Feasibility study of axillary reverse mapping for patients with clinically node-negative breast cancer.

BACKGROUND: The axillary reverse mapping (ARM) procedure was developed to identify and preserve arm lymphatic drainage during axillary lymph node dissection (ALND), thereby theoretically reducing the incidence of arm lymphedema. However, the oncological safety of this procedure has not yet been determined. METHODS: Two hundred ninety-two patients with clinically negative nodes (cN0) underwent both sentinel lymph node (SLN) biopsy and ARM. SLN was identified by dye and gamma probe methods, and ARM nodes were identified using a fluorescence imaging system. If SLN was histologically positive, ALND was performed with removal of ARM nodes. Otherwise, identified ARM nodes were preserved unless they coincided with SLN. Postoperatively, SLN as well as ARM nodes were histologically examined with H&E staining. RESULTS: SLN was identified in 286 of 292 patients, and ARM nodes were identified in 90 patients. In 54 patients with positive SLN, SLN was the same as the ARM node in 19 patients (the concordance type), whereas it was not an ARM node in the remaining 35 patients (the separate type). Non-SLN and ARM node was not involved in 51 of 54 patients with positive SLN, while it was involved in 3 patients of the concordance type. CONCLUSIONS: When ARM nodes were involved in patients with cN0, these were most often the SLN-ARM nodes. Therefore, it may be concluded that ARM nodes that do not coincide with SLNs might be preserved during ALND in SLN-positive patients.

Endocardial Invasion of Lung Cancer Undiagnosable before Autopsy.

A 59-year-old male patient presented with left chest discomfort on admission. His medical history included encephalitis in childhood and his smoking history was 20 cigarettes per day for 40 years. A physical examination showed an anemic and edematous face with weak respiratory sounds in the left lung. The patient had elevated calcium levels and decreased hemoglobin and potassium. His parathyroid hormone-related protein level was elevated. Thoracic radiography showed cardiomegaly and computed tomography revealed a left lung mass with invasion of the heart and pleural effusion. Magnetic resonance imaging showed endocardial invasion of the tumor mass. Gallium-68 imaging revealed positive accumulation in the region surrounding the heart. No diagnoses were possible upon frequent cytology of his sputum and pleural effusion. The patient died from congestive heart failure with anoxia 38 days after admission. An autopsy revealed tumoral mass occlusion in the left main bronchus and tumoral invasion of the left atrium, left ventricle, and aorta.

Spontaneous remission of epstein-barr virus-positive diffuse large B-cell lymphoma of the elderly.

A 94-year-old female patient presented with anorexia and left axillar lymphadenopathy on admission. Her past history was angina pectoris at 83 years of age and total gastrectomy due to gastric cancer at 87 years. The family history revealed that her son had had a malignant lymphoma, the histopathological diagnosis of which was diffuse large B-cell lymphoma. A physical examination showed both cervical, axillar, and inguinal lymphadenopathy without tenderness. She had elevated lactate dehydrogenase, ferritin, and soluble interleukin-2 receptor (sIL-2R). Whole-body computed tomography confirmed the cervical, axillary, and inguinal lymphadenopathy. Gallium-68 imaging revealed positive accumulation in these superficial lymph nodes. A right inguinal lymph node biopsy showed features of Epstein-Barr virus-associated lymphoproliferative disorder. Immunohistological studies on this lymph node biopsy showed CD20-positive large cells, CD3-positive small cells, and CD30-partly-positive large cells. In situ hybridization showed Epstein-Barr virus-positive, LMP-partly-positive, and EBNA2-negative cells. She refused chemotherapy as her son had died from hematemesis during chemotherapy. She received intravenous hyperalimentation for 1 month after admission. No palpable lymph nodes were identified by physical examination or computed tomography 3 months after admission, and regression of lactate dehydrogenase, ferritin, and sIL-2R was observed. She recovered from anorexia and was discharged. She died from pneumonia 10 months later after initial symptoms of anorexia. The autopsy showed no superficial lymphadenopathy.

