Well-differentiated Tubular Adenocarcinoma Research Articles

Colorectal cancer in Crohn\u2019s disease: a series of 6 cases

BackgroundColorectal cancer (CRC) is the most malignant complication in patients with Crohn’s disease (CD). We report 6 cases of CD-related CRC treated surgically at our hospital.Case presentationFrom 2010 to 2016, six CD patients were diagnosed with CRC. All patients were diagnosed with CD at < 25 years old, and the interval from onset of CD to diagnosis of CRC was > 10 years (range, 15–42 years) in all patients. The histological type of cancer was mucinous carcinoma in two cases, well-differentiated tubular adenocarcinoma in two cases, and moderately differentiated tubular adenocarcinoma in two cases. CRC was detected by screening colonoscopy in three cases (50%), and from clinical symptoms in the remaining three cases (50%). Two cases underwent colonoscopy within 2 months after symptom onset, detecting CRC in the relatively early stage. However, one case was diagnosed with advanced-stage CRC by endoscopy 1 year after symptom onset, and experienced poor prognosis.ConclusionsRegular surveillance colonoscopy is needed to detect early-stage CRC in CD patients. Clear surveillance methods need to be established based on evidence.

A case of early rectal carcinoma with submucosal tumor-like morphology

Submucosal tumor (SMT)-like colorectal cancer is relatively rare. The patient was a 59-year-old man who underwent colonoscopy after a positive fecal occult blood test. Colonoscopy showed a protruded lesion of 10mm in the lower rectum. On initial observation, conventional endoscopy showed that the lesion was covered with normal mucosa and its surface was reddish with small dimples. A neuroendocrine tumor was suspected, and a biopsy was performed, but the pathological diagnosis was adenocarcinoma. Re-examination 3weeks later showed a depression at the surface of the lesion owing to the biopsy. Magnifying NBI showed a vessel pattern of uneven and irregular distribution, and an irregular surface pattern in the depressed area. Magnifying observations with crystal violet staining showed irregular pit patterns. The preoperative diagnosis was submucosal invasive cancer, and operation was performed. The final pathological diagnosis was well-differentiated tubular adenocarcinoma with deep submucosal invasion. The tumor was primarily localized in the submucosal layer and was covered by non-neoplastic mucosa except for the depressed area. The tumor was not exposed on the surface and was proliferating under the mucosa, which resulted in an SMT-like morphology. Our present case indicates that colorectal cancers should be differentially considered when SMT lesions are detected.

A case of mucosal prolapse syndrome complicated by well-differentiated tubular adenocarcinoma and high-grade adenoma after long-term follow-up by colonoscopy

This study included a 45-year-old woman. In 20XX, we performed colonoscopy (CS) on fresh bloody stools, and a diagnosis of rectal mucosal prolapse syndrome (MPS) was made. In 20XX+14 years, CS was reexamined because of fresh bloody stools, and a biopsy of the same site revealed well-differentiated tubular adenocarcinoma. The lesion was resected via endoscopic submucosal dissection (ESD) and histopathologically diagnosed as MPS with high-grade adenoma and well-differentiated tubular adenocarcinoma. The symptoms improved after ESD, and no recurrence was observed during the 18-month follow-up. We experienced a case of a well-differentiated tubular adenocarcinoma in MPS during the long-term follow-up of MPS. In this case, performing ESD was useful not only for cancer treatment but also in terms of therapeutic effects on symptoms. Although MPS is a chronic benign inflammatory disorder, characterized by rectal mucosal prolapse with fibromuscular obliteration, it is necessary to consider the possibility of the appearance of cancer during the follow-up of MPS.

Endoscopic submucosal tunnel dissection with ring-thread countertraction for a large gastric tumor with extensive severe fibrosis

