Primary pancreatic glomus tumor invading into the superior mesenteric vein: a case report.

BACKGROUND: Glomus tumors are subcutaneous tumors arising from glomus bodies, thermoregulatory components of the skin. These tumors could occur in visceral organs where glomus bodies are not normally present. Herein, we report a case of primary pancreatic glomus tumor with aggressive direct invasion into the superior mesenteric vein (SMV). To the best of our knowledge, this is the second case report of a glomus tumor arising in the pancreas. CASE PRESENTATION: A 46-year-old woman was referred to our hospital due to vomiting with epigastric and back pain. Dynamic-CT revealed a well-circumscribed hypervascular mass, measuring 37 mm in its maximal diameter involving the pancreatic head. Both CT and endoscopic ultrasonography (EUS) revealed direct invasion into the SMV and radiologically suspected tumor thrombus. Biopsy sample obtained by EUS-guided fine needle aspiration revealed proliferation of small cells, round-to-oval tumor cells with round nuclei and scant cytoplasm. A histological diagnosis of pancreatic neuroendocrine tumor, G1 was initially considered. Therefore, subtotal stomach-preserving pancreatoduodenectomy using Child-II reconstruction was subsequently performed. Her SMV was resected and reconstructed due to extensive tumor involvement. Subsequent histopathological analysis revealed solid tumor cells proliferation that comprised oval-shaped nuclei and scant cytoplasm around disorganized or slit-shaped vessels in hematoxylin-eosin-stained slides. Immunohistochemical analysis then demonstrated positive immunoreactivity for smooth muscle actin, vimentin, and CD34, but negative for chromogranin A, synaptophysin, CD56, and signal transducer and activator of transcription 6. Based on these histological findings of resected specimens, the lesion was subsequently diagnosed as a primary pancreatic glomus tumor harboring direct invasion into the SMV. Her postoperative course was uneventful and annual surveys for the following 4 years post-op detected no clinical signs of recurrence. CONCLUSIONS: We report a very rare case of glomus tumor of the pancreas accompanied by venous invasion. Curative surgical resection is the best treatment option for pancreatic glomus tumors. Although pancreatic glomus tumor is rare, it should be taken into consideration in the differential diagnosis of a pancreatic solid tumor with hypervascularity.

[A Case of Thymic Carcinoma of Postoperative Liver and Mediastinal Lymph Node Metastases Where Long-Term Survival Was Achieved through Multidisciplinary Treatment].

The patient was a 67-year-old man. At the age of 60, he underwent resection of thymic carcinoma with partial resection of the right upper lobe of the lung because of invasive thymic carcinoma. The pathological diagnosis was Masaoka stage Ⅲ squamous cell carcinoma. Follow-up examination 2 years after surgery showed metastases to the mediastinall ymph node and liver. After undergoing radiotherapy of 50 Gy to the mediastinal lymph node metastasis, partial hepatectomy was performed for metastatic liver cancer. Post-operation, he received 4 courses of combination therapy of carboplatin and paclitaxel. Five years post-hepatectomy, the patient developed liver metastasis again and underwent hepatectomy for local control. Postoperative recurrent cases of thymic carcinoma generally have poor prognosis. We describe a patient with thymic carcinoma of postoperative liver and mediastinal lymph node metastases who achieved long-term survival through multidisciplinary treatment.

[A Case Report of a Difficult to Diagnose, Extremely Well-Differentiated Stomach Adenocarcinoma Diagnosed by Biopsy].

A Japanese man in his 60s presented with complaints of epigastric pain and weight loss. A gastrointestinal endoscopy revealed multiple gastric ulcers and an irregular mound located on the wall of the lower gastric body along the greater curvature, which was suspected to be cancerous. A biopsy revealed that it was a Group 2 tumor even though the biopsy was repeated 4 times. He was referred to our hospital and 3 biopsies were performed. The final result classified the tumor as Group 4. The patient underwent surgery and the pathological examination revealed an extremely well-differentiated adenocarcinoma( EWDA). An EWDA is characterized by a well-formed mucinous gland with little or no nuclear atypia, which makes preoperative biopsy diagnosis difficult.

[Two-Stage Radical Resection of a Case of Colon Cancer with Abdominal Wall Invasion and Cholangiocarcinoma].

