Differences in the diagnostic criteria used by Japanese and Western pathologists to diagnose colorectal carcinoma

BACKGROUND

In view of the many studies of early stage colorectal carcinoma from Japan, it is essential to know whether the criteria for the histologic diagnosis of colorectal carcinoma are similar in Japan and Western countries.

METHODS

Eight expert pathologists from Japan (4), North America (2), and Europe (2) individually reviewed microscope slides of 20 colorectal lesions from Japanese patients who had undergone endoscopic mucosal resection or surgery because early stage carcinoma and/or adenoma was suspected. The pathologists indicated the pathologic findings on which they based each diagnosis.

RESULTS

For 11 slides that showed adenoma according to the Western pathologists with low grade dysplasia according to at least half of them, the Japanese diagnosed definite carcinoma with or without adenoma in 4 cases and adenoma in 5, and in 2 cases they were equally divided between a diagnosis of adenoma and carcinoma. For five slides showing adenoma with high grade dysplasia according to the Western pathologists, the Japanese diagnosed definite carcinoma with adenoma in three cases and adenoma in one, and in one case they were equally divided between a diagnosis of adenoma and carcinoma. For one case in which the Western pathologists were equally divided between a diagnosis of carcinoma and adenoma with high grade dysplasia, all the Japanese pathologists diagnosed definite carcinoma with or without adenoma. Three slides showed definite carcinoma with or without adenoma, according to both the Western and the Japanese pathologists. The presence of invasion was the most important diagnostic criterion of colorectal carcinoma for the Western pathologists, whereas for the Japanese the nuclear features and glandular structures were more important.

CONCLUSIONS

In Japan, colorectal carcinoma is diagnosed on the basis of nuclear and structural criteria, even in cases considered by Western pathologists to be noninvasive lesions with low grade dysplasia. This diagnostic practice may contribute to the relatively high incidence of early stage colorectal carcinoma reported in Japan as compared with Western countries.

Endoscopic mucosal resection for advanced non-polypoid colorectal adenoma and early stage carcinoma

PURPOSE

Endoscopic mucosal resection (EMR) techniques were evaluated in the treatment of flat and sessile colorectal neoplasm.

PATIENTS AND METHODS

Fifty-seven patients (32 female, 25 male) with non-polypoid colorectal lesions (n = 71, size >or= 10 mm) were included in the study. Tumor location, shape, size, and depth (in malignant lesions) were determined by endoscopy and endoscopic ultrasound. EMR was performed using snare resection, endoscopic aspiration mucosectomy, or EMR using a cap-fitted endoscope.

RESULTS

Lesion size ranged from 10 to 50 mm. Complete resection was achieved in 59 of 61 benign and 6 of 8 malignant tumors. Thirty-five tumors were excised in one segment and 34 tumors in piecemeal technique. Pathological examination of neoplasm treated by EMR showed adenoma in 61 and early-stage carcinoma in 8 cases. Because of the non-lifting sign, 2 of 71 tumors were not treated endoscopically and referred to surgical resection revealing a T2 adenocarcinoma in both cases. Resection was incomplete in 2 of 61 adenomas with histological positive resection margin. Complications occurred in 2 patients, with 1 bleeding treated endoscopically and 1 perforation treated by surgery. Local recurrence was observed in 2 of 59 completely resected adenomas and in none of 6 early-stage carcinomas during a mean follow-up of 18 months (range 6 to 30 months).

CONCLUSION

Advanced non-polypoid colorectal adenomas and early-stage carcinomas can be safely and effectively resected by endoscopic mucosal resection.

Appendix and cecum. Embryology, anatomy, and surgical applications

Surgeons should be familiar with surgery of the cecum and appendix because the diseases of this region, especially appendicitis, are the most common indications for surgical exploration. Usually, diagnosis of appendicitis and appendectomy are not difficult, but atypical location of the appendix or other anatomic anomalies can make the diagnosis of appendicitis and appendectomy difficult. In cases of atypical anatomy or diffuse clinical picture, especially in young adults or elderly patients, the spectrum of embryologic and anatomic anomalies must be kept in mind to make the correct treatment decision for individual patients. If doubt persists, explorative laparotomy must be performed to avoid overlooking rare, acute, intra-abdominal abnormalities.

