1,721,234 research outputs found
Corso Istituzionale SOI - C - OFTALMOPLASTICA: APPROCCIO CLINICO PRATICO ALLA PATOLOGIA DELL'ORBITA
No full textObiettivo: Il corso si propone di fornire all'oftalmologo le linee guida di comportamento da seguire quando ci si trova di fronte ad un problema di patologia orbitaria. Sinossi: Partendo da una prima classificazione di base che distingue la patologia in: traumatica, infiammatoria, distiroidea e neoplastica, vengono indicati i diversi segni clinici da ricercare, le eventuali indagini strumentali da richiedere e le possibili terapie mediche e/o chirurgiche da eseguire nelle modalità e nei tempi ritenuti più corretti. Trattandosi, inoltre, di una branca di confine viene sottolineata l'importanza della collaborazione con gli specialistiaffini: neurochirurgo, oncologo, radiologo e radioterapista, anatomo-patologo, che personalmente illustreranno il loro ruolo fondamentale nella costituzione di una equipe multidisciplinare di patologia orbitaria
EUS in mediastinal and lung lesions/EBUS
No full textEnclosed between the sternum, the lungs and the vertebral column, the mediastinum is one of the least accessible areas of the body; the need to explore mediastinal structures is mainly represented by lymph nodal investigations for staging of non small cell lung cancer (NSCLC), detection of direct mediastinal involvement in lung cancer (LC), and the diagnosis of indeterminate mediastinal masses. Mediastinal lymph nodes can be investigated with different techniques, each one carrying advantages and limitations. Contrast enhanced computed tomography (CT) is recommended as first diagnostic step, although it is poorly sensitive in the diagnosis of small lymph nodes (≥ 1cm); moreover, reactive lymph nodes larger than 1 cm. may present additional diagnostic difficulties. Positron emission tomography (PET) is highly effective in staging advanced disease but is less specific in the diagnosis of metastatic lymph nodes because of a significant false positive rate (>20%)—hence its specificity is too low to be used as the sole criteria for surgery exclusion. Mediastinoscopy (MS) is considered the gold standard for mediastinal investigation and is generally recommended before LC therapeutic surgery; however, MS requires general anaesthesia, is associated with a significant rate of false negatives (10/15%) mainly related to the difficulties in exploring the posterior mediastinum but has a low complication rate (2/3%). As in primary LC, broncoscopic techniques fail to diagnose up to 30% of LC: in fact, the overall sensitivity of bronchoscopy (FB) in the diagnosis of LC is about 80%, but this percentage decreases in case of peripheral lesions. Therefore histological or cytological evaluations are still necessary to accurately diagnose and stage LC and other mediastinal masses, despite the variable sensitivity of blind transbronchial FNA and transthoracic FNA. Trans-oesophageal endoscopic ultrasound (EUS) combined with fine-needle aspiration (EUS-FNA) and, more recently, endobronchial ultrasound guided trans-bronchial needle aspiration (EBUS-TBNA) have completely changed the diagnostic approach to mediastinal masses and lymph nodes. Both techniques have demonstrated very high sensitivity and specificity, with sensitivity values ranging between 80% - 90%y for EUS-FNA and 90% - 100% for EBUS-TBNA according to different series, proving to be the best performing methods compared to others. In addition to the advantages shared by the two techniques, EUS allows better access to the posterior/inferior mediastinum, namely to sub carinal and paraoesophageal (7 and 8 levels) lymph nodes and to the masses proximal to the oesophagus; EBUS allows better access to peritracheal nodes(?) and to the regions adjacent to the main bronchi, and seems to be more useful for right-sided lymph nodes. Selection of EUS or EBUS to sample specific lymph node stations should be performed on the basis of PET and CT scans, and the availability of both techniques might, in a very near future, replace MS. Moreover since lymphadenopathy after treatment of malignancy is not a definitive sign of recurrence, preliminary studies have used EUS and EBUS to restage mediastinal LN after CHEMO-XR therapy in NSCLC patients.From a cytopathological point of view, the first task is to assess the adequacy of the diagnostic material and its management. In this perspective, the on site evaluation is considered indispensable—albeit time consuming—and requires that the different work schedules coincide. Liquid-based-thin-layer cytological technique provides high-quality specimens