Endosonographic evaluation of c-kit-positive gastrointestinal stromal tumor

BACKGROUND

Endosonographic features of c-kit-positive gastrointestinal stromal tumors (GISTs) were compared with those of leiomyomas and schwannomas.

METHODS

Twenty-four patients with gastric mesenchymal tumors who underwent endoscopic ultrasonography (EUS) and surgical treatment were enrolled. GISTs were defined as c-kit (CD117)-positive tumors, leiomyomas as desmin-positive and c-kit-negative tumors, and schwannomas as S-100-positive and c-kit-negative tumors. Invasion to adjacent organs or more than 20 mitotic counts per 50 high power fields indicated malignancy.

RESULTS

There were 19 GISTs, three leiomyomas, and two schwannomas. All five malignant tumors were GISTs. A marginal halo was found in 12 of 19 GISTs and in both of the schwannomas, but not in any of the three leiomyomas. The echogenicities of GISTs were low but higher than that of the normal proper muscle layer, whereas those of leiomyomas and schwannomas were usually low. Lobulation of the tumor surface was documented only in GISTs, particularly in malignant ones. The tumor doubling time of a malignant GIST was 9.3 months, and that of six benign GISTs was 18.7 months (range = 10.7-28.0 months).

CONCLUSION

Marginal halo and relatively higher echogenicity on EUS might suggest GIST. Marginal lobulation and a short doubling time may be signs of a malignant GIST.

Visualizing the gastric wall with a 30-MHz ultrasonic miniprobe: ex vivo imaging of normal gastric sites and sites of early gastric cancer

BACKGROUND

This study was performed to determine the echo layer structures of the normal gastric wall and early gastric cancer when visualized with a 30-MHz ultrasonic miniprobe.

METHODS

Twelve surgically resected gastric specimens were used for an ex vivo study. Eighteen normal sites and 12 early gastric cancer sites were scanned with an Olympus (XUM-S30-25R) probe with a frequency of 30-MHz. Endoscopic ultrasound images were compared with corresponding histopathologic sections stained with hematoxylin and eosin.

RESULTS

The normal mucosa was visualized as at least four alternating echo layers; the muscularis mucosa was delineated at all normal sites. Lymphoid aggregates within the mucosa could be seen. The submucosa was clearly visualized in most cases, but the muscularis propria and subserosa were seldom depicted due to attenuation of ultrasound waves. At the sites of gastric cancer, the layered architecture of the mucosa was disturbed by an irregular hypoechoic lesion. Minimal submucosal infiltration (400 and 750 micrometer) was clearly depicted in two cases, without ulceration at or around the tumor site. However, attenuation at the site of a deep ulcer scar prevented adequate visualization of the tumor extent in two other cases with ulceration.

CONCLUSION

A 30-MHz ultrasonic miniprobe may provide additional imaging information of the gastric wall and could play a role in the assessment of early cancer lesions.

Effect of herbal medicine keishi-to (TJ-45) and its components on rat pancreatic acinar cell injuries in vivo and in vitro

BACKGROUND

In an attempt to clarify the mechanism of the effect of a herbal medicine, Saiko-keishi-to (TJ-10), which is a combination of Keishi-to (TJ-45) and Sho-saiko-to (TJ-9), we investigated the effects of these two herbal medicines and their components on pancreatic acinar cell injury models in vivo and in vitro.

METHODS

Four-week-old male WBN/Kob rats were fed an MB-3 pellet diet containing herbal medicine (TJ-9, TJ-10 and TJ-45). Expressions of pancreatitis-associated protein (PAP) and manganese superoxide dismutase (Mn-SOD) were analyzed with a reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. The herbal medicines and two of their components, Keihi (Cinnamomi cortex) and Shakuyaku (Paeoniae radix alba), were tested in vitro using an arginine-treated rat pancreatic acinar AR4-2J cell injury model. The inducible nitric oxide synthase (iNOS) was assayed in in vitro experiments.

RESULTS

TJ-45-treated WBN/Kob rats showed no evidence of pancreatitis whereas there were pathological changes of chronic pancreatitis in TJ-9-treated WBN/Kob rats. PAP was not expressed and Mn-SOD expression was increased in the TJ-10-, and TJ-45-treated rats. The herbal medicines and two components suppressed PAP mRNA expression and enhanced Mn-SOD and iNOS mRNA expression in arginine-treated AR4-2J cells.

CONCLUSION

These results suggest that the herbal medicine TJ-45 is effective for chronic pancreatitis caused by pancreatic ischemia.

Pancreatitis-associated protein levels in pancreatic juice from patients with pancreatic diseases

BACKGROUND

Pancreatitis-associated protein (PAP), the acute-phase protein of the pancreas, is overexpressed in acute pancreatitis. Serum PAP levels were reported to be useful as an indicator of the severity, prognosis and healing of acute pancreatitis. Although PAP was originally identified in pancreatic juice, there has been no clinical report on PAP levels in pancreatic juice. This study was conducted to determine levels of PAP in pancreatic juice (PJ-PAP) in various human pancreatic diseases.

METHODS

PAP levels in endoscopically aspirated PJ were measured by enzyme-linked immunosorbent assay in 86 patients with pancreatic diseases.

RESULTS

55% of 22 patients with pancreatic cancer (PC) and 25% of 49 patients with chronic pancreatitis (CP) were positive (> 350 ng/ml) for PJ-PAP. PJ-PAP levels were significantly higher in PC than in CP, in which PJ-PAP was also significantly higher than in 15 control subjects. There was no significant correlation between PJ-PAP and serum PAP, and combination assay of serum PAP and/or PJ-PAP detected 80% of PC cases and 44% of CP cases.

CONCLUSIONS

We have demonstrated that human PAP could be detected in pancreatic juice from patients with pancreatic diseases. Determination of PAP in pancreatic juice might be helpful for early detection of pancreatic injury.

EUS and ERCP features of nonalcoholic duct-destructive, mass-forming pancreatitis before and after treatment with prednisolone

Nonalcoholic, duct-destructive, mass-forming pancreatitis in a 28-year-old man was presented with endoscopic ultrasonographic (EUS) and endoscopic retrograde cholangiopancreatographic (ERCP) findings before and after corticoid therapy. Because this disease is often mistaken for a malignant tumor, EUS combined with ERCP may provide imaging characteristics useful for differentiation from malignant tumor, for early diagnosis, and for monitoring therapeutic effects.

Myxedema accompanied by huge portal-systemic shunt without portal hypertension

A 43-year-old woman with a huge portal-systemic shunt accompanied by myxedema showed slow speech and behavior. Several imaging studies revealed a bold portal-systemic shunt from the splenic vein to the left renal vein. In addition, hypothyroidism caused by chronic thyroiditis was diagnosed, and synthesized thyroxine replacement was effective for the symptoms. However, the serum ammonia and indocyanin green retention remained in the abnormal range, nevertheless the portal vein pressure was normal and findings of liver cirrohsis were not recognized histologically. Surgical shunt closure was performed, resulting in normalized serum ammonia levels and serum branched chain amino acids /aromatic amino acids ratio, and improvement of the ammonia tolerance test.

