Detailed Pathological Evaluation Research Articles

Clinical feasibility of duodenum-preserving pancreatic head resection for neuroendocrine tumors of the pancreatic head as an intermediate procedure between enucleation and pancreaticoduodenectomy.

This study was performed to demonstrate the clinical application of duodenum-preserving pancreatic head resection (DPPHR) as a surgical treatment for pancreatic neuroendocrine tumors (PNETs) in terms of both curability and maintenance of postoperative quality of life. Seven patients diagnosed with PNETs underwent DPPHR from January 2011 to December 2021 at our institution. We investigated the clinical relevance of DPPHR based on the patients' clinicopathological findings. The median operative time was 492min, and the median blood loss was 302g. Postoperative complications were evaluated according to the Clavien-Dindo classification, and postoperative intra-abdominal bleeding was observed in one patient. Pathological examination revealed a World Health Organization classification of G1 in six patients and G2 in one patient. Microvascular invasion was observed in two patients (29%); however, no patients developed lymph node metastasis or recurrence during the follow-up period. A daughter lesion was observed near the primary tumor in one patient. All patients achieved curative resection, and no tumor specimens showed positive margins. DPPHR facilitates anatomical resection of the pancreatic head in patients with PNETs as well as detailed pathological evaluation of the resected specimen. Therefore, this surgical procedure is an acceptable alternative to pancreaticoduodenectomy or enucleation for patients with PNETs.

Artificial intelligence-based prediction model of malignant lung nodules for preoperative planning.

8034 Background: The histopathological prediction of malignant lung nodules is crucial for preoperative planning, but it always remains not precise until the detailed pathological evaluation is performed after the surgery. Thus, to define the histology types (in situ adenocarcinoma (AIS), microinvasive adenocarcinoma (MIA), and invasive adenocarcinoma (IA)) of pulmonary adenocarcinoma appearing as lung nodules before the operation and reduce unnecessary invasive diagnosis and treatment operations, we developed a classification model of based on CT images. Methods: Patients who were diagnosed with pulmonary adenocarcinoma (tumor diameter ≤ 3cm) at Nanfang Hospital, Southern Medical University, China, were retrospectively enrolled, including detailed pathology results, computed tomography (CT) images, and basic information. Through training the model proposed in our previous study, we proposed a new model for defining histopathological types. Then, we used this data to train and compare the diagnostic efficacy of our model with another previously reported deep learning (DL) model (that was a segmentation - classification model with the 3D Unet++ - ResNet-50 combined model) and machine learning (ML) model (that was a traditional model Grey Level Co-occurrence Matrices (GLCM) as the feature extractor and the support vector machine (SVM) as the classifier) in the same method. Results: A total of 2061 patients (with 395 of AIS, 334 of MIA and 1332 of IA) were retrospectively enrolled from January 2019 to April 2022. The data from 2/3 of the patients were randomly selected for training and another 1/3 for verifying. Through training and verifying, our model shows much better diagnostic efficacy, with areas under receiver operating characteristic (ROC) curves with 95% confidence interval (CI) of 0.97(0.96, 0.98), comparing with those of the ML model of 0.77(0.73, 0.81) and the DL model of (0.90(0.88, 0.92). The heatmap visualization of the proposed model shows the classification ability with prediction probabilities of our model clearly and understandably. Conclusions: In this study, we developed a novel artificial intelligence multi-task learning model to precisely predict the pathology type of malignant lung nodules with satisfying diagnostic efficacy, which might provide a new and reliable way for preoperative planning of lung nodules. Further external verifying should be done in the future. In addition, prediction of the growth patterns of pulmonary adenocarcinoma could be more helpful in addition to predicting histopathological types.

Pathologic Predictors of Response to Treatment of Immune Checkpoint Inhibitor-Induced Kidney Injury.

