Predicting the Severity and Prognosis of Trismus after Intensity-Modulated Radiation Therapy for Oral Cancer Patients by Magnetic Resonance Imaging

To develop magnetic resonance imaging (MRI) indicators to predict trismus outcome for post-operative oral cavity cancer patients who received adjuvant intensity-modulated radiation therapy (IMRT), 22 patients with oral cancer treated with IMRT were studied over a two-year period. Signal abnormality scores (SA scores) were computed from Likert-type ratings of the abnormalities of nine masticator structures and compared with the Mann-Whitney U-test and Kruskal–Wallis one-way ANOVA test between groups. Seventeen patients (77.3%) experienced different degrees of trismus during the two-year follow-up period. The SA score correlated with the trismus grade (r = 0.52, p<0.005). Patients having progressive trismus had higher mean doses of radiation to multiple structures, including the masticator and lateral pterygoid muscles, and the parotid gland (p<0.05). In addition, this group also had higher SA-masticator muscle dose product at 6 months and SA scores at 12 months (p<0.05). At the optimum cut-off points of 0.38 for the propensity score, the sensitivity was 100% and the specificity was 93% for predicting the prognosis of the trismus patients. The SA score, as determined using MRI, can reflect the radiation injury and correlate to trismus severity. Together with the radiation dose, it could serve as a useful biomarker to predict the outcome and guide the management of trismus following radiation therapy

Mixed Lung Mucoepidermoid Carcinoma and Adenocarcinoma With Identical Mutations in an Epidermal Growth Factor Receptor Gene

Lung cancers presenting two different histologic types are relatively rare. This paper presents a case report of mixed lung cancer comprising mucoepidermoid carcinoma and conventional adenocarcinoma, a combination that has not been reported previously. These two carcinomas showed distinct morphologic and immunohistochemical features. However, gene analysis revealed identical mutations in each component, which indicates they possess a monoclonal origin. Specifically, we identified the same mutation in exon 19 of the epidermal growth factor receptor gene. Molecular analysis further substantiated a monoclonal origin with divergent differentiation, as opposed to the collision of discrete tumors. (C) 2014 by The Society of Thoracic Surgeon

Extraocular well-differentiated sebaceous tumors with overlying cutaneous horns: four tumors in three patients

BackgroundSebaceous tumors are adnexal neoplasms showing sebocytic differentiation. They range from benign to malignant and are associated with Muir-Torre syndrome (MTS). Several clinical and histopathological features associated with MTS have been described. Sebaceous tumors with an overlying cutaneous horn are extremely rare. MethodsHematoxylin and eosin-stained slides were retrospectively reviewed to identify sebaceous tumors with marked hyperkeratosis, a condition that is often associated with cutaneous horns. Clinical correlation and mismatch repair protein immunohistochemical studies were then conducted. ResultsFour tumors from three patients were identified in our archive. Three were classified as sebaceous adenomas, and the fourth was considered as a borderline sebaceous tumor favoring well-differentiated sebaceous carcinoma. All cases showed loss of expression of mismatch repair proteins (three tumors from two patients exhibited lost expression of MSH2 and MSH6, and the fourth exhibited lost expression of MLH1 and PMS2). Additionally, one patient presented characteristic clinical manifestations of MTS, including multiple sebaceous adenomas and visceral carcinomas. ConclusionsWe suggest that extraocular well-differentiated sebaceous neoplasms with overlying cutaneous horns may be an indication of underlying mismatch repair protein deficiency and potential MTS. This distinctive morphology might be an exaggerated combination of other features associated with MTS, i.e. keratoacanthoma-like architecture and extensive holocrine secretion

Identify the common DNA viral pathogens from formalin-fixed paraffin-embedded myocardium tissues of myocarditis

