A case of early-stage type 3 gastric neuroendocrine tumor in the upper body of the stomach: is endoscopic resection feasible?

Although gastric neuroendocrine tumors (NETs) are uncommon compared with gastric carcinomas, the incidence of NETs has been recently increasing. Gastric NETs are classified into three subgroups, and among these, gastrin-independent sporadic type 3 gastric NETs have a poor prognosis because of frequent lymph node or distant metastasis. We experienced a case of an early-stage type 3 gastric NET associated with lymphovascular and submucosal invasion. In a 54 year-old woman, esophagogastroduodenoscopy performed during a health screening identified an elevated lesion of the upper body of the stomach. The results of immunohistochemical analyses of endoscopic biopsy specimens obtained from the lesion were positive for chromogranin A and synaptophysin, indicating an NET. Because the patient's serum gastrin level was normal and she had no predisposing conditions for NET development, the tumor was diagnosed as a type 3 gastric NET. The patient underwent local resection of the tumor and regional lymph node dissection. The resected specimen indicated a diagnosis of type 3 gastric NET with invasion into the submucosa and lymphatic duct. This is an extremely rare case of an early-stage type 3 gastric NET. Our discussion provides insight into the pathogenesis and development of these tumors and the appropriate therapeutic strategy.

Gastric type III heterotopic pancreas presenting as adenomyoma in the antrum of the stomach: a case report.

Although heterotopic pancreas usually occurs in the stomach and rarely presents as a submucosal tumor, an accurate preoperative diagnosis is often difficult because of the variety of clinical symptoms and findings depending on the size and location of the lesion. We experienced a case of gastric type III heterotopic pancreas presenting as a gastric adenomyoma in the antrum of the stomach. A 62-year-old woman visited a local hospital for epigastric discomfort. An esophagogastroduodenoscopy study indicated a submucosal tumor in the greater curvature of the gastric antrum. The patient underwent surgical resection of the tumor because it was enlarged. The histological sections of the resected specimen showed that the tumor was composed of ductular structures lined by tall columnar epithelia and a prominent smooth muscle stroma with no atypical cells. The tumor was compatible with Heinrich's type III heterotopic pancreas, which presented as an adenomyoma of the stomach. These findings provide useful histological features and some insight into a better understanding of the embryonic origin and development of adenomyoma and heterotopic pancreas in the antrum of the stomach.

[Significance of Inflammatory/Nutritional Index in Pathological Stage â ¡-â ¢ Colorectal Cancer].

The aim of this study was to evaluate the inflammatory/nutritional index in patients with colorectal cancer. A total of 600 patients with pStage Ⅱ-Ⅲ colorectal cancer who underwent radical resection at our hospital between January 2008 and September 2022 were retrospectively reviewed. Onodera's prognostic nutritional index(OPNI), CRP-to-albumin ratio, modified Glasgow prognostic score, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, lymphocyte-to-monocyte ratio were measured preoperatively. Clinical and pathological data were assessed using univariate and multivariate analysis to determine prognostic factors for overall survival(OS), relapse-free survival(RFS)and post-relapse overall survival (PROS). Moreover, these patients were divided into high and low groups based on OPNI, these survival outcome for OS, RFS and PROS were assessed using Kaplan-Meier analysis with the logrank test. In multivariate analysis, the independent prognostic factors were gender, age, OPNI, histological type, pStage for OS, gender, OPNI, venous invasion and pStage for RFS, and OPNI, histological type and resection of recurrent site for PROS. In Kaplan-Meier analysis, patients in the low OPNI group had significant poor prognosis for OS, RFS and PROS. OPNI is a useful prognostic factor in colorectal cancer.

Gastric collision tumor composed of early-stage gastric carcinoma and gastrointestinal stromal tumor: a case report.

Collision tumors composed of adenocarcinoma and gastrointestinal stromal tumor (GIST) of the stomach are extremely uncommon, and only a few cases have been reported in the English literature. In the present case, a 67-year-old woman visited a local hospital for vomiting and hematemesis. An esophagogastroduodenoscopy study indicated an elevated lesion with ulceration. Histology of the endoscopic biopsy specimen indicated gastric adenocarcinoma. The patient underwent laparoscopic distal gastrectomy with D2 lymph node dissection. The resected specimen showed that the primary tumor consisted of a GIST and that early-stage gastric carcinoma coexisted in the mucosa surrounding the central ulceration of the GIST. Although close contact of the adenocarcinoma and GIST was observed on the mucosal surface, no intermixing of tumor cells was observed in the primary tumor. This case is an extremely rare case of a collision tumor composed of early-stage gastric adenocarcinoma and GIST occurring in the stomach, which provides some insight into a better understanding of the pathogenesis of collision tumors.

