Tumor grade 2 as the independent predictor for lymph node metastasis in 10–20 mm sized rectal neuroendocrine tumor

Purpose@#Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10–20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10–20 mm sized rectal NET and utilize them to decide upon the treatment strategy. @*Methods@#Twenty-eight patients with 10–20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (–) groups, and their respective data were analyzed. @*Results@#Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (–) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17–1,188.64; P=0.010). @*Conclusion@#Tumor grade 2 was the independent factor predicting LNM in 10–20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.

Synchronous Quadruple Colon Cancer With Two Lesions Previously Obscured by Ischemic Colitis, Plus Bladder Cancer and Thymoma: A Case Report

Synchronous quadruple colorectal cancer (CRC) is extremely rare without genetic alterations. We present a case of synchronous quadruple CRC with 2 lesions previously obscured by ischemic colitis. A 73-year-old woman was admitted to our emergency department. An abdominal computed tomography revealed ischemic colitis and irregular wall thickening of the sigmoid colon and sigmoid-descending junction, suspicious of 2 colon cancers. A colonoscopy examination revealed a fungating mass 20 cm from the anal verge, as well as ischemic colitis spanning the mucosa from the sigmoid colon to the transverse colon. The patient underwent laparoscopic Hartmann procedure. Pathologic examination confirmed both lesions as adenocarcinomas with microsatellite stable. Seven months postoperatively, instead of a laparoscopic Hartmann reversal, a laparoscopic total colectomy was performed due to the continued presence of severe ischemic colitis. The pathologic report suggested the presence of 2 distinct invasive adenocarcinomas in the descending colon without genetic alterations such as microsatellite instability.

Tumor grade 2 as the independent predictor for lymph node metastasis in 10–20 mm sized rectal neuroendocrine tumor

Purpose@#Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10–20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10–20 mm sized rectal NET and utilize them to decide upon the treatment strategy. @*Methods@#Twenty-eight patients with 10–20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (–) groups, and their respective data were analyzed. @*Results@#Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (–) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17–1,188.64; P=0.010). @*Conclusion@#Tumor grade 2 was the independent factor predicting LNM in 10–20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.

Synchronous Quadruple Colon Cancer With Two Lesions Previously Obscured by Ischemic Colitis, Plus Bladder Cancer and Thymoma: A Case Report

Synchronous quadruple colorectal cancer (CRC) is extremely rare without genetic alterations. We present a case of synchronous quadruple CRC with 2 lesions previously obscured by ischemic colitis. A 73-year-old woman was admitted to our emergency department. An abdominal computed tomography revealed ischemic colitis and irregular wall thickening of the sigmoid colon and sigmoid-descending junction, suspicious of 2 colon cancers. A colonoscopy examination revealed a fungating mass 20 cm from the anal verge, as well as ischemic colitis spanning the mucosa from the sigmoid colon to the transverse colon. The patient underwent laparoscopic Hartmann procedure. Pathologic examination confirmed both lesions as adenocarcinomas with microsatellite stable. Seven months postoperatively, instead of a laparoscopic Hartmann reversal, a laparoscopic total colectomy was performed due to the continued presence of severe ischemic colitis. The pathologic report suggested the presence of 2 distinct invasive adenocarcinomas in the descending colon without genetic alterations such as microsatellite instability.

Perianal extragastrointestinal stromal tumor

An extragastrointestinal stromal tumor (EGIST) is a gastrointestinal stromal tumor that arises outside of the gastrointestinal tract. Most EGISTs are located in the omentum, mesentery, and retroperitoneum. The occurrence of an EGIST at the perianal region is very rare. Herein, we report our experience with EGISTs in the perianal area and review the literature. A 70-year-old man presented to our hospital with a 2-year history of anal discomfort. A pelvic magnetic resonance imaging scan showed a homogenous, well-defined, soft tissue density mass. The patient underwent mass excision, and the pathological examination confirmed that the mass was an EGIST. The size of the tumor was 4.3×3.2 cm, and the mitotic count was 1 per 50 high-power fields. The tumor cells were immunohistochemically positive for KIT and CD34 but were negative for S-100 and alpha-smooth muscle actin. There were no other abnormal findings in the gastrointestinal tract; upon pathological review, this case was confirmed as perianal EGIST. Therefore, EGIST should be considered as a differential diagnosis of perianal masses.

