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Vos AM, Pijnenborg L, van Vliet S, Kodach LL, Ciompi F, van der Post RS, Simmer F, Nagtegaal ID. Biological background of colorectal polyps and carcinomas with heterotopic ossification: A national study and literature review. Hum Pathol 2024; 145:34-41. [PMID: 38367815 DOI: 10.1016/j.humpath.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 02/19/2024]
Abstract
The biological mechanisms and potential clinical impact of heterotopic ossification (HO) in colorectal neoplasms are not fully understood. This study investigates the clinicopathological characteristics of colorectal neoplasms associated with HO and examines the potential role of the bone morphogenetic protein (BMP) pathway in development of HO. An artificial intelligence (AI) based classification of colorectal cancers (CRC) exhibiting HO and their association with consensus molecular subtypes (CMS) is performed. The study included 77 cases via the Dutch nationwide Pathology databank. Immunohistochemistry for BMP2, SMAD4, and Osterix was performed. An AI algorithm assessed the tumour-stroma ratio to approximate the CMS. A literature search yielded 96 case reports, which were analysed and compared with our cases for clinicopathological parameters. HO was more frequently observed in our cohort in traditional serrated adenomas (25%), tubulovillous adenomas (25%) and juvenile polyps (25%), while in the literature it was most often seen in juvenile polyps (38.2%) and inflammatory polyps (29.4%). In both cohorts, carcinomas were mostly conventional (>60%) followed by mucinous and serrated adenocarcinomas. Higher expression of BMP2, SMAD4, and Osterix was observed in tumour and/or stromal cells directly surrounding bone, indicating activation of the BMP pathway. The tumour-stroma analysis appointed >50% of the cases to the mesenchymal subtype (CMS4) (59%). HO has a predilection for serrated and juvenile/inflammatory polyps, mucinous and serrated adenocarcinomas. BMP signalling is activated and seems to play a role in formation of HO in colorectal neoplasms. In line with TGFβ/BMP pathway activation associated with CMS4 CRC, HO seems associated with CMS4.
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Affiliation(s)
- Anne-Marie Vos
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Lieke Pijnenborg
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Shannon van Vliet
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Liudmila L Kodach
- Department of Molecular Pathology, Dutch Cancer Institute, Amsterdam, the Netherlands
| | - Francesco Ciompi
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rachel S van der Post
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Femke Simmer
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
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Fukuda T, Egashira R, Ueno M, Hashisako M, Sumikawa H, Tominaga J, Yamada D, Fukuoka J, Misumi S, Ojiri H, Hatabu H, Johkoh T. Stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities on CT. Insights Imaging 2023; 14:177. [PMID: 37857741 PMCID: PMC10587054 DOI: 10.1186/s13244-023-01501-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/12/2023] [Indexed: 10/21/2023] Open
Abstract
High-attenuation pulmonary abnormalities are commonly seen on CT. These findings are increasingly encountered with the growing number of CT examinations and the wide availability of thin-slice images. The abnormalities include benign lesions, such as infectious granulomatous diseases and metabolic diseases, and malignant tumors, such as lung cancers and metastatic tumors. Due to the wide spectrum of diseases, the proper diagnosis of high-attenuation abnormalities can be challenging. The assessment of these abnormal findings requires scrutiny, and the treatment is imperative. Our proposed stepwise diagnostic algorithm consists of five steps. Step 1: Establish the presence or absence of metallic artifacts. Step 2: Identify associated nodular or mass-like soft tissue components. Step 3: Establish the presence of solitary or multiple lesions if identified in Step 2. Step 4: Ascertain the predominant distribution in the upper or lower lungs if not identified in Step 2. Step 5: Identify the morphological pattern, such as linear, consolidation, nodular, or micronodular if not identified in Step 4. These five steps to diagnosing high-attenuation abnormalities subdivide the lesions into nine categories. This stepwise radiologic diagnostic approach could help to narrow the differential diagnosis for various pulmonary high-attenuation abnormalities and to achieve a precise diagnosis.Critical relevance statement Our proposed stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities may help to recognize a variety of those high-attenuation findings, to determine whether the associated diseases require further investigation, and to guide appropriate patient management. Key points • To provide a stepwise diagnostic approach to high-attenuation pulmonary abnormalities.• To familiarize radiologists with the varying cause of high-attenuation pulmonary abnormalities.• To recognize which high-attenuation abnormalities require scrutiny and prompt treatment.
