Growth characteristics of rectal carcinoid tumors

PURPOSE

Tissue growth depends on both cell proliferation and cell death. This study was designed to examine the growth characteristics of rectal carcinoid tumors.

METHODS

Fifty rectal carcinoid tumors were studied clinicopathologically and experimentally. Expression of Ki-67, TGF-alpha, p53, and bcl-2 was examined immunohistochemically, and apoptotic cells were identified by the in situ DNA nick end labeling method. EGF receptor expression was examined by a colorimetric in situ mRNA hybridization technique.

RESULTS

The median Ki-67 labeling index (LI) in all lesions was 0.62 +/- 0.59%. Ki-67 LI was significantly (p < 0.01) higher in lesions larger than 5 mm than in lesions smaller than 5 mm. TGF-alpha was expressed more frequently (p < 0.01) in lesions larger than 5 mm (100%) than in lesions smaller than 5 mm (65.2%). Ki-67 LI was significantly (p < 0. 05) higher in lesions with TGF-alpha expression than in lesions without TGF-alpha expression. The in situ hybridization revealed EGF receptor expression in all 46 lesions with intact mRNA (100%), and coexpression of TGF-alpha and EGF receptor was found in 39 of the 46 (84.8%) lesions. The median apoptotic index (AI) in all lesions was 0.15 +/- 0.12%. AI has increased with tumor size and was significantly (p < 0.05) higher in lesions with a higher Ki-67 LI than in lesions with a lower Ki-67 LI. p53 protein was detected in only 1 patient who had liver metastases, and the gene mutation was confirmed by polymerase chain reaction and single-strand conformation polymorphism analysis. bcl-2 expression was absent in all lesions.

CONCLUSIONS

The Ki-67 LI indicated a low cellular proliferative activity in rectal carcinoid tumors. AI was very low, and was significantly correlated with proliferative rate. Inhibition of apoptosis by mutated p53 or bcl-2 may not have occurred in most of these tumors. TGF-alpha/EGF receptor autocrine mechanisms may play a possible role in tumor growth, and the cellular proliferative activity may increase as tumors grow larger.

Conditions of curability after endoscopic resection for colorectal carcinoma with submucosally massive invasion

The deepest invasive portion of colorectal carcinoma (CRC) is considered to be the part, which ultimately will invade, spread locally and give metastasis. We have previously reported that histologic differentiation at the deepest invasive portion of CRC closely correlate with metastatic potential and is useful in understanding the curability of endoscopic mucosal resection (EMR). The aim of this study is to clarify the conditions of curative EMR for CRC with submucosally (sm) massive invasion. A total of 521 cases with sm invasive CRC (Group A, 470 surgically resected cases; Group B, 51 followed-up cases after EMR) were studied. The depth of sm invasion was defined as the practically measured distance from muscularis mucosae. Histologic subclassification was performed at the deepest invasive tumor margin as: well-differentiated (W), moderately differentiated (M) and poorly differentiated (Por). By assessing glandular configuration and cellular arrangement, M type was further subdivided into two different groups; moderately-well differentiated (Mw) and moderately-poorly differentiated (Mp). In group A, lymph node (LN) metastasis was detected in 45 (9.6%) of 470 cases. W or Mw lesions showed LN metastasis in 4.9% (19/388). Mp or Por lesions showed LN metastasis in 37.3% (25/67) (W/Mw vs Mp/Por; p<0.01). Of 45 cases with LN metastasis that could be measured the practical distance of sm invasion, W or Mw lesions showed no LN metastasis in cases within 1,500 micrometer invasion. However, Mp or Por lesions showed LN metastasis in cases within 1,500 micrometer invasion (5/15, 33.3%, minimum 400 micrometer invasion; so-called scanty invasion). In group B, none of 51 cases died of LN metastasis and showed no other metastasis, although 17 cases (33.3%) showed an sm invasion more than 1,500 micrometer. These results indicated that CRC even with sm massive invasion can be cured by complete EMR on conditions that the depth of sm invasion is within 1,500 micrometer and histologic grade at the deepest invasive portion is W or Mw, if there are no vessel involvement. However, cases with Mp or Por grade were not curative by EMR, even if they showed an sm scanty invasion.

