Idiopathic dilatation of the submandibular gland duct

Lithiasis and stenosis may cause salivary duct dilatation due to the increased pressure in the duct upstream of the obstruction. Idiopathic dilatations, also called megaducts, with no associated increase in pressure, have only been described in the parotid gland. The aim of this study was to describe the characteristics of submandibular duct dilatation unrelated to lithiasis, stenosis, or an imperforate duct, to report the existence of submandibular megaducts. This retrospective single-centre study included patients treated at La Conception University Hospital, Marseille, France, between 2007 and 2019. Patients with submandibular duct dilatation of ≥4 mm confirmed by magnetic resonance imaging sialography (sialo-MRI), who also underwent sialendoscopy to identify any associated stenosis, were included. Patients with lithiasis, stenosis, an imperforate ostium, or a history of trauma or surgery to the floor of the mouth were excluded. Five patients (three female, two male) aged 30-76 years with idiopathic duct dilatations in nine submandibular glands were included. The most commonly reported symptoms were submandibular swelling, pruritus, and discomfort, mostly outside mealtimes. Recurrence of symptoms after treatment was frequent. This study is novel in describing submandibular megaducts as opposed to dilatation caused by high pressure associated with stenosis, with confirmation by sialo-MRI and sialendoscopy.

Transoral removal of submandibular hilar lithiasis: results on the salivary duct system, glandular parenchyma, and quality-of-life recovery

OBJECTIVE(S)

To confirm that hilar transoral submandibular sialolitectomy (TOSL) is the first treatment option for submandibular hilar lithiasis (SHL) in terms of glandular parenchyma recovery, salivary system restoration, and patient quality of life (QoL) improvement.

METHODS

Depending on whether the stone was easily palpable, TOSL was carried out with or without sialendoscopy. For the first time in the literature, Magnetic Resonance Sialography (MR-Si) was performed before and after TOSL, to evaluate stone characteristics, glandular parenchyma status, hilum dilation and main duct recanalization. Radiological data was examined independently by two radiologists. COSQ, a recently validated and specific questionnaire, was used to assess associated QoL.

RESULTS

Between 2017 and 2022, 29 TOSL patients were examined. With a high interobserver correlation, MR-Si was confirmed as a very useful radiological test in the pre- and post-surgical evaluation of SHL. The salivary main duct was completely recanalized in all cases. The presence of lithiasis was found in 4 patients (13.8%). After surgery, the majority of patients (79.31%) had hilum dilation. There was a statistically significant improvement in parenchyma status, but no significant progression to glandular atrophy. After surgery, COSQ mean values always improved (22.5 to 4.5).

CONCLUSIONS

TOSL is the ideal surgical technique for the management of SHL, resulting in improved parenchymal inflammatory changes, recanalization of Wharton's duct, and enhancement patients' QoL. As a result, before removing the submandibular gland, TOSL should be considered as the first treatment option for SHL.

Percutaneous transhepatic cholangioscopy for benign and malignant biliary disease using a novel short single-operator cholangioscope

BACKGROUND

The length of conventional single-use cholangioscopes poses a challenge for percutaneous or laparoscopic approaches for direct visualization of the biliary tract. The aim of this retrospective observational clinical study was to assess the use of a dedicated percutaneous short single-operator cholangioscope (PSSOC) for diagnosis and treatment of benign or malignant biliary diseases.

METHODS

Retrospective analysis of a prospectively maintained database including all consecutive patients undergoing percutaneous transhepatic cholangioscopy with the PSSOC between 06/2021 and 01/2023.

RESULTS

Forty patients were included (22F/18 M, age 58.7 ± 16.7 years). The diagnostic and therapeutic management plan was based on procedural findings. Indications were bile duct obstruction associated with complex anatomy (n = 13), choledocholithiasis (n = 11), suspected malignant stenosis of the biliary tract (n = 11), biliary stent placement (n = 2) and removal (n = 1), and failed endoscopic retrograde cholangiopancreatography (n = 2). The cholangioscopies were diagnostic (n = 5), therapeutic (n = 20) or both simultaneously (n = 15). The most frequent procedures were electrohydraulic lithotripsy (n = 25) and biopsy sampling (n = 12). Complications occurred in 7 cases (17.5%), including cholangitis (n = 4, B2), pleural perforation (n = 1, B2), portal bleeding (n = 1, B3), and Tako-Tsubo syndrome (n = 1, B3), classified according to the Society of Interventional Radiology classification. Intraprocedural visual diagnosis was confirmed by the histopathologic result in 11/12 patients in which biopsies were performed (91.7%). PSSOC was relevant to avoid surgery in 2 patients (5%) with indeterminate strictures, allowing to rule out malignancy and treat the lithiasis.

CONCLUSIONS

Direct visualization of the biliary tract enabled targeted biopsies for histopathological diagnosis. The visual and histopathological diagnoses were concordant in all but one case. Percutaneous cholangioscopy with a dedicated PSSOC allows to optimize identification and treatment of complex biliary disease including biliary lithiasis while assessing bile duct patency. The clinical use of the novel PSSOC system was safe and effective and could prevent surgical exploration in select patients.

A novel prognostic model for diagnosing atypical bile duct hyperplasia in patients with intrahepatic lithiasis

There is no specific method for the preoperative diagnosis of atypical bile duct hyperplasia, which is a precursor of cholangiocarcinoma. This study aimed to create a new model for diagnosing atypical bile duct hyperplasia based on routine laboratory tests in patients with intrahepatic lithiasis.The new diagnostic model was developed with a derivation cohort that included 375 patients with intrahepatic lithiasis. Clinical and pathological data were retrospectively collected. Prognostic factors were evaluated with univariate and logistic regression analyses. The validation cohort included 136 patients who were retrospectively screened to quantify the model's predictive value.Age and Carbohydrate Antigen 19-9 (CA-199) were revealed to be diagnostic indicators of atypical bile duct hyperplasia in patients with intrahepatic lithiasis. The new diagnostic model was created with the formula: -6.612 + (0.002 × CA-199) + (0.072 × Age). The area under the receiver operating curve of the model was 0.721. With 0.25 as the cutoff point, the sensitivity and specificity of this model in the derivation cohort were 13.9% and 95.9%, respectively. In the validation cohort, these values were 28.5% and 88.7%, respectively. The novel model has an acceptable and stable ability to predict atypical hyperplasia in the intrahepatic bile duct.This novel model provides a simple system for diagnosing atypical bile duct hyperplasia before surgery in patients with intrahepatic lithiasis.

