Margin-negative limited resection of metastatic pancreatic tumors from rectal cancer preoperatively diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsies: report of two cases

Pancreatic tumor metastasis from colorectal cancer is very rare. This study evaluated the significance of an endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) and surgical treatment. Case 1 was a 67-year-old male with a history of rectal cancer (6 years ago) and lung metastases (5 years ago) who had two masses in the pancreatic head and body. Case 2 was a 58-year-old male with the history of rectal cancer and simultaneous lung metastasis (7 years ago) who had a mass in the pancreatic body. Imaging studies showed stenosis of the pancreatic duct with distal dilatation in both cases, mimicking primary pancreatic cancer. An EUS-FNAB with immunohistochemical staining made a definitive diagnosis of pancreatic metastasis from rectal cancer. Both patients received margin-negative limited resection, middle-segment-preserving pancreatectomy and distal pancreatectomy, respectively, and were alive 16 and 6 months after pancreatectomy, respectively. An EUS-FNAB is helpful to make a definitive diagnosis of pancreatic metastasis and in determining the subsequent therapeutic approach.     

Endoscopic treatment for early rectal cancer

Endoscopic treatment for early rectal cancer was investigated. The characteristics of early rectal cancer were compared with those of early colon cancer, and the advantages of endoscopic treatment were evaluated. The indications for endoscopic resection are mucosal cancer, slight submucosal invasion without vessel or lymphatic involvement, poorly differentiated adenocarcinoma, and sprouting. The presence of other characteristics indicates the need for surgical resection. Early rectal cancers in the form of laterally spreading tumors of the non-granular, pseudodepressed type should be treated with endoscopic submucosal dissection due to the high incidence of submucosal invasion. The decision on the procedure for the treatment of early rectal cancer may be complicated because of the anatomic character and function of the ano-rectal area, complications of anal dysfunction, and incidence of leakage from the anastomosis after surgery. A precise diagnosis after endoscopic examination based on the pit pattern with magnifying endoscopy may be an effective aid in selecting the most appropriate endoscopic treatment for early rectal cancer.     

Long-term survival after surgical resection of metachronous lung,brain and thyroid gland metastases from rectal cancer: A case report

Introduction and importanceBrain and thyroid metastasis from rectal cancer are uncommon, and the prognosis is poor. We report a patient with rectal cancer who developed metachronous lung, brain and thyroid metastases. Each metastatic lesion was curatively resected resulting in prolonged survival.Case presentationA 60-year-old male underwent rectal cancer resection, and the pathological diagnosis was tubular adenocarcinoma, pT2,pN1a,M0, pStageⅢa. Ten years after rectal resection, a solitary tumor in the left lung was detected. The tumor was resected thoracoscopically and the pathological diagnosis was metastatic tumor. Three years after the pulmonary resection, a solitary brain tumor was detected. The tumor was removed surgically, and the pathology was metastatic tumor. Two years after brain resection, a thyroid mass was detected. A partial thyroidectomy was performed and the pathology with immunohistochemical staining confirmed the thyroid lesion as a metastasis from the previous rectal cancer. Four years after thyroid resection (19 years after the initial rectal resection), he died from multiple lung and bone metastases.Clinical discussionColorectal metastases to the brain and thyroid gland are uncommon and are usually found with other distant metastases. Overall survival has been reported to be extremely poor. In this patient, lung, brain, and thyroid metastases were solitary and metachronous, and each lesion was curatively resected. Surgical treatment might contribute to prolonged survival.ConclusionThe treatment strategy of each patient should be individualized and depends on the timing of metastasis development. Selected patients with complete resection of metachronous metastases may have prolonged survival.     

