Thyroid Fine-Needle Aspiration Cytology Practice in Korea

We reviewed the current status of thyroid fine-needle aspiration cytology (FNAC) in Korea. Thyroid aspiration biopsy was first introduced in Korea in 1977. Currently, radiologists aspirate the thyroid nodule under the guidance of ultrasonography, and cytologic interpretation is only legally approved when a cytopathologist makes the diagnosis. In 2008, eight thyroid-related societies came together to form the Korean Thyroid Association. The Korean Society for Cytopathology and the endocrine pathology study group of the Korean Society for Pathologists have been updating the cytologic diagnostic guidelines. The Bethesda System for Reporting Thyroid Cytopathology was first introduced in 2009, and has been used by up to 94% of institutions by 2016. The average diagnosis rates are as follows for each category: I (12.4%), II (57.9%), III (10.4%), IV (2.9%), V (3.7%), and VI (12.7%). The malignancy rates in surgical cases are as follows for each category: I (28.7%), II (27.8%), III (50.6%), IV (52.3%), V (90.7%), and VI (100.0%). Liquid-based cytology has been used since 2010, and it was utilized by 68% of institutions in 2016. The categorization of thyroid lesions into “atypia of undetermined significance” or “follicular lesion of undetermined significance” is necessary to draw consensus in our society. Immunocytochemistry for galectin-3 and BRAF is used. Additionally, a molecular test for BRAF in thyroid FNACs is actively used. Core biopsies were performed in only 44% of institutions. Even the institutions that perform core biopsies only perform them for less than 3% of all FNACs. However, only 5% of institutions performed core biopsies up to three times more than FNAC.

High-quality cell block preparation from scraping of conventional cytology slide: a technical report on a modified cytoscrape cell block technique

Background: Immunocytochemistry (ICC) on formalin-fixed paraffin embedded cell blocks is an ancillary tool commonly recruited for differential diagnoses of fine needle aspiration cytology (FNAC) samples. However, the quality of conventional cell blocks in terms of adequate cellularity and evenness of distribution of cytologic material is not always satisfactory for ICC. We introduce a modified agarose-based cytoscrape cell block (CCB) technique that can be effectively used for the preparation of cell blocks from scrapings of conventional FNAC slides. Methods: A decoverslipped FNAC slide was mounted with a small amount of water. The cytological material was scraped off the slide into a tissue mold by scraping with a cell scraper. The cytoscrape material was pelleted by centrifugation and pre-embedded in ultra-low gelling temperature agarose and then re-embedded in conventional agarose. The final agarose gel disk was processed and embedded in paraffin. Results: The quality of the ICC on the CCB sections was identical to that of the immunohistochemical stains on histological sections. By scrapping and harvesting the entirety of the cytological material off the cytology slide into a compact agarose cell button, we could avoid the risk of losing diagnostic material during the CCB preparation. Conclusion: This modified CCB technique enables concentration and focusing of minute material while maintaining the entire amount of the cytoscrape material on the viewing spot of the CCB sections. We believe this technique can be effectively used to improve the level of confidence in diagnosis of FNAC especially when the FNAC slides are the only sample available.

Early onset of puberty in an obese boy with Klinefelter syndrome

Klinefelter syndrome (KS) is one of the most common disease entities characterized by X-chromosomal aberration causing the primary hypogonadism in adult men. Patients with KS seem to be typically characterized by tall, slender bodies with delayed puberty and hypergonadotropic hypogonadism. However, it has been known that they have a broad spectrum of phenotype ranging from almost normal external appearances to typical phenotype. Only 25% KS Patients are ever diagnosed because KS remains unrecognized. Also, boys with KS have an onset of pubertal development within the normal range, not delayed onset of puberty. Adolescents with KS are generally diagnosed as having the lack of pubertal progress. Early detection of KS can be difficult without awareness. We report an unusual case of early onset of puberty in obese boy with KS who presented with a unilateral non-hormone secreting testicular teratoma.

