Endoscopic features ot Lipohyperplasia m the Large Intestine

Abstract: We reviewed 18 cases of large intestinal lipohyperplasia (LPH) to clarify the clinical and endoscopic features of this lesion. LPH was found in the ileocecal valve in 16 patients (88.9%). On colonoscopic examination, LPH showed a submucosal tumor-like lesion with a smooth surface. The color was slightly yellowish or the same as that of the surrounding mucosa and the cushion sign was positive in all cases. According to endoscopic features, LPH in the ileocecal valve was classified into three types. The diffuse type showed a symmetrically swollen ileocecal valve. In contrast, the localized type displayed polypoid protrusion from the ileocecal valve. The intermediate type showed partial protrusion with asymmetrical swelling of the valve. Four patients had the diffuse type, three the intermediate type and nine the localized type. The upper lip of the ileocecal valve was more frequently involved in the localized and intermediate types. On rare occasion, LPH was recognized as hemispherical mucosal elevation in the ascending colon and rectum. Histological examination revealed infiltration of mature adipose tissue in the submucosal layer. It was noted that five of the 18 patients had associated malignancies of the gastrointestinal tract. As to therapy, six patients received endoscopic polypectomy and one underwent right hemicolectomy for associated advanced cancer in the cecum. In summary, this review shows that LPH is recognized primarily as focal or diffuse swelling of the ileocecal valve. On colonoscopic examination the possibility of such a lesion in the ileocecal valve should be kept in mind.     

Metastatic Hepatocellular Carcinoma of the Stomach Presenting as a Bleeding Polypoid Lesion

Abstract: This is a report of a case of hepatocellular carcinoma (HCC) with gastric metastasis and a review of 20 cases of gastric metastasis of HCC in Japan. A 67-year-old man was diagnosed as having HCC in May 1991, and underwent transcatheter arterial embolization in June 1991 and February 1992. He came to us with hematemesis in November 1992. An endoscopic examination revealed a semipedun-culated polypoid lesion with bleeding spots at the fornix of the stomach. The polypoid lesion was resected by endoscopic snare polypectomy to prevent rebleeding and in order to make a definitive diagnosis. Histological examination of the resected specimen, 15X10X6 mm in size, revealed well-differentiated HCC with bile production.     

Unusual metastasis of hepatocellular carcinoma to the esophagus

This report describes a case of metastatic hepatocellular carcinoma (HCC) presenting as a polypoid mass in the lower esophagus. The patient was a 63-year-old man with HCC. An endoscopic examination revealed a pedunculated polypoid mass, about 3 cm in diameter, at the lower part of the esophagus. The biopsy specimen obtained from the tumor revealed that the mass consisted of a pseudoglandular arrangement of tumor cells, and the tumor was diagnosed as metastatic HCC. There were no symptoms due to esophageal tumor. He died of progressive hepatic failure. Cases of premortem-diagnosed esophageal metastasis from HCC are extremely rare.     

Hepatocellular carcinoma with direct invasion to the stomach

A 71-year-old man was admitted to our hospital with abdominal pain. Hepatocellular carcinoma (HCC) had been diagnosed 2 years earlier and he had undergone 7 courses of intra-hepato-arterial chemotherapy (IHAC). We performed gastrointestinal fiberscopy and identified a massive protrusion on the lesser curvature. Abdominal contrast-enhanced computed tomography revealed multiple hepatic masses and an extrahepatic enlarged mass with invasion to the pancreas and stomach. A specimen for endoscopic biopsy revealed adenocarcinoma that stained positive for alpha-fetoprotein. Gastrointestinal bleeding resulting from direct invasion of HCC is unusual.     

A Case Report of Crohn's Disease Confined to the Appendix

Abstract: A 36-year-old man was admitted to our hospital with complaints of right lower abdominal pain and fever. Radiological and endoscopic examination revealed a polypoid lesion composed of several nodules in the orifice of the appendix in addition to irregular ulcers among the nodules. Macroscopic examination of the ileocolectomized specimen also revealed a polypoid lesion in the orifice of the appendix and a thickened appendiceal wall. The resected appendix and the polypoid lesion in the cecum exhibited Crohn's disease as characterized by transmural inflammation with non-caseating epithelioid granulomas and fissuring ulcers. This patient was diagnosed as a rare case of Crohn's disease confined to the appendix manifesting as a polypoid lesion in the orifice of the appendix.     

Endoscopic Diagnosis of a Giant Esophageal Leiomyosarcoma

A giant polypoid lesion of the cervical esophagus was discovered on barium swallow in a patient with minimal dysphagia. Endoscopy revealed a whitish, polypoid intraluminal mass with superficial ulcerations and mucosal biopsies, necrotic epithelium plus spindle cells consistent with leiomyoma. At exploration, a leiomyosarcoma with microvascular invasion was excised. The clinical features and value of endoscopic biopsies are reviewed for this and other cases reported in the literature.     

