Lymphoid Hyperplasia of the Gallbladder Extending to the Bile Duct.

A 72-year-old woman was referred for the examination of wall thickening of the bile duct and a polyp-like lesion on the gallbladder. The bile duct and gallbladder lesions were observed to be continuous on abdominal ultrasonography. We performed a bile duct biopsy, and pathological findings showed hyperplasia of the lymphoid follicles without malignancy. We considered these two lesions to be the same lesion, and laparoscopic cholecystectomy was performed to make a definite diagnosis. The pathological examination of the resected gallbladder also showed hyperplasia of the lymphoid follicles. We diagnosed the patient with lymphoid hyperplasia of the gallbladder extending to the bile duct.

[A Case of Gastric Small Cell Carcinoma with Rapid Regrowth after Surgery].

The patient was a 59-year-old man with type 2 advanced gastric cancer in the antrum. Abdominal computed tomography revealed the primary tumor with regional lymph node metastasis. Distal gastrectomy and D2 lymph node dissection were performed. Histopathological findings indicated gastric small cell carcinoma. Lymph node metastasis was observed microscopically in the #6 lymph nodes. Peritoneal lavage cytology was positive. The pathologic stage of the disease was pT2(MP), med, INF b, ly2, v2, pPM0, pDM0, pN2(6/33: #5, #6), M1, P0, CY1, H0, stage Ⅳ, R1(cy+). After surgery, he received chemotherapy with capecitabine plus oxaliplatin. However, after 1 course of therapy the disease had progressed, and the patient was diagnosed with peritoneal metastasis. Chemotherapy of CDDP plus CPT-11 was initiated, and after 5 courses the patient died.

A Japanese Case of Esophageal Lichen Planus that Was Successfully Treated with Systemic Corticosteroids.

Esophageal lichen planus (ELP) is rare and only about 80 cases have been reported in the literature. An 85-year-old woman presented with dysphagia and odynophagia. Endoscopy revealed a severe stricture in the proximal esophagus. Oral examinations at two years after the first endoscopy revealed erosions around the gingiva, and an examination of biopsy specimens taken from the site of erosion led to a diagnosis of oral lichen planus. Esophageal endoscopy was performed again, and biopsy specimens showed spongiosis and necrotic keratinocytes in the epithelium (civatte bodies). The patient was diagnosed with ELP and was treated with systemic corticosteroids, which resulted in clinical relief.

[A Case of Long-Term Disease-Free Survival of a Gastric Cancer Patient with Peritoneal Dissemination and Transverse Colon Invasion].

A 71-year-old man visited our hospital because ofepigastralgia and anorexia. Upper gastrointestinal endoscopy revealed type 1 gastric cancer. Contrast-enhanced abdominal CT revealed gastric wall thickening in the midgastric region and direct invasion ofthe transverse colon. CT findings also revealed a suspicion ofdissemination on the omentum and para-aortic lymph node swelling. We diagnosed gastric cancer with transverse colon invasion. Therefore, we performed distal gastrectomy with transverse colectomy and D2+No.16b1 lymph node dissection after obtaining patient consent. We observed direct tumor invasion into the transverse colon and seeding nodules on the omentum. Liver metastasis was not seen, and ascitic cytology was negative. He was discharged 16 days postoperatively, without any complications. Histopathological analysis revealed poorly differentiated adenocarcinoma and gastrocolic fistula. Postoperatively, S-1 was administered for 4 years as adjuvant chemotherapy. There has been no recurrence for 9 years after surgery.

[A Case of Intussusception Caused by Colon Cancer in A 25-Year-Old Woman].

A 25-year-old woman presented to our hospital with left flank pain and diarrhea. Contrast-enhanced abdominal computed tomography(CT)showed a target sign in the descending colon. She was diagnosed with intussusception of the colon. Colonoscopy revealed a tumor at the splenic flexure. We performed surgery and found an invaginated transverse colon at the splenic flexure. Reduction was unsuccessful with Hutchinson's maneuver, and we performed partial resection of the invaginated colon. Histopathological diagnosis was adenocarcinoma, tub1, SM2. Adult intussusception is uncommon, especially in young adults. It is usually caused by a polyp or tumor. We report a case of intussusception caused by colon cancer in a young female patient, and review the literature.

