Effect of CT fluoroscopy-guided transpulmonary radiofrequency ablation of liver tumours on the lung

OBJECTIVE

We retrospectively evaluated the effect of transpulmonary radiofrequency ablation (RFA) of liver tumours on the lung.

METHODS

16 patients (10 males and 6 females; mean age, 65.2 years) with 16 liver tumours (mean diameter 1.5 cm) underwent transpulmonary RFA under CT fluoroscopic guidance. The tumours were either hepatocellular carcinoma (n=14) or liver metastasis (n=12). All 16 liver tumours were undetectable with ultrasonography. The pulmonary function values at 3 months after transpulmonary RFA were compared with baseline (i.e. values before RFA).

RESULTS

In 8 of 16 sessions, minor pulmonary complications occurred, including small pneumothorax (n=8) and small pleural effusion (n=1). In two sessions, major pulmonary complications occurred, including pneumothorax requiring a chest tube (n=2). These chest tubes were removed at 4 and 6 days, and these patients were discharged 7 and 10 days after RFA, respectively, without any sequelae. The pulmonary function values we evaluated were forced expiratory volume in 1 s (FEV1.0) and vital capacity (VC). The mean values of FEV1.0 before and 3 months after RFA were 2.55 l and 2.59 l, respectively; the mean values of VC before and 3 months after RFA were 3.20 l and 3.27 l, respectively. These pulmonary values did not show any significant worsening (p=0.393 and 0.255 for FEV1.0 and VC, respectively).

CONCLUSION

There was no significant lung injury causing a fatal or intractable complication after transpulmonary RFA of liver tumours.

p53 immunoreactivity in Barrett's metaplasia, dysplasia, and adenocarcinoma--a case report

Barrett's esophagus is a condition in which the stratified squamous epithelium of the esophagus is replaced by a columnar epithelium with malignant potential. Mutations of the tumor-suppressor gene p53 have been implicated in the evolution of esophageal carcinomas. The aim of this study was to determine whether p53 immunoreactivity in Barrett's esophagus is a marker of neoplasia and, if so, when it occurs in the metaplasia-dysplasia-carcinoma sequence. We treated a patient with esophageal carcinoma arising from the Barrett's esophagus. Consecutive evidence existed for a metaplasia-dysplasia-carcinoma in the same specimen. Immunohistochemical staining with the monoclonal antibody was used to detect the intranuclear protein product of mutated p53. No p53 immunoreactivity was seen in specimen of Barrett's mucosa. p53 immunoreactivity was found only in specimen of dysplasia and carcinoma. Immunoreactivity occurs late in the metaplasia-dysplasia-carcinoma sequence, during the transition to high-grade dysplasia.

T cell repertoire in primary biliary cirrhosis: a common T cell clone and repertoire change after treatment

T cell repertoire was analyzed in three early-stage primary biliary cirrhosis (PBC) patients, using reverse transcription-polymerase chain reaction and single-strand conformation polymorphism. Multiple expanded clones were demonstrated in livers and peripheral blood lymphocytes (PBL) of all three patients. Comparison of the repertoire of different parts of the liver demonstrated the presence of common clones in various Vbeta families. Comparison of the repertoire between the liver and PBL demonstrated that both CD4 and CD8 T cell clones were expanded. Sequence analysis of complementarity determining region 3 of the expanded clones revealed that relatively conserved amino acids were utilized in each patient and that an identical CD4 T cell clone having Vbeta16 was present in all three patients. The number of expanded T cell clones in PBL decreased markedly after the treatment with prednisolone. These results suggest that common T cell clones may play a pathogenic role in PBC.

Prognostic significance of expression of thymidine phosphorylase and vascular endothelial growth factor in human gastric carcinoma

BACKGROUND AND OBJECTIVES

Both thymidine phosphorylase (dThdPase) and vascular endothelial growth factor (VEGF) are well-characterized inducers of angiogenesis. The purpose of this study was to examine the expression of these antigens and their prognostic significance in gastric carcinoma.

METHODS

Medical records of 102 patients with stage II tumor were retrospectively reviewed. Primary tumors were studied by immunohistochemical staining for dThdPase and VEGF.

RESULTS

Positive dThdPase expression was observed in 52 (51%) tumors and positive VEGF expression in 53 (52%) tumors. There was a significant correlation between the positive expression of VEGF and lymphatic invasion. The patients with dThdPase-positive carcinoma showed a significantly worse prognosis than those with dThdPase-negative carcinoma in stage II. Moreover, the frequency of hepatic recurrence was significantly higher in the patients with dThdPase-positive and VEGF-positive tumors than in those with dThdPase-negative and VEGF-negative tumors.

CONCLUSIONS

Combination analysis of dThdPase and VEGF expression in gastric carcinoma appears to be well-characterized inductors of prognosis and metastasis.

Laparoscopic findings in primary sclerosing cholangitis

BACKGROUND AND STUDY AIMS

Primary sclerosing cholangitis (PSC) is a cholestatic disease characterized by segmental narrowing and dilatation of bile ducts. Few studies have been performed on the laparoscopic findings associated with this disease, and the present study was intended to assess the usefulness of laparoscopy for the diagnosis and staging of PSC.

PATIENTS AND METHODS

Six patients were examined by laparoscopy with liver biopsy. Repeated laparoscopy was performed in three patients.

RESULTS

Laparoscopy revealed coarse surface irregularity and discoloration. Surface irregularity was classified into four grades: smooth, shallowly depressed, undulated, and nodular. The affected area showed whitish yellow discoloration. The discolored area was demonstrated as a poorly stained area by intravenous injection of indocyanine green (ICG). Lobular markings became apparent because of the yellow color change in the portal tract, resulting in a leopardskin-like appearance. Lymph-vessel dilatation was seen in advanced stages. Repeated laparoscopy of a patient without treatment demonstrated a progression from a smooth surface to a shallow depression with leopardskin-like markings. On the other hand, the two patients treated with immunosuppressive agents showed improvement of liver swelling and disappearance of the leopardskin-like markings and lymph-vessel dilatation.

