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Lingual lymph node metastases are rarely seen in carcinoma of the tongue, and these nodes are not removed during neck dissection. Lingual lymph nodes are classified into medial and lateral groups, and metastasis to the former is extremely rare. A 55-year-old male with squamous cell carcinoma of the tongue, (stage T4aN0M0), underwent hemiglossectomy with neck dissection and free flap reconstruction. The lingual septum had a mass, 8 mm in size, which was diagnosed as medial lingual lymph node metastasis on histopathology. The patient developed multiple distant metastases and died of disease 18 months after the initial surgery. The presence of medial lymph node metastasis could result in contralateral neck metastases and worsen prognosis. Such cases may warrant more intensive therapy than recommended by current guidelines.

A 48-year-old woman with severe pain and numbness of her right leg and foot was admitted to our hospital. She had never smoked and had little exposure to passive smoking. Initially, polyarteritis nodosa with anti-phospholipid antibodies was considered. Combination therapy with methylprednisolone pulse therapy, intravenous cyclophosphamide pulse therapy, vasodilators, antiplatelet agents, and anticoagulants was not effective. Vasculopathy was progressive, and she presented with gangrene of the toes. She required amputation of her right leg. The pathological findings of the amputated leg revealed thromboangiitis obliterans (TAO). TAO should be considered even in non-smoking women. Non-response to immunosuppressant and anticoagulant therapies may be a clue to the diagnosis of TAO.

In Japanese patients with non-muscle-invasive urothelial carcinoma of the bladder, the impact of body mass index (BMI) on recurrence following transurethral resection of bladder tumor (TURBT) is unclear. The present study retrospectively examined data collected from 50 patients diagnosed with primary urothelial carcinoma of the bladder (pTa, pTis, and pT1) who had previously undergone TURBT surgery. Two BMI cut-off points for predicting disease recurrence were evaluated: i) A threshold generated through receiver operating characteristic (ROC) curve analysis; ii) the World Health Organization BMI index (24 kg/m2) for overweight status in Japanese populations. Univariate and multivariate analyses were applied to assess individual variables (BMI included) and the effect they had on recurrence-free survival (RFS). Median RFS and BMI values of 19.72 months (range, 3.13–72.13 months) and 23.37 kg/m2 (range, 14.72–36.84 kg/m2), respectively, were recorded. In multivariate analyses, higher continuous BMI was significantly associated with shorter RFS (P=0.019). Based on a ROC-generated BMI cut-off point (23.4 kg/m2), patients were ranked with either a high (≥23.4 kg/m2) or low (23.4 kg/m2 were significantly associated with shorter RFS (P=0.028). Intravesical Bacillus Calmette-Guérin treatment and history of upper-tract urothelial carcinoma were also independently associated (P=0.044 and P=0.010, respectively). However, BMI values >24 kg/m2 (customary cut-off point) had no significant impact on RFS (P=0.066). Thus, a higher BMI status was revealed to be independently predictive of shorter RFS in Japanese patients undergoing TURBT for urothelial carcinoma of the bladder. A greater number of samples are required in order to determine optimal BMI cut-off points in Japanese patients and to investigate whether weight reduction intervention may improve prognosis.

Catastrophic antiphospholipid syndrome (CAPS) survivors rarely relapse. We herein report a case of a second CAPS episode with an unusual subacute course and no microangiopathic hemolytic anemia (MAHA), a common CAPS symptom. During the first episode, the 69-year-old woman responded well to high-dose glucocorticoids and plasma exchange. On relapse, these treatments plus rituximab were ineffective and she died of multi-organ failure and bacterial cholangitis. The absence of MAHA and a subacute course do not exclude a CAPS recurrence.

The aim of this study is to investigate the role of androgen receptor (AR) expression on clinicopathologic characteristics, first recurrence free survival (RFS), progression free survival (PFS) and multiple recurrences in non-muscle invasive bladder cancer (NMIBC). AR expression in 40 paraffin-embedded specimens of primarily diagnosed NMIBC after transurethral resection was examined by immunohistochemistry using a monoclonal AR antibody. Associations between AR expression and clinicopathologic features and prognosis were statistically assessed. Multivariate Cox proportional hazards model was applied for evaluating predictive factors on RFS and PFS. For multiple recurrences, we used the Andersen-Gill model. AR was positive in 20/40 (50%) cases. Twenty-three patients (57.5%) had no recurrence, 10 (25.0%) had one recurrence, and 7 (17.5%) experienced more than one recurrence. AR expression and clinicopathologic features were not significantly correlated (P >0.05). Univariate analyses showed that AR expression was significantly associated with RFS and PFS (P

