[A case of pedunculated colonic adenoma with pseudocarcinomatous invasion and squamous metaplasia occurring in the sigmoid colon].

A case of pedunculated colonic adenoma with pseudocarcinomatous invasion and squamous metaplasia occurring in the sigmoid colon is reported. The patient was a 65-year-old man who visited our hospital for further evaluation of a positive fecal occult blood test. Colonoscopy revealed a pedunculated polyp with a thick swollen stalk in the sigmoid colon. EUS revealed a hyperechoic lesion in the stalk. However, endosonographically, the third and fourth layers of the colonic wall were shown to be normal. It was suspected to be a colonic adenoma with pseudocarcinomatous invasion from these endoscopic findings. Endoscopic polypectomy was performed. Histological examination of the specimen revealed tubular adenoma with moderate epithelial atypia and submucosal displacement of adenomatous glands with variable cystic changes. Squamous metaplasia and hemosiderin deposition were also seen in the mucosal and submucosal layer, respectively. This polyp was diagnosed as a colonic adenoma with pseudocarcinomatous invasion with squamous metaplasia.

Usefulness and safety of 0.4% sodium hyaluronate solution as a submucosal fluid "cushion" for endoscopic resection of colorectal mucosal neoplasms: a prospective multi-center open-label trial.

BACKGROUND: Sodium hyaluronate (SH) solution has been used for submucosal injection in endoscopic resection to create a long-lasting submucosal fluid "cushion". Recently, we proved the usefulness and safety of 0.4% SH solution in endoscopic resection for gastric mucosal tumors. To evaluate the usefulness of 0.4% SH as a submucosal injection solution for colorectal endoscopic resection, we conducted an open-label clinical trial on six referral hospitals in Japan. METHODS: A prospective multi-center open-label study was designed. A total of 41 patients with 5-20 mm neoplastic lesions localized in the colorectal mucosa at six referral hospitals in Japan in a single year period from December 2002 to November 2003 were enrolled and underwent endoscopic resection with SH. The usefulness of 0.4% SH was assessed by the en bloc complete resection and the formation and maintenance of mucosal lesion-lifting during endoscopic resection. Safety was evaluated by analyzing adverse events during the study period. RESULTS: The usefulness rate was high (82.5%; 33/40). The following secondary outcome measures were noted: 1) steepness of mucosal lesion-lifting, 75.0% (30/40); 2) intraoperative complications, 10.0% (4/40); 3) time required for mucosal resection, 6.7 min; 4) volume of submucosal injection, 6.8 mL and 5) ease of mucosal resection, 87.5% (35/40). Two adverse events of bleeding potentially related to 0.4% SH were reported. CONCLUSION: Using 0.4% SH solution enabled sufficient lifting of a colorectal intramucosal lesion during endoscopic resection, reducing the need for additional injections and the risk of perforation. Therefore, 0.4% SH may contribute to the reduction of complications and serve as a promising submucosal injection solution due to its potentially superior safety in comparison to normal saline solution.

Composite paraganglioma-ganglioneuroma in the retroperitoneum.

BACKGROUND: Paragangliomas occur most commonly in head and neck region and much less frequently, they are found in the retroperitoneum. Composite paraganglioma-ganglioneuroma of the retroperitoneum is very rare. CASE PRESENTATION: We present an unusual case of retroperitoneal composite paraganglioma-ganglioneuroma discovered on computed tomography in a 63-year-old female patient. Routine hematological examination and biochemical tests were within normal limits. Plasma adrenaline was 0.042 ng/ml, plasma noradrenaline 0.341 ng/ml, and plasma dopamine <0.01 ng/ml. An abdominal contrast-enhanced CT scan and magnetic resonance imaging revealed a 6.5 cm heterogeneous retroperitoneal mass with a cystic component. The retroperitoneal tumor accumulated (131)I-Metaiodobenzylguanidine ((131)I-MIBG) 48 hours after radioisotope injection. Under the diagnosis of paraganglioma in the retroperitoneum, the patient underwent surgery. The resected tumor (6.5 x 5 x 3 cm) was solid and easily removed en bloc. The cut surface of the tumor and histology revealed two different components in the tumor: paraganglioma centrally and ganglioneuroma on the periphery. She remains disease-free 18 months after surgery. CONCLUSION: This case reminds us that neuroendocrine tumor should be included in the differential diagnosis of a retroperitoneal mass although composite paraganglioma-ganglioneuroma in the retroperitoneum is very rare.

