Squamous Cell Carcinoma Arising from Aparaurethral Region

A 69-year-old man was referred to our hospital with dysuria and gross hematuria associated with a rapidly growing perineal mass. Serum squamous cell carcinoma (SCC) antigen level was high (2.4 ng/mL). Magnetic resonance imaging examination revealed a tumor posterior and inferior to the pendular urethra with a cystic lesion inside. Tumor resection together with total penectomy was performed. Pathohistological findings revealed well-differentiated SCC arising from the paraurethral region. The patient remained free of disease without adjuvant therapy at 70 months after surgery. To our knowledge, this is the second reported case of paraurethral SCC.

Pink-color sign in esophageal squamous neoplasia, and speculation regarding the underlying mechanism

AIM:To investigate the reasons for the occurrence of the pink-color sign of iodine-unstained lesions. METHODS:In chromoendoscopy, the pink-color sign of iodine-unstained lesions is recognized as useful for the diagnosis of esophageal squamous cell carcinoma. Patients with superficial esophageal neoplasms treated by endoscopic resection were included in the study. Areas of mucosa with and without the pink-color sign were evaluated histologically. The following histologic features that were possibly associated with the pinkcolor sign were evaluated. The keratinous layer and basal cell layer were classified as present or absent. Cellular atypia was classified as high grade, moderate grade or low grade, based on nuclear irregularity, mitotic figures, loss of polarity, chromatin pattern and nuclear/cytoplasmic ratio. Vascular change was assessed based on dilatation, tortuosity, caliber change and variability in shape. Vessels with these four findings were classified as positive for vascular change. Endoscopic images of the lesions were captured immediately after iodine staining, 2-3 min after iodine staining and after complete fading of iodine staining. Quantitative analysis of color changes after iodine staining was also performed. RESULTS:A total of 61 superficial esophageal neoplasms in 54 patients were included in the study. The lesions were located in the cervical esophagus in one case, the upper thoracic esophagus in 10 cases, the mid-thoracic esophagus in 33 cases, and the lower thoracic esophagus in 17 cases. The median diameter of the lesions was 20 mm (range:2-74 mm). Of the 61 lesions, 28 were classified as pink-color sign positive and 33 as pink-color sign negative. The histologic diagnosis was high-grade intraepithelial neoplasia (HGIN) or cancer invading into the lamina propria in 26 of the 28 pink-color sign positive lesions. There was a significant association between pink-color sign positive epithelium and HGIN or invasive cancer (P = 0.0001). Univariate analyses found that absence of the keratinous layer and cellular atypia were significantly associated with the pink-color sign. After Bonferroni correction, there were no significant associations between the pink-color sign and presence of the basal membrane or vascular change. Multivariate analyses found that only absence of the keratinous layer was independently associated with the pink-color sign (OR = 58.8, 95%CI:5.5-632).Quantitative analysis was performed on 10 superficial esophageal neoplasms with both pink-color sign positive and negative areas in 10 patients. Pink-color sign positive mucosa had a lower mean color value in the late phase (pinkish color) than in the early phase (yellowish color), and had similar mean color values in the late and final phases. These findings suggest that pinkcolor positive mucosa underwent color fading from the color of the iodine (yellow) to the color of the mucosa (pink) within 2-3 min after iodine staining. Pink-color sign negative mucosa had similar mean color values in the late and early phases (yellowish color), and had a lower mean color value in the final phase (pinkish color) than in the late phase. These findings suggest that pink-color sign negative mucosa did not undergo color fading during the 2-3 min after iodine staining, and underwent color fading only after spraying of sodium thiosulfate. CONCLUSION:The pink-color sign was associated with absence of the keratinous layer. This sign may be caused by early fading of iodine staining.

