Introduction: Primary sinovial sarcoma (PSS) is a very rare malignancy in lung, although lung is the most common organ-based site for metastatic synovial sarcoma. It is a high grade malignant mesenchymal neoplasm showing variable epithelial differentation and characterized by a balanced translocation t(X, 18). Case report: We report a case of a 67- year-old male presented with long lasting cough, chest pain and fever. Chest radiography and computer tomography scan revealed a large well defined lung mass invading hilum of the lung, which was indicated for the lung resection. Histopatological examination showed high-cellulare spindle cell malignant tumor. Immunohistochemically,neoplastic cells were positive for vimentin, TLE-1, Bcl-2, focally positive for cytokeratin AE1/AE3, cytokeratin 7, cytokeratin 18, cytokeratin 19, EMA, calponin and negative for CK 5/6, S100, STAT6, CD34, SMA, Desmin, CD99 and CD 117, which determinate a diagnosis of monophasic PSS of lung. Specific translocation t(X, 18) was detected by fluorescent in situ hybridization (FISH). Conclusion: Diagnosis of PSS in lung may create various diagnostic challenges. It can be established only after exclusion of metastatic sarcoma of other localizations and spindle cell primary lung malignancies. Molecular testing proved to be very helpful or necessary when spindle cell synovial sarcoma was recognized in uncommon sites.

Aim: To determine the degree of correlation between TTF-1 (+) expression and EGFR mutation status in lung adenocarcinoma. Introduction: Adenocarcinoma of the lung is mainly diagnosed based on standard morphological criteria. The thyroid gland transcription factor (TTF-1) is currently the most commonly used immunohistochemical marker in the differentiation of invasive adenocarcinoma of the lung from another primary and metastatic carcinoma, has a prognostic significance and is a predictor of the EGFR mutation status. Material and Methods: This retrospective study enrolled 60 patients with histologically confirmed primary lung adenocarcinoma who underwent lung cancer surgery at Institute for lung disease Vojvodina between 2010 and 2015. Tumor specimens of these patients were investigated for TTF-1 expression and mutations in EGFR using immunohistochemistry and PCR analysis. Statistical analysis is in statistic software Statistica 12. Results: The study included 35 men and 25 women, with an average age of 61.8 ą 8.08 years. Of the 60 cases, TTF-1 ( ) expression was recorded in 52 (87%) (p <0.001), the statistical difference is not significant when comparing smoking habitsby gender, and tumor size among them. EGFR ( ) mutation status was found in 3/60 (5%) cases [egzon 21 (2) and exon 20 (1)], of which TTF-1 (+) expression was in two cases. Conclusion: There is a statistically significant difference between the TTF-1 (-) and TTF-1 (+) adenocarcinoma and a high degree of correlation between EGFR mutation status and TTF-1 (+) expression.

Aim: The aim of our study was to investigate hepatoprotective properties of bile acids (BA), natural ursodeoxycholic (UDK) and semisynthetic 12-monoketocholic acid (MK) by testing the levels of liver enzymes, malonyldehyde (MDA) as an indicator of hepatocyte oxidative damage, activity of antioxidant enzymes, histological analysis of liver tissue and immunohistochemical analysis of hepatocyte proliferation, activation of nuclear farnesoid-X receptor (FXR), apoptosis and proliferation markers. Introduction: The hepatocyte metabolism is extremely intense, and the processes that take place in hepatocytes are diverse, which makes them highly susceptible to oxidative damage that is the basis of many diseases. Two popular models of oxidative stress induction are the use of ethinylestradiol and the cholestasis model, as well as the use of aloxan and aloxan-diabetes model. Results: Male Wistar rats were used in this study. Control group (K) received only saline (0.5 ml/kg). Three groups received ethinylestradiol (EE group, 0.5 mg/kg) as monotherapy or in combination with 12-monoketocholic (E-MK, 4 mg/kg) or ursodeoxycholic acid (EPLENARY ORAL PRESENTATION 24 MATERIA MEDICA • Vol. 34 • Issue 1, suplement 1 • april 2018. UDK, 25 mg/kg). In order to increase the level of oxidative stress, in three groups monodose of aloxan was administered in addition to ethinyl estradiol, either alone (AE group), or treated additionally with 12-monoketocholic (AE-MK) and ursodeoxocholic (AE-UDK) acid at the above dosages. Liver tissue was sampled for histological analysis and biochemical analysis of liver enzymes and bilirubin (AST, ALT, GGT, bilirubin total (BLRu) and direct (BLRd)), oxidative damage (MDA), levels of antioxidant enzymes catalase (CAT), glutathione-peroxidase (GSH-Px), glutathione-reductase (GSH-R), glutathione-S-transferase (GSH-ST). In groups EE and AE, AST, ALT and GGT