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Background: Neoadjuvant chemotherapy for advanced gastric cancer is expected to improve prognoses. However, as there is no method to evaluate neoadjuvant chemotherapeutic efficacy before gastrectomy, some patients at high risk for a poor prognosis undergo gastrectomy. The aim of the present study was to investigate whether endoscopy could be useful for assessing the efficacy of neoadjuvant chemotherapy. Methods: In this retrospective study, we analyzed the data of 41 patients who received neoadjuvant chemotherapy followed by gastrectomy at our institution to investigate whether responsiveness to neoadjuvant chemotherapy, as assessed with endoscopy, can serve as a surrogate marker for histological grades 1b or higher in the Japanese Classification of Gastric Carcinoma (JCGC) scheme. Results: There were 32 (78.0%) responders and 9 (22.0%) nonresponders to neoadjuvant chemotherapy, as observed in endoscopic evaluations. Among the endoscopic responders, 24 (75.0%) had cancer of histological grade 1b or higher, and 15 (46.9%) had cancer of grade 2 or higher. Among the endoscopic nonresponders, 1 (11.1%) patient had histological grade 1b cancer. Compared with endoscopic nonresponders, endoscopic responders were more likely to show a histological response (chi-square test: p = 0.0005 for JCGC grade 1b or higher; p = 0.0099 for JCGC grade 2 or higher). Conclusions: Most endoscopic responders showed JCGC histological responses. Evaluation of neoadjuvant chemotherapeutic efficacy by endoscopy in gastric cancer may be useful before gastrectomy. As this was a retrospective study, further investigations are required. The protocol was approved by the ethics review committee at Osaka Medical College (No. 2422) and was registered in the University Hospital Medical Information Network Clinical Trial Registry (UMIN000033088).

Background Intestinal endometriosis is a common benign disease among menstruating women that affects the intestinal tract. Case presentation This case report presents seven Japanese cases of intestinal endometriosis with colorectal cancer treated by laparoscopic surgery. Five of the seven cases reported here are women presenting with bowel obstruction due to colorectal endometriosis with colorectal cancer. It can be confused with serious lesions such as advanced colorectal cancer with peritoneal involvement or invasion of adjacent organs (T4). Conclusions Therefore, we should consider the probability that the cause of bowel obstruction is not T4 but intestinal endometriosis. For surgical treatment, we recommend laparoscopic surgery for colorectal resection because of its benefits of differential diagnosis of T4, preserving fertility, and preventing excessive surgical stress. We performed laparoscopic resection in seven patients with intestinal endometriosis and colorectal cancer. These cases demonstrate the difficulty of establishing a differential diagnosis of intestinal endometriosis with colorectal cancer from T4.

Linked color imaging (LCI) is a novel endoscopic system used to increase color contrast. As LCI does not decrease luminal brightness, it may improve the detection of colonic neoplasms. However, the extent to which LCI improves the visibility of colonic polyps has not yet been determined. Between December 2016 and May 2017, patients who received total colonoscopy were consecutively recruited into this retrospective, single-center study. For each polyp identified, images obtained from white light (WL) imaging, blue laser imaging (BLI), and LCI of the same lesion and its surrounding mucosa were evaluated. The color differences (ΔE) between each lesion and its surrounding mucosa in non-magnified images were computed quantitatively using the CIELAB color space, which defines color perception according to colorimetric values, and compared among WL, BLI, LCI, and chromoendoscopy. The ΔE between the vessel and non-vessel areas in magnified images was also assessed. Of the 64 patients who were incorporated into this study, non-magnified and magnified (×80) images from 113 and 95 polyps, respectively, were assessed. The ΔE was intensified by LCI and chromoendoscopy compared with WL and BLI. The ΔE of neoplastic lesions was also intensified by LCI. In magnified images, BLI and LCI significantly increased the ΔE between the vessel and non-vessel areas compared with WL. Luminal brightness, indicated by L*, was not impaired by LCI; however, was reduced by BLI compared with WL and LCI. These results suggest that LCI enhanced the detection of colonic neoplasms without impairing luminal brightness. We propose the routine use of LCI for colonic polyp detection and BLI for magnifying observations of colonic polyps detected by LCI.