Immune-related adverse events are a management challenge in patients receiving immune checkpoint inhibitors (ICIs). The most common renal immune-related adverse event, acute interstitial nephritis (AIN), is associated with patient morbidity and mortality. AIN, characterized by infiltration of renal tissue with immune cells, may be analogous to kidney transplant rejection. We evaluated clinical variables and pathologic findings to identify predictors of renal response and overall survival (OS) in patients with ICI-induced AIN. We reviewed the records and biopsy specimens of all 35 patients treated for ICI-induced AIN at our institution, between August 2007 and August 2020, who had biopsy specimens available. Two board-certified renal pathologists graded the severity of inflammation and chronicity using transplant rejection Banff criteria and performed immunohistochemistry analysis. Patients were categorized as renal responders if creatinine had any improvement or returned to baseline within 3 months of initiating treatment for AIN. Clinical and pathologic characteristics and OS were compared between responders and non-responders. Patients with high levels of interstitial fibrosis were less likely to be responders than those with less fibrosis (p = 0.02). Inflammation, tubulitis, the number of eosinophils and neutrophils, and the clustering or presence of CD8+, CD4+, CD20+, or CD68+ cells were not associated with renal response. Responders had better OS than non-responders (12-month OS rate 77% compared with 27%, p = 0.025). Responders who received concurrent ICIs had the best OS, and non-responders who did not receive concurrent ICIs had the worst OS (12-month OS rate 100% for renal response and concurrent ICIs, 72% for renal response and no concurrent ICIs, and 27% for no renal response and no concurrent ICIs; p = 0.041). This is the first analysis of ICI induced nephritis where a detailed pathological and clinical evaluation was performed to predict renal response. Low levels of interstitial fibrosis in kidney tissue are associated with renal response to treatment for ICI-induced AIN, and the renal response and use of concurrent ICIs are associated with better OS in these patients. Our findings highlight the importance of the early diagnosis and treatment of ICI-AIN, while continuing concurrent ICI therapy.

A pilot study of micro-CT-based whole tissue imaging (WTI) on endoscopic submucosal dissection (ESD) specimens

Endoscopic submucosal dissection can remove large superficial gastrointestinal lesions in en bloc. A detailed pathological evaluation of the resected specimen is required to assess the risk of recurrence after treatment. However, the current method of sectioning specimens to a thickness of a few millimeters does not provide information between the sections that are lost during the preparation. In this study, we have produced three-dimensional images of the entire dissected lesion for nine samples by using micro-CT imaging system. Although it was difficult to diagnose histological type on micro-CT images, it successfully evaluates the extent of the lesion and its surgical margins. Micro-CT images can depict sites that cannot be observed by the conventional pathological diagnostic process, suggesting that it may be useful to use in a complementary manner.

How to Perform a High-Quality Endoscopic Submucosal Dissection

How to Perform a High-Quality Endoscopic Submucosal Dissection

Unusual giant multilocular mesothelial cyst of mediastinum

BackgroundIntrathoracic mesothelial cysts are congenital lesions induced by the abnormal development of the pericardial coelom. There have been a few reports of giant mesothelial cyst of the superior mediastinum, but the preferred treatment remains a controversial topic. We herein report a rare case of successful removal of giant mesothelial cyst that was incidentally detected during a medical checkup.Case presentationA 53-year-old man with a feeling of mild chest tightness was referred to our hospital for the evaluation of an abnormal shadow of the mediastinum on chest X-ray. Computed tomography showed a multilocular, homogenous, large cyst in the superior mediastinum measuring 18 cm in size without contrast enhancement and with spotty calcification, and magnetic resonance imaging showed a low intensity on T1-weighted images and high intensity on T2-weighted images. Therefore, a cystic thymoma, thymic cyst, lymphangioma, cystic teratoma or pericardial cyst was suspected as the preoperative diagnosis. Despite mild symptoms, the patient underwent total thymectomy under median sternotomy for an appropriate diagnosis and treatment. The pathological diagnosis was giant multilocular mesothelial cyst.ConclusionsIntrathoracic mesothelial cyst is a benign cyst and generally asymptomatic, but can sometimes induce critical chest clinical symptoms if untreated, depending on its size. In our case, complete surgical resection and a detailed pathological evaluation was effective for making the appropriate diagnosis and delivering treatment. In addition, an immunohistological evaluation is effective for diagnosing mesothelial cysts when it is difficult to distinguish the cyst from other cystic lesions.

