Sarcoidosis with Pancreatic Mass, Endobronchial Nodules, and Miliary Opacities in the Lung

Sarcoidosis affects multiple organs and rarely has unusual manifestations. A 78-year-old woman was referred to our hospital for coughing symptoms. A chest computed tomography (CT) scan revealed bilateral diffuse miliary patterns and right pleural effusion. Bronchoscopy showed multiple nodules in the carina and the bronchus intermedius. A CT scan of her abdomen revealed hypovascular lesions involving the pancreatic head and body. A transbronchial lung biopsy, bronchial mucosal biopsy, and endoscopic ultrasound-guided fine-needle aspiration of the pancreatic mass demonstrated non-caseating granulomas. We diagnosed the patient with sarcoidosis. She received no treatment for sarcoidosis and has been followed up for one year, during which no pulmonary disease progression had been observed and the pancreatic masses partially regressed.

Residual cholesteatoma revealed by endoscopy after microsurgery

Residual cholesteatoma revealed by endoscopy after microsurgery.

OBJECTIVE

To endoscopically examine common sites of residual cholesteatoma occurrence after microscopic ear surgery.

METHODS

Thirty patients (15 men and 15 women; age range: 7-81 years) who underwent treatment for middle ear cholesteatoma (20 patients with pars flaccida :holesteatoma and 10 patients with pars tensa cholesteatoma) were selected. Following the removal of the cholesteatoma matrix via microscopy, residual matrix presence was assessed using an endoscope system. Additional resection was performed if the residual matrix was detected. Sites of residual matrix and their rates of incidence were then investigated.

RESULTS

Residual matrix was observed in nine out of the 30 (30%) patients by endoscopy after microscopic surgery. Residual matrix was observed in eight out of the 20 (40%) patients with pars flaccida cholesteatoma and in one out of :he 10 (10%) patients with pars tensa cholesteatoma. Residual matrix was observed in six out of the 14 (43%) patients who underwent canal wall up (CWU) tympanomastoidectomy and in three out of the 13 (23%) patients who underwent -anal wall down (CWD) tympanomastoidectomy. Sites of residual matrix included the tegmen tympani in two patients, he medial scutal surface in three patients, the tympanic sinus in two patients and the anterior epitympanic recess in three patients. The risk of residual matrix was greater in patients with pars flaccida cholesteatoma than in those with pars tensa :holesteatoma. The attic, tympanic sinus and anterior epitympanic recess are common sites of residual cholesteatoma.

CONCLUSION

Endoscopy is advantageous for the assessment of residual cholesteatoma in hidden areas.

Myxoid epithelioid gastrointestinal stromal tumor harboring an unreported PDGFRA mutation: report of a case and review of the literature

Activating mutations of platelet-derived growth factor receptor α (PDGFRA) are detected in a significant proportion of gastrointestinal stromal tumors (GISTs), in addition to the more frequent mutation in c-kit. GISTs with PDGFRA mutations have been found to have several characteristic morphological features, sometimes allowing to discriminate them from GISTs with c-kit mutations. Among these, epithelioid morphology in tumor cells and tumor-infiltrating mast cells are powerful predictors of PDGFRA mutations. Although myxoid stroma by itself is not so much a reliable predictor of PDGFRA mutation, myxoid stroma in conjunction with epithelioid morphology in tumor cells is a powerful predictor of mutations in this gene. GISTs showing either weak or negative immunoreactivity for c-kit and epithelioid cells with myxoid stroma are called myxoid epithelioid GISTs, which typically show PDGFRA mutation. Herein, we presented a case of a 59-year-old woman with myxoid epithelioid GIST of the stomach. A unique finding in this case was eosinophil infiltration, probably more numerous than mast cells; mast cell infiltration is known to be usually found in myxoid epithelioid GIST. The existence of a similar mechanism in eosinophil and mast cell recruitment via tumor-producing stem cell factor is speculated. Mutational analyses revealed a PDGFRA exon 18 mutation: D842_H845del, D846N. Combined deletion and substitution mutation has been reported in rare instances, but to the best of our knowledge, D846N has not been documented.

Intraductal papillary neoplasm of the bile duct, gastric type, arising in the intrapancreatic common bile duct could progress to colloid carcinoma: report of a case

Intraductal papillary neoplasm of the bile duct (IPNB) exists in a pathway of multistep-carcinogenesis toward cholangiocarcinoma. Four subtypes are observed in IPNB, pancreatobiliary type, intestinal type, gastric type, and oncocytic type, similarly to the corresponding disease in the pancreas, intraductal papillary mucinous neoplasm (IPMN). IPNB can present with or without macroscopically visible mucin secretion. IPNB usually progresses to tubular adenocarcinoma. However, there are a limited number of well-described cases of gastric-type IPNB progressing not to tubular adenocarcinoma but to colloid carcinoma. Herein, we present a case of an 82-year-old female patient with gastric-type IPNB in the intrapancreatic common bile duct without macroscopically visible mucin secretion, which progressed to colloid carcinoma. As IPNB, especially without visible mucin secretion, is considered to be a heterogeneous group of diseases, such an unexpected association could occur.