Abnormal expression of E-cadherin and beta-catenin may be a molecular marker of submucosal invasion and lymph node metastasis in early gastric cancer

BACKGROUND: Impaired expression of E-cadherin and alpha- and beta-catenin is frequently observed in several human cancers. The aim of this study was to examine immunohistochemical expression of these adhesion molecules, focusing on early gastric carcinomas, and to investigate differences between differentiated and undifferentiated gastric cancer at the early phase of carcinogenesis. METHODS: Immunohistochemical staining of E-cadherin and alpha- and beta-catenin was performed using specimens from 143 patients with early gastric cancer. RESULTS: Abnormal E-cadherin and beta-catenin staining correlated with depth of tumour invasion in differentiated-type tumours. In contrast, abnormal staining was frequently found even in intramucosal carcinoma of undifferentiated-type tumours, suggesting an apparent difference in the onset of E-cadherin-catenin complex abnormality between the two cancer types. Absent staining of beta-catenin was associated with lymph node metastasis. Multivariate analysis revealed abnormal E-cadherin expression as an independent factor that correlated with submucosal invasion in early gastric cancer. CONCLUSION: Abnormal E-cadherin expression is a possible marker of submucosal invasion in differentiated-type early gastric cancer and absent beta-catenin staining could be used as a predictor of lymph node metastasis in both types.     

A rectal carcinoid tumor of less than 1 cm in diameter with lymph node metastasis: A case report and a review of the literature

We report herein, a patient with a rectal carcinoid tumor of less than 1 cm in diameter with lymph node metastasis, and discuss a surgical policy for these lesions with reference to other such cases reported in the literature. A 40 year old female was admitted with a rectal mass and colonoscopy revealed a subpedunculated lesion, 1 cm in diameter, with a depression in its tip. A diagnosis of carcinoid was made by biopsy and transsacral excision performed. The excised specimen revealed a subpedunculated lesion measuring 7×6×6 mm with a central depression. The tumor was histologically confined to the submucosa but lymphatic invasion with pararectal lymph node involvement was observed. A radical proctectomy was thus performed. The incidence of metastasis from rectal carcinoids with a diameter of 1 cm or less is very low ranging from 1.5 to 3.4 per cent, and it therefore seems that most lesions of 1 cm or less in diameter can be treated by local excision alone. Thus, although it is recommended that local excision be performed first to determine the extent of spread, lymphatic vessel invasion and lymph node metastasis, radical surgery is indicated if lymphatic invasion or nodal involvement is present, even when muscle invasion is absent.     

A rectal carcinoid tumor of less than 1 cm in diameter with lymph node metastasis: a case report and a review of the literature

We report herein, a patient with a rectal carcinoid tumor of less than 1 cm in diameter with lymph node metastasis, and discuss a surgical policy for these lesions with reference to other such cases reported in the literature. A 40 year old female was admitted with a rectal mass and colonoscopy revealed a subpedunculated lesion, 1 cm in diameter, with a depression in its tip. A diagnosis of carcinoid was made by biopsy and transsacral excision performed. The excised specimen revealed a subpedunculated lesion measuring 7 X 6 X 6 mm with a central depression. The tumor was histologically confined to the submucosa but lymphatic invasion with pararectal lymph node involvement was observed. A radical proctectomy was thus performed. The incidence of metastasis from rectal carcinoids with a diameter of 1 cm or less is very low ranging from 1.5 to 3.4 per cent, and it therefore seems that most lesions of 1 cm or less in diameter can be treated by local excision alone. Thus, although it is recommended that local excision be performed first to determine the extent of spread, lymphatic vessel invasion and lymph node metastasis, radical surgery is indicated if lymphatic invasion or nodal involvement is present, even when muscle invasion is absent.     

A thoracoscopic resection of pulmonary metastasis from breast cancer: a case report with a 27-year disease-free interval

A 70-year-old woman, who had undergone a right radical mastectomy for breast cancer 27 years previously, was found to have a tumor measuring 15 mm in diameter between the S5 area and the S8 area of the left lung. We suspected it to be either metastatic or primary lung cancer based on preoperatively any conclusive diagnosis. We thus performed a thoracoscopic partial lung resection and pericardial resection. The pathological diagnosis of the resected specimen was pulmonary metastasis from the previous breast cancer, since the pathological findings of the lung lesion were closely similar to those of the previous breast lesion. Using immunohistochemical methods, the tumor cells show positive staining for anti-estrogen receptor antibody. In lung tumor cases in which the patient has undergone a breast cancer resection, even more than 20 years previously, surgeons must not rule out the possibility of recurrence. Thoracoscopic surgery is considered to be most effective method for both making a definitive diagnosis and for performing curative treatment.     

