Takeo Maekawa

Pseudolymphoma of the liver associated with Sjögren's syndrome

Sjo¨grens syndrome (SS) is known to be associated with pseudolymphoma in several organs. We describe a patient with SS complicated by a hepatic pseudolymphoma. Although the development of a hepatic pseudolymphoma is extremely rare, this disorder should be taken into consideration in the differential diagnosis of space occupying lesions related to autoimmune diseases such as SS.Sjögrens syndrome (SS) is known to be associated with pseudolymphoma in several organs. We describe a patient with SS complicated by a hepatic pseudolymphoma. Although the development of a hepatic pseudolymphoma is extremely rare, this disorder should be taken into consideration in the differential diagnosis of space occupying lesions related to autoimmune diseases such as SS.

Multiple esophagogastric granular cell tumors.

Multiple granular cell tumors of the esophagus and the stomach found in a 53-year-old man are reported. One lesion was detected within the lower thoracic esophagus and seven lesions were detected in the stomach. The esophageal tumor was resected endoscopically, and gastrectomy was performed for the multiple gastric lesions. Histologically, the tumors consisted of spindle or polyhedral cells and the cytoplasm contained punctated eosinophilic granules with positive immunohistochemical staining for S-100 protein. The tumors were mainly located in the submucosal layer. Some tumor cells were seen in the mucosae propria and the muscularis propria. The tumor cells were only slightly positive for p53- and Ki-67-immunohistochemical stainings. Based on these findings, we diagnosed the granular cell tumors as benign. Granular cell tumor is comparatively rare in clinical practice, but a few such tumors have been seen in the digestive tract. A few cases of multiple esophagogastric granular cell tumors have also been reported in the literature.

Primary gastric lymphoma with spontaneous perforation: report of a case.

Abstract Primary gastric lymphoma with spontaneous perforation is rare. We report herein the case of a 53-year-old-man who was admitted to our hospital with severe epigastralgia. Emergency endoscopic examination showed a perforated gastric tumor in the lower body of the greater curvature, and a distal subtotal gastrectomy with lymph node dissection was performed. The resected tumor measured 10.0 × 8.0 cm and was associated with an area of ulceration, 8.0 × 6.0 cm in size, and perforation, 1.0 × 0.5 cm in size. Pathological examination confirmed a diagnosis of B-cell malignant lymphoma of the diffuse, medium-sized cell type. According to the Ann Arbor and Naqvi classifications, the lymphoma was stage II and stage III, respectively. Postoperative adjuvant chemotherapy comprising cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) was given. The patient is currently well with no signs of recurrence, 2 years 4 months after his operation.

CYSTIC LYMPHANGIOMAS OF THE COLON

Abstract: We report a patient with cystic lymphangiomas diagnosed by endoscopic ultrasonography and resected by partial polypectomy. A 42-year-old woman consulted a nearby physician because of a positive fecal occult blood test. Barium enema and colonoscopy revealed the presence of abnormalities. On March 11, 1997, she was admitted to our department for further evaluation and treatment. A barium enema examination revealed two protruding lesions in the transverse colon. Colonoscopy showed a teardrop-type mass in the left side of the transverse colon. The mass was cushion-sign positive, and its shape readily changed on respiration and with changes in body position. Another superficial smooth mass was found in the right side of the transverse colon. Ultrasonography of the colon confirmed the presence of a submucosal mass showing a cyst-like pattern. Cystic lymphangiomas were diagnosed and resected endoscopically. Histopathological examination revealed markedly dilated ducts consisting of a single layer of endothelial cells in the submucosa of the colon. The diagnosis was cystic lymphangioma.

A case of triple synchronous cancers occurring in the gallbladder, common bile duct, and pancreas.

We report a 74-year-old man with triple synchronous cancers occurring in the gallbladder, common bile duct, and pancreas. The patient had consulted a nearby physician because of epigastralgia and icterus. On September 30, 1997, the patient was admitted to our department for further evaluation and treatment. Abdominal computed tomography (CT) showed dilatation of the common bile duct, cystic duct, and intrahepatic bile duct, and swelling of the gallbladder. On CT, the wall of the distal common bile duct was thick and a low-density mass was detected on the left side. Cholangiography, performed via percutaneous transhepatic cholangiodrainage (PTCD), revealed stenosis of the distal common bile duct. Endoscopic retrograde pancreatography (ERP) showed marked dilatation of the main pancreatic duct. On October 17, 1997, pancreatoduodenectomy was performed under the diagnosis of carcinoma of common bile duct and pancreas. Histopathological examination revealed poorly differentiated tubular adenocarcinoma of the common bile duct, well-differentiated tubular adenocarcinoma of the gallbladder, and mucinous cystadenocarcinoma of the pancreas. These three tumors were histopathologically different. Moreover, p53-positive nuclei were recognized only in the pancreas tumor. These findings suggested that the oncogenic mechanisms of multiple synchronous cancers were not the result of only abnormal DNA reparative mechanisms.

