[Indication for limited surgery on small lung cancer tumors measuring 1cm or less in diameter on preoperative computed tomography and long-term results]

OBJECTIVE

Non-invasive lung cancers showed a good prognosis after limited surgery. But it is still uncertain about invasive lung cancers. We investigated the indications for limited surgery for small lung cancer tumors measuring 1 cm or less in diameter on preoperative computed tomography (CT).

METHODS

This study retrospectively analyzed of 1,245 patients who underwent complete resection of lung cancer between 1989 and 2004 in our hospital. Sixty-two patients (5%) had tumors measuring 1 cm or less in diameter. The probability of survival was calculated using the Kaplan-Meier method.

RESULTS

All diseases were detected by medical checkup, 52 % of the patients were not definitively diagnosed with lung cancer before surgery. Adenocarcinoma was histologically diagnosed in 49 patients (79%). Other histologic types included squamous cell carcinoma (8), large cell carcinoma (1), small cell carcinoma (1), carcinoid (2), and adenosquamous cell carcinoma (1). Fifty-seven patients (92%) showed pathologic stage IA. The other stages were IB (2), IIA (1), and IIIB (2). There were 14 bronchioloalveolar carcinomas (25% of IA diseases). The 5-year survival rates of IA patients were 90%. The 5-year survival rate of patients with tumors measuring 1cm or less diameter was 91% after lobectomy or pneumonectomy, and 90% after wedge resection or segmentectomy. There were 3 deaths from cancer recurrence, while there were no deaths in 14 patients with bronchioloalveolar carcinoma

CONCLUSION

After limited surgery, non-invasive cancer showed good long-term results, while invasive cancer showed a recurrence rate of 2.3% to 79% even though the tumor measured 1 cm or less in diameter on preoperative CT.

[Thymoma transformed to thymic carcinoma with brain and bone metastases 6 years after recurrence]

We report a man who developed brain and bone metastases 6 years after resection of recurrent thymoma. The patient underwent surgery for B2-thymoma [World Health Organization (WHO) classification] without microscopic capsular invasion at 50-year-old. The next year, he underwent the second surgery for recurrent B2-thymoma as pleural dissemination. Seven months after the second surgery, he developed recurrence of pleural dissemination. The patient refused any further aggressive treatment, including surgery, chemotherapy, and radiotherapy. The pleural disease did not increase over 6 years, then suddenly enlarged. Thereafter, the patient developed left hemiparesis due to brain metastases, followed by bone metastases. Immunochemical studies of the metastatic tumors demonstrated that these lesions seemed to be poorly differentiated thymic carcinoma (small cell carcinoma) on WHO classification. We concluded that the thymoma transformed to thymic carcinoma with brain and bone metastases during 6 years.

[Neuro-Behcet disease mimicking a thalamic tumor]

A case of neuro-Behcet disease presenting as a thalamo-lenticular expanding lesion is reported. A 41-year-old female was admitted with mental deterioration and right hemiparesis. She had been suffering from recurrent oral and genital ulcers and erythema nodosum for several years before admission. Neurological examination on admission revealed poor mental activity, dysarthria and right hemiparesis. Lumbar puncture showed CSF pleocytosis. CT and MRI revealed a thalamo-lenticular expanding lesion. CT showed a homogeneous hypodense lesion of the left lenticulothalamic region, which was enhanced in the central part, exerting a mild mass effect. MRI also revealed the lesion better. The T2 weighted images showed a high intensity signal in the left thalamo-lenticular region and the left peduncle. The T1 weighted images showed a low signal in the corresponding areas with a central enhancement with Gd-DTPA. EEG, SPECT and angiography indicated normal findings. Histologic study of the brain biopsy tissue ruled out a tumor but did not show any specific diagnosis. The patient improved with steroid therapy. In conclusion, the clinical and radiological presentation of neuro-Behcet disease can mimic a cerebral tumor. In such cases, stereotactic biopsy is useful to exclude suspicion of a cerebral tumor.

Recurrent malignant variant of phosphaturic mesenchymal tumor with oncogenic osteomalacia

Phosphaturic mesenchymal tumor is a rare neoplasm which causes osteomalacia or rickets. The tumor typically follows a benign clinical course. Even in the rare malignant cases, local recurrence and distant metastasis are uncommon. We report on an example of a malignant phosphaturic mesenchymal tumor which recurred several times over 16 years concurrently causing hypophosphatemia, bone pain, and osteomalacia. Following each surgery, symptoms and hypophosphatemia improved. The patient died of disease 17 years after the first surgery. Histologically, the initial tumor was composed of small spindle cells with clusters of giant cells, prominent blood vessels, poorly formed cartilaginous areas, and crystalline material. Cytological atypia was minimal. Following multiple recurrences, the tumor demonstrated areas of high-grade sarcoma exhibiting marked pleomorphism, numerous mitotic figures, and p53 overexpression. This case illustrates the potential lethality of incompletely removed phosphaturic mesenchymal tumors.

Collagenous fibroma of the arm: a report of two cases

A recently proposed addition to fibrous tumors in soft tissue was first described as desmoplastic fibroblastoma and later renamed collagenous fibroma. This tumor is clinically and morphologically distinct and benign. However, only a few series have been reported, and the clinicopathologic features are not widely recognized. We present two cases of collagenous fibroma of the arm. Both patients presented with an enlarging, well-circumscribed and mobile soft tissue mass. Magnetic resonance imaging showed areas of low signal intensity on both T1- and T2-weighted sequences. Needle aspiration cytology revealed nondiagnostic samples because of the low cellularity of the tumors. Each of the resected tumors was composed of low-cellular spindle- to stellate-shaped cells in a fibrous matrix with clear margination. After the marginal excisions, no recurrences were observed. Clinicians should be aware of this entity to prevent overtreatment, because imaging findings and cytologic features are similar to those of desmoid tumor.

