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
GRUPPO DI STUDIO
GIPaD
GRUPPO DI STUDIO
GISm
Giovedì, 25 ottobre 2012
Sala
GIOTTO
2° piano
GRUPPO DI STUDIO
PaGine
Sala
BOTTICEllI
2° piano
GRUPPO DI STUDIO
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
SImPOSIO NON ECm
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
SImPOSIO NON ECm
HOlOGIC
Sala
BRUNEllESCHI
4° piano
GRUPPO DI STUDIO
GIUP
COmUNICaZIONI
ORalI:
Gastroenterico
Sala
BRUNEllESCHI
4° piano
PaTOlOGIa
mammaRIa:
aGGIORNamENTI
PaTOlOGIa
mammaRIa 2
SImPOSIO NON ECm
ROCHE PHaRma
Sala
mICHElaNGElO
piano terra
GRUPPO DI STUDIO
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:
Genitale maschile e
femminile
COmUNICaZIONI
ORalI:
Genitale maschile e
femminile
COmUNICaZIONI
ORalI:
Genitale maschile e
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
SImPOSIO NON ECm
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
Giovedì, 25 ottobre 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Venerdì, 26 ottobre 2012
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
Paper not received
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
Paper not received
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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,
Venerdì, 26 ottobre 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
Am J Surg Pathol 1998;22:1043-7.
22 Riddell RH, Iwafuchi M. Problems arising from Eastern and Western
Criteri di idoneità del fegato nel trapianto
C. Mescoli
Paper not received
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
Sala Caravaggio – 10.30-12.30
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
Venerdì, 26 ottobre 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Paper not received
La biopsia trans bronchiale: inquadramento
generale e casi paradigmatici
M. Barbareschi
Paper not received
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 .
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Paper not received
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Paper not received
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
Venerdì, 26 ottobre 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Sala Botticelli – 10.30-12.30
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Venerdì, 26 ottobre 2012
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
Paper not received
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
Paper not received
“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.
Sala Brunelleschi – 10.30-12.30
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
Paper not received
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
Paper not received
Carcinoma invasivo duttale vs lobulare: distinte
entità o facce della stessa medaglia?
E. Orvieto
Paper not received
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Venerdì, 26 ottobre 2012
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 NET
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 NET
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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 .
Type 4 ECL-cell NET
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.
Am J Surg Pathol 1991;15:592-8.
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
Paper not received
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).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Anatomia Patologica, Department of Pathology, University of Verona
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Paper not received
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Sabato, 27 ottobre 2012
Sala Caravaggio – 08.30-10.30
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Sala Caravaggio – 11.30-12.30
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
Paper not received
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 .
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Sabato, 27 ottobre 2012
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,
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
Sabato, 27 ottobre 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Sabato, 27 ottobre 2012
Sala Botticelli – 08.30-10.30
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
Anatomia Patologica, Department of Pathology, University of Verona
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Paper not received
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Sabato, 27 ottobre 2012
Sala Brunelleschi – 08.30-11.30
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Paper not received
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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%).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Sala Brunelleschi – 11.30-12.30
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
Sabato, 27 ottobre 2012
Sala Michelangelo – 08.30-10.30
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
Paper not received
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Sala Michelangelo – 11.30-12.30
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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-
Giovedì, 25 ottobre 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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

COmuNiCaziONi ORali
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
271
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%
mutation ex19 34 50,00%
mutation ex21 30 44,12%
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

272
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).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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

COmuNiCaziONi ORali
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
273
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

274
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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

COmuNiCaziONi ORali
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.
275
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.

276
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.

COmuNiCaziONi ORali
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.
Giovedì, 25 ottobre 2012
Sala Giotto – ore 16,30-18,00
277
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-

278
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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

COmuNiCaziONi ORali
Tab. I.
R-MSFTs
Case Autors Age Sex
Max
diameter
(cm)
1
Vallat-Decouvelaere
et al. (1998)
40 M 17
2
Vallat-Decouvelaere
et al. (1998)
63 f 4,5
3
Vallat-Decouvelaere
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.
279
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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

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

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

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

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

COmuNiCaziONi ORali
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
dell’Aquila, L’Aquila, Italia; 2 U.O.C. Anatomia Patologica, Ospedale Civile
“San Salvatore”, L’Aquila, Italia
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.
Material and methods. We report on a case of a 72-year-old man
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).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.

COmuNiCaziONi ORali
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
Giovedì, 25 ottobre 2012
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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

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

COmuNiCaziONi ORali
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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)
- with a 10% discrepancy 66,7% (10/15)
- with a 15% discrepancy 86,7% (13/15)
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.

COmuNiCaziONi ORali
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,
Sezione di Anatomia Patologica
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.

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

COmuNiCaziONi ORali
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Giovedì, 25 ottobre 2012
Sala Michelangelo – ore 17,00-18,00
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.

