Minoru Okumura

Early gastric cancer with Krukenberg tumor and review of cases of intramucosal gastric cancers with Krukenberg tumor

A 47-year-old woman was admitted because of hypermenorrhea. Transvaginal ultrasonography revealed an ovarian tumor and myoma uteri, and total hysterectomy with bilateral salpingo-oophorectomy was performed. Histology revealed signet-ring cell carcinoma in the right ovary. In order to find out the primary site of this tumor, gastroendoscopy was performed after the operation, and showed a IIc lesion in the lower body of the stomach; biopsy specimens showed signet-ring cell carcinoma similar to that in the right ovary. Total gastrectomy revealed that the lesion was an early gastric cancer confined to the mucosa, but there was lymphatic invasion slightly beneath the muscularis mucosa, with regional lymph node metastasis. In the light of a review of the seven cases of early gastric cancer with Krukenberg tumor previously reported, lymphatic metastasis seemed to be the most likely pathway of ovarian metastasis in early gastric cancers.

Malignant change in a duodenal adenoma in familial adenomatous polyposis: Report of a case

Patients with FAP (familial adenomatous polyposis) are known to be at high risk for duodenal cancer. Although the adenoma-carcinoma sequence is thought to exist in the duodenum, clinical observation of the development of duodenal adenoma to cancer has rarely been reported. We outline a 44-yr-old postcolectomy man with FAP who underwent regular gastroduodenoscopy annually or biannually and was found to be harboring duodenal ampullary cancer 5 yr after colectomy. Endoscopic and pathological examination of the ampullary lesion during these 5 yr revealed progression of pathology from adenoma to carcinoma. Pathology of the surgical specimen confirmed ampullary cancer. This in vivo demonstration of the adenoma-carcinoma sequence highlights the current limitations of duodenal surveillance in FAP.

Successful utilization of coronary covered stents to treat a common hepatic artery pseudoaneurysm secondary to pancreatic fistula after Whipple’s procedure: Report of a case

A 73-year-old man underwent a pylorus-preserving Whipple’s procedure for distal cholangiocarcinoma. His postoperative course was complicated by the formation of a pancreatic fistula, which was initially managed conservatively. On postoperative day (POD) 86, he lost 100 ml of blood from the site of the pancreatic fistula. Contrast-enhanced computed tomography (CT) showed a pseudoaneurysm, 12 mm in diameter, in the common hepatic artery. The diameter of the pseudoaneurysm increased to 15 mm on POD 89, so we implanted coronary covered stents to prevent massive bleeding from rupture and to retain hepatic arterial flow. Six days after implantation, computed tomography findings confirmed a thrombosed pseudoaneurysm as well as patent hepatic arterial flow. Follow-up CT 18 months after surgery showed patent hepatic arterial flow. There have been no signs of rebleeding or abnormal liver function.

Retroperitoneal lymphangioma with a duodenal lesion in an adult.

A multilocular-cystic and cavernous, retroperitoneal tumor was found in a 40-year-old man whose past medical history was unremarkable. On admission, he complained of a large and still growing intra-abdominal mass associated with dull pain and a low-grade fever. Laboratory findings revealed leukocytosis and C-reactive protein elevation, compatible with inflammation of the tumor. Percutaneous aspiration of the tumor was performed under transabdominal ultrasonographic guidance, and continuous drainage of fluid from within the tumor ameliorated his symptoms. From preoperative examinations, including radiological imaging, fluid aspiration, and endoscopy with biopsy, a diagnosis of retroperitoneal lymphangioma was made. Laparotomy revealed extensive adhesions between the tumor and both the duodenum and the pancreatic head. A pancreaticoduodenectomy was therefore performed. At 3-year follow-up, there was no sign of recurrence. Retroperitoneal lymphangioma is an uncommon disorder, and the cavernous type is extremely rare. The duodenal lesion was an important feature of the present case, and endoscopic biopsy of this lesion facilitated precise preoperative diagnosis of retroperitoneal lymphangioma.

Impact of 5-fluorouracil metabolizing enzymes on chemotherapy in patients with resectable colorectal cancer.

Although 5-fluorouracil (5-FU) is an important drug for colorectal cancer (CRC) treatment, no useful biomarker is currently available to predict treatment response. Since 5-FU is converted into active or inactive forms by orotate phosphoribosyltransferase (OPRT) or dihydropyrimidine dehydrogenase (DPD), a correlation between these enzymes and response to 5-FU has been suggested. However, such a correlation has not been investigated prospectively. Therefore, in the present study, we aimed to prospectively evaluate whether OPRT and DPD were predictive factors of the response to 5-FU treatment in patients with resectable CRC. The present investigation was designed as a multicenter prospective cohort study. OPRT and DPD activities were assessed in biopsy samples, obtained surgically from patients with resectable CRC. The OPRT/DPD ratio was calculated and the cut-off values for this ratio were determined for 5-year disease-free survival (DFS) and overall survival (OS). Patients were treated with 5-FU/leucovorin (LV) regimens and oral 5-FU. The endpoint of this study was the correlation between the OPRT/DPD ratio and 5-year DFS and OS. The cut-off value for the OPRT/DPD ratio was determined by using the maximum χ2 statistic method against 5-year DFS and OS. Sixty-eight patients were enrolled from July 2003 to May 2005. The median follow-up period was 1925 days. The OPRT/DPD ratio cut-off values for 5-year DFS and OS were 0.015 and 0.013, respectively. During the 5-year DFS and OS periods, patients with higher cut-off values had a better prognosis than those with lower ratios (P=0.03 and 0.02, respectively). In conclusion, our results suggest that the OPRT/DPD ratio could be a predictive factor for response to 5-FU/LV adjuvant chemotherapy.