Revealing the role of early peripancreatic bacterial contamination and Enterococcus faecalis in pancreatic fistula development after pancreaticoduodenectomy: Implications for useful antibiotic prophylaxis-An observational cohort study.

BACKGROUND: Peripancreatic bacterial contamination (PBC) is a critical factor contributing to the development of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). Controlling pathogenic bacteria is essential in preventing CR-POPF; however, the precise relationship between specific bacteria and CR-POPF remains unclear. This study aimed to investigate the relationship between PBC and CR-POPF after PD, with a focus on identifying potentially causative bacteria. METHODS: This prospective observational study enrolled 370 patients who underwent PD. Microbial cultures were routinely collected from peripancreatic drain fluid on postoperative days (PODs) 1, 3, and 6. Predictive factors for CR-POPF and the bacteria involved in PBC were investigated. RESULTS: CR-POPF occurred in 86 (23.2%) patients. In multivariate analysis, PBC on POD1 (Odds ratio [OR] = 3.59; P = 0.005) was one of the main independent predictive factors for CR-POPF, while prophylactic use of antibiotics other than piperacillin/tazobactam independently influenced PBC on POD1 (OR = 2.95; P = 0.010). Notably, Enterococcus spp., particularly Enterococcus faecalis, were significantly isolated from PBC in patients with CR-POPF compared to those without CR-POPF on PODs 1 and 3 (P < 0.001), and they displayed high resistance to all cephalosporins. CONCLUSIONS: Early PBC plays a pivotal role in the development of CR-POPF following PD. Prophylactic antibiotic administration, specifically targeting Enterococcus faecalis, may effectively mitigate early PBC and subsequently reduce the risk of CR-POPF. This research sheds light on the importance of bacterial control strategies in preventing CR-POPF after PD.

Development of a Biomarker-Based Scoring System Predicting Early Recurrence of Resectable Pancreatic Duct Adenocarcinoma.

BACKGROUND: Resectable pancreatic ductal adenocarcinoma (R-PDAC) often recurs early after radical resection, which is associated with poor prognosis. Predicting early recurrence preoperatively is useful for determining the optimal treatment. PATIENTS AND METHODS: One hundred and seventy-eight patients diagnosed with R-PDAC on computed tomography (CT) imaging and undergoing radical resection at Hirosaki University Hospital from 2005 to 2019 were retrospectively analyzed. Patients with recurrence within 6 months after resection formed the early recurrence (ER) group, while other patients constituted the non-early recurrence (non-ER) group. Early recurrence prediction score (ERP score) was developed using preoperative parameters. RESULTS: ER was observed in 45 patients (25.3%). The ER group had significantly higher preoperative CA19-9 (p = 0.03), serum SPan-1 (p = 0.006), and CT tumor diameter (p = 0.01) compared with the non-ER group. The receiver operating characteristic (ROC) curve analysis identified cutoff values for CA19-9 (133 U/mL), SPan-1 (78.2 U/mL), and preoperative tumor diameter (23 mm). When the parameter exceeded the cutoff level, 1 point was given, and the total score of the three factors was defined as the ERP score. The group with an ERP score of 3 had postoperative recurrence-free survival (RFS) of 5.5 months (95% CI 3.02-7.98). Multivariate analysis for ER-related perioperative and surgical factors identified ERP score of 3 [odds ratio (OR) 4.63 (95% CI 1.82-11.78), p = 0.0013] and R1 resection [OR 3.20 (95% CI 1.01-10.17), p = 0.049] as independent predictors of ER. CONCLUSIONS: For R-PDAC, ER could be predicted by the scoring system using preoperative serum CA19-9 and SPan-1 levels and CT tumor diameter, which may have great significance in identifying patients with poor prognoses and avoiding unnecessary surgery.

[A Case of Non-Resectable Pancreatic Cancer with Multiple Hepatic Metastases Treated with FOLFIRINOX Therapy and Conversion Surgery].

