Extremely rare case of H-type gallbladder duplication coexistent with carcinoma: a case report and review of the literature.

INTRODUCTION: Multiple gallbladders represent a rare congenital disorder, and coexistence with carcinoma is extremely rare, leading to a high possibility of misdiagnosis and surgical complications. In this study, a case was reported and the literature was reviewed. CASE PRESENTATION: An 80-year-old woman was diagnosed with acute cholecystitis via ultrasonography and was successfully treated with antibiotics. After the patient's biliary colic relapsed, she was referred to our hospital. Multiple imaging modalities revealed duplication of her gallbladder (H-type) and suggested coexistence with carcinoma. According to preoperative evaluations, we assumed the patient had stage IIIA disease, and cholecystectomy, cholangiography using a near-infrared ray vision system, and sectionectomy of segments 4a and 5 were performed. Contrary to the high standardized uptake values obtained by 18F-fluoro-2-deoxy-D-glucose positron emission tomography, gallbladder carcinoma was pathologically diagnosed as stage 0 mucosal cancer. Seven days after the operation, portal thrombosis of the posterior branch was revealed, and conservative therapy was indicated; satisfactory results were achieved. The patient was discharged 65 days after surgery. No recurrence was observed for 1 year after surgery. CONCLUSIONS: An extremely rare case of malignancy in a duplicated gallbladder was reported, and the literature was reviewed. Accurate estimations are feasible for diagnoses of multiple gallbladders, where correct evaluations are vital, especially in malignant cases. Because of the possibility of malignancy, resected accessory gallbladders should be scrutinized pathologically.

A case report: Feasibility of a near infrared ray vision system (Photo dynamic eye®) for the postoperative ischemic complication of gallbladder carcinoma.

INTRODUCTION: Radical resection with or without preserving extra-hepatic bile duct has shown similar prognoses for gallbladder carcinoma (GB ca), although aggressive resection is essential. In preserving bile duct, ischemic complications are serious, life-threatening serious problems. Correct evaluation of the blood flow to the biliary tract is crucial. CASE PRESENTATION: A case of gallbladder ca in a 62-year-old man was reported. The patient was diagnosed with stage Ⅱ GB ca (T2, N0, M0) by ultrasonography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography. Cholecystectomy and intraoperative frozen section examination were planned. After recognition of invasion to subserosa and negative cystic duct margin, radical dissection of the lymph nodes in the hepatoduodenal ligament with preserving biliary tract was performed. Three days after the operation, biliary peritonitis was revealed. Emergency laparotomy showed ischemic bile leakage. Proper blood flow of the biliary system was realized by a near-infrared ray vision system (Photo Dynamic Eye®: HAMAMATSU Photonics) using indocyanine green. Primary suture of the extra-hepatic biliary duct and T-tube drainage were selected. No stricture of the bile system nor recurrence was recognized for two years after surgery. DISCUSSION: In the case of ischemic biliary complications, whether to preserve the extrahepatic bile duct is a critical issue for the surgeons. In this case study, the feasibility of authentic indocyanine green near-infrared imaging was shown for postoperative ischemic biliary situations. CONCLUSIONS: Authentic indocyanine green near-infrared imaging was feasible for the estimation of the blood flow to the postoperative ischemic biliary complication.

Case: Authentic multimodal therapy and liver resection for an initially unresectable intrahepatic cholangiocarcinoma.

