Hyalinizing Trabecular Tumor (HTT) of Thyroid: Two Case Report / 대한내분비외과학회지

Hyalinizing trabecular tumor (HTT), a type of thyroid lesion, was first reported by Carney in 1987 and has since been reported continuously. Due to its histological non-specificity, HTT can be misdiagnosed as papillary thyroid cancer or medullary thyroid cancer. For this reason, over treatment might occur; for example, total thyroidectomy and lymphadenectomy. Diagnosis and treatment is a challenge because there is still controversy regarding HTT characters. We report on two cases. One patient was a 48-year-old female and the other was a 46-year-old female. Both patients complained of a thyroid mass and were diagnosed as HTT.

The Clinical Outcome of Combined Organ Resection during Radical Gastrectomy

PURPOSE: Combined organ resection is a common operation in gastric cancer surgery. The aim of this study is to investigate the risk of combined minor organ resection (GB, gynecologic organ, appendix etc) in gastric cancer surgery. METHODS: The clinical data from 673 consecutive patients who underwent gastrectomy for gastric cancer at a single center were retrospectively analyzed. We investigated clinical data between open groups (OG) and laparoscopy groups (LAG), and we divided the patients into 3 groups: no resection group, minor organ resection group and major organ (spleen, pancreas, and colon) resection group. RESULTS: There were higher complication rates in major organ resection group (59.3%, 53.8%) than no resection (32.3%, 19.1%) or minor organ resection groups (38.7%, 20%) both in OG and LAG (P<0.05). However, there were longer hospital stays in minor (22.2 days) and major resection groups (24.1) than no resection group (16.2) in OG, but stays were longer in major resection group (30.9) than minor (14.5) and no resection group (16.2) in LAG (P<0.01). Operative times were longer in minor (287 min) and major organ resection group (310) than no resection group (243) in OG (P<0.00). However, operation time was longer in major resection group (505) than minor (415) and no resection group (370) in LAG (P=0.00). CONCLUSION: Combined minor organ resection with gastrectomy does not increase morbidity, and there is no statistical difference in hospital stay and op time than no resection group in LAG.

The Risk Factors of Reflux Complication after Gastrectomy for Proximal Gastric Cancer

PURPOSE: The aim of this study was to investigate the risk factors of reflux associated complications (reflux symptoms, reflux esophagitis, and esophageal stricture) after gastrectomy for proximal gastric cancer. METHODS: 150 patients with proximal gastric cancer were included from January 2005 to December 2008. Their medical and surgical records were retrospectively analyzed concerning clinical and pathologic characteristics, operation methods, morbidity, reflux associated complications and nutritional states. RESULTS: Tumor sizes and operation methods were statistically significant in univariate analysis of risk factors for reflux associated complications (P0.05). However, reflux complications were significantly more common in proximal gastrectomy groups (72.4%) than in total gastrectomy groups (29.5%). Severe reflux esophagitis (LA classification C or D) was found in only proximal gastrectomy groups. CONCLUSION: Total gastrectomy is favorable for proximal early gastric cancer in terms of reduced esophageal reflux complications.

Percutaneous Pericardiostomy and Trastuzumab Monotherapy for Treating Pericardial Metastasis from Breast Cancer and this Presented as Cardiac Tamponade

Although autopsy studies suggest that malignant pericardial effusion is present in up to 15% of the patients suffering with malignancies, symptomatic pericardial effusion presenting as a first manifestation of systemic recurrence in a breast cancer patient is a rare condition. Symptomatic malignant pericardial effusion requires prompt attention and intervention since it can lead to the cardiac tamponade. Treatment of symptomatic pericardial effusion includes pericardial decompression and systemic or intrapericardial chemotherapy. We recently experienced a patient with early breast cancer who developed cardiac tamponade from malignant pericardial effusion as a first manifestation of systemic recurrence 4 years after her initial surgery. The patient was treated with percutaneous pericardiocentesis and she subsequently received systemic trastuzumab. After 6 cycles of trastuzumab, the follow-up CT showed complete disappearance of the pericardial effusion and the mediastinal lymph nodes.

