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Topic:Pathophysiology

Pathophysiology in horses involves the study of functional changes that occur in the body as a result of disease or injury. This field examines the mechanisms through which diseases develop and progress, as well as how they affect the body's normal physiological processes. In equine research, pathophysiology encompasses a wide range of conditions, including respiratory disorders, musculoskeletal injuries, gastrointestinal diseases, and metabolic syndromes. Understanding these processes helps in identifying potential therapeutic targets and developing effective treatment strategies. This page collects peer-reviewed research studies and scholarly articles that explore the underlying mechanisms, clinical manifestations, and implications of various pathophysiological conditions in equine health.
Associations of plasma sphingolipid profiles with insulin response during oral glucose testing in Icelandic horses.
Journal of veterinary internal medicine    June 8, 2021   Volume 35, Issue 4 2009-2018 doi: 10.1111/jvim.16200
Leung YH, Kenéz Á, Grob AJ, Feige K, Warnken T.Sphingolipids modulate insulin sensitivity in mammals. Increased synthesis of ceramides is linked to decreased insulin sensitivity of tissues. Conversely, activation of the insulin signaling pathway can downregulate ceramide synthesis. Elucidating the association between sphingolipid metabolism and insulin response during oral glucose testing may help explain the pathophysiology of insulin dysregulation in horses. Objective: Horses with insulin dysregulation will have a plasma sphingolipid profile characterized by increased ceramide concentrations. The plasma sphingolipid profile will have dec...
Alterations in the Expression Profile of Serum miR-155, miR-223, miR-17, miR-200a, miR-205, as well as Levels of Interleukin 6, and Prostaglandins during Endometritis in Arabian Mares.
Veterinary sciences    June 4, 2021   Volume 8, Issue 6 98 doi: 10.3390/vetsci8060098
Ibrahim S, Hedia M, Taqi MO, Derbala MK, Mahmoud KGM, Ahmed Y, Ismail S, El-Belely M.So far the intimate link between serum microRNA (miRNA) and uterine inflammation in mares is unknown. We aimed (I) to investigate expression profile of eca-miR-155, eca-miR-223, eca-miR-17, eca-miR-200a, and eca-miR-205 (II) and to measure concentrations of interleukin 6 (IL-6), and prostaglandins (PGF and PGE) in serum of mares with healthy and abnormal uterine status (endometritis). This study was conducted on 80 Arabian mares: young (4-7 years), and old (8-14 years). Mares were divided into 48 sub-fertile (endometritis) and 32 fertile (control) at stud farms. Serum was collected for measuri...
Glucocorticoid treatment in horses with asthma: A narrative review.
Journal of veterinary internal medicine    June 3, 2021   Volume 35, Issue 4 2045-2057 doi: 10.1111/jvim.16189
Mainguy-Seers S, Lavoie JP.Despite substantial research efforts to improve the treatment and outcome of horses with asthma, glucocorticoids (GC) remain the cornerstone of drug treatment of this prevalent disease. The high efficacy of GC to relieve airway obstruction explains their extensive use despite potential deleterious effects. However, much is yet to be uncovered concerning GC use in horses with asthma, including the comparative efficacy of the different drugs, the determination of minimal effective doses and the mechanisms underlying their variable modulation of airway inflammation. The objectives of this structu...
Evaluation of the Filum Terminale in Hereditary Equine Regional Dermal Asthenia.
Veterinary pathology    May 31, 2021   Volume 58, Issue 6 1100-1106 doi: 10.1177/03009858211018660
McElroy A, Klinge PM, Sledge D, Donahue JE, Glabman RA, Rashmir A.The objectives of this study were to describe the anatomy, histology, and ultrastructure of the equine filum terminale (FT) and to describe the FT in hereditary equine regional dermal asthenia (HERDA), a model of human Ehlers-Danlos syndromes (EDS). Those humans suffer from tethered cord syndrome (TCS) caused by an abnormally structured FT wherein its attachment at the base of the vertebral column leads to long-term stretch-induced injury to the spinal cord. The pathophysiology of TCS in EDS is poorly understood, and there is a need for an animal model of the condition. Histopathologic and ult...
Equine Hoof Stem Progenitor Cells (HPC) CD29 + /Nestin + /K15 + - a Novel Dermal/epidermal Stem Cell Population With a Potential Critical Role for Laminitis Treatment.