E-cadherin-negative acinar cell carcinoma of the pancreas: report of a case showing a solid pseudopapillary growth pattern

E-cadherin expression patterns in acinar cell carcinomas (ACCs) of the pancreas have not been well documented. Herein, we present a hitherto undescribed case of E-cadherin-negative ACC with a solid pseudopapillary growth pattern in a 65-year-old man. We used an antibody against the extracellular domain of E-cadherin. As a further unusual status in ACC, faint β-catenin expression was observed in the cytoplasm of carcinoma cells. Morphological distinction from a solid pseudopapillary neoplasm (SPN) of the pancreas might be problematic in such a case, because of their similarities concerned with the growth pattern and E-cadherin negativity. Without nuclear accumulation of β-catenin, a diagnosis of SPN was almost excluded. Immunoreactivity for trypsin and BCL10 made an accurate diagnosis of ACC to this case. The tumor recurred 10 months post-surgery as rapidly enlarging masses in the liver, presumably indicating the aggressiveness of the E-cadherin-negative phenotype among ACCs.

Xanthogranulomatous gastritis associated with actinomycosis: report of a case presenting as a large submucosal mass

Xanthogranulomatous gastritis (XGG) is a rarely encountered condition, and its causative mechanism is still unclear. Given that some types of xanthogranulomatous inflammation (XGI) are associated with pathogens, infection should be considered as a possible cause of XGG. Herein, we report a case of an 86-year-old woman presenting with a large, bleeding lesion resembling a submucosal tumor. Distal gastrectomy was performed, and the surgically resected specimen revealed a mass measuring 6 × 4.5 × 3 cm and appearing yellowish on the cut surface. Histopathological examination revealed a few Actinomyces "sulfur granules" and cellular composition characteristic of XGI, supporting a diagnosis of XGG associated with actinomycosis. Gastric actinomycosis is a rare condition and has not previously been reported in association with XGG, although rare cases of XGI associated with actinomycosis have been documented in other organs.

[Esophageal involvement in a case of eosinophilic gastroenteritis]

A 43-year-old woman presented with severe diarrhea and vomiting in addition to abdominal distension and dysphagia which had persisted for a month. Endoscopic biopsies revealed a significant eosinophilic infiltration in the mucosal layer of the esophagus, duodenum and ileum, yielding a diagnosis of eosinophilic gastroenteritis (EG) with esophageal involvement. The endoscopic examination of esophageal lesion in this case showed linear fissures and concentric rings, both of which are characteristic findings observed in eosinophilic esophagitis (EE). This suggests that these characteristic endoscopic findings in EE can also be applied to the results of endoscopic examinations for esophageal involvement in EG.

Long-term prognosis of patients after endoscopic sphincterotomy for choledocholithiasis

INTRODUCTION

The aims of the present study were to clarify the long-term prognosis of endoscopic sphincterotomy (EST) for choledocholithiasis and to evaluate the need for cholecystectomy after EST.

METHODS

Between 1993 and 2007, 262 patients who underwent successful EST for choledocholithiasis were followed up for more than 6 months). Eighteen patients had previously undergone cholecystectomy (Group A), 129 had a calculous gallbladder (GB) and underwent cholecystectomy after EST (Group B), 46 had a calculous GB in situ (Group C), and 69 had an acalculous GB in situ (Group D). Late complications, including recurrence of choledocholithiasis, acute cholecystitis and biliary carcinoma, were evaluated.

RESULTS

Of the 262 patients, late complications occurred in 34 patients (13.0%) and recurrence of choledocholithiasis occurred in 29 patients (11.1%). The rate of late complications was higher in Group C (23.9%) than in Group B (7.8%) (P < 0.001). The rate of recurrent choledocholithiasis was higher in Group C (17.4%) than in Group B (7.8%) (P < 0.05). Univariate analysis indicated that pneumobilia after EST was associated with the recurrence of choledocholithiasis (P < 0.001). Acute cholecystitis occurred in eight (7.0%) of 115 patients with intact GB. A gallbladder carcinoma was found after EST. Late complications were not serious and endoscopically or surgically manageable.

CONCLUSIONS

EST for choledocholithiasis is safe and effective. Cholecystectomy after EST is recommended in patients with calculous GB, but is not necessary in patients with acalculous GB. Pneumobilia was associated with the recurrence of choledocholithiasis.

