetico-terapeutico in tale ambito. 

Pleuropulmonary lymphoproliferative diseases 

M. Chilosi 


Pulmonary presentations of lymphoproliferative diseases are 

rare, accounting for less than 4% of lymphomas primarily 

involving extranodal sites, and can occur in three different 

ways: First, as primary lymphomas arising within the lung parenchyma; 

second, as secondary spreads from the circulation; 

third, as secondary site of involvement from neighbouring 

sites (e.g. from mediastinal lymph nodes or thymus). These 

three presentations have different diagnostic, prognostic and 

therapeutic implications 1 2 . Precise pathologic diagnosis and 

molecular characterisation is required in all cases, following 

W.H.O. classification criteria. Radiologic features include 

pulmonary consolidation, solid pulmonary opacities, hilar 

adenopathy or pleural effusion. Principles of treatment vary 

with the different histology. 

Three broad categories of lymphoma of the lung require recognition: 

the most common histologic subtype is represented 

by low grade mucosa-associated lymphoid tissue (MALT) 

lymphoma, often in the past considered as a pseudotumour 

because of its long indolent natural history. In primary pulmonary 

MALT lymphomas, cytogenetic abnormalities are 

common (75%) and heterogeneous, encompassing API2- 

MALT1 and IGH-MALT1, which are mutually exclusive [3,4]. 

Morphologically, lymphoma cells are similar to normal marginal-zone 

cells, exhibiting a spectrum of cytological features 

(small-round cells, centrocyte-like cells, monocytoid cells), 

characterised by small and irregular nuclei, inconspicuous nucleoli, 

and abundant clear cytoplasm. Neoplastic lymphocytes 

typically accumulate around non-neoplastic lymphoid follicles, 

forming poorly defined sheets of cells at the periphery 

of the mantle zones, extending into the lung parenchyma. The 

presence of reactive follicles, that can be particularly abun- 

Venerdi, 26 ottobre 2012 

Sala Michelangelo – 10.30-12.30 

Linfomi extranodali problematiche diagnositche 

Moderatori: Simonetta Di Lollo (Firenze), Fabio Facchetti (Vicenza) 

235 

dant and are presumably pre-existing the lymphoma development, 

can pose diagnostic problems at morphological and also 

immunophenotypical analysis. In rare instances, large B-cell 

lymphoma can present primarily in the lung, often associated 

to low-grade MALT lymphoma. A variety of uncommon 

primary lymphomas include lymphomatoid granulomatosis, 

nasal-type T-cell lymphoma, intravascular B-cell lymphomas, 

anaplastic CD30+ large cell lymphoma, classic-type Hodgkin’s 

lymphoma, and others. 

Lymphomatoid granulomatosis (LYG)[5]. This term defines 

an angiocentric and angiodestructive lymphoproliferative 

disease involving extranodal sites. The term LYG includes 

a group of related lesions characterised by the infiltration of 

pulmonary parenchyma by an heterogeneous cell population 

composed of a large number of T-lymphocytes, a variable 

proportion of large EBV-infected B-cells, (as defined by 

expression of B-cell related antigens CD20 and CD79a, 

and EBV markers such as LMP-1 and EBER). LYG lesions 

are heterogeneous, and have been graded depending on the 

proportion of neoplastic B cells, the degree of lymphocytic 

atypia, and the heterogeneity of the infiltrate, distinguishing 

three grades characterised by varying proliferation index and 

prognostic differences. The grade 3 forms can be considered 

as diffuse large B-cell lymphomas, with features of T-cell rich 

DLBCL. LYG needs to be distinguished from other diseases 

characterised by zonal necrosis and prominent angioinvasion, 

including extranodal NK/T (nasal-type) T-cell lymphoma, and 

Wegener’s granulomatosis. 

Nasal-type T/NK lymphomas when occurring in the lung can 

present many similarities with LYG, including angioinvasion, 

expression of markers of EBV infection, necrosis, immune 

disturbances and a rich T-cell infiltrate exhibiting cytotoxic 

immunophenotype, as defined by the expression of CD8, TIA- 

1, granzyme-B, and perforin [6]. 

Hodgkin’s lymphoma (HL). Primary pulmonary HL is a rare, 

but distinct disease, involving the upper lobes and presenting 

as a solitary mass, as multinodular, or more rarely as endobronchial. 

The involvement of mediastinal lymph nodes must 

be excluded to define the lymphoma as truly primary. The 

differential diagnosis includes a variety of lung diseases, and 

a surgical biopsy is needed. Neoplastic nodules are formed by 

an heterogeneous cell population, including many inflammatory 

cells (macrophages, T lymphocytes, granulocytes) and 

isolated atypical cells characterised by the cytological features 

and immunophenotype of Reed-Sternberg/Hodgkin’s cells. 

Various modifications can be observed in the parenchyma 

adjacent to the neoplastic nodules of Hodgkin’s lymphoma, 

including focal organising pneumonia, endoalveolar accumulations 

of foamy macrophages and interstitial lymphoid 

infiltration. 

Secondary lymphomas. Secondary lung localization by lymphomas 

occurs with relative frequency (up to 20.5% at autopsy), 

with different patterns of infiltration (peribronchial/ 

perivascular, nodular, alveolar, interstitial, pleural, endobronchial). 

The lymphangitic pattern is frequent in B-cell lympho-

236 

mas and leukemias, whereas the nodular and interstitial patterns 

are mainly observed in Hodgkin’s lymphoma and T-cell 

lymphomas respectively. 

references 

1 Addis BJ, Hyjek E, Isaacson PG. Primary pulmonary lymphoma: a reappraisal 

of its histogenesis and its relationship to pseudolymphoma 

and lymphoid interstitial pneumonia. Histopathology 1988;13:1-17. 

2 Chilosi M, Zinzani PL, Poletti V. Lymphoproliferative lung disorders. 

Semin Respir Crit Care Med 2005;26:490-501. 

3 Kurtin PJ, Myers JL, Adlakha H, et al. Pathologic and clinical features 

of primary pulmonary extranodal marginal zone B-cell lymphoma of 

MALT type. Am J Surg Pathol 2001;25:997-1008. 

4 Remstein ED, Kurtin PJ, Einerson RR, et al. Primary pulmonary 

MALT lymphomas show frequent and heterogeneous cytogenetic abnormalities, 

including aneuploidy and translocations involving API2 

and MALT1 and IGH and MALT1. Leukemia 2004;18:156-60. 

5 Guinee D Jr, Jaffe E, Kingma D, et al. Pulmonary lymphomatoid granulomatosis. 

Evidence for a proliferation of Epstein-Barr virus infected 

B-lymphocytes with a prominent T-cell component and vasculitis. Am 

J Surg Pathol 1994;18:753-64. 

6 Kanavaros P, De Bruin PC, Briere J, et al. Epstein-Barr virus (EBV) in 

extranodal T-cell non-Hodgkin’s lymphomas (T-NHL). Identification 

of nasal T-NHL as a distinct clinicopathological entity associated with 

EBV. Leuk Lymphoma 1995;18:27-34. 

Processi linfoproliferativi del tratto gastroenterico 

S. Uccella 

Università dell’Insubria, Dipartimento di Scienze Cliniche e Morfologiche, 

Unità di Anatomia Patologica, Varese 

La localizzazione dei processi linfoproliferativi nel tratto 

gastrointestinale (TGI) è un evento frequente e, di converso, 

il tubo digerente costituisce la sede primitiva maggiormente 

interessata dall’insorgenza di linfomi extranodali. Tutte le categorie 

di linfomi che insorgono negli organi linfoidi primitivi 

possono essere ritrovate in sede gastrointestinale. Si tratta, in 

prevalenza, di linfomi non-Hodgkin a cellule B e, in analogia 

con quanto accade per i linfomi nodali, il linfoma diffuso a 

grandi cellule B (LDGCB) rappresenta l’istotipo più frequente. 

Tuttavia nel TGI si osservano anche due tipi di linfomi 

peculiari, la cui patogenesi appare strettamente correlata con 

eventi sede-specifici: il linfoma della zona marginale extranodale 

tipo MALT, che include anche la malattia immunoproliferativa 

del piccolo intestino (IPSID) e il linfoma a cellule 

T enteropatia-associato (EATL). Il TGI è, inoltre, una sede 

frequente di insorgenza delle malattie linfoproliferative posttrapianto. 

Nell’ambito del TGI, il linfomi insorgono con una 

maggiore frequenza nello stomaco (60%-75%), seguito dal 

piccolo (20%-30%) e, infine, dal grosso intestino (6%-12%). 

I linfomi del TGI possono costituire un problema diagnostico 

a causa della aspecificità della presentazione clinica e del tipo 

di materiale esaminabile al microscopio, spesso costituito 

da piccole biopsie con artefatti da prelievo. Con l’eccezione 

delle neoplasie a grandi cellule B o T, che non costituiscono 

una difficoltà per il patologo, i linfomi del TGI necessitano 

frequentemente di un approccio diagnostico integrato, con 

l’impiego di metodiche immunoistochimiche, citofluorimetriche, 

biomolecolari e di citogenetica, senza mai dimenticare un 

completo inquadramento clinico del paziente. 

Saranno qui discussi i caratteri distintivi e le principali problematiche 

diagnostiche relativi alle malattie linfoproliferative 

più frequentemente osservate nel TGI. 

Il linfoma della zona marginale extranodale tipo MALT (linfoma 

MALT gastrico e IPSID) 

La maggiore incidenza di linfomi MALT nello stomaco 


rispetto alle altre sedi del TGI è correlata all’infezione da 

parte di Helicobacter pylori, che sembra essere critica per 

la linfomagenesi e la cui eradicazione porta alla regressione 

della neoplasia in una elevata quota di casi in stadio iniziale. 

I criteri morfologici per la diagnosi del linfoma MALT gastrico 

sono ben definiti e risiedono nel riconoscimento di una 

popolazione neoplastica polimorfa costituita da cellule B della 

zona marginale, di dimensioni e aspetto variabile (elementi 

centrocito-simili, monocitoidi, plasmocitoidi, fino a vere e 

proprie plasmacellule, rari centroblasti). Le cellule neoplastiche 

tendono ad invadere la lamina propria e il compartimento 

epiteliale (formando le caratteristiche lesioni linfoepiteliali) e 

a colonizzare i follicoli linfoidi reattivi. La diagnosi differenziale 

con altri linfomi a basso grado si basa, quando necessario, 

sulla valutazione immunoistochimica. 

Le principali problematiche che emergono nella diagnostica 

istopatologica dei linfomi MALT gastrici sono la diagnosi 

differenziale con gli infiltrati linfoidi reattivi, la valutazione 

della componente a cellule grandi eventualmente presente e, 

infine, la gestione della malattia residua. 

La malattia immunoproliferativa del piccolo intestino (IPSID), 

anche conosciuta come malattia delle catene alfa, è un linfoma 

raro, MALT-associato, probabilmente correlato all’infezione 

da Campylobacter jejuni. Caratteristica di questo linfoma è la 

secrezione di immunoglobuline monotipiche e tronche, costituite 

solo da catene pesanti alfa, osservabili come paraproteina 

nel siero. Questa malattia colpisce prevalentemente i bambini 

e i giovani adulti in aree geografiche definite: il bacino 

mediterraneo, l’Africa, il Medio Oriente e l’Asia orientale. I 

sintomi clinici sono la diarrea e i dolori addominali associati 

a malassorbimento e protidodispersione. Dal punto di vista 

istopatologico questo linfoma può presentarsi con uno spettro 

morfologico che va da un linfoma a basso grado tipo MALT 

a un linfoma ad alto grado tipo LDGCB. In analogia con i 

linfomi MALT gastrici, gli stadi iniziali di questa malattia 

regrediscono in seguito alla terapia antimicrobica. 

Il linfoma a cellule T enteropatia-associato (EATL). 

La classificazione WHO riconosce due forme di EATL, tipo 

I e tipo II, quest’ultima detta anche variante monomorfa. Entrambe 

risultano associate alla malattia celiaca, benché il tipo 

II possa insorgere anche comeforma sporadica. Il quadro istologico 

è variabile, ma il più delle volte è dominato da cellule 

di grandi dimensioni con nuclei pleomorfi e talvolta multipli 

o anaplastici. La variante monomorfa (tipo II) è costituita da 

cellule di aspetto uniforme, poco più grandi di un linfocito, 

con nuclei lievemente irregolari, piccoli nucleoli e una rima di 

citoplasma chiaro. Le cellule neoplastiche mostrano frequentemente 

epiteliotropismo. 

La mucosa intestinale perineoplastica mostra segni di atrofia villare, 

iperplasia delle cripte, aumento delle cellule infiammatorie 

nella lamina propria e infiltrato linfocitario intraepiteliale. Nel 

tipo I queste alterazioni, riconducibili alla malattia celiaca, sono 

osservabili in tutti i tratti del piccolo intestino, con uno spettro 

di gravità, mentre nel tipo II esse possono essere circoscritte 

alla sede del linfoma. Nelle forme di EATL associate a malattia 

celiaca refrattaria, i linfociti intraepiteliali presenti nella mucosa 

non neoplastica hanno anomalie immunofenotipiche e citogenetiche, 

sono monoclonali e possono essere quindi interpretati 

come parte del clone neoplastico. D’altro canto, in soggetti con 

malattia celiaca refrattaria non affetti da EATL, è stato dimostrato 

che i linfociti T intraepiteliali mostrano un riarrangiamento 

monoclonale del TCR e che un identico riarrangiamento è presente 

nei linfomi insorti durante il follow up. Si ipotizza quindi 

l’esistenza di un EATL in situ o “criptico”, il che implica la 

necessità di seguire nel tempo i pazienti con malattia celiaca re-

RElaziONi 

frattaria con monitoraggio dell’immunofenotipo e della clonalità 

dei linfociti T intraepiteliali. 

La diagnosi differenziale del EATL include altri linfomi a 

grandi cellule, i linfomi a cellule T periferiche e, per quanto 

riguarda il tipo II, frequentemente CD56 e CD8-positivo, anche 

le proliferazioni a cellule NK. 

I linfomi diffusi a grandi cellule B gastrointestinali (LDGCB-GI) 

La maggior parte dei linfomi gastrointestinali, indipendentemente 

dalla sede di insorgenza, sono LDGCB. Una questione 

controversa riguardo i LDGCB-GI è costituita dalla relazione 

di queste neoplasie con i linfomi MALT. La presenza di una 

componente di linfoma MALT è osservabile in una quota di 

casi e testimonia la possibilità di una trasformazione da una 

forma a basso grado a una ad alto grado. È comunque da 

postulare anche una origine de novo dei LDGCB, in analogia 

con quanto accade nelle sedi nodali. Recentemente, è stato 

dimostrato che anche i LDGCB insorti de novo rispondono al 

trattamento anti-Helicobacter. Un altro punto importante, che 

non è ancora del tutto chiarito, riguarda eventuali differenze 

biologiche e anatomocliniche tra i LDGCB-GI e quelli nodali 

e tra le forme insorte nei diversi segmenti del TGI. 

I linfomi B a piccole cellule non-MALT del TGI 

Il linfoma a cellule mantellari (LCM) ed il linfoma follicolare 

(LF) possono presentasi con una certa frequenza nel TGI, sia 

sotto forma di localizzazione di una malattia sistemica, sia, 

più raramente, come malattia primitiva. Entrambi possono 

presentarsi sotto forma di plurime lesioni polipoidi (poliposi 

linfomatoide). Il LF tende a localizzarsi elettivamente nel 

piccolo intestino, mentre il LCM ha una predilezione per il 

grosso intestino e il retto. La diagnosi di queste forme si basa 

sui criteri morfologici, immunofenotipici e genetici utilizzati 

per queste entità nelle sedi nodali. La prognosi del LF primitivo 

del TGI sembra essere migliore rispetto a quella delle 

forme nodali, mentre il LCM mantiene, anche quando insorge 

primitivamente in questa sede, un prognosi infausta. 

I linfomi gastrointestinali nei pazienti immunosoppressi 

I linfomi che insorgono nei pazienti immunosoppressi sono 

estremamente eterogenei, ma condividono alcune caratteristiche 

come la frequente presentazione in sede extranodale, 

la morfologia ad alto grado, la derivazione dalle cellule della 

linea B, l’associazione con l’infezione da EBV e il decorso 

clinico aggressivo. Mentre sono molto rari i linfomi del TGI 

associati ad immunodeficienze congenite, nella malattia linfoproliferativa 

post-trapianto (PTLD) il TGI sembra essere 

una delle sedi più frequentemente colpite. Per quanto riguarda 

i pazienti con AIDS, la frequenza dei linfomi del TGI, molto 

elevata in passato, si è ridotta drasticamente in seguito all’introduzione 

delle terapie anti-retrovirali (HAART). Nel TGI è 

possibile osservare tutto lo spettro della PTLD. 

Bibliografia 

Burke JS. Lymphoproliferative Disorders of the Gastrointestinal Tract 

A Review and Pragmatic Guide to Diagnosis. Arch Pathol Lab Med 

2011;135:1283-97. 

Ferreri AJM, Freschi M, Dell’Oro S, et al. Prognostic Significance of the 

histopathologic recognition of low- and high-grade components in stage 

I-II B-cell gastric lymphomas. Am J Surg Pathol 2001;25:95-102. 

Heise W. GI-lymphomas in immunosuppressed patients (organ transplantation; 

HIV). Best Pract Res Clin Gastroenterol 2010;24:57-69. 

Isaacson PG, Du M-Q. Gastrointestinal lymphoma: where morphology 

meets molecular biology. J Pathol 2005;205:255-74. 

Ko YH, Karnan S, Kim KM, et al. Enteropathy-associated T-cell lymphoma—a 

clinicopathologic and array comparative genomic hybridization 

study. Hum Pathol 2010;41:1231-7. 

Kodama T, Ohshima K, Nomura K, et al. Lymphomatous polyposis of 

the gastrointestinal tract, including mantle cell lymphoma, follicular 

lymphoma and mucosa-associated lymphoid tissue lymphoma. Histopathology 

2005;47:467-78. 

237 

Kuo SH, Yeh KH, Wu MS, et al. Helicobacter pylori eradication therapy 

is effective in the treatment of early-stage H pylori-positive gastric 

diffuse large B-cell lymphomas. Blood 2012;119:4838-44. 

Lecuit M, Abachin E, Matin A, et al. Immunoproliferative small intestinal 

disease associated with Campylobacter jejuni. N Engl J Med 

2004;350:239-48. 

Mansoor A, Pittaluga S, Beck PL, et al. NK-cell enteropathy: a benign 

NK-cell lymphoproliferative disease mimicking intestinal lymphomaclinicopathological 

features and follow-up in a unique case series. 

Blood 2011;117:1447-52. 

Stathis A, Chini C, Bertoni F, et al. Long-term outcome following Helicobacter 

pylori eradication in a retrospective study of 105 patients with 

localized gastric marginal zone B-cell lymphoma of MALT type. Ann 

Oncol 2009;20:1086-93. 

Swerdlow SH, Campo E, Harris NL, et al, eds. Haematopoietic and Lymphoid 

Tissues. Lyon, France: IARC Press 2008, pp. 214-17. World 

Health Organization Classification of Tumours. 4th ed 

Takeuchi K, Yokoyama M, Ishizawa S, et al. Lymphomatoid gastropathy: 

a distinct clinicopathologic entity of self-limited pseudomalignant NKcell 

proliferation. Blood 2010;116:5631-7. 

Tibiletti MG, Milani K, Martin V, et al.; International Extranodal Lymphoma 

Study Group (IELSG). Chromosome instability and translocation 

t(11;18) in primary gastric marginal zone B-cell lymphoma of 

MALT-type. Hematol Oncol 2007;25:184-8. 

Processi linfoproliferativi intravascolari 

F. Facchetti 


The metastatic phenomenon: insights into 

biology and therapy 

M.C. Mihm 

Brigham and Women’s Hospital, Havard Medical School Boston, MA 

In 1889, the hypothesis of the “seed and soil” was first described 

by Dr. Stephen Paget. He designated the “seed” as the 

tumor cell and the “soil” as the receptive site for the tumor to 

grow and result in a successful metastasis. In this presentation 

we will amplify upon this concept as it applies to melanoma as 

well as other malignant tumors and emphasize the changes in 

the primary tumor necessary to lead to the metastatic phenomenon. 

We will further elaborate on the stromal contribution 

to the metastatic phenomenon. This will include the concept 

of “cancer associated fibroblasts” and their role in metastatic 

development and prognosis. 

The “soil” will be described and special emphasis will be 

placed on the concept of the metastatic niche. Thus, the 

formation of this niche is crucial to the concept of the metastasis. 

The cells and stroma that comprise the niche will be 

discussed, as well as the events that transpire as the tumor 

enters the niche. The establishment of the niche appears to 

be under control of the primary tumor. The importance of the 

type of primary and the organ in which the niche occurs will 

be elucidated. Various experimental approaches in rodents 

will be presented. The extrinsic factors that likewise affect the 

changes in the primary and the metastasis will be discussed. 

One of the purposes of our understanding the metastatic process 

is to find targets or sites as well as specific antagonists of 

these targets that my help to block the metastatic process. It is 

clear in animal experiments that the metastatic phenomenon 

can be blocked, for example, by antibodies directed at specific 

crucial targets in the cascade. Thus, the process of metastasis 

from very beginning with changes in the primary tumor to the 

final site of tumor deposit and resultant tumor growth will be 

reviewed.

238 

Patobiologia della parete aortica 

e inquadramento nosologico 

A. Angelini 

Patologia Cardiovascolare, Università di Padova, Padova 

L’aorta è una arteria elastica,che come tutte le arterie del nostro 

corpo, è composta da tre tonache: l’intima, media e avventizia. 

L’intima comprende un singolo strato di cellule endoteliali, adagiate 

su tessuto connettivo lasso. La membrana elastica interna 

la separa dalla tonaca media che è costituita da cellule muscolari 

lisce immerse in una matrice fibrillare densa composta di 

proteine strutturali; la membrana elastica esterna la separa a sua 

volta dall’avventizia che contiene fibroblasti e fibre collagene. 

La tonaca media è caratterizzata da unità lamellari morfofunzionali 

che conferiscono viscoelasticità alla parete e sono 

composte da strati concentrici di filamenti di fibre collagene 

ed elastiche con interposte a sandwich cellule muscolari lisce. 

Le unità lamellari esercitano una azione di tensione e proprietà 

elastiche di recoil, permettendo all’aorta di sopportare 

pressioni elevate e di ritornare al suo diametro iniziale durante 

la diastole. 

I segmenti aortici contengono un diverso numero di unità 

lamellari in ordine decrescente dall’aorta toracica a quella 

addominale: l’aorta toracica contiene 55-60 unità lamellare 

divise in zone avascolarizzate e vascolarizzate, mentre l’aorta 

addominale ne contiene in genere 28-32e non è vascolarizzata. 

Le prime 28-30 unità lamellari dalla superficie endoluminare 

che sono avascolarizzate, ricevono apporto di ossigeno 

e sostanze nutritizie per diffusione trans-intimale dal lume. 

All’aumentare del loro numero i vasa vasorum dall’avventizia 

penetrano verso l’interno della parete determinando una zona 

vascolarizzata (1/3 esterno) 1,2 . 

Esiste una grande eterogeneità dei vari segmenti aortici che si 

manifesta con una diversa suscettibilità alla sviluppo dell’ateroscelrosi, 

con diverse proprietà meccaniche, proteolitiche e 

cellulari che danno ragione dei peculiari aspetti del rimodellamento 

vascolare 3-6 . 

Durante la crescita, la tonaca media si rimodella in modo 

diverso sopra e sotto il diaframma, aumentando di spessore 

con modalità diverse in aorta toracica ed addominale. In aorta 

toracica, che ha un maggiore contenuto di elastina, vengono 

sintetizzate nuove unità lamellari, mentre nell’aorta addominale 

l’aumento di spessore avviene mediante un ampliamento 

di ogni unità già esistenti alla nascita 7 . Entrambi questi meccanismi 

di crescita, tuttavia, contribuiscono a mantenere un 

rapporto costante tra diametro medio aortico e spessore della 

parete, influenzando sia lo stress che la tensione parietale per 

unità lamellare. Le forze meccaniche possono alterare l’attività 

trascrizionale delle cellule muscolari lisce influenzando sia 

la struttura della matrice, sia la sopravvivenza delle cellule 8 . 

La parete aortica è una struttura dinamica e finemente regolata 

che svolge sofisticate funzioni in particolare ambiente emodinamico, 

accanto alla funzione base di servire come condotto 




Cardiopatologia 

L’aorta e il patologo 

Moderatori: Gilda Caruso (Bari), Pietro Gallo (Roma) 

che veicola il sangue dal ventricolo sinistro in periferia. La 

regolazione dell’omeostasi parietale comprende meccanismi 

attivi e interazioni tra le sue principali componenti strutturali 

e specifiche vie di regolazione. In termini emodinamici la distensibilità 

aortica viene descritta come un cambiamento nel 

raggio aortico prodotto da un aumento di pressione, mentre 

per rigidità o resistenza alla deformazione si intende la mancanza 

di distensibilità. 

Aumentando la rigidità (stiffness) si assiste ad un aumento 

del carico di lavoro del ventricolo. Al contrario, le proprietà 

contrattili intrinseche, in associazione con la capacità di recoil 

elastico della aorta ascendente ottimizzano la forma e la propagazione 

dell’onda di flusso attraverso l’albero vascolare, un 

importante determinante dell’efficienza e della distribuzione 

del flusso ematico. Una attiva regolazione della forma e della 

dimensione dell’aorta ha anche un effetto diretto sul volume 

di sangue e sulla pressione. 

Componenti strutturali dell’aorta 

Cellule muscolari lisce 

Le cellule muscolari lisce non sono cellule terminalmente 

differenziate, ma posseggono proprietà contrattili e secretive 

e possono alternare stati di quiescenza, di attività contrattile 

o proliferativa. La contrazione delle cellule muscolari lisce 

dipende dall’interazione tra alfa actina muscolare liscia e catena 

pesante della miosina. Il Complesso acto-miosinico nel 

citoplasma è direttamente ancorato alla membrana cellulare 

attraverso proteine di ancoraggio come la talina, la vinculina, 

l’alfa-actinina e il filamento a. La contrazione cellulare perciò 

determina cambiamenti di forma, migrazione e allineamento, 

importanti elementi nell’omeostasi della parete aortica. In aggiunta 

alle loro proprietà contrattili, le cellule muscolari lisce 

posseggono importanti proprietà secretorie che garantiscono 

la sintesi e la sostituzione/riparazione di varie componenti 

della matrice che regolano la struttura della parete vascolare 

(collagene, elastina, fibrillino, fibulina). Queste proprietà sintetiche 

rispondono a stimoli biochimici come TGF beta1, o a 

stimoli meccanici come lo strain cellulare. Molto importante 

le cellule muscolari lisce possono interagire direttamente con 

differenti componenti della matrice cellulare attraverso recettori 

(integrine, g-protein coupled recettori e recettori della 

famiglia del discoidin domine). L’interazione tra cellula e 

matrice extracellulare regola la funzione della parete aortica. 

Le cellule muscolari lisce della parete possono trasformare 

stimoli meccanici in risposte biologiche(mechano trasduttori) 

che portano ad una risposta intracellulare(riarrangiamento 

del citoscheletro e allineamento delle fibre da stress) e 

cambiamenti extracellulari (sintesi, allineamento e riparazione 

di particolari componenti extracellulari) che a loro 

volta possono essere trasmessi direttamente alle cellule 

attraverso un complesso biomolecolare costituito da Citoscheletro 

della cellula muscolare liscia-Recettori-Matrice 

extracellulare L’alterazioni di uno di questi elementi del

RElaziONi 

complesso può determinare un’alterazione nell’omeostasi 

parietale e risultare in cambiamenti nella struttura e nelle 

proprietà meccaniche dell’aorta con il risultato di disarray 

delle cellule muscolari lisce e frammentazione dell’elastina 

9 10 . Sono state identificate varie mutazioni genetiche a 

carico del complesso cellula-recettori-matrice che portano 

allo sviluppo degli aneurismi: Gene FBN1, che codifica per 

la fibrillino 1 (nella sindrome di marfan); il gene COL3A1, 

che codifica per il collagene III (Erlens_Danslos) il gene 

ACTA2, che codifica per l’actina (TAA)e il gene MYH11 

che codifica per la Beta-miosina (TAA e dotto arterioso). 

La regolazione dell’espressione genica delle cellule muscolari 

lisce dell’aorta attraverso citokine e fattori di crescita 

viene considerato un determinante maggiore nella crescita 

degli aneurismi. Le citochine sono mediatori intercellulari 

che determinano la risposta immunologica a stimoli diversi, 

e una sottofamiglia le chemokine, specificamente agiscono 

come potenti fattori di chemiotassi ed attivazione dei leucociti. 

Il TGFBeta, un peptide della crescita che fa parte di una grande 

famiglia di messaggeri implicati in numerose vie di segnale 

cellulare che regolano angiogenesi, apoptosi e fibrosi, mantiene 

la normale morfologia dei vasi attraverso la stimolazione 

di prodotti della matrice e attraverso l’inibizione di mediatori 

dell’infiammazione. 

Collagene 

Il collagene di tipo I e III rappresentano i tipi di collagene 

maggiormente rappresentati nella parete aortica e ne garantiscono 

la tensione e la rigidità. Il collagene di tipo IV costituisce 

invece la membrana elastica interna sulla quale sono 

adese le cellule endoteliali. Oltre a tale attività meccanica 

il collagene svolge un ruolo funzionale di attivazione della 

cascata intracellulare che detrmina l’adesione tra cellule e 

cellule e la proliferazione cellulare attraverso il legame ai 

recettori di superficie delle cellule. Il collagene agisce anche 

come reservoir per fattori solubili come IL-2. Alterazioni dei 

geni che codificano per le fibre collagene possono pertanto 

favorire lo sviluppo degli aneurismi. 

Elastina 

L’elastina è la più importante proteina della matrice extracellulare 

che costituisce circa 50% del contenuto secco dell’aorta 

toracica. L’elastina è sintetizzata dalle cellule muscolari lisce 

della media in risposta a stimoli meccanici come la distensione 

o la pressione, e conferisce distensibilità e il recoil. Accanto 

a queste proprietà meccaniche l’elastina svolge un ruolo 

attivo di regolazione della componente cellulare della parete 

aortica. Può interagire con le cellule muscolari lisce attraverso 

i recettori delle integrine e le proteine che legano l’elastina 

per modulare l’organizzazione dell’actina del citoscheletro ed 

inibire la proliferazione e la migrazione cellulare. 

Fibrillina 

Accanto all’elastina e al collagene, le microfibrille della matrice 

comprendono un insieme di proteine come la fibrillina 

e la fibulina. La fibrillino 1 e 2, sono codificate da geni sul 

cromosoma 15 e 5, sono due isoforme molto ben caratterizzate. 

La fibrillino 1 è una componente strutturale maggiore che 

contribuisce alla resistenza della parete e forma un lattice che 

circonda le fibre elastiche. La fibrillino 1 sequestra e regola 

l’attività del fattore di crescita ed altre proteine della matrice 

come il TGFbeta1 e BMP. La fibrillina 1 può anche attivare 

direttamente la via del segnale intracellulare attraverso il legame 

ai recettori dell’integrina. 

Fibulina 

La fibulina agisce come regolatore metabolico della matrice. 

La fibulina 5 agisce come supporto per il deposito delle fibre 

239 

elastiche nella matrice ed ha un ruolo fondamentale nella 

formazione delle unità lamellari attraverso la connessione tra 

elastina e le cellule muscolari lisce. 

Metalloproteinasi 

Le metallo proteinasi con i loro inibitori tissutali giocano un 

ruolo fondamentale nell’omeostasi parietale e nello sviluppo 

degli aneurismi. Le metallo proteinasi sono divise in sottoclassi 

in base al substrato di degradazione, gelatinasi, elastasi, 

collagenasi. Le metallo proteinasi 2 e 9, che appartengono al 

gruppo delle gelatinasi, degradano fibrille collagene denaturate, 

l’elastina ed il collagene di tipo IV, V, e VI insieme 

ad altre componenti della matrice extracellulare. La metallo 

proteinasi 2 o gelatinasi A, è costitutivamente espressa dalle 

cellule muscolari lisce della media ed è in grado di degradare 

collagene interstiziale, clivando il collagene di tipo I che costituisce 

circa il 60% del contenuto di collagene dell’aorta. La 

metallo proteinasi 9, o gelatinasi B,è prodotta dai macrofagi, 

fibroblasti o cellule muscolari lisce con fenotipo sintetico. 

Una diversa eterogeneità regionale si osserva nella produzione 

di metallo proteinasi. L’invecchiamento si associa ad elevati 

livelli di metallo proteinasi 2 nell’aorta toracica. Un maggior 

contenuto di gelatinasi A o metallo proteinasi 2 sarebbe 

evidenziato nel segmento addominale prono allo sviluppo di 

aneurismi. La metallo proteinasi 9 o gelatinasi B al contrario 

ha dimostrato di giocare un ruolo fondamentale nello sviluppo 

di aneurismi toracici. Nell’aorta normale cellule muscolari 

lisce, fibroblasti e miofibroblasti non producono metalloproteinasi 

9 e alterazioni di segnale tra cellula-cellula e cellula 

–matrice determina una modifica nell’attività trascrizionale e 

nella sua produzione. Elevati livelli di metallo proteinasi sono 

ripetutamente documentati negli aneurismi addominali e considerati 

di origine dai macrofagi che infiltrano l’avventizia. Le 

cellule muscolari lisce dell’aorta esprimono costitutivamente 

gli inibitori tissutali delle metallo proteinasi 1 e 2 e quest’ultimo 

è stato dimostrato inibire molte metallo proteinasi, in 

particolare la metallo proteinasi 9. Tuttavia la funzione degli 

inibitori delle metallo proteinasi è più complessa ed oltre ad 

inibire sia la metallo proteinasi 2 che la 9, l’inibitore 2 agisce 

anche come complesso di attivazione delle metalloproteinasi2. 

La relazione tra metallo proteinasi e inibitori determina il 

turnover della matrice nel tessuto normale e la degradazione 

associata alla formazione degli aneurismi può essere determinata 

dal prevalere della proteolisi. 

Bibliografia 

1 Wolinsky H, Glagov S. Comparison of abdominal and thoracic aortic 

medial structure in mammals. Deviation of man from the usual pattern. 

Circ Res 1969;25:677-86. 

2 Wolinsky H. Comparison of medial growth of human thoracic and 

abdominal aortas. Circ Res 1970;27:531-8. 

3 El-Hamamsy I, Yacoub MH. Cellular and molecular mechanisms of 

thoracic aortic aneurysms. Nat Rev Cardiol 2009;6:771-86. 

4 Ruddy JM, Jones JA, Spinale FG, et al. Regional heterogeneity within 

the aorta: relevance to aneurysm disease. J Thorac Cardiovasc Surg 

2008;136:1123-30. 

5 Halloran BG, Davis VA, McManus BM, et al. Localization of aortic 

disease is associated with intrinsic differences in aortic structure. J 

Surg Res 1995;59:17-22. 

6 Halloran BG, Baxter BT. Pathogenesis of aneurysms. Semin Vasc 

Surg 1995;8:85-92. 

7 Kim BS, Nikolovski J, Bonadio J, et al. Cyclic mechanical strain 

regulates the development of engineered smooth muscle tissue. Nat 

Biotechnol 1999;17:979-83. 

8 Maniotis AJ, Chen CS, Ingber DE. Demonstration of mechanical 

connections between integrins, cytoskeletal filaments, and nucleoplasm 

that stabilize nuclear structure. Proc Natl Acad Sci U S A. 

1997;94:849-54. 

9 Berrier AL, Yamada KM. Cell-matrix adhesion. J Cell Physiol 

2007;213:565-73.

240 

10 Luo BH, Carman CV, Springer TA. Structural basis of integrin regulation 

and signaling. Annu Rev Immunol. 2007;25:619-47. Review. 

PubMed PMID: 17201681; PubMed Central PMCID: PMC1952532. 

Inquadramento nosografico delle aortopatie 

Le aortopatie comprendono un vasto gruppo di patologie a 

carico dell’aorta che talora presentano quadri anatomopatologici 

che possono sovrapporsi e rendere più complessa la loro 

diagnosi. Possono essere classificate in: 

Aortiti infettive e non infettive. In tale capitolo rientra anche 

l’aneurisma infiammatorio aterosclerotico. 

Aterosclerosi aortica 

Degenerative 

Neoplastiche 

Malformative-congenite 

Possono essere acquisite o geneticamente determinate e causare 

aneurismi, dissezioni o stenosi-occlusioni. 

Criteri diagnostici istopatologici nella patologia della aorta 

Documento di consenso del Gruppo di Studio SIAPeC-IAP di 

cardiopatologia 

http://www.siapec.it/index.php?Mod=Pagina&Pagina=1338 

Aortopatia degenerativa 

C. Basso 

Università di Padova 

Con questo termine si definisce un gruppo di patologie caratterizzate 

da lesioni degenerative a carico delle componenti 

cellulare ed extracellulare della tonaca media dell’aorta, che 

tipicamente non sono secondarie a patologia infiammatoria o 

ad aterosclerosi. La manifestazione clinica più caratteristica è 

rappresentata dagli aneurismi dell’aorta toracica (più frequenti 

nel tratto ascendente), con anulo-ectasia aortica e insufficienza 

valvolare, nonché dalla dissezione aortica. 

Per decenni il concetto di patologia degenerativa si è identificato 

“tout court” con la cosiddetta “medionecrosi aortica 

idiopatica (cistica)”, termine introdotto alla fine degli anni 

’20 e riportato spesso come sindrome di Gsell-Erdheim. 

Questo termine è stato ampiamente utilizzato, e continua ad 

esserlo tuttora, per definire il substrato istopatologico delle 

lesioni degenerative della tonaca media, per quanto negli anni 

ne sia stata più volte sottolineata la scarsa appropriatezza nel 

definire e richiamare le lesioni principali. 

Il quadro istopatologico si compone di lesioni elementari 

che interessano le diverse componenti strutturali della tonaca 

media: fibre elastiche: diradamento e/o frammentazione e/o 

scomparsa delle fibre elastiche; fibre collagene: aumento 

delle fibre collagene; cellule muscolari lisce: riduzione o 

scomparsa. Una lesione particolare è la “necrosi laminare 

acellulata”, caratterizzata da perdita a banda delle cellule 

muscolari lisce, con collasso delle fibre elastiche e collagene; 

matrice extracellulare non fibrillare (mucopolisaccaridica o 

glicosaminoglicanica), accumulo di materiale mucoide all’interno 

di spazi pseudocistici di dimensioni variabili. La valutazione 

di tali lesioni elementari richiede, oltre alla colorazione 

di routine con ematossilina-eosina, altre colorazioni istomorfologiche 

per l’evidenziazione delle fibre collagene ed 

elastiche e dei mucopolisaccaridi, nonché prelievi multipli in 

sedi diverse, data la non uniforme distribuzione delle lesioni. 

Nel tentativo di fornire una valutazione non solo qualitativa 

ma anche quantitativa delle alterazioni degenerative della 

tonaca media aortica, sono stati proposti diversi sistemi di 

“grading”. Sebbene a tutt’oggi non sia riconosciuto alcun va- 


lore predittivo del sistema di “grading” dal punto di vista clinico 

e soprattutto prognostico, è opinione di questo gruppo di 

consenso che sia necessario sempre formulare una valutazione 

semiquantitativa delle lesioni istopatologiche elementari repertate, 

data l’ampia variabilità di spettro di lesioni, da minimo 

a grave danno distruttivo parietale. I sistemi di “grading” 

più noti ed utilizzati sono quelli tradizionali di Schlatmann & 

Becker e di Larson & Edwards. 

In tempi recenti, con la scoperta del locus e quindi del primo 

gene malattia della fibrillina 1 nella sindrome di Marfan, il 

paradigma della patologia degenerativa della tonaca media 

aortica come malattia “idiopatica” è definitivamente cambiato. 

Oggi infatti, da un punto di vista eziopatogenetico, la 

patologia degenerativa della tonaca media aortica deve essere 

distinta in 2 grandi categorie: l’aortopatia degenerativa sporadica 

e l’aortopatia degenerativa familiare, quest’ultima 

distinta ulteriormente in sindromica e non-sindromica. 

Le alterazioni istopatologiche di tipo degenerativo possono 

essere il risultato di: 

1. un normale processo di “aging”, con danno e riparazione 

che si verificano fisiologicamente nell’aorta; 

2. un processo accelerato e precoce in soggetti con alterate 

forze emodinamiche (es. ipertensione arteriosa, coartazione 

con danno eccessivo di parete) o in soggetti con malattie 

eredo-familiari sindromiche o non-sindromiche del tessuto 

connettivo (es. sindrome di Marfan). In quest’ultimo gruppo, 

si colloca anche la valvola aortica bicuspide, cardiopatia 

congenita che può presentarsi associata o meno a coartazione 

aortica, di cui si conosce ancora poco dal punto di vista 

genetico e per la quale solo raramente è stata riportata una 

eredo-familiarità. Tale condizione sembra accompagnarsi 

in un sottogruppo di soggetti a patologia degenerativa della 

tonaca media aortica a rischio di dilatazione e/o dissezione. 

Nelle diverse situazioni patologiche, primitive e secondarie, e 

nello stesso processo di aging, le differenze fra tali alterazioni 

istopatologiche sono di tipo quantitativo più che qualitativo. 

Gli effetti del danno parietale provocato dalle alterate forze 

emodinamiche possono sommarsi a quelli conseguenti ad un’ 

eventuale patologia congenita. 

Leone O, Agozzino L, Angelini A, Bartoloni G, Basso C, Caruso 

G, D’Amati G, Pucci A, Thiene G, Gallo P. Criteria for 

histopathologic diagnosis of aortic disease consensus statement 

from the SIAPEC-IAP study group of “cardiovascular 

pathology” in collaboration with the association for Italian 

cardiovascular pathology. Pathol 

L’aorta ed il patologo: aterosclerosi aortica 

A. Pucci 

Anatomia Patologica- Azienda Ospedaliero-Universitaria Pisana, 

Pisa 

L’aterosclerosi è una malattia complessa, multifattoriale ed 

a carattere evolutivo delle arterie elastiche e muscolari di 

grande e medio calibro caratterizzata da lesioni intimali (definite 

comunemente placche) che possono essere inizialmente 

rappresentate da minute aree di ispessimento (lesioni elementari), 

ma la cui evoluzione può causare lesioni complicate. 

L’aterosclerosi è oggi ritenuta una malattia infiammatoria cronica; 

biomarkers circolanti di infiammazione come la Proteina 

C-Reattiva sono considerati possibili indicatori dello stato 

della malattia aterosclerotica. Diversi fattori, sia genetici (come 

l’ipercolesterolemia familiare, l’omocistinuria, malattie 

della coagulazione) sia ambientali (dieta, fumo, ipertensione,

RElaziONi 

malattie dismetaboliche, stress, abitudini di vita) hanno un 

importante ruolo eziopatogenetico. 

Secondo le più recenti proposte classificative, le lesioni aterosclerotiche 

aortiche possono essere classificate in Lesioni 

intimali non progressive (Ispessimento intimale adattativo e 

Xantoma intimale) ed in Lesioni aterosclerotiche progressive 

(Ispessimento intimale patologico, Fibroateroma precoce, 

Fibroateroma avanzato, Fibroateroma con cappuccio sottile, 

Placca con Rottura, Placca con Rottura in Riparazione, Placca 

fibrocalcifica). 

Lesioni intimali non progressive 

Ispessimento intimale adattativo Si presenta macroscopicamente 

come ispessimento biancastro sulla superficie intimale. 

Microscopicamente è costituito da fibrocellule muscolari lisce 

nel contesto di una matrice contenente glicosoaminoglicani 

e collagene. La membrana elastica interna appare integra. 

L’ispessimento intimale adattativo viene rilevato frequentemente 

in giovani adulti, nell’aorta toracica. 

Xantoma intimale (Macchie e Strie lipidiche) Le macchie 

lipidiche sono formazioni macroscopicamnete evidenti come 

lesioni piane, giallastre e nette 50% del volume totale della placca) 

hanno un ruolo importante nella rottura di placca. 

Rottura di placca È rappresentata da una interruzione del cappuccio 

fibroso a cui corrisponde la formazione di un trombo 

che si continua con il sottostante core. In genere sono lesioni 

con abbondante core necrotico ed infiltrazione del cappuccio 

(generalmente sottile) da parte di linfociti e macrofagi. La rottura 

può determinare, oltre alla trombosi, imbibizione emorragica 

della placca (con conseguente rapido accrescimento 

volumetrico). La rottura di placca non comporta occlusione 

dell’aorta, visto il diametro del vaso ma espone a rischio di 

complicanze tromboemboliche. Una delle sedi più frequenti è 

l’aorta addominale. 

Rottura di placca in riparazione La rottura di placca può 

andare incontro spontaneamente a riparazione ad opera delle 

cellule muscolari lisce vascolari che secernono una matrice 

extracellulare ricca di glicosaminoglicani. Nelle placche con 

rottura del cappuccio, questo è sostituito, in corrispondenza 

della soluzione di continuo, da cellule muscolari lisce, proteoglicani 

e collagene. Possono essere presenti o assenti lipidi, 

e stratificazioni di collagene, fibrina e piastrine. Possono 

conseguire fenomeni di retrazione e costrizione del segmento 

vascolare coinvolto, ma nell’aorta questo non determina stenosi 

del lume. 

Placca fibrocalcifica Nel processo di progressione ed evoluzione 

delle lesioni aterosclerotiche aortiche, sono frequenti 

fenomeni di calcificazione sotto forma di grossolani (e macroscopicamente 

evidenti) depositi di sali di calcio nell’ambito di 

una placca prevalentemente fibrosa. 

Le alterazioni e il rimaneggiamento della parete aortica nelle 

placche estese e complicate possono contribuire alla dilatazione 

aneurismatica del tratto aortico interessato dall’aterosclerosi. 

Gli aneurismi aortici che insorgono su lesioni 

aterosclerotiche sono aneurismi veri, in cui cioè la parete 

dilatata è assottigliata ma costituita da tutte le sue componenti. 

La maggioranza degli aneurismi dell’aorta addominale 

sono aterosclerotici, singoli e localizzati nel tratto infrarenale, 

mentre nell’aorta toracica la malattia aneurismatica è più frequentemente 

dovuta ad altre cause. Nella popolazione anziana 

maschile dei Paesi sviluppati, gli aneurismi (aterosclerotici) 

dell’aorta addominale hanno una prevalenza del 3-8% e rappresentano 

l’1% delle cause di morte. Le loro dimensioni sono 

variabili, in gran parte comprese tra 5 e 10 cm di diametro. 

Microscopicamente, l’aorta adiacente all’aneurisma generalmente 

manifesta grave aterosclerosi con ipotrofia della tonaca 

media, angiogenesi, flogosi, calcificazioni e nella tonaca 

avventizia è spesso presente fibrosi ed una moderata reazione 

infiammatoria. Le complicanze dell’aneurisma aterosclerotico 

dell’aorta sono essenzialmente correlate con la rottura, 

l’infezione e l’embolizzazione. La rottura di un aneurisma 

dell’aorta addominale può essere fatale ed avvenire in pa-

242 

zienti asintomatici, la sede più frequente è la porzione laterale 

sinistra della parete aortica, tra 2 e 5 cm dall’origine delle arterie 

renali. La conseguente emorragia si può estendere nello 

spazio retroperitoneale e provocare uno shock ipovolemico, o 

risultare contenuta dai tessuti molli periaortici per un periodo 

di tempo non prevedibile. 

Le alterazioni e il rimaneggiamento della parete aortica 

nelle placche estese e complicate possono coinvolgere la 

tonaca media, determinando la c.d. ulcera penetrante dovuta 

all’estensione dell’ulcerazione di una placca per un breve 

tratto nella media con formazione di un cratere sulla superficie 

luminale, senza distensione della superficie esterna del vaso. 

La frequenza di tale lesione non è nota ma sembra essere poco 

comune. La sede preferenziale è l’aorta addominale. 

Nell’aorta, l’anatomia del vaso (in particolare il suo calibro) 

fa sì che abbiano in genere rilevanza i fenomeni di trombosi 

e di embolizzazione distale, ma non le stenosi. L’aorta ateromatosa 

può essere una fonte di emboli periferici o viscerali; 

le placche si possono ulcerare rilasciando (soprattutto 

i fibroateromi) il loro contenuto nel torrente circolatorio e 

provocare embolizzazione distale con la possibilità che gli 

organi distali vadano incontro ad atrofia, ischemia o infarto. 

Le conseguenze cliniche dipendono dalla presenza di vasi 

collaterali. 

Aortiti 

G. D’Amati 

Dipartimento di Scienze Radiologiche, Oncologiche ed Anatomo Patologiche, 

Sapienza, Università di Roma. 

Con il termine di aortite definiamo un’infiammazione della 

parete aortica che coinvolge invariabilmente la tonaca media. 

La flogosi è associata in maniera variabile ad altri reperti istopatologici, 

come la distruzione delle fibre elastiche, la necrosi 

e la fibrosi. L’interessamento della giunzione medio-intimale 

e dell’intima è frequente, mentre quello dell’avventizia è 

variabile. La classificazione più seguita delle aortiti, adottata 

anche da questo gruppo di esperti, si basa sulla suddivisione 

in forme infettive e non infettive ed offre il vantaggio di essere 

funzionale alla terapia di queste affezioni. 

Verranno trattati i principali quadri istologici delle aortiti, i 

contesti in cui il patologo si trova a fare diagnosi di queste 

affezioni, i problemi di diagnostica differenziale, gli accorgimenti 

tecnici per ottimizzare la diagnosi. 

zone grigie ed implicazioni future 

O. Leone 

Azienda Ospedaliero-Universitaria Sant’Orsola-Malpighi, Anatomia 

ed Istologia Patologica, Bologna 

Le aortopatie sono numerose ed eterogenee ed alla loro genesi 

concorrono complessi sistemi cellulari e molecolari, che interagiscono 

nel determinare il danno parietale ed i conseguenti 

eventi clinici delle aortopatie acute (dissezione o rottura) e 

croniche (aneurismi/cronicizzazione di quadri acuti) e la loro 

progressione/estensione. L’aumento delle conoscenze sulla 

struttura e funzione della parete aortica e sulla sua fisiopatologia 

ed istopatologia sta delineando un più complesso 

approccio conoscitivo alla patologia dell’aorta, tale che l’osservatorio 

clinico non rappresenta più oggi l’unica prospettiva 

di valutazione. 

Le problematiche emergenti investono tematiche classificative, 

patogenetiche e diagnostiche, che rendono meno univoca 


l’interpretazione di quadri dapprima valutati in modo più 

grossolano e sbrigativo. Ci poniamo quindi più domande, 

alle quali possiamo per ora dare solo risposte parziali: da qui 

l’esistenza di zone grigie, che stiamo imparando a valorizzare 

come aree conoscitive in evoluzione, che potranno comportare 

importanti cambi di paradigma nell’approccio clinicoterapeutico 

alle aortopatie. 

L’osservatorio istopatologico 

La transizione intervenuta negli ultimi due decenni dallo 

studio anatomo-patologico preminentemente macroscopico 

ad un più approfondito studio istopatologico ha consentito 

di ampliare la realtà clinica della patologia aortica, creando 

un ponte con i complessi meccanismi biologici operanti nella 

parete vasale e le basi per un inquadramento nosografico più 

aderente ai reali meccanismi patogenetici in gioco. 

Due esempi paradigmatici: 

l’acquisizione che il capitolo delle aortopatie infiammatorie 

sia caratterizzato da un ampio spettro di quadri infiammatori, 

non più limitati solo alle classiche aortiti; 

la sempre maggiore consapevolezza che il capitolo delle aortopatie 

degenerative non infiammatorie accomuni, all’interno 

di un’unica etichetta, malattie molto eterogenee sia dal punto 

di vista eziologico che clinico. 

Le zone grigie 

Riconoscono differenti problematiche: 

l’esistenza di quadri overlapping (aterosclerosi infiammata, 

periaortite cronica, aneurisma infiammatorio, alcune forme di 

aortite) nel contesto di uno spettro eziopatogenetico, patologico 

e clinico-evolutivo variegato; 

la presenza di entità nosologiche non ancora ben definite dal 

punto di vista eziopatogenetico e patologico (es. periaortite 

cronica); 

l’effettiva possibilità che si realizzino quadri patologici misti, 

in cui coesistono aortopatie differenti (un’aortopatia con classiche 

lesioni degenerative può complicarsi con l’aterosclerosi 

o un’aortite); 

lo stesso processo evolutivo delle aortopatie, che può condizionare 

la comparsa di aspetti istopatologici differenti da 

quelli della malattia di base. 

Implicazioni future 

Alcuni spunti di riflessione su possibili futuri cambi di paradigma 

nell’approccio conoscitivo e clinico-terapeutico rispetto 

alle conoscenze classiche sulla patologia aortica, possono 

essere così riassunti: 

L’aorta come organo con ampio spettro di funzioni e non come 

semplice condotto passivo, le cui peculiari caratteristiche 

biologiche e le importanti funzioni emodinamiche consentono 

la regolazione dell’omeostasi parietale. 

Dalla globalità alla distrettualità. Le diverse caratteristiche 

embriologiche, strutturali, bioumorali e meccaniche dell’aorta 

toracica e addominale sono alla base della sostanziale eterogeneità 

dei vari segmenti, che determina corrispettivi funzionali 

e patologici differenti. 

Dall’aterosclerosi all’infiammazione. Il binomio aterosclerosi-infiammazione, 

ben noto in letteratura e documentato 

da alcune indubbie evidenze clinico-laboratoristiche, ha la 

sua massima evidenza nell’aorta e, come tale, può costituire 

un modello di lavoro per ottenere informazioni utili sotto il 

profilo della stratificazione prognostica e dell’individuazione 

di nuovi target terapeutici. 

Dall’intima all’avventizia: andata e ritorno. Per quanto l’intima 

abbia attirato per molti anni l’attenzione dei ricercatori 

e dei clinici, costituendo il bersaglio iniziale dell’insulto alla 

parete vascolare, si sta oggi rivalutando sempre più il ruolo 

dell’avventizia come sede finale dell’elaborazione della

RElaziONi 

risposta al danno e la sede principale dello sviluppo delle reazioni 

immuni adattative. La risposta avventiziale influenza 

direttamente o indirettamente la biologia dell’intera parete 

arteriosa e dei tessuti circostanti e contribuisce attivamente 

al rimodellamento parietale, con pattern differenziati 

a seconda della natura dell’insulto e del tipo di mediatori 

generati. 

Dalla valutazione dimensionale all’analisi morfologica e 

funzionale. Le recenti acquisizioni in tema di patologia aortica, 

alla luce della complessità dei substrati istopatologici, 

biomolecolari e fisiopatologici, deve indurre a riconsiderare il 

Sabato 27 ottobre 


Trapianti 

Tavola rotonda: il trapianto comincia dalla donazione. Una necessaria 

consapevolezza dell U.O. di Anatomia Patologica e delle direzioni aziendali: 

esperienze a confronto 

Moderatori: Walter Franco Grigioni (Bologna), Oscar Nappi (Napoli) 

A. D’Errico, F.W. Grigioni 

SSD Diagnostica istopatologica e molecolare degli organi solidi e 

del relativo trapianto U.O. Anatomia e Istologia Patologica. Azienda 

Ospedaliero-Universitaria Policlinico S. Orsola-Malpighi. Bologna 

Il rischio di trasmissione di malattie neoplastiche è aumentato 

in questi ultimi anni soprattutto in relazione all’applicazione 

del concetto di espansione dei criteri nella donazione degli 

organi. 

Per queste ragioni le linee guida internazionali sulla sicurezza 

in ambito donativo hanno proposto di utilizzare protocolli 

stringenti di selezione dei donatori ponendo particolare attenzione 

alla storia clinica, ai parametri sierologici ed a una attenta 

valutazione degli organi e delle cavità durante l’espianto. 

Nello stesso tempo è emerso il concetto che alcuni tumori 

seppur maligni presentino un rischio di trasmissione neoplastica 

estremamente basso, in questa prospettiva gli organi di 

243 

work-up diagnostico delle aortopatie, allargandolo ad una valutazione 

clinica “sistemica” (malattie genetiche del connettivo, 

malattie metaboliche, malattie sistemiche su base immune), 

che si avvalga dello studio approfondito con le tecniche 

di imaging (non più esclusivamente limitato al solo rilievo 

del diametro aortico), dello studio tissutale istopatologico, 

dell’analisi biomolecolare e genetica. Questa prospettiva può 

fornire elementi utili sia per la gestione del singolo paziente 

con malattia aortica che per la stratificazione prognostica, e 

potrebbe consentire in un prossimo futuro anche l’individuazione 

di nuovi target terapeutici. 

un donatore affetto da una neoplasia di questo tipo, possono 

essere utilizzabili previo consenso informato e non solo nei 

casi di emergenza clinica. 

A questo gruppo di tumori appartengono, secondo i Registri 

Internazionali e Le linee Guida Europee per la Sicurezza in 

ambito di donazione, i carcinomi renali grado I-II/IV sec. 

Fuhrman di dimensioni inferiori a 4 cm (pT1a), gli adenocarcinomi 

prostatici confinati alla prostata con Gleason score 3+3 

o e+4, il micro carcinoma papillare della tiroide, ed i tumori 

del sistema nervoso centrale a basso grado. 

In relazione a quanto esposto, appare intuibile che il concetto 

di espansione nei criteri di donazione abbia alla base una organizzazione 

strutturata che preveda un team di professionisti 

con diverse competenze e con la massima integrazione al fine 

di evitare l’utilizzo di donatori ad elevato rischio e di non 

scartare organi da donatori che per età o condizioni cliniche 

potrebbero rappresentare “a priori” donatori non idonei.

244 

Anatomia patologica e citopatologia: 

distribuzione nazionale dei servizi, qualità del 

referto citologico e ruolo della citoassistenza. 

Osservatorio nazionale siapec sul contenzioso 

L. Resta 


Cytopathology: pathologist and 

cytotechnologists traning in european union 

and Italy 

A. Fassina1 , L. Resta2 , L. Alessandrini1 , M. Tötsch3 1 Department of Medicine, Pathology & Cytopathology; University 

of Padova, Italy; 2 Department of Emergency and Organ Transplantation, 

Pathology & Cytopathology, University of Bari; 3 Institute of 

Cytology, University Hospital Graz, Medical University of Graz, Austria 

In Pathology, the traditional division between “surgical pathology” 

and “cytology” led to attitudes and feelings, which 

in the past caused debates and incomprehension among the 

different actors of the same discipline. Recent advances in 

cytology performance and new technology application to the 

scant cytological material justify the new awareness for a 

diverse approach to cytology 1 . Cytopathology is regarded as 

integral part of pathology and well-trained pathologists must 

be able to cover basic diagnosis in gynaecological and nongynaecological 

cytology. 

In 2010, the Editorial Advisory Board of the journal Cytopathology 

carried out a survey of medical training in cytopathology, 

aimed to explore the current situation in undergraduate 

and postgraduate training in different European countries 2 . 

The results demonstrated serious deficiencies in cytopathology 

training, in manpower and resources, also in institutions with 

otherwise adequate programmes. The main deficiencies were 

the time variability of training, the lack of specifically trained 

cytopathologists, the lack of training to a high level of competence 

and the work overload and shortage of training facilities in 

the centres with adequate schools and potentially good training 

programmes. It was evident that training in cytopathology was 

more likely to involve screening slides than gaining hands-on 

experience with FNA and rapid on-site assessment and less than 

a third of trainees gained sufficient experience to be allowed to 

sign out reports. Moreover, another relevant point was that nonmedical 

staff signed out negative cervical cytology according 

to 48.1% of responses, particularly in large laboratories, while 

rarely they signed out non-gynaecological cytology, except 

for negative sputum and urine. In that survey conclusions, it 

was clear that cytopathology training was overly dependent on 

local centers of excellence and that training varied too much. 

Cytopathology practice varies so much from country to country 

in Europe that a common definition of cytotechnologists’ and 

pathologists’ education and their role was mandatory 2 . 



Sala Giotto – 08.30-10.30 

Citologia 1 

Il ruolo della citodiagnostica nell’attuale Sistema Sanitario nazionale 

Moderatori: Paolo Dalla Palma (Trento), Ambrogio Fassina (Padova) 

In 2011, in Split, delegates of the European Union of Medical 

Specialists (EUMS) were invited from all over Europe to 

discuss the harmonization of pathology in Europe, and they 

considered gynaecological and non-gynaecological cytology 

an integral part of the pathology common trunk, and that cytology 

required a special and defined training, as a mandatory 

obligation to guarantee standardized high quality cytology 

diagnoses to patients and referring doctors. Cytopathology 

is an integral part of Pathology and cannot be left to other 

disciplines, and non-medical practitioners are not authorized 

to sign out cytological diagnoses. It was finally concluded 

that well-trained pathologists should be able to cover all the 

‘fields’, ‘branches’ or ‘ramifications’ of cytopathology, in order 

to avoid the dangerous situations where clinicians prepare 

and read slides and smears themselves 3 . 

In June 2012, in Paris, UEMS members voted and accepted 

the Split conclusions with the obligation to set standards 

for the pathology training, to allow young pathologists to 

be trained and ⁄or work all over the European Union, and to 

re-integrate disciplines such as neuropathology, dermatopathology 

and cytopathology in pathology. This charter will 

not provoke significant changes to cytology training in the 

large part of European countries, where pathologists already 

practice cytology, whereas few countries, such as Greece and 

Croatia, where cytology is practiced as a separate discipline, 

need time to re-assess their statutory profiles 4 . 

In Italy, the cytopathology board of SIAPEC regularly gathered 

and discussed the problems regarding work organization 

and training, encouraging regional correspondents to intervene. 

In particular, all over Italy one can find excellent courses 

either in diagnostic or in molecular cytopathology, courses 

for Residents in training (Accademia Nazionale di Medicina), 

as well as International Tutorials (Trieste) and Congresses. 

As an open question still remains the cytotechnologist position 

in the present and future of Pathology departments. In 

view of the training that Bio-Medical Techniques laureates 

will undergo to play a new role to definitely assess sample 

adequacy, disease characteristics, HPV and II-level cervical 

cytology, FNA and molecular cytology, we all Pathologists, 

Academics, and active Technicians along with the political 

authorities, must re-think their formal and practical training 

as well as their professional profiles. 

references 

1 Schmitt F, Vielh P, Zeppa P. Cytology for pathologists: two sides 

of the same coin or different views of the same side? Cytopathology 

2012;23:345-6. 

2 Anshu HA, Cochand-Priollet B, et al. Survey of medical training in 

cytopathology carried out by the journal Cytopathology. Cytopathology 

2010;21:147-56. 

3 Totsch M, Vass L, Fassina A. The UEMS training charter for pathology: 

a common trunk and a challenge ahead for EFCS. Cytopathology 

2011;22:349-51. 

4 Tötsch M, Cuvelier C, Vass L, et al. On behalf of the participants of 

the UEMS Section ⁄Board of Pathology meeting in Paris 2012. The 

UEMS Section ⁄Board of Pathology, Chapter 6: Requirement for Rec-

RElaziONi 

ognition of Postgraduate Training in Pathology: a presentation of the 

Paris Document. Cytopathology 2012;23:295-9. 

Il carico di lavoro della citologia in un reparto 

standard di anatomia patologica 

P. Dalla Palma 

Anatomia ed Istologia Patologica e Citodiagnostica- Ospedale S. 

Chiara- TRENTO 

Il carico di lavoro dell’Anatomia Patologica è costantemente 

in aumento non tanto come numero totale dei casi da diagnosticare 

in un anno ma per la crescente complessità diagnostica 

e per le sempre più puntuali richieste da parte del personale 

medico richiedente. La citologia non è certo una eccezione in 

tal senso, anzi la sempre maggiore necessità di una precisa definizione 

patologica delle varie entità ricorrendo ove possibile 

a tecniche mini-invasive ha decisamente cambiato il “peso” 

in altre parole il”carico di lavoro” della citologia. La diagnosi 

“Positivo” o “Cellule Tumorali Maligne” che fino ad alcuni 

anni fa era sufficiente ora necessità di molte altre precisazioni 

con integrazione del dato morfologico con quello istochimico, 

immunoistochimico e biomolecolare. 

Si inizia con il prelievo e vi è sempre maggiore necessità di 

una valutazione prediagnostica dell’adeguatezza del materiale 

prelevato. Chi meglio del citopatologo può fornire indicazioni 

su come prelevare il materiale, di come trattarlo e di come 

fissarlo? Solo chi poi ha la responsabilità diagnostica si rende 

conto della delicatezza di questo passaggio. Inoltre talora è 

necessario un esame semeiologico del paziente, una vera e 

propria visita medica. Tutto ciò richiede oltre che “expertise” 

anche del tempo medico di cui tenere conto allorquando si 

fanno i piani di lavoro. Nuove tecniche come l’ecoendoscopia, 

vista la sua complessità, necessitano di una valutazione istantanea 

dell’adeguatezza del materiale raccolto dal momento 

che una ripetizione dell’esame oltre che costosa, è complessa. 

Stante la carenza di personale medico comune anche ad altre 

specialità un primo quesito è quello di valutare se la valutazione 

dell’adeguatezza non possa essere effettuata da personale 

tecnico (citotecnico) adeguatamente addestrato. 

Una volta giunto in laboratorio il materiale prelevato va trattato 

nel modo più opportuno (strisciato, centrifugato, citoincluso, 

colorato in vari modi e con varie tecniche anche non 

convenzionali, ecc). 

Al pari di tutti gli esami di Anatomia Patologica non si può 

prescindere nemmeno in citologia da una ottimizzazione ed 

una standardizzazione dei preparati. Anche questa fase pertanto 

richiede controlli e procedure che richiedono tempo che 

spesso non viene calcolato nei carichi di lavoro. 

Vi è poi la fase diagnostica vera e propria che, almeno per 

la parte relativa alla citologia cervico-vaginale, può essere 

preceduta da un pre-screening da parte del personale citotecnico 

con o senza un aiuto di macchine per la lettura computer 

assistita. Anche in questo campo però vi sono delle novità che 

presto potrebbero impattare pesantemente nel lavoro del citopatologo: 

l’introduzione di un test molecolare per la ricerca 

del HPV come test primario, necessariamente selezionerà un 

numero di casi (Pap Test) decisamente inferiore (circa il 10%) 

che però rappresenterà una popolazione a rischio elevato e 

quindi si passerà da una citologia di screening ad una citologia 

diagnostica a responsabilità dirigenziale e non tecnica. Il 

personale citotecnico che attualmente opera nei reparti di anatomia 

patologica potrà essere indirizzato anche allo screening 

della citologia extravaginale? E se la risposta sarà affermativa 

a quale tipo di citologia? Esfoliativa e/o anche agoaspirativa? 

245 

Negli Stati Uniti i citotecnici già di routine lo fanno. 

Un problema ancora più delicato è quello del carico di lavoro 

delle singole figure professionali coinvolte nella citologia. 

Per quel che riguarda il carico di lavoro dei citotecnici siamo 

stati abituati a misurarlo con il numero di vetrini screenati al 

giorno. L’introduzione dei preparati in fase liquida con una 

minore area coperta dal materiale biologico avrebbe dovuto 

comportare una maggiore produttività mentre ciò non si è di 

fatto verificato nella maggioranza dei Centri. L’aggiunta dei 

sistemi computer assistiti avrebbe dovuto aggiungere ancora 

una percentuale alla produttività giornaliera ma tutto ciò 

non si è di fatto verificato almeno in Italia almeno in misura 

significativa. Si naviga nella vaghezza in mancanza di reali 

standard di riferimento. Recenti studi fatti negli USA hanno 

ipotizzato carichi di lavoro fino a 100 preparati al giorno specificando 

che preparati visti con i sistemi di lettura computer 

assistita e verificati solo sui campi di interesse individuati 

equivarrebbero a mezzo vetrino rispetto ad un vetrino visto al 

microscopio ottico tradizionale e ad un vetrino e mezzo se visti 

sia sui campi preselezionati che poi controllati in modo tradizionale. 

Un lavoro analogo in Inghilterra eseguito anch’esso 

recentemente riporta invece valori di 32 vetrini screenati al 

giorno. Le differenze sono macroscopiche. 

Interessante è poi il correttivo delle ECA (epithelial cellular 

abnormalities) caratteristiche di ciascun laboratorio perché 

all’aumentare della percentuale di ECA corrisponderebbe una 

diminuzione del numero di vetrini da screenare: fino a 140 se 

un laboratorio ha una percentuale di ECA del 5%, fino a 70 

se tale percentuale sale al 10% e fino a 35 se tale percentuale 

sale al 20%. 

Il carico di lavoro del personale dirigente è meno ampiamente 

valutato in letteratura. Certamente dipende in modo 

significativo da cosa fa il personale dirigente oltre al compito 

diagnostico (esegue direttamente i prelievi? visita il paziente? 

fa parte di gruppi multidisciplinari per la pianificazione terapeutica 

dei singoli casi? ecc). 

Quel che è sicuro che il carico di lavoro è pesante ed in costante 

aumento, almeno se si desidera avere una eccellente qualità 

diagnostica. Troppo spesso i Colleghi dediti all’istopatologia 

non sono consci del lavoro eseguito dal citopatologo. Parlano 

ad esempio del carico di lavoro legato alla riduzione dei pezzi 

anatomici dimenticandosi della citoassistenza e del tempo 

necessario per eseguire direttamente o almeno essere presenti 

per valutare l’adeguatezza del materiale. La citologia diagnostica 

a tutti i livelli non deve essere pertanto considerata 

“figlia di un Dio minore”. 

Diagnosi definitiva citologica, nuove terapie e 

monitoraggio della terapia 

R. Dina 

Dept of Cellular Pathology, Hammersmith Hospital, Imperial College 

NHS Trust 

Nel UK la diagnostica citologica, intesa come diagnosi definitiva, 

è ufficialmente integrata nelle line guida dei tumori 

polmonari, tiroidei e pancreatici mentre negli altri distretti del 

corpo – testa e collo, mediastino, ginecologico è considerata 

come una diagnosi iniziale o di screening. Una eccezione è 

rappresentata dai tumori di origine sconosciuta la cui diagnosi 

di origine è spesso demandata alla citologia 1 . 

Mentre ormai l’immunocitochimica (ICH) è entrata nella routine 

diagnostica, con > 280 anticorpi routinariamente in uso 

nel nostro laboratorio, su materiale citologico è fondamentale 

ottimizzare le metodiche specificamente per materiale cito-

246 

Fig. 1 

logico o cell-blocks, conoscendone i vantaggi e svantaggi 

oltrechè’ i limiti di interpretazione. La centralizzazione dei 

servizi’ di citologia ha portato ad un sempre maggiore utilizzo 

della Citologia in fase liquida (LBC) che permette una ottima 

preservazione delle caratteristiche antigeniche delle cellule 

nonché del RNA e 2 . La citometria a flusso richiede cellule 

non fissate ed il suo utilizzo richiede la vicinanza del laboratorio: 

la scarsa preservazione delle cellule puo’ generare infatti 

artefatti interpretativi 3 . 

La diagnosi citologica puo’ essere considerate definitiva nei 

tumori solidi quando include non solo una classificazione 

diagnostica ma anche informazioni prognostiche e predittive 

di risposta a terapie specifiche. 

La citologia aspirativa è il metodo più accurato ed efficiente 

nella diagnosi di noduli tiroidei 1 . Nello UK si utilizza la 

classificazione Thy1-5 che è simile ma non del tutto sovrapponibile 

alla Bethesda. La categoria Thy3, che include 

le lesioni follicolari indeterminate nonché la Thy4 (sospetto 

per neoplasia maligna) e Thy5 (maligno) devono essere 

discusse obbligatoriamente negli incontri multidiciplinari 

(Multi Discipinary Team meeting- MDT) al fine di valutare 

l’asportazione o meno. Mentre alcuni dati della letteratura 

hanno di volta in volta suggerito marcatori come CK19, 


galectina-3 ed HBME-1 nella pratica clinica non sono 

considerati sufficentemente specifici. Anche se una tipica 

diagnosi citologica di carcinoma papillare della tiroide gia’ 

fornisce importanti informazioni terapeutiche e di risposta 

alla terapia chirurgica o radiosotopica, ulteriori informazioni 

classificative si possono ottenere anche mediante una analisi 

mutazionale di BRAF V600E che facilita l’assegnazione 

delle lesioni follicolari indeterminate in categorie ad alto 

rischio di carcinoma 4 5 . Purtroppo nei carcinoma folliculari 

puri alterazioni mutazionali sono meno specifiche. Recentemente 

Nikiforov ha dimostrato come la rilevazione di mutazioni 

di BRAF,RAS,PAX9/PPAR e RET/PTC aumentavano 

l’accuratezza complessiva della citologia di noduli tiroidei e 

come la diagnostica molecolare possa essere cost-effective 

nel caso di lesioni follicolari indeterminate 6 . Tuttavia questi 

dati non considerano i costi relativi alla possibilita’ di falsi 

positivi nella diagnostica molecolare. 

La citologia polmonare sia ottenuta tramite EBUS che con 

metodi più tradizionali è l’area di maggiore successo nella 

integrazione tra diagnosi morfologica e diagnostica molecolare, 

anche in considerazione della scarsa percentuale di tumori 

(70%) suscettibili di terapia chirurgica. L’identificazione di 

EGFR giustifica l’utilizzo di inibitori della Tyrosin-kinase 

(TLIs) mentre il riconoscimento di carcinoma squamoso evita 

l’uso di bevacizumab. Gli adenocarcinomi con riarrangiamento 

di ALK rispondono a crizotinib. L’utilizzo quindi di 

un pannello di anticorpi per differenziare i due principali tipi 

di non-small cell carcinomas (NSCLC) è quindi essenziale 7 

e deve essere combinato nell’algoritmo raccomandato nella 

classificazione del 2011: 

La gestione del materiale citologico deve essere ottimizzata 

in funzione dei test molecolari (EGFR, ALK,KRAS,FGFR1, 

DDR2 etc) via via validati. 

La prognosi dell’adenocarcinoma pancreatico è tuttora pesante, 

con una sopravvivenza del 5% a 5 anni. La diagnosi citologica 

mediante EUS è spesso definitiva nei casi inoperabili 

ed ha una PPV > 95% nei tumori solidi. Più del 90% dei casi 

sporadici sono associati a mutazioni di KRAS e/o p16 e dal 

50%al 75% dei casi mostrano mutazioni di p53. Numerose 

mutazioni sono tuttavia anche presenti in lesioni non-neoplastiche 

e l’integrazione tra morfologia ed analisi molecolare 

deve avvenire nell’ambito del MDT. 

Bibliografia 

1 Schmitt F, Barroca H. Cancer Cytopathology 2012;120:145-60. 

2 Clark DP. Cancer Cytopathology 2009;117:289-97. 

3 Davidson B, Dong HP, Berner A, et al. Diagn Cytopathol 2012:40:525- 

35. 

4 Ohori NP, Singhal R, Nikiforova MN, et al. Cancer Cytopathol 

2012;doi 10.1002/cncy.21229 

5 Marchetti I, Lessi F, Mazzanti CM, et al. Thyroid 2009;19:837-42. 

6 Nikiforov I. J Clin Endocrinol Metab 2012,97:1905-12. 

7 Travis WD, Brambilla E, Noguchi M, et al. Arch Pathol Lab Med 

2012:136:1-17.

RElaziONi 

Thyroid aspiration cytology 

G. Fadda 

Chief of the Cytopathology Section, Division of Anatomic Pathology 

and Histology, Catholic University, Rome (Italy 

Nodular lesions represent a very common problem for the clinicians 

as well as a diagnostic challenge for the pathologists. 

Up to 5% of the general population has a palpable thyroid 

nodule though only approximately 5% of these clinically 

apparent thyroid nodules actually harbour malignancy. The 

real challenge facing general practitioners, endocrinologists, 

surgeons, and pathologists is to reach an accurate preoperative 

diagnosis of malignancy and to ensure that the patient receives 

a timely and appropriate treatment. FNA is the only test that 

can provide a definitive preoperative diagnosis of malignancy. 

The sensitivity and specificity of FNA are reported to be 68- 

98% and 56-100%, respectively. FNAB is also regarded as the 

most accurate method for the selection of patients with thyroid 

nodules for surgery or for the ‘wait and see’ management and 

it can be considered a very cost-effective diagnostic test. The 

use of liquid-based techniques (LBC) applied to FNA specimens 

for the cytological evaluation of thyroid nodules is still 

controversial. Although the transition to this methodology 

requires adaptation by technologists and cytopathologists who 

evaluate the samples, it appears to be a valuable investment. 

An innovative diagnostic approach includes the addition and 

the enforcement of molecular diagnostics on FNA material. As 

good quality nucleic acid can be extracted from thyroid cells 

processed by LBC the molecular diagnosis will be playing a 

role in the management of patients with suspected endocrine 

neoplasms. Considering that the most common malignancy of 

the thyroid gland is papillary carcinoma (PC), the evaluation 

of a thyroid nodule on FNA is, therefore, primarily a search 

for PC. More than half of PCs harbor one of several mutations 

involving both Ret/PTC and PAX8/PPAR_ rearrangements and 

the mutations of RAS and BRAF genes. The identification of 

one or many of these genetic alterations on FNA specimens 

from thyroid lesions may improve the diagnostic yield of this 

technique, especially in indeterminate cases. 

Although PC is typically an indolent disease, recurrence is 

common (15%-30% of patients), even in early-stage disease. 

In vitro studies in benign thyroid cell models have demonstrated 

a particularly important role for BRAF as a central 

regulator of thyroid-specific protein expression (i.e., differentiation) 

and proliferative capacity. At the molecular level, 

mutations resulting in a V600E substitution in BRAF and 

consequent constitutive activation occur in more than 50% of 

PCs in adults. This figure makes BRAF mutations the most 

common defined genetic abnormality in thyroid cancers. In 

several studies, the presence of a BRAF mutation has been 

associated with a more aggressive clinical course. Therefore 

it might be crucial to identify patients at higher risk of recurrence 

so that a more aggressive therapy and a closer monitoring 

can be realized. In this way, molecular investigation 

performed on FNA could also assume a prognostic role. 


Sala Giotto – 11.30-12.30 

Citologia agoaspirativa in twitter: tutto in sei minuti e tre slide 

Moderatori: Luigi Di Bonito (Trieste), Cesare Gentili (Massa Carrara) 

247 

references 

Fadda G, Rossi ED. Liquid based cytology in fine needle aspiration biopsies 

of the thyroid gland. Acta Cytol 2011; 55:389-400. 

Fadda G, Rossi ED, Raffaelli M, et al. Fine-Needle aspiration biopsy of 

thyroid Lesions processed by thin-layer cytology: one-year institutional 

experience with histologic correlation. Thyroid 2006;16: 975-81. 

Musholt TJ, Fottner C, Weber MM, et al. Detection of papillary carcinoma 

by analysis of BRAF and RET/PTC1 mutations in fine needle aspiration 

biopsies of thyroid nodules. World J Surg 2010;34:2595-603. 

Soares P, Trovisco V, Rocha AS, et al. Braf mutations typical of papillary 

thyroid carcinoma are more frequently detected in undifferentiated 

than in insular and insular-like poorly differentiated carcinomas. 

Virchows Arch 2004;444:572-76. 

Eszlinger M, Paschke R. Molecular fine-needle aspiration biopsy diagnosis 

of thyroid nodules by tumor specific mutations and gene expression 

patterns. J. Mol Cell.Endocrin 2010;322:29-37. 

Elisei R, Ugolini C, Viola D, et al. BRAF mutation and outcome of patients 

with papillary thyroid carcinoma: a 15-year median follow-up 

study. J Clin.Endocrinol.Metab 2008;93:3943-50. 

Nikiforova MN, Nikiforov Y. Molecular diagnostics and predictors in 

thyroid cancer. Thyroid 2009;19:1351-61. 

Nikiforov YE, Steward DL, Robinson-Smith TM, et al. Molecular testing 

for mutations in improving the fine needle aspiration diagnosis of 

thyroid nodules. J Clin Endocrinol.Metab 2009;94:2092-98. 

Fine needle cytology / core needle biopsy in 

pancreatic tumors 

G. Zamboni 

Departement o Pathology, University of Verona, Ospedale Don Calabria, 

Negrar, Verona, Italy 

The extensive utilisation of imaging has increased the discovery 

of pancreatic masses. Unfortunately, most (80 to 90 percent) 

of the clinically detected masses in the pancreas are adenocarcinomas. 

With the exception of functioning endocrine 

tumors, characterised by a specific clinical picture, the other 

pancreatic tumors manifest with either non-specific symptoms, 

or symptoms similar to pancreatitis. Although a correct 

diagnosis is mandatory to plan the therapeutic approach and 

establish a prognosis, accurate preoperative diagnosis sometimes 

is very difficult to achieve. 

The ideal diagnostic test, as in other disease, should be the tissue 

diagnosis with a trucut biopsy, since the tissue can be also 

used for ancillary studies. Unfortunately, diagnostic pancreatic 

tissue biopsies are not always available. The less invasive 

methods, like the FNAB with US guidance or the EUS-guided 

biopsies have a better level of safety and are considered reliable 

in detecting the presence of malignant cells, although of 

lower sensitivity. Independently on the used sampling method 

the accuracy of pathologic evaluation is higher when a pathologist 

makes the procedures or cooperates to them. 

Whether a lesion should be punctured or not it depends on 

many different aspects, and most of them are basically clinical 

and radiological ones. In many centres, if a mass is resectable 

the surgeons perform a pancreatectomy. A morphological diagnosis 

has to be served to all patients, either on the primary 

or secondary lesions, before to plan chemotherapy.

248 

In ductal carcinoma the cytologic smears are characterized 

by high celluarity, and the presence of relatively pure neoplastic 

cellular component. Major criteria of malignancy are 

considered: the presence of nuclear crowding and overlapping, 

the irregular chromatin distribution and the irregular 

nuclear contour, whereas minor criteria are the nuclear 

enlargement, the presence of single malignant cells, necrosis 

and mitosis. 

In the biopsy interpretation of a primary pancreatic lesion 

eight features are proposed as particularly helpful in the 

differential diagnosis with chronic pancreatitis: the loss of 

lobular architectural, resulting in a hazard distribution of 

glands, the variation in nuclear area greater than 4 to 1 from 

cell to cell, prominent and multiple nucleoli, the presence of 

incomplete glands, intraluminal necrosis, glands immediately 

adjacent to muscular artery, perineural invasion by glands and 

vascular invasion. 

Endocrine Neoplasms. The smears are hypercellular with 

a clean background, except for high grade neoplasia. The 

cells can be individually dispersed or arranged in clusters. 

The nuclei are frequently uniform, round to oval, with a salt 

and pepper pattern (coarse, finely distributed chromatin) but 

sometimes they can be pleomorphic and hyperchromatic. 

Acinar Cell Carcinoma. The loosely cohesive groups of cells 

show the typical acinar differentiation with a cytoplasm filled 

with deeply eosinophylic granules. The cells show signs of 

Marcatori predittivi morfo-molecolari in 

oncologia 

C. Doglioni 

U.O. Anatomia Patologica, Istituto Scientifico San Raffaele, Università 

Vita-Salute, Milano 

Estrogen Receptor represented in the early eighties the first 

predictive morpho-molecular marker utilized by Pathologists 

in helping Oncologists to select the appropriate therapy in 

breast cancer patients; it is still the most frequently assessed 

marker in pathology labs. The identification of gene alterations 

as molecular targets of several new drugs has prompted 

the introduction of new molecular diagnostic tests in our labs, 

most of which do not necessitate a morphological approach. 

However morphology based techniques, including immunohistochemistry 

and FISH, still have and they will maintain 

an important role in this scenario. FISH is a morphological 

technique and it is the gold standard for evaluating several 

relevant molecular targets i.e HER2, ALK1, ROS1. Mutation 

specific antibodies are new tools for evaluating specific mutations 

by immunohistochemistry in the tissue context; they can 

couple specificity and sensitivity at the single cell level. Examples 

of these mutation specific antibodies are EGFR E746- 

A750 del, EGFR L858R, IDH1 R132H, BRAF1 V600E: they 




Fattori predittivi 

Moderatore: Marco Chilosi (Verona) 

atypia, with prominent nucleoli and mitoses; necrotic debris 

are frequently found. 

To avoid the most frequent pitfalls, the pathologist should know 

in first instance all the clinical and radiological relevant features. 

The most important technical informations he has to know differ 

in solid and cystic lesions. In solid lesions the most important 

differential diagnosis is between ductal carcinoma and chronic 

pancreatitis, especially the tumor-forming pancreatitis, like the 

autoimmune pancreatitis. In cystic lesions, the most important 

bias are sampling errors. The recognition of gastric and duodenal 

epithelial contamination is the most important elements to be 

considered in the EUS-guided FNA cytology, especially in the 

differential diagnosis of mucin-secreting low grade neoplasia. 

The overdiagnosis of carcinoma has to be avoid in the presence 

of cellular atypia due to gastritis or duodenitis. 

The immuncytochemical features of ductal adenocarcinoma, 

are the expression of MUC1 and the lack of MUC2. MU- 

C5AC, normally expressed by the gastric mucous surface 

cells, are expressed in gastric type Intraductal papillary mucinous 

neoplasms. 

In endocrine neoplasms, the diagnosis may be confirmed by 

the immunohistochemical demonstration of endocrine markers 

such as chromogranin A and synaptophysin and the detection 

of hormone production. 

In acinar cell carcinoma, the most informative immunihistochemically 

stain is the acinar marker trypsin. 

represent an useful complement to mutation analysis and they 

could also, in selected case, surrogate molecular testing. 

Morpho-molecular predictive markers in nSCLC 

M. Chilosi, M. Brunelli 


The introduction of new therapeutic strategies in the clinical 

management of lung carcinoma has significantly changed 

the diagnostic approach to non-small cell lung carcinoma 

(NSCLC), and an increasing number of molecular tests with 

predictive significance that can be obtained using different 

approaches (immunohistochemical analysis, FISH, sequencing, 

etc.) are currently under investigation. Pathologists are 

requested to provide precise information regarding the histotype 

as defined by up-dated WHO classification, since the 

predictive role of histology has been clearly defined, and a 

generic diagnosis of NSCLC is not sufficient. The precise distinction 

of lung adenocarcinoma from squamous carcinoma 

is mandatory in all cases, also when very small amount of 

tissue is available (e.g. on cytological preparations and small 

biopsies). The search for an optimal immunophenotypic panel 

has been the matter of several studies and different marker 

combinations and protocols have been proposed to define a

RElaziONi 

“gold-standard panel”. Information regarding specific molecular 

abnormalities of neoplastic cells is necessary in order 

to assess the eligibility of Patients to specific “targeted” therapies. 

New strategies are currently under evaluation to define 

simplified diagnostic charts based on morpho-molecular techniques 

useful to detect and quantify abnormalities in target 

pathways. FISH analysis is the gold-standard technique for 

evaluate the presence of gene translocations, amplifications, 

gains and losses (e.g. FISH analysis for ALK translocation, 

FGFR1 gene amplification). New antibodies can provide better 

evaluation of target-protein expression (e.g. ALK). The 

availability of mutation-specific monoclonal antibodies (e.g. 

specific for BRAF V600E mutation) can represent a promising 

tool in future studies. BRAF and C-MET genes are going 

to be promising biomarkers, selected for new clinical trials. 

Co-targeting more molecular pathways such as pi3k–Akt, 

Ras–Erk, T790M, and c-Met, together with ErbB receptors, 

may produce anticancer effects that are more optimal. 

An extremely important key-point will be to understand the 

driven receptor regulators involved in receptor degradation or 

recycling. An ubiquitin lipase c-Cbl involved in internalization 

and degradation of the epidermal growth factor receptor 

(egfr) is frequently mutated or lost in lung cancer and stressactivated 

kinases such as p38 have been implicated in egfr 

recycling and endosomal accumulation. Those events may 

contribute to resistance to antibody or tyrosine kinase inhibitors 

in the treatment of NSCLC. Overall, co-targeting key 

pathways involved in receptor recycling and receptor activity 

may increase treatment efficacy and decrease the development 

of tumour resistance. 

Since the 1980s, chemotherapy for patients with non-smallcell 

lung cancer has been shown to provide a small improvement 

in survival. In the early 1990s, platinum-based regimens 

became the treatment of choice. In 2002, the Eastern Cooperative 

Oncology Group 1594 clinical trial showed that there was 

no overall survival difference among four common chemotherapy 

regimens used in non-small-cell lung cancer. It was 

not until 2006 when the introduction of biologic agents into 

the field of lung cancer improved, for the first time ever, median 

overall survival beyond 1 year. Nowadays, we recognize 

that there are differences between all histological subtypes 

of non-small-cell lung cancer in terms of their response to 

specific agents. All these plus the introduction of molecular 

medicine have resulted in the identification of markers for 

prognosis and prediction in lung cancer. 

ALK 

In a subset of patients with NSCLC, the anaplastic lymphoma 

kinase (ALK) and echinoderm microtubule-associated protein 

like 4 (EML4) gene have been recently found to undergo 

fusion as a result of an inversion on the short arm of chromosome 

2 resulting in the novel oncogene EML4-ALK. This 

gene rearrangement occurs largely independent from EGFR or 

K-Ras mutations. Patients with this fusion oncogene tend to be 

younger, have adenocarcinoma with acinar histology, and be 

never or light smokers. The overall incidence of EML4-ALK 

rearrangement has been reported to be 4% - 7%. Patients 

harboring the fusion oncogene were retrospectively studied 

to examine its effect on both cytotoxic chemotherapy and 

tyrosine kinase inhibitor therapy response. When comparing 

those who did and did not harbor the EML4-ALK fusion oncogene, 

there were no differences in response rates or time to 

progression in those treated with platinum-based combination 

therapy, whereas there was no clinical response and a time to 

progression of 5 months for those treated with EGFR TKIs. 

While these patients appear to be resistant to EGFR TKIs 

249 

such as erlotinib and gefitinib, the small molecule tyrosine 

kinase inhibitor crizotinib has shown activity against cell lines 

containing the EML4-ALK fusion oncogene. A Phase II trial 

of NSCLC patients who harbored EML4-ALK demonstrated 

a radiographic response rate of 57% and a disease control rate 

of 87% at eight weeks after receiving crizotinib 250 mg twice 

daily. Progression free survival at six months had an estimated 

probability of 72%. These results have led to a phase III trial 

comparing crioztinib to standard, single-agent docetaxel or 

pemetrexed in EML4-ALK positive NSCLC patients with 

metastatic disease who have received one prior line of chemotherapy 

(NCT00932893). 

EGFR 

Several studies have shown that EGFR over-expression, as 

determined by immunohistochemistry, appears to confer 

a poor prognosis in patients with NSCLC. However, these 

results have not been confirmed in other studies. Given the 

conflicting data that are currently available, EGFR does not 

have a clear role as a prognostic marker in NSCLCs. With the 

recent advances in the development of EGFR-targeted therapy, 

however, it has become increasingly important to define 

predictive markers that identify a subset of patients who are 

most likely to benefit from EGFR-TKI therapy. Since particular 

subtypes of NSCLC (squamous carcinomas, mucinous adenocarcinomas) 

do not usually harbor EGFR mutations, these 

histological subtypes can be defines as predictive, especially 

when validated by refined immunohistochemical profiles. 

FGFR1 

Non-small cell lung carcinoma cell line harboring focal amplification 

of FGFR1 is dependent on FGFR1 activity for 

cell growth, as treatment of this cell line either with FGFR1specific 

shRNAs or with FGFR small molecule enzymatic 

inhibitors leads to cell growth inhibition. A significant subset 

of squamous cell lung cancer usually show gains of FGFR-1. 

3q 

Squamous cell lung carcinoma usually show 3q gains and is 

a sensitive marker of squamous cell differentiation. The locus 

specific 3q region harbours several targeted genes and may 

show promising value as predictiveness to new inhibitors. 

Fattori predittivi morfo-molecolari nel 

carcinoma renale 

G. Martignoni, M. Brunelli, D. Segala 

Università di Verona, Dipartimento di Patologia e Diagnostica, Verona 

Renal cell carcinoma (RCC) accounts for about 3% of all new 

cancer cases and the incidence rates for all stages have been 

steadily rising over the last three decades. Approximately 

one-third of patients present with metastatic disease at the 

initial diagnosis and more than 40% of patients will eventually 

die from their cancer. Despite the introduction of new treatment 

regimens, surgical resection remains the only curative 

therapy for RCC. However, up to 50% of patients undergoing 

nephrectomy for clinically localized RCC will develop local 

recurrence or distant metastasis. 

RCC comprises a heterogeneous group of epithelial tumors 

with various cytogenetic and molecular abnormalities and different 

histological features. The taxonomy of renal epithelial 

neoplasms has evolved greatly over the past two decades. 

Landmark consensus conferences held in Heidelberg (1996) 

and Rochester (1997) laid the foundations for our modern 

classification system. Detailed morphological studies incorporating 

contemporary immunohistochemical and molecular

250 

techniques have resulted in the current classification of renal 

epithelial neoplasms as outlined in the 2004 World Health Organization 

(WHO) monograph. The common renal cell carcinomas 

of clear cell, papillary and chromophobe types, account 

for 85–90% of the renal tubular malignancies encountered in 

routine practice. The remaining 10–15% includes a variety of 

uncommon sporadic and familial carcinomas, some of which 

have been recently described, along with a group of unclassified 

carcinomas. Selected uncommon, recently described and 

emerging forms of renal cell carcinoma are discussed in the 

current Literature, in particular the mucinous tubular spindlecell 

carcinoma, tubulocystic carcinoma, translocation carcinoma, 

carcinoma in neuroblastoma survivors, dialysis associated 

carcinoma, oncocytic papillary renal cell carcinoma, clear cell 

papillary renal cell carcinoma, clear cell renal carcinoma with 

prominent leiomyomatous proliferation. 

At a molecular diagnostic level, cytogenetic studies have 

shown that 3p deletions are linked to clear cell RCC, occurring 

in 40-70% of tumors with this histological subtype. LOH 

analyses with matched pairs of RCC tumor/normal kidney 

DNA have detected losses of 3p sequences in about 80% of 

clear cell RCCs. A very high prevalence of 3p deletions (98%) 

has been reported in DNA extracted from tumor cell lines 

after culture. This discrepancy suggests that there may be 

intratumoral heterogeneity of 3p deletions in RCCs. Previous 

molecular studies demonstrated that at least three separate regions 

are critical in the development of RCCs, one coincident 

with the VHL disease gene on 3p25.5, one at 3p21-22, and 

one at 3pl3-14. The VHL gene on 3p25.5 is the most likely 

candidate for a clear cell renal tumor suppressor gene because 

somatic VHL gene mutations were identified in about 50% of 

RCCs. It seems likely that VHL inactivation occurs even more 

fre quently because hypermethylation of the VHL promoter 

region, yet another mechanism for gene inactivation, has been 

observed in an additional 20% of RCCs. Thus it is assumed 

that the inactivation of one or more genes on 3p plays a role 

in RCC initiation. Aiming at a potential diagnostic application 

of genetic analyses, the extent of genetic heterogeneity that 

involves potential marker alterations is of importance. At light 

of emerging renal tumours with a clear cell-like morphology 

but characterized by lack of 3p abnormalities and VHL mutation, 

the knowledge of the heterogeneity in small and larger 

tumours and the impact of routine molecular techniques in the 

diagnostic practice need to be evaluated and the magnitude of 

this pitfall be seized. 

At a prognostication level, several algorithms and nomograms 

for RCC survival or recurrence after nephrectomy have 

been developed that incorporate multiple clinicopathological 

prognostic factors such as TNM stage, Fuhrman grade, tumor 

size, performance status. Accumulation of genetic aberrations 

plays a pivotal role in the initiation and prognosis of RCC and 

other cancers. Integration of genetic markers into traditional 

approaches may allow a more accurate prediction of prognosis. 

Conventional cytogenetic and gene expression profiling 

identified a number of chromosome aberrations in development 

ccRCC. Several chromosomal abnormalities, such as 

deletions of 8p, 9p, and 14q, have all been suggested to correlate 

with worse stage and grade, but only a minority of studies 

included survival as an end point. Previous studies suggest 

that gain of chromosome 5q is associated with improved overall 

survival and that losses of 8p and 9p chromosomal material 

predict poorer recurrence-free survival. The ultimate goal of a 

cytogenetic stratification is to improve post-operative clinical 

risk-stratification systems via the incorporation of cytogenetic 

data, which may help to personalize therapy and surveillance. 


Moreover, recent Literature focused on models developed to 

predict survival of RCC patients. Two mathematical models 

including clinical variables only (Yaycioglu, cI 0.651; Cindolo, 

cI 0.672); 2 algorithms including also pathological variables 

(SSIGN, cI 0.819; UISS, cI 0.79-0.84), 5 nomograms 

(Kattan, cI 0.76-0.86; Sorbellini, cI 0.82; Kim 2004, cI 0.79, 

Kim 2005, cI 0.68; Karakiewicz, cI 0.86); 2 algorithms for 

patients with metastatic disease (Motzer, Leibovich). 

One of the most applicable prognostic score among the most 

common clear cell renal cell carcinoma treated with radical 

nephrectomy is the SSIGN score. The SSIGN (Size, Staging, 

Grading, Necrosis) score allows clinicians to assess the effects 

of tumor characteristics on outcome, which can be used to 

improve treatment, and develop and assess adjuvant therapies 

for renal cell carcinoma. Many of common models focus on 

metastatic renal cell carcinoma only and divided patients according 

to risk. 

The SSIGN is the most accurate algorithm for clear cell RCC, 

while the UISS allowed the evaluation of patients regardless 

of tumor histotype. The Sorbellini nomogram is applicable 

only for patients with clear cell RCC, while the Kattan and 

Karakiewicz nomograms also provide information for other 

histotypes. Metastatic patients can be evaluated with Leibovich 

and Motzer algorithms. Two models combine molecular 

markers and clinical features (Kim 2004-2005). 

Overall, these models do not include cytogenetic abnormalities. 

Only recently, loss of chromosome 9, can provide additional 

prognostic information to standard clinicopathologic 

variables. Genetic information can provide important prognostic 

information that augments standard clinicopathologic 

analysis. The magnitude of this prognostic information has to 

be validated. 

Finally, at a molecular target level, there is substantial 

evidence of an association between mutation on von Hippel- 

Lindau (VHL) gene and the earliest stages of tumorigenesis 

of RCC. The main consequence of VHL loss is the upregulation 

of downstream proangiogenic factors leading to highly 

vascular tumors. Overexpression of hypoxia inducible factor 

(HIF) is also caused by the mammalian target of rapamycin 

(mTOR), a key component of signaling pathways inside the 

cell, involved in cell proliferation. The inhibition of proangiogenic 

factors and mTOR was the main idea behind the 

development of new targeted agents in advanced RCC. Since 

December 2005, 3 targeted agents have been approved by the 

U.S. Food and Drug Administration (FDA) for the treatment 

of advanced RCC: sorafenib, sunitinib and temsirolimus. Sorafenib 

and sunitinib are synthetic, orally active agents shown 

to directly inhibit vascular endothelial growth factor receptors 

-2 and -3 (VEGFR-2, VEGFR-3) and platelet-derived growth 

factor receptor beta (PDGFR-beta), while temsirolimus is an 

mTOR inhibitor. 

MGMT evaluation in patientes whit glioblastoma 

and high grade glioma 

F. Castiglione1 , A.M. Buccoliero2 , I. Aguzzi3 , D. Moncini1 

, M. Panfili3 , P. Pretelli1 , B. Detti, G. Peruzzi1 , G. Rossi 

Degl’Innocenti1 , G.L. Taddei1 1 Università di Firenze Dipartimento di Area Critica Medico- Chirurgica. 

Sezione di Anatomia Patologica; 2 Azienda Ospedaliro, Universitaria 

Meyer; 3 Quiagen Italia 

Introduction. Glioblastoma is the most common and most 

aggressive brain tumor that had an average survival of an 

year from the diagnosis. Standard therapy consists in sur-

RElaziONi 

gery, followed by radiotherapy. In the last thirty years the 

role of adjuvant therapy with chemotherapy has been long 

investigated and discussed. Some cooperative clinical trials 

studied the addition of various chemotherapy regimens to 

radiotherapy but no randomized phase III clinical trials demonstrated 

a benefit from the employment of adjuvant chemotherapy 

based on nitrosourea. Furthermore, a meta-analysis 

comprising 12 randomized studies suggested a little survival 

benefit in those patients who were treated with chemotherapy. 

Temozolomide, an oral alkylating agent of recent introduction, 

has demonstrated antineoplastic activity as single 

agent in the treatment of relapsing glioma. Temozolomide 

fulfills its tumoricidal activity by altering DNA and by determining 

consequently genetic damages that are incompatible 

with cell life. Recent studies demonstrated a key role 

of the enzyme O-6-methylguanine-DNA-methyltransferase 

(MGMT) in the resistance mechanism to alkylating drugs. In 

fact this enzyme removes the genetic alteration produced by 

alkylating agents and protects therefore the neoplastic cell 

from the lethal damages induced by these drugs. According 

to the knowledge of MGMT-induced repair mechanisms and 

with the intent to overcome the resistance to temozolomide 

in GBM, some studies have developed new temozolomide 

administration methods able to work on MGMT. In fact, 

the administration of 75 mg/m 2 temozolomide for six weeks 

demonstrated a reduction of MGMT enzyme activity. The 

reduction of this enzyme activity is important because low 

levels of MGMT in tumor tissue are associated with longer 

survival in patients with glioblastoma treated with adjuvant 

chemotherapy. Furthermore, if associated with radiotherapy, 

it can improve its efficacy. On the basis of these assumptions 

the EORTC (European Organization for Research and Treatment 

of Cancer) and the NCIC (National Cancer Institute of 

Canada) have planned and developed a broad randomized 

phase III study that includes 573 patients, treated in 85 

European and Canadian centers. This study has compared 

efficacy and tolerability of radiotherapy alone compared to 

the treatment with temozolomide, concomitant and adjuvant 

to radiotherapy. 

Methods. Patients with a new histological diagnosis of glioblastoma 

have been randomized to receive only radiotherapy 

(focal irradiation divided in daily fraction of 2 Gy administered 

five days a week for six weeks, for a total administration 

of 60 Gy) or radiotherapy with a daily continuous treatment 

with temozolomide (75 mg/m 2 /die, seven days a week, from 

the first to the last day of radiotherapy), followed by six cycles 

of adjuvant treatment with temozolomide (from 150 to 200 

mg/ m 2 /die, for five days every 28 days). The main objective 

has been the survival assessment. 

Results. 573 patients, coming from 85 European and Canadian 

centers, have been randomized. The average age was 56 

years old and 84 % of patients underwent debulking surgery. 

To a median follow-up of 28 months, median survival was 

of 14.6 months in patients treated with radiotherapy and te- 

251 

mozolomide, and of 12.1 months in those patients who were 

treated only with radiotherapy. Hazard ratio for death risk in 

the radiotherapy-temozolomide set had been of 0.63 (95% 

confidence interval, 0.52 - 0.75; p

252 

Predictive factors in colorectal carcinoma 

beyond KrAS 

A. Scarpa, V. Corbo 

Dipartimento di Patologia e Diagnostica, Policlinico GB Rossi, Università 

di Verona 

EGFR targeted monoclonal antibodies (cetuximab and panitumumab) 

have paved the way to the individualized treatments 

of metastatic colorectal cancer (mCRC). KRAS mutations 

emerged as the major negative predictor of response to those 

therapies. Mutations of KRAS occur in about 40% of mCRCs 

thus enabling for the selection of patients that might respond 

to anti-EGFR treatments. Unfortunately, the concept of a 

binary relationship between mutations in a given gene and 

response to therapy is not valid for mCRCs. Indeed, KRAS 

mutations testing showed high specificity but low sensitivity. 

A genetic basis for that failure has been recently demonstrated 

by studies focusing on additional genes involved in downstream 

EGFR signaling. Oncogenic mutations of BRAF or 

PIK3CA and mutations of the tumor suppressor PTEN have 

emerged as additional negative predictive markers. mCRCs 

lacking alterations of those genes (defined “quadruple negative”) 

have the highest probability to respond to anti-EGFR 

therapies. Very recent evidences showing that distinct mutations 

in a single cancer gene (such as codon-specific mutations 

of PIK3CA) might have different roles in response 

to therapy further complicated the scenario. However, the 

effective translation of these findings into clinical practice 

will empower the selection of patients eligible for anti-EGFR 

therapies. At the same time, despite genetic analysis of tumor 

samples are now part of the work of most pathology departments, 

the uncovering of the genetic milieu of individual 

colorectal cancer pose new challenges: testing simultaneously 

multiple genes in individual tumors using limited amount 

of tissue samples such as biopsy. The development of very 

sensitive and informative assay platforms is therefore mandatory. 

In line with this, a newly founded European Consortium 

coordinates a multi-institutional effort for the development 

and the implementation of a dedicated multi-gene panel test 

to be used for therapy decision and prognostic stratification 

in colon cancer. 

Predittività nel carcinoma mammario: 

uno sguardo oltre i fattori convenzionali 

A. Sapino 



Sabato 27 ottobre 2012 

Sala Botticelli - 11.30-12.30 

Fattori predittivi molecolari 

Moderatori: Antonio Marchetti (Chieti), Giancarlo Troncone (Napoli) 

Analysis of egfr mutations in circulating tumor 

cells by massively parallel sequencing 

F. Buttitta 

Cardiovascular and Oncological Molecular Medicine Unit, Ce.S.I. 

(Centro Scienze dell’Invecchiamento)- University “G. d’Annunzio”, 

Chieti 

The management of patients with advanced non-small cell 

lung cancer (NSCLC) is currently based on the assessment of 

EGFR mutations. The mutation test is routinely performed on 

resected neoplastic tissues, biopsies or cytological samples. For 

several patients with advanced lung cancer or with progressive 

disease, it can be a challenge to obtain biological material for 

molecular analysis. Circulating tumor cells (CTC) are rare 

cells detectable in the blood of neoplastic patients and their 

enumeration has been shown to correlate with clinical outcome 

in patients with several types of malignancies. Furthermore, 

CTCs appear to be a non-invasive source of tumor cells, providing 

real-time information on biomarker status without the 

need for invasive re-biopsy. Over the last few years, a set of 

novel technologies for CTCs detection has emerged, including 

nucleic-acid-based and cytometric approaches. The first class 

of methods is predominantly represented by very sensitive 

PCR-based techniques for the detection of specific DNA or 

RNA sequences. More recently, there has been a shift towards 

cytometric procedures because these methods allow the cells 

to maintain integrity in order to be identified and counted. The 

most widely used CTC detection platform is the CellSearch 

system (Veridex LLC, Huntingdon Valley, PA, USA), which 

is the only technology to have received FDA approval for the 

enumeration of CTC in whole blood of patients affected by 

breast, prostate and colon cancer. CellSearch platform utilizes 

a semi-automated immunomagnetic bead-based separation to 

enrich CTCs. However, CTCs isolation is until now a challenge, 

because they occur at very low concentration of one cell 

in the background of millions of white blood cells. Therefore, 

their molecular characterization requires extremely sensitive 

and specific procedures. We decided to analyze EGFR mutation 

in CTCs isolated from plasma of a series of lung cancer 

patients. The CTCs enriched by CellSearch platform were 

subsequently analyzed by massively parallel sequencing on GS 

Junior 454-Roche, a novel approach that can allow the detection 

of genetic mutations even if they are present in a minority 

of DNA molecules. This platform is able to run thousands of 

gene sequences per sample from a single PCR and therefore 

it is an ideal approach for gene sequencing of rare DNA molecules, 

such as those extracted from circulating tumor cells in 

a high background of white cells. 

Le mutazioni del gene BrAF nel trattamento del 

melanoma metastatico 

F. Castiglione 

Paper not received

RElaziONi 



Qualità e sicurezza nei servizi di anatomia patologica – Parte I 

Moderatori: Domenico Ientile (Palermo), Fabio Vecchio (Roma) 

Linee guida del Ministero della Salute per il 

miglioramento della qualità e sicurezza delle 

cure 

A. Ghirardini 

Ministero della Salute, Direzione Generale della programmazione 

Sanitaria 

La Sicurezza dei Pazienti è una componente strutturale dei 

Livelli Essenziali di Assistenza, a forte valenza etica, che il 

SSN assume come requisito per l’erogazione delle prestazioni 

sanitarie previste dai LEA. In questa linea il Ministero della 

Salute, Direzione Generale della programmazione Sanitaria ha 

condotto azioni di sistema, nell’ambito delle attività strategiche 

del Ministero della salute, con riferimento alla introduzione ed 

implementazione delle attività di Clinical Governance, di cui la 

sicurezza dei pazienti rappresenta uno dei pilastri fondamentali. 

Sulla base dello sviluppo della cultura della sicurezza “imparare 

dall’errore”, il cui principio è quello di apprendere dall’errore 

per mettere in atto misure efficaci di prevenzione, è in corso 

e sarò ulteriormente rafforzata la progressiva implementazione 

di tre livelli di intervento, tra loro complementari e rispondenti 

ai criteri di priorità nazionale: 

il monitoraggio per la raccolta delle informazioni relative agli 

eventi avversi e dei sinistri, tramite un sistema informatico 

che consenta agli enti ed utenti autorizzati di poter alimentare 

le basi dati degli eventi sentinella e delle denunce di sinistro, 

che consenta ai livelli di Governo (Centrale e Regionale) di 

monitorare la dimensione del problema degli errori in sanità e 

la sua distribuzione specifica; 

le raccomandazioni elaborate sulla base delle informazioni 

raccolte tramite il monitoraggio, hanno lo scopo di fornire 

indicazioni agli operatori circa le azioni da intraprendere per 

migliorare la qualità dell’assistenza 

la formazione del personale che ha lo scopo di incrementare la 

conoscenza degli operatori rispetto a metodi e strumenti per il 

miglioramento della sicurezza dei pazienti, tramite la definizione 

e la relativa erogazione di un piano formativo a tutti gli 

operatori sanitari che operano nel servizio sanitario nazionale, 

favorendo le capacità di analisi e di messa in atto di misure di 

contrasto rispetto agli errori. 

Quality control in anatomic pathology 

L. Viberti 

Direttore S.C. Anatomia Patologica Ospedali Martini e Valdese di 

Torino, ASL TO1 

Each Department of Pathology should prepare a quality 

control plan for minimizing diagnostic error rate that in the 

literature varies from 0.26 to 1.2%. 

The final report is the expression of all the steps of pathologists’ 

work that starts with the reception of the specimen and 

ends with the histological diagnosis. The main reasons of the 

errors may be: defective identification, defective specimen, 

defective report and defective interpretation. 

253 

The defective interpretation may have no impact on care, or 

can vary from a minimal harm to a severe harm. 

The review method is considered the best way to operate a 

control on diagnostic quality, and the selection of cases to 

check can be a tool for the risk management. 

The recommendations of Association of Directors of Anatomic 

and Surgical pathology for surgical and autopsy pathology, 

suggest that intra-departmental consultation must be 

carried out in reviewing selected cases by the diagnostic staff 

as a group or by a consultant pathologist and that these ways 

should be indicated in the pathology report. 

For intra-operative consultation is recommended that all cases 

must be regularly reviewed and that the concordance level 

must be placed in the following categories: agreement, deferral-appropriate, 

deferral-inappropriate, disagreement-minor, 

and disagreement-major. One considers that an acceptable 

threshold for disagreement major case is 3% and for deferred 

inappropriate cases is 10%. 

Random case review is suggested and also clinical indicators 

on the basis of the organ or lesion or procedure can be selected 

for systematic re-evaluation. 

It is also important to maintain an acceptable turnaround 

times for Surgical Pathology reports, as expression of risk 

monitoring. 

The using of sign-out check list, based on previously published 

literature on causes of discrepancies in pathology laboratories, 

can help pathologist to evaluate the risk of making 

incorrect decision and select the cases for a second review. 

Standardizzazione delle procedure: come, cosa 

e perchè 

R. Giardini 

Istituti Ospitalieri di Cremona, Anatomia Patologica, Cremona 

L’anatomia patologica e la medicina di laboratorio stanno 

attualmente sperimentando svariati modelli di cambiamento, 

che, con molta probabilità, saranno in grado di modificare 

profondamente, in un futuro non troppo lontano, il modo di 

praticare la specialità: svariate tecniche innovative in immunocitochimica, 

l’espansione della patologia molecolare e 

l’estesa informatizzazione stanno portando all’acquisizione di 

nuove ed eccitanti informazioni nel campo della diagnostica 

anatomopatologica. Questo fenomeno, tuttavia, se da un lato 

incrementa le finalità dell’informazione diagnostica, aggiungendovi 

dati di tipo prognostico e predittivo di risposta alla 

terapia, dall’altro impone la necessità di verificare, attraverso 

meccanismi di convalida basati sull’evidenza, che le informazioni 

prodotte siano “di qualità”. L’applicazione sempre più 

estensiva della tecnologia esige, ogni giorno di più, che anche 

il patologo debba sforzarsi di abbandonare l’”eminence based 

medicine”, sinora seguita in virtù del carattere eminentemente 

interpretativo della propria disciplina, per basarsi su più robusti 

gradi di evidenza. 

I manuali di procedure e le linee guida nascono come strumen-

254 

to che ha l’obiettivo di permettere all’operatore di fare scelte 

“informate”, basandosi sull’analisi delle prove scientifiche e 

sulla valutazione dei rischi e dei benefici di qualsiasi azione. 

Di più, manuali di procedure e linee guida si sono rivelati uno 

strumento di aggiornamento per i professionisti, di educazione 

ed informazione per i pazienti e di riferimento esterno con cui 

si rende possibile una verifica di quel che il professionista è 

in grado di produrre. Tutto questo può essere riassunto nel 

concetto di qualità della prestazione professionale. 

Anche se l’anatomia patologica diagnostica è ancora relativamente 

lenta nell’abbracciare la pratica ed i principi 

della medicina basata sull’evidenza, in parte perché storicamente 

il patologo è stato, da sempre, “l’evidenza” rispetto 

all’elucubrazioni cliniche, la pratica operativa all’interno 

d’una struttura d’anatomia patologica, dato l’alto livello 

d’interscambio intra- ed extra-aziendale (consultazioni, centralizzazioni 

di casistiche, controlli di qualità, campagne di 

screening) è improntata abitualmente e, per così dire, fisiologicamente, 

al conformarsi a protocolli e standard definiti 

ed accettati, anche se, abbastanza spesso, non capillarmente 

estesi a tutti i professionisti e talora conosciuti solo all’interno 

di una specifica branca di specializzazione, per organo 

e/o per patologia. Questo, tuttavia, avviene spesso in modo 

implicito, non formalizzato e, comunque, non come risultato 

di procedure metodologicamente rigorose ed esplicitamente 

dichiarate. Al contrario, sono prove di un implicito bisogno 

di riferimenti consolidati quegli strumenti procedurali che, 

nel tempo, sono stati messi a punto, a livelli quasi sempre 

qualitativamente elevati, da parte dei gruppi di studio nati 

in seno alla società scientifica o da parte di sezioni regionali 

della stessa. 

In effetti, da qualche tempo è stato avviato un confronto all’interno 

della SIAPEC-IAP sull’uso di strumenti di lavoro, come 

manuali delle procedure, linee guida diagnostiche, indicazioni 

di controlli di qualità, che, a nostro parere, sono sempre più 

rilevanti nell’attività diagnostica e che esprimono una valenza 

particolare, sia per l’accreditamento e la certificazione delle 

strutture di anatomia patologica, sia per il ruolo che il loro 

uso assume nella gestione del rischio nella nostra specialità. 

D’altro canto, che si voglia, o non si voglia, considerare 

l’anatomia patologica una branca delle medicine di laboratorio 

(quest’ultime connotate da un’impostazione analitica che 

contrasta con l’innegabile sintesi del referto della prima) va 

prendendo piede presso realtà istituzionali come le regioni 

l’estensione anche all’anatomia patologica di programmi per 

l’implementazione della qualità. Alcune regioni hanno elencato, 

sulla base di indicazioni di gruppi di esperti, criteri minimi 

per controlli di qualità interni. Altre realtà, come, ad esempio, 

il Piemonte, la Lombardia, il Lazio, hanno esperimentato 

controlli di qualità esterni volti alla concordanza diagnostica 

citoistologica o alla determinazione di fattori prognostici. 

Altri programmi, previsti da regioni come la Toscana e la 

Lombardia, possono comprendere variegate tematiche e modalità 

di svolgimento: collaborazione paritetica tra gli esperti 

per la definizione di procedure, linee guida ed ogni altra forma 

documentale, mediante incontri organizzati su tematiche 

specifiche relative: alla definizione di protocolli comuni per 

il monitoraggio della qualità dell’intero processo operativo 

(fasi preanalitica, analitica e postanalitica), a linee guida per 

l’accreditamento professionale, anche mediante audit, alla 

costruzione o alla revisione delle modalità di attuazione del 

controllo di qualità interno; incontri di formazione professionale 

rivolti agli operatori; effettuazione di visite ispettive da 

parte di esperti operanti in ambiti territoriali diversi, sino alla 

valorizzazione delle strutture regionali coinvolte nella gestio- 


ne della valutazione esterna di qualità. Alcune realtà istituzionali 

sono ben consce, attraverso il parere di esperti chiamati 

a costituire dei veri e propri comitati di riferimento, della 

particolarità della nostra disciplina, che rende difficoltoso 

istituire programmi di verifica di qualità che accertino l’intero 

processo anatomopatologico: ad esempio la non ancora risolta 

questione di poter riconoscere, anche in anatomia patologica, 

valori critici (diagnosi critiche) che possano essere utilizzate 

come riferimento per definire la qualità di tutto il processo di 

produzione di una diagnosi. 

Nell’ambito del pianeta qualità, dal punto di vista istituzionale, 

la SIAPEC-IAP ha costituito nel 2002 un gruppo di lavoro 

per definire le strategie dell’Associazione in merito a linee 

guida che possano essere rilevanti per l’attività anatomopatologica, 

redatte secondo i seguenti principali criteri: multidisciplinarietà 

del gruppo di lavoro autore delle linee guida, 

esplicito processo di ricerca bibliografica e grado dell’evidenza 

secondo manuale ASSR (ora AGENAS). Nell’ambito 

della collaborazione con AIOM stati istituiti gruppi di esperti 

che hanno redatto raccomandazioni per specifici argomenti di 

carattere biomolecolare, mentre alcuni gruppi di studio hanno 

pubblicato le modalità per una refertazione completa ed accurata 

di determinate patologie. Uno dei compiti che attende 

ora la società scientifica è sicuramente la sistematizzazione e 

l’imprimatur istituzionale e la successiva diffusione di quanto 

prodotto, i primi attraverso uno stimolo ai vari gruppi di studio 

di patologia e con un sistema di convalida da parte del gruppo 

di lavoro, e la seconda con la pubblicazione in uno spazio dedicato 

sul sito istituzionale. Ben più difficile, ma ugualmente 

essenziale e non più procrastinabile, lo stabilire le regole del 

gioco nel campo della verifica di qualità: in questo campo le 

necessità da soddisfare sono definire, in primis, la qualità e la 

riproducibilità di quanto deve essere controllato e l’estensione 

del controllo a tutte le fasi del processo diagnostico, con 

criteri di valutazione trasparenti e riproducibili. Rientrano 

nell’ambito della verifica di qualità: la valutazione di processo, 

di estrema rilevanza in considerazione della relativamente 

scarsa automazione dei processi diagnostici; la valutazione 

delle dotazioni e delle competenze logistiche e strumentali; la 

valutazione delle competenze tecniche, che comprende la valutazione 

delle tecniche immunocitochimiche e biomolecolari, 

anche attraverso sistemi di valutazione internazionale; la valutazione 

delle competenze diagnostiche, singole o di squadra. 

Nel caso della valutazione esterna di qualità risulta ancora più 

cruciale il ruolo delle segreterie regionali, indispensabile tramite 

tra le indicazioni della società e le esigenze di controllo 

delle istituzioni. 

La comunicazione della diagnosi istopatologica: 

destinatari, tempi di emissione e normative 

di riferimento 

G. Santeusanio 


La seconda opinione in anatomia patologica: 

introduzione al tema 

A. Fabiano 

Ospedale S.Giovanni Calibita Fatebenefratelli, UOC Anatomia 

Patologica, Roma 

È diritto del paziente per ottenere il miglior trattamento terapeutico 

per la sua patologia. In tale ambito c’è sempre un

RElaziONi 

maggior numero di pazienti che scelgono di farsi curare in 

strutture diverse da quelle dove è stata posta la diagnosi. Ed 

è a tutela del paziente e dell’istituzione la revisione diagnostica 

che comprende spesso quella istopatologica. Esiste un 

problema generale per l’anatomia patologica costituito dalla 

responsabilità dell’archivio istocitopatologico, questo determina 

alcunecriticità: 

a) il materiale non ripetibile come gli ago aspirati e il blocchetto 

di inclusione; b) il materiale da ago biopsia che può 

esaurirsi se utilizzato oltre che per fini diagnostici anche per 

la consulenza; 

c) la consegna del preparato su cui è stata posta la diagnosi o 

della sezione successivamente allestita. 

Tutto questo determina la necessità di acquisire delle linee 

guida per la richiesta, la restituzione e l’archiviazione della 

consulenza. La SIAPEC ha da tempo redatto delle raccomandazioni 

che sono inserite nelle linee guida della società e che 

vanno a proteggere il patologo da smarrimenti, impossibilità 

diagnostica del materiale fornito al paziente a fini consulenziali. 

Per il terzo aspetto, in attesa che la digitalizzazione del 

vetrino consenta il trasferimento di immagini, a mio parere 

è meglio conservare in archivio l’originale, ma se proprio 

si ritiene o lo si deve fornite è utile specificare che è stato 

consegnare il vetrino originale specificando che il materiale 

in archivio potrebbe non riprodurre la lesione su cui è stata 

formulata la diagnosi. 

Nel caso di consulenza su richiesta del paziente il reperto è 

spesso a disposizione dei non addetti ai lavori ed è assolutamente 

consigliabile che il consulente nel formulare il proprio 

referto diagnostico deve esprimere un parere seppur generico 

sulla propia concordanza con quanto precedentemente formulato. 

Questo per evitare che variazioni terminologiche siano 

intese come variazioni diagnostiche. 

Le consulenze possono essere, anche, richieste dal patologo 

per ottenere un parere da un collega esperto su quella determinata 

patologia, il problema non risolto è il valore legale di tale 

consulenza. In termini pratici se citare o meno la consulenza 

all’interno del referto e il valore giuridico che questo determina. 

In effetti il parere deve essere formulato per iscritto 

dal patologo, ma tale parere deve essere inserito per motivi 

assicurativi in un percorso istituzionalizzato. 

Occorre che sia validato dalle istituzioni (convenzioni, pagamento 

ecc.) consiglio, quindi, in assenza di questo un parere 

amicale da parte “dell’esperto patologo” che sia dal richiedente 

considerato di “conforto alla propria diagnosi”. 

Utile comunque formulare un elenco dei patologi consulenti a 

cui il servizio vuole rivolgersi in caso di necessità. Altrettanto 

importante è che la diagnosi del consulente sia criticamente 

valutata per poter giungere poi ad una diagnosi condivisa. 

L’istituto della mediazione civile nella 

responsabilità medica 

V. Cuffaro 

Ordinario di istituzioni di diritto privato nell’Università di Firenze 

1. L’incontro rappresenta una preziosa occasione per fare il 

punto ad oltre un anno dalla entrata in vigore, della innovativa 

disciplina introdotta dal decreto legislativo 4 marzo 2010 n. 

28. Disciplina integrata dalla emanazione del d.m. 18 ottobre 

2010 n. 280, riguardante l’organizzazione degli organismi di 

mediazione e l’approvazione delle indennità loro spettanti. 

Può essere utile innanzi tutto ricordare che l’istituto della 

mediazione può apparire nuovo rispetto al processo civile, 

ma certo non è sconosciuto nel panorama della produzione 

255 

legislativa nazionale che, da tempo, sta cercando di introdurre 

degli strumenti in qualche misura alternativi al processo. In 

termini necessariamente sintetici deve essere ricordato che 

nelle leggi sulla riforma delle Camere di Commercio, sul 

contratto di subfornitura, sul contratto di franchising sono già 

previsti strumenti conciliativi, ed altrettanto è avvenuto per 

quanto riguarda la disciplina delle controversie tra consumatori 

ed operatori bancari ovvero tra consumatori ed intermediari 

finanziari che pure affida ad una preliminare conciliazione la 

soluzione delle relative controversie. 

In questo panorama, l’istituto della mediazione obbligatoria, 

introdotto con il provvedimento del 2010, aspira a porsi come 

modello organico e funzionale allo svolgimento del processo 

civile; non di ogni processo civile, ma solo di quei processi 

che riguardano le non poche materie espressamente individuate 

dalla legge. 

2. Volendo esporre le linee portanti della nuova disciplina, 

possono essere individuati almeno quattro punti essenziali 

dell’istituto della mediazione obbligatoria. 

Per le controversie riguardanti determinate materie è prescritto, 

prima di iniziare il giudizio, l’obbligo di cercare una 

conciliazione. 

La conciliazione è affidata ad organismi, pubblici o privati, 

che devono rispettare determinati requisiti e sono sottoposti 

alla vigilanza ed al controllo del Ministero della Giustizia. 

Lo svolgimento della mediazione con un esito positivo, nel 

senso che le parti della potenziale controversia raggiungono 

una intesa conciliativa, determina vantaggi sul piano fiscale 

per le stesse parti. 

L’esito negativo della mediazione obbligatoria determina possibili 

ripercussioni sul processo. 

I quattro punti ora sinteticamente esposti sono certo suscettibili 

di maggiore approfondimento e la letteratura giuridica 

più recente è stata, infatti, prodiga di analisi e commenti. La 

quantità dei contributi è di ostacolo ad una sintesi in questa 

sede, ma almeno alcuni profili possono essere riassunti. 

Dunque, lo svolgimento della mediazione è obbligatorio. Lo 

strumento adottato dal legislatore per imporre alle parti un 

preventivo tentativo di conciliazione è quello della condizione 

di procedibilità dell’azione. Tecnicamente, il giudizio 

non può proseguire quando il giudice accerti che non è stata 

svolta la preventiva mediazione. Il quadro è tuttavia più articolato, 

in quanto l’art. 5, comma 1, della legge prevede che 

l’improcedibilità può essere non solo eccepita dal convenuto 

ma anche rilevata d’ufficio dal giudice nella prima udienza; 

l’art. 5, comma 2, delinea una mediazione successiva alla instaurazione 

del giudizio, cui il giudice può sollecitare le parti 

anche nella fase di appello; inoltre l’art. 5, comma 5, fa salva 

la possibilità che in contratti, statuti ed atti costitutivi societari 

sia previsto un obbligo preventivo di conciliazione, tale da 

determinare comunque una improcedibilità, tuttavia relativa 

giacché rimessa, in questo caso, solo all’eccezione della parte. 

L’esito positivo della mediazione e, quindi, il raggiungimento 

di una intesa conciliativa è agevolato da diversi vantaggi 

previsti sia per le parti che per i mediatori. Quanto alle parti, 

merita ricordare che a norma dell’art. 12, il verbale che reca 

l’accordo è idoneo a divenire titolo esecutivo e quindi ad 

essere utilizzato per la espropriazione forzata, l’esecuzione 

in forma specifica e l’iscrizione di ipoteca giudiziale; inoltre, 

l’art. 17 comma 3, esclude dall’imposta di registro sino al 

valore di € 50.000,00 il verbale recante l’accordo conciliativo, 

mentre, ai sensi dell’art. 20 comma 1, le somme corrisposte 

agli organismi di conciliazione valgono a costituire un credito 

di imposta sino alla concorrenza dell’importo di € 500,00.

256 

Quanto ai mediatori, in caso di successo della mediazione 

sono previste delle maggiorazioni massime delle indennità 

dovute, nella misura non superiore al 25%. 

L’esito negativo della mediazione, sia a motivo del rifiuto 

dell’altra parte di partecipare al procedimento sia per il mancato 

raggiungimento dell’intesa conciliativa, determina la 

possibilità di un complesso di effetti negativi. 

Infatti, se a norma dell’art. 11, co. 4 il mediatore deve fare 

menzione nel verbale del fallimento della mediazione per 

mancata partecipazione di una delle parti al procedimento, 

l’art. 8, co. 5 stabilisce che il giudice «dalla mancata partecipazione 

senza giustificato motivo al procedimento... può 

desumere argomenti di prova nel successivo giudizio ai sensi 

dell’art. 116 secondo comma c.p.c.». Ancora a rafforzare 

il meccanismo diretto a dissuadere dalla mancata partecipazione 

alla mediazione, sono previsti due ulteriori strumenti. 

Il disposto dell’art. 13, co. 1, prevede che se la decisione 

«corrisponde interamente al contenuto della proposta», il 

giudice: esclude la ripetizione delle spese per il vincitore che 

avrebbe potuto accettare la proposta conseguendo il medesimo 

risultato; condanna anzi al vincitore al pagamento delle 

spese a favore del soccombente; condanna altresì al versamento 

di una somma pari al contributo unificato; condanna 

al pagamento delle indennità corrisposte per la mediazione. 

Inoltre, ai sensi dell’art. 13, co 2, se la decisione «non corrisponde 

interamente al contenuto della proposta», ma «se 

ricorrono gravi ed eccezionali ragioni» il giudice può invece 

escludere la ripetizione delle spese sostenute dalla parte 

vincitrice per le indennità corrisposte al mediatore ed ai suoi 

eventuali ausiliari. Il quadro del sistema sanzionatorio è 

completato dalla previsione dell’art. 13, là dove è precisato 

che «resta ferma l’applicabilità degli articoli 92 e 96 del 

codice di procedura civile», norme riguardanti la responsabilità 

processuale. 

3. Questo sommariamente riassunto è, dunque, l’impianto 

della legge che impone, prima di intraprendere il giudizio il 

ricorso alla mediazione, appunto obbligatoria, in vista di una 

possibile conciliazione. 

Lo strumento della mediazione si iscrive così nell’ambito degli 

strumenti dichiaratamente disincentivanti che dovrebbero 

condurre alla auspicata diminuzione delle cause affidate al 

sistema giudiziario. 

Vien fatto di osservare che, in tal modo, il legislatore sembra 

non comprendere che l’alternatività della conciliazione si 

declina non rispetto alla ‘centralità’ della giurisdizione (che 

resta prerogativa dello Stato costituzionalmente garantita: artt. 

24 e 111 Cost.) bensì riguardo alla ‘priorità’ della giurisdizione, 

nel senso, esattamente colto dagli interpreti, dello «stato 

psicologico istintivo, in base al quale il ricorso alla giurisdizione 

viene invocato come il primo ed immediato rimedio». 

In altre parole, la conciliazione non può né deve supplire alle 

deficienze del sistema giudiziario, ma dovrebbe invece offrire 

solo una strada alternativa al giudizio. 

I dati raccolti nei primi sei mesi di operatività dell’istituto della 

mediazione, quindi nel periodo da marzo a settembre 2011, 

non sono certo incoraggianti. 

Gli uffici del Ministero della Giustizia riferiscono che nel 

suddetto periodo sono stati iniziati 33.000 procedimenti e, di 

questi 19.000 sono stati definiti. Quanto alle materie, il 26% 

delle controversie ha riguardato i diritti reali, mentre l’11% è 

riferibile a cause per il risarcimento di danni da responsabilità 

medica. Il 20% delle controversie si attesta su un valore tra i 

1.000 e i 5.000 euro. Solo il 27,7% dei ‘convenuti’ ha aderito 

alla richiesta di mediazione, ma quando entrambe le parti 


sono presenti innanzi al mediatore la composizione con esito 

positivo è raggiunta nel 58% dei casi. 

Dati, questi, che impongono allora di considerare il novero 

delle controversie rispetto al quale la mediazione è obbligatoria. 

Le controversie, indicate per materia, sono specificamente 

elencate nell’art. 5, senza che sia espressamente enunciato il 

criterio in forza del quale sono state selezionate. Solo nella 

relazione illustrativa al decreto si trovano elencati i tre criteri 

che avrebbero guidato la selezione. Il primo criterio terrebbe 

conto di controversie riguardanti rapporti di durata - condominio, 

locazione, comodato, affitto di azienda – nonché, ma 

con una evidente forzatura, di rapporti in cui sono coinvolti 

soggetti appartenenti: alla stessa famiglia [successione ereditaria 

e patti di famiglia], allo stesso gruppo sociale [divisione], 

alla stessa area territoriale [diritti reali]. Il secondo criterio ha 

invece riguardo alle controversie inerenti obbligazioni risarcitorie, 

senza distinguere tra le fonti dell’obbligazione e quindi 

tra responsabilità contrattuale o extracontrattuale, nelle quali 

si trovano accomunate fattispecie di diverso spessore: danni 

da circolazione di autoveicoli e natanti, danni da responsabilità 

medica, danni da diffamazione a mezzo stampa «o altro 

mezzo di pubblicità». Il terzo criterio attiene, poi, alle controversie 

riguardanti contratti assicurativi, bancari e finanziari, 

con il rinvio ai procedimenti conciliativi già previsti nella 

legislazione vigente. 

Dunque, a stare alla Relazione illustrativa del provvedimento, 

un criterio non c’è o, almeno, non è unitario. 

A tale riguardo possono qui essere formulati rilievi necessariamente 

sintetici. 

Mentre lo strumento della mediazione può apparire ragionevole 

con riferimento alla tipologia dei rapporti di durata, 

in quanto, sorta una controversia, un accordo amichevole 

è auspicabile rispetto a situazioni destinate a protrarsi nel 

tempo, meno comprensibile è l’inserimento nella lista delle 

controversie relative a questioni successorie o divisionali che, 

da un lato, non attengono di per sé a rapporti di durata, dall’altro, 

presupponendo competenze tecniche elevate (si pensi, ad 

esempio, ad una impugnativa di testamento ovvero ad una divisione 

per masse plurime), ben difficilmente potranno essere 

guidate verso una soluzione condivisa. 

Anche rispetto ai giudizi in tema di responsabilità, è certamente 

comprensibile lo scopo deflattivo che giustifica il riferimento 

alle controversie sulla responsabilità da circolazione 

di autoveicoli (anche se è da chiedersi quale sarà la risposta 

di un ‘mercato’ del quale sono protagonisti avvocati, periti, 

liquidatori etc.), mentre meno comprensibile è il riferimento 

alle altre ipotesi. Di fronte alle fattispecie di responsabilità 

medica, occorre infatti considerare che tali controversie 

possono comportare valutazioni particolarmente complesse 

sul piano dell’accertamento e quindi difficilmente gestibili 

senza l’ausilio dei consulenti tecnici, con il conseguente appesantimento 

della procedura che, invece, si vorrebbe snella 

ed informale. 

4. Resta, da ultimo, il novero dei problemi che la nuova disciplina 

necessariamente determina. 

Del primo si è già fatto cenno. La materia della responsabilità 

medica è individuata con una formula («risarcimento del danno 

derivante... da responsabilità medica») particolarmente 

ampia: gli operatori del settore sanno bene che rispetto alle 

controversie in tema di responsabilità, il quadro è variegato. 

Vengono innanzi tutto in considerazione i diversi titoli di 

responsabilità, a seconda che venga prospettata una responsabilità 

da inadempimento dalle obbligazioni derivanti dal

RElaziONi 

contratto, retta quindi dal dettato degli artt. 1218 e ss. cod. 

civ. ovvero una responsabilità da fatto illecito, collocata 

nell’ambito normativo dell’art. 2043 cod. civ.. Diversi sono 

poi i soggetti coinvolti nelle domande risarcitorie dei pazienti 

che assumono di aver subito un pregiudizio dall’atto medico 

o dall’atto clinico, in quanto la pretesa risarcitoria è sovente 

diretta – naturalmente a seconda della particolarità della singola 

fattispecie - non soltanto nei confronti del medico che ha 

eseguito l’intervento, ma anche verso gli altri professionisti 

coinvolti nelle fasi precedenti e successive ed ancora verso la 

struttura nella quale è stata eseguita la prestazione. Un panorama, 

quindi, non omogeneo e francamente poco ‘gestibile’ 

all’interno di un procedimento di mediazione. 

Procedimento che, come già rilevato, il legislatore ha delineato 

come snello e rapido nella durata, in quanto ha previsto 

che debba concludersi entro quattro mesi. Risultato, questo, 

difficilmente perseguibile quando, come avviene in tema di 

responsabilità medica, siano invece necessari delicati e sovente 

complessi accertamenti peritali. Anche la durata costituisce, 

quindi, un nodo problematico. 

Altre questioni ed altri problemi, attinenti allo svolgimento 

del procedimento, in questa sede possono essere soltanto 

elencati, senza necessità di una dettagliata analisi tecnica circa 

la compatibilità con le regole che reggono il processo civile. 

In primo luogo, manca qualsiasi previsione sul luogo di 

svolgimento della procedura di mediazione, il che rende possibile 

che la domanda di mediazione sia presentata presso un 

organismo di un luogo diverso dal Foro presso il quale dovrà 

invece instaurarsi il giudizio. Considerato che già sussistono 

una pluralità di organismi, sembra di poter osservare che nel 

momento in cui andrà a regime il sistema delineato nel decreto, 

dovrebbero essere presenti una pluralità di enti – pubblici 

e privati, costituiti dai diversi consigli degli Ordini, ma anche 

da associazioni e società di professionisti – tutti astrattamente 

idonei a fornire il servizio di mediazione. Rispetto a tale 

pluralità di organismi, tale forse da creare una sorta di ‘forum 

shopping’, potrebbe dunque accadere che ciascuno dei litiganti 

si rivolga ad un organismo diverso. La norma dell’art. 

4, comma 1 indica a tale riguardo, quale criterio di soluzione, 

quello della prevenzione, nel senso che «in caso di più domande 

relative alla stessa controversia la mediazione si svolge 

davanti all’organismo presso il quale è stata presentata la 

prima domanda», ma è facile immaginare le questioni che 

potranno al riguardo determinarsi. 

In secondo luogo, manca la considerazione della possibilità 

di domande riconvenzionali, così come nulla è previsto circa 

la possibilità della chiamata di terzo nel procedimento. 

Istituto, questo della chiamata di terzo, che ha certo particolare 

applicazione proprio nella materia della responsabilità 

medica. 

Altra questione, particolarmente delicata in relazione alla materia 

della responsabilità medica, è determinata dalla formula 

che si legge nell’art. 11, co. 1, là dove prevede che «quando 

l’accordo non è raggiunto, il mediatore può formulare una 

proposta di conciliazione». Formula che lascia spazio ad una 

serie di domande. Il regolamento dell’organismo potrebbe 

prevedere che il mediatore formuli comunque la proposta? 

Ancora, la proposta può essere formulata in caso di mancata 

partecipazione di una parte al procedimento di mediazione? 

Infine, la proposta deve essere motivata? Domande che, allo 

stato, in assenza di una qualche indicazione tratta dai lavori 

preparatori ed ovviamente di una compiuta elaborazione 

giurisprudenziale, possono ricevere risposte solo nel segno 

della ragionevolezza. Quanto alle due prime domande, la 

considerazione degli effetti che, a norma dell’art. 13, deriva- 

257 

no dalla formulazione della proposta, induce a ritenere che 

entrambe debbano ricevere una risposta negativa giacché 

l’effetto sanzionatorio non può essere imposto all’altra parte, 

mentre la mancata partecipazione al procedimento trova già 

specifica sanzione nel combinato disposto degli artt. 8, comma 

5 del decreto e 116, comma 2 cod. proc. civile. Quanto 

alla motivazione della proposta, dovrebbe essere esclusa dalle 

disposizioni che impongono al mediatore la inutilizzabilità di 

quanto acquisito nel corso del procedimento. D’altronde, una 

eventuale motivazione finirebbe per avvicinare la proposta ad 

una sorta di decisione; un risultato incongruo con la ratio del 

procedimento di mediazione. 

Resta l’ultima e certamente più difficile questione. 

Il vero e centrale problema rimane, a mio avviso, quello delle 

persone che comporranno gli organismi di mediazione e che in 

concreto svolgeranno il ruolo di mediatore. Se, infatti, merita 

apprezzamento l’impegno intellettuale ed etico che ha suggerito 

la scelta legislativa di creare un modello effettivamente 

alternativo alla controversia dinanzi ai giudici, non possiamo 

dimenticare che la partita sulla efficienza e, prima ancora sulla 

credibilità, dell’istituto della mediazione obbligatoria si gioca 

tutta su questo punto, ed è su tale aspetto della vicenda che 

dovrà rivolgersi il rigore del Ministero nel vigilare sugli organismi 

e degli organismi nel vigilare sui mediatori individuati. 

L’esperienza negativa sul tentativo obbligatorio di conciliazione 

in materia di lavoro trova una delle principali spiegazioni 

nella mancanza di professionalità delle persone cui il 

tentativo è stato affidato; e tale esperienza non può essere 

dimenticata se si intende realizzare uno strumento di soluzione 

delle controversie effettivamente alternativo alla giurisdizione. 

Altrimenti dovremmo constatare che l’articolato e 

complesso impianto sulla mediazione obbligatoria conduce al 

solo risultato di determinare un differimento di quattro o più 

mesi della data di inizio del processo. 

Epidemologia degli eventi avversi e gestione 

del rischio clinico 

R. Tartaglia, S. Albolino, T. Bellandi, E. Bianchini, A. Biggeri, 

G. Fabbro, L. Bevilacqua, A. Dell’Erba, G. Privitera, 

L. Sommella 

Adverse events and preventable consequences: retrospective study in 

five large Italian hospitals, Epidemiol Prev. 2012 May;36(3-4):151-61. 

Negli ospedali italiani si sbaglia più o meno quanto in quelli 

francesi, spagnoli, olandesi e canadesi: in circa 5 casi su cento. 

Molto meno se si considera la mediana dei tassi dei più importanti 

studi (9%) pubblicati su riviste accreditate. 

Ma soprattutto, in oltre il 56% dei casi gli errori clinici possono 

essere prevenuti. In questo caso il dato internazionale, pari 

al 43,5%, è più favorevole rispetto a quello italiano. 

Il primo studio italiano sull’epidemiologia degli eventi avversi 

(Tartaglia et al., 2012), finanziato dal Ministero della 

Salute, ha consentito di determinare il tasso d’incidenza degli 

eventi avversi nel nostro Paese e la loro prevenibilità mediante 

la revisione sistematica e con modalità predefinite di 

7.573 cartelle cliniche. I revisori impegnati nel secondo step 

di analisi erano medici opportunamente addestrati e formati a 

svolgere tale verifica. 

Lo studio ha misurato l’incidenza degli eventi avversi causati 

o evidenziati durante i ricoveri avvenuti in un anno in cinque 

grandi ospedali italiani. 

Sono stati inoltre calcolati i seguenti parametri: la percentuale 

dei pazienti riammessi per evento avverso; il grado di prevenibilità 

degli eventi avversi; le specialità più coinvolte.

258 

L’incidenza media complessiva di eventi avversi è stata determinata 

del 5,2%, quella mediana del 5,5%: è coerente con l’atteso 

nel protocollo di studio e si colloca a un livello in media più basso 

rispetto al tasso mediano degli studi internazionali (9,2%). 

La distribuzione di eventi avversi per specialità è risultata prevalente 

in area medica (37,5%); contrariamente ad altri studi, 

la chirurgia è in seconda posizione (30,1%), seguita da pronto 

soccorso (6,2%) e ostetricia (4,4%). 



Riguardo alle conseguenze degli eventi avversi, essi possono 

essere di più tipologie: prevale il prolungamento della degenza 

come conseguenza più frequente, seguito dalla presenza 

di una disabilità al momento della dimissione, mentre il decesso 

del paziente ha un’occorrenza mediana del 9,5%. La 

concordanza tra revisori è risultata piuttosto elevata (in media 

superiore al 95%). 

Qualità e sicurezza nei servizi di anatomia patologica – Parte II 

Moderatori: Domenico Ientile (Palermo), Fabio Vecchio (Roma) 

L’errore di diagnosi e variabilità diagnostica in 

anatomia patologica 

A. Fabiano 

Ospedale S. Giovanni Calibita Fatebenefratelli, UOC Anatomia Patologica, 

Roma 

La diagnosi clinica di un patologia si basa sull’analisi dei 

segni clinici e sintomatici di un paziente e dal risultato di 

specifiche indagini strutturali. La diagnosi istopatologica è un 

documento medico di importanza notevole che deve descrivere 

in modo meticoloso e conciso tutte le rilevanti caratteristiche 

del caso e trasmetterle al clinico, deve essere formulata 

rapidamente, deve essere accurata, deve essere una sintesi 

interpretativa degli aspetti morfologici strutturali e delle caratteristiche 

istocitopatologiche che costituiscono la lesione. Nel 

referto il patologo deve evitare termini tecnici, istologici, che 

non hanno importanza clinica e concentrarsi su quegli aspetti 

relativi alla terapia e alla prognosi che possono essere utilizzati 

dal clinico per un miglior inquadramento terapeutico. 

Con la consegna di un prelievo un anatomia patologica si 

innesca una serie complessa di eventi che hanno come fine 

la diagnosi istopatologica. I processi che costituiscono tale 

percorso risultano potersi riassumere in processi pre-analitici, 

analitici e post-analitici. In tutte queste fasi di accettazione, 

allestimento, formulazione della diagnosi e consegna della 

diagnosi è possibile che si possano inserire degli eventi che 

determinano un errore. “L’errore consiste semplicemente nel 

fatto che non sembra essere tale “ (Cartesio) e in medicina 

“si parla di errore quando l’esito di un’azione (prestazione o 

procedimento più complesso) non ha raggiunto i risultati che 

ci si era prefissati” (Carta sicurezza 2001) o anche lo si può 

interpretare come “un evento inatteso correlato a processo 

assistenziale e che comporta un danno al paziente non intenzionale 

e indesiderabile” (Ministero della Salute 2006). Noi ci 

occuperemo esclusivamente dell’errore nella diagnostica istocitopatologica. 

Varie possono essere le cause di errore, si possono 

riassumere in errore di distrazione, errore di sufficienza, 

errore di arroganza, errore da ignoranza. Si definisce errore 

medico un’omissione di intervento o un intervento inappropriato 

a cui consegue un evento avverso per il paziente e 

clinicamente significativo. Evidentemente errore diagnostico 

l’aver interpretato un carcinoma invasivo della mammella G3, 

ad esempio, come fibroadenoma; è invece un errore di diversa 

rilevanza clinica se un lipoma è stato interpretato come lipoma 

atipico o liposarcoma ben differenziato, in questo caso si 

parlerà di variabilità diagnostica che appartiene ad un gruppo 

di diagnosi istopatologiche che non hanno una riproducibilità 

accertata e la cui variabilità diagnostica non determina risvolti 

clinici gravi per il paziente. Esempi di variabilità diagnostica 

sono praticamente riportabili in tutte le patologie e possono 

raggiungere in alcuni casi livelli di discordanza anche elevata. 

Tale variabilità diagnostica che è valutata come detto in 

maniera anche percentualmente significativa non determina 

variazioni cliniche rilevanti ed è legata alla capacità interpretativa 

del singolo patologo, alla sua sensibilità diagnostica, 

dato personale non riproducibile e non incontrovertibile. Al 

contrario della variabilità diagnostica la cui possibilità di verifica 

è stata accertata da diversi lavori, la percentuale di errore 

in anatomia patologica risulta praticamente mai accertata, gli 

unici lavori si riferiscono ad errori che hanno determinato 

verifiche medico-legali. 

In linea di massima l’errore in anatomia patologica risulta 

nettamente inferiore rispetto all’errore clinico e da valutazioni 

generali emerse in alcuni lavori recenti non dovrebbe superare 

0,5-1% di tutta la diagnostica anatomo-patologica. Ottimisticamente 

l’errore ha anche un valore pedagogico intrinseco che 

può riassumersi dallo “sbagliando si impara” legato al comune 

buon senso all’”accrescimento della conoscenza e specialmente 

della conoscenza scientifica consiste nell’imparare 

dagli errore che abbiamo commesso “ (K.Popper). 

Eliminare l’errore è praticamente impossibile, possiamo 

però limitarlo con controlli di qualità intra-laboratorio ed 

inter(extra) laboratorio. A nostro parere nel controllo di qualità 

intra-laboratorio occorre scegliere un metodo in cui ci sia 

una revisione che preveda una revisione di preparati istologici. 

Tra i metodi più seguiti sono: a)Revisione con doppia firma 

di tutti i casi positivi; b) Revisione con doppia firma di tutti 

i casi; c) Revisione del 10% random dei casi; d) Discussione 

collegiale dei casi difficili; e) Revisione con doppia firma dei 

casi sentinella, intendendosi casi che il collega ritiene degni di 

essere rivisitati e ridiscussi con un collega dello stesso reparto. 

Buona norma è: 1) non firmare una diagnosi se non è stata 

mai diagnosticata dal gruppo; 2) avere per alcuni settori diagnostici 

un gruppo di patologi di riferimento; 3) certificare la 

lista dei consulenti esterni; 4) valutare in modalità critica la 

diagnosi del consulente esterno. 

