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Background: A significant increase in the incidence of papillary thyroid carcinoma (PTC) in subjects exposed to radiation at a young age is a well-documented health consequence of the Chernobyl accident. The ongoing Thyroid Ultrasound Examination (TUE) program in children and adolescents of Fukushima Prefecture in Japan also indicated a high prevalence of PTC although its attribution to radiation exposure is a subject of debate. The objective of this study was to perform histopathological analysis of tumor architecture and invasive properties in (i) radiogenic post-Chernobyl and sporadic PTCs from Ukraine, and (ii) PTCs in patients from Fukushima and other Prefectures of Japan of comparable age groups. Methods: The Ukrainian radiogenic PTCs included 245 PTCs from patients who resided in three highly 131I-contaminated regions and 165 sporadic PTCs diagnosed in residents of the same regions who were born after the accident and therefore not exposed to radioiodine. The Japanese series included 115 PTCs detected during the preliminary and the first full-scale surveys of the TUE in Fukushima and 223 PTCs from patients resident in other Prefectures. All of the subjects were included in the main statistical analysis. Three additional analyses were performed limiting the subjects to children, adolescents, and adults. Results: Ukrainian radiogenic PTC was characterized by the higher frequency of tumors with a dominant solid-trabecular growth pattern and higher invasiveness, more frequent extrathyroidal extension, lymphatic/vascular invasion, regional and distant metastases when compared with sporadic Ukrainian PTC. The integrative "invasiveness score," based on five cancer characteristics, was also higher in the radiogenic group. The differences were most pronounced in children. In contrast, no significant differences in tumor morphology or invasiveness were observed between the two Japanese groups or the three age subgroups. The only statistically significant findings were the higher proportion of male patients, smaller mean tumor size, and higher frequency of T1b tumors in the Fukushima group. Conclusions: The difference in morphological features that indicate biological behavior of PTC between the radiation-related and sporadic groups from Ukraine, together with the lack of such in the two groups from Japan, strongly suggest a nonradiogenic etiology of PTC from Fukushima and other Prefectures.

Histological classification and cytology reporting format described in General Rules for the Description of Thyroid Cancer, the 8th edition (2019) (the Japanese General Rules) were briefly introduced. Moreover, the differences between "the Japanese General Rules", and WHO Histological Classification, the 4th edition (2017) and The Bethesda System for Reporting Thyroid Cytopathology, the 2nd edition (2018) were also explained. The Japanese General Rules did not accept the borderline lesions of thyroid tumor which were newly shown in WHO Histological Classification. We believe it is not necessary to introduce these borderline lesions in daily practice in Japan. Borderline lesions were proposed for avoiding over-surgery for thyroid cancer patients. In the United States, when the patient is diagnosed as malignant on cytology, total thyroidectomy is generally recommended. However, there is no over-surgery in Japan, because surgeons have several choices of treatment for thyroid cancer patients. This article is the first that the Japanese General Rules was shown by foreign language. Therefore, this will be advantageous to us when we present our opinion concerning histology and cytology of thyroid tumor to the world.

BACKGROUND Carcinosarcoma (spindle cell carcinoma) of the esophagus is an extremely rare event; the etiology and origins of this neoplasm have not yet been determined. Epithelial-mesenchymal transition (EMT) has been associated with invasion and metastasis, and may be related to the generation of a stem cell population within this tumor. CASE SUMMARY We present the case of a 61-year-old male with nausea and fever. Upper gastrointestinal endoscopy revealed the presence of type 1 and 0-IIc lesions located 35 cm from the incisors toward the esophago-gastric junction. Thoracoscopic esophagectomy was performed. Macroscopic analysis revealed three polypoid lesions in the abdominal esophagus that accompanied the main lesion in the lower thoracic esophagus and 0-IIc lesions that spread continuously with them. Histologically, the lesions included proliferating spindle cells. Adeno-carcinomatous components were detected in a section near the foot, and squamous cell carcinoma was identified in the mucosa at the base of the tumor. The patient was diagnosed with multiple carcinosarcomas, staged at pT1b (SM3), pN1 (#110, #7), cM0, Stage II (sarcomatous metastasis to the lymph nodes). Spindle cells did not express E-cadherin but were positive for EMT markers, including zinc finger E-box-binding homeobox 1, TWIST, and snail family transcriptional repressor 2. The patient has experienced no recurrence at 5 years and 2 mo after surgery. CONCLUSION This report suggests that multiple sarcomatous tumors may be generated from primary squamous cell carcinoma via mechanisms related to EMT.

Background Thyroid ultrasound screening for children aged 0 to 18 years was performed in Fukushima following the accident at the Fukushima Daiichi Nuclear Power Plant. As a result, many thyroid cancer cases were detected. To explore the carcinogenic mechanisms of these cancers, we analyzed their clinicopathological and genetic features. Methods We analyzed 138 cases (52 males and 86 females) who had undergone surgery between 2013 and 2016 at Fukushima Medical University Hospital. Postoperative pathological diagnosis revealed 136 (98.6%) cases of papillary thyroid cancer (PTC). Results The BRAFV600E mutation was detected using direct DNA sequencing in 96 (69.6%) of the thyroid cancer cases. In addition, oncogenic rearrangements were detected in 23 cases (16.7%). Regarding chromosomal rearrangements, 8 (5.8%) RET/PTC1, 6 (4.3%) ETV6(ex4)/NTRK3, 2 (1.4%) STRN/ALK, and 1 each of RET/PTC3, AFAP1L2/RET, PPFIBP/RET, KIAA1217/RET, ΔRFP/RET, SQSTM1/NTRK3 and TPR/NTRK1 were detected. Tumor size was smaller in the BRAFV600E mutation cases (12.8 ± 6.8 mm) than in wild-type BRAF cases (20.9 ± 10.5 mm). In the BRAFV600E mutation cases, 83 (86.5%) showed lymph node metastasis, whereas 26 (61.9%) of the wild-type BRAF cases showed lymph node metastasis. Conclusions The BRAFV600E mutation was mainly detected in residents of Fukushima, which was different from post-Chernobyl PTC cases with RET/PTC3 rearrangement. PTC with the BRAFV600E mutation was smaller but was shown in the high rate of central cervical lymph node metastasis than the wild-type BRAF PTC in the young population of Fukushima.

