Miliary tuberculosis-associated hemophagocytic lymphohistiocytosis with a high level of soluble interleukin-2 receptor successfully treated with concomitant recombinant thrombomodulin: A case report.

Hemophagocytic lymphohistiocytosis (HLH) is a fatal disease characterized by a highly inflammatory state due to the abnormal activation of T lymphocytes and macrophages. Miliary tuberculosis (MTB) is a rare cause of HLH and its clinical appearances occasionally resembles that of intravascular lymphoma (IVL). A 76-year-old woman presented with persistent fever and fatigue. Abnormal laboratory findings showing thrombocytopenia (13,000/µL), hypofibrinogenemia (101 mg/dL), hyperferritinemia (2,312 ng/mL), and markedly elevated soluble interleukin-2 receptor (sIL-2R) level (32,200 U/mL), in addition, hemophagocytosis in the bone marrow (BM) smear, were suggestive of IVL-associated HLH. The pathology of the BM biopsy specimen showed granuloma with non-caseous necrosis, and culture tests using sputum, gastric fluid, urine, and peripheral and bone marrow blood revealed the presence of Mycobacterium tuberculosis, leading to the final diagnosis of MTB-associated HLH. Anti-TB medications and corticosteroids were administered, but thrombocytopenia, hypofibrinogenemia, and hyperferritinemia persisted. Concomitant use of recombinant thrombomodulin (rTM) enabled regression of clinical status. In this case, BM biopsy served as the diagnosis of MTB-associated HLH, although IVL-associated HLH is initially suspected by an extremely high level of sIL-2R. Furthermore, this case report informs that using rTM could improve the outcomes of MTB-associated HLH.

A case of cerebral paragonimiasis misdiagnosed as eosinophilic granulomatosis with polyangiitis.

Paragonimiasis is a parasitic disease caused by Paragonimus westermani infection, and migration to the brain results in cerebral paragonimiasis. Cerebral paragonimiasis is now extremely rare, but a few cases are still reported. A 48-year-old Japanese woman presented with right-hand convulsion, right-hand numbness, sputum, and fatigue. Chest computed tomography demonstrated multiple nodular lesions, and head computed tomography revealed a hemorrhagic lesion in the left motor cortex. Magnetic resonance imaging revealed multiple small ring-shaped lesions with surrounding edema. Laboratory evaluation demonstrated peripheral eosinophilia. We considered eosinophilic granulomatosis with polyangiitis and started steroid treatment as a diagnostic therapy since we wanted to avoid cerebral lesion biopsy if possible. However, the patient underwent craniotomy surgery after steroid treatment for four months because a new intracerebral mass lesion had appeared. Trematode eggs were detected in the sample, and the final diagnosis was cerebral paragonimiasis. The patient was successfully treated with praziquantel. Cerebral paragonimiasis is extremely rare but should be considered in the differential diagnosis if atypical intracranial hemorrhage and peripheral eosinophilia are observed.

Breast cancer hormone receptor negativity, triple-negative type, mastectomy and not receiving adjuvant radiotherapy were associated with axillary recurrence after sentinel lymph node biopsy.

BACKGROUND: Axillary lymph node dissection (ALND) can be avoided in selected patients with positive sentinel lymph nodes (SLNs). However, regional lymph node recurrence may occur after SLN biopsy (SLNB). This study aimed to identify the risk factors for axillary recurrence to ensure safe axillary surgery. METHODS: Between June 2004 and December 2017, a total of 1056 women underwent SLNB without ALND. Patient data were prospectively entered into the breast cancer database at Kawaguchi Municipal Medical Center. From October 2012, we did not perform ALND in patients with (a) 1 or 2 positive SLNs, (b) positive SLNs that were unmatted or did not show gross extra nodal extension, (c) a clinical tumor size ≤5 cm, and in (d) those who received adjuvant endocrine therapy or chemotherapy and radiotherapy. Subsequently, appropriate adjuvant systemic and/or radiation treatment was administered. RESULTS: Of the 1056 patients included, 996 had negative SLNs, 49 had positive SLNs, and 11 had undetectable SLNs. The identification rate for SLNs was 99.0%, and the median number of removed SLNs was 2. During the median 6.9-year follow-up period, 10 patients (1.0%) showed axillary recurrence without SLNs metastasis. Hormone receptor negativity (p < 0.01), triple-negative type (0.047), mastectomy (<0.01) and not receiving adjuvant radiotherapy (<0.01) were significantly related to axillary recurrence. CONCLUSION: ALND can be safely avoided in selected patients with early breast cancer. Patients with hormone receptor-negative tumors, especially triple-negative breast cancer, patients who underwent mastectomy without ALND or those who did not receive adjuvant radiotherapy should be followed up carefully.

