[A Case of Solitary Liver Metastasis of Low-Grade Endometrial Stromal Sarcoma 31 Years after Resection of Primary Lesion]

A 73-year-old woman was referred to our hospital after a liver tumor was discovered during an abdominal ultrasonography. Thirty-one years ago, she underwent a total hysterectomy for uterine myoma and was diagnosed with a leiomyoma. Twenty years ago, she underwent a bilateral oophorectomy for an ovarian tumor and was diagnosed with a luteinized theca cell tumor accompanied by sclerosing peritonitis. A CT scan and MRI revealed a 65-mm tumor in the S6-7 of the liver. There was no sign of any lesions other than in the liver, and TACE was performed for suspected hepatocellular carcinoma. However, a favorable treatment outcome was unable to be obtained and a posthepatic segmental resection was performed. Histopathological morphology suggested a similarity to endometrial stromal cells and, considering the history of myoma of the uterus and ovarian tumor, immunohistological staining was carried out. The myoma of the uterus and the ovarian and liver tumors were all CD10(+), α⊖SMA(-), MIB-1 index 3%. The uterine myoma, which was initially operated on, was rediagnosed as a low-grade endometrial stromal sarcoma. After 11 years, ovarian metastasis was observed, and after 31 years liver metastasis occurred. Examples of resection of liver metastasis of endometrial stromal sarcoma are extremely rare and, we will include a review of the literature in this report.

Testicular sarcoidosis with bilateral scrotal swelling

INTRODUCTION

Sarcoidosis is a disease in which noncaseating granulomas form in several organs, particularly in the lungs and skin. Male genitourinary involvement in sarcoidosis is uncommon.

CASE PRESENTATION

A 32-year-old male with painless bilateral scrotal swelling who was diagnosed with lung sarcoidosis presented to our hospital. Serum tumor marker levels were normal. Scattered hypoechoic mass lesions in both testes were noted on ultrasound examination. Biopsy of both testes revealed pathologically noncaseating epithelioid cell granuloma, and perihilar lymphadenopathy and a granulomatous lung nodule were found on chest computed tomography. Semen examination was performed after the biopsy, demonstrating oligospermia. A corticosteroid regimen was administered. After treatment, no abnormal accumulation in both testes was observed on gallium-67 scintigraphy, and semen examination demonstrated the mild improvement of the sperm count.

CONCLUSION

Treatments for testicular sarcoidosis vary, and malignancy and fertility must be considered.

Significance of neoadjuvant chemoradiotherapy for borderline resectable pancreatic head cancer: Pathological local invasion and microvessel invasion analysis

Borderline resectable pancreatic head cancer (BR-PHC) has low resectability due to vascular invasion. Although the clinical effects of neoadjuvant chemoradiotherapy (NAC-RT) for BR-PHC have been examined, few studies have reported its pathological aspects. The present study retrospectively investigated the effect of NAC-RT on the histological features of BR-PHC. A total of 29 patients with BR-PHC who underwent NAC-RT, and 55 controls with resectable PHC, who underwent pancreaticoduodenectomy at the Kurume University Hospital. Tumor staging, lymphovascular invasion (LVI), and microvessel invasion (MVI) were evaluated. The median tumor size in the NAC-RT group was 2.0 cm, and it was smaller than that of the control group (P=0.006). The rates of lymph node metastasis, LVI, and MVI were significantly lower in the NAC-RT group (P<0.001, 0.002, and 0.015, respectively). Overall survival in the NAC-RT group was comparable to that in the control group, although patients with BR-PHC generally had a poorer prognosis than those with resectable PHC. Patients in the NAC-RT group without portal vein invasion (PVI) had a significantly better prognosis than those with PVI in the control group (P=0.002). NAC-RT may be beneficial for patients with BR-PHC by inhibiting local invasion and metastasis as prognosis following resection could be equivalent to that of patients with conventional ductal adenocarcinoma.

Prognostic impact of p16 and PD-L1 expression in patients with oropharyngeal squamous cell carcinoma receiving a definitive treatment

Aims

Limited information is available regarding the precise differences in the tumour immune microenvironment (TIM) of patients with human papilloma virus (HPV)-associated and non-HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Here, we retrospectively reviewed 137 patients with OPSCC treated with a definitive treatment to identify molecular relationships in the TIM.

Materials and methods

We used immunohistochemical analysis to assess p16 status, programmed death ligand 1 (PD-L1) level, and/or CD8⁺ tumour-infiltrating lymphocyte (TIL) density, followed by prognostic evaluation of these immune-related parameters.

Results

Multivariate analyses demonstrated that PD-L1 level on immune cells but not on tumour cells or CD8⁺ TIL density was a significant predictive factor of disease-free survival (DFS) and overall survival (OS). Additionally, subgroup analyses demonstrated that patients positive for p16 and PD-L1 expression on immune cells had favourable DFS and OS, whereas patients negative for p16 and PD-L1 expression on immune cells showed worse DFS and OS.

Conclusions

We demonstrated that PD-L1 expression on immune cells but not tumour cells might represent a useful prognostic biomarker in patients with OPSCC receiving a definitive treatment. We propose that a co-assessment of p16 and PD-L1 expression on immune cells would have greater prognostic potential compared with evaluation of each factor alone in patients with OPSCC.

PD-L1 expression in pancreatic adenosquamous carcinoma: PD-L1 expression is limited to the squamous component

AIM

We examined the programmed death-ligand 1 (PD-L1) expression in surgically resected pancreatic adenosquamous carcinoma (PASC) samples. Furthermore, the detection rate was also assessed using biopsy cases obtained from endoscopic ultrasound-guided fine needle aspiration (EUS-FNA).

