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Randomization of left-right body asymmetry, situs viscerum inversus (heterotaxy), is commonly associated with primary ciliary dyskinesia (PCD) resulting from an abnormal ciliary structure, with approximately 50% of PCD patients exhibiting organ laterality defects. I herein report an intrauterine fetal death case, in which an autopsy revealed two lobes of the bilateral lungs as well as heterotaxy of abdominal organs (right-sided spleen and inversion of the alimentary and biliary organs). Whole-exome sequencing (WES) identified a heterozygous single-nucleotide change (c.12775T>C) in exon 68 of the DNAH9 gene, which is a rare single-nucleotide polymorphism (SNP) of rs746081639 and results in the amino acid change of p.C4259R. WES also identified a rare SNP of rs763089682 (c.121G>A) in the RSPH1 gene that causes a heterozygous amino acid alteration of p.G41R. The frequencies of both SNPs, C in rs746081639 and A in rs763089682, are 0.00000824, and a polyphen-2 analysis predicted these amino acid changes to be probably damaging, with a score of 1.000. The combination of extremely rare SNPs in DNAH9 and RSPH1 genes might have been the possible mechanism underlying the development of the laterality defect in the present case.

A 44-year-old man presented to our hospital with lower gastrointestinal bleeding. We performed balloon-assisted enteroscopy, which revealed diverticulum and stricture at the ileum . The patient underwent segmental small bowel resection and diagnosed with Meckel's diverticulum. We should keep in mind the possibility of intestinal stricture due to Meckel's diverticulum.

Minifascicular neuropathy (MN) is an extremely rare developmental malformation in which peripheral nerves are composed of many small fascicles. Only one patient with MN with 46XY gonadal dysgenesis (GD) was found to carry a mutation affecting the start codon in desert hedgehog (DHH). We identified an identical novel rearrangement mutation of DHH in two consanguineous families with MN, confirming mutations in DHH cause MN with 46XY GD. The patients with the 46XY karyotype developed GD, whereas a patient with the 46XX karyotype did not. These findings further support that DHH has important roles in perineural formation and male gonadal differentiation.

Background Hepatic epithelioid hemangioendothelioma (HEH) is rare; it is reported in Case presentation The present report describes the histologically proven three HEH cases evaluated using Sonazoid® CEUS. Case 1 was a 33-year-old female patient with no relevant past medical history, who experienced right upper quadrant pain. Conventional abdominal US revealed multiple low echoic liver nodules with vague borderlines. In CEUS, the vascularity of the nodules was similar to that seen in the neighboring normal liver. Later in the portal venous and late phases (PVLP) and post vascular phase, washout of Sonazoid® was detected in the nodules. Case 2 was a 93-year-old female patient with a previous medical history including operations for breast cancer and ovary cancer in her 50’s. Conventional abdominal US revealed multiple low echoic nodules, some of which contained cystic lesions. In the early vascular phase of CEUS, nodules excluding the central anechoic regions were enhanced from peripheral sites. Although the enhancement inside the nodules persisted in both the PVLP and post vascular phase, anechoic areas in the center of some nodules were not enhanced at all. Case 3 was a 39-year-old male patient presented with right upper-quadrant pain, without any relevant past medical history. Conventional abdominal US revealed multiple low echoic liver nodules. In the early vascular phase of CEUS, nodules were gradually enhanced from the peripheral sites as ringed enhancement. Sonazoid®was washed out from the nodules in the PVLP and post vascular phase. Conclusions The most important feature was peripheral enhancement in the early vascular phase. In case 2, the enhancement of the parenchyma of liver nodules persisted even in the PVLP; indicating the lower degree of malignant potential than others. Actually, the tumors did not extend without any treatment in case 2. Since case 2 is the first case report of HEH with cystic lesions, in patients with liver nodules including cystic lesions, HEH is a potential diagnosis.

Additional file 1: Figure S1. (a) The graphics in abdominal plain CT and (b) the CECT equilibrium phase of case1 are shown. (c) The chest CT of case1 also revealed multiple lung nodules (arrow). (d) The lesions in the liver of case1 exhibited high signal intensity on axial T2WI. (e) The arterial dominant phase and (f) the hepatocellular phase in Gd-EOB-DTPA are shown. (g) In immunostaining (200×), a histological section of a hepatic specimen obtained via percutaneous liver needle biopsy in case 1 was positive for factor VIII. Figure S2. (a) The noncontrast CT of case2 revealed multiple hypodense liver nodules, with cystic lesions. (b) In the equilibrium phase of CECT, enhancement persisted inside the tumors. (c) T2WI showed multiple hyperintense liver nodules. (d) The size of liver tumors in the arterial dominant phase of CECT and (e) in the equilibrium phase have not increased when approximately 70 months has passes after the diagnosis was made. (f) In immunostaining (200×), a histological section of a hepatic specimen obtained via percutaneous liver needle biopsy in case 2 was positive for factor VIII. Figure S3. (a) The noncontrast CT of case3 revealed multiple hypodense liver nodules. (b) The graphics of abdominal CT in the arterial dominant phase and (c) in the equilibrium phase are shown. (d) The arterial dominant phase in Gd-EOB-DTPA is shown. (e) The size of liver tumors of case3 in the arterial dominant phase of CECT have not increased when approximately 49 months has passes after the diagnosis was made. (f) In immunostaining (200×), a histological section of a hepatic specimen obtained via percutaneous liver needle biopsy in case 3 was positive for factor VIII.