[Case of pancreatic mucosa-associated lymphoid tissue (MALT) lymphoma]

A 77-year-old woman underwent abdominal ultrasonic diagnosis in a screening test for diabetes mellitus. A 65 x 45 mm tumor with low echo level was revealed and located from the uncinate process of the pancreas to the body. Contrast-enhanced computed tomography demonstrated the pancreas had a low density area in the arterial phase and a comparable area in the equilibrium phase, compared with the parenchyma of the normal pancreas. Gallium-scintigraphy showed strong accumulation, consistent with the tumor. Mucosa-associated lymphoid tissue (MALT) lymphoma was diagnosed by endosonography-guided fine-needle aspiration biopsy (EUS-FNAB). Complete remission was achieved after radiation therapy.

[Retroperitoneal fibrosis and Castleman disease in two patients with high IgG4 levels]

With the cumulative increase in the number of autoimmune pancreatitis cases, the disease is now widely accepted as a symptom of IgG4-related systemic disease. We recently experienced two cases of retroperitoneal fibrosis and Castleman disease presenting high IgG4 levels without evident pancreatic lesions. Both patients were successfully treated with steroid therapy. It is necessary to acknowledge that retroperitoneal fibrosis and Castleman disease, with or without pancreatic lesions, may have aspects of IgG4-related systemic disease and that the measurement of serum IgG4 and tissue immunostaining for IgG4 should be considered for diagnosing and treating the conditions.

[A case of Castlemans disease (plasma cell type) in which autoimmune pancreatitis developed 6 years later]

In 1998 a 74-year-old man, he had a medical checkup and mediastinal and hilar lymph node hyperplasia were discovered. Since the lymph nodes showed a tendency to increase in size, mediastinal lymph node biopsy was performed in the following year. Castlemans disease was diagnosed, and he was followed up. In 2005, autoimmune pancreatitis (AIP) developed. At this time, the mediastinal lymph node that had been biopsied was stained with anti-IgG4 antibody. Further examinations on pancreatic lesions associated with Castlemans disease and AIP are necessary in relation to IgG4-related systemic diseases.

[A case of colonic obstruction due to post-operative stenosis of the colon and multiple enteroliths]

An 81-year-old man who had under gone two abdominal surgeries and temporary colostomy 30 years previously was admitted due to lower abdominal pain and vomiting. An abdominal X-ray film and abdominal CT scan showed intestinal distension and multiple calcareous deposits in the colon. Gastrografin enema examination revealed smooth stenosis at the sigmoid colon and many additional defects. Endoscopy could not be performed due to the stenosis. He did not agree to surgery. Seven months later, he was admitted again, due to colonic obstruction. Surgery was performed which revealed colonic obstruction as the source of post-operative stenosis of the sigmoid colon and multiple enteroliths. The stones consisted of a core and a hull and contained ammonium magnesium phosphate.

[Superior mesenteric arterial thrombosis complicating ulcerative colitis: A case report]

36-year-old men with ulcerative colitis was attacked by the colic. The thrombus in superior mesenteric artery was revealed by computed tomography. Because the effect of the thrombolysis under intrarterial angiography was insufficient, thrombectomy was enforced under the laparotomy in the same day. The arterial thrombosis is extremely rare in the complication of ulcerative colitis. The activity of ulcerative colitis as one of factors of the appearance of thrombus was suggested.

Functional organisation of anterior thoracic stretch receptors in the deep-sea isopod Bathynomus doederleini: behavioural, morphological and physiological studies

The relationship between segmental mobility and the organisation of thoracic stretch receptors was examined in the deep-sea isopod Bathynomus doederleini, which shows a developed adaptive behaviour during digging. The movements of segments during digging were analysed from video recordings, which showed that a large excursion occurred in the anterior thoracic segments. Dye-fills of axons revealed four types of thoracic stretch receptor (TSR): an N-cell type (TSR-1), a differentiated N-cell type (TSR-2), a muscle receptor organ (MRO)-type with a long, single receptor muscle (TSR-3) and an MRO-type with a short, single receptor muscle (TSR-4 to TSR-7). Physiologically, TSR-1 and TSR-2 are tonic-type stretch receptors. TSR-3 to TSR-7 show two kinds of stretch-activated responses, a tonic response and a phasico-tonic response in which responses are maintained as long as the stretch stimulus is delivered. Both TSR-2, with a long muscle strand, and TSR-3, with a single, long receptor muscle, have a wide dynamic range in their stretch-activated response. In addition, TSR-2 is controlled by an intersegmental inhibitory reflex from TSR-3. These results suggest that, although TSR-1 has no receptor muscle and TSR-2 has a less-differentiated receptor-like muscle, they are fully functional position detectors of segmental movements, as are the MRO-type receptors TSR-3 to TSR-7.