Utility of blasts with a clear halo around the nucleolus as a predictive indicator for disease progression in patients with myelodysplastic syndromes and aplastic anemia

This study was designed to evaluate the utility of blasts with a clear halo around their nucleoli (BCHN) as a predictive indicator of disease progression in myelodysplastic syndromes (MDSs) and aplastic anemia (AA). Bone marrow aspirates from 75 patients with MDSs and 18 with AA were fixed in 95% ethanol solution or 10% neutral formalin and stained with the Papanicolaou method. BCHNs were detected in 57 of 75 patients with MDSs and in 10 of 18 AA patients. Disease progression was restrictedly observed in 17 patients with MDSs who had BCHNs at onset and in 1 patient with AA. The proportion of BCHNs increased with disease progression in these 16 of 17 patients with MDSs. The presence of BCHNs at onset and the increase in proportion of BCHNs during the clinical course of MDSs were significant indications for predicting disease progression.

Repeated dedifferentiation of low-grade intraosseous osteosarcoma

Low-grade intraosseous osteosarcoma is an uncommon bone tumor that is characterized by minimum cytological atypism and a much better prognosis than conventional osteosarcoma. This report describes a patient who had a low-grade osteosarcoma that mimicked fibrous dysplasia (FD). The tumor had an area of high-grade sarcoma at the initial diagnosis. Ten years after incomplete resection of FD-like tumor, local recurrence with areas of high-grade tumor developed. This case illustrates the potential of dedifferentiation in low-grade intraosseous osteosarcoma.

Solitary myofibromatosis of the skull

We present a case of solitary infantile myofibromatosis of the skull in a 3-month-old boy. A right parietal subcutaneous lump was found at birth, and it increased in size over the ensuing 3 months. Surgery was performed, and a diagnosis of myofibromatosis was confirmed histopathologically. Solitary myofibromatosis of the skull is extremely rare. The radiographical, CT, and MR appearances, as well as histopathological findings, are described in this article.

Primary duodenal MALT lymphoma

Primary duodenal MALT lymphoma (MALToma) is a very rare neoplasm arising from the mucosa-associated lymphoid tissue of the duodenum. We report a 55-year-old woman with MALToma located in the descending duodenum and accompanying Helicobacter pylori infection of the stomach. We performed operative resection due to involvement of the papilla of Vater and submucosal tumor infiltration. Despite wide mucosal spreading, postoperative examination revealed only a small amount of MALToma cells infiltrating into the submucosa. No invasion into the adjacent structure or metastasis to regional lymph nodes was confirmed, suggesting the disease could have been controlled by eradication of Helicobacter pylori.

Osteosarcoma metastatic to the kidneys without lung involvement

Symptomatic renal metastasis is very rare in osteosarcoma. A few reported cases had pulmonary metastases before renal involvement. We present a case of metastatic renal osteosarcoma without pulmonary involvement. The patient presented with hematuria 8 years after initial treatment of osteosarcoma of the left distal femur. Computed tomography revealed a bilateral calcified renal mass. The patient died of disease 4 months after detection of the metastases. At autopsy, metastatic osteosarcoma was discovered in the bilateral kidney, both renal veins, inferior vena cava and right atrium. There was no pulmonary involvement. We emphasize the need for renal evaluation for the follow-up of patients with osteosarcoma.

Solitary infantile myofibromatosis involving the clavicle

A rare case of solitary infantile myofibromatosis of bone is reported in the right clavicle of a 15-year-old boy. A radiograph demonstrated an osteolytic lesion with a sharp margin and a sclerotic rim. CT revealed a circumscribed lesion with slight expansion of the cortex. On MRI the lesion appeared isointense to muscle on T1-weighted images, bright on T2-weighted images, and showed marked gadolinium enhancement. The patient was well, without evidence of recurrence or metastasis, 4 years and 5 months following resection.

CT-guided agar marking for localization of nonpalpable peripheral pulmonary lesions

BACKGROUND

Small pulmonary lesions with ground-glass opacity (GGO) are increasingly detected by CT; however, intraoperative localization of such lesions is difficult because these lesions are often invisible and nonpalpable.

STUDY OBJECTIVES

To localize and resect nonpalpable and invisible small pulmonary lesions, a new marking technique that we call "agar marking" was developed.

METHODS AND PATIENTS

Powdered agar was dissolved in distilled water at a concentration of 5% and kept at > 50 degrees C to maintain its liquid form. Agar was injected through an 18-gauge needle and placed near the target lesion with CT. After animal experiments, agar marking was applied to the nine patients who had lesions < 20 mm in diameter and lesions with GGO. The mean diameter of these lesions was 11 mm, with a mean depth of 19 mm from the pleural surface on CT.

RESULTS

Agar could be detected as a hard nodule by manual palpation, and the lesion was resected during thoracotomy in all cases. There were no complications associated with the agar injection, aside from one case of slight pneumothorax.

CONCLUSIONS

Agar marking may represent a feasible alternative technique for localizing nonpalpable occult lesions located away from the pleural surface.

Do the level of nodal disease according to the TNM classification and the number of involved cervical nodes reflect prognosis in patients with differentiated carcinoma of the thyroid gland?

