Tandem high-dose chemotherapy and autologous stem cell rescue in patients over 1 year of age with stage 4 neuroblastoma

From June 1997 to August 2005, 52 consecutive newly diagnosed stage 4 neuroblastoma patients over 1 year of age were assigned to receive tandem high-dose chemotherapy and autologous stem cell rescue (HDCT/ASCR) as consolidation therapy. Fifty of the 52 patients underwent a first HDCT/ASCR and 44 patients underwent a second HDCT/ASCR. Eight patients (15.4%) died from treatment-related toxicity (seven during the second HDCT/ASCR). Total body irradiation (TBI) in the first HDCT/ASCR and a shorter interval (< 12 weeks) between the first and second HDCT/ASCR were associated with a higher rate of treatment-related death in the second HDCT/ASCR (P = 0.032 and 0.095, respectively). The tumor relapsed or progressed in 11 patients, and 33 patients remained event free with a median follow-up of 53 months (range 19-117) from diagnosis. The 5-year event-free survival (EFS) (+/- 95% confidence interval) for all 52 patients was 62.1+/-13.7%. The application of TBI and local radiotherapy, and a longer interval between the first and second HDCT/ASCR were independently associated with a better EFS (P = 0.026, 0.007 and 0.020, respectively). However, further studies will be needed to decrease the toxic death rate in the second HDCT/ASCR while reducing the relapse rate.

Malignant lymphoma of the central nervous system: difficult histologic diagnosis after glucocorticoid therapy prior to biopsy

Four cases of central nervous system (CNS) lymphoma are reported which presented obstacles in diagnosis due to steroid treatment prior to biopsy. Reliable diagnoses were provided by molecular analysis. Malignant lymphoma of the CNS may be indistinguishable from other conditions, even in view of the gravity of the diagnosis. All patients had a previous history of glucocorticoid injection, for 2-18 days prior to stereotactic brain biopsy. The pathologic examination revealed in all cases axonal destruction and reactive gliosis with a variable infiltration of B- or T lymphocytes and macrophages. Characteristically, scattered degenerating small round cells with pyknotic or fragmented nuclei were also observed. However, the molecular assessment of paraffin-embedded tissues revealed the monoclonal IgH gene rearrangement, which allowed the confident diagnosis of B cell lymphoma. The histopathological findings of the present cases suggest that the tumor cells might be selectively destroyed by steroid treatment, which may render diagnosis impossible. Thus, molecular genetic investigation constitutes an important tool for establishing a diagnosis of CNS lymphoma obscured by steroid administration. This is especially true in cases where a paucity of tumor cells is observed or when monoclonality fails to be demonstrated by immunohistochemical tests.

Gliofibroma with extensive calcified deposits

Gliofibroma is a rare astrocytic neoplasm of young people that shows abundant deposition of collagenous matrix around glial cells. It shares some clinical and pathologic features with desmoplastic cerebral astrocytoma of infancy or desmoplastic infantile ganglioglioma. However, histogenesis or clinical behavior of these tumors is not fully known. Here, we report a case of gliofibroma with unusual extensive calcification which complicated radiologic as well as pathologic diagnosis.

Cutaneous bronchogenic cyst of the abdominal wall

We report a case of the unusual location of a cutaneous bronchogenic cyst on the abdominal wall. The patient was a 9-month-old boy who had presented with a 1.5 cm-sized polypoid mass, present since birth. Pathological examination of the excised mass revealed multiple small cystic structures surrounded by the fibroadipose tissue. The lining epithelium consisted of either pseudostratified ciliated columnar epithelium with goblet cells or a single layer of ciliated or non-ciliated cuboidal to columnar cells. The cystic walls contained a well-developed smooth muscle bundle, mucous glands and hyaline cartilage plate. This lesion was adherent to the peritoneum, but there was no direct communication with the abdominal cavity. Cutaneous bronchogenic cyst located in the abdominal wall has not been described in the English literature. The present case suggests a possible origin from a downward migration, from the sequestered bud of a tracheobronchial tree primordium along the midline of the body surface, during embryonic development.

Protracted diarrhea: results of the five-year survey in a tertiary hospital in Korea

The syndrome of protracted diarrhea (PD) includes several diseases with diverse etiologies. This study was conducted to characterize the spectrum of causes, clinical manifestations, and the outcomes of PD. A retrospective analysis of the clinical and pathological findings was performed on 25 patients with diarrhea starting within the first 2 yr of life and a requirement of parenteral nutrition (PN). According to the intestinal histopathology, patients were classified into four groups: immune enteropathy (12 cases), lymphangiectasia (6 cases), epithelial dysplasia (5 cases), and unclassified (2 cases). All patients with epithelial dysplasia had earlier onset of diarrhea and longer duration of PN than those in the other groups. Three patients (12%) had an evidence of a familial condition. Five patients (three with microvillous inclusion disease and two with immune enteropathy) died. Sixteen patients recovered, and three (two with primary lymphangiectasia and one with microvillous inclusion disease) still had diarrhea. One patient underwent intestinal transplantation for tufting enteropathy. In conclusion, infants with PD should be referred to specialized centers where advanced diagnostic and therapeutic facilities are available, because histological analysis is critical for the diagnosis of PD, and PN or intestinal transplantation is the only therapeutic option in a subset of cases.

