Treatment of Advanced Pancreatic Body and Tail Cancer by En Bloc Distal Pancreatectomy with Transverse Mesocolon Resection Using a Mesenteric Approach

BACKGROUND

Pancreatic body and tail cancer easily invades retroperitoneal tissue, including the transverse mesocolon. It is difficult to ensure a dissected peripancreatic margin with standard distal pancreatectomy for advanced pancreatic body and tail cancer. Thus, we developed a novel surgical procedure to ensure dissection of the peripancreatic margin. This involved performing dissection deeper than the fusion fascia of Toldt and further extensive en bloc resection of the root of the transverse mesocolon. We performed distal pancreatectomy with transverse mesocolon resection (DP-TCR) using a mesenteric approach and achieved good outcomes.

METHODS

There are two main considerations for surgical procedures using a mesenteric approach: 1) dissection deeper than the fusion fascia of Toldt (securing the vertical margin) and 2) modular resection of the pancreatic body and tail, with the root of the transverse mesocolon and adjacent organs in a horizontal direction (ensuring the caudal margin).

RESULTS

From 2017 to 2019, we performed DP-TCR using a mesenteric approach for six patients with advanced pancreatic body and tail cancer. Histopathological radical surgery was possible in all patients who underwent DP-TCR. No Clavien-Dindo grade IIIa or worse perioperative complications were observed in any patient.

CONCLUSIONS

We believe that DP-TCR is useful as a radical surgery for advanced pancreatic body and tail cancer with extrapancreatic invasion.

A case of nonfunctioning pancreatic endocrine tumor with atypical imaging findings due to prominent fibrosis of the tumor stroma

The patient, a 56-year-old woman, was found during routine checkup to have a disorder of hepatic function. Abdominal ultrasonography showed an ill-defined hypoechoic mass in the head and body of the pancreas; however, no blood-flow signal was observed within the tumor on Doppler ultrasonography. Abdominal computed tomography showed a low-density area in the arterial and portal venous phases. The lesion was visualized as an area of low signal intensity on both T1- and T2-weighted magnetic resonance images, whereas fluorodeoxyglucose positron emission tomography showed fluorodeoxyglucose accumulation in the tumor. Although a preoperative diagnosis was difficult to make, a rapid cytologic examination revealed evidence of a pancreatic endocrine tumor, and subtotal stomach-preserving pancreaticoduodenectomy with portal vein resection was performed. Histopathological examination showed tumor cell nests scattered in abundant fibrotic tissue; the tumor cells had proliferated in a cord-like fashion and showed immunostaining for chromogranin A. Staining for fibroblast activation protein α was seen in the fibroblastic cells contained within the fibrous stroma surrounding the tumor cell nests, whereas both the fibroblastic cells in the tumor and those in the stroma showed a high rate of staining for thrombospondin. We presume that tumor-associated fibroblasts were involved in the fibrosis of the tumor stroma.

The Frey procedure with the use of 2 types of ultrasonically activated scalpels for chronic pancreatitis: report of a case

A surgical procedure is the only way to relieve intractable pain in patients with chronic pancreatitis and an inflammatory mass in the pancreas head. Although the Frey procedure is safer and more effective for pain relief than is standard pancreaticodudenectomy, it is often associated with such complications as pancreatic fistula and postoperative hemorrhage. A 64-year-old man was admitted to our hospital because of increasingly frequent episodes of epigastralgia. This patient had continued to abuse alcohol until recently and was regularly using painkillers to relieve severe pain due to chronic pancreatitis. The patient underwent the Frey procedure with the use of 2 types of ultrasonically activated scalpel. There were no surgery-related complications. The patient was discharged 18 days after the operation. Neither recurrence of pain nor locoregional complications have been observed for 2 years after the procedure. Herein we report the use of the Frey procedure to treat an enlarged mass of the pancreatic head and discuss the efficacy of the ultrasonically activated scalpel for excavation of the pancreatic head and long dichotomy of the pancreatic duct.

Left posterior approach pancreaticoduodenectomy with total mesopancreas excision and circumferential lymphadenectomy around the superior mesenteric artery for pancreatic head carcinoma

BACKGROUND

In most cases of pancreatic head cancer, surgery often results in noncurative resection, which is frequently related to inadequate clearance of the mesopancreas.

PURPOSE

The aim of this report is to introduce the surgical technique of left posterior approach pancreaticoduodenectomy (PD) with total mesopancreas excision and circumferential lymphadenectomy around the superior mesenteric artery (SMA) (LPA-PD) and to examine whether this procedure increases the rate of true curative resection and decreases the rate of locoregional recurrence.

PATIENTS AND METHODS

Nineteen patients underwent standard PD, and 19 patients underwent LPA-PD. The demographic characteristics, intraoperative outcomes (mean operative time and mean blood loss), postoperative outcomes (complications, type of recurrence and survival), and pathological findings (R number, number of removed regional lymph nodes and positive resection margins) were evaluated.

RESULTS

The patient characteristics did not differ significantly between the groups. The mean blood loss in the LPA-PD group was significantly less than that in the standard PD group (p<0.05). The incidence rate of postoperative complications did not differ between the groups. No surgery-related deaths occurred in either group. The number of removed regional lymph nodes around the superior mesenteric artery in the LPA-PD group was significantly greater than that in the standard PD group (p<0.01). The R0 resection rate in the LPA-PD group was higher, although not significantly so, than that in the standard PD group. The resection margin of the mesopancreas was negative in all patients of the LPA-PD group. The rate of locoregional recurrence in the LPA-PD group was significantly lower than that in the standard PD group (p<0.01). The postoperative survival rate did not differ significantly between the groups.

CONCLUSION

Our method of LPA-PD helps secure the negative margin of the mesopancreas and enables complete circumferential lymphadenectomy around the SMA. Therefore, LPA-PD may increase the true curative resection rate and decrease the locoregional recurrence rate compared with standard PD.