Gastric cancer is highly prevalent in Lynch syndrome patients with atrophic gastritis.

Although gastric cancer is one of the Lynch syndrome (LS)-related tumors, the clinicopathological features of gastric cancer in patients with LS remain uncertain. To investigate the incidence risk and clinicopathological features of gastric neoplasms in LS, we conducted a retrospective cohort study in Japanese LS patients. LS patients with pathogenic mismatch repair (MMR) gene variants were extracted from the LS registry of the National Cancer Center Hospital, Japan. Cumulative risks of gastric neoplasm, including dysplasia and cancer, were estimated using the Kaplan-Meier method. Gastric atrophy was evaluated endoscopically and/or histologically. Immunohistochemical staining for MMR proteins was performed for all available specimens. Of 118 eligible patients, 26 patients were diagnosed with 58 gastric neoplasms. The cumulative incidence of gastric neoplasm was 41.0% (95% confidence interval, 26.9-55.0) at the age of 70. Of these, 13 (50%) patients developed synchronous and/or metachronous multiple gastric neoplasms. Among the 49 gastric neoplasms available for detailed pathological evaluation, all were associated with intestinal metaplasia. Immunohistochemically, 42 (86%) were MMR-deficient. The individuals with gastric atrophy had a significantly higher risk of developing gastric neoplasms compared with those without gastric atrophy (26 cases/54 individuals vs. 0 cases/53 individuals) (P = 0.026). LS patients, particularly those with atrophic gastritis, are at high risk of gastric neoplasm and often develop multiple tumors. Endoscopic surveillance for gastric cancer is recommended for LS patients, especially those with atrophic gastritis.

Preclinical Evaluation of Mesh Implants: The Pathologist's Perspective.

Surgical and laparoscopic implantation of mesh devices is on the rise for a variety of applications. The complexity and range of evolving mesh designs calls for consistent and detailed pathologic evaluation in determining host responses and assessing overall safety. This review addresses the components of evaluation of mesh implants in animal models, with emphasis on histologic parameters, semiquantitative scoring matrices, and morphometric analyses that have been specifically adapted to this class of implants. Necropsy assessment should include implant persistence, architecture, and associated host responses such as exudation and adhesions. Microscopic evaluation should focus on primary relevant responses such as bioresorption, integration/tissue ingrowth, neovascularization, and inflammation. Selection of the best means of processing and evaluation can be complicated, as meshes may include one or more biologic components (e.g., collagen), synthetic polymer fibers, coatings, and other molecules. The architecture of some meshes can influence tissue responses and complicate sampling, sectioning, and evaluation. Recognition of specific study objectives and knowledge of anticipated responses helps to determine the appropriate histologic or immunochemical stains, while understanding of mesh composition and anticipated persistence in tissue determines the suitability of paraffin or resin embedding, and both guide the evaluation of mesh devices in the preclinical setting.

Detailed pathologic evaluation of low dose CT (LDCT) detected stage I/0 lung adenocarcinomas (ADCA).

