Predicting factors for survival of patients with unresectable pancreatic cancer: a management guideline

BACKGROUND/AIMS

When pancreatic cancer cannot be resected, palliative procedures including gastroenteric bypass and biliary bypass may be selected. However, since predicting survival is difficult, indication of these procedures remains unclear. This study was designed to elucidate the prognostic factors of patients with unresectable pancreatic cancer in order to improve their quality of life.

METHODOLOGY

We treated 187 consecutive patients with unresectable pancreatic cancer at the Kobe University Hospital. Fifteen prognostic variables for survival were analyzed (sex, age, the degree of pain, diet, presence of jaundice, main site of the tumor, tumor size, major vessel invasion, liver metastasis, peritoneal dissemination, distal metastasis and operative procedures) in surgically treated patients (n = 125). All patients were followed until death. Cox's proportional hazard model and logistic regression models were used to determine the factors influencing the survival of patients with unresectable pancreatic cancer.

RESULTS

Cox's proportional hazard model revealed that duodenal invasion (p = 0.001) and liver metastasis (p < 0.0001) significantly influenced the survival of the patients with unresectable pancreatic cancer. In multivariate logistic regression analysis, liver metastasis (p = 0.009) and peritoneal dissemination (p = 0.004) were significant factors on the six-month survival after palliative operation.

CONCLUSIONS

Liver metastasis and peritoneal dissemination were negative predictive factors for the six-month survival of patients with unresectable pancreatic cancer. Palliative bypass surgery is recommended for patients expected to survive long-term (more than six-months).

Factors influencing hepaticojejunostomy leak following pancreaticoduodenal resection; importance of anastomotic leak test

BACKGROUND/AIMS

Pancreatic fistula is a common complication after pancreaticoduodenostomy. Prevention of a concomitant bile leak from hepaticojejunostomy is important because it could lead to more serious complications including intraperitoneal abscess, subsequent sepsis and massive hemorrhage by activating pancreatic fistula. This study was designed to determine perioperative risk factors of the hepaticojejunostomy leak for the purpose of decreasing this morbidity.

METHODOLOGY

Clinical records of 107 consecutive pancreaticoduodenal resections were reviewed. hepaticojejunostomy anastomoses were performed using absorbable sutures in an end-to-side, single-layer and interrupted fashion. A total of 8 presumed perioperative risk factors were analyzed. They included advanced age, low serum albumin, low serum total cholesterol, impaired glucose tolerance and placement of a biliary drainage catheter as preoperative factors, and dilated common hepatic duct and undone anastomotic leak test as intraoperative factors. In addition, transanastomotic stenting techniques including retrograde transhepatic bile drainage, T-tube and transjejunal drainage were compared with respect to hepaticojejunostomy leak rates.

RESULTS

Hepaticojejunostomy leak was demonstrated in 9 patients (8%). Anastomotic leak testing only achieved statistical significance (p = 0.04). It is noteworthy that no hepaticojejunostomy leak developed among 28 patients who underwent this test through a retrograde transhepatic bile drainage catheter. In addition, the frequency of bile leaks (14/107) associated with the transanastomotic stenting techniques urged the necessity of appropriate intraperitoneal drain placement.

CONCLUSIONS

Careful anastomotic procedures with a subsequent anastomotic leak test most effectively prevent hepaticojejunostomy leak after pancreaticoduodenal resection.

Does radical resection improve the survival in patients with carcinoma of the gallbladder who are 75 years old and older?

Radical resections have been reported to improve the surgical outcome for patients with carcinoma of the gallbladder. In recent years surgeons have had more opportunities to operate on elderly patients. We investigated whether the survival rate of aged patients who had radical resections were better than rates for those who had simple cholecystectomy. Of the 300 patients treated for carcinoma of the gallbladder between 1971 and 1999, 206 resected cases (except pancreaticoduodenectomy and hepatectomy) were divided into two groups: age 75 years or older, 54 patients (the older group), and age less than 75 years, 152 patients (the younger group). Clinical features and progression of the carcinomas did not differ between the two groups. In the older group, 22 patients (40.7%) had simple cholecystectomy, 32 (59.3%) had radical resections; in the younger group, 65 patients (42.8%) had simple cholecystectomy, and 87 (57.3%) had radical resection. None of the older patients who had radical resection died postoperatively. Postoperative survival was not different between the two groups. In the older group the 5-year survival rate for patients who had radical resections was better (60.9%) than the rate for those who had simple cholecystectomy (14.1%) (p = 0.0098). Radical resection is effective for the aged patients with the carcinoma of gallbladder.

Selection of pancreaticojejunostomy techniques according to pancreatic texture and duct size

HYPOTHESIS

Selection of proper pancreaticojejunostomy techniques according to pancreatic texture and the main duct size reduces the pancreatic fistula rate.

DESIGN AND PATIENTS

Data from 50 consecutive patients undergoing pancreatoduodenectomy with 3 different anastomotic techniques prospectively used according to pancreatic texture and the main duct size were analyzed. Duct-invagination anastomosis was selected for pancreata with a small duct (n = 34 [29 with a soft texture and 5 with a hard texture]). Stitches between the stump parenchyma and the jejunal seromuscular layer were added to this anastomosis procedure only for the hard pancreata. Pancreata with a large duct were reconstructed with a conventional duct-to-mucosa anastomosis (n = 16).