Pedunculated inverted hyperplastic polyp of the sigmoid colon treated with endoscopic polypectomy.

A case of inverted hyperplastic polyp of the sigmoid colon is reported. The patient was a 67-year-old woman who visited our hospital for further evaluation of constipation. Colonoscopy revealed a pedunculated polyp with linear central depression, about 12 mm in diameter, in the sigmoid colon. Excluding the polyp, there was no lesion in the colorectum. Endoscopic polypectomy was performed. Histological examination of the specimen revealed a stalked polyp that had scattered goblet cells and elongated tubules with serrated profiles in the superficial portion. The nodules of deep tubules impinged on the muscularis mucosae. Proliferation of fibromuscular tissue was not seen in the polyp. There was no evidence of malignancy. This polyp was diagnosed as an inverted hyperplastic polyp. Pedunculated-type inverted hyperplastic polyp of the colon is rare.

[A case of liposarcoma of the ascending colon mesenterium].

We encountered a rare case of liposarcoma of the ascending colon mesenterium. A 53-year-old man visited our hospital because of a mass, 12x8cm in diameter, in the right upper abdomen. On computed tomography (CT), the tumor showed irregular density with a smooth surface and was enhanced irregularly. A part of the tumor protruded into the colon in the upper portion of the ascending colon. The tumor was surgically resected by right hemicolectomy. Histological diagnosis of the tumor was well-differentiated liposarcoma, sclerosing variant. Radiological findings seemed to reflect the pathological findings well.

Three cases of Solitary Peutz-Jeghers-type hamartomatous polyp in the duodenum.

A solitary Peutz-Jeghers-type hamartomatous polyp in the duodenum is rare, and few reports have described its characteristic endoscopic features. We describe three cases of solitary Peutz-Jeghers-type hamartomatous polyp and their endoscopic findings in detail. The polyp in all of our three cases showed an irregularly lobular or nodular surface, whereas adenomas often show a regularly nodular or granular surface. The color of the polyp was whitish in all of our cases. In the present cases, close observation by endoscopy revealed that the solitary Peutz-Jeghers-type hamartomatous polyps looked whitish because of the presence of diffusely scattered white spots on the surface of the polyps. Duodenal polyps that exhibit the aforementioned endoscopic characteristics may be diagnosed as Peutz-Jeghers-type hamartomatous polyps and treated by polypectomy because of the malignant potential.

Lobulated inflammatory myoglandular polyp in the ascending colon observed by magnifying endoscopy and treated with endoscopic polypectomy.

The patient was a 33-year-old man with hematochezia. Colonoscopy revealed a lobulated peduncular polyp with bleeding, about 40 mm in diameter, in the ascending colon. The polyp had both red and white components and a mosaic pattern. Magnifying observation revealed a red rugged surface component, and smooth white nodules with enlarged round or oval crypt openings. Endoscopic polypectomy was performed. Histological examination of the specimen revealed inflammatory granulation tissue in the lamina propria, proliferation of smooth muscle, and hyperplastic glands with cystic change. This polyp was diagnosed as inflammatory myoglandular polyp (IMGP). Lobulated-type IMGP in the ascending colon is rare.

Ileal schwannoma developing into ileocolic intussusception.