8543 Background: Although LDCT lung screening improves survival, some worry that indolent BAC-like ADCA may be over-detected/treated. Comprehensive histologic subtyping has recently been adopted to improve grading and thus risk stratification in lung ADCA. We report a detailed pathologic comparison of stage I/0 lung ADCAs detected by LDCT screening vs. incidentally discovered ADCAs stratified by NCCN risk criteria. Methods: We performed comprehensive histologic subtyping on 35 consecutive stage I/0 LDCT screen detected ADCAs in patients meeting NCCN group 1/2 high risk (HR) criteria and compared to incidentally detected stage I/0 ADCAs meeting HR (n = 41) or low-risk (LR, n = 28) criteria. Results: Screen detected and incidentally detected ADCAs from HR groups show an equally low-rate of indolent, non-invasive/minimally invasive ADCAs (9%) compared to LR patients (36%). Aggressive solid predominant ADCAs were equally more frequent in HR patients from screen and incidentally detected patients (19%) compared to LR patients (6%). The rate of angiolymphatic invasion (59%) and air space invasion (32-34%) were similarly elevated in HR screen and incidental patients compared to LR patients (39% & 17% respectively). A collection of lepidic predominant (BAC-like) ADCAs associated with aggressive non-predominant cribriform and/or solid patterns, elevated mitotic rates, and high proportion of lymphatic invasion were uniquely observed in the screen-detected group (12%). Subgroup analysis of screen detected NCCN group 1 vs. 2 shows group 2 tumors exhibit histologic features which are at least as aggressive as group 1 tumors, albeit at smaller invasive sizes (1.2 cm vs. 1.5 cm) and lower stage (IA 75% vs. 61%). Conclusions: This is the first detailed pathologic comparison of LDCT screen detected vs incidentally discovered stage I/0 ADCA. Tumors from HR patients are pathologically more aggressive than LR tumors. Not all BAC-like tumors in LDCT screen detected patients should be presumed indolent given that approximately half of these bear histologic features of aggressive ADCAs while still in a lepidic predominant phase. NCCN group 2 tumors are similar to group 1 and should be further studied.

P1.02-033 Mesenchymal Transformation is the Most Common Histomorphologic Changes in the Rebiopsy of Lung Cancer Patients with EGFR-TKI Resistance

Histomorphologic changes are known to be associated the acquired resistance of the epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKI) treatment. Rebiopsy is usually used to detect the underlying molecular mechanism of resistance, however meticulous histologic examination is very important to identify the change of cancer phenotype. Here we tried to investigate histomorphologic changes between the initial and rebiopsy specimens. We retrospectively evaluated the initial biopsy and rebiopsy specimens of 60 patients with acquired resistance to EGFR-TKI between 2010 and 2016 in Seoul National University Bundang Hospital, Republic of Korea. EGFR mutation tests were performed in all specimens. Various histologic parameters including spindle cell components, discohesive growth pattern and stromal change, subtype of the tumor and nuclear grade were evaluated. In addition, immunohistochemistry (IHC) for epithelial-mesenchymal transition (EMT) markers (E-cadherin and vimentin) and neuroendocrine markers (CD56 and synaptophysin) was performed. In rebiopsy specimens, 18 cases (30%) showed changes of cellular morphology including spindle cell components and discohesive growth pattern representing EMT features. On IHC, acquisition of vimentin expression in spindle cell components and decreased expression of E-cadherin in adenocarcinoma of rebiopsy specimens were identified. Furthermore, histologic transformation to small cell carcinoma (2 cases, 3.3%) with expression of neuroendocrine markers and squamous differentiation (2 cases, 3.3%) were observed. In this study, histologic transformation to EMT is the most frequent finding in rebiopsy samples of the patients with EGFR-TKI resistance while small cell carcinoma has been known to be the most common in the literatures. Although EMT has been reported to be about 5% of EGFR-TKI resistance, we observed it in approximately 30% of our rebiopsy cases. These findings suggest that detailed and meticulous pathologic evaluation plays an important role to find delicate histomorphologic changes associated with EGFR-TKI resistance.

Sudden Death Due to Sarcoma: An Unusual Case and Literature Review

Background: Sudden death has varied causes, and autopsy is usually required to determine cause of death. Sarcoma involvement is very infrequent, and detailed pathological evaluation is needed for correct diagnosis. When the medical history of the deceased is unavailable and autopsy is not performed, the true cause of death will not be established. Here we present an unusual case of sarcoma involving heart and lung. We also review 13 cases found in the literature with sarcoma involvement in sudden death.

Gastric adenocarcinoma of the fundic gland (chief cell-predominant type): A review of endoscopic and clinicopathological features.