for diagnostic purposes; this approach might produce high-quality specimens without the need for direct on-site evaluation, although at present there is only limited experience supporting this solution. In some institution cytotechnologists are deputed to this task whereas(although??) cytological interpretation of the corresponding samples may be complex even for experienced cytopathologists. Adequacy criteria are not well established: the quantitative evaluation of lymphocytes is generally considered a criteria of adequacy for EUS/EBUS lymph node specimens(?) whereas, in metastatic lymph node smears, lymphocytes may be scanty or even absent. Oesophageal or bronchial cells contamination is frequently observed in these cytological samples and should not bear on adequacy. As for the diagnostic difficulties, bronchial contamination, especially by metaplastic or dysplastic cells, can cause problems in the differential diagnosis, as epithelial cells may lead to “atypical” or even false positive diagnoses. Therefore recognizing bronchial or oesophageal contamination is important to avoid diagnostic pitfalls. At the same time, dense lymphoid groups with large cells intermingled with mature lymphocytes, possibly combined with crushed nuclei, can be confused with small-cell LC. Technical factors may also represent additional difficulties: as in other cytological samples, air drying and poor preservation may blur the cytological features of contaminant epithelial cells and reserve cell hyperplasia. Cell block sections are helpful in clarifying these cytological difficulties, but incorrect on-site evaluation may determine the need for repeat testing, thus delaying the final diagnosis. Therefore, whenever possible, adequacy evaluation and cytological diagnoses should be performed by experienced cytopathologists. In fact, reproducibility of the cytological diagnosis obtained by EBUS-TBNA and EUS-FNA has proven to be excellent among experienced cytopathologists; cytopathologists with less experience in this type of sampling have shown a steep learning curve and, after specific training, the reproducibility of their diagnoses was markedly improved. Therefore it seems that on-site evaluation performed by experienced pathologists is necessary to keep high levels of sensitivity and specificity. The need for experienced cytopathologists is also related to the increasing variety of possible targets and corresponding pathological processes: metastases from different sites, sarcoidosis, mesenchimal tumours and other pathological processes, diagnosed by EUS-FNA, have been described, and their evaluation requires specific cytopathological experience. As for the diagnosis of primary LC and mediastinal masses, the task of the cytopathologist is to identify the histotype, especially with regard to the distinction between small-cell and non-small LC, and to diagnose mediastinal masses. In these cases, other than adequacy, on site evaluation should determine the management of residual FNA and possible repetition to obtain additional diagnostic material. Paraffin embedded cell blocks of formalin fixed cells and small tissue fragments generally provide excellent material to visualize dense cell groups, as well as for the immunocytochemical determinations necessary to diagnose “solid” tumours and Hodgkin lymphoma. In case of non-Hodgkin lymphoma, residual cells and/or additional passes may be suspended in buffered solution or RMPI for flow-cytometric evaluation. Therefore, considering the generally scanty diagnostic material available, its management during the on-site evaluation is an important step of the diagnostic algorithm. Finally, new targeted therapies appear promising for an improved prognosis of NSCLC, and phenotypic and genetic profiles are necessary to assess their biological features. At the same time, an accurate cytological diagnosis on EUS-EBUS specimens, avoiding MS or unnecessary surgical treatments, reduces the need to collect additional biologic material in up to 50% of the cases. Therefore, in these instances, FNA provides the only diagnostic material to be utilized for molecular assessment.In conclusion, among the diagnostic procedures available for mediastinal pathologies, EUS-FNA and EBUS-TBNA are accurate, minimally invasive, and relatively expensive. Immediate assessment of adequacy and specific experience in cytopathology are necessary for an optimal outcome of the whole diagnostic procedure
Amyloid Deposits in Bone Marrow Smears of Multiple Myeloma
