Shigeto Makino

Extranodal Spreading of Esophageal Squamous Cell Carcinoma: Clinicopathological Characteristics and Prognostic Impact

BackgroundMicroscopic cancer spreading to extranodal connective tissues (extranodal spreading: ENS) is occasionally found in resected specimens from patients with esophageal squamous cell carcinoma (SCC), but the prognostic impact of ENS remains unclear. The aims of this study were to elucidate the prognostic impact of ENS to help determine the most suitable management for the patients with ENS.MethodsWe histologically re-evaluated 7,349 lymph nodes obtained from 171 patients with SCC of the thoracic esophagus who underwent potentially curable resection between 1992 and 2003. We defined ENS as microscopic penetration of tumor cells from metastatic lymph nodes or tumor cell dissemination into extranodal connective tissues.ResultsExtranodal spreading was found in 37 (21.6%) patients, and it had a significant relationship with diameter and depth of the tumor, lymphatic and venous invasion, intramural metastasis, and number of metastatic nodes. Patients who were ENS positive were at higher risk of recurrence, and their overall survival rate was lower than that for ENS-negative patients. Furthermore, recurrent risk was higher and overall survival rate was lower in ENS-positive patients than in ENS-negative patients when they had 1–3 metastatic nodes, but recurrent risk and overall survival rate of the patients with 4 or more metastatic nodes were very similar in ENS-positive and ENS-negative patients.ConclusionsThe present findings suggest that in SCC of the thoracic esophagus, the presence of ENS increases recurrent risk and reduces the overall survival of the patients with 1–3 metastatic nodes. Patients showing ENS should be managed in the same way as patients with 4 or more metastatic nodes.

A successful case of oral molecularly targeted therapy with imatinib for peritoneal metastasis of a gastrointestinal stromal tumor.

Gastrointestinal stromal tumors (GISTs) are a group of neoplasms arising from mesenchymal stem cells of the gastrointestinal tract. The prognosis of metastatic or recurrent GISTs is poor, because these tumors resist chemotherapy and radiotherapy. We report a patient with recurrent GIST who underwent molecularly targeted therapy with imatinib, a novel oral tyrosine kinase inhibitor. A 50-year-old woman presented with a huge intra-abdominal mass. The patient had a history of gastrectomy for GIST and hepatectomy for its metastases. She also underwent surgery for resection of peritoneal metastases 9 months before. The abdominal mass was 26 × 17 × 12 cm in size, as determined by magnetic resonance imaging, and was diagnosed as a peritoneal relapse of GIST. Treatment with 400 mg of imatinib daily was started. After 1 week of treatment with imatinib, reduction of the abdominal tumor began to be recognized on palpation. Computed tomographic scanning on day 28 revealed that the tumor had liquefactively regressed and had reduced in size by 66%. The major side effect was leg edema, which was easily manageable with furosemide. The patient has been receiving imatinib treatment in our outpatient clinic, and the tumor regression has continued for 9 months. Imatinib shows promise as a safe and effective drug for the treatment of patients with recurrent GISTs.

Breast Signet-ring Cell Lobular Carcinoma Presenting with Duodenal Obstruction and Acute Pancreatitis

We report here an extremely rare case of breast signet-ring cell carcinoma (SRCC) initially manifesting as duodenal metastasis and acute pancreatitis. A 62-year-old female presented with duodenal obstruction and swollen head of the pancreas, and the diagnosis of acute pancreatitis was initially made. Upper gastrointestinal endoscopy revealed duodenal stenosis with erosive mucosa, with signet-ring cells infiltrating the submucosal layer, suggesting duodenal metastasis of SRCC. Despite absence of a palpable mass in both breasts, computed tomography revealed diffuse enhancement of the left breast in addition to left axillary lymphadenopathy. Histological examination of mammary needle biopsy samples revealed SRCC with a non-invasive lobular carcinoma component. Primary breast SRCC with duodenal metastasis was therefore diagnosed. The patient underwent palliative surgery twice for intestinal obstruction due to peritoneal dissemination. She has remained alive without bowel obstruction for 18 months while being treated with cytotoxic chemotherapies.

A case of multiple esophageal carcinomas concomitant with achalasia

A 51-year-old man had been diagnosed with esophageal achalasia 26 years previously; however, regular medical examination was not performed. He presented to the hospital for severe back pain and increased dysphagia during the past 7 months. Endoscopic examination showed the presence of multiple primary carcinoma of the esophagus with achalasia. An esophagogram showed sigmoid-type achalasia with grade III dilatation. Subtotal esophagectomy with mediastinal and abdominal lymphadenectomy was performed. Histopathological examination showed three squamous cell carcinomas at pStage IVB, including pT3 and pM1b. Furthermore, all the three lesions located in the large, slightly iodine-stained area showed hyperplasia with inflammatory cells. Although adjuvant chemotherapy was administered, the patient died of recurrence on the right chest wall and in the stomach, liver, and left iliac bone at 23 months after operation. A patient with esophageal achalasia should be carefully followed up by endoscopy with iodine staining.