BACKGROUND: Langerhans cell histiocytosis (LCH) is a proliferative disorder of immune dendritic cells. Diagnosis by electron microscopy or immunostaining is both expensive and time consuming; and also requires advanced techniques often unavailable at hospitals in third world countries. This leads to both under-diagnosis and increased patient mortality.

PURPOSE: To evaluate Fine Needle Aspiration Cytology (FNAC) as a cost-effective and rapid method for diagnosing LCH. Design: Over the period of 10 years, nine (n=9) patients with generalized lymphadenopathy were examined by FNAC and cytology (at theNational Institute for Child Health, Karachi) showed the outlined features suggestive of LCH. In all patients, therapy with methylprednisolone and etoposide was started soon after cytological diagnosis.

RESULTS: Six out of nine patients showed significant improvement. Later immunostaining with S-100 and PNA and CD1a confirmed the presence of LCH in all cases.

CONCLUSIONS: Rapid and cost-effective diagnosis by FNA and routine cytology can lead to enhanced patient survival. Careful histological examination prevents misdiagnosis as tuberculosis and wrongful treatment with anti-tuberculosis drugs.

Case report:
We report the case of the second pregancy of young non consanguineous healthy couple.
At 12 weeks of gestation, ultrasound scan displayed an increased nuchal translucency at 4 mm. A karyotype was made on chorionic villous sample, showing a 12p12.1 deletion on both direct examination and culture. At 22 weeks, ultrasound scan demonstrated a homogenous hyperechogenic mass in the right hemitorax. After counselling, the parents opted for termination of pregnancy.
The female fetus weighed 630 g and measured 27,5 cm crown-feet and 20 cm crown-rump, consistent with gestational age.
Post mortem examination showed a facial dysmorphism with microphtalmia, broad nose, anteverted nostrils, large and low set ears, microretrognathia.

At internal examination, the right inferior pulmonary lobe was enlarged, shifting the heart and left lung to the left. On cut section, the right pulmonary mass was homogenous and firm. No macrocysts were seen. No other visceral malformations were found.
At histology, the right lobe mass was made of small structures lined with cuboidal epithelium, resembling the early canalicular stage of development. This lesion was diagnosed as congenital pulmonary airway malformation type III.

 

Discusion:
Patients with CPAM are now known for being at risk for bronchopulmonary cancer, specially the bronchioloalveolar type.
KRAS mutation, known to be associated with lung cancer, is located in 12p12.1 locus.
Array CGH of our case displayed a 15.6 megabase deletion, including the KRAS gene. To our knowledge, the association of CPAM and 12p12.1 has never been reported.

Array CGH of our case displayed a 15.6 megabase deletion, including the KRAS gene.
To our knowledge, the association of CPAM and 12p12.1 has never been reported.
Our observation could be a supplementary argument for the relationship between CPAM and lung cancer, being the "missing link". CPAM 3 could represent a preneoplastic lesion, although most of the CPAM complicated by lung cancers are CPAM type 1.

Background: Non-Wilms kidney tumors are rare. They are usually represented by rhabdoid tumor of kidney (RTK), clear cell sarcoma of the kidney (CCSK), and mesoblastic nephroma (MN). These tumors show differences in clinical characteristics, morphology, immunophenotype, and molecular alterations that usually lead to a correct differential diagnosis. We report here about a case of non-Wilms renal malignant sarcomatous tumor featuring neither any of these histotypes nor any other reported specific sarcoma-type.

Case history: A 6-month-old boy underwent total nephrectomy for a 9 cm mass, partly solid and partly cystic, with hemorrhagic and necrotic components on imaging. At histology, it was formed by bundles of macronucleolated spindle cells and areas of oval cells in a retiform pattern in a myxoid stroma. Necrosis and hemorrhage were present. Mitotic index was high. The tumor infiltrated the renal sinus, the renal capsule and the perirenal fat. No nephrogenic rests were present. Immunocytochemically, it showed reactivity only for S100 protein (focal) and CD34 (rare cells). Negative were WT1, smooth muscle actin, desmin, keratins. INI1 was positive, ruling out a strange form of RTK. Negative were the analyses for the t(12;15) and fusion transcript ETV6/NTRK3 of infantile fibrosarcoma/cellular MN. The age of the baby and the brisk mitotic activity were unusual for a CCSK. No typical areas of CCSK were found after an extensive sampling.

Conclusions: Eventually, for practical purposes this tumor was considered as an undifferentiated sarcoma of kidney. More cases are required to establish if this tumor represents a distinct histotype among non-Wilms renal tumors.

 

Gorlin syndrome is a rare disease characterized by the occurrence of keratocystic odontogenic tumors (OKTs), baso-cellular carcinomas, palmoplantar « pits », ovarian fibromas and medulloblastomas. In about 98% of cases, this syndrome is related to a dominant mutation of PATCH1, a suppressor tumor gene implicated  in the sonic hedgehog way and in embryonic development.

According to 2005 WHO, OKTs are considered as invasive and recurrent maxillary benign tumors.

The aim of this study is to compare clinical, pathological and molecular datas of pediatric OKTs in a series of 10 children, aged 9 to 19 years, 5 of which occurring in a context of Gorlin syndrome (11 OKTs) and 5 as sporadic cases (5 OKTs).

Syndromic OKTs are characterized by their early onset, their clinical aggressiveness and their recurrence tendency.

Morphologically, syndromic OKTs have a higher number of suprabasal epithelial layers, more intraparietal epithelial rests (100% vs 40%), more daughter cysts (80% vs 0%) and a lower suprabasal  proliferative index (35% versus 52%).

Genes implicated in odontogenesis (DLX, MSX) and NFkB activators implicated in osteoclastogenesis (RANK, RANKL, OPG) are currently analyzed by RT-PCR and immunohistochemestry to better understand the interaction between tumor evolution and peritumoral osteolysis in a therapeutic perspective by Denosumab, a human monoclonal antibody against RANKL.

 

We present a case of proximal-type epithelioid sarcoma in an 8 year old boy. There was a 6 week history of slowly enlarging mass in the left medial canthal region. There was no preceding illness but he had been experiencing some headaches. There was proptosis with lateral and inferior displacement of the eye. CT scan of his sinuses showed a destructive lesion of the left anterior ethmoid sinus and orbit measuring 7.4cm x 5.9cm x 5.4cm. MR scan confirmed breach of the anterior skull base with involvement of the dura. Clinical suspicion was of rhabdomyosarcoma.

 

Histology of curette biopsy samples from the tumour showed solid sheets of large pleomorphic epithelioid cells with abundant eosinophilic cytoplasm and open vesicular nuclei with large prominent nucleoli. The cytoplasm of many of the tumour cells contained large peri-nuclear D-PAS positive crystalloid inclusion-like bodies and multinucleate tumour cells were identified. There were a moderate number of mitoses with occasional atypical mitotic figures. Apoptotic bodies and areas of necrosis were also identified, focally.

 

There was an unusual pattern of immunohistochemical reactivity with tumour cells being negative for ALK-1, HMB45, CAM 5.2, CD30, AE1/3, GFAP, myogenic markers (Myo-D1, Myogenin and D33) and the INI1 deletion (almost all tumour cell nuclei retained staining). The tumour cells showed positive reaction with labelling for vimentin, NSE and EMA with occasional S100 and CD68 positive cells.

 

On subsequent resection of the tumour (orbital exenteration) the entire left side of the face has been removed including eyebrow, orbit, left eye ball and ethmoidal bone with surrounding soft tissues. Our investigation confirmed involvement of almost all margins of the resection sample by tumour. The patient is currently receiving chemotherapy treatment according to EpSSG (European Sarcoma StudyStudy group) protocol for non-renal rhabdoid tumours as well as radiotherapy.

 

Proximal-type epithelioid sarcoma is a rare and more aggressive sub-type of classical epithelioid sarcoma which frequently exhibits a rhabdoid phenotype. These tumours have many features over-lapping malignant extra-renal rhabdoid tumours (ERRT) and some authors believe it to represent a variant of ERRT, arising in proximal or axial locations. Whilst the cytogenetics of  proximal-type epithelioid sarcoma have not been fully reported, it is noteworthy that, in common with ERRT,  some examples exhibit genetic aberrations on chromosome 22q.

Multiple steps of mesenchymal-epithelial transition involving a wide variety of transcription factors are necessary for proper human renal development. Investigations of animal models identified Lim1 as a crucial transcription factor in this process. In our study we therefore examined the role of LIM1 in human renal development and in different renal neoplasms.

Methods:

Different stages of regular developed kidneys as well as multicystic dysplastic kidneys and different renal neoplasms were investigated by immunohistochemistry. In a cell culture model we tested the influence of LIM1 on the cell cycle.

Results:

LIM1 showed a distinct nuclear expression between 10 and 30 weeks of gestation, whereas all the multicystic dysplastic kidneys were entirely negative. LIM1 was focally identified in epithelial and blastemal areas of nephroblastomas, however, all clear cell and papillary renal cell carcinomas were completely negative.

Overexpression of LIM1 in a mesenchymal cell line revealed no influence on the cell cycle.

Conclusions:

Our results demonstrate a distinctive role of LIM1 in regular human renal development, but no crucial impact on the pathogenesis of renal neoplasms.

Aim: Muscle biopsy is an important diagnostic tool for muscular dystrophies and mitochondrial disorders, helping differential diagnosis and guiding molecular studies in many cases. However, some patients may show histological features of both a dystrophic process and mitochondrial abnormalities, making specific diagnosis more difficult. We present two series of cases with dystrophic and mitochondrial changes together and discuss clinicopathological clues for correct diagnosis.

Material and methods: We investigated our archive of muscle biopsies for cases showing histological features compatible with mitochondrial disease (abnormal mitochondria, ragged-red or ragged-blue fibers, cytochrome-c-oxidase deficiency) and looked for correlation of these features with clinical findings. We identified two groups of patients with similar clinical presentation and dystrophic process accompanying mitochondrial pathology in muscle.

