Metastatic gastric cancer arising from breast carcinoma: endoscopic ultrasonographic aspects

Linitis plastica of the stomach was diagnosed in four patients. Endoscopic ultrasonography (EUS) was performed in four cases; they were monitored by EUS and had their treatment adapted accordingly. According to the present study, the typical criteria of gastric linitis at EUS are: (a) rigidity of the gastric wall; (b) a wall thickness exceeding 6 mm; (c) a second enlarged layer marginally more echogenic than the fourth hypoechogenic layer (muscularis propria); (d) a third hyperechogenic enlarged layer; and (e) a poor demarcation between layers. Gastric linitis appears more likely to be specific metastasis from lobular breast carcinoma. In most of the follow-up cases, EUS showed correlation with a subsequent decrease of the CA15.3 level. At present, EUS seems to be the most effective and least invasive examination for clinical diagnosis and treatment surveillance of secondary gastric linitis arising from infiltrating lobular carcinoma (ILC) of the breast.     

Evaluation of acetic acid-induced gastric ulcers in dogs by endoscopic ultrasonography

To clarify the ability of endoscopic ultrasonography (EUS) to diagnose gastric ulcer, we induced gastric ulcer (19 open ulcers and 11 ulcer scars) by injecting acetic acid into the stomach via an endoscope in 15 dogs. The stomachs were resected and scanned by EUS in a water bath, and the findings were compared with the histologic observations. The ulcer depth was correctly diagnosed in 29 of 30 instances (96.7%). In active, open ulcers the width and depth of the ulcer crater and the thickness of the gastric wall around the crater measured in the photographs obtained by EUS corresponded with those observed in histologic photographs. In the ulcers disrupting the muscularis propria layer the distance between the disrupted muscularis propria layer in EUS also corresponded to the histologic observations. In all ulcer lesions the low-echoic area below the ulcer in EUS corresponded to the histologic area of granulation or fibrosis. However, it was difficult to distinguish granulation from fibrosis by EUS. EUS is thus considered useful for evaluating gastric ulcers quantitatively in the clinical setting.     

Lymph node metastasis in gastric cancer in the upper third of the stomach--surgical treatment on the basis of the anatomical distribution of positive node

BACKGROUND/AIMS: Little is known about the most appropriate surgical procedure for gastric cancer in the upper third of the stomach. The objective of this study was to determine the most appropriate surgical treatment for gastric cancer in the upper third of the stomach. METHODOLOGY: The clinicopathological characteristics of 115 node-positive gastric cancers in the upper third of the stomach were reviewed retrospectively and compared with those of 111 node-negative gastric cancers in the upper third of the stomach. RESULTS: Node-positive gastric cancers showed higher rates of peritoneal metastasis (p < 0.005), larger tumor sizes (p < 0.005), deeper tumor penetration (p < 0.005), higher rates of diffuse type in histology (p < 0.025), and more advanced histological stages (p < 0.005), than node-negative gastric cancers. Patients with node-positive gastric cancer demonstrated a poorer survival rate than those with node-negative gastric cancer (p < 0.005). Lymph node metastasis along the lower stomach was observed in cases of gastric cancer which had invaded beyond the muscularis propria of the stomach but not in those confined within the muscularis propria. No lymph node metastasis in the splenic hilum was found in association with gastric cancer when the depth was limited to the mucosa or the submucosa. CONCLUSION: The appropriate surgical procedures for the treatment of gastric cancer in the upper third of the stomach are as follows: a) proximal gastrectomy without splenectomy for gastric cancer when the depth is limited to the mucosa or the submucosa, b) proximal gastrectomy with splenectomy for gastric cancer when the depth of invasion extends to the muscularis propria, c) total gastrectomy with splenectomy for gastric cancer when the depth of invasion extends beyond the muscularis propria.     

Late follow-up results of operative ankle arthroscopy in patients under local anaesthesia