[Intractable pneumothorax secondary to pulmonary metastasis of angiosarcoma].

A 68-year-old male suffered from right pneumothorax and was admitted to our hospital. He had a previous history of angiosarcoma of the scalp, and had received local resection and chemoradiotherapy. Chest computed tomography (CT) on admission revealed right pneumothorax and bilateral multiple thin-walled cavities of the lung. We performed partial resection of right lung. Histopathological examination showed a small metastatic lesion around the thin-walled cavities of the lung. Four months after the 1st lung resection, he suffered left pneumothorax. We performed partial resection of the left lung. Ten days after the 2nd lung resection, left pneumothorax recurred. Nine days later, he also developed right pneumothorax. We performed the 3rd operation for right lung. Thoracoscopy demonstrated multiple bullas in right lung and it showed impossibility for radical surgery. Although surgical resection for pneumothorax secondary to metastatic lung cancer is usually efficient, it is very hard to manage the pneumothorax of metastatic angiosarcoma.

Predicting recurrence following curative surgery in stage I non-small cell lung cancer patients using an angiogenesis-associated factor.

There are still difficulties in determining the risk of recurrence to decide whether to perform selective adjuvant treatment for stage I non-small cell lung cancer. This study reviewed 122 stage I patients who underwent curative surgery to assess the usefulness of an angiogenesis-associated factor as a predictor of recurrence. By immunohistochemical examination, we collected information about tumor-induced vascular endothelial growth factor (VEGF)-A and -C expression at the primary site. During the median follow-up period of 120 months, the overall 10-year survival rate was 53.5%. The 10-year survival rates according to VEGF-A/C expression were as follows: VEGF-A high/VEGF-C high group, 26.0%; VEGF-A high/VEGF-C low group, 42.7%; VEGF-A low/VEGF-C high group, 73.1%; VEGF-A low/VEGF-C low group, 65.1%. The VEGF-A high/VEGF-C high group showed the worst outcome. The diagnostic values of the marker combination for predicting recurrence were as follows: sensitivity, 71.4%; specificity, 63.8%; and accuracy, 65.6%. When stratified by T factor, preferable high values for both negative predictive value and specificity were obtained in patients with stage IA disease. In order to select the patients eligible for selective adjuvant therapy at early stages, especially in stage IA disease, simultaneous assessment of tumor-induced VEGF-A/C warrants further study.

A subgroup of intrahepatic cholangiocarcinoma with an infiltrating replacement growth pattern and a resemblance to reactive proliferating bile ductules: 'bile ductular carcinoma'.

AIMS: The histogenesis and biological behaviour of peripheral intrahepatic cholangiocarcinoma (peripheral CC) remain unclarified. The aim of this study was to examine the growth pattern of peripheral CC (24 cases) in comparison with hepatocellular carcinoma (HCC, 27 cases) and metastatic colorectal adenocarcinoma (MCA, 24 cases). METHODS AND RESULTS: Tumour/surrounding liver borders were classified as: (i) fibrous encapsulation, (ii) compressive growth, and (iii) infiltrating replacement. Nineteen of 24 peripheral CCs showed (iii), whereas 23 of 27 HCCs showed (i) and 17 of 24 MCAs showed (ii). In (iii), carcinoma cells infiltrated the surrounding liver without compression, and hepatic supporting vascular structures such as portal tracts were secondarily incorporated into the tumour. In (i) and (ii), the surrounding liver was compressed and no or few portal tracts were incorporated within the tumour. Fifteen of 24 peripheral CCs were composed of carcinoma cells resembling reactive bile ductules and these cells were positive for neural cell adhesion molecule (NCAM), a marker of proliferating bile ductules. The remaining nine peripheral CCs were composed of ordinary adenocarcinoma and negative for NCAM. CONCLUSIONS: A subgroup of peripheral CCs with an infiltrating replacement growth pattern resembles reactive bile ductules and expresses NCAM. 'Bile ductular carcinoma' may be a better term for this subgroup.