Introduction: Immune checkpoint inhibitors (ICIs), particularly anti-PD-1 antibody, have dramatically changed cancer treatment; however, fatal immune-related adverse events (irAEs) can develop. Here, we describe a severe case of sclerosing cholangitis-like irAE. We report the use of 3 immunosuppressive agents that resulted in the death of the patient due to treatment inefficacy. According to a postmarketing study of nivolumab, the frequency of ICI-related sclerosing cholangitis is 0.27% and that of ICI-related cholangitis is 0.20%. There have been 4 case reports of sclerosing cholangitis-like irAE, with imaging findings, including typical intrahepatic bile duct beaded constriction in primary sclerosing cholangitis. Treatment starts with prednisolone and is combined with an immunosuppressant in refractory cases. There are no reports of severe cases that ultimately led to death. Patients concerns: The patient is a 64-year-old male with Stage IV squamous cell lung carcinoma; he was hospitalized with abdominal pain and elevation of aspartate transaminase and alanine transaminase, approximately 4 months after ICI administration was suspended. This occurred because the patient treated with nivolumab as the second-line chemotherapy and developed type 1 diabetes mellitus after 11 courses. Diagnosis: A grade 3 increase in bilirubin was observed and he was diagnosed with sclerosing cholangitis, based on magnetic resonance cholangiopancreatography imaging and pathological findings of the liver and bile duct. Interventions: Prednisolone, mycophenolate mofetil, and tacrolimus combination therapy was administered. Outcomes: The treatment was difficult and failed. He died from liver failure 8 months after diagnosis. In this case, hepatitis and cholangitis, mainly alanine transaminase-dominant liver disorder, developed in the early stages of irAEs. Although he showed some improvement after prednisolone administration, bilirubin levels began rising again, and sclerosing cholangitis did not improve even with the use of 3 immunosuppressive agents recommended by the ESMO Clinical Practice Guidelines for immune-related hepatotoxicity management. Although the antitumor effect showed a complete response, liver failure led to death. Conclusion: This is the first case report on the ineffectiveness of triple immunosuppressant combination therapy recommended by the guidelines for immune-related hepatotoxicity. It is necessary to develop more appropriate treatment for severe sclerosing cholangitis-like irAE based on the robust evidence.

Meningiomas may be classified as neurofibromin 2 (NF2)-associated and non-NF2 meningiomas depending on the presence or absence of molecular alterations in the NF2 gene. One of the characteristic histological features of meningiomas is the whorl formation of neoplastic arachnoid cells. NF2 is a human homolog of the Drosophila gene, Merlin (Mer). In humans, NF2 is the gene responsible for the disease neurofibromatosis type II, which results in the development of brain tumors, including acoustic neurinoma and meningioma. The present study aimed to investigate the molecular pathogenesis of spinal meningioma. It was hypothesized that the whorl formation of meningiomas may occur as a result of a disturbance in the planar cell polarity (PCP) of arachnoid cells, thus, genes understood to govern PCP signaling were analyzed for alterations. Whole exome sequencing followed by Sanger sequencing validation was performed for the analysis of spinal meningioma tissue obtained from a 42-year-old Japanese female. The sequencing identified a nonsynonymous mutation of c.3597G>C, resulting in p.Q1199H, in the FAT atypical cadherin 2 (FAT2) gene. FAT2 is homologous to the Drosophila Fat (Ft) gene, which belongs to the cadherin superfamily. Drosophila Fat is involved in PCP, tumor suppression and Hippo (Hpo) signaling, which is associated with Mer. Taken together, the results of the present study concluded that human FAT2 may function as a key molecule that governs not only PCP, but also NF2-Hpo signaling in arachnoid cells; thus, a mutation in this gene may result in spinal meningioma.

Gene mutations are involved in the development of malignant mesothelioma. Important mutations have been identified in the genes for cyclin-dependent kinase inhibitor 2A (p16) alternative reading frame, breast cancer-associated protein 1 (BAP1) and neurofibromatosis type 2 (NF2). Previously, the utility of detecting the loss of BAP1 by immunohistochemistry (IHC) and p16-deletion by fluorescence in situ hybridization has been identified in several studies. However, NF2-associated examinations have not been performed. The present study aimed to evaluate the expression of yes-associated protein 1 (YAP1) and tafazzin (TAZ) protein, which are associated with NF2 gene mutations, in malignant mesothelioma (MM) and reactive mesothelial cells (RMCs). Formalin-fixed paraffin-embedded tissues from 31 MM and 33 RMC samples were analyzed. The expression of YAP1 and TAZ protein were examined by IHC. Positivity for YAP1 was identified 27/31 MM and 15/33 RMC samples. Positivity for TAZ was identified in 28/31 MM and 18/33 RMC samples. Using the optimal cutoff points determined by the receiver operating characteristic curve, a positive IHC result for YAP1 and TAZ was 74% sensitive and 94% specific for detecting MM. The results indicate that increased expression of YAP1 and TAZ may be associated with mesothelial tumorization, and aid in the diagnosis of MM.

Objectives: Interleukin-(IL-)17-mediated cells contribute to the imbalance of cellular immunity in the pathogenesis of immune thrombocytopenia (ITP). We examined samples of bone marrow (BM) clots to determine if IL-17-mediated immunological changes involve the BM and to identify clinical predictors of treatment response. Methods: We enrolled 33 patients with chronic ITP. BM clots were obtained before treatment and stained with the following markers: CD3, CD4, CD8, CD20, CD25, CD68, CD163, and IL-17. Pathological findings and clinical information, including laboratory data, were compared between the patients and 11 control subjects and between IL-17-high and -low-expression groups. Results: Univariate analysis revealed increased cells expressing CD68, CD163, and IL-17 in the patients with ITP than in the control subjects (P = 0.02, 0.001, and 0.001, respectively). The expression of both CD68 and CD163 showed correlation with IL-17 expression (r = 0.60 and 0.48, respectively). Responses to Eltrombopag were better in the IL-17-low-expression group than in the IL-17-high-expression group (P = 0.056). Conclusions: Macrophages and monocytes were associated with IL-17 expression in patients with ITP. We demonstrated that ITP is associated with IL-17-expressing monocytes/macrophages and might be more difficult to treat.

