A case of brainstem encephalitis diagnosed by stereotactic biopsy

Brainstem encephalitis is a rare form of encephalitis which should be differentiated from cerebrovascular and neoplastic diseases. The authors report a case of viral brainstem encephalitis mimicking malignant lymphoma. A 55-year-old female was admitted to our hospital with gradually progressive diplopia and left hemiplegia. CT scan revealed low density lesions in the right globus pallidus and the anterior limb of the internal capsule. MRI demonstrated high intensity signals extending into the right cerebral peduncle, temporal lobe, thalamus and the contralateral thalamus on FLAIR images. Petechial hemorrhages were seen in the affected lesions, but no enhancement was observed following administration of a contrast material. CSF examination revealed mild mononuclear cell dominant pleocytosis. Both early and delayed images of 123I-IMP SPECT revealed marked hot spots corresponding to the lesions on FLAIR images. CT-guided stereotactic biopsy was useful for early diagnosis.     

A case of non-Hodgkin's lymphoma presenting with acute renal failure diagnosed by renal biopsy]

We report a case of non-Hodgkin's lymphoma (NHL) presenting with acute renal failure. A-56-year-old male was admitted to our hospital on October, 1997 with fever and renal dysfunction. Physical examination showed no abnormality except for hepatomegaly. Body surface lymphadenopathy was not observed. Computed tomography (CT) of the abdomen showed markedly enlarged kidneys bilaterally and a mass of soft tissue density, which was considered as a swelling lymph node, around the aortic artery. The renal biopsy revealed parenchymal involvement of the NHL cells without normal tubulo-interstitial structure, but the glomeruli were almost intact. Our case rapidly fell into oliguria and acute renal failure, hence needed hemodialysis. After chemotherapy was performed, his renal function gradually improved and the kidney became smaller on subsequent CT. Unfortunately, the patient happened to suffer from methicillin-resistant staphylococcus aureus (MRSA) infection in a neutropenic state and died. Necropsy revealed recovery of the renal interstitium without residual NHL cells. Renal lymphoma without any other organ or nodal involvement is a rare type of NHL, which considered primary renal lymphoma (PRL). However, we believe this case to have been a result of lymphomatous infiltration of the kidneys in disseminated lymphoma.     

A case of subfrontal schwannoma]

We encountered a rare case of subfrontal schwannoma. A 55-year-old woman had received resection of a left frontal tumor because of hyposmia, at the age of 28 years. On June 10, 1989, she was admitted with the chief complaint of progressive contraction of visual field. Neurologic examination revealed anosmia, impaired vision and concentric contraction of visual field. Fundoscopy showed optic atrophy. CT examination demonstrated a calcified mass of mixed density which was occupying her nasal cavity, ethmoid sinus and anterior skull base. The lesion was enhanced with contrast medium. MRI clearly depicted the extension of the lesion and a low signal intensity area in the left frontal lobe as a postoperative scar. Angiography showed hypovascularity. The tumor was totally removed by bifrontal craniotomy on August 22, 1989. Infiltration into the brain or compression of the optic nerve was not detected. The dura on the cranial base side was damaged and lost by infiltration of the tumor, normal olfactory bulb was not able to be identified, and the cribriform plate was broken. The anterior skull base was reconstituted by covering the dural defect with cadaveric dura and the bony defect with a pericranium. HE staining showed Antoni A&B types of schwannoma. Postoperative course was uneventful. In this case, it is most likely that a remnant of the tumor resected when she was 28 years old had developed subfrontal schwannoma a long time after the operation, although the histological type at that time was unknown. It is also possible that a primary tumor in the nasal cavity or paranasal sinus may have extended into the cranium.(ABSTRACT TRUNCATED AT 250 WORDS)     

Gastric leiomyoblastoma. A case report]

The authors report a case of gastric leiomyoblastoma, a rare benign neoplasm that can sometimes undergo a malignant course. The main clinical an pathological issues are reviewed, in order to offer guidance as to the best suited surgical approach.     

A case of intrascrotal extratesticular schwannoma]

A 71-year-old man visited our hospital with a complaint of a right intrascrotal mass. An elastic hard mass was palpable in the right intrascrotal extratesticular space. Ultrasonography, computed tomographic scan and magnetic resonance imaging showed a left intrascrotal extratesticular tumor. However, preoperative diagnosis was not decided. Tumor resection was performed, and the histological diagnosis was schwannoma. Intrascrotal extratesticular schwannoma is very rare, and this case was considered as the second report in Japan.     