SETTING

A university hospital department of digestive surgery.

RESULTS

The morbidity was 40% (20 of 50 patients) in this series. Four patients (8%) with a soft pancreas and a small duct developed a pancreatic stump leak after duct-invagination anastomosis, but all of them were removed without sequelae. No pancreatic anastomotic leak was seen in this series, which resulted in no mortality, no remnant pancreatectomy, and only 1 relaparotomy in the consecutive 50 patients.

CONCLUSION

The proper selection of pancreatic reconstruction techniques according to our criteria may reduce the pancreatic fistula rate, eliminate risky pancreatic anastomotic leaks, and result in excellent outcomes for those undergoing pancreatoduodenectomy.

Risk factors influencing pancreatic leakage and the mortality after pancreaticoduodenectomy in a medium-volume hospital

BACKGROUND/AIMS

This study was designed to evaluate risk factors influencing pancreatic leakage and pancreatic leakage-related mortality in a medium-volume hospital.

METHODOLOGY

We retrospectively reviewed the clinical records of 107 patients who underwent pancreaticoduodenectomy at the Kobe University Hospital. Fourteen predictive factors for pancreatic leakage and the pancreatic leakage-related mortality were evaluated using univariate and multivariate logistic regression models.

RESULTS

In univariate analysis, the degree of pancreatic fibrosis, type of resection (PD/PPPD), anastomosis techniques (invagination or duct-to-mucosa anastomosis), anastomosis sites (jejunum/stomach), and the presence of congestion in anastomosis sites significantly influenced pancreatic leakage, and the degree of pancreatic fibrosis influenced pancreatic leakage-related mortality. Multivariate logistic regression analysis revealed that congestion in anastomosis sites was the strongest parameter for pancreatic leakage. Univariate analysis of the patients with normal/mild fibrosing pancreas revealed that pancreatic leakage was influenced by type of resection, anastomosis techniques, anastomosis sites, congestion in anastomosis sites and the management of pancreas parenchyma.

CONCLUSIONS

In a medium-volume hospital, reconstruction after pancreaticoduodenectomy should be performed with careful attention to pancreas and anastomosis sites. In the patients with normal/mild fibrosing pancreas, duct-to-mucosa anastomosis without suturing the pancreas parenchyma may be a useful technique for reconstruction.

Inhibitory effect of epigallocatechin-3-gallate on growth and invasion in human biliary tract carcinoma cells

Based on recent evidence that tea consumption contributes to a decreased incidence of human carcinomas, a number of investigators have focused on the mechanisms of cancer prevention by tea extracts, especially green tea polyphenols. Epigallocatechin-3-gallate (EGCG) is a representative polyphenol that inhibits the activity of the cyclin-dependent kinases of cdk2 and cdk4. This suggests that EGCG may exert its growth-inhibitory effects through modulation of G1 regulatory proteins such as cdk2 and cdk4. The human biliary tract carcinoma cells (TGBC-2, SK-ChA-1, and NOZC-1) were treated with different doses of EGCG (0, 25, 50, 100, and 200 mM) for 48 hours in cell medium. Cell proliferation was analyzed by WST-1 colorimetric assay. For the cell-invasion analysis, the cells were incubated with 100 mM of EGCG for 2 hours. The cells were then added into a Matrigel-coated Cell Insert. After incubation at 37 degrees C for 24 hours, the cells visible through the Matrigel were counted under the microscope. All human biliary tract cancer cells studied showed a significant suppression of cell growth by EGCG treatment in a dose-dependent manner (27.2%, 16.0%, and 10.1%, in TGBC-2, SK-ChA-1, and NOZC-1, respectively, at the dose of 200 mM). Epigallocatechin-3-gallate treatment also produced a significant suppression of invasive ability of the carcinoma cells (12.6%, 11.2%, 7.9%, in TGBC-2, SK-ChA-1, and NOZC-1, respectively, at a dose of 100 mM). These data indicated that EGCG might be a potent biological inhibitor of human biliary tract cancers, reducing their proliferative and invasive activities.

Prognostic significance of S100A4 expression in gallbladder cancer

The calcium-binding protein S100A4 has been characterized as a metastasis-inducing molecule, and regulates cell motility and invasiveness of cancer cells. In order to clarify the significance of the expression of S100A4 as a prognostic factor in gallbladder cancer, S100A4 expression in resected gallbladder cancers were examined using an immunohistochemical staining technique. The relationship between S100A4 expression and clinicopathological factors including prognosis were evaluated. Twenty-five of 60 cases (42%) demonstrated positive staining for S100A4. There was no statistically significant association between S100A4 and histological grade, T, N, M factor, presence of stone, or stage. Kaplan-Meier method showed the 5-year survival rate of the group staining positive for S100A4 (31.5%) to be statistically poorer than that of the group staining negative for S100A4 (78.2%). Also in T2 cases, the 5-year survival rate of the group staining positive for S100A4 (57.1%) was statistically poorer than that of the group staining negative for S100A4 (83.3%). On univariate analysis, positive staining for S100A4 was a significant prognostic factor, and the hazard ratio was 4.05. On multivariate analysis, positive staining for S100A4 is also a significant predictor of prognosis second to T factor. These results indicate that positive staining for S100A4 is useful in assessing the prognosis of patients with gallbladder cancer as well as TNM factors.

