A rare case of intradural and extramedullary epidermoid cyst after repetitive epidural anesthesia: case report and review of the literature.

BACKGROUND: Spinal epidermoid cysts are benign tumors, which are rarely seen as an intradural extramedullary spinal cord tumor in the conus medullaris region. Acquired spinal epidermoid cysts are mostly caused by iatrogenic procedures, such as lumbar puncture, and the majority of acquired spinal epidermoid cysts have been reported below the L1 level, because lumbar puncture is usually performed around the iliac crest. Here, we report an extremely rare case of an epidermoid cyst that occurred as an intradural and extramedullary spinal cord tumor attached to the conus medullaris after repetitive epidural anesthesia. CASE PRESENTATION: A 67-year-old female presented with a low back pain and left sciatica. Although the patient had experienced occasional mild low back pain for several years, her low back pain markedly worsened 2 months before her visit, as well as newly developed left sciatica resulting in intermittent claudication. She had a history of several abdominal surgeries. All abdominal procedures were performed under general anesthesia with epidural anesthesia in her thoracolumbar spine. Magnetic resonance imaging of her lumbar spine demonstrated an intradural extramedullary spinal cord tumor at the T12-L1 level. Because her symptoms deteriorated, the tumor excision was performed using microscopy. Histological examination of the specimens demonstrated that the cyst walls lined with stratified squamous keratinizing epithelium surrounded by the outer layer of collagenous tissue with the absence of skin adnexa. A diagnosis of epidermoid cysts was confirmed. Her MRI showed complete resection of the tumor, and there was no recurrence at 2-year follow-up. CONCLUSIONS: In this case report, epidermoid cells might be contaminated into the spinal canal during repetitive epidural anesthesia. The patient was successfully treated by complete resection, and there was no recurrence at 2-year follow-up with a good clinical outcome. However, long-term follow-up is required for a potential risk of tumor recurrence.

Mass-forming type 1 autoimmune pancreatitis mimicking pancreatic cancer.

We reported three cases of mass-forming type 1 autoimmune pancreatitis (AIP) that were preoperatively suspected to be pancreatic cancer, and reviewed their clinicopathological features. Radiological findings in the patients revealed hypoattenuating masses in the early phase or a stricture of the main pancreatic duct with upstream dilatation, which was consistent with the diagnosis of pancreatic cancer. Histopathologically, the lesions were well demarcated and met all diagnostic criteria for immunoglobulin G4 (IgG4)-related AIP, including the presence of periductal lymphoplasmacytic infiltration, obliterative phlebitis, storiform fibrosis and abundant IgG4-positive plasma cells. However, the adjacent uninvolved pancreatic duct and lobular structures were well preserved. And in all patients, none or some of the aforementioned characteristics were observed. We suggest that some cases of focal AIP may progress to more severe grades and exhibit mass formation, although remaining localized. These focal cases of AIP are difficult to distinguish from pancreatic cancer. To our knowledge, this report is the first to present a histopathological comparison of mass-forming AIP with the adjacent uninvolved pancreatic tissues.

Successful resolution of a hemorrhagic pancreatic pseudocyst ruptured into the stomach complicating obstructive pancreatitis due to pancreatic cancer: a case report.

