Determination of Malignant and Invasive Predictors in Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Suggested Scoring Formula

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 +/- 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.

The Efficacy of Simple Cholecystectomy among Patients with T2 Gallbladder Cancer

PURPOSE: Stage-related treatment has been recommended for gallbladder cancer (GBC). When patients with T2 tumors undergo an extended cholecystectomy, the 5-year survival rates have been reported to be 64~100%. But when patients with T2 tumors undergo simple cholecystectomy, the 5-year survival rates have been reported to be only 20~40%. The question may rise as to which patients benefit from simple cholecystectomy among patients with T2 GBC. We investigated the survivals and the facts leading to death or recurrence after simple cholecystectomy for T2 GBC. METHODS: Between Mar. 2001 and Dec. 2007, 13 patients had refused second radical operation for T2 GBC incidentally discovered after simple cholecystectomy. Survival analyses were evaluated by clinopathological factors. RESULTS: The 1-, 3- and 4-year overall survival rates were 84.6%, 76.2% and 38.1% and 1- and 3-year disease-free survival rates were 69.2%, 51.3%. The factors affected survival rates were low serum albumin titer and R1 resection (Lymph node metastasis or cystic duct involvement in microscopic finding) (P<0.05). CONCLUSION: Simple cholecystectomy is not a curative method of T2 GBC, because it reveals lower 5-year survival rates compared to those of extended cholecystectomy or radical surgery. But in the case when the patient refuses reoperation or it is difficult to undergo reoperation because of severe underlying disease, simple cholecystectomy with normal albumin titer or the absence of lymph node metastasis and absence of cystic duct involvement in microscopic findings may help the long-term survivals after simple cholecystectomy.

Pseudomembranous Colitis after Gastrointestinal Operation

PURPOSE: The risk factors of pseudomembranous colitis (PMC) are well known. However, there have been no studies of PMC after gastrointestinal operation. The aim of this study was to evaluate the risk factors and to establish the guiding principles for PMC after gastrointestinal operation. METHODS: We performed a retrospective study of 39 PMC patients after gastrointestinal operation from January 2004 to December 2008. A control group of one hundred and seventeen matched to a PMC group by date of operation was chosen in a random fashion. Preoperative, operative, and postoperative factors of PMC were evaluated. RESULTS: The incidence of PMC after gastrointestinal operation was 0.63%. On univariate analysis, among preoperative factors, albumin, PT-INR and neutropenia were significant risk factors for PMC. There was no difference in the operative factors. Among postoperative factors, duration of cephalosporin, aminoglycoside, H2 blocker administration were significant risk factors for PMC after gastrointestinal operation. And transfusion, duration of NPO, length of stay in intensive care unit (ICU) and postoperative intraabddominal abscess, pneumonia were also significant risk factors. On multivariate analysis, the independent risk factors for PMC after gastrointestinal operation were duration of aminoglycoside administration, transfusion volume and length of stay in ICU. When period of study was divided by three months, incidence of PMC at a specific period was high. After limiting of prophylactic antibiotics, incidence of PMC fell to 0.36%. CONCLUSION: To prevent PMC after gastrointestinal operation, we need sustained efforts to establish stricter guidelines about prophylactic antibiotics and transfusion, and to minimize length of stay in ICU.

An Experimental Model of Partial Auto-liver Transplantation in Pig with Intrahepatic Inferior Vena Cava Reconstruction Using a GORE-TEX(R) Vascular Graft

PURPOSE: Experimental animal models are useful training methods for liver transplantation, despite of ethical issues. The aims of this study are to examine the technical feasibility of living donor liver transplantation in pigs and to address the ethical problems. METHODS: Eight pigs were used in this experiment. The pig liver was divided via a left hemi-hepatectomy without inflow occlusion. The GORE-TEX(R) Vascular Graft was used as a replacement for the inferior vena cava during the graft. After the bench technique, the remnant right lobe of the pig was removed. During the anhepatic phase, an abdominal aortic clamp in combination with general hypothermia was applied, instead of using a conventional bypass procedure. RESULTS: Anhepatic time was 41.3+/-7.0 min and cold ischemic time was 200.3+/-29.4 min. The 1(st), 4(th), and 8(th) pig died because of declamping shock and arrhythmia on releasing the abdominal aortic clamp. Three pigs had five postoperative complications: pneumonia, gastrointestinal bleeding, IVC thrombosis, portal vein thrombosis, and bile duct stricture. The 6th pig received a hepaticojejunostomy due to stricture of the anastomosis site at 37 days after transplantation. CONCLUSION: Pigs are economically and ethically more convenient compared to primate models. For auto-liver transplantation, no immunotherapy was needed. The pigs lived relatively long, allowing operative faults to be detected and studied. This experimental model will be useful training for living donor liver transplantation.