Late-onset trichloroethylene-induced hypersensitivity syndrome after intermittent exposure to low-dose trichloroethylene

Occupational exposure to trichloroethylene (TCE) can occasionally induce severe cutaneous disorders, including hypersensitivity syndrome and Stevens-Johnson syndrome. The clinical manifestation of TCE hypersensitivity syndrome is quite similar to that of drug-induced hypersensitivity syndrome and includes skin lesions, hepatitis, fever, and lymphadenopathy. Almost all cases of TCE hypersensitivity syndrome developed within 2–8 weeks after the first exposure to TCE in an occupational setting. This typical course and clinical feature of hypersensitivity syndrome together with occupational history of TCE contact may lead to prompt diagnosis and treatment of this potentially fatal disease. This report describes a 32-year-old man who has been intermittently engaged in cleaning work using TCE for about 3 years, and then developed TCE hypersensitivity syndrome. To the best of our knowledge, this is the first case of TCE hypersensitivity syndrome with a long duration of symptom onset due to intermittent exposure to TCE. Thus, physicians should take thorough occupational history when seeing a patient with hypersensitivity syndrome has neither history of drug intake nor regular exposure to TCE.

Prognostic Implication of Semi-quantitative Immunohistochemical Assessment of CD20 Expression in Diffuse Large B-Cell Lymphoma

BACKGROUND: Immunohistochemical demonstration of CD20 in diffuse large B-cell lymphoma (DLBCL) is prerequisite not only for the diagnosis but also for assigning patients to rituximab-containing chemotherapy. However, little is known about the impact of abundance of CD20 expression assessed by immunohistochemistry on the clinical outcome of DLBCL. We performed a semi-quantitative immunohistochemical analysis of CD20 expression in DLBCL to examine the prognostic implication of the level of CD20 expression. METHODS: Pre-treatment diagnostic tissue samples from 48 DLBCL patients who were treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) regimen were represented in a tissue microarray and immunostained for CD20. The relative abundance of CD20 expression was semi-quantitatively scored using a web-based ImmunoMembrane plug-in. Receiver operating characteristic curve analysis was used to determine a prognostically relevant cut-off score in order to dichotomize the patients into CD20-high versus CD20-low groups. RESULTS: The levels of CD20 expression were heterogeneous among the patients, with a wide and linear distribution of scores. Patients in CD20-low group showed significantly poor clinical outcome. CONCLUSIONS: The levels of CD20 expression in DLBCL are heterogeneous among the patients with DLBCL. A subgroup of the patients with CD20 expression levels below the cut-off score showed poor clinical outcome.

Renoprotective Effects of a Highly Selective A3 Adenosine Receptor Antagonist in a Mouse Model of Adriamycin-induced Nephropathy

The concentration of adenosine in the normal kidney increases markedly during renal hypoxia, ischemia, and inflammation. A recent study reported that an A3 adenosine receptor (A3AR) antagonist attenuated the progression of renal fibrosis. The adriamycin (ADX)-induced nephropathy model induces podocyte injury, which results in severe proteinuria and progressive glomerulosclerosis. In this study, we investigated the preventive effect of a highly selective A3AR antagonist (LJ1888) in ADX-induced nephropathy. Three groups of six-week-old Balb/c mice were treated with ADX (11 mg/kg) for four weeks and LJ1888 (10 mg/kg) for two weeks as following: 1) control; 2) ADX; and 3) ADX + LJ1888. ADX treatment decreased body weight without a change in water and food intake, but this was ameliorated by LJ1888 treatment. Interestingly, LJ1888 lowered plasma creatinine level, proteinuria, and albuminuria, which had increased during ADX treatment. Furthermore, LJ1888 inhibited urinary nephrin excretion as a podocyte injury marker, and urine 8-isoprostane and kidney lipid peroxide concentration, which are markers of oxidative stress, increased after injection of ADX. ADX also induced the activation of proinflammatory and profibrotic molecules such as TGF-β1, MCP-1, PAI-1, type IV collagen, NF-κB, NOX4, TLR4, TNFα, IL-1β, and IFN-γ, but they were remarkably suppressed after LJ1888 treatment. In conclusion, our results suggest that LJ1888 has a renoprotective effect in ADX-induced nephropathy, which might be associated with podocyte injury through oxidative stress. Therefore, LJ1888, a selective A3AR antagonist, could be considered as a potential therapeutic agent in renal glomerular diseases which include podocyte injury and proteinuria.

Corrigendum: Effects of Toll-like receptor antagonist 4,5-dihydro-3-phenyl-5-isoxasole acetic acid on the progression of kidney disease in mice on a high-fat diet Volume 33, Issue 1, March 2014, Pages 33-44

The authors apologize for a wrong unit in the table 1.

