[A Case of Sinusoidal Obstruction Syndrome and Nodular Regenerative Hyperplasia after Using Oxaliplatin for Rectal Cancer].

We present a case of a 44-year-old woman with rectal cancer(cT2N3M0, cStage Ⅲb)treated with 4 capecitabine-oxaliplatin( CAPOX)therapy courses, followed by laparoscopic intersphincteric resection. The patient received 7 postoperative, adjuvant CAPOX therapy courses. After 16 months since the final CAPOX administration, computed tomography(CT) revealed multiple liver tumors, showing early enhancement, and a jejunal mesenteric mass suspected to be a gastrointestinal stromal tumor(GIST). To overcome the percutaneous needle biopsy limitation, laparoscopic partial hepatectomy and laparoscopic- assisted partial intestinal resection were performed. Two liver lesions were diagnosed as nodular regenerative hyperplasia( NRH)with sinusoidal obstruction syndrome(SOS), supported by the hyperplasia and sinusoidal dilatation pathological findings, consequential to using oxaliplatin. Considering the rarity of NRH, using oxaliplatin may be proven vital in the differential diagnosis.

[Successful Control of Hyperammonemia with BRTO of a Splenorenal Shunt Induced by CAPOX Therapy].

Among portosystemic shunts, splenorenal shunts can cause increased portal pressure, which in turn can bring about hyperammonemia, resulting in hepatic encephalopathy. In recent years, it has been reported that oxaliplatin(OX), a key chemotherapy drug in colorectal cancer, can precipitate splenorenal shunts due to sinusoidal injury. We report a case of hyperammonemia post oxaliplatin therapy. A 72-year-old male patient who had undergone surgical resection for(RS)rectal cancer with hepatic metastasis had been receiving capecitabine plus OX(CAPOX)as adjuvant chemotherapy. During his 7th course of treatment, he visited the outpatient clinic with complaints of weakness, dysarthria, and urinary incontinence. Laboratory findings showed an elevated NH3 level (200 µg/dL), and subsequent abdominal computed tomography revealed a splenorenal shunt, which was attributed to OX. Balloon-occluded retrograde transvenous obliteration(BRTO)was then performed. The patient has been routinely followed up in the outpatient clinic and has had no recurrence of hyperammonemia or cancer 14 months after the procedure. In retrospect, the splenorenal shunt was present on his first visit, therefore, hyperammonemia could have been prevented at the time of commencement of chemotherapy. We report our case, along with the relevant literature.

The enhancing effects of hyperbaric oxygen on mouse skin carcinogenesis.

The effects of hyperbaric oxygen (HBO) on mouse skin two-stage chemical carcinogenesis were examined. Six-week-old inbred CD-1 female mice were divided into the following five groups: group 1, normoxia and application of 25 nmol 7,12-dimethylbenz[a]anthracene (DMBA) and 8.5 nmol 12-O-tetradecanoylphorbol-13-acetate (TPA) (n=19); group 2, HBO and DMBA/TPA (n=21); group 3, HBO and DMBA/acetone (n=3); group 4, normoxia and acetone (n=3); and group 5, non-treatment group (n=5). HBO was started at the same time as DMBA. Mice were euthanized at 23 weeks after the start of the experiment. Mice in group 2 showed the occurrence of tumors at 8 weeks after the beginning of the experiment, while the occurrence of tumors in mice in group 1 was observed beginning at 9 weeks. There was a difference in occurrence among low-grade papillomas, high-grade papillomas and SCCs in both groups 1 and 2 by the χ (2)-test at end of the experiment (p<0.05). The Ki-67 labeling indices of tumors revealed that the percentages of positive cells in low-grade papillomas in groups 1 and 2 were 15.27 ± 2.54% and 29.67 ± 2.82%, respectively (p<0.01). The results suggested that the tumors in group 2, which was treated with HBO, were more progressive than those in group 1, which was not treated with HBO. In this study, HBO accelerated tumor cell proliferation and advanced tumor progression in skin carcinogenesis by DMBA/TPA.

[Hypoxia after cesarean section in a patient with myotonic dystrophy].

