Evaluation of carcinomatous pleuritis on initial relapse in patients with lung cancer who underwent complete resection

The purpose of this study was to evaluate the clinical characteristics and results of lung cancer patients with carcinomatous pleuritis on initial relapse. Over the past decade, seven patients out of 595 surgically treated lung cancer patients developed carcinomatous pleuritis as the initial sign of relapse. All patients had undergone complete resection of the primary peripheral type adenocarcinoma. Only 3 cases showed obvious visceral pleural invasion, while venous or lymphatic invasion were frequently found in the histological sections. The mean disease-free interval after surgery was 30.9 months. The median survival after the development of carcinomatous pleuritis was 14 months. The results showed the possible association of blood/lymphatic routes with the development of this type of recurrence. In some lung cancer patients with carcinomatous pleuritis on initial relapse, long-term survival can be expected by aggressive interventions consisting of intrathoracic and/or systemic chemotherapies.

Endosonographic evaluation of c-kit-positive gastrointestinal stromal tumor

BACKGROUND

Endosonographic features of c-kit-positive gastrointestinal stromal tumors (GISTs) were compared with those of leiomyomas and schwannomas.

METHODS

Twenty-four patients with gastric mesenchymal tumors who underwent endoscopic ultrasonography (EUS) and surgical treatment were enrolled. GISTs were defined as c-kit (CD117)-positive tumors, leiomyomas as desmin-positive and c-kit-negative tumors, and schwannomas as S-100-positive and c-kit-negative tumors. Invasion to adjacent organs or more than 20 mitotic counts per 50 high power fields indicated malignancy.

RESULTS

There were 19 GISTs, three leiomyomas, and two schwannomas. All five malignant tumors were GISTs. A marginal halo was found in 12 of 19 GISTs and in both of the schwannomas, but not in any of the three leiomyomas. The echogenicities of GISTs were low but higher than that of the normal proper muscle layer, whereas those of leiomyomas and schwannomas were usually low. Lobulation of the tumor surface was documented only in GISTs, particularly in malignant ones. The tumor doubling time of a malignant GIST was 9.3 months, and that of six benign GISTs was 18.7 months (range = 10.7-28.0 months).

CONCLUSION

Marginal halo and relatively higher echogenicity on EUS might suggest GIST. Marginal lobulation and a short doubling time may be signs of a malignant GIST.

Pulmonary blastoma in a child: report of a case

We describe herein the case of a 2-year-old girl found to have a pulmonary blastoma (PB). The child was admitted to our hospital with the chief complaints of coughing and left-sided chest pain. On admission, a chest X-ray revealed a large mass in the left lung, which measured 10cm in diameter. Computed tomography and magnetic resonance imaging showed a marginally and heterogeneously enhanced tumor filling the left hemithorax. Pathologic findings of the fine-needle aspiration were suggestive of neuroblastoma. Subsequently, a left pneumonectomy with lymph node dissection was performed and histopathological examination confirmed that the tumor was a PB (type III). After the definitive diagnosis was made the patient received combination chemotherapy, and no evidence of recurrence has been seen in the 5 months since surgery.

Immunohistochemical study with antibody to glycoprotein GCDFP-15 for metastatic lung cancer from breast cancer

Even when gross pathologic specimens are available, evaluation is always complicated due to the difficulty in distinguishing the pathologic diagnosis of an adenocarcinoma as a pulmonary metastasis of the breast or lung. In this paper, we describe the usefulness of a preoperative immunohistochemical study using gross cystic disease fluid protein-15 (GCDFP-15). A 50-year-old woman, who had undergone a right radical mastectomy due to an infiltrating ductal carcinoma 4 years previously, was admitted because of an abnormal shadow on chest roentgenography. A chest CT scan showed a nodule 20 mm in diameter with an irregular margin and vascular involvement in the S3 region of the right lung. Though the specimen from a percutaneous CT guided needle biopsy revealed characteristic pathologic findings of a primary lung adenocarcinoma under H.E. stain, which was recommended for lobar resection, we re-examined that specimen immunohistochemically, which disclosed that the tumor cells were negative for the antibody to pulmonary surfactant apoprotein and were positive for GCDFP-15 antibody. Therefore, the diagnosis of a metastatic breast carcinoma in the lung was established. Upon her request, a wedge resection of the right upper lobe including the tumor was performed under video-assisted thoracoscopic surgery (VATS). Her postoperative course was uneventful.

Lumbar paraspinal myonecrosis after abdominal vascular surgery: a case report

STUDY DESIGN

Case report.

OBJECTIVES

Lumbar paraspinal myonecrosis after abdominal vascular surgery.

SUMMARY OF BACKGROUND DATA

Lumbar paraspinal myonecrosis does not appear to have been reported previously.

METHODS

A patient who had severe back pain after abdominal vascular surgery was observed with computed tomographic scans and histologic examination of a specimen obtained in open biopsy.

