A case of IIa + IIc type early carcinoma of the rectum, with no invasion of the submucosa

A case of a IIa + IIc type early carcinoma of the rectum is reported. A 62-year-old man, who had been checked by immunological latex agglutination faecal occult blood testing, underwent a colorectal examination at Hakodate Chu-o Hospital. A barium enema revealed a slightly elevated lesion with a central depression in the lower rectum. Colonoscopic examination showed a IIa + IIc type of early rectal carcinoma. Study of the resected specimen also confirmed a IIa + IIc type early rectal carcinoma, 17 x 15 mm in diameter. Histologically, a lesion was located within the mucosa and consisted of both a carcinoma and an adenoma. Immunological latex agglutination faecal occult blood testing was thought to be useful for mass screening detection of a colorectal carcinoma.     

Endoscopic resection with local injection of HSE (ERHSE) in early gastric carcinomas

We have developed a new therapeutic method of endoscopic resection with local injection of HSE (ERHSE) for the early gastric carcinomas. ERHSE was performed for a total of seventy eight lesions of seventy five cases. Seventy eight early gastric carcinomas consisted of IIc (35), IIa (32), I (6), IIa + IIc (4) and IIc + IIa (1). Ten cases out of 75 underwent gastrectomy, because the invasion of carcinoma was detected in the submucosa or to the resected margin. No evidence of local recurrence has been obtained in the sixty five cases treated by this method.     

A case of superficial squamous cell carcinoma of the esophagus showing multicentric development

A 43-year-old male was admitted to the hospital with a complaint of mild dysphagia. A barium esophagogram showed an annular narrowing in the lower esophagus. Further, an endoscopic examination revealed erosive mucosa of the esophagus about 35 cm anal to the incisor. Lugol staining also revealed a geographical unstained lesion. The histologic diagnosis of a biopsy specimen indicated a squamous cell carcinoma and a total resection of the esophagus was performed. The operated material macroscopically showed a tumor of a superficially mixed type (IIa + IIc + IIb). The resected specimen histologically consisted of 18 squamous carcinomas that were separated with the normal squamous epithelium from each other. The major part of these lesions were limited to the epithelium, and only a few specimens microscopically showed an invasion of cancer nests in the propria mucosae. Great permeation of cancer cells into lymph vessels and the metastasis of one regional lymph node also were noted. Taken together, these findings indicated that the squamous cell carcinomas of this case seemed to have multicentrically developed from the normal esophageal mucosa.     

Barium Granuloma of the Rectum

Two cases of barium granuloma of the rectum diagnosed by rectal biopsy 26 months and 3 months after their last barium enema examinations are described. That a barium enema may require the patient to undergo a rectal biopsy at a later date to exclude carcinoma is a reminder of the constant care required in the performance of this examination.     

A case of effective regimen of tegafur and uracil (UFT)/leucovorin (LV) plus irinotecan (CPT-11) for advanced rectal carcinoma with severe pelvic infiltration to be performed curative resection

A 72-year-old man was admitted to our hospital, complaining of severe diarrhea. Computed tomography, barium enema and colonoscopy revealed a cysto-rectal fistula and massive invasion to middle rectum and retroperitoneal space from the main tumor in the upper rectum. Because of obstruction of passage of stool, sigmoid colostomy was performed. Oral UFT/LV+CPT-11 were undertaken after surgery for 4 cycles to remarkably reduce the tumor both clinically and on an outpatient basis. During this period, no side effect was detected, and a performance status (PS) of 0 has been maintained. As the result, radical resection was performed 5 months after the first operation. The histological effect was judged to be grade 2. Furthermore, no recurrence was recognized after 16 months postoperatively. Therefore, oral administration of UFT/LV+CPT-11 was considered as effective neoadjuvant chemotherapy for advanced rectal carcinoma, and this also could be a promising regimen to maintain the quality of life (QOL) for patients in ambulatory therapy.     

