OUP accepted manuscript

Coronavirus disease 2019 (COVID-19) was thought to have respiratory symptoms as the main manifestation, but it has become clear that extrapulmonary symptoms such as gastrointestinal disorders also occur. There are several reports of intussusception associated with COVID-19 in children, but these are rare in adults. In this report, we present a case of cystic intestinal duplication that enlarged during the course of COVID-19 treatment and resulted in intussusception. Right hemicolectomy was performed for intussusception due to the cystic lesion. To the best of our knowledge, this is the first resected case of intussusception due to alimentary tract duplication after COVID-19 infection.

Successful Treatment with 5-fluorouracil and Levofolinate Calcium in Advanced Gastric Cancer Patient with Disseminated Intravascular Coagulation

A 32-year-old woman was found to have a gastric adenocarcinoma with multiple bone metastases. Chemotherapy in the first, second and third-line was not effective. Blood examinations showed disseminated intravascular coagulation(DIC)at the end of the second-line chemotherapy. The fourth-line chemotherapy, infusional 5-fluorouracil and levofolinate calcium was performed. This resulted in a good response for DIC. This palliative therapy was effective and safety.

Inflammatory pseudotumor of the spleen: report of a case with emphasis on contrast-enhanced ultrasound findings

Splenic inflammatory pseudotumor is a rare pathology, and the literature stresses the difficulty of preoperative diagnosis. There are no previous reports of contrast-enhanced ultrasound findings for this tumor in the literature. Our case appears to be the first to be examined using this technique. In our case, contrast-enhanced ultrasound showed the mass to be homogeneously and less enhanced than the surrounding parenchyma in all phases, and it included fine enhanced spots. We also briefly review the literature.

Modified administration schedule of docetaxel, cisplatin, and fluorouracil for advanced or recurrent gastric cancer with gastrointestinal stenosis

PURPOSE

To evaluate the safety and efficacy of a modified administration schedule of docetaxel, cisplatin, and fluorouracil (mDCF)in patients with advanced gastric cancer with gastrointestinal stenosis in clinical practice.

METHODS

In the chemotherapy-naïve patients who had metastatic or recurrent histologically confirmed gastric cancer, docetaxel(40mg/m2), levofolinate(200mg/m / / / 2), fluorouracil(400mg/m2)on day 1, fluorouracil 1,000 mg/m2d-2 days intravenous continuous in fusion beginning on day 1, and cisplatin(40mg/m2)on day 3 was administered every 2 weeks.

RESULTS

Six patients received mDCF therapy. In 5 patients with measurable disease, the overall response rate was 86%. Median progression-free survival was 310 days and median overall survival was 599 days. Symptom improvement after the first cycle of mDCF was obtained in all patients. Grade 3 or 4 leukopenia and neutropenia were observed in 2(33%)and 6(100%)patients, respectively. There were no treatment-related deaths.

CONCLUSION

mDCF seems to be active against metastatic and recurrent gastric cancer with gastrointestinal stenosis. Further study is needed to confirm the efficacy and safety of mDCF regimen.

The efficacy of gastrectomy plus chemotherapy for stage IV gastric cancer

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Background: Metastatic gastric adenocarcinoma is an incurable condition. Despite the recently reported benefits of chemotherapies, the prognosis of advanced gastric cancer remains poor. The role of surgical resection is still debatable. Therefore, we investigated the efficacy of gastrectomy plus chemotherapy for stage IV gastric cancer.

Methods: We retrospectively evaluated the efficacy of gastrectomy plus chemotherapy for treating stage IV gastric cancer. Among the 753 patients with gastric cancer treated with gastrectomy at our institute between 2003 and 2010, a total of 70 patients classified into stage IV and underwent gastrectomy with perioperative chemotherapy were included in this study. In the analysis, particular attention was paid to the prognostic factors of age, gender, tissue type, metastatic site, pre or postoperative chemotherapy, single agent or combination chemotherapy and the reason for gastrectomy (palliative surgery due to stenosis, bleeding or perforation and reduction surgery). The survival rate was calculated by the Kaplan Meier method and a statistical analysis was performed using the log-rank test. Survival was calculated from the beginning of the treatment until the last follow-up or death from any cause.