Stem cell reviews and reports    May 26, 2021   Volume 17, Issue 4 1478-1485 doi: 10.1007/s12015-021-10187-x
Marycz K, Pielok A, Kornicka-Garbowska K.Laminitis is a life threating, extremely painful and frequently recurrent disease of horses which affects hoof structure. It results from the disruption of blood flow to the laminae, contributing to laminitis and in severe separation of bone from the hoof capsule. Still, the pathophysiology of the disease remains unclear, mainly due to its complexity. In the light of the presented data, in the extremally difficult process of tissue structure restoration after disruption, a novel type of progenitor cells may be involved. Herein, we isolated and performed the initial characterization of stem pro...
Development of a constant pressure perfused ex vivo model of the equine larynx.
PloS one    May 20, 2021   Volume 16, Issue 5 e0251530 doi: 10.1371/journal.pone.0251530
Otto S, Michler JK, Dhein S, Mülling CKW.Distal axonopathy is seen in a broad range of species including equine patients. In horses, this degenerative disorder of the recurrent laryngeal nerve is described as recurrent laryngeal neuropathy (RLN). The dysfunctional innervation of the cricoarytenoideus dorsalis muscle (CAD) leads to a loss of performance in affected horses. In general, ex vivo models of the larynx are rare and for equine patients, just one short report is available. To allow for testing new therapy approaches in an isolated organ model, we examined equine larynges in a constant pressure perfused setup. In order to chec...
Studies of molecular pathways associated with blood neutrophil corticosteroid insensitivity in equine asthma.
Veterinary immunology and immunopathology    May 9, 2021   Volume 237 110265 doi: 10.1016/j.vetimm.2021.110265
Pourali Dogaheh S, Boivin R, Lavoie JP.Severe equine asthma is characterized by airway hyperresponsiveness, neutrophilic inflammation and structural alterations of the lower airways. In asthmatic horses with neutrophilic inflammation, there is insensitivity to corticosteroids characterized by the persistence of neutrophils within the airways with therapy. We hypothesized that hypoxia or oxidative stress in the microenvironment of the lung contributes to this insensitivity of neutrophils to corticosteroids in asthmatic horses. Blood neutrophils isolated from horses with severe asthma (N = 8) and from healthy controls (N = 8)...
Tandem Mass Tag (TMT) Proteomic Analysis of Saliva in Horses with Acute Abdominal Disease.
Animals : an open access journal from MDPI    April 30, 2021   Volume 11, Issue 5 1304 doi: 10.3390/ani11051304
Muñoz-Prieto A, Escribano D, Contreras-Aguilar MD, Horvatić A, Guillemin N, Jacobsen S, Cerón JJ, Mrljak V.The aim of this study was to investigate the changes in the salivary proteome in horses with acute abdominal disease (AAD) using a tandem mass tags (TMT)-based proteomic approach. The saliva samples from eight horses with AAD were compared with six healthy horses in the proteomic study. Additionally, saliva samples from eight horses with AAD and eight controls were used to validate lactoferrin (LF) in saliva. The TMT analysis quantified 118 proteins. Of these, 17 differed significantly between horses with AAD and the healthy controls, 11 being downregulated and 6 upregulated. Our results showe...
Equine Antebrachial Compartment Syndrome Secondary to Flexor Muscle Myopathy With Subsequent Muscle Atrophy And Tendonitis: A Case Report.
Journal of equine veterinary science    April 8, 2021   Volume 101 103462 doi: 10.1016/j.jevs.2021.103462
Costa F, Brunsting J, Corrêa F.This case report describes a 16-year-old jumping stallion that had a marked swelling over the left antebrachial area along with substantial lameness after a fall. The horse was weight bearing but lame (4/5; AAEP scale) at the walk with marked enlargement in the caudal aspect of the antebrachial region. After a static musculoskeletal examination, radiography and ultrasonography the horse was diagnosed with flexor muscle myopathy and presumptive extremity compartment syndrome. Following medical treatment, the horse improved clinically over several days. Six-months post injury the horse showed fl...
“One Health” in tendinopathy research: Current concepts.
