Self-expanding stainless steel stent application in rectosigmoid stricture

In recent years, several reports on the experimental and clinical applications of the Gianturco stent (self-expanding stainless steel stent) have been published. However, to our knowledge, the use of stents in rectosigmoid strictures has not been reported. We used self-expanding stainless steel stents to dilate rectosigmoid strictures caused by nonresectable recurrent neoplasm. Insertion and dilation (sigmoid colon and rectum) in two patients were successful. Accordingly, these patients were able to maintain bowel activity and avoid palliative loop colostomy. We believe that this procedure is effective for nonresectable rectosigmoid stricture due to recurrent neoplasm.

Eosinophilic bodies in pyloric and Brunner's gland cells

A previously unreported cell phenotype occurred in the pyloric and Brunner glands in two gastrectomy specimens. The cells were characterised by homogeneous, eosinophilic material in the cytoplasm. The eosinophilic material had an abnormally strong reactivity for Cystatin C, a protein found recently in the normal secretion of pyloric and Brunner's gland cells. The reason for the apparent cytoplasmic accumulation of cystatin C in the two patients described remains unclear.

Immunohistochemical study of the histogenesis of esophageal carcinosarcoma

In order to clarify the histogenesis and the direction of differentiation of spindle-cell and sarcomatous components of esophageal carcinosarcoma, 20 cases of the disease were reviewed histologically and immunohistochemically using the avidin-biotin-peroxidase complex method with monoclonal and polyclonal antibodies to various keratins, vimentin, desmin, muscle specific actin and S-100 protein. A gradual transition between carcinomatous and spindle cell sarcomatous components was present histologically in all 20 cases. Positive immunoreactivity for keratins was found in carcinomatous areas in all cases. Spindle cells in the transitional areas were positive for keratins in nine cases and for vimentin in five. Two cases demonstrated trace positive reactions to both keratin and vimentin in the same areas of transitional spindle cells between carcinomatous and sarcomatous components. The sarcomatous component showed an immunohistochemically positive reaction for vimentin in ten cases and for desmin in two. In one of the 20 cases, chondrosarcomatous cells were seen which showed a positive reaction to S-100 protein but were negative to keratin. The findings strongly suggested that neoplastic epithelial cells may show dedifferentiation to transforming spindle cells and also disdifferentiation to non-epithelial sarcoma like chondrosarcoma and leiomyosarcoma.

Surgical treatment of thoracic esophageal carcinoma directly invading the lung

BACKGROUND

The authors examined 63 patients with thoracic esophageal carcinoma directly invading the adjacent lung. Four of them had esophago-pulmonary fistulas. One patient received exploratory thoracotomy and exposure to radiation, and 62 underwent esophagectomy with mediastinal and abdominal lymph node dissection. A resection of the seized lung and the esophagus was performed in 39 patients (Group A), and 23 received esophagectomy with part of the tumor remaining intact (Group B).

METHODS

The results of treatment were compared between the two groups.

RESULTS

Operative blood loss, mortality, and complications in both groups showed no difference. The average number of dissected lymph nodes in Group A was significantly larger than that in Group B (P less than 0.01). Histologic examination revealed that 22 (56.4%) lesions in Group A invaded the pulmonary parenchyma, a finding that indicates the difficulty of gross diagnosis of tumor infiltration. Five-year survival rates for patients in Groups A and B were 21.1% and 8.7%, respectively. The survival curve for patients in Group A was significantly better than for those in Group B (P less than 0.05).

CONCLUSIONS

Pulmonary resection and aggressive lymph node dissection are recommended for patients with esophageal carcinoma that invades the adjacent lung.

High incidence of nuclear accumulation of p53 protein in gastric cancer

The accumulation of p53 protein in the nuclei of cancer cells is known to correlate well with the presence of mutations in the p53 gene. We therefore investigated the immunohistochemical reactivity of the anti-p53 antibody, PAb1801, in specimens taken from 149 cases of primary gastric cancer and processed by acetone fixation, in order to elucidate the incidence and clinicopathological significance of p53 alterations in gastric cancer. Thirty-four out of 99 (34%) advanced gastric cancers and 11 out of 50 (22%) early gastric cancers showed positive reactions in the nuclei. The nuclei of non-cancerous cells, including gastric glandular epithelial cells, however, were not stained. Histopathologically, a nuclear accumulation of p53 protein was seen frequently in papillary adenocarcinoma, well- to moderately-differentiated tubular adenocarcinoma and poorly-differentiated adenocarcinoma with solid nests or focal tubular structures (43/101, 43%), but was rarely seen in signet-ring cell carcinoma, mucinous adenocarcinoma or poorly-differentiated adenocarcinoma growing in a scattered manner (2/48, 4%). There was no correlation between stainability of p53 protein and clinicopathological features such as depth of tumor invasion, microscopic lymphatic invasion, microscopic venous invasion, nodal involvement and clinicopathological stage in papillary adenocarcinoma, well- to moderately-differentiated tubular adenocarcinoma and poorly-differentiated adenocarcinoma with solid nests or focal tubular structures. The results suggest papillary adenocarcinoma, well- to moderately-differentiated tubular adenocarcinoma and poorly-differentiated adenocarcinoma with solid nests or focal tubular structures to share a common carcinogenetic pathway in which mutation of the p53 gene has an important role to play at a relatively early stage. Additionally, we showed the applicability of immunohistochemical detection of p53 protein in endoscopic biopsy material routinely formalin-fixed. The current method may be of some help in routine practice in discriminating between normal, precancerous and cancer cells in the stomach.

Adenocarcinoma in Barrett's esophagus following total resection of the gastric remnant: a case report

We report a case of adenocarcinoma in Barrett's esophagus following a total resection of the gastric remnant. A 52-year-old man had undergone a distal gastrectomy for gastric cancer at 33 years of age and a total resection of the gastric remnant for local recurrence of the gastric cancer at 35 years of age. Repeated endoscopic examinations revealed the sequence of reflux esophagitis and Barrett's esophagus. Furthermore, adenocarcinoma in Barrett's esophagus was detected in December, 1989. A subtotal esophagectomy was performed in January, 1990. The elevated lesion in the lower esophagus showed coarse lobulation and measured 7.4 x 3.2 cm. The histologic type was that of well-differentiated adenocarcinoma, with the invasion limited to the muscularis mucosae without lymph node involvement. Severe dysplasia was seen adjacent to the definite carcinoma. The case supports the acquired theory of pathogenesis for Barrett's esophagus and suggests that reflux esophagitis after total gastrectomy may result in a dysplasia-carcinoma sequence.

