Tumor Embolism Through Right-to-Left Shunt Due to Venous Invasion of Esophageal Carcinoma.

A 69-year-old man was admitted to the hospital with right hemiparesis and global aphasia. Perfusion computed tomography imaging revealed ischemic penumbra in the middle cerebral artery territory. Angiography showed left middle cerebral artery occlusion. Mechanical thrombectomy with one pass was performed, and successful recanalization was obtained. Embolic material was retrieved; it contained tumor fragments with atypical keratinizing squamous cell carcinoma. Contrast computed tomography imaging indicated tumor invasion into the superior vena cava, and contrast transcranial Doppler indicated the presence of a right-to-left shunt after the Valsalva maneuver. We diagnosed the patient with acute ischemic stroke of large vessel occlusion due to venous invasion of esophageal carcinoma via a right-to-left shunt. To the best of our knowledge, this is the first case of embolic occlusion resulting from an extracardiac tumor via a right-to-left shunt. Contrast transcranial Doppler potentially detects right-to-left shunts in patients who cannot undergo transesophageal echocardiography.

Cholesterol Crystals in Embolic Debris are Associated with Postoperative Cerebral Embolism after Carotid Artery Stenting.

OBJECT: We investigated possible associations among the presence of cholesterol crystals in embolic debris, the proportions of debris components, and postoperative cerebral embolism in patients undergoing carotid artery stenting (CAS). METHODS: Sixty-seven consecutive procedures were performed for internal carotid artery stenosis with CAS at our hospital between November 2015 and February 2018. Procedures for emergency CAS for stroke in evolution or crescendo transient ischemic attack were excluded (n = 12). The embolic debris from remaining procedures (n = 55) was stained with hematoxylin-eosin and the red blood cells, white blood cells, and fibrin were quantified by color-based segmentation. Cholesterol crystals and calcification were examined histopathologically. Diffusion-weighted imaging (DWI) was performed 1-3 days after CAS, and the images were used to classify procedures according to the presence of new lesions. RESULTS: Of the 55 CAS procedures, new DWI lesions were identified after 32. One patient had symptomatic cerebral embolism. Higher proportions of patients with cholesterol crystals in embolic debris (17 vs. 78%, p < 0.001) and higher proportion of white blood cells (mean 2.3 [0-9.9] vs. 4.2% [0-29.9%], p < 0.01) were observed in the embolic debris of procedures with and without new DWI lesions. CONCLUSIONS: Cholesterol crystals were common in the embolic debris from patients with postoperative ischemic lesions after CAS. These results suggest that inflammatory destabilization of the intraplaque lipid component is related to postprocedural DWI lesions.

Randomized controlled study of the efficacy and safety of continuous saline bladder irrigation after transurethral resection for the treatment of non-muscle-invasive bladder cancer.

OBJECTIVE: To evaluate the efficacy and safety of continuous saline bladder irrigation (CSBI) after transurethral resection of bladder tumour (TURBT) in patients with low- to intermediate-risk non-muscle invasive bladder cancer (NMIBC). PATIENTS AND METHODS: In this prospective randomized study, 250 patients with primary low- to intermediate-risk tumours were enrolled. Patients were randomly allocated to receive CSBI (2 000 mL/h for the first 1 h, then 1 000 mL/h for 2 h, followed by 500 mL/h for 15 h) or a single immediate instillation of mitomycin C (MMC) after TURBT. The primary endpoint was recurrence-free survival, and secondary endpoints were progression-free survival and adverse events. RESULTS: A total of 227 patients (114 in the CSBI group and 113 in MMC group) remained for analysis after exclusion criteria had been applied. The median follow-up period was 37 months. No significant differences in patient characteristics were observed between the groups. The 5-year recurrence-free rates for CSBI and MMC were 62.6% (95% confidence interval [CI] 0.49-0.73) and 70.4% (95% CI 0.59-0.78), respectively. Kaplan-Meier analysis of recurrence-free survival did not show any significant differences between the groups (log-rank test P = 0.53). Furthermore, there were no significant differences between the groups in terms of tumour progression rate and the median time to first recurrence. The incidence of adverse events was significantly lower in the CSBI group. CONCLUSIONS: The results show that CSBI after TURBT may be a treatment option for patients with low- to intermediate-risk NMIBC in terms of its prophylactic effect and safety.

Plexiform schwannoma of the rectum.

