Pulmonary tumor thrombotic microangiopathy showing aggressive course after transurethral resection of urinary bladder: an autopsy case report.

A 77-year-old man developed pulmonary tumor thrombotic microangiopathy (PTTM) 2 days after undergoing transurethral resection for urothelial carcinoma (G3) of the urinary bladder and died of respiratory failure 6 days later. Histological findings demonstrated marked intimal fibrocellular proliferation, fibrin thrombi, and both cancer cells and fibrin thrombi in the arteries of the lungs, findings consistent with PTTM. Prominent stenosis in arteries smaller than 300 µm was also seen. The Ki-67 labeling index of primary and metastasized cancer cells was 62.4 % and 70.2 %, respectively. The membranes of metastasized cancer cells expressed E-cadherin, similar to membranes in the urinary bladder. An aggressive PTTM course is affected by intimal fibrocellular proliferation and the high cell proliferation of cancer cells. Furthermore, prominent stenosis in small arteries and membranous staining of E-cadherin of metastasized cells suggest that cancer cells formed clusters by maintaining adhesion molecules and migrated into the arteries of the lungs, where they easily caused damage to the endothelium of small arteries, in contrast to dispersed cancer cells.

[Case of a sigmoid colon cancer with metachronous metastases of the stomach and the abdominal wall].

We report a rare case of a 73-year-old man with gastric metastasis from colorectal cancer. Tumors of the stomach and the right side abdominal wall were diagnosed by FDG/PET-CT. Upper gastrointestinal endoscopy revealed a submucosal tumor with central depression in the fornix of the stomach. Since sigmoidectomy had been performed for cancer 39 months ago, we suspected metastasis. Proximal gastrectomy and resection of the tumor of the abdominal wall were performed. Histological findings showed moderately differentiated adenocarcinoma in the submucosal tumor. Immunohistochemical studies revealed focal positive staining for CK20 and diffuse for CDX2. These findings were similar to those of his primary sigmoid colon cancer and therefore metastasis was diagnosed.

Endometrial Stromal Sarcoma Arising from Endometrial Polyp: A Case Report.

Endometrial stromal sarcoma (ESS) is a rare malignant tumor of the uterus. We report an uncommon case of ESS composed of both low-grade ESS and high-grade ESS arising from an endometrial polyp. On the findings of magnetic resonance imaging and contrast computed tomography, a patient was suspected of having uterine malignant tumor. She underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Macroscopically, the tumor was a polypoid lesion in the uterine cavity. The tumor was an endometrial polyp with ESS components. ESS was composed of low-grade ESS and high-grade ESS. By immunohistochemistry, both an endometrial polyp and low-grade ESS showed a positivity for CD10, estrogen receptor (ER), and progesterone receptor (PR). However, high-grade ESS showed only a focal and weak CD10 positivity with no immunostaining for ER and PR. A focal or diffuse positivity for α-smooth muscle actin and desmin was noted in both low-grade and high-grade ESS. The positive rates of Ki-67 and p53 in high-grade ESS were elevated up to over 95%. She was diagnosed as having ESS in a stage IA. After surgery, she received no further treatment. She has been without recurrence for 4 years since an initial surgery. In conclusion, immunohistochemical analyses are useful for make an accurate diagnosis of ESS showing a transition from low-grade ESS to high-grade ESS in addition to the conventional method.

Aggressive Granulosa Cell Tumor of the Ovary with Rapid Recurrence: a Case Report and Review of the Literature.

Aggressive adult granulosa cell tumor (AGCT) of the ovary remains uncommon. We report a case of aggressive AGCT of the ovary who had rapid recurrence at two months after surgery. A patient was referred for further examination of a pelvic tumor. She underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy. In the areas showing a sarcomatoid pattern, the mitotic count were 25/10 HPFs, and the mitoses were most prominent in foci composed of pleomorphic cells with enlarged and bizarre nuclei. In some areas, tumor cells with relatively uniform nuclei proliferated in a trabecular pattern. The mitotic count was 4/10 HPFs. Tumor cells were diffusely positive for α-inhibin. She was diagnosed as having aggressive AGCT. The Ki-67 labeling index in the sarcomatoid AGCT was higher (40%) than that in the areas of typical AGCT (3%). Immunostaining for p53 in the sarcomatoid AGCT was almost strongly positive, but that in typical AGCT was negative. Two months later after the initial surgery, a recurrent abdominal 12 cm-sized mass developed after performing adjuvant chemotherapy consisting of paclitaxel and carboplatin. She died of the disease at 3 months after initial surgery. A markedly higher mitotic count, a higher Ki-67 labeling index, and strong immunoreactivity of p53 in AGCT suggests highly malignant potential. In such a case, a careful follow-up is warranted due to the possibility of rapid recurrence.

