The Prognostic Significance of Tumor Budding, Tumor Nodules, and Lymph Node Extracapsular Extension in Stage III Colorectal Cancer Patients

PURPOSE: The prognosis of advanced colorectal cancer patients may be different even for the same TNM staging. The characteristic features of tumors, such as tumor budding, tumor nodules, and extracapsular extension (ECE) of lymph nodes, can influence the disease progression and the outcome for patients. Tumor budding occurs what at the invasion front of colorectal adenocarcinomas, tumor cells, singly or in small aggregates, become detached from the neoplastic glands, and it can be divided it into two groups, low grade (0~16 foci in a field) and high grade (17 or more foci in a field). A tumor nodule is histologically identified within the fatty tissue or the detached fatty tissue around the dissected lymph nodes, or is a place picked up as lymph nodes from resected specimens which contain no lymph node components. ECE is defined as a tumor extension beyond the node capsule. The aims of this study were to evaluate the clinical significance of tumor budding, tumor nodules, and ECE of lymph nodes as prognostic factors in Stage III colorectal cancer patients. METHODS: We analyzed the disease-free and overall 5-year survival rates and recurrence rates in 94 Stage-III colorectal cancer patients according to tumor the budding intensity, the tumor nodules, and the lymph node ECE status. RESULTS: Of the entire group, the 5-year disease-free and overall survival rates were 49%, and 50%, respectively. The 5-year disease-free and overall survival rates were higher in the low-grade tumor budding group than in the high-grade group (58% vs 33%, P=0.045, 61% vs 39%, P=0.003). The 5-year disease-free and overall survival rates in patients with tumor nodules were lower than those in patients without one (44% vs 69%, P=0.086, 47% vs 77%, P=0.018). The recurrence rate was also higher in the group with tumor nodules than without one (80% vs 52%, P=0.045). The 5-year disease-free and overall survival rates were higher in the ECE negative group than in the positive one (68% vs 37%, P=0.018, 75% vs 42%, P=0.001). The recurrence rate was also higher in the ECE positive group than in the negative group (78% vs 46%, P=0.008). The existence of ECE and tumor nodule were strongly related to systemic recurrence (P=0.006, P=0.033), but not to the local recurrence (P=0.777, P=0.611). Considering the analysis of the recurrence pattern by N stage classification, there is no statistical difference in the N2 patient group, but there was in the existence of ECE and tumor nodule were strongly related to the systemic recurrence in N1 group (P=0.019, P=0.028). These three factors were scored according to the existence, and the score range was divided into two prognostic groups, high risk group (> or =2) and low risk group (<2). The high risk group was significantly associated with systemic recurrence (P= 0.004) rather than recurrence (P=0.865), and these score value were only significant in the N1 patient group (P=0.007) rather than in the N2 group (P=0.927). The high risk group also showed poor overall survival rate compared with the low risk one in only the N1 group (P=0.002), but nof in the N2 group (P=0.193). On multivariate analysis, UICC stage and ECE were two significant factors for tumor recurrence and the 5-year disease-free survival rate. CONCLUSIONS: These data showed that even if similar lymph node metastasis existed in advanced colorectal cancer patients, there was a different 5-year disease-free survival rate and overall survival rate according to the tumor budding, tumor nodule, and ECE status. On multivariate analysis, UICC stage and ECE were two significant factors for the tumor recurrence and the 5-year disease-free survival rate. Our results suggest that tumor budding, tumor nodule, and ECE of lymph node are excellent parameters to provide a confident prediction of clinical outcome.

Epidermoid Cyst in Hepatoduodenal Ligament

A 39-year-old man was admitted to our hospital because of an intermittent, epigastric, abdominal pain and abdominal bloating. Magnetic resonance Cholangiopancreatography (MRCP) showed a 4x6 cm sized heterogenous cystic mass in the hilum of the liver. The mass seemed not to have originated from the liver, but was rather located at the anterior portion of the inferior vena cava and the caudate lobe, and superior to the head of the pancreas. The common bile duct (CBD) was displaced laterally by the mass, but the other biliary tree was normal. A presumptively diagnosed hematoma or high- protein mucous component filled cystic mass was later proved to be a large mass located in the hepatoduodenal ligament on laparotomy, and was completely removed by meticulous dissection. The histopathological diagnosis confirmed an epidermoid cyst.

