Shoji Hirasaki

Predictive factors of lymph node metastasis in patients with undifferentiated early gastric cancers.

Background For intramucosal differentiated early gastric cancer that has little risk of lymph node metastasis, local treatment such as endoscopic mucosal resection has been generally accepted as an adequate treatment. We studied clinicopathological characteristics of undifferentiated early gastric cancer at our institution to identify the predictive factors for lymph node metastasis and qualify lesions that should be referred for gastrectomy and not endoscopic mucosal resection. Methods We retrospectively analyzed the clinicopathological features (patient age and gender, tumor size, location, macroscopic type and histological type, presence of ulceration, depth of tumor invasion, and lymphatic-vascular involvement) in 332 patients with undifferentiated early gastric cancer who underwent gastrectomy with regional lymph node dissection. Results Lymph node metastasis was observed in 45 patients (14%). Univariate analysis revealed that depth of tumor invasion (submucosa), tumor size (>30 mm), and lymphatic-vascular involvement (positive) were associated with lymph node metastasis. Only lymphatic-vascular involvement (positive) was found to have a significant association (odds ratio, 7.4; 95% confidence interval, 2.9–19.0) by multivariate analysis. Conclusions Lymphatic-vascular involvement was the only independent predictive risk factor for lymph node metastasis. This pathologic factor was not useful for identifying patients at high risk of lymph node metastasis who should be offered gastrectomy rather than endoscopic mucosal resection.

Unusual variant of left paraduodenal hernia herniated into the mesocolic fossa leading to jejunal strangulation

Abstract: Paraduodenal hernia is a rare condition in which the small bowel loops are herniated into an unusual fossa in the periduodenal area. We treated a patient with paraduodenal hernia diagnosed pre-operatively. A 28-year-old woman was admitted to our hospital because of intermittent abdominal pain. Abdominal ultrasonography revealed a large tumor adjacent to the pancreas. Provisional diagnosis made according to computed tomography (CT) findings was tumor of the pancreas tail. However, on a CT scan performed after the administration of diatrizoate meglumine/diatrizoate sodium (Gastrografin, Schering, Berlin, Germany) the mass was shown as a jejunum loop located between the stomach and the pancreas body. Subsequent laparotomy revealed that the jejunum loop was herniated into an unusually large mesocolic fossa and that the hernial orifice was covered by the adhesion between the transverse and descending colons. It seemed that the small intestine within the mesocolic fossa was strangulated by this adhesion. The patients abdominal pain resolved postoperatively. These observations suggest that paraduodenal hernia should be suspected in patients with chronic, atypical abdominal pain, regardless of the findings for small bowel obstruction.

Granular cell tumor occurring in the sigmoid colon treated by endoscopic mucosal resection using a transparent cap (EMR-C)

A case of granular cell tumor occurring in the sigmoid colon is reported. The patient, a 56-year-old man, visited our hospital for further evaluation of occult blood in his stool. Endoscopic examination revealed a yellowish, hemispheric submucosal tumor (SMT) with redness, about 6 mm in diameter, in the sigmoid colon. Endoscopic mucosal resection using a transparent cap (EMR-C) was performed, and histological examination revealed that the tumor consisted of a nested growth of large tumor cells with ample granular cytoplasm and small round nuclei. The tumor cells expressed S-100 protein and were stained with neuron-specific enolase (NSE) and periodic acid-Schiff, but were negative for desmin, vimentin, and cytokeratin. The resected tumor was diagnosed as a granular cell tumor. This may be the first report of a colorectal granular cell tumor successfully treated with EMR-C.

Active intestinal tuberculosis with esophageal candidiasis due to idiopathic CD4+ T-lymphocytopenia in an elderly woman.

Abstract: We describe a case of intestinal tuberculosis and esophageal candidiasis in an 85-year-old Japanese woman with idiopathic CD4+ T-lymphocytopenia (ICL). The patient exhibited clinical symptoms of odynophagia, bloody diarrhea, and high fever. Physical examination on admission showed a poor nutritional status. Endoscopic examination of the upper digestive tract revealed the esophageal mucosa to be covered with yellowish-white plaque-like lesions. Colonoscopic examination revealed multiple annular ulcerations with bleeding. She was diagnosed with intestinal tuberculosis by polymerase chain reaction (PCR) and fecal culture. Her CD4+ T-lymphocyte count was 178/mm3 and no evidence of human immunodeficiency virus (HIV) infection was found. She was successfully treated with fluconazole and antituberculosis drugs. This case emphasizes the importance of opportunistic infections in elderly patients with predisposing conditions such as ICL.

Mixed connective tissue disease associated with idiopathic portal hypertension and chronic thyroiditis

We report a patient with mixed connective tissue disease (MCTD) associated with idiopathic portal hypertension (IPH) and chronic thyroiditis. The patient was a 68-year-old Japanese woman who was admitted to our hospital for treatment of bleeding esophageal varices. She had previously exhibited Raynauds phenomenon and had had arthritis for about 30 years. She also had had high titers anti-U1 of ribonucleoprotein (RNP) anti-single strand-DNA autoantibodies for 2 years, and had been diagnosed with MCTD 1 year previously. The bleeding from esophageal varices was successfully stopped by endoscopic injection sclerotherapy. Results of laboratory examinations, imaging examinations, and laparoscopy, including liver biopsy, indicated that the esophageal varices were caused by portal hypertension due to IPH. The patient also had a diffusely firm and enlarged goiter and hypothyroidism, and she exhibited anti-thyroid microsomal antibodies and anti-thyroglobulin antibodies, she was diagnosed as having a complication of chronic thyroiditis. This association of MCTD, IPH, and chronic thyroiditis is quite rare and provides a unique opportunity to observe immunological involvement in the pathogenesis of IPH.