Perianal extragastrointestinal stromal tumor

An extragastrointestinal stromal tumor (EGIST) is a gastrointestinal stromal tumor that arises outside of the gastrointestinal tract. Most EGISTs are located in the omentum, mesentery, and retroperitoneum. The occurrence of an EGIST at the perianal region is very rare. Herein, we report our experience with EGISTs in the perianal area and review the literature. A 70-year-old man presented to our hospital with a 2-year history of anal discomfort. A pelvic magnetic resonance imaging scan showed a homogenous, well-defined, soft tissue density mass. The patient underwent mass excision, and the pathological examination confirmed that the mass was an EGIST. The size of the tumor was 4.3×3.2 cm, and the mitotic count was 1 per 50 high-power fields. The tumor cells were immunohistochemically positive for KIT and CD34 but were negative for S-100 and alpha-smooth muscle actin. There were no other abnormal findings in the gastrointestinal tract; upon pathological review, this case was confirmed as perianal EGIST. Therefore, EGIST should be considered as a differential diagnosis of perianal masses.

Gerstmann-Sträussler-Scheinker Disease (Pro102Leu) Presenting as Rapidly Progressive Dementia

Genetic prion diseases account for about 10-15% of all cases of human prion disease and are caused by mutations in the prion protein gene. Gerstmann-Sträussler-Scheinker (GSS) disease is a rare genetic prion disease, which is characterized by slowly progressive cerebellar ataxia and the occurrence of cognitive decline in the later stage. P102L is the most common mutation in GSS. We report a patient with a P102L mutation that initially manifested as rapidly progressive dementia without cerebellar symptoms.

Cancer-Associated Fibroblasts and Desmoplastic Reactions Related to Cancer Invasiveness in Patients With Colorectal Cancer

PURPOSE: We evaluated the relationship of cancer-associated fibroblasts (CAFs) and desmoplastic reactions with cancer invasiveness and long-term outcomes in patients with colorectal cancer (CRC). METHODS: Histologic evaluation of mature CAFs and desmoplasia was performed by observing the collagen fiber structure and fibroblast cytomorphology in the intratumoral stroma and invasive front of CRC tissues. Cancer-cell invasiveness was evaluated using lymphatic invasion, vascular invasion, perineural invasion, tumor budding, and tumor growth patterns. Overall survival and systemic recurrence were analyzed. A network analysis was performed between CAF maturation, desmoplastic reaction, and cancer invasiveness. RESULTS: The proportions of mature CAFs in the intratumoral stroma and the invasive front were 57.6% and 60.3%, respectively. Epidermal growth factor receptor (EGFR) overexpression was significantly higher in the mature CAFs in the invasive front as compared to immature CAFs. Lymphatic invasion increased as the number of mature fibroblasts in the intratumoral stroma increased. Tumor budding was observed in almost half of both mature and immature stroma samples and occurred more frequently in infiltrating tumors. On network analysis, well-connected islands were identified that was associated with EGFR overexpression, CAF maturation, and infiltrating tumor growth patterns leading to tumor budding. CONCLUSION: The maturity of CAFs and desmoplastic reactions were associated with cancer invasion. However, the cytomorphologic characteristics of CAFs were insufficient as an independent prognostic factor for patients with CRC.

Prediction of Late Postoperative Hemorrhage after Whipple Procedure Using Computed Tomography Performed During Early Postoperative Period

OBJECTIVE: Postpancreatectomy hemorrhage (PPH) is an uncommon but serious complication of Whipple surgery. To evaluate the radiologic features associated with late PPH at the first postoperative follow up CT, before bleeding. MATERIALS AND METHODS: To evaluate the radiological features associated with late PPH at the first follow-up CT, two radiologists retrospectively reviewed the initial postoperative follow-up CT images of 151 patients, who had undergone Whipple surgery. Twenty patients showed PPH due to vascular problem or anastomotic ulcer. The research compared CT and clinical findings of 20 patients with late PPH and 131 patients without late PPH, including presence of suggestive feature of pancreatic fistula (presence of air at fluid along pancreaticojejunostomy [PJ]), abscess (fluid collection with an enhancing rim or gas), fluid along hepaticojejunostomy or PJ, the density of ascites, and the size of visible gastroduodenal artery (GDA) stump. RESULTS: CT findings including pancreatic fistula, abscess, and large GDA stump were associated with PPH on univariate analysis (p ≤ 0.009). On multivariate analysis, radiological features suggestive of a pancreatic fistula, abscess, and a GDA stump > 4.45 mm were associated with PPH (p ≤ 0.031). CONCLUSION: Early postoperative CT findings including GDA stump size larger than 4.45 mm, fluid collection with an enhancing rim or gas, and air at fluid along PJ, could predict late PPH.

