Acute diffuse thyroid swelling after fine-needle aspiration: A case report and review of the literature.

Fine-needle aspiration (FNA) is the first-line and a cost-effective examination method of nonfunctional thyroid nodules. Acute transient thyroid swelling after an FNA is a rare complication, and to date, only 14 cases have been reported in the English literature. Herein, we report a case of a 26-year-old woman with acute transient thyroid swelling, which occurred after an ultrasound-guided FNA of a thyroid nodule. Although the patient had undergone an FNA without complication 2 years previously, the second FNA caused acute thyroid swelling. The present case emphasizes the potential risk of acute thyroid swelling associated with every FNA procedure.

[Long-Term Survival in a Patient with Abdominal Wall Metastasis of Early Gastric Cancer-A Case Report].

A 76-year-old man was diagnosed with type 1 early gastric cancer. Attempted ESD on the lesion resulted in perforation, and distal gastrectomy with D1+dissection was performed. After 1 year and 6 months, a mass measuring 2.4 cm appeared in the abdominal wall. Cytological examination revealed adenocarcinoma, and the patient was diagnosed with abdominal wall metastasis of gastric cancer. There were no evidences of recurrence in the other organs, and extraction was performed. After 6 months, 1 year, and 2 years, the same metastases were found in the abdominal wall, and repeated extractions were performed. All 4 masses had resulted from the metastasis of gastric cancer, but the patient has been alive without recurrence for 1 year and 6 months after the surgery.

Laparoscopic repair of hepatic herniation through a ventral incisional hernia: a case report.

BACKGROUND: Ventral incisional hernia is a common problem after abdominal surgery. Most patients with these hernias present with greater omentum and gastrointestinal prolapse. However, hepatic herniation through a ventral incisional hernia is a rare phenomenon that has been seldom reported in the literature. We report the case of a ventral incisional hernia with hepatic herniation treated with laparoscopic repair. CASE PRESENTATION: A 68-year-old Japanese women with a history of myocardial resection for hypertrophic cardiomyopathy 1 year earlier was admitted to our hospital with symptoms of vomiting and epigastric pain. Physical examination showed a 4-cm epigastric mass. Abdominal computed tomography revealed left hepatic lobe herniation through the lower edge of a mid-sternal incision. We diagnosed the patient with a ventral incisional hernia with hepatic herniation. The patient underwent laparoscopic hernia repair. During an 18-month follow-up, no recurrence or symptoms have been observed. CONCLUSIONS: To the best of our knowledge, this is the first case report of laparoscopic repair of ventral incisional hernias with hepatic herniation. Laparoscopic repair was useful and suitable for this rare herniation due to its minimally invasive nature and ability to achieve sufficient visibility of the surgical field. Laparoscopic repair could be a potential treatment option for elective surgery for this disease, which is often treated conservatively.

Laparoscopic excision of a solitary fibrous tumor originating from the abdominal wall: a case report.

Solitary fibrous tumors (SFTs) are mesenchymal fibroblastic tumors, and forms of SFTs that originate from the abdominal wall are extremely rare. Here we report a case of a nonpalpable SFT along the abdominal wall. Abdominal magnetic resonance (MR) imaging showed a well-circumscribed mass measuring 5 cm in diameter with heterogeneous signal intensity on T2-weighted MR images; this mass was diagnosed as a benign abdominal tumor of unknown origin. Successful laparoscopic excision of the tumor was performed. Histological examination revealed a benign extrapleural SFT. No tumor recurrence was observed after 20-month follow-up. This is the first case of laparoscopic excision of an SFT originating from the abdominal wall. Our report highlights the safety and usefulness of laparoscopic excision of abdominal wall tumors such as SFTs. This approach is an underutilized surgical treatment that can be applied to select cases of SFT in the abdominal cavity.

Successful diagnosis and treatment of double common bile duct with cholelithiasis by laparoscopic cholecystectomy.

