Sofosbuvir/Velpatasvir Plus Ribavirin Combination Therapy for Patients with Hepatitis C Virus Genotype 1a, 2a, or 3b after Glecaprevir/Pibrentasvir Therapy Failed

Glecaprevir/pibrentasvir (GLE/PIB) is a pan-genotype anti-hepatitis C virus (HCV) therapy with high efficacy and safety. However, evidence supporting retreatment following failure of the GLE/PIB regimen is limited. We herein report 3 non-cirrhotic cases involving two men aged 51 and 58 years old and a woman aged 68 years old infected with HCV genotype 1a, 2a, and 3b respectively who failed anti-HCV therapies including GLE/PIB therapy. With combination therapy of sofosbuvir/velpatasvir plus ribavirin (SOF/VEL+RBV) for 24 weeks, all 3 patients had achieved a sustained viral response (SVR) at 24 weeks after completing treatment. SOF/VEL+RBV therapy was effective for retreatment of HCV after failure of GLE/PIB therapy.

Primary Mediastinal Germ Cell Tumor in a Middle-Aged Woman: Case Report and Literature Review

Although primary mediastinal germ cell tumors are found much more frequently among young males than among other people, we recently encountered a middle-aged woman with the disease. The patient was a 59-year-old woman who complained mainly of anterior chest pain. Chest CT scans revealed a nonhomogeneous mass measuring 7 x 7 cm in the anterior mediastinal area, accompanied by signs suggestive of mediastinal invasion of the tumor. Reduction surgery was performed. The pathologic diagnosis was mediastinal dysgerminoma. The patient received postoperative radiochemotherapy but died due to liver metastasis 11 months after surgery.

[A Case of HER2-Positive Breast Cancer Treated with Nipple-Sparing Mastectomywith Immediate Reconstruction Using a Tissue Expander after Nab-Paclitaxel Combined with Chemotherapy]

A 59-year-old woman presented to our hospital with a mass in her left breast. Mammography and ultrasound showed a 9 ×11×12mm mass in her left breast, and left axillary lymph adenopathy. Core needle biopsy and pathological examination confirmed the diagnosis of ER-negative, PgR-negative, HER2-positive invasive ductal carcinoma with axillary lymph metastasis. Dynamic computed tomography(CT)and bone scintigraphy showed no metastasis. A diagnosis ofbreast cancer with stage II A(T1N1M0)was made, and we started neoadjuvant chemotherapy. After 4 cycles of chemotherapy with 5-fluorouracil/ epirubicin/cyclophosphamide in 3-weekly cycles, we administered combination chemotherapy ofnab -paclitaxel and trastuzumab in 3-weekly cycles. After 7 months, the tumor disappeared and the axillary lymph node got significantly smaller. We performed nipple-sparing mastectomy/axillary lymph nodes dissection/tissue-expander placement. The pathological examination ofthe resected tumor confirmed a pathological complete response(pCR). The patient was treated with implant reconstruction and adjuvant therapy. One year has passed after the surgery, and no significant problem has been observed.

Involvement of autoimmunity to REG, a regeneration factor, in patients with primary Sjögren's syndrome

The regenerating gene (Reg) was isolated originally as a gene specifically over-expressed in regenerating pancreatic islets and constitute a growth factor family. Reg gene product (Reg) is important in the pathophysiology of various human inflammatory diseases. Recently, the possible involvement of human REG in the regeneration of salivary ductal epithelial cells of patients with primary Sjögren's syndrome (SS) was reported. However, the expression of the REG family genes in minor salivary glands (MSG) and the occurrence of anti-REG Iα autoantibodies in SS patients were obscured. In this study, we examined the expression of REG family genes in the MSG of SS and screened anti-REG Iα autoantibodies in SS. The mRNA levels of REG family genes in MSG were quantified using real-time reverse transcription-polymerase chain reaction (RT-PCR) and REG Iα expression in the MSG was analysed by immunohistochemistry. The mRNA level of REG Iα in the MSG of SS patients was significantly higher than that of control. REG Iα protein was expressed highly in SS ductal epithelial cells. Anti-REG Iα autoantibodies in the sera were found in 11% of SS. All the MSG in the anti-REG Iα autoantibody-positive group showed REG Iα expression, whereas only 40% showed REG Iα expression in the anti-REG Iα autoantibody-negative group. The anti-REG Iα autoantibody-positive group showed significantly lower saliva secretion and a higher ratio of grade 4 (by Rubin-Holt) in sialography. These data suggest strongly that autoimmunity to REG Iα might play a role in the degeneration of MSG ductal epithelial cells in primary SS.

Invasive growth of hepatic angiomyolipoma; a hitherto unreported ominous histological feature

AIMS

Although histological features of hepatic angiomyolipoma (AML) are highly variable, true malignant change is extremely rare. The aim was to review the histological features of invasive growth and clinical outcomes in 39 cases of hepatic AML.

METHODS AND RESULTS

An invasive growth pattern into surrounding hepatic parenchyma, portal triads and/or around hepatic veins was found in 24 of 39 tumours (62%). One variant showed tumour cells replacing hepatocytes within the liver cell cords. The other consisted of portal or perivascular invasive growth along blood vessels. In the former pattern, small isolated tumour cell clusters were occasionally found in the vicinity of the main mass, showing a sprouting pattern. Although these histological features suggest malignancy, distant metastases were not found in any of the cases within a mean follow-up period of 6.8 years.

CONCLUSIONS

A previously unrecognized histological feature of an invasive growth pattern, which suggests malignancy and might promote an erroneous diagnosis, was frequently found in hepatic AMLs. However, among about 180 reported hepatic AMLs, including the present cases, only one hepatic AML with distant metastasis has been reported to date and nearly all hepatic AMLs behave in a benign fashion. Therefore, pathologists should not overdiagnose malignancy based solely on the histological invasive growth patterns described in this paper.

Intraluminal duodenal diverticulum: MR findings

We report a case of intraluminal duodenal diverticulum with special reference to its magnetic resonance imaging findings. An intraluminal duodenal fluid collection surrounded by a hypointense rim on T2-weighted or magnetic resonance cholangiopancreatographic images, the shape of which is changed by peristalsis, is considered to be almost diagnostic for intraluminal duodenal diverticulum.