Usefulness of supernatant of pancreatic juice for genetic analysis of K-ras in diagnosis of pancreatic carcinoma

AIMS

To ascertain whether analysis of K-ras mutations at codon 12 (KRM) in the supernatant of pure pancreatic juice (PPJ) is more useful for the diagnosis of pancreatic carcinoma (PCa) than that in sediment, the authors analyzed KRM in DNA extract from not only the sediment but also the supernatant of PPJ and compared the results.

METHODOLOGY

PPJ was collected endoscopically from 19 patients with PCa and 25 patients with chronic pancreatitis (CP). DNA was extracted from the supernatant and the sediment of PPJ. Mutant allele-specific amplification (MASA) was performed for KRM analysis with the DNA extracts from these samples.

RESULTS

The incidence of KRM in the supernatant of PPJ was 89% (17 of 19) in patients with PCa and 28% (7 of 25) in patients with CP, whereas that in the sediment was 79% (15 of 19) in patients with PCa and 20% (5 of 25) in patients with CP. Although there was no significant difference in KRM incidence between supernatant and sediment, the positive rate of KRM was higher in the former. Additionally, with regard to the PCa cases, KRM were found in the supernatant alone in four cases and in the sediment alone in two cases. Consequently, by a combination assay, all of the patients with PCa showed KRM in either the supernatant or sediment of PPJ. Although there was no relation between the incidence of KRM in PPJ and the location and size of tumor, and clinical stage of carcinoma in the patients with PCa, two patients with clinical stage I disease showed KRM in the supernatant.

CONCLUSION

These results suggest that the positive rate of KRM in the supernatant is not lower than that in the sediment, and simultaneous analysis of KRM in the supernatant and sediment of PPJ enhances the genetic diagnosis of PCa.

Complete regression of colonic adenomas after treatment with sulindac in Gardner's syndrome: a 4-year follow-up

A 22-year-old woman with Gardner's syndrome in whom long-term sulindac therapy, without surgical treatment, was effective in inducing complete regression of colonic adenomas is reported. One hundred milligrams of sulindac was administered twice daily after endoscopic polypectomy. Follow-up colonoscopy 6 months later revealed an encouraging regression of colonic adenomas. The tumors had disappeared after 40 months of sulindac treatment. A sustained effect was identified even after 51 months. Ten milligrams of famotidine was coadministered to prevent side effects of sulindac. Although the effect of sulindac on colorectal adenomas may be transient, this therapy may be useful for postponing prophylactic colectomy, especially for the sparse type of familial adenomatous polyposis.

P8 expression is induced in acinar cells during chronic pancreatitis

The p8 gene is barely expressed in the normal pancreas, but is overexpressed in acute pancreatitis. To elucidate the dynamic expression of p8 mRNA and its significance in the course of chronic pancreatitis, we investigated the p8 expression in spontaneous chronic pancreatitis in the WBN/Kob rat as well as in humans and arginine-treated rat pancreatic acinar AR4-2J cells. p8 mRNA was significantly increased at 12 weeks when chronic pancreatitis first appeared in the WBN/Kob rats. p8 was immunolocalized in the acinar cell nuclei. Acinar cell apoptosis was significantly increased at 12 and 20 weeks in the WBN/Kob rats. In AR4-2J cells, p8 mRNA was significantly induced at 4 hr after arginine addition. Apoptosis of AR4-2J cells was not increased during the strong expression of p8 mRNA. These results suggest that p8 is induced in the acinar cells during chronic pancreatitis as the self-defence mechanism against proapoptotic insults.

Effect of camostat mesilate on the expression of pancreatitis-associated protein (PAP), p8, and cytokines in rat spontaneous chronic pancreatitis

An oral protease inhibitor, camostat mesilate (CM) has been used clinically for chronic pancreatitis (CP) in Japan, but it lacks enough scientific evidence of its effectiveness. The aim of this study was to analyze the effect of CM on the gene expressions of pancreatitis-associated protein (PAP), p8, and cytokines such as interleukin-6 and transforming growth factor-beta1 in spontaneous CP model (WBN/Kob rats). CM (10 mg/100 g body weight), mixed in MB-3 diet, was administered orally and gene expressions were analyzed by reverse transcription-polymerase chain reaction. In untreated WBN/Kob rats, the gene expressions of all the four factors peaked at 12 weeks, whereas they were significantly suppressed in the CM-treated rats. CM significantly increased the body weight and pancreatic wet weight, and it significantly inhibited inflammatory changes and fibrosis of the pancreas. These results suggest that CM inhibits pancreatic inflammation and fibrosis through the suppression of gene expressions of PAP, p8, and cytokines in CP.

Clinical management of intraductal papillary mucinous tumors of the pancreas based on imaging findings

The aim of this study was to assess the imaging findings of pathologically proven intraductal papillary-mucinous tumors of the pancreas and the natural history of follow-up cases, and to optimize the therapeutic management of patients with these tumors according to their imaging findings. All nine patients with main duct type tumors were histologically diagnosed as having adenocarcinoma or adenoma, with no hyperplastic lesion. The images failed to discriminate between the two histologic types. In 26 patients with branch duct type tumors, all but one with intraductal mural nodules or tumors of > or = 30 mm had adenocarcinoma or adenoma, regardless of the caliber of the main duct. Of the nine patients with tumors < 30 mm and no mural nodules. three had adenoma, and six had hyperplasia. All of four patients had hyperplasia, with the additional caliber of the main duct being < 6 mm. In a series of 23 cases in which the patient was followed-up, no apparent progression was found in 17 patients who had no mural nodules and tumors of < 30 mm. Given these results, patients with main duct type tumors, and those with branch duct type tumors showing mural nodules or a tumor diameter of > or = 30 mm, are at high risk of developing neoplasms, including adenocarcinoma, for which surgical resection should be considered, whereas those patients with tumors < 30 mm and no mural nodules can be followed.

Overexpression of p8 is inversely correlated with apoptosis in pancreatic cancer

A recently identified gene, p8, has cell growth-promoting activity and is strongly induced in acute pancreatitis. In this study, we detected p8 and single-stranded DNA (ssDNA) for apoptosis by immunohistochemistry in human pancreatic cancer. The p8 was overexpressed (>30% per 1000 cancer cells) in 26 of 44 (59%) pancreatic cancers, and apoptosis (ssDNA-positive cells >10% per 1000 cancer cells) was recognized in 18 of 44 (41%) pancreatic cancers. There was a significant inverse correlation between the p8 overexpression and apoptosis (P < 0.05). Moreover, the expression pattern of high p8 and low ssDNA was seen significantly more often in lower age (<65 years), in moderately or poorly differentiated cancers, and in node-positive cases (P < 0.05). The p8 expression and apoptosis were not significantly correlated with survival. These results suggest that p8 overexpression is involved in antiapoptotic activity and the biological characteristics of pancreatic cancer.