Intussusception is rare in adults. We describe a 47-year-old man with ileal schwannoma that led to ileocolic intussusception. Abdominal ultrasonography, abdominal CT scan and barium enema confirmed an ileal tumor. Colonoscopy revealed a peduncular submucosal tumor (SMT) 75 mm long with an ulcerated apex at the ascending colon. The provisional diagnosis was a gastrointestinal stromal tumor of the terminal ileum. Ileocecal resection was carried out and the tumor was histologically diagnosed as schwannoma. Abdominal pain resolved postoperatively. This case reminds us that ileal schwannoma should be included in the differential diagnosis of intussusception caused by an SMT in the intestine.

A ruptured large extraluminal ileal gastrointestinal stromal tumor causing hemoperitoneum.

We describe an 87-year-old woman with a large ileal gastrointestinal stromal tumor (GIST) causing hemoperitoneum. A CT scan demonstrated a large heterogeneous mass measuring about 13 cm multiply 11 cm in the pelvis and hemoperitoneum, with a non-uniform enhancement pattern. The mass was diagnosed as a GIST originating from the gastrointestinal tract. She underwent an urgent laparotomy and an ileal GIST with a rupture was found 130 cm from the anal to the Treitz's ligament. Hemoperitoneum caused by ileal GIST rupture is a rare condition. Bleeding in the large tumor leading to rupture of the capsule might cause hemoperitoneum in the present case.

Minute signet ring cell carcinoma occurring in gastric hyperplastic polyp.

We describe a 45-year-old woman with minute signet ring cell carcinoma occurring in a gastric hyperplastic polyp. A biopsy specimen obtained from the gastric hyperplastic polyp revealed signet ring cell carcinoma. Endoscopic mucosal resection (EMR) was performed to confirm the diagnosis. Histological examination of the EMR specimen revealed focal signet ring cell carcinoma in the hyperplastic polyp. There are few cases of gastric hyperplastic polyp associated with signet ring cell carcinoma.

Inflammatory fibroid polyp occurring in the transverse colon diagnosed by endoscopic biopsy.

A case of an inflammatory fibroid polyp occurring in the transverse colon and diagnosed by endoscopic biopsy is reported. The patient was an 82-year-old man who visited our hospital for further evaluation of occult blood in stool. The Colonoscopy revealed a small, red, and peduncular polyp, about 6 mm in diameter, in the transverse colon. Histological examination of the biopsy specimen obtained from the polyp revealed proliferation of fibroblasts and infiltration of inflammatory cells such as plasma cells and eosinophils. This polyp was diagnosed as an inflammatory fibroid polyp, which can appear in many different locations throughout gastrointestinal tract, though still rare in the transverse colon.

Treatment of over 20 mm gastric cancer by endoscopic submucosal dissection using an insulation-tipped diathermic knife.

AIM: To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife (IT-ESD) for the treatment of patients with over 20 mm early gastric cancer (EGC). METHODS: A total of 112 patients with over 10 mm EGC were treated with IT-ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 5 year period from January 2002 to December 2006, including 40 patients with over 20 mm EGC. We compared patient backgrounds, the one-piece resection rate, complete resection (CR) rate, operation time, bleeding rate, perforation rate between patients with over 20 mm EGC [over 20 mm group (21-40 mm)] and the remaining patients (under 20 mm group). RESULTS: We found no significant difference in the rate of underlying cardiopulmonary disease (over 20 mm group vs under 20 mm group, 5.0% vs 5.6%), one-piece resection rate (95% vs 96%), CR rate (85% vs 89%), operation time (72.3 min vs 66.5 min), bleeding rate (5% vs 4.2%), and perforation rate (0% vs 1.4%) between the 2 groups. Three patients in each group had submucosal invasion and two in each groups underwent additional surgery. CONCLUSION: There was no significant difference in the outcome resulting from IT-ESD between the 2 groups. Our study proves that IT-ESD is a feasible treatment for patients with over 20 mm mucosal gastric cancer although the long-term outcome should be evaluated in the future.

