Invasive lobular carcinoma of the breast with colonic metastasis: a case series of three patients.

BACKGROUND: Although metastatic spread of breast cancer to the gastrointestinal tract is very rare, it is more likely to occur in invasive lobular carcinoma (ILC) than in ductal carcinoma. Colonic metastasis is particularly rare, and the treatment strategies for these cases are not clearly defined. Herein, we report three cases of ILC with various abdominal symptoms associated with colonic metastasis. CASE PRESENTATION: Case 1 A 70-year-old female patient with vomiting and melena was referred to our hospital. Endoscopic examination revealed a Dieulafoy ulcer in the rectum and an elevated lesion in the descending colon. She also had two breast nodules, and was diagnosed as ILC with colonic metastasis. Considering her general condition, the best supportive care (BSC) was offered. The patient died 4 months after confirmation of the diagnosis. Case 2 An 80-year-old female patient presented with diarrhea and vomiting. She was diagnosed with ILC with colonic metastasis, and a coloscopy revealed stenosis of the transverse colon with a metastatic lesion. Ileosigmoid bypass surgery was performed for intestinal obstruction, and systemic treatment for breast cancer was initiated. The patient developed peritoneal carcinomatosis and died 1 year and 2 months after surgery. Case 3 A 56-year-old female patient underwent left total mastectomy for ILC, and laparoscopic transverse colectomy was conducted for a colonic lesion 9 years and 2 months after. The diagnosis as colonic metastasis was not confirmed at that time. Two years and 2 months later, torose lesions were detected in the hepatic flexural and descending colon, and histopathological findings indicated that all colon tumors, including the previously resected tumor, were metastatic spread of ILC. Systemic treatment was continued, but the transverse colonic lesion penetrated the abdominal wall, and an abscess formed 2 years and 11 months after the resection. The fistula improved by continuous suction drainage following ileostomy but recurred, and the patient died 3 years and 8 months after colectomy. CONCLUSIONS: Colonic metastases from breast cancer can trigger various abdominal symptoms, and the prognosis in these cases is generally poor. In selected cases, surgical treatment for abdominal symptoms and subsequent systemic therapy can contribute to a prolonged prognosis.

Invasive thymoma metastases to the pancreas: A case report.

INTRODUCTION AND IMPORTANCE: Thymoma is the most common type of tumor that develops in the thymic epithelial cells. Although thymomas can invade surrounding organs in the chest cavity, extrathoracic metastasis is very rare, and little is known about the prognosis and effective treatments for such tumors. Herein, we report a case of an invasive thymoma metastasizing to the pancreas after incomplete resection. CASE PRESENTATION: A 47-year-old man presented to our hospital with an anterior mediastinal mass. Although a thymic tumor was suspected, complete resection was not achieved because the tumor had invaded the pulmonary artery trunk, superior pulmonary vein, and left brachiocephalic vein. The pathological diagnosis was a Type B3 thymoma. The patient underwent chemotherapy and radiotherapy after surgery. Three years after surgery, computed tomography indicated a pancreatic mass suggestive of pancreatic cancer. Distal pancreatectomy was performed after neoadjuvant chemotherapy and radiotherapy. The pancreatic mass was diagnosed as Type B3 thymoma metastasis. Thirteen months after surgery for the pancreatic lesion, the patient underwent resection of the bilateral lung metastases. CLINICAL DISCUSSION: To the best of our knowledge, only four cases of metastatic thymic tumors in the pancreas have been reported. All patients who underwent surgical resection for pancreatic metastasis survived for >6 months including our case. CONCLUSION: In cases of thymic tumors with metastasis to extra-thoracic organs, complete resection of the metastatic lesions can contribute to prolonged survival.

Hepatocellular carcinoma with regional lymphadenopathy caused by sarcoid-like reaction: a case report.

