[A case of local recurrence developing thirty-nine years after mastectomy for breast cancer].

Here we report a case of breast cancer that recurred after a 39-year latency period. A 73-year-old woman,who had undergone radical mastectomy for left breast cancer 39 years previously,consulted our hospital complaining of lymphedema in the left arm. A computed tomography(CT)scan showed a growth of soft tissue in the left chest wall. A core needle biopsy resulted in the pathological diagnosis of metastatic adenocarcinoma,which stained positively for estrogen and progesterone receptors,but not for human epidermal growth factor receptor 2(HER2). Diagnosed with local recurrence of breast cancer, the patient was consequently treated with hormone therapy using anastrozole and achieved a partial response. The patient is currently free from further recurrent disease at 7 months. We report this late recurrence of breast cancer 39 years following mastectomy,suggesting that possible recurrence of this disease with more than a 30-year latency period should be taken into consideration.

Homodyne readout on dc-removed coaxial holographic data storage.

Multiplexing characteristics of a dc-removed coaxial holographic storage system were evaluated for what is believed to be the first time. Our dc-removed coaxial system achieved 3.5 times higher raw data density than a conventional coaxial system that involved dc recording. The increase of the data density was due not only to less M/# consumption but also to the effects of signal amplification and noise reduction by use of the positive and negative images reconstructed from the same holograms.

Groove pancreatic carcinoma.

The groove area is localized between the head of the pancreas, the duodenum, and the common bile duct. Differentiating of groove pancreatitis from pancreatic carcinoma is often difficult. Herein, we report a 54-year-old woman with groove pancreatic adenocarcinoma presenting epigastralgia, jaundice, and vomiting. The diagnosis was confirmed by computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic biopsy. The patient underwent pancreatoduodenectomy. Microscopically, well-differentiated adenocarcinoma was mainly located in Santorini's duct, but there was no invasion to the main pancreatic duct. The patient followed a satisfactory post operative course. She is doing well without recurrence 15 months after the surgery. It is very difficult to differentiate groove pancreatic carcinoma from groove pancreatitis. To avoid unnecessary surgical treatment, endoscopic biopsy and observation of the duodenum are useful for diagnosis. However, keeping in mind the differential diagnosis of pancreatic head carcinoma is necessary.

Oncolytic viral therapy for human pancreatic cancer cells by reovirus.

PURPOSE: Pancreatic cancer has a poor prognosis and few effective therapies are available. The oncolytic effect of reovirus has been observed in cancer cells with an activated Ras signaling pathway, and pancreatic cancer may be a candidate target for reovirus because K-ras mutation is frequently found in pancreatic cancer. EXPERIMENTAL DESIGN: In this study, we examined the feasibility of using reovirus (serotype 3) as an antihuman pancreatic cancer agent. RESULTS: Reovirus was able to infect five human pancreatic cancer cell lines (Panc1, MIApaca-2, PK1, PK9, and BxPC3) in vitro. We also confirmed that the Ras activity in these cancer cell lines was elevated compared with that in the normal cell line and that susceptibility to reovirus was associated with the Ras activity of these cells. In a unilateral murine xenograft model using Panc1 and BxPC3 cell lines, each tumor growth was suppressed by intratumoral injection of reovirus. Furthermore, local injection of reovirus also had systemic antitumor effects in a bilateral xenograft model using Panc1 cell line. Immunohistochemical examination revealed that reovirus replication was observed within the tumor but not in surrounding normal tissue. CONCLUSIONS: These results suggest that reovirus can be considered for a novel therapy against pancreatic cancer.

Value of serum carbohydrate antigen 19-9 for predicting extrahepatic metastasis in patients with liver metastasis from colorectal carcinoma.

