[Effectiveness of adjuvant chemotherapy using gemcitabine for resected pancreatic cancer].

BACKGROUND: The aim was to evaluate the adjuvant chemotherapy using gemcitabine (GEM) for resected pancreatic cancer. METHODS: We investigated 69 patients who had undergone curative operations for pancreatic cancer. They were classified into two groups of patients using GEM (group A: 37) and patients with surgery alone (group B: 32) between 2009 and 1998. Outcomes, including disease-free survival (DFS), median survival time (MST), and adverse events were reported retrospectively. Patients assigned to the gemcitabine group received GEM at a dose of 800 mg/m² on days 1, 8 and 15, every 4 weeks for 5 cycles. RESULTS: DFS and MST did not differ significantly between group A and group B (DFS; group A: 10. 4 vs group B 8. 0 months, MST; group A: 21. 7 vs group B 16. 3 months). The estimated overall survival rates at 3 and 5 years were 40% and 25. 7%, respectively, in group A, and 12. 9% and 12. 9% in group B. Grade 3 or 4 toxicity revealed 8.1%with leucopenia, 2. 7% with thrombocytopenia, and 2. 7% with nausea. RESULTS: Adjuvant chemotherapy using gemcitabine for resected pancreatic cancer contributes to prolonged DFS, MST, and estimated overall survival.

Pancreaticoduodenectomies with a duct-to-mucosa pancreaticojejunostomy anastomosis with and without a stenting tube showed no differences in long-term follow-up.

BACKGROUND/PURPOSE: The aim of this study was to evaluate the long-term complications of pancreaticoduodenectomy with a duct-to-mucosa pancreaticojejunostomy anastomosis without a stenting tube. METHODS: Patients were followed for at least 3 years after pancreaticoduodenectomy. They were classified into two groups: duct-to-mucosa pancreaticojejunostomy anastomosis with a stenting tube (group A: 24) and without a stenting tube (group B: 21). Outcomes, including complications and dilatation of the pancreatic duct, were reported retrospectively. RESULTS: The following complication rates were found for group A: morbidity 29.1%, cholangitis 12.5%, nonalcoholic steatohepatitis 4.2%, liver abscess 4.2%, intrahepatic stones 4.2%, abnormal glucose tolerance (progression of diabetes) 20.8%, and dilatation of the pancreatic duct 20.8%. In group B, the rates for morbidity (14.3%) and abnormal glucose tolerance (19%), and dilatation of the pancreatic duct (4.8%) were lower than those in group A, but all results lacked statistical significance. CONCLUSIONS: Pancreaticoduodenectomy with a duct-to-mucosa anastomosis of pancreaticojejunostomy with or without a stenting tube showed no difference in long-term follow-up.

Pancreatic schwannoma: a case report and literature review with special reference to imaging features.

CONTEXT: We report the imaging features of pancreatic schwannomas, a rare benign type of pancreatic tumor. CASE REPORT: A 66-year-old woman was admitted to our hospital with a pancreatic tumor indicated in medical examinations. Computed tomography (CT), magnetic resonance imaging (MRI) and endoscopic ultrasonography (EUS) revealed a solid and cystic tumor, 3 cm in diameter, within the body of the pancreas. Contrast-enhanced CT, MRI and ultrasonography showed partial enhancement in the solid component. Endoscopic retrograde cholangiopancreatography (ERCP) and angiography showed no abnormal findings. A distal pancreatectomy together with a splenectomy and lymph node dissection were performed with a tentative diagnosis of mucinous cystic neoplasm of the pancreas. The cut surface of the resected pancreas showed a well-demarcated, pale yellow, solid tumor within the pancreas parenchyma. Histopathological examination of the tumor revealed proliferation of the spindle cells showing interlacing and palisading patterns. Immunohistochemically, these spindle cells were positive for S-100 protein and vimentin, and negative for alpha-smooth muscle actin, CD34, and cytokeratin. Thus the tumor was diagnosed as a pancreatic schwannoma. CONCLUSION: CT and US can detect pancreatic schwannomas as solid and cystic masses, and MRI shows a relatively characteristic feature. Imaging procedures such as CT, MRI and US are able to differentiate a pancreatic tumor, such as a pancreatic schwannoma.

Appraisal of the Imaizumi modification of the Beger procedure: the TWMU experience.

