The first case of POEMS syndrome with synchronous breast cancer: What are the associated diagnostic challenges?

Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, Skin changes (POEMS) syndrome is a rare plasma cell disorder that causes a paraneoplastic syndrome. We report the first case of POEMS syndrome with synchronous breast cancer. The patient was at risk of being misdiagnosed with metastatic cancer, and it is important to emphasize that physical examinations provided vital diagnostic clues.

Primary rectal diffuse large B-cell lymphoma associated with ulcerative colitis: a case report.

We need to be aware of primary intestinal lymphoproliferative disease (PILD) associated with ulcerative colitis (UC). We should carefully monitor UC patients, particularly patients who meet the following conditions; a previous Epstein-Barr virus infection, treatment duration ≧4 years, male, and age ≧50 years.

Adenocarcinoma arising in small sessile serrated adenoma/polyp (SSA/P) of the colon: clinicopathological study of eight lesions.

We reviewed the clinicopathological findings of eight cases of sessile serrated adenoma/polyps (SSA/Ps) with carcinoma, the largest diameter of which was 10 mm or less. All lesions were polyps located in the right side of the colon. Four lesions showed submucosal invasion and one lesion invaded the proper muscle layer. The depth of invasion, however, did not seem to be related to the carcinoma area size. Most carcinomas were well to moderately differentiated tubular adenocarcinomas focally showing some serrated appearances, and the predominant component of one carcinoma was a poorly differentiated medullary growth with inflammatory stroma. Rapid progression to invasive carcinoma from SSA/P was suggested for the carcinoma with proper muscle invasion whereas one submucosally invasive carcinoma was considered to progress over 7 years. Immunohistochemically, it was suggested that with or without hMLH1 protein loss, alterations of p53 and/or Wnt signaling pathway can be involved in the cancerization through SSA/Ps. The carcinomas irregularly imitated the mucin expression of the SSA/Ps (positive for MUC5AC and MUC2, and MUC6 expression in crypt bases), which was lost with progression of the carcinomas. Analyses of small SSA/P lesions with cancerization would facilitate the understanding of the mode of progression of SSA/Ps and their early detection.

Histopathological and immunohistochemical findings of 20 autopsy cases with 2009 H1N1 virus infection.

Twenty autopsy cases with 2009 pandemic influenza A (2009 H1N1) virus infection, performed between August 2009 and February 2010, were histopathologically analyzed. Hematoxylin-eosin staining, immunohistochemistry for type A influenza nucleoprotein antigen, and real-time reverse transcription-PCR assay for viral RNA were performed on formalin-fixed and paraffin-embedded specimens. In addition, the D222G amino acid substitution in influenza virus hemagglutinin, which binds to specific cell receptors, was analyzed in formalin-fixed and paraffin-embedded trachea and lung sections by direct sequencing of PCR-amplified products. There were several histopathological patterns in the lung according to the most remarkable findings in each case: acute diffuse alveolar damage (DAD) with a hyaline membrane (four cases), organized DAD (one case), acute massive intra-alveolar edema with variable degrees of hemorrhage (three cases), neutrophilic bronchopneumonia (five cases) and tracheobronchitis with limited histopathological changes in alveoli (four cases). In two cases, the main findings were due to preexisting disease. Influenza virus antigen was only detected in the respiratory tract in 10 cases by immunohistochemistry. The antigen was detected in type II pneumocytes (three cases) in the epithelial cells of the trachea, bronchi and glands (six cases), and in the epithelial cells in both of the above (one case). The four cases with acute DAD presented with antigen-positive type II pneumocytes. In one case, the D222G substitution was detected in the lung as a major sequence, although 222D was prominent in the trachea, suggesting that selection of the viral clones occurred in the respiratory tract. In five cases, the pathogenesis of 2009 H1N1 was confirmed to be viral infection in pneumocytes, which caused severe alveolar damage and fatal viral pneumonia. Further studies on both host and viral factors in autopsy or biopsy materials will be essential to elucidate the other pathogenic factors involved in influenza virus infection.

Histiocytoid breast carcinoma: solid variant of invasive lobular carcinoma with decreased expression of both E-cadherin and CD44 epithelial variant.