Clinical significance of molecular genetic changes in sporadic invasive pituitary adenomas

Several molecular and genetic changes have been found in pituitary adenomas. We looked for correlations between these changes and the degree of invasiveness of the tumors. The invasiveness of 11 pituitary adenomas was graded by Hardy classification. We examined the retinoblastoma gene (RB1.20 on chromosome 13q) and the region around the MEN1 locus (chromosome 11q13.1-5) for loss of heterozygosity. Also examined are p53 mutations using single strain conformation polymorphism, p53 protein overexpression using immuno cytochemistry, homozygous deletions of p15 and p16 by polymerase chain reaction, and cellular proliferative activity using MIB-1 antibody. Six tumors (54.5%) had an LOH at either RB1.20 or the MEN1 locus. LOHs were found more frequently in Grade 4 and stage E tumors (72% and 67%) than in Grade 3 and stage D tumors (25% and 40%). However, no mutation or overexpression of p53 was found. No homozygous deletions of p15 or p16 were identified. The cell proliferative index ranged from 0 to 3%. LOH at 11q13 and 13q may be valuable in predicting the invasiveness of pituitary adenomas.

Thymic ultrasound. I. Intrathymic anatomy in infants

BACKGROUND

The gross appearance and echogenicity of the normal thymus have been described, but specific intrathymic anatomy has not been evaluated with imaging.

SUBJECTS AND METHODS

The thymus from a 34-week-gestation stillborn male was examined with ultrasound, and the images were correlated with microscopic findings. Thymic ultrasound was performed in 12 infants without any evidence of thymic abnormality, severe infection, or chronic illness. Images were evaluated focusing on intrathymic parenchymal anatomy and compared to the liver, spleen, and thyroid gland.

RESULTS

In the specimen thymus, ultrasound demonstrated connective-tissue septa as echogenic linear structures. The cortex was relatively hypoechoic, whereas the medulla was echogenic. The blood vessels within the septa were seen as discrete echoes. In vivo ultrasound demonstrated multiple branching echogenic linear structures and foci throughout the parenchyma, representing connective-tissue septa or blood vessels within the septa. The normal thymus was easily differentiated from the liver, spleen, and thyroid glands.

CONCLUSION

Ultrasound is capable of demonstrating intrathymic anatomy, including the medulla, cortex, septa, and blood vessels in a fresh specimen. In vivo connective-tissue septa and blood vessels in the thymic parenchyma produce a unique echo pattern.

Thymic ultrasound. II. Diagnosis of aberrant cervical thymus

BACKGROUND

The aberrant cervical thymus is an uncommon entity to be considered in the differential diagnosis of neck masses in children, so a preoperative diagnosis has rarely been made.

OBJECTIVE

The purpose of this study was to assess the ultrasound features of aberrant cervical thymus and determine if recognition of the previously described unique intrathymic echo pattern allows us to make a specific diagnosis.

MATERIALS AND METHODS

We present four patients with an aberrant cervical thymus and one patient with a cervical thymic cyst. All five patients had ultrasound, which was evaluated with special attention to the detailed echo pattern of the mass. In two patients, the mass was surgically removed. Four patients had MRI, which was evaluated. Medical records were reviewed.

RESULTS

In all cases, the mass was painless and nontender. All occurred in the expected path of the thymopharyngeal duct. In four patients, ultrasound demonstrated multiple echogenic linear structures and foci previously described as characteristic echo pattern of normal thymic tissue. In one patient, ultrasound showed a large cystic mass and echogenic solid component superiorly with a characteristic echo pattern of normal thymus.

CONCLUSIONS

The ultrasound appearance of thymic tissue is unique, allowing a specific diagnosis of aberrant cervical thymus. Biopsy or other imaging is probably not indicated when it presents with typical clinical features.

CD99 immunoreactivity in ependymoma

The expression of CD99 in normal ependymal cells and ependymoma has been reported. However, only limited numbers of tumors have been studied, and the pattern of CD99 expression has not been described. The authors' purpose was to investigate CD99 immunoreactivity in ependymoma and its use for differential diagnosis. Twenty-five ependymomas were immunostained with antibody directed at CD99. The result of immunostaining of ependymomas was compared with 63 nonependymal tumors that histologically resemble ependymal neoplasms. The nonependymal tumors included 19 astrocytic tumors, 6 oligodendroglial tumors, 8 choroid plexus neoplasms, 2 central neurocytomas, 5 medulloblastomas, 10 primitive neuroectodermal tumors (PNET), and 13 pituitary adenomas. All ependymomas showed strong expression of CD99 in membranous pattern with intracytoplasmic or intercellular dots (ICDs). The expression pattern of CD99 was not correlated with histologic type or grade of ependymomas. Among 63 nonependymal tumors, 11 (17.5%) showed incomplete membrane staining for CD99; diffuse in 4 PNETs and focal in 5 choroid plexus neoplasms (3 papillomas and 2 carcinomas) and one each of pituitary adenoma and oligodendroglioma. The ICD was not found in nonependymal tumors except a case of choroid plexus papilloma. However, membrane staining or ICD for CD99 was not distinctive in nonependymal tumors. In conclusion, the characteristic pattern of anti-CD99 antibody, i.e., diffuse strong membranous immunostaining with ICDs, is useful in distinguishing ependymomas from the central nervous system tumors that histologically mimic ependymoma.

Surgical treatment of intractable epilepsy accompanying cortical dysplasia

OBJECT

Surgical treatment of cortical dysplasia (CD) together with intractable seizures is challenging because both visualization and localization of the lesion are difficult, correlation with seizure foci requires comprehensive study, and the surgical outcomes reported thus far are unsatisfactory. The authors report their experience in the surgical treatment of CD classified according to a surgical point of view.