Quantitation of gastric intestinal metaplasia by morphometry in Japanese patients

With the aid of an image processor, the length of the intestinal metaplasia (IM) was recorded in 33 gastrectomy specimens (23 with early gastric cancer and 10 with gastric peptic ulcer). A total of 1917 sections were analyzed. The length of the areas with IM and the total length of the muscularis mucosa were measured in individual sections. The resulting ratio (length of IM/length of muscularis mucosa) was noted as the intestinal metaplasia index (IMI), as an expression of the extension of IM in the specimens. The IMI was influenced by the age of the patient and by the histologic type of the tumor: a higher IMI was found among older patients and among patients with adenocarcinoma of intestinal type. A comparison with a similar study done in gastrectomy specimens from Swedish patients indicates that despite the latter group being older, and the tumors being more advanced, the IM was much more extended in the gastric mucosa of the Japanese patients with gastric adenocarcinomas of intestinal type. From the results it is suggested that extended IM in the gastric mucosa may have some bearing on the histogenesis of gastric carcinomas, particularly adenocarcinomas of intestinal type.

Diffusely infiltrating primary colorectal carcinoma of linitis plastica and lymphangiosis types

A review of 2369 cases of resected primary colorectal carcinoma identified 15 cases of diffusely infiltrating colorectal carcinoma. Depending on the histologic pattern and extent, these cases were classified as linitis plastica (LP) type (seven cases) or lymphangiosis (LA) type (eight cases). The LP type consisted of poorly differentiated adenocarcinoma or signet ring cell carcinoma; it showed an annularly thickened and rigid bowel wall. The LA type consisted of moderately differentiated adenocarcinoma. The colon wall of the LA type was hemilaterally thickened at the mesenteric side. The prognosis was extremely poor for both types. The LP type mainly had peritoneal dissemination (70%), but the LA type frequently had distant metastasis (88%). Early diagnosis and curative operation are important for both types; however, the LA type also requires therapy for distant metastasis.

Analysis of cytosol CA15-3, carcinoembryonic antigen, estrogen and progesterone receptors in breast cancer tissues

Cytosol levels of carcinoembryonic antigen (CEA), CA15-3, estrogen receptor (ER) and progesterone receptor (PgR) of 194 primary breast cancer tissues were measured. ER and PgR determined by enzyme immunoassay methods correlated inversely with Page's grades of histological atypia and mitotic rate. Cytosol CA15-3 correlated inversely with the grades of tubular and nuclear atypia and positively with the mitotic rate. CA15-3 correlated positively with ER and PgR. Cytosol CEA showed no correlation with the pathological grade or hormone receptor status. These results indicate that hormone receptor-positive breast cancers tend to have more differentiated morphology and slower growth rate than those without those receptors and that the cytosol CA15-3 level may reflect some of the intrinsic malignant potency, particularly the growth rate, of breast cancer. Cytosol CA15-3 as well as the hormone receptor status may have prognostic value for patients with breast cancer.

[Histological and biological evaluation of preoperative radiotherapy on T1N0 breast carcinoma]

In order to clarify the role of radiotherapy in breast preserving surgery for early breast cancer, histological and biological effects of preoperative radiation were evaluated. Thirty-five T1N0 patients were treated by preoperative radiotherapy with beta-tron, cumulative doses of which were ranging from 25 Gy (5 Gy x 5) to 40 Gy (8 Gy x 5) and underwent subsequent modified radical mastectomy 2 or 3 weeks after the termination of radiotherapy. Clinical tumor shrinkage more than 50% was observed in 25 out of 35 cases (71%) but did not directly correlate with histological effects. Radiotherapy was basically ineffective within 25-30 Gy, whereas histological effects more than Grade 2 were gained in 8 out of 25 patients (32%), who had received 40 Gy or more. In the preoperative radiation group, there were more ER(+), PgR(+) and histologically well-differentiated cases than in the non-radiated stage I patients. Mitotic figures were also significantly reduced after radiotherapy, whereas the expression of c-erB-2 protein was unchanged between these two groups. Our data indicate the various radiosensitivity of breast cancer cells and the indication of hormone therapy for the conservative treatment of breast carcinoma.

Intramural metastasis of thoracic esophageal carcinoma

Of 393 patients with squamous-cell carcinoma in the thoracic esophagus, 60 were found by histologic examination to have intramural metastasis. Metastases in 50 of these were identified by gross inspection. There appeared to be no preference for location proximal to the primary lesion. Eighteen patients had metastasis to the gastric wall, which suggested the existence of communicating lymphatic channels between the wall of the esophagus and the stomach. All 60 primary tumors invaded beyond the submucosa. These 60 patients (group A) were compared with a group of matched control patients without intramural metastasis (group B). The tumor size in group A was significantly larger than in group B (p less than 0.01). The number of patients with lymph-node metastasis was significantly higher in group A (p less than 0.01), and the average number of positive nodes in group A was greater than in group B (p less than 0.01). Recurrent disease in the mediastinal lymph nodes and in the liver is characteristic of group A. The survival curve for patients in group A was significantly lower than that for group B (p less than 0.001). Conventional radiotherapy or chemotherapy after surgery were ineffective in improving prognosis. These results indicate that the presence of intramural metastasis is an important factor to consider when evaluating the prognosis of patients with squamous-cell carcinoma of the esophagus.

