Association of Microbial Dysbiosis with Gallbladder Diseases Identified by Bile Microbiome Profiling

Background@#Cholecystitis is an important risk factor for gallbladder cancer, but the bile microbiome and its association with gallbladder disease has not been investigated fully.We aimed to analyze the bile microbiome in normal conditions, chronic cholecystitis, and gallbladder cancer, and to identify candidate bacteria that play an important role in gallbladder carcinogenesis. @*Methods@#We performed metagenome sequencing on bile samples of 10 healthy individuals, 10 patients with chronic cholecystitis, and 5 patients with gallbladder cancer, and compared the clinical, radiological, and pathological characteristics of the participants. @*Results@#No significant bacterial signal was identified in the normal bile. The predominant dysbiotic bacteria in both chronic cholecystitis and gallbladder cancer were those belonging to the Enterobacteriaceae family. Klebsiella increased significantly in the order of normal, chronic cholecystitis, and gallbladder cancer. Patients with chronic cholecystitis and dysbiotic microbiome patterns had larger gallstones and showed marked epithelial atypia, which are considered as precancerous conditions. @*Conclusion@#We investigated the bile microbiome in normal, chronic cholecystitis, and gallbladder cancer. We suggest possible roles of Enterobacteriaceae, including Klebsiella, in gallbladder carcinogenesis. Our findings reveal a possible link between a dysbiotic bile microbiome and the development of chronic calculous cholecystitis and gallbladder cancer.

Association of Microbial Dysbiosis with Gallbladder Diseases Identified by Bile Microbiome Profiling

Background@#Cholecystitis is an important risk factor for gallbladder cancer, but the bile microbiome and its association with gallbladder disease has not been investigated fully.We aimed to analyze the bile microbiome in normal conditions, chronic cholecystitis, and gallbladder cancer, and to identify candidate bacteria that play an important role in gallbladder carcinogenesis. @*Methods@#We performed metagenome sequencing on bile samples of 10 healthy individuals, 10 patients with chronic cholecystitis, and 5 patients with gallbladder cancer, and compared the clinical, radiological, and pathological characteristics of the participants. @*Results@#No significant bacterial signal was identified in the normal bile. The predominant dysbiotic bacteria in both chronic cholecystitis and gallbladder cancer were those belonging to the Enterobacteriaceae family. Klebsiella increased significantly in the order of normal, chronic cholecystitis, and gallbladder cancer. Patients with chronic cholecystitis and dysbiotic microbiome patterns had larger gallstones and showed marked epithelial atypia, which are considered as precancerous conditions. @*Conclusion@#We investigated the bile microbiome in normal, chronic cholecystitis, and gallbladder cancer. We suggest possible roles of Enterobacteriaceae, including Klebsiella, in gallbladder carcinogenesis. Our findings reveal a possible link between a dysbiotic bile microbiome and the development of chronic calculous cholecystitis and gallbladder cancer.

Association between dietary intake and postlaparoscopic cholecystectomic symptoms in patients with gallbladder disease

BACKGROUND/AIMS: After cholecystectomy, patients have reported postcholecystectomic syndromes such as abdominal symptoms, dyspepsia, and diarrhea, which suggest a relationship between cholecystectomic symptoms and diet, although the details of this association remain unclear. The present study investigated the hypothesis that dietary intake of nutrients and foods was significantly associated with postcholecystectomic syndromes. METHODS: Gallstone patients (n = 59) who underwent laparoscopic cholecystectomy were enrolled, and dietary intake and clinical parameters were assessed immediately postcholecystectomy and 3 months later. RESULTS: There were no significant differences in biochemical measurements or characteristics between symptomatic and asymptomatic patients. Immediately postcholecystectomy, there were no significant differences in consumption of nutrients or foods between symptomatic and asymptomatic patients. However, 3 months after cholecystectomy, symptomatic patients consumed more animal protein, cholesterol, and eggs, and fewer vegetables than did asymptomatic patients. Multivariable-adjusted regression analyses also indicated that the risk for symptoms was positively associated with intake of animal protein, cholesterol, and eggs, but negatively associated with intake of vegetables after adjusting for confounders. In addition, symptomatic patients consumed more bread-based breakfast foods, while asymptomatic patients consumed more rice. CONCLUSIONS: Postcholecystectomic syndromes were positively associated with intake of cholesterol, animal protein, and eggs, and negatively associated with intake of vegetables, suggesting that diet was plays a role in postcholecystectomic syndromes.