BACKGROUND: Hematemesis is uncommon as an initial presenting symptom in pancreatic cancer. We present herein a case of a pseudoaneurysm that ruptured and fistulized into the stomach. The pseudoaneurysm was secondary to a pancreatic pseudocyst complicating obstructive pancreatitis due to pancreatic cancer. The patient was successfully treated using trans-arterial embolization followed by curative surgery. CASE PRESENTATION: A 61-year-old man presented to the emergency room with hematemesis. Laboratory examinations revealed a low level of hemoglobin (5.0 g/dl). The patient had presented to another hospital due to hematemesis 1 month before presenting to our hospital. A low-density mass in the pancreatic body with dilatation of the distal main pancreatic duct and a pseudocyst in the pancreatic tail had been observed by radiology at the previous hospital. Further investigation had been planned. Abdominal computed tomography on admission to our hospital demonstrated a pseudoaneurysm in close contact with the wall of the pseudocyst of the pancreatic tail, compressing the stomach. The pseudoaneurysm had not been detected by abdominal computed tomography at the previous hospital. Emergency selective angiography revealed that the pseudoaneurysm arose from the left gastroepiploic artery branching from the splenic artery. Trans-arterial embolization of the left gastroepiploic artery through the splenic artery was successfully performed. Elective distal pancreatectomy and splenectomy with regional lymph node dissection combined with partial resection of the stomach was performed 3 weeks after coil embolization. Pathological examination revealed a moderately differentiated tubular adenocarcinoma in the pancreatic body with regional lymph node metastasis and revealed the pseudoaneurysm rupturing into the pancreatic pseudocyst. The patient has experienced no tumor recurrence or metastasis during 1 year of follow-up. CONCLUSIONS: Spontaneous rupture of a pseudoaneurysm is a rare and potentially lethal complication of a pancreatic pseudocyst. Most affected patients have a history of alcoholism and suffer from acute or chronic pancreatitis. To our knowledge, this is the first reported case of a hemorrhagic pancreatic pseudocyst complicating obstructive pancreatitis due to pancreatic cancer.

[A Case of Advanced Esophageal Cancer and Tongue Cancer Treated with Induction DCF Chemotherapy Followed by Radical Surgery].

A man in his 60s was admitted for the treatment of advanced cervical esophageal cancer with metastasis to the lymph nodes and advanced tongue cancer with metastasis to the lymph nodes. Esophageal cancer was suspected to have invaded the trachea. The tongue cancer was located on the left side and had invaded beyond the median line of the tongue. Both cancers were pathologically diagnosed as squamous cell carcinomas. Therefore, it was determined that pharyngo-laryngo- esophagectomy and total glossectomy were required prior to the treatment. However, after 2 courses of docetaxel/cisplatin/ 5-FU combined induction chemotherapy, both cancers remarkably decreased; consequently, an esophagectomy to preserve laryngeal function and partial glossectomy could be performed simultaneously. The patient is well without recurrence 1 year post-surgery.

Adenosquamous carcinoma of the ampulla of Vater: a case report and literature review.

BACKGROUND: Adenosquamous carcinoma of the ampulla of Vater is extremely rare, and its clinicopathological features are limited and described in few previous case reports. Here, we report curative resection of adenosquamous carcinoma of the ampulla of Vater at an early stage. CASE PRESENTATION: An 81-year-old woman was referred to our hospital for investigation of the frequent elevation of hepatic and biliary enzymes and dilatation of the intrahepatic bile ducts. Preoperative examinations revealed an exposed reddish tumor in the ampulla of Vater, which was diagnosed on biopsy to be adenocarcinoma with squamous cell carcinoma component. Pylorus-preserving pancreaticoduodenectomy with regional lymph node dissection was performed. Pathological examinations revealed the presence of two malignant components in the lesion, including poorly differentiated tubular adenocarcinoma and squamous cell carcinoma, without invasion beyond the sphincter of Oddi or into the duodenal submucosa. These squamous cell carcinoma and adenocarcinoma components in the tumor comprised approximately 30 and 70% of the lesion, respectively. No metastasis into regional lymph nodes was observed, and the patient experienced no tumor recurrence or metastasis until 20 months after surgery. CONCLUSION: We identified only six reported cases of adenosquamous carcinoma of the ampulla of Vater in the English literature, and all of these patients died of recurrence within 14 months after surgery. To the best of our knowledge, this is the first report of adenosquamous carcinoma of the ampulla of Vater that was curatively resected at an early stage. Although more number of studies on clinicopathological findings are required to determine the appropriate surgical indication, we suggest that surgery remains the mainstay therapy for adenosquamous carcinoma of the ampulla of Vater detected at an early stage.

Myoepithelioma-like Tumors of the Vulvar Region: A Distinctive Group of SMARCB1-deficient Neoplasms.