BACKGROUND/PURPOSE: We developed the Imaizumi modification of the Beger procedure, a duodenum-preserving pancreatic head resection. The Imaizumi modification allows for removal of more of the subtotal pancreatic head than in the conventional Beger procedure, including the intrapancreatic bile duct, for chronic pancreatitis with common bile duct stenosis. A retrospective study was performed to evaluate the efficacy of the Imaizumi modification compared to a pylorus-preserving pancreaticoduodenectomy (PPPD), based on the early and late postoperative results. METHODS: A group of 14 patients who underwent the Beger procedure with the Imaizumi modification to treat chronic pancreatitis from November 1997 to December 2005 was investigated retrospectively. This group was compared to a group of 21 patients who underwent PPPD from November 1997 to December 2003. The median follow-up period was 3.6 years (range 3.1-5.7 years) for the Imaizumi modification group and 4.0 years (range 3.0-8.3 years) for the PPPD group. RESULTS: A pancreatic fistula formed in 7% of the Imaizumi modification patients (PPPD 5%), pain relief was achieved in 92% (PPPD 94%), complete professional rehabilitation was achieved in 71% (PPPD 67%), insulin-dependent diabetes mellitus was present in 43 versus 36% before the procedure (PPPD 62 versus 38% before the procedure), and body weight improved in 79% (PPPD 48%). No significant differences were found between the two groups for the early postoperative complications and the late postoperative outcome 3 years after the procedure. However, the Imaizumi modification group exhibited an encouraging tendency to have a lower rate of new-onset exocrine and endocrine insufficiency than the PPPD group. CONCLUSIONS: Our Imaizumi modification of the Beger procedure, including intrapancreatic bile duct resection, represents a useful alternative for the treatment of chronic pancreatitis with an inflammatory mass and bile duct stenosis in the pancreatic head.

[A case of pathologic complete response of primary esophageal carcinoma treated with 5-FU/CDDP as neoadjuvant chemotherapy].

A 77-year-old man with advanced esophageal carcinoma and lymph node swelling of abdomen and mediastinum, underwent neoadjuvant chemotherapy (NAC) with 5-FU/CDDP. Adverse reactions were general fatigue and nausea of grade 3 and stomatitis of grade 2. Primary tumor and lymph node swelling revealed remarkable effectiveness after 1 course of NAC, so 2 courses of NAC were given. The esophageal carcinoma was not found by endoscopy, and a biopsy specimen revealed inflammatory granulation. Lymph node on CT examination disappeared in the abdomen and reduced in the mediastinum. Because of retention of lymph node swelling, radical resection of the esophageal carcinoma was performed. Pathologic examination of the resected specimen revealed no malignant cells in the esophagus, and 3 lymph node metastases (pStage III). He had no recurrence in 15 months after the operation. Because NAC was markedly effective for primary tumor and lymph node of esophageal carcinoma, a radical operation was performed.

Pancreaticojejunostomy of duct to mucosa anastomosis can be performed more safely without than with a stenting tube.

BACKGROUND: The aim of this study was to evaluate the safety of performing a pancreaticojejunostomy with a duct-to-mucosa anastomosis without a stenting tube. METHODS: One hundred twenty-one patients with pancreaticojejunostomy, classified into 2 groups of those with duct-to-mucosa anastomoses with stenting tubes (group A; n = 49) and without stenting tubes (group B; n = 72), were investigated. Outcomes, including complications and survival rates, are reported. RESULTS: In group A, morbidity was 32.7%, 6.7% had pancreatic fistulas, 14.3% had delayed gastric emptying, 6.1% had remnant pancreatitis, 2% had intra-abdominal abscesses, 2% had intra-abdominal bleeding, and mortality was 2%. In group B, morbidity (15.3%) and delayed gastric emptying (2.8%) showed significant differences from group A. Other results were nonsignificant. In the normal soft pancreas, pancreatic fistulas in group B (3.3%) were less frequent than in group A (12.5%). CONCLUSION: Pancreaticojejunostomy of a duct-to-mucosa anastomosis could be performed more safely without than with a stenting tube to obtain a definitive anastomosis and transection of the pancreas.

Bi-weekly irinotecan hydrochloride and cisplatin as a second-line chemotherapy for patients with advanced gastric cancer.