Predictive value of cathepsin D and Ki-67 expression at the deepest penetration site for lymph node metastases in gastric cancer

To search for reliable predictors for lymph node metastasis, we immunohistochemically analyzed surgically resected gastric cancer specimens that showed invasion of submucosa (sm) and muscularis propria (mp) of the tumor. The analysis investigated cathepsin D and Ki-67 expression in 136 specimens that were divided into an sm1/sm2 group and an sm3/mp group. In sm1/sm2 group, the incidence of lymph node metastases was significantly higher in tumors with high Ki-67 labeling index (LI) (44%) than in those with low Ki-67 LI (0%). In sm3/mp group, the incidence of lymph node metastases was significantly higher in cathepsin D-positive (56%) and high Ki-67 LI tumors (64%) than in cathepsin D-negative (33%) and low Ki-67 LI (33%). Combined analysis of cathesin D expression and Ki-67 LI correlated strongly with lymph node metastases. No lesions with cathepsin D-negative expression and low Ki-67 LI had lymph node metastases in either group. Cathepsin D and Ki-67 expression may be useful predictors for lymph node metastases in gastric cancer with sm and mp invasion. As predictors, they can identify lesions without lymph node metastases and indicate lesions not needing additional treatment after endoscopic mucosal resection and laparoscopic gastrectomy.

Pit pattern diagnosis of early colorectal carcinoma by magnifying colonoscopy: clinical and histological implications

The relation between subclassification of V type pit pattern and histopathologic features, particularly, in regards to the invasion depth, was examined in 75 cases of early colorectal carcinoma. After we classified two grades (VA, VN) of V type pit pattern, we subclassified VN type pit pattern into three subtypes (Grade A, B, and C) according to the degree of appearance of VN pit pattern. V type pit pattern subclassification was diagnosed with use of a magnifying colonoscope. There were 37 VA type lesions, 8 VN.Grade A type, 16 VN.Grade B type, and 14 VN.Grade C type lesions. The incidence of submucosal massive invasion (sm2, sm3) rates was 5 (14%) of the 37 VA type lesions, 3 (38%) of the 8 VN.Grade A type, 15 (94%) of the 16 VN.Grade B type and 14 (100%) of the 14 VN.Grade C type lesions, respectively. The incidence of desmoplastic reaction (++) levels in VN.Grade B and C type lesions was significantly higher than that in VA type lesions (P<0.01), and that in VN.Grade C type lesions was significantly higher than that in VN.Grade A type lesions (P<0.05). The incidence of pit disorder or destruction (+) and (++) levels in VN.Grade B and C type lesions was significantly higher than that in VA type lesions (P<0.01), and that in VN.Grade C type lesions was significantly higher than that in VN.Grade A type lesions (P<0.01). The incidence of high grade carcinoma in VN.Grade B and C type lesions was significantly higher than that in VA type lesions (P<0.01), and that in VN.Grade C type lesions was significantly higher than that in VN.Grade A type lesions (P<0.05). These findings indicate that V type pit pattern subclassification, including our new subtype, is useful for predicting the detail invasion depth of early colorectal carcinoma. These V pit pattern subtypes are based on the degrees of desmoplastic reaction, pit disorder or destruction, and histologic grade of carcinoma.

Telomere reduction in human liver tissues with age and chronic inflammation

Telomere shortening in human liver with aging and chronic inflammation was examined by hybridization protection assay using telomere and Alu probes. The reduction rate of telomere repeats in normal liver (23 samples from patients 17-81 years old) was 120 bp per year, which is in good agreement with the reported reduction rate in fibroblasts of 50-150 bp at each cell division and replacement rate of human liver cells, once a year. Mean telomere repeat length shortened to about 10 kbp in normal livers from 80-year-old individuals. The number of telomere repeats in chronic hepatitis (26 samples) and liver cirrhosis (11 samples) was significantly lower than that in normal liver of the same age (P < 0. 01). Telomere length in all these chronic liver disease samples, other than two exceptions, was not reduced shorter than 5 kbp, which was assumed to give a limit of proliferation (Hayflick's limit) to untransformed cells.