T1 colorectal carcinomas (CRCs) are an initial site of metastatic spread. Various risk factors for lymph node metastasis have been investigated in T1 CRCs. However, the major step in the entire process of metastasis remains unclear. In terms of carcinoma invasion and metastasis, matrix metalloproteinases (MMPs) have recently gained increasing attention. Notably, MMP-7 is frequently overexpressed in CRCs, but its implication has not been determined in T1 CRCs yet. The present study aimed to clarify the associations between the pathological risk factors of T1 CRCs and MMP-7. In the current study, 211 lesions of T1 CRC that were resected endoscopically or surgically at Showa University Northern Yokohama Hospital (Yokohama, Japan) between April 2008 and December 2009 were retrospectively analyzed. MMP-7 was immunostained and evaluated by its frequency of expression. Pathological factors of T1 CRCs were analyzed in association with MMP-7 expression. Furthermore, the ultrastructural alterations of carcinoma invasion were examined using low vacuum-scanning electron microscopy (LV-SEM). MMP-7 expression was associated with venous invasion (P=0.005), and LV-SEM revealed the disappearance of the normal structure of collagen and elastic fibers of veins invaded by tumor cells expressing MMP-7. At the invasive front, MMP-7 has a vital role in carcinoma invasion, correlating with venous invasion of T1 CRCs.

Angiogenesis is essential for tumor growth and metastasis. CD105 is reportedly a specific marker for tumor angiogenesis. It has been demonstrated that monoclonal antibodies to CD105 have high affinity for activated endothelial cells. A relationship between metastasis and microvessel density (MVD), as an indicator of neovascularization, has been identified in patients with colorectal cancer as shown by the presence of monoclonal antibodies to CD105. However, data on potentially confounding factors such as lymphatic and vascular infiltration and tumor size are lacking. We further investigated the relationship between MVD and distant metastasis, along with potentially confounding clinicopathological factors, to more precisely characterize this relationship. In this retrospective study, we analyzed colorectal cancer specimens surgically or endoscopically resected from January to September 2009. We defined MVD as the number of microvessels stained by monoclonal antibodies to CD105 per ×400 field. Selected clinicopathological factors were analyzed and stepwise multivariate logistic regression was performed to identify independent risk factors for distant metastasis. We analyzed 129 lesions. The median follow-up time was 34 months (range, 6-85 months) in patients with distant metastasis and 61 months (range, 60-86 months) in those without distant metastasis. At the time of resection or during subsequent follow-up, 32 patients had distant metastases. The MVD was significantly greater in patients with than without distant metastases (mean ± standard deviation: 10.4±4.9 vs. 7.6±3.3, P=0.008; Welch's t-test). Stepwise multivariate logistic regression indicated that MVD, regional lymph node metastasis, and tumor size were independent risk factors for distant metastases. Combining assessment of monoclonal antibodies to CD105-positive MVD with assessment of regional lymph node metastasis and tumor size may help to identify patients who need more intensive surveillance after surgery for colorectal cancer.

The aim of the present study is to address whether the molecular pathogenesis is identical among multiple basal cell carcinomas (BCCs) present in the same nevoid basal cell carcinoma syndrome (NBCCS) patient. Patient 1 is a 61-year-old (yo) Japanese female whose clinical characteristics and findings of a genetic analysis of PTCH1 have been previously described. Patient 2 is patient 1's 64-yo sister who also suffered from NBCCS with a single base deletion at nucleotide 2613 in exon 16 (c.2613delC) in one PTCH1 allele. Thirteen and 3 independent specimens of BCC were applied for a molecular analysis of loss of heterozygosity (LOH) in PTCH1 in patients 1 and 2, respectively. Of particular note is that all BCC specimens examined showed a loss of the wild-type allele of exon 16 in PTCH1, thus indicating that LOH results in the biallelic disruption of PTCH1 in multiple BCCs that develop in an age- and location-independent manner in the same patient. These results indicate that the germline single base deletion of PTCH1 (c.2613 delC) is a first hit and the LOH of the wild-type allele is a second hit, implying that all 16 BCCs detected in these NBCCS sisters fit the standard two-hit model.

A 75-year-old man was diagnosed with gastric cancer. Fifty years previously, he had undergone gastroenterostomy with a Braun enteroenterostomy. At present, a distal gastrectomy and small intestinal partial resection were performed. Intraoperatively, the tumor was localized to the previous stomal site. HE staining showed that the tumor comprised two elements: a tubular adenocarcinoma on the gastric side and a neuroendocrine carcinoma (NEC) on the jejunal side. The final pathologic diagnosis was mixed adenoneuroendocrine carcinoma based on an immunohistochemical analysis of endocrine markers and an elevated Ki-67 labeling index. The risk of later cancer development cancer recurrence near the gastrojejunostomy site is well known. Potentially, chronic enterogastric bile reflux may irritate the gastric mucosa and act as a promoter. Gastric NEC has a strong malignant potential. We suspect that, in the present case, the constant exposure to secondary bile may have induced a gastric mucosal adenocarcinoma, which finally differentiated into a NEC.

To help pathologists avoid misdiagnosis of intraductal neoplasms arising from the pancreatobiliary system, we report two cases that illustrate diagnostic pitfalls. The first is of a 66-year-old man who complained of appetite loss. An early examination led to a diagnosis of intraductal papillary mucinous neoplasm. Macroscopically, a multilocular cyst without visible mucin was identified. Histologically, the compartments consisted of complex fusion of tubular glands surrounded by dilated pancreatic duct. The neoplasm resembled an acinar cell cystadenocarcinoma. However, the neoplastic cells were negative for trypsin. Thus, the final histopathologic diagnosis was an unusual cystic variant of intraductal tubulopapillary neoplasm (ITPN) of the pancreas. The second case is of a 71-year-old man who complained of right upper quadrant pain. Although bile duct stone was suspected, a polypoid nodule was extracted. Histologically, the nodule was composed of tubular glands, with some complex fusion and focal dysplasia, consistent with carcinoma. In addition, lack of MUC-5AC expression led to an initial impression of ITPN of the bile duct. However, the neoplasm showed dysplastic cells based on the columnar cells resembling pyloric glands, indicating the sequential progression. Thus, the final histopathological diagnosis was intraductal papillary neoplasm of the bile duct with high-grade intraepithelial neoplasia. Because phenotypic variants of intraductal neoplasms of the pancreatobiliary system exist, ITPN and ITPN-mimicking tumor must be carefully differentiated from other intraductal neoplasms.