METHODS

The definition of CD used in this study was a dysplastic lesion visible on magnetic resonance (MR) images or a lesion that, although not visible on MR images, was diagnosed as moderate-to-severe dysplasia by using pathological analysis. During the last 4.5 years, the authors treated 36 patients with intractable epilepsy accompanied by CD. They divided the 36 cases of CD into four characteristic groups: Group A, diffuse bilateral hemispheric dysplasia; Group B, diffuse lobar dysplasia; Group C, focal dysplasia; and Group D, a moderate to severe degree of CD with a normal appearance on MR images. All but one patient in Group C were monitored in the epilepsy monitoring unit by using subdural electrodes for seizure localization and functional mapping. The incidence of CD among a cohort of 291 patients who had undergone epilepsy surgery at the authors' center during the study period was 12.4%. The mean age of the 36 patients was 21.3 years and the mean age at seizure onset was 8.5 years. The mean follow-up period was 26 months. Twenty-six patients (72.2%) belonged to Engel Class I or II (20 and six, respectively). There were five cases in Group A, nine in Group B, nine in Group C, and 13 in Group D. Patients in Groups A and B were significantly younger at seizure onset and had significantly poorer surgical outcomes compared with patients in Groups C and D (p < 0.05). If outcome is compared on the basis of the extent of removal of CD, patients in whom CD was completely removed had significantly better outcomes than those in whom CD was only partially removed (p < 0.001).

CONCLUSIONS

The authors conclude that intractable epilepsy accompanied by CD can be treated surgically using comprehensive preoperative approaches. Deliberate resective procedures aimed at complete removal of dysplastic tissue ensure excellent seizure control without permanent neurological deficit.

Arrangement of the systemic and pulmonary venous components of the atrial chambers in hearts with isomeric atrial appendages

BACKGROUND

The morphological definition of atrial chambers, and the determination of atrial laterality, are based on analysis of the structure of the atrial appendages. The systemic and pulmonary venous connections to the heart, nonetheless, are important in the management of patients having isomeric appendages. In this study, therefore, we analysed the morphology of the postero-superior walls of the atrial chambers so as to provide evidence concerning the morphogenetic background of those hearts, and to improve operative management.

METHODS

We reviewed 15 autopsied specimens with isomeric right appendages, and 10 with isomeric left appendages, paying particular attention to the morphology of the systemic and pulmonary venous connections. The postero-superior walls of the atrial chambers can be made up of the atrial body, the systemic venous components, or the pulmonary venous component. We analysed the contributions made by each of these components.

RESULTS

The postero-superior walls of the atrial chambers were markedly variable, but could be grouped into five patterns. Bilaterally well-developed systemic venous components and absence of the pulmonary venous component within the hypoplastic atrial body were present in 9 hearts with extracardiac pulmonary venous connections in the setting of right isomerism. Bilaterally well-developed systemic venous components, and a hypoplastic pulmonary venous component within the hypoplastic atrial body, were present in 5 hearts with intracardiac pulmonary venous connections in right isomerism. Bilaterally well-developed systemic venous components, and a hypoplastic pulmonary venous component within the sizable atrial body, were present in 1 heart with an intracardiac pulmonary venous connection in right isomerism. A well-developed pulmonary venous component within the atrial body, and hypoplasia of one systemic venous component, were present in 7 hearts with left isomerism. A well-developed pulmonary venous component within the atrial body, and hypoplasia of bilateral systemic venous components, were present in 3 hearts with left isomerism.

CONCLUSIONS

The postero-superior walls of the atrial chambers in hearts with isomeric atrial appendages can be analysed on the basis of a compound structure made of bilateral systemic venous components, a central pulmonary venous component, and the body of the atrium. Hearts with isomeric right appendages have absence or hypoplasia of the pulmonary venous component, while hearts with isomeric left appendages have hypoplastic systemic venous components.

Focal cortical dysplasia: comparison of MRI and FDG-PET

PURPOSE

The purpose of this work was to compare the use of MRI and [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET) in the diagnosis of focal cortical dysplasia (FCD).

METHOD

Nineteen patients with surgically proven FCD were analyzed retrospectively. MRI was performed in all patients, and FDG-PET was performed in 17 patients. We compared the MR and FDG-PET findings of FCD according to the histologic findings that were classified into three grades.

RESULTS

Four cases were classified as Grade I, 4 cases as Grade II, and 11 cases as Grade III FCD. The lesions were detected on MRI in 9 (82%) of the 11 patients with Grade III FCD and in only 1 (13%) of the 8 patients with Grade I and II FCD. Cortical hypometabolism of the lesion was revealed on FDG-PET in 6 (86%) of the 7 patients with Grade I and II FCD and in 9 (90%) of the 10 patients with Grade III FCD. The extent of the cortical abnormality was larger on FDG-PET than on MRI in 11 (65%) of the 17 patients.

CONCLUSION

FDG-PET is more useful in delineating the cortical abnormality in patients with mild degrees of FCD. The extent of the lesion was larger or similar on FDG-PET compared with that of the MRI.

Myocardial injury-induced fibroblast proliferation facilitates retroviral-mediated gene transfer to the rat heart in vivo

BACKGROUND

Efficient and stable transfer of therapeutic DNA into injured myocardium would be an initial step towards a genetic treatment aimed at myocardial repair after myocardial infarction. Proliferating cardiac fibroblasts in the healing myocardium could be a compelling target for retroviral infection. We evaluated the feasibility of direct in vivo gene transfer into injured myocardium using a high-titer, stable retroviral vector.

METHODS

Using the TE-FLY-A-based MFG retroviral vector harboring nlsLacZ reporter, the gene transfer efficiency was assessed first in vitro in rat cardiac fibroblasts, followed by in vivo evaluation in healing rat myocardium after local freeze-thaw injury. A total of 2.5 x 10(7) infectious units of retrovirus were injected into the injured region of a beating rat heart. The transduced cells were identified by X-gal staining and immunohistochemistry.

RESULTS

Highly efficient transduction of cardiac fibroblasts was observed in vitro with 98% of the cells transduced with single infection. The cell proliferation index in the cardiac granulation tissue appeared maximal 3 days after cryoinjury. Retroviral injection into the injured beating heart induced gene expression localized to the wound repair region. One week after retrovirus injection, 14% of the cells in the reparative tissue were beta-gal-positive, while 4% were beta-gal-positive after 4 weeks. The transduced cells were mostly myofibroblasts.

