Macrocystic and non-necrotic salivary duct carcinoma of the submandibular gland: A case report.

Salivary duct carcinoma (SDC) is a major malignant salivary gland tumor that usually forms a solid tumor. Non-necrotic macrocystic SDCs have rarely been reported among salivary gland tumors. A 78-year-old Japanese man with a submandibular gland tumor was evaluated radiologically, pathologically, and immunohistochemically. A multilocular lesion with a maximum size of 6 cm was radiologically observed in the left submandibular region. It had been noticed 20 years earlier. Malignant cytological result was obtained, and surgical resection was performed. Pathological examination revealed a non-necrotic, macrocystic submandibular gland tumor lined with glandular, cribriform, or papillary forms of atypical cuboidal cells. Frankly invasive components were observed in intercystic areas. Intraductal, mucoepidermoid, and secretory carcinomas were identified as pathological differential diagnoses because of their macrocystic morphology. We diagnosed SDC because there was no intraductal growth based on the lack of myoepithelial markers, diffuse immunoreactivity to gross cystic disease fluid protein15, androgen receptor, and mammaglobin and immunonegativity to S100 and p63. Postoperative positron emission tomography revealed the absence of lymph node and distant metastases. The patient was disease-free 9 months after surgery. Salivary duct carcinoma can be included in the differential diagnoses of cystic salivary gland tumors.

Schwannoma-like uterine leiomyoma with fever of unknown origin and surgical management in a middle-aged woman: A case report.

Herein, we describe a 42-year-old woman with multiple uterine leiomyomas with interesting clinical and histologic findings. She had no medical history, except for uterine myomas, which were diagnosed in her early 30s. She presented with fever and lower abdominal pain, and her symptoms did not respond to antibiotics and antipyretics. The clinical evaluation suggested that degeneration of the largest myoma might be the cause of her symptoms, and pyomyoma was suspected. As she had sustained lower abdominal pain, hysterectomy and bilateral salpingectomy were performed. Histopathological examination confirmed the presence of usual-type uterine leiomyomas without suppurative inflammation. The largest tumor showed a rare morphology with a predominant schwannoma-like growth pattern and infarct-type necrosis. Thus, schwannoma-like leiomyoma was diagnosed. This rare tumor might be one of the manifestations of hereditary leiomyomatosis and renal cell cancer syndrome; however, this patient was unlikely to have that rare syndrome. Herein, the clinical, radiological, and pathologic findings of a schwannoma-like leiomyoma are presented and we have raised the question of whether patients with schwannoma-like uterine leiomyoma are more likely to be associated with hereditary leiomyomatosis and renal cell cancer syndrome than those with usual-type uterine leiomyoma.

Primary syphilis presenting as a painful unilateral inguinal lymphadenopathy, without cutaneous manifestations, in a 71-year-old Japanese man: A case report.

Syphilitic infection is usually observed in young patients, and the first stage of the disease (primary syphilis) is characterized by painless cutaneous and lymph node lesions. Herein, we describe a 71-year-old Japanese man with primary syphilis that presented as unilateral inguinal lymphadenopathy without skin lesions. Originally, an incarcerated hernia was clinically suspected. The lymph node pathologically showed suppurative lymphadenitis with vague granulomas; immunohistochemistry was highly suggestive of a syphilitic infection. Primary syphilis was confirmed by positive serological tests. Syphilitic infection should be included in the clinicopathological differential diagnoses for patients with inguinal lymphadenopathy, even in elderly patients without skin lesions.

Adrenal Schwannoma in an Elderly Man: A Case Report and Literature Review.

Schwannoma is a common mesenchymal neoplasm; however, adrenal schwannoma is rare, and it is frequently misdiagnosed as adrenal cortical adenoma. We herein report a 91-year-old Japanese man with right adrenal schwannoma that was pathologically diagnosed after adrenalectomy. To our knowledge, this is the first case of adrenal schwannoma in the oldest patient and with the longest follow-up period reported, including radiological images from 10 years earlier.

