Small bowel obstruction from distant metastasis of primary breast cancer: a case report

Gastrointestinal (GI) tract metastasis of primary breast cancer is very rare. We present a patient with small bowel obstruction from distant metastasis of primary breast cancer. Each characteristic features of concern of GI tract distant metastasis from many pervious studies has been reported differently. We should remember that GI tract metastasis may coexist when patients with breast cancer have intermittent or recurrent abdominal pain with or without obstructive symptoms.

Papillary Apocrine Metaplasia of the Breast Mimicking Papillary Neoplasm: A Case Report

Apocrine metaplasia is a benign fibrocystic change characterized by dilated acini lined by columnar cells with apocrine features. These apocrine-like cells form papillary clumps of cells extending into the cystic space called papillary apocrine metaplasia. The researchers report a case of a 48-year-old woman who presented with a palpable mass in the right breast. Breast ultrasonography and MRI showed a large complex cystic and solid mass. A differential diagnosis included intraductal papilloma or intracystic papillary carcinoma. She underwent surgery and the final diagnosis was papillary apocrine metaplasia.

Leukocytoclastic Vasculitis of the Breast: A Case Report

Leukocytoclastic vasculitis is a rare disease characterized by neutrophil and immune-complex deposition in the small vessel walls. We report a 47-year-old female patient with leukocytoclastic vasculitis of the breast, presenting as breast edema on mammography, irregular hypoechoic lesion with central necrosis on ultrasonography and regionally distributed heterogeneous non-mass enhancement on magnetic resonance imaging.

Young Age Is Associated with Increased Locoregional Recurrence in Node-Positive Breast Cancer with Luminal Subtypes / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The effects of biological subtypes within breast cancer on prognosis are influenced by age at diagnosis. We investigated the association of young age with locoregional recurrence (LRR) between patients with luminal subtypes versus those with nonluminal subtypes. MATERIALS AND METHODS: Medical records of 524 breast cancer patients with positive lymph nodes between 1999 and 2010 were reviewed retrospectively. All patients received curative surgery and adjuvant chemotherapy based on contemporary guidelines. Radiation was delivered for patients who underwent breast conserving surgery or those who had four or more positive lymph nodes after mastectomy. Adjuvant hormone therapy was administered to 413 patients with positive hormone receptors according to their menstrual status. RESULTS: During median follow-up of 84 months, the 10-year locoregional recurrence-free survival rate (LRRFS) was 84.3% for all patients. Patients < 40 years showed significantly worse 10-year LRRFS than those ≥ 40 years (73.2% vs. 89.0%, respectively; p=0.01). The negative effect of young age on LRRFS was only observed in luminal subtypes (69.7% for < 40 years vs. 90.8% for ≥ 40 years; p < 0.01). Multivariate analysis using luminal subtypes ≥ 40 years as a reference revealed luminal subtypes < 40 years were significantly associated with increased risk of LRR (hazard ratio, 2.33; p < 0.01). CONCLUSION: Young breast cancer patients with positive lymph nodes had a higher risk of LRR than those aged ≥ 40 years. This detrimental effect of young age on LRR was confined in luminal subtypes.

Evaluation of the VE1 Antibody in Thyroid Cytology Using Ex Vivo Papillary Thyroid Carcinoma Specimens