A 63-year-old man was admitted to our hospital because of persistent fever, weight loss, painful foot, and purpura on his extremities. He had lower extremity peripheral neuropathy, and skin biopsy of the purpura revealed vasculitis. Serum tests for myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA), proteinase 3-ANCA, and ANCA (indirect fluorescent antibody method) were all negative. Computed tomography revealed a 6-cm large, irregularly shaped lesion in the right kidney, while the nasal sinuses and lungs were intact. Based on these findings, a diagnosis of suspected systemic vasculitis associated with renal cell carcinoma was made. Thus, right nephrectomy was performed. However, the pathological findings showed a large infarct with necrotizing vasculitis of the arcuate, interlobular, and perinephric small arteries and a crescent formation in the glomerulus. Based on these findings, he was diagnosed with microscopic polyangiitis. Due to rapidly worsening symptoms of purpura and neuropathy, treatment with a high dose of corticosteroid was initiated on postoperative day 2, which led to improvement of his symptoms. Vasculitis accompanied with a mass-like lesion is occasionally confused with malignancy. The lesion in our patient was considered to have originated by asymptomatic renal infarction. This case suggests that a renal mass-like lesion with vasculitis should be diagnosed with care.

症例は26歳，女性．魚介類の生食歴は明らかでなく，微熱と右下腹部痛が数日続き，右下腹部痛が増強したため紹介され来院した．高熱を伴い腹膜刺激症状を有していたため，緊急手術を施行した．手術所見では，回腸末端近傍の回腸に約20cmにわたる範囲で，全周性の炎症所見と複数の狭窄および腸間膜の著明な肥厚を認め，病変部を含め切除した．標本の肉眼所見では，腸間膜側に深い縦走潰瘍を認め，Crohn病の肉眼所見に類似していた．病理組織学的検査では潰瘍の深部に破壊されたアニサキス虫体を認め，その周囲に好酸球性肉芽腫と膿瘍を認めた．以上より腸アニサキス症により，深い縦走潰瘍を形成したと診断した．一般には腸アニサキス症では全身状態が良好で腹部症状も軽いと言われているが，稀に本例のように激しい経過をとる症例が存在することを念頭に置いた対処が必要であると思われた．

We investigated the immunohistochemical characteristics of 13 cases of odontogenic carcinoma, including 3 cases of ameloblastic carcinoma, 9 cases of primary intraosseous squamous cell carcinoma (PIOSCC), and 1 case of ghost cell odontogenic carcinoma (GCOC), to elucidate the origin and determine diagnostic markers of odontogenic carcinoma. Thirty cases of gingival squamous cell carcinoma (gSCC) were included for comparison. All ameloblastic carcinomas and GCOC cases, as well as 6 of 9 PIOSCC cases, exhibited immunoreactivity for CK19, whereas only 3 of 30 gSCC cases were positive for CK19. Two cases of ameloblastic carcinoma and only 1 case of PIOSCC expressed CD56; however, CD56 was not expressed in any gSCC cases. All odontogenic carcinoma cases except a single GCOC case were negative for calretinin. These findings indicate that immunoreactivity to CK19 is useful to identify odontogenic origin of the odontogenic carcinomas including PIOSCC, and it may also be useful for distinguishing PIOSCC from gSCC.

An autopsy case of primary small cell carcinoma (SCC) of the prostate in a 68-year-old man is reported. The patient was admitted to hospital because of a bloody stool and suspected rectal cancer. However, a diagnosis of prostate cancer was made on the basis of a digital rectal examination, the serum level of prostate-specific antigen, and a needle biopsy of the prostate. The patient also experienced a syndrome of inappropriate secretion of antidiuretic hormone. He died 29 days after admission. At autopsy, the tumor had invaded the rectum, bladder and pelvic peritoneum. Metastases to the heart, vertebrae and lymph nodes were observed. Microscopically, the tumor was composed of small round cells that showed a solid growth pattern. Rosette formations were observed. Immunohistochemically, the tumor cells were positive for a prostatic epithelial marker and neuroendocrine markers. A high level of antidiuretic hormone was detected in the tumor tissue. To our knowledge, this is the first reported case of SCC of the prostate in which both a prostatic epithelial marker and neuroendocrine markers have been found in the same tumor. This finding supports the hypothesis that SCC of the prostate originates from a multipotential stem cell of the prostatic epithelium.

