Differences in early imaging features and pattern of progression on CT between intrahepatic biliary metastasis of colorectal origin and intrahepatic non-mass-forming cholangiocarcinoma in patients with extrabiliary malignancy.

PURPOSE: To assess the differences in early imaging features and progression pattern on CT between intrahepatic biliary metastasis (IBM) and non-mass-forming cholangiocarcinoma (NMFC) in patients with extrabiliary malignancy. METHODS: This retrospective study included 35 patients who were surgically and pathologically confirmed with IBM (n = 14) or NMFC (n = 21) at the time of or after surgery for extrabiliary malignancy. Two observers evaluated the following aspects of biliary lesions on initial or follow-up CT images: location, characteristics of intrahepatic duct (IHD) dilatation, presence of duct wall thickening, and periductal infiltration lesion or periductal expansile mass. RESULTS: All IBMs were associated with colorectal cancer (p = 0.032). As early imaging features on CT, smooth tapered localized IHD dilatation without duct wall thickening and peripheral duct involvement were observed significantly more often in IBM, and IHD dilatation with abrupt tapering or irregularity of transition site and bile duct wall thickening were significantly more common in NMFC (all p < 0.05). Regarding progression pattern, periductal expansile mass was present only in IBM, whereas periductal infiltrative lesion was present only in NMFC (p < 0.001). CONCLUSION: In the differentiation between IBM and NMFC in patients with extrabiliary malignancy, the differences in early imaging features and progression pattern of the two diseases revealed in this study would be helpful for diagnosis.

Granular cell tumor of the gastrointestinal tract: histologic and immunohistochemical analysis of 98 cases.

Granular cell tumors (GCTs) are uncommon benign neoplasms in the gastrointestinal (GI) tract, and our current understanding of GCT in GI tract is limited. A total of 98 GCTs were retrieved from 95 patients, and the clinicopathological and immunohistochemical features were compared. The male-to-female ratio was 2.2:1 and with a mean age of 49 years. The mean tumor size was 0.37 cm. Seventy-three esophageal (75%), 21 colorectal (21%), and 4 gastric (4%) GCTs were included. Gastric (mean, 0.75 cm) and colorectal (0.6 cm) GCTs were significantly larger than esophageal tumors (0.27 cm; P<.001). Colonic and gastric GCTs showed a more infiltrative growth pattern (P<.001) and peritumoral lymphoid cuffs (P<.001) than esophageal tumors. Involvement of mucosa, submucosa, and both were noted in 58 cases (59%), 11 cases (11%), and 28 cases (29%), respectively. One GCT from the sigmoid colon (1%) had infiltration to pericolic soft tissue and with lymph node metastasis. High frequency of immunolabeling for S-100 protein (81/81, 100%), CD56 (55/58, 95%), CD68 (58/61, 95%), SOX-10 (54/58, 93%), and inhibin-α (30/58, 52%) were observed. In summary, GCTs in the GI tract were observed with the following frequency: esophagus, colorectum, and stomach. Colorectal and gastric GCTs were larger and had infiltrative growth and more lymphoid cuffs than esophageal GCTs. Although invasive GCT was rare, it could be observed in the GI tract. Inhibin-α expression were more common in colonic GCTs than esophageal tumors. High S-100 protein, CD56, CD68, and SOX-10 expression rates were observed in GCTs from GI tracts.

What determines the periportal free air, and ligamentum teres and falciform ligament signs on CT: can these specific air distributions be valuable predictors of gastroduodenal perforation?

PURPOSE: The purpose of this retrospective study was to determine what gives rise to the periportal free air, and ligamentum teres and falciform ligament signs on CT in patients with gastrointestinal (GI) tract perforation, and whether these specific air distributions can play a clinically meaningful role in the diagnosis of gastroduodenal perforation. MATERIAL AND METHODS: Ninety-three patients who underwent a diagnostic CT scan before laparotomy for a GI tract perforation were included. The readers assessed the presence of specific air distributions on CT (periportal free air, and ligamentum teres and falciform ligament signs). The readers also assessed the presence of strong predictors of gastroduodenal perforation (focal defects in the stomach and duodenal bulb wall, concentrated extraluminal air bubbles in close proximity to the stomach and duodenal bulb, and wall thickening at the stomach and duodenal bulb). The specific air distributions were assessed according to perforation sites, and the elapsed time and amount of free air, and then compared with the strong predictors of gastroduodenal perforation by using statistical analysis. RESULTS: All specific air distributions were more frequently present in patients with gastroduodenal perforation than lower GI tract perforation, but only the falciform ligament sign was statistically significant (p<0.05). The presence of all three specific air distributions was demonstrated in only 13 (20.6%) of 63 patients with gastroduodenal perforation. Regardless of the perforation sites, the falciform ligament sign was present significantly more frequently with an increase in the amount of free air on multiple logistic regression analysis (adjusted odds ratio, 1.29; p<0.001). The sensitivity, specificity, accuracy, and positive predictive and negative predictive values of each strong predictor for the diagnosis of gastroduodenal perforation were higher than those of specific air distributions. The focal wall thickening (accuracy, 95.7%) was the most useful parameter for the diagnosis of gastroduodenal perforation. CONCLUSION: The prediction of the perforation site of the GI tract on CT should be based on the presence of strong predictors of the site of bowel perforation, and the specific free air distribution should be regarded as complementary predictors.

