Occult lung metastases of papillary thyroid cancer detected in a resected pulmonary arteriovenous malformation specimen.

A 41-year-old man with exertional dyspnea was referred to our hospital. Chest computed tomography (CT) showed a pulmonary arteriovenous malformation (PAVM) in the left lingular lobe, and magnetic resonance imaging showed a brain abscess. After antimicrobial therapy, the patient underwent thoracoscopic lingulectomy of the PAVM. Pathological examination revealed lung metastases of papillary thyroid cancer (PTC) that were undetectable by CT. The patient underwent total thyroidectomy and D2b lymphadenectomy for the PTC (the pathological stage was T1bN2M1, Stage II). After surgery, the patient received 100 mCi of 131Iodine; post-treatment scans revealed only neck (remnant) uptake and the patient continued with thyroid hormone replacement therapy. To the best of our knowledge, this is the first report of a case of combined PAVM and occult lung metastases of PTC. Clinicians should remember that they may detect micro lung metastases of any cancer when investigating resected lung specimens.

Utility of a 21-gauge Menghini-type biopsy needle with the rolling method for an endoscopic ultrasound-guided histological diagnosis of autoimmune pancreatitis: a retrospective study.

BACKGROUND: The histological diagnosis of autoimmune pancreatitis (AIP) by an endoscopic ultrasound (EUS)-guided approach is still challenging. METHODS: We investigated the utility of the 21-gauge Menghini-type biopsy needle with the rolling method for the histological diagnosis of AIP, in comparison with conventional 22-gauge needles. Among total 28 patients, rate of definitive histological diagnosis, acquired sample area of tissue, rate of histopathological diagnosis of AIP, and adverse events were retrospectively analyzed. RESULTS: Definitive histological diagnoses were successfully accomplished in all 14 patients (100%) treated with a Menghini-type needle, and in 57% of cases (8/14) treated with conventional 22-gauge needles (P < 0.001). The median sample area of the tissue, except for blood contamination, was remarkably larger by the Menghini-type needle than by conventional-type needles (6.2 [IQR, 4.5-8.8] versus 0.7 [IQR, 0.2-2.0] mm2, P < 0.001), and the area per punctures was approximately 4 times larger (1.4 [IQR: 0.9-2.9] versus 0.3 [IQR: 0.1-0.6] mm2/puncture, P < 0.001). Based on the International Consensus Diagnostic Criteria, lymphoplasmacytic infiltration, abundant IgG4-postive cells, storiform fibrosis, and obliterative phlebitis were found in 86%/29%, 64%/0%, 36%/0%, and 7%/0% patients who were treated with the Menghini-type needle and conventional-type needles, respectively. Consequently, histopathological diagnosis with type 1 AIP (lever 1 or 2) was achieved in 9 patients (64%) treated with the Menghini-type needle and in no patient treated with conventional-type needles (P < 0.001). Two patients who had mild post-procedural pancreatitis improved with conservative treatment, and no bleeding occurred in patients treated with the Menghini-type needle. CONCLUSION: EUS-guided rolling method with the 21-gauge Menghini-type biopsy needle is useful for the histopathological diagnosis of AIP, due to its abundant acquisition of good-quality tissue from the pancreas.

Primary hepatic gastrinoma being diagnosed preoperatively: a case report and literature review.

BACKGROUND: A majority of gastrinomas causing Zollinger-Ellison syndrome are located in the duodenum or pancreas. Primary hepatic gastrinomas are rare and difficult to diagnose. We report a rare case of primary hepatic gastrinoma, which could be diagnosed preoperatively. CASE PRESENTATION: A 29-year-old man with a 55-mm tumor in segments 5 and 6 (S 5/6) of the liver was admitted to our hospital. After thorough investigations, he was treated for a suspected inflammatory pseudotumor and advised to undergo routine follow-up. Two years later, he revisited our hospital with a complaint of abdominal pain, vomiting, and diarrhea. Upper gastrointestinal endoscopy revealed multiple duodenal ulcers. His serum gastrin level was 2350 pg/mL (normal: 37-172 pg/mL), suggesting Zollinger-Ellison syndrome. Abdominal computed tomography showed a 78-mm hypervascular tumor with cystic degeneration in the S 5/6 region of the liver, with a potential to increase over time. The tumor showed hypointensity on T2-weighted and hyperintensity on diffusion-weighted abdominal contrast-enhanced magnetic resonance imaging. Somatostatin receptor scintigraphy (SRS) only detected a hepatic tumor. No tumors in the gastrinoma triangle were detected by endoscopic ultrasonography. Hence, selective arterial calcium injection (SACI) test was performed to determine the location of the gastrinoma. The serum gastrin concentration increased from 4620 pg/mL to 23,600 pg/mL at 20 s after calcium gluconate injection into the proper hepatic artery. Conversely, no effect on serum gastrin level was observed after the injection into any other arteries. Extended right hepatic lobectomy and cholecystectomy were performed after percutaneous transhepatic portal vein embolization. A histopathological examination of the liver tumor revealed a gastrinoma. The patient's serum gastrin concentration on postoperative day 1 decreased to 65 pg/mL. CONCLUSION: We report a surgical case of primary hepatic gastrinoma correctly diagnosed preoperatively. The patient underwent extended right hepatic lobectomy, resulting in a histological definitive diagnosis of primary hepatic gastrinoma.

[Use of a somatostatin analog to improve a patient's condition and the subsequent diagnosis of pancreatic VIPoma:a case report].

