A surgical case of pulmonary adenocarcinoma complicated with pulmonary infarction presenting as an intrapulmonary metastasis

Pulmonary adenocarcinoma complicated with a pulmonary infarction presenting as an intrapulmonary metastasis is relatively rare. We present a case of pulmonary infarction manifesting as intrapulmonary metastases of lung cancer. A previously healthy 59-year-old woman was admitted to our hospital on May 16, 2002 for evaluation of multiple abnormal radiographic shadows in the right lower lung field. Laboratory tests showed no abnormalities except for a slight elevation of carcinoembryonic antigens. Computed tomography of the chest revealed a hilar mass lesion with parenchymal lesions in the periphery of the right lower lobe, highly suspected to be a pulmonary adenocarcinoma with intrapulmonary metastases. A diagnosis of pulmonary adenocarcinoma was confirmed by a transbronchial brushing examination. A right middle and lower bilobectomy with mediastinal lymph node dissection was needed by hilum lymphadenopathy and a lower lobe invasion of the main tumor. Histopathological findings of the resected specimens revealed poorly differentiated adenocarcinoma of the lung with N1 (#11i) disease and multiple pulmonary infarctions with coagulation necrosis and recanalization. Pulmonary infarctions are demonstrated on chest x-rays as round or polygonal in shape, and located at the periphery of the same lobe as the primary tumor. Computed tomography is more sensitive than conventional radiography in the detection of pulmonary infarction. Our case suggests that pulmonary infarction associated with lung cancer should be considered as one important cause of peripheral pulmonary nodules.

Endoscopic in vivo evaluation of tissue atypia in the esophagus using a newly designed integrated endocytoscope: a pilot trial

BACKGROUND AND STUDY AIMS

A newly designed magnifying endoscope featuring an endocytoscopy function provided by ultrahigh magnification was evaluated in a pilot study in patients with various types of benign and malignant pathology in the esophagus.

PATIENTS AND METHODS

Seventy-five consecutive patients were included in the study from 15 March to 21 December 2005. Twenty-nine patients with specific esophageal lesions that had been detected by regular or narrow-band imaging, or both, were further evaluated using endocytoscopy, followed by tissue biopsy or resection. During the endocytoscopic examinations, the esophageal mucosa was stained with 0.5 % methylene blue. The endocytoscopic findings were graded from 1 to 5 in an endocytoscopic atypia (ECA) classification. The final histopathological diagnoses based on biopsies or resected specimens were as follows: category 1 in the Vienna classification, n = 4; category 2, n = 6; category 3, n = 1; category 4, n = 10; and category 5, n = 7. The endocytoscopic diagnoses were compared with the histopathological diagnoses.

RESULTS

Clear endocytoscopic images were obtained in all cases. In definitely malignant lesions, the cell nuclei had an enlarged and irregularly arranged appearance (grade ECA 5). The positive predictive value for malignancy (grades ECA 4 and 5) was 94 %; the false-negative rate was 16.7 %, and the false-positive rate was 6.3 %. The overall accuracy of endocytoscopy for differentiating between nonmalignant tissue (categories 1 - 3 in the Vienna classification) and malignant tissue (categories 4 and 5) was 82 %.

CONCLUSIONS

These preliminary results suggest that incorporating endocytoscopy facilities into a standard endoscope may be helpful in characterizing tissue in a variety of esophageal lesions. The potential clinical impact of this method in relation to other gastrointestinal organs requires further study.

[Completion pneumonectomy 9 years after middle lobectomy for adenocarcinoma]

Completion pneumonectomy (CP) is a difficult operation in which the surgeon must use techniques such as intrapericardial ligation of the pulmonary vessels. We report herein a case of CP for a patient with recurrent lung cancer. A 63-year-old man was admitted to our hospital for evaluation of abnormal shadows in the right lung field in October 2002. Right middle lobectomy with mediastinal lymph node dissection had been performed in February 1993. Computed tomography (CT) revealed a hilar mass in the right upper lobe the day after admission. Bronchofiberscopic cytology revealed squamous cell carcinoma. Right completion pneumonectomy was performed on suspicion of metachronous multiple lung cancers 4 days later. Histopathologically, resected specimens represented adenosquamous carcinoma similar to the prior lesion from the middle lobe, and examination revealed that the tumor represented a recurrence following middle lobectomy. The patient remains well as of 19 months postoperatively.

