Small intestinal metastasis from renal cell carcinoma exhibiting rare findings.

Small intestinal metastasis from renal cell carcinoma (RCC) has only rarely been described. We report two patients who developed small bowel metastases from RCC showing different clinicopathological characteristics. Both patients underwent hemilateral nephrectomy for RCC and developed lung metastases metachronously or simultaneously. One patient developed occlusive ileus caused by multiple polypoid tumours composed of sarcomatoid tissue in the jejunum shortly after nephrectomy. The other patient presented melaena due to bleeding from a Borrmann 2-like tumour in the jejunum six years after nephrectomy. Clinically, his disease was slow-growing. Sarcomatoid histology and Borrmann 2-like tumour in this report are rare findings in metastatic tumour of RCC in the small bowel.

[Induction chemoradiotherapy in small adenocarcinoma of the lung with bulky mediatinal lymph node metastasis].

A 56-year-old man, who visited our hospital due to chest pain, was pointed out a large tumor, 60 mm in diameter, on the left superior mediastinum on the chest computed tomography (CT) scan. He was diagnosed as having mediastinal lymph nodes metastasis of adenocarcinoma through video-assisted thoracoscopic surgery (VATS) biopsy. He received induction chemoradiotherapy: cisplatin and paclitaxel were administered once per week for 2 weeks, and radiotherapy was simultaneously performed. No serious adverse reactions were noted. The ipsilateral mediastinal lymph nodes dissection was performed. Intraoperative frozen section analysis showed a small nodule in the left upper lobe, 5 mm in diameter, was adenocarcinoma. He was finally diagnosed as having mediastinal lymph nodes metastasis from the small adenocarcinoma of the lung, and left upper lobectomy was performed. Histopathological examination of the mediastinal lymph nodes showed no evidence of viable maligmant cell. Induction chemoradiotherapy with cisplatin and paclitaxel might be effective treatment for locally advanced non-small cell lung cancer.

Gastric cancer with Virchow's and multiple lung metastases showing a remarkable response to preoperative chemotherapy: report of a case.

We report herein a rare case with advanced gastric cancer combined with group 4 lymph node and lung metastases that responded remarkably to neoadjuvant chemotherapy. A 65-year-old man was found to have a well-differentiated type 3 gastric cancer that invaded the duodenum locally and was accompanied with Virchow's, para-aortic lymph nodes, and multiple lung metastases based on physical, endoscopic, and radiological examinations. In addition, his carbohydrate antigen (CA) 19-9 was elevated to 3965U/ml, and CA72-4 to 46U/ml. Prior to surgery, he was treated with 5-fluorouracil (5-FU; 500mg/body per day) and low-dose cisplatinum (CDDP; 10mg/body per day) as neoadjuvant chemotherapy for 6 weeks. As a result, a partial response was obtained in all lesions, and CA19-9 and CA72-4 decreased to 463U/ml and 9.4U/ml, respectively. Four weeks after the completion of neoadjuvant chemotherapy, a distal gastrectomy was performed, and a histopathological examination of the resected specimen showed a grade 2 response to chemotherapy. Immunohistochemically, the thymidylate synthase expression level was very low in the tumor tissues, which might account for the good response to the combination chemotherapy with 5-FU and CDDP observed in the present case.

[A case of superior mediastinal neurinoma resected from the supra-clavicular area].

We report a case of superior mediastinal neurinoma that was resected from the supra-clavicular area. An abnormal shadow on the chest X-ray film was pointed out in a 53-year-old male. A left supra-clavicular mass was subsequently also discovered. We underwent extirpation of the tumor through supra-clavicular approach and confirmed to be a neurinoma histologically. We consider supra-clavicular approach which allows a good view might be useful.

[A case of metachronous lung cancer in which tumor developed within the different ipsilateral lobe over a short period of time and completion pneumonectomy was required].

A 51-year-old man underwent a middle-lower lobectomy for squamous cell carcinoma on February 8, 1996. In July, 1997, a computed tomography revealed a mass shadow in the right upper lung field. Completion pneumonectomy was performed. Histopathological examination showed poorly differentiated adenocarcinoma. This case was the shortest time to occurrence of second tumor in our metachronous lung cancer cases. We must always give attention to exist second primary lung cancer and double primary lung cancer after resection of primary lung cancer.

[A case of primitive neuroectodermal tumor of the kidney].