Widespread mesenteric phlebosclerosis presenting as intestinal obstruction due to stenosis of the right-sided colon.

Mesenteric phlebosclerosis is a rare form of intestinal ischemia characterized by thickening of the right-sided colon and calcification of the mesenteric vein. We describe the case of a 58-year-old woman admitted to our hospital because of abdominal pain and distension. An abdominal computed tomography study revealed remarkable dilatation and fluid collection of the small intestine compatible with intestinal obstruction, which was considered to be the result of stenosis of the ascending colon. The thickened wall of the cecum and ascending colon was associated with calcification of the colonic wall and mesenteric veins. Colonoscopy showed dark purple discoloration of the edematous mucosa from the splenic flexure through the hepatic flexure, at which point the colonoscope could not be advanced further because of stenosis of the ascending colon. Over 10 years previously, the patient had taken an herbal medicine containing gardenia fruit, which can cause mesenteric phlebosclerosis. An extensive colonic resection was performed after intestinal decompression. This case highlights extensive mesenteric phlebosclerosis causing intestinal obstruction from the cecum through the proximal portion of the sigmoid colon, which was treated with extensive colonic resection.

Uniportal video-assisted thoracic surgery and perioperative pirfenidone for lung cancer and idiopathic pulmonary fibrosis: a case report.

Patients with idiopathic pulmonary fibrosis (IPF) occasionally experience acute exacerbations after surgery for lung cancer. Several recent studies have revealed a prophylactic effect of perioperative pirfenidone treatment on postoperative acute exacerbations of IPF in patients with lung cancer. A 75-year-old woman consulted with her pulmonologist because of an IPF shadow detected by follow-up chest computed tomography 2 months after surgical treatment of biliary cancer. Another 7 months later, chest computed tomography showed a 23- × 14-mm nodule located in the right lower lobe with high accumulation of fluorodeoxyglucose detected by positron emission tomography, resulting in a radiological diagnosis of primary lung cancer with IPF. We administered perioperative pirfenidone treatment followed by right lower lobectomy using uniportal video-assisted thoracoscopic surgery after attaining a pathological diagnosis of adenocarcinoma. The patient developed no acute exacerbations of IPF during the postoperative period, and she had no recurrence of lung cancer for 15 months after surgery. We successfully used a combination of perioperative antifibrotic medication and minimally invasive surgery after lung cancer surgery in a patient with IPF.

A bronchial mucous gland adenoma harboring GNAS R201C mutation.

We present a case of bronchial mucous gland adenoma (MGA) and discuss the results of its cytomorphological and cytogenetic examination serving as a basis for the differential diagnosis. To our best knowledge, this is a first report that demonstrate a GNAS gene (R201C) mutation in mucous gland adenoma, which may play an important role in MGA tumorigenesis, as is the case in other mucinous-type epithelial neoplasms of various organs.

A case of gastric ischemia caused by massive gastric dilatation due to superior mesenteric artery syndrome.

Gastric ischemia is extremely rare and its endoscopic findings appear similar to those of malignant tumors, which makes accurate diagnosis difficult. We present the case of a 41-year-old woman who was admitted to our hospital for severe abdominal pain and vomiting. Laboratory data at the time of admission indicated high serum levels of C-reactive protein, fibrin/fibrinogen degradation products and D-dimer. An abdominal computed tomography (CT) scan revealed a massive dilatation of the stomach and descending portion of the duodenum, which abruptly narrowed at the portion between the superior mesenteric artery and the aorta, indicating massive gastric and duodenal dilatation due to superior mesenteric artery syndrome. Decompression of the upper gastrointestinal tract using a nasogastric tube was started immediately. An esophagogastroduodenoscopy revealed a massive, irregular ulcerative lesion with ill-defined boundaries located in the posterior wall along the greater curvature of the stomach. Although this lesion mimicked a malignant lesion, the biopsy findings revealed a benign gastric ulcer, indicating that the lesion was gastric ischemia caused by the increased intragastric pressure resulting from the massive dilatation. The gastric ischemia healing process was successfully observed through repeated endoscopic examinations of the upper gastrointestinal tract. The patient's abdominal symptoms disappeared within 10 days and she was discharged from the hospital 23 days after the abdominal episode. This case highlights gastric ischemia associated with an acute massive gastric dilatation resulting in increased intragastric pressure caused by superior mesenteric artery syndrome.

