Primary Mediastinal Germ Cell Tumor in a Middle-Aged Woman: Case Report and Literature Review

Although primary mediastinal germ cell tumors are found much more frequently among young males than among other people, we recently encountered a middle-aged woman with the disease. The patient was a 59-year-old woman who complained mainly of anterior chest pain. Chest CT scans revealed a nonhomogeneous mass measuring 7 x 7 cm in the anterior mediastinal area, accompanied by signs suggestive of mediastinal invasion of the tumor. Reduction surgery was performed. The pathologic diagnosis was mediastinal dysgerminoma. The patient received postoperative radiochemotherapy but died due to liver metastasis 11 months after surgery.

Gluteal Abscess Caused by Perforating Rectal Cancer: Case Report and Review of the Literature

An unusual case is described in which an abscess developed remote from a carcinoma of the rectum. A 52-year-old Japanese man developed a gluteal abscess six months after radiation therapy for unresectable carcinoma of the rectum. This case is presented with a review of the literature. Perforating carcinoma of the colon and rectum with abscess formation is best treated by preliminary total diversion colostomy and local drainage of the abscess. However, the mortality rate is still high.

Patients with End-stage Interstitial Lung Disease may have More Problems with Dyspnea than End-stage Lung Cancer Patients

Introduction:

Patients with end-stage interstitial  lung disease (ILD) do not appear to receive adequate palliative care despite apparent suffering before death. The aim of this study was to evaluate their signs, symptoms, and treatment received before death.

Methods:

Patients with ILD and lung cancer (LC) who were hospitalized and died in our hospital were enrolled retrospectively. Signs and symptoms and treatments at 7 days, 3 days, and 1 day before death were evaluated and compared between the two groups of patients.

Results:

A total of 23 patients with ILD and 59 patients with LC group were eligible for participation. Significantly more LC patients had loss of consciousness than ILD patients on 7 days (ILD: LC = 1 [5.6%]:24 [41%], P = 0.013), 3 days (1 [5.6%]:33 [56%], P < 0.001). Significantly more ILD patients had dyspnea than LC patients on 3 days (16 [89%]:38 [64%], P = 0.047) 1 day before death (21 [91%]:33 [56%], P = 0.001). On 1 day before death, significantly more LC patients received morphine than ILD patients (2 [8.7%]: 14 [24%], P = 0.015). More ILD patients received sedation (11 [48%]: 11 [19%], P = 0.007).

Conclusions:

End-stage ILD patients may experience dyspnea more frequently than terminal LC patients, and they need sedation. Morphine should be administered to ILD patients who have dyspnea. Additional prospective studies are needed.

Prognostic factors in patients with terminal stage lung cancer

BACKGROUND

Lung cancer is the leading cause of cancer-related death.(1) Accurate prediction of survival in the terminal stage is important, because it may help patients make a rational decision. Although several prognostic scores have been described as effective indicators of outcome, these scores were intended for patients with other types of cancers. There is no prognostic score for patients with terminal-stage lung cancer.

OBJECTIVE

The aim of this study was to determine prognostic factors for patients with terminal-stage lung cancer.

SETTING/SUBJECTS

Patients in our palliative care unit (PCU) were selected retrospectively and divided into two independent groups, training and testing. Univariate and multivariate analyses were performed on data from the training group to detect independent prognostic factors, while data from patients in the testing group were analyzed to validate whether these prognostic factors predicted near-term death.

RESULTS

Ninety-three patients (69 in the training group and 24 in the testing group) were included in the analyses. Multivariate analysis showed that fatigue, anorexia, desaturation, hyponatremia, and hypoalbuminemia were independent prognostic factors in the training group. Mean survival time in patients who had more than three of these five factors was 9.2±2.6 days (p=0.012). In the testing group, the presence of more than three of these five factors predicted death within two weeks, with a sensitivity of 100% and specificity of 75%.

CONCLUSIONS

This study revealed that fatigue, anorexia, desaturation, hyponatremia, and hypoalbuminemia may be short-term prognostic factors in terminally ill lung cancer patients. In particular, the presence of more than three of these factors predicted death within two weeks.

EFFICACY OF MULTI-SLICE COMPUTED TOMOGRAPHY CHOLANGIOGRAPHY BEFORE LAPAROSCOPIC CHOLECYSTECTOMY

BACKGROUND

Bile duct injury is one of the serious surgical complications of laparoscopic cholecystectomy (LC). Clear biliary tract imaging to detect the anomaly of the bile ducts before operation is thought to be useful to prevent this complication. The objective of this study was to investigate the preoperative feasibility of using multi-slice computed tomography scanning after drip infusion cholangiography-computed tomography (DIC-CT) for LC.

METHODS

Laparoscopic cholecystectomies were carried out in 33 patients and DIC-CT and magnetic resonance cholangiography (MRC) were also carried out in all of these patients. We evaluated the recognition of the junction of the cystic duct and detection of anomalies of the extrahepatic bile ducts using the latter two methods.

RESULTS

In 33 patients, DIC-CT showed the junction of the cystic duct in 31 (94%) and MRC in 25 (76%) patients, respectively. Anomalies of the extrahepatic bile ducts or the cystic duct were detected in four (12%) patients by DIC-CT, but MRC could show only one of these lesions. There were no major adverse reactions in either examination.

CONCLUSION

DIC-CT is an efficacious preoperative technique as compared with MRC for the biliary tract imaging. DIC-CT may be of benefit for both patients scheduled to undergo LC and their surgeons.

Tissue oxygen saturation during colorectal surgery measured by near-infrared spectroscopy: pilot study to predict anastomotic complications

INTRODUCTION

We investigated the relation between tissue oxygen saturation measured by near-infrared spectroscopy (NIRS) and anastomotic complications associated with colorectal surgery.