Una delle conclusioni a cui possiamo giungere su un argomento 

che sarà ed è fonte di enorme discussione è che dell’errore 

non dobbiamo impaurirci, dobbiamo soltanto capire ed 

apprendere che esiste. Occorre seguire procedure che tentino

RElaziONi 

di limitarlo e fare in modo che tra i patologi sia ben chiara la 

differenza tra errore e variabilità diagnostica. 

L’errore è un evento plurifattoriale che comprende anche la 

cattiva interpretazione del caso, la variabilità diagnostica è 

legata esclusivamente alla sensibilità diagnostica del singolo 

patologo. 

Il controllo di gestione in anatomia patologica: 

dall’accettazione all’archiviazione 

P. Dalla Palma 

Anatomia Patologica, Ospedale S. Chiara, Trento 

I vari processi che vanno dall’accettazione delle biopsie e dei 

pezzi operatori fino all’archiviazione dei relativi preparati 

istologici è codificata da molto tempo con procedure standard. 

Tuttavia la complessità dei passaggi, talora eseguiti per 

consuetudine e in parte privi di valore aggiunto (“waste”) e 

la molteplicità dei vari attori coinvolti comportano problemi 

di tracciabilità e la possibilità di errori con conseguenze che 

potrebbero essere anche gravi per la salute dell’utente finale, 

cioè del cittadino/utente. 

Il monitoraggio delle singole fasi dell’intero processo con 

l’eliminazione di passaggi “waste”, l’applicazione dei principi 

della “lean technology” con l’esatta individuazione di chi fa 

che cosa, di quando la fa e di come la fa, l’importante introduzione 

dell’automazione supportata dall’”Information Technology” 

anche nei nostri laboratori, permettono che il lavoro 

della “Surgical Pathology” possa migliorare continuamente 

(Quality Improvement”)verso l’eccellenza 

Presenteremo pertanto un modello di tutto ciò,sviluppato in 

collaborazione con la ditta informatica “Dedalus”, indipendente 

dalle attrezzature in uso ma ancora in fase di affinamento 

le cui principali ed attuali fasi sviluppate sono: 

Accettazione: sul modello di quanto già sviluppato in molti 

laboratori di patologia clinica si è seguito l’”order entry”. I 

casi sono pre-accettati in reparto con verifica in tale sedi della 

parte anagrafica, della correttezza dell’accoppiamento con 

il materiale inviato e delle notizie cliniche necessarie per la 

diagnosi. 

Introduzione nel data base di anatomia patologica e produzione 

dei codici identificativi: Un semplice invio nel data 

base del reparto è sufficiente per generare il foglio di lavoro 

virtuale (sostituito da monitor al posto della carta) e dei codici 



259 

(a barre o data matrix) necessari per continuare il processo. 

Riduzione pezzi ed inclusione: Ogni fase lavorativa viene controllata 

dall’accoppiamento dei codici presenti in successione: 

nei contenitori e sulla cassetta d’inclusione, da quest’ultima 

versus il blocchetto, dal blocchetto versus il vetrino, dal vetrino 

alla coloratrice con monta vetrino. 

Controllo e Consegna: prima della consegna del caso (più vetrini) 

al medico per la successiva refertazione, viene fatto un 

ulteriore controllo di verifica che tutto sia stato completato nel 

modo stabilito. L’adozione di procedure standard prevedibili 

fin dall’accettazione per patologia particolare è particolarmente 

utile in tal senso. 

Lettura dei preparati ed introduzione della diagnosi nel 

data base: Il medico refertante identifica in modo unitario il 

caso passando nel lettore ottico i vetrini corrispondenti. Può 

interagire con il laboratorio ordinando indagini ulteriori da 

richiedersi, sempre per via telematica ai vari laboratori per ulteriori 

campionamenti, ulteriori sezioni a vari livelli, ulteriori 

colorazioni istochimiche o immunoistochimiche. 

Conclusione del caso: dopo aver posto la firma elettronica il 

caso è chiuso e la relativa risposta disponibile in tempo reale 

per il clinico / medico di base richiedenti attraverso i sistemi 

informatici ospedalieri. 

Archiviazione: si tratta di una fase ancora non completamente 

sviluppata. Recentemente però sono apparsi sul mercato 

sistemi di archiviazione intelligente che possano facilitare il 

recupero dei blocchetti e/o dei relativi vetrini. 

Ogni singolo operatore che opera in una delle varie fasi del 

processo deve “logarsi” nel sistema con le proprie credenziali 

assumendosene la responsabilità. In tal modo è possibile sempre 

verificare i vari carichi di lavoro ed intervenire anche sul 

versante del miglioramento della qualità laddove necessario. 

Tutto il sistema può apparire complicato ed indaginoso ma 

certamente va nel senso del quality improvement riducendo 

sensibilmente il numero dei possibili errori, dando indicazioni 

precise della tracciabilità e dei carichi di lavoro individuali ed 

in ultima analisi fornendo un servizio migliore. 

La qualità in anatomia patologica e il ruolo della 

società scientifica 

G. Santeusanio, R. Giardini 


Percorso tecnico – diagnostico: La tradizione che ha generato l’innovazione, 

tra sicurezza e tecnologia 

Tracciabilità in Anatomia Patologica. Dal 

prelievo del campione alla diagnosi: “la 

tracciabilità che passa dalle nostre mani…” 

M. Dal Santo 

Anatomia Patologica, Osp. S. Chiara, Trento 

L’iter del processo lavorativo in Anatomia Patologica è 

Moderatori: Mara Dal Santo (Trento), Carmelo Lupo (Palermo) 

molto complesso e coinvolge più figure professionali e 

molte fasi lavorative con punti critici e di rischio d’errore. 

Per questo diventa essenziale attuare degli interventi sia 

a livello procedurale che tecnologico per diminuire il più 

possibile l’errore. 

Nel mercato sono già disponibili tecnologie che si avvalgono 

dei bar-code bidimensionali e sarà cura del Servizio di

260 

Anatomia Patologica scegliere quella più adatta alla propria 

organizzazione. 

Utilizzando il processo lavorativo dell’Istologia si possono 

identificare con facilità i punti critici più soggetti ad errore e 

adottare quindi i correttivi appropriati. 

Un punto di partenza molto importante è sicuramente il cosiddetto 

“order entry”, cioè una richiesta inviata per via informatica 

riportante i dati anagrafici del paziente, materiale, sede 

del prelievo, ecc. inviata via web direttamente dal reparto richiedente. 

In questo modo si eliminano gli errori in fase di accettazione 

dovuti a errori di trascrizione e/o di interpretazione. 

A questo punto si acquisiscono i dati e si producono sia il 

foglio di lavoro che le etichette da apporre ai contenitori riportanti 

il corrispondente n° istologico e il codice 2D, che verrà 

richiamato per tutte le fasi lavorative utilizzando una penna 

ottica. Sicuramente questo è un punto fondamentale per la 

sicurezza del paziente. 

Un altro punto importamte è l’utilizzo di stampigliatrici collegate 

con il sistema operativo sia per le bio-cassette che per i 

vetrini che riporteranno sempre il codice 2D. 

In seguito tutto il flusso di lavoro dall’accettazione, campionamento, 

processazione, inclusione, taglio, colorazione, 

consegna al Medico, ulteriori colorazioni e/o indagini speciali, 

viene monitorato e “tracciato” in modo che se si verifica 

un’errore, il sistema si blocca e andando a verificare l’incongruenza 

è possibile rilevare le non conformità e apportare 

subiti gli opportuni correttivi. Ogni operatore per tutte le fasi 

lavorative utilizzerà la propria password e in questo modo 

viene anche tracciato il “chi fa che cosa”. 

Anche tutte le altre strumentazioni utilizzate per colorazioni 

e/o indagini speciali possono essere interfacciate con il 

sistema operativo in uso, in modo da seguire tutto il flusso 

lavorativo. 

Una volta consegnato l’esame al Patologo, anche per la lettura 

del vetrino e la diagnosi viene utilizzato il codice 2D, in modo 

da evitare anche in questa fase errori di scambio tra i vetrini. 

In conclusione l’utilizzo dei codici 2D utilizzati nel sistema 

gestionale del Servizio, permette di avere tutta la tracciabilità 

completa dell’esame durante tutto l’iter lavorativo diminuendo 

sensibilmente il margine d’errore in favore della sicurezza 

del paziente. 

Identificando gli attori dei singoli processi si aumenta il grado 

di responsabilità permettendo di verificare la performance 

professionale e di ricorrere a correttivi qualora gli errori (mai 

azzerabili) si ripetano con una certa frequenza. Permettono 

infine un controllo dei carichi di lavoro in modo del tutto 

oggettivo identificando eventuali carenze lavorative che altrimenti 

sarebbero difficilmente identificabili. 

Sperimentazione tecnica e qualità del 

preparato istologico: percorso metodologico 

nel laboratorio di anatomia patologica 

M. Cadei, P.G. Grigolato 

Cattedra di Anatomia Patologica II, Università di Brescia 

Nel laboratorio di Anatomia Patologica l’allestimento 

dei campioni istologici è rimasto pressoché inalterato nel 

tempo e dalla fissazione alla processazione dei campioni 

istologici, la principale implementazione metodologica 

è stata legata alla innovazione strumentale (processatori, 

coloratori ecc.). 

Da qualche tempo, anche in conseguenza all’introduzione 

della legislazione sulla sicurezza è stata posta attenzione 

anche riguardo all’utilizzo di sostanze che, da sempre con- 


siderate indiscutibili (formalina, xilolo, alcool), hanno invece 

cominciato a trovare sul mercato validi concorrenti. 

Se indubbiamente questo merito è da riconoscere alle Aziende 

del settore che hanno fortemente sviluppato la ricerca di possibili 

prodotti non tossici in grado di competere con i reagenti 

tradizionali, c’è da dire che in molti laboratori si è assistito ad 

una maggiore apertura rispetto a prodotti non convenzionali. 

La nostra sperimentazione, iniziata qualche anno fa con 

l’utilizzo di “prodotti alternativi” della fissazione dei tessuti 

di origine murina, si è perfezionata nel tempo con la sperimentazione 

su tessuti umani di routine giunti presso il nostro 

Servizio per la diagnosi istopatologica. Oggetto del nostro 

studio sono stati la valutazione morfologica del preparato 

istologico, le tecniche istochimiche ed immunoistochimiche, 

l’analisi citofluorimetrica le indagini bio-molecolari, che ad 

oggi sempre più frequentemente vengono richieste ad integrazione 

della diagnostica. 

L’esperienza, finalizzata a dimostrare l’esistenza sul mercato 

di un prodotto adatto alle attuali esigenze normative, di buona 

qualità morfologica ed adeguato alle necessità metodologiche 

più evolute, dovrà essere completata con ulteriori miglioramenti 

tecnici e l’ottimizzazione per un possibile utilizzo 

routinario di laboratorio. 

Tecniche di diagnostica molecolare: attualità e 

nuove prospettive 

C. Lupo 

Casa di Cura di Alta Specialità La Maddalena, Palermo 

La diagnostica molecolare in Anatomia Patologica gioca un 

ruolo fondamentale nella gestione del paziente oncologico. 

L’impiego di tecniche molecolari, finalizzate alla detection di 

target specifici, a corredo della diagnosi anatomopatologica, 

permette la stratificazione dei pazienti in sottogruppi e di conseguenza 

la scelta della terapia più appropriata per ciascuno. 

Sappiamo che i test di diagnostica molecolare non possono 

prescindere da un corretto management del campione istologico 

e citologico finalizzato all’analisi molecolare. Le procedure 

interne di ciascun laboratorio identificano e definiscono il 

“workflow” del precorso tecnico-diagnostico. In quest’ottica 

è fondamentale individuare ed eliminare le variabili preanalitiche 

ed analitiche che possono condizionare pesantemente 

il dato molecolare. Un altro punto imprescindibile per questo 

tipo di diagnostica è il concetto di “idoneità” del materiale 

da analizzare. Poiché l’idoneità del campione da analizzare 

condiziona pesantemenmte il dato molecolare, in questa fase 

risulta essenziale la figura dell’anatomopatologo. Altrettanto 

importante è la competenza e l’esperienza dello staff dedicato. 

Grazie all’impiego di tecniche di diagnostica molecolare si 

eseguono test predittivi di risposta al farmaco. Nella terapia 

mirata dei tumori solidi ad esempio, troviamo test, che oramai 

fanno parte della diagnostica di routine, quali le analisi delle 

mutazioni del gene K-RAS nel carcinoma del colon-retto, del 

gene BRAF nel melanoma metastatico, del gene EGFR nel 

carcinoma non a piccole cellule del polmone (NSCLC). Per 

lo studio delle mutazioni dei geni sopra descritti è necessario 

estrarre il DNA genomico dal tessuto tumorale fissato in 

formalina ed incluso in paraffina o da campioni citologici. Il 

DNA estratto è poi analizzato attraverso diverse tecniche tra 

le quali, ad esempio, la PCR Real-Time, TaqMelt Real-time 

PCR, il sequenziamento diretto ed il pirosequenziamento. 

Di recente, nel carcinoma non a piccole cellule del polmone 

(NSCLC), si esegue lo studio del riarrangiamento del gene 

ALK. La valutazione di ALK si può effettuare mediante l’im-

RElaziONi 

piego della tecnica FISH (Fluorescence in situ hybridization) 

con sonde Break Apart. Dalle metodiche descritte, emerge 

l’importanza della qualità e dell’attendibilità del dato molecolare. 

Queste due caratteristiche sono fondamentali in un 

contesto di efficienza che tenga conto anche della tempistica 

con la quale il dato molecolare viene trasmesso al medico 

oncologo richiedente. A tal proposito, molto spesso, risulta 

utile e preziosa anche la collaborazione anche tra i Servizi 

di Anatomia Patologica quando il campione istologico da 

analizzare è all’esterno del laboratorio che effettuerà l’analisi 

molecolare. Dell’ottimizzazione di questo tipo di interazione 

ne beneficia l’oncologo che richiede il test, anche lavorando 

in una struttura a distanza, ma soprattutto il paziente che può 

ricevere il risultato dell’analisi molecolare senza spostarsi. 

A “regolamentare” questa materia, grazie ai documenti sulle 

“raccomandazioni” per la corretta esecuzione dei test sopra 

descritti, sono i gruppi di studio della SIAPEC ed i controlli di 

qualità promossi da SIAPEC ed AIOM. Grazie alle due Società 

Scientifiche esistono dei programmi di qualità nazionali che 

permettono ai centri partecipanti di potersi validare. Questo è 

un enorme valore aggiunto sia per la tutela del paziente che 

per l’attendibilità del dato molecolare inteso come prodotto 

finale di una sommatoria di fattori. Le tecniche di diagnostica 

molecolare in Anatomia Patologica oggi sono una realtà 

imprescindibile nella pratica oncologica ed aprono intressanti 

prospettive al altri target molecolari che attualmente sono in 

corso di validazione. L’esigenza è quella di avere sempre più 

informazioni relative allo stato mutazionale dei geni implicati 

nelle patologie oncologiche. L’evoluzione delle tecnologie 

biomediche vede la possibilità di eseguire sequenziamenti su 

piattaforme di nuova generazione (Next-Generation Sequencing). 

Questo tipo sviluppo tecnologico ha portato anche una 

diminuizone dei costi e dei tempi per l’esecuzione dei test. 

L’appropriato utilizzo di queste tecnologie richiede specifiche 

competenze professionali ed una collaborazione sempre maggiore 

tra le figure interdisciplinari coinvolte. Concludendo, si 

può certamente affermare che stiamo assistendo ad un “balzo 

evoluzionistico” della diagnostica molecolare all’interno dei 

Servizi di Anatomia Patologica. Tuttò ciò sarà un valore aggiunto 

per diagnosi del paziente, sempre più ricca di informazioni, 

solo se si terrà presente lo storico bagaglio della cultura 

anatomopatologica. Senza questa cultura, che contestualizza 

le informazioni, tutti i dati molecolari ricavati dalle moderne 

tecnologie non si tradurrebbero in potenziali target terapeutici, 

ma bensì in dati di laboratorio del tutto aspecifici. 

Il campione citologico nella diagnostica 

molecolare 

A. Iaccarino 

Dipartimento di Scienze Biomorfologiche e Funzionali, Università di 

Napoli Federico II, Napoli 

In an increased number of settings, cytology represents the 

only source of sampling and it often substitutes histology as 

an independent diagnostic modality. Thus, DNA molecular 

targets to stratify patients for targeted therapy are often evaluated 

on cytology. This talk discusses the applications and 

limitations of DNA mutational testing on cytology. Respect to 

histology, most cytological samples have the advantages of a 

purer population of tumor cells, with low stromal component, 

a better preserved DNA and of assessing at the same time of 

sample collection cellular adequacy for DNA testing. Any 

cytological slide is fixed within seconds of being obtained, 

whereas surgical tissues may frequently be maintained at 

261 

room temperature for lengthy periods before being processed 

and fixed. Because 5 μm tissue sections usually divide nuclei, 

most sectioned nuclei on a histology slide will contain 

only a portion of the genome. In comparison, each nucleus 

is preserved intact in most cytological preparations, so fewer 

cells are required for similar quantities of DNA. The cellular 

composition and in particular the ratio between normal and 

neoplastic cells is dependent on the source of the cytological 

specimen. Differences exists between exfoliative and aspirative 

cytological specimens. Effusions, brushings and washings 

frequently contain numerous non-lesional cells, making the 

selective isolation of neoplastic cells difficult. FNA ensures 

a more selective sampling; a single FNA pass yields up to 1 

million of neoplastic cells 1 , with a minimal stromal contamination 

2 . Symmans et al, who evaluated neoplastic and stromal 

cell components in paired FNA and breast core needle biopsy 

(CBX), showed that the FNA samples contained more tumor 

cells (80% vs. 50%) and fewer stromal cells (5% vs. 30%) 

than the CBX samples 2 . In such a pure population of tumor 

cells with intact nuclei, a gene mutation can be detected even 

from the extremely small specimens, as those that in routine 

may residue after extensive diagnostic workup with special 

stains. In fact, a very low amount (0.5–2 mm 2 ) cell block 3 or a needle rinse 

may be sufficient for mutation detection 4-6 

To fully exploit the potential of the cytological sample, beside 

high standard cellular morphology, care should also be taken 

to preserve DNA quality within the sample 7 . Alcohol-based 

fixatives are significantly better than formalin; this latter reduces 

the quality of extracted nucleic acids by causing wide 

spread cross-linkage between nucleic acids and proteins, 

limiting the length of the DNA fragments that can be successfully 

amplified and increasing the number of cells required for 

accurate testing. Conversely, fixative solutions used in liquidbased 

cytology do not have the same problems with DNA 

degradation that is seen in formalin-fixed paraffin embedded 

tissue. Since preservative solution have been designed for optimal 

preservation of nucleic acids, the DNA extracted from 

liquid-based cytology (LBC) samples has higher yield, longterm 

stability, optimal 260/280 ratios and fragments not less 

than 400 bp.. The stability of PreservCyt (Cytyc Corporation, 

Boxborough, MA), a methanol-based medium used in liquid 

cytology is high and sample can be stored for 4-5 years before 

the specimens accrue significant losses in DNA integrity as 

detected by PCR 8 . 

Besides fixation effects the type of cytological biospecimen 

from which DNA is extracted also matters. Sample collection 

and processing may greatly differ leading to many different 

cytopreparation types. Direct smears, CBs and monolayer 

preparations 2 have advantages and drawbacks in mutational 

assays. Owing to the high quality of nucleic acids that can be 

extracted and the ease of immediate assessment for specimen 

adequacy, direct smears have extensively been exploited for 

BRAF 9-10 and EGFR testing 11-12 ; in most of studies the design 

was retrospective and the results obtained on either Diff-Quik 

or Papanicolaou direct smears were compared to those obtained 

on matched histological samples. Also CBs were employed 

for mutational testing As a general rule, direct smears 

are a more robust and valuable DNA source than matched cell 

blocks. and Diff-Quik stained smears yield a better preserved 

DNA than the Papanicolaou ones 13 . 

A cytopathologist’s onsite evaluation of the harvested material, 

confirming the presence of a sizeable number of neoplastic 

cells, may be crucial. However, in a busy pathology department 

it may not be possible to provide a cytology team for the

262 

assessment of adequacy, because it can take up to 45 min for 

a single procedure 14 . Liquid-based cytology (LBC) makes the 

processing of material easier and eliminates the need for slide 

preparation by clinicians. Iinstead of being smeared, cells are 

rinsed into a liquid preservative collection medium and processed 

on automated devices to prepare a monolayered LBC 

slide. Respect to the smear methods, LBC has the advantages 

of increased cellularity, a smaller examination area, a shorter 

examination time, reduced obscurement by blood or inflammatory 

cells, and more preserved nuclear details. Because 

only a portion of the collected cells is typically needed for 

the preparation of a liquid-based cytologic slide, the remaining 

specimen can be used for repeat cytology or mutational 

testing. LBC is an emerging solution to the application of 

molecular techniques to cytology. Liquid-based collection is 

currently the mode of choice for HPV testing in cervical cytology 

. Residual liquid-based preparation cytologic samples 

from thyroid and lung have successful been used for DNA 

based mutational testing. 

Preserving the informativeness of the aspirated material for 

both traditional and molecular approaches may be crucial. For 

example in thyroid and pancreatic cytology, DNA mutational 

testing can refine indeterminate microscopic diagnosis only 

when cytological specimens are properly handled to provide 

morphological and molecular information. To this end each of 

the steps of traditional cytology, such as preparation of FNAB 

material, search for morphological criteria and assignment to 

the correct diagnosis, needs to be preserved and collection of 

additional material for molecular testing, by further aspiration 

of nodules, needle washout with nucleic acids preserving 

solution or storage of FNABs samples at low temperature, 

should not interfere with routine practice. Then the relevance 

of the additional diagnostic information is fulfilled when 

interpreted in the context of cytology by pathologists. This 

calls for a change of cytotechnologists and cytopathologists 

mentality to collect and process the cytological samples not 

only for microscopy but also to assess clinically relevant 

molecular markers. 



references 

1 Centeno BA, Enkemann SA, Coppola D, et al. Classification of human 

tumors using gene expression profiles obtained after microarray analysis 

of fine-needle aspiration biopsy samples. Cancer 2005;105:101-9. 

2 Symmans WF, Ayers M, Clark EA, et al. Total RNA yield and microarray 

gene expression profiles from fine-needle aspiration biopsy and coreneedle 

biopsy samples of breast carcinoma. Cancer 2003;97:2960-71. 

3 Aisner DL, Deshpande C, Baloch Z, et al. Evaluation of EGFR mutation 

status in cytology specimens: An institutional experience. Diagn 

Cytopathol 2011;E-pub Nov 18 

4 Troncone G, Cozzolino I, Fedele M, et al. Preparation of thyroid FNA 

material for routine cytology and BRAF testing: a validation study. 

Diagn Cytopathol 2010;38:172-6. 

5 Lee YS, Jin GY, Han YM, et al. Computed tomography-guided transthoracic 

needle aspiration biopsy of intrapulmonary lesions: utility of 

a liquid-based cytopreparatory technique. Acta Cytol 2008;52:665-70. 

6 Zatelli MC, Trasforini G, Leoni S, et al. BRAF V600E mutation analysis 

increases diagnostic accuracy for papillary thyroid carcinoma in 

fine-needle aspiration biopsies. Eur J Endocrinol 2009;161:467-73. 

7 Schmitt FC. Molecular cytopathology and flow cytometry: pre-analytical 

procedures matter. Cytopathology 2011;22:355-7. 

8 Castle PE, Hildesheim A, Schiffman M, et al. Stability of archived 

liquid-based cytologic specimens. Cancer 2003;99:320-2. 

9 Cohen MB, Egerter DP, Holly EA, et al. Pancreatic adenocarcinoma: 

regression analysis to identify improved cytologic criteria. Diagn Cytopathol 

1991;7:341-5. 

10 Kim SK, Kim DL, Han HS, et al. Pyrosequencing analysis for detection 

of a BRAFV600E mutation in an FNAB specimen of thyroid 

nodules. Diagn Mol Pathol 2008;17:118-25. 

11 Chowdhuri SR, Xi L, Pham TH, Hanson J, Rodriguez-Canales J, 

Berman A, Rajan A, Giaccone G, Emmert-Buck M, Raffeld M and 

others. EGFR and KRAS mutation analysis in cytologic samples of 

lung adenocarcinoma enabled by laser capture microdissection. Mod 

Pathol 2012;25(4):548-55. 

12 Boldrini L, Gisfredi S, Ursino S, et al. Mutational analysis in cytological 

specimens of advanced lung adenocarcinoma: a sensitive method 

for molecular diagnosis. J Thorac Oncol 2007;2:1086-90. 

13 Killian JK, Walker RL, Suuriniemi M, et al. Archival fine-needle aspiration 

cytopathology (FNAC) samples: untapped resource for clinical 

molecular profiling. J Mol Diagn 2010;12:739-45. 

14 Natu S, Hoffman J, Siddiqui M, et al. The role of endobronchial 

ultrasound guided transbronchial needle aspiration cytology in the 

investigation of mediastinal lymphadenopathy and masses, the North 

Tees experience. J Clin Pathol 2010;63:445-51. 

Management Sanitario: organizzazione, gestione e coordinamento 

Moderatori: Alfredo Barbetti (Firenze), Francesco Caruso (Pavia), Tiziano Zanin (Genova) 

Si può andare nel passato andando sempre 

verso il futuro 

A. Barbetti, T. Berlingieri 

Università ed Ospedale di provenienza: AOUC Careggi, Firenze, ASF 

10, Firenze 

Coniugare il futuro può significare anche un ritorno al passato 

nei modelli organizzativi, nei requisiti scolastici di accesso, 

nelle metodiche, nella qualificazione professionale? Essere 

adeguati al futuro richiede profonde riflessioni e consapevolezza. 

nell’ambito del controllo di gestione quanto e 

come incide un cambiamento organizzativo? 

T. Zanin 

E.O. Ospedali Galliera, S.C. Anatomia Patologica, Genova 

La nuova organizzazione sanitaria prevede tra i vari organismi 

anche il Controllo di Gestione. 

In un’azienda esso è volto a guidare la gestione verso il conseguimento 

degli obiettivi stabiliti in sede di pianificazione 

operativa, rilevando, attraverso la misurazione di appositi 

indicatori, lo scostamento tra obiettivi pianificati e risultati 

conseguiti e informando di tali scostamenti gli organi responsabili, 

affinché possano decidere e attuare le opportune azioni 

correttive. 

In pratica è lo strumento che governa le linee strategiche e gli

RElaziONi 

obiettivi di budget di un’Azienda Ospedaliera, coinvolgendo 

direttamente tutti i Dipartimenti e le strutture dell’Azienda 

stessa. 

Il processo di controllo di gestione si svolge secondo un ciclo 

periodico, normalmente annuale, articolato nelle seguenti fasi: 

controllo antecedente; 

controllo concomitante; 

controllo susseguente. 

Controllo antecedente o budgeting 

Il controllo antecedente o budgeting si interfaccia con il sistema 

di pianificazione e si sostanzia nella predisposizione del 

budget. Attraverso questo strumento gli obiettivi operativi: 

vengono resi misurabili, con la definizione di indicatori e di 

un target (o traguardo), ossia di un valore che l’indicatore deve 

assumere per poter dire che l’obiettivo è stato conseguito; 

vengono corredati della previsione delle risorse (umane, finanziarie 

ecc.) necessarie al loro conseguimento, misurate in 

termini monetari e, precisamente, in termini di costo; 

vengono assegnati, unitamente alle risorse, agli organi aziendali 

responsabili del loro conseguimento, che prendono il 

nome di centri di responsabilità. 

Gli indicatori possono essere: 

di efficacia, quando sono esprimibili come rapporto tra un 

risultato raggiunto e un obiettivo prestabilito; 

di efficienza, quando sono esprimibili come rapporto tra un 

risultato raggiunto e le risorse impiegate per raggiungerlo, 

espresse in termini di costo (quando le risorse sono espresse 

in termini di quantità materiale si hanno invece indicatori di 

produttività, di solito considerati non appropriati per il controllo 

di gestione). 

Spesso gli elementi del budget sono stabiliti di comune 

accordo tra il manager preposto al centro di responsabilità 

e il vertice aziendale (o il suo manager superiore), secondo 

la logica del management by objectives (MbO). In questo 

modo il budget diviene una sorta di contratto tra il manager 

preposto al centro di responsabilità e l’azienda, in base al 

quale il primo s’impegna a raggiungere gli obiettivi pianificati 

e la seconda a mettergli a disposizione le risorse indicate 

nel budget. 

Centri di responsabilità 

I centri di responsabilità, che intervengono in un’Azienda 

Ospedaliera, possono essere: 

centri di costo, se la loro missione consiste nel minimizzare un 

costo. I centri di costo si distinguono ulteriormente in: 

centri di costo standard, allorché sia possibile rapportare il 

costo al volume di output (ad esempio determinando un costo 

unitario) e stabilire un costo standard al quale tale rapporto 

deve tendere; 

centri di costo discrezionale o centri di spesa, allorché, non 

potendosi stabilire un costo standard, si stabilisce un massimale 

di spesa e si dà al centro la missione di massimizzare il 

suo output rispettando tale massimale; 

Ovviamente un centro di responsabilità può essere responsabilizzato 

per un ricavo, un costo, un profitto o un rendimento del 

capitale investito in tanto in quanto disponga delle “leve” per 

controllare i fattori che lo determinano, in particolare, i centri 

di costo sono tipicamente direzioni di funzione. 

Nel sistema organizzativo di un’Azienda Sanitaria qualunque 

Dipartimento, Struttura Complessa, Struttura Semplice è un 

“centro di costo” pertanto risulta nel sistema un centro di 

responsabilità. 

Controllo concomitante e susseguente 

Il controllo concomitante si svolge parallelamente alla gestione 

e consiste: 

nella misurazione periodica degli indicatori, attraverso la rile- 

263 

vazione dei costi (diretti ed indiretti, per definire il cosiddetto 

costo pieno) e dei risultati; 

nella trasmissione delle informazioni così raccolte ai centri di 

responsabilità e al vertice aziendale (o ai superiori del preposto 

al centro di responsabilità); 

nella decisione, da parte dei destinatari delle predette informazioni, 

di azioni correttive volte a colmare il gap tra risultati 

attesi e risultati effettivi; 

nell’attuazione di tali decisioni. 

Il controllo susseguente chiude il ciclo di controllo di gestione 

e si sostanzia nella comunicazione ai centri di responsabilità 

e al vertice aziendale (o al superiore del preposto al centro 

di responsabilità) delle informazioni sulla misurazione finale 

degli indicatori, con lo scopo di: 

supportare il successivo ciclo di budgeting; 

fornire elementi per la valutazione del manager preposto al 

centro di responsabilità, quando il sistema di valutazione del 

personale è integrato con il sistema di controllo di gestione, 

come suggerisce la già ricordata metodologia del management 

by objectives. 

Tanto il controllo concomitante quanto quello susseguente si 

sostanziano nel reporting, ossia nella trasmissione ai centri di 

responsabilità e al vertice aziendale (o ai superiori dei preposti 

ai centri di responsabilità) di sintesi informative (i report) da 

parte dell’organo di controllo di gestione. È pertanto 

necessario progettare attentamente il sistema di reporting in 

modo da far pervenire l’informazione giusta, alle persone 

giuste, nel momento giusto. 

Quindi nell’ottica dei principi del controllo di gestione di 

un’azienda sanitaria un eventuale cambiamento organizzativo, 

dettato da cambiamenti strutturali piuttosto che da modificazioni 

relative al personale, e/o cambiamenti relativi all’afferenza 

delle prestazioni, ecc., pone i responsabili di una struttura 

nella condizione di perseguire comunque quegli obiettivi 

di efficacia ed efficienza richiesti al fine di poter raggiungere 

al meglio gli obiettivi di budget assegnati. 

Tali cambiamenti possono essere anche richiesti dall’inserimento 

nel processo delle metodiche Lean al fine di ridurre al 

minimo tutti i “punti” di non valore presenti, l’applicazione di 

queste tecniche sicuramente porta dei benefici nel controllo di 

gestione e nel contempo comportano dei cambiamenti organizzativi 

anche di rilievo. 

Infine onde poter gestire al meglio, per la parte di competenza, 

il controllo di gestione il personale referente e/o responsabile 

deve altresì gestire tutte quelle fasi importanti quali lo scarico 

di magazzino, la verifica dei legami tra prestazioni e materiali 

di consumo, ecc. 

Il lavoro degli operatori dell’Anatomia Patologica, ed in 

particolare del TSLB, sta sicuramente cambiando e la modificazione 

culturale in corso non è sempre attuata; infatti uno 

degli scogli più grandi è quello della disponibilità dell’operatore 

a percepire i cambiamenti in atto e gestirli nell’ottica di 

una crescita professionale ed in un miglioramento lavorativo 

quotidiano. 

Applicazione delle tecniche lean nella 

riorganizzazione delle attività del laboratorio di 

anatomia patologica: orientamento costante al 

miglioramento 

E. Anelli 

Ente Ospedaliero Ospedali Galliera di Genova 

Una Sanità di qualità ed accessibile a tutti è un diritto fondamentale 

ed inalienabile di ogni persona che vive nel nostro

264 

paese ed il nostro SSN, di fatto, investe molto in questo. 

Da una parte ci troviamo di fronte alla nascita in termini 

europei di un progetto per la sanità e la ricerca avanzata che 

opta per un vero sistema di centri di eccellenza europei che 

possano competere a livelli mondiali, dall’altra si contrappone 

uno scenario concreto del SSN sempre più in crisi. Sebbene 

l’organizzazione sanitaria si sia continuamente innovata nella 

best practice e nel management, questo non sembra essere 

sufficiente. È necessaria una trasformazione radicale tramite 

l’adozione di nuovi approcci gestionali da applicare all’Healthcare. 

Obiettivo del Progetto, in coerenza con il piano strategico, è 

quello di verificare l’applicabilità dell’approccio Lean (Toyota 

System Production), il cui focus è la ricerca dello spreco 

all’interno dei processi, alla Rete dei Servizi e nello specifico 

alle attività di laboratorio di Anatomia Patologica con conseguente 

riorganizzazione “snella”. 

In un momento storico quale l’attuale ove le carenze di risorse 

umane ed economiche generano incertezze è doveroso 

chiedersi: “ stiamo facendo bene quello che stiamo facendo?” 

L’applicazione sperimentale delle tecniche Lean ha avuto 

durata di 9 mesi, da settembre 2010 a maggio 2011, l’approccio 

metodologico è stato caratterizzato da una rigorosa 

e scrupolosa applicazione ad ogni minima fase del processo 

cito-istologico. 

Indicatori utilizzati: takt time, lead time, 5s, heijunka, diagramma 

a spaghetti, errori, visual management ed in più il progetto 

vede l’applicazione di una nuova tecnica: “Case Management” 

tipica del Sistema ad Intensità di Cura Variabile dove settimanalmente 

viene designato un responsabile dei codici gialli 

(urgenza correlata a bisogno terapeutico) che dovrà seguire 

pedissequamente il percorso degli istologici e che ne garantirà 

il buonfine, un responsabile definito tutor dei kanban gialli. 

La sperimentazione si è avvalsa delle 4 fasi che caratterizzano 

l’approccio Lean: 

Analisi situazione attuale 

Mappatura del flusso del valore 

Definizione degli sprechi 

Eliminazione sprechi e ridisegno del processo. 

Dall’analisi dei risultati sono emersi gli 8 sprechi (MUDA) 

riscontrabili in sanità in tutte le fasi del processo, sprechi a 

cui è stato possibile quindi dare un volto ed un nome, cosa 

non fattibile con le sole flow chart e con gli usuali indicatori 

di esito e di processo. 

Eliminando gli sprechi con un approccio snello la riorganizzazione 

si propone negli spazi attuali di facile attuazione. 

Alcuni numeri emersi dopo valutazione dei risultati: 

FASE accettazione interni: probabilità 

di near miss = 30% con il ridisegno Lean scende al 

3% 

FASE riduzione istologica: attività di maggior valore = 16% 

con il ridisegno Lean sale al 41% 

NUMERO COLLI DI BOTTIGLIA nel processo: = 4 

con il ridisegno Lean scende a 0 

EFFICACIA giornaliera per kanban gialli 

(urgenze bisogno cura del paziente) raggiunge 

l’80% con il ridisegno Lean e l’utilizzo del CASE MANA- 

GEMENT sale al 99% 

Dopo il ridisegno del processo, trasformato in un flusso, per 

mantenere la performances appare necessario il continuo monitoraggio 

di nuovi indicatori quali: 

1) n° di interruzioni al flusso dovute a variabili organizzative 


con relativa scheda di segnalazione, 

2) no value giornaliero (ore/minuti) espresso in % su 

100% di valore di 7 ore 12’ in fase “campionamento” da 

mantenere < al 16%, 

3) n°errori/disservizi fase “accettazione interni, 

4) efficacia giornaliera: codici gialli tagliati / codici gialli 

arrivati, 

5) scostamento annuale in % dall’obiettivo: una refertazione 

di valore = il rispetto dei tempi di risposta in base 

ai codici colori secondo l’intensità del bisogno di cura del 

paziente. 

Nella riorganizzazione sarà anche rimodulato, infatti, il sistema 

di refertazione, non più basato sulla tipologia d’esame 

ma, tenendo conto dell’intensità del bisogno di cura variabile, 

diviso nelle 3 fasce d’intensità: 

-casi kanban (cartellino) rosso = esame intraoperatorio- 

I tempistica: casi kanban “ giallo = urgenza 

II tempistica: casi kanban “ verde = priorità 

III tempistica: casi kanban “ bianco= elezione 

Conclusioni. I risultati appaiono sorprendenti: prima dell’applicazione 

delle tecniche la S.C Anatomia ed Istologia Patologica 

era sempre in linea con gli indicatori di esito e processo 

e raggiungeva sempre gli obiettivi di budget, lamentava solo 

carenza di personale e demotivazione, in realtà si è dimostrato 

un Servizio inefficiente in molte fasi del processo. 

Il Progetto in definitiva ha raggiunto il suo obiettivo, l’approccio 

Lean può essere applicato anche alla Rete dei Servizi ed ha 

dimostrato non solo che è possibile scovare inefficienze non 

altrimenti definibili, ma anche che, senza gravare sulle risorse, 

ma al contrario ottimizzandole, si può lavorare meglio e con 

più qualità e quindi che, eliminati gli sprechi, con un semplice 

ridisegno si può ottenere un vero Cell Design ovvero una cella 

di lavoro pulsante dove tutto ciò che si fa è di VALORE per 

il paziente e dove, quest’ultimo, è veramente posto al centro 

per una sanità “patient focused”, ma con una marcia in più: il 

tutto a pari risorse. 

Bibliografia 

AA.VV. Ospedale per intensità di cure in medicina interna. Progetto 

sperimentale FADOI LAZIO, Società scientifica di medicina interna 

2010. 

Basso A, Bosani R, Massimo F, et al. Progetto Lean HealthCare: nuovi 

paradigmi organizzativi per le strutture sanitarie. Rivista Quaderni 

dell’Aretè n. 9, 2009. 

Bolognese L. Sviluppare e verificare nuovi modelli assistenziali in 

sanità: la prospettiva del cardiologo. Giornale Italiano di Cardiologia 

2011;12, Il Pensiero Scientifico Editore. 

Bonfanti M. Il modello dell’intensità di cura in Toscana. In: Atti del VIII 

Congresso Regionale FADOI Toscana, IV regionale ANIMO, Arezzo 

2009. 

Del Ministro V. La sanità toscana.Un bilancio per il futuro. Gruppo di 

lavoro-la rete dei servizi e la gestione dell’ospedale per intensità di cure, 

Centro di promozione della Salute Franco Bisaglia. Cortona 2010. 

Floris PL. Six Sigma.Organizzare l’azienda partendo dal cliente. Milano: 

Franco Angeli Editore 2008. 

Graban M. Lean hospitals:improving quality,patient safety and employee 

satisfaction. Productivity Press Ed. 2008. 

Lagostena A. La migliore assistenza nel Nuovo Ospedale Galliera per 

linee di attività ad intensità di cura - L.E.A.N. di Genova. Pubblicato 

sul Sito Internet dell’E.O. Galliera, Genova 2009. 

Natalucci S. Analisi dei processi del laboratorio sperimentale del CNIPA. 

UNINFORM GROUP CNIPA, Roma 2007. 

Nicosia PG, Nicosia F. Tecniche lean in sanità. Milano: Franco Angeli 

Editore 2008. 

Nicosia F. L’ospedale snello. Management Sanitario per una sanità a 

flusso controllato ed intensità di cure. Milano: Franco Angeli Editore 

2008.

RElaziONi 

Nicosia F. Il nuovo ospedale è snello. Milano: Franco Angeli Editore 

2010. 

Nicosia F. Un percorso chirurgico snello. In: Galliera News, rivista trimestrale 

di informazione sanitaria e aziendale E.O. Ospedali Galliera 

Genova, n.1 anno 2, 2011. 

Pignatto A, Regazzo C, Tiberi P. Intensità di cure e complessità 

dell’assistenza: i due nuovi paradigmi dell’organizzazione ospedaliera. 

In: Rivista Attualità Agorà n.44, 2010. 

Velo F, Rangoni B. Health and Care policy and Fundamental Rights in 

Europe, ELF, Bruxelles 2009. 

Womack JP, Jones DT. Lean thinking. Milano: Guerini e Associati 1997. 

Siti Internet: 

www.galliera.it, “Progetti in corso E.O.Ospedali Galliera”, consultato 

in data 20/9/2010 

www.galliera.it, “Scheda tecnica progetto preliminare Nuovo Ospedale 

Galliera”, consultato in data 5/1/2011 

www.salute.toscana.it, “Scheda terapeutica unica”, quaderno della Collana 

Campagne per la sicurezza del paziente del Servizio Sanitario Toscano, 

Redazione di T.Bellandi, F.Ranzani, consultato in data 16/4/2011 

265 

www.galliera.it,”Documento gestione processo Anatomia Patologica 

E.O.Ospedali Galliera”, consultato in data 12/12/2010 

www.galliera.it, “Documento gestione processo Analisi chimico-cliniche 

E.O.Ospedali Galliera”, consultato in data 5/12/2010; 

www.liguriainformasalute.it, “Cartografia regionale sanitaria”, consultato 

in data 16/09/2010 

Documentazione, Atti, Normative: 

Abbott Diagnostics, “Innovare con semplicità” Put science on your side. 

Roma 2009. 

Convention Galliera “L’Ospedale del futuro nel futuro Ospedale”, 

Genova 10/6/2011. 

Carta dei Servizi E.O.Ospedali Galliera. Genova 2011. 

Piano Strategico 2009/2011 E.O. Ospedali Galliera. Genova 2008. 

Piano Socio-Sanitario Regionale della Liguria 2009/2011. 

SOCIOLAB per ARS. Rapporto sulle interviste: La riorganizzazione per 

intensità di cura nell’Azienda ospedaliera-Universitaria di Careggi. 

Firenze 2009.

patHOlOGiCa 2012;104:267-358 COMUnICAzIOnI OrALI 

BIOLOGIA MOLECOLArE 

The alteration of lipid metabolism in Burkitt 

lymphoma identifies a novel diagnostic marker: 

the adipophilin 

M.R. Ambrosio1 , P.P. Piccaluga2 , M. Ponzoni3 , B.J. Rocca1 , 

V. Malagnino1 , M. Onorati1 , G. De Falco1 ,V. Calbi4 , M. Ogwang4 , 

K.N. Naresh5 , S.A. Pileri2 , C. Doglioni3 , L. Leoncini1 , S. Lazzi1 1 Department of Human Pathology and Oncology, Anatomic Pathology 

Section University of Siena, Italy; 2 Molecular Pathology Laboratory, Haematopathology 

Unit, Department of Haematology and Oncology “L. and 

A. Seràgnoli”, S. Orsola-Malpighi Hospital, University of Bologna, Italy; 

3 Pathology Unit, Department of Oncology, University Scientific Institute 

San Raffaele, Milan, Italy; 4 Saint Mary Hospital, Lacor Gulu, Uguanda; 

5 Department of Histopathology, Hammersmith Hospital Campus, Imperial 

College, London UK 

Background. Burkitt lymphoma (BL) is listed in the WHO classification 

of lymphoid tumours as an ‘aggressive B-cell non-Hodgkin 

lymphoma’. None of the histological, immunohistochemical 

or molecular parameters can be singly used for the diagnosis of 

BL and the WHO classification suggests that a combination of 

several techniques is necessary. BL has very characteristic cytologic 

features on fine needle aspiration cytology (FNAC) where the 

identification of the typical cytoplasmic vacuoles in the lymphoid 

cells represents a diagnostic hallmark. These vacuoles containing 

lipids cannot be seen on histological preparations. The formation, 

maintenance, modification and involution of lipid droplets is crucially 

regulated by a family of lipid droplet- associated proteins 

(PAT-proteins), to which belong five members, usually referred to 

as PLIN proteins. The presence of lipid vacuoles in the cytoplasm 

may suggest that biosynthesis of lipids and other macromolecules 

is altered in BL as there is increasing evidence of lipid metabolism 

reprogramming in tumour cells. This study was designed to analyse 

the lipid metabolism in BL. 

Materials and methods. A total of sixty formalin-fixed and 

paraffin-embedded specimens were investigated at the Department 

of Human Pathology and Oncology, Anatomic Pathologic 

Section, University of Siena, Italy. The initial diagnosis of these 

cases was: BL in 43, diffuse large B-cell lymphoma (DLBCL) 

in 30 and B-cell lymphoma unclassifiable with features intermediate 

between DLBCL and BL (DLBCL/BL) in 7. The slides 

were reviewed by two expert haematopathologists and classified 

according to the scoring system recently designed by Naresh 

et al. for aggressive B-cell lymphomas which distinguishes 

BL and not BL. According to the algorithm, we identified 47 

BL and 33 not BL. Histological sections were stained with 

adipophilin antibody and the pattern of immunostaining as well 

as the labelling intensity was evaluated. The statistical association 

between the distribution of expression of adipophilin and 

the diagnostic category (BL and not BL) was evaluated, with 

P < 0.05 considered as being statistically significant. Moreover, 

we analyzed Gene expression profiling (GEP) data of 13 BL 

and 20 DLBCL, focusing on the expression of ADFP (PLIN2), 

and other genes related to lipid metabolism (SCD, SCD5, FASN, 

USF1, PPARA). 

Results. We found adipophilin as the only member of the PATprotein 

family expressed in BL. Moreover, supervised analysis 

revealed that 5 other genes involved in lipid metabolism were 

differentially expressed (fold change > 2; p < 0.05) in BL and 

DLBCL. While SCD and PPARA, were up-regulated in DL- 


Sala Donatello – ore 15,00-18,00 

BCLs, SCD5, FASN and USF1 were up-regulated in BL. To 

confirm GEP results, adipophilin expression was investigated 

by immunohistochemistry in BL and not-BL cases. A strong immunoreactivity, 

characterized by single or multiple droplets in 

the cytoplasm and clustering of these to the outer nuclear membrane, 

was observed in 45 out of 47 BL cases. Weak positivity 

characterized by dispersed fine lipid droplets in the cytoplasm 

of a small minority of cells was detected in 3 out of 33 cases 

of not-BL. 30 of 33 not-BL cases did not show any expression 

of adipophilin. Macrophages showed a granular staining within 

the cytoplasm, and this served as an internal positive control. 

The proportion of cases positive for adipophilin expression 

was significantly higher (p < 0.05) in BL cases than the not- 

BL cases. Interestingly, the three cases of not-BL category that 

showed weak, fine positivity were characterized by a diffuse 

proliferation of medium- to large-sized cells with irregular 

nuclear contours and relatively large nucleoli. Starry-sky macrophages, 

mitoses and apoptosis were prominent, and reactive 

small lymphocytes were scanty. This morphological features 

corresponded to score 1 (range: 0-3) on the algorithm for aggressive 

B-cell lymphomas proposed by Naresh et al. and may 

well represent B cell lymphoma, unclassifiable with features 

intermediate between DLBCL and BL. 

Conclusions. Our results suggest that accumulation of lipid 

vacuoles is due to an altered lipid metabolism in BL and may 

reflect a metabolic phenotype promoting tumourigenesis. Rapidly 

dividing tumour cells require rapid generation and release 

of adipophilin droplets. The increased number of adipophilin 

lipid droplets may thus be related to the high proliferation rate 

of this tumour, the fastest growing tumour in humans. Lipid 

vacuoles may be specifically recognized by a monoclonal 

antibody against adipophilin, which may therefore be a useful 

marker for the diagnosis of BL because of its peculiar 

expression pattern. This peptide might represent an interesting 

candidate for interventional strategies (e.g. target therapy or 

vaccine therapy), in fact, a recent preliminary study has investigated 

the possible use of adipophilin as a T-cell epitope to 

induce antigen-specific cytotoxic T-lymphocytes and mediate 

tumour cell lysis. 

A better knowledge of lipid metabolism alteration in BL can 

potentially provide new markers to improve diagnosis and prognosis 

as well as novel therapeutic approaches for BL treatment. 

references 

DeBerardinis RJ, Lum JJ, Hatzivassiliou G, et al. The biology of cancer: 

metabolic reprogramming fuels cell growth and proliferation. Cell 

Metab 2008;7:11-20. 

Fujimoto T, Ohsaki Y, Cheng J, et al. Lipid droplets: a classic organelle 

with new out. Histochem Cell Biol 2008;130:263-79. 

Leoncini L, Raphael M, Stein H, et al. Lymphoma In: World Health Organization 

Classification of Tumours Haematopoietic and Lymphoid 

tissues. Lyon, France: IARC Press 2008, p. 262. 

Menendez JA, Lupu R. Fatty acid synthase and the lipogenic phenotype 

in cancer pathogenesis. Nat Rev Cancer 2007;7:763-77. 

Muthusamy K, Halbert G, Roberts F. Immunohistochemical staining for 

adipophilin, perilipin and TIP47. J Clin Pathol 2006;59:1166-70. 

Naresh KN, Hazem AHI, Lazzi S, et. al. Diagnosis of Burkitt Lymphoma 

using an algorithmic approach-applicable in both resource-poor and 

resource-rich countries. BJH 2011 Jul 1 [Epub ahead of print]. 

Piccaluga PP, De Falco G, Kustagi M, et. al. Gene expression analysis uncovers 

similarity and differences among Burkitt lymphoma subtypes. 

Blood 2011;117:3596-608. 

Swinnen JV, Brusselmans K, Verhoeven G. Increased lipogenesis in 

cancer cells: new players, novel targets. Curr Opin Clin Nutr Metab 

Care 2006;9:358-65.

268 

Schmidt SM, Schag K, Mu¨ ller MR, et al. Induction of Adipophilin- 

Specific Cytotoxic T Lymphocytes Using a Novel HLA-A2-Binding 

Peptide That Mediates Tumor Cell Lysis. Cancer research 

2004;64:1164-70. 

Tennant DA, Durán RV, Boulahbel H, et al. Metabolic transformation in 

cancer. Carcinogenesis 2009;30:1269-80. 

Yamashita T, Honda M, Takatori H, et al. Activation of lipogenic pathway 

correlates with cell proliferation and poor prognosis in hepatocellular 

carcinoma. J Hepatol 2009;50:100-10. 

Vander Heiden MG, Cantley LC, Thompson CB. Understanding the Warburg 

effect: the metabolic requirements of cell proliferation. Science 

2009;324:1029-33. 

Primary Hodgkin lymphoma of the anus: 

case report and brief review of the literature 

M.R. Ambrosio1 , B.J. Rocca1 , M.G. Mastrogiulio1 , A. Barone1 , 

G. De Falco1 , A. Costa2 , C. Bellan1 , S. Lazzi1 1 Department of Human Pathology and Oncology, Pathological Anatomy 

Section, University of Siena, Italy; 2 Surgery Unit Valdichiana Hospital, 

Montepulciano, Italy 

Background. Primary anorectal lymphomas are very rare, with 

a higher incidence in human immunodeficiency virus positive 

(HIV+) patients. Most are high-grade B-cell non-Hodgkin 

lymphomas (NHL) often associated with Epstein-Barr virus 

(EBV). Anorectal Hodgkin lymphoma (HL) is rarer, accounting 

for 20% of gastrointestinal HL in HIV+ individuals. In immunodeficiency 

virus negative (HIV-) patients it is uncommon 

and it has been reported particularly in the context of inflammatory 

bowel disease (IBD). Primary HL of the anus has never 

been previously described. We report the first case of anal HL 

in a HIV- patient without IBD, highlighting the importance of 

differential diagnosis with EBV-induced lymphoproliferative 

disease (EBV-LPDs). 

Materials and methods. a 83-year-old man presented to the 

Surgery Unit of Valdichiana Hospital complaining of tenesmus 

and mucous bloody diarrhea, that lasted for 1 month. Digital 

rectal examination revealed a friable, hemorrhagic lesion located 

in the anal canal. The rest of the physical examination 

was unremarkable. No superficial lymphadenopathy or hepatomegaly 

were identified. A rectoscopy showed an ulcerative 

lesion of the anal canal. The ulcer extended through the entire 

anal wall, the margins were protruding. A whole body computed 

tomography (CT) scan showed an ill-defined tumor, 40x15 

mm, extending through the entire right wall of the anal canal. 

Mild (10 mm) regional lymphadenopathy was also identified. 

No periaortic lymphadenopathy or lesions in the liver, spleen 

and lungs were detected. A complete blood count was normal. 

The clinical differential diagnosis included: localized anal 

carcinoma, anal isolated ulcer, Crohn disease. Tissue samples 

were taken; formalin-fixed, paraffin-embedded tissue blocks 

were cut and stained for hematoxylin and eosin. The following 

antibodies were checked: CD45, CD20, CD3, CD30, CD15, 

OCT-2, BOB-1, LMP-1, Cytomegalovirus (CMV). In situ hybridization 

analysis for EBV small-encoded RNA (EBER) was 

also performed as well as Polymerase chain reaction (PCR) for 

Human Papillomavirus (HPV). 

Results. the surgical specimens consisted of 5 friable brownish 

fragments ranging between 10 and 40 mm in maximum diameter. 

Histologically, all the fragments showed similar morphologic 

features: not well-circumscribed ulcerated mucosal lesions were 

associated to a polymorphous infiltrate with a mixture of lymphocytes, 

plasma cells, histiocytes, immunoblasts and scattered 

eosinophils. Reed-Sternberg (RS) and Hodgkin cells (HC) were 

present in variable number. The adjacent squamous epithelium 

showed reactive nuclear atypia. The neoplastic cells were positive 

for CD30 and CD15 with a paranuclear and membranous 

pattern of staining, and for LMP-1; they were negative for CD45, 

CD20, CD3, Oct-2, Bob-1. Immunohistochemistry for CMV was 


negative. In situ hybridization analysis for EBER was positive 

whereas PCR for HPV was negative. The histological, immunohistochemical 

and in situ hybridization findings supported the 

diagnosis of classical HL. A post-diagnosis 2-fluoro-2-deoxy-Dglucose 

(FDG)-PET/CT showed an area of abnormally high FDG 

uptake in the anal canal and in the left inguinal lymph nodes. 

The patient received pelvic irradiation with 40 Gy. At present 

(6 months after the initial diagnosis) the patient is alive without 

any clinical, endoscopic and radiologic signs of local relapse or 

active HL. 

Conclusions. This is the first case of an isolated anal localization 

of HL in a HIV- patient. In our review of the literature, we 

have identified only two cases of ano-rectal HL but no cases 

exclusively located in the anus. In both cases the patients were 

male of 33-year old, HIV+. The lack of complete clinical, 

and immunohistochemical data as well as EBV status in one 

of the cases calls into question the diagnosis of primary HL. 

Diagnosis of extranodal HL can be challenging because of the 

polymorphic nature of the cellular infiltrate, the paucity of the 

malignant cells and the fact that normal anorectal mucosa is devoid 

of lymphoid tissue. However, lymphoid infiltration can be 

induced in the context of chronic inflammation or immune deficiency. 

Differential diagnosis with atypical lymphoid hyperplasia, 

particularly associated with virus, as such as EBV, may 

be difficult and a combination of clinical, morphologic and 

immunophenotypic parameters is useful in reaching the correct 

diagnosis. EBV-LPDs are lymphoid proliferations that arise as 

a result of immunodeficiency due to a primary immunodeficiency 

or immunoregulatory disorder (i.e. HIV infection, posttransplant 

setting, iatrogenic cause such as methotrexate and 

TNF-ɑ antagonists and ageing). In physiologic circumstances 

the inherent propensity of EBV to induce B-cell proliferation 

is counterbalanced by complex immunologic interactions that 

maintain the overall number of EBV-infected B cells in the 

body at a very low level. Immunosuppression affects various 

aspects of immune homeostasis and surveillance, thus permitting 

the emergence of EBV-induced EBV-LPDs. Specifically, 

in the elderly the T-cell response seems most profoundly affected, 

with the accumulation of clonal CD8 positive T-cells 

with mature, memory cell phenotypes but diminished functionality, 

owing to a markedly restricted epitope specific repertoire 

and a 100-fold decrease of T-cell specificities. In EBV-LPDs 

the lesion are superficial and well-demarcated with a rim of 

small lymphocytes, and plasmacytoid apoptotic cells which are 

considered a hallmark of retained normal control mechanisms. 

Moreover, RS and H-like cells showed wide range in size; 

they are CD45 and Oct-2 positive, with variable expression 

of Bob-1 and CD15. On the contrary in HL, RS and HC, as 

in our case, are CD30 and CD15 positive and CD45 negative 

with lack of expression of Oct-2 and Bob-1. In summary, we 

report an unusual case of HL arising in the anus of 83-year-old 

man in which only the association between clinical, histological 

and radiologic findings led us to a correct diagnosis. The 

importance of distinguish HL from EBV-LPDs, particularly in 

organs not common affected by HL, is stressed and the need 

for caution when considering such a diagnosis in HIV- patients 

with no history of IBD is underlined. 

references 

Dojcinov SD, Venkataraman G, Raffeld M, et al. EBV positive mucocutaneous 

ulcer-a study of 26 cases associated with various sources of 

immunosuppression. Am J Surg Pathol 2010;34:405-17. 

Pagano L, Ratto C, Teofili L, et al. Isolated primary Hodgkin’s disease 

of rectum. Haematologica 2000;85:986-7. 

Valbuena JR, Gualco G, Espejo-Plascencia I, et al. Classical Hodgkin 

lymphoma arising in the rectum. Ann Diagn Pathol 2005;9:38-42. 

Vasiliu V, Suarez F, Canioni D, et al. Anorectal Epstein-Barr virus infection 

mimicking Hodgkin lymphoma in an immunocompetent man. Am 

J Surg Pathol 2010;34:1715-9.

COmuNiCaziONi ORali 

Solitary T-cell psuedolymphoma with monoclonal 

TCr rearrangement: is it a true pseudolymphoma 

or a T-cell lymphoma in early stage? 

G. Crisman1 , D. Signoretto2 , S. Bonin3 , G. Trevisan4 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 

dell’Aquila, L’Aquila, Italia; 2 U.C.O. Anatomia Patologica, Università di 

Trieste, Trieste, Italia; 3 Dip. Univ. Cl. di Scienze Mediche, Chirurgiche e 

della Salute, Università di Trieste, Trieste, Italia; 4 U.C.O. Dermatologia e 

Venereologia, Università di Trieste, Trieste, Italia 

Background. Cutaneous Pseudolymphoma refers to a group of 

skin disorders characterized by a benign lymphoprolipherative 

reaction that may simulate cutaneous malignant lymphomas clinically 

and/or histologically. 

Material and methods. We report on a case of a 43-year-old 

woman presented with a solitary, indolent, erythematous plaque 

on the right hand. Anamnestic data were unremarkable. In the 

clinical suspicion of a Pagetoid Reticulosis (PR), supported by 

the persistence of the lesion even after several localized treatment 

and the site of involvement, a punch biopsy has been performed. 

Results. Histological features revealed a band-like subepidermal 

infiltrate, mainly composed by lymphocytes, with minimal exocytosis 

of lymphocytes into the epidermis. Several plasma cells 

have been noticed as well. Immunohistochemistry for CD3, CD4, 

CD8, CD43, CD20 and CD5 showed a predominance of T-cells, 

but B-cells resulted consistently present. Several cells were also 

immunopositve for CD138, and kappa and lambda immunoglobulin, 

thus a consistent presence of plasma cells was noticed. 

An inconsistent expression of CD56, and few CD30+ cells have 

been also observed. Clonally rearranged T-cell receptor genes 

have been detected twice. 

Conclusions. Even though the clinical presentation, the histopathological 

features and the clonal rearrangement of the TCR 

genes were suggestive for PR, the presence of a consistent 

Fig. 1. Clinical presentation of the patient. 

Fig. 2 A and B. histological features revealed a mixed inflammatory 

infiltrate involving the upper dermis with few foci of epidermotropism 

(H&E, 10x and 20x magnification). 

Fig. 3 A and B. immunoistochemical stains: strong positivity for Cd3 

(fig. 3a. 4x magnification) and Cd8 (fig. 3B, 10x magnification). 

Fig. 4. monoclonal rearragement of the tCR genes. 

269 

number of plasma cells in the context of a such mixed infiltrate 

suggested a diagnosis of solitary T-cell pseudolymphoma. This 

entity represents one of the most challenging diagnosis among 

cutaneous lymphomas. Due to its unclear differential diagnostic 

criteria and to its variable clinicopathological features, many 

overlaps with cutaneous small/medium pleomorphic T-cell lymphoma 

have been reported so far, thus generating a confusing 

literature on this topic. Several cases of solitary T-cell pseudolymphoma 

with a monoclonal rearrangement of the TCR genes 

have been reported and it is still unclear if they represent wholly 

benign lymphoid proliferations or variant of cutaneous T-cell 

lymphoma with a very favorable course. Anyhow, surgical excision 

is the gold standard treatment in those cases and recurrence 

are uncommon. 

The authors would like to underline the importance of the clinicopathological 

and biomolecular correlation in the aim to achieve 

the correct diagnosis and avoid overtreatment. 

references 

1 Hodak E, Phenig E, Amichai B, et al. Unilesional mycosis fungoides: 

a study of seven cases. Dermatology 2000;201:300-6. 

2 van der Putte SC, Toonstra J, Felten PC, et al. Solitary nonepidermotropic 

T cell pseudolymphoma of the skin. J Am Acad Dermatol 

1986;14:444-53. 

3 Beltraminelli H, Leinweber B, Kerl H, et al. Primary cutaneous CD4+ 

small-/medium-sized pleomorphic T-cell lymphoma: a cutaneous nodular 

proliferation of pleomorphic T lymphocytes of undetermined significance? 

A study of 136 cases. Am J Dermatopathol 2009;31:317-22. 

4 Martin SJ, Cohen PR, Cho-Vega JH, et al. CD8+ Pagetoid Reticulosis 

Presenting as a Solitary Foot Plaque in a Young Woman. J Clin Aesthet 

Dermatol 2010;3:46-9. 

5 Cho-Vega JH, Tschen JA, Duvic M, et al. Early-stage mycosis fungoides 

variants: case-based review. Ann Diagn Pathol 2010;14:369-85. 

6 Matsuzaki Y, Kimura K, Nakano H, et al. Localized pagetoid reticulosis 

(Woringer-Kolopp disease) in early childhood. J Am Acad 

Dermatol 2009;61:120-3.

270 

7 Mourtzinos N, Puri PK, Wang G, et al. CD4/CD8 double negative pagetoid 

reticulosis: a case report and literature review. J Cutan Pathol 

2010;37:491-6. 

HPV-DnA load in squamous cervical intraepithelial 

lesions (SIL): correlation with histologic 

and viral findings 

B. Dal Bello1 , A. Spinillo2 , B. Gardella2 , P. Alberizzi1 , M. Roccio2 

, S. Cesari1 , E.M. Silini3 1 Fondazione IRCCS Policlinico San Matteo, Università di Pavia, SC 

Anatomia Patologica, Pavia, Italy; 2 Fondazione IRCCS Policlinico San 

Matteo- Università di Pavia, SC Ostetricia e Ginecologia, Pavia, Italy; 

3 Azienda Ospedaliero-Universitaria di Parma, SC Anatomia Patologica, 

Parma, Italy 

Background. The role of HPV load in the development and progression 

of SIL is unclear and its relationship with other virological 

features is controversial 1 2 . We aimed to define the correlation 

of HPV titres with relevant clinical and virological findings in 

women undergoing colposcopy for abnormal cervical cytology. 

Materials and methods. We evaluated cervical scrapings, 

collected in ThinPrep-Preserv-Cyt solution from 501 women 

(mean age 37 yrs) undergoing colposcopy for abnormal cytology. 

Full HPV genotyping by INNOLiPA SPF-10 (EXTRA test, 

Innogenetics) was available in all sample 3 . During colposcopy, 

397 (79%) women had targeted cervical biopsy. DNA extraction 

from cervical scrapings was performed using an automatic 

instrument (Magtration system 12GC, VODEN). HPV DNA 

quantification was obtained by real time PCR (RotorGene, 

Explera) using SPF10 primers. beta-globin gene was quantified 

to normalize HPV loads. Stepwise logistic regression analysis 

Tab. I. Correlation of HpV load with histologic, virologic and clinical features. 


was performed to evaluate the association between viral load 

and viral genotypes adjusting for number of infecting type and 

lesion severity. Multinomial logistic regression was performed 

to correlate viral load with histological and virological findings. 

Results. Overall, LSIL was diagnosed in 42.5% and HSIL/ 

carcinoma in 32% of women. HPV genotyping identified 27 different 

viral types. Multiple infections were present in 217 (43%) 

scrapings. In 68 (13.5%) samples no specific viral type was found 

(untypable). Correlations of clinical, virological and histological 

features with viral load are summarized in Table I. 

HPV DNA titre and HPV/beta-globin ratio significantly increased 

with severity of cytological (p 0.001) and histological lesions (p 

0.011), multiple infection (p 0.000), number of HPV types (p 

0.000), and class of oncogenic risk. More specifically, multiple 

HR and HR-LR type infections had higher viral titres than single 

HR and LR type infections (p 0.000), whereas untypable samples 

had lower titres than other groups. Age and menopausal status 

didn’t affect viral load. 

Viral titres were positively correlated with infections by HPV 

type 6 (p 0.006), 31 (p 0.025), 53 (p 0.003), 56 (p 0.016), 66 (p 

0.010) and 82 (p 0.018); no correlation was found for HPV 16. 

At stepwise regression analysis after correction for number of viral 

types and lesion severity, normalized HPV titres were directly 

correlated with infections by HPV 31, 44, 66 and 74 and inversely 

correlated with HPV 18 and 35. 

At multivariate analysis, viral titres significantly correlated with 

the number of infecting types (p 0.000) and the presence of low 

grade SIL (p 0.043). 

Discussion. Available data regarding HVP load and its clinical 

significance are still controversial and limited by sample size and 

Variable Category n HPV titres HPV/b globin ratio p 

Cyto/histo diagnosis 

histologic diagnosis 

Multiple infection 

Number of viral types 

class of oncogenic risk 

age 

Negative 140 10.25±8.4 1.42±1.67 

lSil 225 10.6±5.1 1.51±0.91 

hSil 129 11.03±6.0 1.55±0.77 

Negative 102 9.76±5.0 1.32±0.80 

lSil 169 10.58±5.3 1.48±0.92 

hSil/carcinoma 126 10.97±6.1 1.63±0.65 

No viral type 68 7.85±5.4 0.92±0.42 

Single 216 9.58±5.1 1.26±0.57 

Multiple 217 12.66±7.4 8.35±7.78 

0 68 7.85±5.4 0.93±0.42 

1 216 9.58±5.1 1.23±0.57 

2 82 12.35±9.8 1.81±2.11 

3 70 11.98±6.1 1,71±0.82 

4 42 13.74±4.9 2.33±1.28 

5 23 13.84±4.3 2.22±0.72 

No viral type 68 7.85±5.4 0.93±0.42 

lR single 48 9.94±4.1 1.29±0.63 

hR-lR 110 13.41±8.8 2.08±1.86 

hR single 160 9.40±5.3 1.24±0.56 

hR multiple 106 11.82±5.5 1.77±1.05 

Unclassified 8 11±5.8 1.39±0.57 

< 21 9.93±4.5 1.38±0.93 

22-30 11.3±6.1 26.3±2.54 

31-40 (reference) 154 9.80±5.1 1.50±0.94 

41-50 11.2±8.6 1.50±0.75 

> 50 10.6±5.4 1.58±1.72 

0.001 

0.011 

0.000 

0.000 

0.000 

0.789


differences in study design, clinical end point and methodological 

approach among studies (1,2,4-9). 

In our series, overall HPV loads correlated with SIL grade, multiple 

infections, number of viral types and class of oncogenic risk. 

Untypable infections had lower viral titres. The presence of HPV 

16 did not significantly influence viral titre also after correction 

for number of viral types and lesion severity. Multivariate statistical 

analysis confirmed an independent association of viral loads 

with multiple HPV types and SIL severity. 

The methodological strength points of our study are: a) sample 

size (more than 500 cervical scrapings from mono-institutional 

colposcopic setting); b) automated DNA extraction; c) full genotyping 

approach using SPF-10 primers; d) overall HPV load 

evaluation by PCR using SPF-10 primers; e) histologic features 

of targeted cervical biopsies in 80% of cases; f) multivariate 

statistical analysis. The analytical sensitivity of SPF- 10 Lipa is the 

highest among available HPV typing assays and its clinical use 

has been previously validated 3 . 

Potential limitations of the study are cross-sectional design and 

lack of specific-type load. 

Conclusions. Cervical HPV loads as assessed by highly sensitive, 

broad coverage, consensus SPF-10 primers correlate with 

severity of histologic lesions and with virological features such 

as multiple infection, number of infecting types and class of 

oncogenic risk. The presence of HPV 16 does not significantly 

influence overall HPV load. Larger series with standardized 

methodological approaches are necessary to definitely clarify the 

role of viral load in the clinical management of SIL. 

references 

1 Constandinou-Williams C, et al. Is Human Papillomavirus viral load 

a clinically useful predictive marker: a longitudinal study. Cancer 

Epidemiol Biomarkers Prev 2010;19:832-7. 

2 Manawapat A, et al. Physical state and viral load as predictive biomarkers 

for persistence and progression of HPV16-positive cervical 

lesions: results from a population based long-term prospective cohort 

study. Am J Cancer Res 2012;2:192-03. 

3 Dal Bello, et al. Cervical infections by multiple human papillomavirus 

(HPV) genotypes: Prevalence and impact on the risk of precancerous 

epithelial lesions. J Med Virol 2009;81:703-12. 

4 Theelen W, et al. Increase in viral load, viral integration, and gain 

of telomerase genes during uterine cervical carcinogenesis can be 

simultaneously assessed by the HPV 16/18 MLPA –assay. Am J Pathol 

2010;177:2022-33. 

5 Marks M, et al. Kinetics of DNA load predict HPV16 viral clearance. 

J Clin Virol 2011;5:44-9. 

6 Carcopino X, et al. Evaluation of type-specific HPV persistence and 

high risk HPV viral load quantitation in HPV positive women under 

30 with normal cervical cytology. J Med Virol 2011;83:637-43. 

7 Xi LF, et al. Viral load in the natural history of Human Papillomavirus 

type 16 infection: a nested case-control study. J Infect Dis 

2011;203:1425-33. 

8 Carcopino X, et al. Significance of HPV16 and 18 viral load quantitation 

in women referred for colposcopy. J Med Virol 2012;84:306-13. 

9 Carcopino X, et al. Two years outcome of women infected with high 

risk HPV having normal clposcopy following low-grade or equivocal 

cytologic abnormalities: are HPV 16 and 18 viral load clinically useful 

predictive markers? J Med Virol 2012;84:964-72. 

EGFr analysis of 511 patients with non small cell 

lung cancer 

G. De Maglio1 , E. Masiero1 , S. Cernic1 , G. Fasola2 , S. Pizzolitto1 1 SOC Anatomia Patologica, Azienda Ospedaliero-Universitaria Santa 

Maria della Misericordia, Udine, Italy; 2 Dipartimento di Oncologia, 

Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, 

Italy. 

Background. EGFR mutations are the most widely studied 

biomarker in patients affected by non-small cell lung cancer 

(NSCLC). 

In Caucasian people mutation rate is reported in 10-15% of 


adenocarcinomas, with prevalence of never-smoker female and 

adenocarcinoma histotype. 

The most common activating mutations of EGFR gene are deletions 

in exon 19 and single nucleotide substitution in exon 21, occurring 

altogether in about 90% of cases. Literature data suggest 

a different clinical outcome between patients harbouring different 

EGFR mutation. 

We sought to determine frequency and distribution of EGFR 

activating mutations in a cohort of patients analysed in a single 

institution, over the past two years. 

Methods. In the period July 2010-May 2012, 511 cases of 

NSCLC patients from several Medical Oncology Departments of 

Friuli Venezia Giulia were screened for EGFR mutations in exons 

18-19-20-21. Samples were represented by primary tumors or 

metastatic sites and resulted in small endoscopic biopsies, surgery 

samples and cytological specimens, either paraffin-embedded 

pleural fluids or smeared washing/brushing. 

DNA extraction was performed using QIAamp DNA Mini kit 

(QIAGEN, Germany), after tumor manual microdissection for 

obtaining the most neoplastic cell enrichment. 

Molecular analysis were performed by pyrosequencing on Pyro- 

Mark Q96 ID instrument (QIAGEN, Germany) with EGFR TKI 

response® (sensitivity) (Diatech Pharmacogenetics, Italy) for the 

assessment of activating EGFR mutations in exons 18, 19 and 21. 

Results. Among the 511 patients, 68 (13.30%) had any EGFR 

mutations (exon 18 or exon 19 or exon 21). There were distributed 

as represented in tables below. 

In our series of patients exon 19 deletions were present in 50% 

of mutated cases, with the most prevalence of E746-A750del15 

mutation. L858R mutation in exon 21 was found in 39,7% of 

mutated cases, resulting in the 90% of all exon 21 mutations. 

No indeterminate results were obtained in the last 6 months. 

Results were accessible to the oncologist in a medium time of 5 

consecutive days from the availability of the sample. 

Patients 511 

any mutation 

(exon18, exon 19, exon 21) 

68 (13.30%) 

mutation ex18 4 5,88% 



Exon 18 

Exon 19 

Exon 21 

Number of patients 

G719S/d 3 

G719a 1 

E746-a750del15 26 

l747-a750 > p 1 

l747-S752del 1 

l747-p753 > S 1 

S752-i759del 1 

indeterminate 4 

l858R 27 

l861Q 3 

Conclusions. In our experience cytologic samples were equivalent 

to histologic samples for test success rate in identifying


EGFR mutations and showed advantages compared to very small 

endoscopic biopsies. 

In the last few months we observed a decrease of indeterminate 

results, probably due to better compliance with sample selection 

and manual microdissection. However in some cases, neoplastic 

cells amount was lower than requested by sensitivity detection 

rate, suggesting the need of more representative samples to analyse. 

Frequency and distribution of mutations reported in literature 

have been confirmed. Clinical follow up is necessary in order to 

investigate the different clinical outcome of patients with different 

mutations. 

references 

Herbst RS, et al. Lung cancer. N Engl J Med 2008;359:1367-80. 

Pirker R, et al. Consensus for EGFR Mutation Testing in Non-small Cell 

Lung Cancer. J Thorac Oncol 2010;5:1706-1. 

Won Y-W, et al. Comparison of clinical outcome of patients with nonsmall-cell 

lung cancer harbouring epidermal growth factor receptor 

exon 19 or exon 21 mutations. J Clin Pathol 2011;64:947-52. 

Multiple mutation analysis of EGFr pathway: 

a potential molecular prognostic biomarker 

in advanced colorectal cancer 

G. De Maglio1 , L. Foltran2 , F. Pisa3 , G. Aprile2 , E. Masiero1 , 

S. Cernic1 , E.S. Lutrino2 , G. Falconieri1 , G. Fasola2 , S. Pizzolitto1 1 Department of Pathology, University Hospital Santa Maria della Misericordia, 

Udine, Italy; 2 Department of Oncology, University Hospital Santa 

Maria della Misericordia, Udine, Italy; 3 Institute of Hygiene and Clinical 

Epidemiology, University Hospital Santa Maria della Misericordia, Udine, 

Italy 

Background. KRAS mutations in codons 12-13 are proved to 

predict resistance to anti-EGFR antibodies, but their prognostic 

value is still controversial. Instead BRAF mutation is widely 

recognised as a strong negative prognostic factor in metastatic 

colorectal cancer. Mutations in NRAS, PIK3CA or other downstream 

components of the EGFR pathway may give a potential 

impact on overall survival. 

Method. A consecutive series of 201 advanced colorectal cancer 

were tested for KRAS, BRAF, PIK3CA and NRAS. After tissue 

microdissection in order to obtain more than 50% cancer cells enrichment, 

DNA was extracted with commercial reagents (QIAmp 

DNA Mini kit, Qiagen, Germany) and genotyping was performed 

by pyrosequencing on PyroMark TM Q96 ID instrument (Qiagen, 

Germany) with commercially available kits Anti-EGFR MoAb 

response® (Diatech pharmacogenetics, Italy). 

Overall survival was calculated for all patients. 

For statistical analysis cases were subdivided in 4 categories: 

(1) KRAS (codons 12-13) mutated tumors; (2) BRAF mutated 

tumors; (3) tumors mutated in PIK3CA, NRAS or KRAS (codons 

61-146) (4) all-wild type tumors. Log-rank test was applied for 

statistical analysis. 

Results. In 96 (47,8%) patients KRAS mutations were detected: 

86 (42,8%) were in codons 12-13, 5 (2,5%) were in codon 61 and 

5 (2,5%) in codon 146. 

BRAF V600E mutation was present in 11 (5,5%) samples. 

PIK3CA mutated tumors were 33 (16,4%): 26 (12,9%) in exon 9 

and 7 (3,5%) in exon 20. 

NRAS mutations were found in and 7 (3,5%) tumors: 3 (1,5%) 

in codon 12, 3 (1,5%) in codon 61 and 1 case harboured a G13R 

mutation. 

Concomitant KRAS/PIK3CA mutations were observed in 24 

(11,9%) patients. All other mutations were mutually exclusive. 

KRAS/BRAF/PIK3CA/NRAS all wild-type patients had the longest 

survival (p = 0.002). Patients harboring BRAF mutation had 

reduced survival (p = 0.006). Mutations of any codon of KRAS 

(12-13-61-146) apparently had a negative impact on survival 

(p = 0.03). 


Conclusions. Early mutational profiling of all EGFR pathway 

components in advanced colorectal cancer patients could be 

useful in the identification of different molecular prognostic 

subgroups. This information may help clinicians in treatment 

selection and stratification in clinical trials. 

references 

1 Bardelli A, et al. Molecular mechanisms of resistance to cetuximab and 

panitumumab in colorectal cancer. J Clin Oncol 2010;28:1254-61. 

2 Custodio A, et al. Prognostic and predictive biomarkers for epidermal 

growth factor receptor-targeted therapy in colorectal cancer: Beyond 

KRAS mutations. Crit Rev Oncol Hematol 2012 May 28. [Epub ahead 

of print] 

3 De Roock W, et al. Effects of KRAS, BRAF, NRAS, and PIK3CA mutations 

on the efficacy of cetuximab plus chemotherapy in chemotherapy-refractory 

metastatic colorectal cancer: a retrospective consortium 

analysis. Lancet Oncol 2010;11:753-62. 

4 Sartore-Bianchi A, et al. Integrated molecular dissection of the epidermal 

growth factor receptor (EGFR) oncogenic pathway to predict 

response to EGFR-targeted monoclonal antibodies in metastatic 

colorectal cancer. Target Oncol 2010;5:19-28. 

BrAF test and cytological diagnosis with only 

a FnC. diagnostic accurancy 

G. Di Benedetto 

Medical Doctor of Cytopathology, UOS Cytopathology ASl Ce 

Introduction. Fine needle cytology (FNC) is considered the gold 

standard diagnostic test in the evaluation of a thyroid nodule. It is 

a simple, cost effective, readily repeatable and quick to perform 

test, with excellent patient compliance 1 . 

More recently, FNC has been combined to biomolecular analysis. 

In particular has been well studied V600-E Braf mutation. 

BRAF gene mutations are common in human cancers 2 . Many 

studies have reported a particularly high prevalence of V600- 

BRAF mutations in Papillary Thyroid Carcinoma 3 4 . Remarkably, 

this mutation has consistently been reported to be specific 

for PTC, with no benign thyroid neoplasms having been found 

to harbour BRAF mutation. Moreover, BRAF mutation has been 

demonstrated to be a novel prognostic biomarker that predicts 

poor clinicopathological outcomes, such as increased incidence 

of extrathyroidal invasion and distant metastasis of the tumor 3 4 . 

To facilitate widespread use of this test, sample collection procedures 

have to be standardized step-by-step. In particular, the way 

in which the aspirated samples is aliquoted into routine smears 

and the buffer for DNA extraction is crucial 5 . 

The aim of our study was undertaken to assess whether with a 

one-time withdrawal thyroid (FNC) our method of FNC preparation 

is suitable to implement BRAF testing. 

Materials and methods. In our study Fine Needle Cytology 

(FNC) are carried out, under ultrasound guidance aided by the 

ecographist and cytopathologist. 

253 FNC cases were performed in the outpatient clinic at the 

second University of Naples (SUN). Prior written and informed 

consent was obtained from each patient. 

Ultrasound criteria. The following ultrasonographical features 

were considered to identify a suspicious nodule: hypoechoic appearance, 

irregular nodular margins, vascular pattern of the nodule 

from a Doppler ultrasound and the presence of intranodular 

microcalcifications. 

Biopsy procedure. Upon assessment of patient, we acquired one 

biopsy for each nodule with a 23 gauge needle without suction. 

The preparations were smeared by pathologist onto one glass 

slide, air dried and stained with Diff-Quick. Cell adequacy was 

carried out for each patient. The needle was washed aspirating 

2cc of physiologic solution and was collected into a tube. The 

material was collected for molecular testing. 

Cytological classification. The assessment of cytological specimens 

was performed according to the Italian Society of Pathology


Tab. I. 

CYTOLOGIC DIAGNOSES 

CYTOLOGY 

CLASSIFICATION RESULTS 

Not neoplastic tir2 227 (89%) 

follicular suspicious tir3 15 (5.8%) 

Suggestive for malignancy 

tir4 

4 (1.6%) 

Positive for malignancy tir5 12 (4.6%) 

total 

and Cytology (SIAPEC) consensus conference morphological 

criteria: Tir2 - negative for malignant cells; Tir3 - follicular neoplasia/atypia 

of indeterminate significance: Tir4 - suggestive for 

malignant neoplasm: Heterogeneous group of lesions characterized 

by few neoplastic malignant cells, numerically insufficient 

to make diagnosis or presenting cytological atypia insufficient 

to make a diagnosis; Tir5 - positive for malignancy: This group 

includes all the cases with positive cytology. 

Molecular Biology. The cellular material collected for molecular 

testing has been selected about centrifugation and used for DNA 

extraction. 

Extraction. DNA was achieved with a salting-out method (Miller). 

Purity assay and evaluation was assessed by spectrophotometry 

(Biophotomaker Eppendorf), while the degree of integrity was 

evaluated with electrophoresis. Have been considered sufficient 

100 nanograms of DNA extract. 

V600--Braf Mutation. The confirmation of V600-Braf Mutation 

was employed with the gene sequencing (Biosystem kit) and 

scanning on automatic analyzer ABI PRISM 310 (Genetic Analyzer 

Applied Biosystem) (Figure 2). 

For the evaluation of DNA samples validity we provide to amplify 

a region of Tyreoglobuline gene. Gene presence proves the 

adequacy of sample. 

Tab. II. 

CYTOLOGY 

tir2 

NOT 

NEOPLASTIC 

220 tn 

follow-up 

tir3 1 fp 

tir4 

258 

FOLLICULAR 

ADENOMA 


Cyto-Histological correlation. Thyroid nodules were histologically 

classified and compared with the cytology. Cytological 

diagnoses of Tir3, Tir4, Tir5 were considered correlated with 

surgery (true positive) when the histological diagnosis was of 

follicular adenoma, follicular carcinoma, papillary carcinoma and 

other malignancies. The cytological diagnoses of Tir2, (true negative), 

were considered correlated when the follow-up has shown 

that the thyroid nodule remained unchanged in size. 

Statistical Analysis. For the calculation of diagnostic accuracy, 

we considered true positive with histological diagnosis of malignant 

neoplasm or follicular adenoma; on the other side, we 

considered false positive, when the surgery is not necessary, with 

histological diagnosis of nodular goiter. Furthermore, patients 

with cytological diagnosis of benignant lesions were considered 

as true negative only if the thyroid nodule remained unchanged to 

the subsequent follow-up. To calculate diagnostic accuracy, we 

excluded the sensitivity, since it is strictly dependent on the 

false negative and follow up of TiR2 not exclude the possibility 

of a neoplasm. 

Therefore we calculated the diagnostic accuracy of FNC only 

with the specificity, the predictive value of positive and predictive 

value of malignancy. 

Results. Cytology and Dna extraction. Table I shows the distributions 

of cytologic diagnoses as follows: Tir2 = 227;Tir3 = 15; 

Tir4 = 4; Tir5 = 12. 

All tests showed positive for thyroglobulin and the amount of 

DNA extracted was grater than 100 nanograms. 

V600 Braf Mutation. The V600-BRAF mutation was found on 

2/15 (13.3%) of Tir3, 2/4(50%) of Tir4 and 7/12 (75%) of Tir5 

and wherefore on 11/23 of Tir3-4-5. 

11/258 (4.2%) of every FNC resulted mutated. 

Cyto-Histologic correlation. The cytologic-histologic correlations 

are shown in Table II. 

23 patients with cytological diagnosis of TiR3-4-5 underwent 

thyroidectomy and subsequent histological examination which 

revealed 17 papillary carcinomas, 4 follicular adenomas, 1 follicular 

carcinoma, 1 nodular goiter. The cyto histological correlation 

between follicular neoplasia, including adenomas, was 

found in 21 patients (Tp). In two cases (Fp), we did not found 

correlation and histologic diagnosis was nodular goiter. 

FOLLICULAR 

CARCINOMA 

PAPILLARY 

CARCINOMA 

4 tp 2 tp 

1 Braf+ 

1 fp 

3 tp 

1 Braf+ 

tir5 12 tp 

9 Braf+ 

diagnostic accuracy: true positive:22; false positive: 2; true Negative: 220; false Negative: 0; Specificity = tn/(tn+fp) = 220/222 = 98.2%; 

false positive Rate = fp/(tp+fp) 2/24 = 8.3%; false malignant Rate = fp*/(tp+fp = 6/24 = 25%. Braf+ tir3 = 14..2%;tir4 = 25 %; tir5 = 75%; = 

totale = 11/17 = 64.7%. 

fp* = fp+follicular adenoma


The specificity of the FNC was 98.2, the false positive rate was 

of 8.3%, the false malignant value was of 29% and 25% using 

V600-BRAF. 

Discussion. In patients with unquestionable cytological evidences 

of PTC, the preoperative detection of the V600E BRAF 

mutation may have a direct impact on treatment. Recently, Xing 4 

suggested that, for prognostic purpose, perhaps all patients with 

cytologically diagnosed PTC should be preoperatively tested for 

BRAF mutation. In this respect, this test provides information 

that are additional and non redundant to those provided by a well 

taken and correctly interpreted thyroid FNA. 

With an one-time withdrawal thyroid (FNC), we obtained cytological 

and molecular data that may be useful both for diagnosis 

and prognosis of the patient. We consider important to obtain 

additional molecular information with a single withdrawal from 

thyroid nodules to avoid unnecessary steps how to call the patient 

with all the problems inherent in it. We keep the material in suspension 

and carry out cytological research BRAF V600 mutation. 

In our study eleven FNC had a conclusive cytological evidence of 

PTC (Tir5), four FNC had a souspicius cytological of PTC (Tir4), 

fifteen FNC had an undeterminate diagnosis (Tir3) and 227 not 

neoplastic (Tir2). 

Regardless of the sample collection methodology, all FNC were 

suitable for molecular analysis and were tested with a sequence 

of thyroglobulin and the amount of extracted DNA was more 

than one hundred nanograms, deemed sufficient quantities; in 

three cases Tir5 and two cases Tir4 V600 BRAF mutation was 

detected. In all remaining cases classified Tir2, V600E BRAF 

mutation was not detected. 

Our data showed that, in a routine clinical setting, FNC specimens 

can be handled properly to provide both morphological and 

molecular information. Our study focusing on the single steps 

required to aliquot the aspirated material into routine smears 

and DNA extraction buffer may help to implement BRAF testing 

in the prognostic evaluation of PTC diagnosed by FNA. Our 

proposed method ensures that this test does not interfere with 

conventional cytology diagnostic accuracy. 

references 

1 Dean DS, Gharib H. Epidemiology of thyroid nodules. Best Pract Res 

Clin Endocrinol Metab 2008;22:901-11. 

2 Davies H, Bignell GR, Cox C, Stephens P, et al. 2002 Mutations of the 

BRAF gene in human cancer. Nature 417:949-54. 

3 Cohen Y, Xing M, Mambo E, et al. BRAF mutation in papillary thyroid 

carcinoma. J Natl Cancer Inst 2003;95:625-7. 

4 Xing M, Westra WH, Tufano RP, et al. BRAF mutation predicts poorer 

clinical prognosis for papillary thyroid cancer. J Clin Endocrinol Metab 

2005;90:6373-9. 

5 Troncone G, Cozzolino I, Fedele M, et al. Preparation of Thyroid FNA 

Material for Routine Cytology and BRAF Testing: A Validation Study. 

Diagnostic Cytopathology2009;38(3). 

6 Hassell LA, Gillies EM, Dunn ST. Cytologic and molecular diagnosis 

of thyroid cancers: Is it Time for Routine. Cancer Cytopathol 2011: 

10.1002/.20186. 

Sensitivity and positive predictive value 

of HMB-45 and MArT-1 as immunocytochemical 

markers of recurrent/metastatic melanoma on 

fine needle cytology samples: an experience with 

250 cases in 5 years (2007-2012) 

F. Fulciniti1 , A. Galzerano2 , A. Cipolletta Campanile1 , A. Gioioso1 , 

F. Caccavello1 1 S.S.D. di Citopatologia, S.C. di Anatomia Patologica e Citopatologia, 

Istituto Nazionale Tumori “Fondazione G. Pascale”, Naples, Italy; 2 Pathology 

Unit, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal 

Background. Metastatic melanoma may be difficult to distinguish 

from other neoplasms such as carcinomas, lymphomas or 

sarcomas due to its highly variable morphologic picture. Even 

though the various cytomorphologic presentations of melanoma 


on Fine Needle Cytology (FNC) samples are well known to 

cytopathologists, a diagnosis of recurrent/metastatic melanoma 

should always be validated by appropriate ancillary techniques, 

due to its usually unfavorable prognostic and medico-legal implications. 

Immunocytochemical stains for melanocytic markers 

on FNC samples should couple the highest possible diagnostic 

accuracy with the least possible number of immunocytochemical 

stains on a given sample to be both accurate and cost-effective. 

Materials and methods. We retrospectively analyzed 250 cases 

of recurrent/metastatic melanoma diagnosed on FNC samples 

from various body sites between January 2007 and May 2012 

in Our Institution. There were 99 female- and 151 male patients 

(F/M ratio 1/ 1.5), with a median age of 59 yrs. All of the cytological 

diagnoses were confirmed by tissue study and clinicopathological 

follow-up. For each patient, one representative 

routine, wet-fixed Papanicolaou-stained smear was dismounted 

and stained for HMB 45 (Novocastra, clone HMB 45) by a semiautomated 

immunostainer (Leica, Bond Max). Positive cases 

showed a diffuse, usually intense, granular cytoplasmic positivity 

in > 10% of the neoplastic cells. In cases with negative HMB45 

staining with cytomorphologic features suggestive for recurrent/ 

metastatic melanoma, a supplementary wet-fixed Papanicolaoustained 

smear was dismounted and stained for MART-1 (Melan- 

A, Novocastra, Clone A 103). MART-1 staining was generally 

more diffuse (> 30% of the neoplastic cells) than HMB 45 in 34 

cases in which both immunostains were performed on the same 

case (13.6 %). HMB-45 and MART-1 staining results were used 

to determine the sensitivity and positive predictive value of immunocytochemistry. 

Results. Of 250 cases, 231 were positive for HMB-45, with a 

sensitivity of 92,4%, and 19 were negative (7.6%), while of 34 

cases in which we performed MART-1, 27 were positive, with 

a corresponding sensitivity of 79%. 15 cases were positive for 

HMB45 and MART1. The combined sensitivity HMB-45+ and/ 

or MART-1+ was 98%. The positive predictive value of a positive 

HMB-45 stain and/or and positive MART-1 stain was 100%. 

Both HMB45 and MART-1 were negative in 5 cases (2%). The 

negativity was correlated to cellular necrosis in 1 case, to a diagnosis 

of desmoplastic melanoma in 2 cases (which were double 

negative also on histology) and to the amelanic epithelioid phenotype 

in 2 more cases. 

Conclusion. HMB-45 and MART-1 demonstrated to be very 

sensitive and cost-effective to confirm the cytomorphological 

diagnosis of recurrent/ metastatic melanoma on FNC samples. 

We suggest the routine usage of HMB-45 or both HMB-45 and 

MART-1 versus the usage of extended immunocytochemical 

panels. HMB45 staining seems to have a superior outcome when 

used on alcohol fixed smears as opposed to formalin-fixed cells 

blocks. Microphthalmia transcription factor (MITF) or other alternative 

markers for melanoma should be tested on desmoplastic 

or other variants of melanoma which are double negative for 

HMB45 and MART-1-. 

references 

1 Fetsch PA, Marincola FM, Filie A, et al. Melanoma-associated antigen 

recognized by T cells (MART-1): the advent of a preferred immunocytochemical 

antibody for the diagnosis of metastatic malignant 

melanoma with fine-needle aspiration. Cancer.1999;87:37-42. 

2 Sheffield MV, Yee H, Dorvault CC, et al. Comparison of five antibodies 

as markers in the diagnosis of melanoma in cytologic preparations. 

Am J Clin Pathol 2002;118:930-6. 

3 Dorvault CC, Weilbaecher KN, Yee H, et al. Microphthalmia transcription 

factor: a sensitive and specific marker for malignant melanoma 

in cytologic specimens. Cancer 2001;93:337-43. 

4 Murali R, Thompson JF, Uren RF, et al. Fine-needle biopsy of metastatic 

melanoma: clinical use and new applications. Lancet Oncol 

2010;11:391-400


BrAF mutation analysis in metastatic malignant 

melanoma 

R. Gafà, G. Querzoli, L. Ulazzi, I. Maestri, R. Mazzoni, G. Lanza 

Section of Pathology, Department of Experimental and Diagnostic Medicine, 

University of Ferrara 

Background. Treatment of metastatic melanoma is rapidly 

evolving due to an improved understanding of the molecular 

pathogenesis of the disease and the development of therapies 

targeting specific genetic aberrations. Of particular importance 

in melanoma is the mitogen-activated protein kinase (MAPK) 

pathway which normally regulates cell growth, proliferation 

and differentiation. Aberrant activation of the MAPK pathway 

is present in over 80% of primary malignant melanomas as a 

result of activating mutations in either NRAS, HRAS, BRAF, 

GNAQ or KIT genes. Such mutations have been documented 

in all subtypes of cutaneous malignant melanomas and the 

frequency of these mutations varies across different melanoma 

variants and sites. For example, BRAF mutant melanomas 

tipically occur on skin sites intermittently exposed to the sun 

and histologically are characterized by features of superficial 

spreading melanomas. In contrast tumors with the histological 

features of acral lentiginous melanoma usually show KIT 

mutations. 

Constitutively activating somatic missense mutations in 

the BRAF gene are detectable in a wide variety of human 

cancers. The point mutation V600E in exon 15 is the most 

common and is found in 80% of the mutated tumors. Among 

BRAF mutant melanomas, 74-90% display V600E and 16- 

29% V600K mutations. The frequency of BRAF mutation 

in primary melanoma ranges from 36 to 45% and 42-55% in 

metastatic melanoma. 

Recent clinical studies demonstrated improved survival in patients 

affected by BRAF V600E mutated metastatic melanoma 

treated with specific BRAF inhibitors. Therefore, BRAF mutational 

status evaluation has been introduced as a diagnostic test 

for the selection of patients with metastatic melanoma to undergo 

this novel tailored treatment. 

Aim of the present study was to evaluate exon 15 BRAF gene 

mutation in a series of cutaneous melanomas which developed 

metastatic disease. 

Methods. The study included 8 primary melanomas and 30 metastases 

from melanomas diagnosed in 38 patients from 2009 to 

2012. Mean age at diagnosis was 60 years (range 29-84 years). 

Evaluation of BRAF mutation was investigated by direct DNA 

sequencing on DNA extracted from formalin-fixed paraffin embedded 

tissue samples. Careful microdissection of selected areas 

was performed to obtain an high fraction of neoplastic cells (at 

least 60%). All tha analyses were completely performed twice. 

Results. BRAF mutation was detected in 19 of 38 cases (50%). In 

particular BRAF V600E mutation was found in 16 cases (42.1%), 

and BRAF V600K mutation in 3 cases (7.9%). Among the 16 

cases with BRAF V600E mutation one case showed a tandem 

mutation of V600E (two base-pair substitution TG > AA). In 

metastatic melanoma (30 cases) BRAF V600E mutation was 

demonstrated in 12 cases (40%) and BRAF V600K mutation in 

3 cases (10%). 

Conclusions. Exon 15 BRAF mutation can be detected in a half 

of patients with metastatic melanoma and V600E mutation represents 

the large majority of the mutations detected. Our results are 

in agreement with the data reported in the literature. 

BRAF mutation analysis is a reliable molecular diagnostic test to 

be employed in the choice of the most appropriate treatment for 

patients with metastatic melanoma. 

references 

1 Woodman SE, et al. New strategies in melanoma: molecular testing in 

advanced disease. Clin Cancer Res 2012;18:1195-200. 


2 Platz A, et al. Human cutaneous melanoma; a review of NRAS and 

BRAF mutation frequencies in relation to histogenetic subclass and 

body site. Mol Oncol 2008;1:395-405. 

3 Arkenau H-T, et al. Targeting BRAF for patients with melanoma. Br J 

Cancer 2011;104:392-8. 

4 Curtin JA, et al. Distinct sets of genetic alterations in melanoma. N 

Engl J Med 2005;353:2135-47. 

5 Davies H, et al. Mutations of the BRAF gene in human cancer. Nature 

2002;417:949-54. 

6 Algazi AP, Soon CW, Daud AI. Treatment of cutaneous melanoma: 

current approaches and future prospects. Cancer Manag Res 

2010;2:197-211. 

KrAS mutation testing on different areas 

of primary colorectal adenocarcinomas 

with mucinous component 

G. Giuffrè, A. Ieni, V. Barresi, A. Simone, R. Scarfì, G. Branca, 

G. Tuccari 

Department of Human Pathology, University of Messina, A.O.U. “Policlinico 

G. Martino”, Messina, Italy 

Background. KRAS mutations occurs in 30% to 50% of colorectal 

cancer (CRC) and the most common mutations are in 

codons 12 and 13, leading to continuous activation of downstream 

pathways. In metastatic CRC these activation mutations 

are predictive of nonresponse to anti-epidermal growth factor 

receptor therapy, therefore KRAS mutation testing is considered 

an essential prerequisite in therapeutic choice. Mutational analysis 

is carried out in primary tumour as well as in metastases 

and it is recommended that tissues should contain at least 70% 

of tumour cells. However, KRAS intratumoural heterogeneity 

may lead to discordant results when several specimens from 

the same tumour are analysed, especially when low sensitive 

methods are utilized. 

More than 90% of CRCs are adenocarcinomas and some of 

these show mucinous areas. Only when more than 50% of the 

lesion is composed of pools of extracellular mucin containing 

malignant epithelium, the CRC is considered as a histopathological 

variant and it is classified as mucinous adenocarcinoma. 

Clinical and molecular studies have suggested that this histopathological 

variant behaves differently from more common 

histological subtypes of CRC, also for KRAS status. The aim 

of this study is to evaluate the mutational status of KRAS on 

different areas of colorectal adenocarcinomas with a mucinous 

component < 50%. 

Methods. We analyzed the mutational status of KRAS on a 

series of 20 formalin-fixed, paraffin-embedded, advanced CRC 

specimens taken from an equal number of patients. Each sample 

was classified as adenocarcinoma with mucinous areas (< 50%) 

and DNA extraction was performed by laser-microdissection 

with respect to the different histological types present in the 

same section. Mutant KRAS was detected using a high sensitive 

mutation kit (KRAS StripAssay, ViennaLab, Austria) that identifies 

ten more frequent somatic mutations located in codons 12 

and 13 (Gly12Ala, Gly12Arg, Gly12Asp, Gly12Cys, Gly12Ile, 

Gly12Leu, Gly12Ser, Gly12Val, Gly13Asp and Gly13Cys) using 

mutant-enriched allele-specific PCR and reverse-hybridization. 

Results. We found a KRAS single mutations in 10/20 (50%) 

patients. In particular, in 9 patients the same mutation was detected 

in adenocarcinomatous as well as in mucinous areas. On 

the contrary, in one case we found a mutation (Gly12Asp) in the 

adenocarcinomatous area but not in mucinous component of the 

same tumour. 

Conclusions. Intratumoural heterogeneity of KRAS status is not 

frequent in adenocarcinomas with a mucinous component.


role of molecular biology in ovarian cancer 

prognostic implications 

I. Montagnani, F. Castiglione, A.M. Buccoliero, P. Pretelli, 

D. Moncini, D. Rossi Degl’Innocenti, G. Scarselli, G.L. Taddei 

Università degli studi di Firenze. AOUC Careggi, Dipartimento di Area 

Critica Medico Chirurgica sezione di Anatomia Patologica, Firenze 

Epithelial ovarian cancer comprises the majority of the malignant 

ovarian tumors in adult woman. These neoplasms are classified 

into distinct morphologic categories based on the histologic 

appearance into: serous, mucinous, endometrioid, clear cell, 

transitional, squamous, mixed and undifferentiated type.This heterogeneous 

group of neoplasms is composed of benign tumors in 

more than 60% of cases. The malignant form are generally (more 

than 90% of cases) detected in advanced stages (III or IV stage) 

and in these cases the death for disease arises to 60%. Actually 

the first line therapy for these patients is based on traditional chemotherapy 

(using cisplatino and taxolo); this treatment influences 

the disease-free-survival, but not the mortality. 

In this study we select 67 cases of high grade serous ovarian carcinoma 

(G3 grade) and we propose to analyse KRAS gene with 

PCR Sequencing. We want to identify the presence of mutation 

in this gene according to the cancerogenesis progression model 

introduced by Robert J. Kurman. 

We find that in the case of wild-type KRAS patients have higher 

disease-free-survival and that mutated gene (in codon 12 or 13) 

occurs precociously in cancerogenesis. 

These observations stand out statistic significative prognostic 

values of KRAS mutation in high grade serous carcinoma. Furthermore 

these results prospect the possibility to use a specific 

treatment for these patients using targeted immunotherapy to 

increase the overall survival. 

Epigenetic alterations in oral cancer: 

study of HMLH1, MGMT and rAr-beta-2 by 

methylation specific PCr (MSP) 

G. Pannone1 , A. Santoro1 , M. Mattoni1 , S. Papagerakis2 , 

S. Staibano3 , G. De Rosa3 , B. Pantaleo1 1 Department of Surgical Sciences, Section of Pathological Anatomy, University 

of Foggia, Foggia, Italy; 2 Department of Otolaryngology, Head 

and Neck Surgery and Oncology, Medical School University of Michigan 

Ann Arbor, Ann Arbor, MI, USA; 3 Department of Biomorphological and 

Functional Sciense-Session of Pathological Anatomy- University of Naples 

FedericoII, Naples,Italy 

Background. Hyper-methylation of cytosine base in CpG islands 

of gene promoters is an epigenetic phenomenon able to down 

regulate the expression of genes. When an oncogene expression 

is influenced, this phenomenon is directly linked with carcinogenesis 

1 . In oral district, many genes are considered to cause 

OSCC if their methylation status is altered. In our laboratory 

we have analysed, in a series of primary OSCCs with matched 

normal oral mucosa, the methylation status of a panel of genes, 

including hMLH1, MGMT, and RAR-beta-2, in order to define 

an epigenetic fingerprint of the oral cancer. 

Materials and methods. Thirty-seven cases of formalin-fixed, 

paraffin-embedded OSCC with relative controls of normal oral 

epithelium were analysed by methylation specific PCR (MSP). 

Also in this work we have observed different frequencies of gene 

methylation. For all genes, the Wald Test and the logistic multiple 

regression were performed, in order to verify the association 

between methylation status of gene promoter (covariates) and 

presence of cancer (response variable). 

Results. Characteristically, and in addition to the literature 

reported data, we have noted that also the healthy oral mucosa 

shows a methylated background. In our study population the 

most frequently methylated gene in cancer was represented by 

hMLH1(53%), although higher levels of methylation were found 


in control oral mucosa. RAR-beta-2 and MGMT promoter hypermethylation 

was found in both cases only in 13.5% of OSCCs, 

but more frequently in healthy oral mucosa (respectively, 28.5% 

and 23% of studied cases). Therefore, The Wald test confirmed 

the statistical significance for RAR-beta-2 (p = 0.044; CI at 95%). 

Conclusions. Similarly to other reviewed and here commented 

works, this study highlights the importance of epigenetic silencing, 

showing that a panel of genes may be useful in clinical 

practice separating normal oral epithelia from the cancerous 

ones if their DNAs were analysed by methylation specific PCR 

technique. All these results not only shed light on a molecular 

mechanism contributing to OSCC tumorigenesis, but also suggest 

that employing of an epigenetic fingerprint, together with the 

classical histo-pathological parameters, may improve the current 

diagnostic tools, but also contribute indirectly to therapeutics as 

predictor of choice for the correct clinical management of oral 

neoplastic and pre-neoplastic lesions. 

references 

1 Kulkarni V, Saranath D. Concurrent hypermethylation of multiple 

regulatory genes in chewing tobacco associated oral squamous cell 

carcinomas and adjacent normal tissues. Oral Oncol 2004;40:145-53. 

2 Pannone G, Bufo P, Santoro A, et al. WNT pathway in oral cancer: 

epigenetic inactivation of WNT-inhibitors. Oncol Rep 2010;24:1035-41. 

The endometriotic ovarian cysts: 

diagnostic possibility in molecular biology 

P. Pretelli, F. Castiglione, D. Moncini, A.M. Buccoliero, E. Projetto, 

I. Montagnani, D. Rossi Degl’Innocenti, G.L. Taddei 

Università di Firenze Dipartimento di Area Critica Medico- Chirurgica. 

Sezione di Anatomia Patologica 

Endometriosis is one of the most common benign disorders which 

affects 10-15% of all women in reproductive age. This pathology 

is defined as the presence of endometrial-like tissue (glands 

and stroma) outside the uterine cavity. The ectopic endometrium 

responds, as the normal endometrium, to stimuli of the ovarian hormones, 

especially estrogen, taking attitudes proliferative and functional 

typical of the normal endometrium. This induces a chronic 

inflammatory reaction, scar tissue, and adhesions that may distort a 

woman’s pelvic anatomy. Endometriosis is a debilitating condition 

characterized by high recurrence rates. Patients with endometriosis 

mainly complain of pelvic pain, dysmenorrhea, and dyspareunia. 

The etiology and pathogenesis remain unclear. 

Homeobox genes are regulatory genes with a common 180-183 

bp sequenze (homeobox) coding for a 61 amino-acis domain 

definite as homeodomain. This homeodomain is a DNA binding 

domain and acts as transcription factor during normal embryonic 

development. In human class homeobox genes, also termed HOX 

genes, are organized in 4 cluster HOXA, HOB, HOXC and HOXD, 

situated on separated chromosomes, 7, 12, 17 and 2, respectively. 

Each cluster contain between 9-11 genes for a total of 39 clustered 

human Hox genes. During development, Hox genes are expressed 

in accordance with gene position within its cluster and in rostralcaudal 

manner. In the last years was born a interest on a possible 

role of human Hox genes and many studies are trying to find a relation 

between an inappropriate expression of these genes and tumor 

progression and metastasis, nevertheless HOX genes are also expressed 

in normal cells to maintain the tissue and organ physiology. 

The differential diagnosis of endometriotic lesion compared to 

non endometriotic lesion is important for the management of 

these patients to establish an adequate pharmacologic therapy. 

The diagnosi of endometriotic disease may be clinically suspected 

by the patient’s history and by the surgeon’s evaluation, 

but it can only be established by histopathological evaluation. 

Sometimes the histological diagnosis of endometriosis is very 

difficult because of the changes occurring in the lesions after 

bleeding and fibrosis.


The aim of the study was to analyze the expression levels of Hox 

genes in endometriotic and non endometriotic tissue with real 

time quantitative polymerase chain reaction (Real- time PCR) in 

fresh tissue to identify a possible molecular marker in cases with 

difficult differential diagnosis of endometriosis lesions. 

OCT-3/4 gene expression is lost in both well 

and poorly differentiated human prostate 

adenocarcinoma and it is up-regulated by 

hormone therapy 

M.G. Tupone, C. Sorrentino, S. Di Meo, T. D’Antuono, P. Musiani, 

E. Di Carlo 

Section of Anatomic Pathology and Molecular Medicine, Department of 

Medicine and Sciences of Aging, “G. d’Annunzio” University of Chieti- 

Pescara, Chieti, Italy; Ce.S.I. Aging Research Center, “G. d’Annunzio” 

University Foundation, Chieti, Italy. 

Introduction. Oct-3/4 is a master regulator that orchestrate the 

self‐renewal and pluripotency of embryonic stem cells 1 . Cancer 

and embryonic stem cells exhibit similar behavior, including immortal, 

undifferentiated, and invasive activities 2 . Tumors with 

intense expression of this stem cell marker are usually associated 

with further progression and shorter cancer-related survival compared 

with those with moderate and low expressions 3 . However, 

its role is still unclear in the biology of prostate cancer (PCa), a 

histologically heterogeneous and multifocal disease leading to a 

smoldering or a very aggressive malignancy. 

Materials and methods. We gained a good experience in the study 

of the PCa microenvironment by laser capture microdissection 

(LCM), a technology that allows isolation, for molecular analyses, 

of individual cell populations 4 5 . Thus, LCM, followed by realtime 

RT-PCR were used to determine Oct-3/4 gene expression 

levels in the normal and cancerous prostatic epithelium and stroma, 

discriminating neoplastic foci with low (well differentiated) versus 

high (poorly differentiated) Gleason grade (≤ 3 versus ˃ 3). Epithelial 

and stromal cells were isolated from cancerous and normal 

(selected from the prostatic lobe opposite to the PCa or the normal 

prostatic tissue far from the cancer) prostate specimens from 55 

untreated and 35 androgen deprivation therapy (ADT)-treated PCa 

patients who underwent radical prostatectomy for PCa, and normal 

prostate specimens from 12 patients who had undergone cystoprostatectomy 

for bladder cancer (control patients). 

OSSO E PArTI MOLLI 

Primary epithelioid hemangioendothelioma 

of the lymph node: a case report 

M. Ballotta, L. Borghi, A. Rasi, R. Mencarelli 

Anatomia Patologica Dipartimento Patologia Clinica, Azienda Ulss 18, 

Rovigo 

Introduction. Epithelioid hemangioendothelioma, first described 

by Weiss and Enzinger in 1982, is a rare vascular tumour of 

intermediated malignancy. It may occur in the skin, deep soft 

tissue, bone or viscera, particularly in liver and lung it could be 

misinterpreted as carcinoma. 

We describe a rare case of primary epithelioid hemangioendothelioma 

of lymph node. 


Sala Giotto – ore 16,30-18,00 


Results. Oct-3/4 gene expression significantly (P < 0.05) diverged 

between normal and neoplastic microdissected epithelial 

cell populations, in particular, it was ~7 times lower in neoplastic 

epithelium from both low and high grade PCa versus normal 

epithelium. Furthermore, expression levels were very low in both 

normal and cancer associated stromal compartments and comparable 

to those observed in the neoplastic epithelium. Interestingly, 

hormone therapy increased Oct-3/4 gene expression levels 

particularly in the normal prostatic epithelium and high grade 

PCa-associated stroma. 

The mean expression level of Oct-3/4 in normal samples from the 

untreated patients was not significantly different to that obtained 

in normal samples from controls. 

Conclusions. By contrast with findings observed in many other 

types of cancer, our preliminary data show that Oct-3/4 expression 

is lost in PCa, particularly in the neoplastic epithelial glands, 

independently from its differentiation grade. Up-regulation of this 

“stemness” marker by ADT may represent, in the normal epithelium, 

its enrichment in normal stem cells after the death of AR + 

differentiated cells, as opposed, in the stroma of poorly differentiated 

PCa, its enrichment in neoplastic mesenchymal stem cells, 

suggesting dissimilar effects of hormone therapy on the prostate. 

The mechanisms underlying Oct-3/4 gene expression regulation 

and its significance in PCa are currently under investigation in 

our laboratories. 

references 

1 Nichols J, Zevnik B, Anastassiadis K, et al. Formation of pluripotent 

stem cells in the mammalian embryo depends on the POU transcription 

factor Oct4. Cell 1998;95:379-91. 

2 Reya T, Morrison SJ, Clarke MF, et al. Stem cells, cancer, and cancer 

stem cells. Nature 2001;414:105-11. 

3 Wang Y, Armstrong SA. Cancer: inappropriate expression of stem 

cell programs? Cell Stem Cell 2008;2:297-9. 

4 Sorrentino C, Musiani P, Pompa P, et al. Androgen deprivation boosts 

prostatic infiltration of cytotoxic and regulatory T lymphocytes and 

has no effect on disease-free survival in prostate cancer patients. Clin 

Cancer Res 2011;17:1571-81. 

5 Di Carlo E, D’Antuono T, Pompa P, et al. The lack of epithelial interleukin-7 

and BAFF/BLyS gene expression in prostate cancer as a 

possible mechanism of tumor escape from immunosurveillance. Clin 

Cancer Res 2009;15:2979-87. 

Case report. A 49 year old man presented a painful swelling of a 

right axillary lymph node. The node was tender, mobile and with 

irregular borders. Laboratory data were normal. The US revealed 

an enlarged (3 cm in maximum diameter) inhomogeneous lymph 

node hyper-echoic at the periphery and with an ipo-anahecoic 

central area. At TC no other lymph node resulted enlarged. 

Lymph node was removed. At histology lymph node architecture 

was effaced by a proliferation of polygonal, stellate or plump 

spindle cells, arranged in short strands or solid nests (Fig. 1). 

Tumour cells had abundant eosinophilic hyaline cytoplasm, 

which was frequently vacuolated forming primitive vascular 

channels, finding that could be misinterpreted as mucine vacuoles 

of adenocarcinoma, if intraluminal erythrocytes were not detected 

(Fig. 2). The nuclei showed mild to moderate pleomorphism, 1 

mitosis x 10 HPF, focal spindling of the cells and some foci of 

necrosis. At the periphery of the lymph node, aspect of intravas-


Fig. 1. 

cular growth was observed. At the immunostain the epithelioid 

cells were positive for CD31, CD34, Factor VIII related antigen 

(Fig. 3). 

CK and S100 were negative. Our diagnostic hypothesis was of 

epithelioid hemangioendothelioma. It’s requested a second opinion 

that confirmed the diagnosis. 

Discussion. Epithelioid hemangioendothelioma can be misinterpreted 

as carcinoma, melanoma and various sarcoma with 

epithelioid appearance. Appropriate immunostains may provide 

Fig. 2. 

Fig. 3. 


the most reliable clues for differentiation. About one fourth 

of epithelioid hemangioendotheliomas express cytokeratin but 

the staining is less intense and focal compared to carcinoma or 

epithelioid sarcoma. Classic lesion lacking high grade areas, 

including high nuclear grade, frequent mitotic activity, necrosis 

and sheet-like growth, have a recurrence risk rate of 10% to 15%, 

a metastatic risk of 25% and a mortality rate of 10% to 15%, as 

reported in literature. Primary epithelioid hemangioendothelioma 

of lymph node is very rare, but well documented. It is particularly 

likely to be mistaken for metastatic carcinoma. Careful histological 

diagnosis is essential for accurate clinical management and for 

avoiding over-treatment. The patient is disease free after 1 year of 

follow up, as confirmed by CT and MR. 

references 

Chan JK, Frizzera G, Flectcher C, et al. Primary vascular tumours of 

lymph nodes other the Kaposi’s sarcoma: analysis of 39 cases and 

delineation of two new entities. Am J Surg Pathol 1992;16:335-50. 

Enzinger and Weiss Soft tissue tumours, 5th e. 681-7. 

Folpe LA, Inwards CY. Bone and soft tissue pathology. 183-6. 

retroperitoneal malignant solitary fibrous tumor 

mimicking renal tumor. Case report and review 

of the literature 

M. Basciu2 , S. Blanco3 , M. Grasso3 , G. Cattoretti2 , G. Bovo1 1 Department of Pathology, Azienda Ospedaliera San Gerardo, Monza, 

Italy; 2 Department of Pathology, Department of Surgical Science, Università 

Degli Studi di Milano-Bicocca, Milano, Italy and Azienda Ospedaliera 

San Gerardo, Monza, Italy; 3 Department of Urology, Azienda Ospedaliera 

San Gerardo, Monza, Italy 

Retroperitoneal malignant solitary fibrous tumors (R-MSFTs) 

and renal malignant solitary fibrous tumors (K-MSFTs) have 

been reported rarely. We report a case of a 35-years-old man with 

lumbar pain and CT-scan positivity for a tumor of lower pole of 

left kidney. The patient underwent radical nephrectomy and a diagnosis 

of spindle cells neoplasia was rendered on intra-operatory 

frozen section examination. 

The mass, which arrived separately from the kidney and measured 

13 cm and weighed 636 gr, was encapsulated and, on a side, 

presented an area of surgical cauterization. 

Histologically the tumor was characterized by an expansive 

growth, and bulged into a fibrous pseudo-capsule. Cytologically 

the neoplasia consisted of pleomorphic, high-grade spindle cells 

with high mitotic activity (20x10 HPF in more active areas) 

and sometimes there were atypical mitotic figures. The tumor 

presented numerous, sometimes dysmorphic, vessels with arterializations 

and haemangiopericytoma-like features. 

Necrosis was not present, although there was a prominent sclerosis 

in the centre of the tumor. 

Immunohistochemistry showed weak but diffuse expression of 

CD34, strong and diffuse expression of CD99, positivity for vimentin 

and for p53; proliferative index (Ki-67) was about 20%. 

Bcl-2, S-100, CD31, HMB45, HHF3-actin, SM-actin, CK-AE1/ 

AE3, and EMA were immunonegative. 

Macroscopically kidney presented on the lower pole an area of 

surgical cauterization that corresponded histologically to sclerosis 

by tumor compressive effect. 

The final diagnosis was retroperitoneal malignant solitary fibrous 

tumor and it was confirmed by a second opinion. 

Reviewing the literature, a total of 12 R-MSFTs and 4 K-MSFTs 

were reported (see Tab. I). Sex ratio was 1/1,75 M/F for R- 

MSFTs and 1/4 M/F for K-MSFTs. Median age at the time of 

surgery was 50 for R-MSFTs (max. 70; min. 35) and 54 for K- 

MSFTs (max. 76; min. 36). Tumor size varied from 4,5 to 22 cm 

for R-MSFTs (median size 13,87 cm) and from 7 to 12 cm for 

K-MSFTs (median size 9,25 cm). 

It has been postulated two mechanisms for the development of 

MSFTs. The first possibility is that these malignancies occur de


Tab. I. 

R-MSFTs 

Case Autors Age Sex 

Max 

diameter 

(cm) 

1 

Vallat-Decouvelaere 

et al. (1998) 

40 M 17 

2 


et al. (1998) 

63 f 4,5 

3 


et al. (1998) 

70 f 10 

4 Nakatami et al. (2002) 56 f NK 

5 ito el al. (2008) 48 f 5,5 

6 Bishop el al. (2010) 44 f 13,7 

7 Bishop el al. (2010) 57 M 17,5 

8 Bae et al. (2011) 59 M 22 

9 collini et al. (2012) 43 f 22 

10 collini et al. (2012) 41 M 11 

11 collini et al. (2012) 43 f 16 

12 Present case 35 M 13 

K-MSFTs 

Case Autors Age Sex 

Max 

diameter 

(cm) 

1 fine et al. (2006) 76 M 12 

2 Magro et al. (2008) 34 f 9 

3 Hsieh et al (2011) 50 f 9 

4 de Martino et al. (2012) 68 f 7 

novo and grow rapidly. The other possible mechanism is transformation 

(“de-differentiation”) within a pre-existing benign SFT. 

Our case would fall into the first category. 

references 

1 Collini P, Negri T, Barisella M, et al. High-grade sarcomatous overgrowth 

in solitary fibrous tumors: a clinicopathologic study of 10 

cases. Am J Surg Pathol 2012;36:1002-15. 

2 Fine SW, McCarthy DM, Chan TY, et al. Malignant solitary fibrous 

tumor of the kidney. Report of a case and comprehensive review of the 

literature. Arch Pathol Lab Med 2006;130:857-61. 

3 Ito H, Fukuda M, Imamura Y, et al. A malignant solitary fibrous tumor 

in the retroperitoneum. Int J Clin Oncol 2008;13:173-5. 

Two cases of a rare vascular neoplasms: retiform 

hemangioendothelioma 

G. Crisman1 , A. D’Amuri2 , G. Coletti3 , F. Floccari2 , M. Cazzato4 , 

E. Villani2 , S.A. Senatore2 , A.P. Dei Tos5 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 

dell’Aquila, L’Aquila, Italia; 2 U.O.C. Anatomia Patologica, P.O. Gallipoli, 

ASL Lecce, Lecce; 3 U.O.C. Anatomia Patologica, Ospedale Civile 

“San Salvatore”, L’Aquila; 4 U.O.C. Chirurgia Generale, P.O. Gallipoli, 

ASL Lecce, Lecce; 5 Anatomia Patologica, Osp. “Ss. Maria di Ca’ Foncello”, 

Treviso 

Background. First described in 1994, Retiform Hemangioendothelioma 

(RH) represents an extremely rare, distinctive form of 

low-grade malignant angiosarcoma, characterized by a net-like 

growth pattern, a high rate of local recurrence and a low frequency 

of metastasis. It occurs most often on the extremities of 

young adults. A single cutaneous plaque or subcutaneous nodule 

is the most common clinical presentation. 

According to the literature, less than 30 cases have been reported 

Fig. 1. Clinical presentation of the first case. 


Fig. 2 A and B.: Histological features of the lesions: vascular proliferation 

within the entire dermis up to the subcutaneous tissue (H&E, 

4x magnification). 

Fig. 3 A and B: arborizing blood vessels lined by monomorphic hobnail 

endothelial cells showing minimal to mild cytologic atypia (H&E, 

20x magnification). 

so far, and only two cases being reported with lymph node metastasis. 

Material and methods. We report on a cases of a 60-yearold 

woman presented to the Surgical Department of Gallipoli 

General Hospital (Lecce, Italy) with a 2-years history of a 

palpable, asymptomatic, subcutaneous mass about 7 cm indiameter 

on the abdominal wall. Anamnestic data were unremarkable. 

On cut, the mass had an outer layer of yellow-tan 

color and elastic consistenc. Several months later, a 53-yearold 

woman presented to the Dermatology Department of “San 

Salvatore” General Hospital of L’Aquila for a small, asymp-

280 

Fig. 4 A and B. immunostains for factor-Viii-related antigen and 

Vimentin: strong positivity of the tumor cells (factor-Viii-related antigen, 

10x magnification; Vimentin, 10x magnification). 

tomatic, persistent ovoid lesion of 1 cm in-diameter sited on 

the abdominal wall. 

Results. Histological features of both lesions revealed a mass 

mainly composed by arborizing blood vessels arranged in a 

retiform pattern, and lined by monomorphic hobnail endothelial 

cells that showed minimal to mild cytologic atypia. Immunohistochemically, 

the tumor cells reacted with endothelial markers 

(CD34, factor-VIII-related antigen), and vimentin, and were 

negative for cytokeratin, S-100, Melan-A, leukocyte common 

antigen (LCA) and Actin. Ki-67 showed a low proliferation index 

in tumor cells (5%). 

Conclusions. Histological differential diagnoses should include 

hobnail hemangioma, Dabska tumor and angiosarcoma. No 

fatal cases of RH have been reported so far, but since 3 cases 

of metastatic RH have been published and a high recurrence 

rate has been highlighted, an accurate diagnosis is important to 

assess the correct therapeutic approach. Thus, a wide surgical 

excision with proven tumor-free margins is the optimal choice 

of treatment. 

references 

Calonje E, Fletcher CD, Wilson-Jones E, et al. Retiform hemangioendothelioma: 

A distinctive form of low-grade angiosarcoma delineated in 

a series of 15 patients. Am J Surg Pathol 1994;18:115-25. 

Calonje E. Retiform haemangioendothelioma. In: Fletcher CD, Krishnan 

Unni K, Mertens F, editors. World Health Organization Classification 

of Tumours. Pathology and Genetics of Tumours of Soft Tissue and 

Bone. Lyon: IARC Press 2002; p. 165-6. 

Tan D, Kraybill W, Cheney RT, et al. Retiform hemangioendothelioma: 

A case report and review of the literature. J Cutan Pathol 

2005;32:634-7. 

Parsons A, Sheehan DJ, Sangueza OP. Retiform hemangioendotheliomas 

usually do not express D2-40 and VEGFR-3. Am J Dermatopathol 

2008;30:31-3. 

Duke D, Dvorak A, Harris TJ, et al. Multiple retiform hemangioendotheliomas: 

A low-grade angiosarcoma. Am J Dermatopathol 

1996;18;606-10. 

Ioannidou D, PanayIotides J, Krasagakis K, et al. Retiform hemangioendothelioma 

presenting as bruise-like plaque in an adult woman. Int J 

Dermatol 2006:45:53-5. 

Dufau JP, Pierre C, De Saint Maur PP, et al. Retiform hemangioendothelioma. 

Ann Pathol 1997;17:47-51. 

Requena L, Sangueza OP. Cutaneous vascular proliferation, Part III: 

Malignant neoplasms, other cutaneous neoplasms with significant vascular 

component, and disorders erroneously considered as vascular 

neoplasms. J Am Acad Dermatol 1998;38:143-75. 

Mentzel T, Tartanen TA, Kutzner H. Hobnail hemangioma (targetoid 

hemosiderotic hemangioma): Clinicopathological and immunohistochemical 

analysis of 62 cases. J Cutan Pathol 1999;26:279. 


Microscopic imaging of lymphangiogenesis 

in cutaneous melanoma: still a questionable 

predictor of sentinel lymph node metastasis 

G. Falconieri, G. De Maglio, S. Pizzolitto 

General Hospital, Pathology, Udine 

Background. Several parameters have been devised to predict 

sentinel lymph node (SLN) involvement in infiltrating cutaneous 

malignant melanoma including tumor thickness, microscopic 

depth (or Clark’s level) of invasion, vascular involvement, ulceration 

or decreased peri- and/or intratumoral lymphoid infiltration. 

However, the role of lymphangiogenesis in melanoma is not clear 

and specific studies addressing lymphatic vessel density (LVD) 

and SLN status are underreported. 

Study design. All cases of pT1 invasive melanoma microscopically 

(> 1 mm Breslow thick) with available SLN biopsy were 

reviewed. Sections from cutaneous tumors were stained with 

monoclonal antibody D2-40 obtained from commercial source. 

Histologic sections should be adequate as to have at least 5 microscopic 

tumor fields for scanning at 20x magnification using a 

25x eyepiece. LVD per squared millimiter was assessed counting 

lymphatics on at least 5 consecutive tumor fields. Microscopic 

assessment of extratumoral lymphatic involvement was carried 

out as well. 

Results. A total number of 136 melanomas fulfilling the design 

were included in the study. Positive SLN cases were 29/136 

(21.3%). In these cases, LVD in primary melanoma ranged from 

0.05 to 1.84 per squared mm (average 0.34); in negative SLN 

cases LVD ranged from 0.05 to 5.1 (average 1.29), P = 0.34. Histologic 

involvement of peritumoral dermal/hypodermal lymphatics 

was documented in 7/29 of melanomas associated with a positive 

SLN and in 4/107 cases of negative SLN biopsy (P = 0.005). 

Conclusion. A low LVD in invasive melanoma was more frequently 

associated with a positive SLN, although the difference 

was found to be not statistically significant. Involvement of 

extratumoral lymphatics proved to be a better predictor of SLN 

metastases 

restrictive dermopathy: a case report 

F. Moltrasio, M. Basciu, F.M. Bosisio, S. Maitz, A. Scatigno, 

G. Cattoretti, V. Lucchini, M.S. Cuttin 

Department of Pathology, Hospital San Gerardo, University of Milan- 

Bicocca, Monza, Italy; Ambulatory of Genetics, Pediatrics Clinic, MBBM 

Foundation, Monza, Italy 

The restrictive dermopathy (RD) is a rare and lethal genodermatoses 

with a known predominant autosomal recessive inheritance. 

The phenotype can be caused by dominant mutations of 

the LMNA gene (primary laminopathy) with the presence of 

truncated forms of pre-Lamin A or by recessive mutations in the 

gene ZMPSTE24 (secondary laminopathy). However, the majority 

of the cases described in the literature have homozygous or 

compound heterozygous mutations of the ZMPSTE24 gene 1 . 

This mechanism causes abolition of the production of mature 

lamin A and the consequent accumulation of farnesyl-prelamin 

A, which is claimed to be toxic to cells and causes nuclear enlargement, 

mis-shapening and changes in the localization patter 

of heterochromatin 2 . 

The restrictive dermopathy is also called tight skin contracture 

syndrome, in which tautness of skin causes akinesia or hypokinesia 

deformation sequence (FADS) 3 . 

The RD is mainly characterized by intrauterine fetal growth 

retardation and early neonatal lethal course, tight and rigid skin 

with lacerations and erosions, prominent superficial vasculature, 

multiple joint contractures, sparse or absent eyelashes and eyebrows 

and facial dysmorphism with small and typical “O-shaped” 

mouth, small pinched nose and micrognathia. Histologically, the


Fig. 1. 

skin usually shows hyperkeratosis, flattened dermo-epidermal 

junction with absence of rete ridges, thinned and dense fibrotic 

dermis with collagenous bands arranged parallel to the epidermis. 

Other typical features are the missing of elastic fibers and subcutaneous 

adipose tissue layer increased 4 . 

We describe a premature newborn boy of non-consanguineous 

parents who presented a global growth retardation, multiple joint 

contractures and radiological abnormalities. The pregnancy was 

complicated by podalic presentation and premature rupture of 

membrane (PROM). The baby was prematurely born at 30 weeks 

of gestation by cesarean section and died during delivery. 

On autoptic examination, the baby patient had a fixed expression 

with facial features as hypertelorism, mouth in the ‘o’ position, 

absent eyelashes and eyebrows, thick hair, small nose, retromicrognathia, 

low-set ears. The skin was thin, shiny, translucent 

with superficial vessels very evident, erythematous, fissurated 

in the axillary and inguinal folds and long nails. Were no found 

alterations of internal organs (Fig. 1). 

At microscopic examination, skin showed flattening of rete 

ridges, compact dermis with thinning of the collagen fibers and 

extreme poverty of elastic fiber. Also were found the absence of 

the pilo-sebaceous and glandular structures and expanding of the 

subdermal adipose tissue (Fig. 2). 

We demonstrated the presence of omozygous c.1085dupT mutation 

in ZMPSTE24 gene in DNA of the proband and heterozygous 

c.1085dupT mutations in DNA of parents. 

RD can be prenatally diagnosed and early recognition of this 

Fig. 2. 

281 

syndrome is important for determining the prognosis of infants 

and the best course of parental counseling. 

references 

1 Ahmad Z, Phadke SR, Arch E, et al. Homozygous null mutations in 

ZMPSTE24 in restrictive dermopathy: evidence of genetic heterogeneity. 

Clin Genet 2012;81:158-64. 

2 Navarro CL, De Sandre-Giovannoli A, Bernard R, et al. Lamin A 

and ZMPSTE24 (FACE-1) defects cause nuclear disorganization and 

identify restrictive dermopathy as a lethal neonatal laminopathy. Hum 

Mol Genet 2004;13:2493-503. 

3 Mau U, Kendziorra H, Kaiser P, et al. Restrictive dermopathy: report 

and review. Am J Med Genet 1997;71:179-85. 

4 Morais P, Magina S, Ribeiro Mdo C, et al. Restrictive dermopathy--a 

lethal congenital laminopathy. Case report and review of the literature. 

Eur J Pediatr 2009;168:1007-12. 

non-neural granular cell tumor of the skin 

with lymph node metastasis. Case report 

A.L. Tosi, M.C. Montesco 

SS Diagnostica Melanomi e Sarcomi, Istituto Oncologico Veneto, 

I.R.C.C.S., Padova 

Introduction. Cutaneous non-neural granular cell tumor is a rare 

entity, first described by Le Boit in 1991, as “primitive polypoid 

granular cell tumor”. 

This subset of granular cell tumours does not express S100 protein 

in contrast to the classic form described by Abrikossoff and 

its line of differentiation still remains enigmatic. 

Despite the presence of cytological atypia and mitotic activity, 

these lesions seem to pursue a favourable outcome and only two 

cases with metastasis to regional lymph node have been reported 

in the scientific literature. Hereby, we present an additional case 

of primitive polypoid granular cell tumor of the skin with lymph 

node metastasis. 

Case Report. A 30-year-old-man with a melanoma in the left 

arm was admitted to the Melanoma and Sarcoma Unit of the 

Oncological Institute of Veneto to undergo a sentinel lymph node 

biopsy. Physical examination revealed a mass in the contralateral 

axilla, suggestive of lipoma by ultrasound examination. A local 

excision was performed. Grossly, the lesion, measuring 6,8 cm 

in the largest diameter, was well circumscribed and capsulated. 

Histological examination revealed a lymph node metastasis composed 

of spindled-shaped to round, polygonal cells with abundant 

granular eosinophilic cytoplasm and vesicular nuclei with prominent 

nucleolus. The cells exhibited mild to moderate focal atypia 

and rare mitotic figures. 

Immunohistochemical analysis showed reactivity for CD68 and 

NKI-C3, while S100 protein as well as melanocytic, epithelial, 

myoid and other neural markers were negative. On the basis of 

histological and immunohistochemical features a diagnosis of 

non-neural granular cell tumor lymph node metastasis was suggested. 

A review of the patient’s medical history revealed that 

8 years earlier a polypoid non-neural granular cell tumor of the 

right side of the back had been removed. 

Conclusions. Although non- neural granular cell tumors were 

considered as a form of neoplasm that behaves in a benign 

fashion, the evidence of cases with metastatic evolution raises 

challenging questions about the true nature of these lesions. 

Moreover, although only three cases with metastasis have been 

analyzed, the risk of metastases spread seems to be unpredictable 

on the basis of histological examination. In fact, our case, as those 

previously reported, presented the same histologically features of 

tumors that behave indolently. 

references 

LeBoit PE, Barr RJ, Burall S, et al. Primitive polypoid granular cell 

tumor and other cutaneous granular- cell neoplasms of apparent nonneural 

origin. Am J Surg Pathol 1991;15:48-58. 

Lazar AJF, Fletcher CDM. Primitive nonneural granular cell tumors

282 

of skin. Clinicopathologic analysis of 13 cases. Am J Surg Pathol 

2005;29:927-34. 

Chaundhry IH, Calonje E. Dermal non-neural granular cell tumour (socalled 

primitive polypoid granular cell tumour): a distinctive entity 

further delineated in a clinicopathological study of 11 cases. Histopathology 

2005;47:179-85. 

GASTrOEnTErICO 

Lung sarcomatous carcinoma metastatic to a 

villous adenoma of the colon. report of a case 

G. Abbona1 , D. Bellis1 , M. Risio2 , L. Viberti1 1 Dipartimento dei Servizi, Anatomia Patologica, ASLTO1, Ospedale Martini, 

Torino; 2 Anatomia Patologica IRCC Candiolo 

The phenomenon of tumor-to-tumor metastasis has been described 

in the literature in over 100 cases reports. Virtually any 

benign or malignant tumor can be a recipient: renal cell carcinoma 

is the most common tumor recipient of metastasis; on 

the other end carcinoma of the bronchus is the most consistent 

metastatic donor. 

We report the first case of a lung sarcomatous carcinoma metastasizing 

to a villous adenoma of the colon. 

A 65 year old male presented to medical attention with shortness 

of breath. Imaging studies showed a pulmonary mass infiltrating 

the mediastinum. The fine needle biopsy of the lesion revealed 

a fusocellular neoplasm with massive necrosis. On immunohistochemistry 

the neoplastic cells showed focal positivity for 

CK 7, but were negative for TTF1, p63, CK 5/6 and synaptophysin. 

A diagnosis of poorly differentiated carcinoma of the 

lung with sarcomatous features was made. Two months later at 

colonscopy, a polypoid intraluminal lesion measuring 2 cm was 

resected. Histology showed typical features of villous adenoma 

with high grade dysplasia (intramucosal adenocarcinoma). One 

histologic section exhibited a small focus of malignant rounded 

and fusated neoplastic cells, infiltrating the superficial lamina 

propria between the adenomatous glands, citomorphologically 

very similar to the cells of lung carcinoma. Serial sections failed 

to demonstrate point of origin from the adenomatous epithelium. 

Immunohistochemical studies clearly delineated two neoplastic 

components in the polyp. The adenomatous cells were strongly 

positive to CK 20 and CDX-2, while CK7 was negative. Meanwhile 

the small focus of malignant rounded and fusated cells 

showed complete negativity to antibodies CK 20, CDX-2, TTF1 

and synaptophysin. However these cells were positive to vimentin, 

keratin AE1-AE3 and focally to CK7. The distinctly dimorphic 

histological and immunohistochemical appearances were 

the best clue to suspect the metastatic nature of the fusocellular 

component of the polyp. 

Metastasis of a malignant neoplasm to a benign tumor is an 

infrequent event. Adenomatous polyps of the colon have been 

only described on seven occasions acting as host tumors. In these 

cases, gastric carcinoma was the most common donor neoplasm 

(4 cases), followed by cutaneous melanoma (2 cases) and breast 

carcinoma (1 case); lung tumor has never been reported as donor 

neoplasm. 

The vast majority of malignant lesions found in adenomatous 

polyps in the colon are the consequences of malignant transformation 

from benign neoplastic colonic adenomatous tissue. The 



Sala Brunelleschi – ore 15,00-18,00 

Habeeb AA, Salama S. Primitive nonneural granular cell tumor (socalled 

atypical polypoid granular cell tumour). Report of 2 cases with 

immunohistochemical and ultrastructural correlation. Am J Dermatopathol 

2008;30:156-9. 

Habeeb AA, Weinreb I, Ghazarian D. Primitive non-neural granular 

cell tumour with lymph node metastasis. J Clin Pathol 2009;62:847-9. 

possibility that colonic adenomatous polyps could be recipient of 

metastatic tumors should be considered whenever a distinct dimorphic 

pattern is encountered. This could change the treatment 

and may require an appropriate workup. 

Much debate has ensued over the phenomenon of tumor-to-tumor 

metastasis. Some attribute the event to a casual occurrence, where 

other offer more likely hypotheses. The highly active, richly 

vascularized and inflamed stroma of the host tumors has been 

claimed to be a fertile microenviroment for tumor metastasis. 

These theories are probably only part of a complex mechanism 

that at present is poorly understood. 

references 

Bismar TA, et al. Metastatic foci of signet ring cell carcinoma in a tubular 

adenoma of the colon. Arch Pathol Lab Med 2003;127:1509-12. 

Bohn OL, et al. Tumor-to-tumor metastasis: renal cell carcinoma metastatic 

to papillary carcinoma of thyroid-report of a case and review of 

the literature. Head and Neck Pathology 2009;3:327–330. 

Grignon DJ et al: Malignant melanoma with metastasis to a colonic polyp. 

Am J Gastroenterol.1988;83:1298-300. 

Moody P et al: Tumor-to-tumor metastasis: pathology and neuroimaging 

considerations. Int J Clin Exp Pathol. 2012; 5: 367–373. 

Ozuner G. Colonoscopic detection of a malignant melanoma metastatic to 

a tubular adenoma of the colon: report of a case. Dis Colon Rectum 

2002;45:1681-4. 

Rodríguez Salas N, et al. Colonic anastomosis and colonic polyp mucosal 

metastasis of signet ring cell gastric adenocarcinoma. Clin Transl 

Oncol 2010;12:238-9. 

Sella A, et al. Renal cell cancer: best recipient of tumor-to-tumor metastasis. 

Urology 1987;30:35-8. 

Tiszlavicz L. Metastasis of a stomach carcinoma in a solitary adenomatous 

cecal polyp. Zentralbl Allg Pathol 1990;136:277-82. 

Uriev L, et al. Signet ring cell infiltration in tubular adenoma of ascending 

colon. Pathol Res Pract 2004;200:707-12. 

Wiltz O, et al. Breast carcinoma metastatic to a solitary adenomatous 

polyp in the colon. Arch Pathol Lab Med 1984;108:318-20. 

Liver collagen proportionate area and septal 

thickness/nodule size: a comparison for predicting 

decompensation in cirrhosis 

S. Bruno1 , T.V. Luong2 , F. Grillo1 , G. Isgrò3 , E. Tsochatzis3 , 

A. Hall2 , A.P. Dhillon2 , A.K. Burroughs3 1 University of Genova, Histopathology, DISC, Azienda Ospedaliera e 

Universitaria San Martino-IRCCS, Genova; 2 Department of Histopathology, 

Royal Free Hospital, London, UK; 3 The Royal Free Sheila Sherlock 

Liver Centre and University Department of Surgery UCL and Royal Free 

Hospital, London, UK 

Introduction. Cirrhosis is the end stage of chronic liver disease 

and WHO 1977 1 defined it as “a diffuse process, characterized by 

fibrosis and conversion of the normal architecture into structurally 

abnormal nodules.” 

Liver biopsy is the gold standard for grading and staging of liver 

disease. Cirrhosis may be classified as either compensated or 

decompensated according to the absence or presence of clinical


complications. Up till now no histological characteristic has 

been shown to correlate with the clinical severity of disease. 

Currently the best predictive association with severity is HVPG. 

Recently, histological parameters have been evaluated. Analysis 

of nodule diameter and septal thickness has been shown 

to correlate with HVPG (Sethasine et al.) 2 as has the digital 

morphometric quantitation of collagen with the demonstration 

of Collagen Proportionate Area (CPA) by using computer assisted 

digital image analysis of picroSirius red stained sections 

(Calvaruso et al.) 

3 4. 

The aim of this study is to compare proposed histological subclassifications 

of cirrhosis, as suggested by several groups in the 

Literature (Sethasine et al, Nagula et al, Kumar et al and Kim et 

al.) 2 5 6 7 and to define which histological parameters, including 

CPA, are able to correlate with the clinical evolution of cirrhosis 

and above all which have good inter and intra observer reproducibility. 

Methods. From a case series of 159 cirrhotic patients with liver 

biopsies performed at the Royal Free Hospital in London, from 

January 2003 to December 2007, 69 biopsies were analyzed (aetiology 

was as follows: alcoholic liver disease - 38%, HCV - 27%, 

cryptogenic - 13% and other causes - 22%). Exclusion criteria 

were biopsies length (≤ 10mm) and excessive tissue fragmentation. 

Fifty-three patients were clinically followed up for a mean of 46 

months. For each biopsy the following were evaluated: Laennec 

scoring system, number and size of cirrhotic nodules, fibrous 

septa thickness and CPA (using picroSirius red stain). Statistical 

analysis (t-test or Kruskall-Wallis test; cox regression analysis 

for future decompensation evaluation) was performed to identify 

which parameter correlated with decompensation. Intra/interobserver 

agreement was performed by repeating evaluation on 20 

biopsies and calculating concordance coefficients. 

Results. Out of the 69 patients evaluated, 44 were compensated 

at time of biopsy (group 1) while 25 were decompensated (group 

2). Eleven patients from group 1, decompensated during follow 

up. Out of all of the histological parameters evaluated, nodule 

size (p = 0.001), septal width (p = 0.019) and CPA (p < 0.001) 

were statistically correlated with decompensation at the time of 

biopsy while only CPA was significantly associated with future 

decompensation (OR 1.117, 95%CI 1.032-1.210, p = 0.006). 

CPA was also the only variable with high intra and interobserver 

concordance (0.98). 

Conclusion. Histological characteristics such as nodule size, septal 

width and CPA are associated with future clinical decompensation. 

CPA was better than nodule/septa assessment and was the 

only independently associated factor for future decompensation. 

In addition CPA was the most reproducible parameter. Thus CPA 

has predictive power and could be used to sub-classify cirrhosis, 

identify patients who are at a greater risk of decompensation. 

references 

1 Anthony PP, Ishak KG, Nayak NC, et al. The morphology of cirrhosis: 

definition, nomenclature and classification. Bulletin of the World 

Health Organisarion 1977;55:521-4. 

2 Sethasine S, Jain D, Groszmann RJ et al. Quantitative Histological-Hemodynamic 

Correlations in Cirrhosis. Hepatology 

2012;55:1146-53. 

3 Calvaruso V, Dhillon AP, Tsochatzis E, et al. Proportionate Area predicts 

decompensation in patients with recurrent HCV cirrhosis after 

liver transplantation. J Gastroenterol Hepatol 2012.2 

4 Calvaruso V, Burroughs AK, Standish R, et al. Computer-assisted 

image analysis of liver collagen: relationship to Ishak scoring and 

hepatic venous pressure gradient. Hepatology 2009;49:1236-44. 

5 Nagula S, Jain D, Groszmann RJ, et al. Histological-hemodynamic 

correlation in cirrhosis-a histological classification of the severity of 

cirrhosis. J Hepatol 2006;44:111-7. 

6 Kumar M, Sakhuja P, Kumar A, et al. Histological subclassification 

of cirrhosis based on histological haemodynamic correlation. Aliment 

Pharmacol Ther 2008;27:771-9. 

283 

7 Kim MY, Cho MY, Baik SK, et al. Histological subclassification of 

cirrhosis using the Laennec fibrosis scoring system correlates with 

clinical stage and grade of portal hypertension. Journal of Hepatology 

2011;24. 

hErG1 as a novel biomarker in pancreatic cancer 

M. Callea3 , A. Arcangeli1 , E. Lastraioli1 , A. Sette1 , G. Perrone3 , 

D. Borzomati4 , F. Di Costanzo2 , R. Coppola4 , A. Onetti Muda3 1 Department of Experimental Pathology and Oncology, University of Florence; 

2 Medical Oncology, Azienda Ospedaliero-Universitaria Careggi, 

Florence, 3 Anatomical Pathology and 4 General Surgery Unit, Campus 

Bio-Medico University of Rome, Rome, Italy 

Introduction. Mounting evidence indicates that Ion Channels 

and Transporters (ICT) are expressed aberrantly in cancer and 

underlie many of the hallmarks of cancer. Proving their therapeutic 

potential, treatments targeting Cl- channels and carbonic 

anhydrase IX have successfully entered phase II clinical trials 

in brain and kidney cancer. Thus, proteins involved in membrane 

transport, long known as important drug targets in other 

diseases (channelopathies), are a new class of therapeutic and/or 

diagnostic targets in oncology. Several studies demonstrated that 

the ether a- gò gò-related gene (hERG1) potassium channels is 

expressed in several types of human cancers. hERG1 has a pleiotropic 

regulatory effect on cancer (cell proliferation, survival, 

invasiveness and angiogenesis). Finally, hERG1 is emerging as a 

novel prognostic marker in acute leukemias and GI tract cancer. 

Here we report the preliminary results of hERG1 expression in 

pancreatic ductal adenocarcinoma (PDAC). 

Materials and methods. Immunohistochemical staining for 

hERG1 was performed using a monoclonal anti-hERG1 antibody 

on formalin-fixed pancreatic TMA sections. A total of 44 PDAC 

patients were evaluated (median age: 65 aa; M:24; F:20), consecutively 

collected at the Campus Bio-Medico University from 

March 2007 to March 2010; in each case, two 1.2 mm-diameter 

cores were punched in a predefined tumor region and two additional 

cores were taken from an adjacent non-neoplastic area. 

A minimum of two-year f-up was available in all cases. hERG1 

immunostaining was evaluated on the basis of a semiquantitative 

score system taking into account percentage and staining intensity 

of tumor cells. 

Results. hERG1 specific immunostaining was observed in Langherans 

islets, mainly attributable to the expression in beta cells, 

whereas no expression was detected in normal pancreatic parenchyma. 

