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OBJECTIVE: To evaluate the efficacy of ultrasonography for the diagnosis of cervical lymph node metastasis in esophageal carcinoma. SUMMARY BACKGROUND DATA: Ultrasound (US) examination is useful for diagnosing lymph node metastasis. However, few reports have examined its role in the decision to perform cervical lymph node dissection in esophageal carcinoma. METHODS: Ultrasound examination was performed to evaluate cervical lymph node metastasis in 519 patients with esophageal carcinoma. The patients were divided into 5 groups according to treatment received: group 1, 153 patients who underwent curative resection of primary tumor by right thoracotomy and complete bilateral cervical lymphadenectomy; group 2, 112 patients who underwent curative resection of primary tumor by right thoracotomy but without cervical lymphadenectomy; group 3, 78 patients who underwent esophagectomy by left thoracotomy or blunt dissection with or without removal of cervical lymph nodes; group 4, 76 patients with palliative resection without cervical lymphadenectomy; and group 5, 100 patients without any surgical treatment. US diagnosis was compared with histologic findings or cervical lymph node recurrence. RESULTS: Lymph node metastasis was detected in 30.8% of patients (160/519). The sensitivity, specificity, and accuracy of US diagnosis in group 1 were 74.5%, 94.1%, and 87.6%, respectively. Cervical lymph node recurrence was seen in 7 patients (4.6%) in group 1, in 4 patients (3.6%) in group 2, and 3 patients (3.8%) in group 3. Although the incidence of cervical lymph node metastasis as determined by US examination was high in groups 4 and 5, almost none of the patients died of cervical lymph node metastasis. CONCLUSIONS: Ultrasound examination plays a useful role in the decision to perform cervical lymph node dissection in patients with esophageal carcinoma, particularly in those with potentially curative dissection.

Endoscopic mucosal resection (EMR) has recently been standardized for mucosal cancer of the esophagus. It may be hypothesized that EMR may be considered to be curative for superficial esophageal cancer (SEC), if the possibility of lymph node metastasis can be excluded beforehand. Ninety patients with p-T1 tumours who underwent esophagectomy were studied. Their primary lesions were stained with anti-Desmoglein 1 antigens using the ABC method. The p-T1 tumors were subdivided into three categories: carcinoma limited to the lamina propria mucosae (19 patients, SEC1), carcinoma invading the lamina muscularis mucosae or with invasion just into the submucosa (27 patients, SEC2), and carcinoma definitely invading the submucosa (44 patients, SEC3). Lymph node metastasis was not observed in the SEC1 patients but was observed in 19% of the SEC2 patients and 41% of the SEC3 patients. None of the SEC1 or SEC2 patients had lymph node metastasis when preserved Desmoglein 1 expression was obtained. The EMR appears to be appropriate therapy for SEC1. Our findings indicate that, for SEC2, preserved expression of Desmoglein 1 may be a helpful aid to exclude the possibility of lymph node metastases. Transthoracic esophagectomy with lymphadenectomy should be selected in the SEC3 patients.

We retrospectively analyzed the clinicopathologic findings, treatment and outcome of 22 patients with synchronous or metachronous carcinomas of the esophagus and head and neck. The patients with metachronous cancers in whom esophageal cancer occurred first had either an early-stage esophageal carcinoma or only one positive lymph node. Similarly, five of 10 patients with metachronous cancers in whom head and neck cancer was the first tumor had early-stage esophageal carcinomas. The esophageal lesion was mucosal carcinoma in four patients which was found by endoscopy with the iodine dye method. In the patients with synchronous cancers either one or both carcinomas were advanced, and the prognosis of these patients was poor compared with those of patients with metachronous carcinomas. Accordingly, endoscopic surveillance for early detection of metachronous lesions are encouraged.

