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Carcinosarcoma of the esophagus is a rare malignant neoplasm. It often presents as a large intraluminal polypoid tumor with early onset of symptoms resulting in prompt diagnosis. We present here the first case of a carcinosarcoma of the esophagus that had a basaloid squamous cell carcinoma component in addition to the osteosarcoma and without a transitional zone. A 57-year-old man was diagnosed with a polypoid tumor in middle third of the esophagus causing dysphagia. Local recurrence and solitary pulmonary metastasis occurred 16 and 30 months after initial excision of the tumor, respectively. Prompt and aggressive surgical resection is mandatory for carcinosarcoma of the esophagus.

This study was designed to determine the expression of p16, p53, and CD117 in gastrointestinal tract endocrine tumors. Immunohistochemical studies of p16, p53, and CD117 were performed in 57 gastrointestinal tract endocrine tumors, including 22 poorly differentiated endocrine carcinomas (PDECs) and 35 well-differentiated endocrine tumors (WDETs). Overexpression of p16 and p53 was observed in 16 (73%) and 10 (45%) of the PDECs, respectively, whereas only 1 WDET showed overexpression of p53 and none showed overexpression of p16. A total of 18 (82%) of the PDECs showed overexpression of p16 or p53 proteins. This is closely associated with PDEC (P < .0001). By using overexpression of p16 or p53 as the criteria for PDEC, the sensitivity and specificity are 81.8% and 97.1%, respectively, with positive and negative predictive values of 94.7% and 89.5%, respectively. CD117 was not detected in any of the 57 gastrointestinal endocrine tumors by immunohistochemical analysis. Endocrine cells are distributed throughout the body and frequently found in the gastrointestinal tract, pancreas, lung, thyroid, adrenal glands, and many other organs. Although the gastrointestinal tract has the largest population of endocrine cells, endocrine carcinomas of the gastrointestinal tract are rare. 1 Endocrine tumors in the gastrointestinal tract are classified as well-differentiated endocrine tumor (WDET), including typical carcinoid and atypical carcinoid, and poorly differentiated endocrine carcinoma (PDEC), including small cell carcinoma and large cell carcinoma. 2 Clinically, WDETs are generally indolent and resistant to chemotherapy, whereas PDECs are more aggressive but may respond transiently to cisplatin-based chemotherapy. 1-3 There are relatively fewer studies on gastrointestinal tract endocrine tumors compared with pulmonary neuroendocrine tumors. Most staging systems and treatment protocols for gastrointestinal tract endocrine tumors are derived from experience in similar lesions of neuroendocrine tumors in the lung based on the presumption that these diseases are similar in many aspects. 1

Hepatocyte growth factor (HGF) is a potent hepatocyte mitogen and may stimulate the proliferation and invasiveness of human hepatocellular carcinoma (HCC) cells through the c-met receptor. This study evaluates the significance of serum HGF levels in patients undergoing HCC resection.The peripheral and portal sera and HCC and non-tumorous tissues of 40 HCC patients, with tumor TNM stage I (n=12), II (n=17), and III (n=11) diseases, who underwent hepatic resection were prospectively collected. Serum HGF levels were determined by enzyme-linked immunosorbent assay. The c-met protein expressions were examined by immunohistochemistry. Median follow-up time was 69 months.The prehepatectomy portal HGF levels (median, 622pg/mL) were significantly higher than peripheral HGF levels (564pg/mL) (P=0.026). The posthepatectomy portal HGF levels (699pg/mL) were significantly higher than prehepatectomy portal HGF levels (P0.001). C-met expression was detected in 87.5% HCC and in 85.0% non-tumorous liver tissues. By Cox multivariate analysis, posthepatectomy portal HGF level699pg/mL (P0.001), multiple tumors (P=0.042), and TNM stages II (P=0.019) and III (P=0.009) were independent factors related with survival. Patients with a posthepatectomy portal HCG level699pg/mL and with a positive c-met expression in HCC tissue have the worst survival.In HCC patients, high peripheral and portal HGF serum levels related with poor prognosis after hepatic resection. Hepatocyte growth factor and c-met receptor can be targets of future HCC postoperative treatment.