Pseudomyxoma peritonei (PMP) is characterized by extensive mucinous ascites following rupture of mucinous neoplasms of an intra-abdominal origin, and contain secreted gel-forming mucins such as MUC2 and MUC5AC. We encountered a 66-year-old Japanese man complaining of abdominal distension. Ascites at the site was gelatinous upon gross examination, and needle aspirate smears showed histiocytes and many mucinous balls wrapped in spindle cells, which were positive for vimentin, pan-cytokeratin, and podoplanin. The cell block showed several adenocarcinoma clusters, which were positive for MUC2, MUC5AC, CK20, and CDX-2, and negative for CK7. From these findings, a diagnosis of PMP arising from colon cancer was indicated. Cytoreductive surgery was performed, and the cystic diverticulum was found to be infiltrated by tumor cells in the sigmoid colon that caused PMP. Mucinous balls surrounded by mesothelial cells and MUC2-positive adenocarcinoma cells are useful clues in the diagnosis of PMP. Diagn. Cytopathol. 2016;44:628-631. © 2016 Wiley Periodicals, Inc.

Mesenteric panniculitis (MP) is a benign fibroinflammatory process characterized by the presence of fat necrosis, chronic inflammation and fibrosis in the mesentery. Although various causal factors, such as malignancy, chronic inflammatory conditions and autoimmune processes, have been identified, the precise etiology remains unknown. We herein report a rare case of MP accompanying Sjögren's syndrome in which a mass lesion and intestinal stenosis were observed simultaneously. This condition led to ileus, which was effectively treated using prednisolone.

Diverticular colitis is chronic inflammation of the colon where diverticula are present. The endoscopic and histopathological findings of this disease are sometimes similar to those of ulcerative colitis, and several reports describe cases of diverticular colitis that progressed to typical ulcerative colitis. A 77-year-old woman with intramesenteric penetration of the sigmoid diverticulum underwent low anterior resection. One month later, the patient experienced anastomotic leakage, and transverse colostomy was performed. Six months after the colostomy, the patient returned to the hospital with complaints of bloody discharge from the rectum and stoma. Colonoscopy revealed newly developed loss of vascular pattern and a granular appearance of the mucosa in the rectum that had not been present at prior examinations. She was diagnosed with ulcerative colitis, which developed after colectomy, and treated with mesalazine and high-dose prednisolone, but the clinical and endoscopic response was poor. Finally, the patient underwent total proctocolectomy and ileal pouch anal anastomosis with diverting ileostomy. As a few reports have described, diverticular colitis can progress to typical ulcerative colitis after surgery in some cases, suggesting a possible pathogenic similarity between the two diseases and association between colorectal surgery and disease progression.

The appropriateness of endoscopic resection in patients with T1 colorectal carcinomas is unclear. Highly precise predictors of lymph node metastasis are required to optimize the outcomes of treatments for T1 colorectal carcinomas.The purpose of this work was to identify predictors of lymph node metastasis by examining the clinicopathologic significance of immunophenotypes found in T1 colorectal carcinomas.This was a retrospective study.The study was conducted at a university hospital.Included were 265 patients with T1 colorectal carcinoma who underwent radical surgery.Patients with T1 colorectal carcinoma were managed.Immunophenotypes were associated with various clinicopathologic parameters, and CD10 expression was strongly associated with lymph node metastasis.The levels of MUC2, MUC5AC, and CD10 expression were individually significantly associated with tumor location, growth pattern, histologic type, invasive potential, and metastatic potential. The incidence of lymph node metastasis was significantly associated with each of the 5 following parameters: depth of submucosal invasion (p = 0.005), tumor budding (p0.001), lymphatic invasion (p0.001), MUC2 expression (p = 0.006), and CD10 expression (p0.001). Multivariate analysis showed that CD10 expression (OR, 9.2 [95% CI, 2.5-39.8]; p = 0.001) and lymphatic invasion (OR, 6.3 [95% CI, 2.5-17.7]; p0.001) were independently associated with lymph node metastasis.This study was limited by its small sample size, intraobserver variation attributed to immunohistochemical staining, and potential selection bias because surgically resected specimens were collected instead of endoscopically resected specimens.We suggest that CD10 expression is closely associated with lymph node metastasis in T1 colorectal carcinoma.

The patient was a 40-year-old man who had suffered from Crohn's disease (CD) for 19 years and developed an intractable perianal fistula and two strictures in the small bowel. Dilatation of the two strictures using double-balloon endoscopy did not improve the subileus symptoms. An anal canal adenocarcinoma was also detected using double-balloon endoscopy. The ileum and rectoperianal area were partially resected, and a precise immunohistochemical pathologic assessment revealed that all three lesions were fistula-associated adenocarcinomas. Accumulating endoscopic findings of CD-associated cancer and precise pathologic diagnostic findings will help to establish a suitable surveillance method.