Acantholytic squamous cell carcinoma of the lung with marked lymphogenous metastases and high titers of myeloperoxidase-antineutrophil cytoplasmic antibodies: a case report.

BACKGROUND: Acantholytic squamous cell carcinoma (ASQCC), histologically characterized by intercellular bridge loosening, is recognized as a rare variant of squamous cell carcinoma (SQCC). ASQCC may demonstrate a worse prognosis than conventional SQCC. Pulmonary ASQCC is particularly rare; its biological behavior and prognostic data have not been reported. CASE PRESENTATION: We report the clinical and autopsy findings of a 71-year-old Japanese man with pulmonary ASQCC. Pulmonary lesions, suggestive of idiopathic interstitial pneumonia, were radiologically observed 3 and 6 years prior to the patient's most recent hospitalization; however, the patient did not undergo further medical examinations. Upon being discovered unconscious, the patient was admitted to our hospital. Dehydration and lower limb muscle weakness were noted, as were laboratory findings of coagulation abnormalities and renal dysfunction. Computed tomography helped confirm a 21-mm peripheral nodule in the upper left lobe of the lung, with associated swollen lymph nodes in the bilateral hilar, mediastinal, and para-aortic regions. Brain and spinal lesions, suggestive of neurological disturbances, were not found. Small cell lung carcinoma was suspected, upon admission, but high serum levels of squamous cell carcinoma antigen and cytokeratin-19 fragments were present. Therefore, advanced lung cancer, possibly SQCC, was diagnosed. The patient was treated with best supportive therapy, and died one month after admission. Hypercalcemia and high serum levels of parathyroid hormone-related protein (PTHrP) and myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) titers were observed. Progressive renal insufficiency was absent due to improved renal function subsequent to hydration. An autopsy helped confirm the left lung tumor as an ASQCC associated with pulmonary lymphangitic carcinomatosis and multiple metastases in the lungs and lymph nodes. Skin lesions suggesting malignant tumors were absent. The metastatic lesions consisted largely of acantholytic tumor cells, and the lungs showed usual interstitial pneumonia pattern; vasculitis was absent. CONCLUSIONS: This is the first reported case of pulmonary ASQCC resulting in an aggressive clinical course, with marked lymphogenous metastases and PTHrP-associated hypercalcemia. The high serum MPO-ANCA titers were clinicopathologically insignificant, but may have been related to the pulmonary interstitial lesion. Pulmonary ASQCC represents a highly malignant subset of lung cancer.

Cytological findings of ROS1-rearranged lung adenocarcinoma.

ROS1-rearranged lung adenocarcinoma has been recently identified. We report a case of ROS1-rearranged lung adenocarcinoma with special emphasis on cytological findings. Here, we report a case of young woman with ROS1-rearranged lung adenocarcinoma diagnosed by cytology and discuss the clinical, cytological, and molecular findings. Cytologically, the tumor consisted of small tight clusters of cells with high nuclear/cytoplasmic ratio. Nuclei were enlarged and small nucleoli were occasionally observed. Signet-ring cells were focally identified. Neoplastic cells were positive for ROS1 immunocytochemistry. Subsequently, the translocation of ROS1 gene was confirmed in a histological specimen. In conclusion, the specific histology of adenocarcinoma on cytological materials should promote testing for ROS1 immunohistochemistry. Immunocytochemical detection of ROS1 protein helps identify patients suitable for molecular targeted therapy.

Hepatoid Adenocarcinoma of the Extrahepatic Bile Duct in a Patient with Polysplenia Syndrome.

Hepatoid adenocarcinoma (HAC) is a rare subtype of extrahepatic adenocarcinoma that is characterized by its morphological and functional similarities to hepatocellular carcinoma. We herein present a novel case of HAC arising from the extrahepatic bile duct in a 75-year-old Japanese woman with polysplenia syndrome. This is the second reported case of HAC arising from this site. The tumor induced jaundice and hemobilia. A total of four isolated intraductal polypoid masses of HAC were found. No recurrence was seen five months after surgery. Further reports of similar cases will be needed to clarify the clinical characteristics and the prognosis of this malignancy.