To assist physicians in recognizing the potentially fatal onset of symptoms in cases of fulminant bacterial infection, we analyzed 11 autopsy cases of such infection (four caused by Streptococcus pneumoniae, four by S. pyogenes, one by S. dysgalactiae subsp. equisimilis, one by Staphylococcus aureus, and one by Vibrio vulnificus). Clinicohistopathologic features were evaluated. All patients experienced sudden onset of hypotension and multiple organ failure, leading to unexpected death. Blood culture confirmed bacteremia. The main chief complaints were gastrointestinal symptoms (45%) and limb pain (36%). All had an underlying chronic illness (82%), e.g., a hematologic disorder (36.3%) or liver cirrhosis (27.2%). Necrotizing fasciitis occurred in only 55% of cases, with none involving pneumococcal infection. Laboratory tests typically showed C-reactive protein elevation but without leukocytosis, indicating a high-level inflammatory state. In ten cases, death was attributed to circulatory collapse due to sepsis; severe pulmonary congestion and hemorrhage were present in these cases. The onset of fulminant bacterial infection depends on both virulence of the bacterium and status of the host defense system.

BACKGROUND/AIMS Because of the notion that pancreatic and duodenal homeobox 1 (PdX-1)-positive cells are pancreatic stem cells that contribute to the differentiation and proliferation of exocrine cells, we examined PdX-1-associated changes in the morphology of rat pancreatic acinar cells that occur between the late fetal and early neonatal periods. METHODS Light and electron microscopy and PdX-1 and MIB-5 immunohistochemistry were used to examine pancreatic tissues obtained from fetal rats 22 days postconception (dpc), from newborn rats 48 and 72 hours after natural birth, and from rats 7 days after natural birth. RESULTS At 22 dpc, the cytoplasm of the acinar cells was large and eosinophilic due to accumulation of dense and numerous zymogen granules. Zymogen granules, rough endoplasmic reticulum, and other organelles were distributed throughout the cytoplasm. At 48 hours, i.e., just after feeding, the cytoplasm appeared smaller, less eosinophilic, and vacuolated. Electron microscopic examination showed cleaved nuclei and fewer zymogen granules. Expression of both PdX-1 and MIB-5 was increased at 48 hours. At 72 hours, acinar cell cytoplasm was decreased in size. At 7 days, the acinar cells were larger, biphasic distribution of zymogen granules was seen on the eosinophilic apical side, and rough endoplasmic reticulum and other ergastoplasms were seen on the basophilic basal side, typical of mature pancreatic acinar cells. Expression of PdX-1 and MIB-5 was markedly decreased in acinar cells. CONCLUSION Our findings indicate dynamic PdX-1-associated morphologic change from fetal to mature pancreatic acinar cells between 48 and 72 hours after birth.

The most commonly used fixative in effusion cytology is formalin. In the present study, the immunocytochemical properties of formalin-fixed and alcohol-fixed specimens were compared to evaluate the usefulness of alcohol-fixed cytocentrifuged preparations for routine cytologic diagnosis. A total of 269 effusion samples and 17 primary antibodies were used. The sensitivity of immunocytochemical studies in alcohol-fixed specimens was similar and correlated to that of formalin-fixed specimens, suggesting that alcohol-fixed cytocentrifuged preparations are useful in effusion cytology. Pretreatment with or without heat-induced antigen retrieval revealed that antigen retrieval was unnecessary for immunocytochemical studies with most primary antibodies in alcohol-fixed cytocentrifuged preparations. The present study describes the use of immunocytochemical studies with alcohol-fixed cytocentrifuged preparations for diagnosis in routine effusion cytology.

To assist physicians, especially young physicians, in identifying tuberculosis (TB) infection before the terminal stage, we analyzed 7 cases of numerous tuberculous granulomas in multiple organs and compared clinical and autopsy findings between cases. Patients ranged in age from 41 to 86 years at the time of death. The main chief complaint was fever of unknown origin (3 of 7 cases [43%]). The main underlying conditions were liver cirrhosis (2 of 7 cases [29%]) and chronic renal failure (2 of 7 cases [29%]). Two patients (29%) had been given methylprednisolone pulse therapy for various lung disorders. Active TB was not diagnosed before autopsy in 4 of 7 (57%) patients. Calcified lesions indicative of old TB were present in 4 of 7 (57%) patients. Thus, miliary tuberculosis may represent a re-emergence of latent TB infection in these cases. Various histologic features of nonreactive exudative inflammation were seen, along with granulomas containing Langhans giant cells with or without caseous necrosis in hypervascular organs, such as the lung, liver, and bone marrow. Physicians should be mindful of the possibility of miliary TB when older patients with hepatorenal disease and a history of TB infection have undergone immunosuppressive treatment. Active tuberculous infection can depend on the presence of an underlying disease and immunocompromise.