Educational Benefits of Intraoperative Indocyanine Green Angiography for Surgical Beginners During Laparoscopic Colorectal Surgery

PURPOSE: The aim of this study is to evaluate the safety and usefulness of indocyanine green (ICG) angiography in laparoscopic colorectal surgery and to explore its educational benefits in surgical beginners. METHODS: From July to October of 2015, a total of 21 patients with colorectal cancer underwent laparoscopic surgery using the fluorescence-guided imaging system, IMAGE1 S™ (Karl Storz, Germany). Real-time ICG fluorescence images and red inversion images were juxtaposed with standard white-light images for assessment of colonic perfusion. A surgical beginner group comprised of medical students (n=11) and surgical residents (n=11) were then questioned postoperatively about the colonic transection line and mesenteric vascular integrity across various image modes to determine the most proper view for surgical decision. RESULTS: A total of 21 patients underwent laparoscopic colorectal surgery using ICG angiography. Mean patient age was 69.7 years (52~77 years). Mean time-to-detection for the marginal arteries and colonic wall were 26.7 (range, 4~45) and 47.3 (range, 20~77) seconds, respectively. No injection-related adverse events were observed. Rate of change in the colonic transection line across modes was 59.9% (33.3~66.7%) in the surgical beginners. Decisions made by surgical beginners on the transection line were varied with the standard image, but converged to 81.8% in the ICG with red inversion mode. Surgical beginners preferred ICG with red inversion mode for assessment of mesenteric vascular integrity. CONCLUSION: ICG angiography seems to be safe and useful in evaluating colonic perfusion for transection decisions and could have educational benefits for surgical beginners in training to make surgical decisions.

Laparoscopic Splenectomy for a Patient with Splenomegaly and Hypersplenism due to Idiopathic Portal Hypertension

Idiopathic portal hypertension (IPH) is a rare disorder which is clinically characterized by portal hypertension, splenomegaly, hypersplenism and the absence of liver cirrhosis. Patients with IPH have massive splenomegaly leading to increased portal venous flow and subsequent portal hypertension. In selected IPH patients with splenomegaly and hypersplenism, splenectomy can be regarded as an effective treatment protocol for decreasing portal hypertension. We report a case of a 44-year-old woman who was diagnosed with IPH accompanied by splenomegaly and hypersplenism. She underwent laparoscopic splenectomy and clinical symptoms and hypersplenism resolved. Our study shows that laparoscopic splenectomy can be considered as a procedure for treating patients with splenomegaly and hypersplenism due to IPH.

Distribution and Impact of the Visceral Fat Area in Patients With Colorectal Cancer

PURPOSE: The purposes of this study were to investigate the distribution of the visceral fat area (VFA) and general obesity and to compare visceral and general obesity as predictors of surgical outcomes of a colorectal cancer resection. METHODS: The prospectively collected data of 102 patients with preoperatively-diagnosed sigmoid colon or rectal cancer who had undergone a curative resection at Pusan National University Yangsan Hospital between April 2011 and September 2012 were reviewed retrospectively. Men with a VFA of >130 cm2 and women with a VFA of >90 cm2 were classified as obese (VFA-O, n = 22), and the remaining patients were classified as nonobese (VFA-NO, n = 80). RESULTS: No differences in morbidity, mortality, postoperative bowel recovery, and readmission rate after surgery were observed between the 2 groups. However, a significantly higher number of harvested lymph nodes was observed in the VFA-NO group compared with the VFA-O group (19.0 +/- 1.0 vs. 13.5 +/- 1.2, respectively, P = 0.001). CONCLUSION: Visceral obesity has no influence on intraoperative difficulties, postoperative complications, and postoperative recovery in patients with sigmoid colon or rectal cancer.

Diffuse Skeletal Hemangiomatosis Mimicking Sacroiliitis

Hemangiomatosis of the skeletal system is a rare disease without specific symptoms and signs. We describe a 20-year-old patient with low back pain, whose plain radiographs of sacroiliac (SI) joint showed irregular sclerotic lesions. The patient was finally confirmed with skeletal hemangiomatosis by magnetic resonance imaging (MRI) and excisional biopsy of the lesion. The present case suggests that if patients with abnormal lesions of the SI joint in the plain radiographs do not have typical inflammatory back pain, advanced imaging is required to make an accurate diagnosis. Our case also emphasizes the importance of MRI and biopsy in establishing the diagnosis.

