Case report of a patient with multiple lesions of the stomach, including multiple cancers and an adenomatous polyp.

This paper describes an unusual case of an 80-year-old man followed up for multifocal gastric cancers. There were three separate polypoid carcinomas and one adenomatous polyp with no sign of malignancy. We measured the DNA content of the gastric cancer and adenomatous cells obtained from endoscopically biopsied specimens. The adenomatous polyp and one of the cancerous lesions showed DNA diploidy. The other two cancerous lesions showed DNA aneuploidy, with different DNA index (DI) values (1.12 and 1.64, respectively). It is considered that the three cancers arose from different stem lines. However, an operation was not performed because the patient refused gastrectomy, and therefore only conservative follow up has been continued. Presentation of this case is followed by a detailed discussion focusing on the possible development of carcinoma in gastric adenomatous polyps in view of the data from the literature.

Implications of flow cytometry in preoperative detection of biologic variables of gastric cancer and malignant condition of gastric remnant cells obtained by endoscopic biopsy.

Flow cytometric (FCM) DNA studies were performed on cell suspensions obtained by endoscopic biopsy in 73 patients with gastric cancer and in 61 patients with gastric remnant. In cancer, DNA aneuploidies were detected in 49 tumors (67.1%), including 51.7% (15/29) of early gastric cancers and 77.3% (34/44) of advanced gastric cancers. Nuclear DNA content of biopsy materials had a significant correlation with that of surgically obtained ones, providing the estimation of the original ploidy pattern and DNA index (p < 0.01). The serosal invasion, lymph node metastasis, lymphatic invasion, and vascular invasion of the DNA aneuploidy were significantly higher than those of the DNA diploidy (p < 0.05). In patients with gastric remnant, 9 biopsy specimens in the anastomotic site showed DNA aneuploidy (13.9%). The DNA measurement of the endoscopically obtained specimens may provide additional preoperative information and help to identify biologic variables.

Spontaneously perforated pyometra presenting as diffuse peritonitis: report of a case.

We report herein a rare case of spontaneously perforated pyometra found in a 72-year-old woman who was admitted to our hospital with abdominal pain and vomiting. A distended abdomen with muscular rigidity, a positive Blumberg sign, and a WBC count of 11,900/mm3 indicated diffuse peritonitis, although a plain abdominal X-ray film revealed no free air in the peritoneal cavity. An emergency laparotomy was performed, which revealed a lot of pus, and perforation in the fundus of a distended uterus. The patient was therefore diagnosed as having suffered uterine perforation associating with a pyometra, and a total hysterectomy with bilateral salpingo-oophorectomy was carried out. Histological examination revealed a pyometra with inflammation and destruction of the endometrium and myometrium, and cervical occlusion with no evidence of malignancy. Postoperatively, the patient developed a subcutaneous abscess and pneumonia, but recovered and was discharged on the 74th day after her operation. Thus, although rare, spontaneously perforated pyometra should be considered when elderly women present with acute abdominal symptoms.

Histopathologic and flow cytometric analysis of colorectal polyps resected at endoscopy.

Forty-seven colorectal polyps of various histologic types were studied using retrospective flow cytometric (FCM) DNA analysis to determine the prevalence of aneuploid cell populations and whether they were associated with any particular histologic features. Overall, 6 of 47 polyps (12.8%) contained DNA aneuploid cells, comprising 4 adenomatous polyps, 1 of 12 with mild atypia (8.3%), 2 of 19 with moderate atypia (10.5%) and 1 of 4 with severe atypia (25.0%), and 2 of 4 polyps (50.0%) with histologic features of carcinoma in situ (CIS). The incidence of DNA aneuploid cells in CIS was significantly higher than that of all adenomatous polyps (p = 0.043). All of the 8 hyperplastic polyps were diploid. The detection of aneuploidy as a marker of increased risk for malignant transformation was possible even in colorectal adenomas measuring < or = 10 mm. These results show that retrospective FCM analysis can detect DNA aneuploidy in adenomatous polyps and that DNA aneuploidy may occur before histologic evidence of invasive carcinoma.

A case report of resected primary duodenal carcinoma associated with early gastric cancer and cumulative results at 21 institutions in Japan.

A case of primary duodenal carcinoma simultaneously associated with an early gastric cancer is reported. A 72-year-old woman complaining of appetite loss and nausea was admitted in June 1988. Endoscopic examination showed an ulcerative lesion in the angle of the stomach and a Borrmann type 2 tumor in the bulb of the duodenum. Both lesions were revealed to be adenocarcinomas by histological examination of obtained biopsy specimens. Synchronous carcinoma was diagnosed and pancreatoduodenectomy and lymph node dissection were performed. The primary tumor of the duodenum was histologically a moderately differentiated adenocarcinoma, and the gastric cancer was a tumor limited to the mucosa. Metastasis was recognized in a regional lymph node (No. 14A). There has been no recurrence during the 4-year postoperative follow-up period. This result suggests that pancreatoduodenectomy with systematic regional lymph node dissection can greatly contribute to prolonging the survival of patients with advanced duodenal cancer. This case is very rare, in that curative operation was performed for a primary duodenal carcinoma simultaneously associated with an early gastric cancer.

A clinicopathological study on intrahepatic cholesterol gallstones.