Epithelial to mesenchymal transition of mesothelial cells in tuberculous pleurisy.

PURPOSE: Tuberculous pleurisy is the most frequent extrapulmonary manifestation of tuberculosis. In spite of adequate treatment, pleural fibrosis is a common complication, but the mechanism has not been elucidated. This study is to determine whether epithelial to mesenchymal transition (EMT) of mesothelial cells occurs in tuberculous pleurisy. MATERIALS AND METHODS: Normal pleural mesothelial cells, isolated from irrigation fluids during operations for primary spontaneous pneumothorax, were characterized by immunofluorescence and reverse transcription polymerase chain reaction (RT-PCR). These cells were treated in vitro with various cytokines, which were produced in the effluents of tuberculous pleurisy. The isolated cells from the effluents of tuberculous pleurisy were analyzed by immunofluorescence and RT-PCR analysis. RESULTS: The isolated cells from the irrigation fluid of primary spontaneous pneumothorax had epithelial characteristics. These cells, with transforming growth factor-ß1 and/or interleukin-1ß treatment, underwent phenotypic transition from epithelial to mesenchymal cells, with the loss of epithelial morphology and reduction in cytokeratin and E-cadherin expression. Effluent analysis from tuberculous pleurisy using immunofluorescence and RT-PCR demonstrated two phenotypes that showed mesenchymal characteristics and both epithelial & mesencymal characteristics. CONCLUSION: Our results suggest that pleural mesothelial cells in tuberculous pleurisy have been implicated in pleural fibrosis through EMT.

Differential expression of ezrin in epithelial skin tumors: cytoplasmic ezrin immunoreactivity in squamous cell carcinoma.

BACKGROUND: Ezrin is a cytoskeleton linker protein that is actively involved in regulating the growth and metastatic capacity of cancer cells. The purpose of the study was to assess the expression pattern of ezrin in normal skin and various epithelial neoplasms. METHODS: We used immunohistochemical techniques to examine the expression of ezrin in paraffin-embedded tissues of squamous cell carcinoma (n = 23), basal cell carcinoma (n = 10), Bowen's disease (n = 10), actinic keratosis (n = 10), keratoacanthoma (n = 9), seborrheic keratosis (n = 5), psoriasis vulgaris (n = 5), and normal control skin (n = 5). RESULTS: In Bowen's disease, actinic keratosis, keratoacanthoma, and seborrheic keratosis, ezrin was dominantly expressed in the cell membrane except for the cornified layer. In squamous cell carcinoma (SCC) specimens, the percentage of ezrin-positive cells was increased compared with Bowen's disease, actinic keratosis, keratoacanthoma, and seborrheic keratosis. Especially in SCC samples, ezrin expression was markedly expressed in the cytoplasm. In addition, there was a correlation between the pattern of ezrin expression and tumor differentiation in SCC. Basal cell carcinoma showed intense and diffuse staining especially in the solid growth pattern. CONCLUSIONS: Our findings suggest that dysregulation of ezrin may be important in the development of cutaneous epithelial malignancies and tumor grade. We suggest that the cytoplasmic localization of ezrin may be useful in the diagnosis of skin SCC.

Diagnostic performance of CT in the detection of intestinal ischemia associated with small-bowel obstruction using maximal attenuation of region of interest.