Liver metastasis with intraductal invasion originating from rectal cancer: Report of a case

We report a case of liver metastasis with intraductal invasion from colorectal cancer. The patient underwent abdominoperineal resection of the rectum for rectal cancer, and a computed tomography (CT) scan, done 4 years later, revealed a low-density lobular mass in the left lobe of the liver, with a tumor embolus in the second branch of the left bile duct (B2). Because the preoperative imaging findings showed an intraductal growth pattern, we performed a left lobectomy of the liver for intrahepatic cholangiocarcinoma (IHCC). Immunohistochemically, the carcinoma cells, including the intraductal growth, were focally positive for Cytokeratin (CK) 20, but negative for CK 7. This CK staining pattern suggested that the liver tumor was a metastasis from the previously resected rectal cancer. Thus, metastases from colorectal cancer can involve intraductal growth.     

Pulmonary adenocarcinoma complicated with pulmonary infarction presented as intrapulmonary metastases: a report of a case.

Pulmonary adenocarcinoma complicated with a pulmonary infarction presenting as an intrapulmonary metastasis is relatively rare. We present a case of pulmonary infarction manifesting as intrapulmonary metastases of lung cancer. A previously healthy 59-year-old woman was admitted to our hospital for evaluation of abnormal shadows in the right lower lung field. Laboratory tests showed no abnormalities except for a slight elevation of carcinoembryonic antigens (CEAs). Computed tomography (CT) of the chest revealed a hilar mass lesion with parenchymal lesions in the periphery of the right lower lobe, highly suspected to be a pulmonary adenocarcinoma with intrapulmonary metastases. A diagnosis of pulmonary adenocarcinoma was confirmed by a transbronchial brushing examination. A right middle and lower bilobectomy with mediastinal lymph node dissection was due to hilar lymphadenopathy and a lower lobe invasion of the main tumor. Histopathological findings of the resected specimens revealed poorly differentiated adenocarcinoma of the lung with N1 (number 11i and 12 l) disease and multiple pulmonary infarctions with coagulation necrosis and recanalization. Our case suggests that pulmonary infarction associated with lung cancer should be considered as one important cause of peripheral pulmonary nodules.     

Study of the diagnostic difference between the clinical diagnostic criteria and results of immunohistochemical staining of multiple primary lung cancers

AIM: When multiple synchronous or metachronous lung cancer lesions are identified, discrimination of multicentric lung cancers from intrapulmonary metastases by clinical findings is often difficult. When tissue types have the same pathological features, such as combinations of squamous cell carcinoma (SCC), adenocarcinoma (AD) or bronchiolo-alveolar cell carcinoma (BAC), it is especially difficult to distinguish a 2(nd) primary lung cancer from a metastatic lesion. A new strategy for accurate diagnosis of multiple synchronous or metachronous lung cancer is needed because of the difficulty of histological discrimination. METHODS: Of 363 patients with primary lung cancer for which surgeries were conducted at our hospital, 7 cases were diagnosed as synchronous multiple lung cancer (BAC-BAC in 4 cases and SCC-BAC in 3 cases) and 8 cases (BAC-BAC in 2 cases, AD-BAC in 1 case, AD-AD in 1 case, SCC-AD in 1 case and SCC-SCC in 3 cases) were diagnosed as metachronous multiple lung cancer according to the clinical diagnostic criteria. This study focused on 8 cases with the combinations AD-AD, AD-BAC, or BAC-BAC. For immunohistochemical staining, we used the antibodies to 6 antigens as follows: CK-19, p53, CEA, Hup-1, PE-10, and Ki-67. RESULTS: Of 4 cases diagnosed as synchronous lung cancer according to the clinical diagnostic criteria, differing immunohistochemical stained images of the lesions were observed in 3 cases, while in the 4th case almost identical immunohistochemical stained images were obtained, which indicated the 2 lesions were the primary and metastatic focuses. Of 4 cases diagnosed as metachronous lung cancer according to the clinical diagnostic criteria, almost identical stained images were seen in 3 cases, which indicated the 2 lesions were the primary and metastatic focuses. CONCLUSION: In general, Type A and Type B in Noguchi's BAC classification, tended to be multiple synchronous or metachronous lung cancer lesions, while AD and Type C in Noguchi's BAC classification tended to be the metastatic focus. For the focuses with tissue type of BAC-BAC, the staining using CK-19, PE-10, and Ki-67 was useful in distinguishing multiple primary lung cancer from pulmonary metastasis in cases with a combination of AD and BAC.     