Plexiform schwannoma is a benign peripheral nerve sheath tumor composed exclusively of Schwann cells arranged in a plexiform pattern. Most plexiform schwannomas are skin tumors and visceral localization is very rare. To our knowledge, there are six cases localized in visceral organs. We describe herein the first known case of plexiform schwannoma of the rectum resected by endoscopic submucosal dissection (ESD). A 77-year-old woman presented with a short history of anal pain. Sigmoidoscopy demonstrated a submucosal tumor, 20 mm in diameter, of the rectum below the peritoneal reflection (Rb). We resected the tumorby ESD. The tumor consisted of multiple white nodules in the submucosal layer. Microscopic examination revealed that the tumor was composed mainly of Antoni A tissue, compatible with conventional schwannoma. Immunohistochemically, the tumor was positive for S-100, and negative for α-smooth muscle actin, c-kit and CD-34. No evidence of recurrence has been found in 2 years of follow up.

Endoscopic Laryngopharyngeal Surgery Combined with Endoscopic Submucosal Dissection as a Treatment Option for Superficial Hypopharyngeal Cancer with Suspected Synchronous Lymph Node Metastasis.

We report 4 cases of hypopharyngeal cancer preoperatively suspected with synchronous lymph node metastases. Pathologic lymph node metastasis was confirmed in three of the four cases. All 4 cases underwent endoscopic laryngopharyngeal surgery (ELPS) combined with endoscopic submucosal dissection (ESD) and subsequent lymph node dissection as an optional treatment rather than the standard treatment. Peroral resection for primary site was selected because of the expected decline in quality of life (QoL) after radical surgery. Among 4 patients, one developed local recurrence; however, the other three remained recurrence-free and survived without any additional treatment. Furthermore, the patient who developed local recurrence had a recurrence-free survival for more than 5 years, with additional chemoradiation therapy. No disorders in speech, swallowing, or breathing was observed during the follow-up period. ELPS combined with ESD is generally indicated for laryngopharyngeal cancer without synchronous lymph node metastasis. However, this can be a treatment option for patients may wish to preserve a greater QoL after treatment. In the future, when more data on the results and long-term prognosis of this treatment are accumulated, it may be possible to discuss its validity further.

[A case of jejunal malignant melanoma diagnosed by enteroscopy and pre-operative biopsy].

We report a case of 72-year-old man found to have a primary malignant melanoma in the jejunum. The patient was noted to be anemic and had lower abdominal pain on his visit to the Department of Gastroenterology. However, an upper gastrointestinal series and colonofiberscopic examination revealed no abnormalities. After clinical examinations, the radiological workup, which included CT, X-ray of the small intestine and single-balloon enteroscopy, revealed an intraluminal polypoid tumor, with a patchy light gray and black pattern. Pre-operative biopsy specimens revealed a malignant melanoma. Segmental intestinal resection with regional lymph node dissection was performed. The tumor size was 7.0×9.5×5.8cm. Nodal metastasis was seen only in the mesenteric node draining from the tumor-bearing intestinal segment (stage IIIa). Adjuvant chemotherapy with dacarbazine, nimustine hydrochloride and vincristine sulfate was performed, and the patient was able to recover his level of activity of daily living for 6 months.

Impact of noninvasive down-staging after transurethral resection of bladder tumor plus systemic chemotherapy on bladder-sparing strategy in patients with muscle-invasive bladder cancer.

OBJECTIVE: To identify the optimal selection criteria for bladder sparing strategy with transurethral resection of bladder tumor (TURBT) and systemic chemotherapy in patients with muscle-invasive bladder cancer (MIBC). METHODS: We conducted a retrospective cohort study in 71 patients with MIBC (T2-4aN0M0) who desire to bladder preservation received neoadjuvant chemotherapy (NAC) after maximal TURBT, followed by clinical restaging and second-TURBT. Fifty-eight of 71 patients with no residual tumor on the second-TURBT were placed on conservative management for bladder sparing (BS). Noninvasive down-staging (NID) was defined as cT0/Ta/Tis/T1N0 at first-TURBT after NAC and no residual tumor on second-TURBT. Overall survival (OS) and cystectomy-free survival (CFS) were assessed according to the response of NAC in the BS group by using Kaplan-Meier methods. Cox proportional hazards regression model was used to identify independent variables predicting OS. RESULTS: At a median follow-up of 40 months 5-year OS and CFS in patients with NID and non-NID were 89.1% versus 20.8% and 84.8% versus 16.7%, respectively. Multivariate analysis showed that the ≥3 cycles of NAC (hazard ratio [HR] 0.14, 95% confidential index [CI] 0.03-0.7; P = 0.017) and achievement of NID (HR 0.11, 95% CI 0.03-0.46, P = 0.002) favorably associated with OS. CONCLUSIONS: Patients who achieved NID might be optimal candidates for the bladder sparing strategy with maximum TURBT plus NAC followed by second-TURBT.

