Endoscopic examination of a 60-year-old man revealed multiple erosions in the gastric antrum. After 6 months, erosions also formed in the duodenal bulb and systemic lymph nodes become enlarged. After 20 months, the gastroduodenal erosions developed into mucosal ulcers, and the systemic lymph node swelling progressed. Histological examination of the neck lymph node showed mantle cell lymphoma (MCL). This result agreed with the results of the gastroduodenal biopsy. This case was diagnosed as recurrent primary gastric MCL in other areas, with systemic lymph node metastasis and bone marrow invasion. Hyper-CVAD (cyclophosphamide, doxorubicin, vincristine, and dexamethasone), high-dose methotrexate and cytarabine in combination with Rituximab and stem cell transplantation was performed. The gastroduodenal lesions and atypical cells in the bone marrow disappeared after 2 cycles of the chemotherapy. Metastatic lymph node swelling regressed after stem cell transplantation. We have had no evidence of recurrence for 50 months. Primary gastric MCL is very rare and cyclin D1 immunohistochemistry and FISH assay were very useful for the diagnosis of MCL.
We present two cases of late recurrence after gastrectomy for gastric carcinoma. Both patients had medical examinations regularly and had no symptom of recurrence and serum tumor markers remained normal after surgery. 7 and 8 years after resection of gastric cancer, serum tumor marker levels elevated and cancer recurrence was confirmed by lymph node swelling by CT and PET study. Case 1 was a 69-year-old woman. 7 years after distal gastrectomy, CA 19-9 elevated and late recurrence of gastric carcinoma was diagnosed. Case 2 was a 63-year-old woman, 8 years after total gastrectomy, CEA elevated and late recurrence of gastric carcinoma was diagnosed. Late recurrence more than 5 years after resection of gastric cancer is not rare, and periodic examination of tumor markers would be helpful to diagnose recurrence before it becomes symptomatic.
A 58-year-old man with refractory ulcerative colitis underwent subtotal colectomy 4 months after the diagnosis. He developed intense back pain and high fever 9 days after the operation. Findings of a CT scan and an MRI confirmed the diagnosis of pyogenic spondylitis, and Candida albicans was cultured from the biopsy specimen. His clinical condition gradually improved after receiving therapy with rest and antifungal agents. Physicians should be aware of the possibility of pyogenic spondylitis in patients with back pain is treated for ulcerative colitis.
A 83-year-old man was admitted to our hospital with a large hepatic tumor located in lateral segment. Alpha-fetoprotein was 7ng/ml, and protein induced by vitamin K deficiency and antagonist-II (PIVKA-II) was 50792mAU/ml. The tumor was diagnosed as hepatocellular carcinoma (HCC) by angiographically assisted CT. No ascites was detected and major serological findings were T-Bil 0.7mg/dl, Alb 4.2g/dl, and PT 129%. Because of advanced age and a history of heart disease, he was treated with transarterial chemoembolization using cisplatin (Lip-TACE). The total dose was 128mg of cisplatin and 15ml of lipiodol. No adverse effects appeared. After the third session of Lip-TACE, the levels of PIVKA-II became negative and continued within the normal range for 26 months. We confirmed a decrease of HCC with lipiodol accumulation by abdominal CT, and the response rate was PR. He has been well for 3 years since the first Lip-TACE procedure.
A 46-year-old woman was admitted to our hospital with hepatic encephalopathy due to alcoholic liver disease. A hepatic nodule (20 mm in diameter) in S7 was enhanced in the early phase of contrast CT. No significant findings were observed in the late phase of contrast CT and SPIO MRI. The late phase of CT during hepatic arteriography showed corona-like enhancement of the nodule. The nodule was diagnosed as a hypervascular hyperplastic nodule, based on histological examinations and immunohistochemical results with antibodies against CD68 and CD34.
A 25-year-old man was admitted to our hospital because of abdominal fullness. Abdominal enhanced CT, ultrasonography, and MRI revealed massive ascites and obstruction of the hepatic veins and the inferior vena cava. Gastrointestinal endoscopy showed F3 esophageal varices with the so-called "red color sign". A diagnosis of Budd-Chiari syndrome (BCS) was confirmed by angiography which detected membranous obstruction of the hepatic veins. The cause of BCS in this patient was unclear. After treatment with percutaneous transluminal angioplasty (PTA), his ascites and esophageal varices improved.
A 74-year-old woman was admitted to our hospital with recurrent massive lower gastrointestinal bleeding. She had a history of type C liver cirrhosis and appendectomy, and had undergone endoscopic ligation of esophageal varices one year before. Three-dimensional CTA revealed ileal varices in the right lower quadrant of the abdomen. Superior mesenteric arteriography demonstrated varices at the corresponding area and collateral veins from the superior mesenteric vein to the right ovarian vein. Ileal varices were diagnosed and ileal resection was performed. At surgery, exposed vessels were present at the mucosal surface of the resected specimen and they were thought to be the origin of hemorrhage. In conclusion, bleeding from small intestinal varices, though uncommon, should be considered when the origin of melena is unidentified in a patient with liver cirrhosis.
A 56-year-old woman was admitted to our department for further evaluation of a hypoechoic mass in the pancreatic head detected by abdominal ultrasonography during a medical check-up. Abdominal and endoscopic ultrasonography demonstrated a demarcated round hypoechoic mass 15mm in size without dilation of the main pancreatic duct, and ERP showed a normal main pancreatic duct and branch duct. Because pancreatic cancer was strongly suspected based on dynamic CT and MRI findings, she underwent pancreatoduodenectomy. Pathologically, the tumor was diagnosed as well-differentiated adenocarcinoma in the pancreatic head, 13mm in diameter, 10mm apart from the main pancreatic duct. The main pancreatic duct was completely free of cancer cells and the origin of the cancer was considered to be the epithelium of a peripheral branch duct.