Remnant Lesion Research Articles

Combined Transanal and Laparoscopic Approach for Full-Thickness Local Excision of Locally Advanced Rectal Cancer Following Near-Complete Response after Chemotherapy

Abstract Improving neoadjuvant therapies for locally advanced rectal cancer (LARC) has increased the rates of clinical complete response (cCR). The watch-and-wait approach has emerged as a viable strategy for patients with cCR, avoiding the potential morbidity of radical surgery. However, the management of near-complete response (nCR) remains controversial. We present a case of a 46-year-old male with cT4, node indeterminate, mid-to-upper rectal adenocarcinoma. The patient declined radical resection and radiotherapy. Clinical nCR of the tumor was confirmed on imaging and endoscopy following six cycles of oxaliplatin and capecitabine (chemotherapy only). He underwent full-thickness local excision of the remnant lesion using a combined transanal and laparoscopic approach. Histopathological examination revealed high-grade dysplasia without residual malignancy. There has been no evidence of tumor recurrence at nine months post-surgery. This case demonstrates the safety and feasibility of minimally invasive local excision in selected patients with nCR following neoadjuvant therapy for LARC.

Outcomes of Osteoid Osteoma Treated by Percutaneous CT-Guided Radiofrequency Ablation.

Introduction Osteoid osteomas are the most frequent true benign bone tumor in the adolescent age group and the third most prevalent benign bone tumor overall. This study was designed to assess the effectiveness of the procedure and correlate it with the analgesia offered because of the significant burden of this illness and new literature supporting the successful outcomes of image-guided percutaneous radiofrequency ablation (RFA) in osteoid osteoma. Methodology This hospital-based interventional trial was carried out in a tertiary care referral center. Forty-two patients with osteoid osteoma, ranging in age from 9 to 30, were included in the study. The patients received RFA guided by computed tomography (CT), and they were postoperatively monitored at one, two, and four weeks and three, six months, and 12 months. A numerical pain scale (NPS) was used to evaluate the patient's pain both before and after the procedure. The preoperative and postoperative results were contrasted. Results A total of 42 participants were enrolled in the study. Eight (19.05%) women and 34 (80.95%) men made up the group. Complete pain alleviation (NPS=0) was attained in 42.8% and 96.4% of the study groupinthe first and second weeks post-procedure. Almost all patients began protected weight-bearing at one week, according to their level of pain tolerance. Osteoid osteoma of the talus was a remnant lesion in one patient that required further treatment after two weeks. During the duration of the follow-up, no problems were recorded. Conclusion Percutaneous CT-guided RFA of osteoid osteoma is a safe, minimally invasive procedure and greatly reduces the duration of hospitalization. It has excellent functional outcomes and no known complications.

