Massive subcutaneous emphysema, bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoscrotum after multiple direct laryngoscopies: an autopsy case report.

Multiple endotracheal intubation (ETI) attempts increase the risk of airway-related adverse events. However, little is known about autopsy findings after severe ETI-related complications. We present the detailed pathological findings in a patient with severe ETI-related complications. A 77-year-old obese male suffered cardiopulmonary arrest after choking at a rehabilitation facility. Spontaneous circulation returned after chest compressions and foreign-body removal. After multiple failed direct laryngoscopies, the patient was transferred to our hospital. He had massive subcutaneous emphysema, bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoscrotum on admission, and died from hypoxic brain injury 15 h later. Autopsy revealed severe oropharyngeal, laryngeal, and left lung lower lobe injury. The likely mechanisms of diffuse emphysema were (1) oropharyngeal injury associated with multiple ETI attempts and excessive ventilation pressures and (2) left lung lower lobe injury associated with chest compressions and other resuscitative procedures. Multiple laryngoscopies can cause severe upper-airway injury, worsen respiratory status, and make ETI more difficult-a vicious circle that can be prevented by limiting ETI attempts. This is particularly important in unfavorable environments, in which backup devices and personnel are not easily obtained. The pathological findings in our patient caution against repeated attempts at ETI during resuscitation.

Hydropic leiomyoma-like ovarian tumor: a case report.

Uterine leiomyomas, benign tumors common in reproductive-aged women, can display rare variants such as hydropic leiomyoma (HL), which exhibit unique histological features like zonal edema and increased vascularity. However, due to its rarity, comprehensive clinical knowledge about HL is limited. We report a case of a 49-year-old Japanese woman who was premenopausal and nulliparous, presenting with a two-year history of abdominal distension. An MRI scan revealed a 20 cm mass in the posterior part of the uterus, exhibiting characteristics suggestive of an ovarian tumor. During laparotomy, a cystic tumor connected with a swollen fibroid was found, and pathology confirmed HL. This case emphasizes that hydropic leiomyomas can mimic malignant tumors on ultrasonography due to their atypical features, necessitating additional evaluations using alternative imaging techniques or histopathological examinations for accurate diagnosis and appropriate management. The patient recovered uneventfully, broadening our understanding of HL's clinical presentation.

Patient with esophageal cancer showing remission of nephrotic syndrome after esophagectomy: report of a case.

A 73-year-old male patient was admitted to our hospital due to bilateral leg edema and proteinuria in April 2009. After admission, nephrotic syndrome (membranous nephropathy) was diagnosed. At that point, a cancer screening test was performed; however, no abnormalities were noted. Medical treatment with prednisolone and cyclosporine was started, which resulted in the temporary improvement of markers of laboratory data. The patient was re-examined in November of the same year, and esophageal cancer (squamous cell carcinoma, T2N0M0 Stage IIA according to the UICC TNM classification) was detected in the lower thoracic esophagus. Subtotal esophagectomy was performed via right thoracolaparotomy with two-field lymph node dissection. Although the patient's course was complicated by respiratory failure, he was discharged after 38 days. After performing esophagectomy, prompt amelioration of the nephrotic syndrome occurred, allowing the withdrawal of prednisolone and cyclosporine. There has been no recurrence of esophageal cancer or relapse of nephrotic syndrome during a period of 18 months after esophagectomy.

Simultaneous resection of metastatic melanoma in the esophagus and primary cutaneous melanoma showing partial regression: report of a case.

We herein describe a case of melanoma that metastasized to the esophagus from a primary melanoma of the abdominal skin in a 40-year-old female. Esophagography and endoscopy demonstrated a 30-mm protruding mass in the proximal third of the esophagus, and this was diagnosed as malignant melanoma by mucosal biopsy. The patient also had a pigmented lesion on her abdominal skin, which was diagnosed immunohistochemically as a primary malignant melanoma from the resected specimen. The esophageal tumor was resected by transthoracic esophagectomy. Histopathologically, the radial growth phase of the tumor cells was not present in the esophageal lesion, which was diagnosed as melanoma metastatic to the esophagus. Postoperatively, the patient received 5 courses of DAV-Feron chemotherapy. Eight months after the chemotherapy, multiple metastases developed, including to the subcutis, bronchus, liver, adrenal gland and mediastinum. Chemotherapy was not effective at this stage. The patient died of multiple organ failure 21 months after initial esophagectomy.