Clinical relevance of aberrant polypoid nodule scar after endoscopic submucosal dissection

AIM To describe a series of patients with aberrant polypoid nodule scar developed after gastric endoscopic submucosal dissection(ESD), and to discuss its pathogenesis and clinical management. METHODS We reviewed retrospectively the endoscopic database of two academic institutions located in Brazil and Japan and searched for all patients that underwent ESD to manage gastric neoplasms from 2003 to 2015. The criteria for admission in the study were:(1) successful en bloc ESD procedure with R0 and curative resection confirmed histologically;(2) postoperative endoscopic examination with identification of a polypoid nodule scar(PNS) at ESD scar;(3) biopsies of the PNS with hyperplastic or regenerative tissue, reviewed by two independent experienced gastrointestinal pathologists, one from each Institution. Data were examined for patient demographics, Helicobacter pylori status, precise neoplastic lesion location in the stomach, tumor size, histopathological assessment of the ESD specimen, and postoperative information including medical management, endoscopic and histological findings, and clinical outcome.RESULTS A total of 14 patients(10 men/4 women) fulfilled the inclusion criteria and were enrolled in this study. One center contributed with 8 cases out of 60 patients(13.3%) from 2008 to 2015. The second center contributed with 6 cases(1.7%) out of 343 patients from 2003 to 2015. Postoperative endoscopic follow-up revealed similar findings in all patients: A protruded polypoid appearing nodule situated in the center of the ESD scar surrounded by convergence of folds. Biopsies samples were taken from PNS, and histological assessment revealed in all cases regenerative and hyperplastic tissue, without recurrent tumor or dysplasia. Primary neoplastic lesions were located in the antrum in 13 patients and in the angle in one patient. PNS did not develop in any patient after ESD undertaken for tumors located in the corpus, fundus or cardia. All patients have been followed systematically on an annual basis and no malignant recurrence in the ESD scar has been identified(mean follow-up period: 45 mo).CONCLUSION PNS may occur after ESD for antral lesions and endoscopically look concerning, especially for the patient or the family doctor. However, as long as curative R0 resection was successfully achieved and histology demonstrates only regenerative and hyperplastic tissue, PNS should be viewed as a benign alteration that does not require any type of intervention, other than endoscopic surveillance.

Single-incision laparoscopic cecectomy for low-grade appendiceal mucinous neoplasm after laparoscopic rectectomy

In this case report,we discuss single-incision laparoscopic cecectomy for low-grade appendiceal neoplasm after laparoscopic anterior resection for rectal cancer.The optimal surgical therapy for low-grade appendiceal neoplasm is controversial;currently,the options include appendectomy,cecectomy,right hemicolectomy,and open or laparoscopic surgery.Due to the risk of pseudomyxoma peritonei,complete resection without rupture is necessary.We have encountered 5 cases of lowgrade appendiceal neoplasm and all 5 patients had no lymph node metastasis.We chose the appendectomy or cecectomy without lymph node dissection if preoperative imaging studies did not suspect malignancy.In the present case,we performed cecectomy without lymph node dissection by single-incision laparoscopic surgery(SILS),which is reported to be a reduced port surgery associated with decreased invasiveness and patient stress compared with conventional laparoscopic surgery.We are confident that SILS is a feasible alternative to traditional surgical procedures for borderline tumors,such as low-grade appendiceal neoplasms.

Hepatoma-derived growth factor expression as a prognostic marker in cervical cancer