Can Non-expert Physicians Use the Japan Narrow-band Imaging Expert Team Classification to Diagnose Colonic Polyps Effectively?

OBJECTIVES: In 2014, the Japan narrow-band imaging expert team (JNET) proposed the first unified colorectal narrow-band imaging magnifying classification system, the JNET classification. The clinical usefulness of this system has been well established in JNET member institutions, but its suitability for use by "non-expert physicians" (physicians with no expertise in the use of JNET classification) remains unclear. This study aimed to examine the clinical usefulness of the JNET classification by "non-expert physicians". METHODS: We retrospectively analyzed 852 consecutive patients who underwent screening colonoscopy following a positive fecal occult blood test between January 2017 and May 2018. Endoscopic results from colon polyp diagnosis by physicians who started using the JNET classification (JNET group) were compared with those of physicians who did not (control group). Mann-Whitney U test and Fisher's exact test were used to compare continuous and categorical variables, respectively. RESULTS: The median patient age was 68 years, and the male-to-female ratio was 1:0.84. When no lesions were found, the median withdrawal time was significantly different between groups (JNET group: 12 min; control group: 15 min; P < 0.01). The number of resected adenomas per colonoscopy was significantly higher in the JNET group (1.7) than in the control group (1.2; P < 0.01). Among the resected lesions, 8.9% in the JNET group and 17% in the control group were non-neoplastic lesions that did not require resection (P < 0.01). CONCLUSIONS: Colon polyp diagnosis using the JNET classification can reduce unnecessary resection during magnifying colonoscopy when conducted by "non-expert physicians".

[Pathology of Kawasaki disease].

Kawasaki disease (KD), an acute febrile disorder with systemic arteritis predominantly in the coronary arteries, is the leading cause of acquired heart disease in childhood. Since many KD patients have reached adulthood, the question arises whether post-KD arteritis lesions can become a risk factor for atherosclerosis of coronary arteries. We immunohistochemically investigated post-KD coronary arteries obtained from autopsied patients. All coronary arteries with KD revealed marked and diffuse intimal proliferation, and occasional sites revealed aneurysmal formation. Coronary arteries, with intervals more than 5 years after the onset, showed distinct atherosclerotic changes of intimal lesions associated with dedifferentiation of smooth muscle cells. These results strongly suggest that post-KD intimal lesions can become atherosclerotic plaques.

Erythrocyte-Rich Thrombus Is Associated with Reduced Number of Maneuvers and Procedure Time in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy.

BACKGROUND: Only few studies have investigated the relationship between the histopathology of retrieved thrombi and clinical outcomes. This study aimed to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion. METHODS: At our institution, 79 patients were treated by mechanical thrombectomy using a stent retriever and/or aspiration catheter between August 2015 and August 2016. The retrieved thrombi were quantitatively analyzed to quantify red blood cells, white blood cells, and fibrin by area. We divided the patients into two groups - a fibrin-rich group and an erythrocyte-rich group - based on the predominant composition in the thrombus. The groups were compared for imaging, clinical, and neurointerventional data. RESULTS: The retrieved thrombi from 43 patients with acute stroke from internal carotid artery, middle cerebral artery, or basilar artery occlusion were histologically analyzed. Erythrocyte-rich thrombi were present in 18 cases, while fibrin-rich thrombi were present in 25 cases. A cardioembolic etiology was significantly more prevalent among the patients with fibrin-rich thrombi than among those with erythrocyte-rich thrombi. Attenuation of thrombus density as shown on computed tomography images was greater in patients with erythrocyte-rich thrombi than in those with fibrin-rich thrombi. All other clinical and laboratory characteristics remained the same. Patients with erythrocyte-rich thrombi had a smaller number of recanalization maneuvers, shorter procedure times, a shorter time interval between arrival and recanalization, and a higher percentage of stent retrievers in the final recanalization procedure. The occluded vessels did not differ significantly. CONCLUSIONS: In this study, erythrocyte-rich thrombus was associated with noncardioembolic etiology, higher thrombus density, and reduced procedure time.

