Falls from heights while clearing snow in Akita prefecture: Re-evaluation after preventive countermeasures and public service.

BACKGROUND: This study was performed to re-examine the incidence of falls from heights while clearing snow in Akita prefecture after implementation of preventive countermeasures and a public service campaign. METHODS: This was a retrospective analysis of registration data from the section regarding prevention against natural disasters in the Akita prefectural office. The study population comprised all patients who fell from heights while clearing snow and were transported to the emergency department from December 2015 to March 2018. RESULTS: In total, 168 individuals (159 male, 9 female) fell from heights while clearing snow. Their mean age was 65.7 years (range, 19-92 years). The largest proportion of falls occurred in January (54.2%; 91 patients). The most common region in which the falls occurred was the inland part of the southern district of Akita prefecture, which accounted for 73.8% of the falls (124 patients). Individuals aged ≥65 years constituted 52.9% of the patients (n = 89). The most common mechanism of injury was a fall from a rooftop, which accounted for 62.5% of the falls (105 patients), followed by a fall from a ladder (31.0%; 52 patients). The most common sites of injury were the upper and lower extremities (39.2%; 66 patients), followed by the spine (36.3%; 61 patients). Seven of the patients died. CONCLUSIONS: Compared with a previous study by Hatakeyama et al. (Falls from heights while clearing snow in Akita Prefecture. Rinsyou Seikeigeka Clin Orthop Surg 2013 Nov; 48(11): 1091-4 [in Japanese]), the total number of patients who fell from heights while clearing snow decreased by one-half. However, the number of persons aged ≥65 years increased and constituted 52.9% of the patients, reflecting the rapidly expanding older population in Akita prefecture.

An epidemiological study of traumatic spinal cord injuries in the fastest aging area in Japan.

STUDY DESIGN: Retrospective epidemiological study. OBJECTIVE: To investigate the epidemiology of traumatic spinal cord injury (TSCI) in the fastest aging area in Japan. SETTING: Hospitals in Akita Prefecture, Japan. Akita Prefecture has the highest ratio of people aged 65 or older in Japan (30.4% in 2012 and 34.6% in 2016). METHODS: Patients with acute TSCI who required hospital treatment between 2012 and 2016 were included. The incidence of TSCI, cause, level, skeletal injury, and Frankel grade were investigated. RESULTS: The mean annual incidence of TSCI excluding Frankel E was 86 per million (range 86-104 per million) during the 5-year study period, with a mean age of 65.9 years (male, 75.1%) and patients in their 60s as the largest age group. Cervical injury was seen in 89.8%, and cervical TSCI without skeletal injury was seen in 65.5%. Frankel D was the most common neurological deficit (53.5%). The most common cause was falls on level surfaces (32.1%), followed by low falls (21.6%) and road traffic accidents (15.6%). CONCLUSIONS: Recent incidence and characteristics of TSCI in the fastest aging society in Japan are presented. The incidence of incomplete cervical TSCI and falls on level surfaces appear to be increasing.

Limaprost or Pregabalin: Preoperative and Postoperative Medication for Pain due to Lumbar Spinal Stenosis.

PURPOSE: We aimed to evaluate the incidence of (and risk factors for) postoperative pregabalin and/or limaprost to treat persistent numbness and/or pain of the lower extremities after lumbar spinal stenosis (LSS) surgery. METHODS: Medical records of 329 patients (168 men, 161 women; average age 70 years) were retrospectively reviewed for data on the duration of LSS diagnosis; LSS disease; preoperative medication (limaprost, pregabalin, or combined limaprost/pregabalin; duration); symptoms; preoperative/postoperative intermittent claudication (IC); operation type; and postoperative medication and period. RESULTS: Limaprost, pregabalin, and combined limaprost/pregabalin were prescribed preoperatively for 43%, 7%, and 5% of patients, respectively. At an average of 21 months postoperatively, limaprost, pregabalin, and combined therapy were prescribed in 11%, 8%, 4% of patients, respectively. Medication requirement was significantly lower postoperatively than preoperatively (P < 0.0001). Significant risk factors for required postoperative medication were required preoperative medication (odds ratio [OR] 3.088, 95% confidence interval [CI] 1.679 to 5.681]; postoperative period (OR 1.063, 95% CI 1.031 to 1.096); and postoperative IC (OR 3.868, 95% CI 1.481 to 10.103). A negative impact from postoperative medication was seen in patients who had undergone decompression surgery (OR 0.589, 95% CI 0.377 to 0.918). CONCLUSIONS: Overall, 23% of LSS patients required medication for pain and/or numbness at 21 months postoperatively. Significant factors portending required postoperative medication were preoperative medication, longer postoperative period, and postoperative IC. A negative influence from postoperative medication was seen in patients who had undergone decompression surgery without fusion.