Cushing's syndrome due to young small-cell lung cancer (SCLC) is recognized as being extremely rare. We herein present the case of a 35-year-old nonsmoking man who presented with thirst and polyuria. Laboratory examinations showed hyperglycemia, hypokalemia and liver enzyme elevation. Imaging examinations revealed the presence of multiple liver tumors and lymph node swelling. The levels of serum neuroendocrine tumor markers were elevated. The patient was diagnosed with SCLC based on the pathological examination of a biopsy specimen from the right supraclavicular lymph node. The physical findings, including proximal myopathy, truncal obesity and pigmentation suggested high levels of glucocorticoids. An immunohistochemical examination of the tumor showed that it was positive for adrenocorticotropin (ACTH). An endocrinological investigation allowed for the definitive diagnosis of SCLC with ectopic ACTH production.

Pseudomyxoma peritonei (PMP) is characterized by extensive mucinous ascites following rupture of mucinous neoplasms of an intra-abdominal origin, and contain secreted gel-forming mucins such as MUC2 and MUC5AC. We encountered a 66-year-old Japanese man complaining of abdominal distension. Ascites at the site was gelatinous upon gross examination, and needle aspirate smears showed histiocytes and many mucinous balls wrapped in spindle cells, which were positive for vimentin, pan-cytokeratin, and podoplanin. The cell block showed several adenocarcinoma clusters, which were positive for MUC2, MUC5AC, CK20, and CDX-2, and negative for CK7. From these findings, a diagnosis of PMP arising from colon cancer was indicated. Cytoreductive surgery was performed, and the cystic diverticulum was found to be infiltrated by tumor cells in the sigmoid colon that caused PMP. Mucinous balls surrounded by mesothelial cells and MUC2-positive adenocarcinoma cells are useful clues in the diagnosis of PMP. Diagn. Cytopathol. 2016;44:628-631. © 2016 Wiley Periodicals, Inc.

Yersinia enterocolitica (YE) infection is a rare cause of intestinal intussusception, especially in adults. We herein, report a case of adult intussusception due to YE enterocolitis. A 24-year-old woman was admitted because of severe abdominal pain. She was clinically diagnosed with ileocolic intussusception on the basis of the findings of computed tomography (CT) and a gastrografin enema. Manual surgical reduction was sufficient to alleviate the intussusception. A histological examination of the lymph nodes around the ileocecum excluded lymphoma. Serological testing revealed that the cause of the intussusception was a YE infection. The patient's postoperative course was good and no recurrence was seen during the follow-up.

Background. Multiple gastric carcinomas often arise in gastric mucosa with chronic gastritis, particularly severe intestinal metaplasia. In regard to such characteristics, several clinicopathological risk factors for multiple carcinomas have been reported, but no clinically useful criteria are available at present for assessing the onset of multiple gastric carcinomas. If the risk for multiple gastric carcinomas could be accurately assessed, effi cient and accurate surveillance could be performed following minimally invasive therapies. Methods. In the present study, we investigated clinicopathological differences between 94 cases of multiple early gastric carcinomas and 285 cases of solitary early gastric carcinoma. We tested 379 specimens of gastric carcinomas that had been surgically resected at the Department of General and Gastroenterological Surgery of Osaka Medical College, Japan, from April 1999 to December 2006. Results. Univariate analysis of clinicopathological factors in the present study showed that multiple gastric carcinomas were signifi cantly correlated to old age (≥65 years), well- and moderately differentiated histological type, mucin phenotype (intestinal type), distribution of atrophic mucosa in the stomach (severe), degree of intestinal metaplasia in the surrounding mucosa (severe), and heterotopic glandular cysts. Multivariate analysis using the stepwise method identifi ed age (≥65 years) and degree of intestinal metaplasia in the surrounding mucosa (severe) as signifi cant independent risk factors for multiple gastric carcinomas. Conclusion. While other studies have shown risk factors for multiple gastric carcinomas, the present study is unique in showing risk assessment criteria based on a combination of risk factors for multiple gastric carcinomas.

