A 62 years-old male visited us to undergo further detailed examination following the positive fecal occult blood test. Type-Ip lesion revealing a fine villous structure at the top was discerned endoscopically which resulted in the diagnosis of serrated adenoma. EMR (endoscopic mucosal resection) was well indicated. At the second endoscopic examination for EMR, however, in the lower part of the lesion, an irregularly-shaped concavity, endoscopically rigid, revealing the loss of villous structure was present, leading to the suspect diagnosis of sm2 invasive cancer in adenoma. Accordingly, the treatment was switched from EMR to surgical operation. Furthermore, through endoscopy just before the surgical operation, the concavity deepened along with the whitish coating, which was strongly indicative of sm2 cancer. Laparoscopic assisted partial resection was carried out in the ascending colon. Pathologically diagnosed as moderately differentiated adenocarcinoma in serrated adenoma, sm2, ly2, v2, n0. The malignant potential of serrated adenoma is considered to be almost equal to that of ordinary adenoma. Taking into consideration that the larger the diameter of a lesion becomes, the greater the malignant incidence grows, and that there actually exists sm invasive cancer originating from serrated adenoma requiring surgical operation, we are expected to scrutinize the lesion of serrated adenoma through endoscopy as to whether it is cancerous or not.
A case of 42-year-old male diagnosed as submucosal tumor with pronounced calcification was encountered. An abnormal shadow was pointed out on the posterior wall of the lower body in the gastric mass screening. Diagnosed as submucosal tumor in terms of upper GI, endscopy, followed by EUS which revealed acoustic shadow suggestive of calcification. Diagnosed as gastric leiomyoma preoperatively, partial gastrectomy was carried out along with the strong desire of resection from the patient. The tumor clearly deliniated was elastic hard, of which surface was accompained by mucosal congestion and atrophic change, diagnosed as submucosal tumor, 20×15×9mm in size. Histopathologically, the bulk of the tumor became fibrous and organized accompained by chronic inflammation such as lymph follicle formation. Furthermore, a great number of calcifications were present all over with no evidence of tumor cell components. Because of the evident degeneration, the origin of the tumor was not be concluded. The tumor, however, was deduced to have orginated from leiomyoma.
Indication of endoscopic treatment to Type-I colon cancer is still controversial. In order to diagnose the cancerous depth invasion precisely, 65 lesions of Type-I were analysed in terms of endoscopic appearance. 1) Type-I sm cancers were split into two subdivisions : typical group (30 lesions) and modified group (35) . 2) Both groups significantly differed in the cancerous depth invasion (p<0.01, chisquare test) , resulting in the fact that modified group reaches much deeper than typical group (Table 1) . In typical group, sm1 80%, sm2 20%. In modified group, sm1 2.9%, sm2 and sm3 97.1%. Furthermore, modified group comprised erosive-ulcerative, nodular, and mixed type. With erosive-ulcerative, all 18 lesions proved sm2 or deeper. With nodular, 9 sm2 but one sm1. With mixed, all 7 lesions proved sm2 or deeper. 3) Pertaining to the group and differentiation, group of typical and modified was significantly associated with the incidence of well/moderately differentiated cancer (p<0.01) . Typical group was linked with well differentiated cancer (73.3%) , modified group linked with moderately differentiated cancer (82.9%) . 4) With vessel invasion, ly (+) was significantly higher in modified group (p<0.01) , while also so was v (+) in modified group. Ly (+) by 20% in typical group while in modified, ly (+) 80%. V (+) by 3.3% in typical while in modified, v (+) by 31.4%. To sum up, it was concluded that it is of the first importance to deal with Type-I sm cancer depending on the subdivision of typical group and modified group in order to discriminate sm1 from sm2 and deeper. This subdivision is useful to decide on a proper treatment between endoscopic removal and surgical operation with the precise preoperative diagnosis over cancerous depth invasion.
A 67 year-old male underwent endoscopic examination because of the positive occult blood test for a type Is lesion to be detected in the sigmoid colon. On the second endoscopic examination, 42 days later, the appearance came to alter very drastically to reveal the two storied arch structure of polyp on polyp measuring 10mm and indicative of sm2 type Is early cancer, no EMR performed. More 20 days later, through detailed magnifying endoscopic examination, the protrusion on the top previously pointed out thoroughly collapsed. Cancer was present at the rising part of the lesion and a depressed territory was discernible on the surface accompanying a central internal concave. After crystal violet staining, pit pattern of type VI was present at the rising part of the lesion, pit pattern of type VI+VN was admitted in the depression territory and the internal concave. Accordingly, the lesion was concluded as sm2, 3 cancer to be resected by laparoscopically aided colectomy. Pathologically type Is 11×10×4mm, sm2, moderately diff aderoca predominantly but poorly diff aderoca at the outpost of cancer, no adenoma component, ly 2, v1, n1 (+) , polypoid growth derived. Type Is sm cancer, which should have been diagnosed as sm2 upon close scrutiny even at the initial examination, showed proliferation and collapse resulting in the formation of the depression in the elevation, possibly or probably, associated with the progression to small type 2.
A 75-year-old male turned out positive for the fecal occult blood test without any complaints. A pedunculated but broad-based lesion measuring about 10mm and lacking in mobility was discerned in the sigmoid colon, the top of which assumed an asymmetric and expansive growth. The surface looked uneven and reddened causing haemorrhagic fragility resulting in the formation of depressed erosions and nodules, which was deduced to be indicative of sm2 or deeper cancer. Barium enema likewise revealed no mobility. The entire lesion comprised VI pit, and VN pit was also discerned in depressed portions. Pathologically, well to moderately differentiated cancer (high grade atypia) without adenoma component, cancerous depth sm1, ly0, v0, cut end (－) , interstitial permeation from the bottom of glands present. Despite the features indicative of sm2 or deeper, the lesion resulted in minimally invasive sm1. The present case cautioned us not to make an over-diagnosis between mucosal and sm2 cancer in that there actually exists the limitation or the very difficulty in the clinical diagnosis concerned.
Plasma high density lipoprotein cholesterol and other serum lipids were evaluated in 45 patients with hyperthyroid and 5 patients with hypothyroid and compared with 21 sex- and age-matched controls.Total cholesterol, HDL-C and LDL-C were reduced in hyperthyroid as compared with normal controls. 8 patients were restudied after restoration of euthyroid and showed significant increase in serum lipids.Total cholesterol and LDL-C were increased in hypothyroid but HDL-C was reduced as compared with normal. After T4 replacement therapy total cholesterol and LDL-C were normalized rapidly, but HDL-C was increased gradually. Atherogenic index was higher in patients with hypothyroid. This finding seems to enhance the risk of coronary atherosclerosis.Total cholesterol and LDL-C showed inverse relation to changes of T4. However no clear correlation was found in HDL-C.
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