CONCLUSIONS

Local gene transfer to the healing rat heart is feasible by retrovirus in vivo. This observation may serve as a useful guide for the development of gene therapy aimed at myocardial repair after myocardial infarction.

Infantile fibromatosis in childhood: findings on MR imaging and pathologic correlation

AIM

The objective of this study was to analyse the MR imaging findings of infantile fibromatosis of childhood and to correlate them with histopathological features.

MATERIALS AND METHODS

Seven patients with histologically proven infantile fibromatosis were included in this study. The findings on MR images were retrospectively evaluated and then correlated with the pathological features. Findings on MR imaging evaluated included signal intensity, extent of hyperintense area on T2-weighted images, margins of the lesion, the degree and pattern of enhancement and the presence of fatty tissue. Pathological features evaluated included cellularity, collagenization, and myxoid change. A five point scale was used for the evaluation of the extent of hyperintense area on MR imaging, and each of pathological features.

RESULTS

On T1-weighted images, the lesions were iso-intense in two patients; iso- and hypointense in three; and iso-, hypo- and hyperintense in two. On T2-weighted images, iso-, hypo- and hyperintense areas were mixed in all patients, the hyperintense area being the largest portion of the lesion. The margins of the lesions were infiltrative in four patients (57%), smooth in two (29%) and mixed in one (14%). Enhancement was marked in five patients (72%) and diffuse in five (71%). Regardless of the hyperintense signal intensity on T2-weighted images, the grades of each pathologic feature were variable.

CONCLUSION

Infantile fibromatosis on MR imaging causes an enhancing mass, that is largely hyperintense on T2-weighted images. Areas of high signal intensity on T2-weighted images corresponded to variable grades of cellularity, collagenization, or myxoid change.

White-matter change in mesial temporal sclerosis: correlation of MRI with PET, pathology, and clinical features

PURPOSE

To assess the magnetic resonance imaging (MRI), positron emission tomography (PET), pathology, and clinical findings of patients with the MRI feature of white-matter change (WMC) in the anterior temporal lobe.

METHODS

Fifty-six patients with pathologically proven mesial temporal sclerosis were included in this study. MRI and 18F-2-deoxyglucose-(FDG) PET images were obtained before surgery in all patients. The patients were divided into two groups according to the presence of WMC on their MRI. WMC consists of an indistinct gray-white matter demarcation and an increased signal intensity of the anterior temporal lobe on T2-weighted images. The two groups were then compared in terms of MRI, PET, pathology, and clinical features.

RESULTS

The MRI feature of WMC was observed in 18 (32%) of the 56 patients. PET images of those patients revealed more severe hypometabolism of the ipsilateral temporal lobes (p< 0.05). In terms of histologic findings, larger numbers of heterotopic neurons were observed in the anterior temporal lobe white matter of these patients who also shared the following clinical features: earlier seizure onset, frequent history of febrile convulsions, and favorable surgical outcomes.

CONCLUSIONS

The MRI feature of WMC is an additive sign for correct seizure lateralization and may be related to a favorable surgical outcome in patients with temporal lobe epilepsy.

Solitary fibrous tumor of the lacrimal sac

PURPOSE

Solitary fibrous tumor is a rare spindle cell tumor arising in the pleura. We report two cases of this tumor occurring in the lacrimal sac.

METHODS

A 23-year-old man and a 34-year-old woman presented with a medial canthal mass. They underwent surgical excision of their tumors.

RESULTS

Solitary fibrous tumors were diagnosed by light microscopy, immunohistochemical study, and electron microscopy. Immunohistochemical staining showed that tumor cells were reactive with vimentin and CD34 and demonstrated no smooth muscle or neural differentiation (nonreactive with desmin and S-100 protein).

CONCLUSIONS

The findings indicate that solitary fibrous tumor can occur in the lacrimal sac and may recur locally if it is removed incompletely. To our knowledge, these are the first reported cases of solitary fibrous tumors occurring in the lacrimal sac.

Intramuscular vascular malformations of an extremity: findings on MR imaging and pathologic correlation

OBJECTIVE

To analyze the findings of intramuscular vascular malformations of an extremity on MR imaging and to correlate these findings with histopathologic examination.

DESIGN AND PATIENTS

The findings on MR imaging and the medical records of 14 patients with an intramuscular vascular malformation of the extremity were retrospectively studied. All patients underwent surgical excision. Diagnoses were based on the results of pathologic examination. Findings on MR imaging were noted and correlated with the histopathologic findings.

RESULTS

Intramuscular vascular malformations of an extremity showed multi-septate, honeycomb, or mixed appearance on MR imaging. Multi-septate areas correlated with dilated and communicating vascular spaces with flattened endothelium. Honeycomb areas corresponded to vascular spaces with inconspicuous small lumina and thickened vascular walls. Areas of increased signal intensity on T2-weighted images were found in all intramuscular vascular malformations. Infiltrative margins were more commonly seen in intramuscular lymphaticovenous malformations. Adherence to neurovascular structures and orientation of the lesion along the long axis of the affected muscle were more commonly seen in intramuscular venous malformations.

CONCLUSIONS

Intramuscular vascular malformations showed either a multi-septate, honeycomb, or mixed appearance, reflecting the size of the vascular spaces and the thickness of the smooth muscles of the vessel walls. Prediction of the subtype of an intramuscular vascular malformation of an extremity on MR imaging seems to be difficult, although there are associated findings that may be helpful in the differential diagnosis of each subtype.