Neuro-Behcet's Disease Presenting as Hypertrophic Pachymeningitis

A 25-year-old man presented with blurred vision and chronic headache. His brain MRI revealed bilateral frontal pachymeningeal enhancement with leptomeningeal enhancement. The patient had experienced recurrent oral ulcer and had anterior uveitis and papulopustules skin lesion. We diagnosed him with hypertrophic pachymeningitis (HP) associated with neuro-Behcet's disease (NBD). There have been few reports describing HP in patients with NBD. We report a case of NBD presenting as HP.

Ectopic Human Fasciola hepatica Infection by an Adult Worm in the Mesocolon

We report here an ectopic case of Fasciola hepatica infection confirmed by recovery of an adult worm in the mesocolon. A 56-year-old female was admitted to our hospital with discomfort and pain in the left lower quadrant of the abdomen. Abdominal CT showed 3 abscesses in the left upper quadrant, mesentery, and pelvic cavity. On surgical exploration, abscess pockets were found in the mesocolon of the sigmoid colon and transverse colon. A leaf-like worm found in the abscess pocket of the mesocolon of the left colon was diagnosed as an adult fluke of F. hepatica. Histologically, numerous eggs of F. hepatica were noted with acute and chronic granulomatous inflammations in the subserosa and pericolic adipose tissues. Conclusively, a rare case of ectopic fascioliasis has been confirmed in this study by the adult worm recovery of F. hepatica in the mesocolon.

Clinical Features and Outcomes of Endoscopic Treatment for Stones in Stemware-Shaped Common Bile Ducts: A Multicenter Data Analysis

BACKGROUND/AIMS: Various anatomical features of the biliary tree affect ability to remove difficult common bile duct (CBD) stones. In this study, we evaluated the clinical characteristics and outcomes of the endoscopic treatment of stones in stemware-shaped CBDs. METHODS: Thirty-four patients with a stone and a stemware-shaped CBD who were treated at different tertiary referral centers from January 2008 to December 2012 were studied retrospectively. When stone removal failed, percutaneous or direct peroral cholangioscopic lithotripsy, endoscopic retrograde biliary drainage, or surgery was performed as a second-line procedure. RESULTS: The overall success rate of the first-line procedure was 41.2%. Five of the 34 patients (14.7%) experienced procedure-related complications. No procedure-related mortality occurred. Mechanical lithotripsy was required to completely remove stones in 13 patients (38.2%). Conversion to a second-line procedure was required in 20 patients (58.8%). Mechanical lithotripsy was needed in 75% and 66.7% of those with a stone size of or =1 cm, respectively. Stone recurrence occurred in two patients (9.1%) after 6 months and 27 months, respectively. CONCLUSIONS: The endoscopic treatment of stones in a stemware-shaped CBD is challenging. The careful assessment of difficult CBD stones is required before endoscopic procedures.

Percutaneous Papillary Large Balloon Dilation during Percutaneous Cholangioscopic Lithotripsy for the Treatment of Large Bile-Duct Stones: A Feasibility Study

When access to a major duodenal papilla or endoscopic retrograde cholangiopancreatography has failed, percutaneous transhepatic cholangioscopic lithotripsy (PTCS-L) may be useful for removing common bile duct (CBD) stones. However, the feasibility and usefulness of percutaneous transhepatic papillary large-balloon dilation (PPLBD) during PTCS-L for the removal of large CBD stones has not been established. We aimed to determine the safety and efficacy of PPLBD for the treatment of large CBD stones. Eleven patients with large CBD stones in whom the access to the major papilla or bile duct had failed were enrolled prospectively. Papillary dilation was performed using a large (12-20 mm) dilation balloon catheter via the percutaneous transhepatic route. Post-procedure adverse events and efficacy of the stone retrieval were measured. The initial success rate of PPLBD was 100%. No patient required a basket to remove a stone after PPLBD. Electrohydraulic lithotripsy was required in 2 (18.2%) patients. The median time to complete stone removal after PPLBD was 17.8 min and no adverse events occurred after PPLBD. Asymptomatic hyperamylasemia was not encountered in any patients. This study indicates that PPLBD is safe and effective for removal of large CBD stones.