Hypercalcemia in patients with esophageal carcinoma. The pathophysiologic role of parathyroid hormone-related protein

To elucidate the actual incidence of hypercalcemia in patients with esophageal carcinoma, 382 consecutive cases admitted to the National Cancer Center Hospital (Tokyo, Japan) from 1983 to 1988 were investigated. Hypercalcemia was detected in 5 patients of 376 (1.3%) at the time of primary detection of cancer, and in 45 patients of 120 (38%) patients with recurrent or unresectable cancer who were monitored within 2 months of death. These observations demonstrated that this electrolyte imbalance is a frequent paraneoplastic syndrome observed in patients with advanced esophageal carcinoma. With regard to the etiology, bone metastases were detected in 13 of 49 patients with hypercalcemia; the remaining 36 patients were assumed to be induced by the production of hypercalcemic substance(s) by tumor tissues. Parathyroid hormone-related protein (PTHrP) is a newly discovered factor which increases serum calcium in vivo. The detection of PTHrP mRNA in tumor tissues as well as the production of PTHrP-like immunoreactivity by tumor tissues were closely associated with the development of hypercalcemia, suggesting that PTHrP is the major cause of hypercalcemia in patients with esophageal carcinoma.

A possible error in the interpretation of gastric carcinoma

Isolated clusters of pyloric cells having homogeneous, eosinophilic (i.e., "glassy") cytoplasm were present in 6 (18.2%) of 33 consecutive gastrectomy specimens. Clusters with "glassy" cells displayed either a glandular arrangement or appeared as cohesive clusters. Cohesive clusters could be misinterpreted as signet-ring cell adenocarcinoma. However, remnants of the apical mucous secretion from the "ordinary" pyloric cells, the nuclei usually near the free border of the cells, as well as the negative reaction in the "glassy" cytoplasm for neutral and acid mucins, helped to differentiate them from signet-ring adenocarcinoma cells.

Lymph node metastasis in thoracic esophageal carcinoma

Seventy-nine patients with thoracic esophageal carcinoma underwent transthoracic esophagectomy with neck, mediastinal, and abdominal lymphadenectomy. The operative mortality rate was 3.8%. Fifty-seven patients (72.2%) had metastasis in the lymph nodes. Though three patients with carcinoma classified as pTis had no positive nodes, nine (50.0%) of the patients with a pT1 carcinoma had positive nodes. The 5-year survival rate for 57 patients with positive nodes was 33.6%. Twenty-nine patients (36.7%) had positive nodes in the neck; 47 (59.5% ), in the mediastinum; and 33 (41.8%), in the abdomen. Their 5-year survival rates were 30.0%, 24.4%, and 38.4%, respectively. The differences between these rates were not statistically significant. These results indicate that the neck lymph nodes should be regarded as part of the regional lymph nodes and that esophagectomy with wide lymph node dissection improves the long-term survival of patients with thoracic esophageal carcinoma.

The prognostic value of tumor-associated carbohydrate structures correlated with gene amplifications in human breast carcinomas

The effects of cell surface sugar chains combined with certain gene amplifications of breast cancers on the prognosis of patients were studied and the relationships between the sugar chains of cancer cells and amplifications of the proto-oncogenes c-myc, int-2 and c-erb B-2, evaluated. One hundred and fifty three human breast carcinoma tissues were investigated by an immunohistochemical technique using the avidinbiotin-peroxidase method with 1 lectin (HPA; Helix Pomatia) and 4 monoclonal antibodies (B-72-3, St-439, anti-Tn and anti-T). The positive rates of HPA, St-439, B-72-3, anti-Tn and anti-T were 43 per cent (63/153), 52 per cent (80/153), 53 per cent (81/153), 64 per cent (98/153) and 89 per cent (136/153), respectively. Patients whose cancers had positive HPA staining were found to have a lower survival rate than those with negative HPA staining (p less than 0.05), whereas those whose cancers had positive St-439 staining showed a better prognosis than those with negative St-439 staining (p less than 0.01). The positive rate of HPA was related to the gene amplification of c-myc proto-oncogene (p less than 0.01), whereas the negative rate of St-439 was correlated with the gene amplification of c-erb B-2 (p less than 0.01). These data indicate the prognostic value of HPA and St-439 and also the relationships between the gene amplifications and carbohydrate structures in breast cancer cells.

Primary malignant melanoma of the esophagus: report of four cases

We report four cases of malignant melanoma of the esophagus treated at the National Cancer Center Hospital in Tokyo over a period of 28 years. There were three men and one woman. One patient had been diagnosed as having Werner's syndrome. The three male patients smoked and were alcohol drinkers. The chief complaint was dysphagia--three patients--and pain on swallowing--one patient. All the tumors were polypoid, and three were large at the time of initial diagnosis. Histological diagnoses were made by examining endoscopic biopsy specimens, and confirmed with resected specimens in three cases. Esophagectomy was performed in three patients, the other receiving radiotherapy. Three patients died of recurrent disease in a rather short period of time, as in many reported cases. The mean survival for the three patients was eight months. The fourth, who had a superficial polypoid lesion and received esophagectomy and adjuvant chemotherapy, lived for 29 months. The combination of early detection and extended radical surgery followed by adjuvant chemotherapy may offer a better prognosis than in the past.

Triple carcinomas in Cronkhite-Canada syndrome

The present report describes a 69-year-old man displaying the clinical features of the Cronkhite-Canada syndrome. After taking medicine for the common cold, he suffered hypogeusia and watery diarrhea, eruptions on the lower extremities and an 8 kg loss in body weight. All his finger and toenails began to fall out. He underwent an upper gastrointestinal examination, upon which multiple polyps of the stomach were detected. Three years later, he again developed diarrhea, bloody stools, body weight loss and eruptions on the lower extremities. An upper gastrointestinal series showed a diverticulum of the esophagus and multiple polyps in the stomach. A barium enema examination revealed polyps throughout the entire colon. Endoscopical biopsy specimens revealed juvenile type polyps and adenomas. The patient was treated with predonine therapy and, in a few days, his symptoms improved. Following the predonine therapy, an upper gastrointestinal endoscopy revealed superficial esophageal cancer and early gastric cancer. The patient received successful surgical treatment. Macroscopically, the esophageal cancer was of the superficial type, and its histologic type was that of moderately-differentiated squamous cell carcinoma. The gross finding on the stomach cancer was one of superficial depressed type, and its histologic type was that of well-differentiated tubular adenocarcinoma. One year later, lung cancer was detected. The gross appearance of the resected lung tumor was one of a grayish-white color and the neoplasm was histologically diagnosed as undifferentiated carcinoma, small and large cell type. The coexistence of carcinoma of the gastrointestinal tract with Cronkhite-Canada syndrome has been reported in 21 cases. We have found no report, however, of lung cancer associated with Cronkhite-Canada syndrome. The case described herein is, therefore, the first case of Cronkhite-Canada syndrome to be associated with esophageal, gastric and lung cancer.