Various methods of traction have been reported for gastric endoscopic submucosal dissection (ESD). We report a successful case in which a new traction method combining a tunnel and a ring-thread counter traction was effective. The patient was a 78-year-old man with early gastric cancer; an 85-mm tumor was located at the lesser curvature of the upper gastric body (Fig. 1). The macroscopic type was 0-IIa, and there were no obvious findings of suspected submucosal invasive carcinoma, such as irregular protrusion, surface depression, and nonextension sign. Multiple ulcer scars were found on the anterior and posterior sides of the lesion. The histological type from the biopsy was well-differentiated tubular adenocarcinoma. The ESD was performed using a single-channel endoscope (GIF-Q260J; Olympus Co, Tokyo, Japan). The tumor resection devices used were the DualKnife (KD-650L, Olympus Co) and the ITknife2 (KD-611L, Olympus Co), and the solution for local injection was a mixture of 0.4% sodium hyaluronate and indigo carmine with diluted epinephrine. First, we made a circumferential incision; next we created the submucosal tunnel from the oral side to the anal side (Figs. 2 and 3). By creating the tunnel, the dissection line was clear in the fibrosis part of the anterior side, but we could not approach the posterior side because the fibrosis area was extensive. Therefore, we attached a ring-shaped thread (made of floss) with 2 endoclips to connect the oral side of the lesion to the greater curvature side (Fig. 4). In this case, the diameter of the ring was about 10 mm, and it was used to pull the lesion at the lesser curvature side of the stomach to the greater curvature side. The thread provided good traction for the fibrosis area and thus allowed us to perform submucosal dissection of the side of the tunnel (Fig. 5). Finally, the lesion was completely resected en bloc without any adverse events. The lesion was 85 x 60 mm in size, and histological examination revealed it to be well-differentiated intramucosal carcinoma, with no lymphovascular invasion. All of the margins were tumor-free (Fig. 6).Figure 3The submucosal tunnel was created from the oral side to the anal side.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4The ring-shaped thread was attached to connect the oral side of the lesion to the greater curvature side of the stomach.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Severe fibrosis area in the side of the tunnel, in which the dissection line became clearer after attaching the ring-shaped thread.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6The opened specimen revealed intramucosal carcinoma and negative margins; the lesion was 85 × 60 mm in size.View Large Image Figure ViewerDownload Hi-res image Download (PPT) For difficult lesions, it has been a problem to provide the traction to secure a good view in ESD. The effectiveness of endoscopic submucosal tunnel dissection (ESTD) has been reported as a good method for providing traction.1Feng X. Linghu E. Chai N. et al.Endoscopic submucosal tunnel dissection for large gastric neoplastic lesions: a case-matched controlled study.Gastroenterol Res Pract. 2018; 2018: 1419369Crossref PubMed Scopus (12) Google Scholar,2Zhang X. Shi D. Yu Z. et al.A multicenter retrospective study of endoscopic submucosal tunnel dissection for large lesser gastric curvature superficial neoplasms.Surg Endosc. 2019; 33: 1910-1919Crossref PubMed Scopus (16) Google Scholar However, ESTD alone did not provide enough traction in this case because of the lesion size and extensive severe fibrosis. In such a situation, combined use of traction by using ring-thread counter traction was effective (Fig. 7). Several techniques, such as “clip and snare” and “internal traction method,” which have been reported previously, were effective traction methods using similar devices.3Matsumoto K. Nagahara A. Sakamoto N. et al.A new traction device for facilitating endoscopic submucosal dissection (ESD) for early gastric cancer: the “medical ring.Endoscopy. 2011; 43: E67-E68Crossref PubMed Scopus (38) Google Scholar,4Baldaque-Silva F. Vilas-Boas F. Velosa M. et al.Endoscopic submucosal dissection of gastric lesions using the “yo-yo technique.Endoscopy. 2013; 45: 218-221Crossref PubMed Google Scholar However, those methods may require the assistant’s habituation or reinsertion of the endoscope, may have limited traction direction, or may not be suitable for large lesions. This method is considered to be simple and inexpensive, it does not require another assistant, it is suitable for large lesions, and it allows the operator to decide the direction of traction depending on the clip position. Based on this case, ESTD with ring-thread counter traction may be effective for large gastric tumors with extensive severe fibrosis (Video 1, available online at www.VideoGIE.org). All authors disclosed no financial relationships relevant to this article. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlMmNjMGQ2NzQxODZmZjRkNzI3YjU3ZDFjMjg1ZDVhZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NDY0ODkzfQ.gjaAez8j4Wr7199z-8bz3AYl8ncfOCfLRgaEsH4OE7H9yCZAYPnM0006xSLBE4vncFqGsiVdbvauHJcXsP5a3vC-PIUtJNyKU7KEaWLsQh59uksWMYqxRjTJS6X37IfWhWF8CjiUUNa-Jsfewy7I6agXdcaWiHProO0Fvkni2RUlSPSl7riUHuQpxZTt-NvxUrO8hvbcSSucxmz4OiHij1oXIFMAsliqITH7sHPk2foVQ7FKA_avs_kgdTgn_3OYBOO8R39XmswaCFGWvgvpmIAd4dFL6LJnyQKKAaN25BzdysFcTD6l_moN-MScWPBTDI2wG1sO02VNkwJlFtwROw Download .mp4 (73.36 MB) Help with .mp4 files Video 1A large gastric tumor with severe fibrosis was successfully resected by endoscopic submucosal tunnel dissection with ring-thread counter traction.