Endoscopic ultrasound-guided biliary drainage:Bilateral systems drainage via left duct approach

Endoscopic ultrasound(EUS)-guided biliary drainage is accepted as a less invasive,alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hilar obstruction undergo EUSguided hepaticogastrostomy. The authors present the case of a 77-year-old man with advanced hilar cholangiocarcinoma who had undergone a rouxen-Y hepaticojejunostomy several months prior. He developed progressive jaundice and a low-grade fever that persisted for one week. The enteroscopic-assisted endoscopic retrograde cholangiopancreatography failed,thus the patient was scheduled for EUS-guided biliary drainage. In order to obtain adequate drainage,both intrahepatic systems were drained. This report describes the technique used for bilateral drainage via a transgastric approach. Currently,only a few different techniques for EUS-guided right system drainage have been reported in the literature. This case demonstrates that bilateral EUS-guided biliary drainage is feasible and effective in patients with hilar cholangiocarcinoma,and thus can be used as an alternative to percutaneous biliary drainage.     

Varioliform mucosal polypoid lesions in intestinal tract in a patient with adult T-cell leukemia

We describe a case of adult T-cell leukemia (ATL) with intestinal infiltration. In the early clinical stage, the endoscopic findings for the intestine were similar to those of amebic enterocolitis, i.e., varioliform mucosal polypoid lesions, and amebic cyst was detected with stool examination. Although no specific pathological factor could be identified on biopsy, the patient was treated for amebiasis as a diagnostic therapy. the findings of varioliform mucosal polypoid lesions were detected in the duodenum on endoscopic examination, but the lesions eventually disappeared during the treatment for amebiasis. We then suspected lymphoma partially masked by, the amebiasis. Immunological staining of a specimen of the colonic mucosa revealed T cell invasion and Southern blotting demonstrated adult T-cell leukemia provirus invasion. Thus, ATL cell infiltration of the intestinal tract was confirmed It is suggested that systemic disease should also be considered when varioliform mucosal polypoid lesions are found on colonoscopic examination.     

Photodynamic therapy prolongs metal stent patency in patients with unresectable hilar cholangiocarcinoma

AIM:To evaluate the effect of photodynamic therapy (PDT) on metal stent patency in patients with unresectable hilar cholangiocarcinoma (CC). METHODS:This was a retrospective analysis of patients with hilar CC referred to our institution from December, 1999 to January, 2011. Out of 232 patients, thirty-three patients with unresectable hilar CC were treated. Eighteen patients in the PDT group were treated with uncovered metal stents after one session of PDT. Fifteen patients in the control group were treated with metal stents alone. Porfimer sodium (2 mg/kg) was administered intravenously to PDT patients. Fortyeight hours later, PDT was administered using a diffusing fiber that was advanced across the tumor by either endoscopic retrograde cholangiopancreatography or percutaneous cholangiography. After performance of PDT, uncovered metal stents were inserted to ensure adequate decompression and bile drainage. Patient survival rates and cumulative stent patency were calculated using Kaplan-Meier analysis with the log-rank test. RESULTS:The PDT and control patients were comparable with respect to age, gender, health status, pretreatment bilirubin, and hilar CC stage. When compared to control, the PDT group was associated with significantly prolonged stent patency (median 244 ± 66 and 177 ± 45 d, respectively, P = 0.002) and longer patient survival (median 356 ± 213 and 230 ± 73 d, respectively, P = 0.006). Early complication rates were similar between the groups (PDT group 17%, control group 13%) and all patients were treated conservatively. Stent malfunctions occurred in 14 PDT patients (78%) and 12 control patients (80%). Of these 26 patients, twenty-two were treated endoscopically and four were treated with external drainage. CONCLUSION:Metal stenting after one session of PDT may be safe with acceptable complication rates. The PDT group was associated with a significantly longer stent patency than the control group in patients with unresectable hilar CC.     

Mallory-Weiss tear during gastric endoscopic submucosal dissection

A 78-year-old woman was referred to our department for treatment of an early gastric cancer. Esophagogastroduodenoscopy (EGD) demonstrated a flat elevated lesion and a polypoid lesion on the greater curvature of the antrum. Histological analysis of, endoscopic biopsy samples taken from these lesions revealed an adenocarcinoma and a hyperplastic polyp, respectively. ESD was conducted for removal of the lesions. Carbon dioxide (CO2) in- stead of room air was used for insufflation, and the patient was adequately sedated without struggling or vomiting during the treatment. No significant bleeding from the lesion was observed during ESD, but fresh blood was identified endoscopically. Surprisingly, a Mallory- Weiss tear with active bleeding was detected on the lesser curvature of the gastric corpus. A total of eight hemoclips were applied for hemostasis. Both lesions were completely removed en bloc, and no bleeding or perforation developed after ESD. Histologically, the first lesion was apapillary carcinoma limited to the mucosal layer and without lymphovascular invasion or involvement of the surgical margins, while the second lesion was a benign hyperplastic polyp.     