Journal of orthopaedic research : official publication of the Orthopaedic Research Society    April 2, 2021   Volume 39, Issue 8 1596-1602 doi: 10.1002/jor.25035
Smith RKW, McIlwraith CW.Tendinopathy remains one of the most common musculoskeletal disorders affecting both human and equine athletes and presents a considerable therapeutic challenge. The following workshop report comes from the third Dorothy Havemeyer Symposium of Tendinopathy which provided a unique overview of our current understanding of both the basic science and the clinical challenges for diagnosing and treating tendinopathy in both species. Pathologically, tendon demonstrates alterations in both cellular, molecular, structural, and biomechanical features, leading to a spectrum of pathological endotypes. To ...
Metabolism and global protein glycosylation are differentially expressed in healthy and osteoarthritic equine carpal synovial fluid.
Equine veterinary journal    March 18, 2021   Volume 54, Issue 2 323-333 doi: 10.1111/evj.13440
Noordwijk KJ, Qin R, Diaz-Rubio ME, Zhang S, Su J, Mahal LK, Reesink HL.Carpal osteochondral fragmentation and subsequent post-traumatic osteoarthritis (PTOA) are leading causes of wastage in the equine athlete. Identification of synovial fluid biomarkers could contribute to the diagnosis and understanding of osteoarthritis (OA) pathophysiology. Objective: The aim of this study was to identify differentially expressed metabolic and glycosylation pathways in synovial fluid from healthy horses and horses with naturally occurring carpal OA. Methods: Cross-sectional, in vivo metabolomics and glycomics study. Methods: In cohort 1, carpal synovial fluid (n = 12 horses...
Apoptosis in epithelial cells and its correlation with leukocyte accumulation in lamellar tissue from horses subjected to experimental sepsis-associated laminitis.
Research in veterinary science    March 9, 2021   Volume 136 318-323 doi: 10.1016/j.rvsc.2021.03.009
Catunda APN, Alves GES, Paes Leme FO, Carvalho AM, Leise BS, Johnson PJ, Faleiros RR.Inflammation and apoptosis in the hoof lamellar interface both contribute to the early stages of sepsis-associated laminitis, but it is not clear whether apoptosis is occurring before the onset of inflammation or is being provoked by inflammation. Apoptosis and inflammation were therefore measured in lamellar tissues obtained at different time points throughout the early stages of experimentally induced laminitis. Apoptotic cells and leukocyte were enumerated in archived paraffin embedded lamellar tissue samples from previous experiments in which acute laminitis was induced using Black Walnut ...
Multiple Simultaneous Proliferative Lesions on the Prepuce and Penis of a Gelding.
Journal of equine veterinary science    February 28, 2021   Volume 101 103426 doi: 10.1016/j.jevs.2021.103426
Veado HC, Silva AS, Fagundes JLA, Bittencourt AA, de Castro MB, Câmara ACL.Skin lesions are among the leading diseases in equids, and the urogenital region is considered the third most frequently affected body location with tumors and tumor-like skin lesions in horses. Tumor-like skin lesions or multiple tumors of different types in the equine prepuce and penis are a challenging clinical presentation leading to misdiagnosis and subsequent ineffective treatment. An 18-year-old 395-kg male mixed-breed gelding was referred for evaluation of preputial enlargement. Clinical examination revealed a 2.5 × 2.0 × 0.8 cm proliferative ulcerated lesion on the penile mucosa...
In vitro assessment of the motion of equine proximal sesamoid bones relative to the third metacarpal bone under physiologic midstance loads.
American journal of veterinary research    February 26, 2021   Volume 82, Issue 3 198-206 doi: 10.2460/ajvr.82.3.198
Shaffer SK, Sachs N, Garcia TC, Fyhrie DP, Stover SM.To assess the motion of the proximal sesamoid bones (PSBs) relative to the third metacarpal bone (MC3) of equine forelimbs during physiologic midstance loads. Methods: 8 musculoskeletally normal forelimbs (7 right and 1 left) from 8 adult equine cadavers. Methods: Each forelimb was harvested at the mid-radius level and mounted in a material testing system so the hoof could be moved in a dorsal direction while the radius and MC3 remained vertical. The PSBs were instrumented with 2 linear variable differential transformers to record movement between the 2 bones. The limb was sequentially loaded ...
Evidence for anti-inflammatory effects of firocoxib administered to mares with experimentally induced placentitis.