Influence of avilamycin administration and its subsequent withdrawal on emergence and disappearance of antimicrobial resistance in enterococci in the intestine of broiler chickens.

AIMS: To investigate the influence of avilamycin (AVM) administration and its subsequent withdrawal on the emergence and disappearance of AVM-resistant enterococci in the intestine of broiler chickens. METHODS AND RESULTS: Five chicks each of C, L and H groups were given the basal diet, the basal diet supplemented with 5 g AVM/ton and the basal diet supplemented with 50 g AVM/ton, respectively. The AVM-resistant Enterococcus faecalis population did not emerge during 30 days of the AVM administration period, whereas the AVM-resistant Enterococcus faecium with a minimum inhibitory concentration of >512 microg ml(-1) in the faeces of chicks of the L and H groups emerged on 3 and 1 days after the AVM administration, respectively. Thereafter, the AVM-resistant Ent. faecium population density in both L and H groups maintained high levels during the AVM administration period. Twenty days after the AVM withdrawal, the AVM-resistant Ent. faecium population disappeared from the intestines of both four of five chicks of L group and three of five chicks of H group. The AVM-resistant Ent. faecium population density in one chick from each of the groups, L and H, did not change before and after the AVM removal. CONCLUSIONS: The AVM-resistant Ent. faecium emerged during the AVM administration, and disappeared from the intestine of most chicks after the AVM withdrawal. However, the AVM-resistant Ent. faecium persisted in some chicks 20 days after AVM withdrawal. SIGNIFICANCE AND IMPACT OF THE STUDY: Our results suggest that introducing an AVM withdrawal period could minimize the risk of AVM-resistant Ent. faecium becoming carcass contaminants, and that prudent antibiotic use alone is not sufficient to stem emergence of the AVM-resistant Ent. faecium.

[Surgical results of non-small cell lung cancer invading parietal pleura and chest wall].

This retrospective analysis was undertaken to review our results of treatment of lung cancers with invasion of non-apical and non-vertebral chest wall structures. In summary of our experience, although relatively good prognosis can be expected in N0M0 patients with the histological type of adenocarcinoma by initial operation, distant relapse remains a major problem of the disease. Furthermore, our results are in agreement with the idea that postoperative adjuvant therapy is of little value in patients with complete resection. To ameliorate surgical outcomes, induction treatment should be considered and preoperative staging assessment needs to be strictly done for proper selection of patients with this locally advanced disease. The indication of initial operation needs to be cautiously determined for patients with this disease.

Solid serous cystadenoma of the pancreas: MR imaging with pathologic correlation.

We report a case of solid type serous cystadenoma of the pancreas. Computed tomographic and magnetic resonance (MR) images showed a hypervascular solid tumor that was difficult to differentiate from endocrine tumor of the pancreas. However, the tumor showed marked hyperintensity similar to that of hepatic cyst on MR cholangiopancreatography, indicating not a solid but rather a cystic nature. MR cholangiopancreatography (heavily T2-weighted image) is quite useful for clearly differentiating solid from cystic tumors.

The results of therapy for bilateral multiple primary lung cancers: 30 years experience in a single centre.

AIMS: This study reviews our 30 years experience in the clinical assessment and surgical management of bilateral multiple primary lung cancer (BMPLC). METHODS: Between January 1973 and December 2001, 1906 patients with primary lung cancer underwent surgical resection in Kanazawa University Hospital. Thirty-seven patients (1.9%) who had developed a BMPLC using the criteria of Martini and Antakli. RESULTS: Eighteen patients had synchronous lesions, and 18 patients had metachronous lesions. One patient had synchronous and metachronous lesions. Overall 10-year survival was 56%. The actuarial 5-year survival for bilateral synchronous cancers was 69%, median survival (MST) 90 months (range 8-153 months), and 10-year survival was 47%. The actuarial 5-year survival for second metachronous cancers was 51%, with an MST of 114 months (range 6-192 months). CONCLUSION: Aggressive surgical therapy is effective in patients with a bilateral MPLC if they satisfy the usual criteria of operability. The surgical methods that preserve healthy lung tissue such as sleeve resection and limited resection must be selected in compliance with cancer characters.