A case of lung cancer with cyst formation]

A 70-year-old man was admitted with a nodule adjacent to a cystic lesion in the right lower lung field. Diagnosis of lung cancer was made by transbronchial biopsy. A series of chest radiographs revealed that a cystic lesion had presented 8 years before, and that a nodule appeared on the hilar side of the cyst 5 years later. The cyst may have been formed by the check-valve mechanism due to the lung cancer.     

Gastrointestinal mantle cell lymphoma with isolated mass and multiple lymphomatous polyposis: report of two cases

We herein report two patients with mantle cell lymphoma (MCL), who had isolated mass and multiple lymphomatous polyposis (MLP) in the gastrointestinal tract. In case 1, esophagogastroduodenoscopy revealed a protruding mass in the duodenum and double-balloon endoscopy disclosed numerous polypoid lesions in the ileum. Case 2 had polyposis in the duodenum and a large mass-forming lesion in the ascending colon. Based on the histologic and immunohistochemical findings of the biopsy specimens, the diagnosis of MCL was made in both patients. A combination of isolated mass and MLP is considered as characteristic endoscopic findings of intestinal lesions of MCL.     

A Case of Poorly Differentiated Early Adenocarcinoma of the Stomach Forming a Protruded Type Lesion

Abstract: A case of poorly differentiated adenocarcinoma (undifferentiated type by Nakamura, diffuse type by Lauren) of the stomach infiltrating the submucosa and forming a protruded type lesion is reported. A 60-year-old man underwent endoscopic examination, which revealed a protruded type lesion with a nodular configuration and shallow ulceration accompanied by slough along the greater curvature of the upper gastric body, which was proved to be poorly differentiated adenocarcinoma by endoscopic biopsy. The patient underwent radical surgery, consisting of total gastrectomy with pancreato-splenectomy. Macroscopic observation of the resected specimen revealed a protruded type lesion, measuring 30 mm in diameter, in the fundus along the greater curvature. The surface of the lesion had an irregular and nodular configuration with erythema and superficial erosions. Although, in the setting of early gastric cancer, poorly differentiated adenocarcinomas are usually macroscopically depressed or ulcerated type, this case presented a protruded type lesion (polypoid type). We report this unusual case because of its extremely important implications in the discussion of gastric cancer therapy.     

A case of endobronchial sarcoidosis presenting as a polypoid lesion]

A 51-year-old woman was admitted to our hospital because of deterioration of abnormal chest shadows. Though the shadows had been pointed out at another hospital about two years before, no evaluation had been made at that time. A chest CT scan showed multiple small nodular shadows and thickening of the bronchovascular bundles bilaterally, and marked swollen lymph nodes in the axilla, mediastinum, and bilateral the hili of both lungs. Bronchoscopic evaluation revealed bronchial mucosal hypervascularity and a polypoid lesion at the orifice of the right B8b. The transbronchial biopsy specimen of the polypoid lesion showed non-caseating epithelioid cell granulomas in the bronchial mucosa. The bronchoalveolar lavage revealed a increase in the total number of cells including high levels of lymphocytes. Therefore, a diagnosis of sarcoidosis was made. This is a very rare case of endobronchial sarcoidosis. However, biopsy specimens of normal mucosa in sarcoidosis often show a microscopic sarcoid process, so a diagnosis of endobronchial sarcoidosis in this case should be given prudently.     

Extranodal non-Hodgkin's lymphoma associated with systemic bone metastasis and secondary myelofibrosis

A 68-year-old woman was admitted in March 1997 because of lumbago, fever, vomiting, and general malaise. Laboratory data disclosed anemia and severe hypercalcemia (7.7 mEq/l). Multiple osteolytic lesions were detected in the patient's vertebra, pelvis, and bilateral tibia by x-ray films and 99mTc bone scintigrams. Bone marrow aspiration sample was not obtained due to dry tap. Marked myelofibrosis and proliferation of lymphoid cells were revealed by a bone marrow biopsy specimen. Immunohistochemical analysis showed that cells in the biopsy specimen were positive for L-26 and LCA, but not for UCHL-1. Gastrointestinal endoscopic examination found multiple polypoid lesions in the stomach; biopsy specimens of the lesion tissue disclosed invasion by B lymphoid cells. A diagnosis of diffuse large B cell lymphoma was thus made. THP-COP chemotherapy was performed, but only minimal response was obtained. Lymphoma cells subsequently invaded the brain stem, and the patient eventually died of respiratory failure.     