Intraoperative lymphatic mapping and sentinel lymph node biopsy in patients with papillary carcinoma of the thyroid gland

We examined the feasibility of sentinel lymph node biopsy for thyroid cancer. Thirty-eight patients with papillary thyroid carcinoma underwent intraoperative lymphatic mapping and sentinel lymph node biopsy. At surgery, we exposed the thyroid gland and used a tuberculin syringe to inject 0.2 ml of 1% patent blue dye directly into the thyroid mass. The lymphatics and the lymph node dyed with blue dyes, was excised as a sentinel lymph node. Modified radical neck dissection was performed following sentinel lymph node biopsy and the diagnostic ability of sentinel lymph node biopsy was examined. A sentinel lymph node was identified successfully in 27 (71%) of 38 patients. Sentinel lymph node biopsy removed one to three lymph nodes (median, two nodes). Eighteen patients had paratracheal sentinel lymph nodes, five patients had jugular sentinel lymph nodes, and four patients had both. Histological nodal metastasis was recognized in 16 of 27 cases. The positive rate of cancer metastases in sentinel lymph nodes was 58%, which was significantly higher than 11% in non-sentinel lymph nodes. Diagnostic ability of sentinel lymph node biopsy showed that accuracy was 89%, sensitivity was 84%, and specificity was 100%. Our preliminary study indicated that sentinel lymph node biopsy was available on detection of non-palpable nodal metastasis in the patients with thyroid cancer; however, further experience and refinement are needed.

Differentiation of soft tissue haemangioma by 201Tl scintigraphy

Radiological diagnosis of deep soft tissue is often difficult. In the present study, thallium-201 ( Tl) uptake into haemangiomas and deep malignant soft tissue tumours was investigated in order to assess its clinical utility. Tl scintigraphy was reviewed in four patients presenting with soft tissue haemangiomas. Early and delayed planar images, obtained at 15 min and 3 h following the intravenous injection of Tl (111 MBq), were examined. The Tl uptake ratio was calculated by dividing the count density of the tumour region of interest (ROI) by that of the background ROI. Results were compared with those of five cases of rhabdomyosarcoma and a single instance of angiosarcoma. All haemangioma lesions demonstrated increased Tl uptake in early images. However, Tl uptake in delayed images was markedly decreased. No significant differences were observed in the early uptake ratio between haemangiomas (1.60-2.72) and reference malignant tumours (1.48-2.45); however, the difference was significant in delayed images (range, 1.01-1.26 vs. 1.43-2.03, respectively) ( P<0.02). Deep soft tissue haemangiomas revealed Tl accumulation in early images; however, a rapid washout was observed in delayed images. This distinctive feature may facilitate the use of Tl scintigraphy in the diagnosis of haemangiomas.

Mapping sentinel nodes in patients with early-stage gastric carcinoma

BACKGROUND

Nodal status in gastric carcinoma is related not only to prognosis but also to the extent of nodal dissection. However, a method for accurate assessment of nodal status during operation has not been established. This study aimed to map the sentinel nodes of gastric carcinoma and to estimate the clinical usefulness of sentinel node biopsy.

METHODS

Following laparotomy, a vital dye (0.2 ml 2 per cent patent blue) was injected through a gastroscope into the submucosal layer at four sites around a clinical T1 gastric carcinoma. The dye immediately appeared at the serosal surface and stained lymphatic vessels and nodes. The stained nodes were removed and examined by frozen sectioning.

RESULTS

The assay was successful in mapping the lymphatic basins in 203 (96.2 per cent) of 211 patients. The dye stained one or more metastatic nodes in 31 patients, but failed to indicate a metastatic node in four patients with a large involved node. Meticulous postoperative examination of all resected nodes in the standard paraffin slices revealed no new metastases. The accuracy of the assay was 98.0 per cent.

CONCLUSION

The method was accurate in predicting nodal status in patients with early-stage gastric carcinoma.

Intense 201 Tl uptake in giant-cell tumour of bone

The aim of this study was to determine the characteristics and clinical usefulness of 201Tl scintigraphy in giant-cell tumour of bone (GCT). Twenty-one patients with histopathologically proven benign GCT (22 lesions; 18 primary and four recurrent) underwent 201Tl scintigraphy. We also studied conventional osteosarcoma (10 lesions), a very common primary malignant bone tumour; and chordoma in the sacrum (four lesions), an entity requiring differential diagnosis from GCT of the sacrum. Early and delayed planar imaging was performed at 15 min (early) and 3 h (delayed) after the intravenous injection of 201Tl chloride (111 MBq). The Tl uptake ratio was calculated by dividing the count density of the tumour region of interest (ROI) by that of the background ROI. All GCT lesions showed increased Tl uptake in both early and delayed images. The mean Tl uptake ratios of primary GCT were 4.7 (range, 2.0-11.1) in the early images and 2.2 (range, 1.4-3.6) in the delayed images, and those of recurrent lesions were 5.8 (range, 2.4-11.5) in the early images and 2.7 (range, 2.0-4.3) in the delayed images. There were no significant differences between the uptake ratios in GCT and osteosarcoma, but the values of GCT tended to be higher than those of osteosarcoma, 3.1 (range, 1.7-4.4) in the early images and 1.8 (range, 1.3-2.3) in the delayed images. Chordoma did not show appreciable Tl uptake: the uptake ratio was 1.19 (range, 0.98-1.5) in the early images and 1.1 (range, 1.0-1.3) in the delayed images. In GCT, a benign lesion, Tl scintigraphy demonstrated marked uptake in both primary and recurrent lesions with no exceptions, precluding the use of Tl scintigraphy for the differential diagnosis of GCT from malignant tumours. However, the Tl scintigraphy can be used for excluding GCT when no lesional Tl uptake is observed, and diagnosing recurrent lesions on post-operative follow-up.

[Treatment for bilateral multiple lung cancers]

During a 27-year period 1,839 patients with lung cancer were treated at Kanazawa University Hospital. Of these 1,839 patients, 25 (1.3%) were classified as bilateral multiple lung cancers by Martini's criteria. They consisted of 14 synchronous carcinomas and 11 metachronous carcinomas. For the patients with synchronous carcinomas, 5 underwent bilateral operation, and 5 underwent ipsilateral operation and contralateral combination therapy (Nd:YAG, irradiation or chemotherapy). Four did not undergo operation. While for the patients with metachronous carcinomas, 9 underwent operation for bilateral lesions, 2 were treated by radiotherapy for the second primary lung cancer. When a pulmonary resection for bilateral multiple lung cancers is required, radicality and the need to preserve residual respiratory function and cardiac function (FEV1.0 more than 500 ml/DSA, performance status) must be considered in making the decision to operation. The 5-year survival rate was 67%, 41%, and 33% in cases treated by operation for bilateral lesions, ipsilateral operation and contralateral combination therapy, and non-surgical therapy. Multidisciplinary treatment based on surgical resection contributed to good prognosis of bilateral multiple lung cancers. A long-term detailed follow-up is necessary to detect second lung carcinoma after the first operation as soon as possible.

Can tumor size be a guide for limited surgical intervention in patients with peripheral non-small cell lung cancer? Assessment from the point of view of nodal micrometastasis

OBJECTIVE

We sought to determine the critical diameter of a peripheral non-small cell lung cancer tumor less than which no evidence of nodal micrometastasis is present.

METHODS

Samples of 3081 lymph nodes from 181 patients with stage I peripheral lung cancer (155 with adenocarcinoma and 26 with squamous cell carcinoma) who had undergone complete resection with systematic lymphadenectomy were used in the study. In the samples immunohistochemical staining for cytokeratin was performed. The expression of vascular endothelial growth factor (VEGF) at primary sites was also immunohistochemically assessed.