BACKGROUND AND OBJECTIVES

The importance of nodal involvement as a prognostic factor in differentiated carcinoma of the thyroid gland remains controversial. We therefore attempted to confirm the prognostic factors in differentiated thyroid carcinoma, with special reference to nodal status.

PATIENTS AND METHODS

A total of 139 patients with differentiated thyroid cancer followed for 2-27 years, with a median follow-up of 7 years were studied. All patients underwent surgical resection, either subtotal, total, or lobectomy, with modified radical neck dissection. Survival was calculated using the Kaplan-Meier method.

RESULTS

Ten (7%) patients have died from thyroid cancer. Adverse prognostic factors included age >45 years (P=0.0120), the presence of distant metastases (P=0.0006), and TNM stage (P=0.0002). The number of lymph nodes dissected ranged from 6 to 92, with an average of 26. Lymph node metastases were found in 102 (73%) patients. There was no difference in survival according to the level of nodal disease by the TNM classification. Furthermore, the number of cervical lymph nodes involved had no effect on the survival.

CONCLUSION

Our results suggest that the presence of histologically confirmed lymph node metastases is not an important prognostic factor in patients with differentiated thyroid carcinoma.

Focal orbital amyloidosis presenting as rectus muscle enlargement: CT and MR findings

We report a case of focal orbital amyloidosis involving rectus muscles, which is an extremely rare clinical condition. CT scans showed rectus muscle enlargement with punctate calcifications. Heterogeneous hypointensity was present on T2-weighted MR images, and homogeneous enhancement was seen on fat-saturated contrast-enhanced images of the muscles. These imaging findings seem to be suggestive of amyloidosis. Focal amyloidosis should be included in the differential diagnosis of extraocular muscle enlargement.

Expression of deoxycytidine kinase (dCK) gene in leukemic cells in childhood: decreased expression of dCK gene in relapsed leukemia

Competitive RT-PCR was used to determine the quantitative variation in the expression of deoxycytidine kinase (dCK) gene in childhood leukemic cells. The degree of dCK gene expression varied over a 50-fold range. In two cases in which both primary and relapsed leukemic cells were analysed, decreased expression of dCK gene was found in relapsed leukemic cells. The sequence variation analysis using bisbenzimide/polyethylene glycol electrophoresis demonstrated no sequence alteration of dCK cDNA in all cases. These results indicate that the expression of dCK gene varies in patients and suggests decreased expression of the dCK gene as one of the mechanisms responsible for clinical resistance to ara-C.

Malignant melanoma extending along the ulnar, median, and musculocutaneous nerves: a case report

We analyzed a case of malignant melanoma that resembled malignant peripheral nerve sheath tumor with marked neurotropism. The subungual tumor in the right ring finger extended along the ulnar nerve for a distance of 30 cm, as well as along the median and musculocutaneous nerves, with lymph nodal metastases. The tumor consisted of interlacing spindle-shaped cells with large nuclei and distinct nucleolei. Immunohistochemically, the tumor cells were diffusely positive for S-100 protein. Five years after forequarter amputation, the patient is alive without disease. Malignant melanoma has the potential of invading several major peripheral nerves and must be distinguished from malignant peripheral nerve sheath tumor, which rarely metastasizes to regional lymph nodes.

Proportion of blasts with a clear halo around nucleoli at the end of induction therapy of acute myeloid leukemia correlates with achievement of complete remission, remission duration and relapse

Bone marrow aspirates from 60 patients with acute myeloid leukemia (AML) were investigated using 95% ethanol fixation Papanicolaou stained preparations. The blasts were grouped into those with a clear halo around nucleoli (BCHN) and those without a clear halo. The patients were classified into three groups according to the degree of persistent BCHN at the end of induction therapy: group 1, no BCHN; group 2, less than 1% BCHN; and group 3, 1% or more BCHN. All patients in groups 1 (17 cases) and 2 (12 cases), and 12 of 31 cases in group 3 achieved complete remission (CR). Of 17 patients in group 1, two underwent bone marrow transplantation and two died from infection. Of the 37 patients who achieved CR, relapse was observed in two of 13 patients in group 1, and in all patients in groups 2 and 3. As to the patients treated with N4-behenoyl-1-beta-D-arabinofuranosyl-cytosine + daunorubicin + 6-mercaptopurine + prednisolone (BHAC-DMP) protocol, the percentages and number of BCHN at the diagnosis of AML in group 1 were significantly lower than those of groups 2 and 3. The percentage and number of BCHN at the diagnosis of AML were significant factors for the achievement of CR and for the prediction of long-term outcome. The reduction of BCHN to less than 1% at the end of induction therapy is a good indicator for the achievement of CR, and the disappearance of BCHN is a useful target for a long-lasting first CR; conversely, the persistence of BCHN is a major adverse factor for relapse.

Lipidized (foamy) tumor cells in a spinal cord ependymoma with collagenous metaplasia

We report a 49-year-old woman with a spinal cord ependymoma located in the thoracolumbar region. At surgery, a soft dark-grayish tumor, which contained a hard whitish area, was removed. The specimen was a moderately cellular tumor with a central core made up of collagen nodules poor in cellular elements. Many of the tumor cells possessed ground glass-like eosinophilic cytoplasm, and frequently foamy tumor cells were evident. Perivascular pseudorosettes, ependymal rosettes and canals were present, the latter being rare. Many tumor cells, including those with foamy cytoplasm, were positive for glial fibrillary acidic protein. Similar tumor cells were also seen among, and even within, the collagen nodules. The MIB-1 labeling index was 0.66%. Ultrastructurally, the frequent lipidized tumor cells were ependymal in nature; cytoplasmic 10-nm-wide filaments, and intracytoplasmic lumina and intercellular microrosettes lined by microvilli were evident. Cilia were very rare. We considered the present case to be an unusual, lipidized variant of ependymoma. The collagen nodules appeared to be produced by the tumor cells themselves.