A woman in her 50s was admitted to our hospital with fever and lower abdominal swelling. Abdominal CT/MRI examinations revealed irregular thickening of the transverse colon wall, which was attached to a subcutaneous abscess. An abdominal wall mass, a patent urachus, and a tumor in the 5th segment of the liver were also noted. Colonoscopy revealed type 2 advanced transverse colon cancer. The solitary, sessile tumor was observed at the apex of the bladder under cystoscopy, suggesting the formation of the urachal carcinoma. Transcutaneous liver biopsy obtained from the liver tumor indicated adenocarcinoma, which was morphologically different from the existing transverse colon cancer. Right hemicolectomy with resection of the umbilicus, abdominal wall, urachus, and part of the bladder wall was performed. Diagnosis of the transverse colon cancer invading the abdominal wall and bladder was confirmed by histopathological examination. Hepatectomy was performed in the next surgery, and the tumor was histopathologically diagnosed as an intrahepatic cholangiocarcinoma. Both the transverse colon cancer and the intrahepatic cholangiocarcinoma were radically resected. Radical surgical diagnostic resection may be valuable in cases of multicentric cancers of unknown primary origin, if radical resection of each individual tumor is required.

[A Case of Esophageal Carcinoma with Large Intramural Metastasis to the Stomach].

We report a rare case of esophageal carcinoma with gastric wall metastasis. A 73-year-old man with dysphagia underwent endoscopy and upper GI series and chest-abdominal computed tomography, revealing esophageal carcinoma and gastric cancer, which was diagnosed as squamous cell carcinoma by biopsy. The esophageal carcinoma was located in the lower thoracic esophagus(Lt). Total gastrectomy was performed. The resected specimen showed a type 3 tumor measuring 7×7 cm in the anterior wall of the stomach. Pathologically, the depth of invasion of the stomach was SE. He died 3 months after the operation. Esophageal carcinoma with gastric intramural metastasis is very rare and has a dismal prognosis. We report a rare case of esophageal carcinoma with large intramural metastasis to the stomach.

[A Case of Triple Negative Spindle Cell Carcinoma of the Breast and Improved Quality of Life Following Irinotecan Chemotherapy].

We report a case of triple negative spindle cell carcinoma of the breast, responsive to irinotecan chemotherapy. A 49-year old woman who had a tumor in the chest wall with a skin ulcer visited our hospital. After being diagnosed with triple negative spindle cell carcinoma of the breast, she underwent surgery, adjuvant chemotherapy, and radiation at the other hospital. Fourteen months after the surgery, she developed an ipsilateral breast tumor as a result of local recurrence. Since eribulin and paclitaxel plus bevacizumab chemotherapies were not effective, she was transferred to our hospital, and we administered irinotecan as third-line chemotherapy. Skin lesions and effusion were reduced and her quality of life improved for 4 months.

[A Case of Unresectable Locally Advanced Pancreatic Cancer Resulted in R0 Surgery after Chemotherapy].

A 67-year-old man visited our hospital for jaundice. Abdominal dynamic CT showed the hypovascular tumor at the head of the pancreas that surrounded superior mesenteric artery(SMA)at an angle of 220 degree. No metastasis in lymph nodes and other organs was observed. We diagnosed the tumor unresectable locally advanced(UR-LA)pancreatic cancer. Chemotherapy was administered with gemcitabine and nab-paclitaxel(GEM+nab-PTX)and achieved partial response. Regression in size and in range around SMA to an angle of 150 was observed. We assessed it possible to resect the tumor curatively, and performed subtotal stomach preserving pancreaticoduodenectomy and dissection of the plexus around the SMA, resulted in R0 surgery. Adjuvant chemotherapy was administered, and no recurrence was observed up to present, more than a year. It is suggested that GEM+nab-PTX can be effective as the primary therapy against UR-LA pancreatic cancer.

[Recurrent Gastric Carcinoma(Endocrine Cell Type)Successfully Treated with Multidisciplinary Therapy - A Case Report].

