A case of spindle cell sarcomatous change of hepatic ducts manifesting as obstructive jaundice.

Spindle cell carcinoma is a rare tumor commonly occurring in the upper aerodigestive tract. We report a 62-year-old male with spindle cell sarcomatous change located at the hepatic hilum, resulting in obstructive jaundice. The patient died after an extended resective operation. The rare disease and its histogenesis is discussed.

Technique and management of percutaneous transhepatic cholangial drainage for treating an obstructive jaundice.

BACKGROUND/AIM: The authors report on the experience they have gained with regard to the techniques and management of percutaneous transhepatic cholangial drainage (PTCD) as a non-operative method for providing biliary drainage in treating 1,012 patients with obstructive jaundice. MATERIALS AND METHODS: The PTCD puncture for drainage was performed under fluoroscopic guidance for 603 patients between January 1968 and October, 1980, and under ultrasonic guidance for 409 patients between August, 1978 and July, 1994. RESULTS: The incidence of complications after the fluoroscopically-guided puncture was 6.0%, the early post-PTCD complications consisting of hemobilia(5 patients), shock due to an increased the intrabiliary pressure following an injection from the contrast material (12 patients), and shock due to a decrease in the intrabiliary pressure (13 patients), and the late complications consisting of bile peritonitis caused by catheter displacement (6 patients). In contrast, the incidence of post-PTCD complications after the ultrasonically-guided puncture amounted to only 0.7%, which was dramatically lower, and the only complication that occurred was a late complication due to PTCD-tube displacement. CONCLUSION: Thus, monitoring the PTCD-tube is important to complete recovery from the PTCD procedure.

Right side hepatic resection under right thoracoabdominal incision with special reference to a highly anatomical systematized method.

The results of 31 right side hepatic resections approached through thoracoabdominal incision are described, with emphasis on the benefit of the approach and systematized liver resection. Regarding postoperative mortality rate (0%) and morbidity rate (32.3%), the thoracoabdominal approach for right side hepatic resection seemed as safe and effective as the conventional abdominal approach. Even though there were no significant differences in the complications, the fluctuation of alanine aminotransferase and the hospital stay, the average operation time for the right segmentectomy through the thoracoabdominal approach was 1.3 hours less (p = 0.0078) than that of the abdominal approach. Technically, this approach was accomplished in almost the same fashion as in the abdominal approach by the utilization of systematized hepatic resection. Thoracotomy itself was not more harmful than the abdominal approach, even in patients with impaired liver function. This combination could take the advantage of a shorter operation time.

Highly anatomically systematized hepatic resection with Glissonean sheath code transection at the hepatic hilus.

We have developed a new method of hepatic resection, in which the cancer-bearing Glissonean code (G-code) branches are served using a hilar approach for an anatomically systematized resection. Since the hepatic artery, portal vein and bile duct are surrounded by connective tissue, the portal triad can be treated as a fibroid code both outside and inside the liver. Compared to the ramification pattern of the hepatic artery, portal vein and bile duct, that of the G-code is simpler. In all our surgical procedures of hepatic resections, the cancer bearing G-code branch is selectively cut using a hilar approach before the dissection of the parenchyma of the liver. We have experienced 168 cases of several types of hepatic resection for hepatocellular carcinoma. Only in three cases was it impossible to accomplish the transection of some third branches using a hilar approach.

[Multidisciplinary treatment of esophageal carcinoma].