Comparison of utility of tumor size and apparent diffusion coefficient for differentiation of low- and high-grade clear-cell renal cell carcinoma.

BACKGROUND: There is a significant correlation between tumor size and tumor grade for clear-cell renal cell carcinoma (RCC) in pathology. Thus, apparent diffusion coefficient (ADC) of clear-cell RCC might be influenced by tumor size. PURPOSE: To compare the utility of tumor size and ADC for distinguishing low-grade from high-grade clear-cell RCC. MATERIAL AND METHODS: Forty-nine patients undergoing preoperative magnetic resonance imaging were retrospectively assessed. ADC values were calculated using b-value combinations of 0 and 800 s/mm(2) at 1.5 T. Two radiologists in consensus measured ADC values via small region of interest (ROI) (mean ROI area, 88.8 mm(2); range, 80-108 mm(2)) placement on an area of solid tumor on a single slice. Maximum tumor diameter was measured at the maximum tumor area. A single pathologist reviewed all pathological slides to determine the nuclear grade according to the Fuhrman classification. The utility of ADC, tumor size, and ADC/size ratio for distinguishing low-grade from high-grade tumors was assessed. Receiver-operating characteristic (ROC) analysis and regression analysis of the each index were performed. The correlation between ADC and tumor size was also investigated. RESULTS: The 49 clear-cell RCC included 34 low-grade and 15 high-grade tumors. The differences of ADC, tumor size, and ADC/size ratio between high-grade and low-grade tumors were statistically significant (P <0.05). The area under the ROC curve of ADC, tumor size, and ADC/size ratio were 0.802, 0.763, and 0.804 respectively. However, using regression analysis, only ADC (P <0.05) was statistically significant index as independent risk factors for high-grade clear-cell RCC. Moreover, weak significant correlation was observed between tumor size and ADC (R(2) = 0.3865, P <0.01). CONCLUSION: There was a weak significant correlation between tumor size and ADC value of clear-cell RCC. Using ROC and regression analysis, ADC was statistically significant index for distinguishing low-grade from high-grade clear-cell RCC more than tumor size and ADC/size ratio.

Skin temperature in lower hind limb subjected to distal vein arterialization in rats.

Vascular surgery for distal vein arterialization (DVA) has been adopted clinically as a strategy for saving arteriosclerotic lower limbs from amputation. To gain more detailed information on DVA, the present study investigated the procedure in hind limbs of rats under isoflurane anesthesia. Since successful DVA requires destruction of venous valves, a coronary angioplasty catheter guidewire was used to destroy valves either solely in the femoral vein or in both femoral and popliteal veins. The femoral artery was then anastomosed to the femoral vein with sutures under binocular microsopic control. Changes in the distribution of skin blood flow in the hind limbs were studied with a thermal camera. Skin temperature increased in the thigh and knee after femoral venous valve destruction, but hyperthermia was observed in the distal leg and foot only when the valves in the popliteal vein were also disrupted. These results showed that increased arterial blood flow could be established by DVA surgery in both the proximal and distal regions of the hind limbs.

KRAS and MAPK1 gene amplification in type II ovarian carcinomas.

In this study, we examined the clinical significance of KRAS and MAPK1 amplification and assessed whether these amplified genes were potential therapeutic targets in type II ovarian carcinoma. Using fluorescence in situ hybridization, immunohistochemistry, and retrospectively collected clinical data, KRAS and MAPK1 amplifications were identified in 9 (13.2%) and 5 (7.4%) of 68 type II ovarian carcinoma tissue samples, respectively. Interestingly, co-amplification of KRAS and MAPK1 seemed to be absent in the type II ovarian carcinomas tested, except one case. Active phospho-ERK1/2 was identified in 26 (38.2%) out of 68 type II ovarian carcinomas and did not correlate with KRAS or MAPK1 amplification. There was no significant relationship between KRAS amplification and overall or progression-free survival in patients with type II ovarian carcinoma. However, patients with MAPK1 amplification had significantly poorer progression-free survival than patients without MAPK1 amplification. Moreover, type II ovarian carcinoma cells with concomitant KRAS amplification and mutation exhibited dramatic growth reduction following treatment with the MEK inhibitor PD0325901. These findings indicate that KRAS/MAPK1 amplification is critical for the growth of a subset of type II ovarian carcinomas. Additionally, RAS/RAF/MEK/ERK pathway-targeted therapy may benefit selected patients with type II ovarian carcinoma harboring KRAS/MAPK1 amplifications.

