Clinical and endoscopic features of adult T-cell leukemia/lymphoma with duodenal involvement

We describe three cases of adult T-cell leukemia/lymphoma (ATLL) with duodenal involvement and provide a review of the literature. The first case, a 74-year-old woman with acute subtype of ATLL, had multiple polypoid lesions from the bulbus extending into the descending portion of the duodenum. The second case, a 70-year-old man with lymphoma subtype of ATLL, had a polypoid tumor in the descending portion of the duodenum and multiple protruded lesions in the small and large intestines. The third case, a 67-year-old man with lymphoma subtype of ATLL, had a flat-elevated lesion in the descending portion of the duodenum, as well as a gastric ulcerated lesion. Biopsies from these lesions showed mucosal invasion of ATLL cells in each case. All patients received combination chemotherapy, which was successful in the first and third cases, accompanied by the disappearance of gastroduodenal lesions.     

Inflammatory fibroid polyp of the stomach. Report of three unusual cases.

Three patients with inflammatory fibroid polyp (IFP) of the stomach underwent operation with a diagnosis of submucosal tumor, polyp, and intramural tumor of the stomach, respectively. Resected specimens grossly showed a deep ulcer accompanied by surrounding upheaval, a sausagelike polyp 6.5 cm long, and a pedunculated tumor with a short pedicle, respectively. Histologic examination showed that each lesion was typical of IFP of the stomach, with a mixture of fibroblasts and thin-walled blood vessels, and further by an intense infiltrate of eosinophils. These cases indicate that IFP of the stomach can vary in gross appearance. Practitioners and pathologists must remember that not only a polypoid lesion, but also a pedunculated or even ulcerated lesion, in the gastric antrum may be IFP.     

Splenosis presenting as an ulcerated gastric mass: endoscopic and endoscopic ultrasonographic imaging

A case of an ulcerated gastric wall mass ultimately found to be splenosis is presented in which the index patient had endoscopic and endoscopic ultrasonographic evaluation prior to resection. Although no visual features identified this mass as a splenic implant preoperatively, the lesion appeared to be atypical for leiomyoma, which led to surgical intervention. The role of endoscopic ultrasonography in assessing isolated gastric masses is discussed.     

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.     

Chronic recurrent volvulus of the colonic splenic flexure associated with the eventration of left diaphragm]

The eventration of diaphragm is usually found incidentally on chest X-ray or sometimes presented as acute gastric volvulus. However, colonic volvulus on splenic flexure area complicated by diaphragmatic eventration is extremely rare. A 25 year old man complained of upper abdominal pain for three days. He had a history of brain injury during infant period, and had epilepsy and mental retardation. Plain chest X-ray showed left diaphragmatic eventration and marked dilatation of colon on splenic flexure area which had not been changed for last three years. Barium enema showed bird beak appearance on distal colon near the splenic flexure. Colonoscopic reduction failed. After decompression with rectal and nasogastric tubes, colonic volvulus was relieved. To prevent the recurrence of volvulus, we performed segmental resection of left colon including splenic flexure area and repaired the left diaphragmatic eventration. After the operation, the patient had no further recurrent episode of volvulus although ileus persisted.     

Pneumatosis cystoides intestinalis treated with hyperbaric oxygen therapy: usefulness of an endoscopic ultrasonic catheter probe for diagnosis

A 67-year-old woman was admitted to our hospital with a complaint of abdominal pain. Barium enema examination and colonoscopy showed numerous round polypoid lesions covered with normal mucosa in the area from the ascending colon to the splenic flexure. Endoscopic ultrasound examination with an ultrasonic catheter probe revealed a strong echo with distal acoustic shadowing in the third layer of the diseased colonic wall, which suggested the presence of gas in the submucosa. The gaseous cysts disappeared completely after hyberbaric oxygen therapy at 2 to 3 atmospheres absolute (60 minutes, twice a day) for 30 consecutive days.     

