Supra-ampullary duodenectomy in a patient with positive distal resection margin after subtotal gastrectomy for gastric cancer: a case report

Resection margin involvement after curative intent resection for gastric cancer results in a poor prognosis and deprives the patient of the chance for a cure. Reoperation to achieve an R0 status should guarantee tolerable morbidity and achievement of negative margins. We performed laparoscopic distal gastrectomy with extracorporeal Billroth II reconstruction in a 56-year-old woman with gastric cancer following neoadjuvant chemotherapy. Scattered cancer cells were observed in the proximal and distal resection margins on immunohistochemical staining for cytokeratin. Two weeks postoperatively, remnant total gastrectomy and supra-ampullary duodenectomy were performed. Before reoperation, percutaneous transhepatic gallbladder drainage and angiocatheter placement outside the ampulla of Vater (AoV) via the cystic duct were performed to avoid pancreaticoduodenectomy and to obtain the maximal distal margin. Duodenal transection was performed 1 cm above the AoV. The resected duodenum was 4 cm in length. The patient had no postoperative complications and received adjuvant chemotherapy 1 month after the reoperation.

Chondroid Syringoma on Face

Chondroid syringoma is a rare mixed tumor of the skin which is composed of both mesenchymal and epithelial cells. Its incidence at less than 0.1% and is frequently located on the head and neck. Chondroid syringoma is easily confused with epidermal cysts. Since malignant forms of chondroid syringoma have been reported, accurate and timely diagnosis is important for proper management. We report clinical and histological features of chondroid syringoma in 5 patients treated at our institution. In most of the cases, chondroid syringoma presented as a round, firm, nodular or cystic lesion that had well marginated heterogeneity in sonography. Clinically, all of the lesions were removed by simple excision. Microscopically, all five tumors were well circumscribed and consisted of epithelial, myoepithelial, and stromal components. The epithelial component formed tubules lined by one or more rows of eosinophilic epithelial cells. The outer layer of tubules appeared to be flattened myoepithelial cells. The stroma is myxoid and contained spindle shaped myoepithelial cells. We expect that the clinical, sonographic, and histological data from our report may help clinicians who are confronted with various kinds of analogous facial lesions to decide the most proper management for their patients.

Chondroid Syringoma on Face

Chondroid syringoma is a rare mixed tumor of the skin which is composed of both mesenchymal and epithelial cells. Its incidence at less than 0.1% and is frequently located on the head and neck. Chondroid syringoma is easily confused with epidermal cysts. Since malignant forms of chondroid syringoma have been reported, accurate and timely diagnosis is important for proper management. We report clinical and histological features of chondroid syringoma in 5 patients treated at our institution. In most of the cases, chondroid syringoma presented as a round, firm, nodular or cystic lesion that had well marginated heterogeneity in sonography. Clinically, all of the lesions were removed by simple excision. Microscopically, all five tumors were well circumscribed and consisted of epithelial, myoepithelial, and stromal components. The epithelial component formed tubules lined by one or more rows of eosinophilic epithelial cells. The outer layer of tubules appeared to be flattened myoepithelial cells. The stroma is myxoid and contained spindle shaped myoepithelial cells. We expect that the clinical, sonographic, and histological data from our report may help clinicians who are confronted with various kinds of analogous facial lesions to decide the most proper management for their patients.

Ureteral Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue, Chronic Inflammation, and Renal Artery Atherosclerosis

No abstract available.

Subcutaneous sarcoidosis presenting as a suprapubic mass, acute kidney injury, and hypercalcemia

No abstract available.

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.

Spindle Cell Rhabdomyosacoma of Uterus: A Case Study

Uterine rhabdomyosarcoma (RMS) typically presents as a mixed epithelial and mesenchymal tumors. Pure RMSs of the female genital tract are uncommon. Spindle cell variant of RMS is a rare morphologic subtype of embryonal RMS and mostly occurs in the paratesticular region of children. Here, we present a case of uterine spindle cell RMS in a 76-year-old woman. The tumor, 20x15x7 cm in size, was highly necrotic and adherent to the colon and rectum. Tumor cells were mostly spindle-shaped, and isolated rhabdomyoblasts were scattered. Immunohistochemical stains for myoglobin and myo-D1 showed diffuse positivity for tumor cells. The patient died only of disease three months after diagnosis.

