Mitsuharu Tamakawa

Growth rates of primary and metastatic lesions of renal cell carcinoma

Abstract Background: The natural history and growth rate of renal cell carcinoma (RCC) have not yet been determined. The growth rates of primary lesions in incidentally found RCC were compared with those of metastatic lesions.

The Spectrum of Findings in Supra-Aortic Takayasu’s Arteritis as Seen on Spiral CT Angiography and Digital Subtraction Angiography

Takayasu’s arteritis (TA) mainly affects the aorta and its major branches. The lesions are distributed in all elastic arteries that possess vasa vasorum. The frequency of the sites of arterial involvement reflects racial and geographic differences [1–7]. In Japan, stenosis or occlusion of the supra-aortic arch branches is commonly observed and leads to pulseless disease [5–7]. We present the spiral CT angiography (CTA) and intraarterial digital subtraction angiography (IA-DSA) findings of the aortic arch in TA. The spectrum of findings on CTA are stenosis, occlusion, dilatation, arterial wall thickening, and calcification of the aortic arch branches.

Radiotherapy for Kimura's disease: the optimum dosage.

PURPOSE To evaluate retrospectively the optimum dosage of irradiation for Kimuras disease. METHODS AND MATERIALS Twenty patients with Kimuras disease were treated with radiotherapy. The sex ratio was 19 males to 1 female. The mean ages at onset, initial treatment, and radiotherapy were 26.2, 29.5, and 32.2 years, respectively. Radiotherapy was mainly applied for residual or recurrent tumors. The eosinophil count increased by more than 10% in 18 of the 20 patients. In most instances, irradiation was given through a single field with dosages ranging from 20 to 44 Gy. RESULTS At the completion of radiotherapy, a marked response in tumor size was noted in all cases. The minimum follow-up was 48 months. Local control was obtained in 23 of 31 lesions (74.1%). At dosages of < or =25 Gy, 26-30 Gy, and > 30 Gy, local control was obtained in 2 of 8 (25.0%), 9 of 10 (90.0%), and 12 of 13 sites (92.3%), respectively. CONCLUSIONS Radiotherapy is an effective treatment for Kimuras disease. This strongly suggests that no surgical procedure other than a biopsy should be carried out. The radiation field should be limited to the lesion and swelling of the adjacent lymph nodes as much as possible, with a optimum dosage of 26-30 Gy regardless of tumor size.

Double-subtraction maximum intensity projection MR angiography for detecting the artery of Adamkiewicz and differentiating it from the drainage vein

To evaluate the efficacy of double‐subtraction magnetic resonance angiography (MRA) (subtraction of the subtracted venous phase image from the subtracted arterial dominant phase image) for depicting the artery of Adamkiewicz and differentiating it from the drainage vein.

A Role for Preoperative Systemic Chemotherapy in Node-positive Upper Tract Urothelial Carcinoma Treated with Radical Nephroureterectomy

OBJECTIVE There are few reports investigating the potential benefits of preoperative systemic chemotherapy for patients with node-positive upper tract urothelial carcinoma. The purpose of this study was to examine the impact of preoperative systemic chemotherapy on the clinical outcomes of patients with node-positive upper tract urothelial carcinoma treated by radical nephroureterectomy. METHODS Data were collected on 195 consecutive patients with upper tract urothelial carcinoma treated by radical nephroureterectomy between 1995 and 2010 at a single institute. Of these, 29 patients with node-positive disease but no visceral metastasis were retrospectively evaluated. In patients who underwent preoperative systemic chemotherapy, tumor response, post-therapy pathological downstaging to either residual disease at radical nephroureterectomy or no residual lymph node metastasis (pN0) and toxicity were the endpoints of interest. Overall survival was compared between two groups: those with and without preoperative chemotherapy. RESULTS All patients underwent regional lymphadenectomy. Overall, 15 patients (52%) underwent preoperative systemic chemotherapy. Pathological downstaging was achieved in 47%, including pN0, but there was no pathological complete response. Eighty-six percent of the patients with pathological downstaging had no evidence of recurrence. The median overall survivals were 38 and 9 months for patients with and without preoperative systemic chemotherapy, respectively (hazard ratio: 0.26, P = 0.015, log-rank test). There was no significant difference in operative morbidity between the two groups, and no operations were delayed because of preoperative chemotherapy. CONCLUSIONS The survival of patients who undergo preoperative systemic chemotherapy following radical nephroureterectomy seems to be superior to that of those undergoing radical nephroureterectomy alone. However, to confirm this, prospective randomized studies are needed.