INTRODUCTION: Although curative resection is an outstanding prognostic factor of intrahepatic cholangiocarcinoma (ICC), certain segments remain unresectable. The standard therapy for initially unresectable ICC is uncertain. In this case report, we reported the feasibility of multimodal chemotherapy and curative resection. CASE: A 59-year-old Asian woman with back pain was referred to the hospital by her family physician regarding liver mass visible on ultrasonography. At admission, the carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were high, and images showed characteristic signs of ICC with intrahepatic metastases and invasions to on the right Glisson's sheath. Multimodal therapy was applied to the ICC, which could not be resected at first. The therapy comprised hepatic arterial chemoembolization with drug-eluting beads (DEB-TACE), angiographic subsegmentectomy (AS), and systemic chemotherapy. Downstaging of the ICC, which results in curative resection, was planned due to non-normalization of the tumor markers, and pathological analysis revealed complete remission. At 34 months after the surgery, the patient was alive without relapse. DISCUSSION: Recently, chemotherapy and/or an interventional approach were reported to be feasible, although unresectable advanced ICC has a poor prognosis. Some studies have reported that multimodal chemotherapy and R0 resection of initially unresectable ICC can prolong survival time. However, some reports have shown high morbidity and mortality associated with initially unresectable ICC treated with multimodal chemotherapy and R0 resection. Our study resulted in complete remission without complications. CONCLUSION: Multimodal chemotherapy and hepatic curative resection on locally advanced ICC are feasible treatment approaches for initially unresectable ICC.

[A Case of Advanced Transverse Colon Cancer with Nephrotic Syndrome Treated with Curative Resection and Complete Adjuvant Chemotherapy].

A 74-year-old woman was diagnosed as having transverse colon cancer after diagnosis of nephrotic syndrome caused by membranous nephropathy. Although she had hypoproteinemia and hypoalbuminemia, we judged that she had no major nutritional problem. In previous, similar case reports, the use of human serum albumin and fresh-frozen plasma was suggested to be important to avoid complications in the perioperative period. Thus, we used the same in our patient in the perioperative period. In addition, we paid special attention to perioperative nutrition management and used total parenteral nutrition in perioperative period. We performed laparoscopic assisted right hemicolectomy. On the 15th day after the surgical resection, the patient was discharged without any problems. We considered that postoperative adjuvant chemotherapy with XELOX (CapeOX)should be performed because the TNM pathological stage was pStage III b. Regarding adjuvant chemotherapy for gastrointestinal cancer with nephrotic syndrome, no previous reports detailed the indications for postoperative adjuvant chemotherapy. Upon introduction of adjuvant chemotherapy, we determined adaptation in accordance with the general adaptation criteria. While observing the patient's progress with a nephrologist, we safely completed the scheduled 8 courses adjuvant chemotherapy.

ICAM-1 signal transduction in cells stimulated with neutrophil elastase.

Neutrophil elastase, which enhances intercellular adhesion molecule-1 (ICAM-1) expression in endothelial cells, plays an important role in ischemia/reperfusion injury. Here, we investigated signal transduction of ICAM-1 expression in endothelial cells stimulated by neutrophil elastase. Pretreatment of animals with the neutrophil elastase inhibitor, ONO-5046.Na significantly decreased the number of neutrophils or Mac-1(+) (CD11b/CD18) cells in ischemic liver lobes after reperfusion. ICAM-1 expression in the rat endothelial cell line (WK-5) was significantly upregulated after stimulation with neutrophil elastase, but this reaction was inhibited by the neutrophil elastase inhibitor ONO-5046.Na. ICAM-1 mRNA expression, which is induced by neutrophil elastase in a dose-dependent manner, was repressed by the alpha1-protease inhibitor. ICAM-1 expression, stimulated by neutrophil elastase, was partially reduced by a diacylglycerol kinase inhibitor and protein kinase C inhibitor, but was completely inhibited by a phospholipase C inhibitor, cytosolic Ca(2+) chelator, calmodulin antagonist, and nuclear transcription factor kappa B inhibitor. Binding of (125)I-neutrophil elastase to WK-5 cells was competitively inhibited by the addition of unlabeled neutrophil elastase. The neutrophil elastase inhibitor significantly reduces ICAM-1 expression and Mac-1(+) cell accumulation in ischemic liver lobes after reperfusion. Neutrophil elastase stimulates ICAM-1 expression in endothelial cells by intracellular signal transduction via activation of diacylglycerol kinase, protein kinase C, phospholipase C, Ca(2+)-calmodulin, and nuclear transcription factor kappa B.

