Vol 46, No 4 (2018)

Aim: Combined clinical and morphological analysis of the pancreatic neuroendocrine tumor (pNET) spectrum according to the new World Health Organization classification: patient distribution, hormonal status, morphological grading, somatostatin receptor 2 (SSR2) and 5 (SSR5) expression, the choice of tissue-specific markers for the differential diagnosis of primary NET in the pancreas based on metastases with unknown primary tumor.

Materials and methods: The study was performed with 472 tissue samples from pNETs taken from patients. Morphological analysis consisted of histological and immunohistochemical examination with a panel of antibodies to chromogranin A, synaptophysin, CD56, insulin, glucagon, somatostatin, gastrin, calcitonin, adrenocorticotropic hormone (ACTH), serotonin, pancreatic polypeptide, cytokeratins (CK) of a wide spectrum, CK7 and CK19, p53, Ki-67, SSR 2 and SSR5, PDX-1, Isl-1, and NESP-55.

Results: In women, the prevalence of pNETS was 2.3 higher than in men (2.3:1). We were able to identify 299 (63.3%) insulinomas, 134 (28.4%) non-functioning NETs, 28 (5.9%) gastrinomas and 1.8% rare tumors (somatostatinomas, “calcitoninomas” and ACTH-producing). Metastatic tumors were found in 16.5% of the cases. Multiple endocrine neoplasia syndrome type 1 was confirmed in 11.9% of the pNET patients, and in 30.8% of those aged below 30 years. Multiple tumors (2 to 10) were found in 32 patients by the time of the diagnosis or occurred at 7 to 18 years after initial surgery. 28.3% of the tumors were CK19-positive, with 54.4% of them being metastatic. Insulinomas were least prone to metastasizing (5.7% of the cases), with 41.2% of them being CK19-positive. Metastases were found in 70.4, 66.7, 100, and 100% of gastrinomas, “calcitoninomas”, ACTH-producing, and somatostatinomas, respectively, with CK19-positivity found in 85.2, 66.7, 66.7, and 100% of these tumors. SSR2 expression was observed in all gastrinomas and “calcitoninomas”, in 90.5% of “glucagonomas”, 85.7% of PPomas, and 66.7% of somatostatinomas. SSR5 expression was significantly less frequent. 86.3% of the studied tumors were PDX-1-positive: all somatostatinomas, 97.4% of insulinomas, 92.3% of gastrinomas, 83.3% of PPomas, 80% of the non-functioning NETs. PDX-1-negativity was identified in all “calcitoninomas” and in 57.1% of the non-functioning “glucagonomas”. 83.3% and 90.9% of the pNETs were Isl-1 and NESP-55-positive, respectively.

Conclusion: Combined morphological and immunohistochemical examination of pNETs allows for the correct diagnosis, assessment of their prognosis and choice of the most effective treatment. The malignancy grade of pNETs depends on the cell immunophenotype and is higher in the cases with co-expression of the markers of neuroendocrine and ductal differentiation (CK19), as well as with ectopic hormonal production.

Background: Over the last 10 years the incidence of gastric cancer has declined significantly. Nevertheless, it remains one of the most prevalent malignancies both in Russia and worldwide. Therefore, the problems of early diagnostics, prognosis and individualized treatment choice are still on the agenda. Much attention is paid to the evaluation of molecular biological characteristics of the tumor, as well as to the development of multiparametric prognostic systems for gastric cancer based on its identified characteristics. An important place among potential tumor biological markers belongs to matrix metalloproteinases (MMPs) involved into all the stages of tumor progression, first of all, into the regulation of invasion and metastasizing.

Aim: Comparative quantitative evaluation of some MMP family members (MMP-2, 7, and 9) and one of the tissue MMP inhibitors (TIMP-2) levels in the tumors and adjacent histologically unchanged mucosa in gastric cancer patients, the analysis of their associations with the main clinical and pathological features of the disease and its prognosis.