Detection of circulating tumor cells in a patient with intravascular lymphomatosis: a case study examined by the cytology method

Detection of circulating tumor cells in a patient with intravascular lymphomatosis (IVL) of the lung is reported. Peripheral blood cells were suspended in an isotonic sodium chloride solution, and red blood cells were lysed. The suspension was smeared on glass slides, fixed in 95% ethanol solution and stained using the Papanicolaou method. At the diagnosis of IVL, approximately 65 tumor cells were detected in one smear preparation, which contained about 8 x 10(5) nucleated cells. However, tumor cells disappeared from peripheral blood when those in the lung were eliminated by multiagent chemotherapy. Cytology examination of peripheral blood cells may be of assistance in the early diagnosis of IVL and in the assessment of therapeutic intervention.

High reactivity of monoclonal antibody (TO73) with human malignant tumor cell line

The biological characteristics of a new monoclonal antibody (TO73) reacting with a vincristine-resistant human leukemic cell line (KY-VCR) were evaluated. Immunological and electron-immunological studies showed that TO73 reacted with the surface glycoprotein of KY-VCR. TO73 was found to have no effect on cell growth and intracellular uptake of vincristine. In human neoplastic cell lines, TO73 was found to react with 11 of 27 (41%) cell lines. With regard to de novo primary tumor with one exception, TO73 did not react with any of the examined primary tumor cells. The patient with TO73-positive leukemia died of induction failure due to drug resistance. Complete remission was achieved in the other leukemic patients. These results indicate that TO73 antigen may be associated with immortalization of tumor cells and poor prognosis in some cases.

Immunohistochemical localization of endothelin-1, endothelin-3 and endothelin receptors in human pheochromocytoma and paraganglioma

Endothelin (ET) and its receptor system have been shown to exert various biological effects on different types of cells in addition to their well-known vasoconstrictor activity. Recently ET-1, ET-3 and the ETB receptor have been shown to play an important role in the development of neural crest-derived cells and, in this context, pheochromocytomas have been reported to harbor ET-1. Endothelin-3 or ET receptor subtypes, however, have not been examined in pheochromocytoma and paraganglioma so far. In the present study the immunohistochemical localization of ET-1/big ET-1, ET-3/big ET-3 and the ETA and ETB receptors were investigated to clarify the biological characteristics of these two tumors using 32 pheochromocytomas and 11 extra-adrenal paragangliomas. Endothelin-1/big ET-1 was detected in 19 pheochromocytomas (59%) and eight paragangliomas (72%), while ET-3/big ET-3 was detected in 10 pheochromocytomas (31%) and three paragangliomas (27%). The ETA receptor was found in 21 pheochromocytomas (66%) and in eight paragangliomas (73%), while the ETB receptor was found in 25 pheochromocytomas (78%) and in eight paragangliomas (73%). Normal adrenomedullary cells lacked each antigen examined. Endothelin-immunoreactive tumor cells were distributed focally or in a manner scattered, while receptor-immunostained tumor cells were distributed with a focal pattern for the ETA receptor and with a focal or diffuse pattern for the ETB receptor. Endothelin and its receptor coexisted in the same tumor in 21 of 28 ET-positive pheochromocytomas and in eight of 10 ET-positive paragangliomas. In addition, seven pheochromocytomas and two paragangliomas revealed positivity of the receptor(s) irrespective of the absence of ET-immunoreactivity. In conclusion, ET and its receptor are frequently and concomitantly expressed in the pheochromocytoma and paraganglioma. From the highly frequent expression of this system or the receptor(s), ET-receptor-mediated signal transduction of these tumors concerning growth and/or cell survival is expected, although definite biological significance of this ligand-receptor system in these tumors awaits further investigation.

Pigmented renal cell carcinoma: accumulation of abnormal lysosomal granules

AIMS

Five cases of renal cell carcinoma (RCC) with abnormal pigmentation have been examined by histochemical, immunohistochemical and ultrastructural methods.

METHODS AND RESULTS

Compared with conventional RCCs, there was no difference in histological findings of each case, except for the presence of pigmented cells. In three cases, tumour cells possessing various sized brown granules with neuromelanin-like features were scattered throughout the tumour. The granules observed in one of the others were angulated lysosomes and in another tumour cells in the pigmented areas possessed the granules closely resembling those of granular cell tumour. However, melanosome or neurosecretory granules could not be detected in any of the cases examined. In three cases, some of these abnormal granules showed a weak acid phosphatase activity. On immunohistochemical examination, tumour cells showed a positive immunoreaction for epithelial markers and lacked any antigens suggesting neuroectodermal or neuroendocrine differentiation. The granules in three cases were faintly positive for lysozyme and KP-1.

CONCLUSIONS

These findings indicate that abnormal pigmentation of RCCs examined in this study is attributed to accumulation of abnormal lysosomal granules in the neoplastic cells.

