Successful Endoscopic Resection of Tubulovillous Adenoma Arising in Choledochocele / 대한췌담도학회지

Choledochocele is the least common type of choledochal cyst. Choledochocele has a potential for carcinogenesis, but only a handful of cases with concurrent ampullary carcinoma have been reported. We recently experienced a case of choledochocele with tubulovillous adenoma with focal high-grade dysplasia, which was successfully and completely resected en bloc via endoscopic papillectomy. Prior to endoscopic papillectomy, the endoscopic ultrasonography was able to accurately diagnose the ampullary tumor arising in choledochocele. Herein, we would like to report this case and discuss the potential of malignant transformation and the usefulness of endoscopic ultrasonography in choledochocele.

Negative pressure is not necessary for using fine-needle aspiration biopsy to diagnose suspected thyroid nodules: a prospective randomized study

PURPOSE: Fine-needle aspiration biopsy (FNAB) can be used to diagnose thyroid cancer and other tumors. Although FNAB without negative pressure (FNAB−P) reduces the risk of blood contamination, FNAB with negative pressure (FNAB+P) increases the sensitivity of the biopsy results. Therefore, we performed a randomized study of FNAB with or without negative pressure to identify the better diagnostic method. METHODS: Between March 2016 and February 2017, 172 consecutive patients were enrolled to investigate >0.5 cm nodules with indeterminate or suspicious malignant features. Patients were randomly assigned to the FNAB+P group (a 50 mL syringe was used to provide negative pressure) or to the FNAB−P group (passive collection of blood in the needle's hub). The 2 methods' diagnostic adequacy and quality were evaluated using an objective scoring system. The study's protocol was registered with the World Health Organization Clinical Research Information Service (http://cris.nih.go.kr/cris, KCT0001857). RESULTS: The patients were randomly assigned to the FNAB+P group (n = 86) or the FNAB−P group (n = 86). There were no significant intergroup differences in nodule position, size, age, consistency, calcification, BRAF mutation, or pathology. Evaluation of diagnostic adequacy parameters revealed no significant differences in background blood/clot (P = 0.728), amount of cellular material (P = 0.052), degree of cellular degeneration (P = 0.622), degree of cellular trauma (P = 0.979), or retention of appropriate architecture (P = 0.487). Furthermore, there was no significant intergroup difference in the diagnostic quality (P = 0.634). CONCLUSION: This prospective randomized study failed to detect significant differences in the diagnostic adequacy and quality of FNAB with or without negative pressure. Therefore, the examiner may select whichever FNAB method they prefer.

Small Cell Lung Cancer with Mutation of Epidermal Growth Factor Receptor in Patients with Lung Adenocarcinoma Resistant to Gefitinib / 대한내과학회지

Most epidermal growth factor receptor (EGFR) gene mutations are detected in lung adenocarcinomas. In contrast, these mutations have rarely been reported in small cell lung cancer (SCLC). We herein report two cases of EGFR-mutant SCLC transformed from and combined with lung adenocarcinoma. In one case, SCLC appeared to be transformed from EGFR mutant 19-del adenocarcinoma when the patient became resistant to gefitinib. The other patient had combined EGFR-mutant 19-del SCLC and adenocarcinoma at the initial diagnosis, which was resistant to gefitinib at multiple sites. Further comparative molecular analyses of these histologically distinct tumors would provide useful information regarding the role of EGFR mutation in the pathogenesis of SCLC. In conclusion, despite the presence of the same EGFR mutation, gefitinib was not effective in treatment of SCLC. Therefore, confirmation of SCLC cell morphology may become an important means of predicting resistance to EGFR tyrosine kinase inhibitors in addition to common secondary genetic alterations.

Unusual Treatment of Gastric Mucosa Associated Lymphoid Tissue Lymphoma Unresponsive to Helicobacter pylori Eradication

The connection between Helicobacter pylori and mucosa-associated lymphoid tissue (MALT) lymphoma is well established. H. pylori eradication is the initial treatment for MALT lymphoma. However, in H. pylori negative cases or unresponsive patients after successful eradication, radiation, systemic therapies, and surgical resection should be considered. Also local treatment modalities such as endoscopic mucosal resection (EMR) may be a therapeutic option in cases of low grade, localized MALT lymphoma. Herein, we report a case of a 53-year-old man who had a persistent endoscopic mass and tumor cells on histology for 5 months despite H. pylori eradication. Because of no early response to H. pylori eradication, the possibility of the presence of a high-grade lymphoma component, the proximal location of the tumor, and the exophytic nature of the tumor, we decided to perform EMR for complete resection. After EMR, the patient remained in complete remission throughout the 15-month follow up. In our case, endoscopic resection could lead to a more rapid complete remission. Therefore, we suggest that endoscopic resection may be a useful option for low-grade exophytic-type gastric MALT lymphoma treatment with no response to H. pylori eradication.

