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contents
sadržaj
Pozdravna reč
472
Welcome address
Kongresni Odbori
473
Congress Commitees
Organizator
475
Organizer
HEMATOPATOLGIJA-Kratki kurs 1
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HEMATHOPATHOLOGY-Short Course 1
Reaktivne limfadenopatije u
svakodnevnoj praksi
Vesna Čemerikić-Martinović
Difuzni B krupnoćelijski limfom:varijante,
podgrupe i podtipovi
Maja Peruničić Jovanović
HEMATOLOGIJA-Kratki kurs 2
Reactive lymphadenopathy in
daily practice
Vesna Cemerikic-Martinovic
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494
Problematične „Low grade” lezije u
limfoproliferativnoj patologiji
Stefan Dojčinov
Problematuične “High grade” lezije u
limfoproliferativnoj patologiji
Snježana dotlić
Diffuse large B cell lymphoma: variants,
subgroups and subtypes/entities
Maja Perunicic Jovanovic
Problematic “Low Grade” Lesions in
Lymphoproliferative Pathology
Stefan Dojcinov
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Problematic “High Grade” Lesions in
Lymphoproliferative Pathology
Snjezana Dotlic
Klasičan Hočkin limfom - diferencijalna
dijagnoza i tumotska mikrosredina
Slavko Gašparov
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Classical Hodgkin lymphoma – differential
diagnosis and tumour microenvironment
Slavko Gasparov
HEMATOPATOLGIJA-Kratki kurs 3
504
Proliferacije plazma ćelija
Tatjana Terzić
GINEKOLOŠKA PATOLOGIJA
Kratki kurs 1
Plasma cell proliferations
Tatjana Terzic
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Patologija vulve – izabrane teme
Vukomanović Đurđević Biserka
Tumori uterusa
Svetlana Milenković
Važan napredak u
ginekološkoj patologiji
Sanjiv menek
GYNECOLOGICAL PATHOLOGY
Short Course 1
Vulvar Pathology - Selected Topisc
Vukomanovic Djurdjevic Biserka
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528
Tumors of the uterus
Svetlana Milenkovic
Important Recent Advances in
Gynaecological Pathology
Sanjiv Manek
contents
sadržaj
Kratki kurs 1
533
Placenta-nemi svedok (klinički i medicinskopravni značaj patohistološkog ispitivanja)
Marina Kos
Novine u dijagnostici
trofoblastnihbolesti
Mihaela Mocko Kaćanski
NOVINE U PATOLOGIJI
Placenta – a silent witness: clinical and forensic
importance of placental examination
Marina Kos
540
Recent advances in diagnostics of
trophoblastic disease
Mihaela Mocko Kacanski
548
NEWS IN PATHOLOGY
Endomiokardna biopsija: juče, danas i
sutra
Jovan D. Vasiljević
Neuromišićne biopsije – tri godine nacionalnog
iskustva
Sanja M. Milenković
Uvodno predavanje 3
Endomyocardial biopsy: yesterday, today and
tomorrow
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Neuromuscular biopsy - a review of 3 years
nacional experience
Sanja M. Milenkovic
573
Keynote Lecture 3
Cervikalna citologija i histologija u kontekstu
skrining programa
Sanjiv Menek
Uvodno predavanje 4
Cervical cytology and histology in the context of
a screening programme
Sanjiv Manek
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Profilaksa i rana detekcija HPV poveyanih
neoplayija
Hans Ikenberg
USMENE PREZENTACIJE
Keynote Lecture 4
Prophylaxis and Early Detection of HPVRelated Neoplasia
Hans Ikenberg
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Uloga eksfolijativne citologije u dijagnostici
tumora donjeg urinarnog trakta
Mirjana Ćuk, Slavica Knežević Ušaj, Radoslav
Gajanin, Aleksandar Supić, Radmil Marić
Ekspresija survivina kod bolesnika sa novootkrivenim nodalnim difuznim B krupnoćelijskim
limfomom
Olivera Marković, Dragomir Marisavljević, Vesna
Čemerikić, Biljana Mihaljević, Branka Filipović
GYNECOLOGICAL PATHOLOGY
Short Course 1
ORAL FREE PAPER SESSIONS
The role of exfoliative cytology in diagnosis of
lower urinary tract tumor
Mirjana Cuk, Slavica Knezevic Usaj, Radoslav
Gajanin, Aleksandar Supic, Maric Radmil
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Survivin expression in patients with newly
diagnosed nodal diffuse large B cell
lymphoma
Olivera Markovic, Dragomir Marisavljevic, Vesna
Cemerikic, Biljana Mihaljevic, Filipovic Branka
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sadržaj
Prognostički značaj CD 68 pozitivnih makrofaga
pridruženih tumoru u uznapredovalom
stadijumu klasičnog Hočkinovog limfoma
Ljubomir Jaković, Biljana Mihaljević, Maja
Peruničić-Jovanović, Andrija Bogdanović, Boško Andelić, Vladimir Bumbaširević
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The prognostic significance of CD 68 positive
tumor associated macrophages in advanced stage classical Hodgkin lymphoma
Ljubomir Jakovic, Biljana Mihaljevic, Maja
Perunicic-Jovanovic, Andrija Bogdanovic, Boško Andelic, Vladimir Bumbasirevic
Mogućnosti i ograničenja “imprint” citološke
tehnike u dijagnostici koštanih i mekotkivnih
tumora
Jelena Sopta, Zoran Vučinić, Jelena Bokun , Dušan
Ristić , Vesna Mijučić
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Possibilities and limitations of „imprint” cytological techniques in diagnostics of bone and soft
tissue tumors
Jelena Sopta , Zoran Vucinic, Jelena Bokun, Dusan
Ristic , Vesna Mijucic
Imunoekspresija katepsina D kod
meningioma
Zorana Vukašinovic-Bokun, Lidija Prijić-Plećević,
Milica Lavrnić, Nenad Miladinović, Marija Nikolić, Sanja M. Milenković
590
Immunoexpression of Cathepsin D in
meningiomas
Zorana Vukasinovic Bokun, Lidija Prijic-Plecevic,
Milica Lavrnic, Nenad Miladinovic, Marija Nikolic, Sanja M. Milenkovic
Nanog kao potencijalni marker kancerskih
matičnih ćelija kod pacijenata sa gliomima
visokog gradusa
Irena Dimov, Sladana Ugrenović, Slavica Stojnev,
Miloš Kostić, Tasic Desanka, Vladislav Stefanović
Imunohistohemijska ekspresija p53 u
Wilms-ovom tumoru
Sanja Radojevic-Škodrić, Dimitrije Brašanac,
Ljiljana Bogdanović, Milena Jovanović, Ivana
Baralić, Gordana Basta-Jovanović
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592
Nanog as the potential marker of the cancer
stem cells in the high grade
glioma patients
Irena DimoV, Sladana Ugrenovic, Slavica Stojnev,
Milos Kostic, Desanka Tasic, Vladislav Stefanovic
Immunohistochemical expression of p53 in
Wilms tumor
Sanja Radojevic-Skodric, Dimitrije Brasanac,
Ljiljana Bogdanovic, Milena Jovanovic, Ivana
Baralic, Gordana Basta-Jovanovic
Ispoljavanje FGFR1 i NCAM molekula u
karcinomima bubrega
Jasmina Marković-Lipkovski, Sanja Ćirović,
Dragan Mitrović, Duško Dunđerović, Cane Tulić
593
Expression of FGFR1 and NCAM in renal
tumors
Jasmina Markovic-Lipkovski, Sanja Cirovic,
Dragan Mitrovic, Dusko Dunderovic, Cane Tulic
POSTER PREZENTACIJE 1
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POSTER PRESENTATIONS 1
POSTER PREZENTACIJE 2
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POSTER PRESENTATIONS 2
Beograd Belgrade Beograd Belgrade Beograd Belgrade Beograd Belgrade
Welcome address
Pozdravna reč
Poštovane koleginice i kolege,
Veliko nam je zadovoljstvo i čast da Vas pozdravimo u ime Udruženja patologa i citologa Srbije i da
Vam poželimo uspešno učešće u radu 14. Kongresa
Udruženja patologa i citologa Srbije koji se održava
od 14.-16. juna 2012. godine, ponovo u Beogradu,
kao i pre 37 godina, kada je održan II Kongres patologa Jugoslavije. 14. Kongres UPCS je naš prvi kongres koji se održava pod pokroviteljstvom Evropskog
udruženja patologije.
Naše najveće bogatstvo su naši doktori, naši
članovi, zahvaljujući čijem radu, često i pored skromnih uslova i opreme za rad, uspevamo da održimo
zavidan nivo stručnog i naučnog rada. U poslednjih
nekoliko godina, uspeli smo da organizujemo niz
značajnih aktivnosti, a posebno ističemo pet ESCOP
škola (2009 - 2012) i kolektivno članstvo u ESP što
je, uvereni smo, samo početak, puta kojim patologija Srbije vraća ugled i prepoznatljivost u svetu
Organizovanje Evropskog kongresa patologa
u Beogradu 2015. godine je naš najveći uspeh, ponos i velika šansa da mlade kolege uvedemo u svet
razvijenih patologija.
Nadamo se da će 14. Kongres UPCS biti zanimljiv i sadržajan. Služiće, ne samo razmeni
stručnih i naučnih iskustava, nego i započinjanju novih projekata, obnavljanju starih i stvaranju novih
prijateljstava.
Ponosni smo što se u Udruženju oseća duh
i atmosfera preovladavanja znanja i ideja, a ne zvanja, te u tom smislu učesnici će biti ne samo akademici ili profesori, već i mladi eksperti, asistenti, docenti ili vodeći patolozi u našim regionalnim zdravstvenim ustanovama
Dobro došli!
Welcome!
Predsednik Izvršnog odbora
Predsednik Organizacionog odbora
Predsednik Naučnog odbora
472
Dear colleagues,
It is our great pleasure and honor to greet you
on behalf of the Serbia Pathologists and Cytologists
Association and wish you a successful participation
in the work of the Congress which is to be held in
June 2012 in Belgrade, where the 2nd Congress of
Pathologists and Cytologists of Yugoslavia was held
37 years ago. 14th Congress of the SPCA is our first
Congress held under the auspices of the European
Society of Pathology.
Our most valuable asset are our doctors, our
members, and thanks to their hard work we manage to maintain an enviable level of professional and
scientific work, despite our modest working conditions. In the recent years we have managed to organize a number of significant activities. Amongst them,
I would like to mention five ESCOP schools (2009 2012) and collective membership in the ESP, which
is just the beginning of our efforts to regain reputation
and recognition of pathology of Serbia in the world.
The organization of the European Congress
of Pathology in 2015 is our biggest success, pride and
a great chance to introduce our young colleagues to
the world of developed pathologies
We hope that the 14th Congress of SPCA
will be interesting and educational. Not only it will
serve for exchanging scientific experience, but also
for starting new joint projects, renewal of old and beginning of new friendships.
We are proud that the atmosphere of knowledge and ideas rather than people’s titles prevails in the
Association and, in this sense, the participants will
not only be academics or professors, but also young
experts, assistants and leading pathologists of our regional institutions.
Sanja M. Milenkovic
President of the Executive Committe
President of the Organising Committee
Jovan D. Vasiljevic
President of the Scientific Committee
14. Kongres udruženja patologa i citologa Srbije sa međunarodnim učešćem, Beograd 14-16 juna, 2012
14 th Congress of Serbian Association of Pathologists and Cytologists with international participation, Belgrade 14-16 June, 2012
Kongresni Odbori/Congress Committees
Izvršni odbor/Executive Committee
Organizacioni odbor/Organising Committee
Predsednik/President
Sekretar/Secretary
Milos Mihajilović
Sekretar/Secretary
Članovi/Members
Dragan Mihailović
Goran Stanojević
Marjan Micev
Slaviša Djuričić
Svetislav Tatić
Živka Eri
Članovi/Members
Biserka Vukomanović-Đurđević
Mihaela Mocko-Kaćanski
Maja Peruničić-Jovanović
Snežana Vatrićević
Naučni odbor/ Scientific Committee
Počasni odbor/Honorary Committee
Ministar zdravlja Republike Srbije
Prof. dr Zoran Stanković
Predstavnik Srpske Akademije nauka i umetnosto
Akademik Prof. dr Vladimir Kanjuh
Rektor Univerziteta U Beogradu
Akademik Prof. dr Vladimir Bumbaširević
Predsednika SLD
Prof. dr Radoje Čolović
Predsednik Lekarske komore Srbije
Prim. dr Tatjana Radosavljević
Gradski sekretar za zdravstvo
Prof. dr Zoran Blagojević
Direktori Instituta za patologiju
Prof. dr Gordana Basta-Jovanović, Beograd
Prof. dr Ratko Ilić, Niš
Prof. dr Milan Knežević, Kragujevac
Sekretar/Secretary
Jelena Sopta
Članovi/Members
Gordan Vujanić, GB
Hans Ikenberg, Nemačka
J. Han van Krieken, Holandija
Jasmina Marković-Lipkovski, Srbija
Marco Santucci, Italija
Miroslav Đokić, SAD
Radoslav Gajanin, BH
Sanjiv Manek, GB
Sigurd Lax, Austrija
Slavica Knežević-Ušaj, Srbija
Slavko Gašparov, Hrvatska
Snežana Jančić, Srbija
Stefan Dojčinov, GB
Tatjana Terzić, Srbija
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474
Organizator/Organizer
475
Beograd Belgrade Beograd Belgrade Beograd Belgrade Beograd Belgrade
About Belgrade
O Beogradu
Beograd je središte kulture i umetnosti Srbije. U
Beogradu stvaraju naši najznačajniji umetnici , a godišnje se održi više od 11.000 pozorišnih predstava, izložbi, koncerata, performansa i drugih umetničkih programa, gostuju brojni eminentni stvaraoci iz sveta umetnosti. Beograd je sedište najviših državnih i nacionalnih institucija kulture i umetnosti:
Srpske akademije nauka i umetnosti, Narodne biblioteke Srbije, Narodnog muzeja, Narodnog pozorišta
i Univerziteta umetnosti. Grad Beograd je osnivač i
pokrovitelj 11 manifestacija u oblasti kulture (FEST,
BITEF, BEMUS, BELEF, Međunarodno takmičenje
muzičke omladine, Festival dokumentarnog i kratkometražnog filma, Oktobarski salon, Radost Evrope,
Beogradski sajam knjiga, Filmski festival u Sopotu
i Beogradski džez festival)
Uopsteno govoreci, Beogradjani su prijatni i gostoljubivi, a moze se reci da su im ironija, crni humor i pozitivan stav pomogli da prevazicu teska vremena. Beogradjanke su lepe zene sa osecajem za modu, a Beogradjani visoki i zgodni. Iskreni su ljubitelji
sporta, posebno vole kosarku, fudbal i tennis. Tokom
dana ,za vreme kratke pauze ili za vreme poslovnog
sastanka, uzivaju u kaficima dok je vece rezervisano
za klubove i diskoteke..
Ko je imao sreće, da se jutros probudi u Beogradu,
može se smatrati da je za danas dovoljno postigao u
životu. Svako dalje insistiranje na još nečemu, bilo bi neskromno.“
Belgrade is the most flourishing heart of culture
in Serbia! It offers an assorted selection of arts and
cultural attractions: from art exhibitions to music
performances, museums, architecture, theatres, photography and much more. Every year about 11.000
national and International cultural-artistic actvities take place in Belgrade: festivals such as FEST
(Film Festival), BITEF (Theatre Festival), BELEF
(Summer Festival) and BEMUS (Music Festival)
along with the Book Fair and others.
Generally speaking Belgraders are outgoing and
friendly people: irony, self-criticism and black humor
are the attitudes that helped Serbs overcome difficult
times. Among its visitors Belgrade women are beautiful and with a sense for fashion and style while men
are tall and handsome. Belgraders are big sports fans,
they love particularly basketball, soccer and tennis.
During the day Belgraders enjoy cafès both for a short
break and for business meetings, meanwhile during
the evening clubs and discos are always crowded: the
vibrant and ever-changing nightlife is something not
to be miss when visiting Belgrade
Who was lucky this morning, to wake up in
Belgrade, can be considered achieved enough in
life for today. Any further insisting on something
more it would be immodest“
Dusko Radovic
Duško Radović
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HEMATOPATOLGIJA- kratki kurs 1/HEMATHOPATOLOGY Short Course 1
Reaktivne limfadenopatije u
svakodnevnoj praksi
Reactive lymphadenopathy in daily
practice
Beo-lab, Beograd, Srbija
Beo-lab, Belgrade, Serbia
Apstrakt
Limfadenopatije su čest klinički nalaz u pacijenata svih uzrasta. Predstavljaju reakciju limfnog tkiva na različite spoljašnje i unutrašnje stimulanse. Najveći broj limfadenopatija su benigne
promene koje mogu da liče na limfome i različite
druge tumore tako da su njihovo poznavanje i diferencijalna dijagnoza bitni za isključivanje maligne bolesti. Limfni čvorovi veći od 1,5cm u najvećem prečniku, supraklavikularna lokalizacija i
generalizovana limfadenopatija pobuđuju sumnju
na malignu etiologiju. Lokalizovana limfadenopatija u starijih osoba je uvek sumnjiva na metastatski tumor. U slučaju generalizovane limfadenopatije limfomi, metastaze solidnih tumora i različite promene benigne etiologije se moraju razmatrati u diferencijalnoj dijagnozi. Benigne limfadenopatije se mogu podeliti na folikularno-nodularne, sinusne, interfolikularne ili mešovite i difuzne
u zavisnosti od izgleda promena u različitim delovima limfnog čvora. Promene su dinamične tako
da njihov izgled zavisi od momenta uzimanja biopsije. Najčešće benigne limfadenopatije su folikularna hiperplazija i limfadenitis u toksoplazmozi. U novije doba sve više viđamo limfadenopatije
koje su posledica ugrađivanja implantata i proteza
(silikonska limfadenopatija) ili su posledica davanja različitih kontrastnih sredstava (lipidna limfadenopatija). Specifična dijagnoza i diferencijacija
od malignih bolesti zahteva korelaciju između kliničkih nalaza, morfologije limfnog tkiva, seroloških analiza i rezultata imunohistohemijskih, molekularnih i genetskih analiza.
Ključne reči: limfadenopatije, klasifikacija, dijagnostika, FISH
Abstract
Lymphadenopathy is a common clinical finding,
affecting patients of all ages. The majority of lymphadenopathies are reactive processes of lymph nodes in
response to a variety of exogenous and endogenous
stimulants. They are non-neoplastic conditions that
can mimic lymphoma and other malignant tumors.
Therefore their recognition and differential diagnosis is of great importance in order to rule-out the neoplastic disease. Signs of malignant etiology include lymph nodes >1,5cm in diameter, supraclavicular
localization and generalized lymphadenopathy. A metastatic carcinoma is always in the differential diagnosis of localized lympadenophaty in older individuals.
In case of generalized lymphadenopathy lymphomas,
metastatic solid tumors and various benign etiologies
need to be considered. The reactive lymphadenopathies are grouped into four major categories according
to their predominant architectural histologic pattern:
follicular-nodular, sinus, interfollicular or mixed, and
diffuse. As reactive conditions of the lymph nodes are
dynamic processes the predominant pattern may differ
depending on when during the course of the disease the biopsy is performed. The most common reactive lymphadenopaties are follicular hyperplasia and
toxoplasmic lymphadenitis. Nowdays some lymphadenopathies with foreign-body reaction are side effects
of silicone prostheses (silicone lymphadenopathy) and
various contrast media (lipid lymphadenopathy). A
specific diagnosis and differentiation from neoplastic
disease often requires correlation among the morphologic features, the clinical history, serologic studies,
immunohistochemistry and molecular genetic analysis.
Key words: lymphadenopathy, classification, diagnosis, FISH
Uvod
U ljudskom telu postoji oko 600 limfnih čvorova. Promene u njihovoj veličini, broju i konzistenciji se
označavaju kao limfadenopatija. Čest je klinički nalaz u svim uzrastima. Preporuka je da se pacijenti sa limfadenopatijom većom od 1cm koja perzistira šest nedelja obavezno podvrgnu detaljnoj dijagnostičkoj proceduri, uključujući i biopsiju (1). Limfni čvorovi čiji je prečnik manji od 1cm se smatraju normalnim, mada to
477
zavisi od njihove lokalizacije. Ingvinalni čvorovi veći od 1,5cm se smatraju izmenjenim dok je kod epitrohlearnih kriterijum 0,5cm. Godišnja incidenca limfadenopatije je oko 0,6%-0,7% u opštoj populaciji (1). Stoga
tkivo limfnih čvorova predstavlja jedan od najčešćih biopsijskih materijala u patohistološkim laboratorijama.
Osnovni problem koji se postavlja pred patologa je da li je limfadenopatija benigna ili maligna. Precizna dijagnoza zahteva korelaciju između kliničkih nalaza, morfologije izmenjenog limfnog tkiva, seroloških analiza, histohemijskih bojenja, uključujući i ona za identifikaciju mikroorganizama, imunohistohemijskih, molekularnih i genetskih analiza.
U oko 50%-60% slučajeva postavi se pozitivna dijagnoza specifične limfadenopatije, različitih infektivnih limfadenitisa, metastaskih tumora i limfoma. Najveći broj uvećanih limfnih čvorova (40%-55%) je benigan i predstavlja nespecifičnu reakciju na različite antigene, bilo strane, bilo sopstvene. U opštim bolnicama
neoplazme se nađu u oko 1%-2% biopsija limfnih čvorova, dok se u specijalizovanim ustanovama taj broj
penje na 60%. U velikoj studiji autora iz Velike Britanije (2) koja je obuhvatila 550 bolesnika sa limfadenopatijom, 95 (17,3%) je imalo malignu bolest, od kojih 62 limfoproliferativnu bolest (19 Hodkinov limfom,
18 difuzni B-krupnoćelijski non-Hodgkinov limfom, a ostatak su bili različiti NHL). U 168 bolesnika je dijagnostikovana nespecifična, reaktivna limfadenopatija, u 139 benigne limfadenopatije različitih uzroka a u
21 bolesnika benigni tumori.
Prvi korak u dijagnostici limfadenopatija je detaljno poznavanje kliničkih simptoma i karakteristika bolesti (3): postoje li znaci ili simptomi koji ukazuju na infekciju ili neoplazmu; postoje li simptomi kao što su
bol, groznica, temperatura, gubitak težine, znojenje, osip po koži i sl.; epidemiološki podaci koji se odnose na
ishranu, seksualne navike, profesionalno izlaganje štetnim materijama, uzimanje lekova i supstanci koji mogu da izazovu limfadenopatiju, postojanje proteza i implantata itd.
Uzrast bolesnika je bitan. U dečijem uzrastu najveći broj limfadenopatija je benigan dok se u odraslih verovatnoća maligne limfadenopatije povećava sa starošću. Bolno uvećanje čvorova je obično benigno. Pokretni limfni čvorovi koji se brzo uvećavaju su verovatno ne-neoplastični za razliku od fiksiranih koji se sporo uvećavaju.
Lokalizovana limfadenopatija (75%) je češća od generalizovane (25%). Limfni čvorovi glave i vrata su
najčešće uvećani (55%), zatim slede ingvinalni (14%), aksilarni (5%), dok su supraklavikularni uvećani u 1%
slučajeva. Lokalizacija limfadenopatije može biti značajna jer često ukazuje na njen uzrok. Limfni čvorovi na
vratu su najpre uvećani u infektivnoj mononukleozi, toksoplazmozi i drugim infekcijama ali i u limfoproliferativnim bolestima. Supraklavikularni limfni čvorovi su često udruženi sa malignom bolešću (25% pacijenata mlađih od 40 godina i u 90% starijih od 40 godina). Generalizovana limfadenopatija koja predstavlja uvećane limfne čvorove u više od tri regije, više ukazuje na malignitet.
Uzroci limfadenopatija su različiti (4, 5):
• Infekcije (streptokok, stafilokok, tuberkuloza, atipične mikobakterije, toksoplazmoza, bolest mačije ogrebotine, sifilis, gljivice, paraziti, Epstein-Barrov virus, HIV, citomegalovirus, herpesvirus itd.)
• Autoimune bolesti (reumatoidni artritis, SLE, Sjögrenov sindrom)
• Lekovi (dilantin, antikonvulzanti, antibiotici, aspirin, alopurinol)
• Sarkoidoza
• Amiloidoza
• Whippleova bolest
• Vakcine
• Silikonski implantati, kontrastna sredstva, proteze
• Bolesti nakupljanja (Guacherova bolest)
• Benigne limfoproliferativne bolesti (Kikuchieva bolest, Kawasakieva bolest, Kimurina bolest, RosaiDorfmanova bolest, progresivna transformacija germinativnih centara, vaskularna transformacija sinusa, inflamatorni pseudotumor, Castlemanova bolest, dermatopatska limfadenopatija)
• Maligne limfoproliferativne bolesti (non-Hodgkinovi limfomi, Hodgkinovi limfomi, akutne i hronične mijeloidne leukemije)
• Metastaski tumori
478
Diferencijalna dijagnoza limfadenopatije je jako široka, slična diferencijalnoj dijagnozi nejasnih febrilnih stanja ili povećane sedimentacije eritrocita. Diferencijalne dijagnoze se mogu grupisati prema akronimu
CHICAGO (Cancers, Hypersensitivity syndromes, Infections, Connective tissue diseases, Atypical lymphoproliferative disorders, Granulomatous lesions, Other unusual causes of lymphadenopathy) (6).
Benigne limfadenopatije se mogu podeliti na folikularno-nodularne, sinusne, interfolikularne ili mešovite i difuzne u zavisnosti od izgleda promena u različitim delovima limfnog čvora (tabela 1). Ova podela nije
striktna jer se često vide kombinacije promena u različitim odeljcima limfnog čvora. S druge strane promene
su dinamične tako da njihov izgled zavisi od momenta uzimanja biopsije.
Folikularno-nodularne
Nespecifična, reaktivna folikularna hiperplazija
Autoimune bolesti (reumatoidni artritis)
HIV limfadenopatija
Sifilis
Castlemanova bolest, hijalino-vaskularni tip
Progresivna transformacija germinativnih centara
Hiperplazija mantle zone
Mikobakterijski pseudotumor
Sinusne
Sinus histiocitoza
Kontrastna sredstva, proteze, silikonski implantati
Whippleova bolest
Vaskularna transformacija sinusa
Rosai-Dorfmanova bolest
Sinus histiocitoza sa masivnom limfadenopatijom
Hemofagocitni sindrom
Interfolikularne ili mešovite
Parakortikalna hiperplazija i dermatopatska reakcija
Granulomatozni limfadenitis
Nenekrotizirajući granulomi
Nekrotizirajući granulomi
Tuberkuloza
Gljivične infekcije
Bolest mačije ogrebotine
Kimurina bolest
Limfadenitis u toksoplazmozi
Sistemski lupus
Kikuchieva bolest
Kawasakieva bolest
Inflamatorni pseudotumor
Bacilarna angiomatoza
Limfadenopatije u sklopu imunodeficijencije
Difuzne
Infektivna mononukleoza
Citomegalovirus infekcija
Herpes simplex limfadenitis
Dilantinska limfadenopatija
Tabela 1. Morfološka klasifikacija reaktivnih limfadenopatija
479
U radu će biti detaljno prikazane reaktivna folikularna hiperplazija i limfadenitis u sklopu toksoplazmoze kao najčešće benigne limfadenopatije koje srećemo u našem podneblju. Ponekad, floridna reakcija limfnog tkiva može imati atipičan morfološki izgled te se može zameniti za limfom (7). Uz to će biti prikazane
neke limfadenopatije koje sve više viđamo, a mogu predstavljati diferencijalno-dijagnostički problem: silikonske i lipidne limfadenopatije.
Reaktivna folikularna hiperplazija
Folikularna hiperplazija (FH) je najčešća reaktivna limfadenopatija. Predstavlja umnožavanje sekundarnih limfoidnih folikula ili germinativnih centara po jedinici površine limfnog čvora. Jedan od kriterijuma za
postavljanje dijagnoze je da >90% limfoidnih folikula sadrži aktivne germinativne centre. Folikuli su uvećani, hipertrofični, nepravilnog oblika. Česta je u dečijem uzrastu a ređa u starijem; retko se vidi posle 60-te godine kada je obično u sklopu reumatoidnog artritisa ili neke druge autoimune bolesti (8). Osnovni problem u
dijagnostici reaktivne folikularne hiperplazije je diferencijacija od folikularnog NHL.
FH je posledica antigene aktivacije B-limfocita (izazvane najčešće stranim, bakterijskim antigenima, ali
ne-retko i sopstvenim). Ova aktivacija dovodi do somatskih mutacija, sazrevanja, klonalne ekspanzije i selekcije limfoidnih ćelija čiji je rezultat stvaranje plazma ćelija i produkcija antitela. Proces se može i morfološki pratiti u limfnom tkivu. Prisustvo brojnih apoptotskih tela i „tingible body“ makrofaga je morfološki znak
klonalne selekcije, a brojne mitoze ukazuju na proliferativnu prirodu procesa. Citološke promene od malog,
okruglog limfocita preko krupnih centroblasta i imunoblasta do zrelih limfocita sa potpunom antigenom selekcijom koje vidimo kao centrocite, su histološki dokaz aktivacije imunog sistema.
Makroskopski, limfni čvorovi su sjajni, na preseku granulirane površine, a ponekad se mogu videti i lako
uzdignuti noduli. Nažalost, isto ovako izgledaju i NHL koji pokazuju folikularni tip rasta.
Mikroskopski, slikom dominiraju umnoženi limfoidni folikuli različite veličine i oblika, raspoređeni po
svim odeljcima limfnog čvora (korteks, parakorteks, medula). Građa limfnog čvora je u osnovi očuvana, uz
prisutan sinusni sistem. Reaktivni folikuli se obično ne nalaze van kapsule i u perinodalnom masnom i vezivnom tkivu za razliku od neoplastičnih folikula u folikularnom NHL. Na reaktivnu prirodu procesa ukazuju polarizacija folikula, očuvana mantle zona i prisustvo „tingible body“ makrofaga koji germinativnim centrima daju izgled zvezdanog neba (starry sky). Germinativni centri su upadljivi. Unutar njih postoji polimorfna ćelijska populacija centrocita, centroblasta i par imunoblasta. Krupne ćelije preovlađuju tako da germinativni centri deluju svetlo. Retikularna osnova je očuvana ili lako potisnuta ka periferiji, za razliku od folikularnog NHL gde je značajno zgusnuta i potisnuta ka periferiji. U folikularnom limfomu, folikuli su obično
sitniji, mnogobrojniji, zgusnutiji, međusobno relativno jednaki, bez mantle zone u „back-to-back“ položaju,
bez polarizacije. Ćelijski sastav germinativnih centara je monomorfan tako da deluju „mirnije“ od FH, bez
„tingible body“ makrofaga. Dominiraju sitnije ćelije, centrociti pa germinativni centri izgledaju tamnije (8).
U starijih bolesnika germinativni centri pokazuju manji stepen aktivacije nego kod mlađih tako da se folikularna hiperplazija lako zameni za folikularni NHL.
Imunohistohemijski, germinativni centri se sastoje uglavnom od CD20+ B-ćelija, izmešanih sa različitim
brojem CD4+, CD57+ T-limfocita kao i PD-1+ intrafolikularnih T-ćelija. Germinativni centri su BCL2 negativni za razliku od neoplastičnih folikula u folikularnom limfomu koji su BCL2 pozitivni. Ispitivanje sa BCL2
se uvek mora raditi zajedno sa reakcijama na CD20 i CD3 jer brojni BCL2+ T-limfociti mogu biti prisutni i
u reaktivnim folikulima što se može pogrešno protumačiti kao BCL2+ NHL. Ekspresija BCL2 je obično jača u ćelijama folikularnog limfoma nego u okolnoj mantle ili interfolikularnoj zoni. Oko 5%-25% folikularnih NHL je BCL2 negativno. Pozitivnost opada sa gradusom; u folikularnim limfomima gradusa 3 se kreće
od 50% do 75%. U slučaju sumnje na BCL2 negativan folikularni NHL obavezno uraditi FISH ili PCR analizu jer postoji BCL2 rearanžman, bez obzira na imunohistohemijsku negativnost (sl.1).
I benigni i neoplastični folikuli eksprimiraju CD10 i BCL6, mada je ekspresija CD10 nešto slabija u folikularnoj hiperplaziji. BCL6 može biti pozitivan samo u delu ćelija folikularnog limfoma, za razliku od folikularne hiperplazije u kojoj su sve ćelije pozitivne. Proliferativni marker Ki-67 može biti od velike koristi u
480
diferencijaciji FH od folikularnog limfoma: u reaktivnoj hiperplaziji skoro sve ćelije su Ki-67 pozitivne dok
je u folikularnom limfomu ta pozitivnost daleko manja, obično 10-20%, retko do 60% i to u GR3. U folikularnoj hiperplaziji ćelije u proliferaciji su često skoncentrisane u jednoj polovini germinativnog centra što odražava zonalnu organizaciju proliferacije i selekciju ćelija za apoptozu u reaktivnom germinativnom centru. U
folikularnom NHL malobrojne Ki-67 pozitivne ćelije su obično razbacane po celoj površini germinativnog
centra. Niska proliferacija u folikularnim limfoidnim lezijama je uvek visoko suspektna na NHL.
Imunohistohemijski dokaz monoklonalnosti, odnosno dokaz restrikcije lakih lanaca imunoglobulina (κ,
λ) na smrznutim presecima ili putem protočne cytometrije je relativno pouzdana metoda za razlikovanje folikularnog NHL od FH. Lawrence i saradnici su prikazali pouzdane rezultate (64 pozitivnih od 67 slučajeva
FH) primenom monoklonskih antitela (κ, λ) proizvođača Silver Lake Research Corporation (Monrovia, CA)
(9) na parafinskim presecima limfnih čvorova. Nažalost, ovi markeri nisu registrovani u našoj zemlji pa su
nam za sada nedostupni. Komercijalna antitela koja se kod nas mogu naći za parafinske preseke ne daju pouzdane rezultate.
Slika
1.
Karakteristike
reaktivne
folikularne hiperplazije (FH) i folikularnog
NHL (FL)
Folikularna
hiperplazija
se
odlikuje
polarizacijom folikula, očuvanom mantle
zonom i prisustvom „tingible body“
makrofaga u germinativnim centrima. Unutar
germinativnih centara postoji polimorfna
ćelijska populacija centrocita, centroblasta
i par imunoblasta (detalj). U folikularnom
limfomu, folikuli su bez polariteta i mantle
zone. Nema makrofaga a ćelijski sastav
germinativnih centara je monomorfan tako da
dominiraju centrociti (detalj).
Imunohistohemijski, germinativni centri U
FH su BCL2 negativni a u FL pozitivni. U
reaktivnoj hiperplaziji skoro sve ćelije su Ki67 pozitivne dok je u folikularnom limfomu
ta pozitivnost daleko manja.
U FH BCL2 gen nije rearanžiran, dok je u FL
rearanžiran, t(14;18). FiISH analiza pokazuje
normalan BCL2 signal u jedrima ćelija FH i
translokaciju BCL2 u FL
481
Prema različitim literaturnim podacima, u 5-15% slučajeva diferencijalna dijagnoza između reaktivne limfoidne proliferacije i malignog limfoma zahteva molekularne genetske analize. Reaktivne limfoproliferacije
imaju poliklonski rearanžman imunoglobulinskih (Ig) ili T-ćelijskih receptorskih (TCR) gena, za razliku od
malignih koje imaju monoklonski rearanžman. Molekularne genetske analize (Southern blot i PCR) su najpouzdanije metode za detekciju imunoglobulinskih, TCR i BCL2 rearanžmana u FH. Za razliku od imunofenotipizacije, njima se može utvrditi prisustvo male klonalne populacije ćelija i može se utvrditi monoklonalnost
u imunohistohemijski Ig i BCL2 negativnim tumorima. Southern blot je preciznija metoda, ali je problem što
zahteva sveže, nefiksirano tkivo. PCR analiza je manje senzitivna, mada se sa pojavom novih standardizovanih reagenasa i metoda za PCR-baziranu klonalnost (BIOMED-2 Concerted Action BMH4 CT98-3936) senzitivnost značajno poboljšala (99% u B-ćelijskim NHL i 94% u T-ćelijskim) (10).
Histološki reaktivne proliferacije predstavljaju široki spektar lezija sastavljenih od heterogene populacije
poliklonskih limfocita preko lezija koje sadrže (oligo)klonalne aktivirane limfoidne ćelije ili, ponekad, monoklonsku komponentu. U studiji Van Kriekena i saradnika (11) urađena je ekstenzivna PCR analiza svih
mogućih Ig/TCR genskih rearanžmana i translokacija t(11;14) i t(14;18) u 109 reaktivnih limfoidnih lezija,
od kojih su 74 bile FH. U 75% slučajeva utvrđena je jasna poliklonalnost za Ig/TCR. U 10% (11/106) su uočeni jasni monoklonski produkti za jedan ili više Ig/TCR rearanžmana. U 2 od ovih 11, ponovnom patohistološkom analizom je utvrđeno delimično zahvatanje limfnog tkiva limfomom. Nalaz klonalnosti u reaktivnim
lezijama zahteva tesnu saradnju patologa i molekularnog biologa u tumačenju rezultata da bi se izbegle potencijalne greške. Treba isključiti moguće tehničke poteškoće, imunobiološke karakteristike (EBV infekciju i
sl.) i ako je rezultat suspektan klinički pratiti bolesnika, uz eventualne ponovljene biopsije sa ponovnim molekularnim analizama da bi se došlo do tačne dijagnoze.
Različiti spektar hromozomskih aberacija (strukturnih i numeričkih) je utvrđen u 17% reaktivnih limfadenopatija (116 pacijenata), među kojima najveći broj pripada FH (12). Kariotipske anomalije su češće u generalizovanoj nego u lokalizovanoj limfadenopatiji. U 40% promene su bile na hromozomu 14, pre svega
translokacije koje zahvataju IGH lokus. Rearanžman BCL6 je detektovan u 20%. Pacijenti su praćeni 5 godina i samo kod jednog se pojavio NHL.
Najveći problem u diferencijalnoj dijagnozi FH je folikularni limfom. U najvećem broju slučajeva diferencijacija se može izvršiti na osnovu arhitekturalnih i citomorfoloških karakteristika. U komplikovanim i nejasnim
slučajevima neophodna je detaljna imunohistohemijska i citogenetska analiza (sl. 1). Morfološki, imunohistohemijski i molekularni parametri za razlikovanje FH od folikularnog NHL su prikazani na tabeli 2. Poseban
problem predstavlja BCL2 negativan folikularni limfom (10-15%) kada se dijagnoza može postaviti samo po
utvrđivanju klonalnosti B-ćelijske populacije i citogenetskoj analizi. Različiti NHL koji mogu da rastu folikularno (NHL marginalne zone, mantle-ćelijski NHL i sitnoćelijski difuzni NHL) kao i Hodgkinov limfom
tipa nodularne limfocitne predominacije mogu predstavljati problem u diferencijalnoj dijagnozi. Za diferencijaciju je neophodna pažljiva morfološka evaluacija, uz detaljno imunohistohemijsko i, eventualno, citogenetsko ispitivanje (FISH, PCR). U diskriminaciji između reaktivnih proliferacija i NHL ekspresije gena (mRNA
microarray), može biti od velike koristi. Pokazano je da u reaktivnoj limfadenopatiji postoji niža ekspresija
gena vezanih za imuni odgovor u odnosu na NHL (13). Postoji i redukovana ekspresija TAF3 i LDB2 gena.
482
KarakteristikaFHFL
Arhitektura čvora
očuvana
narušena
Retikularna/FDRC osnova
očuvana
kondenzovana, iskidana
Germinativni centri
granica
jasna
nejasna,”back to back”
veličina i oblik
nejednaki
relativno jednaki
mantle zona
prisutna
odsutna ili uska
polarnost folikula
često prisutna
nedostaje
perinodalno tkivo
odsutni folikuli
prisutni folikuli uz fibrozu
mitoze
brojne
retke
Citologija folikula
centrociti
malobrojni
mnogobrojni
centroblasti
mnogobrojni
malobrojni
”starry sky”
upadljiv
nema
Interfolikularna zona
mešovita ćelijska populacija
sitne ćelije (centorc.)
plazmociti
često (poliklonski)
ponekad (monoklonski)
imunoblasti
nema
ponekad
inflamatorni infiltrat
nema
prisutan
Imunohistohemija
CD20
+
+
CD10
+ (slabo)
+
BCL2
-
+
Ki-67
visok
nizak
Fascin u FDRC
+
Genetika
klonalnost
poliklonska
monoklonska
rearanžman BCL2
nema
ima, t(14;18)
Tabela 2. Histološke, imunohistohemijske i genetske karakteristike korisne za razlikovanje FH i folikularnog NHL
Toxoplasma limfadenitis
Toxoplasma gondii je jedan od najuspešnijih parazita na našoj planeti jer je njime inficirano više od trećine čovečanstva. Otkrivena je 1908. godine u Tunisu (Nicolle i Manceaux). Uzročnik je oko 15%-20% svih
limfadenopatija. Prenosioci toksoplazme najčešće su mačke i, znatno ređe, psi. Jedan od čestih puteva infekcije je konzumiranje termički nedovoljno obradjenog mesa i povrća. Ređi putevi prenošenja obuhvataju laboratorijske infekcije, infekcije preko transfuzije krvi i transplantiranih organa i infekciju nerođenog ploda
preko majke (14).
Životni ciklus toksoplazme je osoben utoliko što se seksualni razvoj odigrava samo kod životinja iz porodice mačaka, a aseksualni kod svih ostalih domaćina. Kod mačke se razvoj parazita završava stvaranjem neinfektivnih oocista, koje inficirana mačka stolicom izbacuje u spoljnu sredinu. Posle 48 sati na spoljnoj temperaturi, ove oociste prelaze u spore i postaju visoko infektivne i veoma izdržljive: mogu da prežive u zemljištu do 18 meseci. Otporne su na uobičajene dezinficijense, a uništavaju ih isušivanje i temperatura iznad
60oC. Kod svih ostalih prelaznih domaćina, uključujući i čoveka, odvija se životni ciklus u kome se pojavljuju tahizoiti (2-6 μm veliki polumesečasti organizmi) koji se brzo dele, i bradizoiti (unutar intracelularne ciste) koji se sporo dele.
Čovek se najčešće inficira preko usta (digestivnog trakta), unošenjem bilo tkivnih cista bilo oocista. Posle
unošenja bilo kog od ovih infektivnih oblika, pod dejstvom želudačnog soka dolazi do brzog razlaganja opne
ciste i oslobađanja parazita, koji prelaze u tahizoite i prodiru u sve vrste ćelija organizma. Međutim, infekcija
483
podstiče imuni odgovor domaćina, pa paraziti da bi se zaštitili (ponovo) prelaze u oblik bradizoita koji se
okružuju opnom (cista). Ciste se uglavnom smeštaju u tkivima slabije dostupnim imunom sistemu (centralni
nervni sistem, oko, skeletni mišić, srce). Vrlo dugo preživljavaju, praktično doživotno, izazivajući trajnu latentnu odnosno hroničnu infekciju, i ova sposobnost konverzije u manje zahtevni životni oblik i predstavlja
suštinu parazitizma Toxoplasme gondii.
Infekcija toksoplazmom je veoma rasprostranjena i zastupljena na svim krajevima Zemljine kugle. U SAD
varira od 13%-68%, zavisno od regije, pri čemu se 30% uzima kao prosek. U Evropi se zapažaju velike razlike u prokuženosti toksoplazmom: od 23-33% u Velikoj Britaniji, preko 62% u Austriji, do 67% u Francuskoj.
U velikoj studiji Đuraković-Đaković i saradnika seroepidemiološkim ispitivanjem 2936 žena u periodu 1988.
do 1997.godine utvrđena je prevalenca infekcije u 69% sa tendencijom pada tokom godina (od 88% do 39%),
sa najvećom incidencom u Vojvodini (15).
Toksoplazmoza je neobična infektivna bolest. Pored činjenice da je jedna od najčešćih infektivnih bolesti ona je u većini slučajeva asimptomatska. Kod 10-20% inficiranih može doći do uvećanja limfnih čvorova (najčešće zadnjih vratnih, ređe aksilarnih i ingvinalnih), uz lako povišenu temperaturu, malaksalost, bol u
mišićima, znojenje, kožnu ospu, pa i uvećanje jetre i slezine. Kako tegobe posle nekoliko meseci i spontano
iščezavaju, nije potrebna terapija. Sistemska toksoplazmoza je jedna od najznačajnijih oportunističkih infekcija u sklopu AIDS i jatrogene imunosupresije. Toksoplazmoza je najbitnija fetalna transplacentarna infekcija koja može da ošteti plod.
Karakteristična trijada histoloških nalaza u limfnom čvoru upućuje na toksoplazmozu: folikularna hiperplazija, sitni klasteri epiteloidnih histiocita i hiperplazija monocitoidnih B-ćelija unutar sinusoida (16). Ova
trijada ima specifičnost od 91-97% u dijagnozi toksoplazmoze što je potvrđeno i PCR analizom.
Folikuli su uvećani, krupnih, aktivnih germinativnih centara u kojima postoji povećan broj centroblasta i
veliki broj „tingible body“ makrofaga. Pojedinačne, krupne epiteloidne ćelije se vide u korteksu i parakorteksu. Prisutni su i brojni sitni klasteri epiteloidnih histiocita u parakorteksu ali i unutar germinativnih centra, što
je karakteristično za toksoplazmozu. Germinativni centri stoga imaju nepravilnu, „nazubljenu“ ivicu. Ponekad
se vide i veći klasteri epiteloidnih ćelija, tzv. „makrogranulomi“ koji sadrže više od 25 epiteloidnih histiocita. Pravih granuloma i multijedarnih džinovskih ćelija nema. Monocitoidne B-ćelije su krupne ćelije, oštrih
granica, obilne, svetle citoplazme, relativno sitnog, tamnog jedra, neupadljivog nukleolusa. Raspoređene su
u vidu plaža i ostrva oko i unutar sinusa limfnog čvora. Ponekad se nađu i perivaskularno (sl.2). Nekroza nema. Ciste parazita unutar makrofaga se retko nađu (u 1% slučajeva u AFIP-ovoj seriji). U obolelih od AIDS
brojni slobodni tahizoiti se mogu naći u raznim tkivima. Najbolje se vide u Giemsom obojenim razmazima i
inprintima. Mogu se identifikovati i imunohistohemijski.
Pozitivan serološki nalaz je najbitniji za potvrdu dijagnoze. Dijagnoza se može potvrditi i imunohistohemijski anti-Toxoplasmosa antitelom ili PCR analizom (pozitivan rezultat u 83% u slučaju postojanja karakteristične dijagnostičke trijade) (17).
Slika 2. Toksoplazma limfadenopatija
484
Toksoplazma limfadenitis sa folikularnom hiperplazijom (FH), klasterima epiteloidnih histiocita (EH) u
parakorteksu i u germinativnim centrima i hiperplazijom monocitoidnih B-ćelija (HMC), H&E.
Diferencijalno dijagnostički na prvom mestu je limfadenitis u sklopu HIV infekcije i lajšmanijaze. Infektivna
mononukleoza, bolest mačije ogrebotine i citomegalovirusni limfadenitis u ranoj fazi morfološki liče na toksoplazmozni limfadenitis. Sarkoidoza može predstavljati problem ali u njoj obično postoje jasno formirani granulomi i džinovske ćelije se uvek nađu. Dermatopatska limfadenopatija dolazi u obzir, ali nju odlikuje prisustvo melanina i lipida. Ponekad se sinus histiocitoza sa masivnom limfadenopatijom (Rosai-Dorfmanova bolest) zameni za toksoplazmozu ali se u ovoj bolesti histiociti nalaze unutar proširenih sinusa, a ne u tkivu. Neke
forme NHL (Lennertov T-ćelijski NHL) mogu imati klastere epiteloidnih histiocita kao i Hodgkinov limfom.
Limfadenopatije u XXI veku
Silikonska limfadenopatija
Medicinski silikon se sastoji od polimera dimetilsiloksana. Postoji u čvrstoj formi (sličnoj gumi), kao gel
i kao ulje. Sve tri forme se široko upotrebljavaju kao implantati u kozmetičke, ortopedske ili rekonstruktivne svrhe (naročito dojke po mastektomiji). Silikonsko ulje, gel ili guma su potencijalni bioaktivni agensi koji
mogu da izazovu reakciju tkiva domaćina. Silikonski implantati mogu da rupturiraju (što su stariji mogućnost
rupture je veća), a ubrizgani gel ili ulje mogu da se rasprše po tkivima i da dospeju u limfotok i krvotok kojima se šire na udaljena mesta, uključujući i limfne čvorove (20). Jedna od čestih komplikacija ovih ruptura je
silikonska limfadenopatija sve više dolazi kao diferencijalno dijagnostički problem i u klinici i u patologiji.
Silikonska limfadenopatija može nastati u regionalnim limfnim čvorovima kao reakcija na silikonske implantate u dojkama i na drugim mestima, usled direktnog ubrizgavanja silikona ili posle artroplastike malih
zglobova. Prvi put je opisana 1978. godine (18). Najčešće se pojavljuje u aksilarnim limfnim čvorovima kada se klinički često zameni za metastazu karcinoma dojke. Incidenca silikonske limfadenopatije kod artroplastike malih zglobova se kreće od 1,8% do 13% (19). Može se javiti i nekoliko godina po ugrađivanju proteze. Silikon se, ako nije nestao prilkom obrade tkiva, lako prepoznaje u tkivu. U vidu je sitnih, providnih kapi
amorfnog materijal koji ne polarizuje. Preseci deblji od 4μm (najbolje 10-30μm) su najbolji za njegovu identifikaciju jer se onda silikon ne gubi pri procesiranju tkiva.
Morfološki, normalna nodalna arhitektura je zamenjena sitnim i krupnim vakuolama koje deluju ili kao
„prazne“ (jer je silikon ispran prilikom obrade tkiva) ili sadrže zaostale silikonske depozite (20). Džinovske
ćelije tipa stranog tela i granulomi (silikonomi) se mogu naći u sinusima i parenhimu (sl.3).
Slika 3. Silikonska limfadenopatija
485
U limfnom tkivu se vide brojne sitne i krupne vakuole koje deluju ili kao „prazne“ (jer je silikon ispran
prilikom obrade tkiva) ili sadrže zaostale silikonske depozite u vidu sitnih, providnih kapi amorfnog materijal. Detalj: džinovske ćelije tipa stranog tela sa silikonskim kapima u citoplazmi, H&E.
U citoplazmi džinovskih ćelija se može naći silikon i inkluziona telašca. Mogu se videti i makrofagi penušave citoplazme, uz upadljivu sinus histiocitozu. Silkon se može identifikovati infracrvenom spektroskopijom ili bojenjem na Oil red O (ne uspeva uvek).
Klinički podaci su presudni za postavljanje dijagnoze. Diferencijalno-dijagnostički u obzir dolaze razna
nakupljanja lipidnih materija (lipidna limfadenopatija), Whippleova bolest i atipične mikobakterioze. U poslednje dve se diferencijacija lako izvrši bojenjem na PAS ili prikazivanjem acido-rezistentnih bacila.
Lipidna limfadenopatija
Granulomatozna reakcija po tipu stranog tela na lipide u obliku lipogranuloma se može videti u limfnim
čvorovima. Lipidna limfadenopatija je česta u starijih i gojaznih, kod dugotrajne parenteralne ishrane, kod
raznih lezija žučne kese i žučnih puteva, u blizini hematoma, nekroza i nekih tumora. Uz to se može pojaviti
kao posledica davanja kontrasta na bazi ulja. Nekada su se ovakvi kontrasti davali u limfografiji (21), a danas
se ponekad daju u angiografiji. Depo lekovi koji se daju u vidu lipidnih rastvora mogu dovesti do ove limfadenopatije. Mi smo imali dva slučaja neobične lipidne limfadenopatije: u submandibularnom limfnom čvoru
po ubrizgavanju Botoxa radi zatezanja lica (sl.4A); u aksilarnom limfnom čvoru kao posledicu akumpukture.
Sinusni sistem je proširen i ispunjen makrofagima koji u citoplazmi sadrže masne kapljice različite veličine koje imponuju kao prazne vakuole. Uz njih se vide epiteloidne i džinovske ćelije tipa stranog tela, ali nema pravih granuloma (sl.4B). Mogu se naći limfociti i plazmociti, a ponekad i eozinofili. Lipidne kapljice se
mogu videti i unutar atrofičnih germinativnih centara.
Diferencijalno dijagnostički, pored silikonske limfadenopatije u obzir dolaze i infekcije atipičnim mikobakterijama i gljivicama kao i Whippleova bolest.
Slika 4.
A. Lipidna limfadenopatija kao posledica ubrizgavanja Botoxa.
Narušena građa limfnog tkiva usled prisustva brojnih krupnih masnih kapi bez ikakve reakcije u tkivu, H&E.
B. Lipidna limfadenopatija.po ubrizgavanju kontrasta za angiografiju.
Narušena građa limfnog tkiva usled prisustva brojnih masnih kapi i nakupljanja džinovskih ćelija tipa stranog tela, H&E. Detalj: Džinovske želije tipa stranog tela koje okružuju lipidne kapi. U citoplazmi se vide masne kapi, H&E.
486
Imati u vidu:
Reaktivne limfadenopatije mogu imati dramatičnu i „divlju“ histološku sliku tako da se lako mogu pogrešno dijagnostikovati kao limfom što može imati katastrofalne posledice po pacijenta.
U razlikovanju folikularne hiperplazije od folikularnog NHL, prisustvo folikula van kapsule, pogotovo uz
fibrozu, govori u prilog limfoma. Interfolikularno prisustvo centrocita je odlika folikularnog NHL.
Germinativni centri u folikularnoj hiperplaziji su imunohistohemijski BCL2 negativni. Uvek imati na umu
BCL2 negativan folikularni NHL. U slučaju sumnje na BCL2 negativan folikularni NHL obavezno uraditi
FISH ili PCR jer postoji BCL2 rearanžman.
Manje monoklonske B- i T-ćelijske populacije se mogu naći u reaktivnoj hiperplaziji. Ovakav nalaz uvek
tumačiti u kontekstu kliničke i morfološke slike.
Ako posle svih dostupnih ispitivanja niste sigurni da li je reč o FH ili nekom NHL bolje se izjasniti da je
benigno, uz savet da se bolesnik klinički prati (watch and wait).
Toksoplazmozni limfadenitis odlikuje trijada: folikularna hiperplazija, sitni klasteri epiteloidnih histiocita i hiperplazija monocitoidnih B-ćelija unutar sinusoida. Ovaj morfološki nalaz se mora potvrditi serološki
i/ili imunohistohemijski i PCR reakcijom u tkivu.
Klinički podaci o kozmetičkim, rekonstruktivnim ili ortopedskim protezama kao i o davanju kontrasta i lekova na bazi ulja su presudni za postavljanje dijagnoze silikonske ili lipidne limfadenopatije.
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2. Chau I, Kelleher MT, Cunningham D, Norman AR, Wotherspoon A, Trott P, Rhys-Evans P, Querci Della Rovere G,
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3. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician. 1998;58(6):1313-20.
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Cabecadas, P Gaulard, B Jasani, JF Garcia, M Ott, ML Hannsmann, F Berger, M Hummel, F Davi, M Bruggemann,
FL Lavender, E Schuuring, PA Evans, H White, G Salles, PJ Groenen, P Gameiro, Ch Pott, and JJ Dongen. Improved
reliability of lymphoma diagnostics via PCR-based clonality testing: report of the BIOMED-2 Concerted Action
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11.Langerak AW, Molina TJ, Lavender FL, Pearson D, Flohr T, Sambade C, Schuuring E, Al Saati T, van Dongen JJ, van
Krieken JH. Polymerase chain reaction-based clonality testing in tissue samples with reactive lymphoproliferations:
usefulness and pitfalls. A report of the BIOMED-2 Concerted Action MH4-CT98-3936. Leukemia. 2007;21(2):222-9.
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in reactive lymphoid hyperplasia: byproducts of the germinal centre reaction or indicators of lymphoma? Hematol
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and reactive lymphadenopathy in lymph node biopsies by gene expression profiling. BMC Med Genomics. 2011;4:27.
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Srbiji kao osnov programa prevencije kongenitalne toksoplazmoze. Srp Arh Celok Lek. 2003, 31(3-4):162-167.
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19.Péoc’h M, Duprez D, Grice G, Fabre-Bocquentin B, Gressin R, Pasquier B. Silicone lymphadenopathy mimicking a
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Difuzni B krupnoćelijski limfom:
varijante, podgrupe i podtipovi
Diffuse large B cell lymphoma: variants,
subgroups and subtypes/entities
Maja Peruničić Jovanović
Maja Perunicic Jovanovic
Služba za patohistologiju, Klinički centar Srbije,
Beograd, Srbija
Department of Pathology, Clinical Center of Serbia,
Belgrade, Serbia
Apstrakt
Difuzni B krupnoćelijski limfom (DBKL) je
najčešći limfoidni tumor i predstavlja klinički, patološki i biološki veoma heterogenu grupu tumora. Novije studije su podelile difuzne B krupnoćelijske limfome u različite morfološke varijante, molekularne i imunofenotipske podgrupe i entitete.Imunofenotipska podela DBKL, na tip porekla germinativnog centra (GCB) i negerminativnih (non-GCB), koristeći kombinaciju antitela CD10, BCL6 i MUM1, ne korelira u potpunosti sa profilom genske ekspresije, GCB tipa i aktiviranih B ćelija (ABC). Neke studije su pokazale
da kombinacija ekspresije CD10, BCL6 i MUM1
može podeliti pacijente sa DBKL u one sa dužim
i kraćim preživljavanjem.Klasifikacija Svetske
Zdravstvene Organizacije (SZO) iz 2008. godine prepoznaje grupu agresivnih B ćelijskih limfoma koja se ne može klasifikovati ni kao Burkitt-ov
limfom ni DBKL, i kategoriju B ćelijskih neoplazmi sa karakteristikama između DBKL i klasičnog
Hodgkin-ovog limfoma.Takođe, nova klasifikacija
prepoznaje starosno doba pacijenta, mesto nastanka tumora i kliničke faktore u definisanju varijanti
DBKL. Klasifikacija SZO iz 2008. je rezultat uspešne međunarodne saradnje između patologa, biologa i kliničara, ali heterogena grupa DBKL će i
dalje biti predmet istraživanja.
Ključne reči: difuzan veliki B ćelijski limfom,
WHO klasifikacija, genski profil
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most
common type of lymphoma worldwide, and represents
a clinically, pathologically and biologicaly very heterogeneous group of tumours. Recent studies have subdivided diffuse large B cell lymphomas into morphological
variants, molecular and immunophenotypical subgroups and distinct entities. An immunophenotypical subdivision of DLBCL, into germinal centre-like (GCB)
and non-germinal centre-like (non-GCB) subgroups,
using a combination of antibodies to CD10, BCL6 and
MUM1, does not correlate exactly with gene expresion
profile of GCB and activated peripheral B-cells (ABC).
Some studies reported that combination of CD10, BCL6
and MUM1 expression could subdivide DLBCL patients into long- and short-time survivors.The WHO
classification of 2008. recognizes a group of aggressive B-cell lymphomas that are not readily classified as
either Burkitt lymphoma (BL) or DLBCL, and provisional category of B-cell neoplasms with features intermidiate between DLBCL and classical Hodgkin lymphoma. Furthermore, the new classification recognizes
the patient age, site-specific categories, and clinical factors in defining variants of DLBCL.The WHO classification of 2008. is the result of successful international
collaboration among pathologists, biologists and clinicians, but heterogeneous group of DLBCL will be the
subject of further investigation.
Key words: diffuse large B cell lymphoma, WHO
classification, gene expresion profil
Uvod
Difuzni B krupnoćelijski limfom (DBKL) je najčešći limfoidni tumor i čini oko 30-40% svih non-Hodgkin limfoma kod odraslih, sa petogodišnjim preživljavanjem oko 50%1. Predstavlja grupu tumora koja je
heterogena po svom kliničkom ishodu, morfologiji, imunofenotipu, molekularnoj genetici i citogenetici 1,2.
Morfološka, biološka i klinička heterogenost je prepoznata od strane Svetske Zdravstvene Organizacije (SZO),
tako da u Klasifikaciji tumora hematopoetskog i limfoidnog tkiva SZO iz 2008. postoje različite morfološke
varijante DBKL, molekularne i imunohistohemijske podgrupe DBKL, kao i različiti klinički entiteti. DBKL
koji nisu drugačije specifikovani (not otherwise specified, NOS) obuhvataju one tipove DBKL koji ne pripadaju specifičnim podtipovima ili entitetima1.
489
Promene u klasifikaciji limfoma, koje su rezultat novih saznanja nastalih na osnovu kliničkih i laboratorijskih istraživanja, su pokušaj da se bolje definiše heterogenost ovih bolesti. Klasifikacija limfoma iz 2008.
godine, predviđa prepoznavanje ranih i in situ lezija, prepoznavanje starosne dobi kao karakteristike određenih limfomskih entiteta, kako kod starijih osoba tako i kod dece, kao i prepoznavanje „border-line“ kategorija2. Takođe, u Četvrto izdanje klasifikacije Tumora Hematopoetskog i Limfoidnog tkiva, uključeni su i neki
provizionalni entiteti 1,2 (Tabela 1.).
Tip
Difuzni B krupnoćelijski limfom,
(DBKL) NOS
Difuzni B krupnoćelijski limfom, podtipovi
Ostali limfomi krupnih B ćelija
“Borderline” limfomi
B-ćelijski limfom, neklasifikovan, sa karakteristikama
između DBKL i Burkitt-ovog limfoma
B-ćelijski limfom, neklasifikovan, sa karakteristikama
između DBKL i Hodgkin-ovog limfoma
Morfološke varijante
Centroblastni
Imunoblastni
Anaplastični
Retke morfološke varijante
Molekularne podgrupe
GCB tip
ABC tip
Imunohistohemijske podgrupe
CD5 + DBKL
GCB
Non-GCB
DBKL T-cell/histiocyte-rich tip
Primarni DBKL centralnog nervnog sistema
Primarni kutani DBKL, leg type
EBV pozitivni DBKL starijih
Primarni medijastinalni B krupnoćelijski limfom
Intravaskularni B krupnoćelijski limfom
DBKL udružen sa hroničnom inflamacijom
Limfomatoidna granulomatoza
Intravaskularni B krupnoćelijski limfom
ALK+ B krupnoćelijski limfom
Plazmablastni limfom
Krupnoćelijski limfom udružen sa HHV8+
Castleman-ovom bolešću
Primarni efuzioni limfom
Tabela 1. Klasifikacija tumora hematopoetskog i limfoidnog tkiva
Difuzni B krupnoćelijski limfom, NOS (Diffuse large B cell lymphoma, not otherwise specified;
DLBCL, NOS)
Difuzni B krupnoćelijski limfom je neoplazma difuznog tipa rasta, sastavljena od krupnih limfoidnih ćelija koje eksprimiraju B ćelijske antigene (CD20, CD79α, ili Pax-5)1. Obično nastaju de novo, kao primarni,
ali mogu nastati i transformacijom manje agresivnih limfoma kao što su hronična limfocitna leukemija, folikularni limfom, limfom marginalne zone ili limfoplazmocitni limfom. Najčešće se javlja u sedmoj deceniji života, ali se može videti i kod dece. Nešto je češći kod muškaraca u odnosu na žene. Bolest se prezentuje
kao brzorastuća nodalna ili ekstranodalna tumorska masa, kod imunokompetentnih, ali i kod pacijenata sa različitim oblicima imunosupresije 1,2.
490
Imunohistohemijska analiza je postala integralni deo dijagnostičke hematopatologije i neophodna je u dijagnostici limfoma3,4. Ograničen panel antitela (CD20, CD79α, CD10, BCL-6, MUM-1/IRF-4 i CD138) može mnogo pomoći u svrstavanju različitih tipova limfoma u skladu sa morfološkim izgledom i stepenom diferencijacije 4. Određeni markeri korespondiraju sa setom ključnih proteina uključenih u ćelijski ciklus, apoptozu i B ćelijsku diferencijaciju 4,5.
U poslednjih 10 godina, na osnovu istraživanja u oblasti molekularne genetike i imunohistohemije, napravljen je veliki napredak u subklasifikaciji DBKL u klinički relevantne grupe: porekla germinativnog centra (GCB) i non-GCB tip ili aktiviranih B ćelija (ABC). Stadijum diferencijacije B limfocita na kome se dešava neoplastična transformacija može definisati biološko ponašanje i ishod bolesti kod pacijenata sa DBKL.
Mnoge studije su pokazale da podela DBKL na grupu tumora koji imaju profil B ćelija porekla germinativnog
centra (GCB) i na grupu tumora koji imaju profil aktiviranih B ćelija (ABC odnosno “non GCB”) ima klinički značaj, odnosno da pacijenti iz GCB grupe imaju značajno bolje preživljavanje. Odkako su prepoznati biološki podtipovi DBKL na bazi „gene expression profiling”, istraživanje kliničkog značaja ovakve podele je
postalo predmet mnogih studija6,7,8. Međutim, ovakve analize nisu lako primenljive u svakodnevnoj praksi,
jer zavise od dostupnosti zamrznutih uzoraka, kao i sofisticiranih laboratorijskih metoda.
Hans i saradnici su predložili algoritam koji je baziran na imunohistohemijskoj ekspresiji sledećih markera: CD10, bcl-6 i MUM-1/IRF4, a pomoću koga se mogu razlikovati raziličite grupe DBKL 8. Kombinovanom
analizom ekspresije ovih antitela u skladu sa predloženim algoritmom može biti surogat za “gene expression”
potpis prognostički različitih tipova8. Difuzni B krupnoćelijski limfomi porekla germinativnog centra (GCB)
su imunohistohemijski CD10+ (>30% ćelija) ili CD10-, BCL-6+ i IRF4/MUM-1-1. Svi ostali slučajevi se svrstavaju u non-GCB tip (Slika 1.).
dBKL,
centroblastni
GCB tip
CD10
bcl-6
MUM-1
CD10
bcl-6
MUM-1
dBKL,
centroblastni
non GCB tip
Slika 1. Imunohistohemijski profil DBKL
DBKL koji imaju profil B ćelija porekla germinativnog centra (GCB) imaju bolju prognozu od onih koji su non-GCB tip (imaju profil aktiviranih B ćelija (ABC)8, iako neke studije ne potvrđuju ovu hipotezu9.
491
Novi entiteti
U definisanju nekoliko novih entiteta, starosno doba i mesto nastanka tumora igraju veliku ulogu. Promene
u klasifikaciji B ćelijskih limfoma su nastale kao rezultat prepoznavanja važnosti mesta nastanka tumora kao
i određenih kliničkih karakteristika10.
EBV+ DBKL starijih osoba je klinički agresivan tumor, koji najverovatnije nastaje zbog oslabljenog imunološkog statusa. Češće se javlja na ekstranodalnim lokalizacijama. Tumorske ćelije su polimorfne, mogu
podsećati na Hodgkin-ove i Reed-Strenberg-ove, uz čestu nekrozu i inflamatorni infiltrat. DBKL udružen sa
hroničnom inflamacijom je drugi EBV+ tumor sa određenim kliničkim karakteristikama, koji nastaje u specifičnim situacijama, najčešće na terenu prolongirane hronične inflamacije.
Druge specifične kategorije DBKL vezane za mesto nastanka su DBKL centralnog nervnog sistema i primarni kutani DBKL, „leg type“. Primarni kutani DBKL, „leg type“ pokazuje profil aktiviranih B ćelija (ABC)
u većini slučajeva. Takođe, primarni CNS DBKL pokazuje specifičan genski potpis, na osnovu kojeg se izdvaja kao poseban entitet.
“Borderline” limfomi
Savremene studije su skrenule pažnju na biološko, morfološko i imunohistohemijsko preklapanje između
klasičnog Hodgkin-ovog limfoma i nekih B krupnoćelijskih limfoma, posebno primarnog medijastinalnog B
krupnoćelijskog limfoma (PMBL) i medijastinalnog klasičnog Hodgkinovog limfoma, (cHL) tip nodularne
skleroze. „gene expression profiling”, analize su potvrdile biološku povezanost ovih tumora. Obe neoplazme
nastaju u medijastinumu, kod mlađih osoba1,2,10.
Klasifikacija SZO iz 2008. prepoznaje kategoriju tumora nazvanu B ćelijska neoplazma, sa karakteristikama između DBKL i Hodgkin-ovog limfoma. Ovi tumori nastaju najčešće kod mlađih muškaraca i ponašaju se agresivnije od PMBL i cHL.
Takođe, prepoznata je grupa limfoma koju nije moguće klasifikovati ni kao Burkitt ni kao DBKL.Ova kategorija je nazvana B-ćelijski limfom, sa karakteristikama između DBKL i Burkitt-ovog limfoma1,2,10. Ovi
limfomi se javljaju kod odraslih osoba i pokazuju imunofenotip germinativnog centra i podsećaju na Burkittov limfom ali nemaju citomorfološke karakteristike Burkitt-ovog limfoma.Ovaj entitet takođe uključuje slučejeve sa translokacijom i myc i bcl-2 („double hit“). Finalnu dijagnozu je moguće postaviti kao skup morfoloških, imunofenotipskih i molekularnih karakteristika1,2,10.
Terapija
Standardni terapijski pristup za pacijente sa DBKL je CHOP (cyclophosphamide, doxorubicine, vincristine, prednisone) ili u kombinaciji sa rituximab-om (R-CHOP)1,6,9,10,11. Pri donošenju odluke koji terapijski
protokol primeniti, rukovodimo se mnogobrojnim parametrima u cilju tzv. individualizacije terapije. Svakako
da najveći značaj imaju prognozni indeksi, odnosno, Internacionalni Prognostički Indeks (IPI) za agresivne
limfome, a na osnovu kojih se bolesnici dele u one sa niskim, srednjim ili visokim rizikom za nastanak progresije bolesti11. Internacionalni Prognostički Indeks (IPI), se bazira na pet nezavisnih prognostičkih faktora,
uključujući starosnu dob, Ann Arbor tumorski stadijum, nivo serumske laktat dehidrogenaze (LDH), performans status i broj ekstranodalnih lokalizacija.
Zaključak
U svim kliničkim modelima, uključujući IPI indeks, postoji značajna heterogenost u ishodu, koja se ogleda u različitom preživljavanju pacijenata sa identičnim prognostičkim skorom2,7,11. Iako značajan procenat
pacijenata sa DBKL može biti uspešno lečen kombinacijom različitih terapijskih procedura, ne postoji dostupan ni biološki ni klinički skor koji bi razlikovao pacijente koji mogu biti lečeni standardnom terapijom i one
pacijente koji zahtevaju novi terapijski pristup7,11.
492
Mnoge studije su pokazale da podela DBKL na grupu tumora koji imaju profil B ćelija porekla germinativnog centra (GCB) i na grupu tumora koji imaju profil aktiviranih B ćelija (ABC odnosno “non GCB”) ima
klinički značaj, odnosno da pacijenti iz GCB grupe imaju značajno bolje preživljavanje. Umesto skupe i teško
dostupne tehnologije “cDNA microarray gene expression profiling” može se koristiti imunohistohemijska analiza, pomoću koje je moguće klasifikovati DBKL u molekularno i prognostički različite grupe. Ovakav pristup
omogućava široku praktičnu primenu u svakodnevnoj kliničkoj praksi. Od izuzetnog značaja je identifikovati, u vreme postavljanja dijagnoze, one pacijente koji mogu imati koristi od agresivnijeg terapijskog pristupa.
Promene u klasifikaciji limfoma iz 2008. su nastale kao rezultat saradnje između patologa, kliničara, biologa u pokušaju da se poboljša preciznost dijagnostikovanja i terapijski pristup1,2,10. Dati su odgovori na moga pitanja ali istovremeno otvorena nova koja će biti predmet istraživanja u budućnosti, posebno u heterogenoj grupi DBKL, NOS.
Literatura:
1. Swerdlow S.H., Campo E., Harris N.L., Jaffe E.S., Pileri S.A., Stein H., Thiele J., Vardiman J.W. (Eds): WHO
Classification of Tumours of Haematopoietic and lymphoid Tissues. IARC: Lyon 2008
2. Jaffe E.S.:The 2008 WHO classification of lymphomas: implication for clinical practice and translational research.
Hematology Am Soc Hematol Educ Program. 2009:523-31.
3. Pileri S A, Dirnhofer S, Went Ph, Ascani S, Sabattini E, Marafioti T, Tzankov A, Leoncini L, Falini B & Zinzani P
L. Diffuse large B-cell lymphoma: one or more entities? Present controversies and possible tools for its subklassification. Histopathology 2002;41: 482-509
4. Garcia F. C, MD; Swerdlow H.S, MD. Best practices in Contemporary Diagnostic immunohistochemistry. Panel
Approach to Hematolymphoid Proliferations. Arch Pathol Lab Med 2009; 133:756-765.
5. Russell A. Higgins, MD; Jennofer E. Blankenship, MD; Marsha C. Kinney, MD: Application of Immunohistochemistry
in the Diagnosis of Non-Hodgkin and Hodgkin Lymphoma. Arch Pathol Lab Med 2008;132:441-461.
6. Lossos IS, Morgensztern D. Prognostic biomarkers in diffuse large B-cell lymphoma. J Clin Oncol. 2006;24:995-1007.
7. De Yong D, Rosenwald A, Chhanabhai M, Gaulard P, Klapper W, Lee A, et al. Immunohistochemical prognostic
markers in diffuse large B-cell lymphoma: validation of tissue microarray as perequisite for broad clinical applications- A study from Lunenburg Lymphoma Biomarker Consortium. J Clin Oncol. 2007; 25:805-812.
8. Hans CP, Weisenburger DD, Greiner TC, Gascoyne RD, Delabie J, Ott G et al. Confirmation of the molecular classification of diffuse large B-cell lymphoma by immunohistochemistry using a tissue microarray. Blood. 2004;103:275-282.
9. Gustaaf W. van Imhoff et al. Prognostic Impact of Germinal Center-Associated Proteins and Chromosomal Breakpoints
in poor-Risk Diffuse Large B-Cell Lymphoma. Journal of Clinical Oncology, 2006;25:4135-4142.
10.Jaffe S. E. and Pittaluga S.:Aggressive B-Cell Lymphomas: A Review of New and Old Entities in the WHO
Classification. Hematology Am Soc Hematol Educ Program. 2011;2011:506-14.
11.Biasoli I, Morais JC, Scheliga A, Milito CB, Romano S, Land M et al. CD10 and Bcl-2 expression combined with the
International Prognostic index can identify subgroups of patients with diffuse large-cell lymphoma with very good
or very poor prognoses. Histopathology. 2005; 46(3):328-33.
493
Problematic “Low Grade” Lesions in Lymphoproliferative Pathology
Stefan Dojcinov
All Wales Lymphoma Panel
University Hospital of Wales, Cardiff, United Kingdom
Abstract
Pathological diagnosis of lymphoproliferative processes has been associated with a high error rate of 1735%, compared to a low diagnostic error incidence of 1-3% in general histopathology. In lymphoma diagnosis, one half of the diagnostic errors result in significant clinical consequences such as delayed or inappropriate therapy, unnecessary treatment, avoidable morbidity and compromised survival.1 Inherent pathological
ambiguity of lymphoproliferative processes, interpretational subjectivity, unfamiliarity with diagnostic criteria and novel entities, lack of expert opinion, inappropriate laboratory support and poor clinico-pathological
correlation are the main reasons behind most pitfalls in this subspecialty.
Over the past 20 years, advances in classification have aided pathologists to better characterise lymphoid
proliferation. The WHO lymphoma classification has imposed additional requirements for genetic and molecular interrogations. As a result, it has now been widely advocated that diagnosis of lymphoproliferative processes is centralised and conducted in dedicated, highly specialised laboratories.2
However, even in the context of central pathology review of lymphoid proliferations, the initial steps in selecting cases for referral depend on the diagnostic skills of generalist pathologists. Their familiarity with reactive conditions many of which closely mimic neoplasms, is essential. Reactive lymphoproliferations represent 10-20% of the cases referred to subspecialist diagnostic services. This high referral rate outlines the pathological ambiguity of these conditions and their difficult differential diagnosis with lymphoma. In many instances, this is complicated by a dramatic clinical presentation resulting in high concern and “pressure” from
clinicians, which may further compromise diagnostic confidence. Such conditions comprise a variety of morphological patterns including follicular proliferations, paracortical expansions, intrasinusoidal and necrotizing processes. In the recent update of the WHO lymphoma classification there is a “plethora” of new entities which further widen the differential diagnosis of reactive lesions and “low grade” lymphomas. This particularly refers to a spectrum of early lesions which sit at the interface between the reactive and neoplastic.
In the context of this review, “low grade” lesions are not considered to represent a homogeneous group of
entities. This colloquial term is here used for diverse both reactive and neoplastic processes the clinical course of which is mostly non-aggressive, even though the morphological features may sometimes imply otherwise. Examples of difficult differential diagnoses and newly recognised entities with their clinical implications
are discussed with emphasis on the importance of clinico-pathological correlation.
Reactive lymphoproliferations with nodular architecture may mimic lymphoma (and vice versa):
Progressive transformation of germinal centres is a rare reactive process of uncertain aetiology which
may result in bulky lymphadenopathy. The morphological features mimic nodular lymphocyte predominant
Hodgkin lymphoma or follicular lymphoma. Diagnosis relies on the identification of disrupted but retained
components of the lymphoid follicles, without L&H cells. Other nodular/follicular proliferations including
florid non-specific follicular hyperplasia and hyaline vascular variant of Castleman’s disease pose a differential diagnosis with lymphomas exerting a nodular growth pattern. This relates primarily to variants of follicular lymphoma (FL)(Grade 3A/B, “floral variant”, FL with hyaline vascular changes). Appreciation of retained lymph node architecture is essential for diagnosis. Difficult cases may need clonality and genetic studies.3
“In situ” and early neoplastic lesions in lymphoproliferative pathology do exist: Follicular lymphoma
in situ is a recently recognised entity representing an early phase of neoplastic transformation with uncertain
494
potential for progression.4,5 The typical morphological and immunophenotypic features distinguish it from
partial involvement of lymph nodes by systemic lymphoma. Recognition of this condition prevents unnecessary treatment and patient anxiety. Early and “in situ” forms of other lymphomas include monoclonal B-cell
lymphocytosis 6, 7, “in situ” mantle cell lymphoma8, intestinal FL9, intraepithelial monoclonal T-cell lymphoproliferation associated with refractory celiac disease10 and early lesions of EBV positive age related lymphoproliferations.11, 12 Accurate recognition of these entities has important clinical implications.
Lymphomas may display “reactive” architectural and immunocytochemical patterns; “Aggressive”
looking morphology does not always indicate an aggressive clinical course: Follicular lymphoma grade 3B is part of the morphological spectrum of FL but appears to be different from grades 1, 2 and 3A. The
genetic makeup of grade 3B is closer to the clinically aggressive diffuse large B-cell lymphoma.13, 14 Due to
high proliferation, abundance of tingible body macrophages and immunohistochemical negativity for Bcl2
FL grade 3B could be misinterpreted as reactive follicular hyperplasia. This is particularly problematic in cases of paediatric FL.15 In adults, grade 3B is currently managed as most other aggressive large B-cell lymphoma, so accurate diagnosis of this subgroup is of high clinical relevance. However, childhood cases pursue
an indolent course, despite grade 3 morphology.
Florid, atypical blastic lymphoproliferations could be reactive: Infectious mononucleosis affects young individuals often presenting as an alarming, rapidly developing lymphadenopathy with a worrying histological appearance which may suggest lymphoma. Diagnosis relies on the identification of the polymorphous nature of the infiltrate, retention of lymph node architecture and EBV positivity. The differential diagnosis usually includes classical Hodgkin lymphoma or T-cell rich B-cell lymphoma. In very young patients
a consideration should also be given to EBV positive T-cell lymphoproliferation of childhood. Similar problems may be seen with Kikuchi lymphadenitis, drug induced or post-vaccinal reactions further expanding the
differential diagnosis. Clinico-pathological correlation is essential but early laboratory investigations (“monospot”) may be misleading.16, 17
Dramatic clinical presentation with massive or generalised lymphadenopathy is not always due to
lymphoma: Rosai – Dorfman disease (sinus histiocytosis with massive lymphadenopathy) presents with
massive localised or generalised lymph node enlargement, occasionally with extranodal involvement. Severe
constitutional symptoms are common. Diagnosis relies on the identification of an intrasinusoidal proliferation of histiocytes with a specific S100/CD68 positive immunophenotype. The course is self limiting but administration of steroids may be beneficial.16 The differential diagnosis includes non-specific sinus histiocytosis
and infection but also a sinusoidal spread of tumours such as carcinoma, melanoma, angiosarcoma, anaplastic large cell lymphoma or “villous/sinusoidal” large B-cell lymphoma. Examples of other reactive conditions resulting in a dramatic clinical presentation where the pathological diagnosis may be problematic include plasma cell variant of Castleman’s disease18 and infectious mononucleosis.
Clinical history and correlation are essential for accurate diagnosis, prognostication and choice of
management: EBV positive mucocutaneous ulcer (EBVMCU) is a localised immunosuppression associated B-cell lymphoproliferation involving skin and a range of mucosal sites, most commonly oropharynx. It
displays Hodgkin-like morphological features and is frequently misdiagnosed as such. Despite its aggressive
appearance, EBVMCU is an “early lesion” and follows an indolent course upon reduction of immunosuppression. However, with sustained iatrogenic immunosuppression this process is locally destructive and patients
may receive unnecessary aggressive treatment.11, 12 This new entity is used to highlight a range of lymphoproliferations associated with various immunosuppressive aetiologies.11, 12, 14 History of immunosuppression
is often omitted from the information available to the pathologist and some clinicians may not be aware of its
importance in the context of B-cell lymphoproliferations.14, 16, 17
495
Formalised communication between pathologists and clinicians in the form of Multidisciplinary Meetings
(MDM) would prevent most misdiagnosis due to lack of relevant clinical information. It hugely aids diagnosis and management and has become essential. Professional regulatory and advisory bodies highlight the mandatory requirement for MDMs as part of the patient management pathway.19
Key learning points:
All the common patterns of reactive lymphoid hyperplasias morphologically overlap with a range of lymphomas. Recognition of architecture retention by simple stains such as CD20, CD3 and bcl2 is often very helpful.