[Aneurysmal bone cyst arising in the rib; report of a case]

We experienced with a relatively rare case of an aneurysmal bone cyst (ABC) arising in the left rib. A 34-year-old female, had experienced chest discomfort on the left anterior side and pain for 1 year. A chest X-ray suggested a left chest wall tumor involving the ribs. Computed tomography (CT), magnetic resonance imaging (MRI) and a bone scintigram revealed an expansive tumor of the anterior portion of the left 4th rib involving the 3rd and 5th rib with "blow out appearance" and "fluid-fluid level". Wide excision of the tumor and adjacent muscle tissue was performed with an antero-axillary incision. Chest wall reconstruction was performed with prolene mesh (140 x 90 mm). The resected specimen showed an encapsulated bony mass (75 x 60 x 35 mm) with multiple blood-filled spaces. Histopathological diagnosis was an ABC originating in the left 4th rib. She has been doing well with no evidence of recurrence 12 months postoperatively.

[Esophageal gastrointestinal stromal tumor surrounding the middle esophagus with dysphagia for 8 years; report of a case]

In September 2002, a 24-year-old woman complaining dysphagia with an abnormal shadow in a chest X-ray was admitted to our hospital. Endoscopic ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) showed a hypo-echoic, low-density mass surrounding the middle esophagus. Bronchofiberscopy and gastrofiberscopy showed compression from the outside of bronchus and esophagus. No ulcer formation was found. Transbronchial aspiration biopsy and esophageal biopsy showed no malignancy. After 14 cm thoractomy, extirpation of the tumor was performed. The solid tumor was 10.5 x 3.0 x 2.5 cm in dimension, and the cut surface of the tumor was light yellow. Immunohistochemically, the tumor cells were positive for c-kit, SMA, CD34, and S-100. Histopathologically, the tumor was diagnosed as gastrointestinal stromal tumor (GIST), combined smooth muscle-neural type. A postoperative upper gastrointestinal tract barium study showed no stenosis. She is doing well without evidence of tumor recurrence at 12 months postoperatively. Although GIST is the most common mensenchymal tumor of the human gastrointestinal tract, this case is reported because the GIST arising from the middle esophagus is very rare.

Squamous reepithelialization after circumferential endoscopic mucosal resection of superficial carcinoma arising in Barrett's esophagus

Recent reports on the results of endoscopic ablation of Barrett's mucosa have been promising, particularly when total mucosal ablation is coupled with aggressive acid-suppression treatment using high-dose proton-pump inhibitor therapy. There is also a considerable literature on reepithelialization after ablative treatments in Barrett's esophagus. This report describes a case of multifocal superficial adenocarcinoma arising in Barrett's mucosa that was successfully treated with total circumferential endoscopic mucosal resection, with a subsequent follow-up of more than 2 years. This is the first report describing the process of squamous reepithelialization after endoscopic mucosal resection in Barrett's esophagus.

Virtual histology of colorectal lesions using laser-scanning confocal microscopy

BACKGROUND AND STUDY AIMS

Histological examination of gastrointestinal lesions is currently based on light-microscopic examination of thin-slice specimens, with hematoxylin and eosin staining. A study of the use of laser-scanning confocal microscopy (LCM) to obtain immediate microscopic images of untreated specimens for examining colorectal lesions was carried out. A probe-type LCM prototype endomicroscope that can be passed through the working channel of an endoscope has also been developed.

MATERIALS AND METHODS

The study materials consisted of colorectal lesions resected either endoscopically or surgically at Showa University Northern Yokohama Hospital. One hundred untreated specimens were examined using LCM. The histopathological findings in the lesions were seven cases of normal colonic mucosa, five hyperplastic polyps, 68 adenomas with low-grade dysplasia, 10 adenomas with high-grade dysplasia, and 10 adenocarcinomas. An argon laser beam with a wavelength of 488 nm was used for the LCM study. Observation of the resected normal colonic mucosa (in vitro) and the rectal mucosa of a healthy volunteer (in vivo) was possible using the endomicroscope. The LCM images for each specimen were compared with the hematoxylin-eosin-stained histopathological cross-sections.

RESULTS

The LCM images corresponded well with the conventional hematoxylin-eosin light-microscopic images. The nuclei were not visualized in normal mucosa or hyperplastic polyps. In adenomas with high-grade dysplasia and carcinomas, nuclei were more often visible than in adenomas with low-grade dysplasia. The rate of visualization of nuclei was significantly different ( P < 0.01) between these two groups (60.0 % vs. 10.3 %). In LCM images using endomicroscope, it was possible to recognize the orifices of the colonic glands and goblet cells both in vitro and in vivo.