COmuNiCaziONi ORali
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Venerdì, 26 ottobre 2012
Sala Donatello – ore 17,00-18,30
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
Section, University of Siena, Italy; 2 University “Magna Graecia” of Catanzaro,
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

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

COmuNiCaziONi ORali
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Department of Human Pathology and Oncology, Pathological Anatomy
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.

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

COmuNiCaziONi ORali
GEnITALE MASCHILE E FEMMInILE
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-
Venerdì, 26 ottobre 2012
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
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. 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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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).

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

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

COmuNiCaziONi ORali
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
GEnITALE MASCHILE E FEMMInILE
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Venerdì, 26 ottobre 2012
Sala Giotto – ore 17,00-18,30
(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

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

COmuNiCaziONi ORali
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.
Sezione di Anatomia Patologica
Neonatal hemochromatosis is a rare clinical pathologic entity,
defined by severe neonatal liver failure of intrauterine onset
associated with intra-and extra- hepatic 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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
dell’Aquila, L’Aquila, Italia; 2 U.O.C. Anatomia Patologica, Ospedale Civile
“San Salvatore”, L’Aquila, Italia
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).

COmuNiCaziONi ORali
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
Section, University of Siena, Italy; 2 University “Magna Graecia” of Catanzaro,
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
GEnITALE MASCHILE E FEMMInILE
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Venerdì, 26 ottobre 2012
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

COmuNiCaziONi ORali
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Venerdì, 26 ottobre 2012
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%)

COmuNiCaziONi ORali
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.
3 Rapporto AIRTUM 2006. Epidemiol Prev 2006;30(suppl. 2):1-147.
4 Ziglioli F, Maestroni U, Dinale F, et al. Carcinoma in situ (CIS) of the
testis. Acta Biomed 2011;82:162-9.
5 Rapporto AIRTUM 2011. Epidemiol Prev 2011;35(suppl. 3):1-200.
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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

COmuNiCaziONi ORali
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
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. 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.
Material and methods. We report on a case of a 58-year-old
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 *
Department of Human Pathology and Oncology, Pathological Anatomy
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Venerdì, 26 ottobre 2012
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-

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

COmuNiCaziONi ORali
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
≥10% of cortical peritubular capillaries with
ptc 2 capillaritis, with max 5 to 10 luminal inflammatory
cells
≥10% of cortical peritubular capillaries with
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Venerdì, 26 ottobre 2012
Sala Michelangelo – ore 17,00-18,30
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.
Am J Surg Pathol 2007;31:1149-60.
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-

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

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

COmuNiCaziONi ORali
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-
Sabato, 27 ottobre 2012
Sala Donatello – ore 8,30-10,30
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).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.

COmuNiCaziONi ORali
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Fig. 1.
Fig. 2.
Fig. 3.

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

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

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

COmuNiCaziONi ORali
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,
University of Siena, Italy
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
Sabato, 27 ottobre 2012
Sala Donatello – ore 10,30-11,30
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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).

COmuNiCaziONi ORali
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
dell’Aquila, L’Aquila, Italia; 3 U.O.C. Anatomia Patologica, P.O. “SS
Filippo e Nicola”, Avezzano (AQ), Italia; 4 U.O.C. Anatomia Patologica
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.
Material and methods. We report on a case of a 62-year-old man
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Sabato, 27 ottobre 2012
Sala Giotto – ore 10,30-11,30
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

COmuNiCaziONi ORali
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.
Material and methods. We report on a case of a 67-year-old
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,
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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

COmuNiCaziONi ORali
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).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
Sabato, 27 ottobre 2012
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.

COmuNiCaziONi ORali
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
Department of Human Pathology and Oncology, Anatomic Pathology Section,
University of Siena, Italy
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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,
R. Franco, G. Botti
Pathology Department, National Cancer Institute “Fondazione G. Pascale”,
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
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 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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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 .
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
GEnITALE MASCHILE E FEMMInILE
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
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 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
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 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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
Am J Surg Pathol 1993;17:1187-9.
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
Pathology Unit, Garbagnate Milanese, AO “G. Salvini” Garbagnate Milanese,
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Pathology Unit, Garbagnate Milanese, AO “G. Salvini” Garbagnate Milanese,
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).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Pathology Department, National Cancer Institute “Fondazione G. Pascale”,
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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-
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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 Gonz´alez-Guerra E, Haro MR, Fari˜na MC, et al. Glomeruloid haemangioma
is not always associated with POEMS syndrome. Clin Exp
Dermatol 2008.
6 V´elez D, Delgado-Jim´enez Y, Fraga J. Solitary glomeruloid haemangioma
without POEMS syndrome. J Cutan Pathol 2005;32:449.
7 Pi ˜na-Oviedo S, L´opez-Pati ˜no 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).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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).
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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,
R. Franco, G. Botti
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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
Department of Human Pathology and Oncology, Anatomic Pathology Section,
University of Siena, Italy
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.
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
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.,
274
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.,
276
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