Splenic Lymphangioma of the Spleen in an Elderly Patient

A splenic cystic lymphangioma is a very rare benign condition, and is classified as one of the cystic proliferations of the spleen. They are considered to result from developmental malformation of the lymphatic system and can be divided roughly into two types according to the extent of the disease: the isolated type, where only the spleen is involved, and the widespread type, where splenic involvement is an expression of multiple organ involvement. Thery are usually seen in children and often found incidentally. Herein, a case of cystic lymphangioma of the spleen in an elderly woman is presented, with emphasis on the rarity of cases in old age and on the problems of differential diagnosis in relation to other cystic proliferations of the spleen.

Clinical Analysis of an Acute Intestinal Obstruction with a Paraduodenal Hernia

PURPOSE: A paraduodenal hernia is an uncommon congenital disease that manifests as an intestinal obstruction, which may lead to strangulation and, subsequently, result in gangrene of the intestine. In this retrospective study, 12 paraduodenal hernia cases were evaluated and the clinical prognostic factors investigated. METHODS: Paraduodenal hernias leading to intestinal obstructions were noted in 12 patients. The patients were retrospectively evaluated with respect to signs and symptoms. The laboratory and radiological findings, type of operation, time elapsed between the onset of symptoms and laparotomy and postoperative complications and hospital stays were also reviewed. The relationships between clinical factors and outcomes were also statistically evaluated. RESULTS: In our series, postoperative short bowel syndrome was encountered in one patient (case 1) with bowel strangulation, but there were no mortalities. The time elapsed between the onset of symptoms and laparotomy was found to be longer in the patients with strangulation than in those without (6.8+/-4.5 day versus 4.1+/-3.6 day). Additionally, the postoperative hospital stay was longer in those patients with strangulation (24.4+/-11.6 day versus 15.3+/-7.7 day), but the relationship was not statistically significant (P=0.283 and 0.130, respectively). CONCLUSION: Since the preoperative diagnosis of a paraduodenal hernia is very difficult, due to the lack of specific signs and symptoms, the postoperative complications can only be decreased with early surgical intervention in those patients with an acute intestinal obstruction. Although the postoperative morbidity and mortality were not correlated with any of the factors evaluated in this study, further study will be needed to evaluate the significance of the time elapsed between the onset of symptoms and a laparotomy as a prognostic factor.

Deep Vein Thrombosis after Surgery for Gastrointestinal Cancer: Incidence and Correlation with Risk Factors

PURPOSE: Deep vein thrombosis (DVT) is recognized as a common complication in surgical patients in western countries, and especially for high risk patients. However there is little informations on the incidence and risk factors of DVT after gastrointestinal cancer surgery in Korea. The aim of this study is to evaluate the incidence and risk factors of DVT after gastrointestinal cancer surgery that is performed without antithrombotic prophylaxis. METHOD: From August 2003 to February 2004, 107 patients who underwent gastrointestinal cancer surgery were evaluated prospectively. Hypercoagulability studies were done before the operation or before any blood transfusion, and the other clinical risk factors were also examined. All the patients were examined between the 5th and 10th postoperative day with duplex ultrasonographic assessment of both lower extremities. RESULT: DVT was found in 8 patients (7.5%) and two patients had symptomatic DVT. Five patients showed thrombi in there calf veins, two patients in the popliteal vein, and one patient in the iliac vein. The DVT group showed a significantly higher incidence of hyperhomocysteinemia than non-DVT group. There was no statistically significant difference between the DVT and non-DVT group according to other risk factors. CONCLUSION: The incidence of DVT after intra-abdominal cancer surgery in Koreans is significantly lower than for the patients in western countries. Considering the lower rate of proximal DVT, routine prophylaxis for DVT appears to be unwarranted in Koreans before and after intra-abdominal cancer surgery. Finally we did not identify a correlation between DVT and the so-call risk factors except for hyperhomocysteinemia. It would be interesting to perform further studies to clarify the association between hyperhomocysteinemia and DVT in cancer patients.