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Affiliation(s)
- Taiki Fukuda
- Department of Radiology, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Ryoko Egashira
- Department of Radiology, Faculty of Medicine, Saga University, 5-1-1, Nabeshima, Saga-City, Saga, 849-8501, Japan
| | - Midori Ueno
- Department of Radiology, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishi-Ku, Kitakyushu, Fukuoka, 807-8556, Japan
| | - Mikiko Hashisako
- Department of Pathology, Kyushu University, 3-1-1, Maidashi, Higashi-Ku, Fukuoka-City, Fukuoka, 812-8582, Japan
| | - Hiromitsu Sumikawa
- Department of Radiology, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180, Nagasone-Cho, Kita-Ku, Sakai-City, Osaka, 591-8555, Japan
| | - Junya Tominaga
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-Ku, Sendai, 980-8574, Japan
| | - Daisuke Yamada
- Department of Radiology, St. Luke's International Hospital, 9-1, Akashicho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Junya Fukuoka
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki-City, Nagasaki, 852-8523, Japan
| | - Shigeki Misumi
- Department of Radiology, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Hiroya Ojiri
- Department of Radiology, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Hiroto Hatabu
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Takeshi Johkoh
- Department of Radiology, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki, Hyogo, 660-8511, Japan
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Townsend KS, Johnson PJ, Kuroki K. Head and neck squamous cell carcinoma with heterotopic ossification, lymphovascular invasion, and nodal and pulmonary metastases in a 23-year-old Morgan gelding. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2023; 64:627-632. [PMID: 37397690 PMCID: PMC10286139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Primary squamous cell carcinoma of the head and neck occurs in the skin or squamous epithelial lining tissues of the oral cavity, pharynx, larynx, and sinonasal tract. Although it is a common tumor in horses, distant metastatic spread to the lung is rare. This report describes a case of metastatic pulmonary squamous cell carcinoma in a 23-year-old Morgan gelding. The clinical signs displayed by this gelding in some ways mimicked the typical presentation of equine multinodular pulmonary fibrosis or thoracic lymphoma. The postmortem diagnosis in this case was head and neck squamous cell carcinoma, but a primary site of origin could not be ascertained. Cancer-associated heterotopic ossification (HO) was also identified in this case; this is an exceedingly rare finding with equine pulmonary neoplasia. Key clinical message: Careful physical examination should be undertaken in all horses presenting with clinical signs of intrathoracic disease. Clinical and radiographic abnormalities in this case of pulmonary metastatic disease resembled some of those associated with interstitial pneumonia. Rarely encountered in domestic animal species, there has been only 1 previous report of HO in a case of oronasal carcinoma in a horse.
