History of distal gastrectomy prevents metabolic syndrome and chronic kidney disease.

AIMS: Chronic kidney disease (CKD) due to metabolic syndrome has recently become a social problem in Japan. In this report, the associations between the history of distal gastrectomy (DG) and the incidence of metabolic syndrome or CKD were evaluated. METHODS: Arteriosclerosis-related factors were compared among patients with a history of DG who were <70 years old (n=41) and controls selected at random (n=410) after matching for age and sex. RESULTS: The patients with a history of DG were less obese than controls and had lower low-density lipoprotein cholesterol and higher high-density lipoprotein cholesterol serum levels. Furthermore, they had an excellent estimated glomerular filtration rate, which was used as an index of CKD. CONCLUSIONS: These findings suggest that a history of DG prevents metabolic syndrome and reduces the risk of CKD.

Traumatic Abdominal Wall Hernia: A Case Report of High-Energy Type without Surgical Repair.

Repair of traumatic abdominal wall hernia (TAWH) has been reported to be necessary. Reported here is one case of TAWH without repair. A 27-year-old man was accidentally sandwiched between a rock and a truck and admitted to our emergency department. There was a swelling of 10 cm in the right upper quadrant of the abdomen. The enhanced computed tomographic scan demonstrated a large abdominal wall muscular defect, transverse colon protrusion, and the presence of subcutaneous emphysema at the site. Based on these findings, lacerated transverse colon entrapped in TAWH was diagnosed. The patient underwent emergency laparotomy for laceration of the transverse colon, duodenum and pancreas, and open book fracture of the pelvis. Repair of the hernia was not performed because of the possibility of abscess formation by stool contamination. However, the hernia disappeared and the patient is doing well without recurrence of hernia 16 months after injury.

A case of lymphocytic mastopathy requiring differential diagnosis from primary breast lymphoma.

Lymphocytic mastopathy is a benign breast disease characterized by dense fibrosis, lobular atrophy, and aggregates of lymphocytes in a periductal and perivascular distribution. The condition affects young to middle-aged women and frequently shows an association with diabetes mellitus or autoimmune disorders. Here, we report a case of the disease clinically and radiologically mimicking primary breast neoplasms. The patient was a 50-year-old woman without diabetes who presented with two firm lumps in her right breast. Breast imaging findings from mammography, ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI), respectively, revealed an abnormal appearance suspicious of malignancy. A core-needle biopsy specimen showed atypical accumulation of lymphoid cells, which was not easy to differentiate from primary breast lymphomas. Moreover, (18)fluorodeoxyglucose positron emission tomography (FDG-PET) examination detected abnormal uptake in the same lesions. Histological examination of a surgically obtained specimen showed characteristic appearance of lymphocytic mastopathy, which predominantly consisted of B-lymphocytes. In our case, it was difficult to distinguish this entity from breast cancer or low-grade B-cell lymphoma without surgical biopsy.

Multiple repeat metastasectomies for recurrences of colorectal cancer.

BACKGROUND/AIM: The disease-free interval after resection of the primary tumour was found to be an independent significant prognostic factor for single repeat metastasectomy for colorectal cancer. In the present study, the intervals from resection to relapse for multiple repeat metastasectomies were evaluated. METHODS: Sixteen patients who underwent multiple repeat metastasectomies after the first curative resection were studied to determine whether their intervals from resection to relapse were associated with the prognosis. RESULTS: The patients could be classified into three types by the intervals from resection to relapse: (1) the intervals of 4 patients between recurrences were constant and lasted a few years (long-term regular-type group); (2) those of 6 patients were almost constant between recurrences and lasted about 1 year (short-term regular-type group), and (3) the intervals of 6 patients became shorter with each recurrence (shortening-type group). 3 of the 4 patients in the long-term regular-type group, 2 of the 6 patients in the short-term regular-type group, and none of the 6 patients in the shortening-type group are currently alive without recurrence. The survival rate was significantly higher in the long-term regular-type group than in the shortening-type group. CONCLUSION: For patients with constant intervals of relapse, achieving curative resection is the most relevant prognostic factor for a favourable prognosis after repeat metastasectomies for recurrence of colorectal cancer.