Effect of eicosapentaenoic acid (EPA) on tight junction permeability in intestinal monolayer cells

The purpose of this study is to evaluate the effect of C18 and C20 long chain fatty acids on tight junction permeability in a model of intestinal epithelium.

METHODS

Confluent Caco-2 cells on porous filters with double chamber system were used to measure fluorescein sulfonic acid (FS) permeability and transepithelial electrical resistance (TEER). Lactate dehydrogenase release and ultrastructure were evaluated. Effect of 200 microM eicosapentaenoic acid (EPA, C20:5 n-3), arachidonic acid (AA, C20: 4 n-6), alpha-linoleic acid (ALA, C18: 3 n-3), linoleic acid (LA, C18: 2 n-6), or oleic acid (OA, C18: 1 n-9) enrichment in the culture medium during 24 hours were compared. The effect of the cyclooxygenase inhibitor, indomethacin, lipoxygenase inhibitors, NDGA or AA861, and antioxidant, BHT, was evaluated as a mechanism to change tight junction permeability.

RESULTS

Caco-2 cells formed polarized columnar epithelial cells with densely packed microvilli and well developed junctional complexes. Addition of EPA enhanced FS permeability to 3.0+/-1.6-fold and lowered TEER to 0.59+/-1.2-fold vs. control with concentration dependency without cell injury (P<0.01-0.05). OA, AA or LA did not change, but ALA enhanced tight junction permeability. Indomethacin and AA861 normalized the changes mediated by EPA.

CONCLUSIONS

EPA affects tight junction permeability in intestinal monolayer cells specifically and concentration dependently via cyclooxygenase and lipoxygenase products.

[Changes in neuropsychological functions following cardiovascular surgery]

This study was designed to elucidate if there is a potential hazard of developing neuropsychological deterioration after major cardiovascular surgery. Neuropsychological functions were studied in 49 patients before and after cardiac (coronary artery bypass, cardiac valve replacement, etc.) and thoracic aortic surgery (aortic aneurysm). Neuropsychological examinations using 5 batteries (Mini-Mental State Examination, Cross Cultural Cognitive Examination, Miyake's Verbal Memory Test, Benton Visual Retention Test and Wisconsin Card Sorting Test) were performed before surgery and subsequently at 3 weeks and 8 months after. Twenty-five of 49 patients (51%) showed a significant deterioration at least in one of the test batteries. There was no significant relation between age or educational levels and post-surgical impairment of cognitive function. The impairment of cognitive function was found mainly in the "memory function". Follow up examinations were carried out on 31 of the 49 patients 8 months after surgery. Among these patients, 13 patients did not show any changes in cognitive function throughout the study period. Eleven of the 16 patients who developed a decrease in cognitive function for a certain period after surgery (3 weeks), recovered to the same level at the follow-up examination that it was prior to the surgery. Cognitive function in five patients did not improve and remained at the decreased level. The other two patients whose function was normal at the first post-surgical examination, were found to have developed impairment of cognitive function at the follow up. Although the patients had some deficits on their neuropsychological function, they scarcely complained about any problems in their daily life.(ABSTRACT TRUNCATED AT 250 WORDS)

Automatic determination of hydroperoxides of phosphatidylcholine and phosphatidylethanolamine in human plasma

An automatic method for the determination of hydroperoxides of phosphatidylcholine (PC) and phosphatidylethanolamine (PE) is reported. Sample plasma was deproteinized with a fourfold volume of methanol. After centrifugation, the supernatant was injected directly into an HPLC system without further treatment. The hydroperoxides of PC and PE were concentrated and washed on an ODS column followed by introduction into two analytical columns, a silica gel and an aminopropylsilica gel column, which were connected in series, by column switching. After the separation, they were detected by postcolumn detection with diphenyl-1-pyrenylphosphine. The compounds were determined at picomole levels within 30 min with good reproducibilities. By using only a silica gel column as an analytical column, PC hydroperoxides were determined within 20 min, and samples could be injected into it at 15-min intervals. Those methods made it possible to inject a sample of up to 2 ml at one time and up to 8 ml by repeated injections and to determine phospholipid hydroperoxides in human plasma at picomole levels.

[A case report of leiomyosarcoma of the rectum]

A case of leiomyosarcoma of the rectum and a review of the relevant Japanese literature is reported. A 33-year-old man, suspected of having a rectal tumor was admitted to out hospital for though examination. The tumor was located at the anterior wall of the rectum behind the prostatic gland. A preoperative perineal biopsy was done and the pathological diameters was a leiomyosarcoma. The abdominoperineal resection was performed but the nerve was able to be preserved. The postoperative quality of life has been good. The difficulties in arriving at a histological differentiation of a simple tumors of the rectum from a malignant smooth muscle tumor of the rectum is discussed.