Analysis of Early Gastric Cancer Cases Collected from Major Hospitals and Intitutes in Japan

An analysis of 17,212 lesions from 15,933 patients with earlygastric cancer collected from 110 major hospitals and institutesin Japan is presented. The percentage of patients with early gastric cancer was highamong persons in their 60s and 50s. The sex ratio (F/M) was0.5 but it was higher for younger people than for old people.Regarding distribution of the types of early gastric cancer,the depressed group (Types IIe, III) accounted for 73.9% andthe elevated group (Types I, IIa) accounted for 15.3%. The elevated group was more frequent in the older age group.In regard to the type and invasion, slight invasion was prominentin types lIb and IIa, while deep invasion was prominent in IIa+ IIc. The metastatic rate was 18.4% for IIa + IIc, 11.8% forI and 11% for IIe. The frequency of lymph node metastasis was+4% in intramucosal cancer, 18.9% in submucosal cancer and 11.4%in total. The type in which multiple cancers were most frequentwas lIb, followed by IIa. The percentage of differentiated adenocarcinoma was 91.9% inthe elevated group and was found more often among the aged. Undifferentiated adenocarcinoma occurred more often among theyoung. The relationship between site and histology, locationand invasion, location and lymph node metastasis etc. were alsoinvestigated. We believe that these results should be very usefulfor detection and treatment of early gastric cancer. The rate of detection of small cancer is increasing year byyear. This increase can be explained by the progress and widespreadapplication of endo-scopy, which will continue to play a largerole in diagnosis and treatment of gastric cancer.     

A clinicopathological study of signet-ring cell carcinomas of the stomach

Surgically resected signet-ring cell carcinomas of the stomach have been clinicopathologically investigated. Although this type of carcinoma was found to be widely spread in the propria mucosa, a deeper invasion beyond the submucosa appeared more slowly than in other types of carcinomas. For example, the larger the early carcinoma in which the invasion was restricted to within the submucosa, the greater the incidence of a signet-ring cell carcinoma increase, especially in cases involving the mucosa. The incidence of a nodal metastasis was found to be lower than in cases of a moderately and poorly-differentiated adenocarcinoma in the early stage. However, when the signet-ring cell carcinomas invaded beyond the submucosa, the tumor cells spread rapidly and widely in the wall with a subsequent abdominal implantation, causing ascites and peritonitis carcinomatosa. It seemed likely that this deep invasion was accelerated by cellular change, such as the enlargement of nucleus, cellular atypy, and a decreased mucin production. As signet-ring cell carcinoma arise from the neck of glands and infiltrate the propria mucosae under the superficial epithelium, diagnosis by the barium enema and an endoscopic examination is very difficult in the case of small-size lesions. In lesions greater than 1 cm in diameter, these carcinomas usually showed an erosive and/or ulcerated appearance.     

A case of rectal carcinoma that disappeared following preoperative chemotherapy with an FT-207 suppository--confirmed by a thorough histologic examination of the resected specimen

Presented is the case of a patient, a 56-year-old female, who had complained of bloody stool and constipation. A barium enema and endoscopic examination revealed a tumor (Type 2) with a crater surrounded by a thick embankment, extending from the anterior wall to the left wall of the lower rectum. Biopsy specimens of the tumor disclosed a well-differentiated adenocarcinoma. A FT-207 suppository (1500 mg/day) was administered preoperatively for 50 days (total dose 75 g). On February 16, 1987, the patient underwent an abdominoperineal excision. The resected specimen took on the appearance of a chronic ulcer with an irregular depression, measuring 2.0 x 3.0 cm in size, in the lower rectum. The histology of the lesion also indicated a chronic ulcer, the base of which consisted of fibrosis covered with regenerative mucosa. No cancer cells or nests were demonstrated even serial tissue sections. As far as the rectal carcinoma is concerned, there has been no reported case of its disappearance by preoperative chemotherapy. The above results suggest that preoperative adjuvant chemotherapy can be quite effective against an advanced rectal carcinoma.     

Five cases of rectal cancer showing remarkable response to suppository administration of tegafur

Five cases of rectal cancer, one male and 4 females, were preoperatively treated with Tegafur suppositories at 1,500 mg per day, for 8 to 21 days (mean, 14 days). These tumors were 2 early cancers and 3 advanced cancers, the configuration of which were one IIa type, one IIa + IIc type and 3 Borrmann 2 types. Their size ranged from 1.3 to 4.2 cm in diameter. Curative resections were performed in all cases, and the examination of the resected specimen revealed marked effects of Tegafur as follows: 1) Reduction of tumor size, 2) disappearance of cancer wall, 3) degeneration of cancer cells and destruction of cancer glands accompanied by fibrous stroma with infiltration of lymphocytes and plasma cells, 4) formation of xanthogranulomatous tissue with foamy histiocytes, which were characteristic findings showing that cancer tissue had been present there. As a result, rectal cancer clearly showed remarkable response to suppository administration of Tegafur for only about two weeks, if the tumor cells were sensitive to the drug.     

