A Collision Tumor Composed of Adenocarcinoma and Malignant Lymphoma in the Remnant Stomach After Pancreatoduodenectomy: Report of a Case

The occurrence of a collision tumor in the stomach, consisting of adenocarcinoma and malignant lymphoma, is extremely rare. We report herein the case of a patient who had undergone a pancreatoduodenectomy for bile duct cancer 5 year earlier, in whom an ulcerating tumor of the remnant stomach developed and grew rapidly within 5 months. Surgical exploration revealed a tumor in the remnant stomach, multiple liver metastases, and multiple lymph node metastases. Total resection of the remnant stomach was performed, and pathological examination revealed a collision tumor consisting of adenocarcinoma and malignant lymphoma. The patient died of liver metastases and lymph node metastases 7 months after his second operation. The coexistence of both adenocarcinoma and malignant lymphoma of the remnant stomach and the etiology of this unusual combination, never previously reported, is discussed. Received: December 20, 1999 / Accepted: November 20, 2000     

Lymphatic flow of the remnant stomach

Aiming at establishing an appropriate lymph node dissection for carcinoma of the remnant stomach and of the lower esophageal carcinoma in the status post-gastrectomy, lymphatic flow was investigated clinically as well as experimentally. Nineteen cases of carcinoma of the remnant stomach and 8 cases of esophageal carcinoma after partial gastrectomy were studied. Lymph node metastasis of the remnant stomach carcinoma were more frequently seen at perigastrium, splenic hilum, and along splenic artery. Those further extended to para-aortic and diaphragmatic nodes. Three cases of lower esophageal carcinoma after gastrectomy had massive nodal involvement at perigastrium, as well as intra-thoracic lymph nodes. Experimentally 5-Fu emulsion was injected submucosally under endoscope in 25 dogs and subserosally in 6 rabbits. 5-Fu contents in lymph nodes were measured 30 minutes after injection. The most prominent difference in lymphatic flow from the remnant stomach was increase in ascending flow into intrathoracic lymph nodes through para-aorta. This increment was seen irrespective of Billroth I or II anastomosis. On the contrary, descending lymphatic flow from the lower esophagus into the intra-abdominal lymph nodes was not disturbed by gastrectomy. Cardiac lymph node dissection in rabbits accelerated ascending flow. Those results would indicate the necessity of complete block of ascending flow in cases of the remnant stomach carcinoma and of intra-abdominal lymph node dissection in those of the lower esophageal carcinoma after gastrectomy.     

Adenosquamous Carcinoma of the Sigmoid Colon: Report of a Case

A case of adenosquamous carcinoma of the sigmoid colon is presented herein. An 85-year-old woman without any symptoms was admitted to our hospital to undergo detailed examinations of the colon and rectum. Colonoscopy showed a huge type 2 tumor in the sigmoid colon. A typical sigmoid colectomy and lymph node dissection were performed. A histopathological investigation demonstrated adenosquamous carcinoma invading the subserosa. Although an absolute curative resection was performed, she died of metastatic lung carcinoma 14 months after the operation. Received: October 18, 2000 / Accepted: May 15, 2001     

Adenosquamous carcinoma arising in Barrett''s esophagus

Primary adenocarcinoma of the esophagus is rare in Japan and, in most cases, arises from Barrett's esophagus epithelium. A 72-year-old man reporting heartburn and dysphagia and preoperatively diagnosed with adenosquamous carcinoma arising from Barrett's esophagus underwent thoracic esophagectomy and lymph node dissection in curative resection. Pathological diagnosis of the resected specimen showed adenosquamous carcinoma (coexistent adenocarcinoma and squamous cell carcinoma) invasive to the submucosal layer; metastasis was found in regional lymph nodes. Pathological staging was pT1bN1M0, stage II. Unfortunately, the man died of liver and lung metastasis 17 months postoperatively. To our knowledge, this rare case is only the fifth reported in the English literature on adenosquamous carcinoma arising from Barrett's esophagus.     

