A resected case of acinar cell carcinoma of the pancreas with liver metastasis following chemotherapy using modified FOLFIRINOX.

BACKGROUND: Acinar cell carcinoma of the pancreas is a rare exocrine malignancy representing less than 1% of all pancreatic neoplasms. It has been reported that it responds to treatment differently from pancreatic ductal adenocarcinoma and the treatment algorithm for acinar cell carcinoma usually depends on the stage of the respective tumor and the patient's current status. CASE PRESENTATION: A 60-year-old man presented with upper abdominal pain and anorexia. Abdominal ultrasonography showed a large-sized hepatic mass and he was referred to our hospital. Contrast-enhanced computed tomography demonstrated a 110-mm low-density area occupying the right hemi-liver and an enhanced mass of 70 × 56 mm in the tail of the pancreas, which seemed to directly infiltrate into the spleen. The case was diagnosed as acinar cell carcinoma with a simultaneous liver metastasis identified by liver biopsy. Upfront resection of pancreatic cancer with distant metastasis might not be considered as an optimal choice, and in this case chemotherapy was administered prior to curative resection. Chemotherapy using the modified FOLFIRINOX regimen was undertaken, resulting in a partial remission; the liver tumor reduced in size from 110 to 47 mm and the pancreatic tumor from 70 to 40 mm. The patient then safely underwent curative hepatic resection with distal pancreato-splenectomy. Histological examinations revealed small-sized atypical cells with large nuclei that had formed acinar patterns, and immunostaining with trypsin was positive in tumor cells, which was in accordance with acinar cell carcinoma. More than 3 years later, the patient is doing well without any recurrence. CONCLUSION: Aggressive and curative surgery in combination with chemotherapy such as FOLFIRINOX could be a treatment option to achieve long-term survival in cases of acinar cell carcinoma with liver metastases.

[A Case of Long-Term Clinical Complete Response after Chemotherapy for Locally Advanced Rectal Cancer].

With the advancement ofchemotherapy against colorectal cancer, clinical complete responses(cCR)are more frequently observed. We report a case oflocally advanced rectal cancer with maintained long-term cCR after chemotherapy alone. Detailed examinations ofa man in his 60s revealed that he had poorly controlled diabetes mellitus, with elevated serum CEA and CA19-9 levels. Colonoscopy revealed rectal cancer(Rba). Besides the prostate invasion observed in the CT scan, intestinal obstruction was caused by a tumor that required surgical removal. However, the tumor was unresectable due to prostate and pelvic wall metastases; therefore, only sigmoid colostomy was performed. After 6 courses of mFOLFOX6, the tumor shrunk, and prostate invasion reduced as confirmed by the CT scan. Chemotherapy was switched to sLV/5FU2 due to the occurrence of peripheral neuropathy. No tumor was found after 20 courses of treatment, and cCR was achieved after 58 courses ofcontinuous and consecutive treatment. Throughout the treatment, radical resection was proposed to the patient; however, the surgery was not performed because of his lifestyle, ie, heavy smoking, which resulted in poor blood sugar control. The patient appears to be tumor free for 7 years after the initiation of chemotherapy.

[A Case of Transverse Colon Cancer Metastasized to the Spermatic Cord after Resection of Peritoneal Dissemination].

We report a rare case of spermatic cord metastasis from colon cancer. A man in his 50s underwent extended right hemicolectomy for transverse colon cancer followed by resection of a peritoneal recurrence. After receiving adjuvant chemotherapy for 6 months, he became aware of a right inguinal mass. A spermatic cord tumor was noted on computed tomography(CT) and FDG/PET-CT. He underwent radical orchiectomy. The resected tumor was histologically compatible with the colon cancer. Although he received additional chemotherapy, right inguinal recurrence was resected 6 months after orchiectomy. Colon cancer is the second most common origin, after gastric cancer, of metastatic spermatic tumor. As several metastatic routes have been reported, peritoneal seeding is mostly suspected in this case.

[A case of laparoscopic partial hepatectomy and splenectomy for hepatocellular carcinoma and pancytopenia].

A 69-year-old woman with chronic hepatitis B and esophageal varices was admitted to our hospital because of a hepatocellular carcinoma( HCC) measuring 3 cm in segment S3. Computed tomography( CT) scan revealed splenomegaly, and the platelet count was 6.0×104/µL. Partial hepatectomy and splenectomy were performed sequentially under laparoscopic guidance in a right half-lateral decubitus position, using 7 working ports. The operation time was 237 min, and the amount of bleeding was 26 mL. Her postoperative course was uneventful, and she was discharged on the 10th day after the operation.

[A case of superficial carcinoma in a diverticulum of the thoracic esophagus].