No full textObjective: Amyloid deposits (AD) in bone marrow (BM) of multiple myeloma (MM) patients might herald systemic AL amyloidosis. The purpose of this study has been to detect AD in bone marrow smears of MM patients and to compare AD status with clinical and Ig serological status (light and heavy chains).Methods: BM smears of 22 consecutive patients were utilized; twelve were from patients at diagnosis and 10 from patients after effective treatment or relapsed. BM air-dried smears were stained by Congo red and evaluated by transmission birefringence microscopy. AD were identified as diffuse, dense, blob-like amorphous pink material with sharp outlines or focal strips of pink, stroma-like material with bone marrow cells tightly attached. These AD showed apple-green birefringence in both presentations. Plasma cell intracellular reddish spindle-shaped inclusions (Auer rods–like) were also detected in positive cases. Both cytological presentations were considered positive.Results: Eleven cases (50%) were positive for AD: no relations with clinical status (5 patients at the diagnosis and 6 with advanced disease), bone marrow plasma cell percentage or Ig isotype were found. Conclusions: AD may be easily detected on BM smears by Congo red stain and their incidence seems higher than that reported in literature (about 15%). Enlarged cohort and prolonged follow-up are needed to assess their possible prognostic significance
Flow Cytometry Phenotypization of Intrathyroidal Lymphoid Infiltrate and Thyroidal Functional Status in Hashimoto Thyroiditis on Fine-Needle Cytology Samples
No full textObjective: Intrathyroidal lymphoid infiltrate (TLI) may show qualitative and quantitative differences in Hashimoto thyroiditis (HT); thyroidal functional status (TFS) may differ among HT patients. The aim of this study has been to evaluate TLI in different TFS of HT.Methods: Flow-cytometry (FC) was applied to thyroidal fine-needle cytology samples (FNC) in 23 patients. TLI was analyzed using the following fluoresceinated antibodies: CD3, CD4, CD5, CD8, CD10, CD19, CD25, CD69, CD95 (FAS). TFS was determined by serum TSH, FT3, FT4 immunoassays, in specific clinical settings, to classify the patients as euthyroid (16) and hypothyroid (7). Pearson's correlation coefficient was used to evaluate possible correlations between CD4/CD8 ratio, CD4+ CD25+ CD69-: regulatory T (Treg) cells proportion, CD95 expression and TFS.Results: B-lymphocytes (CD19+, CD10±, CD5-, CD3-) were present in 18 cases, T-lymphocytes (CD19-, CD10-, CD5+, CD3+) in all the cases. CD4/CD8≥2:1 ratio was observed in 16 euthyroid and 3 hypothyroid; CD4/CD8≤1:1 ratio in none of euthyroid and in 4 hypothyroid. CD4+ CD25+ CD69- Treg cells proportion was lower in hypothyroid than in the euthyroid patients; CD4+, CD25+, CD95(FAS)+ were mainly expressed in hypothyroidism. Statistical analysis did not demonstrate associations among CD4/CD8 ratios, Treg cells proportions and CD95 expression in the two TFS. Conclusions: FNC may be used to assess TLI in HT. Intrathyroidal CD4/CD8 ≤ 1:1 ratio, CD4+, CD25+, CD69- cells reduction and CD95(FAS)+ are expression of Treg cells apoptosis and might be related to intense thyroidal damage and risk of hypothyroidism. Further studies are needed to assess their possible prognostic significance
Citologia aspirativa in patologia mammaria
No full textLa diffusione dello screening mammografico di massa ha portato all'attenzione di radiologi, clinici e patologi, un numero sempre crescente di semplici immagini e vere lesioni mammarie non palpabili. Gli aspetti radiologici ed ecografici permettono una discriminazione certa tra lesioni benigne e neoplastiche solo in una parte dei casi; in un numero elevato di casi, l' imaging da solo non riesce a diagnosticare con certezza queste lesioni che pertanto necessitano di un accertamento morfologico diretto. Non considerando in questa sede le lesioni di maggiori dimensioni e quelle piccole per le quali esiste una concordanza tra clinica ed imaging “ab inizio”, oggetto di questo intervento è il contributo citologico e/o istologico che il patologo è chiamato a dare nelle lesioni mammarie neoplastiche e non neoplastiche “piccole”, di non univoca interpretazione ecografia e radiologica, sottoposte pertanto a biopsia aspirative per ago sottile o ad indagine bioptica non escissionale mediante ago tranciante. Le lesioni non neoplastiche che più frequentemente sono sottoposte ad accertamento diretto sono costituite da un insieme abbastanza eterogeneo identificate in corso di mammografia o ecografia. Le più frequenti sono distorsioni strutturali che non recedono alla compressione mirata ed addensamenti a margini sfumati, entrambe con