RESULTS

Nodal micrometastasis was detected in 44 patients. The mean tumor sizes were 2.2 +/- 1.3 cm (range, 1.0-7.0 cm) in nodal micrometastasis-positive adenocarcinoma, 2.1 +/- 0.9 cm (range, 0.5-6.0 cm) in nodal micrometastasis-negative adenocarcinoma, 4.8 +/- 2.3 cm (range, 2.2-10.0 cm) in nodal micrometastasis-positive squamous cell carcinoma, and 3.2 +/- 2.1 cm (range, 0-9.0 cm) in nodal micrometastasis-negative squamous cell carcinoma. The tumor size in the nodal micrometastasis-positive group tended to be greater than that in the nodal micrometastasis-negative group in squamous cell carcinomas, but there was no significant difference in adenocarcinomas. Nodal micrometastasis was not found in patients with squamous cell carcinoma of 2.0 cm or less in diameter. However, nodal micrometastasis was found in 20% (19/95) of the patients with adenocarcinoma of 1.1 to 2.0 cm in diameter and even in 4 of 11 patients with adenocarcinoma of 1.0 cm or less. Among the patients with nodal micrometastasis, survival of patients with vascular endothelial growth factor overexpression was worse than that of patients without it. The survival of patients with nodal micrometastasis without vascular endothelial growth factor overexpression was comparable with that of patients without nodal micrometastasis.

CONCLUSION

A limited surgical intervention without lymphadenectomy is validated for squamous cell carcinoma of 2.0 cm or less without pleural involvement. In adenocarcinoma the tumor size itself is not a reliable guide for nodal micrometastasis status. In patients with nodal micrometastasis with vascular endothelial growth factor overexpression, the risk of systemic disease should be considered.

Thymic lesions in patients with myasthenia gravis: characterization with thallium 201 scintigraphy

PURPOSE

To assess thallium 201 ((201)Tl) single photon emission computed tomography (SPECT) for evaluation of thymic lesions associated with myasthenia gravis (MG), including lymphoid follicular hyperplasia (LFH) and thymoma.

MATERIALS AND METHODS

(201)Tl SPECT and computed tomography (CT) were performed preoperatively in 46 patients with MG who had undergone thymectomy. SPECT was conducted 15 (early image) and 180 (delayed image) minutes after (201)Tl injection. Results were visually assessed, and (201)Tl uptake ratios (thymic lesion count density/lung count density) were measured for quantitative analysis. Uptake was analyzed among the normal thymus, LFH, and thymoma patient groups.

RESULTS

Histopathologic results indicated a normal thymus, LFH, and thymoma in 19, 16, and 11 patients, respectively. Mean uptake ratios in the normal thymus, LFH, and thymoma were 0.96 (95% CI: 0.90, 1.03), 1.14 (95% CI: 1.04, 1.25), and 1.87 (95% CI: 1.56, 2.25), respectively, on early images and 1.09 (95% CI: 1.00, 1.18), 1.65 (95% CI: 1.48, 1.85), and 2.03 (95% CI: 1.65, 2.50), respectively, on delayed images. Thymoma showed more intense (201)Tl accumulation than did the normal thymus (P <.001) and LFH (P <.001) on early images. Both thymoma (P <.001) and LFH (P <.001) displayed more intense uptake than did the normal thymus on delayed images.

CONCLUSION

(201)Tl SPECT can enable differentiation between normal thymus, LFH, and thymoma in patients with MG.

[Primary small cell carcinoma of the kidney: a case report]

A 43-year-old male visited our hospital with the complaint of right flank colicky pain. Computed tomographic (CT)-scan and angiography showed large renal tumor with liver invasion and tumor thrombosis in the vena cava. Multiple lung and bone tumors were also recognized. Percutaneous biopsy of the renal tumor revealed small cell carcinoma. Multiple lung masses were diagnosed as metastatic tumors according to the results of bronchoscopic biopsy. Chemotherapy including cisplatinum and etoposide was performed without success. He died 6 months after the diagnosis. Autopsy specimen revealed primary small cell carcinoma of the right kidney. To our knowledge, this is the seventh case as primary renal small cell carcinoma in the world literature.

Sentinel lymph node biopsy in breast cancer using blue dye with or without isotope localization

BACKGROUND

The purpose of this study was to determine the feasibility of sentinel lymph node (SLN) biopsy using blue dye with or without isotope localization to predict the presence of axillary and internal mammary lymph node (IMN) metastases in patients with breast cancer. We also investigated whether multiple sectioning of the SLN could improve the accuracy of frozen section examination.

METHOD

One-hundred twenty-six patients underwent dye-guided or dye- and gamma probe-guided SLN biopsy followed by complete axillary lymph node dissection (ALND). No ALND was performed in the 14 patients with small tumors and a negative SLN. In addition, 69 patients underwent IMN biopsy.

RESULTS

The axillary SLN was identified in 123 of 140 (88%) patients. An accuracy rate of 90% was obtained by frozen section examination of the SLN, which increased to 100% in patients examined with a greater number of sections. Lymphatic flow to the IMN and/or a radioactive hot spot in the IMN was found in 9 of 102 (9%) patients, while a hot node was detected using a gamma probe in only 2 of these patients. No involvement of the IMNs was found histologically in these 9 patients. IMN involvement was found in 7 of 61 (11%) patients without lymphatic flow to the IMNs or a hot spot by lymphoscintigraphy or who did not undergo lymphoscintigraphy.

CONCLUSION

ALND can be avoided in patients with small breast cancers and a negative SLN. SLN biopsy guided by lymphatic mapping is unreliable for identifying metastases to IMNs.

Juxtaglomerular cell tumor of the kidney treated with nephron-sparing surgery

A case of juxtaglomerular cell tumor of the right kidney is reported. A 30-year-old woman visited us with a complaint of headaches. Severe hypertension and an elevated level of plasma renin activity was seen at the initial evaluation. Computerized tomographic angiography revealed tumor vessels in the low-density mass in the right kidney. The preoperative diagnosis was renin-secreting tumor of the kidney, and nephron-sparing surgery was performed. The pathological findings showed a juxtaglomerular cell tumor. Postoperatively, prompt normalization of blood pressure and a reduced plasma renin activity level were observed.

Extraskeletal myxoid chondrosarcoma with multiple skeletal metastases

Pulmonary metastases are not unusual in extraskeletal myxoid chondrosarcoma; however, only two patients have been reported with multiple bony metastases. We report here one patient with extraskeletal myxoid chondrosarcoma associated with lung and multiple bony metastases. After chemotherapy, the primary lesion was resected, but lung and multiple bony metastases were found 20 months later. The bony metastases were in the right femur, right humerus, and at multiple vertebral levels. Because of a pathologic fracture of the right femur, the metastases in the right femur and right humerus were surgically stabilized. After chemotherapy, the lung metastases were resected, and those in the vertebral bodies were treated with radiotherapy.

