Rituximab in remission induction and maintenance therapy for microscopic polyangiitis associated with gastric cancer: A case report.

We herein report a case of a patient with gastric cancer-associated microscopic polyangiitis (MPA) who was treated with combination glucocorticoids and rituximab (RTX) for remission induction and maintenance, and finally to discontinue glucocorticoids without recurrence of gastric cancer or MPA in a year. A 69-year-old man was suspected of having MPA because of fever, high C-reactive protein levels, neuritis, and a high titer of myeloperoxidase-anti-neutrophil cytoplasmic antibody (MPO-ANCA). Upper gastrointestinal endoscopy indicated early-stage gastric cancer, for which he underwent surgery preceded by immunosuppressive therapy for vasculitis. Histopathological images showed vasculitis in the vicinity of the cancerous tissue, suggesting an association between gastric cancer and vasculitis. Postoperatively, fever and inflammatory response improved, but MPO-ANCA increased further and the patient developed alveolar hemorrhage. He resulted in remission with high-dose glucocorticoids and RTX, and he received maintenance therapy with RTX without additional immunosuppressive agents. After 1 year of treatment, he was able to discontinue glucocorticoids without recurrence of gastric cancer or vasculitis. There is no established treatment for malignancy-associated vasculitis other than glucocorticoids. Although more cases need to be accumulated in the future, RTX is expected to be useful in malignancy-associated vasculitis.

Groove pancreatic carcinoma.

The groove area is localized between the head of the pancreas, the duodenum, and the common bile duct. Differentiating of groove pancreatitis from pancreatic carcinoma is often difficult. Herein, we report a 54-year-old woman with groove pancreatic adenocarcinoma presenting epigastralgia, jaundice, and vomiting. The diagnosis was confirmed by computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic biopsy. The patient underwent pancreatoduodenectomy. Microscopically, well-differentiated adenocarcinoma was mainly located in Santorini's duct, but there was no invasion to the main pancreatic duct. The patient followed a satisfactory post operative course. She is doing well without recurrence 15 months after the surgery. It is very difficult to differentiate groove pancreatic carcinoma from groove pancreatitis. To avoid unnecessary surgical treatment, endoscopic biopsy and observation of the duodenum are useful for diagnosis. However, keeping in mind the differential diagnosis of pancreatic head carcinoma is necessary.

Efficacy of oncolytic reovirus against liver metastasis from pancreatic cancer in immunocompetent models.

Liver metastasis is common in pancreatic cancer patients, and the current treatments are insufficient to improve the clinical outcome. Recently, tumor-targeted replication-competent viruses have been developed as cancer therapy. The aim of this study was to clarify the efficacy of oncolytic reovirus against liver metastases from pancreatic cancer in immunocompetent models. Reovirus serotype 3 and three hamster pancreatic cancer cell lines (HPD1NR, HPD2NR, and HaP-T1) were used in this study. The susceptibility of reovirus to these cell lines was examined. The effect of intraportal administration of reovirus against metastatic liver tumors was evaluated in vivo. Reovirus infected all cell lines and propagated via an activated Ras signalling pathway in vitro. In syngeneic hamster models using the HPD2NR cell line, intraportal administration of reovirus significantly decreased the number and size of treated tumors in comparison with non-treated tumors. Immunohistochemical examination revealed reovirus replication within the tumor cells but not in the surrounding normal tissue and organs. There were no reovirus-related toxicities and deaths. Our results indicate that intraportal administration of reovirus is effective and safe in immunocompetent and syngeneic hamster models of liver metastases from pancreatic cancer, suggesting that reovirus can be developed into an effective therapeutic modality in future.

Safety and efficacy of laparoscopic distal pancreatectomy for the treatment of pancreatic disease.