A case of spontaneous parasitic myoma in a patient without a history of myomectomy treated laparoscopically.

Parasitic myoma (PM) is a rare disease in which multiple leiomyomas are intraperitoneally formed. Recently, an increasing number of cases due to specimen morcellation during minimally invasive surgery has been reported. We present the first case of a PM identified intraoperatively during laparoscopic hysterectomy. A 40-year-old Japanese multiparous woman presented to our hospital with heavy menstrual bleeding. She had no history of previous surgery. Magnetic resonance imaging showed uterine myomas. As the patient did not wish for further pregnancy, she underwent oral gonadotropin-releasing hormone antagonist therapy followed by a total laparoscopic hysterectomy. Intraoperatively, we identified a thumb-sized tumor on the left side of the peritoneum. Histopathological examination showed evidence of benign leiomyoma.

Curative resection of a huge malignant pancreatic endocrine tumor by pancreatoduodenectomy with portal and superior mesenteric vein resection and reconstruction using the right ovarian vein: report of a case.

Nonfunctioning pancreatic endocrine tumors (PETs) are rare and generally asymptomatic. A 68-year-old woman who had refused treatment for a pancreatic mass, revealed by ultrasonography to be 55 mm in diameter, was referred to us again 29 months later with jaundice. Investigations showed an 82-mm tumor in the head of pancreas, exposed from the papilla of Vater to the duodenal lumen. After biliary decompression and drainage, we performed pancreatoduodenectomy with resection of the portal vein and superior mesenteric vein, followed by reconstruction using a cylindrically customized autologous graft harvested from the right ovarian vein. The tumor was resected curatively. Microscopically, it consisted of trabecular and ribbon-like arrangement of neoplastic cells. Immunohistochemical staining was positive for chromogranin A and synaptophysin and negative for insulin, gastrin, glucagons, somatostatin, and pancreatic peptide. Although metastasis was detected in a lymph node along the superior mesenteric vein with perineural invasion, the portal and superior mesenteric veins had not been invaded. The diagnosis was well-differentiated nonfunctioning PET. The patient had an uneventful postoperative course, and there has been no evidence of recurrence in 12 months.

Endocytoscopic observation of esophageal squamous cell carcinoma.

The endocytoscopy system (ECS), adapted for clinical use in 2003, is an ultra-high-power magnifying endoscope that allows observations at the cell level. ECS is based on the technology of light-contact microscopy. The most evident use of ECS is for real-time, high-resolution diagnosis of nuclear abnormalities, mainly in patients with esophageal cancer. Up to now, three different types of ECS have been available. This diagnostic tool makes it possible to omit histological examination of biopsy samples in approximately 84% of esophageal squamous cell carcinoma, as evidence for both an increase of cell density and nuclear abnormalities is considered to be convincing proof that a lesion is malignant. Here we describe the features of ECS and the background that led to its development, and review the published literature pertaining to the observation of esophageal neoplasms using ECS.

A case report of recurrent intussusception caused by small bowel lymphangioma in an adult.