An Autopsy Case of Edwardsiella tarda Meningoencephalitis.

A 62-year-old male with a history of alcohol abuse was admitted with a headache and rapidly progressing altered consciousness that led to coma over several hours. Blood and cerebrospinal fluid cultures were positive for Edwardsiella tarda. Despite prompt treatment initiation, the patient died on the third hospital day. Autopsy showed meningitis of the entire cerebrum with ventriculitis, and alcoholic fatty liver was observed. Clinicians should be cognizant of E. tarda meningoencephalitis, a rare presentation which can be associated with poor outcomes in patients with excessive alcohol consumption and alcoholic liver disease.

Development and external validation of a nomogram to predict high-grade papillary bladder cancer before first-time transurethral resection of the bladder tumor.

BACKGROUND: The aim of this study was to identify the clinical predictors related to the risk of high-grade papillary bladder cancer before first-time transurethral resection of a bladder tumor (TUR-Bt), and to develop and validate a nomogram predicting the risk of high-grade papillary bladder cancer. METHODS: A retrospective clinical study of consecutive patients who underwent first-time TUR-Bt for papillary bladder cancer was performed. Medical records were reviewed uniformly, and the following data were collected: age, sex, episodes of urinary symptoms, tumor size, number of tumors, location of the largest tumor (lateral walls, base, posterior wall, dome, and anterior wall), tumor appearance (papillary or non-papillary, pedunculated or sessile), and urinary cytology. Data from 254 patients (Group A) were used for the development of a nomogram, while data from 170 patients (Group B) were used for its external validation. RESULTS: High-grade papillary bladder cancer was pathologically diagnosed in 51.6 and 74.6% of Group A and Group B patients, respectively. Based on univariable analyses in Group A, macrohematuria, tumor size, multiple tumors, appearance, and positive urinary cytology were selected as variables to incorporate into a nomogram. The AUC value was 0.81 for the internal validation (Group A), and 0.78 for the external validation (Group B). This novel nomogram can predict high-grade papillary bladder cancer accurately. CONCLUSIONS: The present nomogram can help clinicians calculate the probability in patients with bladder cancer before TUR-Bt and decide on earlier intervention and priorities for the treatment of patients diagnosed with bladder cancer.

[Syphilitic orchitis: a case report].

Tertiary syphilis is recently a rare disease in Japan. In this paper, we report a rare case of syphilitic orchitis. The patient was in his early forties. The left scrotal contents were swelling and a low echoic nodule measuring about 30 mm in diameter was detected on ultrasonography. Serum alpha fetoprotein, lactate dehydrogenase, and beta subunit of human chorionic gonadotropin were within the normal range, whereas Treponema pallidum hemagglutination assay and rapid plasma reagin were strongly positive. High orchiectomy was performed for suspicion of testicular tumor. Histological findings showed the non-specific inflammatory granuloma with lympho-plasmatic infiltration. It was diagnosed as granulomatous inflammation of left testis caused by syphilis.

[A case of carcinosarcoma of the urinary bladder].

A 66-year-old woman visited our hospital complaining of painful, irritative urinary symptoms and macroscopic hematuria. Cystoscopy revealed a non-papillary tumor covered with necrotic tissue on the right side of the posterior wall of the bladder. Transurethral resection was performed ; histologically, the tumor was found to be composed of carcinomatous and sarcomatous elements. The carcinomatous element consisted of urothelial and squamous cell carcinomas. The sarcomatous element was composed of osteosarcoma, chondrosarcoma and spindle cell sarcoma. Immunohistochemical examination showed that the carcinomatous component was positive for cytokeratin and the sarcomatous component was positive for S-100 protein. The patient underwent total cystectomy with ileal conduit under the diagnosis of carcinosarcoma. Pathological examination showed no residual tumor. She was followed up with no signs of recurrence or metastasis. Computed tomography (CT) at nine months following surgery showed no evidence of recurrence. However, thirteen months after the operation, she complained of lower abdominal pain, and CT demonstrated a bulky intrapelvic tumor and right hydronephrosis. Her condition worsened rapidly and she died one month later.

[A case of urachal carcinoma treated with S-1/CDDP combination chemotherapy].