胆囊腺鳞癌和鳞癌与胆囊腺癌的临床对比研究

目的 探讨胆囊腺鳞癌和鳞癌的临床特点.方法 回顾性分析112例胆囊癌患者的临床资料,将其中11例胆囊腺鳞癌和鳞癌的临床特点和预后与同期收治的101例胆囊腺癌进行比较.结果 腺鳞癌/鳞癌组与腺癌组的肿瘤浸润分期为13或T4的比例分别为100%和53%,两组的差异有统计学意义(X2=7.013,P=0.008).腺鳞癌/鳞癌与进展期腺癌(T3或T4期)的远处转移发生率分别为0和35%,差异有统计学意义(X2=3.900,P=0.048),两组的淋巴结转移率为82%和87%(X2=0.000,P=1.000).腺鳞癌/鳞癌组和进展期的腺癌组的胃肠道侵犯发生率分别为45%和15%,差异无统计学意义(X2=3.618,P=0.054).两组的中位生存期分别为5个月和4个月,生存差异无统计学意义(X2=0.359,P=0.549).结论 胆囊腺鳞癌和鳞癌的局部侵袭性强,而远处转移率低.淋巴结转移情况与腺癌相似.     

Proximal subtotal gastrectomy for the treatment of carcinoma of the upper third of the stomach: Its indications based on lymph node metastasis and perigastric lymphatic flow

To clarify the indications for a proximal subtotal gastrectomy in the treatment of carcinoma in the upper third of the stomach based on lymph node metastases, 1055 patients in whom either a D₂ or greater lymph node removal was performed were reviewed. In the patients in which the lesion was confined to the upper stomach and did not invade beyond the muscularis propria of the stomach wall, no metastases to either the lymph nodes above and below the pylorus or the lymph nodes along the greater curvature were observed. A lymphatic flow study revealed a minimal flow to these nodes from the upper stomach in patients without lymph node metastasis, but in cases with lymph node metastases the lymphatic flow changed. The indications for a proximal subtotal gastrectomy for a carcinoma of upper third of the stomach therefore must fulfill the following two conditions: (1) The deepest layer of cancerous invasion does not extend beyond the muscularis propria of the stomach wall, and (2) No macroscopic evidence of lymph node metastasis can be detected during surgery.     

Adenosquamous carcinoma arising in Barrett's esophagus

Primary adenocarcinoma of the esophagus is rare in Japan and, in most cases, arises from Barrett's esophagus epithelium. A 72-year-old man reporting heartburn and dysphagia and preoperatively diagnosed with adenosquamous carcinoma arising from Barrett's esophagus underwent thoracic esophagectomy and lymph node dissection in curative resection. Pathological diagnosis of the resected specimen showed adenosquamous carcinoma (coexistent adenocarcinoma and squamous cell carcinoma) invasive to the submucosal layer; metastasis was found in regional lymph nodes. Pathological staging was pT1bN1M0, stage II. Unfortunately, the man died of liver and lung metastasis 17 months postoperatively. To our knowledge, this rare case is only the fifth reported in the English literature on adenosquamous carcinoma arising from Barrett's esophagus.     

Primary adenosquamous carcinoma of the liver: case report

We describe a case of adenosquamous carcinoma of the liver, including treatment for the recurrence. A 67-year-old man with prolonged high fever was diagnosed with a mass lesion in the left lobe of the liver seen by imaging studies. That mass lesion was histologically diagnosed as cholangiocarcinoma by needle biopsy. Left hepatic lobectomy was performed, and a tumor was found that measured 8.0 × 7.0 × 6.0 cm. It was a yellowish white solid mass without macroscopic invasion of the intrahepatic bile duct. Histological examination of the resected specimen revealed both adenocarcinoma and squamous cell carcinoma. The postoperative course was uneventful, but abdominal computed tomography 3 months after operation revealed seven masses in the remnant liver. We diagnosed recurrence of the tumor, and intrahepatic arterial infusion of cisplatin and 5-fluorouracil was begun. A partial remission resulted. Progression-free survival after chemotherapy lasted 2 months. However, the tumor markers and remnant tumor size increased gradually 9 months after the operation, and he died 14 months after surgery. We also review 41 cases of adenosquamous carcinoma of the liver reported in the Japanese and English language literature, including the present case. Received: May 6, 2002 / Accepted: July 5, 2002 Offprint requests to: E. Suzuki     