Neuroendocrine tumors of the thyroid gland are generally considered to derive from parafollicular endocrine cells (C cells) and are generally referred to as medullary thyroid carcinomas (MTC). Calcitonin secretion is almost always detected in MTC and a prerequisite for both clinical and pathological diagnosis. Thyroid neuroendocrine tumors without any apparent calcitonin secretion reflect a diagnostic dilemma because non-calcitonin-producing MTCs have virtually not been characterized. Here, we report a case of primary thyroid neuroendocrine tumors lacking calcitonin secretion or expression. The tumor cells expressed cytokeratins, chromogranin A, and synaptophysin, all of which were consistent with epithelial and neuroendocrine differentiation. Thyroid transcription factor-1 paired box gene 8, and carcinoembryonic antigen were also immunohistochemically detected, consistent with its thyroid origin. However, the tumor was negative for calcitonin both by immunohistochemistry and in situ hybridization, hence, not meeting the definition of MTC. Despite the loss of calcitonin expression, immunoreactivity for the calcitonin-gene-related peptide was detected in the tumor. Somatic gene mutations of RET, H-RAS, K-RAS, or BRAF were not detected in this case. A limited number of calcitonin non-producing thyroid neuroendocrine tumors are available in the scientific literature available in English, and its etiology and clinical manifestations remain largely unknown. Our case, along with the rare, previously reported cases, suggests that calcitonin non-producing neuroendocrine tumors of the thyroid gland are most likely derived from C cells, but should be differentiated from ordinary MTCs.

We report a histologically pure stage 1 seminoma with an elevated human chorionic gonadotropin (hCG). A 38 year-old man was referred for the evaluation of the left testicular swelling. He showed an elevated serum hCG level of 25,265 mIU/ml with normal a fetoprotein and lactate dehydrogenase. Imaging showed heterogeneous tumor without any metastatic lesions. We conducted 4 courses of chemotherapy before detecting hCG nadir. The final pathological report showed pure seminoma with syncytiotrophoblastic cells but no choriocarcinoma components. The patient remains disease free until present time. The case raised several questions regarding diagnosis and treatment strategy for bulky testicular seminoma.

Comprehensive crystal structural study is performed for BiFeO3 (BFO) film grown on KTaO3 (KTO) substrate using transmission electron microscopy (TEM) and x-ray diffraction (XRD). Nano-beam electron diffraction (NBED) combined with structure factor calculation and high resolution TEM images clearly reveal that the crystal structure within BFO thin film is rhombohedral BFO, i.e., bulk BFO phase. Epitaxial relationship found by NBED indicates the BFO film grows in a manner that minimizes lattice mismatch with KTO. It further suggests BFO film is under slight biaxial tensile stress (~0.35%) along in-plane direction. XRD reveals BFO lattice is under compressive stress (~1.6%), along out-of-plane direction as a result of the biaxial tensile strain applied along in-plane direction. This leads to Poisson’s ratio of ~0.68. In addition, we demonstrate (1) why hexagonal notation rather than pseudocubic one is required for accurate BFO phase evaluation and (2) a new XRD method that shows how rhombohedral BFO can readily be identified among other phases by measuring a rhombohedral specific Bragg’s reflection.

Background and study aims: Intramucosal vascular density differs between differentiated and undifferentiated type gastric carcinomas. This study aimed to evaluate the microvascular density characteristics of these two types of carcinoma using magnifying endoscopy with narrow-band imaging (ME-NBI). Patients and methods: In total, 42 differentiated and 10 undifferentiated types were evaluated. The microvessels observed using ME-NBI were extracted from stored still images and the microvascular density in the two carcinoma types was analyzed. Histological vascular density in resected specimens was also evaluated using CD34 immunostaining. Results: There were significant differences between the microvascular density in the differentiated and undifferentiated types of carcinoma (10.02 ± 4.72 % vs 4.02 ± 0.40 %; P

A one-year, four month-old boy who had suffered from Kawasaki disease died suddenly during convalescence despite intensive gamma-globulin treatment. Autopsy revealed a) sausage-like aneurysms of the left and right coronary arteries and fresh thrombosis in the right coronary aneurysm, b) fresh transmural myocardial necrosis in the whole wall of the left ventricle and the anterior part of the wall of the right ventricle, and c) swelling of the cervical lymph nodes and thymus (60 g). Histologically, fibrocellular thickening of the intima and destruction of the media and internal elastic lamina were conspicuous in the area of the aneurysm, but those of the intima and media in the areas adjacent to the aneurysm were mild. Abrupt narrowing of the lumen at the border between the aneurysm and periphery of the right coronary artery was detected, and this may have been responsible for formation of the thrombus in the right coronary aneurysm. In the systemic arteries, perivascular fibrosis was very noticeable despite less severe injury to the intima and media. These findings suggest that severe inflammation of the periarterial regions was present in the acute phase. The lymph system still showed inflammation, supporting the infectious or toxic nature of Kawasaki disease.

UNLABELLED Conduction defect caused by lamin A/C gene mutation. INTRODUCTION Mutations of lamin A/C gene (LMNA) cause dilated cardiomyopathy (DCM) with atrioventricular (AV) conduction defect, although the electrophysiological and histological profiles are not fully understood. METHODS AND RESULTS We analyzed a large Japanese family (21 affected and 203 unaffected members) of DCM with AV block. The responsible LMNA mutation of IVS3-10A>G was novel and caused an aberrant splicing. The first clinical manifestation was low-grade AV block or atrial fibrillation (AF), which developed in affected members aged >or=30 years. We observed that the AV block progressed to third-degree within several years. The electrophysiological study of the four affected members revealed an impairment of intra-AV nodal conduction. Because of advanced AV block, pacemakers were implanted in 14 out of 21 affected members at the mean age of 44 years. Three affected members died suddenly and two affected members died of heart failure and/or ventricular tachycardia (VT) even after the pacemaker implantation. Postmortem examination showed conspicuous fibrofatty degeneration of the AV node. Endomyocardial biopsies showed remarkably deformed nuclei and substantial glycogen deposits in the subsarcolemma. CONCLUSION The clinical phenotype in this family was characterized by (1) the first manifestation of the prolonged PQ interval or AF in adolescence, (2) progressive intra-AV nodal block to the third degree in several years, and (3) progressive heart failure after pacemaker implantation. Histological study revealed preferential degeneration at the AV node area and novel cellular damages in the working myocardium.