A primitive neuroectodermal tumor (PNET) is a solid tumor originating from the neural crest. This tumor is known to occur in the central nervous system and soft tissue, but recently determined to also invade the kidney. Although primary renal PNET is very rare, we encountered a case of primary renal PNET with multiple lung metastasis. This case was a 35-year-old man with a chief complaint of macroscopic hematuria, which he noticed in January 1996. He was hospitalized because of right renal tumor detected with ultrasonography. On CT scan, a low-density solid tumor with a maximum diameter of 8 cm was visualized in the right kidney. Low-signal and high-signal tumorous lesions were demonstrated in the same region on T 1-weighted and T 2-weighted MR images, respectively. Then right radical nephrectomy was performed on Feb. 5, 1996. On histopathological observation, the tumor was composed of small tumor cells with solid growth. Immunohistochemical staining revealed that the tumor was positive for CD 99. Thus our final diagnosis was primary right renal PNET. Although 2 metastatic lesions with a diameter of about 1 cm were observed in the right lower lung before the time of surgery, pulmonary metastatic lesions markedly increased in number 3 months after surgery. Thus we initiated CAP chemotherapy with cyclophosphamide, doxorubicin, and CDDP. After 3 cycles, pulmonary metastatic lesions disappeared at CT scan, indicating complete remission. However, a tumor with a maximum diameter of about 10 cm recurred in the retroperitoneum 7 months after complete remission. Although 2 cycles of CAV/PE therapy with cyclophosphamide, doxorubicin, vincristine, CDDP, and VP-16 were performed following resection of the retroperitoneal tumor, he showed no response and decreased 24 months after surgery.

Expression of tissue factor in non-small-cell lung cancers and its relationship to metastasis.

Tissue factor (TF) is an initiator of the extrinsic cascade of blood coagulation. Although recent studies have revealed a relationship between metastatic properties and TF expression in some neoplastic cells, the significance of TF in lung cancer, especially in non-small-cell lung cancer (NSCLC), is still unclear. In this study, TF was detected in NSCLC cell lines by functional study, Western blot analysis and immunocytochemical staining. TF levels in eight NSCLC cell lines were also quantitated by enzyme-linked immunosorbent assay (ELISA), and TF expression was evaluated in 55 specimens of surgically resected NSCLCs. NSCLC cell lines derived from metastatic lesions produced high levels of TF (48.3+/-23.5 ng 10(-6) cells, mean +/- s.e.m.), whereas those derived from primary lesions produced low levels of TF (0.2+/-0.1 ng 10(-6) cells). Immunohistochemical studies disclosed significantly stronger staining for TF in cells from NSCLC patients with metastasis than in those without metastasis. Among the 28 patients with metastasis, ten were strongly positive, 16 were moderately positive and two were negative for TF. In contrast, among the 27 patients without metastasis, only two were strongly positive, 18 were moderately positive and seven were negative for TF. Therefore, malignant cells from patients with lung cancer produce various levels of TF, and TF may play an important role in the metastatic process.

[A case of mediastinal cavernous hemangioma resected through thoracoscope].

A case of mediastinal cavernous hemangioma was reported. An abnormal shadow on the chest X-ray film was pointed out in a 55-year-old male. CT scan and MRI revealed a right posterior mediastinal tumor but did not aid in the final diagnosis. We underwent extirpation of the tumor through thoracoscope and confirmed to be a cavernous hemangioma histologically. No major vascular connections between the tumor and major vessels were found. It was useful of thoracoscopic surgery in this case.

Brainstem pathology of infantile Gaucher's disease with only wave I and II of auditory brainstem response.

We studied the auditory brainstem response (ABR) and neuropathology in a female infant who died at six months of age because of typical infantile Gaucher's disease. The patient was hospitalized for hepatosplenomegaly and failure to thrive. Her ABR showed only waves I and II. The neuropathological study disclosed that: (1) Gaucher's cells were found in the perivascular region of the cerebrum and anterior ventral nucleus of the thalamus. (2) Gliosis was found in the dorsal part of the brainstem rather than the ventral part. (3) Neuronal cells in the superior olivary nucleus were lost, and marked gliosis was found in the cochlear nucleus. The disappearance of wave III and later waves of ABR could be supported by these pathological findings.

[A case report of the atypical tuberculosis associated with AIDS].