Clinical Significance of Epstein-Barr Virus Expression in Breast Cancer / 한국유방암학회지

PURPOSE: Epstein-Barr Virus (EBV) is well understood as an oncogenic virus in human tumors. Its association with breast cancers has been reported but is still in controversy. So we have examined the expression of EBV in breast cancers and evaluated the relationship between the well-known prognositc factors of breast cancer and EBV expression. METHODS: A retrospective study was conducted with patients who had been re-evaluated to confirm the diagnosis based on immunohistochemical analysis with EBNA-2 expression, between January 1991 and December 2002. The cases were assigned to the positive lesion that displayed 10% or more of immunoreactive cells. RESULTS: The expressions of EBNA-2(Ebstein Barr virus nuclear antigen - 2) were noted in 26 (21.1%) out of 123 cases of breast cancer patients and 4 (20%) out of 20 cases in a control group of benign tumors. The expression of EBV in breast cancers and that of a control group were not different significantly. But, the correlation between the expression of EBNA-2 and ER status was noted statistically significant (P=0.040). CONCLUSION: Judging from the results of our study, EBV infection detected in breast cancer seems to be latent and the association of EBV to breast cancer is less likely related.

Ruptured Solitary Splenic Metastasis of Gastric Cancer after Gastric Cancer Operation

Solitary malignant splenic metastasis is uncommon and usually occurs in association with widely disseminated metastatic disease. Splenic metastasis usually occurs late in the disease course, with widespread involvement of other organs and rarely shows any presenting symptoms. Virtually all primary tumors have been known to metastasize to the spleen. The common ones include melanoma, lung, breast and ovary cancer, but metastasis from gastric cancer is very rare. When solitary spleen metastasis is suspected in a clinical setting, aggressive treatment is indicated such as splenectomy followed by combined modality treatment to prevent dissemination of the disease. We experienced a case of solitary spleen metastasis and rupture after gastric cancer operation and reviewed the associated literatures.

The Expression of NIS and Pendrin in Thyroid Cancer Tissues with Real Time RT-PCR / 대한내분비외과학회지

PURPOSE: It has not been clearly investigated how iodine can be trapped from the extracellular space into thyroid follicular cells, the defective iodide-trapping mechanism appears to be an early and constant feature during oncogenic transformation of thyroid cells. In recent studies, NIS and pendrin are associated with the trapping process. Thus, in order to reveal this uncertain relationship, each of the quantitative expressions of NIS and pendrin in various thyroid tissues were evaluated by real time RT-PCR. METHODS: This study included 63 patients who had undergone thyroidectomy in Uijongbu St. Mary's hospital from Jan. 2000 to Jan. 2003. 13 cases of normal thyroid, 17 cases of hypofunctioning thyroid adenomas, and 33 cases of thyroid cancer were examined. The thyroid cancer group was further divided into high and low risk group according to the AMES score, and the NIS and pendrin levels were compared between the two groups. Real time RT-PCR was conducted with the extracted RNAs, using GAPDH as the control. RESULTS: As for pendrin, its expression was decreased by 7% in the thyroid adenoma group compared with that of normal thyroid, while there was a 59% decrease in thyroid cancer cases. NIS expression was decreased by 20% in the thyroid adenoma group, and a 40% decrease was found in thyroid cancer group. Due to the impediment of pendrin in both high and low risk group of thyroid cancer, there was a 19% decrease in the high risk group compared with the low risk group. As for the impediment of NIS in the high risk group, an increase of 30% was found. However, no statistical significance was shown (P=0.344 vs P=0.688). CONCLUSION: According to this study, it can be inferred that the decrease in the expressions of NIS and pendrin are related to tumorigenesis of thyroid cancer. Also, further research is needed to reveal the cause of genetic transformation, as well as the value of utilization of NIS and pendrin as tumor markers.