原发性胃腺鳞癌和胃鳞癌的临床病理特点分析

目的 探讨原发性胃腺鳞癌和胃鳞癌的临床病理特点.方法 回顾性分析12例原发性胃腺鳞癌和胃鳞癌的临床病理资料,对腺鳞癌进行CK17及CK18免疫组化染色.结果 本组原发性胃腺鳞癌和胃鳞癌病例占同期全部外科治疗胃癌病例的0.28%,其中原发性胃腺鳞癌10例,胃鳞癌2例;男10例,女2例;平均年龄65岁.主要临床症状有上腹隐痛或胀痛不适,呕血及黑便.术前胃镜活检确诊率为33%(4/12).肿瘤直径≤5 cm 3例,>5 cm 9例.根治性切除8例,姑息性切除4例.TNM分期Ⅰ期1例,Ⅲ期5例,Ⅳ期6例.本组术后2年内死于肿瘤转移复发10例,其中4例腺鳞癌姑息切除患者存活少于半年,且鳞癌和腺癌所占瘤体成分均在30%以上.术后3年死于其他疾病1例,术后5个月存活1例.结论 原发性胃腺鳞癌和胃鳞癌在临床上少见,具有独特的临床病理特点,腺鳞癌预后较差可能与其兼有腺癌和鳞癌两种恶性生物学行为有关.     

云南省单中心279例甲状腺乳头状癌再手术原因分析

目的:探讨甲状腺乳头状癌(PTC)再手术患者复发原因及影响因素。方法:回顾性分析2007年1月—2016年6月间昆明医科大学第一附属医院甲状腺疾病诊治中心279例行再手术的PTC患者临床资料。结果:279例患者中,残余甲状腺复发156例(55.9%),淋巴结转移215例(77.1%),后者包括中央区135例(48.4%)和侧方151例(54.1%)。统计分析显示,女性、≥45岁是残余甲状腺复发的独立危险因素(均P0.05);未行中央区淋巴结清扫(CND)、初次手术行于县级医院是中央区淋巴结转移的独立危险因素(均P0.05);男性、初次术式为甲状腺全切或近全切(TT/NTT)、CND为侧方淋巴结转移的独立危险因素(均P0.05)。初次手术后中位复发时间专业甲状腺中心为33个月,主要为侧方(26.8%)和中央区淋巴结转移(42.9%);省级医院为24个月,主要为中央区区淋巴结转移(32.8%)和残余甲状腺复发(29.9%);地州级24个月、县级12个月,主要原因为残余甲状腺复发(36.7%,45.9%)。再次手术后,158例获随访10~123个月,死亡1例(0.4%)、永久性声音嘶哑7例(4.4%)、永久性低钙血症19例(12.0%)、131I治疗失分化9例(5.7%),复发22例(13.9%)。结论:非专科手术和不规范的术式导致PTC术后甲状腺和淋巴结转移率增高从而再手术的主要原因;选择单侧腺叶切除或TT/NTT+病灶同侧/双侧CND和/或加行侧方淋巴结清扫可有效降低复发率。再次手术患者永久性手术并发症和失分化发生率均较高,故应在初始治疗中采取规范化治疗方案,减少复发风险。     

A clinical study of small advanced lung cancer with metastasis to mediastinal lymph node

From January 1981 through December 1989, 15 patients with small advanced lung cancer were treated surgically at the Tenri Hospital. In these cases, the diameter of peripheral lung cancer did not exceed 3.0 cm (T1) and mediastinal lymph nodes were proved to be N2 postoperatively by lymph node dissection or sampling. The histological types were as follows: 8 adenocarcinoma, 4 large cell carcinoma, 1 squamous cell carcinoma, 1 small cell carcinoma, and 1 adenosquamous carcinoma. All but one patient were received postoperative chemotherapy and/or radiotherapy. The survival rate was 44.5% at 3 years, and median survival time was 36 months. The mediastinal lymph node metastasis with small peripheral lung cancer (T1N2) was ominous, and it should be said that complete mediastinal lymph node dissection and adjuvant therapy were indispensable to small advanced adenocarcinoma of lung.     