Multilocular cystic leiomyoma of the anterolateral abdominal wall: A case report and literature review.

RATIONALE: Leiomyomas arising from the anterolateral abdominal wall are uncommon, and their pathogenesis remains unknown. We present the 15th case of such a tumor, having this unique tumor morphology, followed by a detailed discussion on disease pathogenesis. PATIENT CONCERNS: A 48-year-old, asymptomatic perimenopausal, multiparous Japanese woman presented with a left-sided pelvic mass. She had no history of previous surgeries or uterine leiomyomas. Although a transabdominal ultrasonogram raised suspicions of an ovarian tumor, a transvaginal ultrasonogram confirmed normal ovaries. Radiological images showed a multilocular cystic mass with enhanced solid lesions connected to the uterus. Retrospective radiological evaluation showed that the mass was largely connected to the peritoneum of the anterolateral abdominal wall. INTERVENTIONS: Intraoperatively, the mass appeared as a dome-like protrusion from the left lower quadrant of the abdominal wall, without connection to the uterus, ovaries, or the left round ligament. No other peritoneal masses were seen. The mass was easily enucleated from the abdominal wall. Pathology confirmed that the mass was a leiomyoma with hydropic and myxoid degeneration. No striated muscle tissues were noted between the tumor and resection margin, but a thin smooth muscle layer, positive for hormone receptors, was present at the periphery, suggesting the origin of the tumor. LESSONS: Benign leiomyomas of the anterolateral abdominal wall likely originate from Müllerian-like smooth muscle remnants in this region. They should be considered in the differential diagnosis of solid and cystic masses and be distinguished from uterine and ovarian masses on imaging to avoid unnecessary organ resection.

A subserosal, pedunculated, multilocular uterine leiomyoma with ovarian tumor-like morphology and histological architecture of adenomatoid tumors: a case report and review of the literature.

BACKGROUND: Uterine leiomyomas are common uterine tumors, and typical cases of leiomyoma are easily diagnosed by imaging study. However, uterine leiomyomas are often altered by degenerative changes, which can cause difficulty and confusion in their clinical diagnosis. We describe the 17th reported case of a uterine leiomyoma clinically diagnosed as an ovarian tumor; however, the present case shows the most detailed radiological evaluation, including contrast-enhanced magnetic resonance imaging. We first show that a uterine leiomyoma can histologically mimic an adenomatoid tumor. CASE PRESENTATION: A 47-year-old premenopausal, nulliparous Japanese woman with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia had lower abdominal pain. Ultrasonography confirmed a 6-cm mass in the right-sided space of the pelvic cavity. Magnetic resonance imaging evaluation showed that a multilocular mass was present near the uterus, and a mucinous ovarian tumor was considered. Emergency surgery due to acute abdomen was performed under the diagnosis of pedicle torsion of the ovarian tumor. During surgery, a pedunculated uterine mass without stalk torsion was seen. The mass grossly contained serous and hemorrhagic fluids in the cavities, and pathology examination confirmed that the mass was a leiomyoma with hydropic and cystic degeneration. Anastomosing thin cord-like arrangements of the leiomyoma cells mimicked the architecture of adenomatoid tumors. The tumor cells were positive for the microphthalmia transcription factor but negative for other melanoma markers. Three days postoperatively, she was discharged without sequelae. CONCLUSIONS: Marked intratumoral deposition of fluids may induce the multilocular morphology of a tumor, and the cellular arrangement of the tumor cells with hydropic degeneration mimicked an adenomatoid tumor in this case. Clinicians need to be aware that a subserosal leiomyoma with cystic and hydropic degeneration can mimic an ovarian tumor, and pathologists should be aware that such leiomyomas can mimic adenomatoid tumors. Additionally, perivascular epithelioid cell tumors should not be diagnosed only based on its immunoreactivity for the microphthalmia transcription factor.