A pathologic study of abdominal lymphangiomas

Abdominal lymphangiomas are uncommon angiomatous tumor occurring mainly in childhood. This is a retrospective clinicopathologic study of 17 cases of abdominal lymphangioma. The patients included are five children and 12 adults, with a mean age at initial presentation of 30.7 years (age ranges 3-63). The locations of the tumors were mesentery (5), retroperitoneum (4), colon (3), omentum (3), mesocolon (1) and gallbladder (1). Infiltrative growth was more common pattern than entirely circumscribed pattern. Masses were mostly multilocular cysts and contained chyle or serous fluid. On immunohistochemical staining, 16 cases were reactive for either CD31 or factor VIII-related antigen. These fact would suggest that intra-abdominal lymphangiomas simulate the immunohistochemical features of collecting lymphatics. Follow up was possible in 12 cases for 3-50 months (mean 19 months) and only one patient showed local recurrence. Although abdominal lymphangiomas are rare in adulthood and correct preoperative diagnosis is difficult, awareness of such a possibility in adulthood will contribute to make a correct preoperative diagnosis.

Microvillus inclusion disease in two Korean infants

We report two cases of microvillus inclusion disease and these are the first cases in Korea. The two babies (one baby had a sibling who died of diarrhea in the neonatal period) had excreted their stools up to 200 ml/kg per day since several days after birth. Workup's included extensive infectious, immunologic, hormonal and rheumatologic studies, all of which were negative or normal. Diagnosis rested on the ultrastructural finding of intracytoplasmic inclusions that contained intact microvilli on electron microscopy. We tried somatostatin analogue (octreotide, 4 micrograms/kg/day), cholestyramine (up to 4g t.i.d.), steroid (prednisone, 2 mg/kg/day) and intravenous epidermal growth factor (100 ng/kg/hr for 2 weeks), but there was mild improvement with cholestyramine (decrease stool volume) and epidermal growth factor (increase the number of microvilli per cell) but no improvement was noted with the other treatments. Although it is a rare disorder and the prognosis of microvillus inclusion disease is poor, it must be considered if an infant has chronic secretory diarrhea.

Pseudopapillary neurocytoma of temporal lobe with glial differentiation

We present a case of cerebral neurocytoma with unusual pseudopapillary pattern, which was a predominant feature in the tumor and was characterized histologically by hyalinized vascular cores surrounded by a single or multilayered small round cells. Vascular hyalinization was also evident in the linear arborizing capillary networks in the cellular mass of the tumor. Immunohistochemically, the tumor cells were strongly positive for synaptophysin and neuron-specific enolase except some cells lining the pseudopapillae, which showed immunoreactivity for glial fibrillary acidic protein, vimentin and S-100 protein. Ultrastructural examination revealed neuritic process of the tumor cells with occasional synaptic structures and neurosecretory granules. This report suggests that neurocytoma should be included in the differential diagnosis of papillary tumors in the central nervous system.

Congenital cystic adenomatoid malformation of the lung: CT-pathologic correlation

OBJECTIVE

The purpose of this study was to correlate CT findings of congenital cystic adenomatoid malformation (CCAM) of the lung with pathologic findings.

MATERIALS AND METHODS

CT scans of CCAM from 21 consecutive patients were analyzed retrospectively by two chest radiologists who achieved consensus. Pathologic findings were assessed by an experienced pulmonary pathologist. Preoperative CT findings were correlated with pathologic findings.

RESULTS

Areas with small cysts (< 2 cm in diameter) were seen on CT scans in 19 (90%) of 21 patients, whereas areas with a large cyst (> 2 cm in diameter) were observed in 18 patients (86%). Areas of consolidation (n = 9; 43%) with heterogeneous attenuation on enhanced scans and areas of low attenuation (lower than normal lung) around cystic lesions (n = 6; 29%) were also seen on CT scans. The diameter of the largest cyst seen on CT scans in each patient ranged from 1.0 to 8.0 cm (median, 4.5 cm). Cysts that CT showed to be filled with air, fluid, or both correlated completely with the pathologic findings. Areas of consolidation corresponded histologically to areas of glandular or bronchiolar structures with or without areas of endogenous lipoid or organizing pneumonia or mucus plugs. Areas of low attenuation corresponded to areas of microcysts blended with normal lung parenchyma.

CONCLUSION

CT scans show the variable internal characteristics of CCAM and can suggest the underlying pathology of such lesions.

Rare variant of total anomalous pulmonary venous connection: intrapulmonary drainage of one lung by the other--a case report and review of the literature

Total anomalous pulmonary venous connection is an uncommon congenital cardiovascular anomaly but one that occurs frequently in the asplenia syndrome. We present a rare type of total anomalous pulmonary venous connection in a 4-month-old baby with the asplenia syndrome. In this patient, all of the left pulmonary veins united to form a common pulmonary vein, which crossed the mediastinum and then proceeded in an intrapulmonary fashion in the right lung. A small pulmonary vein emerged from the right upper lobe and drained into the right superior vena cava. Nine other cases have been reported, four also with asplenia, five with otherwise normal cardiac anatomy apart from an atrial septal defect. The incidence of pulmonary venous obstruction is high, at least 70%. Two cases, both with a normal heart, had corrective surgery. One with no pulmonary venous obstruction was repaired successfully. Embryologically, this type of total anomalous pulmonary venous connection represents a developmental error early in embryonic development before the venous connection between the two lungs and the cardinal veins involute.