[Subclassification of stage IV gastric cancer].

We studied the prognosis of 185 stage IV gastric cancer cases. The univariate analysis and multivariate analysis suggested that liver metastases (H) and peritoneal disseminations (P) were prognostic factors, the number of factors may be it, and lymph nodes metastases (N) and invasion to the other organs (T) were not it. Based on these findings, we proposed a subclassification of stage IV: IVa [T1-3N3-or T4N2] and IVb [the others]. The survival rates for IVa significantly exceeded those of IVb and did not differ from those of 25 stage IIIb gastric cancer cases.

[A case of adult neuroblastoma arising in the retroperitoneum following a poorly aggressive course].

A 69-year-old man complaining of enlarged cervical mass, appetite loss and lower abdominal pain was found to have abdominal tumors in heaps forming a large mass around the retroperitoneum. The biopsy specimen in the cervical mass showed undifferentiated carcinoma with neuroendocrine feature. This malignancy followed a poorly aggressive course and caused death in only 24 hospital days. The disease was diagnosed as undifferentiated neuroblastoma arising in the retroperitoneum by autopsy with appropriate immunohistochemical studies. Adult neuroblastoma in the peritoneum is rare and our case showed a aggressive behavior and unfortunate outcome.

[Augmented regional pancreatoduodenectomy ensures an excellent pain control for the case with pancreatic cancer invading the superior mesenteric artery and vein].

A 49-year-old woman with a complaint of severe abdominal pain and lumbargo was diagnosed with pancreatic cancer invading the superior mesenteric artery and vein. Since the lesion was unresectable by general Whipple's procedure, she was treated with gemcitabine and opiate. However, these treatments resulted in failure due to the side effects such as bone marrow suppression, severe nausea, and constipation. After the bone marrow suppression disappeared, she received augmented regional pancreatoduodenectomy, which is a pylorus preserving pancreatoduodenectomy with resection of the superior mesenteric artery and vein. Consequently, she could have a good QOL without opiates.

Acute respiratory distress syndrome is a serious complication of microwave coagulation therapy for liver tumors.

BACKGROUND: Acute respiratory distress syndrome (ARDS), also known as noncardiogenic pulmonary edema, is a severe complication in cirrhotic patients undergoing microwave coagulation therapy (MCT) for liver tumor. In this study, cirrhotic patients with ARDS after MCT were compared with others without ARDS. METHODS: Four patients with ARDS after open MCT and 17 other patients without ARDS were compared in terms of preoperative status, intraoperative findings, and postoperative management. RESULTS: The preoperative Child-Pugh score and intraoperative amount of irradiation showed no significant differences were observed. The postoperative cumulative water balance until the third day was 1,692 +/- 1,315 mL for the ARDS group and 165 +/- 1,524 mL for the non-ARDS group (P = .079), and by the fourth day the respective values were 1,992 +/- 1,585 mL and 66 +/- 1,685 mL, showing a significant difference (P = .049). The postoperative cumulative sodium administration until the third day was 510 +/- 132 mEq for the ARDS group and 362 +/- 122 mEq for the non-ARDS group with a significant difference (P = .044), and by the fourth day the respective values were 642 +/- 141 mEq and 477 +/- 160 mEq (P = .073). Of the 17 patients in the non-ARDS group, 6 were given aldosterone antagonist until the fourth postoperative day, but it was not administered to any of the patients in the ARDS group. CONCLUSIONS: The water balance and sodium administration have to be closely monitored to prevent cirrhotic patients undergoing MCT from developing ARDS. Aldosterone antagonist appears to be useful for the prevention of ARDS.

[Lymphatic basin dissection and function-preserving limited gastrectomy for early-stage gastric carcinoma].

