Early Colorectal Epithelial Neoplasm in Korea: A Multicenter Survey of Pathologic Diagnosis

BACKGROUND: The incidence of early colorectal epithelial neoplasm (ECEN) is increasing, and its pathologic diagnosis is important for patient care. We investigated the incidence of ECEN and the current status of its pathologic diagnosis. METHODS: We collected datasheets from 25 institutes in Korea for the incidence of colorectal adenoma with high grade dysplasia (HGD) and low grade dysplasia in years 2005, 2007, and 2009; and early colorectal carcinoma in the year 2009. We also surveyed the diagnostic terminology of ECEN currently used by the participating pathologists. RESULTS: The average percentage of diagnoses of adenoma HGD was 7.0%, 5.0%, and 3.4% in years 2005, 2007, and 2009, respectively. The range of incidence rates of adenoma HGD across the participating institutes has gradually narrowed over the years 2005 to 2009. The incidence rate of early colorectal carcinoma in the year 2009 was 21.2%. The participants did not share a single criterion or terminology for the diagnosis of adenoma HGD. The majority accepted the diagnostic terms that distinguished noninvasive, mucosal confined, and submucosal invasive carcinoma. CONCLUSIONS: Further research requirements suggested are a diagnostic consensus for the histopathologic diagnosis of ECEN; and standardization of diagnostic terminology critical for determining the disease code.

Giant Peritoneal Loose Body in the Pelvic Cavity

We report a case of a large peritoneal loose body diagnosed on computed tomography. The most common causes of a peritoneal loose body are thought to be torsion and separation of the appendices epiploicae. Peritoneal loose bodies are usually small, 0.5 to 2.5 cm in diameter. However, "giant" peritoneal loose bodies, larger than 4 cm in diameter, are an uncommon disease and present with various symptoms, and are difficult to diagnose preoperatively. Especially, abdominal large peritoneal loose bodies are frequently misdiagnosed as tumorous disease preoperatively. In our case, the loose body appeared as a round pelvic mass with central calcifications and a distinct fat plane separating it from adjacent organs. Preoperatively, we suspected a tumorous lesion from the wall of the upper rectum; however, at laparoscopy, a large peritoneal loose body was detected. An extraction of the giant peritoneal loose body was performed laparoscopically.

Clinical Study and Review of Articles (Korean) about Retrorectal Developmental Cysts in Adults

PURPOSE: A retrorectal developmental cyst (tailgut cyst, epidermoid cyst, dermoid cyst, teratoma, and duplication) is very rare disease, and the symptoms are not characteristic so that sometimes this disease is still misdiagnosed as a supralevator abscess or a complex anal fistula. We would like to present a clinical approach to this disease. METHODS: We retrospectively examined the charts of 15 patients who were treated for retrorectal cysts from January 2001 to November 2009. RESULTS: All 15 patients were female. The average age was 41 years (range, 21 to 60 years). Fourteen patients (93.3%) were symptomatic, and the most common symptom was anal pain or discomfort. Nine patients (60%) had more than one previous operation (range, 1 to 9 times) for a supralevator abscess, an anal fistula, etc. In 12 patients (80%), the diagnosis could be made by using the medical history and physical examination. Thirteen cysts (80%) were excised completely through the posterior approach. The average diameter of the cysts was 4.8 cm (range, 2 to 10 cm). Pathologic diagnoses were 8 tailgut cysts (53.3%), 5 epidermoid cysts (33.3%) and 2 dermoid cysts (13.3%). The average follow-up period was 18.3 months (range, 1 to 64 months). CONCLUSION: In our experience, high suspicion and physical examination are the most important diagnostic methods. If a female patient has a history of multiple perianal operations, a retrorectal bulging soft mass, a posterior anal dimple, and no conventional creamy foul odorous pus in drainage, the possibility of a retrorectal developmental cyst must be considered.