A 28-year-old woman, 35 week-pregnant, underwent emergency cesarean section. Although she had no apparent symptoms before the operation, myotonic dystrophy was suspected from physical examination and laboratory data. The anesthesiologist in charge recognized only high creatine kinase. Combined spinal-epidural anesthesia was performed. During the operation and on the 1st postoperative day, Spo2 remained 99% with 3 l x min(-1) oxygen administration. However, on the 2nd postoperative day Spo2 decreased. The low Spo2 persisted for 4 days. Hypoventilation and difficulty in expectoration as a result of respiratory muscle weakness might have been the cause of the prolonged hypoxemia.

[Reversal of rocuronium induced neuromuscular block with sugammadex in a patient with myasthenia gravis].

We report a patient with myasthenia gravis whose rocuronium induced neuromuscular block was reversed with sugammadex. A 26-year-old man, 175 cm and 76 kg, with myasthenia gravis, was scheduled for extended thymectomy under general anesthesia. An epidural catheter was inserted at the T5-6 interspace before induction of general anesthesia. Anesthesia was induced with propofol and remifentanil. Rocuronium was given in divided doses to obtain > 95% neuromuscular block to intubate the trachea. The ED50 and ED95 of rocuronium for this patient were 0.18 mg x kg(-1) and 0.39 mg x kg(-1), respectively. The values were similar to the ED50 and ED95 of rocuronium for normal patients. General anesthesia was maintained with propofol and remifentanil. Additional doses of rocuronium were given intermittently. Sugammadex, 2 mg x kg(-1), was given at the end of the surgery. The train-of-four ratio reached 93% 105 sec later. His postoperative course was uneventful.

Rapid growing mediastinal ectopic pancreas within ruptured thymic cyst treated using video-assisted thoracic surgery.

Ectopic pancreas (EP) is typically found within other gastrointestinal organs. Its discovery in other parts of the body, especially in the mediastinum, is exceedingly rare. This paper presents a case of a 17-year-old female patient with EP in a large, rapidly growing thymic cyst. She presented to our institution with persistent chest pain. Video-assisted thoracic surgery revealed a mediastinal mass in the setting of pleural effusion. Analysis of the fluid contents of the mass and the pleural effusion demonstrated high levels of pancreatic amylase, which supported the presence of pancreatic tissue within the mass. This is the first reported case of EP in a thymic cyst with an active pancreatic exocrine function. It is also the first reported case of mediastinal EP rupture secondary to autodigestion by amylase.

Post-mortem biopsy of a patient with late exacerbation of COVID-19 pneumonia.

Pathological findings of coronavirus disease (COVID-19) have rarely been reported owing to its contagious nature. Here, we treated an 82-year-old man whose condition was diagnosed as COVID-19 pneumonia, which exacerbated approximately 25 days after the initial onset. The patient died despite receiving intensive care. Post-mortem percutaneous needle biopsy of the lungs and liver tissue was performed, including genomic analysis, immunochemical tests, and pathological studies. Histopathology of the lungs showed both exudative and organizing diffuse alveolar damage. Supposedly, the organizing phase of acute respiratory distress syndrome (ARDS) induced COVID-19. Polymerase chain reaction (PCR) test and immunostaining of biopsy specimens showed negative results for COVID-19. Post-mortem percutaneous needle biopsy was more effective in reducing the risk of contagiousness than autopsy.

Application of the Milan System for Reporting Salivary Gland Cytopathology: A 10-Year Experience in a Single Japanese Institution.