BACKGROUND/AIMS: Serum levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) are frequently elevated in patients with colorectal carcinoma. However, the predictive utility of these two markers has not been fully investigated in patients with liver metastasis. METHODOLOGY: We retrospectively analyzed data obtained from 90 hepatectomy or non-hepatectomy patients with liver metastases from colorectal carcinoma. We examined correlation between serum levels of CEA and CA19-9 and other clinicopathologic factors and performed univariate and multivariate analyses to determine the impact of these tumor markers on extrahepatic metastasis after admission to our hospital. RESULTS: CEA elevation correlated to advanced age (> or = 60 years), and CA19-9 elevation correlated with the site (colon) of primary tumor. Univariate analysis showed that treatment without hepatectomy, > or = 4 hepatic tumors, and CA19-9 elevation had been an adverse effect on extrahepatic disease-free survival time after admission. Multivariate analysis showed that CA19-9 elevation (risk ratio, 1.84) and treatment without hepatectomy (risk ratio, 1.62) had a significant effect on extrahepatic disease-free time. CONCLUSIONS: In patients with colorectal liver metastasis, elevation of serum CA19-9 is a risk factor for extrahepatic metastasis, and CEA appears to be useless for predicting extrahepatic metastasis in these patients.

Hepatocellular carcinoma in young adults.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) is uncommon in adolescent and young adult Japanese. The aim of this study was to examine the clinicopathological analysis of Japanese young adults with HCC. METHODOLOGY: We reviewed the cases of 11 patients with HCC who were between 13 and 40 years of age. RESULTS: All patients were HBs antigen-positive patients, and most of them had relatively good liver function. Eight patients (72.7%) had abdominal pain directly caused by advanced tumors. Most patients had highly advanced HCC; 9 patients (81.8%) had tumors larger than 10cm in diameter, and all had portal invasion. Nine patients had intrahepatic tumor dissemination. Among 8 patients who underwent hepatectomy 6 survived more than 1 year, and 1 patient has been alive 71 months without disease. The other 3 patients, whose tumors could not be resected, died within 5 months of diagnosis. CONCLUSIONS: These results suggest that cases of HCC in young adults are rarely detected early because of their relatively good liver function despite their higher positive rate for HBs antigen. Therefore, early screening for cancer is particularly important in young adults who are HBs antigen-positive.

Inhibition of indoleamine 2,3-dioxygenase suppresses NK cell activity and accelerates tumor growth.

Indoleamine 2,3-dioxygenase (IDO), a tryptophan catabolizing enzyme, is induced under various pathological conditions, including viral and bacterial infection, allograft rejection, cerebral ischemia, and tumor growth. We have previously reported that the expression of IDO mRNA was increased in some clinical cases of hepatocellular carcinoma in which the recurrence-free survival rate in these IDO-positive patients was significantly higher than that in patients without IDO mRNA induction in tumors. Additionally, IDO expressed in tumors was localized not to the tumor cells but instead to tumor-infiltrating cells by immunohistochemistry. In this study, in order to elucidate the mechanisms underlying anti-tumor effect of IDO, we investigated whether IDO inhibitor (1-methyl-dl-tryptophan, 1MT) affects the growth of subcutaneous B16 tumors in mice. Subsequently, the activity of natural killer (NK) cells was investigated under the conditions of inhibited IDO activity in vivo and in vitro. IDO mRNA expression of B16 cells, B16 subcutaneous tumor, sprenocytes of mice, and human NK cells were studied by reverse transcription-polymerase chain reaction. B16 subcutaneous tumor growth with or without IDO inhibition was observed and cytotoxic activity of NK cells were investigated under the conditions of inhibited IDO activity in vivo and in vitro. IDO mRNA was expressed in B16 subcutaneous tumor, splenocytes of tumor bearing mice, co-cultured splenocytes with B16, and human NK cells. On day 14, after injection of B16 melanoma cells, the sizes of tumors in IDO-inhibited mice were significantly larger than those in control mice. The cytotoxic activity of mice NK cells was reduced by IDO inhibition in vivo. In vitro inhibition of IDO, NK activity was reduced in dose-dependent manner of 1MT. In conclusion, these results indicated that IDO plays an important role in anti-tumor immunity by regulating cytotoxic activity of NK cells.

