Remnant Lesion Research Articles

Evolution of Vestibular Schwannoma After Removal of Epidermoid Cyst of the Same Location -Case Report-

A 71-year-old man presented with vestibular schwannoma manifesting as hearing disturbance and truncal ataxia 16 years after removal of a cerebellopontine angle (CPA) epidermoid cyst, and located adjacent to the remnant lesion. The patient first presented with a 6-month history of right trigeminal neuralgia. Neuroimaging demonstrated a right CPA lesion, suggestive of an epidermoid cyst. Right lateral suboccipital craniotomy was performed and the histological diagnosis was epidermoid cyst. A small lesion remained, but the symptoms were relieved. Sixteen years later, the patient presented with right auditory disturbance, vertigo, and truncal ataxia. Magnetic resonance imaging revealed a multiple cystic mass adjacent to the remnant epidermoid cyst in the right CPA. The lesion was removed and the histological diagnosis was vestibular schwannoma associated with the epidermoid cyst. The irritative effect of the remnant epidermoid cyst or surgical procedures may have caused the vestibular schwannoma, but no evidence of the evolution of the different types of tumors was found.

Endoscopic KTP Laser Photocoagulation Therapy for Pharyngolaryngeal Venous Malformations in Adults

Venous malformations are benign lesions with thin, fragile mucosa overlying a vascular stroma. Vascular anomalies often manifest as subglottic lesions in infants, but venous malformations in adults are rare in the pharyngolaryngeal region. The treatments include open and endoscopic surgery; intraoperative bleeding is often troublesome. Angiolytic lasers such as the potassium titanyl phosphate (KTP) laser enable photocoagulation for such hemorrhagic lesions without bleeding; we report findings from a series of adult patients. Seven adults were treated with a KTP laser set at a low power of 1.5 W in continuous mode. Photocoagulation was easily performed for shallow lesions; however, laser irradiation of bulky venous malformations resulted only in surface photocoagulation. In such cases, the crust remaining after photocoagulation was removed, and laser energy was repeatedly delivered until no remnant lesion was seen. An office procedure using flexible endoscopy was performed under topical anesthesia for 1 patient with a limited lesion. The lesions were well controlled in all cases without major complications. A patient with a large obstructing lesion had a relapse. Because the recurrent lesion is small and the patient does not desire additional treatment at this time, she is being observed carefully. Photocoagulation using the KTP laser is a feasible and relatively safe treatment for pharyngolaryngeal venous malformations in adults.

Serial pancreas, liver and duodenal metastasis from renal clear cell cancer: a case report

In August 2004, a 76-year-old patient was referred to our hospital for progressive loss of appetite, accompanied with mild upper abdominal distention, pain, hiccups and dyspepsia over a recent 3 months period. Reviewing his disease history showed that 16 months before admission (April 2003), he was diagnosed with a recurring left renal clear cell cancer (immunohistochemical staining of tumor cells were positive for CK and Vim, but negative for SMA, HMB-45 and HHF-35, Fig.1) 10 years after a nephrectomy due to a right renal cancer. At that time, he was treated with photodynamic therapy followed by bio-immunotherapy(interleukine-2 plus lymphokine-activated killer cells). Follow-up by an abdominal CT scan every 3 months showed significant regression of the left renal carcinoma. Physical examination on admission showed that his abdomen was flat and soft with no abdominal tenderness or jaundice, and the liver, spleen or masses were not palpable. Routine, serum levels of hepatobiliary enzymes and bilirubin as well as tumor markers including α-fetoprotein (AFP), carcinoembryonic antigen (CEA), carbohydrate antigen (CA)50, CA19-9 and CA125 were all normal. An abdominal ultrasonic examination revealed dilatation of the common bile duct due to a mass in the inferior part of the common bile duct as well as a neoplasm in both head and body of the pancreas. A further positron emission tomography (PET-CT) examination revealed a low-malignant pancreatic tumor but no malignant signs in other parts of the body, with a left renal carcinoma remnant lesion present (Fig.2A,B). Endoscopic retrograde cholangiopancreatography (ERCP) showed an ellipse filling defect in the lower common bile duct with dilataton of the upper common duct (Fig.2C). An ultrasound-directed needle biopsy of the pancreas demonstrated infiltration of clear carcinoma cells in the connective tissue, with immunohistochemical staining being positive for CD10 but negative for CA19-9 or CEA. Therefore, diagnosis of pancreatic metastasis from renal clear cell cancer was established, and an intra-bile duct stent was implanted in the inferior part of common bile duct, followed by three-dimensional conformal radiotherapy (3DCRT) and high intensive focused ultrasound (HIFU) directed to the tumorous pancreatic head along with subcutaneous administration of somatostatin. Follow-up abdominal CT showed no sig-

