A Concurrence of Adenocarcinoma with Micropapillary Features and Composite Glandular-Endocrine Cell Carcinoma in the Stomach

We report a unique case of synchronous double primary gastric cancer consisting of adenocarcinoma components with micropapillary features and composite glandular-endocrine cell carcinoma components. The patient was a 53-year-old man presenting with a 6-month history of epigastric pain and diarrhea. A subtotal gastrectomy was performed. Histologically, one tumor was composed of micropapillary carcinoma components (50%) with tight clusters of micropapillary aggregates lying in the empty spaces, admixed with moderately differentiated adenocarcinoma components. MUC-1 was expressed at the stromal edge of the micropapillary component. The other tumor was composed of atypical carcinoid-like neuroendocrine carcinoma (50%), adenocarcinoid (30%), and adenocarcinoma components (20%). The neuroendocrine components were positive for CD56, synaptophysin, chromogranin, and creatine kinase. The adenocarcinoid components were positive for both carcinoembryonic antigen and neuroendocrine markers (amphicrine differentiation). This case is unique, due to the peculiar histologic micropapillary pattern and the histologic spectrum of adenocarcinoma adenocarcinoid-neuroendocrine carcinoma of the synchronous composite tumor.

Colon Cancer After Acute Diverticulitis Treatment

Diverticulitis is the most common clinical complication of diverticular disease, affecting 10-25% of the patients with diverticula. The prevalences of diverticulitis and colon cancer tend to increase with age and are higher in industrialized countries. Consequently, diverticulitis and colon cancer have been reported to have similar epidemiological characteristics. However, the relationship between these diseases remains controversial, as is the performance of routine colonoscopy after an episode of diverticulitis to exclude colon cancer. Recently, we experienced three cases of colon cancer after treating acute diverticulitis, based on which we suggest the importance of follow-up colonoscopy after acute diverticulitis.

Expression of E-cadherin, beta-catenin, Cdx2 and MMP7 in pT2 and N1/N2 Gastric Cancer: Relationship with Tumor Recurrence within 2-Year Period

PURPOSE: The aim of this study was to examine the expression of E-cadherin, beta-catenin, Cdx2, MMP7 in gastric cancer and to evaluate the clinical significance of these molecules in tumor recurrence within 2 years of pT2 and N1/N2 gastric cancer. METHODS: In 122 patients who underwent radical resection of gastric cancer, we investigated the association between the expression of these molecules and clinicopathologic factors by immunohistochemistry. The included criteria were pT2 and N1 or N2 (6th AJCC TNM). RESULTS: The expression of MMP7 was significantly associated with N stage (N1 vs. N2) (P=0.011). The negative expression of beta-catenin was strongly correlated with tumor recurrence within a 2-year period. However, the expression of these molecules was not related with recurrent sites. Multivariate analysis demonstrated that negative expression of beta-catenin was an independent predictor for tumor recurrence within 2 years (OR 2.366; 95% CI 1.056~5.297; P=0.036). CONCLUSION: Negative expression of beta-catenin may serve as a significant indicator for predicting tumor recurrence within a 2-year period in pT2 and N1/N2 gastric cancer.

Case of Abdominal Compartment Syndrome Treated by using a Bedside Open Linea Alba Fasciotomy

Abdominal compartment syndrome (ACS) is a life-threatening disorder caused by rapidly increasing intraabdominal pressure. ACS can result in multiorgan failure and carries a mortality of 60~70%. The treatment of choice in ACS is surgical decompression. There are very few reports of ACS and experience in Korea. We report 12-year-old male patient who developed an abdominal compartment syndrome due to traffic-accident-induced retroperitoneal hematomas, Which was successfully treated by performing a bedside emergency surgical decompression with open linea alba fasciotomy with intact peritoneum. When patients do not respond to medical therapy, a decompressive laparotomy is the last surgical resort. In patients with severe abdominal compartment syndrome, the use of a linea alba fasciotomy is an effective intervention to lower intra-abdominal hypertension (IAH) without the morbidity of a laparotomy. Use of a linea alba fasciotomy as a first-line intervention before committing to full abdominal decompression in patients with abdominal compartment syndrome improves physiological variables without mortality. Consideration for a linea alba fasciotomy as a bridge before full abdominal decompression needs further evaluation in patients with polytrauma abdominal compartment syndrome.