Expression of tumor necrosis factor-alpha, interleukin-6, and interferon-gamma in spontaneous chronic pancreatitis in the WBN/Kob rat

To clarify the pathophysiological significance of cytokines in chronic pancreatitis (CP), we analyzed tissue expressions of various cytokines in the onset and progression of spontaneous CP in the WBN/Kob rat. Four-week-old male WBN/Kob rats were fed a special pellet diet (MB-3) for 20 weeks, and 6 rats were killed every 4 weeks. Pathologically, CP occurred at 12 weeks and progressed thereafter. The inflammation and fibrosis peaked at 12 and 16 weeks, respectively. By semiquantitative reverse transcription-polymerase chain reaction, the expression of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and interferon (IFN)-gamma mRNAs peaked at 8, 12, and 16 weeks, respectively. Immunohistochemistry showed IL-6 expression in infiltrating inflammatory cells and vascular endothelial cells, whereas TNF-alpha was expressed in both acinar and infiltrating cells. IFN-gamma was localized to acinar, infiltrating and ductal cells, and its expression intensity showed significant correlation with those of fibrosis, type III collagen and alpha-smooth muscle actin. The in situ hybridization results were consistent with the RT-PCR data. These results suggest that tissue expressions of TNF-alpha and IL-6 are involved in the onset of pancreatitis and that IFN-gamma expression is related to the progression of CP.

Pneumatosis intestinalis and hepatic portal venous gas caused by mesenteric ischemia in an aged person

An 82-year-old woman complaining of abdominal pain and vomiting was admitted to our emergency department. Abdominal X-ray, ultrasonography, and computed tomography showed hepatic portal venous gas, as well as pneumatosis intestinalis. We first suspected superior mesenteric arterial thrombosis. However, her physical findings, including computed tomography scanning and laboratory data, did not support the presence of bowel necrosis. The gas disappeared after 1 day. After the 12th day, she had recovered with conservative therapy, and she was discharged on the 41st day. Many reports indicate that hepatic portal venous gas is often associated with bowel necrosis, and urgent operation is recommended in such instances. In this patient, total colonoscopy on the 7th day revealed longitudinal redness, suggesting mesenteric ischemia. Thus, we speculate that this is a rare case of mesenteric ischemia without bowel necrosis associated with both pneumatosis intestinalis and hepatic portal venous gas.

Hepatic peribiliary cysts diagnosed by magnetic resonance cholangiography

We report a 76-year-old man with hepatic peribiliary cysts diagnosed by magnetic resonance cholangiopancreatography (MRCP). On his first admission, in 1991, the patient was misidentified as having localized dilatation of the left intrahepatic bile ducts, from the ultrasound (US) and computed tomographic (CT) findings, or primary sclerosing cholangitis from endoscopic retrograde cholangiopancreatography (ERCP). However, US and CT in 1998 suggested worsening of the lesions. MRCP was performed for the first time, revealing hepatic peribiliary cysts in the hepatic hilum and along the left hepatic ducts. Drip infusion cholangiography (DIC)-CT confirmed the extraluminal compression of the bile ducts, caused by the cysts, without an influx of contrast medium into the hepatic peribiliary cysts. Retrospective evaluation showed increases in the size and number of the cysts in 1998 compared with the findings in 1996.

Expression of clusterin in pancreatic acinar cell injuries in vivo and in vitro

Clusterin is a secretory glycoprotein that is highly induced in several tissues in response to injury. The pathophysiologic significance of clusterin in the pancreas remains largely unknown. The aim of this work was to examine whether clusterin is expressed in spontaneous chronic pancreatitis in the WBN/Kob rat and to investigate the relationship between clusterin and apoptosis in pancreatic acinar AR4-2J cells. In the in vivo study, 4-week-old male WBN/Kob rats developed chronic pancreatitis at 12 weeks. Clusterin mRNA was expressed after 12 weeks and then decreased. Immunohistochemistry showed clusterin expression in the acinar cells. In the in vitro study, clusterin mRNA and protein were strongly induced in AR4-2J cells treated either with arginine, menadione, tumor necrosis factor-alpha or transforming growth factor-beta1. In the time course study with arginine or menadione, clusterin mRNA was expressed after 4 hours and peaked at 8 and 24 hours, whereas DNA fragmentation peaked at 72 hours. Our results show that clusterin is overexpressed in the pancreas at the onset of chronic pancreatitis in vivo and in cultured acinar cells in response to various stimuli in vitro, suggesting that clusterin is a defense mechanism of the exocrine pancreas.

Presacral ganglioneuroma arising in an elderly man with persistent constipation

Presacral ganglioneuroma in a 70-year-old man with persistent constipation and its features on computed tomography, magnetic resonance, and endoscopic ultrasonography are presented. Barium enema study and laparotomy showed that constipation was caused mainly by extrinsic compression from this tumor. Computed tomography, magnetic resonance, endoscopic ultrasonographic features such as well-defined solid tumor with a cystic component and punctate calcifications may facilitate early diagnosis of this rare tumor.

Expression of p8 in human pancreatic cancer

The p8 gene is a recently identified gene with mitogenic activity. p8 expression is induced in acute pancreatitis, pancreatic development, and regeneration. However, the expression of p8 in pancreatic cancer is not reported. We investigated p8 expression in 72 human pancreatic tissues, including 38 pancreatic cancers (PCs), by immunohistochemistry. p8 was overexpressed (positive cells >25% in 1,000 cells) in 71% (27 of 38) of PCs, but in only 17% (3 of 18) of chronic pancreatitis cases. There was no overexpression in mucinous cystadenoma or in normal pancreas. The p8 overexpression rate in PC was significantly higher than that in other conditions (P < 0.05). Reverse transcription-PCR analysis confirmed p8 mRNA overexpression (tumor/nontumor ratio >2) in 75% (3 of 4) of PCs. p8 was overexpressed also in human pancreatic cancer cell lines (MIA PaCa-2 and PANC-1). These results suggest that p8 is involved in the development of pancreatic cancer, reflecting its mitogenic activity.

Antifibrotic effect of the herbal medicine Saiko-keishi-to (TJ-10) on chronic pancreatitis in the WBN/Kob rat

Chronic pancreatitis is characterized by fibrosis. We reported an anti-inflammatory effect of the herbal medicine Saiko-keishi-to (TJ-10) on chronic pancreatitis. This study aimed to elucidate the antifibrotic effect of TJ-10. Four-week-old male WBN/Kob rats were fed a special pellet diet (MB-3) with or without TJ-10 (80 mg/100 g body weight) for 20 weeks. Pancreata were histopathologically examined at every 4 weeks, and the expression of fibrosis-related factors such as transforming growth factor beta1 (TGF-beta1), fibronectin (FN), alpha-smooth muscle actin (alpha-SMA), and type III collagen was analyzed. In untreated WBN/Kob rats, chronic pancreatitis developed at 12 weeks and progressed with marked fibrosis at 16 weeks, and the expression of TGF-beta1 and FN peaked at 12 weeks. However, in the TJ-10-treated rats, the rate of pancreatic fibrosis and the expression of TGF-beta1, FN, alpha-SMA, and type III collagen at 12 and 16 weeks decreased significantly compared to those in the untreated rats. These results suggest that TJ-10 inhibits the pancreatic fibrosis by the suppression of TGF-beta1 expression.