CONCLUSIONS

Laparoscopy may provide useful information for the diagnosis and staging of PSC.

Aberrant expression of cytokeratin 7 as a histological marker of progression in primary biliary cirrhosis

AIM

We evaluated the aberrant expression of cytokeratin 7 (CK-7) in hepatocytes as a marker of cholestasis and progression in primary biliary cirrhosis (PBC).

PATIENTS AND METHODS

The expression of CK-7 was studied by immunohistochemistry in 83 cases of PBC. This expression was compared with biochemical data, the deposition of copper-associated protein, and previous histological classifications.

RESULTS

In normal liver, CK-7 was expressed exclusively in bile duct epithelial cells (BDE). In PBC, the expression was also observed in hepatocytes. The expression pattern was classified as follows: Grade 0, BDE as in normal; Grade 1, proliferated bile ductules; Grade 2, periportal hepatocytes in addition to proliferated bile ductules; Grade 3, intralobular hepatocytes; Grade 4, the majority of hepatocytes. The grades correlated with serum bilirubin levels but not with serum levels of biliary enzymes. A discrepancy between the CK-7 grading and Ludwig's classification was noted in cases with Stage 1 of the CK-7 grading who were considered Stage 2 or 3 in Ludwig's classification, suggesting that cholestasis and inflammatory activity might be independent events.

CONCLUSIONS

These results suggest that the aberrant expression of CK-7 in hepatocytes may be a marker of chronic cholestasis and progression in PBC.

Treatment of patients with gastric cancer and duodenal invasion

We retrospectively examined clinicopathologic features of gastric cancer with duodenal invasion to clarify the effect of surgical treatment that include pancreaticoduodenectomy (PD). Among 2504 patients with gastric cancer, 69 (2.8%) who had gastric cancer and duodenal invasion resected by surgical treatment were investigated. The mode of the duodenal invasion was grouped into three categories: mucosal type, submucosal type, and nodal type. Mucosal type is invasion of the duodenal mucosal layer, submucosal type is invasion of the submucosal layer or deeper, and nodal type is invasion from nodal metastatic lesions around the pancreatic head. The 5-year survival rates of curative PD and curative gastrectomy were 37.3% and 33.8%, respectively. Despite the incidence of adjacent tissue infiltration and significantly higher duodenal invasion average length in cases with PD than in cases with gastrectomy, there was no significant difference in the survival curves. However, the prognoses of the cases with nodal-type invasion were significantly poorer, and all these patients died within 2 years, regardless of whether curative PD had been performed. Curative PD improves the prognosis of cases with long duodenal invasion or pancreas infiltration except for nodal-type duodenal invasion.

Vascular integrin beta 3 and its relation to pulmonary metastasis of colorectal carcinoma

Integrin alpha v-beta 3 is involved in tumor angiogenesis while the clinical significance of beta 3 integrin expression in colorectal cancer and lung metastases. Analysis was performed on 51 colorectal cancer patients (22 with subsequent lung metastasis and 29 without lung metastasis). Fifty-one primary tumors and 22 lung metastases were examined for immunohistochemical detection of integrin beta 3. We found that the antibody VNR 5 to integrin beta 3 prefentially stains the blood vessels of small caliber. Indeed, vascular integrin beta 3 index was significantly higher in tumors of patients with lung metastasis than in those without lung metastasis. In the patients with lung metastases, vascular integrin beta 3 index was significantly lower in lung metastases than in primary tumors. It was immunohistochemically proved that integrin beta 3 is an important vascular endothelial cell market for lung metastasis.

Prognostic significance of expression of thymidine phosphorylase and vascular endothelial growth factor in human gastric carcinoma

BACKGROUND AND OBJECTIVES

Both thymidine phosphorylase (dThdPase) and vascular endothelial growth factor (VEGF) are well-characterized inducers of angiogenesis. The purpose of this study was to examine the expression of these antigens and their prognostic significance in gastric carcinoma.

METHODS

Medical records of 102 patients with stage II tumor were retrospectively reviewed. Primary tumors were studied by immunohistochemical staining for dThdPase and VEGF.

RESULTS

Positive dThdPase expression was observed in 52 (51%) tumors and positive VEGF expression in 53 (52%) tumors. There was a significant correlation between the positive expression of VEGF and lymphatic invasion. The patients with dThdPase-positive carcinoma showed a significantly worse prognosis than those with dThdPase-negative carcinoma in stage II. Moreover, the frequency of hepatic recurrence was significantly higher in the patients with dThdPase-positive and VEGF-positive tumors than in those with dThdPase-negative and VEGF-negative tumors.

CONCLUSIONS

Combination analysis of dThdPase and VEGF expression in gastric carcinoma appears to be well-characterized inductors of prognosis and metastasis.

Long-term postoperative functional evaluation of pylorus preservation in Imanaga pancreatoduodenectomy

Our purpose was to determine whether pylorus-preservation in the Imanaga (PpPDI) method minimizes postoperative impairment of gastrointestinal function. Nine patients who had undergone PpPDI (postoperative years: 5.7 +/- 2.6) and nine patients who had undergone conventional Imanaga pancreatoduodenectomy (PDI) (postoperative years: 6.8 +/- 2.0) were evaluated for symptoms, nutritional parameters, and physiologic function of the biliary tract and residual stomach using gastric emptying and hepatobiliary scintigraphy. The body weight recovered to 99.3% +/- 3.8% of pre-illness body weight in PpPDI, showing a significantly better recovery than in patients after the PDI procedure (91.0% +/- 6.4%, P < 0.05). The mean gastric emptying half-time (GET1/2) in the upright position after PDI was significantly shorter (42.3 min) than after PpPDI (80.8 min, P < 0.05). Mixture of food with bile was conserved better in the PpPDI group than in the PDI group. In the long term, the pylorus-preserving Imanaga-type procedure minimizes disruption of gastric function and asynchrony between ingested food and bile.

