[A case of splenic artery aneurysm simulating a pancreas tumor]

A 46-year-old man was admitted to our hospital for further evaluation of a hypoechogenic mass in the pancreatic body. He had no history of hypertension, pancreatitis, abdominal trauma, or portal hypertension. He had no abdominal symptoms. A contrast-enhanced CT scan demonstrated a hypodense, round shaped mass. EUS and MRI also showed it to be a pancreatic mass. Because of the tumor size of more than 30mm and the possibility of malignancy, distal pancreatectomy was performed. Microscopic findings showed the mass was the dissection of the proximal splenic artery. The true lumen of the dissecting aneurysm was occluded and the false lumen developed fusiform dilatation. Moreover, microscopic findings revealed the rupture of the false lumen complicated by pseudoaneurysm. We finally diagnosed the lesion simulating a pancreatic tumor as the pseudoaneurysm of the splenic artery.

[Combination of irinotecan and Mitomycin C as second-line chemotherapy for patients with unresectable advanced or recurrent gastric cancer in clinical practice]

BACKGROUND

Recently, combination S-1 and CDDP chemotherapy is considered as a standard regimen for unresectable or recurrent gastric cancer. Second-line chemotherapy is reportedly important to improve survival, and combination of Irinotecan and Mitomycin C as second-line chemotherapy has proven effective in phase II study of JCOG 0109-DI.

PURPOSE

We assessed the efficacy of combination of Irinotecan and Mitomycin C as second-line chemotherapy for unresectable and recurrent gastric cancer.

PATIENTS AND METHODS

We treated 12 patients receiving combination of Irinotecan and Mitomycin C as second-line chemotherapy between Nov. 2002 and Apr. 2006.

RESULTS

The response rate was 42% including 2 complete response. Progression-free survival was 6.1 months, and time to progression was 5.4 months. Median survival time after the start of second-line chemotherapy was 11.2 months, and after first-line treatment 20.5 months. One-year survival rate was 50%, and 2-year survival rate was 33%.

CONCLUSION

In our hospital, combination of Irinotecan and Mitomycin C as second-line chemotherapy prolonged median survival time, and seemed to be an effective regimen.

A new endoscopic tattooing technique for identifying the location of colonic lesions during laparoscopic surgery: a comparison with the conventional technique

BACKGROUND AND STUDY AIMS

Knowledge of the exact location of colorectal lesions is necessary but difficult to establish during surgery. Thus, endoscopic tattooing has been used as an important preoperative marker for identification. Using the conventional technique, we injected tattooing agents directly into the colonic wall. However, to make sure that the tattooing agents were adequately injected into the submucosal layer, and to prevent spillage into the peritoneal cavity, we modified the conventional method and developed a new tattooing technique: using India ink with prior and subsequent injection of saline into the submucosa. The aim of this study was to retrospectively assess the clinical utility and potential complications of the above two techniques of endoscopic tattooing using India ink.

PATIENTS AND METHODS

A total of 153 patients underwent laparoscopically assisted colectomy at the National Cancer Center Hospital East, Kashiwa, Chiba, Japan, between June 1994 and December 1999, and 91 patients underwent preoperative endoscopic tattooing by either the conventional or the new technique. The conventional and new techniques were used from June 1994 to December 1997 (n = 36) and from January 1998 to December 1999 (n = 55), respectively. Informed consent was obtained from all the patients.

RESULTS

Using the conventional technique, the exact location of the lesion was identified in 31 of 36 cases (86.1 %) during surgery. The complications of this procedure were silent local peritonitis in two patients and reactive lymph node swelling in one patient (3/36, 8.3 %). Using the new technique, in 54 of 55 cases lesions (98 %) were easily identified (p = 0.034),and in only one there was a small leakage of India ink into the peritoneal cavity (1/55; 1.8 %), no other serious complications were observed.

CONCLUSIONS

The results demonstrate that our new technique for endoscopic tattooing is probably better than the conventional technique for clinical use, in terms of diagnostic accuracy and safety, but this would have to be proven in a randomized comparison.

Assessment of colorectal lesions using magnifying colonoscopy and mucosal dye spraying: can significant lesions be distinguished?

BACKGROUND AND STUDY AIMS

Assessing the nature of lesions at the time of colonoscopy is important, and magnifying colonoscopy allows examination of mucosal crypt patterns. In this study, we assessed mucosal crypt patterns to see whether we could predict the histological findings.

PATIENTS AND METHODS

This retrospective study of total colonoscopy using magnifying colonoscopy involved 4445 patients between December 1993 and July 1998 at the National Cancer Center Hospital East. The mucosal crypt patterns of 3438 lesions were observed under magnifying colonoscopy with 0.2% indigo carmine solution, and classified according to a modified Kudo classification (type I to V). After endoscopic or surgical resection (3291 cases and 147 cases, respectively), histopathological examination was performed.

RESULTS

The diagnostic accuracy of magnifying endoscopy for non-neoplastic lesions was 75% (117/157), for adenomatous polyps it was 94% (3006/3186), and for invasive carcinomas it was 85 % (81/95).