Endodontic file in an appendix / 대한내과학회지

Once ingested foreign bodies pass through the stomach, 80 to 90 percent of them will exit via the gastrointestinal tract and they are excreted naturally in 7-10 days; surgical treatment is not required in most case. But once foreign bodies permeate the appendix, it is difficult for them to be excreted again to the cecum; therefore, this can possibly cause appendicitis or perforation. Especially in case of long, pointed, thin, stiff, sharp and/or metalic objects, the risk of perforation will increase. We attempted to remove an endodontic file in the appendix by colonoscopy. This was done in a patient who came to hospital because he swallowed an endodontic file during endodontic therapy. But we failed to retrieve it, and so we got rid of the foreign body by performing elective surgery before the occurrence of complications. We report here on surgical removal of an apppendiceal foreign body along with a review of the literature.

Fournier's Gangrene: Clinical Analysis of 11 Patients

PURPOSE: Fournier's gangrene is a rare and rapidly progressive infection of the genitalia, perineum, and abdominal wall. The mortality rate from this infection ranges from 0 to 67 percent. One of the most important determinants of the overall outcome is early recognition and extensive surgical debridement combined with broad-spectrum antibiotics therapy. The objective of this study was to review the clinical outcomes of 11 consecutive patients who suffered with Fournier's gangrene and the related medical literature to highlight the current status of this disease. METHODS: We retrospectively reviewed the records of 11 patients with the Fournier's gangrene who had been treated at Gyeongsang National University Hospital between March 1995 and March 2005. RESULTS: The mean age was 60 years (range: 38~82), and the male to female ratio was 8 : 3. The most common cause of Fournier's gangrene was perianal abscess (n=4, 36.3%) and the most common disease associated with Fournier's gangrene was diabetes mellitus (n=6, 54.5%). The most common cultured organisms were E. coli and K. pneumoniae. We performed aggressive surgical debridement combined with broad spectrum antibiotics therapy. The number of surgical procedures per patients ranged between 1 and 7 (mean: 2.63). Diverting colostomy was required in 36.3% (n=4) of the cases. Two cases received reconstructive plastic surgery. The mortality rate of 11 patients was 27.2% (n=3) and the cause of death was sepsis. CONCLUSION: Fournier's gangrene is a life-threatening disease, but the mortality rate can be diminished via early diagnosis, aggressive surgical intervention, and the use of broad- spectrum antibiotics.

Intussusception after Blunt Abdominal Trauma in Adult

Intussusception is rare in adults accounting for 5% of all cases. It can be caused by various lesions but is rarely the result of trauma. Recently we encountered a case of adult intussusception after blunt abdominal trauma without any other leading causes. We report this case with a review of the relevant literatures.

Clinical Implication of Galectin-1 Expression in Human Breast Cancer / 한국유방암학회지

PURPOSE: The role of different galectins in the pathogenesis of different types of malignancy is now being intensely investigated. In this study, authors investigated the level of galectin-1 expression in human breast cancer tissue to define its relationship to the tumor invasiveness and tumor progression. METHODS: Formalin-fixed, paraffin-embedded tissues from 79 randomly selected breast cancer patients were used to perform immunohistochemical staining for galectin-1. The primary antibody was diluted mouse monoclonal antibody against galectin-1. The staining results were then interpreted by an experienced pathologist, and the results were compared between the groups having different pathologic variables. RESULTS: In breast cancer patients, galectin-1 was diversely expressed in the cancer tissue. Galectin-1 was expressed in both cancer cells and cancer-associated stromal cells. The levels of galectin-1 expression in cancer-associated stromal cells were higher in patients with invasive carcinoma (p = 0.001), in patients with advanced T stages (p = 0.007), and in patients with advanced TNM stages (p = 0.007). The galectin-1 expression in cancer-associated stromal cells was also higher in patients with lymph node metastasis and advanced N stages, but did not reach a statistically significant level. The galectin-1 expression in cancer cell did not have any correlation with pathologic variables. CONCLUSION: This is the first study that has demonstrated the relationship of galectin-1 expression with the tumor invasiveness and tumor progression in human breast cancer. Further large-scaled studies are needed to define the prognostic value of galectin-1 in breast cancer patients, and the exact role of galectin-1 should be investigated more thoroughly.