Circumferential Zig-Zag Pattern Suggesting a Superficial Origin of Colorectal Cancer

Abstract: The early stage of colorectal cancer is divided into two morphological types polypoid and superficial. What percentage of advanced cancer is derived from the polypoid or superficial type is a matter of concern. The ratio of superficial variety among of ulcerated cancers was studied using those 2 cm or less in diameter, which often retain mucosal cancer. The existence of horizontal growing mucosal cancer at the marginal area of ulcerated cancer is a hallmark showing the lesion being of superficial origin. Eight (57 %) out of the 14 cases of ulcerated cancer, 2 cm or less, had this finding. This suggests that more than half of smaller colorectal cancers are of superficial origin. A zig-zag pattern (ZZP) was evident in 3 cases of superficial origin. No cases in the nonsuperficial group had the ZZP. The existence of circumferential ZZP during colonoscopic observation indicates that the cancer is of superficial origin.     

Heterotopic pancreatic tissue in the gastric cardia: A case report and literature review

The heterotopic pancreas, which is usually described as an untypical presence of pancreatic tissue without any anatomic or vascular continuity with the pancreas, is relatively rare. Clinical manifestations may include bleeding, inflammation, pain and obstruction; however, in most cases it remains silent and is diagnosed during autopsy. Here, we report a case of ectopic pancreatic lesion located in the gastric cardia. The patient was a 73-year-old woman who had a history(over four months) of chronic epigastric pain accompanied by heartburn. Esophagogastroduodenoscopy revealed inflammatory changes throughout the stomach and lower esophagus, as well as a flat polypoid mass with benign features located in the gastric cardia, approx. 10 mm below the “Z” line, measuring approx. 7 mm in diameter. Endoscopic biopsy forceps were used to remove the lesion. Histological examination of the lesion revealed the presence of heterotopic pancreatic tissue in the gastric mucosa. On the basis of the presented case, we suggest that pancreatic ectopia should be a part of differential diagnosis, not only when dealing with submucosal gastric lesions, but also with those that are small, flat and/or untypically located.     

Gastric leiomyoblastoma with metastases to the liver. A 36-year follow-up study

A patient presented with large intrahepatic tumoral masses 36 yr after the initial detection of multiple liver metastases during a gastrectomy. The operation had been performed to remove four ulcerated polypoid gastric lesions. Reexamination of the previous liver and gastric biopsy specimens revealed a gastric leiomyoblastoma with metastases to the liver. The smooth muscle origin of this tumor was confirmed by positive staining for desmin intermediate filaments. This very long survival is extremely unusual in cases of metastatic gastric leiomyoblastoma.     

A case of colon obstruction developed during the recovery period of acute pancreatitis]

Complications of acute pancreatitis usually occur in pancreas and its contiguous organs. The prevalence of colonic invasion is rare, however, the consequence is fatal, with mortality above 50%. The initial symptoms and onset times are variable and major affected sites are transverse colon and splenic flexure. The spread of inflammatory exudates into the colon is the main mechanism of colonic invasion. If the colonic stenosis develops, it is necessary to manage it surgically. We report a case who arrived at the hospital with watery diarrhea and abdominal distension in the recovery period of acute alcoholic pancreatitis and was diagnosed as a colonic obstruction in the splenic flexure. The patient underwent loop ileostomy instead of the resection of the lesion because of severe adhesion around the splenic flexure. The patient died due to sepsis 5 days after the operation.     

A Case of Spontaneous Regression of Primary Malignant Lymphoma of the Stomach

A 62-year-old female who complained of discomfort in her upper abdominal region and a poor appetite had an endoscopically documented polypoid lesion with a shallow irregular central depression at the lesser curvature of the angulus. A diagnosis of malignant lymphoma was made following a gastric biopsy. A gastric endoscopy performed about 20 days later revealed a marked increase in size with an ulcerated surface the margin of which had an auricle-like shape. These findings were compatible with a diagnosis of malignant lymphoma of the stomach. No medical therapy, such as antineoplastic agents, was given during the follow-up period. A gastric resection was performed 1.5 months after the initial endoscopy. A detailed histopathological examination of the resected gastric specimen revealed a U1-II type ulcer scar but no malignant lymphoma cells. Very few cases of a complete spontaneous regression of a malignant lymphoma of the stomach have been reported either within or outside of Japan though it is well known that lymphomas show rapid morphological changes in some patients who are followed-up without any specific therapy. These rare case reports in the literature are reviewed and discussed together with our present case.     