A case of pancreatic serous cystadenoma with obstructive jaundice

A 62‐year‐old man with precordial pain and fever consulted a local practitioner. Blood tests revealed jaundice. Acute cholecystitis was diagnosed on ultrasonographic examination, and percutaneous transluminal gall‐bladder drainage was performed. The patient was referred to the Department of Surgery for operation. Imaging studies performed via a drain disclosed compression and stenosis of the lower portion of the common bile duct. A computed tomographic scan showed a multilocular nodule‐like low‐density area measuring 2.0 × 2.0 cm in diameter at the head of the pancreas. Endoscopic retrograde cholangiopancreatography disclosed compression and stenosis of the main pancreatic duct at the head of the pancreas. Angiographic examination revealed encasement of the intrapancreatic branch of the posterior pancreatic arcade, located in the same area as the compression stenosis of the bile duct. The results of imaging studies suggested cancer of the head of the pancreas, and a pancreatoduodenectomy was performed. The resected specimen included a mass measuring 3.5 × 2.7 × 1.7 cm, which was located at the head of the pancreas. On examination of a cut section, the mass was found to consist of small multilocular cysts. The cysts invaded the intrapancreatic bile duct. The histopathological diagnosis was serous cystadenoma.

A case of esophageal schwannoma and literature analysis of 18 cases

An extremely rare case of esophageal schwannoma in a 40-year-old woman is reported. She presented with a history of dysphagia persisting for a few years. After close examination the patient underwent surgery under a diagnosis of leiomyoma of the esophagus. The tumor was found in the muscle layers of the esophageal wall, and was enucleated with part of the esophageal mucosa. Histological examination of the tumor demonstrated proliferation of spindle-shaped cells. Immunohistochemically, the tumor cells were diffusely positive for S-100 protein. The pathological diagnosis of this tumor was esophageal schwannoma. To date, only 18 cases of esophageal schwannoma, including our case, have been reported in Japan. This rare case is reported here, together with a review of the literature.

Filling defects at the hepatic hilum due to compression by the right hepatic artery in cholangiography.

It has been accepted widely that filling defects in cholangiography are attributed to stones or tumors. However, we have recognized that filling defects at the hepatic hilum in cholangiography are caused by compression of the hepatic duct by the right hepatic artery.We studied 125 cases by cholangiography. Of these, 34 cases were subjected to simultaneous percutaneous transhepatic cholangiography and selective visceral arteriography. Among 125 cases, 25 cases (20%) showed filling defects at the hepatic hilum from compression by the right hepatic artery.

A CASE OF GROOVE PANCREATITIS WITH DUODENAL STENOSIS

A 58‐year‐old man presented with a 2‐month history of nausea and vomiting. Blood levels of hepatic enzymes and pancreatitis markers were slightly elevated. Hypotonic duodenographic and endoscopic examinations revealed stenosis encircling the descending duodenum. A computed tomography (CT) scan showed inflammatory changes in the head of the pancreas and thickening of the duodenal wall. Magnetic resonance cholangiography demonstrated stenosis of the intrapancreatic segment of the common bile duct and diffuse dilatation of the main pancreatic duct, without irregularity. At laparotomy, microscopic examination of a needle biopsy specimen of the head of pancreas revealed no evidence of malignancy. Distal gastrectomy with Billroth II anastomosis was performed. Microscopically, fibrous thickening of the duodenal wall, serositis and hyperplasia of Brunners glands were found. The presence of duodenal stenosis due to segmental pancreatitis, referred to as groove pancreatitis, was confirmed. The elevated blood levels of pancreatitis markers returned to the normal range 8 months after the operation. Ultrasonic echography and abdominal CT also revealed a marked reduction in dilatation of the extrahepatic bile duct and the main pancreatic duct. In patients suspected of having pancreatic carcinoma or regional pancreatitis, groove pancreatitis should be included in the differential diagnosis.

PRIMARY GASTRIC LYMPHOMA WITH ARTERIAL BLEEDING

We experienced a case of primary gastric lymphoma with arterial bleeding. The case was an 88‐year‐old‐man who was admitted to our hospital with hematemesis. Gastroduodenal endoscopy revealed a gastric ulcerating tumor with arterial bleeding in the posterior wall of the angular gastric region, and a distal subtotal gastrectomy with lymph node dissection was performed. The resected tumor measured 7.0 × 3.0 cm in size with a blood vessel visible in the bottom of the ulcer. Pathologic examination confirmed a diagnosis of B‐cell malignant lymphoma of the diffuse large cell type. Metastasis was detected in nos 3 and 5 lymph nodes. According to the Ann Arbor and Naquvi classifications, the lymphoma was stage IIE and II, respectively. One year and 10 months after the operation, a computed tomography scan revealed a few swollen lymph nodes around the abdominal aorta. Recurrence of lymphoma was confirmed and chemotherapy comprising cyclophosphamide, doxorubin, vincristine and predonisolone was given at half the ordinary adult dose.