Abstract 5145: Nestin as a novel angiogenic marker and target for anti-angiogenic therapy in human pancreatic cancer

Background: Tumor angiogenesis is an important factor in the proliferation and metastasis of pancreatic ductal adenocarcinoma (PDAC). CD34, CD31 and factor VIII-related antigen are commonly used as endothelial cell markers for tumor vessels. However, these markers identify not only newly formed small tumor vessels, but also pre-existing large blood vessels. Nestin, a class VI intermediate filament protein, has been reported to be up-regulated in endothelial cells accompanying the process of angiogenesis. In an acute pancreatitis murine model, we have previously reported that nestin is strongly expressed in proliferating endothelial cells. Furthermore, we have reported that nestin-positive blood vessels correlated with a poor prognosis in colorectal cancer. In this study, we examined the effectiveness of nestin as an angiogenic marker and potent target for anti-angiogenic therapy in PDAC. Methods: Tissues from 45 patients with PDAC were immunostained with nestin and other common vascular endothelial markers including CD34, CD31 and factor VIII-related antigen. We measured the number and dimension of the nestin- and CD34-positive blood vessels using image analyzing software. In addition, we compared proliferation activity between nestin- and CD34-positive vessels as determined by PCNA-labeling indices. To clarify the roles of nestin in endothelial cells, we transfected siRNA targeting nestin transcripts to mouse endothelial TKD2cells, and performed cell growth and migration assays. Results: Immunohistochemically, CD34, CD31 and factor VIII-related antigen were localized in blood vessels of all sizes, while nestin was localized only in the small blood vessels in PDAC tissues. Nestin was also expressed in myofibroblasts and nerve fibers, but not in lymphatic vessels. In image analyzing software, nestin-positive vessels were small in number, and they formed small lumen compare with CD34-positive blood vessels. Nestin-positive vessels showed higher PCNA-labeling indices than those of CD34-positive vessels. Nestin was expressed in small and proliferating blood vessels in PDAC tissues, suggesting that nestin plays important roles in tumor angiogenesis in cancer. Knock down of nestin in mouse endothelial cells using siRNA inhibited the cell growth, but not cell migration in vitro. Conclusion: Nestin was specifically expressed in small and proliferating blood vessels in pancreatic cancer tissues, indicating that nestin is a useful angiogenic marker in cancer. Furthermore, nestin may be a novel therapeutic target for inhibition of tumor angiogenesis in pancreatic cancer patients.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 5145. doi:10.1158/1538-7445.AM2011-5145

[Pancreaticoduodenal lymph node metastasis of neuroendocrine carcinoma of unknown primary associated with duodenal carcinoma]

A 73-year-old man was admitted with bloody stool. Duodenoscopy showed a hemorrhagic ulceration in the duodenum on the side opposite to the papilla of Vater. Abdominal CT demonstrated a well-defined hypervascular mass, adjacent to the lesion of the duodenum. Although as duodenal GIST was diagnosed, histologic examination for frozen sections during the procedure revealed tubular adenocarcinoma of the duodenum and pancreaticoduodenal lymph node metastasis of neuroendocrine carcinoma. He underwent a subtotal stomach-preserving pancreaticoduodenectomy. Clinicopathologically, the neuroendocrine carcinoma of the pancreaticoduodenal lymph node was considered to be metastasis from an unknown primary lesion.

Placement of percutaneous transhepatic biliary stent using a silicone drain with channels

This report describes a method for percutaneous transhepatic biliary stenting with a BLAKE Silicone Drain, and discusses the usefulness of placement of the drain connected to a J-VAC Suction Reservoir for the treatment of stenotic hepaticojejunostomy. Percutaneous transhepatic biliary drainage was performed under ultrasonographic guidance in a patient with stenotic hepaticojejunostomy after hepatectomy for hepatic hilum malignancy. The technique used was as follows. After dilatation of the drainage root, an 11-Fr tube with several side holes was passed through the stenosis of the hepaticojejunostomy. A 10-Fr BLAKE Silicone Drain is flexible, which precludes one-step insertion. One week after insertion of the 11-Fr tube, a 0.035-inch guidewire was inserted into the tube. After removal of the 11-Fr tube, the guidewire was put into the channel of a 10-Fr BLAKE Silicone Drain. The drain was inserted into the jejunal limb through the intrahepatic bile duct and was connected to a J-VAC Suction Reservoir. Low-pressure continued suction was applied. Patients can be discharged after insertion of the 10-Fr BLAKE Silicone Drain connected to the J-VAC Suction Reservoir. Placement of a percutaneous transhepatic biliary stent using a 10-Fr BLAKE Silicone Drain connected to a J-VAC Suction Reservoir is useful for the treatment of stenotic hepaticojejunostomy.

Experimental pancreatic cancer model using PGHAM-1 cells: characteristics and experimental therapeutic trials

We developed short-term pancreatic cancer models in hamsters using PGHAM-1 cells and examined the utility of the models for research on metastasis and for therapeutic trials. With 3 PGHAM-1 models, including 1) primary pancreatic cancer and simultaneous liver metastasis by intrapancreatic transplantation, 2) liver metastasis alone by intrasplenic transplantation, 3) peritoneal dissemination by intraperitoneal transplantation, within 21 days after inoculation, we studied the specific characteristics of metastases and the effects of several antiangiogenic substances on primary and metastatic pancreatic tumors. Several experiments showed that vascular endotherial growth factor and anatomical characteristics were important factors for metastasis. In therapeutic experiments, the incidence, size, diameter, microvessel density, and apoptotic index of the tumors were preferably influenced by the antiangiogenic substances. In addition, PGHAM-1-Luc, which is luciferase-positive PGHAM-1 cell line, was newly developed and is expected to be a useful new animal model. These models would be suitable for the study of pathogenesis of pancreatic cancer and its metastasis and for preclinical trials of chemotherapeutic agents, such as antiangiogenic substances.

