Synchronous Primary Leiomyosarcoma in the Thoracic Vertebra and the Liver / 대한소화기학회지

This is a case report of simultaneous primary leiomyosarcomas in the spine and liver. A 64-year-old woman presented to the Seoul Paik Hospital with epigastric discomfort and constipation that she had experienced for two months. A physical examination revealed severe tenderness around the thoraco-lumbar junction. Esophagogastroduodenoscopy showed an ulceroinfiltrative lesion on the gastric angle. An abdominopelvic CT scan revealed two low attenuated lesions in the S4 and S8 regions of the liver, as well as a soft tissue mass at the T10 vertebra. Percutaneous ultrasonography-guided needle biopsy of the hepatic nodules revealed a leiomyosarcoma. The tumor at the T10 vertebra was removed to avoid spinal cord compression. The histology of this tumor was compatible with that of leiomyosarcoma. The potential primary sites for leiomyosarcoma, including the lung, thyroid, breast, kidney, genitourinary organs, and gastrointestinal tract, were subsequently investigated. No detectable abnormal findings that would suggest the origin of the tumor were found. Synchronous primary leiomyosarcomas in the spine and liver are quite rare and have a poor prognosis.

Synchronous Primary Leiomyosarcoma in the Thoracic Vertebra and the Liver / 대한소화기병학회잡지

This is a case report of simultaneous primary leiomyosarcomas in the spine and liver. A 64-year-old woman presented to the Seoul Paik Hospital with epigastric discomfort and constipation that she had experienced for two months. A physical examination revealed severe tenderness around the thoraco-lumbar junction. Esophagogastroduodenoscopy showed an ulceroinfiltrative lesion on the gastric angle. An abdominopelvic CT scan revealed two low attenuated lesions in the S4 and S8 regions of the liver, as well as a soft tissue mass at the T10 vertebra. Percutaneous ultrasonography-guided needle biopsy of the hepatic nodules revealed a leiomyosarcoma. The tumor at the T10 vertebra was removed to avoid spinal cord compression. The histology of this tumor was compatible with that of leiomyosarcoma. The potential primary sites for leiomyosarcoma, including the lung, thyroid, breast, kidney, genitourinary organs, and gastrointestinal tract, were subsequently investigated. No detectable abnormal findings that would suggest the origin of the tumor were found. Synchronous primary leiomyosarcomas in the spine and liver are quite rare and have a poor prognosis.

Secondary publication Traumatic Rupture of a Huge Renal Angiomyolipoma in a Tuberous Sclerosis Patient / 대한법의학회지

A renal angiomyolipoma (AML) is an unusual benign tumor that is composed of adipose tissue, smooth muscle, and abnormal blood vessels. AMLs can occur sporadically or can be associated with tuberous sclerosis. A ruptured renal AML may manifest as lift-threatening hypovolemic shock or sudden death. Herein, the authors present an autopsy case of traumatic rupture of a renal AML in a patient with tuberous sclerosis.

Secondary publication Asphyxia due to Oxygen Deficiency by Evaporated Liquid Nitrogen / 대한법의학회지

An 18-year-old man collapsed at his workplace while putting desiccant into a cylindrical mixer, 2 m x 1 m in dimension, which contained rubber powder. His coworker found him collapsed, and he was transported to a hospital by a 119 rescue team, where he died. Prior to the incident, liquid nitrogen had been placed into the mixer to lower the temperature of the rubber powder. There were no injuries or disease that could have caused death. Analysis of the gas in the mixer revealed that the O2 concentration had dropped to 3.7% in 2 minutes following addition of the liquid nitrogen. Therefore, it was concluded that the cause of death was asphyxia due to oxygen deficiency caused by liquid nitrogen evaporation.

Death by Subdural Hematoma with Metastatic Carcinoma of Unknown Origin: An Autopsy Case Report / 대한법의학회지

Dural metastasis associated with chronic subdural hematoma is very rare in patients with malignant neoplasms; it may be difficult to distinguish malignant neoplasms from chronic subdural hematoma. Chronic subdural hematoma is usually a late manifestation of malignant tumors, which contributes to the severity of the prognosis. The scans obtained by using magnetic resonance imaging or computed tomography may be misleading when a subdural hematoma masks the underlying tumor. Herein, we report a case of a subdural hematoma with dural metastasis of unknown origin in a 45-year-old woman; however, the neoplasm was not detected until autopsy.

