Argon plasma coagulation for Barrett's esophagus with low-grade dysplasia: a randomized trial with long-term follow-up on the impact of power setting and proton pump inhibitor dose

BACKGROUND

This study evaluated the impact of power setting and proton pump inhibitor (PPI) dose on efficacy and safety of argon plasma coagulation (APC) of Barrett's esophagus (BE) with low-grade dysplasia (LGD). METHODS : 71 patients were randomized to APC with power set at 90 W or 60 W followed by 120 mg or 40 mg omeprazole. The primary outcome was the rate of complete (endoscopic and histologic) ablation of BE at 6 weeks. Secondary outcomes included safety and long-term efficacy. RESULTS : Complete ablation rate in the 90 W/120 mg, 90 W/40 mg, and 60 W/120 mg groups was 78 % (18/23; 95 % confidence interval [CI] 61-95), 60 % (15/25; 95 %CI 41-79), 74 % (17/23; 95 %CI 56-92), respectively, at 6 weeks and 70 % (16/23; 95 %CI 51-88), 52 % (13/25; 95 %CI 32-72), and 65 % (15/23; 95 %CI 46-85) at 2 years post-treatment (differences not significant). Additional APC was required in 28 patients (23 residual and 5 recurrent BE). At median follow-up of 108 months, 66/71 patients (93 %; 95 %CI 87-99) maintained complete ablation. No high-grade dysplasia or adenocarcinoma developed. Overall, adverse events (97 % mild) did not differ significantly between groups. Chest pain/discomfort was more frequent in patients receiving 90 W vs. 60 W power (P < 0.001). One patient had esophageal perforation and two developed stenosis.

CONCLUSIONS

APC power setting and PPI dose did not impact efficacy and safety of BE ablation. Complete ablation of BE with LGD was durable in > 90 % of patients, without any evidence of neoplasia progression in the long term.

Immunohistochemical features and staging of early gastric cancer

INTRODUCTION

The aim of this study was to analyze the particularities of early gastric cancer (EGC) and their importance for staging, prognosis, and therapy.

MATERIAL AND METHODS

A total of 338 GCs diagnosed and surgically removed in three medical institutes from Eastern Europe were retrospectively examined, and the EGCs were further examined. Besides the demographic factors and tumor characteristics, immunostains were performed with E-cadherin, HER-2, p53, Ki67, MLH-1, MSH-2, COX-2, VEGF-A, CD31, and CD105.

RESULTS

From the 338 GCs, 29 were EGCs, the average being similar in Poland and Hungary (12.37% and 13.33% respectively) but lower in Romania (5.61%). The rate of lymph node metastases was 20.69% (n = 6). Two of the cases presented liver metastases, both of them having a multifocal aspect. In 1 of these cases, limited to the mucosa, intramural carcinomatosis of the lymph vessels was seen in submucosa, muscularis propria, and subserosa. COX-2 positivity was observed in 14 (48.72%) cases. COX-2 was directly correlated with microvessel density determined with CD31 (p < 0.001) and CD105 (p = 0.03). Same correlation with CD31 and CD105 was seen for HER-2 (p = 0.03 and p = 0.0007). The only negative independent prognostic factors for overall survival were tumor localization at the proximal stomach and male gender, regardless of age.

CONCLUSIONS

In EGCs, intramural carcinomatosis of the lymph vessels and multifocality should be separately described in every surgical pathology report, as indicators of aggressiveness. Microsatellite status, E-cadherin, HER-2, p53, and Ki67 do not have prognostic value in EGC, but the highly angiogenic pattern is a possible therapeutic target.