Interestingly, a moderate to intense signal was observed 

in over 50% of tumor cells of 26/44 PDAC. The median overall 

survival in hEGR1 positive patients was 18 months (IQR 7-35), 

significantly shorter than in in patients without hERG1 protein 

expression (39 months, IQR 24-83) (p = 0.05). 

Conclusion. Our preliminary results suggest that hERG1 might 

represent a novel prognostic marker and a potential target for 

therapy in PDAC. 

The new fully automated system for Ki67 

evaluation in assessing tumor grade in pancreatic 

neuroendocrine tumors (PnETs) 

D. Campani1 , N. Funel1 , P. Faviana1 , L.U. Pollina1 , M. Denaro1 , 

N. De Lio2 , V. Perrone2 , U. Boggi2 , F. Basolo1 1 Unit of Pathologic Anatomy, Department of Surgery, University of Pisa, 

Pisa; 2 Unit of General and Transplant Surgery, Department of Oncology, 

Pisa 

Introduction. Neuroendocrine Tumors (NETs) are diseases with 

varying degrees of aggressiveness and differentiation. The international 

guidelines drive the pathologist to assess histological 

evaluation of differentiation and grade 1 . Differentiation refers 

to the extent to wich the neoplastic cells resemble their non neoplastic 

counterparts. Well differentiated gatro-enteropancreatic

284 

NETs have organoid arrangement, cells are relatively uniform 

and present diffuse expression of neuroendocrine markers. Poorly 

differentiated NETs are less resembling normal neuroendocrine 

cells, the architecture is diffuse and the immunoexpression of 

neuroendocrine markers is more limited. Grade considers the 

aggressiveness. Low grade tumors are relatively indolent; high 

grade neoplasias are very aggressive and intermediate grade 

NETs have not a predictable course, but generally are moderately 

aggressive. Grading evaluation of NETs is based on the number 

of mitoses and the number of Ki-67 positive cells 2 3 . This type of 

evaluation is closely subjective as the major difficulty consists in 

defining exactly the percentage of Ki-67 positive cells. The aim 

of this study was to evaluate the actual number of positive Ki-67 

tumor cells in fully automatic computerized modality, comparing 

the obtained results with those of the pathologist. 

Materials an methods. In this study, we evaluated tumor grade 

of 22 cases of Pancreatic NETs (PNETs) using a computerized 

high-resolution acquisition system (D-Sight, Menarini Florence, 

Italy) which includes the acquisition of the entire histological 

section immunostained for the Ki-67, for each case. Positivity 

assessment was made by counting at least 2000 tumor representative 

cells. The tumor grade was previously assessed by three pathologists 

using the mitotic rate (number of mitoses per 10 HPF) 

and the Ki-67 labeling index (count multiple regions with highest 

labeling density). The two groups of analyses were evaluated by 

T-test (p < 0.05 for significant results). 

Results. Statistical analysis showed no significant differences 

when comparing the results obtained by computerized analysis 

and those obtained from pathologist. However, the computerized 

evaluation was rapid, reproducible and operator-independent. 

Furthermore, the D-sight system was also able to provide the 

percentage of different nuclear staining intensity (1+, 2+, 3+). 

Discussion. Pathological grading for PNETs is currently of fundamental 

importance to the setting of adjuvant therapy in carcinomas. 

The possibility to evaluate the Ki-67 value in a safe, rapid 

and reproducible way, and could greatly enhance the work of the 

pathologist and oncologist within PNET. 

references 

1 Bosman F, Carneiro F, HrubanR, et al., eds. WHO Classification of 

tumours of the digestive system. Lyon, France: IARC Press 2010. 

2 Rindi G, Kloppel G, Alhman H, et al. TNM staging of foregut (neuro) 

endocrine tumors: a consensus proposal including a grading system. 

Virchows Arch 2006;449:395-401. 

3 Rindi G, Kloppel G, Couvelard A, et al. TNM staging of midgut and 

hindgut (neuro)endocrine tumors: a consensus proposal including a 

grading system. Virchows Arch 2007;451:757-62. 

Synchronous tumors: a rare case of two different 

mesenchymal lesion in a 72-year-old man 

G. Crisman1 , V. Ciuffetelli2 , L. Sollima1 , L. Melchiorri1 , A. Chiominto2 

, G. Calvisi2 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 

dell’Aquila, L’Aquila, Italia; 2 U.O.C. Anatomia Patologica, Ospedale Civile 

“San Salvatore”, L’Aquila, Italia 

Background. Solitary fibrous tumor and GIST are tumors of 

mesenchymal origin that occur in adult patients with equal 

distribution in both sexes. The solitary fibrous tumor generally 

occurs in the pleura, only few cases of extrathoracic onset have 

been described (i.e., retroperitoneum, deep soft tissues, abdominal 

cavity, head and neck region, pelvic region, orbit, meninges, 

mediastinum, peritoneum). 

The GIST (gastrointestinal stromal tumor) represents the most 

common mesenchymal tumors of the gastrointestinal tract. Several 

authors suggested an origin from intestinal cell of Cajal, an 

intestinal pacemaker cell. GIST may arise anywhere along the 

gastrointestinal tract, but the stomach and, less commonly, the 

intestine represent the most frequent site of onset, even though 


Fig. 1. Solitary fibrous tumor. a: usual histological features. (H&E, 

4x magnification). B: tumor cells strongly stained for Vimentin (Vimentin, 

10x magnification). C: tumor cells were negative for Cd117 

(Cd117, 10 x magnification). 

several GIST cases have been reported in the mesentery, omentum, 

or retroperitoneum. 

Material and methods. We report on a case of synchronous presentation 

of both solitary fibrous tumor and GIST. A 72-year-old 

man presented with an ovoidal, well-circumscribed pelvic mass 

of 9 cm in-diameter and a vegetant lesion of 3cm in-diameter 

with a overlying nodule of 9 cm in-diameter sited in the small 

intestine. 

Results. The pelvic mass, of soft-elastic consistency, revealed 

peripheral histological features of a benign solitary fibrous tumor 

with stromal hyalinization, whereas features of usual malignant 

solitary fibrous tumor, with rich cellularity, nuclear atypia, high 

mitotic index and high proliferation index (Ki 67 + in 40% of 

neoplastic cells) was detected in the central part. Immunohistochemically, 

tumor cells strongly stained for CD34 and Vimentin, 

and were negativite for CD68, p53, Desmin, Myogenin, CD117, 

S-100. 

Histological examinations of the small-bowel lesion revealed the 

presence of a usual gastrointestinal stromal tumor (GIST), with 

spindle cells and focal epithelioid aspects. High mitotic index 

and high proliferation index (10 more mitoses per 50 HPF) was 

detected, thus classifying this GIST as a high risk of recurrence. 

Fig. 2. GiSt. a: Histological features (H&E, 2x magnification); B: Epithelioid 

and spindle cells (H&E, 20 x magnification). C: tumor cells 

strongly stained for Cd117 (Cd117, 10 x magnification).


Immunohistochemical analysis revealed a positive staining of the 

tumor cells for CD117, smooth muscle actin, a focal positivity for 

CD34 and a negativity for S-100. 

Conclusions. When two or more tumors onset simultaneously 

or consecutively in several organs or systems, it is possible to 

talk about synchronous tumors, whereas metachronous tumors 

are those arising at different time. GIST is an uncommon mesenchymal 

neoplasm of the digestive tract but it has been reported 

as synchronous tumor with several kind of malignancies, such as 

adenocarcinoma, carcinoid, colorectal carcinoma, renal cell caricinoma, 

carcinoid. Several aetiopathogenetical hypothesis have 

been postulated but the mechanism of this sinchronicity is still 

unknown. At the best of our knowledge, this seem to be the first 

case reporting a simultaneous development of two mesenchymal 

tumor and several considerations could be suggested in this case. 

references 

1 Maiorana A, Fante R, Maria Cesinaro A, et al. Synchronous occurrence 

of epithelial and stromal tumors in the stomach: a report of 6 

cases. Arch Pathol Lab Med 2000;124:682-6. 

2 Lin YL, Tzeng JE, Wei CK, et al. Small gastrointestinal stromal tumor 

concomitant with early gastric cancer: a case report. World J Gastroenterol 

2006;12:815-7. 

3 Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal 

stromal tumors: A consensus approach. Hum Pathol 2002;33:459-65. 

4 Nishida T, Hirota S, Taniguchi M, et al. Familial gastrointestinal 

stromal tumours with germline mutation of the KIT gene. Nat Genet 

1998;19:323-4. 

5 Ruka W, Rutkowski P, Nowecki Z, et al. Other malignant neoplasms 

in patients with gastrointestinal stromal tumors (GIST). Med Sci 

Monit 2004;10:LE13-4. 

6 Carney JA. Gastric stromal sarcoma, pulmonary chondroma, and 

extra-adrenal paraganglioma (Carney Triad): natural history, adrenocortical 

component, and possible familial occurrence. Mayo Clin 

Proc 1999;74:543-52. 

7 Kaffes A, Hughes L, Hollinshead J, et al. Synchronous primary adenocarcinoma, 

mucosa-associated lymphoid tissue lymphoma and a stromal 

tumor in a Helicobacter pylori-infected stomach. J Gastroenterol 

Hepatol 2002;17:1033-6. 

8 Urbanczyk K, Limon J, Korobowicz E, et al. Gastrointestinal stromal 

tumors. A multicenter experience. Pol J Pathol 2005;56:51-61. 

Intra-abdominal splenosis: a case report 

of a challenging entity 

G. Crisman1 , E. Di Cola1 , I. Cicchinelli1 , A.R. Vitale2 , T. Curti2 , 

G. Calvisi3 , L. Scipioni4 , G. Coletti3 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 

dell’Aquila, L’Aquila, Italia; 2 U.O.C. Anatomia Patologica, P.O. “SS 

Filippo e Nicola”, Avezzano (AQ), Italia; 3 U.O.C. Anatomia Patologica 

Ospedale Civile “San Salvatore”, L’Aquila, Italia; 4 U.O.C. Chirurgia 

Generale, P.O. “SS Filippo e Nicola”, Avezzano (AQ), Italia 

Background. Intraabdominal splenosis represents a benign, non 

uncommon, generally asymptomatic entity due to auto-implantation 

of spleen fragment into other sites randomly, not spleen 

bed, which grow and form small splenic nodules which closely 

resemble, in anatomy and physiology, a normal spleen. This condition 

is usually diagnosed by a CT scan or MRI, or even surgical 

procedure. Firstly described by Von Kuttner in 1910, during an 

autopsy, the term splenosis has been suggested for the first time 

by Buchbinder and Lipkopf in 1939. Splenic implants are usually 

multiple and may be located anywhere in the peritoneal cavity, 

unusual locations are represented by pleural cavity, pelvis and 

subcutaneous tissue. Due to its variable clinical presentation, it 

could be misdiagnosed as a malignancy and anamnestic data (i.e., 

history of splenectomy, blunt abdominal trauma) and histopathological 

correlation play a pivotal role in the aim to achieve the 

correct diagnosis. 

Material and methods. We report on a case of a 51-year-old man 

presented with diffuse abdominal pain, arising in the epigastric 

region and irradiated to the whole abdomen, nausea, fatigue and 

Fig. 1. Histopathological features closely resemble a normal splenic 

tissue (H&E, 4x magnification). 

285 

severe acidity. The patient referred a history of left post-traumatic 

nephrectomy and splenectomy about twenty years before. Admission 

studies included complete blood count, which revealed 

anemia (hemoglobin was 7.8 mg/dl; reference range: 13.8 to 

17.2 mg/dl), whereas an abdominal non-contrast CT scan showed 

multiple, diffuse, rounded masses formations with a maximum of 

6 cm in-diameter. An incisional biopsy of the biggest lesion has 

been performed. 

Results. Histological examination of the specimens revealed a 

mass mainly composed by lymphocytes of small and medium 

size associated with neutrophils and eosinophils, plasma cells, 

histiocytes and follicular structures, sometimes with a prominent 

germinal center, within a fibrous stroma organized in a reticular 

pattern. Immunohistochemical analysis revealed a positivity of 

the lymphocytes for CD3, CD4, CD20. CD8 and CD31 positivity 

highlight the presence of a typical splenic vascular structure. The 

negativity for Factor VIII, glycophorin C, Myeloperoxidase and 

Bcl-2 led us to exclude an extramedullary hematopoiesis. 

Conclusions. Intraabdominal splenosis is a benign condition 

characterized by ectopic auto-transplantation of splenic tissue 

after trauma or surgery, often misdiagnosed as a metastatic process 

for its characteristic radiological pattern. It is usually easy to 

distinguish an intraabdominal splenosis from an accessory spleen. 

As a matter of fact, the latter usually present as a single lesion 

(rarely more than three) and is supplied by a branch of the splenic 

artery. Over 75% of accessory spleens are found in the splenic 

bed and they are present in up to 40% of autopsies. Clinical 

manifestations of intraabdominal splenosis are nonspecific and 

diffuse abdominal pain represents the most common symptom. 

Thus, especially in this kind of entity an accurate anamnestic 

data collection represents important diagnostic tool. An history 

of blunt abdominal trauma and/or splenectomy in patients pre- 

Fig. 2. the positivity of the vascular structures for Cd8 confirmed 

their splenic origin. (Cd8, 10x magnification).

286 

senting intraperitoneal multiple lesions could lead the clinician 

and the radiologist to an appropriate suspicion of intraabdominal 

splenosis, avoiding unnecessary invasive diagnostic procedures. 

Moreover, in challenging cases, biopsy and histological examination, 

supported by immunohistochemistry, are fundamental in 

defining the nature of the lesion precisely. 

references 

1 Peitsidis P, Akrivos T, Vecchini G, et al. Splenosis of the peritoneal 

cavity resembling an adnexal tumor: case report. Clin Exp Obstet 

Gynecol 2007;34:120-2. 

2 Ksiadzyna D. A case report of abdominal splenosis – a practical 

mini-review for a gastroenterologist. J Gastrointestin Liver Dis 2011; 

20:321-4. 

3 Lyu Y, Ji B, Wang G, et al. Abdominal multiple splenosis mimicking 

liver and colon tumors: a case report and review of the literature. Int 

J Med Sci 2012;9:174-7. 

4 Galloro P, Marino Marsilia G, Nappi O. Hepatic splenosis diasogned 

by fine needle aspiration cytology. Pathologica 2003;96:57-9. 

Extranodal marginal zone lymphomas of gastric 

malt: a clinicopathological case series 

C. Fondi¹, F. Castiglione¹, M. Paglierani¹, B. Puccini², L. Rigacci², 

L. Novelli¹, S. Di Lollo¹ 

1 Dip.Area Critica Medico chirurgica sezione di Anatomia Patologica, 

AOU Careggi, Firenze; 2 SOD Ematologia AOU Careggi, Firenze 

The gastrointestinal tract is the most common site of lymphomas 

onset, accounting for 7% to 20% of these all. In the stomach 

lymphomas can onset from all lymphoid cells, both germinal and 

extragerminal, and those arising from B-cells of marginal zone 

(MALT) are particularly frequent. The development of gastric 

lymphomas is strongly linked to chronic Helicobacter Pylori 

(HP) infection. Actually, indeed, the research of the presence of 

HP in all endoscopic gastric biopsies with lymphoproliferative 

disease is always demanded by clinicians and also the first step of 

the treatment, dependently by the stage of the disease, is the HP 

pharmacological eradication. 

Gastric lymphoma is characterized by various genomic lesions, 

including chromosomal translocations, such as t(11;18) 

(q21;q21), t(14;18)(q32;q21), t(1;14)(p22;q32) and t(3;14) 

(p13;q32), and umbalanced genomic aberrations, such as gains of 

chromosomes 3/3q and 18/18q or deletion of chromosome 6q23. 

These alterations seem to condition the tumour biology and its 

HP dependence. 

We describe the clinical and pathologic features of MALT gastric 

lymphomas arised from 1996 to 2011 in 44 patients (22 males and 

22 females, with a median age about 60 years, range 31 to 89). 

Clinical follow-up is available for 22 cases: 13 cases are alive 

without disease, 4 cases are alive with a relapse, 5 cases are dead 

for disease, 0 cases are dead for other causes. 

Our study wants to investigate clinical, endoscopic and pathologic 

features of gastric MALT lymphomas in relation to their 

genetic pattern with the aim to identify, originally, clusters of 

lymphomas that are sensitive to the pharmacological eradication 

of Helicobacter Pylori, and to define, when it is possible, the 

prognostic evaluation of the disease. 

KrAS and BrAF genotyping of synchronous 

colorectal carcinomas 

R. Giannini1 , C. Lupi2 , E. Sensi2 , F. Loupakis3 , C. Cremolini3 , 

A. Servadio2 , A. Falcone3 1, 2 

, G. Fontanini 

1 2 Department of Surgery, University of Pisa, Pisa; Unit of Pathologic 

Anatomy, Azienda Ospedaliera Universitaria Pisana, Pisa; 3 Unit of Oncology, 

Azienda Ospedaliera Universitaria Pisana, Pisa 

Introduction. Two monoclonal antibodies cetuximab and panitumumab 

targeting the epidermal growth factor receptor (EGFR) 

have been approved in Europe and the United States for the 


treatment of metastatic CRC in 2004 and 2007, respectively. 

Subsequently somatic gain-of-function KRAS (and BRAF) mutations 

have been identified as a reliable strong negative predictor 

for the response to anti-EGFR treatment in CRC. KRAS protein is 

involved in one of several EGFR signal transduction cascades. It 

is activated following ligands binding to the extracellular domain 

of EGFR, triggering downstream events including activation of 

the mitogen-activated protein kinases (MAPK) 1 . Several mutation 

in KRAS codons 12, 13 and 61, lead to constitutively active 

KRAS protein, and thus EGFR-independent activation of the 

MAPK pathway. In details, point mutations located in codons 

12 and 13 represent about 98% of all KRAS mutations in CRC. 

Based on these findings, the European Medicines Agency (EMA) 

has made palliative cetuximab and panitumumab therapy of CRC 

dependent on KRAS wild-type status of the tumor tissue, irrespective 

of whether applied in combination with conventional chemotherapy 

or as singular drugs. BRAF, downstream from KRAS in 

the MAPK pathway, is subject to activating mutation inducing 

resistance to EGFR treatment. 

As a consequence, several tests for KRAS and BRAF mutations 

have been developed involving DNA extracted from a single 

tumor tissue block, followed by a mutation-specific PCR-based 

assay or sequencing of the relevant codons. To date, direct sequencing 

analysis is still considered the gold standard despite 

the overall low sensitivity of the method. Recently, methods like 

pyrosequencing and real-time polymerase chain reaction (PCR) 

being very common. Real-time PCR based methods have a high 

sensitivity and the ability to identify a mutation present namely 

in less than 1-5% of the cells sampled. Pyrosequencing claimed a 

lower sensitivity assessable in about 10% mutated cells. 

The sensitivity and specificity of the genotyping tests should be 

of clinical relevance for the reasons that: 1) the tissue sampled 

for KRAS mutation contains a small fraction of malignant cells 

and a large fraction of stromal and inflammatory cells; 2) the 

genetic heterogeneity of the tissues with regard to (for example) 

KRAS (and/or BRAF) mutational status due to the fact that cancer 

development is a multistep process in which cells continuously 

gain deoxyribonucleic acid (DNA) aberrations. An aberration 

that gives the cell a survival or a growth advantage will initially 

be present in a small proportion of the tumor cells. As a consequence, 

given the dynamic nature of malignancy, it is biologically 

plausible that a certain moment the tumor cells will be heterogeneous 

for some of the aberrations gained; 3) the genetic heterogeneity 

of synchronous colorectal cancer as a consequence of, one 

or both, the above mentioned circumstances or the independent 

origin of the tumors. 

Synchronous colorectal carcinoma (SC) refers to two primary 

colorectal carcinomas detected in a single individual simultaneously 

2 . Generally, SC has an incidence of 3-5 % and a worse prognosis 

than solitary colorectal carcinoma. Although, the prognostic 

significance of cancer synchronicity remains inconclusive 3 4 . By 

a molecular point of view SC has overall more frequent mutations 

in BRAF, and are more frequently CIMP- and MSI-high status 5 . 

both in concordant than in discordant way within the SC pairs 3 . 

In the present study we assessed the genotype of 33 SC referring 

to KRas and BRAF gene mutational status. 

Materials and methods. Patients and Samples: a series of 33 patients 

with synchronous colorectal carcinomas (SC) were selected 

from a consecutive series of 500 cases derived from the files 

of the Unit of Surgical Pathology of the Azienda Ospedaliero- 

Universitaria Pisana Pisa, from January 2006 to March 2010. 

All cases were retrospectively reviewed by two pathologist (A. 

S., G. F.) and tumor stages were determined according to TNM 

classification (American Joint Committee on Cancer, 6th ed.). 

All selected patients had two carcinomas, that were grossly, 

unequivocally separated by normal colorectal mucosa at the first 

diagnosis of colorectal cancer (ref 1). Among the carcinomas, the 

index lesion (IL) were defined to be the tumor that were the most


advanced pathologically or largest, while, the other lesions were 

designated as the concurrent lesion (ref 2 e vedi 8 della 2). In all 

cases, single samples were taken from both index and concurrent 

lesion. 

Additional lymph node metastases were reported for 19 patients 

and in 4 cases were also described distant metastases, for 3 patients 

were only reported the distant metastases. In the case of 

multiple lymph node and/or distant metastases, each reported 

and/or available metastatic nodes or distant metastases were 

analyzed. 

Microdissection and DNA extraction: 55 paraffin embeddedformalin 

fixed (FFPE) tumors tissues were collected from 27 

patients affected from synchronous colorectal cancer. 

Each paraffin blocks were serially cut into four 10-µm-thick sections. 

The last section was stained with hematoxilin-eosin (H&E) 

and the area of tumor was identified by.pathologist. 

Afterwards, the tumor cells were manually microdissected from 

the three unstained sections, transferred in 180 ul of ATL buffer 

and digested with 20 ul proteinase K overnight at 56 °C. DNA 

isolation was performed in accordance with the tissue protocol by 

QIAamp DNA Mini Kit (QIAGEN). 

The nucleic acids were eluted in a volume of 40 ul AE buffer and 

DNA content was measured with a Nanodrop-1000 spectrophotometer 

(Thermo Fisher Scientific Inc., Waltham, MA). 

Detection of KRAS and BRAF mutation by Pyrosequencing: 5 

μL of genomic DNA concentrated 20ng/μL was amplified using 

Anti-EGFR MoAb response ® (KRAS status) and Anti-EGFR 

MoAb response ® (BRAF status) both CE-IVD marked kits (DIA- 

TECH Pharmacogenetics, Italy) on Rotor-Gene TM 6000 (Corbett 

Research, Australia) following the manufacturer’s instructions. 

The resulting PCR product was immobilized onto magnetic 

streptavidin-coated beads via the biotin/streptavidin interaction 

(…). The bead/DNA complex was then washed and added to 1.65 

pmol of pyrosequencing primer including in the same kit. The 

primed single-stranded DNA templates were then transferred to 

the microtitre plate-based PSQ HS 96 A Pyrosequencer (Biotage, 

Sweden), where real-time sequencing of the sequence surrounding 

codons 12 and 13 of KRAS exon 2 was performed by using 

PyroMark Gold Q96 reagents (QIAGEN) on PyroMark TM Q96 

ID instrument (Biotage, Sweden).Finally, results were analyzed 

using PyroMark Q24 1.0.9 software. 

Results. KRAS/BRAF mutational status of the index lesion: a total 

of 14 KRAS mutations were detected among the 33 index lesion, 

with a mutation rate of 42.0%; in detail, 10 out of 12 mutations 

were in KRAS codon 12 and 2 in codon 13. Three index tumors 

(9%) carried the BRAFV600E mutation. 

KRAS/BRAF mutational status of the concurrent lesion: KRAS 

mutations were found in 12 (36%) of the concurrent lesions, 

9 (27%) were located in KRAS codon 12 and 3 (9%) in codon 

13 (Table 1). Three concurrent lesion (9%) were BRAFV600E 

mutated. KRAS/BRAF mutational status of the node and distant 

metastases: a total of 7 and 4 KRAS mutations were found in analyzed 

lymph mode and distant metastases respectively; while, 3 

and 1 BRAF mutations were found in node and distant metastases 

respectively. 

KRAS/BRAF mutations distribution among the index tumor and 

concurrent lesion: KRAS mutational status. Among the 33 synchronous 

colorectal cancer tested, a total of 17 cases (51.5%) 

showed the same genotype (genetically homogeneous), while 

16 (48.5%) were different (genetically heterogeneous). 14 out 

of 17 homogeneous cases, were wild-type in the index and 

concurrent lesions while 3 cases showed the same mutation in 

both toumors. Among KRAS heterogeneous cases twelve had 

a discordant KRAS mutational status between the two lesions 

and 4 harbored a different mutation. BRAF mutational status. 

31 cases (90.9%) were genetically homogeneous and 2 (7.4%) 

heterogeneous. Considering the homogeneous pair 29 were 

wild-type and 2 showed the V600E mutation in both the lesion. 

287 

Interestingly, the 2 cases with a discordant BRAF mutational 

status are mutated in index lesion in one case and in the concurrent 

lesion the other. 

KRAS/BRAF mutations distribution among the index tumor, 

concurrent lesion, lymph node and distant metastases: genotype 

concordance between synchronous tumors and relative metastases 

were found in 8 out of 17 (47%) analyzed cases; namely, 

5 cases were WT for both KRAS and BRAF; while, 2 and 1 

cases were KRAS and BRAF mutated respectively in genetically 

homogeneous way. The other 9 cases showed genotype differences 

in an heterogeneous manner (Table 1). Worth mentioning: 

one case showed KRAS G12V mutation in the index lesion 

and G12S in the concurrent lesion, analyzed metastases showed 

G12V in two and G12S in one metastatic lymph node while the 

distant metastases resulted G12A similar to the index lesion; 

one case showed KRAS G12D in the index lesion and BRAF 

V600E in the concurrent lesion, while the distant metastasis 

resulted KRAS G12D; one case was BRAF V600E in the index 

and in both lymph node and distant metastases, while concurrent 

lesion was KRAS G13D. 

Discussion. The results of this study demonstrate that KRas and 

BRAF mutations distribution is heterogeneous in 16 (48.5%) out 

of 33 SC analyzed. Interestingly, 10 patients has one mutated tumor 

while the other one is wild type. By a clinical point of view 

this observation suggest that the examination of an arbitrarily 

selected archival tumor sample may carry the risk of a non representative 

genotype. In our series until 30% of the cases could 

receive an inadequate treatment. In conclusion, we suggest that 

the genotyping should be performed on all the tumor indicated in 

the histological diagnosis. 

references 

1 Di Nicolantonio F, Martini M, Molinari F, et al. Wild-type BRAF is 

required for response to panitumumab or cetuximab in metastatic 

colorectal cancer. J Clin Oncol 2008;26:5705-12. 

2 Wang HZ, Huang XF, Wang Y, et al. Clinical features, diagnosis, 

treatment and prognosis of multiple primary colorectal carcinoma. 

World J Gastroenterol 2004;10:2136-9. 

3 Balschun K, Haag J, Wenke AK, et al. KRAS, NRAS, PIK3CA exon 

20, and BRAF genotypes in synchronous and metachronous primary 

colorectal cancers diagnostic and therapeutic implications. J Mol 

Diagn 2011;13:436-45. 

4 Baldus SE, Schaefer KL, Engers R, et al. Prevalence and heterogeneity 

of KRAS, BRAF, and PIK3CA mutations in primary colorectal 

adenocarcinomas and their corresponding metastases. Clin Cancer 

Res 2010;16:790-9. 

5 Nosho K, Kure S, Irahara N, et al. A prospective cohort study shows 

unique epigenetic, genetic, and prognostic features of synchronous 

colorectal cancers. Gastroenterology 2009;137:1609-20 e1-3. 

Colorectal micropapillary carcinoma: 

a clinico-pathologic study 

G. Lanza, C. Gnudi, G. Querzoli, E. Magri, F. Mora, R. Mazzoni, 

C. Zampini, R. Gafà 

Section of Pathology, Department of Experimental and Diagnostic Medicine, 

University of Ferrara 

Background. Micropapillary carcinoma (MPC) has been recently 

introduced in the 2010 WHO classification of tumours of 

the colon and rectum as a rare variant of adenocarcinoma. From 

the histological point of view the micropapillary component is 

characterized by the presence of small and irregular papillary-like 

aggregates of cells contained in thin lacunar spaces delimited by 

fibrous stroma. It is important to emphasize that the micropapillary 

aspects can be frequently demonstrated in the context of 

conventional adenocarcinomas. 

The interest in the micropapillary histology is mainly determined 

by the fact that its presence is associated in tumors of various organs 

with a higher incidence of nodal and distant metastases, with 

aggressive histological features and reduced survival.

288 

Methods. In this study we examined a series of 192 colorectal 

carcinomas surgically resected from January 2003 to 

June 2010. Histological evaluation was done using standard 

histologic sections stained with hematoxylin and eosin. The 

tumors were widely sampled, with a number of tissue blocks 

of approximately one per cm in largest tumor diameter. A 

carcinoma was classified as micropapillary when micropapillary 

tufts lacking true fibrovascular cores and surrounded by 

empty lacunar spaces represented at least 5% of the tumor area 

in histologic sections. 

Results. 29 of the 192 tumors (15.1%) were classified as MPC. 

In most cases the MP component represented < 30% of the 

tumor volume. MP carcinomas were observed more often in 

males than females (19.8% vs. 8.6%, P = 0.04). In contrast patient’s 

age was not significantly related with the presence of MP 

features. A highly significant relationship was evident between 

MP component and tumor site. A MP component was present 

in 27.9% of tumors located in the rectum, in 20% of tumors of 

the left colon (descending and sigmoid colon) and in 7.1% of 

tumors arising in the proximal colon (right and transverse colon) 

(P = 0.003). MPCs were more often in advanced stages (III 

and IV) compared to conventional adenocarcinomas (72.4% vs. 

34.4%, P < 0.001). In addition, MPCs showed a more advanced 

pT category (P = 0.03), more frequent involvement of the serosa 

(41.4% vs. 21.5%, P = 0.03) and a much greater propensity 

to lymph node metastasis (69.0% vs. 31.9%, P < 0.001) than 

conventional adenocarcinomas. 48.3% of MPCs showed 4 or 

more lymph node metastases, while only 15.3% of common 

adenocarcinomas were classified as pN2. The frequency of distant 

metastases at diagnosis was higher in the MPCs (17.2% vs. 

9.8%), but the difference did not reach statistical significance. 

Tumors with a MP component also showed more frequently 

an infiltrative pattern of growth (47.4% vs. 13.8%, P = 0.002) 

and extramural venous invasion (37.9% vs. 16.6%, P = 0.01). 

Finally in our study 24 of the 29 MPCs (82.8%) were classified 

as poorly differentiated (high grade), while only 22.1% of conventional 

carcinomas were high grade (P < 0.001). 

Conclusions. The results we obtained confirm the characteristics 

of pathological aggressiveness of the MPCs reported in 

literature and highlight the high propensity to lymph node metastasis 

of these tumors. The prognostic significance of the MP 

histotype has been evaluated only in a limited number of studies. 

Given the association between MP component and lymph 

node metastasis, distant metastasis and other pathological 

parameters of aggressiveness, it is expected that this histological 

type is characterized by a generally poor prognosis, with 

survival rates lower than those observed in common adenocarcinomas 

and mucinous adenocarcinomas. Further studies 

are certainly necessary to verify if the MP histology represents 

a prognostic factor more important and reproducible than the 

degree of differentiation and to define the biomolecular and 

genetic basis of this tumour type. 

references 

1 Verdù M, et al. Clinicopathological and molecular characterization of 

colorectal micropapillary carcinoma. Mod Pathol 2011;24:729-38. 

2 Xu F, et al. Micropapillary component in colorectal carcinoma is 

associated with lymph node metastasis in T1 and T2 stages and 

decreased survival time in TNM stages I and II. Am J Surg Pathol 

2009;33:1287-92. 

3 Kim M-J, et al. Invasive colorectal micropapillary carcinoma: an 

aggressive variant of adenocarcinoma. Hum Pathol 2006;37:809-15. 

4 Haupt B, et al. Colorectal adenocarcinoma with micropapillary 

pattern and its association with lymph node metastasis. Mod Pathol 

2007;20:729-33. 

Sakamoto K. Primary invasive micropapilklary carcinoma of the colon. 

Histopathology 2005;47:479-84. 


Usefulness of anti-TCrGD antibody in gluten 

sensitivity diagnosis on formalin-fixed paraffinembedded 

biopsies 

S. Lonardi1 , V. Villanacci1 , A. Lanzini2 , F. Lanzarotto2 , L. Lorenzi1 

, U. Volta3 , F. Facchetti1 1 2 Department of Pathology, Gastroenterology Unit, Spedali Civili-University 

of Brescia, 3 Department of Clinical Medicine, St Orsola-Malpighi 

Hospital-University of Bologna, Bologna, Italy 

Introduction. Small bowel intraepithelial lymphocytosis (IL) may 

depend from different causes, including Gluten Sensitive Enteropathy 

(GSE). 1 Demonstration of increased number of duodenal 

T-cell receptor gamma-delta (TCRGD) positive intraepithelial 

lymphocytes (IELs) has been used to support GSE diagnosis on 

frozen material. 2-3 We have evaluated an anti-TCRGD antibody on 

formalin-fixed paraffin embedded (FFPE) small bowel biopsies. 

Material and methods. Anti-CD3 (clone SP7, 1:100) and anti- 

TCRGD (TCR CgM1, clone g3.20, 1:400) from Thermo Scientific, 

Fremont, CA) were applied by immunohistochemistry on 59 FFPE 

biopsies from 18 cases of celiac disease (CD) with mild/severe atrophy, 

19 cases of IL in CD patients on Gluten Free Diet (IL-GFD), 

14 cases of IL (6/14 with abnormal serology for GSE), and 8 controls 

(CTR) with mild duodenitis and negative CD serology and genotyping. 

Sections were digitalized with Aperio Scanscope (Nikon) 

and IELs/100 epithelial cells (EC) were counted in six high power 

fields. For statistic analysis the Mann-Whitney test was applied. 

Results. CD3+ IELs were significantly higher in CD (mean±SD 

52.0±15.3) (Figure 1A), IL-GFD (43.6±18.3) and IL (46.3±16.6) 

(Figure 2A) compared to CTR (24.1±7.6) (p = 0.0004, p = 0.0019 

and p = 0.0006, respectively) (Figure 3A) 

Fig. 1. immunohistochemistry for Cd3 (a) and tCRGd (B) in Cd; original 

magnification: 200x. 

Fig. 2. immunohistochemistry for Cd3 (a) and tCRGd (B) in il with 

abnormal serology; original magnification: 200x. 

Fig. 3. Cd3+ and tCRGd+cells/100 EC in Cd, il-Gfd, il were significantly 

different compared to CtR (a-B). p-value in a: * Cd vs CtR p = 0.0004, 

** il-Gfd vs CtR p = 0.0019, *** il vs CtR p = 0.0006. p-value in B: * Cd 

vs CtR p < 0.0001, ** il-Gfd vs CtR p = 0.0004, *** il vs CtR p = 0.0046.


Fig. 4. tCRGd+cells/100 EC were significantly different between il 

with normal and abnormal serology. 

TCRGD+ IELs were significantly higher in CD (21.4±11.7) (Figure 

1B), IL-GFD (16.2±8.7) and IL (9.9±6.6) (Figure 2B) compared 

to CTR (3.4±1.0) (p < 0.0001, p = 0.0004 and p = 0.0046, 

respectively) (Figure 3B). 

In contrast to CD3+ IELs, TCRGD+ IELs were significantly 

higher in CD and IL-GFD compared with IL (p = 0.0010 and 

p = 0.0126 respectively). 

Furthermore, TCRGD+ IELs discriminated between IL with 

normal (6.7±2.9) and abnormal (14.2±8) serology (p = 0.02) 

(Figure 4). 

Discussion . TCRGD+IELs can be identified on FFPE samples; 

their evaluation adds useful information for the workup of small 

bowel biopsies and GSE diagnosis. They may recognize IL cases 

with abnormal serology, possibly representing early GSE stages. 

references 

1 Brown I, et al. Arch Pathol Lab Med 2006;130:1020-5. 

2 Arranz E, et al. Gut 1994;35:476-82. 

3 Järvinen TT, et al. Am J Gastroenterol 2003;98:1332-7. 

Apoptosis related biomarkers in advanced 

colorectal cancer: chemotherapy outcome 

and carcinogenesis 

F. Melotti, F. Pietrantonio, A. Pellegrinelli, L. Battaglia, A. Cesa 

Bianchi, G. Pelosi, F. de Braud, E. Leo, M. Milione 

Fondazione IRCCS Istituto Nazionale Dei Tumori, Department of pathology 

and Laboratory Medicine, Milan 

Background. Apoptosis-related biomarkers may predict chemosensitivity 

of advanced gastrointestinal cancers in vivo 1 2 . TP53 

gene usually remains wild type throughout the progression from 

normal mucosa to adenoma development and an alteration of the 

p53 gene appears to be a late step in the progression of colorectal 

tumorigenesis 3 . Despite the considerable body of evidence in support 

of the adenoma-carcinoma sequence, the de novo theory still 

has some support and may be mediated by alternative mechanisms. 

Materials and methods. Forty-nine patients, affected by synchronous 

or metachronous metastatic colorectal cancer, were 

enrolled from August 2002 to October 2004 at the coordinator 

center “Istituto Nazionale dei Tumori” of Milan and treated 

within a randomized phase II trial with first-line UFT/leucovorin 

(LV) plus irinotecan (TEGAFIRI) versus UFT/LV plus oxaliplatin 

(TEGAFOX) (4). ERCC1, Bax and TP53 expression was 

assessed by immunohistochemistry on paraffin sections. The 

samples were scored positive if more than 5% of tumor cells 

showed specific staining. Tissue blocks of primary resected tumors 

were also evaluated in a subset of thirty-nine pts for residual 

adenomatous component. 

289 

Results. ERCC1 and TP53 failed to show any correlation with 

outcome in terms of response to chemotherapy and progressionfree/overall 

survival. Responses significantly lower in Baxpositive 

vs Bax-negative (Odds Ratio [OR] = 0.26; p = 0.03 by 

logistic regression): 25% (6/24) vs 56% (14/25). No significant 

differences in terms of outcome in TEGAFOX-treated pts, while 

Bax-positive pts in TEGAFIRI subgroup had lower response rate 

as compared to Bax-negative (OR = 0.11; p = 0.03 by logistic 

regression): 18% (2/11) vs 67% (8/12). Residual adenoma component 

in primary colorectal cancer specimens was < 10% in 

27 (69%) cases and was > 10% in 12 (31%). TP53 expression 

was significantly higher in the group without residual adenoma 

vs the one with adenomatous component: 15/27, 56% vs 2/12, 

17%, P = 0.03 by Fisher’s exact test), while Bax and ERCC1 

were not associated with morphological characteristics. Notably, 

one patient with TP53 expression and residual adenoma showed 

microsatellite instability. 

Conclusions. TP53 alteration may accelerate the progression of 

adenoma-carcinoma sequence or even allow a de novo colorectal 

carcinogenesis. However, TP53 expression does not seem to affect 

chemotherapy outcome, while Bax positivity may identify a 

subset of patients with particular sensitivity to irinotecan-based 

regimens. 

refereces 

1 Benhattar J, Cerottini JP, Saraga E, et al. P53 mutations as a possible 

predictor of response to chemotherapy in metastatic colorectal carcinomas. 

Int J Cancer 1996; 69:190-2. 

2 Pietrantonio F, Biondani P, de Braud F, et al. Bax espression in predictive 

of favorable clinical outcome in chemonaive advanced gastric 

cancer patients trated with capecitabine, oxaliplatin and irinotecan 

regimen. Transl Oncol. 2012;5:155-9. 

3 Baker SJ, Preisinger AC, Jessup JM, et al. P53 gene mutations occur 

in combination with 17p allelic deletions as late events in colorectal 

tumorigenesis. Cancer Res 1990;50:7717-22. 

4 Bajetta E, Celio L, Ferrario E, et al. Capecitabine plus oxaliplatin and 

irinotecan regimen every other week: a phase I/II study in first-line 

treatment of metastasic colorectal cancer. Ann Oncol 2007;18:1810-6. 

Cutaneous melanoma metastatic to the gallbladder: 

an additional case 

V. Mourmouras1 , M.R. Ambrosio2 , B.J. Rocca2 , S. Giunti1 , 

A. Amorosi1 1 2 Centro Oncologico Fiorentino, Sesto Fiorentino and Departement of 

Human Pathology and Oncology, Anatomic Pathology Section, University 

of Siena, Italy 

Background. Malignant cutaneous melanoma can metastasize to 

virtually any organ. The most common sites of distant metastases 

are lungs, liver and brain. Only 2% to 4% of patients with melanoma 

will be diagnosed with gastrointestinal metastasis during 

the course of the disease, the most common sites being the small 

bowel, colon and stomach. Metastatic melanoma to the gallbladder 

is extremely rare and it is associated with a poor prognosis. 

Material and methods. A 27 year-old woman was admitted to 

our clinic with abdominal pain in her right upper quadrant, and 

associated nausea and vomiting. Laboratory tests were within 

normal limits. On ultrasound examination of the abdomen a 

polypoid lesion within the gallbladder wall was demonstrated. 

A clinical diagnosis of chronic cholecystitis was made and the 

patient underwent laparotomy and cholecystectomy. Two years 

earlier, she underwent surgical removal of a primary cutaneous 

melanoma. 

Results. The surgical specimen consisted of a 7 cm-long gallbladder 

which macroscopically showed an ulcerated, polypoid, 

black lesion in the fundus. The lumen was filled with bile. At 

pathological examination, the wall of the gallbladder was diffusely 

infiltrated by epithelioid and spindle, pigmented cells 

forming a nodule. The superficial epithelium was focally eroded

290 

and no junctional activity was observed. Immunohistochemical 

staining showed a strong positivity of the neoplastic cells for 

S-100 protein and HMB-45, as well as negativity for epithelial 

markers. On clinical, morphological and immunohistochemical 

basis the diagnosis of a metastatic focus of a cutaneous malignant 

melanoma was made. 

Conclusion. Melanoma has a propensity to spread extensively, 

often involving multiple visceral sites. Biliary symptoms in a 

patient with a history of cutaneous melanoma should be investigated 

as a possible evidence of biliary tract metastases. Gallbladder 

metastasis represent a rare event as first site of recurrence 

as occurred in our case herein reported. The distinction between 

primary and metastatic lesions can be complicated on the basis 

of clinical, radiological and histopathological features, however 

the presence of a past history of melanoma in the skin or in other 

common primary sites combined with the absence of junctional 

activity orientate to the diagnosis of metastatic lesion. In absence 

of adjuvant therapy the surgical approach is the only treatment 

that may assure a better survival. 

references 

Vernadakis S, Rallis G, Danias N, et al. Metastatic melanoma of the gallbladder: 

an unusual clinical presentation of acute cholecystitis. World 

J Gastroenterol 2009;15:3434-6. 

Alimova E, Gorin I, Gressier L, et al. Metastatic melanoma of the gallbladder: 

two cases. Ann Dermatol Venereol 2009;136:368-70. 

Gwynne S, Abbas T. The gallbladder as the first site of metastatic 

disease in a patient with melanoma. Hematol Oncol Stem Cell Ther 

2008;1:197-8. 

Marone U, Caracò C, Losito S, et al. Laparoscopic cholecystectomy for 

melanoma metastatic to the gallbladder: is it an adequate surgical 

procedure? Report of a case and review of the literature. World J Surg 

Oncol 2007;11:141. 

Gastric medullary carcinoma: the importance 

of a lymphoid infiltrate 

L. Sollima1 , G. Crisman1 , V. Ciuffetelli2 , G. Calvisi2 , G. Coletti2 , 

P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 



Background. First described by Schminke and Regaud and 

Reverchen in 1921, LymphoEpithelioma-Like Carcinoma (LE- 

LC) represents an uncommon, poorly differentiated neoplasia 

with an associated background of lymphocytes. Also known as 

Medullary Carcinoma, LELC of the stomach is characterized by 

a relatively favorable prognosis. 


who underwent a total gastrectomy for an ulcerated lesion sited 

on the small gastric curve, endoscopically detected. Grossly, an 

ulcerated lesion of 2 cm in-diameter was detected close to the 

lower oesophageal sphincter. 

Results. Histological examination revealed a poorly differenti- 

Fig. 1 a. Histologica features: Expansive growth pattern with welldefined 

borders (H&E, 4x magnification); fig. 1 B: Nests of tumor 

cells with moderate pleomorphism and diffuse syncytial aspects, 

surrounded by a non-desmoplastic stroma with a dense lymphocytic 

infiltrate (H&E, 4x megnification). 


Fig. 2. immunohistochemical stains: a: lymphoid infiltrated appeared 

mainly composed by t-Cd4+ lymphocytes (Cd4, 4x magnification); 

B: Several t-Cd8+ lymphocytes were also present (Cd8, 4x magnification); 

C: Several B-cell Cd20+ lymphoid follicles (Cd20, 10x magnification). 

ated adenocarcinoma with medullary features, charatherized by 

expansive growth pattern and well-defined borders, involving 

all the gastric wall up to the inner third of the smooth muscle 

layer. The lesion was mainly composed by nests of tumor cells 

with moderate pleomorphism and diffuse syncytial aspects, surrounded 

by a non-desmoplastic stroma with a dense lymphocytic 

infiltrate. Immunohistochemical analysis revealed an inflammatory 

infiltrate mainly composed by T lymphocytes (CD8 + and 

CD4 +), arranged between the nests showing a direct contact with 

tumor cells. Several histiocytes CD68+ within the stroma have 

been also observed. Moreover, CD20 + B-cells follicoles were 

present at the periphery of the lesion and within the submucosa. 

Few intraepithelial T lymphocytes CD8 + have been observed 

as well. 

Conclusions. Despite of its undifferentiated appearance, gastric 

LELC has a favourable course, thus suggesting a possible role 

of the lymphoid infiltrate as a defensive reaction against the 

tumor. According to the literature, a close relationship between 

medullary gastric carcinoma and Epstein-Barr virus infection has 

been suggested but in our case EBV infection was not detected. 

Differential diagnosis should include lymphomas thus, the immunohistochemical 

assesment of the lymphoid infiltrate is crucial in 

the aim to achieve the correct diagnosis. 

references 

1 Iwashita A, Ueyama T, Yamada Y, et al. Clinicopathological study on 

medullary carcinoma with lymphoid stroma of the stomach. I to Cho 

(Stomach and Intestine) 1991;10:1159-66. 

2 Minamoto T, Mai M, Watanabe K, et al. Medullary carcinoma with 

lymphocytic infiltration of the stomach. Clinicopathologic study of 

the subpopulations of infiltrating lymphocytes in the tumor. Cancer 

1990;66:945-52. 

3 Burke AP, Yen TSB, Shekitka KM, et al. Lymphoepithelial carcinoma 

of the stomach with Epstein-Barr virus demonstrated by polymerase 

chain reaction. Mod Pathol 1990;3:377-80. 

4 Sousa H, Pinto-Correia AL, Medeiros R, et al. Epstein-Barr virus is 

associated with gastric carcinoma: the question is what is the significance? 

World J Gastroenterol 2008;14:4347-51. 

5 Watanabe H, Enjoji M, Imai T. Gastric carcinoma with lymphoid 

stroma. Its morphologic characteristics and prognostic correlations. 

Cancer 1976;38:232-43.


LOH analysis of WnT-activated hepatocellular 

carcinomas (HCC) 

E. Tamburini1 , B. Dal Bello2 , N. Campanini1 , C. Azzoni1 , L. Bottarelli1 

, S. Pizzi1 , P. Soliani3 , S. Rossi4 , E.M. Silini1 1 Department of Pathology and Laboratory Medicine, Anatomic Pathology, 

Azienda Ospedaliero-Universitaria di Parma, Via Gramsci, 14, Parma, 

Italy; 2 Department of Anatomic Pathology and 4 VI Internal Medicine, 

Fondazione IRCCS, Policlinico S. Matteo, Viale Golgi, 19, Pavia, Italy, 

3 Department of General Surgery, Azienda Sanitaria locale di Ravenna, 

Viale Tullo Masi, 3, Ravenna, Italy. 

Background. Wnt-activated HCCs are a specific tumor entity 

with distinct morphology and improved survival that are characterized 

by nuclear immunoreactivity for β-catenin (CTNN1) and 

overexpression of glutamine synthetase (GS) 1-3 . We evaluated 

the loss of heterozygosity (LOH) profile at different chromosomal 

loci in a series of HCCs according to CTNN1/GS status 

to identify recurrent genetic events potentially relevant in this 

specific pathways of hepatocarcinogenesis. 

Materials and methods. 84 surgical-resected HCCs were considered 

divided into 56 cases and 28 controls according to tissue 

immunoreactivity for GS/CTNN1 expression. Analysis were performed 

on DNA extracted from formalin-fixed paraffin-embedded 

tissues after manual microdissection. Direct sequencing for 

CTNN1 mutations and LOH analysis using a panel of 18 microsatellite 

mapping at 1p, 8p, 16p, 17p and 19q, were performed 4-6 . 

In tumors showing distinct areas of neoplastic progression,the 

analysis was performed separately in each component. 

Results. CTNN1 mutations were identified in 13/70 (19%) 

HCCs: 12 in GS/CTNN1+ (24.4%), 1 in GS/CTNN1- (5%) 

(p = 0.04). Identified mutations were: 1 mononucleotide deletion 

and 12 missense mutations, mainly involving codons 32, 

33, 37 and 45. Overall LOH frequency at main chromosomal 

regions was: 8p (58%), 16p (52%), 1p (50%), 17p (48%), and 

19q (32%). Losses at 8p12-p22 and 17p12-13 correlated with 

InTErESSE GEnErALE 

Vintage antibodies outlast the expiration date 

by 10-26 years 

M.C. Argentieri1 , A. Vanzati1 , C. Parravicini2 , G. Cattoretti1 1AO San Gerardo e Universitá di Milano-Bicocca, Monza (MB), 2 AO 

Luigi Sacco, Milano, Italy 

Primary antibodies represent an essential ancillary technique for 

histopathology, both for the diagnosis and for planning the treatment 

of several classes of patients. 

Between 10% and 20% of the surgical specimens received by 

our institutions undergo immunostaining. We currently maintain 

a panel of about 150 primary antibodies, some of which are used 

fairly often (anti- keratin, S-100, CD45, CD3, CD20 etc.), others 

once or twice a year, although their use is not redundant. The cost 

of maintaining such a large panel is aggravated by the fact that, 

once they pass the expiration date written on the label, they may 

not be used for diagnosis. The lab using expired reagents may be 

fined for that. 

The cost of the primary antibodies represents about 60% of the 

budget allocated for in vitro reagents (with the exclusion of 


Sala Michelangelo – ore 15,00-17,00 

291 

CTNN1 immunoreactivity (p = 0.02, p = 0.05) and mutations 

(p = 0.04), conversely deletion at 1p34.2, 8p21.3-22 and 

16p11.2 were associated with CTNN1 wild-type (p = 0.04, 

p = 0.05, p = 0.05 respectively). Some genetic changes correlated 

with clinico-pathological features of the HCCs: 8p, 17p with 

age (p = 0.0006, p = 0.04); 16p, 19q with cirrhosis (p = 0.0005, 

p = 0.02); 17p with vascular invasion and histologic grade 

(p = 0.03, p = 0.04); 1p, 8p and 19q with nodule size > 3 cm 

(p = 0.02, p = 0.04, p = 0.007 respectively). Losses at 1p21-22, 

17p12-13 and 19q13.41 were associated with disease progression 

(p = 0.03, p = 0.01, p = 0.03 respectively). 

Conclusions. CTNN1 mutations confirm the predictive role 

of immunohistochemistry for CTNN1/GS in definition Wntactivated 

HCCs. Overall, chromosomal instability in the analyzed 

regions is high. No specific LOH events are characteristic of the 

Wnt-activated HCCs although they show a distinct genetic profile. 

Indeed, LOH profiles segregate not only with different tumor 

types, but also with other common clinico-pathological variables. 

references 

1 Dal Bello B, Rosa L, Campanini N, et al. Glutamine synthetase immunostaining 

correlates with pathologic features of hepatocellular 

carcinoma and better survival after radiofrequency thermal ablation. 

Clin Cancer Res 2010;16:2157-66. 

2 Laurent-Puig P, Legoix P, Bluteau O, et al. Genetic alterations associated 

with hepatocellular carcinomas define distinct pathways of 

hepatocarcinogenesis. Gastroenterology 2001;120:1763-73. 

3 Audard V, Grimber G, Elie C, et al. Cholestasis is a marker for hepatocellular 

carcinomas displaying beta-catenin mutations. J Pathol 

2007;212:345-52. 

4 Piao Z, Park C, Park JH, et al. Allelotype analysis of hepatocellular 

carcinoma. Int J Cancer 1998;75:29-33. 

5 Nagai H, Pineau P, Tiollais P, et al., Comprehensive allelotyping of 

human hepatocellular carcinoma. Oncogene 1997;14:2927-33. 

6 Austinat M, Dunsch R, Wittekind C, et al. Correlation between betacatenin 

mutations and expression of Wnt-signaling target genes in 

hepatocellular carcinoma. Mol Cancer 2008;7:21. 

solvent, alcohol and paraffin). Replacing outdated reagents adds 

up to this cost, despite a handful of well designed publications 

(Tubbs, Nagle et al. 1998; Balaton, Drachenberg et al. 1999; 

Vigliani and Babache 2002; Savage and DeYoung 2010) which 

showed excellent performance of primary antibodies which expired 

12 to 32 months before they were used. 

We retrieved antibodies which were constantly kept at +4C since 

having been received by two different labs, selecting the ones 

dating before year 2000. Conditions for the experiment were that 

they should not have been dried out, not being contaminated and 

being either in the original vial or proof of the invoice could be 

demonstrated. 

All the antibodies shown in the table performed exceptionally 

well, despite being kept for up to 26 years in the fridge. 

These results were anticipated by isolated reports about antibodies 

performing well 134 months after the expiration date. The 

panel we chose is limited but well representative of the most used 

antibodies in the daily practice. All of them are older than 134 

months and all survived. 

These results should prompt a revision of the recommendation 

to discard primary antibodies which have passed the expiration 

date. This recommendation, as we have shown, has no basis, being 

much more relevant the conditions (cold ischemia, fixation,

292 

dehydration) with which the tissue has been processed. In addition, 

considerable money saving may be accomplished, moving 

the focus on other necessary spending such as quality control. 

Acknowledgments. We wish to thank Prof. TT Sun, D Crawford, 

RM Steinman, PJ Martin, R Cardiff, JC Gluckman, D Lane, MF 

Greaves and many others for donating antibodies. Lorella Riva, 

Angelita Ferri and the whole Laboratory Technician staff contributed 

to the project. MCA was supported by a generous grant 

from Prof. F. Uggeri. 

references 

Balaton A J, Drachenberg CB, et al. Satisfactory Performance of Primary 

Antibodies Beyond Manufacturers’ Recommended Expiration 

Dates. Applied Immunohistochemistry & Molecular Morphology 

1999;7:221-5. 

Savage EC, DeYoung BR. Antibody expiration in the context of resource 

limitation: what is the evidence basis? American Journal of Clinical 

Pathology 2010;134:60-4. 

Tubbs RR, Nagle R, et al. Extension of useful reagent shelf life beyond 

manufacturers’ recommendations. Cell Markers Committee of the 

College of American Pathologists. Archives of pathology & laboratory 

medicine 1998;122:1051-2. 

Vigliani R, Babache N. Primary antisera before and after the expiration 

date. Comparative immunohistochemical observations and analysis of 

data sheets and labels. Pathologica 2002;94:121-9. 


Antibody Clone Isotype Supplied as Year Source Lab 

Keratin aE1 igg1 supernatant 1986 tt Sun gc 

Keratin aE3 igg1 supernatant 1986 tt Sun gc 

tP53 Pab1801 igg1 supernatant 1987 D crawford gc 

EMa E29 igg2a supernatant 1990 Dako cP 

Muscle actin HHf35 igg1 RtU 1993 

Enzo 

pharmaceuticals 

cP 

cD45R0 Uchl1 igg2a supernatant 1994 Dako cP 

cD3 Na Rb RtU 1996 Dako cP 

Cd79a Hm57 igg1 supernatant 2000 Dako cP 

Fig. 1. 

a: Mca holding the 1986 original tubes; B: aE-1, liver; C: aE-3, liver; 

d: actin, gut; E: Ki-67, tonsil; f: Cd3, tonsil; G: Cd79a, tonsil; H: Cd34, 

tonsil. 

Introduction of a routinely new collection 

and preparation system for urine cytology: 

method and impact evaluation 

A. Bondi, R. Rapezzi, S. Negri 

U.O. Anatomia, Istologia Patologica e Citodiagnostica. Ospedale Maggiore 

Bologna, AUSL Bologna 

Background. According to data from the Mortality Registry in 

Emilia Romagna Region (1998-2004), almost 500 deaths a year 

are due to bladder cancer, of which slightly more than 100 women 

and almost 400 men. 

The relative risk for the municipality of Bologna is > 1.3 and has 

a very uniform distribution, especially among males. It ‘a rare 

cancer before age of 40 and increases after 60. 

The proposed health intervention has affected the entire province 

of Bologna, whose catchment area up to 2008 December 31 consisted 

of 1,105,764 inhabitants of which over 900,000 reside on 

the district of Bologna AUSL. 

The project stems from the need of business planning, rationalization 

and control of health care and has involved all stakeholders 

actors in the reorganization process, first the 3 Anatomic Pathologies 

and the CUP (Unified Booking Centre) service. 

The classical method of urine preparation for cytology samples 

consists in fresh processing: for each patient were collected three 

samples obtained in different days, processed separately. 

Materials and Methods. We have designed a cardboard box 

with foam housings three cans of 150 ml each, containing 35 ml 

of fixative consisting of a mixture of ethanol (> 95%), methanol 

(< 3%) and buffered formalin (< 0.5%) (manufacturer Diapath). 

The patient adds approximately 100 ml of urine to the fixative 

and the box can be stored for up to seven days in cool. 

In the laboratory, the three samples are mixed and processed together 

on a filtration ramp using a polycarbonate membrane with 

5 microns porosity to set up a single cytology preparation stained 

with Papanicolou technique. 

Results and discussion. In this study we show a comparison 

between two years: one (2011) using the new established method 

and other (2008) where the sample was collected with the classical 

method. The samples are classified according to WHO 2004 

(modified for cytology): Inadequate (prepared without transitional 

items), Negative (including acute and chronic inflammation 

pattern, simple and papillary hyperplasia pattern without atypia), 

Hyperplasia with nuclear atypia (mainly papillary), 

Suspect (not conclusive for diagnosis of cancer) and Positive 

(transitional cell carcinoma and NAS). 

For the two periods, the distribution of diagnoses considered 

“negative” (no clinical study required) and “atypical / positive” 

(further diagnostic tests required), shows no significant deviations 

(negative decreased from 90 to 89% and Atypical / Positives 

from 8.8 to 8.5%). 

Inadequate samples are doubled in 2011. Since the indication 

for inadequate samples is the repetition of test, we checked the


Tab. I. distribution of urine cytology diagnosis for the years 2008 and 2011. 

CYTOLOGICAL DIAGNOSIS 

results for repeated samples. Out of 171 cases of inadequate resulting 

in 2011, only in one of them inadequacy was due to the 

presence of abundant artifact material, the remaining 170 cases 

did not show transitional cells. 

Among these 85 cases, corresponding to 50%, repeated the test 

during the year and resulted negative. So when a cytology examination 

of urine is inadequate with the simultaneous filtration 

of three samples, we have reasonable certainty that the sample is 

actually negative. 

In the “negative” group are doubled papillary hyperplasia, increased 

from 2 to 4% in 2011, while among the “positive” group 

the papillary hyperplasia with atypia reached 5% in 2011 compared 

to previous 2%. 

The positive predictive value (PPV) for atypical papillary hyperplasia 

was particularly powerful (0.75); while lowest, as expected, 

the VPP of hyperplasia without atypia (0.38). 

Conclusion. The introduction of the new system for the collection 

of urine material with fixative alcohol and the change in 

assembly method (completely and together filtration of the three 

samples), made it possible to increase the number of performance 

per year of 67%, also the good preservation of cellular elements, 

due to the presence of fixative to the time of sampling, has allowed 

to improve the morphological detail and to better identify 

the cases to send for more detailed diagnosis. 

references 

Rosenthal D, Raab SS. Cytologic Detection of Urothelial Lesions. 

Springer 2005. 

Eble JN, Sauter G, Epstein JI, et al., eds. W.H.O. Classification of Tumours. 

Pathology and Genetics of Tumours of the Urinary System and 

Male Genital Organs. Lyon: IARC Press 2004. 

Planz B, Jochims E, Deix T, et al. The role of urinary cytology for detection 

of bladder cancer. Eur J Surg Oncol 2005:31:304-8. 

Rapezzi R, Bondi A. Streamlining the urinary oncology cytological service 

in the metropolitan area. Pathologica 2010:04:153-4. 

2008 2011 

iNaDEQUatE 50 1% 1% 171 2% 2% 

NEgatiVE (no inflammation) 2961 62% 4229 59% 

NEgatiVE acute inflammation 485 10% 273 4% 

NEGatiVE chronic inflammation 567 12% 1441 20% 

hYPERPlaSia 207 4% 123 1% 

PaPillaRY hYPERPlaSia 95 2% 4315 90% 270 4% 6336 89% 

HYpERplaSia WitH atYpia 203 2% 349 5% 

SUSPEct 37 2% 14 1% 

PoSitiVE 185 4% 425 8.8% 239 3% 602 8,50% 

UrInE SAMPLE TOTAL 4790 21318 

PATIEnT TOTAL 1597 7106 

Tab. II. Cyto/histological comparison of histology panels of papillary 

hyperplasia and papillary hyperplasia with dysplasia. 

Papillary 

hyperplasia 13 

Papillary 

hyperplasia 

with atipa 20 

HISTOLOGY CYTOLOGY 

Negative Dysplasia/ 

Cancer 

8 5 PPV 0,38 

PNV 

0,61 

5 15 PPV 0,75 

PNV 

0,25 

293 

Diagnostic reproducibility on a digital evaluation 

system slide in cytology and histology in 

oncologic screening 

A. Bondi, S. Lega, P. Crucitti, P. Pierotti, R. Rapezzi, P. Sassoli 

de’ Bianchi1 , C. Naldoni1 Anatomia Patologica Ospedale Maggiore, Azienda USL di Bologna, 

Italia; 1 Direzione Generale Sanità e Politiche Sociali, Regione Emilia- 

Romagna, Italia 

Background. Diagnostic reproducibility and accuracy in cytology 

and histology are the main issues in Oncologic Screening of cervix, 

breast and colorectal cancer: it can be achieved by programs 

for quality assurance (QA). The slides set standard represents the 

most used method to compare diagnostic proficiency, the chance 

of interpreting microscopic digital photographs provided an interesting 

alternative to read conventional microscope slides. 

The whole digital slide observed in a computer screen is a third, 

interesting, option to reach the goal. In fact all the information on 

conventional samples are transferred into a file, easily archived, 

catalogued, duplicated or advice for quality control, but is especially 

available at distance and from multiple locations simultaneously 

with drastic reduction of time needed to achieve proficiency 

test reproducibility 1 . 

The production of digital slides with modern scanners is relatively 

simple and quick. All suppliers offer services into private 

or public networks server in the literature 2 and software able to 

track scanned cases stored in comprehensive database to build 

large casistic archives online 3 Tools are already available for 

a teleconference discussion of cases with vision of cytological 

preparations on line 4 5 , educational programs with integrated digital 

slides are poorly developed or proficiency tests for continuing 

education and professional updating are easily accessible. 

A project on Virtual Microscopy and Digital Pathology has been 

conducted in Emilia-Romagna Region (Italy) with the goal to 

promote quality in diagnostic cytology and histology in Screening 

programs by testing a different system involving pathologists 

and cytologists using digital slides, with a faster and reproducible 

program easier to manage than standard diagnostic sets and by 

distance for retraining of patrhologists with a final consensus 

meeting. 

The aim has been reached with the realization of a management 

system for cytological and histological whole-slides digital images 

and related clinical data and the building of a picture archive 

and communication system (PACS) among pathologists of our 

(and probably other) region. This must be backed by software 

for the realization of network slide seminars to perform periodic 

diagnostic reproducibility and proficiency test. The cases, col-

294 

lected and properly catalogued in an online, easily accessible and 

systemic digital archive of slides, with diagnoses discussed in 

clinical and pathologic audit meetings and validated by experts, 

can be used as diagnostic reference tools (case registry online). 

The cataloguing and indexing is performed with NAP codes 

derived from SNOMED 6 , which contains terms and definitions 

in Italian and English and encompasses extensive synonyms and 

complex researches. 

Material and methods. The cancer screening group of the Emilia-Romagna 

Region (Italy) set up a picture, archive and communication 

system (PACS) devoted to pathologists for cooperative 

diagnosis, teaching and training, teleconsulting, documentation 

of rare cases and pilot experiences; furthermore selected cases 

are catalogued in the PACS with the aim to check the diagnostic 

concordance in regional oncologic screening (cervix, breast and 

colon). The PACS system is made by two Aperio scanner and an 

adequate internet server where the described programs performe 

(see Fig. 1) 7 . 

The slides have been digitalized using an Aperio scanner, 20x for 

histology and 40x for cytology and an internet server was used 

to store the files, arranged into a Spectrum database (Aperio). An 

e-learning platform (Docebo) 8 has been used to built interface 

for the applicants: cases and slides were considered “teaching 

instruments” for the educational software (slide seminars) and appropriate 

questioning forms have been designed with the diagnostic 

occurrences of Bethesda System 2011 for cytology and CIN 

options for histology for the cervical cancer and of International 

guidelines for breast and colorectal cancer. 

Nowadays the diagnostic reproducibility has been performed in 

colorectal and cervical cancer screening (Bologna October 2010, 

Bologna June 2011), and for breast cancer is ongoing (Bologna 

June 2012). In all three slide seminars a number of cases have 

been selected by a committee of pathologists working in regional 

anatomo-pathologic units. 

Colorectal cancer screening was the first retraining slide seminar 

for pathologists performed with these features in our region and 

probably in Italy. 

Three regional units (Bologna, Cesena and Ferrara) were involved 

by sending representative histological cases of all main 

diagnostic occurrences to test the diagnostic reproducibility; 28 

histological cases were collected. A definite and limited time interval 

was indicated to study slides, then a consensus conference 

was organized in the same day. 

the second Seminar of QA to test the diagnostic reproducibility 

was performed in cervical cancer screening program; 30 cytological 

and 30 histological cases have been selected by a committee 

of pathologists among the cases proposed by the regional units. 

All main diagnostic occurrences were represented, basic clinical 

information and relevant follow-up information were available; 

the cases have been completely anonymized. 

A 30 days interval was indicated to study the slides, then a 

consensus conference has been programmed at the end of the 

evaluation to present the results and discuss cases. Before the 

meeting each participant received a report with the gold standard 

diagnosis performed buy the committee and her/his diagnosis and 

concordance result. 

Results and discussion. 15 pathologists of regional units attended 

the colon-rectal QA and the diagnostic reproducibility 

have been evaluated matching their results with the final gold 

standard diagnosis reached during the consensus conference. The 

observed agreement was 69% and the overall performance of the 

participating pathologists was assessed with a statistical analysis 

using Cohen’s kappa: the average value was 0.64 (substantial). 

95 cytologists and 32 histopathologists have been involved 

in the cervical cancer screening QA. 

The diagnostic reproducibility has been evaluated using the final 

diagnosis reached in the consensus conference: in 2 out of 30 cytological 

cases the diagnosis was different from the diagnosis of 


the committee, while all histologic diagnoses were in agreement. 

The observed agreement was 73%. 

Conclusion. Whole digital slide is suitable for proficiency tests 

and the internet e-learning platform allows to share cases and to 

get the answers from participants, in a easier way than by of a set 

of conventional slides. 

The quality of whole slides is very good, approaching optical 

microscopic resolution. 

In a cytological environment the bias is to get a perfect focus 

in all parts of the slide; the wider area of slide to examine and 

the higher number of diagnostic classes may justify a worse 

agreement of the pathologists and a poorer performance (lower 

Cohen’s kappa) than histology. 

We have produced an integrated environment that includes many 

of the modern aspects of digital pathology that can be shared with 

the PACS system in many laboratories of the region, including 

quality promotion and control of image interpretation in cytology 

and histology applied to cancer screening. 

references 

1 Demichelis F, Della Mea V, Forti S, et al. Digital storage of glass 

slides for quality assurance in histopathology and cytopathology. J 

Telemed Telecare 2002;8:138-42. 

2 Wilbur DC, Madi K, Colvin RB, et al. Whole-slide imaging digital 

pathology as a platform for teleconsultation: a pilot study using paired 

subspecialist correlations. Arch Pathol Lab Med 2009;133:1949-53. 

3 Huisman A, Looijen A, van den Brink SM, et al. Creation of a fully 

digital pathology slide archive by high-volume tissue slide scanning. 

Hum Pathol 2010;41:751-7. 

4 Saysell E, Routley C. Telemedicine in community-based palliative 

care: evaluation of a videolink teleconference project. Int J Palliat 

Nurs 2003;9:489-95. 

5 Weinstein RS, Graham AR, Richter LC, et al. Overview of telepathology, 

virtual microscopy, and whole slide imaging: prospects for the 

future. Hum Pathol 2009;40:1057-69. 

6 College of American Pathologists. SNOMED - Systematized Nomenclature 

of Medicine, ed 2. Skokie, Ill.,USA: College of American 

Pathologists 1979. 

7 Bondi A, Pierotti P, Crucitti P, et al. The virtual slide in the promotion 

of cytologic and hystologic quality in oncologic screenings. Ann Ist 

Super Sanita 2010;46:144-50. 

8 Docebo: e-learning open source platform. www.docebo.org. 

nAP: a unifiing diagnosis coding system 

for anatomic pathology 

A. Bondi, P. Crucitti, S. Lega 

Anatomia Patologica Ospedale Maggiore, Azienda USL di Bologna, Italia 

Background. Organization in a systematic way pass through the 

classification for all scientific information. In medical field, the 

broad diagnosis terminology has produced the SNOMED code, 

the most comprehensive, multilingual clinical terminology in the 

world. A subset called “Micro glossary for Pathology” has also 

been translated into Italian language 1 . SNOMED CT (Clinical 

Terminology) is the last version of the Nomenclature: it has an 

international copyright registered by the International Health Terminology 

Standards Development Organisation (IHTSDO), an 

international not-for-profit organization, based in Denmark 2 and 

in someway related to WHO. A formal and economic agreement 

is needed between IHTSDO and the local Government be allowed 

to use the code in a Country. 

Adverse events during the distribution in Italy of the first translated 

version of SNOMED and the lack of an agreement with 

the copyright holder caused a consequent autonomous development 

of “self-made” codes, often completely different from the 

international version. Due to “codes heterogeneity” exchanges 

of data among Pathologists and with Institutional and epidemiologic 

entities, i.e. Tumour Registries and official epidemiological 

archives are difficult. From these assumptions, a study group 

promoted by SIAPEC-IAP has obtained the coding tables in use


in the leading Institutions of Anatomic Pathology in Italy and in 

the most diffuse Laboratory Information Systems (LIS) to plan 

a strategy to converge in a national coding system. This operation 

should also re-direct Italian Pathology to the international 

scenario, favouring and coordinating cultural and scientific collaborations 

between the Associations involved in medical informatics, 

epidemiology and tumour registry. Actors of this project 

are Scientific Societies of the field (SIAPEC-IAP and AIRTum), 

the Italian Contributor Centre of WHO for Health Codes (CC- 

WHO) and few Regional Health Agencies (Friuli-Venezia Giulia, 

Liguria and the cooperation of Emilia-Romagna and Lombardia). 

Aim of the Nomenclature for Anatomic Pathology (NAP) is to 

become the national reference, for improvements and updating, 

shared by the Pathologists’ community. 

Material and Methods. A common nomenclature for Italian Pathologies 

has been built on the existing ones. This tool, namely 

the Nomenclature of Pathology Italian (NAP), was designed with 

the following characteristics: 

Identification of a work group, constituted by Pathologists from 

different Italian Anatomic Pathology, an operator editing different 

tables (see below), sometimes in collaboration with other 

centre; a group coordinator; 

ICD-O 3 acquisition to create the core of NAP 3 ; 

The tables in use in major Italian Institutions were compared with 

ICD-O 3 and fused together: similar conceptual meaning of the 

words with different codes have been unified; 

As fare-nomenclature for procedure has been adopted that from 

SIAPEC-IAP of 2002 and published on website of the Society; 

The system to represent the results of laboratory methods, especially 

those of molecular biology, has been derived from LOINC 

- Logical Observation Identifiers Names and Codes, the largest 

and most popular system for Clinical Pathology; 

Where possible, a logical connection with SNOMED International 

and, indirectly, with SNOMED CT was maintained; 

Synonyms, obsolete terms and acronyms that have emerged from 

the tables obtained to arrange the NAP are all managed. 

NAP code. NAP is a multi-axes coding system, namely a complex 

medical concept is broken into many simple concepts represented 

by codes. This criterion is the same established for SNOP 

and afterwards in SNOMED until the International NAP concepts 

are organized in chapters or knowledge axes: Topography, Morphology, 

Procedures, Diseases, Links, Chemicals, Physicals, Living 

Organisms and other less important. 

Each concept belongs to a Chapter (to whom is hierarchical 

related by a connector, called SUPER) and is represented by a 

CODE and a DESCRIPTION. 

The code is composed of 10 alphanumerical characters, the 

first of which is a letter representing the chapter, followed by 

a hyphen. Central digits of code are derived from ICD-O or 

SNOMED, while the last digit of each code, the more on the right, 

is reserved to synonyms and acronyms: if 0 (zero) indicates the 

main term, in any other case represents a synonymous. 

The description consists in a scope describing the concept in Italian 

and in English languages. 

NAP and others nomenclatures 

ICD-O. ICD-O 3 represents the core of NAP. In facts NAP code 

is constituted by 10 digit and morphology chapters “M-8” e “M- 

9” exactly include ICD-O codes. 

NAP Code for cancer: M-8000300B - ICD-O Code for cancer: 

M-8000/3 

The letter at the beginning, hyphen (optional in ICD-O), and 

initial 4 numbers are identical to ICD-O, last three digit of NAP 

code allows to manage synonyms and acronyms, that are not essential 

for Tumour Registries, but may be very useful for medical 

(and pathological) records. 

For topographic codes have been adopted criteria followed in 

SNOMED International and were added link to ICD-O topography, 

too broad for applications in Anatomic Pathology. 

295 

SNOMED CT. Structure of NAP code is clearly inspired by 

SNOP and to first version of SNOMED, but absolutely missing 

the systematic of these two nomenclatures. 

Semantic organization of SNOMED CT is markedly different 

through the elaboration of knowledge engineering gradually 

more elaborate (4): code is no longer “speaking” but a unique 

16 digit code, unmanageable in a direct coding (manual). Each 

concept identified by unique code, can be expressed by more 

terms, one of them “preferred”. A strict system of reference and 

attribute manages relations between terms and allows inference, 

logical and semantic links. 

SNOMED CT is the more widespread multilingual medical vocabulary 

ever realized, but information system of Italian Pathology 

are still bound to second version of SNOMED or in some 

case to SNOMED International, but none apply the version “References 

Terminology” (RT) nor “Clinical Terms” (CT). 

In this view NAP has also the role of a bridge to unify Italian 

codes into SNOMED CT and ICD 11, where presumably it will 

converge. 

LOINC. The system, utilized for Clinical Pathology Laboratory 

and for quantification of exams, can easily be applied to molecular 

biology to. However in Pathologic Anatomy, even if there are 

study to map or link parts of SNOMED to LOINC 5 , these two 

coding systems are not exclusive, namely the use of one of them 

is not sufficient. 

Release of NAP versions. First target of NAP is to maintain 

aligned the different versions produced after addiction or modification 

of codes resulting from comparison with new tables: 

presumably a four or six-monthly updating. 

Results and discussion. Advantages of NAP. The availability 

of a unified nomenclature, realized and diffuse from the Italian 

Scientific Society of Anatomic Pathology represents the basis to 

cancel differences between diagnostic nomenclatures of Italian 

Pathologists and to recognize the value of the big work in terms 

of coding produced every day from Pathologies in our country. 

The outcome in terms of data entirety, information sharing in 

medical records (local or network), case studies, epidemiology 

analysis, relation with Tumour and Pathology Registries has a big 

potential scientific and practice, to improve the role of Pathology. 

Limits of NAP. The NAP is a local vocabulary to drive Italian 

Pathologies to SNOMED and more generally to ICD 11, that will 

be available in 2015. 

NAP has been built from the fusion of many tables validated from 

many years use in important Institutions, but without systematic 

in many fields of medical science, or in other words doesn’t cover 

the huge vocabulary of systematic nomenclature drawn by Roger 

Coté into SNOP and later into SNOMED 6 . 

NAP needs in fact periodic maintenance of terms and a scientific 

committee to validate new terms, corrections and to drive relations 

with international catalogues, first of all WHO, to coherently 

direct evolution. 

references 

1 Bondi A, Nesti P, Rossi Mori A. SNOMED International. Microglossario 

di patologia (Lingua italiana), ed 1. Udine:, Pubblicazioni 

Medico Scientifiche 1995. 

2 International Health Terminology Standards Development Organisation 

(IHTSDO). http://www.ihtsdo.org/. 

3 Giacomin A, Ferretti S. ICD-O Classificazione Internazionale delle 

Malattie per l’Oncologia. Terza Edizione. Traduzione Italiana di 

“International Diseases Classification for Oncology” (C) WHO 2000. 

Milano: Inferenze Scarl 2005. 

4 Lee D, Cornet R, Lau F. Implications of SNOMED CT versioning. Int 

J Med Inform 2011;80:442-53. 

5 Bodenreider O. Issues in mapping LOINC laboratory tests to SNOMED 

CT. AMIA Annu Symp Proc 2008;51-5. 

6 Cote’ RA. The SNOP-SNOMED concept: evolution towards a common 

medical nomenclature and classification. Pathologist 1977;31:383-98.

296 

Histologic quality control of frozen samples using 

matching FFPE tissue – preliminary results of our 

institutional biobank 

E. Mattioli1 , E. Foglia Manzillo1 , V. Rubini1 , F. Palma2 , A. Paradiso3 

1 2 

, G. Simone 

1 2 Institutional BioBank at Anatomic Pathology Unit; Anatomic Pathology 

Unit; 3 Scientific Management National Cancer Research Centre, Istituto 

Tumori “Giovanni Paolo II” 

Background. Biobanking is an emerging discipline which is becoming 

more and more important in the contemporary research 

scenario, as it is aimed at providing high quality samples (particularly 

frozen ones) for biomolecular investigation. Integral part of 

biobanking operations are tissue quality control (QC) procedures, 

which verify and assure the adequacy of the collected samples 

for research purposes 1-4 . Pathologists are particularly involved 

in histological QC, which verifies that the banked samples are 

representative of the whole lesion and are suitable for research 

purposes, according to their pathological attributes. At our 

Institution, we perform histological QC procedures by evaluating 

critical immuno-morphological features (tumor cellularity, 

amount of necrosis, inflammatory infiltrate, fibrosis and nonneoplastic 

tissue components, proliferative index) not only on 

the frozen biobank samples, but also on matching formalin-fixed, 

paraffin-embedded (FFPE) material, which is easier to handle 

and provides better morphological detail. Aim of this study was 

to verify the concordance of those features on sections from the 

frozen aliquots and from the corresponding paraffin tissue blocks. 

Materials and methods. At our Pathology Department, as a 

routine procedure, each biobank-dedicated tissue sample is cut in 

two “mirror-matching halves”: one half is reduced into aliquotes, 

which are weighed and frozen; the other half is sent to routine histological 

processing to prepare a “specular” FFPE tissue block. 15 

consecutive breast cancer cases from our Institutional Biobank were 

considered for this study. For each case, multiple sections were cut 

from one frozen aliquot and from the specular FFPE block; critical 

parameters (percentage of tumor cells, MIB-1 proliferative index) 

were then evaluated on both frozen and paraffin sections. 

Results. The comparison of frozen aliquots with specular FFPE 

tissue showed a variable degree of discrepancy, due to the intrinsic 

heterogeneity of tumor tissue (Fig. 1). Predictably, the 

fraction of concordant cases significantly varied according to the 

stringency of the discrepancy threshold chosen (Tab. I). As for 

the percentage of neoplastic cells, 60% of cases (9/15) showed 

concordant values between frozen and paraffin sections when a 

10% deviation was allowed; raising the allowed deviation to 20% 

Fig. 1. heterogeneous miB-1 labeling in one of our breast cancer 

cases. 


Tab. I. figures of tumor cellularity and miB-1 labeling of each couple 

of samples (frozen and ffpE) are shown on the left side. Concordance 

percentages for different discrepancy thresholds are shown on the right 

side. Colors highlight different discrepancy thresholds. 

Case ID Tumor 

cellularity 

MIB-1 labeling 

142/12 frozen 50% 10% 

142/12 ffpE 50% 13% 

139/12 frozen 35% 17% 

139/12 ffpE 35% 25% 

135/12 frozen 20% 2% 

135/12 ffpE 20% 3% 

100/12 frozen 20% 60% 

100/12 ffpE 25% 40% 

133/12 frozen 60% 90% 

133/12 ffpE 70% 85% 

99/12 frozen 65% 50% 

99/12 ffpE 75% 38% 

87/12 frozen 85% 28% 

87/12 ffpE 80% 15% 

92/12 frozen 60% 7% 

92/12 ffpE 70% 17% 

95/12 frozen 70% 15% 

95/12 ffpE 70% 10% 

105/12 frozen 55% 35% 

105/12 ffpE 70% 18% 

144/12 frozen 50% 10% 

144/12 ffpE 70% 15% 

97/12 frozen 60% 12% 

97/12 ffpE 40% 7% 

132/12 frozen 38% 5% 

132/12 ffpE 75% 15% 

145/12 frozen 30% 20% 

145/12 ffpE 55% 20% 

94/12 frozen 40% 50% 

94/12 ffpE 80% 40% 

Concordance rates 

tumor cellularity 

- with a 10% discrepancy 60% (9/15) 

- with a 15% discrepancy 66,7% (10/15) 

- with a 20% discrepancy 

miB-1 labeling index 

80% (12/15) 

- with a 5% discrepancy 40% (6/15) 



brought the concordance fraction up to 80% (12/15). As for the 

proliferative index, only 40% of cases (6/15) showed concordant 

results when allowing a strict 5% discrepancy between frozen 

aliquots and specular FFPE tissue, while concordance raised to 

86.7% (13/15 cases) when tolerating a 15% deviation.


Conclusions. Specular FFPE blocks, which are easy to store and 

to cut into sections and offer optimal morphological detail, can 

provide plenty of useful information about the corresponding 

frozen samples and can therefore be used for biobanking QC 

procedures. However, because of the intrinsic heterogeneity possessed 

by neoplastic lesions, specular blocks may not accurately 

represent the tissue composition and the biological attributes 

of each single frozen aliquot. On the other hand, for the same 

reason a single frozen aliquot may not be fully representative of 

the whole lesion, as evaluated on specular FFPE blocks. All this 

must be taken into account when planning and performing frozen 

sample QC procedures involving the use of matching FFPE material. 

Particular care must be exercised in choosing the discrepancy 

thresholds, as they can greatly affect the outcome of the process. 

references 

1 Botti G, et al. Sample conservation: freezing, fixation and quality 

control. Pathologica 2008. 

2 Mager SR, et al. Standard operating procedure for the collection of 

fresh frozen tissue samples. Eur J Cancer 2007. 

3 Morente MM, et al. TuBaFrost 2: Standardising tissue collection and 

quality control procedures for a European virtual frozen tissue bank 

network. Eur J Cancer 2006. 

4 ISBER. Best Practices for Repositories – Collection, Storage, Retrieval 

and Distribution of Biological Materials for Research. Cell Preserv 

Tech 2008. 

FnA: who must perform this procedure? 

S. Negri, L. Gaetti, G. Calabrese, G. Granchelli, R. Fante, D. Azzolini 

* , A. Bellomi 

Azienda Ospedaliera C. Poma, Mantova, Servizio di Anatomia Patologica, 

* Servizio di Diagnostica per immagini 

Preface. The Pathologic Anatomy Unit at Mantova Hospital has 

been equipped with a FNA laboratory since 1984. 

At first, this Unit dealt with palpable nodules only, and then with 

instrumentally-detected lesions in close collaboration with radi 

ologists. 

The diagnostic quality of our work enabled us to treat 2000 cases 

per year by 1990 and this figure has gone up to 3000 since 2000, 

with an ever increasing number of FNA on echographic guidance. 

The reliability of this diagnostic procedure has led to a very high 

number of requests for instrumentally-guided exams also in relation 

to other organs, both deep and superficial. 

This increase, not supported by an adequate number of pathologists, 

often compels other professional figures such echographists 

or clinicians to perform the exam. 

The high number of requests and the decision of the Head of the 

Radiology Unit no longer to perform FNA in collaboration with 

pathologists, have caused pathologists to provide themselves 

with the necessary equipment and staff (surgery, echograph and 

nurse) in order to be able to perform this exam without help from 

a radiologist. 

Materials and methods. After an adequate training period in 

which a radiologist instructed a pathologist in the use of the 

ecograph, this technique was employed simultaneously by two 

pathologists, one detecting the lesion, and the other positioning 

the needle and collecting the specimen. 

Once the training period of the 5 pathologists forming the team 

was over, we moved to the last stage in which a single pathologist 

used the ecograph with one hand, while he used the other to 

position the needle and collect the specimen. No FNA have been 

carried out without a preceding radiologic diagnosis or adequate 

imaging. 

Results. In the period of five years (from 2007 to 2011) in which 

the procedure described above was employed, 3399 FNA were 

performed, of which 1985 on the thyroid, 567 on the breast, 61 

on the salivary glands, 299 on lymph nodes and 487 on nodules 

detected at various locations (see tab- I). 

297 

The percentage of inadequates depends on the location of the 

nodule to be examined and varies from 7.3% in the case of nodules 

detected at various locations, to 2,2% for mammary ones, 

with an average value of 4.53 % (see table 2). 

The values of sensitivity and specificity VPP and VPN will be 

considered later on. 

The methods and results of FNA performed by pathologists will 

be compared with those of FNA carried out by radiologists and 

with those reported in the literature. 

Discussion. FNA on echographic guidance is the most widespread 

procedure in the field of oncological diagnostics. However, 

its nationwide use is hampered by the lack of professional figures 

to be entrusted with the preparation of the material. What’s 

more, the need to integrate the professional skills of the cytologist 

with those of the radiologist is hindered by the fact that these two 

figures work in two different departments. 

The lack of collaboration between pathologists and radiologists 

may lead to poor results, which makes it necessary to use more 

expensive and invasive methodologies with an increase in discomfort 

for patients. 

The Pathologist and radiologist must collaborate blending their 

professional skills with the purpose of providing patients with a 

quick, reliable diagnosis essential for effective treatment. 

“Siapec” and its own Cytology committee should address the 

issue of FNA with proposals, based on their competence, to organise 

training courses which must find new ways of enhancing 

effective interaction between radiologists and cytopathologists. 

In 2011 with the help of the “ Servizio di Sviluppo Organizzativo 

e Formazione Aziendale” we organized two editions of a training 

course called “Instrumentally-guided FNA. From theory to 

practice”. 

The aim of the project was to uniform and optimize the instructions 

and methodology of FNA on echographic guidance in dealing 

with both palpable and non palpable lesions. 

The expected changes were:

298 

- improvement in the quality of FNA on echographic guidance; 

- improvement in the quality of diagnosis; 

- reduced discomfort for Patients. 

The aim of the training course was: 

to provide extensive knowledge of: 

- echographic diagnostics 

- cytologic diagnostics 

- FNA procedures for cytologic diagnostics 

to provide technical abilities in the management of FNA on echographic 

guidance. 

The lecturers were radiologists with regard to echographic diagnostics, 

and pathologists as far as cytologic diagnostics and FNA 

procedures were concerned. The course will be repeated in 2013 

with another two editions. 

The preliminary data that we collected from 2007 to 2011 allow 

us to conclude that a properly trained pathologist is perfectly 

capable of performing FNA on ecographic guidance without help 

from a radiologist. 

Hepatocellular carcinoma with fatty change 

insurgent on hepatocellular adenona in noncirrhotic 

liver: report of a case 

E. Projetto, V. Terrinazzi, F. Castiglione, C. Comin, L. Messerini 

Università di Firenze Dipartimento di Area Critica Medico-Chirurgica, 


Hepatocellular carcinoma (HCC) is one of the more common malignancy 

in the world. HCC is strongly associated with Hepatitis 

B infection and liver cirrhosis. We report a case of a 33-year-old 

woman who developed an hepatocellular carcinoma without liver 

cirrhosis but in association with a marked liver steatosis. 

The patient underwent hepatic resection of the fifth and sixth 

segment. Macroscopically the resected liver parenchyma appeared 

almost entirely replaced by yellowish multinodular lesions 

together with diffuse hemorrhagic-necrotic areas. Histologically, 

the nodules were composed of atypical hepatocytes; the architectural 

pattern was trabecular and acinar.The reticulinstain showed 

that the reticular trama was interrupted in several areas, suggesting 

the diagnosis of HCC. The histopathological diagnosis of 

HCC was also supported by immunohistochemistry (CD34, HSA, 

CD10, pCEA). Interestingly, most of the neoplastic cells showed 

a marked steatosis. The histologic pattern was consistent with the 

final diagnosis of hepatocellular carcinoma with fatty change. 

Diagnostic use of tissue microarray technology: 

how, when 

D. Pilla, F. Bosisio, G. Cattoretti 

AO San Gerardo e Universitá di Milano-Bicocca, 20900 Monza (MB) 

Fifteen years and threethousand more publications after the first 

(Kononen J, et al. Nat Med 1998;4:844-7), Tissue Microarray 

technology (TMA) is used largely if not only for research, to produce 

high throughput data from formalin fixed, paraffin embedded 

(FFPE) samples. The publications dealing with the diagnostic 

use of the TMA may be counted on one hand. This may be due 

to several factors: few centers have a daily volume of cases amenable 

to TMA use (breast, colon, lung) high enough to justify the 

setup and the turnaround time (TAT) required for diagnosis. In 

addition, pathologist, whose daily routine implies sampling, are 

wary of underrepresentation of the lesion due to limited sampling 

because of heterogeneity in the tissue. Lastly, and in addition 

to what has been stated before, because the TMA technology is 

perceived as a research tool, able to provide prognostic rather 

than diagnostic results, thus not useful for the day-to-day routine. 

The throughput that can be afforded with the TMA allows the 

gathering of data whose analysis is not affected by tissue heterogeneity 

or individual sampling errors (Nocito A, et al. J Pathol 


2001;194:34-57; Camp RL, et al. J Clin Oncol 2008;26:5630-7). 

Key to diagnosis in Pathology is the control of errors in identifying 

patients and samples. This issue has not been raised so far 

when using the TMA technology. This is surprising, because 

the same rule applies to research and industrial procedures. We 

addressed and solved this issue, opening the use of the TMA 

technology to its use for diagnosis. 

We introduced the use of a Code128 1D barcode on slide labels, 

TMA blocks and TMA slides. The barcode on routine slides contains 

the unique slide ID. We fetched from the LIS via a barcode 

reader and a small query created by our LIS vendor five fields: 

slide ID (the leading item to track the case), accession number, 

specimen and block, patient’s unique ID and date of accession. 

The slides selected and marked by the pathologists are scanned 

and a resulting small database file is inserted directly into the 

donor block window of the Galileo (ISEnet srl) TMA arrayer 

program. Next, the acceptor block ID, barcoded in advance on 

the recipient virgin block, is scanned into the program. The array 

construction must fulfill the following standards: 

- intrinsically asymmetric design, with a design which can guarantee 

asymmetry even upon loss of a single spot or a row. 

- no sectors, randomly placed patient’s samples if replicated 

samples are required. 

- barcode ID-recognition driven verification of each donor block 

before coring. 

All these features are available with several TMA instruments, 

including the Galileo CK4500 (ISEnet srl). 

The TMA design and the associated data are exported from Galileo 

as an xml file, which is fed to an Aperio Spectrum database 

(Aperio, USA). Sections cut from the TMA and stained in single, 

double or multiple immunohistochemistry or immunofluorescence 

are labeled with the TMA ID, barcoded, and scanned on 

an Aperio Scanscope CS or FL scanner, enabled for barcode 

recognition. 

The match between individual whole slide images (WSI) and the 

corresponding TMA design is made via an automated recognition 

of the ID on the design and the slide, provided with an ad-hoc 

software patch developed by Nikon Italia and Aperio. 

Once the correct design and the associated data are linked to the 

TMA WSI, the process of segmentation is started by superimposing 

a design grid on the correctly oriented WSI. To fulfill the 

identification of each sample, the grid must be a lattice of circles 

connected by fixed linear segments, to be adjusted to the WSI of 

the slide. The software then generates individual images for each 

patient, with an analytical error estimated around 1 every 85.000 

reads (Snyder ML, et al. Clin Chem 2010;56:1554-60). This error 

rate is lower than the pre-analytical error of the system. Patient’s 

images are reached from the LIS by the use of any of the unique 

ID built in the system, and a diagnosis can be rendered. 

The diagnostic use of TMA technology opens up new fields 

for pathologists, both because of the cost-saving and tissuesparing 

ability of the technology and because of the intrinsic high 

throughput power. 

One field is screening each and every colon, ovary and endometrial 

cancer for mutation mismatch repair (MMR) protein loss, in 

order to identify patients with a genetic rather than somatic cause 

for the loss (Funkhouser WK, et al. J Mol Diagn 2012;14:91- 

103). Together with the analysis for BRAF mutations, this approach 

is able to identify > 90% of the cancer prone families in 

the area served by the Pathology Department. 

A second field is the identification of rare (< 5%) patients with 

a cancer phenotype amenable to personalized therapy. Five % of 

colon cancers express Her2 (Nathanson, DR. et al. Int J Cancer 

105, 796–802, 2003) or have ALK genomic amplification (Lipson 

D, et al. Nat Med 2012;18:382-4), yet it is economically unpractical 

to stain each and every colon cancer for these phenotypes. 

A third emerging field is tracking tumor heterogeneity; staining 

whole sections from multiple blocks of large tumors (e.g.


kidney) is unpractical. However, several cases may be sampled 

and stained if multiple cores are allocated in a diagnostic TMA. 

We wish to thank Roberto Marotta (Noemalife), Stefano Faggi, 

Emanuele Martella (Nikon Italia and Aperio), Paolo Forlani, 

Maurizio Falavigna, Pasquale DeBlasio (ISEnet), Simone Borghesi 

(UNIMIB) for great collaboration with this project. Maria 

Cristina Argentieri e Angelita Ferri contributed to the project. 

The Tissue Microarrayer and the Aperio Scanscope FL were 

provided through a grant from the Regione Lombardia (Call for 

Independent Research, DDG 6716 del 1/7/2009). 

Blastomycosis-like pyoderma: a case report 

of a rare entity 

G. Crisman1 , A. D’Amuri2 , F. Floccari 2 , E. Villani2 , C. Miracco3 , 

A.S. Senatore2 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 

dell’Aquila, L’Aquila, Italia; 2 U.O.C. Anatomia Patologica – P.O. Gallipoli 

– ASL Lecce, Lecce; 3 Anatomia Patologica, Dip. di Patologia Umana 

ed Oncologia, Università di Siena 

Background. First described in 1898 by Hallopeau under the 

term of “pyodermite végétante”, and subsequently redefined as 

“pseudo-epitheliomatous cutane” by Azua and Pons, Blastomycosis-like 

pyoderma (BLP), or pyoderma vegetans, is a rare vegetating 

inflammatory tissue reaction due to a bacterial infection 

(commonly due to Pseudomonas aurigenosa, Proteus mirabilis, 

E. coli, Candida albicans, Staphylococcus aureus, β-hemolytic 

streptococci) generally occurring in patients with reduced immunological 

resistance status. 

Matherial and methods. We report on a case of a 63-year-old 

man presented with one-year history of a dorsal, ulcerated, vegetating, 

reddish nodule with multiple pustules, of 3cm in-diameter. 

Anamnestic data revealed a prostatectomy for an adenocarcinoma 

one year before. 

Results. The lesion has been surgically excised and the histological 

features revealed a marked pseudoepitheliomatous 

hyperplasia with a mixed inflammatory infiltrate composed by 

lymphocytes, plasmacells, neutrophils and eosinophils spreading 

in the superficial and deep dermis. Multiple abscesses and foci of 

necrosis were observed as well. Microbiological stains (Periodic 

acid-Schiff, Gram, Grocott) gave negative results. Immunohistochemical 

stains revealed a positivity of the inflammatory cells for 

CD68, CD20 and CD3. The patient showed a moderate response 

to antibiotics and anti-inflammatory agents. The differential diagnosis 

should include cutaneous metastasis, giant keratoacanthoma, 

squamous cell carcinoma, deep fungal infection (especially, 

North American blastomycosis) and mycobacterial infection. 

Conclusions. Since BLP is a rare condition, an accurate anam- 

Fig. 1. clinical presentation 

of the lesion. 

Fig. 2. Histological features: pseudoepitheliomatous hyperplasia with 

a mixed inflammatory infiltrate (H&E, 4x magnification). 

299 

Fig. 3. mixed inflammatory infiltrate and congestion f the superficial 

plexes of capillaries and vennles of the skin. (H&E, 20x magnification). 

nestic analysis can provide critical information to achieve a correct 

diagnosis. There is no standard treatment and in some cases, 

antibiotics were ineffective despite bacteria were isolated. Some 

authors reported usefulness of a acitretin therapy. 

references 

1 Bianchi L, Carrozzo AM, Orlandi A, et al. Pyoderma vegetans and 

ulcerative colitis. Br J Dermatol 2001;144:1224-7. 

2 Su WP, Duncan SC, Perry HO. Blastomycosis like pyoderma. Arch 

Dermatol 1979;115:170-3. 

3 Trygg KJ, Madison KC. Blastomycosis like pyoderma caused by Pseudomonas 

aeruginosa: Report of a case responsive to ciprofloxacin. J 

Am Acad Dermatol 1990;23:750-2. 

4 Singh M, Kumar B, Kaur S, et al. Blastomycosis like pyoderma. Indian 

J Dermatol Venereol Leprol 1985;51:226-8. 

5 Brown CS, Kligman AM. Mycosis like pyoderma. Arch Dermatol 

1957;75:123-5. 

6 Nguyen RT, Beardmore GL. Blastomycosis-like pyoderma: Successful 

treatment with low-dose acitretin. Australas J Dermatol 

2005;46:97-100.

300 

Telepathology: an important tool in external quality 

assurance for cervical and breast cancer screening 

programmes 

R. Colombari1 , Veneto * cervical and ** breast cancer screening 

group, R. Mencarelli2 , A. Gasparetto3 , C. Cogo4 , A. Rizzo5 1 Anatomic Pathology, Fracastoro Hospital, ULSS 20, Verona, Italy; 

2 Clinical Pathology Department, Local Healthcare Authority, Rovigo, 

Italy; 3 Information Technology Department Local Healthcare Authority, 

Rovigo, Italy; 4 Cancer Registry Veneto Region, Italy; 5 Anatomic Pathology, 

S. James Hospital, ULSS 8, Castelfranco Veneto (Tv), Italy. 

* Veneto cervical cancer screening group: Romano Colombari and Enzo 

Bianchini, Laura Borghi, Loredana Bozzola, Concetta Chiarelli, Duilio 

Della Libera, Licia Laurino, Lorella Marchioro, Barbara Pertoldi, Antonella 

Pinarello, Paola Rossi. 

** Veneto breast cancer screening group: Antonio Rizzo and Enzo Bianchini, 

Laura Borghi, Roberta Boschetto, Giuseppe Briani, Andrea Caneva, 

Elisa Canova, Giovanni Capitanio, Duilio Della Libera, Stefania Dante, 

Orfeo Del Maschio, Roberto Di Pietro, PierPaola Gasparini, Licia Laurino, 

Genesio Leo, Gigliola Ludovichetti, Paolo Machin, Lorella Marchioro, 

Marcello Lo Mele, Enrico Orvieto, Salvatore Paolino, Ida Pavon, Antonella 

Pinarello, Quirino Piubello, Domenico Reale, Daniela Reghellin, 

Vittorio Rucco, Debora Tormen. 

Background. This study is about the application of telepathology 

in external quality assurance (EQA) for cervical and breast cancer 

screening programmes. 

Due to the fact that the EQA is a mandatory requirement for accreditation 

of laboratories providing screening services within 

Veneto, such practice has been applied to organized effective 

mass-screening programme for cervical and breast cancer since 

2008. The EQA experience with slide set circulation on a voluntary 

base by part of the Anatomic Pathology laboratories of this 

Region failed because of several complications in terms of time 

waste, risk of slide loss and/or break down, security of patients’ 

privacy and operators’ anonymity. 

The whole image acquisition technology of cytological and histological 

slides, has become available in the last few years, which 

permits pathologists to store digital images and to examine, thank 

to innovative software, on digital screen, virtual slides scanned 

in a far away laboratory. Moreover each participant can easily 

download from internet an open-source viewer. 

In 2008 a slide scanner (Aperio ScanScope-XT) was installed at 

Anatomic Pathology Laboratory in Rovigo, Italy. This technical 

tool, with the proper ICT (Information and Communication Technology) 

configurations and architecture, became available to the 

Anatomic Pathology Units in Veneto. 

Such technology is still in early application stage, so that we 

evaluate its potential use in EQA for cervical and breast cancer 

screening programmes. 

Material and methods. In 2008 the pathologists involved in 

Veneto mass-screening programme for cervical and breast cancer 

created a committee (one for cervical and one for breast cancer 

screening) entrusted with the task of organizing the EQA for each 

screening program in the region. 

From 2009 to 2011 a year topic has been chosen among those hot 

in the field of cytopathology and histopathology of cervical and 

breast cancer screening. 

Every year, in Veneto each laboratory participating in the project 

selected from routine files 1 to 3 cervical and breast cytologic and 

histologic samples. The selected samples were mailed to Clinical 

Pathology Department in Rovigo, where they have been anonymized 

and digitalized by using a ScanScope-XT. The images 

have been stored on a virtual slide repository available online for 

a web consultation. The personalized free access has been made 

available on website 1 . The experience with virtual slide technical 

tools was very different among the participant pathologists. 

No training, focused on virtual pathology, was given to the participant 

pathologists before the virtual slide-based EQA project 


started. Remote ICT support, when requested, was available to 

each participant. The project manager of each screening group 

collected the anonymized diagnoses. Each committee provided 

a gold standard diagnosis. The discordant cases have been proposed 

for plenary discussion in a year meeting, in the attempt to 

reach agreement among the participants. 

Results. Twenty-three public laboratories out of twenty-four 

active in Veneto joined the project. From 2009 to 2011, virtual 

slides have been created from 98 cervical smears and from the 

102 corresponding biopsies. Similarly, virtual slides have been 

created from 52 breast cancer samples, 48 breast needle core 

biopsies and 95 breast FNAC. On virtual cervical slides, a total 

of 1717 cytological diagnoses and 1719 histopathological diagnoses 

have been obtained; on virtual breast slides, a total of 1717 

cytological diagnoses and 1822 histopathological diagnoses have 

been obtained. 

In 2009 only 59% of the participant laboratories for cervical EQA 

and 80% for breast EQA could successfully evaluate the virtual 

slides. Most of the participants couldn’t download and install 

the viewer or complained the low performances during slides’ 

evaluation. 

In 2009 some non-sense incoherent diagnoses have been registered. 

In 2011 the virtual slides have been successfully evaluated by all 

participants. 

Discussion. EQA has become an integral part of mass-screening 

programme development in Italy. Ideally, the scheme should 

include slide set circulation, but several obstacles prevent the adequate 

diffusion of such practice. The EQA based on circulating 

slides is still practiced but in only a few “niche” applications 2 . 

For this reason, the use of digital slides would represent a helpful 

alternative for the EQA 3 4 . 

The major issues limiting the use of virtual slide-based EQA in 

the first years of our EQA project did not involve image acquisition 

or quality but rather the pathologist’s experience with virtual 

slide technical image management and several issues such as the 

pathologist’s interface and the hospital’s network. The need for 

standardization of technical elements of image has already been 

pointed out 5 6 . Moreover, very recently these technical standards 

in the contest of mass-screening programme have been established 

by a preeminent European committee 7 . 

Several challenges can be pointed for the next few years to allow 

the wide and easy application of virtual pathology in EQA: on 

one hand there is the need to focus on pathologist’s training with 

virtual slide technical tools; on the other hand, there is the need to 

improve the hospital’s network, to homogenize the security policies, 

to adequate the technical tools of each Anatomic Pathology 

Unit to the recently proposed standard 7 . 

These results are encouraging to purse this workgroup, able to 

involve the participants in screening programmes, with a very 

good cost/benefit ratio. 

Acknowledgements. The study was supported by a grant of 

Veneto Region. 

references 

1 Online telepathology service ULSS 18 Rovigo (https://servizi.azisanrovigo.it). 

2 Confortini M, Bondi A, Cariaggi MP, et al. Interlaboratory reproducibility 

of liquid-based equivocal cervical cytology within a randomized 

controlled trial frame work. Diagn Cytopathol 2007;35:541-4. 

3 Leong FJ, Graham AK, Schwarzmann P et al. Clinical trial of telepathology 

as an alternative modality in breast histopathology quality 

assurance. Telemed J 2000;6:373-7. 

4 Lee ES, Kim IS, Choi JS, et al. Accuracy and reproducibility of telecytology 

diagnosis of cervical smears: a tool for quality assurance 

programs. Am J Clin Pathol 2003;119:356-60. 

5 Yagi Y, Gilbertson JR. Digital imaging in pathology: the case for 

standardization. J Telemed Telecare 2005;11:109-16. 

6 Klaus K, Gortler J, Goldmann T, et al. Image standards in tissue-based 

diagnosis (diagnostic surgical pathology). Diagn Pathol 2008;3:17.


7 Ellis I. Quality Assurance Guidelines for Breast Pathology Services 

(second edition). Sheffield NHS Breast Cancer Screening Programme 

July 2011. ISBN 978-1-84463-072-1 (NHSBSP publication n° 02). 

Quality control by tissue microarray 

in immunohistochemistry 

S.A. Tripodi, B.J. Rocca, L. Hako, I. Monciatti, A. Carducci, 

R.M. Ambrosio 

Department of Human Pathology and Oncology, Pathological Anatomy 

Section, University of Siena, Italy 

Background. A growing number of immunohistochemical exams 

is routinely required in histopathology, especially in the field 

of hematopathology. In addition, there is a challenge to introduce 

better quality assurance in immunohistochemistry. An external 

positive control section is included in each immunohistochemical 

analysis as a well-recognized and validated technique for standardizing 

results. Unfortunately, this method is time-consuming 

and expensive, significantly contributing to laboratory costs. On 

the contrary, internal controls are warranted and inexpensive, 

however their use is only feasible in selected diagnoses (i.e. basal 

cells of normal prostatic glands as an internal control in high 

molecular weight cytokeratin expression analyses for prostatic 

cancer). Tissue microarray is a recent technique for the simultaneous 

analysis of hundreds of tissues for protein, DNA and 

RNA content. Recently, the tissue microarray technique has been 

proposed as a tool for internal quality controls in immunohistochemistry. 

This study presents a different strategy for introducing 

an “internal” control in immunohistochemical analyses. 

Materials and methods. A paraffin-embedded tonsil tissue 

cylinder was sampled from a donor block using an automated 

sampler and included as an ‘internal control’ together with a bone 

marrow biopsy in a recipient block, avoiding the use of external 

tonsil tissue control. To validate this technique, the authors compared 

the quality of immunohistochemistry, the workload and 

costs with routine external control in 50 consecutive bone marrow 

biopsies over a 10-day period. 

Results. In our method, only 8 seconds (7-minutes/50 biopsies) 

were spent by technicians for picking-up a tissue core from the 

donor tonsil block and adding it to the receiver block. In contrast, 

in the routine method, technicians spent 3 minutes sectioning an 

additional slide from the tonsil block with a total time of 180 minutes 

for 60 external positive controls that were spared. Then, 200 

additional minutes were needed to perform the immunoassay of 

60 external positive controls. Thus, our method allows us to spare 

a total of 373 minutes as well as all the reagents needed. In terms 

of costs, since 15 Euros are needed to produce an additional slide 

of tonsil tissue and 20 Euros are required for each immunohistochemical 

test, 2100 Euros were spared during the 10-day test. The 

volume of antibodies used for the analysis of each sample was 

301 

not increased and no other work was required. The workload of 

the pathologist who had to interpret the slides was also decreased 

because the control and the sample can be evaluated on the same 

slide (at one glance). In fact there was always a clear separation 

between the control tissue and the sample and the internal control 

tissue core did not affect the immunostaining of the bone marrow 

tissue. The quality of immunostain was good. 

Conclusions. Commercial microarrayers, which can make thinner 

tissue cores (from 0.6 to 2 mm) are increasingly common 

in many university and research facilities, although inexpensive 

disposable punch biopsies could also be employed. Thanks to our 

method the consumption of “donor” tissue was low and dozens of 

tissue cores were obtained from a single tonsillectomy specimen. 

All the control tissues had a valid number of lymphoid follicles. 

In future, the development of cell line tissue microarrays will 

provide standard and widely available control samples for immunohistochemical 

studies in many fields of pathology. In fact, 

although the tonsil tissue displays a large number of antigens, in 

specific cases it is essential to choose a more appropriate tissue 

as positive control. Using this method, control and sample tissues 

were processed at the same time, thus avoiding potential biases 

during the different steps of the analysis. Most of all, the need for 

an external positive control was avoided, reducing the costs and 

laboratory workload. Furthermore, having both the control and 

the sample on the same slide allowed immediate evaluation of the 

immunostain, thus reducing the time required by the pathologist. 

We successfully used this method of quality control in immunohistochemistry 

from 2003 to the present for 2750 bone marrow 

specimens, saving much money and improving quality. 

In conclusion, the method of including tonsillar core tissue as an 

“internal control” in bone marrow biopsies, improves quality control 

in immunohistochemical analysis and achieves the important 

aim of cutting laboratory costs. The method is applicable to many 

fields other than haematopathology. 

references 

1 Pires AR, Andreiuolo Fda M, de Souza SR. TMA for all: a new method 

for the construction of tissue microarrays without recipient paraffin 

block using custom-built needles. Diagn Pathol 2006;1:14. 

2 Sharma SK, Deka L, Gupta R, et al. Tissue microarray construction 

from gross specimens: development of a simple technique. J Clin 

Pathol 2010;63:782-785. 

3 Torlakovic EE, Naresh K, Kremer M, et al. Call for a European programme 

in external quality assurance for bone marrow immunohistochemistry; 

report of a European Bone Marrow Working Group pilot 

study. J Clin Pathol 2009;62:547-551. 

4 Vogel UF. Combining different techniques to construct paraffin tissue 

microarrays of superior quality. Histopathology 2009;54:624-626. 

5 Vogel UF, Bu¨ltmann B. Application of a novel and low cost technique 

to construct paraffin tissue microarrays out of paraffinised needle 

biopsy specimens from patients with breast cancer. J Clin Pathol 

2010;63:640-643.

302 

SISTEMA nErVOSO 

Brain metastases of advanced colorectal cancer: 

molecular profiling 

G. De Maglio1 , E. Masiero1 , G. Aprile2 , M. Casagrande2 , E.S. Lutrino2 

, F. Tuniz3 , F. Laura2 , C.A. Beltrami4 , M. Skrap3 , G. Fasola2 , 

S. Pizzolitto1 1 SOC Anatomia Patologica, Azienda Ospedaliero-Universitaria Santa 

Maria della Misericordia, Udine; 2 Department of Oncology, Azienda 

Ospedaliero-Universitaria Santa Maria della Misericordia, Udine: 3 Department 

of Neurosurgery, Azienda Ospedaliero-Universitaria Santa Maria 

della Misericordia, Udine; 4 Istituto di Anatomia Patologica, Azienda 

Ospedaliero-Universitaria Santa Maria della Misericordia, Udine 

Background. In the last decade, median survival for patients with 

metastatic colorectal cancer has progressively improved and currently 

exceeds 24 months. 

Although previous studies have reported that the incidence of 

brain metastases in those patients is uncommon, improved survival 

for patients with advanced disease makes the development 

of brain metastases a challenging event. It is unclear if postsurgical 

survival may different depending on the disease mutational 

status. 

Methods. We identified a cohort of 47 consecutive colorectal 

carcinoma patients who underwent resection of brain metastases 

in the period 2000-2011. 

Tissue specimens were retrieved, macrodissected, and tested by 

pyrosequencing with Anti-EGFR MoAb response® KRAS status, 

BRAF, PIK3CA, NRAS (Diatech Pharmacogenetics, Italy) 

kits accordingly to manufacturer’s instructions. KRAS has been 

tested for codons 12, 13, 61 and 146, BRAF for exon 15, PIK3CA 

for exons 9 and 20 and NRAS for codons 12, 13 and 61. 

Survival curves were calculated with Kaplan Maier method. 

Results. Median age at time of brain metastases resection was 

65 years (35-82). In brain metastases from colorectal cancer, any 

KRAS mutation was detected in 29 patients (61.7%): 20 (42.6%) 

on codon 12 (G12V, G12D, G12C, G12A, G12S, G12F), 6 

(12.8%) on codon 13 (G13D and G13C) and 3 (6.4%) on codon 

146 (A146V, A146P). Among patients with wild-type status for 

KRAS, 3 (6.4%) harbored V600E BRAF mutation. PIK3CA 

was mutated in 7 (14,9%) patients (5 on exon 9: E542K, E545K, 

E545G and Q546K, 2 on exon 20, H1047R); PIK3CA/KRAS 

mutations were concomitant in 6 cases (12.8%). No NRAS mutations 

were detected. All wild-type patients were 13 (27.7%). Median 

survival was similar between patients with all wild-type tumors 

and patients harboring any mutation in the EGFR-pathway. 

Conclusions. KRAS mutation rate (61.7%) in brain metastases 

was higher than expected in primary colorectal carcinoma. Somatic 

changes in the EGFR-KRAS pathway members were mutually 

exclusive except for PIK3CA and KRAS with no prevalence 

of any particular mutation. 

In our experience, colorectal carcinoma patients with prolonged 

survival have increased risk of developing brain metastases, and 

oncologist need to be aware of this event. 

Although the optimal management of brain lesions is uncertain 

for those patients, a tailored approach including neurosurgery, 

radiosurgery and/or radiotherapy may be helpful. 

Survival following resection does not seem to be influenced by 

tumor mutational status. 

references 

1 Aprile G, et al. Neurosurgical management and postoperative whole- 




brain radiotherapy for colorectal cancer patients with symptomatic 

brain metastases. J Cancer Res Clin Oncol 2009;135:451-7. 

2 Menis J, et al. Brain Metastases from Gastrointestinal Tumours: 

Tailoring the Approach to maximize the Outcome. Crit Rev Oncol 

Hematol 2012 [Epub ahead of print]. 

3 Noura S, et al. Brain Metastasis From Colorectal Cancer: Prognostic 

Factors and Survival. J Surg Oncol 2012 [Epub ahead of print]. 

Chordoid glioma revisited: 

report of a multi-institution study of 6 new cases 

S. Pizzolitto¹, J. Bruner², C.E. Bacchi³, G. De Maglio¹, G. Falconieri¹ 

¹ General Hospital, Pathology, Udine, ²MD Anderson CC, Houston 

Tex, ³Consultorio em Patologia, Botucatu, Brazil 

Background. Although recognized as a distinct histopathologic 

entity in the WHO classification, chordoid glioma (CG) remains 

a controversial lesion. Furthermore, although clinicopathologic 

features have been well illustrated in the literature, specific investigations 

based on patients’ series are limited in the literature. We 

report a series of 6 cases of CG obtained from a multi-institution 

study 

Material and Methods. Cases of CG with available clinical 

information and adequate tissue material were retrieved 

from the archival or consultation files. A standard panel of 

antibodies directed against cytokeratins, glial fibrillary acidic 

protein (GFAP), S100 protein, epithelial membrane antigen 

(EMA) had been applied in all cases. Additional antibodies 

against CD34, brachyury, neurofilaments, progesterone receptors 

were applied in selected cases submitted in consultation 

for a second opinion. In the latter cases, the initial proffered 

interpretation included chordoma, chordoid meningioma, craniopharyngioma, 

metastatic carcinoma, anaplastic glioma. The 

proliferative index was also assessed by means of the ki67/ 

MIB1 antibody. Histochemical stains included PAS and Alcian 

Blue at pH 2.5 

Results. Patients’age was relatively broad (39-70 years, median 

58). Females were 4, males 2. Major complaints included visual 

impairment and mental disturbances. The tumors were located 

within the third ventricle area, yet in one case the lesion was situated 

in the posterior body of the corpus callosum. Tissue sections 

featured epithelioid cells with lightly eosinophilic cytoplasm arranged 

in cords or nests enmeshed within a loose myxoid stroma. 

The tumor background also showed lymphoplasmacytic cells 

either scattered or in discrete nodular aggregates along to Russell 

bodies. The results of immunohistochemical stains were as follows 

(positive/tested cases): GFAP 6/6, S100 protein 2/4, EMA 

(1/4). The remainder antibodies were negative. A low ki67/MIB1 

proliferative fraction (< 5%) was observed. Treatment included 

radiation therapy in one patient. Follow up was available in 4 

cases: no patient died of tumor; 1 patient was alive with recurrent 

tumor 5 years after surgery 

Conclusions. Data from this study confirm that CG is a lowgrade 

tumor affecting usually women with a predilection for the 

third ventricle, however exceptions remarkably occur. Clinical 

course is difficult to predict on a microscopic basis only. In addition, 

the immunohistochemical profile of CG proves to be erratic 

although it appeared useful in reasonably excluding the most 

common microscopic mimickers.


A case of intravascular large b-cell lymphoma 

sharing western- and eastern type features 

A. Vanzati1 , F. Moltrasio1 , M.G. Valente2 , G. Cattoretti1 , 

G. Isimbaldi2 1 Deparment of Pathology, Department of Surgical Science, Unviersità di 

Milano-Bicocca, Milano, Italy and Azienda Ospedaliera San Gerardo, 

Monza, Italy; 2 Department of Pathology, Azienda Ospedaliera San Gerardo, 

Monza, Italy 

A 72 years-old woman complaining with paresthesia and hypomobility 

of legs, was admitted to our neurologic department 10 

days after an hysterectomy was performed in another institution. 

The initial remission, obtained after a multidrug treatment 

including steroids and antibiotics, was followed by the intermittent 

recurrence of the neurologic symptoms. Rapidly, pancytopenia 

and low platelet count was noticed, a macrophageactivation 

syndrome was suspected and a bone marrow biopsy 

showed increased cellularity with large amount of histiocytes 

but no image of hemophagocytosis. Subsequently the patient 

was admitted to the medical department where ciclosporin 

therapy was administrated with initial partial efficacy. Few days 

later renal and lung failure with pulmonary thromboembolism 

made the situation worse: a Guillan-Barrè syndrome rather than 

a chronic inflammatory demyelinating polyneuropathy was hypothesized. 

RMN was performed and showed medullary lesions 

in D11, D12, L1, L5, S1 and S2 in addition to two asymptomatic 

extracerebral masses located at the frontal and parietal lobe and 

referred as meningiomas. The woman died shortly afterwards 

and necropsy was performed. 

Macroscopically, the lungs were markedly congested, the heart 

was flaccid; there was splenomegaly and hepatic steatosis. No 

lymph nodes enlargement we re noted. CNS examination, comprehensive 

of the spinal cord, revealed no superficial changes. No 

cutaneous lesions were noted. 

Routine sampling were obtained from various organs, including 

lymph nodes, standard samples of the brain regions (white and 

grey matter), brainstem and spinal cord comprehensive of the 

roots of the cranial and spinal nerves. 

Microscopically, in almost all organs we noted small capillary 

vessels, mainly arterioles, filled by large cells. The cells had 

very scant cytoplasm, irregular nuclei with open chromatin and 

prominent nucleoli. Their lymphoid nature was confirmed by 

immunohistochemical reactivity for CD79a and CD20. CD3 was 

negative. The microscopic examination of lungs, pancreas, kidney, 

adrenal glands, heart, ovaries, liver, spleen, spinal cord and 

brain revealed the presence of intravascular proliferation of these 

cells. In the lungs, the intraluminal packed cells caused multiple 

acute subpleural infarcts so a diagnosis of multiorgan failure in 

intravascular large B-cell lymphoma (IVL) was rendered. 

Particularly, the examination of CNS slides demonstrated both 

intraparenchymal and meningeal localizations and the roots of the 

spinal nerves presented multiple intravascular deposits of the disease 

in the vascular system of the schwannian sheats. Bone marrow 

was not involved by intravascular neoplastic proliferation. 

IVL is a well recognized entity by WHO classification of tumors 

of lymphoid tissue, that occurs in adult patient (1,2) . Clinically, two 

forms are recognized: the western and eastern ones. Our case presents 

incomplete features of the two forms: macrophage activation 

(with or without hemophagocytosis), thrombocytopenia, involvement 

of spleen, multiorgan localization with failure and rapid 

course are more characteristic of the eastern form. The absence 

Fig. 1. 

Fig. 2. 

303 

of hemophagocytosis and the lymphoma sparing the bone marrow 

seems to not completely satisfy this hypothesis. On the other 

hand, her first symptoms were neurological in origin, typical of 

western form of IVL. This difficulty in classify our case correctly 

underlines the ambiguity of the criteria on which the differentiation 

of the two form of IVL is based. Recent studies tried to solve 

this matter (3) , and hemophagocytosis, irrespective of geographic 

origin, seems to be the key. In conclusion we are still far to understand 

the nature of this disease and more extensive investigations 

need to better define disease and its biological behaviour. 

references 

1 Nakamura S, Ponzoni M, Campo E. Intravascular large B-cell lymphoma. 

In: WHO Classification of Tumours of Haematopoietic and 

Lymphoid Tissues. 4 th ed. 2008:252-253. 

2 Ponzoni M, et al. Definition, diagnosis, and management of intravascular 

large B-cell lymphoma: proposals and perspectives from an 

international consensus meeting. J Clin Oncol. 2007;25:3168-73. 

3 Ferreri AJ, et al. Variations in clinical presentation, frequency 

of hemophagocytosis and clinical behavior of intravascular lymphoma 

diagnosed in different geographical regions. Haematologica 

2007;92:486-92.

304 

GEnITALE MASCHILE E FEMMInILE 

Myxoid leiomyosarcoma of the uterus 

A. Barone1 , M.R. Ambrosio1 , B.J. Rocca1 , M.A.G.M. Butorano1 , 

M.G. Mastrogiulio1 , A. Ambrosio2 , S. Mannucci1 , R. Santopietro1 1 Department of Human Pathology and Oncology, Pathological Anatomy 

Section, University of Siena, Italy; 2 University “Magna Graecia” of Catanzaro, 

Italy 

Background. Uterine sarcomas are rare tumours that account for 

only 3% of all uterine neoplasms and less than 1% of all female 

genital tract cancers. The three most common types of uterine 

sarcomas are malignant mixed mesoderm sarcomas, leiomyosarcomas, 

and endometrial stromal sarcomas. One third of uterine 

sarcomas are leiomyosarcomas, of which myxoid leiomyosarcomas 

(MLMS) are an extremely rare variant which is a diagnostic 

challenge, because of the relatively bland appearance of the cells 

and the hypocellular nature of the proliferation. Infact, the usual 

diagnostic criteria for classification of uterine smooth muscle 

tumours, such as prominent nuclear pleiomorphism and high mitotic 

index (> 10 mitotic figures per 10 high-power fields-HPF), 

are often absent, and the presence of tumour cell necrosis is quite 

difficult to ascertain in myxoid leiomyosarcomas. The presence 

of two of these findings is sufficient for diagnosis of typical 

leyiomiosarcoma, but not for its epithelioid and myxoid variants. 

Only 30 cases of MLMS have been reported to date. We describe 

a further case. 

Materials and methods. A 66-year-old woman who reached 

the menopausal status 15 years ago, presented to the Gynaecologic 

Unit of Siena University Hospital with a 4-month history 

of progressive abdominal enlargement, dyspepsia, abdominal 

pain and uterine bleeding. Thirty years before, the patient had 

undergone right ovariectomy for cystic endometriosis. At pelvic 

examination, a massive, ill-defined, symmetric, soft and slightly 

tender mass was detected extending from the lower abdomen to 

the xiphoid. The uterus and left adnexa were not palpable. Ultrasonography 

(US) and computer tomography revealed an enlarged 

uterus with a huge abdominal mass and a hypoechoic lesion of 

40 mm of the left ovary. Laboratory values were within reference 

range. The clinical diagnosis was uterine leiomyoma. The patient 

underwent total hysterectomy, left salpingo-oophorectomy and 

right ooforectomy. Surgical specimens were formalin-fixed and 

paraffin embedded. From each block, 4-µm thick sections were 

obtained for histology and immunohistochemistry. The following 

antibodies were checked: Cytocheratin AE1/AE3, EMA, Vimentin, 

Desmin, Caldesmon, Smooth Muscle Actin (SMA), Estrogen 

and Progesterone receptors, Ki-67. 

Results. Macroscopically, the uterus was deformed by a huge 

mass growing from the fundus, infiltrating the miometrium 

and the serous covering; the mass measured 11.5x7x3cm and 

was gelatinous. The cut surface was variegated, ranging from 

brownish to amber yellow. Only small solid areas were present. 

Microscopically, the tumor was strikingly myxomatous, with 

large necrotic and hemorrhagic areas. Spindle-shaped cells were 

seen in the copious mucoid matrix, showing nuclear atypia and 

cellular pleomorphic areas. The tumor invaded endothelium-lined 

vascular spaces; the infiltrating borders were jagged and irregular 

with projections into the myometrium. The mitotic count was 20 

mitoses per 10 HPFs. The tumor invaded surrounding tissues and 

the uterine cervix. Immunohistochemically the neoplasm was 

positive for antibodies against SMA, EMA, Vimentin, and Cal- 




desmon. Desmin as well as Progesterone and Estrogen receptors 

were negative. Proliferative index (Ki-67) was about 80%. On the 

basis of these features, a diagnosis of myxoid leiomyosarcoma 

was made. 

Conclusions. Myxoid leiomyosarcoma of the uterus is an 

extremely uncommon and aggressive neoplasm, with a poor 

prognosis despite its bland cytology and histology. It presents 

problems in diagnosis and management to be faced by pathologists, 

gynaecologists and oncologists. It may show little atypia, 

well-circumscribed borders, absence of necrosis and relatively 

low mitotic index which are opposite findings to those characterizing 

the usual uterine leiomyosarcomas. On the contrary, when 

MLMS present infiltrating borders and vascular invasion, as in 

our case, it has to be considered a variant with aggressive behaviour. 

Myxoid inflammatory myofibroblastic tumours (IMTs) are 

the most important lesions to exclude in the differential diagnosis. 

IMTs, which rarely occur in the uterus, may display significant 

myxoid change and increased mitotic activity. The relatively 

young age of many patients with IMT, the presence of an inflammatory 

(lymphoplasmacytic) infiltrate and immunoreactivity 

with ALK1 are useful in distinguishing this entity from myxoid 

leiomyosarcoma. An oedematous, hydropic change that develops 

in some leiomyomas could be confused with myxoid change, 

particularly when it is found in large areas. Hydropic change is 

patchy and appears eosinophilic, in contrast to the basophilic appearance 

of the myxoid areas in myxoid leiomyosarcomas. Also 

endometrial stromal tumours may be characterized by myxoid 

changes. However, typical endometrial stromal cells and prominent 

vascularity are evident somewhere in the lesion. A positive 

immunostain for CD 10 confirms the diagnosis of endometrial 

stromal tumour. Surgery remains the appropriate treatment. However, 

in spite of an aggressive surgical approach and local and 

systemic control, recurrences and metastasis are frequent. 

references 

Burch DM, Tavassoli FA. Myxoid leiomyosarcoma of the uterus. Histopathology 

2011;59:1144-55. 

Toki N, Kashimura M, Hasegawa T, et al. Acta Cytologica 2000;44:415-9. 

Vigone A, Giana M, Surico D, et al. Massive myxoid leiomyosarcoma of 

the uterus. Int J Gynecol Cancer 2005;15:564-7. 

Leiomyomatosis peritonealis disseminata: 

report of a case 

A. Barone1 , M.R. Ambrosio1 , B.J. Rocca1 , M.A-G.M. Butorano1 , 

A. Ambrosio2 , M.G. Mastrogiulio1 , L. Barbagli1 , R. Santopietro1 1 Department of Human Pathology and Oncology, Pathological Anatomy 


Italy 

Background. Leiomyomatosis peritonealis disseminata (LPD) 

is a rare benign disease of unknown etiology of women in the 

reproductive age. It is characterized by multiple smooth muscle 

tumors of varying sizes on the omentum and peritoneal surfaces. 

A possible origin from submesothelial multipotential cells has 

been suggested, although it is not clear if the stimulus to smooth 

cell differentiation is hormonal, genetic or combined hormonal 

and genetic. The condition is associated with high levels of exogenous 

and endogenous female gonadal steroids (e.g. pregnancy, 

prolonged exposure to oral contraceptives and/or combined hormonal 

replacement therapy, granulosa cell tumours of the ovary), 

indicating that oestrogens and progestins play an important role 

in the pathogenesis of LPD as they do in leiomyomata uteri. Most 

LPD cases are clinically benign, but in some instances they may


progress, recur or (rarely) undergo malignant transformation. 

About 103 documented cases were found in the literature: LPD 

patients are mainly females (n. 102) in the reproductive age. We 

present a case of LPD in a 32 year-old woman with a previous 

history of laparoscopic myomectomy. 

Material and methods. A 32-year-old female patient was admitted 

to Siena University Hospital Department of Surgery since she 

presented with abdominal and pelvic pain. Physical examination 

revealed a firm hypogastric mass of 5-cm diameter and multiple 

nodules of abdominal wall. Abdominal ultrasound examination 

demonstrated the presence of numerous roundish peritoneal lesions 

of varying sizes reaching the muscular plane. Past medical 

history revealed a laparoscopic myomectomy. Exploration laparotomy 

showed innumerable, firm, pale-grey, smooth nodules 

on the surface of the omentum, parietal peritoneum, colon and 

rectum muscle. Excision of several of the masses was performed. 

Surgical specimens were formalin-fixed and paraffin-embedded. 

From each block, 4-µm thick sections were obtained for histology 

and immunohistochemistry. The following antibodies where 

checked: cytokeratin AE1/AE3, vimentin, caldesmon, smooth 

muscle actin, HHF-35, oestrogen and progesteron receptors, 

Mib-1. 

Results. On macroscopic examination all the lesions were similar. 

They were solid, firm and whitish and ranged in size from 

10 to 75 mm in maximum diameter. Nodules presented smooth 

external aspects and pale, whorled cut surface. Pinpoint hemorrhages 

were found but there was no macroscopic evidence of 

necrosis. Microscopic examination showed bundles of spindleshaped 

smooth muscle cells, without atypia, necrosis, or mitosis. 

The nodules were embedded in fat tissue, and were mostly well 

circumscribed. Some lesions showed extensive hyaline degeneration 

and foci of calcification. Immunostaining revealed positivity 

of neoplastic cells for smooth muscle actin (SMA), desmin, HHF- 

35, oestrogen and progesteron receptors, and negativity for cytokeratins. 

Proliferative index (Mib-1) was about 8%. Cytological 

examination of the peritoneal liquid revealed only reactive mesothelial 

cells and foamy histiocytes. The final diagnosis was LPD. 

Discussion. Leiomyomatosis peritonealis disseminata is a rare 

condition which is known to often simulate intra-abdominal 

carcinomatosis. Firstly described by Wilson and Peale in 1952, 

103 cases have been reported so far. The pathogenesis remains 

obscure although the associations with pregnancy, prolonged oral 

contraceptive use, subserosal uterine leiomyomata, functional 

granulosa cell tumors and endometriosis indicate hyperestrogenic 

states as a causal factor. Suggested pathogenic mechanisms 

include smooth muscle metaplasia of the subcoelomic mesenchymal 

stem cells (the so-called pluripotent Mullerian stem cells) 

which are distributed throughout the subperitoneal mesenchyma 

or a fibrosing reaction to ectopic omental deciduosis caused by 

hormonal imbalance or excess. In case of individual predisposition 

and hormonal stimulation, Mullerian stem cells proliferate 

along lines of myofibrous differentiation. However, this hypothesis 

does not explain four cases in postmenopausal women 

without hormonal treatment and one case in a male patient. The 

identification of luteinizing hormone (LH) receptor in LPD nodules 

from a post-menopausal woman has suggested that the typical 

postmenopausal increase in LH levels might plays a role in the 

pathogenesis of the condition. In males, etiological mechanisms 

are still obscure. Malignant transformation of LPD is uncommon 

and only ten cases have been described so far. Malignancy 

is thought to be more common in LPD without exogenous or 

increased endogenous exposure and in tumours without expression 

of oestrogen or progesteron receptors. Due to the rarity of 

the condition, there are no definite guidelines on its management, 

however, it has been suggested that more aggressive approaches 

should be followed in higher risk groups. 

Our patient was treated with laparoscopic surgery of many of the 

greater nodules. Eight weeks after surgery she is well. 

305 

references 

Al-Talib A, Tulandi T. Pathophysiology and possible iatrogenic cause 

of leiomyomatosis peritonealis disseminata. Gynecol Obstet Invest 

2010; 69:239-44. 

Carvalho FM, Carvalho JP, Pereira RM, et al. Leiomyomatosis Peritonealis 

Disseminata Associated with Endometriosis and Multiple 

Uterus-Like Mass: Report of Two Cases. Clin Med Insights Case Rep 

2012;5:63-8. 

Jeyarajah S, Chow A, Lloyd J, et al. Follow-up in patients with disseminated 

peritoneal leiomyomatosis: a report of an unusual, high-risk 

case. BMJ Case Rep 2009 (Epub apr 2009). 

Nappi C, Di Spiezio Sardo A, Mandato VD, et al. Leiomyomatosis peritonealis 

disseminata in association with Currarino syndrome? BMC 

Cancer 2006,6:127. 

A potentially dangerous misdiagnosis: a rare case 

of placental mesenchymal dysplasia associated 

with perinatal viral infection and fetal death 

M. Basciu2 , F. Moltrasio2 , F.M. Bosisio2 , P. Vergani3 , M. Verderio3 

, V. Lucchini1 , M.S. Cuttin1 1 Department of Pathology, Azienda Ospedaliera San Gerarndo, Monza, 

Italy; 2 Department of Pathology, Department of Surgical Science, Università 

di Milano-Bicocca, Milano, Italy and Azienda Ospedaliera San 

Gerardo, Monza, Italy; 3 Department of Obstetrics, Azienda Ospedaliera 

San Gerardo, Monza, Italy 

Placental mesenchymal dysplasia (PMD) is a disease with 

unknown etiology characterized by volumetric increase with 

cystic villi and dilated vessels. In literature less than 100 cases 

has been described; about 20% of these are in association with 

the Beckwith-Wiedeman syndrome, while another half are 

associated with IUGR. Other associations are preeclampsia, 

maternal hypertension, polyhydramnios, microsomia, omphalocele 

and kidney abnormalities. Besides, congenital hemangiomas, 

vascular amartoma and hepatic mesenchymal amartomas 

have been described in some of this fetuses. 82% of cases show 

normal female karyotype and in 43% of cases fetal or neonatal 

death occurs. 

We will describe the case of a placenta and a fetus of a 32-yearsold 

which arrived at our observation with the diagnosis of PMD 

and PROM. PMD was suspected on ultrasonography of the second 

trimester. 

The macroscopic placental alterations were: increase of weight 

(1004 gr); presence on about half of fetal surface of a skein of 

dilated and tortuous vessels of variable gauge, with sometimes 

aneurysmal aspect and macroscopic evidence of thrombosis; pronounced 

cord lenght (68 cm) with marked twisting; the presence 

on the cut-surface of hemorrhagic and pseudocystic areas with 

diffused aspects of vesicular chorionic villi. 

The histology of the placental parenchyma was characterized by 

a double villi population: one with increased villous core size 

and hydropic-like features caused by loose stromal connective 

tissue containing numerous vessels with thickened walls, without 

evidence of circumferential trophoblast growth. The second 

population preserved architecture and showed stromal oedema. 

There was evidence of important vascular thrombosis. 

The fetus, a female with normal karyotype (46, XX), macroscopically 

presented a normal development corresponding to 30 weeks 

of gestational age, without malformations and with obvious maceration 

aspects (G2 sec. Potter). 

On elbows cutis there were few vesicles; cephalohematoma was 

present and on examination of visceral pleural and epicardial 

surface hemorrhagic petechiae with pericardial blood effusion (2 

cc) were found. 

The histologic findings of the fetus were lung microhemorrhages 

with horny material in the saccular cavity, and hepatic and adrenal 

necrosis associated with cytopathic cellular changes suggestive 

for viral infection such as nuclear inclusions. 

The conclusive diagnosis was hemorrhagic fetal distress with

306 

liver and adrenal viral localization (presumably Herpes Virus or 

CMV) associated with placental mesenchymal dysplasia. 

The diagnosis of placental mesenchymal dysplasia is in most 

cases clinical; it can sometimes become difficult, only on ultrasound 

features, to distinguish it from a partial hydatidiform mole. 

Indeed both diseases show cystic parenchyma areas but there is 

no increase of serum beta-HCG that occurs only in trophoblast 

diseases. This has an histological evidence because PMD is not 

due to trophoblast hyperplasia, which is on the other hand present 

in partial mole. 

Currently, the pathogenesis of PMD is unknown, the evidence 

of thrombosis in fetal vessels has led the authors to suggest the 

possibility of a maternal thrombophilia. Association with IUGR 

and evidence of chorangiosis has instead brought to theorize a 

possible role of chronic hypoxia. 

However some cases were associated with placental mesenchymal 

genetic mosaicism, which would lead to an abnormal development 

of the mesenchyme while the surrounding trophoblast is 

normal. This is also supported by the association with hamartomas 

in some fetuses. These features, added to the association with 

Beckwith-Wiedemann syndrome and the female preponderance, 

suggest that there may be a mechanism of imprinting. 

In our case, obstetricians have excluded maternal thrombophilic 

disorders and presence of IUGR; it is thus supposed that there 

may have been a sporadic event that led to the development of 

this particular disease, which likely would lead to a weakening of 

the entire placental apparatus (membranes included) and then to 

the occurrence of a untimely rupture of the membranes which is 

a well known cause of perinatal fetal infections. 

references 

1 Beargen R. Miscellaneous placental lesions. In: Manual of pathology 

of the human placenta. 2 nd Ed. Springer 2011. 

2 Zeng X, Chen MF, Bureau Y-A, et al. Placental mesenchymal dysplasia 

and an estimantion of population incidence. Acta Obstet Gynecol 

Scand 2012;91:754-7. 

3 Avgil M, Ornoy A. Herpes simplex virus and Epstein-Barr Virus 

infections in pregnancy: consequences of neonatal or intrauterine 

infection. Reprod Toxicol 2006;21:436-45. 

Espression of P16 InK4A / KI67 dual-stain cytology 

and cytological diagnosis in a population hpv dna- 

Hr positive. correlations and histological follow up 

L. Borghi, P. Rossi, R. Ferro, M. Zanella, R. Mencarelli 

Anatomia Patologica Dipartimento Patologia Clinica, Azienda 

Ulss 18, Rovigo 

Objective of the study. Cytological diagnosis and co-expression 

of p16 INK4a (p16) protein and biomarker Ki67 have been made 

on a selected HR-HPV DNA positive population using Hybrid 

Capture II method. Correlations among cytological - histological 

diagnosis and p16/Ki67 expression patterns, identifying different 

classes of risk that need individual follow-up. 

Materials and methods. Using a single sample for thin-layer 

cytology, HPV DNA-HR test and biomarkers, cytological diagnosis 

has been made in a thin layer (ThinPrep) in a population 

of women aged 25-64 aa HPV DNA-HR positive. In a second 

step a survey for immunocytochemical study p16INK4a /ki67 has 

been made. The simultaneous expression of two biomarkers in 

the same cell of cervical epithelium is a morphology-independent 

marker of deregulation of cell cycle. Using CINtec ® PLUS in pap 

tests the positive staining for both proteins (p16 and Ki67) in the 

same cell shows brown cytoplasm (over-expression of p16) and 

red nucleus (Ki67 expression) (Fig. 1). The investigator with 

CINtec ® PLUS (monoclonal mouse anti-Human p16INK4a antibody, 

Clone E6H4TM , and monoclonal rabbit anti-Human Ki-67 

antibody Clone 274-11 AC3) has been made on 951 cases. The 

immunohystochemical analysis with primary monoclonal mouse 

antibody clone E6H4 TM has been made on histological sections 


Fig. 1 

Results. Cytological correlation and investigation with CINtec ® 

PLUS: co-expression of p16/Ki67 in individual cytological categories. 

Among the negative cytological cases, 3.2% was positive, 

while 96.8% negative. The positivity was confirmed after 

review of the cases, performed by protocol. Among the cases 

of ASC-US, 23% was positive at p16/Ki67 investigation. This 

percentage may increase the VPP for CIN2+ in a diagnostic 

category which does not seem easy to reproduce. Among 

the LSIL cases, 27.2% was positive and therefore subject to 

greater risk of progression to high grade lesions. The 72.8% 

was found negative and therefore likely to get regression of 

the cervical lesion. All the cytological HSIL cases and 76% of 

ASC-H cases were positive in the survey p16/Ki67; all these 

patients, after colposcopy and biopsy had high grade lesions. 

197 cases with a histological follow-up (three months - six 

months) and 84 cases with cytological follow-up have been 

found. Histological diagnosis of high grade lesions were 51: 

35 CIN2 (30 with cytology and P16/Ki67 positive and 5 with 

cytology positive and P16/Ki67 negative) and 16 CIN3 (only 

1 with cytology positive and P16/Ki67 negative); diagnosis of 

low grade lesions were 101 (26 with cytology and P16/Ki67 

positive and 75 with cytology positive and P16/Ki67 negative); 

negative diagnosis were 45 (11 with cytology and P16/Ki67 

positive and 34 with cytology positive and P16/Ki67 negative). 

Conclusions. In cytological negative cases the investigation IIC 

with CINtec ® PLUS can be a valuable support in the clinical 

picture of atrophy / dystrophy (menopause) in which the morphology 

of the “small cells” can give false negatives. Increased 

sensitivity of the cytological test. In ASC-US and LSIL it is essential 

to distinguish lesions with significant risk of progression 

to CIN2 / 3, which will require a shorter- term follow up. The 

same diagnostic categories which are negative at biomarkers regress 

spontaneously and / or rarely progress. For this reason it is 

possible to reduce the risk of over-treatment and to plan a longterm 

follow-up. In cases of ASC-H and HSIL the investigation 

IIC with CINtec ® PLUS confirms the presence of high-grade 

and high risk of progression lesions. However in a low percentage 

it is essential a further study of biomarkers. 

Fig. 2


Fig. 3 

references 

1 Ronco G, Giorgi-Rossi P, Carozzi F, et al. Efficacy of human papillomavirus 

testing for the detection of invasive cervical cancers and 

cervical intraepithelial neoplasia: a randomized controlled trial. 

Lancet Oncol 2010;11:249-57. 

2 Carozzi F, Confortini M, Dalla Palma P, et al. for The New Technologies 

for Cervical Cancer screening (NTCC) working group. Use of 

p16INK4a overexpression to increase the specificity of human papillomavirus 

testing: a nested substudy of the NTCC randomised controlled 

trial. Lancet Oncol 2008;9:937-45. 

3 Said J. Biomarker discovery in urogenital cancer. Biomarkers 

2005;10(Suppl. 1):S83-6. 

4 Luyten A, Scherbring S, Reinecke- Lüthge A, et al. Risk-adapted primary 

HPV cervical cancer screening project in Wolfsburg, Germany 

- Experience over 3 years. J Clin Virol 2009;46:S5-10. 

5 Petry UK, Schmidt D, Scherbring S, et al. Triaging Pap Cytology Negative, 

HPV Positive Cervical Cancer Screening Results with p16INK4a/ 

Ki-67 Dual-stained Cytology. Gynecol Oncol 2011;121:505-9. 

6 Negri G, Egarter-Vigl E, Kasal A, et al. p16INK4a is a useful marker 

for the diagnosis of adenocarcinoma of the cervix uteri and its precursors: 

an immunohistochemical study with immunocytochemical correlations. 

Am J Surg Pathol 2003;27:187-93. 

7 Denton KJ, Bergeron C, Klement P, et al., for the European CINtec 

Cytology Study Group. The Sensitivity and Specificity of p16INK4a 

Cytology in the Triage of ASC-US and LSIL Pap Cytology Results vs 

HPV Testing for Detecting High-Grade Cervical Disease. Am J Clin 

Pathos 2010;134:12-21. 

8 Società Italiana di Colposcopia e Patologia Cervico Vaginale (SICP- 

CV). Gestione del Pap test anormale. Linee guida edizione 2006. 

Colposcopia in Italia 2006;XXI:2-26. 

9 Tsoumpou I, Arbyn M, Kyrgiou M, et al. p16INK4a immunostaining 

in cytological and histological specimens from the uterine cervix: 

a systematic review and meta-analysis. Cancer Treatment Rev 

2009;35:210-20. 

10 Wentzensen N, Bergeron C, Cas F, et al. Triage of women with ASCUS 

and LSIL cytology. Use of qualitative assessment of p16INK4a positive 

cells to identify patients with high-grade cervical intraepithelial 

neoplasia. Cancer Cytopathol 2007;111:58-66. 

Progression of prostate cancer and activity 

of notch receptors under hypoxia 

M.R. Ambrosio1 , G. Danza2 , C. Di Serio3 , B.J. Rocca1 , A. Sacchini1 

, S. Bartolommei1 , F. Tarantini3 , M.T. del Vecchio1 1 2 Department of Pathology, University of Siena Endocrine Unit, Department 

of Clinical Physiopathology, University of Florence (Italy); 3 Geriatric 

Medicine Unit, Department of Critical Care Medicine and Surgery, 

University of Florence (Italy) 

Background. Prostate cancer (PC) represents nearly a quarter of 

all newly diagnosed cases of male cancers. The risk to develop 

PC increases with age, with 75% of cases occurring in men over 

307 

65 years. The majority of PC is slow growing but there are cases 

with aggressive behavior and high risk of metastasis. As suggested 

for many solid tumors, hypoxia seems to play an important 

role in the progression of PC where low oxygen tension correlates 

with resistance to chemo- and radio-therapy and poor clinical 

outcome. It has been reported that chronic conditions of low 

oxygen set off the “hypoxia response” program, orchestrated by 

the hypoxia-inducible factor (HIF)-1α, and convey to tumor cells 

the ability to adapt to the environment with a survival advantage. 

It was previously demonstrated that exposure of LNCaP cells to 

chronic hypoxia (2% oxygen for 7 days) resulted in a significant 

modulation of the Notch receptor-ligand system. In mammals, the 

Notch receptor family includes four members that are anchored 

in the cell membrane as heterodimers and are involved in shortrange 

cell–cell communication, cell-fate decision, patterning and 

cell polarity. Classical Notch ligands, the Delta/Delta-like and 

the Serrate/Jagged family members, are also transmembrane proteins. 

Receptor occupation by ligands promotes two proteolytic 

changes of the receptor protein, exerted by an ADAM metalloprotease 

and a γ-secretase, the latter belonging to the presenilin 

family. Proteolytic cleavage of the receptor releases the intracellular 

domain which enters the cell nucleus to modify gene expression. 

Notch signaling controls cell differentiation across a wide 

range of cell types, both during development and in adult tissues 

and mutations of Notch genes are responsible for several types of 

diseases, including cancer. In this study, we sought to determine 

whether hypoxia activates Notch receptors and whether Notch 

mediated signal plays a role in the progression of PC, focusing 

our attention on Notch 3 receptor. 

Materials and methods. Cell Cultures: LNCaP, an androgen-dependent 

human prostate cancer cell line was obtained from ATCC. 

Hypoxia was achieved by maintaining the cells at 2% oxygen, in 

a CO 2 incubator with oxygen sensor control, and with CO 2 and 

N 2 gas regulators. On cell cultures, immunostaining for Notch 1-3 

was performed. Immunohistochemistry: 170 core needle biopsy 

specimens from 150 PC patients and 20 non-neoplastic patients, 

were used. Immunohistochemical staining was performed on 

4 + 0.5µm-thick sections of each block employing the Ultravision 

Detection System Anti-Polyvalent HRP. Tumor grade and score 

were established according to the Gleason grading system in each 

core needle biopsy. Representative tumor sections were then classified 

as low grade when Gleason score was < 7 and as high grade 

when Gleason score was > 8. Foci of high-grade intra-prostatic 

neoplasia (PIN) were also identified, when present in peritumoral 

areas. Negative core needle biopsy specimens were diagnosed as 

basal cell hyperplasia and atrophy. Notch 3 expression was evaluated 

in all 170 core needle biopsy specimens, while Notch 1 and 

Notch 2 were evaluated on 41 core needle biopsy specimens (33 

neoplastic and 8 non-neoplastic). Immunoreactivity was scored by 

calculating the percentage of positive cells as well as the distribution 

and the intensity of staining, using the HSCORE. 