levels were significantly elevated compared to K group, while the use of bile acids led to a significant reduction in activity of all enzymes as well as total and direct bilirubin. Both acids have the strongest hepatoprotective effect in terms of AST activity and lowering the total bilirubin concentration, whose values using both UDC and MK were lowered to the level of K-group. In terms of ALT and GGT, bile acids showed slight selectivity. Histological analysis of liver in groups EE and AE showed hepatocytes with karyopycnosis and cytoplasmic acidophilia, which indicate the apoptotic cell death, as well as changes in individual hepatocytes corresponding to feathery degeneration. All of these changes weren`t observed in the liver of animals treated with UDK and MK. By analyzing Ki-67 in the tissue of the control group, it was found that up to 5% of the cells exhibited nuclear expression, and a value of 10% was taken as the limit for the enhanced proliferative activity of hepatocytes. In groups that received only hepatotoxic substances, ethinyl estradiol and aloxan, the expression of ki-67 was low as in controls. Animals whose hepatocyte damage was caused only by ethinylestradiol, reflected hepatoprotective properties of bile acids by enhancing hepatocyte proliferation (E-UDK in 50%, and E-MK in 100% of animal). Similar hepatoprotective effects of tested bile acids was seen when comparing group treated with both hepatotoxic substances (AE), and groups cotreated with UDK (all animals had an increased proliferative activity) and MK (80% of animals). Accumulation of hydrophobic acids in ethinylestadiol-induced cholestasis enhances oxidative damage and induces apoptosis, but also activates the expression of nuclear farnesoid-X-receptor. In the K-group, 50% of the animals showed low expression of FXR, and moderate and high expression was present in 25% of animals. In EE and AE groups, high FXR expression was significantly increased (75%, ie 60%) indicating the accumulation of hepatotoxic acids that raise the level of oxidative damage and induce apoptosis. The hepatoprotective effect of UDK and MK, has been demonstrated by the reduced content of hydrophobic acids, ie, the reduced expression of FXR. In groups in which hepatotoxicity and oxidative stress were induced only by ethinylstradiol and were treated with UDK and MK, not a single animal had high FXR expression, and a number with weak expression increased significantly. Similarly, in groups that received two toxic substances and analyzed acids (AE-MK, AE-UDK) 60% of animals had weak FXR expression, which is statistically not different from the control group. Groups treated with ethinylestadiol and aloxan had a significantly higher concentration of malonylaldehyde (MDA), an indicator of oxidative hepatocyte damage. The use of UDK and MK significantly reduced the concentration of MDA, but not to the control group level. The activity of antioxidant enzymes in the EE group did not differ statistically from control, and the use of UDK and MK resulted in significant changes. In the group AE where oxidative stress is enhanced, the activity of all analyzed enzymes is significantly decreased, and the application of UDK and MK significantly enhances the activity of the antioxidative enzymes. In order to examine the hepatotoxicity of oxidative stress and hepatoprotective properties of UDK and MK, the expression of the p53 and Bcl-2 family of proteins was studied. Hepatocytes of the control group did not express the proapoptotic Bax, while in the EE and AE groups, weak expression was present in 50% and 40%, respectively. Using UDK in both EE-UDK and AE-UDK models, Bax was completely reduced to the level of control group, ie no Bax expression was observed. The use of MK in both models led to suppression of Bax (EE-MK, 25%; AE-MK, 0%). The antiapoptotic Bcl-2 protein was detected in the control group in 25% of the individuals, unlike the EE and AE groups, where the expression was completely suppressed. By promoting the expression of Bcl-2 (E-UDK in 25% of individuals, AE-UDK in 40% of individuals), the UDK showed a stronger hepatoprotective activity compared to MK which in the AE-MK group only led to an increase in expression by 20%. In the control group p53, expression was recorded only in the cytoplasm, in 50% of animals, while in the EE and AE groups p53 had nuclear expression in 25%, ie 20% of the individuals, which speaks in favor of more intensive apoptotic action and induction of transcription of other proapoptotic proteins. In groups where UDK was administered, p53 was not present in either the nucleus or the cytoplasm, while MK reduced the expression to the control group level. Conclusion: Ursodeoxycholic and 12-monoketocholic acid have great antioxidative and antiapoptotic capacity, which explains their hepatoprotective effect.