METHODS

Fifteen cases of PASC (six resected and nine EUS-FNA biopsied) from the Kurume University Hospital between 2009 and 2016 were used for the evaluation of PD-L1 expression. As a control group, 34 cases of pancreatic ductal adenocarcinomas (PDACs) were selected. To compare　the positivity and intensity of PD-L1, two types of clones (SP263, E1L3N) were examined for immunostaining. Only the membrane expression of PD-L1 was regarded as positive. The PD-L1 expressions in the squamous cell carcinoma component (SCc), adenocarcinoma component (ACc), and immune cells were assessed separately. The ratio of PD-L1 expression was calculated by counting the positive tumor cells, and tumor proportion score (TPS) was applied (TPS; Null < 1%, low expression; 1 ≤ TPS ≤ 49% and high expression; ≥ 50%).

RESULTS

PD-L1 expression was observed in five surgical PASC samples (83%). This shows that SCc presented a high expression in these cases. However, the overall TPS indicated a low expression. In contrast, only one case (3%) was positive for PD-L1 in PDACs, and the TPS indicated a low expression. No differences in PD-L1 expression were observed between the two clones, SP263 and E1L3N. High PD-L1 expression in the EUS-FNA sample was found in only one case (11%).

DISCUSSION

Although assessment using the tumor cells of PASC samples obtained from EUS-FNA was difficult, this study suggests the selective expression of PD-L1 in the SCc of PASC. Furthermore, it was considered that immune checkpoint inhibitors could provide therapeutic effects selectively on the SCc for the entire range of TPSs, though the PD-L1 expression was low.

SurePath® LBC improves the diagnostic accuracy of intrahepatic and hilar cholangiocarcinoma

INTRODUCTION

The current study aimed to compare cytology using SurePath^® (SP)-LBC and biliary tissue histology (BTH) for the diagnosis of biliary disease.

METHODS

Between January 2014 and December 2016, 57 patients underwent endoscopic retrograde cholangiopancreatography for the diagnosis of biliary disease. Biliary cytological samples were processed using SP-LBC and subsequently BTH was performed. A final diagnosis was confirmed by surgery (23 malignant cases) and clinical follow-up (34 benign and malignant cases): 18 extrahepatic cholangiocarcinoma; 17 intrahepatic/hilar cholangiocarcinoma (intra/H-CC); eight other malignant disease; and 14 benign biliary disease. The diagnoses made using SP-LBC and BTH were classified into four categories: (1) benign; (2) indeterminate; (3) suspicious for malignancy/malignant; and (4) inadequate. In addition, diagnostic accuracy was compared between SP-LBC and BTH.

RESULTS

Although 23% (13/57) of BTH samples were classified as inadequate, all SP-LBC cases were classified as adequate. Among 43 malignant cases, 11 normal, four indeterminate and 28 suspicious for malignancy/malignant were found using SP-LBC (26%, 9% and 65%, respectively), in contrast to 10 inadequate, nine normal, 10 indeterminate and 14 suspicious for malignancy/malignant observed using BTH (23%, 21%, 23%, and 33%, respectively). The identification of malignant cells was strikingly different between SP-LBC and BTH. Furthermore, limited to intra/H-CC, accuracy was significantly higher using SP-LBC than using BTH (P < .001).

CONCLUSIONS

SP-LBC of the biliary tract is a useful and reliable method for diagnosing biliary malignant disease and has an advantage over BTH for detecting malignant cells and accurately diagnosing intra/H-CC.

Granulocyte-colony stimulating factor producing mucinous cystic neoplasm with an associated invasive carcinoma of the pancreas

The present case study documents an autopsy case of granulocyte-colony stimulating factor (G-CSF)-producing mucinous cystic neoplasm (MCN), with an associated invasive carcinoma of the pancreas. A 65-year-old woman presented to Omuta City Hospital (Omuta Japan) with a primary complaint of abdominal pain. Multiple liver nodules and a pancreatic cyst were detected upon abdominal computed tomography. Initially, liver abscess was suspected as the patient exhibited leukocytosis and elevated C-reactive protein level. However, the serum concentration of G-CSF was 98.8 pg/ml (normal, <39.0 pg/ml). At 6 weeks after admission, the patient succumbed to liver failure. At autopsy, a cystic lesion was identified in the pancreatic tail that contained bloody necrotic fluid. Microscopically, the cystic lesion was composed of columnar and mucin-producing epithelium associated with ovarian-type subepithelial stroma. The stroma exhibited positive immunostaining for vimentin, estrogen receptor and progesterone receptor. Calcification on the cystic wall was observed. The tumor invaded the pancreatic parenchyma and metastasized to the liver and lungs. The lesion was diagnosed as invasive adenocarcinoma arising in MCN. By contrast, liver nodules predominantly consisted of pleomorphic cancer cells with small foci of adenocarcinoma. Pancreatic and hepatic cancer cells were confirmed to be positive for G-CSF staining. The present case report indicates that G-CSF-producing MCNs may be associated with an aggressive clinical course, particularly when anaplastic changes are observed.

Intraductal neoplasm of the intrahepatic bile duct: Clinicopathological study of 24 cases

AIM: To investigate the clinicopathological features of intraductal neoplasm of the intrahepatic bile duct (INihB).

METHODS: Clinicopathological features of 24 cases of INihB, which were previously diagnosed as biliary papillomatosis or intraductal growth of intrahepatic biliary neoplasm, were reviewed. Mucin immunohistochemistry was performed for mucin (MUC)1, MUC2, MUC5AC and MUC6. Ki-67, P53 and β-catenin immunoreactivity were also examined. We categorized each tumor as adenoma (low grade), borderline (intermediate grade), and malignant (carcinoma in situ, high grade including tumors with microinvasion).

RESULTS: Among 24 cases of INihB, we identified 24 tumors. Twenty of 24 tumors (83%) were composed of a papillary structure; the same feature observed in intraductal papillary neoplasm of the bile duct (IPNB). In contrast, the remaining four tumors (17%) showed both tubular and papillary structures. In three of the four tumors (75%), macroscopic mucin secretion was limited but microscopic intracellular mucin was evident. Histologically, 16 tumors (67%) were malignant, three (12%) were borderline, and five (21%) were adenoma. Microinvasion was found in four cases (17%). Immunohistochemical analysis revealed that MUC1 was not expressed in the borderline/adenoma group but was expressed only in malignant lesions (P = 0.0095). Ki-67 labeling index (LI) was significantly higher in the malignant group than in the borderline/adenoma group (22.2 ± 15.5 vs 7.5 ± 6.3, P < 0.01). In the 16 malignant cases, expression of MUC5AC showed borderline significant association with high Ki-67 LI (P = 0.0622). Nuclear expression of β-catenin was observed in two (8%) of the 24 tumors, and these two tumors also showed MUC1 expression. P53 was negative in all tumors.

