Hiroshi Akutagawa

Study of clinicopathological factors associated with the occurrence of synchronous multiple gastric carcinomas

BackgroundMultiple gastric carcinomas often arise in gastric mucosa with chronic gastritis, particularly severe intestinal metaplasia. In regard to such characteristics, several clinicopathological risk factors for multiple carcinomas have been reported, but no clinically useful criteria are available at present for assessing the onset of multiple gastric carcinomas. If the risk for multiple gastric carcinomas could be accurately assessed, efficient and accurate surveillance could be performed following minimally invasive therapies.MethodsIn the present study, we investigated clinicopathological differences between 94 cases of multiple early gastric carcinomas and 285 cases of solitary early gastric carcinoma. We tested 379 specimens of gastric carcinomas that had been surgically resected at the Department of General and Gastroenterological Surgery of Osaka Medical College, Japan, from April 1999 to December 2006.ResultsUnivariate analysis of clinicopathological factors in the present study showed that multiple gastric carcinomas were significantly correlated to old age (≥65 years), well- and moderately differentiated histological type, mucin phenotype (intestinal type), distribution of atrophic mucosa in the stomach (severe), degree of intestinal metaplasia in the surrounding mucosa (severe), and heterotopic glandular cysts. Multivariate analysis using the stepwise method identified age (≥65 years) and degree of intestinal metaplasia in the surrounding mucosa (severe) as significant independent risk factors for multiple gastric carcinomas.ConclusionWhile other studies have shown risk factors for multiple gastric carcinomas, the present study is unique in showing risk assessment criteria based on a combination of risk factors for multiple gastric carcinomas.

Predictors of lymph node metastasis in T1 colorectal carcinoma: an immunophenotypic analysis of 265 patients.

BACKGROUND: The appropriateness of endoscopic resection in patients with T1 colorectal carcinomas is unclear. Highly precise predictors of lymph node metastasis are required to optimize the outcomes of treatments for T1 colorectal carcinomas. OBJECTIVE: The purpose of this work was to identify predictors of lymph node metastasis by examining the clinicopathologic significance of immunophenotypes found in T1 colorectal carcinomas. DESIGN: This was a retrospective study. SETTINGS: The study was conducted at a university hospital. PATIENTS: Included were 265 patients with T1 colorectal carcinoma who underwent radical surgery. INTERVENTIONS: Patients with T1 colorectal carcinoma were managed. MAIN OUTCOME MEASURES: Immunophenotypes were associated with various clinicopathologic parameters, and CD10 expression was strongly associated with lymph node metastasis. RESULTS: The levels of MUC2, MUC5AC, and CD10 expression were individually significantly associated with tumor location, growth pattern, histologic type, invasive potential, and metastatic potential. The incidence of lymph node metastasis was significantly associated with each of the 5 following parameters: depth of submucosal invasion (p = 0.005), tumor budding (p < 0.001), lymphatic invasion (p < 0.001), MUC2 expression (p = 0.006), and CD10 expression (p < 0.001). Multivariate analysis showed that CD10 expression (OR, 9.2 [95% CI, 2.5–39.8]; p = 0.001) and lymphatic invasion (OR, 6.3 [95% CI, 2.5–17.7]; p < 0.001) were independently associated with lymph node metastasis. LIMITATIONS: This study was limited by its small sample size, intraobserver variation attributed to immunohistochemical staining, and potential selection bias because surgically resected specimens were collected instead of endoscopically resected specimens. CONCLUSIONS: We suggest that CD10 expression is closely associated with lymph node metastasis in T1 colorectal carcinoma.

Pathological factors related to lymph node metastasis of submucosally invasive gastric cancer: criteria for additional gastrectomy after endoscopic resection

BackgroundThere are currently no universally accepted indications and criteria for additional gastrectomy after endoscopic resection of submucosally invasive cancer. The purpose of the present study was to establish accurate indications and criteria for such additional gastrectomy on the basis of lymph node metastasis risk.MethodsWe investigated 130 submucosally invasive gastric cancers and analyzed the pathological risk factors for lymph node metastasis. The tumors were evaluated for pathological factors in the area of invasion, and factors were compared between the cases with lymph node metastasis and those without.ResultsUnivariate logistic regression analysis showed that tumor minor axis length, depth of invasion, histological classification of the area of submucosal invasion, absence of lymphoid infiltration, ulceration or scar in the lesion, and lymphatic and venous invasion are statistically significant risk factors for lymph node metastasis. Multivariate logistic regression analysis showed that the absence of lymphoid infiltration and the presence of lymphatic invasion are statistically significant as risk factors for lymph node metastasis.ConclusionsWe present a scoring system on the basis of the pathological criteria tested in this study. Our findings enable more accurate identification of patients who should undergo additional gastrectomy after endoscopic resection.