Causes and Clinical Outcomes of Patellar Post Impingement.

BACKGROUND: Patellar post impingement (PPI), which occurs when the post impinges on the patella, may reportedly cause poor total knee arthroplasty (TKA) outcomes. The causes of PPI and its effect on clinical outcomes and symptoms were investigated. MATERIAL AND METHODS: The study subjects were 100 patients who underwent TKA (65 posterior stabilized TKA, 35 bi-cruciate stabilized [BCS] TKA). Whether PPI occurred during surgery was investigated; the patients were then classified into a PPI+ group and a PPI- group, and whether the implant or patellar shape was related to the occurrence of PPI was examined. The measurement parameters included patellar shape, joint range of motion (ROM), and clinical outcome using the new Knee Society Score. RESULTS: There were 38 knees in the PPI+ group and 62 knees in the PPI- group. There was no difference in patellar shape between the 2 groups, but PPI was more frequent in patients with short patellar tendon and those with low patellar height. In terms of implant type, the PPI+ group included 12 patients (18.5%) who underwent posterior stabilized TKA and 26 (74.3%) who underwent BCS TKA. There was no difference between the 2 groups in either joint ROM or new Knee Society Score. These results suggest that the position of the patella and implant shape that causes the post to be positioned anteriorly may contribute to PPI. CONCLUSION: PPI occurred more frequently in knees with low patellar height and in patients who had undergone BCS TKA. PPI had no effect on joint ROM or clinical outcome.

Early and delayed effects of AST-120 on chronic cyclosporine nephropathy.

BACKGROUND: Removal of uraemic toxins by AST-120 (Kremezin(®)) decreases the progression of chronic kidney disease by reducing oxidative stress. We performed this study to evaluate whether AST-120 has a similar effect on progression of cyclosporine (CsA)-induced renal injury. METHODS: Two separate studies were performed in adult Sprague-Dawley rats. First, AST-120 was administered with CsA (15 mg/kg) for 4 weeks (early treatment). Second, AST-120 was administered to the rats for 3 weeks after treatment with CsA for 3 weeks (delayed treatment). Uraemic toxin and oxidative stress were evaluated with plasma indoxyl sulphate (IS) levels and urinary 8-OHdG excretion. The effects of AST-120 on CsA-induced renal injury were evaluated in terms of renal function, interstitial fibrosis, inflammation, and apoptotic cell death. RESULTS: CsA treatment for 4 weeks showed 2-fold increase in plasma IS and urinary 8-OHdG levels compared with the VH group. Early treatment with AST-120 significantly decreased both parameters, and this was accompanied by improved renal function and decreased interstitial inflammation, fibrosis, and apoptotic cell death compared with those of rats that received CsA alone. Delayed treatment with AST-120 also decreased the plasma IS and urinary 8-OHdG levels, and reduced the progression of chronic CsA nephropathy. Furthermore, delayed AST-120 treatment decreased the epithelial-mesenchymal transition in chronic CsA nephropathy. CONCLUSIONS: Removal of uraemic toxins with AST-120 treatment is effective in decreasing the progression of CsA-induced renal injury by reducing oxidative stress.

Pediatric spinal infection with epidural abscess: A report of two cases.

BACKGROUND: Pediatric spinal infections are rare and often accompanied by abscesses. Delayed diagnosis commonly leads to a poor neurological prognosis, emphasizing the need for early diagnosis and treatment. CASE DESCRIPTION: We report on two cases of spinal infection; one in a 5-year-old boy with a T8-11 epidural abscess and one in a 10-year-old boy with an L5-S1 epidural abscess. Both cases improved with conservative therapy. CONCLUSION: Early magnetic resonance imaging diagnosis and systemic treatment in collaboration with pediatricians are key factors in the successful management of children with spinal infections.

