Masao Nunomura

Evaluation of echographic diagnosis of rectal cancer using intrarectal ultrasonic examination

Ultrasonic examinations conducted in order to diagnose the depth of invasion and local lymph node metastases of rectal cancer. The intrarectal approach was performed preoperatively in 99 patients with rectal cancer, using either an Olympus-Aloka ultrasonic endoscopeTM (7.5 MHz) or other probes (Aloka, 7.5 MHz, 5 MHz). Through this method, intrapelvic organs were detected clearly, and hypoechoic findings due to tumors were detected in all patients. The normal rectal wall was echogenically divided into five layers, the third layer being the submucosal and the fourth layer being the proper muscle layer. In some cases, the proper muscle layer was divided into three layers in the echogram. In 79 of 88 patients, the diagnosis of depth of invasion, classified into three groups, was possible. Metastatic lymph nodes were shown as a hypoechoic round mass. In 52 of 71 patients proven to have local lymph node metastases in surgical specimens, lymph node metastases were diagnosed preoperatively. Thus, intrarectal ultrasonography provides valuable information concerning the choice of operating methods for rectal cancer.

Clinical Evaluation of Nerve-sparing Surgery Combined with Preoperative Radiotherapy in Advanced Rectal Cancer Patients

BACKGROUND Since 1984, we have studied nerve-sparing surgery (NSS) combined with preoperative radiotherapy (XRT) in patients with advanced rectal cancer to preserve the genitourinary function without compromising radicality. The present aim was to evaluate the prognosis and the postoperative genitourinary function. METHODS A total of 167 patients with advanced rectal cancer underwent curative nerve-sparing surgery. Among them, 60 underwent the preoperative therapy using irradiation (42.6 Gy) and tegafur suppository. Survival, local recurrence, and postoperative genitourinary function were investigated in these patients. RESULTS The 5-year survival rate was 80.9% and the local recurrence rate was 6.7% in the NSS+XRT group. Almost all of the patients receiving NSS could micturate spontaneously, but preservation of sexual function was not as successful. CONCLUSIONS Better local control and preservation of urinary function were possible in advanced rectal cancer patients by NSS+XRT.

Detection of Epstein-Barr virus in gastric carcinoma cells and surrounding lymphocytes

AbstractBackground. Epstein-Barr virus (EBV), the etiological agent of infectious mononucleosis, has an important role in the oncogenesis of EBV-related malignant diseases. The association of EBV with gastric carcinoma cells has become well known recently, but there are only a few reports concerning its association with surrounding epithelia and infiltrating lymphocytes. In this study, we investigated the association of EBV with gastric carcinoma and surrounding cells. Methods. One hundred and two cases of gastric carcinoma were studied. The specimens were studied for the presence of the EBV genome by polymerase chain reaction (PCR), and then by in situ hybridization (ISH) technique to determine the localization of EBV. Results. Of 97 informative cases, EBV was detected in 21 cases (21.6%) by the PCR method. ISH studies showed that EBV RNA was expressed in 5 of the 97 cases (5.2%) and was localized to the nuclei of carcinoma cells. All these 5 lesions were found in male patients. In these 5 cases, 3 were diffuse type and 2 were intestinal type, and all cases arose in the proximal region of the stomach. EBV RNA was not detected in non-neoplastic epithelia, but it was detected in 24 of the 97 cases (24.7%) in small lymphocytes. Conclusion. EBV was detected in 5.2% of gastric carcinomas and in 24.7% of infiltrating lymphocytes by the ISH method. The high positive rate (21.6%) by the PCR method corresponds to the presence of the EBV genome in surrounding lymphocytes.

Xanthogranulomatous gastritis with pseudosarcomatous changes.

Reported herein is a rare case of xanthogranulomatous inflammation of the gastric wall occurring in a 77‐year‐old man. Two submucosal lesions presented as rapidly enlarging nodules, and biopsy showed interweaving bundles of spindle cells with numerous atypical cells with marked nuclear pleomorphism. The differential diagnosis from mesenchymal malignancies, particularly from a malignant gastrointestinal stromal tumor, was difficult and immunohistochemical investigations could not improve the diagnostic accuracy of HE histology alone. Thus, an erroneous diagnosis of malignancy was made and a partial gastrectomy was performed. On macroscopic examination of the resected material, spontaneous regression of the lesions was observed and microscopic examination showed characteristic features of xanthogranulomatous inflammation; large numbers of foamy histiocytes including multinucleated giant cells were admixed with chronic inflammatory cells and fibrous reaction. Although the precise pathogenesis could not be elucidated, recognition of this unusual morphological appearance is of importance to avoid an overdiagnosis of malignancy.

Nerve-sparing surgery for advanced rectal cancer patients: special reference to Dukes C patients.

Abstract. Several nerve-sparing operations for advanced rectal cancer that aim to preserve genitourinary function without compromising tumor clearance have been developed in Japan. The aim of this study was to evaluate the survival and local recurrence of these procedures in Dukes B and C patients. A total of 177 patients with advanced rectal cancer underwent curative nerve-sparing surgery (NSS) over the last 11 years; 52 were Dukes B patients and 54 were Dukes C. Altogether 36 had Dukes C1 and 18 had Dukes C2 tumors, 13 with lateral lymph node metastases, designated lateral LN(+). The 5-year survival rate was 92% for Dukes B, 67% for Dukes C1, and 39% for Dukes C2 patients: 11% for Dukes C2 patients with lateral LN(+). The local recurrence rate was 6% for Dukes B, 11% for Dukes C1, and 33% for Dukes C2 patients: 20% for the lateral LN(−) group and 39% for the lateral LN(+) group. Almost all of the patients undergoing NSS could micturate spontaneously, but preservation of sexual function was not as successful. Although there is no guarantee of preserving satisfactory sexual function, our NSS is an acceptable procedure for Dukes B, C1, and C2 patients without lateral lymph node metastases.

