A case of pancreatic cancer with liver metastasis which responded to chemotherapy

A case of pancreatic cancer with liver metastasis is reported, in which chemotherapy had a marked effect, with the responses clearly documented. The patient was a 59-year-old male who experienced epigastric pain in February 1985, upper gastrointestinal X-ray examination revealing extragastric compression by the pancreas. He visited the National Cancer Center Hospital, Tokyo, in April 1985 and the diagnosis of pancreatic cancer with liver metastasis was made using the imaging procedures of ultrasonography, computed tomograph scanning and endoscopic retrograde cholangiopancreatography as well as by biochemical and serological tests. At the time a 5 cm tumor was palpable in the middle upper abdomen. The patient was treated with Cis-diaminedichloro platinum, tegafur, and 5-fluorouracil, successively, and the abdominal tumor gradually diminished, finally becoming impalpable. The response was evaluated as one of partial responses (PR) by ultrasonography, and the improvement substantiated by computed tomography and tumor markers.

A case report of synchronous small cell lung cancer and gastric cancer successfully treated with carboplatin

A 53-year-old man complained of anorexia and abdominal distention of one month's duration. The chest X-ray demonstrated a mass in the left lung with hilar and mediastinal adenopathy and a lytic lesion in the right fourth rib. A transbronchoscopic biopsy of the mass revealed oat cell carcinoma (WHO classification). The endoscopic evaluation also revealed a gastric lesion (IIc type). Biopsy of this lesion indicated signet ring cell gastric cancer. An abdominal CT scan demonstrated multiple liver metastases. Based on these findings, the patient was diagnosed as having synchronous lung and gastric primaries, with liver and bone metastasis from lung cancer. Carboplatin (CBDCA) was administered by intravenous drip infusion of 450 mg/m2. After a second treatment with CBDCA about 3 weeks later, the patient achieved a partial response at the primary site of lung cancer as well as at the liver and bone metastases. In addition, repeat endoscopy of the stomach demonstrated a complete regression. A biopsy specimen taken by gastroscopy was negative for cancer cells. Subsequent chemotherapy for small cell lung cancer was administered with cyclophosphamide, adriamycin, and vincristine, and to date there is no evidence of recurrence. Further studies on CBDCA treatment of small cell lung cancer and gastric cancer are needed to establish the efficacy of this drug against these two histologically different cancers.

Small intestinal mucosal hyperplasia caused by an enterokinase inhibitor from red kidney bean in rats

A specific enterokinase inhibitor (EKI) was purified from red kidney bean (RKB). Male weanling rats fed a diet containing this purified EKI (0.06%) for 6 d showed increases in mucosal weights, protein, DNA and lactic dehydrogenase contents in their small intestines compared to age-matched control rats fed a standard diet. Total mucosal EK and disaccharidase activities were, however, decreased in EKI-fed rats. Thus, oral consumption of EKI from RKB led to small intestinal mucosal hyperplasia in rats. The mucosal hyperplasia observed in EKI-fed rats is not likely due to decreased turnover of mucosal proteins as a result of reduced luminal proteases since luminal contents of trypsin, chymotrypsin and elastase in EKI-fed rats were similar to those of control rats. Enterokinase inhibitor may have a direct hyperplastic effect on the small intestine of rats.

Serum levels of vitamin D metabolites in children receiving total parenteral nutrition

Serum levels of 25-hydroxyvitamin D (25-OHD) and 1,25-dihydroxyvitamin D (1,25-(OH)2D) were measured on 19 occasions in seven children receiving total parenteral nutrition (TPN). The daily intakes of vitamin D3 ranged from 44 to 540 IU/day, and all serum samples were obtained after the same daily intake of vitamin D3 for more than 1 month. There was a significant positive correlation between serum 25-OHD levels and parenteral vitamin D3 intakes (r = 0.90, p less than 0.01). In this study, serum 25-OHD levels in all cases taking 200 to 360 IU/day of vitamin D3 were within the normal range. On the other hand, no significant correlation was found between serum 1,25-(OH)2D levels and vitamin D3 intakes, and serum 1,25-(OH)2D levels were normal or elevated in all cases.

