Teruhiko Kasuga

Prognostic Significance of Immunohistochemically Detected Blood and Lymphatic Vessel Invasion in Colorectal Carcinoma: Its Impact on Prognosis

BackgroundThe prognostic significance of blood vessel invasion (BVI) and lymphatic vessel invasion (LVI) is unclear. Because of the absence of specific markers for venous and lymphatic vessels, earlier studies could not reliably distinguish between BVI and LVI.MethodsBy immunostaining for podoplanin and CD34 antigen, we retrospectively investigated LVI and BVI in 419 tissue specimens of colorectal carcinoma. We performed univariate and multivariate analysis of the clinicopathologic features, frequency of recurrence, and outcome of patients with or without LVI and BVI.ResultsThe use of hematoxylin and eosin (H&E) staining to identify BVI and LVI yielded a false positive rate of 9.1% and false negative rate of 12.6%. The incidence of BVI was significantly higher among tumors with LVI than tumors without LVI (P <.001). In logistic multivariate analysis, only LVI (P < .001) was associated with lymph node metastasis and BVI (P = .015) was associated with distant recurrence. Calculating the prognostic relevance, both two invasion types correlated with decreased survival in univariate analysis (both P <.001). In multivariate analysis, BVI (P =.024), lymph node status (P =.003) and tumor stage (P <.001) remained statistically significant factors for survival.ConclusionsOur results suggest that immunohistologic evaluation of BVI and LVI could be useful in colorectal carcinoma indicating the risk of lymph node metastasis and recurrence, thereby contributing to prognostic evaluation.

Increased density and diameter of Lymphatic microvessels correlate with lymph node metastasis in early stage invasive colorectal carcinoma

To determine whether lymphangiogenesis was associated with the development of colorectal carcinoma and whether the mean maximal diameter of lymphatic microvessels (LMMMD) or lymphatic microvessel density (LMVD) is associated with lymph node metastasis in early stage invasive colorectal carcinoma (T1 carcinoma), we used immunohistochemical staining with podoplanin to measure LMMMD and LMVD in intratumoral (LMMMDit, LMVDit) and peritumoral areas (LMMMDpt, LMVDpt) of T1 carcinomas (n=87). By comparing the LMMMD and LMVD in normal large intestine (n=10), adenoma (n=15), and Tis carcinoma (n=15), we found out that the LMVDpt in T1 carcinoma with lymphatic vessel invasion (LVI) was significantly high (P<0.001), and there was a significant decrease in LMMMDpt in T1 carcinoma (P=0.031). Both LMMMDpt and LMVDpt were significantly increased in the T1 carcinomas, with LVI compared with the T1 carcinomas without LVI (P=0.018, P=0.003). Multivariate analysis revealed that LVI and combined greater LMMMDpt and greater LMVDpt were associated with lymph node metastases (P=0.005, P=0.036). These results indicate that lymphangiogenesis might be induced in the surrounding tumor areas of the T1 colorectal carcinoma with LVI; thus, evaluation of the diameter and density of lymphatic microvessels is important in T1 colorectal carcinoma to predict lymph node metastases.

Why is the coexistence of gastric cancer and duodenal ulcer rare? Examination of factors related to both gastric cancer and duodenal ulcer

The coexistence of gastric cancer with duodenal ulcer has been found empirically to be rare, but why it is rare is difficult to explain satisfactorily. To elucidate this question, we carried out a literature review of the subject. The frequency with which the two diseases coexist is 0.1–1.7%, and the main factor associated with both gastric cancer and duodenal ulcer is Helicobacter pylori infection. However, there are marked differences between the disorders of hyperchlorhydria in duodenal ulcer, and hypochlorhydria in gastric cancer. The most acceptable view of the reason for the difference may be that the acquisition of H. pylori infection occurs mainly in childhood, so that the time of acquisition of atrophic gastritis may be the most important, and if atrophic gastritis is not acquired early, high levels of gastric acid may occur, and consequently acute antral gastritis and duodenal ulcer may occur in youth, whereas, in elderly individuals, persistent H. pylori infections and the early appearance of atrophic gastritis may be the causes of low gastric acid, and consequently gastric cancer may occur. In patients with duodenal ulcer, factors such as nonsteroidal anti-inflammatory drugs (NSAIDs) and dupA-H. pylori strains may contribute to preventing the early acquisition of atrophic gastritis, while acid-suppressive therapy and vascular endothelial growth factor and other entities may inhibit atrophic gastritis. In contrast, in gastric cancer, factors such as excessive salt intake, acid-suppressive therapy, polymorphisms of inflammatory cytokines, and the homB-H. pylori strain may contribute to the early acquisition of atrophic gastritis, while factors such as NSAIDs; fruits and vegetables; vitamins A, C, and E; and good nutrition may inhibit it.