Esophageal and pulmonary metastases from ovarian carcinoma: a case report of long-term survival following metastatic resections

A case of ovarian carcinoma which has been followed up for more than 28 years after the initial ovarian resection is reported. A 50-year-old woman came forward with a metastatic esophageal tumor 16 years after a salpingo-oophorectomy for ovarian carcinoma. After irradiation with a dose of 3090 cGy, an esophagectomy and a partial resection of the directly invaded pericardium was successfully performed. Ten years later, progressive dyspnea due to a total collapse of the right lung developed. The right main stem bronchus was almost occluded by an endobronchial tumor, contiguous with the recurrent mass at the previous resectional margin. A right pneumonectomy and a combined resection of the pericardium and left atrium were performed. The patient has been followed up for further two years, and no signs of recurrence are evident. In spite of distant thoracic involvement and its local regrowth, the patient has survived for 28 years following her initial resection with surgical interventions.

Superficial esophageal carcinoma. Surgical treatment and the results

We report 92 patients treated with esophagectomy for superficial esophageal carcinoma (SEC; 9.1% of all resected esophageal cancers at our institution). The operative mortality rate was 5.4%. In 24 cases, cancer invasion was limited to the mucosa, and in 68 to the submucosa. Twenty-three patients in the former group had no lymph node involvement, whereas 24 patients (35.3%) of the latter group had lymph node metastases. The 5-year survival rate after surgery for patients with SEC limited to the mucosa was 83.5%, which was significantly better than that for carcinoma invading the submucosa (54.9%). No recurrent disease occurred in patients with lesions limited to the mucosa. In conclusion, an esophagectomy with wide lymphadenectomy is necessary to provide a better prognosis for SEC invading the submucosa, whereas a less extensive treatment may be considered for SEC limited to the mucosa.

Alveolar soft part sarcoma. A clinicopathologic and immunohistochemical study of 12 cases

Twelve cases of alveolar soft part sarcoma (ASPS) were reviewed. Seven of them arose primarily in the lower extremities, three in the head and neck region, and two in other parts. ASPSs in the head and neck region occurred in children before 10 years of age, whereas ASPSs in the other regions occurred in rather older patients. Moreover, ASPSs of the head and neck were relatively small in size, and were diagnosed earlier than those in other regions. Histologically, six cases (including all the head and neck cases) contained considerable area of small and indistinct alveolar structures. Four cases showed remarkable cellular pleomorphism. Immunohistochemical demonstration of vimentin, desmin, the beta-subunit of enolase and the MM isozyme of creatine kinase, together with the absence of immunoreactive cytokeratin, supported the myogenic nature of this rare tumor. A small number of S-100 protein-positive tumor cells were also observed. Follow-up data for these cases disclosed that the tumors containing considerable area of small alveoli and uniform small tumor cells formed distant metastases at an early stage.

Carcinosarcoma of the esophagus: a twenty-case study

The present report reviews results from 20 carcinosarcoma patients, and compares them with 773 cases of squamous cell carcinoma of the esophagus treated surgically at the National Cancer Center Hospital from 1971 to 1988. Although there were no significant differences in age, sex, symptoms or location between the two groups, the carcinosarcoma group had morphological characteristics as follows. (1) Seventy-five percent of the carcinosarcomas were of the elevated type. (2) The tumor was large. (3) The depth of invasion was limited to the esophageal wall in 80% of the carcinosarcomas. The rate of lymph node metastasis was almost the same, at greater than 65%, in both groups. Moreover, lymph node metastasis occurred at various stages, of the depth of invasion in the carcinosarcoma group. The curative resection rate was higher for carcinosarcoma (80%) than for squamous cell carcinoma (46.5%). There was no significant difference in recurrence rate between them. Compared with the high frequency of lymph node recurrence in the squamous cell carcinoma group, the recurrence due to hematogenous metastasis was more frequent in the carcinosarcoma group. Although the three-year survival rate was higher for carcinosarcoma (62.8%) than for squamous cell carcinoma (28.1%), there was no significant difference in the five-year survival rate between them (26.7 vs. 22.4%). In conclusion, radical esophagectomy with lymph node dissection is a necessary therapy for carcinosarcoma, and careful follow-up, paying special attention to hematogenous metastasis, is required.

Synchronous early gastric cancer

Synchronous early gastric cancer (EGC) has a prevalence of approximately 9%. The barium study findings of 73 patients with 163 synchronous EGC tumors were retrospectively reviewed, and the size, location, and morphologic type of each lesion considered malignant were analyzed and correlated with the endoscopic and final pathologic findings. Barium studies and endoscopy each correctly demonstrated 116 of the 163 synchronous EGC lesions. Those lesions not demonstrated by either technique were small, shallow, or flat and confined to the mucosa. Our results indicate that a careful preoperative evaluation with radiography and endoscopy currently can depict about 70% of these lesions.

A rare case of asynchronous bilateral B-cell lymphoma of the breast

We report an asynchronous bilateral malignant lymphoma of the breast, in a 56-year-old woman, presenting unusual clinical signs and histological features. The patient, who had a family history of breast cancer, had undergone a standard right radical mastectomy four years previously for a non-epithelial malignant tumor. At that time, the tumor was thought to be a stromal sarcoma, because some of the neoplastic cells were elongated or vacuolated. The patient recently became aware of a rapidly growing tumor of the left nipple without erosion or pain. This tumor underwent biopsy, and the histological examination showed a non-Hodgkin's lymphoma of diffuse mixed type. Staging procedures demonstrated no sign of generalized disease. Following a modified left radical mastectomy for optimal local control and accurate staging, adjuvant chemotherapy consisting of vincristine, cyclophosphamide, prednisolone and doxorubicin was initiated. Immunohistochemical staining for PAN-B and leucocyte common antigen revealed both tumors to be malignant lymphomas of B-cell type, and the first lymphoma of the right breast was thought to be showing 'signet ring' cell change. Since the two tumors were morphologically quite different from each other, it was suggested that they were asynchronous bilateral primary malignant lymphomas; however, the possibility remains that the recent left breast tumor is a recurrence of the malignant lymphoma of the right breast. The patient is currently disease-free, 10 months after surgery.