o senza microcalcificazioni. Seguono le cicatrici radiali, “briglie” e fibrosi a banda sia primitive che secondarie a pregressi interventi chirurgici e microcalcificazioni a spot senza addensamento. Le controparti morfologiche di tali quadri non sono né specifiche né costanti; in ordine di frequenza possono essere rappresentate da addensamenti fibrolipomatosi, mastopatia, steatonecrosi, adenosi ed adenosi sclerosanti. Un'altra quota di queste lesioni è identificata ecograficamente ed è rappresentata prevalentemente da addensamenti a margini sfumati, aree specifiche nel contesto di mastopatie a grosse zolle, lesioni ad elevata impedenza acustica, e lesioni che sfuggono alla mammografia per ragioni “topografiche” (retroareolari, del solco sottomammario, del prolungamento ascellare). Anche per queste immagini e lesioni le controparti morfologiche non sono né specifiche né costanti, essendo rappresentate da mastopatie, steatonecrosi, lesioni cistiche a contenuto disomogeneo, lesioni ascessuali inclusa la cisti cheratinica subareolare, fibroadenomi, tessuto mammario ectopico ed idrosadeniti. A queste lesioni di maggiore incidenza vanno inoltre aggiunte lesioni rare e/o ad inusuale presentazione strumentale. Nell'ambito delle malignità, non considerando quelle che presentano caratteri radiologici certi, le lesioni più frequentemente indagate sono il piccolo carcinoma (< 1cm), il carcinoma ben circoscritto e/o privo di microcalficazioni, le microcalcificazioni senza addensamento tissutale e più in generale tutte le varianti “non ordinarie” del carcinoma mammario. I quadri ecografici corrispondenti a malignità nei quali è più spesso richiesto l'intervento diretto del citologo sono rappresentati per lo più da lesioni profonde e/o mammograficamente mute e da aree specifiche nel contesto di addensamenti. Anche a questo insieme di reperti di imaging non sempre corrispondono istotipi specifici; più frequentemente tuttavia si osservano carcinomi duttali ben differenziati e carcinomi lobulari, in tutte le loro possibili varianti.L'indagine morfologica è affidata o alla citologia per ago sottile (FNC) o alla microistologia per ago tranciante o per suzione sotto vuoto. Entrambe queste metodiche presentano vantaggi e limiti, costi e benefici che si stratificano nei singoli pazienti e nelle singole lesioni. La nostra unità operativa utilizza prevalentemente la FNC; molti studi hanno paragonato la sensibilità della microistologia con quella della FNC nella diagnostica di queste lesioni, con risultati contrastanti (1-9). Sebbene la microistologia sembri essere preferita in molti centri è importante ricordare che un esame citologico con assistenza diretta da parte del citopatologo (immediate reporting), consente una valutazione diagnostica contestuale che può essere definitiva, suggerire un immediata ripetizione o, in alternativa, l'impiego della microistologia
Role of Cytopathology in Selecting Patients for Target Treatments.
No full textNon Hodgkin lymphomas (NHL) are a heterogeneous group of lymphoid malignancies comprising morphologically and biologically different lymphoid neoplasms. NHL have been the subject of intensive studies and research that have produced a significant amount of new knowledge concerning the phenotypic, genetic, genomic and proteomic aspects of the different entities composing this group of diseases. This knowledge has determined a better definition of some entities and the further sub-classification of others. In the past few decades, traditional clinical trials have not led to significant improvements in patient survival, and therefore the final goal of an accurate phenotypic and molecular profiling of the single entities composing NHL is the development of medical “tailored” to individual patients treatment and not bound by the rigid application of pre-determined protocols. This treatment should utilize, in a next future, new drugs and compounds with unique mechanisms of actions against distinct molecular targets instead of traditional chemotherapy performed with the same drugs and the same doses for all patients. Fine-needle aspiration cytology (FNA) has gained a defined role in the diagnosis of NHL because, in addition to advantages concerning of the technique, it has been successfully utilized together with flow cytometry (FC) (1), fluorescence in situ hybridization (FISH) (2,3) and other molecular techniques; a recent report has also demonstrated the feasibility of gene expression profiling in NHL FNA specimens (4). The aim of this presentation is therefore to overview the potential role of FNA in selecting NHL patients for