From 1965 until Aug. 1987, a total of 1,249 cases of primary thoracic esophageal carcinoma were resected. Some 70%-80% of these cases treated before 1980 underwent preoperative irradiation. From 1976-1987, in addition to preoperative irradiation, postoperative irradiation of the neck and upper mediastinum was performed in 20% of resected cases. (1) Evaluation of combined radiotherapy: In C greater than 0 resected cases, the postoperative T-shape irradiated group was significantly better than the nonirradiated and preoperative irradiation--only groups, with a risk factor of p less than 0.05, However in comparison to historical controls, no significant improvement was obtained and in the preoperative irradiated group. (2) Multidisciplinary treatment based on preoperative staging: The effectiveness of CDDP treatment in cases of recurrence or non-resectable cancer of the esophagus was 44.4%. Based on these findings, we have administered adjuvant CDDP + VDS in resected cases from 1985 and have obtained encouraging 1-year survival. Since 1985, extended dissection in 3 regions (cervical, thoracic and abdominal) has been carried out. Compared to C greater than 0 resected since 1981, in which dissection of lymph-nodes in two major regions was performed, dissection of lymph-nodes in the three major regions has resulted in an improved 1-2 year survival, despite the increased numbers of stage IV cases. The findings thus indicate that the presence of lymph-node metastasis significantly affects prognosis. Therefore, in cases that are preoperatively evaluated as sm or more extensive invasion, it is necessary to combine extensive lymph-node dissection, postoperative irradiation or chemotherapy.

[Precancerous lesions of the colon and rectum].

Adenomatous polyp, adenomatosis coli and dysplasia in the inflammatory bowel disease are noted as precancerous lesions. 1) Adenomatous polyps are easily found by colonoscopy as protruded lesions and diagnosed by histopathological study. 2) Adenomatosis coli is easily diagnosed by barium enema and colonoscopy. Adenomatosis coli is accompanied with cancer frequently. As soon as adenomatosis coli is detected, we recommend surgery. IRA (total colectomy and ileorectal anastomosis) is mainly undertaken for adenomatosis coli. But when there are many adenomas in the rectum, we recommend IAA (total colectomy, rectal mucosectomy and ileo-anal anastomosis). 3) Diagnosis and therapy of dysplasia accompanied with the inflammatory bowel disease (ulcerative colitis, tuberculosis, Crohn's disease) remain unclear. There is a deep relationship between cancer and dysplasia and inflammation.

[Multidisciplinary treatment of thoracic esophagus carcinoma based on preoperative staging].

Recently, with developments in CT scanning and endoscopic ultrasound (EUS), in addition to conventional ultrasound (US), significant advances have been made in the evaluation of preoperative staging. Evaluation of the presence of A3 invasion is made on the basis of X-ray, CT and EUS findings. In superficial cases of ep, mm or sm, EUS with particular reference to the X-ray and endoscopic appearance is very effective, and in our department the diagnostic accuracy in cases of mucosal lesions is 88%, while it is 84% in sm cases. Diagnosis of metastasis to cervical and abdominal lymph nodes is performed by US, while diagnosis of mediastinal lymph node metastasis is performed by EUS. The accuracy of US for detecting cervical and abdominal lymph node metastases, including those approximately 0.5 cm in size, is 95%, while that of EUS in the diagnosis of metastasis to mediastinal nodes is 89%. The 5-year survival of patients with lymph node metastasis significantly affects prognosis. Based on this, since 1985, extended dissection in the cervical, thoracic and abdominal regions has been carried out. Since 1985, some resected cases have been treated with pre- or postoperative adjuvant chemotherapy regimens, centered primarily on CDDP (majority of cases with CDDP + VDS). A significant improvement has been obtained in the 1-2-year survival of C greater than O resected cases treated since 1985, compared with cases in 1980-1984. This improvement is thought to be due to dissection of lymph nodes in the three major regions, based on more accurate preoperative evaluation and the introduction of postoperative adjuvant chemotherapy.

[Study on the relationship between concentrations of 5-FU and PyNPase activity in tumor tissue during oral 5'-DFUR treatment in patients with advanced colorectal cancer].

Fifty-three patients with advanced colorectal cancer were given single oral doses of 5'-DFUR, 400 mg/body, preoperatively to assess the pharmacokinetics of 5'-DFUR in the patients with colorectal cancer and to investigate schedules for 5'-DFUR treatment. The time courses of PyNPase activity and 5-FU concentration in the resected tissue specimens were determined. This study indicated that: 1) High 5-FU concentration and PyNPase activity were noted in tumor tissue and lymph nodes. 2) Effective 5-FU concentration in tumor tissue was maintained even 24 hours after treatment. 3) Effective lymph node concentration of 5-FU was maintained even 8 hours after treatment. 4) PyNPase activity in tumor tissue was significantly higher than that in the normal intestinal mucosa (p < 0.05). These results suggest that 400 mg of 5'-DFUR at 8-hour intervals provides effective tissue concentrations of 5-FU for the treatment of patients with advanced colorectal cancer.