Double common bile duct (DCBD) is an extremely rare congenital anomaly of the biliary system associated with serious complications. An association between DCBD and inadvertent bile duct injury during surgery has been reported. However, DCBD is difficult to diagnose preoperatively. We report a rare case of DCBD (type 3b), combined with cholelithiasis and cholecystitis, diagnosed preoperatively, and treated safely by laparoscopic cholecystectomy. A 79-year-old woman was admitted with a 1-week history of chest pain. Abdominal computed tomography revealed gallbladder distension with obvious wall thickening. Laparoscopic cholecystectomy was planned to determine the presence of stones in the common bile duct and an anomalous biliary tract. Magnetic resonance cholangiopancreatography (MRCP) was performed, and anomalous anatomy of the biliary tract was suspected. Drip infusion cholangiography with computed tomography (DIC-CT) showed type 3b DCBD. On hospital day 7, laparoscopic cholecystectomy was performed without accessory common bile duct resection. The postoperative course was uneventful, and the patient was discharged on postoperative day 5. To our knowledge, this is the first report of the successful diagnosis of DCBD using DIC-CT. MRCP and DIC-CT can be useful for the pre-operative diagnosis of DCBD to decrease the risk of bile duct injury during surgery.

Sessile serrated adenoma/polyp leading to acute appendicitis with multiple pyogenic liver abscesses: A case report.

INTRODUCTION: Although appendicitis is a common disease, appendicitis concurrent with liver abscesses and sessile serrated adenoma/polyp (SSA/P) is rare. PRESENTATION OF CASE: A 69-year-old man presented with symptoms of abdominal pain and fever. Computed tomography (CT) revealed multiple liver abscesses and an enlarged appendix with a pseudotumoral appearance, which suggested acute appendicitis. In the emergency operation, ileocecal resection was performed for the perforated appendicitis with an inflammatory mass in the ileocecum. On macroscopic examination, the torose lesion was localized at next to the appendiceal orifice. The tumor was diagnosed as SSA/P based on the microscopic finding. The postoperative course was uneventful, and the liver abscesses were cured by antibiotic therapy. The patient was discharged 17days after the surgery. DISCUSSION: In this case, SSA/P localization at next to the appendiceal orifice was suggested as the cause of the perforated appendicitis with multiple liver abscesses. The patient was successfully treated with a combination of surgery and antibiotic therapy. CONCLUSION: This is the first reported case of a patient with SSA/P that led to acute appendicitis with multiple pyogenic liver abscesses.

Afferent loop obstruction with obstructive jaundice and ileus due to an enterolith after distal gastrectomy: A case report.

INTRODUCTION: Afferent loop obstruction is an uncommon complication associated with Billroth II reconstruction or Roux-en-Y reconstruction after gastrectomy. Moreover, cases where the obstruction is caused by enterolith are rare. Here, we report a rare case of afferent loop obstruction caused by an enterolith after Roux-en-Y reconstruction of gastrectomy; subsequently, leading to ileus in the ileum. PRESENTATION OF CASE: An 84-year-old man who received a Roux-en-Y distal gastrectomy for gastric cancer presented with symptoms of fever and jaundice 14 months later. Computed tomography (CT) scan revealed an enterolith in the duodenal afferent loop and a dilated intrahepatic bile duct. Although the obstructive jaundice and fever disappeared with conservative therapy, ileus occurred due to the movement of the enterolith into the ileum, which was refractory to conservative therapy. Therefore, enterotomy was performed to remove the enterolith, and the patient had an uneventful recovery. Histologically, the enterolith derived from food residue. No postsurgical sign of recurrence has been noted for 6 months. CONCLUSION: We report a rare case where an enterolith in a duodenal afferent loop after distal gastrectomy led to obstructive jaundice, and subsequently, caused ileus by its movement into the ileum.

Prognosis in patients with hepatocellular carcinoma correlates to mutations of p53 and/or hMSH2 genes.