A 62-year-old woman was diagnosed with carcinoma of the stomach at another hospital. Distal gastrectomy with D2 dissection was performed and she was referred to our hospital. Histopathological and immunopathological examinations showed the tumor to be composed of adenocarcinoma and neuroendocrine carcinoma. The patient was followed until 4 months after the operation when an abdominal computed tomographic(CT)scan showed a metastatic tumor at S2 and S5/6 of the liver. No other organ metastases were found, and a hepatectomy was performed. The primary tumor of the stomach consisted of adenocarcinoma and neuroendocrine carcinoma; however, the resected metastatic liver tumor consisted of only neuroendocrine carcinoma. Liver and lung metastases appeared 2 months after the operation, and we started chemotherapy with VP-16 and cisplatin. After 8 courses of treatment, the lung metastases showed a CR, and the liver metastasis was SD. She is alive without lung metastases 9 months after the hepatectomy.

[A Case of Rectal Cancer Successfully Treated with Surgery and Stereotactic Radiotherapy for Metachronous Lung Metastases].

A 64-year-old woman underwent polypectomy for a rectal polyp(Isp). Pathological findings were invasion of the submucosa( 3,500 mm diameter), and she underwent anterior resection for rectal cancer(RS, pT1b, pN0, cM0, Stage I )without adjuvant chemotherapy. Lung masses were found in her right(8mm)and left lung(7mm). The tumors enlarged during the 4 month follow-up period. We decided to perform left partial pneumonectomy. The tumor was diagnosed as a lung metastasis from colon cancer by pathology. Because the right tumor was located towards the center, performing right pneumonectomy would have been quite invasive and we feared occult metastases. We decided to apply SRT(50 Gy)to the right tumor. The tumor shrunk and became a scar after treatment. There were no complications such as radiation pneumonitis. The patient was in good health without any recurrence for 12 months after SRT. Surgical resection is an optimal method to control lung metastasis from colon cancer if the lesion is operable. However, in the case of a tumor centrally located, surgical resection may cause deterioration of lung function. There are also cases with contraindications for surgery due to co-morbidities. In addition, there is no consensus on observation periods to exclude occult metastases. SRT can be an effective treatment for lung metastases from colon cancer when there are bilateral lung metastases and no metastases outside the lungs.

Pathologic Assessment of Pancreatic Fibrosis for Objective Prediction of Pancreatic Fistula and Management of Prophylactic Drain Removal After Pancreaticoduodenectomy.

BACKGROUND: Soft pancreatic texture is a commonly accepted risk factor associated with pancreatic fistula (PF) after pancreaticoduodenectomy (PD). However, its evaluation is subjective and its predictive value is limited. The present study was performed to establish intraoperative PF prediction parameter: the pathological assessment of pancreatic fibrosis, which was an objective evaluation that was strongly related to pancreatic consistency. METHODS: Based on the results of a retrospective investigation on grades of pancreatic fibrosis and PF occurrence in 51 consecutive patients, an algorithm for intraoperative selection of early prophylactic drain removal was established. Prophylactic drains of patients with pancreatic fibrosis ≥ 30 % in the frozen section of pancreatic stump were removed on postoperative day (POD) 4. As CRP ≥ 10 mg/dL on POD 4 was a strong risk factor for PF in patients with fibrosis <30 %, the drains of these patients were maintained. RESULTS: The algorithm was applied to 26 consecutive patients. Prophylactic drains were removed in 14 patients and retained in 12 patients on POD 4. No PF was observed in patients with pancreatic fibrosis ≥ 30 % (n = 8). Among six patients with fibrosis <30 %, CRP <10 mg/dL, and without infection in the drain fluid, only two developed grade A PF. All nine patients with pancreatic fibrosis <30 % and CRP ≥ 10 mg/dL developed grade B PF. No grade C PF was observed in any group. CONCLUSIONS: The pathological evaluation of pancreatic fibrosis could objectively predict PF occurrence. Intraoperative assessment of pancreatic fibrosis could be applied to tailor postoperative drain management after PD.

[Calcified amorphous tumor of the right atrium after open heart surgery; report of a case].

A 37-year-old woman, who had undergone surgery of atrial septal defect (ASD) at 12-year-old, developed bradycardia and referred to our hospital. Transthoracic echocardiography revealed high echoic tumor in the right atrium. The image of the tumor was of low intensity by T2 weighted magnetic resonance imaging (MRI) and floating mass with a stalk to the right atrium in cine MRI. She underwent tumor resection under cardiopulmonary bypass. Histopathologilal examination of the tumor was calcified amorphous tumor. The postoperative course was uneventful.

Ciliated hepatic foregut cyst with obstructive jaundice.