We investigated extranodal connective tissue involvement (ECTI) in 39 patients with oesophageal carcinoma. Both the primary tumour and ECTI were immunohistochemically examined using the monoclonal antibody 32-2B for desmosomal glycoprotein 1 (DG1). Connective tissue carcinoma deposits were identified as cells within small lymph nodes, as lymphatic or venous vessel invasion or as widespread invasion beyond the capsule of metastatic lymph nodes. These histological findings were present in at least one area in 20 of 39 patients (51.3%). DG1 immunostaining intensity by tumour was graded as DG1 (++), DG1 (+) or DG1 (-). DG1 (+) or DG1 (-) primary tumours demonstrated lymph node metastases and ECTI more frequently than DG1(++) tumours (P

Background and Study Aims : Esophageal invasion by carcinoma of the cardia may affect the surgical approach. Accurate assessment of esophageal invasion is difficult using endoscopy, computed tomography, or barium contrast radiography. The aim of the present study was to evaluate the use of endoscopic ultrasonography (EUS) in the prediction of esophageal invasion by carcinoma of the cardia. Patients and Methods : EUS (using a linear-array scanner) was carried out prospectively in 47 patients with carcinoma of the cardia who underwent subsequent surgical resection. The findings were correlated with the histopathological assessment of tumor infiltration in the esophagus in the resected specimen. Results : An absence of esophageal invasion was correctly predicted by EUS in 12 of 13 patients. Histopathologically confirmed invasion of the esophagus was correctly predicted in 32 of 34 patients. With a margin of error of 10 mm, the accuracy of EUS in predicting or excluding histologically confirmed invasion of the esophagus was 85.1% (40 of 47 patients). False-positive results with EUS occurred in patients with prominent edematous or fibrous changes in the distal esophagus ; false-negative results with EUS were seen in patients with scattered infiltration of a small number of tumor cells into the mucosal or submucosal layer. Conclusion : EUS can provide the surgeon with additional information on the extent of esophageal infiltration in patients with carcinoma of the gastric cardia, and can therefore assist in the selection of the surgical approach.

Background and Study Aims : The presence or absence of lymph-node metastasis is the single most important factor in determining the strategy for treating superficial carcinoma of the esophagus. In this study, ultrasound (US) and endoscopic ultrasonography (EUS) were used in the diagnosis of lymph-node metastases, and the accuracy and limitations of these methods were assessed. Patients and Methods : Prospectively, 37 patients with superficial esophageal cancer were studied by US and EUS before surgery, and the results were compared with the histological findings. Twelve of the patients had histologically confirmed lymph-node metastases. Ultrasonographic images of the lymph nodes were classified into three types, based on their boundaries and internal echoes. Results : The sensitivity, specificity, and accuracy of predicting mediastinal lymph-node metastasis by EUS diagnosis were 80.0%, 87.5%, and 86.5%, respectively. The sensitivity, specificity, and accuracy of US in the assessment of cervical and abdominal lymph-node metastasis were 71.4%, 86.7%, and 83.3%, respectively. In cases in which there was a solitary metastatic lymph node, the detection rate was higher than in cases with two or more positive nodes. Most metastatic lymph nodes correctly diagnosed by US and EUS were larger than 6 mm and had tumor involving more than one-third of their cross-sectional area. Conclusions : In patients with superficial esophageal carcinomas, US is accurate in staging cervical and abdominal lymph nodes. EUS is accurate in staging mediastinal lymph nodes.

We undertook a comparative histologic study of early stage carcinoma of the esophagus and stomach, with tumor invasion limited to the submucosa. Here we analyze lymph node metastasis, lymphatic invasion, and vascular invasion. Our study is based on a retrospective review of 77 patients with early stage carcinoma of the esophagus and 192 patients with early stage carcinoma of the stomach treated during the period from 1973 through 1991. The incidence of lymph node metastasis and lymphatic invasion was significantly higher in intramucosal or submucosal esophageal cancer than in intramucosal or submucosal gastric cancer. However, there was no significant difference between intramucosal esophageal cancer and submucosal gastric cancer. The metastatic site of lymph nodes in esophageal cancer tended to be distant from the location of primary tumor compared with lymph nodes invaded by gastric cancer. Lymphatic invasion and vessel invasion between submucosal esophageal cancer and submucosal gastric cancer was statistically significant. From these results, we conclude that intraepithelial or intramucosal esophageal cancer is comparable to early stage carcinoma of the stomach, whereas submucosal esophageal cancer is actually an advanced lesion.