Polymorphous low-grade adenocarcinoma of the major salivary glands: report of three cases in an unusual location.

AIMS: Polymorphous low-grade adenocarcinoma (PLGA) is the second most common type of malignant neoplasm in minor salivary glands. Its origin in major salivary glands is considered exceedingly rare. Herein, we present three cases of de novo PLGA arising in major salivary glands. METHODS AND RESULTS: Three cases of PLGA were identified in a large series of primary tumours of major salivary glands. We investigated their clinicopathological profiles, including immunohistochemical features. The three patients (two men and one woman) were 51, 65, and 79 years old. The tumours were 20-30 mm large; two were in the parotid gland and one in the submandibular gland. Histologically, all the tumours had a polymorphous architectural pattern showing predominantly solid, tubular, and cribriform features and invasive growth. Papillary areas were observed focally in two tumours and an 'Indian-file' array in one. The tumour cells had a bland cytological appearance and low mitotic count. Two tumours showed perineural invasion. No preexisting pleomorphic adenoma component was identified. In all cases, tumour cells were positive for epithelial markers, S100 protein, and vimentin but negative for alpha-smooth muscle actin, muscle-specific actin, and glial fibrillary acidic protein. Proliferative activities assessed with the Ki67 labelling index were 4.3%, 7.1%, and 7.6%; no p53 overexpression was observed. Two patients had local recurrence, but none had metastasis or died of tumour. CONCLUSIONS: PLGAs arising in major salivary glands and those in minor salivary glands have similar clinicopathological and immunohistochemical characteristics. It is important to recognize that PLGA can occur ab initio in the major salivary glands, although it is extremely rare.

A comparative histological and morphometric study of vascular changes in idiopathic portal hypertension and alcoholic fibrosis/cirrhosis.

AIM: To examine the pathological changes of hepatic arteries in idiopathic portal hypertension (IPH) which is characterized by the obliteration of the intrahepatic portal vein branches and presinusoidal portal hypertension. METHODS AND RESULTS: Liver specimens (biopsied or surgically resected) from 20 patients with IPH, 20 patients with alcoholic fibrosis/cirrhosis (AF/C) and 20 histologically normal livers were used. The vascular lumina of arterial and venous vessels in portal tracts were morphometrically evaluated by an image analysis system. The ratio of portal venous luminal area to portal tract area (portal venous index) of IPH and that of AF/C were significantly reduced compared with normal liver. The portal venous index for IPH was significantly lower than that for AF/C. The ratio of hepatic arterial luminal area to portal tract area for AF/C was significantly higher than that in normal liver; however, that for IPH was similar to normal. The peribiliary vascular plexus was increased in AF/C but not in IPH. In AF/C, the number of mast cells and macrophages known to be the source of angiogenic substances was significantly increased in the portal tract compared with normal liver, while in IPH it was not increased. CONCLUSIONS: In AF/C, a reduction in portal venous lumen was associated with an increase of hepatic arterial lumen and of angiogenesis-related cells in portal tracts. However, such compensatory arterial changes were not evident in IPH, and this compensatory failure may be a feature of IPH.

Endosonographic evaluation of c-kit-positive gastrointestinal stromal tumor.

