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Background: Preoperative combined chemoradiation treatment (CRT) is now accepted as the treatment of choice due to its benefits of decreasing the primary tumor volume and enhancing the sphincter preservation surgery. Determining whether a patient is responding to therapy is crucial for rectal cancer patients who may benefit from prompt treatment modifications., Objective: To evaluate the use of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in predicting the treatment response., Material and Method: Nineteen patients with histologically proven rectal adenocarcinoma who were candidates for neo-adjuvant CRT were prospectively included. All patients were examined by conventional and DCE-MRi at three time points (pre-, during-, and post-CRT). Surgical resection was performed after complete CRT. The pathological response and Dworak regression grade were assessed. All parameters were blindly analyzed., Results: The median pathologic response rate for all patients was 40%. Dworak regression grades of 0, 1, 2, 3, and 4 were found in 0.0%, 21.1%, 42.1%, 26.3%, and 10.5% of patients, respectively. The tumor thickness and length were 30% and 32.9% lower at during-CRT and 40.6% and 44.7% lower post-CRT and had moderate and fair negative correlations with the pathologic response rate and Dworak regression rate, respectively. Among the DCE-MRI parameters, only a change in the time to peak between pre- and during-CRT was correlated with the Dworak regression grade (p = 0.01). The percentage change in the time to peak in patients with poor regression (grades 0-1) was significantly greater than in patients with intermediate/complete regression (grades 2-4) [139.25% vs. 6.13%]., Conclusion: Changes in the tumor thickness and length evaluated by conventional MRI and the time to peak evaluated by DCE-MRI during CRT may be useful for predicting the treatment response of rectal cancer patients.

Background: MRI, which has high sensitivity in brain tumor detection, cannot reliably determine tumor grading or histology. Diffusion-weighted imaging and apparent diffusion coefficients (ADCs) provide information of tumor cellularity that can correlate with grading., Objective: To investigate ADCs in differentiation low-grade from high-grade pediatric brain tumors., Material and Method: Preoperative MRI, DWI, and ADC images of pediatric patients with pathologically proven brain tumors were retrospectively reviewed at a university hospital in two-year periods and classified into low-grade and high-grade categories. Regions of interest were placed manually at the center and periphery of the solid tumor regions, then ADC values were calculated at "b" values = 0, 1000 sec/mm2., Results: The ADC values were calculated in 15 patients, which included 12 males and three females with an age range from three to 14 years. Seven and eight were with low- and high-grade tumors respectively. The ADC values of low-grade tumors were markedly higher than those of high-grade tumors with statistically significant differences by all methods of measurements at the central peripheral, and average areas on Man-Whitney U test, with p-values of 0.037, 0.009, and 0.021, respectively., Conclusion: MRI with ADCs for preoperative pediatric tumor evaluation may be useful for predicting tendency of tumor grading and surgical planning.

Background: Alveolar rhabdomyosarcoma is a primitive malignant round cell neoplasm, which shows skeletal muscle differentiation. Although their histopathologic and immunohistochemical findings are well known, the cytology, immunocytochemistry and molecular study on pleural effusion have not been well documented., Objective: To apply molecular method in the diagnosis and monitoring of alveolar rhabdomyosarcoma., Case Report: The case of a 14-year-old Thai male, who presented with dyspnea and left pleural effusion. Computed tomography of the chest and abdomen showed a huge heterogeneous enhancing mass at the left retroperitoneum. Pleural fluid cytology showed malignant small round blue cells. Immunocytochemical stains on cell block material showed positive reactivity to vimentin, sarcomeric actin, desmin, MyoD1, myogenin, and CD56 in round cell tumor Reverse transcription-polymerase chain reaction (RT-PCR) demonstrated PAX/FKHR fusion transcript. The patient received chemotherapeutic regimen for advanced-stage rhabdomyosarcoma. Finally, he succumbed to the disease, thirteen months after the diagnosis., Conclusion: Immunocytochemistry on cell block in conjunction with determination of PAX/FKHR fusion mRNA by RT-PCR is a molecular method in the diagnosis and monitoring of alveolar rhabdomyosarcoma inpleural fluid.