Tissue biopsy is essential for the diagnosis and typing of amyloidosis. Given its safety and ease, abdominal fat pad (AFP) is the first biopsy site of choice; bone marrow (BM) biopsy should additionally be performed to identify underlying plasma cell dyscrasia. The aim of the present study was to assess the usefulness of combined biopsy and immunohistochemical staining of AFP and BM tissues for the diagnosis and typing of amyloidosis. A total of 65 patients were examined. Congo red staining and immunohistochemical staining with antibodies were performed. Of 51 patients with systemic amyloidosis, 50 patients were examined with fat pad aspirates and 38 (76 %) cases were positive. All 51 patients were also examined by BM analysis and 25 (49 %) cases were positive. Including both AFP aspirates and BM specimens, 90 % of patients with systemic amyloidosis were Congo red positive. Of the 49 patients with AL amyloidosis, immunohistochemical stains were positive in 67.6 % of patients with AFP aspirates and in 50 % with BM specimens. Combining AFP aspirate and BM examination, immunohistochemical stains yielded positive stains for the corresponding circulating monoclonal immunoglobulin in 72.7 % of cases, and hence these analyses appear to be valuable in diagnosing the type of amyloidosis.

A 67-year-old woman was diagnosed as having acute appendicitis and underwent an appendectomy. The appendix was significantly red in color and swelled which were compatible with acute phlegmonous appendicitis macroscopically. Postoperative histology demonstrated that goblet-cell-like tumor cells extensively infiltrated to the submucosa with perineural invasion. These cells were mucin-producing and were diffusively shown as argyrophilic. Since the same treatment as in advanced cancer was considered appropriate, a right hemicolectomy with lymph node dissection and bilateral oophorectomy were added. No metastasis or residue was observed, but a minor ovarian papillary cystic tumor of borderline malignancy was noted. Goblet cell carcinoid of the appendix is known to be almost as malignant as cancer. Metastasis to the ovary is often found in patients with goblet cell carcinoid of the appendix, but concomitant primary ovarian tumor seems rare like in this patient.

A 35-year-old man was admitted because of severe abdominal pain. He had been treated with medication for Crohn's disease for 10 years. 5-aminosalicil acid and an elemental diet were started 8 months prior to admission. Seven days before admission, the patient took a nonsteroidal antiinflammatory drug for abdominal pain. His abdomen was rigid, and pan-peritonitis was suspected. An abdominal X-ray showed free air under the right leaf of the diaphragm. At laparotomy, the entire small bowel was diffusely erythematous and edematous, and both the mesentery and the bowel wall on the mesentric side were very thick. Perforation of the ileum was observed 230cm distal to the ligament of Treizt. A 20-cm segment of the ileum, including the perforation site, was resected, and an ileostomy was constructed. The ileostomy was successfully closed 5 months later. The postoperatiVe courese was satisfactory, although most of the affected bowel was left in situ.

PURPOSE We prospectively assessed whether enhancement characteristics on dynamic magnetic resonance (MR) imaging could distinguish indeterminate pulmonary nodules. METHODS We evaluated 51 pulmonary nodules in 51 consecutive patients (11 female, 40 male; mean age, 64 years) using dynamic MR images acquired at 0, 10, 20, 30, 40, 50, 60, 70, 80, 90, 120, 150, 180, 210, 240, 360, 480, 600, 720, and 840 s following injection of contrast material. We prospectively evaluated morphologic enhancement patterns, peak rate, time to peak enhancement, steepest slope, and washout of nodules and analyzed statistics to determine any differences between MR parameters, patient age, tumor size, and final diagnosis. RESULTS We found 25 malignant, 12 active inflammatory, and 14 benign nodules. Nodule diameter was significantly larger for malignant than nonmalignant, and benign nodules (P≤0.01). Patients with malignant nodules were significantly older than those with nonmalignant (P=0.01) and active inflammatory (P=0.02) nodules. However, morphologic enhancement patterns, peak rate, time to peak enhancement, steepest slope, and washout characteristics at 2, 4, 8, and 12 min showed no significant difference between malignant and nonmalignant nodules and among malignant, active inflammatory, and benign nodules. CONCLUSION Prospective assessment of dynamic MR images demonstrated their inadequacy for distinguishing indeterminate pulmonary nodules.

We report a very rare case of extensive ductal carcinoma in situ (DCIS) of the breast with secretory features in a 30-year old Japanese woman. The patient presented with a nodule in the lower inner quadrant of the left breast measuring approximately 2–3 cm, accompanied by an irregular tumor shadow with segmental microcalcification on mammography. These findings suggested malignancy, and excisional biopsy was performed following core needle biopsy. Pathological diagnosis was that of DCIS with secretory features. A treatment plan of simple mastectomy and sentinel lymph node biopsy was chosen. Most previous reports have only described invasive secretory carcinoma of the breast. We have only been able to find 2 case reports of non-invasive secretory lesion in the English literature to date. Because the characteristics of this lesion are not widely known, we thought it important to share our findings.