This study calls attention to a new syndrome presenting with gastrointestinal symptoms including abdominal pain, vomiting, and/or hematemesis and endoscopic multiple lesions predominantly in the descending duodenum, without the skin rash observed in Henoch–Schonlein purpura. We examined the gastrointestinal mucosa for IgA deposits in nine children and compared the results with those for three patients with Henoch–Schonlein purpura. In addition, gastroduodenal biopsy specimens of 11 patients with various diseases were studied as controls for IgA staining. Intestinal histology showed nonspecific mucosal inflammation without vasculitis. In six patients without rash (67%), IgA deposition was observed in the capillary wall with the same staining pattern as seen in two patients with Henoch–Schonlein purpura. Compared with the controls (9%), the positive rate of IgA deposition was significantly higher in nonrash patients (P&

Gastrointestinal phenotype in cervical adenocarcinomas was examined by immunohistochemistry and correlated with morphologic features. Antibody panels included anti-MUC2, MUC6, CD10, chromogranin A (CGA) and HIK1083. In addition, expression of p16INK4, a cyclin-dependent kinase inhibitor which is expressed in a variety of high-risk HPV-related conditions, was studied. A total of 94 invasive adenocarcinomas including 20 minimal deviation adenocarcinomas (MDAs) and 72 adenocarcinomas in situ (AIS) were examined. MDAs were most frequently positive for HIK1083 and/or MUC6, two representative gastric markers, with a rate of 95%, followed by intestinal-type adenocarcinomas (IAs) with a rate of 85% whereas only 27% of 56 usual endocervical-type adenocarcinomas (UEAs) were positive. MUC2, a goblet cell marker, was positive in 85% and 25% of IAs and MDAs, respectively, while in only 14% of UEAs. CD10 was positive in 15% of IAs, indicating incomplete intestinal differentiation without a brush border in most of the cases. CGA-positive cells were frequently seen in MDAs and IAs with rates of 60% and 62%, respectively. Nuclear and cytoplasmic p16INK4 positivity was identified in 93% of UEAs, whereas 30% of MDAs were positive for p16INK4. Results in AISs were comparable to their invasive counterparts, but morphologically usual-type AISs identified in eight cases of MDA were frequently positive for HIK1083 (75%) and MUC6 (63%), and p16INK4. Of note was the existence of lobular endocervical glandular hyperplasia (LEGH) with atypical features including cytologic abnormalities, and/or papillary projection, which were identified in this study in pure form (n=3) or in association with MDAs (n=6), but not in cases of other types of adenocarcinomas. These observations indicate that gastrointestinal phenotype is frequently expressed in MDAs and IAs, and there seems to be a possible link between MDA, and LEGH and morphologically usual-type AIS with gastric immunophenotype in histogenesis. Frequent absence of p16INK4 expression in MDAs suggests a possibility that high-risk HPV does not play a crucial role in development of MDAs, in contrast to the majority of endocervical adenocarcinomas. p16INK4 immunohistochemistry appears to be a promising diagnostic tool, but pathologists should be aware of frequent negative staining in MDAs, which can be a source of erroneous diagnosis.

Chronic gastritis is frequently associated with infection of Helicobacter pylori and characterized by tissue infiltration of neutrophils, lymphocytes, and plasma cells. To address the mechanism of lymphocyte infiltration in chronic gastritis, we examined the expression of chemokines and their receptors using frozen sections of chronic gastritis, obtained from 23 patients who underwent gastrectomy for gastric cancer. By immunohistochemistry, lymphocytes in inflamed gastric mucosa expressed CCR5 abundantly, CXCR3 less frequently, and CCR4 sparsely. The numbers of CCR5(+) cells, which were composed of mainly CD8(+) and partly CD4(+) T cells, were positively correlated with the degree of neutrophil infiltration, and decreased in areas with intestinal metaplasia or mucosal atrophy. RANTES/CCL5, one of the ligands of CCR5, was localized mainly in CD8(+) and partly CD4(+) T cells with a characteristic dotted pattern, and such lymphocytes were most densely distributed around the neck region of gastric glands. In situ hybridization confirmed the expression of CCL5 mRNA in these cells, and immunoelectron microscopy revealed localization of CCL5 in the membrane-bound granules, which most probably corresponded to the cytolytic granules of cytotoxic T cells. The numbers of CCL5(+) lymphocytes showed a close correlation with the degree of neutrophil infiltration and markedly decreased in intestinal metaplasia. In conclusion, our data suggest that, together with neutrophils, CCL5(+) T cells, presumably activated cytotoxic T cells, would play important roles in the active inflammatory process of chronic gastritis. Our data also suggest a self-recruiting mechanism involving CCR5 and CCL5 for tissue accumulation of such T cells.

This pictorial essay depicts MR features of benign and malignant parotid tumors. Increased T2 signal intensity is suggestive of pleomorphic adenoma. Tumors with relatively low signal intensity on T2-weighted images are more likely to be malignant even when they are well-demarcated. Fat suppression technique improves the ability to define the boundaries of neoplatic or inflammatory lesions.

The cases of five thyroid tumors were presented and discussed at an international case conference held during the 5th Annual Meeting of the Japanese Endocrine Pathology Society. There was significant disagreement among six pathologists who studied the cases. In this article, we present two of the cases, attempt to explain the reason for disagreement in their diagnoses, and propose what should be done to obtain better consensus in diagnosis.

Background. It is known that abnormal lipid depositions are shown in some renal glomerular diseases. Electron microscopic findings have shown materials with varying degrees of intracytoplasmic electron density, but it has been difficult to prove that they are truly lipids. Methods. Routinely processed Epon-embedded specimens from seven patients with known renal diseases were utilized in this study. Ultrathin sections were cut, and examined by electron microscopy. Then serial 1-μm-thick sections were made stained with Sudan IV. Results. Several patterns of lipid deposition with varying electron densities within the glomeruli were observed by electron microscopy. These lipid depositions were positive for Sudan IV, but showed different colors according to their electron density. Conclusions. The procedure used in the study enables us to recognize light- and electron-microscopic findings of abnormal lipid depositions in serial sections, and may be useful in helping us to simultaneously evaluate the site and nature of these histopathological phenomena.