Ciliated hepatic foregut cysts (CHFCs) are rare congenital cystic lesion that are most often solitary, unilocular, and located in the subcapsular region of the medial segment of the left hepatic lobe. The mucoid fluid contents affect imaging studies and often make definitive diagnosis difficult. CHFCs are usually asymptomatic and found incidentally. We report a 69-year-old female patient with a CHFC causing obstructive jaundice, which was difficult to differentiate from a biliary cystic neoplasm. A well-defined cystic lesion measuring 25 mm in diameter was located in the porta hepatis region. The lesion was densely adherent to the left and right hepatic ducts, riding on the bifurcation, and the common hepatic duct was extrinsically compressed. An extended left hepatectomy was performed. A diagnosis of CHFC was made on the basis of typical histological findings. CHFC should be included in the differential diagnosis for cystic lesions of the liver.

Rejection following donor or recipient preoperative treatment with FTY720 in rat small bowel transplantation.

BACKGROUND: Severe rejection of small bowel transplantation (SBTx) has been ascribed to abundant lymphoid tissues in the small intestine without well-established evidence. However, the role of donor lymphocytes in rejection is still unclear. The novel immunosuppressant, FTY720, is reported to transfer peripheral blood lymphocytes (PBLs) to lymphoid tissues such as mesenteric lymph nodes (MLNs) and Peyer patches (PP). In the present study, the number of donor lymphocytes in the graft was increased by FTY720, and the influence on rejection was studied in a rat model. Furthermore, the number of the PBL of recipient was decreased by FTY720 before SBTx and the effect on rejection was examined. MATERIALS AND METHODS: Orthotopic total SBTx was performed in Brown-Norway and Lewis rats. In the donor pretreatment study, FTY720 was administrated to donor rats 24 h prior to harvesting to increase the number of graft lymphocytes (FTY donor-pretreated group). In contrast, MLNs were surgically removed from the grafts to decrease the number of graft lymphocytes (MLN-resected group). In the recipient pretreatment study, FTY720 was administrated to recipient rats 24 h before SBTx to decrease recipient PBL (FTY group). In contrast, a subclinical dose of cyclosporine A (CsA) was administrated after SBTx (CsA group). Rats were administrated preoperative FTY720 combined with post-SBTx CsA (FTY+CsA group). Graft survival, pathology, lymphocyte count, and subtype were examined. RESULTS: In the donor pretreatment study, pretreatment with FTY720 did not enhance graft rejection. MLN resection did not prolong graft survival. In the recipient pretreatment study, FTY720 caused a significant reduction in the number of infiltrating lymphocytes in the graft, as well as the percentage of recipient CD4+ and CD25+ cells within the graft. FTY720 and CsA synergistically prolonged graft survival. CONCLUSION: SBTx rejection correlated with the number of recipient PBL, and not with the number of donor lymphocytes transplanted together with the graft. The pretreatment of the recipient with FTY720 was effective in the case of combined use of the low-dose postoperative CsA.

Significance of serum type IV collagen level of hepatectomized patients with chronic liver damage.

Type IV collagen, one of the serum markers for hepatic fibrosis, was measured perioperatively in patients with and without chronic liver damage to investigate whether this parameter changes in response to acute stress to the liver and can predict the surgical risk of hepatic resection. The serum type IV collagen level was significantly elevated in patients with liver cirrhosis. There were significant correlations between serum type IV collagen levels and the indocyanine green clearance test and cholinesterase activity, although the correlation coefficients were not high. The size of the resected hepatic mass was not the primary factor to influence the postoperative serum type IV collagen level. In patients with liver cirrhosis, the postoperative serum type IV collagen level increased significantly compared to that in patients with normal liver or chronic hepatitis. Postoperative liver failure occurred in 0%, 11.6%, and 44.4% of patients with preoperative serum type IV collagen levels of <150, < or = 150 to 300, and > or = 300 ng/ml, respectively. In those with postoperative liver failure, the serum type IV collagen levels were significantly higher both pre- and postoperatively compared to those in patients with uneventful courses. Several preoperative liver function tests indicated that type IV collagen is an independent risk factor for postoperative liver failure. Thus perioperative measurement of the serum type IV collagen levels seemed to be useful for predicting the risk of hepatic resection in patients with chronic liver damage.