Search

This study presents the case of a patient with minute type Ha rectal cancer with a diameter at its largest of only 5 mm, with infiltration as far as the submucosal layer (sm) and positive parietal lymph node metastasis. The patient was a 54 year-old male who visited Yasuda Medical Hospital because of diarrhea which appeared in early May 1988. During sigmoidscopy, a small protruding lesion was seen in the rectum (Rs) about 12 cm from the margin of the anus, and the patient was referred to the authors' surgical service for an endoscopic polypectomy because of a biopsy diagnosis of adenocarcinoma. The polyp had a smooth, shiny surface, and had a well demarcated hemispherical shape. A histopathological examination of the polypectomized specimen, showed that it was an invasive carcinoma extending into the submucosal layer without any adenoma component. Since the cut end of the specimen strongly suggested positive cancer cells and lymphatic permeation was also confirmed from the polypectomized specimen, a low anterior resection was performed on August 4, 1988. The postoperative histological examination revealed a small amount of residual cancer cells in the submucosal layer which appeared to be at the cut end of the resected polyp. One metastatic focal point was seen in the pararectal lymphnode, and this patient's case provided valuable suggestions for deciding upon therapeutic policies for early cancer of the large intestine.

The current study attempts to clarify the possible immune response that occurs in medullary carcinoma with lymphocytic infiltration of the stomach by an immunohistochemical analysis of the subpopulations of tumor-infiltrating lymphocytes. This carcinoma was histologically characterized by the sparse population of small nests consisting of poorly differentiated carcinoma cells, widely separated by intervening nondesmoplastic stroma infiltrated uniformly with abundant lymphocytes frequently accompanied by lymph follicles. An immunohistochemical analysis revealed that T-cells were evenly distributed throughout the tumor with intimate contact with individual carcinoma cells, except the lymph follicles consisted mainly of B-cells. Because of the similarities of morphologic features and subpopulations of tumor-infiltrating lymphocytes of this carcinoma to the normal lymphoid tissue, an organized immune response combined with cell-mediated and humoral immunities against the invading carcinoma cells seemed to occur in this type of gastric carcinoma, resulting in a excellent prognosis compared with that in ordinary gastric carcinoma.

Intraepithelial lesion spreading around the main lesion of esophageal carcinoma may be significant for the evaluation of the prognosis. Therefore, we classify it into 5 types from X-ray findings and compare these types with the findings of the resected specimens.i) A-type is characterized by slight rigidity seen at the margin of the esophagus and coarseness of the mucosal pattern.ii) In B-type, together with rigidity of the esophageal wall, a fine granular pattern is seen on double contrast film.iii) C-type, in which nodular and granular features of various sizes are seen, is divided into 2 sub-types, i. e., C1 and C2. Small nodular features belong to C1 and large nodular ones with deep ulcer to C2.iv) Big nodules with smooth surface and scattered lesions with fine elevations characterize D-type.Histological examination of the superficially spread lesion of A-type reveals carcinoma in situ. Likewise, carcinoma in situ with erosion is found in many cases of B-type. In C1- and C2-types, carcinoma infiltrates to or beyond the submucosal layer to form nodules. In most cases of D-type, lymphatic vessel invasion is seen in the mucosal layer and metastatic lesion comes out to the surface of the mucosa.The prognosis of early esophageal carcinoma of A-type is good, but that of B-, C- and D-types is rather poor.

Sixty-two cases of esophageal varices have been examined in our hospital for the last one and a half years. Bleeding varices were found in 32 cases. The characteristic differences in the esophagoscopic findings between bleeding and non-bleeding varices were as follows. (1) Varices extending the entire length of the esophagus were seen in the bleeding cases more often. (2) Bluish varices were seen in 25% of the bleeding cases, while they were found in 8% of the non-bleeding cases. The red sign was found in the majority of the bleeding cases. (3) The tumorous and nodular forms of varices were found in the bleeding cases more frequently. (4) Erosive esophagitis was rare, and it was seen in only 2 of the bleeding cases.Forward viewing fiberscopes, such as the esophagofiberscope and the pan-endoscope, were utilized for the examination of the varices. An esophagofiberscope with a tip bendable up to 210 degrees was especially appropriate for observation throughout the esophagus and the gastric cardia.In 334 cases of urgent endoscopy, gastric or duodenal ulcers were found in 51%. Esophageal varices were seen in 11%, in some of which gastric and/or duodenal lesions were also found.For the surgical treatment of esophageal varices, esophageal transection, splenectomy and devascularization around the stomach have been carried out. Transection of the esophagus was easily performed using a sewing instrument. In a long-term follow-up over one year after surgery, a relapse of varices was seen in 10% of the cases.