Evaluation of anteroposterior accelerometric change after bi-cruciate stabilized total knee arthroplasty and posterior stabilized total knee arthroplasty.

BACKGROUND: In conventional total knee arthroplasty (TKA), the anterior cruciate ligament (ACL) is resected. ACL dysfunction causes knee instability and is regarded as one factor in poor TKA outcomes. In bi-cruciate stabilized (BCS) TKA, the implant reproduces ACL function and provides anterior stability. The objective of this study was to evaluate preoperative and postoperative X-rays and accelerometer gait measurements in patients who underwent BCS TKA and posterior-stabilized (PS) TKA to assess the postoperative acceleration changes of knees after these procedures and to compare them in terms of joint range of motion (ROM) and the New Knee Society Score (New KSS). METHODS: The subjects were 60 patients, 30 of whom underwent BCS TKA and 30 PS TKA. Joint ROM, New KSS, lateral X-rays of the standing extended knee, and accelerometer data were evaluated 12 months postoperatively. RESULTS: There was no significant difference in joint ROM between the groups. Both had good New KSS results, but the functional activity score was significantly higher after BCS TKA than after PS TKA. X-rays showed a lower posterior offset ratio after BCS TKA than after PS TKA, with anteroposterior positioning closer to that of the normal knee. Accelerometer data showed that postoperative anteroposterior acceleration on the femoral side in the stance phase and swing phase was lower after BCS TKA than after PS TKA. CONCLUSION: Compared with PS TKA, BCS TKA resulted in a higher functional activity score, closer positioning to that of the normal knee on lateral X-ray, and lower anteroposterior acceleration on the femoral side.

CKD accelerates development of neointimal hyperplasia in arteriovenous fistulas.

Arteriovenous (AV) access failure resulting from venous neointimal hyperplasia is a major cause of morbidity in patients with ESRD. To understand the role of chronic kidney disease (CKD) in the development of neointimal hyperplasia, we created AV fistulae (common carotid artery to jugular vein in an end-to-side anastomosis) in mice with or without CKD (renal ablation or sham operation). At 2 and 3 wk after operation, neointimal hyperplasia at the site of the AV anastomosis increased 2-fold in animals with CKD compared with controls, but cellular proliferation in the neointimal hyperplastic lesions did not significantly differ between the groups, suggesting that the enhanced neointimal hyperplasia in the setting of CKD may be secondary to a migratory phenotype of vascular smooth muscle cells (VSMC). In ex vivo migration assays, aortic VSMC harvested from mice with CKD migrated significantly greater than VSMC harvested from control mice. Moreover, animals with CKD had higher serum levels of osteopontin, which stimulates VSMC migration. When we treated animals with bone morphogenic protein-7, which promotes VSMC differentiation, before creation of the AV anastomosis, the effect of CKD on the development of neointimal hyperplasia was eliminated. In summary, CKD accelerates development of neointimal hyperplasia at the anastomotic site of an AV fistula, and administration of bone morphogenic protein-7 neutralizes this effect.

The usefulness of planning using a preoperative lateral leg image to determine accurate posterior tibial slope in total knee arthroplasty.

OBJECTIVE: Sagittal alignment of the tibia following total knee arthroplasty (TKA) can affect various factors, such as durability, range of motion, stability, and even kinematics. The aim of the present study was to investigate whether taking plain preoperative lateral leg X-ray images to plan the posterior tibial slope can give an insert placement with more accurate sagittal alignment. METHODS: A total of 100 patients who underwent total TKA with posterior-stabilized prostheses. were divided into a group of 50 cases in which the posterior tibial slope was determined intra-operatively with only the fibular axis as the landmark, and a group of 50 cases in which determination of the posterior tibial slope was planned preoperatively with reference to preoperative lateral leg images. For the posterior slope, tibial cutting was performed with the posterior slope built into the bone cutting guide of the insert as the target. The angle of the fibular axis and the posterior slope of the tibial insert were measured on the postoperative lateral leg X-ray image, and the difference from the target angle was examined in the two groups. RESULTS: In the group in which only the fibular axis was used for reference, the mean deviation from the target was 3.96°, while in the group in which planning was carried out preoperatively using lateral leg X-ray images, the mean deviation was 1.59° (P < 0.05). CONCLUSION: Drawing up a preoperative plan using lateral leg X-ray images gives a useful landmark at low cost for accurate determination of TKA posterior tibial slope.