Biliary tract exploration through a common bile duct incision or left hepatic duct stump in laparoscopic left hemihepatectomy for left side hepatolithiasis: which is better?: A single-center retrospective case-control study

Laparoscopic left hemihepatectomy (LLH) followed by biliary tract exploration is used to treat left-sided hepatolithiasis (LSH). The purpose of this study was to compare the efficacy of 2 methods of biliary tract exploration in LLH:biliary tract exploration through a common bile duct (CBD) incision (with T-tube drainage) or through the left hepatic duct (LHD) stump (without T-tube drainage).LSH patients (113 patients) were recruited retrospectively in our hospital from December 2008 to January 2016. To compare different methods of biliary tract exploration during LLH, the patients were divided into 2 groups: 41 patients underwent biliary tract exploration through the LHD stump (LHD group), and 72 patients underwent biliary tract exploration through a CBD incision (CBD group). Baseline characteristics, surgical outcomes, surgery-related complications, postoperative hospital stay (PHS) and long-term results were compared between the 2 groups.There was no unplanned reoperation in the 2 groups. One patient in the CBD group had a residual stone, which was removed by choledochoscopy 2 months postoperation. Two patients in the LHD group and 3 patients in the CBD group had bile leakage and were cured with abdominal drainage. There were no significant differences in the total operation time, incidence of residual stones and bile leakage between the 2 groups (P > .05). The PHS and the incidence of hypokalemia or hyponatremia in the LHD group were significantly lower than those in the CBD group (P < .05). T-tube-related complications occurred in 13.9% (10/72) of the CBD patients. The mean follow-up period was 37.2 ± 13.8 months. There were no significant differences in the incidence of recurrence stones or cholangitis (P > .05) between the 2 groups.Exploration of the biliary tract through the LHD stump without T-tube drainage is safe with satisfactory short- and long-term results for selected LSH patients.

Morphological and crystal chemical characteristic of panсreatic lithiasis

OBJECTIVE

Introduction: Information on chemical and phase composition of pancreoliths is limited and discrepant. There are reports, that pancreoliths are composed by calcium, phosphate, calcium carbonate or combination of calcium with fatty acids The aim of the work is studying of structural characteristics of pancreatoliths in 5 clinical cases.

PATIENTS AND METHODS

Materials and methods: Morphological and crystal-chemical study of five cases of pathological biomineralization in the pancreas were conducted in the work.

RESULTS

Results: Two stones were located in the pancreatic duct, in other cases - in the ductal system of pancreas. Concretion sizes ranged from 0.5 to 1.5 cm in diameter. Pancreatic lithiasis' form depended on the location: in the duct of Wirsung single concretions were found (they were relatively large, oval stones with smooth, regular edges); multiple, small concretions with irregular edges, coral-like stones dominated in the ductal system of pancreas. Histological study of pancreas showed the signs of chronic pancreatitis, tissue fibrosis, atrophy and edema of glandular component, system distension of ducts, nidal mix-cell inflammatory infiltrates, vessels' plethora. Structural phase and chemical analysis of pathological biominerals responded calcite in all studied cases.

CONCLUSION

Conclusion: The presence of pancreatic lithiasis was found to be accompanied by significant morphological changes of the pancreas. The pancreatolith crystal phase was established to be calcium carbonate in the form of calcite.

Spontaneous inversion of nystagmus without a positional change in the horizontal canal variant of benign paroxysmal positional vertigo

OBJECTIVE

We investigated the neuro-otological findings, including nystagmus, and the clinical course of patients with the horizontal canal variant of benign paroxysmal positional vertigo (HC-BPPV), who showed spontaneous inversion of nystagmus without a positional change. Furthermore, we speculated on the possible mechanism of spontaneous inversion of nystagmus without a positional change.

PATIENTS AND METHODS

The characteristics of spontaneous inversion of positional nystagmus without a positional change were analyzed in 7 patients with HC-BPPV.

RESULTS

All patients were diagnosed as having HC-BPPV. During the positional test, the spontaneous inversion of nystagmus was observed in the same head position in all patients. Spontaneous inversion was observed on both sides in 5 patients, and only on 1 side in 2 patients. All patients presented with geotropic nystagmus in the first phase, and ageotropic nystagmus in the second phase.

CONCLUSIONS

The coexistence of cupulolithiasis and canalolithiasis appears to be a possible mechanism of the spontaneous inversion of positional nystagmus.

Effects of PDE5 Inhibitors and sGC Stimulators in a Rat Model of Artificial Ureteral Calculosis

Urinary colics from calculosis are frequent and intense forms of pain whose current pharmacological treatment remains unsatisfactory. New and more effective drugs are needed to control symptoms and improve stone expulsion. Recent evidence suggested that the Nitric Oxide (NO) / cyclic guanosine monophosphate (cGMP) / phosphodiesterase type 5 (PDE5) system may contribute to ureteral motility influencing stone expulsion. We investigated if PDE5 inhibitors and sGC stimulators influence ureteral contractility, pain behaviour and stone expulsion in a rat model of ureteral calculosis. We investigated: a)the sex-specific PDE5 distribution in the rat ureter; b)the functional in vitro effects of vardenafil and sildenafil (PDE5 inhibitors) and BAY41-2272 (sGC stimulator) on induced ureteral contractility in rats and c)the in vivo effectiveness of vardenafil and BAY41-2272, alone and combined with ketoprofen, vs hyoscine-N-butylbromide alone or combined with ketoprofen, on behavioural pain indicators and stone expulsion in rats with artificial calculosis in one ureter. PDE5 was abundantly expressed in male and female rats’ ureter. In vitro, both vardenafil and BAY41-2272 significantly relaxed pre-contracted ureteral strips. In vivo, all compounds significantly reduced number and global duration of “ureteral crises” and post-stone lumbar muscle hyperalgesia in calculosis rats. The highest level of reduction of the pain behaviour was observed with BAY41-2272 among all spasmolytics administered alone, and with the combination of ketoprofen with BAY41-2272. The percentage of stone expulsion was maximal in the ketoprofen+BAY41-2272 group. The NO/cGMP/PDE5 pathway is involved in the regulation of ureteral contractility and pain behaviour in urinary calculosis. PDE5 inhibitors and sGC stimulators could become a potent new option for treatment of urinary colic pain.