CONCLUSIONS

Laser-scanning confocal microscopy provides immediate images that correspond well with those of hematoxylin-eosin staining. An improved probe-type LCM endomicroscope is being developed which should provide better histological images of colorectal lesions in vivo.

Development of virtual histology and virtual biopsy using laser-scanning confocal microscopy

The aim of this project is to acquire a direct image of histology from in vivo gastrointestinal mucosa. In other words, the task of 'endo-microscope' is to observe the cellular architecture of tissue in vivo during routine endoscopic examination. As the first step to completing this study, resected fresh specimens from the oesophagus. stomach and colon were examined by laser-scanning confocal microscopy (LCM) (Fluoview, Olympus, Tokyo). Fresh untreated mucosal specimens obtained by endoscopic pinch biopsy, polypectomy or endoscopic mucosal resection were collected and placed in normal saline and examined by LCM, collecting the reflective light of a 488-nm wavelength argon laser beam. As the second step, a probe-type LCM 'endo-microscope' was designed and applied to observe the human oral-cavity mucosa. The probe has 4.5-mm outer diameter and 20-cm length, which enables easy access to oral cavity mucosa. The estimated special resolution of the probe is 1-5 microm. A real-time microscopic image directly from ex vivo fresh specimens was acquired. The acquired LCM images corresponded well with the conventional H-E light microscopic images. Cell wall, nucleus and cytoplasm were simultaneously visualized by LCM scanning. This novel method enables serial imaginary microscopic sections on fresh specimens. In addition, a probe-type LCM 'endo-microscope' was designed and was applied to observe human oral cavity mucosa. Virtual histological images from the living oral squamous cell were successfully obtained. LCM images from ex vivo fresh specimens demonstrated the features of the H-E staining histological image. In the next step to accomplish our project, we developed a LCM probe with 4.5-mm outer diameter to obtain a virtual image of human oral cavity mucosa.

Glycemic control and lens transparency in patients with type 1 diabetes mellitus

PURPOSE

To assess quantitatively the cumulative effect of hyperglycemia on lens transparency in patients with juvenile type 1 diabetes mellitus.

METHODS

Subjects were 30 patients (30 eyes) with type 1 diabetes mellitus who had well-documented records on the duration of diabetes mellitus and condition of glycemic control from the onset. They were 35 years of age or younger (mean, 26.0 years), had a history of type 1 diabetes mellitus at least 5 years (mean, 8.4 years), had corrected visual acuity of 20/20 or better, and showed no clinically apparent cataract on slit-lamp examination. Twenty-one eyes of 21 subjects served as age-matched normal controls. They were 35 years of age or younger (mean, 25.7 years), had no diabetes mellitus, had corrected visual acuity of 20/20 or better, and showed no signs of cataract on slit-lamp examination. The degree of lens opacity was quantified using the anterior eye segment analysis system based on the Scheimpflug principle. An index was created to represent the cumulative effect of long-term glycemic control (hyperglycemic accumulation) by multiplying the average hemoglobin A(1c) value and the number of months from the onset.

RESULTS

The patients with diabetes mellitus exhibited significantly greater degree of lens opacity than the normal controls (P =.017, Mann-Whitney U-test). Among the patients with diabetes mellitus, the lens opacity was greater in eyes with retinopathy than those without retinopathy (P =.011). Multiple regression analysis revealed that only the index of hyperglycemic accumulation significantly correlated with the degree of lens opacity (P =.042).

CONCLUSION

Accumulated effect of hyperglycemia is related to the lens transparency in patients with diabetes.

[A case of the old injured vena cava superior found during the operation of lung cancer]

We operated a 78-year-old male with lung cancer and unstable angina pectoris. During the operation of right upper lobe, a mass, with size of 2 cm in diameter was detected on the right postero-lateral side of the superior vena cava, and was resected. Postoperative pathological examination suggested that the mass resulted from an injury made by a Swan-Ganz catheter used before operation. Thus, as insertion of a Swan-Ganz catheter through the right subclavian vein may involve risk, so we concluded that the right internal jugular vein or femoral vein may be preferable as a route of first choice for insertion.