Difficult cases may require additional clonality or cytogenetic studies;
“In situ” and early lymphoms are being increasingly characterised. Awareness of these conditions is needed to prevent unnecessary treatment and to distinguish them from partial involvement by systemic disease;
Reactive lymphoproliferations may result in a worrying histological picture as seen in infectious mononucleosis. This is one of the most misdiagnosed reactive lymphadenitidies with potentially catastrophic clinical consequences. Clinicopathological correlation is essential but laboratory tests may be misleading;
Other reactive lymphadenitidies may have dramatic clinical presentation as seen in Rosai-Dorfman disease, Kikuchi disease and plasma cell variant of Castleman’s disease. In all these conditions conservative therapy is beneficial. While the clinical context is always important, the alarming clinical presentation and increased pressure from clinicians should not impact upon the pathological diagnosis;
Immunosuppression associated B-cell lymphoproliferations represent a wide biological and pathological
spectrum including the new entity of EBV positive mucocutaneous ulcer. Information on immunosuppressive management is frequently lacking from pathology requests. Information on immunosuppression should be
specifically sought;
Referral of reactive conditions to specialist diagnostic services is not unjustified as their precise characterisation may require complex ancillary studies which are routinely unavailable;
MDM has become an essential and mandatory principle in the management of patients.
Literature
1. Lester JF, Dojcinov SD, Attanoos RL, et al. The clinical impact of expert pathological review on lymphoma management: a regional experience. Br J Haematol. 2003;123:463-8.
2. Jaffe ES. Centralized review offers promise for the clinician, the pathologist, and the patient with newly diagnosed
lymphoma. J Clin Oncol. 2011;29:1398-9.
3. Dojcinov SD. Self-Assessment: Lymph node pathology. Current Diagnostic Pathology. 2004;10:500-10.
4. Cong P, Raffeld M, Teruya-Feldstein J, et al. In situ localization of follicular lymphoma: description and analysis by
laser capture microdissection. Blood. 2002;99:3376-82.
5. Jegalian AG, Eberle FC, Pack SD, et al. Follicular lymphoma in situ: clinical implications and comparisons with partial involvement by follicular lymphoma. Blood. 2011;118:2976-84.
6. Dagklis A, Fazi C, Sala C, et al. The immunoglobulin gene repertoire of low-count chronic lymphocytic leukemia
(CLL)-like monoclonal B lymphocytosis is different from CLL: diagnostic implications for clinical monitoring.
Blood. 2009;114:26-32.
7. Gibson SE, Swerdlow SH, Ferry JA, et al. Reassessment of small lymphocytic lymphoma in the era of monoclonal
B-cell lymphocytosis. Haematologica. 2011;96:1144-52.
8. Carvajal-Cuenca A, Sua LF, Silva NM, et al. In situ mantle cell lymphoma: clinical implications of an incidental finding with indolent clinical behavior. Haematologica. 2012;97:270-8.
9. Schmatz AI, Streubel B, Kretschmer-Chott E, et al. Primary follicular lymphoma of the duodenum is a distinct mucosal/submucosal variant of follicular lymphoma: a retrospective study of 63 cases. J Clin Oncol. 2011;29:1445-51.
496
10.Bagdi E, Diss TC, Munson P, et al. Mucosal intra-epithelial lymphocytes in enteropathy-associated T-cell lymphoma, ulcerative jejunitis, and refractory celiac disease constitute a neoplastic population. Blood. 1999;94:260-4.
11.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.
12.Dojcinov SD, Venkataraman G, Pittaluga S, et al. Age-related EBV-associated lymphoproliferative disorders in the
Western population: a spectrum of reactive lymphoid hyperplasia and lymphoma. Blood. 2011;117:4726-35.
13.Ott G, Katzenberger T, Lohr A, et al. Cytomorphologic, immunohistochemical, and cytogenetic profiles of follicular lymphoma: 2 types of follicular lymphoma grade 3. Blood. 2002;99:3806-12.
14.Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissue.
Lyon: IARC; 2008.
15.Agrawal R, Wang J. Pediatric follicular lymphoma: a rare clinicopathologic entity. Arch Pathol Lab Med. 2009;133:142-6.
16.Ferry J.A., Harris N.L. Reactive Lymphoidd Hyperplasia. In: Atlas of Lymphoid Hyperplasia and Lymphoma W.B.
Saunders Company; 1997:9-62.
17.Chan JK, Kwong YL. Common misdiagnoses in lymphomas and avoidance strategies. Lancet Oncol. 2010;11:579-88.
18.Dupin N, Diss TL, Kellam P, et al. HHV-8 is associated with a plasmablastic variant of Castleman disease that is
linked to HHV-8-positive plasmablastic lymphoma. Blood. 2000;95:1406-12.
19.National Institute forClinical Excellence. Guidance on Cancer Services: Improving Outcomes in Haematological
Cancers; The Manual: National Institute for Clinical Excellence, UK; 2003.
497
Problematic “High Grade” Lesions in Lymphoproliferative Pathology
Snjezana Dotlic
Department of Pathology and Cytology
University Hospital Centre Zagreb, Croatia
High error rate in primary lymphoma diagnosis by generalist pathologists has imposed a requirement for
a redesign of diagnostic services in this subspecialty. 1 In all developed countries and in most of the countries in transition, diagnosis of lymphoid proliferations has become centralised, relying on regional panels of
experts and dedicated specialised laboratories. However, the initial steps in the management and subspecialist referral of patients with suspected lymphoma still rely on diagnostic skills of general histopathologists.
Their detailed awareness of classification changes, diagnostic requirements and standards is essential for the
success of the diagnostic pathway.
Here a range of scenarios are highlighted where the outcome of the initial pathological assessment, before any specialist investigations have been carried out, could “sidetrack” the referral process and adversely affect management. The term “High Grade” in this context is used for lesions histologically characterised
by high pleomorphism and “blastic” appearance and also for processes with an aggressive clinical behaviour.
Over the past two decades the wealth of accumulated knowledge on the biology of lymphoid cells and lymphomas culminated in a series of classifications which emphasised the need for extensive immunophenotypic
and genetic interrogation of lymphoid proliferation in the course of pathological diagnosis. 2 As a consequence gone past are the days when treatment of lymphomas could commence after morphological assessment alone. On morphological grounds so many different aggressive lymphomas may show striking similarity. Burkitt
lymphoma (BL), blastoid variant of mantle cell lymphoma, lymphomas of the “grey zone” between BL and
diffuse large B-cell lymphoma (DLBCL), lymphoblastic lymphoma, plasmacytoid dendritic cell neoplasm
and many others may show very similar morphology. This morphological mimicry is further complicated by
similarities aggressive lymphoid malignancies may in certain circumstances show with non-haematological
malignancies and reactive, inflammatory conditions. Examples of this contentious spectrum are provided together with an update of the most recent classification changes and the impact this has made on the practicalities of pathological diagnosis and management.
Abundant reactive lymphoid infiltrate is seen in a range of different tumours: Follicular dendritic
cell tumour / sarcoma is an example of this category. This is an uncommon entity displaying a spectrum of
biological behaviour involving lymph nodes and a range of extranodal sites. The tumour cells amongst the
abundant reactive lymphoid infiltrate could show spindle cell morphology, epithelioid or Reed-Sternberg-cell
features. Accurate diagnosis relies on the recognition of the specific immunophenotype (CD21, CD23, CD35,
clusterin). 2-4 This is of benefit only if this tumour is included in the initial differential diagnosis which should
also consider tumours such as classical Hodgkin lymphoma, T-cell rich B-cell lymphoma, “lymphoepithelioma-like” carcinoma, inflammatory myofibroblastic tumour, metastatic germ cell tumour, medullary carcinoma
of breast, “B-type” thymomas, inflammatory pleomorphic sarcoma or interdigitating dendritic cell sarcoma.
Aggressive lymphomas may be negative for commonly used lymphoid lineage markers: ALK positive large B-cell lymphoma is a rare entity characterised by a high degree of pleomorphism and epithelioid morphology. 5 This aggressive lymphoma in addition displays an aberrant phenotype, lacking expression of CD45 and other lineage markers. The initial use of broad immunocytochemical screens may classify
this lymphoma as undifferentiated malignancy. A range of haematolymphoid neoplasms may display loss of
expression or are by definition characterised by the absence of markers generally considered to be robust lineage discriminators. Such tumours are myeloma, plasmablastic lymphomas, anaplastic large cell lymphoma
and classical Hodgkin lymphoma which may all pose a difficult differential diagnosis with non-haematological malignancies. Plasma cell myeloma as well as other haematological malignancies may also aberrantly
express cytokeratins, which in the context of paucity of expression of other B-cell lineage markers could be
highly confusing.6 In addition, a common tumour such as small cell carcinoma of lung on occasions expresses
498
lymphoid lineage marker PAX5 and lacks most other lineage markers, thus morphologically and immunophenotypically closely resembling lymphoblastic lymphoma. 7
Marked histiocytic infiltrate and granulomatous reaction may morphologically obscure aggressive
lymphomas: Lymphoepithelioid (Lennert) lymphoma is a morphological variant of peripheral T-cell lymphoma of unspecified type. Due to its rich histiocytic infiltrate with formation of granulomas, Lennert lymphoma is frequently misinterpreted as an inflammatory process. 2;8 Granulomatous inflammation and rich histiocytic infiltrate could be diagnostically misleading in a range of lymphoma types such as BL lymphoma 9,
classical Hodgkin lymphoma, nodular lymphocyte predominant Hodgkin lymphoma, T-cell rich B-cell lymphoma, mediastinal large B-cell lymphoma and lymphomatoid granulomatosis.10
Classification changes and how they affect practice: The update of the WHO classification (2008) introduced several new entities.2 It focused on resolving contentious differential diagnoses and providing pathologists and clinicians with therapeutically meaningful classification categories. To resolve sometimes difficult
differential diagnosis between BL and DLBCL, a new category of “B-cell lymphoma, unclassifiable, with features intermediate between BL lymphoma and DLBCL” was introduced. This “grey zone” category encompasses lymphomas with atypical, BL-like morphological features but also with atypical immunophenotypes
and genotypes, including the clinically aggressive “double hit” tumours. 11-13 The practical consequence of this
attempt at more stringent classification is that pathological diagnosis of BL and the “grey zone” overlap with
DLBCL requires mandatory genetic testing for MYC gene rearrangements but also for other most commonly
encountered genetic abnormalities which include rearrangements of the BCL2 and BCL6 genes. In addition,
patterns of MYC rearrangements in BL and those lymphomas which would fall into the “grey zone” category
are different requiring specific testing for both immunoglobulin and non-immunoglobulin gene partners. The
controversy of the differential diagnosis between BL and DLBCL has not been eliminated with the introduction of this category. The strongest criticism of this category is that it does not concern “typical” DLBCLs based on subjective assessment of morphology alone. There is accumulating evidence for the need of systematic genetic testing of morphologically typical DLBCLs which may also show a range of genotypes including
those similar to BL and with much more diversity as seen in the “double hit” cases. This could only be resolved by a consensus on systematic genetic testing of all or most of DLBCLs and with additional clinical agreement how to treat this cases which are currently still being classified using diversely different approaches. 14
This will inevitably change practice of pathologists in the near future, requiring extensive routine genetic diagnosis in the context of highly specialised laboratories.
Key learning points:
Generalist pathologists play an essential initial role in the process of centralised, sub specialist diagnosis of
lymphoid malignancies; Their awareness of non-haematological mimics of lymphoid tumours, and vice versa, is highly important for the process of case selection for the specialist referral pathway;
A range of lymphomas and non-haematological malignancies are characterised by a dense reactive lymphoid infiltrate. In the differential diagnosis even rare entities such as follicular dendritic cell sarcoma should
be considered to enable specific immunocytochemical diagnosis;
A range of high grade lymphomas harbour abundant histiocytic infiltrate and granulomatous reaction which
may obscure the underlying neoplastic process;
Lack of expression of lineage markers such as CD45, CD3 and CD20 does not exclude diagnosis of aggressive lymphomas; Other tumours may in addition mimic lymphomas, expressing markers conventionally
associated to lymphoid lineage;
New classification changes introduced even more controversy and require further consensus amongst the
experts regarding genetic classification of BL and DLBCL. Further consensus on specific treatments is also
needed in this context;
Diagnosis of haematological malignancies has become dependant on systematic genetic interrogation of
the biopsy materials; This is increasingly becoming mandatory for more and more entities and forms basis
for entity specific therapies.
499
Literature
1. Lester JF, Dojcinov SD, Attanoos RL et al. The clinical impact of expert pathological review on lymphoma management: a regional experience. Br.J.Haematol. 2003;123:463-468.
2. Swerdlow SH, Campo E, Harris NL et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissue.
Lyon: IARC; 2008.
3. Chan JK, Fletcher CD, Nayler SJ, Cooper K. Follicular dendritic cell sarcoma. Clinicopathologic analysis of 17 cases suggesting a malignant potential higher than currently recognized. Cancer 1997;79:294-313.
4. Pileri SA, Grogan TM, Harris NL et al. Tumours of histiocytes and accessory dendritic cells: an immunohistochemical approach to classification from the International Lymphoma Study Group based on 61 cases. Histopathology
2002;41:1-29.
5. Laurent C, Do C, Gascoyne RD et al. Anaplastic lymphoma kinase-positive diffuse large B-cell lymphoma: a rare
clinicopathologic entity with poor prognosis. J.Clin.Oncol. 2009;27:4211-4216.
6. Adams H, Schmid P, Dirnhofer S, Tzankov A. Cytokeratin expression in hematological neoplasms: a tissue microarray study on 866 lymphoma and leukemia cases. Pathol.Res.Pract. 2008;204:569-573.
7. Mhawech-Fauceglia P, Saxena R, Zhang S et al. Pax-5 immunoexpression in various types of benign and malignant
tumours: a high-throughput tissue microarray analysis. J.Clin.Pathol. 2007;60:709-714.
8. Spier CM, Lippman SM, Miller TP, Grogan TM. Lennert’s lymphoma. A clinicopathologic study with emphasis on
phenotype and its relationship to survival. Cancer 1988;61:517-524.
9. Schrager JA, Pittaluga S, Raffeld M, Jaffe ES. Granulomatous reaction in Burkitt lymphoma: correlation with EBV
positivity and clinical outcome. Am.J.Surg.Pathol. 2005;29:1115-1116.
10.Jaffe ES, Harris NL, Vardiman JW, Campo E, Arber DA. Hematopathology.: Elsevier, Saunders; 2011.
11.Schrader A, Bentink S, Spang R et al. High myc activity is an independent negative prognostic factor for diffuse
large B cell lymphomas. Int.J.Cancer 2011
12.Hummel M, Bentink S, Berger H et al. A biologic definition of Burkitt’s lymphoma from transcriptional and genomic profiling. N.Engl.J.Med. 2006;354:2419-2430.
13.Jaffe ES, Pittaluga S. Aggressive B-cell lymphomas: a review of new and old entities in the WHO classification.
Hematology.Am.Soc.Hematol.Educ.Program. 2011;2011:506-514.
14.Barrans S, Crouch S, Smith A et al. Rearrangement of MYC is associated with poor prognosis in patients with diffuse large B-cell lymphoma treated in the era of rituximab. J.Clin.Oncol. 2010;28:3360-3365.
500
Classical Hodgkin lymphoma – differential diagnosis and tumour
microenvironment
Slavko Gasparov
Medical School, University of Zagreb
Institute of Pathology and Cytology, University Hospital Merkur, Zagreb, Croatia
Introduction
Hodgkin lymphoma (HL) accounts for approximately 15% to 30% of all malignant lymphomas. According
to current diagnostic criteria, approximately 90% to 95% of HLs fall into the Classical Hodgkin lymphoma
(CHL) category; the remaining cases are nodular lymphocyte-predominant subtype of Hodgkin’s lymphoma
(NLPHL) which is recognized as a separate entity in the World Health Organization (WHO) classification1.
WHO classification is based on the fact that there are clear and consistent histologic, epidemiologic, immunologic, and genetic differences between NLPHL and CHL. NLPHL is an indolent germinal center (GC) B-cell
malignancy, that represents a nodular proliferation comprised of a minority of large neoplastic centroblasts with
multilobated nuclei, the so-called popcorn or lymphocyte-predominant (LP) cells. Immunohistochemically LP
cells are CD20+, PAX5+, BCL6+, EBV-LMP1-, CD30- and CD15-. Background inflammatory infiltrate represent mixture of small B and T lymphocytes1. This type of tumour is characterised clinically by a relatively
indolent course and a very good response to standard therapy in cases with low stage disease. Unfortunately,
the prognosis is unfavourable for advanced stages2.
CHL is also a clonal, malignant lymphoproliferation originating from germinal center B cells3. CHL has a
bimodal age curve in western countries, showing a peak at 15-35 years of age and a second peak later in life at
45-60 years1. A histopathologic diagnosis of CHL is based on the identification of diagnostic Reed-Sternberg
(RS) cells in an appropriate inflammatory background of mixed infiltrate by histiocytes, small lymphocytes,
eosinophils, neutrophils, plasma cells, fibroblasts and colagen. Based on characteristics of the reactive infiltrate and the specific features of neoplastic cells, cases may be subclassified into one of four subtypes: nodular
sclerosis (NSCHL), lymphocyte-rich (LRCHL), mixed cellularity (MCCHL) and lymphocyte-depleted classical Hodgkin lymphoma (LDCHL)1,4. Although most cases can be diagnosed on the basis of morphology alone, diagnostic criteria include the characteristic immunophenotype of the neoplastic population. RS cells and
variants express the CD30 and CD15 antigens in the majority of cases and lack the common leukocyte antigen CD455,6. The LMP-1 protein of EBV is expressed in approximately 25% to 50% of CHLs depending on
the histologic subtype and patient age7. The staining is membranous and cytoplasmic, and usually most neoplastic cells are positive. Etiology of CHL is still questionable, but due to the unique epidemiologic and clinical features of the disease, an infectious cause has long been suspected. Currently, immunohistochemistry
for the EBV latent membrane protein-1 (LMP-1) and nonradioactive in situ hybridization for EBV-encoded
early RNAs (EBERs) are the methods of choice for the detection of EBV in routinely fixed, paraffin-embedded tissues8. Recent data suggest that the EBV status of tumour cells in classical HL could have prognostic
significance for patients with this heterogenous disease9.
Differential diagnosis of Hodgkin lymphoma
Although most cases of CHL can now be safely classified on the basis of morphology and immunohistochemical features, distinction from some subtypes of NHL, reactive disorders, or even nonhematopoietic neoplasms can in some cases be difficult. Furthermore, the differential diagnosis between NLPHL and LRCHL can
be particularly challenging. The morphology of the neoplastic cells is of limited value because LP cells can
occur in both entities, so immunophenotyping and architecture are of paramount importance for the differential diagnosis (CD20, CD30, CD15, CD45, CD3, PD-1, CD57, EBV-LMP, EMA)10,11.
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There are some subtypes of DLBCL that exhibit morphologic and phenotypic overlap with CHL. Those
include primary mediastinal large B-cell lymphoma, THRLBCL, and EBV+ DLBCL of the elderly. There is
also „grey zone“ lymphoma group, the new category of B-cell unclassifiable lymphoma, with features intermediate between DLBCL and CHL that sometimes has to be included in the differential diagnosis1,11.
Anaplastic large cell lymphoma (ALCL) shows some morphologic and phenotypic similarities with CHL.
ALCL tumour cells may resemble RS cells or mononuclear variants, but they are usually smaller than the neoplastic cells of CHL and often show bean-shaped or horseshoe-shaped nuclei (“hallmark” cells) rather than
the round nuclei of Hodgkin cells. Peripheral T-cell lymphomas frequently show a polymorphic inflammatory background with eosinophils, neutrophils, plasma cells, and histiocytes and may contain RS-like giant
cells. For this reasons ALCL as well as the peripheral T-cell lymphoma not otherwise specified (NOS) or angioimmunoblastic T-cell lymphoma (AITL) should sometimes be included in differental diagnosis.
Microenvironment of Hodgkin lymphoma
CHL is the example of a formerly lethal lymphoma that became curable mainly due to the considerable
advances in therapeutic regimens12,13. These therapeutic improvements have transformed CHL into a curable disease in more than 85% of cases. However, a considerable percentage of patients still fail to respond to
current standard therapies requiring more intensive treatments14. Identifying subgroups of patients with poor
prognostic parameters has become the main objective of clinical and biological research. Studies on Hodgkin
and Reed-Sternberg cells- related prognostic biomarkers have been unsuccessful but the microenvironmental composition seems to be of prognostic importance. Using immunohistochemical analysis some authors
found that an increased number of tumour-associated macrophages was strongly associated with shortened
survival in patients with classical Hodgkin lymphoma and provided a new biomarker for risk stratification15.
Some other reports also now support the value of enumerating tumor-associated macrophages in pretreatment
biopsies for outcome prediction in classical HL16,17,18. Their abundant signals could explain the deregulation
of a critical apoptotic pathway in Reed-Sternberg cells that inhibits death in response to cytotoxic agents19.
In HL several biomarkers other than CD68 have been reported to be associated with treatment outcome, in
particular markers expressed by certain T-cell subsets20. A subset of regulatory T-cells (Treg) in the tumour
microenvironment characterized by a CD4+CD25+ phenotype, is also in focus of interest, given the critical role
of these cells in the modification of immune responses. FOXP3 is a master regulator of Treg cells. According
to some autors FOXP3 density can contribute to the prediction of oucome in classical Hodgkin lymphoma.
The important question is whether these findings will have a notable impact on general practice in the management of HL patients. As some authors point out, it is of pivotal importance that a personalized treatment
strategy is developed in the future treatment of patients with HL, identifying at the time of a diagnosis those
individuals with increased resistance to chemotherapy and radiotherapy21.
Literature
1. Swerdlow SH. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France: IARC;
4th edition, 2008.
2. Jackson C, Sirohi B, Cunningham D, Horwich A, Thomas K, Wotherspoon A. Lymphocite-predominant Hodgkin lymphoma – clinical features and treatment outcomes from a 30-year experience. Annals of Oncology 2010;10:2061-2028
3. Kanzler H, Küppers R, Hansmann ML, Rajewsky K. Hodgkin and Reed-Sternberg cells in Hodgkin’s disease
represent the outgrowth of a dominant tumor clone derived from (crippled) germinal center B cells. J Exp Med
1996;184:1495-1505.
4. Harris NL. Hodgkin’s disease: classification and differential diagnosis. Mod Pathol 1999; 12:159-176
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5. von Wasielewski R, Mengel M, Fischer R, Hansmann ML, Hübner K, Franklin J, Tesch H, Paulus U, Werner M, Diehl V,
Georgii A. Classical Hodgkin’s disease: clinical impact of the immunophenotype. Am J Pathol 1997; 151:1123-1130.
6. Said JW. The immunohistochemistry of Hodgkin’s disease. Semin Diagn Pathol 1992; 9:265-271.
7. Herbst H, Steinbrecher E, Niedobitek G, Young LS, Brooks L, Müller-Lantzsch N, Stein H. Distribution and phenotype of Epstein-Barr virus-harboring cells in Hodgkin’s disease. Blood 1992; 80:484-491.
8. Gulley ML, Glaser SL, Craig FE, Borowitz M, Mann RB, Shema SJ, Ambinder RF. Guidelines for interpreting EBER
in situ hybridization and LMP1 immunohistochemical tests for detecting Epstein-Barr virus in Hodgkin lymphoma. Am J Clin Pathol 2002; 117:259-267.
9. Keegan THM, Glaser SL, Clarke CA, Gulley ML, Craig FE, Digiuseppe JA, Dorfman RF, Mann RB, Ambinder RF.
Epstein-Barr virus as a marker of survival after Hodgkin’s lymphoma: A population –based study. J Clin Oncol,
2005: 23;7604-7613
10.Kamel OW, Gelb AB, Shibuya RB, Warnke RA. Leu 7 (CD57) reactivity distinguishes nodular lymphocyte predominance Hodgkin’s disease from nodular sclerosing Hodgkin’s disease, T-cell-rich-B-cell lymphoma and follicular
lymphoma. Am J Pathol 1993; 142:541-546.
11.Jaffe ES. Hematopathology. Philadelphia, PA Elsevier Saunders; 1st edition, 2011.
12.Connors JM. State of the art therapeutics: Hodgkin’s lymphoma. J Clin Oncology, 2005:23;6400-6408.
13.Diehl V, Engert A, Re D. . New strategies for the treatment of advanced stage Hodgkin’s lymphoma. Hematology/
Oncology. 2007:21;897-914.
14.David KA, Mauro L, Evens AM. . Relapsed and refractory Hodgkin lymphoma: transplantation strategies and novel therapeutic options. Curr Treat Options Oncol 2007:8;352-374.
15.Steidl C, Lee T, Shah SP, Farinha P, Han G, Nayar T, Delaney A, et al. Tumor-Associated Macrophages and Survival
in Classic Hodgkin’s Lymphoma. N Engl J Med. 2010:362(10):875-885.
16.Tzankov A, Matter MS, Dirnhofer S. Refined prognostic role of CD68-positive tumor macrophages in the context of
the cellular micromilieu of classical Hodgkin lymphoma. Pathobiology. 2010:77:301-308.
17.Farinha P. Lymphoma associated macrophages predict survival in uniformly treated patients with classical Hl. USCAP
Annual Meeting Abstracts 2011 (1257).
18.Jakovic LR, Mihaljevic BS, Perunicic Jovanovic MD, Bogdanovic AD, Andjelic BM, Bumbasirevic VZ. The prognostic relevance of tumor associated macrophages in advanced stage classical Hodgkin lymphoma. Leuk Lymphoma.
2011:10;1913-19.
19.Tzankov A, Meier C, Hirschmann P, Went P, Pileri SA, Dirnhofer S. Correlation of high numbers of intratumoral
FOXP3+ regulatory T cells with improved survival in germinal center-like diffuse large B-cell lymphoma, follicular lymphoma and classical Hodgkin lymphoma. Haematologica. 2008:93:193-200.
20.Kelley TW, Pohlman B, Elson P, Hsi ED. The ratio of FOXP3+ regulatory T cells to granzyme B+ cytotoxic T/NK
cells predicts prognosis in classical Hodgkin lymphoma and is independet of bcl-2 and MAL expression. Am J Clin
Pathol. 2007;128:958-65.
21.DeVita VT Jr, Costa J. Toward a personalized treatment of Hodgkin’s Disease. N Engl J Med. 2010;362:942-943.
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Proliferacije plazma
ćelija
Plasma cell
proliferations
Tatjana Terzić
Tatjana Terzic
Institut za patologiju, Medicinski fakultet Univerziteta u
Beogradu, Srbija
Institute of Pathology, School of Medicine University of
Belgrade, Serbia
Apstrakt
Abstract
Plazmociti su terminalno diferentovane efektorne
ćelije B-ćelijske linije. Cilj ovog rada je sveobuhvatni prikaz relevantnih podataka o fenotipu plazmocita, reaktivnih i neoplastičnih. Savremena klasifikacija
limfoproliferativnih bolesti po Svetskoj zdravstvenoj
organizaciji se zasniva na koreliranju njihovih morfoloških, histoloških, imunofenotipskih, citogenetskih i kliničkih karakteristika. Primena imunohistohemije je neophodna ne samo u dijagnostici plazmocitnih neoplazmi, već i u određivanju prognoze, kao
i evaluaciji rezidualne bolesti i relapsa.U ovom radu
je istaknut značaj imunohistohemijske analize neneoplastičnih i neoplastičnih proliferacija plazmocita u
cilju lakše dijagnostike, sa posebnim osvrtom na savremene pristupe u njihovoj subklasifikaciji.
Ključne reči: plazma ćelije, proliferacije,
klasifikacija
Plasma cells (PC) are the terminally differentiated effector cells of the B-cell lineage. The aim of
this review is to integrate relevant data on the phenotype of plasma cells, including reactive and malignant PC. The current World Health Organisation
classification of lymphoid neoplasm is based on correlation of their morphologic, histologic, immunophenotypic, genetic and clinical features. The extensive
application of imunohistochemistry is necessary in
diagnosis of plasma cell neoplasm, but also in determining prognosis as well as in evaluating residual/
relapsing disease. This review focuses on immunohistochemical analysis non-neoplastic and neoplastic plasma cell proliferation in facilitating the diagnosis and highlights the recent advances that have been
made with regard to their stratifying.
Key words: plasma cell proliferation, classification
Plasma cells: a new light at the end of B cell development
As the final mediators of a humoral response, plasma cells play a critical role in adaptive immunity. However,
the mechanisms that control the differentiation of germinal center (GC) B cells toward the plasma cell or memory B cell pathway are not known. Both cell types derive from antigen-activated B cells that have undergone the “GC reaction”, in which they specifically modify their immunoglobulin through somatic hypermutation and class-switch recombination.1
Klein et al2 report that the transcription factor Interferon Regulatory Factor 4 (IRF4) is required for the
generation of plasma cells. Transgenic mice with conditional deletion of IRF4 in germinal center B cells lacked post–germinal center plasma cells and were unable to differentiate memory B cells into plasma cells. In
addition, IRF4-deficient B cells had impaired expression of activation-induced deaminase and lacked classswitch recombination, suggesting an independent function for IRF4 in this process.2 These results identify
IRF4 as a crucial transcriptional “switch” in the generation of functionally competent plasma cells. IRF4, also
called MUM1, originally identified as the product of a proto-oncogene involved in chromosomal translocations in multiple myeloma, is capable of transforming cells in vitro and is often abnormally expressed in B
cell lymphomas.3
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Figure 1. Termination of the GC transcriptional programme and post-GC B-cell development1
The GC transcriptional programme culminates in the differentiation of a centroblast into a centrocyte through the stimulation of CD40 mediated by GC T cells that leads to repression of B-cell lymphoma 6 (BCL-6)
by IRF4 (Figure 1).1 This centrocyte stage could represent the common precursor of memory B cells and plasma cells. Inactivation of PAX5 (paired box protein 5) by an unknown stimulus and mechanism appears to
be the first step towards plasma-cell differentiation. The pre-plasmablast stage is characterized by low-levels
of immunoglobulin secretion, which results from the release of the repression of the genes encoding XBP1
(X-box binding protein 1) and J (joining) chain. The subsequent upregulation of BLIMP1 (B-lymphocyteinduced maturation protein 1) and IRF4, during a plasmablast stage, then establishes the characteristic plasma-cell phenotype. BCL-6 and BLIMP1 establish a mutual suppression loop between the centroblast and
the plasmablast and/or plasma cell, respectively. BLIMP1 represses PAX5 in plasmablasts and plasma cells;
evidence suggests that PAX5 might also repress positive-regulatory-domain-containing 1 (Prdm1), which encodes BLIMP1.4 Continued signalling through CD40 may be crucial in driving the centrocyte towards memory B-cell differentiation, and continued PAX5 expression maintains B-cell identity in memory B cells.1
Because they are terminally differentiated, end-stage cells, plasma cells do not divide. However, “plasmablasts” in extrafollicular regions or exiting GCs do undergo cell division just before they become plasma cells.1,
5 The lifespan of nondividing plasma cells varies from a few days to many months. Numerous B cell–specific surface proteins are down-regulated upon plasma cell differentiation, including major histocompatibility
complex (MHC) class II, B220, CD19, CD21 and CD22.6 The proteoglycan syndecan-1 (CD138), which recognizes extracellular matrix and growth factors, is induced on antibody-secreting B cells and is often used as
a marker of plasma cells.7 Most normal plasma cells express CD138, CD38, VS38, cIg, CD19, CD10, EMA,
CD27, CD31, hTPD52, MUM1, CD20v, CD45v and HLA-DR antigens, although there is extensive antigenic
heterogeneity reflecting a spectrum of differentiation that ranges from the immature plasmablast to the mature plasma cell. Among integrin family proteins, which mediate cell-matrix and cell-cell adhesion functions,
VLA-4 (very late antigen 4) is most predominant on plasma cells. Perhaps most important for differential homing of plasma cells, the chemokine receptors CXCR5 and CCR7 are decreased, which reduces responsiveness to the B and T cell zone chemokines CXCL13, CCL19 and CCL21.8 In contrast, expression of CXCR4,
which recognizes CXCL12 present in splenic red pulp, lymph node medullary cords and in bone marrow, remains high.8 These changes mediate movement of plasma cells from the follicles to other locations, including the bone marrow.
The signaling pathways that normal B cells utilize to sense antigens are frequently derailed in B cell malignancies, leading to constitutive activation of prosurvival pathways.9 A better understanding of these issues
will provide major insights into the mechanisms that regulate humoral immunity, as well as in those that lead to its pathological manifestations such as B‑cell lymphomas.
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Immunoglobulin Stains for Clonality Assessment
Staining for kappa and lambda light chains may help to identify the presence of an abnormal clonal population, particularly plasma cells. Immunohistochemistry is less sensitive than flow cytometry for the detection of immunoglobulin expression, as it does not detect surface immunoglobulin. Immunohistochemistry in
fixed tissue relies on some degree of cytoplasmic immunoglobulin production. Plasma cells and immunoblasts strongly express cytoplasmic immunoglobulin, whereas only a small subset of other B-cell proliferations
has detectable immunoglobulin expression by paraffin immunoperoxidase techniques.10
Non-neoplastic plasma cell proliferation
Benign polyclonal plasmacytosis (BPP) was first described in 1988 by Peterson et al. as benign polyclonal
immunoblast proliferation.11 The most common clinical presentations have been fever with leukocytosis and
skin rash. Other presenting signs include lymphadenopathy, dyspnea, hepatosplenomegaly, jaundice, and autoantibodies. The BPP cases showed an association with bacterial sepsis (Staphylococcus aureus, Pseudomonas
aeruginosa), viral infection (hepatitis C, infectious mononucleosis), serum sickness-like syndrome (streptokinase therapy) and immunological disorders and they can be interpreted as a dysregulated hyperactive immune response.12 A reactive increase of polyclonal plasma cells is common and is associated with a variety
of conditions including HIV and other infections, chronic inflammatory diseases, haemopoietic and non-haemopoietic malignant disease, angioimmunoblastic lymphadenopathy, systemic Castleman’s disease, cirrhosis, diabetes mellitus, iron deficiency, megaloblastic anaemia and haemolytic anaemia.13 Pathologically, the
plasma cells increased in number and accounted for 20–40% of nucleated cells of bone marrow. Cytological
features must be assessed as well as plasma cell number. The presence of plasmablasts and marked plasma
cell dysplasia, e.g. giant forms, striking nuclear lobulation and prominent nucleoli, are strongly suggestive of
multiple myeloma. Reactive plasma cells showed mature cytomorphology. Immunoperoxidase studies of light chain determinants for plasma cells and their precursors demonstrated a polyclonal pattern.14 In reactive plasmacytosis immunocytochemistry shows that κ- and λ-expressing plasma cells are present in a ratio of
approximately 2:1. About half the plasma cells express γ heavy chain, about a third α and the remainder µ.13
The plasma cell type of Castleman’s disease (CD) is often associated with polyclonal gammaglobulinemia and increased serum levels of IL-6. Anemia and elevated erythrocyte sedimentation rate are frequent
findings. The most frequent site of involvement is the abdomen, particularly in the small bowel mesentery.15
Lymph node sections show follicular hyperplasia with a well-defined mantle zone, surrounded by sheets of
mature plasma cells and scattered immunoblasts. Vascular proliferation or hyalinization is usually absent. In
approximately 40% of the cases the plasma cells are monotypic and express Ig lambda light chain. The plasma cell type resembles other follicular hyperplasias, such as those associated with rheumatoid arthritis, or
other autoimmune disorders. Plasma cell variant of CD should be considered in the differential diagnosis of
plasma cell neoplasms (primary lymph node plasmacytoma), polyclonal plasma cell-rich lymphoproliferative disorder (marginal zone lymphoma, lymphoplasmacytic lymphoma, Burkitt’s lymphoma with plasmacytoid differentiation, plasmablastic lymphoma, angioimmunoblastic lymphadenopathy with dysproteinemia,
Hodgkin’s lymphoma), plasma cell granuloma, syphilitic lymphadenitis, etc.
Neoplastic plasma cell proliferation
Plasma cell neoplasms encompass a group of diseases with varying clinical manifestations but with at
least one common feature, the production by neoplastic plasma cells with a monoclonal immunoglobulin
protein (M-protein, or paraprotein). These diseases include monoclonal gammopathy of undetermined significance (MGUS), plasma cell myeloma (PCM) (and its clinical variants), plasmacytoma, the monoclonal
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immunoglobulin deposition diseases (primary amyloidosis and monoclonal light and heavy chain deposition diseases) and osteosclerotic myeloma (POEMS syndrome).16
The diagnosis of a plasma cell neoplasm rests on the correlation of clinical and pathological findings. At
one end of the spectrum of plasma cell dyscrasia is monoclonal gammopathy of undetermined significance, which is the most common and relatively indolent form of plasma cell dyscrasia; this contrasts with plasma cell myeloma, which is aggressive and requires treatment. Patients presenting with MGUS demonstrate
no B-symptoms (e.g. weight loss, night sweats), no bone lesions, and no symptoms that indicate organ or tissue impairment. A low level of M-protein of <30 g/L in serum, and clonal plasma cells accounting for <10%
of total marrow cellularity, are characteristic features in MGUS.17 Recent studies indicate that the diagnosis of symptomatic multiple myeloma is always preceded by monoclonal gammopathy for 2 or more years.
Plasma cell myelomas are more advanced neoplasms and classified as either asymptomatic (smouldering) myeloma or symptomatic myeloma. In the former, the patients have either an increase in M-protein (>30
g/L) or an increase in clonal plasma cells (>10%) in the bone marrow without end organ impairment, and
lack symptoms and signs. Symptomatic myeloma is diagnosed when there is end-organ or tissue impairment
(most classically defined as the “CRAB” findings: hypercalcemia, renal insufficiency, anemia and bone lesions) with the presence of M-protein in serum or urine and bone marrow clonal plasma cells or plasmacytoma17. When there are multiple bone lesions or the disease is systemic, the clinical term is multiple myeloma
(MM), as opposed to plasma cell myeloma (plasmacytoma).
The risk that MGUS may evolve to a malignant state (MM, primary amyloidosis, macroglobulinaemia,
chronic lymphocytic leukaemia or plasmacytoma) is about 1–2% of cases per year, and patients are at risk of
progression even after 25 years or more of stable MGUS.18The differences in follow-up, treatment, and survival between MM and MGUS necessitate discrimination between these two entities. Most normal plasma
cells express CD138, CD38, CD19, CD10, CD27, CD45 and HLA-DR antigens19, although there is extensive antigenic heterogeneity reflecting a spectrum of differentiation that ranges from the immature plasmablast
to the mature plasma cell. Benign plasma cells are typically negative for CD117 and CD56. Malignant plasma cells are usually positive for CD27dim, CD28, CD56, and negative for CD19, CD20, and CD45, or dimly positive for CD45.20 However, CD45 and CD20 can be expressed at moderate or higher intensity in 10%
and 20% of cases, respectively. CD56 is negative in about 40% to 45% of MM, as it has in association with
progressive disease.21 CD117 is aberrantly expressed in 30% of cases and is a useful marker for malignancy.
Myeloid markers CD13 and CD33 or CD10 can also be identified in a small subset of cases. Myelomatous
plasma cells may express other antigens associated with different haematopoietic lineages such as CD45R,
CD25, CD2, CD420. The monoclonal antibody CD56⁄NCAM (clone 1B6) seemed to have potential for discriminating between myelomatous, MGUS and reactive plasmacytosis cells in bone marrow sections and aspirates, especially in those cases with low infiltration. 20 Of the MM samples 78% were CD56+ in smears and
92% positive in biopsies. Martín et al. did not find strong CD56 expression in MGUS samples.22 One of five
samples of polyclonal plasmacytosis was CD56+ (a case was considered to be positive for CD56 expression if
>50% of the CD138+ plasma cells expressed NCAM with an intensity on a par with that of the osteoblasts). 22
All normal and malignant PC express CD38 and CD138. However, the level of expression is different and
allows normal PC to be distinguished from malignant PC: myeloma cells express more CD138 but less CD38
than do normal PC23. Bataille et al. have never observed viable CD138– myeloma cells whereas CD38– myeloma cells.23
The normal ratio of plasma cells is 2-4 kappa-expressing cells to each lambda positive cell; a ratio of 8 (or
more) kappa to 1 lambda strongly suggests a monoclonal kappa-positive population and can be readily visualised by ISH with a plasmacytosis of approximately 5% in trephine sections. Conversely, a ratio of even 4
lambda-expressing cells to 1 kappa-positive one indicates the presence of a monoclonal lambda-positive plasma cell population.
Cytologic features of plasma cells in the bone marrow smears may vary from normal-appearing mature
plasma cells to immature and anaplastic forms. Plasmablasts show a high nuclear:cytoplasmic ratio, deep
blue cytoplasm, with or without perinuclear hof, round or irregular nucleus, fine chromatin, and one or several prominent nucleoli. Multinucleated or multilobated plasma cells may be present. Cells with cherry-red,
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round cytoplasmic (Russell bodies) or nuclear (Dutcher bodies) inclusions, as well as cytoplasmic crystals
may be present. Some plasma cells may appear like grapes and demonstrate numerous, round, Ig-containing
cytoplasmic structures (Mott and Morula cells). Blood smears may show rouleaux formation of the red blood
cells or the presence of plasma cells in various proportions. In some patients with multiple myeloma, the neoplastic cells are so immature or atypical that they are cytologically indistinguishable from large cell lymphoma
or other anaplastic tumours, including carcinoma, melanoma and acute leukaemias. Plasmablastic myeloma
and large cell lymphoma with cells having the features of immunoblasts are particularly likely to be confused.
Cytogenetics and molecular genetics are not essential for diagnosis of PCM. Conventional cytogenetic
analysis is frequently unsuccessful but it appears that the detection of deletions of 13q by metaphase analysis may have prognostic value, along with t(4;14) and deletion of TP53 by FISH24. Translocations involving
chromosomes 4, 14, and 16 as well as del17p13 (TP53) have been associated with a poor prognosis.24 DNA
aneuploidy is observed in more than 90%; these are predominantly hyperdiploid, with less than 10% being
hypodiploid, and the latter carries a poor prognosis. The t(11;14) abnormality is found in 10-15% of cases,
resulting in over-expression of cyclin D1.
Different surface molecules could be targeted as individual therapies for either well-defined MM entities
i.e., CD19, CD20, CD27 or CD117, or subpopulations of MM i.e., CD33, CD52.23 Half of MM retain CD27
and its expression is associated with a better prognosis. CD27 expression is lost with myeloma progression.23
The expression of CD117 seems to be restricted to patients with indolent MM.23 Clinical grade monoclonal
antibodies exist for CD20, CD33 and CD52 and clinical trials are ongoing for some of them.
Non-secretory myeloma, which accounts for 1% to 5% of all myelomas, is characterized by the absence
of detectable M-protein in serum and urine. The presenting features of nonsecretory myeloma are similar to
those in patients with a detectable M-protein, except for the absence of renal function impairment and hypercalcemia. The response to therapy and survival of patients with nonsecretory myeloma are similar to those of
patients with measurable M-protein.
Plasma cell leukaemia (PCL) is also a rare form of plasma cell dyscrasia (2% to 4% of all myelomas).
It is a variant of multiple myeloma characterized by greater than or equal to 2 x 109 circulating plasma cells
in one litre of peripheral blood. Pateints can present with primary PCL, or it can evolve from previously recognized multiple myeloma (secondary PCL). The primary form accounts for 60% of the cases. In primary
PCL, the constellation of adverse biologic prognostic factors in patients with advanced aggressive myeloma
is already present at diagnosis. Immunohistochemically, PCL tends to be positive for CD20 (50%) but negative for CD117 and CD56 compared to myeloma. Approximately 90% of secondary PCL cases express CD28
as compared with 30% in primary PCL. The plasma cells express cytoplasmic but not surface Ig light chain.
Primary PCL has a more aggressive clinical presentation than MM, with a higher frequency of extramedullary involvement, anemia, thrombocytopenia, hypercalcemia, and renal failure.
Plasmacytoma
Solitary bone plasmacytomas (SBP) are tumors of neoplastic plasma cells localized to a single bone and
represent 3% of plasma cell neoplasms. Some patients with SBP present with a single painful bone lesion due
to a monoclonal plasma cell infiltrate, and further studies show no evidence of myeloma elsewhere. In other
cases, SBP may be discovered during roentgenographic studies for another condition or the patient presents
with a painless swelling of the sternum, rib, or other bone. Electrophoresis of serum and urine samples reveals monoclonal protein in 24% to 72% of patients with SBP, although levels of the protein are much lower
than those patients with MM. In true solitary or multifocal osseous plasmacytomas, trephine biopsy show no
plasmacytosis and have no demonstrable clonal population of plasma cells. Most patients (70%) eventually
develop systemic disease at a median of 2 to 4 years.
Solitary extramedullary (extraosseous) plasmacytomas tend to be localized to the head and neck regions, where 80% of cases occur, although they can occur in many other parts of the body such as the gastrointestinal tract, central nervous system, and skin. The majority of the tumors do not produce detectable serum
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paraprotein (less than 25%) and the tumors rarely spread (less than 30%). Primary lymph node plasmacytomas (PLNPs) represent 2% of all extramedullary plasmacytomas and 0.5% of lymph node malignant neoplasms. PLNPs can be diagnosed only after exclusion of metastatic multiple myeloma (which metastasizes
to lymph nodes in up to 40% of cases of advanced-stage disease) and metastatic upper respiratory tract plasmacytomas (which represent 76% of extramedullary plasmacytomas and infiltrate cervical lymph nodes in
approximately 15% of cases).25 A total of 33 PLNPs have been described, primarily as single case reports, 7
of them arising in Castleman disease, plasma cell type. Because most PLNPs and other types of extramedullary plasmacytomas show mature plasma cell morphologic features relatively often and because reactive plasmacytoses form dense tumefactive plasma cell infiltrates simulating plasmacytoma in multiple body sites, as
previously reported in the upper respiratory tract.25
Monoclonal immunoglobulin deposition diseases (MIDD)
Primary amyloidosis
In this condition there is deposition of a fibrillary protein in the liver, kidneys, heart, gastrointestinal tract,
peripheral nerves and other tissues resulting in organ impairment. Diagnosis is dependent on demonstration
of amyloid protein and exclusion of secondary (non-immunoglobulin) amyloidosis. The protein binds Congo
Red dyes with apple-green birefringence when viewed under polarised light. The light chain type in primary
amyloidosis is usually lambda, presumably reflecting easier conversion of this protein, compared with kappa,
into beta-pleated sheet structures. Primary amyloidosis is always the result of a clonal plasma cell neoplasm,
but symptoms because of the amyloid deposition usually become clinically evident at a time when the plasma
cell tumor burden is relatively low; most cases have < 10% bone marrow plasma cells with low M-protein levels (< 30 g/L), similar to that seen in MGUS.16 If the plasma cell count and M-protein level are consistent
with MGUS and the patient’s symptoms are entirely attributable to organ damage from amyloid deposition,
the resulting organ failure does not constitute a criterion for the diagnosis of symptomatic PCM, and the diagnosis remains primary amyloidosis. Amyloidosis may also occur in the presence of a larger plasma cell burden and other symptoms of myeloma (≤ 10% of patients with myeloma); if the level of M-protein or the plasma cell count is sufficient for a diagnosis of asymptomatic myeloma, the diagnosis is amyloidosis and PCM.26
Light and heavy chain deposition disorders
These may present with features resembling primary amyloidosis but the protein is non-fibrillary as seen by electron microscopy and does not bind Congo Red. Abnormal protein comprising heavy or light chains (or both) is deposited in tissues such as the heart and liver leading to organ dysfunction. As with primary
amyloidosis, the associated tumor burden is usually low. In light chain deposition disease, the light chain type is usually kappa and neoplastic cells, if identifiable, are usually plasma cells. Heavy chain diseases (mu
and gamma) usually affect older individuals and involve lymph nodes, marrow, spleen and peripheral blood,
with varying lymphocytic, lymphoplasmacytoid and mature plasma cell morphology in cellular components.
Occasional examples appear to be variants of diffuse large B-cell lymphoma. Alpha chain disease differs in
presenting typically with small intestine and mesenteric lymph node involvement causing malabsorption in
younger individuals. The small bowel in alpha chain disease has histological features resembling those seen
in extranodal marginal zone B-cell lymphomas of MALT type.
Osteosclerotic myeloma is a rare form of plasma cell neoplasm (less than 1%) usually seen in POEMS
(polyneuropathy, organomegaly, endocrinopathy, M component, and skin changes) syndrome. The bone changes are characterized by osteosclerosis rather than lytic lesions. The monoclonal protein is usually IgG or IgA
type (with a marked predominance of lambda light chain) and generally less than 3 g/dL. Lymph nodes may
show Castleman disease.
509
Other plasma cell proliferations
Lymphoplasmacytic lymphoma (LPL) is a slowly progressive, clonal disorder of mature B cells, with
features of plasma cell differentiation. In some patients this can be associated with peripheral neuropathy.
Splenomegaly is frequent but not usually massive and lymphadenopathy, when present, is not usually prominent. Waldenströmľs macroglobulinemia (WM) is the term used to describe cases of LPL in which there is
an IgM paraprotein, which may be associated with hyperviscosity. Trephine biopsy histology shows irregular
nodular and paratrabecular infiltrates, with or without additional diffuse interstitial infiltration. Intrasinusoidal
infiltration is uncommon, in contrast with splenic marginal zone and mantle cell lymphomas. Plasma cells may
contain PAS-positive inclusions of immunoglobulin, which may appear in the cytoplasm (Russell bodies) or
indenting the nucleus (Dutcher bodies). The proportions of lymphocytes, lymphoplasmacytoid cells and plasma cells vary widely. There may also be scattered larger blast cells but no true para-immunoblasts or proliferation centres. Accompanying reactive mast cells are often abundant.27 The lymph nodes contain diffuse or
vaguely nodular infiltrates of mixed lymphoid cells encompassing the spectrum described above. Absence of
neoplastic follicles, expanded marginal zones or infiltrates of monocytoid B cells is important in differentiating lymphoplasmacytic lymphoma from other types of small B-cell lymphoma. Immunophenotype of LPL
is Sm IgM+ CD5- CD10- CD19+ CD20+ CD22+ CD23- CD25+ CD27+ FMC7+ CD103- CD138-. Cases
with little evidence of plasma cell differentiation may be confused with other small B-cell lymphomas; immunophenotyping can exclude chronic lymphocytic leukaemia, mantle cell lymphoma and follicular lymphoma,
but not splenic or extranodal marginal zone lymphomas.28
Plasmablastic lymphomas or lymphomas with plasmacytic differentiation
Plasmablastic tumors are composed of large cells with abundant, often eosinophilic cytoplasm and immunoblastic, anaplastic, or plasmacytoid morphology. The classification of tumors with plasmablastic morphology has become increasingly complex.29 Important features to subclassify these neoplasms include the clinical site (oral cavity, body cavity, etc), morphologic spectrum (pure immunoblasts vs mixture of immunoblasts, plasmacytoid cells, and plasma cells), differential antigen expression (CD20, CD138, immunoglobulin,
CD30, and CD56), and association with viruses10. Tumors with plasmablastic morphology typically occur in
patients with an abnormal immune state (HIV positive, posttransplantation, or the elderly). These tumors often arise in the oral cavity or other mucosal sites of the head and neck, or body cavity (PEL), or in association
with multicentric Castleman disease.30 In addition, a Kaposi sarcoma-associated herpesvirus–positive solid
lymphoma/ extracavitary PEL/human herpesvirus 8–associated DLBCL has been described, predominantly in
HIV-positive patients and shows coexpression of EBV. Atypical BL with plasmacytoid differentiation is seen
in HIV-positive patients, representing approximately 20% of AIDS-related NHL. Other tumors with plasmablastic morphology and less association with an immunocompromised state include PBL with plasmacytic
differentiation defined by Colomo et al31 as prominent immunoblasts or plasmablasts but with some admixed
smaller cells with plasmacytic differentiationand by little or weak expression of CD20, DLBCL with prominent plasmablastic/secretory differentiation, pyothorax-associated lymphoma, and PCM with a dysplastic,
plasmablastic appearance. Morphologically, the PBL of the oral cavity and the rare ALK-positive DLBCL
are composed of a very monomorphic, sheetlike proliferation of immunoblasts. PBL with plasmacytic differentiation and DLBCL with secretory differentiation (immunoblasts and plasmacytoid cells) are distinguished by the presence of centroblasts in the latter.10 CD138 and MUM-1, markers of post germinal center/terminal B-cell/plasmacytic differentiation, are useful in identifying the B-cell origin of these tumors that show
variable or negative expression of CD20 and CD79a. 10 Expression of Pax-5 has not been investigated in a
significant number of cases to be informative at the present. Non HIV patients with plasmablastic lymphoma may present with nodal, soft tissue or bone marrow disease. 31 The distinction from myeloma may be problematic. The immunophenotype can be difficult due to lack of the B antigens with weak/ absent CD19 and
510
CD20, PAX5 negative, CD138 positive, CD79 variable, MUM1 positive, CD56 positive (most), CD45 negative (usually) with a few cases expressing ALK1.32
Open questions and future challenges
The 2008 WHO classification of lymphoid neoplasms has been a major consensus effort in updating new
knowledge, concepts, and criteria in the taxonomy of plasma cell neoplasms. However, many questions still
remain.
Literature
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22-33.
2. Klein U, Casola S, Cattoretti G, Shen Q, Lia M, Mo T, Ludwig T, Rajewsky K, Dalla-Favera R. Transcription factor IRF4 controls plasma cell differentiation and class-switch recombination. Nat Immunol. 2006;7(7): 773-782.
3. Iida S, Rao PH, Butler M, Corradini P, Boccadoro M, Klein B, Chaganti RSK, Dalla-Favera R. Deregulation of MUM1/
IRF4 by chromosomal translocation in multiple myeloma. Nat Genet. 1997;17: 226-230.
4. Garcia JF, Roncador G, Garcia JF, Sanz AI, Maestre L, Lucas E, Montes-Moreno S,Fernandez Victoria R, MartinezTorrecuadrara JL, Marafioti T, Mason DY, Piris MA. PRDM1/BLIMP-1 expression in multiple B and T-cell lymphoma. Haematologica 2006; 91: 467-474.
5. Sze DMY, Toellner KM, de Vinuesa CG, Taylor DR, MacLennan ICM. Intrinsic constraint on plasmablast growth
and extrinsic limits of plasma cell survival. J Exp Med. 2000;192(6): 813-822.
6. Calame K. Immunology: end game for B cells. Nature 2001;412: 289-290.
7. Sanderson RD, Lalor P, Bernfield M. B lymphocytes express and lose syndecan at specific stages of differentiation.
Cell Reg. 1989;1: 27–35.
8. Hargreaves, D. C. Hyman PL, Lu TT, Ngo VN, Bidgol A, Suzuki G, Zou YR, Littman DR, Cyster JG. A coordinated change in chemokine responsiveness guides plasma cell movements. J Exp Med. 2001;194: 45–56.
9. Klein U, Pasqualucci L. B-cell receptor signaling derailed in lymphomas. Immunol Cell Biol. 2010;88(4):346-347.
10.Higgins RA, Blankenship JE, Kinney MC. Application of immunohistochemistry in the diagnosis of non-Hodgkin
and Hodgkin lymphoma. Arch Pathol Lab Med. 2008;132: 441–461.
11.Peterson LC, Kueck B, Arthur DC, Dedeker K, Brunning RD. Systemic polyclonal immunoblastic proliferations.
Cancer 1988;61:1350-1358.
12.Li L, Hsu P, Patel K, Saffari Y, Ashley I, Brody J. Polyclonal plasma cell proliferation with marked hypergammaglobulinemia and multiple autoantibodies. Ann Clin Lab Sci. 2006;36(4): 479-484.
13.Bain BJ, Clark DM, Lampert IA, Wilkins BS. Infections and reactive changes. In: Bone marrow pathology (3th ed)
Blackwell Science Ltd, Oxford, 2001.
14.Kojima M, Murayama K, Igarashi T, Masawa N, Shimano S, Nakamura S. Bone marrow plasmacytosis in idiopathic
plasmacytic lymphadenopathy with polyclonal hyperimmunoglobulinemia: a report of four cases. Pathol Res Pract.
2007;203(11): 789-794.
15.Dham A, Peterson BA. Castleman disease. Curr Opin Hematol 2007;14: 354–359.
16.Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, Thiele J, Vardiman JW., eds. WHO classification
of tumours of haematopoietic and lymphoid tissues. Lyon, France: IARC;2008, pp. 200–213.
17.International Myeloma Working Group. Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International MyelomaWorking Group. Br J Haemotol. 2003;121: 749-757.
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HEMATHOPATHOLOGY –Short Course 3
18.Kyle RA, Therneau TM, Rajkumer SV, Offord JR, Larson DR, Plevak MF, L. Joseph Melton LJ. A long-term study
of prognosis in monoclonal gammopathy of undetermined significance. N Engl J Med. 2002;346: 564–569.
19.Ruiz Argüelles GJ, San Miguel JF. Cell surface markers in multiplemyeloma. Mayo Clin Proc. 1994; 69: 684–690.
20.Ely SA, Knowles DM. Expression of CD56 ⁄ neural adhesion molecule correlates with the presence of lytic bone lesions in multiple myeloma and distinguishes myeloma from monoclonal gammopathy of undetermined significance
and lymphomas with plasmacytoid differentiation. Am J Pathol. 2002; 160; 1293–1299.
21.Ashcroft JA, Rawstron AC, Owen RG, Morgan GJ. Phenotyping in myeloma: identification of a rare CD19+ CD56–
subgroup.Blood 2000;96: 156a (Abstract).
22.Martín P, Santón A, Bellas C. Neural cell adhesion molecule expression in plasma cells in bone marrow biopsies and
aspirates allows discrimination between multiple myeloma, monoclonal gammopathy of uncertain significance and
polyclonal plasmacytosis. Histopathology 2004; 44(4): 375-380.
23.Bataille R,Jégo G, Robillard N, Barillé-Nion S, Harousseau JL, Moreau P, Amiot M, Pellat-Deceunynck C. The phenotype of normal, reactive and malignant plasma cells. Identification of “many and multiple myelomas” and of new
targets for myeloma therapy. Haematologica 2006; 91:1234-1240.
24.Stewart AK, Fonseca R. Prognostic and therapeutic significance of myeloma genetics and gene expression profiling.
J Clin Oncol. 2005; 23: 6339-6344.
25.Menke DM, Horny HP, Griesser H, Tiemann M, Katzmann JA, E. Kaiserling E, Parwaresch R, Kyle RA. Primary
lymph node plasmacytomas (Plasmacytic lymphomas). Am J Clin Pathol. 2001;115:119-126.
26.Campo E, Swerdlow SH, Harris NL, Pileri S, Stein H, Jaffe ES. The 2008 WHO classification of lymphoid neoplasms
and beyond: evolving concepts and practical applications. Blood 2011;117: 5019-5032.
27.Wilkins B, Buchan S, Webster J, Jones D. Tryptase-positive mast cells accompany lymphocytic as well as lymphoplasmacytic lymphoma infiltrates in bone marrow trephine biopsies. Histopathology 2001; 39: 150-155.
28.Berger F, Traverse-Glehen A, Felman P, Callet-Bauchu E, Baseggio L, Gazzo S, Thieblemont C, Ffrench M, Magaud
JP, Salles G, Coiffer B. Clinicopathologic features of Waldenstrom’s macroglobulinemia and marginal zone lymphoma: are they distinct or the same entity? Clin Lymphoma 2005; 5: 220-224.
29.Teruya-Feldstein J. Diffuse large B-cell lymphomas with plasmablastic differentiation. Curr Oncol Rep. 2005;7:
357–363.
30.Delecluse HJ, Anagnostopoulos I, Dallenbach F, Hummel M, Marafioti T, Schneider U, Huhn D, Schmidt-Westhausen
A, Reichart PA, Gross U, Stein H. Plasmablastic lymphomas of the oral cavity: a new entity associated with the human immunodeficiency virus infection. Blood 1997; 89:1413- 1420.
31.Colomo L, Loong F, Rives S, Pittaluga S, Martínez A, López-Guillermo A, Ojanguren J, Romagosa V, Jaffe ES,
Campo E. Diffuse large B-cell lymphomas with plasmablastic differentiation represent a heterogeneous group of
disease entities. Am J Surg Pathol. 2004;28: 736–747.
32.Vega F, Chang CC, Medeiros LJ, Udden MM, Cho-Vega JH, Lau CC, Finch CJ, Vilchez RA, McGregor D, Jorgensen
JL. Plasmablastic lymphomas and plasmablastic plasma cell myelomas have nearly identical immunophenotypic
profiles. Mod Pathol. 2005;18: 806-815.
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GINEKOLOŠKA PATOLOGIJA - Kratki kurs 1/GYNECOLOGICAL PATHOLOGY - Short Course 1
Patologija vulve/izabrane teme
Vulvar Pathology - Selected Topisc
Vukomanović Đurđević Biserka,
Vukomanovic Djurdjevic Biserka
Vojnomedicinska akademija Beograd, Srbija
Military Medical Academy, Belgrade, Serbia
Apstrakt
Koža vulve se razlikuje od koze drugih regija po različitoj bakterijskoj flori I uslovima trenja. Dermatološke bolesti vulvarne kože i mukoze se dele u dve grupe. Prvu grupu čine dermatoze
slične ekstravulvarnim dermatozama, a drugu čine dermatoze koje zahvataju predominantno vulvarnu regiju. Spečificne dermatoze vulve su kontaktni dermatitis, lichen planus, lichen sclerosus.
Infektivne bolesti vulve se mogu preneti direktnim
kontaktom. Prepoznavanje tipičnih mikroskopskih
karakteristika pomaze u dijagnostici scabiesa, herpes virusne infekcije i molluscum contagiosuma.
Humani papilloma virusi (HPV) su epiteliotropni
virusi i mogu uzrokovati premalgnu i malignu transformatciju epitelnih ćelija. Sledeći kriterijumi kao
što su virusne promene, klinički parametri i mikroskopski nalaz upućuju na postojanje dva puta
u karcinogenezi skvamoznog karcinoma vulve i
to HPV-zavisni put udružen sa Vulvarnom intraepitelialnom neoplazijom/VIN/ klasičnog tipa i ne
-HPV sa VIN diferentovanog (simlex) tipa često
udruženim sa lichen sclerosusom i/ili vulvarnom
hiperplazijom.Invazivni planocelularni karcinom
je najčešći karcinom vulve. Procena prognostičkih faktora je neophodna komponenta patohistoloskog izveštaja. Visoki gradus tumora, vaskularna invazija, veće dimenzije tumora i dubina invazije zaslužuju imunohistohemijsku analizu limfnih
čvorova radi nalazenja metastaskih ćelija karcinoma. Extramamarna Pagetova bolest je retka. Može
biti primarnog kožnog porekla ili udružena sa nekožnim tumorima gastrointestinalnog ili porekla
mokraćne bešike. Imunohistohemijskla analiza je
važna za odredjivanje primarnog porekla tumora.
Ključne reči: vulve, dermatoza, herpers virus,
šuga, Molluscum contagiosum, humanim papiloma
virusima (HPV), Vulvar intraepitelna neoplazija /
VIN, planocelularni karcinom, ektramamarna Pagets
bolesti
Abstract
Skin of the vulva differs from the other sites
from the different bacterial and friction features.
Dermatologic diseases of vulvar skin and mucosa
can be divided in two groups. The first includes dermatoses similar extravulvar sites,and second includes dermatoses affected predominantly vulvar region.Specific dermatoses of vulva are contact dermatitis, seborrhoic dermatitis, lichen planus, lichen sclerosus. Infectios deseases of vulva can be transmited
by direct contact. Recognition of typical microscopic findings can helped for dignosis of scabies,herpes
virus,molluscum contagiosum diseases of vulva. Human papilloma viruses (HPV) are epithelitrophic viruses and cause premalgnant and malignant
transformation of epithelial cells.According criteria like viral associated changes,clinical paramethars, microscopic features there are two pathways
in carcinogenesissquamous cell carcinoma HPVrelated pathway associated with Vulvar intraepithelial neoplasia/VIN of the classic type, and the nonHPV related with VIN of the differentiated (simlex) type frequently associated with lichen sclerosus and/or vulvar hyperplasia. Invasive squamous carcinoma is the most common carcinoma of vulva. Prognostic factors like stage, extracapsular nodal spread,infiltrative margins, vascular invasion, degree of differentiation, status of adjacent skin, stromal response, p53 overexpression are necessary for
report. High tumor grade, capillary lymphatics invasion, biger tumor size and depth invasion deserve
imunohistochemical analysis lymph nodes for metastatic cells of carcinoma. Extramammary Pagets desease is rare neoplasm. Paget desease can be primary
cutaneus vulvar disease,or associated with noncutaneous carcinoma gastrointenstinal origin or bladder
carcinoma. Immunohistochemical analysis is very
helpful to determine primary origin.
Key words: vulva, dermatoses, herpers virus, scabies, molluscum contagiosum, Human papilloma viruses (HPV), Vulvar intraepithelial neoplasia/VIN,
squamous carcinoma, extramammary Pagets desease
513
Introduction
Skin of the vulva differs from the other sites from the different bacterial and friction features. Dermatologic
diseases of vulvar skin and mucosa can be divided in two groups. The first includes dermatoses similar extravulvar sites,and second includes dermatoses affected predominantly vulvar region1.
Specific dermatoses of vulva
Contact dermatitis
Agents like hygienic, synthetic materials may cause inflammatory response of the squamous epithelium.
Histologic features are not specific and include intracellular and intercellular edema of squamous epithelim,
with edema of dermis and dillatation of blood vessels. Inflammatory infiltrtation consist lymphocytes and histiocytes, and eosinophiles may be or not prominent.
Figure 1. Dermal inflammatory infiltration Figure 2. Fungal organisms on surface vulvar skin
(HEx40)
(PASx40)
Seborrhoic dermatitis
Vulvar erruptions of in obese woman with, frictin cause, exematous apperance can have nonspecific histologic changes. Microscopic features may be akantosis, spongiosis and parakeratosis, with elongation of rete
pegs of epidermis.Mild chronic dermal inflammation persist, and finding fungal and other infectious agents
are according for the diagnosis sebborhoic dermatitis2.
Psoriasis
Vulvar psoriasis may be part of generalize disease or affect vulvar region.Erruptions have sharp dermacated
areas with red surface covered with white plaques. The clinical course can be persistent with progress in chronic and generalized disease, or have remission. Histologic findings are hypekeratosis, parakeratosis,uniform
elongation of rete pegs, lack of granular layer, thinning of stratum malpighii. Munro microabscesses are
accumulation neutrofils in the epidermis.Dermal capillares are dilated, and dermis is with edema,with minimal inflammatory cells1.
514
Lichen planus
Lichen planus may present like vulvar white plaques or lines with pruritus in the womans after 30 years
. It can be localized or generalized and can spontanous regress with exacerbations. Histologic features this
interface dermatitis are akantosis, parakeratosis, hypekeratosis and hypergranulosis with elongation of rete
pegs. Band-like lymphocytic infiltration next the epidermis is typically present and infiltrate extend in epidermis bassal cells.. Liquefaction degeneration of basal epithelial cells is present. Cytoid bodies present degenerated keratinocytes and dysceratotic cells, and they are localized in the epidermis or superficial dermis.
Lichen sclerosus (et atrophicus)
Lichen sclerosus affected predominantly postmenopausal women, but and young womens may be affected.Desease can affect any or all areas of vulva, and may extend perianal skin, or extragenital sites (neck, extremimites). Microscopic features can vary related to stage of desease. In the advanced the epithelium is atrophic, hyperkeratotic in some cases, with flattened rete pegs.In basal layers of epidermis are present edema
and hydropic degeneration what sometimes separate basal cells from the basment membrane in some cases.
Infiltration of lymphocytes in the basal and parabasal layers are visibly. Homogenisation, edema, collagenisation of the dermis are in association with mild chronic inflammation3,4.
Infectious disease of vulva- selected topics
Scabies
Infestation of scabies is related with sexual contact.Pruritic disease cause excoriation, secondary infection.
Microscopic features are epidermal irregular acantosis, focal spongiosis, psoriasiform epidermal hyperplasia
with exoskeleton on the lower stratum corneum, dermal inflammation with perivascular infiltrate of lymphocites and variable numbers of eosinophils5.
Figure 3. Exosceleton of scabies on the surfaceof Figure 4.Vulvar herpes simplex (PASx40)
vulvar skin(HEx10)
Herpesvirus infection
Herpes simplex virus hominis type 2 can be transmited by direct contact.Fever, inguinal lymphadenopathy,
dysuria, urinary retention and vesicles, pustules and painful ulcers are typical clinical findings. Microscopic
515
features of herpes simpex virus infected epithelial cell is nuclear „ground glass“ appearence and typical eosinophilic intranuclear inclusion body predominantly in the margins of lesion, and finally lysis of cells.
Imunohistohemistry for HSV is helpful for diagnosis of viral presence6.
Molluscum contagiosum
Poxyviral disease transmited with direct contact.Vulvar an perianal pruritic papules with central umbilication or punctum are present, and can be single or multiple. Microscopic findings are acantosis, spongiosis,
ballonooning degeneration of epithelial cells which contain intracytoplasmatic eosinophilic inclusion bodies
(Henderson-Paterson ) which push the nucleus on the periphery of cells.Edema and perivascular inflammation with endothelial vascular proliferation are present in the derm. Recognition of typical microscopic findings can be helped with electron mycroscopy of the virus, but wery rare analisis7.
Figure 5. Molluscum contagiosum of vulvar skin
(HEx40)
Human papilloma viruses HPV
Human papilloma viruses (HPV) are epithelitrophic viruses and cause premalgnant and malignant transformation of epithelial cells8. One-half of womens have other deaseases of genital tract cause HPV. Like other
sexually trasmited deseases, direct contact is way for infection.
Low-Risk HPV types for genital premalignant and malignant deseases are 6, 11, 42, 43, 44, IntermediateRisk HPV types are 33, 35, 39, 51, 52 and High-Risk HPV are types 16, 18, 31, 45, 56. HPV type 6,11,16,18,33
are most commonly in vulva8,9.
In the geometric style HPV started with disorders in the lowest third of epithelium where HPV include in
cell nuclei, and transform and deregulate cell cycle and inhibition of apopthosis.
Condyloma are verrucous, papilary lesions of skin or mucous membrane.This benign neoplasms may be
solitary, but may involve cervix, vagina, urethra, peranal skin and anal canal, predominantly in immunosuppresed patients.Central fibrovascular cores covered with squamous epithelium with acantosis, hyperkeratosis, parakeratosis with or without koilocytic atypia in epithelium are microscopic features . Hyperplasia an enlarging of the parabasal cells,with accentation of itracellular bridges and granular layer may be also present.
Perinucler „halos“, with picnotic or enlarged nuclei are present in the superfitial cells, and multinucleated cells
too, but they may be focal or absent.Abnormal mitosis are absent. Viral cytopathic changes are associated with HPV 6 and 11, but lack of koilocytic atypia does not exclude diagnosis of condyloma,an HPV infection8.
Vulvar intraepithelial neoplasia ( VIN) are precancerous changes of the squamous type. International Society
for Study of Vulvovaginal Disease and the International Society of Gineclogical Pathologist recommanded
the use of term VIN.
516
According criteria like viral associated changes,clinical paramethars, microscopic features there are two
pathways in carcinogenesis sqimous cell carcinoma HPV-related pathway associated with VIN of the classic
type, and the non-HPV related with VIN of the differentiated (simlex) type frequently associated with lichen
sclerosus and/or vulvar hyperplasia9,10.
Vulvar intaepithelial neoplasia, classic type are present like focal or multifocal lesions in womens with
HPV infection,and they have concomitant cervical lesion in 50%(). Risk factors are cigarete smokong, immunodeficiency. Microscoping features of VIN are high nucleo-cytoplasmatic ratio, lack of cytoplasmatic maturation of basal and parabasal layers with crowding and cellular disarray,hyperchromasia and nuclear pleomorphism, mitotic figures, parakeratosis, hyperkeratosis,individual-cell keratinisation. Koilocytosis and binucleated and multinucleated cells are present too.Skin appendages are involved often. Imunohistohemichal
analisis p16, p63, survivin are very helpful for diagnostic HPV infection in VIN11,12.
Figure 6. p16 immunoreactivity in cells of VIN Figure 7. p63 immunoreactivity in cells of VIN
(x40)
(x40)
VIN differentiated (simplex) type affected predominantly older patients, andoften associated with vulvar
inflammatory desease or lichen sclerosus. Lesion is predimninatly solitary without assotiation with cervical
desease, and HPV infection.The keratinocytes of differetiated VIN are large and pleomorphic, with eosinophilic cytoplasm in the basal and parabasal keratinocytes in the base of rete ridges.Prominent nucleoli in the enlarged nuclei are present predominantly in basal and parabasal keratinocytes.Elongation and anastomosis of
rete pegs, and keratin pearl within rete may be present. Parakeratosis is often present10.
Some patients have “mixed” VIN lesion, and the report of microscoping findings must have predominant
type of VIN.
Vulvar malignant epithelial tumors - selected topics
Vulvar squamous cell carcinoma
Invasive squamous carcinoma is the most common carcinoma of vulva. Carcinomas associated with HPV
infection affected younger patients in risk groups of smokers, immunosupresion9,13.
Morphologic subtypes of invasive squamous cell carcinoma include keratinizing, nonkeratinizing, basaloid, warty, spindled, verrucous.Prognostic factors like stage, extracapsular nodal spread,infiltrative margins,
vascular invasion, degree of differentiation, status of adjacent skin, stromal response, p53 overexpression are
necessary for report14,15,16.
517
Some authors sugest to detect dendritic cells by the Cd1a immunohistochemical analysis liike prognostic
factor17.
Figure 8.Immunoreactivity CD1a in squamous Figure 9. Metastatic cells of squamous cell carcinoma
cell carcinoma of vulva (x5)
in lymph node(HEx10)
High tumor grade, capillary lymphatics invasion, biger tumor size and depth invasion deserve imunohistochemical analysis lymph nodes for metastatic cells of carcinoma.
Figure 10. Pancitokeratin immunoreaktivity of Figure 10. CK7 immunoreactivity in cells ov
metastatic cells of carcinoma in lymph node (x10)
vulvar Paget desease (x5)
MALIGNANT GLANDULAR TUMOR OF VULVA- selected topic
Vulvar Pagets disease
Extramammary Pagets desease is rare neoplasm, predominantly in the seventh decade. Desease can be focal
or extensive. Microscopic features are typical with intraepidermal proliferation of large, atypical gladular-type cells, with granular or vacuolated cytoplasm and round nuclei with prominent nucleoli. Localisation of this
cells is predominantly in the parabasal area, singly or in clusters, but may be in diferent layers of epithelium
with “Pagetoid spread”. Mitotic figures are present, but not very frequent.
518
Paget desease can be primary cutaneus vulvar disease,or associated with noncutaneous carcinoma gastrointenstinal origin or bladder carcinoma. Immunohistochemical analysis is very helpful to determine primary origin.
Immunohistochemical finding in primary vulvar cutaneus Paget desease are CK7+, EMA+, CEA+, S100,
MelanA-, HMB45-. Immunohistochemical finding in pagetoid rectal adenocarcinoma are CK7-, CK20+,
CEA+. Immunohistochemical finding in pagetoid transitional cell carcinoma are CK7+/-,CK20+/-, CEA+,
Uroplakin+.18
Some author suggest that survivin is useful prognostic marker for vulvar Paget desease19.
Figure 11. Survivin immunoreactivity in cells of vulvar Paget desease (x5)
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2. Actas Dermosifiliogr. 2012;103(4):260-275.
3. Schwartz JL, Clinton TS. Darier’s disease misdiagnosed as severe seborrheic dermatitis.Mil Med 2011;176(12):1457-9.
4. Yasar S, Mumcuoglu CT, Serdar ZA, Gunes P. A case of lichen sclerosus et atrophicus accompanying bullous morphea. Ann Dermatol. 2011;23(Suppl 3):S354-9.
5. Sander BB, Damsgaard K. Lichen sclerosus--a neglected disease.Ugeskr Laeger. 2005;173(46):2951-4.
6. Gaspard L, Laffitte E, Michaud M, Eicher N, Lacour O, Toutous-Trellu L. Scabies.Rev Med Suisse.2006;8(335):718-22,
7. Amaral RL, Giraldo PC, Cursino K, Gonçalves AK, Eleutério J Jr, Giraldo H. Nodular vulvar herpes in an HIVpositive woman.Int J Gynaecol Obstet. 2009;107(3):255.
8. Lin HY, Linn G, Liu CB, Chen CJ, Yu KJ. 4. An immunocompromised woman with severe molluscum contagiosum that
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Tumori uterusa
Tumors of the uterus
Svetlana Milenkovic
Ginekološko akušerska klinika Višegradska, Klinički centar
Srbije, Beograd, Srbija
Gynecology and Obstetrics Clinic Visegradska, Clinical Center
of Serbia, Belgrade, Serbia
Apstrakt
Poslednja revizija klasifikacije tumora uterusa
uradjena je 2003.godine. Prema WHO, karcinomi
endometrijuma podeljeni su u dve grupe, nazvane
tip I i tip II. Tip I - grupa endometrioidnih adenokarcinoma, ima veću učestalost. Serozni i svetloćelijski adenokarcinom su u grupi II, po definiciji su
karcinomi visokog gradusa, loše prognoze, bez jasno definisanih prekursora i predisponirajućih faktora rizika. U tipu I postoji PTEN mutacija, a u tipu II prekomerna ekspresija p53, pa se ova dva biomarkera koriste u njihovoj diferencijalnoj dijagnozi.WHO je definisala trostepeni sistem u odredjivanju gradusa endometrioidnih adenokarcinoma u kome skvamozna komponenta tumora nema
uticaja. Postoje i drugi, dvostepeni, načini gradiranja ovih tumora, ali nisu opšteprihvaćeni. U odredjivanju stadijuma tumora važeća je FIGO klasifikacija 2009. u kome se tumori ograničeni na telo
uterusa dele na stadijum IA i IB.U grupi mezenhimalnih tumora izdvojen je nediferentovani sarkom,
koji se svojom morfologijom i imunohistohemijski razlikuje od leiomiosarkoma i endometrijalnog
stromalnog sarkoma. Prihvaćeni su i novi termini
kao što je UTROSCT, ali i nova teorija o nastanku karcinosarkoma. Smatra se da ovi tumori imaju
epitelno poreklo, zbog čega sarkomska komponenta pokazuje pozitivnost i na epitelne i na mezenhimne markere.Otkriven je i veliki broj novih antitela, koja u dijagnostici i diferencijalnoj dijagnostici
tumora uterusa imaju značaja samo ako se koriste
u korelaciji sa morfološkom slikom i kliničkim podacima (karcinom endometrijuma vs karcinom jajnika, adenosarkom vs adenofibrom).
Abstract
The latest version of uterine tumors classification
was done in 2003. According to WHO classification,
endometrial cancers are divided into two groups, so
called Type I and Type II. Endometrioid adenocarcinoma has a higher frequency and belongs to Type
I. Serous and clear-cell adenocarcinoma, are forming
Type II and by definition, they are high grade cancers
with poor prognosis and no clearly defined precursors and predisposing risk factors. In Type I, there is
a PTEN mutation and in Type II overexpression of
p53. These two biomarkers are used in their differential diagnosis.WHO has defined a three-step system
in determining the grade of endometrioid adenocarcinoma in which squamous component has no significance. There are other, two-step, grading systems
which are not generally accepted.2009 FIGO classification is still in use for tumor staging and according
to that tumors confined to the uterus body are divided into stages IA and IB.
In the group of mesenchyme tumors, undifferentiated sarcoma was separated, due to different morphology and immunohistochemical profile compared
to leiomyoma and endometrial stromal sarcoma. New
terms, like UTROSCT, are accepted as well as new
theory about the origin of carcinosarcoma. Common
believe is that these tumors have epithelial origin and
therefore sarcoma component showed positivity on
epithelial and mesenchymal markers too.
Large number of new antibodies was discovered which in the diagnosis and differential diagnosis
of uterine tumors are only meaningful when used in
correlation with the clinical picture and morphological data (endometrial carcinoma vs. ovarian carcinoma, adenosarcoma vs. adenofibroma).
Uvod
Endometrijalni karcinom je najčešći invazivni tumor ženskog genitalnog trakta u razvijenim zemljama
sveta, a peti po učestalosti maligni tumor žena uopšte. Dva puta češće oboljevaju pripadnice bele rase, ali je
smrtnost veća kod Crnkinja verovatno kao posledica lošeg kvaliteta zdravstvene zaštite i/ili genetskih razloga.
Na osnovu kliničkopatološke slike i molekularno genetskih promena, karcinomi endometrijuma su podeljeni u dva tipa, jednostavno nazvanih Tip I i Tip II.
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Tip I: 90% slučajeva endometrijalnih karcinoma pripada ovoj grupi. Javlja se kod premenopauzalnih i perimenopauzalnih žena, uslovljen je hroničnom estrogenom stimulacijom, a vodeći rizični faktori za njegov nastanak su: ovarijalna disfunkcija, gojaznost, dijabetes i nuliparitet. Najčešće su dobro diferentovani, simulirajući
u histološkoj slici normalne endometrijalne žlezde, pa se zbog toga nazivaju endometrioidni adenokarcinomi. Imaju dobru prognozu, a prihvaćeni patogenetski put njihovog nastanka je sledeći: povećani nivo estrogena → anovulatorni endometrijum → atipična hiperplazija (EIN) → adenokarcinom. Pretpostavka je da je
potrebno da protekne 3 do 5 godina za transformaciju od atipične hiperplazije do adenokarcinoma.
Tip II: Manje učestali tip karcinoma, od koga oboljevaju žene u sedmoj i osmoj deceniji života. Prognostički
su lošiji od prve grupe tumora, nisu uslovljeni hiperestrinizmom, dijabetesom niti gojaznošću, a razvijaju se
na terenu atrofičnog endometrijuma. Ovoj grupi pripadaju serozni i svetlo ćelijski tip adenokarcinoma.
Parametar
Tip I
Tip II
Starost
50-60 godina
70-80 godina
Gojaznost/hiperestrinizam
Česta
neuobičajena
Endometrijum
Anovulatorni
Atrofični
Prekursorna promena
Atipična hiperplazija (EIN)
Nepoznat (EIS?)