Double cancer - hepatocellular carcinoma and intrahepatic cholangiocarcinoma with a spindle-cell variant

Intrahepatic cholangiocarcinoma (ICC) with a spindle-cell variant is very rare. We report here a surgical patient who had double cancer - hepatocellular carcinoma (HCC) and ICC with a spindle-cell variant. In this 70-year-old man, who had a history of hepatic resection for HCC about 2 years previously, two large discrete masses were identified in the right lobe of the liver. A right lobectomy of the liver was performed. Pathological findings revealed that one tumor was a typical HCC, and the other was ICC with sarcomatous lesions. Immunohistochemical examinations of the sarcomatous lesions in ICC demonstrated that some of the spindle cells were positive for keratin, epithelial membrane antigen, and vimentin, but negative for S-100 protein, desmin, and actin. From these findings, we concluded that the sarcomatous lesions of ICC were not a true sarcoma, but sarcomatous transformation of cholangiocarcinoma cells, that is, a spindle-cell variant of ICC.

Expression of telomerase component genes in hepatocellular carcinomas

The aim of the study was to clarify the role of telomerase component genes in hepatocarcinogenesis and to examine both the relationship between the expression of telomerase component genes and histological differentiation in hepatocellular carcinoma (HCC) and the relationship between expression levels of telomerase component genes and telomerase activity in HCCs. Telomerase is a ribonucleoprotein enzyme composed of a template RNA and several proteins. Recently, three such telomerase component genes have been identified: human telomerase reverse transcriptase (hTERT); human telomerase RNA component (hTERC); and telomerase-associated protein 1 (TEP1). The expression of these components was evaluated in 34 HCCs and 24 non-cancerous liver tissues by reverse transcriptase-polymerase chain reaction (RT-PCR). Expression of hTERT mRNA was detected in most HCCs, but not in the non-cancerous tissues (P<0.01). Expression of hTERC was detected in both HCCs and non-cancerous tissues, but the expression level in HCCs was higher than that in non-cancerous tissues (P<0.01) and tended to increase as histological differentiation became less marked. The expression level of hTERT mRNA correlated with relative telomerase activity (P<0.01). These results suggest that telomerase reactivation during hepatocarcinogenesis might be regulated by only hTERT and an increase in telomerase activity level in tumour progression might be regulated by both hTERT and hTERC.

pS2 expression as a possible diagnostic marker of colorectal carcinoma in ulcerative colitis

This study was performed to evaluate the significance of pS2 and MUC1 expressions in ulcerative colitis (UC)-associated colorectal neoplasias. Tissues were collected from 6 patients with UC-associated colorectal neoplasias treated surgically. Specimens were 13 adenocarcinomas, 40 dysplasias (20 high-grade dysplasias, 20 low-grade dysplasias), and 60 normal mucosae. Tissues were also collected from patients without UC treated surgically or endoscopically. pS2, p53, and MUC1 expressions were examined immunohistochemically and compared. The K-ras codon 12 mutation was investigated by single-strand conformation polymorphism analysis. In patients with UC, the incidence of pS2 expression was significantly higher (p<0.01) in adenocarcinomas than it was in dysplasias, and no pS2 expression was seen in normal mucosae. p53 overexpression was detected in 50% (10/20) even in low-grade dysplasias. MUC1 expression was seen only in invasive carcinomas, but it was seen in 100% of cases (3/3). K-ras gene mutations were detected in 2 (20%) of 10 carcinomas. In low and high-grade dysplasias, the incidences of pS2 expression were significantly (p<0.01) lower than the incidences of p53 overexpression, however, in UC-associated carcinomas there was no significant difference; pS2 expression and p53 overexpression were detected in 13 of 13 (100%) cases and in 12 of 13 (92%) cases, respectively. These results suggest that p53 overexpression may be a diagnostic marker of neoplasia, and that pS2 expression may be a diagnostic marker of colorectal carcinoma in case of UC.

Precancerous hepatic nodules had significant levels of telomerase activity determined by sensitive quantitation using a hybridization protection assay

BACKGROUND

Telomeric repeat amplification protocol using internal telomerase assay standard (ITAS) (conventional TRAP) has detected telomerase activity in various malignant tumors. With conventional TRAP, it is difficult to differentiate quantitatively low levels of telomerase activity between well-differentiated hepatocellular carcinomas (HCCs) and dysplastic nodules because of quantitative limitation. To apply a telomerase assay for differential diagnosis, we used a hybridization protection assay combined with TRAP (TRAP/HPA). This combination had better sensitivity and wider linearity than conventional TRAP.