New pancreatic duct-invagination anastomosis using ultrasonic dissection for nonfibrotic pancreas with a nondilated duct

Nonfibrotic pancreases with a nondilated duct are susceptible to pancreatic fistula or leakage following pancreaticoduodenectomy. We developed a novel pancreatic duct-invagination anastomosis using an ultrasonic dissector and applied this technique to 14 consecutive pancreaticoduodenectomies and 1 segmental pancreatectomy for otherwise normal pancreases. With the aid of an ultrasonic dissector, even branch pancreatic ducts were skeletonized, ligated securely, and divided during pancreatic transection. Moreover, the main duct was exposed (> 1 cm) easily by ultrasonic dissection and a small-caliber pancreatic tube was inserted into the duct on the stump. Subsequently, pancreatic duct invagination could be easily done through a 10 G intravenous catheter passed through the gastrointestinal tract. The main duct was anchored to the adjacent serosa, but any pancreatic parenchymal sutures, possibly leading to internal laceration and/or parenchymal ischemia particularly in soft nonfibrotic pancreases, were avoidable during the procedures. All the anastomoses were done within 10 minutes. Only 1 patient (6.7%)developed pancreatic fistula, which resolved spontaneously in 21 days postoperatively. Neither anastomotic leakage nor remnant pancreatitis was seen in this series. Although a prospective, randomized study is needed, this technique may contribute to reduced morbidity after pancreaticoduodenectomy for a nonfibrotic pancreas with a nondilated main duct.

High expression of thymidylate synthase leads to resistance to 5-fluorouracil in biliary tract carcinoma in vitro

To evaluate the effect of chemotherapy of 5-fluorouracil (5-FU) in human biliary tract carcinoma, we studied 5-FU sensitivity, thymidylate synthase (TS) content, and dihydropyrimidine dehydrogenase (DPD) activity in 4 human biliary tract carcinoma cell lines compared to 12 various digestive carcinoma cell lines of human organs in vitro. 5-FU sensitivity in the cell lines was analyzed by MTT assay. TS content was analyzed by the [6-(3)H]FdUMP binding assay method, and DPD activity was analyzed by thin-layer chromatography (TLC). 5-FU IC(50) values of biliary tract carcinoma cell lines were significantly higher than those of the carcinoma cell lines of the other digestive organs: 97, 45, 119, and 194 times the concentration of the other digestive, pancreas, colon, and gastric carcinoma cell lines, respectively. TS content of biliary tract carcinoma cell lines was also significantly greater than that of the carcinoma cell lines of the other organs. No difference in DPD activity, however, was recognized between the carcinoma cell lines of each organ. TS content in the cell lines significantly correlated with 5-FU sensitivity, but DPD activity did not. Therefore, in the present study, TS expression was concluded to influence the high resistance to 5-FU of biliary tract carcinoma in comparison with the carcinomas of the other digestive organs.

Gene gun-mediated oral mucosal transfer of interleukin 12 cDNA coupled with an irradiated melanoma vaccine in a hamster model: successful treatment of oral melanoma and distant skin lesion

Malignant melanoma involving the oral cavity has a highly metastatic potential. Curative surgery is required to resect extensive oral tissues and often results in dysfunction as well as a severe cosmetic deformity in patients with the disease. An alternative technology for the local and sustained delivery of cytokines for cancer immunotherapy has been shown to induce tumor regression, suppression of metastasis, and development of systemic antitumor immunity. However, local immunization of the oral cavity has not previously been studied. In this study, we examined the efficacy of particle-mediated oral gene transfer on luciferase and green fluorescent protein production. The results showed that these proteins were more significantly expressed in oral mucosa than the skin, stomach, liver, and muscle. Using an established oral melanoma model in hamsters, particle-mediated oral gene gun therapy with interleukin (IL) 12 cDNA was then conducted. The results indicated that direct bombardment of mouse IL-12 cDNA suppressed tumor formation and improved the survival rate. The skin tumor model created by inoculation of melanoma cells was also significantly inhibited by the oral bombardment of IL-12 cDNA coupled with an irradiated melanoma vaccine administrated to the oral mucosa, compared to treatment with a percutaneous vaccine. IL-12 gene gun therapy, combined with an oral mucosal vaccine, induced interferon-gamma mRNA expression in the host spleen for a long time. These results suggest that immunization of oral mucosa may induce systemic antitumor immunity more efficiently than immunization of the skin and that oral mucosa may be one of the most suitable tissues for cancer gene therapy by means of particle-mediated gene transfer.