Percutaneous Papillary Large Balloon Dilation during Percutaneous Cholangioscopic Lithotripsy for the Treatment of Large Bile-Duct Stones: A Feasibility Study

When access to a major duodenal papilla or endoscopic retrograde cholangiopancreatography has failed, percutaneous transhepatic cholangioscopic lithotripsy (PTCS-L) may be useful for removing common bile duct (CBD) stones. However, the feasibility and usefulness of percutaneous transhepatic papillary large-balloon dilation (PPLBD) during PTCS-L for the removal of large CBD stones has not been established. We aimed to determine the safety and efficacy of PPLBD for the treatment of large CBD stones. Eleven patients with large CBD stones in whom the access to the major papilla or bile duct had failed were enrolled prospectively. Papillary dilation was performed using a large (12-20 mm) dilation balloon catheter via the percutaneous transhepatic route. Post-procedure adverse events and efficacy of the stone retrieval were measured. The initial success rate of PPLBD was 100%. No patient required a basket to remove a stone after PPLBD. Electrohydraulic lithotripsy was required in 2 (18.2%) patients. The median time to complete stone removal after PPLBD was 17.8 min and no adverse events occurred after PPLBD. Asymptomatic hyperamylasemia was not encountered in any patients. This study indicates that PPLBD is safe and effective for removal of large CBD stones.

Primary Prevention of Alzheimer's Disease: Is It an Attainable Goal?

Alzheimer's disease (AD) is the leading cause of dementia, and the most prevalent neurodegenerative disease in the elderly. The prevalence of AD is predicted to rise as life expectancy grows across populations. The exact cause of this devastating disease is still unknown; however, it is an aging-related multi-factorial disorder, and growing evidence supports the contribution of modifiable environmental factors to unmodifiable factors such as gene and ageing itself. The recent advancement of methodologies and techniques for early diagnosis of AD facilitates the investigation of strategies to reduce the risk for AD progression in the earliest stages of the disease. Pharmacological attempts at curing, halting or modifying it have, by and large, been unsuccessful, and no breakthrough is seen in the near future. However, a lot of elements that seem to contribute to the disease such as risk factors have been identified, mainly from epidemiological and basic research studies. Many of these are amenable to lifestyle modification. Therefore, prevention in the preclinical stage is likely the most effective way to decrease the incidence of this age-associated dreadful neurodegenerative condition, and its associated burden for individuals and society. We provide an overview of modifiable risk factors for AD along with the supporting evidence.

A Case Report of Testicular Sparganosis Misdiagnosed as Testicular Tumor

Sparganosis is a parasitic infestation of human by plerocercoid larvae. Sparganum is usually reported to be found in the subcutaneous tissues as well as other organs, including scrotum. However, testicular sparganosis is extremely rare, because of strong capsule of tunica albuginea. An urban-living 54-yr-old Korean man presented with left scrotal pain for 6 yr. Both testes look normal physically. Ultrasonography revealed poorly defined, heterogeneous mass with increased echogenicity in the left testis. This case was misdiagnosed as testicular tumor and underwent orchiectomy, but was diagnosed as testicular sparganosis by histopathology. Sparganosis should be included for differential diagnosis of testis tumor in countries where sparganosis is prevalent.

A Case of Esophageal Actinomycosis without Treatment in an Immunocompetent Patient

Actinomycosis is a rare, chronic disease, mainly caused by Actinomyces israelii that are present in the normal flora of the oral cavity and gastrointestinal tract. Opportunistic infection can occur if there is a break in the mucosal barrier or immunosuppressant condition. Factors that precipitate actinomycosis include surgery, inflammation, perforation, and intrauterine contraceptive devices. Esophageal actinomycosis is an extremely rare presentation, especially in immunocompetent patients. We report an unusual case of esophageal actinomycosis in an immunocompetent patient with review of the natural course of esophageal actinomycosis without treatment.

ST-Elevation Myocardial Infarction after Intravenous Thrombolysis Treatment for Acute Ischemic Stroke

Intravenous tissue plasminogen activator (IV-tPA) is the standard treatment for acute ischemic stroke. Acute myocardial infarction (AMI) as a complication of IV-tPA therapy is rarely reported. A 56-year-old man was diagnosed with the left middle cerebral artery territory infarction. IV-tPA was administered, and AMI developed 2-hours thereafter. Coronary angiography demonstrated occlusion of the left anterior descending artery and; immediate recanalization was perfomed. The patient recovered without neurological sequelae. We report herein an unusual case of AMI that developed following IV-t-PA therapy for acute ischemic stroke.