Gastric adenocarcinoma of the fundic gland (chief cell-predominant type, GA-FG-CCP) is a rare variant of well-differentiated adenocarcinoma, and has been proposed to be a novel disease entity. GA-FG-CCP originates from the gastric mucosa of the fundic gland region without chronic gastritis or intestinal metaplasia. The majority of GA-FG-CCPs exhibit either a submucosal tumor-like superficial elevated shape or a flat shape on macroscopic examination. Narrow-band imaging with endoscopic magnification may reveal a regular or an irregular microvascular pattern, depending on the degree of tumor exposure to the mucosal surface. Pathological analysis of GA-FG-CCPs is characterized by a high frequency of submucosal invasion, rare occurrences of lymphatic and venous invasion, and low-grade malignancy. Detection of diffuse positivity for pepsinogen-I by immunohistochemistry is specific for GA-FG-CCP. Careful endoscopic examination and detailed pathological evaluation are essential for early and accurate diagnosis of GA-FG-CCP. Nearly all GA-FG-CCPs are treated by endoscopic resection due to their small tumor size and low risk of recurrence or metastasis.

Clinicopathological study of pituitary adenomas in the region of northeast india

Background/aim Pituitary adenomas (PA) are the most common tumours of the pituitary gland. Clinicopathological characteristics of these tumours may vary from population to population. The present study aimed to understand the detailed clinical and pathological characteristics of surgically resected PA in the region of Northeast India. Patients and methods Thirty-two consecutive cases of PA diagnosed and operated at Gauhati Medical College were studied for clinical, pathological, and treatment characteristics in this study between January 2014 and December 2015. The patient group included 20 female and 12 male patients with a median age of 37 years (range: 22–58 years). Results A total of 13/32 (40.63%) cases were nonfunctioning adenomas. Among the hormonally active PA, prolactin-producing adenomas were most common (25%), followed by growth hormone-producing adenomas (18.8%) and adrenocorticotrophic hormone-producing adenomas (15.6%). The most common symptom was headache, followed by visual disturbances, galactorrhoea, acromegaloid and cushingoid features. Menstrual disturbances were present in 50% of the female patients. 23.1% of the cases of nonfunctioning PA were negative for all anterior pituitary hormones on immunohistochemistry. Conclusion PA can have varied presentations. Detailed clinical, hormonal and pathological evaluation is essential for better understanding the nature of the tumour growth and its progression. This study is the first of its kind in the region of Northeast India, showing the relationship of the functioning and nonfunctioning PA with their hormonal profile and immunohistochemical analysis.

What is the best therapeutic strategy for colonoscopy of colorectal neoplasia? Future perspectives from the East.

Development and improvement of endoscopic techniques and devices have changed the treatment of colorectal tumors over the last decade. For the treatment of diminutive polyps, the cold snare technique of the West is becoming a promising treatment in the East because of its short procedure time and low rate of delayed bleeding by eliminating the delayed effect of electrocautery. Rather than using piecemeal endoscopic mucosal resection or surgical resection for the treatment of large superficial tumors, the technique of the East of endoscopic submucosal dissection (ESD) achieves a high success rate of en bloc R0 resection, enabling detailed pathological evaluation with less invasive treatment. This procedure should also be useful in the West where large colorectal tumors are more frequent than in the East. Regarding outcomes, however, in the literature, the definition of 'curative resection' remains somewhat inconsistent and long-term outcomes of patients with deep submucosal and/or lymphovascular invasion in the en bloc specimen have not yet been determined. Large prospective, as well as retrospective, studies of these patients are warranted. When colorectal ESD is difficult because of size or location, the pocket-creation method and/or double-balloon-assisted technique may be useful. In the East, high-quality magnified chromoendoscopy is widely available, and endoscopists try to identify focal submucosal invasion. In the West, a systematic evaluation of surveillance for the prevention of colorectal cancer has been done and is highly refined. The East and West have much to learn from each other.

When prostate cancer remains undetectable: The dilemma.