[A case of alpha-fetoprotein-producing minute mucosal gastric cancer].

The endoscopic examination of a 63-year-old man revealed a IIc lesion, 5 mm in diameter, in the lesser curvature of the gastric body. His serum alpha-fetoprotein (AFP) level was high at 14.3 ng/ml. Immunohistological studies on the biopsy specimens showed a positive reaction for AFP. Endoscopic ultrasonography revealed that the tumor was limited to the second layer of the gastric wall and this tumor was diagnosed as mucosal cancer. The final diagnosis was AFP-producing mucosal gastric cancer (AFPMGC). Cases of AFPMGC are rarely encountered. The present case suggested that even minute mucosal gastric cancer could produce AFP.

[A case of early extrahepatic bile duct cancer showing diffuse growth].

A 74-year-old woman visited our hospital for a health checkup, and liver dysfunction and cholangiectasis were detected. Further examinations revealed a protruding lesion spreading diffusely from the upper to the lower extra-hepatic bile duct. On a diagnosis of extra-hepatic bile duct cancer, the patient underwent pancreato-duodenectomy with preservation of the pyloric ring. Small papillary denticulate lesions, forming papillary adenocarcinoma, was scattered over a flat granular lesion of atypical hyperplasia. This morphological pattern is rare, and suggests that the cancer cells may have derived from atypical hyperplastic epithelium.

[A case of gastric hamartomatous inverted polyp (submucosal tumor type) accompanied by gastric cancer].

Endoscopic examination of a 39-year-old woman revealed a flat-elevated submucosal tumor (SMT) in the upper third area of the stomach and a IIc lesion in the anterior wall of the lower third of the stomach. Endoscopic ultrasonography findings suggested an aberrant pancreas. Both lesions were resected by distal gastrectomy. Histological examination of the SMT revealed the dilated glands with cyst formation and proliferation of smooth muscle bundles in the submucosal layer, and it was diagnosed as a gastric hamartomatous inverted polyp. The IIc lesion was a signet ring cell carcinoma. Cases of gastric hamartomatous inverted polyps coexistent with gastric cancer have been rarely reported in Japan.

A phase I study of doxifluridine combined with weekly paclitaxel for metastatic gastric cancer.

PURPOSE: Based on the synergistic effect in preclinical studies, a phase I clinical trial for the combination of paclitaxel and doxifluridine (an intermetabolite of capecitabine) was performed to determine the recommended dose for the treatment of patients with metastatic gastric cancer. METHODS: The dose of paclitaxel was increased from 60 mg/m2 at level 1 to 90 mg/m2 at level 5. It was administered as a 1-h infusion on days 1 and 8. The dose of doxifluridine was fixed at 600 mg/m2 per day up to level 3, and escalated to 800 mg/m2 per day at levels 4 and 5. It was administered orally for 2 weeks. The treatment was repeated every 3 weeks. RESULTS: A total of 28 patients were enrolled. No dose-limiting toxicity (DLT) was observed at levels 1 and 2 (paclitaxel 70 mg/m2). A DLT of grade 4 neutropenia lasting for more than 4 days was observed in one patient at level 3 (paclitaxel 80 mg/m2). In addition, the first five of six patients in this group experienced grade 3 neutropenia during the first treatment cycle. A further six patients were added in order to confirm the safety of this dosage level, and no more DLTs except for grade 3 nausea in one patient were observed in the second cohort. No DLT was seen in three patients at level 4 (paclitaxel 80 mg/m2). DLTs (grade 3 neuropathy in one patient and a treatment delay of the second cycle for more than 1 week due to grade 3 neutropenia in another) were observed in two out of six patients at level 5 (paclitaxel 90 mg/m2), and this dose level was determined as the maximum tolerated dose. The tumor response rate was 42% (95% confidence interval 20-67%) in 19 patients with measurable lesions. CONCLUSIONS: The recommended dose was determined as 80 mg/m2 of paclitaxel (days 1 and 8) and 800 mg/m2) of doxifluridine (days 1-14) every 3 weeks. The results of this phase I study are encouraging and a phase II trial is thus warranted.