Results: Three infants presenting with hypotonia and high serum creatine kinase had dystrophic changes, which might have led to a diagnosis of congenital muscular dystrophy if cytochrome-c-oxidase deficiency had not been detected in many fibers. Further evaluation of these cases for mitochondrial myopathy led to identification of mitochondrial DNA depletion and TK2 mutations. Another group of patients with muscle weakness, delayed motor milestones and mental retardation showed unusually big mitochondria mostly localized towards the periphery of the fibers, in addition to dystrophic changes. Cytochrome-c-oxidase deficiency was seen in only a few fibers in a few cases.

Aim of study:  We sought  to identify: the number of drug and alcohol related deaths diagnosed at our institution  between 2004 and 2010;   demographic features and   clinical presentation of the cases as well as to determine what samples proved to be more useful in the investigation of these deaths.

Material and methods: A search of histopathology  and toxicology  databases was conducted. All post mortems with  a positive toxicological screen were entered into an anonimised excel form were demographic, clinical and relevant autopsy information   was recorded. According to the relevance of the toxic substance in the causation of  death, the cases  were allocated to one  of three categories: A) toxic- related cause of death; B) non-toxic cause of death and C) other.

Results:  During the period of the study there were 1669 post mortem investigations. 55 cases (3.3%) had a positive toxicological screen. The  cases corresponded to 37 males and 18 females with a mean age of 4.8 years (range: 2 hours to 17 years).  Group A: 10 cases (3 females; 7 males) with average age of 6 years (range: 2 hours to 17 years). The toxic  implicated  in these cases was:  methadone (3 cases; one combined with alcohol and dothiepin);  dothiepin (2 c ); diazepam (1 c); carbon monoxide (2 c); tramadol (1 c); codeine (1 c). Group B: 41 cases (14 females and 27 males); average age of   6 years (range 3 days to 17 years). The causes of death in this group was not related to the toxic and the drugs  found were in  therapeutic use range. Group C: 4  cases (1 female; 3 males); average age  of  10 years (range: 9 days to 15 years). The cause of death in this group could have been related to the toxic identified in the screen or the analysis otherwise allowed identification of cause of death. This corresponded to: cannabis (1 c); diphenydramine (1 c);  dead in bed syndrome in previously undiagnosed Diabetes mellitus (1 c); methadone (1c). The  samples  taken in Group A were: blood (10 c ); urine (6 c); stomach (9 c ); vitreous (4 c); bile (1 c); hair (1 c) and other (1 c CSF; 1 c lung; 1 brain).  5/10 mothers of children in group A disclosed consumption of drugs (either prescribed antidepressants or illicit drugs), alcohol or smoking, either during or after pregnancy.

Conclusion:  The  presence of a  toxic in a lethal  concentration was found in 10 / 1669 post mortem examinations (0.6%) during the period of  the study. This incidence increased to 2.2 % when the analysis was restricted to sudden unexpected and or unexplained deaths (Coroner post mortems). Our results demonstrate the usefulness of performing routine  toxicological screen in these cases.

Pontosubicular necrosis occurs between 30 weeks gestation and two months of age, where there is a history of perinatal distress. The morphological appearances closely resemble apoptosis, and an apoptotic mechanism of neuronal death has been confirmed using a variety of means. Oxidative stress and free radical-induced lipid peroxidation are part of the underlying mechanism. Activated caspase-3, a marker of apoptotic cell death, has been shown to label dying cells in pontosubicular necrosis. We investigated the following hypotheses:

1. Caspase-3 is a more sensitive marker of pontosubicular necrosis than morphology.
2. Caspase-3 immunohistochemistry may identify pontosubicular necrosis in brains with no identifiable lesion but a history suggestive of a recent catastrophic event.
3. Pontosubicular necrosis can be detected following shorter survival after an insult, using Caspase-3 immunocytochemistry than on morphological grounds alone.

Method:
16 clinical cases with known post-mortem delay, with clinical evidence of hypoxic insult, and varying survival at different gestations were studied. Caspase-3 staining was done on sections of pons and hippocampus. Twenty fields were found to be the optimal number to count the total cells, caspase-3 stained cells, and karyorrhectic cells. Rat thymus sections collected at known post-mortem delays were stained as a control for post-mortem autolysis.

Results:
1. Pontosubicular necrosis is not limited to later gestation and may be found at 17 weeks.
2. Caspase-3 immunohistochemistry may show pontosubicular damage following early neonatal death, even in the absence of morphological changes.
3. Caspase-3 immunohistochemistry could be used as a screening tool in evaluating the presence of cellular injury in the pons and subiculum. It is more sensitive than the detection of karyorrhectic nuclei, for which it should prompt a search, does not appear to be affected by survival time or post-mortem delay.

We report a case of absence of the aortic valve cusps in a 22 week fetus with polyhydramnios and cardiomegaly. Antenatal echocardiography revealed a probable double outlet right ventricle and a large perimembranous VSD. Cardiac function was impaired and there was severe aortic regurgitation with a poor prognostic outlook, therefore the pregnancy was terminated.

Post mortem examination of the heart showed situs solitus with atrioventricular concordance. There was arterial concordance with no evidence of a double outlet right ventricle. The left atrium was small and the mitral valve orifice was stenosed (4mm in diameter). The aortic valve orifice was dilated and there were no aortic valve cusps. There was an aneurysmal dilatation of the interventricular septum, presumed to be due to the force of the blood retrogradely entering the left ventricle and hitting the septum. This was misinterpreted as a membranous VSD on echo. The pulmonary valve cusps were present.

Histological examination confirmed the complete absence of aortic valve cusps. There was marked endocardial fibroelastosis of the left and right ventricles but no ischaemic changes were present in the myocardium.

No extracardiac abnormalities were identified and karyotyping was normal.

Absence of the aortic valve cusps (AAV) is an extremely rare congenital cardiac anomaly, first described in 1975 and with only 23 cases reported to date. AAV ususally presents in neonates soon after birth with signs of cyanosis and respiratory distress. The majority of these infants died within days due to severe cardiac failure although, in recent years, successful surgical treatment has been reported.

A spectrum of other cardiac malformations occur in association with AAV and several theories as to the pathogenesis of this condition have been postulated. We present a review of the published literature with an emphasis on the evolution of the understanding of this unique condition over the past 35 years.

INTRODUCTION: Fibroadenomas (FA) are the most common breast masses in adolescent women. Less than 1% of all mammary carcinomas are diagnosed in patients less than 25 years old.
CD117 (c-kit) and CD34 are markers that have been both implied in cancer progression in adult breast lesions.

AIM: Despite numerous immunohistochemical studies on adult breast lesions, childhood mammary lesions are not deliberately studied for the expression of these markers.
We reviewed the literature for CD34 and CD117 expression patterns in benign adult breast lesions and correlated these results with the findings of adolescent patients in our study.

MATERIAL AND METHOD: Nine FAs (3 cellular, 6 simple), 2 tubular adenomas (TA), 1 mammary hamartoma (MH), 2 gynecomastia (GM), 1 benign phyllodes tumor (BPT) are included in the study for the immunohistochemical analysis with CD117 and CD34. Both markers were evaluated by immunoreactive score (IRS): CD117 for both the epithelial and the stromal components and CD34 for the stromal component. The percentage scoring categories were defined as 0, rare-focal groups (1+), <30% cells (2+), >30% cells (3+) .

RESULTS: 15 lesions from 14 adolescent patients (12 female, 2 male) with an average age of 16 years (ranging 13-18 years) evaluated for stromal and epithelial expression patterns of CD117 and CD34. CD117 staining was identified in the epithelium of all cases being diffusely positive in FA and TA group and weakly positive in 1 MH, 2 GMs and 1 BPT. The cytoplasmic c-kit staining was detected in the stroma of 8 cases being weakly to moderately positive. Three FAs (1 cellular, 2 simple), 1 MH, 2 GM and 1 BPT were negative for this marker in the stroma. All cases were strongly and diffusely positive for CD34 except the BPT case. This case presented weak epithelial staining with CD117 in the lesion while the ducts in the surrounding tissue were intensely and diffusely positive . Marked loss of CD34 stromal staining was also prominent when compared with the surrounding stroma .

DISCUSSION: Our study showed that adolescent FAs showed similar staining patterns for CD117 and CD34 as for adult counterparts. We were not able to find any difference in expression patterns between cellular and simple FAs . Our single case of BPT showed significantly different expression patterns for CD117 and CD34 from FAs. Epithelial CD117 and stromal CD34 stainings were significantly less intense than in FAs . Although it is clearly needed to be confirmed in bigger series, significant different expression patterns of CD117 and CD34 in BPT and FAs have led us to think that different oncogenetic pathways may be involved in these two groups of tumor. Another finding was that CD117 was labeled very weakly and focally in male breast epithelium when compared with the female breast epithelium.

INTRODUCTION
Sertoli cell tumors (SCTs) of the testis are extremely rare (0.4-1.5% of all testicular neoplasms) with a heterogeneous pathology. Sertoliform cystadenoma (SCA) is a recently described entity defined as a benign tumor of rete epithelial origin that occurs within the dilated rete and typically has a tubular pattern resembling SCT. This rare tumor occurs mostly in adults: to our knowledge, only 5 cases have been reported to date. The first pediatric case of Sertoliform cystadenoma with unique features is described herein.

CASE REPORT
The patient is a 6 year-old boy presenting with gynecomastia and a left testicular cystic mass.
Histopathologically the tumor was found to originate from the rete channels, filling and distending them with areas of mural Sertoli cell proliferations reminiscent of large cell Sertoli cell tumor (non-calcifying form) and showing widespread intratubular Sertoli cell proliferation islands in the vicinity.

DISCUSSION
We presented herein a unique pediatric case of SCA with overlapping histological features with large cell Sertoli cell tumor (LCSCT) and intratubular large cell Sertoli cell tumor (ITLCHSCT )- unaccompanied with hereditary syndrome - which led us to think that the association of these lesions may not be merely a coincidence but rather that they may be parts of the same spectrum of disease of a common nature.