Materials and methods: Sixty six (66) primary gastric cancer patients (32 male and 34 female) aged 24 to 82 years (median, 61 year) were recruited into the study. Twenty two (22) patients were with stage I of the disease, 11 with stage II, 28 with stage III, and 5 with stage IV. The concentrations of the proteins studied were measured in the tumor and unchanged mucosa extracts by standard direct ELISA kits (Quantikine®, R&D Systems, USA).

Results: Tumor MMP-2, 7 and 9 levels were significantly increased, compared to those in the adjacent histologically unchanged mucosa, in 80, 70 and 72% of gastric cancer patients, respectively, while the increase of TIMP-2 level found in 61% of the tumors was not statistically significant. Tumor MMP-2 and TIMP-2 content was increasing significantly with higher T index – size and advancement of the primary tumor (p < 0.01 and p < 0.05 respectively). Tumor MMP-2 level was also increasing in parallel with the N index (regional lymph node involvement; p < 0.01); it was significantly higher in the patients with distant metastases than in those without them (p < 0.05). Tumor MMP-9 and MMP-7 concentrations were not significantly associated with the indices of the tumor progression. The patients were followed up for 1 to 85 months (median, 18.3 months). According to the univariate analysis, high (> 32.6 ng/mg protein) MMP-2 and low MMP-7 (< 1.1 ng/mg protein) levels in the gastric cancer tissue represent statistically significant unfavorable prognostic factors for overall survival. Increased TIMP-2 level is associated with a non-significant decrease in the overall survival (p > 0.05), whereas the MMP-9 level was unrelated to the gastric cancer prognosis. Only T index (p = 0.0034) and tumor MMP-7 content (p = 0.026) remained independent prognostic factors in the multivariate regression analysis.

Conclusion: The majority of gastric cancer patients demonstrate a significant increase in the expression of three MMP family members, i.e. gelatinases (MMP-2 and 9), and matrilysin (MMP-7), in the tumors, as compared to adjacent histologically unchanged mucosa. Only MMP-2 levels were associated with the disease progression, increasing with higher TNM system indices. High MMP-2 and low MMP-7 content in the gastric cancer tissue are significant unfavorable prognostic factors for the overall survival in the univariate analysis, but only MMP-7 has retained its independent prognostic value in the multivariate assessment.

Rationale: In the recent years molecular genetic prognostic factors are becoming very important for predicting the course of uveal melanoma (UM). In clinical practice, molecular genetic methods are used to identify patients with a high risk of metastases.

Aim: To determine the survival of UM patients after enucleation, depending on molecular genetic aberrations.

Materials and methods: Thirty (30) patients with UM aged from 23 to 83 years were examined and treated. In all cases, enucleation was performed. The removed eyes underwent morphological and molecular genetic and cytogenetic analysis (loss of heterozygocity on chromosomes 1, 3 and 8, methylation of the RASSF1A gene, mutations in GNAQ/11 genes, polymorphism of the ABCB1 gene). The median follow-up was 61 months.

Results: The cumulative 3-year survival of the UM patients was 77.8 ± 8.0%, and the 5-year survival 63.0 ± 9.0%. The mean survival time was 52.8 ± 3.9 months. The patients with chromosome 3 monosomy showed significantly lower 5-year survival rates than the patients with partial monosomy and without loss of heterozygocity in chromosome 3 (log-rank test, χ2 = 14.111, p = 0.001). The loss of heterozygocity on chromosomes 1 and 8, the methylation of the RASSF1A gene, the mutations in GNAQ/11 genes, and the polymorphism of the ABCB1 gene were not associated with poorer vital prognosis.

Conclusion: Molecular genetic aberrations play an important role in predicting the course of the tumor process and determining the risk of hematogenous metastasizing in UM patients. The significant role of chromosome 3 monosomy has been proved. Due to the relatively small cohort (30 patients) and the time factor (analysis of 5-year survival), the role of other molecular genetic changes has not been confirmed, which requires an assessment of not only genetic, but also clinical, echographic and morphological prognostic factors.