Pancreaticobiliary factors in the modulation of small intestinal enterokinase in the rat

Chronic pancreaticobiliary diversion was employed to study the modulation of enterokinase in the small intestine of adult rats. Diversion resulted in apparent trophic changes of the proximal bypassed portion of the intestinal mucosa. An almost complete loss of mucosal enterokinase activity in the proximal duodenum but no increase of enterokinase in the segments distal to reentry of the common duct was found in the pancreaticobiliary-diverted rats. The effect on the enterokinase activity in the proximal segment was specific in that no other brush-border enzymes measured in that segment were decreased. The decrease in enterokinase was partially prevented by dietary supplementation with pancreatic trypsinogen and completely avoided with the addition of a combination of bile acids and trypsinogen. Supplementation with bile acid alone did not preserve the enterokinase levels in the bypassed rats. The results suggested that trypsinogen is the primary factor responsible for modulating enterokinase levels in the proximal small intestine, with bile acids acting as a modifier.

[Difference in clinical treatment between patients histologically diagnosed as group III by the old and new "group classifications" of gastric biopsy]

Since 1971, when the first draft of the "Group Classification", which classifies the atypism of histological structure in biopsy specimens of the stomach, was proposed by the Japanese Research Society For Gastric Cancer, this classification has come into wide use in Japan. It was, however, revised in 1983, and, according to the revised classification, group III was defined as general histological findings in which it is difficult to make a differentiation between benign and malignant by biopsy specimens. Consequently, the new group III includes, various borderline histologies, in addition to the old group III, which had been defined as the histological features corresponding to those observed in gastric adenoma in biopsy specimens. At the National Cancer Center Hospital, 13,909 gastric biopsies were performed during the period between 1973 and 1982. By retrospective review of these, histological findings in 247 lesions of 231 cases corresponded to group III by the old classification (adenomatous type) and in addition to these, 54 lesions of 54 cases to group III by the new classification (non-adenomatous type). We compared the endoscopic and pathological features between the two types, and the following results were obtained: The false-negative rate of malignancy in the non- adenomatous type (24%) was much higher than that in the adenomatous type (6%). The difference between the two may suggest that, with the adoption of the new group classification, clinical treatment of the patients with group III becomes more complicated due to the increase of the false-negative rate. Endoscopically, most (84%) of the lesions in the adenomatous type were seen as polypoid, while in the non-adenomatous type, depressed lesions were dominant (80%). And, endoscopic details of the polypoid or depressed appearances were mostly different between the two types. These nuances of endoscopic appearance between adenomatous and non-adenomatous types are applicable to decisions regarding, adequate clinical treatment for patients diagnosed as group III by the new "group classification." Good communication between the endoscopist and pathologist is indispensable.

[Chemotherapy of pancreatic cancer]

The incidence of pancreatic cancer has been increasing in recent years. In spite of advances in diagnosis with new imaging techniques, the disease is usually advanced by the time of diagnosis. In order to improve the poor prognosis of patients with pancreatic cancer the development of an effective chemotherapy is essential. However, a review of the literature reveals that relatively few drugs have been evaluated for anticancer activity in pancreatic cancer. Anti-cancer drugs whose effectiveness have been confirmed are 5-fluorouracil, mitomycin C, streptozotocin, and adriamycin. A relatively high rate of response using combinations of these drugs has been reported. In addition to these drugs, tegafur is widely used in Japan. Other drugs need further trials and adequate evaluation.