METHODS

A series of 20 patients with colorectal cancer underwent radical surgery with enteric anastomosis. Measurements of tissue oxygen saturation (StO2) were performed at both the proximal and distal portions of the anastomotic site; in cases of anterior resection, we measured StO2 only in the proximal portion.

RESULTS

Two anastomotic complications (one leakage, one stenosis) occurred in the 20 cases. The StO2 in patients with anastomotic complications was 58.0%, and that in patients without complications was 71.0%. Altogether, 18 patients had StO2 values > 66%, and none of them had anastomotic complications. In contrast, 2 patients had StO2 values < 60%, and both had anastomotic complications.

CONCLUSIONS

The StO2 of the anastomotic site can be safely and reliably measured by NIRS during colorectal surgery. Low StO2 on both sides of the anastomosis may indicate an increased risk of anastomotic complications. Further study is needed to determine the cutoff value for StO2 required to prevent serious complications.

Duct-narrowing chronic pancreatitis without immunoserologic abnormality: comparison with duct-narrowing chronic pancreatitis with positive serological evidence and its clinical management

We reviewed the clinical features and clinical course of patients with duct-narrowing chronic pancreatitis who were negative for immunoserologic test results (n = 16) in comparison with the findings for serological test-positive patients (n = 20) in order to determine an adequate treatment for those who had typical morphology of autoimmune pancreatitis in the absence of immunoserologic abnormality. No significant differences were found between the two groups of patients in clinical profiles including associated autoimmune-related diseases, pancreatic histology, and response to steroid therapy. Of the seronegative patients, eight who showed an improvement in narrowing of the main pancreatic duct with steroid therapy and three who did no show an improvement or who relapsed after surgical resection without this therapy had stenosis of the common bile duct with increased levels of serum hepatobiliary enzymes, except for two patients with affected sites limited to the body or tail of the gland. For the remaining five patients, who showed an improvement in pancreatic duct changes or long-term remission after surgery without steroid administration, normal biochemistry test results for liver functions were obtained, with no abnormal cholangiographic findings in the three patients examined. Duct-narrowing chronic pancreatitis without immunoserologic abnormality overlaps in clinical features with that fulfilling the immunoserologic criteria for a diagnosis of autoimmune pancreatitis. In particular, the disease with bile duct involvement should be treated clinically as autoimmune pancreatitis, for which steroid therapy is recommended, even if an autoimmune mechanism is not demonstrated serologically.

[A case of transverse colon cancer with left supraclavicular lymph node metastasis and paraaortic lymph node metastases responding to TS-1]

A 61-year-old man was seen at our hospital because he noticed a mass on the left side of his neck. After examinations, he was diagnosed as transverse colon cancer with the left supraclavicular lymph node metastasis and paraaortic lymph node metastases. Rt. hemicolectomy was performed for the transverse colon cancer. At 15 days after operation, TS-1 chemotherapy was started (each treatment course consisted of daily oral administration of 100 mg TS-1 for 4 weeks followed by 2 drug-free weeks). After the first course, the left supraclavicular lymph node had shrunk markedly in physical findings. After the second course, both the left supraclavicular lymph node metastasis and paraaortic lymph node metastases had disappeared in CT findings. A complete remission was observed after the second course, and was maintained thereafter. The serum level of CA 19-9 decreased from 62 U/ml under the normal value after the second course, and was kept under this normal value. Leukopenia and eruption (grade 2) were the only observed adverse effects. This patient continues to undergo outpatient treatment with good QOL.

Long-term prognosis of duct-narrowing chronic pancreatitis: strategy for steroid treatment

OBJECTIVES

The purpose of this study was to assess the long-term prognosis in patients with duct-narrowing chronic pancreatitis (DNCP) and determine the indications for steroid therapy.

METHODS

We evaluated clinical and imaging outcomes in patients with DNCP classified into 3 groups (A, B, and C) according to the treatment given. Group A included 6 patients who underwent surgical resection. Groups B and C included 21 and 10 patients treated medically with and without steroid therapy, respectively.

RESULTS

In group A, 2 patients relapsed in the remnant pancreas. In group B, pancreatic swelling was resolved in all the patients, and moreover, both the irregular narrowing of the main pancreatic duct (MPD) and the strictures of the common bile duct (CBD) improved after initiation of corticosteroid therapy in all but 1 of the patients, including 5 without immunoserologic abnormality. However, clinical recurrences occurred in 4 patients (19%) during or after the maintenance therapy. In group C, all the patients showed an improvement in swelling of the gland, while only 5 showed improvement of pancreatic duct involvement. Four of these 5 patients did not show any serologic data suggesting autoimmune abnormality or CBD involvement. In all the other 5 patients in whom MPD irregularities did not improve, bile duct strictures or positive immunoserologic test results were noted.

CONCLUSIONS

Steroid therapy is effective for improving pancreatic duct and bile duct lesions in patients with DNCP and is indicated particularly in those with CBD strictures or immunoserologic abnormality, although some patients have recurrences.

[A case of paraaortic lymph nodes metastases responding to TS-1 following surgery for gastric cancer]

A 58-year-old man underwent distal gastrectomy with a D2 lymph adenectomy for advanced gastric cancer (pStage IIIB). Seven months later, abdominal CT revealed multiple paraaortic lymph nodes metastases. Radiation therapy was not effective, so TS-1 chemotherapy was started (each treatment course consisted of daily oral administration of 100 mg TS-1 for 4 weeks followed by 2 drug-free weeks). The CT findings revealed that the metastatic lesion had shrunk markedly after the first course. A complete response was observed after the fifth course, and was maintained thereafter. The serum level of CEA decreased from 337 to 2.7 ng/ml after the third course, but gradually rose again and stayed between 30 and 50 ng/ml. Although the re-elevation of serum CEA level suggested the existence of a recurrent lesion, no sign of recurrence was found by radiographical or endoscopic examinations. Leukocytopenia and anemia (grade 2) were the only observed adverse effects. This patient continues to undergo outpatient treatment with good QOL.