Proposal of a Dukes-MAC-like staging system for gastric cancer

The aim of this study was to present an epidemiological update regarding the classical prognostic parameters of gastric cancer (GC) in 3 countries from Eastern Europe and to suggest a modification of the pTNM staging system. In 333 consecutive cases which were diagnosed between 2003 and 2012 in 3 departments of pathology from Romania, Hungary, and Poland, the following parameters were analyzed: age and gender of patients, tumor localization, macroscopic and microscopic aspects including the degree of discohesivity, depth of tumor infiltration, and pTNM stage. From all of the studied parameters, the following proved to have independent prognostic value, indicating a lower survival rate: presence of distant metastases (p=0.001), lymph node positivity (p=0.0009), depth of tumor infiltration (p=0.04), age over 50 (p=0.02), proximally located tumors (p=0.03), and ulceroinfiltrative or diffusely infiltrative macroscopic aspect (p=0.0002). The pT2N1-3 staged cases showed a worse prognosis compared with the pT3N0 ones (p=0.02). Regardless of depth of invasion, the lymph node status remains the strongest indicator of the survival rate in GC. The pTN staging system should be adapted and a Dukes-MAC-like staging system should include the following groups: stage A1-T1N0, stage A2-T1N1-3, stage B1-T2N0, stage B2-T2N1-3, stage C1-T3N0, stage C2-T3N1-3, and stage D-T4N0-3. The grade of discohesivity/budding is not a prognostic factor in GC.

Adenocarcinoma risk in patients registered with Polish Barrett's Oesophagus Registry

Barrett's Oesophagus (BO) is a complication of chronic gastro-oesophageal reflux disease (GORD) and is a major risk factor for oesophageal adenocarcinoma. Current guidelines are based on data showing a 0.5% annual malignancy progression rate. The Polish Barrett's Oesophagus Registry (POBOR) was established to characterize Polish patients with BO and estimate the risk of malignant progression. POBOR was established in 1999 after a dedicated training of endoscopists and histopathologists. Physicians registered patients using a dedicated registry form. After excluding patients known to have endoscopic treatment for BO, follow-up <1 year and adenocarcinoma found at index endoscopy we have linked patients personal identification numbers (PESEL) with the National Cancer Registry to identify those with a diagnosis of oesophageal or gastric cardia adenocarcinoma. In total, 843 patients were registered [609 men (72.2%), male to female ratio 2.6:1] with median age at diagnosis of 56 years (IQR:47-67). Long segment BE was found at index endoscopy in 294 patients (39.4%) whereas low grade dysplasia in 147 (17.4%). 112 patients (13.3%) fulfilled the exclusion criteria and the remaining 731 were followed for a median of 9.8 years (IQR: 9.3-10.0). After 6779 patient-years, 6 adenocarcinomas were diagnosed yielding an incidence rate of 0.89 per 1000 patients-years (95% confidence interval [CI 0.40-1.97]) which corresponds to annual malignancy progression rate of less than 0.1%. The malignancy rate in patients with low grade dysplasia was 3.70 per 1000 patient-years (95% CI 1.39-9.85). In Polish BO patients the risk of malignant progression was lower than previously reported. It was notably higher in patients with low grade dysplasia than in those with no dysplasia at index endoscopy, which may warrant strict surveillance in these patients.

Suspicious macroscopic features of small malignant colorectal polyps

OBJECTIVE

The aim of this analysis was to retrospectively review video recordings of malignant polyps <10 mm in search for suspicious macroscopic features in white light endoscopy.

METHODS

Database entries and recordings of screening colonoscopies from a single tertiary referral center between June 2009 and December 2012 were reviewed. Malignant polyps <10 mm were analyzed. The recordings were reviewed by two expert endoscopists in search for suspicious morphological features: irregular contours, central depression, contact bleeding, shape deformity, central depression, chicken skin sign, circumscribed area with abnormal vascular and/or surface pattern. Then, six experienced endoscopists watched the recordings in search of listed features. Next, video recordings of these malignant polyps were mixed with randomly drawn video recordings of 20 non-malignant polyps matched by size and reviewed by 14 blinded endoscopists to assess the sensitivity and specificity for the diagnosis of malignant polyps.

RESULTS

Five of the 8651 (0.06%) subjects who underwent screening colonoscopy during the study period were diagnosed with a malignant polyp <10 mm. Only one of them was ad hoc identified by performing endoscopist as suspicious. On recordings review performed by the experts, each of the four remaining polyps presented at least one suspicious macroscopic feature. Presence of these features was confirmed by experienced endoscopists. The sensitivity and specificity for the diagnosis of malignant polyp were 73.21% and 85.35%, respectively, if at least two suspicious macroscopic features defined malignant polyp.

CONCLUSIONS

On careful white light endoscopy examination small malignant colorectal polyps show suspicious macroscopic features, which were frequently unrecognized by examining endoscopists.