Composite type of breast carcinoma with endocrine differentiation: A cytological and immunohistochemical study

We describe a case of breast carcinoma with endocrine differentiation containing a mixture of three different histological features that occurred in a 71‐year‐old woman. Histologically, the tumor was predominantly intraductal, but slightly invasive. In the intraductal lesion, the tumor consisted mainly of ovoid to round cells with a modest to abundant amount of granular eosinophilic cytoplasm or intracytoplasmic mucin (mucin‐producing carcinoma in situ). It also consisted, in part, of plump spindle cells with scant cytoplasm that contained argyrophilic granules in a trabecular pattern or an arrangement of perivascular pseudorosettes (atypical carcinoid tumor like‐features). Mucous lake and tumor cells floating in mucin were seen in the invasive lesion (mucinous carcinoma). Immunohistochemical staining revealed endocrine differentiation of the tumor cells of both intraductal and invasive lesions. These findings suggest that the different histological features derived from pluripotent cells upon endocrine differentiation, and that endocrine differentiation of the tumor cells had already occurred at an earlier stage of carcinogenesis, prior to the appearance of the mucinous carcinoma. Cytologically, plasmacytoid tumor cells appeared in loosely cohesive clusters or as sparsely single cells in a background of a mucinous substance.

Intestinal endometriosis combined with colorectal cancer: a case series

BackgroundIntestinal endometriosis is a common benign disease among menstruating women that affects the intestinal tract.Case presentationThis case report presents seven Japanese cases of intestinal endometriosis with colorectal cancer treated by laparoscopic surgery. Five of the seven cases reported here are women presenting with bowel obstruction due to colorectal endometriosis with colorectal cancer. It can be confused with serious lesions such as advanced colorectal cancer with peritoneal involvement or invasion of adjacent organs (T4).ConclusionsTherefore, we should consider the probability that the cause of bowel obstruction is not T4 but intestinal endometriosis. For surgical treatment, we recommend laparoscopic surgery for colorectal resection because of its benefits of differential diagnosis of T4, preserving fertility, and preventing excessive surgical stress. We performed laparoscopic resection in seven patients with intestinal endometriosis and colorectal cancer. These cases demonstrate the difficulty of establishing a differential diagnosis of intestinal endometriosis with colorectal cancer from T4.

Superficial non-ampullary duodenal cancer identified by small-bowel capsule endoscopy: a case report (with video)

Herein, we report for the first time a case of a surficial superficial non-ampullary duodenal cancer causing obscure intestinal bleeding that was identified by small-bowel capsule endoscopy and treated by endoscopic mucosal resection. A 73-year-old man underwent upper gastrointestinal endoscopy to identify the cause of anemia. Although conventional duodenoscopy revealed a flat, elevated 5-mm lesion with a central recess and “milk-white mucosa” at the inferior duodenal angulus, capsule endoscopy revealed a white nodular 5-mm lesion with central recess at the duodenum slightly to the anal side from the major duodenal papilla. Pathohistological examination revealed a low-grade well-differentiated tubular adenocarcinoma growing locally in the mucosal layer. Although capsule endoscopy detected a nodular lesion, conventional endoscopy revealed a flat, elevated lesion. The cause of this difference in endoscopic findings is considered to be the degree of extension of the intestinal mucosa. In contrast, “milk-white mucosa” as a typical finding of superficial duodenal tumor in conventional endoscopy could be identified as a white mucosal color tone in capsule endoscopy. Conventional endoscopic findings of irregular surface structure in the lesion suggested malignancy. Pathohistologically, the ductal structure of the adenocarcinoma was also distorted. Unfortunately, it was difficult to suggest that the lesion was adenocarcinoma based on the endoscopic findings alone.