OBJECTIVE: The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) is a recently published evidence-based categorization system for salivary gland fine-needle aspiration (FNA). We applied MSRSGC to Japanese cases and evaluated its utility. STUDY DESIGN: A total of 480 FNA cases were reviewed. We recategorized each case into one of the MSRSGC categories. The risk of neoplasm (RON) and the risk of malignancy (ROM) for each diagnostic category in MSRSGC, and the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) for malignancy and for neoplasms were calculated for cases with histological follow-up. In addition, the overall ROM (O-ROM) was calculated for all FNA cases. RESULTS: RON, ROM, and O-ROM rates were as follows - non-diagnostic: 51.3, 5.1, and 1.0%; non-neoplastic: 0, 0, and 0%; atypia of undetermined significance: 83.9, 12.9, and 7.3%; neoplasm, benign: 100, 0, and 0%; salivary gland neoplasm of uncertain malignant potential: 100, 32.1, and 23.7%; suspicious for malignancy: 100, 85.7, and 60%; and malignant: 100, 100, 81.8%. The sensitivity, specificity, and accuracy with (without) indeterminate cases for malignancy were 65 (100), 99 (99), 92% (99%) and PPV and NPV were 96 and 100%, respectively, and those for neoplasms were 84 (100), 100 (100), 85% (100%), and PPV and NPV were 100 and 100%, respectively. CONCLUSIONS: The MSRSGC is useful for stratification of ROM and for promoting the performance of salivary gland FNA. The MSRSGC could be easily introduced in Japan and may improve the Japanese salivary gland FNA status.

Hepatocellular Carcinoma in a Patient With Crohn's Disease.

A 44-year-old woman with a 26-year history of Crohn's disease (CD) presented with intermittent fever, vomiting, and watery diarrhea. Her medication included an elemental diet, mesalazine, and infliximab. Liver profile and viral hepatitis markers were normal. Computed tomography scans showed a hepatic tumor by chance. Serum tumor markers disclosed elevated protein induced by vitamin K absence-II. With a diagnosis of hepatocellular carcinoma (HCC), she underwent a hepatic resection of the tumor, revealing well-to-moderately differentiated HCC. The nontumor region of the liver disclosed the absence of cirrhosis or other diseases. Here, the development of HCC in CD without underlying liver diseases is discussed with a review of the literature.

Paroxysmal Atrioventricular Block in a Relatively Young Patient with COVID-19.

Cardiac involvement has been reported in patients with coronavirus disease 2019 (COVID-19). We herein report a 41-year-old man who presented with recurrent paroxysmal atrioventricular block without showing significant cardiac injuries or comorbidities. The patient was diagnosed with COVID-19 and admitted to our hospital, where he was noted to have paroxysmal atrioventricular block. Cardiac biomarkers, echocardiography, and cardiac magnetic resonance imaging findings were fairly normal. An endomyocardial biopsy performed before the implantation of a permanent pacemaker revealed mild myocardial fibrosis without inflammatory infiltrates. The unusual myocardial involvement of the novel coronavirus was suspected.

Recognition and pathological features of periampullary region adenocarcinoma with an indeterminable origin.

Determination of the primary tumor in periampullary region carcinomas can be difficult, and the pathological assessment and clinicopathological characteristics remain elusive. In this study, we investigated the current recognition and practices for periampullary region adenocarcinoma with an indeterminable origin among expert pathologists through a cognitive survey. Simultaneously, we analyzed a prospective collection of cases with an indeterminable primary tumor diagnosed from 2008 to 2018 to elucidate their clinicopathological features. All cases with pathological indeterminable primary tumors were reported and discussed in a clinicopathological conference to elucidate if it was possible to distinguish the primary tumor clinically and pathologically. From the cognitive survey, over 85% of the pathologists had experienced cases with indeterminable primary tumors; however, 70% of the cases was reported as pancreatic cancer without definitive grounds. Interpretation of the main tumor mass varied, and no standardized method was developed to determine the primary tumor. During a prospective study, 42 of the 392 periampullary carcinoma cases (10.7%) were considered as tumors with a pathological indeterminable origin. After the clinicopathological conferences, 21 (5.4%) remained indeterminable and were considered final indeterminable cases. Histological studies showed that the tumors spread along both the bile duct and main pancreatic duct; this was the most representative finding of the final indeterminable cases. This study is the first to elucidate and recognize the current clinicopathological features of periampullary region adenocarcinomas with an indeterminable origin. Adequate assessment of primary tumors in periampullary region carcinomas will help to optimize epidemiological data of pancreatic and bile duct cancer.