The clinical diagnoses of nodal status (N) and tumor invasion (T) were performed intraoperatively during 1499 consecutive operations for gastric carcinoma and compared with subsequent pathologic diagnoses. An accurate macroscopic diagnosis of N stage was difficult; overall accuracy was only 56.6%. Intraoperative assessment of T stage (particularly of serosal invasion) was correct for 93.2% of early stages of the disease with invasion confined to the mucosa or submucosa (pT1) when the pathologist assessed the T stage in the resected specimen, for 95.6% of advanced tumors invading the serosa (pT3), but for tumors of an intermediate stage with invasion involving the muscularis propria or the subserosa (pT2) in only 41.9% of cases. Macroscopic overestimation occurred in 58.1% of cases with pT2 tumors, which were characterized by carcinomas in the upper third of the stomach, tumors larger than 5 cm, carcinomas of the ulcerating type, differentiated adenocarcinomas, tumors invading the subserosa, and those accompanied by lymph node metastasis or liver metastasis. The overestimated group had a significantly poorer prognosis than the correctly assessed cases (P < 0.05). Since multivariate logistic regression analysis showed that the significant risk factor related to the inaccurate intraoperative assessment of T stage was tumor size, the error in diagnosis may correlate with a greater degree of tumor spread. Surgeons should decide their therapeutic approach at the time of surgery on the basis of their intraoperative assessment of tumor spread. We recommend extensive surgery followed by adequate chemotherapy when serosal invasion is suspected at surgery.     

Human defunctionalized colon: a histopathological and pharmacological study of muscularis propria in resection specimens

Despite the regression of "diversion colitis," temporary functional disorders after bowel continuity restoration could be caused by changes in the smooth muscle of excluded segments; however, studies on the muscularis propria have yielded contradictory results. This study was aimed at evaluating possible histopathological changes in muscular layers and motility of the defunctionalized human colon. Ten patients with defunctionalized colorectum (group A) and 10 controls (group B) underwent restorative or primary resection surgery. Strips were taken proximal to the colostomy (specimens A1) and the defunctionalized segment (specimens A2), and from the proximal (specimens B1) and distal extremity (specimens B2) of resected colons. Measurements of the thickness of the muscularis propria and of the volume density of the myenteric plexus, as well as of spontaneous motility and responses to electrical and pharmacological stimulation were taken. The muscularis propria was thicker in A2 than in A1 specimens (P = 0.004) and in B2 than in B1 specimens (P = 0.007). No differences were recorded either in the myenteric plexus volume density or in colonic motility. No differences were recorded in intergroup comparisons. As no structural or functional changes related to defunctionalization were found, clinical disorders after colorectal restoration could rather result from underlying colonic pathology and/or incomplete distal colon resection.     

An opportunity for exploitation of research in biomedical engineering: the EC Life Sciences Demonstration Projects

The morphology of the ureter of the duck was investigated, using histological, SEM and TEM techniques. The inner perimeter, the total thickness of the ureteral wall and the thickness of each uretral layer were measured. The epithelium was tall columnar and pseudostratified along all the tracts of the ureter and showed a high muco-secretive activity. The lamina propria contained numerous capillaries and aggregates of leucocytes and macrophages. Throughout the lamina propria there was a dense plexus of nerves. Some denuded single nerve fibres were observed between the epithelial basal cells. A plexus of nerves was also observed in the tunica muscularis. The ostium cloacale ureteris opened on a well-developed papilla in the dorsal region of the urodeum. The total thickness of the ureteral wall, the thickness of the lamina propria and the tunica muscularis, and the inner perimeter progressively increased towards the ostium. The above observations suggest that the avian ureter plays an important role in the modification of the urine coming from medullary cones, and in emission of the urine into the cloaca.     

The role of myofibroblasts at the tumor border of invasive colorectal adenocarcinomas

BACKGROUND: In order to elucidate the significance of myofibroblasts in invasive growth of colorectal adenocarcinomas, we examined the number of myofibroblasts at the tumor border of colorectal adenocarcinomas. METHOD: A total of 91 invasive colorectal adenocarcinomas were examined immunohistochemically using anti-alpha-smooth muscle actin (ASMA) and high-molecular-weight caldesmon (h-CD) antibodies; 25 carcinomas confined to the submucosa (sm carcinomas), 40 carcinomas confined to the muscularis propria (mp carcinomas) and 26 carcinomas invading the subserosa or adventitia (ss carcinomas). We considered ASMA-positive and h-CD-negative stromal cells as myofibroblasts. RESULTS: Twenty-seven (67%) of the 40 mp carcinomas and 25 (96%) of the 26 ss carcinomas had a small number of myofibroblasts at the tumor border facing the muscularis propria. CONCLUSIONS: Although direct evidence is lacking, there is a possibility that the further immediately vertical and radial invasion of carcinoma cells into the subserosa or adventitia is associated with a smaller number of myofibroblasts at the tumor border facing the muscularis propria in mp carcinomas, resulting in a low incidence of mp and a high incidence of ss carcinomas in the colorectum.     