Clinical Implication of Galectin-1 Expression in Human Breast Cancer / 한국유방암학회지

PURPOSE: The role of different galectins in the pathogenesis of different types of malignancy is now being intensely investigated. In this study, authors investigated the level of galectin-1 expression in human breast cancer tissue to define its relationship to the tumor invasiveness and tumor progression. METHODS: Formalin-fixed, paraffin-embedded tissues from 79 randomly selected breast cancer patients were used to perform immunohistochemical staining for galectin-1. The primary antibody was diluted mouse monoclonal antibody against galectin-1. The staining results were then interpreted by an experienced pathologist, and the results were compared between the groups having different pathologic variables. RESULTS: In breast cancer patients, galectin-1 was diversely expressed in the cancer tissue. Galectin-1 was expressed in both cancer cells and cancer-associated stromal cells. The levels of galectin-1 expression in cancer-associated stromal cells were higher in patients with invasive carcinoma (p = 0.001), in patients with advanced T stages (p = 0.007), and in patients with advanced TNM stages (p = 0.007). The galectin-1 expression in cancer-associated stromal cells was also higher in patients with lymph node metastasis and advanced N stages, but did not reach a statistically significant level. The galectin-1 expression in cancer cell did not have any correlation with pathologic variables. CONCLUSION: This is the first study that has demonstrated the relationship of galectin-1 expression with the tumor invasiveness and tumor progression in human breast cancer. Further large-scaled studies are needed to define the prognostic value of galectin-1 in breast cancer patients, and the exact role of galectin-1 should be investigated more thoroughly.

Clinical Features of Colorectal Serrated Adenomas

PURPOSE: Colorectal cancer is believed to progress through an adenoma-carcinoma sequence. However, recent evidence increasingly supports the existence of an alternative route for colorectal carcinogenesis through a serrated adenoma, which combines the architectural features of hyperplastic polyps with the cytological features of traditional adenomas. We assessed the characteristics and the endoscopic features of serrated adenomas and compared them with those of hyperplastic polyps and traditional adenomas in Korea. METHODS: The medical records of 344 consecutive patients who underwent a colonoscopic biopsy or polypectomy from January 2003 through August 2004 at Gyeongsang National University Hospital were analyzed retrospectively. RESULTS: Serrated adenomas were seen in 12 cases (3.4%), and the most common site was the rectum (50%). Endoscopically in most cases, the serrated adenomas had small diameters (< or = 0.5 cm) and were single polyps. Morphologically, the serrated adenomas were flat and non-pedunculated. The coincidental rate of the carcinomas was 8.3%. CONCLUSIONS: According to this study, serrated adenomas are generally single, sessile adenomas with diameters less than 5 mm, and they are commonly observed in the left colon, especially in the rectum.

Retrograde Jejuno-gastric Intussusception

Retrograde jejuno-gastric intussusception is an unusual complication after gastroenterostomy. It is very difficult to diagnosis this illness before endoscopy or operation, so a high clinical suspicion is needed to make the diagnosis .There have been only 300 reported cases of this illness. There are four types of jejuno-gastric intussusception that are defined anatomically. Intussusception of the efferent limb of the jejunum is the most frequent type. Although the causative factors are not well known, this disease has a poor outcome unless it's treats promptly within 48 hours. We report here a case of hematemesis caused by intussusceptum from the efferent limb to the afferent limb of Braun anastomosis.

Spontaneous Transmesenteric Hernia in Adult

A 27-year-old female patient presented to the emergency room with abdominal pain and vomiting. The clinical findings including the computed tomography (CT) scan, suggested internal herniation. The patient had no history of previous abdominal operation or peritonitis. At the surgery, a part of the distal jejunum and proximal ileum 90 cm in length was herniated through a 4 cm-sized round mesenteric defect of the mesentery. Spontaneous transmesenteric hernia is a rare cause of internal herniation, but the possibility should be kept in mind even when the patient has no history of abdominal operation or peritonitis.

The Distribution Pattern of Lymphocyte Subsets according to the Level of Serum Albumin in Preoperative Patients with Gastric Cancer

PURPOSE: Considering that nutritional state correlates to immunity, we performed this study to evaluate the correlation by assessing the numerical changes of the levels of serum albumin and lymphocyte subsets. MATERIALS AND METHODS: The study was performed on patients who were diagnosed as having gastric cancer and who underwent curative surgery from August 1998 to August 2004 in the Gyeongsang National University Hospital and whose peripheral blood lymphocyte subsets were tested prior to surgery. The study population was a total of 150 cases. RESULTS: The change in the lymphocyte subsets in relation to the change in the level of serum albumin in all patients with gastric cancer was determined, and was compared to disease stages. When patients were classified by using the level of serum albumin with 3.2 mg/dl as the cut-off point (low group: serum albumin or=3.2 mg/dl), the number of peripheral blood lymphocytes, CD3+ cells, CD4+ cells, CD8+ cells, and CD16+56 cells were, significantly lower in the group with the level of serum albumin below 3.2 mg/dl (low group) than it was in the group with a serum albumin level above 3.2 mg/dl (normal group) (P<0.05). In stage I (n=59), CD16+56 cells were significantly lower in the low group. In stage II (n=29), the number of CD16+56 cells was lower and the ratio of CD4+/CD8+ was higher in the low group than in the normal group significantly. In stage IV (n=33), except for CD19+ cells, the number of all lymphocyte subsets was significantly lower and the ratio of CD4+/CD8+ was significantly higher in the low group. CONCLUSION: The group with a low level of serum albumin had a low absolute number of lymphocyte subsets. Based on this, we reconfirmed that the nutritional state is closely related with the immune state in patients with gastric cancer.

