Pancreatic juice cytology for diagnosing invasive pancreatic carcinoma/high-grade pancreatic intraepithelial neoplasia without visible tumors on endoscopic ultrasound.

OBJECTIVES: Pancreatic ductal adenocarcinoma (PDAC) with a diameter ≤10 mm and high-grade pancreatic intraepithelial neoplasia (HG-PanIN) require pre-operative diagnosis. Most cases present only indirect imaging findings without visible tumors on endoscopic ultrasound (EUS). Therefore, EUS-guided fine-needle aspiration/biopsy is not applicable. An alternative diagnostic method is pancreatic juice cytology (PJC) via endoscopic naso-pancreatic drainage (ENPD-PJC), which is not the standard practice. This study aimed to investigate ENPD-PJC for diagnosing suspected PDAC/HG-PanIN cases without visible tumors on EUS. METHODS: Data of patients with suspected PDAC/HG-PanIN without visible tumors who underwent PJC were retrospectively evaluated. One PJC sample was collected during endoscopic retrograde pancreatography (ERP-PJC), and 12 samples were collected during ENPD-PJC, 3-hourly for cytological analysis. ERP-PJC, ERP/ENPD-PJC, and ENPD-PJC positivity indicated cytologically positive samples. Patients with positive/negative PJC with follow-up for <4-years were excluded as undiagnosed cases. A non-malignant diagnosis was based on histopathological absence/stable imaging findings for ≥4-years. The primary endpoint was to demonstrate that ERP/ENPD-PJC has a higher diagnostic ability than ERP-PJC. RESULTS: Twenty-two patients with histopathologically diagnosed PDAC/HG-PanIN and 31 with a non-malignant diagnosis were enrolled. ERP-PJC, ERP/ENPD-PJC, and ENPD-PJC showed sensitivities of 36.4 %, 86.4 %, and 77.3 %, specificities of 93.5 %, 87.1 %, and 93.5 %, and accuracies of 69.8 %, 86.7 %, and 86.7 %, respectively. ERP/ENPD-PJC and ENPD-PJC demonstrated superior sensitivity and accuracy compared to ERP-PJC. A greater occurrence of positive outcomes markedly distinguished true positives from false positives. CONCLUSIONS: ERP/ENPD-PJC and ENPD-PJC had higher diagnostic accuracies for PDAC/HG-PanIN without visible tumors on EUS. ENPD-PJC is recommended for the diagnosis of these lesions.

Localized biphasic malignant peritoneal mesothelioma presenting as a rectal tumor.

An 84-year-old male presented with bloody stool. On digital rectal examination, a large and firm tumor was palpated in the anterior wall of the rectum at 2 cm from the anal verge. The colonoscopy revealed an ulcerated mass with smooth margins in the anterior wall of the rectum. Enhanced computed tomography showed a huge tumor in the pelvis, invading rectum, urinary bladder and the prostate, with signs of splenic and peritoneal metastases. Findings from an endoscopic biopsy and endoscopic ultrasound-guided fine needle aspiration suggested spindle cell carcinoma. We tentatively diagnosed as spindle cell carcinoma of the rectum and administered panitumumab as palliative chemotherapy. He eventually died at 4 months after the first visit to our institution. The autopsy findings resulted in the confirmed diagnosis as biphasic malignant peritoneal mesothelioma. There are only four previous reports on malignant peritoneal mesothelioma presenting as a colorectal tumor. Although rare, malignant peritoneal mesothelioma should be considered in differential diagnosis of colorectal tumors.

Utility of Endoscopic Ultrasonography Screening for Small Pancreatic Cancer and Proposal for a New Scoring System for Screening.