BACKGROUND: Sarcoid-like reaction (SLR) is a histological pattern of granulomatous inflammation that is clinically differentiated from sarcoidosis. Since SLR is known to occur in several neoplasias and occasionally causes lymphadenopathy and mimics metastatic malignancy, it needs to be considered whether lymphadenopathy is due to metastasis or SLR for the choice of cancer treatment. Few cases of hepatocellular carcinoma (HCC) with SLR have been reported. Here, a case of HCC with lymphadenopathy diagnosed as SLR without metastasis is presented. CASE PRESENTATION: A 69-year-old woman was admitted to our hospital because of upper abdominal pain. She tested positive for hepatitis C virus ribonucleic acid. Imaging modalities showed an 81 × 65-mm-sized tumor with multiple nodules in segment 3 and a 17 × 12-mm-sized tumor in segment 5 with a common HCC enhancement pattern. In addition, a lymph node in the hepatoduodenal ligament was enlarged at 13 mm in size, suggesting the metastasis of HCC. Hepatectomy of the lateral segment and segment 5 and lymph node dissection in the hepatoduodenal ligament were performed. Both tumors in segments 3 and 5 were pathologically diagnosed as HCC without vessel invasion. The tumors contained necrotic cells and epithelioid cell granulomas with multinucleated giant cells, which is typically observed in sarcoidosis. The dissected lymph nodes also contained epithelioid cell granulomas, as well as giant cells with asteroid bodies. There was no malignancy in the lymph nodes. The pathological findings suggested the coexistence of malignancy and sarcoidosis. However, since the patient did not show any typical findings of pulmonary or cardiac sarcoidosis, the case was diagnosed as HCC with SLR in the primary lesion and regional lymph nodes. CONCLUSIONS: SLR needs to be considered in the differential diagnosis when a cancer patient develops lymphadenopathy. However, lymphadenopathy due to SLR is indistinguishable from that due to metastasis even when using multiple imaging modalities. Pathological examinations may be helpful for the diagnosis.

Blind Pouch Syndrome-Associated Enterolithiasis Successfully Treated with Colonoscopy.

Enterolithiasis associated with blind pouch syndrome secondary to functional end-to-end anastomosis is rare, and its endoscopic and radiological features remain poorly described. A 72-year-old woman was admitted to our hospital for abdominal pain and difficulty defecating. Colonoscopy (CS) with Gastrografin revealed a 10 × 8 cm calculus, an anastomotic ulcer, a blind pouch, and an end-to-end anastomosis in the transverse colon. The calculus was successfully crushed and removed with snares and alligator forceps through CS during the ensuing 4-day period. To our knowledge, this is the first report describing the endoscopic and radiological features of blind pouch syndrome-associated enterolithiasis successfully treated with CS.

Perforated Goblet Cell Carcinoid of the Appendix.

Goblet cell carcinoid (GCC) of the perforated appendix is rare, and its pathological features and prognosis remain poorly described. A 71-year-old woman was admitted to our hospital for right lower abdominal pain, vomiting, and high-grade fever. She was diagnosed with acute appendicitis and underwent emergency laparoscopic appendectomy. Intraoperative examination revealed an enlarged and perforated appendix. Histopathological examination revealed GCC of the appendix with subserosal invasion. She underwent laparoscopic ileocecal resection with lymph node dissection (D3) following appendectomy. Histopathological findings showed no residual tumor or lymph node metastases. To the best of our knowledge, this report is a valuable addition to the GCC literature, describing a case of GCC of the appendix presenting as perforated appendix.

Adenocarcinoma arising from an ectopic pancreas in the duodenum: a case report.

BACKGROUND: The malignant transformation of an ectopic pancreas in the duodenum is extremely rare. Herein, we report a case of an adenocarcinoma that arose from an ectopic pancreas. We also reviewed 14 cases of malignant transformations arising from an ectopic pancreas in the duodenum that were previously published. CASE PRESENTATION: An 81-year-old man with a 1-month history of vomiting was admitted to our institution. Esophagogastroduodenoscopy (EGD) and computed tomography (CT) scans revealed an obstruction at the first part of the duodenum. A distal gastrectomy was performed for diagnostic and therapeutic purposes. The histopathological examination of the resected specimen showed adenocarcinoma that arose from an ectopic pancreas (Heinrich type 1). The patient is alive without relapse at 18 months of follow-up. CONCLUSIONS: Adenocarcinoma that arises from an ectopic pancreas should be considered when an obstruction is identified in the duodenum.

Blind Pouch Syndrome-associated Anastomotic Ulcer Diagnosed with Capsule and Double-balloon Endoscopy.

