[Case of Mixed Neuroendocrine-Non-Neuroendocrine Neoplasm of the Papilla of Vater Metastasizing to the Lung after Resection].

A 79-year-old man visited a hospital for right upper abdominal pain and nausea. After conservative treatment for cholangitis and pancreatitis owing to a pancreatic head lesion, he was referred to our hospital for further evaluation and treatment of the lesion. He was diagnosed with pancreatic head cancer or carcinoma of papilla of Vater and underwent subtotal stomach- preserving pancreaticoduodenectomy. Postoperative histopathological examination revealed the coexistence of adenocarcinoma( 60%)and neuroendocrine carcinoma(40%)components, consistent with the diagnosis of mixed neuroendocrine- non-neuroendocrine neoplasm(MiNEN). In addition, regional lymph node metastasis of the adenocarcinoma component was found. Adjuvant chemotherapy was not administered because of a poor performance status. Lung metastasis occurred 13 months after surgery. Chemotherapy with S-1 was administered, and partial response was obtained 17 months after surgery. Herein, we report this rare case of MiNEN of the papilla of Vater with lung metastasis.

[A Case of Xanthogranulomatous Cholecystitis That Is Difficult to Distinguish from Advanced Gallbladder Cancer with Invasion of the Transverse Colon].

A 53-year-old woman was admitted to our hospital because of hepatic dysfunction found during a medical checkup. Cholecystitis was suspected, and unenhanced computed tomography (CT) was initially performed because she had bronchial asthma. However, a tumor-like lesion was seen at the bottom of the gallbladder. Contrast-enhanced CT was performed 3 weeks later, and the tumor-like lesion was enhanced and had increased in size. Endoscopic ultrasound fine-needle aspiration did not reveal any signs of malignancy. Colonoscopy revealed ulcerations in the transverse colon, and invasion from gallbladder cancer was suspected. Our preoperative diagnosis was xanthogranulomatous cholecystitis, but gallbladder cancer could not be excluded. Gallbladder bed resection and partial resection of the transverse colon were performed. Intraoperative frozen section analysis did not reveal any malignant findings; hence, we considered that lymph node dissection was unnecessary. Pathological examination confirmed xanthogranulomatous cholecystitis with abscess formation. In cases of surgery for xanthogranulomatous cholecystitis, it is important to consider that this condition could coexist with gallbladder cancer.

[A Case of Heterochronic Ovarian Metastasis from Sigmoid Colon Cancer after Sigmoidectomy Treated with CapeOX That Included Bevacizumab].

The patient was a 41-year-old woman. When she was 39 years old, she had undergone laparoscopic high anterior resection for sigmoid colon cancer without adjuvant chemotherapy. Histologically, the surgical specimen was type 2, tub2, pT4a (SE), pN0, int, INF b, ly1, v1, and pStage II. Nine months after the operation, she suffered from abdominal fullness. Laborato- rydata showed elevation of tumor markers: the CEA level was 6.48 ng/mL, the CA19-9 level was 89.70 U/mL, and the CA125 level was 662 U/mL. Computed tomographyrevealed bilateral ovarian tumors and lung and peritoneal nodules with massive ascites. Chemotherapywas started with a regimen consisting of capecitabine plus oxaliplatin(CapeOX)that included bevacizumab. After 4 courses, the sizes of the lung and peritoneal nodules had decreased and the amount of ascites was almost zero. However, the ovarian tumors had increased in size and her sense of abdominal fullness had not improved. Bilateral oophorectomy with hysterectomy was performed to alleviate her symptom. Immunohistochemically, the resected ovarian tumors were negative for cytokeratin 7 and positive for cytokeratin 20. CapeOX with bevacizumab was then resumed. However, the lung tumor had graduallyincreased in size, and therefore, she underwent partial resection of the lung for the metastatic lung tumor.

High-dose corticosteroid therapy for erlotinib-induced interstitial lung disease in Japanese patient with advanced pancreatic cancer.