Smooth muscle tumors of the esophagus: clinicopathological findings in six patients

Preoperatively, it is difficult to discriminate leiomyoma and leiomyosarcoma of the esophagus, which are rare smooth muscle tumors. The objective of this study was to evaluate the clinicopathological findings of this unusual lesion. A search of the surgery archives of the Toyama Prefectural Central Hospital of Pathology revealed six cases of esophageal smooth muscle tumors. Clinicopathological findings were reviewed retrospectively. Only three patients (50%) presented with dysphagia, and the remaining three patients were asymptomatic. These patients underwent surgical excision. Histologically four of the six tumors were leiomyomas, and the other two tumors were leiomyosarcomas. Two tumors were in the upper to middle esophagus, and the remaining four were in the distal esophagus. On endoscopic examination, all tumors were noted to be polypoid. The two leiomyosarcomas measured over 5 cm and the four leiomyomas less than 4 cm. Neither ulceration nor necrosis proved to be of use in discriminating leiomyoma and leiomyosarcoma. The two patients with leiomyosarcoma died of liver metastasis 10 and 22 months after the treatment. Patients with leiomyosarcoma presented with distant metastasis and/or recurrence, with hematogeneous metastasis being the predominant type of recurrence.

Apoptosis, cell proliferation and expression of oncogenes in gastric carcinomas induced by preoperative administration of 5-fluorouracil

The purpose of this study was to examine the correlations among enhancement of apoptosis, cell proliferation and expression of oncogenes in gastric carcinomas induced by preoperative oral administration of 5-fluorouracil (5-FU). The occurrence of spontaneous apoptotic cell death in 42 patients with gastric carcinoma was analyzed in the biopsy specimens preoperatively. p53 status was examined by polymerase chain reaction-single strand confirmation polymorphism and sequencing. Fourteen patients received oral administration of 5-FU at 300 mg/body/day for 7 days preoperatively. For detection of apoptotic cells, apoptotic incidences (AIs) were examined by the terminal deoxynucleotidyl transferase-mediated deoxy-uridine triphosphate biotin nick end labeling method, on gastric carcinoma lesions based on the endoscopic findings before administration in the biopsy and resected tissues. Expressions of p53, Bcl-2, Bax gene and proliferating cell nuclear antigen (PCNA) were also examined by immunohistochemical staining. On preoperative biopsy, p53 point mutation was observed in 14 of the 42 tumors. The immunohistochemical staining status and point mutation of p53 gene (positive or negative) were identical in 32 of the 42 tumors (76.2%). The average AIs of the biopsy specimens were 1.58+/-1.26% on p53-negative staining (n=19) and 1.14+/-1.02% on p53-positive staining (n=23), a significant association was not recognized between p53 expression and AI. In the preoperative administration group, the PCNA labeling index was significantly higher in the biopsy specimens than in the resected tissues (43. 6+/-12.8% vs. 35.3+/-8.8%, p<0.01). In addition, postoperatively, the rate of AI was significantly more accelerated in p53-negative staining (n=6) than in p53-positive staining (n=8) (0.89+/-0. 65%right curved arrow 4.18+/-3.26%, p<0.05 vs. 1.20+/-0.60%right curved arrow 2.60+/-2.60%, NS). There was no significant correlation between AI and Bcl-2 or Bax staining. Immunohistochemical analysis of p53 and PCNA stainings in biopsy specimens appears to be a well-characterized indicator of sensitivity of chemotherapy in gastric carcinomas.

Expression of perforin and Fas ligand mRNA in the liver of viral hepatitis

Cytotoxic T lymphocytes (CTLs) play an important role in the pathogenesis of viral hepatitis. We studied the expression of mRNAs of perforin and Fas ligand (Fas-L) in biopsy specimens from chronic hepatitis B (CHB) (15 cases) and hepatitis C (CHC) patients (13 cases). Both perforin and Fas-L mRNAs were detected in all cases of both CHB and CHC. No messages were detected in the control livers from two cases of fatty liver, a case of Gilbert's syndrome, and a case of Dubin-Johnson syndrome. Semiquantitative analysis revealed a positive correlation between the intensity of perforin and Fas-L mRNAs in both CHB and CHC. In CHB, the intensity of both perforin and Fas-L mRNAs showed a positive correlation with the histological activity and serum alanine aminotransferase level, while the correlation was not apparent in CHC. These results suggest that both perforin and Fas/Fas-L systems are involved in the pathogenesis of liver cell injury of CHB and CHC.

Esophageal sarcomas: report of three cases

BACKGROUND/AIMS

Sarcomas of the esophagus, including carcinosarcoma, are rare neoplasms.

METHODS

The clinical and pathologic characteristics of 3 patients with esophageal sarcomas are presented, including the only recorded esophageal carcinosarcoma and 2 patients with leiomyosarcoma.

RESULTS

All 3 patients were males who presented with dysphagia or an abnormal shadow of the mediastinum on a plain chest X-ray. Two tumors were in the middle esophagus, and the remaining one was in the distal esophagus. On endoscopic examination, all three tumors were noted to be polypoid. These patients underwent surgical excision. One patient died 7 days following the operation, and the remaining 2 patients died of liver metastasis 10 and 22 months following the treatment.