Results: The median age was 65 years old. Peritoneal, lymph node and liver metastasis were 28, 23, and 13 patients respectively. Fifty-three patients had diffuse type. Gastrectomy followed by chemotherapy and chemotherapy were 53 patients. Single agent chemotherapy were 42 and combination were 28 patients. Thirty-one patients were underwent palliative surgery and 39 patients were reduction surgery. One-year survival rate of all patients was 43% and the median survival time was 19.9 months. In the statistical analysis, only reduction surgery plus chemotherapy demonstrated significant survival benefit. The median survival time was significantly greater in patients undergoing reduction gastrectomy group than in those undergoing palliative gastrectomy (25.3 versus 9.8 months; p=0.005).

Conclusions: Long-term survival for patients with stage IV gastric cancer who are managed with reduction surgery and chemotherapy is achievable. Further study with a larger number of patients is warranted.

Significance of integrin αvβ5 and erbB3 in enhanced cell migration and liver metastasis of colon carcinomas stimulated by hepatocyte-derived heregulin

To study the mechanisms of the highly liver-metastatic character of colon carcinoma cells, we studied the expression pattern of surface integrins on LS-LM6 (a highly liver-metastatic human colon cancer cell line) and the effects of hepatocyte-derived soluble factors on cell migration. LS-LM6 showed significantly higher expression of integrin αvβ5, a ligand for vitronectin (VN), as compared with its parental cell line (LS174T). A conditioned medium of cultured mouse hepatocytes enhanced VN-mediated cell migration of LS-LM6, which was blocked by neutralizing antibody against integrin αvβ5, while the medium did not affect cell adhesion to VN-coated plastic surfaces. The conditioned medium induced phosphorylation of erbB3 and its heterodimeric partner, erbB2. Heregulin (HRG), a ligand for erbB3, exerted similar effects on VN-mediated cell migration and phosphorylation of erbB3 and erbB2. The conditioned medium contained HRG, and depletion of HRG from the medium by pre-absorption with HRG antibody abolished its effects on cell migration. Heregulin (HRG) was expressed in some hepatocytes in the liver with carcinoma cell metastasis. Furthermore, knockdown of integrin αv and erbB3 by small-interfering RNAs significantly inhibited cell migration induced by HRG as well as liver metastasis in vivo. Finally, we found that HRG-induced cell migration was associated with marked phosphorylation of Akt and that cell migration was suppressed by treatment with specific inhibitors of phosphatidylinositol 3-kinase. Our study suggests that hepatocyte-derived HRG might participate in a highly liver-metastatic phenotype of LS-LM6 through enhancement of integrin αvβ5-mediated cell migration and erbB3/erbB2 signaling.

Palliative resection for stage IV gastric cancer

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Background: Metastatic gastric adenocarcinoma is an incurable condition and little progress has been made in its treatment. The role of palliative surgical resection is still debatable.

Methods: We retrospectively evaluated the efficacy of palliative gastrectomy for treating incurable gastric cancer. In our institution 51 cases were found to have incurable tumors at laparotomy and received palliative gastrectomy from 2003 through 2009. In the analysis, particular attention was paid to the prognostic factors of age, tissue type (diffuse type and intestinal type), metastatic site (liver, peritoneal and lymph node) and postoperative chemotherapy.

Results: One-year survival rate of all patients was 58% and the median survival time was 23.5 months. The median survival time was significantly greater in patients undergoing chemotherapy group than in those not undergoing chemotherapy (24.0 versus 9.4 months; p=0.016).

Conclusions: Long-term survival for patients with stage IV gastric cancer who are managed with surgical resection and chemotherapy is achievable. Further study with a larger number of patients is warranted.

No significant financial relationships to disclose.

Preoperative evaluation of irreversible bowel ischemia in obturator hernia

BACKGROUND/AIMS

Obturator hernia presenting in elderly women accompanies a high rate of bowel resection because of strangulation. Open laparotomy is usually indicated in general anesthesia. However, minimal invasive approaches would be advantageous unless resection is necessary. We aimed to determine clinical and radiological criteria for the selection of these patients.

METHODOLOGY

Preoperative clinical data from 23 cases and known signs of ischemia on CT examination were retrospectively compared to operative findings.