High serum levels of both carcinoembryonic antigen and carbohydrate antigen 19-9 in a patient with sigmoid colon cancer without metastasis.

Carcinoembryonic antigen (CEA) and carbohydrate antigen (CA)19-9 are well known as the most common tumor markers of colon cancer, and levels are used not only for preoperative assessment of extent and outcome of cancer, but also postoperative monitoring of recurrence. We encountered a patient with sigmoid colon cancer showing abnormally high serum levels of CEA (311.1 ng/ml) and CA19-9 (5731.2 U/ml) preoperatively. We could not detect any metastases on computed tomography (CT) or (18)F-fluorodeoxyglucose positron emission tomography/CT. Sigmoidectomy and lymph node dissection were performed. Pathological analysis revealed well-differentiated tubular adenocarcinoma of the sigmoid colon with cancer cells infiltrating to the subserosa, but no lymph node metastases. As of postoperative day 60, serum levels of CEA and CA19-9 were 3.4 ng/ml and 9.2 U/ml, respectively, without any further anti-tumor treatment. This represents a rare case of sigmoid colon cancer with high levels of tumor markers in sera that improved following sigmoidectomy without further anti-cancer treatment.

Diffusion-weighted imaging for parasternal lymph nodes in breast cancer: report of two cases.

We report 2 cases of primary breast cancer with swelling of the parasternal lymph nodes detected on diffusion-weighted imaging (DWI) as small parasternal nodules. After neoadjuvant chemotherapy, DWI showed disappearance of one node but a focus of subtle signal hyperintensity in the other. DWI findings correlated with the results of conventional breast contrast-enhanced magnetic resonance imaging before and after neoadjuvant chemotherapy.

Diffusion-weighted magnetic resonance imaging for assessment after neoadjuvant chemotherapy in breast cancer, based on morphological concepts.

The study aimed to evaluate the utility of diffusion-weighted imaging (DWI) and to assess the response of breast cancer patients to neoadjuvant chemotherapy (NAC), based on morphological concepts. This retrospective study included 35 breast cancer patients (36 lesions) who had conventional magnetic resonance imaging (MRI), with DWI acquired before and after NAC. The morphological pattern of delayed enhancement on MRI before NAC was classified into two types: focal mass (FM), and multiple masses and/or non-mass like (MM/NM), based on Breast Imaging Reporting and Data System (BI-RADS). Of the 36 tumors, 26 were classified as FM and 10 as MM/NM. Tumors were clearly visualized on the initial DWI although one case of suspected MM/NM was not observed on DWI following NAC. A correlation was found between changes in the apparent diffusion coefficient and response rates to NAC in FM tumors (r=0.608, p<0.001), but not in MM/NM tumors (r=0.141, p=0.717). There was agreement between MRI findings after NAC and pathological findings in 30 of the 36 tumors (83.3%). Thus, we concluded that DWI is potentially useful in assessing the response to NAC for breast cancer for tumors diagnosed as FM on the initial conventional MRI.

Perforating branches of the internal thoracic artery in women with breast cancer: an anatomical study for breast-conservation surgery.

Breast reconstruction after breast-conservation surgery is an important issue for breast cancer patients. Various factors are associated with complications, of which blood flow is one of the more important. The perforating branches of the internal thoracic artery (ITA) are key contributors to blood flow in the anterior chest wall. The present study examined the distributions and depths of the perforating branches of the internal thoracic artery using a multi-detector row-computed tomography (MDCT) angiography. The subjects in this prospective study comprised of 38 women with suspected breast cancer who underwent MDCT angiography. The images were analyzed on computer using transverse MDCT source data and volume renderings. A total of 47 perforating branches were found, with 27 (57.4%) originating in the second, 6 (12.8%) in the third and fourth, 5 (10.6%) in the first and 2 branches (4.3%) originating in the fifth intercostal space, with one branch (2.1%) originating opposite the first intercostal space. A strong correlation was identified between the distance from the skin to the branch and adipose thickness at the shallowest and deepest points (P<0.001). The distributions and depths of the perforating branches of ITA identified in this study may be helpful in immediate breast reconstruction following mastectomy or breast-conserving surgery.