A case of primary NK/T-cell lymphoma of the rectum accompanied with ulcerative colitis (UC) in a 73-year-old man is reported. He had a 6-year history of repeated admission to our hospital for UC. Total colonoscopy performed 4 months after resolution of refractory UC complicated by cytomegalovirus colitis showed a markedly submucosal tumor in the rectum, which was histologically diagnosed as malignant lymphoma. The findings of computed tomography of the chest and abdomen, gallium scintigraphy, abdominal ultrasonography, and upper gastrointestinal endoscopy showed no abnormal lesions. Therefore, based on a diagnosis of localized rectal lymphoma with UC, proctocolectomy was performed. The resected specimen showed three submucosal tumors in the rectum with local nodal involvement. Histologically, the tumors were characterized by diffusely infiltrating sheets of large atypical lymphoid cells, which were negative for CD4, CD8, and CD20 but were positive for CD56, CD3, and granzyme B. The presence of Epstein-Barr virus (EBV) infection in neoplastic cells was shown by in situ hybridization for EBV-encoded early small RNA1 (EBER-1). Based on these findings, the patient was diagnosed with primary CD56+ NK/T-cell lymphoma of the rectum (stage IIE). This is the first case report of primary rectal NK/T-cell lymphoma accompanied with UC.

Objective To evaluate local invasion and lymph nodes metastasis of colorectal cancer and mesenteric vascular variations using multidetector-row computed tomography (MDCT) before laparoscopic colorectal surgery. Methods Fifty-one patients with colorectal cancer underwent MDCT. The evaluation items were as follows: (1) local invasion; (2) detected lymph nodes evaluated by short-axis diameter, long-axis diameter, short/long axis diameter ratio, and computed tomography (CT) attenuation; and (3) visualization of mesenteric artery and vein by 3-dimensional-CT angiography. Results First, in the evaluation of local invasion, overall accuracy was 94.1%. Second, the point of 0.8 or greater in short/long-axis diameter ratio was best index for the diagnosis of metastatic lymph nodes. Using this index, the accuracy of the diagnosis per node was 80.5%. Third, 3-dimensional-CT angiography correctly demonstrated variations of the mesenteric artery and vein. Conclusions The MDCT was effective for evaluation of local invasion and lymph nodes metastasis of colorectal cancer and mesenteric vascular variations before laparoscopic surgery.

In the surgical field, benign esophageal tumors are much more uncommon than esophageal malignancies. In particular, fibrovascular polyps of the esophagus are extremely rare. We present a case involving a giant fibrovascular polyp (22 cm × 9 cm) in which not only location and site of origin but also precise polyp type were diagnosed preoperatively using magnetic resonance imaging (MRI). The lesion was then resected safely using a cervical approach. MRI is useful for acquiring valuable information about fibrovascular polyps. This case demonstrates the utility and safety of transcervical esophagotomy in the treatment of giant fibrovascular polyp of the esophagus.

We encountered primary ductal adenocarcinoma of the lacrimal gland in a 67-year-old Japanese man. To the best of our knowledge, only three cases of primary ductal adenocarcinoma of the lacrimal gland have been reported in the literature. The patient was admitted because of visual disturbance, and a mass measuring about 3 cm in diameter was revealed in the right orbit. The mass was resected, and primary ductal adenocarcinoma of the lacrimal gland was diagnosed histopathologically. He died from recurrence at the primary site and metastasis to the brain, lungs, liver, common bile duct, and pancreas 2 years and 10 months after surgery although adjunctive orbital radiotherapy was given. Immunohistochemically, the characteristics of cancer cells were similar to those of salivary duct carcinoma, namely positivity for cytokeratin (CK) 7, 10, 17, 18, 19, and 34betaE12, and negativity for CK20. It was not clear whether the ductal adenocarcinoma originated from the ductal or acinar epithelium of the lacrimal gland, because the immunohistochemical features of both epithelia were identical.

There are currently no universally accepted indications and criteria for additional surgical resection of the colorectum after endoscopic resection of the submucosal invasive cancer. The purpose of the present study is to establish accurate indications and criteria for additional surgical resection of the colorectum, based on the prediction of lymph node metastasis, after endoscopic resection of the submucosal invasive cancer. We investigated 140 submucosal invasive colorectal cancers and analyzed the pathologic factors of lymph node metastasis. The tumors were evaluated for pathologic factors in the invasive area of the submucosal carcinoma and were compared between the cases with lymph node metastasis and those without lymph node metastasis. Lymph node metastasis was observed in 13 cases (9%). Univariate logistic regression analysis showed that the depth of invasion, cribriform-type structural atypia, absence of lymphoid infiltration, lymphatic permeation, and venous permeation were statistically significant as risk factors for lymph node metastasis. Multivariate logistic regression analysis showed that the important risk factors included, in decreasing order, lymphatic permeation, absence of lymphoid infiltration, cribriform-type structural atypia, venous permeation, and depth of invasion. Submucosal invasion of 2 mm or more, and/or, depth of lymphatic permeation of 2 mm or more are risk factors for lymph node metastasis. The pathologic criteria based on our results for additional colectomy enables greater accuracy selection of patients who will undergo further surgical treatment after endoscopic resection.

