A case of spontaneous acute obstructive suppurative pancreatic ductitis associated with intraductal papillary mucinous neoplasms.

A 77-year-old woman was referred to our hospital due to left upper abdominal pain, appetite loss and body weight loss for 1 month. Her past medical history was diabetes and intraductal papillary mucinous neoplasms (IPMNs). She had no fever and physical examination revealed mild tenderness in the left upper abdomen. Blood tests showed elevated inflammatory response with normal serum pancreatic enzymes. Contrast-enhanced CT showed marked swelling of the pancreatic tail, increased peripancreatic fatty tissue density, multiple IPMNs and obscuration of the enlarged main pancreatic duct at the tail. EUS showed there was no obvious mass in the pancreas and protein plug was suspected in the main pancreatic duct. EUS-FNA was performed and pathology showed no malignancy. ERCP showed discharge of purulent pancreatic fluid from the major duodenal papilla and stenosis of the main pancreatic duct at the tail. The culture of the purulent pancreatic fluid revealed Streptococcus aureus, Klebsiella pneumoniae and Pseudomonas aeruginosa, leading to diagnosis of acute obstructive suppurative pancreatic ductitis (AOSPD). Endoscopic nasopancreatic drainage and antimicrobial treatment were started. The inflammatory response improved rapidly and the patient was discharged 30 days after admission. To our knowledge, this is the second reported case of spontaneous AOSPD associated with IPMNs.

Leaching behavior of inert waste landfills.

Inert waste landfills are strictly limited to inert or non-reactive waste materials, nevertheless, due to human negligence or unavoidable circumstances, sometimes, small amounts of biodegradable or chemically reactive waste are mixed and disposed together with the inert waste. Over time, leachate generated from these biodegradable wastes may come into contact with rainfall water and percolate into groundwater and surrounding ground, degrading water quality. Additionally, the large sized industrial plastics present inside the inert waste landfill may trap and store the leachate thus enhancing the risk of contamination due to increased contact time and reducing the mechanical stability of the landfill. In this research, inert waste materials were collected from a Japanese inert waste landfill, and laboratory batch and column leaching tests were performed to determine the leaching behavior of the waste materials with variation in fibrous contents (FC) as 2% and 10% of total inert waste materials. From the batch leaching test, the inert waste was characterized as highly alkaline with a pH value of 10.3 and moderately reduced with a redox potential (Eh) value of 300 mV. The results from the column leaching test indicated that landfilling with 10% FC, comprising sizes below 10 cm, along with an installation of soil layer reduced the concentrations of heavy metals, metalloids, and total organic carbon in the leachate, thus confirming the environmental safety of the inert waste landfill.

RECAM-J 2023-Validation and development of the Japanese version of RECAM for the diagnosis of drug-induced liver injury.

AIM: The diagnosis of drug-induced liver injury (DILI) is challenging. We modified the revised electronic version of the Roussel Uclaf Causality Assessment Method (RUCAM) for the diagnosis of DILI (RECAM), the scoring system developed in US and Spanish cohorts in 2022, and developed RECAM-J 2023 to align with the clinical practice in Japan. In the current study, we introduce RECAM-J 2023 and verify its performance in the context of Japanese patients with DILI. METHODS: After translation of RECAM into Japanese, modifications were made to develop RECAM-J 2023 without any alteration to the scores. To examine the validity and performance of RECAM-J 2023, clinical information on DILI and non-DILI cases in Japan were retrospectively collected. The diagnosis of DILI was made by expert's decision. Then we scored each case using RECAM-J 2023, and calculated area under curve (AUC) values for identification for DILI. RESULTS: We collected data from 538 DILI and 128 non-DILI cases. The sum of highly probable (HP) and probable (PR) cases categorized by RECAM-J 2023 were only 206 (38%) in DILI cases. As the primary cause of low scores was the deduction with missing hepatitis virus markers, which is unlikely to be an issue in prospective applications, we rescored without these deductions. At this time, the sum of HP and PR was raised to 421 (78%). The AUCs of RECAM-J 2023 without deductions were 0.70 and 0.88 for identifying at least HP, and at least PR, respectively. CONCLUSION: RECAM-J 2023, when prospectively used without any missing hepatitis virus markers, provides acceptable performance for identifying at least PR DILI cases in Japanese daily clinical practice.