American journal of reproductive immunology (New York, N.Y. : 1989)    February 10, 2021   Volume 86, Issue 1 e13396 doi: 10.1111/aji.13396
Macpherson ML, Giguère S, Pozor MA, Burden CA, Berghaus LJ, Berghaus RD, Varner JC, Hayna JT, Benson SM, Randell SA, Lyle SK, Kelleman AA, Hart KA....Minimal evidence exists supporting therapeutic selections for equine placentitis. The goal of this study was to characterize the anti-inflammatory effects of firocoxib when administered to mares with placentitis. Mares (gestation D270-300) were assigned to: INFECT (n = 6; placentitis, no treatment), FIRO (n = 6; placentitis, firocoxib, 0.1 mg/kg, PO, daily), and NORM (n = 6; no infection/treatment). Allantoic fluid (8 hours, 24 hours, birth) and amniotic fluid (birth) were collected from mares after infection. Concentrations of IL-1β, IL-6, TNF-α, IL-10, PGF , and PGE in fluids were...
Pathways of calcium regulation, electron transport, and mitochondrial protein translation are molecular signatures of susceptibility to recurrent exertional rhabdomyolysis in Thoroughbred racehorses.
PloS one    February 10, 2021   Volume 16, Issue 2 e0244556 doi: 10.1371/journal.pone.0244556
Aldrich K, Velez-Irizarry D, Fenger C, Schott M, Valberg SJ.Recurrent exertional rhabdomyolysis (RER) is a chronic muscle disorder of unknown etiology in racehorses. A potential role of intramuscular calcium (Ca2+) dysregulation in RER has led to the use of dantrolene to prevent episodes of rhabdomyolysis. We examined differentially expressed proteins (DEP) and gene transcripts (DEG) in gluteal muscle of Thoroughbred race-trained mares after exercise among three groups of 5 horses each; 1) horses susceptible to, but not currently experiencing rhabdomyolysis, 2) healthy horses with no history of RER (control), 3) RER-susceptible horses treated with dant...
Interleukin-6 pathobiology in equine placental infection.
American journal of reproductive immunology (New York, N.Y. : 1989)    February 9, 2021   Volume 85, Issue 5 e13363 doi: 10.1111/aji.13363
Fedorka CE, Scoggin KE, El-Sheikh Ali H, Loux SC, Dini P, Troedsson MHT, Ball BA.Ascending placentitis is the leading cause of abortion in the horse. Interleukin (IL)-6 is considered predictive of placental infection in other species, but little is understood regarding its role in the pathophysiology of ascending placentitis. Sub-acute ascending placentitis was induced via trans-cervical inoculation of S zooepidemicus, and various fluids/serum/tissues collected 8 days later. Concentrations of IL-6 were detected within fetal fluids and serum in inoculated (n = 6) and control (n = 6) mares. RNASeq was performed on the placenta (endometrium and chorioallantois) to asses...
Differential gene expression and Ingenuity Pathway Analysis of bronchoalveolar lavage cells from horses with mild/moderate neutrophilic or mastocytic inflammation on BAL cytology.
Veterinary immunology and immunopathology    February 4, 2021   Volume 234 110195 doi: 10.1016/j.vetimm.2021.110195
Davis KU, Sheats MK.Mild to moderate equine asthma syndrome (mEAS) affects horses of all ages and breeds. To date, the etiology and pathophysiology of mEAS are active areas of research, and it remains incompletely understood whether mEAS horses with different immune cell 'signatures' on BAL cytology represent different phenotypes, distinct pathobiological mechanisms (endotypes), varied environmental conditions, disease severity, genetic predispositions, or all of the above. In this descriptive study, we compared gene expression data from BAL cells isolated from horses with normal BALF cytology (n = 5), to those i...
Rare Case of Spinal Neurosarcoidosis with Concomitant Epidural Lipomatosis.
Case reports in neurological medicine    January 28, 2021   Volume 2021 5952724 doi: 10.1155/2021/5952724
Jaafar N, Khoueiry M, Khoury SJ, Makki A.Spinal neurosarcoidosis is a rare disease that can manifest as myelopathy, radiculopathy, or cauda equine syndrome. Spinal epidural lipomatosis is also a rare condition resulting from overgrowth of epidural fat tissue causing compressive myelopathy. To our knowledge, there are no reports linking epidural lipomatosis and spinal neurosarcoidosis. . We describe a case of progressive myelitis in the presence of concomitant spinal neurosarcoidosis and epidural lipomatosis which was a challenging diagnosis with complete response to treatment after addressing both diseases. Both etiologies are inflam...