MUC Expression in Gallbladder Epithelial Tissues in Cholesterol-Associated Gallbladder Disease

BACKGROUND/AIMS: Gallstone pathogenesis is linked to mucin hypersecretion and bacterial infection. Several mucin genes have been identified in gallbladder epithelial cells (GBECs). We investigated MUC expression in cholesterol-associated gallbladder disease and evaluated the relationship between mucin and bacterial infection. METHODS: The present study involved 20 patients with cholesterol stones with cholecystitis, five with cholesterol stones with cholesterolosis, six with cholesterol polyps, two with gallbladder cancer, and six controls. Canine GBECs treated with lipopolysaccharide were also studied. MUC3, MUC5AC, MUC5B, and MUC6 antibodies were used for dot/slot immunoblotting and immunohistochemical studies of the gallbladder epithelial tissues, canine GBECs, and bile. Reverse-transcription polymerase chain reaction was performed to evaluate MUC3 and MUC5B expression. RESULTS: MUC3, MUC5AC, MUC5B, and MUC6 were expressed in the normal gallbladder epithelium, and of those, MUC3 and MUC5B exhibited the highest expression levels. Greatly increased levels of MUC3 and MUC5B expression were observed in the cholesterol stone group, and slightly increased levels were observed in the cholesterol polyp group; MUC3 and MUC5B mRNA was also upregulated in those groups. Canine GBECs treated with lipopolysaccharide also showed upregulation of MUC3 and MUC5B. CONCLUSIONS: The mucin genes with the highest expression levels in gallbladder tissue in cholesterol-associated diseases were MUC3 and MUC5B. Cholesterol stones and gallbladder infections were associated with increased MUC3 and MUC5B expression.

What is the Safe Training to Educate the Laparoscopic Cholecystectomy for Surgical Residents in Early Learning Curve?

PURPOSE: This study was conducted to investigate the safety of laparoscopic cholecystectomy (LC) performed by surgical residents. METHODS: We reviewed the records of patients who underwent LC for chronic cholecystitis and gallbladder polyps between February 2010 and July 2012. All diagnoses were confirmed by biopsy. All procedures performed by surgical residents were conducted under the close supervision of an experienced laparoscopic surgeon. A standard four-port method was used, and we achieved the critical view of safety in almost all patients. RESULTS: Of 219 LC procedures, 136 were performed by an experienced laparoscopic surgeon, and 83 by surgical residents. There was no significant difference in postoperative hospital stay (1.1 vs. 1.2 days, p=0.337) or complication rates (3.7% vs. 2.4%, p=0.712) between groups. However, the patients operated on by surgical residents had significantly longer operation times (40.7 vs. 63.7 min, p<0.05). CONCLUSION: LC performed by inexperienced surgical residents under the supervision of an experienced surgeon is safe and feasible for chronic cholecystitis and gallbladder polyps. Major bile duct injury is strongly correlated with having performed fewer than 20 LC procedures, so surgical residents must secure the critical view of safety, and the supervising surgeon must confirm it before the cystic duct and cystic artery are ligated.

Positive immunostaining of Sal-like protein 4 is associated with poor patient survival outcome in the large and undifferentiated Korean hepatocellular carcinoma

PURPOSE: Previous studies have shown the role of Sal-like protein 4 (SALL4) as a biomarker in hepatocellular carcinoma (HCC), and some studies have shown the relationship between SALL4 and prognosis. Given the debates in study groups differences in terms of etiologic causes between Western and Asian HCC and detection methods, we attempted to verify the features of SALL4 immunoreactivity and its clinical correlation in Korean HCC patients. METHODS: Immunohistochemical staining of SALL4 of tissue microarrays (TMAs) consisting of 213 surgically resected HCC patients' tissue were scored in a semiquantitative scoring system with immunoreactive score and the results analyzed with clinical outcome, in addition to general demographics and clinical characteristics. RESULTS: SALL4 immunoreactivity was expressed in 50 cases. Relevance between SALL4 and α-FP correlated significantly (P = 0.002). Also, the SALL4-positive patients had considerably higher tumor grade (P < 0.001). The survival analysis showed negative correlation with SALL4 immunoreactivity in all HCC patient groups, but SALL4 immunoreactivity in T3 and T4 HCC correlated with poor prognosis. CONCLUSION: Here, we found that positive immunostaining of SALL4 is correlated with poor patient survival outcome in large and undifferentiated Korean HCC. SALL4 expression showed close relationship with clinical outcomes of HCCs in Korean patients.