CONCLUSION

Esophagectomy or esophagogastrectomy is a surgical choice. Even if metastases are present, a palliative resection can still be performed.

Evaluation of PCNA, p53, K-ras and LOH in endocrine pancreas tumors

BACKGROUND/AIMS

The object of this study was to evaluate the characters of the endocrine pancreas tumors including proliferative activity, p53 mutation, K-ras mutation and microsatellite instability.

METHODOLOGY

The 13 endocrine tumors of the pancreas were enrolled in this study. There were 8 hypervascular tumors and 4 normo- or hypovascular tumors. All cases were immunohistochemically characterized in paraffin sections for the presence of proliferating cell nuclear antigen and p53 protein. Mutation in K-ras at codon 12 was detected by the Mutant-allele-specific amplification system. Microsatellite instability was examined by using frozen tissues in the 2 cases.

RESULTS

Proliferating cell nuclear antigen labeling index range was 0.00-0.62 (0.26 +/- 0.23). p53 was positive in 4/13 tumors. K-ras codon 12 mutation was not detected in any tumors. PCNA LI was significantly lower in hypervascular tumors (0.16 +/- 0.20) than normo- or hypovascular tumors (0.44 +/- 0.17) (P < 0.05). PCNA LI was significantly lower in the p53-positive tumors (0.48 +/- 0.17) than the p53-negative tumors (0.17 +/- 0.18) (P < 0.05). K-ras codon 12 mutation was not detected in any tumors. Loss of heterozygosity in 3p was detected in 1 tumor.

CONCLUSIONS

Hypervascular endocrine pancreas tumors have low proliferative activity. p53 mutation influences proliferation as the late event of tumor progression.

Strategy for pancreatic endocrine tumors

BACKGROUND/AIMS

The endocrine tumors of the pancreas are rare diseases and there is no established standard therapy for the liver metastasis of pancreatic endocrine tumors. In this study, the therapy for the pancreatic endocrine tumors was evaluated.

METHODOLOGY

The endocrine pancreas tumors of 13 patients had been surgically treated. All primary tumors were completely resected. The liver metastasis was recognized in 4 patients. Partial resection of the liver was performed in 2 patients. Lipiodol-transcatheter arterial embolization was performed for synchronous unresectable liver metastases in the other 2 patients.

RESULTS

The patients with no liver metastases survived without recurrence (max: 18.8 yr; mean follow-up: 9.2 yr). The patient with resected synchronous solitary liver metastasis died of recurrent multiple liver metastases 5 months after surgery. The other patient with the metachronous liver metastasis completely resected survived 13.9 years. In the 2 patients with unresectable numerous liver metastases, after lipiodol-transcatheter arterial embolization, tumor necrosis rate was more than 90% in both cases and serum gastrin level was normalized.

CONCLUSIONS

Complete resection of liver metastasis is favorable, whereas lipiodol-transcatheter arterial embolization is effective for unresectable liver metastases from pancreatic endocrine tumors as palliation. Complete resection of the primary site is recommended even in the cases with unresectable numerous liver metastases.

Cytokine profile in the liver of primary biliary cirrhosis

We characterized the cytokine profile in the liver of patients with primary biliary cirrhosis (PBC). Total RNA was extracted from the biopsy specimens of 9 patients with early-stage PBC, 10 with chronic hepatitis C (CHC), and 4 normal controls. cDNA was prepared and amplified with a polymerase chain reaction using primers for interferon (IFN)-gamma and interleukin (IL)-2, -4, -5, -6, -10, -12 (p40), and -15. Cytokines such as IFN-gamma and IL-5, -6, -10, -12, and -15 were expressed in most cases of PBC. Expression rates of IL-5 and IL-6 were higher than in CHC and controls. The higher expression rate of IL-5 in PBC was associated with eosinophil infiltration. IL-2 and IL-4 were rarely detected. Semiquantitative analysis revealed that the expression of IFN-gamma and IL-10 was reversed in PBC and CHC: high IFN-gamma and low IL-10 in PBC and high IL-10 and low IFN-gamma in CHC. These results suggest that cytokine expression is skewed in PBC and both Th1 and Th2 cytokines may play a role in the pathogenesis.

Number of lymph node metastases influences survival in patients with thoracic esophageal carcinoma: therapeutic value of radiation treatment for recurrence

We retrospectively investigated whether the number of involved lymph nodes and the radiation therapy for recurrence affect survival in patients with thoracic esophageal carcinoma. Eighty-nine patients underwent surgical resection and reconstruction for thoracic esophageal squamous cell carcinoma beyond the mucosal layer. Patients were classified into three groups: group 1 comprised 40 patients without lymph node involvement; group 2 comprised 34 patients with 1-3 positive nodes; and group 3 comprised 15 patients with > or = 4 involved lymph nodes. The 3-year and 5-year survival rates were 77.5% and 73.2% respectively in group 1, 64.8% and 55.8% respectively in group 2, and 28.1% and 0% respectively in group 3. The mean survival time (MST) mean +/- SD of the patients in group 3 (772.1 +/- 146.2 days) was significantly shorter than that of patients in group 1 (3728.5 +/- 320.7 days, p < 0.0001) and group 2 (2330.4 +/- 344.3 days, p = 0.0130). The MST of the patients in group 2 was also significantly shorter than that of patients in group 1 (p = 0.0366). Patients with recurrent lymph nodes that were localized were treated effectively with radiation therapy. We conclude that the number of lymph node metastases influences survival in thoracic esophageal cancer. Early detection as well as radiation therapy for recurrent lymph node metastases is effective in improving long-term survival.

A new examination for both biliary and gastrointestinal function after pancreatobiliary surgery--single-isotope two-day method

BACKGROUND/AIMS

There are no established tests for both biliary and gastrointestinal function after pancreatobiliary surgery. In this study, mixing of ingested food with bile after long-term postoperative period was evaluated.

