Urothelial carcinoma with plasmocytoid component.
ABSTRACT Plasmocytoid urothelial carcinoma is a rare subtype of tumour of the urinary bladder. Its clinical and histopathological features have not been well characterized. There are few reports of this type of tumour. We report a case of 65-year-old man who was operated in our department for bladder tumour. The pathological diagnosis was high-grade urothelial carcinoma with plasmocytoid component. The patient died shortly thereafter from liver and bone metastasis.
Cited in Index Medicus/MEDLINE, BIOSIS Previews, SCOPUS
Journal of the Italian Society of Anatomic Pathology
and Diagnostic Cytopathology,
Italian Division of the International Academy of Pathology
Vol. 101 December 2009
Società Italiana di Anatomia Patologica e Citopatologia Diagnostica,
Divisione Italiana della International Academy of Pathology
Gestational diabetes insipidus:
a morphological study of the placenta
F. CASTIGLIONE, A.M. BuCCOLIERO, F. GARBINI, C.F. GHERI, D. MONCINI, G. POGGI, V. SALADINO,
D. ROSSI DEGL’INNOCENTI, R.G. GHERI*, G.L. TADDEI
Department of Human Pathology and Oncology, university of Florence, School of Medicine, Florence; * unit of Endocrinology
San Giuseppe Hospital, Empoli, Italy
Francesca Castiglione, Department of Human Pathology and On-
cology, university of Florence, School of Medicine, viale G.B.
Morgagni 85, 50134 Florence, Italy - Tel. +39 055 4478121 - Fax
+39 055 4379868.
Gestational diabetes insipidus • Morphological study of placenta
Gestational diabetes insipidus (GDI) refers to the state of exces-
sive water intake and hypotonic polyuria. Those cases manifest-
ing in pregnancy and referred to as GDI may persist thereafter
or may be a transient latent form that resolves after delivery.
Microscopic examination of affected subjects has not been pre-
viously reported. In the literature, there are various case reports
and case series on diabetes insipidus in pregnancy. In this study,
we present a case that had transient diabetes insipidus during
pregnancy in which the placenta was examined.
Gestational diabetes insipidus (GDI) is a rare endocrin-
opathy complicating pregnancy with an incidence of
approximately four in every 100,000 pregnancies 1 2.
Polyuria, polydypsia, excessive thirst and dehydration
are the main features of the disease. The aetiology is
thought to depend on excessive vasopressinase activity,
a placental enzyme that degrades arginine vasopressin
(AVP), but not 1-deamino-8-d-arginine vasopressin
(dDAVP), which is a synthetic form with a different N-
terminal 3. GDI can be categorized into two groups de-
pending on the response to arginine vasopressin (AVP)
and dDAVP: vasopressin-resistant and dDAVP resistant
(nephrogenic), and vasopressin and dDAVP-sensitive
(central) 1 3.
Although there is an increase in AVP levels in pregnan-
cy to maintain sufficient antidiuretic activity, decreased
renal effect due to its increased catabolism by placental
vasopressinase may result in and is the main cause of
GDI 4. Another factor contributing to the pathophysiol-
ogy is transient liver dysfunction in which vasopressi-
nase degradation in liver is decreased, explaining its
association with acute fatty liver during pregnancy and
HELLP syndrome 5. Microscopic examination of the
placenta in affected subjected has not been previously
reportde. In the literature, there are various case reports
and case series regarding diabetes insipidus in preg-
nancy . Herein, we present a case of transient diabetes
insipidus in pregnancy in whom placental examination
A 36-year-old Caucasian patient was referred in the 33th
week of gestation with symptoms of polyuria, poly-
dypsia, inability to tolerate oral intake, weight loss and
fatigue that began in the third trimester and worsened
with time. The prenatal course was uncomplicated un-
til 30 weeks; after that time, urination and oral intake
progressively increased to the degree that upon pres-
entation, she could not tolerate a sufficient quantity of
water to quench her thirst. Her past medical story was
unremarkable. The women had 2 previous pregnancies:
the first physiological, and the second was a twin preg-
nancy with foetal intrauterine death in the 20th week.