Results. Modulation of Notch receptors during hypoxia in LNCaP 

cells: Notch 1 and Notch 2 receptors are down-regulated in LNCaP 

cells under hypoxia; in fact after 7 days of hypoxia only a mild 

cytoplasmic staining can be observed. As far as Notch 3 receptor is 

concerned, under normoxic conditions a mild staining was present, 

mainly in the cytoplasm. After 24 hours of hypoxia, the stain became 

more evident and after 7 days the intensity of Notch 3 staining 

was stronger and the protein became nuclear. Gleason grade 

and score: among the 150 biopsy specimens from cancer patients, 

33 were diagnosed as Gleason score 6, 61 as Gleason score 7, 32 as 

Gleason score 8, 20 as Gleason score 9, and 4 as Gleason score 10. 

They were classified as low grade (n = 94) and high-grade (n = 56) 

adenocarcinoma. The 20 negative biopsies showed atrophy (n = 12) 

and atrophy plus basal cell hyperplasia (n = 8). Expression of Notch 

receptors in non neoplastic prostatic tissue and in high grade PIN: 

the immunohistochemical analysis showed different reactivity of 

prostatic epithelium, in non neoplastic and neoplastic glands. Cy-

308 

toplasmic HSCORE 1 for Notch 1 and 3 was evident respectively 

in 4 and 5 out of 12 needle biopsies with atrophy. Notch expression 

was not evident in the 8 cases with basal cell hyperplasia. 

Cytoplasmic HSCORE 1 for Notch-1 and Notch-3 were found in 6 

out of 11 high-grade PIN cases adjacent to neoplastic glands, more 

intense at the apical pole of the glandular cells. On the contrary, 

no expression of Notch-2 was appreciated in negative biopsies and 

in high grade PIN. Muscle cells intermingled with non-neoplastic 

glands and high-grade PIN, and vascular endothelial cells showed 

some degree of Notch 1-3 staining. Expression of Notch receptors 

in PC: neoplastic glands showed different HSCORE values and 

different immunoreactivity location accordingly to the Gleason 

grade and to the antibody evaluated. Notch 1 was expressed in 

80% of Gleason grade 3, with 60% showing a HSCORE 1. Only 

2 cases Gleason grade 4 (9%) showed Notch 1 positivity, with a 

HSCORE 1. None of the Gleason grade 5 was Notch 1 positive. 

Only 2 out of 23 high-grade tumors expressed Notch-1, with a 

HSCORE 1. Notch 2 expression was observed in 20% of Gleason 

grade 3 and in 4.5% of Gleason grade 4, with a HSCORE 1. None 

of the Gleason grade 5 was Notch 2 positive. In any case, Notch 

1 and Notch 2 staining was confined to the cytoplasm. Higher 

Notch-3 expression (HSCORE 3) was observed more frequently 

in Gleason high grade cases (121 out of 127 cases) in comparison 

with Gleason low grade (20 out of 88 cases) (p < 0.001). Higher 

Notch-3 immunostaining (HSCORE 3) occurred more frequently 

in tumors with a higher Gleason score (n = 53) in comparison with 

low-grade tumors (n = 39) (p < 0.001). Gleason high grade cases 

often showed nuclear expression (n = 115) than Gleason low grade 

cases (n = 6) (p < 0.001). These data suggest progression of Notch 

3 receptor expression and activation with tumor malignancy. 

Discussion. It is well-known that androgen sensitivity is a major 

determinant of PC outcome. However, there is still insufficient 

information as to which signaling pathways are deranged in 

more aggressive, clinically localized PC. Identification of these 

pathways may result in the design of innovative therapies aimed 

at specific molecular targets. Recently, the gene expression profile 

of Gleason low grade and high grade tumors was compared 

Among the genes that were found to be differentially expressed, 

members of the Notch and EGFR signal transduction pathways 

appeared to be up-regulated in high grade localized PC. In this 

study, we found that the level of Notch 3 receptor protein was 

significantly correlated with Gleason grade in human PC biopsies 

and that Notch 3 staining was mainly nuclear in high grade 

tumors, suggesting receptor activation. We also observed that 

Notch 3 was strongly activated in LNCaP cells during hypoxia. 

Preliminary data from our group suggest that activation of Notch 

3 under hypoxia increases the ability of PC cells to proliferate 

and to form colonies in soft agar. On these bases, we propose that 

Notch 3 immunostaining of localized PC biopsies may increase 

our ability to identify those tumors with worse prognosis that may 

require a more aggressive therapy. Moreover, Notch 3 signaling 

pathway may be a candidate for an innovative targeted therapy. 

references 

Andersson ER, Sandberg R, Lendahl U. Notch signaling: simplicity in 

design, versatility in function. Development 2011;138:3593-612. 

Danza G, Di Serio C, Rosati F, et al. Notch signaling modulates hypoxia-induced 

neuroendocrine differentiation of human prostate cancer 

cells. Mol Cancer Res 2012 ;10:230-8. 

Epstein JI, Netto GJ. Grading of prostatic adenocarcinoma. In: Pine J, 

McGough, editors. Biopsy Interpretation of the Prostate. Philadelphia: 

Lippincott Williams and Wilkins 2007, pp. 175-202. 

Ghafar MA, Anastasiadis AG, Chen MW, et al. Acute hypoxia increases 

the aggressive characteristics and survival properties of prostate cancer 

cells. Prostate 2003;54:58-67. 

Long Q, Johnson BA, Osunkoya AO, et al. Protein-Coding and MicroR- 

NA Biomarkers of Recurrence of Prostate Cancer Following Radical 

Prostatectomy. Am J Pathol 2011;179:46-54. 

Stewart GD, Ross JA, McLaren DB, et al. The relevance of a hypoxic 

tumour microenvironment in prostate cancer. BJUI 2009;105:8-13. 


GDP-4-keto-6-deoxy-mannose-3,5-epimerase-4reductase 

as a novel diagnostic and prognostic 

marker in prostate carcinoma 

M.R. Ambrosio, P. Guazzi, B.J. Rocca, S. Bartolommei, A. Sacchini, 

M.T. del Vecchio, S.A. Tripodi, F. Arcuri 


Section, University of Siena, Italy 

Background. It is well known that the structure of carbohydrates 

produced by cells changes during carcinogenesis; in this frame, 

alterations in fucosylation patterns, as the result of different levels 

of expression for various fucosyltransferase have been studied. 

Overexpression of fucosylation enzymes and high production of 

GDP-fucose is common in cancer, promoting metastatic potential. 

The regulation of fucosylation is a complex phenomenon, involving 

several systems that control fucosyltransferases or substrate 

availabilities. The level of fucosyltransferases and intracellular 

GDP-L-fucose, a sugar nucleotide and a common donor substrate 

for all fucosyltransferases, may regulate that of fucosylated glycoproteins. 

In fucosylation process, L-fucose (6-deoxy-L-galactose) 

monomers are transferred to target GDP-L-fucose in the cytosol 

via two different pathway, named the salvage pathway and the 

de novo pathway. In the de novo pathway, GDP-L-fucose is synthesized 

from GDP-mannose via an oxidation, an epimerization, 

and a reduction. These steps are catalyzed by two enzymes, GDPmannose-4,6-dehydratase 

and GDP-4-keto-6-deoxy-mannose-3,5epimerase-4-reductase. 

In humans, the latter enzyme is designated 

as FX. It has been reported that FX-knockout mice exhibit a complete 

deficiency of cellular fucosylation, demonstrating that the 

de novo pathway is the major route for cellular GDP-L-fucose 

biosynthesis in vivo. Recent studies on prostatic carcinoma cell 

lines (LNCaP) have shown that PSA derived from LNCaP cells 

contain more fucosylated and N-acetylgalactosaminylated residues 

than those from normal and benign prostatic hyperplasia (BPH) 

tissues, suggesting a role of cellular fucosylation in prostatic adenocarcinoma. 

The aim of this study is to elucidate whether FX is 

involved in prostatic carcinogenesis, and to evaluate its potential 

role as diagnostic and prognostic marker. 

Materials and methods. Western blotting and Real Timequantitative 

PCR analysis were carried out on BPH and prostatic 

carcinoma (PCa) specimens obtained from patients undergoing 

adenomectomy and radical prostatectomy at the Urology Division 

of Siena University Hospital. Immediately after surgery, 

specimens were rinsed in sterile PBS at room temperature, blotted 

dry, cut with a razor blade. Aliquots for western blotting analysis 

and RNA extraction were snap-frozen and stored in liquid nitrogen. 

For immunohistochemical evaluation, the material consisted 

of 120 core needle biopsy specimen from 70 prostate cancer 

patients, and from 50 cancer-free patients, collected between 

January and June 2011. The mean age of the patients was 70.4 

(range: 54 to 86 years). None of the patients received adjuvant 

therapy. Core needle biopsy specimens were immediately fixed 

in 10% buffered formalin and embedded in paraffin. From each 

block, 4 µm-thick sections were cut and stained with hematoxylin 

and eosin. Tumor grade was established according to the Gleason 

grading system and the tumors classified as low grade when the 

score was < 7 and as high grade when the score was > 8. Foci of 

high-grade intraepithelial neoplasia (PIN) were also identified. 

Cancer-free core needle biopsy specimens may contain basal cell 

hyperplasia, atrophy, acute or chronic inflammation. Immunohistochemical 

staining was performed on 4 + 0.5µm-thick sections 

of each block employing the Ultravision Detection System 

Anti-Polyvalent HRP and semiquantitatively scored by HSCORE 

(HSCORE = ∑ i i*P i), using the following categories: 1 (no staining 

or weak, but detectable staining), 2 (moderate staining) and 

3 (intense staining). Statistical analysis was performed using a 

statistical software package (SYSTAT-7). A P value < 0.05 was 

considered statistically significant.


Results. Expression analysis of FX mRNA in BPH and PCa tissues. 

Amplification of cDNA carried out in presence of human 

FX primers revealed the presence of fucosidasis transcript in 

both BPH and PCa tissues analysed. The average of mRNA FX 

normalized levels in PCa tissues resulted almost twice higher 

than in BPH tissues [1.833±0.66 vs 0.931±0.5 (t = -3.458; 

P = 0.003)]. 

Expression analysis of FX protein in BPH and PCa tissues. 

The presence of an immunoreactive band corresponding to FX 

revealed the presence of the protein in both the PCa and BPH 

tissues analyzed. Results of optical densitometry indicated that 

the average OD ratio of FX protein is higher in PCa tissues 

than in BPH tissues (0.644±0.100 vs 0.130±0.017), showing a 

consistent increase of FX protein expression in tumoral tissues 

(P < 0.001). 

Immunohistochemistry. Among the 74 biopsy specimens from 

cancer patient, 22 were diagnosed Gleason score 6, 20 Gleason 

score 7, 24 Gleason score 8, and 8 Gleason score 9. Therefore 

they were classified as low grade (n = 42) and high-grade 

(n = 32) adenocarcinoma. The 50 cancer-free biopsies showed 

basal cell hyperplasia (n = 12), acute and chronic inflammation 

(n = 18) and atrophy (n = 20). FX expression was observed 

only in the cytoplasm. Low levels (HSCORE 1) of FX expression 

were found in 8 out of 12 cases of basal cell hyperplasia. 

High-grade PIN areas adjacent to adenocarcinoma did not show 

FX immunostaining. Higher FX expression (HSCORE 3) was 

observed more frequently in Gleason high grade cases in comparison 

with Gleason low grade cases [χ 2 = 62.954; degrees of 

freedom (df) = 2; p < 0.001). Higher fucosidasis immunostaining 

(HSCORE 3) occurred more frequently in tumors with an 

higher Gleason score in comparison with low-grade tumors 

(χ 2 = 40.759; df = 2; p < 0.001). 

Discussion. These findings suggest that alterations of fucosylation 

are involved in prostate cancer aggressiveness, resulting in 

high levels of FX and activation of de novo pathway for GDP- 

L-fucose synthesis in high grade adenocarcinoma, in which we 

found the stronger expression of FX that is probably related to 

a more dedifferentiated tumoral phenotype. Moreover, the observation 

that FX staining is also present in benign human basal 

cells confirm the hypothesis that basal cells include cells of 

origin of prostate cancer. Nonetheless, the role of fucosylation 

in prostatic carcinogenesis should be adequately considered 

and confirmed by further studies. Deregulation of FX might 

be used as a novel promising molecular target for therapy and 

FX immunostaining may increase our ability to identify those 

tumors with worse prognosis that may require a more aggressive 

treatment. 

references 

Epstein JI, Netto GJ. Grading of prostatic adenocarcinoma. In: Pine J, 

McGough, editors. Biopsy Interpretation of the Prostate. Philadelphia: 

Lippincott Williams and Wilkins 2007, pp. 175-202. 

Fukushima K, Satoh T, Baba Set al. alpha1,2-Fucosylated and beta- 

N-acetylgalactosaminylated prostate-specific antigen as an efficient 

marker of prostatic cancer. Glycobiology 2010 ;20:452-60. 

Noda K, Miyoshi E, Gu J, et al. Relationship between elevated FX 

expression and increased production of 

GDP-L-fucose, a common donor substrate 

for fucosylation in human hepatocellular 

carcinoma and hepatoma cell lines. Cancer 

Res 2003;63:6282-9. 

Taylor RA, Toivanen R, Frydenberg M, et 

al. Human Epithelial Basal Cells Are 

Cells of Origin of Prostate Cancer, Independent 

of CD133 Status. Stem Cells 

2012;30:1087-96. 

309 

neuroblastoma in situ in a case of fetal hydrops 

and death in utero 

F.M. Bosisio1 , V. Lucchini2 , A. Vanzati1 , F. Moltrasio1 , M. Basciu1 

, G. Cattoretti1 , M.S. Cuttin2 1 Università di Milano-Bicocca, Scuola di specialità aggregata Milano- 

Milano Bicocca-Brescia, Monza; 2 AO San Gerardo, UO di Anatomia Patologica, 

Monza 

Introduction. Neuroblastoma is the most common malignant 

perinatal tumour in the fetus but is unusual to see in neonates 

because the tumour can regress spontaneously. In many cases, 

neuroblastoma resulted associated with fetal hydrops. Here we 

present a case of a stillbirth fetus with hydrops in which we found 

an otherwise occult neuroblastoma in situ. 

Matherials and methods. Autopsy was performed. Samples 

taken from all of the viscera were formalin-fixed and paraffinembedded. 

Routine slides were obtained from the paraffin blocks 

and stained with Hematoxilin-Eosin. Immunohistochemical analysis 

was performed utilizing authomatic immunostaining system. 

Results: Case Report. On the 24th gestational week of an otherwise 

normal pregnancy (no maternal infections, ematological diseases 

nor tossiemia), on the routine ultrasonography was detected 

fetal hydrops. The long bone length was at the 5° percentile. 

At the autopsy, the fetus was a male weighting 2044 g, with a 

total length of 36 cm, a crown-rump length of 25 cm, a cranial 

circumference of 30 cm and a foot length of 5,8 cm. Biometric 

measurements recollected the gestational age at the 30th week, but 

they were not applicable in this case to estimate the true gestational 

age because of the very important fetal hydrops. Moderate 

maceration phenomena were present at external examination, 

corresponding to a Potter Grade 2 (Fig. 1). 

At the internal examination no malformation of the viscera was 

present, but viscera were dislocated due to an important ascitic 

effusion (ca 200cc). 

Microscopic examination revealed lungs in the saccular phase, 

with a LW/BW = 0,0058 and a RAC of 4. The gonade proved to 

be differentiated in testicular tissue. The spleen was congested 

Fig. 1. the fetus presented important fetal hydrops and a maceration 

estimated as a grade 2 of Potter 

Fig. 2 aggregates of neuroblasts in the medulla of the adrenal gland. Small blu cells organized in 

nodular aggregates and cords. they resulted NSE+.

310 

and the thymus showed a grade II depletion. The adrenal glands 

presented at low magnification multiple nodular aggregate of 

small round blue cells morphologically compatible at high magnification 

with neuroblasts (Fig. 2). The neuroblasts appeared 

to be organized in nests and cords, completely confined in the 

medulla of the adrenal gland. Immunohistochemistry proved the 

origin from the neural crest, being NSE expressed by the whole 

population. A diagnosis of neuroblastoma in situ was made. 

Discussion and conclusion. Tumors are defined congenital when 

they are present in the fetus or in the neonate up to 3 months after 

birth. Neuroblastoma is the most common malignant perinatal 

tumour in the fetus, but most of them has a very good prognosis 

even if metastatic 1 . Despite being the most common malignant 

tumour in the neonatal period, neuroblastoma in unusual to see in 

neonates because the tumour can regress spontaneously 2 . When 

it does not regress, it can evolute to a very aggressive disease. 

The early development in the neonatal period suggest that intrauterine 

and also preconception exposures may have a role in the 

etiopathogenesis of the tumour. Fertility drugs and occupational 

chemical exposures are the most suspected agents, while genetic 

causes are very infrequent (e.g. ALK mutation). Diagnosis in 

antenatal period is made by ultrasound examination. The major 

differential diagnosis is with adrenal emorrage that can generate 

a suprarenal mass similar to the cystic form of neuroblastoma. 

Metastatic spread is rare in neonates compared to older children. 

Urinary cathecolamine metabolites (vanillylmandelic acid and 

homovanillic acid) are raised in almost 80% of the cases. Their 

measurement, together with the bone marrow aspirate, create the 

basis for the diagnosis where the tissue analysis is impossible. 

In the current staging system (The International Neuroblastoma 

Risk Group Staging System, INRGSS) neuroblastoma in the neonatal 

period is classified in a special stage, MS (4S). In this stage, 

babies may have a small or undetectable primary lesion with metastasis 

to the liver, skin and bone marrow. Most of these lesions 

regress spontaneously so that this group generally is characterized 

by a better prognosis. 

To detect congenital neuroblastoma in utero, a screening program 

based on ultrasound was proposed, but soon abandoned because 

no overall benefit was found, with the result that infants whose 

disease may have regressed naturally might undergo unnecessary 

surgery and chemotherapy 3 . 

Neuroblastoma can associate with other pathological conditions. 

First of all, neuroblastoma can be found associated with congenital 

malformation. Being neuroblastoma cells neural crest-derived 

cells, it may be considered plausible an association between 

neuroblastoma and cardiac defects, since neural crest is essential 

in cardiogenesis as well. Nevertheless, the results of studies on 

the matter are contradictive, some showing correlation and others 

no 4 . The more actual ESCALE study carried out in France 

has pointed out the positive association between neuroblastoma 

and congenital malformation, expecially for cases with MYCN 

oncogene amplification, as well as a negative association with a 

maternal history of spontaneous abortion. It is to note however 

that no cardiac malformation were found in the neuroblastoma 

French casuistic 5 . In our case, no malformations were present 

in association with the neuroblastoma. However, the fetus presented 

an important hydrops, that must be the cause of the death 

in uterus. Several cases of fetal hydrops has been associated with 

tumours 6-9 , and the main findings associated with hydrops in 

presence of tumor are hydramnios, a tumor mass, placentomegaly 


and stillbirth. None of these features were present in our case. 

Interestingly, no hydropic fetus with cardiac rabdomioma, brain 

tumor, rhabdoid tumour, histiocytosis as well as neuroblastoma 

survived at birth 9 . 

Altough reported also at 20 weeks gestation, diagnosis of neuroblastoma 

is usually made after 32 weeks. During embryologic 

development of the adrenal gland, neuroblastic nodules can be 

normally found in the medulla and they are indistinguishable 

from neuroblastoma in situ with a maximum peak at 17-20 

weeks, after which they undergo physiological involution. If this 

happens, they never become clinically evident. Cistic neuroblastomas 

have only small aggregates of neuroblasts in the cyst wall, 

with a clinical course more favorable. They can represent the 

normal involution process of the antenatal neuroblastoma 10 . In 

our case, the gestational age was earlier compared to the normal 

age of detection of the neuroblastoma (32 weeks gestation), but 

this finding is coherent with the stage of the disease, that is still 

in situ, then not detectable by routine ultrasonography. Although, 

the gestational age is too late to consider this neuroblastic aggregates 

as neuroblastic nodules, as we found the pregnancy at the 

time of the delivery of the stillborn fetus between the 24 and 30 

weeks, due to the difficulty to establish the gestational weeks in 

an hydropic fetus. 

Tumor stage at the diagnosis is the major prognostic factor. Stage 

I disease represents the neuroblastoma confined to the adrenal 

gland, at stage II the neoplasia extends locally without crossing 

the midline. Midline becomes crossed by the neoplasia at stage 

III, and so on to the stage IVS where metastasis are present to 

the liver, skin and bone marrow. In addition to stage some biologic 

marker can influence prognosis, that are amplification of the 

Myc-N oncogene and the DNAcontent of the tumor cells 10 . Altough 

most fetal neuroblastomas are in stage I, they don’t remain 

localized to the gland but they can metastatize expecially in case 

of solid tumors. So, as in our case, also Stage I neuroblastomas 

can lead to death the fetus. In our case, the hydrops is the main 

cause of death and the link with the neuroblastoma is given by the 

fact that other causes of hydrops have been completely excluded 

by the clinician, and no other malformations that could justificate 

the fetal hydrops and death has been found at the autopsy. 

references 

Avni FE, Massez A, Cassart M. Tumours of the fetal body: a review. 

Pediatr Radiol 2009. 

Dejkhamron P, et al. Persistent hyperinsulemic hypoglycemia of infancy 

associated with congenital neuroblastoma: a case report. 

Laakhoo K, Sowerbutts H. Neonatal Tumours. Pediatr Surg Int 

2010;26:1159-68. 

vanEngelen K, et al. Prevalence of congenital heart defects in neuroblastoma 

patients: a cohort study and systematic review of literature. Eur 

J Pediatr 2009;168:1081-90. 

Munzer C, Menegaux F, Lacour B, et al. Birth-related characteristics, 

congenital malformation, maternal reproductive history and neuroblastoma: 

the ESCALE study (SFCE). Int J Cancer 2008;122:2315-21. 

Johnson AT, Halbert D. Hydramnios with hydrops fetalis and disseminated 

fetal neuroblastoma. N C Med J 1974;35:289-91. 

Van der Sikke JVV, Balk AG. Congenital neuroblastoma presenting as 

hydrops fetalis. Obstet Gynecol 1980;55:250-3. 

Miric Tesanic D, Habek D, Vasilij O, et al. Metastatic fetal neuroblastoma 

with non immune fetal hydrops. Ultraschall Med 2010;31:520-2. 

Hart IJr. Fetal Hydrops associated with tumours. Amer J Perinatol 

2008;25:043-068. 

Woodward PJ, et al. A comprehensive review of fetal tumors with pathologic 

correlation. Radiographics 2005;25:215-42.



Choriocarcinomatous differentiation in a low-grade 

endometrioid adenocarcinoma: 

a rare histopathological finding in an otherwise 

healthy perimenopausal woman 

G. Crisman1 , L. Sollima1 , M. Di Nicola2 , V. Accurti2 , F. Patacchiola3 

, G. Coletti4 , P. Leocata1 , G. Carta2 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 

dell’Aquila, L’Aquila, Italia; 2 U.O.C. Ginecologia ed Ostetricia D.U., 

Università degli Studi dell’Aquila, L’Aquila, Italia; 3 U.O.C. Ginecologia 

ed Ostetricia, Ospedale “Val Vibrata”, Sant’Omero (TE), Italia; 4 U.O.C. 

Anatomia Patologica, Ospedale Civile “San Salvatore”, L’Aquila, Italia 

Background. A choriocarcinomatous differentiation has been 

reported in association with some cancer types, especially with 

those arising in the female genital tract and rarely with carcinomas 

of other sites (i.e., urinary tract, gastrointestinal tract, lung 

and breast). We report on a case of a 50-year-old woman with 

a low-grade endometrioid adenocarcinoma (EAC) with choriocarcinomatous 

differentiation (CD). Up to now, less than twenty 

cases have been reported so far 1-16 . 

Material and methods. We report on a case of a 50- year-old 

nulliparous, peri-menopausal woman presented to our Department 

with an enlarged uterus, high serum CA125 levels, and persistent 

metrorrhagia. Anamnestic data revealed a eighteen-month 

history of multiple intramural and subserous uterine myomas and 

dysfunctional uterine bleeding, in the absence of the conventional 

risk factor for endometrial adenocarcinoma, such as hypertension, 

obesity or diabetes. A previous diagnostic hysteroscopy 

with biopsy, performed after the first clinical examination in 

March 2010, ruled out a diagnosis of glandular hyperplasia of 

the endometrium. In September 2011, the patient presented to 

our Department with an enlarged uterus reaching the transumbilical 

plane. Serum CA125 levels significantly increased up to 241 

mU /ml eighteen months later. An abdominal hysterectomy with 

salpingo-oophorectomy was performed. 

Grossly, the uterus appeared enlarged and deformed by the presence 

of many intramural and subserous miomas. 

Results. Histopathological features revealed tumor mainly composed 

of a well-differentiated endometrioid adenocarcinoma with 

an admixed component of cytotrophoblast-like pleomorphic cells 

with large, rounded nuclei and clear cytoplasm, and syncityallike 

cells with multiple, irregular and hyperchromatic nuclei and 

eosinophilic cytoplasm. Immunohistochemical stainings showed 

a strong and diffuse positivity for Cytokeratin 7 and Cytokeratin 

AE1/AE2 of the EAC tumor cells whereas a negativity for 

p53 was detected. A single submillimetric focus of myometrial 

invasion was observed and highlighted by the Cytokeratin AE1/ 

AE3 stain. Stains for Cytokeratin AE1/AE2, β-hCG and HER-2 

showed a positive reaction in syncytiotrophoblast-like cells. 

Thus, a diagnosis of low-grade (G1) endometrioid adenocarcinoma 

(EAC) with choriocarcinomatous differentiation (CD) was 

posed. 

Up to now, the patient’s health conditions are good, with any 

evidence of local or distant metastases. 

Conclusions. First described by Civantos and Rywlin in 1972, 

endometrial adenocarcinoma with choriocarcinomatous differentiation 

is still considered a very rare entity with an aggressive 

biological course. It usually occurs in middle age women, with a 

mean age of 69.7 years (range 48-88). The aetiology and patho- 


Sala Caravaggio – ore 17,00-18,30 

311 

Fig. 1A and B. a well-differentiated endometrioid adenocarcinoma 

with an admixed component of cytotrophoblast-like pleomorphic 

cells with large, rounded nuclei and clear cytoplasm, and syncityal-like 

cells with multiple, irregular and hyperchromatic nuclei and eosinophilic 

cytoplasm. (H&E, 4x and 20x magnification). 

genesis of a trophoblastic differentiation within adenocarcinoma 

of the endometrium is still poorly understood. Abnormal uterine 

bleeding, bloodstained vaginal discharge and/or abdominal pain 

represent the most common clinical presentations. Surgical treatment 

represents the gold standard therapy of this kind of tumors, 

even though chemotherapy has been sometimes suggested in addition. 

A close follow-up is recommended. 

Up to now, less than twenty cases have been reported so far 1-16 . 

A CD has been reported in association with some kind of tumors, 

generally sited in the female genital tract and rarely with 

carcinomas of other sites (i.e., urinary tract, gastrointestinal tract, 

lung and breast). Thus, a differential diagnosis with giant cell 

carcinoma, carcinosarcoma, undifferentiated carcinoma with 

giant cells should be considered and an accurate anamnestical, 

clinical, histopathological and immunohistochemical study 

should be performed in the aim to achieve the correct diagnosis. 

The presence of at least a focus of a conventional EAC should 

support the diagnosis of a CD, as well as an advanced age of the 

patient, the presence of syncityal-like giant β-hCG positive cells, 

as in the present case. 

Since a CD is reported to have an aggressive biological course, 

with early extensive metastases and poor prognosis if compared 

to other gynaecological cancers without this component, the goal 

of every pathologist is to achieve the correct diagnosis in the aim 

to improve the patient’s outcome, by ensuring that the most appropriate 

therapy approach is chosen. 

Fig. 2. Strong expression for Cytokeratin 7 in both component (CK7, 

10x magnification).

312 

Fig. 3. β-hCG (a) and HER-2 (B) showed a positive reaction in syncytiotrophoblast-like 

cells (10x magnification). 

references 

1 Civantos F, Rywlin A. Carcinomas with trophoblastic differentiation 

and secretion of chorionic gonadotrophins. Cancer 1972;29:689-798. 

2 Akbulut M, Tosun H, Soysal ME. Endometrioid carcinoma of the endometrium 

with choriocarcinomatous differentiation: a case report and 

review of the literature. Obstet Gynecol Oztekin O Arch 2008;278:79-84. 

3 Yamada T, Mori H, Kanemura M. et al. Endometrial carcinoma with 

choriocarcinomatous differentiation: a case report and review of the 

literature. Gynecol Oncol 2009;113:291-4. 

4 Akbulut M, Tosun H, Soysal ME, et al. Endometrioid carcinoma of the 

endometrium with choriocarcinomatous differentiation: a case report 

and review of the literature. Arch Gynecol Obstet 2008;278:79-84. 

5 Horn LC, Hanel C, Bartholdt E, et al. Serous carcinoma of the endometrium 

with choriocarcinomatous differentiation: a case report 

and review of the literature indicate the existence of 2 prognostically 

relevant tumor types. Int J Gynecol Pathol 2006;25:247-51. 

6 Patil S, Ramakrishna KA, Rao SG, et al. Choriocarcinoma - a rare 

association with squamous cell carcinoma of esophagus. Indian J 

Gastroenterol 2006;25:42-3. 

7 Dennis PM, Turner AG. Primary choriocarcinoma of the bladder 

evolving from a transitional cell carcinoma. J Clin Pathol 

1984;37:503-5. 

8 Grammatico D, Grignon DJ, Eberwein P, et al. Transitional cell carcinoma 

of the renal pelvis with choriocarcinomatous differentiation. 

Immunohistochemical and immunoelectron microscopic assessment of 

human chorionic gonadotropin production by transitional cell carcinoma 

of the urinary bladder. Cancer 1993;71:1835-41. 

9 Yoon JH, Kim MS, Kook EH, et al. Primary gastric choriocarcinoma: 

two case reports and review of the literatures. Cancer Res Treat 

2008;40:145-50. 

10 Verbeek W, Schulten HJ, Sperling M, et al. Rectal adenocarcinoma 

with choriocarcinomatous differentiation: clinical and genetic aspects. 

Hum Pathol 2004;35:1427-30. 

11 Chen F, Tatsumi A, Numoto S. Combined choriocarcinoma and adenocarcinoma 

of the lung occurring in a man: case report and review 

of the literature. Cancer 2001;91:123-9. 

12 Erhan Y, Ozdemir N, Zekioglu O, et al. Breast carcinomas with choriocarcinomatous 

features: case reports and review of the literature. 

Breast J 2002;8:244-8. 

13 Maesta I, Michelin OC, Traiman P, et al. Primary non-gestational 

choriocarcinoma of the uterine cervix: a case report. Gynecol Oncol 

2005;98:146-50. 

14 Schwab KE, Chan RW, Gargett CE. Putative stem cell activity of 

human endometrial epithelial and stromal cells during the menstrual 

cycle. Fertil Steril 2005;84(Suppl. 2):1124-30. 

Adenomatoid tumor of the uterus: 

a case report of a rare benign entity 

G. Crisman1 , I. Cicchinelli1 , A.R. Vitale2 , G. Coletti3 , S. Di Rito1 , 

F. Patacchiola4 , G. Carta5 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 



Ospedale Civile “San Salvatore”, L’Aquila, Italia; 4 U.O.C. Ginecologia 

ed Ostetricia, Ospedale “Val Vibrata”, Sant’Omero (TE), Italia; 5 U.O.C. 

Ginecologia ed Ostetricia D.U., Università dell’Aquila, L’Aquila, Italia 

Background. First described by Golden and Ash in 1945, Adenomatoid 

Tumor represents a benign neoplasm occurring most 


Fig. 1. Histological features of the lesion: revealed prominent fascicles 

of smooth muscle with scattered cuboidal and signet ring-like cells 

with an optical white, scant cytoplasm (a: H&E, 10x magnification; B: 

H&E, 20x magnification). 

frequently in the epididymis in males and the fallopian tubes in 

females. According to the literature, less frequently adenomatoid 

tumor occurs in the uterus, with an incidence of only 10 in 8000 

hysterectomy specimens in one series. The histogenesis of the 

adenomatoid tumor is still debatable, but recently a mesothelial 

origin has been proved by ultrastructural and immunohistochemical 

studies. 

Material and methods. We experienced a case of an adenomatoid 

tumor in a 32-year-old woman who presented to the Gynaecological 

Department with an uterine mass of 2,5 cm in-diameter. 

Clinical diagnosis of a myomatous nodule was posed and the 

mass has been surgically removed and sent to the Pathology Unit. 

Grossly, the nodule presented as a whitish, rounded mass, of 

hard-elastic consistency, measuring 2,5x2,5x1,3 cm. 

Results. Histological features of the lesion revealed prominent 

fascicles of smooth muscle with scattered cuboidal and signet 

ring-like cells with an optical white, scant cytoplasm. Mild 

nuclear atypia of these cells and low mitotic activity was observed 

as well. The tumor cells positively expressed CK AE1/ 

AE3, Calretinin, and D2-40, and did not express alpha-inhibitin 

and Melan-A. The prominent smooth muscle component strongly 

stained for Actin. Thus, a diagnosis of Adenomatoid Tumor was 

posed. 

Conclusions. The characteristic histopathological features usually 

lead to the correct diagnosis in the majority of adenomatoid 

tumors. However, several unusual features may result in a di- 

Fig. 2. a. tumor cells strongly stained for Calretinin (Calretinin, 10x 

magnification). B. tumor cells strongly stained for Cytokeratin aE1/ 

aE3 (CK aE1/aE3, 20x magnification). 

Fig. 3. a. tumor cells strongly stained for d2-40 (d2-40, 20x magnification). 

B: the prominent smooth muscle component strongly 

stained for actin (actin, 10x magnification).


agnostic challenge. As in the present case, a prominent smooth 

muscle component with only scattered tumor cells may be 

mistaken for a leiomyoma, even though an association between 

adenomatoid tumors and leiomyomas seem to be not uncommon. 

Moreover, adenomatoid tumors with a solid growth pattern or 

cords of cells may be mistaken for an infiltrating malignant epithelial 

or mesothelial neoplasm. A differential diagnosis with a 

signet ring cell adenocarcinoma should be considered when small 

cells with small vacuoles are observed. In conclusion, we underline 

the importance to investigate each gynaecological lesion with 

great attention, in the aim to avoid over or under treatment in such 

challenging cases. 

references 

1 Goddard MJ, Grant JW. Adenomatoid tomours; a mucin histochemical 

and immunohistochemical study. Histopathology 1992;20:57-71. 

2 Nogales FF, Isaac MA, Hardisson D, et al. Adenomatoid tumors of the 

uterus: an analysis of 60 cases. Int J Gynecol Pathol 2001;21:34-40. 

3 Quigley JC, Hart WR. Adenomatoid tumors of the uterus. Am J Clin 

Pathol 1981;76:627-35. 

4 Young RH, Silva EG, Scully RE. Ovarian and juxtaovarian adenomatoid 

tumors: a report of six cases. Int J Gynecol Pathol 1991;10:364- 

72. 

5 Amre R, Constantino J, Lu S, et al. Pathologic quiz case: a 52-yearold 

woman with a uterine mass. Arch Pathol Lab Med 2005;129:77-8. 

6 Skinnider BF, Young RH. Infarcted adenomatoid tumor; a report of 

five cases of a facet of a benign neoplasm that may cause diagnostic 

difficulty. Am J Surg Pathol 2004;28:77-83. 

7 Epstein JI. Urologic disorders: Differential Diagnosis in Pathology. 

New York, NY: Igasku-Shoin 1992, pp. 173-4. 

8 Golden A, Ash JE. Adenomatoid tumors of the genital tract. Am J 

Pathol 1945;21:63-79. 

9 Tiltman AJ. Adenomatoid tumors of the uterus and adnexa. Histopathology 

1980;4:437-43. 

10 Hes O, Perez-Montiel P, Alvarado Cabrer I, et al. Thread-like bridging 

strands: a morphologic feature present in all adenomatoid tumors. 

Ann Diagn Pathol 2003;7:273-7. 

11 Phillips V, McCluggage WG, Young RH. Oxyphilic adenomatoid 

tumor of the ovary: a case report with discussion of the differential 

diagnosis of ovarian tumors with vacuoles and related spaces. Int J 

Gynecol Pathol 2007;26:16-20. 

12 Irikoma M, Takahashi K, Kurioka H, et al. Uterine adenomatoid 

tumors confirmed by immunohistochemical staining. Arch Gynecol 

Obstet 2001;265:151-4. 

13 Palacios J, Manrique AS, Villaespesa AR, et al. Cystic adenomatoid 

tumor of the uterus. Int J Gynecol Pathol 1991;10:296-301. 

A new monoclonal antibody kit for detecting HPV 

E7 oncoprotein: could it be a suitable, specific 

biomarker for hpv infection in cervical biopsies? 

G. Crisman1 , A.R. Vitale2 , L. Sollima1 , S. Bonin3 , V. Ciuffetelli4 , 

A. Dal Mas4 , S. Saltarelli4 , L. Muzzolini5 , P. Zago5 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 

dell’Aquila, L’Aquila, Italia; 2 U.O.C. Anatomia Patologica, P.O. “SS. 

Filippo e Nicola”, Avezzano (AQ), Italia; 3 Dip. Univ. Cl. di Scienze Mediche, 

Chirurgiche e della Salute, Università di Trieste, Trieste, Italia; 

4 U.O.C. Anatomia Patologica, Ospedale Civile “San Salvatore”, L’Aquila, 

Italia; 5 Adriacell SpA, Trieste, Italia 

Introduction. The association of human papilloma virus (HPV) 

infection and cervical intraepithelial neoplasia (CIN) is well 

recognized. High-risk human papillomavirus (HR-HPV) infection 

are responsible of the vast majority of CINs and cervical 

carcinomas (CC) whereas the low-risk HPV(LR-HPV) types are 

rarely found. 

The different oncogenic potential of HR-HPV and LR-HPV is 

due to the different interactions of two major viral oncoproteins, 

E6 and E7, with cellular regulatory proteins, p53 and pRb. Interaction 

of HPV E6 and E7 oncogenic proteins with key regulatory 

cellular proteins leads to up regulation of p16INK4a , a CDK 

inhibitor. The overexpression of p16INK4a represents nowadays an 

indirect immunohistochemical marker for HPV infection, even 

313 

Fig. 1. HpV E7 viral oncoprotein expression in CiN1 (a), CiN2 (B) and 

CiN3(C) lesions. the expression strongly correlates with the grade of 

ciN 

though p16 INK4a -negative CINs and CCs are described. Thus, a 

more specific biomarker for HPV infection is needed. 

We investigated the expression of a new immunohistochemical 

monoclonal antibody kit which detects high-risk E7 oncogenic 

proteins of the Alpha-Papillomavirus genus (species 5,6,7 and 9) 

and compared the results with the p16 INK4a expression in CINs. 

Material and methods. Retrospective analysis of 50 paraffinembedded 

samples of diagnostic biopsies and surgical materials 

was performed by immunohistochemistry using commercially 

Fig. 2. a 20-year old woman with a pap smear diagnosis of l-Sil. 

Histological features of the cervical biopsy revealed a CiN1 lesion (a), 

p16 negative (B), HpV E7 viral oncoprotein positive (C). pCR investigations 

confirmed the presence of HpV 31 dNa.

314 

available mouse monoclonal antibody to p16 (clone E6H4) and 

monoclonal antibody kit to HPV E7 viral oncoprotein. All samples 

were tested for the presence of HPV DNA using a consensus 

GP5+/ GP6+ PCR and a small sample of CIN1 lesions p16- E7+ 

was tested for LCR-E7-PCR. 

Results. p16 immunoreactivity was found to be both nuclear 

and/or cytoplasmic. HPV E7 viral oncoprotein expression was 

found to be both nuclear and/or cytoplasmatic as well. The normal 

cervical epithelium was predominantly negative for p16 and 

completely negative for HPV E7 viral oncoprotein. Despite 17 

CIN1 lesions showed a p16 negativity, HPV E7 viral oncoprotein 

expression was detected in all samples. 14 CIN1 p16+ lesions, 5 

CIN2 lesions and 5 CIN3 lesions showed a HPV E7 viral oncoprotein 

expression increased in parallel with the grade of CIN. 

10 normal cervical tissues have been selected as controls and 

resulted negative for the stain with HPV E7 viral oncoprotein. 

Conclusions. HPV E7 viral oncoprotein expression strongly 

correlates with the grade of CIN and represents a sensitive and 

specific marker of HPV infection, since its viral origin. Thus, the 

interpretation of the HPV E7 viral oncoprotein immunoreactivity 

results does not rely on subjective criteria. 

references 

1 Guo F, Liu Y, Wang X, et al. Human Papillomavirus Infection and 

Esophageal Squamous Cell Carcinoma: A Case-Control Study. Cancer 

Epidemiol Biomarkers Prev 2012 Mar 15. 

2 Zhang K, Li JT, Li SY, et al. Integration of human papillomavirus 

18 DNA in esophageal carcinoma 109 cells. World J Gastroenterol 

2011;17:4242-6. 

3 Volgareva GM, Zavalishina LE, Golovina DA, et al. Detection of 

oncoprotein E7 HPV16 in the cancer and normal urinary bladder 

urothelium. Arkh Patol 2009;71:29-30. 

4 Thomas J, Primeaux T. Is p16 immunohistochemistry a more costeffective 

method for identification of human papilloma virus-associated 

head and neck squamous cell carcinoma? Ann Diagn Pathol 

2012;16:91-9. 

5 Kostopoulou E, Samara M, Kollia P, et al. Different patterns of p16 

immunoreactivity in cervical biopsies: correlation to lesion grade and 

HPV detection, with a review of the literature. Eur J Gynaecol Oncol 

2011;32:54-61. 

6 Benevolo M, Terrenato I, Mottolese M, et al. Comparative evaluation 

of nm23 and p16 expression as biomarkers of high-risk human papillomavirus 

infection and cervical intraepithelial neoplasia 2(+) lesions 

of the uterine cervix. Histopathology. 2010 Oct;57(4):580-6. doi: 

10.1111/j.1365-2559.2010.03674.x. 

Prognostic role of histological parameters 

in ovarian epithelial cancers: a population 

based analysis 

A. Caldarella 1 , E. Crocetti1 , G. Amunni1 , G.L. Taddei2 , 

A.M. Buccoliero3 , F. Castiglione2 , D. Moncini2 , E. Proietto2 , 

A. Corbinelli1 , T. Intrieri1 , G. Manneschi1 , L. Nemcova1 , C. Sacchettini1 

, E. Paci1 1 2 Institute for Study and Cancer Prevention (ISPO), Florence; Service of 

Pathology, Anna Meyer Children Hospital, Florence; 3 Section of Pathological 

Anatomy, Department of Medical and Surgical Critical Care, University 

of Florence, Florence 

Background. A model for ovarian carcinogenesis in primary 

epithelial ovarian cancer based on two histological categories 

was recently proposed to identify a prognostic impact. According 

to this model, we evaluate the clinicopathological characteristics 

and the survival rates in a population based series of ovarian 

cancer patients. 

Materials and methods. Through the Tuscan Cancer Registry all 

histological reports of invasive ovarian epithelial cancer cases diagnosed 

during the period 2000-2005 in the provinces of Florence 

and Prato, central Italy, were retrieved and information on age at 

diagnosis, tumor size, lymph node status, histological type, grade 

of differentiation, and pathological stage (I-II vs III-IV) were 


collected. Histological type was categorized as serous, mucinous, 

endometrioid, clear cell, Brenner, carcinosarcoma, undifferentiated 

and other types (carcinoma nos and rare types). According to 

histological grade, carcinomas were classified as well, moderately 

and poorly differentiated carcinoma. Two risk categories, according 

to a combination of histotype and grade of tumor, were identified: 

high (poorly differentiated serous type, poorly differentiated 

endometroid type, undifferentiated tumors) and low (well/ 

moderate differentiated serous type, well/moderate differentiated 

endometroid type, clear cell type, mucinous type) risk. 

Results. Out of 991 patients with diagnosis of ovarian epithelial 

invasive cancer, the most frequently histological diagnosis type 

was serous carcinoma (39%), and nearly half of tumors were 

poorly differentiated (43%). According to the two-risk categories 

model, 50.3% of patients had low risk at time of diagnosis; these 

patients were younger and with earlier stage cancer than patients 

with high risk cancer (p < 0.05). The 5-year survival rates for 

high and low risk patients were 38% and 62%, respectively 

(P < 0.000). A Cox proportional hazards model analysis including 

age and stage at diagnosis indicated that the ‘new’ histological 

characterization have an independent prognostic factor (HR for 

high vs low 1.55 CI.23-1.97). 

Conclusions. Our study showed that the combination of histological 

type and grade of differentiation has significant prognostic 

role in epithelial ovarian cancer. When compared with high risk 

patients, low risk patients appear to present at younger age and 

earlier stage and have significantly higher survival. 

references 

1 Kurman RJ, Shih I-M. Pathogenesis of ovarian cancer. Lessons from 

morphology and molecular biology and their clinical implications. Int 

J Gynecol Pathol 2008;27:151-60. 

2 Braicu EI, Sehouli J, Richter R, et al. Role of histological type on surgical 

outcome and survival following radical primary tumor debulking 

of epithelial ovarian, fallopian tube and peritoneal cancers. Brit J 

Cancer 2011;105:1818-24. 

Dystrophic calcified nodule of the testis: 

a case report, a review of the literature 

and a few aetiopathogenetic hypothesis 

I. Cicchinelli1 , G. Crisman1 , A.R. Vitale2 , T. Curti2 , F. Brunelli2 , 

G. Calvisi3 , M. Quaglieri4 , G. Coletti3 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 



Ospedale Civile “San Salvatore”, L’Aquila, Italia; 4 U.O.C. Chirurgia 

Generale, Ospedale Civile Castel di Sangro, Castel di Sangro (AQ), Italia 

Background. First described by Minkowitz et al., the dystrophic 

calcified nodule of the testis represents an extremely rare lesion, 

with a generally favourable course and unknown etiology. However, 

since several benign and malignant testicular lesion can be 

associated with an intratesticular calcification, even though this 

aspect is really an uncommon finding, an accurate differential 

diagnosis should be performed in the aim to exclude malignancies. 

As a matter of fact, testis neoplasms represent up to 10% of 

the tumors of the male reproductive system with three distinctive 

peaks of incidence (children < 5 years, between the second and 

the fourth decades of life and men > 60 years). According to the 

literature, this report on a solitary dystrophic calcified nodule 

seems to be the sixth case of this poorly-understood entity. 

Material and methods. A 26-year-old man presented to Castel di 

Sangro General Hospital (L’Aquila, Italy) with a four-day history 

of left scrotal discomfort only in the upright standing posture. 

Physical examination revealed a left testicle’s mass, without 

changes of the superficial skin. The patient denied any constitutional 

symptoms or pain in supine position. The right testicle was 

normal. In the suspicion of a varicocele, the patient underwent to 

a scrotal US, which revealed a III grade varicocele and a nodular,


Fig. 1. ultrasound examination: presence of a calcified lesion on the 

top of his left testis, of 11mm in –diameter. 

Fig. 2. dystrophic calcification characterized by focal and distinct 

mild osteoblastic activity. (H&E, 4x (a) and 20x (B) magnification). 

calcified lesion on the top of his left testis, of 11mm in –diameter. 

Results. An incisional biopsy of the nodular lesion has been 

performed and the histological features revealed a dystrophic 

calcification with a mild osteoblastic activity and no evidence of 

ischemia, orchitis, epididymitis, hematoma, necrosis or neoplasia. 

The fibrous capsula of the nodule did not show osteoblasts or calcification. 

Immunohistochemical analysis for PLAP and CD117 

resulted negative. Thus, a diagnosis of intratesticular dystrophic 

calcified nodule was posed. 

Conclusions. Several benign and malignant testicular lesion can 

be asscociated with an intratesticular calcification. As a matter of 

fact, spermatic granulomas, phleboliths, or vascular calcification 

may present with solitary calcified foci, whereas multiple scattered 

echogenic foci within the testis should suggest a testicular 

microlithiasis, a very rare condition. Inflammatory disease of the 

epididymis could result in a calcification but it is usually extratesticular. 

Infections, trauma and malignant neolplasms (i.e., large 

calcyfing Sertoli cell tumor) could present with intratesticular 

calcification, thus an accurate physical examination of the patient 

and of the histological sections of the involved testis should performed 

in the aim to achieve the correct diagnosis and avoid over 

or undertreatment. 

references 

1 Sigiyama T, Hirano Y, Ushiyama T, et al. Burned-out testicular tumor. 

Department of Urology, Hamamatsu Universty School of Medicine. 

Hinyokika Kiyo 2000;46:829-32. 

2 Minkowitz S, Soloway H, Soscia J. Ossifying interstitial cell tumor of 

the testes. J Urol 1965;94:592-5. 

3 Yoneda F, Kagawa S, Kurokawa K. Dystrophic calcifying nodule with 

osteoid metaplasia of the testis. Br J Urol 1979;51:413. 

4 Minkowitz G, Lee M, Minkowitz S. Pilomatricoma of the testicle: an 

ossifying testicular tumor with hair matrix differentiation. Arch Pathol 

Lab Med 1995;119:96-9. 

315 

5 Mesia L, Georgsson S, Zuretti A. Ossified intratesticular mucinous 

tumor. Arch Pathol Lab Med 1999;123:244-6. 

6 Comiter CV, Renshaw AA, Benson CB, et al. Burned out primary 

testicular cancer; sonographic and pathologic characteristics. J Urol 

1996;156:85-8. 

7 Viola P, Claudi R, Pompa P, et al. A diagnostic dilemma: dystrophic 

calcified nodule of the testicle in a patient with no other symptoms. 

Case report and review of the literature. Urol Int 2012;88:232-4. 

Placental lesions in fetal growth restriction 

with different etiologies 

B. Dal Bello1 , A. Spinillo2 , B. Gardella2 , S. Cesari1 , E.M. Silini3 1 Fondazione IRCCS Policlinico San Matteo- Università degli Studi di 

Pavia, SC Anatomia Patologica, Pavia, Italy; 2 Fondazione IRCCS Policlinico 

San Matteo- Università degli Studi di Pavia, SC Ostetricia e Ginecologia, 

Pavia, Italy; 3 Azienda Ospedaliero-Universitaria di Parma, SC 

Anatomia Patologica, Parma, Italy 

Background. Fetal growth restriction (FGR) and preeclampsia 

(PE) are “great obstetrical syndromes” that share defective deep 

placentation as a common pathogenetic mechanism 1 2 . Placental 

abnormalities have been described in FGR, but little is known 

about the prevalence and the distribution of histological lesions 

according to the etiology and the clinical severity of the disease 3 4 . 

We performed a detailed and systematic study of placental pathology 

in FGR and compared individual lesions and patterns of 

lesions between pre-eclamptic and normotensive FGR. 

Material and methods. A monoinstitutional, retrospective series 

of 126 singleton pregnancies complicated by FGR was followed 

until delivery. FGR and PE were diagnosed according to ACOG 

criteria. 

Placentas were analysed according to a standardized protocol 

and all slides were blindly reviewed by two experienced pathologists. 

Pathologic findings were assessed and recorded using a 

predefined set of variables according to the classification of the 

Perinatal Section of the Society for Pediatric Pathology 5-7 ; both 

elementary lesions and pathologic patterns were considered. 

Logistic regression analysis was performed to evaluate clinicopathological 

correlations adjusting for confounders. Logistic 

equations included PE as outcome variable and individual histologic 

findings, gestational age at birth and ratio of placental to 

neonatal weight as explanatory variables. 

Results. PE was diagnosed in 54 (43%) of pregnancies. A lower 

gestational age at delivery (p 0.01), a shorter time to delivery (p 

0.048) and a lower neonatal weight (p 0.001) were found in FGR 

associated with PE. No difference in neonatal outcome was found 

in PE compared to normotensive FGR. 

Macroscopic and histologic findings of the 126 placentas are 

summarized in Table I. 

Organized infarctions (63% vs, 32%, p 0.001) and several elementary 

microscopic lesions were identified more frequently in 

the FGR group with PE, including: increased syncitial knots (p 

0.006), atherosis of spiral arteries (p 0.003), mural arterial hypertrophy 

(p 0.065), muscular spiral arteries (p 0.044), giant trophoblastic 

cells (p 0.004) and immature intermediate trophoblast at 

implantation site (p 0.003). Conversely, chronic villitis was more 

common in the normotensive FGRs (p 0.016). 

A superficial implantation pattern was identified with higher 

prevalence in FGR with PE (78% vs 52.1%, p 0.003). 

After correction for gestational age at delivery and for placental/ 

neonatal weight ratio, organised infarction (p 0.001), increased 

syncitial knots (p 0.037), atherosis (p 0.044), giant trophoblastic 

cells (p 0.029), immature intermediate trophoblast (p 0.020) and 

superficial implantation pattern (p 0.035) directly correlated with 

FGR associated with PE, while chronic villitis was inversely correlated 

(p 0.033). 

Discussion. Elementary lesions related to superficial implantation 

were highly prevalent in placentas from FGR pregnancies 

and their frequency was significantly higher in PE. The maternal

316 

vascular insufficiency pattern was more frequent in the PE group, 

although highly represented also among normotensive FGR. Finally, 

chronic villitis was more common in normotensive FGR. 

Few studies have performed a systematic pathological assessment 

of FGR placentas or have correlated histology findings with 

clinical outcome and FGR etiology 8 9 . Previous studies were also 

limited by small sample size, different inclusion criterion, variability 

in clinical and pathologic measures, and lack of multivariate 

statistical analysis. Recently, Kovo et al (10) reported a higher 


Tab. I. placental pathologic findings in 126 pregnancies complicated by fGR according to the presence of pE. 

Variables 

Variables detected at gross examination 

Category 

With PE 

n 54 (%) 

W/o PE 

n 72 (%) 

p 

placental weight (g) mean±ds 266±74 266±96 0.203 

Placental maximum diameter (cm) mean±ds 14.0±2.3 14.1±2.4 0.816 

Placental minimum diameter (cm) mean±ds 11.1±2.1 11.6±2.2 0.223 

placental maximum width (cm) mean±ds 2.6±0.6 2.7±0.8 0.445 

placental minimum width (cm) mean±ds 1.5±0.6 1.7±0.6 0.031 

Cord length (cm) mean±ds 23.9±10.0 24.5±10.9 0.767 

cord diameter (cm) mean±ds 1.0±0.3 1.0±0.3 0.627 

Retroplacental hematoma Present 4 (7.4) 5 (6.9) 0.920 

intervillous thrombus Present 5 (9.2) 12 (16.7) 0.228 

Recent infarction Present 11 (20.4) 8 (11.1) 0.151 

organized infarction Present 34 (63) 23 (31.9) 0.001 

Chronic abruption Present 2 (3.7) 0 0.100 

fibrin deposition 

Microscopic variables 

Mild 

Massive 

3 (5.5) 

1 (1.8) 

6 (8.3) 

2 (2.8) 

0.782 

Chorionamnionatis grade 

Mild 

Moderate-severe 

3 (5.5) 

0 

5 (6.9) 

1 (1.4) 

0.647 

Chorionamnionitis stage 

1 

2 

3 (5.5) 

0 

3 (4.2) 

3 (4.2) 

0.301 

inflammatory fetal reaction Present 0 1 (1.4) 0.385 

acute villitis Present 1 (1.8) 1 (1.4) 0.837 

Chronic villitis Present 4 (7.4) 17 (23.6) 0.016 

fetal thrombotic vasculopathy Present 2 (3.7) 4 (5.5) 0.629 

fVt+ avascular villi Present 15 (27.8) 16 (22.2) 0.474 

fVt grade 

Mild 

Moderate-severe 

6 (11.1) 

9 (16.7) 

9 (12.5) 

7 (9.7) 

0.510 

Meconium staining of membranes Present 38 (70.4) 53 (73.6) 0.688 

Syncitial knots 

< 30% 

> 30% 

12 (22.2) 

38 (70.4) 

29 (40.3) 

30 (41.7) 

0.006 

Villous agglutination < 20 

> 20 

10 (18.5) 

7 (13) 

13 (18.1) 

6 (8.3) 

0.685 

intervillous fibrin deposition mild-moderate 

Marked 

30 (55.5) 

14 (25.9) 

42 (58.3) 

22 (30.5) 

0.482 

Villous hypoplasia Present 13 (24.1) 15 (20.8) 0.665 

atherosis of spiral arteries Present 20/51 (39.2) 11/71 (15.5) 0.003 

mural arterial hypertrophy Present 31 (57.4) 29 (40.3) 0.065 

Muscular arteries in basal plate Present 24/46 (52.2) 23/69 (33.3) 0.044 

trophoblastic giant cells Present 38 (70.4) 31/70 (44.3) 0.004 

immature intermediate trophoblast 

Class of pathological lesions 

Present 42 (77.8) 36/70 (51.4) 0.003 

Superficial implantation Present 42 (77.8) 37/71 (52.1) 0.003 

infection/inflammation Present 3 (5.5) 7 (9.7) 0.392 

fetal vascular damage Present 15 (27.8) 16 (22.2) 0.474 

Maternal vascular damage Present 33 (61.1) 35 (48.6) 0.164 

prevalence of maternal vascular lesions in PE-associated FGR 

than in normotensive FGR and in PE without FGR; conversely, 

fetal vascular anomalies and chronic villitis were more frequent 

in normotensive FGR. 

The strength points of our study are: a) standardized pathologic 

evaluation, including systematic macroscopic examination and 

sampling of the placentas, use of validated diagnostic criteria, 

semiquantitive scoring of elementary histological features, 

analysis of patterns of lesions; b) reproducibility of pathologic


evaluation that was blindly reviewed by two dedicated pathologists 

(with satisfactory positive and negative agreement); c) comparison 

of histological pattern in FGR with different etiology; d) 

multivariate statistical analysis to assess for independent associations. 

We adopted a multivariate analysis model that corrects data 

for gestational age and placental weight as pathologic lesions are 

strongly dependent on the developmental stage. 

Potential limitations of the study are related to the: a) current 

criteria used to define the maternal underperfusion pattern; 

b) monoinstitutional and retrospective design that may have 

introduced a selection bias; c) lack of control placentas from 

pregnancies either complicated only by PE and not FGR and of 

uncomplicated pregnancies. 

Conclusions. FGR with different etiology show differences in 

type, prevalence and distribution of placental lesions suggesting 

a different relevance in the development and clinical evolution 

of FGR. Further studies with stringent and validated criteria are 

needed to definitely clarify the significance of placental pathology 

in FGR with different etiology. 

references 

1 Brosens I. The “Great Obstetrical Syndromes” are associated with 

disorders of deep placentation. Am J Obstet Gynecol 2011;204:193- 

201. 

2 Romero R, et al. Placental disorders in the genesis of the great obstetrical 

disorders. In: Pijnenborg R, Brosens I, Romero R, editors. Placental 

Bed Disorders. Cambridge University Press 2010, pp. 271-89. 

3 Roberts DJ, et al. The placenta in preeclampsia and intrauterine 

growth restriction. J Clin Pathol 2008;61:1254-60. 

4 Tomas SZ, et al. Morphological characteristics of placentas associated 

with idiopathicintrauterine growth retardation: a clinicopathologic 

study. Eur J Obstet Gynecol Reprod Biol 2010;152:39-43. 

5 Redline R, et al. Maternal vascular underperfusion: nosology and 

reproducibility of placental reaction patterns. Ped and Dev Path 

2004;7:237-49. 

6 Redline R, et al. Fetal vascular obstructive lesions: nosology and 

reproducibility of placental reaction patterns. Ped and Dev Path 

2004;7:443-52. 

7 Redline R, et al. Amniotic infection syndrome: nosology and reproducibility 

of placental reaction patterns. Ped and Dev Path 2003;6:435-48. 

8 Aviram A, et al. Placental aetiology of foetal growth restriction: clinical 

and pathological differences. Early Hum Dev 2010;86:59-63. 

9 Vedmedovska N, et al. Placental pathology in fetal growth restriction. 

Eur J Obstet Gynecol Reprod Biol 2011;155:36-40. 

10 Kovo M, et al. Placental vascular lesion differences in pregnancyinduced 

hypertension and normotensive growth restriction. Am J 

Obstet Gynecol 2010;202:561.e1-5. 

A case of primary peritoneal malignant mixed 

mullerian tumor 

E. Di Cola1 , G. Crisman1 , A.R. Vitale2 , T. Curti2 , S. Discepoli2 , 

G. Coletti3 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 

degli Studi dell’Aquila, L’Aquila, Italia, 2 U.O.C. Anatomia Patologica, 

P.O. “SS. Filippo e Nicola”, Avezzano (AQ), Italia; 3 U.O.C. Anatomia 

Patologica, Ospedale Civile “San Salvatore”, L’Aquila, Italia 

Background. Extragenital malignant mixed mesodermal (Müllerian) 

tumors (MMMT) are very rare neoplasms, with aggressive 

behaviour. The characteristic histological feature is represented 

by a biphasic pattern, consisting of both epithelial and mesenchymal 

component. Endometrium represents the most common 

site of onset, even though few cases arising from tube, cervix and 

vagina have been described. Only 31 cases of primary peritoneal 

MMMT have been reported so far, and other extragenital (i.e., 

ureters) sites of onset seem to be even rarer. 

The etiology and histopathogenesis of these kind of tumors 

remains controversial and the correlation between primary peritoneal 

MMMT and the expression for estrogen receptor (ER) and 

progesterone receptor (PR) has not been documented yet. 

Material and methods. A 86-year-old woman presented to the 

317 

Fig. 1. a. Epithelial (squamous) differentiation of the lesion (H&E, 20x 

magnification). B: mesenchymal (cartilagineous) differentiation of the 

lesion. (H&E, 10x magnification). 

Fig. 2. a: pan- Cytokeratins positivity of the epithelial component 

(paN-CK, 10x magnification). B: Smooth-muscle actin positivity of the 

mesenchymal component (Sma, 10x magnification). 

Hospital of Avezzano with acute abdomen and anemia. Abdominal 

ultrasound examination revealed a large, rounded mass with 

ill-defined margins of the lower abdominal wall, displacing adjacent 

small-bowel loops. 

The patient underwent abdominal surgery and a bulky abdominal, 

bleeding mass of 20cm in-diameter, arising from the peritoneum, 

has been excised. Moreover, several masses scattered on the parietal 

and visceral peritoneum have been detected as well. 

The postoperative course showed a mild improvement of the patient’s 

clinical however, the situation suddenly worsened and the 

patient died shortly after. 

Results. Histological examination of the surgical specimens revealed 

a tumor mainly composed by an epithelial carcinomatous 

component (tubulo-papillary and squamous type) and a smaller 

mesenchymal component, characterized by well differentiated 

stromal elements including cartilage and smooth muscle, and 

undifferentiated stromal cells. 

Immunohystochemical stains revealed a biphasic pattern of the 

tumor: the epithelial component strongly stained for Cytokeratins, 

whereas the stromal component strongly stains for mesenchymal 

markers, such as smooth-muscle actin and Vimentin. Any 

expression for ER and PR was detected. 

Conclusions. We reported a rare case of primary, aggressive 

peritoneal MMMT, occurring in an old, post-menopausal woman, 

presenting with the classical biphasic pattern (epithelial and stromal 

differentiation) with a prevalence of the well-differentiated 

adenocarcinomatous component on the squamous carcinomatous 

component, in association with heterologous aspects of the 

sarcomatous component. The authors suggested that the lack of 

expression of hormonal receptors could represent a lack of hormonal 

control. 

references 

1 Ferrie RK, Ross RC. Retroperitoneal mullerian carcinosarcoma. Can 

Med Assoc J 1967;97:1290-2. 

2 Cokelaere K, Michielsen P, De Vos R, et al. Primary Mesenteric Malignant 

Mixed Mesodermal Tumor with Neuroendocrine Differentiation. 

Mod Pathol 2001;14:515-20. 

3 Choong SYM, Scurry JP, Planner RS, et al. Extrauterine malignant 

mixed Mullerian tumor of primary peritoneal origin. Pathology 

1994;26:497-8.

318 

4 Chen KTK, Walk RW. Extragenital malignant mixed Mullerian tumor. 

Gynecol Oncol 1988;30:422-6. 

5 Ko ML, Jeng CJ, Huang SH, et al. Primary peritoneal carcinosarcoma 


Comparative clinical and immunophenotypic 

study of placental alkaline phosphatase 

and human chorionic gonadotropin, 

in different stages of placental development, 

in normal and pathological conditions 

A. Nocita, A. Tommasini, F. Vitale, S. Mazza, F. Vittimberga, 

F. Tallarigo 

U.O.C. Anatomia Patologica e Citodiagnostica, P.O. San Giovanni di Dio, 

ASP Crotone 

Introduction. The placenta undergoes a continuous process 

from conception to birth. During its development, the placenta 

performs numerous functions, and produces various biologically 

active compounds, which are for most proteins. A large 

number of these proteins, has been identified and named according 

to their biological activity. Examples are specific placental 

hormones hCG (human Chorionic Gonadotropin) and hPL (human 

placental lactogen) and enzymes specific placental PLAP 

(Placental Alkaline Phosphatase), DAO (diamine oxidase) and 

CAP (Cystine Aminopeptidase Ossitocinasi. These proteins have 

special functions related to pregnancy. Are synthesized by the 

trophoblast and decidua, and then secreted in large amounts in the 

maternal circulation. The experimental study has been performed, 

is divided into two parts: the first were compared with serology 

immunohistochemical hCG, this double-chain glycoprotein hormone, 

normally present in blood and urine during pregnancy, is 

secreted by placental tissue almost immediately after implantation, 

and serves primarily to support the corpus luteum during 

the first weeks of pregnancy. In the second part of this work were 

evaluated the distribution of hCG and PLAP in the placentas 

of normal fetuses in all ages of gestation, and in pathological 

placentas (partial mole idatiformi in the first two quarters and 

gestosis in the third quarter). PLAP, tested in the second part 

of the study, a sialoprotein is localized to the apical membrane 

of syncytiotrophoblast cells, released into the maternal circulation, 

and increases gradually with the progress of concentration 

of the pregnancy. The qualitative and quantitative expression of 

the antibody in question, is estimated in terms of immunohistochemistry 

in placental trophoblastic compartments; noting that 

the assessment of positive immunohistochemical reaction to these 

antigens (hCG and PLAP) may find application in the differential 

diagnosis of placental pathology. 

Material and methods. The immunohistochemical investigations 

were conducted on 116 histological samples of placentas, 

30 spontaneous abortions in the first quarter, 28 of the second 

trimester of pregnancy, and 31 samples from placentas during 

the third quarter of spontaneous delivery. As for the pathological 

cases, were examined 15 cases of mole idatiformi type partial and 

12 placentas from women with gestosis. The gestational age of 

the grinding wheels idatiformi is between the 9th and 20th week, 

while that of placentas gestosis, is between 24° and 37° week. 

The survey performed immunohistochemistry, had as main objec- 




(malignant mixed müllerian tumor): Report of a case with five year 

disease free survival after surgery and chemoradiation and a review 

of literature. Acta Oncol 2005;44:756-60. 

tive to analyze the antibody distribuizione hCG and PLAP in the 

placentas of normal fetuses at different gestational ages, assessing 

their quantitative expression in different placental cell compartments, 

highlighting also, as the reactivity of these antigens could 

be used, with the support of serological data, in the differential 

diagnosis of these diseases. 

Results. The pattern of antibody positivity is citoplasm polyclonal 

hCG. His expression immunohistochemical, observed in 

the different gestational ages, increases exponentially from the 

5 the week of gestation, reaching a peak at 9 weeks, this would 

probably be determined by the maximum development of both 

trophoblastic layers: syncytium and cytotrophoblast. Soon after, 

the expression begins to decrease gradually until 28 weeks, then 

decline sharply until the end of pregnancy. The profile of immunophenotypic 

‘antibody in question is perfectly comparable 

with the trend serological, in fact, the serum concentration of 

hCG, increases exponentially, doubling every 2 days, for the first 

5-6 weeks. 

The peak of approximately 100,000 U / L, is reached between 

the 7 th and 10 th week of pregnancy. Subsequently, its concentration 

decreases by 10 times, before reaching a plateau at 

around 16 weeks and remained constant for the remainder of the 

pregnancy, then decreases sharply after delivery. As regards the 

profile of immunophenotypic PLAP, this has a trend inversely 

proportional to hCG, as the positivity of PLAP, begins to be detectable 

by 9 weeks gestation, increases steadily up to 25 weeks 

and then grows logarithmically throughout the third quarter. 

Comparing the two immunophenotypic profiles, shows that 

PLAP has a trend inversely proportional to hCG. In placentes 

pathological conditions, particularly in the grinding wheel partial 

mole has PLAP antibody has a pattern of positivity differently 

than normal placentas of fetuses. Indeed, as early as the 9 th 

week, we begin to observe the increase of PLAP, with increased 

cytoplasmic positivity, while maintaining its typical logarithmic 

trend but with higher values in all gestational ages studied (up to 

20 weeks). While for the ‘hCG, the immunohistochemical score 

slightly higher than the physiological condition. The two trends 

are similar in the first and second trimester placentas examined. 

These results are also confirmed by the serum concentrations of 

hCG glycoprotein, which comparing them with those measured 

in physiological conditions, shows a high elevations, which are 

considered useful from a laboratory point of view in the differential 

diagnosis with immunophenotypic profile. Interesting data 

were observed in the placentas gestosis, (24°-37° weeks), which 

showed a profile immunophenotypic, similar and comparable to 

that of the first trimester placentas physiological (5°-16° week), 

with a sharp increase in values. From the data obtained, the hypothesis 

emerges that the overproduction of secreted glycoprotein 

for the entire first quarter (as known from the literature) and 

physiologically degraded, is considered one of the most potent 

stimulators for the release of relaxin, increasing its concentration 

and contributing to the onset of gestosis. The second part of the 

study focused on the description and microscopic examination of 

tissues of the trophoblast: syncytiotrophoblast and cytotrophoblast, 

in the various placental sites after immunohistochemical 

investigation. The immunohistochemical criteria of hCG and


PLAP in normal placentas, in connection with gestational age, 

are interpreted by semi-quantitative score of the number of cells, 

ranging from strong and diffuse (+ + +), to weak and focal (+ / 

-) up to the absence of reaction (---).We describe our observation 

in saying that the villi in the first quarter are positive with typing 

antibody trophoblastic hCG in both layers, in fact the color 

is intense and widespread also inside the villous stroma. In the 

second quarter up to 18 weeks typing with the hCG antibody 

is kept constant, and then begins to decrease slowly, localizing 

primarily to the syncytiotrophoblast. In the third quarter, a positive 

cytoplasmic hCG becomes very weak and focal, limited to 

the syncytiotrophoblast (also for the fact that at this gestational 

cytotrophoblast disappears almost completely). With regard to 

the PLAP to the first quarter, the positivity is only faintly visible 

at the level of syncytiotrophoblast and the number of typed villi 

is extremely low and focused to the villi tertiary. Subsequently, 

the PLAP, begins to take on a more positive at the level of the 

apical membrane of cells syncytial, and consequently its expression 

increases progressively throughout the second quarter. In 

the third quarter, the pattern of distribution of PLAP becomes 

smooth and continuous, the reaction can be observed along the 

apical and basal membrane of the syncytium, and also in the 

cytoplasm in the form of granules. Regarding the pathological 

aspect, the molar placentas described, concerning the first two 

trimesters of gestation, while suffering from gestosis placentas 

are of the third quarter. In partial mole idatiformi (PMH), the 

pattern of expression of hCG is entirely similar and overlapping 

with the physiological condition in both the first in the second 

quarter. While the immunoreactivity of PLAP for the syncytiotrophoblast, 

occurs early compared to normal placentas, therefore, is 

more marked at the same gestational age in the first and second 

quarter. Interesting results have been observed in gestosis, where 

the pattern of expression of hCG, differed totally from the normal 

condition, in that the distribution of the antibody, the third quarter, 

was uniformly spread on all the villi, unlike the physiological 

condition in which there was a lack of positive (in the placenta at 

term). For PLAP were not substantial differences. 

Conclusions. The PLAP, immunophenotypic pattern has a more 

intense and widespread in the placentas of the first molars and 

the second quarter, compared to the physiological condition; 

therefore can be proposed as a marker in the diagnosis of this 

disease. The HCG is immunohistochemically overexpressed in 

gestosis. This aspect, would suggest the direct involvement of 

this glycoprotein, in the onset of eclamptic syndrome, so it would 

be advisable to monitor serum of this hormone, even after the 

first trimester of pregnancy in those at risk. In conclusion, the 

immunohistochemical study of HCG and PLAP, may find new 

applications in the diagnostic protocols of placental pathology: 

gestosis and wheel partial mole. 

Mismatch repair system in endometriotic tissue 

and eutopic endometrium of unaffected women 

M. Orsaria, T. Grassi, A. Calcagno, S. Marzinotto, A.P. Londero, 

C.A. Beltrami, D. Marchesoni, L. Mariuzzi 

University Hospital of Udine 

Introduction. Endometriosis is a gynecological disorder, with 

etiology still partially unknown, and is classically defined as the 

presence of endometrial-like glands and stroma outside the uterus 

(Calcagno et al., 2011; Bulun, 2009; Giudice, 2004). 

There is evidence in the literature that oxidative stress is a component 

of the inflammatory reaction associated with endometriosis, 

where, the cyclical shedding of endometrial-like cell in endometriotic 

lesion involves the release of pro-oxidant factors, such as 

heme and iron that can induce oxidative stress and DNA damage 

(Kobayashi et al., 2009). As a consequence, tissue changes due 

to chronic inflammation, associated with endometriosis, are 

319 

accompanied by alterations at a molecular level due to local 

oxidative stress reactions such as mutations to DNA single base 

pairs. These processes have been studied in the context of chronic 

inflammation in the epithelium leading to the development of 

cancer (Chang et al., 2002). 

Microsatellite instability (MSI) is a phenomenon that is characterized 

by a defective function of the DNA mismatch repair (MMR) 

system. MSI is seen in some chronically inflamed tissues even in 

the absence of genetic inactivation of the MMR system (Chang 

et al., 2002). Moreover, oxidative stress associated with chronic 

inflammation might damage protein components of the MMR 

system, leading to its functional inactivation (Kobayashi et al., 

2009). 

Although MMR system defective function is implicated in the 

molecular pathogenesis of epithelial cell carcinogenesis (Kobayashi 

et al., 2009), new data suggest that such dysfunction is also 

found in mesenchymal cells undergoing tissue remodeling in 

chronic inflammatory disorders (Floer et al., 2008; Seifert, 2006). 

Also endometriosis seams to be associated to tissue remodeling 

and adhesion formation due to fibroblast cells growth attempting 

to repair the chronic inflammation. It is now known that non-malignant 

DNA alterations occur in atherosclerosis, asthma, chronic 

obstructive pulmonary disease, rheumatoid arthritis, and Crohn’s 

disease (Floer et al., 2008; Lee et al., 2003; Samara et al., 2006; 

Simelyte et al., 2004). These studies hypothesized that alterations 

in mesenchymal cells and their behavior could be linked to an accumulation 

in DNA damage, which may be directly related to an 

altered DNA-MMR function involved in specific disease pathophysiology. 

That could lead to uncontrolled cell proliferation associated 

to benign pathology or may be implicated in neoplastic 

transformation. 

In a previous publication we found high cytoplasmic expression 

of aurora A kinase (AAK) in a subgroup of endometriotic lesions 

with higher prevalence of endometriosis relapse. It is known that 

AAK is overexpressed in cancer and is associated with genomic 

instability. Therefore we hypothesized the existence of a subtype 

of endometriosis characterized by genomic instability that we 

could speculate to be associated to cancer development (Calcagno 

et al., 2011). 

Materials and methods. From the registry of the Pathology 

Department of the University Hospital of Udine, a total of 246 

women who had a histopathological diagnosis of endometriosis 

between January 2000 and December 2010 were identified. We 

included all Caucasian women of reproductive age at the time 

of intervention who had not taken any hormone therapy during 

the year before surgery. Eutopic endometrial tissue was obtained 

from formalin-fixed paraffin-embedded uterine tissues from all 

women who underwent hysterectomy for leiomyoma during the 

period from 2006 to 2010. All caucasian women with regular 

menses without endometrial pathology, histological diagnosis of 

adenomyosis, or use of hormonal medication during the year before 

surgery were included (Calcagno et al., 2011). We obtained 

71 endometrial core biopsies from 71 women. We tested the 

following antibodies: MLH1, MSH2, MSH6, PMS2, Aurora A, 

Ki-67. The staining was semiquantitatively evaluated as H-score 

(product of percentage of positive cells and the intensity of staining) 

or percentage of positive cells when Ki-67 was considered. 

Results. In our study 80% of the lesions considered were from 

ovarian endometriosis, 2% from bowel endometriosis, and 18% 

from other abdominopelvic endometriotic tissue locations. We 

analyzed our TMA model to find possible defective function of 

the DNA MMR system. Hence, we looked for absence of specific 

immunostaining for any of the studied MMR system proteins. 

We found no significant difference between normal endometrium 

and both glandular and stromal components of ETs and in the 

prevalence of negative staining of any of the MMR system proteins 

among those ET samples staining positively for glandular 

cytoplasmic AAK.

320 

H-score value of MSH2 in glandular and stromal components 

were higher than other MMR system proteins. Furthermore, 

MMR system protein expression correlate positively with Ki- 

67 expression, but those correlations were significant only for 

MSH6 and PMS2 in glandular component of ETs and MSH2 in 

glandular and stromal components of ETs (p < 0.05). We found 

significant differences in the whole population of our TMA 

model among stromal and glandular MLH1 staining, stromal and 

glandular MSH2 staining and stromal PMS2 staining. 

In endometriotic tissue expressing positive glandular cytoplasmic 

staining for aurora A kinase, we found differences in MLH1 and 

PMS2 glandular component staining values and MSH2 stromal 

and glandular component staining values. MSH2 glandular and 

stromal staining values were significantly higher in ETs than 

proliferative and secretory endometrium. 

Discussion. Genetic instability, which leads to an accumulation 

of various genetic abnormalities, has been considered an essential 

component of the human neoplastic transformation process. MSI 

is now considered as one of the most promising markers and 

indicators of prognosis in human carcinogenesis. In premalignant 

conditions in the endometrium it was found increased MSI in 

atypical endometrial hyperplasia associated with endometrial 

carcinoma (Ali-Fehmi et al., 2006). In this study we found no 

significant microsatellite instability in endometriotic tissues. 

Moreover, we found MSH2 to be significantly correlated to Ki-67 

expression in both stromal and glandular components of ET and 

to be expressed at a significant higher level in ET than eutopic 

endometrium. 

In our previous publication we found in a sub-group of women 

affected by endometriosis a high cytoplasmic expression of AAK 

and this group was found to be associated with higher recurrence 

rate than the group with AAK negative staining ET (Calcagno et 

al., 2011). In malignant pathologies high AAK expression was associated 

with genomic instability (Calcagno et al., 2011), and for 

this reason we analyzed MMR protein expression specifically in 

this subgroup of patients where we found glandular and stromal 

staining of MSH2 and glandular staining of MLH1 and PMS2 

to be expressed at a higher level than healthy endometrium. The 

exact role of MMR protein elevation in tumorigenesis is still 

speculative but may involve aberrant and improper binding to 

inactivate the MMR system. MMR protein elevation may be a 

predictor of biochemical recurrence after surgery for endometriotic 

lesion. This finding may identify a potential new marker for 

recurrent endometriosis and uncover a potentially novel pathway 

for targeted therapeutics. 

During the development and progression of endometriotic lesions, 

excess fibrosis may lead to scarring, chronic pain, and 

alteration of tissue function, all of which are characteristics of 

this disease (Nasu et al., 2009). One of the molecular changes 

associated with exposure to oxidative stress is genetic damage, 

including mutations to DNA single base pairs. Immunohistochemical 

staining revealed an increased expression of MSH2 

in tissues affected by Crohn’s disease as well in myofibroblasts 

isolated from chronically inflamed bowel, which is linked to an 

increased proliferative capacity of myofibroblasts compared with 

control cells. In our analysis we demonstrated that MSH2 H-score 

values in glandular and stromal components were higher than 

other MMR proteins in ETs. Glandular MSH2 H-score values 

were also higher in non-ovarian and bowel ETs than other locations 

and normal endometrium; while the stromal H-score was 

apparently higher in bowel ETs than all other localizations and 

normal endometrium. Floer et al demonstrated in Crohn’s disease 

an isolated increased expression of MSH2 in response to oxidative 

stress and the increased expression of MSH2 was associated 

to increased cell proliferation (Floer et al., 2008). In our study 

we found MSH2 positivity to be significantly correlated to Ki-67 

positivity in both stromal and glandular components. Therefore 

MSH2 could play an important role in regulating ETs prolifera- 


tion. Floer et al demonstrated in vitro that simvastatin reduced 

MSH2 expression, mesenchymal cells proliferation, and intracellular 

super-oxide generation (Floer et al., 2008). Recent studies 

have shown that statins reduce the growth of human endometrial 

and endometriotic stromal cells (Sokalska et al., 2010; Nasu et 

al., 2009). 

Conclusions. We found no significant microsatellite instability 

in ET. The group of ETs with glandular cytoplasmic staining 

for AAK had higher MMR proteins expression suggesting an 

increased activity of this system in this subset of endometriotic 

lesions. Furthermore, increased expression of MSH2 in endometriotic 

cells appears to be linked to their increased proliferative 

capacity and may be a pathophysiological mechanism underlying 

endometriosis proliferation and scar formation in endometriosis. 

This could be a possible therapeutic target since in recent studies 

MSH2 was downregulated in vitro by statins administration. 

references 

1 Calcagno A, Grassi T, Mariuzzi L, et al. Expression patterns of aurora 

a and b kinases, ki-67 and the estrogen and progesterone receptors 

determined using an endometriosis tissue microarray model. Hum 

Reprod 2011;26:2731-41. 

2 Bulun SE. Endometriosis. N Engl J Med 2009;360:268-79. 

3 Giudice LC, Kao LC. Endometriosis. Lancet 2004;364:1789-99. 

4 Kobayashi H, Kajiwara H, Kanayama S, et al. Molecular pathogenesis 

of endometriosis-associated clear cell carcinoma of the ovary 

(review). Oncol Rep 2009;22:233-40. 

5 Chang CL, Marra G, Chauhan DP, et al. Oxidative stress inactivates 

the human dna mismatch repair system. Am J Physiol Cell Physiol 

2002;283:C148-54. 

6 Floer M, Binion DG, Nelson VM, et al. Role of muts homolog 2 

(msh2) in intestinal myofibroblast proliferation during crohn’s disease 

stricture formation. Am J Physiol Gastrointest Liver Physiol 

2008;295:G581-90. 

7 Seifert M, Reichrath J. The role of the human dna mismatch repair 

gene hmsh2 in dna repair, cell cycle control and apoptosis: implications 

for pathogenesis, progression and therapy of cancer. J Mol 

Histol 2006;37:301-7. 

8 Lee SH, Chang DK, Goel A, et al. Microsatellite instability and suppressed 

dna repair enzyme expression in rheumatoid arthritis. J Immunol 

2003;170:2214-20. 

9 Samara K, Zervou M, Siafakas NM, et al. Microsatellite dna instability 

in benign lung diseases. Respir Med 2006;100:202-11. 

10 Simelyte E, Boyle DL, Firestein GS. Dna mismatch repair enzyme 

expression in synovial tissue. Ann Rheum Dis 2004;63:1695-9. 

11 Ali-Fehmi R, Khalifeh I, Bandyopadhyay S, et al. Patterns of loss of 

heterozygosity at 10q23.3 and microsatellite instability in endometriosis, 

atypical endometriosis, and ovarian carcinoma arising in association 

with endometriosis. Int J Gynecol Pathol 2006;25:223-9. 

12 Nasu K, Yuge A, Tsuno A, et al. Simvastatin inhibits the proliferation 

and the contractility of human endometriotic stromal cells: 

a promising agent for the treatment of endometriosis. Fertil Steril 

2009;92:2097-9. 

13 Sokalska A, Wong DH, Cress A, et al. Simvastatin induces apoptosis 

and alters cytoskeleton in endometrial stromal cells. J Clin Endocrinol 

Metab 2010;95:3453-9. 

Expression and prognostic significance of APE1/ 

ref1 and nPM1 proteins in ovarian serous cancer 

M. Orsaria * , A.P. Londero * , G. Tell, S. Marzinotto, V. Capodicasa, 

M. Poletto, C. Vascotto, C. Sacco, L. Mariuzzi; * These 

authors contributed equally to the article 

University Hospital of Udine 

Introduction. Ovarian cancer is a low prevalence tumor (3.1% 

of female cancers in our region) but it is a leading cause of death 

among gynecologic malignancies due to the advance stage at 

diagnosis, recurrences, and chemoresistance. Therefore, three 

points appear of paramount importance: early diagnosis (Rossi et 

al., 2011), better prognosis determination (among the majority of 

affected women), and therapy improvement (new possible therapeutic 

targets, new drugs to overcome tumor chemoresistance,


or identification of patients who would benefit from particular 

therapies). 

The mechanisms of DNA repair seem involved both in development 

and in chemoresistance of ovarian cancer (Bast et al., 2009; 

Alvero et al., 2009). In this article we focus our attention on the 

immunohistochemical expression of two proteins involved in 

DNA repair mechanisms: APE1/Ref-1 (APE1) and nucleolar/ 

nucleoplasmic protein Nucleophosmin 1 (NPM1). 

APE1 is the main apurinic/apyrimidinic endonuclease in mammalian 

cells and catalyzes a rate limiting step in BER. Upregulation 

of this ubiquitous and vital protein is at the basis of chemoresistance 

in several tumors, such as hepatic, prostate and ovarian 

cancers; for this reasons the protein is emerging as a promising 

target for combination cancer therapy (Kelley et al., 2011; Wilson 

and Simeonov, 2010). 

Nucleophosmin 1 (NPM1) is an abundant protein, which specifically 

resides within the granular region of the nucleolus, 

implicated in a variety of cellular processes including centrosome 

duplication, maintenance of the genome integrity and ribosome 

biogenesis (Frehlick et al., 2007). 

We have found that NPM1 plays a significant stimulatory effect 

on APE1 DNA-repair activity in BER and that the loss of this 

interaction impacts on proliferation of tumor cell lines, thus providing 

a new means through which APE1 may affect cell growth 

and gene expression in cancer cells. 

These evidences suggest that an aberrant APE1/NPM1 functional 

interaction can be associated with the genomic instability of 

cancers and support the concept that interfering with the APE1/ 

NPM1 association may be a good approach for improving sensitization 

of patients to chemotherapy. 

Objective. To correlate the expression profile of APE1/Ref-1 

(APE1) with that of nucleolar/nucleoplasmic protein Nucleophosmin 

1 (NPM1) in association with the tumor aggressiveness 

and its progression. 

Material and Methods. Retrospective study considering a tissue 

microarray of 82 women who had a pathological diagnosis 

of ovarian serous carcinoma between January 2003 and July 

2008. We included only primary interventions with a diagnosis 

of ovarian serous carcinoma and we excluded all patients who 

performed chemotherapy before surgery. All these cases were 

staged according to the International Federation of Gynecology 

and Obstetrics (FIGO) staging system (Stages I, II, III, IV) and to 

the TNM classification of malignant tumors for ovarian cancer; 

the histopathological grading of these cases was also evaluated 

using both Silverberg (grade 1, 2, 3) and Malpica System (low 

and high grade). Information such as clinical history and management 

for each patient were gathered using clinical files. Data 

included age at intervention, date and radicality of intervention, 

contingent assumption of any hormonal or non-hormonal therapy, 

parity, gravidity, last menses before intervention, and clinical 

follow up until January 2011. The Tissue Microarray technique 

was used to simultaneously analyze multiple tissues. Protein 

expression was assessed by immunohistochemistry on primitive 

tumor masses and synchronous peritoneal metastases if present. 

Semiquantitative analysis of the immunohistochemical staining 

was performed independently by two pathologists and the 

staining was semiquantitatively evaluated as H-score (product of 

percentage of positivity and intensity). 

Results. The mean age at surgery was 63.35 years (±12.12), 

76% were postmenopausal and the median overall survival was 

40 months (22-56) after the first operation. In 60% of cases, the 

stage was greater than or equal to FIGO III with a grade 3 of Silverberg 

in 69% of cases. Moreover, all the women were treated 

similarly with repeated surgery and chemotherapy if feasible. 

APE1 and NPM1 semiquantitative immunohistochemical scores 

were significantly correlated in ovarian serous cancer. Both 

primitive ovarian mass and peritoneal metastasis were expressing 

in a comparable manner these two proteins. Then, a significant 

321 

Fig. 1. Kaplan-meier curves of overall survival, fiGO staging, Silverberg 

grading, and nucleolar/nucleoplasmic protein Nucleophosmin 1 

(NPM1) expression (p-values refer to log-rank test). (a): Stage iii-iV and 

Npm1 expression, among the stage iii-iV (dot-dash line) considering 

NPM1 expression we identified two subgroups. one subgroup of 

women with a nuclear Npm1 H-score above the 50th percentile of 

the distribution (H-score > 10, dashed line) showed a significant lower 

survival than the subgroup with H-score under the 50th percentile 

of the distribution (solid line) (log-rank test p < 0.05). (b): Npm1 Hscore 

in stage i-ii and iii-iV (p-value refers to Wilcoxon test). (c): G3 

Silverberg grade and Npm1 expression; among the grade 3 (dot-dash 

line), considering Npm1 expression we identified two subgroups. One 

subgroup of women with a nuclear Npm1 H-score above the 50th 

percentile of the distribution (H-score > 10, dashed line) showed a 

significant lower survival than the subgroup with H-score under the 

50th percentile of the distribution (solid line) (log-rank test p < 0.05). 

over-expression of nuclear NPM1 protein in ovarian cancer was 

present among women who had a worse prognosis. Considering 

the NPM1 expression in stage III-IV cancers (5 years overall 

survival 32% CI.95 21-49%) we had identified two subgroups 

one with low protein expression and 5 years overall survival of 

48% (31%-76%) and one subgroup with high protein expression 

and 5 year overall survival of 17% (7%-43%) (p < 0.05) (see 

Figure). We found also the same pattern of differences in high 

grade tumors. The same were found in Cox proportional hazards 

multivariate regression model where NPM1 nuclear staining was 

a significant independent factor for overall survival after correction 

for stage, grade, women age, cytoreduction completeness, 

and platinum resistance. 

Conclusions. Our study demonstrated an over-expression of 

nuclear NPM1 proteins in ovarian cancer among women who 

had a worse prognosis. Interestingly, we found a significant 

positive correlation between APE1 and NPM1 H-scores possibly 

associated with the emerging role that these two proteins play 

in the onset of chemoresistance that may be associated to their 

function in DNA repair. The relative contribution of NPM1 overexpression 

to cancer progression may be ascribable to its roles 

in the generation of a permissive condition for further oncogenic 

transformation, associated to its indirect stimulatory effect on 

APE1 (Fantini et al., 2010; Vascotto et al., 2009). The presence 

of high NPM1 levels may limit DNA damage and the DNA damage 

response (due to increased BER), associated with oncogenic 

stressor signals activation in a normal cell, and therefore may 

support, in association with an increased APE1 expression level, 

cell survival during cancer development. Our evidence suggests 

that overexpression of APE1/NPM1 proteins can be associated 

with cancer aggresiveness, which supports the concept that interfering 

with APE1/NPM1 interaction may be a good candidate 

for improving sensitization of cancer cells to chemotherapy and 

radiotherapy. This data could influence the clinical management 

(prognosis determination) and the planning of future therapies 

suggesting new paths for drug development and testing on ovar-

322 

ian cancer due to the important role of this protein in DNA repair 

mechanisms. 

In this paper, we have not inspected which of the known APE1 

function is associated with NPM1 overexpression even though it 

is plausible that both BER and rRNA activities may be affected 

thus impacting on cell proliferation and cell survival. Work along 

these lines is currently ongoing in our laboratory. 

reference 

Rossi A, Braghin C, Soldano F, et al. A proposal for a new scoring system 

to evaluate pelvic masses: Pelvic Masses Score (PMS). Eur J Obstet 

Gynecol Reprod Biol 2011. 

Bast RC Jr, Hennessy B, Mills GB. The biology of ovarian cancer: new 

opportunities for translation. Nat Rev Cancer 2009;9:415-28. 

Alvero AB, Chen R, Fu HH, et al. Molecular phenotyping of human 

ovarian cancer stem cells unravels the mechanisms for repair and 

chemoresistance. Cell Cycle 2009;8:158-66. 

Kelley MR, Georgiadis MM, Fishel ML. APE1/Ref-1Role in Redox Signaling: 

Translational Applications of Targeting the Redox Function of the 

DNA Repair/Redox Protein APE1/Ref-1. Curr Mol Pharmacol 2011. 

Wilson DM 3rd, Simeonov A. Small molecule inhibitors of DNA repair 

nuclease activities of APE1. Cell Mol Life Sci 2010;67:3621-31. 

Frehlick LJ, Eirín-López JM, Ausió J. New insights into the nucleophosmin/nucleoplasmin 

family of nuclear chaperones. Bioessays 

2007;29:49-59. 

Fantini D, Vascotto C, Marasco D, et al. Critical lysine residues within 

the overlooked N-terminal domain of human APE1 regulate its biological 

functions. Nucleic Acids Res 2010;38:8239-56. 

Vascotto C, Cesaratto L, Zeef LAH, et al. Genome-wide analysis and proteomic 

studies reveal APE1/Ref-1 multifunctional role in mammalian 

cells. Proteomics 2009;9:1058-74. 

neonatal hemochromatosis: a case report 

P. Pretelli, F. Castiglione, D. Moncini, A.M. Buccoliero, E. Projetto, 

I. Montagnani, L. Messerini, G.L. Taddei 

Università di Firenze Dipartimento di Area Critica Medico-Chirurgica. 


Neonatal hemochromatosis is a rare clinical pathologic entity, 

defined by severe neonatal liver failure of intrauterine onset 

associated with intra-and extrahepatic siderosis that spares 

reticuloendothelial system. It is the most frequently recognized 

cause of liver failure in neonates. The cause is unknown but it 

may develop secondary to abnormal fetoplacental iron handling 

or perinatal liver disease or be familial or as a consequence of 

gestational alloimmune disease. It’s a syndrome with a common 

feature rather than a single pathologic entity, with maternal 

transmission and a high recurrence in the sib ship. Death from 

multisystem organ failure usually occurs in the first few days or 

weeks of life. 

A case of neonatal hemochromatosis in a 1-hour-old female 

is described. She presented with hypotonia, mild jaundice, 

and respiratory difficulty immediately after birth. She had no 

evidence of congenital infection, immune-related hemolysis 

or exogenous iron uptake. Postmortem examination revealed 

abnormal facial features. The organs were of normal weight for 

his age except a small liver and lungs, and a large spleen. The 

most prominent changes were in the liver and pancreas. The 

liver was coarsely nodular and fibrotic. The lobular architecture 

was totally distorted by innumerable multinucleated giant cells, 

loss or collapse of the hepatocytes, and diffuse fibrosis. A large 

amount of hemosiderin was seen in the liver, pancreatic acini 

and thyroid follicular cells. Scanty amount of hemosiderin was 

also found in the myocardial fibers and renal tubular cells. The 

pancreas showed hyperplasia and hypertrophy of the islets. The 

spleen showed severe congestion and a moderate extramedullary 

hemopoiesis but no deposits of hemosiderin. This patient 

had three siblings died in neonatal period, one of which had 

clinical features of neonatal hemochromatosis. 

The diagnosis is suspected in the presence of severely impaired 


hepatic synthetic function accompanied by high serum ferritin 

levels, but is confirmed only by demonstration of increased hepatic 

iron stores, and extra-hepatic siderosis shown by autopsy or 

in vivo, which can be achieved by biopsy of the minor salivary 

glands or magnetic resonance imaging. Neonatal hemochromatosis 

is the most common specific indication for liver transplantation 

in the first three months of life and appears to be the 

treatment of choice, and must as well be considered as soon as 

it becomes apparent that medical support, which should include 

chelation-antioxidant treatment, is ineffective, before irreversible 

neurological complications appear. 

Testicular hemangioendothelioma: a case report 

G. Crisman1 , L. Melchiorri1 , V. Ciuffetelli2 , A. Chiominto2 , 

G. Coletti2 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 



Background. Hemangioendothelioma is a rare vascular tumor 

characterized by a proliferation of endothelial cells. It is a borderline 

neoplasm, which can occur in every organ and tissue, 

even though the liver and the skin represent the most common 

site of involvement. Testis represents a very rare site of onset of 

this kind of lesion. 

Material and methods. We report on a case of a 50-years-old 

man presented at the Urological Department of Avezzano General 

Hospital with a solid, painless mass of the right testis, causing 

a scrotal oedema. The patient denied any history of previous 

trauma, orchiepydidimitis, varicocele, urological surgery and referred 

a few-day history of testicular discomfort. Physical examination 

revealed an enlarged right testis with a prominent mass, 

hard in consistency. The left testicle was within normal limits. 

US examination revealed a hypervascularized, well-defined mass 

of the right testis and a grade 1 varicocele. Any morphological 

alteration of the left testicle has been detected. 

Results. The patient underwent a orhiectomy and sections of 

the surgical specimen revealed the presence of a rounded, firm, 

well-circumscribed whitish mass of 1,3 cm in-diameter. The 

remainder of testis, cord and epiddymis were otherwise normal. 

Histological features of the mass revealed a vascular tumor 

mainly composed by plump endothelial cells arranged in short 

strands, cords, or small clusters of epithelioid, round, to slightly 

spindled endothelial cells that formed at least focally, intracellular 

lumina. The endothelial nuclei appeared larger but not 

hyperchromatic. The lesion strongly stained for CD31, CD34, 

Inhibin, Calretinin and D2-40. Thus, a diagnosis of hemangioendothelioma 

was posed. 

Conclusions. The authors underline the importance of achieving 

the correct diagnosis in such challenging cases, since only 

few reports of testicular emangioendothelioma have been reported 

so far. 

Fig. 1 a and B. Histological features: clusters of epithelioid, round, to 

slightly spindled endothelial cells that formed at least focally, intracellular 

lumina, represent the main component of this lesion (H&E, 4x 

magnification, 20x magnification).


references 

1 Robbins SL. Pathology, 3rd ed. Philadelphia: W. Saunders, Co. 1967, 

p. 614. 

2 Fletcher CDM, Unni KK, Mertens F (Eds). World Health Organisation 

Classification of Tumours. Pathology and genetics of tumours of 

soft tissue and bone. IARC Press: Lyon 2002. 

3 Fletcher C. The evolving concept of hemangioendothelioma. British 

Division of IAP 2006. 

4 Marks A, Sutherland DR, Bailey D, et al. Characterization and distribution 

of an oncofetal antigen (M2Aantigen) expressed on testicular 

germ cell tumours. Br J Cancer 1999;80:569-78. 

5 Bailey D, Baumal R, Law J, et al. Production of a monoclonal antibody 

specific for seminomas and dysgerminomas. Proc Natl Acad Sci 

USA 1986;83:5291-5. 

6 Bailey D, Marks A, Stratis M, et al. Immunohistochemical staining of 

germ cell tumors and intratubular malignant germ cells of the testis 

using antibody to placental alkaline phosphatase and a monoclonal 

antiseminoma antibody. Mod Pathol 1991;4:167-71. 

7 Sonne SB, Herlihy AS, Hoei-Hansen CE, et al. Identity of M2A 

(D2-40) antigen and gp36 (Aggrus, T1A-2, podoplanin) in human 

developing testis, testicular carcinoma in situ and germ-cell tumours. 

VirchowsArch 2006;449:200-6. 

8 Stein JJ. Hemangioendothelioma of the testis. J Urol 1975;113:201-3. 

9 Cricco CF Jr, Buck AS. Hemangioendothelioma of the testis: second 

reported case. J Urol 1980;123:131-2. 

10 Hilary K, Hargreaves HK, Scully RE, et al. Benign hemangioendothelioma 

of the testis: case report with electron microscopic 

documentation and review of the literature. Am J Clin Pathol 

1982;77:637-42. 

CIntec® PLUS immunocytochemistry: 

a tool for the cytological diagnosis 

of glandular lesions of the cervix uteri 

A. Ravarino1 , S. Nemolato1 , E. Macciocu2 , M. Fraschini3 , 

G. Senes1 , G. Faa1 , G. Negri2 1 Department of Pathology, University Hospital San Giovanni di Dio of 

Cagliari, Italy, 2 Department of Pathology, Central Hospital Bolzano, Bolzano, 

Italy; 3 Department of Electrical and Electronic Engineering, Univeristy 

of Cagliari, Italy 

Cytology of glandular lesions of the cervix uteri is sometimes difficult 

to evaluate because reactive conditions of the endocervical 

epithelia may mimic neoplasia. CINtec PLUS is a novel biomarker 

that combines p16 and Ki67 using a double stain technique. 

In squamous lesions of the cervix uteri, CINtec Plus has already 

shown a high sensitivity and specificity 1 . As far as we know, 

however, no study evaluated CINtec PLUS on a large group of 

histology-confirmed glandular lesions of the cervix uteri. 

In this study, we evaluated the usefulness of CINtec PLUS p16/ 

Ki-67 double stain for the diagnosis of glandular lesions of the 

cervix uteri in liquid-based cytologic specimens 2 . 

The study included 47 abnormal ThinPrep (Hologic) liquid-based 

cytologies with a subsequent histological diagnosis of adenocarcinoma, 

in situ or with early invasion, and 16 samples with negative 

follow-up. All samples were stained with CINtec PLUS p16/ 

Ki-67 double stain (Roche-mtm, Heidelberg). 

Of the neoplastic samples, 7 were excluded because of insuf- 

Tab. I. CiNtec pluS immunocytochemistry in 63 liquid-based cytologies. 

323 

ficient residual cellularity or loss of neoplastic cells. Of the adequate 

samples, 92.5% were stained with Cintec PLUS (Fig. 1), 

whereas 7.5% were judged inconclusive. The samples of all inconclusive 

cases had been stored at room temperature for at least 

3 years. Of the 16 negative samples, 15 (93.8%) stained negative 

and only one (6.2%) showed positive clusters of cells (Tab. I). 

By applying the Fisher’s exact test sensitivity, specificity, positive 

predictive value, and negative predictive value were 93.75%, 

97.37%, 83.33% and 92.50% respectively. 

In conclusion, our study shows that CINtec PLUS may be helpful 

for the diagnosis of glandular lesions of the cervix uteri and 

may reduce the risk of false negatives as well as the number of 

uncertain borderline reports. 

references 

1 Schmidt D, Bergeron C, Denton KJ, et al. European CINtec Cytology 

Study Group. p16/Ki-67 Dual-Stain cytology in the triage of ASCUS 

and LSIL papanicolaou cytology: results from the european equivocal 

or mildly abnormal papanicolaou cytology study. Cancer Cytopathol 

2011;119:158-66. 

2 Ravarino A, Nemolato S, Macciocu E, et al. Evaluation of CINtec® 

PLUS immunocytochemistry as a tool for the cytological diagnosis of 

glandular lesions of the cervix uteri. Am J Clin Pathol 2012, in press. 

Large cell neuroendocrine carcinoma of the ovary 

associated with well differentiated neuroendocrine 

tumor of the appendix 

B.J. Rocca1 , M.R. Ambrosio1 , M.A.G.M. Butorano1 , A. Ginori1 , 

A. Ambrosio2 , C. Cardone1 , M. Vestri1 , R. Santopietro1 1 Department of Human Pathology and Oncology, Pathological Anatomy 


Italy 

Background. neuroendocrine differentiation may be documented 

in a variety of ovarian tumors including surface epithelial tumors, 

Follow-up CINtec + CINtec - Inconclusive Inadeguate Total 

Positive 37 (92.5%) 0 3 (7.5%) 40 

Negative 1 (6.2%) 15 (93.8%) 0 16 

Excluded 2* 5 7 

total 38 17 3 5 63 

* no residual neoplastic cells 

Fig. 1. aiS. Sheet of positive cells: the red-stained nuclei are readily 

evident on the background of the brown-stained cytoplasm (40x).

324 

Sertoli-Leydig cell tumors, teratomas, carcinoid tumor, small 

cell carcinoma, large cell neuroendocrine carcinoma (LCNC). 

The latter has been previously described twenty-nine times in 

the literature and usually associated with another type of surface 

epithelial tumor, usually a mucinous histotype. Only few cases of 

pure LCNC of the ovary have been reported to date. Herein, we 

describe the first case of simultaneous occurrence of primitive 

pure large cell neuroendocrine carcinoma of the ovary with a well 

differentiated neuroendocrine tumor of the appendix. 

Materials and methods. A 58 year-old female with no significant 

past medical history presented with abdominal discomfort, 

nausea and general fatigue. Abdominal ultrasonography (US) 

and whole body computed tomography (CT) showed a 3-cm solid 

tumor in the right ovary. The pre-operative diagnosis was that of 

ovarian cancer, thus the patient underwent total hysterectomy, 

bilateral salpingo-oophorectomy, omentectomy and appendicectomy. 

After fixation in 10% formaldehyde, sections were taken 

from the tumour for histological examination and the following 

antibodies were checked: cytokeratin 7 and 20, WT1, Vimentin, 

estrogen and progesterone receptors, chromogranin, synaptophysin, 

CD56 both on ovary and appendix samples. 

Results. The left ovary measured 3 cm in largest diameter. The 

serosa was intact and the tube normal. The cut surface was solid 

grey-white with a whitish nodule of 2 cm. The right ovary was 

enlarged by a 2,5 cm-solid whitish-yellow mass infiltrating 

the ovarian capsule. The tube showed multiple nodules on the 

external surface. The uterus was deformed by numerous leiomyomas 

and the appendix was normal. Cytological examination 

of peritoneal fluid showed no malignant cells. Microscopically 

the tumor showed a solid growth pattern and was composed of 

medium to large cells forming sharply demarcated sheets and 

cords with abundant eosinophilic and granular cytoplasm. The 

nuclei showed condensation of nuclear material (salt and pepper 

chromatin) and large prominent nucleoli were present. Foci 

of necrosis were observed. Mitoses were frequent (40 mitotic 

figures per 10 high power field-HPF). Tumor extension to the 

serosa surface and tube infiltration was observed as well as vascular 

invasion. The neuroendocrine differentiation was confirmed 

by immunohistochemistry showing positivity for chromogranin, 

synaptophysin and CD56. Proliferative index (Mib-1) was approximately 

40%. The final diagnosis was pT2aNxMx (TNM7) 

primitive large cell neuroendocrine carcinoma of the ovary. The 

appendix showed a well differentiated neuroendocrine tumor 


Differential roles of SnAI2/SLUG transcription 

factor in the epithelial and stromal compartments 

of the human prostate cancer 

C. Sorrentino, S. Di Meo, M.G. Tupone, T. D’Antuono, P. Musiani, 

E. Di Carlo 

Section of Anatomic Pathology and Molecular Medicine, Department of 

Medicine and Sciences of Aging, “G. d’Annunzio” University of Chieti- 

Pescara, Chieti, Italy; Ce.S.I. Aging Research Center, “G. d’Annunzio” 

University Foundation, Chieti, Italy 

Introduction. SNAI2/SLUG is a zinc-finger transcription factor 

that acts as a master regulator of cell migration 1 , by trigger- 



Sala Botticelli ore 17,00 – 17,36 

(NET) (7 mm in maximum diameter) with a typical organoid 

arrangement of neoplastic cells in nests and trabeculae. Cells 

were small, round and monomorphic with monotonous nuclei, 

inconspicuous nucleoli and characteristic stippled chromatin. The 

tumor infiltrated the sub-serosa. Proliferative index (Mib-1) was 

less than 1%. Neither mitotic figures nor necrosis was appreciated. 

The diagnosis was that of pT2 G1 well-differentiated NET 

(TNM7-ENETS). 

Discussion. Ovarian LCNC is a rare entity, defined as “a malignant 

tumor composed of large cells that show neuroendocrine 

differentiation”. Although mostly in stage I at diagnosis, patients 

usually follow an aggressive poor outcome. The etiology 

of LCNC of the ovary remains unclear. Since most cases are 

admixed with another surface epithelial tumour, it is likely that 

LCNC arises from the concurrent epithelial tumor. This hypothesis 

is supported by the presence of scattered neuroendocrine 

cells reported in the epithelial tumours associated with LCNC as 

well as in ovarian tumors not associated with LCNC. The description 

of 4 cases of pure LCNC suggests the possibility that LCNC 

may arise directly from the ovarian tissue. This hypothesis is 

supported by the fact that isolated neuroendocrine cells have been 

identified in normal ovary. Neuroendocrine carcinomas result 

from multidirectional differentiation of a multipotent epithelial 

stem cell. The occurrence of pure primary ovarian LCNC with 

well differentiated neuroendocrine tumor of the appendix rather 

than being casual may suggest a progression of hyperplastic neuroendocrine 

lesions. It may be speculated that due to a genetic 

imbalance, our patient developed proliferative endocrine cell 

lesions which led to a LCNC in the ovary and to a well differentiated 

neuroendocrine tumor in the appendix. 

references 

Chênevert J, Bessette P, Plante M, et al. Mixed ovarian large cell 

neuroendocrine carcinoma, mucinous adenocarcinoma, and teratoma: 

a report of two cases and review of the literature. Pathol Res 

Pract 2009;205:657-61. 

Draganova-Tacheva RA, Khurana JS, Huang Y, et al. Large cell neuroendocrine 

carcinoma of the ovary associated with serous carcinoma 

with mucin production: a case report and literature review. Int J Clin 

Exp Pathol 2009;2:304-9. 

Lindboe CF. Large cell neuroendocrine carcinoma of the ovary. AP- 

MIS 2007;115:169-76. 

Veras E, Deavers MT, Silva EG, et al. Ovarian nonsmall cell neuroendocrine 

carcinoma: a clinicopathologic and immunohistochemical study 

of 11 cases. Am J Surg Pathol 2007;31:774-82. 

ing epithelial-mesenchymal transition (EMT) during embryonic 

development and tumor metastatization, and also regulates cellcycle 

progression and survival 2 . In this study, we investigated its 

role in prostate cancer (PCa) development and progression, under 

normal and androgen deprivation therapy (ADT) conditions. 

Materials and methods. We used laser capture microdissection 

followed by real-time RT-PCR to determine SLUG gene expression 

levels in normal and cancerous prostatic epithelium and stroma, 

differentiating neoplastic foci with low (well differentiated) 

versus high (poorly differentiated) Gleason grade (≤ 3 versus >) 

3 . Epithelial and stromal cells were isolated from cancerous and 

normal (selected from the prostatic lobe opposite to the PCa or 

normal prostatic tissue far from it) prostate specimens from 55 

untreated and 35 ADT-treated patients who underwent radical 

prostatectomy for PCa, and normal prostate specimens from 12


patients who had undergone cystoprostatectomy for bladder cancer 

(controls). Immunostainings and confocal microscopy were 

used to visualize SLUG expression at the protein level. 

Results. SLUG gene expression levels were significantly 

(P < 0.05) lower in the neoplastic (with no appreciable difference 

between low and high-grade PCa) versus normal prostatic 

epithelia (~12 times in low grade, ~16 times in high grade) and in 

neoplastic versus normal stroma (~4 times in both grades). 

SLUG was predominantly expressed in the stromal rather than 

the epithelial compartment, with higher levels in the neoplastic 

stroma. The mean expression level of SLUG in normal samples 

from the untreated patients was not significantly different to that 

obtained in normal samples from controls. 

Immunostainings showed that, in the normal prostate glands, 

both basal and luminal secretory cells strongly expressed SLUG 

in their nuclei, whereas SLUG staining ranged from very weak 

to moderate in the neoplastic glands. SLUG expression was inversely 

related to that of the cell cycle regulator cyclin D1, and 

the proliferation marker Ki-67. 

Lastly, ADT generally enhanced SLUG expression in the stroma, 

particularly in that of low-grade PCa. 

Conclusions. These preliminary findings suggest that, as observed 

in PCa cell lines (3), in the human prostate tissues, SLUG 

may inhibit neoplastic epithelial cell proliferation rather than act 

as an EMT promoter. It may also have a different role in the PCaassociated 

stroma, whose response to ADT may have important 

clinical and pathological implications. All these issues are the 

subject of ongoing investigation in our laboratories. 

references 

1 Nieto MA, Sargent MG, Wilkinson DG, et al. Control of cell behavior 

during vertebrate development by Slug, a zinc finger gene. Science 

1994;264:835-9. 

2 Barrallo-Gimeno A, Nieto MA. The Snail genes as inducers of cell 

movement and survival: implications in development and cancer. 

Development 2005;132:3151-61. 

3 Liu J, Uygur B, Zhang Z, et al. Slug inhibits proliferation of human 

prostate cancer cells via downregulation of cyclin D1 expression. 

Prostate 2010;70:1768-77. 

Pathological staging of uterine cervical carcinoma 

after neoadjuvant chemotherapy: a predictor 

of survival 

V.G. Vellone1 , D. Lorusso2 , V. Masciullo2 , G. Amodio2 , G. Chiarello1 

, E.D. Rossi1 , G. Fadda1 , G. Scambia1 , G.F. Zannoni2 1 Istituto di Anatomia ed Istologia Patologica, Policlinico A. Gemelli, Università 

Cattolica S.Cuore, Roma; 2 Istituto di Ostetricia e Ginecologia, 

Policlinico A. Gemelli, Università Cattolica S.Cuore, Roma 

Background. Radio-chemotherapy represents a relevant therapeutic 

option for cervical carcinoma. Surgical removal of uterus, 

ovaries, lymph nodes and peritoneal sampling after the neoadjuavant 

treatment give us the unique opportunity to evaluate the real 

ammount of the residual, its anatomic location and its impact on 

overall survival. A staging method is proposed and its implication 

in prognosis is investigated. 

Materials and methods. Study population: 114 cervical cancer 

patients (stage IB-IV FIGO) 

Treatment: platinum based chemotherapy with concomitant 

external beam radioterapy and then radical hysterectomy, lyphadenectomy 

and peritoneal sampling 

Local response classificated as follow 1 2 : 

pR0: Pathological Complete Response 

pR1: Pathological Partial Response 

pR2: Pathological No Response. 

325 

All patients were re-staged according to ypTNM and FIGO staging 

and then combined with pR as follow: 

No Residual Disease (NRD): pR0 Stage 0 

Minimal Residual Disease (MRD): pR1 Stage IA and IB; pR2 

Stage IA 

Local Residual Disease (LRD): pR1 Stage IIA and IIB; pR2 

Stage IB, IIA, IIB 

Metastatic Disease (MD): any pR Stage III and IV 

Mean follow-up: 39 months 

Results. 46 patients resulted NRD; 25 MRD; 23 LRD; 20 MD. 

NRD patients showed a significant advantage in suvival if compared 

to LRD (p < 0,001) and MD (p < 0,001). No significant 

difference were observed with MRD 

LRD showed a slight better survival if compared to MD (p = 0,1). 

Conclusions. A complete pathological staging confirmed its crucial 

role in risk stratification. Furthermore it could be useful for planning 

a second line treatment after surgery in patient with residual. 

referencies 

1 Zannoni GF, Vellone VG, Carbone A. Morphological effects of radiochemotherapy 

on cervical carcinoma: a morphological study of 

50 cases of hysterectomy specimens after neoadjuvant treatment. Int J 

Gynecol Pathol 2008;27:274-81. 

2 Zannoni GF, Vellone VG. Accuracy of Papanicolaou smears in cervical 

cancer patients treated with radiochemotherapy followed by radical 

surgery. Am J Clin Pathol 2008;130:787-94. 

Clinical, pathological and molecular prognostic 

factors for non-endometrioid (type II) endometrial 

carcinoma 

V.G. Vellone1 , A. Fagotti2 , D. Gallo2 , C. Bottoni2 , L. Santoro1 , 

E.D. Rossi1 , G. Fadda1 , G. Scambia1 , G.F. Zannoni2 1 Istituto di Anatomia ed Istologia Patologica, Policlinico A.Gemelli, Università 

Cattolica S.Cuore, Roma; 2 Istituto di Ostetricia e Ginecologia, 

Policlinico A.Gemelli, Università Cattolica S.Cuore, Roma 

Background. Non Endometrioid Endometrial Carcinoma (NEC) 

are an heterogeneus group of neoplasms with a notorius highly 

malignant behaviour, with different features and a worse prognosis 

if compared to conventional endometrioid carcinomas 1 . 

The impact in prognosis of a series of clinical, pathological and 

molecular markers is investigated. 

Materials and methods. Study population: 28 non endometrioid 

endometrial carcinoma patients treated withradical hysterectomy, 

lymph adenectomy and peritoneal sampling. 

Mean Follow up duration: 32 months 

Impact in overall survivall of Patients age, Tumor size, % of 

Myometrial Invasion, Lymph nodes metastases, extralimphonodal 

metastases, Stage, ER, PR, Her2/neu, Ki67, p53, bcl-2 is 

investigated 

Results. NEC confirmed its fame of deadly disease: half of the 

patients died of the disease. We found no prognostic significance 

for Age, Tumor size, % of Myometrial Invasion, Lymph nodes 

metastases, extralimphonodal metastases, Stage, ER, PR, Ki67, 

p53, bcl-2 (p > 0,05). 

Only positivity for Her2/neu (2+ FISH+ or 3+) identified a sub 

population of cases with a worse prognosis (p = 0,03). 

Conclusions. This finding confirm the aggressiveness of these 

neoplasms but rise new opportunities in target terapies for these 

unlucky patients. 

references 

1 Zannoni GF, Vellone VG, Arena V, et al. Does high-grade endometrioid 

carcinoma (grade 3 FIGO) belong to type I or type II endometrial 

cancer? A clinical-pathological and immunohistochemical study. Virchows 

Arch 2010;457:27-34.

326 

EnDOCrInO 

Epidemiological analysis of the histopathological 

features of testicular tumour in patients living 

in a high-risk environmental area 

M. Altomare1 , A. Torrisi2 , A. Torrisi2 , M. Castaing2 , F. Tisano2 , 

A. Madeddu2 , E. Vasquez2 , S. Sciacca2 , S. La Vignera1 , A.E. Calogero1 

, E. Vicari1 1 Section of Endocrinology, Andrology and Internal Medicine and Master 

in Andrological, Human Reproduction and Cellular Physiopathology, Department 

of Medical and Pediatric Sciences; 2Integrated Cancers Registry 

Catania-Messina-Siracusa, Department of Hygiene and Public Health 

“G.F. Ingrassia”, University of Catania, Catania, Italy 

Background/Aim. Testicular tumour is the most common form 

of neoplasia in young or middle-aged men (0-39 years), representing 

the 17.8% of all tumours diagnosed among men of this 

age range, in 2003-2005. The age-specific prevalence rates indicate 

that the number of cases increases quickly starting from adolescence, 

reaching higher values around 25-29 years. From 30th 

year onwards, the prevalence decreases steadily 1 . The testicular 

tumor epidemiologic pattern suggests etiologic factors that may 

be congenital, racial, and geographic. Risk factors for testicular 

tumor include cryptorchidism, a prior history of tumour in one 

testis (the contralateral testis is at increased risk), and a family 

history of testicular tumour. This tumour is sometimes linked 

to other rare conditions which do not allow testes to develop 

normally. Furthermore, the incidence of testicular tumour varies 

markedly according to ethnicity, with geographic variations 

across the world 2 . 

Most testicular tumours begin in germ cells (testicular germ cell 

cancers, TGCC). Despite a common cell of origin, TGCC are 

histologically and clinically classified in seminoma (S) and nonseminoma 

(NS). Among patients with a history of cryptorchidism 

and affected by testicular tumour, S accounts for more than half 

of tumours, and the only distinct subtype is the spermatocytic 

seminoma. NS includes many histological subtypes, such as yolk 

sac tumour, choriocarcinoma, embryonal cell carcinoma, teratoma 

2 . Other histopathological variants of testicular tumour include 

tumours of paratesticular soft tissue (i.e. sarcomas), tumours of 

the gonadal stroma (Leydig cell tumour, Sertoli cell tumour), and 

lymphoid/haematopoietic tumours. Data from the Italian Cancers 

Registries showed that the most frequent form is represented by S 

(50%), followed by embryonal carcinomas (17%), non specified 

malignancies (7%), teratocarcinomas (6%), and teratomas (3%). 

Cryptorchidism is reported in the 6% of testicular tumours 3 . In 

some cases of TGCC-NS, the contemporary presence of different 

histotypes within the same tumour has been reported, but there 

are no data on the association of S with NS tumors. It has been 

suggested that testicular tumour derives from a precocious lesion, 

the in situ carcinoma of the testis, also named intratubular 

germ cell neoplasia (IGCN) or testicular intraepithelial neoplasia 

(TIN) 4 . Prevention and treatment make the 5 years survival very 



Sala Botticelli – ore 17,36-18,30 

high (95%). The mortality trend remains stable between 1998 

and 2005 5 . 

Testicular tumour prevalence has been increasing over the past 

several decades in many developed countries, although the reason 

for this increase is not clear. Some studies suggest that in utero or 

in early childhood exposures, may play a relevant role in the individual 

risk level. In Denmark, a temporal decrease of the sperm 

output associated with an increased testicular tumour prevalence 

has been observed. This increase is associated with urogenital 

malformations such as cryptorchidism and hypospadias and/or 

reduced testicular volume. In other countries, like Finland, the 

opposite occurs. The geographical difference in the incidence of 

these diseases suggests an etiopathogenetic role of environmental 

factors 6-10 . Recent evidences showed that the non classical 

membrane G-protein coupled estrogen receptor (GPER/GPR30) 

mediates the effects of both estrogens and xenoestrogens through 

rapid non genomic activation of signal transduction pathways in 

various human estrogen dependent cancer cells (breast, ovary, endometrium). 

GPER is expressed by human normal adult testicular 

germ cells, specifically overexpressed in seminoma tumours and 

it is able to trigger seminoma cell proliferation in vitro 11 . 

Few years ago, it was suggested that some male reproductive disorders, 

such as cryptorchidism, hypospadias, reduced sperm quality, 

and TGCC, are interlinked and originate from an abnormal 

intrauterine testicular development 12 . This hypothesis has been 

defined testicular dysgenesis syndrome (TDS), and suggests that 

the prenatal period is a highly vulnerable phase, in which the impairment 

of testicular differentiation, genetic diseases, polymorphisms, 

exposure to environmental toxins, lifestyle or disorders 

intrauterine growth, may cause permanent adverse effects 13 14 . 

In Sicily, there is an industrial area, the so-called Melilli-Priolo- 

Augusta (SR) triangle, which has been declared of national interest 

(L. 426/98, art.1) as “area at high risk of environmental crisis” 

(D.L. 30/11/1990). The finding that an increased prevalence of 

urogenital tract malformations (hypospadias) has been reported 

in this area 15 16 lead us to evaluate whether this correlated with 

the presence of testicular tumour in the same area. Preliminary 

data from a study conducted in men living in Melilli’s urban area 

indicate a high prevalence of asthenozoospermia and teratozoospermia 

17 18 . Hence, this study aimed to evaluate the occurrence 

and the histopathological features of testicular tumours in this 

area, and in the overall Eastern Sicily, through the analysis of 

hospital discharge records. 

Materials and methods. The Integrated Cancers Registry database, 

sections of Syracuse (SR), Catania (CT), and Messina 

(ME), was searched. The data relate to the period 2003-2005. 

All incident cases over these three years, for each province, were 

analyzed. A subgroup of cases from the industrial area (IA) was 

identified. We examined age at diagnosis, topography, and histological 

finding. 

Results. Number (N) and age (mean ± SD) of patients, a positive 

history for cryptorchidism (C) (n, % of N), and an overview of 

histological categories (n, % of N) are reported in Table I. 

Testicular tumours in IA were the 25.8% of all those reported 

Tab. I. 

N Years C TGCC-S TGCC-NS Others No data 

SR, all 31 36.1±15.5 1 (3.2%) 19 (61.2%) 11 (35.4%) 1 (3.2%) - 

SR, IA 8 30.6±4.3 - 5 (62.5%) 3 (37.5%) - - 

CT 102 35.2±15 8 (7.8%) 38 (37.2%) 52 (50.9%) 7 (6.8%) 5 (4.9%) 

ME 57 31.8±10.9 6 (10.5%) 28 (49.1%) 23 (40.3%) 2 (3.5%) 4 (7.0%)


Tab. II. 

TCGC-S TCGC-NS 

S AS SS G NS EC MT TC YS CC 

SR, all 16 1 1 1 - 2 - 3 - - 

SR, IA 4 - - - - - - 2 - - 

CT 37 - 1 3 1 17 2 3 1 1 

ME 26 1 1 - 1 7 - 3 - - 

S: seminoma; aS: anaplastic seminoma; SS: spermatocitic seminoma; g: 

germinoma; NS: non seminoma; Ec: embrional carcinoma; Mt: malignat 

teratoma; tC: teratocarcinoma; YS: Yolk sac tumor; CC: choriocarcinoma 

in the province of SR. In two cases (25%), the occurrence of a 

second tumour was reported. Others tumours were: liposarcoma 

(1 SR; 1 CT), Leydig cells tumour (1 CT), non-Hodgkin’s lymphoma 

(2 CT; 1 ME), plasmacytoma (1 CT), B-cells malignant 

lymphoma (1 CT; 1 ME), follicular lymphoma (1 CT). Table 

II shows the histopathological variants distribution of testicular 

tumours. 

Altogether, 34 out of 190 (17.8%) patients had mixed forms of 

testicular tumours, divided into seminoma + non-seminomatous 

(S+NS) (N = 19), and more than one variant of non-seminomatous 

(MNS) (N = 15). Tab. III shows these data, with the 

mean ± SD age of the affected patients. 

Tab. III. 

N 

% of all 

testicular 

cancer 

SR, all 5 16.1 

SR, IA 2 25 

CT 19 18.6 

ME 10 17.5 

S+NS 

(n,%) 

2 

(40%) 

2 

(100%) 

10 

(52.6%) 

7 

(70%) 

Age 

32±4.2 

MNS 

(n,%) 

3 

(60%) 

Age 

30±5.5 

32±4.2 - - 

29±4.4 

28.7±11.3 

9 

(47.3%) 30.7±13.1 

3 

(30%) 

31.6±7.0 

Conclusions. Our data showed a higher prevalence of TGCC- 

NS for the province of Catania, in contrast with the national 

data and with data from other provinces. Seminomas are more 

frequent in patients from IA, but a relevant percentage (25%) of 

these subjects develop a second tumour. Interestingly, in this area 

was found the same percentage of testicular tumours with mixed 

histopathologic variants, and all of these presented seminomatous 

elements. Also for the province of Messina, was found a higher 

percentage of S+NS. Furthermore, we did not find a relationship 

between seminoma and cryptorchidism in all the provinces examined. 

These findings suggested the potential etiopathogenetic role 

of environment in the development of testicular tumours. 

references 

1 Rapporto AIRTUM 2009. Epidemiol Prev 2009;33(suppl. 2):1-26. 

2 Hayes-Lattin B, Nichols CR. Testicular cancer: a prototypic tumor of 

young adults. Semin Oncol 2009;36:432-8. 


4 Ziglioli F, Maestroni U, Dinale F, et al. Carcinoma in situ (CIS) of the 

testis. Acta Biomed 2011;82:162-9. 


6 Vierula M, Niemi M, Keiski A, et al. High and unchanged sperm 

counts of Finnish men. Int J Androl 1996;19:11-7. 

7 Hemminki K, Li X. Cancer risks in Nordic immigrants and their offspring 

in Sweden. Eur J Cancer 2002;38:2428-34. 

8 Boisen KA, Chellakooty M, Schimdt IM, et al. Hypospadias in a 

cohort of 1072 Danish newborn boys: prevalence and relationship 

to placental weight, anthropometrical measurements at birth, and re- 

327 

productive hormone levels at 3 months of age. J Clin Endocrin Metab 

2005;90:4026-41. 

9 Carlsen E, Giwercman A, Keiding N, et al. Evidence for decreasing 

quality of semen during past 50 years. BMJ 1992;305:609-13. 

10 Meeks JJ, Sheinfeld J, Eggener SE. Environmental toxicology of testicular 

cancer. Urol Oncol 2012;30:212-5. 

11 Chevalier N, Vega A, Bouskine A, et al. GPR30, the non-classical 

membrane G protein related estrogen receptor, is overexpressed in 

human seminoma and promotes seminoma cell proliferation. PLoS 

One 2012;7:e34672. 

12 Skakkebaek NE, Rajpert-De Meyts E, Main KM. Testicular dysgenesis 

syndrome: an increasing common developmental disorder with 

environmental aspects. Hum Reprod 2001;16:972-8. 

13 Main KM, Skakkebaek NE, Virtanen HE, et al. Genital anomalies 

in boys and the environment. Best Pract Res Clin Endocrinol Metab 

2010;24:279-89. 

14 Vicari E, Barone N, La Vignera S, et al. Unilateral testicular cancer: 

incidence and effects of a controlateral testiculopathy on the sperm 

output. Minerva Urol Nefrol 2005;57:47-52. 

15 Madeddu A, Bianca S, Contrino L, et al. L’incidenza delle malformazioni 

congenite e la mortalità in provincia di Siracusa negli anni 

1995-2000 nello studio della Commissione istituita dall’O.E.R. 

16 Bianchi F, Bianca S, Linzaline N, et al. Surveillance of congenital 

malformation in Italy: an investigation in the Province of Siracusa. 

Epidemiol Prev 2004;28:87-93. 

17 Altomare M, Vicari LO, Ferrante M, et al. Negative effects of heavy 

metals levels in the seminal plasma of men living in an Eastern Sicily 

environmental risk area. ISEE 2012 Conference in Columbia, South 

Carolina, USA (Abs) (in press). 

18 Altomare M, Vicari LO, Fiore M, et al. Valutazione dei livelli dei 

metalli pesanti nel sangue, nel plasma seminale e negli spermatozoi 

di soggetti in età fertile in un’area ad elevato rischio ambientale della 

Sicilia sudorientale. In: Riproduzione e sessualità dalla sperimentazione 

alla clinica. 2012, pp. 327-30. 

KI-67 heterogeneity in gastroenteropancreatic 

neuroendocrine tumors 

P. Calamaro1 , T. Borra1 , M. Albertelli2 , M.P. Brisigotti1 , S. Bruno1 , 

D. Ferone2 , L. Mastracci1 , F. Grillo1 1 University of Genova, Histopathology, DISC, Azienda Ospedaliera e 

Universitaria “San Martino” IRCCS, Genova; 2 University of Genova, 

Endocrinology, DIMI, Azienda Ospedaliera e Universitaria “San Martino” 

IRCCS, Genova 

Introduction. Prediction of survival is difficult in gastroenteropancreatic 

(GEP) neuroendocrine tumors (NET), due to their highly 

variable clinical course 1 . In order to determine a parameter that 

correlates with survival and optimizes patient management, the 

European Neuroendocrine Tumour Society (ENETs) introduced 

a proliferation-based three-tiered grading system that uses either 

mitotic count (G1: < 2/10 HPF; G2: 2 to 20/10 HPF, G3: > 20/10 

HPF) or Ki67 labeling index (G1: < 2%; G2: 3-20%; G3: > 20%) 2 3 . 

This grading system has been incorporated into the new WHO 2010 

classification of GEP NETs [4]. It is known that proliferation varies 

within the tumor, indeed, ENETs/WHO recommend that at least 40 

to 50 HPF should be counted for mitoses and areas of highest labeling 

(so called “hot spots”) should be identified to determine the Ki67 

index (percentage of positively stained tumors cell nuclei on a 2000 

cell count). When there is discordance between mitotic rate and the 

Ki67 index the highest dictates the final grade 5 . 

Many Authors have proved the reliability of the new grading system 

with survival in many cohorts of patients 6-8 , but to date many 

concerns exist on the heterogeneity of Ki67 in the same tumor or 

in metastatic disease. 

Our aim was to retrospectively study a series of GEP NETs with 

clinical follow-up, and evaluate Ki67 index in order to establish 

whether there is significant variability in different samples of the 

same lesion. Moreover, we studied the variability of Ki67 index 

in a group of patients with multiple primitive NETs on first diagnosis. 

Finally, we wanted to verify if in recurrent disease, local 

or distant, the Ki67 index is different from the primary tumor.

328 

Materials and methods. From the Histopathology archives at 

our center, 170 GEP-NETs (dating from 1993-2011) were identified, 

50 of them with clinical follow-up (mean follow up was 59 

months, range 2-168 months). Our study included cases which 

fulfilled the following criteria: 1) NETs with multiple tissue 

samples of the same primary lesion; 2) multiple primitive NETs; 

3) NETs with synchronous metastases, distant or local; 4) NETs 

with subsequent metachronous metastases, at least 6 months after 

initial presentation (mean to recurrence 96 months, range 24-144 

months). 

Twenty-five cases satisfied the above criteria. For each location 

(primary or metastatic) a maximum of 3 paraffin tissue blocks 

were selected. In case of multiple primitive neuroendocrine 

tumors, at least one sample of each separate lesion was chosen. 

Haematoxylin and eosin (H&E)–stained slides from all the selected 

paraffin blocks were reviewed and re-classified according 

to WHO 2010 and Ki67 immunohistochemistry performed. Proliferation 

(Ki67) index was given as a percentage by counting the 

number of positive tumor cells per 2000 cells, on the foci with 

highest density. 

Results. Demographics: Mean age at diagnosis was 61 years 

(range 37-87 years), F:M ratio was 1:1.2. Among the 25 GEP- 

NETs analyzed, primitive tumors were located in the stomach 

= 2, duodenum = 1, pancreas = 8, ileum = 9, appendix = 2 and 

colon = 1. Two patients had liver metastases with unknown primary. 

Grade at diagnosis was distributed as follows: G1 = 15; 

G2 = 8; G3 = 2. 

Heterogeneity of the primary tumor: Nineteen patients presented 

with 21 tumors, each with more than one sample of the primary 

tumor. Thirteen out of 21 (62%) presented exactly the same Ki67 

percentage and therefore the same grade in each paraffin block. 

Six (29%) tumors presented different Ki67 index between paraffin 

blocks, but with no change in grade, since the variability was 

inside the intervals set by ENETs/WHO. Two (10%) tumors 

showed Ki67 index discrepancy (7% vs 2% and 4% vs 2%) which 

was enough to change grade, in particular between G1 to G2. 

Heterogeneity between the primary tumor and synchronous metastases 

(local and distant): Among 14 patients with documented 

primary tumor and synchronous metastases, 9 (64%) presented 

exactly the same Ki67 index between sites while 2 (14%) manifested 

variability in their Ki67 index, but not in grade. Three 

(21%) cases showed discrepancy in grade between primary and 

metastatic sites. In particular two cases showed an increase in 

proliferation index in nodal metastases (1% vs 5% and 17% vs 

31%) and one case showed increase Ki67 index in mesenteric 

localization (1% vs 5%). One case who presented with multiple 

hepatic metastases showed discrepancy between each metastasis 

(7% vs 1%). 

Heterogeneity between the primary tumor and metachronous 

metastases (local and distant): Six patients underwent surgical 

excision of metachronous metastases during follow up. Three 

(50%) patients showed exactly the same Ki67 index between 

primary tumor and metachronous metastases, while 3 (50%) patients 

showed an increase in Ki67 rate in the metastatic site and a 

change in grade, from G1 to G2 (1% vs 10%; 2% vs 5%; 1% vs 

7%). Two of these cases were metastatic to the liver while one 

was a nodal metastasis. 

Heterogeneity between multiple primary NETs: Three patients 

had multiple primary ileal NETs while 1 patient had multiple 

pancreatic tumors. In one patient with 4 separate ileal NETs, 

all primary tumors had the same proliferative index (G1). In the 

remaining 2 patients, with respectively 6 and 21 ileal NETs, only 

the largest tumors (measuring > 1 cm) were classified as G2 (4% 

and 3% Ki67 index respectively). The remaining smaller lesion 

were all G1 (1-2%). All 12 pancreatic NETs in one patient were 

G1 (1-2%). 

Discussion. We investigated Ki67 index heterogeneity in a group 

of 25 patients with GEP NETs. In particular we evaluated this 


parameter on different paraffin blocks of the same tumor and 

between different synchronous or metachronous locations. 

Ki67 heterogeneity has already been investigated by 2 groups 

[5,9]. In both studies tissue microarrays (TMAs) from paraffin 

blocks of NET liver metastases from well differentiated NETs 

were used and conclusions are that ample sampling is important, 

especially in G2 tumors which present more heterogeneous Ki67 

labeling. These 2 studies however do not focus on whether heterogeneity 

is also important in the primary tumor and therefore 

dependent on sampling. Our results indicate that 10% of tumors 

may have sufficient variability in their Ki67 index to change 

grade when evaluated on different paraffin blocks of the same 

tumor. Size is a probable indication of variability, as our 2 cases 

both measured approximately 2 cm. This issue may be overcome 

by performing Ki67 on more than 1 paraffin block, especially on 

large neoplasms. 

Approximately 20% of patients showed an increase in proliferation 

rate in metastatic sites, and in one case grade increased from 

G2 to G3. Similarly 50% of patients showed an increase in Ki67 

rate in time between the primary tumor and metachronous metastasis. 

Considerations about the exact impact of the metastatic site 

(nodal vs mesenteric vs hepatic) on proliferation are not possible 

in this small series. 

Couvelard et al [9] suggested that all synchronous hepatic NET 

metastases probably have the same proliferation index while we 

identified a patient who had a significant difference between 

proliferation rate (7% vs 1%) and therefore grade (G2 vs G1) 

between different metastases. 

Our results also suggest that when multiple primary NETs are 

seen, Ki67 index may vary between different lesions and may be 

correlated with size. This advocates the sampling of each separate 

primary lesion, especially when more than 1 cm, and respective 

evaluation Ki67. 

In conclusion, heterogeneity in NETs is well recognized and any 

sampling variability may be overcome by evaluating Ki67 on 

multiple tissue blocks. This may however not prove necessary 

in primary tumors as few cases (10%) in our study showed sufficient 

variability to change grade. Differences in grade between 

primary and synchronous and metachronous metastatic site are 

however more important and evaluation of Ki67 at all sites may 

be significant for patient management. In the future these findings 

will be correlated with patient outcome so as to identify whether 

the increase in proliferation rate in secondary sites is important in 

the correct determination of prognosis. 

references 

1 Modlin IM, Oberg K, Chung DC, et al. Gastroenteropancreatic neuroendocrine 

tumours. Lancet Oncol 2008;9:61-72. 

2 Rindi G, Klöppel G, Alhman H, et al.; and all other Frascati Consensus 

Conference participants; European Neuroendocrine Tumor 

Society (ENETS). TNM staging of foregut (neuro)endocrine tumors: 

a consensus proposal including a grading system. Virchows Arch 

2006;449:395-401. 

3 Rindi G, Klöppel G, Couvelard A, et al. TNM staging of midgut and 

hindgut (neuro) endocrine tumors: a consensus proposal including a 

grading system. Virchows Arch 2007;451:757-62. 

4 Bosman FT, Carneiro F, Hruban RH, et al., editors. WHO Classification 

of tumours of the digestive system. Lyon: IARC Press 2010. 

5 Yang Z, Tang LH, Klimstra DS. Effect of tumor heterogeneity on 

the assessment of Ki67 labeling index in well-differentiated neuroendocrine 

tumors metastatic to the liver: implications for prognostic 

stratification. Am J Surg Pathol 2011;35:853-60. 

6 Hochwald SN, Zee S, Conlon KC, et al. Prognostic factors in pancreatic 

endocrine neoplasms: an analysis of 136 cases with a proposal 

for low-grade and intermediate-grade groups. J Clin Oncol 

2002;20:2633-42. 

7 Pape UF, Jann H, Müller-Nordhorn J, et al. Prognostic relevance of 

a novel TNM classification system for upper gastroenteropancreatic 

neuroendocrine tumors. Cancer 2008;113:256-65. 

8 Jann H, Roll S, Couvelard A, et al. Neuroendocrine tumors of midgut


and hindgut origin: tumor-node-metastasis classification determines 

clinical outcome. Cancer 2011;117:3332-41. 

9 Couvelard A, Deschamps L, Ravaud P, et al. Heterogeneity of tumor 

prognostic markers: a reproducibility study applied to liver metastases 

of pancreatic endocrine tumors. Mod Pathol 2009;22:273-81. 

Immunocytochemistry and BrAF mutation analysis 

in thyroid lesions suspicious for malignancy 

diagnosed on liquid- based cytology. 

A new challenge 

E.D. Rossi, M. Martini, P. Straccia, S. Capodimonti, T. Cenci, 

C.P. Lombardi1 , A. Pontecorvi2 , L.M. Larocca, G. Fadda 

Division of Anatomic Pathology and Histology 1 Division of Endocrine 

Surgery, 2 Division of Endocrinology- Università Cattolica del Sacro Cuore, 

“Agostino Gemelli” School of Medicine, Rome 

Introduction. Follicular patterned lesions are a common finding 

in general population for which a preoperative cytological diagnosis 

in order to define a correct therapeutical management, is 

crucial. Approximately 65-70% of fine needle cytologic biopsies 

(FNC) are classified as benign as well as 5-10% are diagnosed 

as malignant. The remaining 25-30% are included in the grey 

zone of the indeterminate diagnoses where benign neoplasms 

cannot be cytologically distinguished by the malignant ones. The 

Suspicious for Malignancy (SM) category represents a cytologic 

category in which the morphology alone is not able to define 

conclusively the malignant nature of a defined lesion. The aim of 

this study is the evaluation of the role of simultaneous analyses of 

immunocytochemistry and BRAF mutation in predicting the outcome 

of SM thyroid follicular lesions diagnosed on liquid based 

cytology (LBC), and, hence, in adding further diagnostic details 

which could guide a better clinical management. Immunocytochemistry 

based on the use of an immunopanel (e.g. HBME-1 

and Galectin 3) has shown a significant role in a better definition 

of low and high risk follicular neoplasms. Activating mutations 

in the V600E locus of BRAF-1 gene have been identified in about 

29-69% of PTC and more than 80% of the tall cell variant (TCV) 

whereas they have not been detected in benign lesions and in the 

majority (80%) of the follicular variants of PTC (FVPC). 

Materials and methods. From October 2010 through June 2011, 

43 SM, processed by liquid based cytology (LBC), were studied 

for the application of an immunopanel made up of HBME-1 and 

Galectin- 3 and for the BRAF mutational analysis. The aspirated 

material was processed with the ThinPrep 2000 technique (Hologic 

Co, Marlborough MA). Immunocytochemistry, carried out 

with the ABC peroxidase method and BRAF mutation analysis, 

using the direct sequencing method, were performed on the residual 

cells stored in the PreservCyt solution. 

Results. Thirty one cases out of 43 (73%) underwent surgery and 

were diagnosed respectively as: 5 benign lesions (BL, including 

Follicular Adenoma), 17 papillary carcinomas, (PTC), 7 follicular 

variants of papillary carcinoma (FVPC) and 2 tall cell variants 

of PC (TCV). All BL resulted negative for the immunopanel 

while all the malignant lesions resulted positive. All 12 cases that 

expressed the BRAF mutation (39%) resulted histologically malignant 

whereas all BL expressed BRAF wild type. A significant 

association between BRAF mutation and cancer multifocality 

was found (p < 0.0001, Odd Ratio, OR 0.003). The presence 

of BRAF mutation was also significantly associated with nodal 

involvement (p < 0.0001, OR 0.0061) and extracapsular invasion 

(p = 0.0001, OR 0.011). A significant association between the 

positive ICC panel and the malignant nature of the tumors was 

assessed (p = 0.0007 OR 55). 

Conclusions. Immunocytochemistry and BRAF gene mutation 

analysis can be successfully carried out on LBC-processed material. 

The simultaneous application of the two techniques on preoperative 

cytology may help in identifying up of 39% carcinomas 

among the category of SM supporting a more aggressive surgical 

329 

decision. In this group a significant correlation with nodal involvement 

and multifocality highlights the role of BRAF analysis 

in discriminating tumours with a more aggressive behaviour from 

those pursuing a favourable clinical course. 

references 

1 Rossi ED, et al. Cancer Cytopathol 2005;105:87-95. 

2 Nikiforova MN, et al. Thyroid 2009;19:1351-61. 

3 Nikiforov YE, et al. J.Clin Endocrinol Metab 2009;94:2092. 

4 Fadda G, et al. Eur J Endocrinol 2011;165:447-53. 

A case of hyalinizing trabecular tumor (HTT) of the 

thyroid gland in patient with multinodular goiter 

G. Crisman1 , A. Marinucci1 , A.R. Vitale2 , T. Curti2 , V. Ciuffetelli3 

, S. Saltarelli3 , G. Calvisi3 , G. Coletti3 , P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 



Ospedale Civile “San Salvatore”, L’Aquila, Italia 

Background. First described by Carney in 1967, Hyalinizing 

Trabecular Tumor (HTT) represents a rare neoplasm. This lesion 

has been defined by the WHO Classification of Tumors 

of Endocrine Organs as “a rare tumor of follicular cell origin 

with a trabecular pattern of growth and marked intratrabecular 

hyalinization”. 

HTT is of follicular derivation with a characteristic architectural 

and histological features, which can mimic that of a Meduallry 

Carcinoma or of a Papillary Carcinoma of the thyroid. 


presented with a thyroid hypercaptant area in a scintigraphic 

evaluation performed as a follow-up evaluation for a previous 

bladder carcinoma. An ultrasonographic examination of her thyroid 

gland revealed the presence of a single, capsulated nodule 

of 25 x 13 x 20 mm in-dimension sited in the left thyroid lobe. 

The remaining glandular area showed multiple colloidal nodules, 

varying in shape and size, compatible with a diagnosis of multinodular 

goiter. No regional lymphadenopathy has been detected 

and Fine-Needle Aspiration Cytology (FNAC) as been performed 

for diagnostic purpose. Cytological examination revealed several 

tireocytes, mainly palced in aggregates, presenting mild to moderate 

nuclear atypia and pseudoinclusions. On the basis of these 

cytologic findings, a Papillary Thy roid Carcinoma (PTC) was 

suspected and patient underwent total thyroidectomy. 

Reslts. Grossly, a capsulated, whitish nodule of 1,8 cm indiameter 

of the left thyroid lobe was detected. Histopathological 

features revealed a lesion mainly composed by oval-shaped 

tireocytes with irregular nuclei and nuclear grooves and pseudoinclusions, 

within a prominent hyalinizing trabecular pattern. 

The remaining thyroid gland consisted of numerous moderately 

sized thyroid follicles and some lymphoid follicles with germinal 

centers. The tumor cells exhibited a positivity for Cytokeratin 

AE1/AE3 and Tireoglobulin and a negativity for Galectin 3, 

Fig. 1. Histological features of the lesion. a: well-circumscribed nodule 

within the left lobe (H&E, 2x magnification). B: trabecular growth 

pattern with inter and intratrabecular.hyaline deposition (H&E, 10x 

magnification).

330 

Fig. 2. Histological features of the lesion. a: oval-shaped tireocytes 

with irregular nuclei and nuclear grooves and pseudoinclu sions (H&E, 

20x magnification). B: tumor cells strongly stained for tireoglobulin. 

(tireoglobulin, 10x magnification). 

Chromogranin and Calcitonin. Thus, a diagnosis of a Hyalinizing 

Trabecular Tumor (HTT) was posed. 

Conclusions. Due to the uncerainty of its nature, the diagnostic 

challenges, and the mimicry of other types of thyroid tumors, 

UrInArIO 

Detection of motile cilia in renal allograft biopsy: 

report of three cases with grade ii acute rejection 

and calcineurin inhibitor nephrotoxicity 

M.R. Ambrosio, B.J. Rocca, A. Barone, M. Brogi, M. de Santi * , 

M.T. del Vecchio * 


Section, University of Siena, Italy; * Both Authors have equally contributed 

to the abstract 

Background. Cilia are hair-like organelles expressed ubiquitously. 

They can be divided into two types: motilia cilia that arise 

from ductal structures epithelial cells and non motilia or primary 

cilia, arising from almost every cell type known. Motilia cilia are 

present in invertebrate and lower vertebrate kidney in which they 

are specialized for fluid propulsion or, perhaps, glomerular filtration. 