METHODOLOGY

Sixteen patients having undergone Imanaga pancreatoduodenectomy (postoperative years = 6.2 +/- 2.0) were evaluated concerning physiologic function of biliary tract and residual stomach using gastric emptying and hepatobiliary scintigraphy.

RESULTS

At least 24 months after Imanaga pancreatoduodenectomy, postoperative patients had reached 95.8 +/- 4.9% of the pre-illness bodyweight. Gastric emptying half-time (GET1/2) ranged from 9-147 min (mean: 60.6 +/- 35.0). The time of bile excretion from liver to jejunum ranged from 5-45 min (mean: 11.3 +/- 7.8). Asynchrony time ranged from -5-40 min (mean: 11.3 +/- 7.8). There was no significant correlation between GET1/2 and recovery of bodyweight (r = -0.042, P = 0.8809). Similarly, there was no significant correlation between the time of bile excretion and recovery of bodyweight (r = 0.042, P = 0.8791). On the other hand, asynchrony time had a significant inverse correlation with recovery of bodyweight (r = -0.590, P = 0.0146).

CONCLUSIONS

Single-isotope two-day method is an original and useful technique to evaluate biliary and gastrointestinal physiologic function after long-term postoperative period.

Cytokine profile in the liver of primary biliary cirrhosis

We characterized the cytokine profile in the liver of patients with primary biliary cirrhosis (PBC). Total RNA was extracted from the biopsy specimens of 9 patients with early-stage PBC, 10 with chronic hepatitis C (CHC), and 4 normal controls. cDNA was prepared and amplified with a polymerase chain reaction using primers for interferon (IFN)-gamma and interleukin (IL)-2, -4, -5, -6, -10, -12 (p40), and -15. Cytokines such as IFN-gamma and IL-5, -6, -10, -12, and -15 were expressed in most cases of PBC. Expression rates of IL-5 and IL-6 were higher than in CHC and controls. The higher expression rate of IL-5 in PBC was associated with eosinophil infiltration. IL-2 and IL-4 were rarely detected. Semiquantitative analysis revealed that the expression of IFN-gamma and IL-10 was reversed in PBC and CHC: high IFN-gamma and low IL-10 in PBC and high IL-10 and low IFN-gamma in CHC. These results suggest that cytokine expression is skewed in PBC and both Th1 and Th2 cytokines may play a role in the pathogenesis.

Fcgamma receptor expression on hepatic macrophages and histological activity of chronic hepatitis

AIMS/BACKGROUND

Activated liver macrophages in chronic hepatitis express a high affinity receptor for IgG named FcgammaRI. This study was performed to find the difference in FcgammaRI expression between chronic hepatitis B (CHB) and C (CHC) with reference to histological activity.

METHODS

Consecutive patients with CHB (20 cases) and CHC (25 cases) were enrolled in the study. Inflammatory activity was evaluated using the modified histological activity index (HAI). FcgammaRI-positive macrophages were quantitatively measured by computer assisted morphometry.

RESULTS

Total HAI score was significantly higher in CHB than in CHC. Confluent necrosis was observed in significantly higher frequency in CHB at Stages 3 5 than in CHC. The percentage area of FcgammaRI-positive macrophages was significantly higher in CHB than in CHC. In CHB, the percentage area of FcgammaRI-positive macrophages correlated with total HAI (<0.01) as well as the degree of confluent necrosis (<0.01), interface hepatitis (<0.05) and portal inflammation (<0.05). FcgammaRI-positive macrophages accumulated mainly at the site of confluent necrosis. In CHC, no correlation was observed between activated macrophages and any histological categories.

CONCLUSION

These results suggest that FcgammaRI-positive macrophages are associated with confluent necrosis in CHB, which is more common in CHB patients than in CHC.

Intussusception of a mucocele of the appendix secondary to an obstruction by endometriosis: report of a case

We treated a patient with a complete invagination of the cecum which contained a mucocele of the appendix secondary to an obstruction by endometriosis. Preoperatively, a barium enema showed a crab's claw-like area without filling in the oral side of the transverse colon. An emergency laparotomy was performed and revealed a mucocele of the appendix to have induced appendicecal invagination; however, no colonic invagination was observed. An appendicecal resection was thus done. Pathologically, the resected specimen was a mucosal hyperplasia with mucin-secreting lesions of the appendix. The theories regarding the pathogenesis of appendicecal mucocele are reviewed and discussed.

Highly aggressive behavior and poor prognosis of small cell carcinoma in the stomach: flow cytometric and immunohistochemical analysis

Small cell carcinoma of the stomach has an aggressive feature, and the survival rate of the patients is poor. The purpose of this study was to determine the clinical course, and effects of histopathologic characteristics of specific tumors including DNA contents and immunohistochemical aspects in patients with small cell carcinoma of the stomach. Medical records of 8 patients who presented with small cell carcinoma of the stomach were retrospectively reviewed. Primary tumors were studied by flow cytometric analysis and immunohistochemical staining for the p53 protein, PCNA (proliferating cell nuclear antigen), factor VIII related antigen (specific for endothelial cells), VEGF (vascular endothelial growth factor) and PD-ECGF (platelet-derived endothelial cell growth factor). DNA aneuploid was observed in 4 cases. Staining for the p53 product was positive in 50% of all the cases. The average PCNA labeling rate (LR) was 71.3+/-9.9%. Positive VEGF expression was found in 7 tumors and positive PD-ECGF expression was found in all tumors. The estimated median survival was 252 days for all the patients. Liver metastases were observed in 4 of the 8 patients, however, surgery and chemotherapy have given us one long-term survivor (43 months). Higher PCNA LR of small cell carcinoma may be an unfavorable characteristic of biological behavior. Moreover, both VEGF and PD-ECGF positivity are well-characterized inducers of hepatic metastasis.