To differentiate reactive mesothelial cells (RMs) from metastatic carcinoma and malignant mesothelioma (MM) in effusion cytology is crucial for the cytologic diagnosis and the management of the patients. In the present study, the immunocytochemical staining profile of the epithelial membrane antigen (EMA), the insulin-like growth factor-II mRNA-binding protein 3 (IMP3), and the glucose transporter-1 (GLUT-1) was examined to distinguish RMs from malignant cells. A total of 171 pleural (n = 87) and peritoneal (n = 84) effusion specimens, including 50 benign effusions with RMs, 11 MM effusions, and 110 metastatic malignant effusions, were evaluated for immunocytochemistry. EMA, IMP3, monoclonal GLUT-1, and polyclonal GLUT-1 immunoreactivity were observed in 26.0%, 6.0%, 20.0%, and 18.0% of RMs, respectively. In contrast to RMs, the immunoreactivity in MM was 100%, 36.4%, 100%, and 90.9%; adenocarcinoma (AC) was 100%, 80.8%, 81.7%, and 72.1%; squamous-cell carcinoma was 83.3%, 83.3%, 83.3%, and 66.7%. EMA, IMP3, mGLUT-1, and pGLUT-1 expressions were observed in 98.4%, 65.6%, 88.5%, and 75.4% in the pleural effusion with malignant cells, and 100%, 88.3%, 78.3%, and 71.7% in ascites containing malignant cells, respectively. The findings of the present study indicate that the immunocytochemical staining for EMA, IMP3, and GLUT-1 is a useful diagnostic tool for distinguishing effusions containing malignant cells from those that contain benign cells, and in particular, we suggest that the combination of mGLUT-1 and EMA, and IMP3 and EMA are extremely useful in pleural effusion and in ascites, respectively.

A tumor suppressor gene at 10q23.3, designated PTEN, encoding a dual-specificity phosphatase with lipid and protein phosphatase activity, has been shown to play an essential role in the pathogenesis of a variety of human cancers. Frequent mutations and deletions of PTEN genes are found in cancer. Little is known, however, about the role that PTEN plays in the pathogenesis of a primary choriocarcinoma derived from gastric adenocarcinoma, an extremely rare choriocarcinoma, or in extragonadal retroperitoneal choriocarcinoma. In this study, genetic alterations occurring in extragonadal choriocarcinoma in two Japanese male patients were examined. Loss of heterozygosity (LOH) analysis using a polymorphic marker of the PTEN gene, IVS4+109ins/delTCTTA, revealed a hemizygous deletion of PTEN not only in the primary gastric choriocarcinoma, but also in the gastric adenocarcinoma. Microsatellite marker D12S1051 likewise showed LOH in both the primary gastric choriocarcinoma and the gastric adenocarcinoma. Mutational analysis of the TP53 gene revealed a point mutation in exon 5 (A536G), which resulted in H179R in the gastric choriocarcinoma but not in the gastric adenocarcinoma. No LOH was found for PTEN in an extragonadal retroperitoneal choriocarcinoma. Microsatellite marker D9S162 showed LOH in the extragonadal retroperitoneal choriocarcinoma, but not in the primary gastric choriocarcinoma. These results indicate that LOH of the PTEN gene and of D12S1051 is the molecular pathogenesis of the gastric adenocarcinoma, and the mutation of the TP53 gene is an additional hit for the oncogenesis of choriocarcinoma arising from gastric adenocarcinoma. However, LOH of the PTEN gene is not a common molecular event for pathogenesis of extragonadal choriocarcinoma. In addition, it was found that expression of PTEN is significantly decreased in the nuclei of syncytiotrophoblast-like cancer cells, compared with those of cytotrophoblast-like cancer cells in choriocarcinoma.

Cowden syndrome (CS), an autosomal dominant disorder, is associated with germline mutations of the PTEN (phosphatase, tensin homolog, deleted on chromosome TEN) gene. PTEN mutations were linked to several human neoplasms. Clinical diagnosis has been based on Consortium criteria, but detection of mutations in the PTEN gene has importance in accurate diagnosis. This article presents a female patient with classic features of the syndrome and gives the result of first PTEN mutation analysis result in a Turkish CS patient. The patient, who suffered from trichilemmomas, papillomatous lesions, lipomas, thyroid lesions, gastrointestinal hamartomas, and fibrocystic disease of the breast, is consistent with the diagnostic criteria of CS. The exons and intron/exon boundaries of the PTEN gene were analyzed by polymerase chain reaction and direct sequencing. We analyzed the clinical features and DNA in a Turkish patient with CS. We found a single-nucleotide substitution in the splicing acceptor site of intron 5 of the PTEN gene (IVS5-2A > C). It is not clear whether which types of PTEN mutations are responsible for particular phenotypes. This germline PTEN mutation, IVS5-2A --> C, has been reported once before, but the clinical features differ from our patient. Also, this is the first reported PTEN mutation from Turkey.

Effusion cytological analyses of amelanotic malignant melanoma (AMM) are very rare and no concise description of AMM related cytomorphologic features using effusion have been reported. Here, we report the cytomorphological, immunohistochemical, and immunocytochemical findings in the effusion cytology of six cases of malignant melanoma (MM), one case of AMM, and five cases of melanotic malignant melanoma. Papanicolaou-stained smears exhibited conspicuous nucleoli, multinucleation, and cytoplasmic vacuolization in all of the MM cases. In addition, the AMM case displayed numerous mitotic figures and intranuclear cytoplasmic inclusions. With regard to the immunohistochemistry findings, all six cases of melanoma were positive for Melan-A/MART-1, HBME-1, and S-100. In the immunohistochemistry analyses, five of six cases of melanoma were positive for WT-1, as was the AMM specimen. Furthermore, because the effusion analysis of malignant mesothelioma proved positive for WT-1, it should be noted that WT-1 effusion analysis is not an appropriate means to distinguish between MM and malignant mesothelioma. We suggest that it is important to recognize cytomorphologic characteristics, such as melanin pigment, conspicuous nucleoli, multinucleation, and cytoplasmic vacuolization, and to choose appropriate antibodies for the correct diagnosis of MM in effusion. Diagn. Cytopathol., 2009. © 2009 Wiley-Liss, Inc.