食道再建術のうち, 胸壁前食道胃吻合はその安全性の反面, 吻合部の縫合不全のおきやすいことが指摘されてきた.今回, 食道と胃の吻合を挙上胃の後壁に端側吻合することにより, 縫合不全の発生をいちじるしく改善することができたので, その術式を中心に報告する.挙上胃の作成には, 右胃動静脈をかなり温存した大きい胃管とし, 伸展が不十分の際は, 胃管の漿筋層を輪状に切離して伸展をはかり, 食道胃吻合は, 挙上胃の最先端より2cm肛側の後壁に, 層々吻合で行うというのが本術式の一連の操作である.従来の40%に近い移開率を, 小縫合不全のみの3.6%に改善することができた.

肝転移を合併しやすい胃癌の特徴を得るため, 肝転移をともなった胃原発巣5cm以下の6症例と5cm以上の26症例を臨床病理学的に比較検討した. その結果, 肉眼的には萎縮領域に発生した小型のBorrmann2型を呈し, 組織型的には一般にいわれている乳頭状や高分化型よりむしろ, 低分化型や中分化型に多く, しかも髄様型の増殖をとるという特徴が認められた. さらに血清α-fetoprotein AFPげやCarcinoembryonic antigen (CEA) が陽性となる症例が多く, 特にAFPは6例中5例も陽性であった. この5例中3例は, 酵素抗体染色により胃原発巣にAFPの局在が証明された. 一方AFP産生胃癌の特徴は, 上述した肝転移を合併しやすい胃癌の特徴ときわめて類似しており, 非常に興味深い所見と考えられた.

Lymph node metastasis was studied in 263 patients with early gastric cancer, and the possibility of limited surgery for carcinoma confined to the mucosa (m-carcinoma) was discussed. Among these patients, 21 (8.0%) were lymph node metastasis-positive. Lymph node metastasis was noted in 5 (3.3%) of 153 patients with m-carcinoma and 16 (14.5%) of 110 patients with carcinoma limited to the submucosa (sm-carcinoma). Lymph node metastasis-positive cases of depressed-type mcarcinoma were characterized by ulcer of ul-III or IV type in relatively wide spread cancerous lesion. The lymph node metastasis-positive cases of protruded-type m-carcinoma consisted of one case of type I composed of poorly differentiated adenocarcinoma and one case with lymph vessel invasion of type IIa+IIc (multiple gastric cancer). Lymph node metastasis-negative cases of m-carcinoma were characterized by small lesions of type IIa, IIb and IIc associated with no ulcer in the cancerous lesion. In surgical management for these cases, it may thus be possible to reduce the extent of lymph node dissection.

The pathological state of corrosive strictures of the esophagus differs in each clinical case depending on the nature and quantity of agents ingested and the mode of ingestion. Therefore, it is mandatory to take a suitable treatment that fits each case of corrosive strictures. For the reason that these strictures are not malignat in general, the authors have performed dilatation by bougienage or a by-pass operation in most cases.It should be noted, however, that carcinoma of the esophagus could occur secondary to corrosive stricture. Forty such cases have been reported in literature and two additional cases were also reported in Japan recently by Nakayama. The incidence of carcinoma of the esophagus has been claimed to be from 22 to 1, 000 times higher in the cases with corrosive stricture than in normal population.If the extent of corrosive stricture is limited or short, bougienage of the stricture is attempted as the first choice. When bougienage is found to be ineffective or the stricture is too extensive, srugical treatment should be considered. Considering the possibility of future development of malignancy at the site of corrosive legions, resection of the constricted portion of the esophagus is more desirable than a by-pass operation. Because of the fact that the procedure should be made from the prophylactic viewpoint, esophagectomy without thoracotomy-the so-called blunt dissection after Akiyama-is considered to be a reasonable and valuable approach. The authors operated one case using the same technique with successful result. Even in non-resected cases, a close long-term follow-up study should be made considering the possibility of later development of carcinoma.

An unusual case of extrahepatic disseminating hepatocellular carcinoma in a 64-year-old man is reported. The initial symptom was abdominal fullness and progressive ascites. Alpha-fetoprotein in the serum was 117,000 ng/ml. Exploratory laparotomy disclosed dissemination of tumor nodules throughout the abdominal cavity without any other possible primary tumor. CT scan, ultrasonography and hepatic angiography were unable to detect any tumor lesion in the liver. The final histologic diagnosis was hepatocellular carcinoma, although at first epithelioid mesothelioma was suspected. The present case of hepatocellular carcinoma was thought to have possibly developed from ectopic liver on the peritoneum. ACTA PATHOL JPN 38: 1575-1581, 1988.