Sentinel node biopsy accurately predicts the nodal status of early-stage gastric carcinomas. Nevertheless, surgeons are concerned about missing a micrometastasis in applying the sentinel node-negative finding to surgery. Of 36 patients who underwent D2 dissection based on positive sentinel node biopsy, 15 patients had histologic metastasis in the sentinel nodes, 20 patients in both the sentinel and nonsentinel nodes in the lymphatic basin system, and 1 in the nodes not only in the basins but also in the nonbasin system. This means that metastases spread along the anatomic lymphatic flows in the early stage. Micrometastases of the sentinel nodes develop prior to histologic appearance, and the neighboring nonsentinel nodes are also possibly involved in the early stage. This suggests that, even in the case of cancer-free sentinel nodes, the basins should be dissected. Since 1995, we have performed lymphatic basin dissections and limited gastric resections on 159 sentinel node-negative patients. The crude survival curve was not different from that of the conventional group. The incidence of postoperative distress such as early satiety, unsatisfactory recovery of body weight dumping syndrome, duodenogastric reflux, and gallstone formation was significantly lower in the limited group than that in the conventional group.

Clinical study of gastric cancer patients with complaint of hematemesis.

Eighteen gastric cancer patients with complaint of hematemesis, who underwent early endoscopic treatment for hemorrhage and received standby oncologic treatment after recovery, were retrospectively compared with 661 gastric cancer patients without complaint of hematemesis. Patients with hematemesis had a statistically high rate of type 2 gastric cancers. Stage I in patients with hematemesis was significantly less frequent than in patients without. Standby gastrectomy after early endoscopic treatment was performed on 17 (94.4%) of the patients with complaint of hematemesis. The resected specimens showed a significant association of hematemesis with serosal invasion, node metastases, and vascular invasion. However, there was no significant association of hematemesis and postoperative complications or prognosis. Our findings suggest that prognosis of gastric cancer patients with hematemesis has improved with the development of endoscopic diagnosis and treatment. For such patients, it is very important to decide on an oncologic treatment plan after endoscopic treatment and accurate assessment of the cancer stage.

Early electroencephalographic findings in patients with anoxic encephalopathy after cardiopulmonary arrest and successful resusitation.

This study investigated whether or not early electroencephalographic (EEG) findings and brain computed tomographic (CT) features reflect the prognosis of comatose patients for 48 h after cardiopulmonary resuscitation (CPR). EEGs and brain CT scans were collected from 21 patients within 72 h after CPR. The EEG findings were classified according to the five Hockaday grades. The Glasgow outcome scale (GOS) applied 3 months after CPR was used for prognosis. Of the nine patients with grade 1 and 2 EEGs, eight had a good outcome (five recovered satisfactorily and three remained moderately disabled). Of the eight patients with grade 4 and 5 EEGs, seven had a poor outcome (three died and four remained in a persistent vegetative state). On the other hand, there was no correlation between early CT features and prognosis except for two severe cases, one whose gray/white matter interface had disappeared and the other with relatively increased density of the thalami, brain stem and cerebellum. These findings suggest that EEG is more useful than CT scan as a diagnostic tool for anoxic encephalopathy after CPR.

Correlation of lymph node metastases and expression of matrix metalloproteinase-7 in patients with gastric cancer.