We describe 9 tumors that resemble soft tissue myoepitheliomas but possess certain traits that do not fit perfectly into this category. These tumors, herein referred to as "myoepithelioma-like tumors of the vulvar region," occurred in the subcutis of the vulva and surrounding regions of adult women aged 24 to 65 years. Histologically, the tumors measured 2 to 7.7 cm and were well circumscribed, focally encapsulated, and lobulated. Tumor cells had an epithelioid to spindled shape, with fine amphophilic cytoplasm, and uniform nuclei with vesicular chromatin and nucleoli. The tumor stroma was relatively hypervascular, and comprised a mixture of myxoid and nonmyxoid components. Myxoid areas accounted for <5% to 95% of the tumor volume, wherein cells proliferated singly or in a loosely cohesive manner. In nonmyxoid areas, tumors cells grew in diffuse sheets or storiform arrangements. Immunohistochemically, all tested tumors were positive for vimentin, epithelial membrane antigen, and estrogen receptor; most tumors expressed actin. All tumors were negative for S100 protein, glial fibrillary acidic protein, and CD34. Cytokeratin expression was absent in all but 2 tumors, which showed rare positivity. SMARCB1 expression was deficient in all cases. EWSR1, FUS, and NR4A3 rearrangements were absent. All tumors were treated through surgery. Although 3 tumors regrew or recurred after intralesional excision, all 9 patients were alive without metastases at a mean follow-up of 66 months. Myoepithelioma-like tumors of the vulvar region constitute a distinct group of tumors, although future research is required to determine whether they are an unusual subtype of soft tissue myoepitheliomas or a separate disease.

Mediastinal schwannoma diagnosed preoperatively as a cyst.

Mediastinal schwannomas are sometimes diagnosed as pericardial or bronchogenic cysts, if cystic degeneration is extensive. When mediastinal schwannomas are not diagnosed as primary cardiac tumors, the use of cardiopulmonary bypass in their resection appears to be infrequent. We report the case of a 48-year-old woman who presented with symptoms from a suspected intrapericardial cyst. Multiple diagnostic images revealed a large mass, potentially a proteinaceous or hemorrhagic cyst, in the transverse sinus behind the ascending aorta and against the left main trunk. After complete resection with the use of cardiopulmonary bypass, the mass was identified as a benign extracardiac schwannoma. More than 3 years postoperatively, the patient had no relevant symptoms. We discuss the preoperative diagnosis, the method of resection, and our broad strategy for dealing with such a case.

Intravenous Lobular Capillary Hemangioma Occurring after Needle Insertion during Routine Health Checkup.

Surgery was performed on a 53-year-old male patient with a painful mass in front of the elbow. The mass originally occurred after needle insertion during a routine health checkup and grew in size during a 1-year period. Intravenous tumor with arterio-venous fistula was diagnosed, and it was resected. Histopathological diagnosis of intravenous lobular capillary hemangioma was made. Occurrence of this tumor after a routine health checkup is rare. The etiology of this tumor occurring simultaneously with arteriovenous fistula is discussed.

Ectopic cervical thymoma located in the carotid triangle.

Ectopic cervical thymoma is an extremely rare tumor thought to arise from ectopic thymic tissue caused by the aberrant migration of the embryonic thymus. We present the case of a 44-year-old woman with an ectopic cervical thymoma located in the carotid triangle. A computed tomography (CT) scan detected a mass in her right carotid triangle. On an unenhanced scan, the tumor showed homogeneous isodensity compared with muscles, and neither fat nor calcification was detected. A contrast-enhanced CT image obtained during the arterial phase showed intratumoral septa, while an image obtained during the parenchymal phase showed cystic changes within the mass. The patient underwent a surgical resection. A histological study enabled a diagnosis of type AB thymoma in which foci with the features of type A thymoma are admixed with foci rich in lymphocytes. This subtype is a benign tumor with a good prognosis. Ectopic cervical thymoma should be included in the differential diagnosis of solid masses located in the carotid triangle when the CT findings are typical of a thymoma.