A 50-year-old woman was diagnosed as having pancreatic head cancer with multiple hepatic metastases. FOLFIRINOX therapy was initiated. After completing 18 courses of therapy, partial remission(PR)was achieved based on images, and surgery was then planed. The subtotal stomach-preserving pancreaticoduodenectomy and hepatic S7 partial resection were performed. Macroscopically, complete resection was achieved. Regarding pathological findings of the primary lesion and hepatic metastatic lesions, fibrous formation and hyalinizing condition induced by chemotherapy were noted; moreover, complete disappearance of cancer cells was detected. However, metastasis of poorly differentiated adenocarcinoma was detected in 12b lymph node tissue. One month after the surgery, postoperative adjunctive chemotherapy with S-1 was initiated. However, new hepatic metastasis was detected 3 months after the surgery. Although recurrence treatment was initiated, the disease progressed, and the patient died 11 months after the surgery.

Calcifying nested stromal epithelial tumor of the liver in a patient with Klinefelter syndrome: a case report and review of the literature.

BACKGROUND: Calcifying nested stromal epithelial tumor (CNSET) is a primary neoplasm of the liver, characterized by well-demarcated nests consisting of spindle and epithelioid cells with calcification and bone formation. An association of Cushing syndrome with CNSET has drawn attention, but the origin of CNSET has not been clarified. CASE PRESENTATION: We report here the case of a 20-year-old male with Klinefelter syndrome who underwent liver resection for an increasing liver tumor that was pathologically diagnosed with CNSET. He was postoperatively followed up and received several examinations, and recurrences and extrahepatic lymph node metastases were detected on the 64th day after surgery. Chemoembolization and chemotherapy were not effective, leading to tumor progression with development of progressive liver failure, and the patient finally died 164 days after hepatectomy. CONCLUSIONS: This case suggests that an imbalance of hormones affects the genesis and progression of CNSET, and indicates the importance of closely following patients with CNSET by imaging with attention to hepatic recurrence and extrahepatic metastases.

[A Case of Long-Term Survival of a Patient with Cholangiocarcinoma and Liver Metastatic Recurrence Who Responded to Gemcitabine plus Cisplatin Therapy].

A 65-year-old woman was diagnosed with cholangiocarcinoma and underwent hepato-pancreatoduodenectomy. The pathological diagnosis was Bpd, circ, papillary-infiltrating type, 51×47×7mm, tub2>tub1>por1, T2, ly1, v1, ne1, pN0, pDM0, pHM0, pEM0, pPV0, pA0, R0, pStageⅠ. She received adjuvant chemotherapy with S-1, which was changed to gemcitabine plus cisplatin therapy(GC therapy)when hepatic recurrence and lymph node metastasis were identified 3 months postoperatively. The hepatic recurrence disappeared, and the lymph node metastasis was reduced after the patient completed 27 courses of GC therapy. We discontinued GC therapy as no recurrence had been observed for a long time. The patient remains well without any evidence of cancer recurrence for more than 48 months postoperatively.

[A Case of Complete Pathological Response of Unresectable Synchronous Colorectal Hepatic Metastasis with Icterus after FOLFOX plus Panitumumab Therapy].

A 35-year-old man was diagnosed with initially unresectable synchronous liver metastases from sigmoid colon cancer. We started FOLFOX plus panitumumab therapy. After 3courses of chemotherapy, the liver metastases became resectable. Sigmoidectomy, extended left lobectomy, and partial hepatectomy were performed. On the final histopathological analysis, all hepatic lesions were fibrotic without viable cancer cells. Nineteen months after the surgery, CT revealed isolated residual liver recurrence in segment 5. After partial hepatectomy, the patient is alive without recurrence. We report a case of pathological complete response with FOLFOX plus panitumumab therapy for initially unresectable colorectal liver metastases with icterus.