Gastric cancer occurred after coronary artery bypass grafting using the right gastroepiploic artery

We recently encountered a rare case where gastric cancer developed in the long-term postoperative stage after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) and distal partial gastrectomy was performed to treat the cancer. The patient was a 64-year-old man. In November 2001, he underwent three-vessel CABG, involving bypassing between the right coronary artery (RCA) and the RGEA, to treat an old myocardial infarction. In May 2003, he was admitted to our hospital because of exacerbation of diabetes mellitus and anemia. Gastric endoscopy revealed gastric cancer affecting the pylorus. Preoperative abdominal angiography showed the RGEA graft remained well patent. In June 2003, he underwent distal partial gastrectomy and regional lymph node dissection. Because the RGEA had been freed adequately to the point of bifurcation of the gastroduodenal artery during the previous CABG, the RGEA graft was preserved during distal partial gastrectomy. When the RGEA is used for CABG, it seems advisable to free the RGEA adequately to a point of bifurcation of the gastroduodenal artery. If done so, regional lymph node dissection around the RGEA is easier to perform when gastric cancer has occurred in these cases, eventually reducing the risk for injury of the graft. Following CABG with the RGEA, it seems essential to perform periodical checks for gastric cancer to facilitate early detection of gastric cancer. The necessity of close follow-up of these cases is endorsed by the fact that healing of gastric cancer by endoscopic mucosal resection (EMR) is highly probable if the cancer is detected at early stages.

Advanced lung cancer invading the left atrium wall treated with pneumonectomy and combined resection of the left atrium using stapling devices: report of two cases

In chest surgery, stapling devices are primarily used to close bronchi. However, they are also used for dissection and suturing between lung lobes, resection and plication of lung tissue (including bullae), combined resection of the superior vena cava, closure of the pulmonary great vessels, closure of the left atrium following combined resection of the left atrium, and so on. We recently treated two cases of advanced lung cancer, which had invaded the left atrial wall, with pneumonectomy and combined resection of the left atrium using stapling devices, and obtained favorable results. For combined resection of the left atrium, it is safer to use stapling devices than vascular clamps, since the latter involve the risk of dislocation during use. Furthermore, since stapling devices require no margin for suturing, the left atrium can be resected at a point sufficiently distant from the cancer, thus allowing for highly radical resection. Stapling devices are also useful because they can be manipulated even within narrow operative fields. When dealing with lung cancer requiring combined resection of the left atrium, pneumonectomy is needed in most cases. When performing surgery for these cases, it is essential to first close and divide the bronchi and pulmonary arteries and veins as far as possible so that adequate adherence around the left atrium can be developed and the entire lung can be lifted up, followed by resection of the left atrium with a stapling device applied to the left atrium without any tension.

[Chondromatous hamartoma of the lung with a unique demonstration on diagnostic imaging; report of a case]

A case of pulmonary hamartoma is reported with clinical, roentgenographical and histopathologic findings. The patient was a 53-year-old woman who had undergone right hemithyroidectomy for thyroid cancer 4 years before. An abnormal shadow, which was a non-clearly demarcated tumor, 2 cm in diameter, in the left middle lung field, was noted on her routine X-ray in February 2001. Physical examination and laboratory data revealed no significant findings, but computed tomography(CT) scans of the chest showed a gathering of small-sized high-density lesions in the nodule. She underwent left S8 segmentectomy on March 21, 2001. The pathology report on the frozen section was pulmonary hamartoma. Histopathologically, the lesion was characterized by a composition of bronchial epithelium, fat tissue and cartilage, with being diagnosed as a chondromatous hamartoma of the lung. The patient's postoperative course was uneventful, and she was discharged with no supportive therapy 14 days after the operation. To date, 14 months after the operation, the patient has been in good condition, without evidence of recurrence or distant metastasis on diagnostic imaging. This case is particularly interesting because a gathering of small-sized pulmonary hamartoma was demonstrated by imaging.

Clinical and imaging features of autoimmune pancreatitis with focal pancreatic swelling or mass formation: comparison with so-called tumor-forming pancreatitis and pancreatic carcinoma

OBJECTIVES

Autoimmune pancreatitis (AIP) with a mass formation or swollen pancreas located in one or two segments of the gland (focal type AIP) has been reported. The aims of this study were to elucidate the relationship of the disease entity between this focal variant and so-called tumor-forming pancreatitis (TFP) and to describe the clinical and imaging features discriminating focal AIP from pancreatic carcinoma (Pca).

METHODS

The clinical, radiologic, and pathologic profiles of nine patients with focal AIP were reviewed retrospectively and compared with those of 11 patients with alcohol-induced TFP and 80 patients with Pca.

RESULTS

The patients with focal AIP were predominantly older (mean age 64.7 +/- 13.6 yr, range 28-78 yr), male, and presenting with obstructive jaundice or focal pancreatic enlargement accompanied by mild abdominal symptoms. In comparison, the patients with alcohol-induced TFP who were mostly middle-aged (mean age 50.1 +/- 7.95 yr, range 39-62 yr), male, and often had attacks of pancreatitis associated with findings of CT scans showing pseudocysts or peripancreatic effusion. Focal AIP usually demonstrated no abnormalities on pancreatograms downstream from the stricture or obstruction and often presented few contrast-filled side branches in the area of main pancreatic duct (MPD) stenosis. These characteristics were similar to the imaging features of Pca. Significant factors differentiating focal AIP from Pca were lower serum levels of CA19-9, homogeneous delayed enhancement evident in dynamic CT scans, and ERCP findings exhibiting a longer stenosed MPD and a thinner MPD upstream from the stricture.