Association of gene alterations and prognosis has not fully been elucidated in hepatocellular carcinoma (HCC). To clarify the relationship between p53 and hMSH2 mutations and prognosis, we analysed these mutations in 83 HCC cases and assessed their association with various clinicopathological factors. The 3-year disease-free survival (DFS) or overall survival (OS) rates in HCC patients with p53 mutation and p53 wild/hMSH2 mutation significantly decreased compared with those without these mutations (14.3% and 37.5% versus 67.5% for DFS; 35.7% and 50.0% versus 96.4% for OS, respectively). In the multivariate analysis, categories by p53 and hMSH2 mutation status, and liver cirrhosis demonstrated statistical significances for DFS and OS. Moreover, the frequency of patients with p53 and/or hMSH2 mutations in intrahepatic metastasis (75.0%) was significantly higher than that in multicentric occurrence (14.3%). Thus, p53 and hMSH2 mutations will be useful for identifying subsets of HCC patients with poor prognosis.

De Garengeot hernia with perforated appendicitis and a groin subcutaneous abscess: A case report.

INTRODUCTION: De Garengeot hernia is rare. Although previous reports have suggested various surgical options according to patient condition, comorbidities, surgeon preference, and clinical findings during surgery, a treatment strategy has not been established. PRESENTATION OF CASE: An 81-year-old woman presented with an irreducible tender mass that was subsequently diagnosed as an incarcerated femoral hernia with a subcutaneous abscess in the right groin. Intraoperative findings revealed a necrotic and perforated appendix strangulated by the femoral ring for which an appendectomy and herniorrhaphy was performed concurrently through the hernia sac. The subcutaneous abscess cavity was washed thoroughly and a drainage tube was placed within it. The patient recovered uneventfully. DISCUSSION: We suggest that the approach through the inguinal incision in both appendectomy and herniorrhaphy with drainage may be useful in avoiding intra-abdominal contamination in cases of de Garengeot hernia with subcutaneous abscess. CONCLUSION: Here, we described a case of de Garengeot hernia with a subcutaneous abscess in the groin. Clinicians should consider de Garengeot hernia in patients with a groin hernia, make an early diagnosis, and promptly provide surgical treatment to reduce the risk of complications.

Thyroid Dysfunction and Autoimmune Thyroid Diseases Among Atomic Bomb Survivors Exposed in Childhood.

Context: The risk of thyroid cancer increases and persists for decades among individuals exposed to ionizing radiation in childhood, although the long-term effects of childhood exposure to medium to low doses of radiation on thyroid dysfunction and autoimmune thyroid diseases have remained unclear. Objective: To evaluate radiation dose responses for the prevalence of thyroid dysfunction and autoimmune thyroid disease among atomic bomb survivors exposed in childhood. Design, Setting, and Participants: Hiroshima and Nagasaki atomic bomb survivors who were younger than 10 years old at exposure underwent thyroid examinations at the Radiation Effects Research Foundation between 2007 and 2011, which was 62 to 66 years after the bombing. Data from 2668 participants (mean age, 68.2 years; 1455 women) with known atomic bomb thyroid radiation doses (mean dose, 0.182 Gy; dose range, 0 to 4.040 Gy) were analyzed. Main Outcome and Measures: Dose-response relationships between atomic bomb radiation dose and the prevalence of hypothyroidism, hyperthyroidism (Graves' disease), and positive for antithyroid antibodies. Results: Prevalences were determined for hypothyroidism (129 cases, 7.8%), hyperthyroidism (32 cases of Graves' disease, 1.2%), and positive for antithyroid antibodies (573 cases, 21.5%). None of these was associated with thyroid radiation dose. Neither thyroid antibody-positive nor -negative hypothyroidism was associated with thyroid radiation dose. Additional analyses using alternative definitions of hypothyroidism and hyperthyroidism found that radiation dose responses were not significant. Conclusions: Radiation effects on thyroid dysfunction and autoimmune thyroid diseases were not observed among atomic bomb survivors exposed in childhood, at 62 to 66 years earlier. The cross-sectional design and survival bias were limitations of this study.

Radiation dose-response relationships for thyroid nodules and autoimmune thyroid diseases in Hiroshima and Nagasaki atomic bomb survivors 55-58 years after radiation exposure.