CONCLUSION: Some cases of INihB have a tubular structure, and are subcategorized as IPNB with tubular structure. MUC1 expression in INihB correlates positively with degree of malignancy.

Benign multicystic peritoneal mesothelioma mimicking recurrence of an ovarian borderline tumor: a case report

Introduction

Benign multicystic peritoneal mesothelioma is an extremely rare tumor that occurs mainly in women in their reproductive age. Its preoperative diagnosis and adequate treatment are quite difficult to attain.

Case presentation

Our patient was a 23-year-old Japanese woman who had a history of right oophorectomy and left ovarian cystectomy for an ovarian tumor at 20 years of age. The left ovarian tumor had been diagnosed on histology as a mucinous borderline tumor. Two years and nine months after the initial operation, multiple cysts were found in our patient. A laparotomy was performed and her uterus, left ovary, omentum and pelvic lymph nodes were removed due to suspicion of recurrence of the borderline tumor. A histological examination, however, revealed that the cysts were not a recurrence of the borderline tumor but rather benign multicystic peritoneal mesothelioma. There were no residual lesions and our patient was followed up with ultrasonography. She remains free from recurrence nine months after treatment.

Conclusion

We report a case of benign multicystic peritoneal mesothelioma mimicking recurrence of an ovarian borderline tumor. Benign multicystic peritoneal mesothelioma should be suspected when a multicystic lesion is present in the pelvis as in the case presented here, especially in patients with previous abdominal surgery.

Simultaneous hepatic relapse of non-Hodgkin's lymphoma and hepatocellular carcinoma in a patient with hepatitis C virus-related cirrhosis

We report a 66-year-old man with hepatitis C virus (HCV)-related cirrhosis and simultaneous hepatic relapse of non-Hodgkin's lymphoma (NHL) and of hepatocellular carcinoma (HCC). Although the liver is frequently involved by NHL, hepatic colocalization of NHL and HCC is rarely detected by imaging techniques. HCV has been suggested to be lymphotrophic as well as hepatotrophic, and therefore has attracted speculation about a causative role in some cases of lymphoma. The patient had a past history of cutaneous diffuse large B cell lymphoma (DLBCL) in concurrence with HCC 32 months previously. Complete remission (CR) had been maintained for both diseases until February 2004, when ultrasonography and computed tomography (CT) showed multiple liver tumors. Two of these, appearing hyperattenuating in the arterial phase of contrast-enhanced CT, were diagnosed histopathologically as HCC, and treated with radiofrequency ablation. The other tumors, hypoattenuating in the portal phase CT, were diagnosed histopathologically as DLBCL, and treated with cyclophosphamide, tetrahydropyranyl-Adriamycin, vincristine and prednisolone (THP-COP) in combination with rituximab. CR was achieved for both DLBCL and HCC. Given the previously demonstrated immune system tropism and perturbation by HCV, the virus might have contributed to the occurrence of the NHL as well as the HCC.

Epidermoid cyst of the ureter: a case report

Epidermal cysts of the upper urinary tract are extremely rare. Only three cases have been reported in the published work written in English, Italian or German. We encountered a case of an epidermoid cyst in the ureter of a 72-year-old male. Findings on urine analysis and radiological examination were useful for establishing a correct diagnosis of epidermoid cyst of the urinary tract.

Prevalence of hepatitis C virus infection in cases of B-cell lymphoma in Japan

AIMS

To determine the prevalence of hepatitis C virus (HCV) infection in B-cell lymphoma in Japan. HCV infection and type II (monoclonal IgM) cryoglobulinaemia (CG) may be involved in the pathogenesis of low-grade B-cell lymphoma (ML) in southern Europe.

METHODS AND RESULTS

Forty-five (11.3%) of 400 B-cell ML cases were HCV antibody (Ab) positive, which was significantly (P < 0.01) higher than the blood donors (2.5%). Among them, 28 diffuse large B-cell lymphoma (DLBCL) cases were included. In the primary sites, 10 (47.6%) of 21 splenic DLBCL and seven (23.3%) of 30 gastric DLBCL were HCV Ab positive, which were significantly (P < 0.05) higher than the myeloma cases (4.9%). HCV infection was rarely (4.2%) detected in 24 lymphoplasmacytic and salivary gland low-grade B-cell ML cases. Type II CG was detected in one myeloma case (3.5%) of 29 HCV+ B-cell ML. By real-time polymerase chain reaction, HCV RNA was detected in fresh tumour tissues of all 11 B-cell ML cases examined. Lymphoma cells were positive for the envelope HCV non-structural (NS)3 and envelope (E2) proteins in six of eight examined B-cell ML cases.

CONCLUSIONS

The rare incidence of type II CG is characteristic of Japanese HCV+ ML patients and may influence the low incidence of low-grade B-cell ML. HCV infection may play a role in lymphomagenesis of splenic and gastric DLBCL.