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Affiliation(s)
- Kile S Townsend
- Veterinary Medicine and Surgery, University of Missouri, 900 East Campus Drive, Columbia, Missouri 65211, USA (Townsend, Johnson); Veterinary Pathobiology, University of Missouri, 1600 East Rollins, Columbia, Missouri 65211, USA (Kuroki)
| | - Philip J Johnson
- Veterinary Medicine and Surgery, University of Missouri, 900 East Campus Drive, Columbia, Missouri 65211, USA (Townsend, Johnson); Veterinary Pathobiology, University of Missouri, 1600 East Rollins, Columbia, Missouri 65211, USA (Kuroki)
| | - Keiichi Kuroki
- Veterinary Medicine and Surgery, University of Missouri, 900 East Campus Drive, Columbia, Missouri 65211, USA (Townsend, Johnson); Veterinary Pathobiology, University of Missouri, 1600 East Rollins, Columbia, Missouri 65211, USA (Kuroki)
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Sharma JR, Agraval H, Yadav UCS. Cigarette smoke induces epithelial-to-mesenchymal transition, stemness, and metastasis in lung adenocarcinoma cells via upregulated RUNX-2/galectin-3 pathway. Life Sci 2023; 318:121480. [PMID: 36775116 DOI: 10.1016/j.lfs.2023.121480] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/31/2023] [Accepted: 02/05/2023] [Indexed: 02/12/2023]
Abstract
AIMS An elevated level of galectin-3, a carbohydrate-binding lectin implicated in tumorigenesis, metastasis, and epithelial-mesenchymal transition (EMT), has been found in cigarette smokers. However, the regulation of its expression and role in the pathogenesis of CS-induced EMT and lung cancer metastasis is unclear. Here, we have investigated the mechanism of CS-induced and galectin-3-mediated EMT in airway epithelial cells (AECs). MAIN METHODS A549 adenocarcinoma cells and primary small airway epithelial cells cultured on an air-liquid interface (ALI) were exposed to cigarette smoke extract (CSE), and MTT, trypan blue, migration, invasion, tumor spheroid and colony formation assays were performed to assess EMT phenotype. Immunoblotting was performed to assess EMT and stemness markers and other regulatory proteins. KEY FINDINGS CSE exposure affected cell survival and morphology, migration, invasion, and clonogenicity of AECs, which were concomitant with an increase in the expression of EMT markers, galectin-3, and runt-related transcription factor-2 (RUNX-2), an osteogenic transcription factor and upstream regulator of galectin-3. Chemical inhibition or silencing of RUNX-2 downregulated galectin-3 and modulated EMT marker expression, migration, invasion, and clonogenicity in CSE-exposed AECs. Recombinant human galectin-3 also induced EMT and stemness-associated changes in the AECs, and GB1107, a galectin-3 inhibitor, ameliorated these changes. Further, CSE-induced intracellular ROS enabled an increase in RUNX-2 and galectin-3 expression, which were reversed by n-acetyl-cysteine. SIGNIFICANCE These results provide a novel mechanistic insight into CSE-induced EMT via RUNX-2/galectin-3 axis mediated through ROS, which promoted EMT-associated changes, including invasion, migration, and stemness in AECs, which could be implicated in CS-induced lung cancer progression.
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Affiliation(s)
- Jiten R Sharma
- School of Life Sciences, Central University of Gujarat, Gandhinagar, Gujarat 382030, India
| | - Hina Agraval
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Umesh C S Yadav
- Special Center for Molecular Medicine, Jawaharlal Nehru University, New Delhi 110067, India.
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Hong P, Lee JS, Lee KS. Pulmonary Heterotopic Ossification Simulating a Pulmonary Hamartoma: Imaging and Pathologic Findings and Differential Diagnosis. Korean J Radiol 2022; 23:688-690. [PMID: 35617995 PMCID: PMC9174498 DOI: 10.3348/kjr.2022.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/04/2022] [Accepted: 04/10/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Pa Hong
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine (SKKU-SOM), Changwon, Korea
| | - Jae Seok Lee
- Department of Pathology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine (SKKU-SOM), Changwon, Korea
| | - Kyung Soo Lee
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine (SKKU-SOM), Changwon, Korea.
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Focally Ossified Minimally Invasive Adenocarcinoma of the Lung Coexisting With Occult Pulmonary Metastases From Thyroid Cancer. J Thorac Imaging 2020; 35:W119-W122. [PMID: 32804878 DOI: 10.1097/rti.0000000000000551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alghamdi M, Mathew T, Breaux A, Chopra H. Goblet Cell Adenocarcinoma With Heterotopic Ossification: A Rare Case Report and Review of Literature. Cureus 2020; 12:e8312. [PMID: 32607295 PMCID: PMC7320657 DOI: 10.7759/cureus.8312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Heterotopic bone formation is a rare phenomenon when associated with gastrointestinal neoplasms. Here we present a rare case of heterotopic ossification associated with goblet cell adenocarcinoma of the appendix, and a literature review of such cases associated with neoplasms within and out of the gastrointestinal tracts. We reviewed the clinical data and when available, immunohistochemical markers of osteoblastic differentiation. Our review shows similar findings to prior reports of apparent high association of heterotopic bone formation with neoplasms with mucinous features. Two, previously proposed main hypotheses of the mechanisms are reviewed. The unique feature about this case is that goblet cell adenocarcinoma was not reported previously in the setting of bone formation.