Adenoma and tiny carcinoma in adenoma of the papilla of Vater--p53 and PCNA

BACKGROUND/AIMS

Adenomas develop only rarely in the small bowel mucosa. We particularly tried to clarify the histologic change in atypia of ampullary adenomas which are not familial polyposis.

METHODOLOGY

Four adenomas, 4 adenocarcinomas, and 4 normal mucosal regions of the ampulla of Vater were investigated in this study. All cases were characterized in paraffin sections for the presence of p53 protein using the anti-p53 monoclonal antibody (DO7, Dako Corp., Glostrup, Denmark) and proliferating cell nuclear antigen using the anti-PCNA antibody (PC 10, Dako A/S, Copenhagen, Denmark). To obtain the percentages (labeling index) of PCNA, a dual wavelength imaging microdensitometer (CAS 200, Elmhurst, IL) was used.

RESULTS

Transition of adenoma into adenocarcinoma was recognized in 2 of 4 cases. Labeling index of PCNA was 12.2% in normal mucosa, 41.3% in adenomas, and 66.0% in adenocarcinoma, respectively. In 2 cases with carcinoma in adenoma, labeling index was higher in carcinomatous lesion than in adenomatous lesion. p53 Protein was positive in all cases of adenocarcinoma of the ampulla of Vater, and not in any case of normal mucosa or adenoma.

CONCLUSIONS

The adenoma-carcinoma sequence was morphologically recognized especially in tiny carcinoma in adenoma of the papilla of Vater. Both p53 mutation and high proliferative activity play important roles for the histogenesis of invasive adenocarcinoma.

Highly aggressive behavior and poor prognosis of small-cell carcinoma in the alimentary tract: flow-cytometric analysis and immunohistochemical staining for the p53 protein and proliferating cell nuclear antigen

The purpose of this study was to determine the clinical course, and effects of the histopathologic characteristics of specific tumors, including DNA contents and immunohistochemical aspects, in patients with small-cell carcinoma of the alimentary tract. Medical records of 14 patients who presented with small-cell carcinoma of the alimentary tract were retrospectively reviewed. Primary tumors were studied by immunohistochemical and flow cytometric analyses. Of these 14 small-cell carcinomas, 4 were esophageal, 8 gastric, and 2 colonic tumors. DNA aneuploidy was observed in 8 tumors. Staining for the p53 product was positive in 57.1% of all the tumors. The average proliferating cell nuclear antigen (PCNA) labeling rate (LR) was 72.4 +/- 11.6%. The average PCNA LR was significantly higher for the p53-positive group (p < 0.05). The estimated median survival was 253 days for all patients. Noncurative resection was associated with a significantly less favorable prognosis (p < 0.01). Distant metastases were observed in 13 of 14 patients. A higher PCNA LR of small-cell carcinoma may be an unfavorable characteristic of biological behavior. The patients with disseminated disease should undergo a symptomatically palliative operation combined with chemotherapy.

Flow cytometric analysis and immunohistochemical staining for the p53 protein and proliferating cell nuclear antigen in submucosal carcinoma of the esophagus

BACKGROUND/AIMS

The aim of this study was to examine the role of p53 gene and tumor proliferating activity using anti-proliferating cell nuclear antigen (PCNA) in squamous cell carcinoma (SCC) of the esophagus with invasion restricted to the submucosa. Their DNA contents and microscopic histopathological aspects were also studied.

METHODOLOGY

Thirty-four submucosal SCC were studied histopathologically including immunohistochemical and flow cytometric analysis.

RESULTS

DNA diploid was observed in 15 (44.1%) and DNA aneuploid in 19 (55.9%) cases. DNA ploidy patterns were relatively closely correlated with survival. Staining for the p53 product was positive in 61.8% of all cases. The average PCNA labeling rate (LR) was 55.9 +/- 16.7%. The incidence of lymph node metastasis was relatively higher in DNA aneuploid and high PCNA LR (> or = 50%) groups. There was, however, no significant correlation between p53 protein expression and lymph node metastasis.

CONCLUSIONS

Our study suggests that DNA aneuploid and high PCNA LR are unfavorable characteristics and that p53 expression may not have a prognostic value.

The time interval between primary colorectal carcinoma resection to occurrence of liver metastases is the most important factor for hepatic resection. Analysis of total course following primary resection of colorectal cancer

The lack of any other effective treatment for colorectal liver metastases makes hepatic resection a primary treatment consideration. Between January 1980 and December 1996, 36 patients with metachronous liver metastases who underwent hepatic resection were reviewed. The age, sex, site of primary lesion, stage, size and number of hepatic metastases, and time interval between primary colorectal carcinoma resection to occurrence of liver metastases (disease-free interval, DFI) were documented. DFI was 569 days on average. Complete removal of primary colorectal cancer and metastatic liver tumour with histologically negative resection margins was accomplished in all cases. The 5 year survival rate following the first operation for primary colorectal cancer was 43.1%. The length of DFI influenced, independently, patients' prognoses based upon not only univariate but also multivariate survival analysis (P<0.01). We conclude that the DFI is the independent prognostic factor for metachronous liver metastases after curative resection of primary tumour.

Primary small cell carcinoma of the esophagus: flow cytometric analysis and immunohistochemical staining for the p53 protein and proliferating cell nuclear antigen

BACKGROUND AND OBJECTIVES

The purpose of this study was to determine the clinical course and effects of histopathologic characteristics of specific tumors including DNA contents and immunohistochemical aspects in patients with small cell carcinoma of the esophagus.