A case of mediastinal neurilemmoma diagnosed by X-ray guided needle biopsy

A 70-year-old female was admitted to our hospital complaining of general lassitude. She had been treated for duodenal ulcer. A routine chest X-ray film at admission showed a large tumorous shadow in the right apical field. A computed tomographic scan revealed that it was a posterior mediastinal tumor containing multiple cystic lesions. After medical treatment for duodenal ulcer, a needle biopsy was performed for histological diagnosis. Under local anesthesia a small skin incision was made in the supraclavicular region to avoid parietal pleura and great vessels and a specimen was obtained by a needle guided by X-ray fluoroscopy. The tumor was diagnosed as neurilemmoma histologically. She was discharged because the complaint subsided. Five months later, however, she was again admitted complaining of righ nuchal pain. Thoracotomy was performed under general anesthesia and the tumor growing from the second intercostal nerve was resected. It was 5 x 4 x 5.5 cm in size, encapsulated and consisted of multiple cystic lesions macroscopically. It was confirmed as Antoni B type neurilemmoma histologically. The nuchal pain subsided and she has been doing well for more than three years after discharge. Recently computed tomography (CT) and ultrasonography (US) have been widely used as a guiding device for needle biopsy. In this case, however, CT guided needle biopsy was not applied for fear of possible complications such as pneumothorax. It was also impossible to perform US guided needle biopsy because the tumor was behind the costal and sternal bones and could not be visualized.(ABSTRACT TRUNCATED AT 250 WORDS)     

Gastric cancer mimicking a submucosal tumor diagnosed by laparoscopic excision biopsy

We report a case of advanced gastric cancer exhibiting the features of a submucosal tumor (SMT) of the gastric body. The patient was a 50-year-old male in whom a gastric SMT was detected during a mass screening examination. Upper gastrointestinal endoscopy revealed a protuberant tumor, 2 cm in diameter, covered with normal-appearing mucosa. Examination of an endoscopic biopsy specimen of the tumor revealed chronic gastritis with regenerative and erosive changes. An endoscopic ultrasound examination demonstrated a hypoechoic mass in the third layer of the gastric wall. The clinical diagnosis was gastric SMT, and the patient's course was monitored. Twenty-six months after the initial visit to our hospital, an endosonograph-guided biopsy revealed Group III (borderline lesion). Three months after the biopsy, the size of the SMT had increased slightly. Laparoscopic wedge resection of the tumor was performed to make a pathologic diagnosis and we were able to make a diagnosis of gastric lymphoepithelioma-like carcinoma intraoperatively. Gastrectomy with lymph node dissection was followed as curative surgery. Laparoscopic total excision biopsy is a useful technique in patients with a gastric SMT whose diagnosis has not been confirmed pathologically.     

A case of metastatic intracerebral malignant schwannoma]

A 53 year old male complaining of headache and left hemiparesis was referred to our hospital on November 11, '89. He had no evidence of von Recklinghausen's disease. He had been operated on because of a well circumscribed tumor in the left paravertebral muscle on July 11, '87, and metastasis in the lower lobe of the left lung on April 20, '88. The pathological diagnosis of both the primary and the metastatic lung tumor was malignant peripheral nerve sheath tumor showing peripheral cell differentiation (malignant schwannoma). Contrast enhanced CT demonstrated an irregularly enhanced mass in the right parietal lobe just before admission. On the night of admission November 12, '89, he suddenly had severe headache and this progressed to hemiparesis. Repeat CT examination was done immediately and revealed intratumoral hemorrhage. On November 19, '89, the tumor was totally removed. His symptoms disappeared postoperatively. The pathological findings of the tumor were the same as those made previously. The patient received radiotherapy to the brain (local 50 Gy and whole brain 30 Gy) and chemotherapy with nitrosourea (MCNU 150mg). He was discharged without neurological deficits. However he had two operations to remove metastatic tumors in the soft tissue of the hip on January 12, and August 17, '90. A very rare case of metastatic intracerebral malignant schwannoma is reported, and the literature on this point is reviewed.     

A case of prostate cancer diagnosed pathologically by bone metastatic site biopsy

A 61-year-old man consulted our hospital complaining of high prostate specific antigen (PSA) value and difficulty to urinate. Prostate biopsy had been performed at another hospital, but did not reveal cancer. PSA was 18.5 ng/ml. Transrectal ultrasound-guided prostate biopsy was performed, but cancer was not detected. Later, PSA rose rapidly, and findings suggesting bone metastasis at right pubic bone and left sacro-ilial joint were found on computed tomography (CT), bone scintigraphy and magnetic resonance imaging (MRI). A repeat prostate biopsy was performed, but cancer was not detected from the prostate. On right pubic bone biopsy, poorly to moderately differentiated adenocarcinoma was detected. PSA immunohistochemical staining was positive, and the diagnosis was bone metastasis from prostate cancer. After endocrine therapy was started, PSA declined and bone metastasis disappeared on bone scintigraphy.     

