Mucosal carcinoma within a colonic diverticulum

We report a case of a mucosal carcinoma and adenoma within a diverticulum in the cecum. Radiographic, endoscopic, and pathologic evaluation of the tumor is presented. Surgical resection was undertaken because of the size and shape of the lesion, risk of perforation, and the possibility of malignancy. A recent review of the literature with respect to clinical signs, diagnosis, growth of the carcinoma, and treatment of tumors around or within diverticula is also presented. A carcinoma or adenoma arising within the diverticulum is very rare. Endoscopic resection of the tumor could entail the risk of perforation, because of the lack of muscular coats in the diverticula. Surgical treatment may be the procedure of choice for lesions near or within the diverticula.

Characteristics of two cancer cell lines derived from metastatic foci in liver and peritoneum of a patient with colon cancer

Two cancer cell lines were established in vitro from a single patient with colon cancer; AKT-CC-K-LM cells from liver metastatic nodules and AKT-CC-K-PC cells from peritoneal dissemination nodules. The two cell lines were similar in doubling time, number of chromosomes, and chromosomal abnormalities. However, they differed in morphology in vitro, in the expression level of cell surface adhesion molecules (carcinoembryonic antigen; CEA, E-cadherin, sialyl Le(a), sialyl Le(x), and CD44v6), and in their metastatic properties. AKT-CC-K-LM cells grew in vitro as adherent clusters and AKT-CC-K-PC cells as adherent single cells. The expression levels of CEA, E-cadherin, sialyl Le(a), and sialyl Le(x) was significantly higher in AKT-CC-K-LM cells. The expression of CD44v6 was significantly higher in AKT-CC-K-PC cells. After the injection of AKT-CC-K-LM cells to the spleen or peritoneal cavity of severe combined immune deficiency mice, metastatic nodules were observed only in the liver. In contrast, the injection of AKT-CC-K-PC cells to the spleen or peritoneal cavity yielded metastatic nodules only in the peritoneal cavity. These cell lines may contribute to elucidating the relationship between cell surface adhesion molecules and the metastatic properties of cancer cells.

Pancytopenia associated with 5-aminosalicylic acid use in a patient with Crohn's disease

We report a case of pancytopenia in a 23-year-old man with Crohn's disease who was treated with 5-aminosalicylic acid (Pentasa; Nisshin, Tokyo, Japan) 3.0 g/day. He developed fever, nausea, diarrhea, and malaise and stopped taking on the third day after commencing Pentasa. Ten days after withdrawal of Pentasa, he was admitted to hospital because of worsening symptoms. Hematologic evaluation disclosed pancytopenia: red blood cells 283 x 10(4)/mm3; white blood cells 700/mm3; and platelets 8000/mm3. Other pertinent laboratory data, including liver and renal function tests results, serology for virus infection, and serum levels of vitamin B12 and folic acids, were normal. Bone marrow examination showed a generalized hypocellular picture, suggestive of drug-induced bone marrow suppression. He received blood transfusion and recombinant human granulocyte colong-stimulating factor (filgrastim). The leucopenia and thrombocytopenia resolved on the 7th and 13th days of hospitalization, respectively. The anemia continued because of bloody stool caused by Crohn's disease. However, reticulocytes were markedly increased in number on the 13th day of hospitalization. He is well at 9 months follow-up. Excluding other causes, Pentasa-associated pancytopenia was considered. The increasing use of this agent is expected, because of the increasing number of patients with inflammatory bowel disease. Careful clinical and hematological monitoring should be performed, especially for the first 3 months, in patients beginning treatment with Pentasa. The drug should be withdrawn immediately if there is a suspicion of blood disorders.

Appendicostomy irrigation for facilitating colonic evacuation in colostomy patients. Preliminary report

A method for bowel irrigation through an appendicostomy (antegrade colonic enema) for patients with a left colostomy is described. The appendicostomy is easily constructed without morbidity. Irrigation through the appendicostomy is performed with minimum equipment, uses a small volume of irrigation water, and takes a relatively short time. This may improve colonic evacuation in patients with left colostomy.