Maspin-related Orchestration of Aggressiveness of Gastric Cancer

BACKGROUND AND STUDY AIM

Although some hypotheses have been postulated on the genesis of gastric cancer (GC), the origin of this disease remains unclear. The aim of this study was to develop a hypothesis about gastric carcinogenesis based on our experience in the field of GC and on published reports on about 28 studies in the field of subcellular maspin expression in GC. In 180 cases of GC, the clinicopathologic features were correlated with the results obtained after paired immunohistochemical stains (tumor/normal mucosa) with 15 antibodies: E-cadherin, HER-2, VEGF, CD31, CD105, COX-2, maspin, bax, bcl-2, p53, Ki67, MLH-1, MSH-2, Mena protein, and vimentin.

RESULTS

Cytoplasmic maspin was observed in foveolar cells with intestinal metaplasia, whereas mixed (combined nuclear-cytoplasmic) expressions were more characteristic of the intramucosal foci of signet-ring cells and dysplastic cells. The tumor cells that expressed cytoplasmic maspin were mostly intestinal type bax/COX-2/Mena/E-cadherin-positive differentiated adenocarcinomas with nodular growth and more superficial invasion. The nuclear shift of maspin was more frequent in HER-2/p53-positive intestinal type adenocarcinomas with diffuse architecture at the invasion front, as well as for node-positive poorly cohesive carcinomas. Loss of maspin expression induced a higher risk of distant metastases, without differences in the survival rate.

CONCLUSIONS

In GC with associated metaplasia, cytoplasmic maspin is predominant; the nuclear shift induces local aggressiveness and risk of node metastases, whereas total loss can indicate a risk of distant metastases. In GC without associated metaplasia, nuclear expression of maspin is retained, indicating a more aggressive behavior.

New Insights in Histogenetic Pathways of Gastric Cancer

The aim of this paper was to describe 3 possible histogenetic pathways for poorly cohesive (diffuse) carcinomas and 2 for intestinal-type gastric carcinomas (GCs), which might influence the behavior of GC. In the present observational study, 102 patients with early (n = 50) and advanced GCs (n = 52) were evaluated, and the histogenetic background was analyzed. All of the cases were sporadic GCs. For particular aspects, Maspin, E-cadherin, and SLUG immunostains were performed. For our final conclusions, the results were correlated with literature data. In early stages, poorly cohesive carcinomas can display 3 histogenetic pathways, with particular molecular behaviors: "carcinoma with intraepithelial pagetoid onset" (with or without a switch from E-cadherin to SLUG positivity), "carcinoma with early lymphatic invasion" (carcinoma limited to mucosa but with carcinomatosis of the lymph vessels from subjacent layers), and "microglandular-type poorly cohesive carcinoma" (the onset is similar with adenocarcinoma but abrupt dedifferentiation can be seen in the submucosa, with persistence of a dual component in the deep layers). The intestinal type carcinoma can be developed on the background of superficially located dysplasia ("classic adenocarcinoma") or in the submucosal heterotopic mucosa ("adenocarcinoma arising from the mucosal infolding in the submucosa"). Based on personal observations correlated with literature data, 5 histopathogenetic pathways are proposed with specific denominations. Each of them can partially explain the aberrant behavior of early gastric cancer.

Hereditary diffuse gastric cancer--An overview

The incidence of gastric cancer varies by up to ten fold throughout the world, and the geographic distribution of hereditary cases is not well explored. Familial clustering is seen in 10% of cases, and approximately 3% of all gastric cancers develop due to hereditary diffuse gastric cancer (HDGC). In this review, the characteristics of HDGC are presented according to molecular particularities, geographic distribution, and other parameters. Based on our experience and the data from the literature, we discuss the possibility of applying a mutation signature (spectrum) study and adductomic approaches to a comparative carcinogenesis of HDGC. We also provide a comprehensive, up-to-date review of genetic counseling and criteria for screening and surveillance of eligible families.

Predictive factors of proximal advanced neoplasia in the large bowel

INTRODUCTION

The aim of the study was to evaluate the impact of sex, age, family history and distal findings on the risk of proximal advanced neoplasia (cancer or advanced adenoma) in the large bowel.