Background: Oculomotor nerve schwannomas are extremely rare tumors. There are only 40 cases reported in the literature. There is no standard treatment for these rare tumors., Case Report: The authors have reported a case of a 41-year-old Thai man presenting with progressive visual loss of the left eye for 6 months without diplopia. Visual acuity was 20/70 in the right and 20/400 in the left. There was no limitation of eye movement. MRI showed a 42.5 ml mass in the suprasellar region compatible with a schwannoma. The patient underwent a leftpterional craniotomy with partial tumor removal. The pathological section confirmed a diagnosis of schwannoma and the patient received postoperative stereotactic radiotherapy, Conclusion: Options for treating these rare tumors include clinical observation, surgical resection or stereotactic radiation. High incidence of complete third nerve palsy following surgery has been reported in the literature. Therefore, a subtotal removal of large oculomotor schwannoma followed by stereotactic radiotherapy could provide a safer alternative compared to radical surgery.

Objective: Determine and compare the clinicopathological findings of cerebral aspergillosis with cerebral candidiasis., Material and Method: The medical records with cerebral aspergillosis and cerebral candidiasis in Ramathibodi Hospital between January 1997 and December 2008 were analyzed. The criterion for the diagnosis of cerebral aspergillosis and cerebral candidiasis was the evidence of fungal elements from histopathologic section. The age, gender neurological manifestations, duration of symptom, associated underlying disease, predisposing risk factor, laboratory data, extent of systemic organ involvement and treatment outcome were analyzed., Results: The present study included cerebral aspergillosis (n = 41) and candidiasis (n = 15). There were 23 male and 33 female patients. The mean and median ages at diagnosis were 39.7 and 45 years, respectively (range, 1 month to 87 years). The clinical presentations included alteration of consciousness (69.6%), fever (60.7%), weakness of the extremity (14.3%), cranial nerve palsy (12.5%), headache (12.59%) and seizure (5.4%). One third of the cases had underlying hematologic malignancy. The cerebral aspergillosis and cerebral candidiasis were associated with corticosteroids treatment in 32.1%. The frequent associated sites of fungal infection included the lungs (73.2%), alimentary tract (33.9%) and sinonasal tract (19.6%)., Conclusion: A diagnosis of cerebral aspergillosis and cerebral candidiasis requires a high index of suspicion especially in immunocompromised patients who presented with alteration of consciousness, fever, focal neurological deficit, headache, and seizure. The patients with cerebral aspergillosis and cerebral candidiasis manifest with similar clinicopathologic features. However, the sinonasal tract infection and abscess formation are more common in cerebral aspergillosis. Associated alimentary tract infection is commonly seen in cerebral candidiasis.

Background: The diagnostic of malignancy in biopsy specimens is very important because it guides to selected treatment option and prognostic prediction. However biopsy specimens usually have small pieces leading to variations of the interpretation by anatomical pathologists., Objective: To detect and correct the errors or the significant discrepancies in the diagnosis of biopsy specimens before sign-out and to determine the frequency of anatomic pathology significant discrepancies., Design: The application of the mutually agreed work instructions (record) for the detection of errors or the significant discrepancies and their process of sign-out. The record of biopsy specimen that received a secondary check (1959 cases, 2005-2007) was analyzed., Results: After a secondary check, 53 cases of non-malignancy for any reason by a second pathologist were included. However when using our definition on significant discrepancies, only 37 cases were considered. Another seven cases with the opinions with malignancy that were of different cell types that do harm to the patients were added. Therefore, 44 cases (2.25%) had truly significant discrepancies., Conclusion: The truly significant discrepancy frequency was 2.25% during the process of pre-sign-out secondary check of malignancy of biopsy specimens. The project has been applied as a routine daily work. It can be an innovative safety program for patient in Thailand.

Background: Metastasizing pleomorphic adenoma is an uncommon malignant tumor of the salivary gland demonstrating benign epithelial and modified myoepithelial elements intermingling with tissue of mucoid, myxoid, or chondroid appearance that inexplicably manifests local or distant metastasis., Objective: To determine the expression of hormonal receptor in the patients with metastasizing pleomorphic adenoma of the major salivary gland., Material and Method: Medical records, clinical and pathologic findings of three patients who were diagnosed as metastasizing pleomorphic adenoma were reviewed. The immunohistochemical stains for estrogen receptor, progesterone receptor, and Ki-67 were performed., Results: Three cases of metastasizing pleomorphic adenoma, clinically presenting as painless, gradually enlarged cervical lymph nodes were reported. The pathologic examinations of the cervical lymph nodes are morphologically and immunohistologically identical to the sialoadenectomy specimen. Immunohistochemical stains show positive reactivity to progesterone receptor but negative reactivity to estrogen receptor in both mesenchymal and epithelial components of pleomorphic adenoma., Conclusion: These are the first reported cases of metastasizing pleomorphic adenoma of the major salivary glands associated with expression of progesterone receptor in both specimens of sialoadenectomy and lymph node biopsy. This finding supports the pathogenesis of benign metastasis of tumor. However, the role of hormonal receptor in the pathogenesis and treatment of salivary metastasizing pleomorphic adenoma should be further investigated.