AIM： To examine the association of hepatoma-derived growth factor （HDGF） expression with the prognosis of patients with cervical cancer of the uterus （CC）. METHODS： HDGF is a unique nuclear growth factor, and it may play an important role in the development and progression of carcinoma. HDGF expression in 88 CC patients aged 23 to 76 years （median, 54 years） was analyzed by immunohistochemistry. A rabbit polyclonal antibody against the C-terminal amino acids （aa 231-240） of the human HDGF sequence was used as primary antibody at a dilution of 1：5000. This specific anti-HDGF antibody was purified using C-terminal peptide-conjugated Sepharose columns. Staining of endothelial cells in the noncancerous areas of each specimen was used as an internal positive control. Samples with more than 80% of tumor cells showing positive immunoreactivity in both the nucleus and cytoplasm were regarded as HDGF index level 2,more than 80% positive immunoreactivity in either the nucleus or cytoplasm as level 1, and less than 80% in both the nucleus and cytoplasm as level 0. The chi-square test and Fisher’s exact probability test were used to examine the relationship between HDGF expression and clinicopathologic parameters, and statistical significance was examined by the log-rank test. Multivariate analysis of factors related to survival was performed using Cox’s proportional hazards regression model. Statistical signifcance was set at P 〈 0.05. RESULTS： The five-year overall survival rate was 82.9%. Fourteen patients died due to tumors, nine of whom had tumor recurrence at 2-21 mo （median, 10 mo） after surgery. Tumor recurrence in five patients was determined at the time of the patients’ deaths. Nineteen cases were regarded as HDGF index level 0, 11 as level 1, and 58 as level 2. Patients with level 2 expression showed higher rates of histological classification of keratinized squamous cell carcinomaand adenosquamous carcinoma （44.8% of level 2 patients and 13.3% in levels 0 and 1）, deep invasion （pT2-4 in 65.5% of level 2 patients, and 30.0% in levels 0 and 1）, the presence of lymphatic invasion （50.0% in level 2, and 20.0% in levels 0 and 1）, and the presence of lymph node metastasis （37.9% in level 2, and 6.7% in levels 0 and 1）. Patients with an HDGF index of level 2 CC showed poorer 5-year overall survival rates than those with level 0 or 1 CC （74.0% and 100%, respectively, P = 0.0036）. Univariate analysis revealed that histological classification （P = 0.04）, depth of tumor invasion （P = 0.0001）, vascular invasion （P = 0.004）, and lymph node metastasis （ P = 0.0001） were significant factors affecting overall survival in addition to HDGF expression. Multivariate analysis revealed HDGF expression level and lymph node metastasis as independent prognostic factors for overall survival （P = 0.0148 and P = 0.0197, respectively）. The prognostic signifcance of HDGF was further analyzed in pT1 andsignifcance of HDGF was further analyzed in pT1 and pT2-4 patient groups, respectively. Among patients with pT1 CC, one the 39 analyzed patients died during the study, and no difference was observed among patients with HDGF index level 0, 1, or 2 CC. However, prognostic signifcance of the HDGF index was observed in the pT2-4 patient group, in which the mortality rates of patients with HDGF index level 2 CC and those with level 0 or 1 CC signifcantly differed （P = 0.0463）. CONCLUSION： The HDGF expression level is of prognostic signifcance in CC.

Desmoid Tumor Mimicking Port Site Recurrence after Laparoscopic Retroperitoneal Lymph Node Dissection for Metastatic Testicular Tumor: A Case Report

Background: Desmoid tumor is a rare benign soft tissue tumor which commonly affects the trunk and extremities. Case presentation: We report a patient who presented with a tumor that slowly grew at the left lower abdominal port site 1 year after post-chemotherapy laparoscopic retroperitoneal lymph node dissection (RPLND) for metastatic testicular tumor. The enlarging mass mimicking port site recurrence after laparoscopic retroperitoneal lymph node dissection for metastatic testicular tumor was diagnosed as a desmoid tumor. Conclusion: To our knowledge, this is the first report of a desmoid tumor that developed after laparoscopic RPLND for a testicular tumor.

Implications of hepatic dysfunction in Kawasaki disease:Time-related changes in aspartate aminotransferase, alanine aminotransferase,total bilirubin,and C-reactive protein levels

Importance:The cause of the hepatic dysfunction that commonly accompanies Kawasaki disease(KD)remains unclear.Objective:We tried to clarify the cause of the hepatic dysfunction.Methods:A total of 381 consecutive patients with acute KD,who had undergone inpatient treatment with intravenous immunoglobulin until the 7th day of illness,were divided into a group of 199 patients with an alanine aminotransferase(ALT)level≥40 IU/L on admission(group I),a group of 52 patients with an ALT level≥40 IU/L at some point after admission(group II),and a group of 130 patients with ALT levels consistently<40 IU/L throughout hospitalization(group III).Aspartate aminotransferase(AST),ALT,total bilirubin(T-Bil),and C-reactive protein(CRP)levels were analyzed over time,and time-courses were compared.results:In the initial stage of illness,in group I,AST,ALT,T-Bil peaked on days 1-3,and AST tended to improve significantly on the 4th day(P<0.001).T-Bil improved on day 5(P<0.01),and ALT improved significantly on day 6(P<0.001).CRP increased every day up to day 6(P<0.001).In group II,AST and ALT increased after admission,and thereafter CRP increased,then decreased.The frequency of use of aspirin and aspirin doses did not differ significantly in the three groups.Interpretation:Recovery from liver dysfunction occurred in the initial stage of illness in group I-within the period of CRP exacerbation,which is an indicator of systemic inflammation.