CONTEXT: Effects of irradiation on thyroid diseases such as thyroid nodules and autoimmune thyroid diseases have not been evaluated among people exposed to radiation more than 50 years in the past. OBJECTIVE: To evaluate the prevalence of thyroid diseases and their radiation-dose responses in atomic bomb survivors. DESIGN, SETTING, AND PARTICIPANTS: Survey study comprising 4091 cohort members (mean age, 70 [SD, 9] years; 1352 men and 2739 women) who participated in the thyroid study at the Radiation Effects Research Foundation. Thyroid examinations were conducted between March 2000 and February 2003. MAIN OUTCOME MEASURES: Prevalence of thyroid diseases, including thyroid nodules (malignant and benign) and autoimmune thyroid diseases, and the dose-response relationship of atomic bomb radiation in each thyroid disease. RESULTS: Thyroid diseases were identified in 1833 (44.8%) of the total participants (436 men [32.2% of men] and 1397 women [51.0% of women]) (P<.001). In 3185 participants, excluding persons exposed in utero, not in the city at the time of the atomic bombings, or with unknown radiation dose, the prevalence of all solid nodules, malignant tumors, benign nodules, and cysts was 14.6%, 2.2%, 4.9%, and 7.7%, respectively. The prevalence of positive thyroid antibodies, antithyroid antibody-positive hypothyroidism, and Graves disease was 28.2%, 3.2%, and 1.2%, respectively. A significant linear dose-response relationship was observed for the prevalence of all solid nodules, malignant tumors, benign nodules, and cysts (P<.001). We estimate that about 28% of all solid nodules, 37% of malignant tumors, 31% of benign nodules, and 25% of cysts are associated with radiation exposure at a mean and median thyroid radiation dose of 0.449 Sv and 0.087 Sv, respectively. No significant dose-response relationship was observed for positive antithyroid antibodies (P = .20), antithyroid antibody-positive hypothyroidism (P = .92), or Graves disease (P = .10). CONCLUSIONS: A significant linear radiation dose response for thyroid nodules, including malignant tumors and benign nodules, exists in atomic bomb survivors. However, there is no significant dose response for autoimmune thyroid diseases.

h-prune affects anaplastic thyroid cancer invasion and metastasis.

Anaplastic thyroid cancer is one of the most aggressive human malignancies and is resistant to multimodal treatments. The expression of h-prune, the human homologue of Drosophila prune, has been reported to be correlated with progression and aggressiveness in various cancers including breast, colorectal and pancreatic cancers. We examined the role of h-prune in anaplastic thyroid cancer cell migration, invasion and metastasis. Immunohistochemical analysis of h-prune was performed with 15 surgically resected specimens of anaplastic thyroid cancers. To investigate cell motility, Boyden chamber, wound healing and matrigel invasion assays were performed using cells from anaplastic thyroid cancer cell lines. A murine orthotopic thyroid cancer model was used to investigate metastatic ability. In the immunohistochemical analysis, only weak focal or no staining of h-prune was observed in non-tumor tissue. In contrast, diffuse staining of h-prune was observed in anaplastic thyroid cancer and lymph node metastasis samples. Both inhibition of h-prune phosphodiesterase activity with dipyridamole and small interfering RNA for h-prune suppressed 8505C and KTC-3 cell motility. In addition, treatment with dipyridamole and decreased expression of h-prune suppressed tumor invasion and pulmonary metastasis in a NOD/Shi-scid, IL-2Rγnull (NOG) mouse orthotopic thyroid cancer model. In conclusion, h-prune is frequently expressed in anaplastic thyroid cancer cells and lymph nodes metastasis, and promotes migration and invasion of anaplastic thyroid cancer cells and metastasis in an anaplastic thyroid cancer model. Thus, h-prune shows promise as a targeting candidate against anaplastic thyroid cancer.

Acute Cholecystitis with Significantly Elevated Levels of Serum Carbohydrate Antigen 19-9.