Early surgical management for periampullary retroperitoneal perforation caused by endoscopic sphincterotomy: report of a case

A 67-year-old woman was admitted to our hospital for surgical management of cancer of the ascending colon. On admission, she had cholangitis due to choledocholithiasis. Abdominal computed tomography, ultrasonography, and magnetic resonance showed cholelithiasis, choledocholithiasis, and multiple liver tumors. Colonoscope showed advanced cancer of the ascending colon. Because of acute obstructive suppurative cholangitis, endoscopic sphincterotomy was performed. During the procedure, periampullary retroperitoneal perforation was identified on radiologic examination. Because computed tomography had shown extravasation of contrast medium and widespread pneumoretroperitoneum, an emergency operation was performed 2 hours after perforation. After cholecystectomy and choledocholithotomy had been performed and all bile duct stones had been removed, periampullary perforation was readily identified close to the duodenal diverticula and easily repaired. The postoperative course was uneventful. This patient could resume oral feeding soon after the operation, and colonic surgery could be performed immediately thereafter. Therefore, early surgical management is a possible first choice of treatment in patients with remaining biliary disease after periampullary perforation.

Multicentric pancreatic intraepithelial neoplasias (PanINs) presenting with the clinical features of chronic pancreatitis

A 46-year-old woman was readmitted to our hospital in August 2005 because of severe abdominal pain and nausea. Computed tomography demonstrated a huge cystic lesion in the retroperitoneal space behind the hepatoduodenal ligament and lesser peritoneal cavity. Endoscopic retrograde pancreatography revealed communication between the dilated main pancreatic duct and a pseudocyst. The condition was preoperatively diagnosed as chronic pancreatitis associated with a pseudocyst or an intraductal papillary mucinous neoplasm without mucin hypersecretion. The patient underwent a distal pancreatectomy with splenectomy. The pathologic diagnosis was multicentric pancreatic intraepithelial neoplasia (PanIN), and histological examination revealed a positive surgical margin around the remnant pancreas. Four months after the surgery, the patient underwent a total pancreatectomy. Macroscopic observation revealed diffuse fibrosis of the pancreatic parenchyma compatible with chronic pancreatitis. Histological examination revealed a constellation of noninvasive intraductal neoplasias with high-grade atypia, diffusely distributed in the small pancreatic ducts of the resected pancreas. Localized fibrosis and cystic dilation of the small ducts were detected in a lobule of exocrine glands draining into a ductule involved by PanIN lesions in the head of the pancreas. In summary, multicentric PanIN lesions are associated with lobular atrophy of the pancreatic parenchyma and chronic pancreatitis-like changes that follow. Total pancreatectomy may be recommended for patients with multicentric precursor lesions throughout the entire pancreas.

Efficacy of a Blake drainR on pancreatic fistula after pancreaticoduodenectomy

BACKGROUND/AIMS

The aim of this study was to evaluate the efficacy of the Blake drain for the management of pancreatic fistula (PF) in comparison with the Duple drain.

METHODOLOGY

Our study consisted of two parts: a retrospective review of 33 patients with PF after pancreaticoduodenectomy, and a basic experiment to investigate the effects of the Blake drain on the management of PF in an animal model.

RESULTS

In the clinical study, 19 patients received Blake drains (B-group) and 14 received Duple drains (D-group). Grade C fistulas with abdominal bleeding developed in only 2 patients in the B-group. All the patients in the B-group healed with conservative treatment (P<0.01). and none of them required percutaneous drainage or reoperation (P<0.05). In the basic experiment, no collections of fluid were detected around the Blake drains. When leakage occurred, it did not lead to abdominal abscess, and a "drain canal" formation linking the anastomosis with the extracorporeal orifice was demonstrated all along the drainage route.

CONCLUSIONS

Blake drains may be efficient therapeutic tools in patients with grade B fistulas. The basic experiment affirms that Blake drains provide excellent drainage and contribute to the formation of "drain canals" effective in localizing and controlling PF.

Improvement of intraoperative frozen section diagnosis in patients with biliary strictures by Levovist injection into the bile duct on color Doppler ultrasonography

BACKGROUND

This study evaluates the efficiency of color Doppler ultrasonography-guided intraoperative pancreatic biopsy (CDUS-IPB) using Levovist injected into the bile duct in conjunction with stimulated acoustic emission (SAE) in patients with biliary strictures.

METHODS

The study was performed on 12 patients. After completing a conventional intraoperative pancreatic biopsy (c-IPB), each subject underwent CDUS with SAE imaging using Levovist. Upon identification of the biliary stricture, the IPB was taken from the area surrounding the stricture on the same imaging setting. Section diagnosis of the CDUS-IPB specimen was compared to that of the c-IPB specimen and resected tissue.

RESULTS

Biliary strictures were identified as enhanced areas of color Doppler signal on CDUS. CDUS-IPB provided adequate specimens from the biliary strictures in all cases and corrected false-negative diagnoses by c-IPB in three cases. Section diagnosis by CDUS-IPB corresponded to the permanent section diagnosis. There were no complications.

CONCLUSIONS

CDUS-IPB with Levovist is an accurate diagnostic tool. The method is especially useful for patients with a suspected malignant biliary stricture who show no tumor mass in preoperative images and no evidence of malignancy on cytologic examinations.

Features and choice of treatment of acute and chronic pancreatic pseudocysts--with special reference to invasive intervention

AIMS

It was the aim of this study to characterize the features of acute and chronic pancreatic pseudocysts (PPs) and to identify the factors predictive of the need for invasive treatment.

METHODS

Thirty-six patients with PPs treated at Nippon Medical School between January 1995 and December 2004 were studied retrospectively. The cases were divided into 4 groups based on 4 features: association with acute pancreatitis, association with chronic pancreatitis, spontaneous resolution, and persistent symptoms requiring therapeutic intervention. Group 1 included 9 patients with acute PPs which resolved spontaneously. Group 2 included 9 patients with acute PPs with persistent symptoms or associated complications requiring interventional treatment. Group 3 included 9 patients with chronic PPs which resolved spontaneously, and group 4 included 9 patients with chronic PPs with persistent symptoms or associated complications requiring interventional treatment.