RESULTS

Computed tomographic scans of the lumbar region demonstrated muscle swelling of the unilateral paraspinal compartment. Histologic examinations of affected muscle revealed fresh ischemic necrosis. A compartmental syndrome was considered from the patient's clinical presentation and radiographic and histologic features. An accompanying secondary infection led to an extensive abscess in the paraspinal compartment. The patient resumed active daily life after aggressive débridements of infected and necrotic muscles.

CONCLUSIONS

A compartmental syndrome in the paraspinal muscle should be kept in mind as a potential cause of acute back pain especially after abdominal vascular surgery.

[Malignant cardiac lymphoma]

A 65-year-old male was admitted to the hospital in shock. The transesophageal echocardiography showed cardiac tumor in the right atrium. The tumor was resected under cardiopulmonary bypass. It was diagnosed as malignant lymphoma of B-cell type by histological examination. After operation, his general condition became satisfactory. Then he received chemotherapy. Twenty days after operation, however, a mass appeared in the right side of chin. It was diagnosed as malignant lymphoma of the same cell type as in the heart. We searched his body with CT and Ga-scanning. No other lesions were found. After the chemotherapy (CHOP, 6 cycles), the mass disappeared. No recurrence was been observed for six months.

Pseudotumor due to pulmonary infarction diagnosed by video-assisted thoracoscopic surgery

We report a case of pulmonary infarction in a 50-year-old man who was referred for an asymptomatic coin lesion in the periphery of the right lower lobe. Computed tomography of the chest demonstrated a subpleural solitary nodule with spicular radiation. Video-assisted thoracoscopic surgery was performed to obtain a histological diagnosis. Thoracoscopic examination showed that the tumor was dark purple and the central portion was gray, indicating blood retention in the lung and necrotic and fibrotic tissue in the central portion. This is the first case of pseudotumor due to pulmonary infarction that was diagnosed by video-assisted thoracoscopic resection.

Expression of CA125 in thoracic endometriosis in a patient with catamenial pneumothorax

A 40-year-old woman had experienced monthly right thoracic pain and productive cough occurring at the beginning of her menstrual period. X-ray findings indicated a diagnosis of catamenial pneumothorax. The serum CA125 level was very high at 159.6 U/ml. Thoracoscopy showed multiple dark cherry-colored nodules with neovascularization on the diaphragm. Following partial resection of the diaphragm thoracic endometriosis was diagnosed. Immunohistochemical staining of these endometrial cells showed antibodies to CA125. She has been well without recurrence for 15 months, and her serum CA125 level was within the normal range after operation.

Frequent expression of mucin core protein MUC1 in non-neoplastic gallbladder mucosa from patients with pancreaticobiliary maljunction

BACKGROUND

Gallbladder carcinoma is known to develop frequently in patients with pancreaticobiliary maljunction, though the causal relationship remains speculative.

METHODS

Histopathologic changes, expression of mucin core protein MUC1 and MUC2, and cell proliferative activities in the gallbladder mucosa from 27 patients with panceaticobiliary maljunction and 21 control gallbladders were examined. Three cases of pancreaticobiliary maljunction were associated with gallbladder carcinoma.

RESULTS

The lining epithelia of the non-neoplastic gallbladder mucosa of pancreaticobiliary maljunction showed frequently papillary hyperplasia and higher proliferative activities, when compared to the control. In 3 cases with carcinoma, MUC1 was expressed on the luminal border and in the cytoplasm of carcinoma cells, particularly in de-differentiated and invasive areas. MUC1 was variably expressed on the luminal surface of the lining epithelia of non-neoplastic gallbladder mucosa in babies, children, youths and adults with pancreaticobiliary maljunction. However, such expression was focally seen in 2 of the 21 control cases (p<0.01). MUC2 was scattered in the hyperplastic and carcinomatous epithelial cells appearing as goblet cells in pancreaticobiliary maljunction and control groups.

CONCLUSIONS

This study suggests that persistent MUC1 expression and increased cell proliferative activities of non-neoplastic gallbladder epithelium of the patients with pancreaticobiliary maljunction after birth reflect an altered phenotype of epithelial cells and these abnormalities may be related to carcinogenesis in such patients.

Lymphoepithelioma-like esophageal carcinoma: report of a case

We herein report the rare case of a patient suffering from lymphoepithelioma-like poorly differentiated squamous cell carcinoma of the esophagus. The patient was a 74-year-old woman in whom an esophageal tumor was found during an operation for thyroid cancer. After performing a subtotal thyroidectomy and cervical esophagectomy, esophageal reconstruction was performed using a free jejunal graft. Based on the results of the pathological examination, the esophageal tumor was diagnosed to be primary lymphoepithelioma-like esophageal cancer, not metastasis of either unknown nasopharyngeal cancer or thyroid cancer. Since surgery, she has survived postoperatively for more than 4 years with no evidence of recurrent disease.