Prognostic contributions of Helix pomatia and carcinoembryonic antigen staining using histochemical techniques in breast carcinomas

Helix Pomatia (HPA) and carcinoembryonic antigen (CEA) staining were studied in 113 primary breast carcinomas, 63 metastatic lymph nodes and 10 resected local recurrences, using the avidin-biotin-peroxidase complex (ABC) method. Positive percentage rates were 41 (46/113) for HPA and 24 (27/113) for CEA in primary tumors, and 80 (8/10) for HPA but only 10 (1/10) for CEA in metastatic lesions. HPA staining showed a statistically significant correlation with negative estrogen receptor (ER) status (r -0.25, P = 0.05) and high nuclear grade (r 0.20, P = 0.04). Cancers with positive HPA staining were associated with a lower survival rate than those without (P = 0.0001), irrespective of menopausal status. CEA staining showed a marginal correlation with survival (P = 0.06: log rank test). The five-year survival rate of 21 cases positive for these two markers was only 5%. Multivariate analysis revealed HPA staining to be the best prognostic factor. The data indicated that HPA staining might be a valuable prognostic factor for breast cancer patients, especially when combined with CEA staining.

[Study of local interstitial hyperthermia induced by low power Nd:YAG laser]

A comparative study of local interstitial hyperthermia induced by low power Nd:YAG laser (laser hyperthermia) and microwave hyperthermia was carried out in vivo and in vitro in an attempt to clarify the therapeutic effect and the mechanism. Both therapies, after seven days, caused marked amounts of coagulated necroses in the transplanted tumors of human pancreatic carcinoma. Immediately after those therapies, electron microscopic examination of the tumor tissues showed membranous, cytoplasmic, nuclear and mitochondrial damage; however, this damage was much more extensive in laser hyperthermia compared to microwave hyperthermia. The cytocidal effects of heating alone, laser hyperthermia and microwave hyperthermia were also studied in vitro. Of the three, laser hyperthermia demonstrated the most notable decrease in viability. Thus, in the mechanism of laser hyperthermia, it seems that the immediate effect is cellular damage caused by both heat energy and Nd:YAG laser light followed by subsequent damage of tumor vessels.

No correlation between L-myc restriction fragment length polymorphism and malignancy of human colorectal cancers

The correlation of the restriction fragment length polymorphism (RFLP) pattern of L-myc with the progressive state of cancer and metastases to lymph nodes or other organs were examined in 35 cases of human colorectal cancer by chi 2 analysis. No significant correlation was found.

Malignant transformation of gastric hyperplastic polyps

Four hundred and seventy-seven hyperplastic polyps, removed by endoscopic polypectomy, were reviewed with special reference to the appearance of dysplastic foci and their malignant transformation. Focal carcinomas were found in 10 hyperplastic polyps, which corresponded to 2.1% of the total of 477 hyperplastic polyps. The location of cancer was at the head or at the surface of the polyp, and was intramucosal. Dysplastic foci equivalent in the degree of histological atypia to adenoma were found adjacent to the cancerous foci in these 10 polyps. Dysplastic foci were also found in 19 hyperplastic polyps without cancerous foci, which corresponded to 4.0% of the total hyperplastic polyps. In connection with the histogenesis of malignant transformation of hyperplastic polyps, the results of clinicopathological examination and immunohistochemical stains strongly suggested that cancer cells arose from the dysplastic area in hyperplastic polyps, rather than directly from nondysplastic hyperplastic epithelium.

[Immunohistochemical study of oncogene-related products in human gastrointestinal malignancies--expression of ras p 21, fes p 85 and EGF receptor]

An immunohistochemical examination by the avidin-biotin-peroxidase complex method was carried out to assess the expression of oncogene-related products, i.e., ras p 21 protein, fes p 85 protein and epidermal-growth-factor (EGF) receptors, in human gastrointestinal malignancies. The presence of ras p 21, fes p 85 and EGF receptors was detected in 48%, 62%, and 62% of 29 colorectal carcinomas and in 65%, 65% and 40% of 20 gastric cancers, respectively. More than one oncogene protein was demonstrated in 18 of 29 colorectal carcinomas and in 10 of 20 gastric cancers. These results suggest that multiple oncogenes are important in the occurrence and progress of gastrointestinal malignancies.

Clinical and radiologic features of hepatocellular carcinoma originating in the caudate lobe

Five patients with hepatocellular carcinoma in the caudate lobe were evaluated. Computed tomography (CT) scan and/or angiography clearly demonstrated multiple intrahepatic metastases in four (80%), and tumor thrombi in the portal vein in two (40%), and in the inferior vena cava in one. Even though there was no recognizable lung metastasis, metastases were found in the orbita in one patient, and in the ribs and thoracic vertebrae in two patients. Four patients died after a mean period of 5.5 months from the initial diagnosis. The mechanism for early invasion into the vessels and multiple intrahepatic metastases of hepatocellular carcinoma arising from the caudate lobe is discussed.

Antibody to the receptor for polymerized human serum albumin in acute and persistent infection with hepatitis B virus

The antibody against the receptor for polymerized human serum albumin was determined by radioimmunoassay. The method involved the inhibition by the test serum, absorbed with HBsAg particles without the receptor, on the binding of polymerized human serum albumin to HBsAg particles with the receptor fixed on a solid support. The amount of polymerized human serum albumin captured by the receptor on HBsAg was then determined by the radiolabeled monoclonal antibody directed to an epitope specific for polymerized human serum albumin. In acute infection, the antibody to the receptor for polymerized human serum albumin appeared in the early recovery phase while HBs antigenemia and elevated transaminase levels were still present, preceding the antibody to HBsAg (anti-HBs). The antibody was detected in 4 (1%) of 358 sera from asymptomatic carriers of HBsAg containing antibody to HBeAg, and in none of 67 sera containing HBeAg. Although the antibody was found in as many as 111 (74%) of 150 sera from blood donors who had presumably acquired anti-HBs after natural infection, it was not detected in any sera from 77 recipients of hepatitis B vaccine who had seroconverted for anti-HBs. On the basis of these observations, the determination of antibody to the receptor for polymerized human serum albumin helps in further understanding the immunity to hepatitis B virus.