Blockade of eosinophil migration and airway hyperresponsiveness by cPLA2-inhibition

We examined the role of a cytosolic phospholipase A2 (cPLA2) in antigen-induced eosinophil infiltration of airways and in airway hyperresponsiveness to methacholine. Inhibition of cPLA2, or blockade of the platelet-activating factor (PAF) receptor, blocked antigen-induced airway hyperresponsiveness and suppressed eosinophil infiltration. Neither cyclooxygenase nor 5-lipoxygenase inhibition had either effect. We show here that, in antigen-sensitized guinea pigs, cPLA2 inhibition prevents both eosinophilic infiltration and subsequent airway hyperresponsiveness after antigen challenge. We also show that this effect is mediated by first-step hydrolysis of membrane phospholipid into lysophospholipid rather than by prostanoid or leukotriene metabolites of arachidonate.

Immunohistochemical detection of cytokeratin 18 and its neo-epitope in Warthin's tumor (adenolymphoma) of the parotid glands

An immunohistochemical method using a monoclonal antibody M30 (MAb M30), which reacts with the product released by cleavage of cytokeratin 18 (CK18) by activated caspase, was used to investigate the presence and extent of apoptosis in 36 cases of Warthin's tumor (WT) of the parotid glands. The distribution of CK18 in WT was also determined and compared with that of the product detected by MAb M30. In WT, CK18 was observed mainly in the tumor cells of duct-like structures, but not in the cells of lymphatic tissues. Positive MAb M30 reaction products were found in luminal contents, duct-like structures and the cytoplasm of some macrophages in lymphatic areas near the duct-like structures in WT. These findings indicated that apoptotic cells are phagocytosed and eliminated as waste by macrophages. It is suggested that a mechanism which regulates the balance of proliferative activity and apoptosis may be closely linked to the growth of WT.

Surgical management of early stage central (hilar) and peripheral nonsmall cell lung carcinoma

BACKGROUND

To the authors' knowledge, the definitions of early lung carcinoma used in Japan are not yet approved internationally. In the current study the diagnostic methods, pathology, and results of the surgical treatment of early hilar and peripheral nonsmall cell lung carcinoma cases defined by Japanese criteria are presented.

METHODS

Between 1977 and 1998, 43 patients with early hilar lung carcinoma were encountered. These patients constituted 14.5% of 200 hilar lung carcinoma patients who underwent resection during the same period. Between 1973 and 1998, there were 174 early peripheral lung carcinomas, which comprised 14.8% of 1173 peripheral lung carcinoma patients who underwent resection during the same period.

RESULTS

The 5-year and 10-year survival rates of the early hilar lung carcinoma were 100% and 96.9%, respectively. The majority of the patients underwent bronchoplastic surgery, such as sleeve lobectomy and parenchymal-sparing surgery including seven sleeve segmentectomies and two second carinal resections. The effectiveness of the parenchymal-sparing resections was assessed by the conventional pulmonary function test as well as perfusion and ventilation scanning. There were 174 cases of peripheral early lung carcinoma among the 218 cases of peripheral lung carcinoma with tumor dimensions of < or = 2 cm. The cell types were 142 (81.6%) cases of adenocarcinoma, 18 (10.3%) cases of squamous cell carcinoma, and 14 (8%) cases of other cell types. These 174 patients comprised 14.8% of 1173 patients with peripheral nonsmall cell lung carcinoma who underwent surgery during the same period. The 5-year and 10-year survival rates for adenocarcinoma were 89.6% and 86.8%, respectively. The 5-year and 10-year survival rates for other cell types were both 71.8%. The overall 5-year and 10-year survival rates were 86.8% and 84.6%, respectively.

CONCLUSIONS

Early lung carcinoma in both the hilar and peripheral regions, is curable if it is properly diagnosed and treated.

Malignant transformation of a giant cell tumor 25 years after initial treatment

The current authors report a patient in whom a malignant fibrous histiocytoma developed long after a benign giant cell tumor of bone was removed from the same site. Twenty-five years after a benign giant cell tumor of the lateral condyle of the proximal tibia had been treated by curettage and iliac bone grafting without radiotherapy, a 53-year-old woman noted progressive pain and an enlarging mass in the same area. Radiographs showed osteolytic change, whereas magnetic resonance imaging indicated a tumor arising at the site of the giant cell tumor and extending beyond the bone. Examination of an open biopsy specimen showed a high-grade malignant fibrous histiocytoma with some areas rich in giant cells. After five courses of caffeine assisted intraarterial chemotherapy, the tumor was resected with an adequate margin, and the defect was reconstructed with an implanted prosthesis of corresponding shape. The extensor mechanism of the knee was reinforced using an allograft of fascia from the tensor fascia lata muscle. The resected specimen showed a good histologic response (95% tumor necrosis) to preoperative chemotherapy. Excellent function in the knee has been regained with no evidence of disease recurrence. Caffeine potentiated chemotherapy was effective in minimizing the extent of tumor excision, in this case of high-grade malignant fibrous histiocytoma representing transformation from a benign giant cell tumor.

[A case of adenocarcinoma complicated with massive leukocytosis and hypercalcemia]

A 66-year-old man was admitted to our hospital complaining of non-productive cough and low-grade fever. Chest X-ray examination revealed a mass shadow in the right hilum. Transbronchial lung biopsy of the tumor mass yielded a diagnosis of adenocarcinoma. Despite repeated chemotherapy using CDDP and VDS, metastasis to the right adrenal gland and right femur occurred, and was accompanied by hypercalcemia and hypophosphatemia. Serological study revealed elevated levels of PTH-rP and G-CSF. Six months after adenocarcinoma was diagnosed, multiple skin metastases of the cancer were observed. Immunohistochemical staining for PTH-rP and G-CSF indicated that production of cytokines had caused a paraneoplastic syndrome including hypercalcemia and leukocytosis. It appeared that the elevation of G-CSF was induced by IL-6 produced from PTH-rP in cancer tissue. Documentation of similar cases is required.

Breast cancer in dense breast: detection with contrast-enhanced dynamic MR imaging

The purpose of this study was to identify contrast enhancement patterns of dense breast parenchyma and to investigate the ability of dynamic magnetic resonance imaging (MRI) to detect cancer in the dense breast. Thirty-two patients with breast cancer in dense breast underwent gadolinium-enhanced dynamic MRI. The detectability of cancer by dynamic MRI, mammography, and physical examination was compared. Two parenchymal enhancement patterns could be identified. One was increasingly multiple patchy enhancement found predominantly in the periphery (type A), and the other was faint enhancement without any nodular opacification (type B). Type A was thought to reflect severe proliferative fibrocystic change (PFC). For both patterns, the detection rate of primary cancers by dynamic MRI was found to be superior to that by other modalities. Dynamic MRI also could detect multifocal cancers, which could not be found with other modalities, although the detectability of these small cancers might be reduced in patients with severe PFC.