We describe a case of breast carcinoma with endocrine differentiation containing a mixture of three different histological features that occurred in a 71-year-old woman. Histologically, the tumor was predominantly intraductal, but slightly invasive. In the intraductal lesion, the tumor consisted mainly of ovoid to round cells with a modest to abundant amount of granular eosinophilic cytoplasm or intracytoplasmic mucin (mucin-producing carcinoma in situ). It also consisted, in part, of plump spindle cells with scant cytoplasm that contained argyrophilic granules in a trabecular pattern or an arrangement of perivascular pseudorosettes (atypical carcinoid tumor like-features). Mucous lake and tumor cells floating in mucin were seen in the invasive lesion (mucinous carcinoma). Immunohistochemical staining revealed endocrine differentiation of the tumor cells of both intraductal and invasive lesions. These findings suggest that the different histological features derived from pluripotent cells upon endocrine differentiation, and that endocrine differentiation of the tumor cells had already occurred at an earlier stage of carcinogenesis, prior to the appearance of the mucinous carcinoma. Cytologically, plasmacytoid tumor cells appeared in loosely cohesive clusters or as sparsely single cells in a background of a mucinous substance.

目的:乳癌の細胞診標本からのhuman epidermal growth factor receptor 2 (HER2) 蛋白発現の検出の可能性, 抗原賦活化の必要性および判定基準を検討した.方法:浸潤性乳管癌 (35例) の腫瘤の中心部を捺印した細胞診標本 (95%アルコール固定) とそれに対応する部の組織標本 (20%ホルマリン固定後パラフィン包埋) を作製し, Hercep Testに準じてHER2蛋白免疫染色を行った. 細胞診標本では, 抗原賦活化群および非賦活化群を作製した. 発現判定にはHercep Testに準じた質的判定およびそれを改良した量的判定 (量的に優勢なスコァをもって判定) を用いた. それぞれの細胞診標本のスコアと組織標本のスコアとの相関を検討した.成績:抗原賦活化の有無および判定方法にかかわらず, 細胞診標本のスコアと組織標本スコアとの間には有意の相関が認められた. 特に, 抗原非賦活化群の細胞診標本について量的判定を行って得られたスコアは組織標本のスコアに最も近似していた.結論:HER2蛋白発現の検出は細胞診標本においても可能であり, 特に抗原非賦活化標本の量的判定結果が組織標本の判定結果に最も近似していた.

症例, 73歳, 女性. 肝右葉を置換するように高度に増殖した胆管細胞癌症例の左葉に典型的な結節性再生性過形成がみられた. 結節性再生性過形成の発生機序は門脈枝閉塞による肝内血流の不均等がもたらす肝細胞の萎縮とそれに対する代償反応であると一般に考えられているが, 本症例では門脈枝の病変はごく軽度であった. これに対して, 肝静脈枝は胆管細胞癌の侵襲とそれによると考えられる内膜肥厚のために狭窄, 閉塞していた. したがって, 本症例の結節性再生性過形成の発生には, 右葉の癌置換による肝細胞消失に対する代償性の左葉肝細胞の増生と, 左葉肝静脈枝の癌侵襲による狭窄, 閉塞の結果としての肝内血流の不均等が関与していると考えられた.

症例は69歳, 女性. 左顔面の鈍痛, 左眼瞼下垂および下垂体機能低下で発症し. 頭蓋骨, 下垂体に原発不明の癌転移が認められ, 剖検によって胆管細胞癌と判明した症例を報告した. その転移経路は, 肺には肺動脈末梢枝にごく少量の癌塞栓がみられるのみであり, 外椎骨静脈叢に高度の癌塞栓がみられたことから, Batsonの提唱した椎骨静脈系を介するものと考えられた. すなわち, 門脈に侵入した胆管細胞癌が奇静脈に流入し, 椎骨静脈系, 脳底静脈叢および海綿静脈洞を経て下垂体および頭蓋骨に転移したと推測される. 胆管細胞癌が椎骨静脈系を介する経路で頭蓋骨および下垂体に転移することは稀であるが, 肺転移のみられない症例ではこのような可能性を念頭において原発巣を検索する必要がある.