Transformacija
Spora
Brza
Tip karcinoma
Endometrioidni
Serozni ili svetloćelijski
Molekularna promena
MSI, PTEN mutacija
p53 mutacija
Familijarni sindrom
HNPCC
Način širenja
Limfni nodusi
peritoneum
Zahvatanje jajnika
Često
Retko
Prognoza
Dobra
Loša
Tabela 1. Sumirane karakteristike karcinoma endometrijuma tipa I i II
Tip I - Endometrioidni adenokarcinom¹
Mikroskopski nalaz: maligne žlezdane strukture koje odgovaraju normalnom proliferativnom endometrijumu, ali se od njega razlikuju kribriformnim rastom, viloglandularnim strukturama, većom nuklearnom atipijom nego u slučaju atipične hiperplazije, kao i oskudnom ili čak otsutnom stromom izmedju. Epitel je najčešće pseudostratifikovan, bazalno orjentisanih uniformnih jedara.Retko, i žlezdane strukture mogu biti izrazito ujednačene, tubularne, stvarajući sliku koja odgovara Sertoli ćelijskom tumoru jajnika. Često su prisutni
i penušavi histiociti u stromi, što po nekim autorima ukazuje na primarno endometrijalno pre nego na cervikalno poreklo tumora, ukoliko postoji diferencijalno dijagnostička dilema. Vrlo bitna karakteristika ove grupe karcinoma je i skvamozna diferencijacija, koja stepenom atipije može varirati: a) diskretna gnezda – morule uniformnih nekeratinizirajućih skvamoznih ćelija koja se obično vide kod EIN ili metaplazije, b)manja
polja čak i bizarne skvamozne diferencijacije sa prominentnom keratinizacijom i nuklearnom atipijom obično
udružena sa slabo diferentovanim tumorom i c) manje upadljiva područja skvamozne diferencijacije sa fokalnom keratinizacijom i većim nuklearnim gradusom koja se teško mogu razlikovati od skvamocelularnog karcinoma i obično su udružena sa slabo diferentovanim endometrioidnim adenokarcinom.
Prognostički značaj skvamozne diferencijacije nekada je bio predmet rasprave, ali se danas smatra da na
prognozu utiče samo stepen diferencijacije žlezdane komponente, pa su termini „adenoakantom“ i „adenoskvamozni“ karcinom napušteni, a prihvaćen je termin „endometrioidni adenokarcinoma sa skvamoznom diferencijacijom“. Pored ovog tipa, u grupi endometrioidnog adenokarcinoma svrstane sudrugi, redji podtipovi²sa:
1) mucinoznom 2) tubalnom (cilijarnom) 3) sekretornom 4)skvamoznom(tranziciocelularnom) diferencijacijom, kao i 5)viloglandularni tip.
Mucinozna diferencijacija: često je prisutna kao minor komponenta uobičajenog tipa endometrioidnog
adenokarcinoma i definiše se prisustvom veće količine intracelularnog mucina. Svojom histološkom gradjom
odgovara endocervikalnom tipu žlezda, ali se mnogo češće sreće u endometrijalnim nego endocervikalnim karcinomima. U retkim slučajevima može se uočiti gastrična ili intestinalna diferencijacija karcinomskih ćelija.
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Tubalna diferencijacija: tubalna diferencijacija je uobičajena i u benignom i u maligno izmenjenom endometrijumu. Termin se koristi u slučajevima veoma izraženog prisustva cilija na površini karcinomskih ćelija
i po definiciji, ovaj karcinom pripada grupi dobro diferentovanih tumora.
Sekretorna diferencijacija: retka je i karakteriše se prisustvom bazalnih ili supranuklearnih vakuola slično
rano sekretornoj fazi, ali su žlezde veće, nepravilnije, sa pregradjivanjem lumena.
Viloglandularni karcinom: dominantna histološka slika su brojne razgranate papile diskretne vezivno
tkivne strome, obložene pseudostratifikovanim endometrioidnim epitelom. U većem broju endometrioidnih
adenokarcinoma (čak i do 30%) može se uočiti izvestan stepen viloglandularne gradje, ali je u samo manje
od 5%slučajeva dominantan mikroskopski nalaz. Postoje izvesna neslaganja oko prognostičkog značaja
ove karcinomske forme u zavisnosti od studije, ali se misli da nema bitne razlike u odnosu na uobičajeni tip
diferencijacije.
FIGO sistem odredjivanja histološkog gradusa
Gradus 1
Manje od 5% tumora su područja solidne gradje
Gradus 2
Područja solidne gradje obuhvataju 5 – 50% tumora
Gradus 3
Područja solidne gradje obuhvataju preko 50% tumora
Napomena: izražena nuklearna atipija povećava gradus tumora za jedan stepen, a prisustvo skvamozne
diferencijacije ne utiče na gradus tumora
Tabela 2. Histološki gradus endometrioidnih adenokarcinoma
Postoje i drugi predloženi načini odredjivanja stepena diferencijacije, jer se kao najveći nedostatak FIGO
sistema ističe problem pri odredjivanju donje predložene granice -5% solidnog rasta izmedju gradusa 1 i 2,
kao i mala razlika u prognozi izmedju njih (92% vs 88% 5-godišnjeg preživljavanja).
Taylor i saradnici predlažu binarni sistem u kojima kod gradusa 2 tumor pokazuje više od 20% solidnog
rasta, što daje veću reproducibilnost u odnosu na trostepeni sistem (κ 0,97 vs 0,53 ).
Lax i saradnici³ takodjesugerišu binarni sistem u kojima o gradusu 2 tumora odlučuju prisutna dva ili više
parametra od sledećih predloženih: (1) više od 50% tumora je solidnog načina rasta (nema uticaja da li se
o radi o skvamoznim ili neskvamoznim poljima), (2)difuzno infiltrativna vs ekspanzivna miometrijalna invazija (3) tumorska nekroza. Za tumore koji su ograničenina endometrijum, 50% ili više solidnih polja i tumorska nekroza odredjuju visoki gradus tumora.U njihovoj analizi postignuta je visoka korelacija u odnosu
na 5-godišnje preživljavanje, ali se kao osnovni nedostatak ističe primenjivost samo na već operisane pacijente, jer je važan kriterijum način miometrijalne invazije.
Endometrioidni adenokarcinom Serozni adenokarcinom
Slika 1. Histološki tipovi carcinoma endometrijuma
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Imunohistohemijski profil: Endometrioidni adenokarcinomi pokazuju ekspresiju pan-citokeratina, EMA,
CA125, dok je ekspresija CEA neuobičajena. Skoro svi su CK7 pozitivni i CK 20 negativni, a mucinozna varijanta je nekada CDX2 pozitivna. Za razliku od ostalih karcinoma, endometrioidni su izrazito vimentin pozitivni. FIGO gradus I i II tumora ispoljavaju pozitivnost za ER i PR kao i oko polovine slučajeva gradusa
3.p53 ekspresija nije uobičajena u gradusu 1 i samo je minimalno izražena u gradusu 2, ali je prisutna u velikom broju slučajeva gradusa 3. Manji panel imunohistohemijskih markera može biti koristan u diferencijalnoj dijagnozi izmedju primarnih endometrijalnih i endocervikalnih karcinoma: p16fokalno+/ER+/PR+ je
profil endometrijalnih, dok se p16difuzno+/ER-/PR- sreće u endocervikalnim tumorima.
Tip II
Ovoj grupi pripadaju dva tipa endometrijalnog karcinoma: serozni (sinonim serozni papilarni adenokarcinom) i svetloćelijski (clear cell) adenokarcinom. Po definiciji, oba tipa tumora pripadaju karcinomima visokog stepena maligniteta i ne gradiraju se.
Serozni (papilarni) adenokarcinom
Entitet koji se izdvaja u poslednjih 20-tak godina, javlja se sa učestalošću manjom od 10% (u nekim studijama oko 1,1%),prepoznat u nekoj od sledećih formi, koje se uzajamno ne isključuju: (1) mešoviti serozni
i endometrioidni adenokarcinom (2)serozni adenokarcinom u polipu (3)serozni karcinom ograničen na endometrijalnu površinu (tzv.intraepitelni karcinom).
Mikroskopska slika: papilarne strukture koje mogu biti velike, široke, nepravilne, obložene tumorskim
ćelijama sa visokim jedarno/citoplazmatskim odnosom su jedna od karakterističnih nalaza. Drugi tip promene je udružen sa prethodnim i odnosi se na eksfolijaciju karcinomskih ćelija sa površine papila (mikropapilarni rast). Treći način rasta je prisustvo mikropapila unutar žlezdanih struktura. U 30-40% slučajeva prisutna su psamoma tela.
Imunohistohemijskiprofil⁴: oko 75% seroznih adenokarcinoma pokazuju p53 ekspresiju, Ki-67 indeks
je izrazito visok (čak 50-75%), a difuzno jaka pozitivnost postoji i za p16. Istovremeno postoji difuzni gubitak ekspresije za ER i PR, ali kao endometrioidni adenokarcinomi obično pokazuju pozitivnost za pan citokeratin, EMA, CA 125, CK 7 i vimentin i gubitak ekspresije CEA. WT1 pozitivnost je prisutna u najviše 2030% slučajeva, što je bitno razlikuje od primarno ovarijalne, tubalne ili peritonealne lokalizacije gde je WT1
pozitivnost prisutna u najmanje 70-80% slučajeva.
Svetloćelijski (clear cell) adenokarcinom
Mikroskopska slika: solidna polja, tubulocistične ili papilarne strukture sagradjene od svetlih, glikogenom
bogatih, ili „hobnail“ ćelija, izrazito atipičnih, bizarnih jedara, sa često prisutnim PAS pozitivnim, dijastaza
rezistentnim eozinofilnim intracelularnim i ekstracelularnim hijalinim globulama.
Mešoviti adenokarcinomi
Mešavina tipa I (endometrioidni/mucinozni) i tipa II (serozni/svetloćelijski) karcinoma u kome je manja
komponenta zastupljena sa najmanje 10% ukupnog volumena tumora naziva se mešovitim adenokarcinom.
Nediferentovani karcinom
Ovaj tumor se izdvaja kao poseban entitet po svojoj histološkoj slici u kojoj postoji potpuni gubitak bilo kakvog tipa diferencijacije karcinomskih ćelija. Treba ga razlikovati odendometrioidnog adenokarcinoma
gradusa 3 u kojem postoje očuvani bar minimalni delovi žlezdane diferencijacije, skvamozne metaplazije ili
eventualne trabekularne gradje.
MEZENHIMALNI TUMORI
Endometrijalni stromalni nodul
Definicija: Jasno ograničeni tumor sagradjen od stromalnih ćelija koje odgovaraju stromalnim endometrijalnim ćelijama proliferativne faze. Izmedju njih se uočavaju brojni sitni krvni sudovi arteriolarnog tipa. Retko
se mogu uočiti prstolike projekcije u miometrijum, ali ne smeju bitidubljeod 3mm⁵.
Diferencijalna dijagnoza: (1)celularni leiomiom (jako pozitivna reakcija za desmin, h-caldesmon i negativna reakcija za CD 10) i (2) endometrijalni stromalni sarkom niskog stepena maligniteta (bazira se na evaluaciji miometrijalne infiltracije i zato se ne može postaviti definitivna dijagnoza na kiretaži!)
Endometrijalni stromalni sarkom (ESS)
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Učestalost ovog tipa tumora je oko 0,2% od svih genitalnih malignih tumora žene.
Mikroskopska slika: hipercelularni tumor sagradjen od uniformnih ćelija tipa endometrijalnih stromalnih
ćelija sa brojnim malim arteriolama koje odgovaraju spiralnim u kasno sekretornom endometrijumu. Izražena
je invazija limfatika, mitotska aktivnost obično je niska (manje od 10 mitoza na 10HPF), a nekroza otsutna.U
nekim slučajevima naglašena je i perivaskularna hijalinizacija.
Endometrijalni stromalni tumori mogu dodatno pokazivati i druge, različite tipove diferencijacije kao što
su: glatko mišićna, obično fokalna i manja od 30%. Ako je prisustvo ove druge komponente veće od 30% tumor se naziva mešovitim endometrijalnim stromalnim i glatkomišićnimtumorom⁶. Takodje, mogu biti prisutni
i elementipolnihtrakajajnika, najčešće u formi anastomozirajućih trabekula ili traka, retko tubula. Ukoliko
predominiraju (pozitivnost na Inhibin!) tumor se naziva „uterine tumor resembling ovarian sex cord stromal
tumor“. Treća varijanta je prisustvo endometrijalnih žlezda koje se sreću u 10-40% slučajeva.
Napomena: Drugi tipovi diferencijacije mogu se javiti i kod endometrijalnih stromalnih nodula kao i kod
endometrijalnih stromalnih sarkoma, niskog stepena maligniteta, pa se kao diferencijalno dijagnostički kriterijum uzima miometrijalna infiltracija.
Diferencijalna dijagnoza: pored stromalnog nodula, uključuje i celularni leiomiom, intravensku leiomiomatozu kao i adenomiozu.
Nediferentovani endometrijalni sarkom
Uterini mezenhimalni tumor viskog stepena maligniteta koji ne pokazuje specifičnu diferencijaciju, ćelijska i nuklearna atipija su veoma izražene, gubi se karakterističan način rasta i vaskularnost ESS niskog stepena maligniteta, izraženo je krvavljenje i nekroza a tumorske ćelije jako liče na sarkomsku komponentu karcinosarkoma, koga je neophodno diferencijalno dijagnostički isključiti. Uopšteno, dijagnoza ovog tipa tumora uglavnom se zasniva na sekvencijalnoj eliminaciji slabo diferentovanog karcinoma, leiomiosarkoma i
karcinosarkoma (od formiranja većeg broja uzoraka za analizu do korišćenja imunohistohemijskih metoda).
Leiomioma
Mikroskopska slika: Anastomozirajuće trake uniformnih, fuziformnih – vretenastih ćelija, nejasnih granica, izduženih jedara, uobičajeno retkih mitoza.
Kod trudnica ili žena koje koriste progesteronsku terapiju krvavljenje, nekroza, edem, miksoidne promene i hipercelularnost se mogu javiti i kod leiomioma.
Patološka dijagnoza
Karakteristična histološka slika
Leiomioma sa povećanom mitotskom aktivnošću 5-10 mitoza/10HPF
Atipični leiomioma
Pleomorfne džinovske tumorske
naglašenom nuklearnom atipijom
Celularni leiomiom
Značajno veća celularnost nego uobičajeno
Epitelioidni leiomiom
Okruglaste/ovalne/poligonalne
odgovaraju epitelnim
Lipoleiomioma
Veći procenat zrelog masnog tkiva
Neurilemmoma-like leiomioma
Naglašeno nuklearno palisadanje koje odgovara
benignim tumorima perifernih nervnih omotača
Intravaskularna leiomiomatoza
„Crvoliki“ intravenski benigni glatkomišićni tumori
Diseminovana peritonealna leiomiomatoza
Histološki benigne, tumorolike glatkomišćne lezije
na peritoneumu ili omentumu
Benigni metastazirajući leiomiom
Histološki benigne glatkomišićne mase u plućima
koje se tumače kao metastaze primarno uterinih
leiomioma
ćelije
ćelije
sa
koje
Tabela br.3. Histološke varijante leiomioma⁷
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Atipični leiomiom Epiteloidni leiomiom
Slika 2. Histološke varijante lejomioma
Leiomiosarkoma
Mikroskopska slika: fascikule vretenatastih mezenhimalnih ćelija sa hiperhromatičnim jedrima, zgrudvanim hromatinom, prominentnim nukleolusima, naglašenom tumorskom nekrozom (koja nije uvek prisutna). Celularnost visoka, mitotske figure brojne, najčešće više od 15/10HPF, a vaskularna invazija prisutna u
25% slučajeva.
Kriterijumi za dijagnozu leiomiosarkoma (WHO 2003.)
1.koagulativna ćelijska nekroza
2.U odsustvu nekroze mora postojati difuzna, umerena do naglašena citološka atipija, a broj mitoza najmanje 10/10HPF.
Epiteloidna varijanta leiomiosarkoma
Mikroskopski nalaz: Hipercelularan tumor, „epiteloidnog“ fenotipa tumorskih ćelija, sa naglašenom citološkom atipijom, tumorskom nekrozom i visokim mitotskim indeksom⁸. Ukoliko nema nekroze, dijagnoza
epiteloidnog leiomiosarkoma zahteva difuznu, umerenu do veoma izraženu citološku atipiju i 5 ili više mitoza na 10HPF.
Miksoidna varijanta leiomiosarkoma
Mikroskopski nalaz: Tumorske ćelije široko razdvojene obilnim miksoidnim materijalom. Niska celularnost i niska mitotska aktivnost se sreće u najvećem broju slučajeva.Medjutim, većina tumora pokazuje izrazit celularni pleomorfizam. Ukoliko nema nekroze, dijagnoza miksoidnog leiomiosarkoma zahteva difuznu,
umerenu do veoma izraženu citološku atipiju i 5 ili više mitoza na 10HPF.
Tumorska nekroza
Prisutna
prisutna
prisutna
Nije prisutna
Nije prisutna
Atipija
Difuzna, umerena do izražena
Nema/laka
Nema/laka
MF/10HPF
Bilo kog stepena
≥10
<10
≥10
<5
Nije prisutna
Nije prisutna
Nije prisutna
Nije prisutna
Nije prisutna
Nema/laka
Nema/laka
Fokalna, umerena do izražena
Fokalna, umerena do izražena
5-9 ili atipične mitotske figure
<5
≥5
≥5
<5
Dijagnoza
leiomiosarkoma
Leiomiosarkoma
STUMP
Leiomiosarkoma
Atipični leiomiom sa niskim
stepen rizika ponovnog
javljanja
STUMP
leiomioma
Mitotski aktivan leiomiom
STUMP
Atipični leiomiom
Tabela br.4 Histološki kriterijumi za dijagnozu glatko mišićnih tumora
526
MEŠOVITI EPITELNI I MEZENHIMNI TUMORI
Maligni mešoviti Milerov tumor (carcinosarcoma)
Po definiciji ovaj tumor predstavlja kombinaciju epitelijalne (karcinomske) i mezenhimalne (sarkomske)
komponente, sa učestalošću do 10% svihendometrijalnihmaligniteta⁹. Iako se danas misli da je poreklo obe
komponente epitelno (pa zbog toga sarkomski delovi tumora pokazuju pozitivnost i za epitelne i za mezenhimne biomarkere) preduslov za dijagnozu je histološki aspekt mezenhimalne diferencijacije. Tradicionalno
se dele na homologi i heterologi tip, što se odredjuje na osnovu diferencijacije sarkomske komponente.
Adenosarkoma
Mikroskopska slika¹⁰: bifazični tumor sa benignom epitelnom i sarkomatoznom – malignom komponentom. Karakteriše se postojanjem kleftova na površini, stromalnog kondenzacijom koja okružuje žlezde i kleftove, a u kojoj se vidi citološka atipija i mitotske figure (više od 1/10HPF). Sarkomska komponenta je najčešće
homologi stromalni sarkom niskog stepena maligniteta, ali se ponekad mogu javiti ielementi heterologe diferencijacije na pr. rabdomiomske, hrskavičave...
Diferencijalna dijagnoza uključuje adenofibrom i botrioidni rabdomiosarkom.
Adenofibroma
Mikroskopska slika: Veoma redak bifazični tumor u kome su benigne i epitelna i mezenhimna komponenta. Površina tumora može biti papilarna, sa kleftovima, ali nema stromalne atipije, mitoza niti periglandularne kondenzacije.
Literatura
1. Albertini AF, Devouassoux-Shisheboran M, Genestie C. Pathology of endometrioid carcinoma.Bull Cancer. 2012
Jan;99(1):7-12.
2. Silvereberg SG.. Tumors of the uterine corpus:epithelialtumours and related conditions.In: Tavassoli FA, DevileePI,eds.
Tumors of the breast and female genital tract. Lyon: WHO; 2003; 2002:218.
3. Lax SF, Kurman RJ, Pizer ES, Wu L, Ronnett BM. A binary archictural grading system for uterin endometrial endometrioid carcinoma has superior reproducibility compared FIGO grading and identifies subsets of advanced –stage
tumors with favourable and unfavourable prognosis. Am J SurgPathol 2000; 24: 1201-1208.
4. Lax SF. Precursor lesions of endometrial carcinoma: diagnostic approach and molecular pathology. Pathologe.
2011;32Suppl 2:p.255-64
5. Dionigi A, Oliva E, Clement PB, Young RH. Endometrial stromal nodules and endometrial stromal tumors with
limited infiltration:aclinicopathologicstady of 50 cases. Am J surgPathol 2002; 26:567-581.
6. ClementPB.The pathology of the uterine smooth muscle tumors and mixed endometrial stromal-smooth muscle tumors: a selective review with emphasis on recent advances. Int J GynecolPathol 2000; 19:39-55.
7. Hendrickson MR, Tavassoli FA, Kempson RL, et al. Mesenchymal tumorous and related lesions. In: Tavassoli FA,
DevileePI,eds.Tumors of the breast and female genital tract. Lyon: IARC Press; 2003; 233-244.
8. Atkins K, Bell S, Kempson RL, Hendrickson MR. Epitheloid smooth muscle tumors of uterus. Mod Pathol 2002;
14(1):132A.
9. RaniKanthan and Jenna-Lynn Senger.Uterine Carcinosarcomas (Malignant Mixed MüllerianTumours): A Review
with Special Emphasis on the Controversies in Management. ObstetGynecol Int. 2011; 2011: 470795.
10.Zaloudek CJ, Norris HJ. Adenofibroma and adenosarcoma oh the uterus: a clinicopathologic study of 35 cases.
Cancer 1981; 48: 354-366.
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Important Recent Advances in Gynaecological Pathology
Sanjiv Manek
Consultant Gynaecological Pathologist
Oxford, UK
In recent years there have been a significant number of changes in gynaecological pathology practice.
Many of these deal with the molecular basis of common and rare gynaecological tumours but there are also
many that deal with morphology, terminology and new perspectives. This talk will focus on a few chosen entities and concepts that have been recently introduced and have reached everyday practice but which can cause problems or diagnostic difficulties and can require alteration in protocols.
The areas to be covered are:
The concept of endometrial intraepithelial neoplasia (EIN)
The concepts of endometrial intraepithelial carcinoma (EIC) and minimal serous carcinoma
Undifferentiated endometrial carcinoma
Inherited endometrial tumour syndromes
The relevance of tubal carcinoma in situ and the preceding dysplastic lesion in the pathogenesis of pelvic
serous carcinoma
The concept of differentiated VIN and its association with squamous carcinoma
Microinvasion in borderline serous ovarian tumours
The implications of the 2009 FIGO staging system for endometrial and vulval malignancies and uterine
sarcomas
Endometrial intraepithelial neoplasia (EIN)
The 2003 WHO and ISGP review of endometrial hyperplasia has retained the following classification.
Hyperplasias (typical) Atypical Hyperplasia
Simple without atypia Simple atypical
Complex without atypia Complex atypical
The atypia refers to cytological rather than architectural atypia and is commonly diagnosed when the nuclear/cytoplasmic ratio is increased and there is loss of axial polarity with nuclei becoming large and rounded
with prominent nucleoli. Mitoses and apoptotic bodies are frequently found.
Because of the common problem of reproducibility in identifying genuine cytological atypia, an alternative classification, the endometrial intraepithelial neoplasia (EIN) system has been proposed and is being increasingly used. In this system, there is a spectrum from benign hyperplasias through EIN to adenocarcinoma.
The EIN approach is supported by morphometric, molecular and genetic data. There is a concept of latency
with PTEN mutation. Some latent glands may involute and others may progress to EIN. From the molecular
point of view, EIN is a monoclonal proliferation with PTEN mutation and microsatellite instability.
Histologically, EIN is identified by:
Foci of atypical hyperplasia at least 1 mm and greater in linear dimension (usually >5-10 gland clusters).
Gland to stroma ratio >1.
Cytological features that are different from those of background glands.
Exclusion of potential mimics such as disordered proliferation, polyps and adenocarcinomas.
Most complex atypical hyperplasias could be reclassified as EIN.
In carcinoma cases with background atypical hyperplasia/EIN, PTEN mutations, b-Catenin, MLH 1 and
K-ras oncogene mutations and microsatellite instability are seen in both processes, lending support to the
fact that atypical hyperplasia/EIN is pre-cancerous. Many studies have shown an increased risk of associated
528
carcinoma when an endometrial biopsy shows atypical hyperplasia. With EIN this risk is up to 46x more than
without EIN.
It may be difficult to distinguish between atypical hyperplasia/EIN and well-differentiated (FIGO Grade
1) endometrial adenocarcinoma. Features which help to identify adenocarcinoma are:
prominent nuclear pleomorphism
a confluent, fused glandular pattern
a cribriform architecture of glands
a confluent papillary pattern
desmoplastic stroma
replacement of stroma by squamous epithelium
The confluent or papillary pattern or squamous epithelial predominance has to occupy at least half of a
low-power field.
EIC and minimal serous carcinoma
Endometrial intraepithelial carcinoma (EIC) or serous EIC is the precursor lesion of serous endometrial
adenocarcinoma and occurs typically in post-menopausal women on a background of atrophy. It comprises
highly pleomorphic cells on the surface and in glands without invasion but with frequent mitoses and prominent nucleoli in atypical nuclei. Mib 1 (Ki67) staining shows a high proliferation index and there is strong
p53 staining indicating p53 gene mutation. Rarely, there may be microinvasion associated with EIC. It is well
known that EICs can be associated with a high incidence of extrauterine metastatic disease despite lack of
invasion in the uterus. Hence, the concept of ‘minimal uterine serous carcinoma’ has developed. This is diagnosed when there is EIC with focal superficial/surface serous carcinoma. These lesions are WT1 and ER negative. Recently, it has been shown that some serous carcinomas are WT1+ and p53 – (?dedifferentiation of
type I cancers). Another lesion, endometrial glandular dysplasia (EmGD) has been described and this appears to be a precursor of EIC.
Undifferentiated endometrial carcinoma
This is a new entity which is now increasingly used but it is poorly recognised because of its ‘weak definition’ in the literature. It is generally included in FIGO G3 endometrioid adenocarcinomas in textbooks. The
WHO definition is ‘no evidence of glandular or squamoid differentiation ‘. The tumour is composed of medium or large cells with a complete absence of glandular differentiation and absent or minimal ( < 10 % ) neuroendocrine differentiation. There are no specific gross features and microscopically there are solid sheets
of these medium or large cells with marked pleomorphism, rhabdoid cells, foci of necrosis and many mitoses (>10/10hpf). Immunohistochemically, they are CK focally positive, EMA positive, Vimentin positive and
<10% cells show 1 positive neuroendocrine marker. Its significance is in that it has a poor prognosis (75 %
cases died of disease), as compared to the excellent prognosis of G2 and intermediate prognosis of G3 endometrioid carcinomas (30% cases died of disease)
Inherited endometrial tumour syndromes
Lynch Syndrome or Hereditary Nonpolyposis Colon Cancer Syndrome (HNPCC) patients are vulnerable
to developing endometrioid adenocarcinomas and this may be the initial presentation in more than 50% of
cases. They usually occur in young pre-menopausal patients and are more common than colorectal cancers in
female patients with this syndrome. The genetic defect is in DNA mismatch repair genes (MLH-1, MSH6 and
529
MSH2). Women with HNPCC have a 20% chance of developing endometrial cancer compared to 3% without
HNPCC. HNPCC/Lynch Syndrome endometrial cancers have the following characteristics:
predilection for isthmic and cornual areas
poor differentiation
peritumoral, Crohn’s-like lymphoid reaction
intratumoral lymphocytic infiltration
higher incidence of lymphatic permeation
higher incidence of mixed carcinomas and carcinosarcomas
Tubal carcinoma in-situ (serous tubal intraepithelial carcinoma – STIC) and its precursor lesions
and the link to pelvic serous carcinoma
There is a vast amount of new data showing the increasing importance of STIC. In a significant number of
cases of endometrial serous carcinoma, including EIC, there is co-existent STIC with similar p53 signatures.
In some cases, the STIC is WT1 negative suggesting spread from the endometrium or at least a field change. In other cases the STIC is WT1 positive indicating a synchronous lesion when the endometrial primary is
WT1 negative. STIC or tubal invasive serous carcinoma may also be the origin of some endometrial serous
carcinomas which have the reversed immunoprofile of WT1 positivity and p53 negativity.
The STIC is also thought to be the origin of many peritoneal and ovarian serous carcinomas particularly in
cases of high grade serous histology. Until recently it was suggested that the p53 signature (synonymous with
tubal dysplasia and the tubal intraepithelial lesions in transition - TILTs) was only limited to BRCA+ cases
but new evidence shows that its importance goes beyond that.
Vulval intraepithelial neoplasia (VIN) and squamous carcinoma (SCC)
There are two distinct types of VIN; each with a related SCC:
Differentiated (Simplex)
Classical (Bowenoid)
1. Undifferentiated appearance
Basaloid ↔ Warty
2. Associated with high risk HPV (16,18)
3. Multifocal
4. ± CIN, VAIN, warts
5. Young women
6. Lower risk for SCC
7. p16 positive
8. p53 negative
9. Associated with basaloid/warty/ verrucous SCC
10. Rare mucinous differentiation
1. Difficult to diagnose in isolation
(i.e. without adjacent SCC)
2. Hyperplastic epithelium with basal atypia
3. Arises in vulval dystrophy (e.g hyperplasia)
or lichen sclerosus
4. Older women
5. p16 negative
6. p53 positive
7. Associated with keratinising SCC
8. Basaloid variant recognised
Recently, there has been a proposal to reclassify VIN. Essentially it has been suggested that in classic VIN,
the VIN 1 category be abandoned because of its rarity and instead be referred to as flat condyloma or HPV
effect and VIN 2 and VIN 3 be lumped together as classic VIN. This change is to reflect the lack of evidence of progression from VIN 1 to VIN 3 (as in the cervix). However, some cases of VIN 1 with high-risk HPV
are known, suggesting VIN 1 could be pre-malignant in nature. Thus, there has also been a proposal to have a
two-tier clarification with low-grade VIN encompassing condylomas and VIN 1 and high-grade VIN encompassing VIN 2 and 3 and also differentiated VIN.
530
Microinvasion in borderline serous ovarian tumours
Is this a risk lesion? The conventional wisdom suggests that it is not but recent data has shown that microinvasion is an adverse prognostic factor independent of stage of disease and implant status in non-pregnant
patients (71% v 97% 5 year survival)
The implications of the 2009 FIGO staging system for endometrial and vulval malignancies
The introduction of lymph node status in endometrial malignancies has meant additional specimens to handle but at the same time the problem of false positive peritoneal fluid cytology has been resolved. Assessment
of cervical involvement by the endometrial malignancy has become easier.
In vulval cancer, there is more detailed analysis of lymph node involvement required with the introduction of substages in stage 3. One now needs to asses how many lymph nodes are involved and what the size
of the metastasis is.
For the first time there are now FIGO stages available for the uterine sarcomas rendering it easier to assign the appropriate stages based on size, etc.
Literature
1. Broaddus RR, Lynch HT, Chen LM, et al. Pathological features of endometrial carcinoma associated with HNPCC:
A comparison with sporadic endometrial carcinoma. Cancer 2006; 106(1): 87-94.
2. Meyer LA, Broaddus RR, Lu LH. Endometrial cancer and Lynch Syndrome: Clinical and pathologic considerations
cancer control, 2009; 16(1): 14-22.
3. WHO classification of tumours: Pathology and Genetics of Tumours of the Breast and Female Genital Organs:
Tumours of the uterine corpus. IARC Press; 2003: 228-233.
4. Bergeron C, Nogales F, Masseroli M, et al. A multicentric European study testing the reproducibility of the WHO
classification of endometrial hyperplasia with a proposal of a simplified working classification for biopsy and curettage specimens. Am J Surg Path 1999; 23: 1102-1108.
5. Mutter GL. Diagnosis of premalignant endometrial disease. J Clin Path, 2002; 55: 326-331.
6. FIGO Committee on Gynaecologic Oncology. Int J Gynaecol & Obs 2009; 105: 103-104.
7. Carlson JW & Mutter GL. Endometrial intraepithelial neoplasia is associated with polyps and frequently has metaplastic change. Histopathology, 2008; 53: 325-332.
8. Zhang W, Liong SX, Yu X, et al. Occurrence of endometrial glandular dysplasia precedes uterine papillary serous
carcinoma. Int J Gynaecol Pathol 2007; 26: 38-52.
9. Miltel K & Da Costa D. Endometrial hyperplasia and carcinoma in endometrial polyps: Clinicopathologic and follow-up findings. Int J Gynaecol Pathol 2008; 27: 45-48.
10.Hui P et al. Minimal uterine serous carcinoma: a clinicopathological study of 40 cases. Mod Pathol 2005; 18: 75-82
11.Sherman ME, Ronnett BM, Ioffe OB, et al. Reproducibility of biopsy diagnosis of endometrial hyperplasia: Evidence
supporting a simplified classification. Int J Gynaecol Pathol 2008; 27: 318-325.
12.Mutter, MD. www.endometrium.org
13.Hirschowitz L, Ganesan R and McCluggage WG. WT1, p53 and ER receptor expression in uterine serous carcinoma. Histopathol 2009; 55: 478-82
14.Rabban JT and Zaloudek CJ. Minimal uterine serous carcinoma: current concepts in diagnosis and prognosis.
Pathology 2007; 39: 125-33
531
15.Longacre TA, McKenney JK, Tazelaar HD et al. Ovarian serous tumours of low malignant potential (borderline tumours): outcome-based study of 276 patients with long-term (> or =5-year) followup. Am J Surg Pathol 2005; 29:
707-723
16.McKenney JK, Balzer BL, Longacre TA. Patterns of stromal invasion in ovarian serous tumours of low malignant
potential (borderline tumours): a reevaluation of the concept of stromal micro-invasion. Am J Surg Pathol 2006;
30: 1209-21
17.Carcangiu ML, Peissel B, Pasini B et al. Incidental carcinomas in prophylactic specimens in BRCA1 and BRCA2
germi-line mutation carriers, with emphasis on fallopian tube lesions: report of 6 cases and review of the literature.
Am J Surg Pathol 2006; 30: 1222-30
18.Jarboe EA, Folins AK, Drapkin R et al. Tubal and ovarian pathways to pelvic epithelial cancer: a pathological perspective. Histopathology 2008; 53: 127-38
532
Placenta – a silent witness: clinical and forensic importance of placental
examination
Marina Kos
Clinical Department of Pathology “Ljudevit Jurak” Clinical Hospital Center “Sestre milosrdnice”, Zagreb, Croatia
University of Zagreb Medical School. Zagreb, Croatia
Introduction
There is no doubt that obstetrics carries high medical liability risk. In many countries, gynecologists-obstetricians who attend childbirths and perform complex obstetric procedures are faced with increasing malpractice insurance premiums and litigation risk. The American College of Obstetricians and Gynecologists (ACOG)
publishes its Survey of Professional Liability since 1983, with the objective to analyze the effect that malpractice litigation has had on the practice of obstetrics and gynecology in the United States1. According to the
2003 ACOG survey, 76.3% of the members who answered the questionnaire have been involved in a lawsuit at least once in their professional career; gynecologists/obstetricians have been sued a total of 2.64 times
per individual over the course of their careers1,2. In the 2006 ACOG Survey, 89% of respondents indicated
that they had been sued during their careers. The average number of claims per obstetrician was 2.6 (3). The
ACOG’s 2009 Survey on Professional Liability showed that nearly 91% of gynecologists/obstetricians had
experienced at least one liability claim filed against them during their professional careers, with an average of
2.69 claims per physician. In 2009, 62% percent of the total reported claims were for obstetric care as opposed to gynecology, the same as in the 2006 Survey3,4. In the 2003 ACOG survey, fetal monitoring, neurologically impaired children, neonatal death, shoulder dystocia, uterine rupture, and “decision-to-incision” time
were identified as clinical factors frequently present in obstetric malpractice cases1. In both 2006 and 2009
Surveys the reasons for claim were neurologically impaired infant (in 31% of cases in both Surveys), stillbirth/neonatal death (with 16 % of cases in both Surveys), and delay or failure in diagnosis (in 11% of cases
in 2009 vs. 14% in 2006)3,4.
In all the Surveys, neurological impair is the leading cause of the reasons for liability claim, with the cerebral palsy being the most serious damage. The possible etiologies have been discussed for years, and although the damage to neural tissue is undebatable, there is still no agreement upon the timing of the damage.
Some authors think that 90% of the cases of cerebral palsy are not due to intrapartum events, while in the opinion of others most of the devastating events occurred in the perinatal period5,6. It is still impossible to firmly determine in each single case whether the hypoxic insult has developed during delivery, in the first few
hours after birth, or was already present before the labor began, as a consequence of long lasting hypoxia during pregnancy.
Careful gross and histopathological examination of the placenta in chosen cases can elucidate the events
that occurred some time before labor, and help to connect and reconstruct the course of disease7,8.
Importance of pathological examination of the placenta
Today, it is undisputable that all the samples of diagnostic value removed from the human body should be
histologically examined, with only a few exceptions, one of them being the healthy human placenta. The placenta forms a functional unit between the mother and the fetus and any pathological event that concerns one
ore both of them will influence the normal function of the placenta, resulting sometimes in morphological
gross and/or histological change(s). It is the most important fetal organ because it is responsible for exchange of all nutrients, oxygen, and fluid from mother to fetus and removal of fetal waste products. It has also been called the ‘‘diary of gestational life’’ 9. The placenta provides important information’s on the timing and
533
etiology of many adverse events, including neurologic injury, fetal distress, infections, growth restriction, demise and many other fetal conditions. It also reflects the intrauterine environment, helps in identification of
unsuspected maternal disorders, such as lupus or maternal vascular disease, and primary placental disorders,
such as maternal floor infarction or chronic villitis. Furthermore, the placenta, being a fetal organ, expresses
the fetal genotype and thus may provide diagnostic information on various genetic, chromosomal, congenital
metabolic, or hematologic disorders10.
Severe abnormalities of the placenta may lead to adverse fetal outcome. Fortunately, the vast majority of
pregnancies and newborns are normal, so only a subset of placentas requires submission to the pathology department for gross and histological examination. However, the clinical indications for placental examination have no gold standards. Some organizations have offered more or less similar guidelines, but the choice
whether the placenta will be sent for histopathological examination is still left to the attending obstetrician.
Indications for pathological examination of the placenta
According to the guidelines issued by College of American Pathologists at their XIX Conference dedicated exclusively to the examination of the placenta and some other considerations, the main indications for placental examination are shown in Table 1.11,12
Maternal conditions
Fetal conditions
Placental conditions
Systemic disorders (e.g. diabetes
mellitus, hypertensive disorders,
collagen vascular disease)
Stillbirth/neonatal death
Abnormalities of the placental
shape
Unexplained third-trimester
bleeding
Multiple pregnancy
Retroplacental hematoma
Severe oligohydramnios
Congenital malformations,
dysmorphic phenotype or
abnormal karyotype
Small or large placental size or
weight for gestational age
Peripartum fever and/or infection
Intrauterine growth restriction
Abnormalities of the umbilical
cord (length, appearence)
Premature delivery
Prematurity
Abnormalities of the fetal
membranes (e.g. amnion
nodosum, meconium staining,
etc)
Drug addiction/alcochol abuse
Hydrops
Invasive procedures with
suspected placental injury
Meconium
Placental abruption
Admittance to neonatal intensive
care unit
Apgar <=3 in 5. minute
Neurological problems (seizures)
Suspected infection
Table 1. The main indications for placental examination (modified from ref. 11, 12)
534
Others recommend that placentas from pregnancy complicated with cholestasis, hepatitis B, human immunodeficiency infection, other maternal diseases with normal pregnancy outcome, placenta previa and postpartum hemorrhage should not be sent for pathological examination in spite of moderate cost of this examination13. These and other guidelines are only recommendations, and each institutions may accept all or only some of them, to meet the needs of the population they serve.
Even with valid indications the human placenta is one of the most under examined specimens. However,
all placentas should be examined grossly, immediately after delivery, by the attending physician or a nurse. To
conclude whether the placenta is normal, or should be sent for pathological examination, the person examining
the placenta should have at least a basic knowledge of placental anatomy and pathology. The description of the
placental shape, the color of the fetal membranes, the insertion and length of the umbilical cord and placental weight must be recorded in the clinical history. Even though the placenta should be left suspended on the
umbilical cord for at least an hour after delivery, this practice is never followed, so the placental weight measured immediately after delivery is about 10 to 20% greater than the real weight because of the blood it contains8. No matter the indications that are followed, the chosen placentas are sent to the pathology department.
Placentas submitted to pathological examination should be accompanied by a specimen requisition form
containing clinical information. The importance of providing the clinical information cannot be overemphasized, because the absence of clinical informations prevents the appropriate evaluation and hampers the conclusions that are drawn from it. The informations that must be included are gravidity and parity, obstetric history,
obstetric estimate of gestational age, route of delivery, fetal birth weight, gender, Apgar scores, maternal and
fetal complications of pregnancy, labor, delivery, and total umbilical cord length. Some institutions even have a dedicated specimen requisition form for the placenta that facilitates the provision of these informations
to the pathologist. The clinician should also state the indication(s) for which the placenta is being submitted14.
The obstetricians should bear in mind that in case bacterial or/and viral cultures, cytogenetic and metabolic
studies are needed the samples must be taken from the fresh placental tissue and in sterile conditions, immediately after delivery, in the delivery room. Depending on a pathologist that is going to examine the placenta,
it can be submitted fresh, without fixative, or in the appropriate amount (10 times placental volume) of fixative, usually 10% buffered formalin. If there is no possibility of the pathological examination of the placenta
in the near future, or a delay is anticipated between delivery and receipt at the pathology department the placenta can be stored in a refrigerator at 4oC for a week. It would be ideal, but is practically impossible in most
institutions, for all placentas not requiring pathological examination to be stored in a refrigerator for a week
in case the clinical status of the newborn changes, so that the placenta can still be pathologically examined.
The placenta should never be deep frozen, because the ice crystals distort the villi, and the fine pathological
changes are impossible to appreciate on histological examination8.
Pathological evaluation and reporting
The fact of life is that in most pathological departments, other biopsies have precedence over placentas,
so the obstetrician often receives the report on a placenta several weeks after submission. The report usually
contains only placental measures and gross description of the placenta and the umbilical cord (frequently not
even that) and the description of the histological appearance is „immature placenta“ or „mature placenta“,
or „placenta without pathological changes“. After reading such reports, many obstetricians that are not convinced in the usefulness of the placental pathological examination in the first place, are discouraged to continue seeking pathological consultation. Placental lesions associated with adverse perinatal outcome can be
roughly divided into those with abnormal blood flow in the maternal circulation, abnormal blood flow in the
fetal circulation, inflammatory processes, and primary placental lesions8,10. Each of these categories is associated with identifiable pathologic lesions. Intrauterine demise or neurologic injury can occur by sudden and
possibly devastating events, by chronic processes that lead to decreased placental and fetal reserves, or by a
combination of both. It is helpful to distinguish between pathologic placental lesions that result in acute and
chronic intrauterine compromise (Table 2.)15
535
Acute
Normal placental weight or weight appropriate for fetal weight
Acute villous edema
Intravillous hemorrhage
Acute retroplacental hemorrhage
Acute meconium staining
Chronic
Abnormal placental weight in relation to fetal weight
Chorangiosis
Fetal normoblastemia
Chronic meconium staining
Meconium associated myonecrosis of cord vessel(s)
Acute or necrotising funisitis
Significant chronic villitis
Amnion nodosum
Significant placental ischemia or infarction
Decidual vasculopathy
Maternal floor infarction/massive perivillous fibrinoid deposition
Fetal thrombotic vasculopathy
Table 2. Placental findings indicating acute and chronic in utero compromise15
The quality of reports on the investigation of the placenta also varies greatly from institution to institution.
One study showed that general surgical pathologists have a higher rate of under diagnosis of placental lesions compared to pediatric pathologists16. These findings underline the fact that the reporting pathologist should be adequately trained and experienced in placental pathology. Templates and checklists for the reporting
of placentas might help to improve the completeness and uniformity of reporting17. The pathological report
on placenta is usually sent only to the attending obstetrician, while the neonatologists or pediatricians caring
for a newborn are not aware of the findings. In the opinion of the author, the copy of the placental pathology
report should be filed in both the mother’s and newborn’s clinical history.
Discussion
Of the ACOG Survey respondents who reported making changes to their obstetric practice as a result of
the risk or fear of professional liability claims or litigation, 30% decreased the number of high-risk obstetric
patients that they accepted. Performing more cesarean sections was reported by 29% of respondents that changed their obstetric practices, and 25.9% stopped offering/performing vaginal births after cesarean (VBACs).
An additional 13.9% decreased the number of total deliveries. About 8% of survey respondents reported that
they had stopped practicing obstetrics altogether4.
Other studies addressing this problem showed that malpractice claims led to a small reduction in physician delivery volume, but they did not have a significant impact on cesarean section rates 18,19. Litigation risk
536
and high malpractice premiums certainly affect negatively the gynecologist-obstetricians’ career satisfaction. The result of a relatively recent study revealed that 43.7% of gynecologist-obstetricians had become less satisfied over the last 5 years and 34.0% would not recommend obstetrics/gynecology to students seeking
career advice20.
Gynecologists/obstetricians are not the only doctors involved in delivery that are sued very frequently.
Anesthesiologists, and pediatricians/neonatologists are also often accused of malpractice in cases of unfavorable outcome of pregnancy. Before 1990 maternal death and newborn death/brain damage were the most
common complications in obstetric anesthesia malpractice claims. Newborn death/brain damage has decreased, yet it still remains also a leading cause of obstetric anesthesia malpractice claims21.
The basis of litigation claims against obstetricians, anesthesiologists and neonatologists is the notion that
fetal death or neurological disabilities are the result of failure or delay in intervention or inappropriate management of injuries believed to have occurred during the process of delivery. The intense fetal monitoring
and changes in methods of delivery have decreased the incidence of cerebral palsy, but not substantially22-24.
One of the reasons for this is that most of the fetal brain injuries occur before hospital admission and the beginning of labor, many of them being the result of intrauterine infection and inflammation, or reduced or interrupted placental vascular perfusion25). The majority of cases of cerebral palsy, particularly in term infants,
are now considered to be due to ante partum events26,27.
In the context of stillbirth or neurological impairment, examination of the placenta may be helpful in several ways. Firstly, the placenta itself may be abnormal and contribute directly to the adverse outcome, (e.g.
when there is a tight umbilical cord knot, maternal floor infarction or a large chorangioma). The category of
primary placental lesions also contains massive perivillous fibrinoid deposition, decidual vasculopathy leading to placental ischemia and/or infarction. Placenta itself may sometimes function normally, but the pathologic findings reflect abnormal intrauterine environment (e.g. intervillous thrombosis in a pale and hydropic
placenta whose villous capillaries contain nucleated fetal red blood cells that reflects fetomaternal hemorrhage). Some findings (such as chorangiosis) reflect an adaptation to adverse intrauterine conditions (hypoxia).
The adverse outcome may be due to pathologic processes that are not placental in origin but that lead to abnormal placental function such as maternal under perfusion and fetal thrombotic vasculopathy. .Many placental lesions develop during the prenatal period, long before labor and delivery. They cannot be prevented even
by the best of obstetrical care, but they can be identified and documented by pathological examination of the
placenta28. In case of adverse pregnancy outcome, the normal placental findings on pathological examination are also very important, because in such a case certain conditions may be ruled out and the attention should be directed elsewhere to look for the cause of injury.
During legal proceedings, the pathologist functioning as an expert witness may be asked to specify a time
frame for a placental lesion. It is often impossible to provide answers accurate to days or hours, but the rough distinction and framework of placental pathologies that result in acute or chronic compromise can be used
for determining the timing of the fetal insult. Pathologic examination provides more information on chronic
than on acute events. However, many acute events can also be diagnosed or confirmed on placental examination. Acute lesions may be associated with sudden catastrophic events whereas chronic lesions develop over a
period of time leading to decreased placental reserves at a minimum. Markedly depleted reserves will render
the infant susceptible to stresses of labor and to more acute events and therefore may also be associated with
significant injury or death. In stillborn or neurologically impaired infants, multiple placental lesions are often
present. By the timing of all lesions found, a sequence of events can be reconstructed in the development of
an adverse intrauterine environment. The decrease of placental reserves and function is usually the result of
synergistic action of multiple lesions of different etiologies that involve different aspects of placental function (fetal or maternal blood circulation). Acute events also frequently occur in combination with chronic processes29. Multiple placental lesions greatly increase the susceptibility of the fetus to neurologic damage29-31.
The type and significance of placental lesions determine the extent to which placental pathology can be
helpful in understanding adverse antenatal and perinatal events. Interpretation of these lesions is complex and
requires experience and insight into clinicopathologic correlation with outcome. However, the most important part of placental examination is ensuring that it is performed, because the slides and paraffin blocks of
537
placental tissue remain in the archives and can be retrieved even after a couple of years, should the need for
revision or expertise arise. A photographic record of gross pathologic findings is also very useful. The gross
and histological pathologic report of the placenta may not completely explain the etiology and timing but is
an important and essential witness in understanding adverse pregnancy outcome. One also has to bear in mind
that placental lesions are not necessarily the cause of unfavorable pregnancy outcome, and some structural
changes may be the consequences of poor fetal condition. The placenta is an easily available specimen and
the costs of a routine pathological examination are moderate, so in all doubtful cases, the clinicians should
not hesitate to ask for a pathological analysis and opinion.
References
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6. Cowan R, Rutherford M, Groenendaal F, et al. Origin and timing of brain lesions in term infants with neonatal encephalopathy. Lancet 2003; 361:736–42.
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claims analysis. Anesthesiology 2009; 110:131-9.
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study. Pediatrics 2002; 110:1220-5.
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28.Ward CJ. Analysis of 500 obstetric and gynecologic malpractice claims: causes and prevention. Am J Obstet Gynecol
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Novine u dijagnostici trofoblastnih
bolesti
Recent advances in diagnostics of
trophoblastic disease
Mihaela Mocko Kaćanski
Mihaela Mocko Kacanski
Odsek patologije, Klinički centar Vojvodine, Novi Sad,
Srbija
Department of Pathology, Clinical CenterVojvodina, Novi
Sad, Serbia
Apstrakt
Abstract
Gestacijske trofoblastne bolesti (GTB) su bolesti
i tumorska stanja u vezi sa trudnoćom a koje se najčešće javljaju u generativnom periodu žene. Ovo su
retki tumori a javljaju se kod neadekvatne proliferacije trofoblasta. U ovim stanjima uvek dolazi do povišenja vrednosti beta subjedinice humanog horionskog gonadotropina (βhCG). Hidatidne mole, parcijalne i kompletne, su u većini slučajeva benignog karaktera i karakterišu se edemom gotovo avaskularnih horionskih resica, nazubljenih ivica, pseudoinkluzijama hiperplastičnog trofoblasta i sincicijalnim
izdancima. Invazivne mole su agresivne lezije trofoblasta sa miometrijalnom i/ili vaskularnom invazijom. Horiokarcinom, trofoblastni tumor posteljičnog
ležišta i epiteloidni trofoblastni tumor su jasno maligni tumori proliferisanog intermedijernog trofoblasta,
sa metastatskim potencijalom. Tumorolika stanja su
placentalni nodul i naglašeno postaljično mesto koji
predstavljaju proliferativne lezije i reaktivne procese
i ne smatraju se pravim tumorima. U GTB najčešći
simptom je vaginalno krvarenje koje je praćeno povišenjem serumskih vrednosti βhCG. GTB moraju biti
potvrđene histološki na većem broju uzoraka. Kontrole
su neophodne kod svih pacijentkinja sa dijagnostikovanom GTB a to se rutinski sprovodi merenjem nivoa
βhCG-a. S obzirom da se kod GTB u svim entitetima
radi o proliferaciji jednog ili više trofoblastnih tkiva,
od izuzetne je važnosti dobro poznavati i uobičajene
razvojne oblike tkiva normalne trudnoće da bi se adekvatno mogli primeniti poznati dijagnostičko histološki kriterijumi tumorskih bolesti ovog tipa.
Ključne reči: gestacijske trofoblastne bolesti, hidatidna mola, horiokarcinom, humani horioni gonadotropin.
Gestational trophoblastic disease (GTD) is a
term used for a group of pregnancy-related tumours, overwhelmingly affecting women of childbearing age. These tumours are rare, and they appear when trophoblastic cells start to grow out of control. In these conditions production of beta subunit
of human chorionic gonadotropin (hCG) is evident.
Hydatidiform moles, partial or complete, are in most
cases benign featured by villous hydrps, scalloping
effect, hyperplastic trophoblastic pseudoinclusions
and syncytiotrophoblastic sprouts. Invasive mole is
an aggressive trophoblastic lesion with myometrial
and/or vascular invasion. Choriocarcinoma, placental site trophoblastic tumor and epitheloid trophoblastic tumor are clearly malignant tumors with proliferation of intermediate trophoblast, with metastatic
potential. Tumor-like trophoblastic conditions are
placental site nodul and exaggerated placental site wich are proliferative lesions and reactive processes and are not considered as true tumor lesions.In
all of these conditions vaginal bleeding is the most
common symptom followed by elevation of serum
beta hCG. GTD has to be confirmed histologically
with extensive sampling of the material. Follow up
is necessary in all women with GTD and it is rutinley done by measurment of serum levels of hCG.
Since GTDs are proliferative conditions of diferent
trophoblastic tisues, pathologists should be well histologicly educated about normal pregnancy stages
and its abnormalities in order of adeqate diagnosing
these rare conditions.
Key words: gestational trophoblastic disease,
hydatid mole, choriocarcinoma, human chorionic
gonadotropin.
Uvod
Gestacijske trofoblastne bolesti (GTB) su lezije trofoblasta različitih proliferativnih kapaciteta i to u rasponu od neneoplastičnih hidatidnih mola (kompletne mole, parcijalne mole i invazivne mole) do jasno neoplastičnih stanja (gestacijski horiokarcinom, trofoblastni tumor posteljičnog ležišta i epiteloidni trofoblastni
540
tumor). Svaki od ovih entiteta ima jasnu sliku ponašanja koja je u vezi sa proliferatinim kapacitetom konstitucionog trofoblasta. Ujedno u sklopu ovih stanja ističu se i dva entiteta i to naglašeno posteljično mesto i placentni nodul kao tumorolika stanja 1,2,3.
Kategorija
Hidatidne mole
Trofoblastni tumori
Tumorolika stanja
Podtipovi
Parcijalna mola
Kompletna mola
Invazivna mola
Horiokarcinom
Trofoblastni tumor posteljičnog ležišta (TTPL)
Epiteloidni trofoblastni tumor (ETT)
Naglašeno posteljično mesto
Placentni nodul/plak
Tabela 1. Vrste mola i tumorolika stanja
U cilju adekvatnog razumevanja faza razvoja ranog trofoblasta neophodno je upoznavanje i shvatanje morfologije i embrionalnih stadijuma kroz koje ovo tkivo u normalnoj trudnoći prolazi. Posle oplodnje, blastocita se diferentuje u embrionalne i ekstraembrionalne ćelije a nešto kasnije nastaje trofoblast odnosno preteča posteljice. Trofoblastne ćelije se dalje diferentuju u vilozni i ekstravilozni trofoblast. Vilozni trofoblast se
sastoji od viloznog citotrofoblasta i sinciciotrofoblasta. Ekstravilozni trofoblast se sastoji od horionske ploče, choriona leave, ćelijskih ostrvaca, septi, implantacionog mesta i bazalne ploče. Vilozni i ekstravilozni trofoblast proizilaze iz različite faze trofoblastne diferencijacije, a isto tako njihove lezije imaju drugačije morfološko, kliničko i biološko ponašanje 4,5,6.
Nedavne studije biomarkerske ekspresije ukazuju na dualnu diferencijaciju ćelijskih populacija u različitim trofoblastnim bolestima. Hidatidne mole su proliferativne lezije viloznog trofoblasta. Horiokarcinom je
jasno maligni tumor čiji trofoblast pokušava da oponaša primitivne ćelije previloznog stadijuma posteljice.
Intermedijerni trofoblast na nivou implantacionog mesta daje ćelije koje daju trofoblastni tumor posteljičnog
ležišta i naglašeno posteljično mesto. Dokazano je da intermedijerni trofoblast u horionu leve daje ćelije koje čine epitelni trofoblastni tumor i placentni nodul 7.
Najveća incidenca hidatidne mole na 1000 trudnoća se registruje u jugo-istočnoj Aziji i to 13 u Indoneziji,
8 na Tajvanu, 5 na Filipinima i Kini a 3.8 u Japanu. Severna Amerika, Evropa i Okeanija imaju najnižu incidencu od oko 0.5 - 1.84 na 1000 trudnoća. Prijavljivanje gestacijskih trofoblastnih tumora značajno varira zbog dijagnostičkih definicija i individualizovanih kriterijuma patologa ali i od uključivanja kliničkih parametara te biohemijskih dijagnostičkih metoda. Najviša stopa gestacijskih trofoblastnih neoplazmi se beleži u Indoneziji i to 5.4 na 1000 trudnoća dok je najniža u severnoj Americi, Evropi i Okeaniji i to oko 0.05
na 1000 trudnoća 8,9.
Velike svetske studije su pokušale da identifikuju rizične faktore za nastanak GTB i najčešće se nalaze starost majke (trudnoće preko 40 godine živora), ranije trudnoće (prethodna molarna trudnoća nosi rizik za kasniji nastanak iste), etnička pripadnost (češće kod malezijki, kineskinja i indonežanki), genetika (češće u pojedinim porodicama) i niski socio-ekonomski status 10,11.
KOMPLETNA HIDATIDNA MOLA – nazvana još i “klasična” mola nosi naziv hidatidna s obzirom da
se makroskopski opis odnosi na grozdaste mase koje su karakteristika ove bolesti. Kompletna mola je proliferativni poremećaj cito i sinciciotrofoblastnog bez razvoja embroina. Kompletna hidatidna mola čiji je celokupan genetski material očinskog porekla rezultat je oplodnje zrelim spermatozoidom jajne ćelije koja je izgubila jedro odnosno hromatin (“prazno jaje” engl. blighted ovum). Sledeće umnožavanje haploidnog spermatozidnog kompleta genetskog materijala vodi ka diploidnom genotipu. Stoga komletne mole su obično genetskog profila 46XX, a mali broj njih je 46XY. Triploidne i tetraploidne komletne mole se javljaju izuzetno
retko i one takođe potiču jedino od očeve DNA 12.
541
Najčešće se kompletne mole kod pacijentkinja prepoznaju vaginalnim krvarenjem do 16 nedelje trudnoće,
dok se ređe od simptoma mogu naći i hiperemeza, toksemija, hipertiroidizam ili plućna embolija. Kod kompletne mole je tipično izraženo povišenje serumskih vrednosti βGCG-a (i preko 100,000 mIU/mL) iznad normalnih vrednosti, dok se na ultrazvučnom pregledu plod ne nalazi ali je prisutan efekat “snežne mećave” (engl. snowstorm) 13. Kod oko 25% pacijentkinja nalaze se preeklampsijske ili eklampsijske tegobe dok oko trećina razvija ovarijalne teka luteinske ciste.
Makroskopski materijal kompletne mole je po pravilu voluminozan, hemoragičan i grožđu sličan sa
manjim ili većim vezikulama a što su edematozno izmenjene horionske resice, dok se plod po pravilu ne
nalazi.
Slika 1. Makroskopski i histološki izgled hidatidne mole.
Histološki jasno formirana mola ima dve osnovne karakteristike i to difuzni edem horionskih resica i naglašena hiperplazija trofoblasta. Stromalni edem horionskih resica je često izražen sa formiranjem centralnih
pukotina (cisterni) koje su acelularne ali sa trofoblastnim inkluzijama. Hiperplazija trofoblasta se karakteriše iregularnom ali difuznom proliferacijom koja je ujedno nepolarna i multifokalna i prostire se oko cele horionske resice. Plaže ili konfuentni agregati intermedijernog trofoblasta se mešaju sa cito ili sinciciotrofoblastom. Citološka atipija na nivou sinciciotrofoblasta i intermedijernog trofoblasta je ponekad izražena uz naglašeniju mitotsku aktivnost na nivou citotrofoblasta i intermedijernog trofoblasta. Iako je vilozna stroma hipocelularna, celularna područja se mogu naći pri vrhovima horionskih resica sa vretenastim ćelijama u miksoidnom matriksu sa brojnim apoptotičnim telima. U ovim horionskim resicama krvni sudovi nedostaju ili su
svedeni na rudimentne strukture 14,15.
S obzirom da u ranim kompletnim molama edem resica ili naglašenija proliferacija trofoblasta ne postoji histološka dijagnostika je izuzetno teška te se u tim situacijama mora posmatrati needematozna stoma koja pokazuje neadekvatnu bulboznu, polipoidnu ili filodesu sličnu konfiguraciju. Stroma je često u ovim slučajevima hipercelularna građena od zvezdastih fibroblasta u miksoidnoj stromi sa velikim brojem apoptotičnih tela i nešto malo rudinentnih krvnih sudova 15,16. Trofoblastna proliferacija je minimalna i samo fokalna,
često slična uobičajenoj gestacjskoj proliferaciji.
Po pravilu, kod kompletnih mola je prisutna jedarna negativnost na p57 antitelo u citotrofoblastu i stromalnim ćelijama dok je kod parcijalnih mola i spontanog abortusa pozitivno u citotrofoblastu, intermendijernom trofoblastu, stromalnim viloznim ćelijama i stromalnim decidualnim ćelijama 17.
Diferencijalna dijagnoza kompletne hidatidne mole podrazumeva normalnu ranu trudnoću, hidropsni edem
ne molarne trudnoće, ektopičnu trudnoću i parcijalnu hidatidnu molu.
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PARCIJALNA HIDATIDNA MOLA - Parcijalne mole su najčešće triploidne i nastaju iz jajne ćelije koja je oplođena sa dva spermatozoida, vođene od očevog ka majčinom hromozomu u odnosu 2:1. Uglavnom
su 69XXX, 69XXY genetskog profila a retko se nalazi i 69XYY. Tetraploidne mole su isto opisane i imaju
odnos očevih i majčinih hromozoma 3:1 18.
Kod parcijalnih mola najčešći simptom je vaginalno krvarenje u kasnom prvom ili početkom drugog trimestra trudnoće. Kod ovih pacijentkinja veličina uterusa odgovara gestacijskoj starosti dok su serumske vrednosti βHCG-a uobičajene ili samo blago povišene a preeklampsija ili eklampsija se retko sreću. Ultrazvučnim
pregledom prisutne su samo fokalne cistične promene na posteljici uz povišenje transverzalnog dijametra gestacijskog meška. Kod parcijalnih hidatidnih mola može se naći plod ali često smanjene veličine za gestacijsku dob te sa karakterističnim malformacijama kao što je sindaktilija, spina bifida, kriptorhizam i renalna hipoplazija 13,19.
Makroskopski, po pravilu, količina kiretiranog materijala je manja nego kod kompletne mole ali je svakako veća nego kod hidropsnog abortusa, dok je izgled uobičajen za trudnoću sa samo fokalno prisutnim grozdastim formacijama.
Histološki kod parcijalnih mola se nalaze dve vrste horionskih resica i to jedne uobičajenog izgleda a druge edematozne, veće i nepravilne. Ove veće nepravilne resice su izreckanih nazubljenih ivica dok su okruglaste trofoblastne pseudoinkluzije česte. Prisutna je ujedno i umerena cirkumskriptna nepolarna trofoblastna hiperplazija bez atipije, dok je formiranje centralnih stromalnih cisterni ređe u odnosu na kompletne mole. Sinciciotrofoblast može ponekad da bude prominentan sa formiranjem izraštaja ili invaginatima odnosno
intracitoplazmatskim lakunama. Fetalni krvni sudovi i eritrociti u njima se često registruju 13,20.
U citotrofoblastu i viloznim stromalnim ćelijama se nalazi pozitivna p57 nuklearna eksperesija 17.
Diferencijalna dijagnostika parcijalnih mola podrazumeva kompletnu molu, hidropsni abortus, gestacije
sa hromozomskim anomalijama, placentalnu mezenhimnu displaziju i blizanačku trudnoću sa kompletnom
molom i jednim prisutnim fetusom.
TROFOBLASTNI TUMOR POSTELJIČNOG LEŽIŠTA (TTPL) - je prava neoplastična proliferacija
ćelija intermedijernog trofoblasta na mestu implantacije koja se zasniva na genetskoj nestabilnosti. Za ovakvu
tumorsku proliferaciju ranije su korišćeni nazivi kao što su atipični horioepiteliom, atipični horiokarcinom,
sinciciom i horioepitelioza ali su tek Scully i Young 1981 godine predložili naziv koji se i do danas koristi 21.
TTPL se najčešće javlja u ranim tridesetim godinama života i preduslov je makar i jedna prethodna trudoća sa kojom ne mora da bude u bliskoj vremenskoj povezanosti. Kod ovih pacijentkinja kao simptom se javlja vaginalno vanmenstrualno krvarenje praćeno uvećanjem materice 22.
U inicijalnoj dijagnostici u oko 80% slučajeva prisutno je blaže do umereno povišenje serumskih vrednosti βHCG-a koje ne prelazi 700 mIU/mL ali koje se duplira u metastatskoj varijante ove bolesti 22.
Makroskopski TTPL se nalazi u endometrijumu u vidu jasno ograničenog čvora ili polipozne mase dok na
poprečnom presku se nalazi žućkasto solidno tkivo mesnatog izgleda sa fokusima nekroze i krvarenja. Duboka
ili transmuralna invazija miometrijuma je česta i nalazi se u oko 50% slučajeva.
Histološki se registruje masivna proliferacija većih, okruglastih, mononuklearnih ili ređe multinuklearnih
ćelija, eozinofilne obilne citoplazme intermedijernog trofoblasta posteljičnog implantacionog mesta. Jedarni
pleomorfizam je povremeno izraženiji kao i povišenje broja mitoza. Tumorsko tkivo je aranžirano u manjim
gnezdima ili trakama gde na periferiji tumora ćelije raslojavaju mišićna vlakna miometrijuma. U stromi se
konstatuju ekstracelularni fibrinski depoziti dok tip vaskularne invazije pokušava da napravi sličanu sliku normalnog trofoblasta. Nekroze i krvarenja su često opsežni i mogu biti dominantni. Horionske resice ili delovi ploda se ne nalaze. Okolni endometrijum može pokazivati deciduiformne promene sa Arias-Stella reakcijom. Metastatski depoziti ovog tumora su građeni isključivo od mononuklearnih trofoblastnih ćelija. Pojedini
TTPL mogu fokalno pokazivati histološku sliku drugih gestacijskih tumora i to najčešće epiteloidnog trofoblastnog tumora 23,24,25.
U dijagnostici TTPL značajnu ulogu igra imunohistohemijska dijagnostika sa difuznom pozitivnom ekspresijom na hPL (humani placentalni laktogen), AE1/3 i CK 18 a fokalnom slabijom pozitivnosti na MUC-4,
543
HSD3B1, CD10, HLA-G, CD146 i hCG dok je p63 negativne ekspresije. Faktor proliferacije Ki-67 je 10%30% 24,25.
Dijagnoza ovog tumora se mora raditi isključivo na operativnom materijalu dok se samo sumnja sme postaviti na materijalu dobijenom kiretmanom. Diferencijalna dijagnoza TTPL je sa naglašenim posteljičnim
mestom, epiteloidnim trofoblastnim tumorom, loše diferentovanim karcinom i epiteloidnim glatko mišićnim
tumorima.
Iako se TTPL terapijski rešava histerektomijom metastaze se beleže u literaturi i nalaze se najčešće u plućima, jetri i vagini.
EPITELOIDNI TROFOBLASTNI TUMOR (ETT) – tumorska proliferacija porekla horionog tipa intermedijernog trofoblasta a u literaturi se opisuje tek stotinak slučajeva od 1989 godine kada je prvi put prepoznat kao zaseban entitet 26. Morfološki je izuzetno sličan planocelularnom karcinomu. EET se može naći zajedno i sa ostalim GTB i to najčešće sa TTPL i horiokarcinomom i tada se ovi tumori nazivaju mešanim
trofoblastnim tumorima.
EET se javlja u generativnom periodu i to 1 – 25 godina nakon trudnoće a praćen je blažim do umerenim
povišenjem serumskih vrednosti βHCG-a (oko 2500 mIU/ml) 26,27.
U oko polovine slučajeva se lokalizuje u telu dok je druga polovina sa mestom ishodišta u grliću materice
te je upravo iz ovog razloga ovaj tumor neadekvatno dijagnostikovan kao planocelularni karcinom. Metastaze
se verifikuju u četvrtine pacijentkinja i nalaze se u plućima, limfnim čvorovima, jetri, žučnoj kesi, bubrezima, pankreasu, kičmenom stubu i vagini 27.
Makroskopski ETT je jasno ograničeni delom cistično-hemoragijski degenerativno izmenjeni čvor do 5cm
koji infiltruje miometrijum u “gurajućem” maniru u širokom frontu.
Histološki nalaze se mononuklearne ćelije horion leve tipa intermedijernog trofoblasta, umerene količine
fino granulirane bledo eozinofilne citoplazme, većih ovalnih jedara sa uočljivim jedarcima a koje su aranžirane u gnezda, trake i solidne plaže. Nuklearni pleomorfizam je blaži do umeren a fokalno se nalaze i pojedinačne više jedarne ćelije. Mitotski indeks je mali (obično 2/10 HPF). Karakteristična osobina ETT je i formiranje gnezda koja su okružena nekrozom i hijalinim matriksom. Nekroze su geografskog tipa dok su mali
krvni sudovi okruženi hijalinom nekrozom. Oko tumorskog tkiva nalazi se deciduiformno izmenjena stroma
endometrijuma ili endocervikalna sluznica 27,28.
Imunohistohemijski u ETT je prisutna pozitivna eksperesija trofoblastnih markera i to H3D3B1, HLA-G,
hPL, Inhibin-alpha i Mel-CAM ali i CK18, AE1/3 te p63. Negativnost se registruje kod CK20, CK 5/6, TTF1, S100, CA-125 i calretininu.
Diferencijalno dijagnostički problem ETT, s obzirom na čestu lokalizaciju u grliću materice, je sa planocelularnim karcinomom. Kod dijagnostike ovog tumora treba razmišljati i o TTPL, horiokarcinomu, nodulu
posteljičnog mesta, epiteloidnom leiomiosarkomu te loše diferentovanom endometrioidnom adenokarcinomu.
GESTACIJSKI HORIOKARCINOM – najagresivnija forma trofoblastne bolesti gde tumor pokušava
da imitira trofoblast razvojne placente. Vaginalno krvarenje je najčešći simptom ali se povremeno nalaze prvo metastatski depoziti u plućima, jetri, centralnom nervnom sistemu ili gastrointestinalnom sistemu a kasnije i primarni tumor.
Javlja se u generativnom periodu, i to u periodu od 1–23 godine nakon trudnoće. Dovodi se u tesnu vezu
sa ostalim GTB ali najčešće sa hidatidnim molama iz kojih može nastati 29,30.
Makroskopski horiokarcinom je veća, destruktivna tamnije mrko – hemoragična masa sa opsežnim nekrotičnim promenama koja masivno infiltruje miometrijum.
Histološki se nalazi destruktivna agresivna nejasno ograničena lezija sa izraženim nekrotičnim i hemoragičnim promenama. Tipičan je bilamelarni tip rasta gde su u centralnim delovima smeštene mononuklearne ćelije dok je periferija okružena višejedarnim sinciciotrofoblastnim ćelijama naglašene citološke atipije i
izraženo povišenog broja mitoza. Horionske resice se ne nalaze kod kompletno formiranih horiokarcinoma.
Okolni endometrijum pokazuje deciduifomne promene dok se u oko polovine slučajeva nalaze na jajnicima
teka-luteinske ciste 29,30.
544
Slika 2. Histološki izgled horiokarcinoma
IN SITU ILI INTRAPLACENTALNI HORIOKARCINOM nastaje u zreloj, razvijenoj, ročnoj placenti i
ima sve karakteristike “klasičnog” horiokarcinoma 31.
Imunohistohemijski sinciciotrofoblastne ćelije su pozitivne na hCG, hPL i HSD3B1 dok su ćelije neoplastičnog intermendijernog trofoblasta pozitivne na HLA-G, MUC-4, CD 146 i hPL. Ki 67 pokazuje proliferaciju oko 90% 32.
Diferencijalna dijagnoza horiokarcinoma je sa kompletnom hidatidnom molom, ranim gestacijskim viloznim trofoblastom, naglašenim posteljičnim mestom, TTPL, ETT, negestacijskim horiokarcinomom te loše
diferentovanim karcinomima uterusa 32.
PERZISTENTNA TROFOBLASTNA NEOPLAZMA – kao termin je prvi put predložena od strane
WHO 2002 godine i podrazumeva perzistentne mole, invazivnu molu, metastatsku molu, horiokarcinom ili
drugu gestacjsku bolest kod kojih perzistiraju osnovni simptomi čak i nakon terapijskih protokola 33. Kod svih
ovih pacijentkinja neophodno je sprovesti hemioterapijski modalitet dopunskog lečenja. Osnovni kriterijum
u dijagnostici ovih stanja su perzistentno povišene serumske vrednosti βHCG-a.
INVAZINA HIDATIDNA MOLA – molarna trudnoća ali sa naglašenim urastanjem horionskih resica u
miometrijum. Kod ovih pacijentkinja prisutno je čak i nakon evakuacione kiretaže vaginalno krvarenje uz
konstantno povišene vrednosti βHCG-a. Makroskopski i histološki se nalazi raslojavanje mišićnog tkiva molarno izmenjenim horionskim resicama i hemoragičnim masama 34.
Slika 3. Histološki izgled invazivne mole u kiretmanu i operativnom materijalu.
545
TUMORIMA SLIČNA TROFOBLASTNA STANJA – Izdvajaju se dva entiteta koja ne predstavljaju tumorske proliferate nego hiperplastične reakcije intermedijernog trofoblasta a to su naglašeno posteljično
mesto (NPM) i posteljični nodul (PN).
POSTELJIČNI NODUL (PN) – je nodularna hiperplazija intermedijernog trofoblasta na horionu leve maksimalnog prečnika 10mm. Javlja se kod pacijentkinja srednje životne dobi oko godinu do dve dana nakon trudnoće, a praćeno je vaginalnim krvarenjem 35.
NAGLAŠENO POSTELJIČNO MESTO (NPM) – Ewing je ovaj entitet 1910 godine nazvao sincicijalni endometritis ali se danas naziv više ne koristi jer nije reč o upalnom procesu. Javlja se u generativnom periodu i predstavlja umnožavanje intermedijernog trofoblasta u endometrijumu i površnom miometrijumu na
mestu implantacije 36.
Nakon potvrđene dijagnoze GTB i tačne tipizacije lezije pacijentkinja dalje podleže dijagnostičko – terapijskim protokolima u cilju stejdžinga i proširenosti bolesti uz obavezno merenje vrednosti βHCG-a jer se na
taj način obezbeđuje adekvatno kasnije kontrolisanje uklonjenosti ili perzistencije tumorskog tkiva.
S obzirom da se kod GTB u svim entitetima radi o proliferaciji jednog ili više trofoblastnih tkiva od izuzetne je važnosti dobro poznavati i uobičajene razvojne oblike tkiva normalne trudnoće da bi se adekvatno
mogli primeniti poznati dijagnostičko histološki kriterijumi tumorskih bolesti ovog tipa 37.
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novine u patologiji/NEWS IN PATHOLOGY
Endomiokardna biopsija:
juče, danas i sutra
Endomyocardial biopsy:
yesterday, today and tomorrow
Institut za patologiju, Medicinski fakultet, Univerzitet u
Beogradu, Beograd, Srbija
Jovan D. Vasiljevic
Abstract
Apstrakt
Glavni ciljevi u ovom radu su bili da se prikaže
aktuelno znanje o primarnim bolestima srčanog mišića, kardiomiopatijama (KMP), da se da njihova klasifikacija, dijagnostičke mogućnosti endomiokardne
biopsije (EMB), da se utvrdi vrednost EMB u izboru najbolje terapije. Uz mnoge kontroverze, EMB se
danas smatra široko prihvaćenom metodom, sa malo komplikacija, i izvodi se rutinski u mnogim kardiološkim centrima. Iako smo mi otpoćeli analizu
EMB još u osamdesetim godinama, danas se EMB
u Beogradu relativno retko radi. Jako je teško dati
odgovor – zašto?
KMP se dele na dve osnovne grupe, prema funkcionalnim i strukturalnim, patološkim karakteristikama, na idiopatske i specifične, odnosno na primarne i sekundarne. Idiopatska grupa se zatim deli na 5 podgrupa: hipertrofičnu, dilatacionu, restriktivnu, aritmogenu KMP desne komore, i neklasifikovane KMP. Specifične KMP se dele na 8 podgrupa, baziranih na etiopatogenetskim karakteristikama.
Na infektivne, sa virusnim miokarditisom (VMK)
kao najčešćim entitetom, na metabolične, uključujući i endokrine poremećaje i bolesti nakupljanja.
Defekti u deficitu oligoelemenata i vitamina, zahvaćenost srca u bolestima vezivnog tkiva, kao i granulomi i neoplazme takađe spadaju u ove grupe oboljenja. Poremećaji (pre)osetljivosti i toksične reakcije, sa dugim nizom substanci koje mogu da utiču na
srce, su vrlo česte u današnjoj patologiji. Na kraju,
u poslednju grupu bi spadala oštećenja srca nastala u sklopu različitih sistemskih sindroma, ipak relativno retkih.
EMB je u svetu u znatnom porastu primene, posebno u dijagnostici akutnog odbacivanja kod srčane trnasplantacije, dijagnostici KMP, posebno VMK,
sa malom stopom komplikacija, te se smatra, efikasnom, korisnom i sigurnom procedurom.
Ključne reči: endomiokardna biopsija, primarna bolest srčanog mišića, kardiomiopatija, dijagnoze, lečenje, immunomodulation, ljudi
548
Institute of Pathology, Medical School, University of
Belgrade, Belgrade, Serbia
The major goals of this presentation are to give
the updated knowledge of primary heart muscle disease, cardiomyopathies (CMP), their classification, the diagnostic possibilities using endomyocardial biopsy (EMB) and to estimate the value of EMB in
the choice of the right therapeutic approach. Despite
many controversies, EMB is today a widely accepted method, with low percentage of complications
for analysing CMPs, and is considered to be a routine procedure in many cardiological centers. Inspite
the fact that we started with the use of EMB in 80’s,
it is not performed often today in Belgrade, like many
yeras ago (2). It’s difficult to say why ?
The CMPs may be subdivided, according to the
functional and structural features, into two groups:
idiopathic and specific, or primary and secundary.
Idipathic group is consisted of 5 subgroups: hypertrophic, dilated, restrictive, arrithmogenic right ventricular CMP and unclassified.
Specific CMPs may be subdivided into 8 groups
mainly based on etiopathogenetic characteristics: infective, with viral myocarditis as the most common
entity, metabolic, including endocrine disorders and
infiltration and storage diseases. Deficiency disorders
and heart involvement in connective tissue disorders
are also included. Granulomas, neoplasms and neuromuscular disorders are also wery often presented
with cardiac disfunction and structural abnormalities.
Sensitivity and toxic reactions with long list of substances wich may affect the heart are probably the most
present today. Finally, the last group represent miscellaneous systemic syndromes with heart affection.
EMB has been increasingly used in the diagnosis
of CMPs, with special influnce on diagnosis of heart
transplant rejection, myocarditis, treatment modalities of different types of myocarditis, with low complication rate, considered effective, usefull and safe procedure.
Key words: endomyocardial biopsy, primary heart muscle disease, cardiomyopathy, diagnosis, treatment, immunomodulation, human
Introduction
The major goals of this presentation are to give the updated knowledge of primary heart muscle disease,
of diagnostic possibilities using endomyocardial biopsy (EMB) and to estimate the value of EMB in the choice of the right therapeutic approach. Despite many controversies, EMB is today a widely accepted method,
with low percentage of complications for analysing cardiomyopathies (CMPs), and is considered to be a routine procedure in many cardiological centers 1. Inspite the fact that we started with the use of EMB in 80’s, it
is not performed often today in Belgrade, like many yeras ago 2. It’s difficult to say why?
INDICATIONS OF EMB
Although the technique of EMB was introduced in the early 1960`s for diagnosing myocarditis and primary
myocardial diseases (Sakakibara and Konno 3, it became popular in the 1970 when “Stanford technique” was
introduced for evaluation of cardiac rejection. Unlike King`s College bioptome technique 4, where left venricular biopsy is usually performed 5, Caves-Schultz or Stanford bioptome uses percutanous approach through the right internal jugular vein. Several biopsy specimens can be obtained, and possible frozen section for
immunohistochemical analysis could be done.
Controversial issues concerning EMB and its clinical indications could be found in the literature 6-8. It is
universally agreed that the value of EMB in the diagnosis and management of cardiac allograft rejection is
well established, in the assessment of anthracycline cardiotoxicity, and myocarditis and secondary myocardial diseases can be readily diagnosed by EMB. Today, there is little dispute about main indications and contraindications for EMB, listed in Tables 1 and 2.
Evaluation of cardiac allograft rejection
Monitoring anthracycline cardiotoxicity
Diagnosis of inflammatory myocarditis
Distinction between restrictive and constrictive heart disease
Diagnosis of specific cadiomyopathies (storage diseases, etc.)
Diagnosis of neoplasm (primary and metastatic)
Idiopathic chest pain
Idiopathic arrhythmia
Idiopathic cardiomyopathies
Table 1. Main indications for EMB
The EMB may provide confirmatory morphologic data in many idiopathic or specific CMPs. While right
ventricular biopsy is easier to perform and likely to make the diagnosis, there may be specific indications for
left EMB.
The contraindications to EMB are few. Bleeding disorders are the most common contraindication. The presence of intraventricular mural thrombus, if involving the left ventricle, may predispose to systemic embolisation, and intracardiac shunts may carry a risk of paradoxical systemic embolisation 9. Prior myocardial infarction and arrhythmogenic right ventricular CMP may also carry a risk. EMB is a technique that can be mastered by a cardiologist with basic cardiac catheterization training. The equipment is standard, and multiple
549
sequential biopsies can be obtained from a single patient, the technique is safer and has fewer serious complications than conventional percutaneous liver or kidney biopsies.
EMB EVALUATION OF CARDIAC ALLOGRAFT REJECTION
Two major problems arise following successful cardiac transplantation: acute rejection and infections, due
to immunosuppression treatment. Untreated, of unnecessary overtreated, acute rejection in heart transplant
patients will frequently result in patient dearth or his marked disability. Therefore, much attention has been
paid to monitor the degree of cardiac allograft rejection and thereby to determine the most appropriate immuno-suppression regimen, especially if myocarditis was present before the transplant 10.
Many different techniques have been used to evaluate the evidence of rejection, such as: electrocardiographic monitoring, echocardiography radioactively labelled different cells or isotopes, magnetic resonance
imaging, etc, So far, none of these techniques have shown to be sensitive enough to replace endomyocardial
biopsy (EMB). Histologic examination of cardiac tissue samples obtained by EMB remains the most effective method for surveillance of cardiac rejection in heart transplant patients. Electron microscopy is not very
useful in the diagnosis of acute cardiac rejection, because longer processing time is required for this method.