Histiocytoid breast carcinoma (HBC) is a rare type of breast carcinoma with morphologic characteristics resembling those of histiocytes. Described herein are cytological and histological findings in a case of HBC. Fine-needle aspiration cytology revealed numerous loosely cohesive tumor cells with abundant foamy to granular cytoplasm and bland-appearing nuclei. The resected tumor exhibited a solid growth pattern instead of classic invasive lobular patterns observed in most reported cases of HBC. However, distinct intracytoplasmic lumina and Pagetoid extension to ducts suggested that this tumor was a variant of invasive lobular carcinoma. To determine the cause of the loose cellular cohesiveness of this HBC, its expression of the epithelium-related cell adhesion molecules E-cadherin and CD44v8-10 (CD44 epithelial variant) was examined. Immunohistochemically, E-cadherin was not detected, similar to most lobular carcinomas. Furthermore, competitive reverse transcription-polymerase chain reaction (RT-PCR) analyses among alternatively spliced variants of CD44 revealed that the ratio of expression of CD44v8-10 to that of CD44v10 (dominant variant in leukocytes) was lower than that for the reference breast carcinoma samples. It is concluded that the present case of HBC was a solid variant of invasive lobular carcinoma exhibiting foamy to granular cytoplasmic change. Decreased expression of both E-cadherin and CD44 epithelial variant may be responsible for the loose cellular cohesiveness observed in HBC.

A case of thymic enlargement in hyperthyroidism in a young woman.

We present the case of a 24-year-old woman with thymic enlargement accompanied by hyperthyroidism. An x-ray incidentally detected her thymic enlargement and the size was estimated to be 226 cm(3) by computed tomography (CT) using three-dimensional analysis. Physical examination revealed a soft diffuse goiter, increased sweating and restlessness; thyroid function tests showed hyperthyroidism. Because the possibility of a thymoma could not be completely excluded, a mediastinal biopsy via a supracervical approach was done that determined the specimen was composed of normal thymic tissue. Together with these findings, the patient's thymic enlargement was likely to be consistent with true thymic hyperplasia. Moreover, we have demonstrated the presence of the thyrotropin (TSH) receptor in her thymus using reverse transcription-polymerase chain reaction (RT-PCR). She was treated with methimazole, resulting in the resolution of not only the thyroid dysfunction but also thymic enlargement. Thymic enlargement has often been recognized as a complication of hyperthyroidism. However, the pathophysiologic mechanisms underlying these conditions remain obscure. Our result raises the speculation that the thymus is also a target organ of autoimmune attack as are the orbital and fibroblasts, which lead to Graves' ophthalmopathy and pretibial dermopathy, respectively.

Expression and alternative splicing pattern of human telomerase reverse transcriptase in human lung cancer cells.

Telomerase activity is generally considered to be necessary for cancer cells to avoid senescence. The expression of human telomerase reverse transcriptase (hTERT) is believed to be a rate-limiting step in telomerase activation. Recently, it has been proposed that the alternative splicing of hTERT is also involved in regulation of telomerase activity. However, the regulatory mechanism of telomerase in cancer cells has not been thoroughly investigated. To clarify it in lung cancer cells, we measured the expression of the hTERT transcript, analyzed its alternative splicing by RT-PCR, and compared it with telomerase activity and telomere length. The expression of the hTERT transcript was positively correlated with telomerase activity in lung cancer cells. Cancer cells with high telomerase activity contained 4 splicing variants of hTERT, and the full-length variant was 31.3-54.2% of the total transcripts. Cells of the TKB-20 cell line, which has extremely low telomerase activity, showed a different splicing pattern of hTERT in addition to low expression. The functional full-length variant was scarcely detected in TKB-20 cells, suggesting that the telomerase activity was repressed by alternative splicing of hTERT. Telomere length was not necessarily correlated with telomerase activity or hTERT expression in lung cancer cells. Cells of the TKB-4 cell line that also showed relatively low telomerase activity (as TKB-20 cells) had long telomeres. In conclusion, hTERT expression is regulated at both the transcriptional and post-transcriptional levels in lung cancer cells, and the alternative splicing of hTERT is involved in the control of telomerase activity.

Inflammatory pseudotumor-like follicular dendritic cell tumor of the spleen.

A case of so-called inflammatory pseudotumor (IPT), occurring in the spleen of a 77-year-old woman, is reported. The spleen contained a well-circumscribed mass with central hemorrhage and necrosis. Histologically, spindle cells were dispersed in a background of abundant inflammatory cells, predominantly lymphocytes and plasma cells. The cells possessed enlarged, sometimes twisted or irregularly folded, nuclei that contained vesicular chromatin, and small but distinct, centrally located nucleoli. Immunohistochemically, the spindle cells were diffusely positive for vimentin, and focally positive for follicular dendritic cell (FDC) markers (Ber-MAC-DRC for CD35 and CNA.42). The Epstein-Barr virus (EBV) was exclusively detected in the spindle cells by in situ hybridization analysis. The cells also expressed the latent membrane protein-1 (LMP-1) of EBV, and polymerase chain reaction (PCR) analysis revealed that the LMP-1 gene had a 30-bp deletion and three point mutations, although their significance remains controversial. Inflammatory pseudotumor is a descriptive term that encompasses several different entities, and recent investigations have revealed the existence of neoplastic entities among IPT. One of the neoplastic IPT, recently designated 'IPT-like FDC tumor', is characterized by proliferation of EBV-positive FDC and commonly occurs in the liver and spleen. Because such tumors are capable of recurrence and metastasis, it is important to consider the possibility of an IPT-like FDC tumor when making a diagnosis of a hepatic/splenic IPT-like lesion.

