Metachronous Liver Metastasis from Alpha-Fetoprotein-Producing Gastric Cancer Successfully Treated with Capecitabine/Oxaliplatin Combination Chemotherapy.

A consensus regarding the treatment of recurrent alpha-fetoprotein-producing gastric carcinoma due to its rarity is lacking. We herein describe a case of such a carcinoma that was associated with metachronous liver metastasis. A 73-year-old man was referred for the surgical treatment of a type 2 gastric tumor that extended from the greater curvature of the gastric corpus to the pylorus. As no remote metastases were detected, the patient underwent open total gastrectomy with lymphadenectomy and Roux-en-Y reconstruction. Histopathological examination revealed regional lymph node metastasis and the invasion of the muscularis propria by a moderately differentiated adenocarcinoma. Immunostaining of the primary tumor was positive for alpha-fetoprotein and negative for human epidermal growth factor receptor 2. Serum alpha-fetoprotein levels decreased to within normal limits after eight courses of S-1 monotherapy; however, levels started to increase, and a hypovascular nodule in segment 5/6 of the liver was detected 3.5 years later. Serum alpha-fetoprotein levels returned to the normal range, and the tumor was undetectable after four courses of capecitabine and oxaliplatin therapy. No recurrence was detected at 1.5-year follow-up. This case demonstrates that combined capecitabine and oxaliplatin therapy can successfully treat metachronous liver metastasis from alpha-fetoprotein-producing gastric carcinoma.

Swyer-James Macleod Syndrome With Progressive Hyperinflation.

Swyer-James Macleod syndrome (SJMS) is a rare disorder characterized by unilateral lung or lobar hyperlucency on chest radiographs. We present a case of SJMS with progressive enlargement of the bulla. A lobectomy was performed because the bulla in the right middle lobe had enlarged and compressed the upper and lower lobes, resulting in severe dyspnea. This treatment improved severe dyspnea and pulmonary function. Surgical resection is a viable option for SJCM patients experiencing short-term progression.

Differences in the pathological diagnosis of colorectal neoplasia between the East and the West: Present status and future perspectives from Japan.

It is well known that there are discrepancies in the diagnosis of gastrointestinal neoplasia between Western and Japanese pathologists. In the West, colorectal cancer (CRC) is defined by invasion through the muscularis mucosa into the submucosa, especially depending on the presence of desmoplasia. In Japan, however, CRC is defined based on a combination of nuclear and architectural abnormalities, regardless of invasion status. As a result, intramucosal carcinoma is diagnosed as high-grade dysplasia and even intramucosal carcinoma with poorly differentiated component is classified as 'Tis' in the West. It is logical and reasonable that the term 'T1' is used to currently describe intramucosal carcinoma. Use of the term 'high-grade dysplasia' for intramucosal CRC is outdated. In order to determine appropriate clinical treatment of CRC, the various risk factors of metastasis should be fully evaluated. With improved contributions and communication between pathologists and clinicians, overtreatment and inadequate follow up can be avoided. The discrepancies in the diagnosis of CRC between Western and Japanese pathologists may be addressed by an increase in East-West exchange. In addition, in the future, molecular analysis may also be useful for establishment of standardized diagnostic criteria of CRC.

Brain metastasis from a lung mucoepidermoid carcinoma mimicking a brain abscess.

BACKGROUND: Mucoepidermoid carcinoma (MEC) is a rare tumor of the lung that accounts for 0.1-0.2% of all pulmonary tumors. To the best of our knowledge, brain metastasis from lung MEC is rare and magnetic resonance imaging (MRI) findings of this lesion have not been documented. CASE DESCRIPTION: We herein report the case of a 72-year-old male. MRI revealed a left parietal tumor showing ring enhancement with medium gadolinium contrast and an evident high intensity area in the nonenhanced central portion on diffusion-weighted images (DWI) mimicking a brain abscess. Histologically, MEC is composed of a mixture of different cell types including mucin-secreting glandular cells and squamous cells. Accordingly, we suggest that the high DWI signal can be explained by the development of intracellular and intraluminal mucin, which have a high viscosity. CONCLUSION: Further accumulation of cases with brain metastasis from MEC is needed to establish the characteristic image findings, which would lead to prompt and adequate treatment.

[A synovial cyst accompanied by asymptomatic lumbar vertebral fracture requiring differentiation from spinal metastasis].

