Yoshio Torii

LUNG CANCER AND CHRONIC INTERSTITIAL PNEUMONIA ASSOCIATED WITH SYSTEMIC SARCOIDOSIS

Lung cancer and chronic interstitial pneumonia associated with systemic sarcoidosis was detected in a 66‐year‐old woman at autopsy. Histologically, hyalinized sarcoid lesions were scattered in cervical lymph nodes, thoracic lymph nodes, abdominal lymph nodes, and spleen. Scattered non‐caseating epithelioid cell granulomas with giant cells were observed in both lungs remoting cancer and chronic interstitial pneumonia. A tumor mass occupying right hilar portion was well‐differentiated squamous cell carcimona involving right upper lobe and right hilar lymph nodes. In the lower lobe of the left lung, a small nodule of poorly differentiated squamous cell carcinoma was detected. Alveolar septa, especially in both lower lobes of the lungs were thickened diffusely with fibrosis, edema, and inflammatory cell infiltration. Alveolar cavities contained hyaline membrane and large mononuclear cells. Atypical bronchiolar epithelial proliferation and squamous metaplasia associated with squamous cell carcinoma were detected. The clinical and pathological characteristics among eight reported cases of lung cancer associated with sarcoidosis and three reported cases of interstitial pneumonia associated with sarcoidosis were reviewed separately. There is no report describing both lung cancer and chronic interstitial pneumonia associated with sarcoidosis.

A case of colonic solitary polypoid ganglioneuroma with a feature of inverted hyperplastic polyp

To the Editor: We describe herein a case of a solitary polypoid colonic ganglioneuroma, together with a feature of inverted hyperplastic polyp obtained by endoscopic mucosal resection. A 71 year-old-man with occult blood of feces on medical check-up was referred to a digestive medicine specialist at our hospital for investigation. The patient had a past history of nephrotic syndrome and acute ileus. He had no particular family history. Laboratory data did not show anemia, positive systemic inflammation signs or biochemical items. After an upper gastrointestinal endoscopy was performed and confirmed chronic atrophic gastritis alone without esophageal or gastric polyp, a total colonoscopy was performed twice; a total of eight colonic polyps were removed by endoscopic mucosal resection. They were located at the ascending (4), transverse (2), descending (1) and sigmoid colon (1). Among them, a polyp sized approximately 10 mm of the transverse colon was endoscopically removed, and histopathologically examined. The tissue was stained with HE, PAS, alcian blue and elastica von Gieson (EVG). For immunohistochemistry, representative sections were examined by the Envision chem mate kit (Dako, Tokyo, Japan), monoclonal for desmin (Dako, 1:200 dilution), N-CAM (CD56, Novocastra, Tokyo, 1:150 dilution), MUC-2, MUC5AC, MUC1, MUC2, CD10, HIK (Novocastra, 1:100–300 dilutions), CEA (Dako, 1:100 dilution), CAM5.2 (Becton & Dickinson, Tokyo, 1:20 dilution), cytokeratin 20 (Dako, 1:160 dilution), chromogranin A (Dako, 1:1000 dilution), synaptophysin (Dako, 1:20 dilution), CD34 (MBL, Nagoya, Japan, 1:2 dilution), D2-40 (Dako, 1:50 dilution), MIB-1 (Ki-67, Novocastra, 1:200 dilution), and p53 (DO7, Dako, 1:100 dilution), and polyclonal for S100 (Dako, 1:10,000 dilution), neurofilament, NSE, vimentin, and GFAP (Dako, 1:300–800) were respectively used. Microscopically, at the panoramic view of HE staining, a polyp in the transverse colon demonstrated submucosal large mucinous spaces covered with a flat-like mucosal layer. With lengthening of the tubules and an irregular serrated configuration of the tubular lining cells, there appeared to be hyperplastic and partly serrated glands with small cystic change in the submucosa (Fig. 1a,b). There was a long shaped-glands across the muscularis mucosa and continuing partly from mucosa to submucosa (Fig. 2a) With PAS and alcian blue, mucinous substances were positive in the large cystic space of submucosa. Around a large cystic area in the submucosa, tiny bundles of spindle cell proliferation with or without sparse ganglion cells was not sufficiently recognized on HE, but their spindle cells and cell surfaces of ganglion cells were immunohistochemically strongly positive for S-100 (Fig. 1c) and N-CAM (CD56, Fig. 2c), but negative for GFAP and synaptophysin. The ganglion cells were clearly positive for NSE (Fig. 2d) and neurofilament. The glandular cells of this sessile polyp expressed positive phenotypes of MUC2, CEA, CAM5.2 and CK20, and positive partly for MUC5AC (Fig. 2b), suggesting mixed phenotype of colonic and gastric mucin. But they were negative for MUC1, MUC6, CD10, HIK, and neuroendocrine markers, chromogranin A and synaptophysin. There was almost no venous permeation with EVG and CD34, and also no lymphatic permeation with D2-40. With desmin, muscularis mucosa was slightly interrupted by elongated glands. MIB-1 was localized positively in basal layer of the colonic glands, and p53 immunohistochemically showed no overexpression. As a result, the polyp was judged as an unusual case of colonic ganglioneuroma with a feature of inverted hyperplastic polyp, expressing mixed phenotype of colonic and gastric mucins. In the present patient, seven other polyps were obtained by EMR including five tubular adenomas and two other hyperplastic polyps in the right-sided colon. All these polyps were non-malignant lesions. A ganglioneuroma (GN) of the gastrointestinal tract is rare tumor composed of ganglion cells, nerve fibers and supporting cells. GNs of the digestive tract are usually divided into solitary polypoid type and multiple ganglioneuromatosis. The latter multiple lesions may often occur in association with the hamartomas of von Rcklinghausen’s disease (NF-1), multiple endocrine neoplasia (MEN IIb) and Cowden syndrome. On the other hand, the hyperplastic polyp is a benign, nonneoplastic colorectal polyp in which there is lengthening of the tubular glands and an irregular serrated configuration of the tubular surface. Rarely, the deep proliferative zone of a hyperplastic polyp may occur in an endophytic growth toward submucosa, termed inverted hyperplastic polyp or hyperplastic polyp with epithelial misplacement. Moreover, colonic hamartomatous inverted polyp was described by Allen in 1966, and consisted of elongated crypts with cystic dilatation located mostly in the submucosa of the rectum. Thereafter, it has been reported that a case of polypoid colonic hamartomatous inverted polyp at mid-transverse colon showed marked cystic dilatation and proliferation of the smooth muscle in the submucosa. Although Yantis et al. described 19 cases of hyperplastic polyp with epithelial misplacement (inverted hyperplastic polyp) into the submucosa, and proposed an etiologic consideration such as resulting from local trauma and subsequent protrusion of epithelium into the submucosa through inherently weak areas in the muscularis Pathology International 2015; 65: 446–449 doi:10.1111/pin.12289 bs_bs_banner