Since the first report on the efficacy of sextant biopsy under transrectal ultrasound guidance, there have been many modifications related to the total number of cores and the localization of biopsies to improve the prostate cancer (PCa) detection rate. The 2010 National Comprehensive Cancer Network Early PCa Detection Guidelines noted the 12-core biopsy scheme as the standard. However, this extended biopsy scheme still fails to detect 20% of high-grade PCa that can be detected by detailed pathological evaluation of radical prostatectomy; therefore, there is need for saturation biopsies. The existence of suspicions of PCa after previous negative biopsy or biopsies represents a valid indication for saturation biopsy. There has been no significant increment in morbidity or in insignificant PCa detection rates when a saturation biopsy scheme was used with an extended biopsy scheme. Along with the improvement in the PCa detection rate, accurate oncological mapping of PCa is another important consideration of saturation biopsies. The ideal number of cores and the diagnostic value of saturation biopsy after the failure of initial therapy are some of the issues that need to be addressed. Preliminary reports have shown that magnetic resonance imaging can improve the PCa detection rate, save patients from unnecessary biopsies, and decrease the need for a high number of cores; however, multiple limitations continue to exist.

Detailed pathologic evaluation on endomyocardial biopsy provides long-term prognostic information in patients with acute myocarditis

The long-term prognosis of biopsy-proven myocarditis is not well known. We hypothesized that a detailed pathological examination of an endomyocardial biopsy (EMB) would reveal prognostic information in patients with acute myocarditis. Fifty-four patients were diagnosed with acute myocarditis based on an EMB. Pathological diagnosis was categorized into lymphocytic dominant (29.6%), eosinophilic dominant (22.2%), and borderline myocarditis (48.1%). Masson's trichrome staining and further immunohistochemical staining for CD3, CD20, CD68, HLA-DR, TLR4, TLR8, enteroviral VP1, and caspase-3 expression were performed. The clinical outcomes were defined as all-cause and cardiovascular (CV) death. During the median 10.4 years of follow up (9.7±5.7 years), the overall all-cause mortality was 20.4% and the CV mortality was 14.8% in patients with acute myocarditis. Lymphocytic dominant myocarditis patients showed a poor clinical outcome when compared with eosinophilic dominant myocarditis patients for both all-cause (37.5% vs. 0%, p=0.015) and CV (31.2% vs. 0%, p=0.029) mortality. Among borderline myocarditis patients, the presence of fibrosis was linked with poor clinical outcomes in both all-cause (75.0% vs. 21.4%, p=0.045) and CV (100.0% vs. 25.0%, p=0.034) mortality. No significant associations between clinical outcome and all other immunohistochemical staining targets were observed. Detailed pathological evaluation on an EMB provides prognostic information in patients with acute myocarditis. EMB evaluation should be considered in patients with suspected myocarditis.

Metastasizing “benign” pleomorphic salivary adenoma: A dramatic case-report and literature review

Pleomorphic salivary adenomas are the most common benign neoplasms affecting the salivary glands. Very occasionally however, metastatic lesions are identified in patients with a history of PSA, which, on detailed pathological evaluation, are found to exhibit all the histological hallmarks of the preceding benign lesions.Diagnosis of benign metastasizing pleomorphic adenoma of the salivary gland is extremely rare and still under debate.We present the first case-report in literature of multiple metachronous nasal cavity, scalp and encephalic metastases of a pleomorphic adenoma of the parotid gland in a young girl.

Primary benign vascular tumors and tumorlike lesions of the kidney: a clinicopathologic analysis of 15 cases