[Enterolith ileus complicating jejunal diverticulosis]

Jejunal diverticulosis is uncommon and usually asymptomatic. One of the rarest complications is ileus due to migrated enteroliths formed in the diverticula. We present a case of a 95-year-old man admitted with small bowel obstruction. During operation extensive jejunal diverticulosis was found along with intraluminal enteroliths causing obstruction of the ileum. An enterotomy was made and three 3 × 3 × 2 cm enteroliths were removed. The patient was discharged on the sixth post-operative day. Less than 50 similar cases have been reported worldwide.

Preliminary study of a new pathological evolution-based clinical hepatolithiasis classification

AIM: To investigate clinical features, treatment strategies and outcomes of patients with hepatolithiasis (HL) undergoing surgical treatment, using a new clinical classification.

METHODS: Sixty-eight HL patients were hospitalized and treated surgically from August 2011 to December 2012 and they were classified into four HL types according to pathological evolution of the disease. These four HL types included type I primary type (defined as no previous biliary tract surgery), type II inflammatory type (with previous biliary tract surgery and cholangitis), type III mass-forming type (HL complicated by hepatic mass-forming lesion), and type IV terminal type (with secondary biliary cirrhosis and resultant portal hypertension). The perioperative data including general information, imaging data, postoperative complications, and immediate and final stone clearance rate were obtained and analyzed.

RESULTS: In all 68 patients, the proportion of HL type I-IV was 50% (34/68), 36.8% (25/68), 10.3% (7/68) and 2.8% (2/68), respectively. Abdominal pain was the main clinical manifestation in type I (88.2%), fever was predominant in type II (52.0%), the malignancy rate in type III was high (71.4%), and portal hypertension and spleen enlargement were common in type IV (2/2, 100.0%). Liver resection rate for types I-III was 79.4%, 72.0% and 71.4%, respectively. The overall incidence of postoperative complications was 23.5% (16/68). There were no perioperative deaths. The average length of hospital stay was 12.7 ± 7.3 d. Immediate and final stone clearance rate was 73.5% (50/68) and 89.7% (61/68), respectively. Fifty-nine of 68 patients (86.8%) were followed- up for > 1 year after surgery, and 96.6% of these patients (57/59) had a good quality of life according to a criterion recommended for postoperative evaluation of quality of life.

CONCLUSION: The pathological evolution-based clinical classification of HL has a role in optimizing treatment strategy, and patients can benefit from this classification when it is used properly.

Broncholithiasis Assessed by Bronchoscopic Saline Solution Injection

A 68-year-old man was admitted with hemoptysis. Bronchoscopy showed bronchial obstruction at the right B(3)bii proximal to the broncholith. The distal end of the bronchoscope was placed in a wedge position at the right B(3)bii. After repeated injection of saline solution through the working channel of the bronchoscope, we observed that the broncholith was freed from the bronchial wall. The broncholith was easily removed with forceps through the working channel of the bronchoscope. Bronchoscopic saline solution injection was safe and effective in confirming the mobility of the broncholith as bronchoscopy alone could not detect the broncholiths due to bronchial occlusion.

Hippuric acid as a significant regulator of supersaturation in calcium oxalate lithiasis: the physiological evidence

At present, the clinical significance of existing physicochemical and biological evidence and especially the results we have obtained from our previous in vitro experiments have been analyzed, and we have come to the conclusion that hippuric acid (C6H5CONHCH2COOH) is a very active solvent of Calcium Oxalate (CaOX) in physiological solutions. Two types of experiments have been discussed: clinical laboratory analysis on the urine excretion of hippuric acid (HA) in patients with CaOX lithiasis and detailed measurements of the kinetics of the dissolution of CaOX calculi in artificial urine, containing various concentrations of HA. It turns out that the most probable value of the HA concentration in the control group is approximately ten times higher than the corresponding value in the group of the stone-formers. Our in vitro analytical measurements demonstrate even a possibility to dissolve CaOX stones in human urine, in which increased concentration of HA have been established. A conclusion can be that drowning out HA is a significant regulator of CaOX supersaturation and thus a regulation of CaOX stone formation in human urine. Discussions have arisen to use increased concentration of HA in urine both as a solubilizator of CaOX stones in the urinary tract and on the purpose of a prolonged metaphylactic treatment.

Characterization and management of testicular pathology in McCune-Albright syndrome

CONTEXT

The testicular phenotype in McCune-Albright syndrome (MAS) has not been well characterized. Boys present with a relatively low incidence of precocious puberty in comparison with girls. Radiographic and histological studies are limited to small series and case reports, which report testicular microlithiasis and Sertoli cell hyperplasia.

OBJECTIVE

Our objective was to characterize the biochemical, radiological, and histological spectrum and clinical management of testicular pathology in males with MAS.

PATIENTS, DESIGN, AND SETTING

Fifty-four males with MAS participated in this prospective cohort study at a clinical research center.

INTERVENTION

Evaluation included testicular exam, pubertal staging, testicular ultrasound, measurement of LH, FSH, and testosterone. Orchiectomies were performed when considered clinically indicated.

MAIN OUTCOME MEASURE

Prevalence and characterization of ultrasound lesions with correlation to histology were evaluated.