CONCLUSIONS

Focal AIP is associated with clinical and radiologic features that are different from those of alcohol-induced TFP. In TFP there are two causative factors, namely, AIP and alcohol-induced chronic pancreatitis. Differential diagnosis of focal AIP from Pca seems to be possible in many cases by evaluating imaging findings such as dynamic CT and ERCP, although focal AIP sometimes shows clinical and radiologic features similar to those of Pca.

Clinical and imaging features of autoimmune pancreatitis with focal pancreatic swelling or mass formation: comparison with so-called tumor-forming pancreatitis and pancreatic carcinoma

OBJECTIVES

Autoimmune pancreatitis (AIP) with a mass formation or swollen pancreas located in one or two segments of the gland (focal type AIP) has been reported. The aims of this study were to elucidate the relationship of the disease entity between this focal variant and so-called tumor-forming pancreatitis (TFP) and to describe the clinical and imaging features discriminating focal AIP from pancreatic carcinoma (Pca).

METHODS

The clinical, radiologic, and pathologic profiles of nine patients with focal AIP were reviewed retrospectively and compared with those of 11 patients with alcohol-induced TFP and 80 patients with Pca.

RESULTS

The patients with focal AIP were predominantly older (mean age 64.7 +/- 13.6 yr, range 28-78 yr), male, and presenting with obstructive jaundice or focal pancreatic enlargement accompanied by mild abdominal symptoms. In comparison, the patients with alcohol-induced TFP who were mostly middle-aged (mean age 50.1 +/- 7.95 yr, range 39-62 yr), male, and often had attacks of pancreatitis associated with findings of CT scans showing pseudocysts or peripancreatic effusion. Focal AIP usually demonstrated no abnormalities on pancreatograms downstream from the stricture or obstruction and often presented few contrast-filled side branches in the area of main pancreatic duct (MPD) stenosis. These characteristics were similar to the imaging features of Pca. Significant factors differentiating focal AIP from Pca were lower serum levels of CA19-9, homogeneous delayed enhancement evident in dynamic CT scans, and ERCP findings exhibiting a longer stenosed MPD and a thinner MPD upstream from the stricture.

CONCLUSIONS

Focal AIP is associated with clinical and radiologic features that are different from those of alcohol-induced TFP. In TFP there are two causative factors, namely, AIP and alcohol-induced chronic pancreatitis. Differential diagnosis of focal AIP from Pca seems to be possible in many cases by evaluating imaging findings such as dynamic CT and ERCP, although focal AIP sometimes shows clinical and radiologic features similar to those of Pca.

Use of a silicone T-tube for management of a tracheal injury in a patient with cervical blunt trauma

A 71-year-old woman fell forward hitting the anterior part of her neck against a table. Bronchoscopy revealed deformation of the cartilage crescent in the cervical trachea (suggestive of cartilage contusion) and a longitudinal tear in the membranous region. Because subcutaneous emphysema and dyspnea developed and progressed, we made a tracheostomy and inserted a silicone T-tube through the stoma to relieve intraluminal pressure. This then served as a stent for the airway after the patient had progressed through the acute stage. The subcutaneous emphysema and pneumomediastinum abated gradually during the 7 days after insertion of the T-tube, which remained in the cervical trachea as a tracheal stent for 2 months thereafter. The T-tube is easy to manage and can be inserted through the stoma without major surgery. As an alternative to tracheotomy, the T-tube is nonirritating, allows speech, aspiration of sputum, and respiration through the nasopharynx, and in general requires little if any special maintenance or cleaning. Furthermore, a relatively long T-tube can be used, and so the stent can occupy a longer section of the trachea than can a tracheostomy tube. We recommend the placement of a T-tube to provide a useful stent for cervical tracheal injury.

Salvage surgery for primary non-Hodgkin's lymphoma of the thyroid gland with histopathological complete response to radio-chemotherapy: report of a case

A 74-year-old woman was admitted to a local hospital for investigation of a rapidly growing mass in her neck, and exertional dyspnea. An open biopsy confirmed a diagnosis of non-Hodgkin's lymphoma of the thyroid (NHLT), of a diffuse large cell type. The patient was referred to our department for radio-chemotherapy for stage I E NHLT. She was given radiotherapy in the form of 40 Gy radiation directed at her neck and superior mediastinum, with one course of chemotherapy using cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP). After radio-chemotherapy, the tumor was obviously smaller. Because the patient refused further chemotherapy, she underwent salvage surgery, after being sufficiently advised, and with her informed consent. Histological examination of the removed thyroid tissue showed that the radio-chemotherapy had produced a complete response. Thus, we believe that an open biopsy should be performed early to confirm the diagnosis of lymphoma histologically and to determine the degree of malignancy. We also stress the fact that NHLT is presently most effectively treated by radiotherapy combined with several courses of CHOP chemotherapy. The role of surgery in the treatment of NHLT is diminishing.

