Yasuhiko Morioka

Small “flat adenoma” of the large bowel with special reference to its clinicopathologic features

Thirty-three small “flat adenomas,” not more than 1 cm in diameter, were collected from surgically and colonoscopically removed specimens, and their colonoscopic and histologic characteristics were described. There were 14 adenomas with mild atypia, five with moderate atypia, 14 with severe atypia (or focal carcinoma limited to the mucosa). The grade of atypia seems to increase with the size of lesions, and these lesions were assumed to play an important role in the adenoma-carcinoma sequence. The importance of recognizing the presence of these small “flat adenomas” in everyday practice is stressed.

Hepatic resection for hepatocellular carcinoma. Clinical features and long-term prognosis.

Ninety-eight hepatic resections for hepatocellular carcinoma were performed on 94 patients from 1963-1985. HBs antigen was positive in 17% of patients, preoperative serum alpha-fetoprotein was more than 20 ng/mL in 70% of patients, and liver cirrhosis was present in 75% of patients. Hospital mortality rate was 19%, and the volume of operative blood loss was the most decisive factor that affected the short-term prognosis. Excluding the 19 hospital deaths, the long-term survival rates of 75 patients were 73%, 42%, and 25% for 1, 3, and 5 years, respectively. Prognostic factors that influenced the long-term prognosis were investigated by comparing the survival curves. Significant differences of survival patterns were noted when analyzed on the basis of preoperative alpha-fetoprotein level (less than or equal to 200 vs. greater than 200 ng/mL), tumor size (less than or equal to 5 vs. greater than 5 cm), and tumor capsule. The recurrence of carcinoma was the main cause of death in 56% (42 patients) who died after discharge from the hospital. The development of effective prevention and treatment against recurrent tumors is necessary to improve long-term prognosis.

Postoperative recurrence of hepatocellular carcinoma.

Sixty-nine patients with hepatocellular carcinoma underwent curative hepatic resections as primary cases from 1981 to 1986. Seven patients died in the hospital after operation. The other 62 patients left the hospital and were closely followed for 25 to 78 months. Recurrence of carcinoma became obvious in 41 (66%) of 62 patients. The clinical and pathologic features of these 41 patients were not significantly different from those of the other patients. Recurrent tumors were found in the residual liver in 38 patients (93%), in the bone in 2 (5%), and in the lung in 1 (2%). Recurrence was diagnosed within 1 year, between 1 and 2 years, and more than 2 years after the operation in 22 (56%), 10 (26%), and 7 (18%) patients, respectively. It was difficult to determine the exact time of recurrence in two patients. There was a significant negative correlation between the size of primary tumor and time until recurrence; the larger the primary tumor, the shorter the time until recurrence. Among the 29 patients who underwent local excisions for their primary tumors, 19 recurrences were observed. Eighteen were found in the residual liver, in the same segment as the primary tumor, or in one near it. Larger hepatic resection for primary tumors is thus advocated to prevent recurrence.

Clinical pathology of endocrine tumors of the pancreas. Analysis of autopsy cases.

A clinicopathological analysis of endocrine tumors of the pancreas, using 800 autopsy cases (422 men, 378 women, mean age 78.7) was accomplished. The results were: (1) Endocrine tumors and similar lesions were found in 3% or 24 cases (25 lesions). Twenty lesions (20 cases) were found to be tumors and five lesions (five cases) were determined to be hyperplasia of Langerhans islets. (2) Incidence of tumor was 10% (6/60) in individuals having histological studies of all sections of the pancreas, and 1.6% (12/738) in individuals having histological studies of three random sections of the pancreas. (3) None of the cases with tumors and hyperplastic lesions showed symptoms of hormone production. (4) Immunohistochemical analysis revealed hormone production in all 20 tumor cases and multiple hormone production was found in 14 of these (70%). (5) Ductular or tubular structures were found in or adjacent to the tumors in 12 cases (60%) and hyperplasia in one case (20%). Langerhans islets, 500 μm or larger in size, were found in three lesions of the tumor (15%). Langerhans islets with the mean diameter of normal islets +2sd or larger also were found around five tumors (25%) and three hyperplasias (60%). The above findings suggest that endocrine tumors of the pancreas are prevalent and that they do not produce symptoms of excessive hormone production even though they do continue to produce hormones. Some of the endocrine tumors or hyperplasias develop from totipotent stem cells of the duct epithelia, and factors promoting the growth of Langerhans islets might exist.

Diverticular disease of the colon in Japan a review of 615 cases

Of 615 patients with diverticular disease of the colon, 429 had diverticula in the cecum and ascending colon, 98 in the sigmoid and descending colon and 88 in both the right- and left-side colon. The right-sided type was, more common in younger people and more predominant in men, whereas the left-sided type was more common in the elderly and showed no difference in numbers between men and women. More than 50 per cent of patients were asymptomatic, and 25 per cent complained of disturbed bowel function. The frequency of diverticulitis was not related to location, but to the number of diverticula. Seventy-seven were complicated by acute inflammation (right-sided diverticulitis, 61, and left-sided diverticulitis, 16). Many patients with right-sided diverticulitis improved with medical treatment and the operative procedure of choice was drainage of the inflamed area with supplemental appendectomy.