Background and Objectives We explored the relationship between the mutation pattern of Ki-ras and the clinicopathological features of colorectal cancers (CRCs). Methods Relationships between clinicopathological parameters and Ki-ras mutation status were analyzed in 255 CRC patients using the chi-square and student t-tests. Kaplan-Meier survival curves were compared using the log-rank test. Results Ki-ras mutation occurred in 43.9% of tumors, and 83% affected codon 12. The most frequent mutations were GGT->GAT (Gly->Asp) (37.5%), followed by GGT->GTT (Gly->Val) (31.3%), both in codon 12. The frequency of Ki-ras mutation was similar for different tumor stages (38.2–47.8%). The mucin component of tumors was significantly associated with Ki-ras mutation. The 4-year overall and disease-free survival was 61% and 54%, respectively, for patients with Ki-ras mutated tumors, and 73% and 60% for patients with nonmutated tumors (not statistically significant). Patients with Ki-ras mutated tumors had lower plasma folate (24 ng/dl) than those bearing nonmutated tumors (37 ng/dl). Patients with G->T Ki-ras mutations had the lowest folate level (22 ng/dl), followed by those with G->A mutations (25 ng/dl). Conclusions Ki-ras mutated colorectal tumors have a higher mucin production and higher differentiation, and are associated with lower plasma folate levels and a relatively poorer disease outcome. J. Surg. Oncol. 2006;94:234–241. © 2006 Wiley-Liss, Inc.

By altering both DNA methylation and nucleotide synthesis, folate metabolism is thought to contribute to colorectal carcinogenesis. We examined the role of folate metabolism in three different phenotypes of sporadic colorectal cancers (CRCs), phenotypes that were classified by the status of microsatellite instability (MSI) and chromosomal instability (CIN): MSI-H, microsatellite stability (MSS)/aneuploidy, and MSS/diploid. A total of 195 sporadic colorectal tumors and another 195 age- and gender-matched healthy volunteers in Taipei-Veteran General Hospital and Taipei City Hospital were collected. We analyzed for MTHFR (methylenetetrahydrofolate reductase) polymorphisms (C677T, A1297C), folate, and vitamin B12 levels. We determined MSI status and DNA ploidy with fluorescent polymerase chain reaction and flow cytometry. Relations between clinicopathological variables and molecular variables were analyzed by χ 2 tests (with Yates’ correction) for categorical variables and Student’s t test for numerical variables. Folate levels (5.02±4.43 ng/ml) were significantly lower in cancer patients than in controls (7.22±4.46 ng/ml). Vitamin B12 level was similar between cancer patients and controls. The frequency of the TT genotype of MTHFR C627T (12.3%) was slightly higher than controls (8.2%), but it did not reach statistical significance (p=0.174). Within the low-folate group (

Solid and pseudopapillary tumor of the pancreas is a benign and low malignant potential tumor. Prognosis is good after surgical resection but its malignant potential is usually defined after metastasis. We compared benign and malignant cases with clinicopathological, immunohistochemical and DNA flow cytometric studies.From January 1991 to July 2004, seven patients were found to have solid and pseudopapillary tumor of the pancreas at Taipei Veterans General Hospital. The paraffin sections were reevaluated with hematoxylineosin stain, immunohistochemical stains, and DNA flow cytometric studies.It included 6 benign and one malignant case. The progesterone receptor, vimentin, neuron-specific enolase, and chromogranin A showed diffused positive stain in all cases. Estrogen receptor and P53 stain were negative in all 7 patients. Synaptophysin stain was negative in 6 no recurrence patients, but was positive only in the patient who suffered from recurrence. DNA flow cytometry showed diploid results in six non-malignant tumors. In the malignant patient, the tumor in the first operation showed diploid result, but tumors in second and third operations showed aneuploidy.Solid and pseudopapillary tumor of the pancreas should be considered as a potentially malignant disease in all patients and regular follow-up is mandatory.

Prognosis for patients with early gastric cancer after surgical resection is excellent. The 5-year or even 10-year survival is more than 90%. In the present study, we investigated the result of treating early gastric cancer surgically in our hospital, with special reference to the risk factor(s) for tumor recurrence and the relationship between age and survival. From January 1988 to December 2002, a total of 479 patients with early gastric cancer underwent resection by our surgeons. Results of preoperative studies, operative findings, histopathology and postoperative follow-up were recorded respectively, and the postoperative disease-related survival, overall survival, tumor recurrence and recurrent patterns were analyzed. The clinicopathological factors were also analyzed to identify the risk factor(s) related to tumor recurrence. Older patients (>75 years old) had a poorer overall survival than younger patients. However, the disease-related survival was not significantly different between the two. Recurrence was observed in 21 patients, the most important factor of which was lymph node status. Lymph node metastases occurred in 54 patients (11.3%)—coming from mucosal tumors in 12 patients (4.4%) and from submucosal tumors in 42 (20.3%). When the size of the mucosal tumor was smaller than 1 cm, no lymph node metastasis was found in our patients. The most important risk factor of recurrence in early gastric cancer is lymph node status. Given the low probability of lymph node metastasis and recurrence in tumors less than 1 cm in diameter limited to the mucosa, more limited surgery maybe appropriate in these carefully selected instances.