Positive immunostaining of Sal-like protein 4 is associated with poor patient survival outcome in the large and undifferentiated Korean hepatocellular carcinoma

PURPOSE: Previous studies have shown the role of Sal-like protein 4 (SALL4) as a biomarker in hepatocellular carcinoma (HCC), and some studies have shown the relationship between SALL4 and prognosis. Given the debates in study groups differences in terms of etiologic causes between Western and Asian HCC and detection methods, we attempted to verify the features of SALL4 immunoreactivity and its clinical correlation in Korean HCC patients. METHODS: Immunohistochemical staining of SALL4 of tissue microarrays (TMAs) consisting of 213 surgically resected HCC patients' tissue were scored in a semiquantitative scoring system with immunoreactive score and the results analyzed with clinical outcome, in addition to general demographics and clinical characteristics. RESULTS: SALL4 immunoreactivity was expressed in 50 cases. Relevance between SALL4 and α-FP correlated significantly (P = 0.002). Also, the SALL4-positive patients had considerably higher tumor grade (P < 0.001). The survival analysis showed negative correlation with SALL4 immunoreactivity in all HCC patient groups, but SALL4 immunoreactivity in T3 and T4 HCC correlated with poor prognosis. CONCLUSION: Here, we found that positive immunostaining of SALL4 is correlated with poor patient survival outcome in large and undifferentiated Korean HCC. SALL4 expression showed close relationship with clinical outcomes of HCCs in Korean patients.

Clinical implications of advances in liver regeneration

Remarkable advances have been made recently in the area of liver regeneration. Even though liver regeneration after liver resection has been widely researched, new clinical applications have provided a better understanding of the process. Hepatic damage induces a process of regeneration that rarely occurs in normal undamaged liver. Many studies have concentrated on the mechanism of hepatocyte regeneration following liver damage. High mortality is usual in patients with terminal liver failure. Patients die when the regenerative process is unable to balance loss due to liver damage. During disease progression, cellular adaptations take place and the organ microenvironment changes. Portal vein embolization and the associating liver partition and portal vein ligation for staged hepatectomy are relatively recent techniques exploiting the remarkable progress in understanding liver regeneration. Living donor liver transplantation is one of the most significant clinical outcomes of research on liver regeneration. Another major clinical field involving liver regeneration is cell therapy using adult stem cells. The aim of this article is to provide an outline of the clinical approaches being undertaken to examine regeneration in liver diseases.

AROS Is a Significant Biomarker for Tumor Aggressiveness in Non-cirrhotic Hepatocellular Carcinoma

Despite a low risk of liver failure and preserved liver function, non-cirrhotic hepatocellular carcinoma (HCC) has a poor prognosis. In the current study, we evaluated an active regulator of SIRT1 (AROS) as a prognostic biomarker in non-cirrhotic HCC. mRNA levels of AROS were measured in tumor and non-tumor tissues obtained from 283 non-cirrhotic HCC patients. AROS expression was exclusively up-regulated in recurrent tissues from the non-cirrhotic HCC patients (P=0.015) and also in tumor tissues irrespective of tumor stage (P<0.001) or BCLC stage (P<0.001). High mRNA levels of AROS were statistically significantly associated with tumor stage (P<0.001), BCLC stage (P=0.007), alpha fetoprotein (AFP) level (P=0.013), microvascular invasion (P=0.001), tumor size (P=0.036), and portal vein invasion (P=0.005). Kaplan-Meir curve analysis demonstrated that HCC patients with higher AROS levels had shorter disease-free survival (DFS) in both the short-term (P<0.001) and long-term (P=0.005) compared to those with low AROS. Cox regression analysis demonstrated that AROS is a significant predictor for DFS along with large tumor size, tumor multiplicity, vascular invasion, and poor tumor differentiation, which are the known prognostic factors. In conclusion, AROS is a significant biomarker for tumor aggressiveness in non-cirrhotic hepatocellular carcinoma.

