Thrombospondin-1 expression as a prognostic predictor of pancreatic ductal carcinoma.

Pancreatic cancer is a malignant tumor with an extremely poor prognosis. Thrombospondin-1 (TSP-1) was suggested to be a potential regulator of tumor growth and metastasis. We examined TSP-1 expression in 77 cases of invasive ductal adenocarcinoma of the pancreas, and analyzed the correlation between the TSP-1 expression pattern and clinicopathological features in pancreatic cancer. TSP-1 immunoreactivity was detected in the cancer stroma. The diffusely positive and focally positive patterns of TSP-1 were found in 33 (42.9%) and 40 (51.9%) of 77 cases, respectively. The TSP-1 diffuse expression was significantly correlated with lymph node metastasis (p<0.01), neural invasion (p<0.05) and TNM stage (p<0.01). The prognostic significance of clinicopathological parameters were analyzed by univariate and multivariate analysis using the log-rank test and the Cox proportional hazards model. Based on the univariate analysis, histological differentiation (p<0.01), lymphatic invasion (p<0.01), venous invasion (p<0.05), neural invasion (p<0.01), TNM stage (p<0.01) and TSP-1 expression (p<0.01) were significant parameters. These observations suggested that TSP-1 plays important roles in cancer cell growth and metastasis of human pancreatic cancer, and that stromal TSP-1 immunoreactivity is a good prognostic predictor of patients with pancreatic cancer.

Effect of pouched reconstruction after total gastrectomy on ERCP and ENBD--report of two cases.

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic nasobiliary drainage (ENBD) are well known to be useful but these procedures are rarely indicated in patients after total gastrectomy, because the endoscopic approach is more difficult in the patients with standard reconstructions such as Roux-en-y esophagojejunostomy after total gastrectomy. Gastric replacement with various enteric reservoirs after gastrectomy has been used to improve the postprandial symptoms and nutrition of patients after total gastrectomy. We have been performing jejunal pouch double tract reconstruction (JPD) after gastrectomy and the patients' postoperative course has been satisfactory. In this report, we describe two cases of biliary tract disorders after total gastrectomy. One was choledocholithiasis and the other was bile leakage after cholecystectomy. In each case, we performed ERCP, and treated with ENBD tube placement, and we obtained satisfactory results. We emphasize that ERCP and ENBD are also useful and easy procedures for biliary tract disease in postgastrectomy patients with JPD reconstruction as well as in patients who have not undergone intestinal reconstruction. The advantages of JPD reconstruction are not only improving the postprandial symptoms and the nutrition of patients after total gastrectomy, but that it provides an easy endoscopic approach to the papilla of Vater.

A case of primary small intestinal cancer diagnosed by laparoscopy.

The patient was a 61-year-old female who developed ileus. Physical findings showed abdominal distension but peritoneal irritation signs were not observed. After the conservative treatment by the ileus tube, encircling stenosis was observed in the jejunum at about 50 cm on the anal side from the Treitz ligament on contrast radiography of the small intestine through the ileus tube. Tumor markers were normal except for mild elevation of IL2-R (609 U/ml). After confirming sufficient bowel decompression and the absence of other lesions, surgery was performed based on a preoperative diagnosis of small intestinal tumor including adhesive ileus, GIST, or malignant lymphoma. First, under the laparoscopic observation, the lesion was resected and definitive diagnosis was established as primary moderately to poorly differentiated adenocarcinoma of the small intestine by rapid intraoperative pathological diagnosis. Then, extensive jejunal resection involving sufficient lymph node dissection was performed as open surgery. Radical surgery was successfully performed.

Undifferentiated spindle and giant cell carcinoma of the common bile duct.

Undifferentiated spindle and giant cell carcinoma of the common bile duct has not been reported previously. We present here a case of 71-year-old man with the undifferentiated spindle and giant cell carcinoma of the common bile duct, including immunohistochemical findings. A nodular infiltrating tumor was located at the lower portion of the extrahepatic bile duct, and measured 1.2 x 0.6 cm in size. Histologically, the tumor was composed of proliferated sarcomatoid spindle tumor cells. Numerous multinucleated giant cells were intermingled with the sarcomatoid spindle tumor cells. Immunohistochemically, the tumor cells were positive for both cytokeratin and vimentin. We speculated that the tumor originated from epithelial cells, and showed sarcomatoid neplastic changes.

Laparoscopic treatment of intestinal intussusception in Peutz-Jeghers syndrome: case report and review of literature.

A 47-year-old woman presented with an abdominal mass and nausea. Abdominal ultrasound and computed tomography (CT) showed a sausage-shaped mass with invagination. One polyp that appeared to exceed 3 cm was found in the sigmoid colon. Laparoscopy confirmed an intussusception mass, and the intussusception was dissected by hand-assisted laparoscopy (HALS). The sigmoid colon was also mobilized to the site of the small incision and resected. Generally, we believe enterectomy including polyps should be avoided as much as possible in Peutz-Jeghers syndrome (PJS) because poly-surgery may lead to short bowel syndrome. In addition, PJS patients often undergo multiple surgery, and therefore dense intra-abdominal adhesions are seen at subsequent laparotomy, which makes surgery increasingly difficult with repeated operations. Laparoscopic-assisted surgery seems beneficial, as in the present case.