PURPOSE: To evaluate the effectiveness of bi-weekly administered irinotecan (CPT-11) and Cisplatin (CDDP) as a second-line chemotherapy for patients with advanced gastric cancer. METHODS: We included 22 patients who were resistant to 5-fluorouracil (5-FU) -based chemotherapy. CPT-11 (80 mg/m (2)) and CDDP (25 mg/m(2)) were administered bi-weekly on days 1 and 15 of a 4-week-cycle, on an outpatient basis except for the first time. Outcome variables include tumor response, toxicity, and survival. RESULTS: Among all patients, 8 responded to the therapy, yielding an overall response rate of 36.4% (complete response, n=1; partial response, n=7), while 14 did not respond (stable disease, n=9; progressive disease, n=5). The time to progression was 5.3 months, and the median survival was 10.6 months. Adverse reactions included Grade 3 or 4 leucopenia (n=4; 18.2%), Grade 3 or 4 thrombocytopenia (n=1; 4.5%) but all of these patients recovered soon (within one week). CONCLUSION: Bi-weekly CPT-11 and CDDP treatment was effective and should be considered as a second-line chemotherapy for patients with advanced gastric cancer who are resistant to 5-FU based chemotherapy.

Small-cell neuroendocrine carcinoma of the ampulla of Vater.

We report a patient (an 80-year-old woman) with anemia and fecal occult blood, who had an emergency operation for carcinoma of the cecum (well-differentiated adenocarcinoma without local lymph node metastasis). Postoperative magnetic resonance cholangiopancreatography, cholangiography, and upper gastroduodenal endoscopy showed a tumor of the ampulla of Vater, and pylorus-preserving pancreatoduodenectomy was performed. Histology of the resected tumor was that of small-cell carcinoma, and immunohistochemistry showed positive staining for neuron-specific enolase, chromogranin A, and synaptophysin, confirming the neuroendocrine nature of the tumor. As the histology of the tumor was distinct from cecal carcinoma, and no tumors were found in other organs, the tumor was diagnosed as primary small-cell neuroendocrine carcinoma of the ampulla of Vater. The patient died due to multiple liver metastases of the carcinoma of the ampulla of Vater 7 months after the pancreatoduodenectomy. The clinical and morphological features of this disease have been reported in nine individuals previously.

[Second-line chemotherapy with bi-weekly CPT-11 and cisplatin for recurrent colorectal cancer resistant to 5-FU based chemotherapy].

Second-line chemotherapy with bi-weekly CPT-11 and cisplatin (CDDP) was given to 19 patients with recurrent colorectal cancer resistant to 5-FU based chemotherapy. The 19 patients consisted of 18 men and 1 woman with a mean age of 61.3 years. Nine patients had liver metastasis, 4 had lung metastasis, 2 had local recurrence, 2 had both local recurrence and lung metastasis, respectively, 1 had local metastasis and lymph node metastasis, and 1 had bone metastasis. CPT-11 (80 mg/m2) and CDDP (30 mg/m2) were administered bi-weekly. The objective overall response rate was 15.8%. The time to progression was 146 days, and the median survival time was 477 days. Grade 3 leucopenia and nausea occurred in 1 patient (5.3%). CPT-11 and CDDP treatment should be considered as second-line chemotherapy for colorectal cancer resistant to 5-FU based chemotherapy.

[A case of recurrent gallbladder cancer responding to combination chemotherapy of TS-1 and CDDP].

A 76-year-old man suffering from advanced gallbladder cancer after hepato-pancreaticoduodenectomy had cholangitis and serum elevation of CA19-9 2 years and 6 months after the operation. A recurrent tumor had been recognized from the hilar to the surrounding inferior vena cava, and stenosis of jejunum utilized for pancreaticocholedoco-jejunostomy. A bypass operation of jejunum was performed. Combination chemotherapy with TS-1 100 mg/day (3 weeks) and CDDP 30 mg/day (day 1, 8 drip infusion) in 1 course was performed, and a partial response (PR) was noted. Diarrhea of grade III and decreased WBC of grade II were recognized, and were improved. Two courses of the same chemotherapeutic regimen were carried out. Among 5 months, recurrent tumor showed preservation of PR. Into 3 course of chemotherapy, radiation therapy was selected for second opinion. But recurrent tumor was enlarged acutely, and radiation therapy was stopped. He died 15 months after the first detection of chemotherapy. The combination chemotherapy of TS-1 and CDDP seems to be beneficial therapy for advanced gallbladder cancer.

Mucosa-associated lymphoid tissue-type lymphoproliferative lesion of the common bile duct.