Apoptosis in rat spontaneous chronic pancreatis: role of the Fas and Fas ligand system

The Fas/Fas ligand (FasL) system is suggested to be correlated to the onset of inflammation and apoptosis in various diseases. However, whether Fas and FasL are expressed in chronic pancreatitis is unknown. The aim of this study was to examine the expression of the Fas/FasL system and to analyze its correlation with apoptosis in a spontaneous chronic pancreatitis model (the WBN/Kob rat). Four-week-old male WBN/Kob rats were fed a special pellet diet (MB-3). Different groups of rats were killed every four weeks, and pancreata were histopathologically examined. Fas and FasL mRNAs in the pancreas were detected with a reverse transcription-polymerase chain reaction method. The cellular localization of Fas and FasL mRNA and protein was determined with in situ hybridization (ISH) and immunohistochemistry (IHC). Apoptosis was detected with a terminal deoxynucleotidyltransferase-mediated method. Fas and FasL mRNA were expressed when the pancreas was still pathologically normal, and showed a biphasic peak at 12 and 20 weeks. ISH and IHC confirmed that Fas and FasL are expressed in the cytoplasm of acinar cells, ductal cells, and lymphocytes. An apoptotic index in acinar cells correlated to the expression of Fas and FasL mRNAs. These results suggest that the expression of the Fas/FasL system is involved in acinar cell apoptosis and the onset and progression of chronic pancreatitis in the WBN/Kob rat.

Does the depth of gastric ulceration influence a modified dual therapy with amoxicillin and lansoprazole for Helicobacter pylori-associated gastric ulcer?

PURPOSE

To clarify whether the depth of ulceration evaluated by endoscopic ultrasonography (EUS) influences a modified dual therapy with amoxicillin and lansoprazole for the treatment of Helicobacter pylori-positive patients with gastric ulcer.

PATIENTS AND METHODS

Twenty-two consecutive cases of gastric ulcer (nine superficial ulcers and 13 deep ulcers) in H pylori-positive patients were studied. Ten of 22 patients received a two-week eradication therapy with amoxicillin 1500 mg/day, lansoprazole 30 mg/day and a new antiulcer agent with features in common with sucralfate, ecabet sodium, 2.0 g/day. They continued to receive the same doses of lansoprazole and ecabet sodium for the next six weeks. The other 12 patients received the same therapy except for those who underwent the four-week amoxicillin treatment. All patients underwent EUS both at the start of the study and eight weeks later. They then received ecabet sodium alone for the next six months as a maintenance therapy, followed by a six-month interval with no treatment. The final endoscopy was done one year after H pylori eradication therapy was completed to evaluate H pylori status and ulcer recurrence.

RESULTS

The rates of endoscopic healing and H pylori eradication in the nine patients with superficial ulcer were 100%, irrespective of the period of amoxicillin treatment. In contrast, the rates of endoscopic evidence of healing and H pylori eradication in the 13 patients with deep ulcer were different for each period of amoxicillin treatment; that is, the rates of reduction in ulcer determined by echo and H pylori eradication in the four patients treated with the two-week amoxicillin course were significantly lower (P=0.03) than those in the nine patients treated with the four-week course.

CONCLUSION

Ulcer depth is likely to influence the success of amoxicillin treatment for H pylori-positive patients with gastric ulcer.

An immunohistochemical analysis of p27 expression in human pancreatic carcinomas

p27 is known as one of the candidate tumor suppressor genes. Although abnormalities including deletion and mutation in this gene are rarely detected, loss of p27 expression has been reported to be correlated with the high degree of malignancy in many human cancers. In the present study, we investigated the status of p27 expression in human pancreatic carcinoma (PC) and assessed the clinicopathologic significance of loss of p27 expression in the development and progression of this malignancy using immunohistochemistry. No nuclear staining for p27 protein existed in 65 (65.7%) of the 99 PC tumors examined. Furthermore, loss of p27 expression was correlated with tumor grade (G1 versus G2 or G3, p < 0.05) or clinical stage (I and II versus III and IV, p < 0.01). The above data suggest that loss of p27 expression is a very common event in PC, and moreover, this alteration might contribute to the progression of this malignant disease. Key Words: Pancreatic carcinoma-p27 protein expression-Immunohistochemistry.

Effect of herbal medicine Saiko-keishi-to (TJ-10) on rat spontaneous chronic pancreatitis: comparison with other herbal medicines

BACKGROUND

In an attempt to obtain evidence of the beneficial effects of TJ-10, we investigated the gene expression of PAP, an acute phase protein specific for pancreatitis in rat spontaneous chronic pancreatitis.

METHODS

Four-wk-old male WBN/Kob rats were fed with MB-3 pellet diet containing herbal medicine. There were two administration groups for each drug: the prophylactic group administered from 4-12 wk, and the therapeutic group administered from 12-20 wk. Untreated control rats were fed with MB-3 alone. Histopathologic changes and PAP gene expressions were analyzed at 12 and 20 wk.

RESULTS

In the prophylactic group, TJ-10-treated WBN/Kob rats showed no evidence of pancreatitis, and there was the amelioration of pancreatitis in the pancreata of the rats treated with other herbal medicines except TJ-24 at 12 wk. PAP mRNA was not expressed in the TJ-10-treated rats, and PAP gene expression was suppressed in rats treated with other drugs except TJ-107. In the therapeutic group, the amelioration of pancreatitis was seen only in TJ-10-treated rats, but PAP gene expression was significantly suppressed in the rats treated with all herbal medicines tested, compared with that in untreated control rats.

CONCLUSION

An herbal medicine Saiko-keishi-to (TJ-10) delayed the onset of chronic pancreatitis in the WBN/Kob rat, and suppressed the pancreatitis-associated protein (PAP) gene expression more significantly than other herbal medicines.

Nonfunctioning islet cell carcinoma of the pancreas with high serum CEA & CA19-9, K-ras codon 12 mutation, and microsatellite instability

A 55-year-old man with nonfunctioning islet cell carcinoma showing elevation of serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels is described with genetic analyses. Pathological examination of the resected specimen revealed two independent islet cell carcinomas, one in the body and the other in the tail of the pancreas. It was proved immunohistochemically that the tumor cells, particularly those in the tail, were immunoreactive to CEA and CA 19-9 and had the property of duct cells, as well as endocrine cells. Gastrin was demonstrated immunohistochemically in these tumor cells, although its level in serum was not elevated. Genetic analyses of the fresh specimens from the tumor in the body revealed K-ras codon 12 mutation and microsatellite instability. These findings are consistent with its progressive clinical course and strongly suggest that these tumors originate, not from the islet cells of Langerhans, but from protodifferentiated cells, capable of giving rise to all the pancreatic cell types.

