[Recurrence of thymoma as pleural dissemination 23-years after surgery]

A 63-year-old female, who was noticed a chest mass approximately 4 cm in diameter on a chest X-ray, was admitted to our hospital. We thought that it was a benign chest wall tumor such as a neurogenic tumor by the findings of the chest computed tomography (CT). Resection of the tumor was performed. Neurogenic tumor was suspected by the frozen section. But it turned out to be a thymoma type AB in permanent preparation. Since she had undergone thymothymectomy 23-years ago, the tumor was considered to be a pleural recurrence of thymoma. We thoroughly checked the chest CT again, and detected another tumor at the right of the thoracic vertebra. Third surgery was performed and the tumor was resected. We experienced recurrence of thymoma as pleural dissemination 23-years after surgery. Thymomas are low-grade malignant tumor, but long-term clinical follow-up is necessary.

[Anti-neutrophil cytoplasmic anti body (ANCA)-negative limited form of Wegener's granulomatosis; report of a case]

A 54-year-old man, who was suspected to suffer from multi-drug resistant lung abcess, was admitted to our hospital. Chest computed tomography (CT) scan showed large cavitary mass in right S6 and nodules in left S1+2 and S10. No abnormal findings were detected without raised immunoglobulin E (IgE) and C-reactive protein (CRP). Anti-neutrophil cytoplasmic antibody (ANCA) was repeatedly negative. We couldn't make a diagnosis by percutaneous biopsy. Finally we performed open lung biopsy of left lung, and Wegener's granulomatosis was diagnosed at last He improved immediately after treatment with prednisolone, cyclophosphamide and sulfamethoxazole-trimethoprim. ANCA-negative Wegener's granulomatosis should be considered when we diagnose multiple pulmonary nodules.

Anti-Hu associated paraneoplastic sensory neuronopathy with upper motor neurone involvement

Paraneoplastic neurological syndrome is characterised by neuronal degeneration with lymphocytic infiltration in various regions of the central and peripheral nervous systems. Motor neurone symptoms may occur as a remote effect of malignancy, and have been considered because of the involvement of lower motor neurones. A case is reported of an 80 year old woman suffering from paraneoplastic sensory neuronopathy with anti-Hu antibody. Postmortem examination showed adenocarcinoma of the gall bladder and small cell carcinoma of the duodenum. Neuronal loss with lymphocytic infiltration was found in the dorsal root ganglia, brain stem, and cerebellum. Despite the absence of upper motor neurone signs, there was severe loss of Betz cells and degeneration of the bilateral pyramidal tracts. To our knowledge, this is the first demonstration of upper motor neurone involvement in anti-Hu associated paraneoplatic syndrome.

Osteosarcomatous differentiation in lung metastases from a malignant phyllodes tumour of the breast

Osteosarcomatous differentiation of a phyllodes tumour in the breast is extremely rare. A 54 year old woman presented with a painless lump in her left breast and a mastectomy was performed. Microscopically, the tumour was diagnosed as a malignant phyllodes tumour, where no osteosarcomatous component was found. One year later, two lung tumours were revealed upon chest x ray and were surgically treated. The tumours revealed osteosarcomatous features, and were thought to be metastases from the phyllodes tumour. The present case is very unusual in that osteosarcomatous features are present only in the metastatic lesion of the phyllodes tumour.

[Results of surgical treatment of pulmonary metastatic tumors and analysis of prognostic factors]

We evaluated surgical outcome and prognostic factors in 35 patients who underwent surgery for pulmonary metastatic tumors. Overall 5-year survival rate was 55.3%. Size of lesions and disease free interval were considered as affecting factors for survival, but not statistically significant. Because number of resected tumors, surgical procedure, laterality (unilateral or bilateral) did not significantly affect survival, we considered that partial resection was appropriate for pulmonary metastases if tumors were complete resected. Tumor size and preoperative serum carcinoembryonic antigen (CEA) levels were significant factors influencing survival for patients of colorectal carcinoma, Ki-67 positive cell ratio for patients of colorectal and breast carcinoma.