Early repeat endoscopic retrograde cholangiopancreatography: Predictive factors and interventions required

Background/aims: Early repeat endoscopic retrograde cholangiopancreatography may be required due to various conditions in patients who underwent planned endoscopic retrograde cholangiopancreatography. We aimed to assess the factors leading to early repeat endoscopic retrograde cholangiopancreatography and to determine the patients who need closer follow-up. Materials and Methods: A total of 691 patients with a mean age of 60.3±16.4 years who had naive papilla on endoscopic retrograde cholangiopancreatography were involved in the study. The patients who required repeat endoscopic retrograde cholangiopancreatography were identified. Presentations, predictive factors, treatment modalities, and outcomes of the patients were investigated. Results: Early repeat endoscopic retrograde cholangiopancreatography was needed in 19 (2.7%) patients. The most common presentation was cholangitis in 10 (52.6%) and unresolved jaundice in 4 (21.1%). Multivariate analysis identified biliary stricture (p=0.024), stricture at the hilus (p=0.005) and unilateral drainage in the presence of hilar stricture (p=0.017) as the independent risk factors for early repeat endoscopic retrograde cholangiopancreatography. Stent migration or dysfunction was the most common underlying cause. Therapeutic interventions were nasobiliary drainage in 13, stent exchange in 4 and stone removal in 2. Additionally, percutaneous drainage in 4 patients, drainage of abscess in 2 patients and percutaneous drainage of gallbladder in 1 patient were performed. Three patients died due to their underlying illness. Conclusions: Unilateral stenting especially in hilar strictures is a predictive factor for early repeat endoscopic retrograde cholangiopancreatography with high mortality. These patients should be under close follow-up.     

A case report of small cell lung cancer with extrahepatic biliary obstruction and intramedullary spinal cord metastasis

A 62-year-old man was admitted to our hospital because of high serum amylase and neck swelling. His chest radiography revealed a mass lesion in the right upper lung. Open lung biopsy specimen established the pathological diagnosis as intermediate type small cell lung cancer. In his clinical course, obstructive jaundice recurred several times with response to combination chemotherapy. The findings of abdominal echogram, computed tomography and endoscopic retrograde cholangiopancreatography suggested that the jaundice was caused by extrahepatic biliary obstruction with parapancreatic lymph node metastasis. He died of spinal bleeding which spread from the medulla oblongata to the thoracic spinal cord. Bleeding was caused by intramedullary spinal cord metastasis. Both extrahepatic biliary obstruction and intramedullary spinal cord metastasis are rare and their symptoms were more prominent than those of the pulmonary lesion.     

Long-term survival with carcinoma arising from a congenital choledochal cyst

We report a case of 11-year survival with carcinoma arising from a congenital choledochal cyst. A 34-year-old Japanese woman was admitted due to epigastric discomfort. Ultrasonography revealed a choledochal cyst involving a polypoid tumor. Endoscopic retrograde cholangiopancreatography revealed pancreaticobiliary maljunction in which the main pancreatic duct joined the dilated common bile duct 2 cm above the papilla of Vater. A choledochal cyst containing a polypoid tumor was resected with the regional lymph nodes. Grossly, a 2×2-cm papillary tumor was noted in the posterior wall of the choledochal cyst. Microscopically, the tumor was well-differentiated tubular adenocarcinoma invading the mucosa and fibromuscular layer. Neither anticancer chemotherapy nor radiotherapy was performed. The patient recovered uneventfully after the operation and has been well for 11 years without evidence of recurrent cancer. The good results in this patient may have been due to the early stage of the cancer.     

An adult case of cervico-mediastinal lymph nodes tuberculosis followed by the development of pulmonary lesions during the treatment with antituberculous drugs

A 27-year-old man was admitted to our hospital due to a painful mass in the right neck and fever. Cervical and superior mediastinal computed tomography showed an enlargement of right supraclavicular lymph node and multiple swollen mediastinal lymph nodes, including low-density areas and contrast medium-enhanced septa and margins. Smears of the pus obtained from right supraclavicular lymph node showed acidfast bacilli identified as Mycobacterium tuberculosis by PCR method. He was treated with antituberculous drugs with INH, RFP, EB, and PZA. PZA was given for initial two months. Six months later, productive cough developed and chest X-ray films showed infiltrative shadow in the right upper lung field. One month after the onset of cough, bronchoscopy revealed a polypoid lesion with a white coating in the right main bronchus. Microscopic examination of the specimen obtained by transbrochial biopsy revealed many epithelioid cell granulomas, consistent with tuberculosis. From these findings, pulmonary lesion was suggested to be due to invasion of the mediastinal lymph node into the bronchus. After one year of antituberculous chemotherapy, the swelling of the cervical-mediastinal lymph nodes was reduced and the abnormal chest X-ray shadows disappeared.