Aim: We present the case of a woman with endobronchial pulmonary synovial sarcoma. Introduction: Primary pulmonary synovial sarcoma is an extremely rare tumor that has the same histomorphological characteristics and chromosomal translocations as the synovial sarcoma of soft tissue origin. Material and Methods: A woman aged 58 years, the smoker, without the current symptoms of the disease, came to our institution because of the nodus that was seen on the CT chest. The polip (26 mm) was located in the lumen of the lower right lobar bronchus. The mediastinal and hilar lymph nodes were not increased. The radiological examination was done as part of a routine control after the meningeoma surgery three years ago. Right lower lobectomy and resection of regional lymph nodes were performed. Results: By a macroscopic examination, in the lumen of the bronchus for the lower right lobes, a clearly limited, nonencapsulated, grayish-white node of 2.6 x 2.6 x 1 cm was found. Histologically, the tumor was showed interweaving fascicular uniform spindle cell with ovoid, pale staining nuclei, and inconspicuous nucleoli, scant cytoplasm and the cell borders indistinct. Immunohistochemical tumor cells were positive for CD99, bcl2 and vimentin. Surgical margins and regional lymph nodes were not affected. A detailed clinical and radiological examination confirmed the primary lung origin of the diagnosed synovial sarcoma. A year after surgery the patient feels good. Conclusion: Morphological and immunohistochemical analysis with detailed clinical and radiological examination confirms the primary lung origin of synovial sarcoma

Aim: Reporting of autopsy case of fatal accidental poisoning by colchicine from meadow saffron. Introduction: Meadow saffron (Colchicum autumnale) is a perennial herbaceous plant similar to the edible wild garlic (Allium ursinum). Toxic substance in meadow saffron is alcaloid colchicine. Colchicine poisoning is a very dangerous condition, which can lead to fatal outcome. Case report: A 50-years-old male was admitted to the hospital complaining of weakness, abdominal pain, nausea, vomiting and diarrhea without blood. Day before he ate two plants thinking they’re wild garlic and seven hours after ingestion he felt first symptoms. During the course of the hospital stay, he had gastroenterocolitis, acute renal failure, hepatic lesion and cardiorespiratory insufficiency with fatal outcome. Post-mortem examination reveled:brain oedema, lung oedema and congestion, heart weighing 700 grams, ventricular hypertrophy, myocardial fibrosis, liver congestion and steatosis, spleen congestion, pancreatic fibrosis. Organs sections were taken for pathohistological analysis. Body fluids and parts of organs were toxicologically analyzed. Pathohistological findings:brain oedema, diffuse perivascular and interstitial myocardial fibrosis, myocardial haemorrhage, lungs congestion and edema, micro- and macrovesicular liver steatosis, centrilobular liver necrosis, lymphocytic inflammatory infiltrate in liver portions, spleen’s red pulp congestion, kidney congestion and interstitial bleeding, coagulation necrosis of the proximal tubules of the kidney. Toxicological analysis showed colchicine in blood-0.011 mg/L, urine-0.051 mg/L, liver with gallbladder-0.007 mg/ kg, kidney-0.008 mg/kg. Conclusion: Ingestion of the meadow saffron can lead to poisoning with fatal outcome due to colchicine. Colchicine intoxication should be suspected in patients with gastrointestinal symptoms after consuming wild plants.