[A Case of Long-Term Survival with Multidisciplinary Therapy for a Patient with Multiple Metastases from Rectal Cancer].

Combined modality therapy is sufficient to treat advanced rectal cancer with multiple metastases. Her, we report a case of long-term survival in a patient with multiple metastases from rectal cancer. A5 8-year-old man had previously undergone low anterior resection for advanced rectal cancer. Multiple liver and lung metastases were identified prior to operation; therefore, we initiated chemotherapy(FOLFOX). Partial resection of metastatic lesions and radiofrequency ablation(RFA)were also administered, but newly developed liver, lung, and adrenal gland metastases were identified. We changed the chemotherapy regimen and administered topical therapies(partial resection, RFA, hepatic arterial infusion chemotherapy, radiotherapy)for each chemotherapy-refractory metastatic lesion. Although the patient is in a tumor-bearing state, he is still alive 10 years after his first operation. This combined modality therapy is an option for patients with chemotherapy-refractory metastases from rectal cancer.

[A Case of Goblet Cell Carcinoid of the Appendix Treated by Laparoscopic Ileocecal Resection after Diagnosis by Colonoscopic Examination for Positive Occult Blood].

A79 -year-old woman underwent colonoscopic examination for positive occult blood. Aneoplastic lesion was seen in the orifice of the vermiform appendix. She was referred to our hospital and underwent colonoscopic examination again. The biopsy revealed poorly differentiated adenocarcinoma or mixed adenoneuroendocrine carcinoma(MANEC), and she was diagnosed with carcinoma of the appendix. She was treated by laparoscopic ileocecal resection with lymph node dissection (D3). Histopathological examination revealed goblet cell carcinoid(GCC)of the appendix with serosal invasion. No metastasis was detected in the dissected lymph nodes. This patient has been followed-up for 6 months after surgery and no recurrences have been detected.

Pyogenic Spondylitis and Diskitis Caused by Helicobacter cinaedi in an Immunocompetent Adult Patient.

We herein describe the first reported case of pyogenic spondylitis and diskitis caused by Helicobacter cinaedi. The results of magnetic resonance imaging and the histology of biopsied tissue were suggestive of acute infection at the lumbar spine. The pathogen was obtained by a blood culture examination and identified by 16S rRNA analysis. Eight weeks of antibiotics therapy resulted in a good clinical course. H. cinaedi infections have been increasingly reported in recent years, but the pathogen's epidemiological and pathological characteristics are still unclear. One of the difficulties in understanding the pathogenesis of H. cinaedi has been the challenges in cultivating the pathogen. Novel strategies for the diagnosis of H. cinaedi must be developed.

Successful treatment of immediate allogeneic myeloablative hematopoietic stem cell transplantation from a HLA-mismatched sibling donor for active systemic epstein-barr virus-positive T-cell lymphoproliferative disease of childhood following primary acute epstein-barr virus infection.

A 22-year-old female was admitted for sustained high fever and diagnosed with systemic Epstein-Barr virus-positive T-cell lymphoproliferative disease. As her clinical course was so aggressive, she immediately underwent allogeneic myeloablative bone marrow transplantation from an HLA-mismatched sibling donor on hospital day 46. The patient has remained in complete remission for 3 years.

Rapidly progressed primary intestinal follicular lymphoma with elevation of soluble interleukin-2 receptor levels.

A 62-year-old Japanese male was diagnosed with primary intestinal follicular lymphoma involving the duodenum, jejunum, and rectum without lymph node involvement. The patient was classified as low risk by the follicular lymphoma international prognostic index (FLIPI) system. Treatment was deferred because he had no symptoms. Eleven months after the diagnosis, his soluble interleukin-2 receptor (sIL-2R) levels had risen from 383 to 617 U/mL. Lymphoma progression involving an enlarged perigastric lymph node was also documented. This report illustrates a case of rapidly progressed intestinal follicular lymphoma, suggesting the possible usefulness of sIL-2R levels as an indicator of lymphoma progression.

Chromoendoscopy of gastric adenoma using an acetic acid indigocarmine mixture.