OBJECTIVE: The purpose of this study was to assess the diagnostic performance of CT in the detection of intestinal ischemia associated with small-bowel obstruction using the maximal attenuation of a region of interest (ROI). MATERIALS AND METHODS: Abdominal CT scans of 60 patients with small-bowel obstruction were retrospectively reviewed. The reference standard of the clinicopathologic groups was classified into four categories: no bowel necrosis, mucosal-submucosal necrosis, superficial muscle necrosis, and transmural necrosis. The viability of the small bowel on CT was evaluated by visual assessment using five categories (i.e., definitely intestinal ischemia, probably intestinal ischemia, possibly intestinal ischemia, equivocal CT results, and no intestinal ischemia) and by measurement of the maximal attenuation of an ROI at selected obstructed small-bowel loops on contrast-enhanced and unenhanced CT scans. Diagnostic performances were evaluated by one-way analysis of variance and receiver operating characteristic (ROC) curve analysis. RESULTS: The sensitivity, specificity, positive and negative predictive values, and accuracy of visual assessment for intestinal ischemia were 91.7% (33/36), 66.7% (16/24), 80.5% (33/41), 84.2% (16/19), and 81.7% (49/60), respectively. The maximal attenuation of the ROIs on contrast-enhanced CT and the subtraction value between the maximal attenuation on contrast-enhanced CT and that on unenhanced CT scans at selected bowel were significantly different according to clinicopathologic group (p < 0.001). The area under the ROC curve of the maximal attenuation subtraction values between contrast-enhanced and unenhanced CT scans (0.995) was higher than that of visual assessment (0.908) for the detection of intestinal ischemia. CONCLUSION: The quantification of bowel wall enhancement using the maximal attenuation of an ROI was a reliable and useful method for the diagnosis of intestinal ischemia and showed good correlation with pathology results.

What is the complementary role of ultrasound evaluation in the diagnosis of acute appendicitis after CT?

The objective of our study was to estimate the complementary role of ultrasound evaluation in the diagnosis of acute appendicitis after abdominoplevic CT. A total of 104 patients initially underwent abdominopelvic CT before appendix US due to acute abdominal pain. All CT examinations were evaluated retrospectively for the presence of acute appendicitis. The findings of appendix on CT were classified into five categories (definite appendicitis, probably appendicitis, equivocal CT findings for diagnosis of appendicitis, probably not appendicitis, and normal looking appendix). Appendix US images and their radiologic reports were also evaluated retrospectively. Then, CT and US findings were correlated with clinical or pathologic diagnosis. Three all patients with definite appendicitis initially on CT again showed US findings of appendicitis. In the 32 patients of probably appendicitis on CT, US showed normal looking appendix in seven patients (21.8%, 7 of 32) who improved with medical treatment and discharged. In the 16 patients of equivocal CT findings for diagnosis of appendicitis, US showed appendicitis in seven patients (43.8%, 7 of 16) and normal looking appendix in nine patients. In the 12 patients of probably not appendicitis on CT, US showed acute appendicitis in two patients (16.7%, 2 of 12). In the 41 patients of normal looking appendix on CT, US showed acute appendicitis in five patients (12.2%, 5 of 41). US reevaluation enables us to avoid misdiagnosis of appendicitis on CT and improve diagnostic accuracy of acute appendicitis.

Disseminated Kikuchi-Fujimoto disease mimicking malignant lymphoma on positron emission tomography in a child.

Kikuchi-Fujimoto disease is a rare and benign disease, characterized by regional cervical lymphadenopathy with fever of unknown origin, affecting mainly young women. This self-limiting disease of unknown etiology has rarely been reported in children, so it has been frequently confused with malignancies. We describe a case of a child who was initially mistaken for malignant lymphoma because of multiple lymph nodes with 18-fluorodeoxyglucose uptake on positron emission tomography and was finally diagnosed with Kikuchi-Fujimoto disease by excisional biopsy of the affected lymph node.

Radiofrequency ablation of the liver abutting stomach: in vivo comparison of gastric injury before and after intragastric saline administration in a porcine model.

PURPOSE: To compare the in vivo gastric injury observed during radiofrequency (RF) ablation of the liver abutting the stomach before and after the intragastric administration of chilled saline. MATERIALS AND METHODS: Twenty RF ablation zones were created in the livers of 10 pigs with a 1-cm-exposed active tip of an internally cooled electrode under ultrasound guidance for 10 min. Ten RF ablation zones were created before (non-saline group) and after (saline group) the intragastric administration of approximately 1000 mL of chilled saline, and 20 RF ablation zones were made in the posterior part of the left lobe abutting the stomach. The frequency and severity of the thermal injury observed in the stomach of the two groups were compared histologically. RESULTS: All the resected gastric specimens showed thermal injuries of varying degrees of severity. The largest diameter of the gastric injury was significantly smaller in the saline group (mean 1.5 cm; range 1.3-1.8 cm) than in the non-saline group (mean 2.1cm; range 1.8-2.4 cm) (p=0.000). The saline group showed significantly less thermal injury to the muscular layer of the gastric wall by the histopathology (p=0.033). CONCLUSIONS: The intragastric administration of chilled saline might be a useful technique for reducing the severity of gastric injury during RF ablation of the liver abutting the stomach.

