Abstract The diagnosis of Celiac Disease (CD) relies on the concordance of pathological, serological, genetic and clinical features. For this reason, the diagnosis of CD is often a challenge. Seronegative celiac disease (SNCD) is defined by the negativity of anti-tissue transglutaminase antibodies in the presence of a positive histology on duodenal biopsy samples, i.e. inflammatory infiltrate of intra-epithelial lymphocytes (IELs > 25/100 enterocytes), mild villous atrophy and uneven brush border associated to human leukocyte antigen (HLA) haplotype DQ2 and/or DQ8. SNCD is characterized by mucosal deposits of tissue transglutaminase (tTG)/anti-tTG immuno-complexes. These may counteract the passage of anti-tTG into the bloodstream, thus explaining seronegativity. Another reason for seronegativity may be found in an incomplete maturation of plasma cells with a consequent failure of antibodies production. This condition often characterizes immunoglobulin deficiencies, and, indeed, SNCD is common in subjects with immunoglobulin deficiencies. The management of SNCD still remains debated. The treatment option for SNCD may be represented by gluten free diet (GFD), but the usefulness and appropriateness of prescribing GFD are controversial. Some evidences support its use only in SNCD subjects showing CD clear clinical picture and compatible HLA status. The choice of GFD administration could be linked to an investigation able to diagnose SNCD in no doubt even if a reliable test is not currently available. On these bases, a test helping the diagnosis of SNCD is justifiable and desirable.

PURPOSE: To describe a rare case of conjunctival leiomyosarcoma initially diagnosed as a poorly differentiated squamous cell carcinoma. METHODS: Clinical, light microscopic, immunohistochemical, and ultrastructural findings are reported. RESULTS: A 56-year-old Caucasian woman was referred with a history of a progressive, rapidly growing mass in her left eye. Biopsy of the mass and histology yielded a first diagnosis of a poorly differentiated conjunctival squamous cell carcinoma. Orbital exenteration was performed 2 weeks later. Macroscopically, the exenteration specimen showed a soft mass completely involving the conjunctiva and extending to the eyelids and orbital structures. Histological examination revealed a malignant tumour composed of atypical, predominantly epithelioid large cells. Immunohistochemical and ultrastructural studies combined with the light microscopic findings contributed to clarify the diagnosis of epithelioid leiomyosarcoma. The patient was started on chemotherapy and radiotherapy, but died a few months later from widespread metastases. CONCLUSIONS: primary involvement of the orbit by a leiomyosarcoma is rare, but this eventuality should be considered in the differential diagnosis of rapidly growing orbital and conjunctival masses.

To investigate tumor necrosis factor-α (TNF-α), syndecan 1 and basic fibroblast growth factor (bFGF) balance in Crohn's disease (CD) strictures.

Colonic lipomas larger than 2 cm in diameter are likely to be symptomatic. In some cases a complication is the first clinical sign. Massive lower intestinal bleeding or obstruction, acute bleeding, prolapse or perforation or, rarely, acute intussusception with intestinal obstruction require urgent surgery. Diagnosis is often made following colonoscopy, which can also have a therapeutic role. Imaging procedures such as CT has a secondary role. Patients with small asymptomatic colonic lipomas need regular follow up. For larger (diameter > 2 cm) and/or symptomatic lipomas, resection should be considered, although the choice between endoscopic or surgical resection remains controversial. We believe that even lipomas > 2 cm can safely be removed by endoscopic resection. If surgery is indicated, we consider laparoscopy to be the ideal approach in all patients for whom minimally invasive surgery is not contraindicated.