Acute pancreatitis occurring in gastric aberrant pancreas treated with surgery and proved by histological examination.

We describe a case of gastric aberrant pancreas with acute pancreatitis. Barium meal examination, endoscopic examination and computed tomography of a 32-year-old man with abdominal pain revealed a submucosal tumor, about 3.5 cm in diameter, at the angulus of his stomach. Endoscopic ultrasonography revealed a hypoechoic mass with anechoic capillary areas. His serum amylase level was high at 262 IU/l. Laparoscopy-assisted local resection was carried out. The resected tumor revealed pancreatic tissue with extensive neutrophil infiltration in the gastric wall and fat necrosis in the subserosa. There are few cases of histologically proven acute pancreatitis in gastric aberrant pancreatic tissue.

Gastritis cystica polyposa concomitant with gastric inflammatory fibroid polyp occurring in an unoperated stomach.

The endoscopic examination of a 61-year-old male patient revealed a protruding lesion in the greater curvature of the lower third area of the stomach. The lesion, 17 mm in size, was resected completely with endoscopic submucosal dissection using an insulated-tip diathermic knife (IT-ESD). Histological examination of the protruding lesion revealed proliferation of fibroblasts and infiltration of inflammatory cells in the mucosa and submucosa, and it was diagnosed as an inflammatory fibroid polyp (IFP). Gastritis cystica polyposa (GCP) was presented adjacent to the IFP. This may be the first report of GCP concomitant with gastric IFP occurring in an unoperated stomach.

Treatment of elderly patients with early gastric cancer by endoscopic submucosal dissection using an insulated-tip diathermic knife.

OBJECTIVE: In recent years, the number of elderly patients with early gastric cancer (EGC) has steadily been increasing. In our institute, endoscopic submucosal dissection (ESD) involving the use of an insulated-tip diathermic knife (IT-ESD) was introduced for the treatment of mucosal gastric carcinoma in 1996. The purpose of this study was to evaluate the effectiveness of IT-ESD for the treatment of elderly patients with EGC. MATERIALS AND METHODS: A total of 144 patients with EGC were treated at Shikoku Cancer Center in the 5-year period from January 2000 to December 2004, including 53 patients over 75 years old. The performance status (PS) for all patients was less than 2. We compared patient's backgrounds, the one-piece resection rate, complete resection (CR) rate, operation time, bleeding rate, perforation rate, blood pressure, and peripheral oxygen saturation (SpO(2)) between patients over 75 years of age (elderly group) and the remaining 91 younger patients (non-elderly group). RESULTS: The rate of having underlying disease was significantly higher for the elderly group (p<0.05) and we found no significant difference for the one-piece resection rate, CR rate, operation time, bleeding rate, and perforation rate between the 2 groups. There were also no significant differences for the frequency of the use of oxygen, pressor and depressor between the 2 groups. CONCLUSION: There was no significant difference in the outcome resulting from ESD between the 2 groups. Our study proves that ESD is a feasible treatment for elderly patients with EGC PS of less than 2.

Unusual metastasis of hepatocellular carcinoma to the esophagus.

This report describes a case of metastatic hepatocellular carcinoma (HCC) presenting as a polypoid mass in the lower esophagus. The patient was a 63-year-old man with HCC. An endoscopic examination revealed a pedunculated polypoid mass, about 3 cm in diameter, at the lower part of the esophagus. The biopsy specimen obtained from the tumor revealed that the mass consisted of a pseudoglandular arrangement of tumor cells, and the tumor was diagnosed as metastatic HCC. There were no symptoms due to esophageal tumor. He died of progressive hepatic failure. Cases of premortem-diagnosed esophageal metastasis from HCC are extremely rare.