Fujio Tomita

Lymphatic routes of the stomach demonstrated by gastric carcinomas with solitary lymph node metastasis.

To clarify whether or not the lymphatic routes that have long been generally accepted are indeed correct, we retrospectively examined the clinical records of patients with solitary lymph node metastasis from gastric carcinoma. From 735 patients gastrectomized with lymph node dissection (more than D1), 51 (7%) were histologically proven to have only one lymph node involved. In 44 of these 51 patients, the involved nodes were all in the perigastric region (N1). There were also 7 patients with a jumping metastasis to the N2–N3 nodes. Three of them were found along the left gastric artery (#7 according to Japanese classification) and the other 4 were found along either the common hepatic artery (#8) or the proper hepatic artery (#12). The depth of invasion was submucosal in 2, proper-muscular in 2, subserosal in 1, and serosa-exposed in 2, and the conclusive stage was II in 2, IIIa in 3, and IIIb in 2. However, 1 of these patients died of liver cirrhosis and 2 died of pneumonia, while the other 4 were still alive at the time of this report more than 5 years after surgery. These results suggest that not every sentinel node is located in the perigastric region near the primary tumor and that, if the preoperative examination indicates submucosal invasion, then a systematic regional lymph node dissection should therefore be carried out.

Case report: Portal-systemic encephalopathy due to a congenital extrahepatic portosystemic shunt

We present a case of portal‐systemic encephalopathy due to a congenital splenorenal shunt. A 69 year old woman was admitted to hospital because of recurrent episodes of disturbed consciousness. The present episode had begun 3 months prior to admission. Although the patient demonstrated mildly slurred speech, the remainder of her neurological examination was unremarkable. She showed no clinical signs of portal hypertension and her liver function, except for a serum hepaplastin test of 58% and an ICG retention rate of 28% at 15 min, was normal. Her serum ammonium level was 210 μg/dL. The venous phase of a superior mesenteric arteriogram revealed a splenorenal shunt and narrowing of the portal vein, which was 4 mm in diameter. The histological findings, demonstrated by a needle liver biopsy specimen, were consistent with mild fibrosis and lymphocytic infiltration. Following the diagnosis of a splenorenal shunt in the absence of liver cirrhosis, ligature of the shunt was performed with a splenectomy. The portal vein pressure after ligature of the shunt rose from 12.5 to 18.8 mmHg. This shunt was thought to be of congenital origin. The high preoperative serum ammonia concentration decreased to the normal range postoperatively and the serum hepaplastin test and ICG retention rate similarly improved postoperatively. A follow‐up superior mesenteric arteriogram was performed during the venous phase, demonstrating resolution of the shunt and decreased portal vein narrowing. The patient has suffered no further episodes of disturbed consciousness postoperatively.

Gastric cancer occurring in a patient with Plummer-Vinson syndrome: Report of a case

We report herein the unusual case of a 59-year-old woman with Plummer-Vinson syndrome who developed gastric cancer. The patient had a longstanding history of dysphagia and iron deficiency anemia, for which she has sporadically taken iron deficiency anemia, for which she had sporadically taken iron supplements that improved the dysphagia to some extent, but not completely. Owing to her tolerance of the dysphagia, she had not been taking iron supplements for the past 17 years. On admission, she was in fair nutritional condition and not anemic. Blood chemistry results were all normal, including the serum iron level. Gastrointestinal radiographic series demonstrated cervical esophageal webs and advanced gastric cancer. Her dysphagia was successfully treated by endoscopic bougienage through the webs, and a distal partial gastrectomy with nodal dissection was performed. Histology of the resected stomach revealed atrophic mucosal change and, by chance, an adenomatous lesion in addition to adenocarcinoma. Her postoperative course was uneventful and she is now well, without any signs of recurrence. Although Plummer-Vinson syndrome is known to be associated with upper alimentary tract cancers, gastric cancer is extremely rare. A discussion on the etiology of Plummer-Vinson syndrome and its link with potential carcinogenesis follows this case report.

Gallbladder cancer associated with cholesterosis

We report herein two cases of carcinoma in situ of the gallbladder associated with cholesterosis. The patient in case 1 was an 81-year-old man who underwent a cholecystectomy for cholelithiasis. The resected specimens revealed gallbladder cancer in the fundus which was diagnosed histologically as mucinous carcinoma. Other findings included 13-mm, 12-mm, and 5-mm poly-poid lesions in the neck of the gallbladder which macroscopically appeared to be cholesterol polyps, but histologically demonstrated carcinoma in situ with cholesterosis. The patient in case 2 was a 76-year-old man in whom ultrasonography revealed a highly echogenic, elevated lesion in the gallbladder. Cholecystectomy was performed, and a 33×28-mm papillary, elevated lesion with cholesterosis was resected from the neck of the gallbladder. Histologically, this was demonstrated to be papillary adenocarcinoma in situ with cholesterosis surrounded by glandular dysplasia. The distribution of the carcinomas and cholesterosis in both of these patients suggests that the adenoma or carcinoma of the gallbladder had occurred first. Then, the tumor epithelium absorbed cholesterol from the bile, and foamy cells were produced. Thus, when treating cholesterol polyps, it should be remembered that it is often difficult to distinguish between cholesterol polyp and gallbladder cancer with cholesterosis.