Embryonal renal remnant in the gubernaculum testis

We present a rare case of embryonal renal remnant found by chance as a mass in the gubernaculum testis during an operation on a right undescended testis. We discuss the relationship between this tissue and paradidymis or supernumerary kidney.

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.

Solitary fibrous tumour: significance of p53 and CD34 immunoreactivity in its malignant transformation

AIMS

To clarify the association of p53 and CD34 expression with development of malignant solitary fibrous tumour we have studied 10 cases of solitary fibrous tumour arising in the pleura, retroperitoneum and pelvic cavity with clinicopathological features of malignancy.

METHODS AND RESULTS

Tumours were localized solid masses with or without necrosis in eight and they nearly totally occupied the pleural cavity in two. Basic histology of the tumours was the proliferation of spindle cells arranged in 'patternless' pattern or in interlacing bundles with nuclear atypia and mitotic activities of various degree. In two, high-grade foci were present within low or intermediate-grade tumours. Recurrent tumours also showed more atypical features than primary tumours in two. Immunohistochemical studies showed CD34 positivity in seven, but three of them showed marked diminution or complete loss of CD34 expression in high-grade foci or a recurrent tumour. Three high-grade cases showed totally negative staining for CD34. p53 was strongly expressed in cases with fatal outcome, clinical recurrence, nuclear atypia, high mitotic activity or local invasion, whereas almost negative in benign tumours.

CONCLUSIONS

Malignant solitary fibrous tumours may occur de novo or by transformation within benign or low-grade tumours and may be associated with p53 mutation. Although CD34 is a useful marker in the diagnosis of solitary fibrous tumour, one should bear in mind that its expression can be lost in high-grade tumours.

[Successful use of fluconazole against semi-invasive--pulmonary aspergillosis]

A 53-year-old man was admitted to the hospital because of productive coughing general malaise, and right-sided chest pain. At 41 years of age he was given a diagnosis of gastric cancer, underwent a and gastrectomy, was treated with anti-cancer drugs. At 49 years of age he suffered from atypical mycobacteriosis and received anti-tuberculosis drugs for 1 year. A chest X-ray film showed infiltrative shadows with a cavity in the right upper lung field. Semi-invasive aspergillosis was diagnosed on the basis of the clinical and radiographic findings, positive sputum cultures, and positive serologic tests. After 8 months of therapy with intravenous and oral fluconazole, no pulmonary aspergillosis was evident. Treatment with fluconazole was effective in this case of semi-invasive aspergillosis.

[Adenosquamous cell carcinoma of the lung with multiple cystic metastases in the liver]

A 70-year-old man was admitted to the hospital because of mild dyspnea, a cough, and hemoptysis. A chest X-ray film and a computed tomographic scan showed a mass in the S1.2 region of the left lung, and swollen mediastinal lymph noes. Cytologic examination of sputum sample resulted in the diagnosis of lung cancer. The tumor did not respond to chemotherapy, and the patient died after seven months. Autopsy disclosed a solid tumor of left lung and many cystic lesions in the liver. Histological examination of the lung lesion revealed adenosquamous cell carcinoma. Metastatic lesions in the liver consisted of adenosquamous cell carcinoma, with predominantly squamous cell carcinoma. Cases of lung cancer in which hepatic metastases have many cystic cavities are rare.

Small intestinal metastasis from esophageal carcinoma associated with small intestinal obstruction: report of a case

The small intestine is rarely involved with metastatic tumors from outside the abdomen, and few case reports have been documented in the literature. We describe herein what to our knowledge is the third case of a solitary metastasis from squamous cell carcinoma (SCC) of the esophagus being found in the jejunum, causing small intestinal obstruction.

Histopathology of the liver in non-cirrhotic portal hypertension of unknown aetiology

Non-cirrhotic, long-standing portal hypertension of unknown aetiology is being re-evaluated histopathologically and clinically. In this study, we examined 107 livers with this condition (92 wedge biopsy and 15 autopsy specimens) from five institutions in Japan. These cases were histologically categorized into four groups: idiopathic portal hypertension (66 cases), nodular regenerative hyperplasia (14 cases), partial nodular transformation (two cases), and incomplete septal cirrhosis (25 cases). These four groups shared several histological features: dense portal fibrosis with portal venous obliteration and intralobular slender fibrosis. In addition, the histopathological features characteristic of one group were also found to a mild degree in other groups. The histopathological lesions preceding portal venous obliteration remain speculative. However, the portal venous obliteration may be responsible for the occurrence of sustained portal hypertension and several of the pathological changes in these livers. It seems likely that idiopathic portal hypertension, nodular regenerative hyperplasia, partial nodular transformation and incomplete septal cirrhosis comprise a family of non-cirrhotic, long-standing portal hypertension in Japan, and the histological differences between them may reflect chronological progression of a single disease.