Differentiating vacuum-assisted breast biopsy from core needle biopsy: Is it necessary?

Needle biopsy has replaced excisional biopsy as a definitive diagnostic technique for breast tumours, although excisional biopsy is still used for complete tumour removal for therapeutic and/or diagnostic purposes. Many vacuum-assisted breast biopsy (VAB) systems have been made available by several manufacturers since the release of the Mammotome (MMT) by Johnson & Johnson in 1995. Several recent discussions have been conducted to identify whether core needle biopsy (CNB) or VAB, is more appropriate. However, currently available VAB systems differ from the conventional system (i.e. articulate arm type 11-gauge(G) MMT), and the characteristics of both CNB and VAB have been improved. In CNB, a 14-G needle is frequently used to obtain a larger sample. By contrast, VAB is considered easier to perform because it uses a thinner needle and a lighter, non-tethered system. When differentiating CNB from VAB, the type of VAB should also be defined. In this review, we discuss the characteristics of ultrasonography-guided VAB and CNB with a focus on practical issues such as the number of samples and volume of tissue obtained during ultrasonography-guided needle biopsy.

Expression of von Hippel-Lindau tumor suppressor protein (pVHL) characteristic of tongue cancer and proliferative lesions in tongue epithelium.

BACKGROUND: Patients with tongue cancer frequently show loss of heterozygosity (LOH) of the von Hippel-Lindau (VHL) tumor suppressor gene. However, expression of VHL protein (pVHL) in tongue cancer has rarely been investigated and remains largely unknown. We performed immunohistochemical staining of pVHL in tongue tissues and dysplasia, and examined the association with LOH and its clinical significance. METHODS: Immunohistochemical staining of pVHL in formalin-fixed, paraffin-embedded sections of cancerous and other tissues from 19 tongue cancer patients showed positivity for LOH of VHL in four samples, negativity in four samples, and was non-informative in 11 samples. The staining pattern of pVHL was also compared with those of cytokeratin (CK) 13 and CK17. RESULTS: In normal tongue tissues, pVHL staining was localized to the cytoplasm of cells in the basal layer and the area of the spinous layer adjacent to the basal layer of stratified squamous epithelium. Positive staining for pVHL was observed in the cytoplasm of cancer cells from all 19 tongue cancer patients. No differences as a result of the presence or absence of LOH were found. Notably, cytoplasm of poorly differentiated invasive cancer cells was less intensely stained than that of well and moderately differentiated invasive cancer cells. pVHL staining was also evident in epithelial dysplasia lesions with pVHL-positive cells expanding from the basal layer to the middle of the spinous layer. However, no CK13 staining was noted in regions of the epithelium, which were positive for pVHL. In contrast, regions with positive staining for CK17 closely coincided with those positive for pVHL. CONCLUSIONS: Positive staining for pVHL was observed in cancerous areas but not in normal tissues. pVHL expression was also detected in lesions of epithelial dysplasia. These findings suggest that pVHL may be a useful marker for proliferative lesions.

Spontaneous breast cancer remission: A case report.