A case of aggressive angiomyxoma of the left labia majora in a 48-year-old woman with clinically presenting progressive enlarged labial mass is reported. The histopathological examination of the lesion characterized was by fibroblasts, myofibroblasts in the myxoid stroma with prominent thick-walled blood vessels. The uterus showed intramural leiomyomata with simple hyperplastic endometrium. The labial mass, uterine leiomyoma and endometrial hyperplasia were immunoreactive for estrogen and progesterone receptors. Clinical and pathologic features with briefly reviewed relevant literatures were discussed. This is the first reported description in the literature of synchronous labial angiomyxoma, endometrial hyperplasia, and uterine leiomyoma.

Objective: Determine the clinicopathological findings in autopsy cases with invasive fungal infection., Material and Method: The autopsy and medical records with invasive fungal infection in Ramathibodi Hospital between January 1997 and December 2006 were analyzed. The criterions for the diagnosis of invasive fungal infection were the evidence of fungal elements from histopathological section. The age, gender underlying predisposing risk factors for the disease, clinical manifestations, extent of systemic organ involvement documented morphologically at autopsy, and fungal culture were analyzed, Results: There were 155 autopsy cases (73 male, 82 female; mean age 45.3 years, range 3 months to 87 years) with the diagnosis of invasive fungal infection. The common clinical presentations were fever (55.5%), and dyspnea (26.5%). The invasive fungal infection was associated with hematologic malignancy in 31%. The common mycoses were aspergillosis and candidiasis, which were observed in 88 and 80 cases, respectively. There were 32 cases (20.6%) of mixed fungal infection. Cultures from autopsy materials were positive for fungus in 80 cases out of 99 cases (80.8%). The most frequent site of fungal infection was in the lungs (74.8%), followed by gastrointestinal tract (28.4%), and brain (26.5%). Invasive fungal infection was diagnosed intravitally in 63.9% of total cases., Conclusion: A diagnosis of invasive fungal infection requires a high index of suspicion, especially in immunocompromised patients who presented with prolonged fever Clinical specimens must be sent for histopathology and fungal culture for a definite diagnosis and an appropriate management. Therefore, the physician should inform the laboratory if invasive fungal infection is suspected because special media are necessary for the best recovery of fungi. In addition, the present study underscores the significance of autopsy as a diagnostic method and means of medical quality control.

Background: Vaginal carcinoma represents 1-2% of all gynecologic malignancies. Most cases reported secondary involvement from adjacent organs including cervix, uterus, and colorectum. Vaginal involvement from adenocarcinoma arising in mature cystic teratoma (MCT) has never been reported., Case: A 29-year-old female presented with postcoital vaginal bleeding. She had had a history of right ovarian adenocarcinoma arising in MCT, FIGO stage IC, for 18 months' duration. Incisional biopsy of the vaginal lesion revealed adenocarcinoma, morphologically and immunohistologically identical to the right oophorectomized specimen. She received three courses of paclitaxel and carboplatin chemotherapy; however, she developed massive right pleural effusion with superior vena cava syndrome and finally succumbed to the disease, three months later., Conclusion: Adenocarcinoma is rarely found in MCT. This is the first case of ovarian adenocarcinoma arising in MCT with secondary vaginal involvement, presenting as postcoital vaginal bleeding.

Salivary duct carcinoma (SDC) is a relatively uncommon malignant tumor of the salivary gland derived from the excretory duct reserve cells of the salivary glands. The authors report a case of SDC in a 34-year-old man who presented with trismus and left sided headache, radiologically by a left parapharyngeal mass involving into the left cavernous sinus and histologically by intraductal growth pattern with a cribriform appearance and comedonecrosis. Perineural invasion of the mandibular branch of trigeminal nerve is demonstrated. Clinical and pathologic features with relevant literatures are reviewed.

A case of spinal and bilateral breast metastasis was reported The primary tumor was an embryonal rhabdomyosarcoma of the left hand. Intralesional resection of metastatic spinal sarcoma was done with concurrence chemotherapy and radiotherapy. The literatures of these rare conditions were reviewed.