RESULTS

Of 54 males, 44 (81%) presented with ultrasound abnormalities including hyperechoic lesions (49%), hypoechoic lesions (30%), microlithiasis (30%), heterogeneity (47%), and focal calcifications (11%). Eight subjects underwent orchiectomy revealing large foci of Leydig cell hyperplasia, which could not be definitively distinguished from Leydig cell tumor. After no subjects developed clinical malignancy, a conservative approach was instituted, and subsequent subjects were followed with serial imaging. Testosterone and gonadotropins were normal in subjects without precocious puberty or pituitary disease. Eleven (21%) presented with precocious puberty, and a combination of aromatase inhibitors, androgen receptor blockers, and leuprolide resulted in improved predicted adult height. In addition, the first cases of testicular adrenal rest and bilateral germ cell tumors in association with MAS are presented.

CONCLUSIONS

Contrary to prevailing thinking, the incidence of gonadal pathology in MAS is equal in males and females. The predominant histopathological finding was Leydig cell hyperplasia, which carries a low risk of malignant transformation and can be managed conservatively.

A case of pulmonary alveolar microlithiasis

Pulmonary alveolar microlithiasis (PAM) is a rare disease with unknown etiology and pathogenesis. It is characterized by diffuse, innumerable, and minute calculi, called microlithiasis in the alveoli. More than half of reported cases are asymptomatic at the time of diagnosis. We describe the first case of PAM in Korea. A 19-yr-old man without respiratory symptoms presented with interstitial thickening on the chest radiograph. His chest high resolution CT scan showed diffusely scattered, ill defined tiny micronodules and interstitial thickening. Open lung biopsy confirmed the diagnosis of PAM. He was followed up for 6 months without treatment, and no progression was noticed.

Testicular microlithiasis and neoplastic lesions in wild eland (Tragelaphus oryx): possible effects of exposure to environmental pollutants?

The purpose of the study was to compare wildlife in the proximity and away from the sources of known industrial pollution. Macroscopic, focal, gritty areas that appeared white were observed in the testes of all 24 South African eland (Tragelaphus oryx) culled in the Rietvlei Nature Reserve (RNR; n=17) between 2001 and 2003 and Suikerbosrand Nature Reserve (SNR; n=7) in 2004. Histopathological evaluation of testes showed multiple intratubular dystrophic calcifications, focal areas of sperm stasis and interstitial chronic cell infiltrates with fibrosis. Spermatogenesis was generally impaired; a few atypical germ cells were also encountered. Sertoli cell vacuolization and sloughing of the seminiferous epithelium were evident. Adenomatous changes of the rete testis, reflective of possible chronic estrogenic exposure, were found. In testes collected from three reference eland in 2007 from the Molopo Nature Reserve (MNR) in the Kalahari/Kgalagadi Desert, except for one focal area of sperm stasis and another with microcalcification, the seminiferous epithelium as well as collecting/rete tubules were normal. Analyses of fat tissue for environmental pollutants showed that 11 out of 17 RNR eland contained a detectable estrogenic chemical p-nonylphenol (mean+/-SD: 184.8+/-24.6 microg/kg fat); no organochlorine chemicals or polychlorinated biphenyls were detected. Of the 7 SNR eland, 5 had detectable octylphenol residues (50.2+/-30.9 microg/kg fat), 3 had detectable p-nonylphenol (137.8+/-77.9 microg/kg fat), 3 had o-p'-DDT (114.9+/-31.1 microg/kg fat), 3 had p-p'-DDT (127.3+/-49.9 microg/kg(79.5+/-30.4 microg/kg fat) and 5 contained o-p'-DDE (27.7+/-9.9 microg/kg fat). One eland from the MNR contained one 70.6 microg o-p'-DDT/kg fat and another p-p'-DDE 61.3 microg/kg fat. Therefore, in eland with testicular abnormalities, significant amounts of various estrogenic chemicals were bioaccumulated in fat samples. It therefore seems likely that the lesions found in RNR and SNR were associated with the relatively high body-burden of environmental pollutants (phenols), although the possibility of systemic infections cannot be ruled out. No testicular abnormalities were found in reference eland. These findings are the first indication of mammalian wildlife being affected by environmental pollution of endocrine disrupting chemicals in South Africa.

Surgical procedures for hepatolithiasis

BACKGROUND/AIMS

The aim of this study is to explore the surgical treatment for hepatolithiasis.

METHODOLOGY

Data of 1431 consecutive patients who underwent surgical treatment from January 2000 to December 2006 in West China Hospital were collected retrospectively and analyzed. Surgical procedures included T-tube insertion combined intraoperative cholangioscopic removal of intrahepatic stones, hepatectomy, cholangiojejunostomy and liver transplantation.

RESULTS

1384 patients were performed T-tube insertion combined intraoperative and postoperative cholangioscopic removal of intrahepatic stones and the rate of residual stone was 11.5%. 370 patients were performed hepatectomy and the rate of residual stone was 2.7%. 23 patients were performed cholangiojejunostomy and the rate of residual stone was 26.1%. 15 patients of hepatolithiasis were performed liver transplantation, and they had survived from liver transplantation.

CONCLUSIONS

T-tube insertion combined intraoperative cholangioscopic removal of intrahepatic stones and cholangioscopic lithotripsy should be considered for patients of hepatolithiasis above all. Hepatic resection is optimal for patients with liver atrophy, liver abscess and biliary stricture. However, liver transplantation is a possible method for end-stage hepatolithiasis.

Rhinolithiasis: the importance of flat panel detector-based cone beam computed tomography in diagnosis and treatment

Rhinolithiasis is a disease caused by deposition of organic and inorganic compounds in the nasal cavity. A nidus may be endogenous or exogenous. Rhinoliths are uncommon and often an asymptomatic condition diagnosed accidentally during a routine examination; but sometimes they may cause complications such as unilateral nasal obstruction, fetid rhinorrhea, or epistaxis. This article describes a case of rhinolith involving a 21-year-old female. The flat panel detector-based cone beam computed tomography (FPD-CBCT) findings, differential diagnosis, and treatment in a case of rhinolith are presented.

Practical value of applying cdc2 kinase shRNA to chronic proliferative cholangitis in treatment of hepatolithiasis

BACKGROUND/AIMS

High stone recurrence and biliary restenosis rates in hepatolithiasis patients have been confirmed to be closely related to postoperatively-remnant chronic proliferative cholangitis (CPC), but effective management strategies have not yet been developed. Since CPC is a type of hyperplastic disease, this study was designed to investigate inhibitory effectiveness of cdc2 k ShRNA on hyperplastic behavior and lithogenic potentiality of CPC.