Histopathologic profiles of coronary atherosclerosis by myocardial bridge underlying myocardial infarction.

OBJECTIVE: Anatomic properties of myocardial bridge (MB) are sometimes responsible for myocardial infarction (MI) through the changes in the atherosclerosis distribution in the left ascending coronary artery (LAD). The purpose of this study was to investigate histopathologic profiles of atherosclerotic lesions resulting from the MB presence in the LAD in the MI cases. METHODS: In 150 consecutive autopsied MI hearts either with MBs [MI(+)MB(+); n = 67] or without MBs [MI(+)MB(-); n = 83] and 100 normal hearts with MBs [MI(-)MB(+)], LADs were consecutively cross-sectioned at 5-mm intervals. The most advanced intimal lesion and unstable plaque-related lesion characteristics (UPLCs) in each section were histopathologically evaluated in conjunction with the anatomic properties of the MB, such as its thickness, length, location, and MB muscle volume burden (MMV: the total volume of MB thickness multiplied by MB length). RESULTS: The MB showed a significantly greater thickness (P = 0.0090), length (P = 0.0300), and MMV (P = 0.0019) in MI(+)MB(+) than in MI(-)MB(+). Mean age of acute MI cases was significantly younger (P = 0.0227) in MI(+)MB(+) than in MI(+)MB(-). Frequency of plaque fissure/rupture in the proximal LAD was significantly higher in acute MI cases of MI(+)MB(+) than in MI(+)MB(-). UPLCs tended to be located proximally in MI(+)MB(+) and frequent 2.0 cm or more proximal to the MB entrance in MI(+)MB(+). CONCLUSION: In MI(+)MB(+), UPLCs tend to be located more proximally, and a plaque in the LAD proximal to the MB is prone to rupture, resulting in MI at younger age.

Development of squamous neoplasia in esophageal iodine-unstained lesions and the alcohol and aldehyde dehydrogenase genotypes of Japanese alcoholic men.

We investigated the development of esophageal neoplasia in biopsy specimens of the distinct iodine-unstained lesions (DIULs) ≥ 5 mm detected in 280 of 2,115 Japanese alcoholic men who underwent screening by esophageal iodine staining. Low-grade intraepithelial neoplasia (LGIN) was diagnosed in 155 of them, high-grade intraepithelial neoplasia (HGIN) in 57, and invasive SCC in 35. The size of the DIULs increased with the degree of neoplasia. Most LGINs were flat and were missed before iodine staining. Some DIULs became a light pink color (PC) about 2 min after staining, and 2.6, 56.1 and 96.0% of the LGIN, HGIN and invasive SCC lesions, respectively, were PC-sign-positive. Multiple DIULs of any size markedly increased the risk of LGIN [adjusted OR (95%CI) = 10.1 (7.12-14.5)], HGIN [27.9 (14.6-53.4)] and invasive SCC [21.6 (10.1-46.4)], and were strongly associated with the presence vs. absence of DIULs ≥ 5 mm [13.3 (9.21-19.1)], inactive heterozygous aldehyde dehydrogenase-2 (ALDH2*1/*2) vs. ALDH2*1/*1 [2.60 (1.79-3.78)], and less-active alcohol dehydrogenase-1B (ADH1B*1/*1) vs. ADH1B*2 allele [2.61 (1.87-3.64)]. The combination of ALDH2*1/*2 and ADH1B*1/*1 synergistically increased the risk of LGIN [4.53 (2.17-9.47)], HGIN [10.4 (4.34-24.7)] and invasive SCC [21.7 (7.96-59.3)]. Esophageal neoplasia developed at earlier ages in those with ALDH2*1/*2. Biopsy-proven HGIN was diagnosed as invasive SCC in 15 (39.5%) of 38 patients after endoscopic mucosectomy or surgery. In conclusion, large size, non-flat appearance, positive PC sign and multiplicity of DIULs and ALDH2*1/*2 and ADH1B*1/*1 were associated with development of esophageal neoplasia in Japanese alcoholics. Biopsy-proven HGIN should be totally resected for both diagnostic and therapeutic purposes.

