Additional staining for lymphovascular invasion is associated with increased estimation of lymph node metastasis in patients with T1 colorectal cancer: Systematic review and meta-analysis.

OBJECTIVES: Lymphovascular invasion (LVI) is a critical risk factor for lymph node metastasis (LNM), which requires additional surgery after endoscopic resection of T1 colorectal cancer (CRC). However, the impact of additional staining on estimating LNM is unclear. This systematic review aimed to evaluate the impact of additional staining on determining LNM in T1 CRC. METHODS: We searched five electronic databases. Outcomes were diagnostic odds ratio (DOR), assessed using hierarchical summary receiver operating characteristic curves, and interobserver agreement among pathologists for positive LVI, assessed using Kappa coefficients (κ). We performed a subgroup analysis of studies that simultaneously included a multivariable analysis for other risk factors (deep submucosal invasion, poor differentiation, and tumor budding). RESULTS: Among the 64 studies (18,097 patients) identified, hematoxylin-eosin (HE) and additional staining for LVI had pooled sensitivities of 0.45 (95% confidence interval [CI] 0.32-0.58) and 0.68 (95% CI 0.44-0.86), specificities of 0.88 (95% CI 0.78-0.94) and 0.76 (95% CI 0.62-0.86), and DORs of 6.26 (95% CI 3.73-10.53) and 6.47 (95% CI 3.40-12.32) for determining LNM, respectively. In multivariable analysis, the DOR of additional staining for LNM (DOR 5.95; 95% CI 2.87-12.33) was higher than that of HE staining (DOR 1.89; 95% CI 1.13-3.16) (P = 0.01). Pooled κ values were 0.37 (95% CI 0.22-0.52) and 0.62 (95% CI 0.04-0.99) for HE and additional staining for LVI, respectively. CONCLUSION: Additional staining for LVI may increase the DOR for LNM and interobserver agreement for positive LVI among pathologists.

Morphological and histological evaluation of the tendon-bone junction in porcine shoulders to create a rotator cuff tear and repair model.

BACKGROUND: This study aimed to morphologically and histologically examine whether pig is useful as models for rotator cuff tear (RCT). METHODS: The morphology of the scapula and humerus bones was evaluated by taking X-ray and three-dimensional computed tomography (3D CT) scans of the right shoulders of five female pigs (age: 4 months). The rotator cuff (RC) footprint at the humeral insertion of these was observed and its shape was measured. Next, they underwent general anesthesia and an acute rotator cuff tear/rotator cuff repair (RCT/RCR) model was created using a deltoid split approach. Four weeks after surgery, the animals were euthanized, the shoulder joints were harvested, and the repaired RC was evaluated by hematoxylin and eosin staining and toluidine blue staining. RESULTS: The scapula of the pig had a vestigial acromion, in contrast to that in humans. The supraspinatus and infraspinatus tendons were connected so as to overlap each other and attached to the postero-superior part of the greater tuberosity. These tendons were located extra-articularly, separate from the joint capsule. The average antero-posterior length of the foot print was 17.4 ± 0.7 mm on the medial margin and 19.1 ± 2.2 mm on the lateral margin. The maximum medial-to-lateral width of it was 5.1 ± 0.5 mm. In all RCT/RCR models at 4 weeks after surgery, the repaired RC compound tendon was visually confirmed to be continuous with the footprint. Histologically, it was confirmed that regeneration of the four-layer structure of the bone-tendon junction had occurred. CONCLUSION: Porcine supraspinatus and infraspinatus attachment to the greater tuberosity have a structure similar to that of sheep and dogs, which is advantageous for creating the RCT/RCR model. It might be used for future in vivo studies of shoulder joint diseases. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: Pigs could potentially serve as a viable model for rotator cuff tears.

The onset of intermetatarsal bursitis in patient with rheumatoid arthritis - Case report of surgical treatment.