Arginine induces apoptosis and gene expression of pancreatitis-associated protein (PAP) in rat pancreatic acinar AR4-2J cells

Arginine-induced pancreatic acinar cell injury has been reported in vivo, but the mechanism involved is unknown. In this study we investigated the effects of arginine on the cell morphology and pancreatitis-associated protein (PAP) gene expression in rat pancreatic acinar AR4-2J cells in vitro. Arginine inhibited the proliferation of AR4-2J cells in a dose-dependent manner. This decrease in proliferation was due to an increase in apoptosis, as assessed by cell morphology and DNA fragmentation. PAP messenger RNA (mRNA) was expressed at doses of 2.5 and 5.0 mg/ml of arginine, and a time-course study showed that the expression started 2 h after arginine addition and peaked at 6 h. Apoptosis was rarely seen when PAP mRNA was highly expressed, but occurred when PAP mRNA expression was decreased. These results suggest that arginine induces apoptosis and PAP gene expression in pancreatic acinar cells and that PAP might inhibit the induction of apoptosis.

Expression of transforming growth factor-beta in spontaneous chronic pancreatitis in the WBN/Kob rat

Transforming growth factor-beta1 (TGF-beta1) is suggested to be a mediator of fibrosis in chronic pancreatitis, but the serial change of TGF-beta1 expression in the onset and progression of chronic pancreatitis is still unclear. We investigated the TGF-beta1 expression in the spontaneous chronic pancreatitis model. Four-week-old male WBN/Kob rats were fed with special pellet diet (MB-3) for 20 weeks. TGF-beta1 mRNA in the pancreas was detected by reverse transcription-polymerase chain reaction assay from four weeks, and its expression peaked at 12 weeks when the pancreatic fibrosis first appeared. The localizations of TGF-beta1 mRNA and protein were confirmed in the cytoplasm of pancreatic acinar and ductal cells by in situ hybridization and immunohistochemistry, respectively. Although fibronectin expression peaked at 12 weeks and correlated with that of TGF-beta1, its elevated expression tended to be prolonged. Pancreatic fibrosis peaked at 16 weeks after the peak of TGF-beta1 expression. These results suggest that TGF-beta1 expression may be a trigger of the fibrotic process of chronic pancreatitis in the WBN/Kob rat.

EUS and K-ras analysis of pure pancreatic juice collected via a duodenoscope after secretin stimulation for diagnosis of pancreatic mass lesion: a prospective study

BACKGROUND

The early diagnosis of pancreatic cancer remains problematic. This prospective study assessed the utility of a combination of endoscopic ultrasound (EUS) and genetic analysis of pure pancreatic juice in the diagnosis of pancreatic mass lesions.

METHODS

One hundred seventy-six patients with suspected pancreatic disease were enrolled and underwent ultrasonography (US), computed tomography (CT), endoscopic retrograde choleangiopancreatography (ERCP), and EUS. Pure pancreatic juice was collected endoscopically after secretin stimulation. K-ras point mutations at codon 12 in the juice were assayed by polymerase chain reaction-restriction fragment length polymorphism.

RESULTS

Thirty-six (20%) patients were found to have solid pancreatic masses including 19 with cancer (7 patients, </= 2 cm) and 17 patients with an inflammatory mass (13 patients, </= 2 cm). US and CT were both less sensitive, particularly in patients with small masses. In 13 patients, small masses (4 cancer and 9 inflammatory masses) were not delineated until EUS. The combination of EUS and K-ras analysis had a high sensitivity (100%; p < 0.05 vs. US) and its accuracy reached 94% (p < 0.01 vs. US).

CONCLUSIONS

EUS and K-ras determination in pure pancreatic juice collected via a duodenoscope may be useful for the diagnosis of pancreatic mass lesions.

K-ras mutations in duodenal aspirate without secretin stimulation for screening of pancreatic and biliary tract carcinoma

BACKGROUND

K-ras mutations at codon 12 (KRM) have been detected in over 80% of tissues and pure pancreatic juice (PPJ) samples from patients with pancreatic carcinoma (PCa) and are promising genetic tumor markers. Aspirating PPJ not only requires technical skill, but is also exhausting for patients. The authors attempted to evaluate whether the detection of KRM in the duodenal aspirate (DA) obtained immediately after endoscopic retrograde cholangiopancreatography (ERCP), an easier sample-collecting method than collecting PPJ, could be useful for the diagnosis of PCa and biliary tract carcinoma (BTCa).

METHODS

DA was collected endoscopically without secretin stimulation immediately after the ERCP procedure from 160 patients: 38 patients with PCa, 38 with chronic pancreatitis (CP), 22 with BTCa, 20 with adenomyomatosis of the gallbladder (AGB), 22 with cholecystolithiasis (CCL), and 20 control subjects. Mutant allele specific amplification (MASA), which is a highly sensitive method for detecting KRM, was performed, with the DNAs extracted from these samples by phenol-chloroform.

RESULTS

The incidence of KRM in DA by MASA was 25 (66%) of the 38 PCa cases, 12 (32%) of the 38 CP cases, and 12 (55%) of the 22 BTCa cases. There was no patient with positive KRM in DA among the 20 cases of AGB, 22 of CCL, and 20 control subjects. The sensitivity was 62% and the specificity 88% in this study design. The KRM incidence was found to be relatively high for the patients with PCa and BTCa by MASA, which is a highly sensitive method, although the incidence of KRM in DA from the patients with PCa was not as high as the incidence in their PPJ with secretin stimulation.

CONCLUSIONS

MASA showed a relatively high incidence of KRM even in the DA, which was easily obtained from the patients with PCa and BTCa without secretin stimulation immediately after ERCP. These results suggest that the detection of KRM in the DA by MASA is useful for the screening of both PCa and BTCa.