METHODS

TRAP/HPA was applied for quantitative measurement of telomerase activity in various hepatic tissues. Telomerase activity was evaluated in 10 precancerous hepatic nodules, 17 well-differentiated HCCs, 19 moderately differentiated HCCs, 5 poorly differentiated HCCs, 22 nontumorous chronic hepatic disease samples, and 2 normal liver tissues.

RESULTS

Telomerase activity in HCCs tended to increase according to the malignant transformation. The average relative telomerase activity in 0.6 microg protein, which was expressed as cell equivalent activity of MKN-1, a gastric carcinoma cell line, was 8.5 in precancerous hepatic nodules, 87 in well-differentiated HCCs, 265 in moderately differentiated HCCs, 447 in poorly differentiated HCCs, and 0.4 in nontumorous hepatic tissues, including chronic liver diseases.

CONCLUSIONS

TRAP/HPA was sensitive enough to distinguish the telomerase activity in precancerous hepatic nodules from that in other lesions. Telomerase activity in precancerous hepatic nodules was higher than that in nontumorous hepatic tissues. However, the activity in precancerous hepatic nodules was lower than that in well-differentiated HCCs, although statistically not significant. The authors suggest that precancerous hepatic nodules with telomerase activity above the diagnostic cutoff level (twice the highest activity in nontumorous hepatic tissues, or the 2 cell equivalent activity of MKN-1) should be treated as malignancy.

Clinical significance of MUC1 and E-cadherin expression, cellular proliferation, and angiogenesis at the deepest invasive portion of colorectal cancer

We examined MUC1 and E-cadherin expression, cellular proliferation, and tumor vascularization at the deepest invasive portion of colorectal cancer in relation to prognosis. One hundred and ten surgically resected specimens of advanced colorectal carcinoma were studied. E-cadherin and MUC1 expression and Ki-67 labeling index (Ki-67 LI) were examined immunohistochemically at the site of deepest tumor invasion. Tumor vascularization was also examined immunohistochemically using anti-CD34 antibody to determine the microvessel count (MVC). In curative resection, patients with a high Ki-67 LI, reduced E-cadherin expression, MUC1-positive and high MVC lesion showed a significantly poorer prognosis than those with a low Ki-67 LI, E-cadherin normal, MUC1-negative and low MVC lesion, respectively. Furthermore, patients with both a high Ki-67 LI and MVC lesion showed a significantly poorer prognosis than those with other Ki-67 LI and MVC relations. Patients with both a MUC1-positive and E-cadherin reduced lesion showed a significantly poorer prognosis than those with both a MUC1-negative and E-cadherin normal lesion. The significant risk factors in order of poorer prognosis by the multivariate analysis among these factors including routinely used clinicopathologic factors were the high MVC, E-cadherin reduced expression, and lymph node metastasis. These findings indicate a high MVC at the site of deepest tumor invasion to be the most important predictor of colorectal cancer prognosis among the factors studied here.

Clinicopathological study of myeloperoxidase anti-neutrophil cytoplasmic antibody-associated glomerulonephritis

AIMS

To investigate the potential prognostic factors for myeloperoxidase anti-neutrophil cytoplasmic antibody- (MPO-ANCA) associated glomerulonephritis.

MATERIALS

The clinical and pathological findings were reviewed in 17 patients with this type of glomerulonephritis.

METHODS

The relationship between the outcome and various clinical and pathological factors were assessed. The relationship between the blood MPO-ANCA level and cellular crescent formation was also investigated.

RESULTS

Patients who died had a significantly lower serum albumin and creatinine clearance than those who survived, but there were no differences of age, blood MPO-ANCA, urinary protein, and serum creatinine levels or cellular crescent formation between the two groups. There was a close relationship between blood MPO-ANCA levels and cellular crescent formation.