The granulocyte/lymphocyte ratio as an independent predictor of tumour growth, metastasis and progression : its clinical applications

Several investigators have suggested that the granulocyte/lymphocyte (G/L) ratio is a good indicator for the evaluation of the condition of a tumour-bearing host, although its prognotic significance is unclear. To further investigate the clinical applications of the G/L ratio, we injected 1x105 and 1x106 Lewis lung carcinoma cells (3LLc) into the feet of 4-week-old C57BL/6 mice separated into groups A, B, C and D (1x105 cells) and E, F, G and H (1x106 cells). For the observation of tumour metastasis and G/L ratio, the mice in groups A-D were sacrificed on days 11, 14, 17 and 21 after inoculation with the 3LLc cells, and the mice in groups E-H on days 7, 11, 14 and 17. The results suggest that in mice the number of granulocytes increases with time after 3LLc cell injection (P<0.05). We also retrospectively investigated the correlation between G/L ratio, clinicopathologic features and prognosis in 62 patients with gastric carcinoma. There was a significant correlation between the G/L ratio and tumour weight (r=0.746, P<0.05), as well as a significant difference between the G/L ratio and the extent of metastases (P<0.05). Additionally, the G/L ratio was significantly associated with lymph node metastasis and higher tumour stage, tumour progression (P=0.017) and 5-year survival (P=0.013). In conclusion, the G/L ratio is associated with tumour progression and shorter survival. The close correlation between G/L ratio and tumour stage or lymph node status suggests that it could be used to predict tumour metastasis, prognosis and overall survival in patients with gastric carcinoma before they undergo surgical treatment.

Spinal Destruction Induced by Chronic Contained Rupture of an Abdominal Aortic Aneurysm: Report of a Case

We report a case of spinal destruction caused by chronic contained rupture of an abdominal aortic aneurysm (AAA). The patient was a 73-year-old man who had undergone coronary artery bypass grafting, sigmoidectomy for colon cancer, and axillofemoral bypass with AAA resection within months of each other, 3 years earlier. Abdominal computed tomography and magnetic resonance imaging showed destruction of the 12th thoracic and 1st lumbar vertebrae. The possibility of a metastatic spine tumor prompted us to consult the orthopedic surgeons, who recommended a spinal percutaneous needle aspiration biopsy. However, the cardiovascular surgeons diagnosed chronic contained rupture of an inflammatory AAA. The patient gradually improved with antimicrobial treatment, but died of disseminated intravascular coagulation the following year. The definitive diagnosis was confirmed by autopsy. We report this case for its educational value, considering the serious consequences that might have occurred had we attempted to biopsy the lesion.

The Use of Autologous Fibrin Glue for the Treatment of Postoperative Fecal Fistula Following an Appendectomy: Report of a Case

We herein report a case of postoperative fecal fistula following an appendectomy which was successfully treated by the use of autologous fibrin glue. An 82-year-old man had acute appendicitis and underwent an appendectomy. Later, a fecal fistula developed and he underwent drainage treatment twice. After 4 weeks of drainage and during the third recurrence, the remaining fistula was successfully treated using autologous fibrin glue, instead of surgery, due to potential complications and the risks of associated with advanced age. No recurrence has been observed for 5 months. In conclusion, autologous fibrin gluing for fecal fistula was found to be a safe, economical, and effective treatment. A search of Medline from 1980 until 2002 revealed no other report of this treatment for postoperative fecal fistula following an appendectomy.