Expression of pancreatitis-associated protein (PAP) in rat spontaneous chronic pancreatitis: effect of herbal medicine Saiko-keishi-to (TJ-10)

Pancreatitis-associated protein (PAP) is almost absent in the normal pancreas but is overexpressed in acute pancreatitis. However, its expression in chronic pancreatitis (CP) is unknown. An herbal medicine Saiko-keishi-to (TJ-10) has long been used clinically for CP, but there is no experimental evidence of the effect of TJ-10 on CP. The aim of this study was to analyze the expression of PAP and the effect of TJ-10 in a spontaneous chronic pancreatitis model. Four-week-old male WBN/Kob rats were fed with a special pellet diet (MB-3), and TJ-10 (80 mg/100 g body weight/day) was orally administered for 16 weeks. The rats were killed at every 4 weeks, and pancreata were histopathologically examined. PAP messenger RNA (mRNA) in the pancreas was detected with a reverse transcription/polymerase chain reaction (RT-PCR) method. The cellular localization of PAP mRNA and protein was analyzed with in situ hybridization (ISH) and immunohistochemistry (IHC). PAP mRNA was expressed from 8 weeks, when the pancreas was still pathologically normal, and reached its peak at 12 weeks, when the pancreatitis first appeared. Then the expression of PAP mRNA was decreased gradually. TJ-10 suppressed the expression of PAP mRNA completely at 8 and 12 weeks. PAP mRNA was slightly expressed at 16 and 20 weeks. ISH and IHC confirmed the PAP mRNA and protein expression in the cytoplasm of acinar cells. These results suggest that PAP mRNA appears before CP, and its peak coincides with the onset of CP. TJ-10 suppressed the PAP expression and delayed the development of CP in the WBN/Kob rat.

Effect of Koso-san on globus pharyngeus

Twenty-three patients with globus pharyngeus were treated with Koso-san (TJ-70) at a dose of 7.5 g/day for at least 14 days. Symptoms disappeared in 18 cases and improved in 3 cases, therefore, the effective rate was 91.3% (21/23). The symptoms disappeared on average within 13.5 days. Terasawa qi-stasis scores were significantly decreased after the treatment. TJ-70 might thus be a remedy for globus pharyngeus with qi-stasis.

Bcl-2 expression related to altered p53 protein and its impact on the progression of human pancreatic carcinoma

p53 and Bcl-2 are two important factors related to apoptosis and tumorigenesis. In this study, a series of 52 cases of pancreatic carcinoma (PC) were investigated using an immunohistochemical assay to determine whether altered expression of Bcl-2 and p53 has an impact on the progression of this malignancy. Cytoplasmic immunoreactivity for Bcl-2 and nuclear staining of p53 was found in 12 (23.1%) and 32 (63.5%) cases of PC respectively. Furthermore, an inverse correlation between the expression of p53 and Bcl-2 existed in this series (P < 0.01). In a subgroup, the proportion of tumours showing that p53-positive and Bcl-2-negative staining was increased with increasing histological grade and clinical stage (P < 0.05), and moreover, the survival period of those patients whose tumour had this staining was shorter than those with other staining patterns of combined p53 and Bcl-2 (P < 0.05). Therefore, it is concluded that simultaneously aberrant expression of Bcl-2 and p53 may confer PC with more malignant clinicopathological characteristics.

Urinary gonadotropin peptide as acute phase reactant: transient elevation after operation for digestive diseases

OBJECTIVE

In order to characterize urinary gonadotropin peptide (UGP) as an acute phase reactant, we focused on the UGP levels after surgical operation.

DESIGN

Fifty cases of gastrointestinal cancer, 4 cases of cancers of other organs and 13 cases of benign digestive diseases were enrolled into this study.

METHODS

UGP levels were measured using an enzyme immunoassay before and after surgery.

RESULTS

Fifty-four (80.6%) of the 67 cases studied showed transient elevations of UGP. Both urinary interleukin (IL)-6 and LH levels were also increased transiently in 49 cases (73.1%). All of these three factors were increased in 38 cases (56.7%), and in 32 (84.2%) of these 38 cases, the order of peak appearance was as follows: IL-6, LH, and UGP. The UGP levels in the group of total gastrectomy were significantly higher than those in the group of partial gastrectomy.

CONCLUSIONS

These results suggest that UGP shows a transient peak after surgery, correlating with levels of cytokines such as IL-6. UGP may be an acute phase reactant, and its levels are correlated with the grade of surgical stress.

Serum levels of pancreatitis-associated protein in digestive diseases with special reference to gastrointestinal cancers

The serum levels of pancreatitis-associated protein (PAP) were measured in 196 patients with digestive diseases and 15 healthy subjects by an enzyme-linked immunosorbent assay. The serum PAP levels were significantly elevated in the patients with gastric, colorectal, biliary tract, hepatocellular, or pancreatic cancers compared with the healthy subjects. After curative resection of the tumor, serum PAP levels were significantly decreased. The serum PAP levels were not related to clinicopathological factors except for the tumor size of pancreatic cancer. There were some cases of PAP-positive and carcinoembryonic antigen (CEA) or carbohydrate antigen (CA) 19-9 -negative gastric and colorectal cancers. The serum PAP levels were also significantly elevated in the patients with acute pancreatitis compared with those in not only the healthy subjects but also the patients with chronic pancreatitis. The peak PAP levels were significantly correlated with the severity of acute pancreatitis and reflected the clinical healing of the disease. The peak of serum PAP was significantly delayed compared with those of other pancreatic enzymes. These results suggest that the increase of serum PAP levels in patients with gastrointestinal cancers reflects an ectopic expression of PAP in cancer cells and that increased serum levels of PAP in acute pancreatitis are correlated with the disease severity and are prolonged than those of other pancreatic markers.

Primary biliary cirrhosis associated with type A gastritis and chronic thyroiditis

We report a patient with primary biliary cirrhosis (PBC) associated with type A gastritis, chronic thyroiditis, and iron deficiency anemia. The patient was a 45-year-old Japanese woman who was admitted to our hospital with severe microcytic and hypochromic anemia, abnormal results for liver function tests, and a diffuse goiter. The diagnosis of PBC (Scheuer's stage II) was confirmed by the presence of specific anti-mitochondrial antibody in high titers and histological examination showing chronic non-suppurative destructive cholangitis with bridging fibrosis. Additionally, marked atrophic mucosa throughout the body and fundus of the stomach was observed endoscopically, and there was positivity for intrinsic factor antibody, an extremely low ratio of serum pepsinogen A to C, and hypergastrinemia, indicating coexisting type A gastritis. The severe anemia was thought to be caused by failure of dietary iron absorption related to achlorhydria with this gastritis. However, the serum level of vitamin B12 was normal. She also had autoimmune thyroiditis. PBC is frequently associated with extrahepatic autoimmune diseases, including ductular lesions. However, the association of PBC with type A gastritis is quite rare, although the stomach is also an exocrine glandular structure. This particular case, in addition to previous reports, leads to a discussion of whether type A gastritis should be regarded as a possible, although uncommon, component disorder of so-called dry gland syndrome.