CONCLUSIONS

Hypoalbuminemia and renal dysfunction may be indicators of a poor prognosis in MPO-ANCA-associated glomerulonephritis. Patients with high blood levels of this antibody and increased cellular crescent formation appear to have active disease, but these factors are not statistically associated with a fatal outcome. Therefore, aggressive treatment may be indicated in patients with active disease initially.

Brain metastasis from hepatocellular carcinoma after radical hepatectomy

Brain metastasis from hepatocellular carcinoma (HCC) is a rare, yet perplexing problem in patients with cancer. We report on 5 patients with metastasis of HCC to the brain after radical hepatectomy. Intrahepatic recurrence occurred in 3 patients, and distant metastasis to sites other than the brain was observed in 3 patients (lung, 2; bone, 1). The symptoms for brain metastasis included headache, hemiparesis, and vomiting. Hemorrhage was found in 4 of 5 patients. All patients had a single nodular lesion in the brain. The alpha-fetoprotein levels were more than 10,000 ng/ml in 4 patients. Two patients underwent surgical resection, 1 received cranial irradiation, and 2 were administered corticosteroids. The interval between diagnosis of the primary cancer and detection of brain metastasis ranged from 2 to 54 months. The mean survival period was only 3 months after diagnosis of brain metastasis. All 5 patients died of neurologic causes. Because no effective treatment for brain metastasis from HCC is available, further study is needed.

Molecular-pathological diagnosis of gastrointestinal tissues and its contribution to cancer histopathology

Multiple genetic and epigenetic alterations of cancer-related genes and molecules are involved in the course of the development and progression of gastrointestinal cancers. These include telomerase activation, genetic instability, and abnormalities of oncogenes, tumor suppressor genes, cell cycle regulators, cell adhesion molecules and DNA repair genes. By analyzing these alterations in pathology specimens, we can improve differential diagnosis of cancer, obtain information of grade of malignancy, and identify patients at high risk for developing multiple primary cancers. Since 1993, a system of molecular-pathological diagnosis was established, and has been performed as a routine service in collaboration with Hiroshima City Medical Association Clinical Laboratory. More than 10 000 cases of gastrointestinal biopsy and surgery have been analyzed, and additional information of differential diagnosis, biological malignancy and tumor multiplicity could be obtained. Molecular-pathological diagnosis may provide a new approach to cancer diagnosis and novel therapeutics for the 21st century. Furthermore, the analysis of the genetic and epigenetic abnormalities in clinical materials may clarify the molecular mechanism of carcinogenesis and comparative morphological changes. From the analyses of p27KIP1 and telomerase in gastrointestinal adenomas, we have learned that morphological abnormality of the nucleus is an indicator for cells with immortality and malignant potential that must participate in super-early diagnosis (detection of true precancerous lesions) of gastrointestinal cancer. Molecular-pathological diagnosis thus contributes to detailed understanding of cancer histopathology and improves the histopathological diagnosis.

Hepatic resection with tumor thrombectomy for hepatocellular carcinoma with tumor thrombi in the major vasculatures

BACKGROUND/AIMS

It is still controversial whether surgical or non-surgical treatments should be adopted for hepatocellular carcinomas (HCC) with tumor thrombi (TT) in the major vasculatures. We evaluate the effectiveness of and the indications for hepatic resection with tumor thrombectomy for such patients.

METHODOLOGY

Seventeen patients with TT in the major vasculatures caused by HCC were enrolled. Eleven patients had Vp3 TT, 5 patients had Vv3 TT, and 1 patient had Vp3 and Vv3 TT, concurrently. Out of the 17 patients, 13 underwent hepatic resections with tumor thrombectomies and the remaining 4 received only hepatic resections without tumor thrombectomies.

RESULTS

In patients with Vp3 TT, median and mean survival times were 7.8 and 18.5 months, respectively, and 1- and 5-year survival rates were 36.4% and 18.2%, respectively. In patients with Vv3 TT, median and mean survival times were 9.9 and 8.4 months, respectively. Patients who underwent hepatic resections with tumor thrombectomies had significantly better prognoses than those who did not receive tumor thrombectomies (p=0.0039).

CONCLUSIONS

The prognosis of HCC patients with TT in the major vasculatures, who have relatively small primary tumors, good hepatic functional reserves and no distant metastases should be good, if hepatic resections with tumor thrombectomies are performed.