Blind pouch syndrome-associated anastomotic ulcer is rare, and its endoscopic features remain poorly described. A 79-year-old man was referred to our hospital for melena. Capsule endoscopy revealed multiple ulcers in the small intestine. Double-balloon endoscopy (DBE) and a gastrografin examination through DBE revealed a potential anastomotic ulcer, a blind pouch, and a side-to-side anastomosis in the middle of the small intestine. Laparoscopic partial resection of the small intestine with anastomosis was performed on the suspected blind pouch syndrome-associated anastomotic ulcer. To our knowledge, this is the first report describing the endoscopic features of a blind pouch syndrome-associated anastomotic ulcer.

A left lung abscess with a displaced subsegmental bronchus and anomalous pulmonary artery and vein: a case report.

BACKGROUND: Since a displaced bronchus related to the left upper lobe is an uncommon anatomical anomaly, it has a risk of being accidentally resected during left upper lobe resection unless they are identified preoperatively. A case of video-assisted thoracic surgery (VATS) segmentectomy that was safely performed under preoperative identification of a displaced subsegmental bronchus and anomalous pulmonary vessels is presented. CASE PRESENTATION: A 48-year-old woman visited our hospital because of an abnormal shadow on a radiograph on a health check. The chest computed tomography (CT) showed a multicystic mass with a diameter of 35 mm on dorsal interlobar parenchyma between the S1+2 and S6 segments in the left lung. The three-dimensional (3D) CT with multiplanar reconstruction showed that B1+2b+c passed to the dorsal side of the left main pulmonary artery (PA), which was considered a displaced bronchus. The branch of A6 arose from the left main PA at the level of the branches of A3 and A1+2, more proximal than the normal anatomy, and passed to the dorsal side of a displaced B1+2b+c. The branch of V1+2 passed between B6 and the bronchus to the basal segment and joined V6 at the dorsal side of the pulmonary hilum. Intraoperative findings of the anatomy of the bronchi and pulmonary vessels were exactly the same as the preoperative 3D CT findings, so segmentectomy of S1+2b+c and S6 by VATS was performed safely. Then there were accessory fissures between S1+2 and S3 and between S6 and the basal segment. The pathological diagnosis was a left lung abscess. CONCLUSIONS: A preoperative 3D CT may be helpful for identifying anatomical anomalies. An anatomical anomaly should be suspected if accessory fissure is found during surgery.

Laparoscopic Resection of a Jejunal Mesenteric Pseudocyst.

An unusual case of a jejunal mesenteric pseudocyst treated by laparoscopic resection is reported. A 44-year-old woman was admitted to our hospital with intermittent upper abdominal pain and diarrhea. Physical examination revealed slight periumbilical tenderness, and no masses were palpable. Contrast-enhanced computed tomography showed a 4-cm-sized nonenhancing high-density mass with a heterogeneous pattern on a proximal small bowel loop. Based on these findings, a gastrointestinal stromal tumor accompanied by hemorrhagic and cystic change, a mesenteric hematoma, or a desmoid tumor was diagnosed. Laparoscopy was performed to obtain an accurate diagnosis. Exploration of the abdominal cavity identified a 4-cm mass originating from the mesentery of the jejunum. Segmental resection of the jejunum and its mesentery, including the mass, was performed. Macroscopically, the mass appeared to be a cystic mass of the jejunal mesentery. The mass within the cyst lumen consisted of white clayish material with no specific pathology. The final pathological diagnosis was a mesenteric pseudocyst. The patient had an uneventful postoperative course.

CD8+ tumor-infiltrating lymphocytes together with CD4+ tumor-infiltrating lymphocytes and dendritic cells improve the prognosis of patients with pancreatic adenocarcinoma.