Dye- and gamma probe-guided sentinel lymph node biopsy in breast cancer patients: using patent blue dye and technetium-99m-labeled human serum albumin

BACKGROUND

Sentinel lymph node (SLN) biopsy is a promising method for the diagnosis of the axillary nodal status. We examined the availability of the SLN biopsy using two mapping procedures: the dye- and gamma probe-guided method, and preoperative lymphoscintigraphy by gamma camera imaging.

METHODS

We enrolled 48 patients with breast cancer. Technetium-99m-labeled human serum albumin was injected into the subdermal tissue above the primary tumor or biopsy cavity, and preoperative gamma camera imaging was performed. After induction of general anesthesia, patent blue dye was injected into the peritumoral area prior to the surgical procedure. A handheld gamma-detection probe was used to assist in SLN detection. Careful dissection was performed to identify blue-stained afferent lymphatic vessels and nodes. An SLN was defined as any blue and/or radioactive node, and was excised. After SLN biopsy, axillary lymph node dissection of level I, II, and III was completed, in order to confirm the diagnostic ability of the SLN biopsy.

RESULTS

Intraoperative SLN identification of axillary lesions was successful in 43 of 48 patients (90%). The dye- and gamma probe-guided method was successful in 25 patients (52%), the dye-guided method alone succeeded in 11 patients (23%), and the gamma probe-guided method alone succeeded in 7 patients (15%). Preoperative lymphoscintigraphy revealed axillary focal accumulations in 29 of 48 patients (60%). All patients who underwent successful preoperative SLN identification by lymphoscintigraphy had successful intraoperative SLN identification. A diagnostic accuracy of 95%, a sensitivity of 89%, and a specificity of 100% were achieved in the diagnosis of axillary metastasis. Internal mammary SLNs were identified in four patients intraoperatively, but we could not detect cancer metastasis in the internal mammary SLNs.

CONCLUSIONS

The dye-guided and gamma probe-guided methods were complementary. Preoperative lymphoscintigraphy was useful to predict intraoperative SLN identification. Further study is necessary to assess the role of SLN biopsy of the internal mammary lymph nodes.

Tumor size and extension of lymph node metastases in N2 lung cancer

In all patients with NSCLC, systematic nodal dissection was performed. Since 1981, 218 stage IIIA-N2 cases were resected. We registered 2 operative mortalities. Overall survival was 23% while, in completely resected cases, survival amounted to 30%. For long-term survival, favourable prognostic factors were cN2 T1-2 N2M0, single mediastinal node involvement and a tumor 20 mm or less in maximum size. The 5 yr survival rates of stage IIIA N2 patients was, respectively 48.1% with tumor diameter < 20 mm, 27.7% with diameter between 21-30 mm, 31.2% with diameter between 31-50 mm and, finally, 16.7% with tumors larger than 51 mm. When micrometastases to lymph nodes in p-stage I (stained with H-E) were examined with immunohistochemical staining, 27% (36 patients of 132) showed micrometastases.

Staging efficacy of breast cancer with sentinel lymphadenectomy

Seventy-two patients underwent dye-guided or dye- and gamma probe-guided sentinel lymphadenectomy (SLND) followed by complete axillary lymph node dissection (ALND). The results of imprint cytology, frozen sections, and permanent sections of the sentinel lymph node (SLN) were compared to each other and to the histologic findings in the nonsentinel nodes. The SLN was identified in 62 (88%) of 72 patients. Evaluation of the SLN on the permanent sections yielded a diagnostic accuracy of 95%, a sensitivity of 89%, and a specificity of 100%, although the reliability of SLN diagnosis using frozen sections or imprint cytology is limited. Therefore, it may be concluded that SLND with multiple sectioning and histopathologic examination of the SLNs can predict the presence or absence of axillary-node metastases in patients with breast cancer. However, further studies will be needed to investigate the value of SLND in respect to the long-term regional control and any possible detriment or benefit to survival, before it can replace routine ALND as the preferred staging operation for operable breast cancer.

Correlation between the blood supply and grade of malignancy of hepatocellular nodules associated with liver cirrhosis: evaluation by CT during intraarterial injection of contrast medium

OBJECTIVE

The purpose of this study is to evaluate the correlation between the intranodular blood supply revealed by CT during intraarterial injection of contrast medium, mainly using helical CT, and the grade of malignancy of hepatocellular nodules associated with liver cirrhosis as classified by the International Working Party of the World Congress of Gastroenterology.

SUBJECTS AND METHODS

We studied 201 histologically proven nodules (101 resected and 100 biopsied nodules), including 47 low-grade dysplastic nodules (low-DNs), 56 high-grade dysplastic nodules (high-DNs), 24 well-differentiated hepatocellular carcinomas (wd-HCCs), and 74 moderately or poorly differentiated HCCs (mp-HCCs), in 139 cirrhotic patients. Findings on CT during arterial portography (n = 201) and CT during hepatic arteriography (n = 74) were reviewed and compared with the histologic diagnosis.

RESULTS

CT findings were classified into four types relative to the surrounding liver: type A (isodense), type B (slightly hypodense), type C (partially hypodense), and type D (markedly hypodense) on CT during arterial portography and type I (isodense), type II (hypodense), type III (partially hyperdense), and type IV (hyperdense) on CT during hepatic arteriography. On CT during arterial portography, the distributions of each type were low-DN (n = 47 [A, n = 36; B, n = 8; C, n = 3]), high-DN (n = 56 [A, n = 18; B, n = 20; C, n = 10; D, n = 8]), wd-HCC (n = 24; [B, n = 4; C, n = 13; D, n = 7]), and mp-HCC (n = 74 [D, n = 74]). On CT during hepatic arteriography, the distributions were low-DN (n = 26 [I, n = 18; II, n = 7; III, n = 1]), high-DN (n = 19 [I, n = 6; II, n = 7; III, n = 4; IV, n = 2]), wd-HCC (n = 15 [I, n = 1; III, n = 8; IV, n = 6]), and mp-HCC (n = 14 [IV, n = 14]). We found a statistically significant correlation between the four types and the grade of malignancy of these nodules.

CONCLUSION

Findings on CT during arterial portography and CT during hepatic arteriography correlated positively with histologic grading when overlap in appearance between dysplastic nodules and HCCs occurred. The concept revealed in this study can apply to diagnoses made on the basis of Doppler sonography, dynamic CT, and MR imaging.