心肌炎（myocarditis）是一種心臟肌肉組織發炎的疾病，且伴隨著心臟功能缺損（cardiac dysfunction）。因為心肌炎有著多變的臨床表現，從一般無明顯徵候、似心肌梗塞的胸痛、心律不整、乃至於猝死都可能，病情迅速惡化常使醫師措手不及，是引起醫療糾紛的病症之一。法醫師常會參與此類死因鑑定，所以心肌炎是個重要的疾病，需要深入研究和了解。 目前在臨床上確定診斷心肌炎需要依靠經心導管心肌切片（endomyocardial biopsy, EMB）後，根據Dallas criteria來做病理診斷。心肌炎的病因很多種，光從型態學上的診斷，不免在先天上受制在致病源上的偵測。國外文獻認為大多數的病源是RNA病毒，我國亦研究RNA病毒為主，所以國內一直缺乏DNA病毒的流行病學資料，本研究想要了解心肌炎中DNA病毒感染的盛行率。於是收集2001年至2005年台大醫院因心肌炎入院病例中，心臟組織病理切片符合Dallas criteria的案例，利用巢式聚合酶連鎖反應加上毛細管電泳從舊組織切片（Archive tissue）中偵測ＤNA病毒基因，包括疱疹病毒第一型（HHV-1）、疱疹病毒第二型（HHV-2）、疱疹病毒第四型（HHV-4）和巨細胞病毒（HHV-5）。共有收集到二十四個檢體，年齡層分佈為六歲到四十八歲。十二個檢體為實驗組，病理診斷為心肌炎，有二個存在巨細胞病毒（human herpes virus 5，Cytomegalovirus），比率為16.7%（2/12）。另外十二個檢體來自法醫解剖的心臟檢體，死因為非心臟因素造成的死亡，病毒反應均呈現陰性。毛細管電泳結果得到的產物大小雖然和理論大小不符，但是實驗組檢體和病毒株檢體大小是相吻合的。除了RNA病毒，DNA病毒亦佔了心肌炎病因的一部份，建議以後臨床上心肌炎的案例都要考慮偵測病毒感染。本方法也可以應用在法醫解剖心肌炎的研究上，了解是何種病毒感染會致死及其流行病學資料，將有助於臨床診斷、判斷預後、或者有可能使用抗病毒藥物治療、以及達到公衛上預防死亡的發生和減少醫療糾紛的功能。Fatal acute myocarditis is a common cause of alleged medicolegal investigation. Forensic pathologists frequently encounter these death investigations, so it is an important disease we have to understand. The etiology of myocarditis is usually inferred from clinical information and preliminary laboratory studies. This study was undertaken to evaluate the molecular analysis of endomyocardial archive tissues in identifying the possibility of common DNA viral pathogens. We collected all available clinical record and endomyocardial archive tissues for patients who had myocarditis recorded as the clinical diagnosis at the National Taiwan University Hospital from 2001 to 2005. Findings for all available patients（6 men and 6 women；median age, 26 years）with myocarditis that fulfilled the Dallas criteria were included in this study. Twelve subjects who had died naturally except heart diseases served as control group from forensic autopsy. Nested polymerase chain reaction （PCR）was used for detection of DNA viral genomes （human herpes virus 1, human herpes virus 2, Epstein-Barr virus, and human herpes virus 5）from endomyocardial biopsied tissues. DNA viral nucleic acid were found in the hearts of 2 patients （16.7%）, including human herpes virus 5（2 patient）. In the control group, no viral genome was detected. In patients with unexplained myocarditis, viral infection really contributes to be an important etiology. We can’t realize which kinds of DNA viral infection based on only microscopic examination of endomyocardial biopsies. Serological tests can help these but it is time-consuming and not very specific. Nested polymerase chain reaction may be an sensitive and specific tool to identify viruses. Then, this may be given as a guide in treating patients in the future, such as viral vaccine prevention. It may be useful in forensic cases to identify the underlying virus infection.口試委員審定書……………………………...……………………………i 誌謝…………………….………………………………………………….ii 中文摘要……………………………………………………...………….iii 英文摘要………………………………………………………………….iv 第一章 緒論…………………………………………………………..1 第一節 前言…………………………………………..….1 第二節 研究背景……..