[A Case of Remnant Pancreatic Cancer after Conversion Surgery for Advanced Distal Bile Duct Cancer Treated with Chemotherapy].

The patient was an 82-year-old man who received a total of 25 courses of GEM/CDDP therapy for unresectable distal bile duct cancer with multiple liver metastases. After the chemotherapy, no liver metastasis was detected on computed tomography. Then, he underwent pancreaticoduodenectomy(ⅡA-1, D2)as a conversion surgery(T2N0M0, fStageⅠB)at 2 years and 11 months after the initial diagnosis. Postoperatively, the patient received GEM therapy for 2 years and had no recurrence. Three years and 10 months after the surgery, computed tomography revealed a tumorous lesion with a poor contrasting effect on the remaining pancreas and a positive accumulation of SUVmax 8.6 was detected at the same site through the FDG-PET examination. We diagnosed the lesion as residual pancreatic cancer and performed remnant total pancreatectomy and splenectomy. The histopathological findings showed tumors arising from the residual pancreatic epithelium; therefore, we diagnosed his lesion as residual pancreatic cancer(T3N1aM0, fStage ⅡB). After the second surgery, he is being treated with adjuvant therapy with S-1 and is alive without recurrence. In this case, long-term survival was possible for 7 years and 4 months from the initial diagnosis of unresectable distal bile duct cancer. Metachronous double cancer of unresectable bile duct and pancreatic cancer is presumed to have a poor prognosis. However, long-term survival is suggested to be possible if multidisciplinary therapies are successful.

[A Case of Pancreatic Acinar Cell Carcinoma in a Young Woman without Recurrence after Systemic Chemotherapy Using S-1].

A 26-year-old woman underwent laparoscopic-assisted distal pancreatectomy and splenectomy for a tumor in the tail of the pancreas. Although the preoperative diagnosis was a solid pseudopapillary tumor, pathological tissue examination revealed that the tumor was a pancreatic acinar cell carcinoma. She was treated with S-1 chemotherapy for 6 months without severe side effects, and no recurrence was detected on several imaging inspections. Acinar cell carcinoma of the pancreas is a rare tumor in young patients, and there are few reports of treatment with postoperative chemotherapy.

Living donor liver transplantation in a pediatric patient with preexisting yolk sac tumor.

There is ongoing discussion regarding the indications and timing of LT for patients with a preexisting extrahepatic malignancy. We herein report a pediatric case that underwent LDLT after therapy for YST. The patient, a 13-year-old female with biliary atresia, had undergone portoenterostomy at 2 months of age. She developed a left ovarian tumor with a high serum alpha-fetoprotein concentration at 10 years of age. She underwent left oophorectomy and was diagnosed with ovarian YST (Stage I). After surgery, hepatopulmonary syndrome progressed gradually. She was examined carefully and exhibited no findings to suggest the recurrence of YST. We decided to perform LDLT at 3 years and 6 months of age after the surgery for YST. The patient is currently alive and doing well without recurrence of YST at approximately 2 years after transplantation. There is no significant difference between the recurrence rate of preexisting extrahepatic malignancy and the incidence of de novo malignancy if specific cases are selected. The indications and period from surgery for preexisting extrahepatic malignancy to LT should thus be determined according to the type and stage of cancer.

[A Case of Duodenal Cancer with Familial Adenomatous Polyposis].

A 34-year-old man was diagnosed with familial adenomatous polyposis(FAP)in September 2011, and he underwent endoscopic mucosal resection(EMR)due to multiple polyps in the duodenum and small intestine. Three months later, duodenal cancer was found, and he underwent a subsequent EMR. The pathological findings showed residual cancer cells in the lateral margin; therefore, EMR was performed again. Total colectomy and partial resection of the small intestine was performed in December 2012. Esophagogastroduodenoscopy(EGD)was then performed every 3-6 months, and EMR was performed 4 times. We followed up the patient annually, starting 2014. In January 2016, recurrence of the duodenal cancer was found; therefore, he underwent a pancreatoduodenectomy. The pathological diagnosis was adenocarcinoma, tub2> tub1, pT1a, N0, M0, fStage I A. There were many adenomas ranging from low-grade to high-grade in the duodenal mucosa. The patient remains well without any evidence of cancer recurrence more than 18 months after the last operation. When treating patients with duodenal adenoma complicated by FAP, regardless of age, strict follow-up is important.