Analysis of unilateral adrenal hyperplasia with primary aldosteronism from the aspect of messenger ribonucleic acid expression for steroidogenic enzymes: a comparative study with adrenal cortices adhering to aldosterone-producing adenoma

Unilateral adrenal hyperplasia with primary aldosteronism is very rare and shows similar endocrine features to aldosterone-producing adenoma and bilateral adrenal hyperplasia. In this study, the mRNA expression of steroidogenic enzymes in unilateral adrenal hyperplasia was examined by in situ hybridization. We found subcapsular micronodules composed of spironolactone body-containing cells, which showed intense expression for 3beta-hydroxysteroid dehydrogenase, 11beta-hydroxylase, 18-hydroxylase, and 21-hydroxylase but not 17alpha-hydroxylase, indicating aldosterone production. This expression pattern was the same as that in unilateral multiple adrenocortical micronodules, reported recently. Additionally, it was noted that a nodule with active aldosterone production was closely adjacent to one showing intense 17alpha-hydroxylase expression. In the adrenal cortices adhering to aldosterone-producing adenoma, the majority of hyperplastic zona glomerulosa and hyperplastic nodules demonstrated a decreased steroidogenic activity. However, minute nodules indicative of active aldosterone production were found at high frequency. These results suggest that the subcapsular micronodules observed might be the root of aldosterone-producing adenoma. Furthermore, we emphasize the need for long-term follow-up after unilateral adrenalectomy or enucleation of the adenoma because of the possibility that buds with autonomous aldosterone production may still be present in the contralateral or remaining adrenal tissue.

Proposal of histological criteria for intraepithelial atypical/proliferative biliary epithelial lesions of the bile duct in hepatolithiasis with respect to cholangiocarcinoma: preliminary report based on interobserver agreement

Biliary lining epithelia of the bile ducts in biliary diseases are known to have intraepithelial atypical/proliferative lesions related to the development of cholangiocarcinoma. The purpose of the present study was to determine the histological criteria for these lesions based on interobserver agreement. Digital images of 30 intraepithelial atypical/proliferative lesions in the stone-containing intrahepatic bile ducts of hepatolithiasis (30 cases) were sent to 10 pathologists. At first, 10 pathologists made a diagnosis (either of reactive/regenerative change, low-grade or high-grade biliary intraepithelial neoplasia (BilIN-1 and BilIN-2), or in situ carcinoma (BilIN-3)) based on their own criteria. The histological criteria for these four lesions were then determined, and the digital images of the same lesions with proposed criteria were re-distributed. Interobserver agreement on these four lesions was slightly improved (kappa = 0.44, first diagnosis; 0.49, second diagnosis) and intraobserver agreement was 'almost perfect' (kappa = 0.82 at both first and second diagnosis). Interobserver agreement between BilIN-1 and BilIN-2 and that between BilIN-2 and BilIN-3 were 'moderate', although the agreement between regenerative/reactive change and BilIN-1 was 'fair'. In this report, we propose histological criteria for reactive/regenerative change, BilIN-1, BilIN-2 and BilIN-3. Improvement of interobserver agreement suggests their applicability in diagnostic and research fields.

Are bile duct lesions of primary biliary cirrhosis distinguishable from those of autoimmune hepatitis and chronic viral hepatitis? Interobserver histological agreement on trimmed bile ducts

BACKGROUND

Primary biliary cirrhosis (PBC) is histopathologically characterized by chronic nonsuppurative destructive cholangitis and ductopenia of interlobular bile ducts. Bile duct injury is also often encountered in chronic viral hepatitis (CVH) and in autoimmune hepatitis (AIH).

METHODS

In this study, we performed interobserver agreement analysis on 90 injured bile ducts from liver specimens of PBC (17 cases), CVH (26 cases), and AIH (18 cases), with 30 bile ducts chosen from each disease group. Digital images of bile ducts with minimal periductal elements were recorded in CD-ROM format and sent to 14 observers (six special hepatopathologists, four local hepatopathologists, and four general pathologists). We analyzed the following issues: (1) diagnostic accuracy of PBC, based only on bile duct lesions; (2) classification of bile duct lesions in AIH cases as destructive cholangitis equivalent to PBC-associated injury, or not.

RESULTS

The diagnostic accuracy of PBC cases with severe bile duct injuries was very high (over 80%), although the accuracy in cases with only mild bile duct injuries was low (50% or less). For AIH, each observer classified 9 of the 30 bile ducts, on average, as destructive cholangitis.

CONCLUSIONS

This study revealed that 66.9% of PBC cases could be diagnosed based on trimmed bile ducts alone. Bile duct injury similar to that in PBC could be encountered in AIH.

Development of a TT virus DNA quantification system using real-time detection PCR

Although TT virus (TTV) was isolated from a cryptogenic posttransfusion hepatitis patient, its pathogenic role remains unclear. It has been reported that the majority of the healthy population is infected with TTV. To elucidate the differences between TTV infection in patients with liver diseases and TTV infection in the healthy population, a quantification system was developed. TTV DNA was quantified by a real-time detection PCR (RTD-PCR) assay on an ABI Prism 7700 sequence detector. With this system, TTV DNA was quantified in 78 hepatitis C virus (HCV)-infected patients (63 with elevated serum alanine aminotransferase [ALT] levels and 15 with normal ALT levels) and in 70 voluntary blood donors (BDs). The quantification range was 2.08 to 7.35 log copies/ml. The intra-assay and interassay coefficients of variation were 0.37 to 6.33% and 0.60 to 7.07%, respectively. The mean serum TTV DNA levels in the HCV-infected patients with both elevated and normal ALT levels and BDs were 3.69 +/- 0.89, 3.45 +/- 0.76, and 3.45 +/- 0.67 log copies/ml, respectively. Comparison of the serum TTV DNA levels among the HCV-infected patients revealed that they were not related to the serum ALT and HCV core protein levels or to the histopathological score on liver biopsy. This study showed that (i) the RTD-PCR assay for the detection of TTV was accurate and had a high degree of sensitivity, (ii) the mean serum TTV DNA level was similar among HCV-infected patients, irrespective of their ALT level, and also among BDs, and (iii) a high serum TTV DNA level does not affect the serum ALT and HCV levels or liver damage in HCV-infected patients.

High prevalance of TT virus infection in Japanese patients with liver diseases and in blood donors

BACKGROUND/AIMS

Although a novel DNA virus, TT virus (TTV), has been isolated from a patient with cryptogenic post-transfusion hepatitis, its pathogenic role remains unclear. To elucidate its prevalence and clinical impact in patients with liver diseases, the presence of TTV DNA was assessed in patients with liver diseases and blood donors (BDs) in Japan using two primer sets, one conventional and the other new and highly sensitive.