Serum carbohydrate antigen 19-9 (CA 19-9), a marker of malignant tumors, is generally slightly elevated in benign conditions. We report a case of acute cholecystitis with a significantly elevated level of serum CA 19-9 based on positron emission tomography (PET)-computed tomography (CT) findings. A 65-year-old woman presented with abdominal pain and fever. A CT image revealed an enlarged gallbladder without tumor shadows. The C-reactive protein (CRP) level was elevated to 7.66 mg/dl. Moreover, the serum CA 19-9 level was significantly elevated to 19,392 U/ml. We started antibiotic treatment, because we suspected acute cholecystitis, but still, we could not ignore the possible presence of malignant tumors. After 11 days of antibiotic treatment, serum CRP and CA 19-9 levels decreased to 0.11 mg/dl and 1,049 U/ml, respectively. There was an accumulation of fluorine 18-labeled fluorodeoxyglucose (maximum standardized uptake value, 9.3) without tumor shadows in the liver, near the gallbladder, on the PET-CT examination. We considered the possibility that the inflammation had spread from the gallbladder to the liver, made a diagnosis of acute cholecystitis, and performed a cholecystectomy 33 days after treatment initiation. The serum CA 19-9 level decreased to 45 U/ml after the surgery. One year after the surgery, the patient was alive, and the serum CA 19-9 level was 34 U/ml. Acute cholecystitis with a significantly high elevation of the serum CA 19-9 level is rare. In such cases, it is important to confirm the change in the serum CA 19-9 level over time after antibiotic treatment and perform imaging studies to distinguish between inflammation and malignancy.

Association of radiation dose with prevalence of thyroid nodules among atomic bomb survivors exposed in childhood (2007-2011).

IMPORTANCE: Few studies have evaluated the association of radiation dose with thyroid nodules among adults exposed to radiation in childhood. OBJECTIVE: To evaluate radiation dose responses on the prevalence of thyroid nodules in atomic bomb survivors exposed in childhood. DESIGN, SETTING, AND PARTICIPANTS: This survey study investigated 3087 Hiroshima and Nagasaki atomic bomb survivors who were younger than 10 years at exposure and participated in the thyroid study of the Adult Health Study at the Radiation Effects Research Foundation. Thyroid examinations including thyroid ultrasonography were conducted between October 2007 and October 2011, and solid nodules underwent fine-needle aspiration biopsy. Data from 2668 participants (86.4% of the total participants; mean age, 68.2 years; 1213 men; and 1455 women) with known atomic bomb thyroid radiation doses (mean dose, 0.182 Gy; median dose, 0.018 Gy; dose range, 0-4.040 Gy) were analyzed. MAIN OUTCOMES AND MEASURES: The prevalence of all thyroid nodules having a diameter of 10 mm or more (consisting of solid nodules [malignant and benign] and cysts), prevalence of small thyroid nodules that were less than 10 mm in diameter detected by ultrasonography, and atomic bomb radiation dose-responses. RESULTS: Thyroid nodules with a diameter of 10 mm or more were identified in 470 participants (17.6%): solid nodules (427 cases [16.0%]), malignant tumors (47 cases [1.8%]), benign nodules (186 cases [7.0%]), and cysts (49 cases [1.8%]), and all were significantly associated with thyroid radiation dose. Excess odds ratios per gray unit were 1.65 (95% CI, 0.89-2.64) for all nodules, 1.72 (95% CI, 0.93-2.75) for solid nodules, 4.40 (95% CI, 1.75-9.97) for malignant tumors, 2.07 (95% CI, 1.16-3.39) for benign nodules, and 1.11 (95% CI, 0.15-3.12) for cysts. The interaction between age at exposure and the dose was significant for the prevalence of all nodules (P = .003) and solid nodules (P < .001), indicating that dose effects were significantly higher with earlier childhood exposure. No interactions were seen for sex, family history of thyroid disease, antithyroid antibodies, or seaweed intake. No dose-response relationships were observed for small (<10-mm diameter) thyroid nodules. CONCLUSIONS AND RELEVANCE: Radiation effects on thyroid nodules exist in atomic bomb survivors 62 to 66 years after their exposure in childhood. However, radiation exposure is not associated with small thyroid nodules.