METHODOLOGY

0.5 ml of P-cdc2 shRNA was injected transpapillarily into the bile duct lumen in a rat model of cholangitis. Then, the effects of cdc2 k ShRNA on CPC were evaluated by histology, immunohistochemistry, RT-PCR, Western blot, biochemistry and enzymatic histochemistry for cdc2 k, PCNA, Ki-67, Procollagen III, Mucin 5AC, beta-glucuronidase and hydroxyproline.

RESULTS

cdc2 k shRNA-3 treatment could efficiently inhibit hyperplasia of biliary epithelium, submucosal gland, and collagen fiber by inhibiting mRNA and protein expressions of the proliferation-related gene, cdc2 k, PCNA and Ki-67, thus holding the promise to control or reverse CPC and its secondary biliary stricture. Also of note, this novel treatment may decrease the lithogenic potential of CPC via inhibition of endogenous beta-glucuronidase and Mucin 5AC expression, hereby facilitating the prevention of stone recurrence.

CONCLUSION

cdc2 k shRNA-3 treatment could effectively inhibit the hyperplastic behavior and lithogenic potentiality of CPC, which might help to prevent the biliary restenosis and stone recurrence.

Occurrence of testicular microlithiasis in androgen insensitive hypogonadal mice

BACKGROUND

Testicular microliths are calcifications found within the seminiferous tubules. In humans, testicular microlithiasis (TM) has an unknown etiology but may be significantly associated with testicular germ cell tumors. Factors inducing microlith development may also, therefore, act as susceptibility factors for malignant testicular conditions. Studies to identify the mechanisms of microlith development have been hampered by the lack of suitable animal models for TM.

METHODS

This was an observational study of the testicular phenotype of different mouse models. The mouse models were: cryptorchid mice, mice lacking androgen receptors (ARs) on the Sertoli cells (SCARKO), mice with a ubiquitous loss of androgen ARs (ARKO), hypogonadal (hpg) mice which lack circulating gonadotrophins, and hpg mice crossed with SCARKO (hpg.SCARKO) and ARKO (hpg.ARKO) mice.

RESULTS

Microscopic TM was seen in 94% of hpg.ARKO mice (n=16) and the mean number of microliths per testis was 81+/-54. Occasional small microliths were seen in 36% (n=11) of hpg testes (mean 2+/-0.5 per testis) and 30% (n=10) of hpg.SCARKO testes (mean 8+/-6 per testis). No microliths were seen in cryptorchid, ARKO or SCARKO mice. There was no significant effect of FSH or androgen on TM in hpg.ARKO mice.

CONCLUSION

We have identified a mouse model of TM and show that lack of endocrine stimulation is a cause of TM. Importantly, this model will provide a means with which to identify the mechanisms of TM development and the underlying changes in protein and gene expression.

Testicular microlithiasisOne case and four points to note

A 38-year-old man with non-specific scrotal complaints was found to have bilateral testicular microlithiasis (TM) sonographically. MRI of the testes failed to depict microlithiasis. Bilateral double biopsies of the testes revealed testicular intraepithelial neoplasia (TIN; carcinoma in situ of the testis) in only one of the two biopsies from the right testis. At the request of the patient the biopsies were repeated, with the same histological result. A right-sided orchiectomy was performed. Histology disclosed TIN in only some tubules of the lower pole of the testis. This case highlights four interesting points: (i) TM may be associated with testicular malignancy; (ii) MRI does not depict TM; (iii) TIN is arranged focally within the testis; and (iv) a two-site biopsy may increase the sensitivity of the diagnosis of TIN.

YOLK SAC TUMOR AND TESTICULAR MICROLITHIASIS

Yolk sac tumor (YST) of prepubertal testis is a peculiar neoplasm with overall good prognosis. There are no known conditions associated with the development of this tumor. The case of a 2-year-old boy with testicular YST and presence of testicular microlithiasis (TM) in the adjacent-still-recognizable testicular tissue is reported. Concentrically laminated microliths were clearly extratubular structures. Ultrasound of the remaining testis revealed microlithiasis. Bilateral TM is being recognized with increasing frequency due to the extensive use of ultrasound. The exact meaning of its finding has not been definitively elucidated, but the association of TM with cryptorchidism, intratubular germ cell neoplasia and germ cell tumors either of the testis or mediastinum is on record. The combination of prepubertal YST and bilateral TM has not been reported previously. Finding of TM at this early age suggests a congenital deranged Sertoli cell function and/or an abnormal gonadal embryogenesis in its pathogenesis.

[Pulmonary alveolar microlithiasis: report of four cases]

INTRODUCTION

Pulmonary alveolar microlithiasis is a rare disease characterised by the formation and deposition of calcium phosphate microliths in the lung. It is an autosomal recessive disorder, for which mutation in the SLC34A2 gene was recently found to be responsible for the disease.

OBSERVATIONS

We report on four cases of pulmonary alveolar microlithiasis. Three patients were asymptomatic. The diagnosis was made after histological confirmation in three patients. The outcome was marked by the death of one patient.

CONCLUSION

Pulmonary alveolar microlithiasis is a rare disease. Diagnosis is made with high-resolution computed tomography, which exhibits the calcic character and distribution of the lesions, thus avoiding the need to perform lung biopsy. We suggest that a literature review be performed.

[General review of rhinolithiases]

OBJECTIVE

The aim of this study was to analyze the clinical presentation and characteristics of rhinolithiasis, a rare and forgotten entity.

METHODS

Between 1990 and 2007, 20 cases of rhinolithiasis presented for consultation. The clinical course noted chronic nasal discharge associated with nasal obstruction. The protocol was the same for all patients: history of disease, meticulous endonasal endoscopy and plain radiography (+/-CT scan).