Endoscopic localization of colon cancers

In order to determine the accuracy of endoscopic localization of colon cancers, the endoscopic location was compared to the actual location at the time of operation in 320 patients who underwent resection of intraabdominal colon cancer between 1983 and 1988. The endoscopic location was correct in 86% of the cases. There were 44 endoscopic errors, including seven missed cancers. One-third of all endoscopic errors occurred when the tumor was in the cecum. We conclude that endoscopy is an accurate method of localizing colon cancers. However, with the advent of laparoscopic surgery and the loss of the ability to palpate the colon, the 14% of endoscopic errors take on a greater importance and additional means for localizing tumors should be pursued in selected cases.

Malignant lymphoma of the large intestine--operative results in Japan

One hundred thirty cases of primary malignant lymphoma of the large intestine in Japan were studied with regard to operative results. The averaged age was 52.6 years and most of the patients were men. Sites of the tumor were the cecum (71.5 per cent), rectum (16.9 per cent) and the ascending colon (6.2 per cent). Surgery was performed for 129 (99.2 per cent) of the 130, of which 71 (55 per cent) were curatively resected. Surgical procedures were mostly Miles operation and the others were anterior resections and hemicolectomies. Postoperative 5 and 10 year survival rates were 34.8 per cent and 33.2 per cent respectively, and the rates after curative resection were 44.2 per cent and 40 per cent respectively. Prognoses were better when the tumor was of 5 cm or less in diameter, intraluminal and without lymph node metastasis. Classified histologically, most of the tumors were of histiocytic type, followed by lymphocytic, mixed type and Hodgkin's disease. Five and ten year survival rates of the curative resection group, by histological type, were both 38.9 per cent for histiocytic type, both 43 per cent for lymphocytic type, 43.8 per cent and 21.9 per cent respectively for mixed type, and both 100 per cent for Hodgkin's disease. Therefore, the operative result of malignant lymphoma in the large intestine was poor compared with results in case of cancer of the large intestine.

Mixed adenoneuroendocrine carcinoma of gastrointestinal tract: report of two cases

Mixed adenoneuroendocrine carcinoma (MANEC) is a rare tumor of the gastrointestinal tract that consists of a dual adenocarcinomatous and neuroendocrine differentiation, each component representing at least 30% of the tumor. To date, only seven cases have been reported in the cecum, and less than 40 in the stomach. Our first case was diagnosed in a 74-years-old female as a polypoid lesion of the cecum with direct invasion in the transverse colon, without lymph node metastases. The second case was diagnosed in the stomach of a 46-years-old male as a polypoid tumor of the antral region that invaded the pancreas and presented metastases in 22 regional lymph nodes. The metastatic tissue was represented by the glandular component. In both cases, the tumor consisted of a moderately-differentiated tubular adenocarcinoma (with mucinous component in Case 1) intermingled with neuroendocrine carcinoma. Ki67 index was lower than 20% in Case 1, respectively higher than 20% in Case 2. The neuroendocrine component was marked by synaptophysin and neuron specific enolase, being negative for Keratins 7/20. The neuroendocrine component represented 60% in Case 1, and 40% in Case 2, respectively. The glandular components were marked by carcinoembryonic antigen, maspin and keratin 20/7 (Case 1/2). Both cases were proved to be microsatellite stable. Independently by the localization and tumor stage, MANECs appear to be highly malignant tumors, with high risk for distant metastases. The aggressiveness seems to depend on the endocrine component, independent of its proportion. The neuroendocrine component could be a dedifferentiated adenocarcinoma with a neuroendocrine phenotype.

Endometriosis of the bowel: role of bowel resection, superficial excision and oophorectomy in treatment

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Influence of postoperative acute-phase response on angiogenesis and tumor growth: open vs. laparoscopic-assisted surgery in mice

Inflammatory responses and tumor growth are increased after laparotomy compared with laparoscopy in some animal models. Proinflammatory cytokines interleukin-6 (IL-6) and interleukin-1 beta (IL-1 beta) upregulate the expression of vascular endothelial growth factor (VEGF). Our aim was to investigate the influence of postoperative inflammatory responses on angiogenesis and tumor growth. 5 x 10(6) B51LiM cells were injected into the cecal wall of Balb/c mice. After 2 weeks, the animals were randomized into the following three groups: open cecectomy (OC), CO(2)-laparoscopic-assisted cecectomy (LC), and helium-laparoscopic-assisted cecectomy (LH). On postoperative day 12, the mice were killed. Tumor load scores and weight were significantly greater after laparotomy than after laparoscopy. Serum IL-6 levels 6 hours after surgery (OC: 4157+/-1297 pg/ml vs. LC: 2514+/-1417 pg/ml vs. LH: 2255+/-1714 pg/ml) and VEGF levels on postoperative day 12 (OC: 231+/-125 pg/ml vs. LC: 45+/-9 pg/ml vs. LH: 49+/-8 pg/ml), measured by enzyme-linked immunosorbent assay, were significantly higher in the laparotomy group. Microvessel density was also significantly higher in the OC group (OC: 34.3+/-11.5 vs. LC: 15.5+/-12.5 vs. LH: 18.5+/-11.9). There was a positive correlation between IL-6 and VEGF postoperative serum levels (rho=0.67; P<0.001). We concluded that increased systemic levels of proinflammatory cytokines and VEGF are associated with increased angiogenesis and tumor growth after laparotomy compared to laparoscopy in mice.