Background: For many decades, women in all age groups have a high risk of mortality and perioperative complications of cardiac surgery (CS), with its cause being unclear until now. Preoperative prediction of cardiovascular complications (CVC), based only on the clinical and instrumental criteria without taking gender into account, also remains unsuccessful. There is an opinion that the structural and functional changes in the myocardium, which exist before the operation, could significantly affect the patient's condition after cardiac surgery.

Aim: To identify morphological and molecular predictors of unfavorable prognosis in chronic heart failure (CHF) patients of both genders after CS.

Materials and methods: The study included 87 CHF patients of both genders referred for an elective cardiac surgery. Before the operation, a standard examination and treatment of CHF and concomitant disorders were performed. A sample of the right atrial appendage (RAA) myocardium that had been resected during the CS, was studied by histological, immunohistochemical (IHC) (expression of caspase-3, bcl-2, MMP-2, TIMP-1, p38α, CD-34) and morphometric methods. At days 10 to 14 after CS, the presence of CVC was assessed in all the participants. We examined the relationship between the development of CVC and morphological changes in the RAA myocardium before surgery, taking into account the patients' gender.

Results: Compared to the group with the favorable postoperative course in the myocardium, in the male/female group with unfavorable post-CS course there was a significant reduction in the cardiomyocyte (CMC) diameter (13.26 ± 3.14; p < 0.01 / 13.99 ± 3.64; p < 0.01), the bulk density (BD) of CMC (55.4 ± 9.45; p < 0.01 / 51.22 ± 10.12; p < 0.01) vol. %, a trophic index (0.24 ± 0.1; p < 0.01 / 0.21 ± 0.06; p < 0.01), as well as a significant increase in the stromal BD (44.91 ± 9.23; p < 0.01 / 47.78 ± 10.12; p <0.01) vol. % and the Kernogan index (1.78 ± 0.49; p < 0.01 / 1.43 ± 0.64; p = 0.143). IHC analysis of the RAA myocardium in the male/female group with an unfavorable postoperative course showed an increase in the amount of caspase-3 (+) CMC (3.9 ± 0.46; p < 0.01 / 3.34 ± 0.4; p < 0.01), an increase in the activity of +/++/+++ p38α (3/30/69; p < 0.01 / 2/39/60; p < 0.01) %, the expression of MMP-2 (2/56/43; p < 0.01 / 0/68/31; p < 0.01) %, with a decrease in the expression of TIMP-1 (19/29/52; p < 0.01 / 8/24/67; p < 0.01) % and BD of CD-34 stromal cells (18.46 ± 8.5; p < 0.01 / 27.54 ± 5.88; p < 0.01) %, compared with groups with a favorable current.

Сonclusion: The study showed the role of caspase-3, MMP-2, and CD-34 in the RAA myocardium as prognostic markers of CVC in the early postoperative period, as well as gender differences in modulation of the apoptotic pathways and inefficiency of anti-apoptotic mechanisms in the RAA myocardium. Based on the assessment of the RAA myocardial reorganization, an integral prognostic picture of the structural and functional changes in the myocardium has been proposed, which makes it possible to identify a special patient cohort with an exceptionally high risk of unfavorable course of the post-CS period.