Primary benign vascular lesions of the kidney are uncommonly encountered in routine surgical pathology practice. They can, however, mimic malignancy or be an incidental finding adjacent to a malignancy. Fifteen specimens harboring 16 primary benign renal lymphatic/vascular lesions were identified from our files from 1999 to 2011 and subjected to a detailed pathologic evaluation and clinicopathologic correlation. Clinical and demographic data were available for all the 15 cases. There were ten males and five female patients with age range of 33-74 years (mean 54 years). Lesions ranged from 0.5 cm to 40 cm (average, 6.6 cm). There were six arteriovenous malformations (AVMs), four hemangiomas, three anastomosing hemangiomas, two lymphangiomas, and one solid intravascular papillary endothelial hyperplasia (IPEH). Five AVMs were located in the kidney parenchyma and one in the pelviureteric system. Additional associated lesions ranged from renal stones to renal cell carcinoma in two cases (one lymphangioma and one AVM). One AVM was associated with a capillary hemangioma in the vicinity, and another with a history of renal cell carcinoma in the contralateral kidney. Capillary hemangiomas and lymphangiomas were noninfiltrative and lacked cytological atypia and mitotic activity. Except for a renal pelvic AVM, all other renal AVMs radiologically mimicked malignancy. The patients had undergone partial or radical nephrectomies except for the renal pelvic AVM which was laparoscopically excised. To the best of our knowledge, none of the cases had any syndromic/systemic associations. Benign vascular lesions of the kidney are rarely seen in routine surgical pathology practice, partly because a vast majority of them are medically treated by embolization. However, lesions mimicking renal malignancy are subjected to surgery. They may exist as isolated lesions or coexist with malignant lesions either in the ipsilateral or the contralateral kidney.

Prognosis and non-sentinel lymph node status of the breast cancer patients with micrometastatic sentinel lymph nodes.

140 Background: Sentinel lymph node biopsy (SLNB) is a more sensitive and accurate nodal staging procedure than axillary lymph node dissection (ALND). Because of detailed pathologic evaluation in SLNs, more nodal micrometastases have been identified. However, it remains controversial whether to perform ALND for patients with micrometastases in SLNs and their prognostic significance is also a matter of debate. The purpose of this study is to determine the non-sentinel lymph node (NSLN) status and prognosis of the patients with micrometastatic SLNs. Methods: A prospective database of 1,012 clinically node-negative, T1-T2 breast cancer patients, who underwent SLNB from January 2002 to Dec 2010 at Keio University Hospital was analyzed. SLNs were detected using a combined method of isosulfun blue dye and small-sized technetium-99m-labeled tin colloid. Intraoperative frozen examination was performed with hematoxylin and eosin (HE) staining. SLNs, fixed and embedded in paraffin, were additionally diagnosed with HE staining and immunohistochemical (IHC) analysis. Results: Micrometastases in SLNs were found in 69 (6.8%) of 1,012 patients. Thirty eight (55.1%) of 69 patients with micrometastatic SLNs underwent immediate or delayed ALND and revealed no NSLN metastasis. Among 31 (44.9%) patients with micrometastatic SLNs who omitted ALND and axillary radiation therapy, no axillary lymph node recurrence has been observed after a median follow-up of 50 months, although 29 patients (93.5%) in these 31 patients received adjuvant systemic therapy. There is no significant difference in recurrence free survival between the patients with micrometastatic and negative SLNs (98.0% vs. 95.7%, respectively). Conclusions: These date suggested that it may not be necessary to perform ALND for the patients with micrometastatic SLNs and the presence of micrometastases in SLNs may not worsen prognosis with proper systemic therapy.

Hydrophilic acrylic intraocular lens optic opacification in a diabetic patient

To report clinicopathologic and ultrastructural feature of one opacified hydrophilic acrylic intraocular lens (IOL) explanted from a diabetic patient. A 48-year-old man underwent trans pars plana vitrectomy and phacoemulsification with implantation of a hydrophilic acrylic lens OS in November 2008. The patient complained of a marked decrease in visual acuity in May 2009 as a result of a milky opalescence of the IOL. Intraocular lens explantation and exchange were performed in August 2009, and the explanted IOL was submitted to our center for detailed pathologic, histochemical and ultrastructural evaluation. It was stained by the von Kossa method for calcium, and also underwent scanning electron microscopy and energy dispersive radiograph spectroscopy to ascertain the nature of the deposits leading to opacification. Opacification of the IOL was found to be the cause of the decreased visual acuity. The opacification involved only the IOL optic, and the haptics was clear. Histochemical and ultrastructural analyses revealed that the opacity was caused by deposition of calcium and phosphate within the lens optic. We believe this report of calcification of the Akreos(®) MI-60 IOL is of clinicopathological importance. Long-term follow-up of diabetic patients implanted with this IOL should be maintained by surgeons and manufacturers.