Collagenous colitis (CC) classically presents with chronic non-bloody watery diarrhea, endoscopically grossly normal-appearing colonic mucosa and thick subepithelial collagen band on histopathology. It is rare in children and only a few cases have been reported in literature, in the form of isolated case reports. In this study we retrospectively analyzed the clinical features of eight cases, which showed presence of thick subepithelial collagen (mean >6µm) deposits in colorectal biopsies. Mucosal changes apart from the collagen band were also recorded. To highlight the collagen band the biopsies were stained with Masson's trichrome stain. The thickness of the collagen band was measured using systematic morphometric approach. In addition, the sections were stained immunohistochemically for tenascin and CD1d, which have proven to be valuable aid in the diagnosis of collagenous colitis. All the patients were Caucasians and no sex predilection was noted. Out of the eight cases selected for the study, five patients presented with the characteristic clinical features of collagenous colitis, of which one developed biopsy proven inflammatory bowel disease during follow-up. Of the remaining three cases, two presented with constipation and one patient had blood in stool. We conclude that collagenous colitis in children can have varied clinical features and may show collagen bands of borderline thickness. Considering the potential of CC to develop inflammatory bowel disease close follow-up of the patients is necessary.

Introduction - Myofibromas are benign mesenchymal tumours with myofibroblastic differentiation. They usually occur in the skin and subcutaneous tissues of the head and neck region of infants. The term myofibromatosis is used when multiple lesions are present. The differential diagnosis of myofibroma is extensive. It is important to establish the correct diagnosis to avoid morbidity from unnecessary aggressive therapy.

Aim of study - To determine the clinicopathologic correlations of myofibroma and myofibromatosis.

Materials and Methods - 97 cases of myofibroma and 17 cases of myofibromatosis were studied. The patient data and material were retrieved from archives of Departments of Pathology and hospital information systems between 1987 and 2010. All slides were reviewed by three of the authors. Immunohistochemical stains consisting of muscle specific actin, smooth muscle actin (SMA) and desmin were scored as positive or negative.

Results - Age of patients at diagnosis ranged between 0 and 70 years and 68% of myofibromas were diagnosed in the first two years of life. All cases of myofibromatosis and 90% of myofibromas occurred in children. Fifty-three percent of myofibroma patients were male and 47% were female, versus 59% and 41% for myofibromatosis. Both in children and adults the head and neck region was the most common site (n=38), followed by the trunk (n=19), lower limbs(n=13), upper limbs(n=8) and viscera(n=4). Most patients (n=76) were treated by excision. No recurrencies were reported. Seventy percent of the myofibromas stained positive for actin, 93% stained positive for SMA and 87% stained negative for desmin.

Conclusion - Myofibromas are benign tumours that predominantly occur in infancy and childhood, whereas myofibromatosis is exclusive to childhood age. Myofibromas occur especially in the head and neck region. They are characterized by positive staining for actin and SMA and negative staining for desmin. The clinical course is self-limited and local excision is sufficient.

We describe the first case of hypertrophic hollow visceral myopathy due to PTRF mutation.

Case Report:
A 12 year old girl was transferred to Alder-Hey for a surgical review with persistent ileus and intermittent pyrexia following an appendicectomy 2 weeks earlier.
The appendectomy specimen reviewed showed serosal inflammation but no true appendicitis. She underwent a second laparotomy with a finding of gross peritonitis, grossly thickened, abnormal descending and sigmoid colon. A stercoral perforation was seen in the sigmoid colon. In view of the diffusely thickened bowel in a known patient of Rippling muscle disease (autoimmune disorder), clinical diagnosis of an infiltratitive disorder (? Lymphoma) was considered. Limited left colectomy was performed.
On gross examination, the bowel wall was diffusely thickened with homogenous ivory white appearance. Histology showed extensive fibrosis and disordered alignment of muscle fibres as intersecting fascicles and in places herring bone pattern.
Based on the morphology, infiltrative disorder was excluded and diagnosis of visceral myopathy was made. In view of the history of Rippling muscle disease, possibility of Caveolinopathy was suggested.
The genetic investigation excluded Caveolin 3 mutation. The clinical review revealed that in addition to RMD she also had lipodystrophy (LD). Based on recent description of LD and RMD associated with PTRF mutation, PTRF gene was evaluated. A homozygous mutation in PTRF gene was confirmed.

Discussion: Caveolins are a family of integral membrane proteins which are the principal components of caveolae membranes. There are three different proteins caveolin-1, 2 and 3 with differential expression in different tissue. Caveolin-1 and 2 are most prominently expressed in endothelial, fibrous and adipose tissue and mutation in Caveolin 1 gene is known to be associated with lipodystrophy. Whereas the expression of caveolin-3 is restricted to striated and smooth muscle and there mutation is known to be associated with skeletal muscle myopathy and cardiomyopathy but hollow visceral (smooth muscle) myopathy has not been described. PTRF gene product is essential for the biogenesis of caveolae and therefore impacts on both caveolin-1 and caveolin-3 expression allowing for the phenotypic characteristics of both a lipodystrophy and myopathy.

Carvajal disease, a cardio-cutaneous syndrome bear close resemblance to Naxos disease, with two exceptions: early and prominent left ventricular involvement and pure fibrosis without adipose replacement. Naxos syndrome results from mutations in Plakoglobin gene where as Carvajal syndrome is linked to Desmoplakin gene mutations.
We describe a case of Cardio-cutaneous syndrome caused by double heterozygous mutations in Desmoplakin gene with early prominent left ventricular involvement but fibro-fatty replacement of myocyte rather than pure fibrosis as described in Carvajal syndrome.

A girl who was being followed up in the dermatology department for thickened skin on her palms and soles presented at the age of 5 years with acute cardiac decompensation. She was found to have dilated cardiomyopathy. Clinical diagnosis of Naxos syndrome was made in view of palmoplantar keratoderma and cardiomyopathy. Genetic tests of Plakoglobin gene failed to reveal any abnormality. However double heterozygous mutation in desmoplakin gene was identified.
She had sudden unexpected death at 8 years of life. Autopsy revealed dilated heart, which on histology showed extensive myocyte loss and fibro-fatty replacement. The changes were more severe in left ventricle. There was no significant inflammation. The skin showed hyperkeratosis, acanthosis and prominent epidermolysis.

This rare case suggests that there is morphological overlap between cardio-cutaneous syndromes arising from abnormalities of different desmosomal proteins. The clinical heterogeneity and histological characteristics in desmosomal cardiomyopathy might be mutation specific and leads to consideration that the spectrum of ARVC should be broadened.

Acknowledgement to Prof A M Christiano, Director , Centre for Human genetics HG, Columbia University, New York for analysis of Desmoplakin and Plakoglobin gene.

Background: While there is a low incidence in the literature of Burkitt Lymphoma (BL) as a post-transplant lymphoproiferative disorder (PTLD), this entity appears to be different than other PTLDs, both in its aggressive clinical presentation and distinct molecular profile. BL-PTLD has the typical morphologic, immunohistochemical, and molecular profile of BL; however, in the post-transplant setting, the expression of Epstein-Barr Virus (EBV) appears to be more prevalent.

Aim: The aim of this study is to characterize all cases of BL-PTLD at our institution in order delineate what specific clinical and pathologic aspects of this disease make it distinctive.

Material and Methods: Cases of pediatric NHL lymphoma, with pathologic criteria of BL, diagnosed in the post-transplant setting, (age 18y and younger) were retrieved from the surgical pathology archives at the Children's Hospital of Pittsburgh of UPMC Department of Pathology, from 1982-2008. Clinical outcomes were obtained along with pathologic review.

Results: Eleven cases of pediatric BL in the post-transplant setting (8 boys, 3 girls) were retrieved over a 28 year period. The cases displayed a monomorphic population of small to intermediate-sized, non-cleaved lymphoid elements with a starry-sky pattern. The immunohistochemical profile was positive for CD20, CD10, bcl-6, with a near 100% Ki-67/MIB-1 proliferation rate index, and negative for TdT. The most common translocation was t(8;14), with one case positive for t(8;22). Pre-transplant EBV serological titers were negative in the majority of patients (78%). Post-transplant EBV serum titers were positive in the majority of patients (80%) with positive EBER in situ hybridization staining at diagnosis. Allograft organs included liver (n=5), heart (n=4), small bowel (n=1), and kidney (n=1). Sites of BL-PTLD involvement included both transplant (liver allograft, n=2) and non-transplant sites (head and neck n=4, abdomen n=4, and kidney n=1). The median time from transplantation to diagnosis was 3 years. The median disease free time was 8.9 years from diagnosis. Eight patients (73%) are alive following chemotherapy, without disease.

Conclusion: BL-PTLD has a higher incidence of EBV infectivity compared to sporadic and immunodeficiency-associated BL. A pathologic interplay between the oncogenic EBV infection and the genetic alteration at the c-MYC gene is likely contributing to this distinctive PTLD.

Background: A large proportion of first-trimester spontaneous abortions is caused by chromosomal disorders. Cytogenetic study of spontaneous abortions is not always performed and a relatively high rate of culture failures is reported. The purpose of the present study was to evaluate the efficiency of FISH in understanding the etiology of spontaneous abortions.

Design: FISH was performed on paraffin-embedded first trimester spontaneous abortions using 15, 16, 18, X, Y CEP probes and 13, 21 and 22 LSI probes panel. One hundred interphasic nuclei were analyzed for each probe. Both the mesenchymal and trophoblastic cells from the placental villous samples were scored. The case was considered pathologic when at least 80% of the nuclei scored showing more (trisomic/tetrasomic) or less (monosomic) of two copies for only one probe. Reliability of the FISH method was demonstrated in control samples in which karyotype was available. Moreover, cells from decidual tissue were not counted, but served as an internal diploid control.

Results: Four hundred fifty-five cases from first trimester spontaneous abortion were examined for both pathological and FISH analysis. 300/455 (66%) cases presented numerical chromosome abnormalities. Trisomies were detected in 78% , poliploidy ( triploidy and tetraploidy) in 11.3%, X monosomy in 6%, mosaic in 3,6% and sexual trisomy (XXX,XXY) in 1% of all pathological cases. Of 235 trisomies, 55.3% was represented by +16 , 22.1% +15, 9.8% +21 , 9% +22, 2.1% +18 and 1.7% +13.

Conclusions: The lack of peculiar morphological criteria to recognize the chromosomal etiology of early spontaneous abortions makes FISH analysis with use of an appropriate probe panel, a surprising test to discover genetically caused abortions.