A Case of Colonic Mucinous Adenocarcinoma in 19-year-old Male Patient

Colorectal cancer is rare in teenagers, especially without known risk factors. Colon cancer in young age is more likely to be diagnosed at advanced-stage, to present unfavorable tumor histology such as mucinous carcinoma, and poor outcome. We report a case of sporadic mucinous adenocarcinoma of the colon in a 19-year-old male patient without any risk factors. He complained of severe left abdominal pain that developed 1 month ago. He had a distended abdomen with severe tenderness on the left lower quadrant. A distal descending colon mass causing mechanical obstruction was observed on abdominal computed tomography. Emergency colonoscopy showed a large, fungating mass obstructing the lumen at 40 cm from the anal verge. Biopsy of the colonic mass suggested a mucinous adenocarcinoma. After decompression by colonic stent, the patient was transferred to the general surgery department for left hemicolectomy. The lesion was confirmed to be a mucinous adenocarcinoma (7.0x4.5 cm). For hereditary nonpolyposis colorectal cancer evaluation, immunohistochemical staining for MLH1 and MSH2 was normal. Reverse transcription polymerase chain reaction analysis did not detect microinstability in any of the markers tested. The patient had no familial history of cancer. Mucinous adenocarcinoma has high frequencies of poor differentiation, advanced tumor stage, loss of mismatch repair gene expression, and increased MUC2 expression. A mucinous histology is considerably more frequent in children and adolescent than in adults. Adequate invasive study is also necessary for young age patients.

Waldenstrom Macroglobulinemia with CD5+ Expression Presented as Cryoglobulinemic Glomerulonephropathy: A Case Report

Waldenstrom macroglobulinemia (WM) is a B-cell lymphoproliferative disorder associated with bone marrow involvement of lymphoplasmacytic lymphoma (LPL) and an IgM monoclonal gammopathy. Generally B-lymphocytes in LPL do not express CD5 that is important for differential diagnosis of B-cell lymphoproliferative disorders. In WM, various renal diseases and type I cryoglobulinemia are well described separately, but cryoglobulinemic glomerulonephropathy is very rarely reported. A 61-yr-old woman complained of generalized edema, cyanosis of the extremities in cold weather, visual disturbance, and pancytopenia. Bone marrow and renal biopsy showed CD5+ expressing B-cells and cryoglobulinemic glomerulonephropathy. With the diagnosis of WM, she received cyclophosphamide, doxorubicin, vincristine and prednisolone chemotherapy and got complete remission. Here, we report a rare case of WM associated with unusual expression of CD5+ B-lymphocytes and cryoglobulinemic glomerulonephropathy, and emphasize the importance of the clinical features in differentiating CD5+ B-cell lymphoproliferative disorders.

A Rare Case of Epiphyseal Chondromyxoid Fibroma of the Proximal Tibia

Chondromyxoid fibroma is an uncommon benign cartilaginous tumor of the bone. It occurs most frequently in the metaphysis of long tubular bones, and an epiphyseal location is exceedingly rare. We present here an unusual case of a chondromyxoid fibroma that occurred in the epiphysis of the proximal tibia with an open growth plate. MR imaging findings of this tumor, which has, to the best of our knowledge, never been described in an epiphyseal location, makes the present case unique.

The Expression Pattern of Annexin A1 in Urinary Bladder Urothelial Carcinoma and Its Clinicopathologic Significance

BACKGROUND: Annexin A1 (ANXA1) is known to be involved in the progression and differentiation of various tumors. However, its significance and role in bladder carcinogenesis has not been fully elucidated. To determine the role ANXA1 plays in urothelial carcinoma (UC), we investigated the expression of ANXA1 protein in normal urothelial tissue, carcinoma in situ (CIS), and UC of the urinary bladder. METHODS: Protein expression level of ANXA1 and its subcellular localization were analyzed in 88 cases of UCs and corresponding 24 normal tissues and 24 CISs by immunohistochemistry. RESULTS: ANXA1 was significantly down-regulated at all subcellular localization in CIS and in the cytoplasm and membrane of cells of UC, compared to normal tissues. No significant correlation between ANXA1 expression level and tumor depth (pT), growth pattern, and recurrence was found. However, cytoplasmic and membranous ANXA1 were significantly up-regulated in high grade than in low grade UC (p=0.02 in cytoplasm and p=0.03 in membrane). CONCLUSIONS: These results suggest that ANXA1 dysregulation is involved in urothelial carcinogenesis and ANXA1 is potentially a marker for the pathologic differentiation of UC.