Two child and three elderly patients underwent craniotomy for organized and/or partially calcified chronic subdural hematomas (CSHs). The characteristic feature of magnetic resonance imaging was a heterogeneous web-like structure in the hematoma cavity. Both children had undergone one side subduroperitoneal shunt for bilateral CSHs when infants. As a result, the opposite hematoma cavities persisted and developed into calcified CSHs after a couple of years. All three elderly patients with senile brain atrophy showed various systemic complications such as cerebral infarction, diabetes mellitus, leg ulceration, cirrhosis, and bleeding tendency. Craniotomy for removal of the hematoma and calcification achieved good results in all patients. Subdural space created by shunt, craniotomy, or brain atrophy and persisting for a certain period, and additional various brain damage such as microcirculatory disorder, meningitis, encephalitis, or premature delivery may be important in generating calcified or organized CSH.

Serum HER-2/neu (c-erbB-2) levels in patients with gastric cancer were evaluated by an enzyme-linked immunosorbent assay and tissue levels of HER-2/neu in the same cohort were determined by immunohistochemistry. Nine (16%) of 57 gastric carcinomas had an overexpression of HER-2/neu detected immunohistochemically. Of these 9 patients, 6 had elevated serum HER-2/neu levels, while 45 of 48 tissue samples with negative staining exhibited normal serum HER-2/neu levels. These results indicated that overall accuracy, positive predictive value, and negative predictive values of their serum measurements were 89, 67 and 94%, respectively. Serum levels of HER-2/neu were correlated with tissue overexpression of HER-2/neu in patients with gastric cancer.

Purpose: The aim of this study was to characterize the CT features of retroperitoneal neurilemmoma. Methods: The CT findings were reviewed in seven patients with retroperitoneal neurilemmoma. Results : All of the tumours were well-demarcated round or oval masses. In five cases, heterogeneous contrast enhancement was noted after contrast medium administration. Areas of minimal enhancement reflected diffuse edema in one tumour. Areas without definite enhancement represented prominent cyst formation in three tumours. There were three cases with tumour calcification (two with punctate calcification and one with mottled calcification). Conclusion: CT findings may suggest the diagnosis of retroperitoneal neurilemmoma preoperatively.

Although nephroblastoma is the commonest renal tumor of childhood, it is rare in adults. In cases of predominantly epithelial type occurring in adulthood, it might be difficult to distinguish it from papillary renal cell carcinoma and metanephric adenoma. Here, we report three cases of adult epithelial nephroblastoma in 24-, 76-, and 21-year-old females. Histologically, the tumors were composed of papillotubular architectures of small and uniform tumor cells with high nucleocytoplasmic ratio without blastemal element. Immunohistochemically, the tumor cells were positive for WT-1 and CD57 but negative for AMACR, which was helpful to exclude the possibility of papillary renal cell carcinoma. Metanephric adenoma is a benign tumor, which can be distinguished by the observation of the cellular atypism and growth pattern. However, nephroblastoma with predominant epithelial element mimics the malignant counterpart of metanephric adenoma, that is, “metanephric adenocarcinoma.”

In patients with Henoch-Schönlein purpura (HSP) presenting with severe gastro-intestinal (GI) symptoms, IgA deposition was studied in endoscopically obtained mucosal biopsies. A total number of 11 patients (male, 7; female, 4) were enrolled in this study; 7 patients underwent upper GI endoscopy and biopsy 1 underwent sigmoidoscopy and 3 underwent both. Upper GI endoscopy in each patient showed various mucosal changes including redness, petechiae, erosions, and ulcerations, most predominant in the second part of the duodenum. Sigmoidoscopy demonstrated no abnormality in two of four patients. Intestinal deposition of IgA was positive in 7 of 11 patients with HSP. Histological examination showed non-specific inflammation of varying degrees in each patient, but no small vessel vasculitis was observed. IgA deposits were seen in only 2 of 23 control subjects with various GI diseases. Positive rate of IgA deposition per patient was significantly higher in patients with HSP than in controls (P0.005).IgA deposition in the GI tract, as in the skin and kidneys, is characteristic of HSP. Intestinal IgA deposition complements the diagnostic criteria of HSP.

( E u j h w p w t t a b d e z m s a c Endoscopic submucosal dissection (ESD) has become the standard treatment for large gastric neoplasms because it allows adequate histological assessment of the depth and lateral spread of the tumor and because local recurrence after multiple-fragment resection is significantly higher than that after en bloc resection. To perform effective and safe ESD, an appropriate endoscopic view is essential; however, there are some locations in which it is difficult for the tip of the endoscope to reach the target. Some tumors are located where it is difficult to get the tip of the endoscope close to the tumor, such as the lesser curvature or anterior wall of the gastric body and lesser curvature of the angulus. To facilitate ESD treatment in these locations that are difficult to reach, we have developed a novel device that can be attached to a conventional endoscope, namely, a one-sided, expandable balloon (OEB).

The case of a 13 year old boy with an inflammatory esophagogastric polyp and ulcerative colitis is described. Endoscopy revealed a typical polyp and gastric fold complex at the esophagogastric junction and a hiatal hernia. Histology of a biopsy specimen confirmed an inflammatory polyp covered by hyperplastic squamous and gastric foveolar epithelium. Continuous 24 hour esophageal manometry suggested gastroesophageal reflux, which may be related to the pathogenesis of the lesion. Follow-up endoscopy showed marked regression of the polyp with medication for reflux esophagitis. This clinical entity is rare in childhood and adolescence, and the manifestations may not be readily recognized. Therefore, endoscopic biopsy is important in children with esophageal polyps. However, polypectomy is unnecessary except when malignancy is suspected or when symptoms persist.

We have performed immunohistochemical and immunochemical studies of steroidogenic enzymes involved in estrogen biosynthesis in 30 cases of gastric carcinoma in order to investigate possible in situ production of estradiol (E 2) in carcinoma cells. Positive incidence of immunoreactivity for E 2, testosterone (T), cholesterol side-chain cleavage enzyme (P-450 scc) and aromatase (P-450 arom) were 17/30 (56.7%), 11/30 (36.7%), 3/30 (10.0%) and 23/30 (76.7%), respectively on light microscopy. Estrogen receptor (ER) immunoreactivity was not observed in any of the 30 cases examined. Normal gastric mucosa was negative for P-450 arom and P-450 scc. Examination of serial sections revealed that immunoreactivity of E 2 and P-450 arom were located in the same cells of carcinomatous glands. Immunoelectron microscopy demonstrated that E 2 and P-450 arom were located along the membrane and cisternae of smooth endoplasmic reticulum (sER). Western blot analysis showed one major band of 55 kDa of P-450 arom in the gastric carcinoma tissues examined. Retrospective analysis of immunohistochemistry of E 2 in 108 cases of gastric carcinoma revealed that E 2 positive carcinoma cases were likely to demonstrate better survival rate than negative cases. These results above strongly suggest that E 2 is produced by de novo expressed aromatase in gastric carcinoma cells and is possibly involved in the biology of gastric carcinoma cells.