However, electron microscopy or immuno-electronmicroscopy may be useful in the research field, for better
understanding the mechanisms of myocyte injury, and in identifying cells involved in the rejection process.
Histologic grading systems for diagnosing cardiac allograft rejection Two major systems were in everyday
use to measure cardiac allograft rejection: qualitative, or Stanford system 11, introduced by M. Billingham, and
quantitative or THI (Texas Heart Institute), system uses the terms mild, moderate and severe, in order to describe the degree of acute rejection. The THI system is based on numerical scale, ranging from 0 to 10, and describe the degree of rejection by assigning to it a numerical value12. A comparison of the THI and Stanford grading systems is illustrated on Table 2. The other important difference between the two systems is that Stanford
system uses, in addition to the amount of mononuclear cells, myocyte necrosis as a criterion for distinguishing
between moderate and severe rejection. The THI system is based on findings of intensity of myocyte degeneration as the criterion to evaluate the degree of rejection. True necrosis is rarely observed in rejection process
except in high grades of rejection and degeneration is usually reversible if the patient is appropriately treated.
Table 2. Comparison of the THI and Stanford grading system of rejection
A modification of the Stanford classification was proposed by Kemnitz and colleagues in so-called “Hannover
classification”. The main difference is subdivision of the mild acute rejection and introduction of early and
late resolution of rejection 13. However, this combination of quantitative and qualitative grading system has
not been widely accepted.
550
Grade
0
1
2
3
4
New nomenclature
No rejection
A - Focal infiltrate without necrosis,
Perivascular or intersticial
B-Diffuse infiltrate without necrosis
One focus with infiltration and/or focal Miocene damage
A - Multifocal infiltration and/or myocyte damage
B - Diffuse inflammatory process with necrosis
Diffuse polimorphonuclear infiltrate with oedema, haemorrhage
and necrosis of cardiomyocytes
Old nomenclature
No rejection
mild rejection
“Focal”, moderate rejection
“mild” moderate
“Border-line” severe
Severe acute rejection
Resolving - rejection in phase of diminution, presented with one smaller number
Resolved - finished rejection, presented with grade 0.
(Modified from: International Society for Heart Transplantation)
Table 3. Standardisation of classification of cardiac allograft rejection
Histologic findings corresponding to the numerical value of 0 (THI system) indicated that there is no evidence of cardiac rejection. A grade of 1 and 2 indicates only perivascular aggregates of mononuclear cells.
Grade 3 indicates that mononuclear cells are extending into the interstitium. Grade 4 do 8 represent presence
of interstitial mononuclear cells with cardiac myocyte degeneration of different, increasing severity cardiac
myocyte degeneration of different, increasing severity. Grade 4 represents occasional myocyte degeneration;
grades 5 and 6 – scattered myocyte degeneration and grades 7 and 8 signify multifocal degeneration (present
in every piece and in all high-power fields).
Maintenance of the cardiac transplant patients
EMBs are performed in heart transplant patients with frequency depending on patient status, level of immunosuppressive agents, and time of previous biopsy. By correlation of the numerical values and date of the patients previous EMB, we can estimate: the degree of rejection, the direction of change (resolving or progressing), and the speed of change 14.
Using the THI grading system 12, we can avoid extensive immunosuppression treatment of hear transplant
patients when impressive cellular infiltrate is present with no evidence of marked degeneration. Or, we can
introduce higher levels of immunosuppressive agents in patients with multifocal myocyte degeneration and
clinical signs of rejection with relatively few mononuclear cells. This change of levels of immunosuppressive treatment is practically impossible under diagnosis of “moderate” rejection.
Other factors of cardiac allograft damage can also be detected by EMB. These include: increased graft
eosinophilia as sensitive indicator of severe graft rejection, eosinophilic coronary arteritis without classical
lymphocytic allograft rejection, occlusive coronary arteritis as consequence of cyclosporine immunosuppression, and evidence of ischemic damage of myocyte in patients with longer survival and present coronary artery disease. Finally, by EMB is possible to identify toxoplasmosis, cytomegalic viral inclusions, fungi, leishmania, and coccidioidomycosis. It is difficult to clinically diagnose these affections of the myocardium. All
these conditions are treatable, which support the use of EMB in maintenance of cardiac transplant patients.
EMB DIAGNOSIS OF CARDIOMYOPATHIES
Idiopathic cardiomyopathies are heart muscle diseases of unknown aetiology (unaccompanied by any other
disease process in the body 15. Different classification have been proposed 16-19. The so-called “secondary
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cardiomyopathies” of known cause are often accompanied or preceded by disease process elsewhere in the
body. We are calling them today - specific cardiomyopathies 16-19, besides familial group, how are also idiopathic 20.
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy (HCM) is another entity with many previous names, definitions, and clinical presentations 21, 22 . Hypertrophhic obstructive CMP, the so-called HOCM, implies that the obstructive element is an essential part of the manifestations. Typical clinical presentation is (1) abnormal stiffness of
the hypertrophied ventricular muscle with impaired distensibility of the left ventricle; (2) a pressure gradient
in systole between the outflow of the left ventricle and the aorta (usually over 60 mmHg and 70 –80 % of patients). Therefore, HCM without obstruction is well-recognised condition with signs confined to a powerful
left ventricle and atria thrust and evidence of pulmonary hypertention. Asymmetrical apical hypertrophy is
another condition recognised by ECG and echocardiography.
In classical HCM, macroscopically, there is bulging, extensive hypertrophy of the left ventricle, especially in the septum of the outflow tract, giving rise to the pressure gradient between the left ventricle and aorta, usually exuding 60 mmHg. This is the most common picture of HCM, also called “subaortic muscular stenosis” and once classified as congenital heart disease. A genetic basis (autosomal dominant trait with almost
complete penetrance) has been established, with sequelae on catecholamin function and abnormal muscle fibre alignment (disarray).
Histological examination shows short myocardial fibres running in all directions (disarray), and often forming
small whorls. Severe hypertrophy of individual myocardial fibres, which often measure 90 -100 m in diameter
is striking (normal range is 5 -12 m, average cell diameter in hypertrophy is about 22-25m). Additional histological features include: large bizarre-shaped nuclei, each surrounded by a clear zone, the so-called “perinuclear
halo”. Various amounts of interstitial fibrosis, often apparently interrupting short myocardial fibres, are seen.
Only the combination of the abnormal features (detailed above) is highly characteristic of HCM and permit diagnosis 23. The so-called “histological HOCM index” is applied and values represent semiquantitative
grading system (values 1-3 for each of the 5 histological features - hypertrophy, disarray, bizarre nuclei with
perinuclear halo, short runs fibres and fibrosis). If the values over 50% of the maximal 15 are obtained, the
PH diagnosis of HCM is confirmed 24, 25.
HCM without obstruction has PH, histochemical and EM changes similar to those already presented, and
on EMB findings it is impossible to distinguish these to conditions. In all, the use of EMB in diagnosis of
HCM is restricted by non-pathognomonic findings, absence of EM or enzymatic differences (22), and should
be used only in combination with clinical data. Probably, the main value of EMB in HCM is to rollout other
possible conditions with similar clinical impairment (amyloidosis, glicogenosis, small vessel diseases, etc.).
Dilated (congestive) cardiomyopathy
This world wide distributed cardiac condition have as main clinical sign congestive heart failure which
may rapidly progress to end-stage heart disease. Today, among different heart transplant candidates, post-viral DCM is the leading condition 27-29.
Macroscopically non-specific features are found. The weight of the heart is around 600-700g with hypertrophy of myocardial wall, but all cardiac chambers are severely dilated and often masking the degree of
hypertrophy. The parietal thrombus is often found. The myocardium is pale and flabby, and the coronary arteries are usually normal and patent 26.
Histologicaly, EMB findings in DCM shows changes that are non-specific, reflecting changes of hypertrophy with various degrees of degeneration and fibroses. The EMB diagnosis can be made only by exclusion of other specific histiological features (MC), and of other causes that may lead to heart failure. Although
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a multifactorial aetiology was estimated likely, many experimental, epidemiological and new sophisticated
pathological methods has shown the strong evidence of linking idiopathic viral myocarditis to DCM. Familial
DCM is also a separate entity, with proof fo different gene involvement 20 .
Alcoholic CMP or alcohol induced heart disease, has no consistent features, and distinction from DCM is
usually impossible on histologic level. Only enzymatic differences between two groups of patients have been
observed by Richardson et al.30 They found that thining and atrophy of the cardiomyocytes, with fatty infiltration, EM characteristics of dilatation of the sarcoplasmic reticulum, lipids, mitochondriosis and increased
number of lysosome, followed by decreases in mitochondrial enzyme activity studied by enzyme histochemistry, represent the changes specific for alcoholic CMP.
Similarly, congestive heart failure associated with pregnancy, in so-called peripartum cardiomyopathy
(PPCMP), cannot be distinguished pathologically from DCM 31. PPCMP is defined as congestive heart failure in the last trimester of pregnancy or within the first six months postpartum. Although positive etiological
connection with different factors have been established (viruses, toxoplasmosis, malnutrition, hypertension,
immunological mechanism, race, number of pregnancies, etc.), unknown multifactorial aetiology is the most
likely 32. Higher incidence of MC in cases of PPCMP suggests that this condition is a separate entity, and similar relation with post-myocardial DCM 31,32.
Restrictive cardiomyopathy
Although a possible association between eosinophilia, endomyocardial disease and adherent thrombi had
been suggested in the late 1800s, it was Loffler in 1936 who described two Swiss patients with hronic heart
failure and marked eosinophilia 33. Latter, this entity was recognised under variety of names: Loffler`s endocarditis parietalis fibroplastica, hypereosinophilic syndrome, endomyocardial fibrosis with eosinophilia,
disseminated eosinophilic collagen disease, etc. and similarities with tropical endomyocardial fibrosis (EMF)
was recognised.
These two conditions give very similar clinical picture that may resemble constrictive pericarditis or mitral insufficiency with pulmonary hypertension, but any hypothesis of common aetiology has to reconcile the
following: myocardial damage has been reported in cases with increased eosinophilia other than Loffler (filariasis, trichinosis, acute leukaemias); some patients with long standing eosinophilia may have no evidence of
EMF; a form of CMP similar to Loffler`s disease has been described in pts without eosinophilia. Brockington
and Olsen have suggested that acquired eosinophilia (including the idiopathic hypereosinophilic syndrome
and eosinophilic leukaemia) lead to Loffler’s endocarditis, and finally endomyocardial fibrosis 34. These two
entities belong to the same disease process with evidence that a large proportion of circulating eosinophils are
abnormal with reduced numbers of crystalloid granules. The degranulation of eosinophils is producing MC
with nospecific fibrosis at the end of the process.
The unitarian hypothesis that “the presence of an eosinophilic leucocytosis, in a susceptible person, by some not completely explained mechanism, causes endomyocardial damage”, is very likely. The cardiac damage is not dependent on the number of circulating eosinophils but on whether they are normal or they might
be releasing their cationic proteins – potentially cardiotoxic agents. Degranulated eosinophils with individual
immunological abnormalities are the basis for pathologycal changes in “eosinophilic heart disease” (EHD),
clinically manifested as RCM. Finally, there are opinions that two form of RCM can be found: one without
eosinophilia, with tipical findings of EMF and called idiopathic RCM, and the other form associated with eosinophilia and named EHD 35.
Macroscopically, the distribution of the thickened endocardium may vary and may involve the left, right
or both ventricles. The endocardium may be several mm thick, and thrombus is superimposed in about 50%
of patients. Fibrous septa, extending for a short distance into the underlying myocardium, are common. The
cardiovascular involvement are shown on Table 4.
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Table 4.Cardiovascular findings in EHD
zone consisted of hyaline collagen. The middle layer is occupied by fibrous tissue and the deepest layer is
the “granulation tissue layer”, with variable number of eosinophils. The myocardial fibres between the septa
may show degenerative changes, like in other CMPs.
The disease passes through 3 stages: first, acute, necrotic phase with inflammatory reaction and variable
number of eosinophils. Interval between onset of symptoms and potential death are measured in weeks. The
second stage is characterised by thrombus formation and represents the complication of eosinophilic endomyocarditis. There is prominent fibrous endocardial thickening, and arteritis may be still present. Interval
between onset of symptoms and death are measured in months. The third, fibrotic stage represent the last phase
with fibrosis and septa made of superficial layer of hyaline collagen, middle layer of fibrous tissue, and deepest layer of chronic inflammatory cell with varying number of eosinophils. These three pathological patterns
of disease are one continious process connected with length of time between onset of disease and death.
EMB diagnosis of EHD is of great importance, especially in children 36. Depending of the time of the biopsy, the possibility of founding degranulated eosinophils, thrombus, and MC, makes the EMB fundamental
techniques in diagnosing this condition 37.
Arrhythmogenic Right Ventricular Cardiomyopathy
This entity is characterised by progressive fibrous-fatty replacement of right ventricular myocardium, mainly the free wall, followed by rhythm disturbances as major clinical problem. Initially, the changes are consistent with regional, and later global, right and some left ventricular involvement, and with relative sparing
of the septum.
Although familial occurence has been documented and a gene defect was recently localized on chromosome 14q23-q24, the etiopathogenesis of the disease is still obscure. Familial form of arrhythmogenic right ventricular cardiomyopathy (ARVC) disease is very common, with autosomal dominant inheritance and
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incomplete penetrance, although a recessive form is also described. Presentation with arrhythmia and sudden
death is also very common, particularly in the young and athletes, as indicated by Thiene et al 38. Contrary
to the genetic form, some recent clinical and morphological findings demonstrated its acquired, progressive,
frequently inflammatory character, and supports the notion of chronic, continuous process of injury and repair. Several hypotheses are made upon pathogenesis of ARVC, with idiopathic myocarditis as the most probable cause (Fontaine, Hofman, et al.).
The findings of adipose tissue in the heart is not allways the indication of pathologic process, and frequency, extent, and distribution of endomyocardial adipose tissue was analysed by morphomety from EMBs in
241 patients, indicating the particularities of adipose replacement in ARVC. It should be noted that pathologic evidence of extensive left ventricular involvement in ARVC was demonstrated. Finally, as possible causes of ARVC apoptosis was implicated, showing how normal and abnormal consequences of apoptosis can
lead from postnatal morphogenesis to paroxysmal arrhythmias39. The frequent findings of MC with myocyte
death lead to the consideration of the disease as chronic MC, with some immune factors involved.
The EMB diagnosis of ARVC should be performed with coution of perforation, and maneuver under
echocardiographic guide is recommended. The usual site for EMB, the interventricular septum, is not the ideal location for biopsy. Unother problem is the fibrous-fatty atrophy and its pahtgnomonity for definitive diagnosis. Adipose and fibrous tissue in the myocardiun is not so specific findings, interstitial replacement is also
often observed in many CMPs, so the issue is to quantify the components, rather then qualify them. As suggested by Angelini et al., the following diagnostic parameters should be obtained by morphometric analysis:
myocardial atrophy with residual myocytes less then 45%; fobrous tissue less then 40%; and fatty tissue more then 3%. The sensitivity and specificity were 67% and )”%, respectively. This quantitative histologic criteria give better definitive diagnosis by tissue characterization then magnetic resonance imaging or other noninvasive procedures 38.
Unclassified Cardiomyopathies
Unclassified CMPs incised a few cases that do not fit readily into any group, like fibroelastosis, noncompacted myocardium, systolic dysfunction with minimal dilatation, mitochondrial disorders in myocardial involvement, etc.
Some of CMPs may present with features of more than one type of CMP (eg. amyloidosis, systemic hypertention), and overlapping morphology is even more common (end-stage HCM with dilatation, peripartum
CMP, alcohol induced heart disease, and other entities similar with DCM).
It is recognised that arrhythmias and conduction tissue diseases may be primary myocardial disorders,
but, at this time, they are not included as cardiomyopathies. They remain as one of the frequent indications
for EMB (mainly to rule-out MC), but as many conditions may present with rrhythm disturbances, they are
not a distinctive entity.
6. EMB DIAGNOSIS OF SPECIFIC CARDIOMYOPATHIES
Specific cardiomyopathies (SCMP) may be defined as “secondary CMPs” or heart muscle disease of known
cause, associated with recognised general disorders. These conditions have been classified by many authorities in this field (15-19), but our approach to the classification of SCMP is mainly based on EMB findings, indicating three main groups of diseases: first, in which the pathognomonic EMB features are seen, that allows
the morpho diagnosis of “specific entity”; second group of diseases in which “specific” morphological features can not be demonstrated, and the diagnosis is made by exclusion 40 .
In spite of this luck of “morphological specificity”, many general condition in which the heart can be affected are classified under SCMP. We strongly believe that division of these two groups, based on possibility of
EMB diagnosis, is the most appropriate way to classify, diagnose and treat SCMP.
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Entities with pathognomonic PH findings
1. Infective diseases (MC)
2. Metabolic (familial storage and endocrine diseases)
3. Infiltrations, granulomas and neoplasia
4. Sensibility and toxic reactions (adriamycin)
Entities with non-pathognomonic PH findings
5. Connective tissue disorders
6. Heredofamilial neuromuscular diseases
7. Deficiencies and avitaminoses
8. Rare syndromes
Table 5. Classification of Specific CMPs (specific heart muscle diseases).
Besides infective diseases (viral, bacterial, fungal, protozoal, etc.), with specific or pathognomonic findings, many storage diseases (glicogenoses, haemochromatosis, amyloidosis, etc.) can be diagnosed by EMB.
All otter specific CMPs have less pathogno-monic findings and only clinical characteristics makes them “specific” heart disease 33.
Glycogen storage disease
Of the twelve types of glycogen storage disease, the heart is involved in three: type II (Pompe,s disease),
deficiency of alpha-4,4-glucosidase (acid maltase); type III (Cori,s disease), a deficiency of the debranching
enzyme amylo-1,6-glucosidae; and type IV (Andersen,s disease), caused by a deficiency of the branching
enzyme alpha-1,4-glucan-6 glucosyltransferase. These diseases are transmitted as autosomal recessives and
are manifest by accumulation of glycogen in various tissues 41. The diagnosis should be based not only on the
demonstration of increased glycogen, but also by demonstration of the enzyme defect. Most cases of glycogen storage disease, causing cardiomegaly, are due to type II glycogenosis. The heart is enlarged, and all
chambers have thickened walls and small cavities. Progressive impairment of myocardial function ensues,
and Pompe,s disease is fatal within the first year of life. Death is due to cardiac failure or respiratory complications. Grossly, the heart appears rubbery and pale pink. There may be fibroelastotic thickening of the endocardium. In histologic sections there will be severe vacuolisation within the central areas of the myocytes,
giving a lacework appearance to the tissue, due to massive deposits of glycogen which displace myofibrils to
the periphery. Myofibrillar loss related to cardiac failure can also be demonstrated ultrastructurally. If a glycogen storage disease is suspected, the endomyocardial biopsy can be fixed in absolute alcohol tryed in preserving the glycogen, and electron microscopy is usually required as well (42). The characteristic ultrastructural
alteration is large collections of glycogen (either free in the cytoplasm in Pompe,s disease, or within lysosomes). The glycogen may be in a morpholo-gical form, granules (type II and III) or in an abnormal form (fibriles, in type IV glycogenosis).
Fabry,s Disease
Fabry,s disease (angiokeratoma corporis diffusum universale) is an X-linked recessive disorder caused by
deficiency of lysosomal alpha-galactosidase A, resulting in excessive deposits of ceramide trihexoside, particularly in the skin, cornea, kidneys, and heart. It is manifest by angiokeratomas, pain and paresthesias of the
extremities, and progressive renal and cardiovascular disease 43. Symptoms relative to the heart include cardiac hypertrophy and dilatation, congestive heart failure, angina, and hypertension, all of which are due to
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deposits of ceramide trihexoside in lysosomes in endothelial cells, smooth muscle and pericytes throughout the
vascular system. Because of these deposits, patients may have myocardial infarction at an early age, microaneurysms, cystic medial necrosis of the aorta, and valvular lesions (mitral stenosis, aortic regurgitation, pulmonic regurgitation). Death is often from congestive heart failure.
Endomyocardial biopsy from patients with Fabry,s disease will demonstrate a lacework appearance of the
myocardial fibres on routine light microscopy, with marked perinuclear vacuolisation and displacement of
the contractile elements to the periphery. In frozen sections, the deposits of ceramide trihexoside appear as
vacuoles, which are sudanophilic and PAS-positive. By electron microscopy, these deposits appear as intralysosomal aggregates of concentric or parallel lamellae, which stain positively by ultrastructural techniques
that demonstrate cardohydrates 44.
Endomyocardial biopsy may be helpful in making the diagnosis of Fabry,s disease, particularly in cases
not recognised in childhood, or in patients who lack the usual signs and symptoms (i.e., proteinuria, corneal apacities).
Cardiac Amyloidosis
Amyloidosis describes disease processes, which are characterised by extracellular deposits of proteins,
which have a beta-pleated sheet conformation. Current classification is based on the biochemistry of the amyloid fibril, and who major groups are recognised: AL, in which fibrils consist of light chains of immunoglobulin, and AA, in which the fibrils consist of fragments of serum amyloid A protein. A third group, in which the
fibrils are comprised predominantly of prealbumin and which occurs in senile cardiac amyloidosis and familial polyneuropathy. The AL form is associated with plasma cell dyscrasias or can occur as localised deposits without evidence of generalised involvement, while AA often occurs with inflammatory processes, such
as rheumatoid arthritis or chronic infection. Amyloid deposits can be found in the heart in elderly people or
as part of generalised amyloidosis. Senile cardiac amyloid has been reported in 30-69% of patients older than
60 years, while 54-90% of patients with generalised amyloidosis (usually AL associated with multiple myeloma, or less often AA) have cardiac involvement 45.
Depending upon its origin and extent, cardiac amyloidosis may be asymptomatic, or it may cause progressive heart failure and refractory arrhythmia. Clinically significant cardiac amyloidosis must be differentiated
from constrictive pericarditis, hypertrophic cardiomyopathy, storage diseases, or other infiltrative myocardial
diseases. It can also manifest as ischemic heart disease, with typical or atypical angina and a “pseudoinfarct”
pattern on ECG, and it may produce arrhythmias or conduction defects. Cardiac amyloidosis produces a stiff
myocardium, which impedes diastolic ventricular filling and creates restrictive hemodynamics.
In clinically significant cardiac amyloidosis, the heart may be heavy and the walls are thickened, firm, and
have a pale colour and rubbery consistency. Amyloid deposits occur in the interstitium, conduction tissue,
valves, endocardium, pericardium, and in small intramural arteries, veins and capillaries. In the myocardium,
amyloid may be found surrounding individual myocytes, or in the form of focal nodular interstitial deposits
that push aside and replace fibres, or both. Myocardial fibrosis may be assesed by different methods 46 In coronary vessels, it may involve all vascular layers and even cause luminal occlusion. The presence of amyloid
can be confirmed by the apple green birefringence it gives under polarised light after Congo red staining, or
by metachromasis with methyl violet, or ultraviolet fluorescence with thioflavin T (the latter may yield false
positives). Amyloid fibrils can also be identified by their characteristic ultrastructural appearance as 7.5 nm
diameter nonbranching fibrils. If clinically indicated, immunohistochemical typing of amyloid can be done
using paraffin embedded sections with antisera against purified amyloid fibril protein and monoclonal antibodies against protein AA.
In patients suspected of having cardiac amyloidosis, an endomyocardial biopsy cannot be substituted by
biopsy of another site, such as the rectum, as only 60-80% of patients with idiopathic (primary) amyloidosis
will have a positive rectal biopsy. At least four biopsy specimens should be obtained to minimise the possibility of a false negative result. While patients with known amyloidosis who have typical echoradiographic
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features do not necessarily need to undergo endomyocardial biopsy, cardiac amyloidosis cannot be excluded
on the basis of negative biopsies of extracardiac tissues. In patients who have clinically unexplained cardiac
disease and suspected amyloidosis, endomyocardial biopsy is a reliable diagnostic procedure.
Cardiac hemochromatosis
Iron deposits occur in the myocardium in idiopathic (familial) hemo-chromatosis as well as in hemosiderosis secondary to iron overload (e.g., multiple transfusions, dietary intake). The clinical manifestations vary,
depending on the extent of myocardial involvement, but patients usually have a dilated, or rarely restrictive,
cardiomyopathy. Some patients are asymptomatic but may have echocardiographic evidence of myocardial
infiltration (increased left ventricular wall thickness). Other abnormalities include ECG changes (ST-segment
and T-wave changes), supraventricular arrhythmias, atrioventricular conduction disturbances, and ventricular arhythmias. The severity of myocardial dysfunction may be proportional to the amount of iron present,
and extensive deposits are usually associated with congestive heart failure (occurring in one third of patients)
which is usually the cause of death 47.
The heart appears brown and may be hypertrophied and/or dilated. Normally, there is no stainable iron within the myocardium. In hemochromatosis/hemosiderosis, iron deposits are more extensive in the epicardial
third, intermediate in the inner (subendocardial) third, and least extensive in the middle third of the ventricular
wall. They are typically perinuclear in location initially, but eventually occupy most of the cells. Involvement
of the conduction system, coronary arteries, and valves in limited. There may be associated fibrosis, in which
case restrictive hemodynamics may be present. As hemochromatosis in usually associated with involvement
of other organs, EMB is not required for diagnosis. If a biopsy is performed, however, multiple specimens
should be obtained to minimise sampling error, since iron deposition may be focal 48.
Cardiac Sarcoidosis
Most patients with cardiac sarcoidosis have clinically apparent systemic sarcoidal involvement, but in some patients the heart may be the primary site, without clinical evidence of other organ involvement. The clinical manifestations are determined by the extent and location of process and may include atrioventricular conduction defects, ventricular arrhythmias, sudden death, congestive heart failure (due to widespread myocardial involvement, ventricular aneurysms, arrhythmias, or cor pulmonale due to pulmonary hypertension), chest
pain with or without ECG changes of ischemia or dysfunction of papillary muscles and mitral regurgitation.
Pericardial abnormalities (effusion, constrictive pericarditis, tamponade) may also occur.
Cardiac sarcoidosis is a focal disease. Therefore, when endomyocardial biopsy is performed in patients
with suspected cardiac involvement, multiple specimens from several sites should be obtained. The predominant sites of myocardial involvement are, in decreasing order of frequency, left ventricular free wall, base on
the interventricular septum, right ventricular free wall, and atrial walls. A negative biopsy does not rule out
the diagnosis of cardiac sarcoidosis 49. The lesions in the heart are identical to those described in the lungs,
consisting of histiocytes, giant cells, lymphocytes and plasma cells. Patchy fibrosis and lymphocytic myocarditis can also be observed but are nonspecific. Other conditions associated with giant cells in the heart that
may need to be distinguished from sarcoid include idiopathic giant cell myocarditis, infective endocarditis,
rheumatoid arthritis, Takayasu,s arteritis, and Wegener,s granulomatosis 50.
In summary, sarcoidosis should be suspected in young adults, especially in blacks, who have cardiomyopathy, conduction disturbances or other ECG abnormalities. Although sarcoid involves the heart in only 20%
of autopsy-proven cases of sarcoidosis, endomyocardial biopsy may aid in the diagnosis.
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Cardiac Tumors
Primary cardiac tumors are rare, ranging in incidence at autopsy from 0.0017 to 0.28%, compared to 1.22%
for metastatic cardiac tumors. The most common primary cardiac tumor is myxoma (40%), followed by angiosarcoma and rhabdomyosarcoma, with these three comprising over half of all cardiac tumors. Other primary
cardiac tumors include papillary fibroelastoma, fibroma and fibrosarcoma, hemangioma, teratoma, and mesothelioma of the atrioventricular node. Metastatic tumors to the heart include lung carcinoma, hematopoietic-lymphoid neoplasms, and melanomas, with cardiac involvement occurring in about 20% of patients with
malignancies. Endomyocardial biopsy has the potential to aid in the diagnosis of primary and secondary cardiac tumors, and there have been several reports in which the diagnosis of an intracardiac tumor was made by
left or right ventricular transvenous biopsy 40. Some patients may benefit from the procedure, which has less discomfort, risk and expense than an open thoracotomy, particularly those in whom the benefit of surgery
might be questionable. The risk of tumor embolization is unknown, but could be a potential problem, particularly if the tumor is friable (i.e., myxomas).
Sensitivity and toxic reactions
Anthracycline cardiotoxicity
Anthracyclines, antineoplastic drugs that include doxorubicin (Adriamycin) and daunomycin, are effective chemotherapeutic agents for the treatment of numerous solid and hematopoietic malignancies. Cardiac
toxicity is a well-recognised complication and is the doselimiting factor in the use of these drugs. While the
usual practice is to administer these agents up to a maximum total dosage of 500-550 mg/m2, some patients
may suffer cardiotoxic effects at lower cumulative doses, particularly if they have pre-existing cardiac disease (including hypertension), are greater than 70 years in age, or have received prior irradiation. Prior cyclophosphamide therapy may also potential the cardiotoxic effects of anthracyclines. There is significant individual variation in a patients susceptibility to anthracycline-induced cardiac damage, with the subsequent development of heart failure. Radionuclide ejection fraction is sensitive but cannot differentiate heart failure due
to other causes from that due to anthracycline alone, and the drug may be withdrawn prematurely in some patients. For these reasons, serial EMBs have become a reliable method to evaluate anthracycline cardiotoxicity 51. The degree of myocardial injury can be estimated by histologic grading of biopsy specimens, and the
EMB is an effective means to monitor patients.
Anthracycline produces both early and late cardiotoxic effects. The early effects, which can occur after one
dose, include a pericarditis-myocarditis syndrome, drug-induced cardiovascular dysfunction, and arrhythmias.
Dose-related myocyte damage and heart failure is directly related to the amount of myocyte damage. The
cardiomyopathy appears 1 to 6 weeks after the last dose is given and prognosis is poor, with death occurring
in 79% of patients. It is not possible to accurately evaluate anthracycline cardiotoxicity by light microscopy. Therefore all EMBs must be submitted for EM 15,52 . Two characteristic lesions can be seen ultrastructurally: sarcotubular dilatation and loss of myofibrils. The extent of these changes are the basis for the grading
system. Sarcotubular dilatation is due to coalescence of dilated sarcoplasmic reticulum and, when severe, can
be seen by light microscopy, but this must be confirmed by electron microscopy. Myofibrillar loss may be
detected by light microscopy by the appearance of small, shrunken cells with homogenous, pale cytoplasm
but, again, this must be confirmed ultrastructurally. If cardiotoxicity is severe, the non-specific finding of interstitial fibrosis may also be seen.The pathogenesis underlying anthracycline cardiotoxicity is not clear. One
postulated mechanism is via generation of free radicals, which has considerable corroborating experimental
evidence. Other possibilities include inhibition of coenzyme Q 10 (ubiquinone) which is involved in oxidative phosphorylation.
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7. SPECIAL VALUE OF EMB IN DIAGNOSIS AND CHOICE OF TREATMENT
MODALITIES OF IDIOPATHIC MYOCARDITIS
Among all SHMD, the most common and important is viral MC, which diagnosis is based mainly on
“Dallas criteria”. By consensus, the authors defined acute MC as “a process characterised by an inflammatory infiltrate of the myocardium with necrosis and/or degeneration of adjacent myocytes which was not typical of the ischaemic damage associated with coronary artery disease”. Idiopathic (presumed viral) MC would be termed “primary MC”, whereas acute MC due to other causes (toxoplasmosis or Chagas disease) would be termed secondary MC. As mentioned previously, the Dallas criteria were defined for the MC trial, therefore, separate terminology was adopted for the first diagnostic biopsy and for the subsequent biopsies 53.
On the first EMB the following diagnoses could be made: (1) active MC, with or without fibrosis: both, an
infiltrate and damage of the adjacent myocytes were required for this diagnosis. (2) Borderline MC: (not diagnostic findings, requiring a repeat biopsy). This term implies that the inflammatory infiltrate is too sparse
or that the myocyte damage is not seen on PH. Additional sections of the original biopsy might demonstrate
diagnostic changes in which active MC can be diagnosed. (3) No evidence of MC: a biopsy in which there is
no inflammatory infiltrate or myocyte damage.
All subsequent biopsies were divided also into three categories. (1) Persistent or ongoing MC: this diagnosis is made when the degree of interstitial infiltrate is the same or worse than on the first biopsy. (2) A resolving (healing) MC: this diagnosis is made when the inflammatory infiltrate is less expressed than in the previous biopsy, and reparative changes are evident. (3) Resolved (healed) MC: where there is now no inflammatory infiltrate remaining and no evidence of ongoing cellular necrosis. Scar tissue ( fibrous replacement or collagen fibrosis) may be present with adjacent compensatory hypertrophy.
It is becoming increasingly apparent that following an acute or subacute episode of MC due to a virus infection, the virus might persist in the cardiac tissues causing a DCM. It is not clear how RNA viruses switch
from acute to persistent infections, but it seems that viral transcription and translation are reduced. The treatment of viral MC may be different and depend on therapeutic approach of the clinician and can be defined as 3 main modalities: conventional therapy, immunosuppressive and immunomodulatory treatment 53-56.
The conventional therapy is mainly based on bed rest, aspirin, and all other necessary cardiac medicaments
(including diuretics, ACE-inhibitors, b-blockers, etc). There is no attempt to eliminate the virus or to interfere with patients’ immune system. From the very “popular” immunosuppressive treatment there was too many
expectations, and unfortunately not very promising results. Introduced and recommended by many, the final
trial had no definitive proof for recommendation of these medicaments.
Finally, the immunomodulatory therapy was introduced. If the viruses are involved in MC (and consequently with DCM), therapeutic use of interferons or its inducers seems to be appropriate, either due to its direct action on the target cell or indirect effects (activation of cytotoxycity, modulation of immune response,
and interaction with other mediators of immune response).
Presuming that heart in MC and DCM may represent a site of low-grade persistent infection, intermediate doses of interferon (IFN) should be considered as a treatment schedule. Administration of IFN in doses
over a certain level does not increase antiviral activity, and too frequent administration may prolong the refractory state of the cells.
We enrolled 180 patients (clinical study by Dr M.Mirić at “Dedinje” Institute) to receive a-interferon
(IFN) with doses of 3-5 million units per day, for 3 months, and thymomodulin 10 mg 3 times per week, for
2 months. Some patients received conventional therapy alone (depending on EMB analysis). Patients were
followed up for 7 years after the end of treatment. Left ventricular function, exercise tolerance and survival
rate were significantly better at long-term follow-up in patients treated with IFN or thymomodulin, than in
conventionally treated patients. These results implicate that immune modulating therapy might represent important contribution for treatment of MC and DCM, and suggest that adding immunomodulators to the conventional therapy improved the functional capacity and survival of these patients 55.
To improve the treatment, Figulla et al. presented a new classification of MC/DCM patients21. The term
idiopathic DCM should be used if myocardial dysfunction of unknown cause is detectable by hemodynamic
560
measurements. According to EMB findings, 4 subsets of MC/DCM can be differentiated: patients without
any infectious agent present on EMB and without inflammatory infiltrate; patients without infectious agent
but with cellular infiltrate; the third group are patients with an infectious agent and with an infiltrate; and the
last group are patients with infectious agent without infiltrate. Those patients without any infectious agents
and without cellular infiltrates should receive unspecific heart failure therapy (conventional). If a virus is detectable, heart failure therapy in combination with a virus-suppressive agent may be more appropriate. If a
cellular infiltrate is present in combination with an infectious agent and severe left ventricular dysfunction is
found, unspecific (conventional) therapy is recommended in combination with a virus-suppressive agent and
cytokine blockers. In the case of an infectious agent without cellular infiltrates, a combination of unspecific
therapy and virus-suppressive agent should be used.
OVERALL DIAGNOSTIC VALUE OF ENDOMYOCARDIAL BIOPSY
During the past three decades, the technique for performing EMBs has been improved substantially.
However, this alone does not explain the increasing clinical use of this procedure. Probably, the combination
of experience, diagnostic accuracy, new technical aspects 57, and sophisticated technique in analysing fresh
myocardial tissue revealed such interest for enlarged EMB applications. The main value of EMB in diagnosis and treatment of primary heart diseases is the possibility of giving the precise diagnosis (with severity and
extent of the pathologic process), followed by the choice of treatment modalities 55,56).
EMB analyses not only aid diagnosis, but also help in the differential diagnosis of endomyocardial fibrosis
from other causes of heart failure57. Further, it has helped to evaluate prognosis, particularly in patients with
congestive CMP. The personal experience of the author extends to biopsies obtained from over 1100 patients.
It has been found that in 82 % of patients, morphological information that is helpful to the referring physician can be obtained. Additional 13% of analysed material present non-specific findings with no PH diagnosis.
Only the remaining 5% of EMB were to small or inadequate material for appropriate diagnosis. If we consider that in non-specific findings we did not found any other new entity or changed the clinical diagnosis, by
elimination these results can also be considered as helpful. In that case, we can estimate clinical merit in over
80% of the cases. With special references to the choice of the treatment, EMB will play even more important
role in the future, for the management of patients with CMPs and SHMD.
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Neuromišićne biopsije – tri godine
nacionalnog iskustva
Neuromuscular biopsy - a review of 3
years nacional experience
Sanja M. Milenkovic
Služba kliničke patologije, Kliničko bolnički centar Zemun,
Beograd, Srbija
Department of Clinical Pathology, Clinical Hospital Centeer
Zemun, Belgrade, Serbia
Apstrakt
Abstract
U ovom radu prikazujemo iskustvo sa 162 konsekutivne neuromišićne biopsije analizirane u period
od 2009 do 2012 godine. Neuromišićne bolesti predstavljaju veliku grupu naslednih i stečenih bolesti koje se karakterišu gubljenjem mišićne mase i slabošću
mišića. Razlikovanje miopatija od perifernih neuropatija, bolesti ćelija prednjih rogova kičmene moždine (i bolesti neuromišićne spojnice zahteva pažljivu
kliničku evaluaciju, laboratorijska, neurofiziološka i
elektromiografska ispitivanja, radiološka ispitivanja
(npr.magnetna rezonanca), mišićnu biopsiju i genetsko ispitivanje. Rezultati mišićne biopsije se isključivo mogu interpretirati u kontekstu prethodno navedenih ispitivanja. U Republici Srbiji je 2009.god. u
Službi kliničke patologije Kliničko bolničkog centra
Zemun, a po odluci Ministarstva zdravlja Republike
Srbije, počela rutinska dijagnostika NMB na biopsijskim uzorcima mišiča, nerava i kože
Ključne reči: biopsija mišića, biopsija nervaa,
imunohistohemija, populaciona studija
In this paper we present the experience with 162
consecutive neuromuscular biopsies analyzed in the
period from 2009 to 2012. Neuromuscular diseases
are a large group of inherited and acquired diseases
that are characterized by loss of muscle mass and
muscle weakness. Distinguishing myopathies from
peripheral neuropathy, diseases of the anterior horn
cells of the spinal cord and the diseases of the neuromuscular junction requires careful clinical evaluation, laboratory, neurophysiological and electromyographical examination, radiological tests, muscle biopsy and genetic testing. Muscle biopsy results can
solely be interpreted in the context of the above tests.
In Serbia, 2009. in Department of Clinical Pathology
Clinical Hospital Center Zemun, a decision by the
Serbian Ministry of Health, began a routine diagnostic biopsy specimens in the NMB muscles, nerves
and skin.
Key words: muscle biopsy, nervaa biopsy, immunohistochemistry, population studies
Uvod
Neuromišićne bolesti predstavljaju veliku grupu naslednih i stečenih bolesti koje se karakterišu gubljenjem
mišićne mase i slabošću mišića. Razlikovanje miopatija od perifernih neuropatija, bolesti ćelija prednjih rogova kičmene moždine (npr. bolest motornog neurona) i bolesti neuromišićne spojnice (mijastenija gravis) zahteva pažljivu kliničku evaluaciju, laboratorijska, neurofiziološka i elektromiografska ispitivanja, radiološka
ispitivanja (npr.magnetna rezonanca), mišićnu biopsiju i genetsko ispitivanje. Rezultati mišićne biopsije se
isključivo mogu interpretirati u kontekstu prethodno navedenih ispitivanja1, 2, 3.
Ni u jednoj grani patologije neuromišićni patolog ne pokazuje toliku sklonost da podržava uputnu kliničku dijagnozu. Prilikom analiziranja neuromišićne biopsije neuromišićni patolog uporno i neprekidno traga
za morfološkim detaljima koji bi potvrdili uputnu dijagnozu4. U tom dugotrajnom procesu, nizu ponovljenih
bojenja i velikom broju preseka on odustaje i počinje da traži alternativne morfološke pokazatelje tek kada je
duboko uveren da nema patognomoničnih promena za predloženu dijagnozu. Takođe, neuropatolog pri analizi neuromišićne biopsije, pokazuje duboko nepoverenje u morfološke promene koje vidi u kontinuirano ih
upoređuje sa naučnim usvojenim standardima i sopstvenim kontrolnim bojenjima.
Mišićne biopsije su još, daleke 1860. godine postale oruđe u dijagnostici neuromišićnih bolesti kada je
Duchenne izveo prvu biopsiju kod pacijenta sa simptomima miopatije 5. Uvođenje enzimohistohemijskih metoda od strane Victora Dubowitz 1970 –tih godina je napravilo revolucionarni napredak u dijagnostici različitih primarnih i sekundarnih bolesti mišića3, 5.
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Novi progress nastaje 90-tih godina dvadesetog veka sa uvođenjem imunohistohemije, a početak 21 veka
je obeležen spektakularnim progresom molekularnih metoda. Terapija neuromuskularnih bolesti takođe pokazuje snažan napredak sa uvođenjem genetskog terapijskog pristupa. Napredak postignut u proteklih 25 godina je omogućio otkrivanje novih uzročnika genetskih defekata sa mnogo novih proteina uključenih u neuromišićne bolesti (ažurirani spisak MDS i odgovornih gena mogu se naći na http://vvv.musclegenetable.org).
Danas, mišićna biopsija uz primenu svih savremenih metoda obrade predstavlja zlatni standard u dijagnostici neuromišićnih bolesti6,3.
Neuromuskularne bolesti (NMB) se javljaju kod ljudi svih uzrasta od rođenja, preko adolescentnog i odraslog doba do duboke starosti. Mogu biti u vidu blagih formi, ali i u vidu teških formi sa smrtnim ishodom.
Ne postoji zemlja ni region na svetu u kome se ove bolesti ne javljaju. U opštoj populaciji incidenca iznosi 1
na 1000 novorođenčadi, muskularne distrofije javljaju sa incidencom 1 na 2000 novorođene dece a, posebno
teška, ali i najčešća Duchenne-ova muskularna distrofija je sa incidence 1 na 3.500 muške novorođene dece7.
Veliki, vekovni, problem pacijenat sa NMB je njihova kulturalna i socijalna marginalizacija u većini zemalja sveta, a posebno u nerazvijenim zemljama i zemljama u razvoju. Pored navedenog problema, dodatni
problem zemalja u razvoju i nerazvijenih zemalja je nepostojanje adekvatne dijagnostike i formiranje nacionalnih baza podataka koje bi omogućile uvid u distribuciju i familijarne rizike oboljevanja.
U Republici Srbiji je 2009.god. u Službi kliničke patologije Kliničko bolničkog centra Zemun, a po odluci
Ministarstva zdravlja Republike Srbije, počela rutinska dijagnostika NMB na biopsijskim uzorcima mišiča,
nerava i kože. Većina pacijenata su pacijenti iz pet centara: Klinike za neurologiju Kliničkog centra Srbije,
Instituta za dečiju neurologiju i psihijatriju, Vojnomedicinske akademije Beograd, Univerzitetske dečije klinike Tiršova Beograd i Kliničkog centra Vojvodine. Takođe, sporadično se upućuju pacijenti iz drugih ustanova u Srbiji, susednih država, ali i iz inostranstva. U cilju formiranja Nacionalne baze za mišićne distrofije
Ministrstvo nauke je odobrilo petogodišnji naučni projekat pod nazivom “Ispitivanje molekularno genetskih,
patohistoloških i biohemijskih karakteristika neuromišićnih bolesti”8 (br. 175083).
U ovom radu prikazujemo naše iskustvo sa 162 konsekutivne neuromišićne biopsije analizirane u period
od 2009 do 2012 godine.
Materijal i metode
Za protekle tri godine je analizirano 162 neuro-mišična biopsijska uzorka dobijena procedurom otvorene
hirurške biopsije4.
Kriterijumi na osnovu kojih su pacijenti uključeni u studiju su:
a) da su bili upućeni iz primarnih i sekundarnih zdravstvenih institucija u referentne centre za adultnu i
dečiju neurologiju
b) da su detaljno, svim raspoloživim metodama pregledani od strane neurologa u referentnim centrima
c) da su biopsije otvorenim putem uzete od strane posebno edukovanih hirurga u Kliničko bolničkom centru Zemun za adultne pacijente, a za dečiji uzrast u Univerzitetskoj dečijoj klinici Tiršova
c) da su sveži reprezentativno uzeti i pripremljeni biopsijski uzorci u vremenskom period ne dužem od 30
minuta dopremljeni u Službu kliničke patologije KBC Zemun
d) Pojedinačni pacijenti, sporadično upućeni iz drugih ustanova ili parafinski blokovi doneti na konsultaciju nisu uključeni u ovu studiju (ukupno 32).
Uzorci biopsija mišića i nerava su obrađeni u Službi kliničke patologije KBC Zemun Beograd. Pravilnom
orjentacijom uzorka pod stereomikroskopom Nikon SMZ1500 i brzim smrzavanje uzorka u tečnom azotu (ili
izopentanu ohlađenom u tečnom azotu) odmah po dostavljanju uzorka iz hirurške sale smo započinjali proces obrade. Pripremano je 20-30 smrznutih preseka na super frost pločicama za histohemiju, enzimohistohemiju ili imunohistohemiju. Obrada se nastavlja procesiranjem uzorka kroz formalinsku fiksaciju do parafinskog kalup, a deo tkiva za elektronsku mikroskopiju smo procesirati kroz 4% glutaraldehid.
Rutinski smo preseke neuromišićnih biopsija bojili hematoksilin eozin (H&E) i modifikovano Gomori trichrom bojenja na osnovu koji smo procenjivali:
arhitekturu mišićnih vlakana (oblik, veličinu, atrofiju i hipertrofiju, poziciju jedara)
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inflamatorne infiltrate
intersticijum i krvne sudove
patognomonične histološke promene za mitohondrijalnie miopatija, nemalinske miopatije, tubularnih agregata i “rimmed” vakuole
Smrznuti preseci tkiva su obrađivani histohemijskim i enzimohistohemijskim metodama bojenja na osnovu standardno preporučenih paleta3 (Tabela 1.)
Spectrin
Dystrophin (N term)
Dystrophin (rod domain)
Dystrophin (C-term)
Utrophin
nNOS
Myotilin
Lamin A/C
Dysferlin Ham1
Dysferlin Ham2
a-Sarcoglycan
b-Sarcoglycan
g-Sarcoglycan
δ-Sarcoglycan
b-Dystroglycan
Collagen VI
Emerin
Desmin
MHC class I
Fast Myosin
Slow Myosin
Develpmental Myosin
Neonatal Myosin
g-Sarcoglycan
Tabela 1. Lista sadrži deo palete antitela za otkrivanje primarnih ili sekundarnih oštećenja, kao i za procenu kvaliteta i očuvanja uzoraka
Imunohistohemijsko bojenje je rađeno automatski u imunostejneru Labvision sa automatskim predtretmanom u PT modulu. Svi uzorci mišićnih biopsija su rutinski bojeni na izoforme miozina Tip 1 (slow), Tip 2
(fast) i neonatalni miozina (Slika ). Kompjuterskim softverom LAS V37 programom je merena veličina vlakana kod svakog uzorka na 100 preseka (50 obojenih brzim miozinom, 50 vlakana obojenih sporim miozinom) po najužem prečniku. Očuvanost mišićne sarkoleme je procenjivana imunohistohemijskim bojenjima
ili na laminin α2 ili collagen VI. Za procenu statusa mnogih protein kod različitih miopatija je bila korišćena
široka paleta komercijalnih antitela dostupnih na tržištu (Tabela 1.). Kompjuterska baza analiziranih uzoraka
je formirana za period 2009-2012 godine. Patohistološki izveštaj je sadržao detaljnu analizu svih parametara
sa reprezentativnim fotografijama, dijagnozom ukoliko je bilo moguće postaviti, ili predlogom za eventualna
dodatana imunohistohemijska, molekularna ili elektronsko mikroskopska ispitivanja.
Rezultati
Analizirano je ukupno 162 uzorka neuromišićne biopsije koje su upućene iz referentnih centara i 31 sporadične biopsije (Dijagram 1.).
Dijagram 1. Broj pacijenata po godinama koji su upućeni iz referentnih centara
566
Od ukupnog broja pacijeneta 34 (21,11%) su bili pacijenti starosti do 10.godina, a najveći broj pacijenata
je bio u starosnim grupama posle 30 godine (Dijagram 2. )
Dijagram 2. Starosna struktura pacijenata
U odnosu na regione republike Srbije nije postojala posebna učestalost pacijenata iz nekog dela Srbije, i
uglavnom su bili pacijenti iz centralnih delova Srbije. (Dijagram 3.).
Dijagram 3. Distribucija pacijenata prema regionima Srbije
U odnosu na grupu bolesti najviše dijagnostikovanuh oboljenja je bilo iz grupe miopatija i miozitisa, a znatan broj je bio i pacijenata sa neurogenim lezijama mišića (Dijagram 4.)
Dijagram 4. Broj pacijenata u odnosu na tip bolesti
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Prilikom analize biopsija postavljene su precizne dijagnoze za mnoge bolest, ali je jedan broj sadržavao
samo opisnu formu uočenih abnormalnosti sa preporukama za dalja uglavnom molekularno genetska ispitivanja. Na HE obojenim preparatima su utvrđivane grupe promene arhitekture ali su postavljene i neke decidne dijagnoze kao npr. (Slika 1.): polyglucosan body disease (Slika 1a.), granulomatozni miozitis (Slika 1b,)
ili Inclusion Body Myositis (Slika 1c.).
Slika 1. Patognomonične histološke promene za određene bolesti mišića i nerva
Takođe, pojedine promene ukazuju na određene proteinske poremećaje koji se mogu potvrditi imunohistohemijskim metodama, kao što je utvrđeno u slučaju dezmonopatije (Slika 2.)
Slika 2. Vakuolarna izmenjenost vlakana sa iregularnom distribucijom dezmina u slučaju dezminopatije
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Primenjena enzimohistohemijska bojenja su omogućila analizu intermiofibrilarne mreže koju grade mitohondrije i sarkoplazmatični retikulum. Abnormalnosti unutrašnje fibrilarne arhitekture su veoma važni pokazatelji mnogih mišićnih bolesti i zahvaljujući ovim bojenjima smo utvrdili postojanje ciljnih tzv.”target” vlakana taman, svetao ili prazan centar bez bojenja mitohondrij i pojavu tzv. “lobuliranih” vlakana je opšta karakteristika ali je česta kod LGMD 2A, Ullrich Congenital Muscular Dystrophy, Bethlem myopathyi sl. (Slika 3).
Slika 3. Abnormalnosti unutrašnje fibrilarne arhitekture mišićaa.
Abnormalnosti u bojenju čistih mitohondrijalnih enzima, kao na primer subsarkolemalnaa akumulacija
succinic dehydrogenase (SDHkoje smo utvrdili u slučajevima dijagnostikovanih mitohondrijalnih miopatija (Slika 3c).
Modifikovano Gomori trichrom bojenje (Engel trichrome uvedeno od strane W. King Engel 1963.god.) je
omogućilo dijagnostiku patognomoničnih abnormalnosti kod: mitohondrijalnih miopatija, nemalinske miopatije, tubularnih agregata i “rimmed” vakuola (Slika 4.).
Slika 4. Patognomonične abnormalnosti kod mitohondrijalne i nemalinske miopatije
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Ova metoda bojenja je bila veoma uspešna kod nervnih biopsija za procenu različitih patoloških stanja, a
posebno demijelinizacija (Slika 5.),
Slika 5 . Uspešnost Modifikovanog Gomori Trichrome bojenja na biosijskim uzorcima nerva
U laboratoriji smo rutinski koristili na parafinskim presecima imunohistohemijsko bojenje na brzi miozin
Tip 2 (Myosin Heavy Chain, Fast, Clone Wb-MHCf) a, na kriostatskim presecima naspori T2 miozin (Myosin
Heavy Chain, Slow, Clone WB-MHCs) (Slika 6.). Pored dva osnovna tipa smo posebno u proceni kongenitalnih miopatija i utvrđivanju da li su atrofična vlakna regeneratorna ili stvarno atrofilčna primeniti i drufe
izoforme miozina: neonatalni i razvojni. (Slika 6.).
Slika 6. Ekspresija različitih izoformi miozina.
Za neke distrofija (udno pojasnih i fascioscapulohumeralnih) su detektovani proteinski defekti i moguće
ih je utvrditi imunohistohemijski što smo primenjivali u dijagnostici korišćenjem svih raspoloživih klonova
(Slika 7 i 8).
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Slika 7. Detektovani proteinski defekti7
Slika 8. Detektovani proteinski defekti
Diskusija
Skeletni mišić je najveći organ u telu i posebno je teško reprezentativno odrediti mesto biopsije. Biceps,
deltoideus i kvadriceps su najčešće birani mišići, ali je uvek optimalno izabrati umereno zahvaćen mišić. Druga
važna tačka uspešne dijagnosstike je reeprezentativno uzorkovanje i sledstvene laboratorijske metode obrade
tkiva koje mogu imati značajan uticaj na rezultat biopsije.
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Zlatni standard u dijagnostici neuromuskularnih bolesti je histološka analiza. U novije vreme je dijagnostika znatno unapređena metodama imunohistohemije, pre svega u sferi utvrđivanja tipa vlakana i potiskuje
50 godina korišćenu tehniku ATP-aza koja je veoma zahtevna i kapriciozna 8,9, 10.
Drugi veoma važan doprinos imunohistohemije je mogućnost utrđivanja statusa pojedinih specifičnih proteinskih defekata što vodi ili decidnom postavljanju dijagnoze ili usmeravanju molekularno genetske analize.
Utvrđivanje populacione distribucije pojedinih naslednih bolesti i familija u kojima se one javljaju predstavlja glavni zadatak ozbiljnog vođenja brige o zdravlju ljudi jedne zemlje. No, u nerazvijenim zemljama
i zemljama u razvoju finansijska nestabilnost i nedovoljna opremljenost laboratorija u tehničkom i kadrovskom smislu usporava taj process. Čak, i u mnogim razvijenim zemljama process stvaranja nacionalnih baza
je predstavljao problem i rešavan je višedecenijski.
Walton i Nattrass12 su 1954 godine publikovali originalan rad u kojem su opisali 105 slučajeva od
Northumberland do Durham u Severnoj Engleskoj. Oni su tada i predložili novu klasifikaciju mišićnih bolesti baziranu na detaljnoj kliničkoj opservaciji. Posle 50 godina, urađena je detaljna populaciona studija12 sa
genetskim analizama u istom region na 1100 pacijenata kod koji su utvrđivane molekularne karakteristike za
31 entitet. Ukupno 75.7% pacijenata je svrstano u taj 31 entitet. Navedena studija takođe ilustruje ogroman
dijagnostički napredak od prvog regionalnog istraživanja pre više od 50 godina.
Literatura
1. Anderson JR. Recommendations for the biopsy procedure and assessment of skeletal muscle biopsies. Virchows
Arch 1997;431(4):227-33.
2. Edwards R, Young A, Wiles M. Needle biopsy of skeletal muscle in the diagnosis of myopathy and the clinical study
of muscle function and repair. N Engl J Med 1980;302(5):261-71.
3. Dubowitz V, Sewry C A. Muscle Biopsy: A Practical Approach. 3rd ed ed. China: Saunders Elsevier; 2007.
4. Milenkovic S, Rakočevic-Stojanovic V. Biopsije mišića: Zašto, ko i kako? Zbornik sažetaka II kongres patologa
Bosne i Hercegovine sa međunaarodnim učešćem, Banja Luka 2012, str.215-227 (predavanje po pozivu)
5. Sundaram C, Uppin SM. Approach to the Interpretation of Muscle Biopsy. In Muscle biopsy. Ed. Sundaram C.
Croatia, InTech 2011:15-33.
6. Rakocević-Stojanović V. Mišićne distrofije. Medicinski fakultet Beograd, I izd., CIBID, 2011, Beograd
7. Nešić S, Andrić N, Jovanović M, Milenković S, Aleksić Kovačević S. Heritable myopathy in a Labrador retriever.
Journal of Comparative pathology 2012;146(1):74 (Meeting Abstract)
8. Padykula HA, Herman E. The specificity of the histochemical method for adenosine triphosphatase. J Histochem
Cytochem 1955;3:170–95.
9. Padykula HA, Herman E. Factors affecting the activity of adenosine triphosphatase and other phosphates as measured by histochemical techniques. J Histochem Cytochem 1955;3:161–9.
10.Brooke MH, Kaiser KK. Some comments on the histochemical characterisation of muscle adenosine triphosphates.
J Histochem Cytochem 1961;17:431–2.
11.Meola G, Bugiardini E, Cardani R. Muscle biopsy.J Neurol. 2012;259(4):601-10.
12.Fiona L. M. Norwood FLM, Harling C, Chinnery FP, Eagle M, Bushby K, Straub V. Prevalence of genetic muscle
isease in NorthernEngland: in-depth analysis of a muscle clinic population. Brain 2009: 132; 3175–3186
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Uvodno predavanje 3/Keynote Lecture 3
Cervical cytology and histology in the context of a screening programme
Sanjiv Manek
Gynaecological Pathologist
Oxford
UK
In the UK, the national cervical cancer screening programme is probably the most established, robust and
rigorous of all screening programmes that has evolved over 25 years. It has seen a multitude of changes based
on evidence obtained from a vast amount of research and observations, as well as from advances in technology. This success has led to a definite impact on cervical cancer incidence with reduced mortality and morbidity related to cervical cancer. More recently, the changes introduced to the programme have been exponential and in the UK we are at the brink of a new direction and a new style of provision of the screening
programme. Throughout the years, there has been a continued effort to understand morphological aspects of
the cytology and histology in cervical neoplasia and many new entities have been recognised or variations of
known entities realised. The intricate measures to ensure quality in the screening programme have led to close working relationships between cytologists, histopathologists, colposcopists, and now, molecular biologists.
The UK cervical cancer screening programme (CCSP) is likely to change significantly in the next few years,
and although reduced in quantity, cytology will still remain an important aspect of it. The importance of histopathology is unlikely to change, but more onus will be placed on the molecular biologists and colposcopists.
In order to discuss and understand the importance of cytology and histology in the cervical screening programme and the absolute requirement of correlation between the two, it is important first to appreciate how the
UK CCSP has evolved and how it has taken with it the evolution of new technologies in cytology leading to
improved correlation between histology and cytology and quality assurance with obvious benefits to the patient.
Milestones in the UK CCSP
1987/8 -
Launch of formal programme.
1989 -
Introduction of 3-tier system of reporting
(Code 7 – moderate dyskaryosis).
1994 -
(Code 8).
Formal introduction and definition of the borderline category
1996 -
Formal introduction of review of screened slides.
1998 -
Introduction of quality assurance measures including external
quality assurance tests.
2000 -Achievable Benchmark Criteria (ABC) I.
2002 -
Terminology refinement.
2003 -Achievable Benchmark Criteria (ABC) II
2005 -
Introduction of the invasive cancer audit
2006 -
Changes in age ranges for screening and follow-up protocols.
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2007 -
Liquid-based cytology (± HPV vaccine).
2011 -
Targets for quick turnaround.
2012 -
Introduction of HPV testing as triage and test of cure
Future -
Networks, automation in screening and HPV testing as a primary screening tool.
Of these milestones, the major ones have been: 1) the ABC I and II documents which have introduced not
only the finer details of morphology in cervical cytology and histology, but also guidelines for reporting within certain parameters; 2) the terminology refinement; 3) the change in screening age ranges; 4) LBC; and 5)
HPV testing. Each time such changes were introduced, there were changes in reporting practice also seen and
considered necessary and the management of patients better defined and tailored. As a result, there has been a
vast amount of literature on morphology in conventional cytology and LBC, as well as literature on outcomes.
Cytology
The main categories of reporting currently are:
Unsatisfactory
Negative
Mild dyskaryosis
Severe dyskaryosis
Severe dyskaryosis ?invasive
Glandular dyskaryosis
Moderate dyskaryosis
Borderline changes – NOS
Warty
?High grade
Glandular
These categories were very well defined in conventional cytology and for many, particularly for severe
dyskaryosis, many patterns have been recognised through careful observation and regular audits. These categories are equally reproducible in LBC and, in fact, are somewhat easier to diagnose. With the advent of HPV
testing, some of these categories will be refined in due course.
Histology
The UK NHS CSP national office has published multiple documents on guidelines and amongst these, there are two on the histopathology of cervical lesions. The main categories to recognise are:
HPV changes
Cervical Intraepithelial Neoplasia (CIN) 1, 2 and 3
CIN 3 with crypt involvement
Low and high grade cervical glandular intraepithelial neoplasia (CGIN)
Early stromal invasion
>Stage 1A2 carcinomas and all the subtypes
Stratified mucinous intraepithelial lesion (SMILE)
Tubo-endometrioid metaplasia
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In the UK, the retention of the 3-tier system of reporting in cytology and histology has allowed detailed
correlation between the two. In everyday practice, correlation plays a very important role in providing the best
management to a patient and it helps to enhance failsafe procedures and to improve quality assurance measures.
Correlation in cervical pathology
Much of cervical biopsy reporting is dependent on correlation with referral or recent cytology. An adequate request form should state the expected degree of abnormality by mentioning the referral cytology findings. This can be accompanied by the colposcopic impression which is useful but less important where correlation is concerned. If clinical details are inadequate or variable, it is good practice to have the past history readily available at the time of reporting both histology and cytology. This allows appropriate and safe prospective reporting. The typical cervical histology report should have a comment on correlation, and where possible, all non-correlation cases should be worked up prospectively prior to issuing the final report. This would
involve examining multiple levels of the biopsy, immunohistochemistry (p16, bcl2, etc) and reviewing the
cytology. If the cytology is confirmed, then the appropriate management could be advised in the histology
report and this includes repeat colposcopy and biopsy. Where relevant, cases should be discussed at dedicated colposcopy MDT meetings. The review of the cytology could be used as a learning exercise when there is
overcall and undercall of abnormalities. Examining levels could mean cutting through the block if necessary,
particularly for high grade lesions.
If the cytology is high grade and confirmed by more than one person, and the subsequent histology is repeatedly lower grade or negative, follow up should be according to cytology in case of vaginal or high grade canal disease.
Problems arise when cytology and histology are divorced and correlation exercises are carried out retrospectively, often with significant delays. Patients may slip through failsafe, which can lead to delayed diagnosis.
The commonest situation of non-correlation is where the cytology has been reported as high grade dyskaryosis and the subsequent biopsy is negative or only low grade. If levels do not reveal any correlating lesions, the
possible reasons to consider are high canal disease, vault disease, tiny lesions and inadequate colposcopy. In
a significant proportion of cases, the expected lesion is discovered in subsequent biopsies. Sometimes a loop
excision is performed as treatment after a biopsy diagnosis of a high grade lesion and there is no correlating
lesion. Once again, the possibility of a tiny lesion (treated by the biopsy) needs to be considered if multiple
levels still do not reveal the expected histology.
Undercall in cytology is usually due to misinterpretation of crowded groups or missing single dyskaryotic
cells that may be small or keratinised, dark or pale. Occasionally immature metaplastic cells can be overlooked.
Overcall in cytology is usually due to mistaking immature or reactive metaplastic cells as high grade
dyskaryosis and crowded groups as microbiopsies of CIN 3.
Correlation with cytology reported as borderline is interesting. Borderline NOS or borderline reactive usually correlates with inflammatory changes or low grade CIN. Occasionally, a high grade lesion is seen and review of the cytology may show high grade dyskaryotic features. Borderline glandular changes may yield reactive features or CGIN on biopsy. It is a matter of experience and constant review of such cases to gain the
confidence to report the cytology as either negative or glandular dyskaryosis.
When LBC was introduced, there was a high incidence of reporting borderline ?high grade dyskaryosis.
Most of these turn out to be CIN 2/3 on histology. With time and with learning from consistent reviews, most
of these can be reclassified as high grade dyskaryosis.
With HPV testing, a new type of correlation challenge is being encountered. What is to be expected when
the cytology is negative and high risk HPV testing is positive? Many biopsies are negative (correlate with cytology) but some are high grade. Review of cytology in such high grade cases tends to show negative features
in most and abnormalities in only a few. In negative biopsy cases, follow up would be return to normal recall
unless the colposcopist decides otherwise. The other conundrum that has emerged is where the first cytology
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after a treatment is negative but HPV testing is positive rendering it necessary to colposcope. In many such
cases, the colposcopy is also negative. The type of further management is then decided by the colposcopist.
One more aspect of correlation in cervical pathology is in cervical cancer staging. Beyond stage 1A2 tumours, which depend on measurements, the more reliable modality for staging is imaging (MRI) and clinical, partly because of the three dimensional nature of lesions. There are a significant number of cases where
staging by pathology is much lower than that shown by imaging; hence, final staging has to be left to multidisciplinary team meetings.
Litigations
Over the years, there have been numerous litigation cases in cervical cancer development. Some are related to surgical issues but most are for possible errors in cytology reporting and occasionally for histology reporting. In the UK there have been famous instances of litigation and these have led to some of the changes
in the CCSP mentioned above. In particular, the invasive cancer audit was introduced as an educational tool
to understand why cancers develop despite women adhering to the screening programme. One has to appreciate that with human interpretation there will be a small percentage of false negative cytology but what is really important in this situation is to know what leads to false negative cytology. The audit is a very useful tool for this and with its use, the UK cytopathologists have seen some common patterns and variations in morphology accountable for false negative reporting. These include the categories of scanty dyskaryosis, small
keratinised cells, small cell (dark) dyskaryosis, pale dyskaryosis and microbiopsies. The ‘litigation’ cell is often the small dyskaryotic cell!
The future
There will be a reduction in the amount of cytology required as a result of HPV testing, to the point where
HPV testing may become the primary screening tool and cytology, the triage test. Much of the cytology screening will be automated, leaving only a small amount for human interpretation. All the processing and screening is likely to be carried out in hyper-laboratories. There will be changes in correlation processes because
histology will need to be matched with the HPV test result rather than with the cytology in low grade lesions.
Despite all the major overhauls, the UK CCSP is likely to remain cost-effective with major benefits which,
when the effects of the HPV vaccine are felt, should see a dramatic reduction in the cervical cancer incidence in the UK whilst avoiding major surgical interventions and hence other complications.
References
1. www.cancerscreening.nhs.uk/cervical
2. www.britishcytology.org.uk
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Prophylaxis and Early Detection of HPV-Related Neoplasia
Herbert Pfister, Cologne, Editor
Monographs in Virology. S. Karger
Detection of HPV DNA and RNA
Hans Ikenberg, Germany
Abstract
The balance between analytical (low) and clinical (high) sensitivity is crucial for the specificity of a routine HPV test as limited specificity will be harmful due to unnecessary treatment of healthy women. Up to
now HPV diagnostics is mainly based on DNA detection for which target and signal amplification methods
are available. PCR techniques can be divided into type-specific and consensus PCRs. Due to its high clinical sensitivity and its relatively high specificity the HC2 test is still regarded as the gold standard in routine
HPV testing. It hybridizes 13 (near) full-length stabilized RNA probes of high-risk HPV types to denatured
target DNA followed by detection via antibodies and chemiluminescence. To avoid costly validation studies for each new HPV test standards for evaluation have been defined. Recently several new HPV detection
assays have been commercialized. They all show promising data in first published studies but still await full
validation according to the criteria mentioned above. Among them only the cobas HPV test has already been
fully validated for use in triage and as adjunct to cytology. HPV 16 and 18 confer a much higher risk for development of a CIN 2+ compared to the other HPV high-risk types. It is therefore appropriate to test for these
HPV types independently. Apart from that testing for individual HPV types is of very limited clinical value
up to now.HPV RNA testing is a promising option with potentially higher specificity. As a first system, the
APTIMA test has now received an FDA approval.
Background
While cytology fails to detect prevalent CIN 2+ in a first approach in half of the cases (McCrory D 1999)
molecular HPV diagnostics is able to achieve this goal in up to 99%. Unlike morphology it also predicts the
risk of developing CIN 2+. Otherwise the presence of HPV DNA often is transient if not even contamination
(Schiffman, Wentzensen et al. 2011). Therefore standardized methods of HPV detection are of utmost importance to achieve clinically relevant results.
Except in some rare conditions only HPV high-risk testing is regarded of clinical value. In this chapter
HPV testing means identification of HPV high-risk types which are defined by their association with cancer. In the future HPV diagnostics may become helpful also for diagnostics of oral, laryngeal and pharyngeal (D’Souza, Kreimer et al. 2007) as well as anal (Frisch, Glimelius et al. 1997) neoplasias. To date it is clinically almost solely used in cervical lesions.
Today HPV diagnostics is a routine tool in three areas. First, triage of cytologically borderline (Wright,
Cox et al. 2002) or low grade (Wright, Massad et al. 2007) abnormalities. Second, as a test of cure after therapy of CIN (Zielinski, Bais et al. 2004).Third, HPV testing as an adjunct to cytology is recommended in major guidelines (Saslow, Runowicz et al. 2002) and meanwhile the replacement of cytology as primary screening method by HPV is intensively discussed (Katki, Kinney et al. 2011).
The detection of HPV is not always indicative of the disease resulting from the infection. A certain amount
of virus has to be present for a certain time in order to induce cervical neoplasia (Josefsson, Magnusson et al.
2000; Snijders, van den Brule et al. 2003). Hence transient infections with HPV and low amounts of virus are
clinically irrelevant. Routine HPV testing requires a clinically defined cut-off value of a detection system to
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avoid HPV positivities which compromise specificity and cause unnecessary further diagnostic procedures
and treatments. It is rare that a 12 year old diagnostic test like HC2 is regarded as gold-standard and the reference of a major guideline. The fact that this holds in clinical HPV testing points to a special situation with
distinct technical requirements not easy to meet.
Methods of HPV detection
Although in-situ-hybridization is able to locate the viral DNA its low sensitivity and lacking ability for highthroughput preclude a routine use (Hesselink, van den Brule et al. 2004). Any routine diagnostic use of HPV
protein detection is excluded by the fact that the HPV oncogenes E6 and E7 are expressed in very differential levels and no validated tests for their detection are available. The inconsistent seroconversion rate even in
persons with high grade cervical lesions precludes any routine serology tests (Wang, Schiffman et al. 2003).
Therefore only HPV DNA and (to a lesser extent) RNA assays are currently available for clinical applications. Because HPV DNA is present in productive as well as in transforming infections but also potentially as
a contamination its detection can primarily not inform about the clinical importance of this finding.
Technically for HPV DNA testing target and signal amplification methods are available. PCR techniques
can be divided into type-specific and consensus (general primer) PCRs. The products of consensus PCRs can
also be used for genotyping, eg by hybridizing them to multiple HPV types fixed on a membrane strip (Linear
Array) or to a DNA chip (Papillocheck).
PCR
Several PCRs for HPV detection are commercially available. The most widely distributed is meanwhile
the cobas assay, a realtime consensus PCR which covers 14 HPV high-risk types and additionally differentiates HPV 16 and 18 (Roche Molecular Diagnostics, Pleasanton, CA; see below). It replaced the Amplicor
test which never met all criteria for routine use.
The linear array assay is a type-specific method detecting 37 high- and low-risk types (Roche) while the
SPF10 assay (Kleter, van Doorn et al. 1999) (Innogenetics, Gent, Belgium), the most sensitive HPV assay
available, identifies 28 types. The most common PCR techniques only available for scientific applications are
the GP5+/6+ (Jacobs, Snijders et al. 1997) and the PGMY (Gravitt, Peyton et al. 2000) general primer sets.
An interesting multiplex variant of GP5+/6+ with Luminex detection with more even coverage of up to 100
different HPV types has been recently presented (Schmitt, Bravo et al. 2006). All these tests target the L1 region of the HPV genome with resulting amplicons from 65 to 450 bp length. Enzyme-immuno assays or reverse line blot assays are used as detection systems. The analytical sensitivity varies from less than 10 copies
with SPF10 primers with purified DNA to around 1000 copies with the GP5+/ 6+ primers in crude extracts
(Snijders, van den Brule et al. 2003). Numerous commercial labs have made up their own PCRs which are at
best internally validated, generally have not been investigated in scientific studies and are therefore less suitable for clinical use.
The analytical sensitivity of PCR can go down to some copies of HPV DNA. Surprisingly that is not reflected in a similar clinical sensitivity. Only a few larger studies showed an ability to identify more than 95%
of CIN 2+ lesions and the median sensitivity of HPV PCR was reported to be 82% in 16 studies (Lorincz and
Smith 2006). This can be explained by several factors. Primers usually targeting the L1 region of the HPV
genome may lack to bind in up to 7% of high grade lesions and cancers that have lost this region (Karlsen,
Kalantari et al. 1996). Other reasons are random partial inhibition (which is not necessarily indicated by internal controls) and competition effects if several HPV types are present (Qu, Jiang et al. 1997). One challenge with consensus HPV PCRs is to obtain an equal and regular level of detection of different HPV types
as shown by the range of sensitivity of the GP5+/6+ assay depending on the HPV type (Jacobs, Snijders et
al. 1997). Another challenge is the adjustment of a reliable cut-off, which is even a major point in ultra-sensitive type-specific PCRs.
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Signal amplification
Two signal amplification technologies (HC2 test, Qiagen, Gaithersburg, MD; Cervista, Hologic, Bedford,
MA) are on the market.
The HC2 test hybridizes 13 (near) full-length stabilized RNA probes of high-risk HPV types to denatured
HPV target DNA followed by detection via antibodies and chemiluminescence. The threshold value of the
system is 1 pg/ml which corresponds to around 5.000 copies of HPV DNA per test (Lorincz and Smith 2006).
It is very robust in the pre-analytical phase, has a simple sample preparation and requires no separate rooms
for different work steps. Up to now only partial automation is available. The inter-laboratory variation of the
HC2 test is very low and its results are highly reproducible (Castle, Wheeler et al. 2004). Respective data on
PCR are less consistent (Quint, Pagliusi et al. 2006). One theoretical drawback of the HC2 test is the lack of
a control for the presence of human cellular material. In routine application this seems to be of minor importance as it shows a sensitivity of up to 99% for CIN 3+ measured on a histology gold standard (Bohmer, van
den Brule et al. 2003) (Castle, Cox et al. 2008) and the low rate of specimens (~1%) without amplification of
a house-keeping gene in major studies (Castle, Gutierrez et al. 2011; Youens, Hosler et al. 2011). Additionally
risk estimates were hardly affected by adjusting for the amount of a housekeeping gene in a PCR system (van
Duin, Snijders et al. 2002). Another potential problem may be a cross reaction with a couple of low-risk HPV
types which was determined to be 7.8% of all positive HC2 results (Castle, Solomon et al. 2008). Because
some of them are regarded in fact as being of intermediate risk, this may even contribute to the high clinical
sensitivity of the test (Castle, Solomon et al. 2008). While the HC2 test out of the vial of the ThinPrep liquidbased cytology has been approved by the FDA there are hints that the performance of the system under these
conditions (which requires an elaborate transformation process) is somewhat poorer than from the standard
medium (Carozzi, Del Mistro et al. 2005).
The clinical sensitivity of the HC2 test is very high, in 26 trials worldwide its median was 94% (Lorincz and
Smith 2006). More than 200.000 women have been included in screening studies with this assay published in
peer reviewed journals. This figure exceeds by far the data available for any single PCR method. Significant
differences in performance were observed between HPV screening studies conducted in Europe and Northern
America reaching up to 99% sensitivity compared to investigations in developing countries. Here regularly
the sensitivity was 20-30% lower which might be explained by weaknesses of regional colposcopy and histology leading to deficits in gold standard definition (Sankaranarayanan, Chatterji et al. 2004). Though in “real
life” the clinical sensitivity even under optimized conditions will not exceed 95-98% due to sampling errors
or minor technical variations (Lorincz and Smith 2006).
Qiagen developed careHPV, a basic version of HC2 without need for running water and main electricity with a turn-around time of only 2.5 hours. That allows further diagnostic or therapeutic procedures in the
same visit. A study in China showed 90% sensitivity for CIN 2+ (Qiao, Sellors et al. 2008). Further trials are
ongoing and a broad roll-out in developing countries is intended.
A second signal amplification test (Cervista, Hologic, Bedford, MA) gained FDA approval in 2009. It uses two isothermal reactions with a proprietary technology (Invader) which detects 14 high-risk HPV types as
a group and in addition HPV 16 and 18 together. First data from the package insert pointed to a much lower
specificity than eg of HC2 and were negatively discussed (Kinney, Stoler et al. 2010). Newly published data showed a similar sensitivity and specificity as with HC2 in a NILM (Quigley, Potter et al. 2011); (Youens,
Hosler et al. 2011) and ASC-US population (Einstein, Martens et al. 2010; Quigley, Potter et al. 2011).
The central role of specificity
The major problem of routine HPV diagnostics is its relatively low specificity which is limited even with
non-DNA-amplifying methods. This restricts its use in a screening approach to women over 30 years (Saslow,
Runowicz et al. 2002). Below this age testing is regarded as useful in case of cytological and/or colposcopic abnormality (triage) and after therapy of CIN as a test of cure (Wright, Cox et al. 2002). But even in this
triage setting the revised ASCCP guidelines in the US discourage HPV testing in the below 20s due to very
579
high remission rates in this age group (Wright, Massad et al. 2007). Currently HPV testing is regarded more
useful i.e. predictive the older the tested women are. If however the appropriate test is used in the appropriate age group screening by HPV DNA testing is able to reach the specificity of cytology as demonstrated by
5 of 26 studies reviewed in a HTA (Mittendorf, Nocon et al. 2007).
The specificity can be increased by raising the viral load cut-off. This can be achieved more easily with
signal-amplifying methods than with PCR. Studies here show a slightly lower (Lorincz and Smith 2006) or
unchanged (Guyot, Karim et al. 2003; Hesselink, Bulkmans et al. 2006) sensitivity, while in either case the
specificity was raised. A recent systematic review underlined these findings (Rebolj, Bonde et al. 2011).
Even though the importance of a minimal viral load for the development of HPV induced disease is obvious there seems to be no clear-cut association between quantitative (real-time PCR) or semiquantitative (HC2)
measurements of viral load and prognostic potential at a level above the detection limit of the HC2 test (Bory,
Cucherousset et al. 2002; Lorincz, Castle et al. 2002; Snijders, van den Brule et al. 2003)
A trade-off between sensitivity and specificity also limits an extension of the number of types covered by
clinical HPV tests. The inclusion of very rarely occurring types beyond the 13-14 included in most tests increases sensitivity minimally, while leading to an unproportional decrease in specificity (Schiffman, Khan et
al. 2005).
The main issue when using HPV testing as an adjunct to cytological screening is the rate of women positive for high-risk HPV in the absence of cytological abnormalities. This rate is usually very low for women of 30 years and older. Among more than 800.000 tests in nearly 600.000 women in California tested with
the HC2 system the rate equalled 3.99% with only about one third of them remaining positive over one year,
thus leaving less than 1.5% for colposcopy (Castle, Fetterman et al. 2009). An even lower rate (1.9%) was
observed among cytologically normal women screened with liquid-based cytology and computer-assistance
(Bansal, Austin et al. 2009). That means that with even an ASC-US rate of just 3% (where at maximum half
of the cases will be HPV positive) the total number of women scheduled for colposcopy will not increase
whereas this group now comprises also all cytologically false-negatives.
The crucial criterion for the clinical value of a routine HPV test is not its analytical but its clinical sensitivity. Because limited specificity will be harmful via unnecessary treatment of healthy women also clinical
sensitivity has to be traded off with specificity (Kinney, Stoler et al. 2010). The observance of a well defined
diagnostic threshold must be guaranteed. Up to now this has only been proven in large-scale studies for the
HC2 and the cobas test. For several reasons as stated above this objective is rather complicated to achieve for
PCR techniques.
A guideline for new HPV tests
It is indispensable that new tests for routine HPV testing prove a balance between clinical sensitivity and
specificity. To avoid costly validation studies for each new HPV test standards for evaluation have been defined by leading experts on the field (Meijer, Berkhof et al. 2009). These standards of noninferiority are based
on the results of numerous large screening studies with HC2 and the GP5+/6+ PCR which set the standards
for cut-off, sensitivity and specificity in clinical use. A new HPV test among women above 30 years should
reach a relative sensitivity of 90% and a relative specificity of 98% of that of the HC2 test. To test for that
around 60 HPV-positive probes of CIN2+ and around 800 HPV-negative specimens are needed. Additionally
an intra- and interlaboratory concordance of at least 87% in 500 specimens is requested.
New commercial HPV tests
2011 data from the largest clinical HPV study conducted until now have been published assessing the cobas HPV test (Roche). The ATHENA trial, comprising over 47.000 women proved performance comparable
to the HC2 test in triage of women with ASC-US cytology (Stoler, Wright et al. 2011) and high sensitivity for
CIN2+ in cytologically normal women (Castle, Stoler et al. 2011). The test has further met the criteria of the
580
guideline for new HPV tests (Heideman, Hesselink et al. 2011). Meanwhile the cobas test has received FDA
approval for triage and co-testing with cytology (each from the Preservcyt LBC vial).
Recently also other new HPV detection assays have been commercialized. The Abbott Real Time High
Risk HPV Test (Abbott Molecular, Wiesbaden, Germany) is a PCR DNA assay which detects 14 high-risk
HPV types as a group-specific test and separately HPV 16 and 18. In a first comparison it showed similar
performance as HC2 and Linear Array (Cuzick, Ambroisine et al. 2010). As did the B&D Viper HPV realtime PCR which detects 14 high-risk HPV types and discriminates 7 of them (Castle, Gutierrez et al. 2011).
A DNA chip test for the type-specific detection of 18 high-risk and 6 low-risk HPV types which is based on
the detection of E1 sequences (Papillocheck, greiner bio-one, Frickenhausen, Germany) was found clinically
compatible with the GP5+/6+ assay (Hesselink, Heideman et al. 2010).