AIM: To investigate the usefulness of chromoendoscopy, using an acetic acid indigocarmine mixture (AIM), for gastric adenoma diagnosed by forceps biopsy. METHODS: A total of 54 lesions in 45 patients diagnosed as gastric adenoma by forceps biopsy were prospectively enrolled in this study and treated by endoscopic submucosal dissection (ESD) between January 2011 and January 2012. AIM-chromoendoscopy (AIM-CE) was performed followed by ESD. AIM solution was sprinkled and images were recorded every 30 s for 3 min. Clinical characteristics such as tumor size (< 2 cm, ≥ 2 cm), surface color in white light endoscopy (WLE) (whitish, normochromic or reddish), macroscopic appearance (flat or elevated, depressed), and reddish change in AIM-CE were selected as valuables. RESULTS: En bloc resection was achieved in all 54 cases, with curative resection of fifty two lesions (96.3%). Twenty three lesions (42.6%) were diagnosed as well-differentiated adenocarcinoma and the remaining 31 lesions (57.4%) were gastric adenoma. All adenocarcinoma lesions were well-differentiated tubular adenocarcinomas and were restricted within the mucosal layer. The sensitivity of reddish color change in AIM-CE is significantly higher than that in WLE (vs tumor size ≥ 2 cm, P = 0.016, vs normochromic or reddish surface color, P = 0.046, vs depressed macroscopic type, P = 0.0030). On the other hand, no significant differences were found in the specificity and accuracy. In univariate analysis, normochromic or reddish surface color in WLE (OR = 3.7, 95%CI: 1.2-12, P = 0.022) and reddish change in AIM-CE (OR = 14, 95%CI: 3.8-70, P < 0.001) were significantly related to diagnosis of early gastric cancer (EGC). In multivariate analysis, only reddish change in AIM-CE (OR = 11, 95%CI: 2.3-66, P = 0.0022) was a significant factor associated with diagnosis of EGC. CONCLUSION: AIM-CE may have potential for screening EGC in patients initially diagnosed as gastric adenoma by forceps biopsy.

Co-infection with invasive pulmonary aspergillosis and Pneumocystis jirovecii pneumonia after corticosteroid therapy.

A 95-year-old man with chronic obstructive pulmonary disease and chronic hepatitis C virus infection was treated for acute lung injury caused by Chlamydophila pneumoniae with antibiotics and high-dose corticosteroids. In total, 7,500 mg methylprednisolone and 680 mg prednisolone were administered over 21 days. However, respiratory failure progressed, and chest computed tomography (CT) scan showed bilateral ground-glass opacity and cavity-forming consolidation in the right upper lobe. Despite intensive therapy, the patient died of multiple organ failure on day 7. CT-guided necropsy was performed, and pathological examination revealed invasive pulmonary aspergillosis and Pneumocystis jirovecii pneumonia. Invasive pulmonary aspergillosis and P. jirovecii pneumonia are both life-threatening opportunistic fungal infections. Co-infection of these organisms is rare but possible if the patient is in an extremely immunocompromised state. Short-term but high-dose systemic corticosteroid therapy was considered to be the risk factor in this case. We should pay more attention to immunocompromised hosts who might be suffering from co-infection of opportunistic infections. Moreover, we need to consider preventive measures in such high-risk cases.

[A case of metastatic carcinoma of the colon after curative resection for gastric cancer].

We report a rare case of metastatic colon cancer that occurred after gastric cancer surgery. The patient was a 63-year- old man who had received distal gastrectomy for type 2 advanced gastric cancer, which was a moderately differentiated adenocarcinoma, pT4a (SE),pN0, P0, CY0, M0, and Stage IIB. He was treated with S-1 for 1 year after the operation. However, levels of CA19-9 gradually increased postoperatively. Subsequently, 2 years and 10 months after the operation, computed tomography indicated a mass in the transverse colon. Colonoscopy showed half-circumferential stenosis in the transverse colon. The histopathological diagnosis was metastasis of gastric cancer. We performed right-hemicolectomy. Histopathology showed a moderately or poorly differentiated adenocarcinoma, which was colonic metastasis of the gastric cancer. After the operation, he was treated with paclitaxel weekly. Our findings suggest that after surgery for gastric cancer, it is worthwhile to monitor for metastatic colorectal cancer.