Recipient blood pre-transplant transfusion prolongs hepatic allograft survival in rats.

BACKGROUND: The pre-transplant administration of donor antigens to recipients is reported to prolong transplanted organ survival. We investigated the effect of pre-transplant intraportal administration of recipient blood on rat hepatic allograft survival. MATERIALS AND METHODS: Male LEW (RT1l) and ACI (RT1a) rats were used as transplant recipients and donors, respectively. Before transplantation, donors were transfused with recipient blood. Experimental animals were divided into groups as follows: group I, no treatment; group II, pre-treatment with recipient blood via the penile vein 7 days before transplantation; group III, pre-treatment with recipient blood via the portal vein 5 days before transplantation; and group IV, pre-treatment with recipient blood via the portal vein 7 days before transplantation. Serum interferon (IFN)-gamma concentrations were measured post-operatively. RESULTS: Animals in group I survived a mean of 10.1 +/- 0.7 days. The survival of groups II and III was 10.6 +/- 1.6 and 13.1 +/- 0.9 days, respectively. The survival rate in group IV was prolonged significantly to 33.7 +/- 2.6 days. Serum concentrations of IFN-gamma were increased significantly in group IV, as compared with group I. The ratio of OX76+CD4+ or OX76+CD8+ T cells to OX76-CD4+ or OX76-CD8+ T cells was greater in group IV, as compared group I. OX76+CD8+ T cells from hepatic allografts in group IV expressed IFN-gamma and interleukin (IL)-10, but not IL-2 mRNA. Apoptotic hepatic infiltrates were greater in group IV, as compared to group I. CONCLUSION: The cytokine profile of donor CD8+ T cells from allografts treated by the intraportal administration of recipient blood is associated with apoptosis of graft-infiltrating cells and the prolonged survival of hepatic allografts in rats.

Hepatic CCR7lowCD62LlowCD45RClow allograft dendritic cells migrate to the splenic red pulp in immunologically unresponsive rats.

Donor dendritic cells (DC) migrate into the recipient spleen after hepatic transplantation. Immunological unresponsiveness to rat hepatic allografts can be induced by prior donor-specific blood transfusion (DST). We investigated homing receptor phenotype and splenic distribution of donor DC after allografting and DST. Immunostaining revealed OX62+ cells in the splenic red pulp of animals receiving pre-transplant DST but only in the white pulp of untreated animals. Most OX62 cells were positive for OX76. There were two subsets of DC in the spleen, CD45RChighOX62+ and CD45RClowOX62+ cells. RT-PCR revealed that CD45RClowOX62+ cells expressed interleukin (IL)-10, while CD45RChighOX62+ cells expressed IL-2 and low levels of IL-10 mRNA. CD45RChighOX62+ cells strongly expressed CCR5 and CCR7, compared with weak expression in CD45RClowOX62+ cells. The Epstein-Barr virus-induced molecule 1 (EBI-1) ligand chemokine (ELC/MIP3beta) was expressed mainly within the splenic white pulp. Mucosal vascular addressin-cell adhesion molecule-1 (MAdCAM-1) was expressed in the marginal zone and white pulp, but expression of splenic MAdCAM-1 was down-regulated in DST-treated animals. L-selectin (CD62L), the ligand for MAdCAM-1, was strongly expressed on CD45RChighOX62+ cells but not on CD45RClowOX62+ cells. In conclusion, differential splenic migration of CCR5lowCCR7lowCD62Llow CD45RClow DC expressing Th2-type cytokines is associated with immunological unresponsiveness to rat hepatic allografts.

Steatotic liver allografts up-regulate UCP-2 expression and suffer necrosis in rats.