Repeated percutaneous aspiration therapy prior to surgery for a pancreatic pseudocyst: report of a case

We describe herein the case of a patient with a giant pancreatic pseudocyst which was first treated with repeated percutaneous aspiration therapy, then cured surgically by a Roux-en Y cystojejunostomy, 26 weeks after its formation. A 41-year-old man developed alcohol-induced acute severe pancreatitis. Computed tomography (CT) performed 10 weeks after the onset revealed a giant cyst, 20 x 18 x 7cm in size, arising from the body and tail of the pancreas and extending to the left loin. Endoscopic retrograde pancreatography (ERP) showed a normal main pancreatic duct without communication to the pseudocyst. As the asymptomatic pseudocyst, the wall of which was less than 2mm thick, had not resolved by 8 weeks after its formation, percutaneous aspiration therapy was performed three times. The patient was treated as an outpatient without any complications. The cyst wall was subsequently confirmed to be mature enough for surgical management to be initiated, and a cystojejunostomy was safely performed. Thus, percutaneous aspiration therapy can enable the surgeon to observe maturation of the cyst wall for a long period in patients with a pancreatic pseudocyst.

Homotypic adhesion through carcinoembryonic antigen plays a role in hepatic metastasis development

We established a cell line with high metastatic potential to the liver (LS-LM4) after four successive repetitions of splenic injection of liver-metastatic cells in SCID mice. This cell line strongly expressed CEA and showed increased homotypic adhesion as compared with the parent cell line (LS174T). To examine the role of CEA in the increased homotypic adhesion, LS-LM4 cells were treated with anti-CEA antibody and subjected to an in vitro adhesion and aggregation assay. Further, to study the role of CEA in the hepatic metastasis of cells with high metastatic potential, LS-LM4 cells were treated with anti-CEA antibody, and the inhibition of hepatic metastasis after splenic injection in vivo was examined. There was a 62% decrease in the homotypic adhesion of anti-CEA antibody-treated (100 microg/ml) LS-LM4 cells under a Ca2+-free condition as compared with the control (P<0.01). Anti-CEA antibody (100 microg/ml) inhibited cell aggregation under a Ca2+-free condition (P<0.05). Treatment with anti-E-cadherin antibody (60 microg/ml) plus anti-CEA antibody (100 microg/ml) inhibited cell aggregation more potently than anti-E-cadherin antibody treatment alone in the presence of Ca2+. In vivo, there was a 75% decrease in the number of hepatic metastatic nodules in the G125 anti-CEA antibody-treated group as compared with the control group (P<0.01). Similarly, there was a 40% decrease in the diameter of metastatic nodules and there was a 90% decrease in total tumor volume of hepatic metastasis in the G125 anti-CEA antibody-treated group as compared with the control (P<0.01). These results suggest that increased metastatic potential to the liver is at least partly due to increased homotypic binding mediated by CEA.

Lymphangioma of the jejunum and mesentery presenting with acute abdomen in an adult

We describe a patient, 54-year-old woman, with lymphangiomas of the jejunum and mesentery presenting as acute abdomen. She had sudden onset of severe abdominal pain with guarding and fever. Physical examination revealed an elastic hard mass, with marked tenderness in the right abdominal region. Ultrasonography and computed tomography revealed a heterogenous mass, 20 x 15 x 8cm in size, in the mesentery. An emergency operation was performed with the diagnosis of diffuse peritonitis due to an inflammatory tumor in the mesentery. At operation, the tumor was found in the mesentery, adhering to a 60-cm segment of the jejunum. Multiple small tumors were seen in the submucosal layer of jejunum. The tumor was excised with a 60cm length of the jejunum. Histologically, the tumors were diagnosed as cavernous lymphangiomas. Although lymphangioma in the abdomen is rare in adults, we should consider it as one of the causes of acute abdomen.