Breast Cancer with Nephrotic Syndrome: Report of Two Cases

We report two cases of women found to have breast cancers within a few months of being diagnosed with nephrotic syndrome. Case 1 was a 53-year-old Japanese woman in whom breast cancer was diagnosed 14 months after the onset of nephrotic syndrome. The histological diagnosis was invasive ductal carcinoma with no lymph node metastasis. We performed a modified radical mastectomy, after which the proteinuria and hypoproteinemia resolved almost completely, and the patient has been disease-free for 5 years since. Case 2 was a 61-year-old Japanese woman in whom breast cancer was diagnosed 2 months after the onset of membranous nephropathy. We performed a modified radical mastectomy and the histological diagnosis was invasive ductal carcinoma with marked lymphatic vessel permeation and involvement of five axillary lymph nodes. Proteinuria and hypoproteinemia did not resolve postoperatively and there is a high possibility of remnant or recurrent cancer. To our knowledge, there are only four other reported cases of paraneoplastic membranous nephropathy complicating breast cancer. However, we speculate that the postoperative resolution of nephrotic syndrome might be a measure of cancer control.     

Gastric remnant necrosis following splenic infarction after distal gastrectomy in a gastric cancer patient

INTRODUCTIONDistal gastrectomy with lymph node dissection is the standard treatment for gastric cancer. Remnant gastric necrosis after distal gastrectomy is very rare and fatal complication.PRESENTATION OF CASEA-78-year-old male diagnosed with advanced gastric cancer underwent distal gastrectomy with lymph node dissection. Postoperative gastric remnant necrosis occurred following splenic infarction. There was thought to be an insufficient blood supply to the gastric remnant due to the lymph node dissection along the proximal splenic artery during the initial surgery. Non-contrast abdominal computed tomography did not reveal any necrosis in the remnant stomach. An endoscopic examination confirmed this diagnosis. Total remnant gastrectomy was performed, and the patient thereafter successfully recovered.DISCUSSIONCareful management of blood vessels and lymph node dissection above the pancreas should be performed to avoid restricting the blood flow and also to prevent gastric remnant necrosis.CONCLUSIONThe knowledge of this fatal complication is crucial for management of postoperative complication. For early and accurate diagnosis, upper gastrointestinal endoscopy is necessary in case of remnant gastric necrosis.     

Function-Preserving Gastrectomy for Early Gastric Cancer

The number of early gastric cancer (EGC) cases has been increasing because of improved diagnostic procedures. Applications of function-preserving gastric cancer surgery may therefore also be increasing because of its low incidence of lymph node metastasis, excellent survival rates, and the possibility of less-invasive procedures such as laparoscopic gastrectomy being used in combination. Pylorus-preserving gastrectomy (PPG) with radical lymph node dissection is one such function-preserving procedure that has been applied for EGC, with the indications, limitations, and survival benefits of PPG already reported in several retrospective studies. Laparoscopy-assisted proximal gastrectomy has also been applied for EGC of the upper third of the stomach, although this procedure can be associated with the 2 major problems of reflux esophagitis and carcinoma arising in the gastric stump. In the patient with EGC in the upper third of the stomach, laparoscopy-assisted subtotal gastrectomy with a preserved very small stomach may provide a better quality of life for the patients and fewer postoperative complications. Finally, the laparoscopy endoscopy cooperative surgery procedure combines endoscopic submucosal dissection with laparoscopic gastric wall resection, which prevents excessive resection and deformation of the stomach after surgery and was recently applied for EGC cases without possibility of lymph node metastasis. Function-preserving laparoscopic gastrectomy is recommended for the treatment of EGC if the indication followed by accurate diagnosis is strictly confirmed. Preservation of remnant stomach sometimes causes severe postoperative dysfunctions such as delayed gastric retention in PPG, esophageal reflux in PG, and gastric stump carcinoma in the remnant stomach. Moreover, these techniques present technical difficulties to the surgeon. Although many retrospective studies showed the functional benefit or oncological safety of function-preserving gastrectomy, further prospective studies using large case series are necessary.     

