Search

Background Pleuroperitoneal communication is a rare disorder that interferes with peritoneal dialysis. Although favorable results of thoracoscopic fistula closure have been reported, there are some cases in which the fistulas cannot be identified by thoracoscopy and the patients are forced to switch to hemodialysis. Case presentation We present two cases of pleuroperitoneal communication in which diaphragmatic fistulas could not be identified thoracoscopically, but could be identified laparoscopically. Patient 1 had difficulty continuing peritoneal dialysis 9 months after its introduction due to right pleural effusion. Although we could not detect the fistula thoracoscopically, we could laparoscopically identify the fistula in the center of the tendon of the right diaphragm and closed the site from the thoracic side. Patient 2 developed dyspnea due to right pleural effusion 6 months after the introduction of peritoneal dialysis. We could not find the fistulas with a thoracoscopic approach, but could identify multiple diaphragmatic fistulas with a laparoscopic approach and close the sites from the thoracic side. Conclusion In the surgical treatment of pleuroperitoneal communication, diaphragmatic fistulas can be identified laparoscopically even when thoracoscopic observation fails to find any fistulas.

Background Although neoadjuvant therapy (Nac) is recommended for high-risk resectable pancreatic cancer (R-PDAC), evidence regarding specific regimes is scarce. This report aimed to investigate the efficacy of S-1 Nac for R-PDAC. Methods In a multicenter phase II trial, we investigated the efficacy of Nac S-1 (an oral fluoropyrimidine agent containing tegafur, gimeracil, and oteracil potassium) in R-PDAC patients. The protocol involved two cycles of preoperative S-1 chemotherapy, followed by surgery, and four cycles of postoperative S-1 chemotherapy. Two-year progression-free survival rates were the primary endpoint. Overall survival (OS) rates and median survival time (MST) were secondary endpoints. Results Forty-nine patients were eligible, and thirty-one patients underwent resection following Nac, as per protocol (31/49; 63.3%). Per-protocol analysis included data from 31 patients, yielding the 2-year PFS rate of 58.1%, and 2-, 3-, and 5-year OS rates of 96.8%, 54.8%, and 44.0%, respectively. MST was 49.2 months. Intention-to-treat analysis involved 49 patients, yielding the 2-year PFS rate of 40.8%, and the 2-, 3-, and 5-year OS rates of 87.8%, 46.9%, and 33.9%, respectively. MST was 35.5 months. Conclusions S-1 single regimen might be an option for Nac in R-PDAC; however, the high drop-out rate (36.7%) was a limitation of this study.

Although neoadjuvant therapy (Nac) is recommended for high-risk resectable pancreatic cancer (R-PDAC), evidence regarding specific regimes is scarce. This report aimed to investigate the efficacy of S-1 Nac for R-PDAC. In a multicenter phase II trial, we investigated the efficacy of Nac S-1 (an oral fluoropyrimidine agent containing tegafur, gimeracil, and oteracil potassium) in R-PDAC patients. The protocol involved two cycles of preoperative S-1 chemotherapy, followed by surgery, and four cycles of postoperative S-1 chemotherapy. Two-year progression-free survival (PFS) rates were the primary endpoint. Overall survival (OS) rates and median survival time (MST) were secondary endpoints. Forty-nine patients were eligible, and 31 patients underwent resection following Nac, as per protocol (31/49; 63.3%). Per-protocol analysis included data from 31 patients, yielding the 2-year PFS rate of 58.1%, and 2-, 3-, and 5-year OS rates of 96.8%, 54.8%, and 44.0%, respectively. MST was 49.2 months. Intention-to-treat analysis involved 49 patients, yielding the 2-year PFS rate of 40.8%, and the 2-, 3-, and 5-year OS rates of 87.8%, 46.9%, and 33.9%, respectively. MST was 35.5 months. S-1 single regimen might be an option for Nac in R-PDAC; however, the high drop-out rate (36.7%) was a limitation of this study.

We report an unusual case of alpha-fetoprotein (AFP)-producing gastric carcinoma with enteroblastic differentiation. A 75-year-old woman was admitted to our hospital with occasional upper abdominal discomfort. We performed gastroscopy and observed a type 2 tumor, primarily in the pyloric region. Histological examination of biopsies confirmed gastric adenocarcinoma. Based on these findings, we diagnosed gastric adenocarcinoma and performed laparoscopic distal gastrectomy with lymph node dissection. Histological examination revealed an invasive lesion composed of adenocarcinoma with a tubulopapillary growth pattern. Tumor cells were cuboidal in shape with characteristically clear cytoplasm rich in glycogen. Two regional lymph node metastases were seen microscopically. Immunohistochemically these cells were positive for AFP, carcinoembryonic antigen, caudal-type homeobox transcription factor 2 and common acute lymphoblastic leukemia antigen. The final diagnosis was AFP-producing gastric carcinoma with enteroblastic differentiation. 26 months after initial surgery, the patient was readmitted to our hospital for gastrointestinal obstruction due to lymph node recurrence.