CONTEXT: Erlotinib is a selective epidermal growth factor receptor tyrosine kinase inhibitor used as a target therapy against non-small lung cancer and advanced pancreatic cancer. A regimen of erlotinib plus gemcitabine has been proven to prolong overall survival in the patient with advanced pancreatic cancer. In addition to common adverse effects, such as diarrhea, mucositis and skin rash (acne form eruptions), acute interstitial lung disease (ILD) has been reported as an infrequent but potentially fatal complication. We here report a case of a Japanese patient with erlotinib-induced ILD in whom high-dose corticosteroid therapy was successful. CASE REPORT: A fifty-five-year-old male with cancer of the head of the pancreas with multiple liver metastases started treatment with gemcitabine plus erlotinib. On the 13th day of erlotinib treatment, he had high fever. Chest computed tomography (CT) scan showed a diffuse ground-glass like infiltration of both lungs. He was diagnosed with ILD, and high-dose corticosteroid therapy was started. Two weeks after the introduction of steroid therapy, the reticular shadow faded away on CT. He was successfully treated with corticosteroid for erlotinib-induced acute ILD although he died 6 months after the initiation of chemotherapy owing to disease progression. CONCLUSION: we showed a case of a successfully treated Japanese patient of erlotinib-induced ILD. Because erlotinib-induced ILD would frequently occur in Japanese patients, closer attention to ILD should be paid for Japanese patients than in Western populations. If erlotinib-induced ILD occurs, a high-dose corticosteroid therapy would be a useful option of treatment.

Liver epithelial cells proliferate under hypoxia and protect the liver from ischemic injury via expression of HIF-1 alpha target genes.

BACKGROUND: The remnant liver after extended liver resection is susceptible to ischemic injury, resulting in the failure of liver regeneration and liver dysfunction. The present study is aimed to investigate the protective role of the liver epithelial cells (LEC), a liver progenitor cell, on hepatocytes with ischemia in vitro and in vivo. METHODS: LECs were isolated from rats and cultured under hypoxic conditions (2% O(2)). The cell viability and intracellular ATP levels were measured. The activation of hypoxia-inducible factor-1α (HIF-1α) was assessed by immunofluorescence. The expression of pyruvate dehydrogenase kinase-1 (PDK-1), stromal cell-derived factor-1 (SDF-1), and chemokine receptor 4 (CXCR4) were measured. Hepatocytes were treated with SDF-1 or LEC-conditioned medium under hypoxia, and cell viability was assessed. Finally, hemorrhagic shock was induced in rats with in vivo induction of endogenous LECs, and liver damage was assessed. RESULTS: In LECs, but not in hepatocytes, cellular viability and intracellular ATP levels were maintained, and nuclear translocation of HIF-1α and expression of pyruvate dehydrogenase kinase-1 mRNA were increased under hypoxic culture conditions. LECs express SDF-1, and CXCR4 expression was increased in hepatocytes under hypoxia. The survival of hepatocytes under hypoxic condition was significantly increased after treatment with SDF-1 or LEC-conditioned medium. The protective effect of conditioned medium was impaired by CXCR4 antagonists. In vivo induction of endogenous LECs suppressed elevation of serum AST and ALT levels after hemorrhage shock and ischemia-reperfusion. CONCLUSION: LECs are resistant to hypoxia and have a protective role for hepatocytes against hypoxia. Our results suggest that induction of endogenous LECs protected the liver from lethal insults by paracrine signaling of SDF-1 and differentiation into parenchymal cells.

Epstein-Barr virus-positive inflammatory pseudotumor of the spleen managed with laparoscopic splenectomy.

We report a case of Epstein-Barr virus (EBV)-positive splenic inflammatory pseudotumor treated by laparoscopic splenectomy. A 66-year-old female without symptoms was found to have a solitary, avascular, solid tumor of the spleen by contrast-enhanced computed tomography. The tumor was compatible with a primary tumor of the spleen. A benign splenic tumor was the most likely diagnosis, but malignant lymphoma could not be ruled out because the serum-soluble interleukin-2 receptor (sIL-2R) level was elevated. Laparoscopic splenectomy was performed to enable a definite diagnosis. Removal of the whole spleen without injury was possible. Possible contamination of the extirpation orifice by cancer cells was carefully prevented by enclosing the spleen in a plastic bag. Histopathological examination showed the tumor to be an EBV-positive inflammatory pseudotumor. To the best of our knowledge, this is only the second report of an EBV-positive splenic inflammatory pseudotumor with an increased serum sIL-2R level. Although EBV-positive inflammatory pseudotumors have been reported to recur, no sign of recurrence has been detected in the present case in the 17 months following splenectomy.