INTRODUCTION: Spontaneous breast cancer remission is a rare phenomenon. We report the disappearance from the remaining breast of a new primary carcinoma that had been confirmed through cytology of a pathological specimen, in a case that is strongly suspected to be spontaneous remission. PRESENTATION OF CASE: A 44-year-old woman underwent breast-conserving surgery for a tumor located on the border between the upper-outer and lower-outer quadrants of the left breast (T2, N1, M0; Stage IIB). Eleven years after surgery, computed tomography indicated a mass in the upper-inner quadrant of the left breast. Excisional biopsy was initially planned for treatment following the definitive diagnosis because cytology revealed malignancy. The patient had noticed tumor regression one month after fine-needle aspiration and repeat ultrasonography performed the day before excisional biopsy confirmed the tumor reduction. On pathological examination, no tumor cells were observed in the mass. DISCUSSION: There was a discrepancy between FNA cytology and pathological diagnosis in our patient. The cytological findings indicated malignancy, but the pathological findings did not. When a tumor's pathological diagnosis is not malignant even though its FNA cytology diagnosis was malignant, sampling error, cytological over-diagnosis or some other error may have occurred. In this case, however, these were not detected. Because fibrosis was visible on pathological examination, we believe that these events corresponded to spontaneous remission. CONCLUSION: We report a rare case of spontaneous remission in which the cancer disappeared on pathological examination although the cytological diagnosis had been malignant.

Significance of fine needle aspiration cytology and vacuum-assisted core needle biopsy for small breast lesions.

BACKGROUND: In recent years, pathological diagnoses have been increasingly required, especially in small breast lesions, because malpractice lawsuits concerning erroneous cytological diagnoses have been commonly reported. Here, we retrospectively evaluated the significance of FNAC and VAB for small breast lesions using ultrasonography guidance. PATIENTS AND METHODS: A total of 1383 cases for which ultrasonography-guided VAB was performed between June 1996 and December 2012 were reviewed. Of these, 455 small breast lesions (239 nonpalpable and 216 nonmass lesions) were included in the study. RESULTS: Ultrasonography-guided FNAC was performed before VAB in 248 cases (54.5%). In 133 cases (53.6%), the results of FNAC were inconclusive. Pathological examinations using VAB revealed malignant and benign lesions in 199 and 256 cases, respectively. Of the 256 benign cases, we performed excisional biopsy in 17 cases (6.6%) and repeated VAB in 8 cases (3.1%). Excisional biopsy revealed malignant lesions in 2 cases. The reason for excisional biopsy was overdiagnosis using FNAC in 6 cases (35%). In all cases of repeated VAB, the pathological diagnosis was benign. The reason for repeated VAB was excision of the lesions in 5 cases (62.5%). The false positive and false negative rates of FNAC were 16.7% and 3.4%, respectively, whereas those of VAB were 0% and 1.0%, respectively. CONCLUSION: Cytology findings for small breast lesions should be considered only when imaging and cytology indicate benign lesions. Therefore, pathological examination without cytological examination should be the initial approach.

Semi-nested real-time reverse transcription polymerase chain reaction methods for the successful quantitation of cytokeratin mRNA expression levels for the subtyping of non-small-cell lung carcinoma using paraffin-embedded and microdissected lung biopsy specimens.

In patients with inoperable advanced non-small cell lung carcinomas (NSCLCs), histological subtyping using small-mount biopsy specimens was often required to decide the indications for drug treatment. The aim of this study was to assess the utility of highly sensitive mRNA quantitation for the subtyping of advanced NSCLC using small formalin fixing and paraffin embedding (FFPE) biopsy samples. Cytokeratin (CK) 6, CK7, CK14, CK18, and thyroid transcription factor (TTF)-1 mRNA expression levels were measured using semi-nested real-time quantitative (snq) reverse-transcribed polymerase chain reaction (RT-PCR) in microdissected tumor cells collected from 52 lung biopsies. Our results using the present snqRT-PCR method showed an improvement in mRNA quantitation from small FFPE samples, and the mRNA expression level using snqRT-PCR was correlated with the immunohistochemical protein expression level. CK7, CK18, and TTF-1 mRNA were expressed at significantly higher levels (P<0.05) in adenocarcinoma (AD) than in squamous cell carcinoma (SQ), while CK6 and CK14 mRNA expression was significantly higher (P<0.05) in SQ than in AD. Each histology-specific CK, particularly CK18 in AD and CK6 in SQ, were shown to be correlated with a poor prognosis (P=0.02, 0.02, respectively). Our results demonstrated that a quantitative CK subtype mRNA analysis from lung biopsy samples can be useful for predicting the histology subtype and prognosis of advanced NSCLC.

