Scaling Lichenoid Eruptions and Sjögren-like Syndrome: Manifestations of Nonfatal Postoperative Transfusion-Associated Graft-versus-Host Disease?

We report a case of an 81-year-old woman in whom lichenoid eruptions and Sjögren-like sicca syndrome developed 45 days after cholecystectomy. During surgery, one unit (130 ml) of unirradiated packed red blood cells from a male donor was transfused. The lichenoid eruptions cleared up with exfoliation; however, sicca symptoms remained during the follow-up period of four years. Histological examinations of both skin and lip biopsy specimens were in agreement with those of graft-versus-host disease (GVHD). A Y-chromosomal body was identified in the lymphocytes in the skin lesion by staining with quinacrine dihydrochloride and in the lip lesion by a method with in situ hybridization. The findings suggest that this case demonstrated the manifestations of non-fatal transfusion-associated GVHD.     

Follicular hyperplasia presenting with a marginal zone pattern in a reactive lymph node lesion

Histologically, the marginal zone pattern of the lymph node is characterized by lymphoid follicles with three distinct layers. The inner layer is composed of follicular center zones, the middle layer of darkly stained mantle zones, and the outer layer of marginal zones. However, the marginal zone pattern is rarely seen in reactive lymph nodes except for mesenteric lymph nodes. We describe the clinicopathologic, immunohistochemical and genotypic findings of six cases of reactive follicular hyperplasia exhibiting the marginal zone pattern. The patients comprised three males and three females (age range 24 to 63 years; medium 56 years). Follow-up data were obtained from five patients. None of them developed malignant lymphomas during the follow-up period of from 5 to 204 months (median 68 months). Histologically, the lesion was characterized by numerous lymphoid follicles and partial distortion of lymph node structure. Varying degrees of progressive transformation of the germinal center (PTGC) were noted in the four cases. The marginal zone pattern was observed in some or most of the lymphoid follicles including PTGC. The marginal zone B cells were small to medium-sized lymphocytes with round or slightly indented nuclei and a broad rim of pale cytoplasm. Some of them had a monocytoid appearance. They were CD20+, CD79a+, sIgM+/-, sIgD-, CD5-, CD10-, CD21-, CD23-, CD43-, CD45RO-, Bcl-6-, cyclin D1-, EMA- and p53-. A portion of them were Bcl-2 positive. Occasional large lymphoid cells with round or indented nuclei and moderate amounts of cytoplasm were observed in the marginal zone in four cases. These large lymphoid cells were usually CD20 positive, but Bcl-6 negative. A small number of them contained polytypic intracytoplasmic immunoglobulins. The polytypic nature of B lymphocytes was demonstrated by immunohistochemistry and polymerase chain reaction. Recognition of unusual marginal zone hyperplasia in reactive lymph node lesions is important to avoid confusion with nodal involvement in various low-grade B cell lymphomas presenting a marginal zone distribution pattern.     

The significance of abdominal para‐aortic lymph node metastasis in patients with lower thoracic esophageal cancer

Para‐aortic lymph node (PALN) recurrence is often seen in patients with lower thoracic esophageal cancer treated by esophagectomy with extended lymph node dissection. However, the clinicopathological characteristics of patients with PALN metastasis and the significance of PALN dissection are unknown. A total of 283 patients with lower thoracic esophageal cancer underwent esophagectomy with lymphadenectomy at our hospital between April 1984 and March 2007. Among these 283 patients, 60 patients were enrolled in this retrospective study according to following criteria: (i) clinical T2 to T4 tumor, (ii) no clinical PALN metastasis, and (iii) received PALN dissection. PALN dissection was indicated by a tumor depth of at least T2 and no severe complications. The clinicopathological data, recurrence pattern, and overall survival were compared between patients with PALN and without PALN metastasis. The mean length of surgery was 587 min and the mean blood loss was 1383 mL. The morbidity was 33.3% and mortality was 5% in this series. Sixteen patients (26.7%) had PALN metastasis; these showed significantly more lymph node metastases (15.8 ± 13.2 vs. 3.0 ± 3.2, P < 0.0001) and significantly worse survival rates (53.3% vs. 79.9% at 1 year, 6.7% vs. 62.0% at 3 years, P < 0.0001) than patients without PALN metastasis. The incidence of lymph node recurrence (P < 0.0001) and hematogenous recurrence (P= 0.0487) was also higher in patients with PALN metastasis than in patients without PALN metastasis. Among the 16 patients with PALN metastasis, a univariate analysis revealed total number of metastatic nodes < 8 (P= 0.0325) to be a significant prognostic factor. A multivariate logistic regression analysis of the regional lymph nodes identified the invasion of the lower mediastinal nodes (hazard ratio = 6.120) and retroperitoneal nodes (hazard ratio = 15.167) to be significantly correlated with PALN metastasis. PALN metastasis is suggested to be related to the systemic spread of lymphatic metastasis even in lower thoracic esophageal cancer. PALN dissection for pathological PALN(+) patients should not be performed. It remains to be determined in future prospective studies whether patients without pathological PALN metastasis, but showing PALN micrometastasis, could achieve improved survival with PALN dissection.     