A 68-year-old woman with an 11-day history of sudden abdominal pain and severe watery diarrhea was transferred to our hospital due to an exacerbation of renal function despite hydration. After treatment for dehydration and acidemia was provided in our intensive care unit, patient's renal function improved. Contrast-enhanced abdominal computed tomography was finally performed, revealing a hypervascular pancreatic mass with multiple hepatic masses. This imaging finding along with her clinical symptoms indicated watery diarrhea hypokalemia achlorhydria (WDHA) syndrome caused by a pancreatic VIPoma. Somatostatin analog was administered immediately leading to the improvement of her diarrhea and her general condition. As a result, endoscopic ultrasonography-guided fine-needle aspiration could be performed. Consequently, she was diagnosed with a pancreatic neuroendocrine tumor. She then underwent surgical resection of the pancreatic tumor and liver metastasis. As revealed in the immunohistochemical analysis of the excised tumor tissue, VIP was highly expressed, resulting in the final diagnosis of pancreatic VIPoma. Therefore, the immediate use of a somatostatin analog is crucial for improving the patient's general condition and achieving a definitive diagnosis pathologically when a patient is suspected of having a pancreatic VIPoma.

Characteristics of Benign and Malignant Bone Tumors Registered in the Hiroshima Tumor Tissue Registry, 1973-2012.

BACKGROUND: Reported information on the characteristics of benign bone tumors is disjointed, and the long-term trends in the occurrence of malignant bone tumors by histological type have not been reported in Japan. Our aim was to describe the characteristics of both benign and malignant bone tumors as described in cases registered in the Hiroshima Tumor Tissue Registry from 1973 to 2012. METHODS: Cases were identified with the International Classification of Diseases for Oncology (ICD-O-3) topography code C40-C41 (bones, joints, and articular cartilage), and histological types were classified according to the World Health Organization 2013 system. We described the distribution of the cases by behavior, sex, skeletal site of tumor occurrence, histological type, period at diagnosis (in 10-year groups), and age at diagnosis (in 10-year groups). RESULTS: We observed 2,542 benign bone tumors, 272 intermediate bone tumors, and 506 malignant bone tumors. We confirmed that 81.6% of benign bone tumors were chondrogenic, consisting primarily of osteochondromas and enchondromas. Giant cell tumor of bone was the most dominant type of intermediate tumor, whereas osteogenic tumors and chondrogenic tumors were the most dominant types of malignant tumors. Among malignant bone tumors, 41.7% of tumors occurred in the long bones of the lower limb, and there were different peaks of age at the time of diagnosis for osteogenic tumors and chondrogenic tumors. A similar distribution of histological types was seen throughout the 40-year observation period. CONCLUSIONS: Osteochondroma and enchondroma differed in terms of the age of the patient at the time of diagnosis and the skeletal sites where the tumors most frequently occurred. Giant cell tumor had a large impact on occurrence as a common type of intermediate bone tumor. CLINICAL RELEVANCE: The results of the present study, based on pathological tissue registry data, provide knowledge about the epidemiological and pathological features of bone tumors in Japan.

Advanced hepatocellular carcinoma with hepatic vein tumor thrombosis and renal dysfunction after hepatic arterial infusion chemotherapy effectively treated by liver resection with active veno-venous bypass: report of a case.

BACKGROUND: Hepatocellular carcinoma (HCC) patients with hepatic vein tumor thrombosis (HVTT) extending to the inferior vena cava (IVC) have an extremely poor prognosis. Here we report a case of HCC with HVTT and renal dysfunction after hepatic arterial infusion chemotherapy (HAIC) successfully treated by liver resection and active veno-venous bypass. CASE PRESENTATION: A 77-year-old man was diagnosed to have a large HCC with intrahepatic metastases and HVTT extending to the IVC. Due to the advanced stage, HAIC with cisplatin was performed 13 times in a period of 17 months. As a consequence of this treatment, the size of the main HCC markedly decreased, and the advanced part of the HVTT went down to the root of the right hepatic vein (RHV). However, because of renal dysfunction, HAIC with cisplatin was discontinued and right hepatectomy with patch graft venoplasty of the root of the RHV was performed. Because progression of renal dysfunction had to be avoided, veno-venous bypass was activated during IVC clamping to prevent renal venous congestion and hypotension. Histological examination showed foci of a moderately differentiated HCC with extensive fibrosis and necrosis in the main HCC. Histologically, the HVTT in the RHV showed massive necrosis and tightly adhered to the vascular wall of the RHV. The postoperative function of the remnant liver was good, and no further deterioration of renal function was detected. The patient did not show signs of recurrence 15 month after surgery. CONCLUSION: In the present case, HAIC using cisplatin in combination with hepatic resection and patch graft venoplasty of the IVC provided a good long-term outcome with no HCC recurrence. Renal function was preserved by using active veno-venous bypass during IVC clamping to prevent renal venous congestion and hypotension.

Extra-Adrenal Retroperitoneal Paraganglioma with Extensive Duodenal Invasion and Inferior Vena Cava Tumor Thrombus.

We report a case of extra-adrenal retroperitoneal paraganglioma (RP) with extensive duodenal invasion and tumor thromboses both in the right testicular vein and in the inferior vena cava (IVC). Because there was rigid adherence between the RP and the abdominal aorta, pancreatoduodenectomy with replacement of the IVC and aorta was performed for complete surgical resection. In the present case, both the mode of progression of the RP and the surgical approach were extremely rare.