Gastric tube reconstruction prevented esophageal reflux after proximal gastrectomy.

Although the standard operation for early cancer of gastric cardia is proximal gastrectomy followed by jejunal interposition, we recently reported a simple and useful technique for proximal gastrectomy with gastric tube reconstruction. The operative procedures included resection of the proximal two-thirds of the stomach, followed by anastomosis between the esophagus and gastric tube, using a circular stapler (Proximate ILS 25; Ethicon, Cincinnati, OH, USA). The gastric tube was about 20 cm long and 4 cm wide. The patient a 76-year-old man had no reflux symptoms such as heartburn, retrosternal pain, and regurgitation. Endoscopy showed no evidence of reflux esophagitis, including mucosal redness, erosion, and ulceration. Ambulatory 24-h pH monitoring indicated that the pH of the lower esophagus was between 6 and 8 when the patient was upright and between 5 and 7 when he was in the supine position. There were nine reflux episodes during the day, and no reflux episode while he was asleep. The duration of each reflux episode was less than 1 min, and the total reflux time was 1 min in the 12-h day (0.1%). These data indicate that reconstruction by gastric tube may prevent esophageal reflux in patients who have undergone proximal gastrectomy for early cancer of the gastric cardia.

Potent stimuli combined with lipopolysaccaride and IFNgamma may improve immunotherapy against HCC by increasing the maturation and subsequent immune response of the dendritic cells.

Dendritic cells (DCs)-based immunotherapy is a new strategy for cancer treatment and has been used in some clinical trials against cancer, including melanoma, and has shown promising results. However, the conventional protocol of DC immunotherapy may not be effective for hepatocellular carcinoma (HCC) because of impaired DC maturation in HCC patients. In order to induce sufficient maturation on HCC derived DCs, we tested various stimuli such as tumor necrosis factor (TNF) alpha, lipopolysaccharide (LPS), interferon (IFN)gamma and CD40-ligand. In stimulating with LPS + IFNgamma, DCs of HCC patients expressed significantly high levels of CD86 (p < 0.05) and produced high levels of IL-12 as compared to DCs stimulated with TNFalpha alone. Moreover, it showed better ability to stimulate allogeneic mixed lymphocyte reaction. It concluded that LPS and IFNgamma was the best combination of stimuli for induction of sufficient maturation on DCs derived from HCC.

Microwave coagulation therapy for unresectable hepatocellular carcinoma.

BACKGROUND/AIMS: Surgical resection is not always feasible for patients with hepatocellular carcinoma. We used microwave coagulation therapy (MCT) as an alternative to resection and evaluated its efficacy. METHODOLOGY: Twenty-four patients with unresectable hepatocellular carcinoma underwent microwave coagulation therapy by laparotomy (n=18), laparoscopy (n=4), or thoracoscopy (n=2) because of advanced liver cirrhosis and/or intrahepatic metastases. One nodule was treated in 11 patients, 2 nodules were treated in 7, 3 nodules were treated in 3, 6 nodules were treated in 1, and 7 nodules were treated in 2. Tumor size ranged from 10 to 50 mm. Liver function was analyzed at the time of initial MCT and at treatment for recurrence. Patient outcomes were studied. RESULTS: Two patients died postoperatively after initial MCT. Other patients showed rapid recovery without hepatic dysfunction. Liver function just before MCT was equivalent to that measured just before treatment for recurrence. One patient developed local recurrence at the margin of the treated tumor. Recurrent nodules in different segments were detected in 15 patients. Transcatheter arterial embolization was performed in 13 recurrences, percutaneous ethanol injection therapy was performed in 1 recurrence, and MCT was performed in 1 recurrence. The 3-year cancer-free survival rate was 9.9%, and the 3-year cumulative survival rate was 83.9%. CONCLUSIONS: Because MCT is indicated for hepatocellular carcinoma patients with advanced liver cirrhosis, intrahepatic recurrences are frequent. Since, liver function is preserved after MCT, however, locoregional therapy can be selected when intrahepatic recurrence is detected, thus improving patient survival rate.