Central Venous Catheterization Via Persistent Left Superior Vena Cava

Although the use of central venous cannulation has been increasing in recent years, it can produce serious complications such as hemothorax, pneumothorax, arterial puncture, and malposition of the catheter. Therefore, post-procedure chest radiograph must be obtained to confirm correct placement of the catheter and to exclude pneumothorax or hemothorax. We experienced an abnormal course of left subclavian catheter along the left border of the heart on post-procedure chest radiograph. Here we report a case of persistent left superior vena cava detected by hemodialysis catheterization in a patient with acute renal failure after ruptured abdominal aortic aneurysm.

Spontaneous Rupture of Renal Artery Aneurysm in a Patient with Untreated Hypertension / 대한신장학회잡지

Spontaneous rupture of renal artery aneurysm is a rare, but life threatening complication with high mortality. The etiology of non-traumatic renal artery aneurysm is fibromuscular dysplasia, atherosclerosis, vasculitis, and pregnancy. We here report a case of spontaneous rupture of renal artery aneurysm in a patient with untreated hypertension. A 39-year-old non-pregnant woman complained of sudden onset of right flank and lower quadrant abdominal pain. Ultrasonography showed large fluid collection in right lower abdomen. Emergency laparotomy demonstrated huge retroperitoneal hematoma due to spontaneous rupture of right renal artery aneurysm. Microscopic examination of the aneurysmal wall revealed intimal hyperplasia without atherosclerotic change.

The Clinical Application of Insulin-like Growth Factor-I Receptor (IGF-IR) and Insulin Receptor Substrate-1 (IRS-1) Expression in Breast Cancer / 한국유방암학회지

PURPOSE: The insulin-like growth factor (IGF) system performs multiple functions in the regulation of breast cancer cell growth. The IGF system is comprised of a complex network of ligands, receptors and related signaling proteins. Two receptors are recognized, the insulin-like growth factor-I receptor (IGF-IR) and the insulin-like growth factor- II receptor (IGF-IIR), one of which, the IGF-IR, is a transmembrane heterodimer structurally similar to the insulin receptor. The activation of the IGF-IR results in the recruitment of adapter proteins, which adapter proteins used by the insulin-like growth factor-I (IGF-I) to transduce its signal to the insulin receptor substrate-1 (IRS-1). This study investigated the relationship between IGF-IR and IRS-1 by using an immunohistochemical staining technique. METHODS: IGF-IR and IRS-1 expression was detected by immunohistochemical staining using paraffin sections in 123 invasive breast carcinoma cases. The results were evaluated with the survival rate and the clinicopathological prognostic variables such as the patient's age, the clinical stage, the histological grade, the estrogen receptor (ER) and the progesterone receptor (PR). RESULTS: The results showed that IGF-IR and IRS-1 expression positively correlated with the ER and PR, and an inverse relationship was found between the IGF-IR and IRS-1 and histological grades. No association was observed between the IGR-IR and IRS-1 and the patent's age and clinical stage. In survival analysis, there was no definite association between the expressions of IGF-IR and IRS-1 and the disease free survival rate. CONCLUSION: IGF-IR and IRS-1 appear to play a role in the progression and differentiation of breast cancer in association with the ER and the PR.