Mixed histology poses a greater risk for noncurative endoscopic resection in early gastric cancers regardless of the predominant histologic types.

Clinicopathologic characteristics and treatment outcomes of mixed-histological-type (MT) early gastric cancers (EGCs) treated with endoscopic submucosal dissection (ESD) have not been sufficiently elucidated. We aimed to clarify them in comparison with pure-histological-type EGCs. We used 3022 consecutive EGCs in 2281 patients treated with ESD from our prospectively maintained database. Cases were stratified into four groups according to the final diagnosis of the resected specimen are as follows: 2780 pure differentiated-type (DT), 127 DT-predominant MT (D-MT), 87 pure undifferentiated-type (UDT), and 28 UDT-predominant MT (U-MT). Clinicopathologic characteristics and treatment outcome were compared between pure DT and D-MT, and between pure UDT and U-MT separately. Risk factors for deep submucosal invasion, lymphovascular invasion, and a final diagnosis of MT were identified using multivariate analysis. Both D-MT (41.7 vs. 92.0%; P < 0.0001) and U-MT (35.7 vs. 75.9%; P = 0.0002) showed a significantly lower curative resection rate than their pure histologic counterparts. Multivariate analysis revealed that MT was an independent risk factor for deep submucosal (OR 6.55; 95% CI, 4.18-10.14) and lymphovascular (OR 4.74; 95% CI, 2.72-8.29) invasion. Preoperative biopsy results that did not show well-differentiated tubular adenocarcinoma (OR 28.2; 95% CI, 18.9-42.9) were an independent risk factor for a final diagnosis of MT. MT poses a greater risk for noncurative resection regardless of the predominant histologic types, reflecting more aggressive malignant potential. Although a biopsy examination rarely shows MT, clinicians should consider the possibility of MT when a biopsy examination does not show well-differentiated tubular adenocarcinoma.

Mixed adenoneuroendocrine carcinoma of the distal bile duct: a case report

BackgroundMixed adenoneuroendocrine carcinoma (MANEC) of the common bile duct (CBD) is very rare, with only 10 reported cases. Here, we report a case of MANEC of the distal bile duct (DBD) that was surgically resected under a diagnosis of cholangiocarcinoma (CCA).Case presentationA 60-year-old male had epigastric pain and was admitted to our hospital for the treatment of a suspected CBD stone. Upon admission, laboratory findings revealed elevated hepatobiliary enzymes including serum aspartate aminotransferase, serum alanine aminotransferase, serum glutamyltransferase, and serum alkaline phosphatase. Both carcinoembryonic antigen and carbohydrate antigen 19-9 were negative. Computed tomography (CT) showed dilation of the CBD. Endoscopic retrograde cholangiopancreatography (ERCP) showed circumferential stenosis and a 5-mm elevated lesion in the DBD. Brush cytology showed atypical ductal cells, indicating adenocarcinoma (AC) of the DBD. Under a diagnosis of CCA of the DBD, a subtotal stomach-preserving pancreaticoduodenectomy was performed. Neither peritoneal dissemination nor lymph node metastasis was found. Microscopically, the lesion was seen to be composed of predominantly well-differentiated tubular AC in the superficial layer of the tumor, admixed with neuroendocrine carcinoma (NEC) in the deeper portion, indicating a diagnosis of MANEC of the DBD. After immunohistochemical staining, NEC components were positive for synaptophysin and CD56 and were for SSTR2, SSTR5, and mammalian target of rapamycin (mTOR). Three months postsurgery, postoperative adjuvant chemotherapy with S-1 was started. More than 3 years postsurgery, he is alive without recurrence.ConclusionsMANEC is highly malignant, progresses rapidly, and has a poor prognosis. Preoperative diagnosis is difficult; therefore, identifying NEC components by immunohistochemical staining using resected specimens is important.

