Hirotaka Sako

Simultaneous detection of B-cells and T-cells by a double immunohistochemical technique using immunogold-silver staining and the avidin-biotin-peroxidase complex method

SummaryA new double immunohistochemical technique for the simultaneous detection of B-cells and T-cells was investigated, using tissue preparations obtained from human axillary lymph nodes and rejected renal allografts. The specimens were immunostained first for the demonstration of B-cells, by the immunogold-silver staining (IGSS) method using Leu-12 monoclonal antibody, and then for T-cells by the avidin-biotin-peroxidase complex (ABC) method using Leu-1 monoclonal antibody. With the present methods, both B-cells and T-cells were clearly detected and distinctively identified without cross-linking of antibodies or double reaction of enzymes.

Azathioprine‐lnduced Megaloblastic Anemia with Pancytopenia 22 Years after Living‐Related Renal Transplantation

Macrocytosis and megaloblastic changes in the bone marrow are frequently seen in renal transplant recipients treated with azathioprine(Az). However, severe anemia is a rare side effect of Az. We recently observed a case of severe megaloblastic anemia with pancytopenia in a renal transplant recipient who had been receiving Az therapy for 22 years. The patient was a 46‐year‐old woman who had been administered Az and prednisolone at a dose of approximately 1.7mg/kg and 0.17 mg/kg daily, respectively. A bone marrow aspiration revealed megaloblastic anemia with the depletion of myeloid cells and megakaryocytes. She did not have vitamin B12 or folate deficiency. Therefore, FK506 (tacrolimus), a macrolide produced by Streptomyces tsukubaensis, which acts directly on T cells and is known to have less myelosuppression than Az, was substituted for Az. Although the leukopenia improved, the anemia and thrombocytopenia did not improve in the short term. She developed dyspnea and severe subcutaneous bleeding of the right lower extremity due to knee contusions. Hemodialysis was started to treat her uremic state. Although it was impossible to evaluate the long‐term effects of FK506 therapy for the pancytopenia in our case, the conversion from Az to a less myelosuppressive drug, such as FK506, should be considered in renal transplant recipients with severe myelosuppression caused by long‐term Az treatment.

Pancreatic cancer: Slow progression in the early stages.

INTRODUCTION The rates of pancreatic cancer development in the early stages of growth remain unclear; but it is generally believed that they demonstrate a rapid degree of progression. There is evidence to suggest that pancreatic cancers measuring less than 1cm demonstrate better survival rates, hence it is clear that detecting pancreatic cancers less than 1cm in size is of paramount importance. However, to date, there has been no scientifically adequate research to show the growth rate of small pancreatic cancers less than 1cm in the early stages. PRESENTATION OF CASE We present the case of a 65-year-old woman whose small pancreatic cancer possibly demonstrated a slow progressive rate as it grew to an invasive carcinoma measuring 1cm diameter from over the 29 months. DISCUSSION It is reasonable to assume that the progression of some pancreatic cancers until 1cm size, can take up to 29 months. During this silent period, it is crucial to detect such a small pancreatic cancer by means of the initial US and subsequent EUS and ERCP. It is clear, therefore, that clinicians have to be aware of the growth rate of small pancreatic cancers and in particular high risk patients should be encouraged to monitor size of the main pancreatic duct by means of US on regular basis. CONCLUSION This could give better outcomes for pancreatic cancer patients. Hopefully, by detecting these lethal, pancreatic cancers in their early stages, it will give us an extension of time to perform effective therapies.

BENIGN CERVICAL TERATOMA IN AN ADULT : REPORT OF A CASE

Cervical teratomas are rarely encountered in adults. We report herein the case of a 21-year-old woman who was admitted to our hospital for surgical treatment of a neck tumor, 7.5×4.5×2.7 cm in size, located in the left lower pole of the thyroid. Ultrasonography (US) and computed tomography (CT) revealed a multicystic tumor. The levels of carcinoembryonic antigen (CEA), carbohydrate antigen 19–9 (CA 19-9), and squamous cell carcinoma-related antigen (SCC) in the cystic fluid were extremely elevated in contrast to the normal levels found in the serum. The tumor was completely excised and histological examination revealed it to be composed of elements derived from the three germ layers, confirming a diagnosis of benign cystic teratoma.

Successful surgical rescue of delayed onset diaphragmatic hernia following radiofrequency ablation for hepatocellular carcinoma

Radiofrequency ablation (RFA) has been established as the mainstay therapy for hepatocellular carcinoma (HCC) in patients deemed unsuitable for surgical resection. However, delayed diaphragmatic hernia can occur as a result of this procedure. There have been only seven other cases reported on this complication in the literature. Considering the recent growth in the popularity of the procedure, it is predictable that the incidence of the diaphragmatic hernia, due to RFA, will definitely increase. This case report is therefore vitally important as it increases clinical awareness of this currently rare complication, which could lead to improved survival rates in these patients. This case concerns an 81-year-old Asian man with a past medical history of cirrhosis and HCC (segment IV and VIII) who presented with a delayed, right diaphragmatic hernia and strangulated ileus 18 months after his original RFA procedure. It is important to implement extra measures to limit the risk of diaphragmatic, thermal injuries when RFA is performed. In particular, gastroenterologists, surgeons and accident and emergency staff should all be aware of this complication proceed with rapid diagnosis and management when patients, who previously underwent RFA, present with acute abdominal pain.