Metabolic profile distinguishes laminitis-susceptible and -resistant ponies before and after feeding a high sugar diet.
BMC veterinary research    January 28, 2021   Volume 17, Issue 1 56 doi: 10.1186/s12917-021-02763-7
Delarocque J, Reiche DB, Meier AD, Warnken T, Feige K, Sillence MN.Insulin dysregulation (ID) is a key risk factor for equine endocrinopathic laminitis, but in many cases ID can only be assessed accurately using dynamic tests. The identification of other biomarkers could provide an alternative or adjunct diagnostic method, to allow early intervention before laminitis develops. The present study characterised the metabolome of ponies with varying degrees of ID using basal and postprandial plasma samples obtained during a previous study, which examined the predictive power of blood insulin levels for the development of laminitis, in ponies fed a high-sugar diet...
Optimisation and validation of immunohistochemical axonal markers for morphological and functional characterisation of equine peripheral nerves.
Equine veterinary journal    January 19, 2021   Volume 53, Issue 6 1188-1198 doi: 10.1111/evj.13403
Almuhanna AH, Cahalan SD, Lane A, Goodwin D, Perkins J, Piercy RJ.Horses are affected by various peripheral nerve disorders but defining their aetiology and pathophysiology is hampered by limited understanding of associated morphological and pathological changes and involvement of specific axonal types. Objective: To investigate the hypothesis that selected antibody markers, used in conjunction with various tissue processing methods, would enable identification of axons with different functional modalities within a range of equine peripheral nerves. Methods: Optimisation and validation study. Methods: A range of antibodies were evaluated immunohistochemicall...
Changes of microbial and metabolome of the equine hindgut during oligofructose-induced laminitis.
BMC veterinary research    January 6, 2021   Volume 17, Issue 1 11 doi: 10.1186/s12917-020-02686-9
Tuniyazi M, He J, Guo J, Li S, Zhang N, Hu X, Fu Y.Laminitis is a common and serve disease which caused by inflammation and pathological changes of the laminar junction. However, the pathologic mechanism remains unclear. In this study we aimed to investigate changes of the gut microbiota and metabolomics in oligofructose-induced laminitis of horses. Results: Animals submitted to treatment with oligofructose had lower fecal pH but higher lactic acid, histamine, and Lipopolysaccharide (LPS) in serum. Meanwhile, oligofructose altered composition of the hindgut bacterial community, demonstrated by increasing relative abundance of Lactobacillus and...
Transcriptomic analysis of equine placenta reveals key regulators and pathways involved in ascending placentitis†.
Biology of reproduction    December 22, 2020   Volume 104, Issue 3 638-656 doi: 10.1093/biolre/ioaa209
El-Sheikh Ali H, Dini P, Scoggin K, Loux S, Fedorka C, Boakari Y, Norris J, Esteller-Vico A, Kalbfleisch T, Ball B.Improved understanding of the molecular mechanisms underlying ascending equine placentitis holds the potential for the development of new diagnostic tools and therapies to forestall placentitis-induced preterm labor. The current study characterized the equine placental transcriptome (chorioallantois [CA] and endometrium [EN]) during placentitis (placentitis group, n = 6) in comparison to gestationally-matched controls (control group, n = 6). Transcriptome analysis identified 2953 and 805 differentially expressed genes in CA and EN during placentitis, respectively. Upstream regulator analys...
Ventricular Restitution Predicts Paroxysmal Atrial Fibrillation in Horses.
Function (Oxford, England)    December 9, 2020   Volume 2, Issue 1 zqaa038 doi: 10.1093/function/zqaa038
Ramírez J, Tinker A.No abstract available
Metabolic changes induced by oral glucose tests in horses and their diagnostic use.
Journal of veterinary internal medicine    December 5, 2020   Volume 35, Issue 1 597-605 doi: 10.1111/jvim.15992
Delarocque J, Frers F, Feige K, Huber K, Jung K, Warnken T.Little is known about the implications of hyperinsulinemia on energy metabolism, and such knowledge might help understand the pathophysiology of insulin dysregulation. Objective: Describe differences in the metabolic response to an oral glucose test, depending on the magnitude of the insulin response. Methods: Twelve Icelandic horses in various metabolic states. Methods: Horses were subjected to 3 oral glucose tests (OGT; 0.5 g/kg body weight glucose). Basal, 120 and 180 minutes samples were analyzed using a combined liquid chromatography tandem mass spectrometry and flow injection analysis ...