胸、腹腔镜联合食管癌手术的临床分析

目的:探讨胸腹腔镜联合手术治疗食管癌的可行性和疗效,并总结相关临床经验。方法:2010年3月至2010年8月采用胸腔镜联合腹腔镜施行7例食管癌切除术,肿瘤均位于食管中上段,行胃体游离并经食管床上提胃体(管状胃)行食管胃颈部吻合术。结果:所有患者均顺利完成腔镜手术,无中转开胸病例,手术时间平均260min,术中平均出血200ml。平均清扫淋巴结12.8枚。术后下床活动时间平均3d,术后平均住院12d。术后1例发生吻合口漏,无其他并发症发生。患者均康复出院,术后随访2～8个月,均恢复良好。结论:胸、腹腔镜联合食管切除术较常规食管癌手术患者创伤小,术后康复快,且淋巴结清扫彻底,值得临床推广。     

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目的　总结原发性胆囊鳞癌、腺鳞癌的诊治经验。方法　回顾性分析了浙江大学医学院附属第二医院 1994～ 2 0 0 3年收治的少见胆囊癌 9例 (鳞癌 1例 ,腺鳞癌 8例 )。结果　行根治性手术 4例 ,姑息性手术 5例。9例中有 8例得到随访 ,均在术后半年内死亡 ,术后中位生存期 5 1d。结论　胆囊鳞癌腺鳞癌恶性程度较高 ,但淋巴结转移相对较晚。对于合适病例应尽可能行根治性胆囊切除 ,必要时行扩大根治性切除 ,术后放疗可能是一个较好的治疗方式。     

Adenosquamous carcinoma of the gallbladder with tumor thrombus in left portal trunk

We report a surgically resected case of adenosquamous carcinoma of the gallbladder accompanied by portal tumor thrombosis, which is regarded as a rare complication. A 73-year-old man was admitted to our hospital because of epigastralgia. Preoperative examinations led to a diagnosis of advanced gallbladder carcinoma with liver metastasis, and operation was performed. Since intraoperative ultrasonography showed a tumor thrombus in the left main portal trunk originating from the metastatic lesion in the left medial segment of the liver, extended left lobectomy with extrahepatic bile duct resection and lymph node dissection was performed, instead of right trisegmentectomy, as proposed preoperatively. Histological examination revealed adenosquamous carcinoma of the gallbladder with medullary growth that was similar to the hepatocellular carcinoma, most notably in the metastatic lesion of the liver and in the portal tumor thrombus. We discuss the relation between portal tumor thrombosis and medullary tumors, and note the atypical operative method employed.     

Surgical treatment of non-small cell lung cancer 1 cm or less in diameter

BACKGROUND: Routine lung cancer screening does not currently exist in the United States. Computed tomography can detect small cancers and may well be the screening choice in the future. Controversy exists, however, regarding the surgical management of these small lung cancers. METHODS: The records of all patients were reviewed who underwent resection of solitary non-small cell lung cancers 1 cm or less in diameter from 1980 through 1999. RESULTS: The study included 100 patients (56 men and 44 women) with a median age of 67 years (range 43 to 84 years). Lobectomy was performed in 71 patients, bilobectomy in 4, segmentectomy in 12, and wedge excision in 13. Ninety-four patients had complete mediastinal lymph node dissection. The cancer was an adenocarcinoma in 48 patients, squamous cell carcinoma in 26, bronchioloalveolar carcinoma in 19, large cell carcinoma in 4, adenosquamous cell carcinoma in 2, and undifferentiated in 1. Tumor diameter ranged from 3 to 10 mm. Seven patients had lymph node metastases (N1, 5 patients; N2, 2 patients). Postsurgical stage was IA in 92 patients, IB in 1, IIA in 5, and IIIA in 2. There were four operative deaths. Follow-up was complete in all patients and ranged from 4 to 214 months (median 43 months). Eighteen patients (18.0%) developed recurrent lung cancer. Overall and lung cancer-specific 5-year survivals were 64.1% and 85.4%, respectively. Patients who underwent lobectomy had significantly better survival and fewer recurrences than patients who had wedge excision or segmentectomy (p = 0.04). CONCLUSIONS: Because recurrent cancer and lymph node metastasis can occur in patients with non-small cell lung cancers 1 cm or less in size, lobectomy with lymph node dissection is warranted when medically possible.     

