HER2-Positive Metaplastic Spindle Cell Carcinoma Associated with Synchronous Bilateral Apocrine Carcinoma of the Breast.

Apocrine carcinoma, which is strictly defined as over 90% of tumor cells showing apocrine differentiation, is a rare variant of breast cancer. Here we report an uncommon case in which apocrine carcinomas developed concurrently in both breasts; in addition, a sarcomatoid spindle cell lesion was coincident in the right breast. Both apocrine carcinomas were immunohistochemically negative for estrogen receptor (ER) and progesterone receptor (PgR), but diffusely positive for androgen receptor (AR), GCDFP-15, and HER2. The presence of intraductal components in bilateral carcinomas and the absence of lymph node metastasis suggested that they were more likely to be individual primary lesions rather than metastatic disease. The spindle cell lesion showed a relatively well-circumscribed nodule contiguous with the apocrine carcinoma. HER2 oncoprotein overexpression was observed not only in the apocrine carcinoma, but also in the spindle cell lesion. Since the spindle cell component was intimately admixed with apocrine carcinoma and had focal cytokeratin expression, we diagnosed it as metaplastic spindle cell carcinoma, which was originated from the apocrine carcinoma. To our knowledge, this is the first case report of a patient with synchronous bilateral apocrine carcinomas coinciding with metaplastic carcinoma.

Real-time tissue elastography: non-invasive evaluation of liver fibrosis in chronic liver disease due to HCV.

BACKGROUND/AIMS: We evaluated the diagnostic efficacy for advanced fibrosis of real-time tissue elastography (RTE), is a newly introduced non-invasive method, in hepatitis C virus (HCV) patients. METHODOLOGY: Sixty-six chronic liver diseases with HCV (CLD-HCV) were evaluated by RTE, FIB-4, and APRI, as well as biopsy or hepatectomy findings. Seventeen healthy volunteers, and 1 with elevation of transaminase and 5 with liver tumors within their normal liver were enrolled for normal controls. Severe fibrosis was defined as METAVIR score 3 or 4. The tissue elasticity value was expressed by LF-index created by the program incorporated in the ultrasound device. The percentage of fibrosis area in each specimen (%FA) was determined with a personal computer. A receiver operating characteristic curve (ROC) was calculated for each non-invasive method of estimation of fibrosis. RESULTS: The values for the area under the ROC for LF-index, APRI, and FIB-4 were 0.88, 0.81, and 0.84, respectively. Accuracy, sensitivity, and specificity for prediction of LF-index (>2.8) for severe fibrosis were 86.5%, 78.6%, and 93.6%, respectively, which were better than those of FIB-4 and APRI. LF-index showed a good relationship to %FA (r=0.276, P=0.020). CONCLUSION: RTE is an effective method for predicting severe fibrosis in CLD-HCV.

Primary malignant melanoma of the esophagogastric junction: Report of a case.

INTRODUCTION: Primary malignant melanoma of the gastrointestinal tract is very rare, especially in the stomach. We report an extremely rare case of primary malignant melanoma of the esophagogastric junction mainly situated in the stomach. PRESENTATION OF CASE: The patient was a 72-year-old woman who complained of shortness of breath due to severe anemia. Upper endoscopy revealed a soft easy-bleeding polypoid tumor just adjacent to the esophagogastric junction in the stomach. Biopsy of the tumor did not indicate a definite result, except malignant tumor. We performed total gastrectomy with splenectomy, and histological and immunohistological examination revealed malignant melanoma of the esophagogastric junction. She had no remote metastasis or lymphnodal metastasis at the point of surgery; however, she died of multiple metastases 11 months after the operation. DISCUSSION: A definite preoperative diagnosis of primary malignant melanoma was very difficult to make from the preoperative biopsy specimen. This present case was first misinterpreted as undifferentiated carcinoma, or malignant lymphoma. Following the diagnosis of malignant melanoma, the question arose as to whether this was primary or metastatic (as malignant melanoma from other sites is known to metastasize to the stomach). Finally this tumor was diagnosed as a primary one due to the pathologic characteristics such as the existence of junctional activities. CONCLUSION: We report an extremely rare case of primary malignant melanoma of the esophagogastric junction present in the stomach.

High aromatase activity and overexpression of epidermal growth factor receptor in fibrolamellar hepatocellular carcinoma in a child.

An 11-year-old boy was admitted with a liver tumor and underwent right trisegmentectomy for a diagnosis of fibrolamellar hepatocellular carcinoma. He had suffered from bilateral gynecomastia for a year, which improved after complete resection of the tumor. The tumor cells had significant aromatase activity (8.03 pmol/g/h) and contained high levels of estradiol (82.1 pg/mL), which contributed to gynecomastia. Furthermore, overexpression of epidermal growth factor receptor was determined in the tumor cells, which suggests that antitumor strategies using epidermal growth factor receptor antagonists may be effective.