Double-contrast barium enema and computerised tomography in the pre-operative evaluation of rectal carcinoma: are they still useful diagnostic procedures?

PURPOSE: In modern management of rectal carcinoma, the preoperative evaluation of disease parameters is important for selection of therapeutic options. Such parameters are currently defined through endorectal ultrasonography or endoscopic ultrasonography. A retrospective analysis of the parameters obtained with double-contrast barium enema (DCBE) and endorectal balloon computed tomography (CT) was conducted to verify the diagnostic reliability of the radiological techniques and to establish whether there is still an indication for their use. METHODS: 53 consecutive patients with adenocarcinoma of the distal half of the rectal ampulla underwent double contrast barium enema examination and CT of the pelvis with endorectal balloon. On the basis of the DCBE and CT assessment we evaluated: 1) the distance between the cranial extremity of the anal canal and the distal margin of the neoplasm; 2) the radial diffusion of the tumor; 3) the metastatic involvement of the perirectal and inferior mesenteric lymph nodes. RESULTS: 1) CT and DBCE measurements of the distal margin tended to coincide, but both tended to overestimate the measurement when compared to the pathologic examination; 2) in the identification of neoplastic infiltration of perirectal fat (T3) CT had 100% sensitivity, 78.7% specificity and 86.8% accuracy; 3) the CT sensitivity for detecting lymph node metastasis was 52.6%, specificity 85.3% and accuracy 73.6%. CONCLUSIONS: The diagnostic information provided by the radiological examinations is comparable to that of clinical and instrumental methods currently employed for staging of rectal carcinoma, although the latter are preferred because they are more readily accessible and less costly. DCBE and CT can therefore be usefully employed for staging of cancer of the rectum in those cases in which there are limitations of the current standard methods.     

A case of metastatic vaginal tumor of rectal cancer

The majority of vaginal metastases from extra-genital tumors are from colorectal cancer. A case of metastases to the vagina from a huge rectal carcinoma is described. A 55-year-old woman was admitted to the hospital because of a barium ileus after upper GI. Further examination revealed that she had a huge rectal carcinoma. Hartmann's operation combined with resection of the right ureter, posterior wall of the uterus and left ovary was performed. Postoperative chemoradiotherapy was performed with 60 Gy of irradiation to the small pelvis with 500 mg/day continuous infusion of 5-FU. After 18 months, she had genital bleeding. Digital examination revealed a vaginal tumor and metastasis of the rectal carcinoma to the vagina was confirmed histologically. Abdominoperineal resection of the rectum and vagina combined with simple total hysterectomy and bilateral salpingo-oophorectomy was performed. Thirty-three months after operation, there is no sign of recurrence.     

Perianal Paget's disease associated with rectal carcinoma: a case report

A 58-year-old man was referred to us because of anal bleeding. Digital rectal examination revealed a 1.2 x 0.8 cm-sessile villous tumor located in the anal canal and lower rectum. Pruritis was lacking and there were no erythematous lesions or any skin lesion in the perianal region. Histologic examination of the excised lesion revealed the presence of an adenocarcinoma within a villous adenoma. The malignancy exhibited well, moderately and poorly differentiated areas with signet-ring cell elements. Because the carcinoma had massively invaded into the submucosa, additional abdominoperineal resection was performed. Microscopic examination of the obtained specimens showed incidental Paget's disease of the anal skin. Although perianal Paget's disease associated with rectal cancer is rare, cautious pathologic examination of the anal and perianal skin in cases with anorectal carcinoma is necessary, even if there are no suggestive clinical findings. If there is perianal Paget's disease, surgical resection with sufficient apparently normal skin and close follow-up are necessary.      

Superficial esophageal carcinoma successfully treated with combined chemotherapy and radiotherapy

A 47-year-old man was admitted to our hospital with the chief complaint of epigastralgia. Endoscopic examination revealed a 0-IIa + IIc lesion in the middle thoracic esophagus, and a biopsy specimen was diagnosed as squamous cell carcinoma. The depth of the cancerous invasion was judged to be sm by endoscopic ultrasonography, and no metastasis to other organs or lymph nodes was detected. Although we believed curative resection was possible, we performed combined chemotherapy and radiotherapy because the patient refused surgery. After 2 courses of chemoradiotherapy, the cancer had disappeared clinically. We have found no evidence of recurrence for 1 year and 8 months. For the patient with superficial esophageal carcinoma who has a high risk or refuses surgery, chemoradiotherapy may be a reasonable alternative.     