BACKGROUND: Endosonographic features of c-kit-positive gastrointestinal stromal tumors (GISTs) were compared with those of leiomyomas and schwannomas. METHODS: Twenty-four patients with gastric mesenchymal tumors who underwent endoscopic ultrasonography (EUS) and surgical treatment were enrolled. GISTs were defined as c-kit (CD117)-positive tumors, leiomyomas as desmin-positive and c-kit-negative tumors, and schwannomas as S-100-positive and c-kit-negative tumors. Invasion to adjacent organs or more than 20 mitotic counts per 50 high power fields indicated malignancy. RESULTS: There were 19 GISTs, three leiomyomas, and two schwannomas. All five malignant tumors were GISTs. A marginal halo was found in 12 of 19 GISTs and in both of the schwannomas, but not in any of the three leiomyomas. The echogenicities of GISTs were low but higher than that of the normal proper muscle layer, whereas those of leiomyomas and schwannomas were usually low. Lobulation of the tumor surface was documented only in GISTs, particularly in malignant ones. The tumor doubling time of a malignant GIST was 9.3 months, and that of six benign GISTs was 18.7 months (range = 10.7-28.0 months). CONCLUSION: Marginal halo and relatively higher echogenicity on EUS might suggest GIST. Marginal lobulation and a short doubling time may be signs of a malignant GIST.

Cystic duct remnant carcinoma with widespread invasion along the extrahepatic bile duct wall: dynamic CT findings.

We report a case of remnant cystic duct carcinoma with widespread invasion along the common bile duct wall. Thin-slice dynamic computed tomography showed circumferential wall thickening of the extrahepatic bile duct (from the common hepatic duct to the intrapancreatic common bile duct) and the remnant cystic duct. Pathologically, the extrahepatic bile duct wall was thickened due to submucosal tumor infiltration by cystic duct papillary adenocarcinoma.

[Treatment for bilateral multiple lung cancers].

During a 27-year period 1,839 patients with lung cancer were treated at Kanazawa University Hospital. Of these 1,839 patients, 25 (1.3%) were classified as bilateral multiple lung cancers by Martini's criteria. They consisted of 14 synchronous carcinomas and 11 metachronous carcinomas. For the patients with synchronous carcinomas, 5 underwent bilateral operation, and 5 underwent ipsilateral operation and contralateral combination therapy (Nd:YAG, irradiation or chemotherapy). Four did not undergo operation. While for the patients with metachronous carcinomas, 9 underwent operation for bilateral lesions, 2 were treated by radiotherapy for the second primary lung cancer. When a pulmonary resection for bilateral multiple lung cancers is required, radicality and the need to preserve residual respiratory function and cardiac function (FEV1.0 more than 500 ml/DSA, performance status) must be considered in making the decision to operation. The 5-year survival rate was 67%, 41%, and 33% in cases treated by operation for bilateral lesions, ipsilateral operation and contralateral combination therapy, and non-surgical therapy. Multidisciplinary treatment based on surgical resection contributed to good prognosis of bilateral multiple lung cancers. A long-term detailed follow-up is necessary to detect second lung carcinoma after the first operation as soon as possible.

Nodal occult metastasis in patients with peripheral lung adenocarcinoma of 2.0 cm or less in diameter.

BACKGROUND: Detection of occult micrometastasis in regional lymph nodes is crucial for diagnosis and selection of appropriate therapy for patients with pN0 non-small-cell lung carcinoma. Using immunohistochemical staining, we evaluated the impact of detection of occult micrometastasis on the prevalence and prognosis of patients with lung adenocarcinoma of 2.0 cm or less in diameter. METHODS: A total of 103 pN0 disease patients with peripheral lung adenocarcinomas of 2.0 cm or less in diameter were enrolled in this study. We studied 1,438 regional lymph nodes for occult micrometastasis by immunohistochemical staining for cytokeratins. RESULTS: Micrometastasis was detected in 49 lymph nodes (3.4%) of 21 patients (20.4%) but not in patients with localized bronchioloalveolar carcinoma or localized bronchioloalveolar carcinoma with foci of collapse of alveolar structure. The 5-year survival rate (61.9%) of patients with micrometastasis was significantly (p = 0.0041) lower than that of patients without micrometastasis (86.3%). CONCLUSIONS: There still remains a risk of nodal micrometastasis in patients with primary peripheral lung adenocarcinoma, even if the diameter of the tumor is smaller than 2.0 cm. Selection of patients for limited surgery should be done prudently, taking into consideration the risk of nodal micrometastasis.