Laparoscopic Gastrectomy with D2 Lymphadenectomy for pT1a Adenocarcinoma: Case Report and Literature Review

Abstract Gastric cancer is one of the most common malignancies, associated with a high mortality and morbidity rate, especially in the elderly, the fourth leading cause of cancer mortality in Europe. Although the rate of diagnosis has declined in recent years, the prognosis of the disease and the mortality rate is still quite high. Laparoscopic surgery, accompanied by lymphadenectomy, is a curative method of treatment, used more and more frequently, especially in Eastern countries, both in the incipient disease and in advanced stages of the disease, which has many advantages over classical surgery. We report the case of an 86-year-old man, who presented for marked physical asthenia, weight loss and severe anemia, in whom we performed laparoscopic distal radical gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction. Histopathological examination established the diagnosis of low-grade / well-differentiated tubular adenocarcinoma G1 (WHO) / intestinal carcinoma (Lauren), with invasion in the lamina propria, developed on an intestinal-type adenoma. 21 lymph nodes were taken without tumor invasion. This case highlights the complexity of laparoscopic intervention, with the proven advantages for the patient, like reduced surgical trauma and pain, with the decrease of postoperative complications, but also the difficulty of the surgical technique which requires advanced laparoscopic skills. Thus, in addition to its proven efficacy in cases of early gastric cancer, the technique can be extended to advanced malignancies, without affecting the oncological safety limit.

Adenocarcinosarcoma at the esophagogastric junction with long esophageal invasion: a case report

BackgroundCarcinosarcoma of the esophagus or esophagogastric junction (EGJ) is a rare malignancy with both carcinomatous and sarcomatous components. There is no report of carcinosarcoma arising from the EGJ wherein the carcinomatous element was adenocarcinoma. We describe a patient with carcinosarcoma of the EGJ in which the carcinomatous element was adenocarcinoma.Case presentationA 52-year-old man was diagnosed with carcinoma on his EGJ after complaining of appetite loss. All tumor markers (carcinoembryonic antigen, squamous cell carcinoma antigen, alpha-fetoprotein, and carbohydrate antigen 19-9) were within the respective normal ranges. Esophagogastroduodenoscopy showed a 150-mm (100 mm esophageal side and 50 mm gastric side) type 1 tumor on his EGJ. A histopathological examination of a biopsy specimen revealed well-differentiated tubular adenocarcinoma at the gastric side; however, only necrotic tissue was noted on the esophageal side. Contrast-enhanced computed tomography did not reveal any invasion of the adjacent structures; however, it did show five swollen regional lymph nodes. 18F-Fluorodeoxyglucose positron emission tomography with computed tomography did not reveal distant metastases. We performed thoracic subtotal esophagectomy, total gastrectomy, and two-field plus left cervical paraesophageal lymphadenectomy. Macroscopically, the lesion consisted of two components: a 7.5-cm type 2 tumor and a 9-cm type 1 tumor at the proximal end of the type 2 tumor. Microscopically, the type 2 tumor showed predominantly solid or cribriform proliferation of tumor cells with clear cytoplasm, which was moderately differentiated adenocarcinoma with enteroblastic-like differentiation. The tumor cells of the adenocarcinoma component had periodic acid-Schiff (PAS)-positive globules and were positive for sal-like protein 4 (SALL 4) and negative for α-fetoprotein (AFP) or human epidermal growth factor receptor type 2 (HER2). The type 1 tumors consisted of the adenocarcinoma-like type 2 tumor and spindle cells (sarcomatous component). Part of the sarcomatous component showed cartilage differentiation. The type 2 and type 1 lesions were continuous lesions. The epicenter of the tumor was located at the EGJ. The adenocarcinoma component was present in 10 of 27 resected lymph nodes. The tumor was diagnosed as carcinosarcoma of the EGJ.ConclusionsWe report a rare patient with carcinosarcoma of the EGJ wherein the carcinomatous element was adenocarcinoma.

A challenging case of gastric endoscopic submucosal dissection: removal of a sizable cancer through altering patient's position and multiple clip-line traction.

A challenging case of gastric endoscopic submucosal dissection: removal of a sizable cancer through altering patient's position and multiple clip-line traction.

A rare case of simultaneous rectal and gastric carcinomas accompanied with inferior mesenteric arterioportal fistula: case report