Rate of detection of lymph node metastasis is correlated with the depth of submucosal invasion in early stage gastric carcinoma.

BACKGROUND: Gastric carcinoma invading the submucosa is often accompanied by lymph node metastasis. However, the relation between the depth of submucosal invasion and the status of metastasis has not been investigated. The objective of this study was to clarify the relation between lymph node status and the histologic features of gastric carcinoma invading the submucosa. METHODS: The histopathology of 118 patients who underwent gastrectomy and lymph node dissection for gastric carcinoma invading the submucosa was examined. These pT1 tumors with invasion of the submucosa were confirmed by histologic examination of the resected specimens. Tumor size, depth of submucosal invasion, histologic type, and macroscopic type were investigated in association with presence or absence of and anatomic level of lymph node metastasis. RESULTS: Among the 118 patients, 16 (14%) had lymph node metastasis, and the status of metastasis significantly correlated with tumor size and depth of submucosal invasion. The frequency of metastasis to perigastric lymph nodes and extragastric lymph nodes was 0% and 0% for < or =1-cm tumors, 5% and 1% for 1- to 4-cm tumors, and 46% and 15% for >4-cm tumors, respectively. There was no lymph from a node metastasis in tumors with less than 300 microm of submucosal invasion. The frequency of lymph node metastasis for tumors with 300-1000 microm and >1000 microm of submucosal invasion were 19% and 14%, respectively. CONCLUSIONS: Tumor size and depth of submucosal invasion serve as simple and useful indicators of lymph node metastasis in early stage gastric carcinoma. Optimal lymph node dissection levels are as follows: 1) local resection (D0) for lesions < or =1 cm, 2) limited lymph node dissection (D1) for 1- to 4-cm lesions, and 3) radical lymph node dissection (D2) for lesions >4 cm. When submucosal invasion of a locally resected tumor is more than 300 microm, additional gastrectomy and lymph node dissection are necessary.     

120例大肠癌的外科治疗

目的 讨论大肠癌的诊断和手术治疗.方法 大肠癌诊断遵循肛门指检、钡剂灌肠、纤维结肠镜检查步骤,对急性梗阻性结肠癌患者,除腹部X线片,条件允许可作钡灌肠,明确梗阻部位.采用梗阻近端肠腔充分减压,大量抗菌素溶液冲洗,尽量使吻合口“上空、中松、下通”引流管放过安全期的方法.结果 肛指检查对诊断直肠癌是可靠的,本组15例急性梗阻左半结肠癌作Ⅰ期切除吻合术,无吻合口瘘发生.结论 对便血、大便习惯改变的患者,必须按上述顺序作肛指和其他检查来提高早期诊断和术后五年生存率,按上述方法,急性梗阻性左半结肠癌Ⅰ期切除吻合是安全的.     

Gastric cancer presenting a variety of macroscopic and histopathological findings

A 68-year-old man was admitted to hospital because of nausea and vomiting. Examination of the upper digestive tract led to a total gastrectomy. A histopathological examination revealed a Borrmann type 3 advanced cancer in the prepyloric antrum that showed a moderately differentiated adenocarcinoma. Found on the anterior wall of the middle corpus was an advanced cancer, mimicking a type IIc early cancer, that was poorly differentiated with dispersed signet ring cells. Between these two advanced cancers, another superficially extended cancer, consisting of a type IIa and IIb early cancer, was found. The type IIa cancer, located on the posterior wall of the angle, was a papillary adenocarcinoma and the type IIb cancer on the lesser curvature of the antrum was moderately differentiated. Therefore this patient displayed not only a type IIa and a type IIb cancer, but also a Borrmann type 3 cancer and an advanced cancer, mimicking type IIc, that were linked into one large lesion. Although the present case was not determined as being a multiple gastric cancer, it suggests the likelihood of a multicentric generation, growth, and extension of synchronous multiple cancers, in view of the variety of macroscopic and histopathological findings presented.     