Cardiac herniation following intrapericardial pneumonectomy with partial pericardiectomy for advanced lung cancer

We present in this paper a case of cardiac herniation following right intrapericardial pneumonectomy after induction chemotherapy. A 52-year-old man with advanced squamous cell carcinoma of the lung was admitted to our hospital suffering from a dry cough and chest pain. An intrapericardial pneumonectomy with partial pericardiectomy (4 x 4 cm) was performed. The pericardial defect was left open. Just prior to removal of the tracheal tube, cardiac herniation occurred with hypotension, arrhythmia and cardiac arrest. A chest X-ray revealed cardiac herniation into the right hemithorax. Re-thoracotomy was performed and the heart was returned to its normal position and the pericardial defect was immediately repaired with an expanded polytetrafluoroethylene (EPTFE) patch. The patient's postoperative course was uneventful. Unless prompt diagnosis and surgical treatment can be accomplished, cardiac herniation can be a fatal complication. We recommend that when pneumonectomy is performed, pericardial defects should be closed with a prosthetic patch, regardless of the defect's size.

Left upper division sleeve segmentectomy for early stage squamous cell carcinoma of the segmental bronchus: report of two cases

Early hilar lung cancer is rare. It is usually curable if properly diagnosed and treated. We recently encountered two cases of early stage squamous cell carcinoma of the left upper division bronchus, which responded well to left upper division sleeve segmentectomy. Case 1 was a 74-year-old man, a heavy smoker, who was referred to our hospital after sputum cytology had resulted in a positive diagnosis while receiving inpatient care for heart failure at another hospital. Bronchoscopy revealed a thickened tumor at the spur between left B(1+2) and B(3). Squamous cell carcinoma was diagnosed by forceps biopsy via bronchoscopy. Left upper division sleeve segmentectomy with lymph node dissection was performed. Since the bronchi to be anastomosed to each other were greatly different in diameter, telescoped anastomosis was used. His postoperative course was uneventful, and he continues to show good respiratory condition, without any evidence of recurrence 25 months after surgery. Case 2 was a 60-year-old man, a heavy smoker, who was identified by sputum cytology as needing detailed examination during a mass screening of high-risk groups for early detection of lung carcinoma. Bronchoscopy revealed a nodular tumor at the orifice of the left upper division bronchus. Squamous cell carcinoma was diagnosed by forceps biopsy via bronchoscopy. Left upper division sleeve segmentectomy with lymph node dissection was performed. During surgery for this case, the lingular bronchus was dissected obliquely to make its cross-section wide enough to match the diameter of the left upper lobe bronchus to which the former was anastomosed. His postoperative course was uneventful, and he shows good respiratory condition, without any evidence of recurrence five months after surgery. The pathological stage was TisN0M0 (stage 0) in both patients, and their tumors were confirmed as early hilar lung cancer. Sleeve segmentectomy, aimed at radical resection of cancer while preserving lung function, can serve as a standard procedure for surgical treatment of cases of early hilar lung cancer confined to the segmental bronchi.

Clinical study of chronic pancreatitis with focal irregular narrowing of the main pancreatic duct and mass formation: comparison with chronic pancreatitis showing diffuse irregular narrowing of the main pancreatic duct

INTRODUCTION

Main pancreatic duct (MPD)-narrowed chronic pancreatitis (CP) may be an autoimmune abnormality. It also has been called autoimmune pancreatitis and sclerosing pancreatitis. It is unclear whether cases with focal pancreatographic changes are part of the same clinical entity as cases with diffuse MPD changes.

AIM AND METHODOLOGY

We reviewed seven cases of chronic pancreatitis (CP) with focal narrowing of the main pancreatic duct (MPD), evidenced by endoscopic retrograde cholangiopancreatography (ERCP), and swelling of one or two segments of the pancreas, evidenced by ultrasonography (US) /computed tomography (CT), and indicated the clinicopathologic features of focal-type MPD-narrowed CP.

RESULTS

The patient group comprised six men and one woman, and their age range was 28-75 years, with a mean of 63.7 years. Affected sites were in the head in two patients, the body in one patient, the tail in one patient, and the body and tail in three patients; ERP showed narrowing in six patients and obstruction in one. Stricture of the lower portion of the common bile duct (CBD) that caused obstructive jaundice was shown by ERC in two cases in which the pancreas head was affected. In all six patients, a dynamic study by CT or MRI homogeneously showed delayed enhancement of involved segments of the pancreas. Serum levels of pancreatic enzyme were elevated in five patients, but only one subject had pancreatitis-like epigastric pain. Serological evidence suggestive of autoimmune abnormality was detected in only three patients with hypergammaglobulinemia (> or =2.0 g/dL) or positive titers of antinuclear antibody (ANA; > or =80). Histological assessment was available for five patients, who characteristically had dense lymphocytic or plasmocytic infiltration with severe fibrosis that caused luminal narrowing. The clinical, serologic, and histologic findings as described above were comparable to those for 12 CP patients with diffuse narrowing of the MPD, diagnosed during the same period. Surgical resection was performed in 5 patients, in 2 of whom a similar inflammatory process recurred in the remnant head of the pancreas, whereas pancreatitis no longer developed in the other 3 patients. One patient was initially treated with steroids, with clinical remission, although there was neither hypergammaglobulinemia nor positive ANA.

CONCLUSION

These results indicate that CP with focal narrowing of the MPD is part of the same clinical spectrum as CP with diffuse narrowing of the MPD, and whether the distribution is diffuse or focal seems to be related to the stage or the extent of the disease. It is therefore important to recognize the possible existence of this focal variant to avoid unnecessary surgery.

Immunohistochemical study of p53, c-erbB-2, and PCNA in barrett's esophagus with dysplasia and adenocarcinoma arising from experimental acid or alkaline reflux model

PURPOSE

An immunohistochemical study of p53, c-erbB-2, and proliferating cell nuclear antigen (PCNA) in Barrett's esophagus with dysplasia and adenocarcinoma, arising from experimental acid or alkaline reflux, was performed in dogs.