Granulomatous colitis associated with botryomycosis of Propionibacterium acnes

Propionibacterium acnes, an anaerobic, non-spore-forming, gram-positive bacillus, is a common inhabitant of the skin, and its virulence is considered to be low in humans. This report describes an unusual case of granulomatous colitis associated with P acnes infection in a 46-year-old woman. The affected cecum exhibited a tumor histologically characterized by massive transmural infiltrates of small lymphocytes and noncaseating epithelioid granulomas with multinucleated giant cells. Botryomycotic granules were also found in the muscular layer and paracolic connective tissues and consisted of gram-positive bacilli with filamentous growth. Polymerase chain reaction confirmed the presence of P acnes 16S ribosomal DNA in the surgical specimen of the colon. The patient developed a postoperative P acnes-induced peritonitis, which subsided with treatment with antibiotics and surgical drainage. The present case indicates that P acnes is one of the possible pathogens for granulomatous colitis.

Interhemispheric cyst causing leg monoparesis in the elderly--case report

A 64-year-old female presented with a rare case of interhemispheric cerebral cyst manifesting as progressive monoparesis in the right lower extremity for 2 years. Surgical excision of the cyst wall was performed and communication to the subdural space was created. Postoperatively, the cyst was greatly reduced in size, and the neurological signs and symptoms were markedly improved. Interhemispheric cyst often presents with motor disturbances such as hemisparesis or paraparesis. These symptoms tend to progress slowly and sometimes years are required for a proper diagnosis. Interhemispheric cyst can also cause slowly progressive monoparesis in the lower extremity.

[Recurrence and pulmonary metastasis of extradural paraganglioma in thoracic vertebral canal: report of a case]

A 70-year-old female was operated on for extradural spinal cord tumor in 1982. Microscopic examination revealed the tumor as paraganglioma. Tumor recurred at paravertebral twice in 1985 and 1989, and they were also resected. In 1995, her chest X-ray film showed round tumor in the right upper field. Exploratory open lung biopsy was performed in 1996, and right upper lobectomy was performed according to for malignant lung tumor because intra-operative microscopic findings showed carcinoid or lung metastasis of paraganglioma. Chest wall tumor at paravertebral was resected at the same time. Postoperative microscopic examination revealed the tumors were same as operated paraganglioma. The 2nd thoracotomy was done in 1999, and two chest wall tumors and a pulmonary nodule in right S8 segment were resected. They were recurrence and pulmonary metastasis of paraganglioma. Now 18 years after initial operation, she is out of hospital in tumor free.

Primary retroperitoneal ganglioneuroblastoma in an adult

A case of retroperitoneal ganglioneuroblastoma in a 60-year-old man is reported. This retroperitoneal tumor was surgically removed and pathologic diagnosis was ganglioneuroblastoma. Ganglioneuroblastoma usually occurs in children and is extremely rare in adults. The characteristics are described of an unusual tumor based on the published reports.

[Activities of antimicrobial agents against 5,180 clinical isolates obtained from 26 medical institutions during 1998 in Japan. Levofloxacin--Surveillance Group]

The surveillance study was conducted to determine the antimicrobial activity of fluoroquinolones (ofloxacin, levofloxacin, ciprofloxacin, tosufloxacin) and other 20 antimicrobial agents against 5,180 clinical isolates obtained from 26 medical institutions during 1998 in Japan. The resistance to fluoroquinolones was remarkable in Enterococci, methicillin-resistant staphylococci and Pseudomonas aeruginosa from UTI. However, many of the common pathogens such as Streptococcus pneumoniae including penicillin-resistant isolates, methicillin-susceptible Stahylococcus aureus, Moraxella catarrhalis, the family of Enterobacteriaceae, Haemophilus influenzae including ampicillin-resistant isolates have been kept to be susceptible to fluoroquinolones. About 90% of P. aeruginosa isolates from RTI were susceptible to fluoroquinolones. In conclusion, the results from this surveillance study suggest that fluoroquinolones are useful in the treatment of various bacterial infections including respiratory infections.