Two cases of primary malignant fibrous histiocytoma of the liver: immunohistochemical expression of ezrin and its relationship with prognosis.

Malignant fibrous histiocytoma (MFH) as soft tissue sarcoma would not be especially noteworthy, but primary hepatic MFH reports are extremely rare. Herein, we report ezrin expression in tumor tissues from two primary hepatic MFH cases with different prognoses. Cases 1 and 2 were both women, ages 45 and 70 years, respectively. Case 1 had an 11 x 10 cm liver tumor in segment (S) 3, and case 2 had two liver tumors, 12 x 8 cm in S5 and 10 x 7 cm in S8. Neither had any other systemic tumors. Cases 1 and 2 survived for two year and ten months and for eight and a half months, respectively, after the initial tumor resection. Microscopically, the tumors of these two cases were similar and showed proliferation of atypical cells, including spindle, pleomorphic and multi-nucleated giant cells arranged in storiform, sheet and/or fascicle patterns, with scattered foci of inflammatory cells, indicating MFH. Ezrin expression in tumor tissue from case 1 was sparse, whereas that of case 2 showed strong ezrin expression in many tumor cells. The present results indicate ezrin immunoreactivity in primary hepatic MFH to correlate possible with prognosis, which is consistent with reports on some other types of malignancies.

Quantitative analysis of human tissue-specific differences in methylation.

Tissue-specific differentially methylated regions (tDMRs) have been identified and implicated for their indispensable involvement in mammalian development and tissue differentiation. In this report, a quantitative DNA methylation analysis was performed for 13 human orthologous regions of recently confirmed mouse tDMRs by using Sequenom Mass Array, by which bisulfite-treated fragments are quantitatively detected using time of flight mass spectroscopy analysis. Eight regions were shown as tDMRs in various tissues from three independent individuals. Testis DNA samples from eight individuals were also analyzed for methylation. Interestingly, there is evidence that the DNA methylation level is divergent among individuals. DNA methylation levels of five testis-specific DMRs were significantly inversely correlated with the number of spermatocytes. However, a positive correlation was seen at tDMRs located near the TRIM38 and CASZ1 genes. Our results indicate that tDMRs are conserved between mouse and human and may have an important role in regulating tissue function, differentiation, and aging.

An impending rupture of a celiac artery aneurysm in a patient with Behçet's disease -- extra-anatomic aorto-common hepatic artery bypass: report of a case.

A celiac artery aneurysm associated with Behçet's disease is extremely rare. We herein present the case of successful surgical treatment for an impending rupture of a large celiac artery aneurysm with a wide proximal neck in a patient associated with Behçet's disease. To our knowledge, this is the first report of a procedure involving extra-anatomic aorto-common hepatic artery (CHA) bypass through the retroperitoneal space implanting a 6-mm expanded polytetrafluoroethylene graft. An 18-month postoperative magnetic resonance angiography scan showed a good patency of the aorto-CHA graft without an anastomotic pseudoaneurysm in a closure of aorta and anastomoses.

Analysis of tissue-specific differentially methylated regions (TDMs) in humans.

Alterations in DNA methylation have been implicated in mammalian development. Hence, the identification of tissue-specific differentially methylated regions (TDMs) is indispensable for understanding its role. Using restriction landmark genomic scanning of six mouse tissues, 150 putative TDMs were identified and 14 were further analyzed. The DNA sequences of the 14 mouse TDMs are analyzed in this study. Six of the human homologous regions show TDMs to both mouse and human and genes in five of these regions have conserved tissue-specific expression: preferential expression in testis. A TDM, DDX4, is further analyzed in nine testis tissues. An increase in methylation of the promoter region is significantly associated with a marked reduction of the gene expression and defects in spermatogenesis, suggesting that hypomethylation of the DDX4 promoter region regulates DDX4 gene expression in spermatogenic cells. Our results indicate that some genomic regions with tissue-specific methylation and expression are conserved between mouse and human and suggest that DNA methylation may have an important role in regulating differentiation and tissue-/cell-specific gene expression of some genes.