OBJECTIVES: This study aimed to evaluate the utility of endoscopic ultrasonography screening for small pancreatic cancer (PC) and propose a new simple scoring system for selecting individuals who should be screened. METHODS: Risk factors or symptoms related to PC were tentatively divided into high- and low-grade risk groups based mainly on reported relative risk values. Numbers of risk factors were designated as risk scores. Endoscopic ultrasonography screening was performed for 632 individuals. We analyzed scores for PC detection prospectively, and risk factors and scores of PC patients retrospectively. RESULTS: We detected 10 small malignant pancreatic neoplasms (size ≤20 mm; 8 PCs; 9 Tis or T1) and 14 advanced PCs. All small PCs and 95.5% of PCs were found in individuals with low-grade risk scores of at least 3 points (P) or high-grade risk scores of at least 1P. Both average risk scores were significantly higher in patients with small PCs (P ≤ 0.04). Cutoffs for low- and high-grade risk scores implying the presence of small PC and all PC were 3P and 1P, respectively. When subjects having one or both cutoff scores were screened, sensitivity and specificity were 100% and 64.4% for small PCs and 95.5% and 64.4% for all PCs. CONCLUSION: Endoscopic ultrasonography screening combining new scoring is effective for detecting small PC.

Radical endoscopic resection is unsuitable for most synchronous, multiple and early gastric cancers.

BACKGROUND/AIMS: It remains unclear whether synchronous, multiple, early gastric cancers can be radically resected with endoscopic resection. METHODOLOGY: Patients who underwent gastrectomy for early gastric cancer were included in this study and divided into two groups: a solitary gastric cancer group and a multiple gastric cancer group. The clinicopathological features of patients in each group were compared and the criteria for endoscopic resection were subsequently investigated. RESULTS: A total of 244 patients were included in the present study. The solitary and multiple gastric cancer groups included 228 patients (93.4%) and 16 patients (6.6%), respectively. The multiple gastric cancer group included 35 lesions, including a greater number of larger tumors and protruded- type tumors, as well as increased incidence of submucosal and lymphatic invasion. Only 2 of 16 cases (12.5%) in the multiple gastric cancer group met the criteria for endoscopic resection. Eleven cases were excluded due to submucosal invasion and three cases were excluded due to undifferentiated histopathological type tumors. CONCLUSIONS: To be suitable for radical endoscopic resection, prompt detection of early gastric cancer is essential, before they become multiple gastric cancers and invade the submucosa.

How should we treat gastric cancer in the very elderly?

BACKGROUND/AIMS: We aimed to clarify the clinicopathological features of gastric cancer in very elderly patients and to identify appropriate surgical therapy for them, focused particularly on their prognosis. METHODOLOGY: Patients who underwent gastrectomy for gastric cancer in Oita University Hospital were included in this study. The patients were divided into two groups: the very elderly group (80 years or older) (E group) and the middle-aged group (ranging from 40 to 79 years) (M group). Their clinicopathological features and postoperative survival were compared. RESULTS: Type 3,4 macroscopic types, INFγ and number of dissected lymph nodes were significantly less in the E group than in the M group (p=0.0092, p=0.0077, p=0.0475, respectively). Overall survival and disease-free survival were shorter for the E group (p=0.0898, p=0.0566, respectively). When other cause-related deaths were considered to be lost to follow-up, there was no significant difference between the E group and the M group. CONCLUSIONS: Whenever radical resection is possible, surgical resection for gastric cancer, even in the very elderly, should not be denied. Nevertheless, surgeons should try to do less invasive surgery, especially for the very elderly.

[Complete response in a patient with liver metastasis of esophageal squamous cell carcinoma treated with docetaxel].

On routine endoscopy a Type 2 tumor was found in the esophagogastric junction of a 74-year-old man. A histological diagnosis of squamous cell carcinoma was made based on a biopsy specimen, and lower esophagectomy and proximal gastrectomy were performed. The pathological diagnosis was pT3, N2, M0, pStage III. A low-dose FP treatment as adjuvant chemotherapy was given for only three weeks due to severe anorexia. A liver metastases measuring 22×24 mm in diameter at the s6 lesion was found with a CT examination a year and a half after the operation. A dose of 70 mg/m2 of docetaxel was given by intervenous infusion, and repeated every four weeks. Toxicities, grade 4 neutropenia and mild pneumonia associated with this chemotherapy regimen, were observed after five cycles. Therefore this treatment was discontinued. CT performed at that time showed a complete response (CR) and no more recurrences for six months. Docetaxel treatment is considered to be safe for outpatients and is one of the cures for metastatic esophageal cancer.