Correlation between tumor size and mode of spread in mass-forming intrahepatic cholangiocarcinoma.

BACKGROUND/AIMS: Mode of spread of intrahepatic cholangiocarcinoma of the mass-forming type (MF-ICC) has not been assessed according to tumor size. METHODOLOGY: We retrospectively evaluated 17 cases of resected MF-ICCs. Tumor size was categorized as follows: < 45 mm (n=4), 45-79 mm (n=7), and > or = 80 mm (n=6). The correlation of tumor size with presence or absence of histological invasion to the portal vein (vp), hepatic vein (vv), intrahepatic metastasis (im), and lymphatic vessel or perineural space (ly/pn) was evaluated. Clinical outcomes of 13 patients who underwent curative resection were also investigated. RESULTS: The positive rates of vp, vv, im, and ly/pn were calculated as 25, 0, 0, and 0% in the < 45-mm group; 86, 29, 86, and 71% in the 45-79-mm group; and 100, 50, 83, and 83% in the > or = 80-mm group, respectively. Of 13 patients who underwent curative resection, 6 of 9 in the > 45-mm group were found to have recurrent diseases in the liver remnant, lymph node, and the lung, whereas one of 4 patients in the < 40-mm group developed peritoneal recurrence. CONCLUSIONS: Systematic hepatectomy without lymphadenectomy might be appropriate for MF-ICC smaller than 45 mm in diameter.

Hepatectomy for liver metastasis from ampullary cancer after pancreatoduodenectomy.

A 51-year-old Japanese woman with a solitary liver metastasis originating from a carcinoma of the ampulla of Vater was successfully treated by partial hepatectomy 19 months after curative pancreatoduodenectomy with lymphadenectomy. Histologic examination revealed a stage III well-differentiated tubular adenocarcinoma (pT2, pN1, and pM0). Postoperative serum concentrations of carcinoembryonic antigen increased exponentially to 133 ng/mL. The carcinoembryonic antigen doubling time was 63 days. Computed tomography and ultrasonography of the abdomen showed a solitary metastasis in segment VI of the liver. Since neither local recurrences nor other distant metastases were detected, the patient underwent partial hepatectomy. Histologic study confirmed the presence of a metastatic liver tumor from the ampullary carcinoma. The carcinoembryonic antigen levels returned to normal immediately after the partial hepatectomy. She was well without signs of recurrence 18 months after partial hepatectomy.

101 hepatectomies under continuous inflow occlusion following simple in-situ liver cooling in patients with chronic liver diseases.

BACKGROUND/AIMS: Hepatic inflow occlusion involves the serious disadvantage of ischemic injury to the remnant liver, particularly in patients with injured parenchyma. Liver hypothermia is one of the solutions for this problem. The purpose of this study was to evaluate simple in-situ liver cooling method of performing hepatic resection under continuous inflow occlusion in patients with chronic liver disease. METHODOLOGY: One hundred and one patients with chronic hepatitis (n = 26) and cirrhosis (n = 75) were included in this retrospective study. They underwent hepatectomy under conditions of continuous inflow occlusion immediately following simple in-situ liver cooling. Laboratory data and intraoperative and postoperative variables were analyzed for the three groups of patients stratified according to the lowest liver tissue temperature achieved: group 1 (> or = 30 degrees C, n = 16), group 2 (< 30 degrees C and > or = 25 degrees C, n = 62) and group 3 (< 25 degrees C, n = 20). RESULTS: Our simple in-situ liver cooling method enabled us to safely resect chronically diseased liver under continuous inflow occlusion (49.8 +/- 7.7 min, mean +/- SD; range, 30 to 70 min) with acceptable operative blood loss (894 +/- 853mL), morbidity (22.7%, 23/101) and mortality (1.0%, 1/101); one patient died of complications unrelated to ischemic injury. Analysis demonstrated that simple liver hypothermia was substantially hepatoprotective against ischemic injury in terms of serum transaminase levels and duration of inflow occlusion, particularly when the liver tissue temperature fell below 30 degrees C (groups 2 and 3). CONCLUSIONS: Hepatic inflow occlusion can be safely employed in a continuous manner for approximately 1 hour, even during resection of chronically diseased liver, particularly when the liver is cooled below 30 degrees C prior to hepatic clamping by our simple in-situ hypothermia technique.