[Classification of US findings of ovarian masses in children]

The ultrasonographic findings of 25 lesions in 23 patients with surgically proven ovarian masses were reviewed. There were 10 cystic teratomas, two simple cysts, two follicular cysts, two mucinous cystadenomas, two NHL, one corpus luteum cyst, one hydrosalpinx, one serous cystadenoma, one yolk sac carcinoma, one dysgerminoma, one embryonal carcinoma, and one mixed form (yolk sac carcinoma, choriocarcinoma). All patients were less than 15 years old. We classified all cases into four patterns: cystic, cystic with mural nodule, mixed, and solid. Eight lesions of the cystic pattern included two simple cysts, two follicular, cysts and one corpus luteum cyst. The other lesions were benign, too. Nine lesions with the cystic with mural nodule pattern consisted of eight cystic teratomas and one mucinous cystadenoma. All lesions were benign. The mixed pattern was seen in four lesions, half of which were malignant, i. e., one embryonal carcinoma and one yolk sac carcinoma. Four lesions with the solid pattern were all malignant masses: one dysgerminoma, two NHL and one mixed form. In this classification, the cystic and cystic with mural nodule patterns are benign, while mixed and solid patterns are highly suggestive of malignancy.

Papillary carcinoma of the thyroid gland with fibromatosis-like stroma: a case report and review of the literature

A new case of a rare variant of papillary carcinoma of the thyroid gland with fibromatosis-like stroma is reported. The patient was a 43-yr-old woman who had a well demarcated tumor that showed an expansive growth from the left thyroid lobe into perithyroidal soft tissues. Histologically, the tumor was composed predominantly of a fibromatosis-like stroma in which were diffusely dispersed small follicles of papillary carcinoma. At the advancing front of extrathyroidal extension of the tumor, fibromyxomatous changes of soft tissues were preceded by infiltration of the papillary carcinoma component. Immunohistochemistry and electron microscopy showed that the stromal cells had a myofibroblastic nature. One metastatically involved lymph node did not show fibromatosis-like stroma. The patient has remained well with no evidence of recurrence for 1 yr.

Thymic carcinoma involving the thyroid gland: report of two cases

Two new cases of thymic carcinoma involving the thyroid gland and manifesting as thyroid tumors are presented. One tumor occurred within the thyroid gland and the other totally involved the thyroid gland. Microscopically they showed lobular architecture separated by fibrous bands and consisted of solid islands of squamoid to spindled epithelial cells with whorl formation resembling Hassall's corpuscle and variable amounts of lymphocytes. The squamoid to spindled epithelial cells were positive for cytokeratin but negative for thyroglobulin and calcitonin and the majority of lymphocytes showed a T-cell phenotype. One of the two cases had been diagnosed initially as squamous cell carcinoma of the thyroid. This type of thyroid carcinoma is relatively rare, but it should be differentiated from other types of thyroid carcinomas, especially squamous cell carcinoma, medullary carcinoma, or anaplastic carcinoma of the thyroid.

[A case of intra-pulmonary lymph nodes presenting as multiple small nodular lesions in both lungs]

A 59-year-old man came to our hospital for further examination of multiple small nodular lesions in both lungs. Chest CT scan revealed multiple nodular lesions in rt-S6, It-S5, and It-S9 (two lesions). All of these nodules measured about 10 mm or less and those in It-S9 had spicula. Bronchoscopic examination did not yield a definitive diagnosis, so open lung biopsy was done. The open lung biopsy specimen revealed intra-pulmonary lymph nodes with anthracosis and pulmonary emphysema. Intrapulmonary lymph nodes are very difficult to distinguish from small lung tumors by radiographic examination alone, so the possibility that small nodules in the lungs may be intra-pulmonary lymph nodes should be kept in mind.

[Long-term survival of a patient with lung cancer with skip metastasis to supraclavicular lymph nodes]

A case of lung cancer with skip metastasis to supraclavicular lymph nodes is described. The patient had undergone radical resection for gastric cancer about nine years ago. For about one year, chemotherapy had been done by Tegafur (600 mg/day) after operation. Radical resection for lung cancer (p/d squamous cell carcinoma) was performed about seven years ago. Pathologically, mediastinal lymph node metastasis could not be detected. The needle aspiration biopsy of supraclavicular lymph node revealed metastasis. Then, radical neck lymph nodes dissection involving supraclavicular lymph nodes and radiation therapy were added. There has been no sign of recurrence so far.

Fibroepithelial polyp of the verumontanum. A case report and literature review

A case of fibroepithelial polyp of the verumontanum in a 20-year-old male is presented. The endoscopic examination revealed polypoid lesion protruding from the verumontanum, and transurethral resection of the tumour was performed. The histopathological diagnosis was fibroepithelial polyp, containing no prostatic glandular structures. As the nomenclature of the lesions is widely varying, we tried to classify polypoid or papillary lesions of the prostatic urethra by a literature review.