An 80-Year-Old Man With Hematochezia and Hyperkalemia

Question: An 80-year-old man with a history of colon cancer with previous resection and a primary anastomosis as well as chronic kidney disease presented to the emergency room with a presyncopal episode. On arrival, he was hypotensive, with a hemoglobin of 9.9 g/dL, blood urea nitrogen of 45 mg/dL, and creatinine of 1.9 mg/dL with a serum potassium of 6.0 mmol/L. The patient’s hyperkalemia was attributed to chronic kidney disease and was managed medically. After treatment for hyperkalemia, on the same day of admission, the patient developed bright red bleeding per rectum. The patient underwent colonoscopy on day 2 of admission, which showed internal hemorrhoids, as well as a dusky appearing mass at the rectosigmoid junction, 13 cm from the anal verge measuring 5 cm in length (Figure A). Biopsies of the mass were obtained, and histologic analysis of the biopsies is shown (Figure B). What is the etiology of these endoscopic and histologic findings? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Histology showed colonic mucosa with ischemic injury, ulceration, acute inflammatory exudates, absence of neoplastic cells, and the presence of sodium polystyrene sulfonate (SPS) crystals (highlighted in the rectangle in Figure B). Immunohistochemical stain for cytomegalovirus was negative (not shown). Upon review of the patient’s medications, 1 dose of SPS (Kayexalate) had been given on the first day of admission before the development of hematochezia. Owing to a suspected sampling error, the patient underwent repeat colonoscopy 5 days after the index endoscopy which showed notable regression of the previously seen pseudotumor (Figure C); biopsies of the remnant lesion showed persistent ischemic type injury with acute inflammatory exudates and SPS crystals (indicated by the blue arrow in Figure D). SPS is a potassium-binding resin used to treat acute hyperkalemia. SPS has been associated with gastrointestinal complications, including ischemic colitis, bleeding, and perforation.1Bui M. Chou S.Y. Faubert P. et al.Resin-induced colonic pseudotumor: rare complication from chronic use of potassium binders in a hemodialysis patient.Case Rep Nephrol. 2016; 20163692086PubMed Google Scholar Ischemic colitis with associated pseudotumor formation is a rare adverse event that can mimic a malignant process, and present as hematochezia or as a radiographically apparent colonic mass.1Bui M. Chou S.Y. Faubert P. et al.Resin-induced colonic pseudotumor: rare complication from chronic use of potassium binders in a hemodialysis patient.Case Rep Nephrol. 2016; 20163692086PubMed Google Scholar These pseudotumors are non-neoplastic, inflammatory, and necrotic lesions that have been reported to occur in the esophagus, colon, and in extraintestinal areas.2Chatila A.T. Bilal M. Merwat S. Kayexalate-induced colonic pseudotumor.Clin Gastroenterol Hepatol. 2019; 17: e73Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar,3Goh L.H. Wong J. Chng T.W. et al.Extra-intestinal sodium polystyrene sulfonate crystal-induced inflammatory pseudotumour in an asymptomatic haemodialysis patient.Int Urol Nephrol. 2021; 53: 1265-1266Crossref PubMed Scopus (1) Google Scholar Although the mechanism is unknown, it is proposed that SPS causes a shift in the osmotic load and, therefore, vascular redirection and then ulceration or ischemia.2Chatila A.T. Bilal M. Merwat S. Kayexalate-induced colonic pseudotumor.Clin Gastroenterol Hepatol. 2019; 17: e73Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The characteristic pathologic finding includes a fish scale pattern seen on hematoxylin and eosin staining representing SPS crystals. SPS-induced pseudotumor formation does not seem to be dose dependent; investigators have reported the development of SPS-induced ischemic pseudotumor after a wide range of doses, ranging from merely 2 doses to scheduled administration up to 1 year.1Bui M. Chou S.Y. Faubert P. et al.Resin-induced colonic pseudotumor: rare complication from chronic use of potassium binders in a hemodialysis patient.Case Rep Nephrol. 2016; 20163692086PubMed Google Scholar, 2Chatila A.T. Bilal M. Merwat S. Kayexalate-induced colonic pseudotumor.Clin Gastroenterol Hepatol. 2019; 17: e73Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 3Goh L.H. Wong J. Chng T.W. et al.Extra-intestinal sodium polystyrene sulfonate crystal-induced inflammatory pseudotumour in an asymptomatic haemodialysis patient.Int Urol Nephrol. 2021; 53: 1265-1266Crossref PubMed Scopus (1) Google Scholar Recognition of this entity is therefore important irrespective of the SPS dose and duration to avoid unnecessary interventions.1Bui M. Chou S.Y. Faubert P. et al.Resin-induced colonic pseudotumor: rare complication from chronic use of potassium binders in a hemodialysis patient.Case Rep Nephrol. 2016; 20163692086PubMed Google Scholar SPS-induced ischemic pseudotumor regresses with discontinuation of the drug. This case highlights the potential for mistaking SPS-induced pseudotumor formation for malignancy. In addition, in the absence of a dose response, a single dose of SPS can lead to the development of ischemic pseudotumor.