EMR of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video)

BACKGROUND AND AIMS

EMR of sessile periappendiceal laterally spreading lesions (PA-LSLs) is technically demanding because of poor endoscopic access to the appendiceal lumen and the thin colonic wall at the base of the cecum. We aimed to assess the feasibility and safety of EMR for PA-LSLs.

METHODS

Consecutive LSLs ≥20 mm and PA-LSLs ≥10 mm detected at 3 academic endoscopy centers from September 2008 until January 2017 were eligible. Prospective patient, procedural, and lesion data were collected. PA-LSLs were compared with LSLs in other colonic locations.

RESULTS

Thirty-eight PA-LSLs were compared with 1721 LSLs. Referral for surgery without an attempt at EMR was more likely with PA-LSLs (28.9% vs 5.1%, P < .001), and those that involved a greater percentage of the appendiceal orifice (AO) were less likely to be attempted (P = .038). Most PA-LSLs (10/11) were not attempted because of deep extension into the appendiceal lumen; 2 of 11 of these surgical specimens contained invasive cancer. Once attempted, complete clearance of visible adenoma (92.6% PA-LSLs vs 97.6% LSLs, P = .14), adverse events, and rates of adenoma recurrence did not vary significantly between PA-LSLs and LSLs. All 7 patients with prior appendicectomy achieved complete adenoma clearance. There were no cases of post-EMR appendicitis. Twenty of 22 PA-LSLs (91%) eligible for surveillance avoided surgery to longest follow-up.

CONCLUSIONS

EMR is a safe, effective, and durable treatment for PA-LSLs when specific criteria are fulfilled. If the distal margin of the PA-LSL within the AO cannot be visualized or if more than 50% of the circumference of the orifice is involved, surgery should be considered. (Clinical trial registration number: NTC01368289.).

Appendiceal mucocoeles and pseudomyxoma peritonei

Mucocoele of the appendix occurs when obstruction of the appendiceal lumen results in mucus accumulation and consequent abnormal dilatation. The most impor-tant aetiology, from a surgical perspective, is either mucinous cystadenoma or cystadenocarcinoma. In the latter, a spontaneous or iatrogenic rupture of the mucocoele can lead to mucinous intraperitoneal ascites, a syndrome known as pseudomyxoma peritonei. Optimal management of mucoceles is achieved through accurate preoperative identification and subsequent careful resection. We report two cases and subsequently discuss the clinical presentation of mucocoeles, their association with pseudomyxoma peritonei and an optimal management of both conditions.

Carcinoma of large bowel in the young

The incidence of large-bowel carcinoma in young people seems to be increasing. Twenty-one cases occurring between the ages of 13 and 25 are reviewed. Most cases were found to be in an advanced state of the disease. High grade malignant growths were found to be twice as common in the young as in adults. The mode of presentation is no different from that in adults and a plea is made for improving results of treatment by earlier diagnosis, which can be established by an increased awareness of the disease in children and young adults.