Summary Background The survival benefit and morbidity after nodal dissection for gastric cancer remains controversial. We aimed to do a single-institution randomised trial to compare D1 (ie, level 1) lymphadenectomy with that of D3 (ie, levels 1, 2, and 3) dissection for gastric cancer in terms of overall survival and disease-free survival. Methods From Oct 7, 1993, to Aug 12, 1999, 335 patients were registered. 221 patients were eligible, 110 of whom were randomly assigned D1 surgery and 111 of whom were randomly assigned D3 surgery, both with curative intent. Three participating surgeons had done at least 25 independent D3 dissections before the start of the trial, and every procedure was verified by pathological analyses. The primary endpoints were 5-year overall survival and 5-year disease-free survival. We also analysed risk of recurrence. Main analyses were done by intention to treat. This trial is registered at the US National Institute of Health website http://www.clinicaltrials.gov/ct/show/NCT00260884. Findings Median follow-up for the 110 (50%) survivors was 94·5 months (range 62·9–135·1). Overall 5-year survival was significantly higher in patients assigned D3 surgery than in those assigned D1 surgery (59·5% [95% CI 50·3–68·7] vs 53·6% [44·2–63·0]; difference beteween groups 5·9% [−7·3 to 19·1], log-rank p=0·041). 215 patients who had R0 resection (ie, no microscopic evidence of residual disease) had recurrence at 5 years of 50·6% [41·1–60·2] for D1 surgery and 40·3% [30·9–49·7] for D3 surgery (difference between groups 10·3% [−3·2 to 23·7], log-rank p=0·197). Interpretation D3 nodal dissection, compared with that of D1, offers a survival benefit for patients with gastric cancer when done by well trained, experienced surgeons.

Lauren's intestinal type of gastric cancer was proposed to be dependent on long-term environmental factors and is always preceded by chronic premalignant change. A cohort study was performed and demonstrated an increased cancer risk of gastric remnant after gastric surgery for benign disease. It is generally believed that after gastrectomy the residual stomach has an environmental change and, thus, enters a neoplastic process. Based on the carcinogenic theory of intestinal-type tumour, it would be of interest to know whether the intestinal-type tumour is more common in gastric remnant cancer. Forty patients with gastric remnant cancer had gastrectomy in the Veterans General Hospital-Taipei. Another 683 patients with primary gastric carcinoma underwent resection and were used as controls. The clinical characteristics, tumour stage and intestinal-type tumour were analysed in gastric remnant cancer and were compared with the various portions of primary gastric carcinoma. Although the overall distribution of intestinal-type carcinoma in gastric remnant (45%) was no different to that of any other portion of stomach cancer, intestinal-type carcinoma was more common in the early stage of gastric remnant (73%) and distal stomach (73%), but not in the proximal stomach (50%), which was supposed to have the same characteristics as the gastric remnant because of identical anatomic location. More than expected, intestinal-type carcinoma in early gastric remnant cancer together with a long incubation interval between primary surgery and later tumour occurrence were compatible with the theory of carcinogenesis of intestinal-type carcinoma.

The significance of tumor volume and its change after concurrent chemoradiotherapy (CCRT) was evaluated.Standard-dose external radiation and oral UFUR plus leucovorin were used to treat 30 middle and lower rectal adenocarcinoma patients. Volume of tumor calculated from images obtained by dynamic MRI of the rectum before and after CCRT was compared to pathological results after definite resection and other clinical data.The T-stage in 15 patients (50%), the N-stage in 13 (72.2%), and overall, the TNM stage in 18 (60%), were downstaged, including 7 (23.3%) with complete responses (CR). Volume of tumor before CCRT (Vpre) and after CCRT (VPost) was 10.3+/-6.1cm3 and 4.2+/-2.2cm3, respectively, and VPre correlated with initial T stage, N stage, age, and location. The net decrease ratio (NDR) of tumor volume was related to Vpre and initial T stage. As to the downstaging effect, VPre was related to incidence of CR; NDR was related to the downstaging of the N stage.All tumors showed volume reduction after CCRT, but the downstaging benefits were not in proportion to the size change. Initially larger tumors had higher ratios of volume reduction, and smaller tumors had higher chance of CR.