Long-term follow-up may be needed for pancreaticobiliary reflux in healthy adults / 대한외과학회지

PURPOSE: The reflux of pancreatic enzymes into the biliary tract is associated with chronic inflammation and increases cellular proliferation of the biliary epithelium, leading to biliary carcinoma. The aim of this study is to detect the incidence of occult pancreaticobiliary reflux (OPBR) in patients who underwent elective cholecystectomy. METHODS: Forty-seven patients with symptomatic gallstones who underwent cholecystectomy were recruited for this study. The gallbladder bile samples were obtained from the specimen of gallbladder and the amylase level was measured. The immunohistochemistry of p53, SMAD4 and Ki-67 were performed for the detection of metaplasia and dysplasia. RESULTS: Biliary amylase was higher than the serum amylase in 10 patients (group A, 15,402.66 +/- 33,592.43 IU/L; group B, 13.06 +/- 18.12 IU/L). The mean age was 67.2 years in group A and 51.2 in group B (P < 0.01). The ratio of male to female was 1:2.3 and 1:1.8 in group A and B, respectively (P = 0.297). Eight patients in group A and thirteen patients in group B had inflammation (P = 0.014). The positive results of the Ki-67 test were exhibited in five cases in each group (P = 0.024). CONCLUSION: Results from the study indicate that the age was older, degree of inflammation and positive rate of Ki-67 were higher when OPBR was suspected. In conclusion, the patients with OPBR would need long-term follow-up, because the OPBR can cause dysplasia and the reflux of pancreatic juice may be considered as a risk factor for extrahepatic bile duct carcinoma.

Clinical Experience of Basosquamous Cell Carcinoma

PURPOSE: Basosquamous carcinoma is a rare malignancy, with features of both basal cell carcinoma and squamous cell carcinoma. It is considered as aggressive tumor with a high risk of recurrence and metastases. Authors report a case of basosquamous cell carcinoma. METHODS: A 72 year-old man, who had an erythematous ulcer on his left auricle, described a slow growing lesion, starting at the posterior surface of the superior helix with a steady increase in size during the past 10 years. At operation, auricular cartilage was grossly invaded by the tumor and was, therefore, amputated with tumor-free margins. RESULTS: Histopathologic examination was revealed a basosquamous cell carcinoma. On positron emission tomography/computed tomography (PET/CT) and neck CT were negative for signs of further nodal involvement or metastases to other organs. At follow-up 6 months later, his wounds were noted to be well healed, with no evidence of local recurrence or identifiable metastases. CONCLUSION: Because basosquamous cell carcinoma has a significant potential to recur and metastasize, surgical excision for this type of carcinoma should be more extensive than that performed for conventional basal cell carcinoma or squamous cell carcinoma. In addition, regional lymph nodes should be monitored and close follow-up should be carried out.

Compression of the Superficial Radial Nerve by Schwannoma: A Case Report

PURPOSE: Schwannoma, a benign peripheral nerve tumor, is slow-growing, encapsulated neoplasm that originates from the Schwann cell of the nerve sheath. Schwannoma most frequently involves the major nerve. Schwannoma occurring in the superficial radial nerve rare. This is a report of our experience with schwannoma arising from the superficial radial nerve with neurologic symptom. METHODS: A 55-year-old woman presented with eight-month history of progressive numbness and paresthesia in dorsum of the thumb and index finger. Physical examination revealed a localized mass on the midforearm. Sonographic examination showed an ovoid, heterogenous, hypoechoic lesion, located eccentrically in related to the superficial radial nerve. The lesion was mobile in the transverse but not in the longitudinal axis of the nerve, which was thought to favour schwannoma rather than neurofibroma. At operation, a 20 x 15 mm ovoid, yellowish grey mass was seen arising from the superficial radial nerve. The tumor present as eccentric masses over which the nerve fibers are splayed. Using operating microscope, the tumor was removed, preserving the surrounding nerve. RESULTS: Histology confirmed that the mass was a benign schwannoma. There were no postoperative complications. After two months the patient had no clinically demonstrable sensory deficit. CONCLUSION: An unsusual case of a schwannoma of the superficial radial nerve is presented. In case with neurologic symptom, prompt surgical decompression must be made to prevent further nerve damage and to restore nerve function early.