Hepatoid adenocarcinoma of the gallbladder with production of alpha-fetoprotein / 대한외과학회지

Hepatoid adenocarcinoma (HAC) is a tumor with aberrant hepatocellular differentiation that occurs in extrahepatic organs. HAC of the gallbladder is rare, and cases of alpha-fetoprotein production are extremely rare. A 61-year-old man was diagnosed with gallbladder adenocarcinoma after laparoscopic cholecystectomy. A radical operation including resection of liver bed and lymph node dissection was performed, and no tumor cell was found. However, at postoperative 19 months, he showed lymphadenopathy of the portocaval area and tumor thrombi in the right portal vein with high levels of serum alpha-fetoprotein. After right hemihepatectomy and portahepatis lymph node dissection was performed, he was diagnosed with metastatic HAC. On reviewing the gallbladder specimen, the tumor finally demonstrated HAC as the primary origin. Despite adjuvant therapy, the patient died from multiple liver metastasis 26 months after cholecystectomy. Although HAC of the gallbladder is a very rare malignancy, awareness of its existence is critical to avoid misdiagnosis.

Acinar Cell Carcinoma of the Pancreas: A Report of Two Cases with Long-term Follow-up and a Review of the Literature

Acinar cell carcinoma (ACC) of the pancreas is a rare malignancy making up approximately 1% of pancreatic non-endocrine malignant tumors. The common finding on computed tomography is a solitary, well-defined, heterogenous hypodense mass with enhancing capsule. ACC is a highly cellular tumor with minimal stroma and a lack of stromal desmoplasia. The accurate diagnosis of ACC cannot typically be done by histology alone but rather requires immunohistochemical staining or electron microscopy for the identification of pancreatic enzymes and zymogen granules. ACC has been considered a cancer with a poor prognosis due to frequent metastasis, a high recurrence rate, and low respectability. Surgical resection is the treatment of choice that can lead to long-term survival. ACC has a better prognosis than ductal carcinoma of the pancreas, but a worse prognosis compared to islet cell carcinoma. We report two cases of ACC with 5-year survival after surgical resection.

Left-sided Gallbladder with Intrahepatic Portal Vein Anomalies: A Single Center Experiences

PURPOSE: The goal of this article was to characterize and explain the etiology of a left-sided gallbladders with intrahepatic portal vein anomalies, and these cases of this unusual anatomy were all encountered at a single center. METHODS: We reviewed the movies recorded during surgery, the database information and the preoperative radiologic examinations of 1,141 patients who underwent cholecystectomies at our institution between August 2007 and July 2010 to assess the presence of left-sided gallbladder and its combined anomalies. RESULTS: Four of 1141 patients (0.35%) were diagnosed with left-sided gallbladder. In all the cases, the gallbladder was located on the left side of the falciform ligament, under the left lobe of the liver with typical abnormal intrahepatic portal venous branching. The right posterior portal vein came directly from the main portal vein, and the right anterior portal vein originated from the left portal vein, but the ligamentum teres joined to the left branch of the portal vein in the liver. CONCLUSION: Left-sided gallbladder with intrahepatic portal venous branching anomaly resulted from the defective development of the central portion of the liver rather than from abnormal regression of the left umbilical vein with persistence of the right umbilical vein.

Acinar Cell Carcinoma of the Pancreas in Korea: Clinicopathologic Analysis of 27 Patients from Korean Literature and 2 Cases from Our Hospital / 대한소화기학회지

BACKGROUND/AIMS: Acinar cell carcinoma (ACC) of the pancreas is a rare malignancy. ACC has been considered a cancer with poor prognosis due to frequent metastasis, a high recurrence rate, and low resectability. The aim of this study was to examine the clinical, radiologic and pathologic features of ACC in Korean patients, and surgical outcome was also investigated. METHODS: We reviewed the clinical records of two patients with ACC who had undergone operation in January 1996 and December 2005 at Hanyang University Medical Center. Through searching of medical journal from 1983 to 2009, 27 patients reported on literatures as Korean ACC patients were reviewed together. The clinical, pathohistologic, and radiologic features, treatment, and prognosis were investigated for all 29 patients. RESULTS: ACC was more common in male, and age at diagnosis ranged from 25 to 68 years (median 54). Symptoms were, mostly abdominal pain and mass. Liver was most common organ of metastasis at diagnosis and recurrence after operation. The mean tumor size was 7.0 cm, and most common location was tail. Of the 29 patients, 22 underwent surgical resection. Excluding 7 cases of not-reported survival, the median survival with operation was 22.4 months compared to 1.5 months with non-operation. CONCLUSIONS: In Korea, the clinical features of ACC include young age, large size, tail location, and nonspecific tumor markers. Surgery should be actively performed in the treatment of ACC regardless of size.