BACKGROUND/AIMS: Matrix metalloproteinase-7 (MMP-7) is thought to play an important role in the progression of cancer invasion. However, the expression of MMP-7 in primary and nodal lesions of gastric cancer is unknown. METHODOLOGY: Expression of MMP-7 protein in primary and nodal lesions of human gastric cancer was evaluated by immunohistochemistry. Expression of MMP-7 mRNA in the sentinel node, i.e. the first lymph node in the lymphatic basin to receive metastases from the primary tumor, was evaluated by reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: Among primary lesions, 73 (48%) of 153 tumors were strongly positive for MMP-7. Strong positivity rates in the primary lesion were associated with deep invasion of the gastric wall, nodal metastases, and infiltration of vessels or lymphatics. Five-year survival rates were 43.8% in patients with strongly positive tumors and 75.0% in patients with weakly positive tumors. Among nodal metastases, 53 (76%) of 70 lesions were strongly positive for MMP-7, which was significantly higher than the strong positivity rate for primary lesions. Strong positivity rates in metastatic lesions were significantly higher when metastatic lymph nodes were present in group 2 or more. All of six patients with peritoneal dissemination in the absence of gastric serosal invasion had nodal metastases strongly positive for MMP-7. Five-year survival rates were 17.5% in patients with strongly positive nodal metastases and 68.6% in patients with weakly positive nodal metastases. RT-PCR demonstrated MMP-7 expression in sentinel nodes of 3 cases of 30. All 3 cases had metastases not only in the sentinel node but also in non-sentinel nodes. However, in 27 cases, including 24 without metastases and 3 with metastases in the sentinel nodes only, expression of MMP-7 in the sentinel nodes was not observed. CONCLUSIONS: MMP-7 may contribute to the invasion of both primary and nodal lesions in patients with gastric cancer. The MMP-7 expression is a useful prognostic factor, and evaluating the expression in sentinel node may help surgeons determine what level of lymph node dissection should be performed.

Breast cancer with endocrine differentiation: report of two cases showing different histologic patterns.

We report two cases of breast cancer with endocrine differentiation. Case 1 was a 56-year-old woman with a 2-cm tumor in the upper outer quadrant of the right breast and right axillary lymphadenopathy. Excisional biopsy suggested carcinoma and we performed breast-conserving surgery with lymph node dissection. Histologic examination revealed breast cancer with endocrine differentiation resembling small cell carcinoma of the lung, with one nodal metastasis. Case 2 was a 71-year-old woman with a 2.5-cm tumor in the upper outer quadrant of the right breast. Aspiration cytology suggested carcinoma and we performed mastectomy with lymph node dissection. Histologic examination revealed a carcinoid tumor, as one of the breast cancers with endocrine differentiation, but no nodal metastasis. The two patients are now disease-free 26 and 12 months after surgery, respectively.

[Sentinel node navigation surgery in early-stage gastric carcinoma: a limited gastric resection with lymphatic basin dissection in sentinel node-negative patients].

The high accuracy of sentinel node biopsy in clinical T1 gastric cancer leads to the idea of excluding conventional D2 from node-negative patients. The question now arises of what to do when sentinel nodes are missed during surgery and micrometastases are over looked in frozen tissue sections. To avoid and correct a mistaken diagnosis, surgeons should remove the lymphatic basin even in the case of negative sentinel nodes, because the basin is exclusively associated with the involved nodes. We call this procedure "lymphatic basin dissection." Gastric lymphatic basins were divided into five compartments corresponding to the feeding artery, and clinical T1 gastric cancer involved a single basin in 42% of patients, two in 47% and three in 12%. Patients with one or two basins can be treated with limited gastric resection, because the devascularization does not cause insufficient blood supply to the remnant stomach. Since 1995, 123 patients have undergone lymphatic basin dissection and limited gastric resection (segmental resection, local resection, proximal gastrectomy, and limited distal gastrectomy) in our institution. There was no recurrence in the limited surgery patients with a median follow-up period of 3.8 years. The overall survival curve after surgery in the limited group is almost the same as that in the conventional group. Quality of life was significantly higher in the limited group than in the conventional group.

Immunohistochemical study of protein induced by vitamin K absence or antagonist II in hepatocellular carcinoma.