[Cystic Duct Cancer with Postoperative Liver Metastasis That Achieved Complete Response after Gemcitabine Treatment - A Case Report].

A 72-year-old woman was diagnosed with gallbladder cancer and underwent extended cholecystectomy and extrahepatic bile duct resection. The pathological findings were CGnBdGb, circ, nodular infiltrating type, 20×10 mm, tub2, pT3b, int, INF c, ly1, v1, ne3, pN0, pDM0, pHM0, pEM0, pPV0, pA0, R0, Stage III A. Because the main localization was in the cystic duct, we diagnosed this as cystic duct cancer. Seven months after surgery, follow-up computed tomography scan revealed a metastatic region in segment 7 of the liver. She underwent chemotherapy with gemcitabine(GEM). After 3 courses of GEM, the metastatic lesion became obscure. After 8 courses, the metastatic lesion disappeared, and the patient showed complete response. We discontinued chemotherapy after 21courses of GEM, and the patient is alive with no signs of recurrence 4 years and 4 months after surgery.

[A Case of Primary Neuroendocrine Carcinoma of the Duodenal Bulb].

A 82-year-old man with anemia underwent upper endoscopy, and a hemorrhagic type 1 tumor was detected on the posterior wall of the duodenal bulb. This patient was diagnosed with neuroendocrine carcinoma(NEC)using biopsy. Distant metastasis was not found on imaging. He was referred to our department for the purpose of surgical therapy and underwent pancreaticoduodenectomy. Based on pathological findings, we diagnosed this patient as having NEC. No postoperative adjuvant chemotherapy was administered, but outpatient clinical follow-up was performed. The patient achieved 16 relapse-free months after surgery. Among the cases of NEC with a primary tumor arising from the digestive tract, cases of NEC of the duodenum that are not papillary carcinoma are rare. We report this case in along with a literature review.

Generation of the antioxidant yellow pigment derived from 4-methylthio-3-butenyl isothiocyanate in salted radish roots (takuan-zuke).

2-[3-(2-Thioxopyrrolidin-3-ylidene)methyl]-tryptophan (TPMT) is a yellow pigment of salted radish roots (takuan-zuke) derived from 4-methylthio-3-butenyl isothiocyanate (MTBITC), the pungent component of radish roots. Here, we prepared salted radish and analyzed the behavior of the yellow pigment and related substances in the dehydration process and long-term salting process. All salted radish samples turned yellow, and their b(*) values increased with time and temperature. The salted radish that was sun-dried and pickled at room temperature turned the brightest yellow, and the generation of TPMT was clearly confirmed. These results indicate that tissue shrinkage due to dehydration, salting temperature, and pH play important roles in the yellowing of takuan-zuke.

Evaluation of the usefulness of the indocyanine green clearance test for chemotherapy-associated liver injury in patients with colorectal cancer liver metastasis.