The management of benign liver tumors in Asian countries endemic for hepatocellular carcinoma (HCC) may be different from that in western countries with a lower prevalence of HCC. The aim of this study was to investigate the characteristics of surgically treated benign liver tumors in a liver disease treatment center in Taiwan, an area prevalent for HCC.Between January 1991 and June 2001, 57 patients with benign liver tumors underwent liver resection. The demographic data, radiologic diagnosis, and postoperative pathologic diagnosis of these patients were reviewed and analyzed.Cavernous hemangioma (n = 15), focal nodular hyperplasia (n = 12), and macro-regenerative nodule (n = 9) were the most frequent pathologic diagnoses of the resected liver tumors. HCC was the most frequent preoperative radiologic diagnosis (27/57, 47%). Four of the 9 macro-regenerative nodules had associated focal dysplastic change. All of the patients with macro-regenerative nodule had a preoperative imaging diagnosis of HCC. Only 1 liver biopsy was performed among the 57 patients.HCC was the most frequent preoperative radiologic diagnosis for benign liver tumors undergoing liver resection at a tertiary referral center in Taiwan. Macro-regenerative nodule of liver was commonly misdiagnosed as HCC by radiology alone in this study. In order to avoid unnecessary surgery, aspiration cytology should be performed for all patients without elevated serum alpha-fetoprotein and typical radiologic features of HCC. Patients with macro-regenerative nodules without atypical hepatocytes can be followed safely without surgical intervention, but when a macro-regenerative nodule with dysplastic change is found, it should be treated either by surgical resection or local ablation.

Before embarking on a clinical human pancreas transplantation program we sought a canine animal model with enteric drainage to refine our technical skills, to evaluate the surgical risks and to study the rejection pictures under modern triple immunosuppression therapy.Twenty donor-recipient pairs of unrelated mongrel dogs underwent pancreaticoduodenal allotransplantation with enteric drainage. All dogs were immunosuppressed by triple therapy with prednisolone, cyclosporine (Neoral) and mycophenolate mofetil (MMF). Rejection grade and surgical risk were evaluated.Group 1 included 10 (50%) dogs surviving at least 14 days. In group 2 surviving less than 14 days, the median survival was 5.5 days, ranging from 1 day to 13 days. The most common complications were duodenal stump leakage and wound infection. Duodenal stump leakage eventually led to mortality in 3 dogs of group 2. Two (in group 2) of the 3 wound infections became too severe to control and caused death. There were 2 dogs complicated with graft necrosis and 2 with graft vascular thrombosis individually, which all resulted in death. Other fatal complications included 1 chyle leakage, 1 intraabdominal abscess and 1 pneumonia individually. Ninety percent in each group developed rejection. Severe rejection developed in 5 (50%) dogs in group 2 (grade 4 and 5), p = 0.033, as compared with none in group 1. The rejection in most cases (90%) of group 1 was mild to moderate, with 4 grade 3, 3 grade 2 and 2 grade 1.Canine pancreas allotransplantation with enteric drainage is a feasible animal model to achieve survival longer than 14 days in 50% cases studied. Duodenal stump leakage was the most common fatal complication in this model. Severity of rejection was closely associated with posttransplant fatal complications and played a crucial role in determining the dog survival.