[Clinical efficacy of high-dose cepharanthine for idiopathic thrombocytopenic purpura: retrospective multicenter analysis].

Cepharanthine (CEP), an alkaloid drug that has a cell membrane stabilizing effect and an immunomodulating effect, has been reported to improve symptoms and signs of chronic immune thrombocytopenia (ITP). In this study, we retrospectively assessed the clinical efficacy and adverse events of high-dose CEP for 47 patients with ITP. The response rate (elevation of platelet count>5×10(4)/µl) was 44%, and CEP treatment was judged useful in clinical aspects by their attending doctors in 77% of the cases. Next, we made a comparative analysis between patients who were administered CEP as a single agent (22 patients) and those administered CEP in combination therapy with prednisolone (PSL) (20 patients). There was a marked increase in platelet count in both groups compared to the count before CEP treatment (P<0.01), and no significant difference was seen between the two groups. High-dose CEP was well tolerated, and in some patients single-agent CEP therapy resulted in a significant elevation of platelets, allowing a reduced dosage of PSL.

Breast cancer with cartilaginous and/or osseous metaplasia diagnosed by lymph nodal metastasis: a case report.

Breast cancer with cartilaginous and/or osseous metaplasia is a type of metaplastic carcinomas and is a rare disease. We report the case of a 49 year-old female who underwent right mastectomy for a large breast tumor. Histological examinations revealed a mixed tumor with both stromal and epithelial elements;the stroma showed poor differentiated spindle-shape and multiform cells with a massive osseous matrix, and atypical epithelial cells, which mainly existed on the surface of the cysts, showed nucleic atypia. The tumor was diagnosed as a malignant phyllodes tumor with osteosarcomatous differentiation;it was not identified as a metaplastic carcinoma because of the lack of proof of a cancerous component. Two years after a mastectomy, swelling of the axillary lymph nodes was found and a biopsy was performed. Histological findings for the lymph node indicated a metastasis of the invasive ductal carcinoma. The primary tumor was re-examined and was considered to be the origin of the lymph nodal metastasis. Lymph nodal metastasis of cancer proved that the primary tumor had cancerous potential, and the pathological diagnosis was altered to a breast cancer with cartilaginous and/or osseous metaplasia.

Expression of thyroglobulin on follicular dendritic cells of thyroid mucosa-associated lymphoid tissue (MALT) lymphoma.

Reportedly, thyroid mucosa-associated lymphoid tissue (MALT) lymphoma is closely associated with Hashimoto's thyroiditis. However, it remains unknown which antigen is closely associated with thyroid MALT lymphoma. We examined whether B cell response to thyroglobulin (Tg), which is a common thyroid-specific autoantigen, is related etiologically to the pathogenesis of thyroid MALT lymphoma. Expression of human Tg antigens and Cluster of differentiation (CD) 35 was examined immunohistochemically in 15 cases of thyroid MALT lymphoma using paraffin-embedded, formalin-fixed tissue specimens. In all cases of thyroid MALT lymphoma, human Tg was detected immunohistochemically in the follicular epithelial cells and follicular dendritic cells (FDCs). These FDCs were positive by double immunostaining for anti-human Tg rabbit polyclonal antibody (Ab) and for CD35. Results showed that the Tg, a thyroid autoantigen, had immunostained the germinal center of the thyroid MALT lymphoma. The Tg was present in the FDCs, as revealed by the staining pattern of the germinal center;this fact was confirmed by double immunostaining of anti-human Tg mouse monoclonal Ab and anti-CD35 mouse monoclonal Ab. The results of our study suggest that Tg is an autoantigen that is recognized by thyroid MALT lymphoma cells.

[Evans syndrome associated with idiopathic mixed-type autoimmune hemolytic anemia].

A 60-year-old man was admitted to our hospital with severe anemia and blood findings showed hemolytic anemia. Further serological examination revealed both warm-reactive autoantibody and cold agglutinin against erythrocytes. The cold agglutinin showed a low titer, 1 : 32 at 4 degrees C, and had a high thermal amplitude of 30 degrees C or higher, resulting in sufficient activity for hemolysis. Since no underlying disorders could be detected, the diagnosis was idiopathic mixed-type autoimmune hemolytic anemia. Although thrombocytopenia (Evans syndrome) subsequently appeared, corticosteroid was extremely effective for both anemia and thrombocytopenia. In this report we describe a rare case of Evans syndrome associated with mixed-type autoimmune hemolytic anemia, which had a dramatic response to corticosteroid therapy.