Benign gastric ulcer associated with Candida infection in a healthy adult

Abstract: A case of benign gastric ulcer associated with Candida infection in a healthy adult is reported. The patient was a 46-year-old man complaining of epigastralgia. Endoscopic examination of the upper digestive tract revealed an elevated lesion with ulceration having an unclear border and thick exudates. The clinical diagnosis based on endoscopic findings was a benign gastric ulcer; however, biopsy was performed to distinguish it from malignant lymphoma. Histological examination of biopsy samples obtained from the base and the edge of the ulcer revealed numerous Candida. Therefore, the patient was diagnosed with Candida-infected gastric ulcer. The ulcer resolved after the administration of antiulcer drugs for 2 months. Predisposing factors for fungal infection were excluded. These observations suggest that Candida-infected gastric ulcer should be suspected in patients with a gastric submucosal tumor-like lesion with a thick, yellowish-white coated ulcer of unclear border on its summit, and this lesion should be distinguished from malignant diseases.

Composite paraganglioma-ganglioneuroma in the retroperitoneum

BackgroundParagangliomas occur most commonly in head and neck region and much less frequently, they are found in the retroperitoneum. Composite paraganglioma-ganglioneuroma of the retroperitoneum is very rare.Case presentationWe present an unusual case of retroperitoneal composite paraganglioma-ganglioneuroma discovered on computed tomography in a 63-year-old female patient. Routine hematological examination and biochemical tests were within normal limits. Plasma adrenaline was 0.042 ng/ml, plasma noradrenaline 0.341 ng/ml, and plasma dopamine <0.01 ng/ml. An abdominal contrast-enhanced CT scan and magnetic resonance imaging revealed a 6.5 cm heterogeneous retroperitoneal mass with a cystic component. The retroperitoneal tumor accumulated 131I-Metaiodobenzylguanidine (131I-MIBG) 48 hours after radioisotope injection. Under the diagnosis of paraganglioma in the retroperitoneum, the patient underwent surgery. The resected tumor (6.5 × 5 × 3 cm) was solid and easily removed en bloc. The cut surface of the tumor and histology revealed two different components in the tumor: paraganglioma centrally and ganglioneuroma on the periphery. She remains disease-free 18 months after surgery.ConclusionThis case reminds us that neuroendocrine tumor should be included in the differential diagnosis of a retroperitoneal mass although composite paraganglioma-ganglioneuroma in the retroperitoneum is very rare.

Gastric hyperplastic polyp associated with proliferation of xanthoma cells observed by magnification narrow-band imaging endoscopy.

A case of gastric hyperplastic polyp with proliferation of xanthoma cells is reported. The patient was a 69-year-old man who visited our hospital for further evaluation of gastric polyps. Endoscopic examination of the upper digestive tract revealed multiple hyperplastic polyps in the gastric antrum. There was a pedunculated polyp with whitish yellow granules, 7 mm in diameter, arising from the greater curvature of the antrum. Magnification narrow-band imaging endoscopy (GIF-H260Z, Olympus) revealed long microcapillaries in the polyp but did not reveal disappearance of the mucosal microstructure or irregular branched capillaries. Endoscopic mucosal resection (EMR) was performed. Histological examination of the specimen revealed the lengthened gastric foveolae in the superficial portion and tight sheet of foamy histiocytes in the lamina propria. Diagnosis of gastric hyperplastic polyp with proliferation of xanthoma cells was made. There was no evidence of malignancy. It is necessary to know that a gastric hyperplastic polyp may associate with gastric xanthoma, although such association is very rare.

PEDUNCULATED INVERTED HYPERPLASTIC POLYP OF THE SIGMOID COLON TREATED WITH ENDOSCOPIC POLYPECTOMY

A case of inverted hyperplastic polyp of the sigmoid colon is reported. The patient was a 67‐year‐old woman who visited our hospital for further evaluation of constipation. Colonoscopy revealed a pedunculated polyp with linear central depression, about 12 mm in diameter, in the sigmoid colon. Excluding the polyp, there was no lesion in the colorectum. Endoscopic polypectomy was performed. Histological examination of the specimen revealed a stalked polyp that had scattered goblet cells and elongated tubules with serrated profiles in the superficial portion. The nodules of deep tubules impinged on the muscularis mucosae. Proliferation of fibromuscular tissue was not seen in the polyp. There was no evidence of malignancy. This polyp was diagnosed as an inverted hyperplastic polyp. Pedunculated‐type inverted hyperplastic polyp of the colon is rare.

Inflammatory myoglandular polyps: a case series of four patients and review of the literature.

Background. Inflammatory myoglandular polyp (IMGP) is a nonneoplastic colorectal polyp. Only a small number of cases have been reported, and the pathogenesis remains unclear. Methods. We analyzed colonoscopy and histologic findings in 4 patients with IMGP. Histologic confirmation of the inflammatory granulation tissue in the lamina propria, proliferation of smooth muscle, and hyperplastic glands with variable cystic changes formed the criteria for the selection of patients. Results. We treated four cases of IMGP and reviewed the literature on this disease. Three cases were located in the sigmoid colon or descending colon. All 4 polyps were identified as red, pedunculated lesions. All 4 cases had no symptoms. In two cases, endoscopic findings of polyps were necessary to be differentiated from juvenile polyps. Conclusions. Pedunculated lesions are the main pattern of IMGP. An analysis of endoscopic and histologic features in IMGP of the colorectum revealed that colonic IMGPs resembled juvenile polyps. On colonoscopy, IMGP should generally be taken into consideration as a differential diagnosis of peduncular polyp.