Short-term Analysis of Pancreaticoduodenectomy with an Application of a Binding Pancreaticojejunostomy and an Endo GIA Stapler

PURPOSE: A pancreaticoduodenectomy is the procedure of choice for managing a periampullary malignancy. This is a complex procedure accompanied with some morbidity. In order to improve postoperative clinical results, we tried to apply a binding pancreaticojejunostomy and Endo GIA stapler during pancreaticoduodenectomy. According to the clinical outcomes, compare this trial with a conventional procedure. METHODS: We evaluated retrospectively clinical results of 30 patients who had received pancreaticoduodenectomy from Jan. 2003 to Dec. 2004 in the Pusan National University Hospital. These cases were divided into two groups; Group I comprised of 16 patients receiving this procedure and Group II comprised of 14 patients receiving conventional procedure. RESULTS: There were some differences in the mean operation time and the amount of blood loss between two groups, but significant difference only in an aspect of blood loss (P=0.042). Postoperative complications were as these: Group I, pancreatic fistula was in 12.5%, intraabdominal bleeding in 6.2%, wound infection in 12.5%; Group II, pancreatic fistula was in 35.7%, intraabdominal bleeding in 21.4%, wound infection & intraabdominal abscess in 7.1%. In Group I, there was a lower morbidity rate than in Group II, but there was a significant difference in the development of a pancrea-tic fistula as a pancreatic parenchymal texture (P=0.021). CONCLUSION: Although there was a small number of cases, it appears that a pancreaticoduodenectomy with the application of a binding pancreaticojejunostomy and Endo GIA stapler can produce good results, also need to get more clinical results.

Experimental Fusiform Aneurysm Model at Common Carotid Artery in Rat

PURPOSE: An ideal suturing material should be strong, easy to handle, should produce minimal tissue reaction and finally should disappear without a trace. Various micro-vascular suture materials have been produced in the past several decades in order to meet these demands. We have used nylon suturing material in experimental microsurgery because it is less expensive than polypropylene. After carotid artery end-to-end anstomosis, we found fusiform aneurysm incidentally. In this study 9-0 nylon (group I) and 9-0 polypropylene (group II) were compared to 10-0 nylon (group III), and 10-0 polypropylene (group IV) in order to survey the incidence of aneurysmal development in each material for use in microvascular surgery. METHOD: Forty Sprague-Dawley rats, 230 g to 350 g body weight, were used for this study. The carotid arteries were anastomosed end-to-end with 9-0 nylon, and 10-0 nylon, in addition to 9-0 polypropylene, and 10-0 polypropylene. The suture number of all arteries was 10 points except for two cases were 11 points due to uncontrolled bleeding. Specimens were harvested 1 week, 3 weeks, 6weeks and 10 weeks postoperatively. RESULT: The number of animals studied during the first week totaled 20 carotid arteries and they showed no interval change. After 3 weeks, we identified aneurysms in following cases: group I 3 cases, group II 2 cases, group III 1 case and group IV 1 case per five cases in each group. After 6 weeks, gross aneurysmal changes seen: group I, all (5) cases; Group II, 2 cases; group III, all (5) cases; Group IV, 3 cases. After 10 weeks, many aneurysms were observed: group I, all (5) cases; group II, all (5) cases; group III, 0 case; group IV, 2 cases. The aneurysms were measured and ranged in size from 1.3 mm to 8.1 mm. Histological analysis for inflammation, fibrosis and medial necrosis at the anastomosis site revealed no significant difference between same sized suture materials. If the experimental aneurysms were more than 5 times the diameter of the carotid artery, the aneurysms were considered to be experimental giant aneurysms. Seventy of our 34 experimental aneurysms were considered to be giant aneurysms. CONCLUSION: Our findings demonstrate that the development of aneurysms was related to size of the suture material and not the type of suturing material used. An ideal suture material for anastomosisof the carotid artery in the rat wasd a 10-0 monofilament suture material with suture numbers was above 10 points. We also made good aneurysm model. When we used 9-0 suture material and suture numbers were below 10 points multiple aneurysms developed. This model demonstrated the development mechanism of giant fusiform aneurysms.