A 49-year-old Japanese male who had been imprisoned for five years then lived with other men complained of fever, constitutional symptoms and a 12 kg weight loss over four-month period. He was referred to us as his gastric washings were positive for acid-fast bacilli (AFB). Chest X-ray showed patchy, infiltrative small shadows primarily in the right upper lung field without hilar adenopathy. Before transfer to our hospital, tuberculosis chemotherapy composed of SM, INH, RFP and PZA was initiated. Over the next three weeks, fever dropped, and the above described abnormal shadows on the chest X-ray improved, leaving small cystic lesions. Although a sputum smear was negative for AFB, M. tuberculosis was isolated from cultured samples and sensitive to all standard anti-tuberculous drugs. AFB were also demonstrated on a touch imprint of biopsied cervical lymph nodes. Sputum samples turned negative one month later both on smear and culture. Moreover, high fever developed and another abnormal shadow indicative of Pneumocystis carinii (PCP) appeared in the left lung field one month after the admission. White plaque was noted in the oral cavity. Dark red nodules were observed on the upper extremities and chest wall, and diagnosed histologically as Kaposi's sarcoma. Serologic testing for HIV was positive both by PA and Western blot methods, thus AIDS was diagnosed according to the CDC surveillance case definition for AIDS with the diagnosis of tuberculosis. The patient died of wasting syndrome on the 90th hospital day. On autopsy, small thin-walled cavities were observed in the right upper lung, correlating with earlier X-ray and CT findings.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of intralobar pulmonary sequestration associated with an accessory diaphragm].

We report one operated case (a 71-year-old female) of intralobar pulmonary sequestration (Pryce's type 1) associated with an accessory diaphragm. The patient had hemoptysis for 5 years. Lateral chest X-ray showed an oblique line attaching to the central portion of the right diaphragm. Selective angiography and ultrasonography showed an aberrant vessel originating from the abdominal aorta. At the time of operation, the pleural cavity was divided into two compartments by a fibrous membrane. The bronchus of the lower compartment and the pulmonary veins ran through a hole in the accessory diaphragm. The aberrant artery flowed into the parts of lung in the upper and lower compartments.

Lipid-rich residual bodies and cathepsin D in the human uterus: ultrastructural and quantitative comparison between normal myometrium and leiomyoma.

The lipid-rich residual bodies (LRRB) (Eyden et al., 1991) in human myometrium and uterine leiomyoma cells, have a distinctive ultrastructure characterised by a rich lipid content. To evaluate the biological or pathological significance in detail, normal myometrium and uterine leiomyoma from 30 human cases were studied by conventional histological, histochemical, immunohistochemical and electron microscopic methods. The study included a quantitative analysis of LRRBs of 3 premenarchic cases, 19 cases having a menstrual cycle, and 8 cases in menopause, in addition to 20 patients with histologically conventional leiomyoma larger than 3 cm in diameter. The study revealed the following findings: 1) immunohistochemical distribution of cathepsin D in the LRRB; 2) histochemical demonstration of neutral fat as the main content of LRRB; 3) statistically significant decrease in the distribution of LRRB in leiomyoma tissue compared with normal myometrium; 4) an absence or minimal distribution of LRRB in premenarchic myometrium; 5) a moderately significant correlation between the frequency of LRRB and patient's age. The distribution of cathepsin D within LRRB and the differential expression of LRRBs in the various smooth muscle cell tissues of the uterus suggest a possible role of ovarian hormones in the genesis of LRRBs which may function in the intra-lysosomal degradation of organelles produced during hormonal cycling.

Multiple pulmonary hyalinizing granulomas associated with systemic idiopathic fibrosis.

A 41-year-old man with progressive nodular infiltration of the lung of about 2 years' duration died of cardiac and respiratory failure. Autopsy revealed bilateral multiple pulmonary hyalinizing granulomas (PHGs) diagnosed on the basis of the characteristic dense hyaline collagen bundles with nonspecific inflammatory infiltration. Constrictive pericarditis, retroperitoneal fibrosis, mediastinal fibrosis, fibrous thickening of the peritoneal and pleural surfaces, and fibrosis of soft tissue of the neck, flank, and hepatic hilar region were present, therefore, a diagnosis of systemic idiopathic fibrosis was made. The patient had anti-thyroglobulin and anti-thyroid microsomal antibodies and lymphocytic thyroiditis. The inflammatory process of PHG of the present case was active and the clinical course was progressive. PHG seems to be a lesion belonging to the systemic idiopathic fibrosis complex. Immunologic abnormalities may be related to PHG and systemic idiopathic fibrosis.

[An evaluation of MR imaging of soft-tissue masses in extremities].

We evaluated 22 soft-tissue masses in the extremities using magnetic resonance (MR) imaging. The twenty-two cases consist of 14 benign lesions and 8 malignant lesions. MR imaging is available to provide the representation of the extent of the masses, though characteristic diagnosis of them could not be identified. We think that there are more advantages to using MR imaging rather than computed tomography (CT) in the evaluation of soft-tissue masses in extremities.

[A case of localized pleural tuberculosis exacerbated during antituberculous chemotherapy].