Estimation of Nitrite-Nitric Oxide Derivative-In Horses with Intestinal Colic by ESR Spectroscopy.
Veterinary sciences    November 29, 2020   Volume 7, Issue 4 191 doi: 10.3390/vetsci7040191
Borunova SF, Tkachev N, Iolchiev B, Artyushina Z, Abramov P, Nikitina M, Silanteva A, Khusnetdinova N, Serezhenkov V.Diseases of the gastrointestinal tract of horses are caused by many factors and have a complex pathogenesis. Developing effective methods of differential diagnostics is of high fundamental and applied importance. The pathogenesis of diseases of the digestive tract of horses accompanied by the development of inflammation and oxidative stress, can be associated with a lack of the nitrogen monoxide which controls many signaling pathways in the body. The level of the nitric oxide (NO) is involved in the regulation of the immune and nervous systems, the tone of all the blood vessels, and the course...
The Role of Neutrophils in the Pathophysiology of Asthma in Humans and Horses.
Inflammation    November 5, 2020   Volume 44, Issue 2 450-465 doi: 10.1007/s10753-020-01362-2
Davis KU, Sheats MK.Asthma is a common and debilitating chronic airway disease that affects people and horses of all ages worldwide. While asthma in humans most commonly involves an excessive type 2 immune response and eosinophilic inflammation, neutrophils have also been recognized as key players in the pathophysiology of asthma, including in the severe asthma phenotype where neutrophilic inflammation predominates. Severe equine asthma syndrome (sEAS) features prominent neutrophilic inflammation and has been increasingly used as a naturally occurring animal model for the study of human neutrophilic asthma. This...
Severe asthma is associated with a remodeling of the pulmonary arteries in horses.
PloS one    October 22, 2020   Volume 15, Issue 10 e0239561 doi: 10.1371/journal.pone.0239561
Ceriotti S, Bullone M, Leclere M, Ferrucci F, Lavoie JP.Pulmonary hypertension and cor pulmonale are complications of severe equine asthma, as a consequence of pulmonary hypoxic vasoconstriction. However, as pulmonary hypertension is only partially reversible by oxygen administration, other etiological factors are likely involved. In human chronic obstructive pulmonary disease, pulmonary artery remodeling contributes to the development of pulmonary hypertension. In rodent models, pulmonary vascular remodeling is present as a consequence of allergic airway inflammation. The present study investigated the presence of remodeling of the pulmonary arter...
Non-weight bearing ultrasonographic examination allows the diagnosis of longitudinal fiber disruption (split) in equine suspensory ligament branches not visible on weight bearing examination. Werpy N, Chapman K, Griffith L.When evaluating suspensory ligament branch splits, there is a discrepancy between high field MRI findings and weight bearing ultrasonographic imaging characteristics. In this descriptive and retrospective case series, ultrasonographic examination was performed on suspensory ligament branches with the limbs in weight bearing and non-weight bearing positions. Suspensory ligament branch splits were defined as linear regions of decreased echogenicity when imaged with the limb in a weight bearing position that increased in size and became anechoic with the limb in a non-weight bearing position. Thi...
Primary Hyperparathyroidism in a Quarter Horse Mare Associated With a Chief Cell Adenoma.
Journal of equine veterinary science    October 17, 2020   Volume 95 103302 doi: 10.1016/j.jevs.2020.103302
Darby S, Porter E, Beatty SSK, Dark MJ, Smith A, Toribio RE, Gomez DE.Primary hyperparathyroidism is rare in large animal species, and little is known regarding its pathophysiology, endocrine and electrolyte derangements, diagnosis, medical management, and prognosis. This report describes the clinicopathologic diagnosis of a parathyroid (PT) gland chief cell adenoma in a 12-year-old Quarter Horse mare, including PT hormone (PTH) and electrolyte disarrangements associated with the neoplasia, the surgical removal of the adenoma, and medical management of the case. This report also describes for the first time the use PTH immunohistochemistry to confirm the nature ...
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