BACKGROUND: Recently, VE1, a monoclonal antibody against the BRAFV600E mutant protein, has been investigated in terms of its detection of the BRAFV600E mutation. Although VE1 immunostaining and molecular methods used to assess papillary thyroid carcinoma in surgical specimens are in good agreement, evaluation of VE1 in thyroid cytology samples is rarely performed, and its diagnostic value in cytology has not been well established. In present study, we explored VE1 immunoexpression in cytology samples from ex vivo papillary thyroid carcinoma specimens in order to minimize limitations of low cellularity and sampling/targeting errors originated from thyroid fineneedle aspiration and compared our results with those obtained using the corresponding papillary thyroid carcinoma tissues. METHODS: The VE1 antibody was evaluated in 21 cases of thyroid cytology obtained directly from ex vivo thyroid specimens. VE1 immunostaining was performed using liquid-based cytology, and the results were compared with those obtained using the corresponding tissues. RESULTS: Of 21 cases, 19 classic papillary thyroid carcinomas had BRAFV600E mutations, whereas two follicular variants expressed wild-type BRAF. VE1 immunoexpression varied according to specimen type. In detection of the BRAFV600E mutation, VE1 immunostaining of the surgical specimen exhibited 100% sensitivity and 100% specificity, whereas VE1 immunostaining of the cytology specimen exhibited only 94.7% sensitivity and 0% specificity. CONCLUSIONS: Our data suggest that VE1 immunostaining of a cytology specimen is less specific than that of a surgical specimen for detection of the BRAFV600E mutation, and that VE1 immunostaining of a cytology specimen should be further evaluated and optimized for clinical use.

Clinicopathologic Changes in Children with Immunoglobulin A Nephritis and Henoch-Schonlein Purpura Nephritis after Cyclosporine A and Angiotensin-converting Enzyme Inhibitor Treatment

PURPOSE: To investigate the clinicopathologic effects of cyclosporine A (CsA) in children with diseases characterized by mesangial immunoglobulin A deposits such as immunoglobulin A nephropathy (IgAN) and Henoch-Schonlein purpura nephritis (HSPN). METHODS: We retrospectively reviewed the clinicopathologic outcomes of 54 children (IgAN, 36; HSPN, 18) treated with CsA. The starting dose of CsA was 5 mg/kg per day, and it was administered in 2 divided doses. The degree of proteinuria and pathologic changes in renal biopsies were evaluated before and after CsA treatment. RESULTS: The mean protein to creatinine ratio decreased from 3.7+/-1.5 to 0.6+/-0.4 (P<0.001), and 32 (59.2%) children achieved complete remission of proteinuria after 1-year CsA treatment. Among the 54 children, 24 maintained normal renal function and 25 exhibited microscopic hematuria or proteinuria at the end of CsA treatment. In the HSPN group, 3 children whose initial biopsies indicated class IIIb disease showed class II disease on follow-up, and the follow-up biopsies of 2 children who had class II disease indicated the same class II disease. In the IgAN group, cortical tubular atrophy occurred in 1 child, and no child with IgAN had cortical interstitial fibrosis or tubular atrophy after 1-year CsA treatment. No significant complications were found in the children treated with CsA. CONCLUSION: Our findings indicate that CsA treatment is effective and beneficial in reducing massive proteinuria and preventing progression to end-stage renal failure in children with glomerular diseases characterized by IgA deposits, such as IgAN and HSPN, within 1 year of treatment.

Exacerbation of Lupus Nephritis in Pregnant Women with Remission of Lupus Nephritis

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder that predominantly affects women of reproductive age. Risk of SLE flare during pregnancy is dependent on disease activity of SLE and proteinuria at the time of conception, which affect pregnancy outcome. We report on three patients who developed renal flares during pregnancy after remission of lupus nephritis before pregnancy. Two patients were treated successfully, with pregnancy outcomes of live births however, another patient's pregnancy was terminated with induced abortion. For SLE patients, family planningis needed until disease activity of SLE has been stable for at least six months prior to the pregnancy. Nevertheless, flares of lupus could develop and influence maternal and fetal outcome. Therefore, renal flares during pregnancy should be recognized and treated immediately.

Risk Reducing Surgery in Carriers with Double Heterozygosity for BRCA1 and BRCA2 Mutations

Among the treatment options for BRCA mutation carriers, risk reducing surgery is the most effective. However, this procedure has been rarely performed in Korea. Interestingly, our case showed double heterozygosity for BRCA1 and BRCA2 mutations. The patient was diagnosed with left renal cancer and left breast cancer at 45-years-of-age, 4 years before risk reducing surgery. The patient received left radical nephrectomy and left partial mastectomy with axillary lymph node dissection. After pretest counseling, the patient underwent genetic testing that identified BRCA1 and BRCA2 mutations. After post-test counseling, the patient decided on intensive surveillance. At 49-years-of-age, the patient was newly diagnosed with contralateral breast cancer. Treatment options were discussed once again. We performed bilateral total mastectomy with immediate reconstruction and prophylactic bilateral salpingo-oophorectomy after multidisciplinary discussion. The patient has been satisfied with the results of surgery. We think this procedure is a recommendable treatment option for BRCA mutation carriers.