[A case of prostatic adenocarcinoma with pulmonary metastases--diagnosis by transbronchial lung biopsy and immunohistochemistry]

Metastatic pulmonary adenocarcinoma was found in a 79-year-old man, who had symptoms of general malaise and poor appetite. An extensive work-up including a transurethral resection of the prostate, failed to establish the primary site of the malignancy. By administering chlormadinone acetate for prostatic hypertrophy, the pulmonary metastases improved dramatically. The tumor cells in the lung, which had previously been obtained by transbronchial lung biopsy, stained positive for prostatic acid phosphatase and prostatic specific antigen. These data suggested that prostatic carcinoma had metastasized to the lung. The prostatic carcinoma was finally confirmed at autopsy.

Intrahepatic cholangiocarcinomas associated with nonbiliary cirrhosis. A clinicopathologic study

To determine the prevalence and clinicopathologic features of cholangiocarcinoma (CC) associated with nonbiliary cirrhosis, we performed a clinicopathologic study. Among the 5,563 autopsies in our laboratories during the past 14 years, 85 (1.5%) were CCs. Four (4.7%) were associated with cirrhosis, due to hepatitis B virus in one case and cryptogenic (probably non-A non-B hepatitis virus) in the remaining three. Clinically, patients with CC and cirrhosis were characterized by male preponderance, lower age, past history of liver injury, and elevated values of zinc sulfate and thymol turbidity tests. Pathologically, all CCs with cirrhosis were basically adenocarcinoma; other histologic features included adenocarcinoma resembling bile ductules without mucin (one case), adenocarcinoma with broad areas of signet ring cell carcinoma (one case), adenocarcinoma with extensive sarcomatoid transformation (one case), and adenocarcinoma associated with hepatoliths (one case). Immunohistochemically, immunophenotypes of carcinoma cells of CC with cirrhosis were not different from those of CC without cirrhosis. Carcinoembryonic antigens, CA19-9, DU-PAN-2, and biliary-type cytokeratins were positive and alpha-fetoprotein was negative, suggesting that our CCs are not hepatocellular neoplasms but true CCs. It must be stressed that there are actual CCs arising in nonbiliary cirrhotic livers.

Immunohistochemical detection of breast specific antigens and cytokeratins in metastatic breast carcinoma in the liver

The present study was performed to evaluate the diagnostic reliability of antibodies to breast carcinoma-specific antigen and antibodies to cytokeratin catalogue in a metastatic hepatic lesion. Immunohistochemical examinations using antibodies to gross cystic disease fluid protein-15 (GCDFP-15), BCA-225 (a glycoprotein secreted by T47D breast carcinoma cell line) and BRST-5 (a glycoprotein identified in SK-BR-7 breast carcinoma cell line), anti-cytokeratin monoclonal antibodies of MA904, AE3, CAM5.2, PKK1 and cytokeratin 19, and polyclonal anti-keratin antibodies were done. These were on 15 cases of primary breast carcinoma, eight cases of metastatic breast carcinoma in the liver, five cases of cholangiocarcinoma, eight cases of hepatocellular carcinoma and 11 cases of metastatic adenocarcinoma of another primary tumor in the liver. Results showed that GCDFP-15 antigen was most reliable: it was 100% positive in both primary and metastatic breast carcinomas unrelated to histological subtypes, and 100% negative in primary or other metastatic carcinomas in the liver. BCA-225 antigen was detected in high amounts in breast carcinomas (100%, 23/23), but it was positive in cholangiocarcinomas (80%, 4/5) and another metastatic carcinoma in the liver (64%, 7/11). BRST-5 was specifically positive in breast carcinomas but the positivity was low (13%, 3/23). Cytokeratin 19 and keratin were useful to discriminate hepatocellular carcinomas (0%, 0/8) from breast carcinomas (87%, 20/23; 96%, 22/23), but they were also positive in cholangiocarcinomas (100%, 5/5) and other metastatic carcinomas in the liver (91%, 10/11).(ABSTRACT TRUNCATED AT 250 WORDS)

Immunohistochemical analysis of gastrointestinal carcinoids

Clinicopathological and immunohistochemical analyses were performed on ten samples of gastrointestinal carcinoids resected in Ishikawa Prefectural Central Hospital. All samples showed positive reaction to chromogranin A. Serotonin was detected in 8 samples, somatostatin in 4 samples, gastrin in 2 samples. Glucagon/Glicentin in 1 sample, and PYY production in 2 samples. CEA production was detected in 8 samples, and microvascular invasion was observed in 6 of these 8 patients. The PCNA/cyclin labeling index (L.I.) of the cases with metastases was significantly higher than those without metastases. In conclusion, the expression of CEA and the PCNA/cyclin L.I. may be useful markers of the malignant potential of carcinoid tumors.