Panperitonitis caused by gangrene of the urinary bladder: report of a successfully treated case.

The patient was a 74-year-old woman with Parkinson's disease who had a past history of total hysterectomy for uterine myoma. She was admitted for a femoral neck fracture and treated conservatively. From the third day of the illness, the patient experienced increased urinary frequency and constant urge to urinate. On the seventh day, the patient developed peritonitis and underwent emergency surgery. Laparotomy confirmed a dark greenish malodorous abscess in the abdominal cavity. The bladder was necrotic and perforated, and the patient was accordingly diagnosed with panperitonitis caused by bladder gangrene. Because almost the entire bladder exhibited full-layer necrosis, it was determined that bladder preservation would not be possible, and total cystectomy, bilateral ureterocutaneostomy, and abdominal drainage were performed. Postoperatively, residual intra-abdominal abscess was present, but this resolved with drainage and antibiotic administration. Here, we present this patient who survived extremely rare panperitonitis caused by bladder gangrene.

[Complete response in an elderly patient with advanced gastric cancer treated with TS-1].

The patient was an 80-year-old man whose complaint was coffee-grounds vomit. He was diagnosed with advanced gastric cancer, T2N1H0P0M0, stage II. Though the curative operation was explained to the patient, he declined it because of complications of advanced age, diabetes and bronchial asthma; chemotherapy was chosen instead. TS-1 (80 mg/day) was administered for 28 days, followed by 14 days rest as one course. A partial response was observed after the first course, and no cancer cells were confirmed by endoscopic biopsy after the fifth course. Moreover, after the 14th course, CT showed a complete regression of lymph node metastasis, and no cancer cells were confirmed by endoscopic biopsy, for a complete response (CR). From now on, as society grays more and more, it is considered that elderly advanced gastric cancer patients with complications will increase. TS-1 single treatment is considered to be safe and outpatient treatment possible as one of the useful cures.

[A case of multiple lung metastases of colon cancer with long-term survival following 5'-DFUR and cimetidine therapy].

A 77-year-old woman treated for diabetes mellitus was admitted to our hospital for further examination of abnormal findings on chest plain radiograph. Many nodular shadows in both lung fields were seen on chest X ray and chest CT scan. Colonoscopic examination revealed a type 2 tumor in the ascending colon. We diagnosed this case as ascending colon carcinoma with multiple lung metastases, and performed right hemicolectomy and D1 lymph node dissection. After surgery, the patient was administered 5'-DFUR 600 mg/body/day, cimetidine 800 mg/body/day orally. Though no remarkable reduction of tumors was recognized, the increase of tumor size was relatively slow. The patient remains alive 3 years after surgery.

Clinical impact of thymidine phosphorylase expression in gastric cancer.

Thymidine phosphorylase (dThdPase) is an enzyme that is involved in pyrimidine nucleoside metabolism and DNA synthesis and converts 5'-deoxy-5-fluorouridine (5'-DFUR) to 5-fluorouracil (5-FU). The aim of this study was to elucidate the relationship between dThdPase expression and biological malignancy, prognosis, and sensitivity to postoperative chemotherapy, using immunohistochemical staining. We studied 148 patients with gastric cancer who underwent surgery at Department of Surgery II in Oita Medical University between 1990 and 1999. Immunohistochemical expression of dThdPase was correlated to clinicopathological factors and postoperative survival. Tumor tissue was dThdPase-positive in 112 patients. The results suggested a relationship between the degree of histological differentiation and dThdPase expression (p=0.0697). Examination of dThdPase expression based on the site of the tumor revealed that the groups with upper or lower gastric cancer included a significantly greater number of dThdPase-positive patients (p=0.0011). Analysis of the patients as a whole showed no significant difference between the survival. In the chemotherapy group, the dThdPase-positive patients tended to have a more favorable prognosis than the dThdPase-negative patients (p=0.0578). The results suggest that postoperative adjuvant chemotherapy that makes use of FU metabolic pathways may improve prognosis in patients with dThdPase-positive gastric cancer.