A rare case of eosinophilic cystitis involving the inside and outside of the urinary bladder associated with an infected urachal cyst

BackgroundEosinophilic cystitis is a rare inflammatory disease of the bladder characterized by eosinophilic infiltration of the bladder wall. Most Eosinophilic cystitis cases present with mucosal lesions of the urinary bladder. We present a very rare case of large mass-forming eosinophilic cystitis, involving the inside and outside of the bladder associated with an infected urachal cyst.Case presentationA 59-year-old man presented with gross hematuria, fever, dysuria, and suprapubic pain. Computed tomography showed a heterogeneously enhancing mass that measured 7.6 cm × 4 cm located on the anterosuperior portion of the bladder with an internal fluid collection. Cystoscopy revealed a raspberry-like mass lesion on the bladder dome. Transurethral resection of the bladder was initially performed. The mass lesion protruding from inside the bladder was removed, and pus-like fluid was drained. The pathologic diagnosis was eosinophilic cystitis. Follow-up computed tomography showed a remnant mass outside the bladder and urachal cyst. To eliminate the remnant lesion, robot-assisted partial cystectomy was performed. The patient showed no evidence of recurrent disease on follow-up cystoscopy and computed tomography for up to 2 years.ConclusionsClinicians should consider the possibility of eosinophilic cystitis in patients who present with hematuria, fever, and suprapubic pain and have both intravesical and extravesical masses.

A Rare Case of Sellar Mass Composed of Primary Leiomyosarcoma and Pituitary Adenoma

Background: Nonfunctioning pituitary adenomas (NFPAs) are most common pituitary tumors, and primary pituitary gland malignancies are extremely rare. Most malignant pituitary gland lesions metastasize from other sites. Primary malignant lesions, such as sarcomas, usually develop after radiotherapy or chemotherapy for other diseases. We report a rare case of primary sellar leiomyosarcoma (LMS) without prior therapy that arose concurrently with a pituitary adenoma. Clinical Case: A 56-year-old woman with ptosis of the right eye, headache, and progressive visual deficits visited our neurosurgery department. She had no medical history besides hypertension. Twelve months ago, she was referred to us because of decreased visual acuity and a 3.5×3.6-cm-sized pituitary mass detected on brain MRI. Normal pituitary functions with mild hyperprolactinemia suggested a nonfunctioning pituitary mass with stalk compression. After transsphenoidal surgery, histopathology revealed a pituitary adenoma; MRI immediately post-surgery revealed no grossly remnant lesion. However, during the current visit, sellar MRI revealed a re-growing mass in the pituitary fossa extending to the sphenoid sinus and compressing the optic chiasm with a suprasellar extension. Functional endoscopic sinus surgery was performed, and histopathology revealed a composite tumor, i.e., a mesenchymal tumor with a pituitary adenoma. On immunohistochemical staining, smooth muscle actin, synaptophysin, and chromagranin were positive; tumor cell mitosis was observed at 7/10 high-power fields. Finally, a composite tumor of myxoid leiomyosarcoma and pituitary adenoma was diagnosed. Hence, systemic chemotherapy with radiotherapy was planned for the remnant lesion. Hormonal replacement therapy with hydrocortisone and thyroxine was also started for subsequent hypopituitarism. Conclusion: NFPA is benign and has good prognosis if it is not grow in size or is completely resected. Conversely, primary sarcomas, such as LMS, show rapid extension and aggressive local invasion. Although their incidence is extremely rare, few primary pituitary sarcoma cases with or without pituitary adenoma have been reported. In the former case, initial diagnosis of pituitary adenoma may lead to delayed diagnosis of combined malignant lesions. Thus, clinicians should consider this possibility and high index of suspicion is required when diagnosing a pituitary mass.

Preoperative evaluation of mammographic microcalcifications after neoadjuvant chemotherapy for breast cancer

To assess the predictive value of preoperative residual mammographic microcalcifications for residual tumours after neoadjuvant chemotherapy (NAC) for breast cancer. This single-centre retrospective study included breast cancer patients who underwent NAC and demonstrated suspicious microcalcifications within or near the tumour bed on mammography from June 2015 to August 2018. The residual microcalcifications and remnant lesion on magnetic resonance imaging (MRI) were correlated with histopathological findings of residual tumours and immunohistochemical markers. A total of 96 patients were included. Ten patients achieved pathological complete response (pCR) and previous suspicious microcalcifications were associated with benign pathology in 10.4% (10/96) of the patients. In the remaining 86 patients who did not achieve pCR, 61.5% (59/96) of the residual microcalcifications were associated with invasive or in situ carcinoma and 28.1% (27/96) with benign pathology. Hormone receptor-positive (HR+) patients had the highest proportion of residual malignant microcalcifications compared to HR- patients (48.9% versus 13.5%, respectively; p=0.019). MRI correlated better than residual microcalcifications on mammography in predicting residual tumour extent in all subtypes (ICC=0.709 versus 0.365). MRI also showed higher correlation with residual tumour size for the HR-/HER2+ and HR-/HER2- subtype (ICC=0.925 and 0.876, respectively). The extent of microcalcifications on mammography after NAC did not correlate with the extent of residual cancer in 38.5% of women. Regardless of the extent of microcalcifications, residual tumour extent on MRI after NAC and molecular subtype could be an accurate tool in evaluating residual cancer after NAC.