Villous Rectal Adenoma as a Rare Cause of Acute Renal Failure (McKittrick-Wheelock Syndrome)

Fluid and electrolyte hypersecretion in a villous adenoma of the rectum was seen in a 72-year-old male suffering from acute renal failure. The patient was found to have prerenal uremia on admission, and received emergency hemodialysis. He then underwent systemic screenings for other possible diseases because of his severe emaciation. A barium enema examination revealed a large villous lesion of the upper rectum. Operative local excision of the tumor was performed. Renal function was restored after radical tumor surgery.McKittrick-Wheelock syndrome could be managed successfully by acute hemodialysis and early surgical resection of rectal tumor.ZusammenfassungBei einem 72-jährigen Mann mit akuter Niereninsuffizienz wurde eine Flüssigkeits- und Elektrolythypersekretion in einem villösen Rektumadenom festgestellt. Bei Krankenhausaufnahme bestand eine prärenale Urämie, und eine notfallmäßige Hämodialyse wurde durchgeführt. Da der Patient extrem abgemagert war, wurde er systemischen Screenings im Hinblick auf andere mögliche Erkrankungen unterzogen. Ein Bariumkontrasteinlauf ergab eine große villöse Läsion des oberen Rektums. Daraufhin wurde eine lokale Tumorexzision durchgeführt. Nach der radikalen Tumoroperation war die Nierenfunktion wiederhergestellt.Das McKittrick-Wheelock-Syndrom ließ sich durch eine Akuthämodialyse und eine frühzeitige Resektion des Nierentumors erfolgreich behandeln.

Acute myelogenous leukemia suddenly developing just after surgery for advanced gastric cancer: report of a case.

We report a case of acute myelogenous leukemia (AML) developing just after surgery for advanced gastric cancer, before adjuvant chemotherapy was started. Immature white blood cells were recognized in the peripheral blood from postoperative day (POD) 1. The patient’s clinical status and bone scintigraphy showed no evidence of bone metastasis. Acute myelogenous leukemia was diagnosed by an aspiration biopsy of the bone marrow. If the AML had developed later and had become remarkable during or after adjuvant chemotherapy, the differential diagnosis between de novoand therapy-related leukemia would have been very difficult. Most leukemias that develop during the course of chemotherapy or radiotherapy, or both, are indisputably considered to be therapy-related. Thus, we report the clinical course of this patient with reference to the related literature to warn surgeons of the possibility of this unusual manifestation.

A CASE OF A COLONIC LIPOMA WITH A RARE MACROSCOPIC MORPHOLOGY WHICH WAS DIAGNOSED BY ENDOSCOPIC RESECTION

稀な形態を呈し内視鏡的切除により診断が得られた大腸脂肪腫の1例を経験したので，文献的考察を含め報告する．57歳，男性．健診にて便潜血反応陽性を指摘され受診．注腸検査では，S状結腸に径約3cm大のポリープ陰影を認め，大腸内視鏡検査では，同部位に表面が分葉状の有茎性ポリープを認めた．生検組織診断では，粘膜上皮の過形成性変化と一部に異型上皮を認めたため，同ポリープに対して内視鏡的ポリープ切除術を施行した．切除されたポリープは，大きさ3.5×3.0×2.0cmで茎部の直径は1.5cm，切除断端面に脂肪組織の露出を認めた．病理組織所見は，粘膜下層に成熟した脂肪細胞の増生像を認め良性の脂肪腫の診断となった．なお，粘膜の陰窩上皮には過形成性変化を認めるも，腫瘍性変化は認めなかった．脂肪腫に関しては切除断端陽性であるが，切除された範囲では悪性所見は認められず経過観察となった．

Two Cases of Complete Response of Recurrent Gastric Cancer treated with Paclitaxel as Second Line Chemotherapy

症例1は72歳の男性で, 幽門側胃切除後肝門部リンパ節腫脹による黄疸, 傍大動脈リンパ節腫脹を認め, 低用量FP療法, TS-1 80mg内服を行うも奏効せず, Paclitaxel (60mg, 3週投与, 1週休薬) の投与を行ったところ, 5か月でcomplete response (以下, CR) を得た. CR後約半年間Paclitaxelを投与し, 長期にわたりCRを維持したが, Paclitaxel 投与中止後約4か月で多発性肝転移を来して不幸な転帰をたどった. 症例2は67歳の男性で, 胃全摘・膵尾側脾合併切除後, TS-1 80mg, CDDP 10mg/weekの投与をしていたが, 多発性肝転移, 傍大動脈リンパ節腫脹出現しPaclitaxel (60mg, 3週投与, 1週休薬) の投与を行った. 9か月後にはCRが得られた. 以後, biweekly投与で約2年7か月間投与を行った. 3年以上経過したが現在もCRを維持している. 今回, 症例1を通してPaclitaxel中止後の何らかの免疫監視機構の破綻などが示唆された. CRが得られた場合でも予後決定臓器への転移では, CR後も1年間は化学療法をすべきと思われた.