BackgroundInferior mesenteric arterioportal fistula (APF) is rare as only 35 case reports in the literature. We herein presented a case of simultaneously double cancer in the rectum and stomach with inferior mesenteric APF, which is the first case report by searching using PubMed. Combination of interventional embolization and surgical operation seemed to be optimal treatment for avoiding postoperative complications and the curability.Case presentationA 66-year-old male with epigastric pain was admitted to a practitioner. He underwent a gastroscopy with biopsy, and cancer located in the lesser curvature of the gastric cardia was found. Enhanced CT did not reveal wall thickening of the stomach and distant metastases, but several swollen lymph nodes were observed in the right cardia. In the arterial phase, dilation of inferior mesenteric vein (IMV) and superior rectal artery (SRA) were noted, which raised suspicions of an arterioportal communication. Colonoscopy revealed a type 2 rectal tumor located 12 cm from the anal verge. The histological diagnosis of well-differentiated tubular adenocarcinoma was confirmed by biopsy. At a first step, we planned to perform a radiological embolization of inflow vessels to APFs except for SRA. Additionally, we determined the interval time of 1 month between the first low anterior rectal resection and the sequential gastrectomy for the purpose of decreasing portal pressure. The postoperative course was uneventful without hemorrhagic complications, and S-1 was taken internally 1 year as adjuvant chemotherapy for gastric cancer. The patient still lives without recurrence of this cancer with APF and portal vein thrombosis 2.5 years after the aforementioned surgeries.ConclusionInferior mesenteric APF and/or arteriovenous fistula (AVF) would be consisted of the several inflow arteries as superior rectal, internal iliac, and median sacral arteries, and outflow veins as inferior mesenteric, internal iliac, and median sacral veins. To determine the therapeutic strategy for left-sided colorectal cancers with abnormal vessel communications of the pelvis, it is significant to comprehend distribution and component vessels of APF and/or AVF.

Early gastric cancer with multiple submucosal heterotopic gastric gland: A case report.

A case of early gastric cancer involving multiple submucosal gastric glands that was treated by distal gastrectomy was described in the present case report. An 85-year-old man was referred to our hospital for the treatment of gastric cancer. Esophagogastroduodenoscopy revealed an irregular, nodular, elevated lesion on the posterior wall of the middle third of the stomach, and biopsy specimens indicated well-differentiated tubular adenocarcinoma. Submucosal tumor (SMT)-like lesions were detected in the area adjacent to the nodular lesion, in the anterior wall side of the middle third of the stomach. Abdominal contrast-enhanced computed tomography showed cystic lesions in the middle part of the stomach, and no mass lesions in the liver. The patient underwent distal gastrectomy with regional lymphadenectomy. Macroscopic examination of the resected specimen showed an SMT-like lesion measuring 2.8×2.6 cm in contact with a superficial, depressed lesion measuring 1.7×0.9 mm in the middle third of the stomach, and another SMT-like lesion measuring 1.5×1.4 cm in diameter, which was also in the middle third of the stomach. The pathological diagnosis was well-differentiated tubular adenocarcinoma invading the gastric submucosal layer without lymph node metastasis, but with nearby submucosal heterotopic gastric gland (SHGG) detected. Following surgery, the patient remained symptom-free without evidence of recurrence for 3 months. The finding of SHGG remains a rare entity, and further studies are warranted to clarify the association between these submucosal lesions and the development of cancer.

A case of successfully resected metachronous gastric and gallbladder metastases from pancreatic body cancer

BackgroundPancreatic ductal adenocarcinoma (PDAC) readily metastasizes to the lymph nodes, liver, lung, and peritoneum; however, gastric and gallbladder metastases are rare. We report a case of metachronous gastric and gallbladder metastases from PDAC.Case presentationThe patient is a 71-year-old man who underwent distal pancreatectomy for PDAC. Seventeen months after the surgery, a 30-mm nodule was detected at the lesser curvature of the stomach, which was diagnosed as recurrence of PDAC in the lymph nodes. He then received gemcitabine and S-1 combination chemotherapy for 6 months. Because tumor size remained approximately the same and tumor marker levels decreased, total gastrectomy and cholecystectomy were performed. Pathological examination showed well-differentiated tubular adenocarcinoma in the subserosa and muscularis propria of the stomach and gallbladder. The patient remains alive at 41 months after the second surgery with liver metastasis.ConclusionWe reported a rare case of metachronous gastric and gallbladder metastases from pancreatic body cancer.

Exploring the possibility of endoscopic submucosal dissection for clinical submucosal invasive early gastric cancers.