HPV Genotyping
Several studies showed a significantly higher risk for development of a CIN 2+ among women positive
for HPV 16, 18 and 45 (which is closely related to HPV 18) compared to positivity for other HPV high-risk
types. This was valid for cytologically normal women (Khan, Castle et al. 2005; Castle, Rodriguez et al. 2009)
as well as with borderline cytologic findings (Wheeler, Hunt et al. 2006). It is therefore appropriate to test for
these HPV types independently. This makes only sense after or in parallel with a HPV high-risk basic test because clinically relevant cases positive for high-risk types beside 16,18 and 45 would otherwise be missed.
It is generally accepted that a diagnosis of individual HPV types is of scientific interest but its clinical value
is currently very limited. First, the risk potential of other HPV types than 16, 18 and 45 is not well defined and
seems to be similar (Khan, Castle et al. 2005), second, even if this potential would be better defined it might
be difficult to implement the routine application of complex type-specific algorithms. Already at present the
follow-up of HPV positivity in clinical practice is rather challenging. Another problem with routine full HPV
typing is the high analytical sensitivity and consecutively lower specificity when using the PCR assays which
are only available for that purpose. On the other hand detection of HPV 16, 18 and 45 can be achieved by a
variant of the HC2 test (which is currently under FDA review) with the same cut-off as the basic test as well
as HPV 16 and 18 can be detected separately with some newer tests like cobas or Cervista.
HPV RNA Testing
A logic approach to overcome some limitations in HPV diagnostics is testing for HPV RNA because elevated expression of viral oncogenes E6 and E7 is associated with malignant transformation by high-risk HPV.
Due to non-transforming activities of HPV oncogenes and subsequent transcription also in non-neoplastic
lesions and the general instability of RNA HPV mRNA analytics is more complicated than initially expected. First promising results (Molden, Kraus et al. 2005) of a commercial assay (pretectprooferTM, norchip,
Klokkarstua/Norway now NuclisenseTM, Biomérieux, Marcy L´Étoile/France) have not be confirmed. In the
PREDICTORS study (Szarewski, Ambroisine et al. 2008) the sensitivity of this test for CIN 2+ was only
73,6%, beside other reasons probably due to the fact that it targets only five HPV types. However, it is not finally determined whether lacking HPV mRNA expression might also indicate high grade disease without the
potential for progression. Another HPV mRNA test, the APTIMA HPV test (Genprobe, San Diego, CA) detects 14 high-risk HPV types as a group and is run on a fully automated system. Data point to a similar sensitivity and a higher specificity of the APTIMA test as for DNA detection assays (Castle, Dockter et al. 2007;
Szarewski, Ambroisine et al. 2008). A promising aspect of the system is that no RNA isolation is required and
sealed vials are used. Late in 2011 it received an FDA approval, joining the HC2, Cervista, and cobas tests.
Very recently a new approach applying several marker transcripts showed high sensitivity for grading HPV
16 positive cervical lesions (Schmitt, Dalstein et al. 2010). A first systematic review attested HPV RNA testing diagnostic potential but saw the need for further studies (Burger, Kornor et al. 2011).
581
Tab. 1. Test systems for the detection of HPV DNA and RNA
Name
HPV DNA
Amplicor
Producer
Technology
Target sequence
HPV types
Genotyping
Approval
Roche
PCR
13 ca
no
careHPV
Qiagen
Signal amp
14 ca
no
Cervista
cobas
GP 5+/6+
Hologic
Roche
non commercial
Signal amp
Realtime PCR
PCR
14 ca
14 ca
14 ca
HPV 16 + 18
HPV 16 + 18
no
CE
WHO
prequalification
FDA + CE
FDA + CE
no
HC2
Qiagen
Signal amp
13 ca
HPV 16 + 18
FDA + CE
Inno-LiPA
Linear Array
Multiplex HPV
Genotyping Kit
Papillocheck
RealTime HR
HPV
Innogenetics
Roche
PCR
PCR
L1
(part) full
genome
L1
L1
L1
(part) full
genome
L1
L1
13 ca + 15 nca
14 ca + 23 nca
yes
yes
CE
CE
Multimetrix
PCR
L1
13 ca + 11 nca
yes
Greiner bioone
PCR
E1
13 ca + 11 nca
yes
CE
Abbott
Realtime PCR
L1
14 ca
HPV 16 + 18
CE
B&D
Realtime PCR
L1
14 ca
HPV 16, 18, 31,
45, 51, 52, 59
Genprobe
TMA
E6/E7 mRNA
14 ca
no
HPV 16 + 18
planned
CE + FDA
Biomérieux
NASBA
E6/E7 mRNA
HPV
16,18,31,33,45
yes
CE
non commercial
mRNA analysis
E1/4/6 + L1
mRNA
16
yes
BD Viper HPV
HPV RNA
APTIMA
Nuclisens EasyQ
HPV
HPV 16
transcriptome
Ca: carcinogenic; CE: EU-registration; FDA: Food and Drug Administration approval; nac: non carcinogenic; NASBA: Nucleic acid sequence-based amplification; Signal amp: signal amplification; TMA:
Transcription-mediated amplification; WHO: World Health Organization
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585
usmene prezentacije/ORAL FREE PAPER SESSIONS
CITOPATOLOGIJA
CITOPATHOLOGY
UP1
Uloga eksfolijativne citologije u
dijagnostici tumora donjeg urinarnog
trakta
OP1
The role of exfoliative cytology in
diagnosis of lower urinary tract
tumor
Mirjana Ćuk1, Slavica Knežević Ušaj2, Radoslav
Gajanin3, Aleksandar Supić4, Radmil Marić4
Mirjana Cuk1, Slavica Knezevic Usaj2, Radoslav
Gajanin3, Supic Aleksandar4, Radmil Maric4
1 Služba
za patologiju i citodijagnostiku, Univerzitetska
bolnica u Foči, Foča, Bosna i Hercegovina
2 Institut za onkologiju Vojvodine, Sremska Kamenica, Srbija
3 Klinički centar Banja Luka, Zavod za patologiju, Banja Luka,
Bosna i Hercegovina
4II hirurška klinika, Univerzitetska bolnica u Foči, Foča, Bosna
i Hercegovina
Cilj: Analiza parametara uspješnosti primjene citologije urina u dijagnostici malignih tumora donjeg
urinarnog trakta.
Uvod: Citologija urinarnog trakta je jedna od najznačajnijih dijagnostickih metoda u urološkoj onkologiji, ali pod jasno definisanim uslovima.
Materijal i metode: U studiju je uključeno 30 pacijenata sa kliničkom dijagnozom hematurije i 5 pacijenata kod kojih je prethodno urađena hirurška resekcija papilarnih tumora mokraćne bešike. Citološki
materijali su bojeni May Grinwald Giemsa metodom
i analizirani svjetlosnim mikroskopom.
Rezultati: Odnos prema polu bio je muškarci:žene
= 6:1. 94,28% pacijenata je bilo starije od 50 godina.
Kod svih pacijenata sa malignitetom bio je prisutan
urotelni karcinom, a samo kod 3 pacijenta ravni infiltrativni tip. Na ukupnom uzorku apsolutna senzitivnost je bila 42,85 %, a specifičnost 100%. U grupi pacijenata sa low- grade lezijama apsolutna senzitivnost je bila 0%. Papilarne karcinome visokog histološkog gradusa smo podijelili u dvije grupe prema stepenu diferentovanosti: u grupi karcinoma sa
HG2 apsolutna senzitivnost je iznosila 62,5%, a u
grupi HG3 apsolutna senzitivnost je iznosila 85,71 %.
Zaključak: Citologija urina je lako primjenjiva
i uspješna metoda za identifikaciju novih i rekurentnih high- grade papilarnih i ravnih karcinoma donjeg urinarnog trakta.
Citologija urina nije adekvatna metoda u otkrivanju low-grade tumora donjeg urinarnog trakta.
Ključne reči: citologija, urin, urotelni karcinom
586
University Hospital in Foca, Pathology and Cytodiagnostics
Department, Foca, BiH
2Oncology Institute of Vojvodina, Sremska Kamenica, Serbia,
3Clinical Centre Banja Luka, Pathology Institute, Banja Luka,
BiH,
4University Hospital in Foca, II Surgery Clinic, Foca, BiH,
1
Aim: The analysis of success parameters of urine cytology application in diagnosis of malignant tumors of lower urinary tract.
Introduction: Cytology of urinary tract is one
of the most significant diagnostic methods in urologic oncology, but under clearly defined conditions.
Material and methods: 30 patients with clinical diagnosis of hematuria were included in this study and 5 patients with previously performed surgical resection of papillary tumors of urinary bladders.
Cytological material was coloured by May Grinwald
Giemsa method and analysed by light microscope.
Results: Sex ratio was male: female = 6:1. 94.28%
of patients were older than 50. In all patients with malignant tumors, urotel cancer was present, and, only
in 3 patients, there was a plane infiltrative type. In all
samples absolute sensitivity was 42.85%, and specificity was 100%. In the group of patients with lowgrade lesions, absolute sensitivity was 0%. Papillar
carcinoma with high histological grade was divided
into two groups according to the level of differentiation: in the group of carcinoma with HG2, absolute
sensitivity was 62.5%, and in the HG3 group, absolute sensitivity was 85.71%.
Conclusion: Cytology of urine is an easily applied and successful method for identification of new
and recurrent high-grade papillar and plane carcinoma of lower urinary tract. Urine cytology is not an
adequate method in diagnosing low-grade tumors of
lower urinary tract.
Key words: cytology, urine, urothelial carcinoma
HEMATOPATOLOGIJA
HAEMATOPATHOLOGY
UP2
Ekspresija survivina kod bolesnika sa
novootkrivenim nodalnim difuznim B
krupnoćelijskim limfomom
OP2
Survivin expression in patients with
newly diagnosed nodal diffuse large B
cell lymphoma
Olivera Marković1, Dragomir Marisavljević1, Vesna
Čemerikić2, Biljana Mihaljević3, Branka Filipović1
Olivera Markovic1, Dragomir Marisavljevic1, Vesna
Cemerikic2, Biljana Mihaljevic3, Branka Filipovic1
2Beolab,
2Beolab,
1Kliničko
bolnički centar Bežanijska kosa, Beograd, Srbija
Beograd, Srbija
3Institut za hematologiju, Klinički centar Srbije, Beograd,
Srbija
Cilj: Ova studija je urađena u cilju utvrđivanja kliničkog i prognostičkog značaja survivina kod bolesnika sa nodalnim DBKL.
Uvod: Survivin je jedan od članova porodice inhibitora apoptoze (IAP) koji ima značajnu ulogu u patogenezi difuznog B krupnoćelijskog limfoma (DBKL).
Materijal i metode: Mi smo analizirali uzorke tkiva limfnog čvora dobijene od 56 bolesnika sa novootkrivenim nodalnim DBKL, lečenih imunohemioterapijom(R-CHOPprotokolom). Ekspresija survivina je analizirana standardnom imunohistohemijskom metodom
na parafinskim isečima tkiva limfnog čvora i procenjivana semikvantitativno kao procenat tumorskih ćelija.
Rezultati: Imunoekspresija survivina (>45% pozitivnih tumorskih ćelija) je registrovana kod 22(39.28%)
bolesnika, u vidu citoplazmatske pozitivnosti kod 15
bolesnika ili mešovite (citoplazmatske i jedarne) pozitivnosti kod 15 bolesnika. Utvrđena je statistički značajna razlika u ekspresiji survivina između GCB i non-GCB podtipa DBKL(p=0.031). Imunoekspresija survivina nije u korelaciji sa IPI bulky bolešću, ekstranodalnom lokalizacijom, vrednošću hemoglobina, ekspresijom Ki-67 i drugim kliničko-patološkim parameterima.
Univarijantna analiza je pokazala da je bolesnici sa ekspresijom survivina imaju značajno lošiji terapijski odgovor i krace preživljavanje u odnosu na bolesnike koji su survivin negativni (p=0.048 and p=0.034, respektivno). Bolesnici sa ekspresijom survivina relapsiraju
češće nego bolesnici koji ga ne eksprimiraju (27.3%
vs. 11.8%), ali ova razlika nije dostigla nivo statističke
značajnosti (p=0.131).
Zaključak: Rezultati ove studije pokazuju da ekspresija survivina ima značajnu ulogu u određivanju toka i prognoze bolesnika sa DBKL lečenih R-CHOP protokolom. Prema tome, survivin predstavlja potencijalni
cilj za terapijske intervencije u DBKL.
Ključne reči: difuzni B krupnoćelijski limfom,
apoptoza, survivin, imunohistohemija, prognoza.
1Clinical
Hospital Center Bezanijska Kosa, Belgrade, Serbia
Belgrade, Serbia
3Institut of Hematology, Clinical Center of Serbia, Belgrade,
Serbia
Aim: The present study was designed to investigate the clinical and prognostic significance of survivin
expression in nodal DLBCL.
Introduction: Survivin is one of the inhibitors of
apoptosis proteins (IAP) that might play an important
role in the pathogenesis of diffuse large B cell lymphoma (DLBCL).
Material and methods: We analyzed lymph node biopsy specimens obtained from 56 patients with
newly diagnosed nodal DLBCL, treated with immunochemotherapy (R-CHOP). The expression of survivin was analyzed using the standard immunohistochemical method on formalin-fixed and routinely processed
paraffin-embedded lymph node specimens, and evaluated semiquantitatively as a percentage of tumor cells.
Results: Survivin immunoexpression (>45% positive tumor cells) was found in 22 (39.28%), and observed as cytoplasmic staining in 15 patients, or mixed staining in 7 patients. A significant difference in survivin
immunoexpression was noticed between the GCB and
the non-GCB subtypes of DLBCL (p=0.031). A univariate analysis showed that survivin positivity was an
unfavorable factor for therapy response and a predictor
of shorter survival in patients with DLBCL (p=0.048
and p=0.034, respectively). Patients with survivin overexpression experienced a relapse more often than patients without expression of this apoptotic protein (27.3%
vs. 11.8%), but this difference did not reach statistical
significance (p=0.131).
Conclusion: The results of this study showed that
disregulation of survivin expression had an important
role in determination of the course of the disease in
patients with nodal DLBCL treated with R-CHOP.
Therefore, survivin represents a potential target for therapeutic intervention in DLBCL
Key words: diffuse large B cell lymphoma, apoptosis, survivin, immunohistochemistry, prognosis.
587
UP3
Prognostički značaj CD 68 pozitivnih
makrofaga pridruženih tumoru u
uznapredovalom stadijumu klasičnog
Hočkinovog limfoma
OP3
The prognostic significance of
CD 68 positive tumor associated
macrophages in advanced stage
classical Hodgkin lymphoma
Ljubomir Jaković1, Biljana Mihaljević1, Maja PeruničićJovanović2, Andrija Bogdanović1, Boško Andelić1,
Vladimir Bumbaširević3
Ljubomir Jakovic1, Biljana Mihaljevic1, Maja
Perunicic Jovanovic2, Andrija Bogdanovic1, Vladimir
Bumbasirevic3
1Klinika
Srbija
2Odeljenje za Histopatologiju, Klinicki Centar Srbije,Beograd,
Srbija
3Institut za Histologiju i Embriologiju, Medicinski fakultet,
Univerzitet u Beogradu, Beograd, Srbija
Clinic for Hematology, Clinical Center of Serbia, Belgrade,
Serbia
2Department for Histopathology, Clinical Center of Serbia,
Belgrade, Serbia
3 Institute for Histology and Embryology, Medical Faculty,
University of Belgrade, Belgrade, Serbia
Cilj: Analizirati prognostički značaj makrofaga pridruženih tumoru (MPT) i standardnih kliničkih parametara u uznapredovalom HL u cilju određivanja inicijalnog
prognoznog modela.
Uvod: Rezultati lečenja Hockinovog limfoma (HL) su
danas bolji nego u prošlosti. Doprinos daljem poboljš anju
rezultata lečenja može dati otkrivanje pouzdanih prognostičkih biomarkera.
Materijal i metode: Prognostički značaj MPT analizirali smo u grupi od 52 bolesnika sa uznapredovalim
HL, lečenih ABVD protokolom u periodu od 1997-2005.
Imunohistohemijska ispitivanja primenom CD68 antitela
su obavljena na tkivnim isečcima limfnih čvorova u trenutku postavljanja dijagnoze. Broj CD68 MPT je analiziran na 10 polja velikog uveličanja i podeljen u dve grupe
(CD68 manje od 25% i CD68 više od 25%). Medijana praćenja je 7 godina, a značaj parametara je određivan u odnosu na vreme do neželjenog događaja i sveukupno preživljavanje u korelaciji sa standardnim kliničkim parametrima.
Rezultati: Bolesnici sa >25% CD68 MPT u poređenju
sa bolesnicima sa =25% CD68 MPT su imali kraće petogodišnje preživljavanje (45% vs. 77% log rank p=0.019) i
trend kraćeg vremena do neželjenog događaja (51 vs. 71%
log rank p=0.19). Nije nađena značajna korelacija sa praćenim kliničkim parametrima. Značajno kraće preživljavanje je bilo udruženo sa IPS>2, voluminoznom tumorskom masom i povišenom sedimentacijom eritrocita (log
rank test, p=0.003, p=0.049, p=0.007). U multivarijantnoj
analizi >25% CD68 MPT, IPS>2 i voluminozna tumorska
masa su pokazale značaj nezavisnih prognostičkih faktora za sveukupno preživljavanje (Cox multivarijantni model p=0.006, p=0.007, p=0.013).
Zaključak: Makrofagi koji su pridruženi tumoru predstavljaju potencijalni prognostički biomarker koji bi mogao doprineti boljoj stratifikaciji rizika bolesnika sa klasičnim HL.
Ključne reči: Makrofagi, uznapredovali Hočkinov
limfom
Aim: To analyze the prognostic value of tumor associated macrophages (TAM) and standard clinical parameters in advanced HL patients in order to determine
optimal initial prognostic model.
Introduction: Although the treatment of Hodgkin
lymphoma (HL) has been improved, distinguishing reliable prognostic biomarkers could better stratify patients for more effective treatment.
Material and methods: In a group of 52 advanced
HL patients treated with ABVD regimen from 19972005, we analyzed the prognostic relevance of TAM
using a CD68 antibody in the immunohistochemical
analysis, on lymph nodes tissue sections, at diagnosis.
The number of CD68 positive TAM was analyzed on
10 different high power microscopy fields (HPF, x400)
and scored (CD68 less than 25% and CD68 grater than
25%). The median follow-up was 7 years (yrs). Their
significance was evaluated according to the response to
treatment (EFS) and survival period (OS) and correlated with standard clinical parametres.
Results: Patients with >25% CD68 TAM compared
to those with =25% had worse 5-yrs OS (45% vs. 77%
log rank p=0.019) and showed trend towards shorter
5-yrs EFS (51 vs. 71% log rank p=0.19). Additionally
no significant correlation with selected clinical features were found. Significantly shorter OS was associated with IPS>2, bulky disease, elevated sedimentation
rate (log rank test, p=0.003, p=0.049, p=0.007, respectively). In multivariate analysis increased CD68 TAM,
IPS>2 and bulky disease were identified as independent
prognostic factors for overall survival (Cox multivariate model, p=0.006, p=0.007, p=0.013, respectively).
Conclusion: Tumor associated macrophages represent potential prognostic biomarker which could contribute to better risk stratification of cHL patients.
Key words: Macrophages, advanced Hodgkin’s
588
za Hematologiju, Klinički Centar Srbije, Beograd,
1
BONE AND SOFT TISSUE
PATHOLOGY
KOŠTANA I MEKOTKIVNA
PATOLOGIJA
UP4
Mogućnosti i ograničenja
“imprint” citološke tehnike u
dijagnostici koštanih i mekotkivnih
tumora
OP4
Possibilities and limitations of
„imprint” cytological techniques in
diagnostics of bone and soft tissue
tumors
Jelena Sopta1, Zoran Vučinić2, Jelena Bokun 3, Dušan
Ristić 3, Vesna Mijučić 3
Jelena Sopta 1, Zoran Vucinic 2, Jelena Bokun 3, Dusan
Ristic 3, Vesna Mijucic 3
Cilj: Cilj ovog rada je da utvrditi stepen korelacije citoloških i definitivnih patohistoloških dijagnoza primenom imprint citološke tehnike u biopsijama
tumora kostiju i mekih tkiva.
Uvod: Koštani i mekotkivnu tumori predstavljaju veliki izazov u standardnoj analizi bioptičkog ili
operatvnog uzoraka. Od svih citoloških tehnika, otisak bioptičkog uzorka („imprint” citološka tehnika)
najbliži i je patohistološkom.
Materijali i metode: Na Institutu za patologiju
Medicinskog fakulteta u Beogradu u period od 5 godina (2007-2011.) uradjeno je 286 imprint citoloških
analiza tumora kostiju i mekih tkiva.
Rezultati: Poredeći rezultate citološke imprint
analize sa definitivnom patohistološkom dijagnozom
utvrdili smo da je stepen sigurnosti u našem uzorku
iznosio 89%.
Zaključak: Mesto citološke analize je sve zapaženije u sklopu multidisciplinarne i sve složenije interperetacije bioptičkog materijala.
Ključne reči: imprint citologija, tumori, kosti,
meka tkiva
Aim: The aim of thys study is to determine the
correlation of cytologic and histologic diagnosis of
definite application of imprint cytology techniques
in tumor biopsies of bone and soft tissue.
Introduction: Bone and soft tissue tumors represent a major challenge in the standard analysis of biopsy samples. Of all cytological techniques, fingerprint biopsy specimen („imprint” cytological techniques) is closest to histopathology.
Materials and Methods: At the Institute of
Pathology, University of Belgrade in the period of 5
years (2007-2011.) was done 286 imprint cytological analysis of bone tumors and soft tissue.
Results: Comparing the results of imprint cytology analysis with definitive histopathological diagnosis we found that the level of security in our sample was 89%.
Conclusion: Place of cytology is noticeable
in the multidisciplinary and more complex biopsy
interpretation.
Key words: imprint cytology, bone, soft tissue,
tumor
1Institut
za patologiju, Medicinski fakultet, Univerzitet u
Beogradu, Srbija
2Institut za ortopedsko hirurške bolesti Banjica, Beograd,
Srbija
3Institut za onkologiju i radiologiju Srbije, Beograd, Srbija
1Medical
Faculty Belgrade,University Belgrade,Institute of
Pathology, Serbia
2Institute for orthopoedic surgery „Banjica”,Belgrade, Serbia
3Institute for Oncology and Radiology, Belgrade, Serbia
589
NEUROPATOLOGIJA
NEUROPATHOLOGY
UP5
Imunoekspresija katepsina D kod
meningioma
OP5
Immunoexpression of Cathepsin D in
meningiomas
Zorana Vukašinovic-Bokun, Lidija Prijić-Plećević,
Milica Lavrnić, Nenad Miladinović, Marija Nikolić,
Zorana Vukasinovic Bokun, Lidija Prijic-Plecevic,
Milica Lavrnic, Nenad Miladinovic, Marija Nikolic,
Sanja M. Milenkovic
Cilj: Ciljevi ove studije bili su definisanje osnovnih socioepidemioloških karakteristika (starost, polna
distribucija pacijenata), prevalenca različitih histoloških tipova meningioma u grupi primarnih i recidivantnih tumora u odnosu na imunoekspresiju katepsina D.
Uvod: Meningiomi su većinom benigni neglijalni
tumori koji nastaju iz ćelija arahnoidalne kape ovojnica mozga i kičmene moždine. Ovi tumori čine 30%
svih primarnih tumora mozga sa godišnjom incidencom od 4,5/100000. Sposobnost recidiviranja je tipična za meningiome. Katepsin D je lizozomalna cisteinska peptidaza koja može imati ulogu u ponašanju agresivnih meningioma.
Materijali i metode: Analizirano je 50 pacijenata
sa primarnim i recidivirajucim meningiomima, operisanih u klinicko-bolničkom centru Zemun tokom
2004 koji su praćeni tokom dve godine. Svi uzorci su
histološki klasifikovani prema WHO klasifikaciji, a
reprezentativni isečci su imunohistohemijski obojeni sa anti-katepsinom D. U grupama primarnih i recidivirajućih meningioma brojane su mitoze na 10 i 20
polja velikog uveličanja, kao faktor tumorske agresivnosti i rezultati su statisticki obrađeni.
Rezultati: Ukupno je analizirano 64 uzorka tumorskog tkiva primarnih i recidivirajućih meningioma. Najveći broj meningioma klasifikovano je kao
WHO gradus I (57 slučajeva). Ostali su pripadali
WHO gradusu II (5) i WHO gradusu III (2). Utvrđena
je statistički značajna razlika u ekspresiji katepsina D
u odnosu na broj mitoza i histološki gradus tumora.
Zaključak: Imunoekspresija katepsina D značajna je kod benignih meningioma te ne može biti upotrebljena kao prognostički faktor maligniteta i agresivnosti tumora. Gubitak pozitivnosti meningioma za
katepsin D može biti signal za potencijalno agresivno biološko ponašanje tumora.
Ključne reči: meningiomi, broj mitoza, katepsin D
Aim: This study was performed to establish the
socioepidemiological caracteristics, the prevalence
of histological types of meningiomas in the groups
of primary and recidivant tumors and Cathepsin D
immunoexpression.
Introduction: Meningiomas are mostly benign
nonglial tumors arising from arachnoidal cap cells of
the brain. They rappresent 30% of all primary brain tumors with an annual incidence of 4,5/100000.
The ability to recurre is a feature typical of meningiomas. Cathepsin D, a lysosomal cistein pepridase
could play a role in the biological behaviour of agressive meningiomas.
Material and methods: We analysed 50 patients
with meningiomas who underwent surgery in KBC
Zemun during the year 2004. All surgical specimen
were evaluated for histologic type of tumor according to WHO classification and representative slides
were immunostained with the anti-Cathepsin D antibody. In primary and recidivant meningioma groups the number of mitosis was counted on 10 and 20
HPF and those results were statistically analyzed.
Results: A total of 64 meningioma specimen have been submitted to histological analysis.Most of the
analysed tumors were graded as the WHO I group (57
cases). The remainder were classified as WHO II (5)
and WHO III (2). A considerable difference was found when the number of mitosis and the histologic
tumor grade have been compared with the Cathepsin
D immunoexpression.
Conclusion: Since Cathepsin D exibits a strong
expression in benign meningiomas, it could not be
used as a prognostic factor of malignancy and invasivness. On the contrary, the loss of positive staining could be an alert for a potentialy agressive biological behaviour.
Key words: meningiomas, mitosis, Cathepsin D
Služba kliničke patologije, Kliničko-bolnički centar Zemun,
Beograd, Srbija
590
Department of Pathology, Clinical Hospital Center Zemun,
Belgrade, Serbia
ORAL FREE PAPER SESSIONS
UP6
Nanog kao potencijalni marker
kancerskih matičnih ćelija kod
pacijenata sa gliomima visokog gradusa
OP6
Nanog as the potential marker
of the cancer stem cells in the
high grade glioma patients
Irena Dimov1, Sladana Ugrenović2, Slavica Stojnev3,
Miloš Kostić1, Tasic Desanka3, Vladislav Stefanović2
Irena Dimov1, Sladana Ugrenovic2, Slavica Stojnev3,
Milos Kostic1, Desanka Tasic3, Vladislav Stefanovic2
2Medicinski
2Faculty
1Institut
za imunologiju, Medicinski fakultet, Niš, Srbija
fakultet, Niš, Srbija
3Institut za patologiju, Medicinski fakultet, Niš, Srbija
Cilj: Reevaluirati Nanog kao potencijalni marker
kancerskih matičnih ćelija i molekularnu terapijsku
metu u gliomima visokog gradusa
Uvod: Visokogradusni gliomi su najsmrtonosniji
tumori mozga, otporni na sve forme terapije. Hipoteza
o kancerskim matičnim ćelijama je koja je u fokusu
novih istraživanja je odraz novih aspekata razumevanja patogeneze malignih tumora uključujući i visokogradusne gliome i pruža mogućnosti za nove terapijske pristupe. Nanog je transkripcioni faktor dokazano povezan sa kapacitetom za samoobnavljanje
embrionalnih i neuralnih stem ćelija. Stoga bi mogao
biti koristan marker matičnih ćelija visokogradusnih
glioma i potencijalna molekularna meta za terapiju.
Materijal i metode: Patohistološki uzorci 79 visokogradusnih glioma su imunohistohemijski bojeni i kmvantifikovani za pozitivnost Nanog nuklearnog antigena.
Rezultati: Nuklearna ekspresija Nanog je pokazala ekstremno visoku ili ekstremno nisku pozitivnost u različitim tumorima. Isti nivo ekspresije pokazan je u recidivima.
Zaključak: Nanog se čini interesantim kao potencijalni genetski marker i može se pokazati kao značajan događaj u patogenezi određenih visoko gradusnih glioma.
Ključne reči: gliomi, kancerske matične ćelije,
Nanog
1Institute
for Immunology, Faculty of Medicine, Nis, Serbia
of Medicine, Nis, Serbia
3Institute for Pathology, Faculty of Medicine, Nis, Serbia
Aim: Reevaluation of Nanog as the potential cancer stem cell (CSC) marker and therapeutic molecular target in the high grade gliomas
Introduction: High grade gliomas are the most
deadly malignant brain tumors, persistant to all forms
of threatment.The rapidly emerging focus on cancer
stem cell (CSC) hypothesis embodies a paradigm shift in our understanding of the pathogenesis of malignomas incuding high grade gliomas, and gives new
hope for more effective therapeutic approach.Nanog
is a transcriptonal factor critically involved with self-renewal of undifferentiated embryonic and neural stem cells. Therefore, it might be useful marker
of the CSCs in the high grade gliomas and potential
molecular target for therapy.
Material and methods: Pathohistological samples 79 high grade gliomas were immunochistocemically stained and quantified for Nanog nuclear
positivity.
Results: The Nanog expression expression in some tumors was extremely high, while in other extremely low or negative. Recurrenbt tumors showed same pattern of expression.
Conclusion: Nanog may be interesting as an genetic marker and might show to be another important genetic point in the development of high grade gliomas.
Key words: gliomas, cancer stem cells, Nanog
591
PERINATALNA I PEDIJATRIJSKA
PATOLOGIJA
PERINATAL AND PEDIATRIC
PATHOLOGY
UP7
Imunohistohemijska ekspresija p53 u
Wilms-ovom tumoru
OP7
Immunohistochemical expression of
p53 in Wilms tumor
Sanja Radojevic-Škodrić1, Dimitrije Brašanac1, Ljiljana
Bogdanović1, Milena Jovanović2, Ivana Baralić3,
Gordana Basta-Jovanović1
Sanja Radojevic-Skodric1, Dimitrije Brasanac1, Ljiljana
Bogdanovic1, Milena Jovanovic2, Ivana Baralic3,
Gordana Basta-Jovanovic1
Cilj: Da se analizira ekspresija p53 imunohistohemijskom metodom u WT kao i odnos ekspresije
sa stadijumom tumora, histološkim tipom i prognostičkom grupom.
Uvod: Brojne studije su pokazale prognosticki
značaj p53 ekspresije u različitim malignim tumorima.
Materijal i metode: Imunohistohemijska ekspresija p53 je analizirana u 59 WT i 5 slučajeva normalnog tkiva bubrega koje nije zahvaćeno tumorom.
Rezultati: 41 od 59 slucajeva WT (61,5%) su pokazali smanjenje ekspresije p53 u poređenju sa nivoom ekspresije u normalnom tkivu bubrega. Sve
tri komponente WT su pokazale smanjenje ekspresije u približno istom procentu. Smanjenje ekspresije p57 je bilo cešće u višim stadijumima (stadijumi
III i IV) u poređenju sa nižim stadijumima WT (stadijum I ai II), u tumorima sa difuznom anaplazijom
u odnosu na ostale histološke tipove i u slučajevima
visokog rizika u odnosu na tumore srednjeg rizika,
ali bez statistički znacajne razlike.
Zaključak: Smanjena ekspresija p53 je mnogo
cešćeuočena u odmaklim stadijumima, u difuznoj
anaplaziji i u tumorima visokog rizika ukazujući da
je smanjena ekspresija p53 povezana sa nepovoljnom prognozom.
Ključne reči: WT, p53, ćelijski ciklus,
imunohistohemija
Aim: To determine p53 immunohistochemical
expression patterns in WTs and to analyze it in relation to tumor stage, histological type and prognostic category.
Introduction: A number of studies have indicated that the expression of cell cycle inhibitor p57
is of prognostic importance in a variety of cancers.
Material and methods: Imunohistostochemical
expression of p53 was analyzed in 59 cases of WT and
in five kidney specimens uninvolved by the tumor.
Results: 41 of 59 WTs (61.5%) showed decreased expression of p53 compared to the expression level in normal kidney tissue. All components of WTs
showed decreased expressed with similar frequency.
Decreased p53 expression was found more often in
high-stage tumors (stage III and IV) compared to lowstage WTs (stages I and II), in diffuse anaplastic WTs
compared to other histological types, and in cases of
high-risk compared to intermediate-risk tumors, but
without significant difference.
Conclusion: Decreased p53 expression was observed more often in advanced stages, in diffuse anaplasia and in high-risk group of WTs, suggesting that
it may be associated with the unfavorable prognosis.
Key words: WT, p53, cell cycle,
immunohistochemical
1Institut
2Institut za mikrobiologiju, Stomatolo ki fakultet, Univerzitet
u Beogradu, Beograd, Srbija
3Institut za bromatologiju, Farmaceutski fakultet, Univerzitet u
Beograd, Beograd, Srbija
592
1Institute
of pathology, Medical School, University of
Belgrade, Serbia
2Institute of microbiology, Dental School, University of
Belgrade, Serbia
3Institute of bromatology, Faculty of Pharmacy, University of
Belgrade, Serbia
UROLOŠKA PATOLOGIJA
UROPATHOLOGY
UP8
Ispoljavanje FGFR1 i NCAM
molekula u karcinomima bubrega
OP8
Expression of FGFR1 and NCAM in
renal tumors
Jasmina Marković-Lipkovski1, Sanja Ćirović1, Dragan
Mitrović1, Duško Dunđerović1, Cane Tulić2
Jasmina Markovic-Lipkovski1, Sanja Cirovic1, Dragan
Mitrovic1, Dusko Dunderovic1, Cane Tulic2
2Urološka
2Clinic
1Institut
za patologiju, Medicinski fakultet, Beograd, Srbija
klinika KCS, Beograd
Cilj: Detekcija koekspresije receptora fbroblast faktora rasta 1 (engl.-FGFR1) i neuralnog ćelijskog adhezionog molekula (engl.-NCAM) u karcinomu bubreznih ćelija (KBĆ).
Uvod: KBĆ potiču od proksimalnih ili distalnih tubula koji vode embrionalno poreklo od mesonefrosa i
tokom fetalnog razvoja nastaju putem mezenhimalno-epitelijalne transformacije. S obzirom da mezonefros
snažno eksprimira NCAM nije iznenađujuće da tokom
tumorske transformacije tubulskih ćelija bubrega dolazi
do ponovne ekspresije NCAM-a. Fibroblast faktori rasta
i njihovi receptori (engl.-FGFR1-4) neophodni su za ćelijski rast i diferencijaciju, pa se mogu ispoljiti i u KBĆ.
Materijali i metode: RT-PCR analizom (engl. –
Reverse Transcriptase Polymerase Chain Reaction)
izvršena je detekcija 3 specifične NCAM izoforme, dok
je ispoljavanje FGFR1 i NCAM antigena u tumorskom
tkivu detektovano imunohistohemijskom i duplom imunofluorecsentnom metodom. Analizirano je ukupno 35
tumora bubrega.
Rezultati: RT-PCR rezultati tumora pokazali su prisustvo NCAM-140 kDa izoforme kod svih testiranih tumora, dok su NCAM-120 i NCAM-180 kDa izoforme
detektovane samo u 3 tumora. Intenzitet ispoljavanja
FGFR1 i NCAM-a nije konstantan u KBĆ. Koekspresija
FGFR1/NCAM detektovana je u polovini analiziranih
uzoraka. Tipovi KBĆ koji eksprimiraju FGFR1/NCAM
su svetloćelijski, papilarni, hromofobni, kao i KBĆ sa
sarkomatoidnom varijantom. Broj FGFR1/NCAM ćelija je u korelaciji se stepenom maligniteta tumora (veći
nuklearni gradus - jača ekspresija FGFR1/NCAM). Ipak
20 % analiziranih KBC bilo je negativno na oba markera, dok je 20 % imalo pozitivnost samo na jedan marker.
Zaključak: FGFR1/NCAM koekspresija nije specifična za određeni tip KBC. Ipak jači intenzitet FGFR1/
NCAM koekspresije kod KBC je u korelaciji sa povećanjem nuklearnog gradusa tumora. S tim u vezi koekspresija FGFR1/NCAM može predstavljati važan pokazatelj agresivnosti KBC.
Ključne reči: FGFR1, NCAM, karcinom bubrežnih
ćelija (KBĆ), nuklearni gradus
1Institute
for Pathology, Medical Faculty, Belgrade, Serbia
of Urology, Clinical Center of Serbia, Belgrade
Aim: Co-expression of FGFR1 and NCAM in tumor samples was analyzed in this study.
Introduction: Fibroblast growth factor receptor
(FGFR1-4) is critical for cell growth and differentiation, and could be over expressed in renal cell carcinoma
(RCC). Most of RCC develop from tubular cells, which
arise from mesenchyme after mesenchymal-epithelial
transformation, these mesenchymal cells widely express neural cell adhesion molecule (NCAM), so NCAM
re-expression is expected in RCC
Material and methods: 35 RCC samples were analyzed. Antibodies for FGFR1 and NCAM were
used in immunohistochemisrty and double immunofluorescent analysis and specific primers for each NCAM
isoform were used in RT-PCR.
Results: RT-PCR analysis showed that NCAM-140
kDa isoform is predominantly expressed in all samples, while isoforms of 120 and 180 kDa were present
in only 3 samples. Expression of FGFR1 and different NCAM molecules slightly varied in renal tumour cells. In half of the analyzed samples co-expression FGFR1/NCAM was detected. Co-expression
of FGFR1/NCAM-was detected in clear cell, papillary, sarcomatoid, and chromophobe RCC. The number of cancer cells which co-expressed FGFR1 and
NCAM seems to correlate with tumour malignancy.
However, 20% of all analyzed samples were negative for both markers and 20% were negative for either
NCAM or FGFR1.
Conclusion: FGFR1 and NCAM are mainly coexpressed on the same RCC cells Co-expression of
FGFR1/NCAM-180 seems to be present on RCC tissue regardless of histological cell type. RCC with high
nuclear grade (III/IV) usually has higher number of
FGFR1/NCAM cells. Interaction between FGFR1 and
NCAM may be relevant for cell migration, growth and
malignancy in RCC.
Key words: FGFR1, NCAM, RCC, nucl
593
POSTER PRESENTATIONS 1/poster prezentacije 1
CITOPATOLOGIJA
CITOPATHOLOGY
P01
Tačnost citološke dijagnostike
metastatske bolesti glave i vrata na
materijalu dobijenom aspiracijom
tankom iglom
The accuracy of fine needle aspiration
cytology in the diagnosis head and
neck metastatic disease
Željka Tatomirović, Vesna Škuletić, Jovana Trimčev,
Lidija Zolotarevski
Military Academy Belgrade, Belgrade, Serbia
Vojnomedicinska akademija, Beograd, Srbija
Cilj: Procena tačnosti citološke dijagnostike metastatske bolesti glave i vrata (GiV) na materijlalu dobijenom aspiracijom tankom iglom (ATI).
Uvod: ATI je dobro poznata tehnika karakterizirana minimalnim komplikacijama, tako da je veoma
pogodna za ovu regiju sa vitalnim organima i različitim tkivima na relativno malom prostoru.
Materijal i metode: Aspiracija je urađena u 54
bolesnika sa metastatskom bolešćuti GiV, iglama od
25 G. Aspiraciju je radio citolog, a razmazi su bojeni May-Grunwald-Giemsom.
Rezultati: Postavljena je citiološka dijagnoza 13
skvamoznih, 8 adeno, 13 nemikrocelularnih, 13 mikrocelularnih i 6 slabo diferencirani metastatskih karcinoma.Korelacijom sa histologijom, potvrdena je dijagnoza svih skvamoznih i mikrocelularnih karcinoma, adenokarcinoma u 6 slučajeva dok je jedan bio
adenoskvamozni, a jedan je citološki pogrešno dijagnosticiran kao skvamozni karcinom. Od 13 citolški
nemikrocelularnih karcinoma, 4 su bila skvamozna, 3
adenokarcinoma, 5 adenoskvamozna, a jedan je ostao
nemikrocelularni karcinom. Od 6 citolo ki slabo diferenciranih karcinoma 4 su bila skvamozna, jedan
adenoskvamozni, a jedan je ostao sa istom dijagnozom. Tri metastaze nisu prepoznate: Jedan liomfoepiteliom (dijagnostkovan kao Hodgkinov limfom),
i dva slučaja metastaze papilarnog karcinoma štitaste žlezde (dijadnostikovane kao nodularna struma i
adenoid cistični karcionom).
Tačnost citološke dijagnostike za metastatsku bolest GiV u ovoj grupi bolesnika je iznosila 94,5%.
Zaključak: Veoma dobra korelacija citoloških,
sa histološkim dijagnozama, pokazala je da je ATI
pogodna kao prva dijagnostička linija kod metastatske bolesti GiV.
Ključne reči: citologija, histologija, aspiracija
tankom iglom, glava i vrat, metastaza
594
Zeljka Tatomirovic, Vesna Skuletic, Jovana Trimcev,
Lidija Zolotarevski
Aim: The aim of this study was to assess the diagnostic accuracy of fine needle aspiration (FNA)
cytology of head and neck (H&N) metastatic disease.
Introduction: FNA cytology is technique associated with minimal complications, very suitable for
obtaining material in the head and neck region.
Material and methods: Aspirations were performed in 54 patients with H&N metastatic disease by
cytologist, using 25 G needles and smears were stained with May-Grunwald-Giemsa.
Results: Cytological diagnosis of 13 squamous, 8
adeno, 13 non small cell, 13 small cell and 6 poorly
differentiated metastatic carcinoma were established.
Histological correlation confirmed FNA diagnosis of
all squamous, and small cell carcinoma, adenocarcinoma in 6 cases, while one was adenoaquamous carcinoma and one was cytologically misdiagnosed as
squamous cell carcinoma. Out of 13 cases cytologically diagnosed as non small cell carcinoma, 4 were
squamous cell carcinoma, 3 adenocarcinoma, 5 adenosquamous carcinoma and one remained non small
cell carcinoma. Out of 6 cases cytologically diagnosed as poorly differentiated carcinoma 4 were squamous cell carcinoma, one adenosquamous carcinoma and one remained with the same diagnosis. Three
metastases were not recognized: One lymphoepithelioma (diagnosed as Hodgkin lymphoma), and 2 cases of metastases of papillary thyroid carcinoma (diagnosed as nodular gotier and adenoid cystic carcinoma). The accuracy FNA cytology for metastatic
H&N disease was 94,5%.
Conclusion: A good concordance between cytological and histological diagnoses, showed that FNA
cytology is suitable as a first line of investigation of
metastatic H&N disease.
Key words: fine needle aspiration, cytology, histology, head, neck, metastasis
DERMATOPATOLOGIJA
DERMATOPATHOLOGY
P02
Ekstraokularni sebacealni
karcinom kože
Exraocular sebaceous carcinoma of
the skin
Nada Vučković, Bojana Andrejić2, Aleksandra
Levakov1, Mirjana Živojinov1, Dejan Vučković3
Nada Vuckovic1, Bojana Andrejic2, Aleksandra
Levakov1, Mirjana Zivojinov1, Dejan Vuckovic3
Cilj: Cilj rada je prikaz retke lokalizacije sebacealnog karcinoma kože.
Uvod: Sebacealni karcinomi čine 1% malignih tumora kože, i po lokalizaciji se dele na okularne i ekstraokularne. Ekstraokularni sebacealni karcinomi su
kod četvrtine ovog broja (0.25% svih karcinoma kože). Klinički izgled ukazuje na brojne benigne i inflamatorne lezije, to utiče na produženje vremena do
postavljenja dijagnoze i adekvatne terapije.
Materijal i metode: Ekscizioni biopsijski uzorak
kože sa tumorom, sa levog ramena, pacijentkinje stare 56 godina. Tumorski nodul je slobodno pokretan,
u odnosu na kožu i niže ležeća tkiva strukture ramena.Rezultati: Makroskopski promena je 2 cm, jasno
ograničena, lobulirana, žute boje, srednje čvrstine i
homogenog izgleda na preseku. Mikroskopski tumorsko tkivo je jasno ograničeno, bez kapsule, bez kontakta sa epidermisom. Tumorski lobuli su sa bazaloidnim ćelijama u perifernom rubu i centralno smeštenim ćelijama, vakuolizovane citoplazme sebacealnog
izgleda. Vidljive su pojedinačne mitoze, nakupine
keratina i fokalne nekroze. Tumorske ćelije su CEA
negativne i EMA pozitivne. Postavljena je dijagnoza
dobro diferentovanog sebacealnog karcinoma kože.
Zaključak: Ekstraokularni sebacealni karcinom
čini manje od 4% svih sebacealnih karcinoma kože.
Usled dobre ograničenosti, obično se dijagnostikuju kao benigna lezije. Iako su ovi tumori veoma retki, neophodno ih je uvrstiti u diferencijalnu dijagnozu tumora kože
Ključne reči: sebacealni adenokarcinom, koža,
ekstraokularni
Aim: The aim of the paper is to present a rare localisation of sebaceous skin carcinoma.
Introduction: Sebaceous carcinoma makes 1%
of skin cancer, and it can be ocular and extraocular.
Extraocular sebaceous carcinoma makes a quarter of
this number (0.25% of skin cancer). The clinical appearance of sebaceous carcinoma may resemble many
benign and inflammatory changes, which contributes to the longer time required to set the correct diagnosis and initiate appropriate treatment.
Material and Methods: The excision skin biopsy of the tumor from a 56-year-old female patient located on left shoulder. The nodule was freely
movable to the skin surface and appeared not to be
firmly attached to deeper structures of the shoulder.
Results: Gross examination revealed clearly demarcated, lobular, yellow, medium firm node, 2 cm
in size with homogeneous appearance on cut section. Histologically, tumour tissue was clearly demarcated, without capsule, without any contact with the
epidermis. Tissue consisted of basaloid cells on the
periphery of tumour lobules, as well as of large
centrally localized cells with vacuolated cytoplasm
showing sebaceous differentiation. A small number
of mitosis, keratin masses and focal necrosis were
noted. Tumour tissue showed CEA negativity and
EMA positivity. The diagnosis of well differentiated
sebaceous carcinoma was made.
Conclusion: Extraocular sebaceous carcinoma is
found in less than 4% of all skin sebaceous carcinomas. Usually, due to well demarcation, they are clinically diagnosed as benign changes. Regardless of
the rare occurrence, it is necessary to include this tumour in the differential diagnosis.
Key words: sebaceous adenocarcinoma, skin,
extraocular
1 Centar
za patologiju i histologiju, Klinicki centar Vojvodine,
Novi Sad, Srbija
2 Odseka za za histologiju i embriologiju, Medicinski fakultet,
Novi Sad, Srbija
3 Centar za patologiju, Institut za plućne bolesti Vojvodine,
Sremska Kamenica, Srbija
1 Center
for Pathology and Histology, Clinical Center of
Vojvodina, Novi Sad, Serbia
2 Department of Histology and Embryology, Faculty of
Medicine, Novi Sad, Serbia
3 Center for Pathology, Institute for Lung Diseases of
Vojvodina, Sremska Kamenica, Serbia
595
P 03
Imunoekspresija protein regulatora
ćelijskog ciklusa (p53 i p16INK4a) i
BCL-2 onkoproteina kod primarnog
melanoma kože
Immunoexpression of cell cycle
regulatory proteina (p53 and
p16INK4a) and BCL-2 oncoproteina
in primary cutaneus melanoma
Miloš Kostov1, Žaklina Mijović2, Dragan Mihailović2,
Snežana Cerović3, Milorad Pavlović4
Milos Kostov1, Zaklina Mijovic2, Dragan Mihailovic2,
Snezana Cerovic3, Milorad Pavlovic4
2Instutut
2Institute
1Odsek
za patologiju, Vojna bolnica Niš, Srbija
za patologiju, Medicinski fakultet Niš, Srbija
3Institut za patologiju i sudsku medicinu, Vojnomedicinska
akademija Beograd, Srbija
4Opšta bolnica Leskovac, Služba za patologiju, Leskovac,
Srbija
Cilj: Cilj studije je da utvrdi učestalost ekspresije p53 i p16INK4a proteina i bcl-2 onkoproteina kod
primarnog melanoma kože.
Uvod: Kontrola ćelijskog ciklusa je ključni događaj u regulaciji normalnog funkcionisanja humanog tkiva, i smatra se da abnormalnosti gena regulatora ćelijskog ciklusa doprinose nastanku nekih humanih malignoma. Melanom nije izuzetak u biologiji tumora i njegovo poreklo predominatno je rezultat akumulacije mutacija gena.
Materijal i metode: Ispitivanje je obuhvatilo 53 uzoraka primarnog melanoma kože.
Imunohistohemijska analiza uradena je primenom
monoklonskih antitela za p53, p16INK4a i bcl-2 i
visoko senzitivne i specifične obeležene streptavidin-biotin kompleksne imunohistohemijske metode
DAKO LSAB TM HRP kit.
Rezultati: Ekspresija mutirane forme p53 proteina utvrđena je kod 33/33 (100%) nodularnih melanoma (NM), dok je kod superficijalno šireceg melanoma
(SSM) nađena kod 13/20 (65%) slučajeva. Statistički
značajne razlike izmedu NM i SSM nađene su za p53
i p16INK4a imunoekspresiju (p < 0,01). Ekspresija
bcl-2 onkoproteina utvrđena je kod 50/54 (94%) melanoma kože. Nisu nađene statistički značajne razlike
izmedu NM i SSM za bcl-2 imunoekspresiju.
Zaključak: Prekomerna ekspresija mutiranog p53
proteina i bcl-2 onkoproteina, uz gubitak ekspresije
p16INK4a proteina kod primarnog mealnoma potvrđuje čest gubitak funkcije ovih tumor supresorskih
gena i onkogena. Prekomerna ekspresija mutiranog
p53 proteina i gubitak ekspresije p16INK4a proteina kod NM ukazuje na vertikalnu fazu rasta tumora.
Ključne reči: Melanom, koža, regulatori ćelijskog ciklusa, Bcl-2, progresija melanoma
596
1Department
Serbia
of Pathology, Military hospital of Nis, Nis,Serbia
of Pathology, Faculty of Medicine, University of Nis,
3Institute
for Pathology and Forensic Medicine, Military
Medical of Academy Belgrade, Serbia
4General hospital of Leskovac, Department of Pathology,
Leskovac, Serbia
Aim: The aim of the study was to determine the
frequency of expression p53 and p16INK4a proteins and bcl-2 oncoprotein in primary skin melanoma.
Introduction: Cell cycle control is a crucial event
in the regulations of human normal tissues functions,
and abnormalities of regulatory cell cycle genes are
considered to contribute to the development of several
human malignancies. Melanoma is not an exception
in the tumor biology and its occurrence is predominantly the result of the gene mutations accumulation.
Material and methods: The study involved
53 samples of the primary melanoma of the skin.
Immunohistochemical analysis was performed using
monoclonal antibodies antihuman for p53, p16INK4a and Bcl-2 and highly sensitive and specifically
marked streptavidin-biotin complex immunoassays
DAKO LSABTM Kit/HRP.
Results: The p53 protein mutated form expression was found in 33/33 (100%) nodular melanoma
(NM), while in the superficially spreading melanoma
(SSM) was found in 13/20 (65%) cases. Statistically
relevant differences between NM and SSM were found for the p53 and p16INK4a immunoexpresion (p
< 0.01). The bcl-2 oncoprotein expression was found
in 50/53 (94%) melanoma of the skin. There were no
significant statistical differences between the NM and
SSM for the bcl-2 immunoexpression.
Conclusion: Overexpression p53 protein and bcl2 oncoprotein, with the loss p16INK4a protein of
expression in the primary melanoma, confirms a frequent loss of function of these tumor suppressor gene
and oncogene. Overexpression of mutated p53 protein and loss p16INK4a protein in NM indicate a vertical tumor growth phase.
Key words: Melanoma, skin, cell cycle regulators, bcl-2, melanoma progression
P04
Hibridni kožni švanom - miksom
omotača nerva
Hybrid schwannoma-nerve sheath
myxoma of the skin
Dimitrije Brašanac, Martina Stojanović
Dimitrije Brasanac, Martina Stojanovic
Cilj: Histopatološka i imunohistohemijska analiza
hibridnog tumora omotača perifernog nerva.
Uvod: Hibridni tumori omotača perifernog nerva,
koji pokazuju nagli ili postepeni prelaz između dve
komponente, se retko opisuju u literaturi. Najčešće
kombinacije su neurofibrom-švanom, švanom-perineuriom i neurofibrom-perineuriom.
Materijal i metode: Analiza pločica bojenih hematoksilin-eozinom i imunohistohemijskom strepatvidin-biotin tehnikom.
Rezultati: Pacijentkinji starosti 55 godina je dijagnostikovan kožni čvor, dimenzija 13x11x7 mm, na
potiljačnom delu glave. Posle hirurške ekscizije uočen je potkožni nastavak (20x15x13mm) u kontinuitetu sa kožnim tumorom. Mikroskopskom analizom
u površnom delu uočeni su multipli lobulusi, u celosti ili delimićno okruženi vezivnim trakama, građeni od vretenastih, ovalnih ili zvezdastih ćelija rasutih
po miksoidnoj supstanci. U dubljim delovima uzorka
nodularnu građu su postupno zamenjivala celularnija
polja, ponegde sa palisadnim ređanjem jedara razdvojenih kolagenom stromom (Verocay-eva telašca). U
površnim delovima jedra su bila okrugla-ovalna, bez
atipije i mitotske aktivnost, dok su se u dubljim, celularnim delovima mogle naći do 2 mitoze/10polja velikog uveličanja. Imunohistohemijsko bojenje pokazalo je S-100 (difuzno) i D2-40 (dublji celularni delovi)
pozitivnost. Periferni delovi miksoidnih lobulusa su
bili pozitivni na epitelni membranski antigen i Glut-1.
Proliferativni indeks (KI-67) je bio 1% u miksoidnim, a 5% u celularnim delovima. Postavljena je dijagnoza hibridnog švanoma-miksoma omotača nerva.
Zaključak: Miksom omotača nerva (NSM) do sada nije opisan kao deo hibridnih tumora omotača nerva. Rezultati imunohistohemijske analize ukazuju da
su švanom i NSM bliski ali zasebni patološki entiteti.
Ključne reči: švanom, miksom omotača nerva,
hibridni tumor, koža, imunohistohemija
Aim: Histopathological and immunohistochemical analysis of hybrid peripheral nerve sheath tumor.
Introduction: Hybrid peripheral nerve sheath tumors showing abrupt or indistinct transition of two
components have been reported uncommonly in the
literature. Most frequent combinations described are
neurofibroma-schwannoma, schwannoma-perineurioma and neurofibroma-perineurioma.
Material and methods: Analysis of slides stained with hematoxylin-eosin and streptavidin-biotin
immunohistochemical method.
Results: A 55-year-old female presented with a
cutaneous node on the occipital region, measuring
13x11x7 mm. Surgical excision revealed subcutaneous extension (20x15x13 mm) continuous with the
skin tumor. Microscopic analysis showed superficial area with multiple lobules, partially or completely
surrounded by fibrous bands, with spindled, oval, or
stellate-shape cells dispersed in myxoid matrix. In
deeper portions of the specimen nodular architecture gradually disappeared, being replaced with cellular
areas, somewhere showing palisaded arrangement of
nuclei separated by an acellular collagen-rich matrix
(Verocay bodies). In superficial parts, cells displayed
small, round to oval, cytologically bland nucleus and
no mitotic figures, whereas in deep cellular areas
up to 2 mitoses/10 high-power fields were detected.
Immunohistochemically, tumor was positive with
S-100 (diffusely), and with D2-40 (deep cellular parts). Epithelial membrane atigen and Glut-1 positive
cells were identified at the periphery of myxoid lobules. Ki-67 labelling index was 1% and 5% in myxoid
and cellular areas, respectively. Diagnosis of hybrid
schwannoma-nerve sheath myxoma has been made.
Conclusion: Nerve sheath myxoma (NSM) has
not been previously identified as a part of hybrid nerve sheath tumors. Results of immunohistochemical
analysis suggest that NSM and schwannoma are closely related but distinct entities.
Key words: schwannoma, nerve sheath myxoma,
hybrid tumor, skin, immunohistochemistry
Institut za patologiju, Medicinski fakultet Univerziteta u
Beogradu, Srbija
Institute of pathology, School of Medičine, University of
Belgrade, Serbia
597
P05
Ožiljna endometrioza i
endosalpingioza kože ingvinuma
Cutaneous inguinal scar
endometriosis and endosalpingiosis
Martina Stojanović1, Dimitrije Brašanac1, Milan
Stojičić2
Martina Stojanovic1, Dimitrije Brasanac1, Milan
Stojicic2
Cilj: Histopatološka i imunohistohemijska analiza ožiljne endometrioze i endosalipingioze kože.
Uvod: Endosalpingioza i endometrioza predstavljaju ektopičan rast epitela jajovoda i endometrijalnih žlezda i strome. Endometrioza kože je poznat entitet sa učestalošću od 1.1% u operisanih pacijentkinja. Endosalpingioza kože je redak entitet sa samo pet
do sada opisanih slučajeva.
Materijal i metode: Analiza preparata bojenih
hematoksilin-eozin i streptavidin-biotin imunohistohemijskom metodom.
Rezultati: U ovom radu prikazujemo slučaj žene starosti 40 godina koja se javila zbog potkožnpg
čvora u desnom ingvinumu, koji je sporo sporo rastao tokom dve godine i boleo tokom menstruacije.
Pacijentkinja je pre 10 godina imala miomektomiju
materice uz duže (trajanja sedam dana) prisustvo hirurškog drena u desnom ingvinumu. Uradena je hirurška ekscizija potkožnog čvora, čvrste konzistencije, dimenzija 40x25x20 mm. Histopatološkom analizom uočene su razbačane žlezde i ciste sa papilarnim
produžecima u potkožnom masnom tkivu i umereno
celularnom ožiljnom vezivu. Žlezde su bile obložene kockastim i cilindricnim epitelom i okružene stromom nalik endometrijalnoj. Papile su bile prekrivene
cilndričnim epitelom sa cilijama i bazalnim ćelijama.
Promene su bile fokalno prisutne na linijama resekcije. Nalaz je odgovarao endometriozi i endosalpingiozi u ožiljku. Imunohistohemijska analiza je potvrdila dijagnozu uz citokeratin 7, estrogen- i progesteron-receptor pozitivne fokuse endometrioze i endosalpingioze, CD10 pozitivnu endometrijalnu stromu
i WT-1 i kalretinin pozitivan tubalni epitel.
Zaključak: Ovo je prvi slucaj kombinovane endosalpingioze i endometrioze kože, kao i prvi slučaj
endosalpingioze u ožiljku i van pupka.
Ključne reči: endosalpingioza, endometrioza, koža, imunohistohemija
Aim: Histopathological and immunohistochemical analysis of cutaneous scar endometriosis and
endosalpingiosis.
Introduction: Endosalpingiosis and endometriosis are an ectopic growth of the Fallopian tube epithelium and endometrial glands and stroma. Cutaneous
endometriosis is well known entity with an incidence of 1.1% in surgically proven cases. Cutaneous endosalpingiosis is a rare entity, with only 5 cases reported up today.
Material and Methods: Analysis of slides stained with hematoxylin-eosin and streptavidin-biotin
immunohistochemical method.
Results: A 40-year-old Caucasian woman presented with a 2-year history of a slowly growing subcutaneous nodule in right inguinum associated with cyclical pain during menses. Her past surgical history revealed myomectomy with prolonged placement of surgical drain in right inguinum. An excision under general anesthesia was made. A firm subcutaneous nodule
measuring 40x25x20 mm was removed. Routine histological examination revealed scattered glands and
cystic spaces with papillary structures within subcutaneous fat tissue and in the moderately cellular fibrous
scar. Glands were covered with cubical to cylindrical epithelium and surrounded with endometrium-like stroma, and papillae were covered with cylindrical
epithelium with cilia and peg cells. These structures
were focally present on surgical margins. Diagnosis
of scar endometriosis and endosalpingiosis has been made. Immunohistochemical analysis confirmed
the diagnosis with cytokeratin 7, estrogen- and progesterone- receptors positive foci of endometriosis and
endosalpingiosis, CD10 positive endometrial stroma
and WT-1 and calretinin positive tubal epithelium.
Conclusion: This is the first case of combined
endosalpingiosis and endometriosis of the skin, and
the first with endosalpingiosis occurring on scar and
outside umbilicus.
Key words: endosalpingiosis, endometriosis,
skin, immunohistochemistry
1Institut
2Klinika za opekotine,plastičnu i rekonstruktivnu hirurgiju,
Klinički centar Srbije, Beograd, Srbija
598
1Institute
of Pathology, Faculty of Medicine, University of
2Clinic for Burns, Plastic and Reconstructive Surgery, Clinical
Centre of Serbia, Belgrade, Serbia
P06
Diferencijalna dijagnostika
mastocitoma i histiocitoma pasa
Differential diagnosis of mastocytoma
and histiocytoma in dogs
Ivana Vučičević, Sladjan Nešić, Sanja
Aleksić-Kovačević
Ivana Vucicevic, Sladjan Nesic, Sanja
Aleksic-Kovacevic
Cilj: Utvrdivanje ekspresije molekula značajnih za
diferencijalnu dijagnozu i kontrolu rasta mastocitoma.
Uvod: Mastocitomi su neoplazme poreklom iz
kostne srži, iz linije opredeljene za mastocite. Kod
pasa čine 7 - 21% od ukupnog broja tumora i mnogi imaju vrlo agresivan klinički tok sa metastazama.
Diferencijalno dijagnosticki ih je teško razlikovati od histiocitoma samo na osnovu patohistološkog
pregleda preparata bojenih hematoksilin-eozinom.
Imunohistohemijsko ispitivanje mastocitoma pored
diferencijalno dijagnostickog značaja, bitno je i sa
aspekta klasifikacije mastocitoma.
Materijal i metode: Ispitivanjem su obuhvaćeni
isečci tumora kože ukupno 30 pasa različitog uzrasta,
rase i pola. Uzorci kože su fiksirani u 10% neutralnom formalinu, a zatim su standarno procesovani do
parafinskih blokova. Parafinski isečci bojeni su hematoksilin-eozinom i specifičnim bojenjem toluidine
blue (TB). Kod isecaka tumora kože pozitivnih na toluidine blue bojenje, uradeno je imunohistohemijsko
ispitivanje za CD117 (c-kit) i CD45RA.
Rezultati: Od 30 uzoraka tumora kože, nakon patohistološkog ispitivanja, utvrdeno je 8 histiocitoma,
a specificnim TB bojenjem potvrdeno je 16 mastocitoma sa intenzivno ljubičasto obojenim granulama histamina. 12 od 16 uzoraka mastocitoma bilo je pozitivno na CD117, to odgovara mastocitomima II gradusa. U njima je takode intenzivna ekspresija CD45RA.
Zaključak: Mastocitomi pasa II gradusa eksprimiraju CD117 i CD45RA. Ovi receptori predstavljaju molekule značajne za ćelijsku proliferaciju, brzinu rasta tumora i metastatski potencijal. Za razliku
od njih, histiocitomi su negativni na TB, brzo regresiraju i benignog su toka.
Ključne reči: CD117, CD45RA, mastocitom, histiocitom, pas
Aim: Determination of molecular expression important for differential diagnosis and growth control
of mastocytomas.
Introduction: The mast cell tumors originating
from bone marrow, the line determined to mast cells.
Mastocitomas represent 7 - 21% of all canine tumors
and many show an aggressive clinical course with
metastases. Differential diagnosis of mastocytoma
and histiocytoma based on histopathological examination of samples stained with hematoxylin-eosin is
very difficult.
Immunohistochemical examination of mastocytomas has not only the differential diagnostic value, but is also important for the mast cell tumors
classification.
Material and Methods: The skin tumor samples
included in this study were from 30 dogs of different ages, breed and sex. After the fixation in 10%
neutral formalin, the skin tumor samples were cut
into slices and processed by routine method to paraffin blocks. For paraffin embedded slices staining
were used hematoxylin-eosin and specific toluidine
blue (TB) staining. TB positive tumor samples were immunohistochemically analyzed for CD117 and
CD45RA expression.
Results: After histopathological analysis of the
30 skin tumor samples, 8 samples were histiocytomas, and using TB specific staining was confirmed
that 16 samples were mastocytomas with purple colored granules of histamine. 12 of 16 mastocytomas
were CD117 positive, which correspond to the grade
II mast cell tumors. They also had intense CD45RA
expression.
Conclusion: Grade II mast cell tumors in dogs express CD117 and CD45RA. These receptors
are important molecules for cell proliferation, tumor
growth rate and metastatic potential. Unlike mastocitomas, histiocytomas were negative for TB, rapidly regresses and has benign course.
Key words: CD117, CD45RA, dog, histiocytoma, mastocytoma
Fakultet veterinarske medicine, Univerzitet u Beogradu,
Beograd, Srbija
Faculty of Veterinary Medičine, University of Belgrade,
Belgrade, Republic of Serbia
599
P07
Elektronska mikroskopija kao
pomoćna metoda u dijagnostici
Histiocitoze - prikaz tri slučaja
Electron microscopy as a supporting
method in a diagnosis of Histiocytosis
- report of tree cases
Tamara Kravić Stevović1, Tamara Martinović1, Jelena
Sopta2, Vesna Čemerikic Martinović3, Slaviša Djurišić4,
Vesna Lačković1
Tamara Kravic Stevovic1, Tamara Martinovic1, Sopta
Jelena2, Vesna Cemerikic Martinovic3, Djuricic Slavisa4,
Lackovic Vesna1
Cilj: Cilj ovog rada je da se prikažu tri bolesnika sa histiocitozom kod kojih je kao pomoćna dijagnostička metoda uradjena ultrastrukturna analiza biopsijskog materijala elektronskim mikroskopom.
Uvod: Histiocitoza Langerhansovih ćelija je klonalna proliferativna bolest ovih antigen prezentujućih dendritičnih ćelija.
Materijali i metode: Uzorak tkiva jednog bolesnika
fiksiran je u glutaraldehidu, dok su uzorci dva bolesnika
bili prethodno fiksirani u formalinu, kalupljeni u parafinu, a kasnije deparafinizirani i fiksirani u glutaraldehidu.
Uzorci fiksirani u glutaraldehidu prvo su ispirani u kakodilatnom puferu, fiksirani u osmijum tetroksidu, dehidrirani u alkoholima rastuće koncentracije i propilenoksidu,
i kalupljeni u EPON-u. Na polutankim isečcima bojenim
toluidin plavim procenjivano je prisustvo Langerhansovih
ćelija, a na ultratankim isečcima, kontrastiranim uranil acetatom i olovo citratom, elektronskim mikroskopom analizirana je ultrastuktura Langerhansovih celija i detektovano prisustvo Birbekovih granula.
Rezultati: Birbekove granule detektovane su
u Langerhansovim ćelijama dva od tri bolesnika.
Karakterističan izgled i mnoštvo Birbekovih granula vidjeno je u uzorku koji je prethodno bio fiksiran u glutaraldehidu. U uzorku koji prethodno nije bio adekvatno fiksiran, tj. koji je bio fiksiran u formalinu, membranske strukture, pa samim tim i Birbekove granule nisu bile u potpunosti očuvane, pa su vidjene retke membranske
tubularne strukture karakterističnog periodičnog izgleda
za Birbekove granule.
Zaključak: Elektronska mikroskopija ima značaja kao
pomoćna dijagnostička metoda u dijagnostici Histiocitoze
Langerhansovih ćelija. Iako se Birbekove granule mogu detektovati i iz parafinskih blokova, u slučaju kada je
moguće uzorak tkiva uzeti ponovo, sa adekvatnom fiksacijom i obradom za elektronsku mikroskopiju, povećava
se verovatnoća i sigurnost detekcije Birbekovih granula.
Ključne reci: histiocitoza, Langerhansove ćelije,
Birbekove granule, ultrastruktura
Aim: The aim of this study is to report tree cases
with histiocytosis in which the electron microscopy as a
supporting method in diagnosis was performed.
Introduction: Langerhans cell histiocytosis is a clonal proliferative disorder of these antigen presenting dendritic cells.
Material and methods: Biopsy material of one patient was fixed in gluaraldehyde, while other two were
fixed in formalin, embedded in paraffin, and later deparaffinized and fixed in glutaraldehyde. Specimens fixed
in glutaraldehyde, were washed in cacodylate buffer,
fixed in osmium tetroxide, dehydrated in alcohols and
propylene oxide, and embedded in EPON. Semi thin
sections, stained with toluidin blue were used to asses
the presence of Langerhans cells, while ultra thin sections, contrasted with uranyl acetate and lead citrate,
were used for ultrastructural analysis and detection of
Birbeck granules.
Results: Birbeck granules were detected in
Langerhans cells of two out of tree patients. Characteristic
appearance and abundance of Birbeck granules were seen in a specimen that was adequately fixed in glutaraldehyde. In the other specimen that was first fixed in formalin, membrane structures, including Birbeck granule, were not completely preserved, due to the inadequate fixation. Rare membrane tubular structures, with characteristical periodicity for Birbeck granules were seen
in this patient.
Conclusion: Electron microscopy is a valuable
supporting method in a diagnosis of Langerhans cell histiocytosis. Although detection of Birberck granules is
possible from paraffin blocks, when it is possible to obtain tissue with adequate fixation, the possibility and specificity of the detection of Birbeck granules is increasing.
Key words: histiocytosis, Langerhans cells, Birbeck
granules, ultrastructure
1Institut
za histologiju i embriologiju, Medicinski Fakultet
2Institut za patologiju, Medicinski Fakultet Beograd, Beograd,
Srbija
3Beo-lab, Beograd, Srbija
4Institut za majku i dete Dr Vukan Čupić, Beograd, Srbija
600
1Institute
for histology and embryology, Medical Faculty
2Institute for pathology, Medical Faculty Belgrade, Belgrade,
Serbia
3Beolab, Belgrade, Serbia
4Mother and Child Health Care Institute of Serbia Dr Vukan
Cupic, Belgrade, Serbia
DIGESTIVNA PATOLOGIJA
P08
Solidni pseudopapilarni tumor
pankreasa
GASTROENTHEROHEPATO
PATHOLOGY
Solid Pseudopapillary Neoplasm of
the Pancreas
Mirjana Živojinov1, Jelena Ilić2, Sandra Trivunić3,
Mihaela Mocko-Kaćanski4, Aleksandra Levakov4, Srđan
Živojinov5
Mirjana Živojinov1, Jelena Ilić2, Sandra Trivunić3,
Mihaela Mocko-Kaćanski4, Aleksandra Levakov4, Srđan
Živojinov5
2Univerzitet
2University
1KCV,
Centar za histologiju i patologiju, Novi Sad,R.Srbija
u Novom Sadu, Medicinski fakultet, Katedra za
histologiju, Novi Sad, Srbija
3KCV, Centar za patologiju i histologiju, Katedra za
patologiju, Novi Sad, Srbija
4KCV, Centar za patologiju i histologiju, Katedra za
histologiju, Novi Sad, Srbija
5KCV, Institut za hirurgiju, Novi Sad, Srbija
Cilj: Prikazati slučaj pacijenta sa pseudopapilarnim
tumorom pankreasa.
Uvod: Solidni pseudopapilarni tumor pankreasa je veoma retka neoplazma opisana od strane Frantz-a 1956. god.
Pretežno je benignog karaktera sa učestalošcu od 1-2% svih
egzokrinih tumora pankreasa. Najčešće se javlja kod adolescentkinja i žena starosti oko 35 godina.
Materijal i metode: Odrađen je imunohistohemijski
profil na Hromogranin, Vimentin, CD56 i S100. Postavljena
je dijagnoza solidnog pseudopapilarnog (cističnog) tumora
pankreasa sa neuroendokrinom diferencijacijom.
Rezultati: U radu je prikazan slučaj pacijentkinje
starosti 22 godine, kojoj je odstranjen deo pankreasa.
Makroskopskim pregledom opisan je inkapsulisan fragment velicine 10x6 cm, sjajne i glatke površine, podlivene krvi. Na preseku se uočava meko tkivo, jasno ograničeno od okolnog tkiva pankreasa u vidu cistične formacije. Na serijskim rezovima se nalaze solidna područja tkiva i manje cistične strukture ispunjene koagulisanom krvi.
Patohistološkom analizom tumorsko tkivo je sagrađeno od
solidnih plaža koje čine okrugle tumorske ćelije, čija su jedra ovalna, pravilna, bez uočljivih jedaraca,oskudne acidofilne citoplazme. Mitoze su retke ( manje od 2 na 10 HPF
). Mestimično se uočavaju papile čija je stroma sagrađena
iz vezivno-vaskularnog, delimično hijalinizovanog tkiva,
a koje su obložene opisanim tumorskim ćelijama. Prisutni
su holesterolski kristali, makrofagi penušave citoplazme,
džinovske ćelije tipa oko stranog tela kao i okruglasta hijalina područja amorfnog izgleda. Prisutno je krvarenje u
vezivnoj hijalinoj kapsuli koja tumorsko tkivo ograđuje
od okolnog tkiva pankreasa, kao i znaci starog krvarenja.
Zaključak: Pravilna dijagnostika ovih tumora je bitna,
s obzirom da se pravovremenom i kompletnom resekcijom
mož e postići potpuno izlečenje ove neoplazme.
Ključne reči: pseudopapilarni tumor, pankreas,
imunohistohemija
1CCV,
Center for histology and pathology, Novi Sad, Serbia
of Novi Sad, Medical faculty, Department for
histology, Novi Sad, Serbia
3CCV, Center for pathology and histology, Department for
pathology, Novi Sad, Serbia
4CCV, Center For pathology and histology, Department for
histology, Novi Sad, Serbia
5CCV, Institut for surgery, Novi Sad, Serbia
Aim: To show case report of pacient with solid pseudopapillary neoplasm of the pancreas.
Introduction: Solid pseudopapillary tumor of the
pancreas is rare neoplasm, described in 1959 by Frantz.
It is mostly of low malignant potential. It accounts for
approximately 1 2% of all exocrine pancreatic tumors. It
occurs predominantly in adolescent girls and young women (mean 35 years).
Material and methods: Positive immunoreactivity
was for Chromogranin, Vimentin, CD56 and S100. After
histological examination, diagnosed of solid pseudopapillary tumor of the pancreas with neuroendocrine differentiation was done.
Results: Our paper showed a case in 22-year-old female with tumor of pancreas. After removing a part of pancreas, pathohistological analysis was done. By macroscopic
examination, it was described encapsulated fragment, size 10x6 cm, shiny and smooth surface with haemorrhage
zones. There was found soft tissue, well demarcated from
the surrounding pancreas. It was in a form of cystic formation. On serial sections there were solid areas and cystic structures filled with coagulated blood. Histologicaly
tumor tissue was built of round cells with ovoid nuclei and
clear cytoplasm. Nucleoli were inconspicuous. Mitotic figures were rare (less than 2 on 10 HPF). In some places
papillae were observed, composed from partially hyalinised connective tissue. Groups of foamy macrophages were accumulated, and there were clusters of lipid crystals
surrounded by foreign body giant cells. There was a haemorrhage in connective hyalinised capsule and signs of
old haemorrhages.
Conclusion: Proper diagnosis of these tumors is important. Considering well-timed diagnosis and complete
resection, healing is possible.
Key words: pseudopapillary neoplasm, pancreas,
immunohistochemistry
601
P09
Prevalenca i tipovi kongenitalnih
anomalija gastrointestinalnog trakta
Prevalence and types of the congenital
anomalies of the gastrointestinal tract
Radmila Janković1, Martina Stojanović1, Branislav
Lekić1, Biljana Parapid2, Srđan Aleksandrić2, Zorica
Stojšić1
Radmila Jankovic1, Martina Stojanovic1, Branislav
Lekić1, Biljana Parapid2, Srdjan Aleksandric2, Zorica
Stojšić1
Cilj: Cilj rada je da se odrede prevalenca i kategorizacija kongenitalnih malformacija gastrointestinalnog trakta u pedijatrijskoj populaciji.
Uvod: Kongenitalne anomalije gastrointestinalnog trakta su retke. Neke od njih su letalne po rodjenju, dok neke anomalije treba razlikovati od drugih
cističnih lezija abdomena.
Materijal i metode: Retrospektivna analiza učestalosti različitih gastrointestinalnih anomalija operisanih u Dečjoj Univerzitetskoj Klinici u Beogradu u
desetogodišnjem periodu (2002-2011). Podaci o makro- i mikromorfologiji prikupljani su iz patoloških
izveštaja arhive Instituta za patologiju u Beogradu.
Rezultati: Registrovano je 113 slučajeva kongenitalnih malformacija gastrointestinalnog trakta: 61
Mekelov divertikulum (54%), 25 intestinalnih atrezija/stenoza (28%) i 14 mezenterijalnih cista crevnog
porekla (12%). Retke anomalije su bile: 4 umbilikoilealne fistula i ciste (3,5%) i divertikulumi želuca, duodenuma i jejunuma (po 0,8%). Najčešći tip atrezije
je bio tip I (11), zatim tip IIIa (5), tip II (4) sa retkom
naslednom formom i tip IIIb (1). Mezenterijalne ciste crevnog porekla su uključivale cistične duplikature u zidu ileuma (9), ileuma i cekuma (2) i u torakoabdominalnoj šupljini (1) i izolovane enterične ciste
u mezenterijumu ileuma (1) i okoline pankreasa (1).
Zaključak: Cistične kongenitalne anomalije gastrointestinalnog trakta neophodno je ispravno diganostikovati i razlikovati od drugih oblika mezenterijalnih cista.
Ključne reči: malformacija gastrointestinalnog
trakta, intestinalna duplikatura, intestinalna atrezija,
mezenterijalna cista
Aim: The aim of this study was to determine the
prevalence and categorize the variants of congenital
malformations of the gastrointestinal tract in the pediatric age.
Introduction: Congenital anomalies of the gastrointestinal tract are relatively rare. Some forms cause inevitably neonatal mortality, and the others are
included in the differential diagnosis of the cystic lesions of the abdominal cavity.
Material and methods: The retrospective
analysis of a 10-year (2002-2011) prevalence of various gastrointestional congenital malformations operated at the University Children’s Hospital Belgrade.
Gross and histological findings were recorded from
the pathology reports of the Institute of Pathology
archival files.
Results: 113 cases of congenital malformations
of the gastrointestinal tract were disclosed as follows:
Meckel s diverticulum, 61 cases (54%), intestinal
atresia/stenosis, 25 (28%) and mesenterial cysts of
enteric origin, 14 (12%). Rare anomalies included
umbilicoileal fistula and vitelline cysts, 4 (3,5%) and
congenital diverticulum of the stomach, duodenum
and jejunum, one case each (0.8%). The most frequent type of intestinal atresia was type I (11), followed
by type IIIa (5), type II (4), type IV (2) including a rare form of hereditary seieve-like atresia and type IIIb
(1). Mesenteric cysts of enteric origin included duplication cyst that were situated within ileum (9), ileum
and cekum (2) and thoracoabdominal cavity (1), as
well as isolated enteric cysts positioned within ileal
mesenterium (1) and immediate to the pancreas (1).
Conclusion: Appropriate diagnosis of cystic congenital anomalies of the gastrointestinal tract is essential regarding the other forms of mesenteric cysts.
Key words: gastrointestinal malformation, intestinal duplication, intestinal atresia, mesenteric cysts
1Institut
za patologiju, Medicinski fakultet Univerziteta u
2Klinika za kardiologiju, Klinički centar Srbije, Beograd,
Srbija
602
1Institute
of pathology, Faculty of medicine, University of
2Division of Cardiology, Clinical Center of Serbia, Belgrade,
Serbia
P10
Imunohistohemijsko proučavanje
ekspresije mucina u želudacnom
karcinomu
Immunohistochemical study
of mucins expression in gastric
carcinoma
Miljan Krstić, Dragan Mihailović, Žaklina Mijović,
Ljubinka Veličković, Slavica Stojnev, Ana Ristić,
Nikola Živković
Krstic Miljan, Dragan Mihailovic, Zaklina Mijovic,
Ljubinka Velickovic, Slavica Stojnev, Ana Ristic,
Nikola Zivkovic
Cilj: Imunohistohemijsko ispitivanje ekspresije
MUC2, MUC5AC, MUC6 kod intestinalnih i difuznih karcinoma želuca sa ciljem utvrdjivanja razlika u ekspresiji i uticaju na diferencijaciju, progresiju i prognozu.
Uvod: Karcinom želuca je, kao jedan od najčešcih
malignih tumora na globalnom svetskom nivou, još
uvek je veliki zdravstveni problem i izazov za kliničare i patologe. Histogeneza nije u potpunosti razjaš
-njena, a saznanja o prekanceroznim lezijama su nekompletirana. Klasifikacione šeme su često komplikovane, ali je najprihvaćenija podela na dva osnovna
tipa, intestinalni i difuzni karcinom želuca. Za svaki
od njih je pretpostavljena drugacija etiologija, karcinogeneza i prognoza.
Materijali i metode: Korišćen je operativni materijal 62 pacijenta sa resekovanim želucem (29 intestinalnih i 33 difuzna). Materijal je obradjivan klasično, bojen hematoxylin i eosin (HE) i imunohistohemijski (EnVisionZ Dual Link System-HRP (DAB
). Korišćena su antitela: 1. MUC2 (Clone Ccp58), 2.
MUC5AC (Clone CLH2) i 3. MUC6 (Clone CLH5)
- Novocastra, Newcastle, UK. Bodovanje imunohistohemijske ekspresije je bazirano na German
ImmunoReactive Score.
Rezultati: Postoji statistički značajna razlika u
ekspresiji MUC5AC (t=0.006) i MUC2 (t=0.004)
izmedju intestinalnih i difuznih karcinoma želuca.
Ekspresija MUC2 opada sa opadanjem diferencijacije. Ekspresija MUC6 ne pokazuje statistički signifikantnu razliku izmedju 2 ispitivane grupe.
Zaključak: Istraživanje je pokazalo da je mucinska
ekspresija koristan dijagnostički parametar za ispravnu histogenetsku dijagnozu i klasifikaciju želudacnih karcinoma.MUC5AC je prediktor za difuzni karcinom želuca, a MUC2 ekspresija je značajno učestalija kod intestinalnog tipa karcinoma želuca i signifikantniji marker stepena diferencijacije.