RESULTS

Rhinolithiasis was found in adults (55%), females, patients living in rural areas (66%) with unfavorable socioeconomic conditions. The diagnosis delay varied between six months and eight years. The examination showed the rhinolith in the form of a grey concretion, primarily unilateral and on the right-hand side in 60% of the patients. Only one bilateral case presented following destruction of the posterior nasal septum. The rhinolith measured between 5 and 50mm in diameter with only three associated foreign bodies (15%). The rhinolith was extracted through the natural pathways under local anesthesia in 60% of the cases. Complications were rare (epistaxis 10%) and favorable progression without recurrence was generally observed after a mean 16 months of follow-up (range, six months to 11 years).

CONCLUSION

Chronic nasal discharge without a history of rhinologic disease requires an endonasal examination under good conditions after retraction. Rhinolithiasis is easily recognized, in particular on imaging studies. Treatment is simple and curative in the majority of cases.

Unusual non-neoplastic lesions of the lung

Many nonneoplastic conditions that may affect the lung are in reality rare or unusual manifestations of metabolic processes, inflammatory conditions, or unknown etiology. Because of their rarity, they can often be confused with malignant neoplasms. Familiarity with these conditions not only will expedite further treatment for these patients but also will avoid the process of more tests or unnecessary surgical procedures. The nomenclature for some of those conditions is still controversial. The clinical outcome of these conditions can be quite variable, with some patients surviving a long number of years and others eventually succumbing to the disease. We will limit our discussion in this review to four of these conditions, including inflammatory pseudotumor (inflammatory myofibroblastic tumor), placental transmogrification of lung, alveolar microlithiasis, and metastatic calcification. Although these lesions are not part of the gamut of neoplastic conditions affecting the lung, they are nonetheless important to recognize, as their outcome may not necessarily be an innocuous one.

Treatment of anterior semi-circular canalithiasis by a sedimentation procedure in a vertical rotatory chair

OBJECTIVES

To describe the video-nystagmographic characteristics, treatment, and results of a specific canalith repositioning procedure (CRP) on patients with canalolithiasis of the anterior semicircular canal (ASC).

MATERIAL AND METHODS

This was a retrospective study conducted from January 2005 to March 2006 on 16 patients treated for a benign paroxysmal positional vertigo (BPPV) of the ASC. Each patient after analysis and diagnosis using two-dimensional video-nystagmography (2DVNG) was treated with a specific CRP in a specific vertical rotatory chair with control of pulse and blood pressure. The effect of this procedure was determined after 1 week with video-nystagmoscopic (VNS) positional control. A 2DVNG bithermic caloric test, an impulse rotatory test, and a vibratory test were performed. Patients were contacted in May 2006 to measure the long-term effect of the CRP results.

RESULTS

In this retrospective study of 16 anterior BPPVs (a BPPV), the sex ratio, the average age, and the symptoms were comparable to those in patients with posterior BPPV (p BPPV). The sedimentation CRP proved to be effective, with all patients cured after 8 days, even though the length of illness before treatment was 11.68 weeks on average. At the time of the study, 13 patients were already cured, 8.07 months on average after the CRP. Three patients relapsed (one in an anterior form, two in a posterior form).

CONCLUSIONS

ASC BPPV is rare, possibly because the DIX HALLPIKE (DH) test does not sufficiently provoke the condition. The hyperextension with the head in the 45-degree upper position, especially in a rotatory chair, is probably more effective. It seems that the prolonged sedimentation in this position is the key to the treatment.

FDG-PET/CT finding of high uptake in pulmonary alveolar microlithiasis

Pulmonary alveolar microlithiasis (PAM) is a rare lung disease characterized by progressive intra-alveolar calcification. We present a case of PAM with abnormal accumulation of 18F-fluorodeoxyglucose (FDG) in both lungs. A 55-year-old man was referred to our hospital for progressive dyspnea. He had been diagnosed with PAM 25 years earlier by transbronchial lung biopsy. High-resolution computed tomography revealed multiple dense calcifications with little aerated lung. Combined positron emission tomography and computed tomography using 18F-FDG (FDG-PET/CT) showed the abnormal accumulation of FDG in both lungs with a maximal standardized uptake value of 7.3. High FDG uptake was observed mainly in the lung regions showing sparing calcification. The patient died of respiratory failure a month later and an autopsy revealed no significant inflammatory changes in either lung. We suspect that the markedly enhanced pulmonary FDG uptake may have some relation to the pathophysiology of PAM.

Broncholithiasis in a cat: clinical findings, long-term evolution and histopathological features

A 14-year-old neutered male Persian cat was evaluated because of an acute exacerbation of a chronic cough of 2-3 years of duration. Physical examination was normal except for the auscultation of accentuated breath sounds and wheezes cranially on both sides of the chest. Complete blood count, biochemical parameters and urinalysis were normal. Thoracic radiographs showed a generalised nodular pattern with multiple mineral opacities. Oral prednisone and doxycycline were prescribed. Two weeks later, the frequency of the cough was significantly reduced. Terbutaline was recommended for relief of acute exacerbations. Three years later the cat was evaluated again due to a non-related disease that led to the euthanasia of the cat. Concerning its respiratory disease, the cat had experienced nearly asymptomatic periods of 3-6 weeks of duration punctuated by acute exacerbation periods of 7-10 days, during which terbutaline was useful to relieve the cough. Thoracic radiographs showed a mild increase in the size and extent of the pulmonary mineralisation. Histopathologically, mild bronchitis and bronchiectasis were evident, accompanied by calcified bronchial plugs and marked hyperplasia and hypertrophy of the seromucinous glands. Based on clinical and pathoanatomical findings, a final diagnosis of miliary broncholithiasis and bronchiectasis was made. Broncholithiasis should be considered in differential diagnosis of pulmonary mineralisation in cats. When no concomitant diseases are present, this rare disease appears to have a slowly progressive evolution that does not appear to carry a bad prognosis and may be satisfactorily managed with combinations of bronchodilators and corticosteroids.

The Canalith Repositioning Procedure with and without Mastoid Oscillation for the Treatment of Benign Paroxysmal Positional Vertigo

OBJECTIVE

To evaluate the efficacy of mastoid oscillation performed with a canalith repositioning procedure (CRP) for the treatment of benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

A total of 137 patients with posterior canal BPPV were treated with an Epley CRP with or without mastoid oscillation at a tertiary care, university-based balance center. Data were collected prospectively from all patients via a preprinted diary which they maintained for 14 days after the maneuver. Patients underwent office evaluation at 2 weeks after the maneuver.