BACKGROUND: Fatty split-liver and living-related liver transplantation is associated with massive hepatocellular necrosis during acute rejection. Uncoupling protein (UCP)-2 is a potential regulator of energy expenditure and ATP production. We investigated the role of UCP-2 and the effects of a metalloprotease inhibitor, Y-39083, on hepatocellular injury in fatty liver allografts in rats. MATERIALS AND METHODS: Rats were treated for 6 weeks with high-ethanol or isocalic dextrose-containing liquid diets that caused characteristic pericentral lipid accumulation. Alcoholic or nonalcoholic fatty livers from ACI (RT1a) rats were transplanted into LEW (RT1l) rats orthotopically. Hepatic necrosis was determined histologically following liver transplantation. UCP-2 mRNA levels in the hepatic allograft and in primary cultured hepatocytes from fatty liver stimulated by tumor necrosis factor (TNF)-alpha were determined. Y-39083 was administered to recipient rats continuously at 5 mg/kg/day using an osmotic infusion mini-pump. RESULTS: The acute rejection index on day 5 posttransplant in alcoholic and nonalcoholic fatty donor livers was higher than in lean grafts. Massive hepatocyte necrosis was more prominent in alcoholic than nonalcoholic fatty liver allografts and was not seen in lean allografts. UCP-2 transcripts in both alcoholic and nonalcoholic fatty liver allografts were higher than in lean allografts. Serum TNF-alpha concentrations in recipient rats with either fatty liver allograft were greater than in animals with lean allografts. In vitro UCP-2 mRNA levels in primary cultured hepatocytes from both alcoholic and nonalcoholic fatty livers increased more after stimulation with TNF-alpha than those from lean livers. In vitro TNF-alpha production by Kupffer cells isolated from alcohol-induced fatty liver allografts on day 3 posttransplant was greater than those from lean allografts. Y-39083 significantly reduced serum concentrations of TNF-alpha and prevented massive hepatocellular necrosis in rats with both alcoholic and nonalcoholic fatty liver allografts. CONCLUSION: Liver grafts with steatosis up-regulated UCP-2. TNF-alpha further enhanced UCP-2 transcripts, inducing massive hepatocellular necrosis during acute rejection. Posttransplantation necrosis may be prevented by metalloprotease inhibitors.

Curcumin inhibits interleukin 8 production and enhances interleukin 8 receptor expression on the cell surface:impact on human pancreatic carcinoma cell growth by autocrine regulation.

BACKGROUND: Curcumin, the yellow pigment in turmeric, has been shown to prevent tumor progression in a variety of tissues in rodents. The authors investigated the effect of curcumin on human carcinoma cell lines to determine whether constitutive interleukin-8 (IL-8) production of tumor cells was correlated with nuclear factor kappaB (NF-kappaB) activation and cell growth activity. METHODS: A human pancreatic carcinoma cell line, SUIT-2, was incubated with various concentrations of curcumin for 2 hours. Biologic features, including IL-8 production, DNA binding activity, transactivation of NF-kappaB, cell growth activity, cell viability, and the expression of IL-8 receptors (CXCR1 and CXCR2) were analyzed. RESULTS: The constitutive production of IL-8 was inhibited by curcumin at concentrations of 10-100 microM in a dose dependent manner. NF-kappaB activity was reduced significantly by curcumin treatment. Pretreatment with curcumin inhibited the growth rate of carcinoma cells significantly. Such cell growth inhibition by curcumin was not recovered by exogenous recombinant IL-8. The investigation of expression in IL-8 receptors, CXCR1 and CXCR2, revealed that the expression of both receptors was enhanced remarkably by curcumin. Exogenous IL-8 could not recover this enhancement of IL-8 receptors. These results suggest that curcumin inhibits IL-8-induced receptor internalization. CONCLUSIONS: The authors concluded that curcumin contributed not only to the inhibition of IL-8 production but also to signal transduction through IL-8 receptors. These data suggest that curcumin reduces numerous IL-8 bioactivities that contribute to tumor growth and carcinoma cell viability. From this point of view, curcumin is a potent anticancer agent that inhibits the production of proinflammatory cytokines, including IL-8, by tumor cells.