RESULTS

Among the 36 patients, 13 were women and 23 were men. The etiologies were pancreatitis due to alcoholism in 18 cases (50.0%), biliary tract disease in 8 cases (22.2%) and other conditions in 10 cases (27.8%). The average duration of follow-up was 24.2 +/- 18.5 months. The patients in group 1 were significantly older than those in group 2 (67.6 +/- 16.1 vs. 40.6 +/- 14.1 years; p = 0.011). The mean size of the PPs was significantly larger in groups 1 and 4 than in group 3 (p < 0.05) and significantly larger in group 2 than in group 4 (p < 0.05). There were no significant differences between groups 1 and 2 in the size of the PPs or in the Ranson score of previous pancreatitis. The increase in size of the PPs during follow-up in each of the spontaneously resolved groups (groups 1 and 3) differed significantly from that in each of the interventional treatment groups (groups 2 and 4; p < 0.05). The main cause of the acute pancreatitis in group 1 was biliary tract disease, while that in group 2 was alcoholism (significantly different, p < 0.05). The number of patients with symptoms related to pseudocysts at the time of diagnosis was significantly higher in group 1 than in group 3.

CONCLUSIONS

Growth of the PPs during follow-up is the strongest predictor of the need for invasive treatment in both acute and chronic cases. Among acute PPs, the size of the pseudocyst is not in itself a predictor of invasive treatment. Invasive treatment may pose higher risks for pseudocysts with an etiology of alcoholic acute pancreatitis. However, the size of the pseudocyst may be a more important prognostic factor than an etiology of pancreatitis. and IAP.

Adenoma of the minor papilla associated with pancreas divisum

Tumors of the minor papilla of the duodenum are quite rare. We report the first documented case of an adenoma of the minor papilla complicating pancreas divisum. A 52-year-old woman was admitted to our hospital for treatment of an asymptomatic duodenal tumor detected by computed tomography scan. Endoscopy showed an 18-mm, whitish-colored, sessile mass located in the descending duodenum proximal to a normal appearing major papilla. Endoscopic retrograde pancreatography revealed divisum of the pancreas with dilatation of pancreatic duct ranged in the dorsal pancreas. Transduodenal minor papillectomy was performed because there is malignant potential of the tumor and the possibility of acute pancreatitis. The Santorini orifice was then re-approximated to the duodenal wall for protection against acute pancreatitis caused by scarring and stenosis of the duct orifice as a possible late complication. The patient's postoperative course was uneventful and she has been asymptomatic without evidence of tumor recurrence or stenosis of the Santorini orifice on endoscopic examination for the last 4 years.

Preventing liver metastasis by resecting the primary pancreatic carcinoma at an early stage of intrapancreatic transplantation in hamsters

PURPOSE

To determine whether early primary pancreatic tumor resection can prevent liver metastases of intrapancreatic transplantation in a hamster model.

METHODS

Cells from the PGHAM-1 cell line were transplanted into the pancreases of 30 Syrian golden hamsters. A suspension of 5 x 10(6) cells was injected into the splenic lobe of each pancreas. The primary pancreatic tumor was resected in 15 of the hamsters 10 days after transplantation (resection group). Fifteen other animals with transplantation but without resection served as controls (control group). All hamsters were killed 21 days after transplantation. The primary pancreatic tumors were measured for size and volume and examined histologically and immunohistologically for angiogenesis and tumor proliferation.

RESULTS

In the resection group, small pancreatic tumors 4.7 +/- 0.94 mm in diameter were found and resected 10 days after transplantation. Neither pancreatic tumors nor liver metastases were found in the resection group at the end of the experiment. All animals in the control group had pancreatic tumors 12.3 +/- 3.29 mm in size, and 11 of 15 (73.3%) had liver metastases. The primary pancreatic tumors in the group with liver metastasis were significantly larger in diameter and volume than those in this group without liver metastasis (p<0.01). In the control group, proliferation of the primary pancreatic tumor, evaluated according to argyrophilic nucleolar organizer region, showed no differences within the pancreatic tumor group. On the other hand, the microvessel density of pancreatic tumors with liver metastases was significantly higher than that of tumors without liver metastases.

CONCLUSIONS

Our results suggest that 10 days after transplantation, the pancreatic tumors were small in size and volume and ready to proliferate but not yet ready to begin metastasizing through angiogenesis. This is one reason why early resection of the primary tumor prevents liver metastasis.

Malignant afferent loop obstruction following pancreaticoduodenectomy: report of two cases

We report two cases of malignant afferent loop obstruction following pancreaticoduodenectomy (PD). Case 1. A 70-year-old woman, who had undergone PD for pancreatic cancer, was referred to our hospital because of fever, jaundice, and abdominal pain. Ultrasonography and abdominal computed tomography demonstrated dilatation of a small bowel loop in the right upper quadrant. Laparotomy confirmed the diagnosis of local recurrent tumor causing occlusion of the afferent limb, and Roux-en-Y bypass was performed. Case 2. A 72-year-old man, who had undergone PD for cancer of the major papilla, was hospitalized with a high-grade fever and epigastric pain. Ultrasonography and abdominal computed tomography revealed a dilated afferent loop and multiple masses in liver. At laparotomy, widespread carcinomatosis was found to have caused afferent loop obstruction, and surgical bypass was performed. In conclusion, the surgical bypass seems to be an effective palliative treatment for afferent loop syndrome after PD.

Malignant afferent loop obstruction following pancreaticoduodenectomy: report of two cases

We report two cases of malignant afferent loop obstruction following pancreaticoduodenectomy (PD). Case 1. A 70-year-old woman, who had undergone PD for pancreatic cancer, was referred to our hospital because of fever, jaundice, and abdominal pain. Ultrasonography and abdominal computed tomography demonstrated dilatation of a small bowel loop in the right upper quadrant. Laparotomy confirmed the diagnosis of local recurrent tumor causing occlusion of the afferent limb, and Roux-en-Y bypass was performed. Case 2. A 72-year-old man, who had undergone PD for cancer of the major papilla, was hospitalized with a high-grade fever and epigastric pain. Ultrasonography and abdominal computed tomography revealed a dilated afferent loop and multiple masses in liver. At laparotomy, widespread carcinomatosis was found to have caused afferent loop obstruction, and surgical bypass was performed. In conclusion, the surgical bypass seems to be an effective palliative treatment for afferent loop syndrome after PD.