INTRODUCTION: Adult intussusception and lymphangioma in gastrointestinal tract are uncommon entities respectively. Recurrent intussusception due to lymphangioma of the small intestine is extremely rare and mimics adhesive small bowel obstruction (SBO). PRESENTATION OF CASE: A 37 year old man presented with acute abdominal pain and vomiting. He had been admitted several times for adhesive SBO after laparoscopic cholecystectomy at age 21. He was initially managed with a long tube placement, with which he used to get well. This time, the symptoms once relieved but soon relapsed, so an exploratory laparotomy was performed. Intraabdominal adhesiolysis was performed alongside the excision of a small segment of damaged jejunum. Intussusception of jejunum was noted and its reduction was also performed. Unfortunately, the symptoms continued after the operation, and computed tomography revealed a recurred intussusception of the jejunum. A reoperation with an additional resection of small intestine surrounding intussusception was performed. The symptoms subsided after the second operation and the patient was discharged. Pathological examination revealed lymphangioma within the affected lumen. DISCUSSION: Intussusception in an adult is often caused by a tumor but can be caused by postoperative adhesion. The reduction is a potential option of treatment if there is no tumor suspected, but sometimes it would be uneasy to affirm the non-existence of tumors. CONCLUSION: We present this rare case of recurrent jejuno-jejunal intussusception caused by small bowel lymphangioma with review of literature. Taking the possibility of recurrence and malignancy into account, the resection should always be considered in such patients.

Methotrexate-associated lymphoproliferative disorder complicated by severe acute respiratory failure and ileal perforation:a case report.

Lymphoproliferative disorder (LPD) is a potentially severe adverse effect of methotrexate (MTX) administration in patients with rheumatoid arthritis (RA). We report a case of MTX-associated LPD (MTX-LPD) in a patient with RA who developed severe pulmonary failure complicated by perforation of the terminal ileum. A 61-year-old woman with RA receiving MTX complained of dyspnea and abdominal pain. She was diagnosed with intestinal perforation and peritonitis, and underwent immediate abdominal surgery. Pathological examinations of the specimen obtained from the resected ileum and a bone marrow aspirate revealed diffuse large B-cell lymphoma. Steroid therapy failed to improve her respiratory failure, but her condition improved after abdominal surgery and suspension of MTX. MTX-LPD can result in multiple life-threatening conditions; however, the symptoms are highly variable. RA patients receiving MTX should thus be monitored carefully, and MTX administration should be stopped immediately on suspicion of MTX-LPD.

Polymyositis associated with urinary bladder cancer: an autopsy case.

A 56-year-old man suffered from muscle weakness with elevated serum creatine kinase. Under diagnosis of polymyositis, the patient was treated with corticosteroid, methotrexate and cyclosporin A. Eleven months after the first signs of muscle weakness, the patient suffered an abrupt onset of anuria and underwent hemodialysis. The patient died of respiratory insufficiency 14 months after the first signs of muscle weakness. Autopsy findings revealed associated urinary bladder cancer with histological indications of adenosquamous cell carcinoma, liver metastasis and cancerous lymphangitis of the lung.

Necrotizing lymphadenitis (NEL) is a systemic disease characterized by blastic transformation of CD8+ cells and apoptosis of CD4+ cells.

This clinicopathological, immunohistochemical, electron microscopic, and serological study of 382 cases (148 male, 234 female) of necrotizing lymphadenitis (NEL) in Japan confirms NEL as a self-limited disease with characteristic clinical features: high fever (38-40 °C), painful cervical lymphadenopathy (88.3 %), and leukopenia (under 4,000/mm(3)) without seasonal occurrence. Patient age varied from 5 to 80 years, but 62.8 % was younger than 30 years. There were five recurrent cases and four familial cases. In several cases, elevated serum aminotransaminase and antinuclear antibodies were found. Early in the disease, peripheral blood CD8+ cells were more abundant than CD4+ cells, but CD8+ cells decreased gradually with clinical progression, leading to an increasing ratio of CD4+/CD8+ cells during clinical course. Morphological features of involved lymph nodes are numerous CD8+ large immunoblasts, smaller CD4+ lymphocytes, plasmacytoid dendritic cells, histiocytes, and macrophages, the latter with phagocytized CD4+ apoptotic lymphocytes. Granulocytes are generally absent. These characteristics suggest that NEL is a reactive disease characterized by diploid disrupted CD4+ cells and CD8+ cells transforming to blastic cells. The etiology of the disease remains unknown, although viral infection is suggested, and its pathogenesis might include autoimmunity. Clinical characteristics and cytological and histological findings on lymph node biopsies can improve NEL diagnosis.