BACKGROUND: Primary Atypical Teratoid/Rhabdoid Tumours (AT/RTs) of the central nervous system are malignant intracranial neoplasms, most frequently infratentorial, occuring in young children and representing 6-7% of CNS tumours in children younger than 2 years. Some of these tumours have been misdiagnosed in the past as primitive neuroectodermal tumours (PNET) because of overlapping histological features. Inactivating mutations of the hSNF5/INI-1 gene in the tumour cells are regarded as a crucial event in the pathogenesis of AT/RTs and distinguish them from other malignant pediatric brain tumours.

OBJECTIVE: The purpose of this study is to report a case of AT/RT, detected by fetal ultrasonography, which is to our knowledge, the first reported fetal case of AT/RT with a particular emphasis on the immunohistochemical and molecular genetic features.

PATIENT: During a heterozygous twin pregnancy, with normal US data at 13 and 21 weeks of gestation, ultrasonography demonstrated, at 28 weeks of gestation, a suprasellar large brain tumour with mass effect on the surrounding parenchyma and ventricular enlargement. Subsequent prenatal MRI showed a rapid tumoral growth. Delivery was induced at 34 WG and gave birth to a macrocephalic stillbirth and a normal premature baby. Karyotype of both twins was normal (46XX).

RESULTS: Macroscopical examination showed a huge tumour, by far more voluminous than the tumour identified prenatally, suggesting an extremely rapid growth. The tumour invaded the most part of the hemispheres and the upper part of brain stem and cerebellum. Histologically the tumour was composed predominantly of undifferentiated small cells identical to those of PNET, associated with scattered small islands of large eosinophilic cells with eccentric nuclei. Numerous foci of necrosis and haemorrhage were observed throughout the tumour. Immunohistochemical studies demonstrated positive reactions of a variable number of small cells for neuronal markers (NF, MAP2, TUJ1), Vimentin, OLIG 2, GFAP and epithelial markers (EMA, CK). The large cells showed a strong immunoreactivity for Smooth Muscle Actin typically expressed by rhabdoid tumour cells. Nuclear immunohistochemical expression of INI-1 protein was absent in all tumour cells, indicating an inactivation of hSNF5/INI-1 gene and confirming the diagnosis of AT/RT. In addition, a molecular study of fetal DNA demonstrated a constitutional heterozygous mutation (c 628 + 1G>A) involving exon 5.

CONCLUSION: The study of this fetal AT/RT indicates the importance of the immunohistochemical study of specific markers (SMA, hSNF5/INI-1) and genetic analysis in malignant brain tumours occuring in young children. It demonstrates also the distinctive features of fetal brain tumours, different from those of identical tumours in children, concerning the location mostly supratentorial versus infratentorial and the particularly aggressive behavior of malignant tumours.

Background
Autosomal recessive congenital ichthyosis (ARCI) is a group of skin disorders characterised by disorders of cornification of the skin, which manifest at birth. More recently a syndrome characterised by the clinical triad of premature birth, thick caseous desquamating epidermis and neonatal asphyxia has been recognised as Ichthyosis Prematurity Syndrome (IPS) and has been mapped to chromosome 9q34.

Case Report
We describe two siblings born prematurely of consanguineous parents, which we believe to be the first reported kindred of IPS in Ireland. The first child was a baby girl born at 35 weeks gestation in a pregnancy complicated by polyhydramnios. The baby developed acute asphyxia after birth, which was unamenable to all resuscitation measures. Autopsy of the neonate revealed respiratory obstruction caused by bronchoalveolar keratinocytic plugs. Histological examination of the skin showed orthokeratotic hyperkeratosis with an intact stratum granulosum and normal non-bulliform epidermis. Electron microscopy showed increased numbers of lipid droplets in the stratum corneum. The second sibling was born at 28 weeks gestation and survived severe neonatal respiratory distress. It became apparent subsequently that he had an ichthyotic skin disorder with palmar plantar keratoderma and a propensity to develop recurrent skin infections as a result of defective skin barrier function.

Conclusion
Ichthyosis prematurity syndrome is a very rare subtype of autosomal recessive congenital ichthyosis associated with mutations in the gene encoding the fatty acid transport protein 4 (FATP4). Normal functioning of fatty acid metabolism is important for the barrier property of the intercellular lipid layer and stratum corneum. The syndrome has obstetric, paediatric and dermatologic implications and is potentially fatal in the neonatal period if unrecognised, but can have a benign course in the older child.

Background and Aims of the Study. While TTF-1 is regularly expressed in the developing thyroid, lung, and forebrain and is commonly applied as a marker for epithelial-derived neoplasms of the lung and thyroid, it also labels other tissues and tumors, including some nephroblastomas (1). WT1 is expressed not only in the kidney and nephroblastomas, but also in other anatomical sites and neoplasms, including ovarian and endometrial cancer, mesothelioma, desmoplastic small round cell tumor, melanoma and acute leukemias. With the aim to investigate how common TTF-1 and WT1 expression is in small round cell tumors of the soft tissues, viscera, and central nervous system (CNS), we undertook this immunohistochemical study on 72 cases affecting children and young adults.

Materials and Methods. The ages of 21 and 30 years were used to define the upper limits of pediatric and young adults, respectively. 72 patients with embryonal tumors were selected for this study, 49 males and 23 females. 62 were in the pediatric age (£ 21 years), 10 were young adults. Embryonal soft tissue and bone tumors (50 cases): 17 Ewing’s sarcoma/primitive neuroectodermal tumors (EWS/pPNET), 12 affecting children and 5 young adults, mostly of superficial and deep somatic soft tissue from various sites, along with 4 visceral-based (kidney, lung, colon, and urinary bladder) and 2 of bone (skull, and femur); 13 peripheral (thoracoabdominal) neuroblastomas (pNB), all occurring in patients < 6 years, mostly of the posterior mediastinum and adrenal, including 2 metastatic tumors; 15 embryonal rhabdomyosarcomas (ERMS), 14 in children and 1 in a young adult, from head & neck, urinary bladder, paratesticular region, internal female genitalia; 5 intrabdominal desmoplastic small round cell tumors (DSRCT), including 1 intrathoracic and 1 intracranial, in patients with age range of 7 to 24 years. Embryonal visceral tumors (12 cases): 5 hepatoblastomas (HB), 4 type I pleuropulmonary blastomas (PPB-I), 1 retinoblastoma (RB), 1 pancreatoblastoma (1 PTB), 1 neck paraganglioblastoma (PGB), all occurring in pediatric patients, with 10 aged less than 4 years, except for PTB affecting a 26 year old male. Embryonal CNS tumors (10 cases): 8 infratentorial PNET/medulloblastoma (MB), and 2 central supratentorial PNET (cPNET), mostly (8:2) in the pediatric age group. In addition, 5 synovial sarcomas (SVS) and 1 ovarian small cell carcinoma of the hypercalcemic-type (SCC HC-type) were included in this study for comparison and contrast. We tested both TTF-1 and WT1 reactivity on formalin-fixed, paraffin embedded tissues in all these tumors. The following antibodies were used: monoclonal antibody TTF-1 (1:30 dilution; clone (G7G3/1) and WT1 (1:50 dilution; clone 6F-H2, directed against the amino terminal domain of WT1 protein). Immunohistochemical staining was performed using the labeled Envision system according to the manufacturer’s recommendations.

Results. In our study, TTF-1 was negative in all the tumors tested, including SVS and ovarian SCC HC-type. The exception was a suprasellar cPNET, that showed immunopositivity in 40% of tumor cell nuclei. 50% of PPB-I showed alveolar-epithelial lining with nuclear TTF-1 immunostaining, as an internal control. No nuclear positivity for WT1 was found in any case of small round cell tumors investigated. The only case of ovarian SCC HC-type included in the study was diffusely and strongly positive for WT1. Cytoplasmic WT1 positivity was strong and diffuse in all 15 ERMS, focal in 53.8% of pNB, focal in 17.6% EWS/ pPNET, focal in 3 and diffuse in 1 of 10 MB and cPNET, diffuse in 50% PPB-I, diffuse in 60% DSRCT, focal in 40% of HB, focal and diffuse in 40% SVS. WT1 was universally positive in the endothelium of both normal and tumor vessels.

Discussion. To the best of our knowledge, TTF-1 has not been previously investigated in a wide array of embryonal tumors. Negative TTF-1 may help in the differential diagnosis of primary PNET of the kidney versus nephroblastoma, which can express TTF-1. We could not reproduce nuclear immunostaining in SVS as previously reported in one case metastatic to the lung. The only TTF-1 positive cPNET is in agreement with previous reports of peri-diencephalic neuroepithelial positive tumors. [2] Nuclear WT1 positivity in ovarian SCC HC-type is in accordance with previous studies and in support of its müllerian origin. [3] Cytoplasmic WT1 positivity in ERMS has previously been reported, and observed in nephroblastomas with rhabdomyomatous component. [4] We used the cytoplasmic WT1 property as an adjunctive marker in a case of spindle cell rhabdomyosarcoma of the heart. [5] Our study supports WT1 as a reliable marker for documenting skeletal muscle differentiation. While the absence of nuclear immunoreactivity in DSRCT agrees with the findings of other investigators who used a similar monoclonal antibody against the amino terminal domain, [6] the retention of cytoplasmic WT1 we observed still needs to be elucidated. The cytoplasmic reactivity for WT1 we observed in DSRCT might reflect its polyphenotypic nature, but needs to be elucidated. WT1 cytoplasmic immunopositivity in embryonal tumors of neural lineage and in the rest of soft tissue tumors is likely nonspecific, but cytoplasmic positivity in a case of MB is intriguing, since it was in fact an already known anaplastic MB, which we had previously diagnosed with immunohistochemical evidence for early rhabdomyoblastic differentiation (nuclear immunopositivity with myogenin). WT1 was consistently positive in the cytoplasm of endothelial cells mainly of tumoral vasculature, partly confirming previous experience, [7] and leading us to select WT1 as perhaps one of the most sensitive endothelial markers currently available (unpublished data of one of us [MB]).

Conclusion. Embryonal neoplasms of soft tissues and viscera, other than a subset of nephroblastomas, do not express nuclear TTF-1. cPNET of the diencephalic region of the forebrain can express TTF-1 in tumor cell nuclei. ERMS consistently exhibits cytoplasmic WT1 immunopositivity. Other embryonal tumors, mainly of neural lineage and of the somatic soft tissues, may variably express cytoplasmic WT1 in a nonspecific fashion. WT1 is perhaps one of the most sensitive endothelial markers in surgical pathology.