Cervical lymph nodes play the role of regional lymph nodes in brain tumour immunity in rats

Recent physiological and anatomical studies have demonstrated that a major fraction of brain interstitial and cerebrospinal fluid drains into cervical lymph nodes (CLN) in a number of experimental animals. To investigate the role of CLN in brain tumour immunity, temporal profiles of MHC class II molecule expression and T lymphocyte subsets in brain tumours, CLN and other lymphoid tissues were analysed by immunocytochemistry. A total of 64 Wistar rats weighing 250 g were used. Two weeks after the transplantation of C6 glioma cells (10(6) cells/1 microl) into a rat brain, expression of MHC class II molecules was induced in the brain and all systemic lymphoid tissues examined. However, the subsequent appearance of CD4 or CD8 positive cells was strictly confined to CLN, and coincided with the infiltration of such cells into the brain tumour 2 weeks after transplantation. In the group of animals in which cervical lymphadenectomy was followed by intracerebral transplantation of C6 glioma cells, infiltration of CD4 or CD8 positive cells into the brain tumour was delayed until 3 weeks after the transplantation, and the production of such cells was by the spleen. These results suggest that CLN act as regional lymph nodes in brain tumour immunity.

Intra-abdominal and retroperitoneal liposarcomas

Nine primary intra-abdominal or retroperitoneal liposarcomas, of which eight were recurrent tumors, were surgically resected and enrolled in this study. Histopathological examination of primary tumors revealed that the number of well-differentiated, pleomorphic and myxoid type was two, four and three, respectively. In two recurrent cases, histological differentiation changed from well-differentiated type into myxoid or pleomorphic types. Prognoses of patients with large tumors (a 20 cm) were significantly poorer than for patients with small tumors (< 20 cm). Labelling index of Ki-67 of recurrent tumors increased in two cases. The tumor size affected prognoses of patients with intra-abdominal or retroperitoneal liposarcoma. Combined resection was important to get a tumor-free margin.

Interleukin-8 inhalation directly provokes bronchoconstriction in guinea pigs

BACKGROUND

Although it has been reported that the concentration of interleukin (IL)-8 in nasal lavage fluid and sputum and its production in bronchial epithelium were increased in asthmatic subjects, the direct effects of IL-8 on the airways in vivo is unclear.

METHODS

We examined bronchoconstriction in response to IL-8 inhalation through an endotracheal cannula in anesthetized, artificially ventilated guinea pigs.

RESULTS

Inhalation of IL-8 at concentrations of 1 and 10 microg/ml caused significant bronchoconstriction, as revealed by the elevation of pressure at the airway opening. Moreover, the bronchoconstriction induced by IL-8 was significantly inhibited by the antihistamines diphenhydramine and terfenadine, suggesting the involvement of histamine release in the IL-8-induced bronchoconstriction. No significant leukocyte infiltration was observed in the bronchoalveolar lavage fluid or histologic findings 25 min after the first IL-8 inhalation.

CONCLUSIONS

IL-8 provokes bronchoconstriction without leukocyte accumulation in the airways, mediated in part by histamine release, in guinea pigs.

Serological studies on CEA, CA 19-9, STn and SLX in colorectal cancer

BACKGROUND/AIMS

Sialyl Le(x) (NeuAca2-3Galb1-4(Fuca1-3)GlcNAc1-R) (SLX) was introduced as cancer-associated. In this study, serological expression of SLX was examined with that of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9) and sialyl Tn antigen (STn) concerning the prognosis and clinicopathological findings of patients with colorectal carcinoma.

METHODOLOGY

One hundred and seventeen patients were operated on for colorectal cancer and were enrolled in this study. Serum CEA, CA 19-9, STn and SLX levels were measured pre-operatively by radioimmunoassays and the cut-off values were 5ng/ml, 37U/ml, 45U/ml, and 38U/ml, respectively.

RESULTS

Serologically, the positive rates of CEA, CA 19-9, STn and SLX antigens were 33.3, 26.5, 23.1, and 17.1%, respectively. The CEA, CA 19-9 and SLX are stage specific in clinical stage. In the CEA, CA 19-9, STn, SLX-positive patients, 5-year survival rates were 41.0, 29.7, 50.1, and 29.1%, respectively. In the tumor marker-positive patients, prognosis was significantly poorer than in the negative patients. In the patients with Curability A or B, the difference in survival between the SLX-positive and negative patients was significant. Multivariate analysis revealed that significant prognostic indicators were accompanying liver metastasis, histological type, depth of invasion, CEA and SLX.

CONCLUSIONS

The combination assay of serum CEA, CA 19-9, STn and SLX will be beneficial for diagnosis and follow-up of colorectal cancer.

Leiomyosarcoma of the larynx

Tumours of smooth muscle origin are extremely rare in the upper aerodigestive tract. Immunohistochemical studies are helpful for accurate diagnosis of leiomyosarcoma. Here, we report a case of well-differentiated laryngeal leiomyosarcoma that showed rapid local growth but no metastasis. Diagnosis and treatment of leiomyosarcoma are discussed.

Histological features predicting malignant transformation of nonmalignant hepatocellular nodules: a prospective study

BACKGROUND & AIMS

Recent advances in imaging modalities allow the identification of borderline hepatocellular nodules that have the potential for malignant transformation. The aim of this study was to elucidate histological predictive features of borderline nodules by needle biopsy for the evolution to hepatocellular carcinoma (HCC).

METHODS

Thirty-four hepatocellular nodules diagnosed by needle biopsy were followed up for more than 6 months. Several histological parameters of these nodules that were related to malignant transformation were evaluated.

RESULTS

During the follow-up periods (median, 35 months), 5 of 34 nodules evolved to HCC during a follow-up of 6-15 months. Significant prognostic features of malignant transformation were an increased ratio of nuclear density of >1.5, clear cell change, small cell dysplasia, and fatty change of the hepatocytes. In multivariate analysis, an increased ratio of nuclear density of >1.5 and clear cell change were independent.

CONCLUSIONS

A nodule with an increased ratio of nuclear density, clear cell change, small cell dysplasia, and fatty change should be recognized to be a high risk for evolution to HCC. Particularly, the former two were independent prognostic factors for malignant transformation.

Dye-Guided Sentinel Lymphadenectomy in Clinically Node-Negative and Node-Positive Breast Cancer Patients

BACKGROUND: Sentinel lymphadenectomy has been used to assess the axillary nodal status in patients with breast cancer in an attempt to avoid unnecessary axillary dissection. Most studies have examined the utility of this procedure in clinically node-negative patients. However, the clinical evaluation of axillary nodes is often inaccurate for both clinically node-negative and clinically node-positive patients. METHODS: We performed dye-guided sentinel lymphadenectomy in both clinically node-negative and clinically node-positive patients with breast cancer. All patients also underwent a formal axillary dissection. The results of imprint cytology, frozen sections, and permanent sections of the sentinel lymph node (SLN) werecompared with each other and with histologic findings of the nonsentinel nodes. RESULTS: The SLN was identified in 30 (79%) of 38 patients with clinically negative nodes, and in 11 (92%) of 12 patients with clinically positive nodes. Forclinically node-negative patients, SLN evaluation yielded a diagnostic accuracyof 90%, a sensitivitiy of 72%, and a specificity of 100%. For clinically node-positive patients, these values were 100%, 100% and 100%, respectively. These values were not significantly different for the two groups of patients. CONCLUSION: Sentinel lymphadenectomy may be useful in assessing the axillarynodal status of both clinically node-positive and clinically node-negative breast cancer patients.