Conversely, primary cilia are present in adult human kidney 

and reabsorb ions and other molecules according to fluid balance 

requirements. Here, we report three interesting cases in which 

motilia cilia, arising from proximal tubular cells, were unexpectedly 

observed in a renal allograft biopsy of patients with grade II 

acute antibody mediated rejection (AMBR), calcineurin inhibitory 

nephrotoxicity and acute tubular necrosis (ATN). Motilia cilia 

are not usually found in human fetal and adult kidneys, and their 

association with specific diseases is still unclear. One potential 

explanation is that motilia cilia arise from proximal tubular cells 

as a reversion to a more primitive or less differentiated state. 

Materials and methods. Three male patients of 56-, 59- and 72 

year-old respectively underwent cadaveric renal transplantation for 

an end-stage renal disease secondary to unknown disease in two 

cases and to IgA nephropathy in one case. The immunosuppression 

regimen comprised mycophenolate mofetil, tacrolimus and prednisolone. 

Two months after surgery, the patients underwent renal biopsy 

examination. Allograft biopsies were taken on clinical indications 

due to acute dysfunction using percutaneous renal needle biopsy 

guided by ultrasound (G18). Slides were prepared according to standard 

techniques and stained with haematoxylin and eosin, periodic 



Sala Brunelleschi – ore 17,00-18,30 

HTT represents a challenging entity and the exact relationship 

between HTT and other malignant lesions needs further investigations. 

references 

1 Carney JA, Ryan J, Goellner JR. Hyalinizing trabecular adenoma of 

the thyroid gland. Am J Surg Pathol 1987;11:583-91. 

2 De Lellis RA, Lloyd RV, Heitz PU, editors. WHO Classification of 

tumours. Pathology & genetics of tumours of endocrine organs. Lyon: 

IARC Press 2004. 

3 Nosè V, Volante M, Papotti M. Hyalinizing trabecular tumor of the 

thyroid: an update. Endocr Pathol 2008;19:1-8. 

4 Zhu H, Qi JP, Wang YW, et al. Hyalinizing trabecular tumor and 

papillary carcinoma of the thyroid. Chin Med J 2010;123:2832–5. 

5 LaGuette J, Matias-Guiu X, Rosai J. Thyroid paraganglioma: a clinicopathologic 

and immunohistochemical study of three cases. 

6 Evenson A, Mowschenson P, Wang H, et al. Hyalinizing trabecular 

adenoma – an uncommon thyroid tumor frequently misdiagnosed as 

papillary or medullary thyroid carcinoma. Am J Surg 2007;193:707–12. 

7 Zhu H, Qi JP, Wang YW, et al. Hyalinizing trabecular tumor and 

papillary carcinoma of the thyroid. Chin Med J 2010;123: 2832-5. 

acid-Schiff (PAS) and Masson’s trichromatic for light examination. 

Immunohistochemical stains were performed on 3 µm- thick sections 

of each block employing the Ultravision Detection System anti- 

Polyvalent HRP (Lab Vision, Fremont, CA, U.S.a.; Bio-Optica). For 

ultrastructural examination, specimens of the fresh tissue are minced 

into approximately 1-mm pieces and immediately fixed in 2.5% 

cacodylate-buffered glutaraldehyde pH 7.3 for 3-4 hours at 4 C°. The 

specimen are washed overnight in the same buffer, fixed in buffered 

1% osmium tetroxide for 2 hours, washed, dehydrated trough a 

graded series of ethanol, cleared in propylene-oxide and embedded in 

Epoxy resin (Araldite). Semithin sections 1 µm thick, cut with glass 

knives on an LKB V Ultratome and stained with toluidine blue, are 

examined with the light microscope for general evaluation of tissue 

morphology. Ultrathin sections from selected areas are cut with a 

diamond knife using the same ultra microtome, retrieved onto copper 

grids, double-stained with uranly acetate and lead citrate and examined 

at 100 kV with a Philips 208 S transmission electron microscope. 

Results. Histology: renal biopsy met Banff criteria of adequacy; 

for allograft pathology and score we used Banff 07 classification. 

Peritubular capillaritis and C4d deposition in peritubular and 

glomerular capillaries were observed. Proximal tubules showed 

luminal dilatation with some intraluminal epithelial necrotic 

cells, and flattening and loss of brush border of epithelial cells; 

scattered proximal tubules were filled by uniformly sized small 

vacuoles (isometric vacuolization). Scattered T (CD3) and B cells 

(CD20+) were present in a edematous interstitium. 

Ultrastructural pathology: glomerular ultrastructural examination 

showed endothelial cell swelling associated with loss of fenestrae; 

capillary lumina were dilated and contained neutrophils, 

lymphocytes and macrophages. Proximal tubular cells showed 

isometric vacuolization, intraluminal detachment of epithelial 

cells, shortening and partial loss of brush border. The presence of 

multipla cilia with a 9+2 microtubular arrangement arising from 

one proximal tubular cells was unexpectedly observed. 

Discussion. The detection of motile cilia has been reported in tubular 

cells that often showed morphological alterations correlated to 

atrophy, loss of brush border, vacuolization and thickening of basal 

membrane, loss of microvilli and sparse scattered mitochondria. 

This kind of correlation is observed also in neoplastic and non neo-


plastic disease of other organs. In the past, Ong et al. suggested that 

the development of motile cilia in tubular cells could represent a 

reversion to a more primitive or less differentiated state consequent 

to different tubular injuries. The presence of motile cilia have not 

been described in human nephrogenesis, but, in the last years, is 

has been shown that two types of epithelial cells, multi-cilia cells 

and principal cells, are present in the epithelia of the zebrafish 

distal pronephric duct. In mammals, pronephros is a nonfunctional 

transitory structure that is replaced by the mesonephros and then by 

the metanephros. In the early life of fish and amphibians, however, 

the pronephros is a functional filtration organ that is likely to give 

rise to metanephron, so to be used as a model for kidney development. 

While motile cilia on the apical side of the multi-cilia cells 

coordinate the movement of the fluid along the lumen of the pronephric 

duct, principal cells, which account for the majority of the 

cells in the kidney, reabsorb ions and other molecules according to 

fluid balance requirements. In our cases proximal tubules showed 

injury due to acute AMBR as well as iatrogenic toxic damage, with 

loss of brush border, detachment from basal membrane and isometric 

vacuolization. These data support the hypothesis of a correlation 

between ciliated metaplasia and morpho-functional alteration of 

tubular cells which recover a primitive phenotype as an adaptive 

response to improve fluid excretion. 

references 

Liu Y, Pathak N, Kramer-Zucker A, et al. Notch signaling controls the 

differentiation of transporting epithelia and multiciliated cells in the 

zebrafish pronephros. Development 2007;134:1111-22. 

Lungarella G, de Santi MM, Tosi P. Ultrastructural study of the ciliated 

cells from renal tubular epithelium in acute progressive glomerulonephritis. 

Ultrastruct Pathol 1984;6:1-7. 

Kramer-Zucker AG, Olale F, Haycraft CJ, et al. Cilia-driven fluid flow in 

the zebrafish pronephros, brain and Kupffer’s vesicle is required for 

normal organogenesis. Development 2005;132:1907-21. 

Ma M, Jiang YJ. Jagged 2a-notch signaling mediates cell fate choice in 

the zebrafish pronephric duct. Plos Genet 2007;3:e18. 

Nadasdy T, Laszik Z, Blick KE, et al. Human acute tubular necrosis: a 

lectin and immunohistochemical study. Hum Pathol 1995;26:230-9. 

Ong AC, Wagner B. Detection of proximal tubular motile cilia in a 

patient with renal sarcoidosis associated with hypercalcemia. Am J 

Kidney Dis 2005;45:1096-9. 

Racusen LC, Solez K, Colvin RB, et al. The Banff 97 working classification 

of renal allograft pathology. Kidney Int 1999;55:713-23. 

Rubio CA, Nesi G, Zampi GC, et al. Gastric ciliated metaplasia. A study 

of 3406 gastrectomy specimen from dwellers of the Atlantic and the 

Pacific basins. J Clin Pathol 2005;58:605-10. 

Solez K, Colvin RB, Racusen LC, et al. Banff 07 classification of renal 

allograft pathology: update and future directions. Am J Transplant 

2008;8:753-60. 

TCTP (translationally controlled tumor protein) 

is present in normal renal cortex and renal cancer 

M.F. Ambrosio, B.J. Rocca, M.G. Mastrogiulio, A. Barone, 

V. Mourmouras, F. Scaramuzzino, N. Palummo, L. Barbagli, 

S.A. Tripodi 

Department of human Pathology and Oncology, Anatomic Pathology Section, 

University of Siena, Italy 

Background. The translationally controlled tumor protein (TCTP) is 

a protein of 23 kDa, ubiquitously expressed in eukaryotes. Its name 

originates from the observation that TCTP transcripts accumulate 

in resting cells and are rapidly translated into the protein when the 

cells require it. Since the discovery of TCTP by Yenofsky, it became 

clear that this protein is involved in multiple biological processes: 

cell growth, apoptosis, cell cycle progression, cell division and 

proliferation. It also functions as a histamine releasing factor and a 

calcium-binding protein. It has been assessed that TCPT is expressed 

in all human tissues except kidney, as reported by “Swiss Prot”, the 

most important database on protein expressions. We decided to use 

renal tissue as negative control for evaluation of TCTP expression by 

331 

immunohistochemistry (IHC). Unexpectedly, a positivity of renal tubular 

epithelium was detected. Thus we carried out a study on TCTP 

expression in normal and neoplastic renal tissue. 

Material and methods. we performed Western blotting and IHC 

on normal and neoplastic renal tissue. Specifically we used 32 

samples of clear cell carcinoma, 21 of papillary carcinoma, 9 

of chromophobe carcinoma and 2 cases of Bellini’s carcinoma. 

Cortical and medullary zone without any lesions were evaluated 

as normal renal tissue. 

Results. Western blot analysis: a single band of molecular weight 

of approximately 23,000 Da was detected in all neoplastic specimens 

and in cortical tissue, not in normal medullary tissue. 

Immunohistochemistry: strong TCTP expression was observed in 

the cytoplasm of the cells of the proximal and distal tubules. Thin 

loop of Henle segment cells, glomerulus parietal cells, podocytes 

and collecting duct cells did not show TCTP positivity. TCTP 

was expressed in all neoplastic specimens, however with different 

patterns of immunostaining: a membrane positivity in clear 

cell carcinoma, a cytoplasmic positivity in papillary and chromophobe 

carcinoma and a cytoplasmic staining with membrane 

reinforce in Bellini’s carcinoma. 

Conclusion. In our study we demonstrated, for the first time, the 

presence of TCTP in proximal and distal tubules while not in 

renal medulla. TCTP was also present in the vascular structures 

and in the urothelium of renal pelvis. Interestingly, immunohistochemical 

distribution of TCTP follows that of calcium reabsorption, 

being stronger in the cortical structures. It may be postulated 

that in normal kidney TCTP acts as calcium-binding protein. The 

expression of TCTP in renal carcinomas may suggest a potential 

role in carcinogenesis but further studies are necessary to confirm 

our findings and to correlate TCTP expression with clinical 

and prognostic determinants in the different tumor histotypes. 

Considering that a series of pharmaceutical compounds are able 

to diminish TCTP expression through down regulation of TCTP 

expression at protein level, larger studies may also help to determine 

whether TCTP may act as a target for drugs, contributing 

to find new alternatives in the treatment of renal carcinoma for 

which adjuvant effective drugs do not exist. 

references 

Susini L, Besse S, Duflaut D, et al. TCTP protects from apoptotic cell 

death by antagonizing bax function. Cell Death Differ 2008;15:1211- 

20. 

Tessari P, Puricelli L, Iori E, et al. Altered chaperone and protein turnover 

regulators expression in cultured skin fibroblasts from type 1 

diabetes mellitus with nephropathy. J Proteome Res 2007; 6:976-86. 

Sanchez JC, Schaller D, Ravier F, et al. Translationally controlled tumor 

protein: a protein identified in several nontumoral cells including 

erythrocytes. Electrophoresi 1997;18:150-5. 

Yarm FR. Plk phosphorylation regulates the microtubule-stabilizing protein 

TCTP. Mol Cell Biol 2002;22:6209-21. 

Tuynder M, Fiucci G, Prieur S, et al. Translationally controlled tumor 

protein is a target of tumor reversion. Proc Natl Acad Sci USA 

2004;101:15364-9. 

Koide Y, Kiyota T, Tonganunt M, et al. Embryonic lethality of fortilinnull 

mutant mice by BMP-pathway overactivation. Biochim Biophys 

Acta 2009;1790:326-38. 

Systemic reactive (AA) amyloidosis complicating 

hyperimmunoglobulinemia D with periodic fever 

syndrome: a case report 

R. Passantino1 , G. Li Cavoli2 , L. Bono2 , A. Ferrantelli2 , C. Giammaresi2 

, C. Tortorici2 , U. Rotolo2 1 Unità Operativa di Anatomia Patologica/Ospedale ARNAS Civico Di 

Cristina Benfratelli, Palermo, Italia; 2 Unità Operativa di Nefrologia e 

Dialisi/ Ospedale ARNAS Civico Di Cristina Benfratelli, Palermo, Italia 

Introduction. Systemic reactive (AA) Amyloidosis is the most 

serious potential complication of the inherited autoinflammatory 

syndromes and frequently results in end-stage renal failure. The

332 

risk of developing this life-threatening condition varies widely 

among these disorders, being higher for patients affected by 

Familial Mediterranean Fever (FMF), Tumor necrosis factor 

Receptor-Associated Periodic Syndrome (TRAPS) and Muckle- 

Wells Syndrome (MWS). In spite of an acute-phase response during 

attacks, there are only few previous published reports of its 

occurrence in Hyperimmunoglobulinemia D with periodic fever 

Syndrome (HIDS). We report a case to describe the occurrence 

of renal AA Amyloidosis causing nephrotic syndrome in a young 

Italian man affected with HIDS. 

Material and methods. The patient, a 29-year-old man of southern 

Italian ancestry, was referred to us in April 2011. Since the 

first months of life he had experienced recurrent attacks of fever 

associated with sore throat, myalgias, vomiting and diarrhoea. 

Later the attacks of fever reduced their frequency but in the last 

year there was an increased frequency of febrile episodes with 

proteinuria in the nephrotic range. Laboratory examinations performed 

showed proteinuria 9.17 g/24 h, a raised erytrocite sedimentation 

rate, a normal C-reactive protein, leukocytosis, serum 

amyloid 3.67 mg/L, serum IgD 233 UI/ml, creatinine 1.09 mg/dl. 

A kidney biopsy was performed. 

Results. Microscopic examination revealed extensive weakly 

eosinophilic amorphous material infiltrating the mesangium, capillary 

walls, tubular basement membranes, interstitium and vessels 

walls. After Congo red staining, the deposits showed intense 

apple-green birefringence under polarized light, consistent with 

the presence of amyloid. On immunohistochemistry, the amyloid 

deposits were intensively and specifically stained with an antiamyloid 

A antibody and were negative for antibodies against k 

and λ light chains. A diagnosis of renal AA Amyloidosis was 

made, Stage III, with diffuse and global glomerular involvement, 

late phase, according to the Staging System of renal Amyloidosis 

proposed by Helmut Hopfer and co-workers recently. Clinical 

and laboratory findings suggested the diagnosis of HIDS. The 

research of TNFRSF1A mutations was negative; the research for 

MVK mutations was positive in heterozygosis and revealed the 

presence of 2 mutations in MVK, namely, V377I and I268T, thus 

confirming the clinical diagnosis of HIGD. The patient started 

therapy with Anakinra. 

Conclusions. Hereditary periodic fevers are a group of rare 

Mendelian disorders characterized by recurrent, self-limited attacks 

of fever and inflammation predominantly involving the 

serosal membranes, the joints and the skin. Five different entities 

belong to this nosologic category, namely, FMF, TRAPS, 

MWS, HIDS and Familial Cold Autoinflammatory Syndrome. 

Patients are at variable risk for the development of systemic 

reactive (AA) Amyloidosis, leading to the nephrotic syndrome 

and renal failure. HIDS is a recessively inherited autoinflammatory 

condition predominantly found in patients originating 

from northwestern Europe. It was described in 1984 in a group 

of children of Dutch ancestry. The disease manifests in infancy 

and is characterized clinically by recurrent attacks of fever typically 

lasting 3-7 days and usually occurring 6-12 times a year. 

These episodes are often accompanied by headache, cervical 

lymphadenopathy, arthritis, diarrhea, vomiting and rash. Attacks 

may be precipitated by immunizations or minor infections and 

the disease usually ameliorates with age. Clinical features are 

accompanied by an acute-phase response and polyclonal elevations 

of serum immunoglobulin D and often IgA concentrations. 

In 1999, HIDS was reported to be associated with mutations 

in the Mevalonate Kinase Gene (MVK), encoding the enzyme 

mevalonate kinase, which is involved in cholesterol, farnesyl 

and isoprenoid biosynthesis. The molecular mechanism by which 

defective activity of mevalonate kinase may lead to fever attacks 

are still unknown. To date, 39-HIDS-associated mutations have 

been described of which the most common encode MVK V377I 

and I268T. In contrast to the other periodic fever syndromes, the 

risk of AA Amyloidosis in HIDS seems to be extremely low. Our 


report contributes the evidence that AA Amyloidosis may occur 

in association with HIDS, indicating the opportunity to envisage, 

during the follow-up of patients with HIDS, the possible occurrence 

of reactive Amyloidosis and to plan the appropriate laboratory 

tests, including the assessment of systemic Amyloidosis, on 

a regular basis. 

references 

Obici L, Manno C, Onetti Muda A, et al. First Report of Systemic Reactive 

(AA) Amyloidosis in a Patient with the Hyperimmunoglobulinemia 

D with Periodic Fever Syndrome. Arthritis & Rheumatism 

2004;50:2966-9. 

Lachmann HJ, Goodman HJB, Andrews PA, et al. AA Amyloidosis Complicating 

Hyperimmunoglobulinemia D with Periodic Fever Syndrome. 

A Report of Two Cases. Arthritis & Rheumatism 2006;54:2010-4. 

Siewert R, Ferber J, Horstmann RD, et al. Hereditary Periodic Fever 

with Systemic Amyloidosis: Is Hyper-IgD Syndrome Really a Benign 

Disease? American Journal of Kidney Disease 2006; 48:E41-5. 

Hopfer H, Thorsten W, Mihatsch MJ. Renal amyloidosis revisited: 

amyloid distribution, dynamics and biochemical type. Nephrol Dial 

Transplant 2011;26:2877-84. 

Late antibody mediated rejection: correlation 

between pathologic and clinical findings and posttransplant 

de novo donor-specific HLA antibodies 

in pediatric kidney recipients 

A.R. Sementa1 , P. Ceriolo1 , F. Ginevri2 , G. Barbano2 , M.C. Coccia1 

, G. Ghiggeri2 , C. Gambini1 1 2 Histopathology and Pediatric Nephrology, Giannina Gaslini Insitute 

IRCCS, Genoa. 

Introduction. Although in recent years short-term renal allograft 

outcome has significantly and progressively improved, late failure 

of kidney transplants remains a relevant clinical problem 1 . 

Thus, clinical and pathological research is focusing its efforts 

towards a better understanding of the mechanisms which lead to 

chronic graft damage 2 , in order to identify markers able to predict 

its onset and guide early or preemptive intervention. Renal biopsy 

remains the most sensitive diagnostic tool for the diagnosis of 

rejection and other causes of graft dysfunction. While the pathologic 

features of graft rejection have been recognized for a long 

time, the pathogenesis of both T cell-mediated rejection (TCMR) 

and antibody-mediated rejection (ABMR) is not fully understood. 

It is widely accepted that ABMR generally has a worse prognosis. 

Recognition of the clinical relevance of alloantibodies (already 

known as mediators of hyperacute rejection) rested on new 

diagnostic techniques which showed that peritubular capillary 

deposition of C4d in renal transplant biopsy is strongly associated 

with a poor prognosis. C4d is a fragment of C4b, an activation 

product of the classic complement pathway. C4d deposition is 

strongly associated with circulating antibody to donor HLA class 

I or class II antigen. The diagnostic criteria for ABMR rest on 

morphological evidence of acute tissue injury; immunopathologic 

evidence for antibody action in peritubular capillaries (C4d 

deposition) and serologic evidence of circulating antibodies to 

donor HLA or other anti-donor endothelial antigens. In response 

to the emerging data and technologies, the 9 th Banff Conference 

on Allograft Pathology up-dated the Banff schema for renal 

allograft rejection 3 . As a result, inclusion of peritubular capillaritis 

grading, C4d scoring and interpretation of C4d deposition 

without morphological evidence of active rejection are among 

the most important updates. A positive association between presence 

of HLA antibodies prior to/after transplantation and poor 

transplant outcome has been widely reported and significantly 

contributed to elucidate the central role of humoral immunity 

in the pathogenesis of chronic allograft damage. Nevertheless, a 

number of patients in which the new solid-phase methods of detecting 

alloantibodies had not demonstrated the presence of HLA


antibodies prior to/after transplantation, and thus considered “low 

immunologic risk patients”, is bound to develop chronic allograft 

dysfunction and, ultimately, graft loss. In the pediatric age, studies 

so far are rather limited. Children are more frequently HLA 

antibody-negative at the time of first transplant, probably owing 

to a reduced exposure to prior sensitizing events. Longitudinal 

post-transplant assessment of HLA antibody appearance and its 

relationship with clinical and pathological findings is of particular 

interest and can offer the bases for graft failure risk stratification 

and improve therapeutic management. Aim of the present study 

is to retrospectively investigate the histological findings and 

clinical data in renal allograft recipients at the Giannina Gaslini 

Children’s Hospital. 

Materials and methods. Between 2003 and 2010, 91 pediatric 

patients were included in the Genoa Pediatric Kidney Transplant 

Program for first allografting. Of these patients, 25 underwent 

graft biopsy for clinical indications, namely functional deterioration, 

delayed graft function or proteinuria. Only patients 

negative for anti-HLA antibodies in the pre-transplant sera and 

with one year minimum follow-up were included in the analysis. 

The de-novo occurrence of anti-HLA-antibodies was detected 

on sequential serum samples collected at 1, 3, 6, 12 months in 

the first post-transplant year and then annually thereafter by luminex 

screening kit and single-antigen analysis. Renal function, 

measured as serum creatinine levels at discharge, at the time of 

anti-HLA antibody detection and at the end of follow up, was 

analyzed in the entire cohort. Clinical characteristics of the patients 

are listed in Table I. 

Histological examination was carried out on sections from paraffin 

blocks stained according to the standard procedure. C4d staining 

was performed on frozen sections by indirect immunofluorescence 

and, in a few cases, by means of immunohistochemistry on 

paraffin sections. 

Rejections were histologically graded following up-dated Banff 

97 criteria. Banff 07 criteria were employed for scoring C4d posi- 

Tab. I. Patients clinical data. 

causes for transplantation 

birth year 

range 

1985-2005 

renal dysplasia/ 

vesicoureteral 

reflux 

13 

females 7 nephronophthisis 3 

males 18 

polycystic kidney 

disease 

2 

age at graft 

(years) 

range 3-20 

mean 14 

focal segmental 

glomerulosclerosis 

alport syndrome 

2 

2 

range 1-65 fanconi syndrome 1 

months between 

graft and first 

biopsy 

mean 22 

WaGR syndrome 

prune Belly 

syndrome 

1 

1 

Tab. II. Quantitative criteria for peritubular capillaritis [it is recommended 

that one comment on the composition (mononuclear cells vs. neutrophils) 

and extent (focal, ≤ 50% vs. diffuse, > 50%) of peritubular capillaritis] 

No significant cortical ptc, or < 10% of ptCs with 

ptc 0 

inflammation 

≥10% of cortical peritubular capillaries with 

ptc 1 capillaritis, with max 3 to 4 luminal inflammatory 

cells 


ptc 2 capillaritis, with max 5 to 10 luminal inflammatory 

cells 


ptc 3 

capillaritis, with max > 10 luminal inflammatory cells 

Tab. III. Scoring of C4d staining (% of biopsy or 5 high-power fields) 

C4d0 Negative 0% 

c4d1 Minimal c4d stain/detection 1 < 10% 

c4d2 focal C4d stain/positive 10–50% 

c4d3 Diffuse c4d stain/positive > 50% 

333 

tive AMR and peritubular capillaritis (ptc) (see Tab. II and III) 3 . 

Results. The results of histological evaluation are shown in 

Tab. IV. Changes related to rejection were grouped into 7 classes 

(acute cell-mediated, acute humoral, cronic, acute cell-mediated 

and cronic, acute humoral and cronic, mixed [acute cell-mediated 

and humoral], mixed and cronic). The findings were correlated 

with the immunophenotypic positivity or negativity of C4d and 

presence of DSA and NDSA. 

All the patients in the group characterized by the DSA and C4d 

positivity showed a histological picture of chronic rejection, 

which was associated with humoral rejection (4 cases) or mixed 

rejection, humoral and cell-mediated (4 cases). The presence of 

ptc was observed in 6 of the 8 total cases. In the group of patients 

with NDSA and negative staining for C4d the predominance of 

pictures of chronic rejection (3 cases) or non-specific findings 

(3 cases) was observed, in the presence of features suspected for 

humoral rejection (ptc 1) in 2 cases. 

The difference of histological picture between the two groups 

of patients is clear-cut. The cases of patients with DSA and in 

which C4d positivity was observed showed humoral or mixed 

rejection (all 8 cases) more frequently than the NDSA group with 

concomitant negativity of C4d (2 suspected cases out of 8). The 

group of DSA+/C4d- patients showed a more varied histological 

picture, namely 4 possible cases of humoral rejection, suspected 

on the only basis of the presence of ptc. 

As far as renal function is concerned, at the end of follow-up a 

significant increase in the creatinine levels was observed in the 

DSA patient group. In the DSA group the increase in creatinine 

levels was greater than in the NDSA group. This finding was in 

agreement with the observation of a few graft losses in the DSA 

group as compared to none in the NDSA group. 

Conclusions. From the histopathological point of view, the main 

result of this longitudinal survey is that antibody-mediated graft 

damage is prevalently, if not exclusively, present in patients developing 

de novo DSA and that this group of patients is at greater 

risk of worsening of renal function and graft loss compared to 

NDSA group. 

Moreover, while the meaning of C4d as an index of humoral rejection 

is now quite established and thus incorporated in up-dated 

Banff criteria, the importance and meaning of ptc is less clear, 

especially as an isolated finding, not associated with C4d positivity. 

The frequent occurrence of ptc in cases C4d-, which turned 

out to be at greater risk of rejection because of DSA positivity, 

suggests that ptc, as a purely histomorphological parameter, is a 

Tab. IV. Histological evaluation (*: humoral rejection suspected on the 

basis of the presence of ptc) 

Type of rejection DSA/C4d+ DSA/C4d- NDSA/C4dacute 

cell-mediated 0 1 0 

acute humoral 0 0 1* 

mixed 0 2 * 1* 

cronic 0 1 2 

acute cell-mediated 

and cronic 

0 2 1 

acute humoral and 

cronic 

4 2 * 0 

mixed and cronic 4 0 0 

aspecific aspects 0 1 3

334 

sensitive and early marker of the possibility of developing humoral 

rejection in those cases with donor-specific antibodies, in 

which deposits of C4d are not found. Its importance in addressing 

a humoral immunity component in those cases where the biopsy 

shows characteristic findings of other mechanisms of rejection 

(cell-mediated acute rejection, chronic graft nephropathy, etc.) is 

still a matter of debate, as not infrequently a combination of these 

features is reported. 

references 

1 Meier-Kriesche HU, Schold JD, Kaplan B. Long-term renal allograft 

survival: have we made significant progress or is it time to rethink our 

analytic and therapeutic strategies? Am J transplant 2004;4:1289-95. 

2 Sellarés J, de Freitas DG, Mengel M, et al. Understanding the causes 

of kidney transplant failure: the dominant role of antibody-mediated 

rejection and nonadherence. Am J Transplant 2011;12:388-99. 

3 Solez K, Colvin RB, Racusen LC, et al. Banff 07 classification of renal 

allograft pathology: updates and future directions. Am J Transplant 

2008;8:753-60. 

Macrophage related markers expression in 

MITF/TFE family renal translocation carcinoma, 

melanotic Xp11 translocation renal cell carcinoma 

and pure epithelioid pecoma (so called epithelioid 

angiomyolipoma of the kidney) 

C. Zampini, D. Segala, E. Munari, M. Pea, S. Gobbo, M. Brunelli, 

F. Bonetti, C. Ghimenton, O. Hes, P. Camparo, S. Pedron, 

C. Pastena, M. Chilosi, J.N. Eble, P. Argani, G. Martignoni 

University of Verona, Verona, Italy; Ospedale Orlandi, Bussolengo, Italy; 

Ospedale Civile Maggiore, Verona, Italy; Charles University and University 

Hospital, Plzen, Czech Republic; Hopital Foch, Suresnes, Paris, 

France; Indiana University School of Medicine, Indianapolis, IN; Johns 

Hopkins Medical Institutions, Baltimore, MD 

Introduction. Cathepsin K is a lysosomal protease recently described 

in MITF/TFE family of translocation renal cell carcinomas 

(tRCC) 1 2 , and angiomyolipoma of the kidney both classic and 

epithelioid (pure epithelioid PEComa (PEP)) 3 . Both tRCC and 

angiomyolipoma are neoplasms expressing MITF/TFE family 

transcription factors 4 5 . Moreover t(6;11) TFEB+ tRCC and PEP 

constantly immunostain for the melanogenesis markers HMB45 

and MART1 such as melanotic Xp11 tRCC, a neoplasm exihibiting 

a unique histologic feature and a distinct immunoprofile, different 

from other Xp11 tRCC with identical chromosome translocations 

involving TFE3 gene 6-8 . These three tumors can show overlapping 

morphological and immunohistochemical features and their differential 

diagnosis can be challenging 9 10 . In this study we investigated 

the expression of macrophage markers (CD68-PGM1, CD68-KP1, 

cathepsin K, CD163) in a series of tRCC, PEP and melanotic Xp11 

tRCC, in order to assess their utility to distinguish them. 

MAMMELLA 

Implant-related breast angiosarcoma: 

report of a case and brief review of the literature 

L. Alessandrini1 , A.L. Tosi2 , M.C. Montesco2 1 Anatomical Pathology Unit, Department of Medicine, University of Padua, 

Italy; 2 Pathology Unit, Oncological Institute of Veneto, Padua, Italy 

Introduction. A large number of women have received breast 




Materials and methods. We studied the immunohistochemical 

expression of CD68-PGM1, CD68-KP1, cathepsin K and CD163 

in 21 tRCC (including 9 PRCC TFE3+ tRCC and 12 t(6;11) 

TFEB+ tRCC), 5 melanotic Xp11 tRCC and 13 PEP. 

Results. All PEP, all t(6;11) TFEB+ tRCC, and all but two 

PRCC TFE3+ tRCC express strongly and diffusely cathepsin 

K whereas the 5 melanotic Xp11 tRCC were weakly positive. 

CD163 resulted positive in 3 out of 7 PEP and in none of 4 t(6;11) 

TFEB+ tRCC, 4 PRCC TFE3+ tRCC and 1 melanotic Xp11 

tRCC. CD68-KP1 was expressed in all 22 tested tumors (4 PRCC 

TFE3+ tRCC, 4 t(6;11) TFEB+ tRCC, 1 melanotic Xp11 tRCC, 

13 PEP) whereas CD68-PGM1 immunostained all 13 PEP, but 

none of the other neoplasms. 

Conclusions. 1) Cathepsin K is consistently expressed in PRCC 

TFE3+ tRCC, t(6;11) TFEB+ tRCC, melanotic Xp11 tRCC and 

PEP; 2) CD68-PGM1 is a useful tool for the differential diagnosis 

between PEP and all the other tRCC, including the HMB45 

positive t(6;11) TFEB+ tRCC; 3) the CD68-PGM1 negativity in 

melanotic Xp11 tRCC seems to relate this tumor more closely to 

tRCC rather than PEP. 

references 

1 Martignoni G, Pea M, Gobbo S, et al. Cathepsin-K immunoreactivity 

distinguishes MiTF/TFE family renal translocation carcinomas from 

other renal carcinomas. Mod Pathol 2009;22:1016-22. 

2 Martignoni G, Gobbo S, Camparo P, et al. Differential expression of 

cathepsin K in neoplasms harboring TFE3 gene fusions. Mod Pathol 

2011;24:1313-9. 

3 Martignoni G, Bonetti F, Chilosi M, et al. Cathepsin K expression 

in the spectrum of perivascular epithelioid cell (PEC) lesions of the 

kidney. Mod Pathol 2012;25:100-11. 

4 Chang KL, Folpe AL. Diagnostic utility of microphthalmia transcription 

factor in malignant melanoma and other tumors. Adv Anat Pathol 

2001;8:273-5. 

5 Martignoni G, Pea M, Reghellin D, et al. Perivascular epithelioid 

cell tumor (PEComa) in the genitourinary tract. Adv Anat Pathol 

2007;14:36-41. 

6 Pea M, Bonetti F, Zamboni G, et al. Melanocyte-marker-HMB-45 

is regularly expressed in angiomyolipoma of the kidney. Pathology 

1991;23:185-8. 

7 Argani P, Ladanyi M. Translocation carcinomas of the kidney. Clin 

Lab Med 2005;25:363-78. 

8 Argani P, Olgac S, Tickoo SK, et al. Xp11 translocation renal cell carcinoma 

in adults: expanded clinical, pathologic, and genetic spectrum. 


9 Argani P, Aulmann S, Karanjawala Z, et al. Melanotic Xp11 translocation 

renal cancers: a distinctive neoplasm with overlapping features of 

PEComa, carcinoma, and melanoma. Am J Surg Pathol 2009;33:609- 

19. 

10 Chang IW, Huang HY, Sung MT. Melanotic Xp11 translocation renal 

cancer: a case with PSF-TFE3 gene fusion and up-regulation of melanogenetic 

transcripts. Am J Surg Pathol 2009;33:1894-901. 

implants (800.000 to 1 million by 1989) either for cosmetic reasons 

or for reconstruction following cancer surgery. In the last 

years great attention has focused on long-term complications of 

breast prostheses, such as cancer. Mesenchymal tumors of the 

breast associated with implants are rare neoplasias that can be 

subdivided into two groups: fibromatoses and sarcomas. The latter 

group, less common than fibromatoses, is characterized by a 

higher histological grade and a longer latency period. 

Angiosarcomas are about 0.05% of all primary malignancies of 

the breast. They can arise de novo or secondary to arm lymph-


edema following radical mastectomy (Stewart Treves syndrome) 

or to local radiotherapy. Only three cases of post-implant angiosarcoma 

are reported in literature. 

Case report. In 2003 a 53-year-old woman underwent simple 

bilateral mastectomy because of an invasive ductal carcinoma 

with nodal involvement and she subsequently had silicone protheses. 

Radiotherapy was not done. Seven years later, the patient 

developed an erythematous plaque on breast skin. A incisional 

biopsy was performed. 

The histological examination demonstrated a skin lesion composed 

of intercommunicating vascular channels, lined by plump 

endothelial cells with hyperchromatic nuclei intermixed with 

spindle cell solid areas, displaying a high mitotic activity. The 

neoplasia was characterized by an infiltrative growth pattern, 

with dissection of dermal collagen fibers and involvement of 

subcutaneous tissue. Immunohistochemistry showed a strong and 

diffuse reactivity for Factor VIII, CD31 and CD34. The morphological 

and immunhistochemical features were suggestive of 

angiosarcoma. 

Given the invasive aspect and the malignant potential of the lesion, 

a wide excision was performed. At gross examination, the 

surgical specimen measured 17x13x3.8 cm and showed on its cut 

surface a spongy, haemorragic ill defined mass of 11x7.3 cm. 

The lesion was multicentric and consisted of rudimentary anastomosing 

vascular channels, displaying invasion of fatty tissue 

and surrounding the prosthetic capsule. The microscopic and immunohistochemical 

features of this neoplasia were very similar 

to those observed in the biopsy and, thus, consistent with the 

diagnosis of spindle cell angiosarcoma of the breast. 

Conclusion. Angiosarcomas affecting the breast could be divided 

into two main categories: primary angiosarcomas and angiosarcomas 

associated with prior radiation therapy or with upper 

limb lymphedema. Due to the increased number of conservative 

treatment for breast carcinoma and the improvement in surgical 

techniques, the incidence of Stewart-Treves syndrome seems to 

have declined; on the contrary, radiation-induced angiosarcomas 

are a well-known iatrogenic problem, whose incidence has risen 

in the last years. Primary neoplasias arise mainly within breast 

parenchyma with secondary involvement of the overlying skin, 

whereas iatrogenic angiosarcomas affect primarily the skin. 

In this case, the lesion occurred around the implant capsule and 

there was no previous radiotherapy. Thus, prosthetic material 

could be addressed as a possible trigger for this neoplasia. However, 

considering the widespread use of artificial breast implants 

and the rarity of primary breast angiosarcomas, it has been difficult 

to unequivocally establish the presence or absence of a causal 

association between implants and mesenchymal neoplasias. 

On one side, an epidemiologic analysis based on National Cancer 

Institute’s SEER data for the years 1973-1990 concluded that 

there was no evidence of an increased risk of breast sarcomas 

associated with the use of silicone implants 8 . 

On the other side, the hypothetic causal relationship between 

angiosarcomas and breast prostheses is supported by a work 

providing evidence of angiosarcomas arising in proximity of foreign 

bodies (shrapnel, Dacron grafts, sponge, bullet) retained for 

prolonged periods in humans 9 . Although extremely uncommon, 

different histological types of sarcoma associated with a variety 

of foreign body arising in different body sites are reported. Thus, 

the foreign material is not supposed to be tumorigenic inherently 

by a chemical interaction, but a solid-state tumorigenesis should 

be proposed as an oncogenetic mechanism, common to all substances. 

It is hypotesized that the foreign material gives rise to 

granulation tissue that, under unknown conditions and after an 

adequate latency, undergoes neoplastic transformation. In this 

case, 3 years after implant placement, two samples of fibrous 

peri-prosthetic tissue were removed, showing microscopically 

foci of foreign body granulomatous reaction. An experimental 

animal model, in which a high incidence of mesenchymal tumors 

335 

were found in 25,8% of the implantation sites of a commercially 

available biomaterial (including silicone) after two years, contributed 

to validate the association between breast implants and 

angiosarcomas. 

Nevertheless, some authors recommend, before defining a sarcoma 

as implant-related, to establish that: 

1 patients with implants have a higher risk for developing sarcomas 

than age-matched controls; 

2 other well-known causes of sarcoma (i.e. radiation) have been 

excluded; 

3 the tumor develops in the immediate site of the biomaterial 

after an appropriate latency. 

Primary breast angiosarcomas are uncommon neoplasms: if related 

to breast implants, they are extremely rare. This clinicopathologic 

entity needs further studies to definitely determine whether 

a causal link between implant and angiosarcomas exists or not 

and eventually by which mechanisms the neoplasia develops. 

references 

1 Cook RR, Delongchamp RR, Woodbury M, et al. The prevalence of 

women with breast implants in the United States-1989. J Clin Epidemiol 

1995;48:519-25. 

2 Balzer BL, Weiss SW. Do biomaterials cause implant-associated mesenchymal 

tumors of the breast? Analysis of 8 new cases and review of 

the literature. Hum Pathol 2009;40:1564-70. 

3 Drijkoningen M, Tavassoli FA, Magro G, et al. Mesenchymal tumors. 

In: Tavassoli FA, DevileeP (eds). Pathology and genetics. Tumours of 

the breast and female genital organs. Lyon: IARC 2003:89-98. 

4 Roncadin M, Massarut S, Perin T, et al. Breast angiosarcoma after 

conservative surgery, radiotherapy and prosthesis implant. Acta Oncologica 

1998;37:209-11. 

5 Cuesta-Mejias T, de Leon-Bojorge B, de la Pena J, et al. Breast 

angiosarcoma in a patient withmultiple surgical procedure and 

breast implant. Report of a case. Ginecolgia y Obstetricia de Mexico 

2002;70:76-81. 

6 Saunders ND, Marshall JS, Anderson RC. A case of chest wall angiosarcoma 

associated with breast implants. J thorac cardiovasc surgery 

2007;134:1076-7. 

7 Nascimento AF, Raut CP, Fletcher CD. Primary angiosarcoma of the 

breast. Clinicopathologic analysis of 49 cases, suggesting that grade 

is not prognostic. Am J Surg Pathol 2008;32:1896-904. 

8 Engel A, Lamm SH, Lai SH. Human breast sarcoma and human 

breast implantation: a time trend analysis based on SEER data (1973- 

1990). J Clin Epidemiol 1995;48:539-44. 

9 Jennings, Peterson I, Axiotis CA, et al. Angiosarcoma associated with 

foreign material: a report of three cases. Cancer 1998;62:2436-44. 

10 Kirkpatrick CH, Alves A, Kockler H, et al. Biomaterial-induced 

sarcoma: a novel model to study preneoplastci change. Am J Path 

2000;156:1455-67. 

Clinical decision-making in breast cancer: 

role of the multidisciplinary team meeting 

D. Andreis1 , V. Zanoni1 , C. Foroni1 , L. Bazzola1 , G. Allevi1 , 

M. Alberio1 , N. Ziglioli1 , P. Bottini1 , L. Olivetti2 , M. Bodini2 , 

R.A. Bottini1 Istituti Ospitalieri di Cremona, Cremona, Italy, 1 U.O. Multidisciplinare di 

Patologia Mammaria e Lab. di Oncologia Molecolare Senologica, 2 U.O. 

Radiologia, 3 U.O. Anatomia e Istologia Patologica e Citodiagnostica, 

4 5 U.O. Radioterapia e Medicina Nucleare, U.O. Chirurgia Generale, 

6 Direzione Strategica 

Background. Multidisciplinary team (MDT) meeting has become 

a best practice for treatment decision in breast cancer (BC) 

patients. MDT offers the best outcome for patients, enabling a 

team of specialists to plan, optimise and provide care tailored 

to each patient’s needs. However, data regarding meeting frequency, 

composition and procedures are still limited. This study 

examines work processes of our BC MDT, to assess concordance 

between meeting recommendations, evidence-based guidelines 

and final treatment implementation.

336 

Methods. Face-to-face MDT meeting is performed twice a week 

at the Cremona BC Care Unit. According to EUSOMA requirements, 

it comprises a group of professionals with expertise in BC 

management, and involves 3 phases: a) a clinical data form is 

made available prior the meeting to every MDT member; b) MDT 

focuses on the patient evaluation to formulate an individuallytailored 

diagnostic-therapeutic program; c) meeting recommendation 

is registered, and communicated to/discussed with the 

patient. MDT prospectively collects data on all cases presented, 

and holds periodic audits. 

Results. From November 2011 to May 2012, 50 consecutive 

MDT meetings and 487 case presentations were recorded. Mean 

duration of the meeting was 75 minutes, with a mean of 11 attendees 

(7 core members). We have found positive correlations 

between number of case presentations and MDT meeting duration 

(r = 0.66, p < 0.000001), and between number of attendees and 

meeting duration (r = 0.29, p < 0.05), suggesting this approach offers 

effective relationships between MDT members, and ensures 

an integrated discussion for treatment decisions.One-hundredfifteen 

new BC diagnoses have been discussed by MDT (mean 

of 2.3 new cases per meeting), 61.8% of whom had indications 

for chemo- and/or hormonal-therapy (40.0% in neoadjuvant setting), 

36.5% surgery and 1.7% other treatments. Concordance 

of MDT meeting recommendations with guidelines was in 72 

of 115 cases (62.6%, 95% confidence interval [CI] 53.1-71.5%). 

Primary reasons of discordance were eligibility for clinical trials 

(55.8%), prognostication assessment by gene expression profiling 

(20.9%), comorbidities (11.6%), pharmacogenetic analysis 

(4.7%), and other motivations (7.0%). We observed a stronger 

concordance with guidelines for surgical recommendation rather 

than oncological (83.3% vs 49.3%, p < 0.001), due to a greater 

availability of innovative strategy patterns through clinical trials. 

Twenty-three recommendations (20.0%, 95% CI 11.0-25.6%) 

have not finally been implemented, due to availability of additional 

clinical information (65.2%), patient choice (26.1%), and 

organizational difficulties (8.7%). 

Conclusions. MDT is a fundamental approach to BC management 

with particular regards to complex cases requiring integrated 

and innovative treatment strategies. Different health and psychosocial 

professionals are regularly well represented at the meeting. 

MDT recommendations were fairly concordant with guidelines, 

rapidly validated, and largely implemented in practice. 

Primary fibromatosis of the breast: a case report 

M. Ballotta, D. Reale, A. Rasi, P. Rossi, R. Mencarelli 

Anatomia Patologica Dipartimento Patologia Clinica, Azienda Ulss 18, 

Rovigo 

Introduction. Primary fibromatosis of the breast is an infiltrating 

fibroblastic and myofibroblastic proliferation with a locally aggressive 

behaviour. It occurs most commonly in young women, 

raising the clinical and radiological suspicion of carcinoma. 

We describe a case of a 51 years old woman with a primary 

fibromatosis of the breast. 10 years earlier a diagnosis of infiltrating 

ductal carcinoma of the same breast, treated with a 

quadrantectomy with axillary lymph nodes dissection and RT 

was performed. 

Case Report. Female patient, 51 years old, in whom upon a 

mammographic and ecographic investigation, presented a stellate 

lesion with some dense calcifications that mimics carcinoma 

about 17 mm in diameter. The patient reported a prior left breast 

quadrantectomy 10 years earlier with histological diagnosis of 

infiltrating ductal carcinoma, without lymph nodes metastases. 

RT was performed. A biopsy sample was collected under CT 

guidance. Microscopic analysis showed a proliferation of fascicles 

of spindle cells, bland and spindle shaped or oval with poorly 

circumscribed cell borders, with moderate deposition of collagen 

consistent with a reactive fibroblastic and miofibroblastic prolif- 


Fig. 1. 

Fig. 2. 

eration. The patient was treated by lumpectomy.At gross examination 

the margins of the lesion are infiltrative, firm consistency 

at the cut (Fig. 1). 

Histologically the lesion was characterized by a proliferation of 

bland – looking spindle cells, with a low mitotic index, organized 

in long sweeping and intersecting fascicles with metaplastic bone 

(Fig. 2). The margins were infiltrative, entrapping adjacent breast 

parenchyma and adipose tissue. At Immunoistochemistry the 

cells exhibited a diffuse expression of vimentin and a heterogeneous 

immunoreactivity to a smooth muscle actin (Fig. 3). 

Cytokeratins, estrogens and progesterone receptors and other 

mesenchimal markers (S100, Cd34 and desmin) were negative. 

A diagnosis of ossifying fascitiis was made. After 1 year, the 

patient presented a local recurrence with the same histological 

characteristics of the primitive lesion, with myxoid change. Cellular 

atypia was absent and rare mitoses were seen (less than 3 x 

HPF). A diagnosis of primary fibromatosis was made even if beta 

catenin resulted negative. 

The diagnosis was confirmed by a consultant expert pathologist. 

None of the genetic disorders associated with fibromatosis was 

present in our patient. 

Discussion. It is important to distinguish fibromatosis from 

benign lesions that have no potential to recur and malignant lesions 

that may metastasize. Nuclear beta catenin expression is 

seen in up to 80% of cases; however it is not entirely specific for


Fig. 3. 

fibromatosis and may be expressed occasionally in metaplastic 

carcinomas or in stroma cells of fibroepithelial lesions. If we 

obtain a history of trauma of or previous surgery we can think to 

a scar. It may be very difficult to recognize the presence of recurrence 

of fibromatosis after surgery. 

Nodular fasciitis has a more diffuse inflammatory infiltrate and 

is more mitotically active. Myofibroblastoma usually has a non 

infiltrative margin and contains thick bands of collagen. Spindle 

cell metaplastic carcinoma can mimic fibromatosis but it is positive 

with cytokeratins. Fibrosarcoma is more cellular, with a significant 

degree of nuclear pleomorphism and abundant mitotic activity. 

Fibromatosis lacks metastatic potential but is locally aggressive, 

with recurrence seen in up to 27% of lesions, within the first 2 

or 3 years.Recurrence is more common in younger patients but; 

histological features do not predict for likeliness of recurrence. 

Wide local excision is the treatment of choice. 

references 

1 Majid A, Fatemi A, Olusegun A, et al. Fibromatosis of the breast. Am 

J Surg Pathol 1079;3:501-6. 

2 Wargotz E, Norris HJ, Austin RM, et al. Fibromatosis of the breast: 

A clinical and pathological study of 28 cases. Am J Surg Pathol 

1987;11:38-45. 

3 Magro G, Gurrera A, Scavo N, et al. La fibromatosi della mammella: 

studio clinico, radiologico e patologico di sei casi. Patologica 

2002;94:238-46. 

4 Balzer BL, Weiss SW. Do biomaterial causes implant associated 

mesenchymal tumours of the breast? Analysis of 8 cases and review of 

the literature. Hum Pathol 2009;40:1564-70. 

5 Neuman HB, Brogi E, Ebrahim A, et al. Desmoid tumours (fibromatoses) 

of the breast. A 25 years experience. Ann Surg Oncol 

2008;15:274-80. 

6 Povoski SP, Jimenez RE. Fibromatosis (desmoid tumour) of the breast 

mimicking a case of ipsilateral metachronous breast cancer. World J 

Surg Oncol 2006;4:57. 

Comparative evaluation of three different 

approaches of sentinel lymph node assessment 

in breast cancer patients: the regina Elena national 

Cancer Institute experience 

S. Buglioni, B. Casini, E. Gallo, L. De Salvo, A. Russo, F. Marandino, 

A. Di Benedetto, E. Melucci, B. Antoniani, C. Ercolani, 

V. D’Alicandro, V. Dimartino, C.A. Amoreo, M. Mottolese, 

E. Pescarmona 

Pathology Department, Regina Elena National Cancer Institute, Rome, Italy 

Background. In our Institution from 2000 to 2007 the detection 

of sentinel lymph node (SLN) metastasis in breast cancer patients 

337 

had been performed postoperatively by a combined histological 

and immunohistological approach. In 2008 the molecular diagnostic 

tool “One Step Nucleic Acid Amplification” (OSNA) was 

adopted in our Institute as routine intraoperative test 1 2 . During 

the first three years, (2008-2010) we evaluated the feasibility 

of OSNA system within our department and we investigated 

whether the performance of the OSNA method was comparable 

to our postoperative histological standard procedures. To this end 

a prospective series of 903 consecutive SLNs from 709 breast 

cancer patients was evaluated. The overall concordance rate for 

OSNA versus histopathology was 96%, with a sensitivity of 94% 

and specificity of 96%. 

After this challenging results and in agreement with other italian 

and european OSNA users in 2011 we decided to analyze the 

whole sentinel node with the OSNA assay. 

Aims. The aim of the present study is to evaluate comparatively 

the results of these three different approaches of SLN assessment 

in order to test their diagnostic sensitivity in the definition of 

the SLN “status” and in the prediction of axillary lymph nodes 

involvement. 

Material and methods. In order to carry out this study we have 

selected three one-year representative periods. 

Period 1 (2008): the whole SLN was analyzed postoperatively by 

standard histological work-out consisting of 6 levels of Haematoxylin 

& Eosin (H&E) and cytokeratin 19 (CK19) immunostaining. 

All SLNs were classified into 4 categories according to the 

seventh edition of the AJCC Staging Manual: positive, macrometastasis 

(> 2.0 mm); positive, micrometastasis (> 0.2 mm to ≤ 2 

mm); negative, ITCs (≤ 0.2 mm); and negative no tumour cells. 

Period 2 (2010): half SLN analyzed by OSNA and half by standard 

histology. The SLNs were cut in 4 equal slices two of these 

slices were analyzed intraoperatively by OSNA method and the 

remaining 2 slices were formalin fixed and paraffin embedded in 

a single block for standard in-house histological method. OSNA- 

CK19 involves a short manual sample preparation step and 

subsequent fully automated amplification of CK19 mRNA based 

on reverse transcription loop-mediated isothermal amplification, 

with results available within 40-50 min. The OSNA results 

were classified as negative (-) (< 250 copies/_l), micrometastasis 

(+) (from ≥ 250 to < 5000 copies/__l) or macrometastases (++) 

(≥ 5000 copies/__l). 

Period 3: (2011): the whole SLN was analyzed by the OSNA assay 

according to the same procedure described above. 

All the patients included in this study with a positive SLN, for 

both micrometastases and macrometastases, underwent axillary 

lymph node dissection (ALND). 

Results. The results are reported in Fig. 1 and Tab. I. 

Period 1: 220 SLNs of 181 patients were analyzed postopera- 

Fig. 1.

338 

Tab. I. 

tively by standard histology. The percentage of patients with a 

positive SLN was 20.4%. Of the 37 positive cases 13 (7%) were 

micrometastases and 24 (13%) were macrometastases. Of the 13 

patients with a positive SLN for micrometastasis who underwent 

ALND only 15% contained residual metastasis. Otherwise 12 out 

of 24 patients (50%) with a SLN positive for macrometastases 

had a positive ALND. 

Period 2: 383 SLNs of 297 patients were analyzed by OSNA assay 

and standard histological method. 229 (76.4%) were negative 

and 70 (23.6%) were positive by both molecular and histological 

methods. Of the overall 70 positive cases 40 were macrometastases 

(14%) and 30 (10%) micrometastases. The ALND was 

positive in 29% and 61% of the patients with a micrometastatic 

and macrometastatic SLN, respectively. 

Period 3: 448 whole SLNs of 336 patients were intraoperatively 

analyzed by the OSNA assay. The percentage of patients with 

a positive SLN was 24.7%. Of the 83 positive cases 12% were 

classified according to OSNA method as micrometastatic (+) and 

13% as macrometastatic (++). The ALND was positive in 29% 

and 59% of the patients with a micro- and macrometastic SLN, 

respectively. 

Conclusions. 1) The OSNA method (performed either alone on 

the whole SLN or in combination with postoperative standard 

histology) is more sensitive in the detection of micrometastasis 

as compared to the histological postoperative procedure. 2) As a 

consequence and in addition, this approach is clinically useful for 

directing intraoperative decisions regarding ALND. 

references 

1 Visser M, Jiwa M, Horstman A, et al. Intra-operative rapid diagnostic 

method based on CK19 mRNA expression for the detection of lymph 

node metastases in breast cancer. Int J Cancer 2008;122:2562-7. 

2 Schem C, Maass N, Bauerschlag DO, Carstensen MHet al. One-step 

nucleic acid amplification-a molecular method for the detection of 

lymph node metastases in breast cancer patients; results of the German 

study group. Virchows Arch 2009;454:203-10. 

Pattern of distant recurrence according 

to the molecular subtypes identified by 

immunohistochemistry in women with early 

breast cancer 

P. Querzoli1 , M. Pedriali1 , A. Schirone2 , M. Indelli2 , A. Santini2 , 

A. Rocchi2 , L. Da Ros2 , A. Frassoldati2 1 Department of Experimental and Diagnostic Medicine, Institute 

of Pathology, Ferrara University, Azienda Ospedaliero, Universitaria 

“S. Anna”, Ferrara; 2 Oncology Unit, Azienda Ospedaliero-Universitaria 

“S. Anna”, Ferrara 

Background. No evidence exists that in early breast cancer patients 

an intensive follow-up is more beneficial than a minimal 

one. However, the recent insight into the breast cancer heterogeneity 

and the availability of new treatments challenge this assumption 

and induce to reconsider the usual follow-up modalities. 

The aim of this study is to investigate the association between molecular 

subtypes and patterns of distant recurrence in breast cancer. 

Materials and methods. We performed a retrospective observational 

mono-institutional study collecting data regarding 500 early breast 

cancer patients surgically treated between 1.1.2006 and 31.12.2007. 

We use IHC to evaluate the profiles of our casuistic using for ER SP1, 


Micrometastasis Macrometastasis 

OSNA + 2011 OSNA +/IHC 

Micro 2010 

IHC micro 2008 Osna ++ 2011 Osna ++/IHC 

macro 2010 

IHC macro 2008 

alND Pos 29% 29% 15% 59% 61% 50% 

alND Neg 71% 71% 85% 41% 39% 50% 

total 100 100 100 100 100 100 

PR 1E2, Mib1 Biomeda, Her2 4B5. All assays are performed by automated 

immunostainer. All markers are evaluated using VIAS Ventana 

by two expert pathologists (PQ, PM). The subtypes were defined as 

Luminal A (ER/PR > 1%, MIB-1 < 14%, HER2 negative), Luminal 

B (ER/PR > 1%, MIB-1 > 14%, HER2 negative), luminal B-HER2 

(ER/PR > 1%, MIB-1 > 14%, HER2 positive), HER2 (ER/PR < 1%, 

HER2 positive) and Triple Negative (ER/PR < 1%, HER2 negative). 

Results. Median follow-up time was 58.1 months (range 6.9- 

72.9). The Distant-Disease Free Survival (Fig. 1) and the incidence 

of first distant recurrence site was significantly different 

among the subtypes: brain metastasis was more frequent in TN 

subtype; bone metastasis was more frequent in Luminal subtypes, 

liver metastasis was more frequent in HER positive subtypes. In 

Luminal A subtype the earlier site of metastasis were lung and 

bone (median D-DFS = 31 months), in Luminal B was bone 

(32 months), in Luminal B-HER2 and HER2 subtypes was liver 

(18 months for both), in TN subtypes lung (median D-DFS = 18 

months). In the multivariate analysis T, ER status, menopausal 

status and TNM stage were confirmed as independent prognostic 

factors in terms of D-DFS, and TNM stage only in terms of OS. 

Conclusions. Organ-specific metastasis may depend on molecular 

subtype of breast cancer. On these basis, we suggest that each 

breast cancer subtype should undergo a different follow-up program 

and that this strategy will improve the detection of relapses 

in a preclinical phase, hopefully to tend a more personalized and 

more tailored treatment. 

Fig. 1. 

Immunohistochemical study of β hemoglobin 

(HBB) expression in human breast carcinoma 

and its potential prognostic value 

L. Ventura1 , M. Capulli2 , C. Mercurio1 , A. Teti2 , N. Rucci2 1 U. O. C. di Anatomia Patologica, Ospedale San Salvatore, L’Aquila; 

2 Dipartimento di Scienze Cliniche Applicate e Biotecnologie, Università, 

L’Aquila, Italy 

Background. In a recent study 1 we performed whole genome


microarray analysis in bone metastases from breast cancer (BrCa) 

patients who developed secondary lesions also in visceral organs 

or with metastases restricted to bone. Patients with metastases 

restricted to bone showed a longer overall survival compared to 

patients who rapidly developed multiple metastases involving 

also visceral organs. Our bioinformatic elaboration unveiled a 

cluster of genes that segregated the two groups. Among them, a 

set of genes was involved in oxygen binding and transport. We 

focused on β hemoglobin (HBB) that was not, so far, associated 

with the metastatic phenotype of BrCa. Based on this observation, 

we hypothesized a role of HBB in tumor progression 1. 

Therefore, the aim of the present study was to investigate HBB 

expression in primary human breast carcinoma and lymph node 

metastases, in order to investigate a potential correlation between 

such expression and known prognostic factors. 

Material and methods. Samples from 36 consecutive and 

unselected patients undergone surgery for breast cancer were 

included in this prospective study. A total of 38 primary lesions 

and 4 lymph node metastases from the same patients were investigated. 

3 cases of fibroadenoma and 1 case of papilloma were also 

included in the study. Histological sections were deparaffinized, 

incubated with 0.07M citrate buffer (pH 6), 15 min at 98° C, for 

antigen retrieval, treated with 3% H 2O 2 and incubated overnight 

at +4°C with the anti-HBB mouse monoclonal antibody (clone 

sc-21757, Santa Cruz Biotechnology Inc., Heidelberg, Germany). 

The staining signals were revealed using the Dako LSAB+ System-HRP. 

Slides were counterstained with Mayer’s hematoxylin. 

Red blood cells were used as internal positive control and negative 

controls were performed in parallel, by omitting primary antibody 

for each case. HBB expression in carcinoma was recorded 

as percentage of positively stained cells and correlated to known 

prognostic factors, namely histologic type, grading, estrogen 

(ER) and progesterone (PR) receptor expression, Ki-67 proliferation 

index and HER-2 score. 

Results. Positive staining was noted in our internal positive 

controls, red blood cells, and in endothelial cells. Multifocal 

immunostaining of extracellular space was noted in 8 cases and 

possibly related to hemoglobin diffusion in the interstitial compartment. 

Strong cytoplasmic positivity was noted in primary 

invasive carcinoma in 22 cases, mainly in scattered elements 

rESPIrATOrIO 

EML4-ALK rearrangements detection by FISH and 

rT-PCr in Formalin Fixed and Paraffin Embebbed 

tissues of non Small Cell Lung Cancer. 

N. Borrelli1 , R. Giannini1 , G. Alì2 , S. Pelliccioni2 , C. Niccoli2 , 

G. Fontanini1,2 1 2 Department of Surgery, University of Pisa, Pisa; Unit of Pathologic 

Anatomy, Azienda Ospedaliera Universitaria Pisana, Pisa 

Introduction. A transforming fusion gene joining the echinoderm 

microtubule-associated protein-like 4 gene (EML4) and the 

anaplastic lymphoma kinase gene (ALK) has recently been found 

in a subset of non-small cell lung cancer (NSCLC). ALK encodes 

a receptor tyrosine kinase, which belongs to the insulin receptor 

superfamily. This protein comprises an extracellular domain, an 

hydrophobic stretch corresponding to a single pass transmem- 



339 

or groups of cells. Percentage of positive cells ranged from 1 to 

45%. Cases with more than 10% positive cells were arbitrarily 

considered positive, accounting for 12 primary tumors. Two of 

four nodal metastases expressed HBB in a higher percentage 

than the primary tumor and one had the same percentage of the 

primary tumor. Primary tumors positive for HBB were 9 poorly 

differentiated (G3) infiltrating ductal carcinomas, 1 moderately 

differentiated (G2) ductal carcinoma and 2 infiltrating lobular 

carcinoma. The average age of the patients was 65.1 (range: 38- 

83). All but one expressed significant levels of hormone receptors, 

with an average proliferation index of 20 (range: 10-35) and 

all but two did not overexpress HER-2. The percentage of HBB 

positive cells was higher in the invasive lesions when compared 

with the coexisting in situ lesions in the 87% of the cases. Benign 

lesions tested, such as fibroadenoma and papilloma, as well as 

adenosis, papillomatosis and normal tissue observed outside the 

main tumor nodule, were all negative. 

Conclusions. Significant positivity of HBB was detected in primary 

BrCa tissue but not in normal breast epithelial cells and benign lesions, 

such as fibroadenoma, papilloma and adenosis, indicating that 

HBB expression is associated with the malignant cell phenotype. 

Infiltrating lesions showed higher percentage of HBB positive cells 

than in situ counterparts, as well as greater values of positivity were 

found in lymph node metastases, compared to the corresponding 

primary tumors. The majority of the HBB positive tumors were high 

grade ductal carcinoma with moderately high proliferation index, 

significant levels of hormone receptors and without HER2 overexpression. 

These findings suggest that HBB expression by neoplastic 

cells may identify a subgroup of lesions with a more aggressive 

potential. Even though follow-up data and further investigation are 

needed to clarify the prognostic value and the statistical significance 

of HBB expression in primary breast cancers, our results suggest a 

possible positive correlation between HBB expression and tumor 

cell aggressiveness, paving the way for a possible use of HBB as a 

novel marker for breast cancer characterization. 

references 

1 Capulli M, Angelucci A, Driouch K, et al. Increased expression of a 

set of genes enriched in oxygen binding function discloses a predisposition 

of breast cancer bone metastases to generate metastasis spread 

in multiple organs. J Bone Mineral Research 2012; in press. 

brane region, and an intracellular kinase domain. It plays an 

important role in the cell proliferation, survival migration, and 

alteration in cytoskeletal rearrangement 1 . EML4 is a cytoplasmic 

protein that is a human homolog of echinoderm microtubule 

associated protein, the major microtubule binding protein in 

dividing sea urchin eggs, and is essential for the formation of 

microtubules 1 . It is composed of a N-terminal basic region, a 

HELP domain and four WD repeats in the C-terminus. EML4 

and ALK are situated on the short arm of chromosome 2 (2p21 

and 2p23, respectively) where they are separated by a distance 

of 12.2 megabases and are oriented in opposite directions 2 . The 

small inversion within chromosome 2p leads to the EML4-ALK 

fusion gene. Multiple EML4-ALK variants have been identified 

since EML4 truncation does not always occur in the same location 

(at exons 2, 6, 13, 14, 15, 18 or 20); the intracellular tyrosine 

kinase domain of ALK (encoded by exon 20) is conserved among 

the variants. The most common variants were E13;A20 (the 

nomenclature refers to the exons in EML4 (E) that are fused to

340 

ALK (A)) and E6;A20, which also referred to as variants 1 and 

3, respectively. These have been respectively detected in 33% 

and 29% of NSCLC patients with EML4-ALK rearrangement 3 4 . 

Consequent to the EML4-ALK rearrangement, the encoded protein 

contains the N-terminal part of EML4 and the intracellular 

catalytic domain of ALK. Replacement of the extracellular and 

transmembrane domain of ALK with a region of EML4 results 

in constitutive dimerization of the kinase domain and thereby a 

consequent increase in its catalytic activity 3 . Detection of ALK 

gene fusion is currently indicated as a predictive marker of treatment 

response to small molecule inibitors of ALK in NSCLC: 

crizotinib. Crizotinib, a new and selective TKI targeting ALK 

and MET has been approved on August 26, 2011, by the FDA 

to treat locally advanced or metastatic NSCLC that harbor the 

abnormal fusion gene. In Phase I and Phase II trials, crizotinib 

was shown to be highly active in patients with advanced ALKpositive 

NSCLC, with overall response rates of 50–60%. EML4- 

ALK is also associated with anti-EGFR TKI resistance. The gold 

standard method to detect ALK rearrangement is fluorescent in 

situ hybridization (FISH). However many published studies using 

reverse transcritase-polymerase chain reaction analysis to characterize 

EML4-ALK. FISH detects any rearrangement involving 

ALK, including potentially rare uncharacterized rearrangement. 

PCR identifies specific fusion variants. Although both/these 

techniques are sensitive and specific for detecting EML4-ALK, 

we want to compare the data obtain through the two different 

approaches. We aimed to estabilish if PCR can be used to take 

additional advantage of genetic analyses, especially in case were 

the FISH was not applicable. 

Matherials and method. This study comprised a series of 46 

patients with NSCLC (39 adenocarcinoma, 5 metastasis of lung 

adenocarcinoma, and 2 Squamous cell lung cancer) who underwent 

surgery in the Department of Surgery at the University of 

Pisa from 2007 to 2011. From each paraffin block, 4 consecutive 

10µm sections were cut to extract the DNA (for EGFR and KRAS 

mutation analysis) and the RNA (for EML4-ALK analysis). 

An adjacent 5µm section was used for FISH (for EML4-ALK 

analysis). All samples were analyzed using both FISH and PCR 

approach in parallel. Nucleic acid was isolated using a commercially 

kit specific to formalin-fixed and paraffin-embedded 

(FFPE) sample. The quality and quantitation of RNA and DNA 

were verified by Agilent 2100 bioanalyzer. RNA (500ng) from 

each sample was reverse transcribed using random hexamer primers 

to produce cDNA from all RNAs. For detection of EML4- 

ALK fusion cDNAs, we have carried out three independent PCR. 

The first one, was performed using a set of primers to identify the 

variant 1; forward primer is located at exon 13 of EML4, whereas 

the reverse primer is located at exon 20 of ALK, resulting in a 

170-base pair PCR product. To search for other variants of rearrangement, 

as described in the study of Soda et al. 3 , we used 

primers that target fusion variant 1 (247-bp). 

These primers could also detect variant 2 which would have 

yielded a considerebly longer amplication (≈1Kb); the forward 

primer Fusion-RT-S is located in exon 13 of EML4, while the 

reverse primer Fusion-RT-AS, in exon 20 of ALK. The latter 

variant may have been expressen in the fusion positive cases 

but missed in our assay because of the difficulties in amplifying 

long amplicons from RNA extracted from FFPE. To analyze 

the shorter variant of EML4-ALK transcript (155/188-bp), the 

variant 3, the ALK Fusion- RT-AS primer was combined with a 

forward primer located in exon 6 of EML4: EML4-ex6F. PCR 

primers GAPDH-S and GAPDH-AS for glyceraldehyde-3phosphate 

dehydrogenase cDNA (452bp) were used as control 

for cDNA integrity. Polymerase chain reaction products were 

assessed and visualized by 1,5% agarose gel electrophoresis. 

PCRs were performed in triplicate, each one in 25µl reactions 

containing 100 ng cDNA, 12,5µl of Taq PCR Master Mix and 

0.5 µl of each primer (20µM). 


To asses for rearrangement of the ALK locus on 2p23 using commercially 

available ALK (Vysis ALK Break Apart FISH Probe 

Kit, Abbott Laboratories) probes we performed on 4µm paraffinembedded 

thin sections. The test employs two differently labeled 

probes on opposite sides of the breakpoint of the ALK gene. 

When hybridized with the Vysis ALK Break Apart FISH Probes, 

the 2p23 ALK region in its native state will be seen as two immediately 

adjacent or fused orange/green (yellow) signals. However, 

if a chromosome rearrangement at the 2p23 ALK breakpoint region 

has occurred, one orange and one green signal separated by 

at least two signal diameters will be seen. Alternatively, a single 

orange signal(deletion of green signal) in addition to a fused or 

broken apart signal may be seen. 

A minimum of 50 tumor cells must be scored and a specimen 

is considered positive for ALK rearrangement when > 15% of 

the cells show split signals. All experiments were done without 

knowledge of the RT-PCR results for EML4-ALK. Mutation 

analysis of EGFR (exons 18-21) and KRAS (codons 12, 13 and 

61) were performed using the HotStarTaq Master Mix Kit, as 

per manufacturer’s instructions. The presence of an appropriate 

PCR product was confirmed by resolving the PCR products on 

a 1.5% agarose gel. PCR products were purified using the PCR 

Purification Kit and sequenced using fluorescent dye-terminator 

chemistry. Mutations were identified by visual analysis of the 

sequence chromatograms using SeqScape. 

Results. Among 46 NSCLC analyzed 6 (13%) showed EML4- 

ALK rearrangement by FISH analysis; while, EML4-ALK transcript, 

detected by RT-PCR, were found in 9 cases of 46 (21.7%). 

Of 9 positive-PCR cases 6 (13%) showed EML4-ALK fusion 

variant 1 and 3 (6.5%) showed EML4-ALK fusion variant 3. 

We identified only one (2.17%) in-frame deletion in EGFR 

exon 19 (E746-A750del); while, single amino acid substitution 

involving codons 12 and 13 of KRAS, were identified in 7 of 46 

NSCLC (15%). In particular, we found that 3 patients had G12C, 

3 patients had G12D and 1 patient had G12S. 

Discussion. An overall concordance of FISH and RT-PCR (being 

either negative or positive in both tests) was found in 39 cases 

(84.7%) and a discrepancy was identified in 7 cases (15.3%). 

In detail, 4 samples resulted positive in both FISH and RT-PCR 

analysis, 2 FISH positive samples were RT-PCR negative, 5 

samples showing transcript expression were FISH negative (or 

below the cut-off value) and 35 samples were negative for EML4- 

ALK rearrangement detection. 

ALK fusion and EGFR and KRAS mutations appears to be mutually 

exclusive. Although, we identified one patient who had both 

EML4-ALK rearrangement and KRAS mutation (G12D); while, 

all positive cases for ALK rearrangement did not show EGFR 

mutations. 

In conclusion, the usefulness of RT-PCR analysis for EML4- 

ALK rearrangement detection is still not fully satisfactory due to 

the fact that either alternative EML4 exons were involved or that 

EML4 was not the ALK fusion partner in all the FISH positive 

patients. As a consequence a multiplex RT-PCR reaction should 

be performed to fully cover the fusion variants but this approach 

is difficult to apply in routine condition poor quality samples. 

Finally FISH analysis remains the gold standard methods for 

EML4-ALK rearrangement detection. 

references 

1 Chiarle R, et al. The anaplastic lymphoma kinase in the pathogenesis 

of cancer. Nat Rev Cancer 2008;8:11-23. 

2 Solomon B, Varella-Garcia M, Camidge DR. ALK gene rearrangements: 

a new therapeutic target in a molecularly defined subset of 

non-small cell lung cancer. J Thorac Oncol 2009;4:1450-4. 

3 Soda M, et al. Identification of the transforming EML4-ALK fusion 

gene in non-small-cell lung cancer. Nature 2007;448:561-6. 

4 Martelli MP, Sozzi G, Hernandez L, et al. EML4-ALK rearrangement 

in non-small cell lung cancer and non-tumor lung tissues. The American 

Journal of Pathology 2009;174:661-670.


True 3q chromosomal amplification in squamous 

cell lung carcinoma by FISH and aCGH molecular 

analysis: impact on targeted drugs 

M. Brunelli1 , E. Bria2 , A. Nottegar1 , S. Cingarlini2 , A. Caliò1 , 

A. Eccher3 , C. Parolini1 , A. Iannucci2 , E. Gilioli3 , S. Pedron1 , 

F. Massari2 , G. Tortora2 , I. Borze4 , S. Knuutila4 , S. Gobbo1 , 

A. Santo5 , L. Tondulli5 , F. Calabrò6 , G. Martignoni1 , M. Chilosi1 1 University of Verona, Department of Pathology and Diagnostic, Verona, 

Italy; 2 University of Verona, Department of Medical Oncology, Verona, 

Italy; 3 Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale 

Civile Maggiore, Pathology Unit, Verona, Italy; 4 University of Helsinki, 

Haartman Insitute, Department of Pathology, Helsinki, Finland; 5 Azienda 

Ospedaliera Universitaria Integrata di Verona, Oncology Unit, Ospedale 

Civile Maggiore, Verona, Italy; 6 Azienda Ospedaliera Universitaria 

Integrata di Verona, Ospedale Civile Maggiore, Thoracic Surgery Unit, 

Verona, Italy 

Introduction. Squamous lung carcinoma lacks specific “ad hoc” 

therapies. Amplification of chromosome 3q is the most common 

genomic aberration and this region harbours genes having role as 

novel targets for therapeutics 1,2,3 . There is no standard definition 

on how to score and report 3q amplification. False versus true 

3q chromosomal amplification in squamous cell lung carcinoma 

may have tremendous impact on trials involving drugs anti-PI3K 

and -SOX2 mapping on 3q 4 . 

Materials and method. Forty squamous lung carcinomas were 

analyzed by FISH to assess chromosome 3q amplification. aCGH 

was performed as gold-standard to avoid false positive amplifications. 

Results. Three clustered patterns of fluorescent signals were observed. 

Eight cases out of 40 (20%) showed ≥ 8 3q signals. Twenty 

out of 40 (50%) showed from 3 to 7 signals. The remaining 

showed two fluorescent signals (30%). When corrected by whole 

chromosome 3 signals, only cases with ≥8 signals maintained a 

LSI 3q/CEP3 ratio > 2. Only the cases showing 3q amplification 

by aCGH (+3q25.3-3q27.3) showed ≥8 fluorescent signals at 

FISH evidencing a 3q/3 ratio > 2. The remaining cases showed 

flat genomic portrait at aCGH on chromosome 3. 

Conclusion. We concluded that: 1) absolute copy number of 

3q chromosomal region may harbour false positive interpretation 

of 3q amplification in squamous cell carcinoma; 2) a case 

results truly “amplified for chromosome 3q” when showing ≥8 

fluorescent 3q signals; 3) trials involving anti-PI3CA and –SOX2 

drugs for squamous lung carcinoma therapy have to consider 

false versus true 

3q chromosomal amplification. 

references 

1 Kettunen E, el-Rifai W, Bjorkqvist AM, et al. A broad amplification 

pattern at 3q in squamous cell lung cancer--a fluorescence in situ 

hybridization study. Cancer Genet Cytogenet 2000:117:66-70. 

2 Qian J, Massion PP. Role of chromosome 3q amplification in lung 

cancer. J Thorac Oncol 2008;3:212-5. 

3 Bjorkqvist AM, Husgafvel-Pursiainen K, Anttila S, et al. DNA gains 

in 3q occur frequently in squamous cell carcinoma of the lung, but not 

in adenocarcinoma. Genes Chromosomes Cancer 1998;22:79-82. 

4 McCaughan F, Pole JC, Bankier AT, et al. Progressive 3q amplification 

consistently targets SOX2 in preinvasive squamous lung cancer. 

Am J Respir Crit Care Med 2010;182:83-91. 

341 

InV(2)(p21p23) and t(2;2)(EMLA4;ALK) detection in 

pure squamous lung carcinoma. time to assess ALK 

translocation in squamous subtype of lung cancer? 

A. Caliò1 , M. Brunelli1 , A. Nottegar1 , S. Pedron1 , S. Knuutila4 , 

F. Simionato2 , S. Cingarlini2 , E. Bria2 , G. Tortora2 , F. Calabrò3 , 

G. Martignoni1 , M. Chilosi1 1 Università di Verona, Dipartimento di Patologia e Diagnostica, Sezione 

di Anatomia Patologica; 2 Università di Verona, Dipartimento di Medicina 

clinica e sperimentale, Sezione di Oncologia medica; 3 Azienda Ospedaliera 

Universitaria Integrata di Verona, Ospedale Civile Maggiore, Unità 

di Chirurgia Toracica, Verona, Italy 

Introduction. In 2007 ALK was shown to be involved in the oncogenesis 

of a subset of non small cell lung cancer (NSCLC) and 

20% NSCLC from never smokers. The most common 5’ fusion 

partner in NSCLC is EML4 (echinoderm microtubule-associated 

protein like 4), but other, rarer 5’ fusion partner, notably, KIF5B 

(kinesin family member 5B) and TGF (TRK- fused gene) have 

also described. The EML4-ALK fusion results from a small inversion 

within the short arm of chromosome 2, which encodes a 

chimeric tyrosine kinase, leading to constitutive activation. 

The main clinico-pathologic features of these NSCLC, to date, 

include younger age at diagnosis, never or light smoking history, 

adenocarcinoma histology, and signet ring cells. However, 

tumors with squamous cell carcinoma or adenosquamous histologies, 

although with much lower frequency than adenocarcinoma, 

have been reported to harbor ALK translocation. Recently, it has 

been raised the question whether squamous cell lung cancer may 

be evaluated for ALK gene rearrangement due to single case 

report evidencing cases of adenosquamous and squamous lung 

cancer ALK translocated. 

Materials and methods. A consecutive series of 55 lung carcinomas 

with pure squamous morphology were analyzed. We 

studied the immunohistochemical expression of protein 63 (p63), 

cytokeratin CK5/6, thyroid transcrition factor 1 TTF-1 and 

Napsin. Moreover, we used two distinct FISH kit; the first one, a 

break apart dual color probe, approved by FDA, has the goal to 

detect the ALK rearrangement but not the partner of the fusion; 

the second one, a dual-color assay Kreatech FISH probes, has 

the specific goal to assess the specific ALK-EML4 t(2;2); inv(2). 

Results. All tumors stained positive, by immunohistochemistry, 

for p63 and CK5/6 and negative for TTF-1 and Napsin. One case 

with diffuse ALK rearrangement was found. Primarly, by using 

FISH technique with a break apart dual color probe, we observed 

the split signals in more than 40% of the nuclei (150 neoplastic 

nuclei scored). Secondarly, by the ALK/EML4 t(2;2); inv(2), the 

squamous carcinomatous tissue showed the ALK-EML4 fusion 

by visualing of 2 red-green fused, 1 red and 1 green fluorescent 

signals in > 70% of nuclei (150 neoplastic nuclei scored) 

Conclusions. We observed a case of lung carcinoma with pure 

squamous morphology with diffuse ALK rearrangement; we additionally 

reviewed the Literature focusing on squamous cell lung 

cancer and adenosquamous carcinoma characterized by ALK 

rearrangement by FISH technique and we found 14 cases and 12 

cases respectively. Furthermore, we did not observed any other 

squamous lung cancer with ALK/EML4 t(2;2); inv(2). 

We think that the histotype per se do not preclude the presence 

of ALK rearrangement and we propose, in agreement with other 

Authors, to screen squamous cell lung carcinoma for ALK rearrangement. 

references 

1 Travis WD, et al. United States lung carcinoma incidence trends: 

declining for most histologic types among males, increasing among 

females. Cancer 1996;77:2464-70. 

2 Travis WD, et al. International association for the study of lung 

cancer/american thoracic society/european respiratory society international 

multidisciplinary classification of lung adenocarcinoma. J 

Thorac Oncol;6:244-85.

342 

3 Soda M, et al. Identification of the transforming EML4-ALK fusion 

gene in non-small-cell lung cancer. Nature 2007;448:561-6. 

4 Soda M, et al. A mouse model for EML4-ALK-positive lung cancer. 

Proc Natl Acad Sci USA 2008;105:19893-7. 

5 Shaw AT, et al. Clinical features and outcome of patients with 

non-small-cell lung cancer who harbor EML4-ALK. J Clin Oncol 

2009;27:4247-53. 

6 Kwak EL, et al. Anaplastic lymphoma kinase inhibition in non-smallcell 

lung cancer. N Engl J Med;363:1693-703. 

7 Chaft JE, et al. ALK-Rearranged Lung Cancer: Adenosquamous Lung 

Cancer Masquerading as Pure Squamous Carcinoma. J Thorac Oncol;7:768-9. 

8 Klempner SJ, et al. ALK translocation in non-small cell lung cancer 

with adenocarcinoma and squamous cell carcinoma markers. J Thorac 

Oncol;6:1439-40. 

9 Kimura H, et al. ALK fusion gene positive lung cancer and 3 

cases treated with an inhibitor for ALK kinase activity. Lung Cancer;75:66-72. 

10 Solomon B, et al. ALK gene rearrangements: a new therapeutic target 

in a molecularly defined subset of non-small cell lung cancer. J Thorac 

Oncol 2009;4:1450-4. 

11 Inamura K, et al. EML4-ALK lung cancers are characterized by rare 

other mutations, a TTF-1 cell lineage, an acinar histology, and young 

onset. Mod Pathol 2009;22:508-15. 

12 Jokoji R, et al. Combination of morphological feature analysis and 

immunohistochemistry is useful for screening of EML4-ALK-positive 

lung adenocarcinoma. J Clin Pathol;63:1066-70. 

13 Rodig SJ, et al. Unique clinicopathologic features characterize ALKrearranged 

lung adenocarcinoma in the western population. Clin 

Cancer Res 2009;15:5216-23. 

14 Boland JM, et al. Anaplastic lymphoma kinase immunoreactivity correlates 

with ALK gene rearrangement and transcriptional up-regulation 

in non-small cell lung carcinomas. Hum Pathol 2009;40:1152-8. 

15 Yoshida A, et al. Comprehensive histologic analysis of ALK-rearranged 

lung carcinomas. Am J Surg Pathol;35:1226-34. 

16 Paik JH, et al. Screening of anaplastic lymphoma kinase rearrangement 

by immunohistochemistry in non-small cell lung cancer: correlation 

with fluorescence in situ hybridization. J Thorac Oncol;6:466-72. 

17 Lee JK, et al. Comparative analyses of overall survival in patients with 

anaplastic lymphoma kinase-positive and matched wild-type advanced 

nonsmall cell lung cancer. Cancer. 

18 Wong DW, et al. The EML4-ALK fusion gene is involved in various 

histologic types of lung cancers from nonsmokers with wild-type 

EGFR and KRAS. Cancer 2009;115:1723-33. 

19 Martelli MP, et al. EML4-ALK rearrangement in non-small cell lung 

cancer and non-tumor lung tissues. Am J Pathol 2009;174:661-70. 

20 Takeuchi K, et al. KIF5B-ALK, a novel fusion oncokinase identified by 

an immunohistochemistry-based diagnostic system for ALK-positive 

lung cancer. Clin Cancer Res 2009;15:3143-9. 

21 Just PA, et al. Histologic subtypes, immunohistochemistry, FISH or 

molecular screening for the accurate diagnosis of ALK-rearrangement 

in lung cancer: A comprehensive study of Caucasian non-smokers. 

Lung Cancer. 

22 Koh PK, et al. Targeted agents in non-small cell lung cancer 

(NSCLC): Clinical developments and rationale for the combination 

with thoracic radiotherapy. Cancer Treat Rev. 

23 Inamura K et al. EML4-ALK fusion is linked to histological characteristics 

in a subset of lung cancers. J Thorac Oncol 2008;3:13-7. 

An unexpected diagnosis of clear cell renal cell 

carcinoma after wedge lung resection 

L. Gnetti1 , R. Manuguerra1 , F. Brigati1 , F.P. Pilato1 , L. Ampollini2 

, E.M. Silini1 1 Azienda Ospedaliero-Universitaria di Parma, Dipartimento Onco-Ematologico 

Internistico, Sezione di Anatomia Patologica; 2 Azienda Ospedaliero-Universitaria 

di Parma, Dipartimento Cardio-Nefro-Polmonare, 

Sezione di Chirurgia Toracica 

Introduction. Simultaneous presentation of two different primary 

malignancy from different sites is known as “collision tumor”. 

The same phenomenon is possible, but very rare, in limph nodes 

(“collision metastasis”). 

Carcinoma metastasizing to lymph nodes cointening a lymphoproliferative 

disorders has also been reported. 


Fig. 1. 

Fig. 2. 

Fig. 3.


To our knowledge, we report the first case of simultaneous occurrence 

of squamous cell carcinoma of the lung and clear cell 

renal cell carcinoma as a collision metastasis from both lesions in 

a peribronchial lymph node. 

Case presentation. The patient was a 74-year-old man, exsmoker, 

with an history of squamous cell carcinoma of the upper 

lobe of the right lung, for wich he underwent a lobectomy 

in 1993. 

In 2011, a chest Computed Tomography scan, revealed a mass in 

the upper lobe of the left lung. A PET scan followed the CT in 

order to identify metastases, with a negative result. 

The transbronchial biopsy confirmed the diagnosis of squamous 

cell carcinoma and a segmentary resection of the left lung was 

subsequently performed. 

rossly, the pulmonary parenchyma, showed a whitish and greyish 

mass, centrally necrotic and with polycyclic edges. The main size 

of the mass was 3 cm. The surrouding tissue presented stasis and 

atelectasis. During the gross examination 9 peribronchial lymph 

nodes were isolated. 

Histologically, the mass was a squamous cell carcinoma, without 

keratinization, moderately differentiated, with areas of comedonecrosis. 

This features were similar to these of the former 

tumor. 

Surprisingly, concurrent metastasis from a clear cell neoplasia 

were detected in six peribronchial lymph nodes, and one of this 

revealed also one metastasis from the squamous cell carcinoma. 

Himmunoistochemical studies were performed to characterize 

the clear cell neoplasia, that revealed the following phenotype: 

positivity for EMA, RCC, Vimentin; negativity for P63, CK7, 

CD68, HMB-45, Melan A, High molecular weight keratin. The 

squamous cell carcinoma was positive for p63, CK5/6; negative 

for RCC and CK20. 

The final diagnosis was the following: “Squamous cell carcinoma, 

moderately differentiated, non-keratinizing. One lymph 

node metastasis of squamous carcinoma and six of clear cell 

neoplasia”. 

A note suggested, into account of the different morphology and 

immunoistochemistry, a diagnostic evalutation of the urogenital 

system in order to exclude a clear cell renal cell carcinoma of 

the kidney. 

In this setting, an abdominal CT scan demonstrated a mass in the 

left kidney, engaging the ipsilateral adrenal gland. The patient underwent 

again to surgery. A radical nefrectomy with consensual 

removal of the adrenal gland were performed. 

Grossly, the lower pole of the kidney presented a variegated nodule, 

greyish, brownish and withish. The main size was 4,5 cm. 

The adrenal gland showed a multinodular aspect. 

The pathologic diagnosis was that of clear cell renal cell carcino- 

Fig. 4. 

Fig. 5. 

Fig. 6. 

343 

ma, G3-4 sec. Fuhrman, infiltrating the surrounding parenchyma 

and, initially, the renal capsule and the renal vein. 

The adrenal gland was uninfiltrated and showed cortical nodular 

hyperplasia. 

Discussion: Collision metastasis of lung and renal carcinoma is 

rare. We suggested the total body examination before surgery. 

In this case the patient made only a chest computed tomography 

scan and a PET that was negative for secondarism. The clinical 

hystory of patient suggested only a lung disease, and the nodule to 

the lung another lung carcinoma. Clear cell renal carcinoma is often 

negative to PET as in our case. The role of pathologist is been 

very useful to indicate clinicians the possibility of a secondarism. 

So the accurate sampling of lymph nodes revealed essential for 

final diagnosis. 

references 

1 Bhavsar T, Liu J, Huang Y. Collision Metastasis of Urothelial and 

Prostate Carcinoma to the Same Lymph Node: A Case Report and 

Review of the Literature. J Med Case Rep 2012;6:124. 

2 Zeng H, Liu C, Zeng YJ, et al. Collision metastasis of breast and thyroid 

carcinoma to a single cervical lymph node: report of a case. Surg 

Today 2012 Apr 7. 

3 Sadat Alavi M, Azarpira N. Medullary and papillary carcinoma of the 

thyroid gland occurring as a collision tumor with lymph node metastasis: 

A case report. J Med Case Rep 2011;5:590. 

4 Deshmukh M, Bal M, Deshpande P, et al. Synchronous squamous 

cell carcinoma of tongue and unicentric cervical Castleman’s disease 

clinically mimicking a stage IV disease: a rare association or coincidence? 

Head Neck Pathol 2011;5:180-3. 

5 Wahner-Roedler DL, Reynolds CA, Boughey JC. Collision tumors 

with synchronous presentation of breast carcinoma and lymphopro-

344 

liferative disorders in the axillary nodes of patients with newly diagnosed 

breast cancer: a case series. Clin Breast Cancer 2011;11:61-6. 

6 Lee HB, Park JC, Lee YS, etal. Unexpected synchronous follicular 

lymphoma of paraaortic and pelvic lymph nodes in a patient 

with endometrial carcinoma: a case report. Eur J Gynaecol Oncol 

2011;32:334-5. 

7 Pastolero G, Coire C, Asa SL, Concurrent Medullary and Papillary 

Carcinomas of Thyroid with Lymph Node Metastases: A Collision 

Phenomenon. American Journal of Surgical Pathology 1996;20:245- 

50. 

8 Zane KW, Shippey JE, Gregory A, et al. Collision Metastasis of Prostatic 

and Colonic Adenocarcinoma: Report of 2 Cases. Archives of 

Pathology & Laboratory Medicine 2004;128:318-20. 

9 Maher AS, Lama Z, Raffat A.S. Collision Metastasis of Breast and 

Ovarian Adenocarcinoma in Axillary Lymph Nodes: A Case Report 

and Review of the Literature. Pathology & oncology research 

2009;15:423-7. 

Toothpick pneumonia, a rare case in adult 

L. Gnetti1 , F. Brigati1 , R. Manuguerra1 , A. Casalini2 , M. Anghinolfi2 

, M. Majori2 , E.M. Silini1 1 Azienda Ospedaliero-Universitaria di Parma, Dipartimento Onco-Ematologico 

Internistico, Sezione di Anatomia Patologica; 2 Azienda Ospedaliero-Universitaria 

di Parma, dipartimento Cardio-Nefro-Polmonare, 

Sezione di Pneumologia ed Endoscopia Toracic. 

Introduction. We present a case of a 39-years-old black man 

with increasing dyspnea and acute respiratory failure initially 

treated for PNX with a pleural drainage. 

Case presentation. Routine chest radiographs revealed a layer of 

PNX in right lung and air space consolidation no better be characterized. 

We found in his history a computed tomography scan 

investigation, with and without contrast medium, made some 

months before for the same problems. The result was a suspected 

foreign body inhalation because CT scan showed the presence of 

area of thickening lung (maybe of inflammatory source), embedding 

a foreign tubular body with calcific density (bone?) inside 

the bronchus of the right lung. We subject the patient to flexible 

bronchoscopy to remove but the foreign body was so embedded 

in the granulation tissue that this reaction didn’t allowed the 

removal of the foreign body. Bronchial aspiration and biopsy 

demonstrated only an inflammatory granulomatous outcome. Due 

to clinical and radiological issue a simple pulmonary lobectomy 

was made. During the sampling we observed inside a bronchial 

branch a foreign wooden body of 28 mm surrounded by parenchimal 

lung with increased consistency. 

Results. The man developed a cronic pneumonia in organization, 

secondary an endobronchial foreign body. At the end, this 

strange, not characterizable foreign body was a toothpick that the 

patient inhalated ten years before. 

Discussion. Foreign pneumonia in adult is rare. The foreign body 

in our patient is also present ten year before to CT, but the patient 

didn’t performed a flexible bronchoscopy. The granulation tissue 

embedded the foreign body preventing the good performance of 

flexible bronchoscopy so the patient went to surgery. In this case 

Fig. 1. 


the sampling begin important to demonstrate the presence of foreign 

body and subsequently the cause of pneumonia. 

references 

1 Lai YF, Wong SL, Chao TY, et al. Bronchial foreign bodies in adults. 

J Formos Med Assoc 1996;95:213-7. 

2 Boyd M, Chatterjee A, Chiles C, et al. Tracheobronchial foreign body 

aspiration in adults. South Med J 2009;102:171-4. 

3 Yonker LM, Fracchia MS. Flexible bronchoscopy, Adv Otorhinolaryngol 

2012;73:12-8. 

4 Takenaka M, Hanagiri T, Ono K, et al. Management of patients with 

bronchial foreign bodies. J UOEH 2011;33:157-61. 

Type II congenital pulmonary airway malformation 

and intralobar pulmonary sequestration: 

a rare association due to a possible defect 

of endodermal/mesoderm development 

M.G. Mastrogiulio, A. Barone, M.R. Ambrosio, A. Ginori, 

A. Carbone, D. Spina 

Section of Pathological Anatomy, Department of Human Pathology and Oncology, 

University of Siena, Policlinico Santa Maria alle Scott, eSiena, Italy 

Background. Bronco-pulmonary malformations include a wide 

variety of abnormalities of the respiratory tract. Lesions are usually 

isolated; however, the association of two or more of them has 

been not rarely described. Their classification has been always 

somewhat problematic as well as their terminology. Congenital 

pulmonary airways malformations and pulmonary sequestrations 

have been included by Gerle (1968) into broncopulmonary 

foregut malformation. Today, there is a substantial agreement in 

the classification of congenital pulmonary airways malformations 

(CPAM). Type I CPAM is characterized by large, multiloculated 

cysts of more than 2 cm in maximum diameter; type II, presents 

cysts of less than 2 cm in maxim diameter; in type III, no macroscopically 

evident cysts can be detected. Pulmonary sequestration 

with systemic vascular connection is a well defined entity. The 

term defines a developmental malformation composed of isolated 

nonfunctioning lung segments with no communication with 

functional tracheobronchial elements of the surrounding lung. Its 

abnormal systemic arterial supply derives from either single or 

multiple vessels from the distal thoracic or proximal abdominal 

aorta or other arteries. Intralobar lung sequestration must be kept 

separate from extralobar sequestration (ELS), since it consists of 

aberrantly located pulmonary bud that develops apart from the 

normal lung. While type II CPAM is frequently associated with 

ELS, the concurrence of CPAM and ILS, although described 

in rare cases, is much more controversial. Herein we illustrated 

such an association, focusing on its pathogenic mechanism and 

classification. 

Materials and methods. A 30-year-old woman was evaluated 

by routine prenatal ultrasound scan (US) at 25 weeks of gestation. 

US showed the presence of multiple large cysts in the right 

lung of the fetus. Anamnesis was negative. A female was born 

by a full-term delivery. At birth, she presented an acute respiratory 

distress syndrome. Heart US showed a moderate left- right 

shunt due to septal interatrial defect. There was also an increased 

venous pulmonary return for a pulmonary sequestration. At chest 

multirow detector computed tomography (MDCT), a multicystic 

mass in the lower lobe of the right lung, was observed. The largest 

cyst was of 23 mm of diameter and presented air-fluid level. 

The mass showed a systemic blood supply from a large arterious 

vessel originating from the abdominal aorta. An enlarged right 

lower pulmonary vein drainage it. A small ectopic bronchus for 

the superior lobe was detected on the right side of the trachea. A 

right lower lobectomy through a postero-lateral thoracotomy was 

performed at the age of 4 month. Post surgery course was free of 

complications. 

Results The surgical specimen consisted of right lower lobe 

measured 7x5x6 cm. In the congested, red-wine basal posterior


segment, at the transition between thoracic and diaphragmatic 

surface, a systemic artery (5 mm in maximum diameter) was 

identified. It branches into the basal pyramid. There was no 

well defined separation between the territory supplied by these 

branches and the remaining lung parenchyma. The cut surface of 

the lung parenchyma showed multiple dilated spaces ranging in 

size from few millimeters to 2 centimeters, 15 of them being more 

than 1 cm in greatest dimension. The intervening normal parenchyma 

was tan-pink colored. The cysts were sometimes encircled 

by a thin wall with the inner surface lined by a translucent mucosa 

without any papillary projections or exudates. The apical segment 

was normal. On microscopic examination, the walls of the cysts 

was 150 micron thick. They were formed by a central area rich 

in blood vessels and lymphatics, separated from the epithelial inner 

layer by bundles of smooth muscle (30 micron thick). Most 

of the cysts were lined by a monostratified ciliated epithelium. 

In some areas, small, sparse islands of cartilage were observed. 

The walls of the cysts were generally smooth, however, a few of 

them had a small number of papillary projections. Mucinous cells 

and striate muscle cells were absent. Pleural blood vessels were 

congested and lymphatic vessels were dilated. Abnormal arterial 

vessel branches were thick and contained uninterrupted, circular 

elastic fibers, as do the normal elastic arteries. They irregularly 

branched into the basal posterior segment, sometimes forming 

conglomerates of contiguous, large vessels not orderly connected 

with the adjacent cystic parenchyma. The parenchyma adjacent 

to the systemic artery branches showed congestion and areas of 

hemorrhagic infarction. Basal segments of the arterial vessels 

were hypoplasic. The epithelial cells lining the cysts showed the 

immunophenotye of bronchiolar epithelial cells: basal positivity 

for p63 and CK5 and apical positivity for TTF1 and CK7. They 

were also positive for D2-40, as were the endothelial cells of the 

lymphatics. No lesions were showed in the apical segment. 

Conclusions. In the case herein described two lesions were present 

in the inferior lobe of the right lung, the type II congenital 

airway malformation (CPAM type II) and the intralobar sequestration 

(ILS), diagnosed on a fetus at 25 weeks of gestation. Both 

lesions were in the basal segments of the right inferior lobe. 

CPAM is frequently associated with bronchial atresia and ELS. 

On the contrary, it is very rarely associated with ILS. Is this latter, 

although very rare, association accidental or due to a pathogenetic 

connection? It is known that, during the development, lung buds 

are enveloped in a continuous mesenchymal background. At an 

early stage, vessels form the foregut-mesodermal pulmonary 

plexus, which is connected with the branchial arteries and, after 

the 13 th week, with the pulmonary arteries. Later on, these connections 

regress. All these stages regulated by molecular interactions 

between mesoderm and endoderm. It may be that these 

interactions are abnormal leading to a endodermal development 

block and, morphologically, to a pseudoglandular pattern. Abnormalities 

of the mesodermal component may prevent the connection 

of the pulmonary plexus with the pulmonary arteries and may 

determine the persistence of the connection with the systemic 

arteries. In fact, in the case herein illustrated, pulmonary vessels 

are hypoplasic in the basal segments. Moreover, the expression in 

our case of the oncofetal antigen M2A (a sialoprotein of the cell 

surface) in the epithelial cells lining the cysts, like the expression 

described in the basal cells of bronchi and bronchiole, confirms a 

possible defect of mesoderm development. Whether this hypothesis 

was true, CPAM might not be an amartomatous lesion since 

it would be not site-dependent but time-dependent. The criterion 

of the time-related endodermal/mesodermal abnormality, might 

be used, in agreement with Clement et al (8), for the classification 

of the “broncopulmonary foregut malformation”. 

references 

Lee ML, Tsao LY, Chaou WT, et al. Yang, Kun-Tu Yeh, Jou-Kou Wang, 

Mei-Hwan Wu, Hung-Chi Lue, Ing-Sh Chiu and Chung-I Chang. 

Revisit on congenital bronchopulmonary vascular malformation: a 

345 

haphazard branching theory of malinosculations and its clinical classification 

and implication. Pediatric Pulmonology 2002;33:1-11. 

Jin ZW, Nakamura T, Yu HC, et al. Fetal anatomy of peripheral lymphatic 

vessels: a D2-40 immunohistochemical study using an 18-week 

human fetus (CRL 155 mm). J Anat 2010;216:671-82. 

Kambouchner M, Bernaudin J-F. Intralobular Pulmonary Limphatic Distribution 

in Normal Human Lung Using D2-40 Antipodoplanin Immunostaining. 

Journal of Histochemistry & cytochemistry 2009;57:643-8. 

Langston C. New concepts in the pathology of congenital lung malformations. 

Seminars in Pediatric Surgery 2003;12:17-37. 

Corbett HJ, Humphrey GME. Pulmunary sequestration. Paediatric Respiratory 

Review 2004;5:59-68. 

Couluris M, Schnapf BM, Gilbert-Barness E. Intralobar Pulmonary 

Sequestration Associated With A Congenital Pulmonary Airway 

Malformation Type II. Fetal and Pediatric Pathology 2007;26:207-12. 

Pulmonary adenocarcinoma metastatic 

to the appendix: an additional case 

V. Mourmouras1 , M.R. Ambrosio2 , B.J. Rocca2 , S. Giunti1 , 

A. Amorosi1 1 2 Centro Oncologico Fiorentino, Sesto Fiorentino; Departement of Human 

Pathology and Oncology, Anatomic Pathology Section, University of 

Siena, Italy 

Background. Malignant tumors of the appendix are rare and metastatic 

neoplasms of the appendix are very uncommon manifestations. 

Of all the cases that have been reported so far, metastatic 

malignancies have been carcinomas of the breast, lung, pancreas, 

kidney and ovary. We herein describe another case of lung adenocarcinoma 

metastatic to the vermiform appendix. 

Material and methods. A 57 year-old white male was admitted 

in the hospital with a 4-day history of right lower quadrant pain. 

The abdomen was tender over McBurney’s point with rebound 

tenderness, and the psoas sign, as well as Rovsing’s sign and 

the obturator sign were positive. The white blood cell count was 

elevated (13.500/µL). Immediate laparotomy, carried out for a 

suspect clinical diagnosis of acute appendicitis, showed localized 

peritonitis. The appendix was perforated and it was obstructed by 

a firm nodule at the distal portion. The postoperative course was 

uneventful. His medical history indicated that 2 years earlier he 

had undergone upper right lung lobectomy due to a lung adenocarcinoma. 

Results. The surgical specimen consisted of a 12 cm-long ileocecal 

specimen, with an appendix measuring 7 cm, covered by 

a yellowish brown exudate. Serial sectioning through the distal 

portion of the appendix showed a whitish, firm nodule measuring 

4.5 cm, which caused marked narrowing of the lumen in this region. 

At the same area a perforation of the wall was found. Histopathologic 

examination showed intact mucosa with an underlying 

adenocarcinoma, appearing as solid and papillary nests, infiltrating 

all the layers of the appendiceal wall, reaching the visceral 

serosa, without penetrating it. Surgical margins were negative and 

regional lymph nodes were free of tumor. Immunohistochemical 

evaluation showed positivity of the neoplastic cells for CK7, 

TTF-1, Napsin-A, and negativity for CK20, as well as CDX2. On 

morphological and immunophenotypical basis the diagnosis of a 

metastatic lung adenocarcinoma was made. 

Conclusion. Tumors of the appendix are very rare, with the majority 

being primary appendiceal malignancies such as carcinoid 

and adenocarcinoma. Metastatic disease to the vermiform appendix 

is an infrequently seen subset of these lesions, with the most 

common primaries being breast, lung, pancreas and kidney. An 

extensive search of the literature showed reports of lung carcinoma 

metastatic to the vermiform appendix to be extremely rare, 

being described only one previous case of pulmonary adenocarcinoma 

metastatic to the appendix. We report an additional case 

of appendiceal metastasis of lung carcinoma, which clinically 

simulated an acute appendicitis. Although this clinical scenario 

is uncommon, it is important for surgeons to bare in mind that

346 

malignancy, either primary or metastatic, can be the cause of 

obstruction and appendicitis in a small but important subpopulation 

of patients. 

references 

Goldstein EB, Savel RH, Walter KL, et al. Extensive stage small cell lung 

cancer presenting as an acute perforated appendix: case report and 

review of the literature. Am Surg 2004;70:706-9. 

Wolf C, Friedl P, Obrist P, et al. Metastasis to the appendix: sonographic 

appearance and review of the literature. J Ultrasound Med 

1999;18:23-5. 

Gopez EV, Mourelatos Z, Rosato EF, et al. Acute appendicitis secondary 

to metastatic bronchogenic adenocarcinoma. Am Surg 1997;63:778- 

80. 

Pang LC. Metastasis-induced acute appendicitis in small cell bronchogenic 

carcinoma. South Med J 1988;81:1461-2. 

Levchenko AM, Vasechko VN, Erusalimskiĭ EL. Metastasis of small-cell 

lung cancer to the appendix. Klin Khir 1985;5:56-7. 

Dieter RA Jr. Carcinoma metastatic to the vermiform appendix: report of 

three cases. Dis Colon Rectum 1970;13:336-40. 

Morphological, immunohistochemical 

and cytogenetic characterization of lung 

adenocarcinomas with enteric differentiation 

A. Nottegar1 , M. Brunelli1 , S. Cingarlini2 , C. Oliosi2 , E. Brunello1 , 

S. Pedron1 , C. Doglioni3 , L. Montagna1 , C. Luchini1 , G. Martignoni1 

, M. Chilosi1 1 University of Verona, Department of Pathology and Diagnostic, Verona, 

Italy; 2 University of Verona, Department of Medical Oncology, Verona, 

Italy; 3 San Raffaele Scientific Institute, Milan, Italy 

Introduction. Pulmonary adenocarcinoma with enteric differentiation 

is described as a variant which shows some histological 

and/or immunohistochemical similarities with colorectal adenocarcinoma 

1, 2 . The International Multidisciplinary Classification 

of Lung Adenocarcinoma defines an adenocarcinoma in which 

the enteric component exceeds 50% 3 . We sought to evaluate the 

morpho-immunophenotypical differentiation in a series of pulmonary 

adenocarcinomas with CDX2 expression. Moreover, we 

gained insight their molecular profile. 

Materials and methods. We analyzed the morphological subtype 

(solid, acinar, papillary, lepidic, mucinous, intestinal and 

mixed subtypes), the immunohistochemical expression of CK7, 

CK20, MUC5 and villin and the EGFR and K-ras mutations of 

43 pulmonary adenocarcinoma which were immunoreactive for 

CDX-2 (23 on specimen and 20 on biopsy). ALK locus was also 

assessed by FISH. 

The percentage of cells positive for CDX-2 was scored as 1 (1- 

10%), 2 (11-25%), 3 (26-50%) and 4 (> 50%). 

Results. The majority of the pulmonary adenocarcinomas showed 

a mixed type (17/43) and had a CDX-2 score 2 (16/43) and 3 

(13/43). 4/43 cases revealed a CDX-2 score 4. 

All the cases were immunoreactive for CK7, 8/24 expressed also 

CK20 and 24/33 MUC5. 

Villin was expressed in 26/43 cases but lacked especially in the 

solid variant and in the solid component of mixed histotypes. 2/27 

cases showed an ALK-translocation. 

EGFR mutation were observed in 10% of cases (2/19) and K-ras 

mutation in 50% of cases (12/24). 

Conclusions. We recognize a significant subset of pulmonary 

adenocarcinomas with a CDX-2 immunoexpression in less than 

50% of neoplastic cells. This subset shows in part immunoexpression 

for villin and MUC5 such as usually do the colonic 

adenocarcinomas. Interestingly, adenocarcinomas with CDX-2 

immunoreactivity have an higher percentage of K-ras mutation 

when compared with other lung adenocarcinomas, differently 

to the EGFR and ALK that show the same percentage to other 

subtypes. The prognosis and the overall clinical impact of this 

heterogeneous group of adenocarcinomas with such aforementioned 

features merit further investigation. 


references 

1 Mazziotta RM BA, Powell CA, Mansukhani M. CDX2 immunostainig 

as a gastrointestinal marker. Expression in lung carcinomas is a potential 

pitfall. Appl Immunohistochem Mol Morphol 2005;13:55-60. 

2 Inamura K, Satoh Y, Okumura S, et al. Pulmonary adenocarcinomas 

with enteric differentiation: histologic and immunohistochemical 

characteristics compared with metastatic colorectal cancers and usual 

pulmonary adenocarcinomas. Am J Surg Pathol 2005;29:660-5. 

3 Travis WD BE, Noguchi M, Nicholson AG, et al. International Association 

for the Study of Lung Cancer/American Thoracic Society/ 

European Respiratory Society: international multidisciplinary classification 

of lung adenocarcinoma: executive summary. Proc Am Thorac 

Soc 2011;8:381-5. 

Histo-cytological diagnostic accuracy in lung cancer 

A. Proietti1 , L. Boldrini1 , G. Alì2 , A. Servadio1 , C. Lupi2 , E. Sensi2 , 

A. Ribechini3 , A. Chella4 , M. Lucchi5 , P. Leocata6 , A. Mussi7 , 

G. Fontanini1 1 Unit of Pathologic Anatomy, Department of Surgery, University of Pisa, 

Pisa; 2 Unit of Pathologic Anatomy, Azienda Ospedaliera Universitaria 

Pisana, Pisa; 3 Unit of Thoracic Endoscopy, Azienda Ospedaliera Universitaria 

Pisana, Pisa; 4 Unit of Pneumology, Azienda Ospedaliera Universitaria 

Pisana, Pisa; 5 Unit of Thoracic Surgery, Azienda Ospedaliera 

Universitaria Pisana, Pisa; 6 Unit of Pathology, Experimental Medicine 

Department, University of L’Aquila, L’Aquila; 7 Unit of Thoracic Surgery, 

Cardiothoracic Department, University of Pisa, Pisa 

Introduction. Lung cancer is the leading cause of cancer-related 

death worldwide, and non-small cell lung cancer (NSCLC) 

accounts for approximately 80% of these cases 1 . In clinical 

practice, however, only 10-15% of all tumors are resected. As 

a consequence, a majority of patients are treated on the basis 

of a diagnosis made from the analysis of a single, small tumor 

biopsy or cytological sample. In recent years, histotype has been 

shown to be a critical variable in clinical decision making, and 

has led to the introduction of newer biologically targeted therapies 

for advanced disease and the development of specifically 

tailored systemic treatments 2 . Consequently, simply classifying 

cancers as SCLC or NSCLC is no longer sufficient. Using this 

recommendation, a diagnosis of NSCLC-not otherwise specified 

(NOS) should be rendered in less than 5% of all cases. Several 

recent studies have analyzed how different panels of immunohistochemical 

markers may be helpful for defining a specific cell 

lineage. and have shown that ADC and SCC have virtually nonoverlapping 

coexpression profiles of thyroid transcription factor 

1 (TTF-1) and p63, respectively. Nevertheless, there is no agreement 

on the use of additional markers. In this study, we evaluated 

the concordance and accuracy of subtyping SCLC and NSCLC, 

including both ADC and SCC, through cytology or small biopsy 

specimens that were obtained during a single procedure in the 

context of our routine practice. Moreover, we compared the diagnostic 

accuracy of surgical specimen diagnosis and immunohistochemical 

(IHC) panels. We appraised the frequency with which 

IHC is used to aid the diagnosis, and compared the specificity and 

sensibility among a selected group of commercial antibodies. We 

also determined whether cytologic and bioptic materials are suitable 

for somatic EGFR and K-RAS genotyping. 

Materials and methods. A review of the histo-cytological database 

was conducted to identify all small biopsy and cytology 

specimens collected for diagnostic purposes in patients with a 

thoracic lesion from 2009 to 2011. In total, 941 patients were 

studied by examining exfoliative and aspirative cytological 

samples. To establish the accuracy of these methods, cytological 

and biopsy diagnoses were compared with subsequent resection 

specimens take at the time of diagnosis. A panel of the following 

immunohistochemical markers was used during the diagnostic 

workup according to validated protocols for NSCLC and SCLC: 

TTF-1, p63, CK34βE12, and CD56. The cytological and bioptical 

diagnoses were then subdivided. Non-neoplastic samples were


defined as “negative”, and neoplastic samples were defined as 

“positive”, “suspicious” or “unclassified” based on the degree of 

diagnostic certainty. Molecular testing for EGFR (exons 18-21) 

and K-RAS (codons 12 and 13) mutations was performed on 231 

positive samples that were judged as adequate (easily identifiable 

tumor cells by light microscopy, with tumor cells representing at 

least 25% of overall cellularity) by the pathologists 20 . All statistical 

analyses were performed using statistical software (JMP® 

8.0.2). A Chi-square test was used to analyze the associations between 

the different variables, and the a priori level of significance 

was set at a p-value of less than 0.05. 

Results. In total, 210 out of the 941 (22.3%) total cytological 

samples were negative for neoplasia, 36 (3.8%) were suspicious 

and 695 (73.9%) were positive for neoplasia. Among the latter 

group, 632 cases (632/695, 90.9%) were primitive lung tumors. 

Five hundred twenty-three cases were classified as NSCLC 

(523/695, 75.2%), 105 (105/695, 15.1%) were diagnosed as 

SCLC, and 67 (67/695, 9.7%) were diagnosed as “other” malignancies. 

NSCLC samples were recorded as adenocarcinomas in 

247 (247/523, 47.2%) cases and squamous cell carcinomas in 198 

(198/523, 37.9%) cases. Seventy-eight cases (78/523, 14.9%) were 

diagnosed as NSCLC-NOS. In addition, we compared the degree 

of diagnostic certainty achieved by exfoliative cytology to that 

achieved by aspirative cytology (FNA). In particular, we found 

that when subtyping NSCLCs, there was a statistically significant 

difference between the two techniques, with exfoliative cytology 

showing higher accuracy in both SCCs and ADCs (p < 0.0001 and 

p = 0.0018, respectively). In contrast, in NSCLC-NOS and SCLCs, 

neither method produced stronger diagnostic certainty (p > 0.05). 

Bioptical histological evaluation was conducted in 439 cases. 

Seventy-four cases (74/439, 16.8%) were negative for neoplasia, 

3 cases (3/439, 0.7%) were suspicious and 362 cases (362/439, 

82.5%) were positive for neoplasia. Among the neoplastic group, 

335 (335/362, 92.6%) were primitive lung tumors, 243 (243/362, 

67.1%) were NSCLC, 75 (75/362, 20.7%) were SCLC, and 44 

(44/362, 12.2%) were defined as “other”. Ninety of the NSCLC 

cases were adenocarcinomas (90/243, 37%), 140 (140/243, 57.6%) 

cases were SCC, and 13 (13/243, 5.4%) cases were diagnosed as 

NOS. Next, we compared the cytological and bioptical diagnosis 

with the subsequent histological diagnosis. There was a statistically 

significant correlation between cytological and histological diagnoses 

and bioptical and surgical diagnoses (p < 0.001). Two hundred 

two of 941 cases (23.6%) could not be subtyped based on the morphology 

of cytological specimens, but after analysis with IHC, a 

tumor subtype was identified. Histological correlation revealed that 

92.8% of IHC-aided diagnoses were correct. Sixteen of 941 cases 

(16/941, 1.7%) could not be subtyped by morphology or by IHC, 

and all of these cases were diagnosed as NSCLC-NOS. We next 

focused on cases that required IHC support for the final diagnosis. 

We found that this approach was able to provide a diagnosis for 

cytological specimens in ADC (p = 0.0168), SCC (p < 0.0001) and 

SCLC (p = 0.0003). However, in NSCLC-NOS, IHC did not verify 

a subtype in 17 of 22 cases (p < 0.0001). For bioptical samples, 

we demonstrated that immunohistochemical stains were able to 

correctly diagnose all of the SCC (p = 0.005) and SCLC cases 

(p = 0.0358). In contrast, IHC was useless in ADC (p = 0.86), and 

it did not aid in the subtyping of NSCLC-NOS (p < 0.0001).Of 

the 231 analyzable specimens, EGFR and KRAS mutations were 

identified in 29 (12.5%) and 62 (31.8%) cases, respectively. Of the 

samples tested, we found that only 4 specimens were inadequate 

for molecular analysis due to insufficient cellularity (4/179, 2.2%), 

and all of these specimens were cytological samples. 

Discussion. The purpose of this study was to directly compare 

the efficacy of lung cancer subtyping in cytology and bioptical 

samples, using IHC to subtype morphologically challenging 

cases. Few studies have been published concerning the accuracy 

of cytology 3 . Despite this lack of data, differentiating 

NSCLC from SCLC and ADC from SCC is becoming extremely 

347 

important and has significant therapeutic implications 4 . Our 

study demonstrates that preoperative diagnoses and subtyping 

in lung cancer are highly accurate, as the diagnostic results of 

these methods were highly concordant with those obtained from 

surgical samples (p < 0.001). Furthermore, we confirmed prior 

observations that endoscopic specimens are highly accurate for 

distinguishing NSCLC from SCLC (p < 0.001). In our study, 

although the subtyping of NSCLC was found to be significantly 

accurate (p < 0.001), it required further inquiry. However, we 

found a low rate of unclassified specimens both in cytology and 

biopsy samples (1.7% and 2.7%, respectively) and this observation 

could be attributable, in part, to the routine utilization of 

IHC staining to aid morphological interpretation. This approach 

has been incorporated into routine practice in recent years, and it 

is recommended in the most recent IASLC/ATS/ERS ADC classification 

proposal 5 . In contrast with previous reports 6 , we found 

that the differentiation of ADC and SCC is not more evident in 

cytological specimens than in small biopsies. In particular, we observed 

that a comparable number of cases required IHC analysis 

to identify a tumor type by both methods, despite having a similar 

degree of certainty and accuracy in NSCLC subtyping. Nevertheless, 

IHC staining of cytological specimens was able to verify the 

diagnosis in NSCLC, ADC, SCC, and SCLC, whereas it was not 

decisive for the correct final diagnosis in ADC and added nothing 

to the morphological diagnosis in bioptical samples. Moreover, 

comparison of exfoliative and aspirative cytology indicated that 

the first method is a more sensitive diagnostic tool, particularly 

for SCC. In our study, we applied IHC stains according to validated 

protocols for NSCLC and SCLC. Our results revealed that the 

diagnostic accuracy (92.8% in both cytology and biopsy) could 

be improved through the introduction of new antibodies, such as 

napsin A, that may be helpful when TTF-1 staining is equivocal. 

Finally, we found that in a large screen of cytologic and bioptic 

specimens submitted for molecular testing, 98% of samples were 

suitable for analysis, similar to data reported in other studies 10 . 

In conclusion, we found that lung cancer diagnosis and subtyping 

of cytologic and bioptic samples are highly feasible and accurate, 

particularly when supported by IHC analysis. 

references 

1 Weir H, Thun M, Hankey B, et al. Annual report to the nation on the 

status of cancer, 1975-200, featuring the uses of surveillance data for 

cancer prevention and control. J Nat Cancer Inst 2003;95:1276-99. 

2 Hirsh FR, Spreafico A, Novello S, et al. The prognostic and predictive 

role of histology in advances nonsmall cell lung cancer: a literature 

review. J Thoracic Oncol 2008;3:1468-81. 

3 Vazquez MF, Koizumi JH, Henschke CI, et al. Reliability of cytologic 

diagnosis of early lung cancer. Cancer 2007;111:252-8. 

4 Mok TS, Wu YL, Thonprasert S, et al. Gefitinib or carboplatin-placitaxel 

in pulmunary adenocarcinoma. N Engl J Med 2009;361:947-57. 

5 Travis WD, Brambilla E, Noguchi M, et al. International association 

for the study of lung cancer/American thoracic society/European respiratory 

society international multidisciplinary classification of lung 

adenocarcinoma. J Thorac Oncol 2011;6:244-85. 

6 Sigel CS, Moreira AL, Travis WD, et al. Subtyping of non-small-cell 

lung carcinoma. A comparison of small biopsy and cytology specimens. 

J Thorac Oncol 2011;6:1849-56. 

Serum and pleural effusion mesothelin detection 

for the non-invasive diagnosis of malignant 

pleural mesothelioma 

S. Roncella1 , P.A. Canessa1 , P. Ferro1 , E. Battolla1 , P. Dessanti1 , 

L. Chiaffi1 , B. Bacigalupo1 , R. Pezzi2 , V. Fontana2 , M.C. Franceschini3 

, M.P. Pistillo2 , F. Fedeli1 1 2 ASL5 “Spezzino”, La Spezia; IRCCS A.O.U. San Martino, IST, Genova; 

3 AIL, Sezione Francesca Lanzone, La Spezia, Italy 

Background. Malignant pleural mesothelioma (MPM) 1 is an 

asbestosis related tumour with rapidly increasing incidence 

worldwide, including the provinces of Genova and La Spezia 2 .

348 

The histological analysis of thoracoscopic biopsies is regarded as 

the diagnostic reference (gold standard) for the diagnosis of PE 

as it has been reported to have 100% specificity for malignancy 

and over 94% diagnostic sensitivity. 

However, biopsy is an invasive method which should be avoided 

where possible. Soluble mesothelin-related peptide (SM) is an 

FDA approved biomarker for diagnosing and monitoring MPM 3 . 

The aim of our study was to analyse the serum and the PE levels 

of SM in patients undergoing pleural biopsy, in order to assess the 

SM contribution to the-non invasive diagnostic work-up of MPM. 

Methods. We evaluated SM at the cut-off levels of 1.08 nM for 

serum (as reported in kits book) and 9.30 nM for PE (as found in 

our previous studies, ref. 4). Both specimens drawn at the same 

time from 81 patients included 33 MPM, 29 benign lesions (Bng) 

and 19 non-MPM pleural metastasis (Mts). SM levels were measured 

by the “MesoMark” ELISA assay kit (Cis-Bio International 

Gif/Yvette; France) according to manufacturers’ instructions. All 

samples were tested in duplicate. 

To effected immunohistochemistry, 5-µm thick paraffin sections 

were mounted on slides and deparaffinized. We performed immunohistochemistry 

using the PATHWAY kit by Benchmark XT 

system (Ventana). Strong reactivity for calretinin and cytokeratin 

5/6 associated with negative reactivity for carcinoembryonic 

antigen (CEA), epithelial membrane antigen (EMA) and thyroid 

transcription factor 1 (TTF1-1) are considered to be supportive of 

the diagnosis of MPM. 

All statistical analyses were performed using Stata (StataCorp. 

Stata Statistical Software Release 11.2 Stata Corporation, College 

Station, TX, 2007). 

Results. Patients with MPM were found to have significantly 

lower SM levels in serum (median 1.37 nM) as compared to PE 

(median 28.20 nM). Both these SM levels were higher than the 

levels found in specimens from patients with Mts (median 0.51 

nM and 3.05 nM, respectively) or Bng (median 0.35 nM and 5.00 

nM, respectively). 

By ROC curve analysis, serum SM in MPM vs Mts yelded an 

AUC of 67.2 (P < 0.020, Se = 57.6%, Sp = 73.7%) and MPM 

vs Bng yielded an AUC of 74.3 (P-value < 0.001, Sp = 89.7%). 

In contrast, SM in PE MPM vs Mts yelded an AUC of 80.5 

(P < 0.001, Se = 78.8%, Sp = 78.9%) whereas MPM vs Bng 

yielded an AUC of 81.0 (P-value < 0.001, Sp = 82.8%). 

We found SM levels ≥ cut off in serum of 19/33 (57.6%) MPM patients, 

in 3/29 (10.3%) of patients with Bng (DOR = 11.8, P-value 

< 0.001) and in 5/19 (26.3%) of patients with Mts (DOR = 3.8, 

P-value < 0.020). In contrast, PE showed SM levels ≥ cut off in 

26/33 (78.8%) MPM, in 5/29 (17.2%) Bng (DOR = 17.8, P-value 

< 0.001) and in 4/19 (21.1%) Mts (DOR = 13.9, P-value < 0.001). 

Finally, in MPM the SM tests in serum and PE showed concordant 

results in 22/33 (66.6%) patients (17 positive sera/PE; 5 

negative sera/PE). In contrast, discordant results were found in 

11/33 (33.4%) MPM (9 positive PE/negative sera; 2 negative PE/ 

positive sera). 

Discussion. An increased level of SM in PE and/or serum can 

help the diagnosis of MPM. Positive SM results would suggest 

the need for further invasive investigations, such as thoracoscopy 

and histology. 

references 

1 Borasio P, Berruti A, Billé A, et al. Malignant pleural mesothelioma: 

clinicopathologic and survival characteristics in a consecutive series 

of 394 patients. Eur J Cardiothorac Surg 2008;33:307-13. 

2 Gennaro V, Ugolini D, Viarengo P, et al. Incidence of pleural 

mesothelioma in Liguria Region, Italy (1996-2002). Eur J Cancer 

2005;41:2709-14. 

3 Robinson BW, Creaney J, Lake R, et al. Mesothelin-family proteins 

and diagnosis of mesothelioma. Lancet 2003;362:1612-6. 

4 Fedeli F, Canessa PA, Ferro P. et al. Detection of solubile mesothelinrelated 

peptides as diagnostic markers of malignant pleural mesothelioma 

effusions. USCAP 2012. Laboratory Investigation 2012;92(Suppl. 

1):Abs n.362. 


nuclear magnetic resonance (nMr)-based 

catabolomic profiling of pleural effusions 

F. Simonato1 , R. Cappellesso1 , P. Vanzani2 , M. Fassan1 , M. Pivato1 , 

A. Olivotto1 , M. Siri1 , L. Zennaro2 , A. Fassina1 1 Department of Medicine, DIMED, Surgical Pathology & Cytopathology 

Unit; 2 Dept. of Biological Chemistry, University of Padova, Italy 

Background. Lung cancer (LC) is the leading cause of cancer 

death worldwide and Non Small Cell Lung Cancer (NSCLC) is 

the main histopathological category (75-80%), including squamous 

cell carcinoma (SCC), adenocarcinoma (AdC) and largecell 

carcinoma subtypes (Califano et al., 2012). SCC and AdC 

account respectively for 42% and 39% of the LC cases. Treatment 

and prognosis depend on the histological type of cancer, the 

stage, and patients’ Performance Status. The introduction of new 

targeted chemotherapic drugs (i.e. tyrosine kinase or angiogenetic 

inhibitors) mandatorily requires the exact definition of LC histotypes 

(Carter and Giaccone, 2012). 

Although often asymptomatic, AdC first presentation may be a 

pleural effusion (PE) (Light RW, 2011). PE is an aberrant accumulation 

of fluid between the two pleural layers; it can be sub-classified 

in transudate and exudate based on the chemical composition 

(protein, lactate dehydrogenase [LDH], albumin, amylase, pH, 

and glucose). The low cell number and the small protein amount 

characterize transudates, resulting from imbalances in hydrostatic 

and oncotic forces across an intact mesothelial barrier (as in heart 

failure or cirrhosis) On the other hand, exudates occur more frequently 

in patients affected by pneumonia or malignancy. Changes 

in metabolism result in modified metabolite composition (chemical 

compounds which are the end products of cellular processes in 

living organisms), and future efforts should be done to characterize 

different metabolomic profiles as novel diagnostic tools. 

Few studies investigated the NMR-based metabolomics (metabolites 

composition) in fluids: i) in human maternal urine and blood 

plasma to study new metabolites markers with predictive value 

for prenatal disorders (Diaz SO, et al., 2011) ii) in urine of rats 

that underwent partial hepatectomy to follow the liver regeneration 

(Bollard et al., 2010). 

Material and methods. In this work we investigated the metabolic 

profiling of PE by using Nuclear Magnetic Resonance (NMR), in 

order to identify significant metabolic biomarkers able to discriminate 

between AdC PE and non neoplastic PE. Unlike other spectrometric 

techniques (as mass spectrometry), NMR can quantify 

compounds in mixtures, as well as to identify unknown metabolites. 

Results. We collected 40 PE samples from heart failure transudates 

and 40 samples from AdC exudates. We added an additional 

buffering at pH 7.4 to the specimens in order to normalize 

the samples at a same pH. 1H NMR spectra were recorded at both 

300MHz and 600MHz, on a Bruker Avance III spectrometer 

equipped with a Z gradient unit, and processed with Topspin 

software (v. 3.1). 

Acquisition of the NMR spectra was carried out to verify eventual 

intra- and inter- individual variations in metabolic profiles 

of AdC and non-neoplastic PEs and identified new molecular 

biomarkers. 

references 

Bollard ME, Contel NR, Ebbels TM, et al. NMR-based metabolic profiling 

identifies biomarkers of liver regeneration following partial hepatectomy 

in the rat, J Proteome Res 2010;9:59-69. 

Califano R, Abidin AZ, Peck R, et al. Management of small cell lung 

cancer: recent developments for optimal care, Drugs. 2012;72:471-90. 

Carter CA, Giaccone G. Treatment of nonsmall cell lung cancer: overcoming 

the resistance to epidermal growth factor receptor inhibitors. 

Curr Opin Oncol 2012;24:123-9. 

Diaz SO, Pinto J, Graça G, et al. Metabolic biomarkers of prenatal disorders: 

an exploratory NMR metabonomics study of second trimester 

maternal urine and blood plasma. J Proteome Res 2011;10:3732-42. 

Light RW. Pleural effusions. Med Clin North Am 2011;95:1055-70.


TESTA COLLO 

Lymphoepithelioma-like carcinoma of the parotid 

gland: a case report and a brief review 

of the western literature 

M.R. Ambrosio, M.G. Mastrogiulio, A. Barone, B.J. Rocca, 

A. Sacchini, C. Cardone, C. Bellan 

Department of Human Pathology and Oncology, Anatomic Pathology Section, 


Background. Salivary gland neoplasms comprise less than 3% of 

all neoplasms of the head and neck region. Eighty percent occur 

in the parotid gland, of which approximately 80% are benign and 

20% are malignant. An exception is represented by the Eskimo 

population, in which 60% of the parotid gland tumors are malignant, 

the majority being lymphoepithelial-like carcinoma (LE- 

LC). LELC is analogous to lymphoepithelial carcinoma (LE) of 

the nasopharynx which is very common among Southern China 

inhabitants. LE is a poorly differentiated carcinoma composed of 

sheets of large atypical epithelial cells intermingled with a benign 

inflammatory infiltrate that is rich in lymphocytes and plasma 

cells. It is equivalent to type 3 nasopharyngeal carcinoma according 

to the World Health Organization classification. A consistent 

feature is the association of this type of carcinoma with Epstein- 

Barr virus (EBV), which is detectable in all tumour cells. EBV is 

detected in LELCs arising in organs of foregut derivation and in 

Asian women but rarely in LELCs of other sites or in non-Asian 

patients. Two thirds of LELC arise de novo, whereas the remaining 

develop in the setting of a preceding or concurrent benign 

lymphoepithelial lesion. To the best of our knowledge, only 7 

cases of this unusual cancer occurring in the salivary glands have 

been described in Western population and only in three cases 

EBV encoded RNAs (EBER) was positive. Herein, we present 

the fourth case associated with EBV infection. 

Materials and methods. A 45-year-old woman was admitted 

to Siena University Hospital for evaluation of a pre-existent (2 

years) painless and tender submandibular mass, which was rapidly 

enlarged in the last two months. She denied any history of 

facial weakness, cervical lymphadenopathy, or recent fever, tooth 

extraction or trauma. On physical examination, a 2.5-cm mass 

was found in the right parotid. It was firm, mobile and non-tender. 

Nuclear magnetic resonance (NMR) detected a 25x15x10 mm 

well-circumscribed lesion in the deep lobe of the right parotid. A 

right total parotidectomy with dissection of a satellite lymph node 

was performed. Tissue sections (4-µm thick) were cut and stained 

with haematoxylin and eosin. Immunohistochemical stains were 

performed on other sections of each block and the following 

antibodies were checked: CD3, CD20, CD10, CD30, vimentin, 

CK20, CK7 and Ki-67. In situ hybridization was performed on 

sections from formalin-fixed, paraffin-embedded samples using 

an oligonucleotide probe for EBER. On the basis of morphological, 

immunohistochemical and molecular biology findings, a 

diagnosis of stage II (according to TNM7) EBV-positive, undifferentiated 

LELC of the parotid gland was made. Eight months 

after surgery the patient is free of disease, as confirmed by NMR. 

Results. At gross examination, the parotid gland appeared almost 

entirely substituted by a yellowish white, firm and multinodular 

lesion measuring 2.5x1.6x1.2 cm. Macroscopically the tumor did 

not involve surgical margins. Microscopically solid carcinomatous 

sheets, trabeculae and isolated small groups of neoplastic epithelial 

cells intermingled with lymphoid tissue and surrounded by fibrous 



349 

tissue were observed. The carcinomatous areas were characterized 

by sometimes crowded and overlapping syncitial-appearing large 

tumor cells with scant amphophilic cytoplasm and haphazardly 

arranged vesicular nuclei. Nuclei had diameters up to 8 times the 

diameter of lymphocyte nuclei and sharply demarcated nuclear 

rims, finely speckled chromatin and prominent, usually single, 

eosinophilic nucleoli. There were nuclear atypia and numerous 

mitotic figures. Minute areas of coagulative necrosis were present. 

The lymphoid component consisted of small lymphocytes and, 

in some areas, formed follicular structures with germinal centers. 

The density of lymphoid tissue varied from areas with a few lymphocytes 

and plasma cells in between carcinomatous islands or 

accompanying carcinomatous trabeculae to areas where abundant 

lymphoid cells broke the tumor islands into small groups of cells. 

The satellite lymph node showed no infiltration by the tumor. 

Carcinomatous cells were positive for cytokeratin 7 and vimentin, 

whereas they were negative for cytokeratin 20 and lymphoid markers. 

The proliferation index (Ki-67) was about 80%. The lymphoid 

tissue contained a mixture of T cells (CD3 positive) and B cells 

(CD20 positive) and follicles with CD10-positive germinal centers. 

Numerous CD30 positive blasts were present. By means of in situ 

hybridization for EBERs, EBER-positive signals were observed in 

both the carcinomatous and lymphoid cells. 

Conclusions. Most of the reported cases of primary LELC of 

the salivary gland occurred in Asian and Eskimos population 

whereas they are uncommon in American and European people. 

The origin and pathogenesis of LELC is still unknown. It is 

thought to arise in either of two settings: malignant transformation 

of an epimyoepithelial island or malignant transformation of 

glandular and ductal inclusions in intraparotid lymph node. The 

association with EBV has suggested a possible role for the virus 

in the etiology but the relationship is generally controversial, 

considering that some LELC (ovary, endometrium, breast, etc...) 

have never been proven to be associated with EBV. In the past, 

it was believed that only foregut-derived organs (salivary gland, 

stomach, thymus, and lung) were susceptible to EBV-associated 

carcinogenesis, perhaps because these organs are in close proximity 

to sites of natural viral replication. However, the absence of 

EBV in LELC of palatine tonsil, which is also a foregut-derived 

organ, suggests that other factors are involved in the pathogenesis 

of the tumour. Some authors have suggested that EBV-associated 

LELC might be related to racial or geographic influences. Thus, 

further studies seem to be necessary to completely elucidate the 

oncogenic role of EBV in these tumors. 

references 

Ambrosio MR, Rocca BJ, Mourmouras V, et al. Lymphoepithelioma-like 

carcinoma of the endometrium. Pathologica 2010;102:57-61. 

Ambrosio MR, Rocca BJ, Onorati M, et al. Lymphoepithelioma- like carcinoma 

of the ovary. Int Surg Pathol 2011;19:514-517. 

Ayache S, Chatelain D, Perret C, et al. The lymphoepithelial carcinoma of 

the parotid gland: a rare tumor for an European patient. Rev Laryngol 

Otol Rhinol (Bord) 2004;125:239-241. 

Białas M, Sińczak A, Choińska-Stefańska A, et al. EBV-positive lymphoepithelial 

carcinoma of salivary gland in a woman of a non-endemic 

area--a case report. Pol J Pathol 2002;53:235-38. 

Kountakis SE, SooHoo W, Maillard A. Lymphoepithelial carcinoma of 

the parotid gland. Ear Nose Throat J 2001;80:803-6. 

Squillaci S, Bertalot G, Vago L, et al. Lymphoepithelioma-like carcinoma 

of the parotid gland. Description of a case with detection of EBV by in 

situ hybridization. Pathologica 92:189-194. 

Wu DL, Shemen L, Brady T, et al. Malignant lymphoepithelial lesion of 

the parotid gland: a case report and review of the literature. Int J Oral 

Maxillofac Surg 2007;36:556-9.

350 

A combined lesion between melanoma 

and squamous cell carcinoma 

F.M. Bosisio1 , M.G. Valente2 , G. Cattoretti1 , M.S. Cuttin2 1 Università di Milano-Bicocca, Scuola di specialità aggregata Milano- 

Milano Bicocca-Brescia, Monza; 2 AO San Gerardo, UO di Anatomia Patologica, 

Monza 

Introduction. In the field of the collision/combined tumors of the 

skin, cases of epithelial-melanocytic lesions have been described, 

though they remain quite rare entities. Among them, it is more 

frequent to found basal cell carcinoma in association with melanoma. 

Melanoma combined with a squamous cell carcinoma is a 

more infrequent possibility. Here we report a case of combined 

lesion of the skin composed by a V Clark level melanoma and a 

minimally invasive squamocellular carcinoma. 

Matherials and methods. The skin biopsy was sampled obtaining 

a section along the minor axis, formalin-fixed and paraffinembedded. 

Routine slides were obtained from the paraffin blocks 

and stained with Hematoxilin-Eosin. Immunohistochemical analysis 

was performed utilizing authomatic immunostaining system. 

Results: case report. A 79-years-old woman presented a discromic 

papular lesion on the right cheek, with a surface appearing 

partly hyperkeratotic and partly ulcerated. The clinical diagnosis 

was of basocellular carcinoma. At low magnification, it is recognizable 

a dome-shaped figure, with an expanded epidermis 

characterized by hyperkeratosis and by the presence of corneal 

pearls. With the increase of the magnification, it becomes visible 

more clearly a colonization of the expanded epidermis by atypical 

spindle cells organized in nests that show wide confluence 

and fusion among them. The nests show a destructive behavior 

toward the epidermis leading to the ulceration of the epidermis 

itself in the central part of the lesion. In the dermal portion, 

the spindle cell population reached the ipodermal tissue, with 

a depth of infiltration of 4,5 mm, and showed several mitoses 

(> 6 / 10 HPF). No vascular nor perineural invasion were found. 

Immunohistochemical stain for Melan-A antigen was perfomed, 

which resulted positive in the spindle cells, identifying a population 

of neoplastic melanocytes. HMB-45 resulted positive in the 

deep dermal part of the lesion (Fig. 1). No superficial spread 

was present at the shoulder of the lesion. A diagnosis of nodular 

melanoma at V Clark level, pT4b, was made. Nevertheless, the 

epidermis surrounding the melanoma presented severe keratinocyte 

atypia, and undefined borders with single keratinocytes 

infiltrating the papillary dermis (Fig 2). Immunostain with CK 

AEI-AE3 resulted perfectly complementary to the melanocytic 

stain, highlighting the invasive single cell component of the 

neoplasia. Therefore, a diagnosis of invasive squamous cell carcinoma 

in association with the previously described melanoma 

was made. 

Discussion and conclusion. When two neoplasm are found 

together, they must be categorized according to Satter et al. 1 as 

collisions tumors if are adjacent but separated; combined tumors 

if there are 2 or more cell population admixed in the same lesion; 

colonized tumors if one population permeates an underlyng 

second tumor, with the condition that the colonizing tumour must 

remain localized within the limits of the second tumoral population; 

and biphenotipic tumors when the two different population 

exhibit coexpression of phenotypically different immunohistochemical 

markers. In our case, the two tumoral population were 

admixed, so this must be considered a combined tumor. Combined 

melanocytic-epithelial lesions are rare. A benign example 

of such entity is the melanoacanthoma, where in-between the 

limits of a keratinocytic acanthoma is homed a proliferation of 

benign melanocytes throughout the thickness of the acathoma 2 . 

Malignant lesions are similarly rare. The most frequent association 

is between melanoma and basal cell carcinoma. The association 

between melanoma and squamous cell carcinoma is far more 

infrequent 3 . The association melanocytic-epithelial lesion has 


Fig. 1. the melanoma is entirely homed into the squamous cell carcinoma 

(a). HmB45 stains a deep clonal nodule of the vertical growth 

phase of the melanoma (B). Cytokeratines aE1-aE3 stain (C) is perfectly 

complementary with maRt-1 stain (d). 

been found also in other organs. A case of atypical melanocytic 

hyperplasia resembling melanoma in situ was described also in 

association with multiple foci of squamous cell carcinoma in 

situ in the esophagus. The peculiarity of this case was that at 

the follow up the lesion regressed, so that the authors concluded 

the paper establishing the reactive nature of the lesion, the same 

as the typical melanocytosis of the esophagus that can be found 

associated with invasive squamocellular carcinoma 4 . Non neoplastic 

melanocytes can be trapped and proliferate in an epithelial 

neoplastic lesion also in the skin 3 . In our case, the more malignant 

lesion is the melanoma, which is a > 4 mm thick and at the 

V Clark level, compared with the squamous cell carcinoma, that 

presents only some invasive foci. It is difficult to assess the prognosis 

of these tumors due to the rarity, but in our case the more 

advanced stage of the melanoma component easily will determine 

the prognosis of the patient. 

Fig. 2. on the shoulder of the lesion atypical keratinocytes are visible 

infiltrating the papillary derma (a); this is easier to see with the 

cytokeratines staining (B). Nests of atypical melanocytes permeates 

all the squamous cell carcinoma (C).


references 

1 Satter EK, Metcalf J, Lountzis N, et al. Tumors composed of malignant 

epithelial and melanocytic populations: a case series and review of 

literature. J cutan Pathol 2009;36:211-9. 

2 Weedon D. Weedon’s skin pathology. 3rd ed. 

3 Cornejo KM, Deng AC. Malignant melanoma within squamous cell 

carcinoma and basal cell carcinoma: is it a combined or a collision 

tumor? A case report and review of literature. Am J Dermatopathol 

2012 May 14. 

4 Walter A, et al. Atypical melanocytic proliferation associated with 

squamous cell carcinoma in situ of the esophagus. Virchows Arch 

2000;437:203-7. 

Granuloma faciale: a possible member of IgG4associated 

sclerosing diseases 

A.M. Cesinaro, S. Lonardi * , F. Facchetti * 

Department of Anatomic Pathology, Azienda Ospedaliero-Universitaria 

Policlinico, Modena, Italy, and * Department of Anatomic Pathology, University 

of Brescia, Brescia, Italy 

Introduction. The pathogenesis of Granuloma Faciale (GF), 

an entity framed in the group of cutaneous chronic vasculitides 

characterized by mixed inflammatory infiltrate with eosinophils 

and plasma cells and perivascular concentric fibrosis 1 , is poorly 

understood. The present study investigated whether GF might be 

part of the spectrum of IgG4-related sclerosing diseases (IgG4- 

RSD) 2 . Cases of Erythema Elevatum Diutinum (EED), a disease 

retained to belong to the same group of cutaneous disorders of 

GF, were also studied for comparison. 

Material and Methods. Thirty-one cases of GF from 18 males 

(age range 36 to 80 yrs, mean 53.05), and 7 females (39 to 85 

yrs, mean 56.7) (M:F = 2.5:1), and 5 cases of EED (4 females 

and 1 male, 38-82 yrs, mean 48.8) were analyzed by immunohistochemistry 

for the expression of IgG and IgG4. In addition, the 

distribution of Th1, T regulatory and Th2 T-cell subsets, respectively 

identified by anti-T-Bet, -FoxP3 and -GATA-3 antibodies, 

was also evaluated. 

Results. Eight out of 31 biopsies (25.8%) from 6/25 patients 

(24%) with GF, fulfilled the criteria for IgG4-RSD. Interestingly, 

all these cases were from males (6/18; 33.3%) and four of them 

showed recurrent and/or multiple lesions. In additional six cases, 

the IgG4/IgG ratio was higher than 40%, but the absolute number 

of IgG4/HPF was lower than 50. None of the 5 EED cases 

fulfilled the criteria for IgG4-RSD, but in one case the IgG4+ 

plasma cells were 50/HPF. The distribution of the T-cell subsets 

expressing T-bet, FoxP3 and GATA-3 was quite variable, in 

general the GATA-3+ lymphocytes were more abundant, but no 

relationship with the number of IgG4+ plasma cells was found. 

Discussion. GF shares with IgG4-RSD histological and immunohistochemical 

features. A pathogenesis related to IgG4+ immunoglobulins 

is possible at least in a subset of patients, particularly 

males with multiple/recurrent lesions. 

351 

Fig. 1. Histological and immunohistochemical features in a case of Gf 

with high content of igG4+ plasma cells. On haematoxylin and eosin (a 

and b) a dense nodular inflammatory infiltrate, involving the dermis, 

is composed by polymorphonuclear neutrophils and eosinophils, 

lymphocytes and plasma cells, and shows focal fibrosis. immunostains 

for igG4+ (c) and igG (d) show a high content and percentage of igG4+ 

plasma cells; the th2, t-reg and th1 t-cell subsets, respectively expressing 

Gata-3 (e), foxp3 (f) and t-bet (g) are differently distributed 

within the infiltrate, with a moderate prevalence of the Gata-3+ cells. 

references 

1 LeBoit PE. Granuloma faciale: a diagnosis deserving of dignity. The 

American Journal of dermatopathology 2002;24:440-3. 

2 Cheuk W, Chan JK. IgG4-related sclerosing disease: a critical appraisal 

of an evolving clinicopathologic entity. Advances in anatomic 

pathology 2010;17:303-32.

352 

TESTA COLLO 

Benign nasal polyposis and wegener’s 

granulomatosis: an unusual association 

G. Crisman1 , I. Riccardo2 , V. Corridore2 , S. Cupillari2 , V. Ciuffetelli1 

, G. Calvisi4 , S. Di Rito1 , V. Ciuffetelli, P. Leocata1 1 Anatomia Patologica, Dipartimento di Scienze della Salute, Università 

dell’Aquila, L’Aquila, Italia; 2 U.O.C. Otorinolaringoiatria, Università 



Ospedale Civile “San Salvatore”, L’Aquila, Italia 

Background. Benign nasal polyposis is a chronic inflammatory 

disease of the nasal and paranasal sinus mucosa, occurring 

in up to 4% of the population, even though its prevalence has 

been reported up to 40% in autopsy series. The etiology is still 

unclear, but associations with allergy, asthma, infection, cystic 

fibrosis, and aspirin sensitivity have been at least suggested. Nasal 

obstruction represents the main presenting symptom, even if 

it can vary depending on the site and size of the polyps; however, 

rhinorrhoea, post nasal drip, anosmia, and rarely facial pain have 

been reported as well. Nasal endoscopy reveals single or multiple 

grey polypoid masses in the nasal cavity. A combination of medical 

therapy and surgery represents the mainstay of treatment and 

since recurrences are not uncommon (severe disease recurring 

in up to 10% of patients), nasal polyps represent a challenging 

diagnosis for the physician. 

Wegener’s granulomatosis (WG) represents the most common 

systemic antineutrophil cytoplasmic antibodies (ANCA) necrotizing 

and granulomatous vasculitis, involving the kidney and the 

upper and lower respiratory tract. Clinical manifestations, histological 

findings and the presence of c-ANCA in serum represent 

the three-pivotal steps to achieve the diagnosis of WG. However, 

the American College of Rheumatology criteria also include: oral 

and nasal inflammation, abnormal chest radiography (nodules, 

fixed infiltrates, or cavities), urinary sediment (hematuria), and 

granulomatous inflammation on biopsy. 


who presented with one-month history of remittent fever (daily 

elevated temperature > 38 C or 100.4 F), not responding to an- 

Fig. 1. clinical presentation: nasal polyps and necrotizing mucosa. 




Fig. 2. histological features: a) a granulomatous vasculitis and some 

foci of hemorrhage can be observed. (H&E, 4x magnification); B) a 

granulomatous vasculitis, prominent lymphoplasmocytic infiltrate, 

thrombosis and vascular necrosis are well-identifiable at higher 

rmagnification(H&E, 10x magnification). 

tibiotic therapy (levofloxacin, piperacillin and tazobactam), and 

nasal obstruction. The General Practitioner suggested a severe 

sinusitis within the context of a benign nasal polyposis. Nasal 

endoscopy revealed a benign nasal polyposis with a necrotizing, 

edematous mucosa. Due to the mucosal friability, only few fragments 

resulted from the endoscopic biopsy. 

