Usefulness of positron emission tomography (PET)/contrast-enhanced computed tomography (CE-CT) in discriminating between malignant and benign intraductal papillary mucinous neoplasms (IPMNs).

BACKGROUND/OBJECTIVES: We evaluated the usefulness of positron emission tomography (PET)/contrast-enhanced computed tomography (CE-CT) in discriminating between malignant and benign intraductal papillary mucinous neoplasms (IPMNs). METHODS: PET/CE-CT imaging was conducted on 29 IPMN lesions, which subsequently underwent surgery. Preoperative findings on PET/CE-CT imaging were compared with the histological findings of the resected specimens to determine the diagnostic accuracy of PET/CE-CT imaging for evaluation of the differential diagnosis between benign and malignant IPMNs. RESULTS: The final diagnoses of the 29 IPMN lesions were 9 benign and 20 malignant. Overall, 18 of the 20 malignant cases were positive for FDG uptake, while 7 of 9 benign cases were negative. The sensitivity, specificity, and diagnostic accuracy for benign/malignant differentiation using FDG uptake as a marker were 90.0%, 77.8%, and 86.2%, respectively. When guideline-based high-risk findings were used as markers, sensitivity, specificity, and diagnostic accuracy for mural nodules were 50.0%, 66.7%, and 55.2%, while they were 40.0%, 56%, and 48.3% for main duct dilatation, respectively. CONCLUSIONS: FDG uptake on PET is a useful new marker for malignancy in benign/malignant differentiation. Because PET/CE-CT imaging is a noninvasive imaging modality that can evaluate FDG uptake in addition to the conventional high-risk findings, we believe it should be the first-line method for determining therapeutic approaches to IPMN.

[A case of reversible encephalopathy syndrome caused by hyponatremia during neoadjuvant 5-FU+CDDP therapy for esophageal cancer].

We present a case of reversible encephalopathy syndrome caused by hyponatremia during neoadjuvant chemotherapy with 5-FU+CDDP for esophageal cancer. A 52-year-old woman visited another hospital with the complaint of discomfort during swallowing. Upper gastrointestinal endoscopy revealed an ulcerated lesion in the lower thoracic esophagus, which was pathologically diagnosed as squamous cell carcinoma. She was admitted to our institution, and the diagnosis of esophageal cancer Mt-Lt, type 2, cT2N1M0, stage II was made. We obtained informed consent for her treatment with both CRT and surgery, and she selected surgery. Therefore, she was administered neoadjuvant chemotherapy with 5-FU+CDDP therapy. On day 4, abnormalities of the central nerve, such as unconsciousness, difficulty in speaking, and muscle cramps were, observed. After the examinations she was diagnosed with encephalopathy. It should be noted that hyponatremia induced by renal sodium wasting syndrome(RSWS)was considerd to be the cause, and we report our case with the literature cited.

Risk factors for metachronous gastric cancer in the remnant stomach after early cancer surgery.

BACKGROUND: Early gastric cancer patients have a good prognosis after radical resection. However, if the patients have a gastric remnant after the surgery, the risk of metachronous gastric cancer remains. The aim of this study was to clarify the risk factors for metachronous gastric cancer after partial gastrectomy for early gastric cancer. METHODS: Data on a series of 1281 consecutive gastrectomy patients with pathologically confirmed early gastric cancer from 1991 to 2007 in Shikoku Cancer Center were analyzed retrospectively. RESULTS: The gastric remnants of 868 patients were periodically surveyed by endoscopic examination. Among those surveyed cases, 26 patients were diagnosed as having metachronous gastric cancer in the gastric remnant. They underwent curative resection by remnant gastrectomy (n = 13 patients) or endoscopic mucosal resection (n = 13 patients). Multivariate analysis showed that male sex, older age, submucosal invasion, and proximal gastrectomy were independent risk factors. CONCLUSIONS: Our data suggested that more intensive endoscopic follow-up is needed for the remnant stomach in patients with these risk factors to detect metachronous gastric cancer at its early stage.