METHODS

Cardiectomy was performed in group A (n = 26) as an acid reflux model, and total gastrectomy was performed in group B (n = 24) as an alkaline reflux model. After surgery, the esophageal mucosa was observed and biopsied endoscopically every 3 months over a period of 6 years. Immunohistochemical staining of p53. c-erbB-2, and PCNA was performed, using biopsied specimens.

RESULTS

In group A, Barrett's esophagus developed in 14 of the 26 dogs. Low-grade dysplasia occurred in 5 of the 26 dogs, and in 1 of these 5 dogs, it developed into high-grade dysplasia. In this animal, adenocarcinoma arose 63 months after the operation. In group B, Barrett's esophagus developed in 10 of the 24 dogs. Low-grade dysplasia was observed in 4 of the 24 dogs. In 1 of these 4 dogs, the dysplasia became high-grade and adenocarcinoma occurred 66 months after the operation. In group A, PCNA was positive in adenocarcinoma; the PCNA labeling index (LI) was 58. c-erbB-2 and p53 were negative in all animals in group A. In group B, PCNA was positive in Barrett's esophagus with high-grade dysplasia and adenocarcinoma; the PCNA LI was 77. p53 was positive in adenocarcinoma. c-erbB-2 was negative in adenocarcinoma. CONCLUSIONS; The results of this study provided evidence of the dysplasia-carcinoma sequence arising from alkaline reflux, as well as from acid reflux. To the best of our knowledge, this is the first report of the use of an alkaline reflux model and a 6-year study using dogs to observe the course of Barrett's esophagus.

Intrathoracic free musculocutaneous flap after open-window thoracostomy for chronic empyema

An 85-year-old man was suffering from right pyothorax caused by methicillin-resistant staphylococcus aureus (MRSA). The empyema cavity was closed by intrathoracic implantation of a free rectus abdominis musculocutaneous (MC) flap using microvascular surgery 2 months after open-window thoracostomy (OWT). Compared with a pedicled MC flap, a free flap has the advantage that it can close a larger empyema cavity since the whole flap can be inserted into the cavity. Although the use of a free MC flap requires a two-stage operation, this method is believed to be more successful for controlling chronic empyema than any other established procedure, including decortication, thoracoplasty or pleuropneumonectomy.

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.

Desmoid tumor of the chest wall following chest surgery: report of a case

Desmoid tumors of the chest wall following chest surgery are a rare occurrence. A case of this disease is reported herein together with a review of the literature. A 74-year-old man, who had previously undergone a right lower lobectomy for squamous cell carcinoma of the lung, was referred to our hospital with an abnormal shadow on his chest X-ray. The tumor, located in the right lateral chest wall, was successfully resected by an aggressive, wide extirpation, and a final diagnosis of a desmoid tumor originating in the chest wall was made. When following up patients after surgery for lung cancer, the possibility of desmoid tumors developing in the incised chest wall should therefore be kept in mind.

[The effects of marital communication and social activity on alienation in married women and men]

Effects of marital communication and friendship- and job-related social activities on emotional support and alienation among married women and men were examined. Causal analyses of questionnaire responses by 259 women and 185 men indicated that for both women and men, richness of marital communication made the spouse more important as the agent of emotional support, and at the same time decreased alienation. Job-related activities decreased women's alienation, while they tended to increase men's alienation. Men's social activities had a negative influence on their marital relation. In short, women and men appeared to seek different psychological functions in social activities, which in turn determined their levels of alienation.

[Social network and social support for married women and their spouses]

This study investigated various psychological aspects of social networks of married women and their spouses A survey data for 259 women and 185 men were analyzed, and main findings were as follows: 1. With marriage, support agents of women and men change extensively in their social networks. Wives have more variety in support agents within their social network, through children to their friends' parents. On the other hand, husbands' agents are likely to be confined to their wives and children. 2. Wives and husbands are similar in that their first choice for seeking advice is their spouse. A friend is the second choice for both of them. While parents, brothers and sisters serve as wives' third choice, there is no third for husbands. 3. Enrichment of wives' social network, based on a well-functioning relationship with husbands, leads to a lower degree of social isolation experienced by them.

[The role of catalase in histologic changes of acute experimental pancreatitis]

We produced acute biliary reflux pancreatitis by an injection of auto-bile in 31 young mongrel dogs. We divided into control group (n = 10), catalase administration group (B1 group, n = 17) and no-administration group (B2 group, n = 14). We studied the histologic changes of the brain tissue in those groups. There was no significant difference in the survival rate between group B1 and B2. In the histologic findings, ischemic cell changes were dominant in both groups within one month, but after 3 or 6 months after operation in group B2, satellitosis and/or neuronophagia was recognized as the irreversible changes. The lipid peroxides level was significant high in group B2. Consequentially, it is natural to think that the production of free radicals have been inhibited by catalase and the histologic changes in the brain in group B1 have been light.

A new surgical procedure consisting of ligation of the common hepatic artery and auto-transplantation of hepatocytes into the spleen for end stage liver cirrhosis accompanied by ascites

The authors developed a new surgical procedure for end stage liver cirrhosis associated with ascites. This procedure consists of ligation of the common hepatic artery and hepatocyte inoculation into the spleen (method A) and in this study is compared with common hepatic artery ligation alone (method B). Six of the eleven dogs operated by method A survived for six months or more with a significant (P < 0.01) difference in the three month survival in comparison with method B. In the hemodynamic study of both methods, the portal vein pressure and portal resistance decreased as a result of operation, but in method B, they returned to preoperative levels and in method A the low levels persisted for more than one year. In our method, liver function improved remarkably after three months. The hepaplastin and the cholinesterase levels increased after three months in method A with a significant difference (P < 0.01) in comparison with method B. The labeling index (L.I.) of intrasplenic hepatocytes also increased three months later. We emphasize that our method is an ideal procedure not only to improve portal haemodynamics but also to improve liver function, in end stage cirrhosis.