There are conflicting data on the biological and prognostic significance of disseminated tumour cells (DTCs) in the bone marrow of colorectal cancer patients since bone metastasis are rare in this disease. The study aimed to determine the origin of bone marrow -DTCs using human colorectal cancer cells in in vivo and in vitro experimental settings. METHOD: CD1 nude female mice were xenotransplanted with SW620 cells (colorectal cancer cell line isolated from a male patient) injected in the colon wall. At autopsy, the presence of SW620 in the bone marrow (BM), colon and other organs/tissues was recognized by detection of the epithelial marker cytokeratin-19 (CK19) and Y-chromosome. In addition SW620 cells or their conditioned media were cultured with human BM cells. RESULTS: Macroscopically evident CK19+/Y-chromosome+ tumours developed only in five mice receiving SW620 cells while putative DTCs (CK19+) were found in the bone marrow of all treated mice. Most of these CK19+ cells were Y-chromosome-negative, only few being Y-chromosome-positive. In vitro SW620 cells or their conditioned medium induced CK19 expression in cultured human bone marrow cells. CONCLUSION: Experimental colorectal cancer can induce the appearance of two distinct CK19+ cell populations in the bone marrow, one of metastatic origin and the other of murine origin. These findings suggest that bone marrow cells may undergo phenotypic modifications induced by cancer cells.

Objectives. The APC gene mutation triggers familial adenomatous polyposis (FAP) and approximately 80% of sporadic colorectal cancers. FAP summarizes the natural history of colorectal cancer because low-and high-grade dysplastic lesions and adenocarcinoma are simultaneously present in the same patients free from individual and environmental variability factors. Estrogen receptor beta (ER beta) has recently been suggested as the most likely mediator of estrogen-related anti-carcinogenic effects in Apc(Min-/+) mice and humans. In this study we assessed the ER beta expression in the intestinal mucosa of FAP patients to verify its possible involvement in tumor progression in colorectal cancer. Material and methods. ER beta and ER alpha expression, cell proliferation (Ki-67) and apoptosis (TUNEL), were evaluated on archival biopsy material from six patients with FAP who underwent colectomy. Results. A progressive significant decrease of ER beta expression was observed in the different stages of the disease as compared to normal mucosa (p < 0.001). Interestingly, a decreased ER beta expression was directly correlated with apoptosis (r = 0.76, p < 0.001), and inversely correlated with cell proliferation (r = 0.54, p < 0.05). Conclusions. ER beta expression is related to the severity of the disease, supporting the role of ER beta as a relevant biomarker of tumor progression and possible chemopreventive target in patients at risk of colonic neoplasia.

BACKGROUND: Even if endometriosis is usually an exclusively gynecological issue, atypical locations fall within the interest of general surgery. The aim of our retrospective study focuses on the need for surgeons to face this rare condition, in order to avoid unnecessary or inadequate treatment. METHODS: We retrospectively analyzed clinical presentations, previous endometriosis diagnosis and surgical acts on a group of 60 patients, whose mean age was 38.2 years old, with extra-genital endometriosis. RESULTS: Among the 60 cases of extra-genital endometriosis collected, bowel foci, 37 cases - 61,7% - were the most frequent; then we collected 13 (21.7%) skin, 7 (11.7%) urinary tract and 3 (5%) whole pelvis localizations. It's important to underline the finding of 2 aggressive malignant transformations. CONCLUSIONS: Extra-genital endometriosis should be considered as a cause of otherwise inexplicable abdominal pain in young women. Since imaging techniques lack in specificity, we propose explorative laparoscopy as a powerful diagnostic means. Moreover laparoscopy can be turned into a therapeutic act, also limiting the adherences issue, which is associated with this illness and would worsen with open surgery. Extra-genital endometriosis should be treated also to avoid rare, but possible, risk of cancerization.

Hepatocellular carcinoma rarely metastasizes to the orbit. We report a 45-year-old male, HBV+, HIV+, with a past history of a liver transplant for ELSD (End stage liver disease) with hepatocellular carcinoma and recurrent HCC, who presented with painful proptosis and diplopia of the left eye. CT scans of the head revealed a large, irregular mass in the left orbit causing superior and lateral destruction of the orbital bone. Biopsy specimens of the orbital tumor showed features of metastatic foci of hepatocellular carcinoma. Only 16 other cases of HCC metastasis to the orbit have been described in literature and this is the first case in a previously transplanted HIV+, HBV+ patient. Key words : Hepatocellular carcinoma, orbit, HIV+, HBV+, liver transplant.