Bronchioloalveolar carcinoma arising in a bronchogenic cyst

We report the case of a 37-year-old woman with a radiographically cystic lung lesion. Lobectomy was performed. Histopathologic examination showed a bronchioloalveolar carcinoma arising in a bronchogenic cyst. This suggests that epithelial cells of bronchogenic cysts can undergo malignant transformation. It may be prudent to recommend complete resection of any bronchogenic cyst.

[Histological study of vascular structure between the dura mater and the outer membrane in chronic subdural hematoma in an adult]

The authors reported the results of histological study of the vascular structure between the dura mater and the outer membrane of chronic subdural hematoma (CSH) in an adult. Many vascular connections were detected at particular part in CSH. According to the microscopical findings and location, these connective vessels were classified into 3 types. 1) Capillary-like vessels had thin walls and narrow diameters. They originated in the middle layer of the dura mater and were connected to macrocapillaries (MC) in the outer membrane. We could not perceive the flow direction in these vessels. 2) Small veins had thin walls and wide diameters. They gathered blood flow of many MC in the outer membrane and entered into the dura mater. Some of them penetrated through the total layer of the dura mater, then flowed into the paraarterial venous sinus of the middle meningeal artery (mmA). 3) Small artery had a thick wall and was about 50 mu in diameter. Though histological continuity was not proved, it was ascertained that the artery originated from a branch of the mmA, and entered the outer membrane. After entering, the small artery separated into many small branches which spread throughout the whole of the outer membrane. The vascular structure of the outer membrane consisted mainly of MC and small arteries with many branches. In this study. We were not able to find the location where both vessels of the outer membrane connected.

Pulmonary alveolar proteinosis in infants

We investigated the histological and molecular characteristics of pulmonary alveolar proteinosis (PAP) in two siblings (a brother and sister) who did not exhibit respiratory distress at birth but who each developed symptoms during infancy. Histological analysis of lung specimens showed positive staining for surfactant proteins in both patients. The polymerase chain reaction revealed expression of messenger RNA for surfactant protein B (SP-B) in the lung specimens. No defect in SP-B which is characteristic of the congenital form of PAP was observed. The concentration of surfactant protein A (SP-A) in bronchial alveolar lavage (BAL) fluid was elevated in patient 1 suggesting the BAL concentration of SP-A may be a clue to the diagnosis of this form of PAP.

CONCLUSION

The accumulation of surfactant protein A in two siblings with an infantile form of pulmonary alveolar proteinosis could be a clue to the diagnosis.

[Histological study of operated cases of chronic subdural hematoma in adults: relationship between dura mater and outer membrane]

In 31 consecutive operated cases of chronic subdural hematoma (CSH) in adults, a histological study of the outer membrane and the dura mater was reported. Only 3 cases had vascular connections between the dura mater and the outer membrane. The vessels from (or to) the dura mater entered into the sinusoidal channel of the outer membrane. Dura mater always showed normal findings and was distinctly separated from the outer membrane, except for vascular connections. Because of this, they were regarded as different tissues. Hemorrhages in and out of the hematoma cavity of the outer membrane were seen in all 12 cases and seemed to be a reason for enlargement of CSH. There were 16 cases of eosinophilic infiltration in the outer membrane. No positive reaction was seen to estrogen receptor staining of either the dura mater or the outer membrane.

[Excision of a chronic expanding hematoma developing after thoracoplasty: a case report]

The patient was a 56-year-old woman who had undergone thoracoplasty for right pulmonary tuberculosis 31 years previously. She consulted her local physician complaining of right shoulder pain. Chest X-rays revealed a mass of the thoracic wall, and the patient was referred to our department. Because of the difficulty in making a diagnosis by needle biopsy and of increased pain, operation was done. The mass was covered by a fibrous capsule, and its center was composed of structure-less material including fibrin and blood cells. A diagnosis of chronic expanding hematoma developing after thoracoplasty was made. Beneath the hematoma, a 5 mm diameter hole communicated with the thoracic cavity. Chronic inflammation at this site appeared to have caused the hematoma.

