Surgical Outcomes of Pancreaticoduodenectomy for Pancreatic Cancer with Proximal Dorsal Jejunal Vein Involvement.

BACKGROUND/PURPOSE: The proximal jejunal vein which branches from the dorsal side of the superior mesenteric vein (SMV) usually drains the inferior pancreatoduodenal veins (IPDVs) and contacts the uncinate process of the pancreas. We focused on this vein, termed the proximal dorsal jejunal vein (PDJV), and evaluated the anatomical classification of the PDJV and surgical outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) with PDJV involvement (PDJVI). METHODS: The jejunal veins that branch from the dorsal side of the SMV above the inferior border of the duodenum are defined as PDJVs. We investigated 121 patients who underwent upfront pancreaticoduodenectomy for PDAC between 2011 and 2017; PDJVs were resected in all patients. The anatomical classification of PDJV was evaluated using multidetector computed tomography. Surgical and prognostic outcomes of pancreticoduodenectomy for PDAC with PDJVI were evaluated. RESULTS: The PDJVs were classified into seven types depending on the position of the first and second jejunal veins relative to the superior mesenteric artery. In all patients, the morbidity and mortality rates were 15.7 and 0.8%, respectively. The rates for parameters including SMV resection, presence of pathological T3-4, R0 resection, and 3-year survival were 46.2, 92.3, 92.3, and 61.1%, respectively, when there was PDJVI (n = 13). When there was no PDJVI (n = 108), the rates were 60.2, 93.5, 86.1, and 58.3%, respectively. Overall, there were no significant differences. CONCLUSIONS: Pancreaticoduodenectomy with PDJV resection is feasible for PDAC with PDJVI and satisfactory overall survival rates are achievable. It may be necessary to reconsider the resectability of PDAC with PDJVI.

High risk of bile duct carcinogenesis after primary resection of a congenital biliary dilatation.

Congenital biliary dilatation (CBD) is a relatively rare disease and highly associated with hepatobiliary malignancies due to pancreaticobiliary maljunction. For the treatment of CBD, the standard surgical method is the excision of the entire extrahepatic duct with a hepaticoenterostomy. However, in recent years, there has been an increase in reports of cancer developing in the biliary or pancreatic duct after hepaticoenterostomy. In this report, we describe the postoperative complications and carcinogenesis in 50 CBD patients according to the method of reconstruction of the bile duct. Hepaticojejunostomy (HJ) was performed in 34 patients and hepaticoduodenostomy (HD) in 16. In the HJ group, there were 7 cases of ascending cholangitis (20.6%), 3 cases of choledocholithiasis (8.8%), 4 cases of anastomotic stricture (11.8%) and 1 case of cholangiocarcinoma (2.9%). In the patient with cholangiocarcinoma, all complications including ascending cholangitis, choledocholithiasis, and anastomotic stricture were present. In the HD group, however, 2 cases of ascending cholangitis (5.9%) were recognized although choledocholithiasis, anastomotic stricture or cholangiocarcinoma were not observed. No significant differences were found in incidences of these complications between HJ and HD. It is unclear which method of reconstruction has a higher risk of carcinogenesis, however, it can be stated that hepaticoenterostomy itself is indeed one of the risk factors for biliary tract carcinoma. In any event, as several researchers have pointed out, since the incidence of bile duct carcinoma after the resection of the extrahepatic bile duct in CBD patients is very high compared to natural control, a long-term follow-up of the patient is necessary.

Immunohistochemical analysis of transforming growth factor beta in gallbladder cancer.

TGF-beta is highly expressed in various cancer cells, yet its mechanism suppressing the cell cycle fails and cell proliferation accelerates, resulting in carcinogenesis. However, there are only a very few reports on animal experiments or clinical specimens with regard to the TGF-beta in gallbladder cancer. We performed immunohistochemical analysis of TGF-beta expression with regard to cell proliferation, angiogenesis, and tumor cell infiltration in clinical specimens of gallbladder cancer. TGF-beta immunoreactivity was significantly higher in advanced cancer than in early cancer. With regard to Ki-67 labeling index, there was no significant difference between early cancer and advanced one. There was no statistically significant difference of the density of pre-existing blood vessels (CD34) between TGF-beta-positive group and negative one. The density of angiogenic vessels (CD105) was significantly greater in the TGF-beta-positive group than in the negative one. Tumor-associated macrophage infiltration was significantly higher in the TGF-beta-positive group than in the negative one. No statistically significant differences in cumulative survival rate were noted between patients in the TGF-beta-positive and TGF-beta-negative groups. In conclusion, our study revealed that in patients with gallbladder cancer, expression of TGF-beta increases according to cancer progression and strongly influences angiogenesis and macrophage infiltration, which contributes to tumor proliferation, but acts weakly on cancer cells by itself.