Clinicopathologic study on pancreatic groove carcinoma

OBJECTIVES

Pancreatic groove carcinoma usually presents with duodenal stenosis. This report describes the clinicopathologic features of 5 cases.

METHODS

All the clinical and radiological features were reviewed retrospectively and analyzed to identify correlations with the histological findings.

RESULTS

Vomiting was an initial symptom in all cases, but obstructive jaundice was not inevitable until the disease progresses. Hypotonic duodenography demonstrated severe postbulbar stenosis. Pathological findings of biopsy specimens showed no evidence of malignancy at the early stage. Computed tomography revealed a hypovascular mass. Magnetic resonance imaging indicated a hypointense mass on T1-weighted images and an isointense to slightly hyperintense mass on T2 images. Macroscopically, the stenosis seemed to be the result of a hard yellowish-white tumor invading the duodenal wall. Histopathologically, an adenocarcinoma arising from the groove infiltrated the submucosal layer of the duodenum circumferentially. No cancer cells were found in the mucosa at the early stage. The intrapancreatic common bile duct was involved at the advanced stage.

CONCLUSIONS

We believe that these features resulted from the anatomical characteristics of the groove involvement and that the string stricture of the duodenum resulted from invasion of the groove tumor into the submucosal layer around the wall.

Incidental gallbladder cancer diagnosed during and after laparoscopic cholecystectomy

With the increasingly widespread acceptance of laparoscopic cholecystectomy (LC), the number of cases of incidental gallbladder carcinoma (GBC) has increased; however, management of incidental GBC is a difficult issue in the absence of established guidelines. The present study aims to evaluate the treatment of patients with incidental GBC diagnosed with LC. We performed a 14-year review of 10 patients with GBC discovered with LC. From April 1991 through March 2004, we performed LC for 1,195 patients at Nippon Medical School Main Hospital. Of these patients, 10 (0.83%) were found to have GBC. Seven patients were women and 3 were men, with a mean age of 61.4 years. Four patients had mucosal tumors (pT1a), 5 had subserosal tumors (pT2), and 1 had a serosal lesion (pT3). Eight of the 10 patients underwent radical surgery. Two patients with pT1a tumors underwent no additional surgery. All 4 patients with pT1a tumors are alive without recurrence. One patient with a pT2 tumor with metastases to the liver and pericholedochal lymph nodes found with additional resection died of recurrence of metastasis to the liver and lung 70 months after LC. One patient with a pT2 tumor died of primary lung cancer 35 months after LC. The remaining 3 patients with pT2 tumors are alive without recurrence 51 to 128 months after surgery. One patient with a pT3 tumor is alive with no recurrence for 9 months. For stage Tis or T1a tumors, LC is sufficient. Patients with T1b tumors should undergo liver-bed resection and lymphadenectomy, and patients with >pT2 tumors should undergo systematic liver resection with lymphadenectomy. Even when incidental GBC diagnosed with LC is advanced, adequate additional surgery may improve the prognosis.

Fracture of an expandable metallic stent placed for biliary obstruction due to common bile duct carcinoma

We report our second case of fracture of a SMART self-expandable metallic stent (Cordis Endovascular, Warren, NJ) placed to treat biliary obstruction due to an unresectable common bile duct carcinoma. An 82-year-old man presented with jaundice. Computed tomography and ultrasonography on admission demonstrated a mass in the lower common bile duct. The mass was identified as a common bile duct obstruction. A SMART stent was inserted. Ten months after stent insertion, two additional SMART stents were inserted to relieve obstructive jaundice due to occlusion of the first stent. Fourteen months after insertion of the first stent, endoscopic examination revealed stenosis of the duodenum due to invasion of the common bile duct carcinoma, prompting us to perform a gastrojejunostomy 1 month later. Three months after gastrojejunostomy, the patient presented with obstructive jaundice and cholangitis. A fracture of one of the stents was then discovered on plain X-ray films and percutaneous transhepatic cholangiography. Two SMART stents were inserted simultaneously. In conclusion, we report the fracture of a SMART stent placed for common bile duct carcinoma. Fracture should be considered as a possible complication after metallic stent insertion.

Autoimmune pancreatitis associated with idiopathic retroperitoneal fibrosis: a case report

A 69-year-old man presented with obstructive jaundice and dark urine. Contrast-enhanced computed tomography revealed an enlarged pancreas with homogenous enhancement. Endoscopic retrograde pancreatography demonstrated short-segmental, irregular narrowing of the main pancreatic duct. The patient underwent exploratory laparotomy and needle biopsies of the pancreas, which showed marked fibrotic change with lymphocyte infiltration. These clinicopathologic findings suggested autoimmune pancreatitis. Four years later, computed tomography demonstrated marked periaortic soft tissue surrounding a calcified infrarenal abdominal aorta compatible with retroperitoneal fibrosis. We diagnosed retroperitoneal fibrosis with noncontiguous pancreatic fibrosis. This patient responded well to corticosteroid treatment. Autoimmune pancreatitis associated with idiopathic retroperitoneal fibrosis seems to be extremely rare, and to our knowledge, only a few cases have been reported.

One-step palliative treatment method for obstructive jaundice caused by unresectable malignancies by percutaneous transhepatic insertion of an expandable metallic stent

AIM: To describe a simple one-step method involving percutaneous transhepatic insertion of an expandable metal stent (EMS) used in the treatment of obstructive jaundice caused by unresectable malignancies.