BACKGROUND/PURPOSE: There are a few reports of laparoscopic distal pancreatectomy in the literature. We describe our experience with laparoscopic distal pancreatectomy and evaluate the safety and efficacy of the procedure in light of other reported findings. METHODS: A retrospective study was performed of all patients who underwent laparoscopic distal pancreatectomy between April 1996 and December 2002 at Oita University Faculty of Medicine. RESULTS: Laparoscopic distal pancreatectomy was attempted in seven patients (three men and four women) with a mean age of 65 years. One patient was converted to open surgery, and two patients required a hand-assistance procedure. There were no complications in any patients. Median operation time for all seven patients was 300 min, and median blood loss was 330 ml. Median postoperative hospital stay was 12 days (range, 7 to 21 days). CONCLUSIONS: Our limited results, together with reported outcomes, suggest that laparoscopic distal pancreatectomy is safe and effective for selected patients. The potential advantages of this procedure include reduced morbidity and reduced hospital stay.

Factors influencing recurrence after surgical treatment for T2 gallbladder carcinoma.

BACKGROUND/AIMS: The overall outcome of T2 gallbladder carcinoma has not been favorable, although there is a modest hope for long-term survival after radical resection. The aim of this study was to examine factors influencing postoperative disease-free survival of patients with T2 gallbladder carcinoma to clarify optimal treatment. METHODOLOGY: Of 53 patients with gallbladder carcinoma who had undergone surgical resection from 1985 to 2000, 22 had T2 carcinoma histologically proved. The significance of variables for disease-free survival was examined retrospectively by the Kaplan-Meier method and the log-rank test. RESULTS: There were 16 patients with stage II (T2N0M0), 6 with stage III (T2N1M0) disease. Eleven patients were treated by extended cholecystectomy with resection of the extrahepatic bile duct, 10 patients underwent extended cholecystectomy without resection of the extrahepatic bile duct, and 1 patient underwent cholecystectomy. All patients underwent lymph node dissection in the hepatoduodenal ligament, below the pancreatic head, and along the common hepatic artery. Lymph node metastasis was present in 6 patients. Lymphatic, venous, and perineural invasions were found in 9, 4, and 4 patients, respectively. The absence of lymphatic invasion was a significant factor related to good postoperative disease-free survival (5-year disease-free survival rate, 88.9% vs. 31.3% in the presence of lymphatic invasion). Lymph node, venous, or perineural invasion, and surgical procedure were not significant factors to good postoperative disease-free survival. CONCLUSIONS: For patients with T2 gallbladder carcinoma, the presence of lymphatic invasion is an unfavorable prognostic indicator that calls for additional treatment after radical surgery.

Laparoscopic resection for nonfunctioning small glucagon-producing tumor: report of a case and review of the literature.

Glucagonoma is a relatively rare type of pancreatic endocrine tumor, and is often well-developed and malignant at detection. We report a case of nonfunctioning small glucagon-producing tumor that was successfully resected by laparoscopic surgery. A 63-year-old woman was admitted to our hospital for further examination of a pancreatic tumor that had been detected incidentally. Hematological data and hormone concentrations were within normal ranges. Abdominal ultrasonography and computed tomography showed a small mass in the body of the pancreas. Laparoscopic distal pancreatectomy was done. Macroscopically, the resected tumor was a yellowish-white, solid mass measuring 8 x 8 x 7 mm. The tumor cells showed positive immunohistochemical staining for chromogranin A and glucagon. The postoperative course was uneventful. To the best of our knowledge, this is the first report of laparoscopic surgery for a nonfunctioning small glucagon-producing tumor. Because of recent improvements in laparoscopic surgery technique, use of this approach for resection of pancreatic benign small endocrine tumors will likely increase in the future.

Oncolytic viral therapy for human pancreatic cancer cells by reovirus.