Solitary schwannoma of the colon: report of two cases

Some patients with gastrointestinal schwannoma (GIS) have been previously reported in the literature. However, GIS of the colon is quite rare. In addition, it is sometimes difficult to differentiate neurogenic tumors from other soft tissue tumors. We herein describe two cases of schwannoma of the colon, while also reviewing the relevant Japanese literature. The first case, a 73-year-old woman underwent a sigmoidectomy with lymph node dissection following the diagnosis of submucosal tumor. In the second case, a submucosal tumor was located in the cecum of a 44-year-old man. An endoscopic tumor resection was performed in the second case. The resected tumors measured 3.6 and 1.0 cm in maximal diameter, respectively. Microscopically, the tumors consisted predominantly of spindle-shaped cells that proliferated in an interlaced fashion. Mitosis was rarely seen in these tumors. Immunohistochemically, the tumor cells were strongly positive for S-100 protein, weakly positive for glial fibrillary acidic protein, and negative for CD34, alpha-smooth-muscle actin, and cytokeratin (CAM 5.2) in both cases. The tumors in the two cases were both diagnosed to be benign schwannoma of the colon. In general, schwannoma of the gastrointestinal tract is considered to be benign and should therefore be distinguished from other spindle-cell tumors or malignancies. Once diagnosed as schwannoma, extensive surgery should be avoided. Actually, such patients tend to show a good postoperative course with no evidence of recurrence.

Psoas abscess and cellulitis of the right gluteal region resulting from carcinoma of the cecum

Although retroperitoneal or psoas abscess is an unusual clinical problem, the insidious and occult characteristics of this abscess sometimes cause diagnostic delays, resulting in considerably high morbidity and mortality. In particular, psoas abscess caused by perforated colon carcinoma is uncommon. We report a case of psoas abscess caused by a carcinoma of the cecum. A 72-year-old Japanese woman was admitted to our hospital, with pain in the right groin and buttock. The pain had appeared 6 months before admission, and the symptoms had then been relieved by oral antibiotics. On March 25, 1999, inflammatory signs in the right buttock indicated localized cellulitis, and incision and drainage was performed at a local hospital. The patient was referred to our hospital on the same day. On admission to our hospital, computed tomography (CT) scan revealed a thick right-sided colonic wall and enlargement of the right ileopsoas muscle. Barium enema and colonofiberscopy revealed an ulcerated tumor occupying the entire circumference of the cecum. A retroperitoneal abscess and fistula had been formed by the retroperitoneal perforation of cecum carcinoma: surgical resection was performed after remission of the local inflammatory signs. Operative findings indicated that the cancerous lesion and its surrounding tissues were firmly attached to the right iliopsoas and major psoas muscle, and en-bloc resection, including adjacent muscular tissue, was performed. The fact that carcinoma of the colon could be a cause of psoas abscess and cellulitis in the gluteal region should be considered when an unexplained psoas abscess is diagnosed.

99mTc-HMPAO granulocyte scintigraphy in the early detection of postoperative asymptomatic recurrence in Crohn's disease

The usefulness of 99mTc-HMPAO scintigraphy in the early detection of postoperative recurrence of Crohn's disease was evaluated in 17 patients undergoing ileocecal resection and prospectively followed up for one year. Scintigraphy was performed 6 and 12 months after surgery and recurrence assessed by colonoscopy within two weeks. As controls, four patients with ileocecal resection for cecal carcinoma were studied. To perform scintigraphy, autologous granulocytes were labeled with 99mTc-HMPAO, injected, and tau-camera images acquired after 30 min and 3 hr. Six months after surgery, 4/8 Crohn's disease patients showed endoscopic recurrence, and 30-min scintigraphy was positive only in these four patients (four true positives, four true negatives). At 12 months, endoscopic recurrence was detected in 10/14 Crohn's disease patients, and 30-min scintigraphy was positive in 9/14 patients (eight true positives, three true negatives, two false negatives, one false positive). Scintigraphy at 3 hr showed a lower specificity in detecting CD recurrence both at 6 and 12 months. The endoscopic and 30-min scintigraphic score were significantly correlated both at 6 and 12 months (P = 0.007; P = 0.04). Scintigraphy was negative in 4/4 controls at 30 min (four true negatives) and positive in 1/4 (one false positive) at 3 hr. We conclude that 99mTc-HMPAO scintigraphy at 30 min is a sensitive technique for the early detection of Crohn's disease recurrence in patients under regular follow-up after surgery.