Desmoglein I (DGI) is major component of the desmosomal membrane core that plays an important role in epithelial cell adhesion. The aim of this study was to explore the correlation between the expression of DGI and the clinicopathological findings of esophageal cancer. DGI expression was immunohistochemically examined using an anti-DGI monoclonal antibody in 139 patients with squamous cell carcinoma of the esophagus. Normal squamous epithelial cells strongly expressed DGI at their cell-cell boundaries. According to the intensity and pattern of DGI expression, the cancerous tissues were divided into three groups: DGI (++), DGI (+), and DGI (-). Of the 139 tumors, 35 (25%) were DGI (++), 65 (47%) were DGI (+), and 39 (28%) were DGI (-). A good inverse correlation between DGI expression and tumor invasion, lymph node metastasis, lymphatic invasion, and vessel invasion was observed. These results indicate that DGI expression may be a significant factor for invasion, metastasis, and prognosis of human esophageal cancer.

The prognosis for patients with carcinoma of the esophagus is poor compared with findings in the instance of malignant growths in other areas of digestive tract. The high incidence of lymph node metastasis is one of the most important factors in poor prognosis for patients with carcinoma of the esophagus. Since December 1982, we have been employing the extended lymph node dissection for thoracic esophageal carcinoma. The extended lymph node dissection signifies the type of dissection which removes the lymph nodes of three fields, namely cervical, mediastinal, and abdominal. The aims of this study are to document the patterns of recurrence after extended lymph node dissection and to evaluate the effectiveness of the 3-field lymph node dissection.

Endorectal ultrasonography (ERUS) with a flexible-type radial scanner (Aloka Co. Ltd., Tokyo, Japan; 7.5 MHz) was applied to 120 patients with rectal cancer for the assessment of wall invasion and pararectal lymph node metastasis. Normal rectal wall was described as a five- or seven-layer structure excluding the lowest part within 3 cm from the anal verge. Loss of normal layers basically indicated the existence of cancer invasion. According to UICC classification, we divided the depth of wall invasion into four ultrasonographic levels (uT1–uT4), and results were correlated with histopathologic findings. Overall accuracy of the assessment was 92.0 percent (103/112). Overestimation occurred in 5 of 60 cases with T3 cancer (8.3 percent), and underestimation occurred in 1 of 19 cases with T2 cancer (5.3 percent) and 3 of 60 cases with T3 cancer (5 percent). Inflammatory cell infiltration was found around the cancer in a considerable number of cases. However, the assessment of wall invasion was hardly affected in our hands. Because the muscularis propria of the rectal wall was often recognized as a three-layer structure, uT2 cancer was subdivided into three subgroups of uPM1, uPM2, and uPM3. The assessment of invasion of sublayers in muscularis propria was possible in 14 of 19 cases (73.7 percent), and correct assessment was achieved in 57 percent of the cases. The ultrasonographic demonstration of pararectal lymph nodes was studied on 98 patients. No swollen lymph nodes were detected ultrasonographically in 35 of 98 cases (35.7 percent), but cancer metastasis was found histopathologically in 5 of these 35 cases (14.3 percent). The metastasis was observed more frequently in lymph nodes with a diameter of more than 5 mm (53.8 percent) and in those with a well-defined boundary and with an uneven and markedly hypoechoic pattern (72.3 percent). Although unable to detect minimal cancer foci, ERUS was considered a very useful tool for the assessment of the depth of cancer invasion in the rectal wall and pararectal lymph node metastasis.

胸部食道癌の頸部リンパ節転移状況を検討するため, 胸部食道癌33例に対し, 両側頸部郭清を行った.その結果頸部リンパ節転移陽性例は8例 (転移率24.2%, 両側2例, 右側3例, 左側3例) であった.占居部位別頸部リンパ節転移率では, Iu 60%, Im 20%, Ei 12.5%と上部ほど高かった.頸部リンパ節転移度は右側4.3%, 左側2.6%で, 両側含めると3.3%であった.また, 術前に頸部リンパ節を触知しえない症例や, 上縦隔最上部リンパ節に転移のない症例でも, 頸部リンパ節転移はおこりえた.頸部郭清範囲は鎖骨上リンパ節 (104) に加え頸部傍気管リンパ節 (101) 領域の郭清が必要と思われる.以上より, 胸部食道癌に対して, 両側頸部郭清は有用と思われる.