PURPOSE: To report a masquerade syndrome secondary to multiple myeloma iris infiltration. DESIGN: Observational case report. METHODS: A 74-year-old Caucasian woman presenting with unilateral hypertensive uveitis and past medical history significant for multiple myeloma underwent aqueous cytology and a trabeculectomy with iridectomy. RESULTS: Cytology revealed atypical plasma cells in the aqueous while the anatomopathologic analysis of iris tissue demonstrated a substitution of the iris tissue by neoplastic plasma cells. After surgery and a new cycle of chemotherapy best-corrected visual acuity and intraocular pressure improved. CONCLUSIONS: Masquerade syndrome should always be considered in elderly uveitis. A correct diagnosis can be life-saving.

A 61-year old man with coeliac disease and chronic lack of appetite, malabsorption and weight loss, despite the gluten-free diet, was operated because of a sub-diaphragmatic free air due to a small-bowel pneumatosis cystoides intestinalis (PCI). The jejunum showed granulomatous lesions with a honeycombed appearance of air cysts in the submucosa/subserosa. We found overexpression of peptide YY (PYY) into only the jejunum with PCI, while the expression was very weak or absent in the tissue without cysts. One year after surgery, he had no abdominal pain or PCI recurrence. The above chronic symptoms were plausibly attributable to the PYY.

Local recurrence continues to be a major problem in rectal cancer. After cancer removal, detection of viable cancer cells could be useful to identify patients at risk for local recurrence. Thus, aim of the study was the detection of residual peritoneal cancer cells with a possible prognostic role for local recurrence. Twenty-nine patients were operated (R0) for low (extraperitoneal) rectal cancer, without neoadjuvant radiochemotherapy. Before and immediately after cancer removal, a peritoneal lavage was done to evaluate by RT-PCR the cytokeratin 20 mRNA on isolated cells and in order to detect cancer cells by the Thin-prep test. After a median follow-up of 39 months, 5 patients died (17%), one for non-cancer-related disease, two (7%) for local recurrence and peritoneal carcinosis, and two for distant metastases. Preoperative cytology with Thin-prep test was positive in 4 patients (14%), while postoperative peritoneal cytology was positive only in 1 patient, different from the previous. No patient developed local or distal recurrence and all were disease-free at the end of the follow-up. RT-PCR analysis was positive on the peritoneal lavage after cancer removal in 11 patients. One died for unrelated cause and no one developed local recurrences. Local recurrence occurred in only 1 of the 2 patients with positive RT-PCR analysis on the first lavage and negative on the second lavage. Our study demonstrates a not important prognostic role of Thin-prep test and RT-PCR of cytokeratin 20 mRNA on the detection of patients at risk for local recurrence after curative resection of rectal cancer.