Angiomyofibroblastoma of the vulva: report of a case with immunohistochemical and molecular analysis.

A 43-year-old woman presented with a mass in the subcutaneous tissue of the right labium majus. A lipoma or Bartholin gland cyst was suspected and excision of the lesion was performed. The lesion was well circumscribed, and histological examination revealed a typical angiomyofibroblastoma. The lesion was composed of alternating hypocellular edematous and hypercellular areas with abundant vessels, and plump tumor cells were loosely dispersed or aggregated mainly around the vessels. Tumor cells were immunoreactive for vimentin and desmin but negative for muscle actins. Ultrastructurally, the tumor cells contained a moderate amount of rough endoplasmic reticulum and abundant intermediate filaments, and had primitive junctions. Pinocytotic vesicles or basal lamina were not evident. Immunohistochemical studies also revealed that the tumor cells expressed basic fibroblast-growth factor, vascular-endothelial-growth factor, and stem-cell factor, factors that may contribute to the rich vascularity and mast cells within the tumor. Reverse transcription-polymerase chain reaction detected high mobility group I-C (HMGI-C) transcripts in the tumor tissue. Because the expression of HMGI-C is regulated by developmental and differentiation processes and is not found in adult normal tissues, HMGI-C may be involved in the tumorigenesis of angiomyofibroblastoma.

A case of liposarcoma with peritonitis due to jejunal perforation.

A 21-year-old man, who had been treated for congenital dilatation of the bile duct 13 years previously, presented with an acute abdomen. The physical examination suggested peritonitis, and an emergent laparotomy was performed. A perforation was foundin the jejunum approximately 100 cm distal to the ligament of Treitz, followed by resection of a 60-cm jejunal segment. No tumorous lesions were found during the operation, and the resected jejunal segment showed only focal myxomatous thickening of the serosa. Despite intensive therapy, he died of uncontrollable septic shock 2 days after the operation. Unexpectedly, however, histological examination revealed a liposarcoma, showing an unclassifiable histology. From the distribution of the lesion and the histological findings, it is thought that a primary lesion was somewhere else, covered by severe adhesions due to the previous operation, and that the tumor cells spreading from it could have caused the jejunal perforation through vascular involvement. Although extremely rare, liposarcomas in the abdomen can cause intestinal perforation. It is important for both clinicians andpathologists to carefully investigate the cause of an unusual clinical presentation such as intestinal perforation.

Complicated mechanisms of class II transactivator transcription deficiency in small cell lung cancer and neuroblastoma.

Small cell lung cancer (SCLC) and neuroblastoma (NB), the most aggressive adult and infant neuroendocrine cancers, respectively, are immunologically characterized by a severe reduction in major histocompatibility complex (MHC) that is indispensable for anti-tumor immunity. We had reported that the severe reduction of MHC in SCLC was caused by a deficient interferon (IFN)-gamma-inducible expression of class II transactivator (CIITA) that is known as a very important transcription factor for IFN-gamma-inducible class II and class I MHC expression (Yazawa T, Kamma H, Fujiwara M, Matsui M, Horiguchi H, Satoh H, Fujimoto M, Yokohama K, Ogata T: Lack of class II transactivator causes severe deficiency of HLA-DR expression in small cell lung cancer. J Pathol 1999, 187:191-199). Here, we demonstrate that the reduction of MHC in NB was also caused by a deficient IFN-gamma-inducible expression of CIITA and that the deficiency in SCLC and NB was caused by similar mechanisms. Human achaete-scute complex homologue (HASH)-1, L-myc, and N-myc, which are specifically overexpressed in SCLC and NB, bound to the E-box in CIITA promoter IV and reduced the transcriptional activity. Anti-sense oligonucleotide experiments revealed that overexpressed L-myc and N-myc lie upstream in the regulatory pathway of HASH-1 expression. The expression of HASH-1 was also up-regulated by IFN-gamma. Our results suggest that SCLC and NB have complicated mechanisms of IFN-gamma-inducible CIITA transcription deficiency through the overexpressed HASH-1, L-myc, and N-myc. These complicated mechanisms may play an important role in the escape from anti-tumor immunity.