Objective: Adenoid cystic carcinoma (ACC) of the tracheobronchial tree is quite uncommon. The clinicopathologic analysis and the therapeutic outcomes of tracheobronchial ACC have been reported earlier. However, their biological behavior should differ from other tracheal neoplasms. Thus, DNA flow cytometric analysis and biomarkers of p53, HER-2/neu and COX-2 for tracheobronchial ACC were investigated in order to evaluate their clinicopathological significance. Methods: Between 1985 and 1999, nine patients with tracheobronchial ACC were included for the study. All the patients had pathologically confirmed ACC. Five were male and four were female. Eight patients underwent surgical resections. Seven paraffin embedded tumors from six patients were available for DNA flow cytomeric analysis and immunohistochemical staining of p53, HER-2/neu and COX-2. Results: Histologically, nine pathologic specimens from eight surgical patients (including one patient received operation twice) showed one grade I, five grade II and three grade III. The mitotic activity, lymphatic invasion and vascular invasion were more frequent in advanced grading tumor. The higher grade tumors seemed to be associated with a higher synthetic phase fraction (SPF). Immunohistochemically, except for one grade II tumor showing positive expression of HER-2/neu, all the seven tumorous samples revealed negative expressions of p53, COX-2 and HER-2/neu. The patient with positive HER-2/neu tumor had distant metastases 4 years after surgery. Conclusions: Complete surgical resection may provide best survival for tracheobronchial ACC. The DNA ploidy and SPF may correlate with tumor grading or metastasis. The overexpressions of HER-2/neu, p53 and COX-2 may impact the prognosis in patients with stage I non-small cell lung cancer, but did not express difference in our patients. q 2002 Elsevier Science B.V. All rights reserved.

INTRODUCTION Patients with pancreatic cancer often present initially in advanced disease with many compromising factors, and yet they may still be responsive to chemotherapy. AIMS The response of 23 patients with advanced pancreatic cancer to continuous infusion therapy was investigated. METHODOLOGY From September 1995 to February 1998, 23 patients with advanced pancreatic cancer, many with compromising factors, were treated with a MEFLEP regimen: biweekly 24-hour infusions of etoposide, 5-fluorouracil, leucovorin, epirubicin, and cisplatin, all given through an infusion pump, plus megestrol acetate, 160 mg/d, taken daily. A total of 145 courses were given. Overall response rate was 21% (4/19) for assessable chemo-naive patients; median survival for all 23 patients was 6 months; 22% of patients were alive at 1 year; and a clinical response benefit was attained in 35%. RESULTS Toxicity was manageable; grade 3 or 4 leukopenia occurred in 1 patient each, 1 patient had fever and grade 3 infection, and grade 3 and 4 hyperammonemic encephalopathy developed in 3 and 1 patients, respectively. All four of the latter patients recovered uneventfully within 2 days of initiation of therapy. Nine patients were evaluated by fluorescence in situ hybridization for the Her-2/neu oncogene, but for only one patient did amplification of the gene occur. She attained complete remission with treatment and lived for 26.7 months after diagnosis. CONCLUSION Biweekly MEFLEP is an active and manageable regimen for patients with advanced pancreatic cancer with compromised clinical status.

Background. Only a few studies on extrahepatic biliary atresia (BA) have reported that the morphological changes of bile canaliculi could predict the clinical outcome after portoenterostomy and provide differential diagnosis of neonatal jaundice. Aminopeptidase N (APN) is an ectoenzyme of bile canaliculi that is involved in bile secretion. In this study, we tried to see whether APN of bile canaliculi had a significant role in BA. Patients and methods. We used monoclonal antibody 9B2 to compare the expression of APN in livers with BA, neonatal hepatitis, and choledochal cysts, as well as in nontumorous portions of pediatric hepatic livers with tumors. The expression of APN in fetuses, preterm babies, and term neonates was also studied. Results. A high degree of 9B2 expression in BA was closely related to poor outcome. Cholestasis in choledochal cysts, rather than neonatal hepatitis, made 9B2 expression stronger. Increasing expression of 9B2 from fetuses to neonates was noted and the degree of 9B2 expression was similar between term neonates and nontumorous portions of pediatric livers with tumors. Interestingly, some cases of BA had 9B2 expression like that of preterm babies. Conclusions. APN of bile canaliculi progressively develops from fetuses to neonates and is well developed in neonates. APN can be induced to stronger expression by obstructive jaundice. The amount of expression of APN of bile canaliculi in BA is a predictor of clinical outcome and may be a tool for implicating the mechanism of BA.