METHODS

We studied 261 samples, 72 with chronic hepatitis associated hepatitis C virus (HCV-CH), 57 with hepatocellular carcinoma associated HCV (HCV-HCC), 12 with HCC without either HCV or hepatitis B virus (NBNC-HCC), and 120 of BDs.

RESULTS

Using two primer sets, TTV DNA was detected in 68 (94.4%), 53 (93.0%), 12 (100%), and 98 (81.7%) HCV-CH, HCV-HCC, NBNC-HCC, and BDs, respectively. The prevalence was not significantly different between HCV-CH and HCV-HCC, or between HCV-HCC and NBNC-HCC. Comparison between patients with and without TTV revealed no significant differences in backgrounds or biochemical findings. Histopathological findings in patients with HCV-CH, and number, maximum diameter, and histological differentiation of HCC also did not demonstrate any relation to TTV infection. TTV strains can be divided into five groups using phylogenetic analysis, but no disease-specific group appears to exist.

CONCLUSIONS

Our data suggest that: 1) TTV is very prevalent among patients with liver diseases and even among BDs in Japan, 2) TTV infection does not impact on liver damage with HCV infection, and 3) TTV infection also does not affect the development or progression of HCC.

Pathology of chronic hepatitis C in children. Child Liver Study Group of Japan

Limited information is available regarding the histology of hepatitis C virus infection in children. The aim of this study was to determine the histological pattern of chronic hepatitis C (CHC) in children, and liver biopsy specimens from 109 pediatric patients with CHC were examined. Each biopsy specimen was evaluated based on a numerical scoring system for the stage of fibrosis (1-4), the grade of portal/periportal necroinflammation (0-4), the grade of lobular necroinflammation (0-4), and their sum (final grade). The histological lesions considered to be characteristic of chronic hepatitis were also evaluated. None of the children had liver cirrhosis, and 105 cases (97%) were stage 1 or 2. Only 4 children were stage 3. Two of these 4 cases showed hemosiderosis. A significant correlation was observed between the staging score and the final grade in the pediatric patients (r = .59; P < .0001). The histological characteristics of adult CHC, such as lymphoid aggregate, bile duct injury, and fatty changes, were also observed in the children. In conclusion, the majority of children with CHC presented with mild fibrosis, but a few showed CHC with lobular distortion and hemosiderosis. Frequent blood transfusion may aggravate hepatic lesions in pediatric CHC.

The role of granulomatous phlebitis and thrombosis in the pathogenesis of cirrhosis and portal hypertension in sarcoidosis

Sarcoidosis often involves the liver with mild elevation of serum enzymes and granulomas histologically. Rarely, chronic cholestasis, portal hypertension, cirrhosis, or nodular hyperplasia may be found. The pathogenesis of the portal hypertension and of the cirrhosis are not understood, in part because large samples of tissue have seldom been described. We describe the clinical and anatomic findings of four patients with sarcoid liver disease in whom the whole livers were available for examination. One patient had cirrhosis, one had diffuse nodular hyperplasia, and two had small regions of parenchymal fibrosis. The first two of these had a history of variceal bleeding and healed portal vein thrombosis. One had chronic cholestasis without cirrhosis. We suggest that the cirrhosis and focal fibrosis were caused by ischemia secondary to primary granulomatous phlebitis of portal and hepatic veins. The portal hypertension in two patients was likely secondary to portal vein thrombosis, because cirrhosis was absent at the onset of variceal bleeding.

Role of ischemia in causing apoptosis, atrophy, and nodular hyperplasia in human liver

Ischemia is known to be a cause of hepatocellular apoptosis and atrophy in experimental animals, but the effect of vascular obstruction on such lesions in the normal or cirrhotic human liver has not been studied. The purpose of this study was to investigate the role of ischemia in the development of apoptosis, atrophy, and nodular hyperplasia in cirrhotic and noncirrhotic human livers. Apoptosis, focal atrophy, and nodular hyperplasia were semiquantitated in 203 liver specimens obtained at transplantation, segmental resection, or autopsy. These parameters were correlated with etiology, stage, activity, and acute and healed portal vein thrombosis (PVT). Large numbers of apoptotic cells were found in livers with acute PVT (17.2/medium-power field [MPF]) and in infarcts of Zahn caused by obstruction of portal veins (PVs) by tumor (16.4/MPF). Smaller numbers of apoptotic cells were found in cirrhosis of various etiologies (3.8-10.0/MPF) and rarely in normal livers (0.16/MPF). Evidence of healed PVT was found in 47% of cirrhotic livers and was associated with nodular hyperplasia (58% vs. 32%, P < .01) and focal atrophy (79% vs. 49%, P < .002). Apoptotic cells were found equally in those with and without healed PVT (40% vs. 38%, not significant). These observations suggest that apoptosis is a transient response to acute ischemia and that atrophy and nodular hyperplasia are chronic responses to ischemia. Vascular obstruction may be an important cause of the apoptosis and atrophy, which are found in nodular regenerative hyperplasia (NRH), infarct of Zahn, chronic hepatitis, and cirrhosis.

Hepatitis C virus RNA present in saliva but absent in breast-milk of the hepatitis C carrier mother

In order to examine whether saliva and breast-milk are mediators of the vertical transmission of hepatitis C virus (HCV) from an HCV carrier mother, serum, saliva, and breast-milk samples from 11 HCV carrier mothers were collected at the time of delivery, and at approximately 1- to 3-months intervals for as long as 30 months postpartum. Serum was also sampled from their children. All samples were analysed for the presence of HCV RNA, using the nested polymerase chain reaction method. No HCV RNA was detected in any breast-milk samples. In saliva, HCV RNA was detected in four of the 11 mothers (36%). These four mothers also had liver function abnormalities. Hepatitis C virus RNA was not detected in any serum samples of the children, and all children had normal liver function. The children were monitored for periods from 2 to 44 months. During this period, there was no evidence of virus transmission. Breast-milk is not likely to be a source of mother-to-child transmission of HCV. Maternal saliva may harbour HCV, but it may not result in infant infection.

