Smooth muscle distribution in the extrahepatic bile duct: histologic and immunohistochemical studies of 122 cases

The distribution of smooth muscle fibers in the extrahepatic bile duct (EBD) wall is not well characterized. We analyzed 101 consecutive Whipple's operation specimens and 21 autopsy specimens for the pattern of smooth muscle distribution in EBD using the Masson-trichrome stain and the desmin immunohistochemical stain. The patterns were categorized as continuous, interrupted, scattered, and no muscle layer. EBDs were divided into lower, middle, and upper portions, and the distribution pattern of smooth muscle fibers was analyzed separately in each portion. Because most surgically resected specimens contained the middle and lower EBDs with only a portion of the upper EBD, only the length of the middle and lower EBDs (common bile duct, CBD) was measured. The mean length of CBD in surgically resected specimens was 6.4 +/- 1.4 cm (men, 6.6 +/- 1.3 cm; women, 6.1 +/- 1.5 cm). The mean length of CBD in autopsy specimens was 6.8 +/- 1.0 cm. The predominant patterns of the lower third of the EBD were interrupted (49%) and continuous (43%). The predominant patterns of the middle third of the EBD were scattered (63%) and interrupted (23%). Those of the upper third of the EBD were no muscle fiber (58%) and scattered (39%). In conclusion, different patterns of smooth muscle distribution were observed in different portions of the EBD. Because scattered muscle fibers or no muscle fibers were the main features of the upper third of the EBD, understanding of this pattern may be helpful for assessment of the depth of invasion or staging of carcinoma of the upper third of the EBD.     

Intravesical adipose tissue: a quantitative study of its presence and location with implications for therapy and prognosis

Accurate pathologic staging of carcinomas of the urinary bladder involves assessment of invasion by the tumor into the bladder wall and beyond into perivesical soft tissue. The presence of tumor within perivesical soft tissue implies pathologic stage pT3 (AJCC/UICC system, 1997). In traditional textbooks of histology, anatomy, pathology, and in the literature, other than a single case report and a brief reference in another paper, there is no information on the presence of adipose tissue in the lamina propria or muscularis propria of the urinary bladder. Nine hundred forty-three sections from 139 cystectomy specimens were evaluated for the presence, location, and quantity of adipose tissue within the lamina propria and muscularis propria. The histology of the perivesical soft tissues and the nature of its delineation from muscularis propria were also analyzed. Adipose tissue was seen within the lamina propria in 53% (74 of 139) of cystectomies and in 17.6% (166 of 943) of the examined sections. It was located predominantly in the deep lamina propria (at or below the muscularis mucosae) in 81.1% (60 of 74) of the cystectomies and in 91% (151 of 166) of the sections. Within the lamina propria it was predominantly seen as small localized aggregates in 92% (153 of 166) of sections. All cases showed adipose tissue within the muscularis propria. Adipose tissue was identified within the superficial (inner) muscularis propria in 54% (512 of 943) of sections and was predominantly in small aggregates in 80.5% (412 of 512) of sections. It was in moderate to abundant quantities within the deep (outer) muscularis propria in 60.7% (572 of 943) of sections. The perivesical soft tissue was almost exclusively composed of adipose tissue with variable vascularity. Delineation of the perivesical adipose tissue from the deep (outer) muscularis propria was typically indistinct because muscle bundles of the latter haphazardly merged with the perivesical adipose tissue. Based on these findings, we conclude that adipose tissue is frequently present in the lamina propria and muscularis propria of the urinary bladder wall, and is usually scant in the former location and frequently abundant in the latter. Awareness of the high frequency of adipose tissue within the urinary bladder wall has prognostic and therapeutic implications. In transurethral resection of bladder tumor (TURBT) specimens, misinterpretation of tumor infiltrating adipose tissue within lamina propria (pT1) as perivesical soft tissue involvement (pT3) may potentially result in unwarranted aggressive management. Substaging of muscle invasive tumors should be performed in cystectomy specimens only, because the junction of muscularis propria and the perivesical adipose tissue is typically ill-defined. Muscularis propria adipose tissue in TURBT specimens may be erroneously assumed to be perivesical adipose tissue, potentially leading to overstaging of the primary tumor.     