Proliferating cell nuclear antigen, p53, and c-erbB-2 expression in relation to clinicopathological variables and prognosis in cancer of the ampulla of Vater

BACKGROUND/AIMS

Various clinicopathological factors have been thought to influence the prognosis of ampullary cancers. Recent advances in molecular biology should provide much useful information on the prognostic factors of ampullary carcinomas.

METHODOLOGY

PCNA (proliferating cell nuclear antigen), p53, and c-erbB-2 were immunohistochemically evaluated in 30 resectable ampullary carcinomas. PCNA, p53, and c-erbB-2 expression, 6 clinicopathological variables, and prognosis were studied and correlations among these factors were investigated.

RESULTS

The mean PCNA-positive rate was 39.1%. The percentages of cases positive for p53 and c-erbB-2 were 53% and 23%, respectively. No correlation was seen between PCNA, p53, or c-erbB-2 expression and clinicopathological variables. The optimum cut-off of PCNA indices influencing recurrence was decided as 40% by receiver operator characteristic curves. The cumulative disease-free survival rate of patients from the > or = 40% PCNA positive rate group was significantly poorer than that of the < 40% PCNA positive rate group (P < 0.01). p53 accumulation and c-erbB-2 expression were not correlated with prognosis. Multivariate analysis revealed that the PCNA positive rate and lymph node metastasis independently contributed to survival (P < 0.05).

CONCLUSIONS

PCNA expression is a useful prognostic marker; however, p53 and c-erbB-2 overexpression are not useful as biomarkers for ampullary cancers.

Changes in the number of gut mucosal T-lymphocytes and macrophages in patients treated by external biliary drainage

OBJECTIVE

To examine the changes in the number of T cells and macrophages in the mucosal lamina propria in the presence or absence of bile in the gastrointestinal tract.

DESIGN

Clinical study.

SETTING

University hospital, Japan.

SUBJECTS

6 patients with obstructive jaundice who had external biliary drainage (drainage group) and 6 patients with no signs of obstructive jaundice (control group).

INTERVENTIONS

Gastrointestinal specimens were taken at the time of operation.

MAIN OUTCOME MEASURES

The number of CD4+ T cells, CD8+ T cells and CD68+ macrophages in the lamina propria mucosae in each group measured immunohistochemically.

RESULTS

The numbers of CD8 T cells and CD68+ macrophages in the lamina propria of the patients treated by external drainage were significantly less than in the control group (p < 0.01). However, there was no difference in the number of CD4+ T cells between the groups (p = 0.45).

CONCLUSIONS

In the absence of bile, mucosal immune function fails as a result of reduced numbers of CD8+ T cells and macrophages.

Surgical treatment for mucin-producing tumors of the pancreas

BACKGROUND/AIMS

Our objectives in this study were to evaluate the surgical treatment for mucin-producing tumor of the pancreas from the clinicopathological and imaging features.

METHODOLOGY

Thirty-one patients with mucin-producing tumor of the pancreas were examined based on clinicopathological analyses to determine the appropriate surgical treatment.

RESULTS

The clinical and imaging features easily distinguished the main duct type of intraductal papillary lesions (type Ia), branch type of intraductal papillary lesions (type Ib) and mucinous cystic neoplasms (type II). From pathological examinations, a dilated main pancreatic duct had the malignant potentiality and multicentric development.

CONCLUSIONS

Pancreatic segments containing a dilated main pancreatic duct should be resected in type Ia. Type Ib is sufficient for partial resection without lymphadenectomy. Type II also requires partial resection of the cystic neoplasm. A standard lymphadenectomy may be an option when type Ia and II show invasive features.

Expression of thymidylate synthase in cancer of the ampulla of Vater

The clinical and therapeutic significance of thymidylate synthase (TS) in cancers of the ampulla of Vater have not yet been reported. We immunohistochemically evaluated TS expression in 33 ampullary cancers using an anti-TS antibody. TS expression, clinicopathologic variables, and survival rates were examined and the correlations between these parameters were identified. Fifteen patients were found to express high levels of TS (high TS group), while 18 patients expressed low levels of TS (low TS group). No significant difference was found between TS expression and clinicopathologic factors. Univariate and multivariate analysis revealed that lymph node metastasis and pancreatic invasion are important variables for independently predicting post-operative survival. Although TS expression was not identified as an important factor for postoperative survival, recurrent cases in patients with chemotherapy existed only in the high TS group. In the present study, it was found that TS expression itself in cancers of the ampulla of Vater has no impact in predicting the prognosis of ampullary cancers, but a chemotherapeutic benefit of evaluating TS expression may exist.

Ampullary carcinoma developing after androgenic steroid therapy for aplastic anemia: Report of a case

Sex steroids influence the development and course of human genital carcinomas including breast, testis, prostata, and ovarian cancers. (1) Other carcinomas such as hepatoma, cholangioma, and pancreatic cancer have also been reported to be related to sex hormones. (2-4) The existence of sex hormone receptors has been demonstrated immunohistochemically in specimens of these diseases. We recently encountered a patient in whom an ampullary carcinoma developed 39 months after the start of androgenic steroid therapy for aplastic anemia. Immunohistochemic analysis of resected tumor specimens of the patient suggested a possible hormonal effect on the tumor oncology.