The long-term pathological evolution of chronic hepatitis C

Most patients infected with hepatitis C virus (HCV) develop chronic hepatitis. Unfortunately, the pathological evolution of this disease over time is not completely understood. We studied 70 HCV-positive patients, from whom 2 to 10 liver biopsy specimens (mean, 3.9) had been obtained during an interval of 1 to 26 years (mean, 8.8 years). Each biopsy specimen was evaluated independently by four pathologists who each provided a numerical score for the grade of portal/periportal necroinflammation (0-4), grade of lobular necroinflammation (0-4), their sum (final grade), and the stage of fibrosis (1-4). The scores were correlated with progression of disease, if any, and transition to cirrhosis. During follow-up, 35 patients (50%) developed cirrhosis. Cirrhosis developed in all patients with a high final grade (> or = 5) of necroinflammation on initial biopsy who were followed for 10 years and in 96% of patients with an intermediate final grade (3.5-4.9) who were followed for 17 years. Only 30.4% of patients with low final grade (< or = 3.4) on initial biopsy developed cirrhosis after 13 years. All patients with evidence of septal fibrosis with incomplete nodularity (stage 3.0-3.4) in the initial biopsy progressed to unequivocal cirrhosis by 10 years. The rate of progression to cirrhosis was accelerated in patients whose initial biopsies showed high-grade and -stage lesions. This study demonstrates the importance of grading and staging liver biopsy lesions in chronic hepatitis C, particularly for patients with high-grade necroinflammation, septal fibrosis, and regions of modularity on initial biopsy who are at high risk of developing advanced cirrhosis in the ensuing decade.

Pathomorphologic comparison of hepatitis C virus-related and hepatitis B virus-related cirrhosis bearing hepatocellular carcinoma

A morphologic comparison between hepatitis C virus-related cirrhosis (HCV cirrhosis) and hepatitis B virus-related cirrhosis (HBV cirrhosis) was performed. The materials consisted of 37 surgical specimens obtained from patients with hepatocellular carcinoma (HCC) positive for antibodies to HCV (anti-HCV) and negative for HBV serologic markers, and 21 specimens from patients positive only for hepatitis B surface antigen (HBsAg). In addition, the evolution of the type of cirrhosis associated with HCC was studied in 43 autopsy cases from 1970 to 1975 and 44 cases from 1989 to 1994. The histological features of HCV cirrhosis are characterized by broadly expanded fibrous septa, small regenerative nodules, and a relatively strong inflammatory reaction with prominent lymphoid aggregation and mild regenerative activity of the hepatocytes. HBV cirrhosis is characterized by larger regenerative nodules, a weak inflammatory reaction, and marked regenerative activity of the hepatocytes. In a comparison of the types of cirrhosis associated with HCC during the six-year period from 1970 to 1975 with the six-year period from 1989 to 1994 at Kurume University School of Medicine, macronodular cirrhosis (which was mostly HBsAg-positive) declined from 38.8% to 13.6%; by 1989-1994, most of the associated cirrhosis was mixed macronodular and micronodular type with anti-HCV in serum (in 84%). The morphologic type of cirrhosis associated with HCC reflected the proportion of viral hepatitis due to HBV or HCV involved.

Pathomorphological study of HCV antibody-positive liver cirrhosis

A morphological investigation was carried out to study the pathological features of liver cirrhosis caused by hepatitis C virus (HCV) infection. The materials consisted of liver specimens taken from 47 cases of anti-HCV antibody-positive liver cirrhosis (37 by surgery for hepatocellular carcinoma and 10 by autopsy), and from 21 cases of hepatitis B surface antigen-positive liver cirrhosis as the control. Liver specimens containing more than 10 regenerative nodules were examined. In addition, a histometric study was conducted to determine the degree of fibrosis and the size of regenerative nodule using a computer image-analysis system. The results showed that the histological characteristics of HCV antibody-positive liver cirrhosis are: (i) broadly expanded fibrous septa and small regenerative nodules; (ii) relatively strong inflammatory reaction and prominent lymphoid aggretation in the fibrous septum; and (iii) mild regenerative activity of the liver parenchyma, and infrequent liver cell dysplasia. These findings may facilitate better understanding of the pathology of HCV antibody-positive liver cirrhosis and more accurate pathological diagnosis by needle biopsy.

Squamous cell carcinoma of the ovary--a case report

A 68-year-old woman presented a one-month history of lower abdominal pain and weight loss, and was admitted to our hospital. On physical examination, a large hard mass was palpated in her right lower abdomen. An ultrasonograph and computed tomographic (CT) scan revealed a right ovarian tumor that measured 6.9 x 4.9 cm in size. A total hysterectomy and bilateral salpingo-oophorectomy were performed. The postoperative diagnosis of the tumor was squamous cell carcinoma (SCC) of the ovary. She died of infection and disseminated intravascular coagulation 5 months after surgery. The clinical and autopsy examinations did not show the primary lesions of SCC except in the right ovary. Mature cystic teratoma, Brenner tumor and endometriosis, which are ordinary regarded as the histogenesis of ovarian SCC, were not found, but a few surface epithelial inclusion cysts with squamous metaplasia were observed in non-cancerous area of the right ovary, and the contiguous transition from the metaplastic cyst wall to SCC was confirmed by stepwise serial sections. The present case suggests that the surface epithelium of ovary could be the fourth possibility in the histogenesis of the ovarian SCC.

Ultrastructural studies of the bile duct in alcoholic liver disease

The fine structural characteristics of the bile duct in patients with alcoholic disease are described. Dark cell metamorphosis, edematous microvilli, and increased number of pinocytotic vesicles on the basal wall surface of the duct epithelium were observed. These alterations may be interpreted as evidence of disordered water metabolism, probably reflecting secretion and reabsorption hyperfunction in the duct epithelium. In addition, widened intercellular spaces in the basal half of the epithelium suggested retention of fluid following reverse pinocytosis along the lateral cell surface. Although no alterations of the duct epithelium distinct from those in patients with other liver diseases were apparent in patients with alcoholic liver disease, the basement membrane of the bile duct exhibited unusual duplication with multiple layers and occasional loop-formation in lacunae on the basal surface.