Extent of mediastinal node metastasis in clinical stage I non-small-cell lung cancer: the role of systematic nodal dissection

OBJECTIVE

To determine the extent of lymph node metastasis in clinical stage I non-small-cell lung cancer (NSCLC).

METHODS

We performed a retrospective review of 524 patients with clinical stage I NSCLC who underwent lobectomy with systematic nodal dissection.

RESULTS

The nodal status was N0 in 409 patients (78%), N1 in 44 (8%), N2 in 67 (13%), and N3 in four (0.8%). Thirty-six patients had single-level mediastinal nodal metastases and 35 had multi-level metastases. The incidence of N2/3 disease in patients with adenocarcinoma/squamous cell carcinoma/other histologic types according to tumor size was 0/0/0%, respectively, in tumors < or = 10 mm in diameter, 12/0/0% in tumors 11-20 mm in diameter, 14/4/23% in tumors 21-30 mm in diameter, and 26/14/20% in tumors >30 mm in diameter. Nodal metastases to the upper mediastinum from middle or lower lobe lesions were frequently observed in 51 N2 adenocarcinomas, whereas those to the lower mediastinum from upper lobe lesions were rare. Of 10 N2 squamous cell carcinomas, seven had regional and three had non-regional nodal metastases. The 5-year survival rate was 68, 43, and 30% in N0, N1, and N2, respectively (P<0.01, N0 versus N1, N0 and N2).

CONCLUSIONS

Systematic mediastinal nodal dissection should be routinely performed for clinical stage I lung cancer to ensure the correct nodal status, but it might be dispensable in the patients with peripheral squamous cell carcinoma < or = 20 mm in diameter, with central squamous cell carcinoma < or = 30 mm, and with adenocarcinoma < or = 10 mm. When systematic nodal dissection cannot be performed, the incidence and extent of nodal metastases should be taken account with respect to histologic type, size, and location of the tumor.

Midcourse thallium-201 scintigraphy to predict tumor response in bone and soft-tissue tumors

The purpose of this study was to assess the predictive power of 201TI scintigraphy in the midcourse of chemotherapy for the final tumor response to chemotherapy in malignant bone and soft-tissue tumors.

METHODS

The 21 patients studied with 201TI scintigraphy were 14 males and 7 females (average age 39.8+/-22.1 yr; age range 8-74 yr). Planar scintigraphy was performed 15 min after injection of 111 MBq 201TI before chemotherapy, after the third chemotherapy cycle (midcourse) in all 21 patients and after the final chemotherapy cycle but before surgery in 11 patients. The 201TI uptake ratio was calculated by dividing the count density of the lesion by that of the contralateral normal area. The percent reduction of the 201TI uptake ratio calculated by 100 x [(prechemotherapy ratio - postchemotherapy ratio)/prechemotherapy ratio] in the midcourse was compared with that after the final course of chemotherapy, and it also was compared with the histologic response.

RESULTS

In patients with histologically complete response [(CR), n=6] and with partial response [(PR), n=5], the percent reduction in 201TI uptake ratio after three cycles of chemotherapy was 64.1%+/-14.4% and 50.9% +/-10.5%, respectively. In patients with histologically no change [(NC), n=10], the percent reduction was 0.40%+/-18.2% after the third cycle; -5.3%+/-20.9% in four patients with full courses of chemotherapy (p < 0.0001 and p < 0.005 compared with the CR and PR groups, respectively). After the final cycle of chemotherapy, the percent reduction in 201TI uptake ratio was 68.6%+/-14.7%, 56.2%+/-6.1% and -0.3%+/-17.2% in the CR, PR and NC groups, respectively (NC versus CR, p < 0.0005; NC versus PR, p < 0.005).

CONCLUSION

Thallium-201 scintigraphy performed in the midcourse of chemotherapy is predictive of the final response to chemotherapy that can be demonstrated histologically. Serial 201TI scintigraphy in the midcourse of chemotherapy is useful in assessing final chemotherapeutic response in the early stage of chemotherapy, and it helps clinicians when choosing the most appropriate treatment strategies in patients with bone and soft-tissue tumors.

Evaluation of p53, Ki-67 and DNA ploidy in both primary rectal carcinomas and locally recurrent tumors

The object of this study was to evaluate cellular markers which included tumor cell p53 expression, cell proliferation antigens and DNA ploidy in both primary and locally recurrent rectal cancer. The study included 16 locally recurrent rectal cancer and 24 non-recurrent primary rectal cancer. Levels of p53 and Ki-67 expression were quantified and the DNA ploidy analyzed. In the locally recurrent group, labelling index of p53 was significantly higher in the short disease-free interval (DFI) (<2 years) group than the long DFI (> or = 2 years) group (p<0.05). It was immunohistochemically proved that DNA aneuploidy was reflected by accumulation of mutated p53 in both primary rectal cancer and locally recurrent tumors. The early local recurrence after curative operation for rectal cancer was associated with the number of p53 positive cells.

Differentiation of hypervascular hepatic pseudolesions from hepatocellular carcinoma: value of single-level dynamic CT during hepatic arteriography

PURPOSE

The purpose of our study was to assess the efficacy of single-level dynamic CT during hepatic arteriography (D-CTA) in the differentiation between hypervascular hepatocellular carcinoma (HCC) and hypervascular pseudolesion.

METHOD

D-CTA was performed in nine cases with HCC and nine cases with pseudolesion. Findings on D-CTA were retrospectively analyzed.

RESULTS

The transition of the stain of pseudolesion on D-CTA was divided into three phases: (1) inflow of the contrast material into the portal vein within the lesion, (2) lesion staining, and (3) fading out of the stain; that of HCC was divided into four phases: (1) inflow of CM into tumor, (2) tumor staining, (3) inflow of CM into the adjacent liver, and (4) coronal stain of adjacent liver. The coronal stain was seen in all HCCs but not in any pseudolesions.

CONCLUSION

The present study suggest that D-CTA is a helpful option in the differentiation between HCC and pseudolesion.

Angiomyolipoma predominantly composed of smooth muscle cells: problems in histological diagnosis

AIMS

Five cases of angiomyolipoma (AML) composed exclusively or predominantly of smooth muscle cells (SMC) are presented to emphasize the histological diversity and to caution against errors in histological diagnosis.

METHODS AND RESULTS

Four tumours were located in the liver and one in the renal capsule. Three patients were female and two were male, ranging from 36 to 76 years of age with a mean age of 50 years. One patient with a renal capsular tumour was associated with tuberous sclerosis. Two tumours were composed predominantly of a spindle-shaped SMC component, whereas three others were composed predominantly of epithelioid SMC elements. AMLs composed exclusively or predominantly of spindle-shaped smooth muscle cells (SMCs) stimulated leiomyoma, whereas AMLs composed exclusively or predominantly of epithelioid SMCs resembled epithelioid leiomyoma or leiomyosarcoma or other sarcoma when cellular atypia was present. However, both spindle and epithelioid SMCs were characteristically positive for HMB-45 melanoma-specific antibody; no other tissue components in either the liver or kidney were reactive to HMB-45.

