We describe a 30-year-old man in whom upper endoscopy revealed multiple gastric carcinoids. The peripheral blood gastrin level was 2400 ng/ml (normal range, <200 ng/ml). Mucosal biopsy of the gastric body and fundus showed no atrophy; typical type A chronic atrophic gastritis was thus unlikely. Neither abdominal computed tomography nor selective angiography showed any evidence of tumor in the pancreas or at its periphery. However, the possibility of microgastrinoma could not be ruled out. We performed radioguided surgery with a somatostatin analog, diethylenetriamine pentaacetic acid-D-Phe1-octreotide labeled with (111)In (Octreo Scan). The location of the carcinoids was confirmed. Gastrinoma was ruled out. Total gastrectomy was performed, and the gastrin level decreased to the normal range. Macroscopically, 20 carcinoid tumors, measuring 30 mm in maximum diameter, were confirmed. Microscopic examination showed large numbers of endocrine cell micronests. Hyperplasia of parietal cells was observed, suggesting early-stage type A chronic atrophic gastritis. The antrum contained increased numbers of gastrin-positive cells, which probably caused the preoperative hypergastrinemia.
A 58-year-old Japanese man complained of dysphagia, and esophagography and endoscopy showed a 7.5-cm-long protruding tumor in his middle esophagus. Biopsy diagnosed the lesion as basaloid squamous carcinoma. We assessed the tumor as T3N0M0 stage II. Preoperative chemoradiotherapy was started, consisting of 3 weeks of intravenous chemotherapy with 10 mg/day cisplatin and 750 mg/day 5-fluorouracil and concurrent total 45-Gy external irradiation applied to the tumor. We evaluated the effectiveness as a partial response and performed curative resection with radical esophagectomy 23 days after the completion of chemoradiotherapy. The pathological findings showed necrosis and degeneration over two-thirds of the tumor. Postoperatively, he returned to physical labor and has had no evidence of recurrence for 5 years. Although basaloid squamous carcinoma of the esophagus is associated with poor prognosis because of its highly malignant potential, preoperative chemoradiotherapy followed by radical esophagectomy may allow for the possibility of improving the prognosis of a fatal process.
With faster CT scanners, asymmetric/heterogeneous enhancement (ASHE) of the internal jugular veins (IJVs) is frequently encountered in the absence of pathology. We investigated the frequency, side, pattern and significance of ASHE in 200 patients with various head and neck lesions. Non-ionic contrast medium (300 mgI/ml) was infused into a forearm vein (right, n = 100); left, n = 100). Forty seconds after contrast medium injection, contiguous 5-mm-thick sections were obtained craniocaudally from the skull base to the aortic arch. CT machines with two different scanning cycle times (3 s, n = 100; 2 s, n = 100) were used. ASHE of the IJVs was observed in 51 patients (25.5%); the patient group receiving a right-sided injection with a 2-s scan cycle machine, showing a higher frequency (44%). ASHE was divided into four patterns: homogeneous low density, focal low density, heterogenous opacification and fluid-fluid level formation. ASHE was frequently observed in routine contrast-enhanced CT of the head and neck. Frequency of ASHE increased when the scanning cycle was shorter. We should be aware of this phenomenon to avoid its misinterpretation as venous thrombosis or other pathology.
15079 Background: The morbidity and survival advantage treated with the combination of hyperfractionated radiotherapy (HF) and biliary stenting has not yet established for patients with unresectable biliary tract cancers. A prospective study was carried out using HF and metallic stent in consecutive patients over 10 years in a single institution. Methods: From 1993 to 2003, consecutive 162 pts (radical 74, postoperative 83, postoperative relapse 5) were treated with HF. Out of 74 radical cases, 71 pts (36 male/35 female; median age 70yrs, range 35–88) were analyzed except 3 cases (manifestation of liver metastasis 1, ascites 1, rejection of treatment 1). Primary sites were; extrahepatic bile duct 56, gall bladder 15. Bile cytology showed adenocarcinoma in every case. HF was administered twice daily by 10MV photon, using 2 portals (ant-post), 3 portals (ant-post-right lateral) or wedged pairs (ant-lateral) with relatively small radiation fields (PTV was CTV +1∼1.5cm). Fractional dose was 1.4Gy with the interfractional interval of 4.5 hrs to a total median dose of 59.8Gy. Endpoints were overall survival and acute and late complications. Results: 1) Obstructive jaundice was relieved before HF through endoscopic biliary drainage in 92.9% (66/71). Metallic stent was applied in 66.2%(47/71), before HF in 35.2% (25/71) and after HF in 31.0% (22/71). 2) Median survival was 8 months (1–90) and 5-year survival was 28%. Multivariate analysis showed total HF dose as a sole significant prognostic factor (p=0.0347). 3) Acute complication was observed mainly in digestive tract, i.e., Grade 1–2 symptoms (anorexia, nausea) in 50.7% (36/71). Late complications were Grade 1–2 gastritis in 9.9% (7/71), Grade 3 gastric ulcer in 2.8% (2/71) and cholangitis in 1.4% (1/71). Conclusions: HF combined with meticulous biliary drainage and stenting by G-I specialists for advanced biliary tract cancers demonstrated excellent pt’s quality of life with less serious morbidities. This modality would offer useful baseline data further with appropriate systemic chemotherapy. No significant financial relationships to disclose.
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