A Case of Incidental Struma Ovarii Confounded with the Metastasis of Papillary Thyroid Cancer

A focal radioactive iodine uptake in the pelvis of a patient with differentiated thyroid cancer needs differential diagnosis besides bone metastasis. Struma ovarii is a rare monodermal ovarian teratoma composed predominantly of mature thyroid tissue; 5-10% of these tumors are malignant. As diagnosis and surgery of thyroid cancer have increased recently, incidental cases of struma ovarii, after radioactive iodine treatment, were occasionally reported. Rare cases of ovary metastasis of thyroid cancer were also reported. We report a case of benign struma ovarii incidentally found in a patient with papillary thyroid cancer. The patient showed a sustained high level of thyroglobulin and focal radioactive iodine uptake in the right pelvis, confused with distant metastasis, after total thyroidectomy and radioactive iodine treatment.

Serial MR Imaging of Intramuscular Hematoma: Experimental Study in a Rat Model with the Pathologic Correlation

OBJECTIVE: We wanted to demonstrate the temporal changes of the magnetic resonance imaging (MRI) findings in experimentally-induced intramuscular hematomas in rats and to correlate these data with the concurrent pathologic observations. MATERIALS AND METHODS: Intramuscular hematoma was induced in 30 rats. The MR images were obtained at 1, 4, 7 and 10 days and at 2, 3, 4, 6 and 8 weeks after muscle injury. The characteristic serial MRI findings were evaluated and the relative signal intensities were calculated. Pathologic specimens were obtained at each time point. RESULTS: On the T1-weighted imaging (T1WI), the intramuscular hematomas exhibited isointensity compared to that of muscle or the development of a high signal intensity (SI) rim on day one after injury. The high SI persisted until eight weeks after injury. On the T2-weighted imaging (T2WI), the hematomas showed high SI or centrally low SI on day one after injury, and mainly high SI after four days. A dark signal rim was apparent after seven days, which was indicative of hemosiderin on the pathology. The gradient echo (GRE) imaging yielded dark signal intensities at all stages. CONCLUSION: Unlike brain hematomas, experimentally-induced intramuscular hematomas show increased SI on both the T1WI and T2WI from the acute stage onward, and this is pathologically correlated with a rich blood supply and rapid healing response to injury in the muscle. On the T2WI and GRE imaging, high SI with a peripheral dark signal rim is apparent from seven days to the chronic stage.

Strongyloidiasis of Gastric and Colonic Mucosa in a Patient with Monoclonal Gammopathy of Undetermined Significance: A Case Report

Here we report a case of Strongyloides stercoralis infection of the gastric and pancolonic mucosa in a 79-year-old female with a monoclonal gammopathy of undetermined significance. Endoscopic biopsies were performed in gastric antrum, cecum, distal ascending colon, and hepatic flexure of the colon. On microscopic examination, there were many adult worms, larvae and eggs in the gastric and colonic mucosa. Worms, larvae, and eggs were located in the crypts and within the lumen of the crypts. The body wall of the adult worm was composed of cuticle and a weak muscle layer. A routine stool examination failed to detect larvae or ova. Based on the histopathologic examination, these parasites were confirmed as S. stercoralis.

Strongyloidiasis of Gastric and Colonic Mucosa in a Patient with Monoclonal Gammopathy of Undetermined Significance: A Case Report

Here we report a case of Strongyloides stercoralis infection of the gastric and pancolonic mucosa in a 79-year-old female with a monoclonal gammopathy of undetermined significance. Endoscopic biopsies were performed in gastric antrum, cecum, distal ascending colon, and hepatic flexure of the colon. On microscopic examination, there were many adult worms, larvae and eggs in the gastric and colonic mucosa. Worms, larvae, and eggs were located in the crypts and within the lumen of the crypts. The body wall of the adult worm was composed of cuticle and a weak muscle layer. A routine stool examination failed to detect larvae or ova. Based on the histopathologic examination, these parasites were confirmed as S. stercoralis.