A case of gallbladder cancer associated with a common bile duct neuroma, and a cystic lesion of the liver with histologic findings similar to those of an inflammatory pseudotumor

We report a rare case of gallbladder cancer associated with a common bile duct neuroma, and a cystic liver lesion with histologic findings similar to an inflammatory pseudotumor, in a patient who had had no previous abdominal surgery. The patient was a 62-year-old man whose major complaint was fever. Ultrasonography and a computed tomography scan revealed gallstones, an elevated lesion in the gallbladder, and a cystic liver lesion. Endoscopic retrograde cholangiopancreatography demonstrated stenosis of the common bile duct. Cultures of the cystic fluid and gallbladder bile were positive forStaphylococcus aureus. The patient underwent hepatectomy (inferior S4, S5, and S6), cholecystectomy, resection of the common bile duct, and right hemicolectomy. The resected specimens revealed gallbladder cancer with the microscopic appearance of a papillary adenocarcinoma, and a 12×4.5×3.5 cm cystic liver lesion with a wall 7 mm thick. Histologic studies of the wall of the cystic liver lesion revealed infiltration by histiocytes and plasma cells, and the presence of fibrous connective tissue, which findings are characteristic of inflammatory pseudotumors. A 9×6 mm elevated lesion, with the microscopic appearance of a neuroma, was resected from the common bile duct.

A long surviving case of resected gastric cancer presenting with a synchronous adrenal metastasis

Clinically curable adrenal metastases are rare. We treated a patient with gastric cancer and a synchronous adrenal metastasis who underwent curative resection. Upper GI examinations of a 75-year-old man revealed a Borrmann 3 gastric tumor in the proximal stomach. CT indicated a giant gastric tumor that invaded the pancreatic tail, and the left adrenal gland seemed normal. He was subjected to a total gastrectomy and a distal pancreatosplenectomy. Because a mass was palpated intraoperatively in the left adrenal gland, it was also removed. The gastric tumor was histopathologically a poorly differentiated adenocarcinoma with scirrhous invasion that invaded the pancreas, and the histopathological findings of the left adrenal tumor were compatible with those of gastric cancer. At present, 6 years after the operation, there has been no clear sign of cancer recurrence. It may be rational to excise the left adrenal gland en bloc in patients with serosa-positive Borrmann 3-4 gastric cancer.

A Study on the Lymph Node Metastases of the Right Side Colon Cancer in Relation to the Location of Cancer and the Arterial Supply.

右側結腸癌109例を対象にリンパ節転移状況を検討し, 以下の結果を得た. 1) 採取リンパ節総数は7,664個, 1症例あたり平均70.3個で, 転移率は49.5%, 転移度は3.4%であった.2) 右結腸への動脈分岐は回結腸, 右結腸および中結腸動脈が独立して分枝する標準型は47w7%のみであった. 3) 肉眼判定と組織学的所見ならびにリンパ節長径と転移度の検討から肉眼判定の困難性が示唆された. 4) 転移率は癌腫部位に関係なく腫瘍近傍リンパ節で最も高く, 次いで中枢側転移が高率で, 主幹動脈に向かう流れが優位を占めた. なお, 腸管軸方向転移は癌腫縁より最長10cmに限られていた. 5) 癌腫部位からみた中枢側転移は盲腸および上行結腸口側1/3の癌では回結腸動脈, 右横行結腸癌では中結腸動脈領城が主で, 他の上行結腸癌では動脈分岐状況に左右され, 3動脈にまたがって転移がみられた. 6) 盲腸および同部の浸潤上行結腸癌の3例で下大静脈前面, 外腸骨動脈周囲リンパ節に転移を認めた. 以上から右側結腸癌に対する郭清術式を考察した.

A Long Surviving Case of Remnant Stomach Cancer with Paraaortic Lymph-node Metastasis. A Patient with Three Primary Cancers Including Remnant Stomach Cancer Gallbladder Cancer and Breast Cancer.

大動脈周囲リンパ節 ((16) b1 inter) 転移陽性であったが切除術後4年5か月の現在再発徴候を認めず健在の1症例を経験した.本症例は64歳の女性で, 残胃癌と同時性に胆嚢癌を切除し, その1年1か月後に右乳癌を切除しえた.既往歴では左乳切 (詳細不明) と胃切除 (巨大皺襞症) がある.残胃癌は肝転移や腹膜播種を認めず, 組織学的には膠様腺癌で漿膜に露出し第4群リンパ節転移陽性で, 残胃全摘膵体尾部脾合併切除兼R2郭清術, また, 胆嚢癌は粘膜内に限局する乳頭腺癌で所属リンパ節転移を認めず, 拡大胆嚢摘除術兼R2郭清術, さらに, 乳癌は1cmの浸潤性乳管癌でリンパ節転移や遠隔転移を認めず, 非定型乳房切除術が施行された.進行した残胃癌は予後不良とされるが, 再建法と進行度に応じた積極的な合併切除とリンパ節郭清を選択することで長期生存の可能性が生じるものと思われた.また担癌患者を診察する際には, 術前術後の他臓器原発癌に留意することが肝要である.