Integrated analyses of the genetic and clinicopathological features of cholangiolocarcinoma: cholangiolocarcinoma may be characterized by mismatch-repair deficiency.

Cholangiolocarcinoma (CLC) is a primary liver carcinoma that resembles the canals of Hering and that has been reported to be associated with stem cell features. Due to its rarity, the nature of CLC remains unclear, and its pathological classification remains controversial. To clarify the positioning of CLC in primary liver cancers and identify characteristics that could distinguish CLC from other liver cancers, we performed integrated analyses using whole-exome sequencing (WES), immunohistochemistry, and a retrospective review of clinical information on eight CLC cases and two cases of recurrent CLC. WES demonstrated that CLC includes IDH1 and BAP1 mutations, which are characteristic of intrahepatic cholangiocarcinoma (iCCA). A mutational signature analysis showed a pattern similar to that of iCCA, which was different from that of hepatocellular carcinoma (HCC). CLC cells, including CK7, CK19, and EpCAM, were positive for cholangiocytic differentiation markers. However, the hepatocytic differentiation marker AFP and stem cell marker SALL4 were completely negative. The immunostaining patterns of CLC with CD56 and epithelial membrane antigen were similar to those of the noncancerous bile ductules. In contrast, mutational signature cluster analyses revealed that CLC formed a cluster associated with mismatch-repair deficiency (dMMR), which was separate from iCCA. Therefore, to evaluate MMR status, we performed immunostaining of four MMR proteins (PMS2, MSH6, MLH1, and MSH2) and detected dMMR in almost all CLCs. In conclusion, CLC had highly similar characteristics to iCCA but not to HCC. CLC can be categorized as a subtype of iCCA. In contrast, CLC has characteristics of dMMR tumors that are not found in iCCA, suggesting that it should be treated distinctly from iCCA. © 2024 The Pathological Society of Great Britain and Ireland.

Natural History of Hepatic Hemangiomas Larger Than 10 cm: Imaging Findings and Clinical Course of 22 Cases.

INTRODUCTION: The natural history of a large hepatic hemangioma is important in determining the treatment strategy. Although several studies have assessed the natural history of hepatic hemangiomas, no study has focused on hepatic hemangiomas measuring >10 cm. The aim of this study was to assess the natural history of hepatic hemangiomas measuring >10 cm by evaluating imaging findings and clinical course. METHODS: Computed tomography (CT) and magnetic resonance imaging (MRI) reports at Kyoto University Hospital, Kyoto, Japan, between January 2001 and March 2023 were retrospectively searched to find adult patients with hepatic hemangiomas >10 cm. Patients who were followed up without treatment for over six months were included. The maximum diameter of the hepatic hemangioma was compared between the baseline and the final CT or MRI. The clinical course of the patients was evaluated. RESULTS: Twenty-two patients (17 women, five men; median age, 51 years) were identified. The median diameter of hepatic hemangiomas in the baseline study was 114 mm. Two patients had abdominal distention at the time of the baseline imaging, whereas the others were asymptomatic. After follow-up without treatment (the median; 95.5 months), enlargement, no change, shrinkage of hepatic hemangioma was observed in six, 11, and five patients, respectively. The median growth rate of hepatic hemangiomas was 2.5 mm/year. Two patients underwent liver resection for hepatic hemangioma, while the others were followed up without treatment. In four patients, symptoms appeared or worsened. Two patients died: one patient died from prostate cancer progression; the cause of death for the other was not confirmed. CONCLUSION: Hepatic hemangiomas show a slow growth rate during follow-up, and shrinkage is occasionally observed. Some patients experience new symptoms or aggravation of symptoms; however, deaths associated with hepatic hemangiomas are uncommon.