The family history was unremarkable for endocrinopa-
thies and liver disease. No therapy was given during
pregnancy, and her symptoms resolved in the third week
F. castiglione et al.
of puerperium. ultrasonography at 35th weeks of gesta-
tion showed a normal amniotic fluid index and foetal
biometry. Physical and gynaecological examinations
were unremarkable. Blood pressure was 105/75 mmHg
and the pulse rate 90/min. The general condition of the
patient was moderate, skin turgor was reduced and her
mouth was completely dry. The patient was admitted
to the hospital for further assessment. The therapy with
dDAVP was begun. The planned caesarean section at
37 weeks of gestation was performed under combined
spinal-epidural anaesthesia with oral dDAVP. A female
foetus of 2,600 g was delivered after one minute the
Apgar score of the fetus was 9. The postoperative course
was uneventful. dDAVP treatment was continued until
After delivery, the placenta was evaluated macroscopi-
cally by the pathologist and then fixed in 10% buffered
in formalin and embedded in paraffin. The placenta
was 500 g with a placental weight index of 5.2 (foetal
weight/placental weight), which is slightly less than nor-
mal (6,2). Macroscopic evaluation showed a placenta
disc of cm 21 x 19 x 2.6. The umbilical cord inserted
eccentrically into the placenta disc. The maternal sur-
face of the placentas was dark red, shiny and coarsely
folded into regular lobulations. The foetal surface of the
chorionic plate was covered by glistening, transparent
amnion. Membranes normally arise from the margin of
the disc. Chorionic arteries and veins branched from the
umbilical cord. There were three umbilical vessels. The
funicle was 27 cm in length and 1.2 cm in diameter. Ten
sections of placental tissue, 2 umbilical cord and 2 of
the amniotic membrane were processed for microscopic
examination after haematoxilin-eosin staining. Micro-
scopic evaluation revealed both old and recent infarcts
in 15% of the placenta (Fig. 1). Fibrinoid necrosis was
detected in 10% of placent (Figs. 2, 3). Scattered areas
of placental “Tenney-Parker” changes were present in 3
of the 10 sections (over 20%) (Fig. 4). Chorioamnionitis
and umbilical cord alterations were absent.
Gestational diabetes insipidus refers to the state of
excessive water intake and hypotonic polyuria. Those
manifesting in pregnancy and referred to as GDI may
persist thereafter or may be a transient latent form that
Fig. 1. placental infarct.
Figs. 2-3. areas of increased perivillous fibrin.
Fig. 4. “tenney-paeker changes” are evident.
gestational diabetes insipidus: a morphological study oF the placenta
resolves after delivery. It may be associated with pre-
eclampsia, acute fatty liver during pregnancy or HELLP
syndrome 3 6. There are no descriptions in literature of
placental morphology in GDI, perhaps because of the
rarity of the disease or to the delay in sample delivery to
the pathologist. It is complex to understand the peculiar
aspects of this pathology. The placenta examined was a
placenta at 37 weeks, presenting focal areas suggesting
advanced villous maturation, infarcts and fibrin depos-
its. These were frequent after 30 week or so, perhaps
non-specific in a GDI placenta. The placental infarct
was a localized region of villi ischemic necrosis, which
is surrounded by coagulated blood. Small infarcts (less
than 3 cm) are found in about one-fourth of placentas
from uncomplicated pregnancies. Placenta infarcts oc-
cur when maternal blood flow through the spiral arteries
is insufficient. A small infarct of less than 3 cm in diam-
eter near the placental margin is a common occurrence,
and as an isolated finding has no clinical significance.
This alteration is often present in placenta after 35
weeks of pregnancy, and is thus not specific of this pa-
thology 7. We consider placenta exam useful in GDI to
determine if these findings are occasional or consistent
with similar cases.
1 Durr JA. Diabetes? insipidus? in? pregnancy. Am J Kidney Dis
2 El-Hennawy AS, Bassi T, Koradia N, Bocirnea. A? Transient?
gestational? diabetes? insipidus:? report? of? two? cases? and? review?
of?pathophysiology?and?treatment. J Matern Fetal Neonatal Med
3 Jin-No Y, Kamiya Y, Okada M, Watanabe O, Ogasawara M,
Fujinami T. Pregnant? woman? with? transient? diabetes? insipi-
dus?resistant?to?1-desamino-8-D-arginine?vasopressin. Endocr J
4 Lindheimer MD, Barron WM, Davison JM. Idiopathic?acute?fatty?
Case?report. Br J Obstet Gynaecol 1987;94:823-4.