The Effect of Adjuvant Chemotherapy on Stage IV (T4N1-3M0 and T1-3N3M0) Gastric Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The optimal chemotherapeutic strategy for gastric cancer patients has not been determined, especially with respect to stage and the curability of gastric cancer. The aim of this study was to evaluate the results of adjuvant chemotherapy on stage IV (T4N1-3M0 and T1-3N3M0) gastric cancer after curative gastrectomy between a chemotherapy (CTX) group and non-chemotherapy (non-CTX) group. MATERIALS AND METHODS: Among 1,760 patients who underwent gastric surgery by 1 surgeon in a single institution, 162 stage IV gastric cancer patients with curative gastrectomy were analyzed retrospectively, excluding patients with TanyNanyM1. One hundred twenty-five patients who received different chemotherapeutic regimens were compared to 37 patients who did not receive chemotherapy for reasons of old age or according to their expressed desire. RESULTS: The clinicopathologic factors which showed a clinically significant difference between the two groups were age and histology, which were not associated with patient survival. The CTX group was younger, and had a larger proportion of undifferentiated gastric cancers than the non-CTX group. The mode of treatment failure revealed no significant difference between the CTX and non-CTX groups. The 1, 3, and 5-year disease-free survival and the 1, 3, and 5-year disease-specific survival of the CTX group were 63.9%, 38.4%, and 32.0%, and 85.4%, 52.3%, and 39.6%, respectively, which were more favorable than the non-CTX group (p=0.015 and p=0.001, respectively). Postoperative adjuvant CTX was an independent risk factor for disease-specific survival of stage IV (T4N1-3M0 and T1-3N3M0) gastric cancer patients after curative gastrectomy by multivariate analysis (odds ratio=2.153; 95% confidence interval=1.349-3.435; p=0.001). CONCLUSIONS: Adjuvant CTX may be associated with survival benefit for younger patients with stage IV (T4N1-3M0 and T1-3N3M0) gastric cancer with undifferentiated histology after curative gastrectomy. A randomized controlled trial to reveal the effect of stage-specific adjuvant chemotherapy should be conducted.

Small cell carcinoma of pancrease

Small cell cancer commonly occurs in the lungs, but it is rarely found in other organs. Small cell cancer that occurs in the pancreas is rare and its progress very rapid, and most patoents' tumor has already spread by metastasis when it is discovered. Although this cancer has a poor prognosis, we report here on treating case with combined curative resection and chemotherapy and showed a good prognosis.

A Remote Educational System in Medicine Using Digital Video Transfer System / 대한소화기내시경학회지

BACKGROUND/AIMS: Telemedicine has opened the door to a wide range of learning experience to the doctors and students working and studying at various remote locations. However, there are limitations to this technology, such as the lack of any approved international standards of ethics. The aim of our study was to establish a telemedical education system using the Digital Video Transfer System (DVTS) on the high-speed network. METHODS: The Asia Pacific Information Infrastructure (APII) link was used to connect Korea with Japan, and the Korea Advanced Research Network (KOREN) was used to connect Busan with Seoul. Teleconferencing and video streaming between Hanyang University Hospital in Seoul and Kyushu University Hospital in Japan were realized using DVTS over the Ipv4 network. RESULTS: Four endoscopic surgeries and two endoscopic procedures were successfully transmitted between Seoul and Kyushu, while concomitant teleconferences were taking place between the two cities throughout the operations. An adequate bandwidth of 60 Mbps was kept for two-line transmissions. The quality of transmitted video image showed no frame loss with a rate of 30 images per second. The sound was also clear, and the time delay was less than 0.3 sec. CONCLUSIONS: We have established an international medical network with high-quality video transmission over Internet medium and this was easy to perform, reliable and economical.

Carcinoid Tumor of the Common Bile Duct and Gallbladder

Carcinoid tumors are derived from Kultschitzky cells, and often found in the appendix, ileum, rectum and bronchus, but those of the biliary tract are rare. Here, the case of a 59-year-old man, unexpectedly found to have a carcinoid tumor obstructing the common bile duct, is reported. A gallbladder carcinoid tumor was also found incidentally during a planned subtotal gastrectomy operation. The literature on carcinoid tumors of the extrahepatic bile duct and gall bladder is also reviewed.