During the primary culture of spleen fragments of newborn mice, a spherical body (d = circa 200 to 300 microns) as a three-dimensional cellular organization was formed. Continued production of blood cells from the spherical body was observed without changing its size for about 2 months of culture. Without growth factor, the spherical bodies produced mainly lymphocytes and macrophages. Addition of interleukin-3 enhanced their granulocyte formation, and this enhancement was observed even after a prolonged maintenance without growth factors. The spherical bodies were composed of a uniform mixture of endothelial cells and fibroblasts within the body, and cell-cell contacts between lymphocytes and fibroblasts were notable in the periphery. With prolonged culture, the spherical bodies showed a definite change in their structure by sorting two cell types and the blood cell production gradually decreased. These results suggested that a three-dimensional structure was required for the maintenance, growth, and differentiation of blood cell progenitors in the long-term spleen culture.

A 62-year-old-male with old inferior myocardial infarction suffered from drug resistant electrical storms and frequent shocks from an implantable cardioverter defibrillator. Emergent radiofrequency catheter ablation was performed. The patient underwent substrate mapping that uses an electro-anatomical mapping system during sinus rhythm because of multiple QRS morphologies and hemodynamic instability during ventricle tachycardia. The electro-anatomical map revealed a massive low voltage zone (

In this study we investigated the immunohistochemical localization of a unique aromatase, a single protein of 51,000 daltons, in the human placenta and ovary at light and electron microscopic levels. Microwave fixation was adopted for the immunoelectron microscopic study because it is an excellent method for preserving antigenicity and subcellular structures in frozen sections. Tissue samples from four immature human placentas, four full-term human placentas, and two human ovaries fixed in 10% formalin were examined by light microscopy. In addition, tissues from three full-term human placentas and one immature human placenta fixed in 4% paraformaldehyde were examined by electron microscopy. By light microscopy, immunoreactivity for this aromatase was located in the syncytiotrophoblast and a part of the cytotrophoblast of the placenta and in the lutein and granulosa cells of the ovary. Immunoelectron microscopy revealed that the aromatase antigen was localized on the surface of the microvilli, the lateral plasma membrane, and in the endoplasmic reticulum (ER) in the syncytiotrophoblast of the placenta. The positive immunoreactivity in the syncytiotrophoblast ER is consistent with previous results using antibodies for other types of aromatase, whereas the reactivity on the microvilli has not been previously described. The present report describes the fine localization of this unique aromatase in placental and ovarian tissues; its localization on the plasma membranes requires further physiological investigation.

Microwave (MW)-stimulated fixation was applied to surgical pathology and preembedding immunoelectron microscopy. Fresh specimens were microwavedin the fixatives for 15-30sec using a conventional MW oven (500W) containing 200ml of water load. The temperature of fixatives was raised to 35-45°C. After MW radiation, the specimens were kept in the same fixatives for 1-4hr at 4°C or at room temperature as the postfixation procedure, which was important for the completion of chemical fixation of whole specimens. For light microscopical examination, buffered 10% formalin was used. Hematoxylin-eosin staining from paraffin-embedded specimens was completed within 24hr with excellent preservation of morphology and immunoreactivity. For conventional electron microscopy, MW fixation in 2.5% glutaraldehyde-2% paraformaldehyde showed excellent preservation of cell organelles. For immunoelectron microscopy by the preembedding method, 4% paraformaldehyde solution containing 0.1% glutaraldehyde was used, followed by one hr postfixation. Simultaneous improvement of both ultrastructure and antigenicity were obtained without any significant changes of the results. Our results indicate that MW-stimulated fixation with postfixation procedure is a useful tool for various fields of morphological investigations, and its beneficial effects were most remarkable for the preembedding immunoelectron microscopy technique.

A case of Castleman disease in the anterior cervical region is presented. Ga-67 scintigraphy revealed moderate uptake in the thyroid region. Thyroid scintigraphy demonstrated the presence of an extrinsic thyroid tumor. Contrast-enhanced CT showed dense homogeneous enhancement within, the tumor. Radionuclide tracer accumulation on gallium scintigraphy as well as dense contrast enhancement on CT scan may be characteristic of Castleman disease. Castleman disease should be considered in the differential diagnosis when increased tracer activity is noted in an anterior cervical extrathyroid tumor on Ga-67 scintigraphy.

The incidence of intracranial aneurysms in childhood is rare, especially in infancy. Spontaneous thrombosis of a cerebral aneurysm in a child is very rare, particularly in a non-giant aneurysm. We report a case of a 1-month-old girl with a distal anterior cerebral artery aneurysm which disappeared spontaneously after subarachnoid hemorrhage and reappeared 6 months later. Surgical resection of the aneurysm was performed and she discharged uneventfully 10 days later. Histological examination revealed an aneurysm with a fibrous muscular layer, absence of the internal elastic lamina and partial hypertrophy of the intimal layer. Though the pathogenesis of this aneurysm is uncertain, two hypotheses are discussed.

CXC chemokine receptor 1 (CXCR1) is one of the important receptors for CXC chemokines with ELR motif, of which interleukin 8 (IL-8; CXCL8) is representative. To identify the cell type(s) of CXCR1-expressing cells in inflamed stomach and gut tissues, we performed immunoperoxidase method using pre-fixed frozen sections. In chronic gastritis associated with Helicobacter pylori infection (7 cases), CXCR1 was positive in neutrophils (polymorphonuclear leucocytes) in the lamina propria near the neck region and those in pit abscess. In ulcerative colitis (6 cases) and Crohn’s disease (5 cases), CXCR1 was sporadically expressed by neutrophils in the mucosa, and particularly CXCR1+ neutrophils were abundantly distributed in inflammatory granulation tissue in ulcer base. Double staining confirmed co-localization of CXCR1 and neutrophil elastase. Neither CD3+ T lymphocytes nor CD68+ macrophages were positive for CXCR1. Immunoelectron microscopy confirmed the cell surface localization of CXCR1. Neutrophils protect the host from microbial pathogens. However, they also cause damages to host tissues in chronic inflammation. Therefore, our study underscores the importance of CXCR1 expression in inflammatory processes.