Regular immunohistochemical localization of endothelin-1 and endothelin-B receptor in normal, hyperplastic and neoplastic human adrenocortical cells

The localization of endothelin (ET)-1/big ET-1, ET-3/big ET-3, ET-A and ET-B receptor was immunohistochemically examined in human adrenal glands composed of 36 normal cases, nine hyperplasia, 70 adenomas and seven carcinomas of cortical cells. In normal adrenals, ET-1/big ET-1 and ET-B receptor were regularly detected in the cortical cells, especially in the zona fasciculata for ET-1 and zona glomerulosa for ET-B receptor but not in the medulla, while ET-A receptor localized occasionally in endothelial cells or rarely in cortical cells and ET-3/big ET-3 was very limited in the cortical cells. In hyperplasia, adenoma and carcinoma, ET-1/big ET-1 and ET-B receptor showed frequent localization, although focal distribution of the ET-B receptor was rather predominant in these groups. ET-A receptor and ET-3/big ET-3 were very infrequently expressed. Functioning versus non-functioning and hypertensive versus normotensive cases revealed no significant differences in the frequency of positive cells for ET-1/big ET-1, ET-3/big ET-3, ET-A receptor or ET-B receptor. Alternatively, the frequency of immunoreactivity to ET-1/big ET-1 or ET-B receptor significantly decreased in hyperplasia, adenoma and carcinoma, when compared with that of normal adrenal cortex. The present study, therefore, indicates that ET-1/big ET-1 and ET-B receptor are a prevalent ligand-receptor system in normal and hyperplastic/neoplastic adrenocortical cells, even with a malignant profile, and may contribute in maintaining adrenocortical cell function or cell viability but not cell growth or systemic hypertension.

[Natural history of cloudy zone of pulmonary adenocarcinoma on HRCT]

Seven pulmonary adenocarcinomas with cloudy zone (CZ), which was defined as a lower density zone in the pulmonary lesion than pulmonary vessels in the surrounding normal lung on high resolution computed tomography (HRCT), were followed up for at least 3 months. There were three tumors with homogeneous CZ, one of which showed no change when rescanned after three months, the others showed enlargement with or without replacement by high density areas on rescanned images obtained after more than one year. Two tumors containing some high density areas on the initial scans showed slight decreases in size on rescanned images obtained after 1 to 3 months. However, on rescanned images obtained after more than 1 year and 9 months, these tumors also showed enlargement of CZ. Pathologically, CZs corresponded to well-differentiated adenocarcinoma of the bronchioloalveolar type with no or mild interstitial change, whereas high density areas mainly corresponded to papillary adenocarcinoma with severe interstitial fibrosis. In conclusion, long-term careful follow-up of CZ is necessary to detect enlargement or the appearance of high density. Unchanged CZ in short-term follow-up should be considered a finding suggestive of malignancy.

Immunohistochemistry of cyclin D3 in pulmonary carcinomas

Cyclin D3, a cell cycle regulator, is encoded in the 6q21 chromosome region. Abnormalities of this gene and its protein product have not been found in normal tissues or in malignancies from human subjects. The expression of cyclin D3 was studied immunohistochemically in archival formalin-fixed, paraffin-embedded specimens from normal organs obtained from three autopsy cases and 237 human primary pulmonary carcinomas. In normal organs, nuclear positivity for cyclin D3 was observed in reactive type-2 pneumocytes, islets of Langerhans, lymphocytes from lymph nodes, superficial cells of transitional epithelium, epithelium of oesophagus, stomach, small intestine and gallbladder, endothelium, smooth muscles, and brain. Proliferating cells such as lymphocytes in the germinal centres and non-proliferating cells such as neurons both demonstrated cyclin D3 immunoreactivity. Cyclin D3 showed obvious nuclear immunoreactivity in 168 pulmonary carcinomas (71%). The proportion of tumour cells that were cyclin D3-positive ranged from 1% to 73% (median, 16%). There was no relationship between cyclin D3 immunoreactivity and histological typing, tumour differentiation, or pathological TNM staging. In pulmonary carcinomas, distinct expression of the cyclin D3 protein is unlikely to be implicated in tumorigenesis, because of its expression in only a small fraction of cancer cells. It may relate to cancer progression. The distribution of cyclin D3 reactivity in the normal tissues suggests that cyclin D3 affects other processes than cell cycle regulation in a lineage-specific manner.

Identification of drug-resistant myeloid leukemic cells by measurement of DNA content, nuclear area, and detection of P-glycoprotein

BACKGROUND

This study was designed to evaluate the significance of aneuploidy in DNA ploidy, nuclear area, and expression of P-glycoprotein (P-GP) in differentiating drug-resistant myeloid leukemic cells (DRMLC) from drug-sensitive myeloid leukemic cells.

METHODS

Bone marrow aspirates from 28 myeloid leukemic patients were fixed in 95% ethanol solution and stained using the Papanicolaou method. The nuclear area and DNA content were measured. An immunohistochemical study was performed using monoclonal antibody (JSB-1) directed against P-GP.

RESULTS

Leukemic cell morphology changed once or twice after the diagnosis of acute myeloid leukemia (AML), blastic crisis (BC) of chronic myeloid leukemia, or chronic neutrophilic leukemia. DRMLC showed severe atypia and were morphologically distinguishable from normal myeloblasts, promyelocytes, and drug-sensitive leukemic cells at the diagnosis of AML or BC. The mean nuclear index (NI) and DNA index (DI) of DRMLC were significantly larger than those of drug-sensitive leukemic cells of AML or BC. The frequency of aneuploidy and P-GP expression was 9.1% and 4.5%, respectively, at the diagnosis of AML or BC, and 92.8% and 28.5%, respectively, for resistant disease. The incidence of heterogeneity in DNA ploidy was 86.3%.