Fifty-six surgically resected intramucosal differentiated adenocarcinomas (DA) of the stomach with a maximum diameter of less than 5 mm were analyzed by mucin histochemistry. Gastric type phenotypic expression was observed in 41.1% of cases, intestinal type in 28.6% and gastric-intestinal type in 28.6% of all cancers. Gastric type phenotypic expression was the most frequent. As the tumor diameter increased, the incidence of DA with gastric phenotype tended to decrease. Intestinal metaplasia of the cancer's surrounding mucosa was absent or slight in DA with gastric phenotype, but moderate to severe in DA with gastric-intestinal phenotype and intestinal phenotype. Morphologically and mucin histochemically, intestinal metaplasia surrounding DA with gastric phenotype was immature and incomplete compared with DA with gastric-intestinal phenotype or intestinal phenotype. It is suggested that a large amount of DA with gastric phenotype is histogenetically derived from the gastric gland proper without intestinal metaplasia. However, as the tumor grows and intestinal metaplasia progresses, intestinal type phenotypic expression appears and then DA with gastric phenotype changes into DA with gastric-intestinal phenotype or intestinal phenotype.

We report a patient with hyperthyroid Graves' disease associated with type A gastritis and a gastric carcinoid tumor. A 45-year-old female visited our hospital because of exophthalmos, and hyperthyroidism was found. TSH receptor antibody and anti-parietal cell antibody were positive in the patient's serum. An endoscopic examination revealed type A gastritis and a gastric carcinoid tumor. The diagnosis of type A gastritis was determined histologically. The gastric carcinoid tumor was solitary and small (less than 5 mm in diameter), and was removed by biopsy. The patient's hypergastrinemia continued after the thyroid function was normalized by treatment with methimazole. Endoscopic surveillance for metachronous gastric carcinoid tumors will therefore be required. The association of Graves' disease, type A gastritis and a gastric carcinoid tumor is discussed.

Yersinia enterocolitica (YE) infection is a rare cause of intestinal intussusception, especially in adults. We herein, report a case of adult intussusception due to YE enterocolitis. A 24-year-old woman was admitted because of severe abdominal pain. She was clinically diagnosed with ileocolic intussusception on the basis of the findings of computed tomography (CT) and a gastrografin enema. Manual surgical reduction was sufficient to alleviate the intussusception. A histological examination of the lymph nodes around the ileocecum excluded lymphoma. Serological testing revealed that the cause of the intussusception was a YE infection. The patient's postoperative course was good and no recurrence was seen during the follow-up.

There are currently no universally accepted indications and criteria for additional gastrectomy after endoscopic resection of submucosally invasive cancer. The purpose of the present study was to establish accurate indications and criteria for such additional gastrectomy on the basis of lymph node metastasis risk.We investigated 130 submucosally invasive gastric cancers and analyzed the pathological risk factors for lymph node metastasis. The tumors were evaluated for pathological factors in the area of invasion, and factors were compared between the cases with lymph node metastasis and those without.Univariate logistic regression analysis showed that tumor minor axis length, depth of invasion, histological classification of the area of submucosal invasion, absence of lymphoid infiltration, ulceration or scar in the lesion, and lymphatic and venous invasion are statistically significant risk factors for lymph node metastasis. Multivariate logistic regression analysis showed that the absence of lymphoid infiltration and the presence of lymphatic invasion are statistically significant as risk factors for lymph node metastasis.We present a scoring system on the basis of the pathological criteria tested in this study. Our findings enable more accurate identification of patients who should undergo additional gastrectomy after endoscopic resection.

The prognostic factor(s) of carcinoma of the ampulla of Vater were analyzed retrospectively and the significance of lymphadenectomy around the superior mesenteric artery and para-aortic region on the clinical outcome was evaluated.From 1985 to 2008, 34 carcinomas of the ampulla of Vater patients who underwent pancreaticoduodenectomy with curative intent were analyzed with respect to tumor extent, operation method and prognosis.Overall 5-year survival was 52.6%. On multivariate analysis, lymph node metastasis, pancreatic invasion, venous invasion, perineural invasion and lymphadenectomy around the superior mesenteric artery were the significant prognostic factors. However, the dissection of para-aortic lymph nodes had no substantial survival benefit. Compared with the duodenal cancer, the prognosis for carcinoma of the ampulla of Vater was significantly worse although no differences in clinicopathological characteristics of patients were observed.Lymph node metastasis, pancreatic invasion, venous invasion, perineural invasion, and lymphadenectomy around the superior mesenteric artery are important prognostic factors. Pylorus-preserving pancreaticoduodenectomy, with lymphadenectomy around the superior mesenteric artery without dissection of para-aortic lymph nodes is recommended as optimal surgery. Though the treatment results were worse than that of duodenal cancer, curative operation should be performed, regardless of site of origin.