References. 1. Bisceglia M, Ragazzi M, Galliani CA, Lastilla G, Rosai J. TTF-1 expression in nephroblastoma. Am J Surg Pathol. 2009;33:454-461. 2. Zamecnik J, Chanova M, Kodet R. Expression of thyroid transcription factor 1 in primary brain tumours. J Clin Pathol. 2004; 57:1111–1113. 3. Carlson JW, Nucci MR, Brodsky J, Crum CP, Hirsch MS. Biomarker-assisted diagnosis of ovarian, cervical and pulmonary small cell carcinomas: the role of TTF-1, WT-1 and HPV analysis. Histopathology. 2007;51:305-312. 4. Carpentieri DF, Nichols K, Chou PM, et al. The expression of WT1 in the differentiation of rhabdomyosarcoma from other pediatric small round blue cell tumors. Mod Pathol. 2002;15:1080–1086. 5. Fraternali Orcioni G, Ravetti JL, Gaggero G, Bocca B, Bisceglia M. Primary embryonal spindle cell cardiac rhabdomyosarcoma: case report. Pathol Res Pract. 2010;206:325-330. 6. Barnoud R, Sabourin JC, Pasquier D, et al. Immunohistochemical expression of WT1 by desmoplastic small round cell tumor: a comparative study with other small round cell tumors. Am J Surg Pathol. 2000;24:830-836. 7. Wagner N, Michiels JF, Schedl A, Wagner KD. The Wilms\' tumour suppressor WT1 is involved in endothelial cell proliferation and migration: expression in tumour vessels in vivo. Oncogene. 2008;27:3662-372.

Aims of the Study. To report our observations on the gonadectomy specimens from 6 patients, 5 with complete AIS and 1 with 17β-HSD3 deficiency.

Materials and Methods. Six pairs of testes from patients clinically diagnosed with either AIS or 17β-HSD3 deficiency were studied. The age at the time of diagnoses was between 3 months and 43 years. All patients underwent bilateral gonadectomy. The testes were in bilateral inguinal hernia sacs, except in the 43-year old, in whom the testes were intra-abdominal. The earliest gonadectomy was performed at the age of 6 years due to early signs of puberty (rapid breast growth and pubic hair) and the latest at the age of 43, the rest underwent prophylactic gonadectomies at or after puberty.

Results. All patients demonstrated a normal 46,XY karyotype. Five patients had the complete form of AIS and one had 17b-HSD3 deficiency. A 43-year old AIS patient was married. Two AIS patients were siblings. The 17β-HSD3 deficiency patient was 15-year old. Macroscopically, the testes of AIS patients measured between 1.8 and 4 cm in maximum diameter, all were accompanied by spermatic cords, and none had identifiable epididymis or vas deferens. The five AIS specimens contained intratesticular parenchymal nodules (multiple in 4, solitary in 1). Two cases (6-year old and 43-year old) had hypoplastic fallopian tubes. Paratubal cystic structures were present in the 43 year-old. Histologically, 3 cases contained Sertoli-Leydig cell hamartomas and foci of Leydig cell hyperplasia. One case contained a 1 cm Sertoli cell tumor resembling sex cord tumor with annular tubules. Smooth muscle fascicles with a pseudoleiomyomatous pattern were seen bilaterally in the upper poles of three pairs of testes, 2 of these in the affected siblings, and the third in the 43 year-old. The testes in the 43 year-old were intra-abdominal, had bilateral hypoplastic fallopian tubes, and solid and cystic Walthard nests in the vicinity of the left and cystically dilated mesonephric rests in the vicinity of the right, along with a small heterotopic nodule of adrenal cortex in the paratestis. Wolffian derivatives (epididymides and deferentia) were absent in all AIS cases. The testes in the only case of 17β-HSD3 deficiency were asymmetrical, measured 2.5 and 4.0 cm, and each had epididymis and vas deferens. The seminiferous tubules showed profound germ cell hypoplasia, but occasional foci of spermatogenesis were identified. There was diffuse interstitial Leydig cell hyperplasia. No pseudoleiomyomatous body was detected.

Discussion and Conclusion. The 5 patients with AIS were of the complete form. However, the phenotypic spectrum may range from complete to partial to mild corresponding to absent and degrees of escalating androgen receptors. Thus, the fully developed phenotype is between statuesque females at one end and male appearance with microphallus, infertility and gynecomastia at the other. AIS is caused by mutations in the gene for the androgen receptor located on the long arm of the chromosome X (Xq11-12) and has a prevalence of about 1:20,000. In addition to features of cryptorchidism but with less mature tubules, testes in patients with the complete form of AIS are mostly devoid of germ cells, may contain hamartomatous tubular nodules, Sertoli cell adenomas, Leydig cell hyperplasia, and intraparenchymal fascicles of smooth muscle. Two of our patients with AIS were siblings (familial form) and represented the subject of a separate publication. [1] Patients with AIS lack androgen-binding activity. 17β-HSD3 deficiency is caused by mutations in HSD17B3 gene (mapped to Ch9q22), with an incidence of 0,65 times that of AIS, even though - as per all autosomal recessive disorders - the incidence may be very high, up to 1:200-1:300, in certain ethnic groups. [2] The external genitalia are those of a female, although ambiguous genitalia may be seen in up to 20% of cases. Wolffian derivatives are normal in this condition, in keeping with the stabilizing effect of androstenedione or due to extratesticular conversion of androstenedione into testosterone. Additional effects are also responsible for the pubic or axillary hair growth, male voice and clitoromegaly which may occur in these latter patients at puberty (transient sex). Wolffian derivatives are well developed in 17β-HSD3 deficiency. The presence/absence of normal epidydimis, vas deferens, and seminal vesicles is an important clue in discriminating between one and the other. Prostate is absent in both. In cases with ambiguous genitalia, 5-alpha-reductase-2 deficiency (MIM #264600) is to be considered as well, especially to distinguish from 17b-HSD3 deficiency in that both have preserved wolffian derived structures. 17β-HSD3 deficiency is distinguished from 5-alpha-reductase-2 deficiency by elevated serum levels of androstenedione. Testes in AIS are found either in inguinal hernial sacs or in the abdominal cavity (50%), while in cases of 17β-HSD3 deficiency, the testes are in inguinal hernial sacs in about 80-90% of cases. Cryptorchidism places patients with both AIS and 17β-HSD3 deficiency at a heightened risk for the development of malignant germ cell tumors, usually after puberty. Bilateral orchiectomy is recommended, the timing may vary according to the clinical situation, although in AIS cases may be preferable after puberty, while in 17β-HSD3 gonadectomy may be preferable before puberty to avoid the virilizing effect at pubescence and improve psychosexual development of sex assignment.

References.

1. Bisceglia M, Magro G, Ben Dor D. Familial complete androgen insensitivity syndrome (Morris syndrome or testicular feminization syndrome) in 2 sisters. Adv Anat Pathol. 2008;15:113-7.

2. Boehmer AL, Brinkmann AO, Sandkuijl LA, et al. 17Beta-hydroxysteroid dehydrogenase-3 deficiency: diagnosis, phenotypic variability, population genetics, and worldwide distribution of ancient and de novo mutations. J Clin Endocrinol Metab. 1999;84:4713-21.

Aim of study In vitro studies have shown that tumour cell lines of ES/PNET overexpress cyclin D1, suggesting its key role in the mechanisms that regulate normal cell cycle during G1-S. The aim of the present study was to assess whether cyclin D1 may be include in the list of diagnostic markers of pediatric ES/PNETs.

Materials & Methods A comparative immunohistochemical analysis of cyclin D1 expression was performed in 20 cases of pediatric ES/PNETs, 10 cases of embryonal rhabdomyosarcoma, 10 cases of alveolar rhabdomyosarcoma, including the solid variant, and 5 cases of desmoplastic round cell tumours to assess its potential usefulness in the differential diagnosis of these tumours.

Results Notably 100% of ES/PNETs expressed cyclin D1, with a diffuse extension, ranging from 60 to 100% of neoplastic cells. In contrast, desmoplastic round cell tumours showed immunoreactivity restricted to 10-20% of cells, whereas both embryonal and alveolar rhabdomyosarcomas lacked any cyclin D1 immunoreactivity.

Conclusion Our preliminary immunohistochemical results suggest that cyclin D1 overexpression may be exploitable as an additional marker in the differential diagnosis of Ewing\'s sarcoma/PNET versus rhabdomyosarcoma, especially the solid variant of alveolar rhabdomyosarcoma. This finding, evaluated appropriately in the context of a large panel of antibodies, may be helpful especially when dealing with small incisional biopsies or ambiguous immunohistochemical results due to sub-optimal fixation, non-specific immunoreactivity or polyphenotypic profile exhibited by neoplastic cells.

Background: Wilms tumor (WT) is the most common malignant renal tumor in pediatric age. With modern multimodal therapies, survival reaches 90%. WT is a highly responsive tumor, and tumor shrinking is a sign of response. Resistance to therapy is generally due to the presence of anaplasia. Occurrence of a renal cell carcinoma (RCC) component associated with WT is rarely reported.

Case history: A 6-year-old girl presented with a renal mass and lung metastases. The tumor was diagnosed as a non-anaplastic WT on biopsy. The tumor was diffusely reactive for WT1. The patient was treated with preoperative vincristine/actinomycin-D/doxorubicin combination chemotherapy along the AIEOP TW2003 Protocol for stage IV WT. Only partial response of the renal mass and response <50% of the lung metastases occurred. In the nephrectomy specimen, the residual viable tumor accounted for 90% of the residual mass. It was formed by microfoci (5%) of WT in the form of rhabdomyoblasts and atrophic epithelial component immunoreactive for WT1. The vast majority (95%) of the residual viable tumor was featured by a tubulo-papillary, nested and solid epithelial component immunoreactive for MiTF, keratins AE1/AE3, keratin 7, CD10, and racemase. It was negative for WT1, TFE3, HMB45, and MART1. It was interpreted as a MiTF-positive RCC. A biopsy of the lung metastases was also performed, showing the presence of MiTF-positive RCC. The pre-treatment renal biopsy was then reviewed. Microfoci of MiTF-positive WT1-negative epithelial component were found. The critical review of imaging disclosed a different radiologic appearance of the two components, with different and discrepant response to chemotherapy, fitting with the two different histotypes. The histological diagnoses prompted the clinicians to pursue surgical removal of all lung metastases. This was obtained, and the girl is still tumor free 18 months from diagnosis.