target treatment. Histone deacetylase inhibitors and BCL6 in aggressive lymphomas: BCL6 protein is normally expressed in germinal b-cells; its primary function is to repress the genes involved in lymphocytes activation differentiation and apoptosis. BCL6 is generally over-expressed in many diffuse large B-cell lymphomas (DLBCL) and chromosomal 3q27 translocation, where the BCL6 gene is located, is observed in about 35% of DLBCL. The deregulation of the gene causes the over-expression of BCL6, which inhibits the apoptosis and the differentiation of germinal centers promoting the arising of malignant clones. It has recently been claimed that, as happens to histones wrapping DNA, the activation of the BCL6 gene may be determined by the acetylation status. Acetylatation of the gene inhibits its repressor function; conversely, deacetylation restores the repressor functions of the gene. In the last few years, some drugs that inhibit histone deacetylase (iHDAC), such as depsipepside, have been shown to be effective in the treatment of NHL over-expressing BCL6. These iHDAC could deactivate the BCL6 gene promoting cell differentiation and apoptosis, and leading to tumor regression. Therefore, proof of BCL6 protein over-expression and/or the t3q27 translocation would provide useful information for therapeutic planning (5), which could be obtained on FNA samples too, enabling the target utilization of these drugs.Ubiquitin-Proteasome and cell cycle proteins: Proteins p21 and p27 are members of the family of cyclin-dependent kinase inhibitors which halt cell cycle progression at the G1-S phase by deactivating the cyclin/cdk complexes. These proteins represent the potential substrate for ubiquitin-proteasome patway, which is a lysosome independent system of intracellular protein degradation. The first anti-ubiquitin-proteasome drug was bortezomib (velcade). Whereas this drug is potentially the cause of several biological effects, bortezomib is considered a target drug for multiple myeloma and specific subtypes of NHL, such as mantle cell lymphoma (MCL). Its main effects are the inhibition of NF-kB and cyclin D1 and the decreased degradation of cell-cycle dependent kinase inibitors such as p27 and p21. From this viewpoint, FNA might be helpful in demonstrating p27 and p21 expression using conventional immunocytochemistry (ICC) (6).Signal transduction inhibitors, cyclins and mantle cell lymphoma:Farnesyltransferase inhibitors (FTIs) and rapamycin represent new classes of signal transduction inhibitors mainly targeting the Ras/MAPK and PI3K/Akt pathways. Rapamycin is a macrolide which inhibits the gene mTOR, deregulating the translation of specific mRNAs required for the progression from G1 to S phase. mTOR mutations have not been observed in human cancers; nonetheless, mTOR is a component in the P13K/Akt pathway which has a role in the proliferation of t and b cells. Rapamycin, which inhibits mTOR, decreases cyclin D2, cyclin D3 and CDK4 and increases the expression of the CDK inhibitor p27. Rapamycin has been shown to be effective on Epstein-Barr virus positive lymphomas and mantle cell lymphomas (MCL). This is not surprising considering the dependence of MCL on Cyclin D1, which is regulated by mTOR activity. FNA may contribute to the diagnosis of MCL in various ways. In fact, despite potentially equivocal cytological features, MCL may be identified on cytological samples by immunocytochemical demonstration of cyclin D1, specific phenotype by FC (1) or t (11;14)(q13,q32) translocation by fluorescence in situ hybridization (FISH) (2). Follicular lymphoma, Bcl-2 over expression and antisense oligonucleotides: Bcl-2 is an apoptosis regulating protein, whose over-expression in follicular lymphoma (FL) is related to Bcl-2 gene translocation on the IGH locus. Bcl-2 over-expression may be associated with chemotherapy resistant disease, aggressive courses of treatment, and poor survival rates in patients with B-cell NHL. Deregulation of this oncoprotein thus represents a possible new way of targeting clinically aggressive FL. Antisense oligonucleotides are single strand, chemically modified DNA molecules that have a nucleotide sequence complementary to the target mRNA and therefore capable of inhibiting the expansion of the target gene. Preclinical studies have shown that Bcl-2 antisense oligonucleotides can effectively decrease Bcl-2 over-expression, reverse chemotherapy resistance and enhance the anti-apoptotic potential of both chemotherapeutic and biological agents. As for the role of FNA, Bcl-2 gene translocation on the IGH locus: t(14-18)(q32;q21) may be