Favorable response after gemcitabine-radiotherapy for invasive pancreatic intraductal papillary mucinous neoplasm: a case report.

The efficacy of chemoradiotherapy for invasive pancreatic ductal carcinoma derived from an intraductal papillary mucinous neoplasm (IPMN) has not been established. The subject of the present report was a 53-year-old man admitted for the treatment of IPMN. The tumor, located in the pancreatic body, was of the mixed type of IPMN, and it involved the branch duct, where it was 38 mm in diameter, and the main duct, where it was 6 mm in diameter. Distal pancreatectomy was performed and the postoperative course was uneventful; however, histopathologic diagnosis revealed invasive ductal carcinoma with a positive surgical margin in the pancreatic duct. Although total pancreatectomy was recommended, chemoradiotherapy (50.4-Gy irradiation and gemcitabine) was preferred by the patient. At 9-month follow up, computed tomography and magnetic resonance imaging showed a cystic mass at the surgical margin of the pancreas. Endoscopic ultrasonography showed a 44-mm cystic lesion with nodules in the remnant pancreas, on the basis of which he underwent total pancreatectomy. Pathologic examination of the resected specimen revealed absence of the epithelium at the surgical margin of the main pancreatic duct, and malignant cells were not detected.

Fulminant type 1 diabetes mellitus.

We present a fatal case of fulminant type 1 diabetes mellitus that was initially diagnosed as upper respiratory tract infection based on pharyngeal redness at a clinic. However, the patient then went into cardiopulmonary arrest, and was transferred to our hospital for treatment. Testing revealed very high levels of blood glucose (86.9 mmol/l), urinary glucose (2+) and ketones (4+). His glycosylated haemoglobin level was almost normal (6.2%; normal <6.2%). Autopsy revealed marked depletion and atrophy of the islets of Langerhans.

Current status and limitations of the newly developed endocytoscope GIF-Y0002 with reference to its diagnostic performance for common esophageal lesions.

OBJECTIVES: To investigate both neoplastic and non-neoplastic lesions of the esophagus and to clarify the features of the surface cell morphology using a newly developed endocytoscope, the GIF-Y0002. METHODS: The surface cell morphology was examined with toluidine blue staining, and histological features of 53 patients with 54 lesions, including 39 patients with esophageal squamous cell carcinoma (ESCC) and 14 patients with 15 non-neoplastic esophageal lesions, were compared. One endoscopist classified the lesions using type classification, and we consulted one pathologist to evaluate the endocytoscopy pictures with regard to neoplasia or non-neoplasia. RESULTS: The overall sensitivity for ESCC of the findings by the endoscopist and pathologist based on GIF-Y0002 observation were 100.0% and 94.9%, respectively; while the specificity was 80.0% and 46.7%. For the 3 cases of low-grade intraepithelial neoplasia, 2 were diagnosed as Type 2 and one case as suspected neoplasia by the endoscopist while the pathologist considered 2 cases to be neoplastic. Among the 9 cases of esophagitis, the endoscopist diagnosed 2 cases as Type 2 or 3, which was suggestive of neoplasia, whereas the pathologist diagnosed 6 cases to be neoplastic. CONCLUSION: The low percentage of specificity for the pathologist's diagnosis was considered to be attributed to the low magnification power of the GIF-Y0002. A further increase in the magnifying power of this instrument will be necessary to broaden its clinical applications.

Successful combination therapy of radical liver resection with 5-fluorouracil/leucovorin, oxaliplatin, plus bevacizumab for ascending colon cancer with pulmonary and 43 liver metastases: report of a case.