BACKGROUND AND OBJECTIVES: Protein induced by vitamin K absence or antagonist II (PIVKA-II) has been used as a tumor marker of hepatocellular carcinoma (HCC). In this study, we examined the expressions of PIVKA-II in HCC tissues. METHODS: Expression of PIVKA-II in HCC was evaluated with the avidin-biotin-peroxidase complex method. Paraffin-embedded HCC tissues obtained from 48 patients were subjected to immunohistochemical staining using the anti-PIVKA-II antibody monoclonal antibody (MU-3) (Eisai, Tokyo, Japan). RESULTS: The tissue PIVKA-II positivity rate of 12/23 (52.2%) in HCC with vascular infiltration was significantly higher than the rate of 4/25 (16.0%) in HCC without such infiltration. Further, the tissue PIVKA-II positivity rate of 13/28 (46.4%) in HCC of tumor stage III or IV was significantly higher than the rate of 3/20 (6.0%) in HCC of tumor stage I or II. Overall survival rate tended to be lower in the tissue-PIVKA-II-positive than -negative patients. CONCLUSIONS: PIVKA-II may play an important role in progression of HCC and is useful not only as a tumor marker but also as a prognostic factor.

Lymphoplasmacytic sclerosing pancreatocholangitis successfully treated by pancreatoduodenectomy.

A 68-year-old man complaining of jaundice was admitted to our hospital in October 1996. Radiological imaging studies, including dynamic computed tomography, endoscopic retrograde cholangiography, and angiography, were highly suggestive of pancreatic head cancer, and laparotomy was performed on October 25, 1996. On gross examination, the pancreas appeared firm, as in chronic pancreatitis, with a mass lesion in the pancreatic head measuring 35 x 35 x 25 mm. A pylorus-preserving pancreatoduodenectomy was carried out. Histological findings were characterized by uniform fibrosis with diffuse lymphoplasmacytic infiltration and lymph follicles in the thickened wall of the bile duct and in and around the pancreas, with acinar atrophy. The histological diagnosis was lymphoplasmacytic sclerosing pancreatocholangitis. Approximately 5 years postoperatively, the patient was alive and well without adjunctive corticosteroid therapy. This positive result suggests that pancreatoduodenectomy may be effective for lymphoplasmacytic sclerosing pancreatocholangitis that is localized in the pancreatic head.

Myxoid malignant fibrous histiocytoma of the breast: report of a case.

Malignant fibrous histiocytoma (MFH) is the most common type of soft tissue sarcoma, but it rarely develops as a primary tumor in the breast. Furthermore, no case of the myxoid variant of MFH in the breast has ever been documented. We report the case of a 52-year-old woman with a breast tumor that was immunohistochemically confirmed to be myxoid MFH. She underwent a radical mastectomy and is currently well with no evidence of local recurrence or metastatic spread after 3 years of follow-up.

Histological subtypes of ductal carcinoma in situ of the breast.

BACKGROUND: It has become common to divide ductal carcinoma in situ (DCIS) of the breast into two main groups, comedo or noncomedo by tumor morphology. But noncomedo DCIS can be further stratified into several morphological patterns that exhibit several different growth patterns and most DCIS lesions have more than one pattern. In this study, DCIS elements were classified by morphological pattern and the association between predominant or recessive elements of DCIS lesions and clinicopathological findings was evaluated. METHODS: DCIS lesions from 46 patients were studied regarding the histological architectural patterns: comedo, cribriform, papillary, solid and micropapillary. The predominant architectural pattern which comprised more than 50% of the cells of the cancerous lesion was defined as the major element of the tumor and minor elements consisted of less than 50% but more than 25% of cells comprising the tumor. RESULTS: Of 24 tumors containing a comedo pattern as the major or minor element, 9 (38%) had microscopic intraductal spread over 2 cm and 11 (46%) had involvement of lobules, which was significantly higher than that observed in other types. Of 20 tumors containing a cribriform pattern as the major or minor element, 8 (40%) had microscopic intraductal spread over 2 cm and 9 (45%) had involvement of lobules, which was significantly higher than that seen in other types. Of 10 tumors containing a papillary type as the major or minor element, 5 (50%) had discrete multicentric lesions in the ipsilateral or contralateral breast, which was significantly higher than that seen in other types. CONCLUSIONS: DCIS lesions containing a comedo or cribriform element are more likely to have microscopic spread and involvement of lobules and DCIS lesions containing a papillary element are likely to be multicentric, whether the pattern are predominant in the tumor or not.