The current standard treatment modality for clinical submucosal invasive (cT1b) early gastric cancer (EGC) is surgery. However, there are discrepancies in T staging between pre- and post-operative findings, and in cases of overestimation, patients may lose the opportunity to preserve the stomach. The aim of this study was to analyze surgical outcomes of cT1b EGC and determine the pre-treatment factors favoring ESD. Patients who underwent gastrectomy for cT1b EGC with a tumor size of 30mm or less in diameter and differentiated-type histology were retrospectively reviewed from January 2010 to December 2014. According to the final surgical pathologic results, two groups were classified: patients whose pathologic results qualified for current ESD indication (ESD-qualified group, n = 203) and patients whose pathologic results made them ineligible for ESD (ESD-disqualified group, n = 261). The preoperative clinical characteristics were compared. Forty-three percent of the patients (203/464) who underwent gastrectomy for cT1b EGC qualified for ESD; their endoscopic lesion tended to be smaller than 20mm in size and located in the distal part of stomach. In addition, the ESD-qualified group showed a significantly higher proportion of well-differentiated tubular adenocarcinoma on endoscopic biopsy and of the flat/depressed type in the endoscopic evaluation. Forty-three percent of the patients with cT1b EGC who underwent gastrectomy had a chance to preserve their stomach by ESD. Therefore, pre-treatment factors such as endoscopic lesion size, location, histology, and gross type should be considered for treatment modality selection for cT1b EGC.

Analysis of clinicopathology and risk of lymph nodes metastasis in 315 patients with early gastric cancer according to World Health Organization criteria

Objective To investigate the clinicopathologic features of Chinese patients with early gastric cancer (EGC) according to the World Health Organization(WHO) diagnostic criteria, and to explore the risk factors of lymph node metastasis (LNM) in EGC. Methods From 2002 to 2017, at the Second Affiliated Hospital of Nantong University, and from 2014 to 2017, at the People′s Hospital of Qidong City, the People′s Hospital of Haimen City and the People′s Hospital of Rugao City, 315 EGC patients with complete clinicopathological data were enrolled. The clinicopathologic features were analyzed including gender, age, tumor location, tumor size, macroscopic type, histological type (WHO), differentiation degree, depth of tumor invasion, Lauren subtype, infiltration pattern, ulceration, lymphoid follicles, lymphovascular invasion and perineural invasion. Chi-square test and Fisher′s exact test were performed for univariate analysis and the logistic regression was used for multivariate analysis. Results The ratio of EGC was 10.0% (315/3 140) of patients with gastric cancer and received surgery during the same period. Among the 315 EGC, the ratio of well-differentiated tubular adenocarcinoma was 11.7% (37/315), which was lower than 24.8%(2 752/11 104) in Japan and 19.9%(41/206) in South Korea, and the differences were statistically significant (χ2=28.208, P<0.01; χ2=6.510, P=0.011), however there was no statistically significant difference when compared with Western countries (11.9%, 8/67; χ2=0.002, P=0.964). Among the 276 patients who underwent radical gastrectomy, 49(17.8%) patients had with LNM. The results of univariate analysis showed that tumor size, macroscopic type, differentiation degree, depth of invasion, infiltration pattern, ulceration and lymphovascular invasion were related with LNM (χ2=9.327, 6.038, 6.381, 34.983, 19.309, 52.297 and 5.058; all P<0.05). The results of multivariate analysis revealed that lymphovascular invasion and ulceration were the independent risk factors of LNM (odd ratio (OR)=7.028 and 2.566, both P<0.05). Conclusions There is obvious difference in pathological diagnostic standard of well-differentiated tubular adenocarcinoma between China, Japan and South Korea, which may influence the therapeutic strategy of EGC. Lymphovascular invasion and ulceration are independent risk factors of LNM in EGC. Key words: Early gastric cancer; Histpatholology; Lymph node metastasis; Clinicopathology

Endoscopic and clinicopathological features of intramucosal, histologically mixed-type, low-grade, well-differentiated gastric tubular adenocarcinoma with the potential for late-onset lymph node metastasis