Chromosomal rearrangements in myoepithelial carcinoma of the breast that presented as metachronic double cancer with invasive ductal carcinoma in the ipsilateral breast

Myoepithelial carcinoma of the breast is an extremely rare tumor composed entirely of malignant spindle cells with myoepithelial differentiation. The majority of previously reported cases have mainly described the clinicopathological features of the disease, and few have presented cytogenetic data. We herein present the case of a 48-year-old woman who was admitted with a left-sided breast lump in the inner upper quadrant that was initially diagnosed as a myoepithelioma with potentially malignant disorder. At 12 months after resection, she complained about a newly developed solid mass in the subareolar region of the ipsilateral breast that was diagnosed as an invasive ductal carcinoma. In addition, 16 months after the initial admission, a re-growing remnant lesion recurred in the inner upper quadrant and was ultimately diagnosed as a myoepithelial carcinoma. Lymph node metastasis of the myoepithelial carcinoma was also observed in her left axillary region 11 months after local recurrence. A cytogenetic analysis showed recurring specific chromosomal alterations both in the locally recurrent and in the lymph-node metastatic lesion: 48, XX, t(5;18)(q13;q23),del(6)(q?),+14. + mar1. To our knowledge, this is the first published report of clonal chromosomal rearrangements in myoepithelial carcinoma of the breast that presented as metachronic double cancer with invasive ductal carcinoma in the ipsilateral breast.

Inflammatory pseudotumor of eyelid: a probable IgG4-related sclerosing disease clinically mimicking eyelid pilomatrixoma

BackgroundOcular adnexal IgG4-related sclerosing disease (IgG4-SD) has been categorized as a novel disease entity. It is characterized by stromal sclerosis and an infiltration of mass-forming lymphoplasmic cells containing many IgG4-positive plasma cells. Although ocular adnexal tissue involvement has been increasingly reported, a focal nodular sub-brow mass is not typical in an IgG4-SD presentation. We report a rare case of probable ocular adnexal IgG4-SD that clinically mimicked eyelid pilomatrixoma.Case presentationA 42-year-old woman presented with a nodular mass in her left sub-brow area. The initial clinical impression of her lesion was eyelid pilomatrixoma. However, the final pathologic diagnosis was IgG4–SD, but extranodal marginal zone B-cell lymphoma could not be excluded. The patient underwent testing to determine tumor malignancy and systemic IgG4-SD involvement. Laboratory testing showed normal IgG and IgG4 serum levels and imaging revealed no remarkable findings. Oral prednisolone was administered and slowly tapered to manage the possible remnant lesion and to prevent disease recurrence. Two years after initiating therapy, there was no evidence of relapse. The patient is under close surveillance for signs of recurrence, systemic involvement, and potential malignant transformation.ConclusionsWe found an unusual case of probable ocular adnexal IgG4-SD, which presented as a unilateral restricted mass involving the sub-brow area. Although the mass was surgically removed, systemic steroid treatment and long-term surveillance were initiated due to the possibility of recurrence, the potential association with systemic disease, and the potential development of extranodal mucosa-associated lymphoid tissue (MALT) lymphoma.