Kidney Transplantation from a Donor Following Cardiac Death Supported with Extracorporeal Membrane Oxygenation

To expand the donor pool, organ donation after cardiac death (DCD) has emerged. However, kidneys from DCD donors have a period of long warm ischemia between cardiac arrest and the harvesting of the organs. Recently, we used extracorporeal membrane oxygenation (ECMO) to minimize ischemic injury during 'no touch' periods in a Maastricht category II DCD donor and performed two successful kidney transplantations. The kidneys were procured from a 49-yr-old male donor. The warm ischemia time was 31 min, and the time of maintained circulation using ECMO was 7 hr 55 min. The cold ischemia time was 9 hr 15 min. The kidneys were transplanted into two recipients and functioned immediately after reperfusion. The grafts showed excellent function at one and three months post-transplantation; serum creatinine (SCr) levels were 1.0 mg/dL and 0.8 mg/dL and the estimated glomerular filtration rates (eGFR) were 63 mL/min/1.73 m2 and 78 mL/min/1.73 m2 in the first recipient, and SCr levels were 1.1 mg/dL and 1.0 mg/dL and eGFR were 56 mL/min/1.73 m2 and 64 mL/min/1.73 m2 in the second recipient. In conclusion, it is suggested that kidney transplantation from a category II DCD donor assisted by ECMO is a reasonable modality for expanding donor pool.

Comparison of Conventional Smear, Cell Block and Liquid-based Preparation in the Evaluation of Bronchial Washing Specimen in Lung Cancer Patients

BACKGROUND: The preparation of conventional smears (CS) from mucoid samples, despite mucolysis, can pose difficulties for cytotechnologists or cytopathologists. In recent years, liquid-based cytology (LBC) devices have been developed in attempts to improve the cytopreparation process. LBC improves both sample collection and sample preparation. Cell block preparations (CB) can be made from residual tissue fluids, and are a useful adjunct to smears. METHODS: We retrospectively reviewed 3 preparations from 209 patients whose diagnosis was later confirmed via bronchoscopic biopsy, fine needle aspiration, gun biopsy or operation. Each case was categorized into one of three groups: "negative," "atypical or suspicious" and "malignant." RESULTS: When conflating the "atypical" and "malignant" categories into a "positive" category, the sensitivity of each preparation was 74.4% in LBC, 72.9% in CS, and 76.5% in CB preparations. Specificity was 98.7%, 94.7% and 98.7%, respectively. By combining LBC and CB, the sensitivity is 78.2%. CONCLUSIONS: Among three different preparation methods, sensitivity is highest in the CB method. LBC has many advantages in evaluating cell morphology and by combining CB method, the sensitivity can be improved slightly. The application of all three methods may prove helpful when one or another method proves diagnostically inconclusive.

Cutaneous leukocytoclastic vasculitis due to anti-tuberculosis medications, rifampin and pyrazinamide

Anti-tuberculosis drugs frequently result in cutaneous adverse reactions, including pruritus, maculopapular exanthems, and urticaria. However, anti-tuberculosis drug-associated cutaneous leukocytoclastic vasculitis (CLV) has been rarely reported. We describe a case of CLV induced by rifampin and pyrazinamide. A 38-year-old male had been diagnosed with pulmonary tuberculosis two months ago and then he started standard anti-tuberculosis therapy with isoniazid, rifampin, ethambutol, and pyrazinamide. Purpuric lesions developed in the extremities after 1.5 months of anti-tuberculosis medication; the lesions progressively spread over the entire body. Histopathology of the purpuric skin lesion was consistent with leukocytoclastic vasculitis. The skin lesion improved after cessation of anti-tuberculosis medications and treatment with oral corticosteroids and antihistamines. Anti-tuberculosis drugs were rechallenged one at a time over 3 days. Purpura recurred on the right forearm and forehead after taking 300 mg of rifampin. The skin lesion disappeared after taking oral prednisolone. Finally, 1,500 mg of pyrazinamide was readministrated, and then purpuric lesions recurred on both forearms. This report describes a case of leukocytoclastic vasculitis secondary to rifampin and pyrazinamide therapy.