A 90-year-old woman with carcinoma of the gall-bladder associated with idiopathic thrombocytopenic purpura is reported. A total of 52.5 g of intact γ-globulin (400 mg/kg/day) and 20 Units of fresh platelets were administered preoperatively. Platelet counts increased from 2.3×104/mm3 to 16.9×104/mm3 after treatment. Cholecystectomy with regional lymph node dissection and splenectomy were safely performed, and the postoperative course was uneventful. The association of carcinoma with ITP is rare and only a small number of cases have been reported in the literature. These cases were collected and briefly reviewed.

食道癌取扱い規約によるstage IV食道癌は, 他の病期の食道癌に比べ予後の面でばらつきが多い.stage IV食道癌の切除例114例について, 各因子別に予後を検索し, 外科治療の適応と有効性について検討した.その結果, stage IV食道癌全例の累積5年生存率は4.7%で, a単独因子で規定されるものはn単独因子で規定されるものより予後は不良であった.また, n単独因子例では, 転移リンパ節個数5個未満のもの, 腹部単独転移例が予後は良く, 頸部・上縦隔リンパ節転移陽性例は予後不良であった.また, stage IV食道癌の亜分類を試みた結果, 現時点では深達度a2以下でリンパ節転移度の低いstage IV食道癌例に対し, 外科治療は有効と思われた.

胸部食道癌根治手術142例を3領域郭清70例と2領域郭清72例にわけて, 拡大リンパ節郭清に伴う術後合併症を検討した. 3領域郭清群の咳嗽反射の出現日は平均518日, 気管内チューブの抜管日は平均7.7日であった. 反回神経麻痺は49%に, 誤嚥は13%に認められた. 肺炎は27% (19/70例) に認められ, 19例中9例 (47%) が誤嚥に続発する肺炎で, その出現は術後平均26日と遅いが, いったん発生すると重篤な肺炎に移行しやすい. 総ビリルビン4mg/dl以上の86%は直接ビリルビン優位で術後5～8日に出現し, 3領域郭清群に出現頻度が高率であった. なお, 3領域郭清群では郭清範囲の拡大にもかかわらず縫合不全の増加は認められなかった.

他臓器浸潤胸部食道癌切除例70例を対象として切除の意義と問題点を検討した.絶対非治癒切除62例, 相対非治癒切除8例 (11%) で, 合併切除は18例 (26%) に行った.積極的に切除を行ったが, 結果的に, わずかに遺残癌巣を認めた17例中10例 (59%) を合併症で失った.死亡例の31% (20/65例) および術後2か月以内死亡の75% (18例) が合併症死であった.術後3か月以降の78%は再発, 再燃による死亡であった.残存癌巣の程度とn因子の有無では, 生存月数に有意の相違は認めなかった.術後2年以上生存した2例は他臓器への浸潤範囲がわずか (2cm2未満) であり, 合併切除を行い, 相対非治癒切除となった症例であった.対象例の50%生存月数は4.5か月, 3年生存率は3%であった.

n3-4 (+) で, 深達度a2までのstageIV食道扁平上皮癌根治切除85例を, 頸部, 後腹膜リンパ節 (No.8, 9, 11, 16) 転移の有無から4型 (頸・後腹膜 (-) 型33例, 後腹膜型18例, 頸部型28例, 頸・後腹膜型6例) に分類し, リンパ節郭清の意義を検討した. 3領域郭清32例では7割が頸部転移, 3割が胸・腹腔内転移によりstIVと規定された. 頸・後腹膜 (-) 型の5年生存率は22%で, 気道群 (No.106,107,109) 転移の有無により予後が左右された. 後腹膜型の5生率は28%で, 気道群から腹腔動脈領域の郭清が重要である. 従来, 3年生存例がなかった頸部型では, 3領域郭清により5生率15%となったが, 郭清範囲内の頸部・上縦隔再発例が多かった. 頸・後腹膜型では, 3年以上生存例を認めなかった.

胸部食道癌の適切なリンパ節郭清範囲を知るために, 44例にリンホシンチグラフィーを行い食道のリンパ流を検討し, さらに, 両側頸部・上縦隔郭清50例の転移状況と対比した. 胸部上・中部食道癌で頸部, 上・中縦隔, 胃上部リンパ節群, 下部食道癌で下縦隔, 胃上部, 腹腔動脈周囲リンパ節群に高い転移率を認めた. 頸部リンパ節ではNo.104とNo.101の下方, 上縦隔ではNo.106右, 左が転移率, RI uptakeともに高い. 上・中部食道から頸部に至る直結型リンパ流のため, 両側頸部郭清は対側の上縦隔郭清と同じ意義を有し, 下部食道からは, 大動脈周囲リンパ節といえども豊富なリンパ流を認めており, これらの部位の検索と郭清を今後積極的に検討すべきである.