OBJECTIVE: Recent studies have demonstrated the importance of tumor immunity for a cancer patient's prognosis. In some types of cancer, it has been shown through immunohistochemical analysis that the existence of CD8+ tumor-infiltrating lymphocytes (TILs) is a crucial factor in determining prognosis. In an experimental model, CD4+ lymphocytes together with CD8+ lymphocytes contributed significantly to tumor immunity. METHODS: Specimens were taken from 80 surgically resected pancreatic adenocarcinomas between 1992 and 1999. Immunohistochemical staining of CD4, CD8, and S100 protein was performed, and the levels of these proteins were determined by microscopic analysis. The percentages of patients in the CD4(+) and CD8(+) groups were 59% (47/80) and 25% (16/80), respectively. When separated into 4 groups, CD4/8(+/+), CD4/8(+/-), CD4/8(-/+) and CD4/8(-/-), the overall survival rate was significantly higher in CD4/8(+/+) patients (13 cases) compared with those in all other groups combined (67 cases; P = 0.0098). CD4/8(+/+) status was negatively correlated with tumor depth and TNM stage. Multivariate analyses showed that CD4/8(+/+) status was an independent favorable prognostic factor. The number of tumor-infiltrating S100 protein positive cells was also significantly higher in the CD4/8(+/+) group than in others (P = 0.0084). CONCLUSIONS: In pancreatic adenocarcinoma, the presence of CD4+ TILs together with CD8+ TILs serves as a good indicator of the patient's outcome after surgical treatment.

CD4+ and CD8+ T cells cooperate to improve prognosis of patients with esophageal squamous cell carcinoma.

The purpose of this study is to clarify the roles of immune cell types, both individually and synergistically, in esophageal squamous cell carcinoma (ESCC). One hundred and twenty-two patients (105 males and 17 females; mean age, 62.3 years) with primary ESCC underwent surgical tumor resection at the Department of Surgical Oncology, School of Medicine, Hokkaido University and two affiliated hospitals between 1989 and 1999. Immunohistochemical analyses were performed for CD4, CD8, and CD57 (surface markers for natural killer cells). Patient prognosis was found to correlate with the number of CD4(+) and CD8(+) T cells in the stroma and the number of CD8(+) T cells within the cancer cell nest. Furthermore, the number of CD8(+) T cells in the stroma and within the cancer cell nest was found to be correlated [correlation coefficient (r) = 0.790; P < 0.0001). However, no correlation was observed between the number of natural killer cells and patient prognosis. Patients were classified into the following four groups based on CD4(+) and CD8(+) T-cell count: CD4/8(+/+), CD4/8(+/-), CD4/8(-/+), CD4/8(-/-). For the general patient pool, as well as for selected p-stage III and IV cases (n = 48), the survival rate for CD4/8(+/+) patients was significantly higher than that for the other three groups (log-rank test, P = 0.0012 and 0.0088, respectively). Multivariate analysis identified CD4/8(+/+) status, T classification, and N classification as independent prognostic factors. In conclusion, cooperation between CD4(+) and CD8(+) T cells correlates strongly with ESCC patient prognosis.

Prognostic value of intratumoral CD8+ T lymphocyte in extrahepatic bile duct carcinoma as essential immune response.

BACKGROUND AND OBJECTIVES: Tumor-infiltrating lymphocytes form an important aspect of the host defense against an expanding neoplasm. CD8+ T cells have been identified as a prognostic factor in several cancers. Here, we investigate that the influence of CD8+ T cells on extrahepatic bile duct carcinoma (EBDC) patient survival. METHODS: CD8+ T cell immunoreactivity in 58 surgically resected EBDC specimens was investigated. The relationship between CD8+ T cell immunoreactivity and clinical and histopathologic features was analyzed. RESULTS: Thirty-two tumors (55%) possessed intratumoral CD8+ T cells. The degree of intratumoral CD8+ T cell immunoreactivity demonstrated a significant relationship to lower numbers of lymph node metastasis, reduced venous invasion, decreased perineural invasion, and better pTNM staging. Intratumoral CD8- T cells were also associated with increased patient survival. Multivariate analysis indicated that the presence of intratumoral CD8+ T cells was an independent prognostic factors. CONCLUSIONS: The infiltration of a cancer cell nest by CD8+ T cells is a reliable marker predicting increased survival of patients with EBDC.

Treatment of Budd-Chiari syndrome with percutaneous transluminal angioplasty: report of a case.