The role of S100A4 gene encoding an S100-related calcium-binding protein in human bile duct adenocarcinoma cell lines: correlation of S100A4 expression and invasive growth in Matrigel Matrix

S100A4, one of the tandemly arranged S100 genes at chromosome 1q21, has been suggested to play a functional role in cell motility and invasiveness of tumor cell growth. We investigated the expression of S100A4 and the in vitro invasiveness of 4 human bile duct adenocarcinoma cell lines by the Matrigel assay. S100A4 was abundantly expressed in 2 adenocarcinoma cell lines whose growth pattern was highly invasive. Induction of antisense S100A4 into one of the cell lines decreased S100A4 mRNA levels and reduced invasiveness. In contrast, induction of sense S100A4 expression into non-invasive KMBC adenocarcinoma cells, which originally lacked S100A4 expression, resulted in apparent invasive potential in the transfected cells compared with the cells with the vector alone. These results suggest that S100A4 expression is well correlated with the invasiveness of human bile duct adenocarcinomas.

Macrocystic serous cystadenoma of the pancreas

We report a 47-year-old woman with macrocystic serous cystadenoma of the pancreas. She had no past history of abdominal surgery, instrumentation, or trauma. Ultrasonography and computed tomography revealed a unilocular cyst in the body of the pancreas. On magnetic resonance imaging, the cyst showed heterogeneous signal intensity on T1-weighted images, and was homogeneously hyperintense and oligolocular is on T2-weighted images. A preoperative diagnosis of mucinous cystic neoplasm of the pancreas was made, and distal pancreatectomy was performed. The resected oligolocular cyst was 5.0 x 4.5 x 3.0 cm and was lined with a single layer of cuboidal epithelium similar to that seen in microcystic serous cystadenomas. Abundant glycogen was demonstrated within the epithelial cells, as assessed by periodic acid-Schiff (PAS) staining with and without diastase digestion. The cyst exhibited a gross appearance distinct from that of typical microcystic adenomas, resulting in diagnostic difficulties for the radiologists and surgeon involved in the patient's care.

Complete agenesis of the dorsal pancreas

Pancreatic anomalies are occasionally reported, but complete agenesis of the dorsal pancreas is extremely rare. We report a 47-year-old woman with complete agenesis of the dorsal pancreas. This patient initially presented with jaundice. Computed tomography did not reveal the pancreatic corpus or tail. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography did not visualize the dorsal pancreatic duct. Choledochojejunostomy was performed because she had obstructive jaundice. At laparotomy, there was an enlarged pancreatic head, but no distal pancreas was seen. Histological examination of the pancreatic biopsy specimen showed scattered islets of Langerhans in diffuse fibrosis, with destruction of the glandular parenchyma. This case was diagnosed as complete agenesis of the dorsal pancreas.

Diagnostic imaging of early gallbladder cancer: retrospective study of 53 cases

To diagnose early gallbladder carcinoma is difficult but essential to improve the survival of the patients with this cancer. Fifty-three early gallbladder cancers were macroscopically divided into protruding and flat types. The diagnostic devises [ultrasonography (US), computed tomography (CT), and drip infusion cholangiography (DIC)] were compared for their ability of early detection. The specimens were examined cytologically for diagnosis during operation and the p53 protein was investigated. Thirty-three cases were of the protruding type, eighteen of the flat type, and two unclassified. Carcinoma tended to be missed when gallstones were present. Preoperative diagnosis of the flat type was difficult. Tumor location did not always correlate with the preoperative diagnosis. Of the misdiagnosed cases of the protruding type, half were missed with US and CT and were not visualized clearly by DIC. Among the flat type cancers, only three had no abnormal findings by diagnostic imaging. Cytologic examination was effective, and p53 was expressed only in early carcinoma, not in adenoma or dysplasia. Even in the presence of gallstones or cholecystitis, any abnormal findings should make one suspicious of gallbladder cancer. Cytology and p53 expression may be useful for the intraoperative diagnosis, and a combination of diagnostic methods is important.

Surgical results of operations for carcinoma of the gallbladder

We evaluated the surgical results for carcinoma of the gallbladder. Between 1971 and 1995 we treated 258 patients, 74 of whom were treated with simple cholecystectomy, 71 with extended cholecystectomy, and 24 with more extended operations. The tumors were classified according to the stage proposed by the Japanese Society of Biliary Surgery. For m and pm carcinoma simple cholecystectomy may have an excellent result. However, it is difficult to know cancer depth exactly before or during operation, especially when combined with inflammation due to gallstones. In Stage I disease, extended cholecystectomy had an excellent result. So extended cholecystectomy is needed even in the early stage of the disease. Second operation is needed in inapparent carcinoma of the gallbladder if the tumor is more than pm or the margin is positive. More extended operations may be needed in advanced stages for curative resection. Extended hepatic lobectomy combined with pancreaticoduodenectomy should be indicated only if the patients are in good condition because of its high postoperative mortality and morbidity without a significant improvement in survival.