[Combined chemotherapy with cisplatin in esophageal cancer].

Combined chemotherapy with cisplatin was performed in patients with advanced esophageal cancer. Two types of administration schedule were used: method I (three-drug combination of cisplatin, bleomycin and methotrexate) and method II (combination of cisplatin, peplomycin and methotrexate). Of 16 cases, 6 (37.5%) showed partial remission. With regard to the method of administration, the response rate for method I was 33%, and that for method II was 43%. Nausea (84%), vomiting (56%), loss of appetite (94%), malaise (75%) and alopecia (25%) were observed as side effects. Nausea and vomiting were ameliorated by use of metoclopramide. In bloodchemistry, anemia (87%), leukopenia (56%), thrombopenia (31%) and increase of BUN (63%) were observed. However, these changes were ameliorated by hydration or blood transfusion. Combined chemotherapy with CDDP should be a more useful future treatment for esophageal cancer.

[A 6-day subrenal capsule assay for predictive testing of primary esophageal cancers].

Subrenal Capsule Assay (SRCA) as a chemosensitivity test was performed on 14 esophageal squamous cell carcinomas in order to select a more effective form of chemotherapy. Of the 14 assays, 12 were evaluable. Mice were treated with anticancer agents (e.g. Cisplatin, Bleomycin, Methotrexate, Vindesine) on days 1 and 3 after transplantation, and on day 6, the sensitivities were determined. Fresh esophageal cancers yielded an evaluable assay rate of 74%. The implant grew progressively for six days in the remaining group of control mice. Histologically, host cell infiltration at the border of the implant was observed from day 3 after transplantation, and cells had degenerated or had been partially replaced by scar tissue by day 6. The results of chemosensitivity tests differed according to the anticancer agent used or from case to case. Clinically, correspondence between the assay results and clinical results was obtained in 5 out of 7 cases. SRCA is a new promising chemosensitivity test which is clinically useful, and the present results indicated the feasibility of its use in developing an effective chemotherapy for esophageal cancer.

[Basic study of chemo-embolization of the liver using hydroxyapatite granules].

The purpose of this study was to elucidate the availability of hydroxyapatite (HAp) granules as a chemoembolic agent in chemo embolization therapy. A mixture of adriamycin (ADM) and an embolic agent (HAp, Lipiodol) was injected via hepatic artery in normal Wistar rats. Then the concentration of ADM in the liver serum transaminase level were measured serially. The remaining ADM in the liver was higher in groups with HAp granules than the others. The serum transaminase, however, were lower in the HAp groups. There are some advantages of HAp using as a chemo embolic agent. (1) HAp is a physiological biomaterial and seem to be safe for human. (2) HAp granules injected into the liver are easily detectable by X ray and ultrasonography. (3) HAp granules have a large surface area and this characteristic is suitable for a carrier of drugs. It is concluded that HAp granules have some necessary prerequisites for a chemo embolic agent and the application to clinical practice may be expected.

[The examination of usefulness of the disposable pump in case of cancer pain relaxation and the economic problem].

Recently, an increasing number of cancer patients being taken care of at home has been able to use morphine to treat their pain by themselves. The most suitable administration method for individual patients-oral, intravenous, subcutaneous or depository--is being investigated. When oral intake becomes difficult, the subcutaneous via of administration is best option because it is the less dangerous and easier to use compared with the other two options. These are also thought to be less useful because it is difficult to judge the exact dosage. The use of pumps might be an economic problem to some patients. We will examine this problem.

[Clinico-pathological studies on the effects of preoperative hyperthermo-chemoradiotherapy of advanced esophageal carcinoma].