METHODS: Fourteen patients diagnosed with obstructive jaundice due to unresectable malignancies were included in the study. The malignancies in these patients were a result of very advanced carcinoma or old age. Percutaneous transhepatic cholangiography was performed under ultrasonographic guidance. After a catheter with an inner metallic guide was advanced into the duodenum, an EMS was placed in the common bile duct, between a point 1 cm beyond the papilla of Vater and the entrance to the hepatic hilum. In cases where it was difficult to span the distance using just a single EMS, an additional stent was positioned. A drainage catheter was left in place to act as a hemostat. The catheter was removed after resolution of cholestasis and stent patency was confirmed 2 or 3 d post-procedure.

RESULTS: One-step insertion of the EMS was achieved in all patients with a procedure mean time of 24.4 min. Out of the patients who required 2 EMS, 4 needed a procedure time exceeding 30 min. The mean time for removal of the catheter post-procedure was 2.3 d. All patients died of malignancy with a mean follow-up time of 7.8 mo. No stent-related complication or stent obstruction was encountered.

CONCLUSIONS: One-step percutaneous transhepatic insertion of EMS is a simple procedure for resolving biliary obstruction and can effectively improve the patient’s quality of life.

Pancreatic Arteriovenous Malformation Involving Adjacent Duodenum with Gastrointestinal Bleeding: Report of a Case

A 54-year-old man was admitted to our hospital with the symptoms of palpitation, dyspnea, and tarry stool. Upper gastroduodenal endoscopy revealed submucosal lesions with vascular ectasia in the second part of the duodenum. Dynamic computed tomography (CT) detected a hypervascular lesion in the pancreatic head and the duodenum. Selective angiography showed proliferation of a vascular network and early filling of the portal vein at the early arterial phase. With a diagnosis of pancreatic arteriovenous malformation (AVM), we performed pylorus-preserving pancreaticoduodenectomy. At laparotomy, localized and meandering vessels were seen on the surface of the head of the pancreas. Histological examination showed dilated tortuous vessels accompanied by severed elastic fibers in the vessel media and blood clot formation. The incidence of pancreatic AVM remains extremely low, and recurrent gastrointestinal bleeding is a frequent complication. To prevent recurrent bleeding and progressive portal hypertension, surgery may be the definitive management of symptomatic AVM.

Changes to levels of serum neuron-specific enolase in a patient with small cell carcinoma of the pancreas

Small cell carcinoma (SCC) of the pancreas is a rare disease, with an extremely poor prognosis; only 24 cases have been reported in the literature. However, as some patients have been successfully treated with combination chemotherapy, it is important to obtain both a definite diagnosis and a precise evaluation of the effect of the treatment. A 69-year-old woman presented with an abdominal tumor and pain. She had been observed for sensory neuropathy and swelling of the pancreatic head by the referring doctor over the previous 9 months. The patient was diagnosed with SCC of the pancreas after surgery and had two courses of combination chemotherapy (cisplatin and etoposide). Initially, the tumor disappeared completely on computed tomography (CT) scans, but she died of disease recurrence 3 months after completing the chemotherapy. Changes in serum neuron-specific enolase (NSE) levels were monitored constantly during the progress of the disease. NSE levels had already increased above the upper limit of normal 8 months before the patient's admission to our hospital, and levels changed concurrently not only with tumor growth but also subsequently with remission and then relapse of the disease after treatment. These results indicate that NSE is a good marker, both as a diagnostic indicator for SCC of the pancreas and as a means of evaluating response to treatment.

Re-expression of reduced VEGF activity in liver metastases of experimental pancreatic cancer

PURPOSE

Vascular endothelial growth factor (VEGF) is thought to play a crucial role in the process of cancer growth and metastasis. In this study, the expression of VEGF in liver metastases of pancreatic cancer was investigated using an established hamster model.

METHODS

Pancreatic cancer cells (PGHAM-1, 1 x 10(6)) derived from N-nitrosobis (2-oxopropyl) amine (BOP)-induced pancreatic tumors in Syrian golden hamsters were transplanted into the pancreas of female hamsters. All hamsters were sacrificed at 21 days after transplantation and used for the histopathological examination of pancreatic and metastatic lesions (primary transplantation model). The metastatic liver tumors were minced with scissors and 1 mm(3) tumors were retransplanted into the pancreas of a second hamster. All hamsters were sacrificed 21 days after retransplantation, and the pancreatic tumors were removed (back transplantation model). Immunohistochemical analyses using antibody against VEGF were performed for all pancreatic and liver tumors. Reverse transcription-polymerase chain reaction (RT-PCR) was performed to examine the expression of VEGF mRNA in the tumors. In addition, we investigated the proliferation of each tumor using Ag-NOR staining.

RESULTS

In the primary transplantation models, VEGF expression in the pancreatic tumors was positive, but that in the liver metastases was only weakly positive or negative. On the other hand, VEGF expression in the pancreatic tumors that had developed from the retransplantation of the liver tumors (back transplantation model) was strongly positive. VEGF mRNA was expressed in the pancreatic tumors of both primary and back transplantation models. In the metastatic liver tumors of the primary transplantation model, VEGF mRNA was expressed in all cases, although the immunohistochemical staining pattern was weakly positive or negative. Similarly, in the metastatic liver tumor of the back transplantation model, VEGF mRNA was expressed in all cases, although the immunohistochemical staining pattern was weakly positive or negative. No significant differences in Ag-NOR scores were found between the models.

CONCLUSION

Our results suggest that VEGF expression usually occurs in PGHAM-1 cells but that VEGF expression is reduced during the process of liver metastasis and revived by retransplantation. Thus, the interrelationship between cancer cells and the organ environment might play an important role in VEGF expression.

Tumor marker measurements of cells in a fine needle used for aspiration cytology

OBJECTIVE

To investigate whether the needle washing could yield sufficient cells for tumor marker (TM) measurements as an ancillary technique to ensure the accuracy of fine needle aspiration cytology (FNAC) of tumors.