Role of Follow Up Endoscopic Examinations in Response Assessment of Patients with Gastric Diffuse Large B Cell Lymphoma

ABSTRACT Aim: According to the guidelines of lymphoma, gastric diffuse large B cell lymphoma (DLBCL) patients are supposed to perform CT and/or PET CT regularly for response assessment after treatment such as chemotherapy and radiation therapy. However, endoscopic examinations and biopsies are not indicated for follow up guidelines. The aim of this study was to investigate the necessity and efficacy of endoscopic examinations when following up during and after treatment of tumor. Methods: This was a retrospective study of 44 consecutive patients who were diagnosed with gastric diffuse large B cell lymphoma, treated and underwent serial follow up endoscopies and biopsies from July 2009 to April 2014 in Seoul St. Mary's hospital. Endoscopic examinations and biopsies were performed at the time of diagnosis and after treatment. Disappearance of mucosal lesion except atrophy, discoloration, and neovascularization was defined as endoscopic remission. We followed the terms of NCCN guidelines (complete remission, partial response, stable disease, progressive disease) to determine clinical response with CT and/or PET CT. Results: A total of 161 endoscopic examinations were performed (median 3.7; range 2-7). Within a median follow up period of 27 months (range 4-57), 39 (89%) patients achieved complete remission in clinical response, while endoscopic remission was found in 34 (77%) patients. Only 32 (73%) patients achieved both forms of remission. 2 of 5 patients who achieved complete remission in clinical response but had remnant lesion at endoscopic examinations have recurred after several months. Patient demographics N = 44 Age 57.8 ± 12.07 (23-76) Male 22 (50%) Number of total f/u endoscopy (mean) 161 (3.7, 2-7) Duration of f/u period per patient (months) 27 (4-57) Clinical response Complete remission 39 (88.7%) Partial response 4 (9.1%) Progressive disease 1 (2.3%) Endoscopic response Complete remission 34 (77.3%) Partial response 7 (15.9%) Progressive disease 1 (2.3%) Conclusions: In gastric DLBCL patients, endoscopic response not always correlates with clinical response, and it also predicts the recurrence of disease as well. Therefore, we suggest that follow up endoscopic examinations and biopsies should be performed in addition to radiologic examinations such as CT and PET CT. Disclosure: All authors have declared no conflicts of interest.

Usefulness of 11C-methionine positron emission tomography for detecting intracranial ameloblastic carcinoma: A case report.

Ameloblastic carcinoma, secondary type, is an extremely rare odontogenic malignant tumor. The present study reports the case of a 58-year-old male with ameloblastic carcinoma that extended into the intracranial space close to the internal carotid artery. Surgical excision was performed, as headaches were being caused via compression by the mass. Small remnants of the tumor remained surrounding the internal carotid artery following surgical resection. Although the remnant tissue was not detected on magnetic resonance imaging or 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET), it was clearly visualized on 11C-methionine PET in the early post-operative follow-up period. No neurological deficits were exhibited during the follow-up period, and 11C-methionine PET was able to detect the remnant lesion distribution in the intracranial space. The current study presents a rare case of ameloblastic carcinoma that extended into the intracranial space. In addition, several diagnostic imaging tools were compared in order to determine the most suitable imaging modality. At present, the patient is continuing a therapeutic course of radiation and evident mass reduction has been observed. However, the therapeutic effects are currently under consideration. To the best of our knowledge, this is the first study on the effectiveness of using 11C-methionine PET for detecting ameloblastic carcinoma with intracranial extension.

A tailored approach for endoscopic treatment of small rectal neuroendocrine tumor.

Resection of rectal neuroendocrine tumors (NETs) less than 1 cm in diameter can be performed using various endoscopic techniques. Endoscopic mucosal resection (EMR) traditionally had suboptimal complete resection rate compared to endoscopic submucosal resection with band ligation (ESMR-L). However, the previous studies did not consider the characteristics of rectal NETs. The aim of our study is to compare the efficacy of ESMR-L and EMR using tailored approach according to the characteristics of rectal NETs. 82 rectal NETs in 77 patients treated by ESMR-L (n = 48) or EMR (n = 34) between September 2007 and October 2012 were retrospectively analyzed. ESMR-L was used for flat-type tumors or tumors with non-lifting sign after submucosal injection. Conventional EMR was used for elevated-type tumors or tumors with well-lifting sign after submucosal injection. The pathological complete resection rate was higher in the ESMR-L group (45 lesions, 93.8%) compared with the EMR group (30 lesions, 88.2%); however, this difference was not significant (p = 0.441). Overall complication did not differ significantly between the ESMR-L group and the EMR group (p = 0.774). There was one case of a remnant lesion in the ESMR-L group, which was managed by EMR after circumferential pre-cutting (EMR-P), and no recurrence has been detected in either the ESMR-L or EMR group. ESMR-L and EMR procedures could have a similar excellent complete resection rate, if we select the endoscopic resection technique according to the characteristics of the small rectal NETs.

