Preoperative Diagnosis and Treatment of Cholecystoduodenal Fistula.

The case is about an 87-year-old female. While staying at a facility, she had a fever and abdominal pain and visited our hospital for an up-close examination and treatment. An abdominal CT scan revealed gallstones, gallbladder enlargement, and common bile duct stones. Endoscopic retrograde cholangiopancreatography was performed to confirm the presence of common bile duct stones, which were extracted. At that time, she was diagnosed with a duodenal fistula of the gallbladder and underwent surgery in our department. The gallbladder and duodenum were firmly adhered, and gallstones were palpated between the gallbladder and duodenum. The gallbladder was incised at the fundus to check the lumen, and gallstones were lodged in the fistula with the duodenum. After the removal of gallstones, the gallbladder was dissected, and a fistula with the duodenum was identified. After treating the cystic duct, the fistula was removed, and the gallbladder was removed. Because the duodenal wall was fragile due to inflammation and the fistula was large and difficult to close simply, the duodenal bulb was separated with a linear stapler, and the stomach and jejunum were reconstructed with a 25-mm CDH using the Roux-en-Y technique. The patient's postoperative course was good, and she was discharged from the hospital.

Intraductal Papillary Mucinous Neoplasm of the Pancreas Associated with Polycystic Liver and Kidney Disease.

A 77-year-old man was pointed out thrombocytopenia and polycystic liver and kidney disease following hypertension and diabetes mellitus and duodenitis. He consulted to our hospital for further examination. Computed tomography (CT) showed multiple cysts in the liver and kidney and also showed cystic lesions in the pancreatic tail. The size of the tumor of pancreas was 3 cm × 4 cm. FDG-PET CT showed FDG uptake in the tumor of the pancreatic tail. It has not showed metastasis in the other organs. The examinations suggested that the cause of thrombocytopenia was infection of Helicobacter pylori or idiopathic thrombocytopenic purpura or drugs. We performed distal pancreatectomy for the tumor of pancreas. Histological findings revealed that the tumor of pancreas was invasive intraductal mucinous carcinoma. He had no recurrence for 3 months after operation. In this case, the patient with autosomal-dominant polycystic kidney disease (ADPKD) and multiple liver cysts developed IPMC. We suggest that some genetic interactions may exist between ADPKD and pancreatic carcinogenesis.

Resection for Primary Retroperitoneal Serous Adenocarcinoma and Liver Metastasis.

Primary retroperitoneal serous adenocarcinoma (PRSA) is a rare malignancy of which only seven cases have been reported in the literature. The clinical features and outcomes of PRSA are not well understood. We herein report a case of PRSA with liver metastasis in a 74-year-old woman who was treated with surgical excision. The tumor cells were positive for estrogen receptor, Wilms tumor 1, PAX8, p53, and cytokeratin AE1/AE3. The final diagnosis was PRSA and liver metastasis. The pathological features of PRSA resemble those of ovarian serous carcinoma, which suggests that a combination of surgical excision with adjuvant chemotherapy may be the best option.

Combination therapies for primary hepatic neuroendocrine carcinoma: a case report.

BACKGROUND: Primary hepatic neuroendocrine carcinomas are extremely rare. Because of the rarity of PHNEC, its clinical features and treatment outcomes are not well understood. A proper diagnosis and the correct therapeutic approach therefore remain clinically challenging. CASE PRESENTATION: A 67-year-old man was admitted to our department because of a liver tumor. Computed tomography revealed a single liver tumor 50 mm in diameter and located in the S3 region. Biopsy and imaging findings resulted in a diagnosis of primary hepatic neuroendocrine carcinoma. Left lateral segmentectomy was performed. Immunohistochemically, the tumor cells were positive for synaptophysin, chromogranin A, and CD56. Ki-67 was positive in > 90% of the tumor cells. The final diagnosis was primary hepatic neuroendocrine carcinoma. The patient suffered two episodes of lymph node recurrence. Nonetheless, the tumor was excised to prolong survival. Thus, after lymphadenectomy, he received adjuvant chemotherapy for 6 months. Two years after surgery, the patient remains alive and in good general condition. CONCLUSIONS: In most cases, primary hepatic neuroendocrine carcinoma, while extremely rare, has a poor prognosis. At present, surgical resection is a priority for curative treatment, but in patients with recurrence, combined therapies are recommended.