CONCLUSIONS

DI and NI values larger than 1.2 and the expression of P-GP are significant indications of DRMLC.

Crystalglobulin-induced vasculopathy accompanying ischemic intestinal lesions of a patient with myeloma

A 37 year old man with multiple myeloma (IgG lambda) developed perforation of the small intestine and had gangrene in his feet. In the resected small intestine and below-knee amputated feet, intravascular deposition of crystals, immunohistochemically positive for IgG and a lambda light chain, were found. Although paraproteins produced in the course of plasma cell dyscrasia may crystallize and cause systemic occlusive vasculopathy, this is the first case with intestinal involvement. Because cryoglobulinemia was absent in this patient, crystals may be derived from the myeloma protein which sometimes crystallizes in the blood without the influence of low temperature.

Multiple myeloma-associated systemic vasculopathy due to crystalglobulin or polyarteritis nodosa

Systemic vasculopathy is a rare complication of multiple myeloma (MM). We describe a patient diagnosed with MM who developed clinical features of systemic vasculopathy including gangrene, livedo reticularis, hypertension, renal failure, and perforation of the small intestine. Histopathologic examination of the small intestine revealed necrotizing vasculitis in the small arteries, along with crystalline deposits in the small vessels. To our knowledge, previously reported cases of systemic vasculopathy associated with MM include at least 9 cases due to crystalglobulin deposition in vessels and 2 due to polyarteritis nodosa. Deposits of crystalglobulin may have induced systemic necrotizing vasculitis in our patient.

Peripheral lung carcinomas associated with central fibrosis and mixed small cell and other histologic components

Three cases of peripheral small cell lung carcinoma (SCLC) with central fibrosis are presented. Central fibrosis is usually present in adenocarcinomas. Cases 1 and 2 are combined SCLCs with components of papillary adenocarcinoma, and case 3 is a mixed SCLC with a large cell component. Small cell components showed intermediate cell type in all cases. In cases 1 and 2, there was a gradual transition between small cell carcinoma and papillary adenocarcinoma. Small cell components showed Grimelius argyrophilia, but other neuroendocrine markers such as neuron specific enolase, chromogranin A, Leu-7 and synaptophysin were negative. The chest X-ray examination of case 1 demonstrated rapid enlargement of a tumor shadow, which was present two years before, for a recent year. Central fibrosis, coexistence of small cell carcinoma and papillary adenocarcinoma, and a change of growth rate in the chest X-ray may suggest that some SCLC derive from papillary adenocarcinomas.

Classification of air density areas in CT-pathologic correlation of pulmonary adenocarcinoma

Air density areas (ADAs) such as air bronchogram, bubble-like area, and cavity on high resolution computed tomography (HRCT) of pulmonary adenocarcinoma were examined to clarify their pathological implications. Forty-two resected specimens of pulmonary adenocarcinoma were histopathologically examined in correlation with the HRCT findings with particular emphasis on ADAs. Forty-one ADAs observed in 32 of 42 cases with pulmonary adenocarcinoma were classified into three types: air bronchogram type (n = 22), bubble-like area type (n = 12), and cavity type (n = 8). Twenty of 22 air bronchogram ADAs corresponded to bronchi. Nine of 12 bubble-like area ADAs corresponded to bronchioles. Only one of eight cavity-ADAs consisted of necrosis. The classification of ADAs in pulmonary adenocarcinoma is considered to be useful in interpreting HRCT findings of pulmonary nodules.

Cloudy nodule on HRCT: a new clinico-radiologic entity of pulmonary adenocarcinoma

We propose cloudy nodule (CN) on HRCT as a special type of pulmonary adenocarcinoma. CN was defined as a cloudy nodular shadow in the peripheral part of the lung with lower density than pulmonary vessels on HRCT. Radiologic images of nine CNs in eight cases were correlated with the pathological findings of the resected specimen. All CNs were clearly demarcated on HRCT. They were pathologically composed of well differentiated adenocarcinoma, mainly bronchioloalveolar type with little or no central scar. Plain films were negative in six of nine cases. CN on HRCT may indicate well-differentiated adenocarcinoma with good prognosis.

Pulmonary myxoid leiomyosarcoma

A primary myxoid leiomyosarcoma arising from the peripheral bronchus of the right middle lobe was removed from a 20 year old man and examined by immunohistochemistry and electron microscopy. The tumor was well circumscribed, yellow-whitish focal polypoid growth into the bronchial lumen and consisted of spindle cells with abundant myxoid substance in the stroma. Intrapulmonary metastasis, invasion to the bronchial wall and a few mitotic figures were found. Immunohistochemically, several, but not all, tumor cells were positive against anti-vimentin, anti-S-100 protein, anti-myosin and anti-muscle specific actin. Ultrastructurally, tumor cells had thin filaments with dense bodies, pinocytic vesicles and discontinuous basal lamina. These findings indicate a myoxoid variant of leiomyosarcoma arising from mesenchyme in the peribronchial area.

Clear cell chondrosarcomas arising from rare sites

Three cases are reported of clear cell chondrosarcoma arising from unusual sites: talus, rib and vertebra. Radiographically, two tumors showed osteolytic features and the vertebral tumor showed osteoplastic change. Histologically, all tumors consisted of clear cells that had a centrally placed nucleus surrounded by clear cytoplasm, osteoclast-like giant cells, areas of conventional chondrosarcoma, and various amounts of reactive bone. The tumor in the talus was initially diagnosed as benign chondroblastoma, but it recurred. The rib tumor showed marked cystic formation stimulating aneurysmal bone cyst. The osteoplastic radiographic feature in vertebral tumor was considered to be due to the abundant bone formation.