Pancreatic resection with ultrasonically activated scalpel: preliminary observations.

BACKGROUND/AIMS: Resection of the pancreas was performed with a surgical knife, electrocautery, or an automatic stapler. We histologically and radiologically evaluated the applicability of the ultrasonically activated scalpel (Coagulating Shears, CS, Ethicon Endo-Surgery, Cincinnati, OH, USA) for resecting pancreatic parenchyma and reported our clinical observations on the use of the coagulating shears. METHODOLOGY: Resection of the pancreas was performed with the coagulating shears in 8 patients and with electrocautery in 5. The pancreas was transected with blunt mode of the coagulating shears at output power level of 3. Histologic thermal degeneration of the surface was evaluated with hematoxylin-eosin and Azan-Mallory staining. Radiologic pancreaticography was carried out on 4 resected specimens. We report 8 practical applications of the coagulating shears and compared its use with that of electrocautery in pancreatic surgery. RESULTS: Histologically, a coagulum of degenerated tissue completely closed each end of the vessels in the transected surface of all cases. The mean breadth of thermal degeneration resulting from the use of the coagulating shears was significantly less than that caused by electrocautery (1.33 +/- 0.21 vs. 3.05 +/- 0.34 mm, respectively) Pancreaticograms showed the closed branches of the pancreatic duct, but the closed main pancreatic duct had burst in 1 of 4 cases. Clinically, pancreatic fistula occurred in 1 of 8 patients who underwent pancreatic surgery with the coagulating shears. CONCLUSIONS: Pancreatic resection with the coagulating shears might be effective and feasible as long as the main pancreatic duct is ligated.

Clinical significance of combined pancreas and portal vein resection in surgery for pancreatic adenocarcinoma.

BACKGROUND/AIMS: Surgical resection remains the only potentially curative treatment for pancreatic adenocarcinoma for which the resectability and prognosis are still poor. The aim of the present study was to evaluate the efficacy of portal vein resection for pancreatic adenocarcinoma. METHODOLOGY: Between August 1983 and December 2000, 69 patients with pancreatic ductal cell carcinoma underwent resection in our department; 22 of the 69 had combined resection of the pancreas and portal vein. When the pancreas could not be separated from the portal vein, the vein was judged to be invaded by cancer and resected. RESULTS: The mortality rate for portal vein resection was 4.5%, which was similar to that in 47 patients with no resection of the portal vein (2.1%). Postoperative histologic analysis showed that 8 (37%) of the patients who underwent portal vein resection did not have cancer invasion to the portal vein, and 3 of them remain disease free to date. The 3-year survival rate of patients undergoing portal vein resection was 21.3%, and that of patients without portal vein resection was 20.0%. CONCLUSIONS: Resection of the portal vein in cases of pancreatic ductal cell carcinoma has no adverse affect on long-term survival for selected patients.

Factors influencing recurrence after surgical treatment for T2 gallbladder carcinoma.