INTRODUCTION: Mono-arthritis and intermetatarsal bursitis according to rheumatoid arthritis aren't aware among general orthopedic surgeon. This report describes a case of surgical treatment of intermetatarsal bursitis. PRESENTATION OF CASE: A 50-year-old female presented with three years of metatarsophalangeal joint pain and deformity. MRI showed bursitis and synovial proliferation around the joint. Synovectomy reduced pain and foot deformity. After surgery, the patient was administered methotrexate. DISCUSSION: There were previous studies reporting intermetatarsal bursitis associated with rheumatoid arthritis, few case reports were found in which surgery and pathological examination were performed. CONCLUSION: Intermetatarsal bursitis is common for patients with rheumatoid arthritis. Early diagnosis and early appropriate treatment is necessary.

Diagnostic Accuracy of Highest-Grade or Predominant Histological Differentiation of T1 Colorectal Cancer in Predicting Lymph Node Metastasis: A Systematic Review and Meta-Analysis.

INTRODUCTION: Treatment guidelines for colorectal cancer (CRC) suggest 2 classifications for histological differentiation-highest grade and predominant. However, the optimal predictor of lymph node metastasis (LNM) in T1 CRC remains unknown. This systematic review aimed to evaluate the impact of the use of highest-grade or predominant differentiation on LNM determination in T1 CRC. METHODS: The study protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO, registration number: CRD42023416971) and was published in OSF ( https://osf.io/TMAUN/ ) on April 13, 2023. We searched 5 electronic databases for studies assessing the diagnostic accuracy of highest-grade or predominant differentiation to determine LNM in T1 CRC. The outcomes were sensitivity and specificity. We simulated 100 cases with T1 CRC, with an LNM incidence of 11.2%, to calculate the differences in false positives and negatives between the highest-grade and predominant differentiations using a bootstrap method. RESULTS: In 42 studies involving 41,290 patients, the differentiation classification had a pooled sensitivity of 0.18 (95% confidence interval [CI] 0.13-0.24) and 0.06 (95% CI 0.04-0.09) ( P < 0.0001) and specificity of 0.95 (95% CI 0.93-0.96) and 0.98 (95% CI 0.97-0.99) ( P < 0.0001) for the highest-grade and predominant differentiations, respectively. In the simulation, the differences in false positives and negatives between the highest-grade and predominant differentiations were 3.0% (range 1.6-4.4) and -1.3% (range -2.0 to -0.7), respectively. DISCUSSION: Highest-grade differentiation may reduce the risk of misclassifying cases with LNM as negative, whereas predominant differentiation may prevent unnecessary surgeries. Further studies should examine differentiation classification using other predictive factors.

A rare presentation of linea alba hernia involving fibrolipoma of the hepatic round ligament: a case report and literature review.

BACKGROUND: Linea alba hernias are relatively rare types of hernias. They manifest as small protrusions situated in the linea alba between the umbilicus and xiphoid cartilage. Usually, hernia contents comprise the pre-peritoneal fat, omentum, and gastrointestinal tract. However, very few cases of linea alba hernias involving the hepatic round ligament have been reported, to date. CASE PRESENTATION: An 80-year-old woman presented with upper abdominal pain and a 1-week history of a mass in the upper midline. Abdominal computed tomography revealed adipose tissue protruding from the abdominal wall contiguous with the hepatic round ligament, suggesting a linea alba hernia. During surgery, the hernial sac content was found to be a mass, which was resected. A linea alba hernia defect measuring 20 mm was repaired using a mesh. Histopathological findings revealed that the mass included mature adipocyte proliferation with broad fibrous septa, which was diagnosed as fibrolipoma of the hepatic round ligament. CONCLUSIONS: We report the first case of a linea alba hernia involving fibrolipoma of the hepatic round ligament worldwide and describe the clinical features, diagnosis, and surgical procedure with a literature review.

Metaplastic breast carcinoma producing prominent basal lamina with neuroendocrine differentiation: A case report.

Metaplastic breast carcinoma (MBC) is a heterogeneous group of invasive breast carcinomas (IBCs) characterized by the differentiation of the neoplastic epithelium toward squamous cells and/or mesenchymal-appearing elements. The present study describes the case of a 42-year-old woman who underwent a mastectomy and sentinel lymph node biopsy for two tumors in their left breast. One of the resected tumors was diagnosed as MBC with neuroendocrine (NE) differentiation and the other was diagnosed as IBC of no special type. The MBC tumor contained a matrix composed of basal lamina with a focal area of myxoid matrix and squamoid differentiation. To the best of our knowledge, the present study is the first report of MBC producing prominent basal lamina. The patient has remained alive and well for >10 years without recurrence, and has been treated with oral and injected anticancer drugs.