An upper gastrointestina(l GI) series revealed a diverticulum in the anterior wall of the middle thoracic esophagus of a 72-year-old man. Endoscopy revealed a type 0-IIc lesion in the esophageal diverticulum. The margin of the lesion was unclear. Biopsy proved that it was squamous cell carcinoma. Endoscopic ultrasonography showed that the deepest layer of the tumor was the lamina propria mucosae (cT1a-LPM) and that the underlying muscularis propria was thinning. No distant metastasis or regional lymph node metastasis was detected. Diverticulectomy or endoscopic submucosal dissection (ESD) was out of indication due to the unclear margin and thin muscularis propria. We conducted mediastinoscopy-assisted esophagectomy. The pathological diagnosis of the resected specimen was moderately differentiated squamous cell carcinoma with invasion to the lamina propria mucosae (pT1a-LPM). Pathological examination proved the thinning of the underlying muscularis propria in the diverticulum. The patient is alive without recurrence at 6 months after surgery.

[A case report of surgical treatment for axillary lymph node metastasis from descending colon cancer].

We report a rare case of a 78-year-old woman with metachronous axillary lymph node metastasis originating from descending colon cancer. Her past medical history included right mastectomy for breast cancer at age 53 and distal gastrectomy for gastric cancer at age 70. She underwent a left hemicolectomy for descending colon adenocarcinoma in April 2011. Four months after that operation, 3 enlarging nodules in the left lung and a swollen left axillary lymph node were detected by computed tomography. No tumor was detected in the left breast by ultrasonography and mammography. The lung tumors were resected thoracoscopically, and the left axillary lymph node was excised. These specimens were histologically diagnosed as moderately differentiated adenocarcinoma, which had metastasized from colon cancer, not from the previous breast or gastric cancer. She received adjuvant chemotherapy with uracil and tegafur (UFT) plus Leucovorin for 6 months and is still alive after 12 months without recurrence.

Transfection of naked nuclear factor-κB decoy oligodeoxynucleotides into liver by rapid portal vein infusion in rats: its effect on ischemia-reperfusion injury of liver.

This study was aimed at examining whether rapid portal vein infusion (RPVI) of a small volume of naked oligodeoxynucleotides (ODNs) could be used to transfect sufficient amounts of nuclear factor-κB (NF-κB) decoy ODN into the liver to suppress NF-κB activation during liver ischemia-reperfusion (I/R) injury, in which NF-κB plays a central role in regulating the production of inflammatory cytokines. One milliliter of naked NF-κB decoy ODN solution was administered into the portal vein for a few seconds. Transfection efficacy was examined by labeling the ODN with a fluorescent tag. Activation of NF-κB was investigated by electrophoretic mobility shift assay. Levels of serum liver enzymes and cytokines were measured during liver I/R injury. NF-κB decoy ODN was preferentially incorporated into Kupffer cells and sinusoidal endothelial cells, but not hepatocytes, in the rat liver. Transfected NF-κB decoy ODN suppressed the function of NF-κB in both Kupffer cells and sinusoidal endothelial cells during liver I/R injury, causing significant decreases in serum tumor necrosis factor-α and interleukin-6 levels 3 hr after reperfusion. Although the decrease in serum liver enzymes was not significant, naked NF-κB decoy ODN was successfully incorporated into Kupffer cells and sinusoidal endothelial cells by rapid portal vein infusion, inhibited NF-κB activation in both cells, and suppressed the production of inflammatory cytokines during the early phase of liver I/R injury.

[Multimodal treatment for MFH originating from the psoas muscle-a case report].

A 51-year-old male presented with lower abdominal mass and thigh and lumbar pain. CT scan showed a large retroperitoneal tumor compressing the lumbar vertebrae and IVC. Arterial infusion of mitomycin C, epirubicin and DSM was performed for unresectable tumor. The tumor was shrunken and the infusion repeated in 6 and 10 weeks later until right femoral palsy occurred. Radical resection with lumbar fascicles and psoas muscle and IORT (25 Gy) was performed. Local recurrence appeared before the sacrum in the next year. Arterial infusion and resection was done. Local recurrence invading the right common iliac artery was found five years later. The tumor and the artery were resected, followed by extra-anatomical ilio-iliac bypass. Local recurrences occurred in the 6th, 7th and 9th year. Radiation therapy was effective. But for the last recurrence, no radiation was applicable because of over dosage. As the most important thing in the treatment of MFH is to resect the tumor with curative margin at the initial operation, and the retroperitoneum and pelvic cavity are not good places to obtain good margins, multimodal treatment including irradiation should have been considered even preoperatively. Also consultation with orthopedic oncologists, radiologists, vascular surgeons and team practice are essential to get curative margins.

[An operated case of metastasis to the small intestine from lung cancer].

We report a rare case of a 68-year-old man with long-term survival after a surgical treatment of solitary metachronous small intestinal metastasis from lung cancer. He underwent a right upper lobectomy for primary lung adenocarcinoma. Thirty -four months after the operation, a tumor of small bowel was detected by computed tomography. The tumor was resected and diagnosed as a metastasis from lung cancer. Eighteen months after resection of metastasis, a tumor located at mesentery of the jejunum was pointed out. The tumor was resected and also diagnosed as a metastasis from lung cancer. The postoperative course was uneventful, and the patient is still alive without recurrence for 3 years after the last operation. We reviewed of 222 Japanese cases that underwent a resection of small intestinal metastasis from lung cancer. Although the prognosis was extremely poor for those who underwent a resection of the primary lung cancer and who had no remnant metastatic lesion at the time of metastasectomy, they seem to have a longer survival time.