Su1505 Salvage Endoscopic Resection for Local Failure After Radiotherapy for Esophageal Squamous Cancer

Su1505 Salvage Endoscopic Resection for Local Failure After Radiotherapy for Esophageal Squamous Cancer Hogara Nishisaki*, Yoshinobu Yamamoto, Ikuya Miki, Masahiro Tsuda, Hideto Inokuchi Hyogo Cancer Center, Akashi, Japan Background: Endoscopic resection(ER;endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) was widely performed for superficial esophageal carcinoma in Japan. However, efficacy and safety of salvage ER for remnant and recurrent lesion with fibrosis after radiotherapy(RT) was little evaluated. Aims: To clarify the efficacy and safety of salvage ER for local failure after RT for esophageal cancer. Methods; We performed a single-institute retrospective study. The patients with local failure after radiotherapy (RT) for esophageal squamous carcinoma (ESCC) were enrolled . We evaluated the rate of curative resection, adverse events and toxicity related to ER. Results: We enrolled 16 patients with 19 lesions. 15 patients were male and one was female, and their median age was 63 (range: 50-85).The tumor location was the upper esophagus in 7 lesions, middle esophagus in 6 lesions and lower esophagus in 6 lesions. The baseline clinical stages before RT or local resection were : stage I in 12, stage II in 2, stage III in one and, stage IV in one patients. The irradiation dose for patients 60Gy in 13 patients, 50.4Gy in 2 patients and 70Gy in one patient. The failure patterns were recurrence after achieving a CR with CRT in 11 patients, and residual tumor just after CRT in 5 patients. The median tumor length was 22mm (range 8-55mm), and the circumference of the lumen was 12 lesions in 1/4, and 5 lesions in 1/4-1/2, and 2lesions in 1/2 . The T stage of the recurrent lesion was T1 in all patients. 7 lesions were performed with EMR, 12 lesions were performed with ESD. None of them had clinical lymph node or distant metastasis on CT evaluation before ER. The rate of en block, curative resection were 79%(15/19) and 79%(15/9),respectively. Esophageal stricture was observed in % (3/16). Neither bleeding nor perforation was observed. At the median follow up period of 28 months (range 3-135), no local recurrence and no metastasis was detected in 12 patients, the local recurrence was detected in one, the lymph node metastasis was detected in two patients, and the liver metastasis was detected in one patients. Conclusion: Salvage ER is a curative treatment option for patients with local failure after RT for esophageal squamous cell carcinoma.

Leiomyoma of the Forehead

Leiomyoma of the Forehead

Spontaneously complete regression of pseudolymphoma of the remnant pancreas after pancreaticoduodenectomy

BackgroundPancreatic pseudolymphoma is extremely rare. MethodWe present multiple pseudolymphomas in the head and body of the pancreas. The hypoechoic lesions observed by endoscopic ultrasound were enhanced in late-phase angio-computed tomography and homogeneously hypointensive in T1-weighted magnetic resonance imaging (MRI). 18F-fluorodeoxyglucose positron emission tomography showed strong accumulation in the lesions. The lesions were suspected to be non-functioning islet cell carcinoma. The intraoperative pathological diagnosis for the specimen obtained by a pylorus-preserving pancreaticoduodenectomy was non-neoplastic lymphoid cells. The remnant lesion in the pancreatic body was preserved. ResultsMacroscopically, the mass was well-circumscribed gray-white colored lesion. The pathological diagnosis was pancreatic pseudolymphoma. The lesion in the remnant pancreas spontaneously disappeared within one year after the operation. ConclusionThe differential diagnosis of pancreatic pseudolymphoma from malignant tumor is very difficult, however, the image findings demonstrated here may be informative. The spontaneous disappearance of pancreatic pseudolymphoma was firstly observed in the present case.

Monitoring Therapeutic Response in a Case of Extrapulmonary Tuberculosis by Serial F-18 FDG PET/CT.

