Fumiyoshi Kojima

Whole genome sequencing discriminates hepatocellular carcinoma with intrahepatic metastasis from multi-centric tumors.

BACKGROUND & AIMS Patients with hepatocellular carcinoma (HCC) have a high-risk of multi-centric (MC) tumor occurrence due to a strong carcinogenic background in the liver. In addition, they have a high risk of intrahepatic metastasis (IM). Liver tumors withIM or MC are profoundly different in their development and clinical outcome. However, clinically or pathologically discriminating between IM and MC can be challenging. This study investigated whether IM or MC could be diagnosed at the molecular level. METHODS We performed whole genome and RNA sequencing analyses of 49 tumors including two extra-hepatic metastases, and one nodule-in-nodule tumor from 23 HCC patients. RESULTS Sequencing-based molecular diagnosis using somatic single nucleotide variation information showed higher sensitivity compared to previous techniques due to the inclusion of a larger number of mutation events. This proved useful in cases, which showed inconsistent clinical diagnoses. In addition, whole genome sequencing offered advantages in profiling of other genetic alterations, such as structural variations, copy number alterations, and variant allele frequencies, and helped to confirm the IM/MCdiagnosis. Divergent alterations between IM tumors with sorafenib treatment, long time-intervals, or tumor-in-tumor nodules indicated high intra-tumor heterogeneity, evolution, and clonal switching of liver cancers. CONCLUSIONS It is important to analyze the differences between IM tumors, in addition to IM/MC diagnosis, before selecting a therapeutic strategy for multiple tumors in the liver. LAY SUMMARY Whole genome sequencing of multiple liver tumors enabled the accuratediagnosis ofmulti-centric occurrence and intrahepatic metastasis using somatic single nucleotide variation information. In addition, genetic discrepancies between tumors help us to understand the physical changes during recurrence and cancer spread.

Novel Methodology for Rapid Detection of KRAS Mutation Using PNA-LNA Mediated Loop-Mediated Isothermal Amplification.

Detecting point mutation of human cancer cells quickly and accurately is gaining in importance for pathological diagnosis and choice of therapeutic approach. In the present study, we present novel methodology, peptide nucleic acid—locked nucleic acid mediated loop-mediated isothermal amplification (PNA-LNA mediated LAMP), for rapid detection of KRAS mutation using advantages of both artificial DNA and LAMP. PNA-LNA mediated LAMP reactions occurred under isothermal temperature conditions of with 4 primary primers set for the target regions on the KRAS gene, clamping PNA probe that was complimentary to the wild type sequence and LNA primers complementary to the mutated sequences. PNA-LNA mediated LAMP was applied for cDNA from 4 kinds of pancreatic carcinoma cell lines with or without KRAS point mutation. The amplified DNA products were verified by naked-eye as well as a real-time PCR equipment. By PNA-LNA mediated LAMP, amplification of wild type KRAS DNA was blocked by clamping PNA probe, whereas, mutant type KRAS DNA was significantly amplified within 50 min. Mutant alleles could be detected in samples which diluted until 0.1% of mutant-to-wild type ratio. On the other hand, mutant alleles could be reproducibly with a mutant-to-wild type ratio of 30% by direct sequencing and of 1% by PNA-clamping PCR. The limit of detection (LOD) of PNA-LNA mediated LAMP was much lower than the other conventional methods. Competition of LNA clamping primers complementary to two different subtypes (G12D and G12V) of mutant KRAS gene indicated different amplification time depend on subtypes of mutant cDNA. PNA-LNA mediated LAMP is a simple, rapid, specific and sensitive methodology for the detection of KRAS mutation.

Tumor budding is an independent risk factor for lymph node metastasis in cutaneous squamous cell carcinoma: a single center retrospective study.

Although tumor budding is acknowledged as a risk factor for lymph node metastasis in certain types of carcinoma, it is not well investigated in cutaneous squamous cell carcinomas (SCCs). In this study, we analyzed the correlation between tumor budding and nodal metastasis in cutaneous SCC.

A novel immunopathological association of IgG4-RD and vasculitis with Hashimoto's thyroiditis

Summary A 73-year-old man with Hashimotos thyroiditis (HT) suffered from purpura on the lower legs. He was diagnosed with IgG4-related disease (IgG4-RD) with serum IgG4 elevation and dacryo-sialadenitis confirmed histologically. Serum Th2 and Treg cytokines, interleukin 7 (IL7), IL8 and Th2 chemokine levels were elevated, while skewed Th1 balance was seen in fluorescence-activated cell sorting (FACS). Therefore, preferential Th1 balance in HT appeared to be followed by IgG4-RD characterized with Th2 and Treg polarization. The commencement of steroid therapy dramatically exacerbated clinical manifestations including IgG4-RD-associated HT. The measurement of cytokine and chemokine levels as well as FACS analysis in the development of IgG4-RD seemed to be beneficial. In conclusion, an innovative association of HT, IgG4-RD and vasculitis was observed. This report also offers novel diagnostic and therapeutic approaches for IgG4-RD. Learning points Recently, a subtype of HT has been considered to be a thyroid manifestation of IgG4-RD, although the etiology of IgG4-RD is not established yet. Immunologically a close association between HT and vasculitis was reported. Leukocytoclastic vasculitis is a rare skin presentation of IgG4-RD. In the current case, during the course of HT, IgG4-RD and leukocytoclastic vasculitis occurred; thus, innate immunity and acquired immunity seem to be involved in the development of IgG4-RD. The measurement of cytokine and chemokines appeared to be beneficial in the development of IgG4-RD. Remarkably, effectiveness of steroid therapy for HT suggested presence of IgG4-RD-associated HT. Therefore, this report highlights the pathogenesis of IgG4-RD and proposes novel therapeutic mechanisms. Clinicians should pay attention to the development of IgG4-RD and vasculitis during long course of HT.