A tumor suppressor gene at 10q23.3, designated PTEN, encoding a dual-specificity phosphatase with lipid and protein phosphatase activity, has been shown to play a pivotal role in the pathogenesis of a variety of human cancers. A frequent loss of heterozygosity (LOH) at 10q is found in melanoma; however, little is known about the role of PTEN in the pathogenesis of a primary malignant melanoma derived from ovarian mature cystic teratoma, which is an extremely rare melanoma. This study examined the genetic alterations involved in the mitogen-activated protein kinase and phosphatidylinositol 3 kinase pathways in an ovarian malignant melanoma. A LOH analysis revealed hemizygous deletion around and in the PTEN gene not only in the ovarian melanoma but also in a mature cystic teratoma. Another case of ovarian mature cystic teratomas in the absence of melanoma also showed allelic loss of the PTEN region. To date, mutations of BRAF, NRAS, and KIT genes have been reported in malignant melanomas. In the present study, D816H and K558E mutations of the KIT gene were revealed in the melanoma arising from a mature cystic teratoma, but not in a mature cystic teratoma. No mutations of the BRAF and NRAS genes were found in the melanoma. These results indicate that LOH of the PTEN region is one of the molecular alterations of an ovarian mature cystic teratoma and a KIT mutation is an additional promotional event associated with the oncogenesis of a melanoma arising from an ovarian mature cystic teratoma.

Primary effusion lymphoma (PEL) is very rare type of non-Hodgkin's lymphoma (NHL) usually confined to the body cavities such as the pleural space, pericardium, and peritoneum. PEL is a human herpes virus-8 (HHV-8)-associated lymphoma and commonly observed in human immunodeficiency virus (HIV)-infected patients. However, HIV-infected patients are extremely fewer in Japan in comparison with those in Western countries; PEL is usually not associated with HIV infection in Japan. This report presents seven Japanese cases of PEL. In situ hybridization revealed that the PEL cells were negative for EBV in all cases. An immunocytological analysis showed that only one case was positive for HHV-8, and PEL cells were positive for CD20 in all cases. MUM1 was positive, but CD10 and CD138 were negative in six cases. One case each was positive for CD30 and BCL-6. The phenotypic patterns of HIV-related is BCL6-/MUM1+/CD138+, thus, the phenotypic findings observed by immunocytochemistry in this study were somehow different from those reported in Western countries. However, the cytomorphological features of PEL cells showed large cell size, abundant basophilic cytoplasm, coarse chromatin, and occasional binucleated or multinucleated cells, similar to a large cell immunoblastic and anaplastic large cell lymphoma, indicating that the cytomorphological characteristics of PE cells in Giemsa and Papanicolaou stain were consistent with those reported abroad. The prognosis for PEL in these cases was poor, but the survival time was variable ranging from 1 month to 54 months, and was different from that of Western cases. No p16/CDKN2A expression was observed, and one case showed PEL cells with a BLIMP1 mutation.

While many recent cases of colonic epiploic appendage causing acute abdomen have been reported, such appendages of the small bowel are extremely rare. We present a 59-year-old woman in whom a small bowel epiploic appendage caused volvulus. She presented with abdominal pain and vomiting in the absence of previous abdominal operations. A diagnosis of small bowel obstruction from strangulation was made. Laparotomy disclosed bloody peritoneal fluid and a closed loop of strangulated small intestine. An adherent band composed of an epiploic appendage and intestine had completely encircled a loop of jejunum, leading to obstruction. This band was released, and approximately 80 cm of gangrenous bowel was resected. Four epiploic appendages 5–6 cm in length were attached to the ileum at the mesenteric border, beginning at a point 70 cm proximal to the terminal ileum.

Well-differentiated papillary mesothelioma (WDPM), a distinct subtype of diffuse malignant mesothelioma, usually occurs in the peritoneum and is seen most commonly in women of reproductive age. Histologic features of WDPM include papillary growth and stout fibrous cores surrounded by a single layer of tumor cells. We present the case of a 73-year-old woman without subjective symptoms who showed signs of peritoneal effusion during a routine examination and for whom cytologic examination of the ascitic fluid was performed. Many spherical clusters, with a smooth external surface composed of a single layer of uniform cuboidal cells, were observed. Within each cluster, a collagenous ball showed light green Papanicolaou staining. Immunohistochemistry of surgical specimens showed tumor cells positive for calretinin, D(2)-40, and HBME-1 staining. The histologic diagnosis was WDPM. The identification of a collagenous ball within these clusters is a useful cytologic finding for the diagnosis of WDPM. WDPM should be suspected when numerous collagenous balls are present by effusion cytology and isolated cells are not.

Objective To analyze a risk factor for the onset of fulminant bacterial infection. Patients and Methods Nine unexpected acute death cases were clinicopathologically analysed. All cases represented the sudden onset of shock symptom, led to acute death within a few days, and later bacteremia was identified. Pathogens were Streptococcus pneumoniae (S. pneumoniae) (5 cases), group A beta Hemolytic Streptococcus pyogenes (S. pyogenes) (3 cases), and Vibrio vulnificus (V. vulnificus) (1 case). Results Seven of the nine patients had underlying chronic illness. S. pneumoniae infection was associated with splenic dysfunction, and group A beta Hemolytic S. pyogenes and V. vulnificus infections were associated with alcoholic liver injury. Group A beta hemolytic S. pyogenes and V. vulnificus infections involved necrotizing fasciitis, and alcoholic liver cirrhosis was confirmed in two of the four patients. Conclusion Despite the different type of bacteria, the onset of fulminant bacterial infection depended upon depressed bacterial phagocytosis in the liver or spleen. Underlying chronic illnesses should be identified as a predisposing common risk factor. It is important to understand the relations between underlying chronic illness and the onset of fulminant infection.