Purpose: The aim of this study was to investigate the possible role of Fas and Fas ligand system in biliary atresia. Methods: Immunohistochemical stains of Fas and Fas ligand (FasL) and in situ hybridization of Fas ligand messenger RNA (mRNA) were performed on paraffin-embedded liver specimens of 36 biliary atresia, 6 choledochal cysts, and 14 nontumorous parts of pediatric liver tumors. Apoptosis was detected by terminal deoxynucleotidyl transferase deoxy-UTP nick end labeling (TUNEL). The grade of liver fibrosis and results of bile drainage on the patients with biliary atresia were compared with the results of FasL expression. Results: Fas protein was positive on the hepatocytes and bile ductule epithelia of all the livers examined and also positive on some monocytes around the portal area in all the biliary atresia patients. FasL protein was positive on bile ductule epithelia in 10 biliary atresia patients and also positive on some monocytes in most of the biliary atresia patients. Positive signals of FasL mRNA were noted on hepatocytes in 4 biliary atresia, bile ductule epithelia in 19 biliary atresia patients, and some monocytes in most of the biliary atresia patients. Apoptotic nuclei were present among monocytes in all the biliary atresia livers but present among bile ductule epithelia only on the BA with positive FasL mRNA signals on ductule epithelium. The fibrosis grade was similar between biliary atresia with positive FasL mRNA signals and negative signals. The bile drainage was better in the biliary atresia without positive FasL mRNA signals. Conclusions: Fas ligand expression on bile ductule epithelia in biliary atresia may be induced to counterattack the infiltrating lymphocytes. Although the factors for post-Kasai bile drainage are multiple, the authors suggest Fas ligand expression on bile ductule epithelia may be a poor prognostic factor by playing a role in the continuous damage and obliteration of intrahepatic bile ducts after Kasai operation. J Pediatr Surg 35:1591-1596. Copyright © 2000 by W.B. Saunders Company.

Abdominal actinomycosis has been called “one of the greatest imitators in clinical practice.”1 In addition, its variety makes it difficult to accumulate experience with the disease. Actinomycosis is a chronic suppurative infection due to a grampositive, non-spore-forming, anaerobic bacteria. The organisms are indigenous in the oral cavity, GI tract, and genital tracts, with opportunistic infection occurring when the mucosal barrier is broken,2 leading to multiple abscess formation, fistula, or a mass lesion. Actinomycosis has three major forms of clinical manifestation: cervicofascial, thoracic,3 and abdominal.4 We present a case of abdominal actinomycosis with an interesting endoscopic and radiologic picture.

It has been proposed that persistent oxidative stress accounts for the increased levels of DNA damage in cancer tissues. We have examined the profile of anti-oxidant enzymes in a transplanted hepatic tumor model by injecting N1S1 rat hepatoma cells into the liver of Sprague-Dawley rats. The transplanted N1S1 tumors displayed characteristics resembling human hepatocellular carcinoma. The immunoreactivities of catalase (CAT), manganese-superoxide dismutase (Mn SOD), copper/zinc-SOD (Cu/Zn SOD), and glutathione peroxidase (GPx) were found to decrease significantly. The enzyme activity in tumors decreased 26.2-, 4.2-, 4.5-, and 5.4-fold for CAT, Mn SOD, Cu/Zn SOD, and GPx, respectively, relative to those in normal liver tissue from the same animals. In contrast, the mRNA levels of CAT and GPx in tumors decreased only 5- and 2-fold, respectively, and the mRNA levels of Cu/Zn SOD and Mn SOD showed either no change or an increase as compared to those of normal liver tissue. The contents of 8-hydroxy-2'-deoxyguanosine (8-OH-dG) and thiobarbituric acid-reactive substances (TBARS) were comparable to those of normal controls. Furthermore, mitochondrial production of superoxide in tumors was 4 times lower than that in normal tissues. In conclusion, the data indicate that the reduced activities of anti-oxidant enzymes in the N1S1 tumor did not cause significant oxidative stress.

Little is known about the biomechanical properties of human ligamentum teres. To more fully understand the ligamentum teres, its dimensions and mechanical properties were measured in 22 cases of acute fracture of the femoral neck and 21 cases of ischemic necrosis of the femoral head. The specimens first were preconditioned and then loaded to failure with a testing machine at a fast strain rate of 100% s(-1). The ischemic necrosis group had a significantly larger volume (3.09 +/- 1.81 ml versus 1.30 +/- 0.62 ml) and cross section area (65.3 +/- 59.1 mm2 versus 30.6 +/- 27.2 mm2) than did the acute fracture group. The former also had a significantly greater ultimate load (234 +/- 168 N versus 130 +/- 111 N) and strain energy to failure (1.22 +/- 1.04 J versus 0.41 +/- 0.39 J), but a significantly smaller linear modulus (4.72 +/- 3.31 MPa versus 8.69 +/- 7.97 MPa) than did the latter. Histologic studies showed differences in the amount of organized collagen and components of subsynovial tissue between the 2 groups. Mechanical and morphologic adaptations of the ligamentum teres in a group of ischemic femoral heads are described, and a possible biomechanical role is suggested for the ligamentum teres in the hip joint in conjunction with the ischemic necrosis of the femoral head.