Ileocolic intussusception in adult due to malignant lymphoma in the cecum with intramural metastasis

A rare adult case of intussusception caused by malignant lymphoma of the cecum with intramural metastasis is reported. The patient was a 24-year-old man. Ileocolic intussusception was diagnosed by characteristic findings on abdominal computed tomography. Endoscopic examination revealed a massive protuberant tumor, 3 cm in diameter, and a semipedunculated polyp, 1 cm in diameter, in the cecum, which had caused the ileocolic intussusception. Endoscopic biopsy specimens failed to yield a definitive diagnosis histologically, but right hemicolectomy with lymph node dissection was performed. On histologic examination of the surgical specimens, both the tumor and the polyp were diagnosed as diffuse lymphoma of medium-sized cell type, and no lymph node involvement was found. The patient responded well to surgical and chemotherapeutic treatment, and has had no recurrence of malignant lymphoma in the 2 years since the surgical treatment. This was a very rare case of an intussusception in an adult patient due to malignant lymphoma in the cecum with intramural metastasis and without lymph node involvement.

Localized necrotizing angiitis of the ileum.

A 20‐year‐old woman was hospitalized repeatedly because of intermittent bouts of intestinal obstruction and the symptoms usually improved with conservative treatments. One year after the first admission the patient was hospitalized in emergency and a laparotomy revealed a circular stricture with a pinhole perforation in the ileum. Histological sections of the stricture showed the characteristic features of microscopic polyangiitis varying from active to resolving stages, which were localized in the ileum. Fibrinoid necrosis, fibroblastic and fibrous proliferation of the intima and fibrous replacement of the media with a variable pan‐ and perivascular inflammatory cell infiltrate were characteristic in the muscular arteries and arterioles. Vascular occlusion by pale eosinophilic, fibrillar‐like materials resembling livedo racemosa of the skin, was noticed in the small arterioles and capillaries. Under no prophylaxis, the postoperative course was uneventful with no recurrence of the illness at an 18‐month follow up. The pathological alterations were distributed focally, occasionally segmentally, and haphazardly, and required detailed examination by stepwise sections for the histological diagnosis.

Clinical Trial for Early Detection of Local Recurrence of Rectal Cancer.

直腸癌局所再発の予後はきわめて不良である.直腸癌治癒切除後の局所再発の早期発見を目的とした新たな経過観察法を考案し, その有用性について検討した.教室での過去8年間の直腸癌治癒切除症例175例を対象とし, 各症例を臨床病理学的因子により再発のhighrisk group, intermediate riskgroup, low rish groupに分類して経過観察を行った.経過観察の検査項目では理学所見, 腫瘍マーカーにultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), およびCT下生検を組合わせ, riskgroup別のプロトコールにより実施した.175例中27例 (15.4%) に局所再発が診断され, この27例中20例はhigh risk group, 7例がintermediate risk groupの症例であった.27例中12例 (44.5%) に治癒的再切除が施行され, この経過観察の有用性が認められた.直腸癌術後の再発のrisk group別の経過観察では, 治癒的再切除の可能な局所再発の早期発見が期待できると考えられた.

Male sexual function following resection for rectal cancer.

69歳以下の男性直腸癌治癒切除例のうち, 骨盤内自律神経を温存しえて再発や転移を認めない症例を対象に, アンケート調査および術前, 術後の性機能検査を行い, 術後の性機能障害について検討した.手術時の平均年齢は55.9歳, アンケート調査時は平均57.7歳であった.アンケート調査結果より, 骨盤内自律神経をすべて温存した群 (全温存群) では勃起障害7.1%, 射精障害21.4%であったのに対し, 下腹神経を損傷し骨盤神経叢を温存した群 (部分温存群) では勃起障害26.3%, 射精障害100%であった.術式別では低位前方切除例および側方郭清非施行例に性機能障害が少なかった.性機能検査結果より, 勃起障害は切手法, AVSS負荷試験で確認されたが, 全温存群においても術後に精液量の減少を認めた.また陰茎の流入動脈系に異常を認めた症例はなく下垂体, 性腺機能にも大きな変動はみられなかった.

Evaluation of preoperative radiation combined with chemotherapy for prevention of local recurrence of rectal cancer.

化学療法を併用した直腸癌術前照射療法 (42.6Gy) が, 術後の局所再発防止にどのような効果を与えているかを知るため, 非照射群37例と照射群44例を臨床病理学的に検討した.局所再発 (術後観察期間平均3年10か月) は非照射群7例18.9%, 照射群2例4.5%であった.局所再発因子の組織学的検討では, 照射群は非照射群に比べ壁深達度a2症例の低値, ew (外科的剥離端までの距離) 2mm未満症例の低値, およびリンパ節転移n2以上の症例の低値がみられ, 両群間に有意差が認められた.さらに照射群のa2症例, ew 2mm未満症例からの局所再発は, 非照射群に比べ明らかに低下していた.これに対し照射群におけるn2以上の症例からは, 非照射群と同様に高い再発率が認められた.以上の結果, 術前照射療法による局所再発の低下は, 壁深達度やewに起因した再発の減少によるところが大きく, 一方リンパ節転移陽性の症例では照射群といえど厳重な経過観察が必要と考えられた.