Ectopic gastric mucosa of the gallbladder: comparison with metaplastic polyp of the gallbladder

We report a case of ectopic gastric mucosa of the gallbladder in a 44-yr-old man. A sessile polypoid lesion 1.0 cm in diameter was seen in the body of the gallbladder, without gallstones. The polypoid lesion consisted of gastric pyloric glands and fundic glands. The surrounding mucosa consisted of ordinary gallbladder epithelium without any metaplastic change. To elucidate the characteristics of this lesion, a clinicopathological comparison was made with metaplastic polyp of the gallbladder.     

Heterotopic gastric mucosa in the gallbladder

We report on a case of heterotopic gastric mucosa in the body of the gallbladder. A 39-year-old man, who was asymptomatic, visited our hospital because of a polypoid lesion in the gallbladder, discovered during a routine health screening. Ultrasonography (US) revealed a broad-based polypoid lesion 1.7 cm in diameter in the body of the gallbladder, which was free of gallstones. The gallbladder mass was faintly enhanced by helical computed tomography. Laparoscopic cholecystectomy was performed because of the possibility of malignancy. The specimen revealed a 1.7 × 1.3 cm polypoid lesion with deep delle in the body, with no gallstones in the gallbladder. Intraoperative frozen examination yielded a diagnosis of hyperplastic polyp of the gallbladder. Histologically, the polypoid lesion consisted of gastric fundic glands located in the whole wall of the gallbladder. The surrounding mucosa consisted of almost normal epithelium without any metaplastic changes. Postoperative technetium 99m-pertechnetate scintigraphy demonstrated no evidence of gastric heterotopia elsewhere in the body. We also review 18 other reports of heterotopic gastric mucosa in the gallbladder in the Japanese medical literature. Received: June 23, 1999 / Accepted: October 22, 1999     

A Huge Polypoid Type Early Gastric Neuroendocrine Cell Carcinoma

Abstract: We report a case of a huge polypoid-type early gastric neuroendocrine cell carcinoma. Upper gastrointestinal endoscopy in a 77-year-old man revealed a gastric polyp on the anterior wall of the corpus. Endoscopically biopsied material from the polyp suggested that the lesion was malignant; specifically a poorly and moderately differentiated tubular adenocarcinoma or adenocarcinoma with neuroendocrine differentiation. Endoscopically the lesion was a huge polypoid type with a broad stalk approximately 40 mm in diameter, and its surface was tabulated with a white coat and erosion. The patient underwent total gastrectomy. The resected specimen histopathologically showed a polypoid mass with medullary carcinoma and indicated endocrine cell differentiation. Immunohis-tochemical findings supported the diagnosis of endocrine cell carcinoma. This case was an early and polypoid-type gastric endocrine cell carcinoma. Since examples of such cases are rare in the literature, we report this case in brief.     

A new in vivo staining method, cresyl violet staining, for fiberoptic magnified observation of carcinoma of the gastric mucosa

A polypoid gastric mucosal lesion with a flat portion was observed by a fiberoptic magnifying endoscope with a new in vivo staining method, cresyl violet staining. The fine surface structure of this lesion showed a characteristic "ruined sulciform pattern" suggesting papillary carcinoma histologically. Successful application of the findings of dissecting microscopy to clinical magnifying endoscopy by means of this new staining material indicates the possibility of diagnosing gastric mucosal carcinomas with much more accuracy.     

A novel approach for robotic mobilization of the splenic flexure

Background

The techniques of robotic splenic flexure mobilization in the colorectal surgery setting are not well defined and have been challenging due to limited range of motion of the second-generation robotic platform in multiple quadrants.

Methods

This report describes a novel technique for robotic splenic flexure mobilization with medial-to-lateral approach without a need for robotic cart repositioning during left-sided colon and rectal surgery. The dissection is started with ligation of the inferior mesenteric artery and vein. Unique in this approach, entering the lesser sac is accomplished by extension of the dissection cranially by lifting up the mesocolon from the anterior surface of the pancreatic body toward the stomach.

Results

This technique presented in the video allows the mobilization of the splenic flexure without excessive tractions and avoidance of potential splenic injuries.

Conclusions

The described novel approach demonstrates total robotic splenic flexure takedown without excessive traction, with improved visualization, and reduction of potential risk of splenic injury. This approach provides totally robotic mobilization of the splenic flexure at single docking without changing the patient’s position.