Extranodal extension in node-positive bladder cancer: the continuing controversy

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Although extranodal extension in node‐positive patients may provide prognostic information in certain urological malignancies, contradictory results have been reported in node‐positive patients after radical cystectomy for bladder cancer. We examined whether extranodal extension could have an impact on the outcomes of node‐positive patients who underwent radical cystectomy for bladder cancer in a single large tertiary hospital. We have shown that the presence of extranodal extension was not an independent prognostic factor in node‐positive patients after radical cystectomy and pelvic lymphadenectomy for bladder cancer.

OBJECTIVE

? To examine whether extranodal extension (ENE) has an impact on the outcome of node‐positive patients who underwent radical cystectomy for bladder cancer.

PATIENTS AND METHODS

? Of 543 consecutive patients who underwent radical cystectomy for urothelial carcinoma of the bladder between 1990 and 2007, 112 patients with lymph node metastasis detected on histological examination were evaluated with regard to recurrence‐free survival (RFS) and disease‐specific survival (DSS) based on ENE status.

RESULTS

? The overall 5‐year RFS and DSS rates were 22.3% and 33.8%, respectively. ENE was observed in 41 (36.6%) of the 112 patients. ? The presence of ENE was associated with advanced pathological nodal status (P= 0.004), more positive lymph nodes (P= 0.006), and higher lymph node density (P < 0.001). ? The incidence of positive ENE increased with large positive lymph node diameter (P < 0.001). ? Multivariate analysis showed that lymph node density (hazard ratio (HR) = 2.39, 95% CI 1.09–5.24, P= 0.029; and HR = 3.13, 1.43–6.84, P= 0.004) and use of adjuvant chemotherapy (HR = 1.80, 1.02–3.20, P= 0.041; and HR = 2.07, 1.13–3.79, P= 0.018) were significant predictors of RFS and DSS, respectively. ? After adjustment for other prognostic factors, ENE was not significantly related to RFS (P= 0.825) and DSS (P= 0.961) by multivariate analysis.

CONCLUSIONS

? The presence of ENE was not an independent prognostic factor in node‐positive patients after radical cystectomy for bladder cancer. ? Additional prospective studies are needed to determine the independent prognostic role of ENE.     

Transduodenal local resection for low-risk group ampulla of vater carcinoma

BACKGROUND: Carcinoma of the ampulla of Vater has a more favorable prognosis, compared to other malignant tumors of the periampullary region, because it usually presents with symptoms in the early stage. However, treatment by local resection only of the ampullary carcinoma remains controversial. The aim of this study was to evaluate the treatment results of the ampulla of Vater carcinoma according to different types of operation in low-risk-group patients. METHODS: We retrospectively reviewed the medical records of 17 low-risk-group patients among a total of 102 patients with ampulla of Vater carcinoma who had underwent curative surgery from 1992 to 2002. All specimens were critically reviewed by a single expert pathologist, and the relationship between surgical outcomes and operation type was assessed. RESULTS: The low-risk group was comprised of 10 men and 7 women with a median age of 57.8 years. Thirteen of 17 patients underwent a pancreaticoduodenectomy (PD) or a pylorus preserving pancreaticoduodenectomy (PPPD), while 4 patients underwent a transduodenal local resection (TDLR). The operation time was significantly shorter in the TDLR group, compared to the PD or PPPD groups. Among the 17 patients, there was only 1 case of recurrence in the inguinal area 33 months after the pancreaticoduodenectomy. CONCLUSIONS: Transduodenal local resection is a comparable mode of operation for low-risk-group patients with Ampulla of Vater carcinoma. In particular, it is essential to evaluate the invasion depth in preoperative endoscopic ultrasonography, cell differentiation in preoperative biopsy, and positivity of resection margin accurately by using frozen section during the operation.     

CT and MR features of nasopharyngeal carcinoma in children and young adults

AIM: To clarify CT and MR features of nasopharyngeal carcinoma (NPC) in children and young adults. METHOD: CT and MR findings of 13 patients (30 years old or younger) with a histopathologic diagnosis of NPC were reviewed. RESULTS: Skull base invasion (12/13), lymphadenopathy (10/13), and infiltrative growth (8/8) were common findings. The signal intensity of tumours was slightly higher than that of muscles in six cases and isointense to that of muscles in two cases on T1-weighted images; it was higher than that of muscle and lower than that of cerebellar grey matter on T2-weighted images in all cases. Internal signals were homogeneous in both pre- and post-Gd-enhanced MR images in all cases. CONCLUSIONS: Despite its rarity in this age group, NPC should be included in a differential diagnosis when CT and MR imaging reveal these features.     