A case of exophytic pedunculated gastrointestinal stromal tumor with cystic changes / 대한내과학회지

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, and cystic changes are commonly observed. However, there have been few reports of cases of exophytic pedunculated GIST with cystic changes. Here, we report a 45-year-old man who presented with a palpable mass in the left upper quadrant of the abdomen. The mucosal folds were endoscopically abnormal, but there was no mucosal lesion. Computed tomography demonstrated a large, low-density cystic lesion surrounding an enhanced nodule in the greater curvature of the gastric body, and there was no tumor infiltration to other organs. The patient underwent hemigastrectomy and the lesion was shown to be an exophytic pedunculated cystic tumor. Histopathological examination showed epithelioid cells with marked hemorrhaging. Immunohistochemical examination indicated that most of the tumor cell cytoplasm was positive for the c-kit protein (CD117) and CD34. The tumor was diagnosed as an exophytic pedunculated GIST of the stomach with cystic changes.

A case of mucinous borderline ovarian tumor associated with undifferentiated sarcoma with angiosarcoma-like appearance / 대한산부인과학회지

The ovarian mucinous tumor associated with true sarcoma is very rare. Four cases of true sarcoma: fibrosarcoma, undifferentiated sarcoma, rhabdomyosarcoma, angiosarcoma in ovarian mucinous tumor have been reported. We present a case of mucinous borderline tumor associated with undifferentiated sarcoma with angiosarcoma-like appearance in 80-year-old woman.

A Case of Mature cystic teratoma in Omentum / 대한산부인과학회지

The mature cystic teratoma of the omentum is a very rare tumor. It is generally believed that autoamputation and reimplantation of an ovarian tumor is the most common etiology of omental teratoma. Abdominal pain is the main presenting symptom of these tumors. A 41-year-old woman was admitted for pelvic mass. At laparotomy, a 8.5 x 7.0 x 7.5 cm mass was found in the pelvic cavity, attached to the omentum with adhesion to bladder. The histopathologic diagnosis was mature cystic teratoma in conjunction with the cyst wall is diffusely necrotic and calcified with hairs. The absence of the left ovary suggested that the tumor underwent autoamputation and reimplantation on the omentum. We report the case with a brief review of literature.

A Case of the Duodenal Bulb Abscess / 대한소화기내시경학회지

Duodenal abscess is a rarely reported disease throughout the entire world. Duodenal abscesses are developed mostly from the complication of duodenal ulcer perforation, and only small percentage of duodenal abscesses are the result of cholecysto-duodenal fistula which was made by gall bladder perforation. We report a 84-year-old male patient who presented to the emergency department with severe anorexia and generalized weakness for 2 weeks. The upper gastrointestinal endoscopy done and revealed a protruding mass at the lesser curvature of the duodenal bulb. As soon as the mass was punched with a biopsy forceps, a large amount of abscess began to pour out into the intestinal lumen. Abdominal CT scan demonstrated the presence of an air-fluid level the in gall bladder and also abscess in the porta hepatitis which was located between the gall bladder and the duodenum. Because the patient refused any surgical intervention, we treated him conservatively with intravenous antibiotics. Patient's symptom of anorexia was slowly resolved, and patient was discharged 10 days later.

Two Cases of Granulosa Cell Tumor of the Ovary / 대한산부인과학회지

Granulosa cell tumors are relatively low-grade malignancies accounting for about 1 to 2% of all primary ovarian neoplasms and have an indolent growth pattern. There are two types of tumors, adult type granulosa cell tumor (AGCT) and juvenile type granulosa cell tumor (JGCT), and each tumor reveals different clinical or histopathological features. The clinical manifestations are mostly associated with estrogen produced by tumor, which are vaginal bleeding or menstrual irregularity in AGCT and precocious puberty in JGCT. Although most patients are diagnosed in early stage with favorable prognosis, some recur after several years. So, continuous follow up is required. Recently, we experienced two cases of adult type granulosa cell tumor and report with a brief review of literatures.