Conclusions: The presence of residual RCC justified in this case the lack of responsiveness to the conventional therapy for WT. The RCC showed MiTF immuoreactivity, linking this tumor to the MiTF/TFE3 translocation family of renal carcinomas, typical of children and young adults. A critical review of imaging disclosed a different radiologic appearance of the two components.

There has been a significant decline in autopsy rates during the past 30 years. This has been further aggravated in paediatric and perinatal pathology by the organ retention controversy emanating from the United Kingdom. When the request for a complete autopsy has been declined superficial examination of the deceased infant or fetus which is non invasive, along with placental examination can provide useful information. This approach, albeit limited, has been a useful alternative to the complete autopsy. The diagnostic effectiveness of this practice which has been employed for many years at the Rotunda Hospital Pathology Department is the subject of this review.

Methods: The superficial post-mortem examination (SPM) at the Rotunda comprises an examination of the external appearance of the body to evaluate any dimorphism be a consultant perinatal paediatric pathologist. Standard measurements and radiology are performed by an anatomical pathology technician. These findings are then recorded in a formal report. The placenta examination includes evaluation of the gross and microscopic anatomy as well as microbiological and cytogenetic analysis. This study reviewed the diagnostic yield from this case material for a total of 8 years (2000- 2007).

Results: A total of 704 reports were reviewed:-of 231 cases > 500 grams, 67cases (29%) were dysmorphic; 142 cases (61%) appeared normally formed in which critical diagnostic information was obtained primarily from the placenta; 22 cases (10%) which remained unexplained. There were 473 cases of miscarriage i.e. birth weight < 500grams:- 50 cases (11%) were dysmorphic; 251 cases (53%) appeared normally formed but in which critical diagnostic information was obtained primarily from the placental examination; and 172 cases (36%) which remained unexplained.

Conclusion:- When parents decline consent for a complete (or limited) autopsy, a superficial post-mortem examination, which is non-invasive, represents a reasonable fall back alternative. In our department it is relatively more useful in infants of birth weight > 500 grams. Because of its limitations, the superficial post-mortem examination should not be seen as a replacement for the standard complete autopsy.

Introduction: Protein S (PS) and Protein C (PC) deficiency are claimed to be associated with impairment of maternal blood flow to the placenta. This study evaluated the effect of these thrombophilias on placental terminal villous structure using stereological measurement.

Methods: Clinical cohorts were obtained from low risk primigravid mothers of 36-41 weeks gestation.. These cohorts comprised 5 cases each with (i) PS levels <20%; (ii) PS levels 20-25%; (iii) PC levels <70% of normal values. 8 placentas from mothers with preeclampsia associated with IUGR (PET-IUGR) and 8 placentas from normal pregnancies provided positive and negative controls respectively. The volume of each placental disc was measured followed by uniform random sampling of 10 full thickness biopsies. 5 fields were examined from coded haematoxylin and eosin stained sections. Stereological assessment comprised star volume and surface area measurements of terminal villi (TV) and of their capillaries. Two-dimension enumeration of syncytial knots was also performed in each case.

Results: There was a statistically significant reduction in the volume fraction of capillaries (PS<20 p=0.043; PS 20-25 p=0.005; PC p=0.002) and of terminal villi (PS<20 p=0.05; PS 20-25 p=0.13; PC p=0.005) in the thrombophilia groups when compared with control values. The levels were commensurate with those noted in the PET-IUGR cohort (capillaries: p=0.002; TV: p=0.03). In addition the surface area of capillaries were reduced in the thrombophilia groups (PS<20 p=0.01; PS 20-25 p=0.005; PC p=0.0002) when compared with control values. This was similar to that found in PET-IUGR (p=0.002). The surface area of terminal villi was reduced in all 3 cohorts similar to PET-IUGR, but was only statistically significant (p=0.017) with protein C. Syncytial knots were not increased when compared with controls.

Conclusions: These findings demonstrate that PC and PS affect placental villi in a way which is similar to PET-IUGR. In addition, the alterations evident in the intermediate PS cohort highlights a requirement for heightened clinical concern in this group.

Aim:
The finding of Retinal Haemorrhages (RH) in a young child always raises the possibility of inflicted injury, particularly in conjunction with intracranial injury. However, it is suggested that RH may occur in accidental injury, or in association with disease processes, leading to diagnostic uncertainty. A systematic review of the literature was performed with two aims: are there features of the RH which distinguish between Abusive Head Trauma (AHT) and non-Abusive Head Trauma (nAHT)? ; what other causes of RH have been recorded in children?

Materials and Methods:

We searched 11 databases, references and conference abstracts from 1950-2009, supplemented by hand searches of key journals and all identified references. Of the 11,420 potential studies, 337 underwent independent reviews by two trained reviewers, drawn from: paediatricians, ophthalmologists or pathologists, using standardised critical appraisal tools. Included: all primary studies of live children <11 years with retinal findings confirmed by an ophthalmologist, due to explicitly confirmed AHT or other cause. Excluded: mixed adult / child data, space occupying lesions, known coagulopathy and pure post-mortem studies. Quality standards in relation to confirmation of aetiology and examination were applied. A multilevel logistic regression analysis was carried out using R (version 2.10.1) on comparative studies that were suitable for analysis, determining the Odds Ratios (OR) and 95% Confidence Intervals (CI).

Results:

Overall, 61 studies addressing trauma, 39 addressing other causes and one addressing both met the inclusion criteria. Of 62 included studies relating to AHT /nAHT, 13 large studies provided prevalence data (828 children, 363 AHT); the remainder were small case series. Overall, RH were found in 78% of AHT, but only 5% of nAHT , and the OR that a child < 3 years of age with RH has been abused, is 14.7 (95% CI 6.39, 33.6), with a probability of 91% (CI 48%, 99%) based on five studies suitable for statistical analysis. Where recorded, 83% of RH in AHT were bilateral, in contrast to 1/12 in nAHT. Recording of details of the retinal findings was inconsistent, limiting further analysis. AHT cases (60/72) had numerous RH, while all eight nAHT had few RH. RH in nAHT were located at the posterior pole, with extension into the periphery occurring less than 10% of the time. Additional features, e.g. retinoschisis and perimacular retinal folds were recorded in isolated case reports of AHT, but their prevalence could not be determined from larger data sets. Neuro-imaging of AHT cases demonstrated an intracranial abnormality in all cases from the comparative studies, but nine cases from non-comparative studies had no abnormality detected on initial scans. The mode of accident in nAHT cases with RH was varied, but included falls, motor vehicle collision and crush injury.

At least 26 other causes of RH are described, nine of which may also be associated with features of inflicted injury (eg bruising, fractures, intracranial haemorrhage). Among conditions proposing RH as a consequence, no evidence was found for acute life threatening event (ALTE) or cough causing RH, possible evidence for seizures giving rise to RH (2/218 cases), but insufficient case numbers in the literature to assess any association with cardiopulmonary (CPR) resuscitation.

Conclusions:

RH are common in Abusive Head Trauma, but may be found in accidental head trauma, including rare cases with extensive RH. No pattern of RH is unique to AHT or nAHT, although certain features were more common in AHT. Additionally, there are at least 26 other causes of RH. Not all inflicted cases have associated intracranial abnormalities, and the true prevalence of RH in other conditions may not be fully recognised - should post mortem eye examination practice be modified?

We present 4 children with a not previously recognized cutaneous hamartoma. All four patients are male, and their lesions appeared during the first months of life as large plaques located on the trunk (3 patients) and thigh (1 patient). They appeared as an infiltrated area of the skin which later became studded with numerous follicular comedo-like openings. Through the years, the lesions progressed to form a big mass of cysts containing and draining a keratinous material, embedded in a lax and thickened skin. These cysts festered and oozed a purulent material every now and then. There were also some comedones and superficial keratinous cysts with black dots. Interestingly, 3 of the 4 patients had definite tuberous sclerosis.

On histopathology, numerous keratin-filled infundibular cysts of variable size are seen in the upper and mid dermis. Gross fascicles of collagen occupy a widened dermis, sparing the adnexae. A striking concentrical perifollicular fibrosis is considered to be responsible for cyst formation. In the hypodermal fatty tissue, thick fibrous septae project from the dermis and there are bands of gross, fascia-like collagen, composed of sclerotic collagen bundles with some spindle shaped fibroblasts interstitially arranged between them. No increased ground substance is seen between the collagen bundles.

We think our patients have a distinctive hamartoma that is most likely related to tuberous sclerosis (TS). It is different from shagreen patches of TS and other TS-unrelated collagen nevi. To the best of our knowledge, no other cases of this complex hamartoma have been reported in the literature. However, a patient with TS has been reported with a large abdominal plaque that was diagnosed as fibrous hamartoma of infancy (1). Although detailed clinical and histopathological data are lacking in this description, gross pathology of the excised sample shows ‘epidermal inclusion cysts’ and ‘ill-defined whitish-gray fibrotic strands admixed with yellow fat in the deep dermis’ which appear parallel to the skin surface. We believe that this patient does not in fact have fibrous hamartoma of infancy, but a similar condition to our patient’s.

(1) Han H-J, Lim GY, You CY. A large infiltrating fibrous hamartoma of infancy in the abdominal wall with rare associated tuberous sclerosis. Pediatr Radiol 2009;39:743-6.

Background. Langerhans cells (LC) are a specialized subpopulation of dendritic cells found in the epidermis, mucosal sites, lymph nodes, thymus, and lung. Their main function is antigen presentation, critical for the activation of naïve and resting memory T cells. [1] Langerhans cell histiocytosis (LCH) represents a clonal expansion of LC that express CD1a, langerin/CD207, and S100 protein and reveal pathognomonic Birbeck granules by ultrastructural examination. Lymph nodal involvement in LCH is rare, and may occur isolated to a lymph node or as part of a multiorgan/multisystem disorder.

Aims of the Study. To present our findings in 5 cases of LCH, 2 localized to lymph nodes and 3 involving lymph nodes as part of disseminated disease.