BACKGROUND/AIMS: The overall outcome of T2 gallbladder carcinoma has not been favorable, although there is a modest hope for long-term survival after radical resection. The aim of this study was to examine factors influencing postoperative disease-free survival of patients with T2 gallbladder carcinoma to clarify optimal treatment. METHODOLOGY: Of 53 patients with gallbladder carcinoma who had undergone surgical resection from 1985 to 2000, 22 had T2 carcinoma histologically proved. The significance of variables for disease-free survival was examined retrospectively by the Kaplan-Meier method and the log-rank test. RESULTS: There were 16 patients with stage II (T2N0M0), 6 with stage III (T2N1M0) disease. Eleven patients were treated by extended cholecystectomy with resection of the extrahepatic bile duct, 10 patients underwent extended cholecystectomy without resection of the extrahepatic bile duct, and 1 patient underwent cholecystectomy. All patients underwent lymph node dissection in the hepatoduodenal ligament, below the pancreatic head, and along the common hepatic artery. Lymph node metastasis was present in 6 patients. Lymphatic, venous, and perineural invasions were found in 9, 4, and 4 patients, respectively. The absence of lymphatic invasion was a significant factor related to good postoperative disease-free survival (5-year disease-free survival rate, 88.9% vs. 31.3% in the presence of lymphatic invasion). Lymph node, venous, or perineural invasion, and surgical procedure were not significant factors to good postoperative disease-free survival. CONCLUSIONS: For patients with T2 gallbladder carcinoma, the presence of lymphatic invasion is an unfavorable prognostic indicator that calls for additional treatment after radical surgery.

Optical noise reduction for dc-removed coaxial holographic data storage.

A method of reconstructing positive and negative images from Fourier holograms recorded without the dc components is demonstrated by use of a coaxial holographic storage system. Reconstructed images are obtained by adding a phase-modulated dc component of the signal beam on reading. Contrast reversal of the reconstructed images can be achieved by reversing the readout reference pattern. This method can realize not only optical noise reduction but also less consumption of the dynamic range of the recording medium, potentially contributing to increasing the number of multiplexed holograms.

Coaxial holographic data storage without recording the dc components.

A technique of recovering the data pages from Fourier holograms recorded without the dc components is demonstrated theoretically and experimentally by use of a coaxial holographic storage system. A reconstructed image is obtained by adding a phase-modulated dc component of the signal beam on reading. The bit error rate of the reconstructed image is comparable with that for the hologram recorded with the dc component as well. Since high intensities of the dc components are not recorded in this technique, the dynamic range of the recording media can be saved, which potentially contributes to increasing the number of multiplexed holograms.

Optical noise reduction by reconstructing positive and negative images from Fourier holograms in coaxial holographic storage systems.

A technique for reconstructing positive and negative images from an identical intensity-modulated hologram is demonstrated theoretically and experimentally by use of a coaxial holographic storage system. Negative images are obtained by adding a phase-modulated dc component of signal beam on reading. By comparing positive and negative images, the bit error rate (BER) is improved by two orders of magnitude. This technique can reduce optical noise of reconstructed images to attain low BERs.

Safety and efficacy of laparoscopic distal pancreatectomy for the treatment of pancreatic disease.

BACKGROUND/PURPOSE: There are a few reports of laparoscopic distal pancreatectomy in the literature. We describe our experience with laparoscopic distal pancreatectomy and evaluate the safety and efficacy of the procedure in light of other reported findings. METHODS: A retrospective study was performed of all patients who underwent laparoscopic distal pancreatectomy between April 1996 and December 2002 at Oita University Faculty of Medicine. RESULTS: Laparoscopic distal pancreatectomy was attempted in seven patients (three men and four women) with a mean age of 65 years. One patient was converted to open surgery, and two patients required a hand-assistance procedure. There were no complications in any patients. Median operation time for all seven patients was 300 min, and median blood loss was 330 ml. Median postoperative hospital stay was 12 days (range, 7 to 21 days). CONCLUSIONS: Our limited results, together with reported outcomes, suggest that laparoscopic distal pancreatectomy is safe and effective for selected patients. The potential advantages of this procedure include reduced morbidity and reduced hospital stay.