Value of apparent diffusion coefficient prior to neoadjuvant therapy is a predictor of histologic response in patients with borderline resectable pancreatic carcinoma

The parameters to predict histological response to neoadjuvant therapy remain controversial in borderline resectable pancreatic carcinoma (BRPC).

Placental mesenchymal dysplasia with severe fetal growth restriction in one placenta of a dichorionic diamniotic twin pregnancy

We report a rare case of placental mesenchymal dysplasia (PMD) with fetal growth restriction (FGR) in one placenta of a dichorionic diamniotic (DD) twin pregnancy. A 24‐year‐old woman was referred to our hospital at 24 weeks’ gestation due to FGR and ipsilateral placental abnormality in DD twins. Ultrasound and magnetic resonance imaging showed one placenta of the FGR fetus was bulky and had multiple cysts, while the other fetus placenta appeared normal. Cesarean section was performed at 32 weeks’ gestation; the first and second neonates weighted 1799 and 1215 g, respectively. Macroscopically, chorionic vessels on the placental surface of the second neonate were prominently enlarged. Pathological findings demonstrated swelling stem villi with enlarged vessels and increased interstitial cells without trophoblast proliferation. Immunostaining for p57kip2 was negative in interstitial cells and cytotrophoblasts of the swelling stem villi. This suggested that PMD occurred in one placenta of the DD twin, leading to early‐onset FGR.

Acquired cystic disease-associated renal cell carcinoma: a clinicopathological study of seven cases

The disease entity of acquired cystic disease (ACD)-associated renal cell carcinoma (RCC) has been recently incorporated into the international renal tumor classification. However, there are a few descriptions on clinicopathologic features. We performed a clinicopathologic study of seven cases with ACD-RCC. All tumors were incidentally found. Histologically, the tumor consisted of microcystic or cribriform pattern of neoplastic cells with deeply eosinophilic to oncocytic cytoplasm in the stroma of oxalate crystal deposition. Three cases contained the area of sarcomatoid transformation, of which one case also demonstrated rhabdoid phenotype foci. Six among seven patients had a hemodialysis history of more than 10 years and two patients showing the dedifferentiation had a hemodialysis history of more than 20 years. The follow-up duration ranged from 18 to 107 months with a mean of 59.1 months. Regarding the outcome, four patients were alive without disease. One patient was alive with metastasis 10 months after the operation. No patient died of disease. Finally, ACD-RCC generally pursues a favorable clinical course, but tumors with a hemodialysis history of more than 20 years may cause the dedifferentiation such as sarcomatoid change or rhabdoid features and this phenomenon may lead to worse clinical outcome.

Adipophilin expression in cutaneous malignant melanoma

The lipogenic pathway is upregulated in cancer cells, including melanomas. However, the pathological significance of cellular lipids in melanocytic lesions has yet to be determined. In this study, we evaluated intracytoplasmic lipid droplets in melanocytic nevi (MNs) and malignant melanomas via immunohistochemical analysis of adipophilin (ADP), which coats lipid droplets.

Macrocystic ductal adenocarcinoma of prostate: A rare gross appearance of prostate cancer

Macroscopic cyst-formation by prostatic adenocarcinoma, herein referred to as macrocystic prostatic adenocarcinoma (MPA), is extremely rare. To date, no studies of prostate cancer performed based on gross cystic appearance have been reported. MPA can include various diseases, one of which is cystadenocarcinoma. Several cases of ductal adenocarcinoma exhibiting a macrocystic appearance have recently been reported; however, the histological and clinicopathological characteristics of MPAs have yet to be characterized and established. Therefore, we aimed to determine the histological and clinicopathological characteristics of MPA, via a multi-institutional investigation. We discovered five patients with MPA out of 1559 treated patients (0.32%); all cases were ductal adenocarcinomas. MPA was found to have three growth patterns: Two cases showed a prevalence of exuberant papillary proliferation with a fibrovascular core in the macroscopic multilocular cysts. Two others predominantly exhibited multilocular cysts lined by flat epithelium with foci of low papillae, and the fifth had a cystic lesion with intracancerous necrosis. Three of the cases showed extraprostatic invasion; however, none of the patients experienced recurrence during the follow-up period. Each predominant growth pattern tended to exhibit unique clinicopathological characteristics with respect to serum prostate specific antigen level and tumor size and location. In conclusion, we demonstrated that MPA is a ductal adenocarcinoma that is composed of intracystic exuberant papillary proliferation and flat proliferation with foci of low papillae, both of which might exhibit different clinicopathololgical appearances.