Results. Histopathological findings revealed a necrotizing vasculitis 

and organizing granulomas of the nasal mucosa in all 

specimens. Edema and lymphoplasmocytic infiltrate with focal 

lymphoid aggregate formation was observed, as well as many 

blood vessels with thrombosis and vascular necrosis within the 

necrotic areas. The possibility of WG was considered and serum 

level of c-ANCA, and pulmonary and renal examinations have 

been performed. Thus, the patient underwent a systemic corticosteroid 

treatment and showed a remarkable improvement of his 

general health conditions and a complete remission of the nasal 

necrotizing lesions within 6 days. Nasal polyposis still persisted, 

as expected. 

Conclusions. The diagnosis of WG can be established at history, 

since laboratory test are non-specific. As a matter of fact, 

c-ANCA serum levels support the diagnosis if present but do not 

exclude it. Radiology can represent a diagnostic tool as well, but 

has many mimics. At the best of our knowledge, less is known 

about the association between WG and benign nasal polyposis. 

Nasal cavities involvement, as well as sinus, orbit, nose and ears 

could also represent a further diagnostic tool in such difficult 

cases. Even after complete remission with steroid, recurrences in 

the targeted organs have been previously reported thus, a close 

follow-up of the patient is recommended. 

Our patient presented with severe systemic symptoms in the 

context of a benign nasal polyposis and this seems to be a very 

unusual presentation of WG. The association between WG and 

Benign Nasal Polyposis requires further investigations. 

In conclusion, the presence of a refractory remittent fever without 

a relevant cause in the context of a common benign nasal polyposis 

should lead to an accurate endoscopy and the presence of 

a necrotizing mucosa should raise the suspicion of a vasculitic 

process. 

references 

Rijuneeta MS, Panda NK, Bambery P. et al. Nasal Polyposis in Wegener’s 

Granulomatosis: A rare presentation. The Internet Journal of 

Otorhinolaryngology 2006;4(2). 

Beltrán Rodríguez Cabo OE, Tona Acedo G. Role of the ears, nose and 

throat specialist in the diagnosis and follow up of patients with primary 

vasculitidies. Reumatol Clin 2011;7(Suppl. 3):S7-11. 

Mujagic S, Sarihodzic S, Huseinagic H, et al. Wegener’s granulomatosis


of the paranasal sinus and central nervous system involvement-diagnostic 

imaging. Acta Neurol Belg 2011;111:241-4. 

Marzano AV, Balice Y, Papini M, et al. Localized Wegener’s granulomatosis. 

J Eur Acad Dermatol Venereol 2011;25:1466-70. 

Malignant melanoma of the nasal sinus: 

a case report on a rare, diruptive disease 

G. Crisman1 , R. Izzo2 , L. Crosta2 , S. Cupillari2 , P. Leocata1 1 U.O.C. Anatomia Patologica, Università dell’Aquila, L’Aquila, Italia, 

2 U.O.C. Otorinolaringoiatria, Università dell’Aquila, L’Aquila, Italia 

Background. Malignant Melanoma of the nasal cavities accounts 

for approximately 3% of all primary head and neck malignant 

neoplasms and for less than 1% of all malignant melanomas. 


man who presented to the Otorhinolaryngoiatric Department 

of L’Aquila with a three-month history of epistaxis and nasal 

obstructive symptoms. Physical examination was otherwise unremarkable. 

The endoscopic examination revealed the presence 

of a non-pigmented, reddish-pink polypoid lesion of 0,8 cm indiameter 

sited on the basis of the right nasal cavity. An excisional 

biopsy has been performed and the resulting fragmented material 

has been sent to the Pathology Unit for a routinely examination. 

Results. Histological features of the five fragments revealed 

a proliferation of small, rounded cells within an hemorragic, 

necrotic material. The differential diagnosis included all types 

of small cells malignancies of this special site, such as neuroendocrine 

small cell carcinoma, esthesioneuroblastomas, Ewing’s 

sarcoma, small-cell malignant melanoma, EBV-associated nasaltype 

extranodal NK/T-cell lymphoma, NUT midline carcinoma. 

Immunohistochemical findings revealed a negativity for Cytokeratin 

7 and 20, NSE, chromogranin, synaptofisin, CD34, CD99, 

CD20, CD3, CD68, p63 whereas tumor cells strongly stained for 

S-100 protein and Melan-A and weakly for CD56, thus leading to 

the diagnosis of a small-cell amelanotic Malignant Melanoma of the 

nasal cavities. Ki-67 protein was expressed in the 70% of the tumor 

cells. The patient subsequently underwent to several CT examinations 

for initial staging, and extensive splenic, liver and pulmonary 

metastases have been observed. Multiple lymhadenomegaly in the 

cervical and submandibular regions have been detected as well. 

Fig. 1. clinical (endoscopic) presentation of 

the lesion. 

Fig. 2 a and B. Histological features: proliferation of small, rounded 

cells within an hemorragic, necrotic material. (H&E, 4x and 10x magnification). 

353 

Fig. 3. a: tumor cells strongly stained for S-100 protein (S-100, 10x 

magnification). B: tumor cells were positive for melan-a immunostain 

(melan-a, 20x magnification). 

Conclusions. First described in 1869 by Lucke, Malignant Melanoma 

of the nasal cavities and paranasal sinus has an incidence 

rate ranging from 0,4 up to 3% of all head and neck malignancies. 

Malignant Melanoma of the nasal cavities shows no sex predilection 

and the 5th and 6th decades represent the mean age group of 

onset. Clinical presentation symptoms include nasal obstruction 

and/or epistaxis and endoscopic examination reveals polypoid 

non-pigmented lesion, often indistinguishable from benign polyposis.Histological 

and immunoistochemical examinations represents 

the gold standard method to achieve the correct diagnosis. 

According to the literature, wide surgical excision in the mainstay 

treatment, since either chemotherapy and radiotherapy seem to be 

not so effective and the prognosis is generally poor. Recurrences 

are frequent, accounting up to 40% of cases. 

references 

1 Terada T. Malignant melanoma of the nasal cavity: a case report 

with examination of KIT and platelet derived growth factor receptorα(PDGFRA). 

Rare Tumors 2011;3:e54. 

2 Uysal IÖ, Misir M, Polat K, et al. Primary malignant melanoma of the 

nasal cavity. J Craniofac Surg 2012;23:e2-5. 

3 Shojaku H, Takakura H, Tachino H, et al. Response to intra-arterial 

cisplatin and concurrent radiotherapy in a patient with primary mucosal 

malignant melanoma of the nasal cavity. Head Neck 2011 Dec 

16. doi: 10.1002/hed.21976. 

4 Jethanamest D, Vila PM, Sikora AG, et al. Predictors of survival 

in mucosal melanoma of the head and neck. Ann Surg Oncol 

2011;18:2748-56. 

5 Clifton N, Harrison L, Bradley PJ, et al. Malignant melanoma of nasal 

cavity and paranasal sinuses: report of 24 patients and literature review. 

J Laryngol Otol 2011;125:479-85. 

Maxillary ameloblastic carcinoma arising 

from an odontogenic cyst in young children 

F. Moltrasio, M.S. Cuttin, V. Morganti, G. Cattoretti, D. Sozzi, 

M.G. Valente 

Department of Pathology, Hospital San Gerardo, University of Milan-Bicocca, 

Monza, Italy; Department of Maxillofacial Surgery, Hospital San 

Gerardo, University of Milano-Bicocca, , Monza, Italy 

Ameloblastic carcinoma (AC) is a rare odontogenic malignancy 

which occurs more commonly in the mandible than in the maxilla 

and may present de novo, ex ameloblastoma or ex odontogenic 

cyst 1 . AC occurs in a wide range of age groups and no sex predilection 

has been noted. AC may present with different clinical conditions: 

as a cystic lesion with benign aspects or with obvious malignant 

features as bone resorption, tooth mobility or ulcerations 2 . 

AC is histologically defined by the coexistence of the typical histopathological 

benign features of ameloblastoma, such as cellular 

nests with peripheral pallisading of basaloid cells with a central 

dyschoesive component, arranged to form a stellate reticulum, 

associated with features of malignancy such as marked nuclear 

atypia, mitotic figures, infiltrative growth pattern and large loss 

of stellate reticulum-like structures. All these features are usually 

present regardless of the presence of distant metastases 3 .

354 

Fig. 3. Microscopic appearance of ameloblastic carcinoma. tumor 

islands with focal features of ameloblastoma (a) and areas with 

obvious malignant aspects as spindle cells, pleomorphism and hyperchromatism, 

increased mitotic ratio (B, C, d).. 

We present a case of a 15-year old man who was diagnosed, by 

occasional OPT, with a large expansive mass at right maxilla. 

CT scan demonstrated a mass measuring 48x37x55 mm, which 

occupied the entire right maxillary sinus, expanding to the orbit 

and the nasal pits. Inferiorly, the tumor eroded the upper alveolar 

arch, and was in contact with the masseter muscle (Fig. 1). 

The patient underwent surgical asportation and avulsion of the 

third upper right molar. 

At macroscopic examination, we found a non-ulcerated cystic 

mass with adherent thin bony plates within an impacted tooth 

and numerous vegetations adherent to the inner surface (Fig. 2). 

Histologically our case showed features of odontogenic cyst with 

associated areas of stellate reticulum with peripheral palisading 

as follicular or plexiform ameloblastoma and tumor islands with 

marked cellular atypia, hyperchromatism, nuclear pleomorphism, 

showing loss of peripheral palisading or nuclear polarity, increased 

mitotic index with 5 mitoses/10HPF (Fig. 3). 

Therefore our diagnosis was ameloblastic carcinoma arising from 

an odontogenic cyst. 

The patient has been followed for 12 months with CT scan of 

head and neck, chest radiograph, neck and abdominal ultrasonography, 

transnasal fibroendoscopy and CT-PET without evidence 

of local recurrences or metastatic localizations. 

references 

1 Lucca M, D’Innocenzo R, Kraus JA, et al. Ameloblastic carcinoma of 

the maxilla: a report of 2 cases. J Oral Maxillofac Surg 2010;68:2564- 

9. 

2 Yoon HJ, Hong SP, Lee JI, et al. Ameloblastic carcinoma: an analysis 

of 6 cases with review of the literature. Oral Surg Oral Med Oral 

Pathol Oral Radiol Endod 2009;108:904-13. 

3 Routray S, Majumdar S. Ameloblastic carcinoma: sometimes a challenge. 

J Oral Maxillofac Pathol 2012;16:156-8. 

A feasibility evaluation on the dentist’s role for 

early diagnosis of oral cancer using a cost/effective 

innovative first level test with micro-biopsy 

R. Navone, S. Gandolfo1 , M. Pentenero1 , G. Tempia Valenta1 1 Dipartimento di Scienze Biomediche ed Oncologia Umana, Università 

di Torino; 1 Dipartimento di Scienze Cliniche e Biologiche, Sezione di 

Medicina ed Oncologia Orale, Università di Torino 

Background. Oral squamous carcinoma (OSCC) and pharyngeal 

cancer are amongst the most frequent malignant neoplasia (in 6th 

place for cancer-related death). Unfortunately, the last 30 years 

have not witnessed any significant improvement in survival rate, 


most likely due to this type of tumour often being diagnosed at 

an advanced stage. Moreover, the therapy required to deal with 

advanced stages leads to a highly compromised quality of life 

for the patient. Conversely, an early diagnosis has shown a high 

5-year survival rate (96.9%) (Pentenero et al., 2011). Noteworthy 

is the fact that numerous OSCC often arise on the site of precursor 

tumoural lesions (dysplasias) and their identification could 

well prevent their malignant transformation. The main obstacle 

facing an early diagnosis of OSCC is that this serious tumoural 

form and its precursors are easily confused with “clinically apparently 

innocent lesions” of inflammatory, traumatic or prosthetic 

origin, routine findings in the dentists’ every-day practise. When 

symptoms involving the oral mucosa appear the individual usually 

refers to his/her G.P., who, in turn, refers the patient to a 

dentist. That is why the dentist and G.P. are potentially able to 

carry out an effective prevention programme for an early OSCC 

diagnosis, as long as they have the necessary “know-how” to do 

so, including which tests to perform first and who to refer the patient 

to for a definitive diagnosis. The first of such tests available 

is the objective examination, which, although is surely necessary 

and efficacious, does not suffice, as it is not able to allow for a 

distinction between oral potentially malignant lesions (OPML) 

from lesions that will never evolve into cancer (Lingen et al., 

2008). Therefore, the use of only an objective examination leads 

to the risk of underestimating OPML and/or early-stage cancer 

or, on the contrary, overestimating clinically apparently innocent 

lesions. First level tests have been proposed to diagnose the intraepithelial 

pre-invasive OPML that require scalpel (surgical) 

biopsy, but also, and above all, to identify those cases that do not, 

which are the majority. The requisites of a first level test include 

it not only being reliable and repeatable, but also user-friendly, 

even in non-expert hands, as well as it having a high sensitivity 

and specificity. To date, the dentist has had only one first level 

test at disposal i.e. oral cytology (Navone et al., 2007, 2011), 

which is not always easy to perform, has a low sensitivity and 

leads to a number of inadequate samples. There is, therefore, an 

evident need for a test with enhanced characteristics. The scalpel 

biopsy, today’s gold standard, is not a good first level test for the 

diagnosis of these lesions (Pentenero et al, 2003) as it is invasive 

and has sampling limits: it can be carried out only in restricted 

areas and on a limited number of sites and the identification of 

the most suitable sampling site is of no easy feat in non-expert 

hands. In fact, it may lead to false-negative results, even in the 

most expert of hands (Pentenero et al., 2003). 

A new sampling technique, called “micro-biopsy”, was developed 

by our team and data published (Navone et al., 2008). The 

technique involves scraping with a dermatological curette to 

obtain microhistological samples, rather than cytological ones. It 

is minimally invasive and has a high sensitivity (97.65%), a high 

negative predictive value (97.33%) and provides a high percentage 

of adequate samples. Although we proposed it be used as a 

first level test, before the data on this research project reported 

herein, we had no information as to the probability a dentist, nonexpert 

in oral mucosal pathology, has in obtaining samples of the 

same level. Therefore, this research was aimed at obtaining data 

on the capacity a dentist, who is not versed in the field, may have 

in the correct use of the micro-biopsy technique with the curette 

and to compare these data with those obtained by more expert 

hands. The research project was carried out in collaboration with 

free-lance dentists, with the aim of evaluating the adequacy of 

their sampling of the oral cavity mucosa lesions they came across 

in the course of their routine practise. 

Materials and methods. We carried out a prospective study 

financed by the Piedmont Region (Ricerca Sanitaria Finalizzata 

2008) in collaboration with A.N.D.I. (the National Italian Association 

of Dentists). A total of 75 free-lance dentists, working 

in the Torino area, were enrolled for a pre-training session on a 

voluntary basis, the only inclusion criteria was that they were


general dental practitioners, who, although experts in their own 

field, had no specialist training in oncology nor specific competence 

in the sector of Oral Medicine and Pathology. The training 

session lasted about 90 minutes and included the use of visual 

aids, such as photographs and a video, so as to provide them with 

the notions necessary to carry out the sampling correctly. At the 

end of the session, each dentist was given a detailed leaflet with 

a description of the sampling technique and 5 kits. The kits contained 

all the material required to carry out the sampling, which 

was to be done on the first five consecutive patients with oral cavity 

lesions of the mucosa during their routine practise. Each kit 

had: 1 disposable dermatological curette, 7mm in diametre, (Acu- 

Dispo Curette®, Acuderm Inc., Ft. Lauderdale, FL, USA); 1 fixing 

vial with Thin Prep® (Cytic Corporation, Marlborough, MA, 

USA); 1 form with patient details e.g. anagraphic data, medical 

anamnesis including the use of alcohol and/or tobacco, the site, 

colour dimension and symptomatology of the lesions, the time 

of onset, whether or not anaesthesia had been used for sampling 

and diagnostic suspicion. The operative protocol recommended 

that sampling be carried out only in the presence of lesions of 

epithelial origin i.e. patches, papules, plaques, verrucous lesions, 

erosions and ulcers. 

The dentist was taught to hold the curette tangential to the lesion 

surface so as to avoid cutting rather than scraping and to continue 

scraping until such times as an adequate amount of tissue fragments 

had been obtained, with visible uniform slight bleeding on 

the whole surface area of the lesion being sampled. The curette 

was then to be placed into the fixing vial and shaken to free 

the fragments. As a rule, no local anaesthesia, topical sprays, 

or emulsions/creams should be used to avoid lubrication of the 

lesion surface, which would reduce scraping efficacy when collecting 

fragments, except in particularly symptomatic cases, or on 

patient request. The micro-biopsies are then embedded in paraffin, 

cut with a microtome, stained with haematoxylin-eosin and 

subjected to histological examination by an expert pathologist. 

The sample is classified on the basis of the histological evaluation: 

ADEQUATE in the presence of a representative strip of 

epithelium (at least 100 non-superficial cells), or INADEQUATE 

when only horny material is present (anucleated cells). 

Results. A total of 50/75 dentists, who took part in the training 

session, took part in the study. Between February 2009 and September 

2011, 152 micro-biopsies were sent for evaluation, from 

sampling carried out on a total of 132 patients, 72 males and 60 

females (M:F = 1.2:1) average age 53.6 years (25-88). 

There were 140/152 adequate samples (92.1%) and 110/140 

(78.5%) had a visible basal membrane (110/140). Whilst 12/152 

(7.9%) were inadequate. The data obtained in this study showed 

that the number of adequate samples obtained in non-expert 

hands were superimposable on those obtained by personnel 

expert in the field i.e. 92.1% and 96.3% respectively; p = 0.167. 

The inadequate samples showed no statistically significant difference 

on the basis of the type of lesion (p = 0.320), or the 

lesion site (p = 0.740). The first-level micro-biopsy examination 

355 

result was confirmed in all cases that were referred for a 2 nd 

level diagnostic test (scalpel biopsy). A histological diagnosis of 

dysplasia was made in 10/140 micro-biopsy samples (7.1%) and 

one carcinoma (0.7%). There were no relevant complications and 

anaesthesia was used in 18.4% of cases. 

Conclusions/Summary. We demonstrated that the micro-biopsy 

technique in expert hands is minimally invasive with a high sensitivity 

(97.65%) and high negative predictive value (97.33%) 

(Navone et al., 2008). Therefore, we hypothesized its use as a 

first level diagnostic test for dentists on the field. The innovative 

research reported herein aimed at evaluating the feasibility of 

such a hypothesis and demonstrated that a brief training session 

sufficed to enable dentists who, although experts in their own 

field, had no specific oncological training, to provide adequate 

samples for histological examination through an economical, 

user-friendly and well accepted first level test. Moreover, to 

the best of our knowledge, for the first time, this study obtained 

valuable information as to the number and type of oral mucosal 

lesions that put the dentist into difficulty when making a differential 

diagnosis in everyday practise. The most common lesions 

sampled were patches, papules, plaques, rather than erosions/ 

ulcers, most likely due to the fact that the latter heal quickly once 

the source of the problem has been identified and modified e.g. 

ill-fitting prosthesis or other factors tied to dental issues. Taken 

as a whole, the lesions sampled and referred for histology had 

relevant oncological characteristics with 7.8% having a definite 

diagnosis of dysplasia or carcinoma, absolutely not to be underestimated. 

Indeed, these data have demonstrated for the first time 

how important the dentist’s role can be in providing early data on 

these types of potentially fatal lesions. Last, but not least, these 

data show how the first level micro-biopsy diagnostic test is able 

to select a small group of patients to be sent for further evaluation 

allowing professionals working in an important health-care sector 

to treat their patients with state-of-the-art technology. Moreover, 

thanks to the follow-up of all the negative cases, future data will 

provide information as to the presence of any false-negative cases 

at the 1 st level test. The adoption of this strategy could, hopefully, 

make a contribution in reducing the percentage of late diagnosis 

in oral mucosal squamous cell carcinoma. 

references 

Lingen MW, Kalmar JR, Karrison T, et al. Critical evaluation of diagnostic 

aids for the detection of oral cancer. Oral Oncol 2008;44:10-22. 

Navone R, Pentenero M, Gandolfo S. Liquid-based cytology in oral cavity 

squamous cell cancer. Current opinion in otolaryngology & head and 

neck surgery 2011;19:77-81. 

Navone R, Pentenero M, Rostan I, et al. Oral potentially malignant lesions: 

first-level micro-histological diagnosis from tissue fragments 

sampled in liquid-based diagnostic cytology. J Oral Pathol Med 

2008;37:358-63. 

Pentenero M, Carrozzo M, Pagano M, et al. Oral mucosal dysplastic 

lesions and early squamous cell carcinomas: underdiagnosis from 

incisional biopsy. Oral diseases 2003;9:68-72. 

Pentenero M, Navone R, Motta F, et al. Clinical features of microinvasive 

stage I oral carcinoma. Oral diseases 2011;17: 298-303.

356 

TESTA COLLO 

TCTP (translationally controlled tumour protein) 

is present in human cornea and increases 

in herpetic keratitis 

M.R. Ambrosio1 , B.J. Rocca1 , M.G. Mastrogiulio1 , E. Cosci1 , 

L. Pacenti1 , F. Arcuri1 , C. Batisti2 , S.A. Tripodi1 1 Departments of Human Pathology and Oncology, Anatomic Pathology Section 

and 2 Departments of Ophthalmology, University of Siena, Siena, Italy 

Background. The translationally controlled tumour protein 

(TCTP), also named fortilin or TPT1 is a protein of 23 kda in 

human, expressed in all eukaryotes. It is encoded by a gene 

mapped to chromosome 13q14.13 and its expression is highly 

regulated both at the transcriptional and translational level and by 

a wide range of extracellular signals. Although TCTP was firstly 

considered as a tumour protein, it has been clarified that it is a 

multifaceted protein implicated in multiple biological processes: 

cell growth, cell cycle progression, division and proliferation. 

An anti-apoptic function of TCTP in human cancer cells has 

also been identified as well as a chaperone-like activity and a 

cytokine-like activity. Recently, an association with a component 

of cytoskeleton network, F-actin, and a role in cell shape regulation 

have been evidenced as its capability to bind tubulin and 

serve as a substrate of Polo-like kinase 1 (Plk1). Ocular vision 

depends on cornea transparency and shape. These properties 

are strictly related to the balance between cell proliferation and 

apoptosis, which are mechanisms regulated by TCTP. Up to 

now, the presence and distribution of TCTP in human cornea 

has not yet well analysed and the reported studies are limited 

to cultured keratocytes and made by proteomics techniques. In 

this study, we evaluate for the first time by immunoblotting, 

reverse transcriptase analysis and immunohistochemistry, TCTP 

presence and distribution in human healthy cornea. Considering 

that recent studies have suggested that apoptosis, calcium levels 

and immunological mechanisms play a role in the pathogenesis 

of herpes virus (HSV) stromal keratitis (HSK), we study TCTP 

expression in HSK. 

Materials and methods. We used 10 samples of healthy 

cornea, 4 obtained after penetrating keratoplasty (PKP) and 6 

from eyes enucleated for retinoblastoma, in which the anterior 

segment was tumor-free. Other 10 cornea tissue samples were 

collected from patients undergoing PKP for sequel of HSK. The 

surgical specimens obtained after PKP were grossly examined 

and halved. An half of the corneal tissue was used to analyse 

protein and RNA, an other half was fixed in 10% buffered 

formalin, embedded in paraffin and processed for histology 

and immunohistochemistry (by anti-human TPT1 mouse monoclonal 

antibody). 

Results. RT-PCR analysis of TCTP mRNA levels: an intense band 

corresponding to the TCTP product was obtained on the agarose 

gel from the cDNA of each cornea specimens examined. 

Western blot analysis: a single band of the approximate molecular 

weight of 23,000 Da was detected in all the specimens tested. 

Immunohistochemistry: in normal cornea, TCTP expression was 

observed in the basal and intermediate cell layers of corneal 

epithelium and, less intensely, in keratocytes and endothelial 

cells. In HSK samples, intense and diffuse TCTP staining was 

observed throughout all layers of corneal epithelium in stromal 

cells (p = 0,001). 



Sala Botticelli – ore 10,30-11,30 

Conclusions. An extensive review of the literature showed previous 

studies concerning the presence of TCTP in cornea limited 

to cultured keratocytes and made by proteomics techniques. In 

our study we have demonstrated the presence of TCTP in human 

cornea by RT-PCR and immunoblotting and we have confirmed 

these data by immunohistochemistry using an antibody against 

TCTP. Considering that apoptosis plays a key role in HSK and 

that apoptosis is controlled by TCTP, we have attempted to find 

a pathogenic correlation between TCTP and HSK, evaluating 

TCTP expression in corneal samples affected by HSK. We have 

observed a strong relationship between the degree of inflammation 

and the expression of TCTP in corneal epithelium as well as 

in the inflammatory infiltrate in HSK with active disease. These 

results suggest a double role of TCTP in herpes keratitis as antiapoptotic 

protein in corneal cells and a cytokine-like protein in 

the stroma where TCTP may be secreted by inflammatory cells, 

probably monocytes, in the extracellular milieu. Apoptosis has 

been shown to be an effective process to limit viral invasion. 

Primary HSV-1 corneal infection stimulates apoptosis of anterior 

keratocytes in the stroma underlying the site of epithelial injury. 

TCTP might modulate the keratocyte apoptotic response limiting 

stromal damage but also trigger the keratocyte apoptotic response 

by soluble mediators released by epithelial injury secondary 

HSV-1 corneal infection. Given the importance of apoptosis as a 

general mechanism for the elimination of normal and pathologically 

altered cells, it might be expected that manipulating apoptosis 

might open up new possibilities to treat HSK. Moreover, 

TCTP may be involved in corneal wound healing and in maintaining 

its transparency and shape, by means of an interaction 

with cytoskeletal proteins. 

references 

Arcuri F, Papa S, Meini A, et al. The translationally controlled tumor 

protein is a novel calcium binding protein of the human placenta 

and regulates calcium handling in trophoblast cells. Biol Reprod 

2005;73:745-51. 

Bommer UA, Thiele BJ. The translationally controlled tumour protein 

(TCTP). Int J Biochem Cell Biol 2004;36:379-85. 

Choi S, Min HJ, Kim M, et al. Proton pump inhibitors exert anti-allergic 

effects by reducing TCTP secretion. PLoS One 2009;4:e5732. 

Esaki S, Goshima F, Katsumi S, et al. Apoptosis induction after herpes 

simplex virus infection differs according to cell type in vivo. Arch 

Virol 2010;155:1235-1245. 

Gnanasekar M, Dakshinamoorthy G, Ramaswamy K. Translationally 

controlled tumor protein is a novel heat shock protein with chaperonelike 

activity. Biochem Biophys Res Commun 2009;386:333-7. 

Gonzalez-Gonzalez LA, Molina-Prat N, Doctor P, et al. Clinical features 

and presentation of infectious scleritis from herpes virus: a report of 

35 cases. Ophtalmology 2012 [Epub ahed of print]. 

Graidist P, Yazawa M, Tonganunt M, et al. Fortilin binds Ca2+ and blocks 

Ca2+-dependent apoptosis in vivo. Biochem J 2007;408:181-91. 

Idone V, Tam C, Goss JW, et al. Repair of injured plasma membrane 

by rapid Ca2+-dependent endocytosis. J Cell Biol 2008;180:905-14. 

Kim M, Min HJ, Won HY, et al. Dimerization of translationally controlled 

tumor protein is essential for its cytokine-like activity. PLoS 

One 2009;4:e6464. 

Rho SB, Lee JH, Park MS, et al. Anti-apoptotic protein TCTP controls 

the stability of the tumor suppressor p53. FEBS Lett 2011;585:29-35. 

Susini L, Besse S, Duflaut D, et al. TCTP protects from apoptotic cell 

death by antagonizing bax function. Cell Death and Differentiation 

2008;15:1211-20. 

Wilson SE, Chaurasia SS, Medeiros FW. Apoptosis in the initiation, 

modulation and termination of the corneal wound healing response. 

Exp Eye Res 2007;85:305-11.


P16 immunohistochemistry, consensus PCr 

HPV-DnA, and in situ hybridization: a combined 

triple method to detect HPV positive oral and 

oropharyngeal squamous cell carcinomas 

G. Pannone1 , A. Santoro1 , M.C. Pedicillo1 , S. Cagiano1 , G. De 

Rosa2 , S. Staibano3 , P. Bufo1 1 Department of Surgical Sciences, Section of Pathological Anatomy, 

University of Foggia, Italy; 2 Dipartimento di Scienze Biomorfologiche 

e Funzionali, Università di Napoli ‘Federico II’, Napoli, Italy; 3 Department 

of Biomorphological and Functional Sciense-Session of Pathological 

Anatomy, University of Naples Federico II, Naples, Italy 

Background. Recent emerging evidences identify Human Papillomavirus 

(HPV) related Head and Neck squamous cell carcinomas 

(HN-SCCs) as a separate subgroup among Head and Neck 

Cancers with different epidemiology, histopathological characteristics, 

therapeutic response to chemo-radiation treatment and 

clinical outcome. However, there is not a worldwide consensus 

on the methods to be used in clinical practice. 

Materials and methods. The endpoint of this study was to demonstrate 

the reliability of a triple method which combines evaluation 

of: 1. p16 protein expression by immunohistochemistry 

(p16-IHC); 2. HPV-DNA genotyping by consensus HPV-DNA 

PCR methods (Consensus PCR); and 3. viral integration into the 

host by in situ hybridization method (ISH). This triple method 

has been applied to HN-SCC originated from oral cavity (OSCC) 

and oropharynx (OPSCC), the two anatomical sites in which high 

risk (HR) HPVs have been clearly implicated as etiologic factors. 

Methylation-Specific PCR (MSP) was performed to study inactivation 

of p16-CDKN2a locus by epigenetic events. Reliability of 

multiple methods was measured by Kappa statistics. 

Results. All the HN-SCCs confirmed HPV positive by PCR and/or 

ISH were also p16 positive by IHC, with the latter showing a very 

high level of sensitivity as single test (100% in both OSCC and OP- 

SCC) but lower specificity level (74% in OSCC and 93% in OPSCC). 

Concordance analysis between ISH and Consensus PCR showed 

a faint agreement in OPSCC (κ = 0.38) and a moderate agreement 

in OSCC (κ = 0.44). Furthermore, the addition of double positive 

score (ISHpositive and Consensus PCR positive) increased significantly 

the specificity of HR-HPV detection on formalin-fixed 

paraffin embedded (FFPE) samples (100% in OSCC and 78.5% 

in OPSCC), but reduced the sensitivity (33% in OSCC and 60% 

in OPSCC). The significant reduction of sensitivity by the double 

method was compensated by a very high sensitivity of p16-IHC 

detection in the triple approach. 

Conclusions. Although HR-HPVs detection is of utmost importance 

in clinical settings for the Head and Neck Cancer patients, 

there is no consensus on which to consider the ‘golden standard’ 

among the numerous detection methods available either as single 

test or combinations. Until recently, quantitative E6 RNA PCR 

has been considered the ‘golden standard’ since it was demonstrated 

to have very high accuracy level and very high statistical 

significance associated with prognostic parameters. In contrast, 

quantitative E6 DNA PCR has proven to have very high level of 

accuracy but lesser prognostic association with clinical outcome 

than the HPV E6 oncoprotein RNA PCR. However, although it 

is theoretically possible to perform quantitative PCR detection 

methods also on FFPE samples, they reach the maximum of accuracy 

on fresh frozen tissue. Furthermore, worldwide diagnostic 

laboratories have not all the same ability to analyze simultaneously 

both FFPE and fresh tissues with these quantitative molecular 

detection methods. Therefore, in the current clinical practice 

a p16-IHC test is considered as sufficient for HPV diagnostic in 

accordance with the recently published Head and Neck Cancer 

international guidelines. Although p16-IHC may serve as a good 

prognostic indicator, our study clearly demonstrated that it is 

not satisfactory when used exclusively as the only HPV detecting 

method. Adding ISH, although known as less sensitive than 

357 

PCR-based detection methods, has the advantage to preserve the 

morphological context of HPV-DNA signals in FFPE samples 

and, thus increase the overall specificity of p16/Consensus PCR 

combination tests. 

references 

Pannone G, Rodolico V, Santoro A, et al. Evaluation of a combined 

triple method to detect causative HPV in oral and oropharyngeal 

squamous cell carcinomas: p16 Immunohistochemistry, Consensus 

PCR HPV-DNA, and In Situ Hybridization. Infect Agent Cancer 

2012;7:4. 

Gillison ML, Koch WM, Capone RB. Evidence for a causal association 

between human papillomavirus and a subset of Head and Neck Cancers. 

J Natl Cancer Inst 2000;92:709–20. 

Lo Muzio L, Campisi G, Giovannelli L, et al. HPV-DNA and survivin 

expression in epithelial oral carcinogenesis: a relationship? Oral 

Oncol 2004;40:736-41. 

Pannone G, Santoro A, Papagerakis S, et al. The role of human papillomavirus 

in the pathogenesis of head & neck squamous cell carcinoma: 

an overview. Infectious Agents and Cancer 2011;6:4. 

Pannone G, Santoro A, Carinci F, et al. Double demonstration of oncogenic 

high risk human papilloma virus DNA and HPV-E7 protein in oral cancers. 

Int J Immunopathol Pharmacol 2011;24(Suppl. 2):95-101. 

Fine needle aspiration diagnosis of papillary 

thyroid carcinoma and metastatic malignant 

melanoma, both sharing braf mutation 

B.J. Rocca, M.R. Ambrosio, A. Ginori, G. Camilli, A. Disanto 



Background. The incidence of cutaneous melanoma (CM) and 

thyroid cancer (TC) has increased in the last years. Risk factors 

that are known to be associated with CM, such as ultraviolet radiation, 

are not known to predispose individuals to TC. Similarly, 

risk factors such as external radiation, are thought to be causative 

for TC but not CM. Thus, there is little evidence in terms 

of epidemiologic support for an association between these two 

cancers. More recently, however, a genetic link between CM and 

TC has been identified. A high percentage of both melanomas 

and papillary carcinomas of the thyroid (PTC) harbor a recurrent 

mutation (i.e. BRAF V600E ) in the BRAF oncogene. The BRAF 

protein kinase is a critical component of the RAS-RAF-MEK- 

MAPK signaling stream, which is frequently activated in human 

cancers. However, another possible physiologic explanation for 

this shared genetic aberration lies in the function of BRAF on 

downstream of the second messenger, c-AMP. Both melanocytestimulating 

hormone (MSH) and thyroid-stimulating hormone 

(TSH) act upon melanocytes and thyroid cells, respectively, 

through engagement of their cognate receptors and induction of 

c-AMP synthesis. Various signaling circuits in melanocytes and 

thyroid cells converge on BRAF, thereby possibly endowing 

these two cell types with a unique vulnerability to BRAF mutagenesis. 

Herein, we report the case of a 65-year-old man with 

PTC and cutaneous malignant melanoma metastatic to masseter 

muscle, both sharing BRAF mutation. 

Materials and methods. A 65-year-old male presented with 

a 6-month history of a solitary 16x14 mm sized nodule in the 

right thyroid lobe. The thyroid stimulating hormone level was 

increased (TSH: 6 mUI/l, reference range: 0,15-4,5 mUI/l) 

and the free T4 level was decreased (FT4: 0,5 ng/dl, reference 

range: 0,8-1,8 ng/dl). The patient presented with a nodule in the 

masseter muscle. Fine needle aspiration (FNA) was performed 

on both lesions, wet fixed and air dried smears were made and 

stained with May-Grunwald Giemsa (MGG) and Papanicolaou. 

Immunocytochemistry for Thyreoglobulin, TTF-1, Melan A and 

HMB-45 were performed. Detection of BRAF mutation in FNA 

material was made. 

Results. Fine needle aspiration cytology (FNAC) of the thyroid 

nodule showed abundant papillary clusters of cells, as well as

358 

monolayered sheets of cells with dense cytoplasm and pale 

nuclei, macrophages and debris. Some cells showed atypia and 

intranuclear vacuoles, These findings were consistent with papillary 

thyroid carcinoma. FNAC of the masseter muscle showed, 

instead, pleomorphic discohesive cells. They had a high nuclear/ 

cytoplasmic ratio. The nuclei were hyperchromatic and characteristically 

showed large nucleoli. Brown to green melanin 

pigment was also found. These findings were consistent with a 

metastatic melanoma and the diagnosis was then confirmed by 

immunocytochemical stainings for S100 and HMB45, which 

were positive. The patient underwent dermatologic visit examination, 

which revealed on the skin of the left leg a 1,8 cm sized, 

black-colored nodule with irregular borders. The histological 

finding of the skin biopsy revealed a T3bN0Mx, Stage IIB 

(TNM7) malignant melanoma. A whole body PET-TC showed 

metastatic lesions in the lungs. BRAF mutation was investigated 

and discovered by both direct sequencing and mutant 

allele-specific PCR amplification for the T to A substitution at 

nucleotide 1799 (V600E). 

Conclusions. Several recent studies have reported the association 

between malignant melanoma and thyroid cancer. The mechanism 

for this is unclear. Some authors have reported that TSH 

is more likely to be expressed by dysplastic nevi than by benign 

nevi, and the dysplastic nevi of melanoma patients have a higher 

TSH expression than that of healthy individuals. Thus, TSH has 

been implicated in the malignant transformation of melanocytes 

to melanoma, and TSH stimulates the growth of melanoma cells. 

On the other hand, it has been suggested that melanoma might induce 

the thyroid dysfunction and this might lead to hypothyroidism 

under the condition of low circulating thyroid hormone levels 

and concomitantly elevated TSH levels, although an autoimmune 

mechanism has also been suggested. Moreover, the rearrangement 

of RET and the mutation of BRAF, which are known to be 

the causes of papillary thyroid carcinoma, are observed in cutaneous 

malignant melanoma. It seems that BRAF plays a key role 

in the development of these two kinds of tumors. As the patients 

with papillary thyroid carcinoma have a higher risk of malignant 

melanoma and vice versa, continuous monitoring in these two 

categories is required. 

references 

Chi Yeon Kim, Seung Hun Lee, Chee Won Oh. Cutaneous Malignant 

Melanoma Associated with Papillary Thyroid Cancer. Ann Dermatol 

2010;22:370-2. 

Ellerhorst JA, Naderi AA, Johnson MK, et al. Expression of thyrotropinreleasing 

hormone by human melanoma and nevi. Clin Cancer 

Res 2004;10:5531-6. 

Ellerhorst JA, Sendi-Naderi A, Johnson MK, et al. Human melanoma cells 

express functional receptors for thyroid-stimulating hormone. Endocr 

Relat Cancer 2006;13:1269-77. 


Goggins W, Daniels GH, Tsao H. Elevation of thyroid cancer risk among 

cutaneous melanoma survivors. Int J Cancer 2006;118:185-8. 

Shah M, Orengo IF, Rosen T. High prevalence of hypothyroidism in male 

patients with cutaneous melanoma. Dermatol Online J 2006;12:1. 

Soares P, Trovisco V, Rocha AS, et al. BRAF mutations and RET/PTC 

rearrangements are alternative events in the etiopathogenesis of 

PTC. Oncogene 2003;22:4578-80. 

nasosinusal melanoma a rare (?) disease and 

potential diagnostic pitfall. 12 years of experience 

V.G. Vellone1 , E. Marrucci1 , F. Bussu2 , M. Rigante2 , C. Parrilla2 , 

G. Paludetti2 , E.D. Rossi1 , G. Fadda1 , G. Rindi1 , G.F. Zannoni1 1 Istituto di Anatomia ed Istologia Patologica-Policlinico A. Gemelli, Università 

Cattolica S. Cuore, Roma; 2 Istituto di Clinica Otorinolaringoiatrica- 

Policlinico A. Gemelli, Università Cattolica S. Cuore, Roma 

Background. Nasosinusal Melanoma represents almost 1% of all 

melanoma. As melanomas arising in other sites they can have a 

protean appearance often resulting in inaccurate diagnoses with 

worrisome consequences in prognosis and treatment planning. 

Materials and methods. The computerized archive of the Surgical 

Pathology Service of Policlinico A. Gemelli (Rome) was 

retrospectively reviewed for the period 2000-2012. We found 13 

cases. In all the cases all the submitted material was included in 

paraffin; from each block two 3 µm thick histological slides was 

cut at different levels and routinely stained in hematoxylin eosin. 

Additional slides from the most significant specimen were cut 

and submitted for immunohistochemistry. 

Results. The mean age of the was 71,5 ± 10,4 years. 4 patients 

were male; 9 patient were female. In most cases the disease manifested 

as large, bleeding polypoid mass resulting in 2-12 paraffin 

blocks.In most of the patients (7 cases) 3 anatomic sites were 

involved; in 3 cases two anatomic sites were involved, in the remaining 

3 cases one anatomic site was involved. The histological 

slides revealed a poorly differentiated epithelioid neoplasm often 

with dischoesive features in 9 cases, the remaining 4 cases were 

mixed neoplasm with epithelioid and spindle cells. Brown, intracellular 

pigment suggestive for melanin was present in 5. cases, 

necrosis was evident in 4 cases. The immunohistochemistry examination 

revealed positivity for Melan A in 13/13 cases; HMB 

45 in 11/11; for S100 in 12/13 cases, Vimentin in 7/7; MITF in 

3/3; Tyrosinase in 1/3. None of the cases showed positivity for 

AE1/AE3, Cromogranin, Synaptofisin or LCA, 

Conclusions. Nasosinusinusal melanomas are not so rare in diagnostic 

routine. They can be mistaken for different neoplasms 

of epithelial, mesechimal or lymphoid origin representing a 

potential diagnostic pitfall. An accurate histological exam with 

an extensive immunohistochemistry panel is required for a final 

correct diagnosis, in particular in the amelanotic cases.

Pathologica 2012;104:359-420 POSTEr 

BIOLOGIA MOLECOLArE 

ThinPrep cytology is a valuable and efficient 

method in detecting egfr mutations in lung 

adenocarcinomas 

V. D’Alicandro, E. Melucci, B. Casini, V. Dimartino, C. Ercolani, 

A. Di Benedetto, C.A. Amoreo, M. Filippetti, M. Milella, P. Visca, 

E. Pescarmona, M. Mottolese 

Regina Elena Cancer Institute, Rome, Italy 

Introduction. Lung cancer is one of the leading causes of cancerrelated 

deaths worldwide and adenocarcinoma is recently becoming 

the most frequent histologic type among non-small-cell lung 

cancers (NSCLC) in many countries. Epidermal growth factor 

receptor (EGFR) is a transmembrane receptor forming dimers 

on ligand binding which stimulates signals through receptor 

autophosphorylation. The activation of these intracellular pathways 

facilitates malignant transformation and tumor progression. 

EGFR, expressed in more than 40% of NSCLC, is mutated in 

about 12-13% of cases in Caucasian population, mainly in the 

adenocarcinoma histotype. Metastasic NSCLC patients have a 

relatively high probability of achieving an objective response to 

EGFR tyrosine kinase inhibitors (TKIs) such as gefitinib or erlotinib, 

only when EGFR gene presents activating mutations in the 

tyrosine kinase domain, mainly in exons 19 and 21. In NSCLC the 

clinical application of TKIs targeting the EGFR requires the analysis 

of gene mutational status 1 . Although cytology is a very common 

and useful approach to evaluate patient eligibility to TKIs, 

the limited number of tumor cells present in the samples may 

constitute a bias for molecular analysis. In the majority of cases, 

DNA was extracted from Papanicolau smears or cell blocks 2 and 

only in very few studies from ThinPrep processed samples 3 . 

Aims. The aims of this study was to evaluate the reliability of 

ThinPrep processed cytological specimens, obtained from primary 

or metastatic lung adenocarcinoma, in detecting EGFR 

gene mutations and to verify whether EGFR mutations rate in 

ThinPrep processed cytological samples presented an accuracy 

and sensitivity similar to bioptic samples. 

Materials and methods. DNA was extracted from 66 Liquid 

Based Cytology (LBC) cases including 33 CT-guided lung, 15 

ultrasound-guided supraclavear or mediastinic lymph nodes and 

5 visceral metastases fine needle aspirates (FNA), 7 bronchial 

washings, 5 pleural effusions and 1 sputum and from histological 

specimens including 32 bronchial and 28 pleural biopsies 

retrospectively selected. Exons 19 and 21 was analyzed by direct 

sequencing. 

Results. The overall specimen insufficiency rate in cytological 

and bioptical samples was similar (12.1% vs 11.7%). In our series 

of 57 valuable LBC (55% of malignant cells in Papanicolau 

smears) we found 7 (12.3%) EGFR mutations, 3 deletions in the 

exon 19 and 4 in exon 21 (L858R). 7 (13.2%) out in 53 valuable 

biopsies, 4 in the exon 21 and 3 in the exon 19. (Tab. I). 

Tab. I. Comparison between EGfR mutations in biopsies and liquid Based 

cytology samples. 

SPECIMENS EGFR WT 

EGFR 

MUTATED 

NON 

VALUABLE 

SPECIMENS 

TOT. 

BiOpSiES 46 7 (13.2%) 7 (11.7%) 60 

cYtologY 51 7 (12.3%) 8 (12.1%) 66 

Conclusions. These results, obtained using LBC, are highly 

concordant with those obtained on bioptic material with an overlapping 

number of non valuable cases. Our findings provided 

evidence that ThinPrep processed cytological specimens are suitable 

for DNA extraction and subsequent EGFR mutation analysis 

by direct sequencing; nevertheless novel and more sensitive 

techniques (i.e. qPCR) than direct sequencing may enhance LBC 

potential in detecting EGFR mutations in NSCLC. 

references 

1 Pao W, Miller VA. Epidermal growth factor receptor mutations, 

small-molecule kinase inhibitors, and non-small-cell lung cancer: current 

knowledge and future directions. J Clin Oncol 2005;23:2556-68. 

2 van Eijk R, Licht J, Schrumpf M, et al. Rapid KRAS, EGFR, BRAF 

and PIK3CA Mutation Analysis of Fine Needle Aspirates from Non- 

Small-Cell Lung Cancer Using Allele-Specific qPCR. PLoS One 

2011;6:e17791. 

3 Lozano MD. Assessment of Epidermal Growth Factor Receptor and 

K-Ras Mutation Status in Cytological Stained Smears of Non-Small 

Cell Lung Cancer Patients: Correlation with Clinical Outcomes. The 

Oncologist 2011;16:877-85. 

B-cell clonality and CD20 expression in classical 

Hodgkin Lymphoma 

L. Marra, M. Cerrone, G. Liguori, V. Gigantino, G. Aquino, 

F. Tisci, V. Relli, L. La Sala, C. Santonastaso, A.R. De Chiara, 

R. Franco, G. Botti 

Pathology Department, National Cancer Institute “Fondazione G. Pascale”, 

Naples, Italy 

Introduction. Hodgkin Lymphoma is defined as a special kind of 

B-cell lymphoma, which usually contains a small number of scattered 

Hodgkin and Reed-Sternberg (HRS) cells in an abundant 

background non neoplastic inflammatory and accessory cells. 

B-cell lymphoma lack of Ig expression and the clonal B-cell 

nature is difficult to be demonstrated, even if in non Hodgkin 

Lymphoma, where it requires both immunohistochemical profiling 

and monoclonality assessment. 

Modern single-cell microdissection technique and molecular genetic 

study demonstrate that HRS cell are derived from germinal 

center B-cell. Some studies report that HRS cells are positive for 

CD20 in 5-58% of CHL cases. 

Recents studies revealed that CD20 expression is an independent 

poor prognostic factor for the failure free survival (FFS) and 

overall survival (OS) in cHL patients, but until now, the role of 

CD20 expression is controversial. 

Today the presence of clonal B-cell receptor rearrangements has 

been considered more supportive of B-cell non-HL. However, the 

evolution of a clonal B HRS cell population during the primary 

local manifestation of HD and persistence and dissemination of 

this clone could indicate that a more advanced B- cell clonality 

suggest a more aggressive behavior. 

In this study, we have correlated CD20 expression in HRS cell 

with B- clonality to evaluate advanced abortive B cell differentiation 

in CHL. 

Material. We have analyzed 80 paraffin-embedded samples cHL 

affects. CD20 expression was determined by immunohistochemistry. 

The scoring criteria for the staining intensity of CD20 were 

based on those described by Rassidakis and Tzankov. On the 

sample with CD20 high expression of HRS cell was performed 

clonality analysis using the BIOMED2 control gene primer set. 

Results and conclusion. CHL is genotypically considered a Bcell 

lymphoma, the classical B-cell marker CD20 is expressed only 

in ~20-30% of such cases. In our study we have observed that 

44% of samples with high score of CD20 expression, described 

by Rassidakis and Tzankov, were monoclonal and all samples 

with absence of CD20 expression have polyclonal pattern. 

Χ 2 – Test shown association between score 3 sec Tzankov and 

B-clonality. 

Our results indicated that the presence routine PCR methods are 

sensitive enough to detect small numbers of malignant cells in 

cHL. We propose the use of clonality in association with immunochemistry 

to identify cHL with B cell differentiation with 

significant prognostic implication.

360 

KB-CD133 enriched cells promote tumor growth 

in xenograft animal models of nude mice 

G. Pannone1 , A. Santoro1 , S. De Maria 2 , M. Mattoni1 , C. Rubini3 , 

P. Bufo1 1 Department of Surgical Sciences, Section of Pathological Anatomy, University 

of Foggia, Viale Luigi Pinto 1, 71122, Foggia, Italy; 2 Department of 

Experimental Medicine, Second University of Naples, Via L. De Crecchio, 7, 

80138, Italy; 3 Department of Neurosciences, Section of Anatomic Pathology, 

Università Politecnica delle Marche, P.zza Roma 22, 60121, Ancona, Italy 

Background. Cancer Stem Cells (CSCs) are cancer cells with 

characteristics of stemness, that are considered tumorigenic, in 

contrast to other non-tumorigenic cancer cells. Several markers 

have been reported to identify the ‘stemness’ identity of cancer 

cells among numerous non stem cell cancer cells. One of the early 

staminal markers employed to test CSC hypothesis was the human 

protein prominin-1/CD133. 

Material and Methods. In this study we have utilized an highly 

tumorigenic epidermoid KB cell line, in order to evaluate the 

ability of CD133+ enriched KB cells to form xenograft tumors 

in animal models. 

We separated the KB-CD133+ and KB-CD133- populations, by 

using immunomagnetic beads and FACS. The separated populations 

were injected in athymic nude mice (BALB/c nu/nu). The 

xenograft tumors have been analysed as regard tumor size and 

for CD133 expression by IHC and for DNA HR-HPV integration 

by ISH, comparing CD133 enriched xenograft tumors versus the 

CD133 non enriched ones. 

Results. Under standard conditions, the KB cell line contains a 

poor population of glycosylated CD133 marker (< 1.0%) when 

investigated with antibodies vs AC133. Finally, enriched CD133 

KB cells possess an higher capacity of tumor growth in xenograft 

models of nude mice, when compared to KB cells that have lost 

CD133 immunoreacivity. 

Conclusion. We show that AC133 epitope is able to select a subpopulation 

of epithelial cancer cells with aggressive behaviour 

and that it may be an useful target in epithelial anti-cancer strategies 

including pharmacological and immunological therapies. 

references 

1 Langan RC, Mullinax JE, Ray S, et al. A Pilot Study Assessing the 

Potential Role of non-CD133 Colorectal Cancer Stem Cells as Biomarkers. 

J Cancer 2012;3:231-40. 

2 Schneider M, Huber J, Hadaschik B, et al. Characterization of colon 

cancer cells: a functional approach characterizing CD133 as a potential 

stem cell marker. BMC Cancer 2012;12:96. 

3 Liu TJ, Sun BC, Zhao XL, et al. CD133(+) cells with cancer stem 

cell characteristics associates with vasculogenic mimicry in triplenegative 

breast cancer. Oncogene 2012;10:1038. 

EML4-ALK in non small cell lung cancer and EGFr 

wild-type patients 

S. Petroni1 , M. Asselti1 , R. Daprile1 , A. Mangia3 , E. Mattioli1 , 

C. Saponaro3 , C. Salvatore1 , D. Galetta2 , G. Simone1 1 2 Anatomic Pathology Unit; Medical Oncology Department, Oncology 

Institute, Bari; 3 Functional Biomorphology Laboratory National Cancer 

Research Centre, Istituto Tumori “Giovanni Paolo II” 

Viale Orazio Flacco, 65, Bari, Italy 

Background. Lung cancer is the first cause of death from carcinoma 

in the world. ALK gene rearrangement, i.e. copy number 

gain or translocation, is present in ∼ 5% of non-small cell lung 

carcinomas (NSCLC) and identifies patients sensitive to ALK 

inhibitors such as Crizotinib. ALK gene (2p23) rearrangement 

predominantly consists of an inversion in chromosome 2p with 

or without interstitial deletion 1 . The aims of this study are: to 

standardize Fluorescence In Situ Hybridation (FISH) method on 

surgical specimens and to select a subset of NSCLC patients who 

could benefit from target therapy with Crizotinib. 


Methods. 19 surgical specimens of lung cancer, 16 males and 3 

females (median age 66 years; range 49-80 years), entered the 

study. 13 cases were adenocarcinomas (ADC), 4 were squamous 

cell carcinomas (SCC), 2 were other malignant diseases; 9/19 

patients were smokers. No patient had received neo-adjuvant 

chemotherapy or radiation therapy. 17/19 were EGFR wild 

type (wt) while 2/19 harboured EGFR mutation (exon 21 and 

19, respectively). In all cases ALK gene rearrangement was 

detected via FISH method (Vysis ALK Break Apart FISH Probe 

Kit). ALK positivity determined by FISH has been defined as 

the presence of > 15% of tumor nuclei showing single 3’ (red) 

fluorescence pattern or split pattern; in split pattern, the splitting 

of the 5’ (green) and 3’ (red) signal must occur by more than 2 

signal diameters. 

Results. One case out 19 (5.3%) presented ALK gene rearrangement 

(Fig. 1-2); this case was an EGFR wild-type adenocarcinoma, 

belonging to a non-smoker, 49 years old patient (Tab.1). 

Conclusion. Our preliminary data confirm other studies 2 demonstrating 

that EML4-ALK translocation is found in 5% of young 

non-smoker patients ( 49 

yrs old 

ADC SCC/ 

other 

EGFR wt EGFR mut 

alK+ 0 1 1 0 1 0 1 0 

alK- 9 9 2 16 12 6 16 2 

total 19 19 19 19 

Fig. 1. Eml4-alK (fiSH) 100x. 

Fig. 2. Eml4-alK (fiSH) 60x.

PoStER 

references 

1 Gerber DE, Minna JD. ALK inhibition for non-small cell lung cancer: 

from discovery to therapy in record time.Cancer Cell. 2010;18:548-51. 

2 Camidge DR, Theodoro M, Maxson DA, et al. Correlations between 

the percentage of tumor cells showing an anaplastic lymphoma kinase 

(ALK) gene rearrangement, ALK signal copy number, and response to 

crizotinib therapy in ALK fluorescence in situ hybridization-positive 

nonsmall cell lung cancer. Cancer 2012;118:4486-94. 

Sparc expression in lung metastases from different 

human tumors: an IHC study realized on a tissue 

micro array and supported by gene expression 

analysis 

F. Zito Marino, G. Scognamiglio, F. Collina, E. La Mantia, 

G. Aquino, G. Gaudioso, V. Relli, R. Sabatino, M. Cantile, 



Naples, Italy 

The extracellular matrix (ECM) is a complex and dynamic structure 

and its perturbation through proteolysis or changes in its 

architecture can disrupt cell-stroma homeostasis favoring tumor 

cell dissemination. Tumor cell attachment and invasion of the 

ECM are viewed as critical events leading to the initiation of 

the metastatic cascade, thus becomes essential better understand 

better the role played by proteins that regulate cell-matrix interactions 

in malignant disease. 

Osteonectin/SPARC (secreted protein acidic rich cysteine) is 

a matricellular glycoprotein that modulates cellular interaction 

with the ECM and is expressed in tissues undergoing remodeling. 

SPARC is differentially expressed in tumors and its surrounding 

stroma in various cancers. Recently, by transcriptomic analysis, 

has identified a set of genes that marks and mediates breast cancer 

metastasis to the lungs, and it was interesting to note that among 

the identified genes, in addition to those involved in cell growth 

and adaptation to the lung microenvironment, is also present 

SPARC. 

In this study, to understand the role of SPARC in directing the 

process of metastasis to the lung tissues, we selected 68 samples 

of lung metastases from different organs/ tissues tumors with 

corresponding primary neoplastic lesions to build a Tissue Micro 

Array, and realized immunohistochemical analysis, supported by 

gene expression investigation by quantitative Real Time PCR. 

Preliminary results showed aberrant expression of SPARC 

mainly in lung metastases originating from cutaneous melanoma 

(40-90% positive cells) and Renal Cell Carcinoma (RCC)(100% 

positive cells). The IHC data are perfectly overlapped to SPARC 

gene expression analysis realized by taqman probes. 

CArDIOCIrCOLATOrIO 

Catastrofic complications secondary to unusual 

structural vascular wall abnormalities 

T. Pusiol, D. Morichetti, M.G. Zorzi 

Dirigente Medico, U.O. Anatomia e Istologia Patologica, Ospedale di 

Rovereto, 

Introduction. Catastrofic complications secondary to unusual 

vascular diseases should be described as single case report in 

order to know dramatic events of usually not lethal vascular 

disorders. 

Materials and methods. Catastrofic complications secondary to 

three cases of unusual structural vascular wall abnormalities have 

been studied. 

Results. Rupture of multiple lienal vein aneurysms in pregnancy. 

A 31-year-old obese pregnant woman in 36th-week, at her third 

gestation, collapsed suddenly at home. The woman was admitted 

361 

to the hospital nearest to her house (almost 25 km). In emergency 

room the clinicians performed clinical and instrumental examines 

which revealed a fatal course, so they did not perform any resuscitation 

maneuvers. Ultrasound examination revealed an acute, 

fetal suffering and the surgeon performed an emergency lower 

segment cesarean cut, in an extreme attempt to save the fetus and 

to understand the cause of the exitus. A massive quantity of blood 

was noted in the abdominal cavity after incision of the peritoneum. 

The fetus was extracted dead from the uterus. The autoptic 

examination of the mother revealed hemorrhagic infiltration of 

the fibroadipose tissue adjacent to the splenic hilus and pancreatic 

tail. The histopathological examination of lineal vein showed a 

diffuse, structural rearrangement. Areas of increase in thickness 

of the vein wall succeeded each other with areas of decrease in 

the thickness itself. This condition was due to an increase of connective 

fibrous tissue, a decreased number of muscular cells and 

interruption of elastic fibers, with consequently increased parietal 

thickness. The decrease of all parietal components was the cause 

of the thinning of the wall. The histology examination showed 

rupture of the wall in saccular aneurysm. Other two aneurysms 

were found along the vein. The wall thickness of lineal, fusiform 

aneurysm was increased for the presence of fibrous connective 

tissue (Fig. 1). The elastic fibers were interrupted. A limited area 

of the fusiform aneurysm wall was thin, with focal interruption 

of all components, at high risk of rupture (Fig. 1). The wall of the 

saccular aneurysm was thinner than normal for reduction of all 

components. Lung edema was present; no significant alteration 

in other organs there found. 

Spontaneous coronary artery dissection in post-partum period. 

A 33 year-old previously healthy female (gravida 1, para 1) had 

given birth to a healthy newborn 3 months before term and was 

found dead on 30.09.2001 at 10.50 am at her home. The autopsy 

findings showed that the heart weighed 300 gr. There were 

some ecchymoses on the anterior portion of the right ventricle. 

The myocardium was red-brown without obvious gross evidence 

of necrosis. The histological examination of the anterior descending 

branch of the left coronary artery showed a more or less 

centric haematoma, located between the coronary tunica media 

and adventitia which flattened and occluded the lumen (Fig. 2). 

The other organs were normal. 

External iliac arteries endofibrosis. 

A 49-year-old man was referred to hospital, relating a severalweek 

history of significant cramping and pain in his thighs and 

calves during exercise. The patient, who was an avid cyclist, had 

initially noticed rapid muscle fatigue in his legs when riding his 

bicycle. Computed tomography angiography identified occlusive 

Fig. 1. fusiform aneurysm. areas of increase in thickness of the vein 

wall succeeded each other with areas of decrease in the thickness 

itself (arrow) (h&E 40x).

362 

Fig. 2 The histological examination of the anterior descending 

branch of the left coronary artery showed a more or less centric 

haematoma, located between the coronary tunica media 

and adventitia flattened and occluded the lumen (H&E 40x). 

Fig. 3 The endofibrotic lesion was composed by myofibroblast 

proliferation with distruped internal elastic membrane. (h&E 

40x). 

stenosis of external iliac arteries (EIAs). Surgery consisted of 

shortening the artery with resection of the fibrotic lesions, and 

enlargement of the arteries with a saphenous vein patch. Histological 

examination of a 3.5 cm. long segment of EIAs showed 

subendothelial plaque with abundant myofibroblast and a distruped 

internal elastic membrane (Fig. 3). Because of the failing 

of this treatment, an aorto-femoral bypass was performed. One 

year after the last surgical treatment, the patient is asymptomatic 

during exercise 

Discussion. Lowenthal and Jacob first reported a case of lienal 

vein aneurysm (LVA) in 1953 1 . LVA occurs predominantly in 

women and the majority of LVAs are asymptomatic, incidental 

findings, until complication as rupture, thrombosis or compression 

of adjacent structures 2 . Rupture of LVA in pregnancy is a 

very unusual and catastrophic event with a very high maternal and 

fetal mortality rate. The present case is the first report with multiple, 

true, saccular and fusiform aneurysms, with lethal rupture 

in pregnancy. The precise etiology of LVA remains unknown, 

because a few of the cases were studied. In the reported cases the 

possible role of hormones leading to structural abnormalities of 

the vascular wall has not been demonstrated, because of the rarity 

of LVA, and so any peculiarity of circulation during pregnancy, 

as hyperdynamic circulation. Different conditions have been associated 

with LVA, including hepatic cirrhosis, portal hyperten- 


sion, pancreatitis and pregnancy, but it can be idiopathic too 3 . In 

all reported cases associated with pregnancy the aneurysm was 

single; the shape, alterations of the vein wall and site were not 

described. Aneurysms of the lienal artery are known more than 

those of lienal vein as site, shape, evolution and management, because 

these ones are diagnosed more frequently as incidental findings 

during assessment for abdominal pain or other disorders 4 . 

The present case is the first report of sudden death of a pregnant 

woman and fetus from a rupture of maternal lineal vein aneurysm, 

complication of multiple aneurysms with accurate histological 

description (Fig. 2). Primary spontaneous coronary artery dissection 

(PSCAD) has been defined as an intramural haematoma of 

the media of the vessel wall (false lumen) which flattens the true 

lumen, leading to blood flow obstruction and acute myocardial 

ischaemia, in the absence of trauma or iatrogenic causes. PSCAD 

is a rare event responsible for acute myocardial ischaemia and 

was first described in 1931 in a 42 year old white woman who 

died suddenly after experiencing chest pain. The disease is also 

know as dissecting aneurysm, intramural haemorrhage or haematoma. 

When secondary causes, such as aortic dissection, trauma, 

coronary angiography,angioplasty, or surgical manipulations are 

excluded 5-7 , the aetiology of spontaneous coronary artery dissection 

remains uncertain and the disease is considered “primary”. 

Most of the patients do not have risk factors for coronary artery 

disease, and hypertension has rarely been reported 5 . On the basis 

of epidemiological data, the condition occurs in one in 20 000 to 

30 000 deliveries and has a high mortality rate for both mother and 

child. The aetiology of PSCAD is unknown. The high incidence 

in pregnancy and puerperium indicates hormonal changes and 

haemodynamic stress as possible factors. Heefner 8 hypothesised 

a two step process for the pathogenesis of SCAD. Firstly, the haemodynamic 

stress of pregnancy leads to an initial intimal rupture. 

This is followed by a delayed bleeding in the tunica media caused 

by the clotting changes that occur during the puerperium 8 . A 

primary rupture of the vasa vasorum into the vessel wall has been 

noted in some cases. Antiphosholipid antibodies may have a role 

in the pathogenesis of dissection by causing endothelial dysfunction, 

although such an association with spontaneous coronary 

artery dissection has not been reported 9 . Arterial endofibrosis 

(E) is an uncommon arterio-occlusive condition that affects highperformance 

endurance athletes, cyclists in particular 10 11 . Patients 

typically present with rapid fatigue and thigh claudication, which 

resolves quickly postexercise. Most patients are found to have 

a simple focal stenosis secondary to fibrotic plaques within the 

external iliac artery. The epidemiology of external iliac artery E 

is not well described. It has been reported that 20% of top-level 

cyclists will develop sports-related flow limitations of the EIAs 12 . 

E is most often described in cyclists, but cases have been reported 

in other groups of endurance athletes including triathletes, runners, 

cross-country skiers, rowers, and rugby players 10 11 . Patients do 

not necessarily need to be professionals. E development has been 

linked to both anatomic and mechanical factors. Studies of affected 

athletes have noted tethering of the EIA to the psoas muscle 

in 50% to 64% of cases 10 12 13 . Further, the middle portion of the 

EIA is subject to both high shear forces and high blood flows 

during maximal exercise. A variety of etiologic factors have been 

suggested, including external compression due to psoas muscle 

hypertrophy, high-flow conditions due to increased cardiac output 

and adaptive systolic hypertension, and kinking/tortuosity. 

Lengthening of the EIA is noted in E patients as the arteries to the 

psoas muscle in the central portion of the vessel create an immobile 

segment “working against” the relatively mobile adjacent segments 

of EIA. The subsequent excess length predisposes the artery 

to repetitive kinking during the pedaling process 13 . This results in 

repeated trauma to the arterial wall, which can cause an inflammatory 

reaction 14 . The endofibrotic lesions have been reported 

to be composed by loose connective tissue matrix with moderate 

to high cellularity consisting of spindle and stellate shaped cells.

PoStER 

In our case the endofibrotic lesions were composed by proliferation 

of myofibroblasts. The E of EIAs and the histological features 

are unique characteristics respect to other similar case reports. 

Conclusions. The clinical course of the present cases show that 

complications secondary to unusual structural vascular wall abnormalities 

may be catastrophic. 

references 

1 Lowenthal M, Jacob H. Aneurysm of splenic vein. Report of a case. 

Acta Med Orient (Tel Aviv) 1953;12:170-4. 

2 Calligaro KD, Ahmed S, Dandora R, et al. Venous aneurysms: surgical 

indication and review of the literature. Surgery 1995;117:1-6. 

3 Koskela O. Rupture of the spleen complicating pregnancy. Ann Chir 

Gynaecol Fenn 1965;54:107-13. 

4 Trastek VF, Pairolero PC, Joyce JW, et al. Splenic artery aneurysms. 

Surgery 1982;91:694-9. 

5 Schmidt JC. Dissecting aneurysms of coronary arteries. Arch Pathol 

1975;99:117-21. 

6 Ehya H, Weitzner S. Postpartum dissecting aneurysm of coronary 

arteries in a patient with sarcoidosis. South Med J 1980;73:87-8. 

7 Bulkley BH, Roberts WC. Dissecting aneurysm (hematoma) limited to 

coronary artery: a clinico-pathologic study of six patients. Am J Med 

1973;55:747-56. 

8 Heefner WA. Dissecting hematoma of the coronary artery: a possible 

complication of oral contraceptive therapy. JAMA 1973;223:550-1. 

9 M Krishnamurthy, R Desai, H Patel. Spontaneous coronary artery 

dissection in the postpartum period: association with antiphospholipid 

antibody. Heart 2004;90:53. 

10 Feugier P, Chevalier JM. Endofibrosis of the iliac arteries: an underestimated 

problem. Acta Chir Belg 2004;104:635-40. 

11 Wijesinghe LD, Coughlin PA, Robertson I, et al. Cyclist’s iliac syndrome: 

temporary relief by balloon angioplast.y Br J Sports Med 

2001;35:70-1. 

12 Schep G, Bender MH, van de Tempel G, et al. Detection and treatment 

of claudication due to functional iliac obstruction in top endurance 

athletes: a prospective study. Lancet 2002;359:466-73 

13 Chevalier JM, Enon B, Walder J, et al. Endofibrosis of the external 

iliac artery in bicycle racers: an unrecognized pathological state. Ann 

Vasc Surg 1986;1:297-303. 

14 Bender MH, Schep G, de Vries WR, et al. Wijn Sports-related flow limitations 

in the iliac arteries in endurance athletes: aetiology, diagnosis, 

treatment, and future developments. Sports Med 2004;34:427-42. 

EnDOCrInO 

HBME-1 and TrOP-2 expression in thyroid lesions: 

a preliminary cyto-histological study 

T. Addati1 , M. Centrone1 , A.L. Marzano1 , S. Petroni1 , O. Popescu1 

, G. Achille2 , S. Russo2 , G. Simone1 1 2 Anatomic Pathology Unit; Otolaryngology Unit National Cancer Research 

Centre, Istituto Tumori “Giovanni Paolo II”, Bari, Italy 

Background. There are still a variable number and a variable terminology 

to define the undetermined Thyroid Fine Needle Cytology 

(ThyFNC). This set of diagnoses led to an still high number 

of unnecessary thyroid surgery, even if, ancillary techniques 

showed to be able in reducing, but not to eliminate, this problem. 

In fact, none of the many immunocytochemal markers tested 

(particularly HBME-1, Galectin-3 and CK19) has been able to 

address surely the undetermined diagnosis versus benign or malignant. 

As a consequence, the Committee V of the NCI Thyroid 

FNA State of the Science Conference, on “utilization of ancillary 

status in Thy FNAs”, in its conclusive remarks, stated that there 

is not sufficient evidence, at this time to use IHC or molecular 

techniques in Indeterminate/Souspicious thyroid FNAs. 

Aim. In this study we analyze the expression of a novel marker, 

TROP-2, that is a cell surface glycoprotein, codified by a gene 

located on p32 of Chr1, a product of the TACTD2 gene family, 

highly expressed in the trophoblasts cells forming the outer 

layer of the blastocyst, which are invasive versus pregnant mi- 

363 

ometrium, because of its role and characteristics, TROP-2 could 

be regarded as an ‘invasive’ normal tissue. 

TROP-2 is present also in choriocarcinomas and in a wide variety 

of epithelial cancers, for example, breast, colon, stomach, 

lung, prostate, ovary, endometrium, uterine cervix and pancreas, 

whereas, there is little or no expression in adult normal tissue. 

Methods. 134 Thy FNCs were selected among 5015 Thy FNCs 

observed in our Institution between 2007 and 2012, because in all 

cytological samples, HBME-1, considered as referral marker for 

Papillary Thyroid Carcinoma (PTC), was determined. 

Results. The 134 Thy FNCs were reclassified according to 

Bethesda System for Thyroid FNA: 70 of them (52.2%) received 

a cytological diagnosis of Atypia/Follicular lesion of 

Undetermined Significance, other 5 cases (3.7%) were classified 

as Follicular/or Oncocytic Neoplasm. Moreover 18 (13.4%) as 

souspicious-PTC, 10 as Papillary Thyroid Cancer (PTC) (7.5%) 

and 25 (18.7%) as Benign nodules diagnosed, were included. 

Moreover, 61 ThyFNCs had adequate material to test TROP-2. In 

76/95 thyroid nodules of the patients which underwent to lobectomy 

or thyroidectomy, there was available histological material 

for both the markers by immunohistochemistry (IHC) (Fig. 1-2). 

Fig. 1. thin layer Cytology: EE 20X (a), HBmE-1 20X (b) and tROp-2 

20X (c). 

A 

B 

C

364 

Fig. 2. Histological sample: EE 5X (a), HBmE-1 5X (b) and tROp-2 5X (c). 

In 134 cytological specimens tested, HBME-1 showed a sensitivity 

of 100% but a specificity of 76.1% whereas, in 61 evaluable 

samples TROP-2 evidenced a Sensitivity of 100% and a specificity 

of 82%. On histological specimens, 82.7% overall agreement 

(p = 0.000, by χ2 test) between the two markers was achieved, 

with a sensitivity of 79% and a specificity of 87 % for HBME-1, 

whereas TROP-2 evidenced a Sensitivity of 67% and a Specificity 

of 94.6%. 

Conclusion. TROP-2 is an available diagnostic tool in thyroid 

cytology such us HBME-1, but our data also evidenced less sensitivity 

in histological samples even if more specificity, probably 

due to technical reasons those request more standardization of 

the method. 

A 

B 

C 


references 

1 Cibas ES, Ali SZ. The Bethesda System for Reporting Thyroid Cytopathology. 

Thyroid 2009;19:1159-65. 

2 Cochand-Priollet B, Dahan H, Laloi-Michelin M, et al. Immunocytochemistry 

with cytokeratin 19 and anti-human mesothelial cell 

antibody (HBME1) increases the diagnostic accuracy of thyroid fineneedle 

aspirations: preliminary report of 150 liquid-based fine-needle 

aspirations with histological control. Thyroid 2011;21:1067-73. 

3 Alberti S, Miotti S, Stella M, et al. Biochemical characterization of 

Trop-2, a cell surface molecule expressed by human carcinomas: formal 

proof that the monoclonal antibodies T16 and MOv-16 recognize 

Trop-2. Hybridoma 1992;11:539-45. 

Ten years of gastroenteropancreatic 

neuroendocrine tumors: is reclassification 

worth while? 

F. Grillo1 , M. Albertelli2 , L. Mastracci1 , M.P. Brisigotti1 , F. Annunziata2 

, M. Arvigo2 , F. Minuto2 , R. Fiocca1 , D. Ferone2 1 2 Histopathology, DISC, Endocrinology, DiMI and Centre of Excellence 

for Biomedical Research. University of Genova, IRCCS Azienda Ospedaliera 

Universitaria San Martino, IST, Istituto Nazionale per la Ricerca 

sul Cancro 

Introduction. Gastro-entero-pancreatic (GEP) neuroendocrine 

tumors (NETs) are rare neoplasms with heterogeneous clinical 

behavior and potential long-term survival 1 2 . In the last decade 

GEP-NET nomenclature and classification have been twice 

reviewed. The 2000 WHO classification 3 had poor prognostic 

power in well differentiated (WD) neoplasms which led to the 

introduction of two new important parameters: grade and stage, 

by ENETS 4 5 ; the former became part of the new 2010 WHO 

classification 6 . Considering the recent introduction of grade and 

stage, their external validation on diverse case series from different 

populations has been called for in the Literature 7 . Retrospective 

reclassification of all cases has not yet been advocated. However 

in view of new targeted therapies, which may be licensed 

for specific grade NETs (eg. Everolimus in G1-G2 pancreatic 

NETs) 8 , this may become important in the future. Our aim was 

to therefore to reclassify retrospectively with grade and stage our 

series, correlate with follow up and identify whether retrospective 

reclassification is feasible. 

Tab. I. distribution of cases according to differentiation, grade and 

stage. 

Differentiation 

(WHO 2000) 

grade 

(ENEtS/WHO 2010) 

Stage 

(Uicc 2009) 

Well 

Differentiated 

Poorly 

Differentiated 

45(90%) 

5(10%) 

g1 31(62%) 

g2 13(26%) 

g3 6(12%) 

i 12 (24%) 

ii 4(9%) 

iii 12%23%) 

iV 22(44%) 

Well 

differentiated 

tumour 

Well 

differentiated 

carcinoma 

14(28%) 

31(62%) 

Materials and methods. From the Histopathology archive at our 

centre, 170 GEP-NETs (1993-2011) were identified. Until now 

50 patients have been reclassified. Mean age at diagnosis was 56 

years, F:M ratio was 1:1.2 and mean follow up was 56 months 

(2-196). The primary sites were; stomach 5; duodenum 3; ileum 

15; appendix 5; colon 6; pancreas 12; liver metastases from unknown 

primary 5. For all cases, slides were reviewed and differentiation, 

grade (as suggested by ENETs – mitotic count/10HPF 

and percentage of Ki67 positive cells counting 2000 neoplastic

PoStER 

Fig. 1. Kaplan-meier survival curves according to a) differentiation (WHO 2000); b) grade; c) grade only in well differentiated tumors which were either 

metastatic or widely invasive (well differentiated carcinomas according to WHO 2000). 

cells) and stage (ENETs and UICC-2009) were re-evaluated. 

Many of the cases were from pre WHO 2000 or 2010 classification 

so all cases were also reclassified according to both systems. 

In cases which did not have a section stained for Ki67 (23/50) 

this was performed. Feasibility was evaluated considering how 

many patients would potentially benefit from reclassification and 

how many man hours both for case retrieval (lab technician) and 

reclassification (lab technician/pathologist) were necessary. 

Results. Distribution of cases with regards to differentiation, 

grade and stage is shown in Tabl I. Correlating differentiation 

with overall survival (OS) WD NETs had strikingly better outcome 

with respect to poorly differentiated ones (see Fig. 1a). 

However only grade identified a subgroup of patients with WD 

lesions with less favorable clinical behavior (OS at 5 yrs: G1 - 

96% vs G2 - 50%) (see Figg. 1b and 1c). Stage was also useful 

though not statistically significant in our small series. At the time 

of reclassification 37/50 patients were alive. If we therefore consider 

only these patients as having benefit from reclassification, 

man hours were in the order of 8 working hours for laboratory 

work and 22 working hours for pathological reclassification (see 

Tab. II). Total mean time necessary for reclassification was just 

under 50 minutes per case. 

Conclusions. Our series confirms the importance of grade and 

stage in prognostic stratification. Reclassification is feasible 

considering that these are relatively rare tumors. In conclusion, 

in consideration of the possible lengthy survival of these patients, 

retrospective classification, especially in cases which may not 

have been previously graded or staged, may influence the choice 

of therapeutic options, even in the future. 

Tab. II. man hours (calculated in minutes) for various steps of reclassification. 

Time in minutes 

for Laboratory 

technician 

Time in 

minutes for 

Pathologist 

case retrieval of 50 cases 0 350 

Slide retrieval of 50 cases 250 0 

paraffin block retrieval of 23 cases* 

Sections and 

165 0 

immunohistochemistry of 23 cases * pathological reclassification 

240 0 

of 50 cases 0 1500 

total for 50 cases 655 (~11hr) 1850(~31hr) 

total for 37 living patients 493 (~8hr) 1325 (~22hr) 

Mean time per case 13 minutes 36 minutes 

* note that for 27 cases Ki67 stain was already available. 

references 

1 Gustafsson BI, Kidd M, Modlin IM. Neuroendocrine tumors of the 

diffuse neuroendocrine system. Curr Opin Oncol 2008;20:1-12. 

2 Modlin IM, Oberg K, Chung DC, et al. Gastroenteropancreatic neuroendocrine 

tumours. Lancet Oncol 2008;9:61-72. 

365 

3 Capella C, Solcia E, Sobin LH, et al. In: Hamilton SR, Aaltonen LA, 

eds. Pathology and Genetics of Tumours of the Digestive System. 

Lyon: IARC Press 2000, pp. 77-82. 

4 Rindi G, Klöppel G, Alhman H, et al; and all other Frascati Consensus 

Conference participants; European Neuroendocrine Tumor 

Society (ENETS). TNM staging of foregut (neuro)endocrine tumors: 

a consensus proposal including a grading system. Virchows Arch 

2006;449:395-401. 

5 Rindi G, Klöppel G, Couvelard A, et al. TNM staging of midgut and 

hindgut (neuro) endocrine tumors: a consensus proposal including a 

grading system.Virchows Arch 2007;451:757-62. 

6 Bosman FT, Carneiro F, Hruban RH, et al, eds. WHO Classification of 

tumours of the digestive system. Lyon: IARC Press 2010. 

7 Volante M, Righi L, Berruti A, et al. The pathological diagnosis of 

neuroendocrine tumors: common questions and tentative answers. 

Virchows Arch 2011;458:393-402. 

8 Yao JC, Shah MH, Ito T, et al; RAD001 in Advanced Neuroendocrine 

Tumors, Third Trial (RADIANT-3) Study Group. Everolimus 

for advanced pancreatic neuroendocrine tumors. N Engl J Med 

2011;364:514-23. 

Coexistence of atypical adenoma, adenoma with 

bizarre nuclei and papillary carcinoma of the thyroid 

T. Pusiol, M.G. Zorzi, D. Morichetti 

Istituto di Anatomia Patologica Ospedale di S Maria del Carmine, Rovereto, 

Tn 

Summary. We report a case of Coexistence of atypical adenoma, 

adenoma with bizarre nuclei and papillary carcinoma of the 

thyroid. 

Introduction. Two variant of follicular adenoma has been 

characterized by nuclear atypia: atypical adenoma and adenoma 

with bizarre nuclei. Atypical adenoma show high cellularity, nuclear 

atypia, or unusual histologic patterns (such as spindle cell 

fascicles), but lacking vascular and capsular invasion on thorough 

sampling. Despite the histologically worrisome appearance, 

this tumour pursues a benign course 1-3 . Adenoma with 

bizarre nuclei are characterized by scattered bizarre nuclei with 

huge size, irregular shape, and striking hyperchromasia. These 

nuclei tend to occur in clusters. They are analogous to nuclei 

seen in many other endocrine tumours and should not be taken 

by themselves as a sign of malignancy 1 . Papillary carcinoma is 

the most common type of thyroid cancer. In the present report 

we describe the coexistence of atypical adenoma, adenoma with 

bizarre nuclei and follicular variant of the papillary carcinoma 

of the thyroid. 

Materials and methods. The first case of coexistence of atypical 

adenoma, adenoma with bizarre nuclei and papillary carcinoma 

of the thyroid. The clinical history of a 72 year-old woman has 

been examined. The histological examination of total thyroidectomy 

has been performed. Expression of p53 has been analyzed. 

Staining for p53 was considered negative if < 5% of the nuclei 

stained.

366 

Results. A 72-year-old woman presented to the endocrinology 

outpatient unit for a routine follow-up visit. The patient underwent 

a total thyroidectomy. 

Histopathologic examination of the thyroid gland revealed a solid 

nodular neoplasm with the longest diameter of 0.8 cm in the upper 

pole of the left lobe. The neoplasm was characterized by an almost 

exclusively follicular pattern of growth. Capsule formation was 

absent. Regardless of follicle size, the nuclei of the lining cells 

have features analogous to those to conventional papillary carcinoma. 

Diagnosis of follicular variant of papillary carcinoma was 

made(Fig. 1). The lower pole of right lobe showed two adjacent 

nodules(Fig. 2). The first had a maximum diameter of 0.9 cm, and 

was capsuled. Histologically the lesion was encapsuled by fibrous 

tissue with extensive calcification and was composed by microfollicular 

pattern with scattered clusters bizarre nuclei(Figg. 3,4). 

Follicular cells with bizarre nuclei were immunoreactive with 

antibody against p53, whereas follicular cells with unremarkable 

nuclei(typical cells) were not stained(Fig. 5). The diagnosis of adenoma 

with bizarre nuclei was made. The second nodule measured 

0.8 cm in diameter maximum and showed complete capsule of 

fibrous tissue. The lesion was composed by closely packed follicles 

lucking lumina. The proliferation was composed by atypical 

bizarre cells with irregular shape and hyperchromatic nuclei. The 

capsular or vascular invasion was absent. The cells were diffusely 

p53 positive. The diagnosis of atypical adenoma was performed. 

Fig. 1. follicular variant of papillary carcinoma of the left lobe (H&E 

4X and 40X in insert). 

Fig. 2. two adjacent nodule of the right lobe (H&E 4X). 


Fig. 3. the nodules were separated by a thick fibrous and calcified 

capsule. (a: the smaller nodule B: the largest nodule) (H&E 10X). 

Fig. 4. the largest nodule (B) showed a pattern microfollicular with 

typical cells (§) and a component with scattered atypical cells (# and 

insert). the smaller nodule was interely composed by atypical, bizarre 

cells (a) (h&E 20X and 40X in insert). 

Fig. 5. the p53 staining was intensely positive in atypical bizarre cells 

whereas was negative in typical follicular cells (H&E 10X). 

Discussion. The biologic significance of atypical adenoma is controversial. 

For this reason atypical adenoma has become for too 

many pathologists, a wastebasket term in which any adenoma that 

looks peculiar or worrisome, even for reasons such as spontaneous 

necrosis or undue mitotic activity, is included. Rosai et al. 4 believed 

the concept of atypical adenoma is imprecise. Chan et al. 5

PoStER 

believed the use of atypical adenoma should be discouraged. P53 

is a well characterized tumour suppressor gene. This gene encodes 

for a nuclear phosphoprotein which is important in the regulation 

of the cell cycle. Mutations of the p53 tumor-suppressor gene represent 

the most common genetic alteration in human tumours. The 

products of this gene is a nuclear protein thought to be involved 

in the control of the cell cycle, apoptosis, and the maintenance 

of genomic stability. The altered protein product of the mutant 

gene has a much extended half-life and can be detected with immunohistochemical 

techniques. It should be noted, however, that 

accumulation of the protein can also occur as a result of epigenetic 

changes, and therefore it is not an obligatory indicator of a gene 

mutation. As far as the thyroid gland is concerned, p53 mutation is 

frequently detected in anaplastic and poorly differerentiated carcinomas 

6-9 . Tzen et al. 10 have analyzed the p53 genes in 2 atypical 

adenomas. Mutations of p53 where detected in the bizarre cells 

but not in the bland-looking follicular cells. Tzen et al. believed 

atypical adenomas showed an identical point mutation in codon 

273 (CGT-CAT), a common mutation in various human cancers, 

including anaplastic carcinoma of the thyroid. This finding supports 

the view of the authors that atypical follicular adenoma is 

a precursor of thyroid anaplastic carcinoma and suggests that 

“atypical adenoma” should not be used to express diagnostic uncertainty 

about the nature of a lesion. Sato et al. 11 have examined 

the immunohistochemical expression of p53 protein in the bizarre 

nuclei of thyroid adenomatous nodule with micro-and macrofollicular 

components, cystic degeneration, a hyalinised region and 

papillary structure. The bizarre cells diffusely expressed p53 protein, 

but the follicular cells were negative. In the study of sato et 

al. no mutation of exons 5-9 of the p53 gene was detected in the 

bizarre nuclei. Sato et al. believed that bizarre nuclei can be seen 

in benign thyroid lesions and overdiagnosis should be avoided 

regardless immunohistochemical overexpression of p53. 

The immunohistochemical expression for p53 has been examined 

in thyroid adenomas. Kanthan 

et al. 12 have examined the p53 expression in twenty five cases of 

thyroid adenomas with hurtle cells changes, both pure and focal. 

The majority of the Hurtle cells where p53 positive and adenomas 

with an increased number of hurtle cells had an a increased percentage 

of p53 staining. Othman et al. 13 have studied the p53 

protein expression in 52 cases of thyroid follicular adenomas 

and have found in 6 case(11.5%). P53 positive. Nasir et al. 14 

have studied p53 expression in 20 follicular adenomas and 21 

follicular carcinomas of the thyroid. These authors found 90% 

of follicular carcinomas exhibited strong nuclear p53 expression. 

P53 stain was seen in only 15% of follicular adenomas. These 

authors believed that immunohistochemical detection of p53 with 

others markers(CD44V6 and CD57) may have practical utility 

differential diagnosis of follicular carcinoma from follicular carcinomas 

from follicular adenomas in routine surgical pathology. 

Hosal et al. 15 also reported weak p53 positivity using immunohistochemistry 

in 1 out of 6 (16,66%) follicular adenoma while 

the positivity was diffuse and strong in all five anaplastic carcinomas 

examined. The present case is the fast report of coesistence 

variant follicular of papillary carcinoma, atypical adenoma and 

adenoma with nuclei bizarre in the same thyroid. The diffuse 

expression of p53 in the bizarre, atypical cells of the adenomas is 

of difficult interpretation. Further studies has been necessary and 

critical review was made regarding the of the utility of immunohistochemical 

detention in the differential diagnosis of follicular 

adenomas from follicular carcinomas. 

references 

1 Hazard JB, Kenyon R. Atypical adenoma of the thyroid. Arch Pathol 

1954;58:554-63. 

2 Lang W, Choritz H, Hundeshagen H. Risk factors in follicular thyroid 

carcinomas. A retrospective follow-up study covering a 14-year 

period with emphasis on morphological findings. Am J Surg Pathol 

1986;10:246-55. 

367 

3 Lang W, Georgii A, Stauch G, et al. The differentiation of atypical adenomas 

and encapsulated follicular carcinomas in the thyroid gland. 

Virchows Arch A Pathol Anat Histol 1980;385:125-41. 

4 Rosai J, Carcangiu ML, Delellis RA. Tumours of the tyroid gland. 

Atlas of tumor pathology Published by the Ardmed Forces Institute of 

Pathology 1992, p. 38. 

5 Chan JKC, Hirokawa H, Evans H.Tumours of Endocrine Organs 

Edited by Ronald A. DeLellis, Ricardo V. Lloyd, Philipp U. Heitz, 

Charis Eng. Published by World Health Organization Classification 

of Tumours IARC press Lyon 2004, p. 98. 

6 Satta MA, Nanni S, Della Casa S, et al. Molecular biology of thyroid 

neoplasms. Rays 2000;25:151-61. 

7 Freeman J, Carrol C, Asa S, et al. Genetic events in the evolution of 

thyroid cancer. J Otolaryngol 2002;31:202-6. 

8 Wynford-Thomas D. Origin and progression of thyroid epithelial tumours: 

cellular and molecular mechanism. Horm Res 1997;47:145-57. 

9 Williams ED. Mechanism and pathogenesis of thyroid cancer in animals 

and man. Mutat Res 1995;333:123-9. 

10 Tzen CY, Huang YW, Fu YS. Is atypical follicular adenoma of the 

thyroid a preinvasive malignancy? Hum Pathol 2003;34:666-9. 

11 Sato K, Shimode Y, Hirokawa M, et al. Thyroid adenomatous nodule 

with bizarre nuclei: a case report and mutation analysis of the p53 

gene. Pathol Res Pract 2008;204:191-5. 

12 Kanthan R, Radhi JM. Immunohistochemical analysis of thyroid adenomas 

with Hurthle cells. Pathology 1998;30:4-6. 

13 Othman NH, Omar E, Mahmood MH, et al. RET and p53 expression in 

thyroid follicular adenoma: a study of 52 cases with 14 years followup. 

Malays J Pathol 2005;27:91-8. 

14 Nasir A, Catalano E, Calafati S, et al. Role of p53, CD44V6 and CD57 

in differentiating between benign and malignant follicular neoplasms 

of the thyroid. In Vivo 2004;18:189-95. 

15 Hosal SA, Apel RL, Freeman JL, et al. Immunohistochemical Localization 

of p53 in Human Thyroid Neoplasms: correlation with biological 

Behaviour. Endocr Pathol 1997;8:21-8. 

GASTrOEnTErICO 

Incidental well differentiated papillary mesothelioma 

of the omentum in a male patient: a case report 

L. Abete, E. Pacella, B. Bocca, T. Celiento, F. Sarocchi, A. Guadagno, 

F. Grillo, L. Mastracci 

Histopathology, DISC, University of Genova - IRCCS Azienda Ospedaliera 

Universitaria San Martino, IST, Istituto Nazionale per la Ricerca 

sul Cancro 

Introduction. Well-differentiated papillary mesothelioma 

(WDPM) is a rare tumor most frequently observed in women 

of reproductive age. It involves most commonly the peritoneum 

although it is rarely seen in other anatomic sites. This neoplasm is 

considered a tumor of uncertain malignant potential although information 

about its biological behavior is still limited. We report 

a rare case of a WDPM in an elderly man. 

Methods and materials. A 70 year old male with a prior recent 

history of complicated inguinal hernia presented to hospital with 

right upper quadrant pain consistent with biliary colic. An abdominal 

ultrasound scan demonstrated multiple small echogenic 

foci in the lumen of the gallbladder suggestive of calculi. He 

underwent an elective laparoscopic cholecystectomy for cholelithiasis. 

During laparoscopic inspection, an unexpected incidental 

lesion located to the omental tissue was noted. It consisted in a 

well-demarcated, rough, whitish ovalar plaque-like proliferation 

on the serosal surface of the omentum measuring 5x4 cm (Fig. 1). 

Moreover, in the abdominal cavity a peritoneal pseudonodule 

containing a Prolene hernioplastic implant and an infarcted epiploic 

appendix were also observed. 

Results. Along with the gallbladder, the omental lesion, the 

infarcted epiploic appendix and the nodular lesion with the entrapped 

Prolene implant were submitted to our Institution for 

pathological examination. The gallbladder grossly measured 

8 cm in length, and several small luminal calculi were found

368 

Fig. 1. Gross appearance of the Wdpm: a whitish rough plaque with 

papillae easily detectable on cut surface. 

within the opened specimen. Histological examination showed a 

chronic follicular cholecystitis. Aspecific findings suggestive for 

prior surgical abdominal interventions, such as numerous foamy 

histiocytes (CD68+), steatonecrosis, fibrosis and mild chronic inflammation 

were noted on the epiploic appendix and on the hard 

fibrous nodule containing the Prolene implant, the latter probably 

representing a hernioplastic plug migrated from the inguinal canal 

and endoved within the abdominal cavity. Microscopic examination 

of the omental peritoneal lesion showed a papillary proliferation 

consisting of thick prominent sclerohyaline cores lined by a 

single row of bland cuboidal mesothelial cells. Immunoperoxydase 

studies demonstrated that the lining cells were positive for 

CK 5/6 and calretinin, thus confirming their mesothelial nature 

(Fig. 2). No mitotic activity, multistratification or significative 

cytological atypia were present. Electron microscopic examination 

further confirmed the mesothelial nature of the cells lining 

the papillary proliferation and their bland cytological ultrastructural 

features consisting of microvilli, rough endoplasmic reticulum, 

microfilaments, and desmosomes (Fig. 3), in keeping with 

previously reported findings 1 . According to the aforementioned 

histological, immunohistochemical and ultrastructural features, a 

diagnosis of WDPM was made. 

In consideration of the substantial benignity of this entity, as 

reported in the literature, in contrast to malignant mesothelioma 

Fig. 2. Histological features of the lesion, consisting of thick, sclerotic 

papillae lined by a single row of non atypical mesothelial cells. a. low 

magnification (2x, H&E); B. detail of the papillae with a thick fibrovascular 

cores (10x, H&E); C. positive immunohistochemical staining for 

Calretinin; d. positive immunohistochemical staining for Ck5/6. 


Fig. 3. ultrastructural features of the mesothelial cells lining the papillae. 

a. Whole mount image of an entire cell; B. Rough endoplasmic 

reticulum and microfilaments. c. Microvilli and desmosomes. 

that notoriously carries a very poor prognosis, the patient was assigned 

to a “watchful waiting” strategy, without further surgical 

or farmacological treatment. A subsequent TC exam, performed 

3 months after the surgical intervention, showed no parenchymal 

lesions suspicious for disease progression and/or extension in 

both thoracic and abdominopelvic scans. Currently the patient is 

still in a follow-up regime. 

Discussion. WDPM is a relatively rare serosal lesion usually affecting 

individuals with no history of asbestos exposure, mostly 

women of reproductive age 2 3 , the omental and pelvic peritoneum 

being the most typical involved areas, and less commonly 

seen at different sites such as pleura 4 5 , pericardium 6 and tunica 

vaginalis 7-10 . Grossly, WDPMs are mostly solitary but can be 

multiple, and appear as gray to white, firm, papillary or nodular 

lesions generally measuring less than 2 cm in diameter, even if 

larger WDPMs (up to 6 cm) have been previously reported 1 2 . 

WDPM must be differentiated at one end of the spectrum from 

mesothelial hyperplastic proliferations and, at the other end, 

from malignant mesothelioma. In mesothelial hyperplasia, that 

not infrequently is characterized by a papillary architecture, 

the papillae have a very thin fibrous core if any, being in most 

cases composed exclusively of mesothelial cells organized in a 

pseudopapillary fashion. Moreover, a reactive flogistic process 

of moderate grade at least, is invariably seen in the adjacent serosa 

3 ; this is an uncommon finding in WDPMs. The differential 

diagnosis of malignant mesothelioma (MM) and WDPM can be, 

at times, very problematic, especially in bioptic material or in 

areas of malignant mesothelioma resembling WDPM. Thorough 

examination of the specimen, given that the material submitted 

for histological examination is representative of the entire 

lesion, should lead to the correct diagnosis in most instances. 

Their clinical and biological behavior is almost invariably benign 

and indolent, even though some have been reported as persistent, 

recurrent or even associated with an aggressive course 

or progression to MM 4 11 . The majority of such cases however 

might well represent undersampled malignant mesotheliomas 

from the beginning. In cases with poorer prognosis, overtreatment 

(adjuvant chemotherapy) may have been the main cause 

of morbidity and mortality associated with WDPMs 2 . It is very 

important to be aware of this pathologic entity, which occurs 

rarely and most commonly as an incidental finding. Accuracy 

and thorough examination is mandatory in order to exclude a 

malignant mesothelioma, which could manifest its invasivity 

and cytologic atypia only in focal areas. At the same time, it 

is necessary to be aware of the indolent biological behavior of 

WDPMs, when correctly diagnosed, in order to prevent overtreatment.

PoStER 

references 

1 Goepel JR. Benign papillary mesothelioma of peritoneum: a histological, 

histochemical and ultrastructural study of six cases. Histopathology 

1981;5:21-30. 

2 Daya D, McCaughey WTE. Well differentiated papillary mesothelioma 

of the peritoneum. Cancer 1990;65:292-6. 

3 Malpica A, Sant’Ambrogio S, Deavers MT, et al. Well-differentiated 

papillary mesothelioma of the female peritoneum: a clinicopathologic 

study of 26 cases. Am J Surg Pathol 2012;36:117-27. 

4 Butnor KJ, Sporn TA, Hammar SP, et al. Well-differentiated papillary 

mesothelioma. Am J Surg Pathol 2001;25:1304-9. 

5 Galateau-Salle F, Vignaud JM, Burke L, et al. Well differentiated 

papillary mesothelioma of the pleura: a series of 24 cases. Am J Surg 

Pathol 2004;28:534-40. 

6 Sane AC, Roggli VL. Curative resection of well differentiated 

papillary mesothelioma of the pericardium. Arch Pathol Lab Med 

1995;119:266-7. 

7 Barbera V, Rubino M. Papillary mesothelioma of the tunica vaginalis. 

Cancer 1957;10:183-9. 

8 Brimo F, Illei PB, Epstein JI. Mesothelioma of the tunica vanginalis: 

a series of eight cases with uncertain malignant potential. Mod Pathol 

2010;23:1165-72. 

9 Chetty R. Well differentiated (benign) papillary mesothelioma of the 

tunica vaginalis. J Clin Pathol 1992;45:1029-30. 

10 Jones MA, Young RH, Scully RE. Malignant mesothelioma of the 

tunica vaginalis: a clinicopathologic analysis of 11 cases with review 

of the literature. Am J Surg Pathol 1995;19:815-25. 

11 Kannerstein M, Churg J. Peritoneal mesothelioma. Hum Pathol 

1977;8:83-94. 

Bile duct lesions in diabetic hepatosclerosis could 

explain raised ALP and GGT in diabetic patients 

T. Celiento1 , E. Nazzari2 , F. Pitto1 , S. Bruno1 , M.P. Brisigotti1 , 

M. Bruzzone1 , L. Mastracci1 , F. Grillo1 University of Genoa 1 Histopathology (DISC); 2 Endocrinology (DIMI) 

Azienda Ospedaliera e Universitaria San Martino-IRCCS-IST, Genoa 

Introduction. Diabetes mellitus (DM) is a complex chronic 

metabolic disease characterized by hyperglycaemia. Many of the 

severe complication of DM, such as diabetic nephropathy, retinopathy, 

peripheral neuropathy and skin ulceration, are the result 

of microangiopathy. High levels of blood glucose may damage 

the sinusoidal endothelial cells via diverse mechanisms. The 

hallmark is thickening of capillary basement membranes in the 

vascular beds of the respective organs and tissue. 

Liver disease associated with DM is common and usually takes 

the form of simple steatosis/non-alcoholic fatty liver disease 

(NAFDL), non-alcoholic steatohepatitis (NASH) 1 or rarely glycogenic 

hepatopathy 2 . 

The liver however may also be a target organ for microvascular 

disease and this finding has been called diabetic hepatosclerosis 

(DH) 3 . Only few reports and case series regarding this rare form 

are found in the Literature 4-6 . The aim of this report is to describe 

a further case of DH and describe bile duct lesions as a new histological 

feature. 

Methods and materials. The patient was male, aged 37 years 

and had a long history of type 1 DM. He had a severe complications 

of diabetes such as retinopathy, nephropathy, peripheral 

neuropathy and systemic hypertension. At the time of hospitalization 

he was oliguric with anasarca. 

Liver function tests were characterized by elevated serum alkaline 

phosphatase and bilirubin with clinical evidence of cholestasis. 

After initial stabilization the patient showed a progressive worsening 

of his general conditions with evidence of acute renal failure 

for which he required dialysis. Septicemia then ensued secondary 

to infection of a lower limb ulcer for which he was placed 

under antibiotic cover and was consequently amputated. His liver 

function tests however were still abnormal (total bilirubin: 14.6 

mg/dL; Direct Bilirubin: 12.3 mg/dL; AST: 9 U/L; ALT: 6 U/L; 

ALP: 1063 U/L; GGT: 209 U/L) and the patient became jaun- 

369 

diced. The clinical differential diagnoses which prompted biopsy 

were steatohepatitis, sepsis, drug induced liver injury or chronic 

bile duct disease. 

Percutaneous liver biopsy (14 mm and 8 mm cores) was performed 

and after formalin fixation and paraffin embedding 4 

µm sections were cut and stained with haematoxylin and eosin, 

Gordon and Sweet’s reticulin stain, Masson’s Trichrome, orcein, 

Perl’s stain for iron and periodic acid-Shiff after diastase digestion 

(DPAS). Further immunohistochemical stains for cytokeratin 

7 for bile duct evaluation and smooth muscle actin (SMA) for 

Fig. 1. a) dense concentric hyaline thickening of portal small hepatic 

artery branches, highlighted by dpaS; b) dense perisinusoidal fibrosis 

mainly in the centrivenular area, demonstrated with trichrome 

staining; c) immunohistochemistry for Sma shows the presence of 

extracellular matrix producing activated stellate cell. 

A 

B 

C

370 

Fig. 2. ductal injury showing “dysplastic-like” modification of the biliary 

epithelium (a) with no evidence of ductular reaction (b). 

A 

B 

activated stellate cells which express myofibroblastic antigens 

were performed. 

The patient developed ileal infarction secondary to atherosclerosis 

of the mesenteric vessels and was resected but died soon after. 

Results. On histologic examination of the biopsy specimen, 

the most striking feature was the presence of dense concentric 

hyaline thickening of portal small hepatic artery branches, 

highlighted by DPAS (Fig. 1a). The change was reminiscent 

of that noted in other organs with diabetic microangiopathy. 

Furthermore dense perisinusoidal fibrosis mainly in the centrivenular 

area, demonstrated with trichrome staining, was 

seen (Fig. 1b) and immunostaining for SMA showed the presence 

of extracellular matrix producing activated stellate cells 

(Fig. 1c). 

Ductal injury showing “dysplastic-like” modification of the biliary 

epithelium was noted but no ductular reaction was present 

(Fig. 2). At a formal count no evidence of ductopenia was seen. 

No copper associated protein deposition was identified. Liver 

architecture was altered due to fibrosis and enlargement of portal 

tracts with only occasional porto-portal fibrous septa. No steatosis 

or necroinflammatory activity were present. No evidence of 

sepsis was seen. 

Conclusions. The report describes a case of DH characterized 

by sinusoidal fibrosis and dense concentric hyaline thickening of 

small hepatic artery branches occurring in a young patient with a 

history of long-standing insulin-dependent DM. 

This lesion was first described by Bernuau in 1982 6 who described 

6 diabetic patients with retinopathy who showed marked 


deposition of collagen fibres within the perisinusoidal space. A 

second report some years later by Latry et al. 7 showed a direct 

correlation between collagenization of Disse’s space and the 

presence of diabetic microangiopathy in both type I and type II 

DM. McGrath et al. 8 also described a case of hepatic sinusoidal 

fibrosis in a diabetic woman. 

Only in 2006 was the term DH applied on a case series 3 composed 

of liver biopsies from 12 diabetic patients with a non-cirrhotic 

form of hepatic sinusoidal fibrosis not associated with NAFDL. 

These researchers also suggested that these lesions probably represent 

a form of diabetic microangiopathy in the liver. 

Further autopsy series identified the incidence of DH in two 

studies. Complete autopsies from 57 adults with DM were reviewed 

for liver pathology and other diabetic complications by 

Hudacko et al. 4 and only 1 case of DH was identified. Furthermore 

in another study from the same year, the incidence of DH 

was evaluated in a 10 year autopsy series of 976 patients, 159 of 

which were diabetic 5 . Approximately 12% of diabetic patients 

were shown to have DH even though the majority were clinically 

silent. This study also confirms that DH is only related to DM and 

is not present with co-existent NAFDL/NASH. 

In our report the laboratory findings were characterized by a 

cholestatic picture with raised bilirubin, ALP and GGT but normal 

transaminases and this is in keeping with the clinical data 

from Harrison et al’s series. Abnormal cholestatic laboratory 

findings indicate that diabetic hepatosclerosis may be associated 

with non-parenchymal hepatic tissue involvement, as opposed 

to the direct parenchymal effects associated with NAFLD. Our 

case showed evidence of ductal injury, with epithelial modifications 

reminiscent of the “dysplastic type lesions” seen in other 

acute bile duct lesions such as GVHD or chronic ductopenic 

rejection (absence of ductular rejection or copper associated 

protein deposition). We postulate that microangiopathy leads 

to acute ischemia of the biliary branches and therefore to acute 

bile duct lesions and elevation of ALP and GGT. This is the 

first report which identifies ductal lesions within this disease 

spectrum. 

In conclusion, diabetic hepatosclerosis may represent a rare hepatic 

form of microvascular disease in DM; the collagenization 

of the space of Disse is positively correlated with the presence 

of diabetic microangiopathy. The underlying causes remain 

unknown at the current time as does prognosis even though the 

patient described in our case report died soon after. 

Further study is needed to precisely characterize diabetic hepatosclerosis 

and to understand the exact mechanism of pathogenesis 

as well as correlation with cholestatic laboratory findings and bile 

duct injury. 

references 

1 Brunt EM. Nonalcoholic steatohepatitis. Semin Liver Dis 2004;24:3- 

20. 

2 Torbenson M, Chen YY, Brunt E, et al. Glycogenic hepatopathy: an 

underrecognized hepatic complication of diabetes mellitus. Am J Surg 

Pathol 2006;30:508-13. 

3 Harrison SA, Brunt EM, Goodman ZD, et al. Diabetic Hepatosclerosis: 

diabetic microangiopathy of the liver. Arch Pathol Lab Med 

2006;130:27-32. 

4 Hudacko R, Sciancalepore JP, Fyfe BS. Diabetic microangiopathy in 

the liver: an autopsy study of incidence and association with other 

diabetic complications. Am J Clin Pathol 2009;132:494-9. 

5 Chen G, Brunt EM. Diabetic hepatosclerosis: a 10-year autopsy series. 

Liver international 2009;1044-9. 

6 Bernuau D, Guillot R, Durand AM, et al. Ultrastructural aspects of 

the liver perisinusoidal space in diabetic patients with and without 

microangiopathy. Diabetes 1982;31:1061-7. 

7 Latry P, Bioulac-Sage P, Echinard E, et al. Perisinusoidal fibrosis and 

basement membrane-like material in the livers of diabetic patients. 

Hum Pathol 1987;18:775-80. 

8 McGrath NM, Yeongt ML. Type 1 diabetes mellitus and hepatic 

sinusoidal fibrosis. British Diabetic Association. Diabetic Medicine 

2000;17:87-8.

PoStER 

MALT lymphoma of the rectum: a case report 

R. Giannatiempo1 , M. Postiglione1 , L. Nugnes1 , R. Franco2 , 

A. Russo1 , A. Nicastro1 , D. Oppressore1 1 UOS Anatomia ed Istologia Patologica /Ospedale Evangelico Fondazione 

Betania, Napoli, Italia; 2 AF Anatomia Patologica/ INT Fondazione G. Pascale, 

Napoli, Italia 

Case presentation. A 64-year-old man had suffered from rectal 

bleeding during defecation for a few weeks, admitted to our 

department. He denied other symptoms or signs including pain, 

weight loss, fatigue or enlargement of lymph nodes. Laboratory 

findings were normal except a slight elevation in the level of 

alkaline phosphatase. 

There was a palpable mass on rectal examination; the mass was 

smooth, firm to hard, and fixed to the rectal wall. 

As further evaluation of the rectal bleeding, colonoscopic examination 

was performed and multiple polypoid lesions were 

observed. However, the appearance of the lesions was not similar 

to the adenomatous polyps that were seen in patients who had 

polyposis syndromes. Instead, lesions were in different sizes from 

millimeters to a few centimeters, connected to each other without 

any normal mucosa in-between, and occupied the lower rectum. 

Multiple biopsies were taken and the histological and immunochemical 

evaluation showed atypical lymphoid cell proliferation 

and lymphoepithelial lesions on the colonic mucosa. 

Histopathological examination of the biopsy specimens from 

the rectal lesion demonstrated a low-grade B cell lymphoma of 

MALT type (Extranodal marginal zone lymphoma) diffuse lymphocytic 

infiltratimg lamina propria, with uniform membranous 

staining of the cells with the B-cell marker CD20). CD5, CD10, 

CD23 and bcl-6 markers were found negative. IgM and bcl-2 

were found positive. Use of polymerase chain reaction (PCR) to 

amplify the immunoglobulin heavy chain (IgH) gene indicated a 

monoclonal pattern. The proliferation index (Ki-67) was high. 

After the diagnosis had been confirmed as low grade MALT lymphoma, 

further evaluation was indicated for stage assessment. 

As additional investigations did not show any evidence of infiltration 

to other organs, the disease was staged as clinical stage I 

rectal lymphoma. 

However, the lesion was enlarged enormously during an observation 

period.This could suggest that the lesion had a tendency to 

advance into a more aggressive clinical course. 

The mass was excised transanally (in pieces, because of friability); 

the tumor measured 5 × 7 cm, localized 1-2 cm proximal to the al 

verge. After surgery, the patient received adjuvant chemotherapy. 

Three months after the completion of therapy, a follow-up 

colonoscopy revealed normal mucosal view. 

In addition, the mucosa was biopsied and the pathological examination 

revealed the complete response of the disease to the therapy. 

During the follow-up, colonoscopic examination and blind biopsies 

were repeated in every 6 months, revealed endoscopically 

and pathologically normal mucosa each time. The patient is still 

alive without any recurrence of the disease 15 months after the 

diagnosis. 

Methacrhonous leiomiosarcoma of small bowel 

with ductal adenocarcinoma of pancreas arising 

with a short interval: a case report 



Betania, Napoli, Italia; 2 AF Anatomia Patologica/ INT Fondazione 

G.Pascale, Napoli, Italia 

Case presentation. A 71 years old man was admitted in the surgical 

emergency with 2 days history of diffuse abdominal pain, 

chest pain, flatulence. 

371 

He denied any associated gastrointestinal symptoms such as nausea, 

weight loss, diarrhea, melena and hematemesis. He also had 

compliant of constipation lasting for the previous 2 days. 

A duodenal ulcer, surgery for an umbilical hernia and chronic 

anemia were mentioned in his medical history. 

The patient has as comorbidities essential hypertension, ischemic 

heart disease, stable angina pectoris and benigne prostate hypertrophy. 

On physical examination he had tachycardia, hypotension but 

body temperature was normal. The abdomen was distended with 

visible peristalsis. There was generalized tenderness on deep 

palpation. Non palpable mass was identified. Bowel sounds 

were exaggerated.. Digital rectal examination was unremarkable. 

Laboratory investigations showed leukocytosis and raised blood 

urea but serum creatinin was within normal range. 

Plain abdominal X-ray in the upright position showed multiple 

air fluid levels below the hemidiaphragms with dilated transverse 

colon and prominent loops of small bowel. 

From the computed tomography (CT) scan of the abdomen a low 

density area was detected and abdominal ultrasonography (US) 

revealed a low echoid mass in the abdominal cavity. 

99m Tc Scintigraphy showed an accumulation in the small intestine 

and a hypervascular mass was supplied from the branch of 

the superior mesenteric artery was demonstrated angiographically. 

With all these findings suggestive of acute intestinal 

obstruction, patient was planned for exploratory laparotomy 

revealing diffuse peritonitis caused by a perforated small intestine 

tumor. Infact intra operatively ileoileal intussusception was 

present 5 cm about to ileo-ceacal junction. The bowel proximal 

to this area was dilataded. There was an intramural mass arising 

from the wall of ileum making the lead point of intussusception. 

So the tumor together about 15 cm of the ileum were extirped 

and enteoenteroanastomosis were performed. Mesenteric lymph 

nodes were enlarged. 

A search of the entire gastrointestinal tract and the peritoneal cavity 

didn’t reaveal other abnormalities. 

Resected specimen of the tumor measured 11x7. Cut surface of 

the specimen revealed a nodular firm tumor which originated 

from the intrinsic muscle layer was observed macroscopically. 

The cut surface was graysh-white and soft with partial lightyellowish 

necrosis. 

Microscopically, the tumor consisted of spindle-shape cells in an 

interlacing or fascicular pattern Mitotic features were occasionally 

encountered at counts of 6 per each 10 high power field. 

The malignant cells were positive for vimentin and smooth muscle 

actin and desmin immunostains. Other immunostains were 

negative (cytocheratin, CD34,CD117, S100). 

The tumor involved the serosal layer with vascular invasion present. 

The proximal and distal margins were free. 

Mesenteric lymph node biopsy showed chronic non specific 

inflammation. The diagnosis of malignant leiomiosarcoma was 

made. 

The patient was referred to Oncology for adjuvant therapy and 

was subjected to regular follow-up without any signs of recurrence 

of disease 12 months after surgery. 

One year later he was referred to surgical emergency for multiple 

episodes of bilous vomiting. Laboratory tests on admission 

showed evidence of anemia, HB 10g/dk, PCR 1,5 mg/dl and 

abnormal tumor markers levels: CEA 9,68 ng/ml, CA 125 41,70 

IU/ml, TPA 109 U/L. 

Computed tomography scan showed an intense homogenously 

enhancing tumor with 3.5 cm in diameter with vanishing limits 

and necrotic areas in the pancreatic head region. The tumor was 

well-demarcated and strongly enhanced on contrastenhanced CT 

images. 

Abdominal ultrasonography revealed 3.5 cm sized, oval-shaped 

hypoechoic solid nodule around the uncinate process of the 

pancreas.

372 

MRI demonstrated pancreas with structural alterations at the 

uncinate portion due to the presence of a nodular mass of around 

3.5cm with a fluid component in itscontext. The formation appeared 

with a vanishing profile and was strictly adherent to the 

anterior wall of the third duodenal. 

On the basis of above findings, the presence of a tumor in the 

uncinate process of the pancreas was strongly suspected. 

The patient was subjected to cefaloduodenopancreasectomy. 

Macroscopic examination of the surgical specimen showed a 

well-demarcated round yellowish mass measuring 4x3.5 cm. 

Final histology demonstrated a ductal adenoncarcinoma of tha 

pancreas (G3) with a signet ring cells component. The neoplasms 

infiltrated the intestinal wall and peripancreatic tissue. None of the 

13 peripancreatic lymph node has shown a center of metastases. 

The patient was kept on regular follow-up by the oncologist for 

palliative cure. 

Gastric metastases from lobular breast carcinoma: 

a diagnostic challenge 

A. Guadagno * , T. Celiento * , F. Sarocchi * , M. Gualco ** , R. Ponte * , 

P. Calamaro * , F. Grillo * , L. Mastracci * 

* ** University of Genoa, Histopathology DISC; IST S.C. of Anatomy, 

Cyto-Histology and Pathology, Azienda Ospedaliera Universitaria San 

Martino-IST- I.R.C.C.S. Largo Rosanna Benzi 10 Genoa, Italy 

Introduction. A study, over a 30-year period from 1993, reports 

more than 1000 cases of gastrointestinal metastases from breast 

cancer 1 . The incidence of extrahepatic gastrointestinal tract 

metastases from lobular carcinoma observed in autopsy studies 

varies in the literature from 6% to 18% with the most commonly 

affected organ being the stomach, small bowel followed by colon 

and rectum 2 . Gastric metastases of breast carcinoma are rare 

but when they occur they represent a major diagnostic dilemma 

especially if incomplete clinical information is given. We report 

two cases of metastatic breast cancer with signet-ring cells to the 

stomach and review the literature. 

Materials and methods. Case report 1: A 63-year old female went 

to gastroenterology consultation complaining of aspecific gastrointestinal 

symptoms. Abdominal CT scan showed thickening of 

the gastric wall without focal thoracic or abdominal lesions. Upper 

gastrointestinal endoscopy showed friable mucosa with two ulcers 

at the antrum and body in a background of linitis plastica. Biopsies 

of the antrum, body and gastric fundus were performed. 

Case report 2: A 64-year old female underwent mastectomy of 

the right breast for lobular carcinoma with positive margins (staging 

not available) at an outside institution. The patient performed 

adjuvant chemotherapy in the same year. Two years later, the 

patient represented complaining of vague gastrointestinal symptoms. 

Abdominal RMI scan showed thickening of the gastric 

wall with severe stenosis, concentric thickening of rectal wall. 

Upper gastrointestinal endoscopy showed erythematous mucosa, 

evidence of linitis plastica, with marked stenosis of the lumen. 

Sigmoidoscopy showed erythematous and edematous mucosa 

with thickened wall and a biopsy of the rectum was performed. 

She underwent a partial gastrectomy because of severe gastric 

stenosis during the same admission. 

Results. Case report 1: Gastric biopsies revealed the presence 

of poorly differentiated carcinoma. The neoplastic cells had eosinophilic 

cytoplasm with signet-ring appearance and hyperchromatic 

nucleus. Cells were non cohesive and dispersed in single 

elements. A first diagnosis of diffuse type non cohesive gastric 

cancer was made. Further clinical information revealed that earlier 

the same year, the patient had been diagnosed with a lobular 

breast carcinoma with axillary lymphadenopathy on VABB core 

biopsy of a mass in her left breast (staging not available) at a 

different institution. The primary breast carcinoma showed the 

following immunohistochemistry (IHC) profile: Cytokeratin 

7 (CK7) positive, Cytokeratin 34βE12 positive, E-Cadherin 


positive, Estrogen receptor (ER) positive, Cytokeratin 20 (CK20) 

negative and Progesterone receptor (PgR) negative. The gastric 

neoplastic cells also stained positive with CK 7, Cytokeratin 

34βE12, gross cystic disease fluid protein-15 (GCDFP-15) and 

ER. Neoplastic cells were negative for CK20, for E-Cadherin 

and for PgR. The diagnosis of metastatic lobular carcinoma (with 

signet-ring cells) to stomach was made. 

Case report 2: Histological examination of rectal biopsies showed 

the presence of isolated neoplastic elements, with signet-ring appearance 

in the lamina propria. Further clinical information was 

sought and only at this point was information of a previous breast 

primary and of gastric wall thickening given to the pathologist. 

IHC was therefore performed and this showed expression of 

CK7, Cytokeratin 34βE12, GCDFP-15 and ER. Neoplastic cells 

were negative for CK20, for caudal type homeobox transcription 

factor 2 (CDX2) and for PgR. Histological examination of the 

gastric specimen showed severe luminal stenosis due to diffuse 

infiltration of atypical cells with signet-ring cells morphology. 

IHC showed the same immunoprofile. The diagnosis of metastatic 

lobular carcinoma (with signet-ring cells) to stomach and 

rectum was made. 

Discussion. Breast cancer is the most frequent malignant tumor 

to metastasize to the gastrointestinal tract in women and is second 

only to malignant melanoma 3 . Metastatic invasive lobular 

carcinoma can mimic gastric cancer 4 5 and incidence of breast 

cancer metastasis to the stomach in long term follow up and post 

mortem studies has been estimated at 2–18% 6 7 . It is important 

to remember that metastatic spread may be seen years after the 

diagnosis of the primary breast lesion. 

Distinction between metastatic lobular breast cancer and diffuse 

type gastric cancer is possible only with adequate clinical information 

and an immunohistochemical panel. Metastatic breast 

carcinoma is usually positive for CK7, GCDFP-15, ER and PgR 

and negative for CK20. CK20 proves to be useful as it is positive 

in gastric cancer while it is not observed in breast carcinomas 8 . 

CK7 is less useful as it is expressed in 90% of breast carcinomas 

and its expression was also observed in 50-64% of primary 

gastric adenocarcinoma 9 . Although primary gastric cancer has 

been reported to show ER and PgR positivity 10 , Van Velthuysen 

et al. 11 report that ERα can be reliably used to diagnose gastric 

metastasis from breast cancer because no primary gastric tumor 

express ERα. They observe that the absence of E-cadherin staining 

was significantly related to metastatic breast carcinoma 12 . 

Furthermore, cytoplasmic positivity for GCDFP-15 may confirm 

mammary origin. Positive staining with GCDFP-15 has been 

found to be a sensitive (55-76%) and specific (95-100%) marker 

for correctly identifying a malignant lesion as metastatic breast 

carcinoma 13 . An excellent correlation between GCDFP-15 

positivity and the origin of a metastatic breast adenocarcinoma 

has been demonstrated. Mammoglobin is another marker, which 

is more sensitive but less specific compared to GCDFP-15. In 

conclusion a correct history of patients and histological examination 

and immunohistochemical analysis of the gastrointestinal 

biopsies in comparison with the original breast cancer histology 

are essential to support the diagnosis of metastatic breast cancer 

to gastrointestinal tract. Clinicians must therefore be aware of the 

difficult differential diagnosis and must supply adequate clinical 

information especially concerning any previous malignancy. 

Case report n. 2. Rectal biopsy: A) (H&E) 40x; B) CK7 40x; C) 

CK20 40x; D) ER 40x; E) GCDFP15 40x. Gastric specimen: F) 

H&E 40x; G) CK 7 10x; H) CK20 10x; I) ER 20x; GCDFP-15 

20x. 

references 

1 Madeya S, Borsch G. Gastrointestinal metastases of breast carcinoma. 

Gastrointest Endoscopy 1993;39:103-4. 

2 Arrangoiz R, Papavasiliou P, Dushkin H, et al. Report and literature 

review: Metastatic lobular carcinoma of the breast an unusual presentation. 

Int J Surg Case Rep 2011;2:301-5.

PoStER 

3 Ciulla A, Castronovo G, Tomasello G, et al. Gastric metastases 

originating from occult breast lobular carcinoma: diagnostic and 

therapeutic problems. World J Surg Oncol 2008;6:78. 

4 Hara F, Kiyoto S, Takabatake D, et al. Metastatic Breast Cancer to 

the Stomach Resembling Early Gastric Cancer. Case Rep Oncol 

2010;3:142-7. 

5 Jones GE, Strauss DC, Forshaw MJ, et al. Breast cancer metastasis to 

the stomach may mimic primary gastric cancer: report of two cases 

and review of literature. World J Surg Oncol 2007;5:75. 

6 Schwarz RE, Klimstra DS, Turnbull ADM. Metastatic breast cancer 

masquerading as gastrointestinal primary. Am J Gastroenterol 

1998;93:111-4. 

7 Cormier WJ, Gaffey TA, Wech JM, et al. Linitis plastica caused 

by metastatic lobular carcinoma of the breast. Mayo Clin Proc 

1980;55:747-53. 

8 Tot T. The role of cytokeratins 20 and 7 and estrogen receptor analysis 

in separation of metastatic lobular carcinoma of the breast and 

metastatic signet ring cell carcinoma of the gastrointestinal tract. 

APMIS 2000;108:467-72. 

9 O’Connell FP, Wang HH, Odze RD. Utility of immunohistochemistry 

in distinguishing primary adenocarcinomas from metastatic 

breast carcinomas in the gastrointestinal tract. Arch Pathol Lab Med 

205;129:338-47. 

10 Matsui M, Kojima O, Kawakami S, et al. The prognosis of patients 

with gastric cancer possessing sex hormone receptors. Surg Today 

1992;22:421-5. 

11 van Velthuysen ML, Taal BG, van der Hoeven JJ, et al. Expression of 

oestrogen receptor and loss of E-cadherin are diagnostic for gastric 

metastasis of breast carcinoma. Histopathology 2005;46:153-7. 

12 Sarrió D, Pérez-Mies B, Hardisson D, et al. Cytoplasmic localization 

of p120ctn and E-cadherin loss characterize lobular breast carcinoma 

from preinvasive to metastatic lesions. Oncogene 2004;23:3272-83. 

13 Honma N, Takubo K, Arai T, et al. Comparative study of monoclonal 

antibody B72.3 and gross cystic disease fluid protein-15 as markers of 

apocrine carcinoma of the breast. APMIS 2006;114:712-9. 

HEr2 status in advanced/metastatic gastric 

carcinomas: a sicilian retrospective multicentric 

analysis 

A. Ieni1,8 , G. Giuffrè1 , S. Lanzafame2 , L. Villari3 , E. Salomone3 , 

E. Roz4 , D. Cabibi5 , V. Franco5 , G. Certo6 , A. Labate6 , C. Nagar7 , 

E. Magliolo8 , B. Brogi9 , C. Fazzari10 , F. Italia10 , G. Tuccari1,11 1 2 Dipartimento di Patologia Umana, Università di Messina; Dipartimento 

Anatomia, Patologia diagnostica, Medicina legale, Igiene e Sanità Pubblica, 

Università di Catania, “Policlinico G. Rodolico”, Catania; 3 A.O.U. 

Vittorio Emanuele II, Catania; 4 Casa di Cura “La Maddalena”, Palermo; 

5 Dipartimento di Patologia Umana, Università di Palermo, A.O.U. “Policlinico 

Giaccone”, Palermo; 6 Casa di Cura “IOMI-Cappellani”, Messina; 

7 U.O.C. Anatomia Patologica, ASP 6 Palermo; 8 U.O.C. Anatomia 

Patologica, ASP 5 Messina; 9 U.O.C. Anatomia Patologica, ASP 8 Siracusa; 

10 Laboratorio Oncopath, Floridia (SR); 11 Programma Interdipartimentale 

di Citodiagnostica e Patologia Molecolare, A.O.U. “Policlinico 

G.Martino”, Messina 

Background. HER2 gene amplification and protein overexpression 

have been suggested as targets for a therapy with anti-HER2 

humanized monoclonal antibody (Trastuzumab) in various cancers. 

Recently, the phase 3 randomized ToGA study showed a 

reduction of 26% in risk of death when Trastuzumab is added 

to chemiotherapy (HR = 0.74) in advanced gastric carcinomas 

(AGC). Moreover, it has been reported that gastric carcinomas 

classified as intestinal type are more likely to be HER2 positive 

(16-34%) than diffuse (2-7%) or mixed (5-20%) types. In 

the present study, we have analyzed HER2 status in a cohort of 

304 surgical cases of advanced/metastatic gastric carcinomas, 

obtained from archives of ten Sicilian anatomopathological units, 

to verify the positive rate of HER2 positive cases, taking into 

consideration also the characteristics of histotype, grade, stage 

and Ki67 expression. 

Methods. From three-hundred four formalin-fixed paraffin-embedded 

tissue blocks of AGC, 4 µm thick parallel sections were 

cut, mounted on silane-coated glasses and subjected to a retrieval 

373 

procedure performed by three changes in 0.01 M citrate buffer 

pH6.0 in a microwave oven at 750W; then each section was 

immunostained for Ki-67 antigen (MIB-1, DAKO Cytomation, 

1:200) and HER2 status (HercepTest AO485 DAKO). The Ki-67 

labelling index (LI) value was calculated as a mean percentage by 

counting the stained nuclei of 1000 tumors cells, utilizing the median 

of 30% as the cut-off point. HER2 expression was evaluated 

by the following score: 0 (no staining), 1+ (faint and discontinous 

staining in < 10% of neoplastic elements), 2+ (light to moderate 

lateral, basolateral or complete staining in > 10% of neoplastic elements), 

3+ (strong, intense lateral, basolateral or complete staining 

in > 10% of neoplastic elements). Cases considered equivocal 

(2+) have been successively assessed by FISH test (pharmDx 

DAKO) or SISH (Ventana, Inform HER2 Dual assay). Statistical 

analysis was performed by Chi-square test. 

Results. Taking into consideration the HER2 positive rate, a 

range of variability was found in different anatomopathological 

units from 7.69% to 21.7%, with a mean value of 17.21%. This 

value is really similar to the mean HER2 positivity rate reported 

in literature (19.2%). Moreover, HER2 overexpression was encountered 

in 51 cases of AGC as a whole; a progressive increase 

in the oncoprotein immunoreactivity was appreciated moving 

from the poorly cohesive histotype (3.5%) to mitochondrion-rich 

(11.1%), tubular/papillary (31.3%) and hepatoid (42.9%) adenocarcinomas. 

Finally, HER2 overexpression was significantly associated 

with high grade (p = 0.011), advanced stage (p = 0.002) 

and high Ki67 LI value (p = 0.015). 

Conclusions. The association of Trastuzumab with chemotherapy 

has been shown to determine an improvement of survival 

in patients with advanced gastric cancers, mostly as the result of 

the survival advantage conferred to patients with amplification 

or overexpression of HER2 protein. On the basis of our findings, 

Trastuzumab should be confirmed as an additional useful 

therapeutic standard option for patients with HER2-positive 

advanced gastric cancers and furtherly in aggressive variants of 

adenocarcinomas. 

Pancreatic solid pseudopapillary neoplasm 

with liver metastasis: a report of three cases 

K. Hirabayashia c , G. Zambonia b , L. Bortesia , P. Castellia , 

M.R. Ballottad , R. Mencarellid a Department of Pathology, Ospedale Sacro Cuore Don Calabria, Verona, 

Italy; b Department of Pathology, University of Verona, Verona, Italy ; 

c Department of Pathology, Tokai University School of Medicine, 143 

Shimokasuya, Isehara, Kanagawa, Japan; d Department of Pathology, 

Ospedale Santa Maria della Misericordia, Rovigo 

Background. Solid pseudopapillary neoplasm (SPN) is a rare 

pancreatic neoplasm composed of poorly cohesive, monomorphic 

cells forming solid and pseudopapillary structures with frequent 

hemorrhagic-cystic degeneration, that predominantly occurs in 

young women. SPN is categorized as a low-grade malignant 

neoplasm 1 . However, SPN rarely metastasizes to the liver or 

peritoneum (5-15% of cases) 1 . The histological differences between 

SPN with metastasis and SPN without metastasis are still 

controversial. Immunohistochemically, SPN usually expresses 

vimentin, α-1-antitrypsin, CD56, progesterone receptor, CD10, 

and nuclear/cytoplasmic β-catenin 2-4 We report of three cases of 

SPN with liver metastasis. 

Clinical presentations. Case 1: a 37-year-old woman from Ospedale 

Sacro Cuore Don Calabria, Verona had a tumor in the pancreatic 

tail and multiple synchronous hepatic masses. Distal pancreatectomy 

and partial resection of the liver were performed. 

Case 2: a-14-year-old woman from Tokai University Hospital, 

Kanagawa, Japan had a tumor in the pancreatic head. Enucleation 

of the pancreatic tumor was performed. About 30 months after 

the first operation, a hepatic tumor was found. Partial resection 

of the hepatic tumor was performed.

374 

Case 3: a-37-year-old woman from Ospedale Santa Maria della 

Misericordia, Rovigo had a tumor in the pancreatic tail. About 

7 months after the first operation, she was found with multiple 

hepatic tumors in the III and IV segment. Partial resection of the 

nodules was performed. 

Macroscopic findings. Case 1: the pancreatic tumor measured 5.0 

× 4.5 × 2.5 cm and was almost completely cystic and calcified. 

The multiple liver tumors were solid, especially the smaller ones, 

and solid and cystic the larger ones. The largest hepatic tumor 

measured 6 cm in diameter. 

Case 2: the pancreatic tumor measured 9 × 8 cm and showed a 

well-circumscribed, solid and cystic appearance with necrosis. 

The hepatic tumor was solid and measured 1.3 × 1.2 ×1.0 cm. 

Case 3: the pancreatic tumor measured 9 cm and showed a whitish, 

well-circumscribed appearance with necrosis. The hepatic 

tumors were whitish, and the largest hepatic tumor measured 3.5 

cm in diameter. 

Histological findings. Case 1 and 2: the pancreatic and hepatic tumor 

specimens showed typical histological features of SPN without 

aggressive features such as high grade atypia, vascular invasion, 

perineural invasion, or high mitotic rate. The tumor cells had 

clear or eosinophilic cytoplasm and small round nuclei arranged 

in sheet-like or peudopapillary structures. Pancreatic tumor of 

Case 1 showed extensive calcification and ossification. Massive 

necrosis was found in the pancreatic tumor of Case 2. Neither apparent 

calcification nor ossification was found in Case 2. 

Case 3: the pancreatic tumor exhibited typical histological and 

cytological features of SPN together with areas with sheet-like or 

pseudopapillary proliferation of tumor cells possessing mildly to 

moderately enlarged nuclei with a relatively high mitotic rate. Tumor 

necrosis together with apoptosis was highly visible. Vascular 

invasion was focally suspected. 

Immunohistochemically, nuclear and membrane β-cateninpositivity 

was present in all cases. Ki67 index was less than 1% 

in Case 1 and 2 and 10-15% in Case 3 

Discussion. We reported three cases of SPN with liver metastasis: 

two patients were in their thirties, one was in her teens, one had synchronous 

metastasis, two had metachronous metastases. Two cases 

showed typical histological features of SPN whereas one showed 

aggressive histological features. Recently, Sumida et al. reviewed 

47 cases of SPN with liver metastasis in the English and Japanese 

literatures 5 . According to their review 5 , features of SPN with liver 

metastasis were as follows: mean age was 35 years (range 11 to 79 

years), Male: Female ratio was1:13.3 (males; 3 cases, females; 40 

cases), synchronous metastases; 54.3% (25/46 cases), resectable 

cases: 40% (16/40 cases). SPN with liver metastasis tend to occur 

in older patients (the mean age of total SPN: 28 years) 1 5 . When 

the metastatic lesion is resected, the prognosis of SPN with liver 

metastasis is as good as that of SPN without metastasis 5 . 

Some author reported the histological features of SPN with 

metastasis: cellular atypia, vascular invasion, local invasion, 

high mitotic rate, high Ki67 index, necrosis, and undifferentiated 

sarcomatoid components 6-11 . Nishihara et al. compared the 

histological features between 3 SPNs with metastasis (liver, peritoneal, 

and/or lymph node) and 19 SPNs without metastasis 11 . 

They suggested that venous invasion, nuclear grade, and prominent 

necrobiotic nests are useful histological parameter to detect 

the malignant potential of SPN 11 . However the cases lacking the 

aggressive features described above have also been reported 12 13 . 

In our present cases, although necrosis was found in Case 2, there 

were no apparent aggressive features in Case 1 and 2. In contrast, 

Case 3 showed aggressive histological features such as high mitotic 

rate, necrosis and high Ki67 index. 

Conclusion. The histological features of SPN with metastasis 

are still controversial. Currently, it would be difficult to predict 

the metastasis of SPN from histological features. SPN patients 

should be followed carefully after surgery regardless of histological 

features. 


references 

1 Bosman FT, Carneiro F, Hruban RH, et al. WHO classification of tumours 

of the digestive system. 4th ed. Lyon: International Agency for 

Research on Cancer 2010. 

2 Notohara K, Hamazaki S, Tsukayama C, et al. Solid-pseudopapillary 

tumor of the pancreas: immunohistochemical localization of neuroendocrine 

markers and CD10. Am J Surg Pathol 2000;24:1361-71. 

3 Abraham SC, Klimstra DS, Wilentz RE, et al. Solid-pseudopapillary 

tumors of the pancreas are genetically distinct from pancreatic ductal 

adenocarcinomas and almost always harbor beta-catenin mutations. 

Am J Pathol 2002;160:1361-9. 

4 Zamboni G, Bonetti F, Scarpa A, et al. Expression of progesterone 

receptors in solid-cystic tumour of the pancreas: a clinicopathological 

and immunohistochemical study of ten cases. Virchows Arch A Pathol 

Anat Histopathol 1993;423:425-31. 

5 Sumida W, Kaneko K, Tainaka T, et al. Liver transplantation for 

multiple liver metastases from solid pseudopapillary tumor of the 

pancreas. J Pediatr Surg 2007;42:e27-31. 

6 Hu JC, Brookings W, Aldridge MC. A case of solid pseudopapillary 

tumour of the pancreas and malignant mesothelioma. J Gastrointest 

Cancer 2007;38:71-3. 

7 Tang LH, Aydin H, Brennan MF, et al. Clinically aggressive solid 

pseudopapillary tumors of the pancreas: a report of two cases with 

components of undifferentiated carcinoma and a comparative clinicopathologic 

analysis of 34 conventional cases. Am J Surg Pathol 

2005;29:512-9. 

8 Hassan I, Celik I, Nies C, et al. Successful treatment of solid-pseudopapillary 

tumor of the pancreas with multiple liver metastases. 

Pancreatology 2005;5:289-94. 

9 Kamei K, Funabiki T, Ochiai M, et al. Three cases of solid and cystic 

tumor of the pancreas. Analysis comparing the histopathological findings 

and DNA histograms. Int J Pancreatol 1991;10:269-78. 

10 J AC, Lozano MD, Rotellar F, et al. Solid pseudopapillary tumor of 

the pancreas (SPPT). Still an unsolved enigma. Rev Esp Enferm Dig 

2010;102:722-8. 

11 Nishihara K, Nagoshi M, Tsuneyoshi M, et al. Papillary cystic tumors 

of the pancreas. Assessment of their malignant potential. Cancer 

1993;71:82-92. 

12 Shimizu M, Matsumoto T, Hirokawa M, et al. Solid-pseudopapillary 

carcinoma of the pancreas. Pathol Int 1999;49:231-4. 

13 Ahmad Z, Yaqoob N, Muzaffar S, et al. Solid and cystic epithelial 

neoplasm of pancreas with metastasis: report of a highly unusual case. 

J Pak Med Assoc 2005;55:37-9. 

Association between tryptase-positive mast cells 

density and par-2 expression in human colorectal 

cancer 

A. Malfettone1 , C. Saponaro1 , N. Silvestris2 , R. Daprile3 , E. Mattioli3 

, A. Paradiso4 , G. Simone3 , A. Mangia1 1 Functional Biomorphology Laboratory, National Cancer Research Centre, 

Istituto Tumori “Giovanni Paolo II”, Bari, Italy; 2 Medical Oncology 

Unit, National Cancer Research Centre, Istituto Tumori “Giovanni Paolo 

II”, Bari, Italy; 3 Pathology Department, National Cancer Research Centre, 

Istituto Tumori “Giovanni Paolo II”, Bari, Italy; 4 Scientific Direction, 

National Cancer Research Centre, Istituto Tumori “Giovanni Paolo II”, 

Bari, Italy 

Introduction. Mast cells (MC) affect growth in various human 

tumors, but their clinical significance in colorectal carcinoma 

(CRC) has not been well studied. As early infiltrating 

elements at the periphery of adenomatous polyps and CRC 1 , 

Tryptase-positive MC (MC-Try) have been observed to directly 

influence outgrowth of the colonic cancer cells by activating the 

protease-activated receptor 2 (PAR-2) 2 . Although experimental 

evidence strongly implicates an active role of PAR-2 in tumor 

progression 3 , their activity in invasive process remain poorly 

understood. 

In this study, we analyzed the relationship between the distribution 

of MC-Try and PAR-2 expression in CRC. 

Material and methods. One hundred and fifteen cases of pathologically 

confirmed primary adenocarcinoma (Duke’s stage 

I-IV) matched with adjacent normal mucosa were investigated

PoStER 

for protein expression of PAR-2 and density of MC-Try by 

immunohistochemical double-staining. PAR-2 expression was 

evaluated both in the areas overexpressing the receptor and at the 

sites where MC most intensively accumulated. The relationship 

of these two tumor markers with clinicopathologic parameters 

were also analyzed. 

Results.The MC count in normal mucosa adjacent to colon cancer 

(79.2 MC/mm 2 , range 22.5-192.7) was significantly higher than 

density in the stroma of the primary CRC (56.3 MC/mm 2 , 15.8- 

97.8) (p < 0.000). Tumor invasive front showed a higher PAR-2 

expression (26.5%, 6.7-62.0) than expression in normal mucosa 

(2.70%, 0-17.7) (p < 0.000). Also in areas where MC-Try most 

intensively accumulated, tumor showed a statistically higher median 

expression of PAR-2 (34.4%, 7.7-78.4) than normal mucosa 

(2.5%, 0-18.9) (p < 0.000). In tumor compartment, a significant 

positive correlation was found between PAR-2 expression and 

MC-Try density (r = 0.393, p< 0.018). 

Moreover, it was demonstrated a higher PAR-2 expression in 

tumors with poor differentiation grade (p = 0.005), positive Peritumoral-Vascular–Invasion 

(p = 0.010) and with positive lymph 

node (p = 0.007) and distant metastasis (p = 0.002) status. Additionally, 

higher MC-Try density occurred in poor differentiation 

grade cancers (p = 0.031) and in male patients (p = 0.004). 

Conclusions. We found that the distribution of MC and PAR-2 

varied passing from tumor to adjacent normal mucosa and the 

increased expression of PAR-2 was positively related to MC-Try 

density and to colonic tumors with poor prognosis. The results 

of our study suggest that, in the context of developing CRC, 

infiltrating MC-Try might influence the expression of PAR-2, 

contributing to tumor invasion and metastasis. Further studies are 

needed to support these observations. 

references 

1 Maltby S, Khazaie K, McNagny KM. Mast cells in tumor growth: 

angiogenesis, tissue remodelling and immune-modulation. Biochim 

Biophys Acta 2009;1796:19-26. 

2 Rattenholl A, Steinhoff M. Proteinase-activated receptor-2 in the 

skin: receptor expression, activation and function during health and 

disease. Drug News Perspect. 2008;21:369-81. 

3 Nishibori M, Mori S, Takahashi HK. Physiology and pathophysiology 

of proteinase-activated receptors (PARs): PAR-2-mediated proliferation 

of colon cancer cell. J Pharmacol Sci 2005;97:25-30. 

An association study of two single nucleotide 

polymorphisms (SnPs) in the SPArC and EGF genes 

with hepatocellular carcinoma 

S. Marasà1 , D. Balasus2 , A. Giacalone2 , L. Marasà2 , L. Giannitrapani2 

, E. Sinagra3 , G. Montalto2 1 2 Institute of Pathologic Anatomy, University of Palermo; Department 

of Clinical Medicine and Emerging Pathologies, University of Palermo; 

3 Division of Internal Medicine, V.Cervello Hospital, Palermo 

Introduction. Hepatocellular carcinoma (HCC) is responsible 

for 85% of all the liver tumors 1 . It is the sixth most common 

neoplasm and the third most frequent cause of cancer-related 

deaths worldwide 2 . HCC incidence varies among countries and 

continents and, is strictly connected to endemic risk factors. 

Theoretically any agents leading to chronic liver inflammation 

could be risk factors. In fact HCV (hepatitis C virus) and HBV 

(hepatitis B virus) infections are widely recognized HCC risk 

factors, they account for 70-80% of HCC cases. The remaining 

percentage of HCCs is caused primarily by aflatoxin B, alcohol, 

hemochromatosis and autoimmune hepatitis 3 , HCC often develops 

from a state of liver cirrhosis.. As for gender, males have 

higher liver cancer rates than females with a 3 to 1 ratio 4 . Despite 

of the fact that HCV infection is the main HCC risk factor not all 

of the HCV-positive subjects develop the disease. This happens 

for almost all the others risk factors. In fact many have founded 

a lot of genetic variations that predispose to liver cancer onset 

375 

and development 5 . In particular a lot of single nucleotide polymorphisms 

(SNPs) have been associated to HCC 6 . Nevertheless 

genetic variations may have different involvements in the disease 

depending on the ethnic groups. In this context the secreted 

protein acidic and rich in cysteine (SPARC) and the epidermal 

growth factor (EGF) protein could be involved in hepatocellular 

carcinogenesis. The aim of this study was to evaluate the association 

between HCC susceptibility and the rs2304052(position 

151034420, substitution T > C) and the rs4444903(position 

111053559, substitution > A) single nucleotide polymorphisms 

(SNPs), located respectively on the SPARC and EGF protein. 

Methods and materials. Genomic DNA was extracted from the 

whole blood samples (75 HCC cases and 170 healthy controls 

were collected from a Southern Italian population).DNA was 

isolated from Buffy coat using the High Pure PCR Template 

Preparation Kit (Roche®). DNA concentration was evaluated 

for every sample through a comparison with four standard DNA 

samples having known concentrations. Genotypes were detected 

by restriction fragment length polymorphism (RFLP) method. 

For the rs2304052 SNP the restriction reaction was performed in 

20 µl with 2 U of EcoO109I. The digestion products were electrophoresed 

on a 2% agarose gel. The digestion with EcoO109I 

produced two fragments of 222 bp and 197 bp in case of C homozygous, 

three fragments of 419 bp, 222 bp and 197 bp in case of 

heterozygous and one fragment in case of T homozygous as it is 

shown in Figure 1. For the rs4444903 SNP the restriction reaction 

was performed in 20 µl with 1 U of AluI. The digestion with AluI 

produced two fragments of 91 bp and 187 bp in case of A homozygous, 

three fragments of 278 bp, 187 bp and 91 bp in case of heterozygous 

and one fragment of 278 bp in case of G homozygous 

as it is shown in Figure 2. Genotype frequencies were evaluated by 

direct gene counting. Control and cases alleles distribution fitted 

to Hardy-Weinberg equilibrium (p 2 + 2pq + q 2 = 1, where p is the 

Fig. 1. 2% agarose gel stained with SYBR Safe®. lane 1, 2: C/t heterozygous. 

lanes 3, 5, and 6: t/t homozygous.lane 4: C/C homozygous. 

l: 100 bp DNa ladder. 

Fig. 2. 2% agarose gel stained with Gel Red®. lane 1: a/a homozygous. 

lane 2: G/a heterozygous. lane 3: G/G homozygous. l: 100 bp dNa ladder.

376 

frequency of the reference allele and q the frequency of the variant). 

Genotype and allele frequencies between case and controls 

were compared with Fisher’s exact test, using 2x2 contingency 

tables. Only p values G polymorphism 

with hepatocellular carcinoma risk: a meta-analysis. Arch Med Res 

2011;42:149-55. 

A solitary polypoid gastric metastasis in renal cell 

carcinoma: an event to be considered 

M. Onorati, P. Uboldi, G. Petracco, S. Romagnoli * , F. Di Nuovo 

Pathology Unit, Garbagnate Milanese, AO “G. Salvini” Garbagnate Milanese, 

Italy. 

* Department of Health Sciences, AO S. Paolo, University of Milan, Medical 

School, Italy 

Introduction. The incidence of gastric metastases is 2,6%. Their 

most common endoscopic appearance is a “volcano-like” polypoid 

mass covered by normal mucosa that may show a central 

ulceration. Although all primary neoplasms can metastasize to 

the stomach, most of them originate from melanoma or breast and 

lung cancer. Metastases from primary neoplasms of the kidney, 

have also been describe. Renal cell carcinoma (RCC) is known 

to spread hematogenously and isolated metastasis to the stomach 

is a rare event. In this report, we describe a gastric recurrence of 

clear-cell renal carcinoma in a patient who underwent nephrectomy 

19 years ago. The case shows that metastatic involvement 

of the stomach should be suspected in any patient with a previous 

history of RCC, presenting with gastrointestinal symptoms, 

although many years after nephrectomy for neoplasm. We also 

pursued a brief review of the literature to update the number of 

cases described until now. 

Methods and results. We report an unusual case of a patient with 

gastric polipoyd metastasis from a RCC. A 82 year-old man was 

admitted to our hospital in Garbagnate Milanese with persisting 


rectal bleeding. On admission severe anaemia was present. He had 

a history of weight loss, epigastric pain and weakness. Because 

of the symptoms and signs, the patient underwent a colonoscopy 

and a gastroscopy. While colonoscopy was negative, gastroscopy 

showed a 30 mm, irregular, polypoid bleeding lesion with superficial 

erosions in the upper part of the corpus near the lesser curvature. 

The lesion was snared with loop biopsy because they did not 

suspect his histological nature and to prevent post-polipectomy 

bleeding. The excision biopsy of the lesion was fixed in formalin 

and stained with Haematoxilin and Eosin. Microscopically, the 

polypoid lesion, covered by ulcerated mucosae, revealed nests 

of neoplastic cells with a solid pattern of growth. The neoplastic 

population showed a peculiar cytological characteristic represented 

by cells with abundant clear cytoplasm. The nuclei were 

round, hyperchromatic with prominent nucleoli. In the absence of 

clinical information cytokeratin-7 was performed to exclude/confirm 

a gastric origin. Subsequently clinicians informed us that the 

patient had a past medical history of left nephrectomy for a clearcell 

RCC in 1992 and a colic resection for a poorly differentiated 

adenocarcinoma of the rectum in 1997. A second set of antibodies 

were tested (CD10, EMA, Vimentin, CK20, and CDX2) on the 

basis of recent clinical information. The neoplastic cells were 

strongly stained with CD10, Cam 5.2 and EMA and Vimentin. 