We encountered two unique cases of papillary carcinoma of the thyroid gland forming fibroma-like nodular tumors. The two cases showed well-defined nodules composed largely of fibromatosis-like stroma with small foci of papillary carcinoma. This type of tumor is relatively rare and has been reported with the name of 'papillary carcinoma of the thyroid with fibromatosis-like stroma or nodular fasciitis-like stroma'. The stromal cells have had myofibroblastic features in all reported cases, including the present cases. The pathogenesis of this tumor is still unknown. We must be careful to differentiate this type of thyroid tumor from fibrosarcomatous anaplastic carcinoma, particularly in the intraoperative consultation. We speculate that this unique tumor is an autonomous proliferation of stromal cells, based on the immunohistochemical analyses of early stromal changes in usual-type papillary carcinoma of the thyroid. The present names of this disease may not represent the proper features of this tumor because all the reported cases formed fibroma-like nodules. We propose the name 'papillary carcinoma forming myofibroblastic nodular tumors'.

We investigated the static and dynamic magnetic properties of thin films of Mn-Co-Ga Heusler compound. Gilbert damping and exchange stiffness constants of the films were evaluated by using the ferromagnetic resonance technique in the X-band regime (f = 9.4 GHz). By analyzing the experimental spectra, magnetic parameters of the films such as the line width and the Gilbert damping were deduced, and the exchange stiffness constant was estimated from the perpendicular standing spin-wave resonance. The Gilbert damping constant was estimated to be 0.017 in a specific film composition. The exchange stiffness constant showed a linear dependence on the film composition.

To examine whether or not optically clear nuclei are one of the fixation artifacts in papillary carcinoma of the thyroid. Experiments using an optimal immersion fixation method by making thin-sliced specimens, 5 × 2 × 2 mm in size were adopted. Fixatives tested were 10% formalin, 10% buffered formalin, mixture of alcohol and formalin (4 : 1), 95% alcohol, 4% phosphate-buffered paraformaldehyde, Carnoy’s fixative, Bouin’s fixative and various concentrations of formalin. Tested thyroid lesions in total were: cases with papillary carcinoma (38); follicular carcinoma (one); follicular adenoma (15); adenomatous goiter (11); Hashimoto’s thyroiditis (two); Grave’s disease (five); and normal thyroid tissue around tumor (five). Routinely processed papillary carcinoma showed a high occurrence (64.6%) of the optically clear nuclei contrasted by a low occurrence (almost 0%) in other lesions. However, this rate in papillary carcinoma decreased (< 35.3%) in all experimental groups irrespective of the choice of fixatives. Frequent occurrence (61.9–66.6%) of the optically clear nuclei was reproduced in papillary carcinoma fixed in a higher concentration of formalin (40–60%) in the experimental groups. These results demonstrated that the optically clear nuclei are one of the fixation artifacts, although still useful as a diagnostic criterion.

A patient with an intermediate state of human T lymphotropic virus type I (HTLV-I) infection and in whom autopsy showed multiple organ failure (MOF) associated with extensive metastatic calcification in systemic organs is described. A 56-year-old man presented with signs and symptoms of advanced cardiac insufficiency, respiratory disturbance and renal failure. Serologically, the anti-human T lymphotropic virus type I (HTLV-I) antibody titer and the levels of both calcium and parathyroid hormone-related peptide (PTHrP) were distinctly elevated. These data suggested a diagnosis of adult T cell lymphoma/leukemia (ATLL). However, examination of a peripheral blood sample revealed only a few atypical lymphoid cells (3%) associated with mild leukocytosis (white blood cell count, 13.7 x 10(3)/mm3). Lymph node swelling was systemic but mild, with some nodes up to 10 mm in diameter. The patient died of MOF. Adult T cell leukemia/lymphoma was unable to be diagnosed definitively because of the short duration of laboratory abnormalities and because of the discrepancy between the laboratory data and the magnitude of lymphoproliferation in both the lymph nodes and peripheral blood. At autopsy, the most conspicuous finding was extensive metastatic calcification in the multiple organs, including the heart, lungs, kidneys, tongue, liver, pancreas, spleen and systemic arterial walls. Very small numbers of medium-sized atypical lymphoid cells admixed with small reactive lymphocytes were identified in multiple organs, with no evidence of massive infiltration. Molecular analyses could not detect monoclonal integration of HTLV-I provirus DNA or monoclonality of T cell lineage cells. Parathyroid hormone-related peptide was demonstrated in the cytoplasm of the atypical lymphoid cells on immunohistochemical examination. The bone trabeculae generally showed distinct evidence of resorption associated with marked proliferation of osteoclasts. These findings suggested that the hypercalcemia in the present case was categorized as humoral hypercalcemia of malignancy rather than local osteolytic hypercalcemia.

Objective. To evaluate the efficacy and safety of omeprazole-based dual and triple regimens for the treatment of children with Helicobacter pylori infection. Methods. Twenty-two patients (3 with gastric ulcer, 12 with duodenal ulcer, and 7 with nodular gastritis alone) were studied. Twelve ulcer patients also had nodular gastritis. The dual regimen included a 2-week course of omeprazole (0.6 mg/kg twice a day) and amoxicillin (30 mg/kg twice a day) (n = 10), and the triple regimen included the dual regimen plus clarithromycin (15 mg/kg twice a day) (n = 12). In patients with active ulcers, omeprazole once daily was administered for another 4 weeks. Endoscopic biopsies were taken before therapy and 4 weeks after completion of a 2-week course of therapy, and patients were followed for 6 months. The gastritis score (grade 0 to 3) and serum anti-H pylori IgG antibody titers were also determined. Results. The regimens were tolerated by all patients. Eradication rates for the dual and triple regimens were 70% and 92%, respectively. Active ulcers completely healed within 6 weeks. Patients with nodular gastritis alone showed different clinical responses to therapy. Pretreatment histology showed chronic gastritis in all patients. Successful H pylori eradication significantly reduced the mean gastritis score from 2.9 to 1.3, but unsuccessful eradication did not reduce it. The disappearance of antral nodularity often coincided with the success of eradication. Successful eradication significantly decreased pretreatment serum anti-H pyloriIgG antibody titers by 29% at 1 month, by 52% at 3 months, and by 67% at 6 months. Side effects were mild and were reported in 23% of patients. Conclusion. An omeprazole-based regimen is safe and may be a better option for eradication of H pylori in children. Antral nodularity is a macroscopic marker of H pyloriinfection.