Multiple myeloma with myelomatous pleural effusion: a case report and review of the literature.

Multiple myeloma (MM) is a malignant neoplasm of plasma cell origin. Pleural effusion may develop in the setting of MM due to various reasons, but myelomatous pleural effusion (MPE) is rare. We report a case of MPE in a patient with advanced MM. A 76-year-old woman with MM was admitted to hospital because of dyspnea. Chest X-ray showed right-sided pleural effusion. Protein electrophoresis of the pleural fluid showed monoclonal protein, and cytology demonstrated monoclonal plasma cells. Hospice care was implemented, and the patient died one month later. We present an analysis of the clinical characteristics of 57 MPE cases reported in the English literature. Our review revealed that MPE patients had poor overall survival irrespective of whether MPE develops in the course of their disease or presents as the initial manifestation of MM. Based on this analysis, MPE is a poor prognostic factor, and aggressive treatment should be considered, especially for patients with early-onset MPE.

Expression of vascular endothelial growth factor-C and its receptor in osteosarcomas.

Vascular endothelial growth factor-C (VEGF-C) and its receptor, vascular endothelial growth factor receptor-3 (VEGFR-3), have been implicated as important factors in the formation of lymphatic vessels, but its role in osteosarcomas has not yet been fully investigated. This study aims to define the expression of VEGF-C and VEGFR-3 in primary and metastatic osteosarcomas and their relationship to various clinicopathologic parameters. Thirty-three primary osteosarcomas and two pulmonary metastatic samples were immunostained for VEGF-C and VEGFR-3. In addition, VEGF-C and vascular endothelial growth factor-D (VEGF-D) mRNA expression levels in three different human osteosarcoma cell lines and control fibroblasts were evaluated by real-time quantitative polymerase chain reaction (PCR). Both VEGF-C and VEGFR-3 were expressed mainly in the cytoplasm of the tumor cells. Of the 35 patients with osteosarcoma, 16 patients (45.7%) showed strong positive reaction with VEGF-C. Four cases (11.4%) were negative, and 15 cases (42.9%) showed weak immunoreactivity. For VEGFR-3, 12 patients (34.3%) showed strong positive reaction. Fifteen cases (42.9%) were negative, and eight cases (22.8%) showed weak immunoreactivity. A significant, positive correlation (Rs=0.42, p=0.01) was found between the expression of VEGF-C and VEGFR-3 in osteosarcomas. The expression of VEGF-C was significantly associated with the osteoblastic subtype and high histologic grade in osteosarcomas. However, the expression of VEGF-C showed no significant correlation with the presence of metastasis. Expression of VEGFR-3 was not related to any clinicopathologic features analyzed. Two of the three osteosarcoma cell lines tested showed amplification of VEGF-C mRNA compared with control cells. No amplification of VEGF-D was noted in these cell lines. Our data suggest that VEGF-C and its receptor are expressed in osteosarcomas. Although the level of VEGF-C was high, it does not seem to have a direct influence on tumor metastasis in osteosarcomas.

Intramucosal Helicobacter pylori in the human and murine stomach: its relationship to the inflammatory reaction in human Helicobacter pylori gastritis.

Intramucosal Helicobacter pylori (H. pylori) has been described in biopsy tissues and culture systems. However, the association of intramucosal H. pylori with histopathologic features has not been evaluated. The purpose of this study is to investigate the relationship between intramucosal H. pylori and inflammatory reactions in H. pylori infection. In 113 randomly selected human gastric biopsies and 20 murine stomachs, which were inoculated with SSI every day for a week, immunohistochemical analysis for intramucosal H. pylori was done and correlated with histologic parameters. Electron microscopic examination was done on murine stomachs. H. pylori infection was present in 104 gastric biopsies and 17 murine stomachs. Intraepithelial immunopositivity for H. pylori was detected in 27 of 104 (26%) biopsies and in 11 of 17 (65%) murine stomachs. Lamina proprial immunopositivity for H. pylori was present in 51 of 104 (48%) biopsies. Neutrophil-associated immunopositivity for H. pylori was observed in 22 of 90 (24%) biopsies with H. pylori chronic active gastritis. Lamina proprial and neutrophil-associated immunopositivity for H. pylori correlated significantly with the density of H. pylori and the grade of acute inflammatory reaction in H. pylori gastritis. Intramucosal location of H. pylori itself or its antigen is closely associated with acute inflammatory reactions and may play an important role in establishing a persistent infection in chronic H. pylori gastritis. Furthermore, lamina proprial and/or neutrophil-associated H. pylori appears to be more important than intraepithelial H. pylori in acute inflammatory reactions of H. pylori gastritis.