Aim: The present a rare case intraocular primary malignant choroidal melanoma. Introduction: Melanoma choroideae is most common intraocular primary tumor of adults. Incidence is 7 cases per 1 million people per year and incidence of this tumor increases with age. Case report: We report 76 years old women who had progressive visual field defects at left eye at least two years. Diagnostic examination of eye was detected a greyish-brown mass of the posterior choroidal pole which was indication for enucleation. Macroscopically bulbus oculi was dimension 28x25x25mm, with optic nerve 5mm length. At the intersection on posterior pole nearby papila of optical nerve was detected ovoid dark lesion diameters 8x3mm. Histopathology examination was showed sharply demarcated solid tumor islands which consists of epithelioid tumor cells with pleomorphic, atypical nuclei, conspicuous nucleoli. Other type of cells were spindle look which formed fascicular shapes. Pigmentation was absent also. There was no significant vascularisation in tumor mass. Sclera was superficially infiltrated by tumor cells. Mitotic activity was absent (0/40HPHF). Immunohistochemistry staining was confirmed melanoma cells: S-100, MelanA , HMB-45 /-. Conclusion: Melanoma in this region is rare, indolent lesion, with bad prognosis. Early detection could prevent further dissemination of disease and many complications. Metastatic choroid melanoma is a highly malignant disease with a limited life expectancy.

Složeni problemi politraumatizovanih pacijenata su veliki izazov za lekare. Brojne povrede kod takvih pacijenata zahtevaju brzo reagovanje po principu prioriteta kojim se greške svode na minimum. Za lečenje trauma pacijenata neophodno je znanje, iskustvo i veština lekara da bi brzo i sveobuhvatno sagledao povređenog i da bi mu ukazao pravovremenu pomoć. Lečenje se izvodi fokusirajući se na prioritetne povrede pacijenta, prateći protokol postupaka koji lekara sistematski vodi tokom zbrinjavanja od najtežih ka lakšim povredama. Ovakve pacijente zbrinjava interdisciplinarni tim zdravstvenih radnika, u kome svako mora da zna svoje mesto i obaveze. Na čelu tima je najiskusniji lekar koji definiše redosled postupaka tokom inicijalnog zbrinjavanja. Samo organizovanim pristupom pandemijskom problemu trauma pacijenata može se pozitivno uticati na smanjenje neposrednog i odloženog mortaliteta i morbiditeta povređenih. U radu je revijalno prikazan pristup politraumatizovanom pacijentu uz inicijalno zbrinjavanje, baziran na prioritetima i prateći protokol koji obezbeđuje najveću efikasnost u lečenju.