Vascular endothelial growth factor and dendritic cells in human squamous cell carcinoma of the oral cavity.

Dendritic cells (DCs) play an important role in the host immune defense against tumors, and there is an inverse correlation between DC density and the expression of vascular endothelial growth factor (VEGF). However, the relationship between VEGF expression in tumors and infiltration of CD1a+ or CD83+ DCs, which express the VEGF receptor (VEGFR), remains unclear. Therefore, in vivo and in vitro studies were conducted to investigate the relationship between VEGF expression and DC subsets in oral squamous cell carcinomas (OSCCs). Strong VEGF expression was detected in cancer tissues from patients with regional lymph node metastasis (PN+ cases). In these tissues, the VEGF expression correlated inversely with the number of CD1a + DCs, but positively with the number of CD83+ DCs. Large amounts of VEGF were secreted by OSCCs cell lines, and their culture supernatants significantly inhibited the production of differentiated CD1a+ DCs from peripheral blood mononuclear cells (PBMCs), whereas differentiated CD83+ DCs were increased. VEGFR-1 and -2 were detected in a few PBMCs and CD1a+ DCs. Furthermore, CD1a mRNA disappeared when recombinant human VEGF165 (rhVEGF165) was added to CD1a+ DCs, while CD83 mRNA increased. These results suggest that, in OSCCs, secreted VEGF might promote escape from tumor immunity by inhibiting the differentiation of CD1a + DCs from progenitor cells and increasing the levels of dysfunctional CD83+ DCs.

[Atherosclerotic regression in the aortas of elderly. (4). Expression of peroxisome proliferator-activated receptors with references of centrally depressed atherosclerotic plaque].

Peroxisome proliferator-activated receptors (PPARs) play an important role in vascular events during progression of atherosclerosis, associated with lipid metabolism, inflammatory response and others. To clarify relationships between the expression of PPARs subtypes and regression, we studied mRNA expression of PPARs subtypes with reverse transcriptase polymerase chain reaction (RT-PCR) and immunohistochemistry, especially in centrally depressed atherosclerotic plaques (depressed plaque) in the aortas of elderly patients, and proposed morphological feature of atherosclerotic regression. Samples were separated from the depressed plaque, atheromatous plaque, and diffuse intimal thickening (DIT) in the aortas of elderly patients at autopsy and they were analyzed for RT-PCR. The depressed plaques obtained were divided into two parts: depressed area and surrounding elevated area. Total RNA was prepared, using the TRIzol Reagent, and was reverse transcribed using random hexamer primers and Thermoscript kit for RT-PCR. Immunohistochemical analysis was processed for mouse anti-PPAR gamma antibody, detected by the ABC method. 1) Decreased foam cells were found in the depressed area than in the surrounding elevated area of the depressed plaque. These foam cells were immunohistochemically positive for HAM56 and strong reactivities for PPAR gamma were found in the nuclei of macrophage-derived foam cells. PPAR gamma was also detected in the nuclei of endothelial cells and smooth muscle cells. 2) Expressions of PPAR alpha and PPAR gamma were found in the depressed plaques with RT-PCR. These expressions were found both in the depressed area and the surrounding elevated area without significant differences. 3) PPAR gamma mRNA expression both in the depressed area and the surrounding elevated area, was greater than in DIT, and was less than in the atheromatous plaque. 4) Expression of PPAR gamma mRNA was intense and increased in the surrounding elevated area than in the depressed area. 5) A significant increase of PPAR gamma expression was found in the atheromatous plaque than in the DIT. 6) There was no significant difference of PPAR alpha mRNA expression between the depressed area and the surrounding elevated area. The depressed plaque has been considered to be a morphological characteristic of regression in recent studies. Expression of mRNA for PPARs was detected in the depressed plaque as well as the atheromatous plaque, furthermore, there were different expressions and intensity of PPARs between the depressed area and the surrounding elevated area of the depressed plaque. These findings suggest that the expression of PPARs may be involved not only in the progression of atherosclerosis but also in regression.