Enterobius vermicularis Ova in a Vaginal Smear

Enterobius vermicularis is one of the most common parasites found in the intestine of humans. The gravid female worms migrate outside the anus to release eggs on the perianal skin. Rarely, they migrate to the genitourinary tract in female patients. We present a case in which pinworm eggs were found in a cervicovaginal smear of a 37-year-old woman. The eggs were elongated oval shaped and flattened on one side. The thick, double contoured birefringent shell stained bright yellow or orange. Some coarsely granular embryos or curved larvae were enclosed in the refractile shell. Empty eggs or wrinkled shells with clumped granular material were also present. Although pinworm eggs are easily identified because of their characteristic morphologic appearance, careful screening is needed due to the frequent masking by inflammatory cells.

Practical Standardization in Renal Biopsy Reporting

BACKGROUND: To standardize renal biopsy reporting and diagnosis, The Renal Pathology Study Group of the Korean Society of Pathologists (RPSKSP) has developed a renal pathology reporting format for the native and allograft kidney. METHODS: A consensus checklist of a provisional renal biopsy format was sent to all members of the RPSKSP. Feed back opinions regarding the practical application of the checklist to the diagnostic work were received. RESULTS: Kidney biopsies require three essential examinations: by light microscopy, immunofluorescence (IF), and electron microscopy (EM). A final report of a renal biopsy should include information on specimen adequacy and a description of the morphologic change using a systematic semiquantitative method for each of the compartments, with optional separate IF and EM reports. CONCLUSIONS: A standard renal biopsy report format is important in establishing clinicopathologic correlations, making reliable prognostic considerations, comparing the findings in sequential biopsies and evaluating the effects of therapy.

A Case of Desmoid Tumor Presenting as Intra-abdominal Abscess / 대한소화기학회지

Desmoid tumor is a rare benign tumor derived from fibrous sheath or musculoaponeurotic structure. The tumor is benign histologically but considered as malignant clinically because it has high propensity on infiltrative growth with local invasion and tendency to recurrence after local excision. Especially, when this tumor happens to be in the intra-abdomen, the prognosis is worse because it can cause intestinal obstruction, ureter obstruction and, fistula formation. It also can invade major vessels in abdomen. This tumor occurs more frequently in patients with familial adenomatous polyposis (FAP), in post-partume women, and at old surgical incision site. However, in this case, the patient had neither previous surgery nor a FAP history. We report a rare case of the young male patient who presented with an acute abdomen and underwent laparotomy and was found to have an intra-abdominal desmoid tumor with abscess formation.

A Case of Superficial Epithelioma with Sebaceous Differentiation / 대한피부과학회지

Superficial epithelioma with sebaceous differentiation (SESD) is a histologically distinct, rare, benign neoplasm characterized by a superficial plate-like proliferation of basaloid cells with broad attachments to the overlying epidermis. Clusters of sebaceous cells were present within the lobules. We herein report a case of SESD in a 73-year-old female.

A Case of Adult-onset Henoch-Schonlein Purpura (HSP) Combined with Post-infectious Glomerulonephritis (PIGN) / 대한신장학회지

Henoch-Schonlein purpura (HSP) is a small-vessel vasculitis that are predominantly observed in children, affecting their skin, joints, gut and kidneys. The renal prognosis of HS nephritis is known to be worse in adults than in children. It is defined by tissue deposition of IgA. In most HSP patients, serum complement levels are usually normal. However, some authors reported abnormalities of serum complement levels in children-onset HSP. The authors report here a rare adult-onset case of HSP combined with post-infectious glomerulonephritis, especially hypocomplementemia and subepithelial 'hump'- like electron dense deposits.