We report clinico-pathological studies on the effect of preoperative hyperthermia and chemotherapy combined with radiotherapy (HCR) for progress of the local curability of advanced esophageal carcinoma. The subjects of these studies were 17 patients who underwent subtotal esophagectomy after preoperative irradiation 40 Gy from 1980 to 1989, of which 8 patients had HCR, 6 patients irradiation only (R), 3 patients both irradiation and chemotherapy (CR). The clinical response rate of the patients with R or CR was 33% (PR 3, MR 3, NC 3), and the histological effective (Ef3 or Ef2) rate was 56% (Ef3 1, Ef2 4, Ef1 4). The clinical response rate of the patients with HCR was 88% (PR 7, MR 1), and the histological effective rate was 100% (Ef3 1 Ef2 7). HCR was more effective than R or CR for the local lesion of esophageal carcinoma histopathologically (p less than 0.05). However, the survival rate of patients with HCR was similar to R and CR, respectively. These results suggest that further improvement of the heating methods and the methods of combining hyperthermia with irradiation and chemotherapy is needed.

[Clinical study of controlled-release preparation of mitomycin C in the treatment of inoperable cancer patients].

The composite substance of Mitomycin C (MMC) and polymer by low temperature radiating polymerization has a characteristic of slow release, the possibility of applying it to local chemotherapy was clinically studied. Buttom-formed preparation (MMC 20 mg) and needle-formed preparation (MMC 5 mg) were applied to the lesions, respectively, by sewing and piercing in 220 cancer patients with non resectable infiltrative lesions. The treatment had a pain-relieving effect in 70 out of 117 cases (60.0%) of painful cancer in the pancreas, biliary duct, liver, etc, and improved the symptoms of digestive organs in 31 out of 93 cases (33.3%). However, the tumor-reducing effect was recognized only in minute localized lesions of hepatic cancer, etc., and the survival period was not prolonged. The treatment caused no severe side effects. From the above results, the local chemotherapy with slow-releasing MMC preparation was concluded to be a useful means of palliative therapy in non-resectable, though its formulation may to be further improved.

[Experiences with FT+BrdU+radiation therapy of esophageal cancer].

Three patients with esophageal cancer, who were treated by FT+BrdU+radiation with good results, are reported. This method is theoretically almost the same as BAR therapy which was originally developed for the treatment of brain cancer using BrdU aimed at enhancing the sensitivity to irradiation. In two patients who had advanced lung cancer on the vertical axis, a good effect was achieved with only 8 Gy and 24 Gy of irradiation. In the other cases, who had circumferentially invasive superficial cancers, we also achieved on effect as good a CR clinically.

[Localization of pancreatic insulinomas by combined radiographic methods].

Seventeen cases with a total of eighteen insulinomas were examined by ultrasonography (US), computed tomography (CT), angiography, percutaneous transhepatic portal and pancreatic venous sampling (PTPS) and intraoperative ultrasonography (IOUS). We discussed about diagnostic accuracy of insulinomas on these diagnostic modalities. Tumor localization was achieved by US in 39%, CT in 72% and angiography in 81%. Although total 15 tumors (83%) can be correctly detected, multiple lesions were not completely ruled out. We recommended the criteria in PTPS as follows: Insulin concentration level above 200 mu U/ml. Or, both of insulin concentration ratio (step-up site/control) above three and elevation of the CPR concentration level on the PTPS. According to these criteria, the accuracy rate was 91%. Overall preoperative diagnostic accuracy was 100%. IOUS allowed us to detect the localization of the tumors completely.

[A surgical treatment for congenital bile duct dilatation with intrahepatic calculi].