METHODS

Medical records of 4 patients who presented with small cell carcinoma of the esophagus were retrospectively reviewed.

RESULTS

DNA aneuploidy was observed in 2 cases. Staining for the p53 product was positive in all cases. The average proliferating cell nuclear antigen (PCNA) labeling rate (LR) was 77.6% (64.0-90.8%). The estimated median survival was 42 days for all patients. Distant metastases were observed in 2 of the 4 patients.

CONCLUSIONS

Higher PCNA LR of small cell carcinoma may be an unfavorable characteristic of biological behavior. Patients with disseminated disease should have symptomatically palliative operation combined with chemotherapy.

Management of continuous anastomosis of pancreatic duct and jejunal mucosa after pancreaticoduodenectomy: historical study of 300 patients

BACKGROUND

Pancreaticojejunostomy is the most problematic anastomosis in the reconstruction after pancreaticoduodenectomy. In the past, much of the morbidity and mortality associated with this operation was related to problems with this anastomosis. Recent data, however, suggest that the use of duct-to-mucosa sutures has led to a marked drop in both morbidity and mortality associated with pancreaticojejunostomy.

METHODS

Among the 300 patients who underwent pancreaticoduodenectomy, including pylorus-preserving pancreaticoduodenectomy, 87 patients underwent traditional pancreaticojejunostomy by invagination of the end of the pancreas into the bowel (group B). Recently three-layer anastomosis was created in 213 patients. The outer layer was created between the pancreatic capsule and the serosa of jejunum. The middle layer was created between the pancreatic parenchyma and the seromuscular wall of jejunum. The inner layer was placed between the pancreatic duct and a small opening in the antimesenteric border of the jejunal mucosa. Among the 213 patients, the inner anastomosis was created with interrupted absorbable sutures (group A1) in 93 patients and continuous absorbable sutures (group A2) in 120 patients.

RESULTS

The three groups were similar with respect to age, gender, and primary disease. In the anastomosis, the incidence of leakage in group A2 (4.2%) was significantly less than in groups B (17.2%, p < 0.01) and A1 (11.8%, p < 0.05). The operative mortality rates were 3.2% in group A1, 1.7% in group A2, and 5.7% in group B.

CONCLUSIONS

We recommend continuous anastomosis of the pancreatic duct and jejunal mucosa as a safe procedure after pancreaticoduodenectomy.

Prognostic factors in resected hepatocellular carcinomas and therapeutic value of transcatheter arterial embolization for recurrences

The authors summarize the results of patients who had hepatectomy for hepatocellular carcinoma (HCC) over a 16-year period. Survival rates for 52 patients with HCC classified according to the Liver Cancer Study Group of Japan were calculated according to various clinicopathological variables. A univariable analysis revealed that alpha-fetoprotein > or =2000 ng/ml, portal involvement, tumor size > or =3.1 cm, and noncurative resection were associated with unfavorable outcomes, while neither the number of tumors nor underlying cirrhosis was associated with such outcomes. Furthermore, some of the patients with recurrence survived long after transcatheter arterial embolization (TAE) for recurrent tumors. Early detection as well as TAE for recurrent HCCs is necessary to improve long-term survival.

Primary leiomyosarcoma arising in the lesser sac: report of a case

We describe herein a very rare case of leiomyosarcoma arising in the lesser sac. A 58-year-old man with a psychiatric disorder was admitted to our department for the investigation of epigastralgia and nausea which he had been suffering since the previous month. A laparotomy revealed that the abdominal mass, found on physical examination, was a primary lesser omental tumor, histological examinations of which confirmed a diagnosis of leiomyosarcoma. The tumor cells showed a DNA diploid pattern. Leiomyosarcoma of the lesser sac is extremely unusual and it is important that it be distinguished from an extraluminal tumor of the abdomen.

Early diagnosis of mucosal squamous cell carcinoma of the esophagus: including two interesting cases of superficial spreading-type and multicentric-type squamous cell carcinomas

We reviewed 10 patients with esophageal mucosal carcinoma in order to improve the early diagnosis of the disease. Histologically seven of the 14 lesions were carcinomas in situ (epithelial cancer), and the other seven lesions were carcinomas confined to the mucosa other than epithelial cancer (muscularis mucosae cancer), all 14 lesions were squamous cell carcinomas (SCC). One of these seven mucosal SCC, which demonstrated an extensive spreading-type SCC in which the size of the SCC was 7 cm long while extending entirely around the esophageal lumen in circumferential spread, is described in detail, and multiple epithelial cancers existed separately in one case. Eleven lesions diagnosed before operation showed abnormal findings on conventional endoscopy regardless of the size and depth of transmural invasion. An additional lesion was visible with dye endoscopy as an unstained area, but it was not visible with radiography or conventional endoscopy. Dye endoscopy using Lugol solution is very important because it allows detection and evaluation of the extent of esophageal mucosal cancer.

Hepatocellular carcinoma presenting as extrahepatic mass on computed tomography

The authors describe an extremely rare case of extrahepatic hepatocellular carcinoma. The patient was a 70-year-old man who was examined by a local doctor because of abdominal discomfort. Barium meal examination demonstrated a defect occupying the lesser curvature of the stomach from the middle of the corpus to the fornix. On an abdominal computed tomography (CT) scan, the lesion, 10 cm in diameter, touched the lower surface of the caudate lobe of the liver. Under laparotomy, the tumor was found between the caudate lobe of the liver and posterior wall of the gastric corpus. As the tumor appeared to be connected with the caudate lobe by a pedicle, only the tumor was resected. Histological examination showed the tumor to be hepatocellular carcinoma of Edmondson's grade III-IV, pedunculated type.