Experimental Fusiform Aneurysm Model at Common Carotid Artery in Rat

PURPOSE: An ideal suturing material should be strong, easy to handle, should produce minimal tissue reaction and finally should disappear without a trace. Various micro-vascular suture materials have been produced in the past several decades in order to meet these demands. We have used nylon suturing material in experimental microsurgery because it is less expensive than polypropylene. After carotid artery end-to-end anstomosis, we found fusiform aneurysm incidentally. In this study 9-0 nylon (group I) and 9-0 polypropylene (group II) were compared to 10-0 nylon (group III), and 10-0 polypropylene (group IV) in order to survey the incidence of aneurysmal development in each material for use in microvascular surgery. METHOD: Forty Sprague-Dawley rats, 230 g to 350 g body weight, were used for this study. The carotid arteries were anastomosed end-to-end with 9-0 nylon, and 10-0 nylon, in addition to 9-0 polypropylene, and 10-0 polypropylene. The suture number of all arteries was 10 points except for two cases were 11 points due to uncontrolled bleeding. Specimens were harvested 1 week, 3 weeks, 6weeks and 10 weeks postoperatively. RESULT: The number of animals studied during the first week totaled 20 carotid arteries and they showed no interval change. After 3 weeks, we identified aneurysms in following cases: group I 3 cases, group II 2 cases, group III 1 case and group IV 1 case per five cases in each group. After 6 weeks, gross aneurysmal changes seen: group I, all (5) cases; Group II, 2 cases; group III, all (5) cases; Group IV, 3 cases. After 10 weeks, many aneurysms were observed: group I, all (5) cases; group II, all (5) cases; group III, 0 case; group IV, 2 cases. The aneurysms were measured and ranged in size from 1.3 mm to 8.1 mm. Histological analysis for inflammation, fibrosis and medial necrosis at the anastomosis site revealed no significant difference between same sized suture materials. If the experimental aneurysms were more than 5 times the diameter of the carotid artery, the aneurysms were considered to be experimental giant aneurysms. Seventy of our 34 experimental aneurysms were considered to be giant aneurysms. CONCLUSION: Our findings demonstrate that the development of aneurysms was related to size of the suture material and not the type of suturing material used. An ideal suture material for anastomosisof the carotid artery in the rat wasd a 10-0 monofilament suture material with suture numbers was above 10 points. We also made good aneurysm model. When we used 9-0 suture material and suture numbers were below 10 points multiple aneurysms developed. This model demonstrated the development mechanism of giant fusiform aneurysms.

The Usefulness of Multiplanar Reconstruction Images in Preoperative CT Evaluation of Advanced Gastric Cancer

PURPOSE: The purpose of this study was to assess the usefulness of multiplanar reconstruction (MPR) images in the preoperative evaluation of advanced gastric cancer. METHODS: Multidetector-row CT (MDCT) was performed on 61 patients with advanced gastric cancer, and the coronal and sagittal multiplanar images reconstructed from the transaxial data. The combined axial and MPR images were compared to the axial images alone to determine if the image quality and diagnostic accuracy had been improved. RESULTS: The observed image quality of the combined axial and MPR images, graded relative to the axial image alone, was fair in 22 (36.1%), good in 27 (44.2%), and excellent in 12 cases (19.7%). For the T staging, the diagnostic accuracy of combining the axial and MPR images (75.4%) was higher than that of the axial image alone (70.7%). However, there was no significant difference in the accuracies between the two methods (McNeamar test, P>0.05). For specific regions, the diagnostic accuracies of combining the axial and MPR images and the axial image alone were as follows: 90.2, and 73.8% with antral lesser curvature involvement; 93.4, and 75.4% with antral greater curvature involvement; 83.6, and 73.8% with gastric angle involvement; 96.7, and 88.5% with liver left lobe invasion; 90.2, and 83.6% with pancreas head invasion and 96.7, and 85.2% with colon or mesocolon invasion, respectively. CONCLUSION: Combining the axial and MPR images does not improve the depiction of the T staging compared to the axial image alone in advanced gastric cancer. However, combining the axial and MPR images improved the imaging quality and diagnostic accuracy of specific regions where the delineation of the conventional axial image was insufficient. Therefore, combining the axial and MPR images may be very useful in the preoperative evaluation of advanced gastric cancers.