Prenatal and postnatal changes of the human tonsillar crypt epithelium

The tonsillar crypt shows infiltration of lymphoid cells in the epithelium and the highly porous or discontinuous basement membrane. However, the relationship between developmental period and the significance of the disrupted epithelial basement membrane and infiltration of lymphoid cells within the human tonsillar crypt epithelium is still obscure. The present study was designed to determine the prenatal and postnatal changes of the human tonsillar crypt epithelium in 4 fetuses, 4 neonates, 1 infant, 5 children and 4 adults using immunohistochemical stains with polyclonal anti-laminin and monoclonal anti-type IV collagen antibody, and transmission electron microscope. The tonsillar crypt epithelium from all fetuses and neonates showed infiltration of many lymphoid cells and an intact basement membrane by immunohistochemistry. Transmission electron microscope revealed pores in the basement membrane through which lymphocytes passed. Tonsils from a 4-month-old infant showed focal disruption of the basement membrane by immunohistochemical staining. The tonsils from children and adults showed that there was massive disruption of the basement membrane with lymphoid cell infiltration in the tonsillar crypt epithelium by immunohistochemical staining and transmission electron microscopy. In conclusion, lymphoid cell infiltration and holes of the basement membrane of the tonsillar crypt epithelium are normal developmental findings, whereas disruption of the basement membrane of the tonsillar crypt epithelium is pathological.

Mansonian schistosomiasis in rectum--report of a case

Schistosomiasis is a snail-transmitted trematodiasis acquired by immersion in water which contains the cercariae. In Korea, six imported cases of urinary schistosomiasis by Schistosoma haematobium and one case of imported cerebral schistosomiasis by S. mansoni were reported. Herein we report a case of S. mansoni infecting rectum of a 46 year-old Korean male, who had been to Saudi Arabia for two years. On colonoscopy for routine physical check up, a 0.4 cm polyp in the rectum was detected and biopsy was done. Microscopically, rectal mucosa showed several granulomas which were composed of macrophages, lymphocytes, neutrophils and eosinophils. The center of each granuloma showed an ovoid egg often containing miracidium. The eggs measured 130 x 60 microns in average size. They had yellowish-brown transparent shell with the characteristic lateral spine. This is the 8th imported case of schistosomiasis in Korea and the second one infected by S. mansoni.

Nonspecific interstitial pneumonia with fibrosis: radiographic and CT findings in seven patients

PURPOSE

To describe the radiographic and computed tomographic (CT) findings in seven patients with nonspecific interstitial pneumonia with fibrosis (NIP).

MATERIALS AND METHODS

NIP was proved pathologically in all patients. Findings at radiography and initial and 1-15-month follow-up CT were reviewed.

RESULTS

The predominant radiographic abnormalities were areas of patchy parenchymal opacification present bilaterally in the middle and lower lung zones in six patients; in one patient, the chest radiograph depicted no abnormality. The most common finding observed on initial thin-section CT scans was bilateral, patchy areas of ground-glass attenuation present alone or with areas of consolidation in five patients (71%) or irregular lines in two (29%). At follow-up CT, the initial parenchymal abnormalities had resolved completely in three patients, improved in another three, and persisted in one.

CONCLUSION

Bilateral patchy areas of opacity depicted radiographically and good clinical response to treatment may differentiate NIP from other interstitial pneumonias.

Fetus in fetu: a case with complete umbilical cord and fetal sac

The authors present a retroperitoneal fetus in fetus in a 3-month-old girl. A 15-cm cystic mass with a monstrous fetuslike structure surrounded by a complete sac containing serous fluid was removed from the left retroperitoneal space. The draining vessel of the cystic mass was connected to the right renal vein of the host. The included fetus weighed 380 g. It had a well-developed umbilical cord, four extremities, head, buttock, and vertebral bodies with a meningomyelocele. The thoracic cavity of the included fetus had only a saclike foregut structure, but the abdominal cavity revealed a full length of intestine with a Meckel diverticulum, bilateral ovaries, urinary bladder, and cloaca with external opening. The cephalic end was composed of well-developed tooth germs, tongue and buccopharynx, mandible, maxilla, sphenoid bone, and salivary glands. Chromosomal study showed 46,XX with a normal G banding pattern. We report this case as an example of fetus in fetu with a complete umbilical cord and fetal membrane.

Effect of tibial lengthening on the gastrocnemius muscle. A histopathologic and morphometric study in rabbits

We observed the changes of the gastrocnemius muscle in relation to the percentage of lengthening of the rabbit's tibia by callotasis. 75 rabbits were separated into 3 lengthening groups, 10, 20, and 30 percent lengthening, respectively. Histopathologic observations, based on the fiber size variation, internalization of the nuclei, degeneration, regeneration, and endomysial fibrosis of muscle fibers, revealed that substantial changes occurred in the latter groups. Histomorphometrically, the decrease in the mean size of Types I and II muscle fibers was observed in all lengthening groups, but there was no significant change in the proportion of the muscle fiber types in any of the lengthening groups.

Central core disease--a case report

Central core disease is a rare congenital myopathy characterized by the formation of "cores" that consist of abnormal arrangement of myofibrils inside the myofibers. We report a 5-year-old Korean girl who showed a fairly typical clinical course of non-progressive muscle weakness. Electrodiagnostic studies showed low-amplitude polyphasic electromyograph and normal nerve conduction velocity. Gastrocnemius muscle biopsy showed central cores in over 80% of the fibers on H&E section. Histochemistry revealed deficient or absent mitochondrial enzyme in the cores and type I predominance. Ultrastructurally both structured and non-structured cores were found separately or simultaneously in one fiber. This case is the first report in the Korean literature.

Autoimmune oophoritis--a case report

A case is described of an autoimmune oophoritis that was diagnosed unexpectedly after a hysterectomy and bilateral salpingo-oophorectomy had been performed on the suspicion of ovarian cysts. The patient was a 43-year-old multiparous woman who presented with vaginal bleeding and lower abdominal pain which she had had for one month. Grossly, the ovaries were enlarged and multicystic. The cysts measured up to 3.0 cm. The major histological change was a lymphoplasmacytic infiltrate in close relation to the theca interna of developing, cystic and atretic follicles, but sparing the primordial follicles. The infiltrate increased in density with the follicular maturation and culminated against the corpus luteum. With involution of the developing follicles, the inflammatory infiltrate subsided to some extent. The proportion of the plasma cells increased with the density of the infiltrates. Immunohistochemical study of the ovarian mononuclear cell infiltrate revealed a mixture of B- and T-lymphocytes. The plasma cells were polyclonal. These histological features of the present case are typical of autoimmune oophoritis although the presence of autoantibodies and hormonal level in the patient's serum were unknown. This case may be identified as in the early active stage of autoimmune oophoritis.