RESULTS

A total of 137 patients were divided equally between the treatment groups. At 48 h post-treatment, 61% (with vibration) and 64% (without vibration) of patients were free of vertigo. At 2 weeks' post-treatment, 74% (with vibration) and 85% (without vibration) were vertigo-free. Residual symptoms of lightheadedness/imbalance were experienced by 32% of patients with vibration and 40% of patients without vibration. None of these differences between groups were statistically significant.

CONCLUSION

The addition of mastoid oscillation to the positioning maneuver does not add any therapeutic benefit.

Granulomatous, hepatolithiasis and hepatomegaly caused by Capillaria hepatica infection: first case report of Thailand

This is the first case report in Thailand of a Capillaria hepatica infection causing a granulomatous hepatic lesion, bile duct dilatation, hepatolithiasis and hepatomegaly. The patient's chief complaint was abdominal pain with fever and chills. Imaging of the liver revealed a 3-cm mass in the postero-inferior sub-segment of the right lobe of the liver with bile duct dilatation. Right hepatectomy and cholecystectomy were performed. Gross pathology of the right hepatectomy revealed focal intrahepatic duct dilatation with prominent periductal fibrosis. The histopathological section revealed chronic inflammation and some granuloma formation surrounding the bile ducts, generalized portal infiltration, prominence of eosinophils and hepatolithiasis. Histopathotogical section revealed oblique sections of C. hepatica egg (size 35.4+/-6.38 microm in width) and brown amorphous pigment.

Association between testicular microlithiasis and primary malignancy of the testis: our experience and review of the literature

PURPOSE

The aims of this study were to evaluate the association of testicular microlithiasis with testicular neoplasm, to assess the accuracy of ultrasonography (US) in comparison with histology in detecting microlithiasis, and to identify the prevalent cytohistological features that accompany testicular cancer.

MATERIALS AND METHODS

Between 2004 and 2005, 14 patients were referred to us for US examination, 13 of whom underwent surgery for testicular cancer. Their age ranged from 19 to 43 years, except for one patient aged 60. US findings and histological examination were compared to assess the accuracy of US in detecting microlithiasis associated with testicular cancer.

RESULTS

In two patients (15.3%), microlithiasis had been detected in a previous US examination, and two patients (15.3%) had altered sperm function. At US examination, testicular cancer was associated with microlithiasis in seven out of 13 patients (53.8%) (the distribution pattern of microlithiasis was intranodular in two, perinodular in two and both intra-and perinodular in three), and colour-Doppler US showed perinodular and intranodular vascularity. Histological evaluation identified nine seminomas, two mixed germ-cell tumours, one embryonal carcinoma, one yolk-sac tumour and one benign Sertoli-cell tumour. In nine (69.2%) patients, microlithiasis was confirmed at histologic evaluation, and its distribution was intranodular in two, perinodular in five and both intra-and perinodular in two. Tubular hyalinisation was demonstrated in 12 out of 13 patients (92.3%).

CONCLUSIONS

Testicular microlithiasis and poor sperm function represent risk factors for testicular cancer: in our study, 30.6% of the patients who developed cancer presented these features. At US examination, testicular microlithiasis is often associated with testicular cancer (53.8%). A high accuracy has been demonstrated for US in detecting microlithiasis (53.8%) compared with histological evaluation (69.2%). At histology, tubular hyalinisation (92.3% of cases) is, with testicular microlithiasis, the most frequent finding in the parenchyma adjacent to testicular cancer.

Biliary intraepithelial neoplasia: an international interobserver agreement study and proposal for diagnostic criteria

Cholangiocarcinoma of the intrahepatic and extrahepatic bile ducts develops through a multistep histopathologic sequence. Premalignant or non-invasive neoplastic lesions of bile ducts have been historically called biliary dysplasia or atypical biliary epithelium. To this date, no standard terminology or classification system has been offered for these lesions. In 2005, a conceptual framework and diagnostic criteria for biliary intraepithelial neoplasia (BilIN) were proposed using the livers of patients with hepatolithiasis. We report herein an international interobserver agreement study on the diagnosis of biliary non-invasive neoplastic lesions with the goal to obtain a consensus on the terminology and grading. Seventeen pathologists from the United States, Europe and Asia participated in this study. They shared a digital file containing histological pictures of 30 foci of non-invasive neoplastic lesions selected from the biliary system of patients suffering from primary sclerosing cholangitis, choledochal cyst or hepatolithiasis. In the criteria, we proposed in 2005, BilIN was classified into three categories based on the degree of atypia: BilIN-1, BilIN-2 and BilIN-3. In this study, consensus was reached for the terminology of BilIN and the three-grade classification system. Interobserver agreement on the diagnosis was moderate (kappa-value=0.45). On the basis of the suggestions and opinions obtained from the 17 participants, the original criteria for BilIN were revised. We now propose a new consensus classification of BilIN that may assist in allowing a more uniform terminology for the diagnosis of biliary non-invasive neoplastic lesions. This classification should help to advance clinical and research applications.

Broncholith caused by donor-acquired histoplasmosis in a lung transplant recipient

A broncholith is a calcified lymph node that erodes into and partially or completely obstructs the bronchial lumen. The natural history of broncholiths is poorly understood. They are frequently encountered in residents of areas that are endemic for Histoplasma capsulatum and Mycobacterium tuberculum. We report the first case of a broncholith in which the fungus Histoplasma capsulatum was transferred from a donor to a lung transplant (LTx) recipient. Our report highlights the time course of broncholith development and its successful management. We suspect that broncholithiasis and transmission of Histoplasma capsulatum from a donor to the recipient are under-reported in the LTx literature. We hypothesize that histoplasmosis can be transmitted from the donor to the recipient and the duration in the formation of calcification of the lymph node or the broncholith can be anywhere from 2 to 10 months.