Disseminated intra-abdominal cystic lymphangiomatosis with severe intestinal bleeding. A case report

We describe cystic lymphangiomatosis with intestinal bleeding developing multiple lymphangiomas in the small intestine, mesentery, mesocolon, omentum, retroperitoneum, and spleen. Small intestinal fluorography showed multiple polypoid lesions, mainly in the jejunum. Ultrasonography, computed tomography, and magnetic resonance imaging showed diffuse cystic tumors in the mesentery and spleen. Cystic lymphangiomatosis was proved by histologic findings of the biopsied specimen at laparotomy.

Detection of circulating anti-p53 antibodies in patients with colorectal carcinoma and the antibody's relation to clinical factors

PURPOSE

Mutation of the p53 tumor suppressor gene is the most common genetic alternation in colorectal carcinoma and is assessed mainly by molecular analysis of the gene sequence or by immunohistochemical analysis of p53 protein accumulation. Purpose of this study was to detect circulating antibody against p53 proteins in serum of patients with colorectal carcinoma and to evaluate its clinical significance.

METHODS

We used immunoblotting techniques to detect circulating anti-p53 antibodies. Relationship among staging, immunohistochemical expression of p53 in the primary tumor, and serum carcinoembryonic antigen level was investigated.

RESULTS

Circulating anti-p53 antibodies were detected in 32 (68 percent) of 47 patients. Antibody was found in patients at all clinical stages of disease. In 33 patients whose sera and primary tumor tissues were available for testing, 16 (48 percent) were positive for both circulating anti-p53 antibody and p53 expression in the tumor. The anti-p53 antibody test was positive in 78 and 56 percent of patients with high and normal serum carcinoembryonic antigen levels, respectively.

CONCLUSION

Detection of anti-p53 antibodies may become a new diagnostic indicator of colorectal carcinomas.

Laparoscopically assisted resection of the lower rectum

We report a new laparoscopic approach to the resection of the lower rectum which has been successfully used in the treatment of a patient with a small rectal carcinoid tumor. Under general anesthesia a pneumo-peritoneum was established with CO2 gas insufflation and the rectum was mobilized from the sacrum including division of the lateral ligaments under the direct view of the laparoscope. The bowel was divided between the sigmoid colon and the rectum using an endoscopic linear stapler, and the rectum was everted through the anal canal. The lower rectum was transected extracorporeally using a linear stapler and the rectal stump was then returned to the anatomical position. An anvil of a circular stapling device into the oral colon stump through a small skin incision on the left lower abdomen was introduced and the shaft of the device through the rectal stump via anus was inserted. The device was then re-approximated under laparoscopic view and fired. Our procedure described here is applicable to the lower rectal lesion as a minimally invasive, safe, and useful therapeutic tool.

Mucinous cystadenoma of appendix concomitant with perityphlic granuloma

We describe a case of mucinous cystadenoma of the appendix with perityphlic granuloma. The patient developed a hard palpable mass in the right lower quadrant and barium enema induced irregular bowel wall at the cecum. Based on a preoperative diagnosis of carcinoma of the appendix, we performed a laparotomy. On operation, we found a tumor mass in the region of the appendix; the mass adhered strongly to the retroperitoneum and cecum. Right hemicolectomy was carried out on a diagnosis of carcinoma of the appendix. Microscopic examination revealed mucinous cystadenoma of the appendix with perityphlic granuloma. Mucinous cystadenoma in the appendix is a rare tumor. In this patient, the tumor was accompanied by granuloma formation in adjacent tissues because of mucin expelled from the appendix. This case emphasizes that granuloma formation can make of difficult to differentiate mucinous cystadenoma in the appendix from cancer.

Blood vessel invasion in metastatic nodes for development of liver metastases in colorectal cancer

BACKGROUND/AIMS

We assessed the importance of blood vessel invasion (BVI) by cancer in the metastatic lymph nodes for the development of liver metastases in colorectal cancer.