A total of 141 cases of congenital bile duct dilatation (excluding those with cancer) were treated at the Department of gastroenterological Surgery of Tokyo Women's Medical College in the past 27 years. The lesion was morphologically classified as Todani type I in 93 patients, type II in 1, type III in 2, type IV-A in 42, and type V or multiple dilatation of the peripheral bile ducts in 3. Cholangiectasis was accompanied by intrahepatic stones in 1 type I patient, 18 type IVA patients, and 2 type V patients. None of type II and type III patients had intrahepatic stones. Of the 21 patients with intrahepatic stones, only 2 (both type IVA) had no history of surgery. In these patients, a common bile duct stone was considered to be the cause of intrahepatic stone formation. Nineteen patients had undergone surgery, comprising cholecystectomy in 2 type V patients, bypass surgery in 5 type IVA patients, and excision of the extrahepatic bile ducts with biliary tract reconstruction in 1 type I and 11 type IVA patients. Of the 12 patients who underwent excision of the extrahepatic bile ducts with biliary tract reconstruction, intrahepatic stone formation was considered to be ascribable to stenosis at the choledocho-jejunostomy site in 3 and to insufficient excision of the extrahepatic bile ducts in 4. Therefore, when performing excision of the extrahepatic bile ducts and biliary tract reconstruction in patients with congenital cholangiectasis, we now take care to achieve thorough excision of the extrahepatic bile ducts and not leave any stenotic region in the porta hepatis. For choledocho-jejunostomy, we join the left and right hepatic ducts as necessary or incise the hepatic duct axialy so as to make the anastomotic orifice large enough. In the 5 remaining patients, intrahepatic stone formation was considered to be due to persistence of intrahepatic bile duct dilatation or stenosis, although there were no technical problem with excision of the extrahepatic ducts and biliary tract reconstruction. In 4 of the 5 patients, partial hepatectomy was performed to remove the intrahepatic stones, but new stones formed again in 2 of them. When intrahepatic bile duct dilatation or stenosis is localized at the periphery of lobule, hepatectomy is indicated. However, when intrahepatic bile duct dilatation or stenosis is extensive in both lobes, no curative technique is available and bile duct dilatation or stenosis wil persist in the liver after surgery. In such cases, the disease may become further complicated by cholangitis and intrahepatic stone formation, making it very difficult to control. Therefore, patients with extensive intrahepatic bile duct dilatation or stenosis should be monitored very carefully even after surgery.

[A case of adrenal myelolipoma].

We report a case of surgically resected adrenal myelolipoma. Myelolipoma of the adrenal gland is a rare, benign and nonfunctioning tumor. The present patient represents the 57th reported clinical case of this tumor. It consists of fatty and hematopoietic tissue. It is asymptomatic and usually found only at autopsy incidentally. Ultrasonography, computed tomography and fine needle biopsy help in the preoperative diagnosis of adrenal myelolipoma. Especially fine needle biopsy is recommended when the diagnosis is doubtful.

[Photodynamic therapy--its application for the treatment of esophageal cancer].

Effect of Photodynamic therapy (PDT) for esophageal cancer was discussed in this study. PDT has been performed on 9 cases of superficial esophageal cancer. All cases were followed periodically by endoscopy for 2 years 2 months to 6 years and no case has any local recurrence. But in 2 cases invaded submucosal layer, lymph node metastasis was recognized. We think PDT is one of the very effective therapies in the treatment of intramucosal cancer.

[Efficacy of extended radical operation based on preoperative staging].

From 1985 to 1988, we have resected 203 cases of the thoracic esophageal cancer with right thoracotomy. Those 203 cases were classified as R3 (bilateral cervical, thoracic and abdominal node dissection), R2 + alpha (left cervical, thoracic and abdominal nodes dissection) and R2 (thoracic and abdominal node dissection) based on preoperative staging. The background of R3 mainly contained Iu cases, advanced cases, positive cases of upper mediastinal metastasis, and that of R2 mostly contained high aged and risk cases, though this group showed low LN metastasis. The incidence of postoperative complications were higher R3 greater than R2 greater than R2 + alpha in order. Pneumonia had no relationship to neck dissection. Recurrent nerve palsy was recognized in R3 group about 16%. Operative mortality mostly belong to high aged group over 70 y.or., noncurative cases and R3 group. The survival rate of C greater than 0 resected cases with right thoracotomy after 1985 showed some improvement compared with the cases of standard R2 dissection by right thoracotomy from 1980-1984. It showed no difference of the curative survival curve among R3, R2 + alpha and R2 groups. Thus, it is effective to improve the survival rate of resected esophageal cancer with our indication based on preoperative staging.