Kimio Matsuura

A 10-year experience of intraoperative radiotherapy for gastric carcinoma and a new surgical method of creating a wider irradiation field for cases of total gastrectomy patients

PURPOSE To improve the prognosis of gastric cancer, radical surgical resection with extensive lymph node dissection plus intraoperative radiation therapy (IORT) was tried in our clinic. In addition, a new operative procedure was created to obtain wider irradiation field for total gastrectomy patients. METHODS AND MATERIALS A total of 183 gastric cancer patients who underwent radical gastrectomy with or without IORT from August 1983 to July 1992 were retrospectively evaluated. The patients were divided into two groups: group 1 consisted of 58 patients who underwent radical operation plus IORT. A single dose of 28 to 30 Gy was delivered around the celiac axis with an electron beam of 12 MeV. Group 2, our historical control group, which showed no difference in age, sex and stage, consisted of 120 patients who underwent only radical surgery. In addition, a new method of total gastrectomy with IORT after mobilization of the tail and body of the pancreas was devised to get wider irradiation field for advanced gastric cancer. RESULTS Of the Stage II gastric cancer patients, all the 11 patients of group 1 are alive, whereas in group 2, the 4-year and the 8-year survival rates were 60% and 48%, respectively. In Stage III patients, the 8-year survival rate of group 1 was 55% vs. 35% in group 2. As for Stage IV patients, the 5-year survival rate of group 1 was 12% and that of group 2 was 13%. CONCLUSION Using this combined treatment modality of radical surgical operation+IORT, improved survival rates were obtained for Stage II and III gastric cancer patients. However, the method was ineffective for more advanced, Stage IV, patients. The wider irradiation field method used for total gastrectomy patients was safe and no complications were encountered.

Ultra-high-resolution scanning electron microscopy of the sarcoplasmic reticulum of the rat atrial myocardial cells.

The sarcoplasmic reticulum (SR) of mammalian ventricular and atrial muscles share common features but also differ because T‐tubules are rare and extended junctional SR is exclusively seen in the atrium. This scanning electron microscope (SEM) study was undertaken to clarify the three‐dimensional organization of the rat atrial SR system. Specific preparations were examined with an ultra‐high‐resolution SEM.

A case of early-stage gastric plasmacytoma.

Extramedullary plasmacytomas are rare, and mostly occur in the upper respiratory tract.1 Those in the gastrointestinal tract2 and stomach constitute approximately 10% and 5%, respectively, of all extramedullary plasmacytomas.2 In particular, cases of early-stage gastric plasmacytoma in which neoplastic cells are confined to the mucosa or submucosa have been extremely rare.3 We report here a case of an early stage, superficially spreading type of gastric plasmacytoma in which the endoscopic features changed after a few months’ interval. Helicobacter pylori were found histopathologically in biopsy specimens. As the mucosal lesion was markedly improved endoscopically, but histologically unchanged after H. pylori eradication, a subtotal gastrectomy was performed. The eradication of H. pylori may improve the endoscopic findings but not affect the histological findings of atypical plasma cell infiltration in gastric plasmacytoma. A 77-year-old man was referred to the medical clinic with nausea that had begun 2 months earlier. In an upper endoscopic study performed on July 7, 1999, irregular reddish mucosa with a shallow ulcer was detected in the anterior wall of the antrum (Fig. 1A). In biopsy specimens, plasmacytoma was suspected. The patient was then referred to our hospital for further evaluation of the gastric lesion, on August 5, 1999. Physical examination on admission showed no remarkable findings. Neither an abdominal mass nor peripheral lymph nodule swelling was noted. Urinalysis, blood analysis, proteinogram, and blood chemistry showed no unusual findings. Bence Jones’ protein was also not detectable in a concentrated urine sample. M protein was not detected. Serum immunoglobulin values were within normal limits. Letter to the editor

Intracystic Carcinoma of the Male Breast: Report of a Case

Abstract We experienced a very rare case of male intracystic breast carcinoma. A 66-year-old man presented at our hospital because of a palpable mass in his right breast. The imaging diagnosis was an intracystic carcinoma with hemorrhagic fluid and two mural nodules. Modified radical mastectomy was performed under general anesthesia. The pathological examination revealed the intracystic papillary carcinoma with foci of microinvasion. The findings of power Doppler ultrasonography and dynamic magnetic resonance imaging were very useful for the differential diagnosis of our case.

Morphological study of the regeneration mechanism of acetic acid-injured colon crypts in the rat

The regeneration mechanism of injured rat colonic mucosa with 1% acetic acid was certified in this study. The injured colons were studied periodically on experimental days 1, 3, 5, 7, 15, and 20 with light and scanning electron microscopy. Specimens were examined in paraffin sections stained with hematoxylin and eosin; crypts were isolated with the HCl digestion method; and three-dimensional stromal collagen tissue was prepared with the NaOH cell maceration method. Damage to the mucosal and submucosal layers peaked between the 1st and 3rd days with edema, regeneration, necrosis, and inflammation. The edema and inflammation subsided, and mucosal atrophy and crypt reduction remained at around 1 week. At 2 weeks the mucosa became thick, and crypts showed many branches in their lower two-thirds; and by 3 weeks the mucosa had recovered to almost normal. The ratio of number of crypts at the base and surface was almost 1.5 on the 15th day and 1.0 on the 20th day, suggesting that each branch progresses upward to create an independent crypt. We believe that the fission mechanism plays an important role in crypt repair after acetic acid injury of the colonic mucosa. As the proliferative zone of the colonic crypt is localized at the crypt base, fission of the crypt starting at the base and progressing up to the surface is the most reasonable and efficient mechanism for repair by increasing the number of crypts.