Inflammatory Fibroid Polyp of the Stomach Mimicking Gastric Cancer

We report a rare case of inflammatory fibroid polyp of the stomach that mimicked gastric cancer. A review of the associated literature is also reported. A 32 year old woman was admitted to our hospital with a history of vomiting and epigastric pain and a weight loss of 10 kg in one month. A radiologic and an endoscopic examination showed a protruding tumor, with diffuse ulceration at the posterior wall of the prepyloric antrum of stomach. Although no malignant cells were histologically confirmed in the biopsy specimens, a subtotal gastrectomy, with a lymphadenectomy, was performed because gastric cancer was suspected, preoperatively. The histopathological diagnosis was an inflammatory fibroid polyp of the stomach. If a submucosal tumor of the stomach is suspected in a preoperative diagnosis, an inflammatory fibroid polyp should be considered as one of the possible differential diagnoses.

Thymidylate Synthase Expression Using Immunohistochemical Staining in Colorectal Cancer

PURPOSE: Thymidylate synthase (TS) is a critical enzyme in the DNA synthesis and an important target of cancer chemotherapeutic agents, such as 5-fluorouracil (5-FU). Recent studies suggest that TS expression is related to the prognosis of various cancers and the mechanism of chmotherapeutic drug resistance. This retrospective study was performed to determine whether TS expressions in primary colorectal tumors influence the overall survival and recurrence for patients with colorectal cancer. METHODS: Intratumoral TS expression was evaluated by immunohistochemical staining using TS-106 monoclonal antibody in primary colorectal cancers of 64 patients who had undergone surgery from July, 1995 to June, 1999. The relationship between TS expressions and patients' survival was evaluated statistically. The median follow-up period was 25.7 months. RESULTS: Overall positive TS expression rate was relatively high (54.7%) in colorectal cancers, and overall disease-free survival rate was significantly higher in the TS positive group (P=0.0204). But there was no statistically significant differences in overall survival rates (P=0.249) and tumor recurrence rates (P=0.732) between positive TS group and negative TS group. CONCLUSIONS: These results suggest that TS expression status in the colorectal cancer tissue is only related to the overall disease-free survival rates, not the overall survival rates and tumor recurrence rates. More objective method and long term follow up study will be required for accurate assessment of clinical importance of TS expression in colorectal cancers.

Spnontaneous Regrssion of liver metastasis in Stage IV-S neuroblastoma after adrenalectomy: One Case Report

Prenatally diagnosed neuroblastomas have been reported in increasing numbers over the past several years. The vast majority are in favorable stages of the disease (stage I, II, IV-S). The authors experienced one case of stage IV-S neuroblastoma of the adrenal gland with liver metastasis, which regressed spontaneously after removal by adrenalectomy. This patient was noticed to have an abdominal mass at prenatal ultrasonography performed at 36weeks of gestation. This tumor was a neuroblastoma of the left adrenal gland with multiple liver metastases. Left adrenalectomy and liver biopsy were performed at 3 months of age. Thirty-eight months after surgery, an MRI demonstrated that the hepatic metastatic lesions had completely regressed without chemotherapy or radiation.

Unusual Spontaneous Gallbladder Perforation in the Body Portion

Spontaneous gallbladder perforation is a rare complication of acute cholecystitis. The mechanism for the development of this complication is not clear, although a vascular anomaly and ischemia of the gallbladder appear to be important predisposing factors. It is rarely diagnosed preoperatively, and the delay in making the definitive diagnosis usually accounts for the increased incidences of morbidity and mortality associated with this complication. We experienced the unusual case of a 64-year-old male pa tient who presented with a 1-h history of generalized, especially right upper quadrant, abdominal pain. He had no history of traumatic, atherosclerotic, cardiovascular, metabolic disease. Abdominal ultrasono graphy demonstrated generalized free intraperitoneal fluid, especially in right lower quadrant, and was otherwise unremarkable. On palpation, his abdomen was rigid, and a provisional diagnosis of perforated peptic ulcer was made. The patient underwent a cholecystectomy. Gross examination of the gallbladder showed a pinhole perforation (1.2x1.0 mm2) in the body, but no gallstones. Microscopic examination of the wall revealed some neutrophile and lymphocyte infiltration and Widal test was negative. The patient had an uneventful recovery.