We report the successful treatment of Budd-Chiari syndrome (BCS) due to an obstruction of the hepatic veins. A 19-year-old man developed bleeding esophageal and gastric varices, and a large amount of ascites was thus caused by portal hypertension. BCS complicated by an obstruction of the major hepatic veins was diagnosed after examinations. We performed percutaneous transluminal angioplasty (PTA). This resulted in a great improvement of BCS, a marked decrease in the pressure of the hepatic veins, and the disappearance of ascites. Restenosis occurred at 1 year and 5 years after the initial angioplasty, for which PTA was repeatedly performed. Nine years after the initial treatment, no stenosis has been observed and the patient has shown a favorable outcome.

High expression of tumor-associated antigen RCAS1 in pancreatic ductal adenocarcinoma is an unfavorable prognostic marker.

RCAS1 (receptor-binding cancer antigen expressed on SiSo cells) is a recently identified human tumor-associated antigen expressed on various cancer cells. It is thought that tumor cells evade immune surveillance by expression of RCAS1, which induces apoptotic cell death in receptor-positive immune cells. The purpose of our study was to investigate the relation between RCAS1 expression and the clinicopathological variables and clinical outcome in patients with pancreatic adenocarcinoma. Immunohistochemical analysis for RCAS1 was performed on paraffin-embedded specimens of 80 patients (mean age, 62 years) who underwent surgical resection for pancreatic adenocarcinoma. Of the 80 specimens, 77 (96%) were positive for RCAS1. No significant correlation was found between RCAS1 expression and age, gender, depth of invasion, tumor diameter, surgical margin, lymphatic invasion, venous invasion or histopathological grading. Borderline correlations between RCAS1 expression were noted for lymph node metastasis and stage (p = 0.0608 and 0.0934, respectively). RCAS1 expression was very frequently observed and the survival of patients with high RCAS1 expression was significantly shorter than that of those with low expression (p = 0.0012). Multivariate analysis using the Cox regression model indicated that high RCAS1 expression was an independent prognostic factor (risk ratio, 3.090; p = 0.0090). These results suggested that RCAS1 might be a significant tumor marker for pancreatic adenocarcinoma and an unfavorable predictor for prognosis of patients who have undergone surgical resection.

RCAS1 expression as a prognostic factor after curative surgery for extrahepatic bile duct carcinoma.

BACKGROUND: RCAS1 (receptor-binding cancer antigen expressed on SiSo cells) is a cancer cell-surface antigen and has been identified as a prognostic factor in several cancers. It is thought that tumor cells escape from immune attack by expressing RCAS1, which induces apoptosis in receptor-positive immune cells. We investigated the relationship between RCAS1 expression and clinicopathologic features and clinical outcome in patients with extrahepatic bile duct carcinoma (EBDC) who underwent curative resection. METHODS: RCAS1 expression was determined by immunohistochemistry in 60 patients with EBDC who underwent curative resection from 1992 to 1999. The patients were divided into two groups on the basis of the extent of RCAS1 expression: a low-expression group (immunoreactivity in <25% of cells) and a high-expression group. Expression was correlated with clinicopathologic features and prognosis. RESULTS: RCAS1 was expressed in 52 (86.7%) of 60 tumors and at a high frequency in all histopathologic stages. High expression of RCAS1 was detected in 46 (76.7%) of 60 cases. No correlation existed between the pattern of RCAS1 expression and any clinicopathologic feature, although high expression did correlate with poor prognosis. High RCAS1 expression was an independent negative predictor for survival. CONCLUSIONS: RCAS1 expression predicts poor outcome in resectable EBDC.

The prognostic significance of RCAS1 expression in squamous cell carcinoma of the oesophagus.

Overexpression of RCAS1 (receptor-binding cancer antigen expressed on SiSo cells) protects cancer cells from immune attack and might be related to poor prognosis in several cancers. We investigated the immunoreactivity of RCAS1 and its correlation with clinicopathological features in 95 patients who underwent surgical resection for oesophageal squamous cell carcinoma. Thirty-two of the 95 (33.7%) cases were strongly positive for RCAS1. RCAS1 showed significant correlations with age and stage grouping. Expression of RCAS1 was associated with shorter postoperative survival. Multivariate analysis indicated that RCAS1 positivity was an independent negative prognostic factor. Our study establishes RCAS1 as a novel prognostic marker for surgically resected oesophageal squamous cell carcinoma.