Analysis of Normal and Cancer Tissue in the Stomach Using Raman Spectroscopy

PURPOSE: Raman spectroscopy is a vibrational spectroscopic technique, which is capable of providing details on the chemical composition, molecular structure and molecular interactions in cells and tissues. The primary objective of this study was to explore Raman spectroscopy for the detection of spectral changes between normal and cancer tissue in the stomach. METHODS: Tissue specimens were obtained from the resected stomach of advanced gastric cancer patients. The normal gastric and cancer tissues were harvested from the middle, lower portion of the stomach and from the tumor mass, respectively. 19 sets (antrum, body and cancer) of spectral data, with clearly defined histopathological findings, were selected in this study. FT-Raman spectroscopy (Bruker Inc., Karsruhe, Germany) was used for tissue Raman studies, with excitation at 1, 064 nm. The Raman spectra from the gastric tissue specimens were obtained with a 20 minute signal acquisition time. RESULTS: In the range 700~1, 900 cm-1, the Raman spectra of gastric antral tissue were dominated by a number of vibrational modes of biomolecules, such as proteins, lipids and nucleic acids. The Raman spectrum pattern of gastric body tissue was similar to that of the antrum, suggesting the structure and composition between the gastric antrum and body are much the same. The Raman spectra differed significantly between the normal and malignant cancer tissues, with cancers showing higher percentage signals for protein, lipid and nucleic acid compared to normal tissue (P<0.05). Difference were observed in the shapes of the Raman spectra between the normal and cancer tissues, particularly in the spectral ranges 1, 250~1, 255, 1, 330~1, 340 and 1, 440~1, 450 cm-1, which contain signals relating to protein and lipid conformations and CH2 bending mode of nucleic acids. CONCLUSION: This study demonstrates the ability of Raman spectroscopy to detect biochemical changes in malignant gastric tissue, and may become a useful adjunct to pathological diagnosis allowing guided biopsies and assessment of adequacy of resection margins.

Comparative Study for the Determination of HER2 gene Amplification and Overexpression in Breast Cancer

PURPOSE: The human epidermal growth factor receptor-2 (HER2) is overexpressed in breast cancer. The subset of patients with breast cancer demonstrating a HER2-positive status has aggressive tumors and a poor prognosis. Knowledge of the HER2 status is prerequisite when considering a patient's eligibility for anti-HER2 targeted therapy (Herceptin(R)). There are several assays available for determining the HER2 status. The aim of this study was to compare and evaluate the HER2 status in breast cancer by means of immunohistochemistry (IHC), FISH and real-time PCR. METHODS: DNA samples from fresh tumor tissues of 20 patients with breast cancer were analyzed with real-time PCR, using the LightCycler-HER2/neu PCR assay. A tissue microarray, containing 20 samples obtained from formalin- fixed, paraffin-embedded tissues, was used for IHC and FISH (PathyVysionTM). RESULTS: The frequencies of HER2 gene amplification for real-time PCR and FISH were 35 and 65% respectively, and the IHC frequency of overexpression was 70%. This study showed 75% concordance between IHC vs. FISH, 65% between IHC vs real-time PCR and 70% between FISH vs. real-time PCR. Considering real-time PCR as the gold standard, this study showed sensitivities and specificities of 100 and 46.2% for IHC, and of 100% and 53.8% for FISH. CONCLUSION: These results demonstrated marked discordance for the HER2 stati according to the various methods used. IHC, a familiar cost-effective test, will undoubtedly remain in routine clinical practice for HER2 screening but confirmatory HER2 testing using either FISH or real-time PCR is recommended for indeterminate cases. Real-time quantitative PCR for HER2 appears to be clinically useful due to its simplicity and ability to produce rapid results.