The most prevalent skin cancer in the transplant organ recipients is squamous cell cancer, followed by basal cell cancer. The skin cancer incidence and related mortality in the transplant organ recipient are significantly higher than those in the general population, which is to be linked with prolonged pharmaceutical immunosuppression. Multiple tumors are also typical for this patient group. The article describes two rare combinations of skin carcinomas with different histological characteristics in patients with cadaver renal allograft (CRA). Clinical case 1: A 43-year old female patient. In 2011, she was transplanted with a CRA due to end-stage renal failure caused by congenital cystic dysplasia (multicystic kidney disease), with subsequent removal of the allograft at 1.5 months after the transplantation. In 2014, she had her second CRA transplanted and until now is on immunosuppressive therapy. In 2013, the patient noticed two slowly growing masses in her right and left supraclavicular areas; they were clinically assessed as basal cell cancer and surgically resected. Histological examination of the resected skin fragments showed squamous cell carcinoma focuses in situ (Bowen's disease), with alternating superficial basalioma focuses; proliferating keratinizing squamous cell cancer with polymorphous structure, with prevailing acantholytic type, morphoeic basal cell carcinoma and basal squamous cell carcinoma were found throughout the dermal layer, up to the subcutaneous tissue. Clinical case 2: A 63-year old male patient was transplanted with CRA in 2007, due to end-stage renal failure caused by nephrolithiasis and chronic pyelonephritis. During the examination performed in 2013, a mushroom-like tumor (with a 3 cm diameter and a stipe of 1 cm in diameter, with erythematous tuberous surface) was found on the anterior neck surface, near the suprasternal notch. The tumor was surgically resected within the normal skin. Histological and immunochemical examinations showed that the mass consisted of two different tumors closely adjacent one to the other and separated by a narrow dermal layer, namely, neuroendocrine Merkel cell skin carcinoma and porocarcinoma with some signs of squamous cell and sebaceous cell differentiation.

Conclusion: The descriptions of the rare cases confirm that transplantation-related skin cancers are highly relevant. Due to continuous renewal of the tissue components that is intrinsic to this organ, and due to deterioration of the immune control over proliferation and differentiation, they are characterized by a multiplicity of histological types and an unfavorable prognosis.

Metastatic tumors of the thyroid gland (TG) are rare. Usually thyroid gland metastases originate from renal, lung, skin and gastrointestinal cancers. Breast cancer metastases are more rare and in various samples amount to 3 to 34% of all cases of the metastatic thyroid disease. We present a rare case of metastatic carcinomatosis into the thyroid goiter in a 63-year old female patient who has received combination therapy for breast cancer. In 2016, right-sided mastectomy was performed due to the right breast cancer (invasive carcinoma, non-specific type, Grade 2, with skin invasion) with subsequent four chemotherapy courses. A slowly growing nodule in the thyroid gland was first found in 2012; in 2017, fine needle aspiration biopsy was performed, which showed a follicular tumor that resulted in thyroidectomy. At the histological examination, against the background of thyroid goiter, multiple small lesions with advanced nuclear polymorphism were found, with doubtful diagnosis. To clarify the histogenesis of the tumor lesions, immunohistochemical assessment was performed. Its first phase included the markers of primary thyroid tumors (thyroglobulin, TTF-1), and the second one consisted of the breast cancer diagnostic panel (mammoglobin, GATA-3, estrogen and progesterone receptors). The results showed multiple small metastases of the invasive breast carcinoma of non-specific type into the thyroid goiter. Taking into account eventual problems of differential diagnosis and significant morphological polymorphism of thyroid tumors, we recommend extending of the immunohistochemistry panel in this patient category.

Kaposi's sarcoma is a multifocal tumor from vascular endothelium with a low grade of malignancy. It develops due to underlying immune deficiency and is associated with human herpesvirus 8. Kaposi's sarcoma of the eyelids is rare, and its diagnosis can be difficult both for ophthalmologists and oncodermatologists. The paper describes six clinical cases of Kaposi's sarcoma with involvement of the eyelids. Three patients had an HIV-associated type of the tumor. One patient had an immunosuppressive type of the tumor during immunosuppressive treatment after kidney transplantation. Two elderly patients had Kaposi's sarcoma of the classic type. Tumors of the eyelids developed after several years of skin involvement. All patients had advanced (nodular) stage of Kaposi's sarcoma of the eyelids, whereas the skin tumors looked as spots (maculas) or papules (macular or papular stage of the disease). The eyelid tumor presented as an extensive dark red tumor nodule distinctly separate from the adjacent tissues. In all cases, the eyelid tumor was big and hindered the sight. All the patients were treated by an oncodermatologist and/or a specialist in infectious diseases, depending on the clinical type of the disease. Kaposi's sarcoma rarely involves the eyelid skin or conjunctiva; however, in immunodeficient patients it must be included into the list for the differential diagnosis of eyelid tumors.