Lymphatic and local spread of T1 and T2 pancreatic cancer. A study of autopsy material.

Eight autopsy cases of pancreatic cancer (duct cell adenocarcinoma) with Tl and T2 primary tumors were studied histologically to examine the exact extent of lymphatic and local spread. Six of them had microscopic metastasis in grossly negative lymph nodes near the primary tumor. In addition, four of them had a few metastatic nodes in the para-aortic region. In cases with lymphatic metastases, the extent of cancer infiltration within lymphatic vessels, nerves, and/or connective tissues was almost the same as that of lymph node metastasis. Major vascular involvement was found in four cases. There was no case in which multicentricity or marked intraductal spread of cancer cells was observed in the pancreas. It has been suggested that most of Tl and T2 pancreatic cancers have a fairly widespread microscopic extension, although extremely small Tl cancers have a very limited extension.

Clinicopathologic features of the flat adenoma.

One hundred twenty-eight small flat adenomas (SFAs) were collected from 101 patients, and the clinicopathologic features were investigated. There were 91 adenomas with mild atypia, 20 with moderate atypia, and 17 with severe atypia. SFAs were found more often in males than in females, with a ratio of 3.4∶1, and the malignancy rate in females (31.8 percent) was higher than in males (9.3 percent). About 38 percent of the patients had a history of colorectal carcinoma, and 65 percent had a history of colorectal neoplasms. Of 37 patients whose family history was traced, 21 had cancer families. SFAs were prone to be found in patients with a history of colorectal neoplasms and a cancer family. Malignancy rate increased with increasing size. The overall malignancy rate was 13.3 percent, which was considerably higher than that of ordinary small polypoid adenomas (2.8 percent). SFAs were situated more proximally (30.9 percent) than ordinary adenomas; however, there was no relationship between site and malignancy. All the lesions showed tubular adenomas, and there was no villous feature. A central depression was noted in 20 lesions, more frequently in adenomas with higher atypia. All but one adenoma with severe atypia showed a component of lower atypia, supporting the adenoma-carcinoma sequence.

Early gastric caner

In order to decide on a treatment strategy against gastric cancers, an accurate preoperative evaluation of the depth of cancer invasion is essential. Preoperative endoscopic diagnosis of the depth of invasion was compared with pathological results of the resected specimen in 206 early gastric cancers and 32 early-like advanced gastric cancers. The endoscopic distinction between early and early-like advanced cancers was correctly made in 83.6% of the cases. Among the early gastric cancers, mucosal and submucosal invasion was correctly presumed in 71.9% of the cases. When the tumor was an elevated type, or located in the antrum, the endoscopic diagnosis tended to be deeper than the true depth. The size of tumor contributed little to the depth diagnosis. Pathomorphological changes on the tips of converging folds were the important clue for diagnosing depth.In order to decide on a treatment strategy against gastric cancers, an accurate preoperative evaluation of the depth of cancer invasion is essential. Preoperative endoscopic diagnosis of the depth of invasion was compared with pathological results of the resected specimen in 206 early gastric cancers and 32 early-like advanced gastric cancers. The endoscopic distinction between early and early-like advanced cancers was correctly made in 83.6% of the cases. Among the early gastric cancers, mucosal and submucosal invasion was correctly presumed in 71.9% of the cases. When the tumor was an elevated type, or located in the antrum, the endoscopic diagnosis tended to be deeper than the true depth. The size of tumor contributed little to the depth diagnosis. Pathomorphological changes on the tips of converging folds were the important clue for diagnosing depth.

Flat adenoma and flat mucosal carcinoma (IIb type)--a new precursor of colorectal carcinoma? Report of two cases.

Two flat adenomas and a flat mucosal carcinoma of the colon were reported in patients with synchronous and metachronous colonic carcinomas. These lesions were almost flat and were not detected by preoperative endoscopic examinations. Colonoscopists should be aware of the presence of flat adenomas, which can be easily missed, and recognize them as lesions that play an important role in the “adenomacarcinoma sequence.

One hundred hepatic resections. Indications and operative results.

The indications and operative results of hepatic resections were investigated in 100 consecutive patients over the past 20 years. There were 61 hepatocellular carcinoma, 13 hepatolithiasis, and 26 other miscellaneous diseases. An overall hospital mortality rate was 25%. It was 26, 0, and 35% in patients with hepatocellular carcinoma, hepatolithiasis, and other diseases, respectively. There was not any significant difference between survived and deceased cases in their preoperative laboratory data. The volume of operative blood loss in deceased cases was significantly larger than that in survived cases, so the influence of operative blood loss on morbidity and mortality was investigated. The incidences of postoperative bleeding, hepatic insufficiency, pulmonary insufficiency, and hospital death were significantly higher in patients whose operative blood loss exceeded 5000 ml. These results indicate that operative blood loss is one of the critical factors that decide the operative prognosis.