[Difference in clinical treatment between patients histologically diagnosed as group III by the old and new "group classifications" of gastric biopsy]

Since 1971, when the first draft of the "Group Classification", which classifies the atypism of histological structure in biopsy specimens of the stomach, was proposed by the Japanese Research Society For Gastric Cancer, this classification has come into wide use in Japan. It was, however, revised in 1983, and, according to the revised classification, group III was defined as general histological findings in which it is difficult to make a differentiation between benign and malignant by biopsy specimens. Consequently, the new group III includes, various borderline histologies, in addition to the old group III, which had been defined as the histological features corresponding to those observed in gastric adenoma in biopsy specimens. At the National Cancer Center Hospital, 13,909 gastric biopsies were performed during the period between 1973 and 1982. By retrospective review of these, histological findings in 247 lesions of 231 cases corresponded to group III by the old classification (adenomatous type) and in addition to these, 54 lesions of 54 cases to group III by the new classification (non-adenomatous type). We compared the endoscopic and pathological features between the two types, and the following results were obtained: The false-negative rate of malignancy in the non- adenomatous type (24%) was much higher than that in the adenomatous type (6%). The difference between the two may suggest that, with the adoption of the new group classification, clinical treatment of the patients with group III becomes more complicated due to the increase of the false-negative rate. Endoscopically, most (84%) of the lesions in the adenomatous type were seen as polypoid, while in the non-adenomatous type, depressed lesions were dominant (80%). And, endoscopic details of the polypoid or depressed appearances were mostly different between the two types. These nuances of endoscopic appearance between adenomatous and non-adenomatous types are applicable to decisions regarding, adequate clinical treatment for patients diagnosed as group III by the new "group classification." Good communication between the endoscopist and pathologist is indispensable.

Binding of bile acids with rat colon and resultant perturbation of membrane organization as studied by uptake measurement and 31P nuclear magnetic resonance spectroscopy

The mode of interaction of deoxycholate (DOC) or lithocholate (LC) with F344 rat colon was examined by measurements of uptake, 31P nuclear magnetic resonance (NMR) spectroscopy and observation of morphological changes. DOC as well as LC was taken up by the colon in a nonsaturable manner with respect to concentration and time, up to 30 min. None of several metabolic inhibitors reduced the uptake of the bile acids, nor did pretreatment of colon segments with chloroform-methanol (2:1, (v/v), heat or trypsin. Further, the bile acids were not transported by the colon against concentration gradients, and they were bound to both the mucosa and serosa equally. From these findings, it is concluded that the bile acids are transported in a passive manner, and no specific receptor for them is contained in colonic mucosa. The uptake of the bile acids by the colon varied with temperature and was related to the fluidity of the colonic membranes. The extent of uptake of dehydrocholate and taurocholate, which do not induce ornithine decarboxylase (ODC) activity, was almost the same as that of LC. The 31P NMR spectra of the colonic mucosal cells indicated that the proportion of the bilayer structure is increased by 0.5 mM DOC. Among a variety of bile acids examined, the extent of membrane alteration was in parallel with the extent of ODC induction. Treatment of the colonic mucosa with 0.5 mM DOC caused marked degeneration of the surface but not the deeper layers of the mucosa. Thus, physiological concentrations of bile acids influence the membrane organization of the colonic mucosa in a nonspecific manner that is possibly related to the tumor-promoting activity.

[ESR (electron spin resonance) analysis of cancer patient lymphocytes stained with hematoporphyrin D]

Administration of hematoporphyrin derivative (HPD) with the association of laser beam irradiation has recently been employed for the diagnosis and treatment of cancer. This methodology is based on the tumor affinity of HPD and the phenomenon of fluorescence generation under the specific wave laser beam. Furthermore, laser irradiation induces a photochemical reaction of HPD, which may kill the HPD uptake cancer cells. Utilizing the electron spin resonance (ESR) that produces HPD radicals, we measured the level of radicals in the lymphocytes separated from the peripheral blood of patients with cancer of various types and sites and that from normal controls, as well as in the culture cancer cells (K-562). The level of radicals in the lymphocytes from the cancer-bearing patients and culture cancer cells was found to be significantly elevated as compared with that in the lymphocytes of normal controls and patients with noncancerous conditions such as SLE, hepatic disease, etc. This procedure appears to be very useful for the diagnosis of cancer, and this is the first report in the world.

Surgical treatment of early gastric cancer

In Japan, R2-gastric resection which consists of gastrectomy, omentectomy and complete removal of Group 1 and 2 regional lymph nodes has been generally accepted as the procedure of choice in the treatment of early gastric cancer during the past 20 years. As a result, surgical treatment for early gastric cancer patients has achieved a very good survival rate, 97.7% and 96.2% 5 and 10 years, respectively, after surgery. To determine a new rationale for surgical treatment for early gastric cancer, the relationship between various prognostic factors and postoperative prognosis in 1,200 patients with early gastric cancer was studied. The survival rate for patients with a single focus of cancer in the stomach was significantly higher than that for patients with multiple foci. The incidence of recurrence was very low (2.8%) as a whole and most recurrence was found in patients who have had invasion into the submucosa with regional lymph node metastasis. The characteristic mode of recurrence was hematogenous metastasis to the liver and lung. The majority of causes of death were non-malignant disease and multiple primary malignant neoplasms. As to the survival rate in relation to the extent of lymph node dissection, no significant difference in survival rate was observed among the three procedures R0-, R1- and R2-resection in single cancer regardless of cancer invasion through the gastric wall. The survival rate for intramucosal carcinoma without lymph node metastases and with Group 1 lymph node metastases in both single and multiple cancer was 100%. In addition, 125 patients with intramucosal polypoid cancer (types I and IIa according to the macroscopic classification of early gastric cancer) showed no lymph node metastasis and had 100% survival. Therefore, from the present study a new rationale for surgical treatment for early gastric cancer is recommended as follows: 1) In general, R1-resection is indicated for intramucosal carcinoma and R2-resection for submucosal carcinoma. 2) Local resection of the tumor or R0-resection with preservation of the regional lymph nodes is thought to be sufficient for an intramucosal polypoid carcinoma less than 2.0 cm in diameter.