Morphological classification of atrial muscle in the atrioventricular junctional area--3-dimensional reconstruction of serial sections of the human heart

To trace anatomical structures that might be associated with the dual atrioventricular (AV) nodal pathway and to investigate the morphologic characteristics of the cells that form these pathways, we examined serial sections of the AV junctional area with a light microscope and reconstructed them 3-dimensionally with a computer. Twelve hearts were obtained at autopsy from patients who had not shown AV conduction disturbances or supraventricular tachycardia before death. The method of Lev et al was used to prepare serial sections. Fascicles of atrial muscle contiguous with the AV node were examined with a light microscope and were classified into 3 groups, on the basis of morphologic characteristics and myocyte diameter. A computer was used to reconstruct 3-dimensionally the course of the fascicles and surrounding structures. At the border of the AV node and bundle of His relatively large myocytes extended directly into the AV bundle from the anterosuperior interatrial septum. Morphologically, the course was considered to be consistent with the fast pathway. In contrast, small cells that entered the AV node from the inferoposterior interatrial septum resembled sinus node cells with few myofibrils and a winding shape. These cells extended from the coronary sinus ostium to the tricuspid valve annulus and are thought to make up the slow pathway.

[An experience of right pneumonectomy in the elderly (aged 82) lung cancer]

Lung cancer in the elderly (over 80 years or over the average life) isn't generally performed surgical treatment, but we performed right pneumonectomy to aged 82 who had taken a right upper lobe's primary squamous cell lung carcinoma. He recovered well. Especially in general pneumonectomy should be avoided to over aged 80 because of the high death rate compare with other operative way (Lobectomy, Segmentectomy, Wedge resection etc.). But we think the operative indication should be determined synthetically (good performance status, not so progressive clinical staging, no existing another disease, etc.). We perform pneumonectomy in the elderly if patient's performance status is 0 or 1, and clinical staging is I or II, and the other laboratory data is good. But most important, we should explain exact information of the disease and perform surgical treatment in case it's received. We should take into consideration reduction surgery for prevention of complication without persisting in standard way of operation.

[CT findings of primary retroperitoneal cystic tumors: special emphasis on the distinction benignancy from malignancy]

We describe the CT findings of primary retroperitoneal cystic tumors in 20 patients (cystic lymphangioma, 9; cystic teratoma, 3; cystic neurinoma, 4; mucinous cystadenocarcinoma, 3; synovial sarcoma, 1). CT findings were retrospectively reviewed and the findings correlated with the pathological findings to determine malignant or benign cystic tumors. Definite criteria for malignancy were invasion to surrounding organ and the presence of distant metastasis. However, the sensitivity of these criteria was very low (25%). Enhancement of an intracystic solid component was a reliable criterion (p < 0.05) for malignancy (sensitivity 75%, specificity 81%, accuracy 80%). Either unilocular cystic appearance or the presence of a "neck" (between the cystic mass and paraaortic region) strongly suggested the possibility of benignancy (specificity 100%). The "neck" was thought to be morphologically specific for cystic lymphangioma.

Effects of acidic fibroblast growth factor on neuronal activity of the parvocellular part in rat paraventricular nucleus

The effects of acidic fibroblast growth factor (aFGF) and its amino-terminal and carboxyl-terminal fragments (aFGF(1-15) and aFGF(114-140), respectively were examined on the neuronal activity in the parvocellular part of the paraventricular nucleus. As well known, this part contains a lot of corticotropin-releasing factor (CRF)-immunoreactive neurons. Application of 1 pg/ml and 2 pg/ml aFGF produced responses in 29.7% and 46.7% of neurons tested, respectively. Half or more than half of the responding neurons increased their discharge rate. Application of 0.2 ng/ml and 0.4 ng/ml aFGF(1-15) (1-15) also elicited response in 46.2% and 68.8% of neurons tested, respectively. Of these responding neurons, more than two third increased their firing rate. However, most of neurons tested for 0.67 ng/ml and 1.33 ng/ml aFGF(114-140) did not respond. Results suggest that aFGF and aFGF(1-15) promote the release of CRF through the activation of CRF-containing neurons.

Cardiac sympathetic innervation in patients with dilated cardiomyopathy--immunohistochemical study using anti-tyrosine hydroxylase antibody

Depletion of norepinephrine in the left ventricular myocardium in cases of dilated cardiomyopathy (DCM) has been suggested. However, there have been few histological studies of the sympathetic nerves, in which myocardial norepinephrine is believed to exist. We performed an immunohistological study of the density of tyrosine hydroxylase (TH, a marker of sympathetic nerves)-positive nerve fiber in endomyocardial biopsy specimens in cases of DCM using antibody against TH. TH-positive nerves were stained brown along with the myocardium, and they were more dense in the right ventricle than in the left ventricle in both the DCM and control groups. The density of TH-positive nerves in cases of DCM was significantly less than that in the control group in the subendocardial myocardium of the right and left ventricles, but especially in the left ventricle. A correlation was observed in the DCM group between the density of TH-positive nerves and the ejection fraction in the right ventricle, but not in the left ventricle. In the failing human heart, a decrease in subendocardial sympathetic nerve density may be one of the causes of myocardial norepinephrine depletion.