CONCLUSIONS

AML is often composed predominantly of SMC elements, and morphological features of the SMC elements are quite variable. Therefore, careful attention must be given to histological assessment of AML. Whenever a pathologist encounters an unfamiliar hepatic or renal tumour, the possibility of AML should be considered. Reactivity for HMB-45, however, confirmed the diagnosis of AML.

Diffuse biliary tract involvement mimicking primary sclerosing cholangitis in an experimental model of chronic graft-versus-host disease in mice

Experimental graft-versus-host disease (GVHD) across minor histocompatibility antigens was developed by injecting spleen and bone marrow cells (9:1) of congenic B10.D2 mice into sublethally irradiated BALB/c mice, and the histologic features of the liver were studied for up to 14 months after transplantation. Both intrahepatic and extrahepatic bile ducts were severely involved in the GVHD process and showed features of non-suppurative cholangitis. Inflammatory cells, mainly lymphocytes, abutted the bile ducts and infiltrated into the duct epithelial layer together with a variety of degenerative changes in the epithelial cells. The peak inflammatory activity occurred about 2-3 weeks after transplantation. Thereafter, the inflammatory cell infiltration around the bile ducts and in the bile duct epithelial layer gradually became reduced in severity, although the infiltration persisted during the entire 14 month observation period. Periductal and duct wall fibroplasia began about 1 week after transplantation and gradually progressed. After 2-3 months post-transplantation, distinct ductal and periductal fibrosis of both intrahepatic and extrahepatic bile ducts was observed. This histologic feature resembled that of primary sclerosing cholangitis (PSC). These results suggest that PSC lesions might develop as a result of chronic cellular immunologic mechanisms in GVHD across minor histocompatibility barriers.

Delayed MR imaging of the liver: correlation of delayed enhancement of hepatic tumors and pathologic appearance

BACKGROUND

The value of delayed magnetic resonance (MR) imaging (6 min) and ultradelayed MR imaging (1-4 h) for differentiating of hepatic tumors was studied.

METHODS

Postcontrast delayed and ultradelayed MR images were obtained after administration of 0.1 mmol/kg of Gd-DTPA in 30 patients with various malignant hepatic tumors.

RESULTS

Delayed enhancement in the center of the tumors was seen in 13 patients on the delayed MR images and in 22 patients on the ultradelayed MR images. On the ultradelayed images, peripheral hypointense rim was seen in 12 patients and central focal hypointense area was seen in eight patients. Pathologically, the portion showing delayed enhancement corresponded to abundant fibrous stroma, the hypointense rim to rich proliferation of tumor cells, and the central hypointense areas to coagulative necrosis.

CONCLUSION

Ultradelayed MR imaging can characterize different tissue components within various hepatic tumors.

Fatal cardiac beta2-microglobulin amyloidosis in patients on long-term hemodialysis

We report two long-term hemodialysis patients who developed severe congestive heart failure attributable to cardiac heavy amyloid deposition. Both patients became hypotensive during dialysis sessions, gradually making it difficult to continue hemodialysis, and they died of congestive heart failure. At autopsy, left ventricle walls in each case contained diffuse extensive deposits of amyloid. The distribution of amyloid was not localized to vessel walls but was widely disseminated throughout the left ventricle walls and replaced myocardial muscle fibers. Immunohistochemical examination showed positive staining for anti-human beta2-microglobulin antibody. We conclude that cardiac dialysis-related amyloidosis should also be considered in long-term hemodialysis patients with congestive heart failure as a life-threatening complication.

Necrotizing bronchial aspergillosis as a cause of hemoptysis in sarcoidosis

The case history is presented of a patient with recurrent massive hemoptysis caused by necrotizing bronchial aspergillosis associated with sarcoidosis. The involved segments (right IX and X) were resected for treatment of the life-threatening hemoptysis. Histologic examination of the resected specimen confirmed the diagnosis. Necrotizing bronchial aspergillosis is a rare variant form of invasive pulmonary aspergillosis and has not been described previously as a cause of hemoptysis in sarcoidosis.

Clinicopathologic study of mucoepidermoid carcinoma of the lung

BACKGROUND

Mucoepidermoid carcinoma is a relatively uncommon form of lung cancer and has generally been viewed as a low grade malignant tumor. The present study was undertaken to establish a clinicopathological characterization of patients with this cancer who were treated surgically at Kanazawa University Hospital.

METHODS

Between 1973 and 1975, 10 patients with mucoepidermoid carcinoma were surgically treated in our department.

RESULTS

The 10-year survival rate after surgery for the central type of carcinoma was 67%, while the 4-year survival rate for the peripheral type was 25%. When the survival rates were analyzed in terms of Conlan's grades, grade 1 cases had a 10-year survival rate of 80%, while the 4-year survival rate for grade 2 and 3 cases was 20%. The four patients who survived 5 years or more following surgery all had a grade 1 central type tumor.

CONCLUSIONS

These results suggest that mucoepidermoid carcinoma of the lung should not be viewed uniformly as a low grade malignant tumor, but that this tumor can sometimes be highly malignant with a poor prognosis. Since this tumor is often difficult to distinguish from adenosquamous carcinoma, and because accurate distinction between these two types of tumor seems to be essential for establishing a prognosis, there is an urgent need for a valid pathological method for differential diagnosis of mucoepidermoid carcinoma.

Hypervascular hepatocellular carcinoma: evaluation of hemodynamics with dynamic CT during hepatic arteriography

PURPOSE

To assess the hemodynamics and the main drainage vessel of hypervascular hepatocellular carcinoma.

MATERIALS AND METHODS

Single-level dynamic computed tomography during hepatic arteriography (CTHA) was performed in 32 patients with hepatocellular carcinoma. Carcinoma was confirmed with histologic (n = 9) or clinical (n = 23) examination results. Single-level CTHA findings were retrospectively analyzed. Histologic specimens from 40 livers with hepatocellular carcinoma were also examined, with special attention to vessels along the rim of the lesion.

RESULTS

Contrast material enhancement on single-level CTHA images occurred in four phases: (a) inflow of the contrast material into tumor, (b) tumor enhancement, (c) inflow of the contrast material into adjacent liver, and (d) corona enhancement of adjacent liver. Corona enhancement was seen in all lesions. A bright branching structure in the corona enhancement area, suggestive of a portal venule, was visible at the start of adjacent liver staining in 21 lesions. Continuity between a tumor sinusoid and a tiny vessel in the inner layer of the pseudocapsule was histologically confirmed in 10 of 40 specimens. Continuity between a tiny vessel in the inner layer and a portal vein in the outer layer of the pseudocapsule was confirmed with findings on serial sections from one liver.

CONCLUSION

The main drainage of hepatocellular carcinoma lesions may be a protal venule.