Collagenous colitis (CC) is a well-known cause of chronic non-bloody diarrhea, especially in elderly women. CC is characterized histopathologically by an increase in the thickness of the subepithelial collagen layer to at least 10 µm, epithelial damage, and chronic inflammation of the lamina propria. Generally, the colonic mucosa in CC is macroscopically normal, although minor, non-specific abnormalities may be found. Due to the recent advancement of endoscopic and diagnostic technologies, however, microscopic mucosal abnormalities and specific longitudinal linear lacerations of the mucosa characteristic of CC have been identified. The association of CC with non-steroidal anti-inflammatory drugs and proton pump inhibitors has also been reported. Since definitive diagnosis of CC has to rely on pathologically documented collagen bands and mononuclear infiltration, the efficiency and precision of colonic biopsy need to be improved. Of the 29 CC patients that we have encountered at our institution, it was in 15 of 29 cases that the endoscopic finding that we performed a biopsy on was apparent. Our comparison of the endoscopic and histopathological findings of CC in the 15 patients showed that the mucosa frequently appeared coarse and nodular on the surface of the mucosa, which was also significantly thicker in collagen bands, demonstrating a strong correlation between collagen band formation and CC. Also, the coarse and nodular surface of the mucosa was most frequently seen affecting the proximal colon. The results suggest that endoscopic observation and biopsy of the proximal colon, where a coarse and nodular surface of the mucosa is often found, may be useful for confirmation of the diagnosis in patients with suspected CC.

Small bowel adenocarcinoma is a relatively uncommon neoplasm that accounts for approximately 0.3% to 2.4% of digestive cancers. In comparison with carcinomas of the other areas of the gastrointestinal tract, the prognosis for small bowel adenocarcinoma is generally worse. The prognostic factors of small bowel adenocarcinoma were analyzed retrospectively, and the significance of operative procedure, lymphadenectomy, and adjuvant chemotherapy was evaluated.From 1990 to 2009, 30 patients with small bowel adenocarcinoma who underwent surgery at Osaka Medical College Hospital were analyzed with respect to tumor extent, operation method, and prognosis.Overall 5-year survival was 52.5%, and the median survival time was 27.0 months. On univariate and multivariate analyses, the location (duodenum vs. jejunum and ileum), size (greater or less than 70 mm), and tumor, nodes, and metastasis (TNM) stage (stage 0 + I + II vs. III + IV) of the tumor were the significant prognostic factors. No differences in survival and recurrence rates were observed between patients undergoing pancreaticoduodenectomy and those undergoing partial resection, between those undergoing mural lymphadenectomy and those undergoing extended lymphadenectomy, or between those with and without adjuvant chemotherapy. The combination of surgery and adjuvant chemotherapy did not control recurrence or improve the prognosis.In small bowel adenocarcinoma, location, size, and TNM stage of the tumors were the independent prognostic factors after curative resections. Partial resection with mural lymphadenectomy may be recommended as optimal surgery for small bowel adenocarcinoma.

"Japanese clinical guidelines for autoimmune pancreatitis" advised to carefully differentiate between two conditions: autoimmune pancreatitis (AIP) and associated sclerosing cholangitis (SC), and pancreatobiliary malignancy.We report a series of three cases for which differential diagnosis of pancreatobiliary carcinoma from AIP and associated SC was crucial.Three patients presented with biliary stenosis secondary to pancreatic swelling or mass lesion, followed by further examinations: Case 1 was first diagnosed as having tumor-forming pancreatitis associated with AIP but eventually proven to be pancreatic head carcinoma; case 2 was operated for suspected bile duct cancer combined with AIP and associated cholangitis, and early cancer was found in the resected specimen; case 3 was operated on for presumed cholangiocarcinoma combined with AIP-associated SC, but no malignancy was found.Current series of cases would raise an alert on diagnosis of AIP and associated SC, and pancreatobiliary malignancy should be carefully excluded by any means. Surgical intervention would be required in selected cases of this clinical entity.