A case of giant cell reparative granuloma concurrent with squamous cell carcinoma of the right temporal bone in a 44-year-old man with clinically presenting otorrhea from the mass of the right acoustic canal with hearing loss is reported. The histopathological examination of the lesion characterizes by multinucleated giant cells with in a fibroblastic stroma and area of keratinizing squamous cell carcinoma. GCRG may have been a local reaction provoked by the squamous cell carcinoma. Clinical and pathological features with briefly reviewed relevant literatures of temporal GCRG describing 24 cases are discussed. The patients have the mean age of 34.8 years. The ages of the patients ranged from 4 months to 72 years old. Temporal bone GCRG shows a male predilection of approximately 3:1. The frequently presenting symptoms of temporal bone GCRG are hearing loss, mass, tinnitus, otalgia, otorrhea, vertigo, headache, facial weakness, and diplopia. This is the first reported description in the literature of temporal bone GCRG concurrent with squamous cell carcinoma.

Lymphoepithelial carcinoma is a relatively uncommon malignant tumor of the salivary gland demonstrating malignant epithelial cells with dense lymphoid stroma. The authors report three cases of lymphoepithelial carcinoma associated with Epstein-Barr virus of the right parotid gland with clinically presenting as painless, gradual enlargement of the preauricular mass. The histopathologic examination of the parotid gland is characterized by malignant epithelial cells with dense lymphoid stroma. Immunohistochemical stains show positive reactivity to cytokeratin and p53 in malignant epithelial cells. In situ hybridization of the Epstein-Barr virus-encoded Ribonucleic acid shows positivity in malignant epithelial cells. Clinical and pathologic features with relevant literatures are discussed. These are the first reported cases of primary parotid lymphoepithelial carcinoma associated with Epstein-Barr virus infection in Thailand and Southeast Asia.

Leiomyoma is a relatively uncommon neoplasm of the epididymis derived from smooth muscle cells. A case of primary leiomyomas simultaneously occurring in both epididymides is reported in a 58-year-old man, clinically presenting painless intra-scrotal masses. The examination of the epididymis characterizes clinically by a firm solid, well-circumscribe mass, and histological spindle cells arranged in interlacing bundles with varying admixtures of fibrous and hyalinized connective tissue. Clinical, histopathologic and immunohistopathologic features, with briefly reviewed relevant literatures describing 7 cases of bilateral leiomyoma of epididymides are discussed. The patients with the mean age of 56.6 years (range 47-62 years) had epididymal mass measuring 5 to 75 millimeters (mean 21.3 millimeters). This is the first reported description of bilateral leiomyoma of epididymides in Thailand.

Kuttner tumor is a relatively uncommon disease of the salivary gland. It is also known as chronic sclerosing sialadenitis or cirrhosis of the submandibular gland. The examination of the submandibular gland characterizes clinically by a firm swelling of the gland, and histologically by progressive periductal sclerosis, dense lymphocytic infiltration with lymphoid follicle formation, reduction of the secretory gland parenchyma and fibrosis. Clinical, cytologic, histopathologic and immunohistopathologic features with briefly reviewed relevant literature describing 231 cases are discussed. The patients with the mean age of 44 years (range 13-81 years) had submandibular masses known to be present for 1 week to 55 years (mean 23.2 years). There is a slight predilection for occurrence in men. This is the first reported description of bilateral Kuttner tumor of submandibular glands in Thailand. It was initially diagnosed as a primary submandibular gland neoplasm that fine needle aspiration revealed to be chronic sialadenitis.

Angiosarcoma is a relatively uncommon primary malignant tumor of the heart derived from the endothelial cells. The authors report a case of primary cardiac angiosarcoma of the right atrium with pulmonary, hepatic, cerebellar and bony metastases in a 46-year-old man who clinically presented as pulmonary hemorrhage. The patient's occupational history had occasional exposure to polyvinyl chloride. The autopsy examination of the cardiac angiosarcoma characterized macroscopically by a right atrial tumor and histologically by anastomosing vascular channels and minute atypical pleomorphic endothelial cells. Immunohistological stainings were positive CD31, CD34 and focal positive factor VII-related antigen. Clinical and pathologic features with briefly reviewed relevant literatures are discussed This is the first reported description in the literature of a primary cardiac angiosarcoma with systemic metastases to multiple organs in Thailand.