Endoscopic treatment of early gastric cancer: polypectomy and laser treatment

With the tremendous development of gastroenterological endoscopy, it has become possible to treat some types of early gastric cancer by endoscopy. There are two principal methods for this purpose, endoscopic polypectomy using a high frequency electric current and laser endoscopy. We developed the technic and instruments of endoscopic polypectomy, in 1972. Since then, we have experienced 358 cases of gastric polypoid lesions treated by endoscopic polypectomy. Nineteen patients with the elevated type of early gastric cancer were treated by endoscopic polypectomy. Seven patients were operated on after polypectomy and 12 were followed without surgery. Out of the 12 patients, nine are alive after more than five years. On the other hand, we started research to apply lasers for treating early gastric cancer in 1978. Since then, 18 patients have been treated by laser endoscopy, with Nd-YAG laser, argon dye laser or a combination of both lasers. We have established criteria for these treatments for early gastric cancer.

The role of the biopsy in diagnosis of early gastric cancer

In order to determine the reliability of endoscopic biopsy in diagnosis of early gastric cancer, and to clarify the problems with biopsies, preoperative endoscopic biopsies from 771 early gastric cancer cases were reviewed and analyzed clinicopathologically in comparison with surgically resected specimens. The 771 cancers were surgically resected at the National Cancer Center Hospital during the period from 1972 to 1982. Definite histological diagnosis was obtained in 87.4% of the carcinomas at the initial biopsies. Repeated biopsy raised the percentage of correct definite diagnoses to 96.1%. False-negative (including suspicion of cancer) diagnosis was most frequent in the case of depressed lesions (50 lesions). Half of the false negatives were found to be due to sampling errors by the endoscopists. The other half of these 50 lesions were diagnosed as "suspicious of malignancy" because of the histological difficulty in differentiating early gastric cancer from regenerative atypia with intestinal metaplasia, or because there was not enough information, or for the other reasons. Most of the 31 false-negative diagnoses at the initial biopsy from elevated lesions were reported as adenoma (group III) or suspicious of carcinoma (group IV), indicating that differential diagnosis between well-differentiated adenocarcinoma and adenoma is very difficult. The result of the present study suggests that repeated biopsy from correct sites and discussion of the lesions between clinicians and pathologists are very important.

Distribution of blood group antigens and CA 19-9 in gastric cancers and non-neoplastic gastric mucosa

The distribution of blood group ABH antigens, their precursor I(Ma) antigen, Lewis a antigen and monoclonal antibody-defined tumor-associated antigen CA 19-9 in gastric cancers and their surrounding non-neoplastic mucosa was studied by using immunohistochemical methods. ABH antigens were localized in the foveolar epithelium except for a few cases presumed to be non-secretors, but ABH antigens were lost focally from metaplastic mucosa. In contrast, Lewis a and I(Ma) antigens were present in the foveolar epithelium of non-secretors and metaplastic mucosa where ABH antigens were not detected. Gastric cancers also showed focal loss of ABH antigens and gain of Lewis a and I(Ma) antigens, and the cancer cells showed marked heterogeneity in antigen expression compared with non-neoplastic mucosa. Expression of incompatible blood group antigen (A-like antigen) reactive with monoclonal anti-A antibody was also detected in cancer cells of blood group O and B cases. CA 19-9 (sialylated-Lewis a) was detected in 62% of gastric cancers and in the restricted areas of gastric mucosa where Lewis a was positive.

Chronological changes in the morphological features of early gastric cancer, especially recent changes in macroscopic findings

At the National Cancer Center, 1,300 patients with early gastric cancer were operated on during a period of 21 years, from 1962 to the end of May 1983, and the chronological sequence of the pathological features was analyzed by dividing the 21 years into five periods (I approximately V). The number of elderly patients, especially those above the age of 70 years increased with time, reaching about 20% of all patients in the later period. As to the CMA classification, lesions in A region (antral region) tended to increase, reaching 32.8% in the last period. Lesions on the anterior and posterior wall increased, reaching 20.2% and 30.5%, respectively. Lesions on the greater curvature side were almost unchanged in frequency. The depressed type of carcinoma tended to increase in frequency in the later period, accounting for 75.3% of the total. The depressed type lesions, especially those consisting mainly of IIc element, were therefore subdivided into deep IIc and shallow IIc. In the later period, shallow IIc or not readily detected indistinct IIc increased markedly, reaching 83.3% in Period V. In the initial period, 40% of the lesions were larger than 5 cm. In the later period, lesions larger than 5 cm decreased to 10%, and more than 40% were 2 cm or smaller. Histologically, differentiated and undifferentiated types were found at almost the same frequency. In the later period, the differentiated type became more frequent, reaching as much as 58.2%. Ulcerative lesions (presence of ulcers or ulcer scars in the cancerous lesions) comprised more than 90% of depressed type early gastric cancer, but gradually decreased to 71.9% in the later period. From these findings, early gastric cancer may be said to be changing. Factors contributing to such changes were studied with reference to the progress and multiplication of diagnostic techniques, changes in age composition of the population and changes in environmental factors.

Malignant peripheral nerve tumors: a clinicopathological and electron microscopic study

Sixteen cases of malignant peripheral nerve tumors that were recorded in the files of the Department of Orthopedics, National Cancer Center Hospital, Tokyo, between 1972-July 1983 were studied clinicopathologically. The patients' ages ranged from 24-51 years, and both sexes were affected equally. Histologically, in 13 cases of nerve sheath tumors the tumors were spindle-cell type, two of these patients had manifestation of multiple neurofibromatosis (von Recklinghausen's disease). One malignant epithelioid schwannoma was found to arise from the tibial nerve. Other two cases were of primitive neuroectodermal tumors (primary malignant peripheral neuroblastoma) which showed rosette formation. The common primary symptoms in all patients were a noticeable mass which increased in size over a variable period of time, with or without associated pain and tenderness. Ultrastructural findings of spindle-cell type (in 7 tumors examined) and epithelioid type (1 tumor) showed evidence of Schwann cell differentiation of the tumors in all cases. Immunohistochemically, by the PAP method (Sternberger), staining for S-100 protein was positive in 3 of 14 tumors. Ultrastructural findings in two S-100 protein-positive cases showed evidence of Schwann cell differentiation better than the S-100 protein-negative cases, such as pronounced interdigitation of cytoplasmic processes, presence of fibrous long-spacing collagen and well-developed basal lamina. Local recurrence occurred in nine patients, and metastasis was found in five. The total 5-year survival rate was 58.5%. Tumors associated with multiple neurofibromatosis and primary peripheral neuroblastomas had the worst prognosis. Complete removal of the tumor by means of wide excision as primary treatment seemed to be the most important factor in decreasing the morbidity and mortality rates.

