Hepatocellular carcinoma arising in the abdominal cavity. An autopsy case of ectopic liver origin

An unusual case of extrahepatic disseminating hepatocellular carcinoma in a 64-year-old man is reported. The initial symptom was abdominal fullness and progressive ascites. Alpha-fetoprotein in the serum was 117,000 ng/ml. Exploratory laparotomy disclosed dissemination of tumor nodules throughout the abdominal cavity without any other possible primary tumor. CT scan, ultrasonography and hepatic angiography were unable to detect any tumor lesion in the liver. The final histologic diagnosis was hepatocellular carcinoma, although at first epithelioid mesothelioma was suspected. The present case of hepatocellular carcinoma was thought to have possibly developed from ectopic liver on the peritoneum.

Endocrine differentiation of gastric adenocarcinoma. The prevalence as evaluated by immunoreactive chromogranin A and its biologic significance

The prevalence of endocrine differentiation of conventional gastric adenocarcinoma was evaluated on the 212 cases (including 62 mucosal carcinomas) of consecutively resected stomach for adenocarcinoma in our hospital using anti-chromogranin A (CGA) antibodies. CGA-positive cells were found in 28 of 150 cases (18.7%) as an integral tumor component. In immunocytochemistry and electron microscopic examinations, we could classify these 28 cases into three groups according to the distribution patterns of CGA-positive cells. The first group consisted of 12 cases in which scattered CGA-positive cells were located in neoplastic glands. The second group consisted of six cases of scirrhous carcinoma in which CGA-positive cells were separated by fibrovascular tissue. The third group consisted of ten cases in which the positive cells were present in clusters. No definite correlation was recognized between the appearance of CGA cells and histologic types of predominance. In the analysis of the hormonal substances coexpressed by CGA-positive cells, immunoreactive serotonin (SER) was found most frequently, and somatostatin (SS), gastrin (GAS), glucagon/glicentin (GLU/GLI), and peptide-tyrosine-tyrosine (PYY) like immunoreactivities were found in a few tumor cells. CGA-positive cells occupied limited parts of the tumors in most cases, and they were noticeably more frequent in advanced stage cases. This might explain why endocrine differentiation reflects the dysexpression of the neoplastic stem cells. Furthermore, absence of mitotic figures in this type of cell and negativity of a single colony composed exclusively of CGA cells in metastatic foci suggested that these cells are in a dormant phase and are probably postmitotic.

Endocrine differentiation of gastric adenocarcinoma. The prevalence as evaluated by immunoreactive chromogranin A and its biologic significance

The prevalence of endocrine differentiation of conventional gastric adenocarcinoma was evaluated on the 212 cases (including 62 mucosal carcinomas) of consecutively resected stomach for adenocarcinoma in our hospital using anti-chromogranin A (CGA) antibodies. CGA-positive cells were found in 28 of 150 cases (18.7%) as an integral tumor component. In immunocytochemistry and electron microscopic examinations, we could classify these 28 cases into three groups according to the distribution patterns of CGA-positive cells. The first group consisted of 12 cases in which scattered CGA-positive cells were located in neoplastic glands. The second group consisted of six cases of scirrhous carcinoma in which CGA-positive cells were separated by fibrovascular tissue. The third group consisted of ten cases in which the positive cells were present in clusters. No definite correlation was recognized between the appearance of CGA cells and histologic types of predominance. In the analysis of the hormonal substances coexpressed by CGA-positive cells, immunoreactive serotonin (SER) was found most frequently, and somatostatin (SS), gastrin (GAS), glucagon/glicentin (GLU/GLI), and peptide-tyrosine-tyrosine (PYY) like immunoreactivities were found in a few tumor cells. CGA-positive cells occupied limited parts of the tumors in most cases, and they were noticeably more frequent in advanced stage cases. This might explain why endocrine differentiation reflects the dysexpression of the neoplastic stem cells. Furthermore, absence of mitotic figures in this type of cell and negativity of a single colony composed exclusively of CGA cells in metastatic foci suggested that these cells are in a dormant phase and are probably postmitotic.