Male choriocarcinoma with metastasis to the jejunum: a case report and review of the literature.

We report on a patient with male choriocarcinoma. The patient was a 31-year-old male patient with jejunal choriocarcinoma that metastasized from the mediastinum. He was admitted complaining of melena and severe anemia. Upper and lower gastrointestinal endosocopy was performed, but no source of bleeding was seen. Chest X-ray and CT revealed a mediastinal tumor 7 cm in size anterior to the arotic arch. Superior mesenteric arteriography showed irregularities and macular opacity in the jejunal artery. An emergency laparatomy was performed because of massive gastrointestinal bleeding. A jejunal tumor approximately 4 cm in size was resected and numerous metastases were observed in the liver and mesentery. Histopathological examination showed metastatic jejunal choriocarcinoma. Gynecomastia was not present and the testes were normal. Serum beta-human chorionic gonadotropin (HCG) was at an abnormally high level of 4,396 ng/mL. Because of metastases to the brain and invasion to the trachea, he died on postoperative day 20. We report this rare case of a male patient with metastases of choriocarcinoma to the gastrointestinal tract from the mediastinum, together with a review of the literature.

[Antitumor effect of paclitaxel for gastric cancer is AUC dependent].

Paclitaxel (PTX), which is used for ovarian cancer, lung cancer, breast cancer and gastric cancer, is administered at a dose of 210 mg/m(2) once every three weeks. However, WHO grade 3-4 hematological and non-hematological toxicity occurred frequently in this manner. In recent studies about ovarian cancer and lung cancer, a schedule in which PTX was given weekly could have the same or better efficacy, with fewer side effects. The response rate of PTX administered every three weeks for gastric cancer, was 23.3 to approximately 28.0%, while that of PTX administered weekly was 24.0 to approximately 25.8%. Because of fewer adverse events, weekly PTX is widely used for gastric cancer in Japan. To prove the validity of PTX weekly administration, we performed a study using six specimens removed surgically and one specimen collected from ascites. A chemosensitivity test was performed on the basis of two assumptions: a high concentration for a short time, and a low concentration for a long time. A similar PTX effect was obtained when the AUC was equal. In this study, we demonstrated that the effect of low-dose PTX was equal to the effect of high-dose PTX in gastric cancer.

Comparison of Atypical and Osteoporotic Femoral Shaft Fractures in the Elderly: A Multicenter Study.

BACKGROUND: In atypical femoral fractures, owing to the high rates of complications and delayed healing that accompany the plate fixation, the most favorable treatment is intramedullary nailing. Although there is insufficient evidence, plate fixation is chosen due to anterolateral bowing of the femur. This study compared the bone healing time and rates of complications in atypical femoral shaft fractures and osteoporotic femoral shaft fractures. METHODS: We searched the medical records of 3 institutions in Japan for patients with femoral shaft fractures who visited between 1 January 2010 and 31 December 2015. We identified 65 patients and excluded 37 among these due to high-energy injuries or being younger than 65 years. Among the remaining patients, we identified 17 and 11 women with atypical (AFF group) and osteoporotic femoral shaft fractures (OP group), respectively. RESULTS: In surgical method, there were differences in intramedullary nailing (94.1% versus 27.2%) (p < 0.01). The mean bone healing time was 11.1 months versus 6.7 months in 2 groups (p < 0.01). Iatrogenic femoral fractures during intramedullary nail insertion were observed in both groups, and reoperation was only seen in atypical femoral fractures treated with a plate fixation, but there was no difference in the rate of complications (23.5% versus 9.1%). CONCLUSIONS: In the atypical femoral fracture group, intramedullary nailing was more chosen, but the bone healing time was delayed and plate fixation cases needed reoperation. There was no significant difference in the rate of complications between the 2 groups.

Loss of beclin 1 expression in ovarian cancer: A potential biomarker for predicting unfavorable outcomes.