     

A Case of Extensive Gastrointestinal Involvement of Malignant Lymphoma Associated with Early Gastric Carcinoma

Abstract: Described is a 59 year old Japanese man With malignant lymphoma involving the stomach, duodenum, terminal ileum, colon and rectum, who developed early gastric carcinoma. Repeated gastroduodenoscopy revealed various appearances of the gastrointestinal involvement in malignant lymphoma, such as giant folds, polypoid lesions, and ulcerations, in addition to a depressed lesion of early gastric carcinoma. Colonoscopy also showed multiple polypoid lesions throughout the large bowel. Though the gastrointestinal involvement in malignant lymphoma is not rare, diffuse multiple polypoid lesions in the entire large bowel as seen in our case have rarely been endoscopically described. The coexistance of malignant lymphoma and gastric carcinoma in our case might be only a coincidence, though some reports of an increasing incidence of second tumors in patients with malignant lymphoma have been published. Further consideration will be needed as to the relationship between malignant lymphoma and the occurence of a second malignancy.     

多层螺旋CT门静脉血管成像在胰源性门脉高压症诊断中的应用

目的 研究多层螺旋CT门静脉血管成像在胰源性门静脉高压患者诊断中的应用.方法 应用16排多层螺旋CT门静脉血管成像,对47例临床怀疑胰腺体尾部病变的患者的门静脉系统形态改变与126例肝源性门脉高压患者和47例正常对照组进行形态学对比观察,并测量胃冠状静脉、门静脉、脾静脉、肠系膜上静脉内径、门静脉期肝实质和门静脉主干CT值,对比肝脏、脾脏体积.结果 在47例胰腺体尾部病变中发现有脾静脉狭窄、闭塞者38例,其中胰腺肿瘤患者27例(71.1%),急慢性胰腺炎患者11例(28.9%).38例胰源性门脉高压患者中,发现食管静脉曲张5例(13.2%),胃底静脉曲张25例(65.8%),胃体静脉曲张22例(57.9%),胃短-胃后静脉显示26例(68.4%),胃冠状静脉显示26例(68.4%),发现胃网膜静脉曲张24例(63.2%),肠系膜静脉曲张1例.脾静脉闭塞14例(36.8%),脾静脉狭窄23例(63.2%).结论 胰源性门脉高压在影像学上表现为脾静脉栓塞,脾脏增大,脾门处大量曲张静脉,胃后-胃短静脉及胃网膜静脉增粗迂曲,胃底和胃体静脉曲张,较少合并食管静脉曲张,肝脏形态大小亦无异常.多层螺旋CT门静脉血管成像检查可为胰源性门脉高压患者提供血管形态、病因诊断等多方面有价值信息,为临床诊断和治疗提供客观的影像学依据.     

Early gastric cancer. Clinicopathologic study

The incidence and clinicopathologic features of early gastric cancer encountered among surgical specimens from gastric resections for carcinoma in a recent three-year period, 1977 to 1979, at the Mallory Institute of Pathology were studied and compared with those of a pre-endoscopic period 10 years earlier, 1967 to 1969. It was found that early gastric cancer now comprises a greatly increased proportion of lesions leading to gastric resection, mainly as a result of endoscopy and biopsy of gastric ulcers of benign appearance. In the recent period, there were six early gastric cancers in a total of 22 gastric resection specimens compared with one in 27 gastric resections performed for carcinoma in the pre-endoscopy period. Five of the six patients in the recent period are alive without evidence of disease four to five years following surgical resection. The single patient in the earlier period died postoperatively. Applying the classification of the Japanese Endoscopic Society, there were three depressed or ulcerated lesions (type IIc or III), three elevated or polypoid lesions (type I or IIa), and a single flat lesion (type IIb). All three ulcerated lesions were interpreted as benign peptic ulcers on conventional upper gastrointestinal studies. Findings on endoscopic biopsy were positive in all cases (six of six). Although not encountered frequently in the United States, early gastric cancer, nonetheless, appears to be indistinguishable from the disease as it is described in Japan in terms of its pathologic morphology, growth patterns, coexistent or related lesions of the stomach, and curability by surgical resection. If early gastric cancer is to be recognized more frequently, knowledge of the disease and a high index of suspicion on the part of physicians are essential.     

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.