Rare pancreatic metastasis of undifferentiated pleomorphic sarcoma originating from the pelvis: A case report.

INTRODUCTION: Undifferentiated pleomorphic sarcoma (UPS) is a reclassification of malignant fibrous histiocytoma by the World Health Organization in 2002. UPS, the most common soft tissue sarcoma reported in adults, mostly recurs as lung disease. Pancreatic metastasis of UPS is extremely rare. We present a rare case of pelvic UPS with pancreatic metastasis. PRESENTATION OF CASE: A 69-year-old man was identified as having mediastinal lymphadenopathy on follow-up computed tomography (CT), 2 years after undergoing surgery for gastric adenocarcinoma (pT4aN3M0/IIIC). Subsequent positron emission tomography-CT (PET/CT) indicated pelvic lesions and magnetic resonance imaging (MRI) showed multiple tumors of the left pubis and femur. Histopathology of diagnostic thoracoscopic lymph node dissection and CT-guided needle biopsy of the left pubic lesion showed UPS. Systemic chemotherapy and targeted molecular therapy reduced multiple pelvic and metastatic tumors. Left pubic primary lesion contraction was achieved with intensity-modulated radiation therapy. CT performed 4 years after treatment initiation showed a 40-mm pancreatic head mass. Lesions other than the pancreatic tumor were in remission, and a pancreatoduodenectomy was performed. Histological analysis confirmed pancreatic metastasis of anaplastic pleomorphic sarcoma. DISCUSSION: Reports of pelvic UPS with pancreatic metastasis, as that of the present case, are extremely rare. UPS is malignant potential tumor, and complete excision is the first treatment option, while the usefulness of chemotherapy or radiation therapy remains uncertain. CONCLUSIONS: Complete resection is vital for local control in pancreatic metastasis of UPS. Sites of recurrence are rare; hence, patients must be carefully followed up.

Primary extranodal non-Hodgkin's lymphoma of the common bile duct manifesting as obstructive jaundice: report of a case.

Primary non-Hodgkin's lymphoma (NHL) of the common bile duct (CBD) manifesting as obstructive jaundice is extremely rare: to our knowledge, only 22 cases of primary NHL arising from the CBD have been reported. The patient in this case report was a 63-year-old man who presented with obstructive jaundice. Abdominal sonography, positron emission tomography, and computed tomography showed a mass with abnormal 18-fluorodeoxyglucose uptake in pancreatic head. Magnetic resonance cholangiopancreatography demonstrated a strictured segment of the CBD with proximal bile duct dilatation. We performed pancreaticoduodenectomy for a presumptive diagnosis of pancreatic head carcinoma or cholangiocarcinoma of the CBD. However, the histological diagnosis was a primary, diffuse, large B-cell lymphoma of the CBD. He received three courses of combination chemotherapy, including rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). The patient remains well, without evidence of tumor recurrence, 8 months after surgery. In summary, primary NHL of the CBD, despite its rarity, should be considered in the differential diagnosis of obstructive jaundice. An accurate histopathologic diagnosis and complete surgical resection, followed by combination chemotherapy plus rituximab may be effective.

Long-term outcome after laparoscopic wedge resection for early gastric cancer.

BACKGROUND: Laparoscopic wedge resection (LWR) can be applied for the management of early gastric cancer without the risk of lymph node metastasis. Although LWR for early gastric cancer is one of the minimally invasive procedures, its radicality in cancer therapy is controversial. This study aimed to evaluate the long-term outcomes after LWR. METHODS: Data on 43 consecutive cases of LWR performed for preoperatively diagnosed mucosal gastric cancer were analyzed retrospectively in terms of long-term outcomes. RESULTS: No postoperative deaths occurred after LWR. Histologically, resected specimens showed submucosal invasion in 11 cases (26%) and positive surgical margins for cancer in 4 cases (9%). Three patients (7%) showed local recurrence near the staple line, and one patient (2%) died due to the local recurrence, but no lesional lymph node or distant recurrence occurred. The overall 5-year survival rate was 88%. The gastric remnant after LWR developed metachronous multiple gastric cancer in five cases (12%). CONCLUSIONS: The findings show a relatively high incidence of positive surgical margin, local recurrence, and gastric remnant cancer after LWR. Although LWR can be performed for properly selected patients, periodic postoperative endoscopic examination is necessary to detect metachronous multiple gastric cancer and local recurrences.