Early Gastric Cancer Just above a Heterotopic Pancreas.

We report the first case of early gastric cancer just above a heterotopic pancreas for which the differential diagnosis was carcinoma arising from heterotopic pancreas. Routine upper gastrointestinal endoscopy in an 83-year-old man with sigmoid colon cancer revealed a gastric cancer in the lesser curvature of the antrum. Endoscopic ultrasonography (EUS) for evaluating the depth of tumor invasion revealed a hypoechoic mass in the submucosal layer. The depth of tumor invasion was diagnosed as muscularis propria. Distal gastrectomy and sigmoidectomy were performed. Histologically, the resected specimen of the stomach unexpectedly revealed a heterotopic pancreas just below the gastric cancer. They were not linked, and the heterotopic pancreas had no dysplasia. The gastric cancer had slightly invaded the submucosa. The hypoechoic mass on EUS was not the invasive tumor but the heterotopic pancreas. The preoperative staging of the gastric cancer on EUS was confounded by the presence of the heterotopic pancreas just below the gastric cancer.

A Case of Burkitt's Lymphoma Involving Both Breasts.

Primary malignant lymphoma of the breast is rare, and Burkitt's lymphoma is especially rare. We report the case of a 44-year-old woman in whom Burkitt's lymphoma involving both breasts was diagnosed. The patient was referred to our hospital because of a diffuse, firm swelling, like a bulky ball, in both breasts. Fine-needle aspiration cytology (FNAC) of both breast masses revealed malignant lymphoma(ML), and diffuse large B-cell lymphoma was diagnosed based on the results of immunohistochemical studies of a core needle biopsy specimen. The gallium scan revealed very hot lesions in both breasts, but there was no evidence of disseminated disease. We instituted initial therapy, with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) plus intrathecal chemotherapy without performing a chromosome analysis, because the clinical course was very aggressive. A CR was achieved, but after eight cycles of CHOP therapy, the ML relapsed. We then resected the mass in the left breast, and when examination of the surgical specimen revealed relapse of ML and t (8;11) (q24;q32) translocation, Burkitt's lymphoma was diagnosed. High-dose chemotherapy followed by peripheral-blood stem cell transplantation was performed, but the patient died 10 months after her initial presentation at our hospital.

A case of "hidden" diabetic nephropathy diagnosed by a combination of renal biopsy findings and continuous glucose monitoring system.

Although diabetic nephropathy is a microvascular complication of diabetes mellitus, some reports suggest that renal biopsy often shows this pathological change without a diagnosis of diabetes mellitus. Here, we report a case of a 65-year-old man who presented with proteinuria, hypoalbuminemia and hypertension without a diagnosis of diabetes mellitus. He drank alcohol regularly and was a heavy smoker. Renal biopsy revealed a diffuse increase in the mesangial area, mesangial nodules or well-developed hyalinosis, interstitial fibrosis, and arteriosclerosis consistent with the changes of diabetic nephropathy. Although we had initially diagnosed him with idiopathic nodular glomerulosclerosis, use of a continuous glucose monitoring system (CGMS) revealed that the changes in his daily blood glucose concentrations met with the diagnostic criteria of diabetes mellitus. Accordingly, we diagnosed him with diabetic nephropathy and initiated treatment for diabetes mellitus. This case suggests that some cases of diabetic nephropathy may be hidden among patients with impaired glucose tolerance, who are not diagnosed with diabetes mellitus. Use of a CGMS may be helpful in diagnosing this type of "hidden" diabetes mellitus. In addition to diet therapy, smoking control, treatment for hypertension, and strict control of hyperglycemia may be important for these patients.

Ewing's sarcoma/primitive neuroectodermal tumor arising from the adrenal gland: a case report and literature review.

We report a rare case of Ewing's sarcoma (ES)/primitive neuroectodermal tumor (PNET) arising from the adrenal gland. A 17-year-old Japanese woman presented with left upper abdominal pain and high fever. Computed tomography and magnetic resonance imaging revealed a 15 × 10 cm tumor replacing the adrenal gland. Preoperative diagnosis was an adrenocortical carcinoma. Resection of the tumor was performed. We obtained the final diagnosis of ES/PNET by immunohistochemical molecular study with positive staining for the MIC2 gene product (CD99) and a Ewing sarcoma breakpoint region 1 (EWSR1) gene rearrangement. Local recurrence was observed one month after the surgery. The patient was then treated with systemic chemotherapy and localized radiotherapy.