We experienced a case with a synovial cyst accompanied by asymptomatic lumbar vertebral fracture that required differentiation from spinal metastasis. An 82-year-old man suffered from right leg and anal pain. Computed tomography (CT) showed L5 spondylolysis. Magnetic resonance images (MRI) revealed an intra spinal cyst and acute lumbar vertebral fracture of L5 vertebral body. The surrounding area of the cyst presented contrast enhancement, and the extradural mass compressed the dural sac. Bone scintigraphy with 99m technetium-MDP demonstrated intense uptake on the right first, fourth, fifth, and seventh ribs and L2, L3, and L5 vertebra. The F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) image demonstrated an increased radiotracer uptake in the L5 vertebra(standardized uptake value(SUV) max=3.5). Spinal metastasis was suspected. Because of the cauda equina compression syndrome, it was surgically removed. Intraoperatively, a well-demarcated extradural cyst was found and compressed the dural sac markedly. The cyst capsule was thin and contained clear, thin fluid with no signs of bleeding. The histological diagnosis was a synovial cyst. His neurological symptoms improved after the surgery. The synovial cyst may enlarge after asymptomatic vertebral fractures.

Spontaneous complete necrosis of hepatocellular carcinoma: A case report and review of the literature.

The present study reports the case of a 68-year-old male patient who presented to Tokyo Rosai Hospital for the treatment of alcoholic liver disease. A high density was observed in liver segment S2, while a tumor, 30 mm in size, exhibiting a low density was observed in the delayed phase upon contrast-enhanced computed tomography (CT), which was performed prior to admission. The tumor appeared slightly poorly defined upon abdominal ultrasound and was observed as a 30 mm low-echoic nodule that was internally heterogeneous. A 5-mm thick contrast enhancement effect was observed in the tumor border in the vascular phase on Sonazoid contrast-enhanced ultrasonography, while a defect in the entire tumor was observed in the post-vascular phase. Dysphagia had commenced three months prior to presentation and a weight loss of ~3 kg was observed. Therefore, the patient was admitted to Tokyo Rosai Hospital due to the presence of a hepatic tumor, and to undergo a close inspection of the cause of the tumor. Upon close inspection, it was determined that the weight loss and aphagia were caused by progressive bulbar paralysis. A contrast-enhanced CT was performed on post-admission day 29 as a follow-up regarding the hepatic tumor. As a result, although no change in the tumor size was observed, the contrast enhancement in the tumor borderline had disappeared. Necrosis of the tumor was considered. However, as viable persistence of the malignant tumor could not be excluded, a hepatic left lobe excision was performed. The patient was diagnosed with hepatocellular carcinoma (HCC) based on the morphology of the cellular necrosis. In addition, occlusion due to thrombus was observed within the blood vessels passing inside the fibrous capsule. It was hypothesized that the formation of a thick fibrous capsule and occlusion due to thrombus in the feeding vessel were possibly involved as the cause of complete spontaneous necrosis. Written informed consent was obtained from the patient.

A case of Krukenberg carcinoma metastasized from colon cancer resembling mucinous cystadenocarcinoma of the ovary.

We report a case of a 44-year-old woman with bilateral ovarian carcinoma that had metastasized from the colon and mimicked primary mucinous cystadenocarcinoma. Macroscopically, both ovarian tumors were large, multiloculated cystic masses with abundant mucinous content. Histologically, they were lined with mucinous epithelium with mild to moderate nuclear atypia and showed stromal invasion and surface involvement. At first, the tumors were diagnosed as bilateral primary ovarian mucinous cystadenocarcinomas. However, three months after surgery, a large villous tumor was discovered in the ascending colon by colonoscopic examination and was surgically resected. Histologically, the colonic tumor was a villous adenomatous tumor with invasive components of mucinous adenocarcinoma composed of well-differentiated adenocarcinoma and exhibited abundant extracellular mucin production. As a villous adenomatous component was present in the mucosal area, the colonic tumor was considered a primary tumor. Therefore, the original diagnosis of bilateral ovarian tumors was revised for consistent with metastasis from the colon carcinoma, in line with the findings of immunohistochemistry and loss of heterozygosity analysis. This case highlights the importance of considering the possibility of metastatic tumors from the gastrointestinal tract in the diagnosis of mucinous ovarian tumors.

Mucinous cystadenocarcinoma of the appendix in which contrast-enhanced ultrasonography was useful for assessing blood flow in a focal nodular lesion in the tumor cavity: A case report.