MATERIAL AND METHODS

Records for 10 111 asymptomatic participants of the Colonoscopy Screening Program (CSP), recruited from the Warsaw region between 2000 and 2004, were analyzed. A multivariate logistic regression model was used to estimate the impact of sex, age, family history and most advanced distal lesions on the occurrence of proximal advanced neoplasia. To enhance comparability of the study two definitions of the proximal colon were applied - either the splenic flexure (1(st)) or the bend between the descending and sigmoid colon (2(nd) definition) represented the boundary.

RESULTS

One hundred and thirty-three (1(st)) and 167 patients (2(nd) definition) were found to have at least one advanced neoplastic lesion in the proximal part, respectively. Eleven and 14 patients were found to have carcinoma, while in 130 and 163 patients at least one proximal advanced adenoma appeared. Men were at twice as high risk of having advanced neoplasia in the proximal colon than women (OR = 1.94, 95% CI: 1.31-2.87, p = 0.001 or OR = 1.69, 95% CI: 1.20-2.40, p = 0.003, respectively). The presence of distal advanced neoplastic lesions was associated with 3.5 times higher risk of proximal advanced neoplasia (OR = 3.58, 95% CI: 2.00-6.43, p < 0.0001 or OR = 3.41, 95% CI: 1.95-5.96, p < 0.0001), respectively.

CONCLUSIONS

The results may confirm some limitation of flexible sigmoidoscopy in the screening settings in comparison with colonoscopy, at least in men and people with distal advanced neoplasia.

Serrated polyps of the colon: how reproducible is their classification?

For several years, the lack of consensus on definition, nomenclature, natural history, and biology of serrated polyps (SPs) of the colon has created considerable confusion among pathologists. According to the latest WHO classification, the family of SPs comprises hyperplastic polyps (HPs), sessile serrated adenomas/polyps (SSA/Ps), and traditional serrated adenomas (TSAs). The term SSA/P with dysplasia has replaced the category of mixed hyperplastic/adenomatous polyps (MPs). The present study aimed to evaluate the reproducibility of the diagnosis of SPs based on currently available diagnostic criteria and interactive consensus development. In an initial round, H&E slides of 70 cases of SPs were circulated among participating pathologists across Europe. This round was followed by a consensus discussion on diagnostic criteria. A second round was performed on the same 70 cases using the revised criteria and definitions according to the recent WHO classification. Data were evaluated for inter-observer agreement using Kappa statistics. In the initial round, for the total of 70 cases, a fair overall kappa value of 0.318 was reached, while in the second round overall kappa value improved to moderate (kappa = 0.557; p < 0.001). Overall kappa values for each diagnostic category also significantly improved in the final round, reaching 0.977 for HP, 0.912 for SSA/P, and 0.845 for TSA (p < 0.001). The diagnostic reproducibility of SPs improves when strictly defined, standardized diagnostic criteria adopted by consensus are applied.

Large intra- and inter-individual variability of genes expression levels limits potential predictive value of molecular diagnosis of dysplasia in Barrett's esophagus

Barrett's esophagus represents a well-defined precursor lesion of esophageal adenocarcinoma, although only a subset of patients with these lesions advances to invasive cancer. Currently, reliable markers predicting neoplastic progression in Barrett's esophagus are lacking. The only clinically useful risk factor is the presence of dysplasia in Barrett's epithelium, but its use as a prognostic marker of disease progression has several significant limitations. Thus, identification of biomarkers of potential prognostic value in dysplasia development in Barrett's esophagus is highly important. The aim of the study was to determine if expression levels of selected genes support histologic diagnosis of dysplastic changes in Barrett's esophagus. Upon rigorous sampling and independent histopathologic examination of endoscopic specimens by two experienced gastrointestinal pathologists, 56 patients with Barrett's esophagus (16 negative for dysplasia, 15 with indefinite, 21 with low-grade, and 4 with high-grade dysplasia) were selected for molecular analysis. The relative mRNA levels of ten selected genes were estimated by quantitative real-time polymerase chain reaction (PCR) analysis. Although expression of nine genes showed trends toward down- or upregulation during progression from Barrett's esophagus without dysplasia to Barrett's esophagus with high-grade dysplasia, only a decrease in S100A2 mRNA levels was statistically significant (P<0.05). However, there was considerable variation among individuals and significant overlapping of ranges. Furthermore, detailed, comparative analysis of serial samples from Barrett's mucosa and normal squamous epithelium shows large intra-individual variability of gene expression levels. In conclusion, expression of this set of ten genes cannot be used as a molecular marker aiding histological examination of dysplasia in Barrett's esophagus. Significant inter- and intra-patient variations of gene expression levels makes use of the selected genes impractical.

Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia

BACKGROUND

Recommendations for colorectal-cancer screening are based solely on age and family history of cancer, not sex.

METHODS

We performed a cross-sectional analysis of the data from a large colonoscopy-based screening program that included 50,148 participants who were 40 to 66 years of age. People 40 to 49 years of age were eligible only if they had a family history of cancer of any type. Of the 43,042 participants 50 to 66 years of age, 13.3% reported a family history of colorectal cancer, as did 66.3% of the 7106 participants who were 40 to 49 years of age. We defined advanced neoplasia as cancer or adenoma that was at least 10 mm in diameter, had high-grade dysplasia, or had villous or tubulovillous histologic characteristics, or any combination thereof. We used multivariate logistic regression to identify associations between participants' characteristics and advanced neoplasia in a primary (or derivation) data set, and we confirmed the associations in a secondary (or validation) data set.

RESULTS

Advanced neoplasia was detected in 2553 (5.9%) participants 50 to 66 years of age and in 243 (3.4%) participants 40 to 49 years of age. The rate of complications during colonoscopy was 0.1%, and no participants died. In the validation set, a logistic-regression model showed that male sex was independently associated with advanced neoplasia (adjusted odds ratio, 1.73; 95% confidence interval, 1.52 to 1.98; P<0.001). In each age group (40 to 49 years, 50 to 54 years, 55 to 59 years, and 60 to 66 years), the number of persons who would have to undergo colorectal-cancer screening in order to detect one advanced neoplasia was significantly lower in men than in women (23 vs. 36, 17 vs. 28, 12 vs. 22, and 10 vs. 18, respectively).

CONCLUSIONS

We detected advanced neoplasia at a significantly higher rate in men than in women, which may warrant refinement of the screening recommendations for colorectal cancer.

Multivariate analysis of risk factors for development of duodenal ulcer in Helicobacter pylori-infected patients

BACKGROUND

Although Helicobacter pylori is a significant etiologic factor of peptic ulcer disease, it remains unknown why ulcers develop only in the minority of infected individuals.

AIM

The aim of this cross-sectional study was to evaluate the association between the presence of duodenal ulcer in H. pylori-infected patients and different risk factors.

METHODS

A total of 122 H. pylori-infected patients were enrolled; 79 had duodenal ulcer and 43 gastritis. Univariate analysis was conducted using either Fisher's exact test or exact Cochrane-Armitage trend test. In multivariate analysis the logistic model was used.

RESULTS

Univariate analysis indicated six factors (male sex, smoking, antral H. pylori density, CAGA presence in antrum, and VACA s1a presence in antrum and corpus). Four factors (sex, smoking-alcohol index, H. pylori density index, and CAGA index) were found to be significant in multivariate analysis. The best model predicting duodenal ulcer included male sex, smoking, presence of H. PYLORI on histopathology in antrum and CAGA presence in corpus.

CONCLUSION

Although several risk factors were significantly associated with duodenal ulcer, we failed in the identification of either a single risk factor or a set of factors that can unequivocally differentiate patients with ulcer from those with gastritis.

Diffuse filiform polyposis of the colon in Crohn's disease. Case report

A case of giant diffuse filiform polyposis of the entire colon with pathological features of Crohn's disease in a 30-year-old man is presented. The most important aspects and difficulties with differential diagnosis of filiform polyposis are discussed.

p53 protein expression in esophageal squamous cell papillomas: a study of 36 lesions

BACKGROUND AND METHODS

In the present study 36 esophageal squamous cell papillomas (ESCP), uncommon benign neoplasms of the esophagus, were investigated retrospectively for p53 immunoreactivity by using the monoclonal antibody PAb 1801. Two ESCPs had previously been found to be human papillomavirus (HPV) type-6-positive.

RESULTS

Only very occasional epithelial cells were stained in two cases, and in three ESCPs p53 staining was restricted to the basal epithelial cells. Both HPV-positive ESCPs remained p53-negative.