Enhancement of tumor uptakes by stabilized Fab homo-oligomers of a chimeric monoclonal antibody against carcinoembryonic antigen

We investigated the effect of stabilized Fab oligomerization by disuccinimidyl suberate on tumor uptake in a pancreatic carcinoma xenograft model in nude mice. Recombinant mouse/human chimeric Fab of the anti-carcinoembryonic antigen (CEA) monoclonal antibody A10, which was previously shown to react specifically with gastrointestinal cancers was used in this study. Fab homo-oligomers (dimers and trimers) chemically linked with ethylene bonds (C-C oligomers) were produced by linkage of chimeric Fab. Oligomers with C-C bonds had similar immunoreactivity against human CEA to parental Fab monomer. In biodistribution studies in animals bearing pancreatic carcinoma xenografts, at 12 and 24 h after infusion, C-C oligomers showed significantly greater uptakes in tumors than Fab or F(ab')2 but lower than IgG. However, oligomers with C-C bonds maintained higher tumor to normal tissue specificity ratios than IgG 24 h post-infusion. In conclusion, tumor uptake was enhanced by Fab oligomerization with C-C bonds, compared to Fab or F(ab')2, perhaps due to the larger molecular size. It was also shown that C-C Fab oligomers could have a potency to deliver high-dose radionuclides with reduced radio-uptakes in normal tissues for the radioimmunotherapy of gastrointestinal carcinomas.

Biliary-enteric anastomosis by means of a single layer of serosubmucosal sutures without T-tube drainage

BACKGROUND

To lessen anastomotic stricture after biliary-enteric anastomosis, we developed a new biliary-enteric anastomosis that uses a single layer of interrupted serosubmucosal sutures without T-tube drainage.

OBJECTIVE

To evaluate the safety and reliability of this new technique in a canine model of choledochoduodenostomy.

METHODS

In 10 beagles, the common bile duct (2 to 3 mm in diameter) was ligated close to the duodenum with 3-0 polyglactin. On the fifth day after operation, the serum bilirubin level was elevated (137 to 205 mumol/L [8 to 12 mg/dL]) and the bile duct was dilated. The anastomosis between serosubmucosal layers of the dilated bile duct (8 to 10 mm in diameter) and duodenum was accomplished with interrupted sutures of 6-0 polyglactin with two needles. Stitches were inserted in the submucosal plane at the cut edge of the duct and duodenum to appose the mucosa accurately and to avoid accidental perforation of the entire thickness of the duct and duodenum. A T tube was not placed.

RESULTS

There was no anastomotic leakage and the bilirubin level was normalized (14 to 17 mumol/L [0.8 to 1.0 mg/dL]) 7 days after operation for anastomosis. Histologic examination of specimens removed 6 or 12 months after operation showed good connective-tissue union and good mucosal continuity between the bile duct and the duodenum. There was no mucosal scarring and contracture or stricture formation.

CONCLUSION

This new technique is simple and reliable and is recommended as an alternative method for restoring the continuity between the bile duct and intestinal tract after operation for obstructive jaundice caused by benign and malignant stricture of the bile duct.

p53 protein expression and prognosis in gallbladder carcinoma and premalignant lesions

BACKGROUND/AIMS

p53 protein expression in gallbladder carcinoma has recently been detected by immunohistochemical techniques, but the relationship between p53 expression and prognosis or clinico-pathological factors is still obscure.

MATERIALS AND METHODS

We investigated 48 gallbladder carcinoma, 7 adenoma and 11 dysplasia cases for p53 expression by immunohistochemical techniques.

RESULTS

p53 expression was positive in 39.6% of gallbladder cancer cases, but in no adenoma or dysplasia cases. No significant correlation was found between p53 overexpression and prognosis or recurrence in 20 patients with carcinoma involvement up to the subserosal layer. p53 overexpression was correlated with DNA aneuploidy pattern and the absence of stones, but was not correlated with clinical staging or lymph node metastasis.

CONCLUSION

These results suggest that p53 gene mutation is related to the transition from premalignancy to malignancy in gallbladder carcinogenesis, as well as DNA ploidy alterations and carcinogenesis unassociated with gallstones, but has no bearing on the prognosis.

K-ras gene mutation in gall bladder carcinomas and dysplasia

Epithelial dysplasia of gall bladder is an important precancerous lesion of gall bladder carcinogenesis. To investigate the frequency of K-ras gene mutation in gall bladder carcinoma and dysplasia, K-ras codon 12 mutations were investigated by the polymerase chain reaction/restriction enzyme based method following direct sequencing. Mutation was detected in 59% (30 of 51) of gall bladder carcinomas, in 73% (8 of 11) of gall bladder dysplasia in gall stone cases, and in 0% of the normal gall bladder epithelium. There was, however, no correlation between K-ras mutation and clinicopathological factors of gall bladder carcinoma. K-ras gene mutation occurs even in gall bladder dysplasia at an incidence similar to that in carcinomas, suggesting that testing for K-ras gene mutation may prove useful as an adjunct to bile cytological or biopsy analysis.