The role of computer-aided 3-dimensional analytic tools and virtual microscopy in the investigation of radiologic-pathologic correlation.

To cope with recent advances in radiologic imaging technology, a corresponding method for pathomorphologic demonstration should be developed to promote better understanding of radiologic-pathologic correlation. We attempted to obtain gross and microscopic images by using a 3-dimensional analytic tool and virtual microscopy and to link these images with multidetector computed tomography images. Surgically resected specimens were sliced to a thickness of 3 mm, and the digital images of each slice were 3-dimensionally reconstructed with RATOC TRI/3D SRF II software. Histology slides were digitized by using virtual microscopy with an Olympus VS-100. We obtained clear gross pathologic images in arbitrary cut sections of organs, and it was possible to rotate these 3-dimensional images at any angle. Furthermore, we created synchronous cut-section movies of computed tomography and gross pathologic images. Subsequently, we switched from these cut-section movies to virtual microscopy images by clicking on the hyperlink button to observe radiologic-pathologic correlation.

Aneurysms of the renal arteries associated with segmental arterial mediolysis in a case of polyarteritis nodosa.

This is the first report of segmental arterial mediolysis (SAM) accompanied with polyarteritis nodosa (PN), and manifesting aneurysms of the renal arteries. A 73-year-old woman was admitted to hospital because of a high fever. Laboratory tests showed leukocytosis with increased CRP level in the serum. Myeloperoxidase-anti-neutrophil cytoplasmic antibody (MPO-ANCA) and proteinase 3 (PR3)-ANCA were negative. There were no signs indicating infection or malignancy. After admission renal function rapidly deteriorated. Treatment was then started with daily oral prednisolone and hemodialysis. On the 40th day of hospitalization the patient suddenly became comatose. Cranial CT showed a subarachnoid hemorrhage. The patient died and an autopsy was performed. The pathological findings showed necrotizing vasculitis of the small arteries in various organs, but not associated with that of arterioles or renal glomerular lesions, indicating PN. Unexpectedly, the segmental arteries of the bilateral kidneys showed vascular lesions of dissecting aneurysms, indicating SAM. This case indicates that SAM is one of the causes of aneurysms in PN and is clinically important when the clinical course of PN patients rapidly advances.

A case of insulin-induced localized lobular panniculitis with evidence for the phagocytosis of insulin by histiocytes.

Insulin-induced localized lipoatrophy is a well-known localized side effect. Although an immune process has been suggested as its etiology, no definitive evidence has been reported to show that insulin is involved. Here, we report the first evidence for the phagocytosis of insulin by histiocytes as a very early stage of lipoatrophy, which was reproducible in two different lobular panniculitis tissues from a 71 year-old male patient. He had taken a subcutaneous insulin injection in his arms because of a sight disturbance. Since these subcutaneous tumors were likely due to inflammation by insulin, a biopsy sample was taken from the subcutaneous tumor of his right arm with his consent. The primary antibodies for insulin (1 : 200) and CD68 (1 : 50) were obtained from DAKO (guinea pig anti-insulin and mouse anti-human CD68). HE staining revealed the infiltration of mononuclear cells and histiocytes into the subcutaneous fat tissue, and some parts of this tissue had fibrosis with rich collagen fibers. These findings are consistent with a lobular panniculitis. Some histiocytes contained intracellular substances with a positive immunoreactivity to insulin. This activity was reduced when the anti-insulin antibody was preincubated with an excess amount of insulin antigen. The same substances were also positive to CD68. Thus, the phagocytosis of insulin by histiocytes appears to occur in this region. Therefore, the activation of subcutaneous macrophages by the complex of insulin and insulin antibodies may account for the initial autoimmune process.

[A case of carcinomatous lymphangitis of the lungs due to stomach cancer responding to TS-1].

We report a case of carcinomatous lymphangitis of the lungs due to and stomach cancer showing remarkable response to TS-1. The patient was a 51-year-old man whose chest x-ray and computed tomography (CT) revealed lymphangitis, and endoscopic examination showed stomach cancer on posterior wall of stomach body. Bone marrow metastasis was suspected because platelet count was 50/microliter, and myelocytes and metamyelocytes emerged in peripheral blood. TS-1 80 mg/day was administered orally for 28 days as 1 course. After 4 courses of TS-1, chest x-ray showed remarkable improvement, and platelet count was normalized. The patient survived for 10 months after the first visit. We suggest that TS-1 is an effective therapy for carcinomatous lymphangitis of the lungs due to stomach cancer.