A clinicopathologic study of carcinoma of the papilla of Vater

With a view to clarify the concept of early carcinoma of the papilla Vateri, we examined the records of 26 patients who were treated at the National Cancer Center Hospital in the past 22 years. The following three factors were considered prognostically important for the identification of carcinomas at early stages: Histologically, 1: cancerous infiltration should not reach the proper muscle layer of the duodenum (d-factor); 2: no infiltration into the pancreas should be observed; 3: no metastasis to lymph nodes should be found. Factor-1 (d-factor) is the most important of these. Therefore early carcinoma of the papilla Vateri should be defined at present as that in which cancerous infiltration is limited to within the sphincter of Oddi. For the early diagnosis of carcinoma of the papilla Vateri, screening should be performed by ultrasonography, and when abnormalities are detected, endoscopic inspection of the duodenum and endoscopic retrograde cholangiopancreatography should be performed. Moreover, it is very important to read carefully the radiograms of the areas near the papillary regions of the duodenum in routine upper-digestive tract X-rays.

A comparative study of the pancreatogram and the histological findings in 2,2'-dihydroxy-di-N-propylnitrosamine-induced pancreatic carcinoma in golden hamsters

2,2'-dihydroxy-di-N-propylnitrosamine (DHPN) at a dose of 250 mg/kg was injected subcutaneously into 28 male Syrian golden hamsters once a week. They were sacrificed and dissected at intervals of one to two weeks beginning from the 8th week until the 20th week after the injection. Pancreatography was performed on every hamster and the chronological changes in their pancreatograms were compared with the histological findings. Marked atypical hyperplasia almost indistinguishable from carcinoma in situ was observed histologically beginning at the 13th week, and infiltrating adenocarcinoma was seen in all the hamsters in and after the 16th week. The pancreatography made it possible to depict even minute changes at an early stage that corresponded to the histological findings. One example was that a slight stenosis in the branch was detected at the 13th week and the picture of stenosis was observed in the main pancreatic duct at the 14th-15th week. This was followed by obstruction in and after the 16th week. These findings support the possibility that the neoplastic process in the hamster pancreas occurs in the branch region earlier than in the main pancreatic duct.

Diagnosis of small carcinoma of the pancreas: importance of ultrasound scanning and endoscopic retrograde cholangiopancreatography (ERCP)

Diagnostic aspects of 23 patients with carcinoma of the pancreas were analyzed and four cases of small cancer (less than 2 cm) were presented. These tumors were resected between January 1975 and December 1982 in the National Cancer Center Hospital, Tokyo. Initial signs and symptoms were generally vague and none of them were specific for pancreatic cancer. The most important clues to the detection of the tumor were jaundice in the cases of pancreas head cancer, and extragastric compression demonstrated by x-ray examination in cases of cancer of the pancreas body and tail. In those cases without jaundice, elevated levels of amylase and glucose in the serum and urine were important findings. In regard to imaging diagnosis, endoscopic retrograde cholangiopancreatography and ultrasonography were the most helpful means of diagnosis of small pancreatic carcinoma.

Diagnosis of early gastric cancer seen as less malignant endoscopically

In order to make the endoscopic diagnosis of early gastric cancer more accurate, we determined the endoscopic and clinicopathological characteristics of the 129 cases of early gastric cancer with less malignant appearance among the 978 cases of the disease with a solitary lesion detected at the National Cancer Center Hospital during the period between 1962 and 1981. According to findings required to make a differential diagnosis, the endoscopic appearance of the 978 cases were divided into the following four groups: 170 cases of polypoid, 587 of ulcerative, 119 of gastritis-like and 102 of advanced cancer-like. Among the four groups, the frequency of cases with less malignant appearance was quite high in the gastritis-like group. The lesion in this group was defined as the cancerous lesion which shows only superficial mucosal abnormality, not associated with any polypoid or ulcerative components. Chronologically, it has been rapidly increasing in recent years. These two paradoxical phenomena in the gastritis-like group, that is, "high frequency of less malignant appearance" and "increase in number of cases" not only indicate the inadequacy of the conventional criteria for the recent cases but also show that the gastritis-like malignancy is detectable. New additional endoscopic criteria for the gastritis-like malignancy, for example, irregular margin of the shallow mucosal depression, disproportion of the mucosal granularity, irregularity on the erythematous change and discoloration are essential in order to detect much more cases with less malignant appearance.