Materials and Methods. Of the 5 cases, 3 were females and 2 males. The 4 paediatric cases ranged in age between 6 months and 16 years, and the young adult was a 21 year-old male. Case 1. 6-month old female, with bilateral cervical and left axillary lymphadenopathy and hepatomegaly with altered liver function tests. Case 2. 7 month-old female, with fever and uncontrollable crying, was found to have abdominal lymphadenopathy and hepatomegaly. Case 3. 4-year old male with asymptomatic right submandibular lymphadenomegaly. Case 4. 16-year old asymptomatic female with a 1-year history of right axillary lymphadenopathy. Case 5. 21-year old male with night sweats, asthenia and bilateral cervical lymphadenopathy. All patients underwent lymph node biopsies, in three cases from the neck (cases 1, 3, 5). An additional axillary node biopsy and liver needle biopsy were performed one month later in case 1. Laparoscopic portal lymph node and wedge liver biopsy were performed in case 2. In one case (case 4) only axillary lymph node biopsy was performed. The lymph nodes measured between 1.3 cm (case 2) and 2.5 cm (case 3). Lymph nodes from 3 cases were received in formalin. In cases 2 and 5 the lymph nodes were received fresh. The nodes from cases 1, 2 and 4 had a uniform, tan-yellow cut surface. Foci of necrosis were discernable in cases 3 and 5. Touch imprints were made in cases 1 and 5, and tissue from each was submitted for microbiological studies (tuberculous lymphadenitis was suspected in case 5). All cases were processed for routine histology and immunohistochemical analysis.

Results. A total of 6 lymph nodes (2 nodes in case 1) were studied. There was subtotal (cases 1, 2 and 3) to total (cases 3 and 5) expansion of the sinuses and paracortical replacement by sheets of histiocyte-like cells admixed with eosinophils and small lymphocytes. Many histiocyte-like cells exhibited deep nuclear grooves typical of LC, showed no significant atypia and there was a very low proliferative index (<1M/10 HPF). LC-like cells were identified on touch imprints in cases 1 and 5. Cases 3 and 5 contained eosinophilic microabscesses and geographic areas of necrosis with eosinophil debris and occasional Charcot-Leyden crystals. A granulomatous response, with palisading epithelioid histiocytes and multinucleated giant cells partly surrounded the foci of necrosis. In four cases, the LC-like cells were strongly immunoreactive for S100 protein, CD1a and langerin (CD207). Case 4 was immunostained for S-100 protein and CD1a only. A categorical diagnosis of LCH was established in all 5 cases. Clinical and imaging examination failed to identify any other sites of disease in 2 patients (cases 3 and 4) at the time of presentation. In case 1, a liver needle biopsy proved negative for LCH, but a solitary osteolytic lesion of the left mastoid process was discovered during investigation of bilateral otitis (multisystem active disease with Low Risk sites). In case 2, the wedge liver biopsy demonstrated portal-centered and periportal LCH, and imaging studies revealed multiple calvarial osteolytic lesions (multisystem active disease with High Risk sites). In case 5, total body CT scan revealed the presence of several intrapulmonary nodules (multisystem active disease).

Follow-up. Case 1: treated with chemotherapy (HS-LCH III protocol) for Group 2 low-risk patients, proved to be an early responder and is now alive with non-active disease 22 months post-diagnosis (8 months off therapy). Case 2: had complete response after 1 year of chemotherapy according to HS-LCH III protocol and now shows no evidence of disease 4 years post treatment. Case 3: received chemotherapy (AIEOP LCH III protocol) and is now free of disease 24 months after diagnosis (12 months off therapy). Case 4: was observed only and is currently healthy 5 years after diagnosis. Case 5: this patient received chemotherapy but was lost to follow-up.

Discussion. It has long been recognized that LCH may involve lymph nodes, either singly [2-4] or as a part of multivisceral disease [4,5].

Primary nodal LCH was identified as a special category after two series, one of 7 and the other of 30 cases, were reported in 1979-1980. [2,3]. The findings were confirmed by a further large series of 20 such cases [6] and smaller series or single case reports. However, primary nodal LCH is rare. In two large series including LCH of any site [4,7], only 5 of 238 (2.1%) and 1 of 314 (0.3%) cases of primary nodal involvement were found. In a series of 43 cases of nodal LCH, isolated nodal disease was seen in only 2 (4.6%). [5] Lymph nodes involved are mostly cervical (21 of 30 in the above quoted series [3]), and may be solitary or multiple. The excellent outcome for localized nodal LCH is nearly universal. Some cases undergo spontaneous remission. In the proper clinical setting, following lymph node biopsy, close clinical observation may suffice. [2,3] The accepted interval to classify a lesion as unifocal is 1 year of nonrecurrent disease. [4]

Multisystem LCH involvement is more frequent than isolated nodal disease. In two series comprising 85 and 96 cases of multifocal LCH, the prevalence of nodal involvement was only 13% [4] and 20% [7], respectively. In another series of 123 paediatric LCH cases, both unifocal (any site) and multisystemic, lymph nodes were found to be involved in 14 (11%), and lymph node was the initial diagnostic biopsy site in 7 (5.5%). [8] Lymph node involvement in multisystem disease is not a negative prognostic factor per se, the outcome depending on the stage, number and specific organs involved and level of dysfunction. [7] Age and stage are critical factors. Clinically, paediatric LCH is divided into Low Risk sites, including skin, bone, lymph nodes and pituitary, and High Risk sites, including lung, liver, bone marrow and spleen. Particular osseous lesions of the skull (mastoid, orbit, and temporal bone) are associated with a higher frequency of diabetes insipidus and brain localization. Early responders to treatment have an almost 3-fold higher probability of overall survival at 3 years than non-responders. [9]

Lymph node involvement in the isolated or disseminated form of LCH may be subtle or massive, focal or global. It usually shows a sinusoidal pattern and often there is replacement of the paracortical regions. [5,6] Necrosis may occur, probably secondarily to the release of lytic enzymes by the ubiquitous eosinophils. [4] A necrotising granulomatous reaction may be rarely seen. [4,6,10]. In cases with substantial nodal replacement, a diagnosis of LCH may be achievable on cytological preparations, either from fine needle aspiration or from touch imprints (as in our cases 2 and 5). LCH may be coincidental in lymph nodes excised for lymphomas (both Hodgkin and non-Hodgkin), carcinomas (e.g., papillary carcinoma of the thyroid) and non-neoplastic lesions (e.g. Rosai-Dorfman disease), where LCH likely represents a paracrine phenomenon. The outcome in these cases is dictated by the underlying primary nodal diseases. [5] The differential diagnosis of nodal LCH includes conditions with a rich component of eosinophils and histiocytes, such as Hodgkin disease of mixed cellularity type, allergic necrotizing granulomatosis, fungal or metazoal diseases and other forms of nodal histiocytoses. The clinical, morphologic, and immunohistochemical features allow distinction from LCH.

Conclusions. Involvement of lymph nodes in LCH is rare. It may be isolated to lymph nodes or be part of multivisceral disease. Unfamiliarity with the findings or failure to recognize its associations with other diseases may pose diagnostic problems. Immunohistochemistry may be critical to establish a categorical diagnosis. The prognosis of isolated lymph nodal LCH is excellent, and lymph node excision biopsy may suffice as definitive treatment. The prognosis of multifocal/multisystem LCH involving lymph nodes is dependent on the number of systems involved and degree of organ dysfunction.

References.

1. Merad M, Ginhoux F, Collin M. Origin, homeostasis and function of Langerhans cells and other langerin-expressing dendritic cells. Nat Rev Immunol. 2008;8:935-947.

2. Williams JW, Dorfman RF. Lymphadenopathy as the initial manifestation of histiocytosis X. Am J Surg Pathol. 1979;3:405-421.

3. Motoi M, Helbron D, Kaiserling E, Lennert K. Eosinophilic granuloma of lymph nodes--a variant of histiocytosis X. Histopathology. 1980;4:585-606.

4. Lieberman PH, Jones CR, Steinman RM, et al. Langerhans cell (eosinophilic) granulomatosis. A clinicopathologic study encompassing 50 years. Am J Surg Pathol. 1996;20:519-552.

5. Favara BE, Steele A. Langerhans cell histiocytosis of lymph nodes: a morphological assessment of 43 biopsies. Pediatr Pathol Lab Med. 1997;17:769-787.

6. Edelweiss M, Medeiros LJ, Suster S, Moran CA. Lymph node involvement by Langerhans cell histiocytosis: a clinicopathologic and immunohistochemical study of 20 cases. Hum Pathol. 2007;38:1463-1469.

7. Howarth DM, Gilchrist GS, Mullan BP, Wiseman GA, Edmonson JH, Schomberg PJ. Langerhans cell histiocytosis: diagnosis, natural history, management, and outcome. Cancer. 1999;85:2278-2290.

8. Braier J, Chantada G, Rosso D, et al. Langerhans cell histiocytosis: retrospective evaluation of 123 patients at a single institution. Pediatr Hematol Oncol. 1999;16:377-385.

9. SavaÅŸan S. An enigmatic disease: childhood Langerhans cell histiocytosis in 2005. Int J Dermatol. 2006;45:182-188.

10. Tan HW, Chuah KL, Goh SG, Yap WM, Tan PH. An unusual cause of granulomatous inflammation: eosinophilic abscess in Langerhans cell histiocytosis. J Clin Pathol. 2006;59:548-549.

Background: Renal medullary carcinoma is a rare, highly aggressive primary renal tumor that affects young patients with sickle cell trait. This tumor arises in the renal medulla and may exhibit rhabdoid features. Malignant rhabdoid tumor is also a high-grade neoplasm that usually occurs in the central nervous system, but also in the kidney and soft tissues of children. Both tumors express keratin, vimentin and epithelial membrane antigen and lack INI1 expression.

Nestin is an intermediate filament protein, which is present in neuroepithelial stem cells and various neoplasms. It was recently shown that nestin is also expressed in pediatric tumors arising in the kidney, including rhabdoid tumor. However, its expression in renal medullary carcinoma is unknown. Because renal medullary carcinoma shares histologic and immunohistochemical features with rhabdoid tumors, we sought to determine whether expression of nestin can help in their differential diagnosis.