Desmoplastic reaction of gastric carcinoma: a light- and electron-microscopic immunohistochemical analysis using collagen type-specific antibodies

The desmoplastic reaction in ten cases of gastric carcinoma was investigated light and electron immunohistochemically by using monospecific antibodies to collagen types. In addition to type I and III collagens, type V collagen was constantly recognized in the fibrous stroma, increasingly of the scirrhous carcinoma. Type IV collagen delineated the basement membranes of carcinoma nests linearly with occasional discontinuity, whereas in the scirrhous carcinoma, it was present along the thick bundles of collagenous fibers. Immunoelectron microscopic studies revealed that type I and III collagens were distributed on the collagen fibers, and type V collagen was stained in the margin of these fibers. These antibodies also reacted in the rough endoplasmic reticulum of fibroblasts or myofibroblasts in a few cases. Type IV collagen was localized in the periphery of smooth muscle cells, endothelial cells of collapsed capillaries, and myofibroblasts scattered in the stroma of scirrhous carcinoma. Carcinoma cells were not reactive with any antibodies examined. These findings suggest that type V collagen, as well as type I and III collagens, is involved in the formation of desmoplastic stroma, and that these collagens are reactively synthesized by fibroblasts and myofibroblasts in some interaction with invading carcinoma cells.

[Effect of a conjugate of adriamycin and an antibody to human alpha-fetoprotein (AFP) on AFP-producing hepatic tumors]

We have studied the effect of an anti-FP antibody coupled via a dextran bridge to adriamycin on six AFP-producing liver tumors (3 cases with hepatoma and 3 cases with liver metastases from an AFP-producing gastric cancer). Results have revealed that MR was observed in 2 out the 5 of surviving evaluated cases. The toxicity of this conjugate was not evident in all cases, except for a low-grade fever. Further, an autopsy revealed no remarkable change in the histology of the case that had ended in death. These results indicate that this conjugate can be considered one of the treatment therapies available for a nonresectable AFP-producing tumor.

[The correlation between the reduction rate of tumor and the survival time of patients as an effect of chemotherapy]

The correlation between reduction rate of tumor by anti-cancer chemotherapy and survival time of patients was studied in 17 cases with liver metastases from 12 stomach cancers and 5 colonic cancers. The survival time ranged from 4 to 15 months (mean 8.4 +/- 4.3 months) in 5 cases with CR or PR, from 6 to 15 months (mean 9.8 +/- 4.1 months) in 4 cases with NC, from 2 to 12 months (mean 8.0 +/- 3.7 months) in 8 cases with PD. There was no correlation between reduction rate of tumor and survival time of patients. The tumor marker doubling times, both before and after chemotherapy, were studied in 5 cases. The difference of doubling time between before and after chemotherapy was not significant. These results suggest that individual doubling time plays an important role in survival time as an effect of chemotherapy.

Vestibulo-ocular (VOR) abnormalities at high rotational frequencies in patients with Menière's disease

Although visual feedback is required to maintain gaze stability during low-frequency rotations (below 1 Hz) because of suboptimal VOR gain in this frequency range, such behavior is not as evident at higher frequencies. Benson and Hydén et al. noted a steady increase in VOR gain in the higher-frequency range (2 to 5 Hz), where visual feedback has little effect. Similar behavior has also been reported in the monkey models. Eleven patients with diagnoses of Meniere's disease had tests of VOR and VOR cancellations performed with the use of pseudorandom oscillations as high as 5 Hz. The responses at various frequencies were compared with normal data from 17 subjects. The VOR gain in patients exhibited a more rapid rise at high frequencies than that observed in normal subjects. For example, at 3.5 Hz the normal gain was 1.09, whereas patients exhibited a gain of 1.35 (mean of 11 subjects). When the performance during VOR cancellation tasks was compared, Meniere's patients appeared to be less able to perform these tasks; however, when the values were compared by use of a cancellation index that compensates for any difference in VOR gain, this apparent difference disappeared.