Entecavir-induced Tubulointerstitial Nephritis / 대한신장학회지

Acute interstitial nephritis is an important cause of acute kidney injury and most often induced by drug therapy. Entecavir is a potent antiviral agent approved for chronic hepatitis B. The antiviral therapy in chronic hepatitis B management is important because it reduces viral replication and liver injury, prevents development of complications, such as liver cirrhosis and hepatocellular carcinoma, and thus improves patient's survival. The advantage of entecavir is its safety profile, particularly in patients with renal dysfunction. Although doses of entecavir are needed to be adjusted for patients with renal dysfunction, there has been no known renal toxicity of the drug itself. Here we report a patient with chronic hepatitis B and normal renal function who developed acute kidney injury due to tubulointerstitial nephritis after 10 months of entecavir therapy. Renal biopsy showed not only acute changes of interstitial nephritis such as marked cortical infiltration with lymphoplasma cells and neutrophils, mesangial matrix expansion, eosinophilic granular casts and degenerative epithelial cells within tubular lumen but also chronic changes, minimal tubular atrophy and interstitial fibrosis. After immunosuppressant therapy with steroids and mycofenolate mofetil, the patient's renal function improved.

A Case of a Kidney Transplant Recipient with Pulmonary Cytomegalovirus and Nocardia Coinfection with Cytomegalovirus Nephropathy / 대한신장학회지

This is the first reported case of a kidney transplant patient in Korea who developed cytomegalovirus and Nocardia pulmonary coinfection simultaneously with cytomegalovirus nephropathy. The patient had a history of end stage renal disease on peritoneal dialysis, diabetes mellitus and pulmonary tuberculosis. He underwent unrelated living kidney transplantation in China. About 5 months after transplantation, he developed high fever and rising serum creatinine for which he was admitted to hospital. Chest CT revealed consolidation in the left upper lung field and lung biopsy showed CMV infected bronchiolitis obliterans with organizing pneumonia. Culture of lung biopsy tissue grew Nocardia farcinica. In addition, he was found to have CMV infection in kidney tissue with positive CMV antigen assay of blood. This case emphasizes that CMV infection, through its effect on systemic immunity, may increase the risk of other opportunistic infection.

Cytologic Features of Diffuse Sclerosing Variant of Papillary Carcinoma: Cytohistopathologic Analysis of 16 Cases

BACKGROUND: The exact preoperative diagnosis of diffuse sclerosing papillary carcinoma (DSPC) is required for aggressive surgical treatment due to its extended involvement with thyroid and neck lymph nodes. The present study investigated the cytomorphologic characteristics of DSPC and identified cytologic features for preoperative diagnosis of DSPC. METHODS: A retrospective review of cytologic and histologic features of 16 patients diagnosed with DSPC after thyroidectomy and underwent preoperative fine needle aspiration cytology (FNAC) was performed. RESULTS: Prominent psammoma bodies were observed in 16 (100%) and 10 (62.5%) cases of histology and FNAC, respectively. Lymphocytes were observed in nine (56.2%) and four (25.0%) cases, and squamous cells were noted in seven cases (43.7%) and one case (6.2%) on histology and FNAC, respectively. Nuclear grooves and inclusions, which are characteristics of papillary carcinoma, were observed in FNAC and histology slides in all 16 cases. CONCLUSIONS: DSPC displays prominent psammoma bodies and characteristic nuclear features of papillary carcinoma such as nuclear groove and inclusion in FNAC. However, the preoperative diagnosis of DSPC using only FNAC could be difficult due to the absence of other characteristic features such as lymphocytes and metaplastic squamous cells.