Miniprobe Endoscopic Ultrasonography Has Limitations in Determining the T Stage in Early Colorectal Cancer

BACKGROUND/AIMS: Mini-probe endoscopic ultrasonography (mEUS) is a useful diagnostic tool for accurate assessment of tumor invasion. The aim of this study was to estimate the accuracy of mEUS in patients with early colorectal cancer (ECC). METHODS: Ninety lesions of ECC underwent mEUS for pre-treatment staging. We divided the lesions into either the mucosal group or the submucosal group according to the mEUS findings. The histological results of the specimens were compared with the mEUS findings. RESULTS: The overall accuracy for assessing the depth of tumor invasion (T stage) was 84.4% (76/90). The accuracy of mEUS was significantly lower for submucosal lesions compared to mucosal lesions (p=0.003) and it was lower for large tumors (> or =2 cm) (p=0.034). The odds ratios of large tumors and submucosal tumors affecting the accuracy of T staging were 3.46 (95% confidence interval [CI], 1.05 to 11.39) and 6.25 (95% CI, 1.85 to 25.14), respectively. When submucosal tumors were combined with large size, the odds ratio was 14.67 (95% CI, 1.46 to 146.96). CONCLUSIONS: The overall accuracy of T stage determination with mEUS was considerably high in patients with ECC; however, the accuracy decreased when tumor size was >2 cm or the tumor had invaded the submucosal layer.

Death by Homicidal Smothering Using Hot Steam Towel: A Case Report / 대한법의학회지

An unusual case of homicide of a 21-year-old man who was smothered with a hot steam towel by his mother and a pastoress in the name of exorcism. Homicidal smothering in adults is rare, but does occur when the victims are not capable of defending themselves in situations such as chronic illness, old age, drug intoxication or when restrained by other people. In this case, distinct facial scalding was a clue to smothering with a hot steam towel.

Forensic Analysis of the Cause of Death and Death on Arrival of Patients at the Emergency Room / 대한법의학회지

From January 2007 to June 2012, 55 autopsy cases were reviewed, in which death occurred outside the hospital and the patients were declared dead on arrival at the emergency departments, in order to compare the clinical and postmortem examination diagnoses of death-on-arrival patients in tertiary hospitals in Busan, Yangsan and Ulsan city. Of 22 non-traumatic deaths, 21 occurred from natural causes and 1 from unknown cause (sudden infant death syndrome, SIDS). Clinical diagnoses were cardiovascular diseases or "non-traumatic" / "unknown" while autopsy diagnoses were majorly cardiovascular diseases, especially coronary artery diseases (72.7%). Of 33 unnatural deaths, the cause of death was blunt trauma in 4 patients, sharp-force injury in 6, falling in 10, gunshot injury in 1, traffic accidents in 3, asphyxia in 2, drowning in 2, fire-related death in 1, and intoxication in 4. There were no definite discrepancies between clinical and autopsy diagnoses, except for 5 non-traumatic deaths and 2 unnatural deaths. These results suggest that the role of the emergency department may be crucial in postmortem investigations.

Fatal Inhalation Injury by Sulfuric Acid Fumes: Case Report / 대한법의학회지

Sulfuric acid can cause local or systemic effects after exposure by inhalation, ingestion, or topical application. Direct ingestion is the main exposure route for fatal sulfuric acid injury. Fatal accidents involving the inhalation of toxic sulfuric acid vapors are rare. Inhalation of sulfuric acid fumes causes severe irritation or corrosive damage to the upper respiratory tract. Consequently, severe congestion, edema, and inflammation of the mucous membranes of the upper respiratory passages hinder the entry of air into the lungs, possibly leading to fatalities in victims. A 35-year-old man died at his home after complaining of a severe sore throat. One day earlier, he had worked in a sulfuric acid tank in a copper-smelting plant while wearing an ordinary gas mask that offered no protection against sulfurous acid vapors. Upon autopsy, the larynx and epiglottis showed pronounced edema, congestion, and inflammation that histologically mimicked an acute bacterial suppurative inflammation, accompanied by severe pulmonary edema. A field analysis of the air inside the sulfuric acid tank revealed SO4(2-) positivity and a 40% sulfuric acid concentration.