Detection of mutations of p53 tumor suppressor gene in pancreatic juice and its application to diagnosis of patients with pancreatic cancer: comparison with K-ras mutation

Because of the difficulty in obtaining biopsy specimens from pancreatic cancer patients, K-ras mutation analysis in pancreatic juice has been used for specific diagnosis. But recently, false positives have been obtained with this method. To improve the genetic diagnosis of pancreatic cancer, detection of p53 gene mutation in pancreatic juice was studied. Pancreatic juice was sampled endoscopically. Single-strand conformation polymorphism analysis was used for p53 mutation analysis. Furthermore, K-ras mutations at codon 12 were also studied in the same pancreatic cancer patients. Of 26 cases of pancreatic cancer, p53 mutations were detected in 11 (42.3%). No mutations were seen in the cases with mucin-producing adenoma nor with chronic pancreatitis. K-ras mutations were detected in 84.0% of cases by RFLP analysis, which has high sensitivity, and in 65.3% by hybridization protection assay, which has high specificity. Using a combination assay with both genes, genetic abnormalities were detected in 92.0% by RFLP and 73.1% by hybridization protection assay including two cases in which p53 alone was positive by both methods. The specificity of p53 mutation for pancreatic cancer is very high. Therefore, simultaneous analysis of p53 and K-ras mutation is suggested to enhance the genetic diagnosis of pancreatic cancer.

Mucin-producing biliary papillomatosis associated with gastrobiliary fistula

We report a case of mucin-producing biliary papillomatosis in a 78-year-old woman. Abdominal ultrasound (US) and computed tomography (CT) showed wall thickening and dilatation of the intrahepatic bile duct (IHBD), as well as a nodular lesion, 1.2 cm in diameter, in the left branch of the IHBD. Gastric endoscopy revealed excretion of bile-containing mucin on the anterior wall of the body of the stomach. Endoscopic ultrasonography (EUS) showed gastrobiliary fistula and discharge of mucin into the stomach. Needle biopsy of the biliary tumor revealed papillary proliferation, but no malignant cells were recognized histologically. Therefore this patient was diagnosed as having mucin-producing biliary papillomatosis forming gastrobiliary fistula. She did not present with obstructive jaundice, probably because of the fistula. She is alive, without obstructive jaundice, 16 months after the diagnosis without having had surgery. This is, to our knowledge, the first reported case of biliary papillomatosis forming gastrobiliary fistula and with the patient free of obstructive jaundice.

Diagnostic value of endoscopic retrograde pancreatography in chronic pancreatitis based on the new criteria proposed by the Japan Pancreas Society in 1995: comparison with the criteria proposed by the Japanese Society of Gastroenterology in 1983

This study evaluated the new criteria for the diagnosis of chronic pancreatitis (CP) with endoscopic retrograde pancreatography (ERP) proposed by the Japan Pancreas Society in 1995 by comparing it with the older criteria of the Japanese Society of Gastroenterology proposed in 1983. No significant differences were noted between the two when the diagnostic sensitivity of ERP was considered in calcifying CP. Among 54 patients of noncalcifying CP (group I) with ERP diagnosis of moderate or advanced pancreatitis by the previous criteria, only one of 22 with the localized type was definite CP. The remaining 21 were ruled out as either definite or probable CP, and six were classified as having chronic obstructive pancreatitis based on the new criteria. In contrast, a diagnosis of definite CP was made not only for all the 32 patients with CP (group I) of diffuse type but also in 11 cases of CP (group II) with diffuse minimal pancreatitis showing irregular dilatation of the side branches with scattered distribution throughout the gland. In a series of 15 follow-up patients with CP (group II) having initial ERP diagnosis of minimal pancreatitis, CP group I developed in three of five cases of diffuse minimal pancreatitis, which is consistent with definite CP by the new criteria, whereas progression to this group of CP was found in none of the 10 patients with localized minimal pancreatitis. These results indicate that although localized CP is excluded from CP, the incidence of diffuse noncalcifying CP diagnosed by ERCP was increased with the new criteria, and detecting radiologic features with diffuse irregular dilatation of the branch ducts based on these criteria may lead to early diagnosis of CP.

Pancreatic cancer associated with granulocyte-colony stimulating factor production confirmed by immunohistochemistry

We report an 83-year-old man with pancreatic body cancer of 4.5 cm in diameter. Peripheral leukocyte count was 15,700/microl and the serum concentration of granulocyte-colony stimulating factor (G-CSF) was 123 pg/ml (normal, 6.0-21.9 pg/ml) on admission. Furthermore, not only K-ras codon 12 (GGT --> GAT) but also p53 at codon 247 (CGG --> CCG) mutations were identified in the pancreatic juice aspirated endoscopically. We performed chemotherapy with two courses of 5-fluorouracil, pirarubicin hydrochloride, and mitomycin-C, resulting in no beneficial effect. After the second course the patient developed interstitial pneumonia, probably caused by anticancer drugs, and died 4 months after the tumor was detected. In the autopsy tissue, the tumor macroscopically occupied the pancreas body and was 7 x 6 x 5 cm in size. Histopathologic diagnosis of the tumor was poorly differentiated adenosquamous carcinoma. Immunohistochemical staining of the autopsy tissue showed that pancreatic cancer cells were positive for G-CSF. This is the first case report of G-CSF-positive pancreatic cancer confirmed by immunohistochemistry.

Quantitative determination of K-ras mutations in pancreatic juice for diagnosis of pancreatic cancer using hybridization protection assay

K-ras mutations at codon 12 (KRM) have been detected in approximately 80% of samples of pure pancreatic juice (PPJ) from patients with pancreatic cancer (PCa) and are a promising potential tumor marker. However, the frequent presence of KRM was reported in PPJ from noncancerous patients as determined by a highly sensitive method, raising questions as to the cancer specificity of this marker. Therefore we evaluated whether the hybridization protection assay (HPA), which can quantitatively determine KRM in PPJ, is useful for the diagnosis of PCa, differentiating from chronic pancreatitis (CP). PPJ was collected endoscopically from 29 patients with PCa, 26 patients with CP, and the 11 cases as the control group. Polymerase chain reaction (PCR) and HPA using an acridinium ester-labeled DNA probe for KRM were performed with DNA extracted from these samples. The results were compared with those obtained by PCR-restriction fragment length polymorphism (RFLP). The mean + 2 SD of chemiluminescence in the control group was 11,020 RLUs. When 11,020 RLUs was taken as the cut-off value, KRM was detected by PCR-HPA in 19 (66%) of 29 of PCa and one (4%) of 26 of CP cases. Analysis of PPJ by PCR-RFLP demonstrated KRM in 22 (79%) of 28 of PCa and five (19%) of 26 of CP cases. However, four of five patients with CP who were KRM-positive by PCR-RFLP were defined as negative by PCR-HPA, suggesting that PCR-HPA is superior to PCR-RFLP for the discrimination between PCa and CP. These findings indicate that quantitative analysis of KRM in PPJ using the PCR-HPA method is a promising approach for the diagnosis of PCa, differentiating from CP with a suitable cut-off value, as in the case with the use of conventional serum tumor marker.