Solitary fibrous tumor (SFT) is a rare stromal neoplasm and usually occurs in the thoracic cavity. We here report a case of retroperitoneal SFT with prominent calcification. A 64-year-old man presented with an incidentally detected retroperitoneal mass in the right upper abdomen. Imaging tests indicated an integrally calcified mass. The lesion was observed for 2 years and laparoscopically resected according to the patient's wish. Microscopically, the mass was mostly occupied by calcification and proliferous spindle cells were scattered with positive CD34 expression. We diagnosed morphologically benign SFT and the patient remained disease-free 1 year after the excision. There has been no report of such integrally calcified SFT. Retroperitoneal SFT is difficult to make a preoperative diagnosis, and careful follow-up after the excision is recommended because morphological malignancy does not always correspond to clinical malignancy.

Radical esophagectomy is a highly invasive operation for esophageal cancer, and improved techniques are being sought to reduce the invasiveness of this procedure. We devised a method in which an assistant inserts their left hand into the thoracic cavity, and the operator inserts their left hand into the abdominal cavity through a small incision in the upper quadrant during an endoscopic procedure. Between 1996 and 1999, we performed endoscopic esophagectomy on 18 patients. The median number of mediastinal lymph nodes removed by thoracoscopic surgery was 20.1 +/- 9.4 and the median number of abdominal lymph nodes removed by laparoscopic surgery was 11.1 +/- 5.6. The number of nodes dissected by endoscopic surgery did not differ significantly from the number of nodes dissected by conventional thoracotomy with laparotomy. Our experience shows that endoscopic esophagectomy with reconstruction of the esophagus assisted by inserting the hand into the thoracic and abdominal cavity, for safety and certainty, is an effective technique that is much less invasive than radical esophagectomy performed by conventional thoracotomy with laparotomy.

中下部胆管と肝内胆管に発生した異時性重複癌の1例を経験したので報告する. 症例は49歳の女性で1994年6月, 中下部胆管癌の診断で膵頭十二指腸切除術(Whipple再建)を施行, 絶対的治癒切除であった. 4年後, 下痢を主訴に再入院し, 腹部CTと胆道造影で中下部胆管癌のPTBD肝内瘻孔癌再発を疑い, 拡大肝左葉切除・尾状葉切除, 肝門部胆管空腸吻合部切除, 右肝内胆管空腸Roux-en-Y吻合を施行した. しかし病理組織学的所見から原発性胆管細胞癌と診断され, 異時性の重複癌と判明した.

We report a case of nonfunctioning endocrine tumor of the pancreas with extrapancreatic growth and cyst formation. A 48-year-old woman was admitted to our hospital with an upper abdominal mass, which was detected during a routine medical checkup. The preoperative diagnosis was a solid cystic tumor of the pancreas. The tumor, which measured about 7 cm in diameter, arose from the head of the pancreas and had a thin stalk, measuring about 1 cm in diameter. The histopathological diagnosis was a malignant nonfunctioning endocrine tumor of the pancreas. Cyst formation occurred in 67% of the reported cases with extrapancreatic growth in Japan. It is speculated that the cyst formation in this disease is related to the large size of the tumor and to the extrapancreatic growth.

We experienced a case which was assumed to be‘true carcinosarcoma’ of the esophagus. The patient was a 59-year-old man complaining of epigastric pain and dysphagia. The lesion was present in the middle intrathoracic esophagus, and was a giant polypoid lesion. A total excision of the thoracic esophagus with three regional dissection was performed. Histopathologically, it was diagnosed as carcinosarcoma of the esophagus. On HE staining, the tumor was mostly composed of sarcoma comprizing of mainly spindle cells, with nest like coexistence of well-differentiated squamous cell carcinoma with keratinization, but no transitional area between two components were seen. Immunohistochemical stainings clearly distinguished the two portions, namely the squamous cell carcinoma portion as positive for keratin and EMA versus the sarcoma portion as positive for α-SMA. Based on these findings together with electron microscopic findings, the tumor was considered to be‘true carcinosarcoma’ of the esophagus.

