Pleuropulmonary pathology of vascular Ehlers–Danlos syndrome: spontaneous laceration,haematoma and fibrous nodules

Kawabata Y, Watanabe A, Yamaguchi S, Aoshima M, Shiraki A, Hatamochi A, Kawamura T, Uchiyama T, Watanabe A & Fukuda Y
(2010) Histopathology 56, 944–950
Pleuropulmonary pathology of vascular Ehlers–Danlos syndrome: spontaneous laceration, haematoma and fibrous nodules Aims: The aim was to clarify the pleuropulmonary pathological findings of vascular Ehlers–Danlos syndrome (vEDS). Methods and results: Nine patients with confirmed vEDS by means of cell culture and/or molecular biological studies who had undergone surgical lung biopsy (SLB), lobectomy or autopsy were studied. Six patients were male and three were female with a mean age of 23.2 years. Histological features were as follows: (i) the main pulmonary lesions related to fragility and spontaneous laceration, these being haematomas in seven, acute haemorrhage in nine, fibrous nodule in eight, with ossification or bone marrow formation in six; vascular disruption in five; intraluminal haemosiderosis in nine; interstitial haemosiderosis in seven, with iron deposition in the alveolar wall and/or vessel wall in five and foreign body reaction in two; emphysematous changes in eight; and bleb formation in two; (ii) secondary iatrogenic pleuropulmonary injuries during SLB or lobectomy comprised pleural laceration in seven of 10 and lung laceration in eight of 10 specimens. Conclusions: Spontaneous laceration of lung tissue is an essential feature and is followed by haematoma and possible fibrous nodule formation.     

A survey of 165 sporotrichosis cases examined in Nagasaki prefecture from 1951 to 2012

A total of 165 sporotrichosis cases occurring in Nagasaki prefecture, and examined at Nagasaki University Hospital, were evaluated. Both males and females were equally affected, with no significant differences in the affected body regions. Lesions were frequently seen on the face (49 cases, 29.5%) and upper limbs (101 cases, 60.9%). The localised cutaneous type of sporotrichosis (105 cases, 62.9%) was much more frequent than the lymphocutaneous type (62 cases, 37.1%). The infection rate in patients over 50 years of age was 73.1%. The most frequent occupation among the patients was farming (52 cases, 37.4%), and 34 patients had a history of injury. Regarding the geographical distribution of sporotrichosis, 48 cases occurred in the Shimabara peninsula (31.2%) and this is much higher than expected for the population size. Before 1994, almost all sporotrichosis cases (112 cases, 96.5%) were treated with potassium iodide (KI). After 1995, the number of patients treated with KI decreased (nine cases, 23.1%), and itraconazole (ITZ) was used in 21 cases (59.0%) and terbinafine in six cases (15.3%). The time between ITZ and KI treatment and cure was 13.8 weeks and 12.5 weeks, respectively. All 116 cases, for which the outcome was known, were cured or improved.     

Engraftment and dissemination of T lymphocytes from primary haemophagocytic lymphohistiocytosis in scid mice

Although primary haemophagocytic lymphohistiocytosis (HLH) is a genetic disorder of T lymphocytes, it remains unclear why T lymphocytes of primary HLH patients preferentially infiltrate the central nervous system and peripheral blood, in addition to the reticuloendothelial systems. We engrafted Herpesvirus saimiri (HVS)-immortalized T-lymphocyte lines established from primary HLH patients into severe combined immunodeficient (scid) mice and examined their capacity to infiltrate mouse organs. A diffuse infiltration of human T lymphocytes was detected in each organ of scid mice treated with 1 x 10(6) T lymphocytes from all four primary HLH patients assessed, whereas no infiltration of T lymphocytes from healthy individuals was observed in any organ. The infiltration of T lymphocytes was mainly observed in the lung, brain and peripheral blood, in association with haemophagocytosis. These cells were positive for HLA-DR, CD3 and either CD8 or CD4, but negative for CD68. Certain markers of proliferation and apoptotic activities were highly positive in these cells. There was no difference between the infiltration pattern of T lymphocytes of primary HLH patients with a perforin deficiency and those without. By Southern blot analysis, T lymphocytes infiltrating mouse organs were observed to be polyclonal. These findings suggest that our murine model implementing HVS-immortalized human T lymphocytes is suitable to clarify the pathogenesis of primary HLH.     

Quantitative analysis of numerical chromosome aberrations in various morphological types of colorectal carcinomas

Quantitative analysis by fluorescence in situ hybridization (FISH) on thin paraffin-embedded tissue sections, using specific probes for chromosomes 11, 17, and 18 was employed in various morphological types of early and advanced colorectal cancer to clarify tumor cytogenetics. The chromosome index (CI) was calculated as a quantitative measure of the chromosome copy number. Compared with the CI of normal epithelium, the CI of chromosome 11 in villous components of adenomas or polypoid early cancers was decreased, while the CI in flat type or advanced colorectal cancers, conversely, was increased (P<0.05). The CI of chromosome 17 in villous components of adenomas and all cancers was higher than that of normal epithelium (P<0.05), but the differences were not significant. In protruding advanced cancers, the CI of chromosome 18 was significantly decreased (P<0.01) compared to the CI of normal epithelium. There was no significant chromosomal heterogeneity between the superficial and the deepest layer in each cancer. In mucosa adjacent to sessile and flat type cancers, the CI of chromosome 17 was significantly higher than the CI in normal epithelium or adenomas (P<0.05). These results suggest that numerical chromosome aberrations are associated with the histological type of adenoma and the morphological diversity of cancer in the colorectum, and that chromosome 17 abnormality occurs in mucosa adjacent to sessile and flat cancers.     