Second primary carcinoma in the gastric tube constructed as an esophageal substitute after esophagectomy

BACKGROUND: The prognosis of esophageal carcinoma has improved, but along with this improvement, concern has increased about the occurrence of second primary carcinoma, especially gastric carcinoma, in tubes constructed from the stomach after esophagectomy. We describe our experience in the diagnosis and treatment of gastric tube carcinoma. STUDY DESIGN: We retrospectively examined 31 cases of gastric tube carcinoma; these cases occurred in 26 patients who received esophagectomy between September 1968 and October 2000. RESULTS: Surgical resection was performed in 10 patients. Gastrectomy with regional lymph node dissection was performed in 7 patients and partial resection of the stomach without lymph node dissection in 3 patients. In 6 patients leakage was encountered after gastrectomy; 3 of these patients died of multiple organ failure. Only one of the gastrectomy patients is alive without disease. Over the past 7 years, 15 patients with 20 lesions have been treated by endoscopic mucosal resection (EMR). Three of these patients required additional operation because of massive submucosal invasion by the tumor. One complication occurred at EMR, but it was successfully treated by conservative therapy. All patients treated by EMR alone were alive with neither local nor distant metastasis during a median followup period of 27.5 months. Of those patients who received surgical resection initially and were diagnosed as inoperable, all 10 had not received periodic checkups and had some symptoms. In contrast, of 15 patients who underwent EMR, all 20 lesions were found by annual followup endoscopic examination in the absence of symptoms. CONCLUSIONS: EMR for gastric tube carcinoma is safe and has few complications, in contrast to surgical resection of the gastric tube, which places a severe burden on the patient and has high morbidity and mortality. Early detection of the tumor by annual endoscopic examination is recommended for achieving good outcomes in gastric tube carcinoma after esophagectomy.     

Recent advances in surgical treatment of thyroid carcinoma

Patients with thyroid carcinoma must be treated considering on the biological behaviour of the tumor. It has been noted that papillary and follicular carcinomas grow very slowly while anaplastic carcinoma very rapidly. Postoperative recurrence rate of differentiated carcinomas was calculated on 390 patients who were followed for over 10 years after various operative procedures. The recurrence rate was closely related to the tumor size rather than operative procedure and was about 10% in carcinoma below 2 cm in diameter for which enucleation or partial thyroidectomy was carried out. Recurrence rate in the remnant thyroid was higher in the group of enucleation and partial thyroidectomy than in the groups of lobectomy and subtotal thyroidectomy. Recurrence in lymph node was found more frequently in the groups of more extended dissection. Operative procedures performed in 97 patients who had recurrence were total removal of the remnant thyroid, extended dissection of mediastinal lymph nodes and combined removal with the trachea and vessels. From these experiences, a criterion of initial operation for thyroid cancer was accomplished. Prophylactic dissection was attempted in recent 193 patients with differentiated carcinoma, and revealed a high frequency of lymph node metastasis, that was 70%. Radiotherapy with 131I was carried out in 21 patients, and regression of metastatic foci was observed in all patients with follicular carcinoma and a half with papillary carcinoma. For anaplastic carcinoma, multidisciplinary treatment was attempted, but no satisfactory effects were obtained.