We report a case of ductal carcinoma in situ (DCIS) of the breast detected by ultrasonographic mass screening in a 51-year-old woman. In a mass screening program for breast cancer, physical examination with inspection and palpation, and ultrasonography (US) were performed. A hypoechoic mass with a slightly irregular margin was detected by US in the lateral upper quadrant of the right breast, at a distance 2 cm from the edge of the nipple. The mass was not detected by physical examinations or by mammography (MMG). The mass, which measured 0.8 × 0.5 cm and was examined by fine needle aspiration biopsy (FNAB) under US guidance, was cytologically diagnosed as class V. Modified radical mastectomy (Auchincloss method) was performed with the patient’s consent. Pathological examination of the resected specimen revealed DCIS (noncomedo type) and occult multiple foci of malignancy which was considered tracking centripetally underneath the nipple. This case suggests that US and FNAB performed under US guidance are useful in the detection and diagnosis, respectively, of a breast mass. We should take multifocality into consideration, particularly with tendency tracking to the nipple, in the treatment of small breast cancers such as DCIS.

The authors report a case of adult T-cell leukemia/lymphoma (ATLL) involving lymph nodes, skin, and spleen. Human T-lymphotropic virus type I (HTLV-I) infection predisposes to the genesis of ATLL. Ga-67 scintigraphy is useful to evaluate the extent and distribution of ATLL in HTLV-I-positive individuals.

This study was designed to investigate ultrastructural changes in parietal cells during treatment with omeprazole. Endoscopic biopsies were performed in patients treated with omeprazole (n = 2) and cimetidine (n = 4) and in normal controls (n = 3). In the patients who received omeprazole, many parietal cells (90.9 and 66.6%) were in the "stimulated" or "partially stimulated" stage. As reported previously, our results suggest that omeprazole fails to prevent the morphological transition of parietal cells to an actively secreting phase, although it strongly inhibits acid secretion. The altered cells frequently demonstrated more marked dilation of the secretory canaliculi, compared with those of normal controls and cimetidine-treated patients. Vacuolation was found in one patient given omeprazole and one given cimetidine. In the former patient, initial famotidine treatment also led to the vacuolation of parietal cells. However, this change does not seem to imply serious parietal cell degeneration. There were no adverse morphological changes in mitochondria and nuclei in any of the groups. In conclusion, vacuolation is not specific to omeprazole. Moreover, if omeprazole is administered at a pharmacologically effective dosage for a short period of time, it may not have serious effects on the ultrastructure of human parietal cells.

We experienced a case of apocrine carcinoma of the breast that is relatively rare. A 42-year-old woman was seen at the faculty because of a right breast tumor. On palpation, there was a well-demarcated mass measuring 1 cm in diameter in AE area of the right breast. Aspiration cytology was carried out, because breast cancer was suspected by breast ultrasonography. Cytological findings of aspirates showed cellular atypism and intracellular eosinophilic granules. Apocrine metaplasia or apocrine carcinoma was pointed out. On preoperative biopsy, the histological structure looked like scirrhous or solid-tubular carcinoma. All cancer cells showed large cubic ones and strongly acidophilic stain and a part of cells showed “snouts projection” in the duct. Histopathological diagnosis was made with apocrine carcinoma. Modified radical mastectomy was performed. Postoperative classification was T1n0m0 in stage 1. She is now doing well without recurrence as of 26 months after the operation

O,p'-DDD is used for the treatment of adrenocortical carcinoma and Cushing's disease. The inhibitory effect of this drug on the adrenal steroid biosynthesis has been described by many authors, but there are very few reports about the sites of action of this drug on adrenal steroid synthesis. This paper presents in vitro studies on adrenal steroidogenesis and hepatic steroid metabolism. The effects of o,p'-DDD on adrenal 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD), 11 beta-hydroxylase (11 beta-OHlase) and 18-hydroxylase (18-OHlase) were examined in vitro using mitochondrial and microsomal fractions prepared by standard centrifugation procedures from the homogenate of bovine adrenal cortices. The concentrations of o,p'-DDD inducing 50% inhibition of 3 beta-HSD, 11 beta-OHlase and 18-OHlase were 8 X 10(-6) M, 1 X 10(-5) M and 3 X 10(-6) M, respectively. This study clearly demonstrates the marked inhibitory effects of o,p'-DDD on 3 beta-HSD in vitro, which was not described previously. The inhibitory effects of o,p'-DDD on these 3 enzymes were diminished by an addition of 0.05 approximately 0.5 mM of cofactor (NADPH or NAD). The results indicate that o,p'-DDD may reduce NADPH or NAD utilization, resulting in the inhibition of steroidogenesis. The effects of o,p'-DDD on hepatic 5 beta-reductase were examined in vitro using rat liver homogenate. O,p'-DDD inhibits 5 beta-reductase, resulting in the decrease of conversion of cortisol to dihydrocortisol and tetrahydrocortisol at the concentration of 10(-3) M.

In order to survey the enzymic activities of steroidogenesis in functioning adrenocortical tumors, we investigated the activities of steroid 21-hydroxylase and 17 alpha-hydroxylase in microsomal fractions of 12 surgically resected adrenocortical tumors associated with Cushing's syndrome (5 adenomas and one carcinoma), primary aldosteronism (5 adenomas) and adrenogenital syndrome (AGS) (one carcinoma), and one adrenocortical hyperplasia resulting from Cushing's disease. Seven adrenal cortices from the patients with mammary carcinoma, renal cell carcinoma or pheochromocytoma were used for normal control. In normal controls 21-hydroxylase activities with progesterone as a substrate were 1.61 +/- 0.25 nmole/min/mg protein and those with 17 alpha-hydroxyprogesterone were 5.22 +/- 1.06 nmole/min/mg protein. The activity of 21-hydroxylase was higher in four cases of 5 aldosteronomas than in normal controls. Those activities in Cushing's adenomas were in the range of normal controls in this study. 17 alpha-hydroxylase activities were much variable from case to case even though in normal controls (4.50 +/- 2.40 nmole/min/mg protein), and in most cases of adenomas 17 alpha-hydroxylase activities were in the range of normal controls. Activities of both hydroxylase in carcinomas were lower than in normal controls. The present paper showed the abnormal steroidogenic enzyme activities in aldosteronomas and adrenocortical carcinomas.