Medial lingual lymph node metastasis in carcinoma of the tongue.

Lingual lymph node metastases are rarely seen in carcinoma of the tongue, and these nodes are not removed during neck dissection. Lingual lymph nodes are classified into medial and lateral groups, and metastasis to the former is extremely rare. A 55-year-old male with squamous cell carcinoma of the tongue, (stage T4aN0M0), underwent hemiglossectomy with neck dissection and free flap reconstruction. The lingual septum had a mass, 8 mm in size, which was diagnosed as medial lingual lymph node metastasis on histopathology. The patient developed multiple distant metastases and died of disease 18 months after the initial surgery. The presence of medial lymph node metastasis could result in contralateral neck metastases and worsen prognosis. Such cases may warrant more intensive therapy than recommended by current guidelines.

A Non-smoking Woman with Anti-phospholipid Antibodies Proved to Have Thromboangiitis Obliterans.

A 48-year-old woman with severe pain and numbness of her right leg and foot was admitted to our hospital. She had never smoked and had little exposure to passive smoking. Initially, polyarteritis nodosa with anti-phospholipid antibodies was considered. Combination therapy with methylprednisolone pulse therapy, intravenous cyclophosphamide pulse therapy, vasodilators, antiplatelet agents, and anticoagulants was not effective. Vasculopathy was progressive, and she presented with gangrene of the toes. She required amputation of her right leg. The pathological findings of the amputated leg revealed thromboangiitis obliterans (TAO). TAO should be considered even in non-smoking women. Non-response to immunosuppressant and anticoagulant therapies may be a clue to the diagnosis of TAO.

Androgen Receptor Predicts First and Multiple Recurrences in Non-Muscle Invasive Urothelial Carcinoma of the Bladder.

The aim of this study is to investigate the role of androgen receptor (AR) expression on clinicopathologic characteristics, first recurrence free survival (RFS), progression free survival (PFS) and multiple recurrences in non-muscle invasive bladder cancer (NMIBC). AR expression in 40 paraffin-embedded specimens of primarily diagnosed NMIBC after transurethral resection was examined by immunohistochemistry using a monoclonal AR antibody. Associations between AR expression and clinicopathologic features and prognosis were statistically assessed. Multivariate Cox proportional hazards model was applied for evaluating predictive factors on RFS and PFS. For multiple recurrences, we used the Andersen-Gill model. AR was positive in 20/40 (50%) cases. Twenty-three patients (57.5%) had no recurrence, 10 (25.0%) had one recurrence, and 7 (17.5%) experienced more than one recurrence. AR expression and clinicopathologic features were not significantly correlated (P >0.05). Univariate analyses showed that AR expression was significantly associated with RFS and PFS (P <0.05). Via multivariate analyses, positive AR expression was significantly associated with lower risk of first recurrence (hazard ratio (HR) = 0.265; 95% confidence interval (95% CI) = 0.084-0.829; P = 0.022). Multivariate analysis of PFS was not feasible in our cohort. Using the multivariate Andersen-Gill model, positive AR expression in the primary tumor was an independent factor predicting lower risk of multiple recurrences (HR = 0.387, 95% CI = 0.161-0.927, P = 0.033). Androgen receptor expression is associated with first and multiple recurrences in NMIBC.

Optimal body mass index cut-point for predicting recurrence-free survival in patients with non-muscle-invasive urothelial carcinoma of bladder.

