Successful treatment with conversion surgery following chemoradiotherapy for unresectable invasive intraductal papillary mucinous neoplasm.

INTRODUCTION: Recent advances in chemotherapy and chemoradiotherapy (CRT) have enabled the use of conversion surgery in selected patients with initially unresectable pancreatic duct adenocarcinoma after a favorable response to preoperative treatment. However, conversion surgery for invasive intraductal papillary mucinous neoplasm (IPMN) has not been reported. CASE REPORT: A 63-year-old man was referred to our hospital for invasive IPMN treatment. Computed tomography revealed a multilocular tumor of 7.2 × 5.8 cm in diameter, which surrounded approximately 180° of the superior mesenteric artery and totally occluded the superior mesenteric vein (SMV). He was diagnosed with unresectable invasive IPMN. CRT was performed using four cycles of S-1 (100 mg/day) based on body surface area for 14 days every 3 weeks plus gemcitabine 1,000 mg/m2 on days 8 and 15 with concurrent radiotherapy (50.4 Gy in 28 fractions). Response to chemotherapy revealed partial response according to the Response Evaluation Criteria in Solid Tumors; subsequently, subtotal stomach-preserving pancreaticoduodenectomy with SMV resection was performed. The postoperative course was uneventful. Four courses of adjuvant chemotherapy with TS-1 100 mg / day were administered postoperatively. At 5 years and 9 months after initiating treatment, the patient was alive without recurrence.

Risk factors for bowel necrosis in patients with hepatic portal venous gas.

PURPOSE: To evaluate the risk factors for bowel necrosis in adult patients with hepatic portal venous gas (HPVG). METHODS: This retrospective study comprised 33 adult patients treated for HPVG between August, 2008 and December, 2011. The patients were divided into a necrotic group (n = 14) and a non-necrotic group (n = 19). We analyzed the clinical demographics, laboratory data, multi-detector computed tomography findings, treatments, and outcomes in each group. RESULTS: Abdominal pain, peritoneal signs, systolic blood pressure, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase (LDH), small intestinal dilatation, poor enhancement of the bowel wall, and intestinal pneumatosis were all significantly associated with bowel necrosis. Moreover, there were significantly more operative cases and deaths in the necrotic group. Multivariate analysis revealed that systolic BP (p = 0.048), LDH (p = 0.022), and intestinal pneumatosis (p = 0.038) were independent risk factors for bowel necrosis. Thus, we created new diagnostic criteria for bowel necrosis based on these three factors, the sensitivity, specificity, and accuracy of which were 100, 78.9, and 87.9 %, respectively. CONCLUSIONS: This study demonstrates new and important findings to evaluate the risk factors for bowel necrosis. Using our diagnostic criteria, the indications for emergency laparotomy can be established more accurately.

[A case of adenoid cystic carcinoma of the thoracic esophagus after neoadjuvant chemotherapy].

A 60-year-old man was admitted to our hospital with a tumor in the thoracic esophagus, and squamous cell carcinoma was detected by endoscopic biopsy. On computed tomography, the tumor was suspected of having invaded adjacent organs by so the patient was given neoadjuvant chemotherapy consisting of low-dose CDDP and 5-FU. After 2 courses of chemotherapy, a subtotal esophagectomy was performed. The resected specimen showed no residual squamous cell carcinoma but another tumor was found in the submucosal layer which had a cribiform pattern in a solid nest. The tumor cells were positive for S-100 protein and an Alcian-blue-positive substance in the gland, so the tumor was diagnosed as an adenoid-cystic carcinoma.

[Case of esophageal cancer successfully performed in early response evaluation for preoperative chemotherapy by FDG-PET].

We present a case of esophageal cancer with multiple lymph node metastases successfully performed early response evaluation for preoperative chemotherapy by FDG-PET. The decrease of SUV from baseline to 11 days after initiation of low-dose FP chemotherapy were 32.8% in the primary lesion, 60.4% in the cervical lymph node and 13.5% in the abdominal lymph node. He underwent extended radical esophagectomy 4 weeks after the end of chemotherapy. The histopathologic response was Grade 1 in the primary lesion, Grade 3 in the cervical lymph node and Grade 0 in the abdominal lymph node. The early response evaluation by FDG-PET in each lesions were consistent with histopathologic response evaluation of after chemotherapy.

Long-term results after cholecystectomy alone for patients with pancreaticobiliary maljunction without bile duct dilatation.