[An autopsy case of dermatomyositis associated with interstitial pneumonia probably due to cytomegalovirus infection]

An autopsy case of dermatomyositis (DM) associated with interstitial pneumonia probably due to cytomegalovirus infection is reported. After corticosteroid therapy for 1 month, a 79-year-old man with DM developed acute respiratory failure due to interstitial pneumonia and died in spite of intensive respiratory care. By polymerase chain reaction method (PCR), DNA of cytomegalovirus (CMV) was detected in the bronchoalveolar lavage fluid (BALF). CMV was also detected by the method of conventional virus culture from BALF. These findings suggested that initial infection or reactivation of CMV had occurred in the lungs. The autopsy specimen revealed the findings of interstitial pneumonia compatible with CMV pneumonitis, but without the presence of intranuclear inclusion bodies. Although the present case of interstitial pneumonia should not strictly be diagnosed as definite CMV pneumonitis without the presence of intranuclear inclusion bodies in the lung tissue, initial infection or reactivation of CMV in the lungs may have contributed to the pathogenesis of interstitial pneumonia. In other cases of collagen vascular disease associated with interstitial pneumonia, CMV or other viruses may contribute to the pathogenesis of interstitial pneumonia.

Pulmonary infiltrates with eosinophilia due to naproxen

An increasing number of drugs have been implicated in the etiology of eosinophilic pneumonia characterized by the development of pulmonary infiltrates, and peripheral blood eosinophilia. Naproxen is a commonly used nonsteroidal anti-inflammatory drug which may be added to the growing list of pharmacologic agents associated with infiltrative pulmonary lesions. A case of eosinophilic pneumonia induced by Naproxen is described. The results of TBLB, a lymphocyte stimulation test, and a challenge test supported this diagnosis.

Demonstration of nucleolar organizer regions in intrahepatic bile duct carcinoma by the silver-staining technique

A silver colloid technique to identify argyrophilic nucleolar organizer region associated protein (AgNOR) was applied to 43 cases of intrahepatic bile duct carcinoma (cholangiocarcinoma, CC), 2 with bile duct adenoma (BDA), 5 with focal duct epithelial hyperplasia (FEH) associated with hepatolithiasis, 15 with posthepatitic ductular proliferation (PHDP) associated with massive or submassive hepatic necrosis and 20 of normal liver. In the present study, only discrete, easily counted black dots within nuclei and silver-stained nucleolus were counted under a magnification of x 400 without oil-immersion objectives. The mean AgNOR count of CC was significantly higher than those of BDA, FEH, PHDP and normal controls (P less than 0.05, P less than 0.001, P less than 0.01, and P less than 0.001, respectively). Among CCs the mean AgNOR numbers of papillary adenocarcinoma (pap), moderately (tub2) and poorly differentiated (por) adenocarcinoma, and adenosquamous carcinoma (as) were significantly higher than that of normal controls (P less than 0.01, P less than 0.001, P less than 0.001 and P less than 0.001, respectively), and those of tub2, por and as were also significantly higher than those of BDA, FEH and PHDP, whereas that of well differentiated tubular adenocarcinoma (tub1) was not different from those of BDA, FEH, PHDP and normal controls, and that of pap was not different from those of BDA, FEH and PHDP. The mean numbers of AgNORs of BDA and FEH were not different from that of normal controls, whereas that of PHDP was significantly higher than that of normal controls (P less than 0.01). Interestingly, the mean AgNOR counts of tubular adenocarcinoma were increased with histologic tumor grades.(ABSTRACT TRUNCATED AT 250 WORDS)

Amyloid deposition in intrahepatic large bile ducts and peribiliary glands in systemic amyloidosis

Amyloid deposition in the hepatic parenchyma and portal tracts in the liver is well known in systemic amyloidosis. We recently experienced an autopsy case of systemic amyloidosis presenting the amyloid deposits in the intrahepatic biliary tree. This experience prompted us to survey 19 autopsy cases of systemic amyloidosis. Amyloid deposition was found just under the lining epithelium of the intrahepatic large bile duct in 10 of 19 cases and around the peribiliary glandular acini in 7 of the 19 cases, respectively. Amyloid deposition in the intrahepatic large bile duct and peribiliary glands was positively correlated with the degree of amyloid deposition in the liver but not with type of amyloid protein. Double-staining of amyloid and vascular endothelium disclosed that amyloid deposition was more closely related to the inner part of the peribiliary vascular plexus and to the vascular plexus encircling the peribiliary glands than the lining biliary epithelium and peribiliary glandular acinar cells themselves. The exact pathogenesis of amyloid deposition in these anatomical components, however, remains unclear. Although our cases failed to show any overt clinical symptomatologies related to amyloid deposition in these biliary components, it seems conceivable that more massive amyloid deposition in these anatomical components could give rise to some clinical symptoms.