Due to the low yield of AFB smear and culture in extrapulmonary tuberculosis, therapeutic responses of patients with extrapulmonary tuberculosis are usually monitored clinically and/or radiographically. Such monitoring techniques, however, are not enough to provide effective diagnosis if a remnant lesion exists after treatment. Tuberculosis presents hypermetabolic activity on F-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) scanning. Reported herein is a case of extrapulmonary tuberculosis where the therapeutic response was assessed via serial F-18 FDG PET/CT scanning, which was useful for detecting the extent of extrapulmonary tuberculosis and for estimating the patient's therapeutic response.

Myoepithelial carcinoma with contralateral invasive micropapillary carcinoma of the breast

Adenomyoepithelioma (AME) is a rare benign tumor composed of myoepithelial cells (MECs) which are located beneath the epithelial cells of exocrine glands, especially in breast and salivary glands. These tumor cells show biphasic proliferation of epithelial and MECs. Malignant AME is characterized by distant metastasis, local recurrence, cytologic atypia, high mitotic activity and infiltrating tumor margins. A 51-year-old woman presented with an 8 months growth in the left breast. She underwent core-needle biopsy and consecutively mammotome assisted biopsy at a local clinic. After resection, she complained about re-growing remnant lesion and a newly developed solid mass in the right breast. Finally, the remnant mass in the left breast was diagnosed with myoepithelial carcinoma. Concurrently, contralateral breast mass was diagnosed with invasive micropapillary carcinoma. Herein we report an unusual case of synchronous myoepithelial carcinoma and invasive micropapillary carcinoma of the breast with a review of literatures.

Optochiasmatic Cavernous Angioma with Rapid Progression after Biopsy Despite Radiation Therapy

We present a rare case of optochiasmatic cavernous angioma (CA) that progressed despite radiation therapy. A 31-year-old female patient presented with sudden loss of left visual acuity and right homonymous hemianopsia. Magnetic resonance imaging (MRI) revealed a suprasellar mass and findings compatible with a craniopharyngioma or an optic glioma with bleeding. An open biopsy was conducted using the transcranial approach, and histological examination revealed gliosis. During the one-year follow-up period, imaging suggested intratumoral bleeding and the mass continued to grow. We recommended re-operation, but the patient refused due to fear of surgery. Consequently, the patient received fractionated radiation therapy (3,000 cGy) to the parasellar area. Despite the radiotherapy, the mass continued to grow for the following 6 years. The final MRI before definitive treatment revealed a multilobulated, multistage hematoma with calcification in the parasellar area, extending into the third ventricle and midbrain. The patient ultimately underwent reoperation due to the growth of the tumor. The mass was completely removed with transcranial surgery, and the pathologic findings indicated a cavernous angioma (CA) without evidence of glioma. As shown in our case, patients may suffer intratumoral hemorrhage after biopsy and radiotherapy. This case places the value of biopsy and radiotherapy for a remnant lesion into question. It also shows that reaching the correct diagnosis is critical, and complete surgical removal is the treatment of choice.

The feasibility of endoscopic submucosal dissection for rectal carcinoid tumors: comparison with endoscopic mucosal resection

Rectal carcinoid tumors are often found incidentally during screening colonoscopy and can be resected using various endoscopic techniques. This study aimed to compare the safety and efficacy of endoscopic submucosal dissection (ESD) with endoscopic mucosal resection (EMR) for rectal carcinoid tumors. Between January 2003 and June 2009, 74 patients (74 lesions) underwent either EMR (n = 28) or ESD (n = 46) for rectal carcinoid tumors. The rate of endoscopic complete resection, pathological complete resection, procedure complications, and tumor recurrence were analyzed retrospectively. The endoscopic complete resection rate was significantly higher in the ESD group (46 lesions, 100 %) compared with the EMR group (25 lesions, 89.3 %) ( P = 0.049). The pathological complete resection rate was higher in the ESD group (38 lesions, 82.6 %) compared with the EMR group (18 lesions, 64.3 %); however, this difference was borderline significant ( P = 0.067). Overall complication rate was not significantly different between the EMR group (3.6 %) and the ESD group (6.3 %). There was one case of remnant lesion in the EMR group, which was managed by ESD, and no recurrence has been detected in either the EMR or ESD groups. This study suggests that ESD might be a feasible treatment technique for small rectal carcinoid tumors. It showed superior efficacy and comparable safety to EMR.