BackgroundIntramucosal, histologically mixed-type, low-grade (LG), well-differentiated gastric tubular adenocarcinomas (tub1s; LG-tub1s) have larger mean diameters and exhibit a higher frequency of the gastric mucin phenotype (G-phenotype) than pure LG-tub1s. In proportion to their increases in diameter, G-phenotype differentiated-type early gastric cancer (EGC) tumours reportedly grow to eventually contain (an) undifferentiated-type component(s) and LG-tub1s, which are included in differentiated-type EGCs, reportedly exhibit changes in their glandular architectural and cytological atypia grades from LG to high-grade (HG) and can grow to contain a moderately differentiated tubular adenocarcinoma (tub2) component and undifferentiated components. Because they generally show a higher frequency of malignancy relative to tumours with a higher atypia grade and lower differentiation degree, it is suggested that, among mixed-type LG-tub1s, G-phenotype LG-tub1s containing an HG-tub2 component (LG-tub1s > HG-tub2) with undifferentiated components might lead to late-onset metastasis to lymph nodes even after a successful endoscopic submucosal dissection (ESD). We aimed to clarify the endoscopic and clinicopathological features of these G-phenotype LG-tub1s > HG-tub2.MethodsOf the 13,217 oesophagogastroduodenoscopies performed at our institutions between September 2008 and March 2016, 185 EGC lesions were evaluated in this retrospective observational study. Among these EGC lesions, 60 intramucosal LG-tub1s were divided into 53 tub1 (44 pure LG-tub1s and nine LG-tub1s containing HG-tub1) lesions and seven LG-tub1 > tub2 (LG-tub1 containing LG- and HG-tub2) lesions.ResultsThe frequencies of the superficial depressed type (P = 0.026), reddish colour (P = 0.006), HG of contained tub2s (P = 0.006), and G-phenotype (P = 0.028) were significantly higher in the LG-tub1 > tub2 group than those in the tub1 group. However, the largest lesion of the LG-tub1 > tub2 group had a superficial flat appearance, an isochromatic colour, an HG-tub2 and an undifferentiated component, and a large diameter greater than 30 mm, and it exhibited a G-phenotype.ConclusionsIntramucosal G-phenotype LG-tub1s > HG-tub2 are potential premalignant stomach neoplasms that may have specific endoscopic and clinicopathological features. However, G-phenotype LG-tub1s > HG-tub2 with undifferentiated component, which potentially show higher malignancy than those without undifferentiated components might change from a reddish to isochromatic colour. Accurately diagnosing, treating, and following-up G-phenotype LG-tub1s > HG-tub2 might decrease the number of patients who experience late-onset metastasis after ESD.

SURGICAL TREATMENT OF REGIONAL RECURRENCE FROM GASTRIC CANCER AFTER MULTIMODAL TREATMENT WITH NEOADJUVANT CHEMORADIOTHERAPY (A CASE REPORT)

Background. Gastric cancer is the fourth most common cancer and the second leading cause of cancer-related death worldwide. Despite many advances in the diagnosis and treatment of gastric cancer, the overall five-year survival rate does not exceed 25–30 %, and distant metastases and loco-regional recurrence develop in more than 50 % of patients. Disease recurrence is not only associated with the presence of tumor micro-metastases at the time of surgery, but also with dissemination of tumor cells during mobilization of the stomach or lymph node dissection. Even after performing radical surgery, the prognosis remains extremely unfavorable. No standardized methods of treatment for isolated loco-regional recurrence have been developed yet. Cases of successful treatment of distant metastases and regional recurrence are sporadic. Case report. We present the case of a 75-year-old patient with histologically proven well-differentiated tubular adenocarcinoma of the stomach. The patient underwent neoadjuvant chemoradiation therapy (total radiotherapy dose was 45 Gy, modified Capox regimen) followed by gastrectomy and D2lymph node dissection. The control examination revealed an isolated regional recurrence of gastric cancer. It was decided to perform surgical treatment for isolated regional gastric cancer recurrence. Conclusion. There is no standardized approach to the treatment of regional recurrence of gastric cancer. Surgical treatment in such cases is a method of choice, especially for patients who previously received neoadjuvant chemoradiotherapy. According to the worldwide literature, the median survival of such patients does not exceed a few months. The key point that determines the effectiveness of neoadjuvant therapy is the achievement of complete or partial pathological response to therapy, thus demonstrating improved survival compared to surgery alone. Therefore, it is extremely important to search for immunohistochemical and molecular genetic markers for predicting tumor response to neoadjuvant therapy in order to administer it for only potential responders.

A long-term survival case treated with conversion surgery following chemotherapy after diagnostic metastasectomy for pancreatic cancer with synchronous liver metastasis