Impact of Caveolin-1 Expression on the Prognosis of Transitional Cell Carcinoma of the Upper Urinary Tract

This study aimed to investigate the relationship of caveolin-1 expression with prognosis in patients with transitional cell carcinoma of the upper urinary tract (TCCUUT). Formalin-fixed, paraffin-embedded tissue sections of TCC-UUT from 98 patients, who had undergone radical nephroureterectomy, were stained immunohistochemically using antibodies against caveolin-1. The expression pattern of caveolin- 1 was compared with the clinicopathological variables. The caveolin-1 expression was significantly correlated with T stage (p<0.001) and grade (p=0.036). The survival rate of patients with caveolin-1 positive tumors was significantly lower than that of patients with caveolin-1 negative tumors (p<0.0001). The univariate analyses identified T stage, grade, and caveolin-1 expression as significant prognostic factors for cancer-specific survival, whereas the multivariate analyses indicated that T stage and caveolin-1 expression were independent prognostic factors. These results show that the increased expression of caveolin-1 is associated with tumor progression and poor prognosis in TCC-UUT, suggesting that caveolin-1 may play an important role in the progression of TCC-UUT.

IgA Nephropathy Associated with Chronic Urate Nephropathy / 대한신장학회지

IgA nephropathy is the most common primary glomerulonephritis and characterized by deposition of IgA in glomerular mesangial area. Chronic urate nephropathy is characterized by precipitation of uric acid crystals in the collecting ducts and medullary interstitium. We report a case of IgA nephropathy associated with chronic urate nephropathy. A 57 year old man underwent percutaneous renal biopsy for gross hematuria, generalized edema and renal failure. Renal biopsy showed typical findings of IgA nephropathy: increased mesangial matrix, cellular proliferation and positive staining of IgA. In addition, crystalline deposits of uric acid, which is typical of chronic urate nephropathy, were seen in the medullary interstitium.

Correlation of Cyclooxygenase-2 Expression and Microvessel Density with Prognosis in Transitional Cell Carcinoma of the Upper Urinary Tract / 대한비뇨기과학회지

PURPOSE: The aim of this study was to investigate the relationship of cyclooxygenase (COX)-2 expression and microvessel density (MVD), a reflection of angiogenesis, with prognosis in patients with transitional cell carcinoma of the upper urinary tract (TCC-UUT). MATERIALS AND METHODS: Formalin-fixed, paraffin-embedded tissue sections of TCC-UUT from 91 patients, who had undergone radical nephroureterectomy, were examined immunohistochemically using antibodies against COX-2 and CD34. MVD was determined with CD34-stained slides. The expression patterns of COX-2 and MVD were compared with the clinicopathological variables. RESULTS: The COX-2 expression was significantly correlated with T stage (p=0.002), N stage (p=0.010), and grade (p=0.027). MVD was also significantly correlated with T stage (p<0.001), N stage (p=0.002), and grade (p=0.001). The COX-2 expression was significantly correlated with MVD (p=0.001). The survival rate of patients with COX-2 positive tumors or high MVD was significantly lower than that of patients with COX-2 negative tumors or low MVD, respectively (p=0.0013, p=0.0312). Univariate analyses identified T stage, N stage, grade, COX-2 expression, and MVD as significant prognostic factors for cancer-specific survival; multivariate analyses indicated that T stage was the only independent prognostic factor. CONCLUSIONS: The increased expression of COX-2 and MVD is associated with a worse prognosis in TCC-UUT. The COX-2 expression is correlated with MVD. These results suggest that COX-2 may play an important role in the progression of TCC-UUT and angiogenesis may be affected by COX-2 during the progression of TCC-UUT.