Erythema multiforme after radiotherapy with aromatase inhibitor administration in breast-conservation treatment for breast cancer.

Generalized eruptions associated with radiotherapy such as erythema multiforme (EM), Steven-Johnson syndrome and toxic epidermal necrolysis are uncommon reactions. A few cases of generalized eruptions during and after radiotherapy have been reported with the use of anticonvulsants and anticancer drugs. However, no reports have described mucocutaneous reactions associated with radiotherapy and concurrent use of anastrozole, an aromatase inhibitor. This report describes EM occurring after radiotherapy performed during breast-conserving treatment for breast cancer in a patient who was taking oral anastrozole.

Sentinel lymph node detection using computed tomography lymphography is accurate after neoadjuvant chemotherapy for breast cancer.

For breast cancer patients who have undergone neoadjuvant chemotherapy (NAC), a sentinel lymph node biopsy (SLNB) has not been recommended until recently. This is due to the possible lymph-flow interruption caused by fibrotic changes following chemotherapy and possible increases in false-negative cases. We investigated the changes in the lymph-flow and the detection of sentinel lymph nodes (SLNs) using computed tomography (CT) lymphography before and after NAC. We enrolled 53 patients with breast cancer who had undergone CT lymphography between May 2004 and April 2006. In total, 75 examinations were performed; 44 before NAC and 31 just after NAC. The CT lymphography procedures were approved by the medical ethics committee of our university. After a comprehensive explanation, written informed consent was obtained from all the patients, prior to enrollment in the study. Differences in changes in the lymph-flow, detection of SLNs, and changes in the number of detected SLNs were examined before and after NAC. Differences in the categoric variables were analyzed using the Chi-square test or Fisher's exact test. The identification rate (90.5%) of the SLNs following NAC was higher than the one before NAC (79.5%). However, no statistically significant difference was noted. No interruptions to the lymph-flow prevented the detection of SLNs by NAC. By performing CT lymphography before and after NAC, the interruption to the lymph-flow can be checked and the site of SLNs can be identified prior to surgery. We found that SLNB is recommended for breast cancer patients with or without NAC.

Sentinel node biopsy in breast cancer patients treated with neoadjuvant chemotherapy.

A sentinel node biopsy (SNB) has been proved to be an accurate method to estimate the axillary lymph node status as a replacement for axillary lymph node dissection (AxLND) in patients with early breast cancer who have not been treated with neoadjuvant chemotherapy (NAC). We examined the feasibility and accuracy of performing SNB after NAC. Seventy breast cancer patients treated with NAC were enrolled in the current study during the period between March 2001 and June 2005. NAC performed preoperatively consisted of three to four times of CAF chemotherapy. Moreover, intra-arterial (subclavian artery and internal mammary artery) infusion of epirubicin and 5-fluorouracil was performed in addition to systemic CAF chemotherapy once to three times in patients with large breast tumors or bulky axillary lymph node metastases. The sentinel nodes were successfully identified in 63 out of 70 patients (identification rate: 90%). The mean number of sentinel nodes removed per patient was 1.5 (range 1-6). Of the 43 patients in whom AxLND was performed after the sentinel nodes were identified, 19 (44.2%) had positive sentinel nodes. In 8 of those 19 patients, the sentinel node was the only cancer positive lymph node. Among the 24 patients who had negative sentinel nodes it was found that one patient had a confirmed false negative result, thus yielding a false negative rate of 5%, and a sensitivity of 95%. There was no false negative patient who had a clinically negative lymph node status (N0) before NAC (17 patients), whereas the false negative rate was 6.3% in the subgroup of patients with a clinically positive lymph node status (N1, N2) before NAC (26 patients). As a result, SNB after NAC is thus considered to be able to effectively predict the axillary lymph node status in patients with a clinically negative lymph node status before NAC.