Fatal case of pancreatic panniculitis caused by occult neuroendocrine tumor in the corresponding organ: A case report and review of the published work

Pancreatic panniculitis (PP) is a rare clinical variant of subcutaneous fat necrosis, developing in patients with a variety of pancreatic diseases such as acute or chronic pancreatitis, tumors and cysts. The tumor-associated PP represents a noteworthy skin manifestation of underlying internal malignancies, also known as dermadrome. Among causative pancreatic tumors, acinar cell carcinoma is the most frequent malignancy; however, little is known about how the origin of tumor cells and progression stage of pancreatic tumors potentially contribute to the establishment of panniculitis. Here, we present a 69-year-old Japanese male case of clinically aggressive PP on the bilateral legs, whose skin lesions developed prior to the diagnosis of occult pancreatic tumor and liver metastasis. Moreover, the immunopathology of the pancreatic lesion revealed neuroendocrine tumor (NET), a rare pathological variant. Skin lesions immediately spread to the upper limbs with extensive ulcerations and necrosis, accompanied by high levels of serum lipase and elastase, but not with other pancreatic enzymes. He died 2 months after the initial development of the skin lesion due to rapid deterioration of general condition. We reviewed 14 cases, including ours, of PP with NET in the pancreas thus far reported, to identify the clinicopathological characteristics regarding to what extent this rare complication could reflect the clinical course of pancreatic tumors and overall prognosis. Our published work review found that the disease has a significant male predominance (male : female, 13:1) and cases with occult pancreatic tumors died within 4 months after the development of their skin lesions. Our case was the poorest prognostic outcome. This report emphasizes that dermatologists should recognize PP with NET, reflecting a fatal prognosis, and to make a prompt diagnosis.

Grading of Atrophic Gastritis is Useful for Risk Stratification in Endoscopic Screening for Gastric Cancer

OBJECTIVES

In order to screen for gastric cancer effectively, its interval should be set according to the risk. This study aimed to determine whether risk stratification is possible using the data obtained from medical examination or endoscopic findings.

METHODS

First, subjects who underwent both cancer screening and medical examination from 2009 to 2015 and underwent cancer screening once more by 2016 were studied. Data such as the lipid profile and history of smoking obtained during the medical examination, and the grade of atrophy and presence of peptic ulcers were studied using multivariate analysis. Next, subjects who underwent cancer screening twice or more between 2009 and 2015 with or without medical examinations were studied to analyze any correlation between the grade of atrophy and cancer occurrence using univariate analysis. In both studies, the status of Helicobacter pylori (HP) infection was determined.

RESULTS

In the multivariate analysis, 9378 subjects were included. Aging, advanced atrophy, presence of ulcers, and uric acid levels were identified as risk factors. Among subjects who underwent successful HP eradication therapy, advanced atrophy and aging were observed to be crucial risk factors. In the univariate analysis, there were 12,941 subjects. Gastric cancer occurred more frequently in the more severe atrophy group (P < 0.001). The annual rate of cancer occurrence in the most severe atrophy group was 0.31%, which was approximately thrice as that in the less atrophy group.

CONCLUSIONS

Risk stratification was possible based on endoscopic examination alone. The interval should be set depending on each case.

A case of diaphragmatic hernia following colonoscopy

An 89-year-old woman with a history of traumatic injury was referred to our hospital for further evaluation of anemia. Two days after colonoscopy, she complained of intermittent abdominal pain. An abdominal computed tomography confirmed a left diaphragmatic defect with a herniated transverse colon. She underwent elective laparoscopic repair of the diaphragmatic hernia. Colonoscopy rarely causes or worsens a diaphragmatic hernia. This is a rare case where we observed the development and exacerbation of a diaphragmatic hernia. It is important to pay attention to the development of a diaphragmatic hernia after colonoscopy for patients with a history of traumatic injury.

[Rupture of a pancreaticoduodenal artery aneurysm into the common bile duct secondary to chronic pancreatitis: a case report]

A 57-year-old man with a history of excessive drinking presented to our emergency department complaining of chest discomfort. He had been attending a clinic for diabetes mellitus and hypertension, at which he had been informed that he had anemia that was worsening. Computed tomography (CT) of the abdomen revealed hemobilia and chronic pancreatitis. Due to complicated cholangitis, endoscopic nasobiliary drainage was performed, and a contrast-enhanced abdominal CT scan showed a pancreaticoduodenal aneurysm close to the common bile duct. We diagnosed a ruptured pancreaticoduodenal artery aneurysm causing hemobilia, and performed selective transcatheter arterial embolization with intravascular microcoils. Complete occlusion of the aneurysm was confirmed on follow-up CT.