Crystalloid formation in gastrointestinal schwannoma

We found intracytoplasmic crystalloids in two of six cases (33.3%) of gastrointestinal (GI) schwannomas. The crystalloid inclusions were periodic acid-Schiff (PAS) positive with diastase-resistance and stained blue with Masson's trichrome. They were needle-shaped and about 1 to 15 microm in length at microscopic levels. They had varying electron density revealed by electron microscopy and some of them showed distinct lattice structure with periodicity of about 9 nm. Survey of soft tissue schwannomas (n = 20) and S-100-negative GI stromal tumors (n = 41) did not detect such crystalloids. Although the origin and differentiation of GI stromal tumors (GISTs) have been a source of controversy, these intracytoplasmic crystalloids may be a marker for Schwann cell differentiation in some GIST.

[Retroperitoneal fibrosis with involvement up to the mediastinal space]

A 60-year-old man presented with sudden palpitations in September 1993, and was admitted to hospital with a diagnosis of atrial fibrillation and heart failure. The patient was suspected of having collagen disease, because of a positive test for antinuclear antibodies and a high sedimentation rate. He was referred to lou hospital. Chest radiographic findings were suggestive of cardiomegaly and cardiac murmurs were audible, which indicated the presence of heart disease. A chest Ct scan revealed a lesion surrounding the intramediastinal large vessels and the heart from the level of the confluence of the left brachiocephalic vein and the superior vena cava. Suspicion of a mediastinal tumor led the patient to be admitted to the respiratory department. Percutaneous needle biopsy with a Trucut needle revealed non-specific chronic inflammation. An abdominal CT scan showed that the lesion surrounding the descending aorta traversed the diaphragm, reached the renal pelvis along both renal arteries, and caused narrowing of the ureter and left hydronephrosis. Based on these findings, retroperitoneal fibrosis was diagnosed. Treatment with steroids caused the lesion to shrink.

[Markedly elevated serum fructosamine in a non-diabetic patient with IgA-kappa type multiple myeloma]

We reported a non-diabetic patient with IgA-kappa multiple myeloma whose serum fructosamine value was markedly elevated. The M-protein from this patient was shown to be conjugated to serum albumin confirmed by immunoelectrophoresis and immunofixation. The fructosamine activity was shown in the high molecular weight fraction by S-300 superfine gel chromatography. Although serum fructosamine values of other three non-diabetic patients with IgA type multiple myeloma were elevated, patients with IgG type multiple myeloma and primary macroglobulinemia had low or normal serum fructosamine values. These findings suggested that glycation of monoclonal IgA of multiple myeloma was much more increased than that of other types of immunoglobulins and monoclonal IgA in this patient was conjugated to serum albumin resulting in the elevated serum fructosamine.

Fibril formation in the rough endoplasmic reticulum of lymphoma cells. A case report with histopathologic, immunohistochemical, electron and immunoelectron microscopic studies

Signet ring cell lymphoma (SRCL) is a relatively new and infrequently described entity, characterized by an intracytoplasmic mass displacing the nucleus at the periphery. We present here a case of a Japanese female aged 73 with a retroperitoneal mass diagnosed as SRCL at autopsy. The neoplastic lymphoid cells showing signet ring appearance, due to the displacement of the nucleus to one side by intracytoplasmic eosinophilic inclusions, were immunoreactive for LCA, L26 and lambda light chains but PAS-negative. A small number of tumor cell nuclei demonstrated proliferating cell nuclear antigen-positive, but signet ring cells were negative. Ultrastructural study disclosed that fibrillary, lamellar or homogenous materials within rough endoplasmic reticulum of the tumor cells were selectively labeled by gold particles to anti-lambda antibody. A periodicity of 20-25 nm was observed in the fibrillary inclusions arranged haphazardly. The morphologic appearances of the case and the differential diagnosis are preceded by a review of the literature.