Case of lipohyperplasia of the ileocecal valve with adenocarcinoma of the ascending colon

A rare case of lipohyperplasia of the ileocecal valve contiguous with adenocarcinoma of the ascending colon is reported. The patient was a 67-year-old female with a chief complaint of muco-bloody stool. Barium enema X-ray study revealed a filling defect in the proximal portion of the ascending colon, suggestive of Borrmann II-type carcinoma and enlargement of the ileocecal valve. Ileocecotomy and right colectomy were performed. Histological examination disclosed that the tumor of the ascending colon consisted of well differentiated adenocarcinoma; the proliferation of fat tissue in the submucosa of the ileocecal valve was diagnosed as lipohyperplasia of the ileocecal valve. The histogenesis of this lipohyperplasia seems to be secondary development induced by the adenocarcinoma of the ascending colon.     

Primary carcinoma of the jejunum combined with colon polyp--report of a case

A 47-year-old female patient with a primary carcinoma of the jejunum combined with colon polyp is presented. Having had an attack of vomiting, she visited our hospital. Oral small intestine radiography revealed a localized stricture with ulceration in the jejunum. Small intestinal endoscopy showed a tumor with an irregular surface and hemorrhagic ulceration. Selective superior mesenteric arteriography revealed a stenosis and deviation of arteries. These findings strongly indicated cancer of the jejunum, and a barium enema study and a colonoscopic examination revealed a polyp in the ascending colon. The resected tumor was histologically diagnosed as a well differentiated adenocarcinoma. CEA-positive cells also were observed. Further, a polypoid lesion in the colon was histologically diagnosed as an adenoma.     

Treatment of early gastric cancer by endoscopic double snare polypectomy (EDSP)

The indication for EDSP was studied in 75 patients with early gastric cancer diagnosed endoscopically which had been obtained over a period of 11 years (1979 to 1985) at the Cancer Institute Hospital, Tokyo and the following results were obtained. EDSP consists of two procedures using double channel fiberscope; a sessile or depressed lesion pulled upward by one snare cautery (standard EDSP) is transformed into a subpedunculated one, which allows another snare cautery of pseudostalk, and it is excised by using coagulation current. EDSP was performed in 53 cases of IIa type and 22 cases of IIc type. Excision by one snare cautery was possible in 90.9% (40/44) of IIa lesion measuring less than 2 cm and in 100% (14/14) of IIc lesion measuring less than 1 cm, the total being 85.3% (64/75). There was no residual cancer in 41 cases of IIa lesion (93.2%) and 17 cases (85.0%) of IIc lesion with two recurrent cancers confirmed by follow-up endoscopy. Residual cancer was found in 6 cases (9.1%) which were operated on. The results mentioned above show the usefulness of EDSP and selection of case without lymph node metastasis permitting complete excision by one snare cautery is of much importance. EDSP is indicated for IIa lesion of differentiated type measuring less than 2 cm, IIc lesion of differentiated type without ulceration measuring less than 1 cm and IIc lesion of undifferentiated type without ulceration measuring less than 0.5 cm that is not located in the fundic gland area.     

Early gastric cancer located just above Dieulafoy's ulcer, with massive bleeding

In 2003, a 69-year-old man visited our emergency department because of hematemesis and anemia. Emergency gastroscopy revealed massive bleeding from Dieulafoy's ulcer in the upper body of the stomach. The arterial bleeding was successfully controlled by endoscopic clipping. Blood transfusion and a proton-pump inhibitor were administered and his condition recovered smoothly. Two weeks after the treatment, type IIa early gastric cancer was detected at the previous bleeding point by follow-up endoscopy. He underwent distal gastrectomy with systematic lymph node dissection (D2), and he had no sign of recurrence until 2005. Histopathological examination revealed an early gastric cancer with submucosal invasion located just above the Dieulafoy's disease. The characteristic finding of Dieulafoy's disease was an enlarged and tortuous artery arising from the subserosa, penetrating the muscle layer, and spreading in the submucosa. Abnormal Dieulafoy's artery coexisting with gastric cancer has been reported in only 17 cases until now. Our clinical and pathological findings led us to the following speculation on the pathogenesis in our patient. Repeated regeneration of the mucosal membrane would have been caused by circulatory disturbance in Dieulafoy's vessels. This regeneration and mucosal dysplasia may have been a factor in promoting the gastric cancer. In the previously reported cases of the coexistence of abnormal Dieulafoy's artery and gastric cancer, the initial gastroscopic examination rarely diagnosed the gastric cancer. Thus, follow-up gastroscopy is essential, so as not to miss such coexisting diseases.