Ovarian small cell carcinoma with K-ras mutation: a case report with genetic analysis

A rare case of ovarian small cell carcinoma is reported. Laboratory examination of a 46-year-old woman with a lower abdominal tumor showed marked hypercalcemia. Her condition deteriorated progressively, and she died one month after admission. A right ovarian tumor, 8 cm in diameter, metastases to multiple organs, and intraperitoneal bleeding were confirmed by autopsy. Microscopically, the small tumor cell had rounded nuclei with small distinct nucleoli and a scanty cytoplasm. Small cell carcinoma was diagnosed from these histological features and the clinical course associated with hypercalcemia. Immunohistochemical studies showed positive staining of neuron specific enolase (NSE) and keratin. Genetic analysis using DNA extracted from paraffin sections of metastatic lesions revealed mutation of K-ras codon 12. Loss of heterozygosity of the p53 and adenomatous polyposis coli (APC) genes was not informative. Previous reports have shown that ras gene mutations occur in 30% of epithelial ovarian tumors and significantly more frequently in mucinous than in other types of ovarian tumors. These results suggest that small cell carcinoma is of epithelial origin and may have a genetic alteration similar to that of mucinous tumors.

Detection of point mutations in K-ras gene at codon 12 in bile from percutaneous transhepatic choledochal drainage tubes for diagnosis of biliary strictures

Detection of K-ras mutations at codon 12 constitutes one modality for diagnosis of pancreatic tumors. We attempted to detect K-ras mutations in DNA from bile collected through percutaneous transhepatic choledochal drainage (PTCD) tubes as a diagnostic approach to biliary strictures. Since bile salts induce cell damage, we first investigated the degeneration of cells according to bile exposure time using cell lines. High-mol-wt DNA could be extracted from cells exposed to bile for 6 h, but not from those exposed for 12 h. However, DNA exposed to bile for up 12 h could be amplified by the polymerase chain reaction (PCR) method. Therefore, K-ras mutations in fresh bile specimens collected from 15 patients through PTCD tubes were examined using PCR with restriction enzyme digestion. K-ras mutations were found in five out of five (100%) pancreatic cancers, all of which were negative according to cytodiagnosis of the same bile. On the other hand, K-ras mutations were not detected in bile from biliary tract cancers or metastatic neoplasms, except for one bile duct carcinoma and one metastatic case. Thus, although K-ras mutation alone is not an absolute marker for cancer, detection of K-ras mutations in fresh bile from PTCD tubes is a useful adjunct for diagnosis of pancreatic carcinomas in cases of biliary tract strictures.

A new technique for pancreaticogastrointestinal anastomosis without suturing the pancreatic parenchyma

BACKGROUND

In an attempt to lessen the incidence of pancreatic fistula and the disruption of pancreatic anastomosis after pancreatoduodenectomy, we have developed a new technique for pancreaticogastrointestinal anastomosis that consists of pancreatectomy using the ultrasonic dissector and implantation of the pancreatic duct into the gastrointestinal tract without suturing the pancreatic parenchyma. The purpose of this study is to evaluate the safety and reliability of this new technique in a canine model of pancreaticogastrostomy and pancreaticoduodenostomy using 10 beagle dogs.

STUDY DESIGN

Canine pancreas was resected using the ultrasonic dissector. In the distal pancreas, a 1-cm long stump of the main pancreatic duct was freed and the other smaller pancreatic ducts were skeletonized and securely ligated. The main pancreatic duct was implanted into the stomach or the duodenum and fixed to the seromuscular layer with purse-string sutures without suturing the pancreatic parenchyma.

RESULTS

There was no anastomotic leakage, signs of peritonitis, or abscess formation, and the pancreas was grossly normal in appearance seven days after operation. Histologic examination of the specimens harvested 30 days after operation revealed good connective tissue union between the pancreas and the gastric or duodenal wall, and good mucosal continuity between the pancreatic duct and the stomach or duodenum.

CONCLUSIONS

This new technique is simple, safe, and reliable, and is recommended as an alternative method for restoring pancreaticogastrointestinal continuity after pancreatoduodenectomy.

Extended cholecystectomy for carcinoma of the gallbladder

We evaluated extended cholecystectomy, wedge resection of the gallbladder bed, and regional lymphadenectomy for carcinoma of the gallbladder. Between 1971 and 1993 we treated 227 patients, 59 of whom were treated with simple cholecystectomy and 66 with extended cholecystectomy. The tumors were classified according to the stages proposed by the Japanese Society of Biliary Surgery. For Stage I and II disease extended cholecystectomy had a better result than simple cholecystectomy. For the extended cholecystectomy cases the cumulative 5-year survival rate was 78.9% for Stage I, 63.6% for Stage II, 44.4% for Stage III, and 8.3% for Stage IV. The survival of Stage I patients was excellent. For cases more advanced than Stage II (S3, N2, Hinf1, and Binf1), the prognosis was significantly worse. In these cases more aggressive surgery may be needed.