[Regional intra-arterial infusion in combination chemotherapy with IFN-beta, MMC and 5-FU (beta-MF chemotherapy) in liver tumors]

The effect of combination chemotherapy with Interferon-beta, Mitomycin C and 5-fluorouracil (beta-MF chemotherapy) on 7 hepatic tumors by intra-arterial administration was studied. Complete remission (CR) was observed in one patient and partial remission (PR) in two patients, the efficacy rate being 42.9%. The survival period was more than one year in 6 patients. Fever was observed in 6 cases, although it was slight in all cases and preventable by pre-treatment with antipyretics. The authors consider that beta-MF chemotherapy can be expected to be one form of treatment for nonresectable gastrointestinal carcinoma.

[Clinicopathological study of AFP producing gastric cancer--significance of AFP in gastric cancer]

We experienced fifteen cases (3.9%) out of 387 with gastric cancer showing elevation of alphafetoprotein (AFP) in serum. In these cases AFP producing cells in primary lesion demonstrated positive for anti-AFP by means of immunohistochemical study. In this report, clinicopathological feature and clinical significance as a tumor marker of gastric cancer were discussed. Gross type showed Borrmann II and III which were located in atrophic area in the stomach. Histological type revealed papillary, moderately differentiated and poorly differentiated adenocarcinoma, all of which showed medullary growth in stroma. In clinical field, liver metastasis was observed in 12(80%) of 15 cases. In these cases, elevation of serum AFP was already observed before the detection of liver metastases by CT or Echo. Immunohistochemical study showed no difference between primary tumor and metastases, and no AFP positive cells were seen in 68 early gastric cancers without elevation of serum AFP.

Muscarine receptors on the rat phrenic nerve, evidence for positive and negative muscarinic feedback mechanisms

Neuronal transmitter stores of the rat phrenic nerve were labelled by incubation with [3H]choline. Release of [3H]acetylcholine was elicited by electrical nerve stimulation (100 or 1,500 pulses, 5 or 25 Hz) or by high potassium (27 mmol/l) and the effects of the muscarine receptor agonist oxotremorine and the antagonist scopolamine were investigated. Neither oxotremorine nor scopolamine affected the basal tritium efflux. A low concentration of oxotremorine (10 nmol/l) enhanced and a high concentration of oxotremorine (1 mumol/l) reduced the electrically evoked [3H]acetylcholine release. Likewise, the high potassium-evoked [3H]acetylcholine release was reduced by a high concentration of oxotremorine. Both effects of oxotremorine, increase and decrease, were abolished by a pretreatment (30 min before the first stimulation period) with 0.1 mumol/l scopolamine. Scopolamine (0.1 mumol/l) alone, enhanced [3H]acetylcholine release evoked by 100 pulses (5 Hz) or by high potassium. Scopolamine, however, reduced [3H]acetylcholine release evoked by 1,500 pulses (5 Hz or 25 Hz). The concentration-response curves obtained for scopolamine under these latter stimulation conditions were flat-running and biphasic which might indicate the involvement of two opposite effects (increase and decrease) of scopolamine under the present stimulation conditions. Both effects of scopolamine were reduced in the presence of 10 mumol/l neostigmine.(ABSTRACT TRUNCATED AT 250 WORDS)

[Determination of serum DU-PAN-2 by enzyme immunoassay in patients with various digestive cancers]

In order to evaluate the usefulness of serum DU-PAN-2, we determined this antigen in 384 patients with various malignancies and in 215 patients with benign diseases using a sandwich enzyme immunoassay system (Kyowa Medex Co.). Elevated DU-PAN-2 levels (greater than 400 U/ml) were observed in 55% of hepatocellular cancers, 50% of pancreatic cancers, and 43% of biliary tract cancers. On the other hand, most false-positive cases with benign diseases were observed in patients with liver injury, especially in the acute phase of acute hepatitis, chronic active hepatitis, and liver cirrhosis. However, in only a few cases with other benign diseases including pancreatitis, increased levels were found. Moreover, among the pancreatic cancer or biliary tract cancer patients studied, DU-PAN-2 was positive in 7 of the 19 CA 19-9-negative (less than 37 U/ml) patients and 32 of the 68 CEA-negative (less than 5 ng/ml) patients. These results indicate that the assay of DU-PAN-2 by EIA may have diagnostic usefulness in digestive cancer, especially pancreatic cancer or biliary tract cancer.