RESULTS

Identification of patients having necrotic bowel was not possible by any clinical parameter or their combination. Patients with necrosis had longer history of symptoms, but acute onset less than 24 h does not exclude the need of resection (negative predictive value 83%). Impaired contrast enhancement was frequently seen on CTs independently from the onset of symptoms suggesting early vascular compromise (sensitivity 80%, specificity 22%), but not helping the differentiation. Signs of ischemia (bowel wall thickening and/or ascites) were present in every resected case while both were absent in 69% of patients having viable bowel.

CONCLUSIONS

Absence of ischemic signs on nonenhanced CT may allow safe and more accurate selection of patients for minimal invasive surgery than any clinical or anamnestic parameter in obturator hernia.

Malignant fibrous histiocytoma of the spleen: report of a case and literature review

There is a marked paucity of reports on malignant fibrous histiocytoma (MFH) of the spleen in the literature, and there are no previous reports of its color Doppler sonographic (US) and contrast-enhanced US findings. We report on an 82-year-old male with splenic MFH (inflammatory subtype), with an emphasis on color Doppler and contrast-enhanced US findings.

Gallbladder adenoma: report of a case with emphasis on contrast-enhanced US findings

There is a marked paucity of contrast-enhanced ultrasound (US) findings of gallbladder disease in the literature, and there is only one previous case of gallbladder adenoma. We report such a case. US showed a 2-cm polypoid lesion at the gallbladder body. Color Doppler US showed the hypervascular nature of the lesion, and contrast-enhanced US revealed the lesion to be homogeneously enhanced, suggesting that the lesion was composed of the same pathology. The lesion was surgically resected, and was found to be an adenoma without cancer foci. This case suggests that contrast-enhanced US is an effective tool in diagnosing a gallbladder adenoma.

Duodenal adenoma with production of massive mucus: report of a case with emphasis on US findings

Duodenal adenoma with massive mucus production is very rare. We report such a case. Ultrasonography (US) showed the presence of massive mucus, and contrast- enhanced US revealed the thickened wall to be homogeneously enhanced, suggesting that the lesion was composed of the same pathology. The US results were confirmed histologically by endoscopically guided biopsy. Thus, contrast-enhanced US helps determine the biopsy point and determine good diagnostic strategies.

[A case of peritoneal dissemination of postoperative primary duodenal cancer successfully treated by TS-1 therapy]

A 62-year-old man reported to our hospital with serious complaints of abdominal pain, vomiting, and weight loss. An endoscopic examination detected a type 2 tumor of the descending limb of the duodenum. With a diagnosis of adenocarcinoma based on the biopsy finding, the patient was subjected to surgery. Laparotomy revealed the presence of a duodenal tumor disseminating to the omentum at the site where the transverse colon is attached. Pancreatoduodenectomy and partial resection of the transverse colon were carried out. CT conducted 6 months after surgery did not show any signs of tumor recurrence; but one year later, extensive tumor dissemination was noted on the hepatic surface. Upon consultation with the patient, a regimen of 80 mg/day of TS-1 given for 4 weeks followed by 2 weeks of a drug-free period was initiated. Six months later, the growth of tumor became arrested, improving his QOL. Nine months later, the tumor growth was progressive and the patient died two years after operation. The patient could gain long-term survival after operation. The TS-1 regimen applied in the present case may constitute a therapeutic strategy to be considered for similar conditions in future.

[A case of effective weekly paclitaxel administration for gastric cancer recurrence with carcinomatous pericarditis]

We reported a case of effective weekly paclitaxel administration for gastric cancer recurrence with carcinomatous pericarditis. A 69-year-old man underwent distal gastrectomy for gastric cancer in December 2001. However, he was re-admitted to the hospital for dyspnea in November 2002. A diagnosis of cardiac tamponade caused by gastric cancer relapse was made, and the patient was treated by weekly paclitaxel administration (90 mg/body) after drainage. It was effective in preventing reaccumulation of the pericardial effusion until his death 73 days after the diagnosis. It is thought that weekly paclitaxel administration can be a treatment for carcinomatous pericarditis.