The Comparison between 6th and 7th UICC/AJCC N Stage for Prognostic Significance in Gastric Cancer

PURPOSE: The 7th edition UICC/AJCC TNM classification for gastric cancer has several changes from the previous edition. Especially, the classification of the number of lymph node metastases (LNM) is reorganized. According to the new TNM system, N stage was categorized to N0 (no LNM), N1 (1~2 LNM), N2 (3~6 LNM), N3 (7 or more LNM). The aim of our study was to compare the prognostic significance of the new (7th) UICC/AJCC N stage with the old (6th). METHODS: From 2000 to 2005 a total of 425 patients who underwent curative resections with D2 and with 15 or more lymph nodes retrieved were studied retrospectively. RESULTS: According to the 7th UICC/AJCC N stage, the 5-year cumulative survival rates (5YSR) of N0, N1, N2, N3 were 96.0%, 79.2%, 58.5% and 24.3%, respectively (P<0.001). Using univariate analysis, the N stage of 7th and 6th UICC/AJCC TNM classification, 7th UICC/AJCC T stage, differentiation of tumor, type of gastrectomy (subtotal and total gastrectomy), size of primary tumor (< or =5, 5<< or =10, 10<) were associated with 5YSR. However, Cox regression multivariate analysis showed the 7th UICC/AJCC N stage to bean independent factor for predicting the 5YSR instead of the 6th UICC/AJCC N stage (P<0.001, hazard ratio (HR) 1.859, 95% confidence interval (CI) 1.576~2.194), including depth of tumor invasion (P<0.001, HR 1.673, 95% CI 1.351~2.073). CONCLUSION: The new (7th) UICC/AJCC N stage is a more reliable prognostic factor of gastric cancer than the old (6th) N stage.

The Analysis of Clinical Characteristics of pT2a and pT2b Gastric Cancer

PURPOSE: T2 gastric cancer is tumor invading proper muscle or subserosal layer. The 2002 American Joint Committee on Cancer subdivided the pT2 gastric adenocarcinoma into a type pT2a (invasion of the proper muscle) and a type pT2b (invasion of the subserosa). The aim of this study was to evaluate the differences between pT2a and pT2b gastric cancers of the clinicopathological features and the prognostic factors. METHODS: A series of curative operations were performed on 194 patients with pT2 gastric cancer from January 1999 to February 2006. We reviewed, retrospectively, the clinicopathologic characteristics, the 3-year disease free survival and the 5-year disease specific survival rates. RESULTS: There were significant clinicopathologic differences between pT2a and pT2b gastric cancer in tumor size and the number of metastatic lymph nodes. Both of the 3-year disease free survival time and the 5-year disease specific survival time were much longer for the pT2a gastric carcinoma patients than those for the pT2b gastric carcinoma patients. CONCLUSION: It is important to consider the differences between pT2a and pT2b gastric cancers for prediction of recurrence or prognosis. Furthermore, new staging of pT2a and pT2b cancer may be necessary.

Spontaneous Perforation of Pyometra Leading to Acute Abdomen

A pyometra is an accumulation of pus in the endometrial cavity mostly due to obstruction of the cervical canal. It is a rare condition, and usually affects postmenopausal women. Moreover, spontaneous rupture of the uterus is an extremely rare complication of pyometra. We present a case of spontaneous perforation of pyometra, which presented as an acute abdomen in emergency and was misdiagnosed as gastrointestinal tract perforation.

Experience with the Use of the Surgical Staplers in Rectal Cancer Surgery

The surgical stapling technique has been recognized as an indispensable tool in rectal cancer surgery. A personal experience in one-hundred patiens is presented for the purpose of appropriate use of the surgical staplers. Three anastomotic techniques used were end-to-end anastomosis in 75 cases, double-stapling in 11 cases, and side-to-end anastomosis in 14 cases. In 88 cases, level of anastomosis was below the peritoneal reflection. Eight cases of stapling errors were found during operation. Among them, 5 cases of instrumental failure were 2 cases of blade defect and each one of difficult extraction, misfiring or tearing over trocar. The other 3 cases of surgical errors come from uneven perirectal excision causing one incomplete doughnut and 2 deficient anastomosis. Distal resection margin was closely related to the location of tumor(p < 0.01), but local recurrence did not associated with it. Two cases of postoperative hematochezia showed self-limiting. Anastomotic leakage occurred in 3 female patients and they were converted into resection. Excluding one leakage from skipped proximal foci, 2 cases occurred in the ultra-low anastomosis. Postoperative stricture was found in 5 cases and they were not associated with internal diameter of circular stapler. They were treated by manual dilatation and bulk-forming laxatives without surgical intervention. Bowel frequency or inability of deferrment was found in 9 cases on 1 month and 5 cases on 6 months postoperatively. They were not related to anastomotic level or stapling method. In conclusion, the stapling technique in rectal cancer surgery is a safe as well as a comfortable technique whenever complication can be amenable to the surgeon.