Immunohistochemistry of cyclin D1 and beta-catenin, and mutational analysis of exon 3 of beta-catenin gene in parathyroid adenomas.

Parathyroid adenomas are benign uniglandular tumors and are the most common cause of primary hyperparathyroidism. Several genetic changes in parathyroid tumors, including inactivation of tumor suppressor genes, activation of oncogenes and loss of heterozygosity at several chromosomal loci, have been reported. In this study, we analyzed the status of cyclin D1 and beta-catenin in 24 cases of parathyroid adenoma. Immunohistochemistry of cyclin D1 showed positive staining in 9 (37.5%) of the 24 parathyroid adenomas. The status of beta-catenin, which has recently been identified as a regulator of cyclin D1 transcription, was examined by direct sequencing of exon 3 of the beta-catenin gene and immunohistochemistry of beta-catenin protein, but neither mutation nor accumulation of beta-catenin was detected in any of the cases. These results indicate that cyclin D1 is frequently accumulated in parathyroid adenomas, independently of dysfunction in the Wnt signaling pathway.

Immunohistochemical and sequencing analyses of the Wnt signaling components in Japanese anaplastic thyroid cancers.

We investigated the status of the components and target genes of the Wnt signaling pathway in Japanese anaplastic thyroid cancers (ATCs) in the present study. Nuclear and cytoplasmic positive staining of beta-catenin, which might indicate the existence of alterations in the Wnt signaling pathway, were found in 40.9% and 63.6% of the 22 ATC samples, respectively. The beta-catenin, adenomatous polyposis coli (APC) and Axin 1 gene mutations were observed in 4.5%, 9.0%, and 81.8% of the 22 ATC samples, respectively. Overexpression of cyclin D1 and c-myc, which are the target genes of the Wnt signaling pathway, was observed in 27.3% and 59.1% of the ATC samples, respectively. There was no significant correlation between nuclear or cytoplasmic positive staining of beta-catenin and nuclear positive staining of cyclin D1 or c-myc. Taken together, the results of beta-catenin immunohistochemistry suggest that alterations in the Wnt signaling pathway are associated with carcinogenesis of ATC, but the frequency of beta-catenin gene mutation in our series is lower than that previously reported. Furthermore, cyclin D1 and c-myc frequently accumulated in ATC, independently of dysfunction in the Wnt signaling pathway.

Gasless laparoscopic hepatic resection for cirrhotic patients with solid liver tumors.

Gasless laparoscopic hepatic resection with a 5-cm minilaparotomy was performed in 10 cirrhotic patients with small liver tumors. To maintain good visualization and working space during hepatic resections, we developed a simple retraction system. Mean operative time and blood loss were 291 minutes and 249 mL, respectively. No blood transfusion was required during the operations. No serious complications occurred such as gas embolism. Our laparoscopic procedures had various advantages. Blood, smoke, and water vapor could be aspirated by suction without disturbance of the visual field. There was no risk of gas embolism. It was possible to use conventional instruments through the ports or the wound made by a minilaparotomy. Hemostasis therefore could be performed easily. The procedure could be applicable to cirrhotic patients with some complications. This laparoscopic procedure is recommended for patients with small HCCs associated with liver cirrhosis who are not candidates for major hepatectomy.

Allochronic overlapping malignancies after renal transplantation in a patient with p53 gene mutation: report of a case.

We report a rare case of the development of various tumors over a 16-year period after renal transplantation. A 56-year-old woman underwent renal transplantation using a US kidney. Immunosuppressive treatment consisted of a triple regimen of methylprednisolone, azathioprine, and mizoribine. Left breast cancer was diagnosed 9 years after the renal transplantation, then colon cancers and meningeal epidermal meningioma were diagnosed, 10 years and 12 years post-transplant, respectively. During the investigations for the breast and colon cancers, a p53 gene mutation was detected. A deterioration of renal function was found 16 years after the transplant and graft biopsy confirmed chronic rejection. We suggest that the effects of the immunosuppressive drugs combined with the p53 gene abnormality accelerated tumor development in this patient.