The most frequent sites for metastases from renal cell carcinoma are the lungs, bones and liver. Metas-tatic tumor to the colon is rare, and to the best of our knowledge, only five cases have been reported in the Japanese literature during the last one decade. A 67-year-old man, who had undergone a right radical nephrectomy for renal cell carcinoma about 4 years previously, experinced constipation. Barium enema examination and colonoscopy showed a mass on the sigmoid colon. On admission, no other abnormal findings than an increase in white blood cell count were noted. Biopsy revealed necrosis and granulation without any malignant findings. Angiography showed a hypervascular mass on the same site. Sigmoid colectomy with resional lymph nodes dissection (D3) was performed. The histopathological findings revealed metastasis from renal cell carcinoma. The patient had been disease-free for 11 months after the surgery. But we think that follow up for patients with a history of renal cell carcinoma must be lifelong.

The interaction between pancreas adenocarcinoma and vascular endothelial cells in vitro was investigated. Culture media of pancreas carcinoma cells PCI-10, but not PCI-24, induced an augmented albumin permeability across the endothelial monolayer, an event which was blocked by the calmodulin antagonist, W-7. Only marginal inhibitory effects were obtained using protein kinase inhibitors, H-7 and HA-1004. When cytokine production by pancreas carcinoma cells was examined, production of IL-6 in large amounts by PCI-10, but not by PCI-24 cells was evident. As recombinant IL-6 generated a dose-dependent permeability increase, and as this effect was inhibited by W-7, we considered that the enhancement of vascular permeability was mediated by this cytokine. The activity of culture supernatants for enhanced permeability was almost completely absorbed by the addition of an antibody specific for IL-6. Tumor-derived IL-6 as a soluble mediator regulates vascular permeability in vitro, and the production of this factor by pancreas adenocarcinoma cells presumably modulates biologic behavior.

We report a case of torsion of ovarian carcinoma pedicle during chemotherapy with bevacizumab and FOLFIRI. A 47-year-old-female who had undergone laparoscopic-assisted sigmoidectomy for sigmoid cancer with multiple metastatic liver tumors, was treated with 3 courses of FOLFOX4 and 9 courses of FOLFIRI. Bevacizumab (BV) was started to administer with FOLFIRI since a CT scan had revealed that metastatic liver tumors had enlarged . Four days after final administration of BV (13th course), she presented lower abdominal pain. CT scan showed an enlarged right ovary sized 20 cm, but no findings suggesting bowel perforation; therefore we assumed her pain was due to enlarged ovarian tumor, which might be metastasis from sigmoid cancer. Increased oral morphine could not relieve her pain. Then, along with sufficient information about the risks of the operation caused by BV, we proposed an operation to remove her enlarged ovary. Day 16 after final administration of BV, we undertook a laparotomy by lower median incision, and found a twisted right adnex with large necrotic ovarian tumor. Pathologists diagnosed the ovarian tumor as primary ovarian cancer. No complication related to BV occurred, and she was moved to the ward for internal medicine 13 days after operation.

We report an unusual case of goblet cell carcinoid (GCC) of the rectum. A 75-year-old man was admitted to our hospital with anal bleeding, and a hard tumor was felt on the anterior wall of the lower rectum during rectal examination. We performed colonoscopy, and found a 30-mm type 2 tumor in the lower rectum and anal canal. Histological examination of biopsies revealed rectal adenocarcinoma. Based on these findings, we diagnosed rectal adenocarcinoma and performed Miles' operation with lymph node dissection. Histological examination revealed an invasive lesion composed of signet-ring-like cells. Seven regional lymph node metastases were seen microscopically. The tumor produced copious mucin, which was stained with Alcian blue. Immunohistochemistry was positive for synaptophysin, chromogranin A, CD56, carcinoembryonic antigen, p53, Ki-67, E-cadherin, and cytokeratin 20. The final diagnosis was GCC of the rectum.

While hemostasis by transcatheter arterial embolization is often the first choice in the initial treatment of ruptured hepatocellular carcinoma, post-transcatheter arterial embolization treatment has not fully been established. We studied the prognoses of ruptured hepatocellular carcinoma cases where hepatectomy was possible after transcatheter arterial embolization.We retrospectively reviewed 10 cases of ruptured hepatocellular carcinoma which had been treated in our institution between 1989 and 1998. In all the 10 cases, emergency transcatheter arterial embolization was performed, which successfully achieved hemostasis.Following the achievement of hemostasis by transcatheter arterial embolization, hepatectomy was carried out in 5 cases after evaluation of general condition, functional liver reserve and extent of tumor spread. There was neither operative nor hospital death. One-year and 3-year survival rates were 100% and 40%, respectively, and 50% survival time was 36 months. In the other 5 patients, hepatectomy was decided to be impossible after evaluation of general condition, functional liver reserve and extent of tumor spread; all of them died within 0.5-10 months after transcatheter arterial embolization.Among the patients with ruptured hepatocellular carcinoma, those in which hepatectomy was decided to be possible after evaluation of general condition, functional liver reserve and extent of tumor spread, following successful hemostasis by transcatheter arterial embolization, had fairly good prognoses.