Ključne reči: karcinom želuca, imunohistohemija, mucini
Aim: Immunohistochemical study of expression of
mucins, that included tissue specimens of the intestinal
and diffuse gastric cancer, has been carried out in order to determine differences in the expression between
the two cancer types, influence on differentiation, progression and their possible significance for prognosis.
Introduction: Gastric carcinoma still represents
a major health problem and remains enigma and a
challenge for both clinicians and pathologists. The histogenesis has not been fully elucidated so far and
the knowledge of precancerous lesions is incomplete. Classification schemes are often complicated, but
the most accepted is the division into intestinal and
diffuse gastric cancer. Each of these two cancer types
has different and specific etiology, carcinogenesis and
prognosis.
Material and methods: The operative material
obtained from 62 patients with stomach carcinoma (29
intestinal and 33 diffuse) was used. The samples were
processed conventionally and HE stained The immunohistochemical analysis was performed using EnVisionŽ
Dual Link System-HRP (DAB ) with MUC2 (Ccp58),
MUC5AC (CLH2) and MUC6 (CLH5) - Novocastra,
Newcastle, UK. Scoring of immunohistochemical
expression was based on German ImmunoReactive
Score.
Results: There was statistically significant difference in expression of MUC5AC and MUC2 between intestinal and diffuse gastric cancer. Expression of
MUC2 decreases with decreasing of differentiation.
Expression of MUC6 showed no statistically significant difference.
Conclusion: The study shows that mucin expression represents a useful diagnostic tool for the correct
histogenetic diagnosis and classification of gastric carcinoma, with MUC5AC being a predictor of diffuse
type, and MUC2 a significant marker for degree of
differentiation.
Key words: Stomach carcinoma, immunohistochemistry, mucins
Institut za patologiju, Medicinski fakultet Niš, Centar za
patologiju, Klinički centar Niš
Department of Pathology, Medical Faculty Nis and Center for
Pathology of Clinical Center Nis
603
ENDOKRINA PATOLOGIJA
P11
Plazmocitni granulom štitaste žlezde
udružen sa Hašimotovim tireoiditisom
Duško Dunđerović1, Tatjana Terzić1, Svetislav Tatić1,
Jasmina Marković- Lipkovski1, Vesna Božić2, Vladan
Živaljević2, Marija Havelka Đuković1
1Institut za patologiju, Medicinski fakultet, Beograd, Srbija
2Klinički centar Srbije, Beograd, Srbija
Cilj: Presentovati slučaj pacijenta sa plazmocitnim granulom, retkim uzrokom strume i hipotireoze.
Uvod: Plazmocitni granulom (plasma cell granulom-PCG) je retka tumoru-slična lezija, sa obimnim plazmocitnim infiltratom u fibrotičnoj stromi. Pojava PCG u štitastoj lezdi je veoma neuobičajena i retka. Do sada je u literaturi opisano 19 slucajeva PCG tireoidne ž lezde od kojih su četiri udružena sa Hašimotovim tireoiditisom.
Materijal i metode: Dijagnoza je postavljena na osnovu analize hematoksilin-eozin obojenih preseka parafinskih
uzoraka, kao i imunohistohemijske analize (CD20, CD3,
CD38, CD138, kappa, lambda, IgG, IgA, IgM, CD56).
Rezultati: Žena starosti 57 godina je primljena radi
operativnog lečenja recidivantne strume. Pacijentkinji je
urađena subtotalna tiroidektomija u 27 godini života. Sa
navršenih 55 godina starosti, primećen je ponovni rast štitaste lezde, zbog čega je bila godinu dana na supstitucionoj terapiji tiroksinom. Preoperativno, biopsijom tankom
iglom (FNAB) postavljena je dijagnoza papilarnog karcinoma. Uradena je totalna leva lobektomija i parcijalna desna lobektomija. Patohistološki, tkivo štitaste žlezde je bilo obimno difuzno prožeto zapaljenskim infiltratom između atrofičnih tireoidnih folikula, sa naglašenom fibrozom
strome. Zapaljenski infiltrat je predstavljen retkim sekundarnim limfnim folikulima (CD20 ) i brojnim plazmocitima (CD38, CD138). Imunohistohemijski, plazmociti su poliklonski (odnos kappa/lambda oko 3:1, dominantno IgG,
CD56-). Fokalno se uočava skvamozna metaplazija rezidualnih tireoidnih folikularnih ćelija. Biohemijska testiranja
funkcije štitaste žlezde i postojanje antitela na tireoidnu peroksidazu su u saglasnosti sa postojanjem Hašhimotovog tireoiditisa. Morfološki i imunohistohemijski nalaz odgovara PCG sa morfološ kim i kliničkim znacima Hašimotovog
tireoiditisa.
Zaključak: Dijagnoza PCG može predstavljati diferencijalno dijagnostički problem u odnosu na papilarni karcinom (posebno u FNAB-u), ekstramedularni plazmocitom,
kao i infektivne i autoimune bolesti.
Ključne reči: struma, Hashimoto thyreoiditis, plazmocitni granulom
604
ENDOCRINE PATHOLOGY
Plasma cell granuloma of the thyroid
gland associated with Hashimoto
thyroiditis
Dusko Dunderovic1, Tatjana Terzic1, Svetislav Tatic1,
Jasmina Markovic- Lipkovski1, Vesna Bozic2, Vladan
Zivaljevic2, Marija Havelka Djukovic1
1Institute
2Clinical
of pathology, Faculty of medicine, Belgrade, Serbia
center of Serbia, Belgrade, Serbia
Aim: To report case of a patient with a plasma cell
granuloma of the thyroid,a rare cause of goiter and
hypothyroidism.
Introduction: Plasma cell granuloma (PCG) is rare
tumor-like lesion, with numerous polyclonal plasma cells
and stromal fibrosis. Thyroid gland involvement by PCG
is rare and unusual. There are only 19 cases in literature
until now, including 4 cases associated with Hashimoto
thyroiditis
Material and methods: The diagnosis was obtained
on review of hematoxylin and eosin stained paraffin- embedded slides and immunohistochemical data (CD20, CD3,
CD38, CD138, kappa, lambda, IgG, IgA, IgM, CD56).
Results: A 57-year-old female, was admitted to hospital for operative treatment of relapsing goiter. Patient
has had subtotal thyroidectomy in the age of 27. Twenty
eight years later, increase of the size of thyroid gland has
been observed. Patient was treated by thyroid hormones
for one year. Preoperatively, fine needle aspiration biopsy (FNAB) was performed and diagnosis of papillary carcinoma has been made. Total left lobectomy and partial
right lobectomy has been done. Histological examination revealed an abundant inflammatory infiltrate between
atrophic thyroid follicles and prominent stromal fibrosis.
Inflammatory infiltrate was composed of rare secondary
lymphoid follicles (CD20 ) and numerous plasma cells
(CD38,CD138 ). Immunohistochemically, plasma cells
were polyclonal (kappa/lambda approximately 3:1, predominantly IgG, CD56-). Focally, squamous metaplasia of
residual thyroid follicles was present. Biochemical functional tests and presence of thyroid peroxidase antibodies were consistent with Hashimoto thyroiditis. Morphological,
immunohistochemical and clinical findings correspond to
PCG associated with Hashimoto thyroiditis.
Conclusion: Diagnosis of PCG could be diagnostic
problem, and differential diagnosis with papillary carcinoma (especially in FNAB), extramedullary plasmacytoma, infectious and autoimmune diseases should be taken
into consideration.
Key words: Goiter, Hashimoto thyreoiditis, plasma
cell granuloma
P12
Medularni karcinom i dobro
diferentovani karcinomi štitaste
žlezde kao komponente kolizionih
tumora: prikaz tri slučaja
Božidar Kovačević, Snežana Cerović, Mile Ignjatović,
Sanja Nikolajević, Petar Noack, Snežana Kuzmić
Janković
Institut za patologiju i sudsku medicinu Vojnomedicinska
akdemija, Beograd, Srbija
Cilj: Prikaz tri slučaja kao kolizionih tumora štitaste
žlezde: dva slučaja predstavljaju istovremeno prisustvo medularnog karcinoma sa papilarnim karcinomom,
u trećem slučaju prijavljujemo udruženost papilarnog
karcinoma sa oksifiolnim karcinomom štitaste žlezde.
Uvod: Primarni kolizioni tumori štitaste ž lezde su
retke neoplazme (manje od 1%), sačinjene od najmanje dve različite histomorfološke komponente koje mogu biti u kontinuitetu ili odvojene normalnim tkivom.
Materijal i metode: Kod tri bolesnika ženskog pola učinjena je totalna tireoidektomija zbog preoperativno citološki i klinički utvrđjene sumnje na postojanje medularnog karcinoma i folikularne lezije nejasnog malignog potencijala nalik oksifilnoj leziji. U svim
slučajevima primenjena je intraopreativna dijagnostika
sa dva odgovora u smislu medularnog karcinoma i jednim odgovorom da se radi o benignoj leziji.
Rezultati: Kod jedne bolesnice utvrdili smo izdvojene tumore lokalizovane u odvojenim lobusima- medularni i papilarni karcinom, dok je u drugom slučaju u
okolini medularnog karcinoma u istom lobusu, kao i
usuprotnom, detektovano nekoliko mikrofokusa papilarnog karcinoma. U trećem slučaju dominanti supstrat
predstavlja nodus sa karakteristikama oksifilnog karcinoma i papilarni karcinom sa multiplim poljima rasta u oba lobusa. Imunohistohemijski profil korišćenjem
antitela za neuroendokrine markere, uz CK19, HBME,
CEA i tireoglobulin pokazao je dvojne antigene strukture u različitim tipovima karcinoma.
Zaključak: Medularni i dobro diferentovani karcinomi folikularne diferencijacije kao komponente
kolizionih tumora imaju različiti maligni potencijal i
biolo ko ponašanje. Njihova dijagnoza i terapija predstavljaju izazov. Tretman kolizionih tumora zavisi od
kombinacije primarnih tumora. Svaka komponenta se
tretira kao nezavisni primarni tumor.
Ključne reči: karcinomi štitaste žlezde, kolizioni
tumori
Medullary and well differented
thyroid carcinomas occurring as a
collision tumors: report of three cases
Bozidar Kovačevic, Snezana Cerovic, Mile Ignjatovic,
Sanja Nikolajevic, Petar Noack, Snezana Kuzmic
Jankovic
Institute of pathology and forensic medicine Military medical
Academy, Belgrade
Aim: We present three cases as a collision tumors
of the thyroid gland: two cases represent simultaneous occurrence of medullary carcinoma (MTC) and
papillary carcinoma (PTC) and the thrid case represents coexistence of an oxyphylic carcinoma and a
PTC of the thyreoid gland.
Introduction: Primary collision tumors of the thyroid gland are rare neoplasms, composed of at least
two different hystomorfologicall components which
can be in continuitiy or separated with normal tissue.
Material and methods: A total thyroidectomy was
performed in the three female patients due to a preoperatively cytologically and clinically confirmed suspicion of the existence of a MTC and a follicular lesion of an uncertain malignant potential, alike to an
oxyphylic lesion. In both cases an intraoperative diagnosis was performed, in two cases with a MTC and
in one case with a benign lesion being diagnosed.
Results: In two patients we detected MTC and
PTC. In the third case we detected oxyphylic carcinoma and a PTC with multiple regions of growth in
both lobes. The immunohistochemical profile (neuroendocrine markers, calcitonine, CEA, thyreoglobuline, CK19, HBME-1) showed antigene structures in
different tumors, which corresponded with two different types of carcinomas in each single case.
Conclusion: MTC and well differented carcinomas of follicular differentiation as components of
the collision tumors have different malignant potential as well as biological behavior. Tretmant of collision tumors depend on the combinantion of primary
tumors. Each component is treated as an independent primary tumor.
Key words: thyroid gland carcinoma, collision
tumors
605
GLAVA I VRAT PATOLOGIJA
HEAD AND NECK PATHOLOGY
P13
Mukozni melanom - prikaz slučaja
Mucosal melanoma - case report
Jordan Radojčić, Dragan Živojinovic, Petar Noack, Milo
Zarić, Jovanka Trifunović, Saša Ristic, Jelena Vrtikapa,
Biserka Vukomanović - Đurdević
Jordan Radojcic, Dragan Zivojinovic, Petar Noack, Milo
Zaric, Jovanka Trifunovic, Sasa Ristic, Jelena Vrtikapa,
Biserka Vukomanovic Djurdevic
Cilj: Prikaz slučaja primarnog malignog melanoma respiratorne sluznice kao ekstremno retkog
tumora.
Uvod: Pacijent u straosti 73 godine se javio sa nespecifičnom simptomatologijom od strane sinonazalnog trakta, znacima nazalne opstrukcije i epistaksom.
Klinickim pregledom je utvrđeno prisustvo ekspanzivne tumorske mase koja je zahvatala sinonazalni
trakt. Učijena je operacija.
Materijal i metode: Imunohistohemijske analize tumorskog tkiva su neophodna dijagnostička procedura. Za definitivni staging bolesti je neophodna
kliničko-patološka korelacija.
Rezultati: Patohistološkim pregledom je pokazano prisustvo loše diferentovanog malignog tumora koga su činile pleomorfne tumorske ćelije epiteloidnog izgleda. Imunohistohemijsko analizom tumorske ćelije su bile Pancitokeratin-, Vimentin, GFAP-,
S100, MelanA, HMB45 . Daljom, detaljnom kliničkom analizom je isključeno postojanje melanoma
van sinonazalnog trakta, što je u korelaciji sa mikroskopskom slikom upućivalo sa se radi o primarnom
malignom melanomu respiratorne sluznice.
Zaključak: Dijagnostika malignog melanoma sinonazalnog trakta zahteva pored standradnog HE bojenja i dopunske imunohistohemijske analize, a za definitivni staging bolesti je neophodna klinička korelacija koja upućuje na primarno ishodište.
Ključne reči: melanom, imunohistohemija, epistaksa, sinonazalni trakt
Aim: Case report of a primary malignant melanoma of the respiratory mucosa as an example of an
extremely rare tumor.
Introduction: A patient aged 73 years was
submitted with nonspecific symptomatology of the
sinonasal cavity, nasal obstruction and epistaxis.
Clinical examination revealed an expansive tumor
mass in the sinonasal cavity. Surgery was performed.
Material and methods: Immunohistochemical
analyses are essential diagnostic tools. For a definitive staging of the disease, a clinico-pathological
correlation is needed.
Results: Pathohistological examination revealed the presence of a poorly differentiated malignant tumor which consisted of pleomorphic epithelial cells. Immunohistochemically, tumor cells were
Pancitokeratin-, Vimentin, GFAP-, S100, MelanA,
HMB45 . Detailed clinical examinations excluded the
presence of melanoma of other localizations, which
confirmed in correlation with the microscopic findings the presence of a primary malignant melanoma of
the respiratory mucosa.
Conclusion: The diagnosis of the malignant melanoma of the sinonasal cavity requires the use of standard HE and additional immunohistochemical staining and analysis. For definitive staging of the disease requires clinical correlation suggests that the primary outcome.
Key words: melanoma, immunohistochemistry,
epistaxis, sinonasal mucosa
Vojnomedicinska akademija, Beograd, Srbija
606
P14
Jugulotimpanični paraganglion
Jugulotympanic paraganglioma
Desanka Tasić-Dimov1, Irena Dimov2, Milan
Stanković3, Aleksandar Stojanov4, Petar Stanković4,
Dragan Dimov1
Desanka Tasic Dimov1, Irena Dimov2, Milan
Stankovic3, Aleksandar Stojanov4, Petar Stankovic4,
Dragan Dimov1
2Institut
2Institute
1Institut
za Patologiju, Medicinski fakultet, Niš, Srbija
za imunologiju, Medicinski fakultet, Niš, Srbija,
3Klinika za otorinolaringologiju, Klinički centar Niš, Srbija,
4Medicinski fakultet, Niš, Srbija,
Cilj: Prikaz slučaja jugulotimpaničnog paraganglioma sa ranim recidivom, neuobičajenog za pol i
uzrast pacijenta.
Uvod: Jugulotimpanični paragangliomi su retki
neuroendokrini tumori, koji pokazuju izrazitu predilekciju za ženski pol i javljaju se većinom u srednjoj
životnoj dobi. Obično se prezentuju u srednjem uhu.
Materijal i metode: Prikazujemo slučaj jugulotimpaničnog paraganglioma kod muškarca životne
dobi od 28 godina sa poremećajem sluha. Tumor je
hirurški uklonjen u delovima. Na osnovu histopatološke slike i imunohistohemijskih analiza utvrđeno je
da se radi o paragangliomu. Posle godinu dana javio
se lokalni recidiv, zbog lokalizacije i invazivne prirode lezije. Metastaze u limfnim nodusima i u udaljenim organima nisu bile prisutne.
Rezultati: Mikroskopski, tumor je bio građen od
solidnih gnezda ćelija (Zellballen) okruženih fibroznim trakama sa brojnim krvnim sudovima tipa kapilara. Jedra tumorskih ćelija bila su uglavnom mala,
okrugla, sa neupadljivim jedarcima, međutim, nađene su i ćelije sa uvećanim, iregularnim i hiperhromnim jedrima. Količina stromalnog vezivnog tkiva je
varirala. Polja sa širokim trakama vezivnog tkiva i
hijalinizovanim masama bila su takođe zastupljena i
dominirala su u recidivantnom tumoru. U recidivantnom tumoru uočena je i infiltracija okolnih struktura. Glavne ćelije su bile imunopozitivne na neuron
specificnu enolazu (NSE) i hromogranin A. Tanke,
izdužene sustentakularne ćelije identifikovane su na
bazi imunopozitivnosti na S-100 protein, ali su bile
relativno retke.
Zaključak: Prikazani slučaj jugulotimpaničnog
paraganglioma kod mladog odraslog muškarca sa
pojavom ranog recidiva ukazuje na nepohodnost daljeg praćenja pacijenta i sugeriše potrebu za genetskom analizom.
Ključne reči: jugulotimpanični paragangliom,
vrat, mlađi muškarac
1Institute
for Pathology, Faculty of Medicine, Nis, Serbia
for Immunology, Faculty of Medicine, Nis, Serbia
3Clinic for Othorinolaringology, Clinical Center of Nis, Serbia,
4Faculty of Medicine, Nis, Serbia Faculty of Medicine,
Nis,Serbija,
Aim: Presentation of jugulotympanic paragangioma with early recurrence unusual for age and sex
of the patient.
Introduction: Jugulotympanic paragangliomas
are uncommon neuroendocrine tumors, show a strong
female predilection and occur mainly in the middle
age group. They usually arise laterally and are present in the middle ear.
Material and methods: The authors present a case of jugulotympanic paragangioma in a 28-year old
man with hearing impairment. The tumor was surgically removed into fragments. The histopathological feature and immunohistochemical analysis revealed that the tumor was paraganglioma. Because of
the invasiveness and location of lesion, local recurrence occurred after one year. The lymph node involvement and distant metastases were not present.
Results: Microscopically, the tumor was composed of solid cell nests (Zellballen) surrounded by fibrous trabeculae containing numerous capillary blood
vessels. The tumor cell nuclei were mainly small and
round with inconspicuous nucleoli, however, cells
with enlarged, irregular and hyperchromatic nuclei
could be easily found. Stromal connective tissue varied throughout the tumor, and areas with fibrous bands
and densely hyalinized masses were present as well,
and dominated in recurred tumor mass. In the recurrent tumor infiltration of surrounding structures were readily seen. The chief cells were immunopositive
for neuron specific enolase (NSE) and chromogranin
A. The thin, elongated sustentacular cells were identified by immunopositivity to S-100 protein, but were relatively sparse.
Conclusion: Presented case of jugulotympanic
paraganglioma with early recurrence in young adult
man indicates that extended follow-up is required and
suggests need for genetic analysis.
Key words: jugulotympanic paraganglioma, neck,
younger man
607
P15
Imunohistohemijska analiza Spindle
- cell carcinoma larinksa - prikaz
slučaja
Immunohistochemical analysis
Spindle-cell carcinoma of the larynx Case report
Biserka Vukomanović-Djurdjević, Jordan Radojičić,
Jovanka Trifunović, Petar Noack, Jelena Ristić, Jelena
Vrtikapa
Biserka Vukomanovic-Djurdjevic, Jordan Radojicic,
Jovanka Trifunovic, Petar Noack, Jelena Ristic, Jelena
Vrtikapa
Cilj: Prikaz značaja imunohistohemije u dijagnozi spindle cell karcinoma
Uvod: Spindle-cell karcinomi su predmet kontoverze u literaturi zbog svoje bifazične strukture lezije sa skvamocelularnim fokusima i učestalom proliferacijom vretenastih ćelija sarkomskog izgleda.
Ovakva slika u literaturi se pominje kao skvamozni
karcinom sa sarkomatozno nalik stromom, polipoidni karcinom, sarkomatoidni karcinom. U analizi tumora je neophodna dijagnostička procedura kojom
se identifikuju komponente tumora.
Materijal i metode: Pacijent starosti 80 godina sa nespecifičnim simptomima od strane larinksa.
Endoskopski dijagnostifikovan tumor je bio lociran
u glotičnoj regiji, polipoidnog izgleda najvećeg prečnika 8mm sa ulceracijom i fibrinskim naslagama.
Rezultati: Mikroskopski u celini je bio sačinjen od
vretenastih kao i atipičnih, bizarnih, dzinovskih ćelija iregularno organizovanih sa vaskularnom invazijom tumorskim tkivom. Površni epitel je pokazivao
displaziju visokog stepena. Imunohistohemijski profil pokazan na tumorskim ćelijama je bio Vimentinpozitivan u svim ćelijama, a markeri HMWCK, PanCK, CK7 su bili pozitivni u delu tumora, a CK5/6,
CK17, CK18, CK20 i S-100 su bili negativni. Naša
dijagnoza je bila spindle-cell karcinom.
Zaključak: Imunohistohemijske analize su neophodne za dijagnostiku spindle cell karcinom larinksa kojom se dokazuje epitelna komponenta tumorskih ćelija.
Ključne reči: larinks, imunohistohemija, spindle cell karcinom
Aim: To show the imortance of immunohistochemistry in the diagnosis of the spindle cell carcinoma
Introduction: Spindle cell carcinomas are an
issue of controversies in the literature, which has its
origin in the characteristic biphasic structure of the
lesion with squamocellular foci and frequent spindle sarcoma-like cell proliferation. This appearance is mentioned in the literature as a squamocellular
carcinoma with a sarkomatoid stroma, as a polypoid carcinoma, as a sarkomatoid carcinoma. For the
analysis, a diagnostical procedure is required which
allows the identification of the tumor component.
Material and methods: A patient aged 80 years was submitted with nonspecific symptoms of the
larynx. The endoscopically diagnosed tumor was
located in the glottic region, was of a polypoid shape
with a diameter of 8mm with an ulcer and fibrinous deposits.
Results: Microscopically, the tumor consisted of
spindle-like as well as atypical, bizarre, giant cells of
an irregular organization and with vascular infiltration. The superficial epithelium showed a high-grade displasy. The immunohistochemical profile within the tumor cells was Vimentin-positive in all cells,
whereas the markers HMWCK, Pan-CK, CK7 were positive in a part of the neoplasm. CK5/6, CK17,
CK18, CK20 and S-100 were negative. Our diagnosis was spindle cell carcinoma.
Conclusion: Immunohistochemical analyses are
necessary for the diagnosis of the spindle cell carcinoma of the larynx, with which aid the epithelial component of tumor cells can be shown.
Key words: larynx, immunohistochemistry, spindle cell carcinoma
Vojnomedicinska Akademija, Beograd, Srbija
608
HEMATOPATOLOGIJA
HAEMATOPATHOLOGY
P16
Morfološke karakteristike
leukemijskih limfocita bolesnika sa
hroničnom limfocitnom leukemijom
posle inkubacije sa lovastatinom
Morphological characteristics of
leukemic cells of patients with chronic
lymphocytic leukemia treated with
lovastatin
Tamara Kravić-Stevović1, Andrija Bogdanović2,
Darinka Bošković2, Vladimir Bumbaširević1
Tamara Kravic-Stevovic1, Andrija Bogdanovic2,
Darinka Boskovic2, Vladimir Bumbasirevic1
Cilj: Cilj rada bio je da se ispita uticaj lovastatina
na pojavu ćelijske smrti leukemijskih limfocita bolesnika sa hroničnom limfocitnom leukemijom (HLL).
Uvod: Lovastatin inhibi e3-hidroksi-3 metil glutaril koenzim A reduktaza, enzim vazan u mevalonatnom
putu sinteze holesterola, ciji su produkti neophodni za
aktivaciju proteina uključenih u procese ćelijske smrti.
Materijali i metode: Mononuklearne ćelije izdvojene iz periferne krvi 30 bolesnika sa HLL inkubirane su u
RPMI-1640 medijumu, sa 10% seruma, i lovastatinom
(10 ľM, 20 ľM, 50 ľM, 100 ľM). Posle 24h inkubacije
(370C, 5% CO2, 98% vlažnosti) uzorci ćelija su bojeni
akridin oranžom i Mitotrackerom, pravljeni su razmazi ćelija, dok je ostatak ćelija fiksiran u glutaraldehidu
i dalje obradjivan radi dobijanja ultratankih preparata.
Rezultati: Elektronskim mikroskopom je utvrdjeno da značajan broj leukemijskih ćelija tretiranih lovastatinom pokazuje karakteristike apoptoze i autofagije,
kao i da ćelije imaju različite promene na mitohondrijama. Procenti apoptoze ćelija inkubiranih sa lovastatinom, odredjivani na razmazima bojenim TUNEL tehnikom, bili su veći od vrednosti dobijenih posle inkubacije bez leka, za sve korišćene koncentracije lovastatina (p<0,05, Exact Wilcoxon test). Indukcija autofagije
u leukemijskim ćelijama tretiranim lovastatinom pokazana je akumulacijom crvenih vezikula obojenih akridin oranžom u citoplazmi ovih ćelija. Primenom konfokalne mikroskopije zaključeno je da Mcl-1 protein u
ćelijama tretiranim lovastatinom prelazi iz citoplazme
u mitohondrije, dok je Bim protein u leukemijskim ćelijama lokalizovan u mitohondrijama, a primena lovastatina ne dovodi do promene lokalizacije ovog proteina.
Zaključak: Rezultati ovog istraživanja pokazuju da
lovastatin dovodi do indukcije ćelijske smrti u leukemijskim ćelijama bolesnika sa HLL.
Ključne reči: lovastatin, HLL, apoptoza, autofagija, ultrastruktura
Aim: The aim of this study was to investigate the
effect of the lovastatin on the induction of the cell death of leukemic lymphocytes of patients with chronic
lymphocytic leukemia (CLL).
Introduction: Lovastatin inhibits 3-hydroxy-3-methil glutaryl coenzyme A reductase, important enzyme
in mevanolate pathway of cholesterol synthesis, whose products are necessary for activation of proteins involved in cell death.
Material and methods: Mononuclear cells isolated
from the peripheral blood of 30 patients with CLL were incubated in RPMI-1640 medium, with 10% serum,
and lovastatin (10 ľM, 20 ľM, 50 ľM, 100 ľM). After
24h of incubation (370C, 5% CO2, 98% humidity) cells
were stained with acridin orange and MitoTracker, cell
smears were made, and the rest of cells were fixed in
glutaraldehyde and processed for electron microscopy.
Results: Significant number of cells treated with lovastatin had ultrastructural characteristics of apoptosis
and autophagy, and changes of mitochondria. Percentage
of apoptotic cells incubated with lovastatin, estimated
on cell smears stained with TUNEL technique, were
higher than the control, for all of the used concentration (p<0,05, Exact Wilcoxon test). Accumulation of red
vesicles stained with acridin orange in lovastatin treated cells confirmed autophagy. Confocal microscope
analysis discovered that Mcl-1 protein changes its position from cytoplasm to mitochondria after treatment
with lovastatin, while Bim protein that is localized in
mitochondria of leukemic cells, do not change its localization after treatment with lovastatin.
Conclusion: The results of this study show that lovastatin induces cell death in leukemic cells of patients with CLL.
Key words: lovastatin, CLL, apoptosis, autophagy,
ultrastructure
1Institut
za histologiju i embriologiju, Medicinski Fakultet
2Klinika za hematologiju, Klinički Centar Srbije, Medicinski
Fakultet Beograd
1Institute
for histology and embryology, Medical Faculty
2Clinic for Haematology, Clinical Centre of Serbia, Faculty of
Medicine, University of Belgrade
609
P17
Ekstranodalni krupnoćelijski NonHodginovi limfomi diferencijalno
dijagnostički problem
Extranodal Diffuse large cell NonHodgin Lymphoma problem in
differentiall diagnosis
Vesna Čemerikić-Martinović1, Olivera Marković2,
Dragomir Marisavljević2, Tamara Martinović3, Vesna
Božić4, Iva Paunović4, Katarina Marković5
Vesna Cemerikic-Martinovic1, Olivera Markovic2,
Dragomir Marisavljevic2, Tamara Martinovic3, Vesna
Bozic4, Iva Paunovic4, Katarina Markovic5
2KBC
2KBC
1Beo-lab,
Beograd, Srbija
Bežanijska kosa, Beograd, Srbija
3Institut za histologiju i embriologiju, Medicinski fakultet
Univerziteta u Beogradu, Beograd, Srbija
4Klinički centar Srbije, Beograd, Srbija
5KBC Zvezdara, Beograd, Srbija
Cilj: Prikazujemo tri slučaja primarnih krupnoćelijskih NHL ekstranodalne lokalizacije.
Uvod: Primarni ekstranodalni non-Hodkinovi limfomi (NHL) čine oko 20-30% limfoidnih tumora. Najčešće
nastaju u digestivnom traktu.
Materijal i metode: Prvi slučaj je muškarac, star 46
godina, kome je gastroskopski vidjen veliki tumor u želucu. Dijagnoza endoskopske biopsije, bez imunohistohemije, je bila anaplastični karcinom želuca. Po uradjenoj gastrektomiji nadjen je veliki ulcerovegetativni tumor, precnika 7cm, uz uvecane limfne čvorove uz malu
i veliku krivinu. U drugog bolesnika, starog 73 godine,
kompjuterska tomografija je otkrila veliki tumor leve
nadbubrežne železde, velicine 9x7cm. Uradjena je leva
adrenalektomija uz splenektomiju. U treceg bolesnika,
starog 42, godine vidjen je veliki tumor u predelu mišica ramena sa aksilarnom limfadenopatijom. Uradena
je biopsija tumora i limfnog cvora.
Rezultati: U sva tri slučaja histološki nalaz je odgovarao slabo diferentovanoj krupnoćelijskoj neoplazmi. U prvog bolesnika postojala je i infiltracija limfnih
čvorova slična metastazi karcinoma, dok je u treceg histološki nalaz u limfnom čvoru odgovarao reaktivnoj hiperplaziji. Posle detaljne imunohistohemijske obrade u
kojoj je korišćen širok panel antitela u prva dva bolesnika je postavljena dijagnoza difuznog B-krupnoćelijskog
NHL, porekla aktivirane B-celije (non-GCB). FISH
analiza limfoma nadbubrega je pokazala da postoji rearan man MYC i BCL2 gena. U trećeg bolesnika je
postavljena dijagnoza anaplastičnog krupnoćelijskog
NHL, ALK (anaplastic large cell lymphoma kinase).
Imunohistohemijska analiza je pokazala da se i u limfnom čvoru nalaze pojedine ALK tumorske ćelije.
Zaključak: Uvek treba misliti na NHL u diferencijalnoj dijagnozi slabo diferentovanih krupnoćelijskih
tumora.
Ključne reči: Ekstranodalni limfomi, krupnoćelijski NHL, NHL nadbubrežne želzde, NHL mišica, NHL
želuca
610
1Beo-lab,
Belgrade, Serbia
Bezanijska kosa, Belgrade, Serbia
3Institute of Histology, Faculty of Medicine, University of
4Clinical Center of Serbia, Belgrade, Serbia,
5KBC Zvezdara, Belgrade, Serbia
Aim: We report three cases of the primary extranodal
large-cell NHL.
Introduction: Primary extranodal non-Hodgkin lymphomas are uncommon and represent 20-30% of all NHL.
Gastrointestinal localization represent the most common
form of extranodal NHL.
Matherial and methods: The first patient, 46-yearold man, had a huge tumor in his stomach that was seen
on endoscopy. Biopsy, without immunohistochemistry revealed anaplastic carcinoma. After the operation the large exophytic, ulcerated lesion measuring 7cm was found
with enlarged lymph nodes in omentum. In second patient,
73-year-old man CT tomography of abdomen demonstrated 9x7cm mass of the left adrenal gland. Laparatomy with
left adrenalectomy and splenectomy was done. Third was
an 42-year-old man who underwent biopsy of a shoulder
muscle mass and enlarged axillary lymph node.
Results: Histological examination revealed poorly
differentiated large cell tumor in all three cases. In the
first patient the lymph nodes were involved by tumor in a
manner of cancer metastases. In third patients the lymph
node showed only reactive changes. Immunohistochemical
studies showed that tumors in first two patient were diffuse
large B-cell NHL with non-GCB phenotype. FISH analysis
show CMYC and BCL2 rerrangement in adrenal NHL.
Immunohistochemical features of the tumor in shoulder
muscle revealed a primary anaplastic large cell NHL with
positive staining for anaplastic large cell lymphoma kinase (ALK). Immunophenotyping showed few ALK positive cells in histologicaly reactive lymph node.
Conclusion: Primary lymphoma should be kept in
mind in the differential diagnosis of poorly differentiated
extranodal tumors.
Key words: Ekstranodal lymphoma, large-cell NHL,
NHL of adrenal gland, NHL of muscle, NHL of stomach
P18
Uticaj polimorfizama FCGR3A
I FCGR2A gena na kliničke
karakteristike i ishod bolesti
kod pacijenata sa difuznim B
krupnoćelijskim limfomom
Impact of FCGR3A and FCGR2A
gene polymorphisms on clinical
characteristics and outcome in
patients with diffuse large B-cell
lymphoma
Trimčev Jovana1, Cikota-Aleksić Bojana2, Tarabar
Olivera3, Tukić Ljiljana3, Magić Zvonko2
Trimcev Jovana1, Cikota-Aleksic Bojana2, Tarabar
Olivera3, Tukic Ljiljana3, Magic Zvonko2
1Institut
za patologiju, Vojnomedicinska akademija, Beograd,
Srbija
2Institut za medicinska istrazivanja, Vojnomedicinska
akademija, Beograd, Srbija
3Klinika za hematologiju, Vojnomedicinska akademija,
Beograd, Srbija
Cilj: Cilj ove studije je da proceni da li polimorfizmi FCGR3A i FCGR2A gena mogu uticati na klinički
tok i ishod bolesti kod pacijenata sa DLBCL koji su lečeni R-CHOP terapijom
Uvod: Difuzni B krupnoćelijski limfomi (DLBCL),
predstavljaju heterogenu grupu limfoproliferativnih
oboljenja sa veoma različitim kliničkim tokom i ishodom bolesti. Tačan mehanizam dejstva R-CHOP terapije nije u potpunosti objašnjen. Pokazano je da polimorfizmi FCGR3A i FCGR2A gena imaju uticaj na afinitet za vezivanje monoklonalnog antitela za FC receptor na efektornoj ćeliji.
Materijal i metode: Studija je uključila 64 pacijenta obolelih od DLBCL, lečenih R-CHOP terapijom.
Genske analize su rađene PCR-RFLP metodom
Rezultati: Nije nađena značajna statistička veza izmedu polimorfizama FCGR3A i FCGR2A gena, i kliničkih karakteristika kod DLBCL ( klinički stadijum, tumorski oblik bolesti, IPI, odgovor na terapiju, učestalost
relapsa i ishoda bolesti), osim kod FCGR2A HR genotipa koji je bio češći kod pacijenata sa poodmaklim stadijumom bolesti (stadijum III i IV). (OR 6.1111, 95%
CI 1.1842-31.5364, p=0.0091). Zapaženo je da je bolji DFS ( preživljavanje bez bolesti), kod pacijenata sa
FCGR2A HR i RR genotipima u poredenju sa pacijentima koji imaju FCGR2A HH genotip. (log rank test,
p=0.0595). FCGR3A genotip nije uticao na DFS. Nije
pokazana značajna veza izmedju FCGR3A i FCGR2A
polimorfizama/genotipa i EFS (preživljavanje bez događaja) I OS (ukupno prež ivljavanje)
Zaključak: Imajući u vidu kliničke karakteristike
i tok bolesti kod pacijenata sa DLBCL, FCGR2A HR
genotip je udružen sa višim kliničkim stadijumom bolesti, dok nosioci FCGR2A HR I RR genotipa imaju
bolji DFS.
Ključne reči: DLBCL, R-CHOP,polimorfizmi gena, FCGR2A, FCGR3A, PCR-RFLP
1Institute
of pathology and forensic medicine, Military medical
academy, Belgrade, Serbia
2Institute of medical research, Military medical academy,
Belgrade, Serbia
3Clinic for hematology, Military medical academy, Belgrade,
Serbia
Aim: The aim of this study was to assess whether
FCGR3A and FCGR2A gene polymorphisms may affect
the clinical course and outcome in DLBCL patients treated with R-CHOP therapy
Introduction: Diffuse large B-cell lymphomas
(DLBCL) represent a heterogeneous group of lymphoproliferative disorders with highly variable clinical course and outcome. The precise mechanism of R-CHOP therapy in DLBCL is not fully elucidated. It has been shown
that polymorphisms of FCGR3A and FCGR2A genes influence the afinity of monoclonal antibodies to the FCreceptor on the effector cells.
Material and methods: The study included 64 DLBCL
patients treated with R-CHOP. Genotype analyses were
performed by PCR-RFLP methodology.
Results: Significant statistical association between
different FCGR3A and FCGR2A gene polymorphisms/
genotypes and clinical characteristics of DLBCL (clinical
stadium, bulky disease, IPI, response to therapy, incidence of relapse and outcome) was not observed, except for
FCGR2A HR genotype, which was more frequent in patients with advanced clinical stage (III and IV) (OR 6.1111,
95% CI 1.1842-31.5364p: 0.0091). However, we observed a trend of better disease free survival(DFS) in patients with FCGR2A HR and RR genotypes than in those with FCGR2A HH genotype (log rank test, p=0.0595).
FCGR3A genotypes haven t influenced DFS. There was
no observed association between FCGR3A and FCGR2A
gene polymorphisms/genotypes and event free survival
(EFS) and overall survival(OS) .
Conclusion: Considering clinical features and course of DLBCL, FCGR2A HR genotype is associated with
advanced clinical stage of DLBCL, while the carriers of
FCGR2A HR and RR genotypes have better DFS.
Key words: DLBCL,R-CHOP, gene polymorphism,
FCGR3A, FCGR2A,PCR-RFLP
611
P19
Nesvakidašnji tumor limfnog čvora,
prikaz slučaja
Unusual tumor of lymph node - a case
report
Zoran Nikin1, Tatjana Kapicl1, Slavica Knežević Ušaj1,
Bratislav Stojiljković1, Milana Panjković, Dragana
Tegeltija2, Aleksandra Lovrenski2
Zoran Nikin, 1, Tatjana Kapicl1, Slavica Knežević Ušaj1,
Bratislav Stojiljković1, Milana Panjković2, Dragana
Tegeltija2, Aleksandra Lovrenski2
1Institut
2Institut
za onkologiju Vojvodine, Sremska Kamenica, Srbija
za plucne bolesti Vojvodine, Sremska Kamenica,
Srbija
Cilj: Prikaz slučaja.
Uvod: Sarkom dendritinih ćelija je retka hematološka bolest.
Materijal i metode: Prikaz slučaja.
Rezultati: Bolesnik starosti 78 godina se javio lekaru u novembru 2011. godine sa brzorastućim bolnim čvorom na vratu od septembra, afebrilan, bez gubitka težine, sa glavoboljom koja prolazi na Diklofen.
CT snimak prikazuje tumor dimenzija 65mm na vratu. Klinička dijagnoza je bila anaplastični karcinom
štitaste žlezde. Na bioptatu patolog se izjašnjava da
je tumor CD 20 negativni difuzni krupno-celijski B
limfom. Hematolozi su zatražili reviziju zbog nekompatibilnosti sa kliničkom slikom. U donetim parafinskim kalupima se nalaze isečci iz tumorom razorenog limfnog čvora sa invazijom okolnog mišicnog
tkiva. Tumorske ćelije su pleomorfne atipične srednje krupne i krupne, obilne acidofilne ili svetle citoplazme, često nejasnih granica, mehurastih jedara sa
vidljivim jedarcima. Prisutne su i “Reed Sternberg like”, vretenaste i potkovičaste celije. U pratećem zapaljenskom infiltratu se nalaze limfociti, plazmaciti, granulociti i makrofagi. Nakon panela dostupnih
imunohistohemijskih analiza je zaključeno da nalaz prvenstveno može odgovarati sarkomu dendritičnih ćelija (Vimentin, S-100, CD10, CD43, CD4,
CD68, CD23 -, CD30 -, CD20 -, CD79a -, CD3 -,
CD5 -, CD8 -, Bcl-6 -, Bcl-2 -, CD56 -, CD138 -, CK
ae1/ae3 -, Thyreoglobulin -, MelanA -, HMB-45 -).
Bolesnik je primio do sada 3 ciklusa terapije po protokolu CHOP, koje je dobro podneo.
Zaključak: Potrebno je uvek sistematično dijagnostikovati pacijente i misliti i na ređe entitete jer
savremena terapija može produ iti ž ivot i povećati
njegov kvalitet.
Ključne reči: dendritične ćelije, sarkom
612
1Institut
for oncology of Vojvodina, Sremska Kamenica,
Serbia
2Institut for pulmonary diseases of Vojvodina, Sremska
Kamenica, Serbia
Aim: Case report.
Introduction: Dendritic cell sarcoma is a rare hematologic disease.
Material and methods: Case report
Results: A 78 years old patient came to doctor
in November 2011. with fast growing and dolorous cervical node since September. He was afebrile,
without losing weight, with headaches relieving on
Diclofen. CT scan showed cervical tumor dimensioned 65mm. Clinical diagnosis was anaplastic carcinoma of thyroid gland. After biopsy pathologist diagnosed CD 20 negative diffuse large B-cell lymphoma.
Hematologists asked for revision due to incompatibility with clinical presentation. We obtained paraffin
embedded tissue samples with lymph node destructed by tumor, invading nearby muscles. Tumor cells
were pleomorphic, middle large and large, with abundant acidophilic or clear cytoplasm, often with unclear borders, with vesicular nuclei and visible nucleoli. “Reed Sternberg like” cells, fusiform and “horse shoe” cells were present too. In the background
there were lymphocytes, plasmacytes, granulocytes
and macrophages. After performing a panel of attainable immunohistochemical analyses it was concluded that the tumor is probably dendritic cell sarcoma (Vimentin, S-100, CD10, CD43, CD4, CD68,
CD23 -, CD30 -, CD20 -, CD79a -, CD3 -, CD5 -,
CD8 -, Bcl-6 -, Bcl-2 -, CD56 -, CD138 -, CK ae1/
ae3 -, Thyreoglobulin -, MelanA -, HMB-45 -). The
patient was treated with 3 CHOP regimens up to date and is in a good condition.
Conclusion: Doctors should always systematically perform diagnostic procedures and think about
rare entities because nowadays therapy can prolong
life and improve its quality.
Key words: dendritic cell, sarcoma
P20
Korelacija između KI67 indeksa i
kariometrijskih varijabli kod neHočkinovih limfoma od B- limfocita
Correlation between Ki-67 index and
karyometric variables in B-cell nonHodgkin lymphomas
Dragan Mihailović, Žaklina Mijović, Nikola Živković,
Miloš Kostov, Miljan Krstić
Dragan Mihailovic, Zaklina Mijovic, Nikola Zivkovic,
Milos Kostov, Miljan Krstic
Cilj: Cilj ovog rada je određivanje korelacije izmedu Ki67 indeksa i kariometrijskih varijabli kod
B-ćelijskih ne-Hočkinovih limfoma.
Uvod: Ki67 je protein koji se sintetiše u aktivnim fazama ćelijskog ciklusa. Poznato je da je kinetika ćelijskog ciklusa od vitalnog znacaja za ponašanje tumora. Kariometrija je objektivni metod koji se
koristi za određivanje veličine, oblika i optičke gustine jedara.
Materijal i metode: U centru za patologiju
Kliničkog centra u Nišu, od januara 2008. godine
do januara 2012. godine imunohistohemijski i kariometrijski ispitano je 20 ne-Hočkinovih limfoma od
B-limfocita (11 difuznih B-krupnoćelijskih limfoma
(DLBCL), 3 folikularna limfoma, 3 mantle-ćelijska
limfoma, 2 medijastinalna difuzna B-krupnoćelijska
limfoma i 1 Burkitt-ov limfom), kao i 7 reaktivnih
hiperplazija. Odredivani su Ki67 indeks i 7 jedarnih
parametara (površina, optička gustina, Feret-ov dijametar, obim, cirkularnost, okruglost i intregrisana optička gustina). Korišćene su digitalne slike rezolucije 1280x1024 piksela, dobijene na mikroskopu NU-2 (Carl Zeiss, Jena, Nemačka) sa objektivom
x63. Korišćen je program ImageJ, za određivanje
kariometrijskih varijabli i Ki67 indeksa (plagin Cell
Counter), na najmanje 100 jedara tumorskih ćelija
kod svakog pacijenta.
Rezultati: Najveće prosečne vrednosti Ki67 indeksa nadene su kod Burkitt limfoma (98%) i DLBCL
(43%) u odnosu na ostale histološke tipove ne-Hočkinovih limfoma od B-limfocita. Statistički značajna pozitivna korelacija nađena je između površine, Feret-ovog dijametra i Ki67 indeksa (p<0.05).
Cirkularnost jedara koja su Ki67 pozitivna je u statistički značajnoj negativnoj korelaciji sa optičkom
gustinom (p<0.05).
Zaključak: Kod B-ćelijskih ne-Holkinovih limfoma Ki67 indeks je u pozitivnoj korelaciji sa veličinom jedara.
Ključne reči: Ćelijski ciklus, Ki67 indeks. neHočkinovi limfomi
Aim: Aim of this study was to estimate correlation between Ki67 index and karyometric variables in
B-cell non-Hodgkin lymphomas.
Introduction: KI67 antigen is a nuclear protein synthesized in the active phase of the cell cycle.
Cell cycle kinetics plays a vital role in tumor behaviors. Karyometry in an objective method to estimate nuclear size, shape and optical density.
Material and methods: At Centre of Pathology,
Clinical Centre of Niš, from January 2008 to January
2012, 20 cases of non-Hodgkin lymphomas (11 diffuse large B-cell lymphomas (DLBCL), 3 follicular
lymphomas, 3 mantle cell lymphomas, 2 mediastinal diffuse large B-cell lymphomas, 1 Burkitt lymphoma) and 7 cases with reactive hyperplasia were
immunohistochemically and karyometricaly analyzed
to Ki67 index and 7 karyometric variables (nuclear
area, optical density, Feret diameter, perimeter, circularity, roundness and integrated optical density).
Using digital pictures of 1280x1024 pixels resolution, obtained on NU-2 microscope (Carl Zeiss, Jena,
Germany) at objective x63, and ImageJ software (plugin Cell Counter), Ki67 index and karyometric variables were estimated on at least a 100 of tumor cell
nuclei per case.
Results: Higher mean values of Ki-67 index were
found in Burkitt lymphoma (98%) and DLBCL (43%)
compared to other histological types of B-cell nonHodgkin lymphomas. Statistically significant positive correlation was found between area, Feret diameter and Ki67 index (p<0.05). Circularity of Ki67
stained nuclei was in statistically negative correlation with optical density (p<0.05).
Conclusion: In B-cell non-Hodgkin lymphomas,
Ki-67 index is in positive correlation with nuclear
size.
Key words: cell cycle, Ki67 index, nonHodgkin
lymphomas.
Centar za patologiju, Klinički Centar Niš, Niš, Srbija
Centre of Pathology, Clinical Centre of Nis, Serbia
613
UROLOŠKA PATOLOGIJA
UROPATHOLOGY
P21
Periacinarne retrakcione pukotine u
adenokarcinomu prostate u korelaciji
sa Gleason scorom i kliničkim
stadijumom
Periacinar retraction clefting
in prostatic adenocarcinoma in
correlation with Gleason score and
clinical stage
Milica Mijović1, Boris Dobrojević2, Danica Vukičević1,
Nebojša Mitić1, Branislav Đerković1, Vladica Nedeljković 1
1Institut
za patologiju, Medicinski fakultet Priština-Kosovska
Mitrovica, Srbija
2Odeljenje patologije, Opšta bolnica Brčko, Brčko Distrikt, BIH
Cilj: Ispitati značaj PRP kao pomoćnog kriterijuma u dijagnozi AP i korelirati ih sa Gleason scorom
i kliničkim stadijumom
Uvod: Periacinarne retrakcione pukotine (PRP)
predstavljaju prazne prostore oko žlezda adenokarcinoma prostate (AP) i smatraju se za pomoćni
dijagnostički kriterijum ako su prisutne u >1/2 žlezda
i ako pri tome zahvataju najmanje 1/2 do 2/3 cirkumferencije žlezde
Materijali i metode: Analizirano je 70 AP.
Materijal za HP analizu dobijen je needle core biopsijom ili radikalnom prostatektomijom. PRP su analizirane na deset neoplastižnih i deset normalnih žlezda na tri različita polja VMU (400x). Gleason score
je odreden na standardnim HE preparatima, klinički
stadijum prema TNM klasifikaciji
Rezultati: Nađene su žlezde sa PRP u >50% žlezdane cirkumferencije u <50% prisutnih žlezda (grupa
2) u 34(48,6%) AP ili u =50% prisutnih žlezda (grupa 3) u 31 (44,3%) AP. Žlezde bez PRP su bile redak nalaz (grupa 1) u 5 (7,1%) AP. ROC kriva pokazaje senzitivnost od 92,9% i specifičnost od 73,3%
(AUC =0.831 ?<0,001). Najčešći Gleason score bio
je 7 i nađen je u 33 (47,14%) AP. Najveći broj AP
dijagnostikovan je u stadijumu IV, kod 31 (44,29%).
Korelacionom neparametarskom analizom navedenih
parametara utvrđena je da su PRP sa zadovoljavajućim koeficijentom korelacije od -0,268 i -0,247, praćeni manje uznapredovalim kliničkim stadijumom i
nižim Gleason scorom
Zaključak: PRP mogu se svrstati u pomoćne kriterijume za dijagnozu AP. Najčešće su kod srednje
diferentovanih AP i u neuznapredovalim kliničkim
stadijumima.
Ključne reči: Prostata, karcinom, periacinarne
retrakcione pukotine
614
Milica Mijovic1, Boris Dobrojevic2, Danica Vukicevic1,
Nebojsa Mitic1, Branislav Đerkovic1, Vladica
Nedeljkovic1
1Institut
of pathology, Medical faculty Pristina-Kosovska
Mitrovica, Serbia
2Department of pathology, General hospital Brcko, Brcko
District, BIH
Aim: Importance of PRC in diagnosis of PA and
their correlation with Gleason score and clinical stage
Introduction: Periacinar retraction clefting (PRC)
are “empty spaces” around glands of prostatic adenocarcinoma (PA) and are supportive criteria if they are present in >1/2 glands and are around 1/2 to 2/3 circumference of gland.
Material and methods. We analyzed 70 PA. Material
for analysis was obtained by needle core biopsy or radical prostatectomy. PRC were analyzed on ten neoplastic and ten normal glands in three different high power
fields (400x). Gleason score was determined on standard HE preparations, clinical stage were determined
by TNM classification.
Results: We found glands with PRC in >50% of
the glandular circumference in <50% of all examined
glands (group 2) in 34 (48,6%) PA or in ≥50% of all
examined glands (group 3) in 31 (44,3%) PA. We found only 5 (7,1%) PA with glands without PRC (group
1). ROC curves showed sensitivity of 92.9% and specificity of 73.3% (AUC = 0831; р<0,001). The most
common Gleason score was 7 and was found in 33
(47.14%) PA. The greatest number of PA was diagnosed in stage IV, in 31 (44.29%). According to nonparametric correlation analysis of these parameters it was
found that the PRC, with satisfactory correlation coefficient of -0.268 and -0.247, are followed by less advanced clinical stage and lower Gleason score.
Conclusion: PRC can be classified as supportive
criteria for diagnosis of PA. They are commonly found in intermediate grade AP and at not-advanced clinical stages.
Key words: Prostate, cancer, periacinar retraction clefting.
P22
Mucinozni adenokarcinom prostate:
histopatološke i imunohistohemijske
karakteristike
Mucinous Adenocarcinoma of the
Prostate: Histopathological and
Immunohistochemical Characteristics
Sandra Trivunic Dajko1, Matilda Djolai1, Nenad
Šolajic1, Jelena Amidžić1, Mirjana Živojinov1, Bojana
Andrejić2, Snežana Božanić1
Sandra Trivunic Dajko1, Matilda Djolai1, Nenad
Solajic1, Jelena Amidzic1, Mirjana Zivojinov1, Bojana
Andrejic2, Snezana Bozanic1
Cilj: Odrediti histopatološke i imunohistohemijske
karakteristike mucinoznog adenokarcinoma prostate.
Uvod: Mucinozni (koloidni) adenokarcinom prostate je subtip prostatičnog karcinoma koji se karakteriše
velikim jezerima ekstracelularnog mucina, prema definiciji najmanje 25% tumorskog volumena i čini 0,4%
svih adenokarcinoma prostate. Tradicionalno je mucinozni adenokarcinom prostate smatran mnogo agresivnijim nego drugi češći tipovi nemucinoznih prostatičnih adenokarcinoma, medutim ova tvrdnja je i osporavana. Imajući u vidu ovu tvrdnju Internacionalno udruženje uroloških patologa je na Konsenzus konferenciji o Gleason gradiranju prostatičnog karcinoma 2005.
godine sugerisalo da bi ovaj subtip tumora trebalo klasifikovati kao Gleason score 8(4 4).
Materijal i metode: Studija je bila retrospektivna i sprovedena je u Centru za patologiju i histologiju Kliničkog Centra Vojvodine. U periodu od januara
2007. godine do marta 2012. godine je analizirana mucinozna komponenta u adenokarcinomu prostate, nakon totalne prostatektomije.
Rezultati: U petogodšnjem periodu ukupno je dijagnostikovano 302 adenokarcinoma prostate, njih 4
je imalo mucinoznu komponentu, ali je ona bila manja
od 25% tumorskog volumena kod 3 slučaja. Kod samo
jednog pacijenta starosti 69 godina, mucinozna komponenta je činila preko 30% tumorskog tkiva, te je tumor klasifikovan kao mucinozni (kololidni) tip adenokarcinoma prostate, Gleason score 4 4(8), pT3aN1.
Imunohistohemijski profil je bio sledeci: PSA+/-,
Androgeni receptori-, CEA -, CK7 -, CK20 i 34ßE12 -.
Zaključak: Zastupljenost mucinoznog adenokarcinoma prostate je u korelaciji sa literaturnim navodima, kao i njegov imunohistohemijski profil, čime ga
jasno razlikujemo od veoma retkog i agresivnog mucinoznog adenokarcinoma prostatične uretre - urinary bladder type .
Ključne reči: prostata adenokarcinom, mucinozni.
Aim: Determine histopathological and immunohistochemical characteristics of the mucinous adenocarcinoma of the prostate.
Introduction: Mucinous (or colloid) adenocarcinoma of the prostate is a subtype of prostate cancer
that is characterized by the large pools of extracellular
mucin that by definition compose at least 25% of the
tumor volumen. Mucinous adenocarcinoma represent
approximately 0.4% of all prostate adenocarcinoma.
Traditionally, mucinous adenocarcinoma of the prostate has been considered to be more agressive than
the more common nonmuconous prostate adenocarcinoma, althougt this notion has been challenged.
Material and methods: Retrospective study was
conducted in the Clinical Center of Vojvodina. From
January 2007 to March 2012 mucinous component
was analyzed in prostate adenocarcinoma and the
material used was from the radical prostatectomy.
Results: Within a five-year period the total of 302
adenocarcinoma of the prostate was diagnosed, only
4 of them had a mucinous component, but it was less than 25% tumor volume in 3 cases. In only one
patient aged 69 years, mucinous component accounted for over 30% of tumor tissue and the tumor was
classified as a mucinous (colloid) type of the prostate adenocarcinoma, Gleason score 4 4 (8), pT3aN1.
Immunohistochemical profile of the tumor was as
follows: PSA + /-, Androgen Receptors + /-, CEA -,
CK7 -, CK20 - and 34ßE12 -.
Conclusion: Presence of the mucinous adenocarcinoma of the prostate is correlated with the literature claims, as well as its immunohistochemical profile, which clearly distinguishes it from a very rare
and aggressive urinary bladder type.
Key words: prostat, adenocarcinoma, mucinous.
Centar za patologiju i histologiju, Klinički centar Vojvodine,
Novi Sad, Srbija.
2Katedra za histologiju i embriologiju, Medicinski fakultet,
Novi Sad, Srbija.
1
1Centar
of pathology and histology, Clinical centar of
Vojvodina, Novi Sad, Serbia.
2Dipartment of histology and embriology, Medical faculty of
Novi Sad, Serbia.
615
P23
Značaj stromalne eozinofilije u
neinvazivnim (pTa) I invazivnim
(pT1) papilarnim urotelnim
karcinomima
Ljiljana Bogdanović1, Sanja Radojević- Škodrić1,
Miodrag Lazić 2, Cane Tulić3, Zoran Džamić3, Gordana
Basta- Jovanović1
1Institut
za Patologiju, Medicinski fakultet, Univerzitet u
2Klinika za urologiju, KBC”Dr Dragisa Mišović”,Beograd,
Srbija
3Institut za urologiju i nefrologiju, Medicinski fakultet,
Univerzitet u Beogradu, Beograd, Srbija
Cilj: Cilj rada bio je da se uporedi broj eozinofila, koji su identifikovani na rutinskim hematoksilin
eozin preparatima, u urotelnom papilarnom karcinomu mokraćne besike sa invazijom lamine proprie.
Uvod: Tumorska eozinofilija je retka, ali je značajan fenomen koji je pronaden u mnogim tumorima. Mnogi autori navode da prisustvo nekog zapaljenskog odgovora u okviru tumora predvida napredovanje mnogih tumora, uključujuci i urotelni karcinom mokraćne bešike.
Materijali i metode: Izmedu 2007. i 2011., 40
bolesnika sa primarnim urotelnim karcinomom mokraćne bešike, koji su imali neku hiruršku intervenciju, su uključeni u ovu studiju. Od njih, 20 je imalo
neinvazivni papilarni UC mokraćne bešike, a 20 invazivni papularni UC. U svim slučajevima odreden
je stadijum i histološki gradus i prisustvo eozinofila u stromi. Eozinofili su brojani na optičkom mikroskopu na 10 uzastopnih polja velikog uveličanja
(uveličanje 400x).
Rezultati: Nadena je statisticki značajna razlika izmedu broja eozinofila u neinvazivnom papilarnom urotelnom karcinomu i invazivnom papilarnom
urotelnom karcinomu mokraćne bešike. Maksimalan
broj eozinofila na jednom i deset vidnih polja velikog
uveličanja statistički je značajno visi u invazivnom
papilarnom urotelnom karcinomu mokraćne bešike.
Zaključak: Ovi rezultati potvrduju da prisustvo
eozinofilne reakcije u stromi ima prognostički i dijagnostički značaj u UC. Razlika u intenzitetu eozinofilne reakcije može se koristiti kao dodatan dijagnostički kriterijum u dijagnozi invazije karcinoma
u laminu propriju.
Ključne reči: stromalna eozinofilija, urotelni
karcinom
616
Significance of stromal eosinophilia in
non-invasive (pTa) and invasive (pT1)
papillary urothelial carcinoma
Ljiljana Bogdanovic1, Sanja Radojevic Skodric1,
Miodrag Lazic 2, Cane Tulic3, Zoran Dzamic3, Gordana
Basta Jovanovic1
1Institute
of Pathology, School of Medicine, University of
2Clinical Center Dr Dragisa Misovic, Department of Urology,
Belgrade, Serbia
3Institute of Urology and Nephrology, School of Medicine,
University of Belgrade, Belgrade, Serbia
Aim: The aim of this study was to compare the
number of eosinophils, identified routinely with hematoxylin and eosin stain, in papillary urothelial carcinoma of the urinary bladder with invasion of lamina propria.
Introduction: Tumor eosinophilia is an uncommon,
but striking phenomenon which has been found in many
tumors. Many authors have indicated that the presence of an inflammatory response within the tumor may
predict progression in many tumors, including urothelial carcinoma (UC) of urinary bladder.
Material and methods: Between 2007. and 2011.,
40 patients with primary UC of bladder, who had undergone surgical treatment, were selected for the study. Of these, 20 had non-invasive papillary UC of the
urinary bladder and 20 had invasive papillary UC. All
cases were reviewed to assess stage and grade of the tumor and presence stromal eosinophilia. The number of
eosinophils in tumor stroma was counted. Eosinophils
was assessed in 10 consecutive fields of vision, under
the optical microscope at 400 x magnification.
Results: A statistically significant association was
shown between the number of eosinophils in non-invasive papillary urothelial carcinoma of the urinary bladder and invasive carcinoma. The maximun number of
eosinophils per one as well as per ten high power fields was significantly higher in invasive papillary urothelial carcinoma.
Conclusion: These results confirm that the presence of eosinophils reaction in tumor stroma has prognostic and diagnostic value in UC. The difference in
the intensity of eosinophilic reactions may be used as
a helpful additional diagnostic tool in diagnosis of lamina propria invasion.
Key words: stromal eosinophilia, urothelial
carcinoma
P24
Ekspresija Estrogenog Receptora B u
nodularnoj hiperplaziji prostate
The Estrogen Receptor B expression
in prostate nodular hyperplasia
Aleksandra Levakov, Mihaela Mocko-Kaćanski,
Mirjana Živojinov, Nada Vučković, Pavle Budakov
Aleksandra Levakov, Mihaela Mocko Kacanski, Mirjana
Zivojinov, Nada Vuckovic, Pavle Budakov
Cilj: Ustanoviti stepen ekspresije i lokalizaciju
ERB u BHP
Uvod: Nakon 50. godine dolazi do proliferacije žlezdanih struktura i strome prostate. Hiperplazija
prostate je povezana sa pomeranjem ravnoteže izmedu androgena i estrogena. Estrogeni uticu na rast, diferencijaciju i funkciju muškog reproduktivnog sistema. ERB je steroidni receptor lokalizovan u jedru
bazalnih ćelija acinusa i manjim delom u stromalnim ćelijama. Bazalne ćelije su androgen nezavisne
i predstavljaju matične ćelije. Sekretorne ćelije sa visokom ekspresijom ERB su diferentovane, androgen
zavisne, bez proliferativnog kapaciteta.
Materijal i metode: Sekstant biopsije sa BHP
su imunohistohemijski bojene na ERB (liofilizirano mišije monoklonalno antitelo razblaženo 1:50
Novocastra). Ocenjena je lokalizacija i stepen ekspresije ERB na uvećanju 40x. Proporcionalni score
predstavlja odnos pozitivnih ćelija u acinusima: 0 nula 1 : 1% 1% 5 >66%. Posmatran je u odnosu na pozitivno obojene fibroblaste i endotelne ćelije.
Rezultati: Najveći stepen ekspresije ERB je u bazalnim ćelijama acinusa (score 4,33), ne to manji u
sekretornim luminalnim ćelijama (score 4), a prisutan je i u stromalnim ćelijama (score 3). Visoka ekspresija ERB je nadena u slučajevima BHP sa PSA:
10 ng/ml (srednji 9,52 ng/ml). Ovakav nalaz se slaze sa većinom aktuelnih radova.
Zaključak: Uloga ERB je u zastitnom dejstvu estrogena na epitel prostate od nepredviđene proliferacije, neoplastične transformacije i oksidativnog oštećenja. ERA ima prolifertivnu ulogu koja se ograničava dejstvom ERB. Gubitak ERB vodi u nekontrolisanu ćelijsku proliferaciju. Lokalizacija ERB u sekretornim ćelijama pokazuje da je diferentovani odeljak
glavna meta estrogenog delovanja u prostati.
Ključne reči: ERB, hiperplazija prostate, bazalne
ćelije, sekretorne ćelije, imunohistohemija
Aim: Expression intensity and localization of
ERB in BHP
Introduction: Prostate acinar and stromal proliferation develops after fifties. Prostatic hyperplasia is
related with disturbed balance between androgens and
estrogens. Estrogens take influence on growth, differentiation and function of male reproductive system.
ERB is steroid receptor located in nuclei of acinar basal cell and partially in stromal cells. Androgen independent basal cells are stem cells. Secretory cells are
differentiated androgen dependent, show high ERB
expression, without proliferating capacity.
Material and methods: Sextant biopsies with
BHP are imumnohistochemistry treated for ERB
(lyophilized mouse monoclonal antibody diluted 1:50 Novocastra). Localization and intensity of
ERB?expression is determined in 40x magnification.
Proportional score presents relation of positive acinar
cells: 0 zero 5 >66%. For comparison are used positive fibroblasts and endothelial cells.
Results: ERB expression is the greatest in acinar
basal cells (score 4,33), lesser in secretory luminal
cells (score 4) and also noticed in stromal cells (score 3). High expression of ERB is registered in prostate hyperplasia with PSA: 10 ng/ml (median 9,52
ng/ml). This finding is in consistency with majority
of current reports.
Conclusion: ERB enables the protection role of
estrogen on prostate epithelium from unpredicted
proliferation, neoplastic transformation and oxidative damage. ERA has a proliferative role determined with ERB action. Losing of ERB leads to uncontrolled cell proliferation. ERB localization in secretory cell indicate that differentiated section is target
of estrogen action in prostate.
Key words: ERB, prostate hyperplasia, basal
cells, secretory cells, immunohistochemistry
Klinički centar Vojvodine, Novi Sad, Srbija
Clinical Center of Vojvodina, Novi Sad, Serbia
617
P25
Angiomyolipom bubrega
Renal angiomyolipoma - case report
Nikola Živkovic1, Dragan Mihailovic1, Sladana
Petrovic1, Zaklina Mijovic1, Aleksandra Radovanovic1,
Simonida Stojanovic1, Ana Ristic Petrovic1, Slavica
Stojnev1
Nikola Zivkovic, Dragan Mihailovic, Sladana Petrovic,
Zaklina Mijovic, Aleksandra Radovanovic, Simonida
Stojanovic, Ana Ristic Petrovic, Slavica Stojnev
Cilj: Prikaz morfoloških i imunohistohemijskih
karakteristika angiomiolipoma u bubregu.
Uvod: Prikaz morfoloških i imunohistohemijskih
karakteristika angiomiolipoma u bubregu.
Materijali i metode: Melan-A, HMB45. CD68,
CD117, CK, CEA
Rezultati: Prikaz pacijenta. Prikazujemo 65 godina starog muškarca sa spontanom rupturom angiomiolipoma, koji je lečen parcijalnom nefrektomijom. Makroskopski, lezija je žute boje, u delovima sa mišićnom komponentom tamno braon boje.
Mikroskopski, lezija je izgrađena od jednakog odnosa masnog, glatkomišićnog tkiva i krvnih sudova.
Masno tkivo čine zrele masne ćelije sa svetlom vakuolizovanom citoplazmom sa malim periferno postavljenim jedrom. Glatke mišićne ćelije su vretenastog
oblika, mestimično epiteloidne sa svetlom eozinofilnom citoplazmom. Vaskularnu komponentu čine veliki krvni sudovi tankih zidova. Imunohistohemijski,
tumorske ćelije su pozitivne na Melan-A, HMB 45,
CD117, CD68. Nasuprot, tumorske ćelije su negativne na S-100 protein, epitelne markere citokeratin i
EMA. Slučajan nalaz je bio mali kortikalni adenom.
Zaključak: Angiomiolipomi su obično benigni
tumori, izuzev epiteloidnog angiomiolipoma, koji
se javlja u 3% slučajeva i može imati agresivan tok
Ključne reči: angiomiolipomi, bubreg,
imunohistohemija
Aim: To present histological and immunohistochemical findings in renal angyomyolipoma
Introduction: Angiomyolipomas are benign neoplasm of the kidney that are composed of fat, smooth muscle, and thick-walled blood vessels in varying
proportions. Tumor is usually present in adults and rarely in children, with an overall median age 50 years.
Material and methods: Melan-A, HMB45.
CD68, CD117, CK, CEA
Results: Case report. We report the case of a
65-year-old man with spontaneous rupture of an angiomyolipoma, who was treated with a partial nephrectomy. Grossly, lesion was predominantly pale yellow,
whereas tumors with an extensive smooth muscle
component are brownish. Microscopically, the lesions
have the relative proportions of fat, smooth muscle,
and blood vessels. The adipose tissue was composed
of uniform fat cells with large cytoplasmic vacuoles
and small peripheral nucleus. The smooth muscle
cells were typically spindle shaped but occasionally
they are epithelioid and have abundant eosinophilic
cytoplasm. The vascular components consisting of
large thick walled tortuous blood vessels. According
to immunohistochemistry, tumor cells were positive
for Melan A, HMB-45, CD117, CD68. Moreover, tumor cells were negative for S-100 protein and epithelial markers such as cytokeratin and epithelial membrane antigen. We were incidentally found small renal adenoma. The cells have round to oval nuclei with
chromatin that ranges from stippled to clumped, as
well as inconspicuous nucleoli.
Conclusion: The true nature of these lesions is
unclear, but they are usually classified as hamartomas. Angiomyolipomas are generally benign lesions,
although the epithelioid angiomyolipoma, a subtype
that occurs in about 3% of cases, can have an aggressive behavior.
Key words: angiomyolipoma, kidney,
1Medicinski
618
fakultet u Nisu, Institut za patologiju, Niš, Srbija
University of Nis, Faculty of Medicine, Institute of Patology,
Nis, Serbia
P26
Non Hodgkin limfom bubrega
Non Hodgkin lymphoma in kidney
Jelena Vještica1, Milica Čekerevac2, Tatjana Terzić1,
Radmila Janković1,Sanja Ćirović1, Vesna Čemerikic3,
Jasmina Marković-Lipkovski1
Jelena Vjestica1, Milica Cekerevac2, Tatjana Terzic1,
Radmila Jankovic1,Sanja Cirovic1, Vesna Cemerikic3,
Jasmina Markovic-Lipkovski1
Institut za patologiju,Medicinski fakultet,Beograd, Srbija
za urologiju, Klinički centar Srbije, Beograd, Srbija
3Laboratorija za patologiju Beolab, Beograd, Srbija
1Institute
2Klinika
2Urology
Cilj: Ovde smo prikazali 3 slučaja non Hodgkin
limfoma bubrega dijagnostikovanih u Kliničkom centru Srbije.
Uvod: Limfomi bubrega su veoma retki i mogu
da se jave u sklopu sistemskih bolesti limfnog tkiva.
Mnogo redje se javljaju kao izolovana forma limfoma
bubrega. Najčešci histološki tip ekstranodalnog limfoma bubrega je difuzni non Hodgkin limfom krupnih
B- ćelija (diffuse large B-cell lymphoma- DLBCL).
Materijal i metode: Analiziran je materijal
Urološke klinike, Kliničkog centra Srbije, dobijen
perkutanom biopsijom bubrega i nefrektomijom.
Materijal je obrađjen i imunohistohemijski analiziran na Institutu za patologiju, Medicinskog fakulteta
u Beogradu, upotrebom markera za tumore bubrđnih
ćelija (RCC, CD10, CK7, Pax-2, vimentin, AMACR,
HMWCK, sinaptofizin) i limfome (bcl-2, bcl-6, Pax2, LCA, CD3, CD5, CD20, CD23, CD30, Cd45Ro,
CD45, CD79a).
Rezultati: Non Hodgkin limfom bubrega dijagnostikovan je kod 3 bolesnice na osnovu morfološkog
izgleda tumorskih ćelija i imunohistohemijskog bojenja. Bolesnice su bile stare 53, 56 i 73 godina. Kod
najstarije bolesnice dijagnoza DLBCL postavljena je
posle nefrektomije. Perkutanom biopsijom bubrega je
kod mlađe bolesnice postavljena dijagnoza DLBCL
bubrega u sklopu sistemskog limfoma, dok je kod
druge bolesnice na osnovu perkutane biopsije bubrega postavljena dijagnoza izolovanog B ćelijskoglimfoma malih limfocita (B-cell small lymphocytic
lymphoma- B-SLL) bubrega.
Zaključak: Non-Hodgkin limfom bubrega dijagnostikovan je kod žena, prosečne starosti 60 godina, nasuprot navedenim podacima iz literature da
limfomi bubrega pogadaju mahom mušku populaciju. Zahvaljujuci imunohistohemijskoj analizi danas
smo u mogućnosti da postavimo dijagnozu limfoma
i na biopsijskom materijalu bubrega.
Ključne reči: Non Hodgkin limfom, bubreg,
imunohistohemija
Aim: We reported 3 cases of non Hodgkin lymphoma in kidney, diagnosed at the Clinical Center of
Serba.
Introduction: Renal lymphomas are very rare and
they can be associated with lymphoid tissue systemic dissease. Rare thay can be diagnossed as primary renal lymphoma. The most common histological subtype encountered is diffuse large B cell lymphoma (DLBCL).
Material and methods: Tissue samples from kidney biopsies and nepherctomy were collected from
Urology Clinic, Clinical center of Serbia. Samples
were analyzed at the Institute for Pathology, Medical
Faculty in Belgrade. Markers for renal carcinoma
cells (RCC, CD10, HMWCK, vimentin, AMACR,
synaptophysin) and for lymphoma (bcl-2, bcl-6, Pax2, LCA, CD3, CD5, CD20, CD23, CD30, CD45Ro,
CD79a) were used and the material was analyzed by
using immunohistochemisty staining.
Results: We diagnosed Non Hodgkin lymphoma in 3 female patients according to morphology
of tumor cells and immunohistochemistry analyses.
Patients were 53, 56, and 73 year old. After nephrectomy the oldest patient was diagnosed with diffuse large B cells non Hodgkin lymphoma (DLBCL).
After kidney biopsies, in one younger patient we diagnosed systemic DLBCL, while the second patient had primary B-cell small lymphocytic lymphoma (B-SLL).
Conclusion: In our study all 3 cases of non
Hodgkin lymphoma in kidney were detected in female patients, in contradictory to previously shown
data that kidney lymphoma are predominant in male population. Using immunohistochemistry analysis
these days we are able to diagnose kidney lymphoma
in kidney biopsy samples.
Key words: Non Hodgkin lymphoma, kidney,
1
for Pathology, School of Medicine, Belgrade,Serbia
clinic, Clinical center of Serbia, Belgrade, Serbia
3Laboratory for pathology,Belgrade, Serbia
619
P27
Primarni maligni mezoteliom tunike
vaginalis testis
Primary malignant tunica
mesothelioma of testicular vaginalis
Milorad Pavlović1, Ljubinka Veličković2, Žaklina
Miović2, Desanka Dimov Tasić2, Irena Dimov3, Miloš
Kostov4
Milorad Pavlovic1, Ljubinka Velickovic2, Jacqueline
Miovic2, Desanka Dimov Tasic2, Irena Dimov3, Milos
Kostov4
2Institut
2Institute
1Služba
patologije, Opšta bolnica Leskovac, Srbija
za patologiju, Medicinski fakultet Niš, Srbija
3Institut za imunologiju, Medicinski fakultet, Niš, Srbija
4Služba za patologiju, Vojna bolnica, Niš, Srbija
Cilj: Prikaz pacijenta sa retkom lokalizacijom malignog mezotelioma.
Uvod: Maligni mezoteliom je retka neoplazma
koja se najčešće javlja na pleuri, peritoneumu i perikardu, a vrlo retko na tunici vaginalis testisa.
Materijal i metode: Resekat tumorske promene i
operativni materijal. Korišćena je klasična obrada materijala i bojenje na HE i imunohistohemijska bojenja.
Rezultati: Prikazujemo redak slučaj malignog
mezotelioma tubulopapilarni epiteloidni tip kod muškarca životne dobi od 72 godine sa hidrokelom i bolovima u predelu levog testisa. Izvršena je hirurška
ekscizija cistične promene na granici testisa i funikulusa. U zidu ciste nađena je tumorska promena prečnika 4mm. Mikroskopski, tumorska lezija je građena
od tubulopapilarnih struktura sa oskudnom vezivno
tkivnom stromom. Tumorske ćelije epiteloidnog tipa
sadržavale su ovalna jedra sa upadljivim jedarcima.
Jedra su pokazivala umereni atipizam i hiperhromaziju, a mitoze su relativno česte. Imunohistohemijski
tumorske ćelije su bile pozitivne na CK 5/6, EMA,
calretinin i mezothelin-1. Na osnovu kliničke, histološke i imunohistohemijske slike postavljena je dijagnoza malignog mezotelioma. CT je isključio prisustvo tumora u maloj karlici i abdomenu. Na operativnom materijalu nadena je tumorska formacija koja
infiltruje funikulus spermatikus i testis, a prisutna je
i na gornjoj ivici resekcije. Nakon četiri meseca pacijent je egzitirao.
Zaključak: Prikazan je slučaj retkog primarnog
malignog mezotelioma tunike vaginalis testisa zbog
izrazito agresivne prirode.
Ključne reči: Maligni mezoteliom, tubulopapilarni epiteloidni tip, testis
620
1Pathology
Department, General Hospital Leskovac, Serbia
of Pathology, School of Medicine, Nis, Serbia
3Institute of Immunology, Faculty of Medicine, Nis, Serbia
4Department of Pathology, Military Hospital Nis, Serbia
Aim: Review of the patient with a rare localization of malignant mesothelioma.
Introduction: Malignant mesothelioma is a rare
neoplasm that occurs most frequently in the pleura,
peritoneum and pericardium, and rarely on the tunic
of vaginalis testis.
Material and methods: The resect of tumor changes and operational material. We used a classical treatment of the material and the HE staining as well as
immunohistochemical staining.
Results: We present a rare case of malignant mesothelioma of tubulopapilar epitheloid type in man
72 years with hydrocell and pain in the left testicle.
Surgical excision of cystic change was performed on
the border of the testicles and the funiculus. The tumor change of 4 mm in diameter was found in the
cyst wall. Microscopically, the tumor lesion was built from tubulopapilar structures with sparse connective tissue of stroma. Tumor cells of epitheloid type contained oval nuclei with distinctive nucleus.
Nucleus showed moderate atypicality and hyper
chromaticity, while mitosis were relatively frequent. Immunohistochemical, tumor cells were positive on CK 5/6, EMA, calretinin and mesothelin-1. The
diagnosis of malignant mesothelioma was set on the
basis of clinical, histological and immunohistochemical images. CT excluded the presence of tumor in
the pelvis and abdomen. Tumor formation that infiltrates funiculus spermaticus and testicle, was found
in the operational material. It was also present on the
upper edge of the resection. After four months the
patient has died.
Conclusion: The case of a rare primary malignant mesothelioma of testicle tunica vaginalis, due
to highly aggressive nature, has been presented.
Key words: malignant mesothelioma, tubulopapilar epitheloid type, testicle
P28
Metastaze sitnoćelijskog karcinoma
pluća u svetloćelijski karcinom
bubrežnih ćelija - prikaz slučaja
Small cell lung carcinoma
metastasized to clear cell renal
carcinoma: a case report
Ivana D. Savić1, Martina M. Stojanović1, Snežana V.
Raljević2, Radmila M. Janković1, Jovan D. Vasiljević1
Ivana D. Savic1, Martina M. Stojanovic1, Snezana V.
Raljevic2, Radmila M. Jankovic1, Jovan D. Vasiljevic1
Cilj: Histopatološka i imunohistohemijska analiza sitnoćelijskog karcinoma pluća (SCKP) u svetloćelijski karcinom bubrežnih ćelija (SCKBC).
Uvod: Prisustvo dva ili više primarnih tumora kod
pacijenta, nije neuobičajeno, ali metastaze jednog tumora u drugi (tumor-u-tumor metastaze)jesu retka
pojava. Najčešći tumori donori metastaza u okviru
ovog fenomena su karcinomi pluća, prostate i štitne
ž lezde, a najčešći tumor primalac ovih metastaza je
karcinom bubrežnih ćelija.
Materijal i metode: Analiza preparata uzoraka
tkiva uzetih na autopsiji, bojenih hematoksilin-eozin
i streptavidin-biotin imunohistohemijskom metodom.
Rezultati: Muškarac, starosti 53 godine je primljen
u Kliniku za pulmologiju Klinickog Centra Srbije,
zbog dispneje, parapereze, gubitka svesti i prisustva
tumorske mase u medijastinumu (prethodno CT-om
verifikovane u okruženoj bolnici). Pacijent je preminuo jedan dan nakon prijema. Na autopsiji je nađen infiltrativan tumor u donjem desnom lobarnom
bronhu sa metastazama u kontralateralnom plućnom
krilu, desnoj nadbubrežnoj žlezdi, epikardu i više
limfnih čvorova (hilusnim, medijastinalnim i vratnim). Histopatološka slika je bila tipična za SCKP.
Takode, na gornjem polu desnog bubrega uočen je
jasno ograničen, žućkast tumor, dimenzija 2.5 x 2
cm. Histopatološkom analizom nađen je SCKBC,
nuklearni gradus II po Fuhrman-u, sa metastatskim
gnezdima SCKP. Imunohistohemijskom analizom
tumora bubrega dijagnoza je potvrđena. U gnezdima SCKP uočena je TTF-1, hromogranin A, sinaptofizin, i CD56 pozitivnost, dok je u SCKBC uočena vimentin, citokeratin, CD10 i RCC pozitivnost.
Zaključak: Ovo je do sada prvi objavljen slučaj
metastaza sitnoćelijskog karcinoma pluća u svetloćelijski karcinom bubrežnih ćelija.
Ključne reči: sitnoćelijski karcinom pluća, svetloćelijski karcinoma bubrežnih ćelija, tumor-u-tumor metastaze
Aim: Histopathological and immunohistochemical analysis of small cell lung carcinoma (SCLC) metastasized to clear cell renal cell carcinoma (ccRCC).
Introduction: Presence of two or more malignancies in a single patient is not uncommon, but
tumor-to-tumor metastases are considered rare. The
most frequent donor tumors are the lung, prostate and
thyroid gland tumors, whereas renal cell carcinoma
is the most common recipient.
Material and methods: Analysis of slides, from
tissue samples collected at the autopsy, stained with
hematoxylin-eosin and streptavidin-biotin immunohistochemical method.
