Carcinosarcoma of the ampulla of Vater: a case report with immunohistochemical and ultrastructural studies.

Carcinosarcoma of the duodenum has not been reported previously, although this type of tumor has been detected in other organs. We present here a case of carcinosarcoma of the duodenum, including immunohistochemical and electron microscopical findings. An ulcerating tumor, located in the duodenal ampullary region, contained two divergent components: ordinary differentiated tubular adenocarcinoma, and sarcomatoid tissue composed of spindle tumor cells. Immunohistochemically, the adenocarcinoma cells were stained with antibodies against epithelial markers including keratin and CA19-9. In contrast, the sarcomatoid tissue was strongly positive for vimentin and was focally positive for myoglobin, keratin, and CA19-9. We speculate that the sarcomatoid element of the carcinosarcoma arose from part of the ordinary adenocarcinoma tissue.

[Asymptomatic pancreatic islet cell tumor (glucagonoma): case report].

A case of asymptomatic pancreatic islet cell tumor (glucagonoma) is reported. A 36-year-old woman undergoing a ultrasonic scan was found to have two masses in the body and tail of the pancreas measuring 5 cm and 4 cm in diameter, respectively. Investigations of serum peptide hormones revealed an elevated glucagon level of 27,500 pg/ml (normal < 100 pg/ml), suggesting the possibility of an islet cell tumor (glucagonoma). The patient, however, was asymptomatic although high levels of glucagon were present. The patient underwent distal pancreatectomy to remove the lesions in the body and tail of the pancreas. Histological findings revealed islet cell tumors of the pancreas, and immuno histochemical staining of the tumor cells demonstrated a positive reaction for chromogranin and glucagon.

Thoracoscopic splanchnicectomy for the relief of intractable abdominal pain.

Video-thoracoscopic transthoracic splanchnicectomy has been applied to patients in the end stage of pancreas cancer who had intractable pain mediated through the splanchnic nerve in the left upper quadrant. The procedure is performed under general anesthesia in a right hemilateral position. Following the establishment of access to the thoracic cavity, the left splanchnic nerve is cut off at the level immediately above the aortic hiatus, through a small opening made in the pleura between the descending aorta and the vertebrae. All patients had immediate and complete relief of pain postoperatively. Only a transient drop in the mean arterial pressure was observed immediately after cutting off the nerve. No other detrimental effect of the procedure on the general condition was observed. No patients developed postoperative complications. The present method may, thus, be a treatment of choice directed toward the relief of intractable abdominal pain in selected patients with pancreatic cancer.

Cavernous transformation of the portal vein coinciding with early gastric cancer and cholelithiasis.

A 71-year-old man who developed jaundice with a high-grade fever was admitted to our hospital. The episode was ascribed to cholecysto-choledocholithiasis. In the preoperative evaluation, a cavernous transformation of the portal vein and an early gastric cancer were found. The patient thereafter underwent an operation for those pathologies after the endoscopic removal of a choledochal stone; cholecystectomy, and a distal gastrectomy with regional lymph node dissection for gastric cancer. The proposed procedures of gastrectomy and cholecystectomy were completed without any major difficulty because no markedly enlarged collateral veins were found in the area where the regional lymph node dissection was carried out. Thanks to advances in imaging modalities, an asymptomatic cavernous transformation of the portal vein coinciding with gastric cancer such as that seen in the present case may be increasingly encountered in the future. The greatest caution, however, needs to be exerted at operation to minimize any unexpected bleeding and to avoid any interruption of the porto-portal shunts in such cases. Further, the reestablishment of the portal blood supply to the liver might be required in advanced cases of gastric cancer, where regional lymph node dissection may necessitate skeletonization of the hepatoduodenal ligament for curative purposes.

[A case of metastatic liver cell carcinoma in the abdominal wall corresponding to the location of a buried arterial catheter].

The authors encountered a case of primary liver cell carcinoma which metastasized to the abdominal wall at a site corresponding to the location of an indwelling catheter for intra-arterial injections. The patient was a 54-year-old male with primary liver cell carcinoma in the posterior inferior segment. Because of a subsegmentectomy of the liver on September 25, 1986 and postoperative chemotherapy, a catheter for intra-arterial injections was inserted from the right gastroepiploic artery. After anticancer agents were administered postoperatively via this catheter, the same catheter was implanted subcutaneously before discharge. From the latter part of June 1987 after discharge, there was an increase in alpha FP and a subcutaneous tumor, which gradually increased in size, was found at a site in the right hypochondrium corresponding to the location of the arterial catheter. Angiography revealed a tumor nourished by the right 10th intercostal artery, and an operation was performed to remove this tumor. From a pathological examination, this case was diagnosed as metastatic liver cell carcinoma (metastasis to the abdominal wall). The tumor was not connected with the liver and matched the site in the abdominal wall where the arterial catheter was embedded. Therefore, implantation of a catheter cannot be ruled out as a mode of metastasis other than the blood stream.