Germanium dioxide-induced nephropathy: a new type of renal disease

Chronic renal failure developed in 5 patients who were taking germanium dioxide (GeO2)-containing compounds. Renal functional deterioration was slow but progressive and dialysis treatment was necessitated temporarily in 2 patients. After the discontinuation of GeO2, the impaired renal function tended to improve but remained abnormal for an observation period of 10-40 months. The lack of proteinuria and hematuria was characterized as the clinical manifestations. Renal biopsy specimens revealed the tubular epithelial cell degeneration containing hematoxylin-positive fine granules on light microscopy, and electron-dense inclusions in the swollen mitochondria on electron microscopy. These findings localized mainly in distal segment of the tubules. In the rats given GeO2 orally for 10 weeks, similar histological lesions were evident, as manifested by marked weight loss, anemia, azotemia, and negative proteinuria. In the rats given carboxyethylgermanium sesquioxide, these changes were not observed and Ge concentration of kidney was significantly lower than in the rats given GeO2. The present study indicates that chronic GeO2 intake causes progressive renal dysfunction characterized by the degeneration of distal tubules.

Effects of human recombinant erythropoietin on anaemia, systemic haemodynamics and renal function in predialysis renal failure patients

Seven anaemic patients with predialysis chronic renal failure were treated with human recombinant erythropoietin. Anaemia was improved, with a 31% increase in haematocrit, but blood pressure increased in all patients with an average of 12% in systolic (P less than 0.01), 14% in diastolic (P less than 0.05) and 13% in mean blood pressure (P less than 0.05). Blood volume was significantly increased by an average of 12%. Cardiac output increased in three of seven patients, and total peripheral resistance in four. GFR, RBF and RPF were not changed but filtration fraction increased significantly (P less than 0.05). It is suggested that blood pressure elevation might be developed as a result of volume expansion, elevated cardiac output, and increased total peripheral resistance.

Does 1 alpha(OH)D3 treatment affect blood pressure levels in maintenance hemodialysis patients?

Forty-eight chronic hemodialysis patients were divided comparably into two groups (24 patients in each). Two micrograms of 1 alpha(OH)D3 was administered to one group for 3 months and its placebo to the other group. In the 1 alpha(OH)D3-treated group, serum total calcium increased from 7.82 +/- 0.11 (mean +/- SEM) to 9.70 +/- 0.27 mg/dl (p less than 0.001) which was significantly higher (p less than 0.001) than control values of 8.86 +/- 0.06 mg/dl from normal volunteers. Systolic, diastolic and mean blood pressures, however, did not change significantly throughout the study. Even in the 9 patients who had a substantial increment of serum calcium of more than 2 mg/dl with hypercalcemia (greater than 10 mg/dl) at 3 months, no significant changes in blood pressure were found. Serum iPTH decreased from 2.83 +/- 0.28 to 0.98 +/- 0.23 ng/ml (p less than 0.001) at 3 months of treatment. Furthermore, a significant inverse correlation was obtained between the changes in serum calcium and iPTH. In the placebo group there were no significant changes in serum calcium, iPTH and blood pressure during the 3-month treatment period. The present study indicates that a substantial increase in serum calcium or a chronic hypercalcemia induced by 1 alpha(OH)D3 treatment in maintenance hemodialysis patients does not accompany a rise in blood pressure, probably due to a concomitant suppression of PTH. The results also suggest that the hypocalcemic state found in hemodialysis patients is not associated with any significant change in blood pressure. The importance of PTH in blood pressure regulation was discussed.

Basal inotropic state in rats with renal hypertension: influence of coronary flow and perfusion pressure

Cardiac performance in renal hypertensive animals has been variously reported as normal, increased, or decreased. Because of the many factors that can alter cardiac function in vivo ventricular contractility was investigated in isolated, paced, isovolumic heart preparations (modified Langendorff). Twenty one hypertensive rats (2 kidney, 1 clip Goldblatt) and 21 matched sham operated controls, were studied. Mean(SD) blood pressure and left ventricular weight were significantly higher in the study rats (228(5) vs 125(2) mmHg and 4.16(0.12) vs 2.35(0.04) mg X kg-1 respectively). In the first experiment performed at 50 mmHg perfusion pressure left ventricular +dP/dt and myocardial flow rate were lower in 12 study rats (mean(SD) 1782(79) vs 2270(105) mmHg X s-1, 5.8(0.4) vs 14.0(1.0) ml X g-1 LV weight X min-1, respectively) than in the controls. In a second experiment performed at 80 mmHg perfusion pressure (nine study hearts and seven controls) the increased myocardial flow rate resulted in a higher left ventricular +dP/dt in both groups, but the study hearts still had a lower mean(SD) myocardial flow rate than the controls (12.5(0.9) vs 19.8(2.2) ml X g-1 LV weight X min-1; the difference in left ventricular +dP/dt became non-significant (2646(186) vs 2951(136) mmHg X s-1). Similarly, at equal myocardial flow rates (study hearts at 80 mmHg perfusion pressure and controls at 50 mmHg perfusion pressure) ventricular performance was similar in the two groups (mean(SD) left ventricular +dP/dt 2270(105) in controls vs 2646(186) mmHg X s-1 in study hearts).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of blood pressure on the progression rate of renal impairment in chronic glomerulonephritis

An effect of high blood pressure on the progression of renal functional deterioration was studied in 23 cases of chronic glomerulonephritis, which showed progressive renal functional impairments during the long-term follow-up period. The slope-of-regression line, which was obtained from the relation between reciprocal serum creatinine concentration (1/Cr) and observation time, was expressed as a progression rate and was evaluated on an association with blood pressure level. The progression rate was found to correlate significantly with the level of diastolic blood pressure (p less than 0.001). It is concluded that the elevation of blood pressure is one of the factors that contribute to the progression of renal functional impairment in chronic glomerulonephritis.