A Case of Intravascular Papillary Endothelial Hyperplasia Combined with Organizing Hematoma of the Lateral Wall of the Nasal Cavity

Intravascular papillary endothelial hyperplasia (IPEH) is an exuberant intravascular endothelial proliferation that in many respects mimics an angiosarcoma. A 78-year-old woman complained of a several month history of left-side nasal obstruction and frequent epistaxis. Preoperative endoscopic examination demonstrated a dark red mass occupying the left nasal cavity. The nasal cavity mass was completely removed under endonasal endoscopy. During the six-month follow-up, the patient had no evidence of recurrent disease. We present here a rare case of IPEH within the nasal cavity that demonstrated the reactive nature of this affliction.

Evaluation of the HPV ISH Assay in Cervical Cancer

BACKGROUND: Human papillomavirus (HPV) infection can be detected by in situ hybridization (ISH), in which a punctate signal pattern indicates integrated HPV DNA and a diffuse pattern denotes the presence of episomal viral DNA. This study was conducted to evaluate the usefulness of an HPV ISH assay for invasive cervical cancer. METHODS: The HPV ISH assay for high-risk HPV and immunohistochemical staining for p16(INK4a), p53, bcl-2, and Ki-67 were performed in a tissue microarray of 279 cervical cancers. RESULTS: High-risk HPV ISH was positive in 194 (69.5%) of the samples. Punctate, diffuse, and mixed signal patterns were observed in 157 (56.3%), one (0.4%), and 36 cases (12.9%), respectively. Positive results in high-risk HPV ISH were associated with p16 and bcl-2 expression (p = 0.01 and p < 0.01, respectively). According to a Cox regression analysis, HPV infection and its surrogate immunohistochemical markers such as p16, bcl-2, and Ki-67 were not independent prognostic factors, but stage and grade were independent prognostic factors. CONCLUSIONS: Our results confirm that an HPV ISH assay is reasonably sensitive for HPV infection and that it might be useful to identify integrated HPV DNA in formalin-fixed and paraffin-embedded specimens. Further study encompassing HPV type, E2/E6 ratio, and therapeutic modality is necessary to understand the clinical meaning of HPV status in cervical cancer.

Evaluation of the HPV ISH Assay in Cervical Cancer

BACKGROUND: Human papillomavirus (HPV) infection can be detected by in situ hybridization (ISH), in which a punctate signal pattern indicates integrated HPV DNA and a diffuse pattern denotes the presence of episomal viral DNA. This study was conducted to evaluate the usefulness of an HPV ISH assay for invasive cervical cancer. METHODS: The HPV ISH assay for high-risk HPV and immunohistochemical staining for p16(INK4a), p53, bcl-2, and Ki-67 were performed in a tissue microarray of 279 cervical cancers. RESULTS: High-risk HPV ISH was positive in 194 (69.5%) of the samples. Punctate, diffuse, and mixed signal patterns were observed in 157 (56.3%), one (0.4%), and 36 cases (12.9%), respectively. Positive results in high-risk HPV ISH were associated with p16 and bcl-2 expression (p = 0.01 and p < 0.01, respectively). According to a Cox regression analysis, HPV infection and its surrogate immunohistochemical markers such as p16, bcl-2, and Ki-67 were not independent prognostic factors, but stage and grade were independent prognostic factors. CONCLUSIONS: Our results confirm that an HPV ISH assay is reasonably sensitive for HPV infection and that it might be useful to identify integrated HPV DNA in formalin-fixed and paraffin-embedded specimens. Further study encompassing HPV type, E2/E6 ratio, and therapeutic modality is necessary to understand the clinical meaning of HPV status in cervical cancer.

Completely Isolated Enteric Duplication Cyst Presenting as an Inguinal Hernia

Enteric duplication cysts are uncommon congenital anomalies whose embryogenesis remains unknown. We report here on an isolated enteric duplication cyst, that presents as an inguinal hernia. A 21-year-old woman was admitted with a month-long history of a palpable mass in the left groin. Radiologically, a computed tomography scan revealed a 3.5 x 2.5 cm sized cystic mass in subcutaneous layers of the left suprapubic area. Microscopically, the cystic wall resembled gut wall. The wall was composed of two distinct muscle layers with the presence of Auerbach's plexus. On examining the entire sections of the cyst wall very carefully, no epithelial lining was found on the inner surface. The submucosa was slightly fibrotic. The diagnosis was a completely isolated enteric duplication cyst.

