Mitsutaka Shoji

Psoas abscess and cellulitis of the right gluteal region resulting from carcinoma of the cecum

Although retroperitoneal or psoas abscess is an unusual clinical problem, the insidious and occult characteristics of this abscess sometimes cause diagnostic delays, resulting in considerably high morbidity and mortality. In particular, psoas abscess caused by perforated colon carcinoma is uncommon. We report a case of psoas abscess caused by a carcinoma of the cecum. A 72-year-old Japanese woman was admitted to our hospital, with pain in the right groin and buttock. The pain had appeared 6 months before admission, and the symptoms had then been relieved by oral antibiotics. On March 25, 1999, inflammatory signs in the right buttock indicated localized cellulitis, and incision and drainage was performed at a local hospital. The patient was referred to our hospital on the same day. On admission to our hospital, computed tomography (CT) scan revealed a thick right-sided colonic wall and enlargement of the right ileopsoas muscle. Barium enema and colonofiberscopy revealed an ulcerated tumor occupying the entire circumference of the cecum. A retroperitoneal abscess and fistula had been formed by the retroperitoneal perforation of cecum carcinoma: surgical resection was performed after remission of the local inflammatory signs. Operative findings indicated that the cancerous lesion and its surrounding tissues were firmly attached to the right iliopsoas and major psoas muscle, and en-bloc resection, including adjacent muscular tissue, was performed. The fact that carcinoma of the colon could be a cause of psoas abscess and cellulitis in the gluteal region should be considered when an unexplained psoas abscess is diagnosed.

Angiomyomatous hamartoma and associated stromal lesions in the right inguinal lymph node: A case report

Angiomyomatous hamartoma is a rare disease with a predisposition for the inguinal lymph nodes. A 51‐year‐old male patient visited a local hospital because of a right inguinal mass, measuring 3 × 4 cm in size, which was resected. The resected specimen showed irregularly distributed thick‐walled vessels in the hilum, extending into the medulla and focally into the cortex of the node, eventually becoming more dispersed and associated with smooth muscle cells splaying into sclerotic stroma. These findings are compatible with an angiomyomatous hamartoma. Another tumor‐like mass appeared shortly after the resection at the same location, but was not an angiomyomatous hamartoma, rather it was composed of edematous stromal tissue with proliferating smooth muscle cells. The stromal component included thick‐walled blood vessels and lymphatics. Although it could not be determined whether these associated changes in the surrounding stroma are a cause or an effect of angiomyomatous hamartoma, they indicate the clinical difficulty in determining an appropriate area of resection and may provide clues to the pathogenesis of angiomyomatous hamartoma.

Abdominal Wall Abscess Associated with Perforated Jejunal Diverticulitis: Report of a Case

We report a case of abdominal wall abscess caused by diverticulitis of the jejunum penetrating through the abdominal wall. A 53-year-old Japanese woman visited a local hospital complaining of abdominal pain and a mass in the left lower abdomen. An abdominal computed tomography scan showed a tumor with isodensity in the left lower abdominal wall. Magnetic resonance imaging showed a mass in the abdominal wall with isointensity in the T1-intensified image and high intensity in the T2-intensified images. The mass was heterogeneous inside and protruded partially toward the intraperitoneal cavity. Ultrasound examination showed a heteroechoic mass extending into the intraperitoneal cavity. Laparotomy revealed a tumor in the abdominal wall with a fistulous tract extending to the jejunum. We resected the abdominal wall tumor with partial resection of the small intestine. The resected specimen contained a tumor with a fistulous tract passing through the abdominal wall. Histological examination revealed remarkable infiltration of neutrophils and a bacterial mass in the abdominal wall tumor, with a fistulous tract connected to the area adjacent to the mesenteric border of the jejunum. These findings suggested that diverticulitis of the jejunum had penetrated through the abdominal wall, leading to the formation of an abscess. We report this case to highlight the need for complete gastrointestinal evaluation with gastrointestinal barium studies and imaging analysis to examine extension of intra-abdominal lesions in patients with an unexplained abdominal wall abscess.

Orotate phosphoribosyltransferase levels measured by a newly established enzyme‐linked immunosorbent assay in gastric carcinoma

A number of enzymes have been shown to be involved in the process of activation and/or degradation of 5‐fluorouracil (5‐FU), and are potential candidates for predicting chemosensitivity to 5‐FU. Among these, orotate phosphoribosyltransferase (OPRT EC 2.4.2.10) is a key enzyme related to the first‐step activation process of 5‐FU and has been shown to be an important enzyme that helps to predict sensitivity to 5‐FU and its related derivatives. We developed a new enzyme‐linked immunosorbent assay (ELISA) to accurately assess intratumoral activity of OPRT. A new sandwich ELISA was established using anti‐OPRT polyclonal antibodies obtained from the rabbit immunized with the recombinant human peptides of the OPRT molecule. OPRT levels were measured in eight human cancer xenografts and in 75 gastric cancer tissues using both a newly established ELISA and a conventional enzyme assay, using radiolabeled 5‐FU as a substrate. There was a significant correlation between OPRT levels measured by this ELISA and OPRT enzyme activity the in eight human cancer xenografts (r2 = 0.782) and gastric carcinoma tissue (r2 = 0.617). The ELISA system for OPRT requires a minimal amount of carcinoma tissue, making it an easy‐to‐use assay system to predict sensitivity to 5‐FU and its derivatives in gastric carcinoma. There was a significant correlation between tumor growth inhibition rates against the oral administration of oral‐uracil/tegafur (UFT) and OPRT enzyme activity in the human cancer xenografts (r2 = 0.574). These results suggest that this newly developed sandwich ELISA system for the quantification of OPRT levels is technically simple, feasible and a useful tool to predict sensitivity to fluoropyrimidine‐based anticancer chemotherapy in patients with gastric carcinoma and other cancers. (Cancer Sci 2006; 97)