Results: A 53-year old male with dyspnea, paraparesis and loss of consciousness was admitted at
the Clinic of Pulmology, Clinical Center of Serbia.
Thoracal CT scan, performed previously in community hospital, showed mediastinal tumorous mass. He
died a day after admission. On autopsy, infiltrative
tumor in the right inferior lobar bronchus was found
with metastases in contralateral lung, right adrenal
gland and epicardium and in multiple lymph nodes
(hilar, mediastinal and neck). Histology was typical for SCLC. Also, in the upper pole of right kidney sharply circumscribed, yellowish tumor measuring 2.5 x 2 cm was noted. Histopathological analysis
showed ccRCC, Fuhrman nuclear grade II, with metastatic nests of small cell lung carcinoma within it.
Immunohistochemical analysis of kidney tumour confirmed the diagnosis with TTF-1, chromogranin A,
synaptophysin and CD56 positivity in SCLC nests
and vimentin, cytokeratin, CD10 and RCC positivity in ccRCC.
Conclusion: According to our knowledge, this the
first reported case of small cell lung carcinoma metastasized to clear cell renal cell carcinoma.
Key words: small cell lung carcinoma, clear cell
renal carcinoma, tumor-to-tumor metastases
1Institut
2Klinika za pulmologiju, Klinički Centar Srbije, Beograd,
Srbija
1Institute
2Clinic of Pulmology, Clinical Center of Serbia, Belgrade,
Serbia,
621
P29
Ispoljavanje razlićitih progenitorskih
markera i njihova korelacija sa
NCAM ekspresijom u fetalnom
bubrežnom tkivu
Sanja Ćirović1, Jelena Vještica1, Martina Stojanović1,
Jasmina Tadić2, Svetislav Tatić1, Jasmina MarkovićLipkovski 1
1Institut
za patologiju, Medicinski fakultet, Beograd, Srbija
klinika „Višegradska”, Beograd,
2Ginekološko-akušerska
Srbija
Cilj: Korelacija NCAM ekspresije sa markerima
stem celija TRA-1-60, CD24, CD133 i CD34 u fetalnom tkivu bubrega.
Uvod: Interakcija izmedu ureteralnog pupoljka i
mezenhimalnih ćelija dovodi to formiranja bubrega tokom embrionalnog razvoja. NCAM se eksprimira na
svim mezenhimalnim ćelijama u ovom periodu i zato se
smatra markerom progenitorskih ćelija bubrega. Novija
istraživanja pokazala su postojanje adultnih renalnih
progenitorskih ćelija koje eksprimiraju CD24 i CD133.
Materijal i metode: Prisustvo NCAM izoformi u
humanom fetalnom tkivu bubrega različite gestacione
starosti analizirano je RT-PCR. Duplom imunofluorescencom detktovana je koekspresija NCAM-a sa markerima stem ćelija: TRA-1-60, CD24, CD133, CD34.
Takode je analizirano i ispoljavanje PSA/NCAM,
FGFR1 i Ki67 na istim uzorcima.
Rezultati: RT-PCR analiza je pokazala postojanje sve 3 NCAM izoforme (120, 140, 180 kDa) u tkivu.
Mezenhimalne ćelije oko ureteralnog pupoljka ispoljile su NCAM PSA/NCAM-CD24-CD133- fenotip. U
ovoj regiji nadene su i FGFR1 NCAM-, kao i CD133
NCAM- i CD34 NCAM- mezenhimalne ćelije. Takode
je primećeno da TRA-1-60, CD24, CD133 eksprimiraju ćelije ureteralnog pupoljka. S druge strane, mezenhimalne ćelije u nefrogenoj zoni (kondenzovanom mezenhimu i njegovim derivatima) imale su NCAM PSA/
NCAM CD24 Ki67 fenotip. PSA/NCAM prisutan je samo u nefrogenoj zoni, kao i retke NCAM/FGFR1 ćelije, u ovoj regiji nisu nađene mezenhimalne ćelije pozitivne na TRA-1-60, CD34, CD133.
Zaključak: Različita koekspresija NCAM-a sa stem
marketima TRA-1-60, CD24, CD133, CD34 ukazuje
na postojanje bar 2 vrste renalnih fetalnih progenitor
ćelija. PSA/NCAM učestvuje u ranom formiranju nefrona. Iznenađujuća je detekcija malog broja NCAM/
FGFR1 ćelija.
Ključne reči: progenitorski-stem markeri, NCAM,
CD24, CD133, TRA-1-60
622
Expression of different progenitor markers in correlation with NCAM in human fetal kidney
Sanja Cirovic1, Jelena Vjestica1, Martina Stojanovic1,
Jasmina Tadic2, Svetislav Tatic1, Serbia Jasmina
Markovic-Lipkovski1
1Institute
for Pathology, Medical Faculty, Belgrade, Serbia
and Gynecology Clinic “Visegradska”, Belgrade,
2Obstetrics
Serbia
Aim: Co-expression of NCAM and other progenitor markers TRA-1-60, CD24, CD133 and CD34
in fetal tissue was investigated in this study.
Introduction: Structures of adult kidney arise
from interactions between metanephric mesenchyme
and ureteric bud. The neural cell adhesion molecule
(NCAM) is widely expressed during development.
Recent study showed CD24 and CD133 positive adult
renal progenitor cells.
Material and methods: Human fetal kidney tissue on different stages of gestation was analyzed
using double immunofluorescent staining of NCAM
and stem cell markers: TRA-1-60, CD24, CD133,
CD34, as well as PSA-NCAM, FGFR1 and Ki67. RTPCR was used to evaluate NCAM isoforms.
Results: RT-PCR shows presence of 120, 140,
and 180 kDa isoforms. Mesenchymal cells around ureteric bud were NCAM PSA/NCAM-CD24CD133-. FGFR1 NCAM- mesenchyme cells were
found in this area, single cells CD133 NCAM- and
CD34 NCAM- were also found here. TRA-1-60,
CD24 and CD133 stain uretetic bud. PSA/NCAM
NCAM, Ki67 NCAM, CD24 NCAM was detected in
nephrogenic zone (cap mesenchyme, pretubular aggregates, renal vesicle, comma and S-shaped body).
In these areas NCAM co-expression with TRA-1-60,
CD34, CD133 and FGFR1 was not detected.
Conclusion: Different co-expression of NCAM
with CD24, CD133, and TRA-1-60 suggests that
more than one type of renal stem cells exist. PSANCAM is important for early development of the nephron. Interestingly, only restricted number of cells coexpressed FGFR1 and NCAM.
Key words: progenitors/stem markers,NCAM,
CD24, CD133, TRA-1-60
P30
Sklerozirajući peritonitis kao
posledica hroničnog lečenja
peritoneumskom dijalizom - prikaz
slučaja
Ivana
Tufegdzić1,
1Institut
Dejan
Pilčević2
za patologiju i sudsku medicinu, Vojnomedicinka
akademija, Beograd, Srbija
2Klinika za nefrologiju, Vojnomedicinska akdemija, Beograd,
Srbija
Cilj: Ukazivanje na moguću posledicu dugotrajnog
lečenja peritoneumskom dijalizom sa pojavim ozbiljne
komplikacije sklerozirajućim peritonitisom.
Uvod: Sklerozirajući peritonitis je retka, ali jedna od
najozbiljnijih komplikacija kod pacijenata na hroničnoj
peritoneumskoj dijalizi. Nejasne je patogeneze, dovodi do
morfoloških promena peritoneumske membrane sa sklerozom, formiranjem adhezija i inkapsulacijom crevnih vijuga i posledičnim (sub)okluzijama i pojavom ultrafiltracione slabosti. Dijagnoza se zasniva na kliničkim simptomima subokluzije, laboratorijskim i radiološkim nalazima, makroskopskim i histopatološkim kriterijumima.
Materijal i metode: Muškarac starosne dobi 52 godine, na programu lečenja peritoneumskom dijalizom
oko 6 godina usled razvoja terminalne bubrežne insuficijencije koja se javila zbog hroničnog glomerulonefritisa. Primljen je zbog peritonitisa klinički manifestovanog bolovima u abdomenu, povraćanjem, razvojem subokluzija i laboratorijskim nalazom koji je pokazao upalni proces. Usled infekcije izlaznog mesta peritonealnog
katetera, pristupilo se vadjenju istog, prilikom čega je
identifikovan zadebljao visceralni peritoneum sa izraženom fibrozom koja fiksira crevne vijuge. Uzet je uzorak
tkiva parijetalnog peritoneuma, sa kojeg su načinjeni hematoksilin-eozin bojeni preparati, kao i specijalnim histohemijskim bojenjem Lendrum s Picro Mallory i imunohistohemijskom metodom Ki67 i SMA.
Rezultati: Nadjene histološke promene su: mezotelna denudacija, deponovanje fibrina uz infiltraciju sa
mononuklearnim celijama i uvećanim aktivisanim fibroblastima, kao i kapilarnom angiogenezom i hijalinizacijom- opisani kriterijumi odgovaraju sklerozirajucem
peritonitisu.
Zaključak: Skerozirajuci peritonitis je ozbiljna komplikacija kod pacijenata na peritoneumskoj dijalizi sa visokim stepenom mortaliteta. Ukoliko postoji klinička
sumnja za razvoj istoga, neophodna je ciljana dijagnostička obrada i histološka evaluacija radi rane detekcije i
adekvatnog terapijskog pristupa.
Ključne reči: Sklerozirajući peritonitis, peritonealna
dijaliza, renalna insuficijencija
Encapsulating peritoneal sclerosis in
patient on peritoneal dialysis-a case
report
Ivana Tufegdzic, Dejan Pilcevic
Institute for pathology and forensic medicine, Military Medical
Academy, Belgrade, Serbia
Clinic for nephrology, Military Medical Academy, Belgrade,
Serbia
Aim: Pointing out the possible consequence of long
term peritoneal dialysis treatment with the most serious complication: encapsulating peritoneal sclerosis.
Introduction: Eencapsulating peritoneal sclerosis is rare, but the most serious complication of chronic peritoneal dialysis treatment. Pathogenesis is not
clear, disease is characterized by sclerotic thickening
of the peritoneal membrane, formation of adhesions,
accompanied by bowel encapsulation and subsequent
bowel (sub)occlusion with ultra filtration weakness.
The diagnosis is established by clinical, laboratory,
radiographic and histological findings.
Material and methods: Male, age 52, on going peritoneal dialysis treatment for last 6 years due to terminal renal failure caused by chronic glomerulonephritis.
He was admitted due to peritonitis with severe abdominal pain, vomiting, developing suboclusions and laboratory findings which point out inflammatory process.
Due to infection of peritoneal catheter, the same was
removed and during that procedure the sclerotic thickening of the peritoneal membrane with bowel sclerosis and fixation had been seen. Histological examination of peritoneal membrane was performed along with
histochemical (Lendrum s Picro Mallory) and immunohistochemical (Ki67 and SMA) analysis.
Results: Histological analysis: mesothelial denudation, fibrin deposition, mononuclear cell infiltration, fibroblast enlargement, capillary angiogenesis and hyalinisation-poposed histological criteria for a diagnosis
of encapsulating peritoneal sclerosis.
Conclusion: Encapsulating peritoneal sclerosis is
the most serious complication of peritoneal dialysis
treatment with high mortality rate. If there is any clinical suspicion, it is a need to establish the possible
diagnosis by clinical criteria and histological evaluation in order to early detection and adequate therapy.
Key words: Encapsulating peritoneal sclerosis, peritoneal dialysis, renal failure
623
GINECOLOGICAL PATHOLOGY
P31
Upotreba Wilms tumor 1
imunohistohemije u evaluaciji
ovarijalnih karcinoma
Use of Wilms tumor 1
immunohistochemistry in the
evaluation of ovarian carcinomas
Biljana Đordević1, Dragan Mihailović1, Simonida
Stojanović1, Živković Nikola1, Danijela Živanović1,
Milorad Pavlović2
Biljana Djordjevic1, Dragan Mihailovic1, Simonida
Stojanovic1, Nikola Zivkovic1, Danijala Zivanovic1,
Milorad Pavlovic2
1Institut
za patologiju, Medicinski fakultet, Univerzitet u Nišu,
Srbija
2Služba patologije, Opšta bolnica Leskovac, Srbija
Cilj: Cilj ove studije bio je da proceni da li Wilms
tumor 1 (WT1) imunohistohemija ima dvostruku upotrebu u evaluaciji tumorskih i endotelnih ćelija karcinoma jajnika.
Uvod: Nedavno je pokazano da WT1 imunohistohemija može biti upotrebljena za analizu tumorskih i
endotelnih ćelija karcinoma jajnika.
Materijal i metode: Parafinski blokovi tkiva janika 40 bolesnica izabrani su iz arhiva Instituta za patologiju Medicinskog fakulteta Univerziteta u Nišu.
Tri uzastopna preseka svakog slučaja bili su predmet
imunohistohemijskih analiza mišijim monoklonskim
antitelima protiv WT1 proteina, dobro definisanog
ovarijalnog markera, CA-125, i fenotipskog markera endotelnih ćelija, CD34, redom.
Rezultati: Različita WT1 imunoreaktivnosti bila
je nađena u tumorskim i endotelnim ćelijama. Više
od 90% WT1 pozitivnih tumorskih i endotelnih ćelija bilo je pozitivno za CA-125 (tumorske ćelije) i
CD34 (endotelne ćelije). Slično, više od 90% CA-125
ili CD34 pozitivnih ćelija eksprimiralo je i WT1 u tumorskim ili endotelnim ćelijama, redom.
Zaključak: Rezultati ove studije sugeri u da WT1
imunohistohemija može biti upotrebljena za procenu tumorskih ćelija i mikrovaskularne gustine kod
karcinoma jajnika. Budući da je WT1 eksprimiran u
tumorskim i endotelnim ćelijama, razvoj terapijskih
sredstava protiv WT1 može da predstavlja efikasnu
terapijsku opciju za karcinoma jajnika.
Ključne reči: Karcinom jajnika, imunohistohemija, WT1 protein
624
1Institute
of Pathology, Faculty of Medicine, University of Nis,
Serbia
2Departmeny of Pathology, General Hospital, Leskovac, Serbia
Aim: The aim of this study was to assess if Wilms
tumor 1 (WT1) immunohistochemistry has dual
usages in the evaluation of tumor and endothelial
cells of ovarian carcinomas.
Introduction: Previous studies revealed that a single WT1 immunohistochemistry can be used to elucidate both the cancer cells and blood vessels of EOCs.
Material and methods: Paraffin-embedded ovarian tissue blocks from 40 patients were retrieved
from the files of the Institute of Pathology, Faculty of
Medicine, University of Nis. A set of three consecutive sections from each case were subjected to immunohistochemical analyses with a mouse monoclonal
antibody against the human WT1 protein, a well defined ovarian tumor marker, CA-125, and a endothelial cell phenotypic marker, CD34, respectively.
Results: Different WT1 immunoreactivity was found in both tumor and endothelial cells. Over 90% of
WT1 positive tumor and endothelial cells were positive for CA-125 and CD34, respectively. Similarly,
over 90% of CA-125 or CD34 positive cells co-express WT1 in tumor or endothelial cells, respectively.
Conclusion: The results of this study suggest that
WT1 immunohistochemistry can be used to assess
both tumor cells and microvascular density in ovarian carcinomas. Since WT1 is expressed in both tumor and endothelial cells, the development of therapeutic agents to target WT1 may provide an effective therapeutic option for ovarian carcinomas.
Key words: Ovarian carcinoma, immunohistochemistry, WT1 protein
P32
Prvi srpski imunohistohemijski
dokazan limfoepitelioma-nalik
karcinom u cerviksu
First Serbian immunohistochemicaly
detected Lymphoepithelioma-like
carcinoma in cervix
Ljiljana Tomić1, Miloš Zarić1, Vuk Milutinović2,
Jovanka Trifunović1
Ljiljana Tomic1, Milos Zaric2, Vuk Milutinovic1,
Jovanka Trifunovic1
2 Opšta
2General
1Vojnomedicinska
Akademija Beograd, Srbija
bolnica Vršac, Srbija
Cilj: Kad god se susretnemo sa loše diferentovanim karcinomom, sa izraženim limfoplazmocitnim
infiltratom, bez obzira na mesto nastanka, treba pomisliti na LELC.
Uvod: Lymphoepithelioma-like carcinom(LELC)
se detektuje van nazofarinksa u 0,7% slučajeva u cervixu, kao primarnom mestu pojave. Literaturno navodi se hipotetska sumnja u povezanost sa Epstajn
Barovim virusom(EBV) na drugim anatomskim pojavnim mestima, osobito kod Azijatkinja a ne kod
belkinja.
Materijal i metode: Lymphoepithelioma-like carcinom je opisan na mnogim mestima, van nazofarinksa. Ova retka forma skvamocelularnog karcinoma opisana je u 0,7% slučajeva cervikalne primarne maligne forme. Smatra se da cervikalni LELC
je u vezi sa Epstein-Barr virusnom (EBV) infekcijom, ali u našem slučaju, je u pitanju belkinja nasuprot Azijatkinji, koje literaturno, imaju, EBV genom.
Rezultati: Mikroskopski pregled je potvrdio loše
diferentovanu formu skvamoznog karcinoma sa prominentnim limfoplazmocitnim infiltratom. Nije dokazana glandularna komponenta. Ćelije su bile krupne,
nejasnih margina-”syncytial”-ni izgled. Tumorske ćelije su bile jako pozitivne na Anti-Epitelni Membrane
antigen(EMA). P63 protein kao homolog p53 proteina, marker skvamozne diferencijacije, bio je difuzno
eksprimovan, sto je isključilo glandularnu ili neuroendokrinu diferencijaciju. Anti-p53 protein takođe
pozitivan. Tumorske ćelije su jako eksprimirale visok proliferativni index Ki-67 (MIB1) u više od 80%
pozitivnih tumorskih jedara. Inflamatorni infiltrat je
bio Leucocyte Common Antigen (LCA) positivan.
Imunohistohemijski EBV nije ubedljivo detektovan.
Zaključak: LELC je retka forma skvamocelularnog karcinoma. Ovo je prvi imunohistohemijski detektovan slučaj lelca kod srpske žene.
Ključne reči: cerviks, belkinja, limfoepiteliomanalik karcinom
1Military
Medical Academy, Belgrade, Serbia
Hospital Vrsac, Serbia
Aim: We present LELC in order to bear in mind
such possibility whenever confronted with poorly
differentiated carcinoma rich in lymphoplasmocytic
infiltration regardless of the anatomic site.
Introduction: Lymphoepithelioma-like carcinomas have been reported outside the nasopharynx in
many sites.This distinct neoplasm is a very rare variant of squamous cell carcinoma accounting for only
0,7% of all uterine cervix primary malignant neoplasms. It has been proposed that cervical LELC may
be related to Epstein-Barr virus infection,likewise
at other locations and it has been demonstrated in
Asian women.
Materialand methods: We report a case of LELC
of the uterine cervix in a 64 year old woman from
Serbia detected immunohistochemically, fungating
tumor, occupied the posterior lip of the cervix.
Results: Microscopic examination of the biopsy specimen disclosed a poorly differentiated nonkeratinizing carcinoma composed of cohesive nests
surrounded by prominent lymphoplasmocytic infiltrate.Small foci of nonkeratinizing carcinoma appeared in the stroma, surrounded by marked inflammatory reaction. Cells were large and had indistinct cell
margins (syncytial-like pattern). The tumor cells were
strongly positive for Anti-Epithelial Membrane antigen. P63 protein as homologue of the p53 protein, being a powerful marker for squamous differentiation,
was diffusely expressed, which excluded a glandular or neuroendocrine differentiation. Anti-p53 protein was expressed as well. Tumor cells also expressed a high proliferative rate i.e. Ki-67 of more than
80% positive tumor nuclei.
Conclusion: LELC is a rare variant of squamous cell carcinoma of the uterine cervix. This is its
first case in Caucasian woman from Serbia detected
immunohistochemicaly.
Key words: cervix, caucasian woman, lymphoepithelioma-like cancer
625
P32
Tumor granuloza ćelija ovarijumaprikaz slučaja
Granulosa cell tumor ovary - case
description
Radmila Bajić1, Golubović Mileta2, Željko Lazović1
Radmila Bajic1, Mileta Golubovic2, Zeljko Lazovic1
1Opšta
bolnica Bijelo Polje, Bijelo Polje, Crna Gora
2Klinicki Centar Crne Gore, Podgorica, Crna Gora
Cilj: Prikaz slučaja
Uvod: Tumori granuloza ćelija spadaju u grupu
ovarijalnih neoplazmi, koje u potpunosti čine granuloza ćelije. Ove novotvorine čine 3% svih tumora
jajnika. Mogu se javiti u svakom uzrastu, ali se dvije
trećine javlja poslije menopauze. Tumori granuloza
ćelija su obično unilateralni. Veličina i građa im variraju od mikroskopskih fokusa do velikih solidnih ili
cističnih inkapsuliranih masa.
Materijal i metode: Pacijentkinja u menopauzi starosti 56 godina primljena na odjeljenje radi operativnog liječenja miomatoznog uterusa. Nakon
klasične histerektomije sa adneksektomijom tumefakcija na lijevom jajniku je bila dimenzija 5x 4x 3 cm,
glatke spoljašnje površine, na presjeku solidne grade,
žutonarandžaste boje, okružena vezivnom kapsulom.
Materijal je u patohistološkoj obradi bojen metodama
HE (hematoksilin eozin) i IHH (imunohistohemijsko
bojenje). Histološki, tumorsko tkivo je komponovano
dominantno u vidu solidnih i trabekularnih formacija.
U centralnim pojedinim djelovima uocavaju se ovalni mali prostori koji sadrže eozinofilan materijal i celularni debris (Call Exnerbodies). Tumorske ćelije su
srednje krupne, blijedoeozinofilne citplazme, nejasnih granica, okruglih hiperhromatičnih jedara, niske
mitotske aktivnosti. Stroma dijelom srednje obilna.
Rezultati: Imunohistohemijska verifikacija:
VIMENTIN jako pozitivan, CK 18 negativan, EMA
negativan i CEA negativan
Zaključak: Patohistološki nalaz: Granulosa Cell
Tumor ovarii (solid type).
Ključne reči: tumor, granuloza ćelije, jajnik
626
1General
2Clinical
Hospital Bijelo Polje, Bijelo Polje, Montenegro
Center of Montenegro, Podgorica, Montenegro
Aim: Case description
Introduction: Granulosa cell tumors belong to
the group of ovarian neoplasms, which entirely consists of granulosa cells. These neoplasms constitute
3% of all ovarian tumors. They can occur at any age,
but two-thirds occurs after menopause. Granulosa cell
tumors are usually unilateral. The size and structure
are moving from microscopic forms to large solid or
cystical encapsulated mass.
Material and methods: The pacient in menopause
at the age of 56 is recived on the department because of operational treatment miomatous uterus.
After classic hysterectomy with adnexectomy tumefact on the left ovary was 5x 4x 3 cm, smooth exterior area, on the cut of solid structure, yellow-orange color, circled with a connective capsule. The
material is in the pathohystological processing coloured with metods of HE (Hematoxylin eosin) and
IHH (Immunohistochemical colour). Histologically,
the tumor was composed predominantly in the form
of solid and trabecular formation. In the central individual parts there are small oval spaces that contain
eosinophilic material and cellular debris (Call Exner
bodies). Tumor cells are medium large, pale eosinophilic cytoplasms, with unclear borders, with round
hiperhromatic sails, with low mitotic activity. Stroma
mostly medium dense.
Results: Immunohystochemical verification:
Vimentin strongly positive, CK 18 is negative, EMA
is negative and CEA negative.
Conclusion: Histopathological Findings:
Granulosa Cell Tumor ovarii (solid type).
Key words: tumor, granulosa cell, ovarii
P33
Distribucija histoloških tipova
carcinoma jajnika na operativnom
i biopsijskom materijalu- GAK
Narodni front Beograd u 2011
Danica Vukičević1, Igor Kuzmanović2, Marijana
Cimbaljević2, Milica Mijović1, Nebojša Mitić1
1Institut
za patologiju, Medicinski fakultet, Priština, Kosovska
Mitrovica, Srbija
2Ginekološko akušerska klinika Narodni front, Beograd, Srbija
Cilj: Utvrđivanje zastupljenosti karcinioma jajnika u celokupnom analiziranom operativnom i biopsijskom materijalu, utvrdivanje distribucije histopatoloških tipova ovog karcinoma, kao i u kom stadijumu
prema TNM klasifikaciji je bolest dijagnostikovana.
Uvod: Od malignih tumora jajnika su najčešći
karcinomi i njihova učestalost se kreće u svetu, prema Svetskoj zdravstvenoj organizaciji u rasponu od
2,0-15,3 a u Srbiji ta vrednost je od 9,11-11,1 na
100.000 žena.
Materijali i metode: Korišcen je biopsijski i operativni materijal koji je obrađen i analiziran u laboratoriji na ginekološko akušerskoj klinici Narodni front
u Beogradu za 2011 godinu.
Rezultati: Od 9119 žena od kojih je uzet biopsijsjki materijal karcinom jajnika je potvrden u 108
(1,18%). Epitelnih malignih tumora je bilo u 75
(69,44%) slucajeva od kojih su borderline tumori
zabeleženi u 17 (22,67%), tumora porekla polnih traka u 6 (5,56%), tumora porekla germinativnih celija
u 4 slučaja (3,70%), mešovitih epitelno-mezenhimnih tumora u 3 slučaja (2,78%), metastatskih karcinoma jajnika u 20 slučajeva (18,52%). Prosecna životna dob pacijentkinja bila je 56,66ą13,23g. Bolest
je najce ce dijagnostikovana u stadijumu FIGO IA u
32.95%, FIGO IIIC u 20.45% dok je u ostalim stadijumima ima značajno manje.
Zaključak: Na analiziranom materijalu najučestaliji histološki tip karcinoma jajnika su epitelni maligni tumori, dok je bolest najčešće dijagnostikovana
u stadijumu FIGO IA.
Ključne reči: Karcinomi jajnika, TNM klasifikacija, Metastatski karcinomi jajnika.
Distribution of histological types of
ovarian cancer in operational and
biopsy material in Gynecological and
Obstretic Clinics Narodni FrontBelgrade during 2001. year
Danica Vukicevic1, Igor Kuzmanovic2, Marijana
Cimbaljevic2, Milica Mijovic1, Nebojsa Mitic1
1Institute
of pathology, Medical school Pristina, Kosovska
Mitrovica, Serbia
2Gynecologic and Obstetrics Clinic Narodni Front, Belgrade,
Serbia
Aim: Determine the presence of ovarian cancer
in the overall analyzed operational and biopsy material, determine the distribution of histological types
of cancer, as well as determine TNM stage in which
the disease is diagnosed.
Introduction: Cancers are the most common malignant ovarian tumors and according to the World
Health Organization, their frequency ranges in the
world, from 2.0 to 15.3. in Serbia, this value is from
9.11-11.1 per 100,000 women.
Material and Methods: Biopsy and operational
material that is processed and analyzed in the laboratory of Gynecologic and Obstetrics Clinic Narodni
Front, Belgrade in 2011.
Results: Of 9119 women of whom the biopsy
material was taken ovarian cancer was confirmed
in 108 cases (1.18%). We found 75 (69.44%) malignant epithelial tumors. Among them there were 17
(22.67%) borderline tumors, 6 cases (5.56%) sex cord
tumors, 4 (3.70%) germ cell tumors, 3 (2.78%) mixed
epithelial-mesenchymal tumors and 20 (18.52%) metastatic ovarian cancer. The average age of patients
was 56.66 ą 13.23 g. The disease was usually diagnosed in FIGO stage IA at 32.95%, FIGO IIIC at
20.45%, while in the other stages is significantly less.
Conclusion: The most common histological type
of ovarian cancer in the analyzed material are epithelial malignant tumors, usually diagnosed in FIGO
stage IA.
Key words: Ovarian cancers, TNM classification, metastatic ovarian cancer.
627
P34
Diferencijalna dijagnostika
džinovskih mnogojedarnih ćelija u
Papanikolau - brisu
Differential Diagnostics of
Multinucleated Giant Cells in the
Papanicolau Smear
Dušan Lalošević1, Milana Panjković2, Marko
Maksimović3, Jovan Maksimović4
Dusan Lalosevic1, Milana Panjkovic2, Marko
Maksimovic3, Jovan Maksimovic4
1Medicinski
2Institut
fakultet i Pasterov zavod Novi Sad, Srbija
za plućne bolesti Vojvodine, Sremska Kamenica,
Srbija
3Klinika za ginekologiju i akušerstvo Vojvodine, Novi Sad,
Srbija
4Ginekološka ambulanta ”Maksimović”, Novi Sad, Srbija
Cilj: Cilj istraživanja je komparacija citološke i
histološke slike džinovskih mnogojedarnih ćelija u
Papanikolau (Papa) brisu i biopsiji grlića materice.
Uvod: Nalaz mnogojedarnih džinovskih ćelija ukazuje na granulomatozno zapaljenje. Mnogojedarne džinovske ćelije mogu biti dva tipa, Langhansove i oko
stranog tela. Međutim, naročito u citološkom razmazu
je teško razlikovati ova dva tipa ćelija. U Papa-brisu
grlića materice taj nalaz je vrlo redak, kao i granulomatozni cervicitis. Bethesda vodič pominje mnogojedarne džinovske ćelije kod starijih žena kao ćelijsku promenu povezanu sa starenjem. Brojna patološka stanja
mogu biti povezana sa mnogojedarnim džinovskim ćelijama u Papa-brisu, ali takođe mogu da imitiraju karcinom ili da budu povezana sa karcinomom. Razmotreni
su etiološki faktori granulomskog cervicitisa, tuberkuloza, talk-granulomi, ceroid granulomi, amebijaza, šistozomijaza, sarkoidoza, Crohn-ova bolest, spirala, kao
i granulomi oko stranog tela.
Materijal i metode:Analizirani su Papa-brisevi i
komparirani sa biopsijskim uzorcima grlića materice.
Od pregledanih 500 Papa-briseva, džinovske mnogojedarne ćelije su nađene samo u jednom slučaju.
Rezultati: Prikaz slučaja.- Pacijentkinja stara 61 godinu, u menopauzi 6 godina, pregledana je u ginekološkoj ambulanti, kada je konvencionalni Papa-bris interpretiran kao diskariotičan. U ponovljenom razmazu vidjena je atrofija, brojni leukociti i džinovske mmnogojedarne ćelije. Nakon toga, urađena je biopsija cerviksa i nađen atrofični cervicitis sa granulomima oko hirurškog konca. Pacijentkinja je imala dve trudnoće od
kojih je poslednja završena sa ginekološkom operacijom pre 32 godine.
Zaključak: Granulomi na hirurški konac posle više od 30 godina od operacije su jako neobičan nalaz, te
je za razjašnjenje pojave džinovskih mnogojedarnih ćelija u Papa-brisu bila potrebna biosija grlića materice.
Ključne reči: Papa-bris, džinovske mnogojedarne
ćelije, granulomi, konac
628
1Faculty
of Medicine and Pasteur Institute of Novi Sad,
Hajduk Veljkova 1, Serbia
2Institute for Pulmonary Diseases of Vojvodina, Sremska
Kamenica, Serbia
3Clinic of Obstetrics and Gynecology of Vojvodina, Novi Sad,
Serbia
4Gynecological clinic “Maksimovic,” Novi Sad, Serbia
Aim:The goal of this study is comparison of cytological and histological pictures with multinucleated giant
cells in Papanicolau (Pap) smear and cervical biopsy.
Introduction: Finding of multinucleated giant
cells strongly suggest a granulomatous inflammation. Multinucleated giant cells may be presented as two
types, Langhans and foreign body giant cells. However,
especially in smears, it is difficult to distinguish these two types of cells. In Pap smears of uterine cervix
this finding is very rare, as well as granulomatous cervicitis. Bethesda manual mentioned multinucleated giant cells in older women as age-related cellular changes. Numerous pathological conditions may be associated with multinucleated giant cells, but also these cells
can mimic cancerous changes in Pap smear and may be
associated with carcinoma. Etiological factors of granulomatous cervicitis are discussed such as tuberculosis, talc-granuloma, ceroid granuloma, amoebiasis, schistosomiasis, sarcoidosis, Crohn disease, contraceptive intrauterine device, and foreign body granulomas.
Material and Methods: Analysis of Pap smears
was performed and compared with conventional biopsies of uterine cervix. Among 500 examined Pap smears, the giant multinuclear cells were found in one case.
Results:Case report.-Female aged 61, 6 years in menopause, was seen in the outpatient gynecology clinics
when conventional Pap smear was interpreted as abnormal with dyscaryosis. In repeated smear, atrophy, many
leukocytes, and multinucleated giant cells were found.
After that, cervical biopsy was performed and chronic
atrophic cervicitis with surgical suture granulomas were
found. Patient had two pregnancy and last one 32 years
ago was finished with gynecologic operation.
Conclusion:Postsurgical granulomas after more than
30 years are very unexpected finding and need biopsy
to resolve Pap smear with giant cells.
Key words: Pap smear, giant multinuclear cells, suture granulomas.
P35
Kombinovani granulosa cell tumor i
mucinozni cistadenom jajnika
Danica Jovanović1, Neda Drndarević1, Popovic Marija2,
Stojadinovic Vladimir2
1Poliklinika
Beo-Lab Beograd,SR Srbija
2Zdravstveni centar Užice, Užice, Srbija
Cilj: Želimo da prikažemo kombinovani tumor
jajnika koji se retko javlja i za koga postoji veoma
malo podataka u literaturi.
Uvod: U literaturi je objavljen mali broj slucajeva kombinovanog tumora jajnika (adult granulosa
cell tumor-AGCT et cystadenoma mucinosum ovarii). Teorije histogeneze uključuju kolizioni tumor i
heterologu mucinoznu diferencijaciju unutar AGCT.
Materijali i metode: Prikazujemo neuobičajeni
tumor jajnika kod pacijentkinje stare 53 g. kod koje je ultrazvučnim pregledom utvrden multicistični
tumor levog jajnika, prečnika 80mm.Hiruški odstranjen tumor bio je promera 90x80x70mm, glatke i sjajne površine, na reseku multicisticnog izgleda, mestimično ispunjen mucinoznim sadrž ajem.
Sa različitih mesta uzeto je 7 isečaka za mikroskopsko ispitivanje koji su obojeni HE metodom.
Reprezentativni isečak iz tumora obojen je imunohistohemijskom metodom za CK7, CK20, a-inhibin i calretinin.
Rezultati: Mikroskopskim ispitivanjem ustanovljen je tumor koga grade dve komponente intimno
povezane jedna sa drugom. Jednu komponentu gradi mešovit mucinozni epitel endocervikalno-intestinalnog tipa na unutrašnjoj strani cisticnih prostora,
difuzno CK7 i fokalno CK20 . Druga komponenta,
granuloza ćelijski tumor, se nalazi odmah ispod epitelne, pozitivna za a-inhibin i calretinin
Zaključak: Intimna povezanost obe komponente ide u prilog teoriji da je mucinozna komponenta
verovatno heterologa mucinozna diferencijacija unutar granulozo ćelijskog tumora.
Ključne reči: Jajnik, cistadenom, granulozoćelijski
tumor
Combined adult granulosa cell tumor
and mucinous cystadenoma of the
ovary
Danica Jovanovic1, Drndarevic Neda1, Marija Popovic2,
Vladimir Stojadinovic2
1Polyclinic
2Health
Beo-Lab Belgrade, Serbia
Center Uzice, Uzice, Serbia
Aim: We would like to describe the combined
ovarian tumor that rarely occurs,and for wich there
is a few data in the literature.
Introduction: Only few cases of combined ovary
tumor (adult granulosa cell tumor-AGCT et mucinosum cystadenoma ovarii) have been described and reported in the literature Theories of histogenesis include a collision tumor and heterologous mucinous differentiation within an AGCT.
Material and Methods: We herein report a rare tumor of the ovary of the 53-year old woman.
Ultrasound examination showed a multicystic tumor
mass in the left ovary, 80 mm in diameter.
Surgically removed tumor diameter measuring
90x80x70mm, with smooth and glossy surface.
Cross-section revealed multicystic appearance, sporadically filled with mucinous content. Samples were taken from seven different sites, for microscopic
examination, stained for routine histology (HE). Only
representative specimens were immunostained for
CK7, CK20, a-inhibin and calretinin.
Results: Microscopically, the tumor was composed of two components that were intimately intermingled. One component was composed of mixed mucinous epithelium of endocervical-intestinal type that lined the inner side of cystic area, diffusely positive for
CK7 and focally immunoreactive for CK20. The other
was a granulosa cell tumor, just below the epithelial component, positive for a-inhibin and calretinin
Conclusion: The intimate admixture of both components supports the theory that the mucinous component is probably heterologous mucinous differentiation within the adult granulosa cell tumor.
Key words: Ovary, cystadenoma, granulosa cell
tumor
629
P36
Prognostički značaj humanog
horionskog gonadotropina i korelacija
sa morfološkim parametrima kod
gestacijskih trofoblastnih bolesti
Prognostic significanse of human
chorionic gonadotrophin and its
correlation with morphology in
gestational trophoblastic diseases
Jelena Amidžić 1, Mihaela Mocko-Kaćanski 1, Matilda
Đolai1, Aleksandra Levakov 1, Mileva Orelj- Popić,
Jelena Amidzic1, Mihaela Mocko-Kacanski1, Matilda
Đolai1, Aleksandra Levakov1, Mileva Orelj- Popic2
Cilj: Prikaz vrednosti humanog horionskog gonadotropina (ßHCG) u serumu i patohistoloških karakteristika kod gestacijskih trofobasnih bolesti, uz procenu
njihove zastupljenosti.
Uvod: Gestacijske trofoblastne bolesti, kao retke
komplikacije trudnoce, obuhvataju oboljenja kod kojih
je prisutna neadekvatna proliferacija tkiva trofoblasta.
Mogu imati različito biološko ponašanje, od benignih
stanja kao što su hidatidne mole (parcijalna i kompletna) i invazivna mola do ređih ali izuzetno agresivnih
horiokarcinoma i tumora ležišta posteljice. Zajednička
karakteristika ovih lezija je da dovode do porasta nivoa
ßHCG-a u krvi, koji je bitan pokazatelj u dijagnostici,
prognozi i praćenju učinka terapije.
Materijal i metode: U istraživanje je uključeno 30
pacijentkinja, starosti od 16 do 49 godina, kod kojih
je u Centru za patologiju i histologiju Kliničkog centra Vojvodine, u periodu od 2009 do 2011, na osnovu
patohistološkog pregleda dijagnostikovana gestacijska
trofoblasna bolest, a za koje postoje kompletni klinički
i patohistološki podaci.
Rezultati: Patohistološkim pregledom odabranih
pacijentkinja dijagnostikovano je: 16 parcijalnih hidatidnih mola (53,33%), 10 kompletnih hidatidnih mola
(33,33%), 2 invazivne hidatidne mole (6,67%), 1 horiokarcinom (3,33%) i 1 trofoblastni tumor posteljičnog
ležišta (3,33%). Srednja vrednost ßHCG-a je kod parcijalnih mola bila 99212 mIU/ml, kod kompletnih mola 230070 mIU/ml, kod invazivnih mola 570150 mIU/
ml, a kod horiokarcinoma 290000 mIU/ml. Kod pacijentkinje sa trofoblastnim tumorom posteljičnog ležišta
nisu nađene povišene vrednosti ovog hormona.
Zaključak: Gestacijske trofoblastne bolesti se najčešće javljaju u reproduktivnom periodu žene, sa najvećom incidencom javljanja hidatidnih mola. Nivo ßHCG-a u krvi može ukazati na biološko ponšanje jer se naglašeno povišene vrednosti nalaze kod agresivnijih formi bolesti.
Ključne reči: gestacijske trofoblastne bolesti, ßHCG
Aim: Correlation of human chorionic gonadotrophin (hCG) values with histopathological features
in gestational trophoblastic diseases (GTD).
Introduction: GTD as uncommon complications of
pregnancy, encompass group of diseases with abnormal proliferation of trophoblast. They include the benign condition such as hydatidiform mole (both partial
and complete), invasive mole and malignant tumours
such as choriocarcinoma and placental site trophoblastic tumour. A common feature of all of these trophoblastic lesions is production of hCG, which is used
as an important marker for estimating presense, prognosis and adequate therapy of disease.
Material and methods: The study population consists of 30 patients (16 to 49 years), with the GTD diagnosed on histological examination of endometrial
curettage in the Pathology and Histology Centre of
Clinical Centre of Vojvodina, from 2009 to 2011. Only
patients with complete medical history were selected
for the study.
Results: Among patients, 16 partial hydatidiform
moles (53.33%), 10 complete hydatidiform moles
(33.33%), 2 invasive moles (6.67%), 1 choriocarcinoma (3.33%) and 1 placental site trophoblastic tumour (3.33%) were diagnosed. Following average serum hCG levels were found: 99212 mIU/ml in patients
with partial hydatidiform moles, 230070 mIU/ml with
complete hydatidiform moles, 570150 mIU/ml with invasive moles, 290000 mIU/ml with choriocarcinoma.
Elevated values of this hormone were not found in patient with placental site trophoblastic tumour.
Conclusion: The majority of GTD occur in generative period, with the highest incidence of mollar pregnaces. Biological behavior can be predicted by serum
levels of hCG, as higher levels are assosiated with an
aggressive forms of disease.
Key words: gestational trophoblastic disease, hCG
1Centar
za patologiju i histologiju, Klinički centar Vojvodine,
Novi Sad, Srbija
2Klinika za ginekologiju i aku erstvo, Klinički centar
Vojvodine, Novi Sad, Srbija
630
1Pathology
and histology centre, Clinical Centre of Vojvodina,
Novi Sad, Serbia
2Clinic of Gynecology and Obstetric,Clinical Centre of
Vojvodina, Novi Sad, Serbia
P37
Korelacija Papanicolau testa sa
atipičnim skvamoznim ćelijama
neodređjenog značaja (ASCUS) i
patohistoloških nalaza
Correaltion between PAP smear
with atypical squamous cells
of undetermined (ASCUS) and
pathohystological findings
Jasmina Atanacković1, Svetlana Milenković1, Biljana
Kastratović- Kotlica2, Milena Mitrović2
Jasmina Atanackovic1, Svetlana Milenkovic1, Biljana
Kastratovic- Kotlica2, Milena Mitrovic2
1Služba
za patohistologiju, Klinički centar Srbije, Beograd, Srbija
za ginekologiju i akušerstvo, Klinički centar Srbije,
Beograd, Srbija
2Klinika
Cilj: Sagledavanje primenjenih morfoloških kriterijuma u citološkoj analizi PAP testa sa atipičnim
skvamoznim ćelijama i njihovo poređenje sa patohistološ kim nalazima, kao zlatnim standardom u
dijagnostici
Uvod: U interpretaciji cervikovaginalnih briseva se koristi numerička PAP klasifikacija, a od
1988. deskriptivna Bethesda klasifikacija, koja uvodi termin atipične skvamozne ćelije neodređenog
značaja-ASCUS. ASCUS se karakteriše citološkim
promenama koje upućuju na skvamozne lezije lakog stepena - L-SIL, ali su kvalitativno i kvantitativno nedovoljne za svrstavanje u L-SIL kategoriju.
Zastupljenost ASCUS je do 5% u referentnim citološkim laboratorijama.
Materijal i metode: U periodu 2008-2009. na
Klinici za ginekologiju i akušerstvo KCS, ukupno je
urađeno 13666 PAP testova, na konvencionalan način,
a bojenih klasičnom Papanicolau metodom. Biopsije
grlića materice sa kiretažom cervikalnog kanala su rađene u slučaju da se ASCUS ponavlja na kontrolnim
pregledima više od dva puta ili ako je udružen sa atipičnom kolposkopijom. Biopsijski materijal je fiksiran u 4% puferisanom formalinu, klasično obrađen,
sečen na 5 mikrona i bojeni HE metodom.
Rezultati: Od ukupno analiziranih 13666 PAP
testova 440 je interpretirano kao ASCUS (3,22%).
Biopsije su urađenje kod 108 pacijenkinja sa ASCUS
i dobijeni su sledeci patohistološki rezultati: 24
(22,22%) H-SIL, 19 (17,59%) L-SIL, 34 (31,48%)
skvamozne metapalazije, 13 (12,03) hiper i parakeratoze, 10 (9,27%), polipa cerviksa i 8 (7,41%) cervicitisa.
Zaključak: Histološka zastupljenost H-SIL od
22,22% nakon ASCUS u odnosu na literaturne podatke od 17,20% se može objasniti time što se kod
nas citološka atipija tipa ASCUS ako je udružena sa
promenama u kolposkopskoj slici odmah bioptira
Ključne reči: Atipične ćelije, PAP test, ASCUS
1Department
of Pathology, Clinical center Srbia, Belgrade,
Serbia
2Clinic of Gynecology and Obstetric,Clinical Centre Serbia,
Belgrade, Serbia
Aim: Perceiving morphological criteria used in
cytological analysis of PAP test with atypical squamous cells and correlation with patohystological findings as golden standard in diagnostic.
Introduction: PAP classification is used as a numerical method in interpretation of cervicovaginal
smears. Since 1988. descriptive Bethesda classification introduces term of atypical squamous cells of
undetermined signifinace-ASCUS. ASCUS is based
on cytological changes that direct to squamous cells
of low-grade aquamous lesions (L-SIL), but their quality and quantity are insufficient to be classified as
L-SIL category
Material and methods: During one year period
(2008. to 2009.) 13666 PAP smears were analysed
in Clinic of gynecology and obstetrics in Belgrade,
using conventional Papaniclolau method. Cervical
biopsies with endocervical curettage were performed in cases when ASCUS was repeated more than
two times or was connected with atypical colposcopic findings. Biopted material was fixed in 4% buffered formalin, classicly processed, cut in leyers of
5 microneand coloured with HE method
Results: From total number of 13666 analiesed PAP smears 440 were interpreted as ASCUS
(3.22%) with the following patohystological results:
24 (22.2%) H-SIL, 19 (17.59%) L-SIL, 34 (31.48%)
squamous metaplasia, 13 (12.03%) hyperkeratosis
and parakeratosis, 10 (9.27%) endocervical polyps
and 8 (7.41%) cervical inflammation.
Conclusion: There are more frequent results of
H-SIL (22.22%) after ASCUS findings. It can be
explained with doing immediate biopsy in all the cases when atypical colposcopic findings are connected with ASCUS
Key words: Atipical cells, PAP test, ASCUS
631
P38
Morfološki sistem bodovanja u
preoperativnoj diferencijaciji
neoplazmi jajnika kod devojčica i
adolescentkinja
Slaviša Đuričić, Zoran B. Stanković, Dragana Stanković,
Đorde Savić, Katarina
Sedlecki – Akugin
Institut za zdravstvenu zaštitu majke i deteta Srbije “Dr Vukan
Čupić”, Beograd, Srbija
Cilj: Procena kliničkog znacaja Uelandovog morfološkog sistema bodovanja u predvidanju osnovnih
patohistoloških kategorija neoplazmi jajnika kod devojčica i adolescentkinja.
Uvod: Korisnost Uelandovog morfološkog sistema bodovanja u predvidanju patohistoloških kategorija neoplazmi jajnika kod dece do danas je nedovoljno ispitana.
Materijal i metode: Statističkim metodama analize procenjivana je povezanost Uelandovog indeksa
i histoloških kategorija neoplazmi jajnika kod devojčica i adolescentkinja operisanih u periodu od januar
1997.-decembar 2006. godine. Evaluiran je i prediktivni značaj serumskih tumorskih markera.
Rezultati: Kod 153 devojčice (uzrasta 6 meseci-19
godina) odstranjeno je 160 tumora jajnika, uključujući 7 bilateralnih. Od toga su 43 devojčice bile u premenarhalnom dobu. Prema patohistološ kom nalazu
kod 62 devojčice radilo se o neneoplastičnim lezijama, kod 68 tumori su bili benigni, kod 30 maligni ili
granične malignosti. Stadijumi maligne bolesti bili su:
I stadijum 18, II 5, III 7 devojčica. Senzitivnost, pozitivna prediktivna vrednost i tačnost Uelandovog indeksa za benigne tumore (skor <7), iznosila je: 0,94,
0,84 i 0,93. Povišen nivo tumorskih markera nađen
je kod 64 pacijentkinje, uključujuci 43 sa benignim
tumorima. Kod 120 pacijetkinja sačuvan je deo neoštećenog tkiva jajnika. U odnosu na sistem bodovanja
tkivo jajnika je sačuvano kod 103 od 109 jajnika sa
Uelandovim skorom =6 i kod 17 jajnika sa skorom =7.
Zaključak: Morfološki sistem bodovanja na
osnovu ultrazvučne analize preporučen od Uelanda
veoma je pouzdan metod za preoperativno razlikovanje benignih od malignih tumora jajnika devojčica
i adeolescentkinja. Tumorski serumski markeri mogu biti korisni u preoperativnoj proceni tumorskog
uvećanja jajnika.
Ključne reči: jajnik, neoplazma, devojčice, adolescencija, sistem bodovanja
632
Morphological scoring system in
preoperative differentiation of
pediatric and adolescence ovarian
tumors
Slavisa Djuricic, Zoran B. Stankovic, Dragana
Stankovic, Djordje Savic, Katarina Sedlecky - Akugin
Mother and Child Health Institute of Serbia, Belgrade, Serbia
Aim: To asses the clinical relevance of Uelands
morphological scoring system in prediction of histopathological categories of ovarian neoplasms in childhood and adolescence.
Introduction: The utility of morphological scoring system in differentiation of main histopathological categories of ovarian neoplasms in childhood
is unquestioned by now.
Material and methods: Morphological assessment using Uelands index were performed for all
patients with histopathological confirmation of ovarian tumor, with evaluation of tumor markers, from
January 1997.-Decembar 2006.
Results: 153 girls (age range 6 months-19 years) were surgically treated for 160 ovarian tumors,
including 7 bilateral. 43/153 girls were in premenarchal period. Histopathology report described 62
non-neoplasms, and 68 benign and 30 malignant neoplasms. Stages of malignant disease were distributed as follows: stage I, 18, stage II, 5, stage III, 7.
Sensitivity, positive predictive value and accuracy
by Ueland s index for benign tumors (score <7) was:
0.94, 0.84, 0.93, respectively. Elevated levels of tumor markers were observed in 64 patients, including
43 with benign tumors. In 120 girls some part of ovarian tissue were preserved during surgery. Depending
on the Ueland s scor we preserved 103/109 ovaries
with score =6 and 17/44 ovaries with score =7.
Conclusion: Ultrasonographic assessment using
morphological analysis and scoring system recommended by Ueland is a very useful procedure
for differentiating benign from malignant ovarian
tumors in children and adolescents. Tumor markers
and endocrinological investigation may also be useful for preoperative evaluation.
Key words: ovary, neoplasm, girls, adolescence, scoring system
P39
Tumori germinativnih ćelija jajnika u
dečjem uzrastu: 35 - godišnji period
Ovarian germ cell tumors of
childhood: 35 years period
Milena Đukić, Gordana Samardžija, Slaviša Đuričić
Milena Djukic, Gordana Samardzija, Slavisa Đuricic
Cilj: Utvrditi epidemiološke i patohistološke karakteristike TGC jajnika u dečijem uzrastu.
Uvod: Tumori germinativnih ćelija jajnika (TGC)
su retki u ranom dečijem uzrastu, ce ce se pojavljuju
u pubertetskom periodu, to se objašnjava hormonalnim fiziološkim promenama. TGC čine više od 50%
svih tumora jajnika i oko 25% svih teratoma u dečijem uzrastu, većinom su benigni teratomi sa dobrom
prognozom. Najčešći maligni tumori u jajniku su disgerminom i tumor žumančane kese.
Materijal i metode: Retrospektivna analiza epidemioloških i patohistoloških karakteristika TGC jajnika u dečjem uzrastu (0-18 godina) operisanih u
Institutu za zdravstvenu za Institutu majke i deteta
Srbije u 35.godišnjem periodu (1976-2011).
Rezultati: U analizu je uključeno 88 bolesnika sa
TGC jajnika. Uzrast pri operaciji bolesnika za benigne teratome je između 32-216 meseci, srednja vrednost (SD) 146,6±50,1, za nezrele teratome između
59-210, SD 149,2±50, a za maligne tumore između 12-216, SD 137,2ą50,4. U svim uzrasnim grupama dominiraju benigni teratomi 55 (62,5%), sa vrhom učestalosti oko puberteta, zatim slede maligni
TGC 23 (26,1%) i nezreli teratomi 10 (11,4%), koji
su cešći u prepubertalnom periodu. Najčešć maligni
TGC su maligni mešoviti tumori 8 (34,8%) i disgerminomi 7 (30,4%).
Zaključak: TGC jajnika u ranom dečijem uzrastu
su retki, najviše je benignih teratoma, dok su ređi maligni tumori, sa predominacijom mešovitih malignih
tumora i disgerminoma. Najređi su nezreli teratomi.
Ključne reči: jajnik, tumori germinativnih celija,
dečiji uzrast, epidemiologija, histopatologija
Aim: The aim of the study was to determine the
epidemiologic and histopathologic characteristics of
ovarian GCT in childhood.
Introduction: Ovarian germ cell tumors (GCT)
are rare in early childhood. They appear more often
in puberty, which is explained by physiological hormonal changes. GCT represent more than 50% of all
ovarian tumors and approximately 25% of all teratomas in childhood, most of which are benign teratomas
with a good prognosis. Most common malignant ovarian tumors are dysgerminoma and yolk sac tumor.
Material and methods: Retrospective analysis of
epidemiologic and histopathologic features of ovarian
GCT in children (0-18 years) operated at the Mother
and Child Health Care Institute of Serbia in the period of 35 years (1976-2011).
Results: The analysis included 88 patients with
ovarian GCT. Age at surgery for benign teratoma
is 32-216 months, mean age (SD) 146.6 ą 50.1, for
immature teratoma 59-210 months, SD 149.2 ą 50.1,
for malignant tumors 12-216 months, SD 137.2 ą
50.4. In all age groups, benign teratomas dominate 55 (62.5%), with peak incidence around puberty,
followed by malignant GCT 23 (26.1%) and immature teratomas 10 (11.4%), which are more common
in prepuberty period. The most common malignant
GCT are malignant mixed 8 (34.8%) and dysgerminoma 7 (30.4%).
Conclusion: Ovarian GTC in early childhood
are rare, being mostly benign teratomas. Malignant
tumors are rare, with a predominance of mixed tumors and dysgerminoma. The rarest are immature
teratomas.
Key words: ovary, germ cell tumors, childhood,
epidemiology, histopathology
1Institut
za zdravstvenu za titu majke i deteta Srbije “Dr Vukan
Mother and Child Health Care Institute of Serbia “dr Vukan
Cupic”, Belgrade, Serbia
633
P40
Uzroci spontanog pobačaja na nivou
placente i pupčane vrpce
Causes of miscarriage at the level of
placenta and umbilical cord
Jovanka Trifunović, Petar Noack, Kristina Noack,
Hristina Djordjević, Momčilo Ristanovic, Mladjen
Veselinovic, Nebojsa Jovčić
Jovanka Trifunovic, Petar Noack, Kristina Noack,
Hristina Djordjevic, Momcilo Ristanovic, Mladjen
Veselinovic, Nebojsa Jovcic
Cilj : Ispitati učestalost patoloških promena na posteljici i pupčanoj vrpci koji su najčešci uzrok spontanog pobačaja.
Uvod: Spontani pobačaj je neželjeni prekid trudnoće, pre nego što je plod sposoban za vanmaterični
život. Uzroci mogu biti od strane majke ili na nivou
fetusa. Promene placente mogu biti uzrokovane poremećajem cirkulacije majke, poremećajima fetalnog
krvotoka i ostalim nevaskularnim lezijama. Najčešće
malformacije pupčanika su vezane za dužinu.
Materijal i metode: Naše ispitivanje predstavlja
retrospektivnu studiju kojom su obuhvaćena oba pola
fetusa u drugom i trećem trimestru trudnoće.Uzorak
obuhvata 60 protokola koji su uzeti sa Instituta za
Patologiju.
Rezultati: Zastupljenost polova bila je 33 muških
fetusa (55%) i 27 ženskih fetusa (45%). Razlika u starosti među polovima nije statistički značajna p=0.222
(p>0.05). Promene na placeti su bile prisutne u 52 slučaja a na pupčaniku u 8 slučajeva. Poremecaji placente kao uzrok spontanog pobačaja su češći jer se
mogu javiti u drugom i trećem trimestru, dok su pobačaji uzrokovani patološkim promenama pupčanika uglavnom ograničeni na zadnji trimestar. Najčešće
promene na placenti su bile: infekcije, infarkt placente, abrupcija placente, placenta previa. Od malformacija pupčanika najviše prisutni su čvorovi koji nastaju usled dugačkog pupčanika.
Zaključak: U ovom ispitivanju smo pokazali
da poremećaji na nivou placente u odnosu na poremećaje na pupčaniku češće dovode do pobačaja.
Najčešći uzrok spontanog pobačaja na nivou placente je infekcija.
Ključne reči: placenta,pupčanik,spontani
pobačaj,učestalost
Aim: Examine the frequency of pathological
changes in the placenta and umbilical cord which
are the most common cause of spontaneous abortion.
Introduction: Spontaneous abortion is the unwanted termination of pregnancy, before the fetus is capable for extrauterine life. Spontaneous abortion may be
caused by mother or fetus. Changes of placenta may
be caused by the mother’s circulatory disorder, fetal
circulatory disorders or other non-vascular malformations. The most frequent umbilical cord malformacion are connected to length.
Material and methods: Our examination is retrospective study and it s covering both sexes of fetus in the second and third trimester of pregnancy .
Sample includes 60 protocols.
Results: Gender was 33 male fetuses (55%) and
27 female fetuses (45%). The difference in age between the sexes was not statistically significant p = 0,222
(p> 0.05). Changes in placenta were present in 52 cases and the umbilical cord in 8 cases. Disorders of
the placenta as a cause of spontaneous miscarriages
are more common because it may occur in the second
and third trimester, while the pathological changes of
umbilical cord usually are limited to the last trimester
The most common changes on placentawere: infection, infarction of the placenta, abruption of placenta, placenta previa .The most common malformations of umbilical cord are nodes that result from long
umbilical cord.
Conclusion: In this study we showed that disturbances at the level of the placenta in relation to the
umbilical cord disorders often leads to abortion. The
most common cause of spontaneous abortions at the
level of the placenta is an infection.
Key words: placenta, umbilical cord, spontaneous abortion, fequency
Vojnomedicinska Akademija, Beograd, Srbija
634
Medical Military Academy, Belgrade, Serbia
PATOLOGIJA DOJKE
BREAST PATHOLOGY
P42
Primarni sitnoćelijski karcinom
dojke: dijagnostička dilema
Primary small cell breast carcinoma :
diagnostic dilemma
Nenad Rsovac, Snežana Vatričević, Zoran Babić
Nenad Rsovac, Snzana Vatricevic, Zoran Babic
Cilj: Predstavljanje našeg iskustva u dijagnostici
primarninog sitnoćelijskog karcinomom dojke
Uvod: Primarni sitnoćelijski karcinom dojke je
redak tumor. Prikazujemo primarni tumor leve dojke kod žene stare 45 godina, klinički prezentovan
kao palpabilna, brzo rastuća tumorska masa, sa pozitivnim limfnim čvorovima u aksili. Radiografski i
ultrazvučno nisu viđeni primarni ili sekundarni tumori izvan dojke.
Materijal i metode: HE, CD117,EMA, CD99,
S-100, NSE, vimentin, HMB45, CD34, CD68, hromogranin A, LCA, CK, sinaptofizin
Rezultati: Na H&E preparatima viđen je maligni epitelni tumor koji pokazuje visoku atipiju malih
do srednjih ćelija, sa slabo granuliranom ili agranuliranom citoplazmom i brojnim mitozama, koji raste
u formi gnezda, međusobno razdvojenih tankim vezivnim septama, a mestimično rasporedjenih u vidu
traka, sa poljima opsežne nekroze i invazijom limfatika. Imunohistohemijski utvrđena je pozitivnost na
CD117, EMA, CD99, kao i delimična pozitivnost
na NSE. Negativni su bili vimentin, HMB45, CD34,
CD68, hromogranin A, LCA, hormondki receptori
ER i PR kao i HER2. CK i sinaptofizin su pokazali
pozitivnost u različitim delovima tumora.
Zaključak: Diferencijalno dijagnostički smo razmatrali invazivni lobularni karcinom dojke sa delovima koji pokazuju neuroendokrinu diferencijaciju,
primarni sitnoćelijski neuroendokrini karcinom dojke ili mešoviti tumor (isprepletanost sitnoćelijske
komponente sa lobularnim karcinomom), to se prema podacima iz literature sreće u oko 40% slučajeva.
Ključne reči: sitnoćelijski karcinom dojke
Aim: Presentation of our experience in diagnostics of primary small call breast carcinoma
Introduction: Primary small cell breast carcinoma is a rare tumor. We present primary left breast tumor in 45 old woman clinically presented as rapidly
growing tumor mass with positive axillary lymph nodes. Radiographic and ultrasound findings were negative for other primary or secondary tumor.
Matherial and methods: HE, CD117,EMA,
CD99, S-100, NSE, vimentin, HMB45, CD34, CD68,
chromogranin A, LCA, CK, sinaptophyisin
Results: HE revealed malignant epithelial tumor
with high atypia of small to medium cells, with poorly granulated or agranulated cytoslasm and numerous mitotic figures, which grows in form of nests
separated with thin fibrous septa, partly arranged
in bundles with huge necrotic zones and lymphatic invasion. Immunohistochemicaly we found positivity for CD117, EMA, CD99, S-100 and partly
NSE. Negativity was recorded for vimentin, HMB45, CD34, Cd68, chromogranih A, LCA, hormon receptors ER i Pr as well as HER2. CK and sinaptophysin was positive in different areas of tumor.
Conclusion: In differential diagnostics we discussed invasive lobular breast carcinoma with neuroendocrine differentiation, neuroendocrine breast tumor or mixed tumor ( small cell carcinoma intermingled with lobular carcinoma) which are reported in
about 40% of cases.
Key words: small cell, breast carcinoma.
Služba patologije, Zdravstveni centar “Studenica”, Kraljevo,
Srbija
Department of Pathology, Health Center “Studenica”,
Kraljevo, Serbia
635
P 43
Bilateralni karcinom dojke –prikaz
slučaja
Boris Dobrojević1, Gordana Mitrović2, Milica Mijović1
1Opšta
bolnica, Brčko Distrikt, BiH
za patologiju, Medicinski fakultet Priština-Kosovska
Mitrovica, Srbija
2Institut
Cilj: Prikazujemo slučaj BKD kod 86-o godišnje žene.
Uvod: Bilateralni karcinom dojke (BKD) se retko
javlja. Njegova incidenca je od 0,3 12%. Etiologija
BKD je nepoznata, ali većina dokaza upućuje da su
to nezavisni tumori, a ne metastaza primarnog karcinoma. Postoji velika neusaglašenost u vezi definicije kad je drugi tumor sinhroni, a kad metahroni.
Materijal i metode: Pacijentkinja je primljena
u bolnicu u januaru 2012. godine. Fizikalnim pregledom nađeni su egzulcerisani tumori na obe dojke, kao i uvećani limfni nodusi u levoj pazušnoj jami. Pacijentkinja u anamnezi navodi da je napipala
tumor na levoj dojci pre 13 godina, a na desnoj pre 7
do 8 godina. Odlukom onkološkog konzilijuma urađena je obostrana simplex mastektomija sa uklanjanjem limfnih nodusa iz leve aksile.
Rezultati: Makroskopski, tumor iz leve dojke egzulcerisan, loptasto nodularan, veličine 75x60x55mm,
beličaste boje, tvrd. Patohistološki postavljena je dijagnoza invazivnog duktusnog karcinoma, gradusa
II sa invazivnom mikropapilarnom komponentom i
DCIS visokog gradusa. U svih šest limfnih nodusa
nađene su metastaze i to mikropapilarne komponente. Tumor iz desne dojke egzulcerisan, loptasto nodularan, veličine 60x55x50mm, sivobeličaste boje, meki. Patohistološki postavljena je dijagnoza invazivnog
mucinoznog karcinoma (tip A). Imunohistohemijski
oba tumora su pozitivni za estrogene i progesteronske receptore, a HER2/neu negativni. O daljem tretmanu čeka se odluka onkolo kog konzilijuma.
Zaključak: Iako je BKD redak, uvek treba misliti na mogućnost nastanka karcinoma u kontralateralnoj dojci.
Ključne reči: bilateralni karcinom, dojka
636
Billateral brest cancer – case report
Boris Dobrojevic1, Milica Mijovic2, Gordana Mitrovic1
1General
Hospital, Brcko District, BiH
of pathology, Medical faculty Priština-Kosovska
Mitrovica, Serbia
2Institut
Aim: We report a case of BBC in 86-year-old
woman.
Introduction: Bilateral breast cancer (BBC) is rare. Its incidence is from 0.3 to 12%. BBC etiology is
unknown, but most evidence suggests that these are
independent tumors, rather than metastasis of primary tumor. There is a large discrepancy regarding
the definition of synchronous or metachronous appearing of second tumor.
Matherial and methods: The patient was admitted to the hospital in January 2012. By physical
examination, egzulcerans tumors in both breasts and
enlarged left armpits lymph nodes were found. The
patient was given information about existence of tumor in left breast during last 13 years and in right breast during last 7-8 years. By the decision of oncology
council a bilateral simple mastectomy with removal
of left armpits lymph nodes was made.
Results: Grossly, the tumor from left breast was
egzulcerans, globular nodular, size 75x60x55mm,
whitish, solid. Histopathological diagnosis was invasive ductal carcinoma, grade II with invasive
micropapillary component and high grade DCIS.
Metastases, dominantly of micropapillary component, were found in all six axillary lymph nodes.
Tumor from right breast was egzulcerans, globular
nodular, size 60x55x50mm, greyishwhite color, softer. Histopathological diagnosis was invasive mucinous cancer (type A). Immunohistochemically both
tumors were positive for estrogen and progesterone
receptors and HER2/neu negative. Further treatment
depends on the decisions of the council of oncology.
Conclusion: Although BBC is a rare, we should
always think of the possibility of cancer in the contralateral breast.
Key words: Key words: bilateral carcinoma,
breast
INFEKTIVNA PATOLOGIJA
P44
Imunohistohemijska analiza
aktiviranih stelatnih ćelija u akutnom
oštećenju jetre
INFECTIOUS DISEEASES
PATHOLOGY
Immunohistochemical analysis of
activated stellate cells in acutely
damaged liver
Nada Tomanović1, Dragan Delić2, Dimitrije Brašanac1,
Ivan Boričić1
Nada Tomanovic1, Dragan Delic2, Dimitrije Brasanac1,
Ivan Boricic1
2Institut
2Institute
1Institut
za patologiju, Medicinski fakultet, Beograd
za infektivne i tropske bolesti, Medicinski fakultet,
1Institute
of Pathology, Medical School, Belgrade
of Infectious and Tropical Diseases, Medical School,
Beograd
Belgrade
Cilj: U ovoj studiji ispitano je prisustvo aktiviranih stelatnih ćelija u akutnom oštećenju tkiva jetre.
Uvod: Nakon oštećenja tkiva jetre, stelatne ćelije se aktiviraju i transdiferenciraju u miofibroblastni fenotip imunoreaktivan na α-glatkomišićni aktin.
Materijali i metode: Retrospektivna studija obuhvatila je uzorke tkiva jetre 9 ispitanika (6 ženskog pola, prosečne starosti 43 godine i 3 muškog pola, prosečne starosti 38 godina) koji su umrli pod kliničkom dijagnozom fulminantnog hepatitisa na Institutu za infektivne i tropske bolesti (Medicinski fakultet Univerziteta
u Beogradu) tokom perioda od 6 godina. Uzorci tkiva
dobijeni su perkutanom iglenom (18-G) nekropsijom i
obrađeni na Institutu za patologiju (Medicinski fakultet
Univerziteta u Beogradu). Nakon standardnog hematoksilin-eozin bojenja, uzorci su bojeni imunohistohemijski na α-glatkomisicni aktin (DAKO, Carpenteria,
Ca, USA, razblaženje 1:100). Prisustvo aktiviranih stelatnih ćelija pozitivnih na α-glatkomišićni aktin evaluirano je u portalnim prostorima i u zonama nekroze.
U svrhu kontrole koristili smo 10 uzoraka tkiva jetre
u kojima nije bilo patoloških promena.
Rezultati: U kontrolnoj grupi, retke, pojedinačne
aktivirane stelatne ćelije bile su prisutne u portalnim
prostorima 7 uzoraka. U grupi ispitanika sa fulminantnim hepatitisom, kod 8 uzoraka je nađena panacinusna nekroza, a u jednom uzorku spojne nekroze
hepatocita. U svim uzorcima uočen je povećan broj
aktiviranih stelatnih celija u portalnim prostorima ali
u zonama nekroze.
Zaključak: U akutnom oštećenju jetre prisutan je
povećan broj aktiviranih stelatnih ćelija u portalnim
prostorima i u zonama nekroze, to se može objasniti ulogom ovih ćelija u remodeliranju ekstracelularnog matriksa i reparaciji.
Ključne reči: stelatne celije, akutno oštećenje
Aim: We investigated presence of activated stellate cells in acutely damaged liver tissue.
Introduction: Upon liver injury, stellate cells become activated and transdifferentiate into extracellular-matrix producing myofibroblasts immunoreactive for a-smooth muscle actin.
Material and methods: Liver tissue samples from
9 patients (6 female, mean age 43 years and 3 male,
mean age 38 years) that died under clinical diagnosis
of fulminant hepatitis at Institute for infectious and
tropical diseases during a 6 year period were included in this retrospective study. Samples were obtained post mortem, percutaneously, using 18-G needle and evaluated at Institute of pathology (Medical
Faculty, Belgrade University). After standard hematoxillin-eosin staining, samples were stained immunohistochemically for a-smooth muscle actin (DAKO,
Carpenteria, Ca, USA, dilution 1: 100). Presence of
activated stellate cells was evaluated in portal spaces and in areas of necrosis. As a control group we
used 10 samples of liver tissue that showed no evidence of histopathological changes.
Results: In control group, rare individual activated stellate cells were present in portal spaces of 7
samples. In fulminant hepatitis group, in 8 samples
there was panacinar necrosis and in one sample there was bridging hepatocyte necrosis. In all examined samples there was an increased number of activated stellate cells in portal spaces as well as in areas of necrosis.
Conclusion: In acutely damaged liver, increased
number of activated stellate cells is present in portal
spaces as well as in areas of necrosis
Key words: stellate cells, acute damage, liver
637
P45
Retke parazitoze u biopsijskom
i autopsijskom materijalu:
Ehinokokoza, dirofilarijaza,
enterobijaza
Ljiljana Đurdev1, Dušan Lalošević2
1
2
Opšta bolnica ‘’Dr Djordje Joanovic’’ Zrenjanin, Srbija
Pasterov zavod, Novi Sad, Srbija
Cilj: Opis morfologije retkih parazitoza ili retke
lokalizacije parazita.
Uvod: Multipna ehinokokoza kao uzrok epilepsije, akutnog infarkta miokarda, te smrtnog ishoda otkrivena tek na obdukciji, dirofilarijaza, novoregistrovana zoonoza kod nas i enterobijaza u adenomu debelog creva, predstavljaju jako redak nalaz te je potrebno poznavanje morfologije parazita. Za razliku
od hidatidnog ehinokoka poznatog po velikim cistama, multilokularni ehinokok daje sitne grozdaste ciste koje rastu kao maligni tumor i čak metastaziraju.
Materijal i metode: Materijal predstavlja obdukcioni nalaz kod slučaja ehinokokoze, kao i bioptički
materijal kod dirofilarijaze i enterobijaze.
Rezultati: Pacijent star 50 godina dobio je epileptični napad, akutni infarkt miokarda i pretkomornu fibrilaciju, te je sutradan preminuo. Na obdukciji
u predelu hilusa desnog pluća nalazi se više cisticnih
formacija do najvećeg precnika 7 cm, koje su delom
kalcifikovane, delom ispunjene kasastim sadržajem,
sa beličastom kapsulom, naležu na perikard, vršeći
spoljnu kompresiju srca. U desnoj hemisferi velikog
mozga nalazi se cista od 5 cm, a na slezini od 4 cm.
U drugom slučaju sa potkolenice u biopsji potkožnog
čvora su nađeni preseci parazita ženke Dirofilaria spp.
U adenomu debelog creva dvogodišnjeg deteta nađen je Enterobius vermicularis, to predstavlja anegdotsku lokalizaciju.
Zaključak: Nas slučaj je dijagnostikovan kao hidatidni ehinokok nalazom kukica parazita u cistama,
jer multilokularni kod čoveka ne razvija protoskolekse, pa prema tome ni kukice. Dirofilarija se identifikuje po karakteristicno naboranoj kutikuli kao i rasporedu unutra njih organa, kao i enterobijaza. Morfološka
identifikacija parazita u bioptičkom i autopsijskom
materijalu predstavlja i dalje standard u dijagnostici.
Ključne reči: patologija, ehinokokoza, dirofilarijaza, enterobijaza
638
Rare parasitic infections in biopsies
and autopsies: Echinococcosis,
dirofilariosis, enterobiasis
Ljiljana Djurdev1, Dusan Lalosevic2
1General
2Pasteur
Hospital Dr Đordje Joannovic Zrenjanin
Institute of Novi Sad, Serbia
Aim: To describe morphology of rare parasitic infections and their unusual localizations.
Introduction: Multiple echinococcosis as cause of epilepsy, acute myocarial infarction and letaly outcome diagnosed by autopsy, dirofilariasis,
newly registered zoonosis in Serbia, and enterobiasis in colon adenoma, are very rare finding that required knowledge of their morphology. Unlike hydatide Echinococcus, multilocular gives a small cluster
of cysts that grow like a malignant tumor, and even
metastasize.
Material and methods: Materials are autopsy case of echinococcosis, and biopsies from dirofilariasis and enterobiasis.
Results: Case reports. - 50 years-old patient was
given epileptic attack, myocardial infarction and atrial fibrillation, and died on the next day. At autopsy,
the right lung hilus consist several cystic formations
to the largest diameter of 7cm, which are partly calcified, partly filled mashy content, with white capsule. Cysts placed against the pericardium performing
external compression of the heart. In the right hemisphere of the brain was a cyst of 5 cm and at the spleen of 4 cm. The second case had hypodermic node
in the leg in biopsy identified as a female Dirofilaria
spp. In adenoma of the colon of two years child was
found Enterobius vermicularis, which is anecdotal
localization.
Conclusion: Our case was diagnosed as a hydatid Echinococcus by finding hooks in cysts, because multilocular in the man does not develop hooks.
Dirofilaria is identified by its characteristic cuticular ridges and structure of internal organs, and enterobiasis too. Morphologically identification of parasites in the bioptic and autopsy material is still standard in the diagnosis.
Key words: pathology, echinococcosis, dirofilariasis, enterobiasis.
KARDIOVASKULARNA
PATOLOGIJA
CARDIOVASCULAR
PATHOLOGY
P46
Apoptoza u virusnom miokarditisu
Apoptosis in viral myocarditis
Sofija Glumac1, Radmila Janković1, Zorica Stojšić1,
Milana Lazić1, Isidora Ranisavljević-Katuca2,
Jelena Marković2, Jovan D. Vasiljević1
Sofija Glumac1, Radmila Jankovic1, Zorica Stojsic1,
Milana Lazic1, Isidora Ranisavljevic-Katuca2,
Jelena Markovic2, Jovan D. Vasiljevic1
2Klinicki
2Department
Cilj: Cilj naučnog rada je da se odredi apoptotski
indeks (AI) kod pacijenata obolelih od VMK i ispita odnos AI kod različitih morfoloških oblika VMK.
Uvod: Virusni miokarditis (VMK) predstavlja zapaljensku infiltraciju srčanog mišića praćenu
oštećenjem kardiomiocita neishemijske etiologije.
Apoptoza je programirana smrt ćelije kojom se putem eliminacije neželjenih ćelijskih elemenata održava normalna gustina ćelijske populacije. Danas se
smatra da apoptoza ima značajnu ulogu u patogenezi različitih kardiovaskularnih oboljenja, kao što su
dilataciona kardiomiopatija, VMK, infarkt miokarda, srčana insuficijencija, itd.
Materijal i metode: Ispitivanjem je obuhvaćeno 30 bolesnika oba pola sa kliničkom dijagnozom
VMK, i to 13 žena (43.3%) i 17 muškaraca (56.7%).
Za postavljanje patohistološke dijagnoze VMK korišćena je modifikacija Dallas-ovih kriterijuma, a za
detekciju apoptoze TUNEL metoda.
Rezultati: Prosečne vrednosti AI u grupi od 30
pacijenata sa MK bile su 4,23 I 12,16 (Med=0,005).
U grupi ispitanika koji su imali fokalni VMK, AI je
iznosio 10,99, to je bila i najveća izmerena vrednost.
U grupi ispitanika sa healing VMK, AI je imao najnižu vrednost 1,55, a u grupi sa akutnim i borderline VMK, izmereni AI je iznosio 3,32, odnosno 3,40.
Zaključak: Naše istraživanje je pokazalo da je
najveća vrednost AI uočena kod fokalnog VMK, ali
da nije bilo statistički značajne razlike izmedu njega i
vrednosti AI kod ostalih stadijuma bolesti, kao ni kod
međugrupnog poredenja vrednosti AI. Naši rezultati
ukazuju na potrebu proširivanja istrazivanja na većem broju ispitanika, primenu dodatnih metoda, pored TUNEL metode, za detekciju apoptoze kod VMK.
Ključne reči: apoptoza, virusni miokarditis,
TUNEL metod
Aim: The aim of this study was to determine apoptotic index (AI) in patients with (VMC) and to compare the rate of AI in groupes with different morphological stages of VMC.
Introduction: Viral myocarditis (VMC) is an inflamatory disease of cardiac muscle that is associated
with non-ischemic cardiomyocyte injury. Apoptosis
is defined as programmed cell death which eliminates most of the damaged and non-functional cells,
managing the normal density of cell population in
human tissues. Apoptosis of cardiomyocytes has been reported to be involved in pathogenesis of cardiovascular diseases like infarction, VMC, heart failure.
Material and methods: Research included 30 patients with clinical diagnosis VMC13 women (43.3%)
and 17 men (56.7%). All 30 patients fullfilled modified histopathological Dallas criteria, while apoptosis was detected using TUNEL method in myocardial tissue sections
Results: The group of 30 patients with VMC demonstrated an elevated rate of AI 4.23 12.16 (Med:
0,005). The group of patients diagnosed with focal
VMC demonstrated the highest rate of AI (10.99). In
patients diagnosed with healing VMC the rate of AI
was 1.55. Increased rates of apoptosis were also find
in borderline (3.40) and acute (3.32) VMC.
Conclusion: Our research has indicated the
highest rate of apoptosis in patients with focal VMC.
The rate of AI in focal VMC was not significantly
increased when compared to AI of other groups. The
rate of AI was not significantly increased when we
compared results amongst groups with different morphological stages of VMC.
Key words: apoptosis, viral myocarditis, TUNEL
method
1Institut
za patologiju, Beograd, Srbija
centar Srbije, Beograd
1Institute
of Pathology, Clinical Centre of Serbia
639
P47
Značaj endomiokardne biopsije u
hipertrofičnoj kardiomiopatiji
The use of endomyocardial biopsy in
hypertrophic cardiomyopathy
Jelena Marković1, Ivana Ranisavljević-Katuca2, Sofija
Glumac2, Radmila Janković2, Jovan D. Vasiljević2
Jelena Markovic1, Isidora Ranisavljevic-Katuca2, Sofija
Glumac2, Radmila Jankovic2, Jovan D. Vasiljevic2
1Odeljenje
torakopulmonalne patologije, Služba za patologiju,
Klinički Centar Srbije, Beograd
2Institut za patologiju, Medicinski fakultet, Beograd
Uvod: Endomiokardna biopsija (EMB) je metoda
koja se koristi u dijagnostikovanju različitih tipova
kardiomiopatija, u cilju praćenja odbacivanja transplantata, evaluaciji miokarditisa, srčane insuficinjencije nepoznatog uzroka, aritmija, toksičnosti lekova
i srčanih neoplazmi.
Cilj: ovog rada je da ukaže kako neinvazivne dijagnostičke metode nisu uvek dovoljne u diferencijalnoj dijagnozi hipertrofične opstruktivne kardiomiopatije i ostalih bolesti srca.
Materijal i metode: Analizirali smo trideset jednu reprezentativnu endomiokardnu biopsiju sa uputnom dijagnozom hipertrofične opstruktivne kardiomiopatije (HOCM). Uzorci su obrađivani standardnom procedurom i bojeni hematoksilin-eozin i specijalnim bojenjem.
Za procenu smo koristili pet parametara (neregularnost pružanja vlakana-dissaray i hipertrofija miokardnih vlakana, kratka vlakna, perinuklearni halo
sa bizarnim jedrima i fibroza) koje smo bodovali od
0 do 3 i prikazali zbir histološkim HOCM indeksom
(HHI), čija vrednost može biti u rasponu 0 do 15, sa
pozitivnim nalazom preko 8.
Rezultati: Histološki nalazi dobijeni endomiokardnom biopsijom trideset jednog pacijenta su pokazali da je kod 8 pacijenata (25,8%) potvrđena uputna
dijagnoza HOCM, kod 6 pacijenata (19,35%) nije bila potvrđena dijagnoza HOCM, jer je HHI bio manji
ili jednak 50%, amiloidoza je dokazana kod jednog
pacijenta (3,22%), miokarditis kod 4 (12,9%), dilataciona kardiomiopatija kod 6 (19,35%) i nespecifične
srčane promene kod 6 pacijenata (19,35%).
Zaključak: Za definitivnu dijagnozu je potreban multidisciplinarni pristup, koji u određenim slučajevima zahteva primenu endomiokardne biopsije,
jer je klinička dijagnoza bila potvrđena u manje od
50% slučajeva.
Ključne reči: Hipertrofična kardiomiopatija, endomiokardna biopsija, patohistologija
640
1Department
2Institute
of Pathology, Clinical Centre of Serbia, Belgrade
Aim: Endomyocardial biopsy (EMB) may be used
to diagnose different types of cardiomyopathies, to
monitor transplant rejection, evaluation of myocarditis, heart failure of unknown origin, arrhythmias,
drug toxicity and heart neoplasmas.
The aim of this presentation is to show how noninvasive cardiac investigations are sometimes not
sufficiently conclusive for distinguishing between
hypertrophic obstructive cardiomyopathy (HOCM)
and the other cardiac diseases.