Significance of hepatic pedicle lymph node involvement in patients with colorectal liver metastases: a prospective study.

BACKGROUND: We investigated whether hepatic pedicle lymph node (HP-LN) involvement is a more significant prognostic factor and whether HP-LN dissection could be efficient in patients with positive HP-LN involvement. METHODS: From 1988 to 1998, HP-LN dissection was prospectively performed in 160 patients undergoing hepatectomy for colorectal liver metastases. Survival of patients with HP-LN involvement limited to the hepatoduodenal ligament and retropancreatic portion (area 1) was compared with that of patients with HP-LN involvement spreading over the common hepatic artery and celiac axis (area 2). RESULTS: HP-LN involvement was detected in 17 patients. The survival rate was significantly lower in patients with HP-LN involvement. HP-LN involvement was the most significant prognostic factor. Survival was significantly higher in patients with HP-LN involvement limited to area 1 than in those with HP-LN involvement spreading over area 2. CONCLUSIONS: HP-LN involvement was the most significant prognostic indicator in patients with colorectal liver metastases. Positive LNs of area 1 should no longer be considered an absolute contraindication to liver resection, but in case of area 2 lymph node involvement, liver resection does not seem justified.

Expression of cyclooxygenase-2 and vascular endothelial growth factor in pancreatic tumors.

Cyclooxygenase (COX)-2 and vascular endothelial growth factor (VEGF) have been reported to be significantly related to carcinogenesis or progression of various cancers. However, there has been no report on the relation between COX-2 and VEGF overexpression in pancreatic tumors. We investigated the overexpression of COX-2 and VEGF immunohistochemically in intraductal papillary-mucinous tumors (IPMT) and invasive ductal carcinoma (IDC) and examined the relationship with clinicopathological factors and the correlation between these immunoactivities in IPMT and IDC. In IPMT, the positive rates of COX-2 overexpression were 0% in 10 areas of hyperplasia, 54.5% of adenoma, 83.3% of intraductal areas of adenocarcinoma, and 66.7% of invasive areas of adenocarcinoma. On the contrary, 47.8% of IDC were positive for COX-2 overexpression. The positive rates of VEGF in IPMT were 10% in areas of hyperplasia, 54.5% of adenoma, 66.7% of intraductal areas of adenocarcinoma and 66.7% of invasive areas of adenocarcinoma. However, in IDC it was 47.8%. Only lymph node metastasis correlated significantly with VEGF overexpression (p=0.04), while the other factors had no significant relationships with either COX-2 or VEGF overexpression. There was a statistically significant correlation between COX-2 and VEGF overexpression in IPMT (p<0.001), in 5 patients with adenoma of which both COX-2 and VEGF were stained in almost exactly the same locations. On the contrary, COX-2 and VEGF overexpression had no statistically significant relationship in IDC. In conclusion, we demonstrate evidence of COX-2 and VEGF overexpression in human pancreatic tumors. Chemoprevention via the suppression of angiogenesis by means of COX-2 inhibitor may be more effective in IPMT than in IDC, because of the strong correlation of both factors especially in IPMT.

Gallbladder metastasis of renal cell carcinoma: report of two cases.

We report two extremely rare cases of metastasis to the gallbladder from renal cell carcinoma. In both men, aged 63 and 80 years, a pedunculated polypoid gallbladder tumor was incidentally found 27 and 8 years after surgery for renal cell carcinoma, respectively. The tumors showed hypervascularity on diagnostic imaging. A histopathological examination showed no tumor cells in the gallbladder mucosa. but clear cell carcinoma was predominantly observed below the mucosal layer. Furthermore, based on various specific and immunohistochemical studies as well as the electronmicroscopic findings, the patients were pathologically diagnosed to have gallbladder metastasis of renal cell carcinoma.