Plasma Ghrelin Level According to Extent of Gastric Resection

PURPOSE: Total gastrectomy is followed by weight loss in the majority of patients, but the reason for this is not clear. Ghrelin, a novely isolated gastric hormone, exerts orexigenic activity. If a circulating ghrelin participates in the adaptive response to weight loss, the weight loss induced by total gastrectomy may be accompanied by impaired ghrelin secretion. METHODS: The blood was collected from gastric cancer patients who have undergone gastric resection, preoperatively and immediately after resection, on the 1st, 3rd and 7th postoperative day. The correlation of the preoperative plasma ghrelin concentration with gender, age and BMI were analyzed. The concentration changes of plasma ghrelin were observed serially after dividing gastrectomized patients into the subtotal gastrectomy group, the total gastrectomy group, and the proximal gastrectomy group. RESULTS: Although statistically not significant, the plasma ghrelin concentration was negatively correlated with age and BMI. In the subtotal gastrectomy group, nadir ghrelin was 48.4 +/- 23.6% of the preoperative value after gastric resection and then gradually increased to 82.4 +/- 19.9% on the 7th postoperative day. In the total gastrectomy group, nadir ghrelin was 36.9 +/- 10.4% of the preoperative value after gastric resection and remained 20.9 +/- 10.9% on the 7th postoperative day. In the proximal gastrectomy group, nadir ghrelin was 29.4 +/- 4.6% after gastric resection, which was followed by a gradual recovery. However, the recovery rate was steadier than compare to the subtotal gastrectomy group, as the concentration was 41.8 +/- 23.1% even on 7th postoperative day. CONCLUSION: The principal site of the ghrelin synthesis is stomach which contributes 60~70% to the circulating concentration of ghrelin. In the case of subtotal gastrectomy, ghrelin production is compensated by the remnant stomach. For this reason total gastrectomy is associated with suppressed ghrelin levels and it possibly contribute to the weight loss.

Experimental Study of Mechanism about Liver Regeneration Using Non-regenerating Liver Transplantation Model in Rats / 한국간담췌외과학회지

PURPOSE: The portal blood influx appears to be essential for liver regeneration after a liver resection and transplant. It was reported that only grafts with a gastro-pancreatic-splenic portal inflow into the graft portal vein could increase in size. The aim of this study was to investigate the impact of the gastro-pancreatic-splenic portal flow on the regeneration of a graft liver in a microsurgical model of heterotopic partial liver transplantation model. METHODS: Sprague-Dawley rats weighing 200 to 300 grams were used in this study. The rats were fasted for 12 hours prior to surgery. Thirty percent of the liver was heterotopically transplanted, to connect the donor's portal vein and suprahepatic vena cava with the recipient's superior mesenteric vein and the suprarenal vena cava, respectively. The donor and original liver were weighed preoperatively and 1, 2, 3, 7 days postoperatively. In addition, the histology of the donor and recipient's liver were examined using optical microscopy, and H & E staining. The proliferative capacity of the donor and recipient hepatocytes was evaluated using immunohistochemistry. RESULTS: The liver weights of the donor and recipient were measured at serial time points after surgery. Progressive enlargement was observed in the original liver. However, in assessing the liver weight, the weight of the donor liver was significantly lower at 2 days, 3 days, and 7 days after surgery than that of the original liver. During the observation periods, prominent histopathological differences were observed between the donor and recipient liver. There was a markedly higher number of PCNA (+) cells in the original liver than in the donor liver. CONCLUSION: The gastro-pancreatic-splenic portal inflow into the graft appears to play an important role in regenerating a partial liver graft. However, several variables such as the ischemic time, bile duct ligation, a small-for-size graft, and hepatic artery reconstruction in this model should be considered.