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Affiliation(s)
- Mohammed Alghamdi
- Pathology, University of Louisville School of Medicine, Louisville, USA
| | - Tiffani Mathew
- Pathology and Laboratory Medicine, University of Louisville, Louisville, USA
| | - Andrea Breaux
- Pathology and Laboratory Medicine, University of Louisville, Louisville, USA
| | - Harpreet Chopra
- Pathology and Laboratory Medicine, University of Louisville, Louisville, USA
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Özşen M, Yalçınkaya U, Akyıldız EÜ, Bayram AS, Gökalp G. Bronchial Carcinoid Tumors with Massive Osseous Metaplasia: A Case Report and Review of the Literature. Turk Patoloji Derg 2020; 36:159-163. [PMID: 30977863 PMCID: PMC10511252 DOI: 10.5146/tjpath.2018.01457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/10/2019] [Indexed: 11/18/2022] Open
Abstract
Bronchial carcinoid tumors are primary lung neoplasms thought to originate from neuroendocrine cells, i.e. Kulchitsky cells, in the bronchial mucosa, although the type of cellular origin has not been clearly understood. A 61-year-old male patient underwent surgery and microscopic examination of the specimen revealed an anastomosing trabecular bony structure among the nests of tumor cells with round nucleus, granular chromatin, and large eosinophilic cytoplasm. Our case has been deemed worthy of being presented as bronchial carcinoid tumor with exaggerated osseous metaplasia.
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Affiliation(s)
- Mine Özşen
- Department of Pathology, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Ulviye Yalçınkaya
- Department of Surgical Pathology, Uludag University, Faculty of Medicine, Bursa, Turkey
| | - Elif Ülker Akyıldız
- Department of Surgical Pathology, Uludag University, Faculty of Medicine, Bursa, Turkey
| | - Ahmet Sami Bayram
- Department of Thorax Surgery, Uludag University, Faculty of Medicine, Bursa, Turkey
| | - Gökhan Gökalp
- Department of Radiology, Uludag University, Faculty of Medicine, Bursa, Turkey
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Lau AG, Kindig MW, Salzar RS, Kent RW. Micromechanical modeling of calcifying human costal cartilage using the generalized method of cells. Acta Biomater 2015; 18:226-35. [PMID: 25712387 DOI: 10.1016/j.actbio.2015.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 02/10/2015] [Accepted: 02/13/2015] [Indexed: 10/24/2022]
Abstract
Various tissues in the human body, including cartilage, are known to calcify with aging. There currently is no material model that accounts for the calcification in the costal cartilage, which could affect the overall structural response of the rib cage, and thus change the mechanisms and resistance to injury. The goal of this study is to investigate, through the development of a calcifying cartilage model, whether the calcification morphologies present in the costal cartilage change its effective material properties. A calcified cartilage material model was developed using the morphologies of calcifications obtained from microCT and the relaxed elastic modulus of the human costal cartilage obtained from indentation testing. The homogenized model of calcifying cartilage found that calcifications alter the effective material behavior of the cartilage, and this effect is highly dependent on the microstructural connectivity of the calcification. Calcifications which are not contiguous with the rib bone and constitute 0-18% of the cartilage volume increase the effective elastic modulus from its baseline value of 5MPa to up to 8MPa. Calcifications which are attached to the rib bone, which typically constitute 18-25% of the cartilage volume, result in effective moduli of 20-66MPa, depending on the microstructure, and introduce marked anisotropy into the material. The calcifying cartilage model developed in this study can be incorporated into biomechanical models of the aging thorax to better understand how calcifications in the aging thorax affect the structural response of the rib cage.