CONCLUSIONS

The combination of magnifying colonoscopy and dye spraying is helpful in determining the nature of colonic lesions as non-neoplastic, adenomas, or invasive carcinomas. Therefore it may be possible to determine, at the time of colonoscopy, which lesions require no treatment, which can be removed endoscopically, and which should be removed by surgery.

Clinicopathological differences between colonic and rectal carcinomas: are they based on the same mechanism of carcinogenesis?

BACKGROUND

There is a difference in the location of colorectal mucosal lesions and invasive cancers.

AIMS

To ascertain whether the location of colorectal neoplasms reflects the carcinogenesis pathway.

METHODS

The subject material consisted of 4147 neoplastic lesions that had been resected endoscopically or surgically from 5025 patients. Mucosal lesions and submucosal cancers were classified into depressed and non-depressed types endoscopically or histologically. The relations between macroscopic type, size, histology, and location were investigated.

RESULTS

(a) Non-depressed type. A total of 1774 of 3454 (51%) mucosal lesions were located in the right colon, 1212 (35%) in the left colon, and 468 (14%) in the rectum. The incidence of mucosal lesions larger than 10 mm was 10% (185/1774) in the right colon, 21% (254/1212) in the left colon, and 27% (127/468) in the rectum. The incidence of mucosal lesions with villous components was 2% (32/1774) in the right colon, 5% (63/1212) in the left colon, and 13% (62/468) in the rectum. The ratio of submucosal cancers to mucosal lesions was significantly higher in the rectum (0.064, 30/469) than in the left (0.034, 43/1279) or right (0.010, 18/1857) colon. (b) Depressed type. The incidences of depressed type mucosal lesions and submucosal cancers were 5% (83/1857) and 17% (3/18) in the right colon, 5% (67/1279) and 5% (2/43) in the left colon, and 0.2% (1/469) and 0% (0/30) in the rectum, respectively.

CONCLUSION

There may be some mechanisms that promote the progression of mucosal lesions to invasive cancers in the left colon and rectum, whereas a de novo pathway from depressed type lesions may be implicated in some cancers of the right colon.

Diagnostic findings in endoscopic screening of superficial colorectal neoplasia: results from a prospective study

BACKGROUND

A prospective study was carried out to clarify the efficacy of an endoscopic screening program for detecting superficial colorectal neoplasias by color changes such as faint redness or discoloration, which have been described as a key finding of these lesions in the literature.

METHODS

We enrolled 716 consecutive cases in this study, but more than half of them did not reveal any abnormalities colonoscopically.

RESULTS

Of the 716 cases, 48 (7%) were examined by magnifying colonoscopy with a dye spraying technique, following the detection of superficial color changes. Sixteen neoplastic lesions (in 16 cases) were detected among the 48 cases and the detection rate was calculated as 2.2% (16/716) in the total number of cases and 33% (16/48) in those showing color abnormalities. Histologically, all of the 16 were adenomas. These neoplastic lesions were most frequent (52%; 11/21) in those showing faint redness in an oval shape, whereas 14 (94%) of the 15 lesions were non-specific in those showing faint redness with unclear margin.

CONCLUSIONS

These results may confirm the diagnostic utility of color abnormality, particularly faint redness in an oval shape, for endoscopic screening of superficial colorectal neoplasias.

Growth patterns and genetic changes of colorectal carcinoma

BACKGROUND

Recent Japanese studies have shown that histogenesis of small colorectal carcinomas can be divided into two groups: polypoid growth arising from polypoid neoplasia, and nonpolypoid growth arising from flat or depressed neoplasia. This classification should be verified with genetic as well as morphologic characteristics.

SUBJECTS AND METHODS

In order to classify our subject into polypoid growth and nonpolypoid growth types both histologically and endoscopically, we selected 42 colorectal carcinomas < 2 cm in size (35 submucosal and seven more advanced). Clinicopathological findings, presence or absence of Ki-ras gene mutation and overexpression of p53 protein were compared between the two types.

RESULTS

Histologically, the cases were divided into 27 of the polypoid growth type and 15 of the nonpolypoid growth type. None of the nonpolypoid growth cases contained adenomatous remnant, wheras this was found in 75% of the polypoid growth cases. No Ki-ras mutation was observed in any of the nonpolypoid growth cases, although it appeared in 44% of the polypoid growth cases. Regarding the overexpression of p53 protein, no significant difference was observed between the two types. The histological and the colonoscopic polypoid growth-nonpolypoid growth classifications correlated well with each other (agreement rate 98%), except for one lesion, which was classified as polypoid growth type endoscopically but as nonpolypoid growth type histologically.

CONCLUSIONS

The histologically defined polypoid growth-nonpolypoid growth classification may indicate a difference in pathway of colorectal carcinogenesis. Also, colonoscopic polypoid growth-nonpolypoid growth classification is available for preoperative estimation of the genetic characteristics of small carcinomas.