PURPOSE: Pancreatic cancer has a poor prognosis and few effective therapies are available. The oncolytic effect of reovirus has been observed in cancer cells with an activated Ras signaling pathway, and pancreatic cancer may be a candidate target for reovirus because K-ras mutation is frequently found in pancreatic cancer. EXPERIMENTAL DESIGN: In this study, we examined the feasibility of using reovirus (serotype 3) as an antihuman pancreatic cancer agent. RESULTS: Reovirus was able to infect five human pancreatic cancer cell lines (Panc1, MIApaca-2, PK1, PK9, and BxPC3) in vitro. We also confirmed that the Ras activity in these cancer cell lines was elevated compared with that in the normal cell line and that susceptibility to reovirus was associated with the Ras activity of these cells. In a unilateral murine xenograft model using Panc1 and BxPC3 cell lines, each tumor growth was suppressed by intratumoral injection of reovirus. Furthermore, local injection of reovirus also had systemic antitumor effects in a bilateral xenograft model using Panc1 cell line. Immunohistochemical examination revealed that reovirus replication was observed within the tumor but not in surrounding normal tissue. CONCLUSIONS: These results suggest that reovirus can be considered for a novel therapy against pancreatic cancer.

Clinical significance of combined pancreas and portal vein resection in surgery for pancreatic adenocarcinoma.

BACKGROUND/AIMS: Surgical resection remains the only potentially curative treatment for pancreatic adenocarcinoma for which the resectability and prognosis are still poor. The aim of the present study was to evaluate the efficacy of portal vein resection for pancreatic adenocarcinoma. METHODOLOGY: Between August 1983 and December 2000, 69 patients with pancreatic ductal cell carcinoma underwent resection in our department; 22 of the 69 had combined resection of the pancreas and portal vein. When the pancreas could not be separated from the portal vein, the vein was judged to be invaded by cancer and resected. RESULTS: The mortality rate for portal vein resection was 4.5%, which was similar to that in 47 patients with no resection of the portal vein (2.1%). Postoperative histologic analysis showed that 8 (37%) of the patients who underwent portal vein resection did not have cancer invasion to the portal vein, and 3 of them remain disease free to date. The 3-year survival rate of patients undergoing portal vein resection was 21.3%, and that of patients without portal vein resection was 20.0%. CONCLUSIONS: Resection of the portal vein in cases of pancreatic ductal cell carcinoma has no adverse affect on long-term survival for selected patients.

Optimal management of the branch duct type intraductal papillary mucinous neoplasms of the pancreas.

BACKGROUND: To determine the optimal management of the intraductal papillary mucinous neoplasms (IPMNs) according to the morphologic type based on distinguishing between benign and malignant diseases. BACKGROUNDS: IPMNs are increasingly recognized clinicopathologic entity. Extended pancreatic resection with radical lymph node dissection has been recommended for treatment. STUDY: A retrospective clinicopathologic study was carried out of the 57 cases with IPMNs who were treated between 1985 and 2001. Forty-three patients with IPMNs underwent resection, and 14 patients with small IPMNs were observed without resection. RESULTS: Among the 43 resected IPMNs, 25 were benign and 18 were malignant. Malignant tumors were significantly greater in diameter than benign tumors (52.9 vs. 30.2 mm, P< 0.05). All main duct type tumors with mural nodules were malignant. All branch duct type tumors less than 30 mm in diameter and without mural nodules were benign. Twelve branch duct type IPMNs size less than 30 mm were not resected and have not progressed. CONCLUSION: These results suggest that the branch duct type IPMNs less than 30 mm and without mural nodules is benign and might be treatable with limited resection or careful observation.

Prolonged survival after repeat resection of pulmonary metastasis from hepatocellular carcinoma.

We report a patient in whom two pulmonary resections were performed for lung metastasis after hepatic resection of hepatocellular carcinoma (HCC). A 56-year-old Japanese man with an 8-year history of chronic liver disease was admitted with elevated serum alpha-fetoprotein (AFP) and a liver tumor that had been detected by ultrasonography. Computed tomography showed a 6-cm tumor in the medial segment of the liver, and partial resection of the medial segment was performed. Thirty-six months after the first operation, pulmonary resection was performed for a solitary metastasis in the left lung. Fifty-one months after the second operation, a solitary metastatic tumor was detected in the right lung, without any evidence of recurrence or other metastatic foci, and thoracoscopic partial resection of the right lung was performed as the third operation. The patient is alive 36 months after the second pulmonary resection, has a normal AFP value, and shows no signs of recurrent or metastatic foci. Repeat pulmonary resection for metastasis from HCC resulted in long-term survival in this patient.