Massive Bleeding from Multiple Jejunal Diverticulosis

Jejunoileal diverticulosis is formed by herniation of mucosa and submucosa through the muscular layer of the bowel wall. The condition usually consists of multiple diverticula at the mesenteric border, in contrast to the true congenital Meckel's diverticulum. Small bowel diverticulum is a rare disease that can give rise to unexpected problems such as malabsorption, perforation, diverticulitis, obstruction and bleeding. Since the reported complication rate is low, uncomplicated small bowel diverticula are generally recommended to be left untreated. Bleeding from a diverticulum is often sudden and massive. We report herein a case of a 43-yearold women who presented with massive bleeding from multiple jejunal diverticula. She had been admitted to hospital one day previously with the chief complaint of severe whole abdominal pain which was aggravated progressively. On physical examination, she showed an acute, ill appearance. The abdomen was slightly distended and tender with rebound tenderness. On the abdomen CT, the jejunal wall was thickened and the mesenteric lymph nodes were enlarged. An emergency laparotomy was performed. Multiple jejunal diverticula, distributed from 20 to 100 cm distal to the ligament of Treitz, were found, along with massive bleeding from diverticulosis. A segment of the jejunum containing all diverticula was resected and end to end anastomosis was performed. Due to the relative rarity of these lesions and their complications, diagnosis is often difficult and delayed. Awareness of their tendency to cause nonspecific abdominal symptoms and serious complications may lead to earlier diagnosis and timely treatment.

A Case of Enteritis Cystica Profunda in the Duodenal Bulb / 대한소화기내시경학회지

Enteritis cystica profunda (ECP) is characterized by mucin-filled cystic spaces that are partially lined by non-neoplastic columnar epithelium, and these are found in the wall of the small bowel. This is a very rare disease compared to cystica profunda involving the stomach or colon. The cause of ECP is still unclear. Most ECP is related to or it may accompany other intestinal diseases. We encountered one case of ECP of the duodenal bulb that presented as polyp, and this was not related to adenocarcinoma or any other intestinal diseases like Crohn's disease or ulcerative colitis. Endoscopic polypectomy was done and the ECP was later confirmed through histological evaluation.

Two Cases of Endometriosis at the Subcutaneous Tissue of the Abdominal Scar after Cesarean Section / 대한산부인과학회잡지

Endometriosis is generally confined to the pelvic viscera and the peritoneum, but it can proliferate in other areas like pleura, skin, extremities, lung, gallbladder, stomach, kidney and surgical scar. Scar endometriosis usually occurs in the surgical scar of previous cesarean sections, hysterotomy and episiotomy. The occurrence of endometrioma in cesarean scar is an infrequent event, usually presenting as a tender abdominal wall mass. We report two cases of abdominal wall endometrioma after cesarean section, which is presented with a brief review of the literature.

Appendicocolic Fistula

An appendicocolic fistula is a rare disease. It seems likely that the appendix becomes adherent to the viscus either before or after its perforation due to appendicitis, so surgeons may become confused when an emergency appendectomy in done. We report one case of an appendicocolic fistula to draw attention to the importance of this fistula and to describe the clinical, the diagnostic, and the therapeutic aspects of the disease.

Primary Neurilemmoma of the Thyroid Gland

Neurilemmoma, like other non-epithelial tumors, seldom occurs in the thyroid gland. We present a case of a 61-year-old woman with a neurilemmoma of her left thyroid lobe. She was clinically and biochemically euthyroid, and underwent a left thyroid lobectomy without complications. The tumor was an encapsulated solid mass, 34x23x1 5mm in size and was diagnosed as neurilemmoma. Neurilemmoma of the thyroid gland tends to develop in the right lobe, but this case was in the left.

Expression of Urokinase-type Plasminogen Activator (uPA) and Plasminogen Activator Inhibitor-1 (PAI-1) in Gallbladder Carcinoma

BACKGROUND: There are evidences that uPA and its inhibitor play a key role in tumor spread. We studied whether uPA and PAI-1 expressions could serve as prognostic parameters along with clinical, gross and microscopic findings in gallbladder carcinomas. METHODS: We analyzed 42 cases of gallbladder carcinomas by immunohistochemical staining and clinicopathologic parameters. RESULTS: uPA and PAI-1 were more frequently expressed in the adenocarcinoma than in the normal or benign gallbladder tissue. The uPA expression in the glands of low grade adenocarcinoma was significantly correlated with both distant and lymph node metastases. The uPA expression in the stroma around the low grade adenocarcinoma was significantly correlated with either distant or lymph node metastasis. The PAI-1 expression was significantly correlated with lymph node metastasis only for both distant and lymph node metastases. In multivariate analysis, the lymphatic invasion was significantly related to poor survival (p= 0.0115). In univariate analysis, the cases without lymphatic invasion had prolonged survival. Positive expression of uPA in the glands of low-grade adenocarcinoma was significantly correlated with poor survival (p=0.0391). CONCLUSION: In conjunction with clinicopathologic findings, expressions of uPA and PAI-1 may be useful prognostic markers in gallbladder carcinomas.