Only a few cases of primary lymphoma of the common bile duct have been reported up to now. Here, we report a mucosa-associated lymphoid tissue (MALT)-type lymphoproliferative lesion of the common bile duct with some considerations about MALT lymphoma and benign lymphoproliferation. The patient, a 71-year-old woman, was admitted to our hospital because of progressive epigastric pain. Abdominal ultrasonography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, and abdominal computed tomography showed a non-specific finding of stenosis of the common bile duct due to thickening of the wall. Angiography provided little diagnostic information. Bile duct carcinoma was diagnosed and pylorus-preserving pancreaticoduodenectomy was performed. Histological examination revealed that the common bile duct was occupied by full-thickness proliferation of lymphoplasma cells with many reactive lymph follicles. The histological features were somewhat consistent with those of MALT lymphoma. However, we could not determine the clonal proliferation of lymphoplasma cells in either immunohistochemical immunoglobulin light chain restriction of the plasma cells or in polymerase chain reaction based immunoglobulin heavy chain gene rearrangement. The present case may be categorized as a borderline lesion close to benign lymphoproliferation. To the best of our knowledge, there have been no reports of cases similar to the present case.

Indications for pancreatoduodenectomy in patients undergoing lymphadenectomy for advanced gallbladder carcinoma.

BACKGROUND/PURPOSE: Carcinoma of the gallbladder shows diverse patterns of spread. The most appropriate surgical procedures according to the depth and extent of the spread of the tumor are still controversial. METHODS: We investigated this surgical problem clinicopathologically, especially regarding the indications for pancreatoduodenectomy (PD), by retrospectively reviewing the clinical records of 216 patients who were surgically treated for advanced gallbladder carcinoma. Detailed studies of resected specimens, in our department, showed that preservation of the pancreas head carried an increased risk of residual microscopic metastases in small peripancreatic lymphatic nodes and ducts. Some patients with curative operations had shown recurrence in lymph nodes around the head of the pancreas within a few years after PD. Therefore, we performed hepatopancreato duodenectomy (HPD) in 93 patients, some of whom underwent the HPD as a prophylactic dissection of peripancreatic lymph nodes and some of whom underwent the HPD as a curative resection due to invasion to the peripancreatic lymph nodes, duodenum, and pancreas, observed macroscopically. The surgical outcome after PD was compared with that obtained after other curative resections (non-HPD). RESULTS: In patients with microscopically negative lymph node metastasis without hepatoduodenal ligament invasion, PD was not necessary for a complete resection of lymphatic metastases around the pancreas head. The 5-year survival rate of these patients who had HPD was not significantly higher than that for non-HPD resections with curative intent (73% vs 63%), and lymphatic recurrence was not marked. On the other hand, in patients with positive lymph node metastases without hepatoduodenal ligament invasion, PD was necessary for a complete resection. The 5-year survival rate after HPD in these patients was significantly improved compared to that after non-HPD resections with curative intent (87% vs 17%), because lymphatic recurrence was reduced (0% vs 80%). CONCLUSIONS: In advanced carcinomas with positive hepatoduodenal ligament invasion, although the basic operative strategy, which inevitably includes right lobectomy, should be curative, PD should not be performed for prophylactic lymphatic resection, because local recurrence in the hepatoduodenal ligament cannot be controlled by PD, and the 5-year survival rate of curative HPD was only 4% (non-HPD resection with curative intent, 18%); moreover, frequent, lethal, major postoperative complications (hepatic failure) occurred after combined right lobectomy.

[A case of gastric cancer with multiple liver metastasis responding to combination therapy of CPT-11 and CDDP].

A 63-year-old man suffering from advanced gastric carcinoma after distal gastric resection had multiple liver metastases 5 months after the operation. He underwent 3 courses of combination chemotherapy of 5-FU 600 mg/day with CDDP 50 mg/day, etoposide 100 mg/day and Leucovorin 30 mg/day for 5 days (FLEP), but progressive disease (PD) was noted. One additional course of combination chemotherapy with CPT-11 140 mg/day and CDDP 40 mg/day biweekly was performed and a complete response (CR) was noted. After 4 months, recurrence of a liver metastasis on S8 was demonstrated and 2 courses of the same chemotherapeutic regimen were carried out. Over 5 months, recurrence of the liver metastasis showed no change (NC) and resection of S8 of the liver was performed. No recurrence was after 6 months, but the patient died 34 months after the first detection of the occurrence of multiple liver metastases. The combination chemotherapy of CPT-11 with CDDP was also administered to other patients at our outpatient clinic and seems to be useful therapy for improving outcome.