症例は78歳の男性で, 左上腹痛, 下痢を主訴に当院に緊急入院した. 左上腹部に圧痛を伴い, 可動性のある手拳大の腫瘤を触知し, 腹部CT, 注腸造影X線検査にて完全翻転した虫垂を先進部とする腸重積症と診断した. ガストログラフィンを用いた注腸整復では, 横行結腸脾曲部の重積を横行結腸中央部までしか解除できず, 緊急手術を施行した. 手術所見は, 盲腸から上行結腸の後腹膜への固定不良と, 回盲部を先進部とし左側横行結腸まで達する腸重積症であった. 手術は結腸右半切除術を施行した. 切除標本では, 重積の先進部に腫瘍性病変は認めず, 虫垂のみが盲腸内に完全に翻転していた. 術後経過は良好で, 術後11日目に退院した. 自験例は, 右結腸の固定不良と完全型虫垂重積が回盲部結腸型の腸重積症を誘発したと推察された.

Extranodal natural killer (NK)/T-cell lymphoma of the nasal type is a rare type of malignant lymphoma that is most common in Asian countries. Here we describe cytomorphologic, immunocytochemical, and molecular cytochemical features of three cases of NK/T-cell lymphoma of the nasal type diagnosed by nasal brush cytology. Cytomorphologic findings common among the three cases included the presence of several cell types, including nasal cavity epithelial cells, histiocytes, phagocytic histiocytes, and lymphoid cells, within a necrotic background. Suspected lymphoma cells were medium to large lymphoid cells possessing light blue and abundant cytoplasm. A characteristic feature of these cells was the presence of the tongue-like projections of cytoplasm from one or both sides of the cells. We believe these intriguing cytologic findings are indicators of NK/T-cell lymphoma of the nasal type. Azurophilic granules were observed in all cases, ranging from extremely fine granules to large granular lymphocyte (LGL)-like granules. Immunocytochemical and molecular cytochemical analyses showed staining for natural killer cell antigen CD56 as well as cytotoxic granule-associated proteins granzyme B7 (GrB7) and T-cell-restricted intercellular antigen-1 (TIA-1). EBV (Epstein-Barr virus) encoded small RNAs (EBER) positivity was shown by in situ hybridization, and no rearrangement of the TCRgamma gene was observed. Comparison between cytobrush and cotton swab methodology showed that cytobrush resulted in more cell-rich specimens than did cotton swabs, suggesting that nasal brush cytology with cytobrush is most useful in the diagnosis of NK/T-cell lymphoma of the nasal type.

Meningiomas may be classified as neurofibromin 2 (NF2)-associated and non-NF2 meningiomas depending on the presence or absence of molecular alterations in the NF2 gene. One of the characteristic histological features of meningiomas is the whorl formation of neoplastic arachnoid cells. NF2 is a human homolog of the Drosophila gene, Merlin (Mer). In humans, NF2 is the gene responsible for the disease neurofibromatosis type II, which results in the development of brain tumors, including acoustic neurinoma and meningioma. The present study aimed to investigate the molecular pathogenesis of spinal meningioma. It was hypothesized that the whorl formation of meningiomas may occur as a result of a disturbance in the planar cell polarity (PCP) of arachnoid cells, thus, genes understood to govern PCP signaling were analyzed for alterations. Whole exome sequencing followed by Sanger sequencing validation was performed for the analysis of spinal meningioma tissue obtained from a 42-year-old Japanese female. The sequencing identified a nonsynonymous mutation of c.3597G>C, resulting in p.Q1199H, in the FAT atypical cadherin 2 (FAT2) gene. FAT2 is homologous to the Drosophila Fat (Ft) gene, which belongs to the cadherin superfamily. Drosophila Fat is involved in PCP, tumor suppression and Hippo (Hpo) signaling, which is associated with Mer. Taken together, the results of the present study concluded that human FAT2 may function as a key molecule that governs not only PCP, but also NF2-Hpo signaling in arachnoid cells; thus, a mutation in this gene may result in spinal meningioma.

We describe a novel method for immunofluorescent detection of multiple antigens in a single paraffin-embedded tissue section. We hypothesized that if fluorescent dyes are resistant to heat treatment, then thermal inactivation of immunoglobulins during antigen detection procedures might make it possible to use multicolor immunofluorescence detection even if the primary antibodies are from the same species. We found that several fluorescent dyes, including fluorescein isothiocyanate (FITC), Cy3 and Cy5, were resistant to heating at 90 degrees Celsius for 15 min, whereas the antigenicities of the primary antibodies were lost completely. This novel method, which uses heat treatment between staining steps, has great advantages for multicolor immunofluorescence because unlabeled primary antibodies from the same species can be used. Therefore, by using this method not only 3 unlabeled mouse monoclonal antibodies but also 3 unlabeled rabbit antisera can be used as primary antibodies for multicolor immunofluorescence.

BACKGROUND Epithelioid sarcoma is a malignant soft tissue tumor of unknown histogenesis. We describe the cytologic findings in a case of primary proximal-type epithelioid sarcoma of the perineum and results of an immunofluorescence analysis of rhabdoid cells from this tumor. To the best of our knowledge, the 3-color immunofluorescence features of proximal-type epithelioid sarcoma have never before been reported. CASE An 8-cm-diameter mass with a 2.5-cm ulcer was found in the perineum of a 36-year-old man. After excision of the tumor, histopathologic examination of the resected specimen suggested a diagnosis of proximal-type epithelioid sarcoma. Fine needle aspiration cytology showed numerous rhabdoid cells with globular intracytoplasmic inclusions. A few isolated cells and polygonal cells were also observed in the smears. Three-color immunofluorescence analysis indicated that the intracytoplasmic inclusions in the rhabdoid cells were positive for cytokeratin, vimentin and CD34. The cytoplasmic staining pattern differed between rhabdoid and epithelioid sarcoma cells. CONCLUSION Immunofluorescent staining of rhabdoid cells from a primary perineal proximal-type epithelioid sarcoma revealed an uneven distribution of cytokeratin in intracytoplasmic inclusions, with the highest concentration at the periphery of the inclusions.