Loss of SWI/SNF complex expression in undifferentiated renal carcinoma in acquired cystic kidney: Letter to the Editor

To the Editor: Loss of the SWI/SNF complex has recently been reported in carcinomas of various organs, including stomach, kidneys, upper urinary tract, and the lung. These carcinomas exhibited similar morphology, undifferentiated pleomorphic or rhabdoid morphology. For the first time, we report an undifferentiated pleomorphic renal carcinoma that developed in a patient with acquired cystic kidney, showing loss of the SWI/SNF complex. A 70-year-old male patient was admitted to our hospital presenting with a fever of unknown origin that had continued for 4 months. He had undergone hemodialysis for 22 years because of chronic glomerulonephritis. Positron emission tomography and computed tomography revealed a left renal tumor and with metastasis to the liver, bone, and paraaortic lymph node. We performed a left nephrectomy for volume reduction and to relieve the fever. After the operation, the patient had no complications and molecular-targeted drugs were administered. He survived with disease for 2 months. Macroscopically, the resected kidney had a multilocular cystic appearance, and a 4.5 4.0 3.5 cm tumor mainly located in the lower pole. The cut surface of the tumor was a whitish solid mass with necrosis and hemorrhage. We prepared 40 hematoxylin-eosin stained slides by whole sectioning of the resected kidney. Microscopically, the carcinoma had invaded the perirenal and sinus fat. Lymphovascular invasion was prominent and the carcinoma was involved in the renal vein. The carcinoma exhibited solid growth (Fig. 1a) with foci of cribriform-like architecture composed of intraand inter-cytoplasmic lumina. The carcinoma had massive necrosis accompanied by prominent inflammatory cells. Carcinoma cells were large and pleomorphic with rhabdoid foci of (Fig. 1b) and spindle cell formation (Fig. 1c). The spindle cells were not prominent and were intermingled with pleomorphic cells. Scattered carcinoma cells with bizarre nuclei and multinucleation were observed. A few oxalate crystals were seen in the carcinoma (Fig. 1b). The carcinoma was composed of only undifferentiated pleomorphic area, without area of differentiated renal carcinoma. Immunohistochemically, the carcinoma was positive for PAX8 and CD10. AMACR was positive for 10% of carcinoma cells and S100A1 was positive for 30% of carcinoma cells. A few carcinoma cells were positive for SALL4. GATA3, carbonic anhydrase IX, RCC marker, CK7, c-kit, ksp-cadherin, CK34bE12, TFE3, OCT3/4, glypican 3, ALK(5A4), and mismatch repair protein (MLH1, MSH2, MSH6, and PMS2) were negative. P53 expression was completely lost. We could not clarify whether the carcinoma had dedifferentiated from another differentiated renal neoplasm or the carcinoma had developed de novo. We supposed that the carcinoma could be classified as acquired cystic disease-associated renal cell carcinoma (ACD-RCC) because the patient had a long history of hemodialysis, and oxalate crystal deposition and cribriform-like growth were observed, but this was contradicted by the tumors immunoprofile, which was atypical for ACD-RCC: immunonegative for AMACR and RCC marker. Accordingly, we diagnosed the carcinoma as undifferentiated pleomorphic renal carcinoma, pT3aN1M1, Stage 4 (UICC 8th). Additionally, we performed immunohistochemical analysis for seven members of the SWI/SNF complex: SMARCA2, SMARCA4 (BRG1), SMARCB1 (INI-1), SMARCC1, SMARCC2, ARID1A, PBRM1 (BAF180). We demonstrated loss of SMCARCA2 (Fig. 1d), SMARCB1 (Fig. 1e), and PBRM1 (Fig. 1f); the other antibodies against the SWI/SNF complex showed intact. The loss of INI-1 expression has only been reported in renal medullary carcinoma and some collecting duct carcinomas in adult renal tumors. Recently, it was reported that putative dedifferentiated renal carcinoma from clear cell renal carcinoma, papillary renal cell carcinoma, and chromophobe renal cell carcinoma showed loss of some constituents of the SWI/SNF complex. However, loss of the SWI/SNF complex had not previously been reported in ACD-RCC or renal cell carcinoma in acquired cystic kidney. We could not demonstrate dedifferentiation from ACD-RCC in this case. However, we suggest that loss of SWI/SNF might be associated with the undifferentiated pleomorphic morphology, including rhabdoid and spindle cells, irrespective of the background of tumor development. To our knowledge, co-loss of SMARCA2, SMARCB1, and PBRM1 has not been reported in renal carcinoma. Further study will be required to determine whether this loss pattern is characteristic of renal cell carcinoma developed in ACD. In conclusion, we reported the loss of the SWI/SNF complex in an undifferentiated renal carcinoma developed in acquired cystic kidney and show a previously unreported co-loss pattern of the SWI/SNF complex in renal