[Evaluation of CA 15-3 radioimmunoassay]

The CA 15-3 RIA kit (Centocor Co.) based on a solid-phase radioimmunoassay was evaluated both experimentally and clinically. The results of a basic study of the reproducibility, recovery and dilution were very satisfactory. Serum levels of CA 15-3 were determined in 211 patients with malignancies including 13 breast cancers, 81 patients with benign diseases and 13 controls. Elevated levels of this antigen (greater than 25 U/ml) were observed in 16.7% of esophageal cancers, 9.7% of gastric cancers, 7.9% of colon cancers, 10% of hepatocellular cancers, 10% of biliary tract cancers, 10% of pancreatic cancers, 33% of lung cancers, and 75% of recurrent breast cancers. Thus, in malignant diseases the positivity was low except for recurrent breast cancer. On the other hand, the false-positive rate in benign diseases was only 3.7% and the false-positive cases had a level of 40 U/ml or less. These results indicate that the serum levels of CA 15-3 may have diagnostic value in patients with recurrent breast cancer.

Study of pursuit and vestibulo-ocular cancellation

This present study, a follow-up of our earlier investigation, further examines the time courses of recovery of oculomotor and vestibular function while patients are under the sedative effect of a single dose of secobarbital (Seconal). The assessment included tests for saccade and smooth pursuit, and the vestibulo-ocular reflex and its cancellation, as evaluated by sinusoidal and pseudorandom rotation in a high-frequency hydraulic chair (up to 5 Hz). Analysis of results showed that the vestibulo-ocular reflex (VOR) gain, depressed soon after drug intake, recovered substantially after a few hours. Changes in VOR gain were more pronounced with higher frequencies of rotation at 2 and 3 Hz, and greater with pseudorandom than sinusoidal stimulation. Under barbiturate influence, pursuit and VOR cancellation followed distinctly different time courses of recovery. This dissociation between VOR cancellation and pursuit supports the theory that these two systems are subserved by different mechanisms. Saccadic hypermetria was also observed after drug intake.

[Study of CEA doubling time in liver metastasis from colonic cancer and postoperative survival time]

We calculate the CEA doubling time of liver metastasis (13 cases) from colonic cancer and studied the factors influencing the growth rate. The doubling time of liver metastasis from colonic cancer ranged from 10 to 112 days (mean 57.8 +/- 35.4 days) was found significantly different among differentiations in histological type. Namely, the doubling time of poorly differentiated adenocarcinoma was shorter than that of well differentiated adenocarcinoma. Moreover the postoperative survival time (Y: months) was found to be significantly correlated with doubling time (X: days); Y = 0.155X + 4.452, r = 0.718, p less than 0.05. These results suggest that the growth rate calculated as CEA doubling time of cancer plays an important role in determining the degree of biological behavior in colonic cancer patients.

[CA 19-9 enzyme immunoassay]

The carbohydrate antigenic determinant (CA 19-9) EIA kit (FUJIREVIO INC) was examined both experimentally and clinically. In the basic study, the standard curve showed linearity from to 240 U/ml, and the intra-and interassay reproducibility was good. Serum levels of CA 19-9 were determined by EIA in 246 cancer patients and 180 patients with benign diseases, and CA 19-9 levels by EIA were compared with those by RIA in concurrent measurement. There was an excellent correlation between the two. The positive of CA 19-9 EIA was almost the same as that of CA 19-9 RIA in cancer patients. False-positive cases by CA 19-9 EIA were somewhat more numerous than those by CA 19-9 RIA in patients with benign diseases, especially liver diseases. However, CA 19-9 assay by EIA is simple and has an excellent reproducibility and accuracy, as does that by RIA. Thus, the CA 19-9 EIA is a very useful assay.

[Combination of missile-induced hypertensive intra-aortic infusion chemotherapy in a patient with hepatocellular carcinoma]

A case of hepatocellular carcinoma was treated with anti-alpha-fetoprotein (AFP) antibody-adriamycin via the hepatic artery with induced hypertension by angiotensin II. A minor response was achieved (from 13.5 X 9.0 cm to 10.5 X 7.5 cm) and serum AFP decreased from 310,000 ng/ml to 26,000 ng/ml. The patient has been doing well during a follow-up period of one year. This result suggests that targeting chemotherapy used for each drug delivery system would be more effective if combined with two or more similar modalities.