放射線療法及び腰椎椎体切除により完全寛解に至った晩期再発非セミノーマの一例

In this report we describe a case of late relapse non-seminomatous germ cell tumor eradicated after 9 years of initial onset. A 20-year-old man complaining of recent aches, vomiting and headaches was diagnosed with right testicular tumor with solitary brain and bilateral lung metastases. At presentation, human chorionic gonadotropin (HCG) was elevated to 22,000 mIU/ml, and alpha-fetoprotein to 79 ng/ml. A right high orchiectomy was performed, followed by a right occipital osteoplastic craniotomy due to the presence of left hemiplesia and anisocoria prior to chemotherapy. Pathologically, the tumors were embryonal carcinoma and yolk sac tumor. The patient received 5 cycles of cisplatin-based PEP chemotherapy (cisplatin, etoposide and peplomycin) after which all the tumor markers fell to within the normal range. The remaining right lung tumor was removed surgically and the remnant lesion was found to be scar tissue. Four years after initial therapy, elevated serum HCG levels were detected. The tumor metastasis showed only HCG elevation responsive to chemotherapy each time followed by relapse and undetectable with all kinds of imaging examinations for 5 years. Finally when the tumor became chemorefractory, conventional computed tomography scan on bone window detected the occult tumor in L4 corporal body. After radiation therapy the tumor was removed by total spondylectomy and there was no viable tumor cells in the specimen pathologically. HCG fell to within normal range according to its half life period after the operation and there is no relapse of HCG after 18 months follow up. CT bone window photography may be sometimes useful to detect occult bone metastasis and salvage surgery combined with radiation therapy may be worth trying in patients with chemorefractory non-seminomatous germ cell tumors.

Malignant transformation eight years after removal of a benign epidermoid cyst: a case␣report

Malignant transformation of benign epidermoid cysts is rare and their prognosis remains poor. A 56-year-old woman presented with left facial hypoesthesia and photophobia in the left eye. She had undergone removal of a benign epidermoid cyst in the cerebellopontine angle 8 years previously. Magnetic resonance imaging of the brain revealed a cystic lesion in the left cerebellopontine angle. The cyst wall was enhanced by gadolinium-DTPA. She underwent removal again and the histopathologic diagnosis was squamous cell carcinoma. Gamma knife radiosurgery was performed on the remnant lesion with a marginal dose of 15 Gy. The tumor shrank rapidly for 2 months after radiosurgery, but recurred 9 months later. She underwent radiosurgery again with a marginal dose of 12 Gy. A gradual increase in the size of the enhanced lesion was seen during the 4-month follow-up period subsequent to the second radiosurgery. Careful observation, employing serial magnetic resonance images, is necessary for incompletely resected epidermoid cysts because intervals before malignant transformation reportedly range from 3 months to 33 years. Newly identified contrast enhancement strongly indicates malignant change in epidermoid cysts. Gamma knife radiosurgery may be useful for short-term control of intracranial squamous cell carcinomas, but long-term effects are presently unknown.