Spirometric and radiological evaluation of the remnant lung long after major pulmonary resection: can compensatory phenomena be recognized in clinical cases?

Purposes

The purpose of this study was to investigate the compensatory phenomena after lung resection in clinical cases by evaluating the spirometric and radiological parameters.

Methods

Forty patients undergoing lobectomy for stage IA lung cancer were divided into the following groups: (A) patients with <10 (n = 20) and (B) patients with ≥10 resected subsegments (n = 20). Comparisons were made of the predicted and observed postoperative values of spirometry and radiological parameters, such as lung volumetry and the “estimated lung weight”. Predicted values were based on the number of resected subsegments. The postoperative time to re-evaluation was at least 1 year for both groups.

Results

The predicted postoperative values of spirometry underestimated the actual values, and the differences were more significant in group B (forced vital capacity, p = 0.006, forced expiratory volume in 1 s, p = 0.011). Focusing on the remnant lungs on the surgical side, group B had significantly larger % postoperative lung volumes (161 ± 6.0 %) and % estimated lung weight (124 ± 5.4 %) than did group A (114 ± 3.8 %, p < 0.0001; 89.5 ± 4.4 %, p < 0.0001, respectively).

Conclusions

Major lung resection in clinical cases causes a compensatory restoration of the pulmonary function and tissue.     

Predictive value of preoperative echocardiographic assessment for postoperative atrial fibrillation after esophagectomy for esophageal cancer

Esophagus - Postoperative atrial fibrillation (POAF) after esophagectomy for esophageal cancer is not uncommon. The aim of this study is to examine whether preoperative transthoracic...     

Tissue factor predicts response to chemotherapy in esophageal cancer

Background

Neoadjuvant chemotherapy (NACT) improves the prognosis of patients with esophageal cancer who respond, but it is not effective in nonresponders. Therefore, it is crucial to establish a reliable method of predicting response before initiation of chemotherapy. Hypercoagulability, which is thought to be because of upregulation of tissue factor (TF) in cancer cells, was reported to be associated with chemoresistance. The aim of this study was to investigate the association between TF expression and response to NACT in esophageal cancer.

Methods

In 67 patients with advanced esophageal cancer, TF expression in pretreatment biopsy samples was evaluated immunohistochemically and correlated with clinicopathologic factors and response to chemotherapy.

Results

TF was expressed by 43.3% of the tumors, but there were no correlations observed with any clinicopathologic parameters examined. Clinical and histologic responses to chemotherapy were significantly worse in TF-positive patients compared with TF-negative patients. Multivariate analysis revealed that TF expression was significantly associated with a poor clinical response (P = 0.0431). TF expression was also independently associated with poor progression-free survival (P = 0.0353).

Conclusions

TF expression levels in pretreatment biopsy samples are useful for predicting response to NACT in advanced esophageal cancer. Further studies of mechanisms underlying the relationship between TF expression and chemosensitivity are needed.     

Usefulness of magnetic resonance sialography in patients with juvenile Sjögren's syndrome

OBJECTIVE: Sialography is an important means for evaluating parotid gland damage in patients with Sj?gren's syndrome (SS). However, 'conventional' X-ray sialography is invasive and sometimes difficult to perform and repeat, especially for young patients. Recently, magnetic resonance (MR) sialography has been used in adult SS patients. In this study, we investigated the usefulness of MR sialography for evaluating parotid gland damage in juvenile SS. METHODS: Eight young patients suffering from SS were studied. MR sialography and X-ray sialography were performed simultaneously in the same patients. The images obtained by both methods were assessed with Rubin-Holt staging. RESULTS: MR sialography detected ductal dilatation in 5 of 8 patients, while it was detected in 7 of 8 patients by X-ray sialography. The stages were the same in 4 patients by both methods. In 3 patients, the stages on X-ray sialography were higher than those on MR sialography; in 1 patient, the stage on MR sialography was higher. The correlation between the stages determined by the 2 methods was 0.85. There were no side effects in MR sialography, whereas 3 patients complained of pain during X-ray sialography. CONCLUSION: MR sialography can evaluate Stage II approximately III parotid gland damage in juvenile SS. Although MR sialography cannot detect subtle changes in the duct, it has no side effects and can be performed repeatedly in young patients. We propose that MR sialography be chosen as the first tool for diagnosing and during follow-up of the status of the glands in juvenile SS.     