K-ras gene mutation related to histological atypias in human colorectal adenomas

To investigate the relationship of oncogene analysis to morphology, we analyzed K-ras gene mutations by dot-blot hybridization with and without consideration of histological atypias in individual colorectal adenomas. Each of 54 colon polyps were divided into two parts after fixation. One part was used as a mass to assess point mutations; the remaining portion of each polyp was paraffin-embedded, stained with hematoxylin and eosin, and examined for point mutations related to histological atypias. In the first part of our study, K-ras gene mutations at codon 12 were detected in 13 cases (24%). In the second part of our study, 12 cases had distinctly different histological atypias. From each of these 12 cases, two areas, one with higher or one with lower grade atypia in the same polyp were excised to analyze for K-ras gene mutation. Two of these 12 cases (17%) had the mutation in different areas of the same tumor. These two cases contained the mutation only in the areas with higher grade atypia, and only one case added information regarding ras mutation upon microdissection when compared to the entire biopsy. These results suggest that oligonucleotide hybridization can identify the majority of cases containing ras mutations despite regional morphologic variation. Individual cases, however, may contain clonal subpopulations within adenomas with different ras sequences from other regions within the same adenoma.

[Diagnosis of gallbladder cancer by imaging techniques: problems, limitations and their explanations, especially with ss invasive cancer]

The preoperative diagnosis of less than ss depth gallbladder cancer is difficult. Its preoperative diagnosis rate was low (27.5%), and even lower with the presence of concomitant gallstone. In the latter case, the diagnosis rate was particularly low when the stones diameter was greater than 1 cm. Gallstones are frequently associated with macromorphologically invasive type of gallbladder cancer and this may be the reason for the lower diagnostic rate. We compared preoperative diagnosis rate of ultrasonography (US), computed tomography (CT) and drip infusion cholecystography (DIC) for each invasion depth. In US, the preoperative diagnosis rate for m depth invasion was 6/16 (37.5%), pm depth was 1/13 (7.7%), and ss depth was 14/41 (34.1%). In CT, its rate for m depth was 3/11 (27.3%), pm depth was 1/10 (10.0%), and ss depth was 11/37 (29.7%). In DIC, its rate for m depth was 3/11 (27.3%), pm depth was 1/10 (10.0%), and ss was depth 1/23 (4.3%). None of the currently used imaging techniques were very accurate in diagnosing gallbladder cancer. Thus, during preoperative work up, if one discovers a gallbladder full of stones, stones of greater than 1 cm in diameter, thickened gallbladder wall, or a non visualized gallbladder with DIC, gallbladder cancer must be highly suspected.

Expression of oncogene products and growth factors in early gallbladder cancer, advanced gallbladder cancer, and chronic cholecystitis

The expression of oncogene products and growth factors (epidermal growth factor, transforming growth factor-beta, erbB-2, ras p 21, and c-myc) in gallbladder cancer and chronic cholecystitis was measured by immunohistochemical staining on paraffin-embedded serial sections. Expression of these products was graded according to staining intensity in an area of positively stained cells. This study reports the detection of oncogene products and growth factors in cholecystitis as well as in early and late gallbladder cancer. The multiexpression of oncogene products and growth factors was greater for both gallbladder cancer groups as compared with the cholecystitis group. The percentage of epidermal growth factor positivity diminished with increased proportion of interstitial tissue and, conversely, the percentage of transforming growth factor positivity increased with increased proportion of interstitial tissue. The proportion of ras positivity was significantly greater in both early and advanced cholecystic cancer as compared with cholecystitis, but also was considerable even for cholecystitis. These results suggest that various oncogenes may have significant roles in gallbladder cancer and that collagen synthesis is reduced by epidermal growth factor and enhanced by transforming growth factor-beta.

Endoscopic mucosectomy for early gastric cancer using modified strip biopsy

We present a modification of strip biopsy (SB), one of the endoscopic treatment modalities for early gastric cancer. Using a side-viewing endoscope and a special electrocautery snare, we treated 6 patients with early carcinoma of the intestinal type with this modified strip biopsy (MSB). All tumors could be completely resected and 5 patients were not operated on: All 5 remained tumor-free at follow-up of at least one year. These results compared favorably with a historical control group of 17 patients with early gastric cancer treated with conventional strip biopsy. We therefore recommend applying our new method of MSB especially in the intestinal type of early gastric carcinoma; these preliminary data however, need confirmation in larger trials.

A case of intestinal T-cell lymphoma with repeated episodes of perforation

A case of intestinal cytotoxic/suppressor T-cell lymphoma with repeated episodes of perforation was seen in a 77-year-old Japanese male who was admitted complaining of severe abdominal pain accompanied by high grade fever. Surgery revealed diffuse peritonitis due to perforation in the sigmoid colon. After a loop sigmoid colostomy the patient recovered to some degree. Seven days later, however, another perforation occurred. Several aneurysmal swellings accompanied by perforation in the small intestine, forming a mass of 5 x 5 cm, were seen. Although the patient tolerated this operation, generalized emaciation proceeded and the patient died 10 days late. Histological examination at the second operation showed diffuse medium-sized lymphoma of the Lymphoma Study Group (LSG) classification infiltrating the entire depth of the intestinal wall. Destruction of muscle cells was prominent. An immunohistochemical study using fresh frozen material was positive for CD3, and CD8. This marked destruction of the muscle layer by lymphoma cells may be associated with repeated episodes of perforation.