Nerve sheath myxoma (neurothekeoma)--a case report

A case of nerve sheath myxoma also called as neurothekeoma in a 33-year-old woman is described. The lesion appeared as a painful, elevated nodule on the scalp for several months, without an appreciable increase in size. Microscopically, it showed typical histologic characteristics of nerve sheath myxoma, and tumor cells revealed strong, positive reaction for S-100 protein and negativity for epithelial membrane antigen (EMA) on immunohistochemical staining. These immunohistochemical findings of this case support the view that the origin cells of this tumor may be schwann cells rather than perineurial cells. The histogenesis and differential diagnosis of this tumor are discussed.

Neonatal hemochromatosis--report of an autopsy case

A case of neonatal hemochromatosis in a 3-hour-old male is described. He presented with hypotonia, mild jaundice, and respiratory difficulty immediately after birth. He had no evidence of congenital infection, immune-related hemolysis or exogenous iron uptake. Postmortem examination revealed abnormal facial features. The organs were of normal weight for his age except a small liver and lungs, and a large spleen. The most prominent changes were in the liver and pancreas. The liver was coarsely nodular and fibrotic. The lobular architecture was totally distorted by innumerable multinucleated giant cells, loss or collapse of the hepatocytes, and diffuse fibrosis. A large amount of hemosiderin was seen in the liver, pancreatic acini and thyroid follicular cells. Scanty amount of hemosiderin was also found in the myocardial fibers and renal tubular cells. The pancreas showed hyperplasia and hypertrophy of the islets. The spleen showed severe congestion and a moderate extramedullary hemopoiesis but no deposits of hemosiderin. This patient had three siblings died in neonatal period, one of which had clinical features of neonatal hemochromatosis.

Telangiectatic osteosarcoma--a case report

Telangiectatic osteosarcoma is a rare and special variant of osteogenic sarcoma with distinct radiologic, gross and microscopic features. This tumor is predominantly lytic, destructive tumor without sclerosis on roentgenogram, and is soft and cystic on gross examination. Histologically aneurysmally dilated spaces lined or traversed by stromal cells producing osteoid are noted. This report concerns a case of telangiectatic osteosarcoma occurring in a 7 years old boy. He presented with pathologic fracture of the right distal tibia, followed by a purely lytic lesion on X-ray examination. This lesion recurred five times during a span of one year. Microscopic features of the biopsy specimen was difficult to differentiate from aneurysmal bone cyst because of prominant blood-filled cyst formation. It was finally identified as osteosarcoma from the below-knee amputation specimen through the close examination for anaplastic osteoid-producing stromal cells in the septa that separate the blood cysts.

Benign cystic mesothelioma of the peritoneum--a case report

A case of benign cystic mesothelioma in a 53-year-old woman is presented. The patient had abdominal pain and a palpable mass for 4 days. This mass was noticed incidentally by an obstetrician. A computed tomographic scan of the abdomen and pelvic sonography showed a cystic mass, 6 x 4 cm, in the right lower quadrant close to the cecum and suggested cystadenocarcinoma of the ovary. Operation showed that the mass involved peritoneum in region of the appendix. Complete removal of the mass was done. Grossly it consisted of multilocular cyst containing clear, serous, gelatinous fluid. The light microscopic examination revealed that this lesion consisted of cystic spaces of various size and intervening connective tissue stroma. The cells lined the cysts varied from flattened to cuboidal with occasionally a picket-fence or hobnailed appearance in areas. Brush borders were seen on the luminal surface of some cells. Electron microscopic examination confirmed that the cells were mesothelial origin. This lesion mimics cystic lymphangioma of the abdomen grossly and light microscopically, from which differential features are discussed.

Congenital absence of ductus arteriosus--an autopsy case

Isolated absence of the ductus arteriosus is extremely rare condition although the ductus arteriosus may be hypoplastic or aplastic in association with other aortic arch anomalies. Authors described a case of isolated agenesis of the ductus arteriosus documented by postmortem examination of a newborn infant who died of pneumonia following operation for a large omphalocele. The heart showed ventricular septal defect. However, no other cardiovascular anomalies were associated in this case. There were three vessels that were taking off from the aorta consisted of the right brachiocephalic artery, left common carotid-artery and left subclavian artery. The anteriorly located pulmonary artery was divided into the right and left pulmonary arteries. There was no connection of vessel between the pulmonary artery and the aorta.

Primary intimal fibroplasia of the renal artery

Two cases of primary intimal fibroplasia of the renal artery with renovascular hypertension are described. Case 1 was 27 year old female who was incidentally found to have blood pressure of 210/130 mmHg on routine physical examination. Renal arteriogram revealed tubular narrowing of the mid protion of the left renal artery. Both patients showed lateralization in renin activity at the involved side renal vein. Case 2 was a 10 year old girl who was first noted to have a hypertension of 180/120mmHg after a sudden attack of seizure, vomiting and altered consciousness. Renal arteriogram showed concentric narrowing of the proximal half of the right renal artery. Histopathologic examination of the affected arterial segments from both cases showed essentially same findings, i,e., diffuse fibrous thickening of the intima occluding the lumen, focal fragmentation, duplication and disappearance of the internal elastic membranes. There were no deposit of lipid and inflammatory cells. The media and adventitia remained intact. The blood pressure of both patients became normal, after the surgery and the patients are in good health up to this time.