A 63-year-old woman was admitted to hospital with pain in the right lower quadrant. Abdominal computed tomography (CT) revealed a 60-mm cystic mass at a site corresponding to the appendix. The mass wall on the appendicular ostium was thickened and enhanced by contrast, while calcification was observed in the mass wall on the appendicular tip. No projection was observed in the mass cavity. On abdominal ultrasonography (US), the mass wall on the appendicular ostium was thickened and projections were observed at two sites in the mass cavity. On contrast-enhanced US (CEUS), only one of these projections was enhanced. Based on the thickened and contrast-enhanced wall of the mass on the appendicular ostium on CT and US, as well as the contrast enhancement of a projection on US, the mass was diagnosed as mucinous cystadenocarcinoma of the appendix. Ileocecal resection was subsequently performed on day 10. A detailed examination of the surgical specimen revealed carcinoma cells in the mass wall on the appendicular ostium. The contrast-enhanced projection was identified as granulation tissue that had grown to come into contact with the tumor, while the non-contrast-enhanced projection was identified as solidified mucus. US enabled successful visualization of projections in the mass cavity that were not visible on abdominal CT. CEUS also proved useful for assessing blood flow in these projections.

Endoscopic nasobiliary drainage improves jaundice attack symptoms in benign recurrent intrahepatic cholestasis: A case report.

A 66-year-old male with unbearable pruritus and jaundice was admitted for detailed examination. Blood tests on admission showed increased bilirubin with a dominant direct fraction. Ultrasonography and computed tomography performed subsequent to admission showed no narrowing or distension of the bile ducts. As the jaundice symptoms were not improved by the oral administration of ursodeoxycholic acid (300 mg/day) that had been started immediately after admission, endoscopic retrograde cholangiopancreatography (ERCP) was performed on hospital day 14. This also showed no abnormalities of the bile ducts. After considerating its potential effects for improving jaundice, endoscopic nasobiliary drainage (ENBD) was performed on the same day and was followed by immediate improvements in pruritus and jaundice. Detailed examinations were performed to identify the cause of the jaundice, which was suspected to be viral hepatitis, autoimmune hepatitis or drug-induced liver injury, however, there were no findings suggestive of any of these conditions. Following a further increase in bilirubin levels, confirmed by additional blood tests, a liver biopsy was performed. Histological findings were consistent with the histological features of benign recurrent intrahepatic cholestasis (BRIC). Although ursodeoxycholic acid is used as a first-line treatment in most cases of BRIC, ENBD should also be considered for patients not responding to this treatment.

A case of branch duct type intraductal papillary neoplasm of the bile duct treated by open surgery after 11 years of follow-up.

The intraductal papillary neoplasm of the bile duct (IPNB) is a novel disease concept that was recently classified as a biliary cystic tumor by the revised World Health Organization classification. This is the case report of a 70-year-old female patient who experienced repeated episodes of obstructive jaundice and cholangitis since 2000, attributed to a mucus-producing hepatic tumor. Surgery was advised due to the repeated episodes; however, the patient refused. In May, 2011, the patient developed jaundice and fever and was treated with antibiotics. Since there was no improvement, the patient was admitted to the Tokyo Rosai Hospital. Abdominal computed tomography (CT) revealed a 50-mm cystic mass with an internal septum in the left hepatic lobe. Although the tumor size had remained almost unchanged compared to the initial CT scan performed in 2000, intra- and extra-hepatic bile duct dilation was more prominent on the second CT scan. Following admission, endoscopic retrograde cholangiopancreatography was performed and revealed an expanded papilla of Vater due to a mucous plug. A balloon catheter was inserted into the bile duct to remove the mucous plug, resulting in the drainage of copious amounts of mucus and infected bile. The patient finally consented to surgery and left hepatic lobectomy was performed. Consequently, the diagnosis of low-grade IPNB was made. Branch duct type IPNB, which is characterized by imaging appearance of a cystic mass and slow progression, is attracting increasing attention. In the present case, a cystic mass was identified in the left hepatic lobe, with no significant change in size after 11 years of follow-up, leading to the diagnosis of branch duct type IPNB. Considering the fact that IPNB is usually treated surgically at the time of diagnosis, the present case, due to the long-term follow-up, provides valuable insight into the natural history of the tumor.

Metastatic skull base tumor from thymic carcinoma mimicking Tolosa-Hunt syndrome.