Clinical analysis of the risk factors for recurrence of HCC and its relationship with HBV

To comprehend the risk factors of recurrence of hepatocellular carcinoma (HCC) and its relationship with the infection patterns of hepatitis B virus (HBV). All materials of 270 cases of postoperative HCC were statistically analyzed by SPSS software. Recurrence and metastasis were classified into early (< or =2 years) and late phase (>2 years). Risk factors for recurrence and metastasis after surgery in each group were analyzed. Out of 270 cases of HCC, 162 cases were followed up in which recurrence and metastasis occurred in 136 cases. There were a lot of risk factors related to recurrence and metastasis of HCC; risk factors contributing to early phase recurrence were serum AFP level, vascular invasion, incisal margin and operative transfusion, gross tumor classification and number of intrahepatic node to late phase recurrence. The HBV infective rate of recurrent HCC was 94.1%, in which "HBsAg, HBeAb, HbcAb" positive pattern reached 45.6%. The proportion of HBV infection in solitary large hepatocellular carcinoma (SLHCC) evidently decreased compared to nodular hepatocellular carcinoma (NHCC) (P<0.05). The early and late recurrence and metastasis after hepatectomy of HCC were associated with different risk factors. The early recurrence may be mediated by vascular invasion and remnant lesion, the late recurrence by tumor's clinical pathology propert, as multicentric carcinogenesis or intrahepatic carcinoma de novo. HBV replication takes a great role in this process. From this study, we found that SLHCC has more satisfactory neoplasm biological behavior than NHCC.

Advanced Esophageal Cancer with Esophago-bronchial Fistula Successfully Treated by Chemoradiation Therapy with Additional Endoscopic Resection: a Case Report

Chemoradiation is potentially curative for esophageal cancer in various stages, but local failure is a major problem. The present case was a 49-year-old male diagnosed with advanced esophageal cancer with an esophago-bronchial fistula and lymph node metastasis. Histological diagnosis by biopsy was adenosquamous cell carcinoma. Chemoradiotherapy comprising intravenous infusion of cisplatin and continuous infusion of 5-fluorouracil with concurrent radiation was initiated in July 1997. In December 1997, after four courses of therapy, partial remission was obtained and the fistula closed with a remnant polypoid lesion at the primary site, which remained even after six courses of treatment. In February 1998, endoscopic polypectomy was performed for the remnant lesion and histological examination revealed that it contained adenocarcinoma cells. Thereafter, no additional treatment was performed and the patient has been disease-free for 3.5 years. This case suggests that additional endoscopic resection is an optional treatment for local failure after chemoradiation.

Primary epiploic appendagitis: evolutionary changes in CT appearance.

To determine the changes in the computed tomographic (CT) appearance of primary epiploic appendagitis. Clinical records and CT scans were reviewed in 10 patients who were initially suspected of having diverticulitis or appendicitis but were later determined to have primary epiploic appendagitis. The scans were obtained at the time of presentation and at follow-up 1-84 weeks later. Initial CT characteristics included mean size of 14 x 21 mm, oval (n = 9) or round (n = 1) shape, mean attenuation of -53 HU, visceral (n = 10) or parietal (n = 7) peritoneal thickening, periappendageal fat stranding (n = 10), adjacent bowel wall thickening (n = 4) or compression (n = 2), and central high-attenuating dot (n = 2). Follow-up CT characteristics included residual abnormality (n = 9); mean size of 10 x 15 mm; oval (n = 6), round (n = 2), or indistinct (n = 1) shape; mean attenuation of -68 HU; visceral (n = 5) or parietal (n = 3) peritoneal thickening; periappendageal fat stranding (n = 1); and central high-attenuating dot (n = 1). CT characteristics of the remnant lesion included smaller lesion with fat attenuation (n = 6), nugget with soft-tissue attenuation (n = 2), and nondescript fat stranding (n = 1). Awareness of the CT appearance of acute and healing primary epiploic appendagitis may help in the differential diagnosis of pericolonic abnormality.