Infrequent expression of p21 is related to altered p53 protein in pancreatic carcinoma

This study is designed to investigate the expression of p21 and its relation to altered p53 protein in pancreatic carcinoma (PC). Immunohistochemical staining of formalin-fixed, paraffin-embedded tissue sections of PC was performed using a monoclonal antibody against p21 (187), with a parallel examination of altered p53 protein. The expression of p21 was only found in 12 of 58 (20.7%) PCs and, moreover, was mainly restricted to the well-differentiated ductal epithelium. Sixty-four % (37 of 58) of PCs showed positive p53 staining, and this change was significantly related to the absence of p21 expression (P < 0.01). In a subgroup, the proportion of the undetectable p21 expression and the expression of p53 were increased with increasing tumor grade but decreased with advancing clinical stage. The results of the present study suggest that the absence of p21 expression is very common in PCs and appears to relate to altered p53 protein. Moreover, the abnormalities involving the expression of p21 and p53 may play a more important role in the development than in the progression of this malignancy.

Expression of multidrug resistance gene (mdr-1) mRNA in gastric and colorectal cancers

Fresh surgical specimens of 52 gastric cancers and 25 colorectal cancers were analyzed for the expression of multidrug resistance (mdr-1) gene mRNA with non-isotopic in situ hybridization (ISH) using a biotin-labeled oligonucleotide probe. The mdr-1 mRNA was expressed in 15.4% in cancerous portions and 1.9% in non-cancerous portions of gastric cancers (p < 0.02). In colorectal cancers, the mdr-1 mRNA was positive in 36% in cancerous portions and 28% in non-cancerous portions. In gastric cancers, the well-differentiated type showed a significantly higher positive rate than the poorly differentiated type (p < 0.01). These results suggest that the mdr-1 mRNA expression in gastric and colorectal cancers is related to the degree of cellular differentiation.

Expression of pancreatitis-associated protein (PAP) mRNA in gastrointestinal cancers

CONCLUSION

Pancreatitis-associated protein (PAP) mRNA is expressed in some cases of gastric and colorectal cancers resulting from an ectopic expression in dedifferentiated cancer cells.

BACKGROUND

The PAP gene is identical to the hepatoma-intestine-pancreas (HIP) gene, which is expressed in hepatoma. Expression in cancer might be another characteristic of PAP.

METHODS

Fresh surgical specimens of 100 gastrointestinal cancers, 14 benign digestive diseases, and six normal organs were studied with nonisotopic in situ hybridization (ISH) using biotin-labeled cDNA probe.

RESULTS

PAP mRNA was detected in 10% (6/60) of gastric cancers, 21.4% (6/28) of colorectal cancers, 20.0% (1/5) of pancreatic cancers and 0% of biliary tract (three), esophageal (one), and hepatocellular cancers (three). Reverse transcription-polymerase chain reaction (RT-PCR) detected PAP mRNA in these ISH-positive cases. PAP mRNA was not detected in noncancerous portions, benign disease tissues, or normal organs except for the small intestine. There was no relationship between PAP mRNA expression and any clinicopathological factors.

Effect of gegen-tang on painful gynecomastia in patients with liver cirrhosis: a brief report

Four patients with liver cirrhosis and complaining of painful gynecomastia were treated with oral administration of Gegen-Tang (TJ-1). Pain disappeared in 3 patients in one week, and in one patient in 4 weeks. The size of gynecomastia did not change significantly on mammography, but palpable induration diminished or disappeared. The patients had been treated with Chaihu (saiko) group drugs for liver diseases, and TJ-1 was used in combination with these drugs. Serum levels of estrogen, progesterone, testosterone, and other sex hormones did not change significantly after TJ-1 treatment. These results suggest that TJ-1 could be used for the painful gynecomastia that is occasionally seen in cirrhotic patients.

Frequent loss of p16 expression and its correlation with clinicopathological parameters in pancreatic carcinoma

Expression of the p16 gene product in human primary pancreatic carcinoma (PC) was investigated in paraffin-embedded tissue using a monoclonal antibody against p16 protein, clone G175-405, by means of immunohistochemistry, and the correlation of results with various clinicopathological parameters was evaluated. All six cases of normal pancreas and all but 1 of 20 cases of chronic pancreatitis expressed p16 protein, whereas 37.5% (3 of 8) of cystadenomas and 41. 9% (26 of 62) of PCs lost p16 expression. There was a significant difference between chronic pancreatitis and PC for frequency of the loss of p16 expression (P < 0.01). Moreover, loss of p16 expression in pancreatic malignancy was significantly associated with histological grade (G1 versus G2 and G3, P < 0.01) but not with sex, age, clinical stage, tumor location, or resectability. The survival period was shorter and metastasis is more likely in those cases that did not show p16 expression than those that did.

Undifferentiated (anaplastic) carcinoma of the pancreas showing sarcomatous change and neoplastic cyst formation

CONCLUSION

Pancreatic undifferentiated (anaplastic) carcinoma contained two components: sarcomatous change of spindle-cell type and a neoplastic cyst. Immunohistochemical analysis suggested that both the sarcomatous and the cystic portions were of epithelial origin. This case showed a "dual" differentiation both into the sarcomatous change and into the cystic lesion.

BACKGROUND

Pancreatic sarcoma or sarcomatous change is very rare. The origin of sarcomatous change is unknown. On the other hand, pancreatic adenocarcinoma sometimes shows necrosis and forms a cystic lesion during its growth, but a neoplastic cyst formation is very rare except for cystadenomas.

METHODS

We report a case of pancreatic undifferentiated (anaplastic) carcinoma associated with sarcomatous change and neoplastic cyst formation. Clinicopathological and immunohistochemical analyses were performed.

RESULTS

A 75-yr-old male was admitted because of low back pain and body weight loss. He died 7 d after admission presenting obstructive jaundice. Autopsy disclosed that the large mass was a poorly differentiated ductal adenocarcinoma, which mostly consisted of sarcomatous components of spindle-cell type. The cystic lesion was a neoplastic cysts with the wall composed of epithelial tumor cells. There was no necrosis or hemorrhage in the cystic cavity. Immunohistochemical analyses suggested that both the tumor and the cystic lesion were of epithelial origin. Sarcomatous changes were recognized also in the metastatic lesions in the liver and lymph nodes. The tumor is considered to be labeled undifferentiated (anaplastic) carcinoma of the pancreas.

Prolonged intrahepatic cholestasis in acute-onset, severe autoimmune hepatitis

A 72-year-old woman was admitted because of jaundice and hepatocellular dysfunction. She was diagnosed with autoimmune hepatitis from laboratory test results showing high titers of antinuclear antibodies and negativity for hepatitis viral markers. Steroid i.v. pulse therapy and oral administration of prednisolone were effective in improving the liver function test results, except for hyperbilirubinemia. Elevated serum bilirubin levels, of approximately 20 mg/dl persisted for more than 6 months, despite the administration of ursodeoxycholic acid. Insulin-glucagon therapy was given for normalization of transaminases and then withdrawn 3 weeks after admission, but it was resumed at 3 months, resulting in a dramatic decrease in serum bilirubin levels, which then normalized in 2.5 months. Liver biopsy 6 months after onset showed chronic active hepatitis with bile plugs. Insulin-glucagon therapy, because of its choleretic effect, may be worth continuing even after recovery of acute hepatic failure.