Effects of an alveolar recruitment manoeuvre guided by lung ultrasound on anaesthesia‐induced atelectasis in infants: a randomised,controlled trial

Atelectasis occurs in the majority of children undergoing general anaesthesia. Lung ultrasound has shown reliable sensitivity and specificity for diagnosing anaesthesia‐induced atelectasis. We assessed the effects of a recruitment manoeuvre on atelectasis using lung ultrasound in infants undergoing general anaesthesia. Forty infants, randomly allocated to either a recruitment manoeuvre group or a control group, received volume‐controlled ventilation with 5 cmH₂O positive end‐expiratory pressure. Lung ultrasound examination was performed twice in each patient, the first a minute after starting mechanical ventilation of the lungs and the second at the end of surgery. Patients in the recruitment manoeuvre group received ultrasound‐guided recruitment manoeuvres after each lung ultrasound examination. The incidence of significant anaesthesia‐induced atelectasis at the second lung ultrasound examination was less in the recruitment manoeuvre group compared with the control group (25% vs. 80%; p = 0.001; odds ratio (OR ) 0.083; 95% confidence interval (CI ): 0.019–0.370). The median (IQR [range]) lung ultrasound scores for consolidation and B‐lines on the second examination were lower in the recruitment manoeuvre group compared with the control group; 6.0 (3.0–9.3 [0.0–14.0]) vs. 13.5 (11.0–16.5 [8.0–23.0]); p < 0.001 and 6.5 (3.0–12.0 [0.0–28.0]) vs. 15.0 (10.8–20.5 [7.0–28.0]); p < 0.001, respectively. The lung ultrasound scores for consolidation on the first and second examinations showed a negative correlation with age (r = ?0.340, p = 0.008; r = ?0.380, p = 0.003). We conclude that ultrasound‐guided recruitment manoeuvres with positive end‐expiratory pressure proved useful in reducing the incidence of anaesthesia‐induced atelectasis in infants, although 5 cmH₂O positive end‐expiratory pressure alone was not sufficient to eliminate it. In addition, the younger the patient, the more susceptible they were to atelectasis.     

Low-level laser irradiation effect on endothelial cells under conditions of hyperglycemia

Diabetes mellitus is considered to be a very serious lifestyle disease leading to cardiovascular complications and impaired wound healing observed in the diabetic foot syndrome. Chronic hyperglycemia is the source of the endothelial activation. The inflammatory process in diabetes is associated with the secretion of inflammatory cytokines by endothelial cells, e.g., tumor necrosis factor-alpha (TNF-α) and interleukin 6 (IL-6). The method of phototherapy using laser beam of low power (LLLT—low-level laser therapy) effectively supports the conventional treatment of diabetic vascular complications such as diabetic foot syndrome. The aim of our study was to evaluate the effect of low-power laser irradiation at two wavelengths (635 and 830 nm) on the secretion of inflammatory factors (TNF-α and IL-6) by the endothelial cell culture—HUVEC line (human umbilical vein endothelial cell)—under conditions of hyperglycemia. It is considered that adverse effects of hyperglycemia on vascular endothelial cells may be corrected by the action of LLLT, especially with the wavelength of 830 nm. It leads to the reduction of TNF-α concentration in the supernatant and enhancement of cell proliferation. Endothelial cells play an important role in the pathogenesis of diabetes; however, a small number of studies evaluate an impact of LLLT on these cells under conditions of hyperglycemia. Further work on this subject is warranted.     

Sarcoma of the Abdominal Aorta Involving Marginal Arteries of the Small Intestine: A Case Report

Primary sarcoma of the aorta is extremely rare. In the past, the disease was commonly diagnosed on autopsy. However, now it is possible to make a diagnosis preoperatively using various imaging studies such as computed tomographic scanning and magnetic resonance imaging. The authors have experienced one case of abdominal aortic sarcoma in a patient who complained of the symptoms of typical intestinal angina. We diagnosed an aortic sarcoma preoperatively but failed to resect the tumor on thoracolaparotomy because of the tumor extension to marginal arteries of the whole small intestine. We recommend preoperative laparoscopy for evaluation of tumor extension to marginal arteries of the small intestine in a patient having aortic sarcoma and intestinal angina if the patient is considered to be a surgical candidate.