Clinicopathologic and Endosonographic Characteristics of Colon Subepithelial Tumors Discovered Incidentally.

BACKGROUND/AIMS: Colonoscopy is commonly used for colorectal cancer screening; therefore, the detection of colon subepithelial tumors (SETs) has also increased. Several research studies have been undertaken to diagnose and treat stomach and rectal SETs. The purpose of this study was to determine a diagnostic point for colon SETs by comparing histological findings with the endoscopic characteristics of colon SETs discovered by chance. METHODS: A total 194 patients underwent an endoscopic ultrasound (EUS) for suspicious colon SETs during a colonoscopy from May 2014 to December 2021. A total of 105 colon SETs, which were histologically diagnosed, were finally included. Fisher's exact test was used to determine the factors associated with malignant SETs. RESULTS: Colon SETs were predominantly present in the right colon (n = 73, 69.5%), particularly in the transverse colon (n = 32, 30.5%). The majority were smaller than 10 mm (n = 88, 83.8%), and they had hard consistencies (n = 84, 80%) and exhibited no surface changes (n = 96, 91.4%). Most of them were found in the submucosal layers (n = 54, 51.4%) and had a hypoechoic pattern (n = 56, 53.3%) in the EUS. Of the histologically confirmed cases, only three (3/105, 2.9%) were malignant. Most benign lesions were lipomas, suspected parasitic infections, or lesions caused by various inflammatory reactions, including fibrous/fibrocalcific lesions and necrotic nodules. All soft lesions were benign. Two of the three malignant lesions were adenocarcinomas, and the other was lymphoma. For the malignant SETs, there was a statistically significant alteration in the surface of the tumors (p < 0.001), and they were located where the muscularis mucosa layer was included (p = 0.008). The potential malignant SETs, granular cell tumors, and neuroendocrine tumors (NETs) had similar features, such as yellowish hypoechoic masses. Colon NETs were only found in the rectosigmoid junction. Parasitic infections and lesions, resulting in various inflammatory reactions, were observed as pale and hard SETs and mostly revealed as mixed echogenic masses located in the muscularis mucosa, submucosa, or multi-layers in the EUS. CONCLUSION: This study showed that small colon SETs were mostly benign lesions. Despite its rarity, pathological confirmation is crucial in cases where the SET has surface changes and has been located in a position where the muscularis mucosa layer was included on the EUS, due to the risk of malignancy.

Decreased Elastic Modulus of Knee Articular Cartilage Based on New Macroscopic Methods Accurately Represents Early Histological Findings of Degeneration.

OBJECTIVE: Ex vivo nanoindentation measurement has reported that elastic modulus decreases as cartilage degenerates, but no method has been established to macroscopically evaluate mechanical properties in vivo. The objective of this study was to evaluate the elastic modulus of knee joint cartilage based on macroscopic methods and to compare it with gross and histological findings of degeneration. DESIGN: Osteochondral sections were taken from 50 knees with osteoarthritis (average age, 75 years) undergoing total knee arthroplasty. The elastic modulus of the cartilage was measured with a specialized elasticity tester. Gross findings were recorded as International Cartilage Repair Society (ICRS) grade. Histological findings were graded as Mankin score and microscopic cartilage thickness measurement. RESULTS: In ICRS grades 0 to 2 knees with normal to moderate cartilage abnormalities, the elastic modulus of cartilage decreased significantly as cartilage degeneration progressed. The elastic modulus of cartilage was 12.2 ± 3.8 N/mm for ICRS grade 0, 6.3 ± 2.6 N/mm for ICRS grade 1, and 3.8 ± 2.4 N/mm for ICRS grade 2. Similarly, elastic modulus was correlated with Mankin score (r = -0.51, P < 0.001). Multiple regression analyses showed that increased Mankin score is the most relevant factor associated with decreased elastic modulus of the cartilage (t-value, -4.53; P < 0.001), followed by increased histological thickness of the cartilage (t-value, -3.15; P = 0.002). CONCLUSIONS: Mechanical properties of damaged knee cartilage assessed with new macroscopic methods are strongly correlated with histological findings. The method has potential to become a nondestructive diagnostic modality for early cartilage damage in the clinical setting.

Acinar cystic transformation of the pancreas-a rare case in a young patient.

Acinar cystic transformation (ACT) is a very rare transformation of the pancreas and has been described in less than 100 cases since its first report in 2002. The aim of this case report is to get a better understanding of this pancreatic transformation, which to date appears to be non-malignant. However, radical surgery was performed in most cases due to misinterpreting the initial diagnosis. ACT may be misdiagnosed for intraductal papillary mucinous neoplasms and is currently not included as a potential differential diagnosis for cystic lesions of the pancreas. ACT belongs to the benign cystic alterations of the pancreas. Despite its rarity, it should be considered as a potential differential diagnosis with regard to cystic lesions in the pancreas, especially in order to avoid unnecessary surgery.

Syphilis, the Great Imitator-Clinical and Dermoscopic Features of a Rare Presentation of Secondary Syphilis.

