Surgical management of endocrine tumor of the pancreas in Japan

Endocrine tumor of the pancreas is potentially malignant. A multicenter analysis of these tumors was conducted to clarity the present status of their surgical management and the subsequent long-term surgical results. The Japan pancreatoduodenectomy (JPD) study group carried out the study; 368 patients were enrolled and variables related to tumor characteristics, surgery, and survival were retrospectively analyzed. There were 222 patients with functioning tumor and 143 patients with nonfunctioning tumor. Malignant tumor was found in 140 of 368 (38%) of the patients, and 63/140 (45%) of these patients had metastatic lesion; the most common site of the metastasis was liver 34/136 (25%), followed by regional lymph nodes 26/136 (19%). Pancreatic resection was performed in 91% of patients with nonfunctional tumor and in 83% of those with malignant tumor, and 73% of the pancreatic resections were done with lymph node dissection. The overall 5-year actuarial survival rate was 76% in patients with malignant tumor. The actuarial 5-year survival rate was 93% in the patients without metastasis and 83% in patients who received curative resection. Multivariate analysis showed that the presence or absence of synchronous metastasis was the sole significant prognostic factor. The results suggest that: (i) malignant endocrine tumor of the pancreas is a curable malignancy when pancreatic resection with lymph node dissection is adopted and (ii) that synchronous metastasis is the dominant prognostic factor. This study was carried out as a group project. The authors' institutions are as follows     

NEW METHOD OF STENTING TREATMENT FOR MALIGNANT DUODENAL STENOSIS: USING DOUBLE‐BALLOON ENTEROSCOPY

Recently, a self‐expandable metallic stent has been recognized for treatment of malignant duodenal stenosis. But the complications by stenting are important problems even now. In the present study, we report our new method of duodenal stenting by using of double‐balloon enteroscopy considered safe and effective.     

Clinical experience of biliary tract carcinoma associated with anomalous union of the pancreaticobiliary ductal system

Between 1978 and 1988, 15 patients with gallbladder cancer and 2 patients with bile duct cancer were seen among 49 patients with anomalous union of the pancreaticobiliary ductal system. Radiographic findings revealed two types of this anomalous condition: one in which the pancreatic duct entered the common bile duct (type 1) and one in which the common bile duct entered the pancreatic duct (type 2). In gallbladder cancer, the common bile duct presented no dilatation, or in some patients, mild dilatation, and type-1 anomalous union was frequently found among these patients. In contrast, the two patients with bile duct cancer had cystic dilatation of the common bile duct and type-2 anomalous union. The bile amylase level, which was determined in seven patients, was extremely high in all the patients. Histopathologically, the tumors in most patients showed papillary to papillo-tubular proliferation in the mucosal layer while atypical epithelial hyperplasia was noted in the vicinity of the tumor area. These findings suggest that this congenital anomaly in both ducts results in a loss of the normal sphincteric mechanism of the duodenal papilla, and that chronic relapsing cholecystitis or cholangitis, caused by the reflux of pancreatic juice into the biliary tract, can induced progressive changes to atypical epithelial hyperplasia which may develop into carcinoma.     

A case of serous cystadenoma of the pancreas with focal malignant changes

Summary We present a serous cystadenoma of the pancreas with focal malignant changes, and describe its characteristic histological features. On gross examination, a tumor was present on the anterior surface of the body of the pancreas and measured approx 25×25⋻20, mm. Microscopically, most tumor cells showed the typical histological features of serous cystadenoma, characterized by a microcystic architecture and glycogenrich cells with a uniform and bland appearance. However, in some areas, a tendency to papillary structures with fibrovascular cores was noted. These papillary lesions were composed mainly of nonmucinous, glycogen-poor epithelial cells, the nuclei of which showed a mild atypia. In addition, vascular and perivascular invasion was focally observed. However, there was no clinical evidence of local or distant metastasis. From these findings, we diagnosed this lesion as a serous cystadenoma of the pancreas with focal malignant changes rather than a serous cystadenocarcinoma of the pancreas.     

Immunohistological studies of fibrous pseudotumor of the testicular tunica vaginalis

A fibrous pseudotumor of the testis from a 46-year-old man was examined histologically and immunohistochemically. The tumor, situated in the tunica vaginalis, appeared as multiple round nodules up to 2 cm in diameter, and was composed largely of fibrous tissue with scanty inflammatory cell infiltration. Besides mesothelial cells covering part of the tumor, foci of piled-up cells were found among the fibrous tumor tissue. The cells in the foci were spindle and polygonal in shape, and contained oval nuclei. Immunohistochemically, these cells were positive for vimentin and keratin, but negative for CEA. Similar features have been found in pleural mesothelioma, supporting the concept that testicular fibrous pseudotumor could represent neoplastic growth of the mesothelium of the tunica vaginalis.     

Suppressive effects of E3330, a novel quinone derivative,on tumor necrosis factor-α generation from monocytes and macrophages

E3330 {(2E)-3-[5-(2,3-dimethoxy-6-methyl-1,4-benzoquinoyl)]-2-nonly-2-propenoic acid}, a novel synthesized hepatoprotective compound, has suppressive effects on tumor necrosis factor- (TNF-) generation from monocytes/macrophagesin vitro. E3330 (1–100 M) reduced lipopolysaccharide (LPS, 10 mg/ml or 1g/ml)-induced TNF- generation from rat resident andPropionibacterium acnes (P. acnes)-elicited peritoneal macrophages, rat and human monocytes, rat Kupffer cells, and splenic mononuclear cells in a concentration-dependent manner. E3330 also (1–100 M) suppressed TNF- generation stimulated with egg-albumin immune complex in ratP. acnes-elicited peritoneal macrophages. Northern blot analysis showed that LPS-induced expression of TNF- messenger RNA (mRNA) in human blood monocytes was suppressed by E3330. These findings indicate that E3330 has a suppressive effect on TNF- generation from monocytes/macrophages, regardless of origin or species, and this effect is based in part on the suppression of TNF- mRNA expression.     