Predicting histologic findings from endoscopic appearance of early gastric cancer

In 156 cases of depressed early gastric cancer in the antrum or corpus, the differences between differentiated and undifferentiated carcinoma were studied by comparing the histological diagnosis of the resected specimens and their endoscopic appearance. We reached the following conclusions: (a) Younger patients more often had undifferentiated carcinoma (mean age: 59.8 years) than differentiated carcinoma (mean age: 77.2 years). (b) One hundred and twenty-five of 156 cases were limited to the mucosa and 29 cases were limited to the submucosa. (c) Undifferentiated gastric cancers more often invaded beyond the mucosa even when the tumor was small than did differentiated tumors. (d) Many differentiated tumors showed a smooth depressed surface, erythema at the edge of the cancer, and tapering of the gastric rugae. (e) In undifferentiated lesions the depressed tumor surface had a varied appearance, with various sized granules and nodules, as well as fading of the mucosal color and fusion of the rugae. It is important at endoscopy to consider not only whether a lesion is benign or a malignant, but also to consider its histological type. In particular, it is vital to detect small, undifferentiated gastric cancers as early as possible.

[Adenomyoma in association with early gastric carcinoma]

Described is a gastric adenomyoma associated with superficial gastric adenocarcinoma that was found in a 72-year-old male. This uncommon benign gastric lesion is believed to be developmental in origin and sometimes categorized as belonging to a subgroup of a heterotopic pancreas. Besides its rarity, an adenomyoma is also known to be a possible cause of a gastric malignancy. Although the focus of the carcinoma in our case was located in the center of the adenomyoma, this finding cannot support the etiology of a gastric carcinoma originating in an adenomyoma. However, the present case appears to imply some relationship between an adenomyoma and a gastric carcinoma.

[A hepatocellular carcinoma revealed by paraplegia caused by a vertebral metastasis]

Described is a 57-year-old male with a complaint of a gait disturbance. On admission to hospital, he was suffering from almost complete paraplegia. Roentgenograms of the spine showed extensive destruction in the body of the second thoracic vertebra. Magnetic resonance computed tomography revealed a vertebral tumor that was compressing the vertebral cord. Thus, a laminectomy of the 1st to 3rd thoracic vertebra was performed to relieve the compression. Histological examination of the tumor showed it to be a metastatic vertebral tumor from a hepatocellular carcinoma (HCC). Subsequently, by abdominal computed tomography and an examination of the AFP serum level the existence of the HCC was confirmed. This is a very rare case of an HCC that was revealed by paraplegia caused by bone metastasis.

[Comparative study of tegafur (p.o.) and mitomycin C (MMC) plus tegafur in cases of unresectable gastric cancer]

Sixteen cases of gastric cancer with liver metastases (H2 less than) as group A, fifteen with distant peritoneal metastases (P2 less than) as group B, twenty-five with distant lymph nodes metastases (N3 less than) as group C, twenty-eight with two prognostic factors as group D, and seven with three factors as group E were treated. A1, B1, C1, D1 and E1 groups were treated with mitomycin C (MMC) (4 mg) + tegafur (FT) (400 mg) (i.v.-weekly) and A2, B2, and C2 group with FT (600 mg) (p.o.-daily). Partial response in the evaluable cases was found in 7 cases and a total response rate was 11.7%. The 50% survival interval was as follows; 8.5 months (M) in A1 group, 10.0 M in A2, 7.2 M in B1, 2.3 M in B2, 10.4 M in C1, 14.2 M in C2, 5.2 M-7.2 M in D1, and 3.1 M in E1. In the cases with H2 less than or N3 less than, FT (p.o.) and with P2 less than, MMC + FT (i.v.) were effective respectively. Chemotherapeutic effect was better in A1 and A2 group from the aspects of prognostic factors and in the cases of poorly differentiated adenocarcinoma from histological types than in B1 and B2 group and well or moderately differentiated adenocarcinoma.

[Two cases of leiomyosarcoma of the duodenum]

Two cases of a leiomyosarcoma of the duodenum are reported. The first patient, a seventy-year-old woman, had experienced repeated instances of melena. She was diagnosed as having a leiomyosarcoma of the duodenum preoperatively, and was successfully given a pancreatoduodenectomy. The second patient, a fifty-one year-old woman, also had experienced instances of melena. Similarly, she was diagnosed an having leiomyosarcoma of the duodenum preoperatively, and was given a partial gastrectomy. A pathological examination showed little mitosis in either patient. The first patient is still alive three months after the operation, and the second patient also has been surviving for twelve years postoperatively.

[A case report of a giant cell carcinoma of the thyroid]

Discussed is a case of a giant cell carcinoma that presented a high value of serum thyroglobulin. Histopathologically, this tumor had been diagnosed as being an anaplastic carcinoma that had transformed from a differentiated carcinoma, with calcification that was thought to have occurred from a preceding adenoma. To study the possibility of a malignant transformation, an immunohistochemical study of a specimen confirmed the production of thyroglobulin and vimentin, though the specimen stained negatively for keratin.

Total gastrectomy with left oblique abdominothoracic approach for gastric cancer involving the esophagus

From January 1972 to December 1982, we performed 70 total gastrectomies with left oblique abdominothoracic approach for gastric cancer involving the esophagus. We emphasize that the diaphragm should be incised "U-shaped" from its origin to avoid respiratory tract failure due to phrenic nerve damage. Combined resection was performed in all cases either because of direct tumor invasion or because of lymph node dissection. Operative mortality occurred in only three cases (4.3%). There were nine cases (12.8%) of postoperative complications; in these cases, the complications were nonfatal. The five-year survival rates of patients were 60% in stage II, 27% in stage III, and 20% in stage IV, according to the Union Internationale Contre le Cancer-1978 staging classifications.