Functional and structural properties of Na+/K(+)-ATPase enzyme in neonatal erythrocytes

Achalasia is a relatively infrequent disorder of oesophageal motility, and is most often easily diagnosed by stationary manometry showing absence of peristalsis and incomplete lower oesophageal sphincter (LOS) relaxation. In rare cases manometric findings may be inconclusive or a malignant underlying disease is suspected. In such cases direct visualization of the LOS by endoscopic ultrasound (EUS) could contribute to securing the diagnosis and possibly lead to earlier diagnosis and treatment. With lower frequency EUS, increased thickness of the inner circular layer of the muscularis propria may be difficult to detect. Available data suggest that high frequency (20 MHz) and 3-D EUS has a potential to reliably discriminate between achalasia patients and normal subjects, and thereby be of diagnostic value.     

Tumors originating in the muscularis mucosae of the recto-sigma

Tumours arising from the muscular layer of the bowel are uncommon and extremely rare when localized in colon and rectum. Most of them arise from the external muscular layer or muscularis propria. Tumours originating in muscularis mucosae or in the vascular system are uncommon. Two hundred rectal leiomyomas and leiomyosarcomas have been described. Tumours originated in the muscularis mucosae are polypoid, pedunculated, benign and most of them will be treated by a polypectomy without recurrence. However leiomyomas arising from the muscularis propia have a 60% of recurrence after local treatment and in some cases the recurrence will be a metastatic leiomyosarcoma. Three tumours arising from muscularis mucosae of the rectum and sigma are presented. All three were diagnosed and removed by colonoscopy. Two were diagnosed as leiomyomas. The third was a low grade leiomyosarcoma and an anterior resection was performed as definitive treatment.     

Squalene promotes the formation of non-bilayer structures in phospholipid model membranes

From the study on correlation between the depth of cancer invasion and the results of surgery, early cancer of the biliary tract may be defined as cancer cell invasion limited to the mucosal or muscularis propria in the case of carcinoma of the gallbladder, and to the mucosal or fibro-muscular layer in the case of carcinoma of the bile duct. With few exceptions, these tumors had no lymph node metastasis, venous invasion, perineural infiltration or involvement of the lymphatic vessels. Since the cumulative 5-year survival rate was 100% after resection of early cancer, the choice of surgical procedures was considered to be extended cholecystectomy for early cancer of the gallbladder, and the standard radical resective operation for early cancer of the bile duct. An accurate diagnosis was not made preoperatively in most cases of early cancer of the biliary tract. The diagnostic approach is discussed, including the recently developed imaging modalities, such as endoscopic ultrasonography and percutaneous transhepatic cholecystoscopy or cholangioscopy.     

Distribution of the interstitial cells of Cajal in the human anorectum

The interstitial cells of Cajal are proposed to have a role in the control of gut motility. The aim of this study was to establish the distribution of interstitial cells of Cajal in the wall of the normal human anorectum. Interstitial cells of Cajal express the proto-oncogene c-kit. Interstitial cells of Cajal were identified in the colon by immunohistochemical staining, using a rabbit polyclonal anti-c-kit antibody. Anorectal tissue was obtained at surgical resection for carcinoma of the colorectum. Density of interstitial cells of Cajal was graded. Statistical analysis was performed using chi2 tests. In the longitudinal and circular muscle layers of the rectum interstitial cells of Cajal were seen in the bulk of the muscle layer. In the intermuscular plane interstitial cells of Cajal encased the myenteric plexus. Interstitial cells of Cajal were found at the inner margin of the circular muscle and in association with neural elements of the submuscular plexus. Within the internal anal sphincter interstitial cells of Cajal were infrequently scattered among the muscle fibres. The density of interstitial cells of Cajal in the internal anal sphincter was significantly lower than that observed in the circular muscle layer of the rectum (P = 0.014). In conclusion, interstitial cells of Cajal are evenly distributed in the layers of the muscularis propria of the rectum, but have a lower density in the internal anal sphincter.     

Diagnosis of superficial-type early carcinoma of the gallbladder by endoscopic ultrasonography--comparison with ultrasonography

The detectability of superficial-type carcinoma of the gallbladder by ultrasonography (US) and endoscopic ultrasonography (EUS) were investigated. Eight patients with such carcinoma of the gallbladder were reviewed. They had undergone both US and EUS previous to surgery. The tumor was detected in 3 patients by US, 2 patients with IIa + IIb-type carcinoma and 1 patient with IIa-type carcinoma. Those lesions were visualized as localized thickening of the gallbladder wall or as broad-based tumor. In 2 patients, lesions were not initially detected by US, but were shown by US after the examination by EUS. The tumor was detected by EUS also in 1 case of IIb + IIa-type carcinoma besides those 3 patients mentioned above. All four of these lesions were visualized as broad-based tumor by EUS. It was difficult to detect pure IIb-type or small IIa-type carcinoma even by EUS. In patients with concomitant acute cholecystitis or gallbladder stone, it was difficult to evaluate the abnormal findings of the gallbladder wall.     