AIM: To evaluate mucosal baseline mRNA expression of tissue transglutaminase 2 (tTG2), interferon gamma (IFNγ), toll-like receptor 2 (TLR2) and Myeloid Differentiation factor 88 (MyD88) in patients with microscopic enteritis (ME). METHODS: We retrospectively enrolled 89 patients with ME of different etiology, which was defined within a 2-year mean period of follow-up. Baseline histological examination was performed on Hematoxylin-Eosin stained sections and CD3 lymphocyte immunohistochemistry was used for intraepithelial lymphocyte count (IELs). ME was defined according to the criteria of Bucharest Consensus Conference. For each patient, formalin embedded biopsy samples of the duodenum referred to the period of ME diagnosis were retrieved. Real-time polymerase chain reaction (RT-PCR) was used to detect the amount of mRNA coding for tTG2, IFNγ, TLR2 and MyD88, and the quantity was expressed as fold change compared to controls. Control group was represented by duodenal normal specimens from 15 healthy subjects undergoing endoscopy for functional symptoms. Comparisons among continuous variables were performed by One way analysis of variance (ANOVA) and Bonferroni's test. The χ(2) test was used for categorical variables. Pearson's test was used to evaluate correlations. Receiver operating curves were drawn for all four markers to estimate sensitivity and specificity in discriminating the development of CD and GS. RESULTS: After a period of follow up of 21.7 ± 11.7 mo, the following diagnoses were achieved: gluten related disorders in 48 subjects (31 CD; 17 GS) and non-gluten related ones in 41 (29 Irritable Bowel Syndrome - IBS; 12 Others). CD patients had the highest tTG2 levels (8.3 ± 4.5). The ANOVA plus Bonferroni analysis showed that CD > Other ME > GS = IBS > negative controls. A cut off value of 2.258 was able to discriminate between CD and GS with a sensitivity of 52.94% and a specificity of 87.1%. Additionally, CD patients had the highest IFNγ levels (8.5 ± 4.1). ANOVA plus Bonferroni demonstrated CD > Other ME > GS = IBS > negative controls. A cut off of 1.853 was able to differentiate CD and GS with a sensitivity of 47.06% and a specificity of 96.77%. Patients with non gluten-related causes of ME exhibited the highest TLR2 levels (6.1 ± 1.9) as follows: Other ME > CD = GS = IBS > negative controls. TLR2 was unable to discriminate CD from GS. Patients with CD overexpressed MyD88 levels similarly to non gluten-related causes of DL (7.8 ± 4.9 and 6.7 ± 2.9), thus CD = Other ME > GS = IBS > negative controls. A cut off of 3.722 was able to differentiate CD from GS with a sensitivity of 52.94% and a specificity of 74.19%. IELs count (15-25 and more than 25/100 enterocytes) strongly correlated with mRNA levels of all tested molecules (P < 0.0001). CONCLUSION: Our results confirm that a single marker is unable to predict a discrimination among ME underlying conditions as well as between CD and GS. Mucosal high levels of tTG and IFNγ mRNA may predict the development of CD more than GS with high specificity, despite an expected low sensitivity. TLR2 does not discriminate the development of CD from GS. MyD88 levels indicate that intestinal permeability is more increased when a severe intestinal damage underlies ME in both gluten related and unrelated conditions. Therefore, the results of the present paper do not seem to show a clear translational value. KEYWORDS: Celiac disease; Gluten sensitivity; Interferon gamma; Microscopic enteritis; MyD88; Tissue transglutaminase; Toll-like receptor 2

Melanomas of the oral cavity are extremely rare. Their rarity and their independence on exposure to UV radiation make them particularly interesting. The authors analyzed an oral multiphasic melanoma composed by a nodular nonpigmented ulcerated central region, a nodular ulcerated pigmented area, a pigmented nonulcerated region, and an area similar to a dysplastic nevus. They determined the expression of some genes involved in the differentiation and cellular transformation in morphologically different regions of melanoma. All these areas were also analyzed by electron microscopy. The various regions composing the melanoma expressed genes involved in melanogenesis and melanoma progression in a different manner. Electron microscopy observation of ultrathin sections of each region evidenced ultrastructural differences, being the cellular architecture more compromised in the most aggressive parts of the neoplasm. This pilot study identified morphological, molecular, and ultrastructural differences that characterize each region of the multiphasic melanoma.