Immunolocalization of peripheral lymph node addressins in normal and neoplastic human thymuses.

Peripheral lymph node addressin is a specific L-selectin ligand of the high endothelial venules that plays an important role in lymphocyte homing to lymph nodes. Tissue selective migration of lymphocytes through this pathway to the thymus has also been proposed. In this work, peripheral lymph node addressin expression was investigated immunohistochemically with a monoclonal antibody, clone MECA-79, in formaldehyde-fixed, paraffin-embedded tissue sections of 5 normal neonatal thymuses, 25 thymomas, 3 thymic carcinomas, and 2 thymic lymphoid hyperplasias. In normal thymuses, peripheral lymph node addressin expression was found in the endothelium of corticomedullary and medullary vessels surrounded by perivascular space. In type B thymomas and thymic lymphoid hyperplasias, peripheral lymph node addressin was detected in the vessels with perivascular spaces, at the medullary differentiation areas, and in paralymphoid follicles, respectively. However, in type A thymomas and thymic carcinomas, MECA-79-positive vessels were restricted to the remnants of pre-existing thymic tissue, and they were absent from the neoplastic areas. These findings suggest that in normal and most neoplastic thymuses, peripheral lymph node addressin is expressed by regions of vascular endothelium corresponding to postcapillary venules that may serve as a pathway for homing of recirculating lymphocytes to the thymus.

Pulmonary dirofilariasis--clinicopathological study.

Pulmonary dirofilariasis (PD), caused by Dirofilaria immitis (D. immitis), the dog heartworm, is not common in humans, though we recently encountered 4 cases. Chest X-ray images from annual health examinations showed a single spherical nodule in the inferior or middle portion of the right lung in each patient. None of the patients showed any clinical symptoms and had no contact with dogs. Hematological results in 3 of the cases were within normal limits, while mild eosinophilia was found in one. Serological tests for the Anti-Dirofilaria antibodies were not performed. There were no characteristic clinical manifestation of PD in any of the patients, however, we consider it important to keep a diagnosis of PD in mind, when we experienced these cases, they present no characteristic clinical manifestations. Pathologically, macroscopic findings showed well-circumscribed nodules that were round peripheral lesions in lungs. Histological results revealed coagulation necrosis with fibrosis and granulation in the nodule edge, which contained inflammatory cells. By means of silver staining, the worm structures in the nodules could be identified well, and the quadrant cells in the sections were numbered about 30. Immunohistochemically, the somatic muscle tissues were stained with anti-Dirofilaria antibody. These findings indicated that the pulmonary lesions in all 4 cases were due to D. immitis.

Coexistence of endometrioid adenocarcinoma in atypical polypoid adenomyoma.

Atypical polypoid adenomyoma (APA) is a rare polypoid tumor of the uterus composed of atypical endometrial glands and smooth muscle cells. Concomitant development of endometrial adenocarcinoma in APA remains infrequent. We report a case of the coexistence of endometrioid adenocarcinoma in APA. A 41-year-old patient presented with abnormal genital bleeding. A polypoid mass was extruded from the external cervical os. She underwent transcervical resection of the polypoid mass arising from the lower uterine segment. Pathological examination revealed APA with the foci of well-differentiated endometrioid adenocarcinoma. Subsequently, she underwent total hysterectomy and bilateral salpingo-oophorectomy. No residual malignant lesions were found. Awareness of the close association of APA with the development of endometrial cancer is warranted. A meticulous pathological evaluation of specimen of APA is necessary for the detection of the coexistence of endometrial cancer.

Nuclear survivin expression in stromal cells of phyllodes tumors and fibroadenomas of the breast.

BACKGROUND/AIM: Survivin is expressed in the nucleus and/or cytoplasm of various types of malignant tumor cells. Nuclear survivin is indispensable for complete mitosis, while cytoplasmic survivin functions as an apoptosis inhibitor. We examined the difference in the survivin expression among stromal cells of fibroadenoma, and benign and malignant phyllodes tumors. MATERIALS AND METHODS: Tumor sections were immunohistochemically stained with an anti-human survivin antibody and the labeling index of survivin was calculated. RESULTS: In stromal cells of all tumors, survivin was expressed in the nuclei but not in the cytoplasm. The labeling indices of the stromal cells in five malignant phyllodes tumors (20.5±3.0) were significantly greater than those observed in eight fibroadenomas (1.9±0.6) or nine benign phyllodes tumors (3.0±0.9). CONCLUSION: In the present study it was shown that stromal cells in malignant phyllodes tumors express nuclear survivin more extensively than stromal cells in benign phyllodes tumors or fibroadenomas.

Expression of adhesion molecules and the proliferative activity of carcinosarcoma of the ovary.