Stage IIIa endometrial carcinoma: MR findings

[PURPOSE]: An attempt was made to evaluate the ability of magnetic resonance (MR) imaging to diagnose stage IIIa endometrial carcinoma. [MATERIALS AND METHODS]: Thirty-three patients with endometrial carcinoma underwent MR imaging and surgery. Surgical staging was classified as I in 21 patients, II in 3 patients and III in 9 patients. The MR images of each patient were retrospectively reviewed by three radiologists. Only the clinical diagnosis of endometrial carcinoma was previously notified. Segmental disruption of the full thickness of the myometrium was considered serosal invasion. Intraperitoneal metastasis was diagnosed according to three criteria (intraperitoneal solid mass of isointensity compared with endometrial lesion, cystic mass excluding benign ovarian cysts, ascites). These evaluations were compared with the surgical findings and analyzed by the kappa statistic. [RESULTS]: The rates of sensitivity and positive predictive value (PPV) for serosal invasion were 33% and 6%, respectively. False positive evaluation frequently occurred when thickness of the intact myometrium was less than 5mm. The rates of sensitivity and PPV for intraperitoneal metastasis were 86% and 72%, respectively. The reason for false negative evaluation was small foci of intraperitoneal metastasis. Overall, sensitivity and PPV for stage IIIa were 86% and 69%, respectively. [CONCLUSION]: MRI was useful in detecting intraperitoneal metastasis of endometrial carcinoma with the exception of diagnosing serosal invasion. It is difficult to detect small foci of peritoneal metastasis. It is necessary to differentiate adnexal metastasis from benign adnexal masses.     

Statistical analysis of 1186 cases of gastric carcinoma: with special reference to advanced lesion (author's transl)

750 cases of advanced gastric carcinoma were macroscopically and microscopically studied in relation with the 10 year survival rate. Most of the patients, 59.3% in female and 68.8% in male, belonged to the 5th and 6th decades. Macroscopically 44.1% of the cases were grouped in Borrmann III type, and secondly Early-Cancer Like Lesion, 26,6%. Histologically, in 510 cases out of 750 (68.0%) serosa was definitely broken by carcinoma cell nests and in 500 cases (66.7%) lymphnode metastasis was observed. The most frequent histological type was diffuse type, 44.9%, and secondly papillotubular type, 21.2%. 10 year survival rate of 516 cases, in which no residual cancer tissue was ascertained and the favorite prognosis could be expected was studied on various factors: Early-Cancer-Like-Lesion and Borrmann I & II types carcinoma, those cases in which the muscularis propria or serosa was preserved, those cases without lymphnode metastasis, and papillotubular or medullary tubular carcinomas showed a favorite prognosis in comparison with other types.     

Jejunal lipomatosis with diverticulosis: report of a case

We herein report the very rare case of a 68-year-old Japanese man with multiple jejunal lipomatosis and diverticulosis. He was admitted to our hospital with the chief complaint of melena and anemia. A barium study of the small bowel showed multiple lipomatosis and diverticulosis. An approximately 200-cm length of the jejunum was therefore resected. Thereafter, two diverticula and 215 lipomas were recognized in the resected specimen. A pathological examination showed mature adipose tissue with fibrous septa in the submucosal and muscularis propria. These findings were thus suggested to be due to the attenuation of the muscularis propria. The complications of lipomatosis are also discussed.     

Treatment outcome of 1,000 cases of endoscopic sinus surgery

To assess the treatment outcome of endoscopic sinus surgery (ESS), 1,000 patients with chronic sinusitis and nasal polyp treated between November 1991 and January 1995 were included in this study. Among them, 754 patients (64.8%) had previous operations from 1 to 25 times with an average of 3.7. Before ESS, axial and coronal CT scans were obtained (window width: 1,000 HU, window level: +90 HU; section thickness: 2 mm with 12 to 16 sections). Patients with clinical stages from I to IV were 9.9%, 21.0%, 15.0% and 54.1% respectively. Bilateral ESS was performed in 95% patients, septoplasty in 27.6%, middle meatal antrostomy in 78.5%. The clinical cure rate was 84.0%, 557 patients were considered as primary healing, 283 patients delayed healing and 160 patients had persistent inflammation. Complications were noted in 18 patients. Bleeding during ESS varied from 10 to 1,800 ml (average 180 ml). The indications, preoperative evaluation, control of bleeding, prevention of complications and prognosis were discussed in detail. The article indicated that the important factors to increase the cure rate are postoperative follow-up and systematic treatment.     

