Hideaki Shimoji

Predictive factors for long-term survival in patients with intrahepatic cholangiocarcinoma

BACKGROUND In order to elucidate the predictive factors for long-term survival in patients with intrahepatic cholangiocarcinoma (ICC), we evaluated 7 patients who survived for more than 5 years (5-year survivors). METHODS We examined the clinicopathologic and biologic factors of the 5-year survivors, and these findings were then compared with those in 20 patients who died within 5 years after surgery (control group). RESULTS In the 5-year survivors, the gross appearance of the tumors included a mass-forming (MF) type in 5 cases, an intraductal growth (IG) type in 1, and another type (microcarcinoma with hepatolithiasis) in 1. No case demonstrated a periductal infiltrating (PI) type. Except for 1 case with an IG type tumor, no lymph node metastasis was seen in any patients. All of the 5-year survivors were classified from stage I to III, and all also underwent a curative resection. The clinicopathologic factors demonstrating significant differences between the 5-year survivors and the control group included the gross type of the tumor, lymph node involvement, the surgical margin, curability, and pTNM stage. CONCLUSION The predictive factors for long-term survival in patients with ICC are thus suggested to include not only tumor staging and curability, but also lymph node metastasis and the gross type of the tumors.

Granular cell tumor of the rectum: a case report and review of the literature.

Abstract: A 47-year-old Japanese woman with a 5-year history of alcoholism was admitted to the Ryukyu University Hospital for the treatment of the alcoholism. For evaluation of observed changes in her bowel habits, she underwent colonoscopy, which revealed seven small polyps spread throughout the entire large intestine. Six of the polyps were in the colon; one was an adenoma and five were hyperplastic polyps. The remaining polyp, in the rectum, was an 8-mm submucosal tumor. Pathological analysis of a biopsy of the lesion in the rectum indicated a possible diagnosis of adenocarcinoma. Endoscopic ultrasonography (EUS) demonstrated a submucosal hypoechoic nodule, involving the mucosa and the muscularis propria. Subsequently, the patient underwent a radical low anterior resection of rectum. The lesion was a submucosal tumor with ulceration. The tumor consisted of granular tumor cells which were positive for S-100 protein, neuron-specific enolase, and periodic acid schiff (PAS) stain, but negative for desmin and vimentin. Granular cell tumor is rare in the gastrointestinal tract. As a result, such tumors can be misinterpreted to indicate a possible malignancy on either a biopsy or EUS.

Primary Malignant Melanoma of the Esophagus Arising from a Melanotic Lesion: Report of a Case

We herein report a case of primary esophageal malignant melanoma in which the development from a preceding benign melanotic lesion and the growing process of the tumor were chronologically observed by serial endoscopic examinations. Biopsy specimens repeatedly taken from the tumor failed to identify the presence of malignant melanoma. A positron emission tomography scan and gross changes of the tumor endoscopically observed were useful for detecting the presence of malignant transformation. The patient eventually died of generalized metastatic disease soon after undergoing an esophagectomy. An early diagnosis may therefore be crucial for improving the treatment outcome of esophageal malignant melanoma. Therefore, esophageal melanotic lesions should be carefully followed up even if biopsy specimens repeatedly show no malignancy.

Perforation Due to Metastatic Tumors of the Ileocecal Region

Abstract. We reviewed our department’s medical records between April 1986 and April 1994 to identify patients who showed acute abdominal symptoms requiring surgical treatment due to metastatic tumors of the small intestine. In group A, seven patients (30%) were treated for acute peritonitis, and all were found to have an intestinal perforation due to hematogenous metastases (group A). In group B, 16 patients (70%) were treated for an intestinal obstruction, and all were found to have disseminated tumors of the small intestine (group B). In group A all tumors were isolated and located exclusively in the ileocecal region, whereas all tumors in group B showed peritoneal dissemination, with no predominant anatomic localization. In general, the intestinal tumors in group A originated from cancers of the upper aerodigestive tract, whereas those in group B originated from advanced cancers in the abdominal cavity. The tumors were significantly smaller and the period between the onset of symptoms from the original malignancy and the onset of abdominal symptoms (perforation or obstruction) was significantly shorter in group A. In conclusion, intestinal metastases located in the ileocecal region have unique clinicopathologic features and so should be recognized as a distinct disease entity. Therefore when patients with a known upper aerodigestive malignancy exhibit acute abdominal symptoms, intestinal metastasis to the ileocecal region, necrotic changes, and perforation should be considered in the differential diagnosis.

Clinicopathological factors predicting R0 resection and long-term survival after esophagectomy in patients with T4 esophageal cancer undergoing induction chemotherapy or chemoradiotherapy

PurposeTo identify clinicopathological factors predicting R0 resection and long-term survival after esophagectomy in patients with T4 esophageal cancer following induction chemotherapy or chemoradiotherapy.MethodsOf 48 patients with T4 esophageal cancer who underwent induction treatment, 30 underwent R0 esophagectomy. The factors predicting R0 resection and prognostic indicators were assessed in the 48 and 30 patients, respectively, using univariate and multivariate analyses.ResultsIn the univariate analyses, the primary tumor response, improvement of dysphagia, the post-induction therapy Glasgow Prognostic Score, an early tumor response and the post-induction therapy serum albumin and C-reactive protein levels were significantly correlated with R0 resection. Multivariate logistic regression analyses revealed that the response status and improvement of dysphagia were independent predictors of R0 resection. The univariate analyses identified a yp-T classification (yp-T0/1 vs. yp-T2/3/4), yp-nodal status and the number of pathologically positive nodes post-therapy (≤1 vs. ≥2) as significant prognostic factors. The multivariate analysis revealed that the number of pathologically positive nodes was the only significant independent prognostic indicator.ConclusionPatients showing an early tumor response to induction treatment and improvement of dysphagia may be appropriate candidates for esophagectomy, and individualized postoperative management strategies should be developed for patients with initially unresectable T4 esophageal cancer who have ≥2 positive nodes post-treatment.