The diagnosis was consistent with metastasis from clear-cell RCC 

also on the basis of the clinical notice. Endoscopic margins were 

free of disease. CT scan of the chest, abdomen and pelvis showed 

no evidence of other metastatic sites. 

Conclusion. RCC account for 3% of all adult malignancy and 

it is more than twice as common in males than females with the 

majority of cases occurring in the sixth decade of life. Although 

the localizing findings of hematuria, pain and a flank mass are the 

classic triad of presenting symptoms, many patients with renal cell 

carcinoma lack any of these and have systemic symptoms such as 

fever, malaise or anemia. Metastases at the time of diagnosis occur 

in 25%-33% of patients since this neoplasm is frequently presenting 

as metastasis of unknown primary site, sometimes in unusual 

sites. The extent of spread of RCC is notoriously unpredictable 

with well-documented cases of spontaneous regression of metastases, 

prolonged course and recurrence 10 years or more after nephrectomy 

in more than 10% of patients who survive so long. Gastric 

metastases from RCC following radical excision of the primary 

tumour is extremely rare. Despite the strong potential for hematogenous 

metastases of RCC and due to its rarity, stomach metastases 

are often not suspected as a cause of gastrointestinal bleeding. This 

case highlights the importance of clinical information to better 

treat the patients with metastases. Investigation for such metastatic 

tumors should be performed routinely in the follow-up of patients 

who have been treated for RCC. To date about 53 cases of gastric 

metastases from RCC, included the present one, have been reported. 

The most complete article was published in 2011 by Eslick 

et al describing 44 cases. They argue that in their series females 

are younger than males and that overall patients age is younger 

than that previously reported in other case series (66 years vs 73 

years). Moreover they argue that on average there is a long interval 

between nephrectomy and presentation with gastric metastases. 

They confirmed, as Greendike et al stated, that in 25% of new 

patients with renal cell carcinoma, there is radiologic evidence of 

metastases at presentation. They highlighted that, although RCC is 

resistant to chemotherapy and the prognosis of patients with remote 

metastasis is extremely poor, more recent developments have occurred 

in the treatment of gastric cancer; therefore the distinction 

between the two entities is fundamental. Our case demonstrates 

how important is the dialogue between clinicians and pathologists 

in order to obtain a rapid and accurate diagnosis of lesions 

which don’t show any apparent unusual presentation (a gastric 

polyp in the present case), but are histopathologically unlikely to 

be primitive in origin. Although the nature of polypoid mass was 

unknown, the choice of the endoscopic polipectomy seemed to be

PoStER 

the better one because the margins were free. Infact, the correct 

diagnosis was useful to avoid total gastrectomy (surgical stress) in 

a old patient thus preventing a worsening of patient’s quality of his 

life. Moreover, our case underlines the importance of an accurate 

follow-up in patients with a past history of RCC, which should not 

exclude the gastrointestinal tract. 

references 

1 Eslick G, et al. Gastric metastasis in renal cell carcinoma: a case 

report and systematic review. J Gastrointest Canc 2011;42:296-301. 

2 Garcia-Campelo R, et al. Renal cell carcinoma: complete pathological 

response in a patient with gastric metastasis of renal cell carcinoma. 

Anti-Cancer Drugs 2010;21(suppl. 1):S13-5. 

3 Kibria R, et al. Upper gastrointestinal bleeding revealing the stomach 

metastases of renal cell carcinoma. J Gastrointest Can. 2009;40:51-5.4. 

4 Pezzoli, et al. Gastrointestinal bleeding from gastric metastasis of 

renal cell carcinoma, treated by endoscopic polypectomy. Endoscopy 

2007:39:E52. 

5 Picchio M, et al. Gastric metastasis from renal cell carcinoma fourteen 

years after radical nephrectomy. Acta chir belg 2000;100:228-30. 

6 Riviello C, et al. Unusual gastric and pancreatic metastatic renal cell 

carcinoma presentation 10 years after surgery and immunotherapy: A 

case report and a review of literature. 2006;12:5234-36. 

7 Sugasawa H, et al. Isolated gastric metastasis from renal cell carcinoma 

19 years after radical nephrectomy. Int J clin Oncol 2010;15:196-200. 

8 Yamamoto D, et al. Metastatic gastric tumor from renal cell carcinoma. 

Gastric Cancer 2009;12:170-3. 

Extramedullary hematopoiesis: rare localization 

in the gastric fundus 

F. Pitto1 , M. Bruzzone1 , P. Cognein2 , P. Calamaro1 , F. Sarocchi1 , 

A. Guadagno1 , F. Grillo1 , L. Mastracci1 1 University of Genoa, IRCCS San martino, IST, U.O. Anatomia Patologica, 

DISC; 2 IRCCS San martino, IST, UOC Gastroenterologia ed endoscopia 

digestiva 

Introduction. Extramedullary hematopoiesis (EMH) is the presence 

of myeloid, erythroid and/or platelet precursors outside the 

bone marrow. The most common sites of EMH are liver, spleen 

and lymph nodes. Less commonly it is possible to find foci of 

EMH elsewhere in the body, i.e. breast, kidney, thymus, adrenal 

gland, pleura, central nervous system1 amongst others. Gastrointestinal 

localizations of EMH are extremely rare and only 3 previous 

cases describe gastric EMH in the literature. 

Materials and methods. We report a case of a 35 year old man 

with Beta Thalassemia (Cooley’s disease) and HCV positivity, 

presenting with severe anemia and gastric pain. Endoscopy 

showed in the gastric fundus a protruding mass of about 4 cm 

with a central ulceration spontaneously bleeding (Fig. 1). CT 

Fig. 1. Endoscopic image of polyp. 

377 

confirmed a solid gastric mass close to the cardias, partially calcified 

and protruding into the lumen, with a polypoid shape and a 

maximum diameter of 40 mm as well as multiple abdominal and 

thoracic adenopathies. EUS showed a hypoechoic mass deriving 

from the muscular layer with well-defined borders. All the techniques 

suggested the possibility of a Gastro-Intestinal Stromal 

Tumor. The surgeon deemed the patient at high risk for surgical 

intervention due to a previous splenectomy and related intraabdominal 

adhesions, so the polypoid mass was endoscopically 

removed for definitive diagnosis. 

Results. Histology revealed that the core of the polypoid mass 

was composed of expanded lamina propria with numerous erythroid 

and myeloid precursor cells between the gastric foveolae 

and gastric glands (Fig. 2). These elements had hyperchromatic, 

angulated nuclei and small to moderate amounts of eosinophilic 

cytoplasm; some had multiple nucleoli (Figg. 3-4). Immunohistochemical 

analysis showed these cells to be negative for cytokeratin 

and positive for glycophorine and myeloperoxidase. These 

morphologic and immunohistochemical features are in keeping 

with foci of extramedullary haematopoiesis composed of red and 

white line cell precursors, lacking megakaryocytes. 

Discussion. EH is a compensatory mechanism for insufficient 

medullary haematopoiesis occurring in patients with various 

haematological disorders, including haemoglobinopathies. The 

previous reported cases all regarded men, two affected by myelofibrosis 

2-3 and the third 4 by chronic myelogenous leukemia; 

Fig. 2. EE, 4x. 

Fig. 3. EE 20x.

378 

Fig. 4. giemsa 20x. 

age ranged between 35 and 75 years. All the reported cases 

presented with a submucosal mass, determining a polypoid 

protrusion. 

Differential diagnosis of gastric polypoid lesions include fundic 

gland polyp, hyperplastic polyp, adenoma or adenocarcinoma, 

raised erosions, lymphoma, gastrointestinal stromal tumours 

and metastatic cancer. This type of presentation suggests that 

EMH, though rare, should be added in the differential diagnosis 

of gastric polyps in patients with insuffcient medullary haematopoiesis. 

references 

1 Koch BL, Bisset GS 3rd, Bisset RR, et al. Intracranial extramedullary 

hematopoiesis: MR findings with pathologic correlation. AJR Am J 

Roentgenol 1994;162:1419-20. 

2 Palmer GM, Shortsleeve MJ. Gastric polyps due to Extramedullary 

Hematopoiesis. AJR 1998:171. 

3 Tiong C, Tai C-J, Chen WY, et al. Multiple sessile polypoid lesions in 

the stomach. BMJ Case Rep 2009;2009:bcr2006110130. 

4 Gomes AS, Harell GS. Tumefactive extramedullary hematopoiesis of 

the stomach. Gastrointestinal Radiology 1976;1:163-5. 

Localized giant inflammatory polyp, a case report 

of a patient without inflammatory bowel disease 

F. Sarocchi1 , M.P. Brisigotti1 , P. Spaggiari2 , M. Montorsi3 , A. Spinelli3 

, R. Ponte1 , L. Mastracci1 , R. Fiocca1 1 University of Genoa Histopathology (DISC), Azienda Ospedaliera Universitaria 

San Martino - IRCCS-IST, Genoa, Italy; 2 University of Milan, 

Department of Histopathology, Humanitas Clinical Institute - IRCCS, Rozzano 

Milan, Italy; 3 University of Milan, Department of General Surgery, 

Humanitas Clinical Institute - IRCCS, Rozzano Milan, Italy 

Introduction. Gastrointestinal polypoid lesions include a great 

variety of different entities both within the neoplastic and nonneoplastic 

spectrum (eg. adenomas, neuroendocrine tumours, 

lymphoid polyps, mesenchymal polyps, vascular ectasias, neural 

lesions etc 1 ). Epithelial polyps develop throughout the gastrointestinal 

system either as sporadic lesions or as part of a polyposis 

or hereditary cancer syndrome. The most common syndromes 

are those that involve neoplastic intestinal adenomas and include 

familial adenomatous polyposis, MYH polyposis and hereditary 

non-polyposis colorectal cancer syndrome (HNPCC). 

We described a rare case of localized giant inflammatory polyp, 

an entity which was first described in 1968 2 . These lesions are 

almost invariably associated with inflammatory bowel disease 

(IBD), especially ulcerative colitis. Our case, however, like others, 

clearly demonstrates that these lesions may also occur in 

patients without history of IBD 3 . 


Materials and methods. A 48 year old woman presented for 

gastroenterology consultation at Emergency after a recent onset 

of multiple episodes of severe abdominal suffering. The pain 

was confined in the right lower quadrant. The patient reported 

weight loss, about 10 kg in 6 months, with no history of diarrhea, 

significant nausea or vomiting, anemia or GI bleeding. She had a 

positive family history for colon cancer. In a first examination she 

presented abdominal swelling, with faecal content, but no palpable 

masses. She had never undergone a colonoscopy in the past. 

The CT scan without contrast showed concentric thickening in 

the ascending colon. No lesions in other abdominal organs were 

identified. Ultrasound also confirmed these findings. 

She tolerated colonoscopy preparation without difficulty. At 

colonoscopy, the terminal ileum and the ileo-cecal (IC) valve 

were normal, however a thickening in proximal ascending colon 

was seen associated with a bulky, pedunculated, frond-like mass. 

The rest of the colon was normal. The endoscopist took biopsies 

from the mass and sent them for histological evaluation. 

Results. The lesional biopsies showed fragments of large bowel 

with prominent stromal inflammation (composed of neutrophils, 

lymphocytes, plasma cells), crypt abscesses and decrease in 

cytoplasmic mucus. In consideration of the low specificity of 

these findings, the endoscopic picture and the family history, 

the patient agreed to surgical evaluation and underwent right 

hemicolectomy. 

Figg. 1, 2. Gross appearance of the localized giant inflammatory polyp 

of the colon, measuring 9 cm in largest diameter, showing numerous 

thin, wormlike filiform polyps.

PoStER 

Grossly, an irregular villous polypoid lesion, measuring 9 cm in 

largest diameter was found in the ascending colon, near the IC 

valve. The lesion showed circumferential growth, with a centrally 

depressed area and extension with small, warm-like polyps of 

gradually decreasing size into the neighbouring normal mucosa 

(Figg. 1, 2). 

Histological examination revealed irregular finger-like projections 

of the mucosa of various sizes 4 (Fig. 3). Crypt architecture 

was markedly distorted, the lamina propria was obliterated by 

fibro-muscular tissue and contained a dense mixed inflammatory 

infiltrate 5 . Crypt abscesses as well as hyperplastic lymphoid follicles 

were frequently observed, while epithelial dysplasia was 

lacking. Some slides showed a circumscribed superficial ulcer 

with a granulation tissue border. The polyps showed fibrous 

cores containing congested and hyalinized vessels with evidence 

of thrombosis 6 . The non-polypoid mucosa of the resection specimen 

was entirely normal, with no evidence of inflammation and 

Fig. 3. microscopic features of the filiform polyps: all lesions are 

finger-like projections (stained with hematoxylin-eosin). 

Fig. 4. appearance of polypoid and nonpolypoid colon, both without 

dysplasia (stained with hematoxylin-eosin). On high magnification, 

crypt abscess and a mixed inflammatory infiltrate within the lamina 

propria are present. 

379 

in particular no evidence of IBD (3) (Fig. 4). In addition, there 

was no evidence of arborizing smooth muscle central cores or 

hyperplastic mucosa to suggest Peutz-Jeghers polyps or evidence 

of cystically dilated glands or expansion of the lamina propria to 

suggest juvenile polyps. 

These findings constituted a diagnosis of localized giant inflammatory 

polyp. 

Discussion. Localized giant inflammatory pseudopolyps were 

first described in 1968 and are usually associated with IBD 2 . 

Little is known about the etiopathogenesis of this entity, mostly 

because of its rarity: some theories consider them as an excessive 

mucosal response due to chronic injury, for example inflammation 

and regeneration in ulcerative colitis 3 . Their distribution and 

size depends on the extent of the primary disorder. 

The appearance (bulky mass, central depression, concentric 

thickening in colon) generally leads to a clinical suspicion of 

carcinoma. 

Our case is a rare localized giant inflammatory polyp not associated 

with IBD; the adjacent colonic mucosa was normal, with no 

evidence of inflammation. 

Two cases of non IBD associated polyps have been previously 

described: both were found in middle aged men, without specific 

symptoms or history of inflammatory bowel disease. Both cases 

lacked dysplastic lesions. Histologic features are similar to our 

case 7 3 . 

In conclusion, localized giant inflammatory polyps of the colon 

represent an uncommon distinct entity. They may very rarely occur 

in patients lacking a history of IBD which may cause serious 

diagnostic problems, especially if malignancy is suspected. 

references 

1 Rosai and Ackerman’s; Tenth Edition; Chapter 11, pp. 773-4. 

2 Hinrichs HR, Goldman H. Localized giant pseudopolyps of the colon. 

JAMA 1968;205:248-9. 

3 Wolf EM, Strasser C, Geboes K, et al. Localized giant inflammatory 

polyp of the colon in a patient without inflammatory bowel disease. 

Virchows Arch 2011;459:245-6. 

4 Lee CG, Lim YJ, Choi JS, et al. Filiform polyposis in the sigmoid 

colon: A case series. World J Gastroenterol 2010;16:2443-7. 

5 Tendler DA, Aboudola S, Zacks JF, et al. Prolapsing Mucosal Polyps: 

An Underrecognized Form of Colonic Polyp - A Clinicopathological 

Study of 15 Cases. The American Journal Of Gastroenterology 

2002;97:370-6. 

6 Oakley GJ III, Schraut WH, Peel R, et al. Diffuse Filiform Polyposis 

With Unique Histology Mimicking Familial Adenomatous Polyposis in 

a Patient Without Inflammatory Bowel Disease. Arch Pathol Lab Med 

2007;131:1821-4. 

7 Tan KH, Meijer S, Donner R. Giant localized pseudopolip of the colon 

without colonic inflammation disease – case report. Neth J Surg 

1987;39:95-97. 

regenerative hepatic nodules in children treated for 

malignancy: a case report and review of literature 

P. Ceriolo1 , V. Vitale2 , M. Bertamino2 , S. Bruno3 , F. Pitto3 , 

C. Rossi3 , M. Bruzzone3 , L. Mastracci3 , F. Grillo3 1 2 Histopathology and Department of Pediatric Hematology and Oncology, 

Giannina Gaslini Institute IRCC, Genova; 3 Histopathology, DISC, 

University of Genova - IRCCS Azienda Ospedaliera Universitaria San 

Martino - IST - Istituto Nazionale per la Ricerca sul Cancro, Genova 

Introduction. The discovery of liver nodules during post-cancer 

surveillance is a diagnostic challenge. Detection of these lesions 

is frequently accidental, during imaging performed in the follow 

up of oncologic patients and it raises important queries as to differential 

diagnosis, including primary and metastatic liver lesions. 

Benign regenerative lesions however have been described in pediatric 

patients after administration of cytoreductive agents or bone 

marrow transplant (BMT) and may be seen frequently 1 . Few of 

these benign lesions however have been biopsied and, in particular, 

no systematic case series of biopsied liver nodules exists. Most au-

380 

thors 2 3 report the benign nature of these lesions with either a diagnosis 

of nodular regenerative hyperplasia (NRH) or focal nodular 

hyperplasia (FNH) being made. We report on a case of multiple 

hypervascular liver nodules in a 20 year old post BMT woman. 

Materials and methods. A 14-year-old female was diagnosed 

with acute lymphoblastic leukemia, at the Giannina Gaslini Pediatric 

Hospital in Genova, in 2005. She presented with generalized 

lymphadenopathy, splenomegaly and mild thrombocytopenia. 

Her treatment consisted of chemotherapy with Ifosfamide, Cyclophosphamide, 

Methotrexate, Daunorubicin, Doxorubicin, Vincristine, 

Vindesine, Etoposide, ARA C, L-ase, 6-mercaptopurine, 

6-Thioguanine, Steroid and allogenic transplant of hemopoietic 

staminal cells by volunteer donor, preceded by total body irradiation 

(1200 cGy) and Etoposide. Immunosuppressive therapy with 

Cyclosporine was stopped after 10 months from transplant. There 

was no evidence of disease recurrence for 5 years after chemotherapy. 

During follow-up the patient developed hypergonadotropic 

hypogonadism, cataract and bile-stones. Liver function tests were 

within normal range and serology was negative for hepatitis C 

and B virus. At 3 years from the end of chemotherapy on routine 

ultrasonography (USG), two hepatic nodules were identified 

respectively in segment 4 and 5. The first measured 3 cm in 

maximum diameter, and was hypovascular at Colour Doppler 

while the second measured 1 cm. Contrast-enhanced CT showed 

multiple hepatic intraparenchymal nodules characterized by rapid 

uptake and rapid wash out of contrast. Review of the most recent 

USG and abdominal CT examinations performed 1 year earlier 

showed no underlying hepatic abnormality. Six months later, 

upper abdominal magnetic resonance imaging (MRI) confirmed 

the lesions seen at USG and CT which appeared slightly enlarged 

(4 cm in maximum diameter) and hyperintense compared to the 

surrounding liver parenchyma in T1 and T2-weighted image. One 

year later USG was performed during follow up which showed 

lesions to be substantially larger (maximum diameter 6 cm) and, 

at Color Doppler, a vascular peripheral ring with some branches 

with centripetal trend were seen. Abdominal MRI was therefore 

performed and it showed a total of 7 lesions in many segments 

ranging from 1 cm to 5.7 cm in diameter. Signal characteristics 

were in keeping with solid nodular hepatocellular lesions. The 

substantial increase in size over time prompted USG-guided 

percutaneous liver biopsy at the IRCCS San Martino Hospital, 

Genova in 2012, when the patient was 20. 

Two liver biopsy cores measuring 23 and 3 mm obtained from the 

5.7 cm lesion were received at the Histopathology section, DISC, 

University of Genova, IRCCS San Martino Hospital. Sections 

were stained with haematoxylin and eosin, Masson’s Trichrome, 

Gordon and Sweet’s Reticulin stain as well as immunohistochemical 

reactions against cytokeratin 7, CD34, smooth muscle actin 

(SMA) and beta catenin. 

Results. Histological examination showed hepatic parenchyma 

composed of hepatocyte plates measuring 1-2 hepatocytes thick 

without atypia and without mitotic activity. Portal tracts with bile 

ducts (Fig. 1a) were documented in all fragments and in some 

minimal ductular reaction was present. No significant fibrosis 

was observed. No abnormal vessels were identified. The reticulin 

histochemical staining was preserved and showed aspects suggestive 

for nodular regenerative hyperplasia. 

As far as vascularization, focal areas of capillarization (identified 

with anti-CD34 antibodies) (Fig. 1b), and above all scattered individual 

arterioles (identified with anti-SMA antibodies) (Fig. 1c) 

were observed. These findings are consistent with the radiological 

assessment of hypervascularity. 

These findings are therefore in keeping with the diagnosis of a benign 

regenerative lesion such as nodular regenerative hyperplasia. 

No malignancy was seen. 

Conclusions. An increased incidence of nodular regenerative lesions 

has been reported in the literature in both adult and pediatric 

oncologic patients post chemotherapy and radiotherapy 3-6 . Most 


patients are asymptomatic and may only show mild abnormalities 

in their liver function tests. When a confident diagnosis of benign 

nodules can be made using imaging, conservative management 

is recommended and these cases can be followed up with serial 

US 2 7 . However when imaging fails to characterize these entities 

definitely or the lesions increase in size or become symptomatic, 

liver biopsy is recommended to make the diagnosis 2 8 . Hypervascularization 

in benign hepatic regenerative lesions, such as FNH 

or NRH of the liver, is mostly interpreted as a compensatory response 

to vascular injury and hepatic circulatory disturbances 9 10 . 

Various references in the literature report that anti-cancer therapies 

may determine the onset of these hepatic lesions precisely 

through therapy-induced vascular injury 2 . 

Most of these regenerative nodules have been described in the 

Literature from a clinical/radiological point of view. No histological 

case series however has up till now completely described the 

pathologic characteristics of such lesions. Most nodules are described 

as being either FNH or NRH even though few have been 

biopsied; considering that nodules are not routinely biopsied, no 

exact knowledge is available about the true histological aspects of 

these regenerative lesions in this specific post-malignancy group. 

We report a case of a 20 year old woman who had undergone a 

BMT in adolescence and was being followed up for multiple hypervascular 

liver lesions, the largest of which was biopsied. 

In particular we confirm the benign regenerative nature of the 

lesion. Furthermore we describe the presence of single arterioles 

within the parenchyma which may explain the hypervascularity 

seen at imaging. Indeed, partial capillarization seen with anti- 

CD34 antibodies is also secondary to hypervascularization. 

These findings have never been described in post chemotherapy 

regenerative nodules to our knowledge. This probably depends 

greatly on the absence of descriptive histological case series as 

most patients are radiologically followed up. This may prove to be 

a distinctive feature of these lesions and identify them as a specific 

subgroup within the spectrum of hepatic regenerative lesions. 

Future collection and evaluation of biopsies from post-treatment 

pediatric livers may be interesting to validate our findings or at 

least accurately describe the histopathologic features. 

references 

1 Snover DC, Weisdorf S, Bloomer J, et al. Nodular regenerative hyperplasia 

of the liver following bone marrow transplantation. Hepatology 

1989;9:443-8. 

2 Icher-De Bouyn C, Leclere J, Raimondo G, et al. Hepatic focal 

nodular hyperplasia in children previously treated for a solid tumor: 

incidence, risk factors and outcome. Cancer 2003;97:3107-13. 

3 Citak EC, Karadeniz C, Oguz A, et al. Nodular regenerative hyperplasia 

and focal nodular hyperplasia of the liver mimicking hepatic 

metastasis in children with solid tumors and a review of literature. 

Pediatric Hematology and Oncology 2007; 24:281-9. 

4 Marabelle A, Campagne D, Déchelotte P, et al. Focal Nodular Hyperplasia 

of the Liver in Patients Previously Treated for Pediatric 

Neoplastic Diseases. J pediatr hematol oncol 2008;30:546-9. 

5 Freidl T, Lackner H, Huber J, et al. Focal nodular hyperplasia in children 

following treatment of hemato-oncologic diseases. Klin Padiatr 

2008;220:384-7. 

6 Wicherts DA, de Haas RJ, Sebagh M, et al. Regenerative Nodular 

Hyperplasia of the Liver Related to Chemotherapy: Impact on Outcome 

of Liver Surgery for Colorectal Metastases. Ann Surg Oncol 

2011;18:659-9. 

7 Joyner BL, Goyal RK, Newman B, et al. Focal nodular hyperplasia of 

the liver: a sequela of tumor therapy. Pediatr Radiol 2005;35:1234-9. 

8 Clouet M, Boulay I, Boudiaf M, et al. Imaging features of nodular 

regenerative hyperplasia of the liver mimicking hepatic metastases. 

Abdom Imaging 1999;24:258-61. 

9 Kumagai H, Masuda T, Oikawa H, et al. Focal nodular hyperplasia of 

the liver: direct evidence of circulatory disturbances. J Gastroenterol 

Hepatol 2000;15:1344-7. 

10 Stromeyer FW, Ishak KG. Nodular transformation (nodular “regenerative” 

hyperplasia) of the liver. A clinicopathologic study of 30 

cases. Hum Pathol 1981;12:60-71.

PoStER 

Expression of ror-1 in pancreatic tumors 

V. Toto 1 , M. Diodoro 2 , M. Mariotti 1 , R. Lattanzio 3 , R. La Sorda 3 , 

L. Stramucci 1 , P. Nisticò 4 , M. Piantelli 3 , E. Pescarmona 2 , M. Iezzi 1 

1 Dipartimento di Medicina e Scienze dell’Invecchiamento, Sezione di 

Anatomia Patologica e Medicina Molecolare, Centro Scienze dell’invecchiamento, 

Fondazione Università G. d’Annunzio, Chieti; 2 Anatomia e 

Istologia Patologica e Citodiagnostica, Regina Elena Istituto Nazionale 

Tumori IRCCS, Roma; 3 Dipartimento di Scienze Biomediche, Sezione di 

Patologia Oncologica, Centro Scienze dell’invecchiamento, Fondazione 

Università G. d’Annunzio, Chieti; 4 Dipartimento Oncologia Sperimentale, 

Laboratorio “B” di Immunologia, Regina Elena Istituto Nazionale 

Tumori IRCCS, Roma 

Introduction. Receptor tyrosine kinases (RTK) are transmembrane 

proteins with ligand-controlled intracellular kinase activity. 

They regulate several cellular activities such as the differentiation, 

proliferation, migration, angiogenesis, survival, and communication 

between cells. Ror1, an orphan tyrosine kinase, belongs 

to the evolutionarily conserved RTK family of Ror, which also 

includes Ror2. Ror1 is expressed during embryogenesis but not 

by normal adult tissues. In tumors, Ror1 was indicated to be 

overexpressed in certain leukemias, breast and lung cancers 1-4 . 

Recently, Ror1 has emerged as a promising target of therapy 

in leukemias by using of monoclonal antibodies 5 . In pancreatic 

cancers, targeted therapies have been sporadically applied. Thus, 

we have examined the expression of Ror1 in pancreatic cancer 

specimens and cell lines to evaluate its clinical potential as therapeutic 

target. 

Material and methods. We have arranged in two Tissue Micro 

Arrays (TMA) duplicate samples from 50 archivial primary pancreatic 

tumors obtained at the “Regina Elena” National Cancer 

Fig. 1. 

Fig. 2. Examples of expression of Ror1 in pancreatic tumors. 

381 

Institute (Rome, Italy) and “SS Annunziata” Hospital (Chieti, 

Italy). Ror1 protein expression was assessed by FACS on pancreatic 

cancer cell lines (PANC-1, CFPAC, L36PI) and by immunohistochemistry 

on TMA. 

Results. All pancreatic cancer cell lines expressed high levels of 

Ror1 on cell membrane (Fig. 1). Immunohistochemically, Ror1 

was not expressed in non-neoplastic pancreatic specimens. In 

pancreatic tumors a diffuse immunoreactivity for Ror1 was found 

in the cytoplasm of neoplastic cells (Figure 2). Forty-nine out of 

50 (98.0%) tumors showed specific cytoplasmic immunoreactivity 

for Ror1. The percentages of Ror1 positive tumor cells ranged 

from 80 to 100, with a mean ± SE of 94.0 ± 2.6. 

Conclusion. Ror1 protein expression is almost always present in 

pancreatic tumors but is never expressed in non-neoplastic pancreatic 

tissues. Thus, Ror1 is a potential target (to be validated as 

predictive) of therapeutic drugs. 

references 

1 Baskar S, et al. Unique cell surface expression of receptor tyrosine 

kinase ROR1 in human B-cell chronic lymphocytic leukemia. Clin 

Cancer Res 2008;14:396-404. 

2 Daneshmanesh AH, et al. Ror1, a cell surface receptor tyrosine kinase 

is expressed in chronic lymphocytic leukemia and may serve as a putative 

target for therapy. Int J Cancer 2008;123:1190-5. 

3 Zhang S, et al. ROR1 is expressed in human breast cancer and associated 

with enhanced tumor-cell growth. PLoS One 2012;7:e31127. 

4 Yamaguchi T, et al. NKX2-1/TITF1/TTF-1-Induced ROR1 is required 

to sustain EGFR survival signaling in lung adenocarcinoma. Cancer 

Cell 2012;21:348-61. 

5 Yang J, et al. Therapeutic potential and challenges of targeting receptor 

tyrosine kinase ROR1 with monoclonal antibodies in B-cell 

malignancies. PLoS One 2011;6:e21018.

382 


Post-partum metrorrhagia and endometritis: 

a retrospective study 

S. Bruno, A. Guadagno, E. Pacella, L. Abete, P. Rossella, O. Dimitri, 

E. Fulcheri 

University of Genoa, Histopathology, DISC, Azienda Ospedaliera e Universitaria 

“San Martino” IRCCS, Genova 

Introduction. Metrorrhagia and endometritis are complications 

than can occur in the post-partum. A placental cause often underlies 

these clinical conditions; examples include disorders of 

implantation or placenta accreta 1 . Occasionally however we may 

find metrorrhagia of varing duration, caused be retention of chorionic 

disc parts, but without signs of accretion. The most frequent 

cause of endometritis is secondary to an ascending infection from 

the birth canal. In fact, the uterine mucosae, after birth, becomes 

extremely sensitive to the effect of different pathogenetic organisms, 

mainly due to the extensive necrotic-haemorrhagic phenomena 

related to the placentas detachment and expulsion. 

Methods and Materials. In our study we evaluated 92 cases of 

uterine cavity revisions performed in the Department of Obstet- 


rics and Gynaecology of the University-IRCCS-IST San Martino 

Hospital, between January 1999 to December 2011 out of a total 

of 25,470 births. 

For each cases we re-evaluated the histological reports. 

Of these 92 cases: 

30 had a “post-partum endometritis” diagnosis 

62 had a “retention of part of the chorionic disc or placenta accreta” 

diagnosis, 

Out of the 92 cases, a further selection was made to include 

only those cases which also had histologic examination of the 

placenta, in order to determine the possible correlation with and 

the main cause of endometritis. We therefore selected 24 patients 

(age range 20-46 years). 

Results: Out of the 24 cases with placenta at histology. Ten 

patients (10/24 - 42%) had a diagnosis of endometritis and histologic 

sampling of the placenta which showed the abnormalities 

as reported in Figure 1. Fourteen cases (14/24 - 58%) had 

a diagnosis of retention of chorionic parts or placenta accreta. 

Out of these, 4 had placenta accreta associated with hypoxia/ 

ischemic injury (HII) in 2 cases, an immature placenta in 1 

case and evidence of chronic villitis in the remaining case. Ten 

patients had retention of chorionic parts associated with a wide 

variety of conditions as shown in Figure 1. In 5 of the 24 cases 

Fig. 1. Schematic rappresentation of the 92 cases selected cases. 24 also had a histologic evaluation of the placenta. dp: diabetic placentopathy. Hii: 

hypoxic/ischemic injury. C: chorionamnionitis.

PoStER 

(see Fig. 1) placental site reactions and 1 placental site nodule 

were seen. 

Conclusions: In the present study our aim is to identify any maternal 

condition which may redispose to endometritis or placental 

retention and therefore to cavity revision in the post-partum. 

Gestational diabetes, in addition to the knowm effects on the 

fetus 2 , is known to be a significant risk factor for endometritis 

3 . We also show that latent dysmetabolic/dysglicemic 

conditions (6/10 patients - 60%) identified as diabetic placentoplathies, 

isolated or in combination with other causes like 

chorionamnionitis or hypoxic-ischemic injury also increase 

endometritis risk. This finding is important as pregnant women 

who were not clinically diabetic during pregnancy may still be 

at risk in the post-partum. These latent conditions are identifiable 

with an accurate histological evaluation of the placenta. If 

we consider causes associated with the retention of parts of the 

chorionic disk we see how the hypoxic-ischemic injury is present 

in 8/10 (80%) cases. This means that even focal hypoxia 

with hypoxic-ischemic injury can involve and lacerate the cotyledons, 

and thus lead to an increased risk of placental retention. 

Furthermore half of the cases of placenta accreta showed HII. 

This may be in keeping with the pathogenetic theories which 

attribute the extravillous trophoblast’s excessive motility to 

be secondary to differences in oxygen tension 4 . Hypoxia may 

therefore further stimulate extravillous trophoblast to infiltrate 

the uterine wall. 

We also noted in 5 of the 24 cases anomalous trophoblastic reactions. 

In particular, 4 of the cases showed exaggerated placental 

site reactions 5 and 1 a placental site nodule 6 7 . These are rare benign 

conditions, due to the growth of elements like intermediate 

trophoblast with proliferation in the endometrium or even, more 

rarely, at the level of myometrium. 

In conclusion the histologic examination of the placenta may 

throw light on possible causes of post-partum complications. In 

particular diabetic placentopathies and HII should be noted in the 

placental histology report. 

references 

1 Benirschke K, Kaufman P. Pathology of the Human Placenta. New 

York: Springer 2000. 

2 Simpson ER, MacDonald PC. Endocrinology of pregnancy. In: Williams 

RH, ed. Textbook of endocrinology, 6 th ed. Philadelphia, London, 

Toronto: Saundrs 1981. 

3 Diamond MP, Entman SS, Salyer SL, et al. Increased risk of endometritis 

and wound infection after cesarean section in insulin-dependent 

diabetic women. Am J Obstet Gynecol 1986;155:297-300. 

4 Genbacev O, Zhou Y, Ludlow JW, et al. Regulation of human placental 

development by oxygen tension. Science 1997;277:1669-72. 

5 . Shih IM, et al. The pathology of intermediate trophoblastic tumors and 

tumor-like lesions. Int J Gynecol Path 2001;20.31. 

6 Santos LD, Fernando SS, Yong JL, et al. Placental Site Nodules and 

Plaques: A Clinicopathological and Immunhistochemical Study of 25 

Cases with Ultrastructural Findings. Pathology 1999;31:328-36. 

7 Young RH, Kurman RJ, Scully RE. Placental site nodules and 

plaques. A clinicopathologic analysis of 20 cases. Am J Surg Pathol 

1990;14:1001-9. 

Endometrial stromal sarcoma: a case report 



Betania, Napoli, Italia;; 2 AF Anatomia Patologica/ INT Fondazione G. Pascale, 


Case presentation. A 37-year-old lady presented with increased 

bleeding per vagina during periods since 1 year. She was a para2, 

live2, with last child birth 8 years back and no history of contraceptive 

use. She had attained menarchy at the age of her previous 

cycles were normal. A pelvic scan taken 1 year back has showed 

normal-sized uterus with a fibroid 3.7 cm×3.4 cm in the anterior 

383 

myometrium. Endometrial thickness was 8 mm. A dilatation and 

curettage was performed and microscopy showed a disordered 

proliferate endometrium. She was given symptomatic treatment 

for menorrhagia. 

One year later she reported to our outpatient clinic with complaints 

of a mass in the lower abdomen and lower abdominal 

pain for three months. The patient was apparently asymptomatic 

one year previously, but then she noticed a mass in the lower 

abdomen that gradually increased in size. She provided a history 

of a rapid increase in size for the past three months. She also had 

associated lower abdominal pain, which was dull and aching in 

type, dragging in nature and continuous with no aggravating or 

relieving factors. She was thinly built. On abdominal examination, 

an irregular midline mass rising from the pelvis was present. 

The upper and lateral borders of the mass could be made out; the 

lower margin could not be ascertained. The mass was firm to 

hard in consistency with restricted mobility and non tender with 

no free fluid. 

Pelvic examination revealed the abdominal pelvic painless mass 

reaching the umbilical point, some parts of this mass are soft but 

the mass dependence on the uterus was not established. 

Abdominal and vaginal ultrasound showed a 10 cm about heterogeneous 

but a well-circumscribed mass, consisting of cystic and 

solid parts whose relationship with the uterus is not well defined. 

No vegetation was noted either inside or outside of the mass. The 

ovaries was not visualized. 

Magnetic resonance imaging (MRI) was indicated to specify 

the seat of the mass and its relationship with the neighborhood 

organs. 

Laboratory investigations including serum was normal. 

Endometrial aspiration was performed changes in view of the 

rapid enlargement of the uterus within the past 4 months. Microscopy 

showed endometrial glands in the secretory phase with 

neoplastic cells, suggestive of low-grade endometrial stromal 

sarcoma 

A total abdominal hysterectomy with bilateral salpingooopherectomy 

was performed. 

The findings were a uniformly enlarged uterus with normal-looking 

tubes and ovaries The tumor had infiltrated the myometrium 

anteriorly. There were no metastatic deposits. The lymph nodes 

were not enlarged. 

Gross finding showed a polypoid and protrude tumor involving in 

the myometrium and tend to bulge above the surrounding myometrium. 

The tumor has a well circumscribed contour, measuring 

10 ×9 × 8 cm and has a fleshy yellow surface. This tumor is 

intramural with no connection to the endometrium. 

Characteristically uniform oval and spindle-shaped cells, suggestive 

of low-grade ESS, infiltrating the entire thickness of the 

myometrium, were noted. In microscopic findings, the tumor 

consists of cells that closely resemble normal proliferative-phase 

endometrial stromal cells with areas of epithelial-like structures 

that have an appearance reminiscent of an ovarian sex cord stromal 

tumor. The tumor cells have uniform, small, darkly staining 

round or oval nuclei with granular chromatin and inconspicuous 

nucleoli. Mitotic activity is less than 3MF/10HPF. 

The epithelial-like cells grow in cords and trabeculae, they are 

cuboidal with scanty amphophilic cytoplasm and nuclei resemble 

those of the surrounding stromal cells. 

The tumor presents expansive, non infiltrative margins that compress 

the surrounding myometrium. 

The tumor was immunoreactive to CD10 and hormonal receptors: 

oestrogen receptor (ER) and progesterone receptor (PR). 

Immunostaining for AML,EMA desmine, cytokeratin AE1/AE3, 

cytokeratin 18, HMB45 were negative. 

A section from the right fallopian tube showed neoplastic cells 

in dilated lymphatic spaces. The cervix and ovaries were normal 

The case was confirmed to be a low-grade endometrial stromal 

sarcoma stage 3, and she was referred to a regional cancer center.

384 

Pure uterine lipoma: a case report 



Betania, Napoli, Italia; 2 AF Anatomia Patologica/ INT Fondazione G. Pascale, 


Case presentation. A 68-year-old post-menopausal woman presented 

with vaginal bleeding and intermittent abdominal pain of 

three-four mounths duration. 

Gynecological examination revealed no abnormalities of the vulva 

or the cylindrical vaginal portion of the cervix. The uterine cavity 

was slightly big in size. The adnexaes were non-palpable, there 

was marked tenderness to palpation, but no evident pathological 

change was detectable on clinical examination. Longitudinal, endovaginal 

ultrasound image of the uterus demonstrated a well-delineated, 

8-cm hyperechoic mass, with a semi-solid characteristic, 

located intramurally in the posterior wall of the uterus. Endometrial 

biopsy showed scanty material with no evidence of malignancy. 

The patient underwent a total abdominal hysterectomy and bilateral 

salpingo-oophorectomy 

The hysterectomy specimen measured 11 × 6 × 5 cms, with 

globular enlargement of the fundus. Both ovaries were atrophic. 

Laparotomy revealed an enlarged uterus with a globular fundal 

mass. The mass was soft-to-firm in consistency and the surface 

was smooth and glistening with no adhesions. A 8 cm soft, yellow, 

well-circumscribed, intramural mass was found within the 

myometrium: there was a very large intramural uterine tumour 

mass which measured 80 mm in greatest diameter and weighed 

740 g. The tumour, which distorted the uterine cavity into an 

enlarged slit, was rounded and well circumscribed but not encapsulated. 

On cut surface the greater part of the tumour appeared, 

homogenous yellow, lobulated and fatty, with displacement of 

the endometrial cavity toward the lower pole. Also the cervix 

appeared normal. 

No areas of necrosis or hemorrhages were seen. A histopathological 

examination showed a thin atrophic endometrium. The 

intramural tumor was composed of only mature adipose tissue. 

No smooth muscle cells or fibrous elements or lipoblasts were 

seen within the tumor. A final diagnosis of primary pure uterine 

lipoma was considered. 

Clearance and persistence of human papillomavirus 

infections in patients with lesions of the cervix 

G. Giuffrè1 , R. Scarfì1 , A. Simone1 , P. Todaro1 , G. De Luca1 , 

M. Le Donne2 , P. A. Nicotina1 1 2 Departments of Human Pathology and Ginecology, Obstetrics and Reproductive 

Medicine, University of Messina, A.O.U. “Policlinico G. Martino”, 

Messina, Italy 

Background. Human papillomavirus (HPV) infection is the 

most common sexually transmitted agent and is a necessary 

condition for the development of invasive cervical cancer that 

represents the third most common malignancy of the female 

genital tract. On the basis of their oncogenic potential, HPV 

have been classified as high- or low-risk types. In particular, 

18 types have been proposed with a probable or definite highoncogenic 

role, while 12 low-risk HPV have been associated 

with benign condylomatous lesions of the anogenital areas, as 

well as low-grade squamous intraepithelial lesions of the cervix. 

However, HPV has been detected also in cervical samples of 10- 

40% of women who have no cytologic abnormalities. Between 

March 2007 and March 2012, a total of 2.369 cervical samples 

of 1.860 Italian women living in province of Messina were 

consecutively tested for HPV from the Laboratory of Molecular 

Biology Applied to Pathologic Anatomy of the Department of 

Human Pathology of our University. In order to evaluate the 

clearance or persistence of HPV in patients with cervical le- 


sions, we have selected 318 patients who underwent several 

times to HPV genotyping. 

Patients and methods. At the first diagnosis, the mean age 

of women was 33.3 + 9.4 (SD) years (range, 17-60 years). In 

particular, 45 patients showed condylomatous cervical lesions, 

while 273 showed squamous cell abnormalities (13 ASCUS, 221 

LSIL, 39 HSIL). The women were followed-up for a mean period 

of 24.6 + 13.9 (SD) months and clinico-pathological data were 

collected at the time of HPV testing also by means of a written 

questionnaire. Outcome was defined as clearance of infection, type 

specific persistence, clearance associate with new HPV infection. 

From each cervical sample the cells were collected by centrifugation 

and total DNA was extracted with the QIAamp DNA mini 

kit (Qiagen GmbH, Germany). HPV genotyping was performed 

by nested PCR and a non-radioactive reverse line blot hybridization 

assay with specific probes for the most frequent HPV types 

(HPV-Type, AB Analytica, Padova, Italy). Hybridisation was 

made by a BeeBlot Instrument and hybrids between biotinylated 

PCR products and specific HPV probes were visualized on the 

strip following the manufacturer’s instructions. In some of the 

cases yielding unidentifiable by line blot genotyping, the corresponding 

HPV DNA was sequenced. 

Results. At the first diagnosis, single HPV infection was detected 

in 171 cases (53.8 %), while multiple infection with different 

HPV-types was found in 147 cases (46.2 %). A high-risk HPV infection 

was detected in 265 patients (83.3 %); of these, 194 (61.0 

%) showed only a single or multiple high-risk HPV infection, 

while the coexistence with a low-risk HPV infection was documented 

in 71 cases. A low-risk HPV infection was found in 124 

(39.0 %) patients and 53 (16.7 %) of these showed only a single 

or multiple low-risk HPV infection. In condylomatous lesions an 

exclusive low-risk HPV infection was found in 34 (75.0 %) cases, 

while a prevalence of high-risk HPV infection was encountered 

in patients with cervical squamous cell abnormalities (69.2 % 

ASCUS, 91.9 % LSIL, 100% HSIL). At the end of follow-up 

period a complete clearance of infection was found in 130 (40.88 

%) patients, while in 92 (28.93 %) a HPV type specific persistence 

was encountered. In the remaining patients, 87 showed a 

clearance associate with a concomitant new HPV infection, while 

8 developed a new infection after a period of complete HPV absence. 

A significant association was found between resolution of 

lesions and viral clearance. Moreover, this latter finding was also 

associated with initial single HPV infection. 

Conclusions. HPV genotyping can provide useful indications in 

the management of patients with squamous intraepithelial lesion 

of cervix. 

“Basaloid-adenoid cystic” carcinoma of the ovary: 

variant of epithelial surface tumor or indipendent 

neoplasia? 

L. Marcolini, A. Pesci, P. Castelli, G. Zamboni 

Ospedale Sacro Cuore Don Calabria di Negrar Dipartimento di Patologia, 

Verona, Italy; Università di Verona Dipartimento di Patologia e Diagnostica, 

Verona, Ital. 

We report a new case of a primary ovarian adenoid-cystic like 

carcinoma resembling salivary gland carcinoma (ACC) in a 53year-old 

woman. The tumor showed a myoepithelial differentiation 

and there was no evidence of an associated ovarian surface 

epithelial-stromal neoplasia. The negativity for PAX 8 rises the 

possibility to consider pure ovarian ACC as a monodermal teratoma 

instead of a surface epithelial tumor. 

Material and methods. A 53-year-old woman referred to the 

Obstetric and Gynecology Department for the presence of leiomyomata 

growing-up in the last 3-4 months. CT-scan revealed 

the presence of a solid mass of the left ovary with a mean 

diameter of 12 cm. A laparoscopic hysterectomy and bilateral 

salpingo-oophorectomy was performed.

PoStER 

Tissue were fixed in 10% formalin solution and embedded in 

paraffin blocks; 4 µm sections were cut and stained with Hematoxylin 

and Eosin. Immunohistochemical staining was performed 

using Leica BOND MAX and Ventana Benchmark XT automated 

immunostaining with the following antibodies (Novocastra): cytokeratin 

AE1-AE3 (1:100); BerEp4 (EpCAM) (1:50); Epithelial 

Membrane Antigen (EMA) (pre-diluited); cytokeratin 5 (1:100); 

p63 (1:50); Synaptophysin (1:50); WT-1 (1:50); (Ventana): 

Estrogen Receptor (pre-diluited), Progesterone Receptor (prediluited), 

Inhibin (Oxford Bio-innovation; 1:100) and PAX 8 

(pre-diluited). 

Pathological findings. The ovary, measuring 10x7x3.5 cm, 

showed a glistening surface and on cut section it was almost completely 

replaced by a solid, well circumscribed, whitish-yellow 

mass, with lobulated appearance and cystic degeneration. 

Microscopically the tumor showed a solid-tubular and cribriform 

pattern, composed by epithelial cells disposed in solid nests and 

trabeculae with central pseudo-lumens. Basophilic hyaline material 

was present within cystic and gland-like spaces. The cells 

palisaded at the periphery of the cords and tubular nests, which 

were encircled by spindle-shaped cells surrounded by a hyaline 

or myxoid-like stroma. The tumor was composed of monomorphic, 

small to medium size cells, with low grade atypia. The 

tumor cells showed a basal-like appearance, with clear, scant 

cytoplasms, oval nuclei, dispersed chromatin and incospicuous 

nucleoli. Mitotic figures were uncommon (mitotic count of 1-2 x 

10 HPF) and no areas of necrosis were identified. No evidence of 

an associated surface epithelial-stromal tumor was found. 

The neoplastic cells resulted weakly positive for pan-keratin AE1/ 

AE3, negative for EMA and strongly positive for CK5 and p63, 

negative for sex-cord stromal markers, inihibin and calretinin, 

for neuroendocrine markers and negative for Estrogen Receptor, 

Progesterone Receptor and PAX 8. 

Discussion. Adenoid cystic carcinoma usually originates from 

major and minor salivary glands, lacrimal and submucosal glands 

of the upper aerodigestive tract and bronchi. Nevertheless, in the 

literature, tumors designated as “adenoid cystic” carcinoma have 

been reported also in eccrine glands of the skin, uterine cervix, 

Bartholin’s gland and the breast. 

Scully and Eichorn first described in 1995 twelve ovarian neoplasm 

resembling salivary gland carcinoma and basal cell carcinoma; 

nine out of twelve cases had a component of ovarian surface 

epithelial neoplasia, mostly endometrioid adenocarcinoma, 

accounting for less than 5% to 75% of the tumor area. Of the three 

cases without epithelial surface neoplasia one was incompletely 

removed and the lesion was not entirely submitted and the two 

other “pure form” were ameloblastoma-like tumors, low grade 

tumor and occurred in young women (19 and 23 years of age), 

an uncommon age for surface epithelial tumors. The Authors 

couldn’t demonstrate any staining for myoepithelial differentiation 

and considered these lesions as variants of several types of 

surface epithelial ovarian neoplasia. 

In 1996 Feczko et al. first described a case of ovarian ACC of 

pure type and discussed about its possible histogenesis: they also 

supported the hypothesis of a celomatic origin and suggested that 

ovarian ACC arises from the surface mesothelium of the ovary 

from metaplastic epithelial cells. 

In 2000 Zámečník et al. described a new case of pure ovarian 

ACC and purposed a clear distinction between adenoid cysticlike 

carcinomas and ovarian ACCs of pure type. Pure ACCs of 

the ovary show typical features of salivary gland ACCs, with a 

myoepithelial component and without any evidence of a surface 

epithelial carcinoma differentiation. The Authors mentioned the 

hypothesis that, in ovarian ACC of pure type, the tumor can represent 

a monodermal component of a teratoma. Nevertheless they 

did not favour this possibility because no association between 

ACC and teratoma has been described in the literature. 

Excluding a metastatic origin of the tumor, in the absence of an 

385 

associated surface epithelial ovarian cancer and with the immunohistochemical 

demonstration of a myoepithelial component, our 

case figures as a primary pure ovarian ACC. 

Even though the histogenesis of ACC in the ovary remains controversial, 

we advance the hypothesis of a teratomatous origin 

of this lesion. PAX 8 represents a sensitive and specific marker 

for tumor of Müllerian origin. Recent papers described a strong 

and diffuse staining of PAX 8 in most of all histologic subtypes 

of primary and metastatic müllerian tumor, with the exception of 

mucinous tumors. Sex-cord stromal tumor and germ cells tumors 

are constantly PAX8 negative. 

The present case was PAX 8 negative and no evidence of teratomatous 

component was identified. Although this hypothesis 

might be investigated by further studies, as the case of struma 

ovarii and carcinoid tumor, ACC may represent a monodermal 

teratoma where the carcinomatous component had over hidden 

the teratoma. 

references 

1 Eichhorn JY, Scully RE. “Adenoid cystic” and basaloid carcinomas 

of the ovary: evidence for a surface epithelial lineage. A report of 12 

cases. Mod Pathol 1995;8:731-40. 

2 Ferry JA, Scully RE. “Adenoid cystic” carcinoma and adenoid basal 

carcinoma of the uterine cervix. Am J Surg Pathol 1998;2:134-44. 

3 Feczko JD, Jentz DL, Roth LM. Adenoid cystic ovarian carcinoma 

compared with other adenoid cystic carcinomas of the female genital 

tract. Mod Pathol 1996;9:413-7. 

4 Russel P, Willis EJ, Watson G. Monomorphic (basal cell) salivary adenoma 

of ovary: report of a case. Ultrastruct Pathol 1995;19:431-8. 

5 Longacre TA, O’Hanlan K, Hendrickson MR. Adenoid cystic carcinoma 

of the submandibular gland with symptomatic ovarian metastases. 

Int J Gynecol Pathol 1996;15:349-55. 

6 Zámecník M, Michal M, Curík R. Adenoid cystic carcinoma of the 

ovary. Arch Pathol Lab Med 2000;124:1529-31. 

7 van Dinh T, Woodruff JD. Adenoid cystic and adenoid basal carcinomas 

of the cervix. Ostet Gynecol 1985;65:705. 

8 Variakojis D, Archer FL, Feldman SA, et al. Cylindroma of the submandibular 

gland metastatic to the ovary to autopsy. Arch Otolaryngology 

1970;92:90. 

9 Ozcan A, Shen SS, Hamilton C, et al. PAX 8 expression in nonneoplastic 

tissues, primary tumors, and metastatic tumors: a comprehensive 

immunohistochemical study. Mod Pathol 2011;24:751-64. 

10 Ozcan A, Liles N, Coffey D, et al. PAX2 and PAX8 expression in 

primary and metastatic Müllerian epithelial tumors: a comprehensive 

comparison. Am J Surg Pathol 2012 Mar 31 [Epub ahead of print]. 

Benign mature cystic teratoma of fallopian tube 

associated with uterine leiomioma in a term 

pregnant woman: a case report 

R.Nenna, C.D. Inchingolo 

U.O.C. di Anatomia Patologica, Ospedale “L.Bonomo”, Andria, ASL BT 

Background. Primary teratomas of the fallopian tube are extremely 

uncommon. To date, about 58 cases have been reported 

in the literature. The majority of cases are benign mature cystic 

or solid, while malignant teratoma of fallopian tube has been 

reported in only four occasions. They occur usually in the fourth 

decade. Their association with nulliparity and reduced parity (less 

than 2) has been noted. Six cases are reported to have been in conjunction 

with tubal ectopic pregnancies. Very rare cases of benign 

cystic teratoma of the unilateral fallopian tube associated with 

an intrauterine term pregnancy are reported. Many have been 

discovered incidentally during an operation or examination of a 

surgical specimen. None of the reported cases were diagnosed 

preoperatively. Tumor rupture with signs of peritonitis has been 

reported. The majority are cystic, show great variation in size 

and are commonly located in the ampulla or the isthmus. They 

can be intraluminal, attached to the serous surface by a pedicule 

and rarely are intramural arising from the muscular layer of the 

fallopian tube. The incidence of tubal teratoma with intrauterine 

leiomioma is very low.

386 

Materials and methods. We present a case of benign mature cystic 

teratoma of the right fallopian tube associated with an intrauterine 

leiomioma found incidentally in a 32 year old term pregnant 

woman subjected to caesarean section. The patient was nulliparous, 

asymptomatic and she had a history of infertility for four and half 

years. She had been no previous treated for subfertility and she had 

no before surgical operations. The patient was pregnant spontaneously. 

It was found a intrauterine leiomyoma and no other maternal 

internal genital alteration during a routine ultrasound fetal. At the 

end of intrauterine pregnancy it was performed cesarean section 

during which the gynecologist executed uterine myomectomy 

and right salpingectomy because right fallopian tube looked to be 

extremely dilated at the ampolla, the apparence which was suggestive 

of a hydrosalpinx or a fallopian neoplasm. The controlateral 

fallopian tube and the right ovary were normal. 

Results. At gross examination, uterine leiomyoma was the size 

3,5x3x2,5 cm and microscopically it was apoplectic cellular leiomyoma. 

Right fallopian tube revealed a 6x5x3 cm intraluminal 

cystic tumor located at the ampolla. It contained a yellowish, 

cheesy, sebaceous material and black hair. Cross section revealed 

a thin wall lined by an opaque yellowish, gray-white wrinkled 

apparent epidermis. Whitin the wall was not calcification. The 

distal and proximal portions of tubal lumen appared normal 

with decidual changes of the mucosal tunic. On microscopic examination, 

the right fallopian tube showed benign mature cystic 

teratoma with focal solid area. The cystic wall was lined mainly 

with skin composed of keratinized well-differentiated squamous 

epithelium, hair follicles or shafts, underlying stratified squamous 

cells, sebaceous and sweat glands. The solid area contained a plug 

of mature fatty tissue in absence of glial and cartilaginous tissues. 

A foreign body-type granulomatous reaction is seen in association 

with hair or epithelial contents of the cyst. 

Discussion. The benign teratoma of the fallopian tube is composed 

of recognizable tissues of ectodermal, mesodermal and 

endodermal origin in any combination. The term dermoid cyst 

was conied over 160 years old. Tubal dermoid cyst is a mature 

teratoma that is composed predominantly of a cyst lined entirely 

or partly by well-differentiated keratin-producing squamous epithelium, 

which emerges from the tubal wall, not continuous with 

the tubal epithelium. Primary teratoma of the fallopian tube is extremely 

uncommon. At the present time, only about 58 cases have 

been reported in the literature. The ages of these patients ranged 

from 21-60 years, with most of them occurring in the fourth 

decade. The diagnosis is almost never made pre-operatively as 

most of these patients are asymptomatic. The common symptom 

are colicky abdominal pain, dysmenorrhoea, leucorrhoea, menstrual 

irregularity and postmenopausal bleeding. It is noted that 

these patients are mainly nulliparous or have parity less than two. 

Unusual presentations of some teratoma of the fallopian tube 

include its co-existence with a tube pregnancy or intrauterine 

term pregnancy, a free floating pelvic mass and rupture into the 

rectum. Their sizes vary widely ranging from 0,4-20 cm. The 

majority are cystic, others are solid. The location is commonly in 

the ampulla or the isthmus. 

Conclusions. Benign teratomas are the most common of all ovarian 

neoplasms and represent a diverse group of tumors that may 

develop at other sites. They develop from a totipotential stem cell. 

The histogenesis is still unclear. One theory suggested the genesis 

from parthenogenetic fertilization of the germ cell in situ because 

teratomas are found along the know pathways of migration of the 

germ cell during foetal development. Another theory suggested the 

process of blastomeric isolation in which some cells of the blastula 

which was sequatrated and later developed into teratomas because 

they still retained their pluripotent character. The diversity of teratoma 

behavior probably reflects the different biological potentials 

of various stem cells, including germ cells and pluripotent embryonic 

cells. Benign teratoma of the fallopian tube associated with 

intramural leyomioma is extremely rare. If the tumor is not large 


enough, preoperative diagnosis is difficult. Prognosis is favorable 

following complete surgical excision. About 5-10% of dermoids 

undergo malignant transformation of any one the component elements 

(most commonly squamous cell carcinoma). 

references 

1 Schuveiller MJ, et al. Unusual Intratubal Location of Dermoid Cyst. 

Journal of Diagnostic Medical Sonography1990;6;229-231. 

2 Lai SF Lim-Tan SK. Benign Teratoma of the fallopian tube: a case 

report. Singapore Med J 1993;34:274-5. 

3 Hoda SA, Huvo AG. Struma salpingis associated with struma ovarii. 


4 Hseih CS, Cheng GF, Liu YG, et al. Benign cystic teratoma of unilateral 

fallopian tube associated with intrauterine pregnancy: a case 

report. Zhonghua Yi Xue Za Zhi (Taipei) 1998;61:239-42. 

5 Yoshioka T, Tanaka T. Mature solid teratoma of the fallopian tube: 

case report. Eur J.Ostet. Gynecol Reprod Biol 2000;89:205-6. 

6 Fattaneh A, Tavassoli PD. Pathology and genetics of tumours of the 

breast and female genital organs. WHO/OMS 2003, p. 211. 

7 Menki A, Bouraoui S, Oueslati B, et al. Mature cystic teratoma of the 

fallopian tube. A case report. Tunis Med 2005;83:48-50. 

8 Johnson C, Hansen KA. Mature cystic teratoma of the fallopian tube. 

Fertility and sterility 2006;86:995-6. 

9 Haslik L, Mara M, Kuzel D, et al. Present occurence of benign teratoma 

of ovary and fallopian tube in a patient with adenexal torsion. 

Ceska Gynekol 2006;71:342-4. 

10 Ingec M, Kadanali S, Erdogan F. Huge teratoma of the fallopian tube: 

a case report. J Reprod Med 2007;52:247-9. 

11 Chao TJ, Chao J, Kuan Lj, et al. Mature solid teratoma of the fallopian 

tube associated with uterine leiomyomas. J Chin Med Assoc 

2008;71:425-7. 

12 Satoe Fujiwara, Yoshiki Yamashita. et al. Mature cystic teratoma of 

the fallopian tube. Fertility and sterility 2010;94:2708-9. 

Pure Yolk Sac Tumor of adult testis: a case report 

R. Nenna1 , G. Albino2 , C.D. Inchingolo1 1 U.O.C. di Anatomia Patologica, Ospedale “ L.Bonomo “, Andria, ASL 

BT; 2 U.O.C. di Urologia, Ospedale “L. Bonomo”, Andria, ASL BT 

Background. Yolk Sac Tumour is a testicular non-seminomatous 

germ cell tumour (NSGCT) characterized by numerous patterns 

that recapitulate the yolk sac, allantois and extraembrionic mesenchyme. 

In the testis YST is seen in two distinct age groups, infants and 

young children and postpubertal males. In young children it is 

almost always seen in pure form. In adults, the pure form is very 

rare because it usually occurs as a component of mixed germ cell 

tumours. 

Materials and methods. A 38-year old man presented the urologist 

complaining acute left scrotal pain for suspected recurrent 

testicular torsion. The pain disappeared with manual testicular 

derotation. 

Scrotal ultrasound showed disruption of the parenchymal texture 

and hypervascularization perharps inflammatory reactive nature 

for focal necrosis by repeated incomplete testis torsion. 

The patient was operated for testicular fixation. With the intent 

to reduce testicular tension, the albuginea tunic was incised at the 

upper pole of left testis and was aspirated serous hemorrhagic 

fluid submitted for cytological examination. Surprisingly, the 

citologic diagnosis was “Germ Cell Malignant Tumour”. 

Therefore, left radical orchiectomy and left emiscrotum skin resection 

were performed. 

Preoperative blood level of Alfa-fetoprotein was 2749 ng/ml, 

while one month after surgery was < 4 ng/ml. The staging TC was 

negative for lymph nodes and distant metastases (N0, M0). The 

patient performed four cycles of chemotherapy. No recurrences 

are found after five months of follow-up. 

Results. On gross examination, testis was enlarged (size 7x6x4 

cm) for presence within it of large, solid, soft and pale grayyellow 

mass (size 4,3x4 cm) with haemorrhage and necrosis. 

The testicular hilum was diffusely haemorrhagic. The tumor has

PoStER 

invaded focally adjacent tunica albuginea but no epididymus, 

tunica vaginalis, spermatic cord and scrotum skin. 

Specimens were fixed in 10% buffered formalin and embedded 

in paraffin. Paraffin sections were stained with hematoxilyn and 

eosin for histological analysis. For immunohistochemical studies, 

sections were incubated with cytokeratin cocktail (Ck AE1/AE3), 

low molecular weight cytokeratin (Ck35BetaH11), PLAP, CD30, 

CD-117 (c-Kit), AlphaFetoProtein (AFP) and Beta-Human Chorionic 

Gonadotropin (BetaHCG). 

On low-power microscopic examination, tumour showed a reticular-microcystic 

pattern, characterized by irregular loose spaces and 

anastomosing thin cords and tubules lined by flat or cuboidal cells. 

Also, papillary clusters of cells and many Schiller-Duval bodies 

were present. Tumoral lymphovascular invasion occurred. All 

tumor cells are positive for Ck AE1/AE3, Ck35BetaH11 and AFP, 

negative for CD30, PLAP, CD117 and BetaHCG. No other germ 

cell components are associated with this tumor. So, our diagnostic 

conclusion was “Pure Yolk Sac Tumour of adult testis”. 

Discussion. Yolk Sac Tumour (or Endodermal Sinus Tumour) 

is a testicular non-seminomatous germ cell tumour (NSGCT) 

characterized by numerous patterns that recapitulate the yolk sac, 

allantois and extraembrionic mesenchyme. 

In the testis YST is seen in two distinct age groups, infants and 

young children (birth to 5 years) and postpubertal males. 

In young children it is almost always seen in pure form and it accounts 

for 75-80% of all childhood testicular neoplasms. 

In adults, it is seen in approximately 40% of NSGCT and the 

pure form is very rare because it usually occurs as a component 

of mixed germ cell tumours. 

Alfa-Fetoprotein levels are elevated in 90 percent of cases. 

On gross examination, the enlarged testis contains a poorly defined, 

lobulated, white-gray or gray-yellow tumor ranging in size 

from 2 to 6 cm in diameter. It may be focally cystic or a solid 

mass with variable consistency, and haemorrhage and necrosis 

may be present. The cut surface often has a mucinous texture. 

Microscopically, the kay to the recognition of YST is the simultaneous 

presence of myriad histologic patterns. The reticularmicrocystic 

pattern is most common. The most distinctive pattern 

is the one forming Schiller-Duval bodies, considered a hallmark 

of YST, in which a central fibrovascular core is surrounded by 

malignant cuboidal to columnar epithelioid cells. Other variations 

include macrocystic, papillary, glandular-alveolar, solid, myxomatous, 

polyvesicular vitelline, hepatoid and enteric patterns. 

Intracellular and extracellular hyaline Pas-positive globules are 

characteristic of yolk sac differentiation. 

Pediatric tumors are not associated with ITGCN (Intratubular 

Germ Cell Neoplasia); in contrast, almost all adult tumors with 

yolk sac tumor occurring as a component of MGCT (Mixed Germ 

Cell Tumors) have ITGCN. Tumor cells are positive for AFP, CK 

AE1/AE3, CK35BetaH11 and negative for CD30, CD117, PLAP 

and BetaHCG. 

Conclusions. There are two groups of prognosis predictive factors 

for yolk sac tumor of testis: 

clinical (age, clinical stage, blood levels of AFP) and morphologic 

(histologic patterns, lymphovascular invasion, pure and 

mixed forms) criteria. 

Age does not appear to be prognostically important even though 

patients less than 2 years old have the best prognosis. 

Clinical stage of disease at initial presentation and degree of AFP 

elevation are important prognostic factors. 

Histologic patterns of YST are not prognostic value. 

Lymphovascular invasion is associated with a worse prognosis. 

In adults with yolk sac differentiation as a part of NSGCT, the 

prognosis varies with the stage of disease, but its presence does 

not appear to affect outcome adversely when current therapeutic 

modalities are used. 

Since pure YST in adults is very rare, little is known about its 

behavior at this time. 

387 

references 

1 Kaplan GW, Cromie WC, Kelalis PP. Prepubertal yolk sac testicular 

tumours: Report of the Testicular Tumor Registry. J. Urol 

1988;140:1109-12. 

2 Montserrat Orri V, López-Bonet E, Garijo G, et al. Pure yolk sac 

tumor of the testis in adults: report of a case. Actas Urol Esp 

1996;20:659-61. 

3 Pinkerton CR. Malignant germ cell tumours in childhood . Eur J Cancer 

1997;33:895-901. 

5 Foster RS, Hermans B, Bihrle R, et al. Clinical stage I Pure Yolk Sac 

Tumor of the testis in adults has different clinical behavior than juvenile 

yolk sac tumor. J Urol 2000;164:1943-4. 

6 Terenziani M, Piva L, et al., Clinical stage I non-seminomatous germ 

cell tumors of the testis in chilhood and adolescence: an analysis of 31 

cases”. J Pediatr Hematol Oncol 2002;24:454-8. 

7 Medica M, Germinale F, Giglio M, et al. Adult testicular pure yolk sac 

tumor. Urol Int 2001;67:94-6. 

8 Denfeng Cao, Humphrey PA. Yolk sac tumor of the testis . The Journal 

of Urology 2001;19. 

9 Wada S, Yoshimura R, Nishisaka N, et al. Primary retroperitoneal 

pure yolk sac tumor in an adult man. Scand J Urol Nephrol 

2001;35:515-7. 

10 Pohl HG, Shukla AR, Metcalfe PD, et al. Prepubertal testis tumors: 

Actual prevalence rate of histological types. J Urol 2004;172:2370-2. 

11 Eble JN, Sauter G, Epstein JI. Sesterhenn “Tumours of the Urinary 

System and Male Genital Organs. WHO Blue Books, 2004: 237-240. 

12 Ulbright TM. Germ cell tumors of the gonads: a selective review emphasizing 

problems in differential diagnosis, newly appreciated, and 

controversial issues! Mod Pathol 2005;18(Suppl. 2):S61-79. 

13 Dadali Mumtaz, Sunay Melih, et al. Pure yolk sac tumor of testis in an 

adult patient: case report. Turkish Journal of Urology 2010;01. 

Leiomyomatosis peritonealis disseminata: 

pregnancy, oral contraception and myomectomy, 

three peculiar features in a single case 

M. Onorati, P. Uboldi, G. Petracco, S. Romagnoli * , M.M. Amidani 

** , F. Di Nuovo 


Italy; * Dept. Health Sciences, University of Milan Medical School, 

Pathology Unit, AO S. Paolo, Milan, Italy; ** Gynecological Unit, Garbagnate 

Milanese, AO “G. Salvini” Garbagnate Milanese, Italy 

Introduction. Leiomyomatosis peritonealis disseminata (LPD) is 

an unusual smooth muscle tumor of unknown origin. It is characterized 

by the presence of multiple nodules of varying sizes 

on the abdominal and pelvic peritoneum, grossly mimicking disseminated 

carcinoma. The tumor was first described in 1952 by 

Wilson and Peale. Taubert et al. (1965) named it leiomyomatosis 

peritonealis disseminata. It appears during reproductive age, especially 

with pregnancy or, more often, in cases of long exposure 

to oral contraceptive agents. According to the hormonal hypothesis, 

Tavassoli and Norris postulated that the pathogenesis of LPD 

involves subperitoneal mesenchymal stem cells that undergo 

metaplasia, being the process promoted by hormonal stimulation. 

LPD has been also found in patients with endometriosis, suggesting 

that both of them derive from the same cell of origin, the 

submesothelial multipotential mesenchymal cells. The hormonal 

theory is supported by experimental studies that have shown 

a development of metaplasia of mesenchymal stem cells and 

subsequent leiomyomatous peritoneal lesions after a prolonged 

administration of high doses of estrogens. At the same time, it 

has been shown that the nodules can be reduced by decreasing 

the estrogen level with gonadotropin-releasing hormone agonists 

(GnRh agonists) or aromatase inhibitors. In recent years, some 

authors reported LPD in women after abdominal miomectomy 

or abdominal hysterectomy. Approximately, 113 cases have been 

published in literature so far, less than 50 reported in pregnant 

women. We report an unusual case of a 36 year old pregnant 

woman with leiomyomatosis peritonealis diffusa, a past history 

of miomectomy and use of oral contraception for three years. 

Decidual areas were present both in the tumour and in the sinus of

388 

an omental lymph node. To the best of our knowledge, this is the 

first case of LPD containing foci of lymph nodal ectopic decidua 

in a pregnant woman with a past history of miomectomy and use 

of oral contraception for three years. 

Methods and results. A 36 year old pregnant woman, at 38 weeks 

of gestation, was admitted to Garbagnate Milanese Hospital for a 

cesarian section. She had previously undergone miomectomy and 

now presented two irregular masses localized in the posterior wall 

of the uterus and identified during pelvic ultrasound for the monitoring 

of the pregnancy. The masses appeared to narrow the uterine 

cavity and to determine a reduced fetal growth. Past medical 

history of the woman revealed a miomectomy in 2007. She was 

using oral contraceptions for 3 years. At the time of the admission 

the patient was in a good condition with stable vital signs. 

Physical examination was unremarkable. Laboratory data were 

within normal limits. During the cesarian section an intraoperative 

biopsy at explorative laparotomy showed multiple peritoneal 

proliferative processes of uncertain significance. Tumors masses 

measured up to 6x5,5x5,5 cm and were disseminated in the majus 

and minus omentum. Due to the difficulties of a complete resection 

the surgeon decided to perform an omentectomy, preserving 

the uterus, to reduce the dimension of the lesions and to obtain 

representative tissue for histopathological examination. On gross 

examination, the omentum measured 21x8x12, consisted of a 

lobulated yellow-whitish tissue and showed multiple, firm and 

well circumscribed nodules. On cut section, the nodules showed 

white, whorled trabeculation. In the omentum a lymph node of 

0,5 cm in greatest diamenter was found. The histologic features of 

the nodules were those of typical benign uterine myomas. There 

was neither necrosis nor cell atypia. Mitoses were not observed. 

The proliferative cell index as determined by Ki-67 was about 

20% of the neoplastic cells. Collagen fibers were intermingled 

with muscle cells as well as with decidual cells scattered throughout 

the tumors and their periphery. Tumor cells were positive for 

vimentin, desmin, smooth muscle actin and muscle specific actin 

and strongly expressed progesterone receptors and oestrogen receptors. 

The omental lymph node showed foci of decidual cells, 

localized in the subcapsular sinus, which were loosely cohesive, 

with abundant eosinophilic cytoplasm, well defined prominent 

cytoplasmic borders and round to oval nuclei with dispersed chromatin 

and single conspicuous nucleoli. Immunohistochemical 

stains (Progesterone +, Oestrogen +, CK AE1-AE3-, CAM 5.2-, 

CD117-) ruled out a metastatic epithelial lesion or GIST lesions. 

The final diagnosis was consistent with benign tumors classified 

as leiomyomatosis with foci of ectopic deciduas which was also 

localized, peculiarly, in one of the omental lymph nodes. 

Discussion. We describe the case of an incidentally detected LPD 

with decidual foci in the tumors and in an omental lymph node in 

a woman with multiple risk factors for this condition: prolonged 

use of oral contraceptives, miomectomy and pregnancy. Several 

studies have illustrated the characteristics of LPD and decidual 

areas, their behavior and their association with other diseases but, 

to our knowledge, only Hsu et al have reported the association 

between LPD and decidua in a lymph node. LPD is difficult to 

diagnose due to its rarity and the possibility of mimicking malignant 

lesions, which are excluded in our cases in the absence 

of mitoses, necrosis and atypia. However, histopathological and 

immunohistochemical findings are diagnostic. On the other hand, 

the exact incidence of ectopic decidua cannot be easily estimated, 

because it is usually an incidental microscopic findings (in 100% 

of omentum biopsies taken during cesarian section and in tubal 

pregnancies and in 30,8% of uteri removed during pregnancy). 

LPD is now interpreted as an hormone-dependent lesion which 

can regress when hormonal stimulation has been removed. Decidual 

areas are frequent in LPD as well as in lymph node during 

pregnancy and can be related to endometriosis. It has been shown 

that decidua in these ectopic areas may be replaced by fibrosis. 

Fibroblasts may become activated as myofibroblasts and smooth 


muscle cells. The use of oral contraceptives and pregnancy can 

favor this metaplastic process. A metaplastic process which also 

involves the subperitoneal mesenchymal stem cells to smooth 

muscle cells, fibroblasts, myofibroblasts and decidual cells. 

However, in our case there were also a uterine myomectomy 

in the anamnesis and this does not allow to exclude a iatrogen 

muscle cells dissemination in the peritoneal cavity. The presence 

of decidual cells in the subcapsular sinus of an omental lymph 

node might let us hypothesize a migration of decidual cells by 

lymphatic vessels from the omentum to the lymph node. Post 

partum the patient underwent a pharmacological treatment with 

GnRh agonists for three months aimed at inducing a menopausal 

condition and reducing the residual LPD. One year post surgery 

the patient was well. Sonographically and in the follow-up CTscan 

there were no signs of persistent leiomyomatosis. 

references 

1 Al-Talib A, Tulandi T. Pathophysiology and possible iatrogenic cause 

of leiomyomatosis peritonealis disseminata. Gynecol Obstet Invest 

2010;69:239-44. 

2 Castro-Boix S, Dopazo-Taboada C, Nadal-Guissard A, et al. Leiomyomatosis 

peritonealis disseminata. Cir Esp 2007;82:125-7. 

3 Heinig J, Neff A, Cirkell U, et al. Recurrent leiomyomatosis peritonealis 

disseminata after hysterectomy and bilateral salpingo-oophorectomy 

during combined hormone replacement therapy. Eur j Obstet 

Gynecol Reprod Biol 2003;111:216-8. 

4 Hsu YH, et al. Leiomyomatosis in pelvic lymph node. Obstet Gynecol 

1981;57(6 Suppl):91S-3. 

5 Kumar S, Sharma JB, Verma D, et al. Disseminated peritoneal leiomyomatosis: 

an unusual complication of laparoscopic myomectomy. 

Arch Gynecol Obstet 2008;278:93-5. 

6 Miyake T, Enomoto T, Veda Y, et al. A case of disseminated peritoneal 

leiomyomatosis developing after laparoscope-assisted myomectomy. 

Gynecol Obstet Invest 2009;67:96-102. 

7 Summa B, Schem C, Weigel M, et al. Leiomymatosis peritonealis 

disseminata in a pregnant woman. Arch Gynecol Obstet 

2010;281:123-7. 

8 Takeda T, Masuhara K, Kamiura S. Successful management of a 

leiomyomatosis peritonealis disseminata with an aromatase inhibitor. 

Obstet Gynecol 2008;112:491-3. 

9 Tavassoli FA, Norris HJ. Peritoneal leiomyomatosis (leiomyomatosis 

peritonealis disseminata): a clinicopathologic study of 20 cases with 

ultrastructural observation. Int J Gynecol Pathol 1982;1:59-74. 

10 Wilson JR, Peale AR. Multiple peritoneal leiomyomas associated 

with a granulose-cell tumor of the ovary. Am J Obstet Gynecol 

1952;64:204-2. 

Primary ovarian lymphoma: an incidental finding 

in two cases 

G. Petracco, P. Uboldi, M. Onorati, A. Del Gobbo * , S. Romagnoli 

* , M. Albertoni, I. Talamo, F. Di Nuovo 


Italy; * Department of Health Sciences, AO S. Paolo, University of 

Milan, Medical School, Italy 

Introduction. Primary ovarian lymphoma is an uncommon 

disease and often pose a diagnostic challenge if his existent is 

not suspected, because most cases of ovarian involvement by 

lymphomas represent secondary involvement. Most are non- 

Hodgkin lymphomas and constitute only the 1,5% of ovarian 

tumors with a prevalence ranging from 0.2% to 1.1%. It affects 

patients over a wide age. The peak of incidence is in the fourth or 

fifth decade for large B-cell lymphoma, whereas follicular lymphoma 

are more often found in older women. The main symptom 

is abdominal pain, with pelvic mass and ascites, which are also 

common in ovarian cancer. A minority of patients have weight 

loss, fatigue, fever or abdominal vaginal bleeding. Most ovarian 

lymphomas are large B-cell lymphomas followed by primary 

ovarian Burkitt’s lymphoma and follicular lymphomas. Ovarian 

lymphoma traditionally has been considered an aggressive tumor 

with a poor outcome; however in more recent reports with com-

PoStER 

bination chemotherapy the prognosis appears similar to that for 

nodal lymphoma of comparable stage and histological type. We 

report two cases of ovarian lymphomas in two woman of 57 and 

79 year-old, which underwent bilateral hystero-annessiectomy 

for leiomyomas and prolapse without clinically appearance of an 

ovarian neoplasm. 

Case reports. First case. A 57 year-old woman with a familiarity 

for lymphomas underwent hystero-annessiectomy for uterine leyomiomas. 

A pre-operative ultrasonography showed three uterine 

leyomiomas but it didn’t report any ovarian alteration. Blood tests 

were normal, and the patient was in good general health. On gross 

examination uterus showed multiple leiomyomas, and the left 

ovary was normal. The right ovary was 4 cm in major diameter 

and showed greyish, fleshy lesion 1.2 cm in major diameter. The 

specimen was fixed in formalin and embedden in paraffin. Thin 

sections were cut and stained with Haemathoxylin/Eosin. Microscopically, 

the tumor was composed of cellular elements of medium-large 

size, monomorphic, with evident atypia, growing in a 

storyform pattern. The neoplastic cells add abundant cytoplasm, 

basophilic to the Giemsa stain and hyperchromatic nuclei with 

evident nucleoli, rarely multiple. The lesion was not delimited by 

a capsule but was well defined from the surrounding parenchyma. 

There were also small foci of necrosis. We performed immunohistochemical 

staining and found positivity for LCA and CD20 

and negativity for CAM 5.2; CD10, CD3, CD5, CD23, CD34 and 

MT1. More over the proliferative cell index has determined by 

Ki67, was positive in the 60% of the neoplastic cells. 

The final diagnosis was of primary ovarian lymphoma, large cell 

B phenotype (WHO 2008). Although ovarian lymphoma traditionally 

has been considered an aggressive tumor with a poor 

prognosis the patient is still alive after chemotherapy. 

Second case. A 79-years old woman underwent hystero-annessiectomy 

for IV grade uterine prolapse. 

The patient was in good health, except for thyroid goiter; blood 

tests and pelvic imaging were normal. On gross examination 

uterus showed an evident prolapse with ulceration of cervix mucosae, 

left ovary was normal. The right ovary was 2 cm in major 

diameter and was fully replaced by a whitish, nodular lesion 

with a firm and rubbery consistency. The specimen was fixed in 

formalin and embedden in paraffin. Thin sections were cut and 

stained with Haemathoxylin/Eosin. Microscopically the neoplastic 

population was constituted by small cells with irregular nuclei 

(centrocytes) with only rare large cells (centroblasts: 1-2 HPF) 

with one or more basophilic nucleoli and a moderate amount of 

cytoplasm. Scattered follicular dendritic cells were intermingled 

with neoplastic cells and showed large nuclei with delicate nuclear 

membranes and prominent nucleoli, often binucleated. The 

tumor cells were positive for CD20, CD10 and bcl-2 and negative 

for CD3, CD5 and ciclyn D1. More over the proliferative cell 

index has determined by Ki67, was positive in the about 30% of 

the neoplastic cells. 

The final diagnosis was of primary ovarian lymphoma, follicular 

type, low grade (grade1) (WHO 2008). The neoplasm had an 

indolent course and patient is still alive after chemoterapy. 

Discussion. Primary ovarian lymphoma is an uncommon disease, 

accounting for 0,5% non Hodgkin lymphomas and 1,5% of all 

ovarian tumours. Most common symptoms are a vague sense 

of heaviness or abdominal pain, a palpable mass and ascites. 

Fox et al proposed three criteria for diagnosing primary ovarian 

lymphoma. At the time of diagnosis, only the ovary must 

be involved by lymphoma; peripheral blood and bone marrow 

must be negative for lymphomatous cells and several months 

must be elapsed between the appereance of the ovarian lesion 

and further lymphoid masses at sites different from ovary. Treatment 

of primary ovarian lymphoma includes surgery followed by 

chemotherapy. The prognosis of primary ovarian lymphoma is 

poor, with survival reported which varies from 0 to 36% with an 

average survival time less than 3 years, similar to that for nodal 

389 

lymphoma of comparable stage and histologic type. Our two 

cases are peculiar because they were detected as incidental findings 

during the work-up of other gynecologic disease, moreover 

they were unilateral without clinical symptoms referred to ovarian 

and peritoneal localization. In conclusion, we must to keep in 

mind that gynaecological lymphoproliferative disorders are rare 

but they exist and so we must suspect it. Moreover the distinction 

between primary and secondary lymphomas has a clinical, therapeutic 

and prognostic significance. 

references 

1 Scully RE. Tumors of the ovary and mal developed gonads. In: Atlas 

of tumor pathology. 2nd series. Washington (DL): Armed Forces Institute 

of Pathology 1979, fascicle 16, pp. 117-27. 

2 Vang R, et al. Ovarian non-Hodgkin lymphoma: a clinicopathologic 

study of eight primary cases. Modern Pathol 2001;14:1093-9. 

3 Neuhauser TS, et al. Follicle center lymphoma involving the female 

genital tract: a morphologic and molecular genetic study of three 

cases. Am Diagn Pathol 2000;4:293-9. 

4 Lagoo AS, et al. Lymphoma of the female genital tract: current status. 

Int J of Gynecol Pathol 2006;25:1-21. 

5 Ozsan N, et al. Clinicopathologic and genetic characterization of follicular 

lymphomas presenting in the ovary reveals 2 distinct subgroups. 

Am J Surg Pathol 35:1691-9. 

6 Barzilay J, et al. Malignant lymphoma of the ovary: report of a case 

and review of the literature. Obstet Gynecol 1984;64:93S. 

Polypoid endocervical adenomyoma: case report 

R. Ponte1 , L. Abete1 , T. Celiento1 , P. Ceriolo1 , E. Pacella1 , 

P. Calamaro1 , S. Bruno1 , P. Sala2 , E. Fulcheri1 1 University of Genoa, IRCCS San martino, IST, U.O. Anatomia Patologica 

DISC; 2 IRCCS San martino, IST, U.O. Ginecologia e Ostetricia 

Introduction. Endocervical adenomyoma is a rare neoplastic 

condition of the uterine cervix, one of a group of endocervical 

benign lesions that may histologically be confused with an aggressive 

cervical carcinoma, adenoma malignum. It represents 

the benign counterpart of atypical polypoid adenomyoma of the 

uterine body which mainly consists of endometrial glands (which 

are atypical and present squamous morules) and smooth muscle 

cells 1 2 . The designation endocervical adenomyoma has been 

used for biphasic tumors composed of irregularly shaped endocervical 

glands with bundles of smooth muscle cells 3 . A gross 

well-circumscribed appearance and intermingling of bundles of 

smooth muscle fibres and benign-looking glands are indicative of 

the diagnosis. There have been only a limited number of reported 

cases and therefore it is important be aware of this entity to avoid 

any diagnostic mistakes, especially in consideration of the differential 

with malignancy 4 . 

Materials and methods. We report a case of adenomyoma of 

endocervical type arising in a 47-year-old female, gravida 3, para 

2, Italian woman. The patient was in good health without any notable 

family history. She had a history of relapsing menometrorrhagia 

and 7 years previously she had had a fibrous peduncolated 

formation in expulsion from the endocervical canal removed. 

Simple ablation without revision of the base plant had been 

performed. Histological examination of the lesion showed this to 

be an endocervical adenomyoma. After six years of good health, 

the symptoms recurred in 2011. The transvaginal ultrasound 

(Figg. 1,2) visualized a single large mass involving deeply the 

cervical wall and slightly protruding on the mucosal surface. In 

consideration of the age of the patient conservative surgical treatment 

by hysteroscopy was decided. This approach permitted the 

removal of the polypoid component only while, in consideration 

of the lesions persistence within the cervix wall, hysterectomy 

was subsequently performed. 

Results. Gross description identified a polypoid tumor which 

measured 3x2x1,5 after hysteroscopic polypectomy. The infiltrating 

lesion was well-circumscribed and measured 3x2,5 cm in size

390 

at hysterectomy. The cut surface was solid, whitish to yellowish, 

and contained some cystic spaces filled with clear mucus. 

Microscopically, the tumor was composed of glands (Fig. 3) 

and cysts lined by a single layer of endocervical-type mucinous 

epithelium with eosinophilic and ciliated metaplasia and admixed 

with smooth muscle. The glands showed focal pseudopapillary 

growth. There was no distinct nuclear atypia in the proliferating 

glands, there were no architectural abnormalities and there was 

no evidence of destructive stromal invasion by the epithelial 

component, including an absence of periglandular desmoplastic 

response. Foci of periglandular chronic inflammation were 

present. Less than five mitotic figures per 10 high-power-fields 

were present in the smooth muscle component. Immunohistochemically, 

smooth muscle was positive for desmin and smooth 

muscle actin and was negative for CD10. 

Conclusions. Endocervical adenomyoma is a rare benign neoplasm 

with glandular as well as stromal proliferation. The differential 

diagnosis includes a variety of lesions in the region, 

most of which are benign pseudoneoplastic processes. These 

lesions include deep endocervical glands or cysts, microglandular 

hyperplasia, tunnel clusters (a tightly packed group of dilated endocervical 

glands with flattened epithelium), lobular endocervical 

glandular hyperplasia and diffuse laminar endocervical gland hyperplasia 

5 6 . These lesions do not have the smooth muscle proliferation 

seen in endocervical adenomyoma, but consist of glands 

in normal or hyperplastic cervical stroma. Another benign lesion 

that has characteristics similar to adenomyoma is endocervicosis: 

the glands, often cystically dilated, are lined by mucinoid-type 

endocervical cells and typically occupy the outer one-third of the 

cervical wall with extension to the paracervical tissues. The most 

clinically important distinction is from an adenoma malignum 

of the uterine cervix, and this may pose a diagnostic problem. 

Figg. 1, 2. transvaginal ultrasound. 1. (left) the uterine cervix appeared 

increased in volume and deformed in its morphology due to the 

presence of a mixed (solid and cystic) lesion in ill-defined margins, a 

diameter of about cm 4, in part projecting into the endocervical canal 

and in part infiltrating the endocervical stroma (the arrow indicates 

the endocervical canal). 2. (Right) the lesion had two components: a 

solid homogeneous hyperechoic (white arrow) and a cystic vacuolar 

(red arrow). 


Figg. 3, 4. EE, 10x. 3.(left) the glands are coated by a single layer of 

endocervical-type mucinous epithelium admixed with smooth muscle. 

4. (Right) Smooth muscle proliferation. 

Figg. 5, 6. 5. (left) desmin, 10x. muscle fibers surrounding an endocervical 

gland. 6. (Right) Ki-67, 20x. lack of replicative activity in the 

glandular and muscolar component. 

Clinical manifestations of mucoid vaginal discharge and the existence 

of florid glandular proliferations extending deep into the 

cervical stroma are of diagnostic help. The histologic features are 

glands with deceptively benign histological appearance. It also 

may grow within the cervix and may not be obvious at clinical 

vaginal inspection. Despite its benign appearance, it may carry a 

poor prognosis. 

Of the few reported cases of endocervical adenomyoma, most 

are isolated reports 7 8 . The largest series reported was in 1996 by 

Gilks et al. 3 , who reported on 10 cases in women ranging from

PoStER 

21 to 55 years in age, the largest measuring 23.0 cm. The lesion 

was described as a well-circumscribed nodule, polypoid in 8 of 

10 cases, often showing gross mucinous cysts. A single layer of 

endocervical mucosa lined the cysts, although in this series, there 

was focal tubal-type epithelium in six cases, and one showed focal 

endometrial glands surrounded by endometrial stroma. The 

glands were arranged in a lobular fashion, with large irregular 

glands showing papillary infolding surrounded by smaller simpler 

glands. 

The rarity of endocervical adenomyoma makes its recognition 

important. Familiarity with the gross and microscopic characteristics 

of both lesions should facilitate correct diagnosis and 

therapy 9 . The risk of recurrence is considerable with hysteroscopic 

polypectomy. Although our findings indicate that cervical 

adenomyoma may recur if only locally excised, no evidence of 

malignant behaviour was present. 

references 

1 Kisu I, Banno K, Yanokura M, et al. Atypical Polypoid Adenomyoma 

(APAM) of the Uterine: Relationship with Endometrial Cancer. Journal 

of Cancer Therapy 2011;2:458-62. 

2 Mazur MT. Atypical Polypoid Adenomyoma of the Endometrium. 

American Journal of Surgical Pathology 1981;5:473-82. 

3 Gilks CB, Young RH, Clement PB, et al. Benign endocervical adenomyomas 

and adenoma malignum. Mod Pathol 1996;9:220-4. 

4 Young RH, Clement PB, Scully RE. Premalignant and malignant lesions 

of the uterine cervix. In: Clement PB, Young RH, eds. Tumors 

and Tumor Like Lesions of the Uterine Corpus and Cervix. New York: 

Churchill Livingstone 1993, p. 85. 

5 Young RH, Clement PB. Endocervicosis involving the uterine cervix: 

a report of four cases of a benign process that may be confused with 

deeply invasive endocervical adenocarcinoma. Int J Gynecol Pathol 

2000;19:322-8. 

6 Nucci MR, Clement PB, Young RH. Lobular endocervical glandular 

neoplasia not otherwise specified: a clinic pathologic analysis 

of thirteen cases of a distinctive pseudoneoplastic lesion and 

comparison with fourteen cases of adenoma malignum. Am J 

SurgPathol1999;23:886-91. 

7 Mikami Y, Maehata K, Fujiwara K et al. Endocervical adenomvoma: 

A case report with histochemical and immunohistochemical studies. 

APMIS 2001;109:546-50. 

8 Ota S, Ushijima K, Nishio S, et al. Polypoid endocervical adenomyoma: 

A case report with clinicopathologic analyses. J Obstet Gynaecol 

Res 2007;33:363-7. 

9 Uppal S, Heller DS, Cracchiolo B. Adenomyoma of the Cervix: Report 

of a Case and Review of the Literature. Departments of Pathology 

& Laboratory Medicine and Obstetrics, Gynecology, & Women’s 

Health, UMDNJ-New Jersey Medical School, Newark. 

Ovarian fibromatous tumours of uncertain 

biological potential: study of three cases 

M.G. Zorzi, T. Pusiol, D. Morichetti 

Dirigente Medico, U.O. Anatomia e Istologia Patologica, Ospedale di Rovereto, 

Rovereto (TN) 

Introduction. About 10% of fibromatous tumours (FTs) exhibit 

increased cellularity, mitotic activity, and less frequently nuclear 

atypia. It is then difficult to classify a case within the group of 

FTs when one or several of these features exist. We report three 

cases of primary ovarian FTs with an average mitotic count of 4 

or more per 10 high-power fields (HPFs) in the absence of nuclear 

atypia and necrosis. 

Materials and methods. The clinical, histological features, treatment, 

and follow-up of three ovarian FTs with increased mitotic 

activity were studied. 

Results. Case 1. A 44-year-old woman presented at our hospital 

with lower abdominal pain of 3 months duration. A total hysterectomy 

with salpingo-oophorectomy was performed. A large 

amount of ascitic fluid was detected, however, no tumor cells 

were observed on cytology. There was no rupture of the capsule 

of the tumours. The left ovary was 18×17×10 cm and weighed 

391 

760g. A cross-section of the tumor revealed multiple lobules of 

various sizes. Uterus and right ovary appeared unremarkable. 

Microscopically, the tumour was densely cellular and involved 

the entire ovary diffusely, with no remaining normal stroma. It 

was composed of spindle-shaped cells arranged in intersecting 

fascicles; the nuclei of the tumor cells were hyperchromatic and 

atypical. Mitotic activity was increased up to 17 mitoses/10 HPFs 

(Fig. 1). The tumor cells were strongly positive for vimentin, and 

negative for smooth muscle actin (SMA), S-100, desmin, h-caldesmon, 

CD10, HMB45, muscle-specific actin, estrogen receptor 

(ER), and progesterone receptor (PR). The Ki-67 proliferation 

index was low (< 1%). No significant atypia or necrosis could be 

observed. The right ovary and uterus were normal. The patient 

has been free from disease, without evidence of recurrence, 10 

years after the initial diagnosis. 

Case 2. A 67 year-old woman looked for assistance to the 

gynaecological consultation due to recent pelvic pain. A total 

hysterectomy with bilateral adnexectomy and an omentectomy 

were performed. No rupture of the capsule occurred on either 

ovary. The right and the left ovaries measured 4×2.5×2 cm and 

3x2.5x2.5 cm. respectively. The external surface of both ovaries 

Fig. 1. Case 1: the tumour was composed of spindle-shaped cell 

arranged in intersecting fascicles. Mitotic activity was increased up to 

17 mitoses/10 high-power fields (arrows) (H&E 100x). 

Fig. 2. Case 2: the tumour of right ovary was composed by cellular proliferation 

of uniform spindle cells arranged in sheets and intersecting 

fascicles. in some areas, thick hyaline fibrous plaques could be observed. 

the nuclei were bland with pointed ends and indistinct nucleoli. 

the mitotic count varied from 4 to 6 per 10 high-power fields (arrows). 

No significant atypia or necrosis could be observed (h&E 100x).

392 

was smooth. Both ovaries were involved enterely by white solid, 

firm, yellow, grey tissue. Histologically, booth ovarian tumor 

were composed of uniform spindle cells arranged in sheets and 

intersecting fascicles. The stroma showed loose areas as well as 

more fibrous areas containing intercellular collagen. In some areas, 

thick hyaline fibrous plaques could be observed. The nuclei 

were bland and slim with pointed ends and indistinct nucleoli. 

The neoplastic cells were positive for vimentin. S100, desmin, 

h-caldesmon, C10, HMB45, muscle-specific actin, estrogen, progesterone 

receptors, CD31, and c-KIT were negative. The mitotic 

count varied from 4 to 6 per 10 HPF (Fig. 2). The Ki-67 proliferation 

index was low (< 1%). No significant atypia or necrosis 

could be observed. Eighteen months after the surgery, no sign of 

new recurrence was noted. 

Discussion. The histologic criteria of ovarian FTs are controversial. 

In 1981, Prat and Scully 1 proposed histologic criteria for the 

distinction of cellular fibromas (CFs) from fibrosarcomas (Fs). 

These authors found that mitotic activity was the most important 

factor in diagnosing the sarcomas, and that nuclear grading 

with cellular pleomorphism was not so much reliable. CFs were 

characterized by densely cellular proliferations of fibroblasts 

with mild to moderate nuclear atypia, a mitotic count of 3 or 

fewer mitotic figures (MFs) per 10 HPFs, and a low malignant 

potential 1 . In contrast, Fs usually exhibited moderate to severe 

nuclear atypia, mitotic counts of 4 or more MFs/10 HPFs, and a 

clinically malignant course in most cases 1 . After the first study 

published by Prat and Scully 1 a number of ovarian Fs with a benign 

clinical course have been reported in the literature in which 

the diagnosis was based on a mitotic count of 4 or more mitotic 

figures/10HPFs 2 . The Atlas of Tumor Pathology, published by 

Armed Forces Institute of Pathology and the World Health Organization 

Classification of Tumours are the textbooks of choice 

consultation for pathologists in the diagnosis of tumour. Scully 

et al. 3 believe that pure Fs are among the most common forms 

of ovarian sarcoma. Microscopic examination shows a densely 

cellular neoplasm with moderate to severe nuclear atypia and an 

average mitotic count of 4 or more per 10 HPFs. Abnormal mitotic 

figures and areas of necrosis and hemorrhage are common 3 . 

In the Chapter “Sex cord-stromal tumours” of the World Health 

Organization Classification of the Breast and Female Genital 

Organs, Tavassoli et al. 4 considered ovary F as a rare fibroblastic 

tumour that typically has 4 or more mitotic figures per 10 high 

power fields as well as significant nuclear atypia. Irving et al. 5 

believe that cellular FT with bland nuclear feaures and mitotic 

count of ≥ 4 MFs/10 HPFs should be considered a mitotically active 

cellular fibroma of the ovary (MACF) rather than an ovarian 

F. The latter term should be reserved for fibroblastic tumors that 

exhibit a combination of moderate to severe atypia and a usually 

high mitotic rate. 

Conclusions. Our cases may be classified as Fs according to Prat 

and Scully 1 histological criteria of and as MACFs of the ovary 

according to Irving et al. 5 criteria. Because of the controversial 

diagnostic criteria, we prefer the terminology ovarian fibromatous 

tumours of uncertain biological potential when an average 

mitotic count of 4 or more per 10HPFs are found and nuclear 

atypia and necrosis are absent. This term reflect the controversial 

prognosis of these tumors. The management of choice of these 

lesions consist of exclusive strict radiological follow-up, in order 

to monitoring recurrences or metastases. 

references 

1 Prat J, Scully RE. Cellular fibromas and fibrosarcomas of the ovary: 

a comparative clinicopathologic analysis of seventeen cases. Cancer 

1981;47:2663-70. 

2 Gultekin M, Dursun P, Ozyuncu O, et al. Primary ovarian fibrosarcoma: 

a case report and review of the literature. Int J Gynecol Cancer 

2005;15:1142-7. 

3 Scully RE, Young RH, Clement PB. Tumors of the Ovary, Maldeveloped 

Gonads, Fallopian Tube, and Broad Ligament. Published by the 


Armed Forces Institute of Pathology, Washington, D.C. 3rd series. 

Fascicle 23, p. 197. 

4 Tavassoli FA, Mooney E, Gersell DJ, et al. “Sex cord-stromal tumours” 

of the World Health Organization Classification of the Breast 

and Female Genital Organs. Edited by Fattaneh A. Tavassoli & Peter 

Devilee. Lyon: IARCPress 2003, p. 151. 

5 Irving JA, Alkushi A, Young RH, et al. Cellular fibromas of the ovary: 

a study of 75 cases including 40 mitotically active tumors emphasizing 

their distinction from fibrosarcoma. Am J Surg Pathol 2006;30:929-38. 

InTErESSE GEnErALE 

P16 and CK20, immunocytochemical double 

staining in urinary cytology: method optimization 

R. Rapezzi, B. Selmi, G. Ferro, P. Crucitti, S. Negri, A. Bondi 

U.O. Anatomia, Istologia Patologica e citodiagnostica, Ospedale Maggiore, 

Azienda USL di Bologna 

Background. Every year more than 7000 patients attend to Anatomic 

Pathology Unit (UO) of Maggiore Hospital in Bologna to 

perform an urine cytological test. 

Since 2009 access to this service has been progressively increased 

by introducing a new procedure for sample collection by addiction 

of alcohol based fixative capable of retaining cellular elements 

well preserved and stable for 7 days at least. 

The urinary cytology test has an important role in the follow up of 

patients treated for urothelial cancer, with a high specificity (95- 

100%) but low sensitivity (38-60%) due to difficulty to correctly 

distinguish between florid benign lesions from well-differentiated 

carcinomas. Therefore immunocytochemical investigations may 

be useful in the follow-up of cystectomized patient or evaluation 

of hyperplastic lesions. 

Loss of heterozygosity at chromosome 9, where houses the 

regulation of p16 synthesis, is an aberration found in urothelial 

cell carcinoma of all stage and grade as well as in dysplastic 

urothelium, possibly representing an early event in urinary bladder 

carcinogenesis.. The expression of P16 protein represents an 

indirect estimate of the most common genetic alteration found in 

bladder cancer and an indication of its ability to replicate. P16 INK4a 

is not found in non-neoplastic urothelium, while is expressed in 

50% of urothelial carcinoma, increasing to 80% in high-grade 

carcinomas. 

CK20 is a high molecular weight cytokeratin little or not expressed 

in normal urothelium, while it is clearly present in transitional 

carcinomas. 

Materials and methods. In our laboratory, samples are obtained 

by simultaneous and complete filtration of 3 samples by a filtration 

system with a vacuum pump of about 25 mmHg average 

pressure and a polycarbonate membranes of ø 5 microns pore. For 

each patient a single glass is set up, stained with Papanicolaou, 

and produces a single diagnosis. The same analyzed material is 

then used for immunocytochemical investigations. 

P16 analysis was performed by a CINtec antibody into the Ventana 

BenchMark XT. Initially the detection system used was 

Phosphatase Red Detection Kit, where positivity is shown by 

nucleus / cytoplasm red staining. 

CK20 analysis was performed by an antibody anti-CK20 also into 

the Ventana BenchMark XT. Initially the detection system used 

was UltraView Universal DAB Detection Kit and positivity was 

detectable as a brown cytoplasmic staining. 

However CK20 positivity, revealed by DAB, completely masked 

P16 positivity revealed by Red. 

Having a single slide, we developed a double immunocytochemical 

staining: P16 has been detected in brown with diaminobenzidine 

(DAB) increasing incubation times and with 

an amplification system and CK20 was detected in Red, after 

appropriate reduction of time and incubation temperature of 

primary antibody.

PoStER 

Results and conclusion. We achieved a good improvement in 

performance by developing P16 with DAB and CK20 with Red. 

Now differentiation between the two antibodies is good, easily 

interpretable and used in diagnostic practice. 

references 

1 Rosenthal D, Raab SS. Cytologic Detection of Urothelial Lesions. 

Springer 2005. 

2 Planz B, Jochims E, Deix T, et al. The role of urinary cytology for 

detection of bladder cancer. Eur J Surg Oncol 2005:31:304-8. 

3 Alameda F, Juanpere N, Pijuan L, et al. Value of p16(INK4a) in the 

diagnosis of low-grade urothelial carcinoma of the urinary bladder 

in urinary cytology. Cancer Cytopathol 2012 Mar 14. doi: 10.1002/ 

cncy.21193 

4 Tauber S, Brunken C, Vierbuchen M. Expression of the tumormarker 

p16INK4a in cytology specimens of the urinary bladder. A new means 

for early recognition and surveillance of urothelial cancer. Urologe A 

2011;50:1130-3. 

5 Melissourgos ND, Kastrinakis NG, Skolarikos A, et al. Cytokeratin- 

20 immunocytology in voided urine exhibits greater sensitivity and 

reliability than standard cytology in the diagnosis of transitional cell 

carcinoma of the bladder. Urology 2005;66:536-41. 

6 Lin S, Hirschowitz SL, Williams C, et al. Cytokeratin 20 as an immunocytochemical 

marker for detection of urothelial carcinoma in 

atypical cytology: preliminary retrospective study on archived urine 

slides. Cancer Detect Prev 2001;25:202-9. 

7 Bhatia A, Dey P, Kumar Y, et al. Expression of cytokeratin 20 in urine 

cytology smears: a potential marker for the detection of urothelial 

carcinoma. Cytopathology 2007;18:84-6. 

8 Eble JN, Sauter G, Epstein JI,et al., eds. World Health Organization 

Classification of Tumours. Pathology and Genetics of Tumours 

of the Urinary System and Male Genital Organs. IARC Press: Lyon 

2004. 

The practical use of pagoda red stain 

in the detection of splenic eosinophilia 

in immediate anaphylactic death 

N. Trani1 , C. Palmiere2 , E. Duzzi1 , E. Mattioli1 , M. Lupi1 , L. Maccio1 

, G. Barbolini1 , L. Reggiani Bonetti1 1 Dipartimento Integrato di Laboratori, Medician Legale e Anatomia Patologica; 

Struttura Complessa di Anatomia, Istologia e Citologia Patologica, 

Azienda Ospadaliero-Universitaria Policlinico di Modena; 2 University 

Center of Legal Medicine, Geneva-Lausanne 

Background. The anaphylaxis is an abnormal allergic reaction 

following to inhalation, ingestion, contact or inoculation of specific 

allergens. Anaphylaxis related deaths are an infrequent event 

that is difficult to objectify during autopsies. Beside the clinical 

and laboratory data, the main forensic findings include upper 

airways edema and erythematous skin-rush. Isolated studies in 

literature have been reported increased mast cells and eosinophils 

in different organs including spleen. 

Materials and Methods. The aim of this study is to evaluate the 

presence of eosinophils in the spleen, in a collection of 10 cases 

of death by anaphylaxis (7 male and 3 female), selected from the 

Archives of the Department Pathology and Forensic Medicine of 

the Policlinico Hospital of Modena (University of Modena and 

Reggio Emilia) and from the University Center of Legal Medicine 

Geneva-Lausanne. Twenty controls (16 male and 4 female) 

were selected, including cases of immediate non-anaphylactic 

death (car-crash, fall). From all cases, representative spleen samples 

were collected and 8 sections were obtained. Conventional 

histology (Hematoxylin-Eosin staining – H&E) and Pagoda Red 

staining (performed in Pathology and Forensic Medicine of the 

Azienda Policlinico of Modena, section of Histochemistry) were 

performed in all cases. The counts of eosinophils, mast cells and 

degranulated mast cells were performed by 3 different observers 

at 40 high power field (HPF) of magnification, valuing a mean of 

10 different fields for slide. 

Results. The mean age of the patients was 60 y.o. (range: 12- 

74). In 9 cases the immediate anaphylactic death followed the 

393 

intramuscular injection of antibiotics (different types of penicillin 

or cephalosporin) and other drugs, while in 1 case it occurred 

consequently to a bee sting. The clinical and laboratory findings 

provided an increased serum level of tryptase in all cases of anaphylaxis. 

Autopsy examinations revealed upper airways edema in 

7 cases and erythematous skin-rush in 4. In 60% of the cases, the 

spleen was large and heavy. All spleens showed evident increases 

in eosinophils (a mean of 3-4 cells/HPF), mast cells (a mean of 

4-5 cells/HPF) and degranulated mast cells (1-2 cells/HPF), the 

latter mainly located in spleen sinuses. The use of Pagoda Red 

staining clearly identified these cells wherever the routinely H&E 

stain was clouded. No increased number of mast cells or eosinophils 

was detected in the controls. 

Conclusion. Spleen seems to be a marking organ in the anaphylaxis, 

becoming as the possible shock-organ in human. Pagoda 

Red staining represents a rapid and low-cost method to prove it. 

MAMMELLA 

PI3K/P-AKT pathway phenotypic alterations 

represents an adverse biologic profile in early stage 

breast cancer patients 

A. Di Benedetto, F. Novelli, E. Bria, E. Melucci, C. Ercolani, 

B. Antoniani, C.A. Amoreo, V. D’Alicandro, V. Dimartino, 

I. Sperduti, L. Perracchio, P. Vici, C. Nisticò, A. Fabi, E. Pescarmona, 

M. Mottolese 

Regina Elena National Cancer Institute, Rome, Italy 

Background. Akt, a serine/threonine protein kinase, is a target 

of phosphoinositide-3-OH kinase (PI3K) and this pathway plays 

a pivotal role in regulating the signalling of many fundamental 

biological processes as apoptosis and cell cycle progression 1 . 

p-Akt regulates cell proliferation modulating the function of numerous 

substrates, such as the cyclin-dependent kinase inhibitors 

(CDKI), p21/Waf1/Cip1 and p27/Kip2. In particular, p27 interacts 

with cyclin E/Cdk2 complex inhibiting the cell cycle progression 

from G1 to S phase and it also acts as a tumor suppressor 

gene. Akt-mediated phosphorylation of p27 impairs its nuclear 

import leading to cytoplasmic p27 accumulation, functionally 

inactivating the growth inhibitory properties of p27 and favoring 

the proliferation of cancer cells 2 . Most authors found that Akt 

activation is associated with a worse outcome among endocrinetreated 

breast cancer (BC) patients 3 . Therefore, the PI3K/Akt 

pathway is attracting considerable attention as a new target for 

therapeutic strategies. 

In this study we analyzed a retrospective series of 133 early stage 

BC patients homogeneously treated with cyclophosphamide/ 

metotrexate/5-fluorouracil (CMF) aimed to investigate the impact 

of PI3K/Akt pathway alterations on disease progression. In 

addition, we evaluated the relationship between p-Akt, PI3K and 

consolidated bio-pathologic parameters (Hormonal Receptors, 

HER2, KI67, T, N, G). 

Materials and methods. Patients: our series of 133 stage I, 

IIa, and IIb BC patients were treated at the Regina Elena Cancer 

Institute between 1997 and 2002. They were submitted to 

quadrantectomy and received 12 courses of CMF-based adjuvant 

therapy. Fifty-three of the 133 (39.8%) patients received hormonal 

maintenance therapy. Immunohistochemistry: sections were 

incubated with the anti-ER-α Monoclonal Antibody (MoAb) 

(Menarini, Florence, Italy) 6F11, the anti-PgR MoAb 1A6 

(Menarini), the anti-HER2 PAb (A0485, Dako, Milan, Italy), 

the anti-Ki67 MoAb MIB-1 (Dako), the anti-p53 MoAb DO7 

(Menarini), the anti-Bcl2 MoAb 124 (Dako), the anti-PI3K (clone 

4, BD Transduction, SIAL, Rome, Italy), the anti-p27 (Dako), 

and the anti-p-Akt (Ser473) (Cell Signaling, EuroClone, Milan, 

Italy). Positive and negative controls were included for each Ab.

394 

Immunoreactions were revealed us- 

Fig. 1. 

ing a streptavidin-biotin enhanced 

immunoperoxidase technique (Super 

Sensitive MultiLink, Menarini, Florence, 

Italy) in an automated autostainer. 

Receiver Operative Curve 

(ROC) analysis was adopted for 

optimal cut-off values. Evaluation 

of the immunohistochemical results, 

blinded to all patient data, was performed 

independently and in blinded 

manner by two investigators (MM 

and FN). Statistical analyses: Multiple 

Correspondence Analysis (MCA) 

was used to identify sub-groups of 

BC patients with different prognosis, 

while uni-and multivariate Cox 

regression analyses were applied to 

determine the impact of parameters 

identified by MCA on 10-yrs Disease 

Free Survival (DFS), together 

with clinico-pathological features. 

Results. In our series of 133 BC 

patients (median follow-up of 107 

months) the MCA analysis (Fig. 1) 

demonstrates the contrast between 

high Ki67/p53+/p-Akt+/PI3K+/ 

HER2+ (Adverse Biologic Factors, 

ABF) and presence of relapse (upper 

right quadrant) vs low Ki67/ 

p53–/p-Akt–/PI3K–/HER2– BC and 

no relapse (lower left quadrant). 

Therefore, this statistical approach Fig. 2. 

may define an Unfavorable Biologic 

Profile (UBP) associated to disease 

progression considering the presence/absence 

of at least 3 variables 

out of the 5 selected as discriminative 

power, (UBP≥3 ABF) and a 

Favourable Biologic Profile (FBP

PoStER 

Identification of cancer stem cells in triple 

negative phenotype of breast carcinoma: 

comparison between different CSCS markers 

M. Di Bonito, F. Collina, G. Scognamiglio, M. D’Aiuto, A. Manna, 

V. Relli, L. La Sala, G. Liguori, M. Cantile, G. Botti 


Naples, Italy 

Triple Negative breast cancer subtype, typically negative for ER, 

PgR and HER2, represents about 20% of all breast carcinomas 

and has a significant clinical relevance being associated with a 

shorter median time to relapse and death and does not respond to 

endocrine therapy or other available targeted agents. 

According to the CSC hypothesis, in the breast as well as in other 

tissues, cancer arises from normal stem cells that undergo oncogenic 

transformation. It has been suggested that the increased 

aggressiveness of breast cancer as well as resistance to standard 

drug therapies may be associated with the presence of stem cell 

populations within the tumor, but identifying the ideal molecular 

marker for the detection of cancer stem cells in breast cancer 

subtypes is rather complex. In fact, contrasting opinions about the 

different CSCs markers used in breast cancer and their prognostic 

value are present in the literature. 

In this study we have selected six different CSCs markers, CD133, 

CD338, CD24, CD44, Ck19, and ALDHA1, and evaluated their 

expression by immunohistochemistry on a specific Triple Negative 

Breast Cancer TMA combined with patient follow-up. 

The data obtained allow us only to confirm the inverse correlation 

between CD24 and CD44 (p value = 0.043) and a trend of statistical 

significance between CD24 and CD338 (p value = 0.065). 

However, at least in this specific subtype of breast cancer, there 

is not a strong correlation/overlap between the different markers 

used, and also none of them has been shown a valid prognostic 

factor, not correlating statistically with DFS and OS. 

The only marker statistically related to the prognostic index of 

cell proliferation, Ki67, was CD338 (p value = 0.046). 

These data make us conclude that the panels of CSCs markers 

currently used for the detection of cancer stem cells in Triple 

Negative breast cancer are inadequate and do not represent the 

useful prognostic markers for this neoplasia. 

Evidence of loss of heterozygosity of an intron 

1 polymorphic sequence of epidermal growth 

factor receptor in normal epithelium surrounding 

basal like breast cancer 

V. Dimartino, E. Melucci, S. Conti, V. D’Alicandro, A. Di 

Benedetto, C.A. Amoreo, E. Pescarmona, A. Fabi, C. Nisticò, 

C. Ercolani, B. Antoniani, L. Perracchio, C. Botti, M. Mottolese 

Regina Elena National Cancer Institute Rome, Italy 

Background. Breast cancer (BC) is currently regarded as a heterogeneous 

disease classified, through gene expression analysis, 

into various molecular subtypes with different biological characteristics 

and clinical behaviour. Within the Triple Negative (TN) 

subtype, defined as a BC with hormonal receptors and HER2 

negative, the expression of the basal cytokeratin (CK5) and 

EGFR may identify a subgroup of very aggressive tumor, called 

basal-like, encompassing about 10% of BC that display a poor 

prognosis 1 . Recently, in vitro and in vivo studies reported that 

the length of a CA Simple Sequence Repeat 1 (CASSRI) dinucleotides 

in the intron 1 of egfr was associated with the expression of 

the protein. In addition, the loss of heterozigosity (LOH) within 

this region would also lead to altered receptor expression 2 3 . 

In this study we aimed to determine the association between LOH 

and overexpression of EGFR in a series of basal-like BC and their 

autologous uninvolved peritumoral tissues (PTT) in comparison 

to normal tissues (NT). 

395 

Material and methods. 41 TN BC, the correspondent PTT 

and the autologous NT were analyzed for EGFR, CK5 expression 

by immunohistochemistry (IHC) and for LOH using 

a capillary electrophoresis. The assessment of LOH on 

the 3 tissue substrates were evaluated comparing the peak 

area of the two alleles using the following equation: LOH 

score = T1XN2/T2XN1, where T is BC or PTT, N is normal 

tissue, 1 is the area under the peak the shorter allele, and 2 to 

the longer allele. The result was significantly different when 

the LOH score was < 0.79 (loss of the longer allele) or > 1.27 

(loss of the shorter allele). 

Results. Of the 41 TN BC, 35 (85%) were basal-like BC (EGFR+ 

and/or CK5+) and were included in the study. Of the 20 EGFR 

positive basal-like BC, 14 (70%) showed LOH whereas of the 

15 EGFR negative/ CK5 + basal-like BC, only 5 (33%) showed 

LOH (p = 0.03) (Tab. I). 

In 9 out of 14 basal-like BC displaying LOH (64%), the PTT 

presented a genetic profile similar to NT and did not show 

LOH. Interestingly, in 5 EGFR positive BC (36%) the PTT 

was different from NT, presented LOH and was EGFR positive 

(Fig. 1). 

Tab. I. Correlation between EGfR protein expression and lOH in 35 

basal-like BC. 

LOH NEG LOH POS TOTAL OF CASES 

EGfR NEG 10 (66%) 5 (33%) 15 

EGfR pOS 6 (30%) 14 (70%) 20 

tOtal Of CaSES 16 19 35 

p = 0.03 

Fig. 1. lOH distribution in ptt of 14 basal-like BC with lOH of CaSSRi 

in the intron 1 of egfr. 

Conclusions. Our data indicate that LOH of CASSRI in the 

intron 1 of egfr is related to EGFR expression in basal-like BC. 

In addition, the evidence of LOH in PTT, denoting the occurrence 

of early molecular alterations in morphologically NT, 

could represent a potential biomarker with diagnostic/prognostic 

implications. 

references 

1 Reis-Filho JS, Tutt ANJ. Triple negative tumours: a critical review. 

Histopathology 2008;52:108-18. 

2 Buerger H, Gebhardt F, Schmidt H, et al. Length and loss of heterozygosity 

of an intron 1 polymorphic sequence of egfr is related to cytogenetic 

alterations and epithelial growth factor receptor expression. 

Cancer Res 2000. 

3 Brandt B, Meyer-Staeckling S, Schmidt H, et al. Mechanisms of egfr 

gene transcription modulation: relationship to cancer risk and therapy 

response. Clin Cancer Res 2006.

396 

Distribution of focal adhesion kinase expression 

in breast cancer molecular subtypes 

C. Ercolani, E. Melucci, A. Di Benedetto, S. Buglioni, C.A. Amoreo, 

V. Dimartino, V. D’Alicandro, B. Antoniani, F. Marandino, 

C. Nisticò, P. Vici, A. Fabi, E. Pescarmona, M. Mottolese 

Regina Elena Cancer Institute, Rome, Italy 

Background. Focal adhesion kinase (FAK) is a protein tyrosine 

kinase which regulates multiple cellular processes including 

growth, differentiation, adhesion, motility and apoptosis and is 

a critical mediator of signalling events between cells and their 

extracellular matrix 1 . 

FAK is highly expressed in invasive breast cancer (BC) where 

its upregulation has been implicated in the acquisition of an 

invasive tumor phenotype. Hierarchical cluster analysis identified 

subgroups of BC with separate gene expression profiles 

which detect four main tumor phenotypes, Luminal A (LA), 

Luminal B (LB), Triple Negative (TN), and HER2 subtype (HS) 

characterized by significant differences in prognosis 2 . Up to 

now, there are no data concerning FAK distribution within the 

molecular BC subtypes. 

Materials and methods. FAK positivity was evaluated by 

immunohistochemistry (IHC) in a retrospective series of 193 

consecutive invasive BC surgically treated at Regina Elena 

Cancer Institute between 2002 and 2005. Associations with conventional 

bio-pathological factors and with molecular subtypes 

were analyzed by Multiple Correspondence Analysis (MCA). 

This statistical approach allowed to determine the impact of 

FAK overexpression within BC molecular 

subtypes and to define a biologic profile 

associated to a more aggressive clinical 

outcome. 

To this end we considered a number of biopathologic 

variables such as tumor size, nodal 

status (N), grading (G), proliferation index 

(Ki-67), p53, Bcl2, p-AKT and p-MAPK. 

The anti-FAK 4.47 (Millipore, Milan, Italy) 

monoclonal antibody was used to detected 

FAK expression which was scored as high 

(2 or 3 intensity and ≥ 90% positive cells) 

or low (0 or 1 intensity and < 90% positive 

cells) (Fig. 1). 

Results. FAK was overexpressed in 41.7% 

of LA, 70% of LB, in 48.0% of HER2 sub- 

Fig. 2. Kaplan-meier estimates of disease-free survival for faK status: (a) all patients and (B) la patients. 

A B 


type and 52.2% of TN BC. The relationship among the different 

bio-pathological factors analysed by MCA, showed that FAK+ tumors 

are located in the quadrant containing HER2 and Basal like 

subtypes associated to more aggressive bio-pathological parameters, 

namely T3-4, N+, G3, p53+, high Ki67, Bcl2˃, p-MAPK+, 

p-AKT+. Of interest, in LA BC, FAK overexpression is significantly 

related to nodal status (p = 0.05), grading (p = 0.007), p53 

nuclear accumulation (p = 0.047) and p-AKT overexpression 

(p = 0.001) and it appears to be a useful tool in identifying a subset 

of LA BC at higher risk of progression (Fig. 2). 

Conclusions. Our data evidenced that FAK expression, although 

evenly distributes across the four molecular subtypes, 

Luminal A, Luminal B, HER2 and Triple Negative, may identify 

Luminal A BC patients with poorer outcome. This issue is of 

particular clinical importance since estrogen receptor-positive 

BC are heterogeneous with regard to their clinical behaviour 

and response to therapies and 30%-40% of these patients will 

develop distant metastases. FAK could represent a novel prognostic 

biomarker useful to better assess the clinical outcome of 

low risk BC patients who would benefit from alternative, more 

aggressive adjuvant therapies. In this context, further investigations 

will need in a larger series of LA BC patients. 

references 

1 McLean GW, Carragher NO, Avizienyte E, et al. The role of focaladhesion 

kinase in cancer - a new therapeutic opportunity. Nat Rev 

Cancer 2005;5:505-15. 

2 Sotiriou C, Pusztai L. Gene-expression signatures in breast cancer. N 

Engl J Med 2009;360:790-800. 

Fig. 1. faK immunostaining in invasive breast carcinomas: (a) high faK expression and (B) 

low faK expression. 

A B

PoStER 

Epidemiological and biomolecular characteristics 

of subcentimetric invasive breast carcinoma: 

a comparison between two different cohorts 

in southern Italy 

A. Ieni1 , G. Giuffrè1 , A. Cascone2 , P. Zeppa2 , G. Branca1 , G. Tuccari1,3 

1Dipartimento di Patologia Umana, Università di Messina, A.O.U. “Policlinico 

G. Martino”, Messina; 2 Dipartimento di Medicina e Chirurgia, Azienda 

Ospedaliera Universitaria “San Giovanni di Dio e Ruggi d’Aragona” 

Università di Salerno; 3 Programma Interdipartimentale di Citodiagnostica 

e Patologia Molecolare, A.O.U. “Policlinico G. Martino”, Messina 

Background. Data concerning human epidermal growth factor 

receptor 2 gene (HER-2) in pT1a,bN0M0 breast cancer are 

conflicting and heterogeneous. In subcentimetric invasive breast 

carcinoma (SIBC), high tumor grade is the most significant factor 

associated with poor prognosis together with younger age, estrogen/progesterone 

receptor–negative status and high Ki-67 index. 

However, in the same group, cases HER-2-positive seem to have 

an higher risk of relapse and related death, although the usage of 

trastuzumab in SIBC is still debatable. In the present study, we 

compared HER-2 status, hormone receptor status and Ki67 index 

in two cohorts of SIBC from two Institutions in Southern Italy 

(Salerno and Messina). 

Methods. Sixty-three cases and thirty-five cases of SIBC were 

collected from the Universities of Messina and Salerno, respectively. 

From formalin-fixed paraffin-embedded tissue blocks 

of SIBC 4 µm thick parallel sections were cut, mounted on 

silane-coated glasses and, after routine retrieval procedure, immunostained 

for ER (ID5, DBA, 1:10), PR (PgR-ICA, Abbott, 

1:10), Ki-67 antigen (MIB-1, DAKO Cytomation, 1:200) and 

HER-2 (HercepTest AO485 DAKO). HER-2 status was scored 

according to manufacturer’s recommendations; equivocal cases 

(2+) were further assessed by FISH test (pharmDx DAKO). 

Statistical analysis was performed to assess the reproducibility 

of data evaluation in the two institutions and then any significant 

differences between the two groups for the considered parameters 

using the Chi-square test. 

Results. SIBC, pT1a cases were 17 (26.98%) in Messina 

and 10 (28.5%) in Salerno series, whereas pT1b cases were 

46 (73.02%) and 35 (71.5%) respectively. High Ki-67 index 

(> 12%) was found in 60% of Messina SIBC cases and 55% 

of Salerno ones. As for the hormonal receptors status, ER immunoreactivity 

was 85% and 83% and PR 74.9 and 77.1 in two 

groups respectively. Finally, considering HER2 status, 15.5% 

of cases were amplified in the Messina cohort and 17.2% in the 

Salerno one. Chi-square test did not show statistical significant 

differences between the two different cohorts for all examined 

parameters. 

Conclusions. HER-2 status, ER/PR status and Ki67 index in 

SIBC are comparable and reproducible in the two institutions 

representing two different geographic areas. The merged cohorts 

are suitable for further investigations and for the evaluation of the 

current guidelines of Trastuzumab treatment in SIBC. 

Triple negative breast ductal invasive carcinomas: 

further immunohistochemical investigations 

A. Ieni1 , V. Barresi1 , R. Cardia1 , C. Crisafulli1 , G. Giuffrè1 , 

G. Ricciardi2 , V. Adamo2 , G. Tuccari1,3 1 Dipartimento di Patologia Umana, Sezione di Anatomia Patologica; 

2 3 Dipartimento di Patologia Umana, Sezione di Oncologia Medica; Programma 

Interdipartimentale di Citodiagnostica e Patologia Molecolare, 

A.O.U. “Policlinico G.Martino”, Università di Messina 

Background. Triple-negative breast cancers (TNBC) represents 

a subtype of invasive carcinomas, immunoistochemically charac- 

397 

terized by a lock of expression of both oestrogen and progesteron 

receptors as well as HER2. This subtype accounts for about 

10-17% of all breast cancer and is more commonly seen women 

younger than 50 years with elevated frequency of distant metastases 

and short oncologic outcome. Morphologic features of TNBC 

are considered greater neoplastic size, solid growth pattern, high 

proliferative fraction, necrosis, increased apoptotic cells and 

generally an infiltrating ductal histotype. To date, chemiotherapy 

remains the only possible therapeutic option in the adjuvant or 

metastatic setting in the TNBC. In the present study, we have 

analyzed the immunohistochemical distribution pattern of some 

biomolecular tissue markers, such as DNA topoisomerasi II α 

(DT-II α), caveolin-1 (Cav-1), androgenic receptors, e-cadherin 

in a cohort of invasive ductal TNBC in order to identify possible 

relationship among them and clinico-pathological characteristics 

as well as survival. 

Methods. From files of the Department of Human Pathology, 

seventy-two formalin-fixed paraffin-embedded tissue blocks of 

TNBC were obtained from an equal number of female patients 

(age range 32-92 yrs, mean 62.1). From each tissue block, 4 

µm thick parallel sections were cut, mounted on silane-coated 

glasses and subjected to immunohistochemical procedures with 

the following antisera: KI-67 (Clone MIB-1; DAKO Corporation, 

Glostrup, Denmark; w.d.1:150); DNA Topoisomerasi II 

α (clone KI-s1; DAKO; w.d.1:150); E-cadherin (clone NCH 

38, DAKO; w.d.1:200); androgenic receptor (clone AR 441, 

DAKO; w.d.1:100); Caveolin-1 (Santa Cruz Biotecnology Inc., 

Santa Cruz, California, USA; w.d. 1:500). 3-3’ diaminobenzidine 

tetrahydrochloride was utilized as chromogen and a slight 

nuclear counterstain was performed by Mayer’s haematoxylin. 

Scoring of each immunostaining was done as elsewhere previously 

reported. The specificity of the binding was assessed by 

omitting the primary antiserum or replacing it with normal rabbit 

serum or phosphate buffered saline solution (PBS, pH 7.4). 

The Chi-square test was used to evaluate the correlations between 

the clinico-pathological variables and all the considered 

immunostainings. 

Results. pTNM showed that, among ductal invasive TNBC, 

16/72 were stage I, 30/72 stage II, 18/72 stage III and only 8/72 

stage IV. 36/72 showed metastases regarding the node status. 

Although before the study started, the observational period of 

patients ranged from 5-152 months, a mean follow-up of 67.7 

months was available only for 31 TNBC cases. An increased 

growth fraction ((> 10% Ki67 LI) was found in 42/72 patients 

(58.3%), while DT-II α (> 13%) was elevated in 40/72 (55.5%). 

Androgen receptors were revealed in 19/72 (26.4 %), whereas 

a high ID score (4-9) for Cav-1 was calculated in 45/72 cases 

(72.5%). Finally, E-cadherin was negative or focally and slightly 

present in neoplastic elements of 43/72 patients (59.7%). Statistical 

analysis documented a positive correlation between Ki-67 LI 

and grade or DNA Topoisomerase II α expression with significant 

p values, (p = 0.02) and (p < 0.001), respectively. Moreover, 

a significant relationship has been found between Cav-1 and 

grade (p = 0.032), Ki-67 LI (p = 0.019) and overall survival and 

progression free survival concerning cases in which the followup 

was available (p = 0.036). The mean overall survival was 47 

months and the mean progression free survival was 27 months. 

Finally, parameters significantly related to overall survival were 

represented by neoplastic stage (p = 0.011) and Cav-1 immunoreactivity 

(p = 0.036). 

Conclusions. Among the analyzed immunohistochemical parameters, 

Cav-1 appears the most useful approach in ductal invasive 

TNBC; moreover, taking into consideration the relationships 

exhisting between antracyclines and DT-II α as well as between 

taxanes and Cav-1, further insights in targeted oncologic therapy 

should be verified in TNBC.

398 

Expression of rOr1 in breast cancer tissue 

and synchronous lymph-node metastasis 

R. Lattanzio1 , R. La Sorda1 , V. Toto2 , M. Piantelli1 , D. Angelucci3 , 

M. Iezzi2 1 Dipartimento di Scienze Biomediche, Sezione di Patologia Oncologica, 

Centro Scienze dell’invecchiamento, Fondazione Università G. d’Annunzio, 

Chieti; 2 Dipartimento di Medicina e Scienze dell’Invecchiamento, 

Sezione di Anatomia Patologica e Medicina Molecolare, Centro Scienze 

dell’invecchiamento, Fondazione Università G. d’Annunzio, Chieti; 

3 U. O. di Anatomia Patologica e Citodiagnostica, Presidio Ospedaliero 

“G.Bernabeo” Ortona, Centro di Riferimento Regionale per la Senologia 

Introduction. Breast cancer is the most common cancer in 

women worldwide 1 2 . ROR1, an orphan tyrosine kinase receptor, 

is expressed in human breast cancer but not in normal breast 

tissues 3 . Recently, ROR1 has emerged as a promising target 

of therapy in tumors 4 . To ascertain the presence of ROR1 as 

potential therapeutic target, we have analysed by immunohistochemistry 

the expression of ROR1 in primary breast tumors and 

in tumor/synchronous lymph-node metastasis pairs. 

Material and methods. Tissue microarrays (TMA) were constructed 

by extracting 2-mm diameter cores of histologically confirmed 

neoplastic areas from 90 paraffin-embedded invasive primary 

breast tumors and matching lymph-node metastasis (n = 21 

pairs). The independent samples t-test was used to compare the 

ROR1 expression in primary tumors and matched lymph-node 

metastases. The SPSS (version 15.0) statistical program (SPSS 

Inc., Chicago, IL) was used for analysis. The cited P value is 

two-sided; P < 0.05 was considered as statistically significant. 

Results. In tumor cells the expression of ROR1 was cytoplasmic 

(Fig. 1). Eighty out of 90 (88.9%) tumors showed specific immunoreactivity 

for ROR1, with a main percentage of positive tumor 

cells of 68.6 ± 3.7SE. Twenty-one tumor/synchronous lymphnode 

metastasis pairs were present in our series of 90 primitive 

breast cancers. Analyzing these pairs we found that metastatic tumors, 

when compared to primary ones, contained higher numbers 

of neoplastic cells expressing ROR1 (P = 0.028) (Tab. I). 

Fig. 1. Example of cytoplasmic expression of RoR1 in paraffin-embedded 

breast cancer tissue. (Scale bar = 20_m). 

Tab. I. ROR1 expression in breast cancer and matched lymph-node metastasis 

(n = 21). 

Mean ± SE* P ° 

Primary tumor 72.8 ± 6.1 0.028 

Metastasis 89.8 ± 4.3 

* Results are expressed as mean percent of positive tumor cells ± standard error 

° independent samples t-test 


Conclusions. As previously reported 3 , our study confirmed 

that ROR1 is highly expressed in breast cancer tissues. Interestingly, 

we additionally found that ROR1 is overexpressed in breast 

cancer lymph-node metastases compared with primary tumors. 

Although a large series are needed to further verify this result, 

ROR1 has also a therapeutic potential in the treatment of breast 

cancer patients with lymph-node metastasis. 

references 

1 Botha JL, Bray F, Sankila R, et al. Breast cancer incidence and mortality 

trends in 16 European countries. Eur J Cancer 2003;39:1718-29. 

2 Cianfrocca M, Goldstein LJ. Prognostic and predictive factors in 

early-stage breast cancer. Oncologist 2004;9:606-16. 

3 Zhang S, Chen L, Cui B, et al. ROR1 is expressed in human breast 

cancer and associated with enhanced tumor-cell growth. PLoS 

One;7:e31127. 

4 Yang J, Baskar S, Kwong KY, et al. Therapeutic potential and challenges 

of targeting receptor tyrosine kinase ROR1 with monoclonal 

antibodies in B-cell malignancies. PLoS One;6:e21018. 

Chromosome 17 polysomy clinical implication in 

a subset of breast cancer patients with HEr-2/neu 

protein expression and negative FISH 

S. Petroni1 , T. Addati1 , E. Mattioli1 , M.A. Caponio1 , M. Centrone1 

, G. Mossa1 , F. Giotta2 , A. Bruno2 , G. Simone1 1 2 Anatomic Pathology Unit, Medical Oncology Department, Oncology 

Institute, Bari; National Cancer Research Centre, Istituto Tumori “Giovanni 

Paolo II”, Bari, Italy 

Background. The HER-2 gene product, a 185 kDa receptor tyrosine 

kinase, is amplified and/or overexpressed in approximately 

20-25% of human breast cancers 1 2 . 

The overexpressed protein is the therapeutic target for the treatment 

with humanized monoclonal antibody Trastuzumab (Herceptin). 

Beside HER-2 gene amplification, a subset of breast cancer 

patients presents different genetic alterations, such as chromosome 

17 polysomy (increased copy number of chromosome 

17). Abnormalities of chromosome 17 are important molecular 

genetic events in human breast cancers. The reported incidence 

of chromosome 17 polysomy, as estimated by FISH, ranges from 

5 to 50%. Previously published data showed that polysomy of 

Chr17 may lead to HER-2 protein overexpression and that these 

cases may be associated or not with HER-2 gene amplification. 

Aim. We analyzed clinical behaviour in a subset of 25 polisomic 

tumors which showed HER-2/neu protein expression in absence 

of HER-2/neu gene amplification in FISH. 

Methods: Twenty-five patient with invasive breast carcinoma 

overexpressing HER-2/neu protein (Fig. 1) but without HER-2/ 

neu gene amplification (FISH test) (Fig. 2) were selected between 

177 polisomic cases (from 2007-to 2009). Immunohistochemical 

staining for estrogen (ER), progesteron (PgR) receptors and 

Ki-67 (MIB-1) was performed on all cases. Follow-up data of 18 

out of 25 patients were avaible. The results were recorded as the 

percentage of immunoreactive cells over at least 1000 cells. Only 

nuclear reactivity for ER, PgR and Ki-67 antigens was taken into 

account during slide evaluation, independently of the intensity 

of the staining. HER-2/neu was evaluated according to FDAapproved 

scoring system. 

Results. All 25 patients had diagnosis of ductal invasive breast 

cancer, 18 out of 25 were grade III and 7 were grade II. Only 4 out 

of 25 cases did not express ER, whereas 8 out of 25 were negative 

to PgR. Regarding to MIB-1, only 3 cases showed a low kinetic 

activity (cut off ≤ 20%). Three of these patients were treated 

with adjuvant chemotherapy including anthracyclines followed 

by trastuzumab for 52 weeks. After a median follow-up of 48 

months 2 patients are disease free, while the remaining patients 

relapsed on bone. 

Conclusions. Conflicting results (Downey et al. Clin Cancer Res 

2010;16:1281-8 and Kaufman et al. J Clin Oncol 2007;25:1009),

PoStER 

Fig. 1. ductal invasive Breast Cancer with strong Her-2 positivity 

(score 3+) (40X). 

Fig. 2. fluorescence in Situ Hybridization. Her-2 non-amplified ductal 

invasive Breast Cancer with Cep17 disorder (Cep17 ≥ 3) (100X). 

but also the recent study by Bartlett et al. (Lancet Oncol 

2010;11:266–74) indicate that large prospective clinical trials are 

necessary to validate whether patients showing increased CEP17 

indeed show a better response to HER2-targeted therapies and 

anthracyclines, also in the absence of HER2 amplification. 

references 

1 Shah SS, Wang Y, Tull J, et al.”. Diagn Mol Pathol 2009;18:30-3. 

2 Bose S, Mohammed M, Shintaku P, et al. Her-2/neu gene amplification 

in low to moderately expressing breast cancers: possible role of 

chromosome 17/Her-2/neu polysomy. Breast J 2001;7:337-44. 

HEr-2/neu overexpression as potential prognostic 

factor in small size breast carcinoma (pT1n0M0) 

S. Petroni1 , M. Asselti1 , A. Bruno2 , F. Palma1 , A.L. Marzano1 , 

F. Giotta2 , G. Simone1 1 2 Anatomic Pathology Unit, Medical Oncology Department; National 

Cancer Research Centre, Istituto Tumori “Giovanni Paolo II”, Bari, Italy 

Background. Patients with primary breast cancer pT1a-bN0M0, 

have generally a favourable prognosis. However relapse occurred 

up to 25% of cases so it is necessary to identify bio-pathological 

and bio-molecular parameters in order to administer target 

therapy 1 2 . The aim of this retrospective study was to identify 

prognostic factors and predictive factors associated with clinical 

outcome. 

399 

Methods. 292 women (median age: 61 years) with pT1N0M0 

breast cancer observed from 2004 until 2010, entered in the study. 

187/292 tumors (64%) were pT1c, whereas 105 (36%) were 

pT1a-b. ER, PgR, Ki-67 status were evaluated using immunohistochemistry 

(IHC); HER-2/neu protein expression was investigated 

by IHC (HercepTest, DAKO), HER-2/neu gene status was 

assessed by FISH and scored according to FDA guidelines 3 . 

Fig. 1. Cdi, ER positive (40x). 

Fig. 2. Cdi, pgR positive (40x). 

Fig. 3. Ki-67 ≥ 20%, Cdi (20x).

400 

Fig. 4. HER-2/neu, score 3+, Cdi (40x). 

Fig. 5. C-erbB2 gene amplification. 

Results. There was no statistical significance for HR expression 

(Figg. 1-2) in two subsets (pT1ab VS pT1c, χ 2 p:0.897). A high 

proliferative activity (Fig. 3) was detected in 75.7% and 24.3% 

respectively for pT1c and pT1a-b (τ-test, p:0.002). HER2/Neu 

was positive (IHC, FISH, Figg. 4-5) in 22/187 (11.8%) cases 

of pT1c and in 9/105 (8.5%) cases of pT1a-b; the proliferative 

activity index was high in both HER2/Neu + subset (τ-test, 

p:0.985). Follow up data (mean FU: 56.3 months; range 9-108 

months) were available in 22/31 patients HER2/Neu + (8 

pT1a-b, 14 pT1c). Two relapses (9.1%) 4 were observed: the 

first (pT1b, G3, high Ki-67 treated only with radio-therapy), 

recurred both locally and on visceral sites; the second patient 

(pT1c, G2, high Ki-67 treated only with hormonal therapy) 

showed a triple negative biological features on a re-biopsy performed 

on liver metastases. 

Conclusion. We observed that different Ki-67 expression 5 , in 

two subset (pT1a-b vs pT1c), is associated with tumor size and 

this difference is lost in HER2/Neu positive cases regardless of 

tumor size (τ-test, p:0.985). We concluded that HER2/neu overexpression/amplification, 

could represent a significant marker 

of high risk of relapse and could be a prognostic and predictive 

factor also in pT1N0M0 breast cancer 6 . 

references 

1 Neville AM, et al. J Clin Oncol;10:696-705. 

2 Sánchez-Muñoz A et al. Breast Journal;17:32-8. 

3 Wolff AC, et al. Arch Pathol Lab Med 2007;131:18-43. 

4 Joensuu H, et al. Clin Cancer Res 2003;9:923-30. 

5 Colleoni M, et al. Annals of Oncology;15:1633-9. 

6 Curigliano G, et al. J Clin Oncol 2009;27:5693-9. 


OSSO E PArTI MOLLI 

Angiomyomatous hamartoma of the left inguinocrural 

area: a case report 

M.P. Brisigotti1 , F. Sarocchi1 , P. Calamaro1 , M. Bruzzone1 , 

F. Spagnolo3 , F. Cafiero4 , M. Trapasso3 , L. Moresco4 , B. Spina2 1 University of Genoa, Histhopathology, DISC, Azienda Ospedaliera e 

Universitaria San Martino-IRCCS-IST, Genoa; 2 National Institute of 

Cancer Research (IST), Pathology Unit, Azienda Ospedaliera e Universitaria 

San Martino-IRCCS-IST, Genoa; 3 National Institute of Cancer Research 

(IST), Plastic Surgery Unit, Azienda Ospedaliera ed Universitaria 

San Martino-IRCCS-IST, Genoa; 4 National Institute of Cancer Research 

(IST), Surgical Oncology Unit, Azienda Ospedaliera ed Universitaria San 

Martino-IRCCS-IST, Genoa 

Introduction. Angiomyomatous hamartoma (AMH) of the 

lymph node is a benign vascular disorder and has been described 

as a primary vascular tumor characterized by the replacement of 

lymph node tissue by blood vessels, smooth muscle and fibrous 

tissue in a sclerotic lymphatic stroma. These tumors of unknown 

etiology, first described by Chan et al in 1992, are rare disease 

and they usually involve inguinal and femoral lymph nodes. 

Materials and methods. The patient is a 29 year old woman with 

left inguino crural poli-adenopathy and a single painfull mass, 

deep in the layers above the femoral nerve and vessels, developed 

over the last three months. Color Doppler Ultrasound and MRI 

revealed a solid mass measuring 2,5 cm with low vascular supply 

and regular margins. A pre-operative lymphoscintigraphy showed 

abnormalities in the lymph node flow in the inguino-crural and 

pelvic lymph nodes. The mass was clinically diagnosed as a 

schwannoma. Since the tumor gradually enlarged, wide excision 

of the mass was performed. 

Results. The gross specimen was composed of fibro-adipose tissue 

measuring 8 x 4 x 2 cm in the contest of which there was a 

nodular single mass measuring 2 cm that, on cut section had a firm, 

gray-white appearance (Fig. 1). The specimen was extensively 

sampled for histologic examination. Microscopically on routine 

hematoxylin and eosin stains the nodular mass was a lymph node 

with a peripheral rim of normal lymphoid tissue, with few residual 

follicles, which was almost completely replaced by a proliferation 

of numerous thick-walled muscular blood vessels (Fig. 2). This 

proliferation was associated with haphazardly arranged bundles of 

smooth muscle cells within a sclerotic stroma. There were also few 

compressed lobules of benign adipocytes. None of the constituent 

cells displayed cytologic atypia. Mitoses and necrosis were absent. 

On immunohistochemical stains there was a strong reactivity for 

smooth muscle actin (SMA) (Fig. 3) and desmin (Fig. 4) in the 

spindle shaped cells dispersed throughout the fibrous tissue confirming 

the muscular origine of these elements. 

Morphological and immunohistochemical results lead to a diagnosis 

of an angiomyomatous hamartoma. 

Fig. 1.

PoStER 

Fig. 2. 

Fig. 3. 

Fig. 4. 

Conclusions. Angiomyomatous hamartoma was first described 

by Chan et al in 1992 in an analysis of primary vascular tumors 

of the lymph nodes other than Kaposi sarcoma. This lesion was 

described as benign and characteristic of inguinal-femoral lymph 

nodes. In this first description the hamartomatous nature of this 

lesion was postulated on the basis of a disorganized growth pattern 

of smooth muscle cells and blood vessels. 

In 2000 Sakurai et al suggested that the pathogenesis of AMH 

may be due to impairment of lymphatic flow. The disease process 

seems to start in the hilum and extends toward the periphery and 

so the normal lymphatic tissue becomes displaced and atrophic. 

The authors also reported that 2 of the 16 cases described in the 

literature presented edema of the ipsilateral extremity. 

Dargent et al supported this theory and reported that the presence 

of a glomeruloid microvascular proliferation, such as in 

primary pulmonary hypertension, may indicate that the lesion 

represent an exuberant angiogenic reaction arising from blood 

vessels located in the hilum of the lymph node and extending to 

the nearby tissues. 

401 

There are even descriptions of AMH outside the inguinal or 

femoral nodes in a cervical limph node and a case in a submandibular 

lymph node. The predilection for the inguinal site may 

be related to the fact that this is also the most frequent site of 

other nodal mesenchymal tumors. Some authors suggested the 

term angiomyolipomatous hamartoma since adipose tissue was 

described as a component of AMH. To our knowledge, only 26 

cases have been reported in literature. Males are affected more 

often than females by a ratio of approximately 4:1. An association 

with HIV immunodeficiency has even been reported. Recurrences 

and metastases of AMH have not been reported, except for 

a single occurrence of a secondary lesion after resection, which 

was presumably due to impaired lymphatic transport. Vascular 

transformation is a distinctive feature of angiomyomatous hamartoma 

and the histologic differential diagnosis of AMH includes 

haemangioma, vascular malformation and post-inflammatory 

lymph node reaction. 

Other differential diagnoses are nodal lymphangiomyomatosis, 

leiomyomatosis and angiomyolipoma of the lymph node. Nodal 

lymphangiomyomatosis occurs exclusively in woman, affects 

thoracic and abdominal lymph nodes and is characterized by the 

presence of smooth muscle cells forming fascicles and sheets 

around anastomosing ectasic vascular spaces. Nodal leiomyomatosis 

involves intra-abdominal lymph node and morphologically 

resembles a leiomyoma with a proliferation of compact bundles 

of smooth muscle cells with an insignificant vascular component. 

Angiomyolipoma of the LN usually affects retroperitoneal 

lymph nodes, is considered a manifestation of multicentricity of 

angiomyolipoma of the kidney. The smooth muscle cells of angiomyolipoma 

show an epithelioid appearance, hypercellularity, 

pleomorphism, prominent perivascular arrangement and positivity 

for melanoma associated antigen HMB-45. 

The origin of these lesions is still unclear. It may rapresent a localized 

malformation in a congenitally damaged lymphatic system. 

An alternative possibility is that chronic impairment of lymphatic 

flow, revealed by radionuclide lymphoscintigraphy, results in the 

development of an angiomyomatous hamartoma. In our case the 

patient showed a significant ginecoide distribution of body fat and 

lower limb lymphostasis and a lymphoscintigraphy documented 

abnormalities in the lymph flow of the inguino crural and pelvic 

lymph nodes, thus supporting Dargent’s pathogenetic theory. 

Although AMH of lymph node is very rare and its recognition 

is important for differential diagnosis with vascular benign and 

malignant tumors of the lymph node. 

references 

1 Chan JKC, Frizzera G, Fletcher CDM, et al. Primary vascular 

tumors of lymphnodes other than Kaposi’s sarcoma. Am J Surg 

Pathol1992;16:335. 

2 Allen PW, Hoffman GJ. Fat in angiomyomatous hamartoma of lymph 

node. Am J Surg Pathol 1993;17:748-9. 

3 Laeng RH, Hotz MA, Borisch B. Angiomyomatous hamartoma of 

cervical lymphnode combined with haemangiomatoids and vascular 

transformation of sinuses. Histopathology 1996;29:80-4. 