MUC1 expression in intramucosal colorectal neoplasms. Possible involvement in histogenesis and progression

PURPOSE

The mucin core peptide MUC1 often is detectable in colorectal carcinoma (CRC) tissue and cell lines. However, whether MUC1 in CRC correlates with tumor histogenesis and progression is unclear. We studied the relationship between MUC1 expression in intramucosal CRC and clinicopathologic features, expression of Ki-67, and p53 protein, and apoptosis.

METHODS

The intramucosal CRC we studied included 140 endoscopically or surgically resected lesions, including 106 low-grade carcinomas and 34 high-grade carcinomas. De novo carcinoma, defined as carcinoma with no adenomatous component, represented 9 of 140 tumors. Three macroscopic types were identified: 57 lesions were polypoid, 55 were superficial and flat, and 28 were granular-type laterally spreading tumors (G-LST). MUC1, Ki-67, and p53 expression were examined immunohistochemically. Apoptotic cells were identified by in situ DNA nick end labeling.

RESULTS

MUC1 expression in high-grade carcinomas was significantly more frequent (p < 0.01) than in low-grade carcinomas; expression in adenomas was almost nil. MUC1 expression in polypoid carcinomas was significantly more frequent (p < 0.05) than in superficial carcinomas or G-LST. MUC1 expression in carcinomas with p53 expression was significantly more frequent (p < 0.01) than in carcinomas not expressing p53. No significant correlation was found between expression of MUC1 and Ki-67 labeling index. MUC1 was expressed more frequently in carcinomas with relatively high apoptotic index (p < 0.01). MUC1 expression did not differ between de novo carcinomas and those developing from adenomas.

CONCLUSIONS

The results suggest that MUC1 is likely to be expressed in the course of colorectal carcinoma development when p53 protein is overexpressed and apoptosis is prominent.

A case of hepatocellular carcinoma with bone metastasis responding to radiotherapy after successful hepatectomy of primary lesion

Radical hepatectomy was carried out on a patient with hepatocellular carcinoma (HCC) located in segment VIII of the liver. The patient was a 56-year-old man who showed positive for hepatitis C antibody and negative for hepatitis B surface antigen. Six months after hepatectomy, a lumbar plane X-ray and computed tomography examination revealed bone metastases in the lumbar vertebrae. The patient was subsequently treated by radiation to the lumbar vertebrae in response to lumbago. The metastatic lesion has been well controlled by radiotherapy on an outpatient basis with no recurrence for 5 years and 3 months. The prognosis of patients with HCC with distant metastases is poor. It is believed that the long survival of this patient can be attributed to successful radiotherapy of the bone metastasis after hepatectomy and the lack of recurrence in the liver.

Frequent p53 gene mutations in serrated adenomas of the colorectum

Serrated adenoma has been recently proposed as a distinct histological lesion of the colorectum. This study examined p53 immunoreactivity, mutations of exons 5-8 of the p53 gene, codon 12 of the Ki-ras gene by PCR-SSCP analyses, and microsatellite instability in 19 serrated adenomas, ten adenocarcinomas in/with serrated adenomas, 23 hyperplastic nodules, four hyperplastic polyps and 29 tubular adenomas of the colorectum. Eleven of 11 (100 per cent) serrated adenomas had p53 immunoreactivity and all six (100 per cent) adenocacinomas in/with serrated adenomas exhibited moderate to severe p53 immunoreactivity. It was confirmed that 9 of 19 (47 per cent) serrated adenomas and 5 of 10 (50 per cent) adenocarcinomas in/with serrated adenomas harboured p53 gene mutations. On the other hand, no p53 gene mutation was detected in the other colorectal lesions. Meanwhile, 11 (58 per cent) serrated adenomas and six (60 per cent) adenocarcinomas in/with serrated adenomas had Ki-ras gene mutations, as also did 9 of 23 (39 per cent) hyperplastic nodules, 3 of 4 (75 per cent) hyperplastic polyps, and 12 of 29 (41 per cent) tubular adenomas. Microsatellite instability was detected in one (5 per cent) serrated adenoma and one (10 per cent) adenocarcinoma in a serrated adenoma. The other lesions did not show microsatellite instability. Serrated adenomas had significantly frequent p53 gene mutations compared with hyperplastic lesions or tubular adenomas (p < 0.005). On the other hand, they did not exhibit significant differences in mutations of the Ki-ras gene or in microsatellite instability. Genetic changes were then examined in small parts of serrated adenomas, such as the upper or lower parts of crypts, to determine the extent of gene mutations by using a microdissection technique. Exon 15 of the APC gene and the DCC gene, in addition to the p53 and Ki-ras genes and microsatellite instability, were analysed. Identical mutations of the p53 gene were found in both invasive adenocarcinomas and adjacent serrated adenomas by direct sequencing, suggesting single clonal origins for those lesions. Mutations of the APC gene and microsatellite instability were heterogeneous in some lesions. No loss of heterozygosity (LOH) of the DCC gene was found. These findings suggest that mutations of the p53 gene are the most characteristic genetic alterations in serrated adenomas, as a relatively early event in a multistep carcinogenic pathway of this type of colorectal lesion, that might be distinct from the ordinary adenoma-carcinoma sequence or from carcinogenesis via mutations of mismatch repair genes.