Continuous saline bladder irrigation after transurethral resection is a prophylactic treatment choice for non-muscle invasive bladder tumor.

BACKGROUND: Instillation of chemotherapy after transurethral resection (TUR) has been considered as an optimal treatment for non-muscle invasive bladder cancer (NMIBC). However, controversy remains regarding the role of chemotherapy instillation. We therefore evaluated the usefulness of continuous saline bladder irrigation (CSBI) after TUR. PATIENTS AND METHODS: Patients with intermediate risk NMIBC were treated by TUR followed by either CSBI (123 patients) or intravesical instillation of mitomycin C (115 patients). Recurrence-free rates were estimated using the Kaplan-Meier method. RESULTS: No significant differences were observed in the recurrence-free rate, period to first recurrence, nor in frequency of recurrence between the CSBI and intravesical chemotherapy groups. Tumor progression rate and local toxicities were significantly higher in the intravesical chemotherapy group. CONCLUSION: CSBI after TUR appears to be a prophylactic treatment choice for intermediate risk NMIBC patients, in terms of its equal prophylactic effect to intravesical chemotherapy with mitomycin C, and its safety and cost benefits.

Further immunohistochemical study of crooke's hyaline change.

In a previous study, we immunohistochemically investigated Crooke's hyaline change and concluded that it was composed of cytokeratin. The present study was undertaken to further identify the cytokeratin subfamily by immunohistochemistry. Twenty-eight postmortem, routinely processed pituitary glands revealing unequivocal Crooke's hyaline change were selected. To demonstrate Crooke's cellsand cytokeratin subfamilies simultaneously, serial hori zontal sections were sliced. Using an avidin-biotin peroxidase complex method, one was stained with a monoclonal antibody against synthesized adrenocorticotropic hormone (ACTH) 1-24, and the adjacent ones were stained with one of eight test monoclonal antibodies against cytokeratin subfamilies (containing cytokeratins 1, 3, 7, 8, 13, 18, and 19, and one containing 1,5, 10, and 11, respectively). A different antibody for each type of cytokeratin was applied. Crooke's cells showed a variable intensity of cytoplasmic stainingfor antibodiesagainst cytokeratins 8 and 18 (molecular weight 52.5 and 45 kD, respectively), from focal to more even and intense staining, revealing a characteristic wide brown ring around the nucleus or under the plasmalemma. The most severely affected cells were totally replaced by dark brown reaction products with no secretory granules detectable in the cytoplasm. However, Crooke's cells did not react with other test anticytokeratin antibodies. Thus far, it can be concluded that Crooke's hyaline change was composed of low-molecular-weight cytokeratin subfamilies 8 and 18, which are found in pairs in normal ACTH cells.

Incidental adenomas of the human pituitary gland.

Using conventional histological technique, we investigated 44 adenomas (31 men, 13 women) incidentally found in 36 pituitaries (25 men, 11 women) obtained from 1,117 unselected autopsies. The overall incidence of adenomas was 3.2% (men, 3.8%; women, 2.4%) without any significant sex predominance. Size, age distribution, and histological appearances of these adenomas were similar to those previously reported by others. Statistical analysis showed that the adenomas had a predilection for occurrence at the anterior margin of the gland. We further investigated 33 available adenomas with immunohistochemistry using antibodies for various adenohypophyseal hormones, S-100 protein, and glial fibrillary acidic protein, of which 6 contained growth hormone, 3 contained growth hormone and prolactin, 7 contained prolactin, 6 contained follicle-stimulating hormone, 3 contained follicle-stimulating and luteinizing hormones, 2 contained thyroid-stimulating and adrenocorticotrophic hormones (separately), and 6 contained no adenohypophyseal hormones. None of adenomas revealed neoplastic proliferation of folliculostellate cells. To investigate tumor proliferation, nucleolar organizer regions were studied in 9 adenomas using the argyrophil method. The mean number per nucleus was slightly higher than that of corresponding, nontumorous adenohypophysis at a statistically significant level. No adenoma caused symptoms of adenohypophyseal hormone abnormalities.