Superficial carcinoma of the esophagus coexisting with esophageal leiomyoma: a case report and review of the Japanese literature

A case of superficial spreading squamous cell carcinoma located just over a leiomyoma is presented. The patient complained of slight dysphagia and an esophagogram showed an elevated tumor in the middle thoracic esophagus. Esophagoscopy revealed an ulcerative mucosal lesion over the elevated lesion and biopsy showed that the lesion was a squamous cell carcinoma. Blunt dissection of the esophagus with esophago-gastro-anastomosis was performed. There was neither lymph vessel invasion nor lymph node metastasis. His post-operative recovery was satisfactory and he is doing well two years after the operation. A review of the Japanese and English literature revealed that a few cases of esophageal carcinoma coexisting with esophageal leiomyoma have been reported. There was no report of superficial esophageal carcinoma coexisting with esophageal leiomyoma. This is the first report of the coexistence of these two lesions, and esophagoscopy is necessary to find a superficial esophageal carcinoma coexisting with esophageal leiomyoma.

A clinical and histopathological study of gastric polyps in familial polyposis coli

Fundic gland area gastric polyps in familial polyposis coli (FPC) were compared with those in non-familial polyposis coli clinicopathologically to elucidate their histogenetic and biological characteristics. Some differences were observed in age, sex, and radiological and endoscopical features. Although the polyps were similar histologically, they showed an apparent histochemical difference between the two groups in periodic borohydride technique/potassium hydroxide/periodic acid-Schiff stain which demonstrates O-acylated sialic acid. The superficial and foveolar epithelium of the polyps was positive in 10 of 12 familial polyposis coli cases, while the epithelium was positive in only one of 13 non-familial polyposis coli cases with the same staining. These results suggest differences between the two groups in the degree of epithelial intestinal metaplasia. The presence of gastric polyps with O-acylated sialic acid therefore indicates the necessity of examination of the colorectum.

[Prognostic factors and surgical method in patients with leiomyosarcoma of the stomach--with special reference to local tumor excision]

Between 1962 and 1982, 48 patients with leiomyosarcoma of the stomach who had undergone resection at the National Cancer Center Hospital were studied to define the prognostic factors clinicopathologically and the criteria of local excision of the tumors. The 5 and 10-year survival rate after resection was 84.3% and 80.5% respectively. Since the extent of surgical resection did not affect survival, gastrectomy is of no greater benefit than local excision. The important prognostic factors were location, size, mitotic index and cellularity of the tumor. Criteria of local tumor excision are defined as tumor location in the anterior wall, small size (much less than 5.0 cm in diameter), low mitotic index (5.0/25 HPF) of low cellularity (0-3/0.0004 mm2).

The intramucosal cysts of the stomach. III. In Japanese subjects with gastric or duodenal ulcers

Gastrectomy specimens from 102 Japanese patients with peptic ulcer disease were examined for intramucosal cysts. The number of cysts for each centimeter of mucosa analyzed (cyst index) was calculated. The intramucosal cysts occurred in 90% of the patients. The mean number of cysts in the 102 specimens was 12.3 (SD +/- 23.45). The resulting cyst index was 3.4 (SD +/- 6.6). Earlier studies have demonstrated a significantly lower cyst index in Swedish patients with peptic ulcer disease. A significantly higher cyst index was found in Japanese and Swedish patients with focal elevated dysplasias and in patients with early gastric cancer. The possibility that some intramucosal cysts of the stomach may be symptomatic of lesions antedating malignant transformation in that organ has been discussed.

A pathologic study of benign breast diseases in Tokyo and New York

Two hundred thirty-two biopsies of benign breast conditions from the National Cancer Center Hospital in Tokyo and 263 comparable biopsies from Memorial Hospital in New York City were reviewed. The component lesions of benign breast disease were identified and evaluated according to their relative frequency for different ages. Apocrine cysts, apocrine hyperplasia, intraductal hyperplasia, sclerosing adenosis, blunt duct hyperplasia, and atypical lobular hyperplasia were at least twice as common in biopsies from American women. Solitary papillomas were twice as common among biopsies from Japanese patients and tended to show more epithelial proliferation and sclerosing papillomatosis than did Americans. No major differences were found in the frequency of cysts, duct stasis, periductal mastitis, sclerosing intraductal papillomatosis, fibroadenomatoid mastopathy or fibroadenomas. Assuming intraductal hyperplasia and atypical lobular hyperplasia may represent premalignant epithelial changes, the high frequency of these lesions in New York biopsies when compared to Tokyo biopsies correlates well with the higher rate of breast cancer in the United States as compared to Japan. The greater frequency of lobular proliferative lesions and apocrine disease in New York suggests that these lesions may be produced by factors which also predispose American women toward breast cancer.

Comparative studies on the histogenesis of squamous carcinoma of esophagus in mice and in human subjects

Histological changes occurring in the esophageal mucosa of 110 C57b1 mice, after protracted topical treatment with diethylnitrosamine, were compared to those present in human esophagus in three patients operated for early esophageal cancer. Both in mice and in human material, the histological changes were classified into slight, moderate or severe dysplasia, carcinoma in situ, questionable invasive carcinoma and invasive carcinoma. Starting from moderate dysplasia, the epithelial-stroma border became irregular with bud formation bulging into the stroma. The findings strongly suggest an association between the degree of cellular atypia, the formation of epithelial buds, and progression towards invasive carcinoma.