QT interval and QT dispersion in eating disorders

BACKGROUND: Eating disorders are thought to be risk factors for cardiac sudden death secondary to arrhythmia. Results in previous studies on QT interval and QT dispersion, markers of fatal arrhythmia, have been inconsistent. METHODS: We prospectively examined 179 female eating disorder patients, being over 18 years old and diagnosed according to the DSM-IV criteria between January 1995 and December 2002, and 52 healthy women. Patients with abnormal plasma electrolytes or taking medications that might influence the electrocardiogram (ECG) were excluded from the study. QT intervals were corrected for heart rate using Bazett's formula and the nomogram method, which is more reliable at extremely low heart rates than Bazett's formula. QT dispersion was measured as the difference between the longest and shortest QT intervals. QT intervals and QT dispersion in each patient group were compared with those in the control group. RESULTS: The 164 eligible patients consisted of 43 patients with anorexia nervosa restricting type, 35 with anorexia nervosa binge eating/purging type, 63 with bulimia nervosa purging type, and 23 with bulimia nervosa non-purging type. There was no significant difference in age between eating disorder patients and controls. QT interval and QT dispersion were significantly longer in all eating disorder subtypes than in the control group. QT interval and QT dispersion were significantly correlated with the rate of body weight loss in bulimia nervosa. CONCLUSIONS: QT interval and QT dispersion were prolonged in both anorexia nervosa and bulimia nervosa. Examination of ECG in eating disorder patients without extremely low body weight also appears to be clinically important.     

Expression of pancreatic trypsinogen in human extrapancreatic gastrointestinal carcinomas

Pancreatic trypsinogen expression in 149 surgically resected extrapancreatic gastrointestinal neoplasms was evaluated immunohistochemically. Immunohistochemistry was performed using a monoclonal antibody against human pancreatic trypsinogen. Pancreatic trypsinogen expression was detected in 28 of 55 gastric carcinomas (50.9%), 22 of 44 colorectal cancers (50%), 12 of 20 gallbladder cancers (60%), nine of 10 extrahepatic bile duct cancers (90%), and none of 20 hepatocellular carcinomas. The intensity of immunoreactivity in the tumor area varied from specimen to specimen, and from area to area within the same specimen. In most cases, however, immunoreactivity was more pronounced at the infiltrative margin of the tumor. Additionally, the highly differentiated carcinoma cells tended to display a focal, fine granular immunoreactive pattern, usually present in the supranuclear cytoplasm, while the poorly differentiated carcinoma cells displayed a fine granular pattern, usually present over the entire cytoplasm. These findings suggest that some extrapancreatic gastrointestinal neoplasms express pancreatic trypsinogen immunoreactive peptides, raising the possibility that secreted pancreatic trypsinogen plays a role in carcinoma invasion and metastasis, as has been shown for other classes of proteases.     

Surgical-management of carcinoma of the middle and distal bile-duct

Forty patients underwent surgical resection for cancer of the middle and distal bile duct. Nineteen patients underwent a curative resection with 3- and 5-year survival rates of 63% and 48%, respectively. None of the patients who underwent a palliative resection survived two years. The factor most strongly associated with recurrence was the presence of tumor in the surgical margin. Recurrence was frequent in patients with disease in the middle portion of the bile duct who underwent extrahepatic biliary resection with choledochojejunostomy, while lower bile duct cancer was associated with peri-aortic or retroperitoneal recurrence. Pancreatoduodenectomy, with combined resection of the portal vein in middle bile duct cancer, regional lymphadenectomy, including peri-aortic lymph nodes and nerve plexus is required for curative resection of middle and distal biliary carcinoma beyond the early noninvasive stage.     

Spreading patterns of hilar bile duct cancer

Spreading patterns of hilar bile duct cancer were investigated based on cases resected in our institution and reported cases in Japan. Forty-seven patients underwent resection in our institution during the past 20 years. Three patients(12%) survived for more than 5 years. The depth of tumor invasion was m or fm in 4 and se or si in 26 patients. Positive cancer invasion in the cut end was classified as hm2 or dm2 in 8 patients and em2 in 13. Twenty-four (60%) of 40 patients investigated histologically had positive lymph node metastases. Invasion of the ss layer or deeper perineural invasion occurred in 92.5%. In terms of direct invasion of the liver, hinf1 occurred in 20(42.6%). Fourteen(29.8%) han invasion of the portal vein(more than vs1). Patients with invasion of the hepatic artery were not resected. The 5-year survival rate by cancer stage was 38% in stage I, 20% in stage II, 16% in stage III, and 0% in stage IV. Surgery was assessed as Cur A in 19 patients (46.3%), Cur B in 7 (17.1%), and Cur C in 15 (36.6%). In Cur A patients the 5-year survival rate was 18%, while that for our Cur B and Cur C patients was 0%. Our patient series was more advanced in terms of cancer stage than the statistical Japanese series and both included a significant number of noncurative cases. Hepatic resection of the right or left lobe, medial segment, and S4a and S5, combined resection of the caudal lobe, and combined portal vein resection are important as radical surgery in the treatment of this cancer.