There have been many reports about the severity of hepatic necrosis caused by fulminant hepatitis; however, the relation between proliferated bile ductules and osteopontin (OPN) expression in inflamed areas in each of the clinical forms of fulminant hepatitis has not been described. To analyze the mechanism in the onset of fulminant hepatitis, we classified not only 16 autopsy cases of fulminant hepatitis into two clinical forms--acute and subacute--but also 3 autopsy cases of late-onset hepatic failure (LOHF) associated with fulminant hepatitis, and examined liver specimens by light microscopy and immunohistochemistry and also serum transaminase levels. Histopathologic study revealed that some of the proliferated bile ductules were associated directly with deteriorating hepatocytes and that bile plugs were present in the proliferated bile ductules. The value of the proliferative cell nuclear antigen labeling index (PCNA-L I) for proliferated bile ductules was very high during the acute form of fulminant hepatitis. Immunohistochemical analysis revealed that OPN expression was higher in the proliferated bile ductules of acute-form fulminant hepatitis than in cirrhotic and normal liver bile ducts. Transaminase levels in acute-form fulminant hepatitis were significantly elevated in comparison with levels in the other forms of the disease. Comparison of acute form fulminant hepatitis with the subacute form and LOHF showed OPN expression in proliferated bile ductules and serum aspartate aminotransferase (ALT)max to be decreased in the subacute form of fulminant hepatitis. OPN expression is an important marker of the degree of liver inflammation, and its regulation mechanism is very important to understanding the pathophysiology of fulminant hepatitis.

背景:乳腺悪性腫瘍としてはまれな乳腺原発悪性リンパ腫5例の細胞像について報告した.症例:患者は52歳から84歳の女性で, 主訴は全例乳房腫瘤であり, 腫瘍径は2.1～8.7cm大であった. 同側リンパ節転移が5例中1例にみられ, この症例は最も腫瘍細胞が大型であった. 穿刺吸引細胞診では5例とも, 豊富な腫瘍細胞が孤立散在性に認められ, 背景にはlymphoglandular bodyがみられた. また個々の腫瘍細胞は比較的小型でN/C比が高く, 大型明瞭な核小体を持ち, クロマチンは細顆粒状で密に増量していた. 著しい核形不整を示す症例が5例中2例に認められた. 以上の所見から全例を細胞学的に悪性リンパ腫と診断し, 組織学的検索で, びまん性大細胞型B細胞性リンパ腫と確認された. 全例に外科的根治術が行われ, 5例中4例に追加化学療法, 3例に放射線療法が施行された.結語:今回報告した全例で, 細胞判定は悪性で, 悪性リンパ腫と推定診断されており, 穿刺吸引細胞診が乳腺原発悪性リンパ腫の摘出生検の縮小に一役を担う検査法になると思われた. 今後は, 乳腺原発悪性リンパ腫の予後を検討するには, 亜分類を含めた詳細な組織学的分類やCD5, bcl-2, p53などの免疫組織学的予後因子を踏まえた検討が必要であると考えられた.

We describe unusual cytologic features of the peritoneal fluid in a patient with immature ovarian teratoma. Immature embryonal and neuroectodermal components of such tumors are rarely observed in the ascites; to our knowledge, there have been only three reports of cytologic findings of immature teratoma cells in the ascites. Our patient was a 26-yr-old woman who presented with a huge pelvic mass. A grade 3 immature right ovarian teratoma was diagnosed pathologically. Cytologic examination of the ascitic fluid revealed a variety of neoplastic cells, including immature neuroepithelial cells forming rosette-like structures, keratinized squamous cells, squamoid metaplastic cells, and immature glial-appearing cells. Immunohistochemical analysis revealed that immature gastrointestinal elements and yolk sac elements were positive for alpha-fetoprotein. This is the first description of the cytologic features of non-neuroepithelial elements in the ascitic fluid in a patient with immature ovarian teratoma.

We employed polymerase chain reaction and DNA sequencing analysis to characterize the PTCH gene in a Japanese nevoid basal cell carcinoma syndrome (NBCCS) patient suffering from meningioma, multiple basal cell carcinoma and epidermal cysts. Direct sequence analyses revealed a novel single base deletion at nucleotide 2613 in exon 16 (2613delC) in one PTCH allele, resulting in the frame shift and the introduction of a premature termination codon in this mutated allele.

A 64-year-old woman with high serum levels of growth hormone, insulin-like growth factor-I (IGF-I), and α-fetoprotein resulting from partially treated acromegaly was found to have a tumor under the left diaphragm. The patient also had a history of type C viral hepatitis. Laparotomy revealed that the tumor was fixed to the diaphragm and connected to the liver and spleen. The tumor was excised with partial resection of the diaphragm, liver, and spleen, and a diagnosis of left-sided pedunculated hepatocellular carcinoma (HCC) was made. Further examination showed a higher level of IGF-I receptor mRNA in the tumor than in the normal liver parenchyma. We believe it is likely that the high serum levels of IGF-I may have played a role in the development of the pedunculated HCC in this patient.

This case report is of a patient with 46XY pure gonadal dysgenesis, who presented with chronic progressive motor and sensory polyneuropathy. The sural nerve biopsy exhibited minifascicle formations accompanied by a marked decrease in myelinated fibers. This is the first report of polyneuropathy with minifascicle formations in 46XY pure gonadal dysgenesis. Because a similar polyneuropathy was recently reported in a case with 46XY partial gonadal dysgenesis, it is possible that these cases represent a new type of hereditary motor and sensory neuropathy associated with gonadal dysgenesis.