Primary malignant melanoma of the esophagus successfully treated by an esophagectomy followed by systemic chemotherapy

Primary malignant melanoma of the esophagus is a rare disease that tends to demonstrate an extremely poor prognosis. We herein describe a case of primary malignant melanoma of the esophagus that was successfully treated. The tumor was incidentally detected by a barium swallow examination performed during a routine medical checkup. The tumor was resected by a transhiatal radical esophagectomy. Histologically, the tumor metastasized to one of the perigastric lymph nodes, although tumor invasion was confined to the submucosa at the primary site. Immunohistochemically, the tumor cells were strongly positive for S100 protein and HMB-45. Postoperatively, systemic chemotherapy consisting of DTIC, ACNU, and VCR was administered. The patient has survived without recurrence for 12 months after these treatments. A transhiatal esophagectomy followed by systemic chemotherapy may therefore be an effective treatment for potentially curable primary melanoma of the esophagus.

Common bile duct blood clot: an unusual cause of ductal filling defects for calculi.

Abstract: We report a case of obstructive jaundice caused by a blood clot in the common bile duct in a 75-year-old man with cirrhosis. Five years prior to his admission, he had undergone a left hepatectomy for hepatocellular carcinoma. At the present admission, he appeared icteric, and endoscopic retrograde cholangiography revealed filling defects in the common bile duct. Choledochotomy was therefore performed for possible common duct stones, and exploration of the duct showed blood clot casts filling the duct. The casts were easily removed, and the patients postoperative course was uneventful. However, he developed ascites and jaundice 1 month later and died of liver failure approximately 3 months after undergoing the choledochotomy. Autopsy revealed hemorrhagic necrosis in the proximal intrahepatic duct of the posterior segment, which was considered to be the cause of the observed hemobilia, as well as the blood clot in the common bile duct at surgery. We report this rare case and discuss the cause of hemobilia.

Microsatellite instability in patients with gastric remnant cancer

Background. About 2% of patients who undergo partial distal gastrectomy for gastroduodenal diseases develop gastric remnant cancer 10 to 30 years after the gastrectomy. It is important in clinical practice to determine a molecular marker to identify patients susceptible to gastric remnant cancer. Methods. We investigated nine gastric remnant cancers (from nine individuals who had gastrectomies for primary gastric cancer or gastroduodenal ulcer) for microsatellite instability (MSI) at six loci, using the polymerase chain reaction (PCR). A control group of ten patients with sporadic gastric cancers in the upper third of the stomach was also similarly analyzed. Results. MSI was demonstrated in eight of nine cancers from the individuals who had had primary gastric cancer or gastroduodenal ulcer (88.9%) compared with two of ten cancers from the individuals with sporadic gastric cancer in the upper third of the stomach (20%). Conclusion. These results suggest that one or more MSI is associated with remnant gastric cancer after gastrectomy.

Fundic adenomyomatosis bulged with the subserosal excessive fat of the gallbladder mimicking polypoid carcinoma: A case report with unusual imaging and morphological features

This report describes a 41-year-old female who presented with adenomyomatosis of the gallbladder mimicking polypoid carcinoma, on the diagnostic imaging findings and revealing unusual histologic features for such a localized adenomyomatosis. The mass was located on the gallbladder liver-side wall at the fundus and papillary hyperechoic growth showed no clear ultrasonographic features of adenomyomatosis. The patient underwent a laparoscopic cholecystectomy with a tentative diagnosis of superficial polypoid carcinoma. Histologically, the tumor bulged due to subserosal excessive fat tissue.

Clinical implications of quantitative pathological and immunohistochemical markers for lymph node metastasis in esophageal cancer patients based on preoperative treatment status

BackgroundWhether the prognostic abilities of markers of lymphatic spread are affected by preoperative chemotherapy or chemoradiotherapy for esophageal cancer has not been clarified. The purpose of this study was to determine significant prognostic predictors related to lymphatic spread in potentially curable esophageal cancer according to preoperative treatment status.MethodsThe prognostic significance of quantitative pathological and immunohistochemical markers of lymphatic spread was determined in 80 esophageal cancer patients undergoing R0 resection with or without preoperative treatment.ResultsUnivariate analysis revealed that the presence or absence of immunohistochemical nodal micrometastasis (iNM), number of pathological nodal metastases (pNM) and iNM, and the ratios of pNM and iNM to removed nodes were significant prognostic predictors in patients undergoing esophagectomy without preoperative treatment. In contrast, only the presence or absence of pNM, number of pNM, and pNM ratio were significant prognostic indicators in patients undergoing esophagectomy after preoperative treatment. Multivariate analysis revealed that the number of iNM, a novel prognostic indicator found in the present study, was the only independent prognostic predictor in the former patients, whereas the number of pNM was the only independent prognostic predictor in the latter patients.ConclusionsIn esophageal cancer, the prognostic values of factors related to lymphatic spread depend on the patient’s preoperative treatment status. Two or more pNM indicated poor prognosis after esophagectomy in patients undergoing preoperative treatment for advanced disease. However, 2 or more iNM indicated poor prognosis after esophagectomy in patients undergoing upfront esophagectomy for less advanced disease.