The detection of the capsular tear at the undersurface of the extensor carpi radialis brevis tendon in chronic tennis elbow: the value of magnetic resonance imaging and computed tomography arthrography

HYPOTHESIS This study compared the diagnostic efficacy of magnetic resonance imaging (MRI) and computed tomography arthrography (CTA) in the assessment of capsular tears at the undersurface of the extensor carpi radials brevis tendon in chronic tennis elbow using arthroscopy as a gold standard. Because of the higher spatial resolution of CT, we hypothesized that CTA is superior to MRI for assessing capsular tears. MATERIALS AND METHODS We retrospectively reviewed 19 consecutive patients with chronic tennis elbow with preoperative MRI and CTA studies who underwent arthroscopic surgery. Three observers with different levels of training and experience (musculoskeletal radiologist, experienced elbow surgeon, and hand fellow) evaluated the capsular tear by MRI and CTA in a blinded manner. The results of the MRI and CTA were compared and the agreement among the 3 observers was determined using an intraclass correlation coefficient (ICC). Then, the results of the MRI and CTA examinations were compared with the intraoperative findings of the arthroscopic examination. The sensitivity, specificity, and κ value were calculated. RESULTS The ICC of CTA (0.855) was superior to MRI (0.645). The sensitivity, specificity, and κ value of CTA were superior to those of MRI in each of the 3 observers. The κ value was 0.79, 0.89, and 0.79 for CTA, and 0.48, 0.48, and 0.27 for MRI for the radiologist, surgeon, and fellow, respectively. CONCLUSIONS CTA was a reliable and accurate diagnostic modality compared with MRI to detect the capsular tear in patients with chronic tennis elbow. CTA was less influenced by the observers experience.

Gadolinium-enhanced dynamic magnetic resonance imaging with endorectal coil for local staging of rectal cancer.

PurposeThe aim of this study was to evaluate the accuracy of dynamic gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) with endorectal coil for assessing tumor invasion based on simple classification criteria.Materials and methodsA total of 58 patients with operable primary rectal cancer underwent preoperative MRI. An enhancement pattern in Gd-enhanced dynamic MRI with regard to tumor penetration was clarified. Retrospectively, two observers independently scored T2-weighted MRI and T2-weighted MRI combined with Gd-enhanced dynamic MRI for tumor penetration using the following criteria: With Gd-enhanced dynamic MRI, T1 tumors showed an early enhanced line around the tumor as rim enhancement; T2 tumors appeared as black lines or double layers, as the muscularis propria kept its integrity; T3 tumors showed partial discontinuity of the muscularis propria as a dotted line and a perforated area as an interrupted line. A confidence level scoring system was used, and receiver operating characteristic curves were generated.ResultsThere were no significant differences at the T1 stage. There were significant differences for observer 1 (P = 0.001 for observer 1) at the T2 stage. There were significant differences for both observers (P = 0.001 for observer 1 and P = 0.005 for observer 2) at the T3 stage.ConclusionOur criteria for Gd-enhanced dynamic MRI were effective for T3 stage tumors.