A 24 year-old male with pulmonary tuberculosis in right upper lobe developed two lesions of extrapulmonary pleural tuberculoma during the course of antituberculous therapy. He had no history of lung tuberculosis nor pleurisy. However, the chest X-ray film on first admission showed scattered nodular shadows in right upper lung field. He had no subjective symptoms and no abnormalities of laboratory findings except mild iron deficiency anemia, from which he recovered completely without specific therapy. Three months after starting the antituberculous therapy including SM, INH, and RFP, a new round homogeneous opacity appeared in the right lower lung field (S4). Chest CT scan revealed the lesions in S10 as well as in S4. Microscopic examination of the specimen obtained by ultrasound-guided needle aspiration biopsy disclosed positive acid-fast bacilli. Because of the lack of effect of drug therapy on pleural lesions, surgical treatment was performed. The visceral pleura was found adherent fibrously to parietal pleura, which was easily separated by hand. However, at the site of lesions, the adhesion was so tight that extrapleural resection was needed. Because lung tissue and tumor were connected tightly, the lung had to be partially resected. Most content of tumors were caseous necrosis. Although main lesion was located outside of the lung, intrapulmonary invasion was also noticed. Double lesions of this kind of disease seem to be very rare. There is no evidence of relapse until eight months after surgery.

[A case of thymoma associated with prostatic cancer].

A case of prostatic cancer treated with an LH-RH analogue depo-preparation was found to have a mediastinal thymoma which was later removed by surgery. The association of thymoma and prostatic cancer has not been documented in the world literature, and it remains to be elucidated whether the occurrence of the both tumors is a coincidence or etiologically inter-related.

Diffuse interstitial pulmonary fibrosis and lung cancer.

Forty-two cases of lung cancer complicated with diffuse interstitial pulmonary fibrosis (DIPF) were selected from 13,056 autopsy cases. They were divided into primary (Group I and II) and secondary (Group III) DIPF, and histopathologic and clinicopathologic studies were made. The prevalence of lung cancer with primary DIPF was 17% (8/47) which was significantly (p less than 0.01) higher than that without DIPF (7% or 886/13,009). All eight cases of lung cancer in Group I and II were male, and 7 had cigarette-smoking history. The anatomical sites of lung cancer and DIPF were all peripheral in origin, and in 7 cases located primarily in the lower lobes (left:right = 6:1). Adenocarcinoma was the most common type. The study suggests that male DIPF patients with long clinical history should be followed thoroughly for lung cancer.

Cellular differentiation of epithelioid sarcoma. An electron-microscopic, enzyme-histochemical, and immunohistochemical study.

For the purpose of clarifying cellular differentiation of epithelioid sarcoma, studies based on various methods were performed. Enzyme histochemical studies showed that epithelioid sarcoma tumor cells have characteristics intermediate between epithelial cells and the large plump cells of synovial sarcoma-incomplete epithelial differentiation. For alkaline phosphatase and adenosine triphosphatase particularly, positive cells and negative cells coexisted, as in the large plump cells of synovial sarcoma. Immunohistochemical studies for alpha 1-antitrypsin, alpha 1-antichymotrypsin, vimentin, and keratin also showed that epithelioid sarcoma tumor cells are very similar to the large plump cells of synovial sarcoma and have incomplete epithelial differentiation. For example, the examinations of serial sections and double staining methods revealed that keratin-positive cells are always vimentin-positive in epithelioid sarcoma and in the monophasic area of synovial sarcoma. Electron-microscopically, bundles of intermediate filaments and filopodia toward the intercellular lumen were observed, as in the monophasic area of synovial sarcoma. The results of enzyme-histochemical and immunohistochemical studies of non-neoplastic synovial lining cells, performed here for the first time, are also discussed.

Histogenesis of clear cell sarcoma of tendons and aponeuroses. An electron-microscopic, biochemical, enzyme histochemical, and immunohistochemical study.

For the purpose of clarifying the histogenesis of clear cell sarcoma of tendons and aponeuroses (CCS) as well as the problem of whether or not CCS is a heterogeneous group of neoplasms, studies based on various methods were performed. Analysis of glycosaminoglycans gave the same results for amelanotic CCS and synovial sarcoma, and the DOPA reaction gave the same negative results for amelanotic CCS and synovial sarcoma. However, the DOPA reaction was also negative in an amelanotic recurrent tumor of a melanotic CCS, and electron-microscopic studies revealed a close resemblance between amelanotic CCS and melanotic CCS. Further, enzyme histochemical studies showed definite differences between synovial sarcoma and amelanotic CCS but gave identical results for amelanotic and melanotic CCS. Immunohistochemical studies revealed the presence of S-100 protein in all CCS cases, both amelanotic and melanotic. These results indicate that CCS is not a heterogeneous group of neoplasms, and that both amelanotic and melanotic CCS are of neural crest origin.