We report the successful treatment of Budd-Chiari syndrome (BCS) due to an obstruction of the hepatic veins. A 19-year-old man developed bleeding esophageal and gastric varices, and a large amount of ascites was thus caused by portal hypertension. BCS complicated by an obstruction of the major hepatic veins was diagnosed after examinations. We performed percutaneous transluminal angioplasty (PTA). This resulted in a great improvement of BCS, a marked decrease in the pressure of the hepatic veins, and the disappearance of ascites. Restenosis occurred at 1 year and 5 years after the initial angioplasty, for which PTA was repeatedly performed. Nine years after the initial treatment, no stenosis has been observed and the patient has shown a favorable outcome.

We present two patients who underwent a portal stent placement for bleeding jejunal varices of the afferent loop caused by extrahepatic portal venous stenosis. Case 1 involved a 66-year-old woman who developed bleeding jejunal varices due to extrahepatic portal venous stenosis 1 year after a pancreaticoduodenectomy with intraoperative radiation therapy. Percutaneous transhepatic balloon dilatation and stent placement were performed. Since undergoing the procedure, no bleeding has occurred. Case 2 concerned a 44-year-old woman who had a rupture and bleeding of jejunal varices 16 years after a choledocojejunostomy. Stenosis was observed from the right and left branches of the portal vein to its intrahepatic branches. Both balloon dilatation and stent placement were attempted. However, the stent could not be fully inserted into the intrahepatic portal vein. Portal stent placement is less invasive and radical, and therefore should be attempted for the treatment of extrahepatic portal venous stenosis. However, there are limits to its application if the stenosis extends to the intrahepatic branches of the portal vein.

Spindle cell carcinoma of the breast was formerly called carcinosarcoma, and is relatively rare. We report a case of spindle cell carcinoma of the breast. The patient was treated with multiple surgeries and achieved long-term survival. The patient was a 52-year-old woman, in whom small induration developed at the areola of the nipple of the right breast. The lesion was resected, and benign tumor was diagnosed pathologically. Four years later, she had recurrence at the scar, and a typical mastectomy was performed. A tumor developed again 5 years later; the lesional focus was at the scar of the right chest wall and invasion of the ribs and the sternum was noted. The sternum and the right costal cartilage of ribs 3-9 were dissected together. The right chest wall was reconstructed and adjuvant radiation therapy performed. Four years after this operation, tumor recurred near the scar and chest wall resection including part of the pericardial cavity and the left lung was performed. However, 6 months later, invasion of the mediastinum, heart and lung were noted. The patient died 16 years after the first surgery. Dermatofibrosarcoma protuberance of the breast was diagnosed at the second operation. However, the diagnosis was changed to spindle cell carcinoma of the breast following immunohistochemical studies. Spindle cell carcinoma of the breast is rare, and definitive histopathological diagnosis is often difficult. When spindle cell carcinoma is suspected, comprehensive diagnostic studies including immunohistochemical examinations should be performed. Even in case with multiple recurrences correctly performed operations may contribute to prolongation of survival.

Cellular adhesion of sialyl-Lewis-a(SLea)-positive pancreas carcinoma to endothelial cells (EC) is augmented by activation of EC via up-regulated E-selectin expression on EC. Co-cultivation of pancreas-carcinoma cells, PCI-24, with human umbilical-vein endothelial cells (HUVEC) for 5 hr at the PCI-to-HUVEC ratio of 1:10 induced E-selectin expression on the endothelial-cell surface, augmenting SLea-positive pancreas-carcinoma cell attachment with HUVEC. Culture supernatants of 6 tested pancreas-carcinoma cell lines contained soluble, E-selectin-inducing factor(s). The E-selectin-inducing effect by the supernatants was blocked by the protein-kinase-C inhibitor, H7. Antibodies against SLea and E-selectin but not SLex or ICAM-1 blocked the increased pancreas-carcinoma-to-endothelial attachment. Paraformaldehyde(PFA)-fixed PCI-24 cells also induced E-selectin on vascular endothelial cells upon direct contact with endothelial cells, indicating the presence of a membrane-bound form. The 6 pancreas-carcinoma lines all produced IL-1 alpha mRNA and protein but not IL-1 beta or TNF-alpha protein and/or mRNA. Absorption of IL-1 alpha from the supernatants by IL-1 alpha-specific antibody almost completely abolished E-selectin-inducing activity. Anti-IL-1 alpha antibody also abolished the E-selectin-inducing activity of PFA-fixed PCI. IL-1 alpha production by PCI cells was up-regulated by TNF-alpha. These observations suggest that substance(s) produced by pancreas-carcinoma cells, in this case, IL-1 alpha, may contribute to pancreas-carcinoma-cell colonization in non-inflamed, distant locations in vivo, by activating vascular endothelial cells.