A 39-year-old male without contributory medical history had sustained progressive double vision, ptosis, and trigeminal pain for 2 weeks. Physical examination revealed total ophthalmoplegia and visual field defect with normal blood examination and chest radiography. Cranial computed tomography revealed a hyperdense mass in the left frontotemporal fossae with bony erosion. Magnetic resonance imaging confirmed a broad-based, intensely enhanced extraaxial tumor of 4x4x4 cm diameter with dural tail sign. Cerebral angiography demonstrated insignificant blood supply both from the internal carotid and middle meningeal arteries. Nearly total tumor resection was achieved via orbitofrontotemporal craniotomy. Intraoperative findings revealed the extraaxial tumor with broad attachment to the dura mater and invasion to the optic and oculomotor nerves. Histological examination revealed hypercellular tumor with significant cell atypism, mitotic activity, and focal necrosis. Immunohistochemical staining was positive for AE1/3 and c-kit, but negative for glial fibrillary acidic protein. Systemic examination performed postoperatively revealed a thymic tumor without additional remote lesions. The final diagnosis was metastatic brain tumor from thymic carcinoma. Rapid progression of neurological impairment inconsistent with a benign extraaxial tumor needs prompt surgical intervention.

[The significance of the combined usage of cytology and the HPV test in cervical cancer screening].

BACKGROUND: In the United States, the combined usage of cytology and the HPV test is employed in cervical cancer screening, but, in Japan, only cytology is performed in most cases. We conducted a comparative analysis of histopathological diagnoses by colposcopy, cytology, and the HPV test, and evaluated the effectiveness of cytology and the significance of its combined use with the HPV test. METHODS: We compared the detection rates using the test for high-risk HPV and cytology, which were conducted in cases with various histological diagnoses. The hybrid capture method was used in the HPV test. The blind test was conducted by 3 cytologists in 14 cases in which the cytological differed from the histological diagnosis by more than 2 classes. RESULTS: There were 89 cases above class IIIb or CIN 3, and 26 cases were below class IIIa. A total of 107 cases were positive on the HPV-DNA test, and 8 cases were negative. CONCLUSION: Cytology is essential as a morphological diagnostic method in cancer screening. In contrast, the HPV test detects the cause of cervical cancer. Therefore, the combined usage of cytology and the HPV test as initial screening for cervical cancer would facilitate the diagnosis of a premalignant lesion or early-stage cervical cancer more promptly and accurately.

Pancreatic, hepatic, splenic, and mesenteric mucinous cystic neoplasms (MCN) are lumped together as extra ovarian MCN.

Mucinous cystic neoplasms (MCN) of the pancreas are mucin-producing cystic tumors with an ovarian-like stroma (OLS). In the present study MCN were obtained from 27 patients. These MCN were derived from 22 pancreas, three livers, spleen, and mesentery. MCN in various organs have common clinicopathological profiles, being unilocular or multilocular cystic tumors, with a fibrous capsule and lined by mucin-secreting epithelium associated with an underlying subepithelial OLS. The OLS showed strong positivity for alpha-smooth muscle actin (alpha-SMA) and vimentin and weak, focal positivity for desmin. Both estrogen receptors and progesterone receptors were expressed in the nuclei of OLS cells. In addition, 20 ovarian MCN and 13 normal ovaries were studied with particular attention to the stroma. The stroma of ovarian MCN was strongly immunopositive for alpha-SMA and vimentin and focally positive for desmin, whereas normal ovarian stroma was immunonegative for both alpha-SMA and desmin. The OLS of MCN mentioned here was similar to the septa of ovarian MCN but not to ovarian stroma. In conclusion, MCN in various organs should be lumped together as 'extra ovarian' MCN. The OLS was identified on the basis of myofibroblastic proliferation both in response to neoplastic development and dependent on hormones.

[Pathology of intraductal papillary-mucinous tumor of the pancreas].

Many intraductal papillary-mucinous tumors (IPMTs) have been diagnosed with improvements in diagnostic imaging techniques. The histology of IPMT is various, including hyperplasia to invasive carcinoma. IPMTs are thought to occur multicentrically through the hyperplasia-adenoma-carcinoma sequence. IPMTs are characterized by genetic heterogeneity associated with histologic heterogeneity that may be due to slow growth and favorable prognosis. However, some IPMTs progress to invasive pancreatic cancer through malignant transformation with aggressive clonal progression. Thus some conventional pancreatic cancers may be derived from IPMTs. Although IPMTs and conventional pancreatic cancer initially occur in the ductal epithelium, they are thought to be totally different entities in terms of large or peripheral pancreatic duct origin, developmental style, genetic alterations, and prognosis. In future, differences and/or similarities will be discussed on the basis of molecular analyses of the carcinogensis of both tumors.