Sudden Death from an Non-diagnosed Paraganglioma after Surgery: A Case Report / 대한법의학회지

Extra-adrenal paragangliomas and pheochromocytomas are rare but clinically important tumors, which produce, store, release, and metabolize catecholamines resulting in unexpected life-threatening effects. It is neither easy nor difficult to clinically diagnose these tumors despite the availability modern clinical methods because signs and symptoms such as recurrent episodes of paroxysmal hypertension and headache are nonspecific. Only a few cases of unexpected death in which the deceased had a non-diagnosed paraganglioma or pheochromocytoma have been reported. Death in these cases is usually sudden and occurs during emergency room care or during a major or minor abdominal operation, without prodromal symptoms. Death is considered to occur because of paroxysmal hypertension, cerebrovascular attacks, abrupt hemorrhage into the tumor parenchyma, or acute left ventricular failure. We report the case of a 73-year-old man who died 12 hours after undergoing decompression surgery for spinal stenosis. A medico-legal autopsy revealed that death in this case resulted from an undiagnosed paraganglioma around the abdominal aorta.

Medicolegal Review of Deaths Related to Propofol Administration: Analysis of 36 Autopsied Cases / 대한법의학회지

Propofol is a widely used anesthetic in anesthesia and sedation. Recent cases of propofol-induced death have been associated with adverse effects, abuse, or intoxication. However, there are few forensic reports of propofol-associated death. We reviewed and analyzed 36 cases of death related to propofol administration recorded by the National Forensic Service in 2000-2011. The number of women was 28 (77.8%). Subjects in their 20s and 30s accounted for 61.1% of cases. Cause included medical accidents, 16 (44.4%); suicides, 2 (5.6%); and undetermined, 18 (50%; suicide/accident). Of the 16 medical accidents, 8 were internal medicine cases (conscious sedation endoscopy), 3 surgical cases, 3 plastic surgery cases, 1 urology case, and 1 obstetrics and gynecology case. In 20 cases of suicide or undetermined (suicide/accident), the victims were nurses (9 cases), doctors (4 cases), hospital administrators (2 cases), homemakers (2 cases), bar hostesses (2 cases) and an office worker (1 case). The doctor included 2 plastic surgeons, an internist, and a resident anesthesiologist. The autopsy findings were nonspecific; congested parenchymal organs (34 cases), pulmonary edema (8 cases), cerebral edema (2 cases), pulmonary and cerebral edema (2 cases), putrefaction (2 cases), mucosal petechiae in the interior of the larynx (1 case), and cerebral ischemic necrosis and pneumonia (1 case). The blood propofol concentrations ranged between 0.007 mg/L (cardiopulmonary resuscitation) or 0.23 mg/L (no cardiopulmonary resuscitation) and 4.38 mg/L in medical accident cases, and from 0.12 mg/L to 108.3 mg/L in suicide or undetermined (suicide/accident) cases. Other drugs were detected in 17 cases and alcohol was detected in only 2 cases. Blood concentrations in cases of medical accident were lower than in cases of undetermined cause.

Hemorrhagic Infarction of the Small Intestine due to Transmesenteric Hernia in an Adolescent: A Case Report / 대한법의학회지

Transmesenteric hernia is so infrequent that sudden unexpected death due to this condition is a very rare occurrence. Because the disease usually occurs in pediatric populations, it is a very rarely observed in adolescents or adults. We report an autopsy case of transmesenteric hernia diagnosed postmortem in an 18-year-old boy who died suddenly after complaining of acute abdominal pains with nausea. Physical examinations, simple abdominal radiographs, and abdominal CT scans failed to provide a clear diagnosis of the illness for 37 h in the hospital. At autopsy, a small round defect of the small bowel mesentery was found, through which a long segment of the small intestine herniated, accompanied by hemorrhagic infarction induced by strangulation obstruction. We would like to present and review this rare autopsy case with medicolegal viewpoints.