In Japanese patients with non-muscle-invasive urothelial carcinoma of the bladder, the impact of body mass index (BMI) on recurrence following transurethral resection of bladder tumor (TURBT) is unclear. The present study retrospectively examined data collected from 50 patients diagnosed with primary urothelial carcinoma of the bladder (pTa, pTis, and pT1) who had previously undergone TURBT surgery. Two BMI cut-off points for predicting disease recurrence were evaluated: i) A threshold generated through receiver operating characteristic (ROC) curve analysis; ii) the World Health Organization BMI index (24 kg/m2) for overweight status in Japanese populations. Univariate and multivariate analyses were applied to assess individual variables (BMI included) and the effect they had on recurrence-free survival (RFS). Median RFS and BMI values of 19.72 months (range, 3.13-72.13 months) and 23.37 kg/m2 (range, 14.72-36.84 kg/m2), respectively, were recorded. In multivariate analyses, higher continuous BMI was significantly associated with shorter RFS (P=0.019). Based on a ROC-generated BMI cut-off point (23.4 kg/m2), patients were ranked with either a high (≥23.4 kg/m2) or low (<23.4 kg/m2) BMI status. Multivariate analysis indicated that BMI values >23.4 kg/m2 were significantly associated with shorter RFS (P=0.028). Intravesical Bacillus Calmette-Guérin treatment and history of upper-tract urothelial carcinoma were also independently associated (P=0.044 and P=0.010, respectively). However, BMI values >24 kg/m2 (customary cut-off point) had no significant impact on RFS (P=0.066). Thus, a higher BMI status was revealed to be independently predictive of shorter RFS in Japanese patients undergoing TURBT for urothelial carcinoma of the bladder. A greater number of samples are required in order to determine optimal BMI cut-off points in Japanese patients and to investigate whether weight reduction intervention may improve prognosis.

Non-Syndromic Familial Keratocystic Odontogenic Tumour: A Rare Case Report in Japanese Identical Twins.

Keratocystic Odontogenic Tumour (KCOT) is unicystic or multicystic intraosseous benign tumour of odontogenic origin that recurs due to locally destructive behaviour. KCOTs are usually the first manifestation of Nevoid Basal Cell Carcinoma Syndrome (NBCCS), an autosomal dominant disorder also known as Gorlin's syndrome and they are most frequently observed familial symptom regardless of patients' nationality. In addition, the recurrence rate and multiplicity of KCOTs is relatively high as compared to that of other sporadic carcinomas. KCOT has been considered as a non-hereditary lesion and its familial onset is an extremely rare event in non-NBCCS cases. Here, we describe previously unreported non-syndromic multiple KCOT cases in identical twins in a Japanese family. The subjects were female Japanese identical twins who were 26 and 27 years old, respectively, at the time of diagnosis for KCOT. They had no major or minor features of NBCCS other than KCOT. Although there were lesions that were likely to be dentigerous cysts based on radiographic findings, one of them was KCOT. This case report highlights the importance of precise diagnosis, choice of surgical method and careful observation for multiplicity or familial onset in sporadic KCOT cases without NBCCS.

Intraosseous inflammatory myofibroblastic tumor of the mandible with a novel ATIC-ALK fusion mutation: a case report.

BACKGROUND: Inflammatory myofibroblastic tumor (IMT) is a rare low-grade malignant neoplasm with a predilection for children and young adults, and typically arises in the lung, abdominopelvic region, and retroperitoneum. IMTs in the maxillofacial region are extreme rare. Approximately 50% of IMT harbor rearrangements of the anaplastic lymphoma kinase (ALK) gene at 2p23 with various fusion partners. CASE PRESENTATION: We herein report a case of intraosseous IMT of the mandible with a novel ATIC-ALK fusion. Tooth 43 did not erupt after the loss of tooth 83 in an 11-year-old girl with no previous history of trauma. Panoramic tomography showed a unilocular radiolucent lesion in the right anterior mandible resorbing the root of tooth 42 and the medial side of the root of tooth 44. Computed tomography revealed a well- circumscribed 3-cm osteolytic lesion of the right anterior mandible eroding the buccal cortical plate. The entire lesion was curetted out. A histopathological examination revealed the proliferation of plump spindle cells with a storiform architecture and lymphocytes scattered around spindle cells. The spindle cells showed diffuse cytoplasmic staining for ALK by immunohistochemistry. A fluorescence in situ hybridization analysis revealed the translocation of a part of the ALK gene locus at chromosome 2p23. A rapid amplification of cDNA ends analysis confirmed the rearrangement of ALK and identified ATIC as a partner of this ALK fusion mutant. CONCLUSION: To the best of our knowledge, this is the first case of intraosseous IMT of the mandible with a novel ATIC-ALK fusion. We also herein reviewed similar tumors reported in the literature.

Abdominal subcutaneous fat pad aspiration and bone marrow examination for the diagnosis of AL amyloidosis: the reliability of immunohistochemistry.