Uncommon Lymphoepithelial Cyst with Sebaceous Glands of the Pancreas

CONTEXT Lymphoepithelial cysts with sebaceous glands of the pancreas are extremely rare, with only 7 cases, including this case, published in English literature. CASE REPORT We herein present the case of a 67-year-old Asian man who underwent a resection of a lymphoepithelial cyst of the pancreas during the follow up care for lung cancer. Fourteen years previously he underwent a right lower lobectomy at the right segment nine for lung cancer. A 20 mm mass in the body of the pancreas was identified by CT scan 4 years ago, and the diagnosis was intraductal papillary mucinous neoplasm (IPMN) at that time. Over a 5-year period, this mass grew to 42 mm without dilatation of the main pancreatic duct. The preoperative evaluation, including endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), indicated a cystic neoplasm with suspicion of malignancy. Intraoperative frozen section revealed a squamous-lined cyst accompanied by sebaceous glands without any malignant findings. Following this pathological finding, resection of the cyst was performed. Consequently, microscopic examination revealed that it was a lymphoepithelial cyst with sebaceous glands of the pancreas. CONCLUSIONS Pancreatic lymphoepithelial cysts can be cured by conservative resection, but if they are asymptomatic and are diagnosed before surgery, no treatment is necessary. To our knowledge, this is the first ever published case of a lymphoepithelial cyst with sebaceous glands of the pancreas, which was found during the follow up care for lung cancer.

Familial hyperparathyroidism: Report of a case

We report herein a case of familial primary hyperparathyroidism diagnosed in a 23-year-old woman who presented with hypercalcemia and urolithiasis. The parathyroid gland was removed, and pathological examination revealed chief cell adenoma. The proband’s younger sister had undergone surgery for parathyroid adenoma at the age of 19, and her aunt had a history of urolithiasis with a high level of serum parathyroid hormone. We have not yet found evidence of any other endocrine disorders suggesting multiple endocrine neoplasia (MEN) type 1 in this pedigree.

Successful liver resection for the unusual case of peripheral intra bile duct growth of liver metastasis from colorectal carcinoma

Peripheral intrabiliary liver metastases (PILM) from colorectal carcinoma are rare, and this feature, which resembles primary cholangiocarcinoma, potentially misleads the accurate diagnosis and subsequent surgical treatment. A 67-year-old man with a medical history of descending colon carcinoma demonstrated an abnormal rise in CA19-9. There was a strong possibility of peripheral cholangiocarcinoma, because Computed tomography detected tumour infiltration into bile duct three. The patient underwent anatomic segment eight and lateral lobe resection. Pathological findings revealed that every tumour was metastatic liver carcinoma due to descending colon carcinoma. Cases of liver metastasis which resemble peripheral cholangiocarcinoma might be difficult to distinguish preoperatively. The correct diagnosis is important in making decisions regarding the surgical management of such patients. Nonanatomic hepatectomy is often performed for liver metastases from colorectal carcinomas. Anatomic hepatectomy, however, should be recommended in cases of PILM.

A CASE OF GRAVES' DISEASE WITH AN ENORMOUS GOITER

症例は33歳,男性.主訴は頸部腫脹.バセドウ病のため他院で抗甲状腺剤,β遮断剤の内服治療を受けていたが, 1年前より急激に甲状腺腫が増大し内科的治療が困難になってきたため,自ら手術を希望し当院に紹介受診となった.受診時は首回りが50cmにもおよぶ巨大甲状腺腫でかつ機能亢進状態にあった.手術時大量出血が予想されたため自己血1,200mlを準備し,ヨウ化カリウム,ステロイド,炭酸リチウムで甲状腺機能抑制を図ったが充分なホルモン分泌抑制が得られないまま甲状腺亜全摘術を施行した.摘出甲状腺重量は786g,術中出血量1,715ml,手術時間9時間54分,推定残置量は3.2gだった.術後一過性甲状腺機能過剰状態と左反回神経麻痺を呈した.術後7カ月目現在首回りは38cm,甲状腺機能低下症を呈しているためレボチロキシンナトリウム(チラーヂンS®)を内服中である.巨大な甲状腺腫に対して外科的治療は非常に有効であるが,推定甲状腺重量が200gを超えると手術手技的難易度が格段に上昇するため,内科的,放射線的治療に抵抗性を有すると判断された場合は,甲状腺腫が大きくなる前に速やかに外科的治療に切り替えるべきであると考えられた.

Double Immunocytochemical Staining Methods

The introduction of immunological techniques into tissue staining methods has enabled the analysis of the pathological state of various diseases. Immunohistochemical methods are based on the specific antigen-antibody reaction and have made possible the differentiation of the fine structure that could not be stained by ordinary histological staining techniques hitherto. For example, two kinds of cells difficult to differentiate by light microscopy can be visualized separately by using immunohistochemistry in conjuction with different antisera. Furthermore, simultaneous visualization of two or more antigens in the same specimen has become desirable in immunohistochemistry for the detection of cytoarchitectural relationships between cellular sources of these antigens and for quantitating cells containing different antigens (Hsu and Soban, 1982). Therefore, many studies on double staining methods have been carried out.