BACKGROUND: To clarify the mechanism underlying the formation of a sarcomatous component of ovarian carcinosarcoma, we investigated the expression of adhesion molecules and the proliferative activity of carcinosarcomas. MATERIALS AND METHODS: We immunohistochemically examined the expression of E-cadherin and ß-catenin, and the Ki-67 labeling index (Ki-67 LI) in six carcinosarcomas containing endometrioid carcinoma as a carcinomatous component. RESULTS: The sarcomatous components of the carcinosarcomas did not express E-cadherin or ß-catenin. All carcinomatous components expressed these molecules but the expression was reduced compared to that in endometrioid ovarian carcinomas. In five of the six carcinosarcomas, the Ki-67 LI of the sarcomatous component was less than that of the carcinomatous component. CONCLUSION: The present results suggest that a carcinomatous component transforms more easily than an ordinary endometrioid carcinoma from the viewpoint of the cell adhesion, and cells in a carcinomatous component continuously transform into sarcomatous cells during the growth of carcinosarcoma.

Synovial osteochondromatosis of the Lisfranc joint: a case report.

Synovial osteochondromatosis arising in the foot is a rare condition. We report a 69-year-old woman with synovial osteochondromatosis of the Lisfranc joint. The patient presented with a 10-year history of left foot pain. Imaging studies showed multiple calcified masses around the Lisfranc joint. We performed a synovectomy and removal of the loose bodies in the dorsal, lateral, and plantar aspects of the Lisfranc joint by dislocating the bases of the fourth and fifth metatarsal bones. To our knowledge, this is only the second case report of synovial osteochondromatosis involving the Lisfranc joint.

Solitary fibrous tumor in the extremity: case report and review of the literature.

A solitary fibrous tumor is a relatively unusual neoplasm first described as a distinctive tumor arising from pleura. Some reports have shown that solitary fibrous tumors also affect extrathoracic regions. The current study presents a literature review with four additional patients with solitary fibrous tumor arising from the extremities to clarify clinicopathologic features. The current four patients were two males and two females, ranging from 17 to 60 years of age. Magnetic resonance imaging scans of the current patients showed inhomogeneous low to intermediate intensity signal on T1-weighted images and inhomogeneous intermediate to high intensity signal on T2-weighted images. Histologically, the tumors were composed of a haphazard proliferation of spindle cells, although cellularity was variable in each case. Two of the four tumors showed hypercellularity of spindle cells with focally myxomatous or hyaline changes, whereas myxomatous patterns with scattered spindle cells throughout the specimens were observed in the other two tumors. Immunohistochemically, all four patients showed positive immunoreactivity for CD34, and two tumors showed focally positive immunoreactivity for bcl-2 protein. During the followup of 12 to 54 months, neither local recurrence nor distant metastasis was detected after wide resection. Examination of the literature and the current patients suggests that solitary fibrous tumors in the extremities are likely to have a malignant potential, although most patients have a benign clinical course. Local wide resection and careful long-term followup are necessary for patients with solitary fibrous tumor in the extremities.

Tarsal tunnel syndrome caused by epineural ganglion of the posterior tibial nerve: report of 2 cases and review of the literature.

Ganglia within the posterior tibial nerve is a rare condition. The authors report 2 cases of epineural ganglion of the posterior tibial nerve, causing tarsal tunnel syndrome. Both cases presented with numbness on the plantar surface of the foot. Magnetic resonance imaging showed the presence of the cyst within the tarsal tunnel. During surgery, these cysts were found within the epineurium of the posterior tibial nerve and were successfully removed without damage to nerve fibers. Both patients were free of symptoms after surgery. Ganglion cysts in the peripheral nerve are either intrafascicular or epineural. Intrafascicular ganglia present beneath the epineurium and involve the nerve fibers, whereas epineural ganglia are located in the epineurium and do not involve the nerve fibers. A review of the literature discusses these concepts. The authors suggest that epineural ganglion should be clinically distinctive from an intrafascicular ganglion because of the differences in surgical treatment, postoperative nerve function, and the recurrence rate.

Leiomyosarcoma arising from soft tissue tumor of the mediastinum.

The occurrence of a leiomyosarcoma (LMS) in soft tissue of the mediastinum is rare. We report a 60-year-old woman with an LMS in mediastinal soft tissue who died 8 months after surgical removal. Pathological, immunohistochemical, and electron microscopic features of this rare tumor are described.

Expression of matrix metalloproteinases, tissue inhibitors of metalloproteinase, collagens, and Ki67 antigen in pleural malignant mesothelioma: an immunohistochemical and electron microscopic study.