Diagnostic utility of endoscopic ultrasonography for preoperative rectal cancer staging estimation

The preoperative staging accuracy of endoscopic ultrasonography (EUS) was assessed in 38 rectal cancer patients who underwent rectal EUS and curative surgery from July 1992 to September 1994. We used a GF-UM20 instrument with both 12- and 7.5-MHz transducers. Compared with the histological findings, the diagnostic accuracy rate for EUS was 76% (29/38) for the invasion depth and 85% (sensitivity) and 72% (specificity) for level one lymph node metastasis, resulting in an overall preoperative staging accuracy of 74% (28/38). The diagnostic accuracy of invasion depth was poor (only 45%: 5/11) in cases shown histologically to be a1 (tumor invasion through muscularis propria into parietal fat), but ranged from 90 to 100% when the a1 cases were excluded. The diagnostic accuracy for level one lymph node metastasis was proportional to the nodal size. The size of lymph nodes that had been diagnosed as metastatic and non-metastatic (P < 0.05) differed significantly. Eighteen (86%) of the 21 metastatic nodes with histologically massive invasion were detected preoperatively by EUS. Eight of the 11 undetected metastatic nodes were either less than 4 mm in diameter or showed only slight invasion. Most (81%) of the level one metastatic nodes larger than 5 mm were found. The worst preoperative staging diagnostic accuracy was for stage II cases (63%: 5/8), and in four of the 10 misdiagnosed cases, the stage was underestimated due to slight nodal invasion or skip metastasis (2 cases each). Although it was difficult to diagnose nodal metastasis correctly in these cases, preoperative staging using EUS was considered useful for diagnosing almost 80% of our rectal cancer cases.

Concurrent chemotherapy and radiation therapy for locally advanced carcinoma of the esophagus

A pilot study was undertaken to clarify the efficacy of concurrent chemoradiotherapy against locally advanced esophageal carcinoma. The 20 patients in this study had previously untreated esophageal carcinoma with evidence of T4 disease and/or distant node metastases. Chemotherapy consisted of protracted infusion of 5-fluorouracil at a dose of 400 mg/m2/day on days 1-5 and 8-12, combined with a 2-h infusion of cisplatinum at 40 mg/m2 on days 1 and 8. Radiation treatment for the mediastinum was administered 5 days per week for 3 wk at 2 Gy/day, along with chemotherapy. These schedules were repeated twice to give a total radiation dose of 60 Gy. For patients who responded, two additional courses of chemotherapy were administered. Five of the 20 patients had UICC stage III disease and 15 had stage IV. Seventeen (85%) of the 20 patients exhibited an objective response, including 6 (30%) complete responses. Local control was excellent with 10 (50%) complete responses. Toxic effects were severe. Major toxicities were leukocytopenia of grade 3 or more in 45% of the patients and esophagitis, including four perforations. There were two treatment-related deaths. The median survival time was 9 mo (range: 2 to 34+). Concurrent chemotherapy and radiotherapy was effective even for locally advanced esophageal carcinoma, but was associated with significant toxicity.

Expression of integrin alpha 3 in gastric and colorectal cancers: its relation to wall contraction and mode of invasion

We macroscopically classified 25 gastric and 23 colorectal advanced cancers into "contracted" and "uncontracted" types, and found immunohistochemically that integrin subunit alpha 3 was more frequently expressed in the extracellular matrix (ECM) in the former than in the latter (75%:9/12 vs. 38%: 5/13 in gastric and 86%:6/7 vs. 25%:4/16 in colorectal cancers, respectively). Integrin subunit alpha 3 was also expressed more frequently in cancers producing transforming growth factor-beta (TGF-beta), which is related to ECM deposition, integrin expression and cell mobility, than in those which did not produce TGF-beta (67%:10/15 vs. 40%:4/10 in gastric and 57%:4/7 vs. 38%:6/16 in colorectal cancers, respectively). In addition, integrin subunit alpha 3 was not expressed in 2 benign gastric ulcers combined with gastric cancer elsewhere in the stomach. On the other hand, a retrospective analysis of 107 cases of rectal cancer which recurred after a curative operation revealed that local recurrence was more frequent in "contracted" than "uncontracted" types (44%:11/25 vs. 26%:21/82). These results may suggest that the abundant interstitial fibrosis which leads to remarkable gastric or colorectal wall contraction is a result of the interaction between cancer cells and ECM, along with the expression of integrin and/or the production of TGF-beta. This fibrosis may also be closely related to the mode of gastric and colorectal cancer invasion.

Small cell carcinoma of the esophagus with an esophago-mediastinal fistula successfully treated by chemoradiation therapy and intubation: a case report

A case of esophageal small cell carcinoma with cervical node metastases and an esophago-mediastinal fistula was treated successfully by chemoradiotherapy. The fistula, after irradiation, was handled successfully by esophageal intubation, followed by infusional 5-fluorouracil and cisplatinum chemotherapy, resulting in the closure of the fistula. Two courses of concurrent chemoradiotherapy, followed by additional cisplatinum and etoposide chemotherapy, were administered. The tumor, including the cervical lymph node metastases, disappeared completely after the treatment.