Effects of Toll-like receptor antagonist 4,5-dihydro-3-phenyl-5-isoxasole acetic acid on the progression of kidney disease in mice on a high-fat diet

BACKGROUND: Obesity-related metabolic disorders are closely associated with inflammation induced by innate immunity. Toll-like receptors (TLRs) play a pivotal role in the innate immune system by activating proinflammatory signaling pathways. GIT27 (4,5-dihydro-3-phenyl-5-isoxasole acetic acid) is an active immunomodulatory agent that primarily targets macrophages and inhibits secretion of tumor necrosis factor alpha [as well as interleukin (IL)-1beta, IL-10, and interferon gamma]. However, the effect of TLR antagonist on kidney diseases has rarely been reported. We investigated whether the TLR antagonist GIT27 has beneficial effects on the progression of kidney disease in obese mice on a high-fat diet (HFD). METHODS: Six-week-old male C57BL/6 mice were divided into three groups: mice fed with normal chow diet (N=4); mice fed with a HFD (60% of total calories from fat, 5.5% from soybean oil, and 54.5% from lard, N=4); and GIT27-treated mice fed with a HFD (N=7). RESULTS: Glucose intolerance, oxidative stress, and lipid abnormalities in HFD mice were improved by GIT27 treatment. In addition, GIT27 treatment decreased the urinary excretion of albumin and protein in obesity-related kidney disease, urinary oxidative stress markers, and inflammatory cytokine levels. This treatment inhibited the expression of proinflammatory cytokines in the kidneys and adipose tissue, and improved extracellular matrix expansion and tubulointerstitial fibrosis in obesity-related kidney disease. CONCLUSION: TLR inhibition by administering GIT27 improved metabolic parameters. GIT27 ameliorates abnormalities of lipid metabolism and may have renoprotective effects on obesity-related kidney disease through its anti-inflammatory properties.

Mesocolon Laceration Following Colonoscopy / 대한소화기학회지

Colonoscopic examination is a safe procedure, however, unexpected complications can sometimes occur. Bleeding and perforation of the colon have been reported as the most common complications. Hemoperitoneum after colonoscopy is an unusual complication, but it may be catastrophic. We report on a 20-year-old man who experienced left low quadrant pain after undergoing colonoscopy. Hemoperitoneum was diagnosed using abdominal CT. A laparoscopic exploration was urgently performed, revealing a lacerated mesocolon of the descending colon. Bleeding of the injured site was controlled without complication. The patient recovered fully without signs of recurrent bleeding. This report implies that if the patient has persistent abdominal pain after undergoing colonoscopy, we should consider hemoperitoneum as one of the causes. To the best of our knowledge, no case of isolated laceration of the mesocolon of the descending colon after colonoscopy has been reported.

A Case of Egg-Shell Calcification of Renal Cell Carcinoma in Continuous Ambulatory Peritoneal Dialysis Patient with Sclerosing Encasulating Peritonitis

Acquired cystic kidney disease (ACKD), a common complication in patients with end-stage renal disease, is characterized by more than three kidney cysts and normal or decreased sizes of both kidneys without any familial history of cystic kidney disease. In autosomal dominant polycystic kidney disease (ADPKD), however, both kidneys are usually enlarged. Extrarenal manifestations are common in ADPKD, including hepatic cysts, seminal vesicle cysts, mitral valve prolapse. A 40-year-old man presented to the emergency clinic at Inha University Hospital with severe abdominal pain, nausea, and vomiting for 3 days. He had been undergoing continuous ambulatory peritoneal dialysis (CAPD) for 15 years, but it was recently changed to hemodialysis owing to sclerosing encapsulating peritonitis (SEP). Radiologic imaging studies revealed bilateral enlarged kidneys with multiple eggshell calcified cysts and some hepatic cysts, which suggested ADPKD. He underwent left nephrectomy, and pathological tests revealed ACKD-associated renal cell carcinoma (RCC) confined to the resected kidney. He was treated with steroids for SEP, and the symptoms resolved. We herein report a case of ACKD-resembling ADPKD-that progressed to RCC in a patient with concurrent SEP who had been undergoing CAPD for 15 years.

Myoepithelial Carcinoma of Soft Tissue: A Case Report and Review of the Literature

No abstract available.