Laparoscopic colectomy for colorectal cancer patients with previous abdominal surgery.

BACKGROUND/AIMS: Laparoscopic colectomy has been widely accepted as a standard operation for colorectal cancer. The use of this procedure for patients with previous abdominal surgery is now well established. The aim of this study was to evaluate the peri-operative and long-term outcomes of such patients, and to compare them to patients without previous surgery. METHODOLOGY: Data on a consecutive 121 cases of laparoscopic colectomy performed for colorectal cancer from 1995-1999 in Shikoku Cancer Center were analyzed retrospectively for peri-operative and long-term outcomes. RESULTS: Twenty one cases (17%) of laparoscopic colectomy were performed for colorectal cancer patients with previous surgery. Although the operation time for the previous surgery group was significantly longer than that of the control group, there was no significant difference in the peri-operative complications and the overall survival between the 2 groups. CONCLUSIONS: Although the previous abdominal surgery increases the time it takes to perform the laparoscopic colectomy, the peri-operative and long-term outcomes were comparable to those from patients without previous surgery.

Higher incidence of gastric remnant cancer after proximal than distal gastrectomy.

BACKGROUND/AIMS: Proximal gastrectomy has been widely accepted as a standard operation for early stage gastric cancer located in the upper third of the stomach. Therefore, cancer of the distal gastric remnant is now increasing. The aims of this study were to clarify and compare the incidences of gastric remnant cancer after proximal and distal gastrectomy. METHODOLOGY: Data on a consecutive series of 809 cases of gastrectomy performed for early gastric cancer from 1991 to 2003 in Shikoku Cancer Center were analyzed retrospectively with respect to the incidence of gastric remnant cancer. RESULTS: We performed distal gastrectomy in 624 patients and proximal gastrectomy in 47 patients during the study period. After those operations, the gastric remnants of 457 cases and 33 cases, respectively, were surveyed periodically by endoscopic examination at our hospital. Among those surveyed cases, 10 patients (2.2%) and 3 patients (9.1%) were diagnosed as having gastric remnant cancer, respectively. The gastric remnant cancer-free survival after proximal gastrectomy was significantly lower than that after distal gastrectomy. CONCLUSIONS: Because of the higher incidence of gastric remnant cancer after proximal gastrectomy, it is more important to survey the gastric remnant after proximal gastrectomy periodically by postoperative endoscopic examination.

Unusual abscesses associated with colon cancer: report of three cases.

Three cases of colon cancer accompanied by unusual abscess formation are reported. Case I : A 77-year-old man was diagnosed with a paracolic abscess formation behind the cecum and a swollen appendix by computed tomography (CT) scan. Case II : An 85-year-old woman was diagnosed with an abscess formation of the right iliopsoas muscle, a swollen appendix, and a thickened right colon wall by CT scan. After antibiotic therapy failed, both patients underwent ileocecal resection urgently under suspicion of appendicitis, but cecal cancer around the entrance to the appendix caused secondary appendicitis in both cases. Case III : A 50-year-old woman was diagnosed with sigmoid colon cancer with an abscess formation in the pelvic cavity concomitant with ovarian tumor. A Hartmann procedure was performed, and a pathological examination revealed that a subserosal abscess behind the sigmoid colon cancer perforated the rectum with abscess formation. All cases were definitively diagnosed intraoperatively. The cancer recurred in cases I and III. We emphasize that precise surgical evaluation has an important role in the diagnosis of these complicated diseases. In addition, surgery affords the patient the best chance of recovery, and in these advanced cases radical treatment is recommended as early as possible.