PATIENTS AND METHODS

The presence of BVI in the primary growth and in the lymph nodes was reviewed in 384 specimens.

RESULTS

In cases with and without BVI in the nodes, the incidence of liver metastases was 49% and 10%, respectively (p < 0.01). The highest incidence of liver metastases was observed in patients with BVI both in the primary tumor and in the metastatic nodes. The next to the highest incidence was observed when BVI was present not in the primary lesion but in the metastatic nodes. When considering the number of metastatic nodes, the incidence of liver metastases was high in cases with BVI in the nodes regardless of the number of metastatic nodes.

CONCLUSION

These data suggest that the BVI in the metastatic nodes is an important factor for the development of liver metastases.

Resection of metastatic thyroid carcinomas to the liver and the kidney: report of a case

Differentiated thyroid cancer is considered to have a quite favorable prognosis. However, some patients die as a result of distant metastasis, which mainly consists of pulmonary, mediastinal, or osteal metastases. The biological features of the tumor, such as a slow growth gradient, indicate the possibility of achieving comparatively satisfactory results in the treatment of such distant metastases. A complete surgical excision of the distant metastases in differentiated thyroid carcinoma has been reported to offer the best chance for prolonged survival. A case of unusual metastasis sites on the caudate lobe of the liver and right kidney occurring in a 72-year-old woman is herein presented. The location of the surgically treated distant metastases of the papillary thyroid carcinoma make this case unique.

A case of toxic megacolon in ulcerative colitis associated with cytomegalovirus infection

Cytomegalovirus (CMV) infection, which has been shown to complicate the course of ulcerative colitis (UC), has been implicated as a possible etiologic factor in the exacerbation of UC, especially in toxic megacolon. However, CMV infection in patients with UC accompanied by toxic megacolon has rarely been reported. Here we report a case of CMV infection of the colon accompanied by toxic megacolon occurring in UC. A 38-year-old woman had been treated with intravenous hydrocortisone, rectal steroid, and central venous alimentation for 6 weeks under the diagnosis of UC. She was transferred to Akita University Hospital because of increasing bloody diarrhea and abdominal pain. Toxic megacolon was identified by examinations on admission, and she underwent a total colectomy. Examination of the surgical specimen showed severe inflammation of the colon. Microscopically, cytomegalic inclusions were observed in and around the endothelial cells in the inflamed submucosal layer. It can be assumed that CMV infection was a secondary, opportunistic invader superimposed on UC, and that it played an important role in altering the clinical course of the patient.

Effect of the combination of hyperthermia and irradiation on human colon cancer cells

The combination of hyperthermia and radiation is considered to have a synergistic effect on mammalian cells, which depends on temperature and duration of time of the hyperthermia and on the sequence in which the modalities are given. The response of cultured colon cancer cells to hyperthermia and ionizing radiation was evaluated using the flow cytometry method by measuring DNA damage. The enhanced DNA damage after combined treatment with hyperthermia and irradiation was recognized after both sequences: heat followed by radiation as well as radiation followed by heat. The results demonstrated that the sequence of radiation plus heat produced more DNA damage on colon cancer cells than did the reverse order. The clinical application of these results is discussed.

Modified technique for handsewn anastomosis following abdominoperineal pull-through operation

A modified technique for handsewn anastomosis after abdominoperineal pull-through resection is described. The technique is a continuous locked modification of the Gambee suture. Simplicity, rapidity, reliability, and firmness are the advantages of this technique.

The size of regional lymph nodes does not correlate with the presence or absence of metastasis in lymph nodes in rectal cancer

We evaluated the relationship between the size of regional lymph nodes and the presence of metastasis in them in rectal cancer. Of 1,064 lymph nodes in 46 specimens, 133 (13%) were found to have metastases. A half of the positive nodes and most of the negative ones were less than 5 mm in diameter. Therefore, we must find lymph nodes smaller than 5 mm in diameter for assessment of lymph node metastasis. Although positive nodes were larger than negative ones, there was no significant difference. However, when comparing the size of lymph nodes in relation to their location, the epi- and pararectal lymph nodes larger than 10 mm in diameter were highly suggestive of metastases, but the size of the lymph node was not a reliable indicator of lymph node metastases in other situations.