Recurred Castleman's disease containing a fibrohistiocytic nodular lesion with vascular occlusion

A recurring case of Castleman's disease containing a fibrohistiocytic nodular lesion is presented. The recurred tumor was found in the mediastinum of a 40 year old Japanese female who had undergone the extirpation of a mediastinal tumor 18 years previously and had been suffering from rheumatoid arthritis 5 years after the initial removal. Microscopically, the present tumor and the initial removed tumor fulfilled the morphologic criteria for the hyaline-vascular type of Castleman's disease. A well-demarcated nodular lesion (1.5 cm in diameter) was located in the present tumor. It consisted of interlacing oval to short spindle-shaped cells positive for factor XIIIa and vimentin, merging with lymphocytes, plasma cells, macrophages and capillaries lined by swollen endothelial cells. Mitotic figures were not noted. Foci of hemorrhage and necrosis were also not detected. The stenosis or occlusion of the large vessels due to intimal fibrosis and medial hypertrophy was observed around the nodular lesion.

[Determination of potential doubling time using in vitro continuous labeling method with bromodeoxyuridine: estimation in head and neck squamous cell carcinoma]

Using in vitro continuous labeling with bromodeoxyuridine and immunohistochemical staining, potential doubling time (Tpot) was calculated in 24 patients with head and neck carcinoma treated with radiotherapy. There was no evident correlation between Tpot and tumor response in the cases treated with external irradiation. However, in one case of T2N0 mesopharyngeal carcinoma with short Tpot, tumor was microscopically residual even though it showed good radioresponsiveness during radiotherapeutic course. Meanwhile, all patients treated with brachytherapy showed complete response in spite of various Tpot. Tpot seems significant in the selection of fractionation to control head and neck carcinoma with external radiotherapy.

[An autopsy case of four primary cancers including malignant meningioma]

The authors describe an autopsy case of a 68-year-old man with four primary cancers diagnosed at autopsy including malignant meningioma, early esophageal cancer, early gastric cancer and lung cancer. Recently, the number of patients with four and five primary cancers has been increasing. According to the Annual of the Pathological Autopsy Cases in Japan, 156 cases were reported during 16 years from 1974 to 1989. In this series, cancers were detected most frequently in stomach, colon, lung, prostate, liver and esophagus. However, only two cases with four and five primary cancers including malignant meningioma were reported. Because occult cancers like prostatic cancers are unexpectedly diagnosed at autopsy, the incidence of four and five primary cancers including malignant meningioma seems to be higher when the central nervous system is examined more frequently at autopsy.

[Metastasis of uterine cervical cancer to the biceps muscle of right upper arm; report of a case]

A hematogenic metastasis to the biceps muscle of right upper arm was reported in a 48-year-old women with recurrent uterine cervical cancer who had undergone radiotherapy. Cancer metastasis to the limb skeletal muscle is very rare. We have not known the similar case report in uterine cervical cancer.

Papillary and cystic tumor of the pancreas. Two cases indistinguishable from islet cell tumor

Two cases of large cystic tumor of the pancreas in two young women are reported. Gross features and conventional light microscopic appearances of these tumors were consistent with those described as being the so-called papillary and cystic tumor (PCT) or solid and cystic tumor. Immunohistochemical staining for neuron-specific enolase was positive diffusely in both cases. Special stainings with Grimelius' silver impregnation, and stainings for insulin, glucagon, and somatostatin also were positive, although the population of positive cells was different in each case. Ultrastructural examinations confirmed the presence of numerous granules, probably neurosecretory, within the cytoplasm of many tumor cells in each case. Therefore, current cases were indistinguishable pathologically from the cystic nonfunctioning islet cell tumor. This study suggests that some PCT of the pancreas consist of endocrine cells predominantly.

Papillary and cystic tumor of the pancreas. Two cases indistinguishable from islet cell tumor

Two cases of large cystic tumor of the pancreas in two young women are reported. Gross features and conventional light microscopic appearances of these tumors were consistent with those described as being the so-called papillary and cystic tumor (PCT) or solid and cystic tumor. Immunohistochemical staining for neuron-specific enolase was positive diffusely in both cases. Special stainings with Grimelius' silver impregnation, and stainings for insulin, glucagon, and somatostatin also were positive, although the population of positive cells was different in each case. Ultrastructural examinations confirmed the presence of numerous granules, probably neurosecretory, within the cytoplasm of many tumor cells in each case. Therefore, current cases were indistinguishable pathologically from the cystic nonfunctioning islet cell tumor. This study suggests that some PCT of the pancreas consist of endocrine cells predominantly.