In order to clarify the pathogenesis and process of the formation of intrahepatic cholesterol gallstones, we examined the clinical features, cholangiograms and pathological findings of eight patients with intrahepatic cholesterol gallstones. When examining the clinical features, one patient was found to have developed intrahepatic cholesterol gallstones 3 years after a complete lithotomy. The cholangiograms of two patients revealed small gallstones in the peripheral bile ducts of the lateral segment of the liver, and these bile ducts showed localized cystic dilatation and were tightly filled with gallstones. Conversely, their other bile ducts which contained no gallstones showed an entirely normal cholangiogram. Pathologically, these two cases showed mild chronic cholangitis, and cholesterol crystals in the peripheral bile ducts. The other six cases showed moderate or severe dilatation of the bile duct and severe chronic proliferative cholangitis. From the above results, we proposed the following theory to explain the pathogenesis and process of the formation of intrahepatic cholesterol stones: The cholesterol crystals in the peripheral intrahepatic bile ducts may be a primitive form of intrahepatic cholesterol gallstones, and the formation of intrahepatic cholesterol gallstones may precede and cause such deformities of the bile ducts as strictures or dilatations.

[CT of the pelvic kidney].

Six cases of unilateral pelvic kidney are presented. CT features are summarized as follows: (1) an absence of a kidney in the renal fossa with normal sized opposite kidney: (2) a pelvic kidney whose hilus faces in various directions; and (3) homogeneous parenchymal enhancement and visualization of the pyelocalyceal system on post-contrast CT. In the study of suspected pelvic kidney, CT is a useful diagnostic tool.

[Effect of PMU hepatic arterial chemotherapy for liver metastases of gastric cancer. Hokuriku Cisplatin Round-table Conference].

We performed PMU hepatic arterial chemotherapy (a combination therapy consisting of intra-hepatic arterial infusion of CDDP and MMC, oral administration of UFT) in 20 patients with gastric cancer and liver metastases. In this method, 1-6 courses of one infusion of CDDP at 70-100 mg/body and MMC of 10 mg/body into the proper hepatic artery were administered at intervals of 3-4 weeks. UFT of 300-400 mg/day was orally administered with the infusion. The primary response for hepatic metastatic lesions was observed in one case of CR, 14 cases of PR, 4 cases of NC, and one case of PD. The efficacy for CR and PR was high at 75%. The median disease-free interval was 56 weeks in responders. The 50% survival period was 11.1 months; one-year survival rate, 42.1%; two-year survival rate, 12.3%; the longest survival period was 108 weeks. Mild and transient side effects were recognized in 17 cases (85%): gastrointestinal symptoms, sense of general malaise, fever, leukocytopenia, and elevated BUN. Thus, the results indicated that this combination chemotherapy was effective for liver metastases of gastric cancer.

[Effect of PMU therapy (CDDP, MMC and UFT) against terminal gastric carcinoma. Hokuriku Cisplatin Round-table Conference].

PMU therapy with 75 mg/m2 of CDDP, 10 mg/body of MMC and 400 mg/day of UFT was performed on 57 patients with terminal gastric carcinoma. The treatment resulted in CR in 2, PR in 9, MR in 1, NC in 16 and PD in 9 of 37 patients with evaluable cases, with a response rate of 30% (11/37 patients). In the 11 responders, the mean disease-free interval was 6.6 months with a median interval of 5 months, and the mean survival period was 9.2 months with a median survival period of 6 months, while in the 46 non-responders, the mean survival period was 6.7 months with a median survival period of 5 months. In all patients, the mean survival period was 7.1 months with a median survival period of 6 months. Adverse reactions to the treatment included gastrointestinal disturbance observed in 77%, nephrotoxicity in 14%, and myelotoxicity in 26% of the patients, but all reactions became normalized during the course of observation. These results have led to the conclusion that PMU therapy may be an effective treatment for terminal gastric carcinoma.

CT of follicular adenoma in the thyroid gland.

Computed tomography was performed in 27 lesions of follicular adenoma. About half of them showed heterogeneous low density areas due to retrogressive changes, especially internal hemorrhage. Seven out of 12 lesions whose contours were poorly defined had chronic focal thyroiditis of the adjacent thyroid gland. Internal hemorrhage was another cause of indistinct contour in two lesions. We stress that CT features of follicular adenomas are modified by their retrogressive changes and inflammation of the adjacent gland.

Radiologic imaging of herniation of the small bowel through a defect in the broad ligament.

Internal herniation through the broad ligament is extremely rare. We report a case in which radiologic examinations including computed tomography (CT) were performed. A strangulated loop in the Douglas fossa was well-demonstrated by CT. CT can provide some clues to the diagnosis of this condition.

Computed tomographic diagnosis of strangulated obstruction.

A case of strangulated obstruction with computed tomographic appearance is reported. CT may be useful for the demonstration of the strangulated loop in a patient with obstructive symptoms and a soft tissue mass in the pelvis shown on plain films of the abdomen.

CT diagnosis of common bile duct stone.

Common bile duct stones were demonstrated as high-density objects on CT in 22 of 45 cases. About 96% of the remaining cases (22 of 23) exhibited other abnormal CT findings which included common bile duct dilatation, concomitant gallbladder stones, and/or presence of intraductal air. CT is a useful diagnostic modality in the elevation of patients with suspected choledocholithiasis.