Changes in the fatty acid composition of the liver with the administration of N-3 polyunsaturated fatty acids and the effects on warm ischemia/reperfusion injury in the rat liver.

Prostanoids play a pivotal role among the inflammatory mediators associated with I/R injury. The aim of this study was to determine the effects of oral supplementation of n-3 polyunsaturated fatty acids (PUFA)-rich oil on inflammatory reactions and microcirculatory disorders caused by a hepatic warm I/R in rats. The rats were orally supplemented with n-3 PUFA-rich oil, n-6 PUFA-rich oil, or the same volume of water for 7 days. The PUFA concentration in the blood and liver tissues were evaluated, and the effects on I/R injury of the liver were assessed. The n-3 PUFA supplementation elevated the n-3/n-6 ratio in the blood and liver tissues. After reperfusion, thromboxane B(2) in the blood and prostaglandin E(2) in the liver were significantly suppressed in the n-3 PUFA-treated rats. Hepatic microcirculation was well maintained from the early phase (30 min) of reperfusion, and the serum concentrations of TNF-alpha and IL-6 were significantly lower in this group. The transaminase blood levels were also suppressed in the n-3 PUFA-treated rats. Expression of COX-2 mRNA was increased in all groups at 2 h after reperfusion but there were no differences among three groups. In conclusion, preoperative n-3/n-6 ratio augmentation in the blood and in the liver can result in a successful alleviation of hepatic I/R injury.

Clinical and prognostic significance of urinary trypsin inhibitor in patients with hepatocellular carcinoma after hepatectomy.

BACKGROUND: Urinary trypsin inhibitor (UTI), produced in the liver, has been considered to suppress inflammation. The production of UTI may decrease after a hepatectomy and thereby increase the incidence of postoperative inflammation. This study investigated whether the changes in the UTI level affected the postoperative course in patients undergoing a hepatectomy for hepatocellular carcinoma (HCC). The prognostic significance of UTI was also analyzed. METHODS: The perioperative plasma UTI was measured in 25 HCC patients who underwent hepatic resection, and the correlation between the kinetics of UTI and clinicopathological factors was investigated. The expression of UTI in the resected specimens was examined by immunohistochemistry in 65 patients. Expression of UTI in the cancer cells were then correlated to both the liver pathology and the clinical outcomes in the corresponding patients. RESULTS: The plasma UTI level greatly decreased on the first postoperative day. This decrease significantly correlated with the resected tumor volume (r (s) = -.530, P = .006), but it had no influence on inflammatory complications. Immunohistochemistry revealed UTI expression in both noncancerous and cancerous lesions. An overexpression of UTI in HCC tissue was found to be an independent prognostic factor for early recurrence (P = .006). CONCLUSIONS: Although UTI plasma levels were noted to decrease after the removal of an HCC tumor, this decrease did not lead to an increase in inflammatory complications. However, overexpression of UTI in cancer was found to be a risk factor for tumor recurrence after resection, suggesting that UTI expression may be a useful prognostic marker.

[A case of surgical treatment for solitary lymph node recurrence of hepatocellular carcinoma simultaneously developed in the mediastinum and abdominal cavity].

We report a surgically treated case of lymph node recurrence from hepatocellular carcinoma (HCC) that occurred simultaneously but individually in the mediastinum and abdominal cavity with no metastasis. A 52-year-old man had undergone left lateral segmentectomy for poorly differentiated HCC. Three months after surgery, abdominal computed tomography revealed an enlarged solitary lymph node along the common hepatic artery. Another isolated mediastinal lymph node was also positive on whole body 18F-fluorodeoxyglucose positron emission tomography. Because no other metastatic lesions were identified, we resected these two lymph nodes under a diagnosis of lymph node metastases from HCC. Histopathologically, both of them were classified as poorly differentiated HCC with solid growth. No further recurrence has been found during 20-month follow-up period. Our experience suggested that even though metastatic lymph nodes of HCC were present in the mediastinum and abdominal cavity, resection may provide survival benefit if each metastasis is individually solitary.

[A clinical study of hepatic arterial infusion chemotherapy with 5-FU and leucovorin for liver metastases].

We followed patients who underwent hepatic arterial infusion chemotherapy (HAI) with 5-FU and Leucovorin for liver metastases. Since CR (complete response) and PR (partial response) were achieved, this therapy seems to be effective. 5-FU metabolized on its first pass through the liver, and the hepatic extraction with rapid HAI is lower than that with slow HAI. It is suggested that control of extrahepatic lesions thought rapid HAI is useful for life prolongation.