No established treatment exists for urachal carcinoma,except curative resection,and its prognosis is poor. More than 80% of urachal carcinomas are adenocarcinomas. We report a case of advanced urachal carcinoma treated with S-1 and cisplatin combination (S-1/CDDP) chemotherapy. The patient,a 61-year-old woman,presented with macroscopic hematuria. A tumor was detected on the bladder dome and transurethral resection was performed. Histopathological findings indicated poorly differentiated adenocarcinoma. Serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were 3.5 ng/ml and 140 U/ml respectively. Magnetic resonance images indicated an extension of this tumor to the retroperioneal space. Metastasis to her right ischium was suspected from bone scintigraphy results. The tumor was diagnosed as stage IVB (Sheldon's category) urachal carcinoma. After one cycle of S-1/CDDP chemotherapy,the size of the tumor on the bladder dome decreased,after which total cystectomy was performed. The surgical margin of the cystectomy specimen was negative for malignant cells,although poorly differentiated adenocarcinoma was still observed in this specimen. The findings of this study indicate that this therapy might be beneficial for treating advanced urachal carcinomas. This is the second report of successful treatment of advanced urachal carcinoma with S-1/CDDP chemotherapy.

[A case of advanced esophageal cancer with no recurrence treated biweekly with postoperative docetaxel/nedaplatin combined chemotherapy after non-curative surgery].

We report a case of non-curatively resected esophageal cancer with no recurrence biweekly treated with postoperative docetaxel/nedaplatin combined chemotherapy. A 59-year-old woman underwent non-curative resection with esophagectomy for advanced esophageal cancer with direct invasion to the descending aorta in August, 2007. Postoperatively, she was treated biweekly with docetaxel/nedaplatin combined chemotherapy 32 times. In this period, there was no finding in the enhanced CTs, and clinically she was free from recurrence. The quality of life of this patient was also good. Thus, postoperative biweekly docetaxel/nedaplatin combined chemotherapy could be effective for advanced esophageal cancer after non-curative surgery and might be promising for long-term survival. This combined chemotherapy could be carried out on an outpatient basis, and the quality of life could also be preserved. More experience must be accumulated using this chemotherapy.

[A case of advanced gastric cancer with peritoneal metastasis successfully treated over 19 months with postoperative chemotherapy after non-curative surgery].

We report a case of non-curatively resected gastric cancer successfully treated with postoperative continuous chemotherapy, resulting in long-term survival of 19 months. A 75-year-old woman underwent non-curative resection with total gastrectomy for advanced gastric cancer with peritoneal metastasis in June, 2005. Postoperatively, at first, she received oral administration of S-1. However, due to grade 2-3 nausea and anorexia, the dose of S-1 was reduced. After four courses, the value of the tumor markers increased. Next, we chose sequential methotrexate and 5-fluorouracil therapy, but no decrease tumor markers could be obtained. Then, 9 months after surgery, biweekly paclitaxel (PTX) chemotherapy was performed. The value of the tumor markers gradually decreased or stopped increasing, and PTX was administered 18 times. In this period, the quality of life of this patient was good. Eighteen months after surgery, the value of the tumor markers increased again, and S-1 and CPT-11 combination therapy was chosen. However, the patient died of brain infarction 19 months after surgery. Thus, continuous and persevering chemotherapy could be effective for advanced gastric cancer with peritoneal metastasis and may be promising for long-term survival.

Large regenerative nodule perfused by the portal vein.

In a 42-year-old Japanese woman with esophageal varices, abdominal ultrasound (US) demonstrated a hyperechoic lesion 3 cm in diameter in segment 4 (S4). This nodular lesion had high intensity on T1-weighted magnetic resonance imaging (MRI), low intensity on T2, and very high intensity on superparamagnetic iron oxide (SPIO) enhanced MRI. Angiography showed sparse distribution of arterial branches and dense distribution of portal branches in S4. Meandering, thin arteries were seen in the peripheral area of the right lobe. The second branches of the portal vein were hardly visualized anywhere in the liver. Computed tomography arterioportography (CTAP) revealed portal blood flow dominance in this nodular lesion. There was no evidence of ischemic liver damage, such as thromboembolic episodes, laboratory data of liver damage, coagulation abnormalities etc. Therefore this abnormality was more likely to be caused by anomalous changes than thrombotic changes. Needle biopsy revealed no atypical cells. Two years later, the nodule size was reduced to 1.9 cm, showing its benign nature. Based on these findings, this lesion was classified as a new type of large regenerative nodule (LRN) associated with anomalies in the portal veins and arteries. This is the first report of an LRN of this size in which portal vein perfusion was dominant. Moreover, this lesion was difficult to differentiate from hepatocellular carcinoma (HCC) by imaging. Analysis of the images and pathological features of this case would contribute to a better understanding of the pathogenesis of nodular lesions of the liver.