A case of long-term survival after pulmonary resection for metachronous pulmonary metastasis of basaloid squamous cell carcinoma of the esophagus

INTRODUCTIONBasaloid squamous cell carcinoma of the esophagus (BSCE) is a rare malignancy among esophageal cancers. We reported a case of 63-year-old woman with metachronous pulmonary metastasis of BSCE, successfully treated by metastasectomy of the left lung.PRESENTATION OF CASEBiopsy specimens of upper gastrointestinal fiberscopy led to diagnosis of poorly differentiated squamous cell carcinoma of the esophagus. Computed tomography revealed metastatic lymph nodes surrounding the bilateral recurrent laryngeal nerve and no evidence of metastasis to distant organs. Curative esophagectomy with three-field lymph node dissection was performed through thoracoscopic approach. Pathological examination of the resected specimens led to diagnosis of BSCE with invasion into the submucosal layer of the esophageal wall. Two years later, a solitary oval-shaped pulmonary lesion of approximately 10 mm was detected in the left lung. Wedge resection of the left upper lobe was performed via thoracoscopic approach. The postoperative course was uneventful. Histologically, the pulmonary lesion was diagnosed as metastatic BSCE. Follow-up indicated no recurrence 9 years after the initial surgery.DISCUSSIONSurgical intervention was acceptable on this case of solitary pulmonary metastasis. However, data are lacking about the efficacy of pulmonary resection for metachronous pulmonary metastasis of BSCE because the postoperative outcome is usually poor. The efficacy of surgical intervention for metastatic lesions of BSCE is debatable and requires further examination.CONCLUSIONAlthough the usefulness of surgical intervention for metastatic lesions from BSCE is controversial, the patients with metachronous solitary metastasis to the lung and without extrapulmonary metastasis would be good candidate for pulmonary resection.     

Variables related to risk of recurrence in rectal cancer without lymph node metastasis

Background: There has been recent interest in the use of local excision for rectal cancer under consideration of patient's quality of life. However, local excision of the primary tumor does not remove the areas of lymphatic spread. Therefore, the decision to use this procedure must be considered carefully. Methods: The authors retrospectively analyzed 142 patients who underwent radical resection of rectal cancer without lymph node metastasis in order to define the risk factors for recurrence. The macroscopic and microscopic pathological characteristics, immunohistochemical staining for p53, and DNA ploidy pattern of the primary tumor were examined as potential predictors of recurrence. Results: The rates for 5-year disease-free survival, local control, freedom from distant metastasis, and overall survival in these 142 patients were 87%, 93%, 93%, and 91%, respectively. Factors related to recurrence and prognosis included the depth of tumor invasion, vascular/lymphatic involvement, tumor differentiation, and tumor size. However, p53 staining and DNA ploidy pattern were not useful indicators. Conclusions: Our findings suggest that adjunctive radiotherapy and chemotherapy should be considered for patients who have rectal cancer without lymph node metastasis in the following situations: tumor invasion of the serosa, vascular/lymphatic involvement, moderately differentiated adenocarcinoma, and lesions >2 cm in diameter. Local excision should not be used in these situations, even if there are no lymph node metastases. The results of this study were presented at the 46th Annual Cancer Symposium of the Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

A surgical case of pulmonary adenocarcinoma complicated with pulmonary infarction presenting as an intrapulmonary metastasis

Pulmonary adenocarcinoma complicated with a pulmonary infarction presenting as an intrapulmonary metastasis is relatively rare. We present a case of pulmonary infarction manifesting as intrapulmonary metastases of lung cancer. A previously healthy 59-year-old woman was admitted to our hospital on May 16, 2002 for evaluation of multiple abnormal radiographic shadows in the right lower lung field. Laboratory tests showed no abnormalities except for a slight elevation of carcinoembryonic antigens. Computed tomography of the chest revealed a hilar mass lesion with parenchymal lesions in the periphery of the right lower lobe, highly suspected to be a pulmonary adenocarcinoma with intrapulmonary metastases. A diagnosis of pulmonary adenocarcinoma was confirmed by a transbronchial brushing examination. A right middle and lower bilobectomy with mediastinal lymph node dissection was needed by hilum lymphadenopathy and a lower lobe invasion of the main tumor. Histopathological findings of the resected specimens revealed poorly differentiated adenocarcinoma of the lung with N1 (#11i) disease and multiple pulmonary infarctions with coagulation necrosis and recanalization. Pulmonary infarctions are demonstrated on chest x-rays as round or polygonal in shape, and located at the periphery of the same lobe as the primary tumor. Computed tomography is more sensitive than conventional radiography in the detection of pulmonary infarction. Our case suggests that pulmonary infarction associated with lung cancer should be considered as one important cause of peripheral pulmonary nodules.     