BackgroundPancreatic cancer with distant metastases is classified as “unresectable,” for which the standard treatment is systemic chemotherapy. The effectiveness of radical resection for pancreatic cancer with distant metastases is unknown. Here, we report a case of long term survival treated with conversion surgery following chemotherapy after diagnostic metastasectomy for pancreatic cancer with synchronous liver metastasis.Case presentationA 73-year-old man was referred to our hospital to examine and treat for cancer of the pancreatic body. Computed tomography (CT) scan revealed a 26-mm hypovascular tumor in contact with the common hepatic artery (CHA) (> 180°), the celiac artery (< 180°), and portal vein at the pancreatic body. Resectability was determined as “borderline resectable.” Two courses of gemcitabine plus S-1 combination therapy (GS) were administered as neoadjuvant chemotherapy (NAC). CT scan showed tumor shrinkage (21 mm), determined as stable disease (SD) according to Response Evaluation Criteria in Solid Tumors (RECIST). Although the abdomen was opened for radical resection, a small nodule on the liver was detected and removed. Since the nodule was diagnosed as adenocarcinoma by intraoperative frozen section, resection of the primary tumor was not performed. After three subsequent courses of GS therapy, no distant metastases were detected under radiological findings. Distal pancreatectomy with celiac artery resection (DP-CAR) was performed as radical surgery 6 months after the initial diagnosis. Histological diagnosis was well-differentiated tubular adenocarcinoma, showing ypT1 ypN1 M1 stage IV, negative surgical margin (R0), and grade III in the Evans classification. S-1 was administered every other day from 6 months after resection up to the present. The patient has been alive with no recurrence for 5 years after the initial diagnosis and 4.5 years after the resection.ConclusionThere is a case that received survival benefits from conversion surgery following chemotherapy after diagnostic metastasectomy in pancreatic cancer with synchronous liver metastasis.

Synchronous primary gallbladder and pancreatic cancer associated with congenital biliary dilatation and pancreaticobiliary maljunction

IntroductionSynchronous double cancer of the gallbladder and pancreas that is associated with congenital biliary dilatation (CBD) and pancreaticobiliary maljunction (PBM) is extremely rare. PBM is frequently reported in Asia, particularly in Japan. We report a surgical case of synchronous double cancer in a patient with primary gallbladder and pancreatic cancer.Presentation of caseA 72-year-old woman with epigastralgia underwent subtotal stomach-preserving pancreaticoduodenectomy and gallbladder bed resection for synchronous primary gallbladder and pancreatic head cancer. Histopathological examination revealed moderately differentiated ductal adenocarcinoma of the pancreatic head and well-differentiated tubular adenocarcinoma at the bottom of the gallbladder.ConclusionSynchronous gallbladder and pancreatic cancer is extremely rare. It is necessary to determine the optimal surgical course taking into consideration the degree of tumor progression. This is the second case of synchronous primary gallbladder and pancreatic cancer associated with CBD accompanied by PBM.

Precursors of gastric cancer : Dysplasia and adenoma

Gastric cancer develops from preneoplastic and early neoplastic precursor lesions. In particular, the intestinal type according to the Lauren classification is driven by chronic inflammation and progresses via achronic gastritis - atrophy/metaplasia - dysplasia - carcinoma sequence. Staging of the extent of atrophy (OLGA) or intestinal metaplasia (OLGIM) enables risk stratification and determines follow-up investigations according to the management of precancerous conditions and lesions in the stomach (MAPS) international guidelines. True adenomatous lesions are relatively rare in the stomach. Three major types need to be considered: the intestinal type (tubular, tubulovillous and villous), the foveolar type (with superficial gastric differentiation) and the pyloric gland adenoma (with deep gastric differentiation). The intestinal type is the most common and needs to be differentiated from nonneoplastic polypoid regenerative hyperplasia, but also from well-differentiated tubular adenocarcinoma.

Synchronous Double Cancer of the Common Bile Duct and the Ampulla of Vater Without Pancreaticobiliary Maljunction: A Case Report

Synchronous double cancers in the biliary system are rare. Double cancer of the common bile duct (CBD) and the ampulla of Vater without pancreaticobiliary maljunction (PBM) is extremely rare. To our knowledge, only 7 cases have been reported previously. Here we report a case of synchronous double cancer of the CBD and the ampulla of Vater without PBM. A 63-year-old man was referred to our hospital with epigastric pain and jaundice. Computed tomography (CT) showed dilatation of both intrahepatic and intrapancreatic bile ducts, and slightly enhanced tumor in the middle part of the CBD and the ampulla of Vater. Endoscopic retrograde cholangiopancreatography (ERCP) showed a tuberous filling defect in the middle part of the CBD and an exposed tumor of the ampulla of Vater. Under a diagnosis of synchronous double cancer of the middle bile duct and the ampulla of Vater, pancreaticoduodenectomy was performed. Histopathologically, the ampulla of Vater tumor was well-differentiated tubular adenocarcinoma while the middle bile duct tumor was moderately-differentiated tubular adenocarcinoma. Normal mucosa was interposed between both tumors. These findings suggest that they were 2 primary tumors. Double cancer of the CBD and the ampulla of Vater without PBM is extremely rare. We report a case of synchronous double cancer of the CBD and the ampulla of Vater without PBM.