Syphilis is characterized by a wide range of variable clinical symptoms; therefore, it is often referred to as "The Great Imitator". Here, we report the case of a 69-year-old hepatitis-C-positive MSM patient, who was admitted to our clinic due to a solitary firm painless erythematous maculopapular lesion with a central crater-like crust on the upper right thigh that occurred two months prior. The dermoscopy showed an erythematous, copper-colored, oval lesion with diffuse monomorphic dotted and glomerular vessels, central crust, and circular scaling (Biett's sign). The histological findings ruled out neoplasia and described a plasma cell infiltrate and endothelial swelling. Finally, the combination of the dermoscopic image, histological findings and the additionally acquired knowledge about the sexual history of the patient at the second visit led to the diagnosis, which was then confirmed with serological tests. Dermoscopy may become a supportive tool to facilitate the recognition of secondary syphilis; however, the reporting of these atypical cases is crucial to highlight the many faces of the disease so that clinicians consider syphilis as part of the differential diagnosis of non-specific lesions.

Retrorectal epidermoid mistaken for perirectal swelling: A case report.

INTRODUCTION AND IMPORTANCE: Epidermoid cysts are developmental cysts of the retrorectal space. They are benign lesions resulting from ectodermal inclusion during neural tube closure. Generally, they are misdiagnosed given that symptoms are often vague and nonspecific. They have a high infection rate (up to 30%) and can be easily mistaken for perirectal abscesses. CASE PRESENTATION: We present a case of an epidermoid cyst in a 58-year-old woman with a retrorectal cyst mistaken for a perianal abscess, which was initially incised and drained and then, after MRI investigation, an anterior resection was performed. CLINICAL DISCUSSION: Epidermoid cysts have a high infection rate (up to 30%). Infected cysts can be easily mistaken for perirectal abscesses, pilonidal disease, or fistulae in ano. CT (computed tomography) used in conjunction with MRI (Magnetic Resonance Imaging) is the gold standard for establishing the diagnosis. A biopsy is never indicated. Surgery is the best treatment, even for asymptomatic lesions. CONCLUSION: Epidermoid cysts are rare and generally misdiagnosed. In fact, symptoms are often vague and nonspecific. Radiologic imaging (especially MRI) is essential for surgical planning and biopsy should be avoided. Once a presacral lesion is diagnosed, even if the patient is asymptomatic, complete resection remains the treatment of choice because of the risk of infection.

First Report of a Low-Grade Pseudomyxoma peritonei Originating from Gall Bladder.

Pseudomyxoma peritonei (PMP) refers to accumulation of mucinous ascites with or without neoplastic cells in the peritoneal cavity. It most commonly originates from a low or a high grade primary appendiceal mucinous neoplasm. Though adenocarcinoma of gall bladder has been reported to give rise to PMP, to the best of our knowledge, this is the first report of a PMP arising from a low grade mucinous tumour of the gall bladder. A 72-year-old patient was diagnosed with PMP 1.5 years after a cholecystectomy. After initial oral TS1 (combination of tegafur, gimeracil and oteracil) and later intraperitoneal (IP) chemotherapy with docetaxel and cisplatin, the patient was operated with the goal of tumour debulking, including removal of 5.5 L of mucinous ascites, an appendectomy, and ovariectomy. The histopathologic report showed a normal appendix and metastasis of PMP to the right ovary. After the exclusion of the 2 most common sites of origin (appendix and ovary), the specimen of the cholecystectomy was reviewed. It showed low grade mucinous tumour in the gall bladder, with immuno-histochemical markers (IHCs) suggestive of CK7, CDX2, MUC 2 positive and CK20, MUC5AC negative. MIB-1 index was 12%. The pathologic report of cytoreductive surgery performed after 7 cycles of IP chemotherapy confirmed the diagnosis of PMP originating from low grade mucinous tumour of the gall bladder. Our case report illustrates a rare disease and highlights that, though peritoneal metastasis from gall bladder cancers are known to have a poor prognosis, the peritoneal dissemination from a low grade mucinous neoplasm of gall bladder (PMP) has a significantly better prognosis due to a better disease biology and improved treatment options currently available for the treatment of PMP.

Moyamoya disease with refractory hypertension associated with peripheral arterial stenosis in the renal parenchyma.

Moyamoya disease (MMD) has long been known to be associated with hypertension. While renal artery stenosis (RAS) is considered one of the causes of hypertension with MMD, most hypertension causes remain unexplained. A boy with MMD was diagnosed with renovascular hypertension (RVH) due to left-sided RAS by angiography. Although nephrectomy on the affected side for unilateral RVH was performed, hypertension poorly improved. Histopathological examination of the resected specimens revealed that the vascular lumen not only of the renal artery but also of peripheral vessels in the renal parenchyma was narrowed. He developed end-stage renal disease caused by multiple wasp stings and received a kidney transplant from a living donor with his remaining right kidney resected. His hypertension improved dramatically just after the operation. In histopathological findings, the narrowed vascular lumen was also observed in the resected right renal parenchyma similar to that in the left kidney. In our case, these pathological findings were the same as those of major vessels previously reported in MMD patients. Immunohistochemical staining with anti-renin antibody on bilateral intrinsic kidneys was strongly revealed in the Juxtaglomerular apparatus. He has been normotensive with the minimum amount of amlodipine since transplantation and resection of his intrinsic right kidney. This is the first report to show the possibility that peripheral arterial stenosis in the renal parenchyma due to MMD would result in refractory hypertension. If MMD patients have hypertension of unknown origin without significant RAS, it should be considered that the etiology may be peripheral arterial stenosis in the renal parenchyma.