Esophageal duplication cyst continuously extending into the peritoneal cavity on the proximal portion of the stomach

Although bronchogenic or esophageal duplication cysts are foregut-derived developmental anomalies most commonly encountered in the mediastinum and rarely in the abdomen, a cyst continuously extending into the abdomen via the esophageal hiatus has not been reported previously. We report a case of esophageal duplication cyst that occurred in the distal esophagus and extended continuously into the proximal portion of the stomach via the esophageal hiatus. A 62-year-old Japanese man was admitted to a local hospital complaining of dysphagia and upper abdominal pain. Abdominal ultrasound and CT scan revealed a cystic mass dorsal to the lateral segment of the liver that extended continuously into the mediastinum via the hiatus. The upper gastrointestinal series and endoscopic examination revealed extramural compression of the distal esophagus without mucosal lesions. Resection of the cystic lesion was performed by thoracotomy followed by laparotomy. The upper part of the cyst originated in the submucosal layer, extending into the muscularis propria of the distal esophagus. Histology of the resected specimen indicated that the cystic wall was composed of two smooth muscle layers and that the inner cystic wall was lined with pseudostratified columnar ciliated and/or squamous epithelium associated without cartilage or respiratory gland, indicating esophageal differentiation. These histological characteristics indicated that the cyst was an esophageal duplication cyst, rather than a bronchogenic cyst. This is the first case of a large esophageal duplication cyst of the distal esophagus continuously extending into the abdomen via the esophageal hiatus. The atypical location of this esophageal duplication cyst provides an insight into the pathogenesis of esophageal duplication cysts.

Pancreatic ductal adenocarcinoma associated with Potter type III cystic disease.

Although polycystic liver disease (PLD) is known to be associated with autosomal dominant polycystic kidney disease, a finding of PLD with pancreatic ductal adenocarcinoma is extremely rare. We have experienced one such case of a ductal adenocarcinoma of the pancreas in a patient with Potter type III cystic disease of the liver and kidney. A 63-year-old man was admitted to our hospital because of obstructive jaundice. Six months previously, on admission to a local hospital for treatment of diabetes mellitus, he had been found to have polycystic disease of the liver and kidney. Ultrasound examination revealed dilatation of the intrahepatic bile duct and the common bile duct. Blood tests showed an elevated total bilirubin level. Abdominal computed tomography scans and magnetic resonance imaging demonstrated polycystic lesions in the liver and the bilateral kidneys. Percutaneous transhepatic cholangio-drainage was performed, and fluorography of the biliary tree revealed obstruction of the lower common bile duct, causing jaundice. This appears to be a case of independent association of pancreatic ductal adenocarcinoma with polycystic disease of the liver and kidney. The patients sister, who also had polycystic disease of the liver and kidney, had died of squamous cell carcinoma of the tongue. Although familial associations of carcinomas with polycystic liver disease may be extremely rare, they provide a perspective for the etiology of polycystic liver disease.

Acute upper gastrointestinal bleeding from multiple Barrett's ulcers associated with metachronous multiple colorectal carcinomas

Although gastroesophageal reflux disease is sometimes associated with esophageal ulcer and/or mucosal erosion, acute upper gastrointestinal bleeding from an esophageal ulcer is uncommon. We report a case of acute gastrointestinal bleeding from one of multiple esophageal ulcers in extensive Barretts esophagus in the postoperative period after low anterior resection performed for descending colon carcinoma. A 74-year-old Japanese woman had undergone sigmoid colon resection 6 years earlier. The patient had a history of repeated reflux esophagitis. She was referred to a local hospital for a simple health screening 5 years after surgery. The patient had noticed bloody stool and felt mild difficulty at defecation 2 weeks before admission. Lower gastrointestinal endoscopy performed at a local hospital revealed a type 2 tumor located approximately 15 cm from the anal verge, which was obviously the cause of the bloody stool and constipation. The patient was admitted to our hospital for surgical treatment. Ten days after the low anterior resection, upper gastrointestinal bleeding occurred. Upper gastrointestinal endoscopy revealed multiple ulcers in the lower esophagus, which had caused the bleeding. Endoscopic biopsy revealed that esophageal ulcer occurred in the Barretts esophagus, extending 15 cm from the functional esophagogastric junction. This case highlights acute upper gastrointestinal bleeding from multiple Barretts ulcers in extensive Barretts epithelium occurring in the postoperative period of colorectal carcinoma, and indicates an association of Barretts esophagus with metachronous multiple colon carcinoma.