In Vivo Differentiation of Mouse Embryonic Stem Cell into Hepatocytes

PURPOSE: Embryonic stem (ES) cells have been regarded as a powerful resource in cell replacement therapy. In recent reports, mouse ES cells have been successfully applied to the treatment of spinal cord injuries, hereditary myelin disorders of the central nervous system and diabetes mellitus. Various liver diseases are another group that could benefit from the availability of stem cell therapy; however, no previous demonstration has been made that shows the differentiation of ES cells into hepatocytes. METHODS: To investigate the in vivo differentiation potential of mouse ES cells, we injected ES cells into the splenic cortex of immuno-suppressed nude mice. RESULTS: In a histological analysis of the teratomas derived from injected ES cells some areas were shown, due to their morphology, to contain typical hepatocytes. The hepatic nature of these cells was further confirmed by immunohistochemical assays using the antibody against alpha-fetoprotein and hepatocyte-specific antibodies. In addition, periodic acid-Shiff staining revealed a small portion of hepatic area in the ES-derived teratoma produced glycogen, implying these cells are functional hepatocytes. CONCLUSION: Our case demonstrated for the first time that mouse ES cells can differentiate in vivo into a mixed population of hepatocytes with different maturation stati, which could potentially extend the usage of ES cells in cell replacement therapy for various liver diseases.

Biliary Cystadenoma and Cystadenocarcinoma of the Liver

PURPOSE: Cystic neoplasms in the liver are rarely seen tumors. Biliary cystadenoma and cystadenocarcinoma constitute less than 5% of intrahepatic cysts originating from the bile duct. The clinicopathologic and radiologic findings are important to arrive at the proper diagnosis and treatment of intrahepatic biliary cystadenoma and cystadenocarcinoma. The aims of this study were to characterize the clinical and pathologic aspects of these lesions, and also to discuss the treatment and prognosis of biliary cystadenoma and cystadenocarcinoma. METHODS: We reviewed the clinical records of six patients who had intrahepatic biliary cystadenoma and cystadenocarcinoma and who had undergone operations from January, 1986 to June, 2002 at Hanyang University Hospital. RESULTS: Primary biliary cystadenoma and cystadenocarcinoma of the intrahepatic biliary systems are rarely seen tumors. Biliary cystadenoma mainly affected women, and this was a different gender preponderance than was seen for biliary cystadenocarcinoma. We found no signs or symptoms that were specific for either of these tumors, and the diagnoses were usually made by abdominal CT and abdominal ultrasonography. These tumors were usually large, multilocular and cystic in appearance. The pathologic findings revealed multiple cystic masses lined with cuboidal to columnar epithelium. The nature of the cystic fluid was usually the mucous type. Of the 6 patients in whom the lesions were completely excised, 4 of the patients are alive. The other 2 patients died of old age and distant metastasis, respectively. CONCLUSION: Surgical resection of the tumor, including a margin of surrounding normal liver parenchyma, was the only curative method. If the tumor is confined in the liver, complete surgical excision yields an excellent prognosis. Complete resection of a biliary cystadenoma and radical resection of a biliary cystadenocarcinoma seem to offer these patients a chance for long-term survival.

Sarcomatoid Carcinoma of the Distal Common Bile Duct: A Case Report

Sarcomatoid carcinoma of the common bile duct (CBD) is an extremely rare malignant neoplasm, which is characterized by the presence of carcinomatous and sarcomatous components. We report a case of sarcomatoid carcinoma arising in the distal CBD. The patient was a 68- year-old woman who presented with abdominal pain. The computed tomography and endoscopic ultrasonography revealed a polypoid mass in the distal CBD. The resected specimen showed a polypoid mass with a narrow stalk in the distal CBD which was confined to the mucosa. The cut surface revealed a gray-whitish solid mass with focal hemorrhage and necrosis. Microscopically, the tumor was composed of carcinomatous and sarcomatous components without any heterologous elements. The sarcomatous area predominently consisted of pleomorphic spindle cells. The carcinomatous component was an adenocarcinoma. On immunohistochemistry, cytokeratin was coexpressed in the carcinomatous and sarcomatous components but vimentin was expressed exclusively in the sarcomatous component. The patient has been doing well for one year postoperatively.