Case report: intestinal infarction after an aneurysmal occlusion of superior mesenteric artery in a patient with Behçet's disease

A patient with Behçet's disease, accompanied by a large aneurysm of superior mesenteric artery, developed an ischemic enteritis with multiple perforated ulcers. The ischemic necrosis of the intestine preceded by recurrent abdominal pain was due to an aneurysmal occlusion of superior mesenteric artery, but not entero-Behçet's disease. This is the first case report of intestinal infarction that occurred in a patient with vasculo-Behçet's disease involving the superior mesenteric artery. Vasculo-Behçet's disease should be included in a differential diagnosis of acute mesenteric artery thrombosis.

The clinical significance of regional variations in histologic differentiation within carcinomas of the colorectum

The clinical significance of the presence or absence of regional variations in histologic differentiation within a primary colorectal carcinoma was investigated in this study. Regional variations in histologic differentiation were judged to be present when the low power field of a microscope was occupied by cancer tissue cytologically and architecturally different from that of the surrounding area. Regional variations in histologic differentiation were noted in 153 (42%) of 368 primary carcinomas. Carcinomas with regional variations were of an anaplastic histologic type and had a higher incidence of lymph node metastasis and a worse prognosis than those without regional variations. Thus, the histologic diversity within a carcinoma is thought to be important for determining the prognosis of patients with colorectal cancer.

Inhibitory effect of cryptoporic acid E, a product from fungus Cryptoporus volvatus, on colon carcinogenesis induced with N-methyl-N-nitrosourea in rats and with 1,2-dimethylhydrazine in mice

The antitumorigenic effect of cryptoporic acid E (CPA-E), a dimeric drimane sesquiterpenoid isolated from the fungus Cryptoporus volvatus, on colon carcinogenesis was investigated. Female F344 rats given an intrarectal instillation of 2 mg of N-methyl-N-nitrosourea 3 times weekly in weeks 1 and 2 were fed diet containing 0.2% CPA-E from week 3. Female ICR mice given 15 weekly intraperitoneal injections of 10 mg of 1,2-dimethylhydrazine/kg body weight during weeks 1 to 15 were fed diet containing 0.06% CPA-E from week 1. The experiment was terminated at week 35 for rats and at week 25 for mice. The incidence and the number of tumors per animal were reduced in CPA-E-fed animals compared to the controls: 31% vs. 75% (P less than 0.05) and 0.4 +/- 0.2 (SEM) vs. 0.9 +/- 0.2 (0.1 greater than P greater than 0.05) in rats, and 31% vs. 63% (0.1 greater than P greater than 0.05) and 0.4 +/- 0.2 vs. 2.4 +/- 0.8 (P less than 0.05) in mice (16 animals in each group). Intrarectal deoxycholic acid-induced colonic mucosal ornithine decarboxylase activity was significantly lowered in CPA-E-fed animals compared to controls. This shows an antipromoting activity of CPA-E against colon carcinogenesis. Thus, it was concluded that CPA-E inhibits colon cancer development in both rats and mice treated with 2 different colon carcinogens.

Postoperative chemotherapy and follow-up program in colon cancer with high serum CEA level

We present a patient with colon cancer who had a high serum CEA level without detectable liver metastases at surgery. He underwent hepatic arterial infusional chemotherapy for suspicious liver metastasis concomitant with colon resection at the initial operation. He was followed closely by monitoring the serum CEA levels as well as abdominal US and CT. Five months after the first operation, a small but apparent metastatic lesion was detected in the liver, for which curative resection was performed. The importance of postoperative management with chemotherapy for occult metastases in the liver and close follow-up by CEA monitoring is discussed for such a patient.