Inflammatory cecal masses in patients presenting with appendicitis

An unexpected inflammatory cecal mass of uncertain etiology encountered during surgery for presumed appendicitis poses a dilemma to the surgeon when deciding the appropriate operative management. A retrospective study was performed to review the pathology and surgical management of this condition. Among 3224 patients who had emergency surgery for a diagnosis of acute appendicitis between January 1990 and December 1997, a group of 52 patients (1.6%) underwent either ileocecal resection or right hemicolectomy for an inflammatory cecal mass of uncertain etiology. The final pathologic diagnosis was cecal diverticulitis in 26 patients (50%), appendiceal phlegmon or abscess in 21 patients (40%), cecal carcinoma in 3 patients (6%), tuberculosis in 1 patient (2%) and schistosomiasis in another patient (2%). Altogether 34 patients underwent ileocecal resection, and 18 patients underwent right hemicolectomy, including the 3 patients with cecal carcinoma. Ileocecal resection was associated with a shorter mean operative time (144 vs. 201 minutes; p < 0.001), a lower morbidity rate (3% vs. 22%; p = 0.043), and a shortened mean postoperative hospital stay (6.8 vs. 11.2 days; p = 0. 011) than right hemicolectomy. There was no mortality in either group. In conclusion, most inflammatory cecal masses are due to benign pathologies and could be managed safely and sufficiently with ileocecal resection. Careful intraoperative assessment including examination of the resected specimen is essential to exclude malignancy, which would require right hemicolectomy.

Impact of intraoperative ultrasonography on treatment strategy for colorectal cancer

The impact of intraoperative ultrasonography (IOUS) on treatment strategy was studied in 122 patients with primary colorectal cancer. All patients underwent preoperative liver imaging by ultrasonography and computed tomography (CT). After curative resection of the primary tumour patients were eligible for adjuvant chemotherapy. The findings on IOUS were assessed by ultrasonography 6 months after laparotomy. Of 34 patients with suspected liver metastases on ultrasonography or CT, the diagnosis was confirmed by IOUS in 21. In the remaining 13 patients the suspect lesions were shown to be benign. Of the 88 patients with normal preoperative imaging results, suspect lesions were detected in five; in four the lesion was found by IOUS only. One of these four also had an extrahepatic metastasis. At follow-up the diagnosis of metastasis proved to be wrong in two of the remaining three patients, so IOUS was helpful in only one patient. Surgical management was not markedly influenced by findings on IOUS in any patient. However, IOUS correctly changed the stage of the disease, and consequently postoperative treatment, in 14 patients (11 per cent). Two patients were erroneously excluded from the adjuvant protocol following an incorrect diagnosis based on IOUS.

Large bowel lymphoma: an analysis of prognostic factors and therapy in 53 patients

BACKGROUND AND OBJECTIVES

We performed a retrospective analysis to assess the influence of different prognostic factors, including the International Prognostic Index (IPI), that can predict the outcome in patients with primary large bowel lymphoma (Stage IE) treated with combined therapy (surgery followed by chemotherapy).

METHODS

All patients were treated with radical surgery followed by six cycles of combined chemotherapy: CHOP-Bleo (cyclophosphamide, doxorubicine, vincristine, prednisone, and bleomycin) or variants (epirubicin instead of doxorubicin). In all cases, an multivariate analysis was performed to identify prognostic factors (if any), including IPI, that can influence outcome.

RESULTS

According to the IPI, event-free survival (EFS) and overall survival were 85% and 87%, respectively, in patients with low and low-intermediate clinical risk that was not statistically significant when compared to patients at high and high-intermediate clinical risk: 69% and 76% (P = 2). Multivariate analysis failed to demonstrate the influence of multiple prognostic factors that were analyzed.

CONCLUSIONS

Combined therapy appears to be an excellent therapeutic approach in this group of patients with prolonged EFS and survival, and without late toxicity. However, no prognostic factors, including IPI, could be identified to define the best therapy, probably because the number of patients, even in large series, is limited. Multicentric studies are necessary to identify prognostic factors to define therapy and outcome in this rare clinical presentation of malignant lymphoma.

Robotic right colectomy using the Da Vinci Single-Site® platform: case report

BACKGROUND

While single-port laparoscopy for abdominal surgery is technically challenging, the Da Vinci Single-Site® robotic surgery platform may help to overcome some of the difficulties of this rapidly evolving technique. The authors of this article present a case of single-incision, robotic right colectomy using this device.

METHODS

A 74-year-old female with malignant polyp of caecum was operated on with a single-site approach using the Da Vinci Single-Site® robotic surgery device. Resection and anastomosis were performed extra-corporeally after undocking the robot.

RESULTS

The procedure was successfully completed in 200 min. No surgical complications occurred during the intervention and the post-operative stay and no conversion to laparotomy or additional trocars were required.

CONCLUSIONS

To the best of our knowledge, this is the first case of right colectomy using the Da Vinci Single-Site® robotic surgery platform to be reported. The procedure is feasible and safe and its main advantages are restoration of triangulation and reduced instrument clashes.