STUDY DESIGN

After obtaining preliminary data that aspirated tumor cells within a 22-gauge needle could be collected by washing it with distilled water for TM measurements, we studied tumor cell numbers and TM values obtained by washing a 22-gauge needle directly after tumor aspiration and another needle after FNAC.

RESULTS

Using 8 resected hepatobiliary and pancreatic carcinomas, the used needles yielded 16.8+/-10.5 x 10(4) cells per milliliter. Used needles from 6 adenocarcinomas expelled 479.2+/-406.5 ng/mL of carcinoembryonic antigen, and 6,561.3+/-5,713.1 ng/mL of CA 19-9, while the needles from 2 hepatomas showed normal values of those markers.

CONCLUSION

A needle used for FNAC contains sufficient cells for TM measurements, which can be ancillary to the differential diagnosis.

Relationship between grade of fibrosis in pancreatic stump and postoperative pancreatic exocrine activity after pancreaticoduodenectomy: with special reference to insufficiency of pancreaticointestinal anastomosis

BACKGROUND

Pancreaticoduodenectomy (PD) has become a standard operation for malignant and benign periampullary diseases. Although the operative mortality of PD has decreased to less than 4% in hospitals with many cases of PD, the leakage of pancreaticointestinal anastomosis (PIA) still carries a substantial risk of lethal outcome. The aim of this study was to evaluate the local factors that affect the incidence of PIA leakage by evaluation of exocrine function and fibrosis in the pancreatic remnant following PD.

METHOD

Twenty-eight patients (17 pancreatic disease, 8 bile duct cancers and 3 ampullary cancers) underwent PD with complete extracorporeal pancreatic juice drainage. The cut-end of the pancreatic remnant was histologically studied for its grade of fibrosis in comparison with the exocrine activity of the pancreatic remnant (EAPR) calculated by the value of the product of volume of drained pancreatic juice and its amylase activity. The influences of those factors and other clinicopathologic data on PIA outcome were evaluated.

RESULTS

The histological grade of fibrosis in the pancreatic stump was inversely correlated with EAPR (rs=0.5848, p=0.0011). Three patients had major leakages and 6 had minor leakages of PIA; all the patients with leakages had biliary or ampullary diseases, but not pancreatic diseases. The incidence of leakage of PIA was significantly higher in the patients with high values of EAPR (p<0.05). None with EAPR less than 10(7) had PIA leakage. The incidence of PIA leakage in low-grade fibrosis of the pancreatic stump was significantly higher than that in high-grade fibrosis (p<0.05). Other clinicopathologic data did not influence the incidence of leakage of PIA.

CONCLUSIONS

The degree of fibrosis in the pancreatic stump is significantly related to the EAPR and affects the development of PIA insufficiency as a local factor.

Anti-tumor effect of N-[3,4-dimethoxycinnamoyl]-anthranilic acid (tranilast) on experimental pancreatic cancer

The anti-tumor effect of N- [3,4-dimethoxycinnamoyl] -anthranilic acid (tranilast) was examined in experimental pancreatic cancer. Proliferation of PGHAM-1 cells was inhibited by tranilast in a dose-dependent manner, showing a significant difference at a concentration of 25 microgram/ml (p<0.05). In colony formation, tranilast reduced the number of colonies at a concentration of 25 microgram/ml (p<0.01). DNA synthesis for 12 hours was attenuated dose-dependently and a significant difference was observed at concentrations of greater than 50 microgram/ml (p<0.05). From cell cycle analysis, a dose-dependent increase in the distribution of G0-G1 phase was observed. In the dorsal air sac model, the mean angiogenesis indices in PGHAM-1 chambers were 4.17 +/- 0.22 (control group) and 2.33 +/- 0.84 (treatment group), and in VEGF chambers they were 3.60 +/- 0.67 (control group) and 1.92 +/- 0.42 (treatment group), In the peritoneal dissemination model, the quantity of sanguineous ascites, the number and the size of diaphragmatic nodules and the microvessel density (MVD) of the metastatic site were reduced by tranilast significantly. In conclusion, the anti-tumor effect of tranilast on proliferation and on tumor-angiogenesis was confirmed in experimental pancreatic cancer.

Alteration in membrane fluidity of rat liver microsomes and of liposomes by protoporphyrin and its anti-lipidperoxidative effect

The effect of protoporphyrin (PP) on membrane fluidity was investigated by electron paramagnetic resonance spectroscopy using doxyl stearate spin probes in relation to the anti-lipidperoxidative effect of PP. PP decreased the membrane fluidity in rat liver microsomes at concentrations above 1 mM and also in phosphatidylcholine (PC)-cholesterol (Cho) (100:8, a molar basis) liposomes. The lipid peroxidation stimulated by Fe2+ and L-ascorbic acid in those membrane preparations was attenuated along with the decrease in membrane fluidity by PP. Similar results were also found in Cho-rich PC (100:30 to 100) liposomes having less fluidity. These results suggest that the decrease in the membrane fluidity caused by PP may be involved in the antioxidative action of PP.

Circadian variation of hepatic glutathione S-transferase activities in the mouse

1. The circadian variation in glutathione S-transferase (GST) activity was studied in the hepatic cytosolic fraction of the male and female mouse. A circadian variation in GST activity towards 1-chloro-2,4-dinitrobenzene (CDNB) was observed in the male, the activity being higher in the light phase (07:00-19:00 h) than in the dark phase (19:00-07:00 h) during a day under normal lighting conditions. 2. The circadian variation was only existed from June to October. The difference between the lowest activity (at 01:00 h) and the highest activity (at 13:00 h) was maximum in August. 3. In both the normal and reversed light/dark cycle (lights on 07:00 and 19:00 h, respectively), reduced glutathione (GSH) content was lowest in the middle of the light period and highest in the middle of the dark period and GST activity toward 1,2-epoxy-3-(p-nitrophenoxy)propane (EPNP) exhibited opposite peaks and troughs. GST activities toward CDNB and 1,2-dichloro-4-nitrobenzene (DCNB) during the normal lighting schedule was higher at 13:00 h than at 01:00 h, but no differences were observed under reversed lighting conditions. 4. A circadian variation in GST activity for CDNB and DCNB was also observed in the female in a similar manner to the male, but the variation in the activity for EPNP was not observed in the female. 5. Thus, the circadian variation of hepatic GST activities in mouse were dependent on the enzyme substrates used, and seemed to be reflected by the difference in each isozyme levels. The daily change in the hepatic GSH levels is also thought involved, at least in part, in the regulation of GST activity.