Non-X histiocytoma, similar to fibrous histiocytoma, in an infant

A case is presented of a female infant with an atypical histiocytoma. A gradually enlarging brown lesion was noted on the left side of the chest at the age of 2 weeks. Microscopic study of a biopsy revealed an ill-defined infiltration of spindle cells with indented nuclei. The tumor cells were positive for CD14, HLA-DR, lysozyme, alpha-1-antitrypsin and alpha-1-antichymotrypsin, and negative for CD1, CD3, CD8, CD10, CD19, CD68 and S-100 by immunohistochemistry. Electron microscopy demonstrated no distinct Birbeck's granules, but aberrant granules were seen in a small number of cells. At 7 months of age, a nodule with similar histologic features was noted in the nuchal region, but was incompletely resected. The patient remains recurrence-free at 36 months of age. This case is thought to be a benign form of non-X histiocytoma.

Pigmented renal cell carcinoma

A rare case of pigmented renal cell carcinoma is presented. The tumor was yellow, somewhat elastic, and soft with focal gray and tan areas. Microscopically, the tumor was a typical renal cell carcinoma of the clear-cell type. Tumor cells containing brown pigment in the cytoplasm were scattered throughout the tumor. Ultrastructurally, the electron-dense granules consistent with the brown pigment noted at the microscopic level showed a coarse or fine granular matrix with or without homogeneous high electron-dense areas, resembling lipofuscin. However, the nature of the pigment was different from that of lipofuscin by the Masson-Fontana method after bleaching and rather similar to neuromelanin. The current case is a rare renal cell carcinoma with pigmentation attributed to abnormally excessive accumulation of neuromelanin pigment.

Peripheral carcinoid tumor of the lung with focal melanin production

A case of carcinoid tumor of the lung with focal melanin production was encountered in a 56 year old Japanese woman. The tumor was found 16 years previously by mass survey chest X-ray and had enlarged two-fold in the intervening period. The tumor consisted of a variety of tumor cells showing a spindle, polygonal and pleomorphic appearance with abundant vasculature in the stroma. All tumor cells showed argyrophilia, together with a few showing argentaffinity. Melanin-containing tumor cells were also present in parts. Ultrastructurally, most tumor cells possessed various numbers of neurosecretory granules and a few of them contained granular type melanosomes. Tumor cells were connected with desmosomes and a few of them contained tonofilament-like microfilaments. Only a few contained both neurosecretory granules and melanin. By immunohistochemistry, serotonin, met-enkephalin and beta-endorphin positive cells were observed scattered throughout the tumor. A few tumor cells positive for tyrosine hydroxylase were also detected. Additionally, most tumor cells were positive for keratin. On the basis of these findings, the tumor of the current case is a pulmonary carcinoid tumor with focal melanin production.

Microcytic variant of thymoma: histological and immunohistochemical findings in two cases

Two cases of microcytic variant of thymoma are presented. Both tumours were well encapsulated with a yellow-whitish colour and soft consistency. Microscopically, they consisted of round cells, having ample vacuolated cytoplasm. Fat droplets were not detected in one case where fat staining was performed. Immunohistochemically, the tumour cells were strongly positive for AE1/AE3, MB1, MB2, and LN1 and faintly positive for epithelial membrane antigen. They lacked any other leucocyte antigens. Leu 7 showed a positive immunoreaction in a ring-like or homogeneous pattern, compatible with the cytoplasmic vacuoles or cytoplasm. Ultrastructurally, the vacuoles resembled cystically dilated rough-surfaced endoplasmic reticulum. Desmosome-like structures (case 1) and intermediate junctions (case 2) were identified between adjacent cells. These findings indicate that the present tumours belong to a category of microcystic thymoma. The vacuoles were attributed to excess accumulation of Leu-7-positive material, probably in the cystically dilated endoplasmic reticulum.

Papillary adenoma of the lung. Histological and ultrastructural findings in two cases

Two cases of papillary adenoma of the lung are presented along with results of histological and ultrastructural examinations. The tumors were encountered in two asymptomatic patients in a mass-survey chest X-ray examination. The chest X-ray films showed the tumors as well demarcated small lesions. Histologically, both tumors arose in the bronchioles and consisted of cuboidal cells resembling type II pneumocytes showing papillary growth with accompanying edematous connective tissue. Several tumor cells each possessed a large eosinophilic intranuclear inclusion. In case 1, ciliated cells and Clara-like cells were also present in the tumor. Ultrastructurally, most of the tumor cells had various numbers of lamellar bodies in their cytoplasm, indicative of type II pneumocytes, and some of case 1 showed features of Clara cells and ciliated cells. The intranuclear inclusions appeared as aggregates of tubular structures or had lamellar body-like features. These findings are identical to those of papillary adenoma arising from the bronchiole.