BACKGROUND: The indocyanine green (ICG) clearance test is reported to be useful for the preoperative evaluation of hepatic functional reserve. However, the ICG clearance test has not been sufficiently investigated in patients with colorectal liver metastasis after chemotherapy. The aim of the present study was to evaluate whether the ICG clearance test is a useful parameter for the preoperative detection of chemotherapy-associated liver injury. METHODS: Ninety-four patients undergoing liver resection for colorectal liver metastasis after chemotherapy were studied. The medical records for each case were retrospectively reviewed. They underwent pathological assessment to clarify the degree of histopathological liver injury of the nontumoral liver parenchyma. In addition, the correlation between the pathological score and the ICG retention rate at 15 min (ICG-R15) was analyzed. RESULTS: Sinusoidal injury was observed in the 31 of 94 patients. Steatohepatitis was observed in the 40 of 94 patients. There was no strong correlation between the preoperative ICG-R15 value and the sinusoidal pathological score (r = 0.117, P = 0.261). There was no strong correlation between the ICG-R15 and the nonalcoholic fatty liver disease activity score (r = 0.215, P = 0.037). CONCLUSIONS: It was difficult to predict the degree of chemotherapy-associated liver injury by the preoperative ICG-R15 value. It is necessary to estimate the hepatic functional reserve based on a combination of several clinical indicators without relying on the ICG test, in order to perform a safe radical liver resection.

Noninvasive Computed Tomography-Based Deep Learning Model Predicts In Vitro Chemosensitivity Assay Results in Pancreatic Cancer.

OBJECTIVES: We aimed to predict in vitro chemosensitivity assay results from computed tomography (CT) images by applying deep learning (DL) to optimize chemotherapy for pancreatic ductal adenocarcinoma (PDAC). MATERIALS AND METHODS: Preoperative enhanced abdominal CT images and the histoculture drug response assay (HDRA) results were collected from 33 PDAC patients undergoing surgery. Deep learning was performed using CT images of both the HDRA-positive and HDRA-negative groups. We trimmed small patches from the entire tumor area. We established various prediction labels for HDRA results with 5-fluorouracil (FU), gemcitabine (GEM), and paclitaxel (PTX). We built a predictive model using a residual convolutional neural network and used 3-fold cross-validation. RESULTS: Of the 33 patients, effective response to FU, GEM, and PTX by HDRA was observed in 19 (57.6%), 11 (33.3%), and 23 (88.5%) patients, respectively. The average accuracy and the area under the receiver operating characteristic curve (AUC) of the model for predicting the effective response to FU were 93.4% and 0.979, respectively. In the prediction of GEM, the models demonstrated high accuracy (92.8%) and AUC (0.969). Likewise, the model for predicting response to PTX had a high performance (accuracy, 95.9%; AUC, 0.979). CONCLUSIONS: Our CT patch-based DL model exhibited high predictive performance in projecting HDRA results. Our study suggests that the DL approach could possibly provide a noninvasive means for the optimization of chemotherapy.

Follicular dendritic cell sarcoma arising from the lymph node of the pancreatic head: a case report with literature review.

A 72-year-old man was referred to our hospital for the examination of a pancreatic head mass. Abdominal computed tomography revealed a contrasted 8-cm-diameter tumor extending from the dorsal pancreatic head to the porta hepatis. The preoperative diagnosis was challenging due to the absence of specific imaging findings and the inability to perform a biopsy. Positron emission tomography/computed tomography and diffusion-weighted imaging suggested a malignant tumor originating from the organs surrounding the pancreatic head. Subtotal stomach-preserving pancreaticoduodenectomy with regional lymph node dissection was performed, as dissection from the pancreatic head proved unfeasible. Pathological examination identified the tumor as an enlarged lymph node consisting of pleomorphic large cells forming clusters, positive for follicular dendritic cell markers cluster of differentiation (CD) 21 and CD23. No evidence of tumor capsule infiltration, other organ infiltration, or metastasis to other lymph nodes was observed. The final diagnosis was nodal follicular dendritic cell sarcoma (FDCS) originating from the pancreatic head lymph nodes. No recurrence occurred at 3 years postoperatively with no postoperative treatment. Intraperitoneal nodal FDCS is extremely rare, and occasionally, it can lead to postoperative recurrence and progression. It is crucial to differentiate neoplastic lymph node enlargement around the pancreatic head from nodal FDCS.

Postoperative long­term outcomes of acute normovolemic hemodilution in pancreatic cancer: A propensity score matching analysis.