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Selected case from the Arkadi M. Rywlin international pathology slide series: diffuse dendriform pulmonary ossification: report of 2 cases with review of the literature. Adv Anat Pathol 2015; 22:59-68. [PMID: 25461781 DOI: 10.1097/pap.0000000000000051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Two cases of diffuse dendriform pulmonary ossification (DPO) are presented, one of the secondary type and the other of the idiopathic type. Case 1 was an adult female patient who underwent thoracic surgery to remove a posterior mediastinal bronchogenic cyst, which was discovered on a computed tomography scan performed after an episode of pneumonia when traction bronchiectasis with interstitial lung disease/fibrosis was also suspected in the lungs. Histologic examination performed on the resected lung tissue revealed numerous scattered small osseous spicules on a background of intense interstitial inflammation and fibrosis, leading to further clinical and laboratory investigations and the final diagnosis of DPO secondary to lung involvement by scleroderma. Case 2 was an adult male patient who underwent thoracoscopic exploration after a computed tomography scan, which revealed traction bronchiectasis with linear thickening of the interstitial lung tissue. Histologic examination of the lung tissue specimen revealed numerous osseous spicules in the absence of interstitial septal inflammation. Noteworthy in this case were also some nodules of collagenized tissue similar to those seen in the lungs of patients affected by Ehlers-Danlos syndrome. The absence of any clinical sign or symptoms related to Ehlers-Danlos syndrome attest to the nonspecificity of these pulmonary fibrous nodules. No case of DPO secondary to scleroderma has been reported in the literature so far, although around half of the patients with scleroderma manifest pulmonary diseases. Idiopathic DPO is even rarer, usually discovered postmortem, with only 20 cases diagnosed in life with lung biopsies taken by open surgery or through a thoracoscopic approach. DPO is often misdiagnosed radiologically as bronchiectasis and/or interstitial lung disease/fibrosis.
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Zhang Q, Yin L, Li B, Meng R, Dao R, Hu S, Qiu X. Pulmonary adenocarcinoma with osseous metaplasia: a rare occurrence possibly associated with early stage? Onco Targets Ther 2013; 6:1631-4. [PMID: 24250229 PMCID: PMC3829678 DOI: 10.2147/ott.s48195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Adenocarcinoma is the most common type of malignant pulmonary tumor, but osseous metaplasia of this tumor is extremely rare. To date, only 21 cases have been reported in the literature worldwide. Here, we report a case of primary pulmonary adenocarcinoma with benign osseous stromal metaplasia in a 60-year-old woman and discuss the pathogenesis of intratumoral ossification and review the relevant literature. We found that pulmonary adenocarcinoma with osseous metaplasia may be more likely to occur in early tumor stages.
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Affiliation(s)
- Qingfu Zhang
- Department of Pathology, The First Affiliated Hospital and College of Basic Medical Sciences, China Medical University, Shenyang, People's Republic of China
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Statistical quality control of total ash, acid-insoluble ash, loss on drying, and hazardous heavy metals contained in the component medicinal herbs of "Ssanghwatang", a widely used oriental formula in Korea. J Nat Med 2012; 67:27-35. [PMID: 22418854 DOI: 10.1007/s11418-012-0640-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 01/29/2012] [Indexed: 10/28/2022]
Abstract
To investigate the current quality control status of raw materials in "Ssanghwatang", a widely used oriental formula effective for fatigue recovery in Korea, 1024 samples of 9 herbs available in Seoul area markets were collected, and the contents of quality inspection items such as total ash, acid-insoluble ash, loss on drying, and hazardous heavy metals (Pb, As, Cd, Hg) were examined. Medicinal herbs requiring quality control, which may not meet the specifications and standards set by the Korea Food and Drug Administration, were selected using robust z-scores, a random variable. Among the quality control items, control of total ash content was required for the Ssanghwatang raw materials Cinnamomi Cortex, Rehmanniae Radix Preparata, Zingiberis Rhizoma, and Zizyphi Fructus; loss on drying for Cinnamomi Cortex; and heavy metal (Cd) for Angelicae Gigantis Radix, Cinnamomi Cortex, and Zingiberis Rhizoma. Additionally, acid-insoluble ash content revealed how many fine soil and sand particles are present in commercial medicinal herbs, which were correlated with heavy metals such as Pb (r = 0.528) and As (r = 0.342) in Rehmanniae Radix Preparata (p < 0.01).
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