Impaired inotropic responses to alpha-adrenergic stimulation in experimental left ventricular hypertrophy

We have previously reported that left ventricular hypertrophy in two-kidney, one-clip renal hypertensive rats (2K-1C RHRs) was associated with diminished inotropic responsiveness to isoproterenol and glucagon, suggesting an alteration in the receptor-adenylate cyclase cascade. The present study was performed to investigate the hypothesis that in these same hearts, inotropic responses to alpha-adrenergic stimuli could be enhanced as a compensatory mechanism. alpha-Adrenergic stimulation was achieved by graded phenylephrine infusion (1.02 to 41.2 microM/min) in the presence of propranolol (10(-7) M). The inotropic response was evaluated in the isovolumetric isolated rat heart (Langendorff preparation) paced at 260 beats/min. Results showed a significantly reduced inotropic response to alpha 1-adrenergic stimulation in 2K-1C RHR hearts irrespective of perfusion pressure (50 or 80 mm Hg [PP50 or PP80]) (+427.5 +/- 62.1 vs +1236 +/- 216.4 mm Hg X sec-1 at PP50, p less than .01 and +339 +/- 98.3 vs +1440 +/- 254 mg Hg X sec-1 at PP80, p less than .001) even when comparison was made at equivalent myocardial flow rates (RHR hearts perfused at 80 mm Hg vs control hearts perfused at 50 mm Hg). Quantitative assessment of number of alpha 1-adrenergic receptors (3H-prazosin binding) showed a significant decrease compared with that in age-matched sham-operated normotensive control rats (45 +/- 2.5 vs 64 +/- 1.7 fmol/mg protein, p less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Massive pulmonary embolism occurring with corticosteroid and diuretics therapy in a minimal-change nephrotic patient

A 32-year-old female with a relapsing minimal-change nephrotic syndrome developed a massive pulmonary embolism during the treatment of prednisolone and diuretics. The use of diuretics in addition to a hypercoagulable state associated with nephrotic syndrome per se and corticosteroid was considered to be a direct causative factor for the event. The careful use of diuretics and a consideration of additional anticoagulant therapy are emphasized.

Outbreaks of egg-drop syndrome-1976 in Japan and its etiological agent

A condition similar to egg-drop syndrome-1976 (EDS-76) occurred in 14 broiler breeding flocks in 2 farms in Japan from December 1978 to January 1980, and it was diagnosed as EDS-76 by serologic and virological investigations. Egg production fell suddenly when the hens were 30 to 55 weeks of age, and the depression lasted 3 to 7 weeks. Production fell 6 to 25%. Depressed egg production was accompanied by the laying of shell-less, soft-shelled, and thin-shelled eggs associated with loss of egg-shell pigment. Eleven isolates of hemagglutinating adenovirus were isolated from cloacal swabs (10 isolates) and a uterus (1 isolate) of hens in one farm. One isolate, cloned and named JPA-1, had the same antigenicity in serologic tests and the same biological and physicochemical properties as the BC14 strain of EDS-76 virus.

1-year controlled trial of 1 alpha-hydroxycholecalciferol in patients on maintenance hemodialysis

A 1-year controlled trial was performed to confirm the effects of 1 alpha-hydroxycholecalciferol (1 alpha-OH-D3) in chronic hemodialysis patients. Initially, a daily dose of 2 micrograms of 1 alpha-OH-D3 was given orally to 24 patients and its placebo to another 24 patients during the first 3 months. For the following 9 months the dose of 1 alpha-OH-D3 or its placebo was reduced to 1 microgram per day in the individual groups. Serum calcium was significantly increased to the normal level after 1 month of treatment and sustained at this level for 1 year. Serum parathyroid hormone was significantly decreased at 3 months. Serum alkaline phosphatase was decreased to the normal level at the 5th month and thereafter. At 2 months serum phosphorus was significantly increased in the 1 alpha-OH-D3 group. None of the patients on 1 alpha-OH-D3 showed increased subperiosteal resorption on X-rays, whereas 8 out of 20 patients on placebo did (p less than 0.002). No adverse effects were seen apart from 3 patients with the 'red eye' of scleral calcification.

Idiopathic membranous glomerulonephritis associated with diabetes mellitus: light, immunofluorescence and electron microscopic study

The present study described 3 patients with idiopathic membranous glomerulonephritis associated with diabetes mellitus. Clinical characteristics of the 3 patients contrasted with diabetic glomerulosclerosis in the following manner: absence of diabetic retinopathy and neuropathy, and presence of nephrotic syndrome associated with relatively short duration of diabetes mellitus. Renal histology showed the characteristic changes of membranous glomerulonephritis along with those of diabetic glomerulosclerosis. Immunofluorescent studies demonstrated a granular pattern of IgG and C3 deposits along the glomerular capillary wall. Electron microscopic study also demonstrated thickening of glomerular basement membrane and increase of mesangial matrix as well as the presence of electron-dense deposits primarily in the subepithelial and mesangial areas.

Comparison of hemodynamics induced by conventional acetate hemodialysis, bicarbonate hemodialysis and ultrafiltration

Six patients on conventional acetate hemodialysis who had a marked decrease in total peripheral resistance index (TPRI) and hypotension after dialysis were selected for study. Systemic hemodynamic factors such as cardiac output, blood pressure, hematocrit and heart rate were measured, and the values were compared to those found after bicarbonate hemodialysis (Bi-HD) or ultrafiltration without simultaneous dialysis (UF) in the same patients. After Bi-HD and UF, the hemodynamic indices remained stable. Hematocrit level was significantly elevated after Bi-HD (+2.7%, P less than 0.05). Heart rate was insignificantly increased after each procedure. We concluded that Bi-HD can prevent unpleasant side effects induced by the decrease in TPRI with acetate hemodialysis. The stability of TPRI resulting from the increase in hematocrit level during Bi-HD may contribute to the prevention of cardiovascular instability.