Hepatic Ischemia-Reperfusion Injury according to Inflow Occlusion in Porcine Liver Surgery / 한국간담췌외과학회지

PURPOSE: There are some methods for preventing massive intraoperative blood loss during major hepatic resection such as temporary vascular occlusion, but this can consequently lead to ischemia and reperfusion injury in the remnant liver. The purpose of this study is to assess ischemia-reperfusion (I/R) injury in a porcine hepatectomy model with continuous or intermittent inflow occlusion of a prolonged duration. METHODS: We performed right hepatic lobectomy in a porcine model with a liver ischemia lasting 120 mins; there was continuous (n=4) or intermittent (8 subsequent periods of 12 min ischemia and 3 min recirculation; n=4) inflow occlusion, and this was followed by 6 hours of reperfusion. We assessed hepatocytic injury by the serum levels of liver enzymes (AST, ALT, LDH), and we assessed the hepatocellular functions by the indocyanine green clearance test, inflammatory reactions by the serum levels of IL-6, and injury to the SECs (sinusoidal endothelial cell) by hyaluronic acid uptake. We compared these parameters during a preischemic period, a ischemic period and reperfusion period between the two groups. RESULTS: There were significant differences in the serum AST levels, IL-6 levels and HA uptake between the continuous and intermittent occlusion groups. In the intermittent occlusion group, we observed 1) less severe hepatocytic injury (p= 0.041) ; 2) more preserved HA uptake meaning less I/R injury (p=0.031) ; and 3) less inflammatory responses in the reperfusion period (p=0.045). CONCLUSION: During prolonged hepatic ischemia in a porcine model, the intermittent inflow occlusion method seemed to cause less hepatocellular injury and less SEC injury when compared to the continuous occlusion method. This means that we can expect less reperfusion injury in the intermittent inflow occlusion during a major hepatic resection with a prolonged ischemia.

Gastric Cancer Diagnosed in a Patient with Extramammary Paget's Disease

Extramammary Paget's disease (EMPD) is a rare intraepithel ial neoplasm arising in apocrine gland-bearing skin. EMPD may be regarded as a skin marker of associated malignancy because it tends to combine a variety of underlying malignancies in up to 50% of cases. Herein a case of gastric cancer diagnosed in a patient with extramammary Paget's disease of the scrotum is reported. The patient was a 65-year-old man whose chief complaint was exanthema of the right scrotum of 3 years duration. Biopsy samples taken from patient showed large, round cells with clear cytoplasm in the epidermis. The final diagnosis was EMPD of the scrotum. The extensive workups, including tumor marker, imaging studies and endoscopy to exclude associated malignancy were performed. Examination of the endoscopic gastric biopsy specimen revealed an adenocarcinoma of the stomach. On the basis of this result, a radical subtotal gastrectomy was successfully performed. This case suggests that, in cases of EMPD, the clinicians should consider the possibility of underlying malignancies and thoroughly examine not only the urogenital tract and lower gastrointestinal tract, but also the visceral organs, such as the stomach, even if there are no clinical symptoms of malignancy.

Analysis of Clinical Features and Factors Predictive of Malignancy in Intraductal Papillary Mucinous Tumor of the Pancreas: Multi-center Analysis in Korea / 한국간담췌외과학회지

BACKGROUND/AIMS: Despite of increasing numbers of reports on intraductal papillary mucinous tumor (IPMT), there is still difficulty in its' diagnosis, treatment and prediction of prognosis. The purpose of this multicenter study was to evaluate the clinico-pathological features of IPMT in Korea and suggest the prediction criteria of malignancy in IPMT. METHODS: We retrospectively reviewed the clinico-pathological data of 208 patients who underwent operations with IPMT between 1993 and 2002 at 28 institutes in Korea. RESULTS: Of the 208 patients with a mean age of 60.5+/-9.7 years, 147 were men and 61 were women. 124 patients underwent pancreatoduodenectomy, 42 distal pancreatectomy, 17 total pancreatectomy, 25 limited pancreas resection. Benign cases were 128 (adenoma (n=62), borderline (n=66)) and malignant cases were 80 (non-invasive (n=29), invasive (n=51)). A significant difference in 5-year survival was observed between benign and malignant group (92.6% vs. 65.3%; p=0.006). Of the 6 factors (age, location, duct dilatation, tumor appearance, main duct type, and tumor size) that showed the statistical difference in univariate analysis between benign and malignant group, we found three significant factors (tumor appearance (p=0.009), tumor size (p=0.023), and dilated duct size (p=0.010)) by multivariate analysis. CONCLUSION: Although overall prognosis of IPMT is superior to ordinary pancreatic cancer, more curative surgery is recommended in malignant IPMT. Tumor appearance (papillary), tumor size (> or =30 mm) and dilated duct size (> or = 12 mm) can be used as preoperative indicators of malig-nancy in IPMT.