Mandibular bone metastasis of rectal cancer: Report of a case

A 56-year-old man was referred with lower rectal cancer showing anal canal invasion and liver metastasis. He underwent an abdominoperineal resection and a partial hepatectomy. Adjuvant therapy with tegafur-uracil and leucovorin was administered postoperatively. Lung metastasis was detected 2 years later and was resected. Right mandibular metastasis was diagnosed 2 months after the resection of the lung metastasis. A partial mandibular resection was performed after chemoradiotherapy, followed by reconstruction with a titanium frame and oral cavity reconstruction with a greater pectoral musculocutaneous flap. The pathological diagnosis was metastatic rectal cancer, and the therapeutic effect chemoradiotherapy was Grade 2. He is presently alive without any evidence of cancer, and has maintained a good quality of life 3 years after the mandibular resection and more than 5 years after his first operation. Mandibular metastasis from rectal cancer is very rare and the prognosis is poor according to the literature, so this case is considered to be very unusual.     

早期大肠癌的诊断及治疗

目的 探讨术前诊断早期大肠癌的方法,并评价其对选择治疗方式的意义。方法 经电子、放大、超声结肠镜观察１５例大肠癌患者肿瘤的大体形态、染色后粘膜腺体开口大小排列特点、肿物浸润深度及淋巴结转移情况,据此对患者进行诊断和临床分期,并制定治疗方案。结果 患者肿瘤直径１～６ｃｍ,以亚有蒂型最多,占５３％（８／１５）;放大内镜观察腺体开口最多见的类型为ⅢＬ加Ⅴ型（８例,５３％）;超声内镜观察粘膜癌１１例,粘膜     

Giant T4 rectal carcinoma mimicking urinary bladder adenocarcinoma accurately diagnosed by immunohistochemistry and successfully treated with total pelvic exenteration: Report of a case

A 54-year-old man, with the chief complaints of hematuria, pollakisuria, and pneumaturia, was referred to our hospital, with a diagnosis of giant urinary bladder adenocarcinoma with massive invasion to the rectum. On the basis of the radiological diagnosis and findings of hematoxylin and eosin (H&E) of biopsy specimens, it was difficult to conclude whether the adenocarcinoma originated in the bladder or in the rectum. The immunohistochemical staining of the biopsy specimens showed cytokeratin 7 (CK7)(−) and CK20(+), which supported the notion that the adenocarcinoma possibly originated from the rectum. Although the prognosis of T4 bladder adenocarcinomas has been reported to be quite poor in comparison with that of transitional cell carcinomas, the postoperative prognosis of T4 rectal adenocarcinomas has been reported to be more favorable and such tumors are recommended to be surgically resected. Because no distant metastasis was detected, the patient underwent total pelvic exenteration with a reconstruction of the ileal conduit. Although the resected tumor measured 12 cm in diameter with n1 metastasis, the radial margin was cancer-negative, and the tumor was curatively resected. The immunohistochemical diagnosis of the resected tumor showed carcinoembryonic antigen(+), CK7(−), CK20(+), thrombomodulin(−), and uroplakin(−), which supported the rectal origin. At present the patient is undergoing postoperative adjuvant chemotherapy for rectal cancer.     

Primary pulmonary mucinous adenocarcinoma in a 15-year-old boy.