……………………………………..1 第一項 心肌炎之臨床表現與鑑別診斷…………………… 1 第二項 心肌炎之疾病診斷…………………………………2 第三項 心肌炎之病因…………………………………………2 第四項 病因的探討非僅由病理學呈現………………………3 第五項 心肌炎和病毒感染的關係………………………3 第六項 心肌炎病因診斷之方法………………………………4 第七項 病毒培養………………………………………………4 第八項 病毒血清學……………………………………………4 第九項 聚合酶連鎖反應………………………………………5 第三節 研究動機……………………………………………………6 第四節 研究的目的………………………………………6 第二章 文獻探討……………………………………………8 第三章 實驗材料與方法……………………………………………10 第一節 實驗材料…………………………………………………10 第一項 病人和檢體來源……………………………………..10 第二項 病毒株（Viral strain）……………………………10 第三項 配套試劑（Kit）………………………………………10 第四項 PCR反應試劑…………………………………………10 第五項 儀器與設備（Equipments and supplies）……………11 第二節 實驗的方法…………………………………………11 第一項 DNA萃取方式…………………………………………11 第二項 Consensus nested PCR………………………………11 第三項 PCR複製過程條件……………………………………11 第四項 PCR複製產物分析方法………………………………12 第四章 實驗結果…………………………………………………13 第一節 洋菜膠電泳分析結果………………………………13 第二節 序列分析結果………………………………………13 第三節 GeneScan分析結果…………………………………13 第四節 實驗結果分析………………………………………13 第五章 實驗討論………………………………………………15 第一節 巢式PCR產物分析……………………………………..15 第二節 2%洋菜膠電泳分析………………………………………15 第三節 PCR產物定序分析………………………………………16 第四節 GeneScan分析…………………………………………16 第五節 實驗組的巢式PCR結果和臨床血清學資料比較……17 第六節 對照組的巢式PCR結果的解釋………………………18 第七節 研究限制…………………………………………………18 第六章 討論與建議………………………………………………20 第一節 結論………………………………………………………20 第二節 建議………………………………………………………20 參考文獻………………………………………………………………22 圖目錄 圖一 第一輪PCR反應實驗組結果之2%洋菜膠電泳圖…（13,15）27 圖二 第一輪PCR反應對照組結果之2%洋菜膠電泳圖……（13）28 圖三 巢式PCR反應實驗組結果之2%洋菜膠電泳圖……（13,15）29 圖四 巢式PCR反應對照組結果之2%洋菜膠電泳圖………（13）30 圖五 HSV-1的GeneScan結果……………………………（13,16）31 圖六 HSV-2的GeneScan結果……………………………（13,16）32 圖七 HHV-5的GeneScan結果……………………………（13,16）33 圖八 S6的GeneScan結果………………………………（13,16）34 圖九 S11的GeneScan結果…………………………………（13,16）35 圖十 LIZ 500 size standard的GeneScan結果…………………（16）36 圖十一 巢式PCR模式圖……………………………………（17）37 圖十二 標準病毒株HHV-1和HHV-1:M10792的序列比較圖（16）38 圖十三 標準病毒株HHV-2和HHV-2：AY038367的序列比較圖………………………………………………………………（16）39 圖十四 標準病毒株HHV-5、S6、S11和HHV-5：AF133627的序列比較圖…………………………………………………………（16）40 表目錄 表一 實驗組病人的基本資料……………………………………（9）41 表二（Ａ） 實驗組病人之血清學資料──RNA病毒…………（9）42 表二（Ｂ） 實驗組病人之血清學資料──DNA病毒………（9）43 表三 引子的序列細節………………………………………（8,9,11）4

Cytological Features of a Metastatic Angiosarcoma in the Lymph Node Diagnosed via Liquid-Based Cytology

Angiosarcoma is a soft tissue sarcoma of vascular origin, with more than half of the cases arising in the skin and affecting primarily the face and scalp of elderly males. Furthermore, cutaneous angiosarcoma exhibits a higher incidence of lymph node metastases than other types of sarcomas. Angiosarcomas are rarely aspirated and are occasionally encountered on cytological samples. It is a diagnostic challenge in evaluating fine needle aspiration (FNA) from a metastatic angiosarcoma without the knowledge of prior history. We present a case of scalp angiosarcoma with disease progression to erythroderma and cervical lymphadenopathy 20 months after. FNA of the cervical node revealed vasoformative features, including hemophagocytosis, formation of an intracytoplasmic lumen/vacuole, endothelial wrapping, and cell grasping. The diagnosis of nodal metastasis by angiosarcoma was confirmed with immunohistochemistry (IHC) using two vascular markers on cell block sections. Our case demonstrates the recognizable cytomorphologic clues for this rare metastatic malignancy