Tissue biopsy is essential for the diagnosis and typing of amyloidosis. Given its safety and ease, abdominal fat pad (AFP) is the first biopsy site of choice; bone marrow (BM) biopsy should additionally be performed to identify underlying plasma cell dyscrasia. The aim of the present study was to assess the usefulness of combined biopsy and immunohistochemical staining of AFP and BM tissues for the diagnosis and typing of amyloidosis. A total of 65 patients were examined. Congo red staining and immunohistochemical staining with antibodies were performed. Of 51 patients with systemic amyloidosis, 50 patients were examined with fat pad aspirates and 38 (76 %) cases were positive. All 51 patients were also examined by BM analysis and 25 (49 %) cases were positive. Including both AFP aspirates and BM specimens, 90 % of patients with systemic amyloidosis were Congo red positive. Of the 49 patients with AL amyloidosis, immunohistochemical stains were positive in 67.6 % of patients with AFP aspirates and in 50 % with BM specimens. Combining AFP aspirate and BM examination, immunohistochemical stains yielded positive stains for the corresponding circulating monoclonal immunoglobulin in 72.7 % of cases, and hence these analyses appear to be valuable in diagnosing the type of amyloidosis.

Atypical Subacute Recurrence of Catastrophic Antiphospholipid Syndrome in a Japanese Female Patient.

Catastrophic antiphospholipid syndrome (CAPS) survivors rarely relapse. We herein report a case of a second CAPS episode with an unusual subacute course and no microangiopathic hemolytic anemia (MAHA), a common CAPS symptom. During the first episode, the 69-year-old woman responded well to high-dose glucocorticoids and plasma exchange. On relapse, these treatments plus rituximab were ineffective and she died of multi-organ failure and bacterial cholangitis. The absence of MAHA and a subacute course do not exclude a CAPS recurrence.

Chronic granulomatous disease with pulmonary mass-like opacities secondary to hypersensitivity pneumonitis: a case report.

INTRODUCTION: Chronic granulomatous disease, one of the primary immunodeficiency syndromes, is characterized by failure of phagocytic capacity due to loss of reactive oxygen species production, as well as formation of granulomas in organs. Clinically, dysregulated inflammation by excessive cytokine production due to loss of reactive oxygen species production is suggested as a cause of noninfectious inflammatory problems such as chronic granulomatous disease colitis. We experienced a rare case of a patient with chronic granulomatous disease with unique pathological and radiological presentations of hypersensitive pneumonitis, which to our knowledge has never been previously reported. CASE PRESENTATION: A 20-year-old Japanese man with chronic granulomatous disease was referred due to cough and abnormal chest imaging findings. Computed tomography of his chest showed diffuse, bilateral, centrilobular nodules and multiple mass lesions in lower lobes that do not fit a common image of hypersensitivity pneumonitis. Pathological findings of both nodules and mass lesions on surgical lung biopsy were homogeneous, and excessive granulomas in the bronchioles and alveolar duct as well as lymphocytic alveolitis were seen, all consistent with hypersensitivity pneumonitis. The radiological and laboratory abnormalities did not improve after antigen avoidance; however, they disappeared after high-dose steroid therapy. CONCLUSIONS: When we encounter a case of hypersensitive pneumonitis showing atypical pulmonary mass-like opacities in a patient with chronic granulomatous disease, we should consider hyperinflammatory status and excessive granuloma formation of chronic granulomatous disease and start with high-dose steroid therapy as treatment.

Evaluation of indeterminate pulmonary nodules with dynamic MR imaging.