[Clinicopathological study of minute stomach cancer]

During the last 10 years, we have experienced 41 cases of minute cancer, which is equivalent to 13.9% of all resected early stomach cancers. Out of 44 lesions in 41 cases, 17 lesions were diagnosed preoperatively, while 27 were unexpectedly detected by serial sections of the resected stomach. Most lesions were located along the lesser curvature of the body and antrum. There was no nodal involvement or vessel permeation. Histologically differentiated adenocarcinomas were encountered in 86.4%, associated with intensive intestinal mucosa in many cases. We have stressed that dye endoscopy using indigo carmine and methylene blue is very useful for the diagnosis of minute cancer.

[Chronology of recurrent gastric cancer]

The growth rate of 49 cases with recurrent gastric cancer was investigated with two tumor markers (AFP & CEA). The average doubling time of liver metastases (24.7 +/- 11.9 days) in 18 cases was significantly shorter from that of lymph node metastases (41.1 +/- 22.4 days) in 13 cases and of peritonitis carcinomatosa (42.2 +/- 19.6 days) in 18 cases. Latent period of recurrent cancer calculated by these doubling times was ranged from 1.0 to 3.5 years (mean 1.7 years) in liver metastases, from 1.0 to 5.0 years (mean 2.7 years) in lymph nodes metastases and from 1.5 to 6.0 years (mean 2.7 years) in peritonitis carcinomatosa. Only in liver metastases, positive correlation between the doubling time (X) and the duration of survival (Y) was observed by expressing the formula Y = 0.45 X-0.58 (R = 0.661, p less than 0.05). It is noteworthy that there is a significant correlation in spite of large differences in background subjects (systemic condition, size of metastatic lesion, etc.) and the growth rate of tumor is considered to play a very important role for determining the degree of biological malignancy of individual cancer patients in relation to survival.

[The metastatic patterns of gastric cancer from its histopathological characteristics in the primary lesion--particularly in relation to peritoneal dissemination and liver metastases]

The purpose of this study was to catagorize the metastatic patterns of advanced gastric cancer into liver and peritoneal metastases from the stromal behavior of the primary lesion in 278 patients. According to our data, peritoneal disseminations were encountered 5.0% of the medullary type, 30.0% of the intermediate type and 38.0% of the scirrhous type, while the corresponding figures for liver metastases were 28.8%, 6.0% and 1.9%, respectively. The differences among the three types were significant with both patterns of metastasis. From the present data, we assume that the histological pattern in the stroma of primary gastric cancer shows the biological behavior of cancer growth and metastatic patterns, particularly in close relation to peritoneal dissemination and liver metastases.

[Evaluation of the measurement of serum carcinoembryonic antigen (CEA) levels using monoclonal antibody]

We measured serum carcinoembryonic antigen (CEA) levels in 164 cancer patients, 153 patients with benign diseases and 45 healthy controls using monoclonal antibody and compared CEA levels by monoclonal antibody (m-CEA) with those by polyclonal antibody (p-CEA). There was a good correlation between m-CEA and p-CEA, especially in cancer patients. The positively of m-CEA was almost the same as that of p-CEA in cancer patients. But, false-positive cases by m-CEA were less common than by p-CEA in non-cancerous patients. Thus, the measurement of m-CEA was not less useful than that of p-CEA.

Bilateral vestibular loss, oscillopsia, and the cervico-ocular reflex

Oscillopsia during head movement occurs in patients with bilateral vestibular loss and may be transient or persistent. To investigate mechanisms underlying recovery we tested the vestibulo-ocular reflex (VOR), visual-vestibular interaction, and the cervico-ocular reflex (COR); we used a pseudorandom oscillatory stimulus with a frequency band width of 0 to 5 Hz in six patients with bilaterally absent caloric responses and in 10 normal controls. Seven control subjects had low-gain COR responses, but these were anticompensatory with respect to the VOR. Three asymptomatic patients with an absent or grossly deficient VOR had increased oculomotor responses at all frequencies when oscillated in light. Compensatory COR responses were detected in these patients but not in patients with persisting oscillopsia. In some patients with bilateral vestibular loss, augmented cervico-ocular and visual reflexes may compensate, at least partially, for an absent VOR.