We report a resected case of effective treatment with S-1+CPT-11 combination chemotherapy for advanced gastric cancer. The patient was a 65-year-old man who had a type 3 gastric cancer from the middle body of the stomach to the angle. An abdominal CT scan demonstrated bulky lymph node metastasis (cType 3, T3, N2, M0, cStage IIIb), which was then treated with S-1+CPT-11 (S-1 80 mg/m2 day 1-21, CPT-11 80 mg/m2 day 1, 15/5 weeksx2 courses)as neoadjuvant chemotherapy. After 2 courses of chemotherapy, the primary lesion and regional metastatic lymph nodes were reduced by CT (cType 3, T2, N2, M0, cStage IIIa). Total gastrectomy with D3 nodal dissection was performed. The histological diagnosis was pT2 (ss), pN0, sH0, pCY0, sP0, sM0, tub2, INF beta, ly0, v1, n0, stage I b, Cur A, and the histological effect of the main tumor was judged to be Grade 1b. He was treated by S-1 after surgery. The patient has been in good health without a recurrence for 3 years after surgery. This case suggests that neoadjuvant chemotherapy with S-1+CPT-11 is a potential regimen for advanced gastric cancer.

ESD was performed safely and reliably and can promise enough patient’s benefits for its difficulty.

Reported herein is an autopsy case of primary hepatic neuroendocrine carcinoma associated with dermatomyositis. A 71-year-old Japanese man, who was diagnosed with dermatomyositis 5 months before death, had multiple tumors within a non-cirrhotic liver. Histopathologically, the tumors were composed of small- and medium-sized round cells with clear cytoplasm arranged in nests, sheets or rosettes. Immunohistochemically, the tumor cells were positive for chromogranin A, neuron-specific enolase and CD56 and were negative for synaptophysin. This tumor was diagnosed as a primary hepatic neuroendocrine carcinoma with metastasis to the lung, gallbladder and lymph nodes around the pancreas and aorta; no primary lesions were detected in any other organ. The tumor cells were also positive for cytokeratin 7, cytokeratin 19 and epithelial membrane antigen but were negative for anti-hepatocyte antibody and AFP. These findings suggest that the tumor originated in intrahepatic bile duct epithelium. Various cancers have been reported in patients with dermatomyositis, but only seven cases of dermatomyositis associated with primary liver cancer have been reported. To the best of the authors' knowledge, this is the first report of dermatomyositis associated with primary hepatic neuroendocrine carcinoma.

Various hepato-biliary complications are an increased incidence in patients with inflammatory bowel disease, and portal bacteremia is well documented in patients with ulcerative colitis (UC). However, few reports mention UC in association with liver abscesses. Recently, there are several reports describing cytomegalovirus (CMV) infection in association with disease exacerbation and steroid refractoriness in patients with UC. Here we present a case of refractory UC accompanied with multiple liver abscesses and CMV colitis. The patient, a 72-year-old male, with a five-year history of repeated admissions to our hospital for UC, presented with an exacerbation of his UC. Sigmoidoscopy performed on admission suggested that his UC was exacerbated, then he was given prednisolone and mesalazine orally, and betamethasone enemas. However, he had exacerbated symptoms. Repeat sigmoidoscopy revealed multiple longitudinal ulcers and pseudopolyps in the rectosigmoid colon. Although immunohistochemical staining of biopsy specimens and the serum testing for antigenemia were negative on admission and after the repeat sigmoidoscopy, they became histologically positive for CMV. Nonetheless, the patient developed spiking fevers, soon after ganciclovir was administered. Laboratory studies revealed an increased white cell count with left shift, and Enterococcus fecalis grew in blood cultures. An abdominal computed tomography (CT) scan was obtained and the diagnosis of liver abscesses associated with UC was made, based on CT results. The hepatic abscesses were successfully treated with intravenous meropenem for 6 wk, without further percutaneous drainage. To our knowledge, this is the first reported case of multiple liver abscesses that develop during UC exacerbation complicated by CMV colitis.

We report a case of giant fibrovascular polyp of the esophagus. The patient was a 69-year-old man who complained of hematemesis. Barium swallowing revealed a long, expansile lesion within the esophagus. Endoscopy demonstrated a pedunculated lesion covered with normal esophageal epithelium. On MRI, the sagittal image showed the characteristic sausage-like shape of the lesion. On T2-weighted images, the lesion demonstrated predominantly low signal intensity, which reflected a fibrous tumor. Opposed-phase imaging showed the area of decreased intensity within the mass, which reflected adipose tissue. MRI was useful for the differential diagnosis of fibrovascular polyp.