demonstrated in FNA samples by FISH (3) and chimeric protein over-expression by immunocytochemistry (ICC) or flow cytometry (FC) (7). Using this latter technique, it is possible to quantify the percentage of follicular, B-cell positive cells by the co-expression of CD10/Bcl-2.Gene expression profiling and diffuse large cell lymphomaMolecular profiles obtained by complementary DNA micro-arrays have shown that DLBCL are composed of at least two different entities with two different gene expression patterns: the germinal cell subtype (GC) and the activated b-cell subtype (ABC), each of them having a different survival rate (8). Moreover, micro-array studies in FL have investigated the gene changes involved in the FL progression into DLBCL. These studies could lead to the better subtyping of DLBCL and the identification of potential new therapeutic targets. As far as the role of FNA is concerned, recent studies have proven the feasibility of FNA-based gene expression profiling. Moreover, compared to archive samples, fresh samples obtained from FNA contain less non-tumoral cells and can be immediately processed, generating gene profiles resembling live profiles (4). Monoclonal antibodies: Monoclonal antibodies represent the first successful result of target therapy; in fact, chimeric anti-CD20 monoclonal antibody (rituximab) has been the most extensively studied and clinically used among the target drugs. The anti-CD20 antibody consists of murine variable regions grafted onto a human IgG1 constant region. The CD20 antigen is an excellent target since it is selective for mature B cells in the absence of precursor B cells. In addition to direct action, rituximab induces apoptosis of Bcl-2 positive cells and has been used as maintenance therapy following standard chemotherapy treatment. Numerous other monoclonal antibodies, unconjugates or radioconjugates have been produced, such as Epratuxumab (anti- CD22), Apolizumab (antiHLA-DR), Alentuzumab (Campat-1H), antiCD40 (antiCD52), Iodine 131 anti-CD20, 90-Yttrium anti-CD20, each of them designed to act against specific antigens. FNA may play an important role in ICC or FC evaluation and quantification of each of the potentially addressed antigens in different phases of the disease (before and after therapy).Conclusions: In conclusion, in a next future the number of therapies available for NHL will probably increase, and the task of the pathologist will be to produce specific information useful for the application of these target therapies. FNA may play a role in this process, combining the advantages of the technique (non-invasive, good tolerance levels, possible immediate evaluation, and possible repetition even in a potential series of samples pre and post-therapy) with the use of ancillary techniques
Citologia aspirativa in patologia emo-linfoproliferativa
No full textFlow cytometry (FC) is a useful adjunct to fine-needle aspiration cytology (FNC) in evaluating lymphoproliferative disorders. We present a critical review of 307 lymph nodal and extra lymph nodal lymphoproliferative disorders diagnosed by fine-needle cytology (FNC) and FC. FC was performed over a four-year period on 185 palpable and 122 impalpable nodal and extra nodal lymphoproliferative processes under ultrasound (US) or computed tomography (CT). FC was performed using the following fluoresceinated antibodies: CD3, CD4/8, CD2/CD7/CD3, CD5/CD10/CD19, CD19/κ/λ, FMC7/CD23/CD19, CD38/CD56/CD19, bcl-2. The series comprised 15 inadequate, 10 suspicious and 135 benign reactive hyperplasias (BRH), 70 primary non-Hodgkin lymphomas (NHL) and 77 relapses of NHL (rNHL). FC/FNC diagnoses of suspicious, NHL and rNHL were controlled either histologically or clinically or by the interphase fluorescence in situ hybridization (FISH) demonstration of t(11;14)(q13;q32) in two cases of mantle cell lymphoma (MCL). BRH were controlled by follow-up. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the FC/FNC diagnoses of NHL, rNHL and BRH were calculated as well as the identification of specific subtypes among the small-cell and medium size NHL. Statistical analysis showed 93% sensitivity, 100% specificity, 100% PPV and 91% NPV in NHL, rNHL and BRH discrimination; as for the subclassification of small cell and medium-size NHL: 63% sensitivity, 88% specificity, 95% PPV and 37% NPV were obtained. FC applied to FNC enhances the precision of cytological diagnosis in lymph-nodal and extra lymph-nodal lymphoproliferative disorders and allows further subclassification in more than half of the cases, thus avoiding invasive surgical biopsies in many patients
- …