p53 Mutation and c-erbB2 Over-expression in Predicting Factor of Responsibility to Neoadjuvant Chemotherapy in Patients with Breast Cancer

PURPOSE: The predictive value of c-erbB2 over-expression, and p53 mutation, to the response rate to neoadjuvant chemotherapy, were assessed in patients with breast cancer. METHODS: Between January 2000 and June 2002, 185 patients, with breast cancer, were put forward for two commonly used chemotherapy regimens prior to surgery. The first 135 received the CMF (cyclophosphamide 600 mg/m2, methotraxate 40 mg/m2, 5-FU 500 mg/m2) regimen, and the remaining 50 the CAF (cyclophosphamide 600 mg/m2, adriamycin 50 mg/m2, 5-FU 500 mg/m2) regimen. The expressions of the estrogen receptor (ER), progesterone receptor (PR), p53 mutation and c-erbB2, were evaluated by immunohistochemistry of needle biopsy samples prior to neoadjuvant chemotherapy. Tumor response was categorized according to the WHO criteria, using the largest diameter in ultrasonography or magnetic resonance imaging. RESULTS: The mean age of the patients in the CMF and CAF groups were 48.8 and 47.4 years. Forty eight (35.6%) and 24 (48.0%) of the patients, in the CMF and CAF groups, respectively, had pathologically partial or complete responses. The tumor size, axillary lymph nodes, lymphatic and vascular invasions, as clinicopathological factors, were significantly correlated with the response to chemotherapy in the CAF group. The absences of ER or PR were also significantly associated with a remission in both the CMF and CAF groups. p53 mutation was not correlated to the response rate of either chemotherapy regimen. There was no significant relationship between the expression of c-erbB2 and the response rate in the CMF group, but a higher percentage of patients with c-erbB2 positive tumors had a response to the CAF regimens. CONCLUSION: p53 mutation is not significantly associated with tumor response, but the over-expression of c-erbB2 can predict the response to the different chemotherapies used in breast cancer.

A Study for Porcine Liver Transplantation Using Nonheart Beating Donor / 한국간담췌외과학회지

BACKGROUND/AIMS: Experimental studies using porcine non- heart beating donors to ameliorate graft injuries in liver transplantation has been conducted. Recently, it has been reported that cellular calcium may have an important role in ischemic injury, which consists of damage during ischemia and impairment at the time of reperfusion. therefore, it is possible that calcium channel blocker might prevent warm ischemic injury of the graft in liver transplantation when administered to the donor before harvesting and to the recipient at reperfusion. the purpose of this study was to investigate the protective effect of a calcium channel blocker diltiazem (DTZ) on hepatic ischemic injury using a porcine model. METHODS: Twenty pigs weighing 20 to 30 kg were enrolled in this study. Cardiac death was induced by direct cardiac injection of potassium chloride. The perfusion of UW (University of Wisconsin) solution started after 30 min of cardiac arrest. Orthotopic liver transplantation was perforated. Group A (experimental group) was administrated of DTZ at a dose of 70microgram/kg bolus iv injection before hepatic ischemia, perfused of 70microgram/L in UW solution and thereafter infused continuously 70microgram/L in 5% dextrose solution. RESULTS: Two ones death occurred among the ten transplant pigs. 24 hour survival rates were 80%. DTZ administrated group showed the hepatic blood flow and arterial ketone body ratio better compared with untreated controls (p<0.05). In addition, the increase of plasma lactate level was suppressed after ischemia (p<0.05). CONCLUSION: Our results suggest that DTZ has a protective effect on ischemic induced hepatic damage and might be useful in the prevention of primary graft failure caused by warm ischemia in liver transplantation.