Creutzfeldt-Jakob disease with florid plaques after cadaveric dura mater graft.

A patient with dura-associated Creutzfeldt-Jakob disease (D-CJD) which occurred about 15 years after a dura mater graft is reported in the present study. The prion protein gene analysis disclosed no mutation. The D-CJD was atypical in: (i), the long interval between the onset of ataxia and the occurrence of dementia; (ii), the presence of transient myoclonus; and (iii), the presence of florid plaques in the brain. The electron-microscopic findings showed bundles of amyloid filaments which radiated from the center of the plaques without degenerating neurites. This case of D-CJD may belong to a new subtype of D-CJD.

Sclerosing encapsulating peritonitis: regional changes of peritoneum.

Sclerosing encapsulating peritonitis (SEP) is characterized by the diffuse appearance of marked sclerotic thickening of the peritoneal membrane. We experienced a case with SEP accompanied by regional changes of peritoneum. A 37-year-old woman with end-stage renal failure was started on continuous ambulatory peritoneal dialysis in 1985 and was transferred to hemodialysis in 1997. She was admitted because of ileus in 1998 with SEP and died of septicemia. The diagnosis of SEP was confirmed via the autopsy. The root of the mesentery was retracted and shortened. Since the peritoneal change was marked in the regions with free margin of mesentery and was less apparent in the regions not adhered to mesentery, it is indicated that mechanical stress also contributes to the occurrence of SEP. Since calcification and ossification were only seen in a free margin of small bowel from mesentery, it is suggested that there is a close relationship between calcification and ossification. Since fibrosis invaded into the muscle layer, dysfunction of bowel movement as well as bowel obstruction contributed to the appearance of ileus. It is suggested that mechanical stress by the root of mesentery which is retracted and shortened also contributes to the appearance of SEP.

Effects of Lentinus edodes mycelia on dietary-induced atherosclerotic involvement in rabbit aorta.

Lentinus edodes mycelia lowers cholesterol levels and acts as an immunomodulator and tumor-inhibitor in animal models. Lentinus edodes mycelia contains eritadenine (C(9)H(11)O(4)N(5)) and glucans among other biological compounds. However, whether or not Lentinus edodes mycelia is anti-atherogenic remains unknown. We examined the effect of Lentinus edodes mycelia (L.E.M) on atherosclerosis in a rabbit model. Thirty-two Japanese white male rabbits were fed with 1.0% cholesterol for 8 weeks, then divided into groups and given 1) 1.0% cholesterol for over 8 weeks (control), 2) 1.0% cholesterol and 1.0% L.E.M for over 8 weeks, 3) 1.0% cholesterol and 2.0% L.E.M for over 8 weeks, and 4) 1.0% cholesterol and 4.0% L.E.M for over 8 weeks (n=8 each group). Total cholesterol (TC) was measured periodically throughout the experiment. After the experimental periods, the aortas were removed and atherosclerotic lesions were examined histologically, immunohistochemically and morphometrically to determine surface involvement (SI) and an atherosclerotic index (AI). Body weight and TC did not significantly differ among the four groups. Decreases in SI were significant in the 1% L.E.M (26.2+/-10.8%) and 2% L.E.M (29.3+/-15.7%) groups compared with the control (48.7+/-15.3%; p < 0.05). The AI was significantly decreased in the 1% L.E.M (6.62+/-4.31) and 2% L.E.M (7.49+/-3.49) groups compared with the control (16.96+/-9.21; p < 0.05). Foam cells aggregated in thickened intima of dietary-induced atherosclerotic lesions in the rabbit aorta. In contrast, the numbers of foam cells in the intima decreased in the experimental group. No-cholesterol-lowering action or dose-dependant effects of L.E.M were determined in this study, but atherosclerotic development was significantly inhibited, indicating that L.E.M had anti-atherogenic properties. L.E.M may inhibit atherosclerotic development in rabbit aorta and be beneficial as a nutritional supplement.