Histopathological predictors of regional lymph node metastasis at the invasive front in early colorectal cancer.

AIMS: In early colorectal cancer (ECC), prediction of lymph node (LN) metastasis is vital for the decision of additional surgical treatment after endoscopic mucosal/submucosal resection. The aim of this study was to determine the relationship between LN metastasis and comprehensive histopathological findings including the cancer microenvironment in ECC. METHODS AND RESULTS: Using 111 ECC cases, including 36 cases with LN metastasis, histopathological observations and immunohistochemistry for lymphatic vessel endothelial hyaluronan receptor-1 (LYVE-1), von Willebrand factor, matrix metalloproteinase-7 (MMP-7), CXC chemokine ligand-12 (CXCL12) and angiopoietin-like-4 (ANGPTL4) were conducted. Relationships between LN metastasis and growth pattern, status of muscularis mucosae, depth of cancer invasion, overall histopathological type, histopathological type at the invasive front, tumour budding, neutrophil infiltration in cancer cells (NIC), fibrotic cancer-stroma type, Crohn's-like lymphoid reaction, microscopic abscess formation and lymphatic invasion were determined. In addition, the expression of MMP-7, CXCL12 and ANGPTL4 in cancer cells at the invasive front were also considered in the context of LN metastasis. By multivariate analysis, lymphatic invasion, NIC and MMP-7 expression at the invasive front were independent predictors of LN metastasis. CONCLUSIONS: LN metastasis is regulated not only by the characteristics of cancer cells but also by microenvironmental factors of lymphatics and neutrophils, especially at the invasive front.

Early detection of superficial squamous cell carcinoma in the head and neck region and esophagus by narrow band imaging: a multicenter randomized controlled trial.

PURPOSE: Most of the esophageal squamous cell carcinomas (ESCCs) and cancers of the head and neck (H&N) region are diagnosed at later stages. To achieve better survival, early detection is necessary. We compared the real-time diagnostic yield of superficial cancer in these regions between conventional white light imaging (WLI) and narrow band imaging (NBI) in high-risk patients. PATIENTS AND METHODS: In a multicenter, prospective, randomized controlled trial, 320 patients with ESCC were randomly assigned to primary WLI followed by NBI (n = 162) or primary NBI followed by WLI (n = 158) in a back-to-back fashion. The primary aim was to compare the real-time detection rates of superficial cancer in the H&N region and the esophagus between WLI and NBI. The secondary aim was to evaluate the diagnostic accuracy of these techniques. RESULTS: NBI detected superficial cancer more frequently than did WLI in both the H&N region and the esophagus (100% v 8%, P < .001; 97% v 55%, P < .001, respectively). The sensitivity of NBI for diagnosis of superficial cancer was 100% and 97.2% in the H&N region and the esophagus, respectively. The accuracy of NBI for diagnosis of superficial cancer was 86.7% and 88.9% in these regions, respectively. The sensitivity and accuracy were significantly higher using NBI than WLI in both regions (P < .001 and P = .02 for the H&N region; P < .001 for both measures for the esophagus, respectively). CONCLUSION: NBI could be the standard examination for the early detection of superficial cancer in the H&N region and the esophagus.

[Urinary bladder metastasis of prostate cancer : a case report].

A 62-year-old man was referred to our outpatient clinic because of his elevated serum prostatic specific antigen level. The transrectal ultrasonography guided biopsy of the prostate revealed prostate cancer. Computed tomography, magnetic resonance imaging (MRI) and bone scintigraphy showed multiple metastases to his bones and lymph nodes. The MRI incidentally revealed a solitary tumor at the right lateral wall of the urinary bladder. Transurethral resection of the bladder tumor was performed, and histopathological examination showed the bladder tumor composed of not urothelial carcinoma but metastatic adenocarcinoma from prostate cancer.