Colonic Histological Criteria Predict Development of Pouchitis after Ileal Pouch: Anal Anastomosis for Patients with Ulcerative Colitis.

BACKGROUND/AIMS: Pouchitis is one of the main complications after ileal pouch-anal anastomosis in patients with ulcerative colitis. The aim of this study was to determine whether the use of colonic histological criteria can predict the development of pouchitis. METHODOLOGY: We retrospectively reviewed 147 patients' clinical data and performed a histological evaluation of the resected total colon using Tanaka's criteria, which comprise the following 6 factors: ulceration (H1), crypt abscesses (H2), degree of mononuclear cell infiltration (MNCI) (H3), segmental distribution of MNCI (H4), eosinophil infiltration (H5), and extent of disease of resected colon (H6). RESULTS: The development of pouchitis and chronic pouchitis within 3 years after restoration of gastrointestinal continuity was recognized in 52 (35.4%) and 26 (17.7%) of the 147 patients, respectively. Using various combinations of each score, the H3 + H4 - H5 scores of patients with pouchitis or chronic pouchitis were significantly higher than those of patients without. A H3 + H4 - H5 score of >0.4 was a statistically significant risk factor for the development of both pouchitis and chronic pouchitis. CONCLUSIONS: The combination of the degree of MNCI, segmental distribution of MNCI, and eosinophil infiltration from histological criteria has utility in predicting the future development of pouchitis, especially chronic pouchitis.

Histology of the Ligament Flavumin Degenerative Lumbar Disease / 대한정형외과학회잡지

PURPOSE: To determine the association between the histological findings of ligamentum flavum (LF) and the clinical symptoms or radiological findings of patients with degenerative lumbar disease. MATERIALS AND METHODS: Twenty-six patients with mono-segmental degenerative lumbar diseases (15 patients with spinal stenosis and 11 patients with degenerative spondylolisthesis) underwent a surgical decompression with en bloc resection of the LF. Tissue specimens of the LF were prepared, and the changes in the elastic and collagen fibers were evaluated. The focal lesions were observed in the LF. The following clinical and radiological parameters were investigated in order to determine the possible association with the histological findings: age, gender, preoperative Japanese Orthopaedic Association (JOA) score, the type of neurogenic intermittent claudication, % slip, height of the intervertebral disc, intervertebral angle, intervertebral angle of motion. RESULTS: There were no significant relationships between the changes in the elastic or collagen fibers and the JOA score. In regard to the focal lesions in the LF, vascularization was observed in 15 cases, calcification in 10, chondrocyte in 9, ossification in 8, ganglion-like cystic lesions in 5 and granulation in 4. The average age of the patients with and without calcification were 70.3 and 63.8 years, respectively. The average preoperative JOA scores of the patients with and without calcification were 13.5 and 15.6 points, respectively. Ossification was more commonly observed in those with degenerative spondylolisthesis (7 cases) than in those with spinal stenosis (1 case). CONCLUSION: Various focal lesions in the LF were observed. Calcification was observed more frequently in elderly patients, and the average preoperative JOA scores of the patients with calcification were lower. Ossification was observed more frequently in patients with degenerative spondylolisthesis (7 cases) than in those with spinal stenosis (1 case), suggesting involvement of a mechanical load in the ossification of ligaments.

A Histopathological Study on the Rheumatoid Arthritis of the Knee Joint / 대한정형외과학회잡지

Twenty cases of the rheumatoid arthritis was carried out the histopathological observation from the affected synovial membrane at the knee joint by the Cops biopsy needle, at the Department of Orthopedic Surgery, Chosun University Hospital. The authors researched the difference to compare with the histological finding and its clinical features. The following results were obtained. 1. The average age was 36.9 years old and the sex ratio between the male and female was 1:2.7. 2. The erythrocyte sedimentation rate and protein amont in the synovial fluid was elevated than the normal value. 3. The most common clinical sign was the morning stiffness with multiple joint pain and moderate swelling, tenderess in the involved joint. 4. The test of rheumatoid factors revealed positive about 70% in the serum and 100% in the joint fluid. 5. The characteristic histological finding on the light microscopical examination was the hyperplasia of surface lining cells, deposition of the fibrin with the fibrinoid necrosis, and vascular hypertrophic changes of the blood vessel in all of those cases. 6. The histological finding had no difference to compare with the clinical course.