Bronchogenic carcinomas are rare in childhood. Furthermore, mucinous (so-called colloid) adenocarcinoma, an unusual variant of pulmonary adenocarcinoma, is extremely rare in the first decade of life. To the best of our knowledge, we report the first case with primary pulmonary mucinous adenocarcinoma at the age of 15. Another interesting aspect of this tumor was its metastasis to thyroid, because metastasis of primary bronchogenic carcinomas to thyroid is uncommon. One can face up with difficulties in the establishment of the definite diagnosis due to its complex and often indistinguishable histopathologic pattern. In this paper we report a patient with pulmonary solid mass and thyroid nodule, initially diagnosed as metastatic thyroid carcinoma in whom postoperative resective surgery confirmed primary pulmonary mucinous adenocarcinoma with synchronous metastasis to thyroid.     

Study of the difference between the clinical diagnostic criteria and results of immunohistochemical staining]

If more than 2 lesions of cancer are observed in the lung, differences in the histology or in situ component is the basic criterion for multicentricity. In addition, remote lung mass with same histology in the absence of both distant metastasis and mediastinal lymphadenopathy is also regarded as multicentricity. We have studied the difference between the clinical diagnostic criteria and the results of immunohistochemical staining. Thirteen patients who were diagnosed as double lung cancers under the clinical of Martini et al or Cortese et al were reviewed. Of them, clinically 6 patients had synchronous double lung cancers and 7 patients had metachronous double lung cancers. Four patients in each group with combination of adenocarcinoma (AD) and bronchiolo-alveolar cell carcinoma (BAC) were studied by immunohistochemical staining. As the result, 3 patients in the former group were defined as the synchronous double lung cancers, however in the latter group, only 1 patients was defined as the metachronous double lung cancers. As for from the histological findings, if either of multiple lung cancer lesion were Noguchi's A or B typed BAC, the patients are prone to have double lung cancers. Subsequently if the histology of the both lesions were the same as AD-AD or Noguchi's C typed BAC-BAC, then the patients are prone to have the metastatic lung cancers.     

Pseudomyxoma peritonei of appendiceal cancer with metastasis to the stomach: report of a case

Appendiceal cancer associated with pseudomyxoma peritonei is a relatively low-grade malignancy rarely associated with extraperitoneal metastasis. We report herein the case of a 71-year-old man in whom a metastasis was found in the stomach 2 years after he underwent surgery for pseudomyxoma peritonei of appendiceal cancer. He was referred to our hospital after presenting with anorexia and vomiting. Gastrofiberscopy, abdominal computed tomography, and ultrasound examination all revealed a mass 4 × 4 cm in size, containing a small ulcer, in the antrum of the greater curvature of the stomach. The histopathological diagnosis made from a biopsy of the tumor was mucinous cystadenocarcinoma. A distal partial gastrectomy was performed and the resected specimens from the appendiceal cancer resected 2 years earlier showed the same histological pattern as that of the gastric lesion. To the best of our knowledge, this is only the second report of pseudomyxoma peritonei secondary to mucinous cystadenocarcinoma of the appendix that metastasized to the stomach. Received: September 12, 2001 / Accepted: January 8, 2002     

The treatment of early colorectal cancer

One hundred and eighty-three patients with early colorectal cancer (mucosal or submucosal carcinoma) were treated endoscopically or surgically from 1962 through 1984 at our hospital. Regional lymph node metastasis was recognized in 6 among 98 submucosal cancers. Lymphatic vessel permeation of cancer cells was also found in 31.8% of submucosal cancers. Local recurrence was observed in 3 patients with submucosal cancer. From our experience, the policy of treatment for early cancer was discussed and proposed. If the growth is pedunculated or small sessile polyp endoscopic polypectomy should be performed and bowel resection must be subsequent when histological examination of resected specimen showed massive cancer invasion to the stalk or submucosal layer. If the growth does not have stalk and is diagnosed early cancer, bowel resection with dissection of surrounding tissues should be recommended for high security, because these growth has more frequently submucosal invasion. For early rectal cancer, transanal or trans-sacral local wedge excision for mucosal or submucosal minute invasion cancer and trans-sacral sleeve resection with dissection of mesorectal tissues for submucosal invasive cancer. When histological examination of resected specimen showed unexpectively more massive invasion near to or into propria muscle layer, more wide bowel resection must be subsequent. If sm massive cancer locates near to anal canal, limited Miles' operation must be also in mind, preserving voiding and sexual functions.