Induction of enterokinase in the rat small intestine following hypersecretion of trypsinogen by chronic trypsin inhibitor feeding

The interrelationship between trypsin/trypsinogen and enterokinase (EK) was studied in rats following induction of trypsinogen hypersecretion by various agents. Both soybean trypsin inhibitor and para-aminobenzamidine increased intraluminal tryptic activities to a level about twice that found in the control rats. This resulted in an increase in the mucosal and the intraluminal contents of EK in the rat small intestine. On the other hand, in cholecystokinin-treated rats, although there was an increase of intraluminal trypsin, the increase was about 80% less than in the inhibitor-fed rats. Under this condition, there was no effect on the mucosal or the intraluminal EK. These results suggested that substantial increase in intraluminal trypsin/trypsinogen levels (two-fold over control) will increase the mucosal and the intraluminal concentrations of EK in the rat small intestine. Our observation extends previous reports that a decreased level of trypsin/trypsinogen, such as in pancreatic insufficiency, leads to a decrease in mucosal EK. These observations, when taken together, strongly support the modulating role of intraluminal trypsin/trypsinogen levels in controlling the EK concentrations in the small intestine.

Endoscopic treatment of early gastric cancer: polypectomy and laser treatment

With the tremendous development of gastroenterological endoscopy, it has become possible to treat some types of early gastric cancer by endoscopy. There are two principal methods for this purpose, endoscopic polypectomy using a high frequency electric current and laser endoscopy. We developed the technic and instruments of endoscopic polypectomy, in 1972. Since then, we have experienced 358 cases of gastric polypoid lesions treated by endoscopic polypectomy. Nineteen patients with the elevated type of early gastric cancer were treated by endoscopic polypectomy. Seven patients were operated on after polypectomy and 12 were followed without surgery. Out of the 12 patients, nine are alive after more than five years. On the other hand, we started research to apply lasers for treating early gastric cancer in 1978. Since then, 18 patients have been treated by laser endoscopy, with Nd-YAG laser, argon dye laser or a combination of both lasers. We have established criteria for these treatments for early gastric cancer.

Breath hydrogen test in infants and children with blind loop syndrome

Breath hydrogen production after oral lactose loading was examined in infants and children with stagnant loop syndrome, blind loop syndrome, or both. All six infants under 3 years of age had bacteriological evidence of small intestinal colonization. The characteristics of the breath hydrogen test in this syndrome are: (a) extremely high basal excretion of breath hydrogen (after overnight fasting); (b) an earlier and greater breath hydrogen value (0.293 +/- 0.201 ml/min/m2: mean +/- SD) after oral lactose administration than formed in lactose malabsorption alone (0.050 +/- 0.041 ml/min/m2); and (c) the observation of a sustained hydrogen rise over several hours. This investigation demonstrated that the breath hydrogen test is a promising and noninvasive tool for diagnosing blind (or stagnant) loop syndrome.

Total parenteral nutrition with a new amino acid solution for infants

The currently available, commercially prepared amino acid mixtures for intravenous usage do not result in completely normal plasma amino acid patterns. Taking into consideration the known imbalances that occur with the commercial preparations, we designed a new amino acid solution (AF). This solution was prepared to contain a low concentration of those amino acids usually found in increased concentrations in plasma during the course of total parenteral nutrition (TPN) with a commercially prepared product (CF) and a high concentration of branched-chain amino acids and arginine. Plasma amino acid concentrations were determined for nine infants receiving CF (Group A) and eight infants receiving AF (Group B) as the protein source while on TPN for 5 days. These data were compared to 2-h postprandial values obtained from breast-fed, growing infants serving as controls. In comparison with controls, the plasma concentrations of threonine, glycine, methionine, phenylalanine, tryptophan, and lysine were higher in infants in group A, while those of taurine, alanine, valine, cystine, isoleucine, and proline were lower. In group B, the levels of valine and leucine were slightly higher, while those of alanine, cystine, tyrosine, histidine, and proline were lower. Mean nitrogen balances in groups A and B were + 112 and + 170 mg/kg/day, respectively. Therefore, our new amino acid solution may be better for infants receiving TPN.