SPONTANEOUS REGRESSION OF PRIMARY RENAL CELL CARCINOMA WITH INFERIOR VENA CAVAL TUMOR THROMBUS

A 51-year-old woman was referred to our hospital with a left renal mass in December 1998. Computerized tomography (CT) of the abdomen revealed a 5 cm. mass in the left kidney with a thrombus in the renal vein extending into the infrahepatic vena cava (fig. 1, a and b). Ultrasonography guided biopsy of the renal mass performed elsewhere revealed malignant cells. The mass and thrombus were enhanced by intravenous bolus injection of contrast medium. Magnetic resonance imaging (MRI) confirmed a left renal mass extending into the inferior vena cava through the left renal vein (fig. 1, c). All findings were diagnostic of left renal cell carcinoma associated with left renal vein and inferior vena caval invasion. Performance status was grade 4. Laboratory findings revealed anemia and increased serum C-reactive protein. Because of poor general condition, the patient was followed with no medical treatment for renal cell carcinoma. In December 2000 CT of the abdomen revealed that the primary tumor in the left kidney had regressed (fig. 2, a). The tumor was not enhanced by intravenous bolus injection of contrast medium. The left renal vein and inferior vena cava seemed to have a normal appearance, which indicated that the tumor thrombus had regressed (fig. 2, b). MRI also showed apparent primary tumor resolution and a normal blood stream in the left renal vein and inferior vena cava (fig. 2, c and d). All findings were diagnostic of spontaneous regression of the left renal cell carcinoma with a tumor thrombus in the renal vein extending into the inferior vena cava.

Reconstructed animation from four-phase grip MRI of the wrist with ulnar-sided pain.

In order to visualize dynamic variations related to ulnar-sided wrist pain, animation was reconstructed from T2* coronal-sectioned magnetic resonance imaging in each of the four phases of grip motion for nine wrists in patients with ulnar pain. Eight of the nine wrists showed a positive ulnar variance of less than 2 mm. Ulnocarpal impaction and triangular fibrocartilage complex injury were assessed on the basis of animation and arthroscopy, respectively. Animation revealed ulnocarpal impaction in four wrists. In one of the four wrists, the torn portion of the articular disc was impinged between the ulnar head and ulnar proximal side of the lunate. In another wrist, the ulnar head impacted the lunate directly through the defect in the articular disc that had previously been excised. An ulnar shortening osteotomy successfully relieved ulnar wrist pain in all four cases with both ulnocarpal impaction and Palmer’s Class II triangular fibrocartilage complex tears. This method demonstrated impairment of the articular disc and longitudinal instability of the distal radioulnar joint simultaneously and should be of value in investigating dynamic pathophysiology causing ulnar wrist pain.

A case of pure sclerosing epithelioid fibrosarcoma with a cytogenetic and fluorescence in situ hybridization study