Premenopausal female smokers show significantly increased estrogen 2-hydroxylation, which may account in part for the anti-estrogenic effects of cigarette smoking. We have measured five major urinary estrogens, including estradiol (E2), estrone (E1), 16 alpha-hydroxyestrone (16 alpha OHE1), estriol (E3), and 2-hydroxyestrone (2OHE1), in premenopausal female smokers and non-smokers, to determine whether increased C-2 hydroxylation affected the urinary excretory patterns in these subjects. While total measured estrogen excretion in the follicular phase did not differ significantly between the two groups, urinary 2OHE1 among the smokers constituted a significantly greater proportion of the total (31.1 vs 18.2%, P less than 0.02). This difference was largely caused by significantly increased urinary 2OHE1 and decreased E3 observed in smokers. A urinary catechol estrogen index, defined by [2OHE1]/[E3], was significantly elevated in smokers compared with non-smokers (1.67 +/- 0.21 vs 0.56 +/- 0.08, P less than 0.001), and this urinary index correlated strongly with radiometrically determined estrogen 2-hydroxylation (r = 0.84, P less than 0.01). Ratios of the various estrogen metabolites did not vary substantially throughout the menstrual cycle. Urinary estrogen indices as described here may therefore be useful in demonstrating differences in estrogen metabolism, specifically 2-hydroxylation vs 16 alpha-hydroxylation, in selected populations.

The effects of canrenone K (Soldactone) on 3 beta-hydroxysteroid dehydrogenase, 11 beta-hydroxylase and 18-hydroxylase activities were determined in vitro using isolated mitochondrial and microsomal fractions of the bovine adrenal glands. There was dose-related inhibition of 3 beta-hydroxysteroid dehydrogenation in the concentration between 10(-8) M and 10(-3) M, and 11 beta-hydroxylation and 18-hydroxylation in the concentration between 10(-7) M and 10(-3) M, respectively. The concentration of 50% inhibition of 3 beta-hydroxysteroid dehydrogenase activity was 8.5 X 10(-7) M and those of 11 beta-hydroxylase and 18-hydroxylase activities were 5 X 10(-5) M and 6 X 10(-6) M, respectively. NADPH added to a mitochondrial fraction or NAD to a microsomal fraction had no effect on the inhibition of conversion in the presence of canrenone K. The results indicate that canrenone K inhibited 3 beta-hydroxysteroid dehydrogenase in the pharmacological dose, 11 beta-hydroxylase and 18-hydroxylase in a higher concentration, and with the exception of NADPH or NAD, it may inhibit the generating system directly.

The activity of 11 beta-hydroxylase was investigated in the mitochondrial fractions of 19 surgically resected adrenocortical tumors associated with Cushing's syndrome (4 adenomas and 2 carcinomas), primary aldosteronism (8 adenomas), adrenogenital syndrome (AGS) (2 carcinomas) and no hormonal symptoms (3 adenomas). Five adrenal cortices from patients with mammary carcinoma, renal cell carcinoma and pheochromocytoma were used for the normal control. The activities of 11 beta-hydroxylation of deoxycorticosterone and of 11-deoxycortisol in the control adrenal cortices were 0.66-2.16 pmole/mg protein/min (mean: 1.28 pmole/mg protein/min) and 0.25-0.77 pmole/mg protein/min (mean: 0.56 pmole/mg protein/min), respectively. The activities in adenomas and carcinomas associated with Cushing's syndrome were in the range of normal control. The activities in aldosteronomas were significantly higher in 4 cases than those of the normal control and in the range of the normal control in 4 cases, suggesting that the higher activity of 11 beta-hydroxylase is one of the important factors causing mineralocorticoid excess. The activities in adrenocortical carcinomas with AGS were significantly lower, corroborating clinical findings of androgen excess with suppressed production of mineralocorticoid or glucocorticoid. The activities in two cases of nonfunctioning adenomas were in the range of the normal control, but the third case showed higher activity than the normal control. These results show that the abnormal activity of mitochondrial 11 beta-hydroxylase exists in some aldosteronomas, non-functioning adrenocortical adenomas and carcinomas with AGS.

Hepatotoxicity of bromobenzene (2 mmole/kg) in combination with toluene or chloro-benzene (4 mmole/kg each) were studied in vivo on the basis of GPT elevation and histological examinations. Both toluene and chlorobenzene suppressed bromobenzene hepatotoxicity 24 hr after the treatment, and chlorobenzene dramatically potentiated the toxicity at 48 hr. The glutathione level became lower at 12 hr and recovered at 24 hr when bromobenzene was given alone. The recovery delayed until 48 hr when chlorobenzene was coadministered. In experiments in vitro with microsomes from phenobarbital-pretreated rats, both toluene and chlorobenzene at 0.6 mM inhibited p-bromophenol formation noncompetitively but had no effect on o-isomer formation. Multiple factors may determine overall hepatotoxicity in combined exposure; bromobenzene hepatotoxicity will be suppressed in the early phase owing to metabolic inhibition of 3,4-epoxidation, but potentiated later because of delayed recovery in the glutathione level. A time-saving yet reliable assay system with an ECD-gas chromatograph was developed for bromobenzene metabolism study.

Fourteen malignant cases of gonadal stromal tumor were found among the cases reported in literature, but the roles of chemotherapy and radiotherapy have not been defined. We treated a malignant case and achieved 98.9 per-cent remission of lung metastases by salvage chemotherapy (cis-platinum + VP-16). A 34 year-old desk-worker, underwent left orchiectomy for testicular tumor on March 20, 1984. Histologic examination showed a malignant gonadal stromal tumor invading into the epididymis. Three course of adjuvant chemotherapy with cis-platinum, vinblastine, and peplomycin (PVP) were performed. However, chest X-ray films 13 months later revealed multiple lung metastases. Although 3 courses of combination chemotherapy with cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP) were given, no remission was obtained. However following 4 courses of combination chemotherapy with cis-platinum and VP-16, 98.9 per-cent remission of lung metastases was achieved. Subsequent bilateral residual lung tumors were resected. However, lung metastases recurred 3 months later, and the patient died on February 29, 1988. The autopsy revealed extensive lung, liver and pancreas metastases, but no lymph node metastases.