Transitional cell carcinoma with sarcomatous elements in the urinary tract. Six cases examined by immunohistochemistry

We report six cases of carcinoma showing sarcomatous change in the urinary tract examined by conventional histochemistry and immunohistochemistry. All of the cases were transitional cell carcinoma with or without focal squamous cell carcinoma. Sarcomatous components resembling spindle cell sarcoma with a marked myxoid stroma or chondrosarcomatous element were also observed in all cases. The sarcomatous elements were closely associated with the areas of squamous cell carcinoma in three cases. Various histochemical staining procedures demonstrated mesenchymal features in the stroma of sarcomatous areas. By immunohistochemical examination, the epithelial components showed positive reactions for keratin, epithelial membrane antigen and, focally, carcinoembryonic antigen. The sarcomatous components revealed a positive immunoreaction for keratin but lacked other epithelial markers in all cases. Chondrosarcomatous elements in two cases were positive for both keratin and S-100 protein. These findings indicate that sarcomatous elements in carcinoma may represent mesenchymal metaplasia with partial or complete loss of epithelial features. However, further study will be necessary in order to determine whether heterogeneous elements, such as chondrosarcomatous areas, are epithelial or truly mesenchymal in origin.

[Clinical application of T-Scan System. 2. Evaluation of soft mouth guards]

Soft mouth guards are effective to prevent traumatic injury in the maxillofacial region. In this study, we tried to find out the effect of soft mouth guards on the distribution and the magnitude of occlusal force using the T-Scan system. Ten adult subjects volunteered to exert maximum biting force wearing three different types of soft mouth guards. With the limitation of the T-scan system reported in our previous article, following results were obtained. 1) Occlusal forces were more evenly distributed with soft mouth guards than without them. 2) Softer mouth guards were more effective for occlusal force distribution. 3) Since occlusal relationship between mouth guards and mandibular arch could alter the distribution pattern a great deal, occlusion of mouth guards should be examined more carefully.

[Mouth guard and occlusal force distribution]

Mouth guards are effective to prevent traumatic injury in maxillofacial region during sports activities. This study was conducted to investigate the influence of wearing mouth guards on occlusal force distribution with the T-scan system. With comparison to the value of average occlusal force level per occlusal point (OFL) on natural dentition and wearing conventional full arch bite plane, following results were obtained. 1) Difference of OFL within the same dental arch became smaller when mouth guards were on. 2) Statistically significant difference in OFL was not found between two mouth guards with different hardness. 3) During three seconds clenching, OFL in posterior region changed great deal at the initiation but stayed at about the same level after that.

Problems of denture wearers regarding denture cleaning

With the increase of elderly population, the number of patients who need removable prostheses increase rapidly. Denture wearers have different problems from non-denture wearers in terms of maintaining oral health. In this study, we attempted to find out specific difficulties of denture wearers with questionnaires regarding social life problems as well as oral hygiene problems. Our results indicated that most of the denture wearers considered the cleaning of denture was essential to maintain their oral health, though methods they employed showed a great deal of difference. Also denture wearers felt difficulties in cleaning their dentures when they went out.

Mouth guard and occlusal force distribution

Mouth guards are effective to prevent traumatic injury in maxillofacial region during sports activities. This study was designed to find out the influence of wearing mouth guards on occlusal force distribution using an occlusal force transducer system (T-Scan system). Occlusal forces were more evenly distributed when mouth guards were in place comparing with natural dentition and with wearing conventional full arch bite planes.

The occurrence of leukemia in a patient with pulmonary asbestosis

A 77-year-old man, who had been a subway construction worker, was admitted to our hospital for surgical treatment of left cheek carcinoma and an examination for pancytopenia on November 17, 1986. Bone marrow aspiration revealed that 10% of the nucleated cells were blasts with morphological atypism. Bone marrow biopsy showed hypocellular marrow and a diffuse increase of argyrophil fibers with the presence of asbestos fibers was observed by microscope. A chest X-ray showed the findings of old tuberculosis and pulmonary asbestosis, and asbestos fibers were demonstrated in the broncho-pulmonary lavage fluid. He was diagnosed to have pulmonary asbestosis complicated with hypoplastic low percentage leukemia.

[A biliary endocrine cell carcinoma: a report of two cases]

An endocrine cell carcinoma is a carcinoid tumor that has an especially malignant prognosis. We herein report on 2 cases of a biliary endocrine cell carcinoma. Case 1 involved a 68 year old man manifesting a fever, jaundice, hepatomegaly and a ballooned gallbladder. After decreasing the jaundice by PTCD, an exploratory abdominal operation was performed. As a tumor was found at the papilla of Vater, a pancreaticoduodenectomy was done. Case 2 involved a 72 year old woman who was diagnosed as having a gallbladder tumor and cholelithiasis. She was given a cholecystectomy and a choledocholithotomy. These 2 cases had hepatic metastasis within a year and subsequently died. Procedurally, an endocrine cell carcinoma should be treated separately from classical carcinoid tumors.

[Clinical application of T-scan System. 1. Sensitivity and reproducibility and its application]

Analyzing occlusal contacts is significant for establishing the occlusal scheme as well as for the diagnosis on dysfunction of stomatognathic system. We tested a new occlusal contact analyzing device (T-Scan: Tekscan Inc. Boston, U.S.A.) for its sensitivity and reproducibility in relation to its clinical application. Following results were obtained. 1) As the modeling of dental arch of this system was not always correct, much care should be needed for identifying the contact location. 2) The minimum amount of load needed for displaying each five step occlusal force increased linear fashion (step 1: 250 g and step 5: 1750 g) when the sensor was vertically pressed on the intersection of force sensitive line. The minimum amount of force changed with the loading condition such as area and direction. Distortion of the sensor could lead the measurement error. 3) Since the time measurement data by this system were shorter than actual length of time and were measured over about 250 g load, light and early occlusal contacts could not be detected.