A pancreaticobiliary maljunction (PB-MJ) without bile duct dilatation is relatively rare. The standard treatment for these patients remains controversial. In this study, we followed up the patients with PB-MJ without bile duct dilatation who mainly underwent a cholecystectomy alone. Eighteen adult patients with PB-MJ without bile duct dilatation (8 males and 10 females with a mean age of 54.8 years) were treated surgically. When the diameter of the common bile duct was less than 10 mm, such bile ducts were diagnosed to have no dilatation. The main clinical indications for surgery were cholecystolithiasis in 12 patients, choledocholithiasis in 3, cholecystocholedocholithiasis in 1, and carcinoma of the gallbladder in 2. The amylase levels of gallbladder bile in 14 patients ranged from 115 to 454,000 IU/ml. A simple cholecystectomy was performed in 12 patients, a cholecystectomy with bile duct drainage was performed in 3, a cholecystectomy with a choledochojejunostomy without bile duct resection was performed in 1, and a cholecystectomy with a lymph node dissection was performed in 2. Three patients died of other diseases. The remaining 15 patients have all been doing well for 20-209 months after surgery. In conclusion, a prophylactic resection of the extrahepatic bile duct and biliary diversion could be unnecessary for patients with PB-MJ without bile duct dilatation, when no bile stasis, such as choledocholithiasis, is observed.

Analysis of microsatellite instability, K-ras gene mutation and p53 protein overexpression in intrahepatic cholangiocarcinoma.

BACKGROUND/AIMS: Genetic alterations are considered to play an important role in both the carcinogenesis and biological behavior of human malignancies. However, the clinical implications of intrahepatic cholangiocarcinoma are poorly understood. We investigated the microsatellite instability, K-ras gene mutations and p53 protein overexpression and their correlation with clinicopathological features to elucidate the clinical implications of genetic alterations in intrahepatic cholangiocarcinoma. METHODOLOGY: In twenty-three cases of surgically treated intrahepatic cholangiocarcinoma, microsatellite instability was examined by a PCR-SSCP analysis and K-ras gene mutation by a PCR-RFLP analysis, p53 protein overexpression by immunohistochemistry. We evaluated the correlation between genetic alterations and clinicopathological features. RESULTS: Microsatellite instability was observed in one case (4.7%), K-ras gene mutation in 9 (39.1%) and positive staining for p53 protein in 5 (21.7%). The incidence of K-ras gene mutations in hilar type intrahepatic cholangiocarcinoma (6 of 8, 75.0%) was significantly higher than that in peripheral type intrahepatic cholangiocarcinoma (3 of 15, 20.0%) (P < 0.05). Furthermore, the incidence of K-ras gene mutations in patients with lymph node metastasis (58.3%) tended to be higher than that in patients without lymph node metastasis (18.2%). The patients with K-ras gene mutations showed a statistically significant worse survival rate than those without such mutations (P < 0.05). No statistically significant correlations were observed between the p53 overexpression and clinicopathological features. CONCLUSIONS: These data suggest that K-ras gene mutations may be involved in the carcinogenesis of intrahepatic cholangiocarcinoma, especially in hilar type intrahepatic cholangiocarcinoma, and thus may be correlated with aggressive biological behavior.

Microsatellite instability in patients with gastric remnant cancer.

BACKGROUND: About 2% of patients who undergo partial distal gastrectomy for gastroduodenal diseases develop gastric remnant cancer 10 to 30 years after the gastrectomy. It is important in clinical practice to determine a molecular marker to identify patients susceptible to gastric remnant cancer.METHODS: We investigated nine gastric remnant cancers (from nine individuals who had gastrectomies for primary gastric cancer or gastroduodenal ulcer) for microsatellite instability (MSI) at six loci, using the polymerase chain reaction (PCR). A control group of ten patients with sporadic gastric cancers in the upper third of the stomach was also similarly analyzed.RESULTS: MSI was demonstrated in eight of nine cancers from the individuals who had had primary gastric cancer or gastroduodenal ulcer (88.9%) compared with two of ten cancers from the individuals with sporadic gastric cancer in the upper third of the stomach (20%).CONCLUSION: These results suggest that one or more MSI is associated with remnant gastric cancer after gastrectomy.

Barrett's adenocarcinoma associated with acquired eventration of the diaphragm.

We report a rare case of Barrett's adenocarcinoma asso-ciated with acquired eventration of the diaphragm in a 71-year-old woman. She initially developed dysphagia and epigastric discomfort in May, 1997. On July 9, she was referred to our Department of Surgery at the Ryukyus University Hospital for thorough examination and treatment. Esophageal adenocarcinoma and eventration of the diaphragm were revealed by exhaustive examinations, including chest X-ray, computed tomography, and magnetic resonance imaging, and proximal gastrectomy with reconstruction of jejunal interposition was performed, on August 8. Histologically, the tumor revealed that the adenocarcinoma arose from short-segment Barrett's esophagus (SSBE). It thus appears that eventration of the diaphragm may induce SSBE and Barrett's adenocarcinoma. We therefore recommend that periodic examinations of the esophagus and stomach be performed in patients with eventration of the diaphragm. Barrett's adenocarcinoma associated with acquired eventration of the diaphragm is reported. Patients with eventration of the diaphragm should undergo periodic examinations of the esophagus and stomach.