Gene Expression Profile Prospectively Predicts Peritoneal Relapse After Curative Surgery of Gastric Cancer

Background

Peritoneal relapse is the most common pattern of tumor progression in advanced gastric cancer. Clinicopathological findings are sometimes inadequate for predicting peritoneal relapse. The aim of this study was to identify patients at high risk of peritoneal relapse in a prospective study based on molecular prediction.

Methods

RNA samples from 141 primary gastric cancer tissues after curative surgery were profiled using oligonucleotide microarrays covering 30,000 human probes. Firstly, we constructed a molecular prediction system and validated its robustness and prognostic validity by 500 times multiple validation by repeated random sampling in a retrospective set of 56 (38 relapse-free and 18 peritoneal-relapse) patients. Secondly, we applied this prediction to 85 patients of the prospective set to assess predictive accuracy and prognostic validity.

Results

In the retrospective phase, repeated random validation yielded ~68% predictive accuracy and a 22-gene expression profile associated with peritoneal relapse was identified. The prediction system identified patients with poor prognosis. In the prospective phase, the molecular prediction yielded 76.9% overall accuracy. Kaplan–Meier analysis of peritoneal-relapse-free survival showed a significant difference between the “good signature group” and “poor signature group” (log-rank p = 0.0017). Multivariate analysis by Cox regression hazards model identified the molecular prediction as the only independent prognostic factor for peritoneal relapse.

Conclusions

Gene expression profile inherent to primary gastric cancer tissues can be useful in prospective prediction of peritoneal relapse after curative surgery, potentially allowing individualized postoperative management to improve the prognosis of patients with advanced gastric cancer.     

Primary hepatic presentation of Hodgkin's lymphoma: A case report

Hodgkin's lymphoma (HL) is in general a lymph node‐based disease. Hepatic involvement usually occurs in the advanced disease. Primary and prominent manifestation of the disease in the liver is extremely rare. We report magnetic resonance imaging leading to diagnosis in a rare case of liver involvement as the first sign of HL.     

Assessment of neoadjuvant chemotherapy for patients with advanced squamous cell carcinoma of the esophagus

Background  Neoadjuvant chemotherapy for advanced esophageal cancer is beneficial for responders, whereas it may provide no clinical benefits or even prove harmful in non-responders. Methods  This study retrospectively compared the pathological findings and prognosis of 60 patients with UICC non-T4 stage III and IV, who received chemotherapy followed by surgery, and 96 patients with non-T4 stage III and IV cancer, who underwent surgery alone. The treatment regimen of cisplatin (70 mg/m²/day on day 1), adriamycin (30 mg/m²/day on day 1), and 5-fluorouracil (750 mg/m²/day on days 1–7) was administered for two cycles. Responders represented patients with histological effect of grade 1b-3 following therapy; non-responders represented those with grade 0-1a histological effect. Results  Survival was not significantly different between the neoadjuvant chemotherapy group and the surgery-alone group. Responders showed a tendency of earlier postoperative pStages than preoperative cStages (P = 0.08), better survival (P = 0.10), significantly fewer metastatic nodes, and significantly less extensive lymphatic invasion than the surgery-alone group. However, non-responders showed no significant differences in the degree of downstaging, number of metastatic nodes, extent of lymphatic and venous invasion, and survival rate as compared with the surgery-alone group. Comparison of overall survival between the chemotherapy and surgery-alone groups after matching for pathological stage showed that the survival of pStage II patients of the chemotherapy group was significantly better than the pStage II patients of the surgery-alone group (P = 0.04), whereas that of pStage III and IV patients of the chemotherapy group was not significantly different from the same-stage patients of the surgery-alone group. Conclusions  These results suggest that chemotherapy improves prognosis of responders significantly more than those who show downstaged pathological stage. However, the chemotherapy does not give any clinical benefit for non-responders.