The Distribution Pattern of Lymphocyte Subsets according to the Level of Serum Albumin in Preoperative Patients with Gastric Cancer

PURPOSE: Considering that nutritional state correlates to immunity, we performed this study to evaluate the correlation by assessing the numerical changes of the levels of serum albumin and lymphocyte subsets. MATERIALS AND METHODS: The study was performed on patients who were diagnosed as having gastric cancer and who underwent curative surgery from August 1998 to August 2004 in the Gyeongsang National University Hospital and whose peripheral blood lymphocyte subsets were tested prior to surgery. The study population was a total of 150 cases. RESULTS: The change in the lymphocyte subsets in relation to the change in the level of serum albumin in all patients with gastric cancer was determined, and was compared to disease stages. When patients were classified by using the level of serum albumin with 3.2 mg/dl as the cut-off point (low group: serum albumin or=3.2 mg/dl), the number of peripheral blood lymphocytes, CD3+ cells, CD4+ cells, CD8+ cells, and CD16+56 cells were, significantly lower in the group with the level of serum albumin below 3.2 mg/dl (low group) than it was in the group with a serum albumin level above 3.2 mg/dl (normal group) (P<0.05). In stage I (n=59), CD16+56 cells were significantly lower in the low group. In stage II (n=29), the number of CD16+56 cells was lower and the ratio of CD4+/CD8+ was higher in the low group than in the normal group significantly. In stage IV (n=33), except for CD19+ cells, the number of all lymphocyte subsets was significantly lower and the ratio of CD4+/CD8+ was significantly higher in the low group. CONCLUSION: The group with a low level of serum albumin had a low absolute number of lymphocyte subsets. Based on this, we reconfirmed that the nutritional state is closely related with the immune state in patients with gastric cancer.

Proximal Jejunal Perforation due to Postgastrectomy Bezoar

Bezoars are conglomerates of vegetable fiber and hair, or concretions of various substances located in the stomach or the intestinal tract. They are classified as phytobezoar, trichobezoar, trichophytobezoar, and concretion. It is shown that the decrease in secretion of pepsin and gastric acid and the delay in gastric emptying might contribute to the formation of bezoars. This case describes the rare complication of the jejunal perforation due to a postgastrectomy bezoar.

Castleman's Disease in Unusual Location; Plasma Cell Variant

Castleman's disease, or angiofollicular lymph node hyperplasia, is a rare tumor of lymphoid origin, of unknown etiology. The expected localization is mediastinum, but rarely retroperitoneum. Localized and multicentric Castleman's diseases may be different clinical disorders, but with overlapping histological features. Recently, we experienced three cases of Castleman's disease. One case was a mixed variant, which presented as a right perirenal mass in a 23-year-old woman. The lesion was detected incidentally on computerized tomography (CT) and successfully resected. The remaining two cases were multicentric, plasma cell variants of Castleman's disease, which presented as an inguinal mass in a 29-year-old male, and as a multiple neck lymphadenopathy in a 63-year-old male, respectively. Although Castleman's disease in the perirenal retroperitoneum is extremely rare, accounting for only 2% of all reported cases, it should be included in the differential diagnosis of the mostly malignant retroperitoneal masses. We suggested that radical surgery may be avoided, given the excellent outcome after a limited excision in solitary retroperitoneal Castleman's disease.