Cystic pulmonary metastases of endometrial stromal sarcoma of the uterus, mimicking lymphangiomyomatosis: a case report with immunohistochemistry of HMB45

A case of endometrial stromal sarcoma (ESS) showed cystic pulmonary metastases mimicking lymphangiomyomatosis (LAM). A 58-year-old female, who had undergone total hysterectomy for low-grade ESS 16 years previously, had repeated bouts of pneumothorax. Multiple thin-walled cysts in the peripheral lung were revealed by radiological examinations. In an open-lung biopsy specimen, cystic lesions were surrounded by layers of spindle-shaped cells of varying thickness that resembled LAM. However, in addition to subtle histologic differences from LAM, HMB45 (antimelanoma antibody) showed positive in LAM (n = 3), but was negative in ESS (n = 2) and the cystic lesions of this case. Using myogenic markers (desmin and alpha-smooth muscle actin), metastatic ESS could be immunohistochemically differentiated from mesenchymal cystic hamartoma (n = 1). HMB45 immunohistochemistry is useful in the differential diagnosis of cystic pulmonary lesions.     

Ubiquity of omnivores in natural ecosystems

A preliminary analysis was published in 1993 of 100 cases of endoscopic sinus surgery (ESS) carried out in our service following a protocol that included sinusitis, nasal polyps, and other endoscopic nasal procedures. Another 100 cases of ESS were analyzed for the present study and compared with the 1993 group. Comparative analysis showed improved results in the second series, with fewer minor complications and no major complications. These findings confirm the general opinion that endoscopic sinus surgery requires an adequate training period before optimal results are obtained.     

An assessment of the anatomical relationship between the pelvic plexus and the rectal wall to determine the indications for its preservation in surgery for rectal cancer

Preservation of the pelvic plexus in surgery for rectal cancer could shorten the distance between the cancer and the lateral resection margin, whereby the curability of the operation may be reduced. To clarify the indications for preserving the pelvic plexus in such surgery, the relationship of the pelvic plexus to the rectum and rectal cancer was investigated anatomically in 12 autopsied specimens and 12 surgical specimens. The rectum and anus were dissected with all the pelvic organs from autopsied cadavers and transverse sections were prepared at 10-mm intervals after fixation. The location of the pelvic plexus was then measured on the tissue preparations, and compared to that of surgical specimens from rectal cancers with concurrent resection of the pelvic plexus. The pelvic plexus was located from 3.3 +/- 1.2 cm above to 2.3 +/- 1.9 cm below the peritoneal reflection in the autopsied specimens. The average distances between the muscularis propria and the pelvic plexus in the autopsied specimens and surgical specimens were 8.3 +/- 3.5 mm and 14.7 +/- 4.5 mm, respectively, showing a significant difference (P < 0.05). Pelvic plexuses were located about 10 mm from the outer margin of rectal muscularis propria. These findings indicate that concurrent resection of the pelvic plexus may be required to secure sufficient surgical clearance in pT3 rectal cancers, especially those invading deeply beyond the muscularis propria (a2).     

Measurements of energy expenditure using isotope-labelled water (2H2(18)O) during an Arctic expedition

An abnormal DNA content has been associated with an unfavorable prognosis in a variety of cancers. In this study, tumor DNA content was measured in patients with gallbladder carcinoma in order to determine whether DNA ploidy pattern was a prognostic indicator. Thirty-six patients who had had a gallbladder carcinoma resected with curative intent were analyzed. Aneuploid tumor (20 cases, 56 per cent) was significantly associated with poorly differentiated adenocarcinoma (p < 0.05), invasion beyond the muscularis propria (p < 0.01), and a high mitotic index (p < 0.0001). A significant advantage in terms of five-year survival was demonstrated in patients with diploid tumors as compared with those with aneuploid tumors (80 per cent versus 24 per cent, respectively, p < 0.005). Aneuploid tumors invading the subserosal layer had a significantly poorer prognosis than diploid tumors with similar depth of invasion (p < 0.05). However, when tumor invasion had extended beyond the serosa, no significant advantage in survival was found between patients with aneuploid and those with diploid tumors. It is concluded that DNA ploidy pattern is a valuable addition to a staging protocol for gallbladder carcinoma.