Material and methods: Thirty-one representative left ventricle biopsies were obtained following
suspected HOCM. Samples underwent routine standard and special staining procedures. Five histologic
parameters were used for assesment (disarray and
hypertrophy of myofibers, myocardial short runs, perinuclear halo and bizarre nuclei and fibrosis) and graded from 0 to 3, presenting in summary Histological
HOCM Index (HHI- ranging from 0-15) with positive findings over 8.
Results: The histological findings in EMB of
thirty-one patients, in 8 patients (25,8%) HOCM diagnosis was confirmed, in 6 (19,35%) HHI was under or equal to 50% of HOCM index (8) so HOCM
diagnosis couldn’t be confirmed, amyloidosis in 1
(3,22%), myocarditis in 4 (12,9%), dilatative CMP
in 6 (19,35%) and unspecific cardiac changes in 6
patients (19,35%).
Conclusion: A definitive diagnosis could be obtained by means of a multidisciplinary approach including EMB findings, because in less than 50% of patients the clinical diagnosis was confirmed.
Key Words: Hypertrophic cardiomypathy, endomyocardial biopsy, pathohistology
P48
Ruptura papilarmog mišica usled
infarkta miokarda
Papillary Muscle Rupture in
Myocardial Infarction
Ranisavljević-Katuca Isidora1, Jelena Marković2, Sofija
Glumac1, Radmila Janković1, Jovan D. Vasiljević1
Ranisavljevic-Katuca Isidora1, Jelena Markovic2, Sofija
Glumac1, Radmila Jankovic1, Jovan D. Vasiljevic1
1Institut
za patologiju, Medicinski fakultet Univerzitet u
Beogradu
2Klinicki centar Srbije, Beograd
Cilj: Cilj rada je utvrditi da li okluzija dominantne koronarne arterije, anatomske varijacije i postojanje anomalija PM mogu da favorizuju nastanak postinfarktne rupture PM.
Uvod: Ruptura papilarnog mišića (PM) je retka,
ali često fatalna mehanička komplikacija akutnog infarkta miokarda(AIM). Ruptura na zadnjem PM je više uobičajena (u oko 75% slučajeva) nego na prednjem PM, jer se zadnji PM ishranjuje preko zadnje
descedentne grane dominantne desne koronarne arterije i u vezi je sa infarktom zadnjeg zida leve komore. Prednji PM se ishranjuje preko dijagonalnih grana prednje descedentne grane leve koronarne arterije
i preko marginalnih grana leve cirkumflekse arterije.
Nekoliko faktora igra važnu ulogu u razvoju rupture
PM: okluzija dominantne koronarne arterije, anatomske varijacije i postojanje anomalija PM.
Materijal i metode: Kao material za istrazivanje
koristili smo nalaze 12 obdukovanih slučajeva postinfarktne rupture PM.
Rezultati: U 11 slučajeva se radilo o akutnom infarktu miokarda zadnjeg zida leve komore, a u jednom slučaju o AIM prednjeg zida leve komore. 10
pacijenata je imalo rupturu zadnjeg PM, a 2 pacijenta rupturu prednjeg PM. Kod 8 pacijenata postojale
su anatomske varijacije PM. U 8 slučajeva desna koronarna arterija je bila dominanatna, a u ostala 4 slučaja se radilo o balansiranoj cirkulaciji.
Zaključak: Morfološke varijante papilarnih
mišića(postojanje više odvojenih mišićnih masa) su
česte i mogu imati značajnu ulogu u nastanku rupture PM.
Ključne reči: papilarni misic, ruptura, infarkt
miokarda
1Institute
of Pathology, Medical School Belgrade
of Pathology, Clinical Centare of Serbia
2Department
Aim: The aim of work is to determine whether
occlusion of the dominant coronary artery, the anatomic variations and existence of anomalies of PMs
may favor the development of postinfarction PMs
rupture.
Introduction: Rupture of a papillary muscle (PM)
is rare but often fatal complication of acute myocardial infarction (AIM). The rupture of the posterior PM
is more common than the anterior one, since the posterior PM has a single blood supply in cases of dominant right coronary artery and is associated with
posterior wall infarctions.The anterior PM has dual blood supplies. Several factors play an important
role in the development of PM rupture: occlusion of
the dominant coronary artery, the anatomic variations and existence of anomalies of PMs.
Material an methods: Twelve autopsy findings
with the diagnosis of acute papillary muscle rupture
in myocardial infarction were reviewed to determine pathologic features of this entity.
Results: 10 patients had posterior PM rupture
and 2 patients the anterior one. The site of AMI was
posterior wall of the left ventricle in 11 patients and
anterior in 1 out of 12. In 8 patients there was anatomic variations of PMs. In 8 cases the right coronary
artery was dominant and in the remain 4 cases a balans circulation was present.
Conclusion: Morphological variants of PMs are
common and may play an important role in the PMs
ruptures
Key words: papillary muscle, rupture, myocardial
641
P49
Prekid aortonog luka –autopsijska
studija 27 slučajeva
Interupted aortic arch –an autopsy
study of 27 cases
Radmila Janković1, Sofija Glumac1, Branislav Lekić1,
Jelena Marković2, Isidora Ranisavljević-Katuca1, Ivana
Savić1, Jovan D. Vasiljević1
Radmila Janković1, Sofija Glumac1, Branislav Lekić1,
Jelena Marković2, Isidora Ranisavljević-Katuca1, Ivana
Savić1, Jovan D. Vasiljević1
2 Služba za patologiju, Klinički centar Srbije, Beograd, Srbija
1
Cilj: Cilj ovog istraživanja je da se utvrde učestalost i tip prekida aortnog luka (PAL), udružene anomalije i uzroci smrti u slučajevima sa PAL.
Uvod: Prekid aortnog luka je realtivno retka urođena srčana anomalija. Od 3 tipa PAL (A, B i C) najčešći je tip B (oko 70%); tip C je najređi (oko 1%).
Materijal i metode: Analizirani su autopsijski
zapisnici slučajeva sa urođenom srčanom manom
(USM) obdukovanih modifikovanom Rokitansky
tehnikom na Institutu za patologiju u Beogradu.
Analizirani period obuhvata 45 godina (1965 – 2010).
Rezultati: USM je nađena u 4,9% autopsijskih
slučajeva. PAL je dijafnostikovan u 27 (1,3) slučajeva USM. 8 slučajeva sa PAL je bilo tipa A, dok je
tip B dijagnostikovan u 18 slučajeva. Tip C je nađen
samo u jednom slučaju.U najvećem broju slučajeva
su postojale udružene srčane anomalije (96%), često
vise od jedne: ductus arteriosus persistens (96%),
defect međukomornog septuma (78%), defect međupretkomornog septuma (30%), bikuspidna aortna
valvula (11%), korigovana transpozicija velikih arterija (7%), atrioventrikularni septani defekt (4%).
Udružene ekstrasrčane anomalije su bile: anomalije urinarnog (26%) i digestivnog trakta (11%), anomalna lobulacija pluća (18%), polisplenija (15%) i
meningocela (4%). Kako ni jedan slučaj sa IAA nije prethodno operisan, uzroci smrti su bili povezani
sa srčanom i kadrio-respiratornom insuficijensijom.
Zaključak: Naši rezultati su slični rezultatima
drugih autora. Pacijeti sa PAL imaju lošu prognozu
ukoliko nisu operisani kako zbog prirode PAL, tako
i zbog udruženosti sa drugim srčanim i ekstrasrčanim anomalijama.
Ključne reči: urođena srčana mana, prekid aortnog luka, udružene anomalije, obdukcija
642
1 Institute
of pathology, Faculty of medicine, University of
2 Department of pathology, Clinical center of Serbia, Belgrade,
Serbia
Aim: The aim of this study was to investigate
frequency and types of interrupted aortic arch (IAA),
associated anomalies and causes of death in cases
with IAA.
Introduction: Interruption of aortic arch is a relatively rare congenital heart anomaly. Out of 3 types
of IAA (A, B and C), type is B is the most common
(70%); type C is rare (1%).
Material and methods: We analyzed autopsy records of cases with congenital heart diseases (CHD)
at Institute of pathology in Belgrade. Autopies were performed during 45 years period (1965 – 2010).
Modified Rokitansky technique was used for CHD.
Results: CHD were found in 4,9% autopsied cases. IAA was present in 27 cases (1,3%) of CHD. We
found 8 IAA type A and 18 IAA type B. Only one
IAA case was type C. Associated cardiac anomalies were present in majority cases of IAA (96%), often more than one: patent ductus arteriosus (96%),
ventricular septal defect (78%), atrial septal defect
(30%), bicuspid aortic valve (11%), corrected transposition of great arteries (7%), atrio-ventricular septal defect (4%). Associated extracardiac anomalies
were: anomalies of the urinary (26%) and digetive
tract (11%), anomalous pulmonary lobulation (18%),
polysplenia (15%) and meningocoele (4%). As none of autopsied IAA cases was operated, the causes
of death were relates to heart failure or cardio-respiratory insufficiency.
Conclusion: Our findings are consistent with majority of large series of IAA. Patients with IAA have
poor prognosis without surgical procedure due nature of IAA, but also due associated cardiac and extracardiac anomaies.
Key words: congenital heart disease, interrupted
aortic arch, associated anomalies, autopsy
KOŠTANA I MEKOTKIVNA
PATOLOGIJA
P50
Parametri u diferencijalnoj dijagnozi
bolesti sinovije - prikaz slučaja
Jordan Radojičić, Petar Novak, Živojinović Dragan,
Miloš Zaric, Jovanka Trifunović, Saša Ristic, Jelena
Vrtikapa, Biserka Vukomanović-Đurdević
Vojnomedicinska Akademija Beograd, Srbija
Cilj: Prikazati bitnosti korelacije rezultata kliničkih pregleda i patohistološke analize.
Uvod: Giht predstavlja metaboličko oboljenje.
Taloženje kristala urata u tkivu produkuje specifične morfološke promene na zglobovima, bubrezima
i drugim organima. Međutim, laboratorijske analize
krvi jesu potreban, ali ne i dovoljan uslov za postavljanje dijagnoze bolesti.
Materijali i metode: Pacijent u starosti od 52 godine javio se u Kliniku za ortopediju i traumatologiju VMA zbog otežanih pokreta kolena usled bolnog stanja.
Rezultati: Na RTG snimcima uočene su subkortikalne ciste i erozije u predelu I metatarzalne kosti obostrano i stiloidnog nastavka ulne jednostrano.
Ustanovljeno je povišenje vrednosti reumatoidnog
faktora (38,8 IU/ml), anti CCP (30 IU/ml) i mokraćne kiseline (467 ľmol/l). Učinjena je sinoviektomija. Metodom polarizacije preparata tkiva nije utvrđeno prisustvo kristala urata. Standardnim HE bojenjem dokazano je postojanje sinovitisa sa fibrinskim
naslagama na površini edematozne, hiperemične sinovije sa resičastim marginama, fokalno sa poljima
fibrinoidne nekroze i palisadnim aranžmanom ćelija
inflamacije sa predominacijom CD4 i CD8 limfocita
uz fokalno prisustvo CD20 limfocita, te je upućivalo
na postojanje reumatoidnog artritisa što je koreliralo
sa nalazima ostalih kliničkih ispitivanja.
Zaključak: Postavljanje dijagnoze bolesti sa morfološkim manifestacijama na sinoviji uključuje korelaciju kako kliničkih ispitivanja tako i detaljnu patohistološku analizu u donošenju definitivne dijagnoze.
Ključne reči: giht, limfociti, erozija, kost
BONE AND SOFT TISSUE
PATHOLOGY
Parameters in the differential
diagnosis of diseases of the synovia case report
Radojicic Jordan, Dragan Zivojinovic, Petar Novak,
Milos Zaric, Jovanka Trifunovic, Saša Ristic, Jelena
Vrtikapa, Biserka Vukomanovic-Đurdevic
Military Medical Academy Belgrade, Serbia
Aim: To show the importance of the correlation
of results of clinical examinations and the pathohistological analysis.
Introduction: Gout represents a metabolic disease. The deposition of uric crystals causes specific
morphological alterations in the joints, kidneys and
other organs. However, laboratory blood analyses
are a necessary, yet not a sufficient condition for the
correct diagnosis.
Material and methods: A patient aged 52 years
was submitted to the Clinic for orthopedics and traumatology of the Military medical academy because
of limited mobility of the knee joint caused by pains.
Results: The X-ray pictures showed subcortical
cysts and erosions in the region of I metatarsal bone bilaterally and, unilaterally, of the styloid processus of the ulna. The levels of the reumatoid factor
(38,8 IU/ml), anti-CCP (30 IU/ml) and uric acid (467
ľmol/l) were increased. A synievectomy was performed. Whereas the polarization method did not reveal uric crystals, the standard HE staining confirmed
the existence of a synovitis with fibrinous deposits
on the edematous, hyperemic synovia with cribriform
margins, focal regions of fibrinoid necrosis and a palisad-like arrangement of inflammatory cells, predominantly of CD4 and CD8 lymphocites with a focal
presence of CD20 lymphocites, which implied the
existence of rheumatoid arthritis, which corresponded with the other clinical examinations.
Conclusion: The procedure to a correct diagnosis of diseases with morphological manifestations in
the synovia includes the correlation of clinical examinations and a detailed pathohistological analysis.
Key words: gout, lymphocites, erosion, bone
643
P51
Intranodalni palisadirajući
miofibroblastom - slučajan nalaz
retkog tumora
Intranodal palisaded
myofibroblastoma as an incidental
findings
Jelena Urošević1, Anđela Tatarinov1, Dragoslav
Nenezić2, Jelena Sopta1
Jelena Urosevic1, Andjela Tatarinov1, Dragoslav
Nenezic2, Jelena Sopta1
Cilj: Tačna dijagnostika intranodalnog palisadirajućeg miofibroblastoma je važna iz terapijskih i prognostičkih razloga. Prikazujemo ovaj redak tumor
koji je otkriven kao slučajan nalaz tokom operacije
aorto-femoralnog by-pass-a.
Uvod: Intranodalni palisadirajući miofibroblastom je redak benigni mezenhimalni tumor, koji gotovo uvek vodi poreklo iz ingvinalnih limfnih nodusa.
Materijali i metode: Hirurški uklonjen bezbolni
ingvinalni tumefakt kod žene stare 66 godina.
Rezultati: Makroskopskim pregledom verifikovana je inkapsulirana čvrsta tumorska masa bez hemoragičnih i nekrotičnih područja. Mikroskopskom
analizom reperzentatvnih uzoraka iz operativnog materijala utvrđeno je prisustvo fibroblastne proliferacije koja potpuno narušava gradju limfnog nodusa.
Tumor čine vretenaste ćelije u palisadnom aranžmanu sa amiantoidnim vlaknima. Imunohistohemijski je
dokazana pozitivnost na vimenntin, alfa-SMA I HHF
35, što ukazuje na miofibroblastnu prirodu tumorskih
ćelija. Na osnovu morfoloških i imunohistohjemijskih
karakteristika tumora postavljena je dijagnoza intranodalnog palisadirajućeg miofibroblastoma.
Zaključak: Intranodalni mezenhimalni tumori su
izuzetno retki. Diferencijalno dijgnostički intranodalni palisadirajući miofibroblastom treba razlikovati od Kapošijevog sarkoma, neurilemoma ili metastatskih sarkoma. Za razliku od malignih mezenhimalnih neoplazija,ovaj tumor se ponaša kao benigna promena i ne zahteva bilo kakvu dalju terapiju,
osim totalne hirurške resekcije. Prikazani pacijent je
2 godine nakon radikalne hirurške ekscizije bez lokalnih znakova bolesti.
Ključne reči: benigni tumor, limfni nodus
Aim: Accurate diagnosis of intranodal palisaded
myofibroblastoma is important for therapeutic and
prognostic reasons. We report a case of this rare lesion that was discovered accidentally, as the inguinal tumor during operation of aorto-femoral by-pass.
Introduction: Intranodal palisaded myofibroblastoma is a rare benign soft tissue tumor, almost always
arising from inguinal lymph nodes.
Material and methods: Surgicaly removed a painless inguinal mass in 66 years old female.
Results: Macroscopic examination demonstrated
incapsulated solid appearance without hemorrhagic
and necrotic areas. Microscopic examination revealed intranodal spindle cell proliferation, with amianthoid fibers. It has a deeply eosinophilic core and lighter periphery. Nuclei of the spindle cells displayed
a palisaded appearance. Immunohistochemistry was
done and the myofibroblastic nature of the tumour
cells was proved by the presence of vimentin, SMA
and HHF-35. S-100 and CD 34 were negative. In light of these results, the case was diagnosed as “intranodal palisaded myofibroblastoma.”
Conclusion: This entity is generally misdiagnosed as intranodal Kaposi’s sarcoma, schwannoma or
metastatic lesions. In contrast to Kaposi’s sarcoma
and metastatic lesions, it behaves in a benign fashion and does not need any further therapy except total
surgical resection of the mass. Presented patient is 2
years after surgical therapy out of disease.
Key words: benign tumor, lymph node
1Institut
Beogradu
2Institut za Kardiovaskularne Bolesti Dedinje, Beograd, Srbija
644
1Institute
Belgrade
2Institute for Cardiovascular Diseases Dedinje
P52
Kavernozni angiomiom kosti - redak
tumor vilice
Cavernosus angiomyoma of bone - a
rare jaw tumor
Andjela Tatarinov1, Jelena Urošević1, Radojica Dražić2,
Zvezdana Tepavčević3, Jelena Sopta1
Andjela Tatarinov1, Jelena Urosevic1, Radojica Drazic2,
Zvezdana Tepavcevic3, Jelena Sopta1
Cilj: Predstavljanje slučaja retkog intraosealnog
tumora koji je pimarno bio dijagnostikovan kao hemangiom kosti
Uvod: Angiomiom je benigni mezenhimalni tumor mekog tkiva koji se sastoji od glatkih mišićnih fascikula i zadebljanih zidova krvnih sudova. Njegova
intraosealna lokalizacija je izuzetno retka
Materijal i metode: Osteolitična lezija u levoj
mandibuli koja je dijagnostikovana digitalnim ortopanom kao incidentalni nalaz kod 61 godišnje
pacijentkinje.
Rezultati: Nakon kiretaže kosti biopsijski material je poslat na patohistološku analizu. Primarna dijagnoza je bila hemangiom kosti. Histološki, tumor
se sastoji od dilatiranih krvnih sudova sa zadebljanjem mi šićnog sloja zida vaskulrnih prostora i fokusima zrelih masnih ćelija.Trihromnim bojenjem po
Masonu se u zidovima krvnih sudova uočavaju zone mišićnog tkiva. Ćelije zida krvog suda su bile pozitivne na bojenje glatko mišicnim aktinom, dezminom, mišićno-spečifičnim aktinom i vimentinom.
Oko tumora koštane gredice su atrofične, istanjene i
redukovane. Navedene mikroskopske karakteristike
ukazivale su na kavernozni tip angioleiomioma, mada je njegova intraosealna lokalizacija izuzetno retka.
Zaključak: Prikazom ovog sličaja želeli smo da
naglasimo da skoro svaki tumor mekih tkiva može
biti prisutan i intraosealno,o čemu treba misliti pri
dijagnostici
Ključne reči: angiomiom, benigni, tumor, kost,
vilica
Aim: To present the case of a very rare intraosseal tumor that is primarily misdiagnosed as bone hemangioma Introduction: Angiomyoma is well
known soft tissue benign mesenchymal tumor composed of smooth muscule fascicles and thick-walled
vessels.Intraosseal localization of this tumor is very
rare and unusual
Material and methods: Osteolytic lesion in left
mandibula diagnosed as an incidental finding in 61
years old female on digital ortopan
Results: After bone curettage bioptical material was sand to pathological analysis. The first diagnosis was bone hemangioma. Histologicaly tumor
was composed of dilated vascular channels with little
muscular thickening of the walls and foci of mature
fat cells. Masson s trichrom stain showed large zone
of muscle tissue in the vascular wall. Walls cells were positive for smooth muscle actin, desmin, muscle
specific actin and vimentin. Bone tissue was analyzed
by tumor, only few bone trabeculs were presented into the biopsy. According to microscopic examination diagnosis were changed into cavernous type angioleiomyoma of bone.
Conclusion: Showing this case we wanted to
emphasize that almost all soft tissue tumors may be
present in the bone
Key words: angiomyoma, benign, tumor, bone
1Institut
Beogradu
2Klinika za oralnu hirurgiju, Stomatološki fakultet, Univerzitet
u Beogradu
3Institut za patologiju,Stomatološki fakultet, Univerzitet u
Beogradu
Institute of Pathology, Faculty of Medicine, University of
Belgrade,Belgrade
2Clinic for Oral Surgery,Faculty of Dentistry, University of
Belgrade,Belgrade
3Institute of Pathology,Faculty of Dentistry, University of
Belgrade, Belgrade
1
645
NEUROPATOLOGIJA
P53
Kraniofaringiomi: 10 godina iskustva
Emilija Manojlović – Gačić1, Milica Skender –
Gazibara1, Tatjana Gazibara2, Savo Raičević3, Danica
Grujičić3
1Institut za patologiju, Medicinski fakultet, Univerzitet u
Begradu, Beograd, Srbija
2Institut za Epidemiologiju, Medicinski fakultet, Univerzitet u
Begradu, Beograd, Srbija,
3Klinika za neurohirurgiju, Klinicki centar Srbije, Beograd,
Srbija
Cilj: Analiza histopatoloških tipova kraniofaringioma, njihove distribucije po uzrastu i polu, intrakranijalnoj lokalizaciji i recidivima u desetogodišnjem periodu.
Uvod: Kraniofaringiomi su benigni, sporo rastući,
lokalno invazivni intrakranijalni tumori porekla epitela Ratkeovog špaga. Pored dva osnovna tipa (adamantinomatozni i papilarni) opisane su i mešovite forme.
Prognostički značaj različitih tipova kraniofaringioma
je kontroverzan.
Materijal i metode: U bazi podataka neurohirurških
biopsija u periodu od 2002-2011 registrovano je 89 novootkrivenih slučajeva kraniofaringioma. Tumorsko tkivo je obradeno rutinskim hematoksilin-eozin bojenjem.
Korišćcene su deskriptivne statističke metode.
Rezultati: Od 89 slučajeva kraniofaringioma (46 ž
ena i 43 muškarca), uzrasta izmedu 4 i 76 godina, bilo
je 74 adamantinomatoznih (prosečna starost 35.68 godina), 13 papilarnih (prosečna starost 48 godina) i 2 mešovita tipa (prosečna starost 46 godina). Bimodalna uzrasna distribucija je uočena kod dece uzrasta 10-19 godina
i odraslih uzrasta 50-59 godina. Svi kraniofaringiomi u
uzrastu unutar prve dve decenije ž ivota bili su adamantinomatoznog tipa. Najčešća lokalizacija je bila supraselarna (43.82%), zatim intra/suparaselarna (15.73%), treća
komora (14.06%), supraselarna/treća komora (13.48%),
intra/supra/paraselarna (6.74%) i intraselarna (5.52%).
Recidivi su se javili kod 16 pacijenata (15 adamantinomatozni, 1 mešoviti tip). Tri pacijenta su imala dva recidiva (dva su bili decaci starosti 8 i 11 godina). Jedna
pacijentkinja je dva meseca nakon subtotalne resekcije
adamantinomatoznog kraniofaringioma preminula usled
tromboembolije pluća dokazane na autopsiji.
Zaključak: Naši rezultati ukazuju na izvesne razlike u
biološkom ponašanju histopatoloških tipova kraniofaringioma. Izgleda da papilarni tip ima bolju prognozu nego
adamantinomatozni. Recidivi su se javili skoro isključivo
kod adamantinomatoznog tipa, koji dominira u uzorku.
Ključne reči: kraniofaringiom, histopatološki podtipovi, recidiv
646
NEUROPATHOLOGY
Craniopharyngiomas: 10-year
experience
Emilija Manojlovic-Gacic1, Milica Skender- Gazibara1,
Tatjana Gazibara2, Savo Raicevic3, Danica Grujicic3
1Institute
of Pathology, School of Medicine, University of
2Institute of Epidemiology, School of Medicine, University
of Belgrade, Belgrade, Serbia, 3Neurosurgery Clinic, Clinical
Centre of Serbia, Belgrade, Serbia
Aim: To investigate histopathological subtypes of
craniopharyngiomas, their distribution according to the
age and gender of patients, intracranial localization and
recurrences in 10-year period.
Introduction: Craniopharyngiomas are histologically benign, slow-growing, locally invasive intracranial tumors, presumably derived from Rathke pouch
epithelium. Beside two primary subtypes (adamantinomatous and papillary) mixed forms have been described. Prognostic significance of these subtypes remains controversial.
Material and methods: In the database of neurosurgical biopsies from 2002-2011 we registered 89
newly diagnosed cases of craniopharyngiomas. Tumor
tissue was treated by routine hematoxylin-eosin method.
Descriptive statistical analysis was performed.
Results: Among 89 cases of craniopharyngioma
(46 females and 43 males), ranging from 4 to 76 years, we found 74 adamantinomatous (mean age 35.68),
13 papillary (mean age 48) and 2 mixed (mean age 46)
subtypes. A bimodal age distribution was present in
children aged 10-19 and adults aged 50-59. All craniopharyngiomas in the first two decades were of adamantinomatous type. The most common localization
was suprasellar (43.82%), followed by intra/suprasellar
(15.73%), third ventricle (14.06%), suprasellar/third ventricle (13.48%), inra/supra/parasellar (6.74%) and intrasellar (5.52%). Sixteen patients developed recurrences
(15 of adamantinomatous, 1 of mixed subtype). Of these,
three cases had two recurrences (two were boys aged 8
and 11). Woman with partially resected adamantinomatous craniopharyngioma died two months after surgery
due to autopsy-proven pulmonary thromboembolism.
Conclusion: Our data showed certain differences
in biological behavior of histopathological subtypes. It
seems that papillary subtype has better prospects than
adamantinomatous. Recurrences were noted almost
exclusively in adamantinomatous subtype which was
predominant in material.
Key words: craniopharyngioma, histopathological
subtypes, recurrence
P54
Deponovanje lipofuscina u neuronima
pasa tokom života
Lipofuscin deposition in dogs neurons
durin the life
Sladjan Nešic1, Milijan Jovanović1, Bojan Ristić2
Sladjan Nesic1, Milijan Jovanovic1, Bojan Ristic2
1Fakultet
veterinarske medicine, Univerzitet u Beogradu,
Beograd
2Veterinarski specijalistički institut, Zaječar, Zaječar, Serbia
Cilj: Mogućnost detetekcije lipofuscina u mozgu različitim metodama kod različitih starosnih kategorija pasa.
Uvod: Lipofuscin je pigment koji nastaje u organizmu živih bića u procesu starenja. On se nakuplja uglavnom u dugoživećim postmitotičkim ćelijama (neuroni). Pigment sadrži i različite unutarćelijske strukture, a primarno se nakuplja u lizozomima.
Materijal i metode: Pregledani su mozgovi 59
obdukovanih pasa. Ispitivani psi su podeljeni na osnovu starosti u 4 grupe: I do 5 godina, II 5-10 godina, III
10-15 godina, IV preko 15 godina. Delovi mozgova
(frontalna kora, parijetalna kora, hipokampus, mali
mozak i produžena moždina) su fiksirani u 10% neutralnom formalinu a posle toga su standarno procesuirani do parafinskih blokova. Parafinski isečci debljine 5μm bojeni su metodama: hematoksilin-eozin, periodic acid Schiff (PAS) i produženom Ziehl-Neelsen.
Rezultati: Granule lipofuscina su uočene u preparatima bojenim sa sve tri metode. U starosnoj kategoriji preko 15 godina pigment je dokazan u 80%
slučajeva, dok taj procenat iznosi 30% u prvoj grupi.
Kod pasa iz I i II grupe lipofuscin se nakupio u neuronima samo u produženoj moždini. U III i IV grupi lipofuscin je detektovan u različitim procentima u
svim ispitivanim regionima mozgova pasa.
Zaključak: Prisustvo lipofuscina u neuronima je
dokazno kod pasa iz sve četiri kategorije. Broj pozitivnih ž ivotinja se povećavao proporcionalno sa
starošću. Lipofuscin se najčešće nagomilava u velikim neuronima pojedinih jedara produžene moždine.
Količina nagomilanog pigmenta se povećava sa starošću pasa kao i njegovo pojavljivanje u neuronima
različitih regija mozga.
Ključne reči: lipofuscin, metode, neuroni, psi
1Faculty
of veterinary medicine,University of
Belgrade,Belgrade, Serbia
2Veterinary specialized institute Zajecar,Zajecar, Serbia
Aim: Possibility of lipofuscin detection using
different methods in various age groups of dogs.
Introduction: Lipofuscin is a pigment that occurs
in the organism in the process of aging. It accumulates mainly in postmitotic long living cells (neurons).
The pigment consists of various intracellular substances and accumulates primarily in lysosomes.
Material and methods: Brain samples were examined from 59 autopsied dogs. Examined dogs were divided into 4 groups according to the age: I up
to 5, II 5-10, III 10-15 and IV over 15 years. Parts
of brains (frontal cortex, parietal cortex, hippocampus, cerebellum and medulla oblongata) was fixed in
10% neutral formalin and processed by routine method to paraffin blocks. For staining of 5ľm thick paraffin slices were used: hematoxylin-eosin, periodic
acid Schiff (PAS) and long Ziehl-Neelsen techniques.
Results: Lipofuscin granules were observed using
all three staining techniques. In the age group over 15
years, pigment was detected in 80% of the examined
dogs, while this percentage was 30% in the first group. In first and second group, lipofuscin accumulated
only in neurons of the medulla oblongata. In the third
and fourth group lipofuscin was detected in various
percentages in neurons of all examined brain sections.
Conclusion: Presence of lipofuscin in neurons
was proven in dogs from all age categories. Number
of positive animals increases proportionally with age.
Lipofuscin most often accumulates in large neurons
of medulla oblongata nuclei. The accumulation of lipofuscin pigment in neurons increases with the dog
s age as well as widespread in neurons of different
brain regions.
Key words: lipofuscin, techniques, neurons, dogs
647
P55
Histoplazmoza centralnog nervnog
sistema imitira tumor mozga: prikaz
slučaja
Central nervous system
histoplasmosis mimics a brain tumor:
a case report
Nanad Miladinović, Milica Lavrnić, Marija Nikolić,
Zorana Bokun, Lidija Prijić-Plećević, Sanja M.
Milenković
Nanad Miladinovic, Milica Lavrnic, Marija Nikolic,
Zorana Bokun, Lidija Prijic - Plećevic, Sanja M.
Milenkovic
Cilj: Prikazujemo slučaj izolovane histoplazmoze centralnog nervnog sistema kod imunokompetentne pacijentkinje
Uvod: Mnogi ne-neoplastični procesi u mozgu se
manifestuju kao “mass” lezije i ponekad ih je veoma
teško razlikovati od tumora mozga. Učestalost CNS
histplasmoze u ne-endemskim oblastima raste, posebno kod imunokompromitovanih osoba.
Materijal i metode: Opisujemo slučaj 48-godišnje
imunokompetentne žene koja je imala glavobolju, meningealne znakove i ataksiju, ali bez dokazane sistemske infekcije. Kompjuterizovana tomografija je pokazala ekspanzivnu masu masu u malom mozgu. Posle
biopsije tkiva uzorci su analizirani rutinski uz primenu
histohemijskih i imunohistohemijskih bojenja.
Rezultati: Histološkom analizom se uočavalo prisustvo malomoždanog parenhima, koji je delom bio
očuvan, a delom pokazivao veoma izražene ishemijske promene sa eozinofilnim ishemijskim neuronima
i izraženom Bergmanovom gliozom. Dominantan nalaz je intenzivna limfocitna (CD45+) infiltracija uz
dominaciju T (CD3+) limfocita. Limfocitni infiltrate
je veoma intenzivan, perivaskularan, pokazuje ekstenziju kroz Virchow-Robin-ove prostore penetrirajući u moždani parehnim. Nekroza moždanog parehnima, i kore i bele mase, je praćena histiocitnom reakcijom i mikroglijalnom proliferacijom bez formiranja granuloma Nisu detektovane virusne partikule
Human Herpes virusa (tip 8), ni Epstein-Barr-ovog virusa. Bojenjem na PAS se uočavaju lezije granulirnog
izgleda, i perivaskularno, i u arahnoideji, ali i u ishemijskom parenhimu. Granule su bile manje od aksonalnih sferoida i bojile su se na Grocott methenamine silverčime smo potvrdili dijagnozu histoplazmoze.
Zaključak: Dijagnostika histoplasmoze CNS može biti teška i ponekad zahteva biopsiju moždanog parenhima, kao i primenu histohemijskih i imunohistohemijskih metoda bojenja radi potvrđivanja.
Ključne reči: Histoplazmoza, centralni nervni sistem, tumor mozga, imunokompetentnost
Aim: We report a case of isolated central nervous
system histoplasmosis in immunocompetent patients
Introduction: Many non-neoplastic diseases manifest as mass lesions and may be indistinguishable from
brain tumors. The frequency of CNS histplasmose in
non-endemic areas is growing, especially in immunocompromised persons.
Material and methods: We describe a 48-year-old
immunocompetent woman who had headache, meningeal irritation signs and cerebellar ataxia but no evidence of systemic infection. Computed tomography
imaging showed an enhancing mass in the cerebellum.
After biopsy tissue samples were analyzed pathohistological with histochemistry and immunohistochemistry.
Results: Histological analysis showed cerebellar parenchyma, which was partly preserved, partly showing
pronounced ischemic changes with eosinophil ischemic neurons and expressed Bergman gliosis. The dominant finding is intense lymphocyte (CD45 +) infiltration of the dominance of T (CD3 +) lymphocytes.
Lymphocytic infiltrate werw very intense, with extension through the Virchow-Robin spaces and penetrated the brain parehnim. Parehnim necrosis of the brain,
and cortex and white matter, was accompanied by histiocytic reaction and microglial proliferation without the
formation of granuloma.Viral particles Human herpes
virus (type 8) or Epstein-Barr’s virus were not detected. PAS staining showed granular lesions in perivascular and arachnoidal localisation, as well as, in the ischemic parenchyma. Granules were smaller than aksonalnih spheroids and stained with Grocott methenamine
silver, which we confirmed diagnosis of histoplasmosis.
Conclusion: The diagnosis of CNS histoplasmosis can be difficult, and sometimes performing a parenchymal biopsy and histochemistry and immunohistochemistry staining is necessary to confirm the
diagnosis
Key words: Histoplasmosis, central nervous system,
brain tumor, immunocompetence.
Služba kliničke patologije, Kliničko-bolnički centar Zemun,
Beograd, Srbija
648
Department of Pathology, Clinical Hospital Center Zemun,
Belgrade, Serbia
PERINATALNA I PEDIJATRIJSKA
PATOLOGIJA
PERINATAL AND PEDIATRIC
PATHOLOGY
P56
Sijamski blizanci – prikaz slučaja
Siamese twins –case report
Lidija Vučković, Marija Milić
Lidija Vuckovic, Marija Milic,
Cilj: Prikaz sijamskih blizanaca kao redak medicinski fenomen
Uvod: Sijamski blizanci su identični blizanci kod
kojih nije došlo do potpune podele tokom ranog fetalnog razvoja, tako da mogu deliti delove tela i organe.
Materijal i metode: Prikaz slučaja
Rezultati: Pacijentkinja stara 30 godina, druga
potpuno nekotrolisana trudnoća se javlja ginekologu u Opštoj bolnici Subotica zbog bolova u stomaku. Uradi se ginekološki pregled i Usg i ustanovi da
je reč o 40/41 nedelji trudnoće. Učini se operacija
Sectio Caesarea. Estrahuju se ženski sijamski blizanci
(Thoracopagus ), težine 6460 gr, dužine 50 cm, Apgar
score 1/0, koji nisu zaplakali. Započete su mere reanimacije i nakon 30 min proglašava se exitus letalis. Sijamski blizanci su poslati na obdukciju gde je
nađeno da su spojeni u predelu grudnog koša i abdomena, sa jednim pupčanikom. Pri spoljšnjem pregledu
uočava se kratak vrat, niže postavljene ušne školjke i
blago uvučene donje usne, normalni ekstremiteti, bez
deformiteta prstiju i patoloških linija na šakama. Po
razdvajanju grudnog koša i abdomena nađeno je da
se pupčanik račva, postoji jedno srce sa dve pretkomore i jednom hipertrofičnom i dilatiranom komorom. Prisutan je jedan timus i jedna uvećana jetra.
Ostali organi su parni i pravilne grade.
Zaključak: Sijamski blizanci nastaju pri nepotpunom razdvajanju embrionalnog diska kod monozigotnih blizanaca. Ova anomalija je veoma retka u
razvijenim zemljama gde se zahvaljujući blagovremenoj ultrazvučnoj dijagnostici takve trudnoće obicno prekidaju. Poslednji slučaj sijamskih blizanaca u
Opštoj bolnici Subotice se desio 1987 godine.
Ključne reči: sijamski blizanci, urođene anomalije
Aim: Presentation of siamese twins as a rare medical phenomenon
Introduction: Siamese twins are identical twins,
but they had no complete separation during early fetal development so they can share some body parts and organs.
Material and ethods: Case review
Results: 30 year old patient report to the gynecologist in Subotica general hospital because of the abdominal pain. Pelvic exemination and Usg was made. It resulted that she was 40/41 weeks pregnant.
Operation Sectio Caesarea was made. The female Siamese twins were extrachted (Thoracopagus ),
weighing 6460 g, length 50 cm, Apgar score 1/0, they
didn`t cried. Resusciation measures were initiated and
after 30 minutes exitus letalis was declared. Siamese
twins were sent for autopsy, where it was found that
they were connected to the chest and abdomen, with
one umbilical cord. The external review showed short
neck, low set ears, slightly recessed lower lip, normal
extrimitates without deformity of the fingers and pathological lines on the hands. By separating the chest
and abdomen, umbilical cord that branched was found. There was one heart with two atria, one hypertrophic and delated ventricul. There was one thymus
and one enlarged liver. Other organs were in pair and
properly developed.
Conclusion: Siamese twins become as a result
of incomplete separation of embryonic disc in monozygotic twins. This anomaly is very rare in developed countries and due to ultrasound diagnosis such
a pregnancy is usually interrupted. The last case of
Siamese twins in Subotica general hospital occured
in 1987.
Key words: siamese twins, congenital anomalies
Opšta bolnica Subotica, Subotica, Srbija
General hospital Subotica, Subotica, Serbia
649
P57
Limfomi u dečijem uzrastu - analiza
desetogodišnjeg rada jedne ustanove
Lymphoma in children - ten-year
analysis in a single institution
Gordana Samardžija, Slaviša Đuričić, Milena Đukić,
Milo Kuzmanović, Dragan Micić, Dragomir Đokić,
Gordana Samardzija, Slavisa Djuricic, Milena Djukic,
Milos Kuzmanovic, Dragan Micic, Dragomir Djokic
Cilj: Procena distribucije limfoma dečijeg doba u
odnosu na uzrast, pol, histološki tip i anatomsku lokalizaciju u nacionalnoj pedijatrijskoj ustanovi.
Uvod: Postoje razlike u incidenci i međusobnom
odnosu histoloških podtipova Hodgkin i non-Hodgkin limfoma (HL, NHL) dečijeg doba izmedu različitih delova sveta.
Materijali i metode: Desetogodiš nja retrospektivna anliza (2002-2011) tipova HL i NHL na osnovu medicinske dokumentacije i tkivnih uzoraka.
Poređenje rezultata sa podacima iz literature.
Rezultati: Lečeno je 117 bolesnika sa limfomom:
58 HL (49.6%), 59 NHL (50.4%). HL: odnos dečaci:
devojčice 33:25 (1.32:1), uzrast se kretao od 4 meseca do 18 godina sa medijanom od 14 godina, nodularna skleroza je bio najčešći podtip (86.2%). NHL:
odnos dečaci: devojčice 47:12 (3.9:1), uzrast se kretao od 12 meseci do 18 godina sa medijanom od 11
godina. Od svih NHL
62.7% su bili porekla B-ćelija, 28.8% T-ćelija i
8.5% neklasifikovani. Histološka distribucija NHL
je bila: Burkitt-ov limfom 49.2%, difuzni B krupnoćelijski 11.9%, anaplastični krupnoćelijski 11.9%,
limfoblastni 20.3% i neklasifikovani NHL 6.7%.
Zastupljenost lokalizacija glava/vrat i abdomen je
bila po 35,5%, medijastinum (19.4%), gonade (4.8%)
i druge lokalizacije (4.8%). Nismo mogli da procenimo tačnu zastupljenost ekstranodalne lokalizacije
kao primarne po to su neki limfomi dijagnostikovani u višim stadijumima sa ispoljenom i nodalnom i
ekstranodalnom zahvaćenošću.
Zaključak: Distribucija limfoma u dečjem uzrastu u odnosu na pol, uzrast, histološke tipove i lokalizaciju u našoj seriji malo se razlikuje od objavljenih velikih svetskih serija i nalazi se najčešće izmedu podataka iz ekonomski razvijenih zemalja i zemalja u razvoju.
Ključne reči: Hodgkin limfom, Non-Hodgkin
limfom, Deca
Aim: The assessment of distribution of childhood
lymphomas according to age, sex, histological types
and anatomic location in a single pediatric institution.
Introduction: There are differences in both incidence and proportion of histological subtypes of
Hodgkin lymphoma and non-Hodgkin lymphoma
(HL, NHL) of childhood in different parts of the
world.
Material and methods: Ten-year retrospective
analysis (2002-2011) of HL and NHL types distribution by reviewing medical documentations and tumor histology. Comparison of results with relevant
data from the literature.
Results: 117 patients with lymphoma were treated: 58 HL (49.6%), 59 NHL (50.4%). HL: male: female ratio 33:25 (1.32:1), median age 14 years, range 4 months-18 years, nodular sclerosis as predominant type (86.2%). NHL: male: female ratio 47:12
(3.9:1), median age 11 years, range 12 months-18
years. Of all NHL 62.7% were B-cell origin, 28.8%
T-cell and unclassified (8.5%). NHL histologic distribution was: Burkitt’s lymphoma 49.2%, diffuse large B-cell 11.9%, anaplastic large cell 11.9%,
lymphoblastic 20.3% and unclassified NHL 6.7%.
The frequency of localization was head/neck and abdomen 35.5% each, mediastinum (19.4%), gonads
(4.8%) and other (4.8%). However, we were not be
able to assess the exact percent of primary extranodal localization because some lymphoma were diagnosed in high stage with both nodal and extranodal
involvement.
Conclusion: Distribution characteristics of childhood lymphomas according to sex, age, histological types and anatomic location in our series are somewhat different from the published series. They are
in the middle range between the relevant data from
economically developed and developing countries.
Key words: Hodgkin lymphoma, Non-Hodgkin
lymphoma, Children
Institut za zdravstvenu zaštitu majke i deteta Srbije “Dr Vukan
650
Mother and Child Health Care Institute of Serbia “Dr Vukan
Cupic”, Belgrade, Serbia
P58
Wilms-ov tumor: mutacija β katenin
gena
Wilms tumor: Mutation in the β
katenin gene
Gordana Basta-Jovanović1, Brašanac Dimitrije1, Ljiljana
Bogdanović1, Sofija Glumac1,
Zoran Krstić2, Sanja Radojević-Škodrić1
Gordana Basta-Jovanovic1, Dimitrije Brasanac1, Ljiljana
Bogdanovic1, Sofija Glumac1,
Zoran Krstic2, Sanja Radojevic-Skodric1
Cilj: Da se analizira ekspresija ß-katenin proteina
u primarnim Wims-ovim tumorima i korelirati sa prisustvom somatskih mutacija ß-katenin gena.
Uvod: Wnt-signalni put ima važnu ulogu u normalnom razvoju bubrega, ali i u tumorogenezi Wilmsovog tumora (WT). Nuklearna translokacija ß-katenin proteina može biti posledica specifičnih mutacija ß-katenin gena.
Materijal i metode: Analizirana je nuklearna ekspresija ß-katenin proteina u 30 slučajeva primarnih
WT-a i ovi rezultati su korelirani sa prisustvom mutacija ß-katenin gena u ispitivanim slučajevima. Za
imunohistohemijsko bojenje korišćena je streptavidin-biotin tehnika, a za detekciju somatskih mutacija PCR i metoda sekvenciranja.
Rezultati: Nuklearna ekspresija ß-katenin proteina je detektovana u 4 od 30 slučajeva WT-a (13,3%).
Nuklearno bojenje u ovim slučajevima je bilo jako,
ali prisutno u manjem broju ćelija (5 % - 20 % celija). Jedra blastemskih ćelija su u većini slučajeva
pozitivna, dok je nuklearna ekspresija ß-katenina u
stromalnoj komponenti uocena u 2 slučaja, a u epitelnoj u samo jednom slučaju WT. Osim toga, pozitivne ćelije su nađene u WT-ima svih stadijuma i u
ne-anaplastičnim WT-ima. Mutacije ß-katenin gena
nisu uočene u analiziranim uzorcima.
Zaključak: Činjenica da je u nekim WT-ima
uocena nuklearna ekspresija ß-katenina i u odsustvu
mutacija ß-katenin gena, ukazuje da mutacije drugih članova Wnt-signalnog puta može doprineti razvoju WT-a.
Ključne reči: WT, ß- katenin, mutacije, nuklearna ekspresija
Aim: To analyze the expression of ß-catenin protein in primary Wilms’ tumor (WT) specimens and
to correlate these results with the mutational status
of the ß-catenin gene.
Introduction: The Wnt-signaling pathway plays
an important role during both normal kidney development and Wilms’ tumorigenesis. Nuclear
translocation of the ß-catenin protein may be caused by specific mutations in the ß-catenin gene itself.
Material and methods: We have analyzed
nuclear expression of ß-catenin protein in 30 primary WTs and correlated these results with the mutational status of the ß-catenin gene in these samples. Immunohistochemistry was performed using
the streptavidin-biotin technique. PCR and sequencing analysis were carried out to examine the presence of somatic mutations of ß-catenin gene.
Results: Nuclear immunoreactivity for ß-catenin
was detected in 4 out of 30 WT (13.3%). Nuclear
positivity, in each case, was found to be very strong,
but usually present only in a fraction of cells ranging
from 5% to 20%. Blastemal cell nuclei preferentially
stained positive, whereas cells of stromal component
showed positivity in 2 cases and epithelial cells displayed nuclear localization of ß-catenin protein only
in single case. Furthermore, nuclear positive cells were found in WTs of all stages and in non-anaplastic
WTs. ß-catenin gene mutations were not detected in
analyzed WTs specimens.
Conclusion: The fact that nuclear expression
of ß-catenin was detected in the absence of ß-catenin gene mutations in some analyzed WTs, suggests
that genetic defects affecting other members of the
Wnt-signalling pathway may contribute to the development of WT.
Key words: WT, ß catenin, mutation, nuclear
expression
1Institut
za patologiju,Medicinski fakultet, Univerzitet u
2Univerzitetska dečija klinika, Beograd, Srbija
1Institute
of pathology, Medical School, University of
2University Children’s Hospital, Belgrade, Serbia
651
PULMONALNA PATOLOGIJA
PULMONARY PATHOLOGY
P59
Uloga imunohistohemijske analize
u u dijagnozi malignog mezotelioma
pleure
The role of immunohistochemical
evaluation in the diagnosis of
malignant pleural mesothelioma
Aleksandra Lovrenski1, Milana Panjković1, Dragana
Tegeltija1, Živka Eri, Slavica Knežević Ušaj2, Zoran
Nikin2
Aleksandra Lovrenski1, Milana Panjkovic1, Dragana
Tegeltija1, Zivka Eri1, Slavica Knezevic Usaj2, Zoran
Nikin2
Cilj: Utvrditi značaj imunohistohemijske analize i
primene pojedinih antitela u dijagnozi malignog mezotelioma pleure.
Uvod: Maligni mezoteliom je agresivan tumor sa visokom stopom mortaliteta. Konačna dijagnoza malignog
mezotelioma pleure postavlja se isključivo patohistološkim pregledom bioptiranog materijala koji se rutinski
nadopunjuje i upotrebom imunohistohemijske analize.
Materijal i metode: Retrospektivno je izvršena analiza klinickih podataka 32 pacijenta kod kojih je u periodu od 2004. do 2009. godine na Institutu za plućne
bolesti Vojvodine u Sremskoj Kamenici patohistološki
postavljena dijagnoza malignog mezotelioma pleure.
Materijal za patohistološku i imunohistohemijsku analizu dobijen je videoasistiranom torakoskopijom (30 uzoraka), transbronhijalnom biopsijom (1 uzorak) i otvorenom biopsijom pluća (1 uzorak). Mikroskopska analiza imunohistohemijski obradenih uzoraka bazirala se
na njihovoj pozitivnosti i negativnosti na određeno antitelo, na koji način je postavljena konačna dijagnoza
malignog mezotelioma određenog tipa.
Rezultati: Citokeratin 5/6 (CK5/6) bio je pozitivan u 63% slučajeva, Calretinin u 94%, a Anti-Human
Mesothelial Cell, Clone HBME-1 (HBME-1) u 80%
slučejeva. Citokeratin 7 (CK7) se pokazao pozitivnim u 78%, a Epithelial membrane antigen (EMA)
u 83% slučejeva. Svi slučajevi (100%) bili su negativni na Thyroid transcription factor 1 (TTF-1),
Carcinoembryonic antigen (CEA), Cytokeratin 20 (CK
20), Epithelial Specific Antigen Ab-7, Clone MOC-31
(MOC 31) i Desmin.
Zaključak: Imunohistohemija je postala esencijalni
dijagnostički postupak u postavljanju dijagnoze i određivanju tipa malignog mezotelioma pleure. Zbog nedostatka samostalnog antitela danas se koristi kombinacija
antitela različite senzitivnosti i specificnosti.
Ključne reči: Maligni mezoteliom, pleura, imunohistohemijska analiza
Aim: Determination of the role of immunohistochemical analysis and some antibodies in the diagnosis of malignant pleural mesothelioma.
Introduction: Malignant mesothelioma of the pleura is aggressive neoplasm with a high mortality. The final
diagnosis of malignant pleural mesothelioma can be made only by pathohistological examination of tissue biopsy that routinely is followed by use of immunohistochemical analysis.
Material and methods: Retrospective analysis of
clinical data from 32 patients diagnosed pathohistologically with malignant pleural mesothelioma in period from
2004. to 2009. year at Institute for Pulmonary Diseases of
Vojvodina was performed. Material for pathohistological
and immunohistochemical analysis was obtained by video
assisted thoracoscopic surgery (30 samples), transbronchial biopsy (1 sample) and open lung biopsy (1 sample). The
microscopic examination of immunohistochemically processed samples was based on their positivity or negativity
to specific antibody, and final diagnosis of malignant pleural mesothelioma of certain type was concluded.
Results: Cytokeratin 5/6 (CK5/6) was positive in 63%
cases, Calretinin in 94% and the Anti-Human Mesothelial
Cell, Clone HBME-1 (HBME-1) in 80% cases. Cytokeratin
7 (CK7) showed positivity in 78% and Epithelial membrane antigen (EMA) in 83% cases. All cases (100%) stainded negative for Thyroid transcription factor 1 (TTF-1),
Carcinoembryonic antigen (CEA), Cytokeratin 20 (CK 20),
Epithelial Specific Antigen Ab-7, Clone MOC-31 (MOC
31), and Desmin.
Conclusion:Immunohistochemistry has become an
essential diagnostic tool for the diagnosis and determination of the type of MPM. Since there is no individual antibody, today is in use a combination of antibodies with
different sensitivity and specificity.
Key words: Malignant mesothelioma, pleura,
1Institut
za plucne bolesti Vojvodine, Sremska Kamenica,
Srbija
2Institut za onkologiju Vojvodine, Sremska Kamenica, Srbija
652
1Institute for pulmonary diseases of Vojvodina, Sremska
Kamenica, Serbia
2Institute of Oncology of Vojvodina, Sremska Kamenica,
Serbia
P60
Imunohistohemijski pristup u
diferencijaciji nemikrocelularnih
karcinoma pluća na malim
biopsijskim uzorcima: prvi korak u
personalizovanoj terapiji
Immunohistochemical approach
in differentiation of non-small cell
lung cancer on small-sized biopsy
samples: the first step in personalized
therapy
Jelena Stojšić1, Jelena Marković1, Irena Jovanić2, Milan
Gajić3
Jelena Stojsic, Jelena Markovic1, Irena Jovanic2, Milan
Gajic3
Cilj: Precizirati optimalni panel monoklonskih antitela u diferencijalnoj dijagnozi NSCLC na malim biopsijskim uzorcima.
Uvod: Ciljna terapija povećava dužinu preživljavanja
i kvalitet života kod pacijenata sa karcinomom pluća ali
zahteva preciznu tipizaciju nemikrocelularnih karcinoma
pluća (NSCLC).
Materijal i metode: 50 biopsijskih uzoraka dobijenih
tokom bronhoskopije ili FNA biopsijom tokom poslednje
dve godine. Prema morfološkom nalazu dijagnostikovana
su 2 skvamocelularna karcinoma(SCC), 6 adenokarcinoma(AC), 9NSCLC verovatno SCC, 11NSCLC - verovatno AC i 22NSCLC(NOS) su bili dijagnostikovani. TTF1, Cytokeratin5, Napsin-A, p63 i CD56 i Synaptophisin
su korišćeni u diferencijaciji NSCLC.
Rezultati: Posle imunohistohemijskog bojenja
13(26.0%)SCC, 27(54.0%) AC, 3(6.0%) NSCLC sa neuroendokrinom diferencijacijom (NSCLC-NE) i 7(14.0%)
NSCLC(NOS) su bili dijagnostikovani. 22NSCLC- prethodno neklasifikovanih su bili dijagnostikovani kao 7SCC
i 7AC, 2NSCLC sa neuroendokrinom diferencijacijom i 6
NSCLC(NOS) su dijagnostikovani posle imunohistohemije. 8(20.5%)NSCLC versus 15(38.5%)AC, p=0.008. TTF1 je bio eksprimiran 23(85.2%) od 27AC, 1(14.3%) od
7NSCLC(NOS) i 2(66.7%) od 22NSCLC-NE. Napsin-A
je bio eksprimiran u 2(15.4%) od 13SCC, 23(85.2%) od
AC, 4(57.1%) od 7NSCLC(NOS) i 1(33.3%) od 3NSCLCNE. Cytokeratin 5 je bio eksprimiranu svih 13(100%)SCC,
2(7.4%) od 27AC i 2(28.6%) od7NSCLC(NOS). p63 je bio
eksprimiran u svih 13(100%)SCC i u 1(3.7%) od 27AC.
TTF-1 i Napsin-A su bili eksprimirani u 85.2%(23/27,
oba), a Cytokeratin5 i p63 u 100%(13/13)SCC. Pozitivnost
CD56 i synaptophisina u 3NSCLC determinisanih kao
NSCLC-NE.
Zaključak: Ni jedno monoklonsko antitelo nije u potpunosti specifično za jedan histološki tip tumora i njegovo poreklo. Optimalni panel u diferencijaciji NSCLC
su TTF-1, p63, Cytokeratina5, CD56, Synaptophisin ali i
Napsin-A ChromograninA.
Ključne reči: karcinom pluća, imunohistohemija.
Aim: To evaluate 6 monoclonal antibodies in
differential diagnosis of NSCLC on small-sized tissue
samples.
Introduction: Target therapy increases survival rate and quality of life of lung cancer patients
but requests precise subtyping of non-small cell lung
carcinoma(NSCLC).
Material and methods: 50 small-sized tissue samples obtained on bronchoscopy or FNAB. According
to morphology before immunohistochemistry 2 squamous cell carcinomas (SCC), 6 adenocarcinomas (AC),
9NSCLC-probably SCC, 11NSCLC-probably AC and
22 unclassified NSCLC were diagnosed. TTF-1, cytokeratin5/6, cytokeratin7, p63 and neuroendocrine markers CD56 and synaptophisin were used in differentiation NSCLC.
Results: After immunohistochemistry 13(26.0%)
SCC, 27(54.0%)AC, 3(6.0%)NSCLC with neuroendocrine differentiation(NSCLC-NE) and 7(14.0%)
NSCLC- unclassified(NOS) were diagnosed. 22NSCLCunclassified were diagnosed as 7SCC and 7AC, respectively, 2NSCLC with neuroendocrine differentiation
and 6NSCLC- unclassified(NOS). Significant difference was found between finally diagnosed 8NSCLC
and 15AC (20.5% versus 38.5%, p: 0.008). TTF-1 and
Cytokeratin7 were expressed in 85.2%(23/27) AC, respectively and Cytokeratin5/6 and p63 in 100%(13/13)
SCC, respectively. Positivity of CD56 and synaptophisin in 3NSCLC determinate as NSCLC-NE.
Conclusion:No one monoclonal antibody is totally specified for one histological type of tumor and
its origin. Optimal panel in differentiation of NSCLC
is TTF-1, cytokeratin7, p63, cytokeratin5/6, CD56,
Synaptophisin and Napsin-A and ChromograninA in
addition.
Key words: lung cancer, immunohistochemistry
1Odeljenje
torakopulmonalne patologije, Služba za
patohistologiju, Klinički Centar Srbije, Beograd
2Služba patohistologije, Institut za onkologiju i radiologiju
Republike Srbije, Beograd, Srbija
3Institut za medicinsku statistiku i informatiku, Medicinski
fakultet, Univerzitet u Beogradu
1 Department
of thoracopulmonary patology, Service of
pathology, Clinical centre of Serbia, Belgrade, Serbia
2Service of pathohistology, Institute for Oncology and
Radiology of Republic of Serbia, Belgrade, Serbia
3Institute for Medical Statistic and Informatic, Medical
Faculty, University of Belgrade, Belgrade, Serbia
653
P61
Imunohistohemijska analiza
“non-small” cell carcinoma pluća
Immunohistochemical analysis of
non-small cell lung carcinoma
Žaklina Mijović1, Dragan Mihailović1, Miloš Kostov2,
Nikola Živković1, Miljan Krstić1,
Zaklina Mijovic1, Dragan Mihailovic1, Milos Kostov2,
Nikola Zivkovic1, Miljan Krstic1, Milorad Pavlovic3
Cilj: Cilj ovog rada je imunohistohemijska analiza “non-small” cell karcinoma pluća na bronhoskopskim biopsijama.
Uvod: Za razliku od prethodne WHO klasifikacije (2004) u kojoj su primarni dijagnostički kriterijumi bazirani na hematoksilin eozin metodi, nova internacionalna multidisciplinarna klasifikacija adenokarcinoma pluća potencira upotrebu imunohistohemijskih bojenja (adenokarcinomatozni marker -tiroidni transkripcioni faktor, TTF-1 i skvamoidni marker -p63 i/iliCK5/6).
Materijal i metode: Bronhoskopske biopsije, fiksirane u formalinu i kalupljene u parafinu, 20 pacijenata sa planocelularnim karcinomom i 20 pacijenata
sa adenokarcinomom pluća su izdvojene iz plućnog
arhiva Instituta za patologiju Medicinskog fakulteta Univerziteta u Nišu. Serijski histološki isečci debljine 4 μm su bojeni hematoksilin eozinom i imunohistohemijskom metodom DAKO LSAB/HRP na
TTF-1 i CK 5/6 antitelo. Za stataističku analizu korišćen je Xi 2 test.
Rezultati: Pozitivna imunoreaktivnost na CK5/6
nađena je kod 18 od 20 (90%) slučajeva planocelularnih karcinoma i u jednom od 20 (5%) slučajeva adenokarcinoma (p<0,01). Kod 16 od 20 (80%) slučajeva adenokarcinoma nađen je pozitivan TTF-1 imunofenotip, dok su svi planocelularni karcinomi bili negativni na ovaj marker (0/20)(p<0,01).
Zaključak: Preporučeni panel imunohistohemijskih markera CK5/6 i TTF-1 je pouzdan u diferenciranju planocelularnog od adenokarcinoma pluća na
bronhoskopskim biopsijskim uzorcima.
Ključne reči: Imunohistohemija, „non-small
cell karcinom pluća, planocelularni karcinom,
adenokarcinom
Aim: The aim of this study was immunohistochemical analysis of non-small cell lung carcinoma in
bronchoscopic biopsy specimens.
Introduction: Unlike previous WHO (2004)
classifications where the primary diagnostic criteria
were based on hematoxylin and eosin method, the
new international multidisciplinary classification of
lung adenocarcinoma (2011) emphasizes the use of
immunohistochemical stain (adenocarcinoma marker -thyroid transcription factor, TTF-1 and squamous marker -p 63 and/or CK5/6).
Material and methods: Formalin-fixed, paraffinembedded bronchoscopic mucosal samples from 20
patients with squamous cell lung carcinoma and 20
patients with adenocarcinoma of the lung were retrieved from pulmonary pathology archives at Institute of
Pathology, Medical Faculty University of Ni . Serial
histologic sections of 4 ľm thickness were stained
with hematoxilin and eosin and immunohistochemical method DAKO LSAB/HRP for TTF-1 and
CK5/6 antibodies. The Xi 2 test was used for statistical analysis.
Results: Positive immunoreactivity for CK5/6
was found in 18 of 20 (90%) cases of squamous cell
carcinomas and in the one case of 20 (5%) adenocarcinomas (p<0,01). In 16 of 20 (80%) cases of adenocarcinomas were found a positive TTF-1 immunophenotype, while all squamous cell carcinomas
were negative for this marker (0/20) (p<0,01).
Conclusion: The proposed panel of immunohistochemical markers CK5/6 and TTF-1is reliable in
distinguishing squamous cell lung carcinoma from
adenocarcinoma in bronchoscopic biopsy specimens.
Key words: Immunohistochemistry, non smallcell lung carcinoma, squamous cell lung carcinoma,
adenocarcinoma
1Institut
Nišu,Srbija
2Služba za patologiju, Vojna bolnica, Niš, Srbija
3Milorad Pavlović, Služba za patologiju, Opšta bolnica
Leskovac,Srbija
654
1Institute
of Pathology, Medical Faculty, University of Nis,
Serbia
2Department of pathology, Military Hospital, Nis, Serbia,
3Department of pathology, General hospital, Leskovac, Serbia
P62
Pleuralna efuzija na autopsiji
Pleural effusion on autopsy
Petar Salević, Dragan Mitrović, Radmila Janković
Petar Salevic, Dragan Mitrovic, Radmila Jankovic
Cilj: Ispitati opštu učestalost, uzročnost, lokalizaciju, zastupljenost tipova i vrednosti količina pleuralnog izliva na obdukciji.
Uvod: I pored mnogobrojnih studija i radova u
dostupnoj literaturi koji su ispitivali mnogobrojne
aspekte pleuralne efuzije do sada nije bilo istraživanja koja su ispitivala karakteristike pleuralne efuzije na obdukciji.
Materijali i metode: Retrospektivnom studijom
su obuhvaćene 302 od 502 obdukovane osobe, podeljene u dve grupe: grupa obdukovanih pacijenata
sa pleuralnom efuzijom (n=229) i kontrolna grupa
(n=73) osobe bez pleuralne efuzije kad kojih su bila prisutna različita patološka stanja koja mogu biti
uzrok pleuralne efuzije.
Rezultati: Pleuralna efuzije bila je ucestalija kod
osoba muškog pola (X2=14,19 p: 0,0002). Najveći
broj obdukovanih sa pleuralnom efuzijom bio je u dve
starosne grupe: 60,0 - 69,9 (23,14%) i 70,0 - 79,9 godina (31,44%). Slabost srca bila je najučestalija medu pojedinačnim uzrocima, dok je u okviru udruženih
uzroka naučestalija bila kombinacija srčane slabosti i
brohopneumonije. Najzastupljeniji tipovi pleuralnog
izliva bili su: transudat (73,80%), eksudat (19,65%) i
krv (2,62%). Količine tecnosti u desnom pleuralnom
prostoru (MED=120 ml) bile su veće od kolicina tečnosti u levom pleuralnom prostoru (MED=100 ml).
Zaključak: Pleuralna efuzija je učestalija kod muškaraca i osoba starosne dobi između 60 i 80 godina.
Pleuralna efuzija predstavlja važan klinički nalaz koji
najčešće upućuje na srčanu slabost, pneumoniju, maligne neoplazme i plućnu emboliju, ali može biti izazvan i ređim uzrocima koji neposredeno ugrožavaju život bolesnika kao što je krvarenje u pleuralnom
prostoru, stoga je u kliničkom radu potrebno posebno obratiti pažnju na mogućnost nastanka pleuralne
efuzije kod bolenika sa navedenim bolestima.
Ključne reči: Pleuralna efuzija, transudat, eksudat, srcana slabost, pneumonija
Aim: To show general frequency, causes, localization, frequencies of different tipes and value of
amount of pleural effusion on autopsy.
Introduction: Beside noumerous studies in available literature that examined various aspects of pleural effusion there was no studies that examined characteristics of pleural effusion on autopsy.
Material and methods: The postmortem retrospective study consisted of 302 persons divided into
two groups, group of patients with pleural effusion
and control group, patients without pleural effusion
who had different pathological condition that might
be causes of pleural effusion.Results: Pleural effusion
was more frequent in males (X2=14.19 0.0002). Most
of the patients with pleural effusion was in two age
groups: 60,0 - 69,9 (23.14%) and 70,0 - 79,9 years
(31.44%). Heart failure was the most common among
single causes, while combination of heart failure and
pneumonia was most common among associated causes. The most frequent tipes of pleural effusion were: transudate (73.80%), exudate(19.65%) and blood (2.62%). Amounts of liquid in right pleural space (MED: 120 ml) were above amounts of liquid in
left pleural space (MED=100 ml).
Conclusion: Pleural effusion is more frequent
within males and persons aged 60 80 years. Pleural
effusion is important clinical finding that in the most
cases implicates on heart failure, pneumonia, malignancy and pulmonary embolism, but also can be caused by some less frequent conditions which immediately endangers patient s life such as bleeding in
pleural space. Therefore it is very important in clinical practise to pay attention on patients whith these conditions.
Key words: Pleural effusion, transudate, exudates, heart failure, pneumonia.
Institute of pathology, Faculty of Medicine, University of
655
uputstvo za autore
Časopis „Materia Medica” izlazi četiri puta godišnje i objavljuje radove iz različitih oblasti biomedicine.
Za publikovanje se primaju sledeće vrste radova: uvodnici (do 5 strana), originalni radovi (do 10 strana), revijalni radovi (do 12 strana), seminarski radovi (do 10 strana) prikazi slučaja (do 5 strana), pisma uredniku
(do 2 strane), prikazi knjiga (do 2 strane), dopisi za rubriku u spomen - „In memoriam” (do 5 strana), istorija
medicine (do 5 strana) i konferencijska saopštenja (do 5 strana). Uređivački odbor se striktno pridržava principa Dobre naučne prakse. Kada pripremaju rad za publikovanje autori moraju da se pridržavaju uputstva koje je predložio Internacionalni komitet za urednike medicinskih časopisa, a koje je publikovano na web sajtu
Internacionalnog komiteta urednika medicinskih časopisa http://www.icmje.org/
UPUTSTVO ZA PRIPREMU RUKOPISA
Koristite Time New Roman, font 12, justify orjentaciju (Ctrl + J) i prored 1,5
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Apstrakt treba da sadrži sledeće delove
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1. Paragraf - 1-2 uvodne rečenice za centralnu rečenicu Centralna rečenica, ključna rečenica prvog paragrafa je odgovor na pitanje „Šta mi znamo” (polje istraživanja). Posle centralne rečenice slede 1-2 završne rečenice za 1. paragraf ili 1-2 prelazne na sledeći paragraf. Poželjno je ovaj deo potkrepiti sa 1-2 reference, ne više od 5, a najbolje je da to budu poglavlja iz udžbenika ili revijalni radovi.
2. Paragraf – 1-2 uvodne rečenice ka centralnoj rečenici drugog paragrafa. Centralna rečenica, ključna rečenica prvog paragrafa je odgovor na pitanje „Šta mi ne znamo” (problem istraživanja). Čitaoca
upoznajete sa postojećim podacima (tuđim i sopstvenim) o problemu koji istražujete, o ograničenjima da se
taj problem reši i o pitanjima na koja odgovori još nisu dati. Citirati samo one reference koje se neposredno
odnose na istraživanje istog predmeta i koja su prethodila vašem istraživanju.
3. Paragraf - Cilj vašeg istraživanja.
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uputstvo za autore
Sugestije:
Ako preterate sa referencama u Uvodu izgubićete „blago” za diskusiju i opteretićete spisak literature (većina časopisa dozvoljava, pa i mi najviše 25-30 referenci. Prilikom prikupljanja reference neophodno je citirato reference novijeg datuma, naravno da neka stara (“kapitalna”) može naći svoje mesto. Redosled referenci koje citirate treba da sledi logičan raspored paragrafa uvoda. Prve reference su one koje se odnose na uopšteno znanje o problem i reference o istraživačkom problem. Zatim slede reference vezane za nova istraživanja - prethodna, aktuelna istraživanja i njihove limitacije
Nikada u Uvodu ne iznositi svoje rezultate
Konkretan cilj se obično navodi u jednoj rečenici (poslednjoj rečenici Uvoda) koja postavlja očekivanja
zbog kojih je istraživanje započeto i zbog kojeg se rad piše. Vodite računa cilj je prva rečenica strukturiranog
apstrakta i poslednja rečenica Uvoda .
4. strana
Materijal i metode
Opišite kako ste došli do rezultata (precizan dizajn studije, metoda koju ste koristili i kako ste analizirali podatke). Tačni podaci gde je studija sprovedena. Budite koncizni ( ne pišete turistički vodič). Ukoliko koristite standatdni metod citirajte referentnu literaturu. Sve mere koje saopštavate u poglavlju rezultati, u poglavlju metode moraju imati opisan način kao se do njih došlo. Prilikom čitanja ovog metoda, treba omogućiti čitaocima da imaju kritički uvid u vaš radi i da ponove vašu studiju baš na onaj način kako ste je vi uradili. Podnaslovi koji se koriste u poglavlju metoda kao što su: učesnici, dizajn studije, specifične metode, analiza podataka... klasično određuju njen sadržaj. Neophodno je da date detalje o odobrenju vaše studije, koje je
dao etički komitet vaše institucije u kojoj je istraživanje sprovedeno. Zbog toga što su etnički principi fundamentalni za dobru istraživačku praksu, mnogi časopisi ne žele da publikuju članke koji ne uključuju detalje
o etničkim odobrenjima (Materia Medica je prihvatila Principe dobre naučne prakse). Čitaoci žele da znaju
na koji ste način uključili ljude u vašu studiju. Stoga, izbor učesnika mora biti jasno opisan i uključujući i isključujući detalji moraju biti opisani u sitnice. Prilikom opisivanja učesnika studije, njihova privatnost mora
biti poštovana. Ne smete uključiti bilo kakve indentifikacione infomacije o njima, u tekstu, tabelama ili fotografijama. Ako se koristi fotografija, pismeni pristanak mora biti uzet od pacijenta ili ako su deca, od njihovih roditelja. Veličinu i karakteristike uzorka, ne stavljajte u poglavlje materijal i metode nego stavite na početak poglavlje rezultati. Mnoge istraživačke studije koriste upitnike pa u poglavlju metode morate dati precizne detalje o upitiniku, koje ste koristili, kako ste ga razvili, i testirali za ponovljivost. U eksperimentalnim
studijama, detalji intervencija i kako su primenjeni moraju biti u potpunosti opisane.
5. Strana
Rezultati
Posle metoda, predstavlja najlakše poglavlje za pisanje. Možete koristiti interesantne kombinacije teksta,
tabli i figura da odgovorite na pitanje studije u vidu jasne priče. Ovo poglavlje iz praktičnih razloga je poželjno pisati posle poglavlja metode, a pre pisanja uvoda i diskusije. Osnovno je da sopstvene rezultate učinite
jasnim za čitaoca kako bi razumeli šta ste radili i dokle ste stigli. Ovo poglavlje mora voditi čitaova kroz proces istraživanja. Dužina ovog poglavlja je određena isključivo brojem rezultata koje želite da prikažete, a ne
onim što vi želite da kažete o tome. Rezultate treba prikazivati postepeno.
Prvo se prikazuju elementi deskriptivne statistike koja opisuje karakteristike uzorka studije. To je prvi paragraf poglavlja rezultati i njegov cilj je da precizno i jasno prikaže detalje vašeg uzorka. To je veoma važno,
jer epidemolozi žele da znaju kako ste definisali karakteristike vašeg uzorka, a kliničari žele da znaju koliko
su učesnici u vašoj studiji slični sa njihovim pacijentima. Po završetku statističke analize podaci i rezultati se
mogu prikazati na tri načina: tekstualno, tabelama i figurama.
Tekst – pojedine rezultate je bolje prikazati jednostavnim rečenicama sa podacima stavljenim u zagradu.
Primer: srednja vrednost proliferativnog potencijala za PCNA (2.20%) je veća nego srednja vrednost za Ki67 P (1.64%) i Cyclin D1 (1.36%).
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uputstvo za autore
Tabele – predstavljaju popis brojeva ili teksta u rubrikama pri čemu je svaka rubrika obeležena. Tabele pored prikazivanja podataka na pregledan način omogućavaju i ekonomično raspologanje prostorom u članku.
Ne treba ih koristiti da bi se pokazao način kretanja nekih rezultata (trend) ili veza između pojedinih rezultata
i to je bolje prikazati figurama (dijagramima). Na primer ukoliko želite da prikažete veličinu uzorka i odnos
polova vaših ispitanika bolje je da koristite tabelu. Međutim, ukoliko želite da prikažete način na koji je pol
povezan sa uzorkom populacije onda je bolje koristiti dijagrame. Legenda tabele se stavlja ispod tabele, levo
orjentisana. U mnogim eksperimentalnim i opservacionim studijama je neophodno da prikažete osnovo upoređivanje studijskih grupa koje takođe definišu sposobnost generalizacije vaših rezultata. Nikada ne nazovite
osnovnu karakteristiku vašeg uzorka ,,demografskim“ jer shodno Oksfordskom rečniku, demografija je grana antropolologiju u kojoj se proučava statistika, rođenja, smrti i bolesti i stoga, to nije prikladno za ovaj kontekst. U bilo kojoj studiji, procenat, srednja vrednost i njena standardna devijacija ili medijana i njen rang su
najprikladnije metode deskriptivne karakteristike i zavise od informacija koje opisuju.
Figure – prikazivanje rezultata figurama podrazumeva korišćenje dijagrama, fotografija, šema, mapa i crtreža kako bi se na jasan i pregledan način prikazali rezultati dobijeni u istraživanju. Postoji više vrsta dijagrama (štapišasti dijagram (engl. bar chart), histogrami učestalosti (engl. histogram) , pogačasti dijagrami (engl. pie chart) , linijski dijagrami (engl. line graph), i grafikoni sa slikama (engl. pictograph) prilagođenih za
opisivanje i prikazivanje različitih vrsta obeležja i rezultata.
Sledeći paragraf poglavlja rezultati se odnosi na opisivanje bivarijantnih analiza.
U trećem paragrafu se opisuju multivarijantne analize i to je mesto gde se završava cilj ili testiranje hipoteze, navedeno na kraju poglavlje uvod. Prilikom pisanja ovog paragrafa jedino je bitno da kažete čitaocu ono što on želi da zna. Nemojte dodavati ili uključivati bilo kakave podatke koji se udaljavalju od glavnog cilja. Podsećamo vas da rezultati i podaci nisu ista stvar, nije potrebno da ponavljate brojeve u tekstu koje ste prikazali u tabelama ili figurama. Čitaoci žele da prime poruku iz tabela ili figura i ne treba im dozvoliti da sami interpretiraju.
6. Strana
Diskusija (1/3 vašeg teksta)
Diskusija je vrlo često najslabiji deo članka. Pojedine stvari u poglavlju diskusija praktično NE SMETE
uraditi:
1. ne ponavljajte činjenice iz uvoda
2. izbegavajte ponavljanje rezultata
3. ne prikazujte rezultate koje niste prikazali u poglavlju rezultati
4. ne postoji ni jedan razlog da podvlačite koliko je „sjajan“ vaš rezultat, dozvolite da čitaoci sami o tome prosude
Diskusija ne predstavlja jednostavno ponavljanje rezultata ili potvrde njihove tačnosti. Svaka diskusija
iznosi ono izvan očiglednosti (engl. beyond the evidence). Svaki članak sadrži zaključak koji se ne nalazi u
poglavlju rezultati. Takođe svaki statistički značajan nalaz nema klinički značaj.
Diskusiju bi trebalo započeti, po mogućstvu jednom rečenicom - ponavljanjem glavnog nalaza. 1. paragraf poglavlja diskusija se jednostavno može početi: „Naša studija pokazuje...” i izneti sažeto nalaz naše studije, po mogućstvu u jednoj rečenici.
2. paragraf - treba izneti jasno i precizno (praktično opširno) prednosti i nedostatke studije sa podjednakim naglaskom na oba elementa. Posebno treba imati na umu da će i urednici i čitaoci biti najzainteresovaniji baš za taj paragraf diskusije. Ukoliko urednik ili čitalac otkriju nedostatke u vašoj studiji, a vi ih niste opisali izgubiće poverenje u vašu studiju, jer praktično se postavlja pitanje: „Kolika je snaga vaše studije ako vi
niste uočili nedostatak”.
3. paragraf se odnosi na studiju koja je izvedena. Neophodno je izneti doprinos studije. Ne treba iznositi
da li je i u kojoj meri bolja od prethodnih studija na osnovu kvaliteta ili nedostataka koje ste izneli u prethodnom paragrafu, nego treba prednosti i nedostatke sopstvene studije uporediti sa prednostima i nedostacimma
drugih studija. Vrlo je važno da naglasite zašto ste vi dobili drugačije rezultate od ostalih ukoliko ste ih dobili. Pažnja! U ovom trenutku postoji opasnost da uđete u sferu špekulacija. Ukoliko ne znate zašto se vaši rezultati razlikuju od drugih iznesite to i ne pretendujte da su vaši ispravni, a tuđi pogrešni.
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uputstvo za autore
U trećem paragrafu možete diskutovati saglasnost ili kontradiktornost vaših rezultata sa rezultatima drugih studija ili opšteprihvaćenih dogmi.
4. Paragraf Vi sada iznosite šta vaša studija “stvarno” znači. Objasnite jasno doprinos vaših rezultata kliničarima ili drugim čitaocima. Ali, vi ste i ovde na opasnoj zemlji. Mnogi urednici i čitaoci prihvataju vaše
rezultate sa opravdanom opreznošću. To je zato što vaši rezultati tek publikovanjem ulaze u fazu kritičkog
mišljenja naučne javnosti i budućeg prihvatanja ili odbacivanja. Dozvolite čitaocu da izgradi sopstveni stav
o vašem istraživanju. Opišite novinu koju je doneo vaš nalaz u odnosu na rezultate drugih studija. Samo se
početnici u pisanju trude da referišu sve članke koje su publikovali identičan aktuelni problem (engl. topic).
Sugestije
Ni jedan časopis nema dovoljno sredstava da štampa svaki detalj i duge članke. Neophodno je izabrati
prikladan broj referenci koje će prikazati željeni uvid (najviše 30). Izbegavajte da citirate apstrakte, a nikada ne citirajte apstrakte starije od dve godine ukoliko nije publikovan originalan članak koji je predstavljen
apstraktom na nekom kongresu ili sastanku.
Možete sebi dozvoliti još jedan paragraf ukoliko želite da diskutujete o pojedinim pitanjima koja ostaju
nejasna i da predložite npr. pravce dajih istraživanja. Na tome će neupadljivo uživati i urednik i čitaoci. Zašto?
Urednik vidi potencijalnu mogućnost za nove članke a čitalac ideju za sopstvena istraživanja. Vi naravno ne
morate iznositi stavove po pitanju novih istraživanja i vaša diskusija može biti bez tog dela. Praktično ne posedujete argumente za sigurnost onoga što predlažete i može biti domen špekulacija. Sada možete izneti jasan zaključak.
Zaključak
Kratko i sažeto iznesite potencijalni značaj vašeg nalaza i koliki je njegov doprinos dotadašnjem znanju.
Pojedine stvari u zaključku praktično NE SMETE uraditi:
1. Ne iznosite zaključke koji nisu potkrepljeni rezultatima
2. Ne iznosite vaše mišljenje kako da se reši neki problem, a da ga pritom niste analizirali u svojoj studiji
3. Ne pišite pregled svih mogućih mehanizama ako ih niste uključuli u svoju studiju
POSLEDNJA STRANA VAŠEG RADA
Literatura
Izvore za istraživačke ideje i sopstveni rad naučnici nalaze u originalnim naučnim člancima. Pravilno citiranje članaka je važno jer predstavlja sa jedne strane izvor informacija, a sa druge strane način izražavanja
poštovanja prema naučniku/cima koji su autori originalnog dela i koji su ga prvi objavilu. Korišćenje ideja
drugih istraživača ili bilo kog dela njihovog pisanja kao sopstvenog, čini se težak etički prekršaj poznat kao
plagijarizam. Reference numerički navodite kroz članaki u vidu liste na kraju članka, koristeći Vancouver stil
Pravila za citiranje originalnih naučnih članaka prema Vancouver stilu podrzumevaju da se autori navode
prezimenima posle kojih slede inicijali imena, bez tačke i pojedini se autori odvajaju samo zarezima. Navodi
se prvih 6 autora(ako ih ima), a posle toga sledi sentenca ,,at al“. Spisak autora se završava tačkom, pa sledi jedan prazan prostor i tada se piše naslov, koji se završava tačkom pa sledi jedan prazan prostor, pa potom
ime časopisa prema previlima index medicus-a. Ne stavlja se tačka, već postoji samo jedan prazan prostor, pa
se posle piše godina publikovanja članka, sledi tačka zarez, pa volumen, dvetačke, a potom broj strane i tačka. Broj sveske ili datum volumena nisu uključeni u citiranje. Sve detalje o pravilnom citiranju možete naći
na web adresi: http://ncbi.nlm.nih.gov/books/bv.fcgi?rid=citmed.TOC&depth=2.
I naravno posetite web adresu International Committee of Medical Journal Editors. Uniform requirements
for manuscripts submitted to Biomedical Journals (http://www.icmje.org), za sva dodatna pitanja ILI SE
OBRATITE REDAKCIJI.
I na kraju to pošaljite na redakciju časopisa kbczpatologija@open.telekom.rs
Obavestićemo vas o prispelom radu i proslediti ga u postupak recenziranja, a vama poslati da potpišete izjavu o sukobu interesa. Naši recenzenti će zajedno sa uredništvom pomoći da dođemo do publikovanog članka.
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