Yoshikazu Mizoguchi

A 79-year-old man was admitted to the hospital because he was pointed out having gastric cancer and hepatic impairment. Upper gastrointestinal fluoroscopy and endoscopic study disclosed type 3 gastric cancer on the lesser curvature of the upper and middle portion of the stomach. Abdominal CT scan showed # 12 lymph node metastasis and tumor embolism at the portal trunk, but SOL was not especially confirmed though the hepatic parenchyma was revealed as slight uneven staining. During preoperative examinations, the patient went into shock after hematemesis and anal bleeding so that an emergency total gastrectomy with splenectomy was performed for hemostasis. Histopathologically, it was well differentiated adenocarcinoma with a strong tendency of vascular invasion, tumor invasion depth of se, intermediate type, INFβ, ly3, and v2. The patient rapidly went into DIC state and died of hemorrhagic shock on the next day. Autopsy revealed metastases to the liver, bone marrow, prostate, and lymph nodes of the hili of the lung and liver, other than portal tumor embolism. Based on the autopsy findings, he died from suddenly progressed hepatic failure due to hepatic metastasis and portal tumor embolism as well as hemorrhagic shock associated with DIC. The hepatic metastasis which could not be demonstrated by preoperative CT was found to be diffuse metastasis of tumor cells which forms no tumor. In all metastatic foci including hepatic metastasis, tumors looked like small cell carcinoma. On immunohistologic stainings, the primary foci and portal tumor embolism which manifested well differentiation were negative for chromogranin A and CD56 (NCAM) stainings, but periportal lymph nodes and hepatic metastasis were positive. On H-E stainings, there were areas showing vascular forming tendency. We consequently considered that dedifferentiation to small cell carcinoma in metastatic foci from well differentiated adenocarcinoma of the primary foci might occur.

Primary tracheal carcinoma is rare. A 58-year-old man had hemoptysis in early March, 1997 and was treated for a polypoid vocal cord by an otorhinolaryngologist. When he was admitted to another hospital on Aug. 23 because of a traffic accident, he expectorated bloody sputum, a cytological examination of which revealed class 111 cells. He was referred to our hospital for more examinations on Sep. 6. Bronchoscopy demonstrated a polypoid tumor in the trachea and a biopsy revealed squamous cell carcinoma. There was no metastasis. Tracheal resection from the 4th to 8th tracheal ring and end-to-end anastomosis was performed on Oct. 21. Pathological examination demonstrated a moderately differentiated squamous cell carcinoma in situ and immunohistochemical examination and in situ hybridization showed positive stainings. A relationship with human papillomavirus was strongly suspected. The postoperative course was uneventful.

A 45-year-old woman presented with a left breast mass. The painless solitary tumor was palpated in the A region of the left breast. Ultrasonography revealed an internally isoechoic mass with a regular margin. Mammography visualized a light spherous tumor with a smooth margin. Histopathologically, the excised specimen was 1.5×1.2cm in size and the section was milk-white in hue and hard. At low magnification, the tumor was relatively illdefined and localized but with no capsule. Mild compression of surrounding glandular ducts was also observed. At high magnification, smooth muscle fascicular or nerve fascicular structures were seen surrounding the ducts and framework. A biphasic pattern was clear in the duct itself and neither a cytological heterotype nucleus nor mytosis was seen in the duct and surrounding cells. Muscle-actin and α-smooth muscle actin staining showed strong positive responses in the cyto-plasms of tumor cells in the vicinity of the duct. These findings confirmed that this localized tumor, growing mainly in smooth muscle cells, was a muscular hamartoma.