Anterior Canal Benign Paroxysmal Positional Vertigo

OBJECTIVE

Evaluate the frequency and characteristics of benign paroxysmal positional vertigo (BPPV) arising from involvement of the anterior semicircular canal (AC) as compared with the posterior canal (PC) and horizontal canal (HC).

STUDY DESIGN

Prospective review of patients with BPPV.

SETTING

Tertiary referral center.

PATIENTS

A total of 260 patients who were evaluated for vertigo were identified as experiencing BPPV.

INTERVENTIONS

Standard vestibular assessment including the use of electrooculography (EOG) or video-oculography (VOG) was completed on all patients. Based on EOG/VOG findings, the BPPV origin was attributed to AC, PC, or HC involvement secondary to canalithiasis versus cupulolithiasis. Treatment was performed with canalith repositioning maneuvers (CRMs) appropriate for type of canal involvement.

RESULTS

For the 260 patients, the positionally induced nystagmus patterns suggested the canal of origin to be AC in 21.2%, PC in 66.9%, and HC in 11.9%. Cupulolithiasis was observed in 27.3% of the AC, 6.3% of the PC, and 41.9% of the HC patients. Head trauma was confirmed in the history preceding the onset of vertigo in 36.4% of the AC, versus 9.2% of the PC and 9.7% of the HC patients (p < 0.001). The number of CRMs completed to treat the BPPV did not differ between canals involved (1.32 for AC, 1.49 for PC, and 1.34 for HC).

CONCLUSION

The direction of subtle vertical-beating nystagmus underlying the torsional component is critical in differentiating AC versus PC origin; EOG/VOG aids in accurate assessment of the vertical component for the diagnosis of canal involvement. AC involvement may be more prevalent than previously appreciated, particularly if the examiner does not appreciate the vertical component of the nystagmus or the diagnosis is made without the assistance of EOG/VOG. Head trauma history is significantly more frequent in AC versus other forms of BPPV, and patients with a history of head trauma should be examined closely for AC involvement. CRM is as successful for treatment of AC BPPV as for other types of BPPV.

Familial pulmonary alveolar microlithiasis diagnosed by bronchoalveolar lavage. A case report

BACKGROUND

Familial alveolar microlithiasis is a rare lung disease. In this study we describe the cytologic features of this disease in bronchoalveolar lavage.

CASE

A 10-year-old girl and her uncle, a 50-year-old man, had dyspnea and diffuse interstitial pattern on chest radiograph with no defined cause at a period of 10 years apart. Open lung biopsy in the girl and transbronchial lung biopsy plus bronchoalveolar lavage (BAL) in the man were per-formed to determine the diagnosis. In cyopen lung biopsy the diagnosis was alveolar microlithiasis. BAL revealed rehtypical microliths (calcospherites), and th transbronchial lung biopsy performed in the same patient failed to disclose superficially reset any significant pathology. In cytologic a smears, extracellular and intracellular concentrically layered purple-brown, round-to-oval microliths were clearly seen. Cyanophilic periodic acid-Schiff positive intracytoplasmic amorphous material was also frequently seen in alveolar macrophages.

CONCLUSION

Familial alveolar microlithiasis is a rare interstitial lung disease that can be easily diagnosed by BAL. This procedure is a very useful tool in diagnosing and classifying some interstitial lung diseases.

Mutations in the SLC34A2 gene are associated with pulmonary alveolar microlithiasis

RATIONALE

Pulmonary alveolar microlithiasis is an autosomal recessive disorder in which microliths are formed in the alveolar space.

OBJECTIVES

To identify the responsible gene that causes pulmonary alveolar microlithiasis.

METHODS

By means of a genomewide single-nucleotide polymorphism analysis using DNA from three patients, we have narrowed the region in which the candidate gene is located. From this region, we have identified a gene that has mutations in all patients with pulmonary alveolar microlithiasis.

MEASUREMENTS AND MAIN RESULTS

We identified a candidate gene, SLC34A2, that encodes a type IIb sodium phosphate cotransporter and that is mutated in six of six patients investigated. SLC34A2 is specifically expressed in type II alveolar cells, and the mutations abolished the normal gene function.

CONCLUSION

Mutations in the SLC34A2 gene that abolish normal gene function cause pulmonary alveolar microlithiasis.

Elevated serum surfactant protein A and D in pulmonary alveolar microlithiasis

Pulmonary alveolar microlithiasis (PAM) is a rare disease characterized by widespread localization of calcispherites in the alveolar spaces. The authors report two cases of PAM, with markedly elevated sera concentrations of surfactant protein-A and surfactant protein-D, which showed a tendency to increase as the disease progressed. Therefore, surfactant protein-A and surfactant protein-D may function as serum markers to monitor the disease activity and progression of PAM.

A case of pulmonary alveolar microlithiasis with cardiac constriction secondary to severe adjacent pleural involvement

Pulmonary alveolar microlithiasis (PAM) is a rare disorder of uncertain etiology and pathogenesis that is characterized by tiny calcium phosphate depositions in lung alveoli. Ectopic organ involvement has been reported infrequently. We hereby present a patient with PAM complicated by severe pleural calcification that has caused a constrictive cardiac physiology, a heretofore unknown occurrence/association. Based on our observations in this particular case, we suggest that a non-invasive echocardiographic examination may be well worth in the investigation of PAM patients in whom symptom onset at an early age has occurred, particularly if severe pleural calcification adjacent to the heart is present.

Pulmonary alveolar microlithiasis and pregnancy

The following is the case of a 36-year old pregnant woman reaching term, suffering from advanced pulmonary alveolar microlithiasis. To our knowledge, this is the first record of such a case.

Bilateral tonsillolithiasis: a case report

Although tonsilloliths are reported to be fairly common, florid cases casting distinct radiopaque shadows on panoramic radiographs are not often reported. This report illustrates such a case as an incidental finding in an asymptomatic 38-year-old female dental patient. Panoramic radiography revealed distinct radiopaque shadows over the ascending rami of the mandible bilaterally. These radiopacities were localized to the palatine tonsils by computerized tomographic inspection. Tonsillectomy was performed and tonsillolithiasis was confirmed by histopathologic examination.