Design: Fifteen renal tumors, ten medullary carcinomas and five malignant rhabdoid tumors, as well as two rhabdoid tumors of the liver were collected from the pathology files of our institutions. Inmunohistochemistry for nestin and INI1 was performed in all the cases with commercial available antibodies (nestin from Abcam at dilution 1:4000 and INI1 from BD Transduction Laboratories at dilution 1:100). Cytoplasmic staining for nestin and nuclear staining for INI1 were considered positive.

Results: From the ten patients with renal medullary carcinoma, a history of sickle cell trait was obtained in seven. The sickle cell trait status in the remaining three patients was unknown. All patients with malignant rhadoid tumors, did not have a history of sickle cell trait. All malignant rhabdoid tumors were positive for nestin- four in more than 80% of the tumor cells and 3 in 10% το 30% of the cells. All medullary carcinomas were negative for nestin. Loss of INI1 expression was observed in all renal medullary carcinomas, as well as malignant rhabdoid tumors.

Conclusion: Because renal medullary carcinoma and rhabdoid tumor have overlapping morphologic and immunohistochemical features, their differential diagnosis can be difficult, especially in patients with unknown sickle cell trait status. Our finding of strong nestin expression in rhabdoid tumors and its absence from all medullary carcinomas of the kidney demonstrates its utility in the differential diagnosis of these tumors.

Introduction: Osteogenesis imperfecta (OI) is a hereditary disorder with osteopenia and increased bone fractures. A classification into four types (OI type I (mild), II (lethal), III (severe) and IV (moderate) was introduced by Sillence et al. Type II OI was subdivided into 3 types on the basis of radiology. OI caused by mutations in the COL1A1/2 genes are inherited as an autosomal dominant disorder. However, not all patients with OI have a collagen type I mutation and in some an autosomal recessive recurrence was observed. It was demonstrated that complete loss-of-function mutations of a protein complex (CRTAP, LEPRE1 and PPIB) in the rough endoplasmic reticulum, which is responsible for 3-hydroxylation of proline in the a1 chain of collagen type I, can cause severe OI.

Materials: In our database we tested patients with severe OI and without a COL1A1/2 mutation with antibodies against the three components of the prolyl-3-hydroxylation complex. Based on radiology no discrimination can be made between type OI IIB and III cases caused by mutations in the COL1A1/2 or in one of the three components of the prolyl-3-hydroxylation complex.

Results and conclusion: three families were found with severe OI (OI type IIB and III) with absent staining in one of the three components of the prolyl-3-hydroxylation complex. In these patients a loss of function mutation was found in the comparable gene CRTAP, P3H1 or CyPB. In the autosomal recessive cases tested no severe type IIA OI was found. Immunohistology can be used to discriminate between the different autosomal recessive forms and mutation analysis can be done on the affected gene for verification. This approach is important for providing an accurate recurrence risk and prenatal diagnosis.

Aim: The aim of this study was to review 110 embryos from spontaneous abortion, between 2001 and 2009 to evaluate abnormalities in development during the first trimester.

Method: Gross examination with dissecting microscope and photography were performed in all cases, and histological sections were carried out. Embryos were classified according to Carnegie stages and were assessed to find developmental defects.

Results: Of the 110 cases studied, 35 weren't evaluable due to the tissue's autolysis. All the remaining 75 cases (68.1%) were assessable. Of these, 42 had neural tube defects (NTD); 28 of them in spine, 11 were from cerebral region and 3 of them showed both defects. Other malformations found were: cardiac anomalies (9) including seven ectopia cordis, facial midline defects (7), abdominoschisis (2), hipertelorism (3) and hipotelorism (3). Haemorrhages were also seen. We found anomalies in the position of the lower limbs in 16 cases, 15 of which were associated with NTD.

Conclusions: Morphological examination of embryos allows a proper definition of the developmental stage and detection of congenital abnormalities. This is useful for adequate genetic counselling and monitoring in subsequent pregnancies. In our series, neural tube defects were the most frequent abnormalities found (56% of all assessable cases) and were often associated with malposition of the lower extremities.

Introduction.  Comparative genomic hybridisation (CGH), also known as chromosomal microarray analysis (CMA), is a molecular cytogenetic method that allows detection of gains or losses in the DNA composition of an individual.  It is not strictly a new technique having first been described at the end of the 20th century.  However it is only in the last 1-2 years that advances in technology have made it sufficiently cost effective to be used in routine clinical practice, for investigation of the underlying cause of fetal abnormalities.  

Aim of Study.  To demonstrate the usefulness of CGH in perinatal pathology by the presentation of two recent cases.

Case reports. 

Case 1. This term infant, with an antenatal diagnosis of an atrioventricular septal defect but a normal karyotype on routine banding, was found to be unexpectedly flat at delivery and could not be resuscitated.  Post mortem examination confirmed the cardiac defect and demonstrated dysmorphic facies, cleft palate, nephrogenic rests and alveolar capillary dysplasia.  DNA extracted from post mortem tissue revealed a deletion from 16q23.3 to q24.2.    This includes the FOX gene cluster on 16q24.1, deletions of which have previously been reported to cause alveolar capillary dysplasia ¹.   Testing of the parents revealed normal results, indicating the anomaly in the baby had arisen de novo.

Case 2. The mother had previously had two male babies with cerebellar aplasia / hypoplasia, leading to a suspected diagnosis of autosomal recessive Joubert's syndrome.  However her third abnormal baby had only mild cerebellar vermis hypoplasia but abnormal Sylvian fissures, and was female.  CGH studies of the DNA of this third baby and one of the previous male babies for whom material was available for testing, revealed a 6p25 deletion that included the FOXC1 gene.  Abnormalities of this gene usually cause eye abnormalities but have  also been associated with cerebellar vermis hypoplasia.  The mother was found to be mosaic for the same deletion.

Conclusion.  Comparative genomic hybridisation is more sensitive than older methods for the demonstration of unbalanced chromosomal changes and allows simultaneous screening for a large number of genetic disorders at the same time.  It will not, however, show balanced structural aberrations such as inversions and translocations if there is no gain or loss of genetic material.  Great care needs to be taken in interpretation of results and the limitations of the technique must be appreciated.  However CGH is becoming an increasingly important tool for providing information for parents and clinicans and in aiding decision making about abnormal pregnancies and the appropriate care of many malformed live born babies.  

1. Stankiewicz P et al.  Genomic and genic deletions of the FOX gene cluster on 16q24.1 and inactivating mutations of FOXF1 cause alveolar capillary dysplasia and other malformations.  Am J Human Genet 2009; 84:780-91

Introduction: DC-SIGN is a mannose binding lectin that initiates interaction between dendritic cells and resting T lymphocytes.  It has been found to be highly expressed in placental tissue on dendritic cells and Hofbauer cells.  It has been proposed that HIV may become adsorbed to DC-SIGN on Hofbauer cells and /or infect Hofbauer cells.  Various mechanisms have been proposed that may allow transfer of virus from the Hofbauer cells to the foetus.   One mechanism includes subsequent adsorption to DC-SIGNR (DC-SIGN related molecule) present on immediately adjacent capillary vascular endothelium.

Materials and methods: 40 term placentas from HIV+ mothers and 21 term placentas from HIV- mothers were processed routinely.  DCSIGN and DCSIGN-R immunohistochemistry was performed. 5 random sets of 10 villi were assessed and an average number of positive cells were counted in each case. In addition, where possible, maternal and cord blood viral loads and maternal CD4 counts were performed.

Results: The median maternal CD4 count was 324.5 and 27% of participants had undetectable viral loads; the median detectable viral load was 3.59 log.

97% of the cord bloods tested had lower than detectable viral loads. HIV+ cases had significantly greater expression of both DCSIGN-R (median values in HIV+ cases, 14.5 positive cells/10villi (pc/10villi), compared to 11 pc/10villi in HIV- cases, p=0.020) and DCSIGN (median values in HIV+ cases, 26.5, compared to 23 in HIV- cases, p=0.037). There was no significant difference between the incidence of placental membrane inflammation (PMI) between HIV positive and HIV negative patients (p=0.173). There was also no difference in expression of DCSIGN and DCSIGN-R in patients with and without PMI.

In addition, the expression of DC-SIGN and DC-SIGN-R was inversely associated with CD4 count in HIV positive cases (p<0.05 for both) and positively associated with maternal viral load (but not statistically significant). 

Conclusions: Both DCSIGN and DCSIGN-R expression were higher in placentas from HIV positive mothers compared to HIV negative cases and this was statistically significant. There was possible in-utero transmission of HIV in one case.  There was no association of DCSIGN or DCSIGN-R expression with the presence of chorioamnionitis, but there was a statistically significant inverse relationship between DC-SIGN and DC-SIGNR expression and maternal CD4 counts in HIV positive cases.

Rhombencephalosynapsis (RES) is regarded as a rare cerebellar malformation in which there is agenesis of the cerebellar vermis with apposition or fusion of the dentate nuclei on histology.  The aetiology of RES is unknown, with no causative genetic or environmental factors identified.   The frequency of RES has been estimated as being 0.13% amongst children undergoing MRI scans for neurological disorders (Pasquier et al, 2009).  RES is heterogeneous, either occurring in isolation or being associated with a variety of malformations in different organ systems. 

We have identified 11 cases at post mortem over a 6 year period, 10 following termination of pregnancy and 1 in a neonatal death. In all cases cerebellar hypoplasia and/or ventriculomegaly was detected on prenatal ultrasound, in 3 other anomalies were also suspected.

At post mortem RES was an isolated malformation in 1 case and in 2 more there were no abnormalities outside the central nervous system. In the remaining 8 cases there were dysmorphic features and/or internal malformations. Vertebral anomalies, renal anomalies and cleft lip±palate, were each found in 3/8 cases and congenital heart disease and unilateral ear abnormalities were each found in 2/8. Other anomalies in single cases were: hypoplastic pancreas; abnormal lung lobation; tracheo-oesophageal fistula/oesophageal atresia (TOF/OA); parietal fontanelle. 1 case had multiple features of VACTERL association, namely TOF/OA, vertebral anomalies, radial aplasia and renal agenesis. In none of the cases was a chromosome abnormality identified and we are not aware of a recurrence in any of the affected families.