Acute normovolemic hemodilution (ANH) is a useful intraoperative blood conservation technique. However, the impact on long-term outcomes in pancreatic ductal adenocarcinoma (PDAC) remains unclear. The present study investigated the impact of ANH on long-term outcomes in patients with PDAC undergoing radical surgery. Data from 155 resectable PDAC cases were collected. Patients were categorized according to whether or not they had received intraoperative allogeneic blood transfusion (ABT) or ANH. Postoperative complications, recurrence-free survival (RFS) and disease-specific survival (DSS), before and after propensity score matching (PSM), were compared among patients who did and did not receive ANH. A total of 44 patients (28.4%) were included in the ANH group and 30 patients (19.4%) were included in the ABT group; 81 (52.3%) patients, comprising the standard management (STD) group, received neither ANH nor ABT. The ABT group had the worst prognosis among them. Before PSM, ANH was significantly associated with decreased RFS (P=0.043) and DSS (P=0.029) compared with the STD group before applying Bonferroni correction; however, no significant difference was observed after applying Bonferroni correction. Cox regression analysis identified ANH as an independent prognostic factor for RFS [relative risk (RR), 1.696; P=0.019] and DSS (RR, 1.876; P=0.009). After PSM, the ANH group exhibited less favorable RFS [median survival time (MST), 12.1 vs. 18.1 months; P=0.097] and DSS (MST, 32.1 vs. 50.5 months; P=0.097) compared with the STD group; however, these differences were not statistically significant. In conclusion, while ANH was not as harmful as ABT, it exhibited potentially more negative effects on long-term postoperative outcomes in PDAC than STD.

[A case of surgical resection of a combined hepatocellular and cholangiocarcinoma after transarterial chemoembolization].

A 48-year-old woman was admitted to our hospital for the treatment of a liver tumor (diameter, 10 cm), which was detected by abdominal contrast-enhanced computed tomography. The tumor occupied mainly the left medial segment and caudate lobe, invaded the left and right hepatic arteries, and obstructed the left portal vein. The tumor was diagnosed as an unresectable intrahepatic cholangiocarcinoma, and chemotherapy (a combination of gemcitabine and S-1) was initiated. Because the tumor continued to grow despite the chemotherapy, we performed transarterial chemoembolization(TACE)as a second-line treatment, which successfully reduced tumor size to 7 cm. Thereafter, surgical resection was performed. Histopathological examination indicated the presence of intrahepatic cholangiocarcinoma, which formed the main component, combined with hepatocellular carcinoma. This tumor was diagnosed as a combined hepatocellular and cholangiocarcinoma. Although adjuvant chemotherapy was not administered because of prolonged pancytopenia, currently, at 5 years after the operation, the patient is alive and has not experienced any recurrence.

[Study of unresectable pancreatic cancer - successful resections after gemcitabine-based chemotherapy].

Pancreatic ductal adenocarcinoma( PDAC) is an extremely malignant tumor and carries a poor prognosis. Therefore, PDAC should be treated with multiple modalities. Chemotherapy has proven effective in some cases of unresectable (UR) PDAC, and there are published reports of cases in which curative surgery could be performed after chemotherapy. We examined the cases from January 2010 through November 2012 in which initially UR PDAC could be treated surgically after chemotherapy. Whether or not each cancer was resectable was evaluated according to the National Comprehensive Cancer Network (NCCN) guidelines. We performed surgery in 7 of the 25 patients initially diagnosed as UR during this period. The cancer proved inoperable in 2 of these 7 patients: 1 patient with peritoneal dissemination and 1 with locally advanced tumor. Some reports have suggested that resection after chemotherapy for UR pancreatic cancer improved the prognosis in patients relative to those in whom surgery was not attempted. From our experience, we believe that it very important for patients undergoing chemotherapy for UR pancreatic cancer to consider surgical treatment.