4 Sakurai Y, Shoji M, Matsubara T, et al. Angiomyomatous hamartoma 

and associated stromal lesions in the right inguinal lymph node: a 

case report. Pathol Int 2000;50:655-9. 

5 Dargent JL, Lespagnard L, Verdebout JM, et al. Glomeruloid microvascular 

proliferation in angiomyomatous hamartoma of the lymph 

node. Virchows Arch 2004;445:320-2. 

6 Piedimonte A, De Nictolis M, Lorenzini P, et al. Angiomyomatous 

hamartoma of inguinal lymph nodes. Plast Reconstr Surg 

2006;117:714-6. 

7 Sullu Y, Gun S, Dabak N, et al. Angiomyomatous hamartoma in the 

inguinal lymph node: A case report. Turkish Journal of Pathology 

2006;22:42-4. 

8 Mauro CS, McGough RL 3rd, Rao UN. Angiomyomatous hamartoma 

of a popliteal lymph node: an unusual cause of posterior knee pain. 

Ann Diagn Pathol 2008;12:372-4. 

9 Ram M, Alsanjari N, Ansari N. Angiomyomatous hamartoma: a rare 

case report with review of the literature. Rare Tumors 2009;1:e25.

402 

10 Barzilai G, Yaakov Schindler Y, Cohen-Kerem R. Angiomyomatous 

hamartoma in a submandibular lymph node: a case report. Ear Nose 

Throat J 2009;88:831-2. 

11 Prusac IK, Juric I, Lamovec J, et al. Angiomyomatous Hamartoma of 

the Popliteal Lymph Nodes in a Patient with Klippel-Trenaunay Syndrome: 

Case Report. Fetal Pediatr Pathol 2011 May 24. 

12 Dzombeta T, Francina M, Matković K, et al. Angiomyolipomatous 

hamartoma of the inguinal lymph node--report of two cases and literature 

review. In Vivo 2012;26:459-62. 

retiform hemangioendothelioma a case report 

M. Bruzzone, A. Guadagno, P. Ceriolo, L. Abete, T. Celiento, 

F. Cabiddu 

University of Genoa, Histopathology, DISC, Azienda Ospedaliera e Universitaria 

San Martino-IRCCS-IST, Genoa 

Introduction. In 1994, Calonje et al. described 15 cases of 

cutaneous vascular neoplasms with low malignant potential, 

characterized by high rate of local recurrence and low frequency 

of metastasis. Thereafter, few case reports have been published 

in the literature. 

Retiform hemangioendothelioma (RH) represents, an intermediate 

grade vascular neoplasm that often persist or recur locally 

but seldom metastasizes; most often occurring in the limbs of 

middle-aged females. This entity is characterized by infiltrative 

vascular spaces arranged in a pattern similar to the rete testis, 

hobnail monomorphic endothelial cells with apical nuclei and 

scanty cytoplasm, prominent endovascular papillae with collagenous 

cores, and prominent mononuclear lymphocytic infiltrate. 

RH differs from angiosarcoma in so much as it lacks cytologic 

atypia and high mitotic rates. 

Materials and methods. A 62-years-old healthy white female 

sought medical help for a slowly growing, ill-defined subcutaneous 

tender mass on the left haunch. There was no clinical history 

of radiation exposure or radiotherapy, and the family history was 

unremarkable. At physical examination no ulceration or throbbing 

was noted and there were no other masses anywhere in the 

body. The dermatologist decided to perform an excisional biopsy 

for diagnosis. 

Results. The gross specimen was composed of skin flap measuring 

mm 10x5x5 with lesion in the form of a 3 mm papule of 

reddish-brown in color. The neoplasm showed a hemorrhagic and 

fleshy cut surface. 

Fig. 1. 

Histological examination of the tumor revealed a ill-defined vascular 

proliferation with numerous elongated vessels resembling 

the shape of rete testis. These vessels were lined by a single 

layer of cuboidal endothelial cells and occasional intraluminal 

papillary tufting of endothelial cells was seen. The cells had high 

nuclear/cytoplasmatic ratio and occasionally grooved bulging 

nuclei (Fig. 2). 


Fig. 2. 

Approximately there were no significant atypia or mitotic figures. 

The immunoistochemical stains showed a positivity for the CD31 

and the CD34 with proliferation index, evaluated with Ki67, of 

around a 25-30% (Fig. 3). 

Fig. 3A. immunoistochemical stain Cd31 

Fig. 3B. immunoistochemical stain Ki67. 

In consideration of the vague tumor boarders, the first excision 

had positive margins and therefore a wide local excision was 

later performed. 

Conclusions. We report on case of retiform hemangioendothelioma 

from a 62 years old woman which came to our attention 

after exicision. 

The differential diagnosis for this case includes hobnail hemangioma, 

retiform hemangioendothelioma, angiosarcoma and Dabska 

tumor. The importance of distinction between these entities 

is based on the striking differences in their clinical behavior and 

outcome. For example angiosarcoma is a tumor that most com-

PoStER 

monly develops in elderly adults and exhibits frankly malignant 

histopathology and clinical behavior, including a high metastatic; 

histologically, although angiosarcoma and RH have in common 

an infiltrative pattern, in conventional angiosarcomas, this is 

characterized by much a more disorganized pattern, with frequent 

sinusoidal or sieve-like collagen bundles. In addition, the vascular 

spaces formed in angiosarcoma tend to be more irregular and jagged 

than those in RH, hobnail hemangioma and Dabska tumor. 

On the other hand, hobnail hemangioma (originally termed targetoid 

hemosiderotic hemangioma) usually presents as a superficial 

tumor involving the limbs or trunk of adult males and usually 

follows a benign course. Microscopically, hobnail hemangioma 

shows a varied growth pattern with dilated superficial blood 

vessels lined by hobnail endothelial cells with only occasional 

intravascular papillary proliferation and with a retiform architecture 

in the reticular dermis, associated hemosiderin deposition 

can be found. 

The rare Dabska’s tumor shows overlapping features with RH, 

including the presence of hobnailed endothelial cells and an 

arborizing architectural pattern. Some authors have considered 

Dabska’s tumor as the infantile counterpart of RH and coined 

the term hobnail hemangioendothelioma to encompass both neoplasms. 

However, it should be noted that there are some divergent 

clinical and histological features between these two neoplasms, 

such as the absence of arborizing rete testis-like architecture and 

the presence of well-formed papillary endothelial projections of 

Dabska’s tumor. 

In summary, RH is a low-grade vascular neoplasm, which involves 

middle-aged adults with a predilection for the female sex. 

Clinically, RH is a locally aggressive neoplasm with a high recurrence 

rate. Correct diagnosis is therefore important expecially 

with regards to distinction from angiosarcoma; RH may recur if 

margins are unvolved but is unlikely to metastasize. 

references 

1 Calonje E, Fletcher CD, Wilson-Jones E, et al. Retiform hemangioendothelioma. 

A distinctive form of low-grade angiosarcoma delineated 

in a series of 15 cases. Am J Surg Pathol 1994;18: 15. 

2 Mentzel T, Stengel B, Katenkamp D. Retiform hemangioendothelioma. 

Clinico-pathologic case report and discussion of the group of 

low malignancy vascular tumors. Pathologe 1997;18:390. 

3 Calonje E, Fletcher CDM. Tumors of the blood vessels/lymphatics. In: 

Fletcher CDM, ed. Diagnostic Histopathology of Tumors. Hong Kong: 

Churchill Livingstone 2000, p. 45. 

4 Nayler SJ, Rubin BP, Calonje E, et al. Composite hemangioendothelioma: 

a complex, low-grade vascular lesion mimicking angiosarcoma. 

Am J Surg Pathol 2000;24:352. 

5 Reis-Filho JS, Paiva ME, Lopes JM.Congenital composite hemangioendothelioma: 

case report and reappraisal of the hemangioendothelioma 

spectrum. J Cutan Pathol 2002;29:226-31. 

6 Dufau JP, Pierre C, De Saint Maur PP, et al. Retiform hemangioendothelioma. 

Ann Pathol 1997;17:47. 

7 Parsons A, Sheehan DJ, Sangueza OP. Retiform hemangioendotheliomas 

usually do not express D2-40 and VEGFR-3. 

8 Tan D, Kraybill W, Cheney RT, et al. Retiform hemangioendothelioma: 

a case report and review of the literature. J Cutan Pathol 

2005;32:634-7. 

9 Wachter DL, Agaimy A. A cutaneous vascular neoplasm with hobnail 

icroscopic morphology and unusual gross features. J Cutan Pathol 

2012;39:454-7. 

10 Dabska M. Malignant endovascular papillary angioendothelioma 

of the skin in childhood. Clinicopathologic study of 6 cases. Cancer 

1969;24:503. 

One patient, two lymphomas: what happened here? 

R. Chiacchio1 , M. Cimminiello2 , A. Benvenuto1 , M. Di Giacomo1A 

, E. Ferri1A , G. Del Vecchio3 , P. Tramutoli3 , M. Pizzuti2 1 UOC di Anatomia Patologica, Azienda Ospedaliera Regionale San Carlo 

di Potenza; 1A UOC di Anatomia Patologica, sezione di Citogenetica, 

Azienda Ospedaliera Regionale San Carlo di Potenza; 2 UOC di Ematologia 

con TMO, Azienda Ospedaliera Regionale San Carlo di Potenza; 

403 

3 UOC di Chirurgia d’Urgenza, Azienda Ospedaliera Regionale San Carlo 

di Potenza 

Introduction. Tcell/histiocyte-rich large B-cell and Burkitt Lymphoma 

are two distinct entities recognized by the current WHO 

classification of lymphoid neoplasms. We report a case of a man 

of 62years old with Tcell/histiocyte-rich large B-cell Lymphoma at 

diagnosis and Burkitt Lymphoma at relapse, four months to onset. 

Case report. A 62-year-old man presented with an 20-day history 

of high-grade fever, decreased appetite and a 7-lb weight loss 

during approximately the past 20 days. The patient had no history 

of malignant disease; superficial and deep lymphadenopathy. 

Biopsy of the mass in left inguinal region are performed. Grossly 

the lymph node, 6 x 4 cm in size, had softe cut surface. Microscopic 

examination revealed a lymph node almost replaced by a 

diffuse proliferation of scattered, single, large B-cells embedded 

in a background of small lymphocytes that represent T-cells and 

variable numbers of histiocytes. The tumour cells are always dispersed. 

Immunohistochemical analysis showed that the large atypical 

cells were positive for CD20, CD10, Bcl6, rare Bcl-2, EMA, 

and negative for CD3, PUI1, PD1, CD30; Ki67index:70%. The 

morphological and immunohistochemical data oriented for a diagnosis 

of large T-cell/histiocyte rich large B-cell Lymphoma. Bone 

marrow biopsy are negative. Clinical study: IIIB; International 

Prognostic Index: 3. Despite chemotherapy with R-CHOP-14 

protocol (cyclophosphamide, doxorubicin, vincristine, prednisone 

and rituximab, every 14 days). The patient had an initial excellent 

response to chemotherapy (PETpost 4cycle was negative), with 

overall improvement in her physical condition, but unfortunately 

2 weeks after fourty cycle of chemotherapy he developed a Citomegalovirus 

pneumoniae. Left inguinal lymph node showed a 

35 days last forty R-CHOP. The histological examination of the 

biopsy of these lymph node revealed a diffuse infiltrate composed 

by uniform tumor cells with multiple small nucleoli and finely 

dispersed chromatin in their nuclei. The tumour has an extremely 

high proliferation fraction as well as a high fraction of apoptosis. 

A “starry sky” pattern is usually present, which in imparted by 

numerous benign macrophages that have ingested apoptotic tumour 

cells. Immunohistochemical analysis showed that the atypical 

cells were positive for CD20, CD10, Bcl6, and negative for 

CD3, Bcl-2, IRF4, EMA; Ki67index:100%. Bone marrow biopsy 

are negative. FISH procedures were carried out on paraffin sections 

of inguinal lymph node according to the recomendation of 

the manifacturers. FISH analysis was performed using theVysis 

LSI-IGH/MYC and CEP8 Tricolor, Dual Fusion Translocation 

Probe for the detection of the translocation (8;14). Fluorescence 

signals were evaluated using a AX70 fluorescence microscope on 

100nuclei and confirmed the presence of the rearrangement. The 

new diagnosis is of Burkitt Lymphoma. Conclusions: we have a 

questions for you: the Burkitt Lymphoma is a second Lymphoma 

or a trasformation of the first Lymphoma? 

An unusual localization of solitary extramedullary 

plasmacytoma: the wrist as particular site 

G. Petracco, M. Onorati, P. Uboldi, S. Romagnoli * , C. D’Urbano 

** , F. Di Nuovo 

Pathology Unit, Pathology Unit, Garbagnate Milanese, AO “G. Salvini” 

Garbagnate Milanese, Italy; * Department of Health Sciences, AO S. Paolo, 

University of Milan, Medical School, Italy; ** Surgical Unit, Garbagnate 

Milanese, AO “G. Salvini” Garbagnate Milanese, Italy 

Introduction. Extraosseus plasmacytoma, so called extramedullary 

plasmacytoma (EMP) is defined by the updated WHO classification 

(2008) as a localized plasma cell neoplasm that arises 

in tissues other than bone. EMP is a rare tumor and accounts for 

3~5% of all plasma cell neoplasm. Approximately 80% of them 

occur in the upper aerodigestive tract. EMP has also been noted 

to arise in other anatomic sites, including lymph nodes, bladder, 

CNS, breast, thyroid, testis, parotid and skin. We describe a case

404 

of an adult woman with a solitary subcutaneous localization of 

EMP in the wrist, without other systemic localizations. Skeletal 

radiographs did not show lytic lesions. To our knowledge, this is 

the first case described in the recent literature. 

Methods and results. A 47 years old woman with no significant 

past medical history presented in our hospital with a nodular 

mass in the wrist. This nodule was mobile respect to the deep 

surface and elastic at the manual palpation. An excisional biopsy 

was performed in the ambulatory of surgery and it was sent to 

our laboratory for histological examination. Macroscopically the 

nodular mass appeared white, elastic and 1,1 cm in the major diameter 

with regular margins. The specimen was fixed in formalin 

and embedded in paraffin. Thin sections were cut and stained 

with Hematoxylin and Eosin. 

Microscopically, the lesion was composed of a homogeneous 

population of medium size plasma cells intermingled with scattered 

giant multinucleated cells. The immunohistochemical stains 

showed a kappa light chain restriction in plasma cell populations 

and a positivity for CD68 in the rare giant cells. The tumor cells 

were positive for CD138 and for CD20 and negative for CK AE1/ 

AE3. Moreover the proliferative cell index as determined by Ki- 

67, was positive in the 40% of the neoplastic population. Necrosis 

and amyloid deposition were absent. The neoplasm was present 

on the surgical margins. 

The diagnosis was consistent with extraosseous plasmacytoma 

without bone marrow localization. The patient was sent to an 

haematological visit. The serum protein electrophoretic pattern 

was normal and the Bence-Jones protein was absent in the urine. 

There were no evidence of anaemia, hypercalcemia and renal 

insufficiency. 

The patient is still alive after six months from the diagnosis without 

developing lytic bone lesions, myeloma-related symptoms 

and local recurrence. 

Discussion. Plasma cell neoplasms are characterized by monoclonal 

proliferation of plasma cells that are associated with a 

single monotypic immunoglobulin product. Plasma cell neoplasms 

most commonly arise in the bone marrow, where they 

are classified as malignant disorder (plasma cell myeloma) or 

benign conditions (monoclonal gammopathy of undertermined 

significance, MGUS). Plasma cell myeloma is either multifocal 

or widely disseminated in the bone marrow and is often complicated 

by osteolytic lesions, pathologic fractures, hypercalcemia, 

anemia and an aggressive course. Plasmacytomas are plasma cell 

neoplasms that are cytologically identical to plasma cell myeloma 

but present as solitary osseous or extraosseous (extramedullary) 

lesions. Recently, Doers GM et al. reviewed plasma cell 

neoplasms in a period of 12 years (1992-2004), and analyzed the 

incidence and survival for plasmacytoma of the bone, for EMP 

and multiple myeloma reported in the United States in this period. 

There were 1543 cases of plasmacytomas, and the 30,7% was 

EMP (474/1543). In all 474 cases of EMP, most patients were 

white male with advanced age, only 41 of them were Asians. To 

date, the largest number of EMP (68 cases) has been reported by 

Bachar et al. 

To our knowledge, this is the first case described in the recent 

literature and it is characterized by an unusual localization of 

EMP in the subcutaneous tissues of the wrist. Our histopathological 

diagnosis was based on the morphological and immunohistochemical 

features of the neoplastic population of the nodular 

lesion, in the absence of other clinical features (no evidence of 

anaemia, monoclonal serum protein, hypercalcemia, renal insufficiency 

and bone marrow localization). The differential diagnosis 

included reactive plasma cell infiltrates that express polyclonal 

kappa and lambda light chain restriction. The demonstration of 

a monoclonal plasma cell population confirmed our diagnosis of 

EMP. The diagnosis was also confirmed by another haematological 

specialize hospital. 

Clinical treatment of these lesions consists of surgery and radia- 


tion therapy to avoid a local recurrence. Regional recurrences 

develop in approximately 30% of the patients. Solitary lesions 

tend to respond to conservative therapy (surgery or radiation) 

and are generally associated with a favourable prognosis. Our 

patient is still alive after six months from the diagnosis. She 

did not undergo radiotherapy and no local recurrences were 

evident. Moreover she did not develop lytic bone lesions and 

myeloma-related symptoms. Considering the peculiar natural 

history of our case, close long-term follow-up is appropriate 

and necessary to avoid dissemination into multiple myeloma. 

Infact, this possibility has been reported to occur in 10-30% 

of extramedullary plasmocytoma cases within the first 5 years, 

especially in the cases with absence of CD 138 expression. 

The clinical relevance of weak/absent CD138 expression is not 

established, but some authors underline that plasma cell tumors 

with absent CD138 expression exhibit more aggressive behaviour. 

We hope that the positivity for CD 138 observed in our 

case and the absence of other visceral and skeletal localization 

favour a good prognosis, although the clinical follow-up in our 

case is relatively short. 

references 

1 Bachar, et al. Solitary extramedullary plasmacytoma of the head 

and neck—Long-term outcome analysis of 68 cases. Head & Neck 

2008;30:1012-9. 

2 Craig G, et al. Extraosseous (extramedullary) plasmacytoma of the 

adrenal gland. Arch Pathol Lab Med 2004;128:e86-8. 

3 Dores GM, et al. Plasmacytoma of bone, extramedullary plasmacytoma, 

and multiple myeloma: incidence and survival in the United 

States, 1992-2004. British Journal of Haematology 2009;144:86-94. 

4 Lee SY, et al. A case of extramedullary plasmacytoma arising from 

the posterior mediastinum. The Korean Journal of Internal Medicine 

2005;20:173-6. 

5 Muscardin LM, et al. Primary cutaneous plasmacytoma: report 

of a case with review of the literature. J Am Acad Dermatol 

2000;43:962-5. 

6 Tuting T, et al. Primary plasmacytoma of the skin. J Am Acad Dermatol 

1996;34:386-90. 

7 Wong KF, et al. Primary cutaneous plasmacytoma – report of two cases 

and review of the literature. Am J Dermatopathol 1994;16:392-7. 

8 Yan B, et al. EBV-Positive plasmacytoma of the submandibular 

gland—Report of a rare case with molecular genetic characterization. 

Head and Neck Pathol 2011;5:389-94. 

9 Zuo, et al. Extraosseous (extramedullary) plasmacytoma: a clinicopathologic 

and immunophenotypic study of 32 Chines cases. Diagnostic 

Pathology 2001;6:123. 

Subscapular elastofibrolipoma: a case report 

S. Squillaci1 , R. Marchione1 , M. Piccolomini1 , S. Polonioli1 , 

B. Mazzola1 , F. Tallarigo2 1 Division of Anatomic Pathology, Hospital of Vallecamonica, Esine 

(Bs), Italy; 2 Division of Anatomic Pathology, Hospital “S.Giovanni di 

Dio”,Crotone, Italy. 

Background. Elastofibroma is an ill defined fibroelastic tumorlike 

lesion that, most commonly, occurs in the tissues between the 

lower portion of the scapula and the chest wall. It is characterized 

by a large number of coarse, enlarged, irregular elastic fibers. 

Extensive adipose component in elastofibroma is an extremely 

rare feature, newly described as elastofibrolipoma (EFL) 1 2 . This 

report refers to an additional case of this peculiar condition. 

Material and methods. We describe a case of a 72-year-old female 

who was referred to Hospital of Vallecamonica for the presence 

of a mass, about 5 cm. in largest size, unilaterally located 

in the subfascial subscapular tissue that was excised. Our Division 

received a vaguely nodular, encapsulated and well circumscribed 

mass, measuring 3,7 cm in its maximum diameter, with 

grey-white cut surface, intermingled with ample yellow adipose 

tissue, and elastic consistence. After fixation in 10% formalin, 

the surgical specimen was paraffin-embedded and stained with

PoStER 

haematoxylin and eosin and Verhoeff’s elastic stain. Additional 

sections were cut for immunohistochemical analysis. 

Results. Microscopically, the lesion was composed of a paucicellular 

collagenous stroma with altered elastic fibers which demarcated 

lobules of mature adipocytes of varying size occupying 

large areas in every high-power microscopic field. Large, coarse, 

deeply eosinophilic elastic fibers were scattered throughout and 

were reactive to Verhoeff’s elastic stain and CD34. In the collagenous 

matrix bland spindle cells were positive for CD34, but 

negative for S-100 protein, desmin and smooth muscle actin. 

Seven months after surgery the patient was free of recurrence. 

Conclusions. EFL was first described by De Nictolis et al. 1 at the 

anterior mediastinum in 1995. Later another case was reported by 

Erkilic et al. 2 . The overall appearance of EFL incorporates aspects 

of elastofibroma as well as lipoma and its origin remains controversial. 

The differential diagnosis includes spindle cell lipoma, angiolipoma, 

myolipoma, angiolipoleiomyoma and malignant tumors 

as spindle cell liposarcoma. Being a recently described lesion we 

believe that the incidence of EFL will increase in future and additional 

cases will help to enlighten the origin of this pathology. 

references 

1 De Nictolis M, Goteri G, Campanati G, et al. Elastofibrolipoma of 

the mediastinum. A previously undescribed benign tumor containing 

abnormal elastic fibers. Am J Surg Pathol 1995;19:364-7. 

2 Erkilic S, Kocer E, Sivrikoz C. Subscapular elastofibroma intermingled 

with adipose tissue. Variant type of elastofibroma or lipoma? 

Ann Diagn Pathol 2005;9:327-9. 

A capillary hemangioma with glomeruloid features. 

report of a case. 

L. Vassallo1 , D. Tacchini1 , M.A.G.M. Butorano1 , V. Lalinga2 1 Patologia Umana e Oncologia, sezione di Anatomia Patologica, Università 

di Siena, Siena (SI); 2 Anatomia Patologica, IRCCS CROB, Rionero 

in Volture (PT) 

Background. Glomeruloid hemangioma (GH) is a distinctive 

histological entity characterized by dome-shaped red papules 

seen most frequently on the trunk and proximal limbs. 

The term ‘glomeruloid hemangioma’ was coined by Chan et al. in 

1990 to describe a multi-focal cutaneous hemangioma, which was 

considered a specific cutaneous marker for POEMS syndrome 

(polyneuropathy – organomegaly – endocrinopathy – M-protein 

– skin abnormality) 1 2 . 

GH consists of a coiled aggregate of capillaries that are found 

inside a dilated/sinusoidal vascular space and that recall the histological 

morphology of the renal glomerulus. However, cases of 

GH without POEMS syndrome have recently been reported. 

The major disorders that enter in to the differential diagnosis of 

GH are Acquired tufted angioma and Lobular capillary hemangioma. 

Materials and methods, A 77-year-old Italian man presented 

with a single red papule, 3mm in diameter, situated on the right 

temple. Complete surgical excision and successive histological 

examination were carried out. 

Results. At scanning magnification, a well circumscribed, unencapsulated, 

unlobulated lesion consisting of a discrete collection 

of vessels embedded in a normally-appearing dermis was seen. 

A sinusoidal vessel was recognizable at the periphery of each 

aggregate of capillaries, in an organoid pattern, resembling renal 

glomeruli. Some aggregates contained a thick-walled blood vessel. 

The overlying epidermis was normal. 

Physical examination of the skin did not show any other cutaneous 

lesions and laboratory and radiological studies excluded the 

presence of POEMS syndrome. 

A diagnosis of Capillary hemangioma, with glomeruloid aspects 

was done. 

Discussion. Glomeruloid hemangioma is almost always associated 

with POEMS syndrome. It may be considered a character- 

405 

istic cutaneous marker of this syndrome and may appear before 

the full-blown POEMS syndrome develops. Cutaneous haemangiomas 

described in patients with POEMS syndrome include microvenular 

haemangiomas, cherry haemangiomas, multinucleate 

cell angiohistiocytomas, and glomeruloid haemangiomas 3 . 

Some authors consider these various lesions as different stages 

in the development of the same lesion, which exhibits different 

degrees of endothelial proliferation in response to angiogenic 

stimuli 4 . Recently, cases of GH not associated with POEMS 

syndrome were described 5-8 . 

GH is characterized by an organoid pattern that resembles a renal 

glomerulus. It was present also in our case, which was histologically 

different from other hemangiomas such as Acquired tufted 

hemangioma and Lobulated capillary hemangioma. We, however, 

found thick-walled vessels associated with capillaries, as 

may be observed in common Lobulated hemangiomas. 

Conclusions. Here we describe a case of a capillary hemangioma 

with glomeruloid appearance, in a patient not affected by the PO- 

EMS syndrome We hypothesize that capillary hemangiomas can 

feature a glomeruloid appearance in some cases. 

references 

1 Chan JKC, Fletcher CDM, Hicklin GA, et al. Glomeruloid hemangioma: 

a distinctive cutaneous lesion of multicentric Castleman’s disease 

associated with POEMS syndrome. Am J Surg Pathol 1990;14:1036. 

2 Bardwick PA, Zvaifler NJ, Gill GN, Newman D, et al. Plasma cell dyscrasia 

with polyneuropathy, organomegaly, endocrinopathy, M protein, 

and skin changes: The POEMS syndrome. Report on two cases 

and a review of the literature. Medicine (Baltimore) 1980;59:311-22. 

3 Perniciaro C. POEMS syndrome. Semin Dermatol 1995;14:162-5. 

4 Marina S, Broshtilova V. POEMS in childhood. Pediatr Dermatol 

2006;23:145-8. 

5 González-Guerra E, Haro MR, Fariña MC, et al. Glomeruloid haemangioma 

is not always associated with POEMS syndrome. Clin Exp 

Dermatol 2008. 

6 Vélez D, Delgado-Jiménez Y, Fraga J. Solitary glomeruloid haemangioma 

without POEMS syndrome. J Cutan Pathol 2005;32:449. 

7 Pi ña-Oviedo S, López-Pati ño S, Ortiz-Hidalgo C. Glomeruloid hemangiomas 

localized to the skin of the trunk with no clinical features 

of POEMS syndrome. Int J Dermatol 2006;45:1449. 

8 Forman SB, Tyler WB, Ferringer TC, et al. Glomeruloid hemangiomas 

without POEMS syndrome: series of three cases. J Cutan Pathol 

2007;34:956. 

Atypical nodular superficial epithelioma 

with sebaceous differentiation 

M.G. Zorzi1 , T. Pusiol1 , D. Morichetti1 , L. Speziali2. 1 Dirigente Medico, U.O. Anatomia e Istologia Patologica, Ospedale di 

Rovereto, Rovereto (TN); 2 Dirigente Medico, Servizio di Dermatologia, 

Ospedale di Rovereto, Rovereto (TN) 

Abstract. The first case of atypical nodular superficial epithelioma 

with sebaceous differentiation is reported in 64-year-old man. 

Introduction. Described initially by Rothko et al. 1 in 1980 as 

a “distinctive cutaneous tumor”, superficial epithelioma with sebaceous 

differentiation (SESD) is characterized by a superficial 

plate-like proliferation of basaloid cells with broad epidermal 

attachments, keratin-filled cysts and clusters of mature sebaceous 

cells within the tumor. Although the reported follow-up periods 

have been somewhat limited, the biological behaviour of SESD, 

confirmed by all cases in our study, indicates that it is benign 2-9 . 

The term “atypical” is used for cutaneous lesions in which a 

degree of atypia is evident, insufficient to merit a diagnosis of 

outright malignancy but which nevertheless is a source of some 

concern to the pathologist. It is a term to use very sparingly and 

it should not represent a wastebasket diagnosis for any cutaneous 

lesion that deviates even minimally from the norm. It should 

be obvious that such atypical lesions must either be benign or 

malignant and that the use of this term merely reflects diagnostic 

uncertainty. In the cutaneous adnexal tumors the distinction

406 

between benign and malignant neoplasms is typically based on 

the assessment of both architectural and cytological features. In 

World Health Organization Classification of tumors, Prof. LeBoit 

8 encoded the clinicopathological diagnostic criteria for distinguishing 

benign from malignant adnexal tumors. Clinically, the 

majority of benign adnexal tumors presents as a nodule or a symmetrical 

papule, with smooth surface of the same colour as the 

patient’s skin. The majority of adnexal carcinomas consists of a 

plaque with irregular shape, often ulcerated. Microscopically, the 

adnexal benign tumors are composed by aggregates of uniform 

epithelial cells with monomorphic nuclei, rare mitosis always 

typical, in the absence of necrosis and ulceration. Also, these tumors 

show smooth and symmetrical edges, form a rounded interface 

with the dermis native and have a vertical growth, compared 

to the cutaneous surface. On the other hand, adnexal carcinomas 

are composed predominantly by markedly irregular aggregates of 

epithelial cells with nuclear pleomorphism, frequent and atypical 

mitosis and massive necrosis. The malignant neoplasms have 

irregular and asymmetrical edges with a horizontal growth and 

infiltrating pattern of the dermis or subcutis. The surrounding 

stroma is poor and irregular, sometimes myxoid. On encountering 

a tumor showing architectural-cytological discordance, a dermatopathologist 

tend to use the term “atypical”. In the present paper 

we report a case of atypical nodular SESD characterized by two 

proliferative components (a superficial plate-like proliferation 

and an invasive deep nodule) with the presence of a high mitotic 

rate and some atypical cells. 

Case report. A 64-year-old man with an end-stage renal disease 

of unkown cause underwent hemodialysis and was submitted to 

underwent unrelated-donor renal transplantation in April 2008. 

Initial immunosuppression consisted of cyclosporine (CsA; 8 

mg/kg/d), Azathioprine (4 mg/kg/d), and prednisone (25 mg/d). 

The post-transplantation follow-up was uneventful, without acute 

rejection and with a progressive recovery of renal function until 

the serum creatinine level reached 1.2 mg/dL. One year later 

azathioprine was replaced by mycophenolate mofeteil (1 g every 

12 hours) due to Azathioprine-induced hepatitis. Liver function 

tests improved after conversion from Azathioprine to mycophenolate 

mofetil,. Twenty-four months after transplantation the 

patient presented with an erosive nodular cutaneous lesion of 

the right cheek, 1cm in maximum diameter. The patient referred 

that the lesion was present for some years. The histological 

examination showed an ulcerative superficial proliferation of 

uniform basaloid cells with multiple attachments to the overlying 

epidermis. The superficial proliferation was in continuity with 

deep nodular growth infiltrating reticular dermis. The nodule was 

well circumscribed, surrounded by connective tissue and showed 

the same cellular composition of the superficial component with 

atypical basaloid cells (Fig. 1). Sebaceous differentiation in the 

form of clusters, lobules and single sebocytes of varying degrees 

of maturity was observed (Fig. 2). Keratine-filled cysts were 

Fig. 1. Ulcerative superficial proliferation of uniform basaloid cells 

with multiple attachments to the overlying epidermis, in continuity 

with deep, nodular, well circumscribed, growth infiltrating reticular 

dermis. (h&E 4X). 


Fig. 2. Sebaceous differentiation in the form of clusters, lobules and 

single sebocytes of varying degrees of maturity was observed in the 

superficial (a: H&E 10X) and in the deep component (B: H&E 20X) of 

the lesion. 

Fig. 3. Keratine-filled cysts were found observed in the superficial (a: 

H&E 10X) and in the deep component (B: H&E 10X) of the lesion. 

found (Fig. 3). The mitotic count averaged 13 per 10 HPFs. Focal 

abnormal keratinisation was present (Fig. 4). We believe that 

the diagnosis of malignancy was not supported because of the 

absence of infiltrative margins. We prefer the term “atypical” 

because numerous basaloid cells showed nuclear atypia and the 

mitotic activity was increased. There has been no evidence of the 

disease for one year after surgery. 

Discussion. The terminology of SESD is controversial. Steffen 

and Ackerman 10 prefer the term “reticulated acanthoma with 

sebaceous differentiation” to SESD because a benign neoplasm of 

sebocytes and keratinocytes with the name “superficial epithelioma” 

may be misinterpreted as a carcinoma by a physician charged 

with responsibility for managing a patient with that neoplasm. 

LeBoeuf et al. 8 believe that SESD may be hamartoma. But these

PoStER 

Fig. 4. High mitotic rate (a: H&E10X) and abnormal squamous differentiation 

(B: H&E10X) were found. 

authors think that the unifying architecthure of the six cases 

presented supports maintenance of the original nomenclature of 

SESD. Sanchez Yus 11 proposed the term “sebomatricoma” to 

encompass the spectrum of benign neoplasms with sebaceous differentiation 

as SESD, well-differentiated sebaceous adenoma, sebaceous 

epithelioma and previously “unclassificable” sebaceous 

neoplasms, often found in patients with Muir-Torre syndrome 

or within nevus sebaceous of Jadassohn. According to LeBoeuf 

et al. 8 we believe that term sebomatricoma is of limited use and 

should be restricted to neoplasms with substantial sebaceous differentiation 

such as sebaceous adenoma, sebaceous epithelioma 

and sebaceous carcinoma. Consequently in LeBoeuf’s 8 study, 

the cases described as “sebomatricomas” by Sanchez Yus et al. 11 

may not be considered in the SESD summary. Sanchez Yus et 

al. 4 described a case of SESD coexisting with three other cutaneous 

tumors: squamous cell carcinoma within the superficial band 

of SESD, undifferentiated apocrine adenocarcinoma infiltrating 

the whole depth of the dermis and immature trichoepitelioma. 

The differential diagnosis of SESD include various neoplasms 

with sebaceous differentiation: seborrheic keratosis with sebaceous 

differentiation, tumor of the follicular infundibulum with 

sebaceous differentiation, verruca vulgaris with sebaceous differentiation 

10 12 . The criteria of distinction between these lesions 

has been widely discussed. One of the major problems associated 

with prolonged immunosuppression is a high occurrence of skin 

malignancies among kidney recipients. Studies have shown that 

non-melanomatous skin cancer is the most frequently occurring 

neoplasm after organ transplantation. 

Conclusions. The present case is the first report of SESD. The 

nodular deep component is the main criteria that justifies the use 

of the term “atypical”, supported by a high mitotic rate and some 

atypical cells. Since the deep nodule was well-circumscribed by 

connective tissue, the malignant nature of the lesion has been 

excluded. Biologically, the lesion should be considered “of uncertain 

significance”. A strict follow-up should be performed for 

these lesions. We can hypothesize that the primary lesion was an 

“usual” SESD. The immunosuppression could be considered the 

trigger of the “atypical” nodular proliferation. 

Acknowledgments. We deeply thank Dr. Kutzner H., Dr. Rütten, 

Prof. Mentzel, Dr. Hantschke, Dr. Paredes and Dr. Schärer, Der- 

407 

matohistopathologische Gemeinschaftspraxis, Friedrichshafen, 

Germany for the histological consultation of this case. 

references 

1 Rothko K, Farmer ER, Zeligman I. Superficial epithelioma with sebaceous 

differentiation. Arch Dermatol 1980;116:329. 

2 Friedman KJ, Boudreau S, Farmer ER. Superficial epithelioma with 

sebaceous differentiation. J Cutan Pathol 1987;14:193-7. 

3 Vaughan TK, Sau P. Superficial epithelioma with sebaceous differentiation. 

J Am Acad Dermatol 1990;23:760. 

4 Sanchez Yus E, Requena L, Simon P, et al. Complex adnexal tumor of 

the primary epithelial germ with distinct patterns of superficial epithelioma 

with sebaceous differentiation, immature trichoepithelioma, and 

apocrine adenocarcinoma. Am J Dermatopathol 1992;14:245. 

5 Kato N, Ueno H. Superficial epithelioma with sebaceous differentiation. 

J Dermatol 1992;19:190. 

6 Akasaka T, Imamura Y, Tomichi N, et al. A case of superficial epithelioma 

with sebaceous differentiation. J Dermatol 1994;21:264. 

7 Lee MJ, Kim YC, Lew W. A case of superficial epithelioma with 

sebaceous differentiation. Yonsei Med J 2003;44:347 

8 LeBoit PE. Appendageal skin tumours: introduction. In: LeBoit PE, 

Burg G, Weedon D, et al., eds. Skin tumours. World Health Organization 

Classification of Tumours. Lyon: IARCPress 2006, p. 123. 

9 Kawachi Y, Fujisawa Y, Furuta J, et al. Superficial epithelioma with 

sebaceous differentiation: immunohistochemical study of keratinocyte 

differentiation markers. Eur J Dermatol 2011;21:1016-7. 

10 Steffen C, Ackerman AB. Reticulated acanthoma with sebaceous 

differentiation. In: Steffen C, Ackerman AB, eds. Neoplasms with 

sebaceous differentiation. Philadelphia: Lea & Febiger 1994a, p. 449. 

11 Sanchez Yus E, Requena L, Simon P, et al. Sebomatricoma: a unifying 

term that encompasses all benign neoplasms with sebaceous differentiation. 

Am J Dermatopathol 1995;17:213. 

12 Steffen C, Ackerman AB. Seborrheic keratosis with sebaceous differentiation. 

In: Steffen C, Ackerman AB, eds. Neoplasms with sebaceous 

differentiation. Philadelphia: Lea & Febiger 1994b, p. 433. 

Apocrine eccrine porocarcinoma with follicular 

and sebaceous differentiation 

M.G. Zorzi1 , T. Pusiol1 , D. Morichetti1 , L. Speziali2 1 Dirigente Medico, U.O. Anatomia e Istologia Patologica, Ospedale di 

Rovereto, Trento; 2 Dirigente Medico, Servizio di Dermatologia, Ospedale 

di Rovereto, Trento 

Introduction. One single unique case of apocrine eccrine porocarcinoma 

(AEP) has been reported in the “sarcomatoid” variant 

by Kazakov et al. with following definition: Occurrence of metaplastic 

carcinoma in association with apocrine poroma is a rare 

event that indicates the existence of a malignant counterpart of 

the latter entity, with can be descriptively referred to as “sarcomatoid 

apocrine porocarcinoma” 1 . We described another case of 

AEP with sebaceous and follicular differentiation. 

Materials and methods. The first case of AEP with follicular 

and sebaceous differentiation is described. 

Results. A 85-year-old women presented with an extensive 

erythematous plaque lesion, 7x5cm sized, with verrucous and 

hyperkeratotic surface, centrally ulcerated, sharp margins and 

slightly infiltrated, of the abdominal wall (Fig. 1). The lesion 

had been present for several years and has grown slowly. During 

the year prior to presentation the lesion had increased in size, 

often producing discomfort and bleeding from friction. Surgical 

excision was performed; after one year of clinical follow-up the 

patient is disease-free. Histological examination showed different 

proliferative patterns in the different areas inside the tumour. 

At the periphery of the tumours anastomosing lobules of small 

uniform cuboidal poroid cells with focal ductal structures (intracitoplasmic 

lumina formation) had proliferated in the upper third 

of the dermis (Fig. 2). A variety of histologic components were 

displayed in the central portion of the tumour corresponding to 

polypoid configuration. The neoplastic nodule showed invasion 

into the deep reticular dermis, with expansile lower borders. The 

maximum deep of tumour invasion was 8 mm. The poroma com-

408 

Fig. 1. Extensive erythematous plaque lesion, 7x5cm sized, with verrucous 

and hyperkeratotic surface, centrally ulcerated, sharp margins 

and slightly infiltrated. (insert: slightly elevated brownish reddish 

tumour with an erosive surface. H&E 4X). 

Fig. 2. at the periphery of the tumours anastomosing lobules of small 

uniform cuboidal poroid cells with focal ductal structures (intracitoplasmic 

lumina formation) had proliferated in the upper third of the 

dermis (h&E 10X). 

Fig. 3. the poroma component consisted of atypical cuboidal cells 

with oval nuclei, scant cytoplasm, intercellular bridges and small 

round ductal structures (h&E 20X). 


ponent consisted of atypical cuboidal cells with oval nuclei, scant 

cytoplasm, intercellular bridges and small round ductal structures 

(Fig. 3). The ductal component is constituted by ducts with lumina 

of variable size, lined by cells with intensely cuticular eosinophilic 

cytoplasm. “Decapitation” secretion was evident with 

intraluminal amorphous eosinophilic material (Fig. 4). Clear cell 

change was found and consisted of ample cytoplasm, hiperchromatic, 

irregular nuclei. These cells contained abundant amount of 

glycogen (Fig. 5). Focal sebaceous and follicular differentiation 

was present (Fig. 6). The comedonecrosis island of tumour cells 

contained central areas of neoplastic cell death with inflammatory 

debris (Fig. 7). Lymphovascular invasion was absent. Distinct 

neovascularization and an infiltrate of inflammatory cells could 

be seen all around the tumour. 

Discussion. Benign cutaneous appendage tumours are common 

and it is surprising that their malignant counterparts are exceedingly 

rare. Traditionally poroid neoplasms have been classified 

as eccrine tumours, relating to the intraepidermal eccrine coil 

epithelium. Poroid neoplasms may show different differentiation, 

reflecting the embryological association of follicular sebaceous 

and ductal structures (folliculosebaceous apocrine units). In 

1963 Pinkus and Mehregan 2 described the first case of eccrine 

Fig. 4. “decapitation” secretion was evident with intraluminal amorphous 

eosinophilic material (H&E 20X). 

Fig. 5. the neoplastic cells contained glycogen (H&E 10X).

PoStER 

Fig. 6. focal sebaceous and follicular differentiation where present 

(h&E 10X). 

Fig. 7. the comedonecrosis island of tumour cells contained central 

areas of neoplastic cell death with inflammatory debris (H&E 10X). 

porocarcinoma (EP) under the title of “Epidermotropic eccrine 

carcinoma”. Since the first description numerous reports have 

appeared in literature 3-5 but no EP has been described with 

ductal component composed by large eosinophilic granular 

cells displaying decapitation secretion, hallmarks of apocrine 

glandular differentiation. We believe that definition of sarcomatoid 

apocrine porocarcinoma described by Kazakov et al. 1 

is not sufficiently supported by histological description and not 

be acceptable. In the original report the tumour is composed by 

prominently keratinized epithelial islands of the poroma that 

blended gradually with the pleomorphic cells of the metaplastic 

carcinoma. According to Kurashige et al. 6 the terminology 

“poroma with metaplastic carcinoma” is the exact definition for 

this tumour. 

Conclusion. The present case is the first report of AEP with 

sebaceous and follicular differentiation, according to embryology 

of poroid neoplasms. 

Acknowledgments. We deeply thank Dr. Rütten, Prof. Mentzel, 

Dr. Hantschke, Dr. Paredes and Dr. Schärer, Dermatohistopathologische 

Gemeinschaftspraxis, Friedrichshafen, Germany for the 

histological consultation of this case. 

references 

1 Kazakov DV, Kutzner H, Spagnolo DV, et al. Sebaceous differentiation 

in poroid neoplasms: report of 11 cases, including a case of 

409 

metaplastic carcinoma associated with apocrine poroma (sarcomatoid 

apocrine porocarcinoma). Am J Dermatopathol 2008;30:21-6. 

2 Pinkus H, Mehregan AH. Epidermotropic eccrine carcinoma. A case 

combining features of eccrine poroma and paget’s dermatosis. Arch 

Dermatol 1963;88:597-606. 

3 Robson A, Greene J, Ansari N, et al. Eccrine porocarcinoma (malignant 

eccrine poroma): a clinicopathologic study of 69 cases. Am J 

Surg Pathol 2001;25:710-20. 

4 Shaw M, McKee PH, Lowe D, et al. Malignant eccrine poroma: a 

study of twenty-seven cases. Br J Dermatol 1982;107:675-80. 

5 Yamamoto O, Haratake J, Yokoyama S, et al. A histopathological 

and ultrastructural study of eccrine porocarcinoma with special 

reference to its subtypes. Virchows Arch A Pathol Anat Histopathol 

1992;420:395-401. 

6 Kurashige Y, Yamamoto T, Okubo Y, et al. Poroma with sebaceous 

differentiation: report of three cases. Australas J Dermatol 

2010;51:131-4. 

rESPIrATOrIO 

Mesothelioma and lung cancer in subjects 

with asbestos exposure: an old and new problem 

D. Bellis1, 2 , S. Capella2,3 , E. Belluso3 , D. Antonini1 , L. Viberti1 , 

D. Mirabelli4 , M. Musa5 , A. Croce5 , C. Rinaudo5 1 Dipartimento dei Servizi, Anatomia Patologica, ASLTO1,Ospedale Martini, 

Torino; 2 Centro Iinterdipartimentale per lo Studio degli Amianti e di 

Altri Particolati Nocivi, G. Scansetti, Università di Torino; 3 Dipartimento 

di Scienze della Terra, Università di Torino; 4 Servizio Universitario di 

Epidemiologia dei Tumori, Registro Mesoteliomi della Regione Piemonte, 

ASLTO1, San Giovanni Battista e Università di Torino; 5 Dipartimento 

di Scienze e Innovazione tecnologica, Università del Piemonte Orientale 

“Amedeo Avogadro”, Alessandria 

Introduction. Although asbestos is banned or restricted in Italy, 

as in many other countries, its health consequences are still expected 

for at least two decades. Asbestos related diseases are 

usually the consequence of occupational exposures, but cases 

after para-occupational or environmental exposure (e.g. by fibres 

naturally occurring in local soil) were also reported. 

Cohort studies confirmed that the risk of lung cancer and mesothelioma 

increases with exposure, with no threshold. 

When there is the slightest suspicion of occupational exposure to 

asbestos in patients who received lung resection or during autopsy, 

confirmation of exposure can be obtained through the count of asbestos 

bodies (ABs) in tissue samples. Traditionally, digested samples 

of lung tissue have been examined under optical microscopy (LM) 

or scanning electron microscopy (SEM) with annexed microanalisis 

(EDS), which allows the fibre composition to be determined. 

Another technique that can be used is Raman spectroscopy. Recently 

synchrotron radiation was used to study the nature of the 

iron coating of ABs. 

In the present study we compare the ABs and asbestos fibre 

concentration in seven cases of mesothelioma and three cases of 

lung cancer. 

Materials and methods. A detailed personal history was recorded, 

including occupational and non-occupational circumstances, 

and exposure to asbestos was assessed according to the protocol 

of the National Mesothelioma Registry. 

Clinical and radiological data were examined for all cases and 

the diagnosis of mesothelioma (n.7) and lung cancer (n. 3) was 

confirmed by immunohistochemistry, following national guidelines 

(3). 

To estimate the concentration of ABs (by LM and SEM) and 

mineral fibres (by SEM-EDS) we used the protocol developed by 

Belluso et al., 2006 1 . 

One case was also analysed by micro-Raman spectroscopy. 

In other two cases synchrotron radiation was used to obtain a high 

resolution elemental mapping of Abs from lung tissue, so that 

chemical elements in covered asbestos fibers could be identified.

410 

Results. In all subjects assessed as occupationally exposed to 

asbestos (3 cases of mesothelioma and 2 of lung cancer) more 

than 1,000 ABs per gdw (by both LM and SEM observation) 

were found, such concentration being internationally accepted 

as suggesting a high probability of past occupational exposure 

to asbestos 2 . 

In all cases we found uncoated fibres. In 2 cases of mesothelioma 

and 1 of lung cancer fibres could not be chemically identified 

because their diameter was too thin. When identification was possible, 

the concentration of asbestos fibres (tremolite, chrysotile 

and crocidolite) was slightly below the limit of 100,000 per gdw 

and that of total inorganic fibres was very high. 

Among individuals with non-occupational exposures (4 cases of 

mesothelioma and 1 of lung cancer) the ABs count by LM was 

above 1,000 per gdw only in two, both with mesothelioma. In one 

of them we found more than 100,000 asbestos fibres per gdw. 

Discussion. A multidisciplinary approach helps to investigate the 

relationship between the occurrence of neoplasms like mesothelioma 

or lung cancer and occupational or environmental asbestos 

exposure at the individual level. 

The mineralogical analysis of lung tissues (identification and 

quantification of inorganic fibres in general, and asbestos in 

particular, in biological tissues) is pivotal in this respect, and we 

believe it is very useful if not necessary to complete the pathological 

diagnosis of asbestos-related malignancies. 

references 

1 Belluso E, Bellis D, Fornero E, et al. Assessment of inorganic fibre 

burden in biological samples by SEM-EDS” – Microchimica Acta 

2006;155:95-100. 

2 Dumortier P, De Vuyst P, Strauss P, et al. Asbestos bodies in bronchoalveolar 

lavage fluids of brake lining and asbestos cement workers. 

British Journal of Industrial medicine 1990;47:91-8. 

3 Pinto C, Ardizzoni A, Betta PG, et al. Expert opinions of the first 

italian consensus conference on the management of malignant pleural 

mesothelioma. Am J Clin Oncol 2011;34:99-109. 

rapid screening of EGFr mutations in lung cancer 

by fluorescence resonance energy transfer (FrET) 

analysis 

M. Cerrone1 , M. Scrima2 , V. Gigantino1 , M.F. Zito1 , G. Gaudioso1 

, F. Tisci, M. Pepe, A.M. Anniciello1 , M. Cantile, R. Franco1 , 

G. Botti1 1 Pathology Department, National Cancer Institute “Fondazione G. Pascale”, 

Naples, Italy; 2 BIOGEM, Ariano Irpino (AV), Italy 

Introduction. Lung cancer has become one of the most 

common among malignant neoplasms in western countries. 

Mutations in the RAS proto-oncogene and epidermal growth 

factor receptor (EGFR) have been mainly found in lung adenocarcinoma, 

and are typically mutually exclusive. EGFR is 

therefore configured as a proto-oncogene upstream of a very 

large downstream targets of possible pathogenetic alterations 

which can lead to self-sufficiency by growth factors. Activating 

mutations in the tyrosine kinase domain activity (ES18-21) 

confer sensitivity to treatment with TK inhibitors. Common 

somatic mutation in EGFR is leucine to arginine substitution at 

amino acid position 858 (L858R) in exon 21, that represent 85% 

to 90% of EGFR mutations reported. The T790M mutation, in 

exon 20, results in an amino acid at position 790 in EGFR, from 

a threonine (T) to a methionine (M). T790M substitution is detected 

as a ‘second-site mutation’ in more than 50% of patients 

who develop acquired resistance to EGFR TKI therapy. Different 

methodologies methodologies can be used and examples 

include PCR and gene sequencing, ARMS-PCR (Amplification 

Refractory Mutation System). 

Aim. In this study, we evaluated a new experimental approach 

for rapid screening of principal and more important EGFR mutations, 

L858Rsubstitution in exon21 and T790M substitutionn at 


exon20, using the fluorescence resonance energy transfer (FRET) 

methodology. 

Methods. We analyzed EGFR gene sequences to design appropriate 

primers and probes to amplify regions containing the 

mutations of interest. Melting temperature of sensor probe is 

more than Anchor. In this report, we examined genomic DNAs 

from lung cancer cell line NSCLC namely NCI1975, that was 

initiated from non-smoker donor, has been used like positive 

control for considered mutation in 20-21 exons of EGFR. 

Moreover we tested 2 large cells carcinoma, 5 adenocercinoma, 

6 epidermoid carcinoma and 2 adeno-squamous carcinoma 

through immunohistochemistry and FRET Probes analysis for 

EGFR mutation. 

Results: NCI1975 cell line showed two peaks, one round 58 °C 

and one 62°C, for T790M and L858R point mutations respectively. 

1/5 adenocarcinoma sample showed a cytoplasmic immunoreactivity 

for antibody specific for L858R point mutation. Mutation 

was also confirmed with FRET Probes analysis, while all NSCLC 

samples were wild type for T790M substitution at exon20. 

Conclusions. Our method has allowed the identification of two 

EGFR mutations in selected lung cancers, and was more rapid 

and effective than traditional methods, as polymerase chain reaction 

(PCR)-based amplification, sequencing and other RT-based 

methodologies. 

First case of diffuse panbronchiolitis in a patient 

with common variable immunodeficiency: a casual 

association or a pathogenetic correlation? 

A. Ginori1 , A. Barone1 , D. Bennett2 , M.G. Mastrogiulio1 , 

M.A.G.M. Butorano1 , A. Fossi2 , P. Rottoli2 , D. Spina1 1 Department of Human Pathology and Oncology, Pathological Anatomy 

Section, University of Siena, Siena, Italy; 2 Respiratory Diseases Section, 

Department of Clinical Medicine and Immunological Sciences, University 

of Siena, Siena, Italy 

Background. Diffuse panbronchiolitis (DPB) is an idiopathic 

inflammatory disease, well recognized in Japan and principally 

affecting the respiratory bronchioles, causing a progressive suppurative 

and severe obstructive respiratory disorder. If left 

untreated, DPB progresses to bronchiectasis, respiratory failure 

and death. The term “diffuse’’ refers to the distribution of the 

lesions throughout both lungs, and the term ‘‘pan-’’ refers to 

the involvement of inflammation in all layers of the respiratory 

bronchioles. DPB usually occurs in the 2 nd -5 th decade of life. The 

prevalence of physician-diagnosed DPB is 11 cases per 100,000 

people. DPB has been associated with Cystic Fibrosis, Bare 

Lymphocyte Syndrome and Human T-cell Lymphotropic Virus 

type 1 (HTLV-1). Here, we describe a case of panbronchiolitis 

in a 41-year-old patient affected by common variable immunodeficiency 

(CVID). This pathology has been associated with many 

respiratory diseases, but, at the best of our knowledge, this is the 

first case described in the literature of a patient affected by CVID 

associated with panbronchiolitis. 

Materials and methods. The patient presented to our Hospital 

with severe dyspnoea, cough and sputum. In anamnesis, the patient 

referred a childhood diagnosis of CVID. Physical examination 

revealed crackles and wheezes. A CT-scan revealed the centrilobular 

distribution of the nodular shadows, often extending to 

small, branching linear areas of attenuation, and a peripheral air 

trapping. In addition, mild diffuse bronchiectasis and bronchial 

wall thickening were present. Pulmonary function tests showed a 

airflow limitation, relatively resistant to bronchodilators. A cytologic 

sputum examination was performed. It showed an intense 

suppurative inflammation, but the research of bacterial and fungal 

microorganisms with the Gram and Grocott stains was negative. 

The respiratory disease got worse and the patient developed a severe 

chronic respiratory failure, and after about a year underwent 

a bilateral lung transplantation.

PoStER 

Results. At gross examination, the lungs showed small white 

nodules centred on small airways, principally in the upper lobes. 

Microscopically, transmural and peribronchial infiltration by lymphoctyes 

and histocytes was found, with prominent involvement 

of respiratory bronchioles. The inflammatory infiltrate had a characteristic 

topography. Most of the histiocytes manifested as foamy 

macrophages, accumulated in a “nodular” pattern distributed 

especially in the wall of respiratory bronchioles, in the surrounding 

interalveolar septa and around the blood and lymphatic vessels. 

The bronchiolar lumen contained neutrophils. The inflammatory 

infiltrate destroyed the bronchiolar epithelium and extended to 

peribronchiolar spaces, with distortion ot the alveolar structure and 

formation of microascessualization areas. A severe peribronchial 

and peribronchiolar fibrosis was also seen. The inflammatory infiltrate 

had been studied with immunohistochemistry stains. Gram 

and Grocott stains were negative for the research of bacterial and 

fungal microorganisms. The diagnosis was necrotizing acute and 

fibrosing chronic panbronchitis and panbronchiolitis. 

Conclusions. Panbronchiolitis is a rare and severe respiratory 

disease that, if left untreated, progresses to respiratory failure 

and death. At the best of our knowledge, this is the first case 

described in the literature of panbronchiolitis in a patient affected 

by CVID, even if DPB has been yet associated in the literature to 

other immunodeficiency conditions. Our hypothesis is that could 

exist a correlation between an immunodeficiency status and the 

development of DPB. 

references 

1 Poletti V, Casoni G, Chilosi M, et al. Diffuse panbronchiolitis. Eur 

Respir J 2006;28:862-71. 

2 Yamanaka A, Saiki S, Tamura S, et al. Problems in chronic obstructive 

bronchial diseases, with special reference to diffuse panbronchiolitis. 

Naika 1969;23:442-51. 

3 Tsang KWT. Diffuse panbronchiolits: diagnosis and treatment. Clin 

Pulm Med 2000;7:245-52. 

nHErF1 as a potential new marker for lung cancer 

progression: a histocytological study 

A. Mangia1 , C. Saponaro1 , A. Malfettone1 , M. Asselti2 , R. Daprile2 , 

D. Galetta3 , G. Simone2 1 2 3 Functional Biomorphology Laboratory; Pathology Departmen; Medical 

Oncology Department, National Cancer Research Centre “Giovanni 

Paolo II”, Bari, Italy 

Background. Lung cancer remains the most common cause of 

cancer death worldwide 1 2 . According with recent classification, 

nonsmall cell lung cancer (NSCLC) accounts for nearly 80% of 

all patients 3 . In approximately 75% of NSCLC patients, cytology 

is often the only possible diagnostic approach. Our previous studies 

showed that alterations of Na+/H+ exchanger regulatory factor 

1 (NHERF1), an adaptor molecule for several cellular receptors 4 , 

correlated with the progression and invasiveness of breast and 

colorectal cancers 5 6 . Aim of this study was to evaluate NHERF1 

role as a potential new marker of lung tumor progression. 

Methods. Differences of NHERF1 expression in the membrane, 

cytoplasmic and nuclear compartments were evaluated on 47 

FNACs, from 26 primary NSCLC (14 squamous cell carcinomas, 

2 small cell lung carcinomas, and 10 adenocarcinomas), and 21 

lung metastases from different sites, by immunohistochemistry. 

Results. Analyzing all 47 FNACs, the cytoplasmic and nuclear 

NHERF1 was statistically higher than membrane expression 

(P < 0.001, P < 0.0001, respectively). Moreover, a similar result 

was observed also when we examined only the 26 primary 

lung cancers (P < 0.05), regardless of histotypes. Instead, in 

the 21 metastatic FNACs nodules, cytoplasmic and nuclear 

NHERF1 expression was higher, but not statistically significantly, 

than membranous compartments. Conclusion. FNAC 

of lung nodules provides a useful material to detect NHERF1 

status. NHERF1 expression in different compartments suggest 

411 

a dynamic role of this marker in primary lung cancer. The high 

NHERF1 expression appears to contribute to the malignant 

phenotype. Further studies focusing this come up to are ongoing 

in our institution. 

references 

1 Hoffman PC, et al. Lancet 2000;355:479-85. 

2 Spira A, et al. N Engl J Med 2004;350:379-92. 

3 Gridelli C, et al. Lung Cancer 2011;74:544-8 

4 Stemmer-Rachamimov AO, et al. Am J Pathol 2001;158:57-62. 

5 Mangia A, et al. Histopathology 2009;55:600-8. 

6 Malfettone A, et al. Experimental and Molecular Pathology 

2012;92:296-303. 

Screening of anaplastic lymphoma kinase 

rearrangement by immunohistochemistry 

and fluorescence in situ hybridization 

in malignant pleural mesothelioma 

S. Salvi1 , S. Boccardo1 , P. Ferro2 , P. Dessanti2 , M.C. Franceschini3 

, S. Varesano1 , M. Truini1 , P.A. Canessa2 , F. Fedeli2 , M.P. Pistillo1 

, S. Roncella2 1 2 IRCCS A.O.U. San Martino, IST, Genova; ASL5 “Spezzino”, La Spezia; 

3 AIL Sezione “ Francesca Lanzone”, La Spezia, Italy 

Background. Malignant pleural mesothelioma (MPM) ( 1 ) is 

an asbestosis related tumor with rapidly increasing incidence 

worldwide including the provinces of Genova and La Spezia 2 . 

No effective treatments are available so far, resulting in median 

survival of less than one year post diagnosis. Therefore, development 

of new strategies like the introduction of molecularly 

targeted therapies are needed. 

The Anaplastic Lymphoma Kinase (ALK) gene mapping on 

chromosome 2, has been found to be rearranged, mutated or 

amplified in a further series of tumours including neuroblastoma 

and non-small cell lung cancer (NSCLC) 3 . Recently, different 

small-molecule inhibitors of ALK tyrosine kinase activity have 

been described 4 . Among them, Crizotinib 4 , was approved by the 

US FDA for the treatment of advanced NSCLC cancer harboring 

the ALK gene rearrangement or chimeric protein produced by 

translocation involving the ALK gene. 

In this study, we analyzed ALK gene and protein status of MPM 

patients to determine their eligibility for Crizotinib therapy. 

Comparison with ALK status in NSCLC patients was also performed. 

Methods. ALK status was assessed on paraffin-embedded tissues 

of MPM and NSCLC tumours. Gene rearrangement was analyzed 

by fluorescence in situ hybridization (FISH) using the “Vysis 

ALK Break Apart FISH Probe Kit ALK” (ABBOTT molecular). 

ALK protein expression was assessed by immunohistochemistry 

(IHC) using “ConfirmTM anti-ALK1 (ALK01) primary Antibody” 

(Ventana). We performed IHC, using the PATHWAY kit by 

Benchmark XT system (Ventana). 

Results. This study included 20 patients (61.8% males, mean 

age 73.0, range 29-93) with MPM (17 epithelioid, 2 bifasic and 

one desmoplastic subtypes) and 50 patients with NSCLC (56.0% 

males, mean age 65.4, range 42-82). 

Tab. I. anaplastic lymphoma kinase status pleural mesothelioma and NSClC 

Anaplastic lymphoma kinase 

Rearrangement Protein expression 

positive/total (%) positive/total (%) 

pleural mesothelioma 0/20 (0.0%) 0/20 (0.0%) 

NSCLC 2/50 (4.0%) 2/50 (4.0%) 

None of the MPM tissues analyzed showed translocations or chimeric 

protein products resulting from translocations involving the 

ALK gene. In contrast, 2/50 (4.0%) NSCLC showed positivity for 

both ALK gene rearrangements and protein expression (Tab. I).

412 

Discussion. Although further studies in larger specimens are 

needed to confirm our findings, these preliminary results show that 

Crizotinib target therapy is not indicated for patients with MPM. 

references 

1 Borasio P, Berruti A, Billé A, et al. Malignant pleural mesothelioma: 

clinicopathologic and survival characteristics in a consecutive series 

of 394 patients. Eur J Cardiothorac Surg 2008;33:307-13. 

2 Gennaro V, Ugolini D, Viarengo P, et al. Incidence of pleural 

mesothelioma in Liguria Region, Italy (1996-2002). Eur J Cancer 

2005;41:2709-14. 

3 Schonherr C, Hallberg B, Palmer R. Anaplastic lymphoma kinase in 

human cancer. Crit Rev Oncog 2012;17:123-43. 

4 Larsen JE, Cascone T, Gerber DE, et al. Targeted therapies for lung 

cancer: clinical experience and novel agents. Cancer J 2011;17:512-27. 

Protein detection/localization and genotyping 

of SIrT 1 polymorphisms in nSCLCs 

G. Scognamiglio 1 , N. Sapere2 , G. Gaudioso 1 , F. Zito Marino, 

F. Tisci1 , L. La Sala1 , E. La Mantia1 , A. Manna1 , R. Franco1 , 

G. Botti1 , M. Intrieri 2 

1 Pathology Department, National Cancer Institute “Fondazione G. Pascale”, 

Naples, Italy; 2 DIMES, Università Del Molise, Campobasso, Italy 

Introduction. Sirtuins are NAD-dependent histone deacetylase 

(class III), highly conserved among species. The human homologue 

of Sir2 is represented by SIRT1 mainly involved in cellular 

longevity. 

SIRT1 has been also strongly linked to several human cances, 

in fact its aberrant expression was related to regulation of tumor 

cell apoptosis, senescence and the DNA damage response, all 

promoting tumor cell survival. Moreover, SIRT1 was associated 

with the tumor suppressor protein p53. In fact, SIRT1 was able 

to regulate protein levels of p53 through deacetylation of residue 

L382, which destabilizes p53, thereby promoting cell survival. 

It was recently identified a SNP, C/T, in the promoter region 

of the gene SIRT1 which causes a different transcriptional 

regulation of SIRT 1 protein in response to the nutritional state. 

In presence of low caloric intake the polymorphism leads to 

increased expression of protein with consequent resistance to 

senescence. 

Aim and Methods. Little information is available in the literature 

on the role of SIRT1 in non-small cell lung carcinomas, for 

this reason the aim of our work was to evaluate the ICH expression 

of SIRT1 and the apoptotic index, by TUNEL assay, in a 

series of NSCLCs included in a TMA, and analyze the presence 

of C/T polymorphism on selected samples by Real Time PCR 

Genotyping. Tissue microarrays (TMA) contained core of tumor 

tissue from 110 patients surgery for NSCLC, most of which are 

represented by adenocarcinomas (52.7%) and squamous cell 

carcinomas (29.0%). The polymorphism was genotyped by Taq- 

Man allelic discrimination assay in a subset of 43 samples. 

Results. Nuclear SIRT1 expression was present in 87.2% of 

samples with low expression in 44.7% of cases, and with high expression 

in 55.2% of cases. Moreover, cytoplasmic expression of 

SIRT1 was detected in the most of specimens, with low positivity 

in 80% of samples and with high expression in 18 % of cases. 

Between these, 40.1% of cases showed also high apoptotic index. 

Regarding genotyping analysis, the polymorphism of SIRT1 was 

present, in 46.5% of selected samples, and specifically the variation 

in C/C versus C/T polymorphism was present in 44.1% of 

cases while 9.30% of samples showed polymorphism T/T. 

Our data show that high expression of SIRT1 appears to be inversely 

correlated with apoptotic index and that the cytoplasmic 

expression of SIRT1, is significantly correlated with disease-free 

survival. Moreover, in presence of the polymorphism T/T, SIRT1 

is always expressed both in the nucleus and in cytoplasmic, while 

in presence of C/C and C/T polymorphisms, SIRT1 present a low 

expression both at nuclear and cytoplasmic level. 


Conclusions. our data underline that the presence of specific 

SIRT 1 polymorphisms associated to its cytoplasmatic expression 

represent a negative prognostic index in NSSLCs. 

TESTA COLLO 

P16InK4a protein expression in oropharyngeal 

squamous cell carcinoma: a preliminary study 

T. Addati1 , M.A. Caponio1 , S. Petroni1 , A. Di Lauro2 , L. Grammatica2 

, O. Popescu1 , A.L. Marzano1 , R. Daprile1 , G. Simone1 1 2 Anatomic Pathology Unit; Otolaryngology Unit, National Cancer Research 

Centre, Istituto Tumori “Giovanni Paolo II”, Bar, Italy 

Background. Squamous Cell Carcinoma is the most common 

cancer of head and neck (HNSCC) and includes cancers of the 

oral cavity, oropharynx, hypopharynx, larynx, sinonasal tract, 

and nasopharynx. HNSCC is the sixth most common type of 

cancer in the world; almost 600,000 cases are reported annually, 

and of these, ≈10% were localized in oropharynx. Incidence and 

localization of HNSCC varies widely, it is the most common 

form of cancer in India, and incidence is higher in countries in 

Latin America than in the United States and northern Europe. 

In addition, men are generally more often affected than women. 

Smoking, alcohol consumption, and betel chewing are traditional 

risk factors for HNSCC and during the past decade several reports 

have documented HPV in oropharynx squamous cell carcinoma 

(OSCC), with prevalence of HPV16 infection. It has been demon- 

Fig. 1. Squamous cell carcinoma of the larynx with p16 iNK4a strongly 

immunoreactions. 20X. 

Fig. 2. Squamous cell carcinoma of the larynx with sporadic p16 iNK4a 

immunoreactions in superficial cells. 20X.

PoStER 

strated that HPV is present in episomal or integrated form into the 

cellular genome and that HPV16-type is highly prevalent (≈90%) 

in OSCC, whereas other HPV types (HPV-31, -33, -58, -59, -62, 

and -72) are less common. Several reports evidenced that HPVpositive 

OSCC has a better clinical outcome than HPV-negative 

ones. Claiming a clinical predictive and prognostic role for HPV 

for prevention and treatment of OSCC. 

P16 INK4a immunohistochemical overexpression is considered as a 

marker for HPV genome integration 1-3 . 

The aim of this study was to analyze p16 INK4A distribution in 

oropharyngeal squamous cell carcinoma to select a subset of patients 

who could benefit of a specific target therapy. 

Methods.We analyzed oropharyngeal specimens of 12 patients 

with well differentiated, keratinizing, squamous cell carcinoma of 

the oral cavity: 10 out of 12 were of the larynx, 1 out of 12 was 

of the uvula and the last was of the lingual mucosa. Four- to five 

μm-thick sections were cut from the 12 paraffin blocks and placed 

on polilysine-coated slides and used for immunohystochemical 

analysis using p16 INK4a monoclonal antibody (clone E6H4, Histology 

V-Kit, ROCHE). 

Results. P16 INK4a expression, in our cohort were strongly expressed 

only in 1 out of 7 well differentiated, keratinizing squamous 

cell carcinoma of the larynx (Fig. 1), whereas 2 out of 7 

cases presented a sporadic p16 INK4a immunoreaction in superficial 

cells (Fig. 2), the last 4 laryngeal samples were negative for 

p16 INK4a expression. No p16 INK4a immunoreaction was found in 

all 3 well differenziated, squamous cell carcinoma of the vocal 

cord. Regarding to squamous cell carcinoma of the uvula and 

lingual mucosa p16 INK4a expression was positive, but its distribu- 

Fig. 3. Squamous cell carcinoma of the uvula with p16 iNK4a immunoreactions 

in basal dysplastic area. 20X. 

Fig. 4. Squamous cell carcinoma of the lingual mucosa with p16 iNK4a 

immunoreactions in basal dysplastic area. 20X. 

413 

tion pattern regarded dysplastic areas rather then carcinomatous 

areas (Figg. 3-4). 

Conclusion. Our data showed, according to current literature, 

that only 3 (25%) out of 12 oropharyngeal squamous cell carcinoma 

presented p16 INK4a overexpression. Even if we analyzed few 

samples, we note that p16 INK4a distribution pattern was different, 

being present both in carcinoma or only with dysplastic cell. We 

could hypothesize that p16 INK4a overexpression could be useful 

in distinguish a subset of patients to address towards targeted 

therapy such us radiotherapy, that showed a better response in 

oropharyngeal squamous cell carcinoma of p16 INK4a positive 

cancer patients. 

references 

1 Mellin Dahlstrand H, Lindquist D, Björnestål L, et al. P16(INK4a) 

correlates to human papillomavirus presence, response to radiotherapy 

and clinical outcome in tonsillar carcinoma. Anticancer 

Res 2005;25:4375-83. 

2 Lewis JS Jr, Chernock RD, Ma XJ, et al. Partial p16 staining in 

oropharyngeal squamous cell carcinoma: extent and pattern correlate 

with human papillomavirus RNA status. Mod Pathol 2012 May 18. 

3 Hoffmann M, Tribius S, Quabius ES, et al. HPV DNA, E6(*) 

I-mRNA expression and p16(INK4A) immunohistochemistry 

in head and neck cancer - How valid is p16(INK4A) as surrogate 

marker?“Cancer Lett 2012;323:88-96. 

Sebaceous variant of epithelial myoepithelial 

carcinoma of the parotid gland: a case report 

with aspiration cytology and histology 

L. Lorenzi, L. Lucini, F. Facchetti, M. Ungari 

1° Department of Anatomic Pathology, Spedali Civili di Brescia, Brescia 

Introduction. Fine needle aspiration of nodules of the salivary 

glands is a minimally invasive procedure but powerful tool in the 

clinical and surgical management of these lesions. New variants 

of epithelial-myoepithelial carcinoma (EMC) have been recently 

described in the literature 1 and here we present the first case of 

aspiration cytology of a sebaceous EMC. 

Case Report. A 67 years old man presented with a nodule in the 

right parotid gland and fine-needle aspiration was performed. The 

cytologic specimen showed high cellularity constituted by two 

distinctive cell types. The main population was composed of clear 

cells showing a large cytoplasm with micro and macro vacuoles 

dislocating the nuclei to the periphery of the cell. The second cell 

type, less numerous, displayed a central nuclei with punctiform 

nucleoli. In the background proteinaceous material with calcifications 

and giant cells was present. No ductal structures were 

recognizable. Diagnosis of neoplastic cytology was made and, in 

the report, a differential diagnosis between acinic cell carcinoma 

and mucoepidermoid carcinoma was suggested. 

Surgical resection of the nodule was performed. It measured 2,5 

cm, was polilobulated, compact, of brown-yellow color and with 

ill-defined borders. On histology the salivary parenchyma was 

infiltrated by a proliferation of multiple nests, occasionally with 

cystic appearance, made of clear cells with micro and macro 

vacuolated cytoplasm displaying a sebaceous differentiation. At 

the periphery of the nodules a single layer of “activated” myoepithelial 

cells with hypercromic nuclei, occasionally atypical, were 

present. Psammomatous calcifications were present, interspersed 

in the lesion. On immunohistochemistry the myoepithelial nature 

of the peripheral cells was confirmed by the strong positivity for 

p63, smooth muscle actin and CD10, of notice, they were negative 

for cytokeratin 5/6 and S100. 

Conclusions. Sebaceous epithelial-myoepithelial carcinoma 

(SEMC) of the salivary gland is a rare entity recently described 1 2 . 

SEMC is a low grade malignancy, similarly to other EMC and is 

generally located in the parotid gland. Differential diagnosis with 

the more aggressive sebaceous carcinoma is crucial and the recognition 

of myoepithelial cells is pivotal in the diagnosis.

414 

references 

1 Seethala RR, Barnes EL, Hunt JL. Am J Surg Pathol. 2007;31:44-57. 

Erratum in: Am J Surg Pathol 2008;32:1923. 

2 Shinozaki A, Nagao T, Endo H, et al. Am J Surg Pathol 2008;32:913-23. 

UrInArIO 

PCA3 ribo probe costruction for ISH analysis 

on tumoral prostatic samples 

G. Aquino1 , M. Cerrone1 , E. La Mantia1 , V. Gigantino1 , A. Marra1 , 

R. Sabatino1 , S. Perdonà2 , C. Santonastaso, R. Franco1 , G. Botti1 1 Pathology Department, National Cancer Institute “Fondazione G. Pascale”, 

Naples, Italy; 2 Urology Department, National Cancer Institute 

“Fondazione G. Pascale”, Naples, Italy 

Prostate cancer (PCa) is the most commonly diagnosed cancer in 

men and the second leading cause of death. The etiology of PCa is 

uncertain, several factors are involved: environmental, hormonal 

and hereditary. 

New diagnostic methods have been developed in recent years, the 

one that has had a greater clinical impact is a non-invasive diagnosis 

of urine, which detects the expression of the PCA3 gene. 

This diagnostic method, based RT-PCR, allows us to reveal the 

‘overexpression of PCA3 RNA (mRNA) in the urine. This indicator 

would allow to discriminate patients who should undergo 

biopsy from patients who only need a close follow-up. The concentration 

of PCA3, in fact, is related to the risk of cancer. 

PCA3 is a non-coding RNA whose gene is located on chromosome 

9, locus: 9q21-q22, there is no corresponding protein and 

possibly detectable by immunohistochemistry. 

Aim. The identification of PCA3 expression in urine represents a 

rapid and non-invasive screening method for PC detection, thus 

derives the interest in the practice of using histological routine to 

enable the identification of borderline lesions. 

The purpose of this study was development of a technique capable 

of detecting the presence of PCA3 RNA on histological 

sections. For this, we have built a digoxigenin-labeled probe for 

detecting several PCA3 isoforms. 

Methods. ISH was performed initially using a 350-bp digoxigenin-labelled 

ribo probe generated by PCR from RNA isolated 

and retro-transcripted from cell line LnCaP, subsequently to overcome 

the problem of RNA degradation we have built a smaller 

probe, respectively 139 bp. We used like a positive control Beta 

actin antisense probe while like negative control we use pca3 

and beta actin sense probe. Experiments were performed on both 

positive and negative controls. ISH was realized both on LnCaP 

cells that on 7-micrometer-thick frozen tissue sections. The efficiency 

of the marking and the quantization of the probe was 

performed by direct evaluation by Dot Blot. 

Results. Preliminary results show a successful hybridization both 

on LnCaP cells and on prostate frozen sections. 

PCA3 and Beta Actin Antisense Probe show a diffuse cytoplasmic 

signals while PCA3 and Beta Actin sense probe don’t show any 

signals. The use of PCA3 on histological samples could permit the 

applications on routine samples in order to identify critical lesions of 

ambiguous interpretation, such as atypical small acinar proliferation. 

Extraprostatic infiltration and vascular invasion in 

prostate cancer: evaluation by proteomic analysis 

S. Bergamini1 , L. Reggiani Bonetti2 , E. Monari1 , E. Bellei1 , 

A. Maiorana2 , T. Ozben3 , A. Tomasi1 1 Department of Laboratories, Pathologic Anatomy and Legal Medicine, 

Section of Toxicology and Clinical Pharmacology and 2 Section of Pathologic 

Anatomy, Medical Faculty, University Hospital of Modena and Reggio 

Emilia, Modena, Italy; 3 Department of Biochemistry, Medical Faculty, 

Akdeniz University, Antalya, Turkey 


Background. Prostate adenocarcinoma (PCa) is one of the 

tumors showed an increased risk, which is still growing, in the 

male population. Of this cancer are known more or less aggressive 

forms that can be distinguished: organ confined PCa (tumor 

confined within the gland), locally advanced PCa (cancer that 

invades beyond the capsule and surrounding structures), metastatic 

PCa (tumor spreading distance generating metastases). The 

main mechanisms through which occurs the progression of the 

disease are extraprostatic infiltration (EPI) and lymph-vascular 

invasion (LVI). EPI occurs when the PCa infiltrates and exceeds 

the prostatic capsule and spreads to the extra-prostatic nervous 

structures, periprostatic soft tissue or seminal vesicles. The LVI 

occurs when cancer cells penetrate into the blood and lymphatic 

systems and reach locations generally distant from the primary 

tumor, in which generate the metastasis. 

Material and methods. In our study, proteomic analysis was 

performed using Surface Enhanced Laser Desorption/Ionization 

– Time of Flight – Mass Spectrometry (SELDI-ToF-MS) technology, 

which allowed us to detect differences in serum protein 

expression between the less aggressive forms of PCa (PCa organ 

confined) and the more aggressive (PCa locally advanced), 

studying in particular the EPI and the LVI. The SELDI-ToF- 

MS is an innovative technology derived from a combination of 

MS with the ProteinChip technology. The ProteinChip are thin 

strips of aluminum with 8 small wells on which is deposited serumsample. 

There are several types of ProteinChip which differ 

in the physico-chemical characteristics of their chromatographic 

surface and therefore for the ability to bind proteins with different 

characteristics. 

Results. The SELDI-ToF-MS analysis of serum profiles revealed 

peaks differentially expressed in PCa with LVI and PCa with EPI 

respected to PCa without ILV and PCa without IEP. Were also 

detected peaks closely related to the Gleason grade. 

Conclusions. Our study is a preliminary SELDI-ToF-MS analysis 

that need to confirm its results through a larger number of 

patients. Additionally will be very important to identify the differentially 

expressed peaks that may be useful serum biomarkers 

to detect, at the time of diagnosis, the presence of ILV and IEP, 

to define the aggressiveness of the tumor, the prognosis and the 

most appropriate treatment. 

Mixed adeno-neuroendocrine carcinoma (MAnEC) 

of the urinary bladder: a case report 

V. Bertolini1 , G. D’Ambrosio1 , P. Consonni2 , S. La Rosa3 , 

F. Sessa1,4 1 2 Dipartimento di Anatomia Patologica, Multimedica, Milano; Divisione 

di Urologia, Multimedica; 3 UO Anatomia Patologica, Ospedale di Circolo, 

Varese; 4 Dipartimento di Scienze Chirurgiche e Morfologiche, Università 

dell’Insubria, Varese. 

Introduction. Primary adenocarcinoma (AC) of the urinary 

bladder is an uncommon neoplasm accounting for 1-2 % of all 

malignant vesical tumours occurring more commonly in males. 

AC of the bladder could show different histologic patterns: enteric 

(colonic), mucinous, signet ring cell, clear cell, hepatoid and 

adenocarcinoma not otherwise specified. The enteric type closely 

resembles adenocarcinoma of the colon 1-3 . 

Neuroendocrine (NE) cells are uncommon in primary AC of the 

bladder, with only few studies concerning its biologic significance 

4-6 . In a series of 16 primary bladder AC by Bollito et al, 

60 % of cases showed NE cells 4 . 

Materials and methods. We report a case of primary AC of the 

bladder with a component of NE differentiation fulfilling the criteria 

of WHO 2010 for MANEC 7 . In addition, for comparison, 

we investigated 6 primary bladder enteric type AC. 

Results. A 42-year old male presented with gross haematuria 

and disuria for 2 months. CT scan revealed a 4.5 cm mass arising 

from the dome and projecting into the lumen of the bladder.

PoStER 

Fig. 1. EE primary intestinal adenocarcinoma of the bladder: glandular 

component (a), solid areas (B) (Original magnification 10x) 

A B 

Fig. 2. iHC in primary intestinal adenocarcinoma of the bladder for 

CdX2 (a) (Original magnification 10x), Chromogranin a(B) (Original 

Magnification 20x). 

A B 

First a cystoscopy with transurethral resection was carried out. 

Histopathological examination revealed an adenocarcinoma with 

enteric differentiation. So the The patient underwent partial cystectomy 

with pelvic lymphoadenectomy Even the surgical specimen 

showed an adenocarcinoma of enteric type, with predominantly 

well formed mucinous glands, a signet ring cell component 

(10%) and solid areas (30%). The tumor infiltrated the bladder 

wall, with diffuse lymphatic invasion but metastases was present 

in only one pelvic lymph node. Both the biopsy and the specimen 

showed the same overlapping immunohistochemical profile 

(IHC): a diffuse intense positivity CDX2 and MUC2 and CK20 

in the mucinous component; cytoplasmic positivity for chromogranin 

A in about 30 % of tumour cells in the solid areas. Any 

stained cell was observed for CK7. The surrounding bladder mucosa 

was unremarkable, with no evidence of in situ carcinoma or 

cystitis glandularis In addition, no urachal remnants or urothelial 

tumoural elements were identified even on extensive sampling of 

the tumor. The final diagnosis was primary intestinal type mixed 

adeno-neuroendocrine carcinoma of the urinary bladder. 

The same IHC panel was performed on all cases of vesical intestinal 

adenocarcinoma. While CK20 and MUC2 showed an 

analogous expression; chromogranin stained few scattered cells 

in only 1 out of 6 cases. 

Conclusions. NE tumours are extremely rare and are generally 

small or large cells type 8 9 . Endocrine cells could possibly be 

present in an adenocarcinoma of the bladder but they are preferentially 

sparse not grouped or clustered togheter. This pattern 

reflects the gastrointestinal counterpart where few endocrine cells 

are found in up to 41% cases. The presence of a conspicuous 

component of endocrine cells (at least 30%) shift the diagnosis 

towards a mixed adeno-neuroendocrine carcinoma. This is the 

first description, of our knowledge, of an adenocarcinoma with a 

endocrine differentiation. 

references 

1 Bostwick DG, Cheng L. Neoplasm of the urinary bladder. In: Urologic 

Surgical Pathology 2 nd ed. Philadelphia, PA: Mosby 2008, pp. 300-7. 

2 Somak R, Parwani AV. Adenocarcinoma of the urinary bladder. Arch 

Pathol Lab Med 2011;135:1601-5. 

3 Shanks JS, Iczkowski KA. Divergent differentiation in urothelial carcinoma 

and other bladder subtypes with selected mimics. Histopathology 

2009;54:885-900. 

4 Bollito ER, Pacchioni D, Lopez-Beltran A. Immunohistochemical 

415 

study of neuroendocrine differentiation in primary glandular lesions 

and tumors of the urinary bladder. Anal Quant Cytol Histol 

2005;27:218-24. 

5 Abenoza P, Manival C, Sibley RK. Adenocarcinoma with neuroendocrine 

differentiation of the urinary bladder. Clinicopathologic, immunohistochemical, 

and ultrastructural study. Arch Pathol Lab Med 

1986;110:1062-6. 

6 Hom JD, King EB, Fraenkel R. Adenocarcinoma with a neuroendocrine 

component arising in the Urachus. A case report. Acta Cytologica 

1990;34:269-74. 

7 th WHO Classification of Tumours of the Digestive System 4 ed. Lyon: 

IARC 2010. 

8 Abrahams NA, Moran C, Reyes AO. Small cell carcinoma of the 

bladder: a contemporary clinicopathological study of 51 cases. Histopathology 

2005;46:57-63. 

9 Cheng L, Pan CX, Yang XJ. Small cell carcinoma of the bladder: a 

clinicopathologic analysis of 64 patients. Cancer 2004;101:957-62. 

Prognostic role of the receptor tyrosine kinase AXL 

and its ligand Gas6 in renal cell carcinoma 

F. Collina, L. Cindolo, L. La Sala, G. Scognamiglio, G. Aquino, 

G. Gaudioso, C. D’Alterio, S. Scala, M. Cantile, R.M. Melillo, 


Background and aim. Renal Cell Carcinomas (RCC) is characterized 

by a complex molecular biology, a variable course and an 

unpredictable behavior. The only curative treatment of RCC is 

surgery and in cases of metastatic RCC, are performed systemic 

therapies such as immunotherapy (IFNα or IL-2). Since 2005, a 

series of tyrosine kinase inhibitors have been approved by the 

FDA for the treatment of advanced stage RCC. 

The Axl proto-oncogene is a receptor tyrosine kinase member of 

TAM receptors family. Some reports indicated that Axl and its 

ligand growth arrest-specific gene-6 (Gas6) might be involved in 

tumor progression of several human cancers. In fact, recently, it 

has been shown that aberrant expression of Axl and Gas6 mRNA 

are strongly correlated with the outcome of patients. 

Little information is available in the literature on the role of AXL 

and Gas6 in RCC, for this reason the aim of our work was to evaluate 

the expression of these markers on a series of 156 RCC samples, 

included in a prognostic TMA, and evaluate their potential association 

to clinicopathological features and outcome of patients. 

Methods. We used microarray technology comprising 156 renal 

cell carcinoma. Axl and Gas6 expression were valued by immunohistochemistry 

using monoclonal antibodies. 

Results and conclusions. Preliminary results show that Axl 

protein expression correlates with the Furhman grade (p value 

= 0.03), histological subtype (p value = 0.04) and disease 

progression (p value = 0.008). Moreover, there is a trend of statistical 

association with tumor size (p value = 0.07) and with Gas6 

expression (p value = 0.078). Our data suggest that Axl might be 

used as a valid prognostic factor in RCC. 

Tubulocystic carcinoma of the kidney: case report 

of a rare subtype of renal cell carcinoma 

A. Ginori1 , D. Tacchini1 , L. Vassallo1 , M.G. Mastrogiulio1 , 

A. Barone1 , M.A.G.M. Butorano1 , S.F. Carbone2 , S. Tripodi1 1 Department of Human Pathology and Oncology, Pathological Anatomy 

Section, University of Siena, Siena, Italy; 2 Department of Radiology, University 

of Siena, Siena, Italy 

Background. A distinctive tumor once described under the term 

low-grade collecting duct carcinoma has recently been classified 

as tubulocystic renal cell carcinoma (TC-RCC). This subtype of 

renal cell carcinoma is not recognized in the World Health Organization 

2004 classification. The tumor occurred in adults (mean 

age, 54 years) with a strong male predominance (7:1). TC-RCC 

is asymptomatic with low potential for metastasis. Up to now, 

less than 60 cases of TC-RCC have been reported in literature.

416 

Herein, we describe a case of this rare tumor of the kidney in a 

47-year-old man. 

Materials and methods. A 47-year-old man presented with 

hematuria. Cytologic examination was negative. Abdominal 

ultrasonography showed a hyperechoic lesion of the left kidney. 

Positron emission tomography, resulted in a very low 18F-fluorodeoxyglucose 

uptake. MRI examination showed a predominant 

medullary localization. The high apparent diffusion coefficient 

and the progressive slow enhancement of inner septa were considered 

diagnostic for a type III cystic lesion according to the 

Bosniak classification and the patient was submitted to surgery. 

A radical nephrectomy was performed. 

Results. Gross examination showed a well circumscribed (2 cm 

in its greatest dimension) nodule in the middle pole of the kidney, 

protruding in the renal sinus with a spongy appearance due to the 

presence of multiple small cysts containing clear serous fluid. 

Microscopically, the tumor had the typical histology and immunophenotype 

of a TC-RCC. It was composed of cysts and small 

tubules lined by flat to columnar eosinophilic cells with round 

regular nuclei and prominent nucleoli. In some areas, an “hobnail” 

appearance was evident. The stroma was thin and fibrotic. 

Immunohistochemistry showed diffuse and strong positivity for 

CD10 and racemase, zonal positivity for CK7 and negativity for 

HMW-CK. Fuhrman nuclear grade was 3 and the WHO staging 

was T1a. 

Conclusions. Tubulocystic carcinoma of the kidney is a rare 

subtype of renal cell carcinoma. In light of its distinctive clinicopathologic 

features and a low but definite metastatic potential, 

this unique subtype of renal cell carcinoma deserves formal recognition 

in the contemporary classification of renal neoplasms. 

references 

1 Amin MB, MacLennan GT, Paraf F, et al. Tubulocystic carcinoma of 

the kidney: clinicopathologic analysis of 29 cases of a distinctive rare 

subtype of renal carcinoma. Mod Pathol 2004;(supp. l):137A. 

2 Amin B, MacLennan GT, Gupta R, et al. Tubulocystic carcinoma of 

the kidney: clinicopathologic analysis of 31 cases of a distinctive rare 

subtype of renal cell carcinoma. Am J Surg Pathol 2009;33:384-92. 

3 MacLennan GT, Cheng L. Tubulocystic carcinoma of the kidney. J 

Urol 2011;185:2348-9. 

4 Azoulay S, Vieillefond A, Paraf F, et al. Tubulocystic carcinoma 

of the kidney: a new entity among renal tumors. Virchows Arch 

2007;451:905-9. 

Bladder metastasis from male breast cancer: 

a rare case report 

A. Labate1 , E. Mazzon3 , G. Certo1 , P. Lo Verde1 , A. Dominici2 1 2 Unità Operativa di Anatomia Patologica; Unità Operativa di Urologia, 

Clinica Cappellani, Giomi, Messina; 3 IRCCS Centro Neurolesi Bonino 

Pulejo Messina 

Abstract. Breast carcinoma is the most common cancer diagnosis 

in women. 

Common metastatic sites include lymph nodes, lung, liver, and 

bone. Metastases to the bladder are exceedingly rare. 

Male breast cancer is extremely rare epithelial tumor representing 

less than 0,8% of all breast cancer, and less than 1% of all cancer 

deaths in man. 

We present a case of metastatic male breast carcinoma to the 

bladder. 

Pazient and methods. Patient of 75 years old already submitted 

in 2005 to radical mastectomy of the right breast with 

axillary lymph node dissection for invasive ductal carcinoma 

(G2 - pT1N3(24/24)M0), and to the following therapeutic 

protocols(FAC- RT 50 Gy and Tamoxifen). We present bilateral 

lung and bones metastasis after four years Following second line 

treatment with exemestane. And than continues with aromasin 

and femara. Six month after presence of suspicious areas of the 

brain. 


The last abdominal computed tomography (TC- 2011) revealed 

diffuse wall thickening of right profile in the blader dome (mm16/ 

contrast impregnation), lynphadenopathy, and right adrenal node 

of 2 cm. Follow third line chemioterapy with liposomal doxorubucina. 

Occult blood was noted in the microscopic examination of the 

urine and oligouria and then anuria occurred. Urine cytology 

was negative for malignant cells. Urethrocystoscopy discovered 

some irregular mucosa in the posterior wall and multiple nodular 

lesions in the bladder 

Under the impression of transitional cell carcinoma or metastases 

from the breast carcinoma, transurethral bladder biopsies were 

performed. 

Histological and immunohistochemical analysis 

The specimens were fixed in 10% buffed formalin, processed in 

the usual manner, and paraffin embedded. Parraffin sections were 

stained with hematoxilyn and eosin for histological evaluation. 

For immunohistochemical studies, section were incubated 

with anti EstrR, anti ProgR and anti Her2-Neu polyclonal 

antibody(DaKo). 

Following incubation with avidin-biotin-peroxidase (envision 

method DaKo); the reaction was detected with 3,3’- diaminobenzidine 

(DaKo). 

The pathological analysis of the bladder tumor demonstrated 

invasive carcinoma of the urinary bladder with moderately to 

poorly differentiated tumoral cells arranged in solid nests and 

whit adenoid pattern,, involving the stroma the lamina propria 

and muscle of the urinary bladder (G3- pT2 - hematoxylin and 

eosin stain) 

The immunohistochemical studies disclosed positive reaction for 

ER (55%), positive for PR (40%) negative/ blande positive reactione 

HER-2/neu/(1+) intense positive reaction for ki67 (45-50%) 

and Ck7 are positive. 

These pathological features were consistent with metastatic invasive 

ductal carcinoma of the breast. 

Discussions. Carcinoma of the breast occurs so infrequently in 

men. 

Urinary bladder is an uncommon site of breast carcinoma metastasis. 

Although breast cancer with bladder metastasis was occasionally 

reported in the literature Most are discovered during autopsy 

reports. 

ER and PR positive tumors respond to hormone therapy and are 

predicted to have a higher disease-free survival than patients with 

ER-negative tumors. 

The expression of ER and PR in the metastatic bladder tumor was 

expected to be like the primary breast tumor. (immunostaging on 

primary lesions: Er -Pr > 90%; Ki 67> 20%; ErB2 neg) 

Metastasis usually occurred many years after diagnosis, and 

the prognosis was poor. Modality for diagnosis in all cases was 

cystoscopy, confirmed on biopsy. The most common histological 

type of bladder cancer is urothelial carcinoma (95%) and metastases 

in most cases are from colonic and prostate carcinoma 

(20%) From breast cancer are < 2%. 

We submitted this case for a double unusualness 

references 

1 Urology 2002;59:138. 

2 Journal of Clinical Oncology 2007;35:4308-10. 

3 WHO Tumours of the urinary System and male genital organs 2002. 

Primary bladder angiosarcoma: case report 

E. Pacella1 , I. Carlo2 , L. Abete1 , S. Bruno1 , G. Anselmi1 , M. Mora1 , 

B. Spina1 1 University of Genoa, Histopathology, DISC, Azienda Ospedaliera ed 

Universitaria San Martino-IRCCS-IST, Genoa, Italy; 2 Urology Unit, Department 

of Surgical Oncology, National Institute for Cancer Research- 

Genoa, Italy

PoStER 

Introduction. Angiosarcoma is a rare vascular neoplasm that 

occurs in adults and most of these are found in the head and neck 

region, or in the extremities. Visceral involvement is much rarer. 

Predisposing factors that are thought to contribute to the development 

of angiosarcoma include ionizing radiation 1 and chemical 

agents, such as vinyl chloride 2 . The association of angiosarcoma 

with therapeutic radiation has been previously described 3 . Nonurothelial 

tumors of the bladder account for less than 5% of all 

bladder tumors in the U.S. 4 . 

Sarcoma represents the most common mesenchymal tumor of the 

bladder and generally shares an extremely aggressive biologic 

behavior. Hematuria is the most common presentation. Other reported 

symptoms include flank or groin pain and dysuria 5-7 . The 

disease has often extended locally outside the confines of the bladder 

or has metastasized at the time of presentation. Lung and liver 

are frequent sites of metastases; lymphatic spread is observed less 

often 5 . Angiosarcoma originating in the bladder reportedly has a 

worse prognosis than for similar tumors arising at other sites 8 5 . 

The first case of bladder angiosarcoma was described in 1907 by 

Jungano 9 ; Thirteen case reports of angiosarcoma of the bladder 

were found in a MEDLINE search; of these cases only 4 patients 

presented with primary bladder lesions and no preexisting disease 

or previous carcinogenic exposure (except for tobacco use). We 

report a case of primary angiosarcoma of the bladder. 

Materials and methods. A 67-year-old, white female, with 

gross hematuria. Biopsy performed by endoscopic transurethral 

resection revealed an infiltrative high grade papillary urothelial 

carcinoma. After one month the patient was operated with radical 

cystectomy. The pathological examination revealed a voluminous 

and extensively necrotic mass with mucosal ulceration. The lesion 

involved the bladder wall and invaded the perivesical soft tissue 

until to the margin of resection. The patient recovered from surgery, 

and was referred for adjuvant chemotherapy and radiation 

therapy. A PET scan performed about 2 months later revealed a 

lung nodule and a framework refers to a pelvic recurrence. 

Results. Histologically, angiosarcoma of the bladder is composed 

of anastomosing vascular channels lined by atypical 

endothelial cells, often with overlying surface ulceration and 

inflammation and typically infiltrating detrusor muscle. The 

poorly differentiated endothelial cells often are pleomorphic with 

large hyperchromatic nuclei, prominent nucleoli, and frequent 

mitotic figures. The malignant cells lining the vascular spaces 

may exhibit a “hobnail” appearance. There is often little or no 

intervening stroma. Vascular channels range in size from small 

capillaries to sinusoidal spaces. A solid growth pattern consisting 

of monomorphic cells with vesicular chromatin and moderate 

amounts of eosinophilic cytoplasm arranged in sheets and nests 

has been described in some cases, and some tumors have exhibited 

epithelioid features 5-7 and 10 . In our case the tumor showed 

predominantly solid structure with papillary areas; the solid areas 

are characterized by epitheliomorphous or spindle medium-sized 

cells, so the first diagnosis on biopsy was to high-grade urothelial 

carcinoma, with papillary aspects. In some areas was evident a 

proliferation of most probably vascular structures anastomosed 

together and lined by atypical elements with prominent “hobnail” 

nucleus. 

There was no evidence of urothelial in situ carcinoma or adjacent 

to or distant from the tumor. Immunohistochemically, angiosarcoma 

stains positively for vimentin, CD31, and CD34 and shows 

variable immunoreactivity for factor VIII–related antigen 6-8 11 . 

The only reported epithelioid angiosarcoma of the bladder 

showed negative immunostaining for keratin AE1/AE3, although 

epithelioid angiosarcoma at other sites may stain positively for 

cytokeratin 86 . In our case the neoplastic elements were positive 

for immunohistochemical staining for vimentin, CD34 and CD31 

and negative for keratin AE1/AE3, MNF116 and cytokeratin 7, 

20 and 34bE12. Moreover, they were negative for pS100, p63, 

Desmin and CD45. 

417 

Conclusions. In considering the diagnosis of a radiation-induced 

sarcoma, Cahan et al. suggested the following criteria: the sarcoma 

should arise in the area previously subjected to irradiation; 

a latent period (at least 7 years) must exist between the time of 

irradiation and development of the sarcoma; the sarcoma must 

be confirmed histologically 18 . The differential diagnosis for angiosarcoma 

of the bladder is hemangioma, which is usually small 

and lacks cytologic atypia, interanastomosing channels, and solid 

areas 8 . Kaposi sarcoma may be seen in the urinary bladder, especially 

in immunocompromised patients. High-grade urothelial 

carcinoma must also be considered in the differential; in such 

tumors, a focus of obvious in situ or invasive carcinoma may be 

present, and tumor cells demonstrate positive immunoreactivity 

for cytokeratin antibodies and lack reactivity for endothelial 

markers such as CD31 and CD34 8 . Immunohistochemical stains 

are often crucial to confirming the diagnosis of angiosarcoma. For 

the distinction between a carcinoma and angiosarcoma, a single 

immunohistochemical stain may not be sufficient to confirm the 

diagnosis. Although no bladder angiosarcomas has been reported 

to have cytokeratin reactivity to date 6 12-14 , up to one third of 

angiosarcomas overall may have cytokeratin reactivity, including 

those without Epithelioid histology 15 16 . While some authors advocate 

CD31 as the most sensitive and specific marker for angiosarcoma, 

staining almost of angiosarcomas in their experience 17 , 

Meis-Kindblom and Kindblom 16 suggest that Factor VIII-related 

antigen (Von Willebrand factor) is the most sensitive marker in 

soft tissue angiosarcomas. Because of conflicting literature and 

variability among immunohistochemistry laboratories, more than 

one endothelial marker may be necessary to support the diagnosis 

of angiosarcoma in a site such as the bladder where the entity is 

rare. Our case, therefore, falls within the group of primitive angiosarcomas 

of the bladder in patients who have not been subjected 

to therapeutic radiation or other recognized risk factors. 

references 

1 Yap J, Chuba PJ, Thomas R, et al. Sarcoma as a second malignancy 

after treatment for breast cancer. Int . Radiat Oncol Biol Phys 

2002;52:1231-7. 

2 Hozo I, Miric D, Bojic L. Liver angiosarcoma and hemangiopericytoma 

after occupational exposure to vinyl chloride monomer. Environ 

Health Perspect 2000;108;793-5. 

3 Nanus DM, Kelsen D, Clark DG. Radiation-induced angiosarcoma. 

Cancer 1987;60:777-9; Navon JD, Rahimzadeh M, Wong AK, et al. 

Angiosarcoma of the bladder after therapeutic irradiation for prostate 

cancer. J Urol 1997;157:1359-60. 

4 Dahm P, Schwend JE. Malignant non-urothelial neoplasms of the 

urinary bladder: a review. Eur Urol 2003;44:672-81. 

5 Engel JD, Kuzel TM, Moceanu MC, et al. Angiosarcoma of the bladder: 

a review. Urology 1998;52:778-84. 

6 Schindler S, De Frias DV, Yu GH. Primary angiosarcoma of the 

bladder: cytomorphology and differential diagnosis. Cytopathology 

1999;10:137-43. 

7 Stroup RM, Chang YC. Angiosarcoma of the bladder: a case report. J 

Urol 1987;137:984-5. 

8 Eble JN, Sauter G, Epstein JI, et al. World Health Organization classification 

of tumours: pathology and genetics of tumours of the urinary 

system and male genital organs. Lyon: IARC Press 2004. 

9 Jungano F. Sur un cas d’angio-sarcome de la vessie. Annales des 

maladies des organs genitourinary 1907;25:1451-61. 

10 Ravi R. Primary angiosarcoma of the urinary bladder. Arch Esp Urol 

1993;46:351-3. 

11 Morgan MA, Moutos DM, Pippitt CH Jr, et al. Vaginal and 

bladder angiosarcoma after therapeutic irradiation. South Med J 

1989;82:1434-6. 

12 Aragona F, Ostardo E, Prayer-Galetti T, et al. Angiosarcoma of the 

bladder; a case report with regard to histologic and immunohistochemical 

findings. Eur Urol 1991;20:161-3. 

13 Navon JD, Rahimzadeh M, Wong AK, et al. Angiosarcoma of the 

bladder after therapeutic irradiation for prostate cancer. J Urol 

1997:157;1359-60. 

14 Stroup RM, Chang YC. Angiosarcoma of the bladder: a case report. J 

Urol 1987;137:984-5.

418 

15 Weiss SW, Goldblum JR. Malignant vascular tumor. In: Weiss SW, 

Goldblum JR, eds. Enzinger and Weiss’s Soft Tissue Tumors. 4 th ed. 

St. Louis, Mo: The CV Mosby Co 2001. pp. 917-54 

16 Meis-Kindblom JM, Kindblom LG. Angiosarcoma of soft tissue: a 

study of 80 cases. Am J Surg Pathol 1998;22:683-97. 

17 Cerilli LA, Wick MR. Immunohistology of soft tissue and osseous 

neoplasms. In: Dabbs DJ, ed. Diagnostic immunohistochemistry. 

Philadelphia, Pa: Churchill Livingstone 2002, pp. 59-112. 

18 Cahan WG, Woodard HQ, Higinbotham NL, et al. Sarcoma arising in 

irradiated 1948. 

Single pancreatic metastasis from renal cell 

carcinoma: a case report 

E. Pacella1 , C. Di Somma2 , S. Boccardo3 , A. Calabrese3 , B. Spina3 1 University of Genoa, Histopathology, DISC, Azienda Ospedaliera ed 

Universitaria San Martino-IRCCS-IST, Genoa, Italy; 2 Department of 

Surgery, Azienda Ospedaliera ed Universitaria San Martino-IRCCS-IST, 

Genoa, Italy; 3 Unit of Histopathology and Cytopathology Azienda Ospedaliera 

ed Universitaria San Martino-IRCCS-IST, Genoa, Italy 

Introduction. The most common sites of RCC metastases are 

lungs, lymph nodes, bone, liver, brain, ipsilateral adrenal gland, 

contralateral kidney, and pancreas 1 . 

Pancreatic metastases are rare, with a reported incidence varying 

from 1.6% to 11% in autopsy studies of patients with advanced 

malignancy. 

Of the primary tumors that can metastasize to the pancreas, renal 

cell carcinoma (RCC) is the most common, followed by lung 

cancer, breast cancer, colon cancer, and melanoma 2 3 . 

Most cases of RCC metastasis to the pancreas present as metachronous 

lesions, often many years after resection of the primary 

tumor. The average time to presentation for pancreatic metastasis 

from RCC is 9.2 years after the initial resection 7 . Autopsy 

data have shown that 2% of patients with RCC have pancreatic 

metastases at the time of their death 8 . 

Although metastasis to the pancreas is most commonly associated 

with disseminated systemic disease 4 5 , RCC typically spreads to 

the pancreas as an isolated lesion. However, in many cases single 

pancreatic metastases only seems to anticipate the onset of multiple 

metastatic spread, even after many years 6 . 

69% of patients with isolated pancreatic metastasis were completely 

asymptomatic at presentation. 

Patients may be completely asymptomatic, or they may develop 

symptoms of epigastric abdominal pain or acute pancreatitis 

secondary to pancreatic ductal obstruction from the metastatic 

lesion. 

Metastases to the pancreas are typically identified in different 

ways: during the initial staging work-up for treatment of 

the primary tumor; trough routine follow-up imaging after the 

primary tumor has been treated; or the patient initially presents 

symptoms related to the pancreatic lesion: however the early 

signs and symptoms of isolated pancreatic metastases are often 

non-specific. 

The diagnosis of pancreatic metastasis is usually made on radiological 

or endoscopic criteria, since most patients do not present 

related symptoms: through imaging techniques, RCC metastatic 

disease to the pancreas can often be distinguished from pancreatic 

ductal adenocarcinoma. Metastases to the pancreas can be multicentric 

and typically do not cause peripancreatic lymphadenopathy; 

these findings can be used to distinguish metastases from 

pancreatic ductal adenocarcinoma. 

Pancreatic metastases do not appear to show a predilection for 

a particular part of the pancreas 9 10 . Three types of metastatic 

involvement of the pancreas have been described in the literature. 

The most common type of all metastases and in particular of 

RCC metastases, reported in 50%-73% of cases, is that of a solitary, 

localized, well-defined mass. A second pattern of multiple 

pancreatic lesions has been reported in 5%-10% of cases, and a 


third pattern of diffuse metastatic infiltration causing generalized 

enlargement of the organ in 15%-44% of cases 11-14 . 

Since the ‘RCC typically extends to the pancreas as an isolated 

lesion, it is often susceptible to surgical treatment 17 and surgical 

resection of metastatic disease is appropriate in certain clinical 

scenarios, depending on the virulence of the primary tumor, the 

extent of metastatic disease, and the functional status of the patient. 

The specific type of surgical resection will depend on the 

location of the tumor within the pancreas. 

Standardized pancreatic resection adapted to the location of 

the tumor, in terms of partial pancreaticoduodenectomy, distal 

pancreatectomy, and total pancreatectomy, is generally recommended 

for the management of isolated pancreatic metastases. 

Five-year survival rates after surgical resection of RCC metastasis 

to the pancreas are 53-75%, whereas patients who choose not 

to undergo surgical resection or who have widely disseminated 

disease have a 5-year survival rate of 5-30% 7 15 16 . 

Materials and methods. We present the case of 58 years old 

woman subject to nephrectomy for cancer of the left kidney; 

the lesion was analyzed at our Unit of Histopathology and 

Cytopathology San Martino-IRCCS-IST of Genoa, and was 

diagnosed as renal cell carcinoma, clear cell type. Two years 

later, a single pancreatic metastasis is diagnosed by imaging 

techniques and the patient is submitted to resection of the tail 

of the pancreas. To macroscopic examination the lesion correspondig 

to a yellowish nodule of 2.8 cm, well circumscribed 

(“pushing” borders), with focal hemorrhage, necrosis and 

cystic degeneration. 

Results. Microscopically the lesion was composed of compact 

and alveolar growth of large polygonal cells with clear cytoplasm, 

distinct but delicate cell boundaries, uniform round nuclei 

and inconspicuous nucleoli. Hhistomorphological characteristics 

of the kidney cancer and pancreatic lesion were compared and 

found to be equal. The diagnosis of metastatic RCC was confirmed 

by histopathological analysis: the neoplastic cells were 

positive for immunohistochemical staining for CD10 and RCC, 

confirming the morphological findings. 

CD10, 20X EE, 10X EE, 2X RCC, 20X 

Conclusions. When metastasis to the pancreas occurs, it is most 

commonly associated with widespread disease dissemination. 

RCC is the most common primary tumor to present with isolated 

solid metastasis to the pancreas, often making it susceptible to 

surgical treatment. 

However, in many cases single pancreatic metastases only seems 

to anticipate the onset of multiple metastatic spread, even after 

many years. 

Five years survival rates after surgical resection of RCC metastases 

to the pancreas are better than those of patients who choose 

not to undergo surgical resection or who have widespread disease. 

references 

1 Ritchie AW, Chisholm GD. The natural history of renal carcinoma. 

Semin Oncol 1983;10:390-400. 

2 Minni F, Casadei R, Perenze B, et al. Pancreatic metastases: observations 

of three cases and review of the literature. Pancreatology 

2004;4:509-20. 

3 Moussa A, Mitry E, Hammel P, et al. Pancreatic metastases: a multicentric 

study of 22 patients. Gastroenterol Clin Biol 2004;28:872-6. 

4 Thadani A, Pais S, Savino J. Metastasis of renal cell carcinoma to 

the pancreas 13 years postnephrectomy. Gastroenterol Hepatol (NY) 

2011;7:697-9. 

5 Rumancik WM, Megibow AJ, Bosniak MA, et al. Metastatic disease 

to the pancreas: evaluation by computed tomography. J Comput Assist 

Tomogr 1984;8:829-34. 

6 Kassabian A, Stein J, Jabbour N, et al. Renal cell carcinoma metastatic 

to the pancreas: a single-institution series and review of the literature. 

7 Showalter SL, Hager E, Yeo CJ. Metastatic disease to the pancreas 

and spleen. Semin Oncol 2008;35:160-71. 

8 Bennington JL. Proceedings: cancer of the kidney—etiology, epidemiology, 

and pathology. Cancer 1973;32:1017-29.

PoStER 

9 Klein KA, Stephens DH, Welch TJ. CT characteristics of metastatic 

disease of the pancreas. Radiographics 1998;18:369-78. 

10 Ng CS, Loyer EM, Iyer RB, et al. Metastases to the pancreas from 

renal cell carcinoma: findings on three-phase contrast-enhanced helical 

CT. AJR Am J Roentgenol 1999;172:1555-9. 

11 Ascenti G, Visalli C, Genitori A, et al. Multiple hypervascular pancreatic 

metastases from renal cell carcinoma: dynamic MR and spiral CT 

in three cases. Clin Imaging 2004;28:349-52. 

12 Scatarige JC, Horton KM, Sheth S, et al. Pancreatic parenchymal 

metastases: observations on helical CT. AJR Am J Roentgenol 

2001;176:695-9. 

13 Ferrozzi F, Bova D, Campodonico F, et al. Pancreatic metastases: CT 

assessment. Eur Radiol 1997;7:241-5. 

14 Muranaka T, Teshima K, Honda H, et al. Computed tomography and 

histologic appearance of pancreatic metastases from distant sources. 

Acta Radiol 1989;30:615-9. 

15 Kavolius JP, Mastorakos DP, Pavlovich C, et al. Resection of metastatic 

renal cell carcinoma. J Clin Oncol 1998;16:2261-6. 

16 Ritchie AW, deKernion JB. The natural history and clinical features 

of renal carcinoma. Semin Nephrol 1987;7:131-9. 

17 Law CH, Wei AC, Hanna SS, et al. Pancreatic resection for metastatic 

renal cell carcinoma: presentation, treatment and outcome. Ann Surg 

Oncol 2003;10:922-6. 

Mucinous tubular and spindle cell carcinoma 

(MTSCC) of the kidney: report of a case 

D. Tacchini, L. Vassallo, M.A.G.M. Butorano, S. Tripodi 



Background. Mucinous tubular and spindle cell carcinomas (MT- 

SCCs) of the kidney are rare epithelial neoplasms with a relatively 

good prognosis a long as they remain low-grade. We present a 

case of mucinous tubular and spindle cell carcinoma of the renal 

medullary in 80 year old woman. Literature was reviewed in order 

to investigate histological features for correct diagnosis. 

Methods. Biopsy samples were routinely processed and stained 

(HE). Morphological diagnosis was confirmed by immunohistochemistry 

(CKAE1/AE; CK7; Pas; Alcian-Pas; CD10; CD117; 

ASM1; Vimentina; HMB45; MELAN A; CK HMW; CK19; 

CK8; CK18; Colloidal Iron. Proliferative activity evaluated 

with Ki-67). 

Results. On gross examination, a well circumscribed nodule 

(2,5 cm in greatest axis) in the renal medullary was noted. Microscopic 

examination showed tightly packed, small, elongated 

tubules with a bland morphology and with transition to spindle 

cells component. In addition some tubules in non neoplastic 

parenchyma showed intraluminal calcifications. Unusual feature 

included foamy macrophages and clear cells immerged in 

a mucinous stroma. Mitoses were rare. High-grade areas were 

not demonstrated. Immunohistochemical analysis showed positive 

staining for epithelial membrane antigen (EMA) and CK7. 

Alcian blue staining revealed abundant mucin in the intervening 

fibrous stroma. Ki-67 index was low (< or = 5%). 

Conclusion. MTSCCs are rare kidney malignancies and are predominantly 

of low grade. Prognosis is relatively good. However, 

patients with high-grade tumours should undergo proper follow-up. 

A correct histological diagnosis is important to direct therapy. 

reference 

1 Grigore A, Toma L, Stoicea M, et al. Rare renal tumor--mucinous 

tubular and spindle cell carcinoma. Rom J Morphol Embryol 

2012;53:167-71. 

2 Song HJ, Ma J, Zhou HB, et al. Mucinous tubular and spindle cell 

carcinoma of kidney: a clinicopathological study. Zhonghua Bing Li 

Xue Za Zhi 2011;40:444-8. 

3 Sarsik B, Sımşır A, Karaarslan S, et al. Mucinous tubular and spindle 

cell carcinoma of kidney and problems in diagnosis. Turk Patoloji 

Derg 2011;27:116-26. 

4 Takagi K, Yamada Y, Uno M, Komeda H, Fujimoto Y. A case of 

mucinous tubular and spindle cell carcinoma of the kidney. Hinyokika 

Kiyo. 2010 Mar;56(3):159-62. 

419 

5 Yang G, Breyer BN, Weiss DA, MacLennan GT. Mucinous tubular 

and spindle cell carcinoma of the kidney. J Urol. 2010 Feb;183(2):738- 

9. Epub 2009 Dec 21. 

6 Yasufuku T, Shigemura K, Fujisawa M. Mucinous tubular and spindle 

cell carcinoma. Int J Urol 2009;16:425-6. 

Diagnostic utility of podoplanin (D2-40) expression 

in prostate gland and seminal vesicles 

L. Ventura1 , G.L. Gravina2 , F. Marampon2 , M. Capulli3 , C. Festuccia3 

, F. Liberati4 1 2 U. O. C. di Anatomia Patologica, Ospedale San Salvatore, L’Aquila; Divisione 

di Radioterapia e Radiobiologia, Dipartimento di Scienze Cliniche 

Applicate e Biotecnologie, Università, L’Aquila; 3 Dipartimento di Scienze 

Cliniche Applicate e Biotecnologie, Università, L’Aquila; 4 U. O. di Anatomia 

Patologica, Ospedale San Camillo De’ Lellis, Rieti, Italy 

Background. Podoplanin is a transmembrane mucoprotein strongly 

and selectively expressed by lymphatic endothelial cells 1 . The 

monoclonal antibody D2-40, directed against human podoplanin, 

has been proved to be useful in detecting lymphovascular invasion 

by neoplasms and in quantifying lymphatic vessel density in 

different tumors 1 . It represents an excellent marker of vascular 

neoplasms with lymphatic differentiation, mesothelial and germ 

cell tumors, but it results always negative in adenocarcinomas. 

Podoplanin expression was also demonstrated in various normal 

cells, such as osteocytes, chondrocytes, follicular dendritic cells, 

type I alveolar cells, myoepithelial cells of the breast 1 and basal 

cells in the prostate 2 3 (Tab. I). 

The aim of this study is to investigate the distribution and features 

of of D2-40 immunoreactivity in tissues from different prostatic 

specimens and its potential diagnostic utility. 

Material and methods. After routine diagnostic histopathology 

examination and reporting, significant paraffin blocks from 50 

selected patients, who underwent needle core biopsy (20 cases), 

trans-urethral resection (7 cases), simple prostatectomy (7 cases) 

and radical prostatectomy (16 cases), were cut to obtain additional 

slides immunostained with a monoclonal antibody directed 

against human podoplanin (clone D2-40, DAKO A/S, Glostrup, 

Denmark). The selected cases included tissues from the different 

zones of the gland and the main prostatic diseases, such as adenocarcinoma, 

PIN, prostatitis, adenosis, hyperplasia and glandular 

atrophy. 

Results. A strong cytoplasmic immunoreactivity of lymphatic 

endotelial cells was observed in all cases and used as an internal 

positive control. Prostatic basal cells were also constantly 

positive, but with a slightly less intensity than that observed in 

endothelial cells. A weak positive signal characterized perineurial 

and Schwann cells of the peripheral nerves, as well as ganglion 

cells within intra- and extraprostatic nervous ganglia. Smooth 

muscle fibers and stromal fibroblasts showed mild immunoreactivity. 

Basal cells of seminal vesicle epithelium showed moderate 

positivity, with a patchy pattern of expression (Tab. II). 

Blood vessels endothelium, normal and hyperplastic luminal 

cells, as well as PIN and adenocarcinoma cells were always 

negative. 

Conclusions. As a specific marker of lymphatic endothelium 1 , 

podoplanin has been used for detecting lymphovascular invasion 

and quantifying lymphatic vessels density in prostate carcinoma. 

Recent contributions underlined its utility as a basal cell marker, 

to avoid potential pitfalls in misinterpretation of lympatic invasion 

2 and in evaluating atypical small acinar proliferation 3 . 

Our results confirm the value of D2-40 in highlighting lympatics 

and basal cells, and its role as a negative marker of adenocarcinoma 

and other glandular lesions. The use of D2-40 in combination 

with other basal cell markers may be indicated in order to identify 

a wider spectrum of basal cells. 

The positivity of peripheral nerves and nervous ganglia may 

be useful in highlighting the invasion of these structures by ad-

420 

enocarcinoma cells and in distinguishing intraprostatic ganglion 

cells from neoplastic cells. The patchy positivity of basal cells in 

the seminal vesicle may be of help to detect portions of seminal 

vesicle that may be present in a core biopsy and to distinguish 

between normal epithelium of seminal vesicles and infiltration of 

the latter by adenocarcinoma glands in radical prostatectomies. 

In conclusion, D2-40 immunostaining in prostate specimens 

helps to identify different cells and structures and may be useful 

in routine diagnostics, particularly in the limited material available 

in core biopsies. 


references 

1 Kalof AN, Cooper K. D2-40 immunohistochemistry – so far! Adv 

Anat Pathol 2009;16:62-4. 

2 Kanner WA, Galgano MT, Atkins KA. Podoplanin expression in basal 

and myoepithelial cells: utility and potential pitfalls. Appl Immunohistochem 

Mol Morphol 2010;18:226-30. 

3 Kuroda N, Katto K, Tamura M, et al. Immunohistochemical application 

of D2-40 as basal cell marker in evaluating atypical small acinar 

proliferation of initial routine prostate needle biospy materials. Med 

Mol Morphol 2010;43:165-9.

Pathologica 2012;104:421-423 InDICE DEGLI AUTOrI 

Abbona G., 282 

Abete L., 367, 382, 389, 

402, 416 

Accurti V., 311 

Achille G., 363 

Adamo V., 397 

Addati T., 363, 398, 412 

Aguzzi I., 250 

Aiello A., 234 

Alberio M., 335 

Alberizzi P., 270 

Albertelli M., 327, 364 

Albertoni M., 388 

Albino G., 386 

Albolino S., 257 

Alessandrini L., 244, 334 

Alì G., 346, 339 

Allevi G., 335 

Altomare M., 326 

Ambrosio A., 304, 323 

Ambrosio M.F., 331 

Ambrosio M.R., 267, 268, 

289, 301, 304, 307, 308, 

323, 330, 344, 345, 349, 

356, 357 

Amidani M.M., 387 

Amodio G., 325 

Amoreo C.A., 337, 359, 

393, 395, 396 

Amorosi A., 289, 345 

Ampollini L., 342 

Amunni G., 314 

Andreis D., 335 

Anelli E., 263 

Angelini A., 238 

Angelucci D., 398 

Anghinolfi M., 344 

Annaratone L., 203 

Anniciello A.M., 410 

Annunziata F., 364 

Anselmi G., 416 

Antoniani B., 337, 393, 

395, 396 

Antonini D., 409 

Aprile G., 272, 302 

Aquino G., 359, 361, 414, 

415 

Arcangeli A., 283 

Arcuri F., 308, 356 

Argani P., 334 

Argentieri M.C., 291 

Arvigo M., 364 

Asselti M., 360, 399 

Azzolin D., 297 

Azzoni C., 291 

Bacchi C.E., 302 

Bacigalupo B., 347 

Balasus D., 375 

Ballotta M.R., 277, 336, 

373 

Barbagli L., 304, 331 

Barbano G., 332 

Barbareschi M., 219, 221 

Barbetti A., 262 

Barbolini G., 393 

Barone A., 268, 304, 330, 

331, 344, 349, 410, 415 

Barresi V., 275, 397 

Bartolommei S., 307, 308 

Basciu M., 278, 280, 305, 

309 

Basolo F., 283 

Basso C., 240 

Batisti C., 356 

Battaglia L., 289 

Battolla E., 347 

Bazzola L., 335 

Bellan C., 268, 349 

Bellandi T., 257 

Bellei E., 414 

Bellis D., 282, 409 

Bellomi A., 297 

Belluso E., 409 

Beltrami C.A., 302, 319 

Bennett D., 410 

Benvenuto A., 403 

Bergamini S., 414 

Berlingieri T., 262 

Bertamino M., 379 

Bertolini V., 414 

Bevilacqua L., 257 

Bianchi S., 229 

Bianchini E., 257 

Biggeri A., 257 

Blanco S., 278 

Bocca B., 367 

Boccardo S., 411, 418 

Bodini M., 335 

Boggi U., 283 

Boldrini L., 346 

Bondi A., 292, 293, 294, 

392 

Bondi C., 225 

Bonetti F., 334 

Bonin S., 269, 313 

Bono L., 331 

Borghi L., 277, 306 

Borra T., 327 

Borrelli N., 339 

Bortesi L., 373 

Borze I., 341 

Borzomati D., 283 

Bosisio F.M., 280, 298, 

305, 309, 350 

Bottarelli L., 291 

Botti C., 395 

Botti G., 359, 361, 395, 

410, 412, 414, 415 

Bottini P., 335 

Bottini R.A., 335 

Bottoni C., 325 

Bovo G., 278 

Branca G., 275, 397 

Bria E., 341, 393 

Brigati F., 342, 344 

Brisigotti M.P., 327, 364, 

369, 378, 400 

Brogi B., 373 

Brogi M., 330 

Brunelli F., 314 

Brunelli M., 248, 249, 334, 

341, 346 

Brunello E., 346 

Bruner J., 302 

Bruno A., 398, 399 

Bruno S., 209, 282, 327, 

369, 379, 382, 389, 416 

Bruzzone M., 369, 377, 

379, 400, 402 

Buccoliero A.M., 204, 250, 

276, 314, 322 

Bufo P., 357 

Bufo P., 360 

Buglioni S., 337 

Buglioni S., 396 

Burroughs A.K., 282 

Bussolati G., 203 

Bussu F., 358 

Butorano M.A.G.M., 304, 

323, 405, 410, 415, 419 

Buttitta F., 252 

Cabibi D., 373 

Cabiddu F., 402 

Caccavello F., 274 

Cadei M., 260 

Cafiero F., 400 

Cagiano S., 357 

Calabrese A., 418 

Calabrese G., 297 

Calabrò F., 341 

Calamaro P., 327, 372, 

377, 389, 400 

Calbi V., 267 

Calcagno A., 319 

Caldarella A., 314 

Caliò A., 341 

Callea F., 205 

Callea M., 283 

Calogero A.E., 326 

Calvisi G., 284, 285, 290, 

314, 329, 352 

Camilli G., 357 

Campani D., 283 

Campanini N., 291 

Camparo P., 334 

Canessa P.A., 347, 411 

Cantile M., 361, 395, 410, 

415 

Capella C., 234 

Capella S., 409 

Capelli P., 234 

Capodicasa V., 320 

Capodimonti S., 329 

Caponio M.A., 398, 412 

Caporalini C., 216 

Cappellesso R., 348 

Capulli M., 338, 419 

Carbone A., 344 

Carbone S.F., 415 

Cardia R., 397 

Cardone C., 323, 349 

Carducci A., 301 

Carlo I., 416 

Carta G., 311, 312 

Casagrande M., 302 

Casalini A., 344 

Casati S., 201 

Cascone A., 397 

Casini B., 337, 359 

Castaing M., 326 

Castellano I., 229 

Castelli P., 373, 384 

Castiglione F., 216, 250, 

252, 276, 286, 298, 

314, 322 

Cataliotti L., 228 

Cattoretti G., 278, 280, 

291, 298, 303, 309, 

350, 353 

Cavazza A., 217, 219, 221 

Cazzato M., 279 

Celiento T., 367, 369, 372, 

389, 402 

Cenci T., 329 

Centrone M., 363, 398 

Ceriolo P., 332, 379, 389, 

402 

Cernic S., 271, 272 

Cerrone M., 359, 410, 414 

Certo G., 373, 416 

Cesa Bianchi A., 289 

Cesari S., 270, 315 

Cesinaro A.M., 351 

Chella A., 346 

Chiacchio R., 403 

Chiaffi L., 347 

Chiarello G., 325 

Chilosi M., 217, 235, 248, 

334, 341, 346 

Chiominto A., 284 

Cicchinelli I., 285, 312, 

314 

Cimminiello M., 403 

Cindolo L., 415 

Cingarlini S., 341, 346 

Cipolletta Campanile A., 


Ciuffetelli V., 284, 290, 

313, 329, 352 

Coccia M.C., 332 

Cognein P., 377 

Cogo C., 300 

Coletti G., 279, 285, 290, 

311, 312, 314, 317, 329 

Collina F., 361, 395, 415 

Collini P., 208 

Colombari R., 300 

Comin C., 298 

Consonni P., 414 

Conti S., 395 

Coppola R., 283 

Corbinelli A., 314 

Corbo V., 252 

Corridore V., 352 

Cosci E., 356 

Costa A., 268 

Cremolini C., 286 

Crisafulli C., 397 

Crisman G., 269, 279, 

284, 285, 290, 299, 311, 

312, 313, 314, 317, 329, 

352, 353 

Croce A., 409 

Crocetti E., 314 

Crosta L., 353 

Crucitti P., 293, 294, 392 

Cuffaro V., 255 

Cupillari S., 352, 353 

Curti T., 285, 314, 317, 

329 

Cuttin M.S., 280, 305, 309, 

350, 353 

D’Aiuto M., 395 

D’Alicandro V., 337, 359, 

393, 395, 396 

D’Alterio C., 415 

D’Amati G., 242 

D’Ambrosio G., 414 

D’Amuri A., 279, 299 

D’Antuono T., 277, 324 

D’errico A., 243 

D’Urbano C., 403 

Da Ros L., 338 

Daidone M.G., 201 

Dal Bello B., 270, 291, 

315 

Dal Mas A., 313 

Dal Santo M., 259 

Dalla Palma P., 245, 259 

Danza G., 307 

Daprile R., 360, 374, 412 

de Braud F., 289 

De Chiara A.R., 359 

De Falco G., 267, 268 

De Lio N., 283 

De Luca G., 384 

De Maglio G., 271, 272, 

280, 302 

De Maria S., 360 

De Nictolis M., 223 

De Rosa G., 276, 357 

De Salvo L., 337 

de Santi M., 330 

Dei Tos P., 205 

Dei Tos A.P., 279 

Del Gobbo A., 388 

Del Vecchio G., 403 

Del Vecchio M.T., 307, 

308, 330 

Dell’Erba A., 257 

Dellapasqua S., 230 

Denaro M., 283 

Dessanti P., 347, 411 

Detti B., 250 

Dhillon A.P., 282 

Di Benedetto A., 337, 359, 

393, 395, 396 

Di Benedetto G., 272 

Di Bonito M., 395 

Di Carlo E., 277, 324 

Di Cola E., 285, 317 

Di Costanzo F., 203, 283 

Di Giacomo M., 403 

Di Lauro A., 412 

Di Lollo S., 286 

Di Meo S., 277, 324 

Di Nicola M., 311 

Di Nuovo F., 376, 387, 

388, 403 

Di Pumpo O., 225 

Di Rito S., 312, 352

422 

Di Serio C., 307 

Di Somma C., 418 

Dimartino V., 337, 359, 

393, 395, 396 

Dimitri O., 382 

Dina R., 245 

Diodoro M., 381 

Disanto A., 357 

Discepoli S., 317 

Doglioni C., 229, 248, 

267, 346 

Dominici A., 416 

Duzzi E., 393 

Eble J.N., 334 

Eccher A., 341 

Ercolani C., 337 

Ercolani C., 359, 393, 395, 

396 

Faa G., 323 

Fabbro G., 257 

Fabi A., 393, 395, 396 

Fabiano A., 254, 258 

Facchetti F., 237, 288, 

351, 413 

Fadda G., 247, 325, 329, 

358 

Fagotti A., 325 

Falcone A., 286 

Falconieri G., 272, 280, 

302 

Fante R., 297 

Fasola G., 271, 272, 302 

Fassan M., 209, 348 

Fassina A., 244, 348 

Faviana P., 283 

Fazzari C., 373 

Fedeli F., 347, 411 

Ferone D., 327, 364 

Ferrantelli A., 331 

Ferri E., 403 

Ferro G., 392 

Ferro P., 347, 411 

Ferro R., 306 

Festuccia C., 419 

Filice M.E., 204 

Filippetti M., 359 

Fiocca R., 364, 378 

Floccari F., 279, 299 

Foglia Manzillo E., 296 

Foltran L., 272 

Fondi C., 216, 286 

Fontana V., 347 

Fontanini G., 222, 286, 

339, 346 

Foroni C., 335 

Foschini M.P., 230 

Fossi A., 410 

Franceschini M.C., 347 

Franceschini M.C., 411 

Franchi A., 206 

Franco R., 359, 361, 371, 

383, 384, 410, 412, 

414, 415 

Franco V., 373 

Fraschini M., 323 

Frassoldati A., 338 

Frau V., 225 

Fulcheri E., 382, 389 

Fulciniti F., 274 

Funel N., 283 

Gaetti L., 297 

Gafà R., 275, 287 

Galetta D., 360 

Gallo D., 325 

Gallo E., 337 

Galuppini F., 211 

Galzerano A., 274 

Gambini C., 332 

Gandolfo S., 354 

Garcea D., 211 

Gardella B., 270, 315 

Gardini A., 211 

Gasparetto A., 300 

Gasparini P., 234 

Gaudioso G., 361, 410, 

412, 415 

Ghiggeri G., 332 

Ghimenton C., 334 

Ghirardini A., 253 

Ghiringhello B., 226 

Giacalone A., 375 

Giammaresi C., 331 

Giannatiempo R., 371, 

383, 384 

Giannini R., 286, 339 

Giannitrapani L., 375 

Giardini R., 253, 259 

Gigantino V., 359, 410, 

414 

Gilioli E., 341 

Ginevri F., 332 

Ginori A., 323, 344, 357 

Ginori A., 410, 415 

Gioioso A., 274 

Giotta F., 398, 399 

Giuffrè G., 275, 373, 384, 

397 

Giunti S., 289, 345 

Gnetti L., 342, 344 

Gnudi C., 287 

Gobbo S., 334, 341 

Grammatica L., 412 

Granchelli G., 297 

Grassi T., 319 

Grasso M., 278 

Gravina G.L., 419 

Graziano P., 221 

Grigioni F.W., 243 

Grigolato P.G., 260 

Grillo F., 209, 282, 327, 

364, 367, 369, 372, 

377, 379 

Guadagno A., 367, 372, 

377, 382, 402 

Gualco M., 372 

Guazzi P., 308 

Hako L., 301 

Hall A., 282 

Hes O., 334 

Hirabayashi K., 373 

Iaccarino A., 261 

Iannucci A., 341 

Ieni A., 275, 373, 397 

Iezzi M., 381, 398 

Inchingolo C.D., 385, 386 

Indelli M., 338 

Intrieri M., 412 

Intrieri T., 314 

Isgrò G., 282 

Isimbaldi G., 303 

Italia F., 373 

Izzo R., 353 

Knuutila S., 341 

La Mantia E., 361, 412, 

414 

La Monica F., 225 

La Rosa S., 231, 414 

La Sala L., 359, 395, 412, 

415 

La Sorda R., 381, 398 

La Vignera S., 326 

Labate A., 373, 416 

Lalinga V., 405 

Lanza G., 216, 275, 287 

Lanzafame S., 373 

Lanzarotto F., 288 

Lanzini A., 288 

Larocca L.M., 329 

Lastraioli E., 283 

Lattanzio R., 381, 398 

Laura F., 302 

Lavitrano M., 201 

Lazzi S., 267, 268 

Le Donne M., 384 

Lega S., 293, 294 

Leo E., 289 

Leocata P., 269, 279, 284, 

285, 290, 299, 311, 312, 

313, 314, 317, 329, 346, 

352, 353 

Leoncini L., 267 

Leone O., 242 

Li Cavoli G., 331 

Liberati F., 419 

Liguori G., 359, 395 

Lo Verde P., 416 

Lombardi C.P., 329 

Lonardi S., 288, 351 

Londero A.P., 319, 320 

Lorenzi L., 288, 413 

Lorusso D., 224, 325 

Loupakis F., 286 

Lucchi M., 346 

Lucchini V., 280, 305, 309 

Luchini C., 346 

Lucini L., 413 

Luong T.V., 282 

Lupi C., 286, 346 

Lupi M., 393 

Lupo C., 260 

Lutrino E.S., 272, 302 

Maccio L., 393 

Macciocu E., 323 

Madeddu A., 326 

Maestri I., 275 

Magliolo E., 373 

Magri E., 287 

Magro G., 228 

Maiorana A., 414 

Maitz S., 280 

Majori M., 344 

Malagnino V., 267 

Malfettone A., 374 

Mangia A., 360, 374 

Manna A., 395, 412 

Manneschi G., 314 

Mannucci S., 304 

Manuguerra R., 342, 344 

Marampon F., 419 

Marandino F., 337, 396 

Marasà L., 375 

Marasà S., 375 

Marchesoni D., 319 

Marchetti A., 220 

Marchiò C., 251 

Marchione R., 404 

Marcolini L., 384 

Marfisi C., 211 

Marinucci A., 329 

Mariotti M., 381 

Mariuzzi L., 319, 320 

Marra A., 414 

Marra L., 359 

Marrucci E., 358 

Martignoni G., 249, 334, 

341, 346 

Martini M., 329 

Marzano A.L., 363, 399, 

412 

Marzinotto S., 319, 320 

Masciullo V., 325 

Masiero E., 271, 272, 302 

Massari F., 341 

Massi G., 228 

Mastracci L., 209, 327, 

364, 367, 369, 372, 377, 

378, 379 

Mastrogiulio M.G., 268, 

304, 331, 344, 349, 356, 

410, 415 

Mattioli E., 296, 360, 374, 

393, 398 

Mattoni M., 276, 360 

Mazza S., 318 

Mazzola B., 404 

Mazzon E., 416 

Mazzoni R., 275, 287 

Mazzucco G., 205 

Melchiorri L., 284 

Melillo R.M., 415 

Melotti F., 234, 289 

Melucci E., 337, 359, 393, 

395, 396 

Mencarelli R., 277, 300, 

306, 336, 373 

Mercurio C., 338 

Mescoli C., 215 

Messerini L., 298, 322 

Micheletti L., 225 

Mihm M.C., 237 

iNDicE DE gli aUtoRi 

Milella M., 359 

Milione M., 234, 289 

Minuto F., 364 

Mirabelli D., 409 

Miracco C., 299 

Moltrasio F., 280, 303, 

305, 309, 353 

Monari E., 414 

Monciatti I., 301 

Moncini D., 250, 276, 

314, 322 

Montagna L., 346 

Montagnani I., 276, 322 

Montalto G., 375 

Montesco M.C., 281, 334 

Montorsi M., 378 

Mora F., 287 

Mora M., 416 

Moresco L., 400 

Morgagni P., 211 

Morganti V., 353 

Morichetti D., 361, 391, 

405, 407 

Mossa G., 398 

Mottolese M., 337, 359, 

393, 395, 396 

Mourmouras V., 289, 331, 

345 

Munari E., 334 

Musa M., 409 

Musiani P., 277, 324 

Mussi A., 346 

Muzzolini L., 313 

Naccarato A.G., 230 

Nagar C., 373 

Naldoni C., 293 

Nardini V., 204 

Naresh K.N., 267 

Navone R., 354 

Nazzari E., 369 

Negri G., 323 

Negri S., 292, 297, 392 

Nemcova L., 314 

Nemolato S., 323 

Nenna R., 385, 386 

Nicastro A., 371, 383, 384 

Niccoli C., 339 

Nicotina A.P., 384 

Nisticò C., 393, 395, 396 

Nisticò P., 381 

Nocita A., 318 

Normanno N., 219 

Nottegar A., 341, 346 

Novelli F., 393 

Novelli L., 216, 286 

Nugnes L., 371, 383, 384 

Ogwang M., 267 

Oliosi C., 346 

Olivetti L., 335 

Olivotto A., 348 

Onetti Muda A., 283 

Onorati M., 267, 376, 387, 

388, 403 

Oppressore D., 371, 383, 

384

iNDicE DEgli aUtoRi 

Orsaria M., 319, 320 

Orvieto E., 230 

Ozben T., 414 

Pacella E., 367, 382, 389, 

416, 418 

Pacenti L., 356 

Paci E., 314 

Paglierani M., 286 

Palma F., 296, 399 

Palmese E., 225 

Palmiere C., 393 

Paludetti G., 358 

Palummo N., 331 

Panfili M., 250 

Pannone G., 276, 357, 360 

Pantaleo B., 276 

Papagerakis S., 276 

Papotti M., 221 

Paradiso A., 296, 374 

Parolini C., 341 

Parravicini C., 291 

Parrilla C., 358 

Passantino R., 331 

Pastena C., 334 

Patacchiola F., 311, 312 

Pea M., 334 

Pedicillo M.C., 357 

Pedriali M., 338 

Pedron S., 334, 341, 346 

Pellegrinelli A., 289 

Pelliccioni S., 339 

Pelosi G., 221, 234, 289 

Pennelli G., 211 

Pentenero M., 354 

Pepe M., 410 

Perdonà S., 414 

Perracchio L., 393, 395 

Perrone F., 234 

Perrone G., 283 

Perrone V., 283 

Peruzzi G., 250 

Pescarmona E., 337, 359, 

381, 393, 395, 396 

Pesci A., 384 

Petracco G., 376, 387, 

388, 403 

Petroni S., 360, 363, 398, 

399, 412 

Pezzi R., 347 

Piantelli M., 381, 398 

Piccaluga P.P., 267 

Piccolomini M., 404 

Pierotti P., 293 

Pietrantonio F., 289 

Pigozzi S., 209 

Pilato F.P., 342 

Pileri S.A., 267 

Pilla D., 298 

Pilotti S., 234 

Pisa F., 272 

Pistillo M.P., 347, 411 

Pitto F., 369, 377, 379 

Pivato M., 348 

Pizzi S., 291 

Pizzolitto S., 271, 272, 

280, 302 

Pizzuti M., 403 

Poletto M., 320 

Pollina L.U., 283 

Polonioli S., 404 

Ponte R., 372, 378, 389 

Pontecorvi A., 329 

Ponzoni M., 235, 267 

Popescu O., 363, 412 

Postiglione M., 371, 383, 

384 

Pretelli P., 250, 276, 322 

Privitera G., 257 

Privitera S.S., 226 

Proietti A., 346 

Proietto E., 314 

Projetto E., 276, 298, 322 

Pucci A., 240 

Puccini B., 286 

Pusiol T., 361, 391, 405, 

407 

Quaglieri M., 314 

Querzoli G., 275, 287 

Querzoli P., 338 

Ragazzi M., 217 

Rapezzi R., 292, 293, 392 

Rasi A., 277, 336 

Raspollini M.R., 224 

Ravarino A., 323 

Reale D., 336 

Reggiani Bonetti L., 393, 

414 

Relli V., 359, 361, 395 

Resta L., 223, 244 

Ribechini A., 346 

Riccardo I., 352 

Ricciardi G., 397 

Rigacci L., 286 

Rigante M., 358 

Rinaudo C., 409 

Rindi G., 231, 358 

Risio M., 282 

Rizzo A., 300 

Rocca B.J., 267, 268, 289, 

301, 304, 307, 308, 323, 

330, 331, 345, 349, 

356, 357 

Rocchi A., 338 

Roccio M., 270 

Romagnoli S., 376, 387, 

388, 403 

Roncella S., 347, 411 

Rossella P., 382 

Rossi C., 379 

Rossi Degl’Innocenti D., 


Rossi Degl’innocenti G., 

250 

Rossi E.D., 325, 329, 358 

Rossi G., 205, 221 

Rossi P., 306, 336 

Rossi S., 207 , 291 

Rotellini M., 216 

Rotolo U., 331 

Rottoli P., 410 

Roz E., 373 

Rubini C., 360 

Rubini V., 296 

Rucci N., 338 

Rugge M., 211 

Russo A., 337, 371, 383, 

384 

Russo S., 363 

Sabatino R., 361, 414 

Sacchettini C., 314 

Sacchini A., 307, 308, 349 

Sacco C., 320 

Sala P., 389 

Salomone E., 373 

Saltarelli S., 313, 329 

Salvatore C., 360 

Salvi S., 411 

Santeusanio G., 254, 259 

Santini A., 338 

Santo A., 341 

Santonastaso C., 359, 414 

Santopietro R., 304, 323 

Santoro A., 276, 357, 360 

Santoro L., 325 

Sapere N., 412 

Sapino A., 203, 252 

Saponaro C., 360, 374 

Saragoni L., 211 

Sarocchi F., 367, 372, 377, 

378, 400 

Sassoli de’ Bianchi P., 293 

Scala S., 415 

Scambia G., 325 

Scaramuzzino F., 331 

Scarfì R., 275, 384 

Scarpa A., 201, 252 

Scarselli G., 276 

Scatigno A., 280 

Schirone A., 338 

Sciacca S., 326 

Scipioni L., 285 

Scognamiglio G., 361, 

395, 412, 415 

Scrima M., 410 

Segala D., 249, 334 

Selmi B., 392 

Sementa A.R., 332 

Senatore S.A., 279, 299 

Senes G., 323 

Sensi E., 286, 346 

Servadio A., 286, 346 

Sessa F., 414 

Sette A., 283 

Signoretto D., 269 

Silini E.M., 270, 291, 315, 

342, 344 

Silvestris N., 374 

Simionato F., 341, 348 

Simone A., 275, 384 

Simone G., 296, 360, 363, 

374, 398, 399, 412 

Sinagra E., 375 

Siri M., 348 

Skrap M., 302 

Soliani P., 291 

Sollima L., 284, 290, 311, 

313 

Sommella L., 257 

Sorrentino C., 277, 324 

Sozzi D., 353 

Sozzi G., 234 

Spaggiari P., 378 

Spagnolo F., 400 

Sperduti I., 393 

Speziali L., 405, 407 

Spina B., 400, 416, 418 

Spina D., 344, 410 

Spinelli A., 378 

Spinillo A., 270, 315 

Squillaci S., 404 

Staibano S., 276, 357 

Straccia P., 329 

Stramucci L., 381 

Tacchini D., 405, 415, 419 

Taddei G.L., 250, 276, 

314, 322 

Tagliavini E., 217 

Talamo I., 388 

Tallarigo F., 318, 404 

Tamburini E., 291 

Tarantini F., 307 

Tartaglia R., 257 

Tell G., 320 

Tempia Valenta G., 354 

Terrinazzi V., 298 

Testi A., 234, 338 

Tisano F., 326 

Tisci F., 359, 410, 412 

Todaro P., 384 

Tomasi A., 414 

Tommasini A., 318 

Tondulli L., 341 

Torrisi A., 326 

Tortora G., 341 

Tortorici C., 331 

Tosi A.L., 281, 334 

Toto V., 381, 398 

Tötsch M., 244 

Tramutoli P., 403 

Trani N., 393 

Trapasso M., 400 

Trevisan G., 269 

Tripodi S.A., 301, 308, 

331, 356, 415, 419 

423 

Truini M., 202, 411 

Tsochatzis E., 282 

Tuccari G., 275, 373, 397 

Tuniz F., 302 

Tupone M.G., 277, 324 

Uboldi P., 376, 387, 388, 

403 

Uccella S., 236 

Ulazzi L., 275 

Ungari M., 413 

Valente M.G., 303, 350, 

353 

Vanzani P., 348 

Vanzati A., 291, 303, 309 

Varesano S., 411 

Vascotto C., 320 

Vasquez E., 326 

Vassallo L., 405, 415, 419 

Vellone V.G., 325, 358 

Ventura L., 338, 419 

Verderio M., 305 

Vergani P., 305 

Vestri M., 323 

Viale G., 229 

Viberti L., 253, 282, 409 

Vicari E., 326 

Vici P., 393, 396 

Villanacci V., 205, 209, 

288 

Villani E., 279, 299 

Villari L., 373 

Visca P., 359 

Vitale A.R., 285, 312, 313, 

314, 317, 329 

Vitale F., 318 

Vitale V., 379 

Vittimberga F., 318 

Vittimberga G., 211 

Volta U., 288 

Zago P., 313 

Zamboni G., 215, 247, 

373, 384 

Zampini C., 287, 334 

Zanella M., 306 

Zanin T., 262 

Zannoni G.F., 223, 325, 

358 

Zanoni V., 335 

Zanotto Valentino M.C., 

225 

Zennaro L., 348 

Zeppa P., 397 

Ziglioli N., 335 

Zito Marino F., 361, 410, 

412 

Zorzi M.G., 361, 391, 405, 

407

Ogni anno il carcinoma polmonare colpisce 1.3 milioni di persone 

e causa 1.18 milioni di decessi. Il tumore polmonare non a piccole 

cellule (NSCLC) è la forma più diffusa di questo carcinoma. 

La ricerca è giunta oggi a significativi progressi: specifiche alterazioni 

molecolari, come le mutazioni del gene EGFR, permettono di 

individuare i pazienti che risponderanno al trattamento personalizzato 

con i nuovi farmaci a bersaglio molecolare. 

La determinazione dello stato mutazionale di EGFR rappresenta 

un passaggio indispensabile per la completa diagnosi. 

La rapidità di esecuzione del test è il fattore determinante 

per l’accesso dei pazienti alla migliore terapia disponibile. 

In Italia è attivo, grazie al supporto di AstraZeneca, il network 

“EGFR FASTnet” che consente a tutti gli ospedali di richiedere 

la determinazione dello stato mutazionale dell’EGFR a selezionati 

laboratori di Biologia Molecolare 

EGFR 

La chiave d’accesso 

alla terapia personalizzata 

del NSCLC 

www.egfrfastnet.it 

EGFR 

FASTnet

Sabato 27 ottobre 2012 - Pacini Editore

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?