The Statistical Analysis on Legal Autopsy in 2010 (The headquarters of National Forensic Service) / 대한법의학회지

This is a statistical analysis based on the data of legal autopsies performed at the Headquarters of the National Forensic Service (NFS), requested by every kind of law enforcement agencies during the year of 2010. NFS is located in Seoul, Korea and has four branches throughout the country. The Seoul NFS covers all legal autopsies in Seoul, Incheon City and Gyeonggi Province and some cases referred from other regions. This report aims to analyze various aspects of 2,425 unusual deaths in Korea, chiefly Seoul and its surrounding area. Followings are the summary of the results. 1. The number of male was 1,777 cases (73.3%) and that of female 648 (26.7%). Male was over twice more than female. The forties were 592 cases (24.4%), the fifties 552 (22.8%), and these two decades occupied 47.2%. 2. Unnatural deaths were 1,377 cases (56.8%), natural 875 (36.1%), and the unknown 173 (7.1%). Among 1,377 unnatural deaths, suicide was 411 (29.8%), homicide 260 (18.9%, accident 417 (30.3%), and the undetermined 289 (21.0%). Homicide occupied 34.7% of trauma, 61.2% of blunt force injury excluding traffic and fall-down injury, and 81.4% of sharp force injury. The homicide rate in asphyxia was 23.9%, but it went up to 60.9% excluding hanging. It showed only 1.3% of homicide in poisoning. 3. Traumatic deaths were 536 cases, occupying 38.9% of 1,377 unnatural deaths, followed by poisoning. Blunt trauma was 138 cases (25.0%) and the leading cause of death in traumatic death. Poisoning was 245 cases, among which the alcohols were dominant (54 cases). Thermal injuries were 119 cases, electrocution 10 cases, and starvation/neglect 2 cases. and 48 cases were directly due to medical procedures. 4. Among 875 natural deaths, heart diseases were 583 cases (66.6%), and vascular diseases 64 (7.3%), and these two categories were added up to 647 (73.9%). 5. Child deaths under the age of 10 were 102 cases. Homicide was 25 cases (65.8%) out of 38 unnatural deaths. Neonates including still births were the leading period of age in unnatural death, counting 73 cases (71.6%).

Hydrothorax Associated with Peritoneal Dialysis / 대한법의학회지

Hydrothorax is an uncommon but a well-recognized complication of peritoneal dialysis, and is estimated at 1.6-10%. It is not a life-threatening condition, but massive hydrothorax (so called 'tension hydrothorax') has been documented rarely. We report an autopsy case showing the right-sided hydrothorax associated with peritoneal dialysis. A 27-year-old man who had suffered chronic renal failure and peritoneal dialysis, was found dead in his room. At autopsy, there were about 3 liters of clear transudate in the right pleural cavity and the right lung was collapsed. The biochemical study of the pleural fluid showed 266 mg/dL of glucose.

Sudden Death Due to Left Atrial Myxoma / 대한법의학회지

The primary tumor of the heart is rare and the myxoma is the most common primary cardiac tumor. Sudden death due to cardiac myxoma is mainly with atrial myxoma, tumor embolization, or obstruction of blood flow at the mitral or tricuspid valve. Thus it appears that histologically benign but potentially lethal. This report describes an unusual cause of sudden unexpected death and the autopsy findings for a 51-years-old woman with left atrial myxoma. She complained fatigue and weight loss during 1 year, without dyspnea or other systemic symptoms. On autopsy, the left atrium is slightly enlarged as ball-shaped. Opening it, a smooth surfaced pale, round and lobulated mass is found, attached on left atrial septum. On cut section, it is dark brown to dark red colored with gelatinous appearance, and shows focal interstitial fibrosis, calcification and hemorrhage. We present a case diagnosed at post-mortem of an left atrial myxoma without any informations of clinical symptoms. The cardiac myxoma must considered for cause of sudden death to cardiac problem.