Inflammatory pseudotumor of the liver associated with malignant disease: report of two cases and a review of the literature.

Two cases of inflammatory pseudotumor (IPT) of the liver associated with gastrointestinal tract cancer are reported. In addition, the etiological correlation between IPT and abscesses of the liver in cancer patients is discussed. The first patient was a 63-year-old woman who underwent distal gastrectomy and partial hepatectomy under a diagnosis of stomach cancer with liver metastasis. The second patient was a 66-year-old man who had undergone surgery for rectal cancer 6 years previously and underwent partial hepatectomy under a diagnosis of metastasis of rectal cancer to the liver. The gastric cancer was a papillary adenocarcinoma limited to the mucosa, and the rectal cancer was a moderately differentiated adenocarcinoma limited to the subserosa. The resected liver tumor in the first case measured 5.5 x 5.0 x 4.0 cm and was 2.5 x 1.9 x 1.6 cm in the second. The cut surface showed that both masses were well circumscribed and divided into lobules by fibrous tissue. They were yellowish white in color and there was no evidence of necrosis or hemorrhage. Histologically the masses consisted of fibrous areas and cellular areas, and the cellular areas consisted of fascicles of plump spindle cells mingled with varying numbers of plasma cells, lymphocytes, and histiocytes. The masses were diagnosed as IPTs. Obliterating phlebitis suggesting infection via the portal vein was seen in the adjacent liver tissue in both cases. According to previous cases reported in the literature, there are three types of cancers associated with hepatic IPT: gastrointestinal tract cancer, biliary tract cancer, and cancers that need strong systemic chemotherapy. The underlying cancer types of IPT of the liver are almost similar to those associated with pyogenic liver abscesses suggesting the etiological correlation between IPT and abscesses of the liver.

[The long-term results of hepatic resection for metastatic lesions from colorectal cancer].

We reviewed the clinical course of 51 patients who underwent hepatic resection for metastatic lesions from colorectal cancer between January 1984 and December 1997. The cumulative survival rate at 3 and 5 years were 57% and 43%, respectively. Sex, age, chronology of liver metastases (LM), number of LM, maximum diameter of LM, macroscopic surgical resection margin, type of hepatic resection, chemotherapy after hepatic resection, and site of primary tumor were not found to be statistically significant prognostic factors. The presence of lymph node metastases for the primary tumor was a predictor of shorter survival duration by univariate analysis (p=0.03). Recurrence was not observed in 15 patients. However, recurrence was observed in 36 patients, of which 4 were in remission by undergoing repeated resection for recurrence sites (2 were in lung, 2 were in liver). Although the long term survival of the 19 patients with no significant remarks to be noted, but no one survived with more than 4 hepatic metastases among the long term survivors.

[Pulmonary resection for metastatic colorectal cancer].

We reviewed the clinical courses of 25 patients who underwent pulmonary resection for metastatic lesions from colorectal cancer between January 1991 and December 2001. The cumulative survivals at 3 and 5 years were 72% and 63%, respectively. Sex, site of the primary tumor, presence of extrapulmonary metastases, disease-free interval, location of pulmonary metastases (PM), number of PM, size of PM, mode of operation, pre-thoracotomy serum carcinoembryonic antigen level, and post-thoracotomy chemotherapy were not found to be statistically significant prognostic factors. Age (70 years < or =) was a predictor of a shorter survival duration by univariate analysis (p = 0.02). Recurrence was observed in 19 patients, 11 of which were lung recurrences. Eight patients underwent repeated pulmonary resection. The median survival in these 8 patients was 23 months after second pulmonary operation. Surgical treatment for pulmonary metastases from colorectal cancer in selected patients might improve prognosis.

[Clinical study of gemcitabine therapy for recurrent or metastatic pancreatic cancer].