Hydroxyl radical scavenging activity of nonsteroidal anti-inflammatory drugs

The hydroxyl radical (.OH)-scavenging activity of d-2-[4-(3-methyl-2-thienyl)phenyl]propionic acid (M-5011), a novel nonsteroidal anti-inflammatory drug (NSAID), and that of several other NSAIDs were investigated by the hyaluronic acid (HA) degradation method and the electron spin resonance (ESR) spin-trapping technique. The superoxide anion (.O2-)-scavenging activity of M-5011 was also measured by the ESR technique. (1) M-5011 and the other NSAIDs examined inhibited the degradation of HA induced by the Fenton reaction system in a dose-dependent manner. (2) M-5011 and the other NSAIDs scavenged .OH directly in a dose-dependent manner. (3) M-5011 was the most potent drug among the NSAIDs tested regarding the scavenging activity of .OH as follows; M-5011 > indomethacin > ketoprofen = suprofen > aspirin. The .OH-scavenging activity of M-5011 was potent in comparison with that of oxidized glutathione (GSSG), an endogenous .OH scavenger. (4) M-5011 did not scavenge .O2-; nor did GSSG. These results suggest that M-5011 acts as a scavenger of .OH at sites with inflammatory lesions.

Resistance of hepatic lysosomes, mitochondria and microsomes of protoporphyrin-administered rats to peroxidative damage

Antioxidative inhibition by protoporphyrin (PP) of peroxidative damage in lysosomes, mitochondria and microsomes of rat liver was investigated at 24 h after an intravenous administration of PP. Using a lysosome-containing (3500 x g) fraction, the release of lysosomal marker enzymes, acid phosphatase and aryl sulfatase, from lysosome which had been stimulated by L-ascorbic acid (AsA), was decreased dose-dependently, as was the inhibition of lipid peroxidation by PP in the fraction. Swelling of mitochondria induced by Fe2+ and AsA was also inhibited in the PP-injected rat. In microsomes, lipid peroxidation stimulated by AsA caused a decrease in activity of a microsomal marker enzyme, glucose 6-phosphatase, and in P450 content. The extent of the decrease by AsA, both in activity and content, was diminished in PP-administered rat liver microsomes. These results indicate that PP protects those subcellular fractions from deterioration by lipid peroxidation.

Involvement of pituitary hormone in the sex-related regulation of hepatic epoxide hydrolase activity in mice

The involvement of the pituitary gland in the expression of sex-related differences in the activities of epoxide hydrolase (EH) in liver was examined in hypophysectomized and neonatally monosodium L-glutamate (MSG)-treated male and female mice. In hypophysectomized mice, the hepatic microsomal EH activity of males and females increased considerably above those of the respective sham-operated controls, and the female activity exceeded that of the sham-operated males. The hypophysectomy caused a decrease in soluble EH activity in males, while the operation led to an elevation of the activity in females. Neonatal treatment with MSG resulted in marked increases of microsomal EH activity in males and females at adulthood and the activity was about 2 times that of the male control mice. Treatment of hypophysectomized males and females with growth hormone (GH) resulted in a significant decrease in microsomal EH activity below those of the corresponding hypophysectomized controls, while the hormone treatment had no effect on the soluble enzyme activities. These results suggest that murine hepatic microsomal EH activity is principally under the suppressive control of the pituitary and GH is a causal hormone involved in the expression of sexual dimorphism in the enzyme activity.

[Antioxidative effect of mammalian liver hydrolyzate on lipid peroxidation]

The antioxidative effect of the mammalian liver hydrolyzate preparation (LH) was investigated mainly in the mouse liver homogenates. At lower concentrations, LH stimulated lipid peroxidation induced by Fe2+ and ascorbic acid in the homogenates, but inhibited completely the oxidation at higher concentrations. LH also inhibited the peroxidation of linolenic acid and linoleic acid. LH reduced 1,1-diphenyl-2-picrylhydrazyl, a free radical model, in a concentration-dependent manner, suggesting that the radical scavenging property of LH is involved in its antioxidative action. Fe2+ and glutathione, contained in LH, seem to act as a stimulator and an inhibitor of peroxidation, respectively.

Sex hormone-related control of hepatic epoxide hydrolase activities in mice

Sex-related differences in hepatic epoxide hydrolase (EH) activities towards 7-(2',3'-epoxy)propoxycoumarin (7-glycidoxycoumarin, GOC) were investigated, mainly in mice but also in rats. Hepatic subcellular EH activities in the ddY mouse were higher in microsomes than in the soluble and mitochondrial fractions and sex-related differences were noted in all the subcellular fractions where males had significantly higher activities than females. Sex differences in the hepatic microsomal and soluble activities similar to those in the ddY strain were also observed in two other strains of mice, A/J and C3H/He, and in Wistar rats. In the ddY strain, castration of the males caused decreases in microsomal and soluble EH activities, while no alteration in the activities in those fractions was found following castration of females. Treatment of the male castrates with testosterone led to recovery of the activities in microsomal and soluble fractions while hormone treatment of female castrates caused a rise only in microsomal activity. Estradiol treatments of both sexes did not cause any changes in the hepatic subcellular activities. In intact ddY mice, testosterone treatment did not affect the male microsomal and soluble EH activities, but resulted in stimulation of both subcellular enzyme activities in females. In contrast, estradiol treatment showed a suppressive effect on both subcellular activities in males, but had no effect on female activities. These results show that hepatic EH activities towards GOC are mainly under androgenic stimulatory control in mice.