Multiple mucosal bridge formations in the stomach, report of a case

An unusual gastric lesion comprising multiple bridges in a 62-year-old woman is presented. Radiographic and endoscopic examination revealed several mucosal bridges and mucosal tags. The resected stomach showed eight mucosal bridges and five mucosal tags along the course of the mucosal folds in the fundic gland area, the former measuring 3 cm in diameter. This paper concludes with short discussion of the etiology of these proliferative gastric lesions from a clinicopathological standpoint.

[AFP producing stomach cancer--a study of transplanted tumor in nude mice]

AFP producing cancer of the stomach was divided into 2 groups; Group A demonstrated a marked elevation of serum AFP levels before gastrectomy and was positive for AFP by PAP staining; group B showed delayed elevation of AFP levels at recurrence or in the terminal stage. Experimentally, we could establish three cell lines from group A and two lines from group B from transplanted tumor in nude mice. Tumor growth, changes of serum AFP levels and PAP staining investigated in each group. Group A and B were not only thought to exhibit different biological behavior, but also different mechanisms in AFP production. Group A cells may have the ability to secrete high levels of AFP; this may be a property of these tumor cells. On the other hand, group B tumor cells initially have little ability to secrete AFP. However, they may transform into AFP producing cells as a phenomenon of cell differentiation.

[The effect of anti-human AFP serum for AFP producing stomach cancer xenotransplanted nude mice]

The effect of anti-human alpha-fetoprotein (AFP) on growth, serum AFP levels and histological changes of two lines of AFP producing stomach cancer serially xenotransplanted in nude mice were examined. The efficacy of anti-human AFP antibody on tumor growth was observed specifically for the tumor producing AFP, but there was great difference on growth between two lines. The AFP levels of the serum disclosed a rapid decrease after administration of antibody and maintained as level of Ong/ml for a long period. On histopathologic examination, there were not observed any changes on the tumor cells and structure and necrotic change was not demonstrated. By the immunohistochemical examination (PAP method), anti-human AFP antibody was identified in tumor even 50 th days later after injection.

Vestibular compensation and nystagmus

In healthy young subjects barbiturate induced vestibular nystagmus was sequentially studied with repeated electronystagmographic recordings. The analysed data together with our earlier studies indicated that, except for vertical nystagmus, spontaneous and different types of positional nystagmus by themselves are not diagnostic of site of lesion. The transition from spontaneous to positional to paroxysmal nystagmus observed in follow up studies of several of these cases indicates that these various types of vestibular nystagmus are likely a measure and reflection of different degrees of vestibular decompensation.

Gastric plasmacytoma: an immunologic and immunohistochemical study

A case of IgG (lambda) secreting plasmacytoma arising in the stomach has been presented. Immunohistochemically, the tumor cells contained IgG-lambda immunoglobulin. Immunoelectrophoretic study on patient's serum revealed in the gamma zone the presence of M protein which reacted specifically with anti-IgG and anti-lambda antisera. Agar electrophoresis and immunofixation electrophoresis with anti-IgG and anti-lambda antisera showed multiple subbands. Neuraminidase treatment of the purified IgG from this patient resulted in gradual reduction of four subbands to two. Electrophoretic charge difference of the monoclonal immunoglobulin may be attributed to incompletely synthesized sugar chains attached to the protein core.

Lymphangioma of the transverse colon treated by transendoscopic polypectomy: report of a case and review of literature

This report concerns a 73-year-old man complaining of intermittent, dull, umbilical pain on one month's duration. Barium-enema examination and endoscopy revealed a hemispheric cystic tumor at the midportion of the transverse colon, and the presumptive diagnosis was cystic submucosal tumor of the colon. Transendoscopic polypectomy was performed and the bulk of the lesion was locally excised from the colonic mucosa. Histologic examination revealed cavernous lymphangioma originating from the submucosa.