A case of biliary cystadenocarcinoma of the liver

We describe a case of biliary cystadenocarcinoma of the liver, a very rare malignant tumor, in a 40-year-old man referred to our hospital because of sporadic abdominal pain. A left lobectomy of the liver was performed, and macroscopic examination of the resected specimen revealed prominent papillary projections in a multiloculated cystic tumor containing mucinous material. Histologic examination of the specimen showed a biliary cystadenocarcinoma without mesenchymal stroma, associated with a cystadenoma. Cystadenoma with mesenchymal stroma (CMS), which occurs exclusively in women, is generally regarded as a precancerous lesion, and patients with biliary cystadenocarcinoma with mesenchymal stroma have a good prognosis. Cystadenoma without mesenchymal stroma arises in both men and women. However, the origin and precancerous lesions of cystadenocarcinoma are unknown. Moreover, the prognosis of patients with biliary cystadenocarcinoma without mesenchymal stroma is poor, especially in men. The cystadenoma without mesenchymal stroma in our patient was considered a precancerous lesion. The present patient has shown no evidence of recurrence in the 8 years after hepatic resection. Previously reported cases of cystadenocarcinoma without mesenchymal stroma, especially those in men, have had a poor outcome. A good outcome in men is very rare.

A patient with a large hepatocellular carcinoma alive 13 years after repeated transcatheter arterial chemoembolization and hepatectomy

We describe a rare case of a large hepatocellular carcinoma (HCC) in a patient who survived 13 years after repeated transcatheter arterial chemoembolization (TAE) and hepatectomy. The patient was a 41-year-old woman found in March 1985 to have a large HCC, measuring 14 x 12 cm in diameter and associated with obstruction of the main portal trunk. She underwent TAE 8 times over a period of 1 year. The serum alpha-fetoprotein level decreased from 18342 to 1871 ng/ml. The patient subsequently underwent left hepatectomy on October 9, 1986. Thirteen years after hepatectomy, the patient is being followed up on an outpatient basis and has had no evidence of recurrence.

Hepatic resection for cavernous hemangiomas of the liver

In this report, we evaluate the indications of, and present our recent strategy for, cavernous hemangioma of the liver. Seven patients with cavernous hemangiomas of the liver, who underwent hepatic resection were enrolled in this study. The lesions were located in the right lobe in 3 patients, the left lobe in 2, and in both the right and left lobes in 2. The longest diameter of the lesions ranged from 1.4 to 14.5 cm (mean, 8.2 cm). The indications for hepatic resection were symptomatic lesions in 3 patients, lesions suspected to be hepatocellular carcinoma in 2, and symptomatic and growing lesions during follow-up in 2. Right lobectomy was performed in 2 patients, left lobectomy with caudate lobectomy in 1 patient, and minor hepatic resection in the other 4 patients. One of the patients who underwent minor hepatic resection had recently received laparoscopy-assisted hepatic resection and one of the three patients who received transfusion during surgery was given an autotransfusion. There were no mortality, and morbidity was minimal. In conclusion, hepatic resection, including laparoscopy-assisted procedures, was considered a safe treatment. Hepatic resection for cavernous hemangioma should be performed only in patients with moderate to severe symptoms, complicated lesions or both, because most benign lesions have a good natural course. Furthermore, in the future, less invasive surgical procedures should be used whenever possible to treat these benign liver tumors.