[Multiple gastrointestinal stromal tumors during nilotinib treatment for chronic myelogenous leukemia in a patient with neurofibromatosis type 1]

A 60-year-old woman with neurofibromatosis type 1 presented to our hospital with melena. She reported a 1-year history of treatment with nilotinib hydrochloride hydrate for chronic myelogenous leukemia. Contrast-enhanced abdominal computed tomography revealed multiple intestinal tumors that were subsequently diagnosed as gastrointestinal stromal tumors (GIST) using single-balloon enteroscopy. Although the tumors showed no significant change over 1 year, partial jejunal resection was performed to confirm the diagnosis. Immunohistochemically, the tumors were GIST.

13C-UBT using an infrared spectrometer for detection of Helicobacter pylori and for monitoring the effects of lansoprazole

The stable isotope [13C]-labeled urea breath test (13C-UBT) is very useful for detecting Helicobacter pylori. Conventionally, a mass spectrometer is used to measure the presence of 13CO2 in breath. However, this technique is complex and expensive. Therefore, we carried out the 13C-UBT using an easy-to-operate infrared spectrometer, and we studied its usefulness. The 95 subjects included 35 patients with gastric ulcers, 32 with duodenal ulcers, 13 with gastroduodenal ulcers, some patients with nonulcer gastroduodenal disease, and normal controls. The 13C-UBT was negative in normal controls and positive in 86 of 91 (95%) patients with illness. Peaks appeared 15 to 30 min after [13C]urea administration. The 33 patients who were 13C-UBT-positive were then given lansoprazole 30 mg/day and the 13C-UBT was repeated after 8 to 16 weeks. Lansoprazole was found to be effective in patients who exhibited peak 13CO2 values that were at least two-thirds less than the pretreatment values. This effect was seen in 16 patients (48%), 13 of whom (81%) had gastric ulcers. Thirteen of the 17 patients (76%) who exhibited no effect had duodenal ulcers, and there were clear treatment response differences between the two types of ulcers.

[Clinical course of patients with hepatocellular carcinoma after surgical resection, with emphasis on the occurrence of hepatic failure]

Postoperative course including serial changes in values of liver function tests and occurrence of hepatic failure was investigated in 59 patients with hepatocellular carcinoma. Eleven cases out of 59 patients were associated with chronic hepatitis (CH group), while remained 48 cases were with liver cirrhosis (25 cases of group A and 23 of group B in Child's classification). There was no significant difference in survival rate or recurrence rate after operation among these three groups. Hepatic failure within one year after hepatectomy was observed in 9%, 28% and 91% of patients in groups CH, Child's A and Child's B, respectively, and the frequency of occurrence of hepatic failure in Child's B group was significantly higher than those of groups CH and Child's A. Hepaplastin test and serum albumin levels recovered from the decline after hepatectomy in groups CH and Child's A. On the other hand, no recovery was found in Child's B group as well as lower levels before operation and that was thought to be the major reason for the frequent occurrence of hepatic failure in Child's B group.

[An assessment of therapeutic effect of hepatocellular carcinoma by the serial changes in serum AFP value]

The therapeutic effect of hepatocellular carcinoma (HCC) was assessed by the serial change of serum AFP value before and after treatment. Subjects were 56 therapies for HCCs in 48 cases, who were diagnosed as inoperative HCCs, and were performed chemotherapy, transcatheter hepatic arterial embolization (TAE) and percutaneous ethanol injection therapy (PEIT). As the indicator of therapeutic effect, the angle (supplement) alpha was used, that was formed by the cross of two lines based on several points of serum AFP value on the hemilogarithm graph before and after treatment respectively. The alpha were distributed from -34 degrees to 118 degrees, and its mean value was 32 +/- 38 degrees (+/-SD). The angle alpha value of cases evaluated as CR or PR was high, and that of PD was low. We could quantitatively assess the effects evaluated as NC by tumor size. The survival curve of group with high alpha value was significantly longer than that of group with low value. It was concluded that this method using angle alpha based on the serial change of serum AFP value was useful for clinical assessment of HCCs treatment.