診断学の進歩と積極的リンパ節郭清の実施に伴い, 食道表在癌とくに, m癌とリンパ節転移を伴うsm癌の頻度が最近の5年間に急増した. m癌, リンパ節転移の無いsm癌, 転移陽性sm癌の病理組織学的所見の差異を中心に検討した結果, m癌はsm癌に比べ腫瘍の厚みと粘膜面からの高低差が小さく, リンパ管侵襲陽性の頻度は転移陽性sm癌で他の2群よりも有意に高かった. sm癌の2群では腫瘍長径・厚み, sm浸潤の長さ・割合・深さ, 浸潤増殖様式, 周囲のdysplasiaなどいずれも転移陽性群で大きい値や浸潤の強い傾向を示した. 肉眼的に隆起・陥凹が強く, 混合型や多発・壁内転移を示すものにリンパ節転移陽性のsm癌が高頻度に存在した. 転移陽性sm癌の生存率は不良であったが, 従来の成績よりも改善傾向がみられた.

Background The aim of this study was to investigate the maintenance of volume as a spacer by comparing vascular supply and apoptosis in an implanted autologous-free dermal fat graft (FDFG) and free fat graft (FFG). An autologous FDFG is a material used in plastic surgery and oncoplastic breast surgery that is ideal for immediate volume replacement after partial mastectomy because of its easy availability and minimal invasion of the donor site; however, immunohistochemical findings and survival procedures have not yet been reported. Methods An experimental protocol using a unique animal model was designed for the present study. The expression of vascular endothelial growth factor (VEGF) was measured in FDFGs and FFGs implanted onto the pectoral major muscle of Wistar rats. Thirty Wistar rats were divided into two groups and postoperatively 1, 2, 4, 8, and 16 weeks (POW1, 2, 4, 8, 16). Six samples from three rats in each group were used as control samples (POW0). Results The thickness of the implanted FDFG was not significantly different from the control sample at POW1, 2, 4, 8, and 16 between FDFG and FFG group; however, the thickness at POW8 and 16 was significantly lesser in the FFG group than in the control samples. The average proportion of fatty tissue to whole tissue ranged from 34.2 to 48.6 % in the FDFG group and from 57.2 to 76.7 % in the FFG group during the observation period; however, there was no significant difference in the proportion of fatty tissue between these two groups. There were no significant differences between the average number of VEGF-positive cells in the FDFG group and the FFG group at POW1, 2, 4, 8, and 16. The average number of TUNEL-positive cells in the early period at POW1 was significantly lower in the FDFG group than in the FFG group. Conclusions This rat model was useful for investigating the mechanisms of angiogenesis, apoptosis, structure maintenance, and fibromatous changes. From the present experimental study, we believe that FDFG is one of the most convenient materials currently available to repair small defects at the time of BCS even in the clinical field.

The celiac axis could be visualized with ultrasound in 140 out of 166 cases (84%). Failure to identify the celiac axis was associated with extensive metastases to the celiac lymph nodes in 73% (19/26) of these cases. The location of lymph nodes in this region could be determined using the celiac axis and its branches as land marks. Celiac lymph nodes can be roughly classified into three types: Type 1--unclear margins and relatively uniform diffuse internal echoes, Type 2--clear margins and weak internal echoes, and Type 3--clear margins and scattered, large internal echoes, frequently seen with notchings. Metastases in celiac lymph nodes were found in 53 of 166 cases, based on histological examination of surgically removed nodes. A preoperative ultrasonic examination indicated lymph node metastases in 39 out of the 53 cases (sensitivity of 74%) and no lymph node metastases in 108 of the remaining 113 cases (specificity of 96%). Most lymph nodes with metastases were of Types 2 or 3. The longer the diameter of the lymph node or the larger the ratio of metastatic area to node cross-sectional area, the higher the detection rate tended to be. These results indicate that ultrasound can be very useful in screening patients for celiac lymph node metastases.