Treatment of Multiple Organ Failure through Sepsis by Surgery and Blood Purification

For the treatment of multiple organ failure (MOF) through sepsis, we have commonly applied various blood purification modalities during the perioperative period. From January 1996 to December 2000, 33 patients with MOF through sepsis were admitted and operated on in the First Department of Surgery, Akita University School of Medicine, and 21 of these 33 patients were treated using various blood purification modalities during the perioperative period: endotoxin-adsorbing therapy using polymyxin B (PMX) in 17 patients, continuous hemofiltration (CHF)/continuous hemodiafiltration (CHDF) in 15 patients, and plasma exchange (PE) and CHDF in 3 patients. Of the outcome of these 33 patients with MOF through sepsis, 17 survived and 16 died (48% mortality). Of the 21 patients with MOF through sepsis treated by surgery and blood purification, 12 survived and 9 died (43% mortality). We evaluated APACHE II and the number of failed organs before operation. Amongst the group with 12 survivors and 9 deaths, Acute Physiology and Chronic Health Evaluation II (APACHE II) was 15 +/- 5, 23 +/- 2 and the number of failed organs was 2.7 +/- 0.7, 3.9 +/- 0.8, respectively. An increased APACHE II score and number of failed organs were significantly associated with mortality. As to the treatment of MOF through sepsis due to acute peritonitis, patients with APACHE II scores ranging from 15 to 20, and those with 2-3 failed organs seem to be the candidates for the application of blood purification during the perioperative period.

Three cases of small hepatocellular carcinoma presenting as obstructive jaundice

BACKGROUND

Despite improved diagnostic tools, it is often difficult to make a correct diagnosis of small hepatocellular carcinoma (HCC) in patients with obstructive jaundice.

CASE OUTLINES

Three cases of small HCC (<2 cm diameter) presenting as obstructive jaundice are reported. All tumours were initially diagnosed as hilar cholangiocarcinoma based on ultrasonography, computed tomography, cholangiography and angiography. Because of insufficient hepatic function, none of the patients underwent hepatic resection. One patient died 8 months after first admission to our hospital, another died of disseminated intravascular coagulation I month after admission, and the third was treated with hepatic arterial infusion chemotherapy and survived >36 months.

CONCLUSION

It is important to consider HCC in the diagnosis of obstructive jaundice in patients who are predisposed to HCC because of liver cirrhosis and/or chronic viral hepatitis, and have elevated serum alpha-fetoprotein.

Outcomes and indications of segmental pancreatectomy. Comparison with distal pancreatectomy

BACKGROUND/AIM

To preserve pancreatic function, segmental pancreatectomy has been proposed for benign or low-malignancy tumors in the pancreatic body. Indications for the procedure, however, are still controversial.

METHODS

In this study, we investigated the advantages and disadvantages of segmental pancreatectomy compared with distal pancreatectomy and subsequently determined indications for segmental pancreatectomy.

RESULTS

The distal pancreatectomy patients had shorter operation times, lower incidence of operative complications, and shorter hospital stays compared to segmental pancreatectomy patients. Endocrine function in distal pancreatectomy patients deteriorated compared to that of segmental pancreatectomy patients. The postoperative 75-gram oral glucose tolerance test showed a diabetic pattern in 3 of 7 distal pancreatectomy patients, whereas none of the segmental pancreatectomy patients became diabetic after surgery. The relation between the length of the removed pancreas and plasma glucose at 2 h after the 75-gram glucose intake showed a significant correlation.

CONCLUSION

According to our results, if the length of removed pancreas is longer than 12 cm, the patients will have a risk of acquiring diabetes. In those cases, the segmental pancreatectomy should be considered.

Acute emphysematous cholecystitis preceded by symptoms of ileus: report of a case

We herein describe a case of acute emphysematous cholecystitis in which the patient presented with symptoms of ileus. The patient was a 72-year-old man with no history of diabetes mellitus. He presented with epigastric pain, vomiting, and low-grade fever. Plain abdominal radiography showed some intestinal gas and niveau, and he was admitted to our hospital with a diagnosis of ileus. The next day, the abdominal pain increased and was accompanied by muscular defense. Plain radiography and computed tomography of the abdomen were carried out, and an emergency laparotomy was performed under a diagnosis of panperitonitis due to a perforation of the gallbladder caused by acute emphysematous cholecystitis. The patient made favorable progress after the operation and was discharged on postoperative day 14. Percutaneous transhepatic gallbladder drainage has been increasingly performed for the treatment of acute emphysematous cholecystitis. but when a perforation of the gallbladder is suspected, a laparotomy first should be considered.