Significance of c-kit and COX-2 Expression in Breast Tissue

BACKGROUND: The proto-oncogene c-kit encodes a transmembrane tyrosine kinase growth factor receptor. Studies have shown that c-kit is highly expressed in normal breast epithelium, but expression is decreased in primary breast cancer. Cyclooxygenase-2 (COX-2) is an inducible enzyme that converts arachidonic acid to prostaglandins. Expression of COX-2 has been reported in malignant tumors including breast cancer. We evaluated the expression of c-kit and COX-2 in benign and malignant lesions of the breast to assess the roles of these proteins in cancer initiation and progression. METHODS: We characterized 20 benign lesions, 20 intraductal carcinomas and 70 invasive breast carcinomas. Immunohistochemical staining for c-kit and COX-2 was performed. RESULTS: Expression of c-kit was detected in 75% of the benign breast lesions, 40% of the intraductal carcinomas and 10% of the invasive carcinomas. COX-2 expression was observed in 80% of the benign lesions, 70% of the intraductal carcinomas and 52% of the invasive carcinomas. Expression of c-kit was significantly correlated with tumor size (p=0.02). COX-2 expression was significantly correlated with negative expression of estrogen receptor and progesterone receptor (p=0.02, p=0.04), Her-2/neu expression (p=0.008) and the high proliferation index (p=0.0002). CONCLUSIONS: Our results suggest that c-kit and COX-2 might be involved in malignant transformation of the mammary epithelium and tumor progression. It is suggested that c-kit and COX-2 can be used as predictive markers and therapeutic targets.

Four cases of gastric submucosal mass suspected as anisakiasis

Anisakiasis is a parasitic disease caused by ingestion of raw fish infected with anisakid larvae. Endoscopic changing patterns of submucosal lesions in chronic gastric anisakiasis have not been known yet. Here we report 4 cases of suspected gastric anisakiasis which were improved during follow-up periods without surgical treatment. The patients presented with abdominal pain, nausea and vomiting after consuming raw marine fish, and visited our gastroenterology outpatient department. Their endoscopic findings showed firm and yellowish submucosal masses accompanied with eccentric erosions. Histologic findings showed severe eosinophilic infiltrations. In blood tests, peripheral eosinophil counts and total IgE levels were elevated. We believed that all cases were caused by larval anisakid infections. The submucosal mass lesions disappeared during the follow-up periods of 2 to 4 mo.

A Case of Recurred Uterine Cervical Cancer Presented as Only Huge Mediastinal Mass / 결핵및호흡기질환

Uterine cervical cancer is the 5(th) most common malignancy in Korean women. With the development of new diagnostic and therapeutic modalities, earlier stage cancers are being diagnosed with longer survival rates being anticipated. Accordingly, recurrent cancers are being encountered more often in clinical practice. Most recurrent uterine cervical cancer patients, have intra-pelvic lesions and adjacent lymph node involvement, while a distant metastasis alone is extremely rare. A mediastinal recurrence of uterine cervical cancer is not common with most manifesting as small lymph node enlargements. We report a case of a 46-year-old woman with recurrent uterine cervical cancer presenting only as a huge mediastinal mass without a local recurrence.

A Case of Intraductal Papillary Mucinous Neoplasm of the Pancreas Arising from Pancreas Divisum without Ventral Pancreatic Duct of Wirsung / 대한소화기학회지

Most reported cases of intraductal papillary mucinous neoplasms (IPMNs) originate from Wirsung's duct or their branches. IPMNs arising from Santorini's duct and its branches have rarely been reported. Eight cases of IPMN arising from Santorini's duct have been published worldwide. However, these cases are associated with incomplete type of pancreas divisum. Recently, one report of IPMN with complete absence of Wirsung's duct has been reported. This patient was a 57-year-old woman who was admitted to the hospital due to progressive jaundice. On endoscopic retrograde cholangiopancreatography, there was a severely bulging ampulla of Vater and patulous minor papilla draining mucinous material and a cystic lesion communicating with the dilated Santorini's duct without any communication with Wirsung's duct. A pancreaticoduodenectomy was performed and the pathologic examination of resected specimen showed no evidence of Wirsung's duct, but an IPMN arising from Santorini's duct with peripancreatic lymph node metastasis. Herein, we report a case of invasive IPMN arising from pancreatic head without ventral pancreatic duct with a review of the relevant literatures.