Sarcomatoid differentiation in renal cell carcinoma (sarcomatoid renal cell carcinoma – sRCC) represents a dedifferentiated high grade neoplasm of the kidney that contains carcinomatous and sarcomatous component. sRCC is an uncommon tumor, with the incidence of 5-8% of renal carcinoma. Sarcomatoid differentiation is a result of divergent differentiation of malignant epithelial cells. During this process tumor cells lose their epithelial features, and acquire mesenchymal characteristics, which provides them higher APSTRAKTI 79 MATERIA MEDICA • Vol. 34 • Issue 1, suplement 1 • april 2018. capacity for migration and metastasis.This phenotype can be encountered in all RCC subtypes, including clear cell, papillary, chromophobe RCC, and carcinomaof collecting duct. Sarcomatoid component may resemble fibrosarcoma or undifferentiated pleomorphic sarcoma. Less often heterologous differentiation can be found, with histologic patterns resembling rhabdomyosarcoma, chondrosarcoma, or osteosarcoma. Rhabdoid phenotype is an aggressive form of divergent differentiation which has been described in clear cell RCC, papillary RCC, as well as in chromophobe RCC (CRRCC). CRRCC comprise about 6% of RCC, and has better prognosis compared to other RCC subtypes. Sarcomatoid differentiation is found in 8% of these tumors, and is an indicator of poor prognosis, as it is in other RCC types. Sarcomatoid component may represent terminally dedifferentiated clone which can arise from any RCC subtype, or can develop from a special clone. Although sRCC is most frequently found in high grade tumors, the occurrence of sarcomatoid differentiation in RCC, Fuhrman 1/2, detected in 30% of the cases, denies the claim that sarcomatoid differentiation is a continual process of classic RCC dedifferentiation, but a consequence of sarcomatoid stem cell activation within the tumor. In a case of sarcomatoid differentiation in renal carcinoma it is necessary to detect focuses of any morphological type of renal cell carcinoma, and to verify the immunohistochemical positivity of sarcomatoid component to epithelial and mesenchymal markers. Their epithelial origin is confirmed by the expression of cytokeratins, and EMA. PAX8, CAIX, and CD10 can be used to confirm the renal origin, which is of particular importance in finding of sarcomatoid cells in needle biopsy, as well as in metastatic RCC. CAIX, p53, and Bcl-2 can play a major role in transformation of RCC to highly malignant neoplasm with sarcomatoid differentiation. The expression of CAIX, p53, and Bcl-2 is indicator of poor prognosis and worse survival of the patients with sRCC. Significant micromorphological parameters that may influence the clinical course of the disease comprise percentage of sarcomatoid differentiation (>50%), presence of vascular invasion, extent of necrosis, and advanced TNM stage. Type and grade of sarcomatoid component, as well as RCC subtype do not influence the clinical outcome. The prognosis of patients with sRCC is worse compared to prognosis of other histologic forms of RCC. Sarcomatoid differentiation in RCC is a significant cause of mortality, with average survival of 4-9 months after diagnosis. The majority of unclassified RCCs contains variable percent of tumor cells with sarcomatoid morphology, without recognizable epithelial component. About 3% of RCC are exclusively sarcomatoid. These tumors are larger, more often invade adrenal glands and other adjacent organs, metastasize more frequently into regional lymph nodes and bones, and have significantly shorter survival (average is 4.3 months). Differential diagnosis of sRCC should exclude primary renal sarcoma, sarcomatoid urothelial carcinoma, and angiomyolipoma. Micromorphologically sRCC may resemble classic sarcoma, however it should be taken into account that primary renal sarcomas are extremely rare in adults, and comprise less than 1% of renal malignancies. The half of primary renal sarcomas are leiomyosarcomas, consisting of smooth muscle component, which is extremely rare in sRCC. In sarcomatoid urothelial carcinoma, the location of tumor is of significance, also the presence of carcinoma in situ, recurrence of urothelial carcinoma, and immunohistochemical positivity to CKhmw and p63. In angiomyolipoma, immunoreactivity to HMB45, as well as the presence of focuses with classic morphology, excludes sarcomatoid RCC. Conclusion: Sarcomatoid differentiation in renal cell carcinoma is a result of divergent differentiation of malignant epithelial cell, and can be found in all renal cell carcinoma subtypes. During this process tumor cells lose their epithelial features, and acquire mesenchymal characteristics, which provides them higher capacity for migration and metastasis. It is very important to recognize the presence of sarcomatoid differentiation in renal cell carcinoma, since it is an indicator of poor prognosis irrespective of RCC subtype.