Potent synergy of dual antitumor peptides for growth suppression of human glioblastoma cell lines.

Molecular targeting agents have become formidable anticancer weapons, which show much promise against the refractory tumors. Functional peptides are among the more desirable of these nanobio-tools. Intracellular delivery of multiple functional peptides forms a basis for potent, non-invasive mode of delivery, providing distinctive therapeutic advantages. Here, we examine growth suppression efficiency of human glioblastomas by dual-peptide targeting. We did simultaneous introduction of two tumor suppressor peptides (p14(ARF) and p16(INK4a) or p16(INK4a) and p21(CIP1) functional peptides) compared with single-peptide introduction using Wr-T-mediated peptide delivery. Wr-T-mediated transport of both p14(ARF) and p16(INK4a) functional peptides (p14-1C and p16-MIS, respectively) into human glioblastoma cell line, U87DeltaEGFR, reversed specific loss of p14 and p16 function, thereby drastically inhibiting tumor growth by >95% within the first 72 h, whereas the growth inhibition was approximately 40% by p14 or p16 single-peptide introduction. Additionally, the combination of p16 and p21(CIP1) (p21-S154A) peptides dramatically suppressed the growth of glioblastoma line Gli36DeltaEGFR, which carries a missense mutation in p53, by >97% after 120 h. Significantly, our murine brain tumor model for dual-peptide delivery showed a substantial average survival enhancement (P < 0.0001) for peptide-treated mice. Wr-T-mediated dual molecular targeting using antitumor peptides is highly effective against growth of aggressive glioblastoma cells in comparison with single molecule targeting. Thus, jointly restoring multiple tumor suppressor functions by Wr-T-peptide delivery represents a powerful approach, with mechanistic implications for development of efficacious molecular targeting therapeutics against intractable human malignancies.

The outcome of gastrointestinal stromal tumors (GISTs) after a surgical resection in our institute.

PURPOSE: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract arising from Cajal's cells and expressing c-kit. In a consensus report, the clinical behavior of GISTs was categorized into risk classes according to the tumor size and mitotic count. We analyzed the risk categories based on GIST patients who underwent a surgical resection at our institute during a period of 15 years. METHODS: We evaluated the risk categories of GISTs and analyzed the outcome and risk categories retrospectively. We presented the MIB-1 score of the tumor instead of mitotic counts for the evaluation of cellular growth because of inaccuracies regarding the mitotic counts. RESULTS: Patients were classified into 4 cases of very low risk, 11 of low risk, 8 of intermediate risk, and 5 of high risk. Four high-risk patients showed recurrence as either liver metastasis or peritoneal dissemination. In addition, local recurrence occurred in one low-risk and one intermediate-risk patient each. CONCLUSION: Our cases confirmed the correlation between the risk categories and the prognosis. A complete resection with sufficient margin must be confirmed even in low-risk cases to prevent local recurrence. Since high-risk patients showed poor prognosis, the adjuvant treatment with chemotherapeutic regimens must therefore be further studied for high-risk patients.

Multiple gastrointestinal stromal tumors in neurofibromatosis type 1 treated with laparoscopic surgery.

Gastrointestinal stromal tumors (GISTs) have been reported to occasionally occur in patients with neurofibromatosis type 1 (NF-1), and many cases have had multiple lesions predominantly involving the small intestine. We report herein a case of multiple GISTs associated with NF-1 from whom laparoscopic surgery was beneficial. In a 79-year-old female admitted with anemia and melena, the abdominal computed tomography revealed a tumor arising from the small intestine. Laparoscopic surgery was performed, and another small tumor was revealed during laparoscopic observation. Extracorporeal partial and wedge resection of the small intestine were undertaken. Both lesions were diagnosed as typical GISTs of low risk. Laparoscopic surgery would be useful for examination and a minimally invasive approach to tumors of the small intestine, especially on cases with the possibility of multiple tumors.