The clinicopathological significance and prognostic value of the expression of proteins associated with autophagy, beclin 1 (BECN1), 1A/1B-light chain 3 (LC3) and high mobility group box-1 protein (HMGB-1), were investigated in patients with ovarian carcinoma, receiving combination chemotherapy with a platinum agent and a taxane. Immunohistochemical staining was performed for autophagy-associated proteins in tumor tissues from 141 patients with ovarian carcinoma. Clinical data were collected retrospectively by reviewing medical charts, and the association between protein expression, clinicopathological features and survival was investigated. Amongst 141 ovarian carcinoma samples, the loss of BECN1, LC3, and HMGB-1 expression was identified in 59 (41.8%), 35 (24.8%), and 66 (46.8%) samples, respectively. Clinicopathological factors were not significantly associated with the loss of BECN1 expression. However, significant associations were demonstrated between the expression of BECN1, LC3, and HMGB-1. In addition, loss of BECN1 expression demonstrated a significant association with poor progression-free and poor overall survival. Multivariate analysis demonstrated that loss of BECN1 expression and postoperative residual tumor were significant independent predictors of poor progression-free survival and poor overall survival. These results indicated that loss of BECN1 expression in ovarian carcinoma is a negative prognosticator in patients receiving platinum-based chemotherapy. Assessment of BECN1 expression may be useful for predicting an unfavorable response to platinum-based chemotherapy in ovarian carcinoma.

Mild hemophilia A diagnosed in a 55-year-old patient after pancreatoduodenectomy for carcinoma of the papilla of vater.

Hemophilia A is a sex-linked hereditary disease, and the total number of patients with this condition is small. It is quite rare for general surgeons to encounter a patient with hemophilia A. Moreover, it is extremely rare for surgeons to encounter adult patients with undiagnosed hemophilia. We describe a patient in whom intra-abdominal bleeding persisted after open abdominal surgery, leading to a diagnosis of hemophilia A. The patient was a 55-year-old man with carcinoma of the papilla of Vater who underwent pancreatoduodenectomy, during and after which hemostatic difficulties were encountered. Our initial diagnosis was complex coagulopathy; however, transfusion of a large volume of fresh frozen plasma did not improve the activated partial thromboplastin time, which led us to suspect hemophilia. Thorough personal and family histories and determination of coagulation factor VIII showed that the patient belonged to a family with hemophilia A, which had not been recognized by his parents, leading to a diagnosis of mild hemophilia A based on decreased coagulation factor VIII levels. After diagnosis, intermittent administration of a coagulation factor VIII product controlled the bleeding. The patient is currently being treated on an outpatient basis and remains free of cancer recurrence.

A case of rectal metastatic tumor in the soft tissue of the hand.

Hand metastases occur infrequently, and metastatic tumors in the soft tissue of the hand caused by rectal cancer are extremely rare. We report a case here. The patient was a 76-year old man. He underwent Miles operation for rectal cancer located in the lower portion of the rectum. Histopathologically, the resected specimen showed well-differentiated adenocarcinoma. Six years postoperatively, a tumor involving the soft tissue of the palma was found in his left hand. The tumor was resected, and pathological examination showed a well-differentiated adenocarcinoma similar to the primary rectal carcinoma. Immunohistochemical examination demonstrated that this hand tumor had metastasized from rectal cancer. Fifteen cases of colorectal metastatic tumors in the hand have been documented, of which three were soft-tissue metastases. This report describes the fourth case.

A case of multiple gastric carcinoids that could not be preoperatively diagnosed.

Here, we report the case of patient with multiple gastric carcinoids showing histopathological behavior similar to that of type I carcinoid tumors of the stomach. The patient was a 61-year-old man diagnosed as having a gastric tumor, which was revealed by follow-up computed tomography. Upper gastrointestinal endoscopy revealed a protruded tumor in the greater curvature and a small polyp in the anterior wall of the upper stomach. A biopsy revealed gastric carcinoid. Because he refused to be operated for gastric carcinoid, upper gastrointestinal endoscopy was performed 5 months later. A malignant transformation of the gastric carcinoid was strongly suspected. Therefore, the patient was admitted for operation. Laboratory findings were normal. With the diagnosis of type III gastric carcinoid, total gastrectomy was performed. Microscopic examination revealed that the carcinoid tumor was confined to the submucosa and that the small polyp mentioned earlier was also a carcinoid. Microcarcinoids and numerous enterochromaffin-like cell hyperplasias were observed along the muscularis propria of the fundus. The tumor differed from typical type I gastric carcinoids in several ways. Immunohistochemical staining for chromogranin A, synaptophysin, and cytokeratin was positive. However, p53 was absent, and the MIB-1 index was low. Two years after surgery, the patient is alive without recurrence.