The Diagnostic Accuracy of Multidetector Row CT for Evaluating the Axillary Lymph Nodes in Patients with Breast Cancer

PURPOSE: We investigated the CT (computed tomography) findings of metastatic lymph nodes (LNs), and we analyzed the diagnostic performance of multidetector row CT (MDCT) for detecting axillary LN metastases in patients with breast cancer. MATERIALS AND METHODS: We investigated 59 patients who preoperatively underwent chest MDCT, and they underwent sentinel LN biopsy or whole axillary LN dissection. We analyzed the morphologic features, the degree of enhancement and the delayed enhancement pattern. We classified the patients into the non-metastatic LN group and the metastatic LN group, and we calculated the diagnostic performance of MDCT for detecting metastatic LNs. RESULTS: When both the morphologic and quantitative criteria were consistent, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 58.1%, 100%, 100% and 68.3%, respectively, and MDCT accurately detected metastatic LNs in 2 patients that were false negative on sentinel LN biopsy. When the morphologic and quantitative criteria were consistent, the sensitivity, specificity, PPV and NPV were 87.1%, 53.6%, 67.5% and 78.9%, respectively. However, MDCT could not detect metastatic LNs, including two micrometastases (a total of 8 micrometastases) that were in each of four patients. CONCLUSION: MDCT can be used to perform the morphology and quantitative analysis of axillary LNs, and this modality has excellent specificity and a PPV for detecting metastatic LNs when the both of the diagnostic criteria are consistent.

Usefulness of Preoperative Breast MRI in Breast Cancer Patients Diagnosed with Tumor Removal Using a US-guided Mammotome

PURPOSE: We evaluated the MRI findings that suggested the presence of a residual cancer after a mammotome biopsy in pathologically proven breast cancer patients and the usefulness of MRI to diagnose a residual cancer and additional lesions. MATERIALS AND METHODS: We reviewed 41 breast cancer patients that underwent an ultrasonography-guided mammotome biopsy for complete resection of a breast lesion. MRI was performed for preoperative assessment and MRI findings suggestive of a residual cancer at the procedure site were analyzed and correlated to the pathological findings. Additional enhancements on breast MRI were analyzed, and the diagnostic accuracy of MRI for occult additional lesions was calculated. RESULTS: A total of 32 (78.0%) patients had a residual tumor. A mass was the most common MRI finding that suggested a residual cancer. Thick rim enhancement or a mass with a non-mass like enhancement were the most suspicious findings that suggested the presence of a residual cancer. The sensitivity, specificity and accuracy of MRI for the detection of a residual cancer were 81.3%, 66.7% and 78.0%, respectively. Additional malignant lesions were found in 7 cases. The sensitivity, specificity and accuracy of MRI for the detection of additional lesions were 100%, 60.0% and 76.5%, respectively. CONCLUSION: Further complete surgery should be performed, as residual tumors are found in 50% of the negative MRI examinations, whereas preoperative MRI is helpful to evaluate occult additional lesions.

Antigen-binding Characteristics of Circulating IgG Autoantibodies to Cytokeratin 18 Protein in Patients with Nonallergic Asthma

Cytokeratin 18 (CK18) protein was identified as an airway epithelial cell autoantigen associated with nonallergic asthma. Cleavage of CK18 protein by caspase-3 is a marker of early apoptosis in epithelial cells. It has been shown that the expression of active caspase-3 was increased in bronchial epithelial cells of asthmatic patients, when compared with healthy controls. To investigate the antigen-binding characteristics of IgG autoantibodies to CK18 protein in nonallergic asthma, the bindings of IgG autoantibodies to the fragments of CK18 protein cleaved by caspase-3 were analyzed by Western blot using serum samples from three patients with nonallergic asthma. Recombinant human CK18 protein was treated by caspase-3 and cleaved into N-terminal fragment (1-397 amino acids) and C-terminal fragment (398-430 amino acids). The binding capacity of IgG autoantibodies to N-terminal fragment of CK18 was maintained in one patient and reduced in other two patients. IgG autoantibodies from all three patients did not bind to C-terminal fragment of CK 18. In conclusion, IgG autoantibodies to CK18 protein from patients with nonallergic asthma seems to preferentially bind to the whole molecule of CK18 protein and their antigen-binding characteristics were heterogeneous among the patients with nonallergic asthma.