[A case with hepatocellular carcinoma with complete remission due to gamma-IFN therapy]

A 65-year-old male was admitted to our hospital with the aim of closer examination of SOL in cirrhotic liver. By abdominal echography, CT and angiography etc., he was diagnosed as LC with multiple HCC, one in S5 about 2.0 cm, another in S1 about 5.0 cm in diameter, and other four small nodules in right lobe. We treated him with recombinant gamma-IFN at dose of 1.6 X 10(7) units/day for 5 consecutive days biweekly. Although until two months the tumours were gradually enlarged in size, then they became smaller, and at five months later after the beginning of gamma-IFN therapy the tumor stains in angiogram disappeared. Then we performed the surgical treatment. Both macro and microscopical findings of tumor specimens in S5, 2. 2 X 2.0 X 1.9 cm in size, showed complete necrotic tissue. Additionally the yellowish small tumor was found on surface of S8, and it was adenomatous hyperplasia histologically.

[Serodiagnosis: tumor marker]

The researches of tumor markers started at the discovery of Bence Jones protein in 1848. Now, alpha-fetoprotein and carcinoembryonic antigen are popular tumor markers and recently several tumor markers using the methods of monoclonal antibodies have been invented. Usually we measure the tumor markers in sera, so the early diagnosis of cancer by the tumor markers are sometimes difficult. For the early diagnosis by tumor markers, inventions of new tumor markers, improvement of assay systems and materials and the combination assays of several tumor markers have been tried. The researches of tumor markers are progressing with those of cancer. We hope we will be able to diagnose early cancer or precancerous state by tumor markers.

Factors affecting serum levels of CA 19-9 with special reference to benign hepatobiliary and pancreatic diseases

In order to elucidate the factors affecting the serum levels of CA 19-9, we analyzed sera of 79 patients with pancreatic cancer and 169 with non-malignant diseases, chiefly consisting of hepatobiliary and pancreatic diseases. Serum CA 19-9 values in patients with pancreatic cancer had no relation to the location of the tumor or presence of jaundice. Similarly, no tendency was observed as to the location and size of tumor or to the grade of differentiation in 12 CA 19-9-negative patients with pancreatic cancer. Serum levels of CA 19-9 in patients with cholelithiasis complicated by cholangitis frequently showed markedly high values, but then rapidly normalized in parallel with the subsiding of inflammation. The behaviour of serum CA 19-9 showed little relation to renal or hepatic failures or to intrahepatic cholestasis. However, slightly elevated levels of the antigen were found in more than half of those patients with fulminant hepatitis showing massive necrosis. In chronic pancreatitis, the prevalence was only 8%; however, an increase was observed at the time of exacerbation in 2 of 5 positive patients. There was hardly any increase in serum levels of CA 19-9 after endoscopic retrograde cholangiopancreatography (ERCP), although serum levels of pancreatic enzymes rose after ERCP in almost all patients. Thus, it appears that CA 19-9 does not easily escape into the bloodstream, unlike pancreatic enzymes.

[Evaluation of the measurement of serum carcinoembryonic antigen (CEA) levels using monoclonal antibody]

We measured serum carcinoembryonic antigen (CEA) levels in 164 cancer patients, 153 patients with benign diseases and 45 healthy controls using monoclonal antibody and compared CEA levels by monoclonal antibody (m-CEA) with those by polyclonal antibody (p-CEA). There was a good correlation between m-CEA and p-CEA, especially in cancer patients. The positively of m-CEA was almost the same as that of p-CEA in cancer patients. But, false-positive cases by m-CEA were less common than by p-CEA in non-cancerous patients. Thus, the measurement of m-CEA was not less useful than that of p-CEA.