5 Yamanaka Y, Takeuchi K, Konda E, Samoto T, Satou A, Mizudori
M, et al. Transient?postpartum?diabetes?insipidus?in?twin?pregnancy?
associated?with?HELLP?syndrome.?J Perinat Med 2002;30:273-5.
6 Harper M, Hatjis CG, Appel RG, Austin WE. Vasopressin-resistant?
renal?function.?A?case?report. J Reprod Med 1987;32:862-5.
7 Salafia CM, Pezzullo JC, López-Zeno JA, Simmens S, Minior
VK, Vintzileos AM. Placental? pathologic? features? of? preterm?
preeclampsia. Am J Obstet Gynecol 1995;173:1097-105.
Simultaneous occurrence of primary diffuse large
B-cell lymphoma and extranodal marginal zone (MALT)
B-cell lymphoma in the gallbladder: a case report
A. GARDINI, L. SARAGONI*, G. LA BARBA, D. GARCEA
Department of General Surgery, * Department of Pathology G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy
Andrea Gardini, G.B. Morgagni-L. Pierantoni Hospital, Depart-
ment of General Surgery, Floor 5 A, via Forlanini 38, 47100 Forlì,
Italy Tel. +39 0543 735500 - Fax +39 0543 735522 - E-mail:
Gallbladder • MALT • Large B-cell lymphoma
Primary lymphoma of the gallbladder is extremely rare. We
present an asymptomatic case of primary combined DLBCL
– MALT lymphoma of the gallbladder in a 78-year-old man in
whom definitive diagnosis was made with laparotomic cholecys-
tectomy. Preoperative diagnosis was supported by NMR, CT and
PET scans. The pathological report identified a polypoid lesion
measuring 3.5 cm in diameter. A non-Hodgkin lymphoma with
two different coexisting patterns was identified histologically:
large diffuse B-cell lymphoma (DLBCL) associated with focal
areas of extranodal marginal zone B-cell lymphoma (MALT-
type) of the gallbladder. The postoperative course was uneventful
and the patient is currently without clinical or radiological signs
of disease. Chemotherapy was not indicated due to cardiopathy.
In conclusion, a primary gallbladder lymphoma is a rare entity.
Radiological findings may be helpful, but cholecistectomy may
be necessary for definitive diagnosis. In this report, we describe
the possible association between MALT and DLBCL of the
Malignant lymphomas usually originate from lymph
nodes, although 40% occur in extranodal tissues or or-
gans. Almost all extranodal lymphomas originate from
the gastrointestinal tract, and the gallbladder is rarely
a primary site of malignant lymphoma. To date, less
than 50 cases have been reported in the literature 1 2.
At present, it is very difficult to differentiate this tu-
mor from adenocarcinoma of the gallbladder. In fact,
the presence of a 2-3 cm intramural gallbladder lesion
with or without lithiasis, and the absence of regional
lymphadenopathy, is often suspected for gallbladder
cancer. While tumor markers may be helpful, they are
often negative even in the presence of gallbladder carci-
noma. There is no well-established method of preopera-
tive diagnosis, and thus most cases reported have been
diagnosed after surgery by pathologic examination. In
this report, we present the radiological and pathological
findings from a case of primary malignant lymphoma of
We report an asymptomatic case of primary combined
DLBCL – MALT lymphoma of the gallbladder in a
78-year-old man in whom definitive diagnosis was pos-
sible using laparotomic cholecystectomy. The patient,
followed for rectocolitis, underwent abdominal ultraso-
nography in August 2008 which revealed a gallbladder
lesion of 2 cm. Abdominal computed tomography (CT
scan – Fig. 1) confirmed the presence of a 2-cm gallblad-
der polypoid lesion without signs of regional enlarged
lymph nodes. Serum levels of carcinoembryonic anti-
gen (CEA) and carbohydrate antigen (CA) 19-9 were
normal. The patient presented a high operative risk due
to severe cardiovascular disease, diabetes and hyperten-
sion and initially refused surgery. Two months later,
the lesions was controlled by NMR, which revealed an
increase in size (3 cm; Fig. 2) and mild splenomegaly.
The patient gave consent for surgery, and tomoscintigra-
phy (PET) was performed before intervention. The PET
scan showed pathological positivity (Fig. 3) only on the
gallbladder lesion (3 cm). Preoperative blood workup
showed reduction of leukocytes (2970/ml) and high
level of β2 globulin, with other parameters within nor-