A diagnostic pitfall: Angiosarcoma of the brain mimicking cavernous angioma.

Primary or secondary angiosarcoma in the central nervous system is rarely reported. We present a rare case of cerebral angiosarcoma, which comprised both poorly-differentiated solid areas and well-differentiated areas that led to the misdiagnosis of cavernous angioma. A 79-year old woman presented with an intracerebral hematoma in the left frontal lobe that was misdiagnosed as a hemorrhage from a cavernous angioma at initial operation. At a second surgery, the lesion was diagnosed as angiosarcoma involving the cerebellum, heart, femur, sacro-iliac bones and other locations. An autopsy suggested that the angiosarcoma of the heart was the primary lesion, which was occult at the time of the initial operation. Angiosarcoma may have areas with different degrees of differentiation and when a cavernous angioma is suspected histopathologically, the specimen should also be carefully explored for poorly-differentiated areas and the diagnosis of primary or secondary angiosarcoma considered.

Dedifferentiated adenoid cystic carcinoma: a clinicopathologic study of 6 cases.

Dedifferentiated adenoid cystic carcinomas are a recently defined, rare variant of adenoid cystic carcinomas characterized histologically by two components: conventional low-grade adenoid cystic carcinoma and high-grade "dedifferentiated" carcinoma. We examined six cases and analyzed their clinicopathologic profiles, including immunohistochemical features and p53 gene alterations. The 6 patients (3 men and 3 women) had a mean age of 46.8 years (range, 34-70 y). The mean size of the tumors was 3.5 cm (range, 1.7-6 cm). The submandibular gland, maxillary sinus, and nasal cavity were involved in 2 cases each. Postoperatively, 5 patients had local recurrence and 5 developed metastatic disease. Five patients died of disease at a mean of 33.7 months after diagnosis (range, 6-69 mo), and one other was alive with disease at 60 months. Histologically, the conventional low-grade adenoid cystic carcinoma component of the tumors consisted of a mixture of cribriform and tubular patterns with scant solid areas. The high-grade dedifferentiated carcinoma component was either a poorly differentiated adenocarcinoma (4 cases) or undifferentiated carcinoma (2 cases). Three tumors were studied immunohistochemically. Myoepithelial markers were expressed in low-grade adenoid cystic carcinoma but not in the dedifferentiated component. In 2 cases, diffusely positive p53 immunoreactivity together with HER-2/neu overexpression was restricted to the dedifferentiated component. Loss of pRb expression was demonstrated only in the dedifferentiated component of the 1 other case. The Ki-67-labeling index was higher in the dedifferentiated component than in the low-grade adenoid cystic carcinoma component. Furthermore, molecular analysis of 2 cases demonstrated the loss of heterozygosity at p53 microsatellite loci, accompanied by p53 gene point mutation, only in the dedifferentiated carcinoma component of 1 case, which was positive for p53 immunostaining. These results indicate that dedifferentiated adenoid cystic carcinoma is a highly aggressive tumor. Because of frequent recurrence and metastasis, the clinical course is short, similar to that of adenoid cystic carcinomas with a predominant solid growth pattern. Limited evidence suggests that p53 abnormalities in combination with HER-2/neu overexpression or loss of pRb expression may have a role in dedifferentiation of adenoid cystic carcinoma.

[Morphological changes of interventricular septum in long-term follow-up cases].

In patients who could be followed by echocardiography for a long period, the clinical significance of sigmoid septum and basal septal hypertrophy including long-term changes was investigated in patients with hypertension. The subjects were 66 patients (24 males and 42 females, mean age: 53 +/- 12 years old) who underwent repeated echocardiography, and the initial examination and observation after long-term follow-up (mean duration of follow-up: 10.8 +/- 1.4 years) were compared. Sigmoid septum was more advanced at the time of initial examination in the hypertensive group than in the normotensive group, but it was similarly advanced after the long-term follow-up in both groups. There was no significant difference in basal septal hypertrophy between the hypertensive and normotensive groups at the time of initial examination, but significant increases in thickening were observed in the hypertensive group after the long-term follow-up. The above findings suggested that morphological changes in the interventricular septum reflect the severity of arteriosclerosis that is expected to be more advanced in hypertensive patients than in normotensive patients.