To the Editor: Sclerosing epithelioid fibrosarcoma (SEF) is a variant of fibrosarcoma characterized by epithelioid fibroblasts arranged in cords and nests in a sclerotic stroma. It is known that a subset of SEF appears to be related to lowgrade fibromyxoid sarcoma (LGFMS).SEF rarely contains the morphology of LGFMS and LGFMS also rarely contains the morphology of SEF. Doyle et al. applied the term ‘hybrid SEF-LGFMS’ for the tumor with hybrid features. MUC4 which was firstly found as a sensitive and specific marker for LGFMS was also shown as a useful marker for SEF later. Thus, the potential relationship between SEF and LGFMS is very interesting. On the other hand, the cytogenetic findings of SEF were not the same as the findings of LGFMS. The translocation, t(7;16)(q33;p11), resulting in the FUS-CREB3L2 fusion gene has been found in approximately two thirds of LGFMS cases. But, the SEF cases which were karyotyped did not show the cytogenetic changes observed in LGFMS although the cytogenetic information of SEF has been limited. Wang et al. showed that FUS rearrangements are rare (2 out of 22 cases) in pure SEF by fluorescence in situ hybridization (FISH). Arbajian et al. recently reported recurrent EWSR1CREB3L1 gene fusions in SEF. EWSR1 gene locates on chromosome 22q12. However, chromosomal abnomalities involving 22q12 have not been observed by the G-banded karyotypic analysis in SEF. We report a case of pure SEF with the karyotypic findings and FISH results. The patient was an 16-year-old Japanese female. She noticed an abdominal mass. Magnetic resonance imaging demonstrated a tumor in the right abdominal external oblique muscle. Biopsy and resection was performed. The patient was alive and free of disease for 18 months after surgery. Macroscopically, the tumor measuring approximately 3.5 × 3.2 × 3.0 cm was observed in the right abdominal external oblique muscle. The tumor was well circumscribed. The cut surface was yellowish-white (Fig. 1a). Necrosis was not observed. On microscopic examination, the tumor cells were embedded in dense fibrous stroma The cellularity was variable. Small to medium sized epithelioid cells were arranged in cords and nests embedded in fibrous stroma (Fig. 1b). The epithelioid cells had relatively bland round and ovoid nuclei. Bone formation and cartilage formation were focally observed (Fig. 1c). Giant cells or highly pleomorphic cells were not seen. The morphology of LGFMS was not found in the tumor. Immunohistochemically, the tumor cells were diffusely positive for MUC4 (clone 8G7; Santa Cruz Biotechnology, Santa Cruz, CA, USA) (Fig. 1d) and vimentin (clone SP20; Nichirei, Tokyo, Japan). The tumor cells were focally positive for EMA (clone E29; DAKO Cyotomation, Glostrup, Denmark) in cytoplasm and negative for desmin (clone D33: Nichirei), beta catenin (clone 14: BD Transduction Laboratories, San Jose, CA, USA), S100 (polyclonal, DAKO Cytomation), cytokeratin (AE1/AE3, Nichirei), bcl-2 and alpha smooth muscle actin (clone 1A4, DAKO Cytomation). Karyotype analysis was performed with G-banding in Sapporo clinical laboratory (Sapporo, Japan) using fresh tissue sample from the surgical specimen. Twenty four metaphases were analyzed. All 24 metaphases revealed numerical and structural abnoromalities as follows: 45, XX, add(1)(p13)x2, + add(1)(p36), der(8)t(8;12)(q22; q13), add(11)(p11), del(11)(q?), −12, −15, −17, add(19) (p11), add(20)(q11), add(22)(q13)x2, + mar (Fig. 2a). FISH analysis was performed on paraffin sections following manufacturer’s protocol, using FUS and EWSR1 dual-color break-apart probes (Vysis, Abbot, IL, USA). Approximately 40% of 200 tumor cells showed one fused (red/green) signal and one or two red split signals per nucleus for EWSR1 break-apart probes (Fig 2b). The cutoff level for scoring aberration was 30% abnormal nuclei. The red split signals corresponded to the 5′ side of EWSR1. The green split signal corresponding to the 3′ side of EWSR1 was absent. The FISH results suggested presence of nonreciprocal translocation involving the EWSR1 gene. On the other hand, tumor cells showed 2 fused (red/green) signals per nucleus for FUS break-apart probes (Fig 2c). Pathologic diagnosis of the present case was pure SEF. FISH analysis suggested the presence of nonreciprocal translocation involving the EWSR1 gene. EWSR1 gene locates on chromosome 22q12. It is also uncertain whether the lack of green signal by FISH represents non-reciprocal translocation of EWSR1 gene or potential deletion involving the telomeric part of 22q12. However, recent literature suggested the presence of nonreciprocal translocation of EWSR1 gene in our ESF case. Recurrent EWSR1CREB3L1 gene fusion were recently shown in SEF by Arbajian et al. They showed that the split signals (2 cases) or the loss of the part flanking the 3′-part (3 cases) of the gene, indicative of involvement in a gene fusion, were seen in 5/10 informative SEF cases for the EWSR1 gene by FISH. It was also shown that RT-PCR for EWSR1-CREB3L1 fusion transcripts detected in-frame fusion in one SEF case with a loss of the part flanking the 3′-part of EWS gene by FISH. The loss of the part flanking the 3′-part of the EWS gene suggests Pathology International 2015; 65: 48–50 doi:10.1111/pin.12223 bs_bs_banner