Immunohistochemical demonstration of growth factors, TGF-alpha, TGF-beta, IGF-I and neu oncogene product in benign and malignant human breast tissues

The expression of growth factors, TGF-alpha, TGF-beta, IGF-I and neu oncogene product was studied immunohistochemically in the tissue of 120 benign and malignant human breasts. Growth factors were found only in benign or malignant mammary epithelial cells and not in stromal cells. Normal and benign lesions were found to be negative for reactivity with each antibody. Carcinoma in situ and invasive breast carcinomas demonstrated a significantly higher percentage of stained cells than that observed in benign lesions; forty (49%) of 82 invasive carcinomas were positive for TGF-alpha, 31 (38%) for TGF-beta, 31 (38%) for IGF-I and 34 (41%) for neu product. No overall correlations were found between expression of each growth factor and the clinical stage or degree of histologic differentiation of the carcinomas. A significant positive correlation was observed between ER status and IGF-I expression and between PgR status and TGF-beta expression. In the majority of the carcinomas, co-expression between TGF-alpha, TGF-beta and IGF-I was observed; the percentage of cases with parallel positive or negative expression of two growth factors was as follows; TGF-alpha - TGF-beta (70%), TGF-alpha - IGF-I (57%), TGF-beta - IGF-I (71%). The concomitant expression of TGF-alpha and neu oncogene product in cell surface was also observed. The relapse-free intervals of the patients were studied in association with expression of each growth factor. TGF-beta-positive tumors showed a significantly better prognosis than TGF-beta - negative tumors (within the first 2 years of observation). However, TGF-alpha, IGF-I and neu overexpression showed no effect on the prognosis of the patients.

'Metaplastic lesions' in intrahepatic bile ducts in hepatolithiasis: a histochemical and immunohistochemical study

Pathology of the intrahepatic bile ducts bearing calculi was examined with an emphasis on metaplasia in 22 cases of hepatolithiasis and in seven cases of normal livers. Normal livers contained few glandular elements within the bile duct walls and no metaplastic lesions or endocrine cells. In hepatolithiasis, a number of mucous glands resembling pyloric glands (pseudopyloric gland metaplasia) were seen within duct walls in all cases. The epithelial cells of the glands were positive for class III mucin with paradoxical concanavalin A staining which is known to be specific for pyloric glands. These cells were also positive for neutral, sialo- and sulfomucin to a variable extent. Intestinal metaplasia, including goblet cell and Paneth cell metaplasia, was found within duct walls and in covering epithelia in five (23%) cases. Endocrine cells, including argyrophil, argentaffin and gut hormone-containing cells were present in these metaplastic lesions in 13 (59%) cases. The occurrence of endocrine cells was closely associated with intestinal metaplasia, although there were a few endocrine cells in metaplastic pseudopyloric glands. These findings suggest that metaplastic lesions similar to the well-known metaplastic lesions in the gallbladder occur in the intrahepatic bile duct walls in hepatolithiasis. The appearance of metaplastic lesions and endocrine cells may be causally related to chronic inflammatory processes associated with hepatolithiasis.

Diffuse sclerosing variant of papillary carcinoma of the thyroid. Report of three cases

Three cases of an unusual diffuse sclerosing variant of papillary carcinoma were found among 370 consecutive malignant tumors of the thyroid gland retained in the surgical pathology files of Kanazawa University Hospital over the last 10 years. The tumors were characterized by diffuse involvement of one or both lobes of the thyroid, dense fibrosis, papillary carcinoma with marked squamous metaplasia and abundant psammoma bodies, heavy lymphocytic infiltration and extensive lymphatic permeation. In two cases, the neoplasms showed more aggressive regional lymph node metastases and local invasion; the patient in the first case underwent surgery three times after initial radical surgery because of regional lymph node recurrences, and the second case showed direct invasion of the thyroid tumor to the larynx and distant metastasis to the lungs. Although the number of examined cases was small, the findings suggest that the diffuse sclerosing variant type has a less favorable prognosis and should be differentiated from papillary carcinomas with excellent prognosis.

[Clinico-pathological study of xanthogranulomatous cholecystitis]

Xanthogranulomatous cholecystitis (XGC) is an uncommon lesion which may form a tumor-like mass in inflamed gallbladders. In a review of 44 cases there were 40 associated with gallstones which had been incarcerated in the neck of the gallbladder, 10 with past histories of abdominal surgeries, 15 with diabetes mellitus, three with carcinomas in the neck of the gallbladder and four with carcinomas in the other organs. Radiologically the differential diagnosis of gallbladder cancer and XGC was difficult in several cases. Thirty five cases of XGC have been diagnosed as chronic cholecystitis and 7 have been mistaken for feature of XGC in the contrast enhancement CT that is, detection of an intramural low density mass with continuously enhanced internal membraneous layer of the gallbladder wall. In view of the clinico-pathological findings of XGC, the lesions appear to result from intramural extravasation of bile and subsequent xanthogranulomatous reaction under obstructive conditions in the neck of the gallbladder. We conclude that XGC is not an uncommon special type of cholecystitis but an accompanied lesion sometimes seen in a kind of cholecystitis.