[Liver tissue fragments transplantation to the spleen]

Sliced liver tissue fragments of strained Wistar-Lewis rat were transplanted to the spleen. Most of transplanted liver tissues showed hyaline degeneration and epithelial ducts, similar to bile ducts, were observed on the seventh day. The liver tissue could not be identified one month after transplantation. But the masses of hepatic cells, having no sinusoid, were observed in some cases 12 months after transplantation. Macroautoradiographic studies with 99mTc-diethyl-IDA, hepato-biliary agent, were performed. The yellowish white portions of the specimens on the seventh day, corresponded to the transplanted liver tissue, indicated the uptake of 99mTc-diethyl-IDA. This means the transplanted fragments were alive and had a role of detoxication. The density of the fragments were 20% to 50% of that of the host liver. The survival ratio in acute hepatic failure induced with carbon tetrachloride (CCl4) increased by the liver tissue fragments transplantation. The density of the transplanted fragments with hepatic injury by the CCl4 increased, compared with that of no injury.

[Intra-abdominal administration of CDDP in the management of carcinomatous peritonitis]

Seven patients with carcinomatous peritonitis were intraperitoneally treated with CDDP. This procedure does not require specific hydration transfusion and much less diuretic. According to Koyama and Saito's criteria, one patient showed complete response, 5 showed partial response and one no change. Following this therapy, 4 patients have lived for more than 6 months. Renal toxicity, which is considered to be the most serious side effect of CDDP, was not found. Alimentary symptoms (nausea, vomiting) were noted in all patients and myelosuppression and abdominal bleeding were recognized in a small number of patients. In conclusion, our method is considered to be advantageous in the treatment of carcinomatus peritonitis.

[A new anticancer preparation, 5-fluorouracil-poly-L-lactic acid microcapsule, and its therapeutic evaluation]

An attempt was made to develop the new anticancer drug inducing enhanced tumor response to arterial chemoembolization therapy. 5-Fluorouracil (5-FU) was microencapsulated with poly L-lactic acid by the organic phase separation technique. This granular preparation containing 5-FU (FU-PLA-mc) was about 200 micron in diameter and was about 40% in 5-FU content. The release of 5-FU in vitro from FU-PLA-mc gradually increased, extending over 50 hours to reach maximum level. When 75 mg of FU-PLA-mc (5-FU content, 30 mg) was infused into normal rabbits through femoral arteries, maximum level of 5-FU in blood was 1.03 +/- 0.16 microgram/g after 15 minutes. Meanwhile, arterial infusion of the same dosage of FU-PLA-mc into VX2 tumor bearing rabbits resulted in the production of high level of 5-FU (2.1 +/- 0.5 micrograms/g) in tumors even after 72 hours. In vivo anticancer effect of FU-PLA-mc was significantly demonstrated; when 75 mg of FU-PLA-mc was administrated to VX2 tumor bearing rabbits through arterial infusion, T/C ratio of mean tumor weight was 0.01% on the 14th day after infusion. After hepatic arterial embolization with FU-PLA-mc in normal rabbits, elevation of serum transaminases was observed, but it was transient. Hepatic arterial chemoembolization with FU-PLA-mc was carried out for 8 patients with hepatic malignancies. Of these 8 patients, partial response was obtained in 3 patients and no severe complication was observed.

[Preoperative treatment with 5-fluorouracil (5-FU) in gastric and colorectal cancer]

Preoperative chemotherapy with 5-FU was carried out on patients with gastric and colorectal cancer. 5-FU was given at a dose of 500 mg daily with a drip infusion for 7 days (Group A), with a one-shot intravenous infusion daily (Group B) and orally for 7 days (Group C). Histological effects were evaluated, using the criteria proposed by Ohboshi. In group A for gastric cancer and in group C for colon cancer, the histological response was stronger at the edge of the cancer than at its surface. In group C for gastric cancer and in group A for colon cancer, the histological response was more remarkable at the surface of the cancer than at its edge. The histological effects on metastatic lymph nodes in gastric cancer were the same as for the cancer nests in groups A and C. 5-FU used as a drip infusion or orally was more effective on metastatic lymph nodes of gastric cancer than on metastatic lymph nodes of colon cancer. 5-FU was detected at a high concentration in tumor tissues of gastric cancer in group A, Grade II response being obtained in 3 of 7 patients. Changes in regional lymph nodes, plasma and other organs in cases of combined resection were not obtained with regard to either the concentration of 5-FU or the histological findings for all three groups.

[Gastric lymphosarcoma associated with early carcinoma (type IIa)--a case report]

We report a case of gastric lymphosarcoma associated with early carcinoma (type IIa). Lymphosarcoma was also seen in the small intestine, but there were no metastatic lesions in the lymph nodes , liver, and peritoneum. This suggest that lymphosarcoma was the primary cancer in both the stomach and small intestine. Microscopically, the early carcinoma was a moderately differentiated tubular adenocarcinoma . Only two earlier cases of coexistent gastric lymphosarcoma and early gastric carcinoma have been reported in the literature.

[An autopsy case of pancreatic cancer with carcinoid tumor of the appendix]

A 78-year-old man with pancreatic carcinoma with carcinoid tumor of the appendix is reported. Upon autopsy, the tumor consisted of poorly differentiated adenocarcinoma with scirrhous-like spreading. In the appendix a carcinoid tumor, size measuring 2 mm X 1 mm, was seen; the carcinoid cells were argentaffin.