At the time of diagnosis, 20% to 25% of patients with colorectal cancer already have liver metastases, the presence of which is a most important prognostic factor. A 64-year-old man was admitted to our hospital for investigation of anemia and multiple liver tumors. Examinations revealed ascending colon carcinoma with more than 40 liver metastases and 2 lung metastases. We performed right hemicolectomy with lymph node dissection, which was followed by 5-fluorouracil/leucovorin, oxaliplatin, plus bevacizumab (FOLFOX-BV). After 4 courses of chemotherapy, the lung metastases were in complete remission and the liver metastases had shrunk. We suggested the option of radical liver resection, but the patient declined initially as he had not suffered any severe side effects of FOLFOX-BV. After 23 courses of the chemotherapy, he agreed to undergo hepatectomy. We performed extended right lobectomy with partial left and caudal lobe resection. All of the macroscopic metastatic lesions were resected. Histopathologically, viable cancer cells were recognized in 7 of the 43 liver metastatic lesions. Postoperatively, FOLFOX-BV was restarted and continued for 10 months. At the time of writing, 15 months after the hepatectomy, the patient was well without evidence of recurrence of the cancer.

Mesenchymal cystic hamartoma of the lung: a rare cause of pneumothorax.

A 14-year-old girl had a left spontaneous pneumothorax. Because closed chest tube drainage failed to obtain expansion of the lung, thoracoscopic bullectomy was performed. Pathological examination of the bulla resulted in the diagnosis of mesenchymal cystic hamartoma, which is a rare cause of pneumothorax.

CD8-positive T cell-induced liver damage was found in a patient with polymyositis.

We describe a case of polymyositis (PM) with liver injury that occurred in a patient with rheumatoid arthritis (RA). A 74-year-old woman who had a 12-year history of RA was admitted to our hospital because of muscle weakness and liver dysfunction. CD8-positive T cell infiltration was found in the interstitium of both the liver and muscle. In addition to the administration of a large amount of prednisolone (PSL), high-dose intravenous immunoglobulin (IVIG) successfully improved myositis and hepatitis. Our case indicates the pathogenic potential of CD8-positive T cells in PM-associated liver injury.

Collateral vessels around the esophageal wall in patients with portal hypertension: comparison of EUS imaging and microscopic findings at autopsy.

BACKGROUND: In patients with portal hypertension, EUS reveals the presence of collateral vessels within and outside the esophageal wall such as esophageal varices, periesophageal collateral veins (peri-ECVs), paraesophageal collateral veins (para-ECVs), and perforating veins. This study retrospectively compared radial EUS images of these collateral vessels with histopathologic findings. METHODS: Four patients with esophageal varices treated by endoscopic injection sclerotherapy were studied. EUS was performed to evaluate the effects of endoscopic injection sclerotherapy. After endoscopic injection sclerotherapy, the segment of the esophagus from the esophagogastric junction to a point 5 cm proximal to junction was imaged with a 20-MHz radial scanning catheter US probe. Esophageal collateral veins outside the esophageal wall were identified as peri-ECVs (veins lateral to muscularis propria or within adventitia) and para-ECVs (veins lateral and separate from muscularis propria) along with perforating veins (veins connecting extramural collateral veins to submucosal varices). At autopsy, the esophagus with surrounding tissue was removed and cross-sectioned at 1-cm intervals from the esophagogastric junction to a point 5 cm proximal to the junction. Radial EUS images were correlated with histopathologic findings. RESULTS: Radial EUS after endoscopic injection sclerotherapy demonstrated peri-ECVs and perforating veins in all cases and para-ECVs in 3 cases. Based on histopathologic findings, veins associated with the esophageal wall were divided into 3 groups: those adjacent to the muscularis propria, veins separated from the wall without contact with the muscularis propria, and veins perforating the muscularis propria. All 3 groups of veins were observed in all cases. These 3 types of veins identified by histopathologic examination corresponded, respectively, to the peri-ECVs, para-ECVs, and perforating veins observed by EUS. CONCLUSION: Collateral esophageal veins demonstrated by radial EUS in patients with portal hypertension correspond to collateral veins identified histopathologically. In patients with portal hypertension, EUS is useful for assessment of vascular anatomy around the esophageal wall.