Intrahepatic cholesterol stones associated with peripheral cholangiocellular carcinoma: an autopsy case

A rare autopsy case of intrahepatic cholesterol stones associated with peripheral intrahepatic cholangiocellular carcinoma is presented. The patient, a 60-yr-old man, was diagnosed as having peritoneal dissemination of adenocarcinoma, and died of respiratory failure 4 months later. At autopsy, intrahepatic cholangiocellular carcinoma was found at the left lateral segment of the liver. The cancer was extensively disseminated to the peritoneal cavity. In addition, the liver harbored a cholesterol stone (1.0 cm in diameter) impacted in the right peripheral bile duct, as well as tiny cholesterol stones (0.1-0.2 cm in diameter) scattered in the intrahepatic peripheral bile ducts. A few tiny cholesterol stones were also present in the cancerous bile ducts. Although the causal relationship between the intrahepatic cholesterol stones and cholangiocellular carcinoma remains speculative, clinicians should be aware of this association.

Hepatic granulomata in long-term hemodialysis patients with hyperaluminumemia

We describe two long-term hemodialysis patients with hyperaluminumemia, in whom multiple granulomata were found in the livers at autopsy. The granulomata were mainly composed of modified macrophages, and aluminum was constantly detected in the cytoplasm of these macrophages by histochemical analysis, as well as by X-ray microanalysis. These granulomata were also found in the spleen and lymph nodes. The constant presence of aluminum in the mononuclear phagocytic system might have been followed by the development of granulomata. Functional disturbances of the liver were not evident.

Hepatic calcification in proliferated bile ductules in a uremic patient

Hepatic calcification in uremia is rare and, to our knowledge, only two cases have been reported in the English literature. In both previous reports, calcification was found in the damaged hepatocytes in the centrilobular to midzonal area of the hepatic lobules. The patient, a 61-year-old man, was uremic due to diabetic nephropathy. He had suffered posttransfusion hepatitis just before his death. Antemortem radiographic examination of the abdomen failed to visualize the calcification in the liver. At autopsy, microscopic examination of the liver revealed bile ductular proliferation and calcification mainly in the ductular epithelial cells. We suggest that calcification could occur preferentially in abnormally proliferated ductules when the serum calcium and serum phosphorus products are elevated.

Macroregenerative nodules of the liver in primary biliary cirrhosis: report of two autopsy cases

Recently, macroregenerative nodules of the liver have been regarded as putative precancerous lesions in human cirrhotic livers. We describe the morphologies of two macroregenerative nodules, one benign and another harboring a malignant hepatocellular focus, occurring in two patients with primary biliary cirrhosis, both at the cirrhotic stage. The macroregenerative nodules of both patients were found incidentally at autopsy. The macroregenerative nodule of case 1 (42-yr-old female) was composed of hyperplastic hepatocytes with little atypia. The macroregenerative nodule of case 2 (67-yr-old male) had a malignant focus, in addition to atypical hepatocytes. The atypical hepatocytes showed mild nuclear crowding, slightly increased nucleocytoplasmic ratio, and mild nuclear hyperchromasia. The malignant focus was free of stainable iron against the mildly siderotic background. These findings may support the concept that macroregenerative nodules can also be a preneoplastic lesion in primary biliary cirrhosis.

Endocrine cells in the intrahepatic biliary tree in normal livers and hepatolithiasis

Endocrine cells in the intrahepatic biliary tree were examined histochemically and immunohistochemically in human infants and adults, as well as in patients with hepatolithiasis. Endocrine cells were sparse but found rather constantly in normal infant livers as well as in adult livers. Almost all endocrine cells were of argyrophil cells or somatostatin-containing cells, and they were usually found in the extramural peribiliary glands in normal livers. On the other hand, in hepatolithiasis in which there were marked proliferation of the peribiliary glands and hyperplasia of surface-lining epithelia, many kinds of endocrine cells were seen in the extramural and intramural peribiliary glands, as well as in the lining epithelial layer. Furthermore, these endocrine cells were hyperplastic in the affected intrahepatic bile duct in two patients with hepatolithiasis. These data suggested that argyrophil cells and somatostatin-containing cells are physiologically present in the intrahepatic biliary tree, and many kinds of other endocrine cells newly appear and even proliferate in hepatolithiasis. These findings imply the participation of reported action of these hormones on bile flow in normal livers and hepatolithiasis.

An autopsy case of malignant histiocytosis with Reed-Sternberg-like cells

We report an autopsy case of malignant histiocytosis. The clinical course was rapidly progressive and terminated with jaundice and respiratory failure. Histologically, there was diffuse infiltration of large atypical cells in the liver, spleen, lymph nodes and bone marrow. It was of interest that these tumor cells contained a number of bizarre multinucleated cells histologically indistinguishable from Reed-Sternberg cells of Hodgkin's disease, and that these atypical cells expressed DAKO M1 (identical to Leu M1) and Ki-1 antigens and also showed binding to peanut agglutinin (PNA), representative markers of Reed-Sternberg cell. An absence of epithelial membrane antigen and presence of Leu M1 antigen in the tumor cells made a diagnosis of Ki-1 lymphoma unlikely. This case study showed that giant or pleomorphic cells indistinguishable histologically and phenotypically from Reed-Sternberg cells occur in malignant histiocytosis.