The Recurrence Pattern of Small Hepatocellular Carcinoma with Tumor-free Margin / 한국간담췌외과학회지

BACKGROUND/AIMS: We studied the patterns of recurrence after resection of relatively small hepatocellular carcinoma, defined as less than 5 cm in diameter, with tumor-free margin, and risk factor for recurrence were re-evaluated for these group. METHODS: The subjects were 25 patients who had undergone tumor removal with tumor-free margin for hepatocellular carcinoma at our department from 1995 to 1998. Tumor-free survival rates of patients with various risk factors were calculated and differences between groups were evaluated. RESULTS: The tumors recurred in 17 patients (68.0%), with 11 patients (64.7% of recurrences) recurring within 1 year of surgery. Recurrent disease was nearly intrahepatic. Univariate retrospective analysis in this study showed the absence of tumor capsule to be significant risk factor. But there is no significant difference in survival rate between capsule (+) groups and capsule (-) groups. CONCLUSION: It was concluded that small hepatocellular carcinoma has no significant difference in clinicopathologic variables except tumor capsule.

Hepatic Angiosarcoma Mimicking Cavernous Hemangioma on Dynamic CT

A hepatic angiosarcoma is a rare primary malignant neoplasm, which accounts for only 2% of all primary hepatic tumors. The prognosis of a hepatic angiosarcoma is very poor, and most patients die within a year of the initial diagnosis. We report a case of a hepatic angiosarcoma in a 57-year-old man. Although a dynamic CT had suggested a carvenous hemangioma 12 months earlier, the tumor size increased and spontaneously ruptured, so surgical resection was mandatory. A pathological examination, including immunohistochemical studies, showed positive staining for CD34 and Factor VIII, which confirmed the diagnosis of an angiosarcoma. Although dynamic CT is an excellent modality for the diagnosis of a cavernous hemangioma of the liver, hepatic angiosarcomas should be ruled out in selected cases, because they may present with very similar CT findings to benign hemangioma.

Histologic Study on Reperfusion Liver after the Revascularization through the Portal Vein or Hepatic Artery Following Heterotopic Partial Liver Transplantation in Rats

PURPOSE: The technique of partial liver transplantation from a living donor was developed to expand the donor pool. However such small grafts may not only be functionally inadequate for the recipient, but will also sustain injury characterized by cholestasis and histological features of ischemia after implantation. Damage to partial liver grafts after reperfusion is frequently observed but the mechanism of injury remains unclear. Injury to partial liver grafts may be related to changes in portal blood flow. In this study, we investigated the histologic changes of the reperfusion of livers after revascularization through the portal vein or hepatic artery following heterotopic partial liver transplantation in rats. METHODS: Inbred Lewis partial liver were transplanted to inbred Brown Norway rats heterotopically in three groups. The first group of transplants, Group I (Portal vein group, n=3) was reperfused firstly through the portal vein. The second group, Group II (Hepatic artery group, n=3) was firstly reperfused through the hepatic artery. The third group, Group III (Control, n=1) was sham-operated. After reperfusion, the liver grafts were procured and fixed in formalin. The reperfusion livers were studied using immunohistochemical staining and in-situ RT PCR. RESULTS: In the H&E staining of the reperfusion livers there were no differences between groups I and II. Using immunohistochemical staining of TNF,R, FAS L, caspase 8 and in-situ RT PCR (NOS mRNA, TNF,R mRNA, FAS mRNA), the hepatic artery first reperfusion liver showed more damage than the portal vein first reperfusion liver. TUNEL staing showed severe apoptosis in hepatic artery reperfusion liver. CONCLUSION: The expression of the apoptosis molecular markers was more prominent in the reperfused liver performed with initial revascularization using the hepatic artery, rather than portal vein. These findings may be due to fact that the high oxygen blood in the hepatic artery is stressful to the reperfusion liver. The routinely used portal vein first revascularization technique decrease reperfusion injury to the graft when compared to hepatic artery first revascularization.