[A case study of advanced gastric cancer patient treated with S-1+paclitaxel/lentinan].

A 47 -year-old male presented with gastric cancer, with right cervical and para-aortic lymph node metastases. The patient had not undergone a curative operation, but was treated with immunochemotherapy in combination with S-1 60 mg/m2(2 weeks administration and 2 weeks rest), paclitaxel 60 mg/m²(day 1, 8, 15), and Lentinan 2mg/body(day 1, 8, 15). After 3 courses of this treatment, no hot-spots were identified on cervical and para-aorta lymph nodes by PET-CT examination. We decided to perform total gastrectomy with D3 lymphadenectomy and Roux-en Y reconstruction. On histopathological examination, no malignancy was seen in the lymph nodes and the main tumor was judged to be grade 2. With this combined immunochemotherapy, the patient had a favorable outcome without side effects, which proved effective for far advanced gastric cancer.

Surgical Control of a Primary Hepatic Carcinoid Tumor: A Case Report.

We report a primary hepatic carcinoid tumor occurring in a 47-year-old man. The patient consulted our hospital complaining of epigastralgia. Abdominal ultrasonography, computed tomography scanning, and magnetic resonance imaging showed a large mass in the right lobe of the liver. FDG-PET revealed 18F-FDG uptake by the right hepatic lobe. The tumor was a solid mass with cystic components, approximately 15 cm in diameter. We conducted an extended right lobectomy of the liver. The resected specimen was a solid tumor with cystic components and hemorrhagic lesion. Microscopic findings showed that the tumor cells had round nuclei and formed trabecular patterns. Immunohistologically, tumor cells were stained positive for chromogranin A, neuron specific enolase, CD56, and S-100. Careful examinations before and after the operation revealed no other possible origin of the tumor. Based on these findings, the tumor was diagnosed as a primary hepatic carcinoid. This is a report of a rare case of a primary hepatic carcinoid tumor with a discussion of several other relevant reports.

Effect of active hexose correlated compound on the production of nitric oxide in hepatocytes.

BACKGROUND: Active hexose correlated compound (AHCC) is a "complex compound" containing polysaccharides. AHCC has been reported to improve the prognosis of postoperative hepatocellular carcinoma patients. However, the molecular mechanism of this improvement is not fully understood. In the diseased liver, nitric oxide (NO) generated by inducible nitric oxide synthase (iNOS) is considered to be a causal factor for various hepatopathies. In this study, the possibility of AHCC regulation of NO production by iNOS was pursued as a potential liver-protecting mechanism. METHODS: Primary cultured rat hepatocytes were treated with interleukin-1beta (IL-1beta) in the presence or absence of AHCC. NO production, iNOS induction, and iNOS signal were analyzed. RESULTS: IL-1beta stimulated iNOS induction through the activation of nuclear factor kappaB (NFkappaB), leading to NO production. The addition of AHCC inhibited NO production, showing >80% inhibition at 8 mg/mL. AHCC also decreased the levels of iNOS protein and mRNA. However, AHCC influenced neither the degradation of inhibitory protein kappaB (IkappaB) nor the activation of NFkappaB stimulated by IL-1beta. Transfection experiments with an iNOS promoter-luciferase construct (iNOS-Luc) revealed that AHCC had no effect on the transactivation activity of the iNOS promoter. By contrast, AHCC inhibited the activity of iNOS-Luc containing a 3'untranslated region (UTR) with adenosine and uridine (AU)-rich elements, which shows the stabilizing activity of iNOS mRNA. CONCLUSIONS: Results indicated that AHCC inhibits the induction of iNOS at the level of transcription, causing a decrease in NO production in hepatocytes. AHCC seems to decrease the levels of iNOS mRNA by reducing mRNA stabilization rather than inhibiting its synthesis.