A Case of Esophageal Hemangioma Treated by Endoscopic Mucosal Resection / 대한소화기내시경학회지

Esophageal hemangioma occurs in fewer than three percent of all benign esophageal neoplasm. To treat symptomatic esophageal hemangioma, surgical resection can be performed. A case of esophageal hemangioma was successfully treated by endoscopic mucosal resection (EMR). The patient was a 50-year-old man who presented with dysphagia and epigastric discomfort. An endoscopic ultrasonography examination revealed an esophageal submucosal mass confined to the submucosal layer, with no continuity with adjacent vessels without regional lymphadenopathy. For diagnosis and symptomatic relief, EMR was performed. The final diagnosis was benign esophageal cavernous hemangioma. No complications have been evident during a 3-year follow-up.

MALT (Mucosa-Associated Lymphoid Tissue) Lymphoma of the Colon / 대한소화기학회지

No abstract available.

Primary Extrapulmonary Small Cell Carcinoma of the Appendix: A Case Report

Primary extrapulmonary small cell carcinoma (EPSCC) of the appendix is an extremely rare entity, and there has been only one previous report on this in the English medical literature. We report here on the first Korean case of EPSCC of the appendix in a 55-year-old woman. The patient had no history of an identified pulmonary tumor, and she presented with constipation and lower abdominal pain. The patient underwent right hemicolectomy with regional lymph node dissection and bilateral salphigo-oophorectomy. The histology of the entire appendiceal tumor revealed pure EPSCC with diffuse immunoreactivity for pancytokeratin, cytokeratin 7, cytokeratin 20, CD56, thyroid transcription factor 1, c-kit and carcinoembryonic antigen, and there was focal weak immunoreactivity for chromogranin A and synaptophysin. After the second cycle of chemotherapy, the condition of the patient gradually deteriorated due to cancer peritonei and the patient died 7 months later. EPSCC of the appendix is a distinctive clinicopathological entity that displays highly aggressive behavior and an unfavorable outcome.

The Usefulness of Endoscopic Ultrasonography in the Diagnosis of Choledocholithiasis without Common Bile Duct Dilatation / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate modality in diagnosis of choledocholithiasis. However, it carries some complications. Endoscopic ultrasonography (EUS) is less invasive than ERCP and used for the diagnosis of choledocholithiasis. Recent studies showed that a usefulness of EUS for the diagnosis of small choledocholithiasis without common bile duct (CBD) dilatation. For such a reason, ERCP is being replaced by EUS in the diagnosis of bile duct stones. The aim of this study was to investigate the accuracy of EUS for the diagnosis of choledocholithiasis without CBD dilatation. METHODS: A total of 66 patients with suspected choledocholithiasis without CBD dilatation were enrolled. EUS were performed in all cases within 48 hours after computed tomography (CT) or ultrasonography (US). Final diagnosis was obtained by ERCP or clinical course (minimum 6 months follow-up). We analyzed the accuracy of US, CT, and EUS, respectively. RESULTS: CT and US were performed in 51 and 15 cases, respectively. CBD stones were detected in 23 (35%) patients by ERCP. EUS showed 100% sensitivity, 95% specificity, 92% positive predictive value, and 100% negative predictive value for identifying CBD stones. CT or US showed 26%, 93%, 67%, and 70%, respectively. There were no EUS-related complications. CONCLUSIONS: EUS was more effective than CT or US and as accurate as ERCP for the diagnosis of small choledocholithiasis without CBD dilatation. Thus, EUS may help to avoid unnecessary diagnostic ERCP and its complication.

A Case of Endoscopic Ultrasound Guided Cholangiography with Antegrade Drainage / 대한소화기내시경학회지

An 84-year-old woman presented with obstructive jaundice due to unresectable gallbladder cancer with a left renal cell carcinoma. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) were unsuccessful because of tumor obstruction of the duodenal bulb, right hepatic duct and distal common bile duct. Endoscopic ultrasound (EUS)-guided biliary drainage with a transgastric approach was performed. A guide-wire was passed through the biliary obstruction and was successfully advanced into the duodenum via the ampulla. The procedure was completed in an antegrade fashion. The obstructed biliary system was successfully decompressed by the insertion of a biliary covered metal stent through the malignant stricture. There were no complications related to the use of this procedure.