Expression of CXCR4 and SDF-1alpha in Primary Breast Cancers and Metastatic Lymph Nodes / 한국유방암학회지

PURPOSE: A CXCR4/stroma derived factor-1alpha (SDF-1alpha, CXCL12) interaction is involved in many metastatic cancer mechanisms, including breast cancer. The primary objectives of this study were to investigate the correlation between CXCR4 and axillary lymph node metastasis and to clarify the interaction between CXCR4 in primary tumor cells and SDF-1alpha in metastatic lymph nodes. An analysis of the correlation between CXCR4, SDF-1alpha and clinicopathologic features was also performed. METHODS: Representative areas from 44 invasive ductal carcinomas were selected for construction of tissue microarrays using a 5 mm punch. Breast cancers (n=44), metastatic axillary lymph nodes (n=18) and non-metastatic axillary lymph nodes (n=26) were immunohistochemically stained for CXCR4, SDF-1alpha, estrogen receptor (ER), progesterone receptor (PR) and HER2. The parameters of age, tumor size, nuclear grade, histologic grade, lymph node status and pathologic node (pN) stage pN0 to pN3 were evaluated. RESULTS: CXCR4 expression was negatively correlated with increased age (p=0.005) and positively correlated with a large tumor size (p=0.043) and PR expression (p=0.027). CXCR4 expression was not correlated with metastatic lymph nodes (p=0.079) and SDF-1alpha expression in metastatic lymph nodes (p=0.062). However, CXCR4 nuclear positivity is correlated with lymph node metastasis (p=0.044). SDF-1alpha was not correlated with any clinicopathologic feature in a statistically significant manner. CONCLUSION: An evaluation of young age, large tumor size and PR expression helps predict lymph node metastasis and poor prognosis. Expression of CXCR4 nuclear positivity is correlated with a poor prognosis.

A case of extraosseous ewing's sarcoma/primitive neuroectodermal tumor of the ovary / 대한산부인과학회지

Ewing's sarcoma/primitive neuroectodermal tumor (ES/PNET) family mainly occurs from skeletal system. ES/PNET from the female reproductive organs such as ovary and uterus has been reported very rarely. Recently, we experienced one case of malignant ovarian neoplasm, which was diagnosed as extraosseous ES/PNET of ovary and received operation and chemotherapy. So, we report this case and include a brief literature review.

Expression of P53, Bcl-2, Bax, and JNK-1 in Relation to the Apoptosis of the Ruptured Rotator Cuff Tendon / 대한정형외과연구학회지

PURPOSE: The causes of rotator cuff tendon tear were excessive overuse, aging process and impingement syndrome and a lot of research of these factors have been performed. But molecular study of cuff tear or apoptosis of rotator cuff tenocyte is not done until now. In this study, the apoptosis level and apoptosis-related gene expression were investigated in the specimens from the torn margin of a rotator cuff tear, and compared with those from normal portion. MATERIALS AND METHODS: Among patients who underwent arthroscopic shoulder surgery between April 2008 to August 2008, 15 patients with complete rotator cuff tear was investigated. These were 10 men and 5 women. The age were from 48 years to 76 years old (average 61.5 years). The contol group were 2 patients with intact subscapularis tendon. Patients with impingement syndrome, partial tear or tendinitis were excluded from the design of the study. Tendon specimen in the tear margin of supraspinatus or infraspinatus tendon was evaluated using Hematoxylin-Eosinophilic stain, TUNNEL assay and immunohistochemistry for p53, Bcl-2, Bax and JNK1 were performed. RESULTS: TUNNEL assay was positive in 5 cases of the 15 specimens. In these cases, 5.4% of the cells were positive. The apoptosis-related gene such as p53, Bcl-2, Bax and JNK-1, and tear size were evaluated. These correlations were evaluated using a correlation analysis of Spearman correlation analysis. Spearman correlation coefficient between apoptosis and bcl-2, and between apoptosis and p53 were 0.625 and 0.71, respectively. These p values were 0.01 and 0.003, respectively. Spearman correlation coefficient between p53 and tear size, and Bax and tear size were 0.58 and 0.76, respectively. These p values were 0.02 and <0.001, respectively. The apoptosis of control group in normal subscapular tendon is zero. CONCLUSION: The increased apopotic index was correlated with increased bcl-2 and p53 gene in Rotator cuff tear patients. The larger tear showed increased p53 and Bax gene expression. Further research in this area will need to reduce apoptosis in the development of the rotator cuff tear.