CONCLUSION

We speculate that these findings are the result of immunohistochemical detection of the stabilized wild-type p53 protein rather then mutated p53 protein.

Malignant transformation of benign epithelial gastric polyps

OBJECTIVES

To compare the malignant potential of hyperplastic polyps and adenomas in relation to different histological classifications and to try to follow the natural history of the BEGP-carcinoma sequence.

METHODS

During a 13-yr period (1981-1993), 811 BEGP were discovered in 432 patients in consecutive esophagogastroscopic examinations in our department. Adequate endoscopic biopsies or polypectomy specimens were histologically diagnosed as hyperplastic polyp in 751 (92.6%) and adenoma in 60 (7.4%) of the lesions, according to WHO classification. Hyperplastic lesions were further divided into two subgroups: 268 were polypoid foveolar hyperplasia (FH) and 483 were typical hyperplastic polyps (HP), according to Elster's classification. Special attention was paid to focal malignancy at the first examination or malignant transformation of BEGP during follow-up. Ninety-six patients with 220 BEGP were followed for 1-11 yr, with an average of 2 yr and 8 months.

RESULTS

According to Elster's classification, there were 10/483 (2.1%) HP and 6/60 (10.0%) adenomas with focal carcinoma. Moreover, in 19/265 patients (7.1%) with HP and in 4/30 patients (13.3%) with adenomas, carcinoma was found elsewhere in the stomach. During our follow-up, 5/131 HP showed different steps of histological transformation: focal intestinal metaplasia in two, focal dysplasia in one, and focal carcinoma in two of them, which is 1.6%, 0.8%, and 1.6%, respectively. In 1/23 adenomas, focal carcinoma developed after 1 yr of observation (4.3%). Separate gastric carcinomas developed outside polyps during follow-up in 2/58 (3.5%) patients with hyperplastic polyps only. None of those with FH had focal carcinoma either at primary biopsy or during long-term observation. All proportions concerning gradual transformation of hyperplastic polyps classified as only one group according to WHO were lower.

CONCLUSIONS

In contrast to hitherto existing opinions, our results give support to the idea that gastric HP, like adenomas, are susceptible to malignant transformation. It seems sensible to separate a subgroup of FH from HP, since FH have no malignant potential until they change their histology to HP. The treatment of FH and HP as one group is the main reason why the malignant potential of hyperplastic polyps is still underestimated.

HIV/AIDS education for nurses in Poland

Funded by an agreement with the World AIDS Foundation, a team of American and Polish healthcare professional was established to provide expert and timely training on HIV/AIDS course for nurses was conducted in Gdansk, Poland. The course identified significant professionals concerns of Polish nurses, including fear of infection, discomfort with male sexuality, and lack of information about drug users. Precourse and postcourse evaluations demonstrated significant changes in level of comfort during discussions of sensitive topics and improvement in instructional self-confidence.

Human papillomavirus infection in esophageal squamous cell papillomas: a study of 29 lesions

The etiology and pathogenesis of esophageal squamous cell papillomas (ESCP), rare benign tumors of human esophagus, are still controversial. Chronic mucosal irritation and infection with human papillomaviruses (HPV) are two proposed etiologies. To investigate these hypotheses, we screened 29 ESCPs from 28 patients originating from Slovenia and Poland for HPV infection using in situ hybridization (ISH) and polymerase chain reaction (PCR). No evidence of HPV DNA was found using ISH. By PCR, the presence of HPV DNA was detected in only one lesion using two different HPV L1 consensus primer sets. The restriction fragment analyses of PCR product showed patterns unique to HPV type 6. All other ESCPs were successfully amplified only with internal control human beta-globin primers. Our results show that HPV DNA is not frequently detectable in ESCPs, even when highly sensitive methods like PCR are used and that other pathogenetic mechanisms are more important in the etiology of ESCPs.

Squamous cell papillomas of the esophagus: report of 20 cases and literature review

A series of 20 patients with 24 squamous cell papillomas of the esophagus are presented. Nonspecific symptoms not directly connected with esophageal disorders were the reason for esophagoscopy. Clinical findings, treatment, and follow-up of the patients in the context of the world literature review of 141 cases reported to date, are discussed.