PURPOSE: We prospectively assessed whether enhancement characteristics on dynamic magnetic resonance (MR) imaging could distinguish indeterminate pulmonary nodules. METHODS: We evaluated 51 pulmonary nodules in 51 consecutive patients (11 female, 40 male; mean age, 64 years) using dynamic MR images acquired at 0, 10, 20, 30, 40, 50, 60, 70, 80, 90, 120, 150, 180, 210, 240, 360, 480, 600, 720, and 840 s following injection of contrast material. We prospectively evaluated morphologic enhancement patterns, peak rate, time to peak enhancement, steepest slope, and washout of nodules and analyzed statistics to determine any differences between MR parameters, patient age, tumor size, and final diagnosis. RESULTS: We found 25 malignant, 12 active inflammatory, and 14 benign nodules. Nodule diameter was significantly larger for malignant than nonmalignant, and benign nodules (P≤0.01). Patients with malignant nodules were significantly older than those with nonmalignant (P=0.01) and active inflammatory (P=0.02) nodules. However, morphologic enhancement patterns, peak rate, time to peak enhancement, steepest slope, and washout characteristics at 2, 4, 8, and 12 min showed no significant difference between malignant and nonmalignant nodules and among malignant, active inflammatory, and benign nodules. CONCLUSION: Prospective assessment of dynamic MR images demonstrated their inadequacy for distinguishing indeterminate pulmonary nodules.

A rare case of extensive ductal carcinoma in situ of the breast with secretory features.

We report a very rare case of extensive ductal carcinoma in situ (DCIS) of the breast with secretory features in a 30-year old Japanese woman. The patient presented with a nodule in the lower inner quadrant of the left breast measuring approximately 2-3 cm, accompanied by an irregular tumor shadow with segmental microcalcification on mammography. These findings suggested malignancy, and excisional biopsy was performed following core needle biopsy. Pathological diagnosis was that of DCIS with secretory features. A treatment plan of simple mastectomy and sentinel lymph node biopsy was chosen. Most previous reports have only described invasive secretory carcinoma of the breast. We have only been able to find 2 case reports of non-invasive secretory lesion in the English literature to date. Because the characteristics of this lesion are not widely known, we thought it important to share our findings.

Lung amyloid nodule detected by 99mTc-aprotinin scintigraphy.

We present a case in which an amyloid lung nodule was diagnosed preoperatively by amyloid scintigraphy (99m)Tc-aprotinin. A 65-year-old man complained of marked weight loss (9 kg) over a period of 6 months. An abnormal shadow in the middle field of the right lung was detected on chest X-ray, corresponding to a 16-mm nodule in the right middle lobe on thoracic computed tomography (CT). Total protein and immunoglobulin G levels were elevated to 8.3 and 2245 mg/dl, respectively, but other blood tests including several tumor marker levels and Cryptococcus antibodies were all within normal range. Fluorodeoxyglucose positron emission tomography showed no uptake by the lung nodule, so lung amyloidosis was considered as differential diagnosis. To avoid risk of bleeding on bronchoscopy, noninvasive amyloid scintigraphy using (99m)Tc-aprotinin was first performed. A nodular, abnormal accumulation was observed in the right middle lung lobe. Diagnostic imaging strongly suggested amyloidosis, so video-assisted thoracic surgery was performed rather than bronchoscopy. Pathological samples showed positive staining with Congo red, and A-λ amyloidosis was diagnosed on the basis of immunostaining. Scintigraphy using (99m)Tc-aprotinin offers a useful, noninvasive method for assessing lung amyloidosis.

[Microscopic polyangiitis with renal mass-like lesion: a case report].

A 63-year-old man was admitted to our hospital because of persistent fever, weight loss, painful foot, and purpura on his extremities. He had lower extremity peripheral neuropathy, and skin biopsy of the purpura revealed vasculitis. Serum tests for myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA), proteinase 3-ANCA, and ANCA (indirect fluorescent antibody method) were all negative. Computed tomography revealed a 6-cm large, irregularly shaped lesion in the right kidney, while the nasal sinuses and lungs were intact. Based on these findings, a diagnosis of suspected systemic vasculitis associated with renal cell carcinoma was made. Thus, right nephrectomy was performed. However, the pathological findings showed a large infarct with necrotizing vasculitis of the arcuate, interlobular, and perinephric small arteries and a crescent formation in the glomerulus. Based on these findings, he was diagnosed with microscopic polyangiitis. Due to rapidly worsening symptoms of purpura and neuropathy, treatment with a high dose of corticosteroid was initiated on postoperative day 2, which led to improvement of his symptoms. Vasculitis accompanied with a mass-like lesion is occasionally confused with malignancy. The lesion in our patient was considered to have originated by asymptomatic renal infarction. This case suggests that a renal mass-like lesion with vasculitis should be diagnosed with care.