Because matrix metalloproteinases (MMPs) degrade extracellular matrix, including basement membrane, and because tissue inhibitors of MMP (TIMPs) suppress MMP activities, MMPs and TIMPs are considered to play important roles in invasion and metastasis in many malignancies. We examined immunohistochemically the expression of MMPs (MMP-1, -2, -3, -7, and -9), TIMPs (TIMP-1 and -2), and collagens (types I, III, and IV) in 16 patients with pleural malignant mesothelioma (PMM; 8 with the epithelial, 4 with the sarcomatous, and 4 with the biphasic type). Electron microscopy revealed that the tumor cells in all types possessed the characteristics of malignant mesotheliomas, including numerous microvilli and moderate amounts of intermediate filaments. Basement lamina was present only focally. The proliferative Ki67 index was at a high level, compared with values reported in various other malignancies. Positive staining for MMP-1 was observed in most tumor cells in all 16 patients (100%). MMP-2 was expressed in most tumor cells in 2 patients (13%). In contrast, MMP-3, -7, and -9 were not detected in any PMM. TIMP-1 and TIMP-2 were expressed in 3 patients (19%) and 2 patients (13%), respectively. The stromal cells were simultaneously positive for MMPs or TIMPs in the patients whose tumor parenchymal cells were positive for each enzyme. These results indicate that the expression of MMP-1 and MMP-2 may be related to PMM invasion and spread. In particular, as MMP-1 was overexpressed in contrast to the lower expression of TIMP-1, MMP-1 is strongly suggested to play an important role in PMM invasion by degrading the tumor stroma. In spite of general agreement that epithelial-type PMM has a better prognosis than other types, there was no significant difference in the Ki67 index among the histological types of PMM.

Synovial sarcoma arising from the pleura: a case report with ultrastructural and immunohistological studies.

Synovial sarcoma commonly occurs in the para-articular regions of the extremities, and rarely in the pleura. We report a 46-year-old woman with primary synovial sarcoma of the pleura. She was admitted with a complaint of left-sided chest pain and exertional dyspnea. She had previously undergone two operations for pleural neoplasm, at the ages of 33 and 36 years. A computed tomography scan revealed an expanded mass in the left thoracic cavity, involving the surrounding tissue. Macroscopic findings demonstrated a 25 x 25 x 15-cm grayish-white mass with hemorrhage beneath the pleura. Both epithelial and spindle cells were observed microscopically. Ultrastructural microscopy of the epithelioid cells demonstrated short, blunt microvilli on the luminal surface, and desmosomes between the neoplastic cells. Immunohistochemically, the tumor cells of the epithelial component were positive for embryonal membrane antigen (EMA), carcinoembryonic antigen (CEA), human mesothelial cells (HBME)-1, and cytokeratin, and the spindle cells were positive for vimentin. These findings led us to a diagnosis of primary synovial sarcoma of the pleura. She had no evidence of recurrence or metastasis after the third operation.

Neural fibrolipoma of the superficial peroneal nerve in the ankle: a case report with immunohistochemical analysis.

This report presents a case of neural fibrolipoma arising from the superficial peroneal nerve in the ankle. A 28-year-old woman was referred with a soft tissue mass in the anterior aspect of the right ankle, which had been gradually enlarging for the past 10 years. Magnetic resonance imaging showed a mass lesion, measuring approximately 8 x 3 x 2 cm, with high to partially low signal intensity on both T1- and T2-weighted images. A band of low signal intensity within the lesion, which is indicative of coexistence with the tumor and the superficial peroneal nerve, could be detected on both T1- and T2-weighted images. The patient underwent an excisional biopsy. The specimen microscopically consisted of nerve bundles and fibro-fatty proliferation with abundant collagen fibers. Immunoreactivity for CD34 antigen antibody was detected in fibrous spindle cells. This is the first report to present an immunohistochemical profile of neural fibrolipoma. Neural fibrolipoma should be considered as a differential diagnosis when a lipomatous lesion is encountered in the foot or ankle as well as in the upper extremities.

Malignant mesothelioma of the pericardium: case reports and immunohistochemical studies including Ki-67 expression.

Pericardial malignant mesothelioma (PMM) is extremely rare compared with pleural cases of mesothelioma. We present the clinical and pathological features of three autopsy cases with PMM. All three cases showed rapid progress and died of heart failure. Detailed examination was obtained from the autopsy. Macroscopic appearances of each case showed a thickened pericardium due to tumor invasion. Microscopic observations of all cases led to a diagnosis of epithelial-type malignant mesothelioma (MM). The results of immunohistochemical examinations were similar to the previous published work on pleural mesothelioma. To disclose the pathological characteristics of PMM, we analyzed Ki-67 labeling index (LI) of three cases of PMM and five cases of pleural MM that died within 2 years. The difference of Ki-67 LI between PMM and pleural MM was not significant (P > 0.05). The poor prognosis of patients with PMM must be caused by restricted cardiac wall motion due to tumor involvement, in addition to the tumor proliferation itself.