Colon cancer in rectal bladder

A large number of patients have been reported with colon cancers following ureterosigmoidostomy, created after total cystectomy. However, there have been few reports of cancer in rectal bladder created instead of ureterosigmoidostomy to reduce the risk of cancer development. We report a case of colon cancer that developed in the rectal bladder 6 years after the operation. A 77-year-old man presented with blood in stools. Colonoscopy revealed a cancer adjacent to the urine inlet to the colonic lumen in rectal bladder. At laparotomy. the cancer was recognized in the rectal bladder. with invasion to the pubic bone. A palliative resection of the rectal bladder, and creation of sigmoid colostomy and ileal conduit were performed. Histologic examination confirmed moderately differentiated adenocarcinoma, which was considered to have originated from the colonic mucosa in the rectal bladder. Colonic mucosa has an increased risk of cancer development after continuous exposure to urine. It is important for gastroenterologists to perform surveillance colonoscopy in patients with urinary diversion into the colon.

Small bowel perforation caused by metastasis from an extra-abdominal malignancy: report of three cases

Small bowel perforation is rarely caused by metastasis from an extra-abdominal malignancy. This report describes three cases of small bowel perforation that occurred secondary to a metastatic tumor. The first case involved a 72-year-old man with malignant lymphoma of the larynx that had been treated with chemo- and radiation therapy; the second involved a 70-year-old man with rhabdomyosarcoma of the mediastinum that had been treated with radiation therapy; and the third involved a 41-year-old man with lung carcinoma that had been treated with surgery 10 months prior to perforation. Each patient presented with acute abdominal pain, had X-ray findings of free air in the abdomen, and underwent limited emergency surgery. Wedge resection and closure of the ileum was performed for the first patient and partial bowel resection with the creation of an intestinal stoma was performed for the second and third patients. In each case, the histologic findings of the resected specimens were consistent with the extra-abdominal primary tumors. Although the patients recovered sufficiently to begin eating and moving about, all three died of cancer or cancer-related complications within 45 days of surgery. We conclude that surgeons should be aware of the poor prognosis of such patients and perform only the minimal surgery required.

Adenocarcinoma at the site of ileoanal anastomosis in Crohn's disease: report of a case

PURPOSE

Proctocolectomy with ileoanal anastomosis has gained acceptance for the treatment of patients with ulcerative colitis. However, there are some patients with Crohn's disease who received ileoanal anastomosis, because some Crohn's colitis is difficult to differentiate from ulcerative colitis. The risk of cancer development at the site of ileoanal anastomosis has not been emphasized in Crohn's disease.

METHODS

A 12-year-old patient with Crohn's disease was treated by proctocolectomy with straight ileoanal anastomosis. Twenty-five years after the operation, the patient noticed the tumor that developed at the site of ileoanal anastomosis.

RESULTS

This article presents a patient with Crohn's disease who developed invasive adenocarcinoma at the site of ileoanal anastomosis 25 years after proctocolectomy with ileoanal anastomosis.

CONCLUSIONS

An ileoanal anastomosis does not eliminate the risk of cancer development, and surveillance after this operation seems advisable.

Long-standing painless intussusception in adults

Long-standing painless intussusception in adults is considered to be rare. We report three such cases with an emphasis on color Doppler results. In our three cases the indication for abdominal US was a palpable mass in all these cases, and intussusception was detected by US at a time when the patients had only very mild abdominal discomfort. Persistence of sufficient blood flow, as was suggested by the color Doppler results, was thought to be the most likely pathomechanism of long-standing painless intussusception. The underlying disease was tuberculosis in two of the three cases. Thus, when encountering patients with painless intussusception, tuberculosis must be kept in mind.

[Improvement of the efficiency of the treatment of gastric cancer by the standardization of the treatment plan]

Standardized treatment plan for gastric cancer was established in our department by which surgeons and nurses understood the treatment schedules of each gastric cancer patient as the common knowledge, and the cooperation of surgeons and nurses could be improved. Furthermore, the modality decreased the length of hospital stay from 35 +/- 15 days to 24 +/- 8 days, which indicated that the number of patients per one bed for one year increased from 10 to 15, and the efficiency of the treatment of gastric cancer patients 50% by our system.

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.