A case of primary adrenal lymphoma diagnosed from percutaneous needle biopsy.

A case of bilateral lymphoma of the adrenal glands is reported. A 72-year-old woman was admitted to our hospital for evaluation of bilateral adrenal masses. A 20-gauge core needle biopsy of the left adrenal tumor was performed under ultrasonographic guidance. The pathological specimen revealed a malignant lymphoma. The diagnostic procedure for adrenal lymphoma is discussed.     

Insulinoma diagnosed by endoscopic ultrasonography-guided biopsy.

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) is a new technique that seems to expand the utility of EUS, making definitive diagnosis of pancreatic lesions possible. However, the exact indications for the method, as well as its limitations, are not fully defined. We report on a patient with an insulinoma in the tail of the pancreas undetected by other imaging modalities that was conclusively diagnosed by EUS-FNA. Endoscopic ultrasonography is a unique imaging modality for localization of small pancreatic lesions. In combination with FNA, it represents a significant improvement for the exact diagnosis of these tumors.     

A case of vesical malacoplakia diagnosed by randomized biopsy of the urinary bladder

Vesical malacoplakia is a relatively rare disease and commonly diagnosed by characteristic cystoscopical findings and histological determination using biopsy specimen. We report here a case of a 53-year-old housewife, with atypical cystoscopical findings, which looked like carcinoma in situ, and in which randomized biopsy helped to make the final diagnosis. This case was successfully controlled by anti-bacterial agents.     

Adrenal hemorrhage diagnosed by ultrasonically-guided biopsy.

Adrenal hemorrhage in adults is an uncommon disease and is usually associated with systemic diseases, trauma or anticoagulation. When adrenal hemorrhage is discovered in chronic course without any suggestive clinical settings, it is difficult to distinguish adrenal hemorrhage correctly before surgical resection. We present a case of adrenal hemorrhage which was incidentally detected as an adrenal mass and was successfully treated in a conservative way based upon histopathological findings obtained by ultrasonically guided biopsy.     

Intramedullary schwannoma. A case report

The intramedullary localization of schwannoma is rare, corresponding to 0.3% of all intraspinal tumors. We report a case of intramedullary schwannoma without symptoms suggestive of neurofibromatosis. This patient presented with symptoms of spinal compression. Total removal of the tumor was achieved. The literature is reviewed about of this rare localization of schwannoma.     

Intrabronchial schwannoma. A case report

A 17-year-old male presented with clinical features of left lung collapse. The diagnosis of isolated intrabronchial schwannoma was obtained by endoscopic biopsy and confirmed after pneumonectomy.     

Technique and tactics of biopsy including puncture]

The biopsy is the key for the exact diagnosis of bone and soft tissue sarcomas. However the biopsy implicates risks that eventually may significantly interfere with the prognosis. The steps of the biopsy can be differentiated in tactical and technical aspects. Tactical aspects include laboratory examinations (e.g. blood count, immunological, chemical tests) in order to establish the prebiopsy differential diagnosis, basic imaging procedures (bone scan, magnetic resonance imaging) and to discuss with the pathologist questions as which region of the tumor might be most informative, how should the material be preserved and whether a frozen section might be useful and allow for initiation of therapy as early as possible. Furthermore the site of the biopsy has to be carefully chosen, the compartments that need being passed through or opened up during biopsy must be considered. The technical aspects refer to the approach and tissue handling during the biopsy itself. Fine needle aspiration allows only for a cytologic, core biopsies for a histologic examination (however only of a small sample), while the open biopsy provides more material for more analyses. Any biopsy (open biopsy as well as percutaneous puncture) contaminates the path with tumor cells and increases the risk of systemic seeding. In order to keep these risks as small as possible the most careful technique and tissue handling is mandatory. The biopsy path has to be completely ('en bloc') resected later for local tumor control.     

Gastric metastasis of malignant fibrous histiocytoma diagnosed preoperatively by endoscopic ultrasound-guided fine-needle aspiration biopsy: Report of a case

Metastatic gastric tumors originating from malignant fibrous histiocytoma (MFH) are rare. We herein report the case of a 75-year-old woman who underwent a distal gastrectomy for gastric metastasis of MFH, who was preoperatively diagnosed by an endoscopic ultrasoundguided fine-needle aspiration biopsy.     

A case of traumatic right diaphragmatic hernia diagnosed by pleurography]

The diagnosis of traumatic diaphragmatic hernia is relatively easy on the left side, but is often difficult on the right, partly because the herniated organ is usually the liver. Recently, we experienced a relatively rare case of traumatic right diaphragmatic hernia and found that pleurography was useful for its diagnosis. This case is reported here together with some discussion of the literature.