A surgically treated long-term survivor of hepatocellular carcinoma with tumor thrombi in the trunk of the portal vein

Prognosis of hepatocellular carcinoma (HCC) patients with tumor thrombi (TT) in the trunk of the portal vein (PV) has been extremely poor. There have been few reports of long-term survivors with such an advanced condition. In this article, the case of a 62-year-old woman of HCC, who survived for 6 years and 9 months after an operation, with TT in the trunk of the PV is described. The patient not only had a primary tumor of 4 cm in diameter with TT but also multiple intrahepatic metastases in the bilateral lobe of the liver. A palliative lateral segmentectomy with tumor thrombectomy through the incised left first branch of the PV was performed. Moreover, an intraoperative ethanol injection for residual intrahepatic metastatic tumors was performed subsequently. Hepatic arterial infusion of anti-cancer drug with Lipiodol, intraportal continuous infusion of 5-FU and percutaneous ethanol injection therapy were performed suitably during the follow-up periods. The patient survived for 6 years and 9 months after operation and died of hepatic insufficiency with cancer. In this case a patient who suffered from HCC with TT in the trunk of the PV was successfully treated by multimodality procedures including hepatic resection with tumor thrombectomy.

Laparoscopy-assisted hepatectomy for a large tumor of the liver

We performed a laparoscopy-assisted hepatectomy on a 52-year-old woman with a large hepatic cavernous hemangioma (longest diameter, 8.5 cm). With the use of Pringle's maneuver, the left lateral segment of the liver was resected with a Cavitron ultrasonic surgical aspirator (CUSA) while lifting the abdominal wall. Postoperative hepatic dysfunction was mild and transient, resolving spontaneously early after surgery. We intend to expand the indications of this minimally invasive procedure for hepatic resection.

Growth patterns in various macroscopic types of noninvasive intramucosal colorectal carcinoma with special reference to apoptosis and cell proliferation

PURPOSE

Apoptotic cell death and cell proliferation play important roles in the histogenesis and development of colorectal carcinoma. The aim of this study was to examine the relationship between apoptosis and cell proliferation in various macroscopic types of intramucosal colorectal carcinoma in relation to the expression of p53 and bcl-2.

METHODS

One hundred forty cases with endoscopically or surgically resected intramucosal colorectal carcinoma were studied. There were 57 cases of polypoid-type carcinomas, 55 cases of superficial-type carcinomas, and 28 cases of granular-type, laterally spreading tumors. Polypoid-type carcinomas were pedunculated, subpedunculated, or sessile polyps. Superficial-type carcinomas were flat lesions with a smooth, even surface. Granular-type, laterally spreading tumors were superficially spreading lesions with aggregates of nodules and a granular surface. Apoptotic cells were identified by the in situ DNA nick end labeling method. Ki-67, p53, and bcl-2 expression were examined immunohistochemically.

RESULTS

The superficial-type carcinoma apoptotic index (30.9 percent) was significantly lower than that of polypoid-type carcinoma (54.4 percent) and granular-type, laterally spreading tumor (60.7 percent). The superficial-type carcinoma proliferative index (67.3 percent) was significantly higher than that of polypoid-type carcinoma (42.1 percent) and granular-type, laterally spreading tumor (28.6 percent). In superficial-type carcinomas the proliferative index in p53-positive carcinomas was significantly higher, and the apoptotic index was higher in carcinomas with a lower proliferative index. There was no significant difference in apoptotic index, proliferative index, or p53 protein overexpression between de novo carcinomas and those that had arisen in precursor adenomas.

CONCLUSIONS

The pattern of cell death and proliferation may vary with different macroscopic types of intramucosal colorectal carcinoma. Superficial-type colorectal carcinomas especially demonstrate diminished apoptosis and increased cell proliferation. This may be useful in understanding their biologic behavior.