A conservative approach to granular cell tumors of the esophagus: four case reports and literature review

We present here four patients with six granular cell tumors of the esophagus: all are women, 22, 38, 47, and 49 yr old. In three of them, single polyps were encountered. In the fourth, age 38, two lesions were found in 1982, and a new one, a satellite polyp, has appeared after 5 yr of follow-up. All of the patients' conditions were followed up [mean time 65 months (16 months to 10 yr)]. In connection with these case reports, we include an up-to-date review of the world literature on this subject.

Carcinoma in hyperplastic polyps of the stomach. An underestimated possibility. Case reports

The formation of carcinoma in the hyperplastic gastric polyp is extremely rare. This paper presents two cases of carcinomas which developed in hyperplastic polyps of the stomach in a 39-year-old man and an 82-year-old man. The problem of malignant transformation of gastric hyperplastic polyps is stressed and discussed in the light of data in the literature.

Multifocal gastric carcinoma arising from hyperplastic and adenomatous polyps

This paper is a presentation of the unusual case of a 61-yr-old woman operated on for multiple gastric cancers. Two of the cancers were found in the hyperplastic polyps and one in the adenoma. Apart from cancers that arose from these polyps, there were four separate polypoid or flat gastric carcinomas and three other hyperplastic polyps with no signs of malignancy, in this case. The presentation is followed by a detailed discussion focusing on the possible development of carcinoma in gastric hyperplastic polyps in view of the data from the literature.

Reduced thickness of gastric mucosa and retarded progression of chronic gastritis in patients with renal failure

Conflicting results are reported in the literature on the structure and function of gastric mucosa in patients with chronic renal failure (CRF). In the present endoscopic study of 68 CRF patients on conservative treatment (regular dialyses or transplantations had not yet been undertaken), we sought to clarify whether CRF leads to hypertrophic or hypotrophic phenomena in gastric mucosa, as interpreted by the presence and grade of gastritis and by the thickness of the gastric mucosa. We found that the mean progression of gastritis in both antrum and body was significantly slower than expected in CFR patients, and that the thickness of both antral and body mucosa was significantly lower in CFR patients than in non-CRF controls. Furthermore, although the thickness of the oxyntic body mucosa in CRF showed a positive correlation to serum gastrin (SeGa) levels and even though 12 of the patients showed high SeGa levels corresponding to those seen in the Zollinger-Ellison synbdrome (300-1500 ng/l), the thickness of the oxyntic body mucosa in CRF patients did not exceed that seen in control subjects with normal SeGa. We conclude that CRF exerts inhibitory effects on the gastric mucosa resulting in retardation in the progression of chronic gastritis and hypotrophy of the gastric mucous membrane.

A conservative approach to adenomas containing invasive carcinoma removed colonoscopically

A controversy exists as to the correct therapeutic approach to colorectal polyps that contain malignancy and are removed colonoscopically. This paper presents our experience in the management of such polyps. Between 1977 and 1983, a total of 117 patients underwent colonoscopic polypectomy for 178 adenomas. Nine adenomas from nine patients showed carcinomatous invasion across the line of muscularis mucosae. None of these carcinomas was poorly differentiated and in all but two cases there was histologic evidence of complete excision. Seven patients whose adenomas containing foci of malignant changes were treated by polypectomy alone are alive without recurrence at periods from six months to over five years (mean, 40 months). The two patients in whom endoscopic removal of cancerous adenomas was found to be either doubtfully complete or incomplete, had further surgical treatment; both are alive and well after one and five years, respectively. Nine other patients whose adenomas containing malignant changes were considered unsuitable for colonoscopic polypectomy, underwent surgical resection and in none was regional lymph node or distant metastases found at laparotomy. In conclusion, our results of local endoscopic excision for adenomas containing malignant changes suggest a conservative approach to such polyps and this policy is supported by the finding that, in none of our operated patients was there any evidence of metastatic disease.

Miliary Crohn's disease

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[Malignant meningioma with extracranial metastases]

The authors report a case of primary malignant meningioma of meninges in the right frontal area with metastases to meninges in the right temporal area and left atrial endocardium and with emboli composed of malignant cells in the vessels of the myocardium, spleen, liver, lungs and pancreas in a 49-year-old woman after commissurotomy performed for rheumatic valvular heart disease.