Nucleolar organizer regions and PCNA expression in prostatic cancers

Argyrophilic nucleolar organizer regions (AgNOR) of 79 prostatic adenocarcinomas, and an immunohistochemical stain using a monoclonal antibody against proliferating cell nuclear antigen (PCNA) of 54 prostatic adenocarcinomas, obtained by needle biopsy and transurethral resection of the prostate between 1986 and 1989, were investigated. A morphological classification was devised to count silver dots based on the relations between intra- and extra-nucleolar AgNOR (type A, B, C and D). Total AgNOR counts were significantly higher in carcinoma (4.2 +/- 1.57) than in the benign prostatic lesions (1.90 +/- 0.24). Count differences of AgNOR were evident in histological differentiation, nuclear anaplasia, and presence of nucleoli, mitosis, lymphatic invasion and vascular invasion. Higher total AgNOR counts were almost always associated with type B and C AgNOR (intranucleolar AgNOR), but were not associated with type A (nucleolus without small dot) nor type D (extra-nucleolar AgNOR). This study shows the diagnostic value of AgNOR in prostatic cancer, and the importance of morphological classification of AgNOR. The survival of patients with higher AgNOR counts (> or = 4.3) was significantly poorer than survival of those with lower AgNOR counts (< 4.3). Significantly more PCNA positive cells were identified in cancer by immunohistochemical stain and correlated with the presence of mitosis, but there was no significant difference in survival rate groups classified by PCNA positivity. It is also suggested that PCNA can be a useful marker of cell proliferation in prostatic lesions, but the AgNOR counts were diagnostically and prognostically more valuable than immunohistochemical PCNA in prostatic lesions. The correlation between AgNOR and PCNA immunoreactivity was not significant.

Lymphatic subpopulations and their transition in myocardial tissue and peripheral blood of patients with biopsy-proven myocarditis

To determine abnormal immune regulation in biopsy-proven active and healed myocarditis cases, lymphatic subpopulations in myocardial tissue and peripheral blood were studied. Among 53 cases examined, 19 were active myocarditis (M) and 34 were healing or healed (HM). Five cases of myocarditis were studied sequentially. The percentages of pan T-cells, B-cells, helper/inducer T-cells (Th/i), suppressor/cytotoxic T-cells (Ts/c), etc per total marker positive cells were calculated by use of monoclonal antibodies. In myocardial tissue, the percentage of Th/i was significantly lower in HM than M (p less than 0.01). The helper/suppressor ratio (OKT4/8) in peripheral blood was 2.43 +/- 0.43 (mean +/- SE) in M, 1.61 +/- 0.19 in HM and 1.34 +/- 0.12 in age-matched controls. In 5 progressive studied cases of M, there was a decrease of the helper/suppressor ratio at 1 to 6 months after the myocarditis. It was concluded that subsidence of the immune reaction in myocardium is related to the healing process of myocarditis and may suggest improved prognosis.

[Histopathological studies of the osteophytes and ossification of the posterior longitudinal ligament (OPLL) in the cervical spine]

To obtain information on ossification around the vertebral body of the cervical spine, we carried out histopathological investigation on 30 autopsy cases. The results were as follows; Intervertebral discs were untouched, anterior osteophytes developed along the anterior longitudinal ligament and they corresponded to anterior spur in spondylosis deformans. Posterior osteophytes around the posterior edges of vertebral body resulted in intervertebral insufficiency, and corresponded to hypertrophic spur in osteochondrosis. Histopathological findings of hyperostotic anterior osteophytes were similar to anterior osteophytes, but in the former there were advanced osteophyte formations. In OPLL of the segmental type, intervertebral discs were degenerated, and ossified mass did not involve the posterior longitudinal ligament of the parts of discs. With regard to morphological appearance and the tendency of increasing ossification, OPLL of the continuous type was similar to hyperostotic anterior osteophytes, without involvement of intervertebral disc. OPLL of the distinctly continuous type was differentiated from that of the segmental type.