Strangulation ileus resulting from encasement of a loop of the small intestine by the great omentum, caused by abnormal adhesion

We treated a patient with a mechanical ileus resulting from encasement of a loop of the small intestine by the great omentum, caused by abnormal adhesion. Apart from its occurrence postoperatively with laparotomy, strangulation of small intestine into the omentum is very rare, and its occurrence without underlying disease, except in children, has not been documented previously.

Prolapse of the small intestine through a ruptured vagina caused during sexual intercourse: report of a case

We report herein the rare case of a 56-year-old woman who suffered vaginal rupture into the peritoneal cavity during sexual intercourse, through which the small intestine prolapsed out from the vaginal opening. The patient had undergone abdominal hysterectomy 4 years earlier. An emergency laparotomy was performed which revealed rupture in the posterior fornix of the vagina and peritonium through which prolapse of the small intestine had occurred. The prolapsed intestine was pulled back into the pelvic cavity, and the vagina and peritonium were repaired. Macroscopically, the operative findings revealed no inflammatory changes or evidence of malignancy in the abdominal cavity. Thus, although rare, a ruptured vagina caused by sexual intercourse should also be considered in the field of surgery, even when a middle-aged woman presents with acute abdominal symptoms without a history of any other traumatic episode.

[A case of gastric cancer responding well to MTX/5-FU (methotrexate/5-fluorouracil) and PMUE (CDDP, MMC, UFT, etoposide) therapies upon lymphnode recurrence]

We encountered a case of non-curatively resected gastric cancer (p1, n4) who responded well to sequential MTX/5-FU therapy and PMUE therapy. A 63-year-old man was admitted to our hospital with complaints of nausea and vomiting. Upper gastrointestinal examination and CT scan revealed Borrmann type 3 gastric cancer with pyloric stenosis and multiple paraaortic lymphnodal metastasis. The patient underwent palliative gastrectomy for extensive gastric cancer (H0, P1, N4, T3, Stage IV b). Histological examination of the resected stomach revealed poorly differentiated adenocarcinoma with paraaortic lymphnodes metastasis (n4) and peritoneal dissemination (p1). Chemotherapy with sequential MTX/5-FU was given 13 times. Ten months after the operation, abdominal pain and back pain required analgesic treatment. Abdominal CT scan revealed increased size of paraaortic lymphnodes, suggesting recurrence. Sequential MTX/5-FU therapy was switched by PMUE therapy. Lymphnode size became smaller and habitual analgesics could be discontinued. Since then he was given MTX/5-FU and PMUE therapies alternately on an ambulant basis. The patient resumed his daily activities at 2 years and 8 months after the operation.

[A late phase II trial of l-leucovorin and 5-fluorouracil in advanced colorectal cancer. l-Leucovorin and 5-FU Study Group (Japan Western Group)]

A multicentral cooperative study was conducted to evaluate the clinical efficacy and toxicity of l-Leucovorin (l-LV) and 5-fluorouracil (5-FU) in advanced colorectal cancer. The administration schedule was a two-hour intravenous infusion of l-LV (250 mg/m2) and an intravenous bolus injection of 5-FU (600 mg/m2), given one hour after the beginning of the l-LV infusion. Sixty-four patients were treated weekly for six weeks followed by two-weeks rest, and then evaluated for response. Complete response and partial response were obtained in 21 patients (32.8%). The median survival time was 12.8 months. The most prominent side effects were anorexia (57.8%), nausea and vomiting (56.3%), diarrhea (48.4%) and myelosuppression such as leucopenia (54.7%), thrombocytopenia (18.8%) and decreased hemoglobin (40.6%). These side effects, however, were within permissible levels. Severe toxicity was prevented by discontinuance of the treatment. From the present study, l-LV and 5-FU combination therapy seems to be a very promising and useful treatment for patients with advanced colorectal carcinoma.

Hepatic resection using a water jet dissector

A newly-designed water jet dissector was used for hepatic resections in humans. To evaluate its usefulness, the water jet dissector was compared to an ultrasonic surgical aspirator in terms of average blood loss and time of operation. In hepatectomies on patients associated with liver cirrhosis, the average blood loss during hepatic resection using the water jet dissector was significantly smaller (P < 0.05) than that with the ultrasonic surgical aspirator. However, in hepatectomies on patients without cirrhosis, the average blood loss during hepatic resection did not significantly differ between the two groups. Neither did the time of operation significantly differ between the two procedures in hepatectomies on patients with and without liver cirrhosis. No serious complications attributable to the use of the water jet dissector were encountered. The water jet dissector is thus considered to be a useful new device for use in the transection of the liver during hepatic resections.

[A case of gastric cancer with multiple liver metastases effectively treated with PMUE (CDDP, MMC, UFT, etoposide) hepatic arterial chemotherapy]

A 62-year-old male patient with progressive gastric cancer and multiple liver metastases (H3, P0, ss gamma, n4) underwent total gastrectomy (R1). After 2 years and 2 months, he was re-hospitalized with epigastric tumor caused by re-manifestation of liver metastasis as well as inappetence. Since a large focus of liver metastasis and intraportal tumor embolism was identified, a continuous intraarterial infusion tube utilizing Infuse-A-Port was inserted in the hepatic artery. After conducting 2 cycles of PMUE intra-arterial chemotherapy, the tumor size was reduced by 84% (PR); and CEA, which had been high upon rehospitalization, recovered to the normal level. After discharge, the patient has been receiving 5-FU arterial infusion as an outpatient and undergoing UFT oral chemotherapy. The efficacy has continued and he has been well for 3 years since operation. Often operations for gastric cancer accompanied with multiple liver metastasis meet with little success, and almost no case of prolonged survival has been reported. In this case, the effectiveness of PMUE arterial infusion chemotherapy was clear, the patient has been well for 3 years since operation, and is an interesting example with seemingly good prospects for long-survival.