Multiple Duodeno-jejunal GIST associated with Pheochromocytoma in Patients with Von Recklinghausen Disease

Type-I neurofibromatosis (NF-I) is an autosomal dominant hereditary condition that may affect the gastrointestinal tract in 25% of cases. Gastrointestinal stromal tumors(GISTs) are rarely noted in associated with NF-I as an gastrointestinal manifestation. We suggest that iron deficiency anemia in patient with NF-1 mandates the endoscopic and radiologic evaluation of the digestive tract to find or rule out neurofibromas and GISTs. Pheochromocytomas have been clinically identified in 0.1 to 5.5% of patients with NF-I. An adrenal mass may be incidentally discovered in any patients and must be evaluated in patients with NF-1 to exclude pheochromocytoma from diagnosis. This report describes the concomitant occurrence of a multiple duodeno-jejunal GISTs and an adrenal pheochromocytoma in patient with NF-I. Immunohistologically, the tumor cells were intensely positive for CD117, focally positive for S-100 and neuron-specific enolase (NSE), whereas negative for smooth muscle actin, and diagnosed as GISTs. The presence of spindle cell hyperplasia in the myenteric plexus may help to better explain the histogenesis of multiple GISTs.

The Accuracy of Imprint Cytology in the Intraoperative Diagnosis of Lymph Node Metastasis in Gastric Cancer Surgery

PURPOSE: Intraoperative assessment of lymph node status is important when performing limited surgery in gastric cancer patients. Currently available techniques are frozen section, imprint cytology, and other molecular methods, and most current studies use the frozen section method. In the present study, the authors focused on the accuracy and the feasibility of imprint cytology as a tool to assess the lymph node status intraoperatively in gastric cancer surgery. MATERIALS AND METHODS: Between April 2001 and March 2003, we performed imprint cytology of the sentinel nodes of 260 consecutive patients. After review by an experienced cytopathologist, the sensitivity, the specificity and the overall accuracy were determined. RESULTS: The time required for intraoperative imprint cytology was 8 minutes, and the sensitivity, the specificity and the overall accuracy were 52.2%, 88.8%, and 73.8%, respectively. CONCLUSION: Imprint cytology can be a useful technique for assessing lymph node status intraoperatively if the sensitivity and the specificity can be improved to an acceptable level.

Laparoscopic Gastric Surgery in Early Gastric Cancer: the Analysis of Early 25 Cases

PUPOSE: The use of laparoscopic surgery for gastric disease has been gaining popularity. However, there has been the controversy over the indications and the standard techniques of laparoscopic gastric surgery in the early gastric cancer (EGC). The purposes of this study were to compare the clinical outcomes among a hand-assisted laparoscopic distal gastrectomy (HALDG), a laparoscopy-assisted distal gastrectomy (LADG), and an open distal gastrectomy (ODG) and to discuss the role of these procedures in the treatment of EGC. MATERIALS AND METHODS: Between August 2001 and July 2004, laparoscopic surgery was performed in our institution on 25 patients, LADG (n=7) and HALDG (n=18) with EGC. Analysis was performed on clinical data such as the operative time, the hospital stay, the start of oral intake, and the number of harvested lymph nodes. Patients were categorized into early and late groups by using the date of surgery and were also grouped by surgical procedure. To evaluate the feasibility and efficacy of laparoscopic surgery for EGC, we compared the clinical data with those for ODGs performed during the same period. RESULTS: There was no difference in the number of harvested lymph nodes between the laparoscopic group and the open group, but the operation time in the laparoscopic group was longer than that in the open group (P<0.05). Also, no significant differences in other clinical data were found between the two groups. Comparing the early and the late periods of the series, the number of harvested lymph nodes for a HALDS increased from 22.31 4.29 to 29.40 3.21 (P<0.05). CONCLUSION: Our early experience with laparoscopic gastric surgery shows that a wide range of possibilities exist for applying laparoscopic gastric surgery to selected gastric cancer patients. However, the surgical procedure should be standardized, and the outcomes of laparoscopic surgery, in comparison to those of open surgery, need to be confirmed based on a large randomized study.

Abdominal Actinomycosis Presented as a Periappendiceal Abscess

The anaerobic gram-positive bands, Actinomycosis israelii, are normal inhabitants of the oral cavity but upper intestinal tract of humans and rarely cause disease. Actinomycosis is an infrequent chronic suppurative infection which usually manifests as fistulas and sinuses or as a mass that simulates a pseudo-neoplastic formation. The cervicofacial region is the most common site of the disease, and the abdomen is the second. Abdominal involvement is traditionally often associated with right-sided infection. Herein, two cases of abdominal actinomycosis detected by the pathologist after a surgical operation, are reported. Before the operation, both patients presented with right lower quadrant pain, a palpable mass and leukocytosis. Preoperative abdominal computerized tomography (CT) was performed, followed by surgical intervention under the impression of a periappendiceal abscess. These cases demonstrate that abdominal actinomys should be included in the differential diagnosis when CT shows an infiltrative and inflammatory intraabdominal mass with localized tenderness.