Personal experience of laparoscopic cholecystectomy

BACKGROUND/AIMS: We performed laparoscopic cholecystectomy with a surgical team consisting of the same operator and the same first assistant to evaluate a personal learning curve of laparoscopic cholecystectomy. METHODOLOGY: In the 135 patients who underwent the laparoscopic cholecystectomy, operative complications, postoperative complications and operative time were evaluated on the basis of using different camera assistants and the chronological advancement of the same operator and the same first assistant. RESULTS: The average operative time was 120 +/- 54 minutes. The operative time was statistically longer in the first ten cases. The major complication during operation, which was ligation of the common bile duct, occurred in the 7th case. The other operative complications, such as minor bile duct injury or mild bleeding, occurred occasionally in spite of experience or inexperience; the operative complications, however, tended to occur under the same camera assistant. On the other hand, the operative time was not related to the use of different camera assistants. CONCLUSIONS: From the personal learning curve of laparoscopic cholecystectomy, operative time is relatively longer in the early 10 cases. Complications tend to occur under the same camera assistant.     

Different expressions of sialyl Tn antigen between polypoid and flat-type early colorectal cancers

PURPOSE: Sialyl Tn (STn) antigen is a cancer-associated carbohydrate antigen expressed in cancers of the digestive tract. We compared the proportion of specimens of flat-type colorectal cancers expressing STn with that of polypoid cancers, by examining the immunohistochemical reactivity of STn in various morphologic types of early and advanced colorectal cancers. METHODS; A total of 111 biopsies from the colorectal area were examined for STn expression, including 11 adenomas, 58 early cancers, and 42 advanced cancers. Each section was stained immunohistochemically for STn antigen. In each section, we examined STn expression in the cancer area, adjacent mucosa, and normal epithelium. RESULTS: STn expression was detected in 90.9 percent of adenomas, 36.2 percent of early cancers (T1), 64.3 percent of advanced cancers (>T1), and 52 percent of mucosa adjacent to cancer. The morphology of cancer tissue did not influence the number of specimens exhibiting STn antigen expression in mucosa adjacent to cancer cells. STn antigen was rarely expressed in flat or depressed-type early cancers (T1; 7.1 percent), and the expression was higher in moderately than in well-differentiated adenocarcinomas. In advanced cancers (>T1), a similar proportion of protruding and small ulcerative cancers expressed STn. CONCLUSION: Our results suggest that the low expression of STn antigen in flat-type cancers may be the result of different mechanisms of cellular transformation during carcinogenesis from the usual adenoma-carcinoma sequence in colorectal neoplasms.     

Principle of perioperative management for hepatic resection and education for young surgeons

BACKGROUND/AIMS: An expert technique and special anatomical or physiological knowledge are needed in the field of hepatic surgery compared to other abdominal surgeries. The establishment of basic policy and operative techniques for hepatectomy and stepwise training for young hepatic surgeons are necessary. METHODOLOGY: We scheduled hepatic resection based on the indocyanine green retention rate at 15 minutes and volumetric analysis. Limited resection or preoperative portal vein embolization was often performed. RESULTS: Between 1994 and December 2005, 338 hepatectomies were performed. Operative procedures included limited or segmental resection in 215 and hemihepatectomy or more extended hepatectomy in 123. Hyperbilirubinemia or hepatic failure after hepatectomy was observed in 15 (4%) and hospital death in 10 (3%). Although death from hepatic failure was observed in 9 of 152 (6%) between 1994 and 1999, the mortality rate has been improved since 2000 (1 of 186 [0.5%]). Senior residents start training with step by step hepatectomy from partial resection to sectionectomy. Hemi-hepatectomy for normal liver is finally permitted after technical consolidation. More complicated hepatectomy must be performed by experienced teaching surgeons. CONCLUSIONS: Competent operative techniques under experienced surgeons and the achievement of safe resection at each stage are the educational policy for hepatectomy.     

Reducing the incidence of post-hepatectomy hepatic complications by preoperatively applying parameters predictive of liver function

Background/purpose

To prevent or reduce hepatic complications after hepatectomy, it is important to employ preoperative predictive parameters and to determine the indications for hepatectomy. In the present study, we evaluated risk parameters in patients who underwent hepatectomy between 1994 and 2003, and selected three parameters to modify the surgical indications. Using these indications before surgery in patients who underwent hepatectomy between 2004 and 2008, we compared the prevalences of postoperative complications in the the two groups of patients.

Methods

We examined 250 consecutive patients who underwent hepatectomy for liver disease [149 in 1994–2003 (termed the early period) and 101 in 2004 to 2008 (termed the later period)].

Results

In the early period, uncontrolled ascites was observed in 55 patients and hepatic failure was observed in 15 of the 149 patients. Multivariate analysis identified volume of the resected liver (≥50%), intraoperative blood loss (≥1500 ml), prothrombin activity (<70%), hyaluronic acid level (≥200 ng/ml), and LHL15 (hepatic uptake ratio of technetium-99m galactosyl human serum albumin (^99mTc-GSA) (<0.85) as risk factors; the latter three parameters were evaluated as predictors of outcome. From 2004, we used these three parameters, in addition to the indocyanine green retention rate at 15 min (ICGR15), as criteria for indications for hepatectomy. Despite the lower prevalence of normal liver in the later period, comparisons showed decreases in the rates of uncontrolled ascites (23 vs. 37%, P = 0.03), hepatic failure (4 vs. 10%, P = 0.12), and hepatic complications (25 vs. 44%, P = 0.003) in patients in the later period compared with these rates in the previous period.

Conclusions

The use of prothrombin activity, and levels of hyaluronic acid and LHL15, as parameters of functional liver reserve in the selection of candidates for surgery reduced the incidence of hepatic complications after hepatectomy.