We present a case in which an amyloid lung nodule was diagnosed preoperatively by amyloid scintigraphy (99m)Tc-aprotinin. A 65-year-old man complained of marked weight loss (9 kg) over a period of 6 months. An abnormal shadow in the middle field of the right lung was detected on chest X-ray, corresponding to a 16-mm nodule in the right middle lobe on thoracic computed tomography (CT). Total protein and immunoglobulin G levels were elevated to 8.3 and 2245 mg/dl, respectively, but other blood tests including several tumor marker levels and Cryptococcus antibodies were all within normal range. Fluorodeoxyglucose positron emission tomography showed no uptake by the lung nodule, so lung amyloidosis was considered as differential diagnosis. To avoid risk of bleeding on bronchoscopy, noninvasive amyloid scintigraphy using (99m)Tc-aprotinin was first performed. A nodular, abnormal accumulation was observed in the right middle lung lobe. Diagnostic imaging strongly suggested amyloidosis, so video-assisted thoracic surgery was performed rather than bronchoscopy. Pathological samples showed positive staining with Congo red, and A-λ amyloidosis was diagnosed on the basis of immunostaining. Scintigraphy using (99m)Tc-aprotinin offers a useful, noninvasive method for assessing lung amyloidosis.

1991年1月より1993年3月の期間に東京医科歯科大学第2外科において拡大電子内視鏡検査を施行され,表面型大腸腫瘍および大腸早期癌と診断された38病変を対象として検討した.まったく隆起を形成しないIcおよびIIbの5病変はいずれも粘膜病変であった.表面隆起を形成する他の33病変を,拡大観察所見で病変の立ち上がり部分と腫瘍のピットパターンの境界が一致するmagnifying colonosco picpolypoid growth type(MCPG(+))24病変と両者の一致しない(MCPG(-))9病変に分類したところ,MCPG(+)群のうち21病変は粘膜病変で,3病変のみがsm癌であり,MCPG(-)群は8病変のsm癌と1病変のpm癌であった.本分類は内視鏡所見による分類であるが,腫瘍の発育・進展過程における表面隆起の成り立ちと関連があり,表面型腫瘍よりsm癌の区別するために有用であると思われる

Laparoscopic technique to assist in the performance of partial colectomy is presented. A 55-year-old male had 1/5 circumference flat elevated lesion with central depression at the middle transverse colon. The colonoscopic diagnosis was early colon carcinoma and unable to resect endoscopically. Instead of performing a laparotomy with its potential morbidity, the lesion was resected by laparoscopic assisted partial transverse colectomy. Post operative course was uneventful, and patient was discharged on 13th post operative day. This technique can be applied to selected patients with early colon carcinoma.

過去15年間に1,085個(597例)の大腸ポリープに対し内視鏡的ポリペクトミーを施行した.これらの症例におけるポリペクトミーの予後について,合併症と予後,大腸早期癌症例の背景因子と予後,腺腫ポリペクトミー後のfollow-upの検討を行った.ポリペクトミーに伴う合併症は5例(0.8%)に認められたが,手術を必要とした例はなく,いずれも予後は良好であった.ポリペクトミーを行った早期癌は65例(Sln癌13例,m癌52例)で,ポリペクトミー症例の11%であった.背景因子として大腸進行癌に併存29%,早期癌多発例12%,腺腫併存例を58%に認めた.現在までのところ早期症例の予後は良好である.腺腫ポリペクトミー後のfollow-up88例の検討では,検査時見逃しの危険性が指摘され,とくに腺腫多発例においては再発見率が高く,risk factorと考えられた.

Introduction Chronic granulomatous disease, one of the primary immunodeficiency syndromes, is characterized by failure of phagocytic capacity due to loss of reactive oxygen species production, as well as formation of granulomas in organs. Clinically, dysregulated inflammation by excessive cytokine production due to loss of reactive oxygen species production is suggested as a cause of noninfectious inflammatory problems such as chronic granulomatous disease colitis. We experienced a rare case of a patient with chronic granulomatous disease with unique pathological and radiological presentations of hypersensitive pneumonitis, which to our knowledge has never been previously reported. Case presentation A 20-year-old Japanese man with chronic granulomatous disease was referred due to cough and abnormal chest imaging findings. Computed tomography of his chest showed diffuse, bilateral, centrilobular nodules and multiple mass lesions in lower lobes that do not fit a common image of hypersensitivity pneumonitis. Pathological findings of both nodules and mass lesions on surgical lung biopsy were homogeneous, and excessive granulomas in the bronchioles and alveolar duct as well as lymphocytic alveolitis were seen, all consistent with hypersensitivity pneumonitis. The radiological and laboratory abnormalities did not improve after antigen avoidance; however, they disappeared after high-dose steroid therapy. Conclusions When we encounter a case of hypersensitive pneumonitis showing atypical pulmonary mass-like opacities in a patient with chronic granulomatous disease, we should consider hyperinflammatory status and excessive granuloma formation of chronic granulomatous disease and start with high-dose steroid therapy as treatment.