Human immunodeficiency virus-associated pulmonary sarcoidosis in a Japanese man as a manifestation of immune reconstitution inflammatory syndrome.

Asymptomatic pulmonary sarcoidosis can develop after starting antiretroviral therapy. The decision on whether to treat sarcoidosis with corticosteroids should be based on the disease severity.

Quadruple Multiple Primary Malignancies: Early Detection of Second Primary Malignancy by Esophagogastroduodenoscopy/Colonoscopy Is Crucial for Patients with Classic Kaposi's Sarcoma.

Currently, Kaposi's sarcoma (KS) is treated following the recommendations of international guidelines. These guidelines recommend esophagogastroduodenoscopy/colonoscopy for detecting multicentric KS of visceral lesions. Second primary malignancies (SPMs) are also a common KS complication; however, information on their detection and treatment is unfortunately not yet indicated in these guidelines. This paper reports on an 86-year-old man who suffered from quadruple primary malignancies: skin classic KS with colon adenocarcinoma, oral squamous cell carcinoma (maxilla), and well-differentiated stomach adenocarcinoma. Gastric cancer was incidentally detected during esophagogastroduodenoscopy, which was performed to detect visceral KS. We suggest that esophagogastroduodenoscopy/colonoscopy be routinely performed during the follow-up of patients with KS. As SPMs are crucial complications in patients with KS, these malignancies should be detected as early as possible.

Direct evidence on the efficacy of GnRH agonist in recurrent steroid cell tumor-not otherwise specified.

BACKGROUND: Steroid cell tumor (SCT) not otherwise specified (NOS) is rare and recurrence and metastasis rarely occurs; therefore, reports regarding its treatment are limited. We report a case of recurrent SCT-NOS treated with gonadotropin releasing hormone agonist (GnRHa) and successful. CASE: A 50-year-old woman underwent a staging laparotomy and diagnosed as SCT-NOS. Multiple liver tumors and intraperitoneal dissemination were detected 5 years 10 months after the initial surgery. As the immunohistochemical analysis showed positive staining for GnRH receptor, GnRHa was attempted. After the first cycle the serum testosterone level was normalized and after six cycles CT scan confirmed reduction of the tumor size. CONCLUSION: Some ovarian SCT-NOS have GnRH receptors; thus, GnRHa may have a reducing effect for these tumors without major adverse event.

Thymoma appearing 9 years after the resection of squamous cell carcinoma of the lip: A case report of triple primary tumors and literature review.

The occurrence of second primary tumor (SPT)following malignancy treatment is common. In patients with head and neck (H&N) cancer, SPTs principally occur in the H&N region, lungs or esophagus. Therefore, patient follow-up after cancer treatment is important in order to detect recurrence, metastasis and new primary tumors. However, no standard guidelines on lifelong follow-up imaging are available. Herein, we report a patient who presented with three metachronous primary tumors-squamous cell carcinoma (SCC) of the tongue, SCC of the lip and type A thymoma. The third tumor was incidentally detected during follow-up using contrast-enhanced computed tomography (CT) 9 years following resection of the second tumor. To the best of our knowledge, this specific combination of metachronous tumors has not yet been reported. Based on the literature review, we observed that thymoma occurs following H&N cancer treatment. Therefore, to ensure that the presence of subsequent thymomas is not overlooked, we suggest regular lifelong follow-up using contrast-enhanced CT in patients who had previously been diagnosed with H&N cancer. The literature review revealed that thymomas occur in patients with H&N cancer and should be detected at the earliest convenience.

Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions.

Secondary postpartum hemorrhage (PPH) and postabortion hemorrhage are rare complications. Retained products of conception (RPOC) is among the most common causes of both secondary PPH and postabortion hemorrhage. Other less common causes of secondary PPH are uterine vascular abnormalities such as arteriovenous malformations and pseudoaneurysms. These are usually related to a history of a procedure such as dilation and curettage or cesarean delivery. Subinvolution of the placental site is an idiopathic cause of secondary PPH; this condition may be underrecognized and therefore could have a higher incidence than currently reported. Gestational trophoblastic disease is rare but commonly presents as secondary PPH and resembles RPOC in radiologic appearance. The first-line imaging modality for secondary PPH is ultrasound, but computed tomography and magnetic resonance imaging may be used if the ultrasound findings are indeterminate. Angiography is an important tool for the definitive diagnosis of uterine vascular abnormalities. Appropriate management requires radiologists to be familiar with the multimodality imaging features of secondary PPH or postabortion hemorrhage.