A morphological study of the pacemaker cells of the aganglionic intestine in Hirschsprung's disease utilizing ls/ls model mice.

Hirschsprung’s disease is a congenital aganglionic neural disorder of the segmental distal intestine characterized by unsettled pathogenesis. The relationship between Hirschsprung’s disease and pacemaker cells (PMC), which almost corresponds to that of the interstitial cells of Cajal (ICC), was morphologically observed at the level of the intermuscular layer corresponding to Auerbach’s plexus using ls/ls mice. These mice are an ideal model because of their large intestinal aganglionosis and gene abnormalities, which are similar to the human form of the disease. Immunostaining using anti-c-kit receptor antibody (ACK2), a marker of PMC, applied to whole-mount muscle-layer specimens, revealed the presence of c-kit immunopositive multipolar cells with many cytoplasmic processes in normal mice. For ls/ls mice, however, there were significantly fewer processes. The average number of processes per positive cell of 2.5 for the aganglionic large intestine was fewer than 3.5 for the large and small intestine of normal mice, indicating the inability to form connections between nerves and PMC in the aganglionic intestine. For normal mice with an Auerbach’s plexus, the process attachment of ICC to the Auerbach’s plexus was observed by scanning electron microscopy. However, for ls/ls mice no attachment to the intermuscular nerve without Auerbach’s plexus was found, although transmission electron microscopy showed no difference in the cell structure and organelles of the c-kit immunopositive cells between the normal and ls/ls mice. These findings suggest that in the aganglionic intestine of Hirschsprung’s disease, aplasia of enteric ganglia induces secondary disturbances during the normal development of intestinal PMC.

An unusual case of solid hamartoma in the liver.

An unusual case of solid hepatic hamartoma, which could not be correctly categorized under the WHO classification, is reported. The well defined, solid nodular lesion, arising in the anterior edge of the left hepatic lobe, was found in a 15‐month‐old female infant. The lesion was composed of irregularly shaped yellow islands of parenchyma and white‐gray nodules of fibrous stroma of various sizes, which were intermingled revealing a mosaic pattern. Prominent bile ductal proliferation was observed histologically in the fibrous stroma, associated in parts with dense or loose periductal bundles and vascular proliferation. The stromal proliferation seemed to result in erosion of the islands of differentiated parenchymal cells with no regeneration. Alpha‐fetoprotein was demonstrated immunohistologically in the parenchymal cells of the lesion. From these findings, the essential component of this solid hamartoma was thought to be markedly proliferating bile ducts associated with periductal fibrosis, resulting in a fibroadenomatous pattern. ACTA PATHOL JPN 38: 75–82, 1988.

Thyroid cancer in children: Report of three cases and a review of the Japanese literature

We experienced three cases of thyroid cancer in children less than 15 years of age between 1982 and 1995. We herein present these three cases with a review of 141 reported cases of childhood thyroid cancer in Japan. Our patients were 6, 13, and 14 years old. The patients, all girls, were diagnosed as having thyroid cancer based on diagnostic imaging. One of them was also diagnosed by a fine-needle aspiration biopsy (FNAB). One of them underwent subtotal thyroidectomy, and the other two underwent lobectomy. Modified neck dissections were performed on all three. Pathologically, the tumors were all papillary carcinomas. Multiple lymph node metastases were present in all patients. However, the postoperative courses have been good, and there have been no signs of recurrence, 10, 8, and 2 years after their respective operations. In 144 reported cases of childhood thyroid cancer in Japan including ours, the youngest patient was a 2-year-old boy, and the female to male ratio was 2.1:1. FNAB was performed in 25 cases, and 23 (92%) of the tumors were diagnosed as malignant. Histologically, 76% were papillary carcinoma and 20% follicular carcinoma. At operation, lymph node metastases were found in 80% of the cases and lung metastases in 17%. For treatment, 88% of the patients received a more extensive operation than a lobectomy. Of the 144 patients, 8 died.

Intraoperative Local Infusion Chemotherapy for Advanced Gastric Cancer

Recently the treatment results of gastric carcinoma has improved because of the increase of early gastric cancer, however, the mortality is still high among patients with advanced disease even those in whom radical resection is possible. Radical surgery with lymph nodes dissection is still the mainstay of therapy [1]. On the other hand, metastases were high frequently found in the distant lymph nodes, such as paraaortic lymph nodes [2]. In view of the numerous possible pathways of lymphatic drainage from the stomach, complete dissection of these lymph nodes is virtually impossible. Locoregional recurrence represents a major pattern of surgical failure in patients who have undergone anticipated curative resection [3,4].

A case of lipoblastoma diagnosed by fine needle aspiration cytology.

良性脂肪芽腫は乳幼児に発生するまれな腫瘍で, 細胞診の報告はほとんどみられない. われわれは穿刺吸引細胞診で診断することができた生後6ヵ月の男児例を経験したので報告する. 多数の成熟脂肪細胞とともに多房性空胞を有する脂肪芽細胞が混在して採取された. 毛細血管も豊富で線維性隔壁様の構造も含まれていた. 脂肪肉腫とは核の異型性, 多形性やクロマチンの増加がみられないこと, 褐色脂肪腫とは典型的な細穎粒状好酸性胞体をもたないこと, 通常の脂肪腫とは豊富な脂肪芽細胞の存在から鑑別可能と考えられる. また, 発症年齢も参考になると思われる.