Eight pancreas carcinoma cell lines of duct cell origin (PCI-6, 10, 19, 24, 35, 43, 55, and 64) were established. Using one of these lines, PCI-24, human umbilical vein endothelial cells (HUVEC), and several recombinant cytokines, conditions and specificity of anti-PCI LAK induction were investigated, with the focus on a search for lymphokine-activated killer (LAK) activity that differentiates neoplastic (PCI) from non-neoplastic (HUVEC) cells. Interferon-gamma (IFN-gamma), IFN-alpha, IL-4, IL-6, and IL-7, but not tumor necrosis factor-alpha (TNF-alpha) or IL-1 beta, induced a weak LAK activity against PCI-24, whereas IL-2-induced (1000 U/mL) LAK exhibited a far more potent cytotoxicity. When these cytokines were added at the suboptimal dose IL-2 (100 U/mL), no significant augmentation in LAK activity was induced. Staphylococcal protein A (SpA) induced LAK activity as potent as that seen with IL-2 (1000 U/mL). Both IL-2-induced and SpA-induced LAK had a potent, dose-dependent cytotoxicity against HUVEC. HUVEC inhibited both IL-2- and SpA-induced LAK cytotoxicity against PCI-24 to almost the same extent as seen with PCI-24. Thus, two potent LAK-inducers did not generate LAK activity that differentiates neoplastic from non-neoplastic cells. Thus, in vitro cytotoxicity of LAK against non-neoplastic endothelial cells is unavoidable when handling cytokines in LAK induction.

The polymerization initiated by 1-phenylethyl radical (PER) and diphenylmethyl radical (DPMR) at 50°C was studied to clarify the causes of deviation in the polymerization rate Rp from Rp∝[C]1/2[M] ([C], initiator concentration and [M], monomer concentration). In the polymerization of styrene initiated by PER, the term defined as primary radical termination (PRT) can not be used to explain the deviation, because of ki≃kp (ki, rate constant of addition of primary radical to monomer and kp, propagation rate constant). Thus, the deviation should be explained by the dependence of polymer-polymer termination (PPT) on chain length. In the polymerization initiated by DPMR, both the PRT term and the dependence of PPT on chain length are necessary to explain the deviation, because of ki≪kp, where ki=37 dm3 mol−1 s−1 (styrene) and 2.5 (methyl methacrylate).

Simple liver cysts occasionally cause pressure symptoms of the abdomen. We herein report an extremely rare case of spontaneous rupture of simple liver cysts. A 65-year-old woman suffered abdominal fullness and dyspnea. Laboratory examinations revealed general inflammation and mild hepatorenal dysfunction. Computed tomography revealed giant polycystic liver and ascites. Echinococcus antibody was not detected. Abdominal paracentesis provided dark brown transparent ascites in which any parasites or tumor cells were not observed. We diagnosed spontaneous rupture of isolated polycystic liver disease (PCLD) and continuously drained the ascites. After the symptoms and laboratory data were improved, resection of liver cysts and left lateral segmentectomy were performed. Histopathologically, simple columnar epithelia inside of cyst walls were observed. The patient remains well without recurrence of the symptoms 10 months after the surgery. We reviewed characteristics of PCLD and considered appropriate treatment for spontaneous rupture of simple liver cysts based on the previous case reports including the present case.

A 33-year-old man suffered sudden abdominal distension without traumatic episodes. He had undergone total splenectomy for hereditary spherocytosis 13 years ago. He was in shock, and his hemoglobin level was 10.5 g/dl. Contrast enhanced computed tomography revealed a giant mass in the left upper abdomen and extravasation of the contrast material into the mass. Excision of the mass was performed, and microscopic examination showed a giant hematoma surrounded by normal splenic tissue. We speculated that an accessory spleen or splenosis had enlarged for the 13 years and ruptured. The patient remained asymptomatic 4 months after the surgery. Spontaneous hemorrhage from accessory spleens or splenosis is extremely rare, and relevant case reports suggest that surgical resection of bleeding sites yields favorable prognosis although preoperative qualitative diagnosis seems to be difficult.