Blue Toe Syndrome: A Case Report

PURPOSE: Blue toe syndrome consists of blue or purplish toes in the absence of a history of obvious trauma, serious cold exposure, or disorders producing generalized cyanosis. It is a life-threatening and still underrecognized disease. It can be commonly occurred by vascular surgery, invasive cutaneous procedures or anticoagulant therapy. Our case is presented of blue toe syndrome related to atheromatous embolization that was presumably triggered by angio CT. METHODS: A 69-year-old man presented with the suddenly developed pain, cyanosis and livedo reticularis of the toes in right foot. Dorsalis pedis pulses were palpable. He had been performed a diagnostic angio CT 1 month earlier. Angio CT revealed diffuse aortic atheromatous plaque in lower abdominal aorta and both common iliac artery. One month after angio CT, he visited our clinic. There was no visible distal first dorsal metatarsal artery and digital artery of right first toe in lower extremity arteriography. A diagnosis was established of blue toe syndrome. Because his symptom was aggravated, we performed the exploration of the right foot. After exposure of first dorsal metatarsal artery, microsurgical atheroembolectomy was done. RESULTS: There were no postoperative complications. After three months the patient had no clinically demonstrable problems. CONCLUSION: Patient with blue toe syndrome is at high risk of limb loss and mortality despite treatment. Blue toe syndrome produces painful, cyanosed toes with preserved pedal pulses. It needs to be aware of blue toe syndrome. Careful history should reveal the diagnosis. Treatment is controversial, however, most believe that anticoagulation therapy should be avoided.

Adult Intussusception due to Cecal Lymphangioma: A Case Report

We present a rare case of adult intussusception due to cecal lymphangioma. A 30-year-old female was admitted to our hospital with abdominal pain and a palpatable mass on the right lower quadrant. Preoperative radiologic studies by ultrasound and computed tomography showed ileocolic intussusception with a multiseptated cystic tumor as a leading point on the cecum. An ileocecectomy was performed, and the postoperative course was uneventful. Histopathology showed a cecal lymphangioma. Although endoscopic polypectomy or endoscopic mucosal resection is recommended for pedunculated or semi-pedunculated colonic lymphangiomas less than 2 cm in size, it is proper to treat large or symptomatic colonic lymphangiomas with limited a bowel resection or a tumor resection.

Sensitivity and Specificity of Screening Mammographies and Ultrasonographies Performed in Women at Seven Health Promotion Centers for One year

PURPOSE: We wanted to evaluate the sensitivity and specificity of screening mammography and ultrasonography for breast examinations and we assessed the clinical usefulness of breast ultrasound for cancer screening. MATERIALS AND METHODS: Of all the women who visited the health promotion center of seven medical institutions from Mar 2004 to Feb 2005, we compared the sensitivity and specificity between a single use of mammography and mammography with ultrasonography for the patients who underwent both mammography and ultrasonography. Here, the reference criteria were the follow-up and the histopathology, which were performed after one year. RESULTS: A total of 1123 patients underwent both mammography and ultrasonography and they could be followed up for a year. For the 1123 patients who underwent both mammography and ultrasonography, the sensitivity and specificity of a single use of mammography were 14.3% and 86.9%, respectively. The sensitivity and specificity of mammography with ultrasonography were 85.7% and 85.9%, respectively. These results showed that the sensitivity was significantly increased when mammography was combined with ultrasonography (< 0.05). CONCLUSION: The sensitivity was improved for the cases that underwent both mammography and ultrasonography.

A case of hyperglycemia-induced hemiballism-hemichorea associated with diabetic ketoacidosis / 대한내과학회지

Hemiballism-hemichorea (HB-HC) is defined as continuous, non-patterned, and involuntary movement involving one side of the body and is often associated with endocrine diseases such as diabetes mellitus (DM) and hyperthyroidism. In Korea, 16 cases of HB-HC associated with non-ketotic hyperglycemia have been reported. Here, we report the first known case of HB-HC associated with type 2 DM and diabetic ketoacidosis (DKA). A 32-year-old man visited our hospital complaining of hemichoreoballistic movement. The patient had no history of DM. In a neurological examination and laboratory tests, HB-HC associated with type 2 DM and DKA was diagnosed. The patient was immediately treated with intravenous hydration and insulin therapy, and completely recovered. DKA and non-ketotic hyperglycemia should be considered as a possible cause of HB-HC, although these are very rare. In HB-HC associated with DKA, strict blood glucose control is needed.