Liver cell adenoma in a neonate--report of an autopsy case

A case of liver cell adenoma that was incidentally found at postmortem examination of a neonate who died of E. coli sepsis is described. The adenoma was a sharply demarcated, not encapsulated mass located subcapsularly in the right lobe, and was pale tan to light yellowish round nodule of 0.9 cm in diameter. Microscopically, the tumor was composed of sheets and cords of uniform and slightly enlarged hepatocytes separated by dilated sinusoids. There were no portal zones or central veins to suggest the normal lobular architecture. The nuclei were bland and the cytoplasm varied from clear to acidophilic, containing lipid vacuoles. Ultrastructural examination showed that the hepatocytes of the tumor had highly differentiated organelles, reminiscent of normal hepatocytes.

Intracranial granulocytic sarcoma (chloroma) in a nonleukemic patient

Chloroma is a granulocytic sarcoma with it's characteristic greenish color. Recently there is an increased number of cases that are apparently aleukemic when the tumor mass is first presented. Recently we experienced a case of granulocytic sarcoma with characteristic green color (chloroma), which showed no evidence of leukemia in the bone marrow and peripheral blood. This patient presented headache, and was diagnosed brain tumor on computed tomography. A left parietal cranietomy was done to remove a large central dome-like mass, 8 cm, involving the dura with a slightly dusky greenish solid appearance. Compact nests of moderately mature granulocytes and immature cells comprised the tumor. Histochemical and electron microscopic studies confirmed these tumor cells as myeloid cells in varying stages of maturation. Several days after the operation, left cervical lymph nodes became palpated, and the biopsied lymph nodes revealed same neoplastic cells seen in the skull. However, bone marrow aspiration, biopsy and peripheral blood smears did not show any evidence of leukemia.

Infantile hemangioendothelioma of the liver--a case report

A case of type 1 infantile hemangioendothelioma of the liver in a 3 month old male infant who had an abdominal mass incidentally noted at 40 days of age, is described. Grossly, the tumor showed a well circumscribed, pinkish gray and gelatinous mass with areas of central necrosis, multifocal thrombi and hemorrhages, and small cysts. Microscopically, the lesion consisted of numerous vascular channels of various size lined by a single layer of flat or plump endothelial cells. Areas of infarction, thrombosis and calcification, and formation of cavernous hemangiomatous foci were also noted in the lesion. Ultrastructurally, the cells had the characteristics of endothelium, including basal lamina, pinocytic vesicles, and Weibel-Palade bodies. Factor VIII-associated antigen was demonstrated in the tumor cells.

Disseminated neonatal herpes simplex virus infection with necrotizing encephalitis--an autopsy case

An autopsy case of disseminated HSV type 2 infection occurring in a neonate at 32 weeks' gestation, delivered by cesarean section after premature rupture of membrane of 7 days duration, is presented. Herpes simplex virus type 2 was isolated from the vesicular skin lesion. The mother and patient had specific antibody to type 2 herpes simplex virus. Patient's parents had denied any herpetic orolabial or genital lesion during or before this pregnancy. Cultures from the cervical and vaginal swabs of the mother were negative for HSV. Postmortem examination showed hepatic necrosis, skin vesicle, devastating necrotizing inflammation of the brain, chorioretinitis and interstitial pneumonitis.

Intestinal Behçet's disease in a child--a case report

Behçet disease is relatively rare in pediatric age group. And the bowel involvement is seen in only a small portion of Behçet disease. However, once the bowel is involved it is potentially life threatening event. We report a 15 year old boy with intestinal Behçet's disease who had a history of recurrent oral and genital ulcers for several years. He underwent right hemicolectomy under the impression of intestinal tumor. Pathologically the lesion was a large sharply delineated ulcer in the cecum. The ulcer was round and deep with elevating margin, and was associated with thickening of affected intestinal wall. Microscopically, the ulcer base consisted of granulation tissue with fissurings and underminings. Characteristic phlebitis and occlusive arterial lesion were seen in intestinal wall. The inflammatory lesion was most pronounced around the ulcer but could be recognizable throughout the resected specimen.

Crohn's disease--a case report

A case of rather typical Crohn's disease in a 10 year old girl is described. She had suffered from intractable abdominal pain, diarrhea and fever for 1 year. Eventual right hemicolectomy revealed diffuse involvement of terminal ileum, cecum and ascending colon by confluent ulcerations and transmural inflammation. Histologically there were numerous well developed non-caseating granulomas scattered transmurally and in regional lymph nodes. Deep penetrating ulcerations were characteristic. Acid fast staining failed to demonstrate any organism. The rarity of Crohn's disease in Korea and this occurrence in pediatric age prompted this report.

Menkes disease--an autopsy case with metal analysis of hair

We report the first case of Menkes' disease in Korea, occurring in a 1 1/2 year old boy with characteristic clinical, arteriographic and pathologic features. Postmortem examination revealed widespread neuronal destruction and abnormally tortuous and elongated large arteries including cerebral, visceral and limb vessels. Microscopically, many of the hairs formed were twisted (pili torti), of varying caliber (monilethrix), and fractured (trichorrhexis nodosa). In the radioactivated analysis of scalp hair, copper elements was not found. The abnormal vessels were characterized by fragmentation and disruption of the internal elastic lamina with intimal proliferation. The neuronal destruction was widespread in the cerebral gray matter and in the cerebellum, and there was associated gliosis. The changes in the cerebellum were particularly severe, with neuronal loss in the internal granular cell layer. Many Purkinje cells were lost, and the remainder showed unusual dendritic sprouts from the cell body and grotesque proliferation of dendritic tree. In other organs, mild chronic peribronchitis, and scattered foci of immature glomeruli in renal cortex were noted.