A Case of H. pylori-associated Granulomatous Gastritis with Hypertrophic Gastropathy

A 46-year-old man had chronic granulomatous gastritis characterized by giant gastric folds with noncaseating epithelioid granulomas including giant cells in the corpus. No definite etiologic factors were detected. Histology and the rapid urease test indicated that H. pylori was present in both the antrum and corpus. The granulomatous gastritis with giant gastric folds improved after H. pylori eradication. This case suggests an association between isolated granulomatous gastritis and H. pylori infection.

Mesenteric Cystic Lymphangioma with Traumatic Hemorrhage

Lymphangiomas are rare benign cystic tumors and they are most often located in the head, neck, and axilla in pediatric patients. The etiology of mesenteric cystic lymphangioma is unknown and the clinical presentation is diverse, ranging from an asymptomatic abdominal tumor to symptoms of an acute abdomen. A 16-year-old male patient presented to the Emergency Department complaining of an increasingly painful abdominal mass. He hit his abdomen against friend's knee during playing soccer. CT scan showed a mesenteric cystic mass that looked like hematoma. Under the diagnosis of a mesenteric hematoma, he underwent emergency laparotomy. The mass in the mesentery was removed. Mesenteric cystic lymphangioma with hemorrhage was confirmed by the pathologic result. We present here a case of a mesenteric cystic lymphangioma with post-traumatic hemorrhage.

Internal Jugular Vein Thrombosis Associated with Metastatic Malignancy

Spontaneous venous thrombosis developing in the internal jugular vein is very unusual. The common causes usually include intravenous drug abuse, jugular vein catheterization, neck dissection, a hypercoagulable state associated with malignancies, neck injury or ovarian overstimulation syndrome. A 30-year-old woman with no remarkable past medical history visited our outpatient office due to neck swelling with pain. She underwent CT scan, Doppler sonogram and fine needle aspiration biopsy. We could confirm metastatic lymphadenopathy and internal jugular vein thrombosis. We present here the case of internal jugular vein thrombosis associated with metastatic malignancy.

Restoration of Reproductive Potential after Autotransplantation of Frozen Ovaries in Mice Pretreated with Cyclophosphamide / 한국유방암학회지

PURPOSE: Infertility due to ovarian failure that is caused by antineoplastic chemotherapeutic agents is one of the primary problems of female cancer atients who are in their reproductive years. It has become important to preserve the reproductive potential of female cancer patients. This study was conducted to determine whether autotransplantation of frozen ovaries can restore reproductive potential. METHODS: This study included 30 female mice that had normal reproductive potential. The mice were divided into 4 groups: the positive control, the negative control, the comparison group, and the experimental group. The positive control group received right total oophorectomy, and the negative control group received bilateral total oophorectomy. Greater than or equal to 90% of the left ovary was removed in the mice of the comparison group, and then cyclophosphamide was administered. In the experimental group, the right ovary taken out by right total oophorectomy, and this was crypreserved using the vitrification method. And then cyclophosphamide was administered. The cryopreserved ovary was autotransplanted to the left gonadal fat pad after greater than or equal to 90% of the left ovary was removed. The reproductive performance in each group was analyzed according to the pregnancy rate after mating. RESULTS: In the positive control group, all five mice became pregnant, and the number of fetuses was 4 to 5 (mean=4.60+/-0.55). In the comparison group, the pregnancy rate was 50%, and the mean number of fetuses was 1.40+/-0.55. In the experimental group, 7 of 10 (70%) mice became pregnant, and the mean number of fetuses was 4.71+/-2.56. There was no significant difference in the number of fetuses between the positive control and the experimental group (p=0.093), but there was a significant difference in the number of fetuses between the comparison group and the experimental group (p=0.019). CONCLUSION: The results of this study suggest that autotransplantation of frozen ovaries using the vitrification method may restore the impaired ovarian function induced by antineoplastic chemotherapeutic agents.

Placenta increta presenting as postabortal uterine mass and hemoperitoneum in the first trimester: A case report / 대한산부인과학회지

Placenta increta is one of lethal complications of pregnancy characterized by invasion of placenta villi into the underlying myometrium and usually presented in early postpartum period with difficult placental removal and massive bleeding. Placenta increta may complicate first and early second-trimester pregnancy loss causing profuse post-curettage hemorrhage but the lesion is rarely found and hard to diagnose. We experienced a case of hemoperitoneum caused by implanted chorionic villi on the uterine serosa regurged from uterine cavity, 6weeks after artificial abortion at gestational age of 5 weeks and 5 days.