Introduction: Hamartomas of the bile duct named von Meyenburg complex are benign liver lesions consisting of dilated bile duct structures with a surrounding fibrous stroma. Their incidence is age-dependent and they are observed about 1% in children and 5%-6% in adults. Von Meyenburg complexes are infrequently observed lesions, characterized by multiple small nodular lesions located below the Glisson’s capsule, and ranging from 0.1 to 1.0 centimeters in diameter. Von Meyenburg complex of the liver are usually detected during laparotomy or autopsies an incidental finding. Multilocular occurrence is possible although they are rarely spread throughout the whole liver, as it was observed in our patient. They are normally asymptomatic, and are incidental findings in asymptomatic patients. They may be found in normal liver tissue, but also in association with Caroli’s syndrome, congenital hepatic fibrosis, autosomal dominant polycystic renal diseas, cholangiocarcinomas and cholangitis. Cholangiocarcinoma which arise from these lesions are usually lower stage and better differentiations than other type of cholangiocarcinoma. The sonographic findings of von Meyenburg complex are variable, including multiple, small, hyperechogenic images, with poorly delimited margins, or even hypoechogenic images with a “target” pattern with a hyperechogenic center and a hypoechogenic periphery, and well delimited margins. A magnetic resonance cholangiography is the best imaging examination of hamartomas of the bile duct, which can distinguish the different forms of dilatation of the bile duct. Histology of von Meyenburg complexes consists of a variable number of dilated small bile ducts, embedded in a fibrous, sometimes hyalinizing stroma. Microscopically, they are characterized by cystic dilatations of the bile duct or clusters of mature bile duct of various sizes, peri-ductal glands, and encompassed by fibrous stroma. The ductules are lined by small cuboidal or flattened cells, with round to oval nuclei. Bile duct hamartomas contain cysts that are more irregularly shaped then normal ducts, and they may also contain eosinophilic debris or inspissated bile. Case report: A 68-year-old male patient with multiple hepatic lesion which ultrasonic and MSCT appearance suggestive of multiple liver metastases was accepted for surgical exploration and liver biopsy. The patient had one mounts symptoms of vomits and weight loss. During surgery numerous whitish irregular lesions of various sizes scattered in the hepatic surface imitating metastatic deposits were noted trough both liver lobe and trough all liver quadrants. Explorations of the rest of abdominal cavity not found any pathological changes or peritoneal carcinomatosis. Liver biopsy was done and taken three samples for analysis. Tissue was brown-yellow-gray color and medium-firm consistency. Histological analysis demonstrated multiple lesions composed of biliary ducts incorporated in fibrotic tissue (Figure 1).There are usually cystic dilatations of some intrahepatic biliary ducts with irregular shape lined with uniform epithelium (Figure 2). The epithel of biliary ducts in von Meyenburg complex were immunohistochemicaly Epithelial Membrane Antigen positive, Pan-Cytokeratin positive, Cytokeratin 7 negative, Cytokeratin 5/6 negative and Carcinoembryonic antigene negative. Also present were signs of cholestasis with small lakes of bile.Conclusion: Von Meyenburg complexes are an important differential diagnosis of liver metastases. Differential diagnosis of liver metastases also includes other benign liver lesions, including hemangiomas, adenomas or infectious lesions e.g. miliary tuberculosis. As the existence of liver metastases is crucial for therapeutic decision making in malignant diseases, this differential diagnosis must be carefully clarified. Since VMC are usually less than 5 mm in size, they can escape preoperative radiologic diagnostics. The macroscopic appearance of von Meyenburg complexes can mimic liver metastasis as demonstrated in our reported patients.

Stafilokokni toksični šok sindrom (STŠS) se obično javlja kod novorođenčadi i dece, ali se povremeno može javiti i kod odraslih. U tom slučaju, obično ukazuje na disfunkciju imunog sistema. Prikazan je slučaj kritično-obolelog odraslog muškarca sa STŠS i simptomima i znacima životno-ugrožavajuće sistemske infekcije (hemodinamska nestabilnost, akutna insuficijencija bubrega, konfuzija). Nakon završenog lečenja (anti-stafilokoni antibiotici, hemodijaliza, vazopresori, suportivna i simptomatska terapija), postignuta je potpuna remisija kod obolelog. Pravovremena dijagnostika i adekvatan tretman je glavno uporište u lečenju STŠS kod odraslih.