Expression of Cyclooxygenase-2 in Human Breast Carcinoma: Relevance to Tumor Angiogenesis and Expression of Estrogen Receptor / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study investigates the COX-2 expression in human primary breast carcinomas and its relationship with both angiogenesis and the expression of estrogen receptor. MATERIALS AND METHODS: COX-2 expression, angiogenesis, and estrogen receptor expression were examined by immunohistochemical methods in 167 human breast carcinomas by using monoclonal antibodies against COX-2, CD34, and estrogen receptor protein. RESULTS: Although COX-2 was expressed in 77.8% of the breast carcinomas (130/167) regardless of histological types, it was not detected at all in benign epithelial cells. Interestingly, COX-2 expression was found to be significantly correlated with tumor angiogenesis (p=0.004), but not with estrogen receptor and other histopathologic parameters. CONCLUSION: The results suggest that COX-2 expression occurs frequently in breast tissue during transformation of benign epithelial cells to malignant cells regardless of the estrogen receptor status. COX-2 expression may play a role in tumor angiogenesis that is responsible for tumor growth and metastasis.

Granular Cell Tumor of the Thyroid

Granular cell tumor is not uncommon and is a well recognized entity which may arise at virtually any site of the body. However, occurrence in the thyroid is extremely rare and has not been described well. Only three cases could be found in the English literatures. We report a case of granular cell tumor of the thyroid in a 30 year-old woman. The tumor was illdefined, infiltrative and was composed of diffuse sheets of polygonal to fusiform cells with abundant eosinophilic granular cytoplasm. The tumor showed evidence of Schwann cell differentiation in immunohistochemical and ultrastructural examinations. Differentiation from more common thyroid tumors having oncocytic granular cytoplasm should be made by immunohistochemistry or electron microscopy.

E-Cadherin Expression in Breast Carcinoma: Correlation with Tumor Grade and Hormone Receptor

E-cadherin (E-CD), a Ca2+ -dependent adhesion molecule, plays a major role in the maintenance of intercellular junctions in normal epithelial cells in most organs. Recently, a correlation has been observed between a loss of E-CD and increased invasiveness of neoplastic cells. In this study, E-CD expression in the breast carcinoma was investigated using monoclonal antibody, anti-E-CD by immunohistochemical method. Expression of E-CD were evaluated in 57 breast carcinomas and correlated with their tumor grade, lymph node involvement, and hormonal receptor status. Histological types included in this study were 54 invasive ductal carcinomas (IDCs) of otherwise not specified and 3 invasive lobular carcinomas. Cases of histologic grade I IDC were 6, grade II 30, and grade III 18. Of 54 IDCs 39 (72.2%) showed moderate to strong linear staining at the cell borders regardless of their histologic grade, status of lymph node metastasis, and status of hormone receptor. Staining intensity of E-CD was reduced in 54 cases (83%) of IDC when compared with that of normal or benign breast lesions (P<0.01). All seven cases of intraductal carcinoma, which were included in 54 IDCs showed one or two grade reduced expression of E-CD than that of infiltrative lesions. Three invasive lobular carcinomas showed strong (1 case), moderate (1 case), and negative reactivity (1 case). The data indicated that loss of E-CD expression is a crucial event in the development of breast carcinoma.

Alpha-Fetoprotein-Producing Carcinoma of the Gallbladder

Alpha-fetoprotein (AFP) is a well-known tumor marker for hepatocellular carcinoma, hepatoblastoma, and yolk sac tumors. There are several studies on AFP-producing tumors that arose from the gastrointestinal tract, pancreas, lung, kidney, and urachal tract. AFP-producing carcinoma of the gallbladder is extremely rare. We report a case of AFP-producing carcinoma of the gallbladder without liver involvement in a 58-year-old man with a gallstone, on which clinical, morphologic, and immunohistochemical studies were performed.