A 65-year-old woman presented with a long standing, progressive exophthalmos of the right eye. Her medical history was significant for Churg Strauss syndrome, and was treated with immunosuppressive therapy. She had undergone two previous orbital biopsies showing inflammatory reactive lymphoid hyperplasia. A diagnosis of orbital inflammation in Churg-Strauss syndrome was suspected, and the immunosuppressive therapy was increased. Because of the lack of response to therapy, a further biopsy was performed, by lateral orbitotomy approach. Biopsy of the mass revealed a granular cell tumor composed of S-100 positive cells with an acidophilic granular cytoplasm and peripheral lymphocytic infiltration. A granular cell tumor, which is very rare in the orbit, should be considered in the differential diagnosis of orbital tumors, and if suspected, an excisional biopsy must be undertaken. Typical histopathological aspect of the granular cell tumor is characterized by the presence of S-100 positive closely packed polygonal cells with a granular cytoplasm

Orbital pseudotumor is a benign, idiopathic, non-infectious and non-neoplastic clinical syndrome characterized by the presence of an inflammatory mass at orbital level with no identifiable cause. The disease is rarely observed in the pediatric population. This article describes a relapsing bilateral orbital pseudotumor in a young girl. The diagnostic implications and treatment strategies are discussed.

Purpose: Description of a patient with a solitary cyst of the pupillary margin iris pigment epithelium (IPE). Methods: A 63-year-old man referred a suspected iris-ciliary body melanoma in his left eye. Based on both clinical examination and ultrasound biomicroscopy, melanoma was considered unlikely. Surgery was under-taken to correct recurrent deterioration of vision due to movement of the lesion across the visual axis. Results: The lesion was excised completely. Ultrasound biomicroscopy and histopathological examination ruled out melanoma and allowed a final diagnosis of primary pupillary margin cyst of the IPE, characterized of pig-mented epithelium, with no connective tissue or vessels. No recurrences or fresh lesions appeared during a one-year follow-up. Conclusions: Primary epithelial iris cysts are usually benign. Treatment is required only in symptomatic patients and those with an uncertain diagnosis. Ultrasound biomicroscopy is indispensable to confirm the clinical diagnosis, follow the clinical course and intervene if surgery is required.

We report three cases of proptosis, in children aged 6, 10 and 12, whereby in all cases the first clinical, radiologic and ultrasonographic diagnosis was lymphangioma, while the final anatomopathological diagnosis was rhabdomyosarcoma. In presence of a rapidly worsening exophthalmos or eyelid swelling in a child, an early correct diagnosis is very important. Imaging techniques play a very important role in the diagnosis, but are often inconclusive and an excisional biopsy (if feasible) must always be considered.

We report three cases of proptosis, in children aged 6, 10 and 12. In all cases the first clinical, radiologic and ultrasonographic diagnosis was lymphangioma, while the final anatomopathological diagnosis was rhabdomyosarcoma. In presence of a rapidly worsening exophthalmos or eyelid swelling in a child, an early diagnosis is very important. Imaging techniques have a very important role in the diagnosis, but are often not conclusive and a excisional biopsy (if feasible) must always be considered.

Molecular testing for KRAS and BRAF mutations in tumor tissue is a fundamental tool to identify patients with metastatic colorectal cancer (CRC) who are eligible for anti-EGFR monoclonal antibody therapy. We here report a molecular analysis by high-resolution melting analysis and direct sequencing of KRAS, BRAF and PIK3CA hot spot mutations in 209 Italian CRC patients. One hundred and ten patients (51%) were identified who were potentially nonresponders to anti-EGFR therapy: 90/209 patients (43%) harboring KRAS mutations, 13/117 (11.1%) with the V600E BRAF mutation, and 7/209 (3.3%) with mutations in PIK3CA exon 20. The prevalence of BRAF and PIK3CA mutations was significantly higher in patients older than 65 years (p=0.014 and p=0.018), while patients with triple-negative tumors were significantly younger than mutation carriers (p=0.000011). Patients with gene mutations also showed a trend towards preferential tumor location in the colon (p=0.026). Moreover, although involving a relatively small number of samples, we report the presence of a discordant mutational profile between primary tumors and secondary lesions (3/9 patients), suggesting that it is worthwhile to test other available tissues in order to better define the efficacy of targeted therapy. Further correlations of specific clinical features with tumor mutational profile could be helpful to predict the response of CRC patients to monoclonal antibody therapy.