P27.04: Ablation of uterine adenomyosis by magnetic resonance guided focused ultrasound surgery (MRgFUS)

We investigated the feasibility of ablating uterine adenomyosis by MR-guided focused ultrasound surgery (MRgFUS) and any adverse events that may arise during, immediately after and 1-week after MRgFUS. The subjects were 40 women with symptomatic adenomyosis, who had completed their family planning. The clinical trial was approved by the Ethics Committee of our hospital. The patients were treated by MRgFUS, a system comprising ExAblate 2000 (InSightec Israel), that generates high intensity focused ultrasound beams, and MRI, that provides real-time visualization of patient anatomy and temperature changes in and around the treated area. The treatment was applied to an area a few millimeters inside the adenomyosis as done in myoma treatment. After treatment, the non-perfused area and ablation result were evaluated through contrast enhanced T1-weighted MR images. Seventeen patients with extensive adenomyosis underwent a second treatment for the remnant lesion. Adverse events were examined during the treatment and one week after MRgFUS. Temperature rise of 60 °C to 90 °C was recorded in the sonicated region of the adenomyosis, and almost all the patients reported mild to moderate pain during the procedure. One patient unable to tolerate pain did not complete the treatment. The architecture at the periphery of the non-perfused area on sagittal view of MR images after the treatment was almost round (type R) in 28 patients, serrated in 7 (type S) and honeycombed (type H) in 4. Type R was considered well ablated, leaving no perfused lesion in the targeted tissue. Watery and thin bloody discharge was often reported by patients at their 1-week follow-up visit. Most of the patients were able to return to work within 3 days of the treatment. The adenomyosis tissue was ablated by MRgFUS, without severe complications. This method for treatment of uterine adenomyosis is promising at this first stage of tissue ablation.

Endoscopic Submucosal Dissection for Early Gastric Cancer and Gastric Adenoma: 3-Years Experience in a Single Center

Background/Aims: Endoscopic submucosal dissection (ESD) enables en-bloc complete resection of various gastrointestinal tumors compared with conventional endoscopic mucosal resection (EMR), and has been promising treatment option of early gastric cancer (EGC). This study aimed to evaluate clinical outcome of ESD for EGC and gastric adenoma using insulation-tipped diathermic knife. Methods: From April 2005 to June 2008, 884 patients (452 EGC and 432 gastric adenomas) were enrolled prospectively after ESD in Seoul National University Hospital. Follow-up endoscopies were performed in 3, 6, 12, 18 months, and then annually. Complete resection rate, complications, concordance of diagnosis in between the pre-treatment forcep-biopsy and pathologic mapping of ESD specimen and synchronous or metachronous lesions during follow-up were evaluated. Results: The median follow-up duration was 13.4 ± 9.7 months (range 3-39 months). The en bloc resection rate was 100%, complete resection rate was 91.1%(801/884) on the pathologic mapping and 96.4% (703/729) in 3-month follow-up endoscopy. Perforation occurred in 1.1% (10/884) and bleeding was noticed in 3.6% (32/884). There was no complication requiring operation or procedure related mortality. Gastric adenoma in the pre-treatment biopsy were finally proven as EGC with pathologic mapping in 22.5% (119/529) of cases. During the follow-up, 2% (9/432) of adenoma cases were retreated for the remnant lesion with argon-plasma coagulation (APC) or additional ESD. Additional surgical resection was performed in 5.1% (23/452) of EGC patients due to a residual lesion, tumor invasion more than deep submucosal layer, lymphatic invasion or undifferentiated carcinoma. Among the 23 surgically resected cases, there was residual carcinoma in 17.4%(4/23) and lymph node metastasis in 21.7% (5/23). One case revealed synchronous lesion at a different location from the initial ESD site (4.3%, 1/23). During follow-up period, 160 synchronous lesions (18.1%) within 1 year and 20 metachronous lesions (2.3%) were reported. No distant or lymph node metastasis was found during the follow-up. Conclusions: ESD shows high complete resection rate and more accurate pathologic diagnosis of EGC and gastric adenoma, and close follow-up is warranted for detection of synchronous or metachronous lesion.