Enhanced proliferation of hepatic progenitor cells in rats after portal branch occlusion.

It is known that hepatic progenitor cells increase in number after liver injury caused by carcinogens, but this injury cannot be reproduced in humans. In order to create a practical source of hepatic progenitor cells, changes in the number of liver epithelial cells (LECs), a type of hepatic progenitor cell, were examined following partial interruption of the portal flow. Efficiency in this isolation procedure was investigated, and isolated LECs were transplanted into livers to demonstrate their differentiation into hepatocytes in vivo.A volume of 70% of Sprague-Dawley rat's livers was exposed to portal vein ligation. LECs, identified as alpha-fetoprotein (AFP)-positive and albumin-negative cells, were counted and LECs isolated from the portal vein ligated-lobe were characterized by immunostaining and Western blotting. Isolated cells were subjected to a 1-week-culture, and the number of colonies formed on dishes was counted. The cells were then transplanted to the livers of genetic analbuminemic rats and identified by immunohistochemistry. The number of LECs in the portal ligated-lobes on day 7 was 14.7 +/- 6.5 cells/1,000 hepatocytes: 18 times higher than numbers in a normal liver. A significant increase was noted from day 3 until day 28. Isolated LECs were AFP-positive, albumin-negative, and cytokeratin-19-positive cells. The number of colonies on the 7th day following portal vein ligation was 42 times higher than in a normal liver. After transplantation of the LECs to the analbuminemic rat, a cluster of albumin-producing cells was present until day 56, suggesting that they differentiate into hepatocytes. We conclude that after portal vein occlusion, the liver can be a good source of hepatic progenitor cell. These results open up the possibility of cellular transplantation for liver functional support in clinical settings.

Acute emphysematous cholecystitis preceded by symptoms of ileus: report of a case.

We herein describe a case of acute emphysematous cholecystitis in which the patient presented with symptoms of ileus. The patient was a 72-year-old man with no history of diabetes mellitus. He presented with epigastric pain, vomiting, and low-grade fever. Plain abdominal radiography showed some intestinal gas and niveau, and he was admitted to our hospital with a diagnosis of ileus. The next day, the abdominal pain increased and was accompanied by muscular defense. Plain radiography and computed tomography of the abdomen were carried out, and an emergency laparotomy was performed under a diagnosis of panperitonitis due to a perforation of the gallbladder caused by acute emphysematous cholecystitis. The patient made favorable progress after the operation and was discharged on postoperative day 14. Percutaneous transhepatic gallbladder drainage has been increasingly performed for the treatment of acute emphysematous cholecystitis. but when a perforation of the gallbladder is suspected, a laparotomy first should be considered.

Outcomes and indications of segmental pancreatectomy. Comparison with distal pancreatectomy.

BACKGROUND/AIM: To preserve pancreatic function, segmental pancreatectomy has been proposed for benign or low-malignancy tumors in the pancreatic body. Indications for the procedure, however, are still controversial. METHODS: In this study, we investigated the advantages and disadvantages of segmental pancreatectomy compared with distal pancreatectomy and subsequently determined indications for segmental pancreatectomy. RESULTS: The distal pancreatectomy patients had shorter operation times, lower incidence of operative complications, and shorter hospital stays compared to segmental pancreatectomy patients. Endocrine function in distal pancreatectomy patients deteriorated compared to that of segmental pancreatectomy patients. The postoperative 75-gram oral glucose tolerance test showed a diabetic pattern in 3 of 7 distal pancreatectomy patients, whereas none of the segmental pancreatectomy patients became diabetic after surgery. The relation between the length of the removed pancreas and plasma glucose at 2 h after the 75-gram glucose intake showed a significant correlation. CONCLUSION: According to our results, if the length of removed pancreas is longer than 12 cm, the patients will have a risk of acquiring diabetes. In those cases, the segmental pancreatectomy should be considered.