[Novel gamma-GTP isoenzyme and hepatocellular carcinoma]

The authors discussed the clinical significance and some properties of the novel gamma-GTP isoenzyme (novel gamma-GTP) which was reported to be specific for sera of hepatocellular carcinoma (HCC) in our previous publications. One or more of specific bands (novel gamma-GTP) such as bands II, II' and I' were electrophoretically detectable in 109 (55%) of 200 patients with HCC, but only in 3% of 279 patients with other hepatobiliary diseases. Novel gamma-GTP was found in 38% of HCC patients with AFP levels below 400 ng/ml. The incidence of novel gamma-GTP was independent of the clinical stage as classified by liver scanning. Even in stage I, where filling defects were not seen, the incidence was 52%. It is concluded that novel gamma-GTP is useful in diagnosis of HCC patients with low levels of AFP or at a relatively early stage. Some properties of gamma-GTP purified from HCC tissues were investigated and compared with those of the normal kidney enzyme. The enzymes from HCC and kidney were identical in enzymatic and immunological properties, whereas a considerable difference was observed in electrophoresis, Con A affinity, effect of neuraminidase and isoelectric point. Respective bands II, II' and I' could be differentiated in Con A affinity and neuraminidase reaction. These results support the possibility that novel gamma-GTP in sera of HCC patients is largely due to a difference in carbohydrate moiety of gamma-GTPs.

[Evaluation of CA 19-9 radioimmunoassay]

A carbohydrate antigenic determinant (CA 19-9) which monoclonal antibody (1116 NS-19-9) recognizes was found by Koprowski et al in 1979. Recently DelVillano et al have developed a forward sandwich radioimmunoassay (RIA) for quantitative measurement of CA 19-9. This CA 19-9 RIA Kit (CENTOCOR) was examined both experimentally and clinically. In the basic study, the standard curve obtained from this assay showed liniality, and the reproducibility of Intra-assay and Inter-assay was good. In the clinical study, using 37 U/ml as the reference value, the CA 19-9 RIA provided excellent sensitivity for pancreatic cancer (84%) and cancer of the biliary tract (69%), and excellent specificity, even among patients with benign gastrointestinal disorders. Moreover, CA 19-9 was suggested to be useful for monitoring of pancreatic cancer. Thus, the data indicate that CA 19-9 RIA can be a useful tumor marker for pancreatic cancer.

[A new tumor marker--novel gamma-GTP isoenzyme]

The authors discussed the clinical significance and some properties of the novel gamma-GTP isoenzyme (novel gamma-GTP) which was reported to be specific for sera of hepatocellular carcinoma (HCC) in our previous publications. One or more of specific bands (novel gamma-GTP) such as bands II, II' and I' were electrophoretically detectable in 109 (55%) of 200 patients with HCC, but only in 3% of 279 patients with other hepatobiliary diseases. Novel gamma-GTP was found in 38% of HCC patients with AFP levels below 400 ng/ml. The incidence of novel gamma-GTP was independent of the clinical stage as classified by liver scanning. Even in stage I, where filling defects were not seen, the incidence was 52%. It is concluded that novel gamma-GTP is useful in diagnosis of HCC patients with low levels of AFP or at a relatively early stage. Some properties of gamma-GTP purified from HCC tissues were investigated and compared with those of the normal kidney enzyme. The enzymes from HCC and kidney were identical in enzymatic and immunological properties, whereas a considerable difference was observed in electrophoresis, Con A affinity, effect of neuraminidase and isoelectric point. Respective bands II, II' and I' could be differentiated in Con A affinity and neuraminidase reaction. These results support the possibility that novel gamma-GTP in sera of HCC patients is largely due to a difference in carbohydrate moiety of gamma-GTPs.

[Tumor markers of hepatocellular carcinoma with special reference to diagnostic efficacy of combination of these markers and relation to its stages]

The authors concurrently determined four markers consisting of novel gamma-GTP isoenzyme (Novel gamma-GTP), variant alkaline phosphatase (VAALP), basic fetoprotein (BFP) and CEA in addition to AFP in 144 patients having HCC. Serum AFP levels below 400ng/ml, a condition commonly seen in sera of hepatobiliary diseases other than HCC were obtained in 60 our of patients, or 42%. There was little correlation among positivities of these markers, and the diagnostic usefulness was increased by combination assay of these markers, except in the case of CEA. Specific diagnosis of HCC could be made in 78% by a combination of Novel gamma-GTP and VAALP in addition to AFP. Moreover, diagnosis of an existing malignancy could be made in 87% by BFP in addition to AFP, Novel gamma-GTP and VAALP. Positive ratios of BFP and CEA increased in proportion to staging, whereas those of AFP and Novel gamma-GTP were independent of the stage and relatively high even in patients within the early stage. In general, incidences of these markers were relatively lower in patients having small HCC, however, markers of a secreting type such as AFP and Novel gamma-GTP were relatively useful for early diagnosis of HCC.