[An autopsy report of pancreatic carcinoma following the achievement of significant prolongation of survival, despite the lack of a definitive diagnosis]

A 56-year-old female presented with chief complaints of epigastric discomfort and jaundice. Various examinations led to a differential diagnosis of carcinoma of she pancreas vs. malignant lymphoma. Chemotherapy and radiotherapy achieved a 50% reduction of the tumor mass and the disappearance of her jaundice. The patient survived for twenty-seven months following initial presentation. On post-mortem examination, she was found to have had carcinoma of the head of the pancreas. We studied the relationship between chemotherapy and the survival time in histologically diagnosed, unresectable pancreatic cancer at this hospital over the last ten years.

Activity of the glycine cleavage system in hyperammonemia treated with benzoate

We investigated levels of the glycine cleavage system in livers of spf-fur mutant mice with ornithine transcarbamylase (OTC) deficiency treated with sodium benzoate. The activities of the glycine cleavage system in benzoate-treated spf/Y males and the control mice livers are not significantly different. We examined plasma folate level and Vit. B6 status in a patient with OTC deficiency during the therapy with benzoate. Plasma folate level and vitamin B6 status during the therapy period and during control period are not different and these data were within normal ranges. The observation suggests that the glycine cleavage system is not the candidate for the increase of the de novo synthesis of glycine in hyperammonemic patients treated with benzoate.

[Two cases of carcinoid tumor of the stomach which responded to oral administration of UFT]

UFT was given to two patients with carcinoid tumor of the stomach and the effect of the drug was evaluated. The first patient was a 67-year-old female. She was admitted because of upper abdominal tumor. Exploratory laparotomy revealed gastric tumor and additional huge tumor with liver metastasis and peritoneal dissemination. Histology of biopsy specimens from gastric tumor and metastatic lesions was a composite type, of carcinoid tumor. Postoperatively UFT (600 mg/day) was given to the patient. During three months of the treatment the size of the large tumor reduced from 10 X 10 cm to 4 X 4cm. The second patient was a 55-year-old male. He was admitted because of severe diarrhea. Biopsy from gastric lesion and metastatic skin lesions revealed carcinoid tumor. After administration of UFT and Mitomycin C, metastatic skin lesions became smaller and some of the lesions disappeared. Two cases suggest a possibility that UFT may be effective for carcinoid tumor of the stomach.

Organic acid metabolism in a patient with ornithine transcarbamylase deficiency

Serum and urinary organic acids in a 9-year-old girl with ornithine transcarbamylase deficiency were investigated. The urinary excretion of alpha-ketoglutarate (alpha-KG) and citrate were abnormally high. An inverse linear correlation was found between the plasma ammonium and alpha-KG levels when the plasma ammonium level was less than 200 micrograms/dl, but not at higher levels, suggesting that on overloading with ammonium, its route of metabolism and compensating mechanism are not functionally normal. After administration of NH4Cl, plasma and urinary levels of alpha-KG, pyruvate and citrate increased, but the urinary succinate level decreased slightly. After oral administration of citrate the plasma alpha-KG level increased and the ammonium level decreased transiently. Our results suggest that administration of citrate or alpha-KG is not effective for reducing hyperammonemia in ornithine transcarbamylase deficiency.