Background The best sites for biopsy-based tests to evaluate H. pylori infection in gastritis with atrophy are not well known. This study aimed to evaluate the site and sensitivity of biopsy-based tests in terms of degree of gastritis with atrophy. Methods One hundred and sixty-four (164) uninvestigated dyspepsia patients were enrolled. Biopsy-based tests (i.e., culture, histology Giemsa stain and rapid urease test) and non-invasive tests (anti-H. pylori IgG) were performed. The gold standard of H. pylori infection was defined according to previous criteria. The sensitivity, specificity, positive predictive rate and negative predictive rate of biopsy-based tests at the gastric antrum and body were calculated in terms of degree of gastritis with atrophy. Results The prevalence rate of H. pylori infection in the 164 patients was 63.4%. Gastritis with atrophy was significantly higher at the antrum than at the body (76% vs. 31%; p Conclusions In moderate to severe gastritis with atrophy, biopsy-based test should include the corpus for avoiding false negative results.

Refractory ascites can occur in patients with various conditions. Although several procedures based on the reinfusion of ascitic fluid have been reported after the failure of bed rest, salt and water restriction, diuretics, intravenous administration of albumin, and repeated paracentesis, these procedures are performed for ascitic fluid removal without dialytic effect. In this study, a flow control reinfusion of ascites during hemodialysis (HD) was performed to demonstrate the efficacy of this method in a lupus patient with massive refractory ascites and respiratory and acute renal failure (ARF). The alleviation of ascites and ARF attests to the success of the flow control reinfusion of ascites during HD. This procedure can control the rate of ascites and body fluid removal simultaneously during HD using the roller pump. In conclusion, with a normal coagulation profile, the procedure of flow control reinfusion of ascites during HD is an effective alternative treatment for the alleviation of refractory ascites with renal failure.

TO THE EDITOR: The article by Gunderson et al provides powerful evidence to support the revised staging system in the seventh edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual for colon cancer. The case numbers of national-based survival data are large enough to explore significant subtle staging factors. However, an interesting point about Tis colon cancers is worthy of deeper discussion, which was not mentioned in the article. We found the contents both in Table 1 and Table 2 in this article showed that a proportion of Tis colon cancers had lymph node metastasis, with a very low incidence. A total of 5,939 patients had Tis colon cancer, and 95 patients (1.6%) had N1 disease and 19 patients (0.32%) had N2 disease. This finding challenges our previous general rule that colon cancer confined to the mucosa has no chance of metastasis and thus no further treatment is needed. According to the previous AJCC consensus in 2000, colon tumors invading the lamina propria up to and including the muscularis mucosae have no associated risk of regional lymph node metastasis. However, recent data using immunohistochemical marker D2-40 have shown the presence of lymphatic channels extending to the colonic mucosa in neoplastic and inflammatory conditions. Literature on the subject of metastatic risk in intramucosal colorectal carcinoma is extremely limited. Only one patient with poorly differentiated intramucosal rectal cancer had recurrence after surgical resection. We reviewed the patient group in our hospital. In total, there were 3,196 patients with colorectal cancer who received treatment at our hospital during 1999 to 2005. Among the 118 patients receiving regional resection for Tis tumors, no lymph node metastasis was found, except in one patient with a polypoid lesion. The pathology slides of this patient were reviewed carefully, and the tumor was actually a T2 lesion that invaded the superficial muscle layer. In fact, certain types of intramucosal cancer can have lymph node metastasis in gastric cancer. In colorectal cancer, data are still lacking regarding lymph node metastasis in intramucosal tumors. We suggest that all pathologic slides of these intramucosal colon cancers with lymph node metastasis in this article should be reviewed carefully, if possible, to certify the actual invasion depth of the tumor. If it is true that lymph node metastasis could occur in intramucosal colon cancer, it will provide us with a new point of view concerning the treatment of this type of tumor. As a result of recent advances for endoscopic procedures, such as endoscopic mucosal resection or endoscopic submucosal dissection, local treatment for early colorectal cancers is generally accepted and widely applied. If intramucosal colon cancers could have risk of metastasis, additional investigation is warranted to define the high-risk group before applying local treatment for these patients.