The clinical efficacy and safety of gemcitabine (GEM) monotherapy were studied retrospectively in the patients with recurrent or metastatic pancreatic cancer. The subjects were 30 patients who were treated with GEM at our center between May 2001 and August 2003. The objective overall response rate was 11% (3/28; 95% confidence interval, 2.3-28%). The disease control rate (CR+PR+SD) was 54%. Grade 3 or 4 neutropenia was most frequently seen in 46%. Non-hematological toxicities were mild. The median survival time was 4.8 months. One-year survival rate was 15%. This study showed the reproducible activity and safety of GEM in practice.

Utility of contrast-enhanced FDG-PET/CT in the clinical management of pancreatic cancer: impact on diagnosis, staging, evaluation of treatment response, and detection of recurrence.

OBJECTIVES: Fluorodeoxyglucose (FDG)-positron emission tomography/contrast-enhanced computed tomography (PET/CE-CT) involving whole-body scanning first by non-CE-CT and FDG-PET followed by CE-CT has been used for detailed examination of pancreatic lesions. We evaluated PET/CE-CT images with regard to differential diagnosis, staging, treatment response, and postoperative recurrence in pancreatic cancer. METHODS: Positron emission tomography/CE-CT was conducted in 108 patients with pancreatic cancer and in 41 patients with other pancreatic tumor diseases. RESULTS: The maximum standardized uptake value (SUV(max)) overlapped in benign and malignant cases, suggesting that differential diagnosis of pancreatic tumors based on the SUV(max) is difficult. In the evaluation of staging in 31 resectable pancreatic cancer by PET/CE-CT, the diagnostic accuracy rate was more than 80% for most factors concerning local invasion and 94% for distant metastasis but only 42% for lymph node metastasis. Significant positive correlations were found between the SUV(max) and tumor size/markers, suggesting that SUV(max) may be a useful indicator for the treatment response. Regarding the diagnosis of the postoperative recurrence, PET/CE-CT correctly detected local recurrence in all the 11 cases of recurrence, whereas abdominal CE-CT detected only 7 of 11 cases, suggesting that PET/CE-CT is superior in this context. CONCLUSIONS: Positron emission tomography/CE-CT is useful for the clinical management of pancreatic cancer.

Solitary fibrous tumor of the pancreas.

A solitary fibrous tumor (SFT) originating in the pancreas is rare. We report a 55-year-old woman with an asymptomatic pancreatic mass incidentally discovered on abdominal ultrasonography. Contrast-enhanced computed tomography (CT) showed a well-demarcated exophytic mass in the pancreatic head with prolonged and delayed enhancement. The mass showed hypointensity on T1-weighted images and heterogeneous hypointensity with spotty hyperintensity foci on T2-weighted images. Fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT showed no significant FDG uptake. The resected mass was composed of spindle cells that were positive for CD34; and hemangiopericytomatous vessels were focally detected. The mass was finally diagnosed as an SFT of the pancreas.

Inflammatory pseudotumor of the liver in a patient with early gastric cancer: CT-histopathological correlation.

A case of inflammatory pseudotumor (IPT) of the liver associated with early gastric cancer is reported. Intravenous contrast-enhanced computed tomography (CT) showed a large, irregularly shaped mass lesion in the left lobe of the liver. The lesion was characterized by peripheral rim-like or septal enhancement and an internal low density area in the delayed phase. The gastric cancer was a papillary adenocarcinoma limited to the mucosa. The resected liver tumor measured 5.5 x 5.0 x 4.0 cm, and its cut surface revealed a well-circumscribed mass divided into lobules by fibrous tissue. Histologically the mass was composed of fibrous areas and cellular areas, and the cellular areas consisted of fascicles of plump spindle cells intermingled with varying numbers of plasma cells, lymphocytes and histiocytes. Thus, the higher attenuation on the enhanced CT scan corresponded to the areas of intense fibrosis, and the areas of lower attenuation corresponded to the predominantly cellular areas. The CT findings of delayed peripheral rim-like or septal enhancement of the hepatic tumor may be a specific finding of IPT.