Nuclear features of infiltrating urothelial carcinoma are distinguished from low-grade noninvasive papillary urothelial carcinoma by image analysis.

Recent advances in computer technology have been made and image analysis (IA) has been introduced into pathological fields. The present study aimed to investigate the utility of IA for the evaluation of nuclear features and staining of immunohistochemistry (IHC) for Ki-67, p53 and GATA-binding protein 3 (GATA-3) in urothelial carcinoma tissue samples. A total of 49 cases of urothelial carcinoma tissue samples were obtained by transurethral resection of bladder tumors, which included 11 low-grade papillary urothelial carcinomas (LGPUCs), 1 non-invasive high-grade urothelial carcinoma and 37 infiltrating urothelial carcinomas (IUCs). Whole slide imaging (WSI) and IA were performed in Feulgen reaction and IHC-stained tissue samples. There was a significant difference in the average nuclear density, standard deviation (SD) of nuclear size and SD of nuclear minimum and maximum diameter between LGPUC and IUC, which is equivalent to the diagnostic features of IUC in nuclear variability, and hyperchromatic nuclei. In addition, the present study revealed that the SD of nuclear density was significantly different between the two groups. Regarding IA in IHC-stained tissue samples, Ki-67 was significantly overexpressed in IUC. Furthermore, the GATA-3 expression level in IUC samples with muscle invasion was significantly downregulated compared with that in non-muscle invasive tumors. The results of the present study suggest that IA in combination with WSI may be a beneficial tool for evaluating morphometric characteristics and performing semi-quantitative analysis of IHC.

Primary Villoglandular Mucinous Adenocarcinoma of the Vulva.

Primary villoglandular mucinous adenocarcinoma of the vulva is rare tumor. We report a case of 68-year-old woman who developed this very uncommon malignant tumor. Immunohistochemical examination of this tumor revealed positive staining for Cytokeratin 20, Mucin 2, and CDX2, although Cytokeratin 7 and Mucin 6 were negative. This positive staining indicated the tumor enteric type characters. In order to exclude the possibility of the metastasis from another site, we thoroughly evaluated clinical data and extensively investigated the whole body. However, we could not detect any other tumors. The patient was treated by tumor resection. The patient remains free of disease 5 years after surgery.

Pre-neoplastic lesion, mucin-depleted foci, reveals de novo high-grade dysplasia in rat colon carcinogenesis.

Aberrant crypt foci (ACF) and mucin-depleted foci (MDF) have recently been recognized as pre-neoplastic lesions in the colon of carcinogen-treated rodents. In the present study, we analyzed the sequential development of ACF and MDF histopathologically in the colon of rats from 5 to 40 weeks after DMH treatment. The numbers of ACF per colon increased over time during the experiment, and were much higher than the number in tumors, while the number of MDF per colon remained unchanged from the early stage (the 5th week after carcinogen exposure), and approximate to those in tumors. The incidence of ACF, which was much higher than that of tumors, also increased gradually in a time-dependent manner. The incidence of MDF, however, was similar to that of tumors and did not change significantly during the whole experiment. No lesion as dysplasia with high-grade (DHG) or adenocarcinoma (AC) were found in any large ACF from the 5th to 40th week histopathologically, whereas all of the large MDF showed DHG or AC features. Even at 5 weeks, MDF showed features of DHG. We classified these into two forms of MDF: flat and protruded MDF. At 40 weeks, the number of flat MDF per colon decreased significantly compared with that at 20 weeks (p<0.05), however, the number of protruded MDF per colon increased (p<0.01), and the percentage of DHG in a protruded MDF lesion decreased but that of AC increased remarkably. In conclusion, MDF may develop into cancer through the so-called 'de novo cancer' pathway.