Failure of p-aminobenzoic acid screening test to diagnose pancreatic insufficiency in Shwachman's syndrome

The 6-h urine recovery of p-aminobenzoic acid (PABA) following the administration of a standard dose of N-benzoyl-L-tyrosyl-p-aminobenzoic acid (BTPABA) was performed in 13 control subjects and two siblings with Shwachman's syndrome. The control subjects showed a recovery of 67 +/- 12.1% (mean +/- 1 SD) of the administered dose, consistent with previously reported values. Unexpectedly, the recovery of PABA in two siblings with Shwachman's syndrome was found to be 67 and 63%, respectively. The values are well within the normal range. In these siblings, fecal chymotrypsin activities were very low when measured with N-acetyl-L-tyrosyl-ethyl ester (ATEE) as substrate, but were normal when BTPABA was the substrate. The duodenal juice of the younger affected child following pancreozymin-secretin stimulation showed very low chymotrypsin activity against ATEE, BTPABA, and N-benzoyl-L-tyrosyl-ethyl ester. These findings suggest that there may be BTPABA-splitting activity in the lower bowel of these siblings with Shwachman's syndrome. This activity might be that of enteric bacteria or of the intestinal mucosa.

[A study on cancers in the gastric remnant -from standpoint of radiology (author's transl)]

A radiologic study was done retrospectively of 51 cases with carcinoma of the gastric remnant. In each case, the gastric remnant was resected in Cancer Institute Hospital from January 1952 to December 1978, 1) Descriptive breakdown of the cases: a. 8 cases had benign lesions at the initial gastrectomy. b. 13 cases were found to have recurrent of cancer in the stump or metastasis. c. 16 cases had multiple cancerous lesions. d. 2 cases showed cancer in the reconstructed stomach after excision of esophageal carcinomas. 3. 12 cases had uncertain background information. 2) Chief complaints: Four out of the six cases of early cancer were asymptomatic. In the advanced carcinomas, 22 cases (60%) complained of dysphagia. 3) Period of time until re-resection and periodic examination: The period of time from the initial gastric resection until re-resection was less than 5 years in 22 cases (45%) and greater than 5 years in 29 cases (57%). Thus, periodic examinations employing both x-ray and endoscopy are very important even after 5 years have elapsed since gastrectomy. 4) Radiologic examination of gastric remnant carcinomas: After gastrectomy, particularly in the early period, careful attention should be paid to hyperplastic or granulomatous changes located at the suture line of the lesser curvature and the anastomosis. The sites of remnant carcinomas were found most frequently along the sutured portion of the lesser curvature or the anterior and posterior parts of the gastric remnant in 11 cases (27.5%). Seven cases (17.5%) were found in the cardia and five cases (12.5%) in the anastomosed portion. Therefore, it is very important to perform double contrast radiographs from the left anterior oblique projection which is close to the right lie projection, and to take pictures of the sites from the lower esophagus to the cardia of the stomach.

[A comparative study between radiologic and macroscopic findings of small cancers less than 1 cm in the antrum of the stomach (author's transl)]

A comparative study was made of macroscopic and radiologic findings about 95 lesions (83 cases) of small cancers (10 mm and below) in the antrum of the stomach, and the following results were obtained. 1) Preoperative diagnostic rate was 11/66 (17%) for lesions of micro-gastric cancers (5 mm and below), and 21/29 (72%) for lesions of small gastric cancers 5.1-10). Lesions of microgastric cancers which were preoperatively diagnosed as such were those with size of 3 to 5 mm accompanied by marginal elevations. 2) Radiologic findings about micro-gastric cancers. Some of the micro-gastric cancers which gave some findings in barium filled pictures existing along the greater or lesser curvature were observed as pictures of slight depression. In the compression pictures were noticed niches of irregular linear or stellar shapes with surrounding translucency. For qualitative diagnosis, the compression method was found most effective. It is considered very important to look for small niches, slight translucency, and slight deformity in the greater or lesser curvature carefully.