AIM: Helicobacter pylori (H pylori) has been linked to chronic gastritis, peptic ulcers, gastric cancer and MALT-lymphoma. Conventional invasive tests are less sensitive than non-invasive tests in diagnosing H pylori infection in patients with bleeding peptic ulcers. Polymerase chain reaction is a sensitive and accurate method for diagnosing H pylori infection. The aim of this study was to evaluate the diagnostic role of mucosal polymerase chain reaction for H pylori infection in patients with bleeding peptic ulcers. METHODS: In patients with bleeding, non-bleeding peptic ulcers and chronic gastritis, we checked rapid urease test, histology, bacterial culture and mucosal polymerase chain reaction for detecting H pylori infection. Positive H pylori infection was defined as positive culture or both a positive histology and a positive rapid urease test. For mucosal polymerase chain reaction of H pylori, we checked vacA (s1a, s1b, s1c, s2, m1, m1T, m2), iceA1, iceA2 and cag A. RESULTS: Between October 2000 and April 2002, 88 patients with bleeding peptic ulcers (males/females: 60/28, gastric ulcers/duodenal ulcers: 55/33), 81 patients with non-bleeding peptic ulcers (males/females: 54/27, gastric ulcers/duodenal ulcers: 45/36) and 37 patients with chronic gastritis (males/females: 24/13) were enrolled in this study. In patients with bleeding peptic ulcers, non-bleeding peptic ulcers and chronic gastritis, 45 patients (51%), 71 patients (88%) and 20 patients (54%) respectively were found to have positive H pylori infection (P

Helicobacter pylori (H pylori ) has been linked to chronic gastritis, peptic ulcer, gastric cancer and MALT-lymphoma. The link of genotypes of H pylori to gastric cancer remains controversial. The aim of this study was to investigate the H pylori vacA alleles, cagA and iceA in patients with gastric cancer in Taiwan.Patients with gastric cancer, peptic ulcer and chronic gastritis were enrolled in this study. We obtained biopsy specimens from the stomach at least 2 cm away from the tumor margin in patients with gastric cancer, and from the antrum of stomach in patients with peptic ulcer or chronic gastritis. DNA extraction and polymerase chain reaction were used to detect the presence or absence of cagA and to assess the polymorphism of vacA and iceA.A total of 168 patients (gastric ulcer: 77, duodenal ulcer: 66, and chronic gastritis: 25) were found to have positive PCR results of the biopsy specimens from patients with peptic ulcer and chronic gastritis. We found positive cagA (139/168, 83%), m2 (84/168, 50%) and iceA1 (125/168, 74%) strains in the majority of patients. In patients with gastric cancer, the vacA s1a and s1c subtypes were less commonly found than those in non-cancer patients (35/66 vs 127/168, P = 0.0001 for s1a and 13/66 vs 93/168, P0.0001 for s1c). In the middle region, the m1T strain in patients with gastric cancer was more than that of non-cancer patients (23/66 vs 33/168, P = 0.02).In Taiwan, H pylori with positive vacA s1a, cagA and iceA1 strains are found in the majority of patients with gastric cancer or non-cancer patients. In patients with gastric cancer, the vacA s1a and s1c subtypes are less and m1T is more than in patients with peptic ulcer and chronic gastritis.

Summary Gastrointestinal stromal tumors are nonepithelial neoplasms of the gastrointestinal tract and have been increasingly recognized in recent years. In contrast, stromal tumor outside the gastrointestinal tract is not frequently found. Here, we present a 57-year-old male patient who had abdominal fullness for several months. It was caused by a 23-cm heterogeneous tumor mass that was successfully removed from the left upper abdominal cavity. The tumor adhered tightly to adjacent organs but postoperative histopathological analysis revealed no direct connection to the stomach, liver, pancreas, spleen, or kidneys. Immunohistochemical examination of the tumor revealed proliferative spindle-shaped cells stained positive for CD117 and CD34 and negative for smooth muscle actin and S-100. The patient received regular follow up. A suspected recurrent liver metastatic lesion was noted 2 years later and radiofrequency ablation of the liver tumor was performed followed by oral imatinib treatment. No tumor recurrence was detected at 3 years after radiofrequency ablation. This case reminds us that extragastrointestinal stromal tumors should be considered in the differential diagnosis when a large heterogeneous mass is present in the abdominal cavity. The characteristics of extragastrointestinal stromal tumor are described and the literature is reviewed in this report.