[Assessment of immunotoxicity of irinotecan determined by the novel method, by which productivity of TNF-alpha from whole blood is stimulated by lipopolysaccharide].

Irinotecan hydrochloride shows much different responses in each patient, and it has severe adverse effects. Therefore, a sensitive marker for the side effect of irinotecan on immunotoxicity may be able to prevent the severe complications by the early detection. We have recently developed a method to assess the immunotoxicity by measuring the productivity of TNF-alpha from whole blood containing monocytes when stimulated by lipopolysaccharide. By using this method, the effects of continuous low-dose irinotecan therapy on immunotoxicity were assessed in 10 patients with advanced gastric or colon cancer. When compared this method with the others such as white blood cell count, lymphocyte blastoid transformation by phytohem agglutinin (PHA), and natural killer cell activity in terms of the sensitivity, immunotoxicity by this method was found earlier than the other methods. Because our original method is easy to perform and sensitive as compared to the conventional methods, it can be widely used as one of the laboratory tests useful for patients treated with immunosuppressive agents.

Intrahepatic sarcomatoid cholangiocarcinoma.

A 69-year-old woman was admitted to our hospital with fever and abdominal pain in the epigastric region. Abdominal ultrasonography demonstrated a well-defined hypoechoic mass in the epigastric region with encasement of the left hepatic lobe and stomach. Computed tomography confirmed a low-density mass, 20 cm in diameter, with enhancing peripheral areas. Angiography revealed the tumor to be hypovascular. After admission, the patient had a persistent fever and anemia that required transfusions of concentrated red blood cells. On the twelfth day after admission, she suffered disseminated intravascular coagulation and underwent an emergency operation. A lateral segmentectomy with dissection of lymph nodes, cholecystectomy, and hemigastrectomy were carried out. The size of the tumor was 22 x 17 x 15 cm. Macroscopically, a cross-section revealed massive necrosis with hemorrhage. Histological examination of the tumor showed a malignant neoplasm with a carcinomatous component and a sarcomatous component, which were partly intermingled. The former consisted of moderately differentiated adenocarcinoma, while the latter consisted of pleomorphic spindle cells. Immunohistochemical examination of the sarcomatous component showed positive staining for vimentin, epithelial membrane antigen, and cytokeratin. The tumor was diagnosed as cholangiocarcinoma with extensive sarcomatous changes, based on these histological and immunohistochemical findings. The patient had an uneventful postoperative course. However, she died 3 months after surgery from dissemination of the carcinoma. The literature on this rare disease is reviewed and discussed.

Improved prognosis of postoperative hepatocellular carcinoma patients when treated with functional foods: a prospective cohort study.

BACKGROUND/AIMS: Active hexose correlated compound (AHCC) is a newly developed functional food. In vitro experiments have shown that AHCC enhances natural killer cell activity, and may be considered a potent biological response modifier in the treatment of cancer patients. However, the effects of AHCC in a clinical setting have not been reported. We seek to determine whether AHCC can improve the prognosis of hepatocellular carcinoma (HCC) patients following surgical treatment. METHODS: A prospective cohort study was performed from February 1, 1992 to December 31, 2001. A total of 269 consecutive patients with histologically confirmed HCC were studied. All of the patients underwent resection of a liver tumor. Time to treatment failure (disease recurrence or death) and ten parameters related to liver function after surgery were examined. RESULTS: Of the 269 patients, 113 received AHCC orally after undergoing curative surgery (AHCC group). The AHCC group had a significantly longer no recurrence period (hazard ratio (HR), 0.639; 95% confidence interval (CI), 0.429-0.952; P=0.0277) and an increased overall survival rate (HR, 0.421; 95% CI, 0.253-0.701; P=0.0009) when compared to the control group by Cox's multivariate analysis. CONCLUSIONS: This study suggests that AHCC intake can improve the prognosis of postoperative HCC patients.